http://e-journal.unair.ac.id/jners | 205 jurnal ners vol. 14, no. 2, april 2019 http://dx.doi.org/10.20473/jn.v14i2.13726 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research correlation between emotional peer support and cyberbullying behaviour in senior high school students emi wuri wuryanningsih, enggal hadi kurniyawan, and emila cahya aisyah faculty of nursing, universitas jember, east java, indonesia abstract introduction: the biggest users of the internet and social media are teenagers. this has an impact on the tendency for harassment behavior known as cyberbullying. this harassment is quite serious because it is massive; it can happen at any time and anywhere. this harassment generally comes from the victim’s peers. this research aimed to analyze the correlation between peer emotional support and the cyber-bullying behavior among the students in senior high school. methods: this research used a cross-sectional study design. the sample size of this study was 246 students in senior high school from the academic year 20182019 collected through purposive sampling. the instrument of this research was emotional support from their peers and cyberbullying behavior. the bivariate analysis used was the spearman test (α<0.05; ci=95%). results: there is a significant correlation between emotional peer support and cyberbullying behavior among the students in senior high school. conclusion: community health nurses should improve the emotional peer support among the students in order to promote the prevention of cyberbullying behavior. article history received: december 6, 2019 accepted: january 14, 2020 keywords cyberbullying; peer emotional support; senior high school student contact emi wuri wuryanningsih  emi_wuri.psik@unej.ac.id  faculty of nursing, universitas jember, east java, indonesia cite this as: wuryanningsih, e. w., kurniyawan, e. h., & aisyah, e. c. (2019). correlation between emotional peer support and cyberbullying behaviour in senior high school students. jurnal ners, 14(2), 205-209. doi:http://dx.doi.org/10.20473/jn.v14i2.13726 introduction one of the characteristics of the development of high school-aged adolescents is that they need friends, that they are eager to try everything that is not yet known to them and they have a desire to explore their natural surroundings (putro, 2017). this has an impact on their use of the internet and social media, which is high in the adolescent age group. data from the indonesian internet service providers association (2018) shows that the number of internet users in indonesia has now reached 88.1 million. most users are teenagers, especially those in high school, reaching 64.7%. teenagers use social media to interact with their friendship groups. the results related to conventional harassment behavior tends to shift towards cyberbullying. a survey was conducted with 259 participants as the sample (202 female), with all of the respondents aged 19–25 years of. in this survey, 58,1% had experienced some form of cyberviolence (ham & livazovic, 2019). cyberbullying perpetration indicates the“repeated violation, harassment and ridicule of others online, or using mobilephones or even other electronic devices” (patchin and hinduja, 2012). cyberbullying is a mischievous behavior that is usually done by individuals or groups intentionally and repetitively on purpose to harm others using computers, phones, and other electronic devices. additionally, this behavior has so far been considered safe because adults do not recognize when the behavior occurs. this is as it is not easy to monitor activity related to the internet (sari, 2016). using technology, people can do things that may bring either good or harm to both themselves and others (utami, 2014). the user of the internet is not limited because all circles can access it quickly and they are free to do anything (bauman, toomey, & walker, 2013). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.13726 e. w. wuryanningish et al. 206 | pissn: 1858-3598  eissn: 2502-5791 in indonesia, there are no age restrictions for smartphone users. there is a vulnerability associated with the negative impact of smartphone use in adolescents, both emotionally and socially. based on the results of the study, it shows that 21% report regular cyber-victimization with a distinct emotional disturbance (31,3%), anger (20,8%), helplessness (13,1%) and sorrow (20,5%) (ham & livazovic, 2019). the victims also feel insecure in any situation and they often experience despair due to the oppression in cyberspace (vaillancourt, faris, & mishna, 2017). the victims feel afraid and uncomfortable with and in their environment, and the victims furthermore feel insecure and threatened in terms of their safety (hidajat, adam, danaparamita, & suhendrik, 2015). cyberbullying behavior that occurs over a long period of time can have an impact on the victim's psychology, such as a loss of self-confidence, increased anxiety and decreased performance (rifauddin, 2016). cyberbullying behavior uses more forms of verbal communication through writing such as what is experienced on the internet and through social media (maya, 2015). willard (2007) indicated a taxonomy of the different types of cyberbullying: 1) flaming (i.e. an online fight), 2) harassment (i.e. repetitive, offensive messages), 3) outing and trickery (i.e. soliciting personal information from someone and then electronically sharing that information without the individual's consent), 4) exclusion (i.e., blocking an individual), 5) impersonation (i.e. posing as the victim), 6) cyberstalking (i.e. sending repetitive threats) and 7) sexting (i.e. distributing pictures of another individual without that person's consent). cyberbullying behavior is usually done freely on the internet. moreover, bullies can sometimes be falsely known; their hidden identity allows them to do anything without fear (narpaduhita & suminar, 2014). cyberbullying perpetrators among teenagers generally comes from among their friends. teenagers will behave in order to be accepted by their group of friends even if this behaviour is not in accordance with their wishes. social support, especially peer emotional support, plays a vital role in preventing cyberbullying behavior. peer emotional support will build empathy when dealing with the adverse behavioral problems that occur in adolescents (steffgen, könig, pfetsch, & melzer, 2011).teens receive more emotional support from their peers than from their parents. this may come from the interdependence between them and their peers in terms of giving and receiving support and motivation, which they usually like to do as part of an exchange (lakon, wang, butts, jose, & hipp, 2017; keliat, 2016). our study aims to analyze the relationship between peer emotional support and cyberbullying behavior in high school-aged adolescents. materials and methods this research used an analytical observation design with a cross-sectional approach. this research was conducted in a senior high school in the district of jember. the population included students from the 10th and 11th grades, totaling 635 students in the 2018-2019 academic year. based on the slovin formula (d=5%), the sample size of this study was 246 students via a proportionate stratified random sampling technique. the data was collected between february and march 2019. the instrument of this research was peer emotional support (12 item questions about empathy, caring, concern, positive regard, and encouragement focused towards the person; α-cronbach score=0,849) and cyberbullying behavior (10 item questions about the identification of the perpretator, victims, both, or none of them regarding cyberbullying; α-cronbach score=0,849). the data collection was conducted after getting a permit from the school. the students were gathered after informed consent was given and through the students filling in the provided questionnaires. after all of the data was collected, bivariate analysis was performed using the spearman test (α<0.05; ci=95%). this study was approved by the health research ethics commission of the faculty of dentistry, university of jember no.334/un25.8/kepk/dl/2019.. table 1. distribution of the respondents by sex, class, the occupation of their parents, the parents' education, height, and student weight referring to the senior high school students, jember (n = 246) characteristics of the respondents n % gender men women 62 184 25,2 74,8 class x xi 125 121 50,8 49,2 parents’ job not working government employees private employees entrepreneurship etc (farmer, laborer) 6 52 73 63 52 2,4 21,1 29,7 25,7 21,1 parents’ education elementary school junior high school senior high school college 4 15 159 68 1,6 6,1 64,6 27,6 height 140-150 cm 151-160 cm 161-170 cm 171-180 cm 37 117 67 25 15,0 47,6 27,2 10,2 body mass index (bmi) less weight normal weight overweight obesity 90 112 41 3 36,6 45,5 16,7 1,2 jurnal ners http://e-journal.unair.ac.id/jners | 207 results several respondent characteristics were used in the present study including gender, parental occupation, the parent’s education and height. based on table 1, the frequency distribution of gender obtained from the 246 respondents yielded that the female respondents outnumbered the male respondents with a total of 184 (74.8%). the score for the most common parental occupation was that of a private worker, with a total of 73 students (29.7%). the second most common occupations were entrepreneurs, civil workers and others. the least common occupation was unemployment. furthermore, the parental education indicator, which had the most common distribution, was that of senior high school. this is as shown in the response from 159 students (64.6%). based on the distribution of height obtained from 246 respondents, most students (as many as 117 students) were 151 to 160 cm tall. the least common distribution was that from only 25 students at 171 to 180 cm tall (10.2%). in table 2, it can be observed that out of the 246 respondents, the male respondents were most often the bullies (as many as 9 students; 14.6%). the table also informs us that the most common parental occupation was that of a private worker; 6 (8.2%) were bullies, 9 (12.3%) were victims and 12 (16.5%) were bullies and victims referring back to this. it was also found that cyberbullying incidents occur very little occur for the respondents whose parents did not go to school or who had graduated only from elementary education; none (0%) of these respondents were either bullies or bullies and the victims of bullying. only 1 (25%) respondent was identified as a victim. table 3, on the other hand, explains that the students who became the research respondents preferred receiving emotional support from their peers (195 students or 79.3%). high peer emotional support means that the students genuinely care about their peers in terms of empathy, caring, concern, positive regard and encouragement. emotional support is usually characterized by the perception of trust in relation to others (shensa, sidani, escobar-viera, et al., 2020). related to this, the indicator of peer emotional support, which was considered to be the most influential, was encouragement toward the person. this is because most of the respondents marked this indicator higher than the other indicators. it was known that from the 246 respondents, most of them (158 64.2%respondents) did not become either bullies or victims. the rest of them (35.8%) were bullies, victims or both. finally, the spearman test resulted in the relationship between the variable of peer emotional support and the variable of cyberbullying behavior as being determined to have a p-value of 0.001. the correlation value was -0.228. in other words, the correlation of the two variables was classified as low. the negative correlation implies table 2. frequency distribution of the respondents' characteristics with the category of cyberbullying in senior high school students, jember (n = 246) characteristics of the respondents cyberbullying category total n (%) perpretator n (%) victim n (%) both n (%) not doing n (%) gender men women 9 (14,6) 16 (8.7) 5 (8,0) 28 (15,2) 5 (8,0) 25 (13,6) 43 (69,4) 115 (62,5) 62 (25,2) 184 (74,8) class x xi 11 (8,8) 14 (11,6) 10 (8) 23 (19) 14 (11,2) 16 (13,2) 90 (72) 68 (56,2) 125 (50,8) 121 (49,2) parents’ job not working government employees private employees entrepreneurship etc (farmer, laborer) 1 (16,7) 7 (13,5) 6 (8,2) 4 (6,3) 7 (13,5) 2 (33,3) 8 (15,4) 9 (12,3) 7 (11,1) 7 (13,5) 0 (0) 6 (11,5) 12 (16,5) 8 (12,7) 4 (7,7) 3 (50) 31 (59,6) 46 (63) 44 (69,8) 34 (65,4) 6 (2,4) 52 (21,1) 73 (29,7) 63 (25,7) 52 (21,1) parents education elementary school junior high school senior high school college 0 (0) 3 (20) 16 (10,1) 6 (8,8) 1 (25) 3 (20) 20 (12,6) 9 (13,2) 0 (0) 1 (6,7) 22 (13,8) 7 (10,3) 3 (75) 8 (53,3) 101 (63,5) 46 (67,6) 4 (1,6) 15 (6,1) 159 (64,6) 68 (27,7) height 140-150 cm 151-160 cm 161-170 cm 171-180 cm 5 (13,5) 10 (8,5) 7 (10,5) 3 (12) 6 (16,2) 17 (14,5) 7 (10,5) 3 (12) 2 (5,4) 16 (13,7) 8 (11,9) 4 (16) 24 (64,9) 74 (63,2) 45 (67,1) 15(60) 37 (15) 117 (47,6) 67 (27,2) 25 (10,2) body mass index (bmi) less weight normal weight overweight obecity 7 (7,8) 13 (11,6) 5 (12,2) 0 (0) 6 (6,7) 10 (8,9) 16 (39) 1 (33,3) 5 (5,5) 19 (17) 5 (12,2) 1 (33,3) 72 (80) 70 (62,5) 15 (36,6) 1 (33,4) 90 (36,6) 112 (45,5) 41 (16,7) 3 (1,2) https://www.sciencedirect.com/science/article/pii/s0165032719316684#! https://www.sciencedirect.com/science/article/pii/s0165032719316684#! https://www.sciencedirect.com/science/article/pii/s0165032719316684#! e. w. wuryanningish et al. 208 | pissn: 1858-3598  eissn: 2502-5791 that the more that cyberbullying behavior is done, the lower the emotional support from their peers. the less the cyberbullying behavior is done, the higher the emotional support given by their peers. discussion as found in the present study focused on 246 respondents, the number of students who were both a bully and a victim of cyberbullying was quite considerable. cyberbullying is commonly done because of the dislike of a person which cannot be directly expressed or uttered in real life. therefore, social media and online platforms are preferred (budiarti, 2016). teenagers who are active users of social media are more prone to cyberbullying behavior as it opens up chances for them to become either bullies or victims of cyberbullying (mesch, 2009). a previous study conducted by febrianti & hartana (2014) obtained the result that females are more involved in cyberbullying than males. the findings of the study do not conform to the findings of the present study where more male students are involved in cyberbullying. male students usually belong to a particular group who like to do bad things to other students outside of the group. cyberbullying usually happens to people or victims who have a different appearance. for example, if they are smaller in body size or if they seem to weigh more (overweight) than others (rahayu, 2012). teenagers with a distinctly bigger or thinner body than their peers tend to be less accepted among their friends, compared to those with an (considered) average body size (kustanti, 2015). emotional support is very crucial because the victims of cyberbullying need to feel comfortable and loved by others, especially their friends (sundari, 2015). several factors influence the high and low emotional support given by peers to the teens that are the receivers of the support and the support provider themselves. emotional support can be in the form of expressions of empathy such as listening, being open, trusting, understanding, compassion, and attention being given. the receiver of the support can be influenced if the receiver of the support does not like to socialize, if they do not get along with others, if they are not motivated to help others and if they not want others to know that she or he needs help. the second factor can be influential because teenagers are not likely to support their friends emotionally if they seem to have nothing (no resource) to help others with, if they struggling with their own depression and if they are not sensitive to their surroundings, thus making them unaware of their friend's emotions (pragwati, 2014). the ability of the students to get emotional support can help them to overcome the problems that are being faced so then the teens are not immersed in the sadness that is being experienced (ristianti, 2008). it is implied in the findings of the present study that there is a correlation between peer emotional support and the cyberbullying behavior of teenagers. it was known that the more that cyberbullying behavior is done, the less peer emotional support is being given. this is because the worse the interactions are among their peers, the more this can lead to cyberbullying behavior. groups of teenagers have a relationship with the cyberbullying behavior of other teenagers. worse interactions among their peers may trigger cyberbullying (hinduja & patchin, n.d.). moreover, their peers can play a role in the media related to informing individuals of the social norms or agreements that are allowed to be done by teens. therefore, teenagers are prone to being involved in cyberbullying because they believe that their negative behavior is confirmed and supported by their friends. in other words, their peers are an essential element in how teenagers behave (budiarti, 2016). researchers argue that cyberbullying behavior is a form of negative behavior that results from a lack of peer emotional support. excellent emotional support will make someone avoid negative behaviors such as cyberbullying. conclusion according to the findings of the study and the discussion in the previous section, it can be concluded that there is a relationship between peer emotional support and cyberbullying behavior.the results imply that the more cyberbullying there is, the lesser peer emotional support has been given. prospective studies can focus more on cyberbullying by taking into account other factors in addition to peer emotional support such as the parent's role and the attitude of the groups of their peers towards cyberbullying. both teachers and parents are expected to play an active role in overseeing the student’s activities when they are interacting via the internet. they should also provide good parenting for the students. table 3. analysis of the relationships between peer emotional support and cyberbullying behavior in senior high school students in jember variable n (%) correlation peer emotional support high peer emotional support (x ≥ 38) medium peer emotional support (22 ≤ x<38) low peer emotional support (x<22) 44 (17,9) 195 (79,3) 7 (2,8) r = -0,228 p = 0,001 cyberbullying behavior categories perpretator victim both (perpretator and victim) not doing (neither perpretator nor victim) 25 (10,2) 33(13,4) 30 (12,2) 158 (64,2) jurnal ners http://e-journal.unair.ac.id/jners | 209 references bauman, s., toomey, r. b., & walker, j. l. (2013). associations among bullying, cyberbullying, and suicide in high school students. journal of adolescence, 36(2), https://doi.org/10.1016/j.adolescence.2012.12.0 01 budiarti, a. i. (2016). pengaruh interaksi dalam peer group terhadap perilaku cyberbullying siswa. jurnal pemikiran sosiologi, 3(1), https://doi.org/10.22146/jps.v3i1.23522 febrianti, r., & hartana, g. t. (2014). cyberbullying pada mahasiswa universitas indonesia. skripsi. jakarta: fakultas psikologi universitas indonesia. hidajat, m., adam, a. r., danaparamita, m., & suhendrik, s. (2015). dampak media sosial dalam cyber bullying. comtech: computer, mathematics and engineering applications, 6(1), https://doi.org/10.21512/comtech.v6i1.2289 hinduja, s., & patchin, j. w. (n.d.). identification, prevention, and response. cyberbullying research center. keliat, b. (2016). prinsip dan praktik keperawatan kesehatan jiwa stuart, edisi indonesia pertama. singapura: elsevier ltd. kustanti, e. r. (2015). gambaran bullying pada pelajar di kota semarang. jurnal psikologi undip14(1), https://doi.org/10.14710/jpu.14.1.29-39 lakon, c. m., wang, c., butts, c. t., jose, r., & hipp, j. r. (2017). cascades of emotional support in friendship networks and adolescent smoking. plos one, 12(6), https://doi.org/10.1371/journal.pone.0180204 livazovic, g & ham, e. (2019). cyberbullying and emotional distress in adolescents: the importance of family, peers and school. heliyon 5: 1-9 https://doi.org/10.1016/j.heliyon.2019.e01992 mesch, g. s. (2009). parental mediation, online activities, and cyberbullying. cyberpsychology and behavior, 12(4), https://doi.org/10.1089/cpb.2009.0068 narpaduhita & suminar. (2014). perbedaan perilaku cyberbullying ditinjau dari persepsi siswa terhadap iklim sekolah di smk negeri 8 surabaya. jurnal psikologi klinis dan kesehatan mental, 3(3), nirwana sari, r. (2016). kecerdasan emosi, anonimitas dan cyberbullying (bully dunia maya). persona:jurnal psikologi indonesia, 5(01), https://doi.org/10.30996/persona.v5i01.741 patchin, j.w., & hinduja, s., (2012). cyberbullying prevention and response: expert perspectives. routledge, new york pragwati, p. y. m. a. (2014). hubungan antara tingkat dukungan sosial teman sebaya degan jenis mekanisme koping terhadap stres pada remaja di sman 8 malang. putro, k.z. (2017). memahami ciri dan tugas perkembangan masa remaja.aplikasia: jurnal aplikasi ilmu-ilmu agama. vol. 17(1): 25-32 online: ejournal.uin-suka.ac.id/pusat/aplikasia issn 1411-8777 rahayu, f. (2012). cyberbullying sebagai dampak negatif penggunaan teknologi informasi. jornal of information system, 8. rifauddin, m. (2016). fenomena cyberbullying pada remaja (studi analisis media sosial facebook). khizanah al-hikmah : jurnal ilmu perpustakaan, informasi, dan kearsipan, 4(1), ristianti, a. (2008). hubungan antara dukungan sosial teman sebaya dengan identitas diri pada remaja di sma pusaka 1 jakarta. jurnal fakultas psikologi universitas gunadarma, 000, 2–4. retrieved from http://publication.gunadarma.ac.id/handle/1234 56789/1581. soemartono, h.k. (2018). survei apjii: penetrasi internet di indonesia capai 143 juta jiwa. buletin asosiasi penyelenggara jasa internet indonesia, steffgen, g., könig, a., pfetsch, j., & melzer, a. (2011). are cyberbullies less empathic? adolescents’ cyberbullying behavior and empathic responsiveness. cyberpsychology, behavior, and social networking, 14(11), 643–648. https://doi.org/10.1089/cyber.2010.0445 sundari, l. (2015). hubungan antara dukungan emosional teman sebaya dengan motivasi berprestasi pada atlet hockey di kabupaten kendal. universitas salatiga. utami, y. c. (2014). cyberbulliying di kalangan remaja (studi tentang korban cyberbullying di kalangan remaja di surabaya). komunitas, 3(3) vaillancourt, t., faris, r., & mishna, f. (2017). cyberbullying in children and youth: implications for health and clinical practice. canadian journal of psychiatry, 62(6), https://doi.org/10.1177/0706743716684791 willard, n.e., 2007. cyberbullying and cyberthreats: responding to the challenge of online social aggression, threats, and distress. research press, champaign, il. https://doi.org/10.1016/j.heliyon.2019.e01992 authors index volume 14 nomor 2 october 2019 afik, al, 193 muflih, 224 ahsan, 193, 215 mundakir, 210 aisyah, emila cahya, 205 noviana, ulva, 199 amin, muhammad, 165 nuraeni, aan, 137 anjaswarni, tri, 129 nursalam, 124, 129, 144, 165, 181, 193, 215 arifin, hidayat, 118 palupi, hendri, 161 asmarani, fajarina lathu, 224 pertiwi, enji meilia era, 151 asri, 210 pratiwi, nadya wahyu, 181 aulia, amira, 155 prawesti, ayu, 137 awaludin, sidik, 151 purnawa, ni luh agustini, 187 devy, shrimarti rukmini, 144, 193 putra, suhartono taat, 124 efendi, ferry, 155 rachmawati, dhian satya, 165 emaliyawati, etika, 137 rondhianto, 215 ernawati, 144 sukartini, tintin, 181 fadillah, nur, 210 sulistyono, agus , 124 fikriana, riza, 193 sumaeru, annas, 151 fitriah, 199 sumara, retno, 210 hargono, rachmat, 165 suwarsi, 224 has, eka misbahatul mar'ah, 155 suwito, joko, 124 hasinuddin, m, 199 wardani, yulia, 172 huda, nuh, 181 widati, sri, 124 izza, elfa lailatul, 118 winarni, sri, 187 kurniyawan, enggal hadi, 205 wulandari, yuanita, 210 kusumaningrum, tiyas, 155 wuryanningsih, emi wuri, 205 kusnanto, 118, 161 yuliati, ignata, 187 mardiyanti, ika, 144 yusuf, ah, 124 melaniani, soenartalina, 215 yuswanto, tri johan agus, 118 mirwanti, ristina, 137 yuwono, slamet riyadi, 161 subject index volume 14 nomor 2 october 2019 a acceptance, 165 acceptance, 165 acupressure, 151 adaptation, 165 adherence, 118 affirmation-tapping, 124 anamneses, 224 audio-visual, 161 b blood glucose, 224 c clinical simulation, 161 competence, 161 complementary,124 coping, 199 coping mechanism, 199 cybercullying, 205 d deliquency, 129 diabetes self management, 215 diabetes-mellitus, 181 diet, 118 diet-compliance, 155 drug compliance, 193 e ethnic foods, 155 f family caregiver capabilities, 215 family rescilience, 165 family support, 144 family support system, 199 foot care behaviour, 181 g gingger compress, 151 gout arthritis, 151 h hemodialysis, 210 high school students, 205 high-risk, 144 hypertension, 193 i idwg, 210 instrument development, 187 j juvenile, 129 l learning strategic, 172 n national competency examination, 172 nesting, 137 o oxygen saturation, 137 p pain, 124 partner support, 210 peer emotional support, 205 practicum, 161 predictor, 172 pregnancy, 144 premature babies, 137 psychosocial, 215 q qrma, 224 r risk factors,129 s self-efficacy, 155, 181 serotonin serum, 124 sociodemographics factors,215 standard operating procedure, 161 stress hospitalisation, 199 t tccni_iv, 187 technological competency, 187 transcultural nursing, 155 tuberculosis, 165 type 2 diabetes mellitus, 118, 155, 215 v validation, 187 w weight, 137 4 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international 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2 0 jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam m.nurs. (hons), (scopus id: 56660628500; h-index: 4); faculty of nursing, universitas airlangga, indonesia international advisory board reviewers 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740; h-index: 13); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200; h-index: 10); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, (scopus id: 8293647300; h-index: 12); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172; h-index: 2); college of nursing, university of the philippines manila, philippines 5. dr. nicola cornally, (scopus id: 36982904800; h-index: 13); school of nursing and midwifery, university college cork, ireland 6. dr. david pickles, (scopus id: 57190150026; h-index: 5); college of nursing & health sciences, flinders university, south australia, australia 7. dr. farhan alshammari, (scopus id: 57192298773; h-index: 3); college of nursing, university of hail, saudi arabia 8. dr. patricia leahy-warren, (scopus id: 55954181800; h-index: 11); school of nursing and midwifery, university college cork, ireland 9. dr. wendy abigail, (scopus id: 24467540600; h-index: 3); school of nursing and midwifery, flinders university, australia 10. dr. chong mei chan, (scopus id: 57189591887; h-index: 2); dept. of nursing faculty of health science, university of malaya, malaysia 11. dr. sonia reisenhofer, (scopus id: 16310818100; h-index: 4); school of nursing and midwifery, la trobe university, australia, australia editor: 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100; h-index: 3); faculty of nursing, universitas airlangga, indonesia 2. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756; h-index: 1); faculty of nursing, universitas airlangga, indonesia, indonesia 3. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 4. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); faculty of nursing, universitas airlangga, indonesia javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/454') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3472') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3469') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3098') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3458') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3784') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3783') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3708') 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nursing, universitas airlangga, indonesia 2. masunatul ubudiyah, faculty of nursing, universitas airlangga, indonesia 3. dluha maf'ula, faculty of nursing,. universitas airlangga, indonesia 4. rifky octavia pradipta, s.kep., ns, faculty of nursing, universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., (scopus id: 57201187775); faculty of nursing, universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/542') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/1605') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10192') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10193') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10603') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/2145') mailto:secretariat_jurnalners@fkp.unair.ac.id http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 7 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on apriori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and m etaanalyses will be dealt with as original articles are, as far as the editorial process is concerned. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and post-publication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following:  introduction: one or two sentences on the background and purpose of the study.  method: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics).  results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals.  conclusions: should relate to the study aims and hypotheses.  keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. 8 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 acknowledgment (optional). acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below:  observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/  qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq  quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/  randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/  study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/  systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/  systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 publication fee jurnal ners charges the author a publication fee amounted to idr 1.000.000 (indonesian author) and usd 100 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within two working days. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 9 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 title page format must be written in times new roman font 12 a. manuscript title b. first author * , second author ** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: ………………………………………………………………………………………………….. f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. 10 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. title page example vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga 11 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 12 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 13 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: ∑ ………............................................................................................... (1) remarks: .............................................................................................................................................. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 o c after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old type of care age groups (years) <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 14 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. https://www.mendeley.com/guides/harvard-citation-guide 15 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author,  hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language.  have read the final version of the manuscript and responsible for what is said in it.  have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website.  hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below.  acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk 1 implementasi sistem manajemen mutu pelayanan keperawatan melalui kepemimpinan mutu kepala ruangan (implementation of quality management system of nursing care through quality leadership of nurse unit manager) ana pratiwi * , aziz alimul hidayat * , ratna agustin * *departemen of nursing, faculty of health science, muhammadiyah university of surabaya jl. sutorejo no. 59 surabaya email: azizhidayat@yahoo.com abstrak pendahuluan: sistem manajemen mutu merupakan suatu tatanan yang menjamin tercapainya tujuan dan sasaran mutu yang direncanakan dalam pelayanan keperawatan. salah satu faktor yang dapat memengaruhi implementasi sistem manajemen mutu di ruangan rawat inap adalah kepemimpinan mutu kepala ruangan. penelitian ini bertujuan untuk mengetahui pengaruh kepemimpinan mutu kepala ruangan terhadap implementasi sistem manajemen mutu pelayanan keperawatan di rumah sakit. metode: metode penelitian ini menggunakan penelitian analitik dengan pendekatan cross sectional. sampel dalam penelitian ini berjumlah 8 ruangan yang terdiri dari paviliun multazam, arofah, sakinah, shofa marwah, annisa, mina, ismail, dan icu yang memenuhi kriteria inklusi dan eksklusi. pengambilan data menggunakan simple random sampling. pengumpulan data dengan menggunakan kuesioner, wawancara dan observasi. analisis data dengan menggunakan uji statistik regresi linear sederhana dengan nilai kemaknaan α ≤ 0,05. hasil: hasil penelitian di dapatkan kepemimpinan mutu kepala ruangan sebagian besar baik (50%) dan implementasi sistem manajemen mutu pelayanan keperawatan juga sebagian besar baik (62,5%). hasil analisa dengan uji regresi linear sederhana di dapatkan ada pengaruh kepemimpinan mutu kepela ruangan terhadap implementasi sistem manajemen mutu ruang rawat inap (ρ= 0,024). kesimpulan: dari hasil penelitian ini diharapkan perawat meningkatkan komitmen dan tanggung jawab dalam mengimplementasi sistem manajemen mutu pelayanan keperawatan di ruang rawat inap sehingga dapat mencapai mutu pelayanan keperawatan yang berkualitas dan dapat meningkatkan kepercayaan, kepuasan pada pasien, keluarga, masyarakat terhadap pelayanan keperawatan. kata kunci : kepemimpinan mutu, implementasi sistem manajemen mutu. abstract introduction: the quality management system is an order that ensures the achievement of goals and quality objectives which are planned in nursing care. one of the factors that may affect the implementation of quality management systems in the inpatient units is the quality leadership of head nurse. this study aims to determine the effect of the quality leadership of the head nurse to the implementation of quality management systems of nursing cares in hospital. methods: the research method uses analytical research with cross-sectional approach. the sample of this study consists of eight wards; they are multazam pavillion, arofah, sakinah, shofa marwah, annisa, mina, ismail, and icu which meet with the inclusion and exclusion criteria. the data was taken by using simple random sampling. the data collection by using questionnaires, interviews and observation. data analysis used a simple statistical linear regression tests with a significance the value of α ≤ 0.05. results: the results showed that the quality of leadership of the head of wards is mostly good (50%) and the implementation of quality management system of nursing care is mostly good (62.5%). results of analysis of the simple linear regression test on the influence of leadership quality of the head nurse through the implementation of the quality management system of inpatient units (ρ = 0.024). conclusion: the results of this study expect the nurses to increase the commitment and responsibility in implementing the quality management system of nursing cares in the inpatient units so as to achieve the excellent quality of nursing cares and can boost confidence, satisfaction of patients, families, and communities on nursing care. keywords: quality leadership, quality management system implementation pendahuluan sistem manajemen mutu merupakan suatu tatanan yang menjamin tercapainya tujuan dan sasaran mutu yang direncanakan termasuk di dalam pelayanan keperawatan (semuel & zulkarnain 2011). salah satu masalah yang sering terjadi di pelayanan keperawatan adalah rendahnya implementasi sistem manajemen mutu pelayanan keperawatan, termasuk dapat di temukan di rs siti khotijah. hal ini berdasarkan penelitian (amaliyah 2014). menyatakan bahwa tiga ruangan di rumah sakit siti khodijah dengan mutu pelayanan keperawatan kurang dan dua ruangan dengan mutu pelayanan keperawatan cukup. faktor yang mempengaruhi mutu pelayanan terdiri atas unsur masukan meliputi tenaga, dana dan sarana, unsur lingkungan meliputi kebijakan, organisasi dan manajemen, dan unsur proses meliputi tindakan medis dan tindakan non medis (azwar 1996). dalam unsur masukan terdapat tenaga dan jurnal ners vol. 11 no.1 april 2016: 1-6 2 kepemimpinan mutu.untuk itu salah satu yang dapat digunakan untuk mengatasi masalah mutu pelayanan adalah melalui perbaikan kepemimpinan yang berbasis mutu, hal jugadapat ditemukan pada penelitian yang dilakukan (dhinamita nivalinda, m.c. inge hartini 2013) bahwa kepemimpinan kepala ruang yang efektif akan mempengaruhi upaya menggerakkan perawat dalam lingkup wewenangnya untuk menerapkan budaya keselamatan pasien. perawat dengan motivasi baik akan menerapkan budaya keselamatan pasien dengan baik. kepemimpinan kepala ruangan memiliki peran penting didalam implementasi sistem manajemen mutu di ruangan karena kepala ruangan mempunyai tanggung jawab dalam mengelola, merencanakan, dan mengendalikan kinerja stafnya dalam manajemen keperawatan (parahita 2010). sehingga untuk mengatasi masalah dalam implementasi sistem manajemen mutu, dapat diatasi dengan kepemimpian mutu kepala ruangan yang berorientasi pada mutu pelayanan. berdasarkan uraian tersebut, maka tujuan penelitian ini adalah menjelaskan pengaruh kepemimpinan mutu kepala ruangan terhadap implementasi sistem manajemen mutu palayanan keperawatan di rumah sakit. bahan dan metode metode penelitian yang di gunakan adalah analitik cross sectional. populasi dalam penelitian ini adalah seluruh ruangan rawat inap di rumah sakit siti khodijah sepanjang pada tahun 2014. sampel dalam penelitian ini adalah ruangan rawat inap sebanyak 8 unit ruangan rawat inap di rumah sakit siti khodijah sepanjang yakni icu, paviliun sofa marwa, paviliun mina, paviliun multazam, paviliun ismail, paviliun arofah, paviliun anisa, paviliun sakinah. pengumpulan data dilakukan selama tiga bulan. sumber data diperoleh berasal dari sumber primer dan sekunder. data primer didapat dari responden melalui pemberian kuesioner dan wawancara secara langsung. prosedur pengumpulan data dilakukan dengan menggunakan cara, kuesioner dan wawancara. kuesioner terdiri atas 20 pertanyaan dengan skala likert, yang meliputi pertanyaan focus tentang perencanaan dengan kriteria yakni (1) analisa situasi, (2) penetapan tujuan, (3) sasaran, (4) kegiatan program, (5) monitoring dan evaluasi. pertanyaan dengan focus tentang pelaksanaan dengan kriteria yakni (1) pelatihan, (2) survey kebutuhan, (3) identifikasi proses, (4) pembentukan tim. pertanyaan dengan focus pertanyaan tentang pemeriksaan dengan kriteria yakni (1) menjalankan sesuai rencana, (2) mengamati hasil, (3) efek yang terjadi, (4) adanya perubahan. pertanyaan fokus tentang perbaikan dengan kriteria yakni (1) studi situasi yang sedang berlangsung, (2) standarisasi, (3) dokumentasi, (4) inovasi ide. analisis data yang digunakan adalah uji regresi linear sederhana untuk mengetahui pengaruh antara variabel independen dan variabel dependen dengan skala data ordinal dan tingkat kemaknaan α ≤ 0,05. hasil tabel 1 menunjukkan bahwa hasil kepemimpinan mutu kepala ruangan yang baik ada 4 ruangan (50%) dan implementasi sistem manajemen mutu pelayanan keperawatan yang baik ada 5 ruangan (62,5%). sedangkan kepemimpinan mutu kepala ruangan yang cukup ada 4 ruangan (50%) dan implementasi sistem manajemen mutu pelayanan keperawatan yang cukup ada 3 ruangan (37,5%). hasil analisis uji regresi linear sederhana didapatkan hasil signifikan dengan ρ=0,024, maka hasil kesimpulannya ada pengaruh kepemimpinan mutu kepala ruangan terhadap implementasi sistem manajemen mutu pelayanan keperawatan di rumah sakit. tabel 1. hasil pengujian hipotesis pengaruh langsung antara kepemimpinan mutu kepala ruangan terhadap implementasi sistem manajemen mutu pelayanan keperawatan kepemimpinan mutu kepala ruangan implementasi ssm baik cukup jumlah n % n % n % baik 4 50% 0 0% 4 50% cukup 1 12,5% 3 37,5% 4 50% jumlah 5 62,5% 3 37,5% 8 100% uji regresi linear sederhana ρ=0.024 (α<0.05) implementasi sistem manajemen mutu (ana pratiwi, dkk.) 3 pembahasan berdasarkan hasil penelitian menunjukkan bahwa kepemimpian mutu kepala ruangan pada 8 ruangan rawat inap menunjukkan bahwa sama besarnya antara kepemimpinan baik dan cukup (50%). hal ini disebabkan karena dari latar belakang pendidikan kepala ruangan mempunyai latar pendidikan yang bervariasi, yakni s1 keperawatan dan diploma keperawatan. makin tinggi tingkat pendidikan seseorang, makin mudah menerima informasi sehingga makin banyak pula pengetahuan yang dimiliki. sebaliknya pendidikan yang kurang akan menghambat perkembangan sikap sesorang terhadap nilai-nilai yang baru diperkenalkan. menurut kopelman dalam (nursalam 2014), faktor penentu organisasi yakni kepemimpinan dan sistem imbalan berpengaruh pada kinerja individu atau organisasi melalui motivasi, sedang faktor penentu organisasi, yakni pendidikan berpengaruh pada kinerja individu atau organisasi melalui variabel pengetahuan, keterampilan atau kemampuan. kemampuan dibangun oleh pengetahuan dan keterampilan tenaga kerja. hal ini juga dapat dilihat dari tiga indikator kepemimpinan mutu kepala ruangan anatara lain perencanaan mutu, pengendalian mutu dan peningkatan mutu. berdasarkan hasil penelitian diperoleh rata-rata perencanaan mutu oleh kepemimpinan mutu kepala ruangan (75,2 %), untuk rata-rata pengendalian mutu oleh kepemimpinan mutu kepala ruangan (83,5 %) dan rata-rata dari peningkatan mutu oleh kepemimpinan mutu kepala ruangan (74,6 %). hal ini sesuai dengan pendapat bahwa perencanaan yang baik akan menentukan keberhasilan kegiatan dan pencapaian tujuan serta menghindari keterperangkapan dalam ketidaksiapan dari seluruh komponen kepemimpinan. fungsi perencanaan sebaiknya dilakukan oleh kepala ruangan secara optimal agar dapat memberikan arah kepada perawat pelaksana, mengurangi dampak perubahan yang terjadi, memperkecil pemborosan atau kelebihan dan menentukan standart yang akan digunakan dalam melakukan pengawasan serta pencapaian tujuan. kepemimpian dalam penegendalian berguna untuk menentukan kegiatan yang akan datang, mengumpulkan umpan balik dan hasil-hasil yang secara periodik ditindaklanjuti dalam rangka membandingkan hasil yang diperoleh dengan perencanaan yang dibuat. menurut juran dalam (wijono 1999) menyatakan mutu tidak datang demikian saja, perlu direncanakan dan dirancang, perencanaan mutu merupakan suatu bagian yang diperlukan yakni melalui perencanaan mutu, pengendalian mutu, dan peningkatan mutu. hal ini sesuai yang dikemukakan oleh (dhinamita nivalinda, m.c. inge hartini 2013) menjelaskan bahwa kepemimpinan kepala ruangan yang efektif akan mempengaruhi upaya menggerakkan perawat dalam lingkup wewenangnya untuk menerapkan budaya keselamatan pasien. perencanaan mutu, pengendalian mutu dan peningkatan mutu oleh kepemimpinan mutu kepala ruangan dibutuhkan dalam menjalankan pengorganisasian diruangan dalam meningkatkan mutu pelayanan keperawatan. disamping itu kepala ruangan diharapkan dapat bertanggung jawab dan mampu melaksanakan manajemen keperawatan sehingga dapat menghasilkan pelayanan yang berkualitas. tujuan akhirnya adalah terciptanya kepuasan pada pasien dan keluarga. berdasarkan hasil penelitian menunjukkan bahwa implementasi sistem manajemen mutu pelayanan keperawatan pada 8 ruangan rawat inap menunjukkan bahwa sebagian besar yaitu baik. hal ini disebabkan karena dalam ruangan/organisasi yang menjalankan sistem manajemen mutu bukan hanya kepala ruangan tetapi perawat pelaksana. sumber daya manusia, komitmen terhadap pekerjaan, tanggung jawab, situasi kerja, evaluasi berkesinambungan dan budaya organisasi juga akan mempengaruhi dalam implementasi sistem manajemen mutu pelayanan keperawatan dalam suatu organisasi/ruangan. komitmen terhadap mutu harus menjadi peran utama setiap pemimpin dan setiap orang dalam lembaga/organisasi untuk meningkatkan mutu karena mutu adalah urusan setiap orang, disamping komitmen kerjasama tim yang solid, kepengawasan yang ketat dan sumber daya yang memadai merupakan faktor yang menentukan keberhasilan peningkatan mutu. budaya kerja sebagai pola kebiasaan yang didasarkan cara pandang atau cara seseorang memberikan makna terhadap kerja yang mewarnai suasana hati dan keyakinan yang kuat atas nilai-nilai yang diyakininya, serta jurnal ners vol. 11 no.1 april 2016: 1-6 4 memiliki semangat bersungguh-sungguh untuk mewujudkan-nya dalam bentuk prestasi kerja. hal ini dapat di lihat dari empat indikator implementasi sistem manajemen mutu pelayanan keperawatan oleh kepala ruangan yakni perencanaan (plan), pelaksanaan (do), pemeriksaan (check), dan perbaikan (action). berdasarkan hasil penelitian diperoleh nilai rata-rata dari perencanaan (plan) oleh kepala ruangan dalam implementasi sistem manajemen mutu pelayanan keperawatan (89,2 %), untuk rata-rata yang diperoleh dari pelaksanaan (do) oleh kepala ruangan dalam implementasi sistem manajemen mutu pelayanan keperawatan (72,5 %), untuk ratarata yang diperoleh dari pemeriksaan (check) oleh kepala ruangan dalam implementasi sistem manajemen mutu pelayanan keperawatan (62,5 %), dan rata-rata dari perbaikan (action) oleh kepala ruangan dalam implementasi sistem manajemen mutu pelayanan keperawatan (62,5 %). menurut deming dalam (wijono 1999) menyatakan untuk membantu menyelenggarakan dan menegakkan organisasi mutu dalam jangka panjang dan berkelanjutan terdiri dari empat tahapan yang satu mengikuti yang lain berulang-ulang yaitu melalui perencanaan (plan), pelaksanaan (do), pemeriksaan (check) dan perbaikan (action). dalam setiap prosesnya senantiasa melakukan perencanaan yang matang, implementasi yang terukur dengan jelas, dilakukan evaluasi dan analisis data yang akurat serta tindakan perbaikan yang sesuai dan monitoring pelaksanaannya agar bisa menuntaskan masalah yang terjadi di organisasi. dalam implementasi sistem manajemen mutu akan sangat efektif apabila setiap bagian dari organisasi memahami fungsi, tanggung jawab, dan keterkaitannya dengan bagian lain dalam sistem tersebut. perencanaan, pelaksanaan, pemeriksaan dan perbaikan oleh kepala ruangan dalam sistem manajemen mutu di ruangan secara tidak langsung akan mempengaruhi baik buruknya mutu pelayanan keperawatan dalam ruangan karena itu dengan implementasi sistem manajemen mutu bertujuan untuk meningkatkan dan memberikan pelayanan yang terbaik kepada pasien dalam menjaga mutu pelayanan keperawatan. hasil penelitian menunjukkan ada pengaruh kepemimpinan mutu kepala ruangan dengan implementasi sistem manajemen mutu pelayanan keperawatan, hal tersebut berdasarkan hasil uji statistik regresi linear sederhana didapatkan hasil signifikan menunjukkan nilai p=0.024 α <0.05. adanya pengaruh juga dapat di lihat dari tiga indikator kepemimpinan mutu yang digunakan yaitu perencanaan mutu, pengendalian mutu dan peningkatan mutu, sedangkan implementasi sistem manajemen mutu dapat dilihat dari empat indikator yang digunakan yaitu perencanaan (plan), pelaksanaan (do), pemeriksaan (check) dan perbaikan (action). dalam perencanaan mutu kepala ruangan kurang melaksanakan identifikasi kepuasan pasien dalam pelayanan keperawatan, dalam pengendalian mutu kepala ruangan kurang bertindak terhadap penyimpangan mutu dengan pengawasan terus-menerus, dalam peningkatan mutu kepala ruangan tidak mengirimkan seminar/pelatihan untuk perawat pelaksana. sedangkan dalam implementasi sistem manajemen mutu dalam perencanaan (plan) ruangan belum memiliki rencana strategis dalam pelayanan, dalam pelaksanaan (do) ruangan tidak memberikan fasilitas untuk seminar/pelatihan pada perawat dan kurang melakukan survey kebutuhan pasien, dalam pemeriksaan (check) ruangan belum melakukan pemeriksaan terhadap program yang telah dilaksanakan dan ruangan kurang melakukan monitoring hasil kinerja perawat dalam memberikan pelayanan keperawatan, dalam perbaikan ruangan kurang menindaklanjuti hasil dari audit. hal ini dikarenakan dalam kepemimpinan mutu kepala ruangan dapat mempengaruhi sistem manajemen mutu pelayanan keperawatan dalam ruangan yang dipimpin oleh kepala ruangan, tetapi dalam implementasi sistem manajemen mutu juga dapat dipengaruhi oleh faktor lain dari ruangan bukan hanya dipengaruhi oleh kepemimpinan kepala ruangan, faktor tersebut yakni kesadaran mutu setiap perawat pelaksanan, sumber daya manusia, komitmen perawat dalam menjalankan pekerjaannya, tanggung jawab dalam tugas keperawatan. hal ini sesuai yang dikemukakan oleh (daisy debora grace pangemanan & tarore 2013) menyatakan bahwa faktor yang dapat mempengaruhi efektivitas penerapan sistem manajemen mutu yaitu kepemimpinan mutu, kesadaran mutu, sumber daya manusia, komitmen manajemen, tanggung jawab manajemen, iklim kerja, implementasi sistem manajemen mutu (ana pratiwi, dkk.) 5 eveluasi berkesinambungan, dan budaya organisasi. komitmen terhadap mutu harus menjadi peran utama setiap pemimpin dan setiap orang dalam lembaga/organisasi untuk meningkatkan mutu karena mutu adalah urusan setiap orang, disamping komitmen kerjasama tim yang solid, kepengawasan yang ketat dan sumber daya yang memadai merupakan faktor yang menentukan keberhasilan peningkatan mutu. menurut juran dalam (wijono 1999) menyatakan mutu tidak datang demikian saja, perlu direncanakan dan dirancang, perencanaan mutu merupakan suatu bagian yang diperlukan yakni melalui perencanaan mutu, pengendalian mutu, dan peningkatan mutu. menurut deming dalam (wijono 1999), untuk membantu menyelenggarakan dan menegakkan organisasi mutu dalam jangka panjang dan berkelanjutan terdiri dari empat tahapan yang satu mengikuti yang lain berulang-ulang yaitu melalui perencanaan (plan), pelaksanaan (do), pemeriksaan (check) dan perbaikan (action). menurut teori kontemporer bahwa teori ini menekankan pada empat komponen penting dalam suatu pengelolaan, yaitu manajer/pemimpin, staf dan atasan, pekerjaan, serta lingkungan. dalam melaksanakan suatu manajemen seorang pemimpin harus mengintegrasikan keempat unsur tersebut untuk mencapai tujuan organisasi. staf atau pegawai adalah manusia sebagai suatu sistem terbuka yang selalu berinteraksi dengan sekitarnya dan berkembang secara dinamis, asumsi terori ini sebagai berikut: (1) manusia memiliki karakteristik yang sangat komplek, mereka mempunyai motivasi yang bervariasi dalam melakukan suatu pekerjaan; (2) motivasi seseorang tidak tetap, tetapi berkembang sesuai perubahan waktu; (3) tujuan bisa berbeda pada situasi yang berbeda pula; (4) produktivitas dipengaruhi oleh tugas yang harus diselesaikan, kempuan seseorang, pengalaman dan kesadaran. proses implementasi sistem manajemen mutu akan efektif bila perencanaan, pelaksanaan, pemeriksaan dan perbaikan dijalankan oleh kepala ruangan dengan baik dan akan lebih baik lagi apabila kepala ruangan denagn kepemimpianannya yang efektif dapat mengontrol dan mengawasi perawat dalam melaksanakan tindakan keperawatan. menurut teori kontingensi dan situasional menekankan bahwa pemimpin yang efektif adalah pemimpin yang melaksanakan tugasnya dengan mengombinasikan antara faktor bawaan, perilaku dan situasi. pemimpin yang efektif memerlukan kemampuan untuk menggunakan proses penyelesaian masalah, mempertahankan kelompok secara efektif, mempunyai kemempuan komunikasi yang baik dengan bawahannya, menunjukkan kejujuran dalam memimpin, kompeten, kreatif dan mampu mengembangkan kelompok. implementasi sistem manajemen mutu pelayanana keperawatan dapat terlakasanan dengan kerjasama antara kepemimpinan mutu kepala ruangan dengan perawat pelaksana yang memberikan pelayanan sesuai standar yang sudah ditetapkan dalam setiap ruangan dan berpedoman pada peningkatan mutu. sehingga akan menghasilkan output yaitu mutu pelayanan keperawatan yang berkualitas yakni kepuasan pada pasien, kenyamanan, keselamatan, tidak terjadinya kecemasan pada pasien, terpenuhinya kebutuhan kebersihan dan perawatan diri, meningkatnya penegetahuan pasien. simpulan dan saran simpulan kepemimpinan mutu kepala ruangan di rs siti khotijah adalah sebagian besar baik (50%) dan implementasi sistem manajemen mutu pelayanan keperawatan juga sebagian besar baik (62,5%). hasil analisa dengan uji regresi linear sederhana pada pengaruh kepemimpinan mutu kepala ruangan terhadap implementasi sistem manajemen mutu pelayanan keperawatan di rumah sakit siti khodijah sepanjang di dapatkan hasil dengan ρ= 0,024 < α = 0,05, sehingga dapat disimpulkan bahwa implementasi sistem manajemen mutu dapat di pengaruhi oleh kepemimpinan mutu kepala ruangan. saran saran yang dapat diberikan adalah untuk meningkatkan mutu pelayanan hendaknya rumah sakit lebih menerapkan sistem manajemen mutu dalam pelayanan keperawatan dan untuk mengimplementasikan sistem mnajemen mutu maka dibutuhkan peran kepemimpinan mutu oleh kepala ruangan. kepustakaan amaliyah, m., 2014. hubungan gaya jurnal ners vol. 11 no.1 april 2016: 1-6 6 kepemimpinan kepala ruangan dan kinerja perawat dengan mutu pelayanan keperawatan di rumah sakit siti khodijah sepanjang. azwar, a., 1996. menjaga mutu pelayanan kesehatan : aplikasi prinsip lingkaran pemecahan masalah, jakarta: pustaka sinar harapan. daisy debora grace pangemanan & tarore, h., 2013. faktor-faktor yang mempengaruhi efektivitas penerapan sistem manajemen mutu iso 9001 : 2008 pada perusahaan kontraktor di kota manado. jurnal ilmiah media engineering, 3(1), pp.49–53. available at: http://ejournal.unsrat.ac.id/index.php/jim e/article/view/4260/3789. dhinamita nivalinda, m.c. inge hartini, a.s., 2013. pengaruh motivasi perawat dan gaya kepemimpinan kepala ruang terhadap penerapan budaya keselamatan pasien oleh perawat pelaksana pada rumah sakit pemerintah di semarang. jurnal manajemen keperawatan, 1(2), pp.138–145. available at: http://jurnal.unimus.ac.id/index.php/jmk / article/view/1010. nursalam, 2014. managemen keperawatan : aplikasi dalam praktik keperawatan profesional, jakarta: salemba medika. parahita, i.k., 2010. analisis kinerja kepala ruang setelah mendapat pelatihan manajemen keperawatan menurut persepsi staf keperawatan di rumah sakit pku muhammadiyah surakarta. unversitas muhammadiyah surakarta. available at: http://eprints.ums.ac.id/9493/1/j2100601 00.pdf. semuel, h. & zulkarnain, j., 2011. pengaruh sistem manajemen mutu iso terhadap kinerja karyawan melalui budaya kualitas perusahaan (studi kasus pt. otsuka indonesia malang). jurnal manajemen dan kewirausahaan, 13(2), pp.162–176. available at: http://jurnalmanajemen.petra.ac.id/index. php/man/article/view/18332/18177. wijono, d., 1999. manajemen mutu pelayanan kesehatan., surabaya: airlangga university press. ners vol 10 no 2 okt 2015.indd 332 budaya organisasi dan quality of nursing work life terhadap kinerja dan kepuasan kerja perawat di rsud dr. soetomo surabaya (cultural organization and quality of nursing work life on nurses performance and job satisfaction in dr. soetomo hospital, surabaya) rini winasih*, nursalam**, ninuk dian k** *rs dr. soetomo, jl. prof. dr. moestopo **fakultas keperawatan universitas airlangga kampus c jl. mulyorejo email: rini_winasih@yahoo.co.id abstrak pendahuluan: upaya untuk meningkatkan kualitas pelayanan rumah sakit seharusnya sejalan dengan upaya untuk meningkatkan kualitas pelayanan keperawatan. kualitas pelayanan dipengaruhi oleh budaya organisasi. tujuan utama dari penelitian ini adalah untuk menjelaskan pengaruh budaya organisasi dan quality of nurses work life (qnwl) terhadap kinerja dan kepuasan kerja perawat di rs dr. soetomo surabaya. metode: penelitian ini menggunakan desain eksplanatori dengan pendekatan cross sectional. populasi adalah seluruh perawat pegawai negeri sipil di ruang bedah rs. dr. soetomo surabaya. sampel sebanyak 95 perawat didapatkan dengan cluster sampling. data dianalisis menggunakan partial least square. hasil: budaya organisasi dipengaruhi oleh faktor objektif. faktor individu tidak mempengaruhi qnwl. faktor yang mempengaruhi qnwl adalah faktor sosial dan lingkungan, faktor operasional, faktor administrasi, dan budaya kerja. qnwl mempengaruhi kinerja dan kepuasan kerja perawat. kepuasan kerja mempengaruhi kinerja perawat. diskusi: budaya organisasi yang kuat, yang dapat menciptakan qnwl yang baik, dapat meningkatkan kinerja dan kepuasan kerja perawat, serta keterlibatan kerja dalam qnwl. kata kunci: budaya organisasi, quality of nursing work life, kinerja dan kepuasan kerja, perawat. abstract introduction: efforts to improve the quality of hospital services should be along with the efforts to improve the quality of nursing services. quality of service is influenced by the organizational culture. the main objective of this study was to explain the effect of organizational culture and quality of nurses work life (qnwl) on nurses performance and job satisfaction in dr. soetomo hospital, surabaya. methods: this study used explanatory survey research design with cross sectional approach. the study population was all civil servants nurses working at surgical wards, dr. soetomo hospital. the study sample comprised 95 nurses selected with cluster sampling. data were analyzed using partial least square. results: the results showed that there was influence of objective factors on organizational culture. individual factors had no influence on qnwl. social and environmental factors affected qnwl. operational factors influenced qnwl. administrative factors affected qnwl. organizational culture influenced qnwl. qnwl affected nurses performance. qnwl significantly affected nurses job satisfaction. nurses job satisfaction affected nurses performance. discussions: strong organizational culture, which can create good quality of work life for nurses, can improve the performance and job satisfaction of nurses in dr. soetomo hospital. further studies needs to be done to analyze the effect of empowerment and job involvement on the quality of nurses work life. keywords: cultural organization, quality of nursing work life, performance and job satisfaction, nurse pendahuluan rumah sakit merupakan salah satu organisasi pelayanan di bidang kesehatan yang memiliki budaya organisasi yang tercermin dalam visi, misi serta tujuan yang ingin dicapai. kualitas pelayanan sangat ditunjang oleh perilaku atau kinerja pemberi pelayanan, salah satunya adalah perawat. perawat merupakan tenaga kesehatan terbanyak di rumah sakit dan memegang peranan penting dalam memberikan pelayanan kesehatan. pelayanan keperawatan sebagai bagian integral dari pelayanan kesehatan mempunyai kontribusi yang sangat besar dalam menentukan kualitas pelayanan di rumah sakit. sehingga setiap upaya untuk meningkatkan kualitas pelayanan rumah sakit harus juga disertai upaya untuk meningkatkan kualitas pelayanan keperawatan. mutu kualitas pelayanan dipengaruhi faktor budaya organisasi. penilaian kualitas pelayanan di salah satu instalasi rawat inap (irna) rsud dr. soetomo surabaya yaitu irna bedah 333 budaya organisasi dan quality of nursing work life (rini winarsih, dkk.) oleh badan penelitian dan pengembangan rsud dr. soetomo surabaya pada tahun 2014 didapatkan tingkat kepuasan pelanggan menurut kepmenpan ada pada level “b” atau baik dengan indeks 79,83, sedangkan menurut pengukuran gap analisis, pelanggan merasa “puas” dengan cs index 90,60. tingginya kepuasan pelanggan ini sangat kontras dengan indeks kepuasan karyawan yang masih pada rentang cukup dengan nilai 62,82. hasil penelitian oleh badan penelitian dan pengembangan rsud dr. soetomo surabaya tahun 2014 di instalasi rawat inap bedah didapatkan data indeks kepuasan karyawan (ikk) seperti tabel di bawah ini. kinerja dan kepuasan kerja karyawan dipengaruhi oleh budaya tempat karyawan tersebut bekerja. budaya mempunyai peranan penting bagi kehidupan suatu organisasi. budaya yang positif menciptakan tumbuhnya komitmen karyawan untuk mencapai tujuan organisasi, demikian sebaliknya. karyawan akan malas bekerja karena tidak ada nilai-nilai positif yang dapat mendorong agar bekerja lebih baik lagi. berdasarkan hal tersebut, maka organisasi hendaknya berusaha menciptakan lingkungan internal yang lebih nyaman, baik fisik maupun psikis. tabel 1. data indeks kepuasan karyawan instalasi rawat inap bedah rsud dr.soetomo surabaya, tahun 2014 no unsur kepuasan nilai ikk mutu 1. kompetensi karyawan 66, 44 c 2. lingkungan kerja 63,28 c 3. remunerasi 49,54 d 4. hubungan antar kerja 74,77 b 5. beban kerja 58,96 c 6. karir 61,46 c 7. komunikasi 65,17 c 8. penilaian kinerja berdasarkan skp 62,47 c 9. manajerial 56,06 c 10. kepemimpinan 69,58 b nilai ikk (indeks kepuasan karyawan) 62,82 mutu kepuasan cukup kepuasan karyawan cukup kepedulian rumah sakit khususnya pemimpin organisasi untuk menciptakan lingkungan kerja yang dapat mendukung tujuan tersebut melalui kinerja sumber daya yang dimiliki. organisasi harus memiliki strategi dan inisiatif yang dapat meningkatkan ke pu a sa n ke r ja k a r yawa n nya melalu i peningkatan kualitas kehidupan kerjanya, khususnya perawat. penelitian ini mengidentifikasi dan menganalisis faktor objektif dari dimensi budaya organisasi terhadap budaya organisasi yang ada di rsud dr. soetomo surabaya, di samping ingin menganalisis faktor internal qnwl yang dapat mempengaruhi kualitas kehidupan kerja perawat di rsud dr. soetomo surabaya, serta menganalisis hubungan budaya organisasi dengan kualitas kehidupan kerja perawat yang dapat berpengaruh terhadap kinerja dan kepuasan kerja perawat. hasil dari penelitian ini dapat menjadi tolak ukur untuk menciptakan dan meningkatkan kualitas kehidupan kerja perawat yang seharusnya, dan semakin meningkatkan kinerja dan kepuasan kerja perawat dalam meningkatkan kualitas layanan kepada pasien di rsud dr. soetomo surabaya. 334 jurnal ners vol. 10 no. 2 oktober 2015: 332–342 bahan dan metode penelitian ini menggunakan desain p e nel it ia n s u r vei ek s pla n at i f de ng a n pendekatan cross sectional. populasi penelitian ini adalah semua perawat pegawai negeri sipil yang berdinas di instalasi rawat inap bedah rsud dr. soetomo surabaya. sampel penelitian ini sebanyak 95 perawat yang dipilih dengan cluster sampling sesuai dengan kriteria inklusi. data diperoleh melalui k uesioner dan analisis data menggunakan partial least square. variabel independen dalam penelitian ini adalah faktor objektif (inovasi dan pengambilan risiko, perhatian pada hal rinci, orientasi hasil, orientasi sdm, orientasi tim, keagresifan dan stabilitas), faktor individu (usia, jenis kelamin, status perkawinan, pendidikan, pangkat, dan masa ker ja), faktor sosial dan lingkungan (komunikasi, kepemimpinan, hubungan antar perawat, hubungan antar departemen, dan hubungan antar profesi), faktor operasional ( jumlah perawat, jadwal dinas, dan pengawasan supervisor), faktor administrasi (kebijakan organisasi, keselamatan dan kesehatan, pengembangan karir, gaji dan remunerasi). variabel intervening adalah budaya organisasi dan kualitas kehidupan kerja perawat. variabel dependen dalam penelitian ini adalah kinerja perawat dan kepuasan kerja perawat. lokasi penelitian di irna bedah rsud dr. soetomo surabaya. waktu penelitian bulan april-mei 2015. gambar 2. hasil akhir uji hipotesis analisis pengaruh budaya organisasi dan kualitas kehidupan kerja perawat terhadap kinerja perawat dan kepuasan kerja perawat di rsud dr. soetomo surabaya. gambar 1. hasil awal uji hipotesis analisis pengaruh budaya organisasi dan kualitas kehidupan kerja perawat terhadap kinerja perawat dan kepuasan kerja perawat di rsud dr. soetomo surabaya. 335 budaya organisasi dan quality of nursing work life (rini winarsih, dkk.) hasil berdasarkan gambar 2 didapatkan hasil akhir uji hipotesis dapat diuraikan sebagai berikut: (1) faktor obyektif: inovasi dan pengambilan risiko, perhatian pada hal rinci, orientasi hasil, orientasi sdm, orientasi tim, keagresifan dan stabilitas mempengaruhi budaya organisasi di rsud dr. soetomo surabaya. (2) faktor sosial dan lingkungan: komunikasi, kepemimpinan, hubungan antar perawat, hubungan antar departemen, dan hubungan antar profesi berpengaruh terhadap kualitas kehidupan kerja perawat di rsud dr. soetomo surabaya. (3) faktor operasional: jumlah perawat, jadwal dinas, dan pengawasan supervisor mempengaruhi kualitas kehidupan kerja perawat di rsud dr. soetomo surabaya. (4) faktor administrasi: kebijakan organisasi, keselamatan dan kesehatan, pengembangan karir, gaji dan remunerasi mempengaruhi kualitas kehidupan kerja perawat di rsud dr. soetomo surabaya. (5) budaya organisasi berpengaruh terhadap kualitas kehidupan kerja perawat di rsud dr. soetomo surabaya. (6) ku alit as keh idupa n ker ja perawat mempengaruhi kinerja perawat di rsud dr. soetomo surabaya. (7) kualitas kehidupan kerja perawat berpengaruh terhadap kepuasan kerja perawat di rsud dr. soetomo surabaya. (8) kepuasan kerja perawat mempengaruhi kinerja perawat di rsud dr. soetomo surabaya. pembahasan budaya organisasi merupakan hal yang kompleks. karakteristik budaya organisasi menur ut robbins (2005) terdiri dari: (1) inovasi dan pengambilan risiko, kondisi di mana karyawan didorong untuk melakukan inovasi dan pengambilan risiko pekerjaannya, (2) perhatian pada hal rinci di mana karyawan diharapkan dapat melakukan prediksi dan dapat melakukan analisis serta perhatian pada hal rinci, (3) orientasi hasil di mana pimpinan lebih berorientasi pada hasil kerja daripada proses kerja, (4) orientasi sumber daya manusia yaitu keputusan manajemen mempertimbangkan pengaruhnya pada karyawan, (5) orientasi tim yaitu pekerjaan perawat lebih berorientasi tim daripada orientasi individu, (6) keagresifan yaitu karyawan agresif dan lebih berorientasi kompetitif daripada orientasi kooperatif, (7) stabilitas di mana keputusan dan tindakan organisasi lebih menekankan pemeliharaan atau berada pada status quo. faktor individu terdiri dari usia, jenis kelamin, status perkawinan, pendidikan, pangkat/jabatan keperawatan, dan masa kerja tidak memiliki pengaruh yang signifikan terhadap kualitas kehidupan kerja perawat di rsud dr. soetomo surabaya. perawat di rsud dr. soetomo surabaya sebagian besar berusia diatas 50 tahun. hal tersebut bisa berdampak positif dalam pekerjaan k hu s u s nya lebi h b e r p e ng a l a m a n d a n pertimbangan, memiliki etika yang kuat, dan berkomitmen terhadap mutu. sisi negatifnya dianggap kurang luwes dan menolak teknologi baru, serta kurang dapat menyesuaikan diri dan terbuka terhadap perubahan. menurut grossmann (1999) pendidikan merupakan salah satu kebutuhan dasar manusia yang diperlukan untuk pengembangan diri. semakin tinggi tingkat pendidikan, semakin mudah menerima dan mengembangkan pengetahuan dan teknologi sehingga dapat meningkatkan produktivitas. faktor sosial dan lingkungan yang terdiri dari komunikasi, kepemimpinan, hubungan antar perawat, hubungan antar departemen, dan hubungan antar profesi berpengaruh terhadap kualitas kehidupan kerja perawat. faktor sosial dan lingkungan di rsud dr. soetomo surabaya pada kategori sedang dan pada indikator hubungan antar perawat pada kategori baik. komunikasi di lingkungan irna bedah rsud dr. soetomo surabaya dinilai sebagian perawat pada kategori cukup. komunikasi yang efektif merupakan elemen penting untuk keberhasilan suatu organisasi. komunikasi dengan teman sejawat dan tenaga kesehatan lainnya dilakukan baik lisan maupun tertulis dengan memenuhi unsur lengkap, adekuat, dan cepat dengan didukung suatu fakta yang memadai. prinsip komunikasi seorang perawat profesional adalah complete, acurate, rapid, dan english (nursalam, 2015). jaringan komunikasi baik formal dan informal perlu 336 jurnal ners vol. 10 no. 2 oktober 2015: 332–342 dibangun antara manajer dan staf. arah komunikasi antara manajemen dan perawat di rsud dr. soetomo surabaya kecenderungan komunikasi ke bawah (top down). sedangkan komunikasi antar perawat lebih banyak pada saat serah terima tugas (overan/timbang terima), di mana diperlukan komunikasi yang jelas tentang kebutuhan pasien, intervensi yang sudah dan yang belum dilaksanakan. kepemimpinan di unit keperawatan di i nst alasi rawat i nap bedah rsu d dr. soetomo dinilai sebagian besar perawat pa d a kategor i sed a ng. ke pem i mpi na n yang dapat menjalankan lima fungsi pokok kepemimpinan akan dapat menciptakan kualitas kerja yang baik. seorang pemimpin har us menjalan kan lima f u ngsi pokok kepemimpinan yaitu fungsi instruksi, fungsi konsultasi, fungsi partisipasi, fungsi delegasi, dan fungsi pengendalian (rivai, 2006). hubungan antar perawat di rsud dr. soetomo tidak terlepas dari tiga pilar yang berperan dalam menciptakan lingkungan kerja perawat yang kondusif antara lain organisasi profesi yait u ppn i kom isa r iat rsu d dr. soetomo, bidang keperawatan, serta komite keperawatan. hubu ngan ant a r depa r temen d an hubungan antar profesi di rsud dr. soetomo pada kategori sedang. kualitas kehidupan kerja perawat mempengaruhi hubungan perawat dengan semua elemen pendukung di rumah sakit secara menyeluruh, hubungan dengan profesi lain termasuk dari organisasi adanya pemahaman keinginan dan kebutuhan perawat akan keamanan lingkungan dan keselamatan kerja ser ta suasana kerja yang nyaman, sehingga perawat termotivasi. hubungan antar departemen di rsud dr. soetomo sebatas koordinasi antar unit ruangan melalui instalasi rawat inap dengan depar temen lainnya. hubungan antar profesi terutama dengan profesi dokter lebih banyak mengarah pada delegasi dan pemberian advis terapi bagi pasien. arah komunikasinya cenderung komunikasi ke bawah (top down). peran kolaborasi antara perawat dengan dokter masih dipertanyakan karena kewenangan perawat yang masih kurang. jumlah, jenis dan kualifikasi tenaga perawat di rsud dr. soetomo surabaya belum terdistribusi dengan baik, sehingga beban kerja di tiap unit instalasi rawat inap bedah tidak merata. beberapa hal yang perlu dipertimbangkan dalam menentukan beban kerja perawat menurut nursalam (2014), yaitu jumlah pasien yang dirawat setiap hari/bulan/ tahun di unit tersebut, tingkat ketergantungan pasien, rata-rata hari perawatan, pengukuran perawatan langsung, perawatan tidak langsung dan pendidikan kesehatan, frekuensi tindakan perawatan yang dibutuhkan pasien, ratarata waktu perawatan langsung, perawatan tidak langsung dan pendidikan kesehatan. ketidaksesuaian antara rasio perawat dengan pasien maupun komposisi perawat dalam setiap jaga akan memberikan kualitas dari pelayanan yang diberikan. jadwal dinas perawat dalam teori manajemen keperawatan merupakan kegiatan pengaturan staf. menurut swansburg (2000) metodologi pengaturan staf keperawatan har us mer upakan proses yang terat u r, sistematis, berdasarkan rasional, diterapkan untuk menentukan jumlah dan jenis personel tenaga keperawatan yang dibutuhkan untuk memberikan asuhan keperawatan pada standar yang ditetapkan sebelumnya pada kelompok pasien dalam situasi tertentu. supervisi atau pengawasan dilakukan untuk menjaga mutu pelayanan keperawatan sesuai standar yang berlaku dan sesuai harapan konsumen. super visi di rsud dr. soetomo belum berjalan sesuai program. supervisi sudah berjalan tapi hanya dilakukan secara informal, dan belum terdokumentasi dengan baik. pelaksanaan supervisi tanpa ada standar operasional prosedur yang baku menyebabkan pengawasan menjadi beban sehingga ada ketidaknyamanan dalam bekerja ketika dilakukan hal tersebut dilakukan oleh atasan. kunci keberhasilan supervisi yaitu fair, feedback, dan follow up. supervisi sebaiknya dilakukan secara terorganisir dan rutin dalam kurun waktu tertentu, melalui petunjuk, peraturan, uraian tugas dan standar. supervisi harus terdokumentasi dengan baik dan benar sehingga penilaian perkembangan 337 budaya organisasi dan quality of nursing work life (rini winarsih, dkk.) kualitas perawat dapat ter pantau dengan baik. kebijakan dasar rsud dr. soetomo surabaya, meliputi perbaikan mutu pelayanan, perbaikan manajemen (sdm) internal rumah sakit, penataan kelembagaan (struktur dan sistem), pemantapan nilai dasar menjadi budaya organisasi, penataan sistem akuntansi keuangan, pengendalian biaya dan struktur anggaran, perbaikan manajemen logistik medik dan non medik, penataan manajemen pendidikan klinik dan penelitian rumah sakit, pengembangan aliansi strategis. kesehatan dan keselamatan ker ja di r umah sakit diperlukan dalam upaya melindungi kemungkinan dampak negatif yang ditimbulkan oleh proses pelayanan kesehatan, maupun keberadaan sarana dan prasarana, obat-obatan dan logistik lainnya yang ada di rs sehingga tidak menimbulkan kecelakaan kerja dan kedaruratan termasuk kebakaran dan bencana yang berdampak pada pekerja rs, pasien, pengunjung dan masyarakat sekitarnya. penjenjangan karir perawat mempunyai m a k n a t i n g k a t a n ko m p e t e n s i u n t u k melaksanakan asuhan keperawatan yang akuntabel dan etis sesuai batas kewenangan. program jenjang karir bagi perawat di rsud dr. soetomo surabaya sudah ada, tetapi pelaksanaan nya belu m sesuai harapan. hal tersebut karena program yang dibuat tanpa diimbangi pelaksanaan yang sesuai, akibatnya jenjang karir masih belum dirasakan manfaatnya oleh perawat. tidak ada perbedaan kompetensi dalam member ikan asu han keperawatan kepada pasien sesuai jenjang pendidikan ataupun perawat klinis. hal tersebut menjadi salah satu kurangnya motivasi perawat untuk melanjutkan pendidikan ke jenjang yang lebih tinggi, sehingga apabila dilakukan penilaian sebagian besar perawat di irna bedah belum pada jenjang pendidikan profesional yaitu minimal sarjana dan profesi ners. pendidikan berkelanjutan diharapkan dapat mengubah pola pikir dalam memberikan keperawatan kepada pasien. r e m u n e r a s i d i r a s a k a n p e r a w a t masih belum sesuai dengan harapan karena masih belum sesuai dengan beban kerja dan kinerja perawat. keterlibatan perawat dalam pengambilan keputusan khususnya mengenai remunerasi masih kurang, karena peran perawat dalam tim remunerasi rumah sakit masih minim. ruangan yang merawat pasien dengan bor lebih dari 90% dengan ketergantungan pasien yang tinggi tidak serta merta mendapat remunerasi yang lebih besar demikian sebaliknya. pembenahan terhadap poin dalam remunerasi yang mengakomodir masa kerja, pendidikan, jadwal dinas dan beban kerja, serta kontribusi perawat dalam pengambilan keputusan sangatlah diperlukan dan diupayakan agar kepuasan kerja perawat meningkat. budaya organisasi berpengaruh positif terhadap kualitas kehidupan kerja perawat di rsud dr. soetomo surabaya. diagnosis budaya organisasi dilakukan berdasarkan tabulasi dari skor organization culture assessment instrument (ocai). analisis budaya organisasi berdasarkan kerangka persaingan nilai (competing value framework) di mana budaya terbagi menjadi 4 kuadran tipe budaya yang dominan yaitu budaya klan (clan culture), budaya pasar (market culture), budaya hierarki (hierarchy culture) dan budaya adhokrasi (adhocracy culture). hasil kuesioner ocai tipe budaya organisasi saat ini di instalasi rawat inap bedah rsud dr. soetomo ada 3 tipe budaya, yaitu clan, hierarchy, dan didominasi budaya adhocracy. budaya adhocracy bercirikan tempat kerja yang dinamis, kewiraswastaan dan kreatif. orang-orang didalamnya berani bertanggung jawab dan mengambil risiko. perekat organisasi adalah komitmen bersama untuk selalu mencoba hal baru/inovasi dan berek sper i men. o rga n isasi mendorong individu dalam organisasi untuk mengambil inisiatif. ruangan bedah a menganut tipe budaya hierarki, di mana budaya ini bercirikan pada tempat kerja yang formal dan terstruktur. standar prosedur menentukan apa yang dikerjakan. pimpinan organisasi bangga sebagai koordinator dan ahli organisasi yang mementingkan efektivitas. menjaga organisasi yang lancar kerjanya adalah prioritas utama. 338 jurnal ners vol. 10 no. 2 oktober 2015: 332–342 aturan formal, disiplin, efisiensi dan kebijakan formal dibutuhkan untuk menjaga kesatuan organisasi. tipe budaya organisasi yang diharapkan dalam lima tahun mendatang di irna bedah rsud dr. soetomo yaitu didominasi budaya organisasi clan dan satu unit mengharapkan budaya market. budaya market merupakan tipe budaya yang diinginkan di ruangan bedah b. tipe budaya ini bercirikan budaya pasar yang tidak ramah, kompetitif serta perilaku konsumen yang cender ung memilih dan tertarik pada nilai-nilai sehingga menempatkan organisasi pada bisnis yang selalu berusaha meningkatkan persaingan. tugas utama manajemen adalah mengendalikan organisasi untuk mencapai produktivitas, hasil, tujuan, se r t a keu nt u nga n. ru a nga n bed a h b merupakan tempat rawat inap dengan pasien klas 3, hal ini perlu ditelaah lebih lanjut apakah budaya harapan ini dapat menjadikan kinerja dan kepuasan kerja perawat lebih meningkat dibandingkan budaya adhocracy yaitu budaya saat ini apabila diterapkan. budaya organisasi saat ini di ruangan bedah d adalah clan yaitu budaya yang memiliki karakter kekeluargaan, di mana terdapat lingkungan yang mengatur dengan baik melalui teamwork, pengembangan sdm, serta memperlakukan konsumen sebagai rekanan. tugas utama dar i manajemen a d a la h me nge nd a l i k a n d a n me mbi n a karyawan sehingga memudahkan mereka unt uk ber par tisipasi. kondisi demikian menunjukkan pada unit pelayanan keperawatan mengharapkan budaya organisasi yang sama dan dapat dipakai sebagai pedoman dalam berperilaku. hasil skor budaya saat ini dengan skor budaya yang diharapkan dapat dilakukan pembandingan. hasil skor budaya organisasi saat ini dan harapan memiliki kesenjangan. pada tipe budaya organisasi clan dan market memiliki kesenjangan positif, ini berarti responden mengharapkan tipe budaya tersebut ditingkatkan. sedangkan pada tipe budaya adhocracy dan hierarchy memiliki kesenjangan negatif, yang berarti responden mengharapkan tipe budaya tersebut berkurang. pe n g u k u r a n b u d a y a o r g a n i s a s i memberikan manfaat utama antara lain anggota organisasi menjadi sadar akan budaya organisasi saat ini dan budaya organisasi yang diinginkan sehingga dapat menjadi momentum unt uk melak ukan per ubahan, resistensi terhadap per ubahan dapat diantisipasi, menjadi dasar untuk rencana perubahan yang sistematis dan bertahap. penilaian ocai akan menjadi langkah intervensi awal untuk memungkinkan perubahan. mendiskusikan h a si l o ca i , m el a k u k a n d i a log d a n peningkatan kesadaran adalah hal yang sangat penting. ini akan mengawali proses mental yang dibutuhkan untuk membawa perubahan yang berkesinambungan. keinginan baik akan diwujudkan menjadi perilaku dan perubahan yang nyata. bud aya organ isasi ad alah sistem makna, nilai-nilai dan kepercayaan yang dianut bersama dalam suat u organisasi yang menjadi r uju kan unt u k ber tindak dan membedakan organisasi satu dengan organisasi lain (robbins, 2005). budaya organisasi selanjutnya menjadi identitas atau karakter utama organisasi yang dipelihara dan dipertahankan. budaya organisasi yang baik dan kuat dapat menciptakan kualitas kehidupan kerja yang baik bagi perawat. rsud dr. soetomo di surabaya dengan klasif ikasi a, rumah sakit pendidikan (teaching hospital), rumah sakit pusat rujukan wilayah indonesia bagian timur (top referal), serta rumah sakit terbesar di wilayah indonesia bagian timur berdiri sejak tahun 1938 sehingga memiliki budaya organisasi yang sudah berakar kuat. menurut robbins (2005) budaya asli diturunkan dari falsafah pendirinya, selanjutnya budaya ini akan sangat mempengaruhi kriteria yang digunakan dalam mempekerjakan karyawan. budaya organisasi tidak terbentuk dengan sendirinya, melainkan dipengaruhi beberapa faktor. faktor yang membent uk budaya organisasi menurut george (2005) adalah karakteristik dari orang-orang di dalam organisasi, etika organisasi, hubungan antar karyawan, dan desain dari budaya organisasi. karakteristik dari orang-orang di dalam 339 budaya organisasi dan quality of nursing work life (rini winarsih, dkk.) organisasi, implikasi penting dari hal ini adalah anggota organisasi mempunyai kemiripan. hubungan antar karyawan dibentuk melalui kebijakan sdm dan praktik nya, seper ti perekrutan, promosi, gaji. ditinjau dari desain, nilai budaya memperkuat proses integrasi dan koordinasi. hasil penelitian untuk mengetahui tipe budaya organisasi yang diharapkan dalam lima tahun mendatang di rsud dr. soetomo didominasi budaya organisasi clan. hal ini sejalan dengan penelitian goodman (2001) bahwa budaya organisasi (nilai budaya kelompok) ber pengar uh positif terhadap kualitas kehidupan kerja yang terdiri dari komitmen organisasi, keterlibatan kerja, pemberdayaan dan kepuasan kerja. budaya yang menekankan nilai budaya kelompok cenderung memiliki kualitas kehidupan kerja yang besar, tapi bukan berarti budaya yang ideal adalah yang menekankan pada nilai kelompok karena penekanan yang terlalu berlebihan pada budaya bisa menyebabkan difungsional organisasi. oleh karena itu competing values framework menekankan pentingnya bagi organisasi untuk menyatukan elemen dari 4 tipe budaya tersebut. penelitian oleh gifford (2002) menunjukkan budaya organisasi memiliki pengaruh terhadap kualitas kehidupan kerja perawat. budaya organisasi dan kualitas kehidupan kerja perawat dapat meningkatkan efektivitas organisasi (an, jiyoung, et al., 2011). keberhasilan suatu organisasi sangat erat kaitan nya dengan k ualitas kiner ja anggotanya. kinerja adalah hasil kerja yang dapat ditampilkan karyawan. kinerja dapat diukur dari hasil kerja, hasil tugas, atau hasil kegiatan dalam kurun waktu tertentu ( notoat modjo, 2009). k iner ja pegawai yang tinggi akan mendukung produktivitas organisasi, sehingga sudah sehar usnya pimpinan organisasi senantiasa memperhatikan pen i ng kat a n k i ner ja a nggot a nya dem i kemajuan organisasi. peningkatan kinerja anggotanya juga erat kaitannya dengan cara bagaimana organisasi mengembangkan budaya organisasi yang ada. budaya organisasi dapat meningkatkan kinerja anggotanya karena menciptakan motivasi yang besar untuk memberikan kemampuan terbaiknya. nilai-nilai yang dianut membuat anggotanya merasa nyaman bekerja, memiliki komitmen dan kesetiaan ser ta ber usaha lebih keras dan mampu meningkatkan kinerja dan kepuasan kerja anggotanya. semakin kuat budaya organisasi, semakin besar dorongan anggotanya untuk maju bersama dengan organisasi. berdasarkan hal tersebut, pengenalan, penciptaan, dan pengembangannya dalam suatu organisasi mutlak diperlukan dalam rangka membangun organisasi yang efektif dan efisien sesuai dengan visi, misi, dan tujuan yang hendak dicapai. organisasi yang memiliki budaya yang kuat akan menghasilkan kinerja yang baik dalam jangka panjang. budaya yang kuat artinya seluruh karyawan memiliki satu persepsi yang sama dalam mencapai tujuan perusahaan. kesatuan persepsi didasarkan pada kesamaan nilai yang diyakini, norma yang dijunjung tinggi, dan pola perilaku yang ditaati (darsono, 2010). budaya yang kuat merupakan kunci kesuksesan sebuah organisasi. menurut ndraha (2004) budaya yang kuat mempunyai tiga ciri, yaitu kejelasan nilai-nilai dan keyakinan (clarity of ordering), penyebaran nilai-nilai dan keyakinan (extent of ordering), dan kekokohan nilai-nilai inti dan keyakinan (core values being intensely held). menurut robbins (2005) budaya yang kuat ditandai oleh nilainilai inti yang dipegang teguh dan disepakati secara luas dalam sebuah organisasi. semakin banyak anggota yang menerima nilai-nilai inti semakin besar komitmen mereka terhadap nilai-nilai tersebut. kualitas kehidupan kerja mempunyai pengaruh terhadap kinerja karena mampu u nt u k men i ng k at k a n per a n ser t a d a n s u m b a n g s i h p a r a a n g g o t a t e r h a d a p organisasi dan menumbuhkan keinginan para karyawan untuk tetap tinggal dalam organisasi. kehidupan kerja perawat yang dipengaruhi faktor lingkungan kerja yang saling berpengaruh terhadap kepuasan perawat dalam mencapai keinginan dan mempunyai harapan tinggi dalam kehidupan melalui upaya bekerja secara professional dalam suasana 340 jurnal ners vol. 10 no. 2 oktober 2015: 332–342 dan lingkungan kerja yang mendukung untuk menciptakan perawat berprestasi, bernilai tinggi, bermanfaat bagi diri sendiri dan rumah sakit, sehingga produktivitas meningkat sesuai tujuan rumah sakit (lee, dai, park, dan mccreary, 2013). budaya organisasi mengacu kepada sistem makna bersama yang dianut oleh anggota-anggota organisasi yang membedakan organisasi itu dari organisasi lain. suatu sistem nilai budaya yang tumbuh menjadi kuat mampu memacu organisasi ke arah perkembangan yang lebih baik. semakin baik budaya kerja maka kinerja akan semakin tinggi begitu juga sebaliknya. hal ini berarti bahwa setiap perbaikan budaya kerja ke arah yang lebih kondusif akan memberikan sumbangan yang sangat berarti bagi peningkatan kinerja pegawai, demikian juga sebaliknya. hasil penelitian waridin dan masrukhin (2006) menunjukkan bahwa budaya organisasi yang diindikasikan dengan budaya dituntutnya pegawai mencari cara-cara yang lebih efektif dan berani menanggung risikonya, cermat dalam melaksanakan pekerjaan, perhatian pada kesejahteraan pegawai, tuntutan konsentrasi yang dicapai, semangat yang tinggi dalam bekerja, serta kewajiban dalam merealisasikan target dan tugas instansi mempunyai pengaruh positif terhadap kinerja pegawai. bud aya orga n isa si d a n k u al it a s kehidupan kerja perawat memiliki pengaruh yang signifikan terhadap kepuasan kerja perawat di rsud dr. soetomo surabaya. sebagian perawat menyatakan kurang puas pada indikator gaji, fasilitas dan promosi. menurut lau (2000) kriteria dari kualitas kehidupan kerja meliputi gaji dan tunjangan, peluang, keamanan dalam bekerja, bangga terhadap pekerjaan dan institusinya, keterbukaan dan keadilan, serta kenyamanan dan keakraban. variabel untuk mendeskripsikan kualitas kehidupan kerja menurut goodman et al, (2001) meliputi kepuasan kerja, komitmen organisasi, pemberdayaan, dan keterlibatan kerja. ha si l p e nel it ia n ma nojlov ich & laschiger (2007) menyat a kan k ualit as keh idupa n ker ja perawat ber penga r u h terhadap kepuasan kerja. penelitian lain yang mendukung dilakukan oleh gayathiri & ramakrishnan (2013) yang menyatakan bahwa ada pengaruh antara kualitas kehidupan kerja perawat terhadap kepuasan kerja. kepuasan kerja perawat berpengaruh terhadap kinerja perawat di rsud dr. soetomo surabaya. kepuasan kerja mempunyai peranan penting terhadap prestasi kerja karyawan, ketika seorang karyawan merasakan kepuasan dalam bekerja maka seorang karyawan akan ber upaya semaksimal mu ngkin dengan segenap kemampuan yang dimiliki untuk menyelesaikan tugasnya, yang akhirnya akan menghasilkan kinerja dan pencapaian yang baik bagi organisasi. k a r y a w a n y a n g m e r a s a p u a s , berkomitmen dan dapat menyesuaikan diri dengan baik untuk lebih berisiko bekerja guna memenuhi tujuan organisasi dan memberikan pelayanan sepenuh hati pada organisasi dengan meningkatkan kinerja yang akan mendukung efektivitas organisasi dibandingkan dengan pekerjaan yang tidak puas. fa k t or-fa k t or ya ng b e r p e nga r u h terhadap kinerja menurut ilyas (2005) meliputi karakteristik pribadi yang terdiri dari usia, jenis kelamin, pengalaman, orientasi dan gaya komunikasi, motivasi, pendapatan dan gaji, lingkungan, organisasi, supervisi dan pengembangan karir. faktor produktivitas organisasi ada empat determinan utama, yaitu prestasi kerja, lingkungan, karakteristik organisasi, karakteristik kerja dan karakteristik individu. karakteristik kerja dan karakteristik organisasi akan memengaruhi karakteristik individu seperti imbalan, penetapan tujuan akan meningkatkan motivasi kerja, sedangkan prosedur seleksi tenaga kerja serta latihan dan program pengembangan akan meningkatkan pengetahuan, keterampilan dan kemampuan dari individu. simpulan dan saran simpulan budaya organisasi yang kuat dapat menciptakan kualitas kehidupan kerja yang baik bagi perawat dalam meningkatkan kinerja dan kepuasan kerja perawat di rsud dr. soetomo surabaya. peningkatan kualitas 341 budaya organisasi dan quality of nursing work life (rini winarsih, dkk.) kehidupan kerja perawat di rsud dr. soetomo surabaya dipengaruhi oleh faktor sosial dan lingkungan, faktor operasional, dan faktor administrasi. saran komitmen manajemen rumah sakit dibutuhkan dalam membangun peningkatan kualitas kehidupan kerja perawat melalui komunikasi yang terbuka, kepemimpinan yang efektif dan dapat menjadi motor penggerak organisasi yang berkualitas, serta hubungan kerja sama yang terjalin dengan baik antar perawat, antar departemen dan antar profesi di lingkungan kerja, pengelolaan sumber daya manusia yang efektif dan efisien, perlakuan yang fair, adil, dan suportif dalam pemberian remunerasi, serta memberikan kesempatan bagi tiap perawat untuk mewujudkan diri dan berperan aktif dalam pengambilan keputusan yang melibatkan pekerjaannya. penelitian selanjutnya perlu dilakukan dengan menganalisis pengaruh empowerment dan job involvement terhadap k ualitas kehidupan kerja perawat. kepustakaan an, jy., yom, yh., ruggiero, j.s. 2011. organizational culture, quality of work life, and organizational effectiveness in korean university hospitals. journal of transcultural nursing, 22(1), 22–30. darsono. 2010. hubungan perceived service quality dan loyalitas:peran trust dan satisfaction sebagai mediator. jurnal bisnis perspektif, vol. 2 no. 1, hal 43– 57. gayathiri, r. & ramakrishnan, l. 2013. quality of work life-linkage with job satisfaction and perfor mance. international journal of business and management invention, 2(1), 1–8. george. 2005. understanding and managing organizational behavior. 5nd edition. upper saddle river: pearson prenticehall. gifford, b.d., zammuto, r.f., goodman, e.a., hill, k.s. 2002. the relationship between hospital unit culture and nurses quality of work life. journal of healthcare management, 47 (1), 13–26. g o o d m a n , e . a ., z a m mut o., g i f ford , b.d. 2001. the competing values framework: understanding the impact of organizational culture on the quality of work life. organization development journal, 19 (3). pg. 58. grossmann. 1999. the human capital model of the demand for health. cambrigde: n a t i o n a l b u r e a u of e c o n o m i c research. ilyas, y. 2005. perencanaan sumber daya manusia rumah sakit. jakarta: fkmui. lau, r.s.m. 2000. quality of work life and performance: an ad hoc investigation of two key elements in the service profi t chain model. international journal of service industry management, 11 (5), 422–434. lee, y-w., dai, y-t, park, c-g., & mccreary, l. l. 2013. predicting quality of work life on nurses’ intention to leave. journal of nursing scholarship, 45(2), 160–168. manojlovich, m. & laschinger, h. 2007. the nursing worklife model: extending and refi ning a new theory. journal of nursing management, 15, 256–263. ndraha, talizuduhu. 2004. budaya organisasi. jakarta: rineka cipta. notoatmojo, s. 2000. metodologi penelitian kesehatan. jakarta: rineka cipta. nursalam. 2013. metodologi penelitian ilmu keperawatan pendekatan praktis. jakarta: salemba medika. nursalam. 2014. manajemen keperawatan. jakarta: salemba medika. organizational culture assessment instrument public administration. ocai online, 2010. republik indonesia. 2009. undang-undang republik indonesia nomor 44 tahun 2009 tentang rumah sakit, jakarta. rivai, veithzal. 2006. manajemen sumber daya manusia untuk perusahaan. jakarta: raja grafi ndo persada. robbins, s. & judge, t. 2008. perilaku organisasi. (terj. d. angelica, r. cahyani, dan a. rosyid) edisi 12. jakarta: salemba empat. (buku asli tahun 2007) 342 jurnal ners vol. 10 no. 2 oktober 2015: 332–342 robbins s. 2005. prinsip-prinsip perilaku organisasi. edisi kelima. (terj. halida dan d. sartika) jakarta: erlangga. swansburg, r.c. 2000. kepemimpinan dan ma n aje me n ke pe ra wata n unt u k perawat klinis, alih bahasa suharyati samba. jakarta: egc. war idin & masr u k in. 2006. pengar uh motivasi kerja, kepuasan kerja, budaya organisasi dan kepemimpinan terhadap kinerja pegawai. ekobis, volume 7, no. 2. ners vol 10 no 2 okt 2015.indd 222 terapi individu reminiscence menurunkan tingkat depresi pada lansia di panti sosial (individual reminiscence therapy can decrease depression level on elderly at social homes) laili nur hidayati*, mustikasari*, yossie susanti eka putri* *fakultas ilmu keperawatan, universitas indonesia, depok kampus ui depok, jawa barat 16424 email: laili.ln36@gmail.com abstrak pendahuluan: penuaan adalah proses alami yang dialami oleh semua manusia. perkembangan psikososial lansia ada pada tahap peningkatan integrasi diri. terapi individu reminiscence merupakan salah satu bentuk penatalaksanaan psikososial pada lansia dengan me-recall ingatan mengenai peristiwa hidup di masa lalu. tujuan dari penelitian ini adalah untuk mengetahui pengaruh terapi individu reminiscence terhadap tingkat depresi lansia yang tinggal di panti sosial. metode: penelitian berdesain quasi eksperimental pre-post test dengan kelompok kontrol. sejumlah 60 lansia direkrut untuk menjadi responden, dibagi menjadi dua kelompok, yaitu kelompok perlakuan (31 orang) dan kontrol (29 orang). variabel independen dalam penelitian ini adalah terapi individu reminiscence 5 sesi, yang diberikan pada kelompok perlakuan. sementara, variabel dependennya adalah tingkat depresi lansia. data dikumpulkan dengan gds (geriatric depression scale), dan dianalisis dengan uji wilcoxon dan mann-whitney dengan level signifikansi α ≤ 0,05. hasil: setelah mendapatkan terapi individu reminiscence diketahui bahwa kelompok perlakuan mengalami penurunan tingkat depresi yang signifikan, dibandingkan dengan kelompok kontrol (p = 0,008). diskusi: terapi individu reminiscence bermanfaat untuk mengatasi depresi pada lansia. perawat dapat mengetahui kepribadian dari masing-masing lansia untuk meningkatkan kualitas pelayanan keperawatan pada lansia tersebut. kata kunci: terapi individu reminiscence, depresi, lansia abstract introduction: aging is a natural process in oldest old. the psychosocial development of the elderly to enhance selfintegration. reminiscence therapy is one of psychosocial treatment for elderly using memory recall of one’s life event in the past. the purpose of this study was to determine the effect of individual reminiscence therapy on depression among elderly in the social homes. methods: the study design was used quasy-eksperiment pre-post test with control group. a total of 60 elderly people were recruited in this study and assigned into two groups, 31 participants in the intervention group and 29 participants in the control group. independent variable was reminiscence therapy five sessions, which given to the intervention group. while, dependent variable was the level of depression on elderly. data were collected by using gds, then analyzed by using wilcoxon and mann-whitney statistical test with level of significance α ≤ 0.05. results: after providing individual reminiscence therapy, the intervention group showed a significant decrease in depression as compared to those in the control group was found (p = 0.008). discussions: the individual reminiscence therapy is useful to overcome depression among elderly. the nurse can know the personality of each elderly so as to improve the quality of nursing care for elderly keywords: individual reminiscence therapy, depression, elderly pendahuluan populasi lanjut usia (berumur 65 tahun atau lebih) secara global meningkat dari 9,2% pada tahun 1990 menjadi 11,7% pada tahun 2013 dan akan terus meningkat proporsinya pada populasi di dunia mencapai 21,1% di tahun 2050 (united nations, 2013). penduduk lansia paling banyak unt uk tahun 2012 adalah provinsi daerah istimewa yogyakarta (13,04%), jawa timur (10,40%) kemudian jawa tengah (10,34%) (kementerian kesehatan ri, 2013). peningkatan jumlah ini akan membawa dampak terhadap berbagai aspek kehidupan, baik pada diri yang bersangkutan, keluarga dan masyarakat. pengkajian keperawatan pada pasien geropsikiatri sangat kompleks, mencakup permasalahan pada biologi, psikologi, dan fak tor sosiok ult u ral yang berhubu ngan dengan proses penuaan (st uar t, 2013). ketidakseimbangan kimiawi otak seperti norephinephrine, serotonin dan dopamin dapat juga menyebabkan depresi mayor (national alliance on mental illness, 2009). 223 terapi individu reminiscence menurunkan tingkat depresi (laili nur hidayati, dkk.) prevalensi gangguan depresi pada populasi lansia di dunia bervariasi rentang 10 –20% tergant ung dari sit uasi budaya setempat. perbandingan terjadinya depresi pada lansia bervariasi dari berbagai benua di dunia dan benua asia berada pada urutan tertinggi (bar ua, ghosh, kar & basilio, 2009). insiden terjadinya depresi pada lansia dihubungkan dengan status kesehatan yang buruk. prevalensi terjadinya depresi cukup tinggi pada lansia yang tinggal di luar rumah, mendapatkan pelayanan kesehatan di rumah, rumah sakit, panti sosial atau setting perawatan lainnya. intervensi psikoterapi pada lansia secara individu dan kelompok keduanya memberikan manfaat yang positif untuk mengatasi depresi. psikoterapi adalah pilihan penanganan yang utama unt u k mer ingan kan depresi dan cemas pada lansia (laidlaw, 2013). menurut poor neselvan dan steefel (2014) dalam hasil penelitiannya bahwa terapi individu reminiscence mampu menurunkan depresi dan harga diri rendah pada lansia yang tinggal di rumah perawatan. reminiscence ber a r t i menga mbil kembali bagian dari masa lalu dan berfokus pada masa lalu tersebut untuk memperkaya kehidupan kita sehari-hari. terapi ini dilakukan secara alamiah dan secara menyenangkan untuk melihat kembali kehidupan di masa lalu. keuntungan yang diperoleh pada lansia dengan membagi pengalamannya di masa lalu akan mengurangi rasa kehilangan, terpisah jarak yang jauh dan keterbatasan fisik yang dialami lansia (schweitzer & bruce, 2008). berdasarkan studi pendahuluan yang dilakukan peneliti di panti sosial tresna werdha (pstw) provinsi daerah istimewa yogyakarta (diy) ditemukan sebagian besar lansia yang tinggal di panti mengalami gejala depresi, sedangkan pelayanan kesehatan yang diberikan belum mengarah pada pemberian pelayanan untuk mengatasi permasalahan psikososial termasuk penanganan depresi. berdasarkan latar belakang di atas, maka peneliti tertarik unt uk meneliti tentang pengar uh terapi individu reminiscence terhadap depresi lansia di panti sosial. bahan dan metode d e s a i n p e nel it ia n me ng g u n a k a n quasi eksperimental sebelum dan sesudah tes dengan kelompok kontrol. kelompok intervensi diberikan terapi generalis dan spesialis: reminiscence individu, sementara kelompok kontrol diberikan terapi generalis saja. populasi penelitian ini lansia yang tinggal di pstw provinsi diy. metode sampling yang digunakan yaitu total sampling dengan beberapa kriteria inklusi. jumlah sampel yang diperoleh sebanyak 60 responden yang dibagi menjadi 31 responden pada kelompok intervensi dan 29 responden pada kelompok kontrol. penelitian ini memperhatikan prinsip etik beneficience, respect for human dignity, justice dan sudah mendapatkan kajian lolos etik untuk mendapatkan kelayakan penelitian pada komite etik di fakultas ilmu keperawatan universitas indonesia. variabel bebas penelitian yaitu terapi generalis dan terapi individu reminiscence. sementara variabel terikat dalam penelitian ini yaitu tingkat depresi lansia. variabel perancu dalam penelitian ini yaitu karakteristik responden meliputi usia, jenis kelamin, pendidikan, status perkawinan, pengalaman kerja masa lalu, lama masuk panti dan penyakit fisik yang dialami. kondisi depresi lansia diukur dengan menggunakan geriatric depression scale (gds) short form. klasif ikasi kategori dibagi menjadi 4 kategori yaitu nilai 0 – 4 dikategorikan normal, nilai 5–8 dikategorikan depresi ringan, nilai 9–11 dikategorikan depresi sedang dan bila skor nilai 12–15 dikategorikan depresi berat (brink & yesavage, 1982 dalam aikman & oehlert, 2000; greenberg, 2012). hasil uji validitas gds nilai r hitung berkisar 0,406–0,826 dan reliabilitas 0,895. instrumen kuesioner c digunakan untuk mengukur harga diri responden dengan menggunakan instrumen yang dikembangkan oleh rosenberg (1965) yaitu rosenberg self esteem scale (rses). hasil uji validitas rses nilai r hitung berkisar 0,457–0,764 dan reliabilitas 0,894. analisis statistik dengan wilcoxon digunakan untuk melihat perbedaan sebelum-sesudah masing-masing pada kelompok intervensi dan kelompok kontrol. sedangkan untuk 224 jurnal ners vol. 10 no. 2 oktober 2015: 222–232 mengetahui pengaruh terapi antara kelompok intervensi dan kelompok kontrol setelah intervensi dilakukan uji statistik dengan mann whitney dengan tingkat signifikansi α ≤ 0.05. hasil ka ra k ter ist i k la nsia berd asa rka n usia memiliki nilai median yang sama antara kelompok inter vensi dan kontrol yaitu 70 tahun. pada kelompok intervensi rentang usia (60–86 tahun), sedangkan pada kelompok kontrol rentang usia (61-90 tahun). karakteristik berdasarkan lama masuk panti pada kelompok intervensi nilai median yaitu 4 tahun dengan lama minimal menghuni panti selama 1 bulan dan terlama 17 tahun. lama masuk panti pada kelompok kontrol memiliki nilai tengah 2 tahun dengan lama minimal 3 bulan dan terlama 12 tahun di panti. karakteristik lansia yang menderita depresi di panti sosial proporsi kedua kelompok sama berdasarkan jenis kelamin lebi h d a r i sepa r u h perempu a n, st at us perkawinan sebagian besar duda/janda, berdasarkan pengalaman kerja lebih banyak pernah bekerja dan karakteristik berdasarkan kond isi kesehat a n lebi h d a r i se pa r u h mengalami penyakit fisik. sedangkan untuk tingkat pendidikan pada kelompok intervensi proporsi yang paling banyak tidak sekolah dan sd dengan jumlah sama, sedangkan pada kelompok kontrol sebagian besar tidak sekolah (lihat tabel 1). analisis perubahan kondisi depresi p a d a k e l o m p o k k o n t r ol y a n g t i d a k mendapatkan terapi individu reminiscence, tetapi hanya mendapatkan terapi generalis saja menggunakan uji wilcoxon menghasilkan p value sebesar 0,046 (lihat tabel 2). tabel 1. karakteristik responden variabel kategori kelompok intervensi (n = 31) kelompok kontrol (n = 29) p value n % n % jenis kelamin laki-laki 12 39 9 31 0,595 perempuan 19 61 20 69 tingkat pendidikan tidak sekolah 9 29 16 55 0,06 sd 9 29 8 27 smp 5 16 0 0 smu 6 19 5 18 diploma 2 7 0 0 status perkawinan pasangan masih hidup 7 23 9 31 0,563 duda/janda 24 77 20 69 pengalaman kerja masa lalu pernah bekerja 19 61 17 58 1,000 tidak bekerja 12 39 12 42 penyakit fi sik yang dialami sakit fi sik 18 58 20 69 0,431 sehat 13 42 9 31 tabel 2. perbedaan kondisi depresi pada lansia yang tidak mendapatkan terapi individu reminiscence variabel n median (min-maks) mean ± sd p value sebelum 29 7 (5 – 14) 7,24 ± 2,54 0,046 sesudah 29 6 (4 – 13) 6,93 ± 2,04 225 terapi individu reminiscence menurunkan tingkat depresi (laili nur hidayati, dkk.) analisis perbedaan nilai median kondisi depresi sebelum dan sesudah intervensi pada kelompok intervensi dengan menggunakan uji wilcoxon menghasilkan p value sebesar 0,008. hasil ini menunjukkan adanya perbedaan yang signifikan kondisi depresi antara sebelum dan sesudah terapi individu reminiscence yaitu terjadi penurunan skor kondisi depresi (lihat tabel 3). analisis statistik perbedaan perubahan kondisi depresi antara kelompok intervensi dan kontrol setelah selesai dilakukan terapi individu reminiscence dianalisis dengan uji nonparametrik mann-whitney. hasil ini menunjukkan bahwa ada perbedaan yang bermakna kondisi depresi antara lansia yang mendapatkan dan tidak mendapatkan terapi individu reminiscence sesudah dilakukan terapi individu reminiscence pada kelompok intervensi dengan nilai p value (0,034) < α (0,05). kesimpulannya pada α = 0,05 lansia yang mendapatkan terapi individu reminiscence mengalami penurunan secara bermakna terhadap kondisi depresi yang dialami (lihat tabel 4). kelompok intervensi terjadi penurunan skor depresi dengan diberikan terapi generalis sebesar 0,84 poin ditambah terapi spesialis individu reminiscence penurunan sebesar 4,23 poin sehingga terjadi penurunan kondisi depresi sebesar 5,07. sed ang kan pad a kelompok kontrol penurunan skor depresi pada pemberian terapi generalis pertama sebesar 0,17 dan pada akhir setelah kelompok inter vensi mendapatkan terapi individu reminiscence penurunan sebesar 0,14 sehingga penurunan kondisi depresi hanya sebesar 0,31 (lihat gambar 1). pembahasan k a r a k t e r i s t i k u si a l a n si a y a n g mengalami depresi di pstw provinsi diy yaitu 70 tahun. miller (2015) menjelaskan bahwa dalam teori biologi dan genetik terjadinya depresi pada lansia, usia yang semakin menua berkaitan dengan atrofi volume otak yang dapat berkontribusi terjadinya latelife depression. rentang usia dalam hasil penelitian ini melebihi usia harapan hidup di indonesia yaitu pada tahun 2011 mencapai 69,65 tahun (kemenkes ri, 2013). u s i a h a r a p a n h i d u p s e m a k i n meningkat dengan dipengar uhi semakin baiknya pelayanan kesehatan mengakibatkan seseorang mencapai usia tua. hasil penelitian keshavarzi, ahmadi dan lankarani (2015) tabel 3. perbedaan kondisi depresi pada lansia sebelum dan sesudah terapi individu reminiscence variabel n median (min-maks) mean ± sd p value sebelum 31 8 (5 – 12) 7,52 ± 1,98 0,008 sesudah 31 2 (0 – 6) 2,45 ± 1,87 tabel 4. analisis perbedaan perubahan kondisi depresi antara lansia yang mendapatkan dan tidak mendapatkan terapi individu reminiscence kelompok n median(min-maks) mean ± sd p value intervensi 31 2 (0 – 6) 2,45 ± 1,87 0,034 kontrol 29 6 (4 – 13) 6,93 ± 2,04 gambar 1. perbandingan penurunan rerata kondisi depresi antara lansia yang mendapat terapi generalis dengan lansia yang mendapat terapi generalis dan terapi individu reminiscence. 226 jurnal ners vol. 10 no. 2 oktober 2015: 222–232 menjelaskan bahwa prevalensi terjadinya depresi semakin meningkat pada usia lanjut dan membutuhkan pelayanan kesehatan yang lebih adekuat pada klien lansia. penelitian mack in et al (2015) bahwa lateonset depression atau depresi yang terjadi saat usia tua berpengaruh pada gangguan memori dan fungsi tubuh. sebaliknya, penelitian forlani et al (2014) prevalensi gejala depresi ringan akan menurun seiring dengan pertambahan usia dikarenakan adanya hambatan untuk mendeteksi depresi pada oldest old secara khusus karena seringkali adanya demensia atau gangguan kognitif. hal ini didukung dengan provinsi diy memiliki jumlah lansia tertinggi sehingga menjadi tantangan ke depan bagi tenaga kesehatan khususnya perawat untuk menjaga kesejahteraan lansia. k a r a k t e r ist i k la ma ma su k pa nt i diketahui pada kelompok intervensi ratarata lansia tinggal lebih lama masuk di panti daripada kelompok kontrol. townsend (2009) menjelaskan lansia secara pribadi lebih menyukai tinggal di rumah sendiri atau milik keluarganya. pada penelitian ini alasan masuk ke panti sebagian besar karena keinginan sendiri dan kondisi ekonomi yang kurang. selain itu, ada lansia yang memilih tinggal di panti dengan alasan agar lebih bisa lebih banyak waktu untuk beribadah dan mendekatkan diri kepada tuhan. lansia dengan komitmen religius yang bagus mempunyai rasio yang rendah terjadinya bunuh diri, penyalahgunaan obat dan perceraian serta bermanfaat untuk kesehatan mental. kondisi ini didukung penelit ia n ya ng d ila k u ka n aly (2010) bahwa agama dan spiritualitas merupakan pengalaman mendasar seseorang yang akan berpengaruh pada kehidupan sehari-hari yang dijalani. lansia yang semakin lama tinggal di panti dengan rutinitas kegiatan yang ada dan aktivitas sehari-hari yang terbatas, sering adanya ketidakcocokan antara lansia satu dengan yang lain membuat lansia menjadi tertekan dan berisiko mengalami depresi. hal ini sejalan dengan penelitian hoover et al (2010) semakin lama lansia tinggal di panti insiden terjadinya depresi semakin meningkat, didukung dengan semakin menurunnya kondisi fisik lansia karena proses penuaan dan juga adanya penyakit fisik yang dialami. lansia semakin panjang usia semakin lama tinggal di panti menjadikan stresor yang lebih tinggi, sehingga perawat harus lebih memperhatikan kondisi lansia dan menggunakan komunikasi terapeutik dalam memberikan perawatan. la n sia ya ng me ngala m i de pre si dari hasil penelitian ini lebih dari separuh perempuan, namun memang dari populasi di panti baik pada kelompok intervensi maupun kontrol yang mendominasi adalah perempuan. miller (2015) menyatakan bahwa jenis kelamin wanita merupakan salah satu faktor demografi yang berpengaruh terjadinya depresi pada lansia. hal ini juga dipengaruhi perubahan biologik yang terjadi pada wanita yaitu lebih cepat daripada laki-laki untuk kehilangan massa otot ditambah dengan proses menopause membuat wanita lebih rentan mengalami osteoporosis (townsend, 2009). fenomena ini sesuai dengan penjelasan stuart (2013) bahwa pada wanita lebih berisiko 20–30% dibandingkan laki-laki untuk terjadi depresi mayor. penelitian misesa, keliat dan wardani (2013) di kalimantan selatan juga mayoritas wanita yang tinggal di panti sosial mengalami depresi, walaupun memang dari sekian banyak lansia yang tinggal di panti lebih banyak wanita. penelitian keshavarzi, ahmadi dan lankarani (2015) memaparkan bahwa 82% depresi pada lansia dialami oleh wanita. the national alliance on mental illness (2009) juga mengemukakan bahwa wanita dua kali lebih besar dibandingkan laki-laki untuk menderita depresi yang serius dikarenakan faktor biologis dan perubahan hormon membuat wanita lebih rentan terkena depresi. stres yang dialami akibat kehilangan pasangan atau anak juga berkontribusi tingginya depresi pada wanita. karakteristik lansia berdasarkan tingkat pendidikan pada penelitian ini mayoritas tidak bersekolah. klasif ikasi pendidikan menurut badan pusat statistik (2015) bahwa pendidikan dasar dimulai dari sekolah dasar (sd)/sederajat dan sekolah menengah pertama (smp)/sederajat. hasil penelitian ini banyak lansia yang pernah sekolah tetapi tidak sampai lulus di tingkat sd/sederajat termasuk sekolah rakyat (sr) sehingga diklasifikasikan tidak sekolah. selain itu 227 terapi individu reminiscence menurunkan tingkat depresi (laili nur hidayati, dkk.) untuk lansia yang berpendidikan tinggi hanya ada pada kelompok intervensi yaitu sebanyak 2 orang yang berpendidikan sampai diploma. penelitian zhou et al (2012) menyatakan bahwa sebagian besar lansia dengan depresi me mpu nyai t i ng k at p e nd id i k a n ya ng rendah. pendidikan yang rendah dengan lingkungan sosial yang kurang mendukung sebagai sumber koping lansia berpengaruh terhadap mekanisme koping lansia saat menghadapi masalah. hal ini sesuai dengan teori penuaan kontinuitas yang menjelaskan bahwa karakteristik strategi koping seseorang telah ada jauh sebelum seseorang menjadi t ua, sehingga kepribadian juga bersifat dinamis dan terus berkelanjutan. tindakan yang bisa dilakukan untuk memprediksi bagaimana seseorang bisa menyesuaikan menjadi tua dengan memeriksa bagaimana orang tersebut mampu menyesuaikan dengan perubahan dalam kehidupannya (miller, 2015). stuart (2013) menyatakan pendidikan akan memengaruhi cara berpikir dan perilaku individu, seseorang dengan pendidikan lebih tinggi akan lebih mudah menerima informasi, mudah mengerti dan mudah menyelesaikan masalah. ha si l r iset me nu nju k k a n ba hwa pendidi kan berkorelasi dengan su mber koping seseorang. pendidikan yang rendah akan ber pengar uh pada pola pemikiran sebagai sumber koping dalam penyelesaian masalah yang terjadi dalam kehidupan. lansia yang tinggal di panti dengan keterbatasan informasi yang diperoleh karena pengetahuan yang rendah, saat mengalami masalah kurang mampu membentuk strategi koping yang akan dipilih. apabila penyelesaian masalah tidak dilakukan dengan baik maka dapat menimbulkan putus asa, tidak bersemangat, selalu berpikiran buruk terhadap diri sendiri yang pada akhir nya dapat menimbulkan depresi pada lansia tersebut. la n sia ya ng me ngala m i de pre si pada penelitian ini sebagian besar dengan status perkawinan duda/janda, baik yang ditinggalkan pasangan meninggal, perceraian maupun pasangan yang masih hidup namun tidak tinggal bersama lagi dikarenakan aturan agama yang tidak memperbolehkan untuk bercerai. faktor yang memengaruhi kondisi status perkawinan duda/janda dikarenakan kematian, faktor ekonomi dan sudah tidak ada kecocokan lagi untuk hidup bersama. kondisi ini didukung dengan hasil penelitian abe et al (2012) bahwa prevalensi dan faktor risiko terjadinya depresi lansia bahwa lansia yang hidup sendirian lebih berisiko mengalami depresi. pasangan yang belum lama meninggal membuat lansia masih dalam kondisi berduka dan kehilangan pasangan, serta harus hidup sendirian dapat meningkatkan risiko terjadinya depresi pada lansia. stuart (2013) menjelaskan bahwa semua orang dengan pengalaman depresi dan perpisahan mempunyai risiko u nt u k melak u kan tindakan bu nu h di r i sehingga pada semua lansia yang menderita depresi harus dikaji juga untuk bunuh diri. qualls dan k night (2006) menjelaskan kehilangan pasangan dan kondisi lain yang terkait apabila tidak tertangani dengan baik maka dapat berlanjut dalam kondisi depresi pada lansia. hal ini juga sesuai dengan penelitian johnson, zhang dan prigerson (2008) bahwa gejala depresi seakan-akan tidak bisa hilang dikarenakan kematian pasangan yang sebelumnya sangat bergantung pada pasangannya tersebut. lansia yang mengalami depresi pada penelitian ini sebagian besar pernah bekerja di masa lalu, walaupun pekerjaan yang dilakukan dengan penghasilan tidak tetap setiap bulannya. pekerjaan yang per nah dilakukan beragam, sebagian besar sebagai buruh, petani dan wiraswasta serta ada juga beberapa sebagai pegawai negeri sipil. kondisi lansia dari bekerja menjadi tidak bekerja lagi dapat berpengaruh timbulnya depresi. hal ini dikarenakan beberapa hal yaitu aktivitas yang menurun, perubahan lingkungan sosial dan penghasilan. stresor bisa diawali saat mulai masa pensiun misalnya adanya tuntutan ekonomi sedangkan penghasilan menurun dan perubahan peran yang terjadi baik dalam keluarga maupun masyarakat. hal ini bisa menimbulkan persepsi diri yang negatif yang semakin lama dapat berisiko terjadi depresi. hasil ini sejalan penelitian yang dilakukan keshavarzi, ahmadi dan lankarani 228 jurnal ners vol. 10 no. 2 oktober 2015: 222–232 (2015) bahwa depresi pada lansia banyak dialami lansia yang tidak bekerja. townsend (2009) menjelaskan bahwa aktivitas yang ber t ujuan mer upakan hal yang penting unt u k mampu beradaptasi dengan baik agar mampu bertahan hidup. selain itu juga mengungkapkan bahwa seseorang dengan ekonomi kurang yang bekerja sepanjang hidupnya dapat lebih miskin saat lansia, sedangkan lainnya menjadi miskin saat tua. lansia dengan ekonomi menengah mempunyai kualitas hidup yang lebih baik. stuart (2013) menjelaskan bahwa pada seseorang yang tidak memiliki penghasilan menjadi salah satu faktor predisposisi terjadinya depresi. penghasilan ini sebagai dukungan secara finansial yang menggambarkan produktivitas lansia, dengan tidak adanya dukungan finansial menjadi beban psikis bagi orang dengan usia lanjut. hasil penelitian ini sesuai penelitian hua et al (2015) pada lansia yang tinggal di kota china menyatakan bahwa terdapat hubungan yang signifikan antara pendapatan rendah dengan terjadinya depresi pada lansia. penghasilan yang diperoleh tidak hanya digunakan dalam pemenuhan kebutuhan sehari-hari saja akan tetapi juga sebagai cadangan pembiayaan kesehatan. lansia dengan semakin bertambahnya usia maka fisik menjadi lebih rentan terhadap penyakit. kondisi sakit yang dialami disertai tidak adanya penghasilan membuat lansia menjadi putus asa dan menjadi beban secara psikologis lansia. peneliti menyarankan kepada lansia yang tinggal di panti sosial agar tidak menjadikan beban dalam dirinya karena sudah tidak punya penghasilan lagi. hal ini dikarenakan untuk pemenuhan kebutuhan sehari-hari sudah dapat terpenuhi dan pembiayaan kesehatan sudah ditanggung dari panti. kondisi yang demikian diharapkan dapat menurunkan tingkat depresi yang dialami lansia. lansia yang tinggal di panti lebih dari separuh yang mengalami sakit fisik. stuart (2013) menjelaskan bahwa insiden terjadinya depresi ditemukan sebagian besar pada pasien dengan penyakit fisik, dengan semakin berat penyakit fisik yang dialami maka tingkat depresi juga semakin tinggi. depresi ini sebagian besar tidak disadari sehingga tidak mendapatkan penanganan dari tenaga kesehatan. townsend (2009) juga mengungkapkan bahwa aktivitas yang biasa dilakukan akan terbatas dikarenakan adanya penyakit atau trauma seiring dengan meningkatnya usia. lansia yang mengalami depresi banyak dikuasai perasaan sedih, menurunnya minat untuk beraktivitas, merasa tidak berguna dan tidak bahagia. hal ini sesuai dengan tanda gejala inti yang muncul pada depresi yaitu anhedonia atau adanya penurunan minat atau kesenangan pada hampir semua aktivitas (taylor, 2014). depresi pada lansia semakin berkembang dikarenakan penyakit fisik dan atau disabilitas (kecacatan) yang terjadi pada lansia (qualls & knight, 2006). kondisi medis yang dihubungkan dengan depresi meliputi diabetes, kanker, stroke, epilepsi, parkinson, penyakit jantung, gagal ginjal kronik dan penyakit endokrin lainnya (stuart, 2013). penelitian hoover et al (2010) pada lansia dengan perawatan yang cukup lama di rumah perawatan diperoleh hasil bahwa nyeri dan penyakit fisik lainnya mempunyai hubungan yang positif dengan munculnya depresi. hal ini berarti penyakit fisik yang dialami di usia tua berisiko timbulnya depresi pada lansia. menur ut hasil penelitian ini lansia yang menderita depresi di pstw provinsi daerah istimewa yogyakarta dikategorikan depresi ringan. nilai median pada kedua kelompok sebelum diberikan terapi hampir sama. depresi merupakan salah satu gangguan alam perasaan (mood) yaitu adanya penurunan mood dengan ditandai adanya perasaan sedih, putus asa, kehilangan minat dalam beraktivitas, munculnya gejala pada gangguan fisik, nafsu makan berubah serta pola tidur juga berubah (townsend, 2009). depresi dapat dialami pada semua umur (stuart, 2013) yang berbeda antara depresi pada lansia dengan usia dewasa. depresi pada saat lansia dibedakan menjadi dua, yaitu early-life onset (depresi kambuh lagi di usia lanjut) dan late life onset (onset terjadinya depresi setelah lansia), dengan lebih tingginya tingkat kesakitan dan 229 terapi individu reminiscence menurunkan tingkat depresi (laili nur hidayati, dkk.) kematian, kecacatan serta ketidaknormalan neu ropsi kolog i k d i hubu ng k a n de nga n penurunan fungsi pada lansia (miller, 2015). pe nu r u n a n skor de pr e si set ela h mendapatkan terapi individu reminiscence dari 7,52 menjadi 2,45 poin yang dikategorikan dari depresi ringan menjadi normal. menurut gillies dan james (1994) menjelaskan bahwa terapi reminiscence dapat dilakukan secara individu maupun kelompok dapat menjadi cara yang terbaik untuk membantu kesendirian pada lansia dengan meningkatkan keterampilan sosial dan komunikasi yang akan menurunkan gejala depresi yang dialami. depresi pada lansia merupakan indikasi diberikannya terapi spesialis keperawatan jiwa sesuai penelitian poor neselvan dan steefel (2014) bahwa reminiscence yang dilakukan secara individu dapat mengatasi depresi lansia yang tinggal di panti. reminiscence berarti memotret kembali bagian kehidupan masa lalu dan berfokus pada diri sendiri untuk memperkaya kehidupan sehari-hari mereka (schweitzer & bruce, 2008). permasalahan setiap individu yang berbeda sehingga mendukung bahwa dalam pelaksanaan terapi reminiscence dilakukan secara individu sehingga bisa f leksibel menyesuaikan dengan kondisi yang dialami masing-masing lansia. bender, baucham, dan norris (1998) mengemukakan bahwa kondisi fisik lansia yang semakin lemah membuat lansia membatasi diri untuk bergabung dalam sebuah kelompok bersama dengan klien lain sehingga diperlukan tindakan yang bersifat perorangan. la nsia ya ng mend apat ka n terapi re m i n i s c e n c e s e c a r a i n d iv id u d a p a t m e n c e r i t a k a n p e n g a l a m a n n y a y a n g menyenangkan sehingga merasa nyaman dan senang karena pikirannya kembali lagi pada memori masa lalu yang menyenangkan. kegiatan yang dilakukan secara individu ini sangat f leksibel menyesuaikan waktu dan tempat yang diinginkan lansia serta bisa bebas terbuka menceritakan apa yang dirasakan lansia karena hanya bersama terapis saja. synder dan lindquist (2002) dalam teorinya mengemukakan bahwa reminiscence yang dilakukan secara individu bersifat informal dengan waktu yang menyesuaikan klien tidak harus terikat satu sama lain seperti dilakukan dalam kelompok. terapi reminiscence yang diberikan secara individu ditujukan untuk memulihkan kondisi depresi yang dialami lansia. hasil penelitian yang dilakukan mcready (2010) dalam hasson (2013) menunjukkan bahwa terapi yang dilak u kan secara individu maka aspek kemanusiaan (humanity) dapat terpenuhi dengan kedekatan secara langsung dan sentuhan yang diberikan. penyembuhan secara emosional tidak akan tercapai dengan teknologi akan tetapi dengan pendekatan secara intim, adanya komunitas, seni, musik dan bermain peran. selain itu juga reminiscence yang dilakukan dengan individu menjadi jalan yang terbaik saat tidak siap untuk bergabung dengan kegiatan berkelompok (schweitzer & bruce, 2008). pel a k s a n a a n p e nel it ia n m a si ngmasing sesi terapi individu reminiscence yang dilakukan dikembangkan yaitu solcos reminiscence model yang dimodifikasi oleh peneliti. sesi terapi yang digunakan secara umum terdiri dari 5 sesi, mulai dari sesi 1 pendahuluan dan memori tentang keluarga; sesi 2 masa anak-anak; sesi 3 pekerjaan; sesi 4 berkeluarga dan mengasuh anak; dan sesi 5 evaluasi integritas diri. per ubahan yang ber makna kondisi depresi yaitu terjadi perubahan yang lebih baik dengan menurunnya skor depresi sebesar 5,07 poin pada kelompok yang mendapatkan terapi individu reminiscence. pada kelompok kontrol yang tidak mendapat terapi individu reminiscence penurunan skor depresi sebesar 0,31 poin. penurunan secara bermakna kondisi depresi antara lansia yang mendapat terapi individu reminiscence dibandingkan dengan lansia yang tidak mendapatkan terapi individu reminiscence. hasil penelitian ini juga membandingkan penurunan kondisi depresi dengan pemberian terapi generalis pada kelompok intervensi sebesar 0,84 dan kelompok kontrol 0,17. penurunan kondisi depresi dengan pemberian terapi spesialis individu reminiscence sebesar 4,23 dan kelompok kontrol yang hanya diberikan terapi generalis sebesar 0,14. selisih 230 jurnal ners vol. 10 no. 2 oktober 2015: 222–232 perbedaan skor depresi ini cukup signifikan, hal ini berarti pada lansia yang menderita depresi lebih efektif apabila diberikan terapi spesialis individu reminiscence dibandingkan hanya terapi generalis saja. lansia pada kelompok yang hanya mendapatkan terapi generalis penur unan kondisi depresinya tidak bermakna dengan kategor i masi h d ala m depresi r i nga n. intervensi yang diberikan tidak secara khusus menangani depresi yang dialami akan tetapi pada respons yang muncul dari lansia tersebut yaitu diagnosa keperawatan harga diri rendah. miller (2015) mengemukakan teorinya bahwa depresi yang muncul pada usia lansia (late life depression) dikaitkan dengan kumpulan gejala depresi yang dialami dan akan berpengaruh pada aktivitas serta kualitas hidup seseorang. penelitian yang dilakukan zhou et al (2012) dengan hasil bahwa terapi reminiscence dapat menurunkan gejala depresi dan meningkatkan harga diri. teori maslow (1954, dalam meiner & lueckenotte, 2006) menjelaskan bahwa setiap individu mempunyai kebutuhan internal yang akan memotivasi perilaku manusia. motivasi setiap individu digambarkan sebagai suatu hirarki kebutuhan yang sangat penting untuk tumbuh dan berkembang sebagai partisipasi aktif dalam kehidupan unt uk mencapai aktualisasi diri. tahap perkembangan terakhir yaitu integritas diri, tahap psikososial ini apabila tidak dapat tercapai dengan baik akan mengakibatkan depresi dan putus asa. intervensi yang bisa diberikan pada lansia yang menderita depresi di panti sosial yaitu reminiscence (melillo & houde, 2011). terapi reminiscence mudah dilakukan dan efisien untuk meningkatkan kapasitas adaptif dan ketahanan (resilience) pada lansia sebagai sumber koping menghadapi situasi buruk yang dialami serta dapat meningkatkan kualitas hidup lansia (melendez, foruna, sales & mayordomo, 2015). penelitian lain yang dilakukan gudex et al (2010) bahwa penggunaan terapi reminiscence mempunyai efek jangka pendek pada depresi lansia sehingga perlu dilakukan secara teratur sebagai aktivitas sosial yang menyenangkan. tindakan ini bisa dilakukan oleh perawat yang ada di panti sosial, sesuai dengan penelitian chen, h. li dan j. li (2012) bahwa berdasarkan p e ngala m a n k l i n i k mela k u k a n t e r api reminiscence, terapi ini dapat dilakukan oleh perawat yang sudah mendapatkan pelatihan terapi reminiscence. hal ini dikarenakan terapi ini tidak menimbulkan efek samping yang berbahaya bagi lansia. perawat juga menjadi tahu lebih banyak kepribadian dari masing-masing lansia dengan berbagai macam pengalaman kehidupan masa lalu serta memberikan kesempatan berinteraksi dengan aktivitas yang menyenangkan. hal ini sesuai dengan seni terapi reminiscence yaitu solcos reminiscence model yang dikembangkan oleh soltys dan coats (1994). model yang dikembangkan dalam penelitian ini menyediakan kerangka ker ja unt u k membantu kegiatan reminiscence tetapi juga mengekspresikan dan memperkaya pendekatan dari pemberi pelayanan kesehatan dalam berinteraksi (soltys & coats, 1995). te r a pi s m e nja d i s e m a k i n m e m a h a m i biograf i kehidupan lansia sehingga akan dapat memberikan tindakan yang berfokus dari masing-masing pengalaman yang sudah dilalui. simpulan dan saran simpulan terapi individu reminiscence yang diberikan pada depresi lansia menurunkan kondisi depresi secara bermakna. perbedaan penurunan kondisi depresi pada lansia yang mendapatkan terapi individu reminiscence lebih besar secara bermakna dibandingkan lansia yang tidak mendapatkan terapi individu reminiscence. saran terapi individu reminiscence bisa diberikan pada setting rumah perawatan, panti sosial, rumah sakit dan masyarakat untuk meningkatkan kualitas asuhan keperawatan pada lansia. penelitian selanjutnya diperlukan untuk mengetahui keefektifan terapi individu reminiscence dengan menurunnya tanda dan gejala depresi dan meningkatnya kemampuan lansia. 231 terapi individu reminiscence menurunkan tingkat depresi (laili nur hidayati, dkk.) kepustakaan aikman, g.g. & oehlert, m.e. 2000. geriatric depression scale: long form versus short form. clinical gerontologist. vol. 22(3/4) 2000 diakses dari http://www. public-health.uiowa.edu/icmha/outreach/ d o c u m e nt s /ge r i a t r ic d e p r e s sio n s c a le. pdf pada tanggal 20 januari 2015 jam 03.20 aly, h.a. 2010. spirituality and psychological well-being in the muslim community: an exploratory study. dissertation. un ited st ates: u m i disser t at ion publishing barua, a., ghosh, m.k., kar, n., & basilio, m.a. 2011. prevalence of depressive disorders in the elderly. ann saudi med 31(6): 620-624. retrieved from http:/ www.ncbi.nlm.nih.gov/pmc/articles/ pmc3221135/?report=reader diakses tanggal 19 januari 2015 jam 14.00 forlani, c., morri, m., ferrari, b., dalmonte, e., manchetti, m., ronchi, d.d., atti, a.r., 2014. prevalence and gender differences in late-life depression: a population-based study. am j geriatry psychiatr y.22:370-380. htt p://dx.doi. org/10.1016/j.jagp.2012.08.015 hasson, j. d. 2013. treatment of depression among the elderly: impact on quality of life (order no. 3564263). available from proquest dissertations & theses global. (1412671964). retrieved from http://search.proquest.com/docview/ 1412671964?accountid=17242 hoover, d. r., siegel, m., lucas, j., kalay, e., gaboda, d., devanand, d. p., & crystal, s. 2010. depression in the fi rst year of stay for elderly long-term nursing home residents in the u.s.a. international psychogeriatrics, 22(7), 1161-71. doi:http://dx.doi.org/10.1017/ s1041610210000578 hua, y., wang, b., wallen, g. r., shao, p., ni, c., & hua, q. 2015. healthpromoting lifestyles and depression in urban elderly chinese. plos one, 10(3) doi:http://dx.doi.org/10.1371/journal. pone.0117998 johnson, j.g., zhang, b., & prigerson. h.g. 2008. investigation of a developmental mo d el of r i s k fo r d e p r e s sio n and suicidality following spousal be re ave me nt. s uicide a n d life threathening behavior. 38 (1), 1–12. kementerian kesehatan republik indonesia. 2013. jendela data dan infor masi kesehatan. buletin issn 2088 – 270x semester 1. keshavarzi, s., ahmadi, s. m., & lankarani, k. b. 2015. the impact of depression and malnutrition on health-related qualit y of life among the elderly iranians. global journal of health science, 7(3), 161-170. retrieved from http://search.proquest.com/docview/ 1644455184?accountid=17242 laidlaw, k. 2013. a defi cit in psychotherapeutic care for older people with depression and anxiety. gerontology, 59 (6), 549–56. doi:http://dx.doi.org/10.1159/000351439 mackin, r.s., nelson, j.c., delucchi, k.l., raue, p.j., satre, d.d., kiosses, d.n., alexopoulos, g.s & arean, p.a. 2014. association of age at depression onset with cognitive functioning in individuals with late-life depression and executive dysf unction. am j geriatry psychiatry.22:12 http://dx.doi. org/10.1016/j.jagp 2014.02.006 miller, c.a., 2015. nursing for wellness in older adults. (7th ed.) china: wolters kluwer health national alliance on mental illness (nami). 2009. depression in older persons fact sheet. diakses dari http://www.nami. org.1(800) 950-nami. arlington diakses pada tanggal 19 januari 2015 jam 4.56 poorneselvan, c, & steefel, l. 2014., the effect of individual reminiscence therapy on self-esteem and depression among institutionalized elderly in india. creative nursing, 20(3), 183-90. retrieved from http://search.proquest.com/docview/ 1551139677?accountid=17242 schweitzer, p. & bruce, e. 2008., remembering yesterday, caring today reminiscence in dementia care a guide to good practice. london: jessica kingsley publishers stuart, gw., 2013. principles and practice of psychiatric nursing. (10th ed.) elsevier mosby: missouri taylor, w.d. 2014. depression i n the elderly. the new england journal of medicine.371;13 d ia k ses pad a 232 jurnal ners vol. 10 no. 2 oktober 2015: 222–232 tanggal 2 maret 2015 jam 10.00 dari http://www.nejm.org/doi/pdf/10.1056/ nejmcp1402180 townsend, mc 2009. psychiatric mental health nursing concepts of care in evidence-based practice. (6th ed.) philadelphia: davis plus company united nations, department of economic and social affairs, population division, 2013. world population ageing 2013. st/esa/ser.a/348 diakses dari http:// w w w.u n.org /en /development /desa / population/publications/pdf/ageing/ worldpopulationageing2013.pdf pada tanggal 19 januari 2015 jam 3.46 zhou, w., he, g., gao, j., yuan, q., feng, h. & zhang, c.k., 2012. the effects of group reminiscence therapy on depression, self-esteem, and affect balance of chinese community-dwelling elderly. archives of gerontology and geriatrics. vol 54(e440-1447). http://e-journal.unair.ac.id/jners | 129 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.12465 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research analysis of the risk factors related to the occurrence of juvenile delinquency behavior tri anjaswarni1, nursalam nursalam2, sri widati1 and ah yusuf2 1 faculty of public health, universitas airlangga, surabaya, east java, indonesia 2 faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: nowadays, juvenile delinquency is increasing in terms of number and type. delinquency and criminality among teenagers is generally categorized as deviant behavior in society and this can be interpreted as a form of teenage resistance to the normative rules and values that apply in society. many risk factors are related to deviant behavior. this study aimed to analyze the risk factors that influence the occurrence of juvenile delinquency. methods: this study used a cross-sectional design and a simple random sampling technique. the calculation results involved 295 samples, consisting of 235 students in junior senior high schools and vocational schools in malang, and 60 teenagers in the 1st class children’s prison of blitar. the independent variables were the individuals, their families, the school environment, their peer groups, coping mechanisms, lifestyle and technology. the dependent variable was juvenile delinquency. the data was collected using a questionnaire. the analysis used a logistic regression test with a significance level of α≤0.05. results: there were six variables that significantly influence juvenile delinquency, namely individual, family, school environment, peers, life style and technology. technology is the variable that has the greatest influence on the occurrence of juvenile delinquency. conclusion: technology is the most influential factor related to the cause of juvenile delinquency. these results indicate that significant shift in the causes of juvenile delinquency from family and peer factors to technological factors. this is quite reasonable because technology is a major need and it is a trend for teenagers at this time. article history received: march 21, 2019 accepted: december 14, 2019 keywords risk factor; delinquency; juvenile contact tri anjaswarni  anjaswarni_azhar@yahoo.co.id  faculty of public health, universitas airlangga, surabaya, east java, indonesia cite this as: anjaswarni, t, nursalam, n, widati, s, and yusuf, a. (2019). analysis of the risk factors related to the occurrence of juvenile delinquency behavior. jurnal ners, 14(2), 129-136. doi:http://dx.doi.org/10.20473/jn.v14i1.12465 introduction juvenile delinquency has occurred since the early 19th century and it has become a global problem, including in indonesia. juvenile delinquency is included in several social disorders and the incidence rate has continued to increase. this phenomenon occurs in all levels of society, in both men and women, in cities and in villages and within high or low socio-economic circles (steketee & gruszczyńska, 2010). delinquency and crime among teenagers is generally categorized as deviant behavior in society. these behavioral deviations can be interpreted as a form of teenage resistance to the normative rules and values that apply in society (badan pusat statistik, 2010). juvenile delinquency is one form of mental health disorder in the community, which directly or indirectly can affect the degree of mental health of the community as a whole. short-term impacts can be dangerous directly to the safety of teenagers and groups. fights, brawls and speeding will potentially lead to injury and possibly even death. narcotics can threaten their lives and society, while potential free sexual behavior can incur the risk of sexually transmitted diseases, and other harmful effects. the long-term impact is the threat of future loss meaning that they cannot take part in the development of the nation and state. this is not in line with the expectation that https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.12465 t. anjaswarni et al. 130 | pissn: 1858-3598  eissn: 2502-5791 teenagers are the spearhead of development and the next generation of the nation (anjaswarni, 2014). it is explained that adolescents have a difficult time. adolescence is a period of transition from childhood to adulthood that is full of responsibility, where they are required to be able to adapt to these changes (stuart, 2014). adaptation failure will lead to problems and behavioral disturbances in the future. this is relevant to the coping mechanisms owned by individuals because coping mechanisms are a measure of the ability of the adolescent to solve problems. furthermore, the factors that play a role in juvenile delinquency refer to the actors who originate from their individual factors. individual factors are internal factors that are related to the abilities and abilities of individuals in running their roles and social activities. individual factors that were measured in this study include life skills, selfefficacy, religion and academic competencies. a factor that also acts as a risk factor for juvenile delinquency is the family. the family is an external factor related to psycho-educative and sociocultural influences which are given by the family to the individual (children), which can impact their development. the family factor is related to the attitudes and habits of the parents when educating and caring for their children including how the parents facilitate the economic needs of the child, including in terms of personal communication patterns and proximity (bonding) (calhoun, glaser, & bartolomucci, 2001; stuart, 2014). the next external factor is the school environment and peer groups. school is an environmental situation that can affect the children's development and health. school factors that become a risk factor for juvenile delinquency are related to various things that exist in the school environment including child relationships with the teachers and their peer group, the presence of children in the school, and adherence to school rules. for the peer group factors that are risk factors for juvenile delinquency, there is the frequency of children being exposed to harmful substances, both through directly seeing and by seeing events in the mass media. included in the peer group factor is attitude and relationship patterns (calhoun et al., 2001). the development and use of technology today also plays a role in the occurrence of delinquency. the incorrect use of technology can have the effect of deviating behavior including violence, theft, and so on. research shows that playing violent video games correlates with the occurrence of aggression in juvenile delinquents that are imprisoned (delisi, vaughn, gentile, anderson, & shook, 2013). another factor that contributes to juvenile delinquency is lifestyle. changes in lifestyle due to environmental differences in the past and present will affect their psychological well-being. individuals who are not able to adapt to these lifestyle changes will experience welfare problems (heath & berman, 2008). a bad lifestyle has the potential to trigger juvenile delinquency. based on the background above, it is necessary to analyze the various risk factors that play a role in juvenile delinquency. the purpose of the study was to analyze the risk factors that influence juvenile delinquency. there are seven factors that will be analyzed in this study, including the individual, coping mechanism, family, school environment, peer, lifestyle and technology factors. materials and methods this type of research was observational with a crosssectional design (nursalam, 2014). data retrieval was carried out from november 2018 to january 2019. the population was teenagers aged 12-19 years. the number of samples consisted of 295 teenagers who attended schools in malang city, east java indonesia, and teenagers who were undergoing coaching in 1st class children’s prison of blitar (235 students and 60 adolescents in the children’s prison). the sampling technique was a simple random sampling. the researchers applied for ethical clearance first. after they had been declared to have passed the ethical test, they then administering the research permit to the national and political unity agency, the education office and the schools selected according to the sampling map. permission was asked of the east java province ministry of law and human rights (kemenkumham) to provide a research permit recommendation to the 1st class children’s prison of blitar. after getting permission, this was followed by the retrieval of the data that began with providing an explanations and informed consent to the students as the respondents with their parents and/or teachers representing the parents. the teenagers in 1st class children’s prison of blitar were with their prison providers or parents to allow the researcher to provide an explanations and to request parental consent through telephone contact or as part of a direct interaction. the data was collected using a questionnaire. the respondents provided an assessment of her or himself by giving an appropriate score. the data was recapitulated, entered into the spss program and analyzed. jurnal ners http://e-journal.unair.ac.id/jners | 131 the data was collected using a questionnaire tested for validity and reliability. this instrument was valid at r = 0,312 and reliable at α = 0,570 – 0,935. the instrument was developed by referring to the juvenile counseling and assessment program model (jcap model). the risk factors included the factors of the individual, family, school, and peer group, coping mechanisms, lifestyle and technology. individual factors include lifestyle, self-efficacy, religious and academic competencies. family factors include economic status, family communication and relations, family function, parenting and bonding. the school environment includes school policy, presence pattern, the teacher-student relation and the child’s relationship with the school. peer group includes the pattern of peer relations, exposure to substances, and peer attitude. coping mechanism includes problem-focused coping, emotion-focused coping, and dysfunctional coping. lifestyle includes physical activities, sleep pattern, free time utilization, and recreation. technological factors include using gadgets, spectacles, and video games (abdulkarim, zainul, & maryani, 2014; baqutayan, 2015; calhoun et al., 2001; heath & berman, 2008; henggeler, edwards, & borduin, 1987; stuart, 2014). the juvenile delinquency instruments were developed based on theory (anjaswarni, 2014; heilbrun, goldstein, & redding, 2005; kratcoski & kratcoski, 1990). the respondents assessed the independent variable associated with himself as the risk factors and their behavior was the dependent variable. the subject circled number 1 (strongly disagree), 2 (disagree), 3 (agree) or 4 (strongly agree) regarding the measured independent variables. for the instruments related to the dependent variable, the respondents were asked to rate the degree of frequency associated with their behavior by circling the numbers 0 (never), 1 (sometimes), 2 (often) and 3 (always). all of the data was analyzed using the spss 20.00 software. the analysis was done in two ways, descriptive and through the bivariate analysis of the risk factors (independent variables) on juvenile delinquency (dependent variable). the logistic regression test used the enter method to find out the magnitude of the influence (odds ratio) of each risk factor on the occurrence of juvenile delinquency. table 1. distribution of respondent’s characteristic based on gender, age, level of education, living with, and law case characteristic adolescent students adolescent in children’s prison n n % n % gander male 110 46,8 60 100 295 female 125 53,2 0 0 age 12 – 15 years old 73 31,1 8 13,3 295 > 15 – 18 years old 117 49,8 28 46,7 > 18 – 19 years old 45 19,1 24 40,0 level of education no school / elementary 0 0 18 30 295 junior high school 122 51,9 30 50 senior high school / vocational educational 113 48,1 12 20 living with nuclear family 191 81,3 22 38 295 father and brothers/sisters 15 6,4 12 20 mother and brothers/sisters 11 4,7 10 16 grandfather / grandmother 4 1,7 8 13 extended family 2 0,9 3 5 alone 12 5,1 5 8 law case (adolescents in children’s prison) fight/brawl/violence 12 20 60 theft/snatching/robbery 15 25 substance abuse 16 26,7 vandalism / destruction 1 1,7 obscene/ free sex/ sex abuse 8 13,3 murder 8 13,3 t. anjaswarni et al. 132 | pissn: 1858-3598  eissn: 2502-5791 this research was approved by the health research ethics commission (kepk) of the faculty of public health, airlangga university surabaya, number 534/ea/kepk/2018. based on the results of the ethical review, the research protocol was declared to have passed the ethical test and thus the study could be continued to the next research process. results the data obtained consists of interval data converted into categorical data. the following describes the results of the descriptive analysis on the distribution of the respondent’s characteristic and each variable. it also shows the results of the bivariate analysis and the effect of the risk factors (independent variables) on juvenile delinquency (dependent variable). distribution of the respondent’s characteristics the respondents consisted of two groups, 1) respondents who were adolescents in junior and senior high school, and vocational school and 2) respondents who were adolescents in the 1st class children’s prison of blitar, see table 1. descriptive analysis of the risk factors (independent variables) the results of the cross-sectional analysis (cross tabulation) between the seven risk factors are related to the individual, coping mechanism, family, school environment, peer group, lifestyle and technology factors, as shown in table 2. the results of the individual factors are divided into three categories, namely individuals with competence that is lacking, good and very good, as seen in table 2. based on table 2, it is known that most individuals have competencies in the good and very good categories. based on cross-tabulation, it is known that juvenile delinquency tends to occur where there are lacking or poor individual characteristics. coping mechanism ranges from table 2: descriptive analysis of the seven risk factors variable (risk factors) juvenile delinquency n not yes individual factors lack 33(43.4%) 43(56.6%) 76(100%) good 77(52.7%) 69(47.3%) 146(100%) very good 47(64.4%) 26(35.6%) 73(100%) total 157(53.2%) 138(46.8%) 295(100%) coping mechanism maladaptive 70(47.3%) 78(52.7%) 148(100%) adaptive 87(59.2%) 60 (47.3%) 147(100%) total 157(53.2%) 138(40.8%) 295(100%) family factors less 32(41.6%) 45(58.4%) 77 (100%) supportive 83(56.5%) 64(43.5%) 147(100%) very supportive 42(59.2%) 29(40.8%) 71 (100%) total 157(53.2%) 138(46.8%) 295(100%) school environmental factors less 23(28%) 59 (72%) 82(100%) support 84 (57.5%) 62 (42.5%) 146(100%) very supportive 50 (64.4%) 17(35.6%) 67(100%) total 157(53.2%) 138(46.8%) 295(100%) peer group factors lack of solidity 70 (80.5%) 17 (19.5%) 87 (100%) solid 79 (57.7%) 58 (42.3%) 137(100%) very solid 8 (11.3%) 63(88.7%) 71 (100%) total 157 (53.2%) 138 (46.8%) 295 (100%) lifestyle factors lack 31 (34.4%) 59(65.6%) 90(100%) good 87(60%) 58(40%) 145(100%) very good 39(65%) 21 (35%) 60(100%) total 157(53.2%) 138(46.8%) 295(100%) technology factors poor / low 78 (83.0%) 16 (17.0%) 94 (100%) enough 66(51.6%) 62 (48.4%) 128 (100%) high 13 (17.8%) 60 (82.2%) 73 (100%) total 157 (53.2%) 138 (46.8%) 295 (100%) jurnal ners http://e-journal.unair.ac.id/jners | 133 adaptive to maladaptive. the results of this coping mechanism analysis have been grouped into two trends; adaptive or maladaptive using certain cut-off points. based on table 2, it is known that juvenile delinquency tends to occur in adolescents with maladaptive coping mechanisms. the results of the family factor analysis can be divided into three categories of support; less family support, supportive, and very supportive. the results in table 2 show that most of the support that the families give to their teenagers is supportive and very supportive. based on percentage, it is known that juvenile delinquency tends to occur in families that are less supportive. the results of the analysis of the school environment factors have been divided into three categories of support, namely that the school environment is less supportive, supportive and very supportive. based on table 2, it is known that the school environment mostly provides support and that it is very supportive. based on percentage, it is known that juvenile delinquency tends to occur in a less supportive school environmental. the results of the analysis of peer groups are divided into three categories, namely the influence of peers who are lack solidity, who are solid and who are very solid. based on percentage, it is known that juvenile delinquency tends to occur in adolescents who make peer friendships that are very solid. the results of the analysis of the lifestyle factors are divided into three categories, namely that their lifestyle is lacking, good or very good. most of the teenager’s lifestyles are in the good and very good categories. based on percentage, it is known that juvenile delinquency tends to occurs in teenagers with a lack of lifestyle. the results of the analysis of the technology factors are divided into three categories, namely the poor use of technology by teenagers, using it enough and using it to a high degree. based on table 2, it is known that most teenagers use technology to a high degree. based on percentage, it is known that juvenile delinquency tends occurs in adolescents who use a lot of technology. descriptive analysis of juvenile delinquency (dependent variable) juvenile delinquency, which is the indicator in this study, contains the 6 types of hate based on the results of the previous studies. the description of juvenile delinquency based on type is as shown in table 3. based on table 3, it is known that the most juvenile behavior refers to substance use including narcotics, alcohol, psychotropics and other addictive substances (napza) in groups, in addition to violent behavior and sexual abuse or harassment. next, to find out the effect strength of the independent variables on the occurrence of juvenile delinquency, logistic regression tests were conducted using the enter method. logistic regression test analysis risk factors for juvenile delinquency the analysis results used to determine the power of influence of the risk factors (independent variable) on juvenile delinquency (dependent variable) can be identified based on the value of the odds ratio (or) as in table 4. based on table 4, the results of the analysis of the individual factors, showed that the p-value = 0.008 at alpha = 0.05, so it can be concluded that the individual factors significantly influence the occurrence of juvenile delinquency. the results of the analysis of coping mechanism, obtained a p-value = 0.186 at alpha = 0.05, so it can be concluded that the coping mechanism factors not significantly influence the occurrence of juvenile delinquency. the results of the analysis of the family factors obtained a p-value = 0.005 at alpha = 0.05, so it can be concluded that family factors significantly influence the occurrence of juvenile delinquency. the results of the analysis of the school environmental factors obtained p-value = 0.000 at alpha = 0.05, so it can be concluded that the table 3. overview of juvenile delinquency based on the type of deviant behavior type of deviant behavior low low moderate serious violent behavior 101 (34.2%) 126 (42.7%) 68 (23.1%) theft/ deprivation 143 (48.5%) 103 (34.9%) 49 (16.6%) use of drugs 140 (47.5%) 84 (28.5%) 71 (24.1%) destructive an property 80 (27.1%) 174 (59.0%) 41 (13.9%) sexual abuse / harassment 120 (40.7%) 115 (39.0%) 60 (20.3%) murder 250 (84.7%) 33 (11.2%) 12 (4.1%) table 4. analysis test results of the risk factors on the occurrence of juvenile delinquency risk factors b pvalue (sig) odds ratio (exp b) individual -0.039 0.008 0.962 coping mechanism -0.038 0.186 0.963 family -0.020 0.005 0.980 school environment -0.116 0.000 0.891 peers 0.268 0.000 1.307 lifestyle -0.111 0.000 0.895 technology 0.346 0.000 1.413 t. anjaswarni et al. 134 | pissn: 1858-3598  eissn: 2502-5791 school environmental factors significant influence the occurrence of juvenile delinquency. the results of the analysis of the peer group factors obtained p-value = 0.000 at alpha = 0.05, so it can be concluded that peer group factors significantly influence the occurrence of juvenile delinquency. the results of the analysis of lifestyle factors obtained p-value = 0.000, at alpha = 0.05, so it can be concluded that lifestyle factors significantly influence the occurrence of juvenile delinquency. the results of the analysis of technological factors obtained p-value = 0,000 at alpha = 0.05, so it can be concluded that technological factors significantly influence the occurrence of juvenile delinquency. based on table 4, it is known that of the seven risk factors, those that have a significant effect on juvenile delinquency total six, namely the variables of the individual, family, school environment, peers, lifestyle and technology. coping mechanisms do not have a significant influence on the occurrence of juvenile delinquency. the results of the analysis also show that technology is the most influential factor in terms of the occurrence of juvenile delinquency with an odds ratio (or) of 1.413. this means that the use of technology in adolescents by 1,413 times will increase the occurrence of juvenile delinquency. based on the or value, it is known that after the technological factors, the factors that influence juvenile delinquency are their peers, family, the individual, lifestyle and the school environment. discussion based on the results of the analysis, it is known that individual factors significantly influence juvenile delinquency. this is quite reasonable because every individual has the right to have the opportunity to do what they want. individuals who do not have the ability or competencies for certain life skills (hard skill and soft skill), who do not have confidence in their success in the future, who do not have a good foundation of faith, have the potential to act according to their wishes. this is in accordance with the researcher's opinion that life skills or individual competence affects juvenile delinquency (calhoun et al., 2001). this is in line with the opinion of robles that life skills in the form of soft skills are the interpersonal qualities and personal attributes that a person has (robles, 2012). soft skills are a personal and interpersonal behavior related to developing and maximizing human appearance or performance. this opinion means that if an individual has life skills or competencies, then they will show their quality of life and avoid inappropriate behavior. conversely, if individuals do not have the ability then they will do something to meet their needs by justifying any means. coping mechanism factors do not have a significant influence on juvenile delinquency. this is not in accordance with the theory that maladaptive coping mechanisms have the potential for delinquency. an individual failure when solving problems will have the potential for behavioral disorders including juvenile delinquency. the problem of juvenile delinquency when it occurs is not only determined by the tendency to use coping mechanisms. it depends on the results of the problem solving that they do and this is supported by the environment, namely the family environment, especially the role of their parents, peers and the school environment, in this case the teacher's role. folkman & lazarus cited by baqutayan (2015) explained that coping mechanisms are cognitive and behavioral efforts to master, reduce, or tolerate demands and stress. coping mechanisms are used by individuals to ease the burden of the effects of stress. this opinion is in accordance with experts who have explained that coping mechanisms are a direct effort in stress management in order to defend themselves to create adaptive behavior. coping mechanisms can be constructive or destructive (stuart, 2014). the results of the family factor analysis found that there is a significant effect on juvenile delinquency. this is accordance with the opinion of experts that the family is a risk factor that affects the occurrence of juvenile delinquency. families that influence juvenile delinquency have high levels of family dynamics, violence, poverty, family dysfunction, and poor family communication and relations (henggeler et al., 1987). this result is also in accordance with the opinion of experts who stated that parenting and bonding has an impact on the children's development. poor parenting results in poor mother-child bonding (poor bonding) which can eventually lead to criminal behavior in children (tremblay & craig, 1997). in the opinion of the researchers, family factors are a risk factor that has a great potential for juvenile delinquency. this should get serious attention. currently, family factors are not a dominant risk factor. there are other factors that are more dominant. this opinion is quite reasonable because each individual child learns life starting from the family environment. families have a significant role in the success of their children in both the present and future. school environment factors significantly influence juvenile delinquency. this is in accordance with experts who state that the school environment is an environment outside of the family that contributes to juvenile delinquency (calhoun et al., 2001). in the opinion of researchers, this is quite reasonable because schools are places where their peers meet, which also has a strong influence on adolescent behavior. the incompatibility of the school policies or rules and the pattern of the teacher-student relations creates the potential for adolescents to rebellion against the existing rules. peers have a significant effect on juvenile delinquency. this is also in line with the researcher jurnal ners http://e-journal.unair.ac.id/jners | 135 who found that juvenile delinquency is related to peer influence, antisocial behavior, and the quality and level of relationships in the group (howell & lipsey, 2012). this is further explained by other experts where bad friendships can result in problems in schools which can eventually lead to criminal behavior in children (tremblay & craig, 1997). in the opinion of the researcher, this is quite reasonable because peers have a big influence. this is because friendships are their main concern. at the age of adolescence, children are more likely to gather with their peers than with their parents. teenagers are comfortable if they gather with their peers because they have the same problems. thus, if the peer group is bad, then it will also have a negative impact on the individual adolescents. lifestyle factors significantly influence juvenile delinquency. this is in accordance with the theory that a good lifestyle will have a good impact on adolescents. conversely, a bad lifestyle will have an adverse effect on adolescents. sleep rest patterns explain that sleep disorders or poor sleep patterns will interfere with emotional stability. individuals become irritable as a result. emotional disorders that occur due to disturbances related to sleep patterns that are not good will have the potential for violence (taylor, lillis, lemone, & lynn, 1997). likewise, the habit of an exercise activity or recreation can reduce tension so as to make the individual behavior more adaptive. the inappropriate use of leisure time and recreational culture will have an impact on health (tekin, 2010). technological factors significantly influence juvenile delinquency. this is in accordance with the opinion which explains that the development of information and communication technology through the internet and cellphones (cellphones) is a phenomenon of modern society that cannot be stopped. this can have an impact on society, both positive and negative (abdulkarim et al., 2014). this result is quite relevant because of the phenomena of life in today's technological era, making the internet and cellphones a necessity. individuals are more pleased with cyberspace than the world of reality by using the internet and cell phone facilities that they have. related to the six indicators of juvenile delinquency behavior, it is known that most juvenile behavior relates to the use of substances including narcotics, alcohol, psychotropics and other addictive substances (napza). this is in addition to violent behavior and sexual abuse. in the opinion of the researchers, this is quite reasonable because adolescence is a period of crisis. it is a period where the person is always curious, and it is a period of trial and error. the amount of information from the various media about substance users (drugs) can stimulate the teens to try them. likewise with violence and sexual abuse. for violence, it is usually driven by a high tolerance for the group or selfesteem that is too high so then they are very sensitive to criticism. regarding sexual abuse, they are usually driven by curiosity and trial and error after being exposed images or videos obtained from downloads from electronic media. furthermore, the results of the logistic regression test with the enter method make it known that there are six risk factors that significantly influence juvenile delinquency, namely individual, family, school environment, peers, lifestyle and technology variables. coping mechanisms do not have a significant influence. associated with coping mechanisms not having a significant effect, in the opinion of the researchers, this is because these factors are not dominant in terms of influencing adolescent attitudes and they are internal. it is known that external factors are factors that have a more powerful influence on adolescents. the possibility of a coping mechanisms will be maladaptive if the external push is too strong in adolescents. the problem of juvenile delinquency is not only determined by the tendency to use coping mechanisms, but it also depends on how they are supported by the environment, especially the family environment, which relates to the role of the parents. the results of the analysis also show that technology is the most influential factor in juvenile delinquency when compared to the other factors. this is in accordance with the opinion that explains that the development of information and communication technology through the internet and cellphones (cellphones) is a phenomenon of modern society which can have an impact on society itself both positively and negatively (abdulkarim et al., 2014). there has been a significant shift in social life related to the cause of adolescent problems. previous research explains that the family is a dominant factor related to the causes of adolescent problems. at this time, the cause of problematic youths (juvenile delinquency) has shifted from the original family and peer factors as the dominant factors to the technological factor. this is quite reasonable because currently, technology has become a major requirement for adolescents. every day, every person and not only teenagers but also children, adults and even old people, use gadgets for their needs. these needs can include games, socializing, communication, or for educational, work and business needs. nowadays, technology is a vital thing. according to the results of the study, prevention efforts are needed to prevent the occurrence of juvenile delinquency. one of the suggested prevention methods is early detection of risk or potential juvenile delinquency by examining the influential risk factors. adolescents should be wise when utilizing technology and choosing their peers. their parents and teachers could and should provide good relations and communication in order to create a conducive environment at home and in school. t. anjaswarni et al. 136 | pissn: 1858-3598  eissn: 2502-5791 conclusion technology is the factor that has the most influence on juvenile delinquency. inappropriate use of technology, for example, the wrong use of gadgets, has the potential for juvenile delinquency. this shows that in the current digital era, there has been a significant shift in the causes of juvenile delinquency, from family and peer factors to technological factors. this is reasonable because technology is now a major need for teenagers. based on these results, further analysis is needed regarding the indicators of the factors that influence juvenile delinquency in order to develop new instruments for the purpose of the early detection of juvenile delinquency behavior. references abdulkarim, a., sriyanto, zainul, a., & maryani, e. (2014). perilaku asertif dan kecenderungan kenakalan remaja berdasarkan pola asuh dan peran media massa. jurnal psikologi, 41(1), 74– 88. anjaswarni, t. (2014). juvenile delinquency, kenakalan remaja: teori, hasil penelitian dan aplikasi asuhan keperawatan. sidoarjo: zifatama publisher. badan pusat statistik. (2010). profil kriminalitas remaja 2010: studi di lembaga pemasyarakatan (lapas) anak di palembang, tangerang, kutoarjo, dan blitar. retrieved from https://www.bps.go.id baqutayan, s. m. s. (2015). stress and coping mechanisms: a historical overview. mediterranean journal of social sciences, 6(2 s1), 479. calhoun, g. b., glaser, b. a., & bartolomucci, c. l. (2001). the juvenile counseling and assessment model and program: a conceptualization and intervention for juvenile delinquency. journal of counseling & development, 79(2), 131–141. delisi, m., vaughn, m. g., gentile, d. a., anderson, c. a., & shook, j. j. (2013). violent video games, delinquency, and youth violence: new evidence. youth violence and juvenile justice, 11(2), 132– 142. heath, c. j., & berman, j. s. (2008). evolutionary lifestyle and mental health. evolutionary psychology, 6(1), 147470490800600100. heilbrun, k., goldstein, n. e. s., & redding, r. e. (2005). juvenile delinquency: prevention, assessment, and intervention. oxford university press. henggeler, s. w., edwards, j., & borduin, c. m. (1987). the family relations of female juvenile delinquents. journal of abnormal child psychology, 15(2), 199–209. howell, j. c., & lipsey, m. w. (2012). based guidelines for juvenile justice programs. justice research and policy, 14(1), 17–34. kratcoski, p. c., & kratcoski, l. d. (1990). juvenile delinquency. prentice-hall englewood cliffs, nj. nursalam, m. (2014). metodologi penelitian ilmu keperawatan edisi 3. jakarta. penerbit salemba medika. robles, m. m. (2012). executive perceptions of the top 10 soft skills needed in today’s workplace. business communication quarterly, 75(4), 453– 465. steketee, m., & gruszczyńska, b. (2010). juvenile delinquency in six new eu member states. european journal on criminal policy and research, 16(2), 111–125. stuart, g. w. (2014). principles and practice of psychiatric nursing-e-book. elsevier health sciences. taylor, c., lillis, c., lemone, p., & lynn, p. a. (1997). fundamentals of nursing: the art and science of nursing care. lippincott-raven. tekin, a. (2010). wild life recreation: utilizing wilderness adventure therapy to prevent delinquency in minors. journal of human sciences, 7(2), 640–654. tremblay, r. e., & craig, w. m. (1997). developmental juvenile delinquency prevention. european journal on criminal policy and research, 5(2), 33–49. wiyani, n. a. (2014). psikologi perkembangan anak usia dini. yogyakarta: gava media. http://e-journal.unair.ac.id/jners | 351 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3.18069 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family counselling enhances environmental control of allergic patients santi dwi lestari, lailatun nikmah, ninuk dian kurniawati faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: allergies can cause complications such as inadequate nutrition, impaired sleep quality, and inhibition of child growth and development. there were about 15% children who suffered from dust allergies in 2017 in indonesia. parents lacking of knowledge about environmental control can increase the prevalence of allergic relapse in children. counselling is a method of health education that aims to improve knowledge, and practice. the purpose of this study was to investigate whether counselling has any influence on allergic related knowledge and environmental control measures skills. methods: the design of study was a pre-experiment design. there were 14 respondents in this study who were recruited at a university hospital based on inclusion criteria with consecutive sampling. the independent variable was counselling, the dependent variable were knowledge and environmental control measures. data were collected using both a questionnaire was developed from the aaaai and a check list was used to determine parents' skills on environmental controls. data were analysed using wilcoxon sign rank test with significance level of α<0,05. results: there was an influence of counselling on knowledge and environmental control measures (knowledge level, p= 0,001; practice level p= 0,001). conclusion: it is concluded that counselling is significantly increased knowledge and environmental control measures level. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords allergy; house dust mites; environmental control; counselling; knowledge; practice contact ninuk dwi kurniawati  ninuk.dk@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: lestari, s.d., nikmah, l., kurniawati, n.d. (2019). family counselling enhances environmental control of allergic patients. jurnal ners, special issues, 351-356. doi:http://dx.doi.org/10.20473/jn.v14i3.18069 introduction despite its importance, the parents’ knowledge and skills regarding house dust mites-environmentalcontrol are still lacking (callahan et al., 2003). globally, a review concluded that awareness of this type of allergy remains low (calderón et al., 2015). if left untreated, the environment full of house dust mites will cause allergy and asthma attack to sensitive individual (hauptman, peden, & phipatanakul, 2018; leas et al., 2018; wilson & platts-mills, 2018). knowledge of parents with children allergic to house dust mites in the allergy outpatient room at the airlangga university hospital regarding environmental control to reduce the house dust mite population is still inadequate. a survey conducted on march 5, 2018. showed that there were 3 out of 3 parents (100%) who were unable to provide the right answer when they were given questions about how to wash linen to reduce the population of house dust mites; and 2 out of 3 parents (66%) have not been able to provide appropriate answers on how to clean the environment to reduce the population of house dust mites. existing studies on environmental controls that have been carried out shows that the knowledge of parents with house dust mite allergic children on environmental control is still low, even in 2003 after being given health education only 50% of parents had good knowledge regarding environmental control. allergy is a hypersensitivity reaction due to induction by ige that is specific to certain allergens, which binds to mast cells. allergens are ingredients that are generally harmless and are found in many environments but can cause allergic reactions if in contact with allergic patients (ghosh et al., 2018; leas https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ninuk.dk@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3. s. d. lestari et al. 352 | pissn: 1858-3598  eissn: 2502-5791 et al., 2018; van boven, arends, braunstahl, & gerth van wijk, 2019; wilson & platts-mills, 2018; wistiani & notoatmojo, 2011). in sort, allergies to house dust mites are a hypersensitivity reaction to house dust mite allergens. dust and dust mites are the most common allergens in the room and most often cause allergies (burge & rogers, 2000; cipriani, calamelli, & ricci, 2017; fujita, matsui, & ito, 2015; leas et al., 2018; reisacher, 2011; rogers, 2003; syarifah, 2016; wilson & platts-mills, 2018; wistiani & notoatmojo, 2011). house dust mites are the most common allergens found in rooms such as in the carpets and beds (calderón et al., 2015; thomas, 2015, 2018). house dust mites are animals of the araknoidea class (leas et al., 2018; rofieq, 2012). stools and debris from house dust mites can cause allergy (judarwanto, 2016; svendsen, gonzales, & commodore, 2018). home dust mite allergies can be reduced by environmental controls (reisacher, 2011; sativa, 2017) however, parents' knowledge of environmental control is considered to be lacking. the prevalence of allergies in the world has continued to increase for more than 50 years. the results of sensitization tests for one or more common allergens in 2016 among school children are close to 40% -50% worldwide. in 2012, 10.6% or 7.8 million children reported respiratory allergies (quamila, 2017). the number of children with allergies in indonesia is estimated at 15% (judarwanto, 2016). the results of research by the university of indonesia showed an increase in the percentage of children under 12 years of age with allergies to pollution and dust up to four times in the last 20 years, from 2% in 1980 and reaching 8% in 2000 (sánchez-borges et al., 2017). knowledge of parents who met the good category amounted to only 50% after being given health education in west virginia in 2003. large number of accessible information about environmental controls to reduce the population of house dust mites, such as mass media, seminars and other health education does not necessarily improve parents' knowledge of environmental control. lack of knowledge of parents about environmental control can increase the prevalence of allergic events in children. allergies can cause other complications such as inadequate nutrition, disruption of the quality of sleep, inhibition of growth and development of children (lorensia, sari, klinis-komunitas, & apoteker, 2017). counselling accompanied with leaflet as media on how to properly control the environment can be given to parents who have kids suffering allergy to house dust mites to enhance the parents’ knowledge regarding allergic environmental control. counselling are chosen because it is not only improving knowledge, but also provide ample time for parents with individual consultation; thus, it can help resolve individual obstacles in controlling the environment. counselling is expected to be able to play a role in the process of behaviour change, namely awareness, interest, evaluation, trial and adoption of the behaviour; therefore, the parents' knowledge, attitude, skills and environmental control measures of house dust mites will increase, resulting in the suppression of the prevalence of allergies. the purpose of this study was to investigate whether counselling has any influence on allergic related knowledge and environmental control measures skills. materials and methods the research design used was pre-experiment with one-group pre-post-test design. the process of data collection was carried out in july, 2018 at an outpatient clinic of allergy of a university hospital in east java. the independent variable in this study was counselling regarding environmental control given to parents or children. the dependent variable in this study is the knowledge and actions of parents or children in environmental control to reduce the population of house dust mites. the population of this study were parents and children with children allergic to house dust mites who were treated at outpatient clinic of allergy universitas airlangga hospital surabaya in july 2018. respondents of 14 people were obtained using consecutive sampling with inclusion criteria: 1) parents with children who were suffering allergies to house dust mites, 2) parents or children with children who were seeking treatment at outpatient clinic of allergy universitas airlangga hospital surabaya 3) parents or children with at least elementary education 4) parents or children who underwent immunotherapy programs every 1 week and 3 weeks . data collection techniques were carried out using a knowledge questionnaire developed from continuing medical education questions examinations sourced from the american academy of allergy, asthma & immunology (aaaai) (tamsuri, 2008) and a check list instrument to determine parents' actions towards environmental controls to reduce house dust mite populations. right. data analysis used the spss 16.0 for windows program and tested the wilcoxon signed rank test statistically, namely p 5 0.05. this research has passed the ethical review from the health research jurnal ners http://e-journal.unair.ac.id/jners | 353 ethics commission at the airlangga university hospital in surabaya and received the research protocol approval with number 160 / keh / 2018. results based on table 2. the majority of respondents had never received other information regarding environmental control before counselling as many as 9 people (64%). a total of 4 respondents received information about environmental control more than 3 months ago or 28.5% of the total respondents. all respondents who had received information about environmental control came from other health education or 36% of the total respondents, and 1 respondent who accessed information about environmental control through the internet in addition to getting other health education or 7% of the total respondents. table 3. shows the wilcoxon signed rank test results. wilcoxon signed rank test is used to test for differences in pre-test and post-test results. the pretest results revealed that the knowledge level of most of the 8 respondents scored less (57%) before being given counselling. an increase in the level of knowledge after being given counselling was 12 respondents (86%) had a good level of knowledge. the wilcoxon signed rank test results obtained p = 0.001 so that p <0.05. this shows that there are differences between the results of the pre-test and post-test. it can be concluded that there is an effect of counselling on the knowledge of environmental control of parents with children allergic to house dust mites. based on table 3, it is known that most of the 7 respondents (50%) were in category of poor in skills of house-dust-mites-allergy environmental control before being given counselling. the level of skills had increased after counselling, which was 9 respondents (64%) in the good category. the wilcoxon signed rank test between pre and post intervention was p = table 1. respondents’ characteristics of family counselling improves environmental control of house-dust-mites. characteristics of respondents n % respondents’ age (year old) 20-29 4 28.5 30-39 7 50 > 40 3 21.5 kid’s age (year old) < 1 1 7 1-3 4 28.5 3-5 5 36 5-6 1 7 6-18 3 21.5 education basic education (grades 1-6) 1 7 basic education (grades 7-9) 1 7 secondary education (grades 10-12) 8 57 higher education 4 29 table 2. information regarding environmental control of house-dust-mites allergy. category n % have received information yes 5 36 no 9 64 when was the last information received (in month) < 3 1 7 > 3 4 28.5 source of information other health education sources 5 36 the internet 1 7 table 3. parents’ knowledge and skills regarding the environmental control of house-dust mites-allergy at pre and post intervention. level knowledge skills pre post pre post n % n % n % n % good 1 7 12 86 1 7 9 64 average 5 36 1 7 6 43 5 36 poor 8 57 1 7 7 50 0 0 mean 4.79 8.64 2 3.64 standar deviation 2.007 1.393 1.359 0.497 p (wilcoxon signed rank test) 0.001 0.001 s. d. lestari et al. 354 | pissn: 1858-3598  eissn: 2502-5791 0.001, suggesting that there were differences between the results of the pre-test and post-test. it can be concluded that there was an effect of counselling on environmental control measures of parents with children allergic to house dust mites. discussion parents’ knowledge of after counselling has increased compared to before counselling. before being given counselling the level of knowledge of the majority of respondents was in the less category while only one respondent was in the good category. after counselling, post-test results show that counselling can facilitate an increase in the level of knowledge of parents towards environmental controls for allergic children to be better. this is indicated by the majority of respondents in the good category, one respondent in the sufficient category and one respondent in the less category. research conducted by lorensia shows that education is effective in increasing knowledge (soekidjo notoatmojo, 2007). health education controls the environment with counselling methods is the right method for parents with allergic children, because counselling can provide assistance to respondents to develop knowledge, and behaviour (soekidjo notoatmojo, 2003). this is consistent with the an existing knowledge developed by lawrence green which divides factors that influence health behaviour into three, namely predisposing factors, supporting factors, and driving factors (l. w. green, 1984). predisposing factors consist of knowledge, attitude, age, and education (soekidjo notoatmojo, 2003, 2007). supporting factors consist of health service personnel and information (l. w. green, 1984). the driving factor consists of family support, health workers, and community leaders. the existence of supporting factors in this case information can increase one's knowledge (l. w. green, 1984). the level of knowledge is also influenced by the learning process (soekidjo notoatmojo, 2007). the learning process is influenced by the conditions of the subject of learning, among others, capture power, intelligence, memory, motivation and so on. rogers (soekidjo notoatmojo, 2005) argues that before accepting an object of learning a sequential process occurs: awareness (the subject is aware of the learning object), interest (the subject feels attracted to the object), evaluation (the subject evaluates the bad or bad object), trial (the subject starts trying to do something in accordance with the object or stimulus), adaption (the subject behaves new in accordance with the knowledge, awareness and attitudes obtained) 21). notoatmodjo argues, one of the factors that influence knowledge is education (soekidjo notoatmojo, 2003). knowledge is closely related to education (soekidjo notoatmojo, 2005). it is expected that the higher the level of education of a person, the higher the knowledge he has. besides education, there are many factors that can affect one's knowledge, including age and experience. the thinking ability will be more mature as the person is getting older. personal experience can also be used as a source of knowledge (tamsuri, 2008). some respondents who have sufficient level of knowledge and one respondent who has a good level of knowledge before being given counselling can occur because respondents have previously obtained information on environmental control from other sources, namely health education received by respondents when children are allergic test respondents and respondents actively seek information through the internet. the demographic data of respondents showed that the majority of respondents were in the category of 30-39 years so that most respondents were still classified as productive age who were still able to digest various information so that respondents could still be active and continue to learn so that the level of knowledge they possessed became better. table 1.4 shows a change in knowledge from 57% of respondents in the category of knowledge level less than 86% of respondents are in the category of good knowledge level. in accordance with the theory of notoatmodjo, the provision of information can facilitate the learning process of individuals to gain a new knowledge (skinner, 1963). counselling can be the best choice in providing health education because counselling implements two-way communication between clients and counsellors so that perceptual inequality can be reduced. another advantage of counselling is the content of counselling based on the problems faced by the client so that the health problems experienced by the client can be solved. however, giving counselling cannot change the knowledge of all respondents. there is one respondent who has not experienced an increase in knowledge; this may be due to several factors including: the age of the respondents who are older than other respondents, and the lack of concentration of respondents during the counselling process takes place. knowledge or cognitive is a very important domain in shaping one's actions (covert behaviour) (soekidjo notoatmojo, 2007). the process of jurnal ners http://e-journal.unair.ac.id/jners | 355 changing respondents' knowledge through counselling will result in changes in house-dust-mite environmental control measures for allergy prevention. the parents’ skills after counselling have increased compared to before counselling. before being given counselling the majority of respondents’ level of skills were in the poor category while only one respondent was in the good category. after counselling, the post-test results showed that counselling can facilitate an increase in the level of parents’ skill for environmental control for allergic children. this is shown in table 1.5 that the majority of respondents became showed good skills in environmental control and some showed sufficient skills. this finding shows that the health education of environmental control with counselling method is the right method for parents with allergic children, because counselling can provide assistance to respondents to develop knowledge, and behaviour (soekidjo notoatmojo, 2007). skinner argues that behaviour is a certain order in terms of feelings (affections), thoughts (cognitions), and predisposing actions (conation) of someone to an aspect in the environment (soekidjo notoatmojo, 2003). action is the realization of a person's knowledge and attitudes in a real act (tamsuri, 2008). changes in actions can occur through processes or stages of change, namely knowledge, attitudes, and actions, which means that someone will only be able to perform well if the person already has a good knowledge and followed by a positive attitude. nevertheless, some study found the different phenomenon: person can perform well even though they have poor knowledge and attitudes they have are still negative (rogers, 2003). anas (l. green, 1991) states that the actions of an individual can arise not necessarily based on knowledge and attitude. while rogers (soekidjo notoatmojo, 2007) argue the sustainability of a skill or performance unsupported with a good knowledge; if a behaviour is not based on knowledge and awareness then the behaviour will not last long. comparison of respondent's actions before and after counselling can be seen in table 1.5 before giving counselling the majority of respondents included in the category of poor skill and action in term of controlling the environment, while only one respondent in the category of good action level. the majority of respondent had not been able to choose the right linen and to choose the right temperature for environmental control. at post interventions, the level of action of the majority of respondents increased to a good category, and some were in average category. these findings can best explained with the precede-procede-lawrence green-theory which assert that the provision of health education can change predisposing factors, supporting factors, and driving factors. the current study targeting the predisposing factors to change the respondents’ knowledge; knowledge acquisition was considered as the important factors formed new skills and actions of environmental control. the process of forming actions goes through stages, such as perceptions, guided responses, mechanisms, and adoption (soekidjo notoatmojo, 2007). counselling can be the best choice in providing health education because counselling implements two-way communication between clients and counsellors so that perceptual inequality can be reduced. another advantage of counselling is the content of counselling based on the problems faced by the client so that the health problems experienced by the client can be solved. some respondents still cannot the right temperature of water used to clean the house for environmental control; this may be due to several factors, among others: lack of enthusiasm of respondents, lack of concentration of respondents and research rooms that use air conditioner so that it can cause respondent's body temperature to cool down. conclusion an increase in the level of knowledge of parents regarding environmental control after counselling. moreover, there was an increase in the level of parental action regarding environmental control after counselling. the results of this study are expected to be the initial data for the next researcher in analyzing and examining parents' knowledge of environmental control. the next researcher is expected to be able to examine the attitude variables that have not been studied in this study, test the validity of the questionnaire used and choose another place for research data collection other than in poly, or can do door to door for research data collection. references burge, h. a., & rogers, c. a. (2000). outdoor allergens. environmental health perspectives, 108(suppl. 4), 653–659. calderón, m. a., linneberg, a., kleine-tebbe, j., de blay, f., hernandez fernandez de rojas, d., virchow, j. c., & demoly, p. (2015). respiratory allergy caused by house dust mites: what do we really know? journal of allergy and clinical immunology, 136(1), 38–48. s. d. lestari et al. 356 | pissn: 1858-3598  eissn: 2502-5791 https://doi.org/10.1016/j.jaci.2014.10.012 callahan, k. ., eggleston, p. ., rand, c. ., kanchanaraksa, s., swarts, l. ., & wood, r. . (2003). knowledge and practice of dust mite control by specialty care. annals of allergy, asthma, and immunology, 90(3), 302–307. cipriani, f., calamelli, e., & ricci, g. (2017). allergen avoidance in allergic asthma. frontiers in pediatrics, 5(may). https://doi.org/10.3389/fped.2017.00103 fujita, m., matsui, t., & ito, a. (2015). biomedical insights into cell adhesion and migration-from a viewpoint of central nervous system tumor immunology. front cell dev biol, 3(october), 55. https://doi.org/10.3389/fcell.2015.00055 ghosh, a., dutta, s., podder, s., mondal, p., laha, a., saha, n. c., … saha, g. k. (2018). sensitivity to house dust mites allergens with atopic asthma and its relationship with cd14 c(-159t) polymorphism in patients of west bengal, india. journal of medical entomology, 55(1), 14–19. https://doi.org/10.1093/jme/tjx178 green, l. (1991). health promotion planning, an educational and environmental approach (mayfield p). california. green, l. w. (1984). modifying and developing health behavior. annual review of public health, 5, 215–236. hauptman, m., peden, d., & phipatanakul, w. (2018). environmental control: the first tenet of allergy. journal of allergy and clinical immunology: in practice, 6(1), 36–37. https://doi.org/10.1016/j.jaip.2017.10.022 judarwanto, w. (2016). alergi makanan: intoleransi makanan. leas, b. f., d’anci, k. e., apter, a. j., bryant-stephens, t., lynch, m. p., kaczmarek, j. l., & umscheid, c. a. (2018). effectiveness of indoor allergen reduction in asthma management: a systematic review. journal of allergy and clinical immunology, 141(5), 1854–1869. https://doi.org/10.1016/j.jaci.2018.02.001 lorensia, a., sari, n. p., klinis-komunitas, d. f., & apoteker, p. s. (2017). efektivitas edukasi untuk meningkatkan pengetahuan masyarakat dalam penanganan rinitis alergi. 3(2), 122–132. quamila, a. (2017). 3 alergi paling umum di indonesia. reisacher, w. r. (2011). allergy treatment: environmental control strategies. otolaryngologic clinics of north america, 44(3), 711–725. https://doi.org/10.1016/j.otc.2011.03.019 rofieq, a. (2012). a model of allergen inhalant reduction level on house dust based on domestic environment management and characteric. proceeding biology education conference, 633–641. surakarta. rogers, c. a. (2003). indoor fungal exposure. immunology and allergy clinics of north america, 23, 501–518. sánchez-borges, m., fernandez-caldas, e., thomas, w. r., chapman, m. d., lee, b. w., caraballo, l., … capriles-hulett, a. (2017). international consensus (icon) on: clinical consequences of mite hypersensitivity, a global problem. world allergy organization journal, 10(1), 1–26. https://doi.org/10.1186/s40413-017-0145-4 sativa, r. l. (2017). di indonesia, dua hal ini yang paling sering picu alergi anak. skinner, b. f. (1963). operant behaviour. americant psychologist, 18(8), 503–515. https://doi.org/http://dx.doi.org/10.1037/h0 045185 soekidjo notoatmojo. (2003). pendidikan dan perilaku kesehatan. jakarta: rineka cipta. soekidjo notoatmojo. (2005). metodologi penelitian kesehatan (2nd ed.). rineka cipta. soekidjo notoatmojo. (2007). promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta. svendsen, e. r., gonzales, m., & commodore, a. (2018). the role of the indoor environment: residential determinants of allergy, asthma and pulmonary function in children from a usmexico border community. science of the total environment, 616–617, 1513–1523. https://doi.org/10.1016/j.scitotenv.2017.10.1 62 syarifah, f. (2016, october). waspadai 7 penyebab alergi paling umum. liputan 6.com. tamsuri, a. (2008). konseling dalam keperawatan. jakarta: egc. thomas, w. r. (2015). hierarchy and molecular properties of house dust mite allergens. allergology international, 64(4), 304–311. https://doi.org/10.1016/j.alit.2015.05.004 thomas, w. r. (2018). ige and t-cell responses to house dust mite allergen components. molecular immunology, 100(november 2017), 120–125. https://doi.org/10.1016/j.molimm.2018.03.01 6 van boven, f. e., arends, l. r., braunstahl, g. j., & gerth van wijk, r. (2019). a re-introduction of environmental mite allergen control strategies for asthma treatment and the debate on their effectiveness. clinical & experimental allergy, (september 2018), 1–10. https://doi.org/10.1111/cea.13340 wilson, j. m., & platts-mills, t. a. e. (2018). home environmental interventions for house dust mite. journal of allergy and clinical immunology: in practice, 6(1), 1–7. https://doi.org/10.1016/j.jaip.2017.10.003 wistiani, & notoatmojo, h. (2011). hubungan pajanan alergen terhadap kejadian alergi pada anak. saripediatri, 13(3), 185–190. 124 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.16421 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the affirmation – tapping on pain perception and serotonin serum level of post – caesarian section patients joko suwito1, suhartono taat putra2, agus sulistyono2 1 medical surgical nursing department, poltekkes kemenkes surabaya, east java, indonesia 2 faculty of medicine, universitas airlangga, surabaya, east java, indonesia abstract introduction: affirmation tapping interventions have been shown to reduce pain complaints in post-operative patients completing conventional treatment. this is thought to be due to serotonin performance but clinical studies have not been conducted. the aim was to compare the mean perception of the pain reported by post-operative patients given affirmationtapping treatment with another treatment as a complementary nursing intervention. this was to see if the performance of the serotonin serum level is different from in other treatments. methods: we used a randomized post-test only control group design carried out in parallel in post-caesarean section patients. the sample totaled 40 patients divided into four groups (10 in affirmation, 10 in tapping, 10 in affirmation-tapping and 10 in the control). they were obtained through simple random sampling. the instruments included affirmation-tapping guidelines, elisa kits and the mcgill melzack pain questionnaire short-form (mpqsf). the independent variable was the intervention of affirmation-tapping and the dependent variables were pain perception and serotonin level. the data was analyzed using simple linear regression. results: the average variant of the serotonin levels in the affirmation-tapping treatment group was higher and thus differed significantly from the other groups. conclusion: affirmation-tapping as a complementary nursing intervention can increase the serotonin serum levels of the post-caesarean section patients by complementing conventional treatments. participant pain complaints were lowest in the affirmation-tapping group with the highest serotonin levels present and these were significantly different to the other groups. affirmation – tapping was recommended as a complementary intervention in nursing post-operative patients that complements conventional treatment. article history received: dec 04, 2019 accepted: dec 16, 2019 keywords affirmation – tapping; complementary; pain; serotonin serum contact joko suwito  jokosw@poltekkesdepkessby.ac.id  medical surgical nursing department, poltekkes kemenkes surabaya, east java, indonesia cite this as: suwoto, j., nursalam, n., putra, s. t., & sulistyono, a. (2019). the affirmation – tapping on pain perception and serotonin serum level of post – caesarian section patients. jurnal ners, 14(2), 124-128. doi:http://dx.doi.org/10.20473/jn.v14i2.16421 introduction post-operative acute pain complaints result in tachycardia, increased blood pressure, decreased alveolar ventilation, and ultimately, wound healing disorders. acute pain complaints can be chronic if it is not treated immediately. due to neural sensitization centrally and peripherally from the n-metil-daspartate (nmda) activation process, this results in long-term potentiation (long-term potentiation), so the pain complaint lasts longer (argoff., 2014). despite the treatment, there are still many complaints of post-operative pain felt by the client. severe pain after cardiac surgery was reported by 28% of patients (bordoni, marelli, morabito, sacconi, & severino, 2017), pain after thoracic surgery was reported in 25% of patients, even to be point of it being chronic. moderate post-sectional caesarean pain was reported in 48.2% of patients, and the incidence of pain was 92,7% (ic 95%: 90,9 -94,2). the average level of pain intensity at the time of worst pain was 6,6 (dp=2,2) (silva, silva, & tatagiba, 2017). complaints of pain result in a disruption of the healing process, wound healing (argoff., 2014) and a disruption of productivity (kawai, kawai, wollan, & https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 125 yawn, 2017). an incomplete pain intervention will reduce a person's quality of life (gibbs et al., 2019). affirmation tapping has been proven to deal with pain complaints, but the scientific proof and how its mechanism of action works needs to be examined. post-operative pain from moderate to severe levels is still perceived by more than half of all patients who have undergone surgery, despite receiving treatment as a standard post-operative patient (ward, guest, goodall, & bantel, 2018; komann, weinmann, schwenkglenks, & meissner, 2019). recommendations for post-operative pain management with treatment includes both drugs and non-drugs, as well as treatment-free therapy (chou et al., 2016) and complementary approaches with affirmation – tapping (mudatsyir, k, & sundari, 2012; wijiyanti, 2010). post-operative nursing care management with affirmation-tapping has been done through the spiritual emotion freedom technique (seft) method in post-operative patients and it provides good benefits (mudatsyir et al., 2012; wijiyanti, 2010). reciting qur'anic verses as a prayer has also helped to reduce the pain of post-operative patients (beiranvand, noaparast, eslamizade, & saeedikia, 2014). the complementary nursing approach has consistently been in line with the nursing care policy, particularly for managing nursing pain. this is still rarely done due to the limited scientific support regarding the performance and effectiveness of complementary affirmative nursing interventions (chou et al., 2016; who, oecd, 2018). the aim was to compare the mean perception of pain reported by post-operative patients given the affirmation – tapping treatment with another treatment as a complementary nursing intervention. this proves that the performance of the serotonin serum level is different from how it is in other treatments, where the affirmative sentences are used as a prayer. they take verses from the qur'an and this is still combined with the stimulation of several acupoints simultaneously. materials and methods this study used a randomized post-test controlled group design in parallel for all treatment groups. the sample of the study was a portion of post-operative caesarean patients taken through simple random sampling for as many as 40 respondents (sakpal, 2010). randomized assignment was then carried out so then there were ten respondents for each group of affirmation, tapping, affirmation-tapping and the control. the criteria for inclusion in the sample was 1) muslim patients post-caesarean section who volunteered to participate after obtaining an explanation and 2) they were approached on the first day after surgery, 3) they were aged 18 41 years, 4) they had no complications outside of pregnancy and childbirth and 5) they received anti-pain treatment according to hospital standards the independent variable was the intervention of affirmation-tapping and the dependent variables were pain perception and serotonin level. the data collection tools were 1) the guidelines of the affirmation tapping procedure, 2) the mcgill melzack pain short-form questionnaire with permission from prof. melzack, with the language adjusted accordingly (katz & melzack, 2011)(hargiyanto, 2008) and 3) the equipment used for taking venous blood specimens (simundic et al., 2017). the serotonin level was analyzed using elisa kits (elabscience, 2019), carried out by the institute of tropical disease (itd) universitas airlangga. the elisa kit used the competitive-elisa principle. the micro elisa plate provided in this kit was pre-coated with st/5-ht. during the reaction, st/5-ht in the sample or standard competes with a fixed amount of st/5-ht on the solid phase supporter for sites on the biotinylated detection ab specific to st/5-ht. excess conjugate and unbound sample or standard were washed from the plate, and avidin conjugated to horseradish peroxidase (hrp) was added to each microplate well and incubated. an tmb substrate solution was then added to each well. the enzymesubstrate reaction was terminated by the addition of a stop solution and the color change was measured spectrophotometrically at a wavelength of 450 nm ± 2 nm. the concentration of st/5-ht in the samples was then determined by comparing the od of the samples to the standard curve (elabscience, 2019). all groups got standard treatment, with the affirmation treatment groups getting these plus affirmations for 10 minutes. the tapping group added tapping for 5 minutes while the affirmation group tapping added affirmations and tapping at the same time for 10 minutes. the control group only received standard treatment four hours after the end of the anesthesia. the distance between the treatments was 8 hours, and they were given four treatments. following this, 10 minutes after the last treatment, the pain perception data was collected using mpqsf. the venous blood specimen was then taken for the examination of the serotonin levels using the elisa method. the data analysis was directed at examining the different effects of serotonin on pain perception due to affirmation tapping. the serotonin data processing and pain perception of the four groups was performed through simple linear regression with a defined level of significance of 95%. the research protocol obtained an ethical approval certificate from the surabaya ethics hospital health research commission, number 073/37/kom.etik/2017. results the characteristics of the participants from all groups have been listed in the following table. the oldest mean age was 32,1 (± 5,8) and the youngest was 29,3 (± 6,1). the highest body weight was 56,5 (± 7,8). the highest body height was 164,5 (± 8,8) and the lowest was 159,6 (± 4,6). the highest systolic pressure was j. suwito, et al. 126 | pissn: 1858-3598  eissn: 2502-5791 127,9 (± 4,3) and the lowest was 125,5 (± 5,0). the highest diastolic pressure was 84,0 (± 7,0) and the lowest was 78,6 (± 5,1). the highest pulse frequency was 88.2 (± 0,6) and the lowest was 84,6 (± 3,8). the highest respiratory rate was 21,2 (± 2,1) and the lowest was 20,4 (± 2,1). the data on age, weight, height, systolic and diastolic pressure, pulse and breathing is normally distributed (-2 <skewness ratio <2), so comparative analysis can be performed between the groups in table 1. from table 2, it can be seen that the highest serotonin mean was found in the affirmation-tapping treatment group (0,69 ± 0,13) with the lowest pain perception (3,20 ± 0,83). in order to test the effect of treatment on pain perception related to the serotonin serum levels, simple linear regression analysis was performed. the normality regression requirements are that there is normally distributed residual data. the normality test results obtained an unstandardized residual sig = 0,072 (> 0,05), so it can be concluded that the distribution is normal. the simple linear regression analysis results obtained a sig value = 0.00 (<0.05). this means that there is an influence between serotonin and pain perception as a result of affirmation tapping. discussion the data processing proves that affirmation tapping treatment can help the patients to reduce pain perception after caesarean section surgery. the clinical trial studies conducted in the hospital prove that affirmative-tapping as a complementary approach has been able to reduce the pain of traumatized patients. the most complementary approach was to utilize integrative medicine for the postoperative care of patients (moon, shin, shin, kwon, & lee, 2017). research on affirmative-tapping approaches has also helped to reduce dysmenorrhoea pain in adolescents (lenni sastra, jasmarizal, 2016). research conducted by wijiyanti has also proven that the affirmation-tapping approach can reduce pain after caesarean section surgery (wijiyanti, 2010). the affirmation-tapping approach has also been proven to reduce the pain suffering of cancer patients (taber, klein, ferrer, kent, & harris, 2016), control fibromyalgia pain complaints (benor, rossiterthornton, & toussaint, 2017) and control the pain and depression complaints of war veterans (beiranvand, noparast, eslamizade, & saeedikia, 2014; church, 2014). the biological perception of pain is an accumulation of stimulus and response performance results that are controlled consciously or outside of the consciousness by the brain, especially the forebrain and the central nervous system including the spinal cord (bushnell, ceko, & low, 2013; thakur, 2015). by utilizing the descendent and ascendant mechanisms of action, the journey of the stimulus and pain response can be controlled using neurotransmitter media via the forebrain and amygdaloid (bourbia, 2015; thompson & neugebauer, 2017). the empowerment of the forebrain by affirmation can eliminate the default inhibition (inhibitory functional work as a necessity) from the amygdaloid (bourbia, 2015) so as to activate the descendent pathway that blocks pain signals that lead to the dorsal horn spinal cord. this means that pain transduction through the ascendant pathways to the central nerves and brain can be prevented (neugebauer, 2015). praying by focusing one’s attention and thoughts on god followed by acupoint stimulation through affirmation-taping will increase the level of serotonin (liu, tan, molassiotis, suen, & shi, 2015; ménard, pfau, hodes, & russo, 2017). this will modulate their pain perception (martin et al., 2017). table 1. characteristic of respondents (n=40) variables groups affirmation (n=10) tapping (n=10) affirmation-tapping (n=10) control (n=10) mean sd mean sd mean sd mean sd age (year) 32.1 5.8 31.1 6.4 31.4 5.1 29.3 6.1 body weight (kg) 55.7 4.9 54.4 7.9 56.5 7.8 52.9 6.4 body height (cm) 164.5 8.8 161.6 5.9 159.6 4.6 160.5 4.2 systolic pressure (mmhg) 126.8 4.7 127.9 4.3 125.9 6.5 125.5 5 diastolic pressure (mmhg) 79.6 1.3 78.6 5.1 81.5 6.9 84 7 pulse rate 88.2 0.6 88.2 3.8 84.6 3.8 87.2 2.7 respiration rate 21 3 20.8 2.5 20.4 2.1 21.2 2.1 *sd: standard deviation table 2. serotonin levels (ng / ml) and pain perception per group (n=40) variables groups affirmation (n=10) tapping (n=10) affirmation-tapping (n=10) control (n=10) mean sd mean sd mean sd mean sd serotonin 0.50 0.02 0.37 0.06 0.69 0.13 0.19 0.03 pain perception 3.93 0.59 4.79 0.6 3.2 0.83 4.92 0.52 *sd: standard deviation jurnal ners http://e-journal.unair.ac.id/jners | 127 affirmations using prayers that are uttered with sincerity and confidence can double the empowerment in the forebrain and amygdaloid, boosting performance so then the function of pain control becomes better and more effective (beiranvand, noparast, et al., 2014; fajarudin, 2006; h.m. amin syukur; fathimah usma, 2012; neugebauer, 2015). tapping as a form of acupoint stimulation can inhibit the transduction of pain from various areas of the body to the center, thereby the pain stimulation from surgical wounds can be inhibited. consequently, the participants do not suffer from pain (liu et al., 2015). affirmations tapping increases serotonin levels, thereby it is able to strengthen the performance of descendent pain inhibition, thus inhibiting the transduction of pain from the peripheral to the center, thus overcoming the pain complaint (emami, 2018). the limitation of this study is that no screening for participants with diabetes mellitus was performed. affirmations done using prayers from al-fatihah followed by tapping on several acupoints can reduce the complaint of post-surgical pain. affirmationtapping interventions can be continued and recommended by nurses who have been trained and licensed to do so. conclusion participant pain complaints were lowest in the affirmation-tapping group with the highest serotonin levels. this is significantly different from the other groups. affirmations tapping has been proven to have a therapeutic effect in the context of overcoming post-caesarean section pain complaints. the novelty of the study is the affirmation-tapping performance when dealing with pain complaints associated with increased serotonin. affirmations tapping with alfatihah prayers can thus be recommended to overcome pain complaints as a complementary approach to nursing. references argoff. (2014). recent management advances in acute postoperative pain. pain practice, 14(5), 477–487. https://doi.org/10.1111/papr.12108. beiranvand, s., noaparast, m., eslamizade, n., & saeedikia, s. (2014). the effects of religion and spirituality on postoperative pain, hemodynamic functioning and anxiety after cesarean section. acta medica iranica, 52(12), 909–915. benor, d., rossiter-thornton, j., & toussaint, l. (2017). a randomized, controlled trial of wholistic hybrid derived from eye movement desensitization and reprocessing and emotional freedom technique (whee) for self-treatment of pain, depression, and anxiety in chronic pain patients. journal of evidence-based complementary and alternative medicine, 22(2), 268–277. https://doi.org/10.1177/2156587216659400 bordoni, b., marelli, f., morabito, b., sacconi, b., & severino, p. (2017). post-sternotomy pain syndrome following cardiac surgery: case report. journal of pain research, 10, 1163–1169. https://doi.org/10.2147/jpr.s129394 bourbia, n. (2015). central nucleus of the amygdala in descending control of painrelated behavior. painosalama oy – turku, finland 2015. bushnell, m. c., ceko, m., & low, l. a. (2013). cognitive and emotional control of pain and its disruption in chronic pain. nature reviews. neuroscience, 14(7), 502–511. https://doi.org/10.1038/nrn3516 chou, r., gordon, d. b., leon-casasola, o. a de, rosenberg, j. m., bickler, s., brennan, t., … wu, c. l. (2016). guidelines on the management of postoperative pain. the journal of pain, 17(2), 131–157. http://dx.doi.org/10.1016/j.jpain.2015.12.008 church, d. (2014). reductions in pain, depression, and anxiety symptoms after ptsd remediation in veterans. explore: the journal of science and healing, 10, 162–169. https://doi.org/10.1016/j.explore.2014.02.005 elabscience. (2019). manual serotonin elisa kits,4th edition, revised in may, 2019 (vol. 2019). fajarudin, f. (2006). seft the fastest and easiest way to overcome various physical and emotional problems. jakarta: pt arga publishing. gibbs, k., beaufort, a., stein, a., leung, t. m., sison, c., & bloom, o. (2019). assessment of pain symptoms and quality of life using the international spinal cord injury data sets in persons with chronic spinal cord injury. spinal cord series and cases, 5, 32. https://doi.org/10.1038/s41394-019-0178-8 h.m. amin syukur; fathimah usma. (2012). dzikrullaah therapy. in a. prasetya hijrah saputra (ed.), terapi hati (pp. 59–68). jakarta: penerbit erlangga. hargiyanto. (2008). differences in the effects of analgesia on electroacupuncture with low, combination and high frequency in low back pain. universitas sebelas maret surakarta. katz, j., & melzack, r. (2011). the mcgill pain questionnaire: development, psychometric properties, and usefulness of the long-form, shortform, and short-form-2. handbook of pain assessment. kawai, k., kawai, a. t., wollan, p., & yawn, b. p. (2017). adverse impacts of chronic pain on healthrelated quality of life, work productivity, depression and anxiety in a community-based study. family practice, 34(6), 656–661. https://doi.org/10.1093/fampra/cmx034 komann, m., weinmann, c., schwenkglenks, m., & j. suwito, et al. 128 | pissn: 1858-3598  eissn: 2502-5791 meissner, w. (2019). non-pharmacological methods and post-operative pain relief: an observational study. anesthesiology and pain medicine, 9(2), 1–7. https://doi.org/10.5812/aapm.84674 lenni sastra, jasmarizal, g. m. s. (2016). the effect of emotional freedom technique (eft) therapy on decreasing dysmenorrhoea pain in adolescents, 1, 34–39. liu, x. l., tan, j. y., molassiotis, a., suen, l. k. p., & shi, y. (2015). acupuncture-point stimulation for postoperative pain control: a systematic review and meta-analysis of randomized controlled trials. evidence-based complementary and alternative medicine, 2015. https://doi.org/10.1155/2015/657809 martin, s. l., power, a., boyle, y., anderson, i. m., silverdale, m. a., & jones, a. k. p. (2017). 5-ht modulation of pain perception in humans. psychopharmacology, 234(19), 2929–2939. https://doi.org/10.1007/s00213-017-4686-6 ménard, c., pfau, m. l., hodes, g. e., & russo, s. j. (2017). immune and neuroendocrine mechanisms of stress vulnerability and resilience. neuropsychopharmacology, 42(1), 62–80. https://doi.org/10.1038/npp.2016.90 moon, s. y., shin, k. m., shin, j. y., kwon, o. j., & lee, j. h. (2017). integrative medicine for postoperative patients: a survey of korean medicine doctors. evidence-based complementary and alternative medicine, 2017. https://doi.org/10.1155/2017/4650343 mudatsyir, m., k, h. p., & sundari, t. (2012). spiritual emotional freedom technique dan nyeri pasien pasca operasi femur. interest : jurnal ilmu kesehatan, 1(1), 44–49. neugebauer, v. (2015). amygdala pain mechanisms. handbook of experimental pharmacology, 227. https://doi.org/10.1007/978-3-662-46450-2_13 sakpal, t. (2010). sample size estimation in clinical trial. perspectives in clinical research, 2010 , 1(2 ,)67–69 . silva, t. c., silva, b., & tatagiba, f. (2017). postoperative pain in women undergoing caesarean section dor pós-operatória em mulheres submetidas à cesariana. enfermeria global, oktober(48), 374–383. http://dx.doi.org/10.6018/eglobal.16.4.267721 simundic, a.-m., bolenius, k., cadamuro, j., church, s., cornes, m. p., van dongen-lases, e. c., … ibarz, m. (2017). eflm recommendation for venous blood sampling. european federation of clinical chemistry and laboratory medicine, (october), 1– 50. taber, j., klein, w., ferrer, r., kent, e., & harris, p. (2016). optimism and spontaneous selfaffirmation are associated with lower likelihood of cognitive impairment and greater positive affect among cancer survivors. ann behav med., 50(2), 198–209. https://doi.org/10.1007/s12160-0159745-9. thakur, m. (2015). neurobiology of pain neuroscience. thompson, j. m., & neugebauer, v. (2017). amygdala plasticity and pain. pain research and management, 2017. https://doi.org/10.1155/2017/8296501 ward, s., guest, c., goodall, i., & bantel, c. (2018). practice and bias in intraoperative pain management: results of a cross-sectional patient study and a survey of anesthesiologists. journal of pain research, 11, 561–570. https://doi.org/10.2147/jpr.s153857 who, oecd, t. w. b. (2018). delivering quality health services. wijiyanti, f. (2010, june 14). effectiveness of spiritual emotional freedom technique (seft) therapy on decreasing pain intensity in sectio caesaria postoperative patients. 408 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17218 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the impact of hospital accreditation on nurses' perceptions of quality of care? tejo trisno, agit pratama putra, and sena wahyu purwanza faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: accreditation is the recognition of the quality of services that have met the national hospital accreditation standards. in implementing hospital accreditation , it covers patient safety goals, patient-focused service standards, hospital management standards, national programs and integration of health education in hospital services. how is the impact of hospital accreditation on the quality of care, especially nursing services in accordance with the perceptions and attitudes of nurses in hospitals. therefore, it is necessary to identify the impact of applying hospital accreditation in accordance with nurses' perceptions and attitudes towards nursing services. methods: for this reason, articles data with a for publication from 20082018 are needed, of the 418 systematic literature articles taken from scopus, science direct, and proquest. there are 15 articles chosen to search for literature with keywords; the impact of accreditation on nurses' perceptions and attitudes about the quality of care. results: five of the 15 articles that fit the design criteria that address the impact of hospital accreditation according to nurses' perceptions and attitudes in improving nursing services. conclusion: the study results show that hospital accreditation make a nurses perception the quality of care. quality of care is the one of impact from hospitals accreditation. nurses in accredited hospitals feel a higher level of quality of health services. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords accreditation; quality service; hospital; nursing service; attitude; quality of care contact tejo trisno  tejo.trisno-2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: trisno, t., putra, a.p., & purwanza, s.w. (2019). the impact of hospital accreditation on nurses' perceptions of quality of care?. jurnal ners, 14(3si), 408-412. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17218 introduction accreditation, defined as public recognition by national health accreditation commission accreditation standards achievement by health organizations, through assessment by external and independent survivors appointed by the ministry of health (reisi, raeissi, sokhanvar, & kakemam, 2019). developing countries often use hospital accreditation to ensure patient quality and safety. however, the adoption of hospital accreditation standards is considered too demanding in the field of health services. in addition, the empirical literature on the benefits of accreditation is rare and this is the first empirical interrupted time series analysis designed to examine the impact of health accreditation on measures of hospital quality (el-jardali, jamal, dimassi, ammar, & tchaghchaghian, 2008). the national hospital accreditation standard is a method for viewing and assessing the quality of health care organizations using external surveyors and published standards. this is often compared to an internal review process where members of the organization develop their own methods and standards to assess quality. there is little evidence available to verify which of the two forms of review have an impact on clinical outcomes and patient care. the accreditation process focuses more on risk management and patient safety than the previous steps to ensure the level of compliance with standards (griffith, 2018). patient safety is important to consider in health care. thus, various programs are included by health institutions to monitor their services including patient safety procedures. accreditation is one program to monitor health services and evaluation processes that are internationally and nationally recognized that are used to assess, promote, and ensure quality and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 409 efficient patient care and patient safety (top & tekingündüz, 2015). accreditation is increasingly being applied as a tool for the government to regulate and guarantee the quality of service quality and patient safety (alswat et al., 2017). hospitals must implement, develop and evaluate an effective, sustainable quality assessment and performance improvement program in all hospitals, based on information systems (sim rs). hospital management must ensure that the program improves patient quality and safety in hospital services, to involve all hospital departments and services (bahrami, chalak, montazeralfaraj, & dehghani tafti, 2014). improving market orientation and patient safety has become a major concern for nursing management. for that nurses, must build a climate of improving quality and patient safety is the key to improving nursing quality (nomura, pruinelli, da silva, lucena, & almeida, 2018). health care facilities are always associated with increased patient safety risks. in the past, the functions of risk management and quality improvement often operated separately in health service organizations. in addition, each individual who is also responsible for each function has a different reporting path. nurses' perceptions of improving quality and patient safety are important in health care organizations. in addition, some hospitals have admitted that patients will receive care with guaranteed safety. high-quality care is very important to protect the institution's financial assets and also to lose, so it is very important to have risk and management plans. in this case, risk management and patient safety professionals correlate in close working relationships (greenfield, pawsey, & braithwaite, 2011). the nurse is responsible for ensuring that caring for the patient with safe care, no danger has occurred. nurses have an important role in patient safety and reduce medical errors. in the past few decades, patient safety has become a high priority health system problem, because of the high potential for side effects in health facilities because it shows the challenge of a weak patient safety culture, in hospitals. therefore, this problem must be integrated into all policy makers and managerial initiatives in our health system, as a top priority (zyoud et al., 2019). nurses as the largest group of healthcare providers in offering direct patient care. the purpose of this study was to describe nurses 'perceptions of the culture of patient safety after hospital accreditation, the correlation between nurses' perceptions of hospital accreditation and improving the quality of nursing services. materials and methods this systematic review is carried out following the steps based on the prisma statement, namely (reisi et al., 2019) formulating research questions, (eljardali et al., 2008) choosing relevant research terms and formulating search phrases in consultation with information specialists in the health sciences, (griffith, 2018) planning a search strategy, (top & tekingündüz, 2015) approve inclusion and exclusion criteria, (alswat et al., 2017) conduct systematic searches in electronic databases, (bahrami et al., 2014) select appropriate research articles and [7] conduct quality assessments of studies chosen for review (moher et al., 2009). search strategy and inclusion criteria systematic searches were collected from proquest (347,327 journals), scopus (418 journals), and sciencedirect (592 journals). search is done using a combination, using boolean terms and quotes to qualify for this study, this article uses a cross-sectional method, one article uses multiple regression analysis, one article uses study intervention and one article uses descriptive research design methods and reviewed design literature and answered research questions. articles that are not relevant to the research questions or not related to nurses' perceptions related to the patient safety culture and hospital accreditation era will be excluded from this study (as shown in figure 1). in the screening process, we get 15 full text articles that meet the requirements of the search key words that match those included in the study, and also according to the purpose of this review. finally, seven (n = 5) articles are selected from this selection process. to sharpen the selection process and find the expected objectives in this literature review, we limit the articles in various electronic databases from various countries that have a diversity of nurse characteristics and various hospital policies related to the patient safety culture. it aims to get the latest information from the topic of nurses' perceptions of the patient safety culture in the era of hospital accreditation, because in this era, it cannot be denied that in all regions of the world, hospital accreditation is one of the requirements in quality hospital service ratings . in all of these studies, the study sample was nurses, according to the purpose of this article, and looked at whether there were significant changes in nurses' perceptions of patient safety culture in the accreditation era, because patient safety was the target of assessment to obtain accredited hospital status (as shown in table 1 ). results based on the research subject we found the number of respondents was 5311 of nurses, 12.112 survey from patients record, 30 staff of health care and director hospitals as 638 respondents. based on the location of the study we found all of studies were conducted at the hospitals. based on the research design, we found thirteen quantitative studies with the type of 9 cross sectional, 2 descriptive correlation, 2 comparation and 2 types of retrospective. for data sources, the questionnaire is the instrument used from the thirteen articles and intervention was conducted from the two articles. we identified several instruments used to measure perception the t. trisno, et al. 410 | pissn: 1858-3598  eissn: 2502-5791 nurses about outcomes of hospitals accreditation to improving quality of care. from the results of a review of fifteen articles it was found that nurses perceived an improvement of quality care in hospitals as an outcome of accreditation. in terms of the benefits of hospitals accreditation (reisi et al., 2019), nurses' perspectives, hospital managers can facilitate accreditation program implementation through financial support, strengthening of commitment and accountability, solving human resource issues, and stop current programs overlapping and revising the accreditation program. according to nurses perception that accreditation standards should also be revised regularly to ensure that they comply with the most recent worldwide standards and continue to be relevant (el-jardali et al., 2008), the impact of hospital accreditation is improve the patient safety level. nurses’ perceptions of patient safety appear to be essential. nurses are important for the improvement of the patient safety culture in health care organizations. accreditation has an overall statistically significant improvement in the perception of the culture of patient safety (griffith, 2018; nomura et al., 2018), participants’ perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program (alswat et al., 2017), nurses perceptions that jci accreditation may help health systems enhance the awareness and ability to prevent maes and achieve successful quality improvements (bahrami et al., 2014). hospital accreditation has a positive impact on quality results especially on the quality of care provided to patients and patient satisfaction (greenfield et al., 2011), nurses have an perception that hospital accreditation had a significant impact on hospitals’ ic infrastructure and performance and accreditation helps teams review their work and improve their ideas about what they have done . . . it clarifies things for staff and gives a sense of direction, clarify issues and be constructive records identified through database searching (n = 347327 ) additional records identified through other sources (n = 1110 ) records after duplicates removed (n = 4515 ) records screened (n = 4025 ) records excluded (n = 1515 ) full-text articles assessed for eligibility (n = 418 ) full-text articles excluded, with reasons (n = 387 ) studies included in qualitative synthesis (n = 15 ) studies included in quantitative synthesis (metaanalysis) (n = 5 ) figure 1 prisma flow chart (moher et al. 20-09). jurnal ners http://e-journal.unair.ac.id/jners | 411 and offer ideas for improvement, felt comfortable and confident to approach the surveyors but they were pressured by time to move on . . . much more time for discussion is necessary, the overall timetable is rushed and often compromised (sekimoto et al., 2008; yildiz & kaya, 2014). interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. hospitals and their units should develop more friendly and intimate working environments that remove nurses’ fear of penalties. administration and managers should support nurses who report their own errors (zyoud et al., 2019), the nurses perception that hospital accreditation improvement in the nursing documentation. educational interventions performed by nurses led to a positive change that improved nursing documentation and, consequently, better care practices (al-awa et al., 2012). discussion the perception of nurses on hospital accreditation outcomes is an increase teamwork and productivity. there needs to be a reward, recognition, leadership and commitment to the accreditation of hospitals so that it can enchance cooperation in improving patient safety (reisi et al., 2019). the impact of hospital accreditation is improve the patient safety. accreditation has an overall advantage over certification in clinical leadership and review but some of these results are statistically significant improvement in the perception of the culture of patient safety . where both systems, active on their own, show a positive relationship with quality management, the effect in combinations seems to be bigger and more significant. the determination and evaluation of the patient safety culture level in hospitals should be viewed as a continuous process where a need for continuous improvements in the hospital patient safety culture exists. to improve the patient safety level, nurses’ perceptions of patient safety appear to be essential. nurses are important for the improvement of the patient safety culture in health care organizations. moreover, some hospitals have recognized that providing (griffith, 2018). nurses' perceptions of the patient safety culture are influenced by many factors including internal nurse factors and external or environmental factors. internal factors are competency and position in the organization and also competence consists of age, level of education, and clinical experience. and it is classified as an external factor that influences nurses' perceptions of the patient's safety culture: leadership, hospital policy, teamwork, management support, open communication, promotion, and appreciation. hospital accreditation had a significant impact on performance and accreditation helps teams review their work and improve their ideas (sekimoto et al., 2008). nurses' perceptions themselves had enough staff and resources to provide quality nursing care, and had good nurse-doctor relationships and collegial presence of nursing leadership visible and competent all factors that are strongly related to the assessment of the safety of patient care in their workplace. the perception of having enough staff and resources might not be consistent with the patient's ratio: actual staff, but it seems to be an important factor related to how nurses see patient safety in their hospital ward or unit. this is a fact that nurses are the largest community in an accredited hospital or not, and the main point is that nurses are the spearhead of hospital services that interact more frequently with patients. thus, the patient safety culture must be the commitment of the nurses. in accreditation, patient safety is one of the objectives assessed, and is the main prerequisite that hospitals must meet various size requirements. there is a significant increase in nurses' perceptions of the patient safety culture in the process and after hospital accreditation. hospital accreditation has a positive impact on quality especially on the quality of care provided to patients and patient satisfaction (sekimoto et al., 2008). hospital accreditation make a nurses have a safety culture rooted in their awareness, it will be a more point in the process of improving the quality of hospital services, of course. nurses part of professional caregivers to patients and the most energy in hospitals in managing patients comprehensively will continue to increase awareness in improving the quality and safety of patients in hospitals. conclusion the study results show that hospital accreditation make a nurses perception the quality of care. quality of care is the one of impact from hospitals accreditation. nurses in accredited hospitals feel a higher level of quality of health services. nurses' perceptions of the patient safety culture are influenced by leadership, commitment, and supporting strategic quality planning, education and training. another influence of the factors is the management of quality and data use compared to their counterparts in non-accredited hospitals. in accredited hospital perception of safety climate was positively correlated with their attitude toward medication error reporting. strengthening the safety climate in the workplace is an important step towards improving patient safety. at the level of the patient safety competency dimension, teamwork and communication are significantly related to the perceived safety climate. therefore, increasing nurse safety competencies, with an emphasis on teamwork and effective communication, can contribute to building a strong safety culture. because there was a lack in the reviewed studies used the cross-sectional and correlation, well-designed such as qualitative should be conducted to more objectively evaluated the fenomena of nurses perception about impact of hospital accreditation on quality of care. t. trisno, et al. 412 | pissn: 1858-3598  eissn: 2502-5791 references al-awa, b., al mazrooa, a., rayes, o., el hati, t., devreux, i., al-noury, k., … el-deek, b. s. (2012). benchmarking the post-accreditation patient safety culture at king abdulaziz university hospital. annals of saudi medicine. https://doi.org/10.5144/0256-4947.2012.143 alswat, k., abdalla, r. a. m., titi, m. a., bakash, m., mehmood, f., zubairi, b., … el-jardali, f. (2017). improving patient safety culture in saudi arabia (2012-2015): trending, improvement and benchmarking. bmc health services research. https://doi.org/10.1186/s12913-017-2461-3 bahrami, m. a., chalak, m., montazeralfaraj, r., & dehghani tafti, a. (2014). iranian nurses’ perception of patient safety culture. iranian red crescent medical journal. https://doi.org/10.5812/ircmj.11894 el-jardali, f., jamal, d., dimassi, h., ammar, w., & tchaghchaghian, v. (2008). the impact of hospital accreditation on quality of care: perception of lebanese nurses. international journal for quality in health care. https://doi.org/10.1093/intqhc/mzn023 greenfield, d., pawsey, m., & braithwaite, j. (2011). what motivates professionals to engage in the accreditation of healthcare organizations? international journal for quality in health care. https://doi.org/10.1093/intqhc/mzq069 griffith, j. r. (2018). is it time to abandon hospital accreditation? american journal of medical quality, 33(1), 30–36. https://doi.org/10.1177/1062860617707578 moher, d., liberati, a., tetzlaff, j., altman, d. g., altman, d., antes, g., … tugwell, p. (2009). preferred reporting items for systematic reviews and meta-analyses: the prisma statement. annals of internal medicine, vol. 151, pp. 264–269. https://doi.org/10.7326/00034819-151-4-200908180-00135 nomura, a. t. g., pruinelli, l., da silva, m. b., lucena, a. d. f., & almeida, m. d. a. (2018). quality of electronic nursing records: the impact of educational interventions during a hospital accreditation process. cin computers informatics nursing. https://doi.org/10.1097/cin.0000000000000 390 reisi, n., raeissi, p., sokhanvar, m., & kakemam, e. (2019). the impact of accreditation on nurses’ perceptions of quality of care in iran and its barriers and facilitators. international journal of health planning and management. https://doi.org/10.1002/hpm.2642 sekimoto, m., imanaka, y., kobayashi, h., okubo, t., kizu, j., kobuse, h., … yamaguchi, a. (2008). impact of hospital accreditation on infection control programs in teaching hospitals in japan. american journal of infection control. https://doi.org/10.1016/j.ajic.2007.04.276 top, m., & tekingündüz, s. (2015). patient safety culture in a turkish public hospital: a study of nurses’ perceptions about patient safety. systemic practice and action research. https://doi.org/10.1007/s11213-014-9320-5 yildiz, a., & kaya, s. (2014). perceptions of nurses on the impact of accreditation on quality of care: a survey in a hospital in turkey. clinical governance. https://doi.org/10.1108/cgij-072013-0021 zyoud, s. h., khaled, s. m., kawasmi, b. m., habeba, a. m., hamadneh, a. t., anabosi, h. h., … al-jabi, s. w. (2019). knowledge about the administration and regulation of high alert medications among nurses in palestine: a cross-sectional study. bmc nursing. https://doi.org/10.1186/s12912-019-0336-0 http://e-journal.unair.ac.id/jners | 331 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17177 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family support required to increase compliance of medical control of patients with cancers nurul ramadhani yaner, tintin sukartini, kristiawati kristiawati, and m ruli maulana faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: long and burdening therapeutic treatments of patients with cancers require social support in order to encourage patient’s medical compliance. family support helps patients remain positive during their treatments so that they can develop physical and psychological fulfillment. this research identifies the correlation between family’s support and the rate of compliance of medical control of patients with cancer. methods: the design was cross-sectional. the population was 60 patients with cancers who were undertaking treatment and 36 respondents were drawn by using a consecutive sampling technique. the independent variable is family support, while the dependent variable is the rate of compliance of patients with cancers in maintaining their medical control. the data was collected using questionnaires adopted from mmas-8 (medication morisky adherence scale) and analyzed by using chi square with a significance rate of α ≤ 0.05. results: the results indicated that the correlation between family’s support and the rate of medical compliance resulted in p=0.006. conclusion: supportive family support is very important in the successful treatment of cancer patients, because the family is closest to the patient, they live together, and also they have the opportunity to meet the needs of cancer patients. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords cancer; family support; medical compliance contact m ruli maulana  m.ruli.maulana2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: yaner, n.r., sukartini, t., kristiawati, k. ,& maulana, m.r. (2019). family support required to increase compliance of medical control of patients with cancers. jurnal ners, 14(3si), 331-335. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17177 introduction the prolonged cancer treatment process, fear of death and the absence of family support creates patient frustration and finally leads to stopping treatment (drop-out). according to (balitbang kemenkes ri, 2013) said that cancer patients do not often follow to treatment for a variety of reasons such as issues of cost, trying alternative treatments and intolerance to the side effects. the success of treatment can be determined by the patient's compliance with the recommended treatment. research on drug adherence to chronic diseases showed that about half of people do not comply with their prescription drugs (balitbang kemenkes ri, 2013). based on a national survey of cancer sufferers, none of the sufferers claimed that they did not always follow the prescribed guidelines correctly and more than half said that they sometimes forgot to take their medication. several studies have shown that adherence to oral drugs for cancer varies greatly. the level of adherence is usually high at the beginning of treatment or for a short period of time, after which it is rarely done again. cancer is still a disease that is a leading cause of death. according to who data in 2010, the global death rate from cancer has reached 13 percent (7.4 million) of total deaths annually, and 70% of cancer deaths occur in lowand middle-income countries. an estimated number of cancer deaths will increase significantly in the coming years, and will reach approximately 13 million deaths per year worldwide in 2030. according to (brannon, l. feist, 2997), prevalence of cancer is highest in indonesian especially yogyakarta (4.1%), central java (2.1%), and bali (2%), while the east java was ranked 10 with prevalence rate (1.6%). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). r. faizah, et al. 332 | pissn: 1858-3598  eissn: 2502-5791 recapitulation of surabaya city health office in 2013 showed that there were 1768 cancer patients enrolled in surabaya. according to data from the health department of surabaya there are three health centers that provide palliative care for people with cancer in tambaksari district, surabaya. the number of patients registered is 60 people, 25 people in gading, 20 people in pacar keling, and 15 people in rangkah primary health care. treatment adherence behavior in cancer patients is essential to increase the cure rate. if it is connected to the green theory (kusuma, 2011), behavior is influenced by three factors, predisposing factors, enabling factors and reinforcing factors. the supporting factors include knowledge, attitudes, beliefs and values of the individual against cancer. enabling factors include the availability of facilities while driving factors include the support of family, friends, health workers, community leaders who lead a cancer patient undergoing treatment compliance. family support greatly supports the successful treatment of cancer patients, for example by reminding patients to routinely undergo cancer treatment. cancer patients given family support in the form of informational support, instrumental support, emotional support and self-esteem support, can increase the quality of life. family support for cancer patients undergoing palliative therapy will positively influence physical and psychological well-being. someone receiving family support feels loved, valuable, and able to share the burden, be confident and encourage hope to reduce stress (green, lw, 2005). the family's role in the cancer client's treatment process is very large. another study conducted relating to family support also concluded that there was a significant relationship between family support and motivation to treat cancer patients (green, lw, 2005). materials and methods design, population, sample, and variables this design was a descriptive correlational research using a cross sectional approach. the population in this study were all patients with cancer in 3 primary health service. affordable population size in this study were 36 people, in the period from march to july 2016. the sampling technique used in this study was total sampling. inclusion criteria in this research were 1) patients with cancer, 2) taking cancer palliative therapy, 3) 18 years old and above, and 4) willing to participate into this study, while exclusion criteria were 1) nomadic patient. the independent variable was family’s support, while the dependent variable was the rate of compliance of patients with cancers in maintaining their medical control. instruments a questionnaire for reviewing family support was adopted based on research (kusuma, 2011). this questionnaire representing questions from 4 sub variables of family support include: emotional support, instrumental support, information support, and self-esteem support. the number of questions was 18 items using a likert scale with a score of 0-3, obtained a range of score from 0 to 54, which are categorized by the formula namely the cut of point 75% of the total score (54), with results: ≤ 40.5: nonsupportive and ≥ 40.5: supportive. to measure patient compliance cancer in taking medicine containing 8 items of questions, the author made a modification by adding question number 8. the question in this questionnaire consists of 7 statements unfavorable and 1 positive statement. every question answered "yes" is given a score 0 and 1 for questions answered "no". the score in this questionnaire is divided into 3, 1) score <6 is said to be low compliance; 2) score 6-7 is moderate compliance; and 3) score 8 is high compliance using mmas-8 (medication morisky adherence scale) that has been translated into indonesian. the questionnaire has tested the validity and reliability with cronbach alpha 0.919. research procedures and analysis this study has passed the ethical review and obtained an ethical approval certificate with no: 203-kepk issued by health research ethics committee of faculty of nursing, universitas airlangga. research data collection was conducted by measuring the main factors of family support and compliance with cancer patients undergoing control by giving questionnaires regarding family support and compliance with cancer patients undergoing treatment. statistical analysis used chi square. the confidence interval was 95% with alpha α = 0,05. results characteristic respondents on table 1 showed that the majority of respondents were female with an average age above 50 years. based on the educational background, the majority of respondents had high school education. if seen from the background of work, most respondents do not have jobs so that the average income of all respondents can be said to be low. based on the table 2 above, it can also be seen that all respondents were married with the majority having a membership of 4 people in one family and the majority of respondents were muslim. the majority of respondents have low compliance of medical control. based on table 3 above, it can be seen that the majority of respondents received support from the family but the value of compliance in medical control is very low. from the chi-square test conducted, a significant relationship between compliance and support was obtained. decision making can be guided by a comparison of the p-value with a significance level, the reject criterion rejects 𝐻0 if the p-value <α (= 0.05) or by comparing the values of the chi-square count with the chi-square table. the results of the chijurnal ners http://e-journal.unair.ac.id/jners | 333 square test between compliance and support show that the p-value is 0.006, where the p-value is less than α (= 0.05), so that the 𝐻0 decision is rejected and it can be concluded that there is a significant relationship between family support and level compliance with control of cancer patients in undergoing palliative treatment at the puskesmas in tambakari sub-district surabaya. discussion the support obtained from the family in this study was in the form of encouragement to recover in medicine, informing about the benefits and risks if not adhering to taking medication, and reminding them to take medication if the patient forgot. in addition, it also provides encouragement in the form of delivering treatment for sick families. support was provided for sick family members to meet their food and drink needs, and also bear the costs of medical treatment. if there are problems faced by survivors, the family must provide advice for problem solving. patients who get good support indicate that the family realizes what the patient really needs. support from the family makes the sufferer not feel burdened with his illness. this is due to the attention of his family, so the sufferer does not feel alone. families can be a significance influencing factor in determining the health beliefs and values of individuals and can also determine the treatment program they can receive. support provided by family table 1. the demographic characteristics (n=36) no. characteristics criteria f % 1. gender man woman 3 33 8.33 91.67 2. age 36-50 years > 50 years 14 22 38.89 61.11 3. education not completed in primary school basic school middle school high school university 2 5 8 20 1 5.56 13.89 22.22 55.56 2.78 4. work does not work labor entrepreneur etc. 25 5 4 2 69.44 13.89 11.11 5.56 5. income per month <650,000 > 650,000 32 4 88.89 11.11 6. marital status married 36 100 7. number of family members 2 people 3 people 4 people 5 people 6 people 8 people 4 5 19 5 2 1 11.11 13.89 52.78 13.89 5.56 2.78 8. religion islam christian 35 1 97.22 2,78 9. the type of cancer breast cancer cervical cancer lung cancer 14 19 3 38.89 52.78 8.33 table 2. family support in patients undergoing cancer treatment and compliance of medical control (n=36) no. variables f % 1. family support supportive non-supportive 28 8 78 22 2. compliance of medical control low moderate 34 2 94 6 table 3. cross tabulation family support and compliance of medical control family support compliance of medical control total low moderate supportive 28 78% 0 0% 28 78% non-supportive 6 17% 2 5% 8 22% total 34 95% 2 5% 36 100% r. faizah, et al. 334 | pissn: 1858-3598  eissn: 2502-5791 members is an important factor in patient compliance with medical treatment that patients undergo. also found that family support is the existence, availability, care of people who can rely on, respect and love people (niven, 2002). friedman explains that the family has 4 types of support that informational support, self-esteem, instrumental and emotional (grant, m ; sun, v ; fujinami, r ; sidhu, r ; otis-green, s ; juarez, g ; ferrell, 2013). informational support is the form of advice, suggestions, advice, guidance, and information sharing. support ratings of whom provide support, recognition, appreciation and attention. instrumental support can be direct assistance as material, labor and equipment. while emotional support may be the family as a peaceful place to rest and recovery as well as helping control over emotions according to researchers, a supportive family is very important in the successful treatment of cancer patients, because the family is the one that is closest to the patient, they live together, the family also has the best opportunity to meet the needs of cancer patients. moreover, family duties were not only to care for the sick, but should include several aspects, including physical, psychological, social, spiritual, information about cancer. in addition, the most important aspect is the recognition of a family when one of its members suffering from cancer. if family support is provided properly, it will bring a positive effect in the recovery process of cancer patients. family duties are to not only care for the sick, but must include several aspects, like physical, psychological, social, spiritual, information about cancer and the most important is the recognition of a family when one of its members is suffering from cancer. in this study the researchers obtained data from 36 respondents and showed that 28 respondents received supportive family support with a percentage of 78%. according to the family support questionnaire that was filled in by patients, it was mostly in question number 1 where the patient said that the family accompanied them during treatment. question number 2 said that the family showed concern by inviting patients to discuss the problems faced by patients. question number 6 said the family provided time and facilities if the patient needed medical treatment. in question number 8 patients say the family is willing to pay for care and treatment while the patient is sick. question number 10 patients say the family helps in carrying out daily activities. question number 12 the patient reminds the family of controls, taking medication, exercising, resting, and eating healthy food. question number 17 patients said the family tended the patient to social activities so that the patient did not feel bored with his illness. green's theory adherence behavior treatment is influenced by fundamental factors or factors that exist within the individual that influence compliance behavior (predisposing factors), reinforcing factors, and factors that support (enabling factors) (friedman, mm, bowden, vr, & jones, 2010). while the factors that affect non-compliance are divided into 4 parts, namely the patient's understanding of instruction, the quality of interaction, family, beliefs, attitudes and personality. according to the researcher, family support and adherence to taking medication is closely related to where one of them does not play an important role, what will happen is not adhering to taking the medication. someone is said to be adherent to treatment if the person is able to complete treatment without ever neglecting any treatment. in this study of 34 respondents (95%) received treatment adherence levels run low. according to the questionnaire that was filled out by the patient most of the patients answered question no. 1 is patient sometimes forgets to take his medicine, question number 2 patients often miss taking medication in the past two weeks, the question number 4 patients said often leave medication at home when was traveling. low level of adherence can be influenced by several factors (samuel, 2011), the characteristics of the illness consist side effects of medical handlers, duration of treatment, and the complexity of care; personal characteristics consist of age, social support, personality and personal beliefs; cultural norms, that attitude or motivation of the patient is the most powerful thing itself, as compliance (sari, 2012). low motivation to health will greatly influence the behavior of patients in disease control. confidence is a spiritual dimension to life. patients with the lowest adherence rates are less committed to the belief and will be so easily discouraged and unable to accept his condition and have an impact on the willingness to control the disease is low. economic factors such as the cost is too expensive to reach health facilities causing someone did not obey to take medication. limitation of the study the limitation of this study was the family support questionnaire, which according to the perception of patients was not from direct family observations. conclusion most respondents who suffer from cancer in the tambaksari district health center surabaya receive supportive family support but have a low level of medication adherence for cancer patients. from this study it can be concluded that family support with the level of adherence to the control of cancer patients in undergoing palliative treatment at the pusaksari district health center in surabaya has a significant relationship. nursing service institutions are expected to provide health promotion to the families of cancer patients regarding cancer and also the role and support that needs to be given to patients. it is also necessary to hold peer groups specifically for cancer patients so that fellow cancer patients can share experiences to support and strengthen each other in the face of cancer so that the risk of jurnal ners http://e-journal.unair.ac.id/jners | 335 complications can be reduced and lead to reductions in mortality and morbidity due to cancer. references balitbang kemenkes ri. (2013). riset kesehatan dasar. jakarta: balitbang kemenkes ri. brannon, l. feist, j. (2997). health psychology : an introduction to behavior and health. california: brooks/cole publishing. friedman, mm, bowden, vr, & jones, e. (2010). family nursing textbook: research, theory, and practice. jakarta: egc. grant, m ; sun, v ; fujinami, r ; sidhu, r ; otis-green, s ; juarez, g ; ferrell, b. (2013). family caregiver burden/skills preparedness, and quality of life in non-small cell lung cancer. green, lw, m. k. (2005). health program planning: an educational and ecological approach (4th ed.). boston: mcgraw-hill. kusuma, h. (2011). hubungan antara depresi dan dukungan keluarga dengan kualitas hidup pasien hiv/aids yang menjalani perawatan di rsup cipto mangunkusumo jakarta. universitas indonesia, 20,21,76-79,111-114,135-139. retrieved from www.lib.ac.id niven, n. (2002). health psychology: an introduction for nurses and other health professionals. jakarta: egc. samuel. (2011). temu pasien kanker payudara: komitmen, kualitas dan kepatuhan. sari, m. (2012). hubungan dukungan keluarga terhadap motivasi pasien kanker payudara dalam menjalani kemoterapi di ruang cendrawasih i rsud arifi n achmad provinsi riau. jurnal ners indonesia. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 62 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.10270 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research barriers in tuberculosis treatment in rural areas (tengger, osing and pandalungan) in indonesia based on public health center professional workers perspectives: a qualitative research r endro sulistyono1, tantut susanto2, and rr dian tristiana3 1 diploma of nursing, faculty of nursing, universitas jember, indonesia 2 faculty of nursing, universitas jember, indonesia 3 faculty of nursing, universitas airlangga, indonesia abstract introduction: tuberculosis (tb) is still one of the main health problems in indonesia. various efforts have been made by the government to handle the tb problem in indonesia, one of which is implementing a direct observed therapy short course (dots) program. however, the handling of tb disease in indonesia, especially in rural areas is still not optimal. this study aims to explore barriers to the handling of tb in rural areas from the perspective of public health center professionals. methods: this study is a qualitative research with a phenomenological approach. sampling was done by purposive sampling with a sample of 8 participants. data is collected through focus group discussions. thematic analysis is carried out using colaizi step. results: this study obtained two themes. theme 1 is the barriers in the aspect of tb patients and theme 2, which is barriers from the aspect of health care facilities. conclusion: this study obtained two themes. theme 1 is the barriers in the aspect of tb patients and theme 2, which is barriers from the aspect of health care facilities. article history received: october 30 2018 accepted: october 28 2019 keywords tuberculosis; rural; health provider; qualitative research contact r endro sulistyono radendro1988@unej.ac.id  diploma of nursing, faculty of nursing, universitas jember, indonesia cite this as: sulistyono, r.e., susanto, t., tristiana, r. d. (2019). barriers in tuberculosis treatment in rural areas (tengger, osing and pandalungan) in indonesia based on public health center professional workers perspectives: a qualitative research. jurnal ners, 14(1), 62-68. doi:http://dx.doi.org/10.20473/jn.v14i1.10270 introduction tuberculosis is an inflammatory disease of the lung parenchyma caused by the bacterium mycobacterium tuberculosis. who states that one third of the world's population has been infected with tuberculosis bacteria. every second there is one person infected with tuberculosis. although indonesia has achieved remarkable progress over the past decade, tuberculosis (tb) is still one of the top four causes of death in indonesia (usaid, 2017). based on global tuberculosis report data in 2016, indonesia ranks second behind india with the most tb patients. the new tb cases in indonesia in 2016 were 360,565 cases (who, 2017). tb treatment in indonesia is a direct observed therapy short-course (dots) strategy promoted by the world health organization with the main goal of achieving successful treatment of tb treatment and a low case notification rate. the aim of this new case discovery program is to find new cases as early as possible so that they can be handled more quickly and do not cause severe complications (who, 2013). tb treatment in rural areas is still not optimal. some obstacles related to the handling of tb are obstacles to the handling of tb diseases such as access to difficult health care places and failure to diagnose tb disease, financial problems (sagbakken, frich, & bjune, 2008), public attitudes and beliefs about tb disease, low level of knowledge about tb (sullivan, esmaili, & cunningham, 2017), stigma and lack of social support (ahmed & martin, 2018). transmission of tb bacteria by individuals who have not been diagnosed with tb or who have not received treatment yet is still a major problem related to tuberculosis. previous study related to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.10270%20%205 jurnal ners http://e-journal.unair.ac.id/jners | 63 prevention efforts by tb sufferers and families have been conducted (hutama, riyanti, & kusumawati, 2019; pratiwi, betty, hargono, & widya, 2012), however the literature related to barriers perceived by public health professional workers in the treatment of tb, especially in rural areas, still needs to be explored. moreover, the health service system in indonesia has experienced many changes related to tb treatment management policies. indonesia is a developing country with many rural areas with low levels of health literacy and unproportional public health facilities spread. health promotion carried out by health workers has often encountered obstacles such as differences in community characteristics, coverage of areas far from the place of service, as well as the dissemination of several topics at once (tuharea, suparwati, & sriatmi, 2014). professional nursing practices often experience problems due to cultural differences between modern culture and traditional culture. barriers related to the handling of tb in rural areas need to be explored to find out what problems can be handled at the public health center and find appropriate ways to reduce the incidence of tb in indonesia. the barriers that felt by public health professional workers is a personal experience that cannot be measured quantitatively. so this study uses a qualitative approach to underpin the study questions. this study aims to explore the barriers perceived by publich health professionals while dealing with tb treatments in rural areas. materials and methods research design this study aims to explore barriers to the handling of tb disease in rural communities from the perspective of public health professional workers who carry out tb treatment programs at public health centers. this study uses qualitative research methods with a phenomenological approach. setting the research area, which is conducted in a public health center, this public health center is handling 12 villages in the klakah sub-district. the population was 54,156 people which is spread in 12 villages and consists of 60 sub villages. health services facility in klakah are one public health center with one supporting public health center, and one medical clinic. the number of tb patients in the klakah public health center has increased from 53 people in 2017 to 83 people in 2018. many tb patients in the klakah public health center have not been recorded. the active tb case finding program is a new program that is implemented in the klakah public health center and is still not optimal. sputum examination is still the only diagnostic examination performed at the klakah clinic. x-ray examination is done in a regional hospital that is quite far from the klakah public health center. participants participants in this study were public health professional workers who handling of tb programs in tengger, osing and pandalungan areas. the number of participants in this study is 8 health professional workers who have different educational backgrounds and professions. data collection the study was conducted at the public health center which handlings 12 villages in the pandalungan, tengger and osing areas which were carried out from july to september 2018. qualitative data collection was carried out by focus group discussions (fgd) method for public health professional workers who served as tuberculosis control program implementers. an interview guide was developed to collect information during the fgd process using voice recorders and field notes taken during the discussion process to record findings in gathering information and confirm the validity of the researcher interpretation. fgds were conducted using indonesian language and madura language (the local language of the area where the study was conducted). the interview question was developed with an opening question in the form of "how are the barriers that perceived by public health professional workers regarding the care of tb patients in rural areas?". this fgd group is considered a natural group because most participants know each other so that it is beneficial for the discussion groups dynamics. the discussion activity was carried out in one of the health centers which was moderated by one of the researchers. the discussion process was recorded using a recording device which was then transcribed and one of the other researchers recorded during the discussion process related to the discussion group dynamics. data analysis qualitative data analysis in this study used analysis using colaizi steps (streubert & carpenter, 2003). firstly, the analysis were started with writing the interview in written form (verbatim). secondly, the verbatim transcript of all of the participants was read repeatedly to identify sentences or words with a particular meaning and provide them with a code figure 1 map of klakah district r. e. sulistyono et al. 64 | pissn: 1858-3598  eissn: 2502-5791 based on the similarities and differences. afterwards, the process also involved explaining the meaning of the significant sentences and collecting and organizing the formulation of category descriptions into a collection of themes, which resulted in the validation theme. categories and themes were extracted from the main idea of the statement and the sentence stated by the participants during the interview process (tristiana, yusuf, fitryasari, wahyuni, & nihayati, 2018). trustworthines the data analysis process is carried out simultaneously with the data retrieval process. data retrieval is stopped when reaching data saturation, where no new themes or new categories are found. the researcher checks all participants after verbatim has been completed. to minimize subjectivity, every verbatim result is analyzed by two researchers. the researcher reads the transcript repeatedly to identify important and significant words or sentences that have meaning and encode them based on similarities and differences. every transcript was then coded systematically against the code frame. codes were merged into categories and then these categories were organized into themes. disagreements were discussed among the research team to reach a final consensus. the principal researcher revisited the main points of the findings with the participants and asked whether they were consistent with their experiences. data analysis was conducted in bahasa language and the final report was translated into english. ethical consideration the health ethics committee of the faculty of dentistry at jember university approved the implementation of this research. results this study involved 8 public health centers professional workers who handling with tb disease at klakah public health center (table 1): five women and three men aged between 34-48 years with the participant profession namely one doctor, six nurses and one medical analyst. the emerging theme was formulated on the basis of the participants' answers to the interview in the focus group discussion questions and the notes during the discussion process. this study has two themes that were explained in order to reflect the purpose of the study. barriers from the patient's aspects discomfort in the side effects of tb drugs public health professional workers said that barriers in efforts to treat tb patients, namely discomfort feeling with anti tb drug side effects, health professional workers said some tb patients stopped taking tb drugs due to discomfort with the perceived side effects of anti tb drugs: "tb patients said that taking anti tuberculosis medicine turns out to be unpleasant feeling, nausea, dizziness, muscle aches, people sometimes unable to endure the side effects that sometimes torture, so they decide to stop the treatment" –nurse lack of knowledge about tuberculosis public health professional workers said that tb patients consider symptoms of cough to be just a common disease: "when people are reminded of the symptoms of coughing, they answer that only a normal cough and they are normal and are not considered a serious illness" -medical doctor– lack of self-awareness most public health professional workers said that the lack of self-awareness of tb patients about their illness, which is not willing to take their own medication and be evaluated, as stated: "awareness level of tb patients is lacking, those who take anti tb drugs in the public health center are other people, even though they are actually capable, so treatment evaluation cannot be done" -nurse table 1 demographic data of public health professional participants characteristic n=8 mean age (in years) age 38.5 sex female 5 male 3 ethnicity professional background nurse 6 medical doctor 1 analyst 1 table 2 theme and category theme category barriers from patients aspects discomfort feeling for anti tb drugs side effects lack of knowledge of tb lack of awareness of tb non-adherence of tb treatment culture and beliefs barriers from health facility aspects health facility access human resources lack of cross-sector colloborations jurnal ners http://e-journal.unair.ac.id/jners | 65 lack of awareness of tb patients related to unclean environment and habit of spitting carelessly despite knowing that tb is an infectious disease: "in rural area, environment pollution chicken cage, mix with home, odr spit randomly" medical doctor – awareness regarding the use of masks to prevent transmission is not carried out by tb sufferers: "the sick only wear a mask if they go to the health center, but not to other places" awareness to prevent transmission to other people is still low even though often delivered when coming to the health center "-nurse non-adherence to treatment the disobedience of tb patients in the tb treatment process is delivered by health workers, tb patients do not take drugs on time, namely: "take it not on schedule, up to a week and two weeks and underestimate taking medicine" -nurse non-adherence to tb treatment is caused because the patient feels bored, every day must take medication: "the patient feels the drug is bored with anti tb drugs, the level of adherence is only 80%, the rate of drop out is because the patient feels healed or some patients reported feels nauseous, dizzy and feels other uncomfortable effects" -nurse tb patients take anti tb drugs were not according to recommendations from health professional workers as stated: "the method of taking medication is not according to the recommended three drugs as well as one drink, but they take the drugs one by one up to four times in a day" -medical doctor– "diagnosing, having difficulty removing the sputum even though it has been taught, thus affecting the results of the examination, health workers believe that clinical symptoms indicate tb so that the examination is referred to thompson's examination with x-rays" whereas the significant result of tb diagnosis was on bta basis "-analyst barriers from health service facilities aspects access to health services public health professional workers stated obstacles related to tb treatment in the form of difficulties in access to health care facilities in the form of distance from public health center that deal with one area farther from the public health center that handles other areas, which are stated as follows: "regional issues was a problem that interfere the tb treatment. we (health care professional workers) unable to refuse patients from other regions. the problem is that we can not evaluate patients from other regions in their home, because we have to return the task to the public health center which covered the patients’ area, that condition caused the dropout rate is high" –nurse "access to health centers in the same area is further from other health centers, so it is difficult to visit or want to contact" nurse distant of public health services from house of tb patients is also an obstacle in handling tb patients: "far distant, is the reason from tb patients to drop out" -nurse lack of human resources the practice of public health center professional workers to actively find tb cases is still not implemented: "case finding habits to find cases are still not used by health workers, because it is a new program from government and we still not understand how to do it in community" medical doctor the number of public health center professional workers who handle tb is limited with a high workload: "the number of public health center professional officers is limited" -nurse the burden of work of many public health center professional workers makes the handling of tb in the community less than optimal: "the task of program holders is so much that it needs to be activated for tb cadres /community health workers in the community" -nurse "once a year there is counseling but not evenly distributed, counseling per village that is financed" nurse lack of cross-sector collaborations public health center professional stated that crosssector collaboration did not work effectively, especially for village administrators as stated: "the activity of the village administrator is still lacking, when they are invited by the public health center to discuss about health problem they never to never come" -medical doctor "there has been no drug treatment supervisor formation with cadres" -nurse "the drug treatment supervisor must be a close person, the family does not understand, the health worker is far away, the cadre is far away, finally it doesn't work" -nurse-. r. e. sulistyono et al. 66 | pissn: 1858-3598  eissn: 2502-5791 discussion one of the barriers to the handling of tb disease that comes from tb patients’ aspects is the discomfort feeling of anti-tb drugs side effects. some patients report experiencing the effects of nausea, dizziness, muscle aches which according to them torture themselves and interfere with daily activities so that they decided to stop tb treatment. previous study stated that the experience of side effects of anti-tb drugs such as joint pain, nausea, dizziness, vomiting (abbas, 2017) which is uncomfortable for the patients causes the patient to stop treatment (sang, obwoge, kangethe, ayiro, & changeiywo, 2017). health professional workers need to approach tb patients to provide counseling to increase the motivation of tb patients in completing tb treatment and provide appropriate interventions to reduce discomfort due to the side effects of anti-tb drugs. lack of knowledge of the community about tb disease is also a barrier to tb treatment completion. the community considers that a prolonged cough is an ordinary cough symptom and does not need to be examined by a health service. previous study has suggested that a low level of knowledge regarding tb disease can prolong and delay the time for tb testing (babatunde, bismark, amaechi, gabriel, & olanike, 2015; getnet, demissie, assefa, mengistie, & worku, 2017). individual behavior associated with the disease will describe the level of individual understanding of the disease(hassan et al., 2017). individuals who do not understand about tb disease, including tb symptoms, will assume that tb disease does not need to be addressed as early as possible. the delay in examining tb symptoms will have an impact on the severity of the disease. health professional workers need to conduct health promotion to the community to improve community knowledge related to tb disease. this is because the tb control and prevention by detecting tb cases in individuals who is at risk of suffering from tb disease will be easier if individuals have good knowledge of tb disease. the government should provide financial assistance for the implementation of tb health promotion, especially in areas with high tb risk and low knowledge of tb, especially in rural areas. people who suffer from tb also have low selfawareness such as not wanting to come to the public health center to take drugs and evaluate the success of tb treatment. tb patients also still spit carelessly, do not keep the environment clean and do not want to wear a mask to prevent transmission of tb disease even though tb patients know that the disease can be contagious. prevention of transmission of tb bacteria in tb patients who have infectious status needs to be done especially in the community (world health organization, 1999). this is due to sputum management discharges from tb patients who are in an infectious condition a high risk procedure for airborne transmission (kaul & nardell, 2011). the attitude of tb patients to the management of sputum disposal is related to the behavior of sputum discharge (mei et al., 2012). patients with tb show a negative attitude towards the management of sputum discharges even though they have been given education by health professional workers. the negative attitude shown by tb patients needs to be reviewed by health workers to determine the right intervention so that tb patients are willing to carry out sputum disposal management in accordance with procedures and safeguarding the environment in order to minimize the risk of transmitting tb bacteria to others. non-adherence to treatment is in the form of not taking anti-tb drugs according to the schedule for weeks, feeling bored because they have to take medication every day, and taking medication that is not in accordance with the advice of health workers. the long duration of tb treatment causes physical and emotional exhaustion of tb patients and their families which can have an impact on medication noncompliance (gebreweld et al., 2018). health professional workers need to explain the impact that might occur in tb patients if they do not take medication according to the doctor's advice. health professional workers also need to convey the effect of drug resistance if tb patients do not take medication in accordance with the medical staff's appointments. communities in rural areas prefer to seek treatment to alternative, traditional healers rather than to health services related to tb treatment. previous research also states that almost more than 50% of tb patients go to alternatives first to overcome the tb disease (viney et al., 2014). people have a culture-related belief in their place of residence in the form of taboos to eat certain foods such as protein. people choose to fast and avoid foods that contain high protein when they know that they are diagnosed with tb disease. while other studies have found that there is insufficient high protein food to be consumed by tb patients that causes noncompliance with tb treatment (mabunda & bradley, 2011) in the study area found a culture that prohibits the consumption of high protein foods when individual are diagnosed to have tb diseases. health professional workers need to approach people who influence the tribes in community in the study area to change the community behavior. the government also needs to facilitate by approaching village administrators and people who are considered influential in these tribes to change beliefs regarding protein foods that should not be consumed by sick people including tb patients. access to remote health care facilities and the location of public health center that handle one other area is closer than the location of the public health center serving the tribal areas of osing, pandalungan and tengger being one of the obstacles in handling tb disease. in indonesia there has been a tiered health service where patients must come to a level i health facility that provides basic health services before going to health facilities at level ii and iii. this means that when tb patients feel sick and need treatment, tb patients cannot go directly to second-level health jurnal ners http://e-journal.unair.ac.id/jners | 67 facilities even though the distance from health services is closer than level i health. this of course can be a cause of tb adherence in tb treatment. previous research has suggested that the distance to a health service place can be a barrier for sufferers to seek treatment at the health care center (tristiana, yusuf, fitryasari, wahyuni, & nihayati, 2018). the government needs to make a breakthrough to overcome the problem of the location of the health service location. in indonesia, public health centers are still limited to a few places, especially in rural areas. the government can provide tb patients with ease of treatment, for example by providing a mobile tb clinic that can reach all rural areas. the number of health professional workers handling tb in rural areas is still limited. the limited number of health professional workers is also one of the obstacles. limitations of tb nurse skills related to intensive case findings (phetlhu, bimerew, mariemodeste, naidoo, & igumbor, 2018) also is one of the obstacles in handling tb disease in the community. the limited number of health professional workers and the high workload that must be borne can hinder the effectiveness of tb treatment. the limited number of officers with wide working areas makes tb treatment not optimal. as stated that the lack of funds related to health promotion and the limited number of health workers make extension activities in the community only carried out once a year. this condition is accompanied by a lack of cross-sector cooperation, especially with village officials. the government needs to facilitate so that cooperation can be established, because community empowerment in handling tb disease needs to be done considering the limited number of health workers. the formation of community health cadres, especially in rural areas with sufficient numbers and good skills training, can reduce the number of tb patients in the tengger, osing and pandalungan tribes. conclusion obstacles related to the handling of tb disease in rural areas in the tengger, pandalungan and osing tribes are obstacles from tb sufferers and also barriers from health facilities. the low level of knowledge and level of public awareness related to tb disease and the persistence of a culture that can inhibit tb handlers need to be addressed. the government in collaboration with health facilities needs to promote health to remote areas in collaboration with people who are considered influential in the area and provide dukun/traditional healer with knowledge of tb in order to accelerate the process of finding tb cases in the community. problems related to access to health services are also still an issue that often occurs in rural areas. the establishment of mobile tb clinics that can reach all rural areas may be used as an alternative in handling tb in rural areas, especially in osing, tengger and pandalungan. acknowledge the researcher expressed his gratitude to all the study participants who had taken the time to discuss the handling of tb in the rural areas of osing, tengger and pandalungan. the researcher also thanked the university of jember for giving the opportunity to carry out this research. references abbas, a. (2017). monitoring of side effects of antituberculosis drugs (atd) on the intensive phase treatment of pulmonary tb patients in makassar. journal of agromedicine and medical sciences, 3(1). https://doi.org/https://doi.org/10.19184/ams .v3i1.4093 ahmed, a., & martin, h. (2018). barriers leading to treatment default among tuberculosis patients in khartoum state, sudan: a qualitative study. open access text. https://doi.org/10.15761/cmi.1000152 babatunde, o. i., bismark, e. c., amaechi, e. n., gabriel, e. i., & olanike, a. r. (2015). determinants of treatment delays among pulmonary tuberculosis patients in enugu metropolis, south-east, nigeria.. 2015;07(11):. doi: health, 7(11), 1506–1516. https://doi.org/10.4236/health.2015.711164. gebreweld, f. h., kifle, m. m., gebremicheal, f. e., simel, l. l., gezae, m. m., ghebreyesus, s. s., … wahd, n. g. (2018). factors influencing adherence to tuberculosis treatment in asmara, eritrea: a qualitative study. j health popul nutr., 37(1). https://doi.org/10.1186/s41043-0170132-y getnet, f., demissie, m., assefa, n., mengistie, b., & worku, a. (2017). delay in diagnosis of pulmonary tuberculosis in low-and middleincome settings: systematic review and metaanalysis. bmc pulm med., 17. https://doi.org/[10.1186/s12890-017-0551-y] hassan, a. o., olukolade, r., ogbuji, q. c., afolabi, s., okwuonye, l. c., kusimo, o. c., … ladipo, o. a. (2017). knowledge about tuberculosis: a precursor to effective tb control—findings from a follow-up national kap study on tuberculosis among nigerians. tuberc res treat. https://doi.org/10.1155/2017/6309092 hutama, h. i., riyanti, e., & kusumawati, a. (2019). gambaran perilaku penderita tb paru dalam pencegahan penularan tb paru di kabupaten klaten. jurnal kesehatan masyarakat, 7(1). kaul, s., & nardell, e. (2011). disposal of sputum in home settings. r. e. sulistyono et al. 68 | pissn: 1858-3598  eissn: 2502-5791 mabunda, j., & bradley, h. (2011). factors contributing to poor performance of directly observed treatment short-course (dots). mopani district, limpopo province and south africa. afr j phys health educ recreation dance suppl., 2(1), 93–107. mei, l., tobe, r., geng, h., ma, y., li, r., wang, w., … xu, l. (2012). a cross-sectional study of sputum handling by and supervision of patients with pulmonary tuberculosis treated at home in china. biosci trends., 6(6), 296–302. doi: 10.5582/bst.2012.v6.6.296 phetlhu, d. r., bimerew, m., marie-modeste, r. r., naidoo, m., & igumbor, j. (2018). nurses’ knowledge of tuberculosis, hiv, and integrated hiv/tb care policies in rural western cape, south africa. journal of the association of nurses in aids care, 29(6). https://doi.org/https://doi.org/10.1016/j.jana .2018.05.008 pratiwi, n. l., betty, r., hargono, r., & widya, n. e. (2012). kemandirian masyarakat dalam perilaku pencegahan penularan tb paru. buletin penelitian sistem kesehatan, 15(2). sagbakken, m., frich, j. c., & bjune, g. (2008). barriers and enablers in the management of tuberculosis treatment in addis ababa, ethiopia: a qualitative study. bmc public health, 8(11). https://doi.org/10.1186/1471-2458-8-11 sang, r. k. a., obwoge, r. o., kangethe, s., ayiro, l. p., & changeiywo, j. m. (2017). patient factors which contribute to non-adherence to tb treatment in kericho and nakuru counties of kenya. science journal of public health, 5(4), 329–334. https://doi.org/10.11648/j.sjph.20170504.18 streubert, h., & carpenter, d. (2003). qualitative research in nursing: advancing the humanistic imperative. philadelphia: lippincott williams & wilkins. sullivan, b. j., esmaili, b. e., & cunningham, c. k. (2017). barriers to initiating tuberculosis treatment in sub-saharan africa: a systematic review focused on children and youth. glob health action., 10(1). https://doi.org/10.1080/16549716.2017.1290 317 tristiana, r. d., yusuf, a., fitryasari, r., wahyuni, s. d., & nihayati, h. e. (2018). perceived barriers on mental health services by the family of patients with mental illness. international journal of nursing sciences, 5(1), 63–67. https://doi.org/https://doi.org/10.1016/j.ijns s.2017.12.003 tuharea, r., suparwati, a., & sriatmi, a. (2014). analisis faktor-faktor yang berhubungan dengan implementasi penemuan pasien tb paru dalam program penanggulangan tb di puskesmas kota semarang. jurnal manajemen kesehatan indonesia, 2, 168–178. usaid. (2017, june). pengendalian tuberkulosis di indonesia: tantangan. news and information. viney, k. a., johnson, p., tagaro, m., fanai, s., linh, n. n., kelly, p., … sleigh, a. (2014). tuberculosis patients’ knowledge and beliefs about tuberculosis: a mixed methods study from the pacific island nation of vanuatu. bmc public health., 14. https://doi.org/10.1186/14712458-14-467 who. (2013). systematic screening for active tuberculosis : principles and recommendations. genewa: world health organization. who. (2017). global tuberculosis report 2017. who. https://doi.org/who/htm/tb/2017.23 world health organization. (1999). tuberculosis infection control in the era of expanding hiv care and treatment. http://dx.doi.org/10.5582/bst.2012.v6.6.296 http://e-journal.unair.ac.id/jners | 1 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.17363 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the psychological capital and anxiety felt by post-market fire disaster victims dian fitria, mustikasari mustikasari, and ria utami panjaitan faculty of nursing, universitas indonesia, west java, indonesia abstract introduction: traditional markets are a financial resource for traders. fire disasters at the traditional markets will have a bad effect in terms of generating both financial and psychological problems. there is a lack of studies about the psychological problems experienced by traditional market fire victims. the aim of this study is to identify the correlation of psychological capital (hope, self-efficacy, resilience, and optimism) with the anxiety level among the victims of market fire disasters in central jakarta. methods: this study used a cross-sectional approach with a non-probability sampling method. this study involved 174 market fire victims from central jakarta. the independent variables were psychological capital, which includes hope, selfefficacy, resilience, and optimism. the dependent variable was anxiety level. the instruments used the hope scale, the general self efficacy scale, the 14-item resilience scale (rs-14), the life orientation test-revised (lot-r) scale and the generalized anxiety disorder scale. the data analysis used an independent t-test, chi-square, and multiple logistic regression prediction modeling. results: the more kiosks burned, the more that the informant’s anxiety increased by about4.845 times after applying a control factor of self-efficacy and optimism with a wald value of 23.146. conclusion: psychological capital (self-efficacy and optimism) have a significant correlation with anxiety in the market fire disaster victims. good self-efficacy and optimism can reduce the level of anxiety felt. this study highlighted that psychological capital is a part of the disaster assessment as the basis for providing disaster nursing interventions. article history received: january 14, 2020 accepted: february 06, 2020 keywords anxiety; market fire victims; optimism; psychological capital; self-efficacy contact dian fitria  titiayu.titi@gmail.com  faculty of nursing, universitas indonesia, west java, indonesia cite this as: fitria, d., murtikasari, m., & panjaitan, r, u. (2020). the psychological capital and anxiety felt by postmarket fire disaster victims. jurnal ners, 15(1). 1-6. doi:http://dx.doi.org/10.20473/jn.v15i1.17363 introduction a disaster is an event that happens suddenly, creating damage, an ecological imbalance, a disrupted livelihood and worsening or even damaging people’s health and the health services. a community will bear a huge burden and require external assistance (landesman, 2014). the centre for research on the epidemiology of disaster (2016) stated that the asian region is the area most impacted by disasters compared to other continents in the world (guha, hoyois, below, 2014). the natural condition and human behavior in indonesia has placed indonesia at number five based on the country’s most impacted by disasters (guha, hoyois, below, 2014). disasters can be either natural or non-natural. fire events are a non-natural disaster that occurs frequently. according to jakarta’s central statistical bureau, based on burnt objects in 2014, there were 1,260 fire events, and 238 among them were in public buildings. industrial buildings and markets were included in this list. there has been a 100% increase from 2014 to 2015 for market fires. the indonesian market sellers’ union reported that in 2014, there were 100 market fires. in 2015, there were 250. therefore, in this paper, the researcher limits the disaster of focus to only non-natural ones with a specific focus on market fires. market fires occur for two reasons: old and inadequate buildings and sub-standard safety and security systems (rarasati, 2013). the impacts of fire can be divided as follows: personal impact, loss of property, and a loss of service (davidson, price, mccauley, ruggiero, 2013). sixty five percent of postdisaster trauma originates from the loss of property. market fire victims lose their property, which reduces https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id d. fitria et al. 2 | pissn: 1858-3598  eissn: 2502-5791 their economic functioning (aslam & tariq, 2010). the disrupted economic functions give way to psychosocial impacts in the form of anxiety for not having a livelihood (knopp, 2016). several research studies have proven that anxiety is the biggest problem after a disaster. psychosocial symptoms (66%) rank number two in terms of postdisaster problems after musculoskeletal problems (79%) (nijrolder, van der velden, grievink, yzermans, 2011). anxiety counts for 30 90% of postdisaster emotional trauma (shoaf, 2014). unmanaged psychosocial issues such as anxiety can worsen into depression, post-traumatic stress disorder (ptsd) and homicidal tendencies. individuals with high psychological capital will succeed in improving their post-trauma living quality (gail, 2013). the resilience when facing a psychological impact due to disaster is highly influenced by the initial resilience “capital” and the initial psychological conditions possessed by each individual. this is called “psychological capital”. psychological capital is an individual’s positive development related to the following characteristics: self-efficacy, positive attribution (optimism) and belief in reaching their target in life (hope). when stressors appear, they are able to persevere and survive (resiliency) (luthans, 2007). individuals with high psychological capital will be able to improve their post-trauma living quality (gail, 2013). based on these explanations, this study intends to examine the correlation between psychological capital and anxiety in the market fire victims. materials and methods this cross-sectional study encompassed 174 respondents recruited using the non-probability sampling. the respondents of this research were the victims of a market fire disaster living in a temporary relocation area who were willing to become a respondent. the researcher collected the data accompanied by the management staff of the traditional market, pd pasar jaya. there were five instruments used in this study. hope was measured using the hope scale questionnaire developed by snyder and their colleagues with a reliability value of 0.897 (snyder, sympson, ybasco, babyak, higgins, 1996). the general self efficacy questionnaire with a reliability value of 0.925 was used to measure self-efficacy (schwarzer & jerusalem, 1995). the assessment of the level of resilience was done using the 14-item resilience scale (rs-14) with a cronbach’s alpha value of 0.81 (wagnild, 1993). the optimism instrument used the life orientation test-revised scale (lot-r) with a reliability alpha of 0.878 (scheier, carver, bridges, 1994). the generalized anxiety disorder questionnaire was used to measure the level of the respondents' anxiety with a croncbach’s alpha score of 0.92 and a reliability value of 0.83 (spitzer, kroenke, williams, lowe, 2006). all of the table 1. mean age of the market fire victims (n=174) variable mean standard deviation age 35.94 7.343 table 2. percentage distribution of gender, the frequency of being market fire victims and the number of kiosks burnt (n=174) variable n % gender men 96 55.2 women 78 44.8 education none 6 3.4 primary 20 11.5 junior high school 73 42 senior high school 63 36.2 college 12 6.9 the frequency of being market fire victims once 67 38.5 twice 89 51.1 >2 18 10.3 the number of kiosks burnt one kiosk 92 52.9 two kiosks 63 36.2 three kiosks 8 4.6 four kiosks 11 6.3 table 3. psychological capital (hope, self-efficacy and optimism) of the market fire victims (n=174) variable mean sd 95% ci hope 75.07 10.39 73.51– 76.62 self-efficacy 28.83 4.180 28.20 – 29.45 optimism 36.43 4.520 35.75 – 37.10 jurnal ners http://e-journal.unair.ac.id/jners | 3 instruments were translated into bahasa indonesian and a reliability value of 0.867 was obtained for this study. the analysis of the research data was carried out through univariate analysis (central tendency and frequency distribution), bivariate analysis (independent t test and chi-square) and multivariate analysis (multiple logistic regression prediction modeling). ethical approval number 83/un2.f12.d /hkp.02.04/2017 was sought from the research ethics committee of the faculty of nursing, universitas indonesia. the data was collected through questionnaires and did not cause any harm to the respondents. the ethical requirements and respondent rights have been fulfilled throughout the research process. results the average age of the respondents was 35.94 years old (table 1). table 2 shows that the majority of respondents were male (55.2%), with the highest education level that of junior high school (42%). the most common response was being a market fire victim twice (51.1%) and the number of kiosks that had burnt most commonly totaled one (53%). table 3 shows the description of psychological capital in the majority of respondents with a mean score of 75.07 (sd = 10.39; 95% ci = 73.51-76.62). self efficacy was 28.83 (sd = 4,180; 95% ci = 28,2029,45), optimism was 36.43 (sd = 35.75-37.10) and having a high resilience was (47.4%) (table 4). table 5 describes that the majority of respondents experience moderate anxiety (66.7%) 3 months after the fire disaster. the characteristics of the respondents’ age and gender do not have a significant correlation with a ptable 4. psychological capital (resilience) of the market fire victims (n=174) variable n % resilience very good 25 14.4 good 83 47.7 average 53 30.5 poor 12 6.9 very poor 1 0.6 table 5. anxiety level of the market fire victims (n=174) variable n % low 58 33.3 moderate 116 66.7 table 6. correlation between age and the anxiety of the market fire victims (n=174) variable mean sd p age anxiety (low) 37.43 8.700 0.058 anxiety (moderate) 35.20 6.474 table 7. correlation between gender, education, the frequency of being a market fire victim and the number of kiosks burnt (n=174) independent variable dependent variable total p low moderate n % n % n % gender 0.196 men 28 29.2 68 70.8 96 55.2 women 30 38.5 48 61.5 78 44.8 education 0.362 none 2 33.3 4 66.7 6 3.4 primary 7 35 13 65 20 11.5 junior high school 30 41.1 43 58.9 73 42 senior high school 15 23.8 48 76.2 63 36.2 college 4 33.3 8 66.7 12 6.9 the frequency of being a market fire victim 0.004 once 28 41.8 39 58.2 67 38 twice 30 33.7 59 66.3 89 52 >2 0 0 18 100 18 10 the number of kiosks burnt 0.000 one kiosk 50 54.3 42 42 92 55.3 two kiosks 3 4.8 60 95.2 63 36.2 three kiosks 0 0 8 100 8 4.6 four kiosks 5 45.5 6 54.5 11 6.3 d. fitria et al. 4 | pissn: 1858-3598  eissn: 2502-5791 value of 0.058 (table 6) and 0.196 (table 7). the number of kiosks burned and the frequency of being a market fire victim have a significant relationship with anxiety (p = 0.004; 0.000) (table 7). table 8 shows that there is a significant correlation between self-efficacy and optimism with anxiety with a p value 0.015, 0.014. hope and resilience do not have a significant relationship with anxiety with a p-value of 0.922 (table 8) and 0.526 (table 9). the more kiosks are burnt, the more that the victim’s anxiety increases by 4.845 times after being controlled by self-efficacy and optimism. discussion the results of the research describe that age has no influence on the level of anxiety experienced by the fire market victims. this is due to the fact that age influences individual ego. however, it does not have any correlation with the anxiety experienced (bonnet, 2007). age does not have a correlation with psychosocial issues but it does have a correlation with the development stages (baily, 2004). age does not guarantee that an individual will have the ability to cope with psychological problems such as anxiety. this is because when people growing older, the ego can either grow up or not depending on the stressors encountered in their life, in the environment and related to their individual values. age does not ensure that a person is adaptable. each age-based life stage relates to developmental tasks that must be fulfilled. the individual achievements that need to be fulfilled related to the developmental tasks influences the ability to solve the psychological problems present, not age. gender does not have a correlation with anxiety in the market fire victims. based on previous studies, traumatic events like traditional market fires influence the ego and developmental tasks, not age. they also no relation towards their ability to solve the anxiety experienced. gender has no influence on the anxiety experienced by individuals especially when referring to the specific cause of the natural disaster (robbins, 2004). this research showed that gender has no relationship on a sudden traumatic event like a market fire disaster. it becomes acceptable that gender does not relate to anxiety. this is because the victims’ ability to face an anxiety-inducing experience depends on the stressor that they have experienced previously, referring to the environment, developmental tasks, ego development and also religious values and their social life. the number of burnt kiosks is a factor influencing the respondents’ anxiety. the more kiosks are burnt, the more than their level of anxiety increases by about 4.845 times after being controlled by self-efficacy and optimism. disasters and their impact are stressors for the victims. the stressors increase with the disasterseverity factor that is experienced, in addition to the disaster frequency and the scope of their losses (math, nirmala, moirangthem & kumar (2015). material damage and associated losses will create table 8. correlation between psychological capital (hope, self-efficacy, and optimism) and the anxiety of the market fire victims (n=174) anxiety n mean sd p hope low 58 74.97 9.935 0.922 moderate 116 75.12 10.615 self-efficacy low 58 29.90 4.154 0.015 moderate 116 28.29 4.059 optimism low 58 36.78 4.645 0.014 moderate 116 35.72 4.435 table 9. correlation between psychological capital (resilience) and the anxiety of the market fire victims (n=174) independent variable dependent variable total p low moderate n % n % n % resilience very good 7 26.9 19 73.1 26 14.9 0.526 good 29 34.9 54 65.1 83 47.4 average 16 30.2 37 69.8 53 30.3 poor 5 41.7 7 58.3 12 6.85 very poor 1 100 0 0 1 0.6 table 10. multivariate logistic regression variable b se wald p exp (b) or (95% ci) self-efficacy -0.303 0.063 23.310 0.000 0.738 0.653-0.835 optimism 0.213 0.059 12.988 0.000 1.238 1.102-1.390 total number of kiosks 1.578 0.328 23.146 0.000 4.845 2.547-9.213 jurnal ners http://e-journal.unair.ac.id/jners | 5 post-fire social and psychological problems. according to the research, there were three impacts as a result of the disaster; the personal impact, a loss of property and a loss of service (davidson, price, mccauley, ruggiero, 2013). the amount of postdisaster material losses sustained caused 65% of the trauma (aslam & tariq, 2010). when the victims lost their products in the market, this meant that they lost financial resources as well. material loss will affect to their family, social, financial and psychological life. there was no severe anxiety level found in the market fire victims due to the grieving of the respondents being in the third phase. the stages of grieving are divided into the three phase. first there is the shock and numbness phase and then yearning, despair and disorganization as the second phase. the third phase is re-organization and recovery. this study was conducted 30 days after a market fire disaster, so the victims therefore have an ability to cope the resulting anxiety. the respondents also passed the acute stress syndrome phase that occurs 2 4 weeks after a disaster (smid, velden, mulders, knipscheer, gersons, kleber, 2013). after 30 days post-disaster, coping mechanisms will begin to emerge, according to the existing results of postdisaster management (kaklauskas, amaratungga & haigh, 2009). based on disaster recovery and reorganization by the management, they provide them with a new kiosk in the relocation area so then the fire victims can still receive transactions as a financial resource, which can relieve some of their anxiety. fire frequency and anxiety were found to have a correlation in the respondents studied. the research concluded that the disaster and its impact become a post-disaster anxiety trigger. this stressor worsens due to the factor of disaster frequency. these stressors increase with the level of disaster-severity factor that is experienced, inclusive of disaster frequency, and the scope of any losses (math, nirmala, moirangthem & kumar (2015). people who have experienced a disaster will experience psychological trauma. this worsens when the victims have successfully rebuilt their business and suddenly encounter the market fire disaster again. their anxiety will be more than it was previously. psychological capital (self-efficacy and optimism) have a significant relationship with anxiety. the respondents’ self-efficacy reached 75%, with another 25% needed to increase the self-efficacy value to the point where it is hoped to lower anxiety. self-efficacy is the belief that the market fire victims possess related to their ability to successfully face a fire disaster. therefore, the ability to find a way out by the respondents has improved through effort and reducing their negative thinking about the event. the respondents’ optimism reached 72%, with 28% more needed to maximize the optimism possessed which is hoped to lower the respondents’ anxiety. it can be said that the respondents have the ability to carry out certain activities in order to rise up following a fire disaster (bandura, 1997). improving optimism can be done through the suppression of pessimism and practicing positive thinking. the results show that there is no correlation between the psychological capital (hope, resilience) and anxiety. the current respondent is a merged survivor in a relocation area, so an adaptation response has been formed and processed within. hope is therefore not correlated with anxiety. hope does not have meaningful correlation with the anxiety experienced by the merged survivors (ozag, 2006). resilience does not have significant correlation with the anxiety experienced by the market fire victims. resilience is not only individualistic. it is a combination of the robustness of the system, infrastructure, government, business, community, and individuals when it comes to withstanding, tolerating, absorbing and recovering (briding, 2014). the resilience of the victim has been built by the pd pasar jaya as a form of management by providing infrastructure for the purpose of relocation with good compensation. the community of fire victims allows them to support, tolerate and recover alongside each other, so good resilience has been formed and processed by the community of the victim. although they are supported by the community and pd pasar jaya, they still experience anxiety. this is the reason why resilience does not have a significant correlation with the anxiety experienced by the market fire victims. conclusion based on the results of this research, it can be concluded that there are two psychological assets with a correlation to anxiety: optimism and selfefficacy. optimizing the respondent’s positive assets can be performed by suppressing their negative feelings and practicing positive ones in order to find a way out. hopefully, the results of this research can be used as an input for market administrators to allow them to provide health clinics for use by the traders. the regional disaster management board can coordinate with the local health office in order to establish a healthcare post for the health team, namely the role of post-disaster psychological nurse. the regional health office, together with the government, can optimize the community program through nurse mapping in community life. therefore, market fire victims with psychosocial issues can be assisted at the community level. further research can be performed to encourage the development of a nursing intervention based on the psychological capital. acknowledgement we extend our gratitude to pd pasar jaya, the faculty of nursing, universitas indonesia and stikes rs husada for their technical and related support. references aslam, n., & tariq, n. (2010) ‘trauma, depression, d. fitria et al. 6 | pissn: 1858-3598  eissn: 2502-5791 anxiety, and stress among individuals living in earthquake affected and unaffected areas’, pakistan journal of psychological research, 25(2), pp. 131–148. bailey, g. t. (2004) the impact of trauma on the psychosocial development in refugees according to erikson’s psychosocial theory. bandura, a. (1997) ‘self-efficacy and health behaviour’, in cambridge handbook of psychology, health and medicine. in a. baum. cambridge: cambridge university press, pp. 160–162. bonnett, h. r. (2007) ‘exploring the relationship between ego development and mental health’. briding, a. j. (2014) an analysis of factors affecting long-term disaster recovery. walden university. available at: http://www.tandfonline.com/doi/abs/10.3846/ 1648-715x.2009.13.117-128. davidson, t. m. et al. (2013) ‘hhs public access’, american journal of community psychology, 52(0), pp. 97–105. doi: 10.1007/s10464-013-9579-1. gail eastman (2013) the relationship between psychological capital and workplace bullying for nurses. guha-sapir, d., hoyois, p. and below, r. (2015) ‘annual disaster statistical review 2014: the numbers and trends’, review literature and arts of the americas, pp. 1–50. doi: 10.1093/rof/rfs003. kaklauskas, a., amaratunga, d. and haigh, r. (2009) ‘knowledge model for post‐disaster management’, international journal of strategic property management, 13(2), pp. 117–128. doi: 10.3846/1648-715x.2009.13.117-128. knopp, k. a. (2016) ‘exploring the relationship of emotional intelligence with mental health status in polish unemployed persons-differences between men and women’, polish psychological bulletin, 47(4), pp. 436–444. doi: 10.1515/ppb2016-0051. landesman, l. y. (2014) case studies public health prepadness & response to disaster. washington dc: jones & barlett publisher. luthans, y. & a. (2007) psychological capital: developing the human competitive edge. oxford university press. math, s. b., nirmala, m. c., moirangthem, s., & kumar, n. c. (2015) ‘disaster management: mental health perspective’, indian journal of psychological medicine, 37(3), pp. 261–271. nijrolder, i. et al. (2011) ‘symptom attribution and presentation in general practice after an extreme life event’, family practice, 28(3), pp. 260–266. doi: 10.1093/fampra/cmq114. ozag, d. (2006) ‘the relationship between the trust, hope, and normative and continuance commitment of merger survivors’, journal of management development, 25(9), pp. 870–883. doi: 10.1108/02621710610692070. rarasati, a. . (2013) asesmen risiko kebakaran pasarpasar di wilayah dki jakarta (studi kasus pasar di lingkungan p.d pasar jaya. robbins, g. (2014) ‘the relationship between generalized anxiety disorder in women and hormonal imbalances, self-efficacy and lifestyle: implications for licensed professional counselors and counselor educators.’, dissertation abstracts international: section b: the sciences and engineering, 74(8–b(e)). scheier, m. f., carver, c. s. and bridges, m. w. (1994) ‘distinguishing optimism from neuroticism ( and trait anxiety , self-mastery , and self-esteem ): a reevaluation of the life orientation test’, 67(6), pp. 1063–1078. schwarzer, r. & jerusalem, m. (1995) ‘general selfefficacy scale (gse)’. shoaf, k. (2014) ‘organizing the health sector for response to disasters’, ciência & saúde coletiva, 19(9), pp. 3705–3715. doi: 10.1590/141381232014199.03722014. smid, g. e. et al. (2013) ‘stress sensitization following a disaster : a prospective study stress sensitization following a disaster : a prospective study’, (2012). doi: 10.1017/s0033291711002765. snyder, c. r. et al. (1996) ‘development and validation of the state hope scale.’, journal of personality and social psychology, 70(2), pp. 321– 335. doi: 10.1037/0022-3514.70.2.321. spitzer, r. l. et al. (2006) ‘a {brief} {measure} for {assessing} {generalized} {anxiety} {disorder}: {the} {gad}-7’, archives of internal medicine, 166(10), pp. 1092–1097. doi: 10.1001/archinte.166.10.1092. wagnild gm, y. h. (1993) ‘development and psychometric evaluation of the resilience scale’, journal of nursing measurement, 1(2), pp. 165– 178. http://e-journal.unair.ac.id/jners | 217 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17103 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the analysis of the influencing factors related to the effectiveness of discharge planning implementation in hospitals: a systematic review hari soebagiyo, kornelis nama beni and tan nina fibriola faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: discharge planning is one of the agendas that is a part of nursing duties. this is not only complicated but it is also a long-term activity, starting from when the patients are admitted to hospital until they are allowed to go home. factually, it cannot be denied that effective nursing discharge planning implementation will provide benefits for the patient, their family and the professionals within the health care setting. based on those facts, the author composed this systematic review with the purpose of identifying the influential factors that have a role in terms of the effectiveness of nursing discharge planning implementation in hospitals methods: the researcher conducted their investigation in february 2019 and this involved the exploration of scientific papers from proquest and scopus using the keywords ‘nursing discharge planning’, ‘effectiveness’ and ‘implementation’. this paper identified 15 relevant research articles from 500 original full texts. these papers were analyzed according to the inclusion criteria and the impeding factors in discharge planning implementation. it involved 1 quasi-rct and 14 descriptive research studies. results: as a result, from the 10.000 respondents, it was found that the enhancing factors include effective communication at 43% and the factors causing impedance in nursing discharge planning effectiveness includes the continuity of staff at 38 %. conclusion: the dominant factor of impedance as stated in the interview sessions was a lack of time to do the nursing discharge planning properly. article history received: december 26, 2019 accepted: december 31, 2019 keywords discharge planning; family; hospital; influence factor, effectiveness contact hari soebagiyo  hari.soebagiyo2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: soebagiyo, h., beni, k. n. & fibriola, t. n. (2019). the analysis of the influencing factors related to the effectiveness of discharge planning implementation in hospitals: a systematic review. jurnal ners, 14(3si), 217-220. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17103 introduction discharge planning is considered to be an important part of the current health services. this form of planning is a systematic planning process starting from when the patient is admitted to hospital. discharge planning must be focused on the patient's problem, which includes prevention, rehabilitative and nursing care that provides the patients and their families with an understanding of the disease and any caring interventions that must be done at home, in addition to explaining the patient's needs and ensuring that they have the references needed for further treatment. the phenomena today of discharge planning for patients is not optimal, where nurses just do a limited form of the implementation of routine activities in the form of the information on re-control. the nonoptimal implementation of discharge planning can be caused by the effectiveness of the process of carrying out this activity. effectiveness is a condition where a job can be done on time and in accordance with the plan that has been set (indonesian dictionary). with effective discharge planning, this can be achieved by a decreased length of stay, decreased readmission and decreased mortality. starting from the points above, the author wanted to explore the factors that may enhance and impede discharge planning implementation. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:hari.soebagiyo-2018@fkp.unair.ac.id mailto:hari.soebagiyo-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). h. soebagiyo, et al. 218 | pissn: 1858-3598  eissn: 2502-5791 materials and methods the method used in the preparation of this systematic review began with the selection of interesting and specific topics. we chose the topic of discharge planning, which is one of the problems in nursing management that has not been resolved up until now. after selecting a topic, we conducted a systematic review and determined the keywords. the keywords used were ‘nursing discharge planning’, ‘influencing factors’, ‘effectiveness’ and ‘implementation’. a journal search was carried out focused on trusted publishers such as scopus and pro-quest with the yearly restriction being between 2004 2018 in the nursing management area. from the 500 articles that were obtained, 15 articles were selected that were in accordance with the established inclusion criteria that examined the enhancing and impending factors in the effectiveness of discharge planning implementation. results based on the results of a review 15 articles collected. the discussion about the factors that can enhance and impend the implementation of discharge planning effectiveness are as follows level of knowledge the level of knowledge of a nurse is an important factor in achieving the effectiveness of discharge planning. in his research has proved that for nurses who have been trained in the method and concept of discharge planning will be more effective in implementing discharge planning than nurses who have not trained (abdulrdha & mansour, 2018). patients readiness for discharge patient readiness to do discharge planning, also an important factor in achieving discharge planning effectiveness with its predictors are: sex, age, education status, marital status will be very helpful in achieving discharge planning, especially when at home (kaya & sainguven, 2018). discharge planning that has applicability capabilities carrie hk et al (2012) states that; the ability of the discharge planning format to be implemented is very influential for effective discharge planning. furthermore in the discussion of the participants from his research also stated that the lack of a number of human resources, skills, and time also greatly affected the implementation of discharge planning effectively (wong et al., 2011). lack of planning of discharge programs and lack of coordination of health workers with different scientific disciplines lack of coordination between health workers with different disciplines also plays a role in discharge planning. ellza y wong et al (2011) explained that the potential barriers included lack of standardized policy-driven discharge planning programs, and lack of communication and coordination among different health service providers and patients in both acute and sub-acute care settings were identified as main system issues. improving the quality of hospital discharge was suggested, including a multidisciplinary approach with clear identified roles among healthcare professionals. communication of health professionals' enhancement of knowledge and patient psychology (wong et al., 2011). lack of nurse communication in hospitals with nurses in community services discussion in research pauline voie (2018) explained that the nicu nurses and parents were not clearly defined, and the public health nurse competence groups were not clearly defined. there is a family role in implementing discharge planning the role of the family cannot be denied that as a support system it is very helpful, especially when the patient is at home. the patient will feel motivated to obey the treatment in order to speed up his recovery. the role of the family as caregiver, observer, and reminder to always remind the importance of being obedient in the treatment corridor (fitzgerald, nurs, & lecturer, 2011). pro-active treatment rooms carry out discharge planning rudd carolyne et al. (2013) in her research, found that treatment rooms that proactively carry out discharge planning will be able to reduce the length of stay and decrease costs (collins, 2017). effective in communication and effective continuity rosemarry watts et al (2005) implies that several factors influence the effectiveness of the implementation of the discharge including; inadequate communication, unplanned discharge, lack of time, lack of knowledge, and continuity of staff. meanwhile, it is found that the factor that enhances effective communication is 43%, and the impedance factor is continuity of staff is 38% (r. watts et al., 2005). discussion in this article of existing studies, an analysis factors influence effective discharge planning implementation at the hospital. from this systematic review, we try to show there are some factors involve in it. the study result implies the effectiveness implementation discharge planning was influenced by level of knowledge of a nurse, patients readiness for discharge, discharge planning that has applicability capabilities, lack of planning of discharge programs and lack of coordination of health workers, family role in implementing discharge planning, proactive treatment rooms carry out discharge planning, and, effective in communication and effective continuity. in this discussion, the author tries to categorise four major points that have a role for jurnal ners http://e-journal.unair.ac.id/jners | 219 effective discharge planning implementation namely; 1.nurse 2.role patient and family in discharge planning 3. discharge planning that has applicability capabilities 4. effective in communication and effective continuity. those items will intercorrelate each other. as it has been explained that discharge planning is one of variance nursing duty agendas. this is not only too complicated but also long term activity, starting from patients are admitted to the hospital until they are allowed to go home. it gives nurse responsibility to do discharge planning properly. there fore, they who have been trained in the method and concept of discharge planning will be more effective in implementing discharge planning than nurses who have not trained (abdulrdha & mansour, 2018). and rooms that proactively carry out discharge planning will be able to reduce the length of stay and decrease costs (collins, 2017) it explain when nurses have good knowledge, awareness, and, motivation regarding discharge planning will be done effectively. furthermore, a skilfull nurse who applies effective discharge planning will really provide good effects on the patient and their family. they will analyse, examine, and educate the need care of the patient and their family, including the need for physical, psychological, cognitive, and, social. it will induce capacity patient readiness to do discharge planning at home (kaya & sainguven, 2018) and the role of the family as a care giver, observer, and a reminder to always remind the importance of being obedient in the treatment corridor (fitzgerald et al., 2011). another discussion of discharge planning is about discharge planning that has less. applicability capabilities, such kind research carrie hk et al. (2012) states that; the ability of the discharge planning format to be implemented is very influential for effective discharge planning (wong et al., 2011). it reflects not only how important to involve many sides nurses/ health worker to create feasible discharge planning. but also standardise policy-driven due discharge planning program. the last, crucial point for effectiveness implementation discharge planning refers to effective in communication and effective continuity. this issue become important because communication in discharge planning must touch all health professional worker/people who have discharge planning interest purposely. communication in the discharge planning is in writing and non-writing form, there fore,it have to be be guaranteed continuity at the right hand and the right form from sender up to receiver. by applying discharge planning that has powerfull .applicability is hoped communication and continuity will be not interrupte. finally, discharge planning provides interventions and can work together in care tasks ners range. the nurses must be able to elaborate co relationships to the interprofessional health worker, patient, and, family patient as support system related to applying an appropriate standardised discharge planning to patients, as the result, quality of nursing care, satisfaction and safety patient will increase also. conclusion based on this study, there is a consideration that discharge planning as an important part of current health services. this planning is a systematic process starting when the patients were admitted and up to allow to the left the hospital. discharge planning must be focused on the patient's needs and problems, which includes prevention, rehabilitative and nursing care that provide patients and families understanding and information the disease and caring interventions for further treatment at home. in deep discussion, the effectiveness implementation discharge planning at hospital was influenced by some factors including; level of knowledge of a nurse, patients readiness for discharge, discharge planning that has applicability capabilities, lack of planning of discharge programs and coordination of health workers, family role in implementing discharge planning, pro-active treatment rooms carry out discharge planning, and, effective in communication and effective continuity. at this moment, the author finds to categorise four major points that have a role for effective discharge planning implementation namely; 1. nurse 2.role patient and family in discharge planning 3. discharge planning that has applicability capabilities 4. effective in communication and effective continuity. those items will intercorrelate each other. by concerning toward some factors that have been discussed before, it will guide nurses to apply an appropriate standardised discharge planning to patients, as the result, quality of nursing care, satisfaction and safety patient will increase also. references abdulrdha, & mansour. (2018). effectiveness of an instructional program on nurse’s knowledge and practice concerning patients discharge planning post cardiac surgery at cardiac centers and hospitals inbaghdad city. journal of nursing management, 26, 707–716. backer, t. e., howard, æ. e. a., & moran, æ. g. e. (2007). the role of effective discharge planning in preventing homelessness. journal primary prevent, 28, 229–243. https://doi.org/10.1007/s10935-007-0095-7 collins, d. (2017). assessing the effectiveness of advanced nurse practitioners undertaking home visits in an out of hours urgent primary care service in england. journal of nursing management, 25, 519–530. durocher, e., gibson, b. e., & rappolt, s. (2016). mediators of marginalisation in discharge planning with older adults. cambridge university press. fitzgerald, l. r., nurs, d. t., & lecturer, s. (2011). hospital discharge : recommendations for performance improvement for family carers of h. soebagiyo, et al. 220 | pissn: 1858-3598  eissn: 2502-5791 people with dementia. australian health review, 364–370. kaya, s., & sainguven, g. (2018). patients’ readiness for discharge: predictors and effects on unplanned readmissions, emergency department visits and death. journal of nursing management. mohamed, s., parker, s., & arbon, p. (2014). a survey of malaysian critical intensive care unit nurses ’ awareness of patients ’ transition experiences ( pe ) and transitional care practice ( tcp ). intensive & critical care nursing, 30(4), 196–203. https://doi.org/10.1016/j.iccn.2013.12.006 roberts, s., & moore, l. (2018). improving discharge planning using the re-engineered discharge programme. journal of nursing management. watts, r., gardner, h., & pierson, j. (2005). factors that enhance or impede critical care nurses ’ discharge planning practices. intensive and critical care nursing, 21, 302–313. https://doi.org/10.1016/j.iccn.2005.01.005 watts, r. j., pierson, j., & gardner, h. (2005). how do critical care nurses define the discharge planning process ? intensive and critical care nursing, 21, 39–46. https://doi.org/10.1016/j.iccn.2004.07.006 wong, e. l. y., yam, c. h. k., cheung, a. w. l., leung, m. c. m., chan, f. w. k., & wong, f. y. y. (2011). barriers to effective discharge planning : a qualitative study investigating the perspectives of frontline healthcare professionals. bmc health services research, 11(1), 242. https://doi.org/10.1186/1472-6963-11-242 yam, c. h. k., wong, e. l. y., cheung, a. w. l., chan, f. w. k., wong, f. y. y., & yeoh, e. (2012). framework and components for effective discharge planning system : a delphi methodology. bmc health services research, 12(1), 1. https://doi.org/10.1186/1472-6963-12-396 yilmaz, m. c., & ozsoy, s. a. (2010). effectiveness of a discharge-planning program and home visits for meeting the physical care needs of children with cancer. springer, 243–253. https://doi.org/10.1007/s00520-009-0650-2 ners vol 10 no 1 april 2015.indd 38 perubahan keluhan gejala prahaid dengan senam aerobik (the changes of premenstrual symptoms after aerobic exercise intervention) sirajudin noor*, raihana norfi tri* *akper intan martapura jl samadi no 1 martapura kalimantan selatan email: judin178@gmail.com abstrak pendahuluan: gejala prahaid merupakan kumpulan gejala fi sik, emosi dan tingkah laku yang terjadi menjelang menstruasi yang dapat mengganggu aktivitas seorang wanita. aktivitas fi sik aerobik dapat meningkatkan tingkat endorfi n, menurunkan estrogen, meningkatkan transportasi oksigen dalam otot dan meningkatkan kesejahteraan psikologis. tujuan penelitian ini adalah mengidentifi kasi perbedaan pengaruh senam aerobik dan pendidikan kesehatan terhadap keluhan gejala prahaid. metode: rancangan penelitian ini menggunakan metode quasy experiment control group design. penelitian dilakukan di akademi keperawatan intan martapura dan akademi kebidanan banjarbaru dengan subjek penelitian adalah seluruh mahasiswa yang tercatat sebagai mahasiswi akademi keperawatan intan martapura dan akademi kebidanan banjarbaru. dengan teknik purposive sampling, didapatkan sebanyak 40 responden. hasil: berdasarkan uji korelasi pearson pada kelompok perlakuan dan kontrol sebelum dilakukan perlakuan didapatkan hasil 0,862 (α > 0,05, berarti tidak ada hubungan keluhan gejala prahaid antara kelompok perlakuan dan kontrol. setelah intervensi didapatkan hasil 0,018 (α < 0,05), berarti ada hubungan senam aerobik dengan keluhan gejala prahaid dengan tingkat kekuatan hubungan lemah yaitu 0,373. dari uji komparatif t test pada kasus dan kontrol sebelum dilakukan perlakuan didapatkan hasil sign 0,862 (α ≥ 0,05), berarti tidak ada perbedaan keluhan gejala prahaid pada kelompok perlakuan dan kontrol. setelah dilakukan intervensi didapatkan hasil sign 0,018 (α < 0,05), berarti ada perbedaan keluhan gejala prahaid pada kelompok perlakuan yang melakukan senam aerobik dengan kontrol yang mendapatkan pendidikan kesehatan. uji paired test pada kasus sebelum dan sesudah dilakukan perlakuan berupa senam aerobik didapatkan hasil sign 0,000 (α < 0,05), berarti ada perbedaan keluhan gejala prahaid sebelum dan sesudah dilakukan senam aerobik. pada kelompok kontrol sebelum dan sesudah dilakukan perlakuan berupa pendidikan kesehatan didapatkan hasil sign 0,056 (α ≥ 0,05), berarti tidak ada perbedaan keluhan prahaid keluhan gejala prahaid sebelum dan sesudah dilakukan pendidikan kesehatan. analisis dan diskusi: bagi mahasiswa yang mengalami keluhan gejala prahaid, sebaiknya melakukan senam aerobik secara teratur sebagai salah satu cara untuk mengurangi keluhan gejala prahaid. kata kunci: keluhan gejala prahaid, senam aerobik, pendidikan kesehatan abstract background: premenstrual syndrome (pms) is a group of physical symptoms, emotions and behaviors that occur cyclically during the luteal phase of the menstrual cycle and disappear after menstruation happened. those symptoms might cause suffering for women and thus require treatment. aerobic physical activity can raise the level of endorphins, decrease estrogen, increase oxygen transport in muscle and improve psychological well-being. the purpose of this study is to identify the differences in the effect of aerobic exercise and health education on the symptoms of premenstrual syndrome. method: this study used quasy ekspriment with pre-posttest control group design. the research was conducted by comparing the symptoms of pms complaints before and after treatment in the control group (education health) and the experimental group (aerobics).the research performed at the academy of nursing intan martapura and midwifery academy banjarbaru with all students who registered as a student of the academy of nursing intan martapura and midwifery academy banjarbaru as the subjects. the technique sampling used in this study was purposive sampling the number of sample was 40 respondents. result: based on pearson correlation test in cases and controls prior to treatment showed α > 0.05 (0.862), meant there was no correlation pms between cases and controls. after treatment in cases and controls showed α <0.05 (0.018), mean there was a correlation between gymnastics aerobics with pms complaints and pms symptoms complaints, with the weak level of strength 0,373. from the comparative t-test in cases and controls prior to treatment showed signs ≥ 0.05 (0.862), means there was no difference of pms complaints in cases and control group. after the treatment in cases and controls showed signs of < 0.05 (0.018), which means there was differences in symptoms of premenstrual complaints on cases that do aerobics with controls who received health education. from paired t-test on cases before and after treatment in the form of aerobics showed sign result 0.000 < 0.05, which means that there were differences in symptoms of premenstrual complaints and menstrual complaints before and after aerobics exercise. in control group before and after treatment showed a sign of health education 0.056 ≥ 0.05 meant no differences on pms complaints and pms symptoms complaints between before and after the education. analysis and discusssion: for the students who had health complaints of pms symptoms, it is suggested to perform regular aerobic exercise as one way to reduce the symptoms of pms complaints. keywords: pms symptoms complaints, aerobics, health education 39 perubahan keluhan gejala prahaid dengan senam aerobik (sirajudin noor dan raihana norfi tri) pendahuluan g e j a l a p r a h a i d ( p r e m e n s t r u a l syndrome) adalah kumpulan gejala fi sik, emosi dan tingkah laku yang terjadi secara siklis selama fase luteal dari siklus menstruasi dan hilang setelah menstruasi terjadi, walaupun kadang-kadang berlangsung terus sampai haid berhenti (wiknjosastro h, 2009). survei epidemiologik pada wanita di eropa, cina dan jepang menunjukkan bahwa 80–90% wanita usia reproduksi pernah mengalami beberapa gejala dan variasi gejala prahaid (arisman, 2010). gejala prahaid mempengaruhi tingkat kualitas hidup. pada mahasiswa dan wanita usia subur, gangguan ini menurunkan produktivitas pendidikan (prestasi akademik) dan pekerjaan, meningkatkan ketidakhadiran di sekolah dan tempat kerja, mengganggu hubungan dengan keluarga dan aktivitas sosial serta meningkatkan penggunaan fasilitas kesehatan. siswa dan wanita usia subur yang menderita gejala prahaid dapat diprediksi setelah bekerja akan absen secara periodik di tempat kerja dan menurunkan produktivitas kerjanya selama 7–10 hari dan atau sama dengan 84–120 hari per tahun, hal ini merupakan status kehilangan personal dan sosial yang bermakna (baziad, 2003; deuster, 1999) penelitian yang dilakukan di finlandia menyebutkan bahwa keluhan gejala prahaid secara signifi kan lebih tinggi pada mereka yang kurang aktif dibandingkan dengan mereka yang melak ukan aktivitas f isik tinggi. meskipun aktivitas fisik memiliki banyak manfaat kesehatan, hubungan dengan berk u rang nya tingkat keparahan gejala pra haid tidak terdokumentasi dengan baik (deuster, 1999). upaya yang bisa dilakukan untuk mengurangi sindroma gejala prahaid adalah dengan melakukan perubahan gaya hidup antara lain dengan melakukan olahraga, diet, dan menghindari stres. dengan olahraga yang teratur diharapkan dapat memperbaiki kenyamanan dan mengembalikan rasa percaya diri. salah satu olahraga yang bisa dilakukan adalah dengan aktivitas fi sik aerobik. dengan aktivitas fi sik aerobik dapat meningkatkan tingkat endorf in, menur unkan estrogen, meningkatkan transportasi oksigen dalam otot dan meningkatkan kesejahteraan psikologis. metode penelitian ini adalah menggunakan metode guosy eksprimennt design dengan pendekatan pretest and postest control design, dilakukan dengan membandingkan keluhan gejala prahaid pada kelompok kontrol dan kelompok eksperimen sebelum dan sesudah dilakukan perlakuan (senam aerobik). bentuk intervensi yang diberikan pada kelompok eksperimen ber upa senam aerobik yang dilakukan selama dua kali dalam seminggu yang berlangsung selama 30 menit, sedangkan pada kelompok kontrol dilakukan dengan memberikan pendidikan kesehatan keluhan gejala prahaid. penelitian dilak u kan di a kademi keperawatan intan martapura dan akademi kebidanan banjar bar u dengan subjek p e nel it ia n a d a la h selu r u h m a h a siswa yang tercatat sebagai mahasiswi akademi keperawatan intan martapura dan akademi kebidanan banjar baru. teknik sampling yang digunakan adalah purposive sampling. jumlah sampel sebanyak 40 responden yang dibagi menjadi kelompok eksperimen 20 responden di akademi keperawatan intan martapura dan kelompok kontrol sebanyak 20 responden di akademi kebidanan banjarbaru. peneliti mengambil jumlah sampel sebanyak 20 orang. hal didasari dari teori gay dan diehl tahun 1992 bahwa untuk penelitian eksperimen sampel minimumnya adalah 15 subjek per grup. kriteria inklusi terdiri dari mahasiswi yang terdaftar dengan jelas seba-gai mahasiswa dan aktif mengikuti perkuliahan di akademi keperawatan intan martapura serta bersedia mengikuti penelitian dan sudah mengalami menstruasi. kriteria eksklusi adalah mahasiswi tidak ada di tempat pada waktu penelitian, mengalami penyakit yang berhubungan dengan kelainan jiwa (gangguan kecemasan, gangguan depresi, gangguan panik), gangguan anatomi reproduksi, dengan dismenorea, menstruasi tidak teratur, dan amenorea, menggunakan alat kontrasepsi dan hamil. variabel yang 40 jurnal ners vol. 10 no. 1 april 2015: 38–47 diteliti dalam penelitian ini adalah variabel bebas adalah senam aerobik (x) dan variabel terikat adalah keluhan gejala prahaid (y). jenis data yang digunakan adalah data primer dan sekunder. data primer dikumpulkan langsung oleh peneliti dengan cara membagikan kuisioner kepada kelompok kontrol dan kelompok eksperimen sebelum dan sesudah dilak u kan senam aerobik. jawaban kusioner dinilai dengan cara memilih skor pada jawaban yang sudah tersedia. kemudian skor dikategorikan menjadi tidak terdapat keluhan prahaid bila skor jawaban 1–10, terdapat keluhan prahaid ringan bila skor jawaban 11–19, keluhan prahaid sedang bila skor jawaban 20–29, keluhan prahaid berat bila skor jawaban ≥ 30. data sekunder dikumpulkan sebagai data pelengkap dalam penelitian ini yaitu didapat dari buku, internet dan data studi pendahuluan. pada kelompok eksperimen sebelum dilakukan latihan maka terlebih dahulu di kategorikan apakah responden ter masuk mempunyai keluhan prahaid atau tidak. begit u diketahui responden mempunyai keluhan prahaid, kemudian diberikan materi dan latihan senam aerobik dilakukan selama 30 menit dua kali dalam seminggu selama 6 minggu. senam dipandu oleh instruktur profesional. setelah 6 minggu kemudian dinilai kembali mengenai keluhan gejala prahaid. kelompok kontrol sebelum diberikan pendidikan kesehatan maka terlebih dahulu dikategorikan apakah responden termasuk mempunyai keluhan prahaid atau tidak. begitu diketahui responden mempunyai keluhan prahaid, kemudian diberikan pendidikan kesehatan berupa pemberian materi keluhan gejala prahaid. setelah 6 minggu kemudian dinilai kembali mengenai keluhan gejala prahaid. unt u k mengetahui keluhan gejala prahaid dengan menggunakan instrumen: the shortened premenstrual assessment form (spaf) yang dikembangkan oleh university california university di san diego. american college of obstetrics gynecology (acog) merekomendasikan kriteria diagnosa keluhan gejala prahaid yaitu instrumen spaf yaitu panduan yang simpel tetapi mempunyai reliabilitas dan validitas yang tinggi. the shortened premenstrual assessment form (spaf) adalah kriteria diagnosa dengan penilaian sederhana yang terdiri dari 10 item, mengenai gejala yang dialami menjelang haid antara lain: 1) payudara tegang, nyeri dan bengkak; 2) merasa tidak berdaya atau kewalahan oleh tuntutan yang luar biasa; 3) merasa tertekan; 4) mudah tersinggung dan marah; 5) sedih, depresi; 6) nyeri otot dan sendi; 7) berat badan bertambah; 8) merasa tidak nyaman, perut terasa penuh atau nyeri; 9) bengkak (oedema) atau retensi cairan dan 10) merasa kembung. tiap item mempunyai nilai maksimal 6, dengan rentang mulai dari gejala yang tidak dirasakan sampai gejala yang sangat berat. sistem penilaian menggunakan ‘1’ bila tidak ada keluhan, angka ‘2’ jika timbul keluhan sangat ringan (gejala yang dialami hanya sedikit terasa), angka ‘3’ jika timbul keluhan sedang (gejala terasa, tetapi tidak mengganggu aktivitas sehari-hari), angka ‘4’ jika timbul keluhan sedang (gejala terasa dan mempengaruhi aktivitas sehari-hari), angka ‘5’ jika timbul keluhan berat (gejala terasa sekali dan terjadi penurunan fungsi, beberapa aktivitas sehari-hari tidak bisa dilakukan), angka 6 jika timbul keluhan berat sekali (gejala sangat terasa sekali, terjadi penurunan fungsi fi sik dan psikis, sehingga tidak mampu melakukan aktivitas sehari-hari). diagnosa keluhan gejala prahaid dapat ditegakkan jika wanita mengalami paling sedikit 5 dari gejala dalam spaf, dan minimal satu dari gejala harus nomor 2, 3, 4 dan 5, dengan skor ≥ 30. penilaian keluhan gejala prahaid dilakukan, jika: 1) skor 1 – 10 berarti tidak mengalami keluhan gejala prahaid; 2) skor 11 – 19 berarti keluhan gejala prahaid ringan; 3) skor 20–29 berarti keluhan gejala prahaid sedang; 4) skor ≥ 30 berarti keluhan gejala prahaid berat. analisis data dilakukan melalui analisis statistik, meliputi analisa univariat untuk mengevaluasi besarnya proporsi dari masingmasing variabel, baik variabel bebas yaitu senam aerobik, variabel terikat: derajat keluhan gejala prahaid yang dideskripsikan dalam bentuk tabel distribusi frekuensi. analisa bivariat untuk menganalisis pengaruh keluhan 41 perubahan keluhan gejala prahaid dengan senam aerobik (sirajudin noor dan raihana norfi tri) gejala prahaid pada kelompok eksperimen dan kelompok kontrol sebelum dan sesudah dilakukan perlakuan menggunakan analisa statistik uji pearson, untuk menganalisis perbedaan keluhan gejala prahaid sebelum dan sesudah dilaksanakan perlakuan pada kelompok eksperimen dan kelompok kontrol dilakukan dengan analisis statistik menggunakan uji t-test, untuk menganalisis perbedaan keluhan gejala prahaid sebelum dan sesudah dilaksanakan senam aerobik pada kelompok eksper imen dila k u kan dengan analisis statistik menggunakan paired t-test, untuk menganalisis perbedaan keluhan gejala prahaid sebelum dan sesudah dilaksanakan pendidikan kesehatan pada kelompok kontrol dilakukan dengan analisis statistik mengguna-kan paired t-test. hasil pengambilan data primer dilakukan pada bulan oktober sampai nopember 2013 di akademi keperawatan intan martapura dan akademi kebidanan yayasan karya husada banjarbaru berjumlah 40 orang yang memenuhi kriteria inklusi. pada mahasiswa akademi keperawatan intan martapura diberi perlakuan berupa senam yang dilakukan sebanyak dua kali dalam satu minggu selama 30 menit dan dilakukan selama 6 minggu. sedangkan pada kelompok kontrol yang diberi perlakuan dengan memberikan pendidikan kesehatan berupa penyuluhan. usia responden < 20 tahun pada kasus (senam) dengan keluhan gejala prahaid terbanyak pada derajat sedang 12 orang (60%), pada kontrol (pendidikan kesehatan) terbanyak pada derajat sedang 12 orang (60%). usia menarche < 12 tahun pada kasus (senam) dengan keluhan gejala prahaid terbanyak pada derajat sedang 14 orang (70%), pada kontrol (pendidikan kesehatan) terbanyak pada derajat sedang 11 orang (55%). riwayat siklus haid teratur pada kasus (senam) dengan keluhan gejala prahaid terbanyak pada derajat sedang 15 orang (75%), pada kontrol (pendidikan kesehatan) terbanyak pada derajat sedang 12 orang (60%). keluhan gejala prahaid pada kasus dan kontrol sebelum diberikan perlakuan terbanyak pada keluhan gejala prahaid ringan, pada kasus 3 (15%) dan pada kontrol 3 (15%), keluhan gejala prahaid sedang pada kasus 12 (60%) dan kontrol 12 (60%), keluhan gejala prahaid berat pada kasus 5 (25%) dan pada kontrol 5 (25%). tabel 1. keluhan gejala prahaid sebelum dan sesudah dilakukan perlakuan (senam aerobik) pada kasus keluhan gejala prahaid kasus pretest posttest tak ringan sedang berat tak ringan sedang berat payudara tegang,nyeri dan bengkak 0 (0%) 0 (0%) 5 (25%) 15 (75%) 1 (5%) 12 (60%) 5 (25%) 2 (10%) merasa tidak mampu berkonsentrasi 1 (5%) 13 (65%) 6 (20%) 0 (0%) 3 (15%) 10 (50%) 7 (35%) 0 (0%) merasa tertekan 0 (0%) 5 (25%) 10 (50%) 5 (25%) 3 (5%) 8 (40%) 7 (35%) 2 (10%) mudah tersinggung dan marah 0 (0%) 3 (15%) 10 (50%) 7 (35%) 7 (35%) 7 (35%) 5 (25%) 1 (5%) merasa sedih,depresi 3 (15%) 11 (55%) 6 (30%) 0 (0%) 7 (35%) 9 (45%) 4 (20%) 0 (0%) nyeri otot dan sendi 3 (15%) 9 (45%) 8 (40%) 0 (0%) 8 (40%) 9 (45%) 3 (15%) 0 (0%) berat badan bertambah 3 (15%) 12 (60%) 5 (25%) 0 (0%) 6 (30%) 11 (55%) 3 (15%) 0 (0%) merasa tidak nyaman, perut terasa penuh atau nyeri 2 (10%) 7 (35%) 11 (55%) 0 (0%) 5 (25%) 8 (40%) 7 (35%) 0 (0%) bengkak (edema) pada kaki 9 (45%) 5 (25%) 1 (5%) 5 (25%) 9 (45%) 9 (45%) 0 (0%) 2 (10%) perut terasa kembung 3 (15%) 3 (15%) 8 (40%) 6 (30%) 4 (20%) 6(30%) 8(40%) 2 (10%) 42 jurnal ners vol. 10 no. 1 april 2015: 38–47 tabel 2. keluhan gejala prahaid sebelum dan sesudah dilakukan perlakuan (pendidikan kesehatan) pada kontrol keluhan gejala prahaid kontrol pretest posttest tak ringan sedang berat tak ringan sedang berat payudara tegang, nyeri dan bengkak 5 (20%) 6 (30%) 9 (45%) 0 (0%) 0 (0%) 7 (35%) 6 (30%) 7 (35%) merasa tidak mampu berkonsentrasi 1 (5%) 8 (40%) 10 (50%) 1 (5%) 3 (15%) 7 (35%) 9 (45%) 1 (5%) merasa tertekan 5 (25%) 7 (35%) 8 (40%) 0 (0%) 1 (5%) 4 (20%) 7 (35%) 8 (40%) mudah tersinggung dan marah 6 (30%) 11 (55%) 3 (15%) 0 (0%) 3 (15%) 4 (20%) 10 (50%) 3 (15%) merasa sedih, depresi 3 (15%) 11 (55%) 5 (25%) 1 (5%) 1 (5%) 2 (105) 11 (55%) 6 (30%) nyeri otot dan sendi 1 (5%) 7 (35%) 9 (45%) 3 (15%) 1 (5%) 7 (35%) 9 (45%) 3 (15%) berat badan bertambah 3 (15%) 5 (25%) 10 (50%) 2 (10%) 3 (15%) 5 (25%) 10 (50%) 2 (10%) merasa tidak nyaman, perut terasa penuh atau nyeri 1 (5%) 3 (15%) 4 (20%) 12 (60%) 1 (5%) 3 (15%) 5 (25%) 11 (55%) bengkak (edema) pada kaki 8 (40%) 7 (35%) 5 (25%) 0 (0%) 1 (5%) 7 (35%) 6 (30%) 6 (30%) perut terasa kembung 14 (70%) 4(20%) 2(10%) 0 (0%) 1 (5%) 3(15%) 10(50%) 6(30%) diagram 1. hasil uji normalitas sebelum dilakukan perlakuan pada kasus hasil observasi keluhan gejala prahaid sesudah perlakuan pada kasus (senam) dan kontrol menunjukkan bahwa keluhan gejala prahaid pada kasus dan kontrol sesudah diberikan perlakuan, pada kasus tidak ada keluhan gejala prahaid ringan 2 (10%), sedangkan kontrol 1 (5%), keluhan gejala prahaid ringan pada kasus 11 (55%) dan pada kontrol 2 (10%), keluhan gejala prahaid sedang pada kasus 5 (25%) dan pada kontrol 13 (65%), keluhan gejala prahaid berat pada kasus 2 (10%) dan pada kontrol 4 (20%). hasil perhitungan statistik menggunakan uji normalitas shapiro wilk pada diagram 1,2,3,4 total pretest pada kasus 0.005, total posttest pada kasus 0.098, total pretest 43 perubahan keluhan gejala prahaid dengan senam aerobik (sirajudin noor dan raihana norfi tri) diagram 2. hasil uji normalitas sesudah dilakukan perlakuan pada kasus diagram 3. hasil uji normalitas sebelum dilakukan perlakuan pada kontrol diagram 4. hasil uji normalitas sesudah dilakukan perlakuan pada kontrol 44 jurnal ners vol. 10 no. 1 april 2015: 38–47 kontrol 0,05 dan total posttest kontrol 0,023, didapatkan hasil pretest dan posttest pada kasus dan kontrol, dengan nilai signif kan ≥ 0,05 berdistribusi normal. pada tabel 3, tabel 4 untuk analisis bivariat, karena datanya berdistribusi normal maka dilakukan uji parametrik, untuk uji korelasi menggunakan uji korelasi pearson dan untuk uji komparasi dilakukan uji t-test dan uji paired test. dari uji korelasi pearson pada kasus dan kontrol sebelum dilakukan perlakuan didapatkan hasil α > 0,05, 0,862 > 0,05, ho diterima, berarti tidak ada hubungan keluhan prahaid keluhan gejala prahaid antara kasus dan kontrol dengan tingkat kekuatan hubungan sangat lemah yaitu 0,28. setelah dilakukan perlakuan pada kasus dan kontrol didapatkan hasil α < 0,05, 0,018 < 0,05, ho ditolak, berarti ada hubungan senam aerobik dengan keluhan prahaid keluhan gejala prahaid dengan tingkat kekuatan hubungan lemah yaitu 0,373. tabel 5 unt u k melihat perbedaan pengaruh perlakuan pada kelompok kasus dan kelompok kontrol dilakukan uji t-test. dari uji komparatif t test pada kasus dan kontrol sebelum dilakukan perlakuan didapatkan hasil sign ≥ 0,05 = 0,862, ho diterima berarti tidak ada perbedaan keluhan prahaid pada kasus dan kontrol. setelah dilakukan perlakuan pada kasus dan kontrol didapatkan hasil sign < 0,05 = 0,018, ho ditolak berarti ada perbedaan keluhan prahaid keluhan gejala prahaid pada kasus yang melakukan senam aerobik dengan kontrol yang mendapatkan pendidikan kesehatan. untuk melihat perbedaan keluhan gejala prahaid pada kasus dan kontrol sebelum dan sesudah perlakuan dilakukan uji paired test. dari uji paired test pada kasus sebelum dan tabel 5. perbedaan keluhan gejala prahaid sebelum dan sesudah perlakuan pada kasus dan kontrol independent samples test levene’s test for equality of variances t-test for equality of means f sig. t df sig. (2-tailed) mean difference std. error difference totfk equal variances assumed .043 .837 .174 38 .862 .35000 2.00640 equal variances not assumed .174 37.795 .862 .35000 2.00640 totpk equal variances assumed 1.009 .322 -2.479 38 .018 -5.55000 2.23898 equal variances not assumed -2.479 37.413 .018 -5.55000 2.23898 tabel 3. hubungan keluhan gejala prahaid sebelum perlakuan pada kasus dan kontrol correlations senam totfk senam pearson correlation 1 -.028 sig. (2-tailed) .862 n 40 40 penkes pearson correlation -.028 1 sig. (2-tailed) .862 n 40 40 tabel 4. hubungan keluhan gejala prahaid sesudah perlakuan pada kasus dan kontrol correlations sename totpk senam pearson correlation 1 .373* sig. (2-tailed) .018 n 40 40 totpk pearson correlation .373* 1 sig. (2-tailed) .018 n 40 40 * correlation is signifi cant at the 0.05 level (2-tailed). 45 perubahan keluhan gejala prahaid dengan senam aerobik (sirajudin noor dan raihana norfi tri) sesudah dilakukan perlakuan berupa senam aerobik didapatkan hasil sign 0,000 < 0,05, ho ditolak yang berarti ada perbedaan keluhan haid keluhan gejala prahaid sebelum dan sesudah dilakukan senam aerobik. pada kontrol sebelum dan sesudah dilakukan perlakuan berupa pendidikan kesehatan didapatkan hasil sign 0,056 ≥ 0,05, ho ditolak berarti tidak ada perbedaan keluhan prahaid (keluhan gejala prahaid) sebelum dan sesudah dilakukan pendidikan kesehatan. pembahasan berdasarkan hasil uji korelasi pearson pada kasus dan kontrol sebelum dilakukan perlakuan didapatkan hasil α > 0,05, 0,862 > 0,05, ho diterima, berarti tidak ada hubungan keluhan prahaid keluhan gejala prahaid antara kasus dan kontrol dengan tingkat kekuatan hubungan sangat lemah yaitu 0,28. dari uji komparatif t-test pada kasus dan kontrol sebelum dilakukan perlakuan didapatkan hasil sign ≥ 0,05 = 0,862, ho diterima berarti tidak ada perbedaan keluhan prahaid pada kasus dan kontrol. kelu h a n p r a h a id ( p re m e n st r u a l syndrome/keluhan gejala prahaid) adalah kumpulan gejala fisik, emosi dan tingkah laku yang terjadi secara siklis selama fase luteal dari siklus menstr uasi dan hilang setelah menstruasi terjadi, walaupun kadangkadang berlangsu ng ter us sampai haid berhenti (wik njosastro, 2009). keluhan prahaid adalah sebuah gangguan periodik pada usia muda dan menengah, yang ditandai oleh gejala emosional dan fi sik yang secara tetap berlangsung selama fase praovulasi dalam periode menstruasi. keluhan prahaid merupakan masalah kesehatan umum yang paling banyak dilaporkan oleh wanita usia subur. saat ini diperkirakan prevalensi keluhan prahaid dari gejala klinis adalah sekitar 12,6 –31% dar i wanita yang mengalami menstruasi.studi epidemiologi menunjukkan kurang lebih 20% dari wanita usia reproduksi mengalami keluhan prahaid tingkat sedang sampai berat. sekitar 75% wanita dengan siklus biasa mengeluhkan beberapa perubahan (gejala premenstruasi) selama periode luteal. dalam penelitian ini, keluhan gejala prahaid pada kasus dan kontrol terbanyak pada keluhan prahaid sedang (60%). penelitian yang dilakukan di pakistan menyebutkan bahwa frekuensi gejala adalah ke m a r a h a n , lek a s m a r a h , kec e m a s a n , kelelahan, sulit konsent rasi, per ubahan suasana hati dan gejala fisik seperti nyeri pay ud a ra d a n ket id a k nyama na n t ubu h secara umum dengan gangguan besar dalam kehidupan sosial, kegiatan dan efi siensi kerja, produktivitas. wanita dengan keluhan gejala prahaid melaporkan gangguan terbesar dalam hubungan pribadi, tingkat kerja terganggu, dan peningkatan ketidakhadiran kerja. bukti klinis saat ini menunjukkan bahwa keluhan gejala prahaid cenderung menjadi penyakit kronis dengan sedikit pemulihan. keluhan gejala prahaid juga dapat mulai kapan saja setelah menarche dan berlanjut sampai ovulasi berakhir saat menopause. ada bukti bahwa beberapa remaja mengalami gejala dan tingkat keparahan yang sama sampai wanita tersebut tua. hasil uji korelasi pearson pada kasus dan kontrol setelah dilakukan perlakuan pada kasus dan kontrol didapatkan hasil α < 0,05, 0,018 < 0,05, berarti ada hubungan senam aerobik dengan keluhan prahaid keluhan gejala prahaid dengan tingkat kekuatan hubungan lemah yaitu 0,373. dari uji komparatif t-test pada kasus dan kontrol setelah dilakukan perlakuan pada kasus dan kontrol didapatkan hasil sign < 0,05 = 0,018, ho ditolak berarti ada perbedaan keluhan prahaid keluhan gejala prahaid pada kasus yang melakukan senam aerobik dengan kontrol yang mendapatkan pendidikan kesehatan. dari uji paired test pada kasus sebelum dan sesudah dilakukan perlakuan berupa senam aerobik didapatkan hasil sign 0,000 < 0,05, yang berarti ada perbedaan keluhan haid keluhan gejala prahaid sebelum dan sesudah dilakukan senam aerobik. hasil penelitian ini menunjukkan, senam aerobik berhubungan dengan keluhan prahaid keluhan gejala prahaid dan terdapat perbedaan keluhan gejala prahaid pada responden yang melakukan senam aerobik dibandingkan dengan yang hanya mendapatkan pendidikan 46 jurnal ners vol. 10 no. 1 april 2015: 38–47 kesehatan berupa penyuluhan. hasil penelitian ini sesuai dengan penelitian aimee kroll, latihan aerobik, khususnya untuk mengurangi kelelahan dan depresi terkait dengan keluhan gejala prahaid. begitu juga penelitian yang dilakukan oleh deuster yang menyebutkan bahwa latihan aerobik dapat menurunkan gejala emosional dan somatik dari responden yang mengalami gejala prahaid. konsep penanganan keluhan gejala prahaid dirancang dalam satu paket yang terdiri dari: perubahan gaya hidup, pemberian suplemen zat gizi, pemberian obat, psikoterapi, serta pengobatan komplemen. perubahan gaya hidup yang terdiri dari diet, olahraga dan menghindari stres. olahraga teratur berfungsi memperbaiki kenyamanan sembari mengembalikan rasa percaya diri. salah satu olahraga yang direkomendasikan dengan melakukan senam aerobik. melakukan senam aerobik dengan frekuensi yang lebih teratur dapat membantu menurunkan gejala keluhan gejala prahaid, karena pada saat melakukan senam aerobik akan menimbulkan rasa senang karena gerakan-gerakan di dalam senam aerobik menyenangkan, sehingga wanita yang melakukan senam dapat mengurangi stres. senam aerobik dibutuhkan banyak energi, sehingga banyak mengoksidasi karbohidrat dan lemak untuk memenuhi energi yang dibutuhkan. senam aerobik dapat menjaga berat badan tidak bertambah. ada beberapa mekanisme biologis di mana aktivitas fisik dapat mengurangi gejala keluhan gejala prahaid. aktivitas fi sik aerobik dapat meningkatkan endorfi n, tingkat penurunan dari estrogen dan hormon steroid lainnya, meningkatkan transportasi oksigen dalam otot, mengurangi kadar kortisol dan meningkatkan kesejahteraan psikologis. endorfi n adalah merupakan suatu komponen seperti morfi n yang diproduksi di otak, dapat mengurangi rasa sakit dan menimbulkan rasa euforia (perasaan senang dan bahagia). olahraga dapat membantu menstabilkan mood, kecemasan dan depresi yang biasa terjadi pada wanita. oleh karena itu olahraga dapat dikaitkan dengan penurunan stres. dengan berolahraga dapat mengurangi pembengkakan (edema) karena keluarnya air dari dalam selsel tubuh. semua mekanisme ini mendukung hubungan terbalik aktivitas fi sik pada gejala prahaid. beberapa studi menunjukkan bahwa latihan aerobik teratur memiliki banyak manfaat, termasuk peningkatan daya untuk aktivitas jantung, pembuluh darah, meningkatkan kepadatan tulang, dan mengurangi stres dan keluhan gejala prahaid. gejala fi sik seperti pembengkakan, berat badan, sakit kepala, dan nyeri payudara mungkin terkait peningkatan aldosteron dalam serum, prostaglandin e2, dan kekurangan vitamin b dan magnesium. peningkatan tingkat prolaktin pada akhir fase luteal adalah salah satu penyebab nyeri payudara dan bengkak, dan olahraga aerobik mungkin mengurangi tingkat hormon ini, dan dengan demikian dapat mengurangi gejala keluhan gejala prahaid. penelitian menunjukkan bahwa kinerja kegiatan fisik mengurangi tingkat aktivitas renin dan meningkatkan kadar estrogen dan progesteron, dan dengan cara ini, menurunkan tingkat serum aldosteron dan reabsorpsi natrium dan air, sehingga mengurangi edema dan memperbaiki gejala fi sik. faktor lain dalam munculnya gejala f isik meningkat prostaglandin e2, yang mengurangi otot kontraksi. kontraksi berulang dalam aerobik olahraga membantu darah vena untuk kembali, sehingga peningkatan prostaglandin dan zat lain yang membantu mencegah dan mengurangi nyeri punggung dan ketidak nyamanan dalam pelvis dan perut. kemungkinan mekanisme lain adalah efek olahraga terhadap tingkat darah leptin pada wanita dengan keluhan gejala prahaid. leptin adalah hormon yang disekresikan dari sel-sel lemak dan mengatur metabolisme hipotalamus hipofi sis gonad dan memiliki peran penting dalam reproduksi manusia. metabolisme hormon ini memberikan efek neuroendocrinologic melalui reseptor di daerah hipotalamus melalui pengendalian emosi. sebuah studi telah menunjukkan bahwa konsentrasi leptin yang beredar di darah wanita dengan keluhan gejala prahaid secara signifi kan lebih tinggi dibandingkan pada wanita tanpa keluhan gejala prahaid, dan kadar hormon 47 perubahan keluhan gejala prahaid dengan senam aerobik (sirajudin noor dan raihana norfi tri) yang tinggi dapat dikaitkan dengan gejala psikologis keluhan gejala prahaid. beberapa penelitian menunjukkan bahwa aktivitas fi sik mengurangi jumlah leptin dalam darah sekitar 30–34%, penurunan tingkat leptin darah pada wanita menurun gejala psikologis keluhan gejala prahaid. simpulan dan saran simpulan sebelum dilakukan perlakuan tidak ad a hubu ngan kelu han prahaid ( pms) antara kasus dan kontrol, sesudah dilakukan perlakuan hubungan senam aerobik dengan keluhan prahaid (pms). sebelum dilakukan perlakuan tidak ada perbedaan keluhan prahaid pada kasus dan kontrol, setelah dilakukan perlakuan pada kasus dan kontrol ada perbedaan keluhan prahaid (pms) pada kasus yang melakukan senam aerobik dengan kont rol yang mend apat kan pendidi kan kesehatan. pada kasus sebelum dan sesudah dilakukan perlakuan berupa senam aerobik ada perbedaan keluhan haid (pms) sebelum dan sesudah dilakukan senam aerobik. saran bagi mahasiswa yang mengalami keluhan gejala prahaid, sebaiknya melakukan senam aerobik secara teratur sebagai salah satu cara untuk mengurangi keluhan gejala prahaid. kepustakaan anim-nyame n, domoney c, panay n, jones j, alaghband zadeh j. plasma leptin concentrations are increased in women with premenstr ual syndrome. hum reprod, 2000; 15: 329–32. arisman m. buku ajar ilmu gizi, gizi dalam daur kehidupan. jakarta: egc; 2010. hlm. 215–33. baziad a. endokrinologi ginekologi. edisi ke 2. media aesculapius fakultas kedokteran universitas indonesia, jakarta. 2003. deuster pa, adera t & south-paul j. biological, social, and behavioral factors associated with premenstrual syndrome. arch fam med. 1999; 8: 122–128. gay, lr dan diehl, pl. 1992. research methods for business and management, macmillan publishhing company, new york. karimian n, rezaeian m, nassaji f. the effects of physical activity on premenstrual syndrome. j med sci zanjan 2006; 13: 8–15 k rool a. recreational physical activit y and premenstrual syndrome college aged women, m.s., universit y of massachusetts amherst, 2010. mahmoodi z, shahpoorian f, bastani f, parsay s, hoseini f, amini l, jahanfar s. the prevalence and severity of premenstrual syndrome (pms) and its’ associated signs and symptoms among college students. australian journal of basic and applied sciences. 2010; 4(8): 3005–9. nusrat et al. frequency, intensity and impact of premenstrual syndrome in medical students, journal of the college of physicians and surgeons pakistan 2008, vol. 18 (8): 481–484. souza ms, cardoso al, yasbek pj, faintuch j. aerobic endurance, energy expenditute, and serum leptin response in obese, sendentary, prepubertal children and adolescents participating in a short-term treadmill protocol. nutrition 2004; 20: 900–4. supar man e, sentosa ir. premenstrual syndrome. jakarta: egc; 2011. sujarwo, ml. the effects of aerobic gymnastics intensity to premestruation syndrome (pms), fakultas kedokteran universitas muhammadiyah yogyakarta. ugar r ize dn, kling ners s, o’br ien s. premenstr ual syndrome: diagnosis and intervention. nurse pract 1998; 23: 40–50. wiknjosastro h, saifuddin ab, rachimhadhi t. il mu ka ndu nga n. ed isi ke 2, jakarta: pt bina pustaka sarwono prawirohardjo; 2009. hlm. 582. wilmore jh, costill dl. physiology of sport and exercise. translated by moeini. tehran: mobtakeran publishers; 2008. p. 150–75. http://e-journal.unair.ac.id/jners | 383 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17168 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the benefits of fasting to improve health conditions and to prevent cardiovascular disease wahyu sukma samudera, gracia victoria fernandez, rahmatul fitriyah, hidayat arifin, shenda maulina wulandari, and roby aji permana faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: fasting is defined as the voluntary abstinence from eating for variable time intervals and it has been associated with potential beneficial impacts on human health. the study was to review the benefits of fasting on cardiovascular health in humans with or without cardiovascular disease. methods: the databases search was done using the keywords ‘fasting’ and ‘cardiovascular system’ using scopus, science direct and proquest, limited to between 2013 and 2019 for publication year. a total of 3.619 articles were obtained and 15 articles involving experimental and non-experimental studies were used as the reference material. results: the findings showed that in people who are healthy, fasting can reduce the inflammatory markers (il-1 & il-6, tnf-α), the oxidative stress marker (malondialdehyde), body weight, abdominal circumference, fasting blood glucose, ldl, triglyceride and blood pressure. in people at risk or with cardiovascular disease, fasting can reduce body weight, body mass index, abdominal circumference, fat percentage, blood pressure, triglyceride, the biomarker of inflammation (serum amyloid a), the biomarker of oxidative stress (protein carbonyl), the biomarker of endothelial dysfunction (asymmetric dimethylarginine) and increase the vascular endothelial growth factor. conclusion: based on these findings, fasting can improve the health condition of people at risk or with cardiovascular disease by improving the risk factors such as blood pressure, overweight and endothelial dysfunction. in people who are healthy, fasting can be used for the prevention of cardiovascular disease by helping to maintain their weight, blood pressure, ldl and triglyceride within the normal limits. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords fasting; cardiovascular; healthy contact wahyu sukma samudera  wahyu.sukma.samudera2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: samudera, w.s., fernandez, g.v., fitriyah, r., permana, r. a., arifin, h., & maulina, s (2019). the benefits of fasting to improve health conditions and to prevent cardiovascular disease. jurnal ners, 14(3si), 383-387. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17168 introduction cardiovascular disease remains a major cause of disability and premature death globally. it is estimated that there are around 17,3 million deaths every year worldwide. it is predicted that there will be an increase to around 27,3 million by 2030(elbashir, awaisu, sa, hajj, & rainkie, 2019). patients with cardiovascular disease requires a high level of involvement from the patient related to control and management of cardiovascular disease (elbashir et al., 2019). moreover, a healthy lifestyle is important to control and/or prevent cardiovascular disease. some research has shown the health improving effect of calorie restriction and intermittent fasting on the cardiovascular system. it also can reduce the risk of cardiovascular disease (elbashir et al., 2019). fasting is a plan that is consciously carried out by the individuals to withhold some or all food and drinks over a certain period of time (faris, jahrami, obaideen, & madkour, 2019). fasting comes in various types and time frames based on what has been determined or the method that has been made by someone (trepanowski et al., 2017). one of the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). w.s. samudera, et al. 384 | pissn: 1858-3598  eissn: 2502-5791 fasting types that is often done is fasting based on religious teachings, in which the fasting practices carried out by someone is on the basis of their faith (trepanowski et al., 2017). some examples of fasting on the basis of belief are when jews fast for 6 days in a year, where greek orthodox christians fast for 180 200 days each year and when the muslims do ramadan fasting for 28 30 days every year (faris et al., 2019). another type of fasting is fasting that is not based on religion. this method of fasting is done by the individual by limiting their calorie intake by 25% of their total intake per day or around 500 kcal (horne, muhlestein, & anderson, 2018). fasting has several benefits for human health and it has become known as a safe method to use to reduce the risk of disease (trepanowski et al., 2017). most individuals use the fasting method to lose weight (kul, savas, & ozturk, 2013). losing weight is one of the ways to improve one's overall health condition. some of the benefits include improving systolic and diastolic blood pressure and improving the body’s insulin levels, total cholesterol and the inflammatory markers in the body (ganesan, habboush, & sultan, 2018). several studies have shown the benefits of fasting on one's health. one of the studies by (faris et al., 2019) showed that ramadan fasting is effectively proven to encourage the loss of weight, a decrease in blood sugar levels and in ldl cholesterol in healthy individuals. other studies (salahuddin, ah, sr, & km, 2014) have shown that fasting can be used as an additional therapy to reduce body weight and blood pressure in middle-aged individuals with hypertension. other studies have also showed that fasting can reduce weight characterized by a decrease in waist circumference and that it can also reduce blood pressure without causing hypotension complications (id, grundler, bergouignan, drinda, & michalsen, 2019). this study aimed to know the benefits of fasting related to improving the present health conditions and preventing diseases of the cardiovascular system in individuals with and without cardiovascular disease. materials and methods research design this study used a systematic review to find out the benefits of fasting on the health of the cardiovascular system. search strategy this research reviews the benefits of fasting through the process of electronic database searching which limited the search years to between 2013 and 2019 using the scopus, science direct, and proquest databases using the following keywords: fasting and cardiovascular health. inclusion and exclusion criteria the inclusion criteria of the research in this systematic review were 1) experimental and nonexperimental studies, 2) research conducted between 2013 and 2019 and 3) research samples or respondents who have or do not have cardiovascular disease. meanwhile, the exclusion criteria in this systematic review was 1) research samples or respondents accompanied by diseases other than cardiovascular and 2) research samples or respondents that are pregnant. article search process the research articles were obtained from 3 databases, namely scopus, science direct, and proquest and 3,619 research articles were initially obtained. a detailed process of the mechanism for selecting the research articles can be seen in table 1. results the results of the review of the 15 journal articles used in the study were related to the benefits of fasting on cardiovascular health in individuals with and without cardiovascular disease. based on table 1, the researcher found some benefits of fasting in terms of improving the human health condition. they were a decrease in the inflammatory markers such as il-1. il-6, tnf-α, malondialdehyde (mda), serum amyloid a, carbonyl protein, a reduction in ldl levels, endothelial dysfunction (asymmetric dimethylarginine), lowered blood pressure, a loss in weight, body mass index, and waist circumference and an increase in the vascular endothelial growth factor (vegf). there were different types of fasting observed in this study: ramadhan(faris et al., 2019) and alternate day fasting(horne et al., 2018). ramadhan fasting is an annual routine agenda for muslims which lasts for 28 30 days(faris et al., 2019). alternate day fasting is when someone restricts their calorie intake by 20-25% of their total calorie intake per day or by approximately 500 kcal per day(horne et al., 2018). figure 1 explains the flow of the study selection; 6 out of 15 articles revealed that fasting could reduce body weight. this is aligned with the introductory part of this study elaborating that fasting methods were used to reduce body weight in some studies. moreover, 3 articles stated that fasting had the therapeutic side effect of reducing blood pressure and ldl level. seven studies observed that the subjects undertook religious fasting or ramadhan fasting which lasts for 28 30 days while the rest of the studies observed subjects using intermittent type of fasting including alternate day fasting. in normal healthy humans without a cardiovascular risk, fasting could help to decrease the inflammation biomarker (il-1, il-6, tnf-α)(faris et al., 2019), oxidative stress (malondialdehyde)(faris et al., 2019), body weight(kul et al., 2013), waist circumstance(sayedda et al., 2013), fasting blood glucose (kul et al., 2013), jurnal ners http://e-journal.unair.ac.id/jners | 385 ldl (kul et al., 2013), trygliceride(ganesan et al., 2018) and blood pressure(id et al., 2019). in humans with a risk of or with cardiovascular disease, fasting could help to decrease their body weight (salahuddin et al., 2014), body mass index(wei et al., 2017), body fat percentage(wei et al., 2017), blood pressure(salahuddin et al., 2014), triglyceride(iso et al., 2014), the biomarker of inflammation (serum amyloid a)(asadi et al., 2015), the biomarker of oxidative stress (protein carbonyl)(asadi et al., 2015) and the biomarker of endothelial dysfunction (asymmetric dimethylarginine)(youse et al., 2014) while increasing the vascular endothelial growth factor (vegf)(youse et al., 2014). discussion this study indicates that fasting has several benefits related to cardiovascular maintenance, both for people with cardiovascular risk and for healthy people. fasting benefits for body weight maintaining based on the research meta-analysis of 21 studies, a total 830 participants were analyzed (531 participants were men and 299 participants were women). the results showed a significant decrease in body weight in the male participants (kul et al., 2013). another study stated that ramadhan fasting could reduce body weight in middle age adults with hypertension (salahuddin et al., 2014). being overweight is triggered by a high fat intake and a low level of physical activity. prevention and management in the context of being overweight can be done by maintaining the balance of diet and physical activity. one of the management efforts used to reduce body weight is fasting (kul et al., 2013). fasting is categorized as a dietary approach to restricting the daily calorie intake in both the short and long term (ganesan et al., 2018). both diet management types, using the ramadhan and alternate day fasting methods, can be done to limit the daily calorie intake. therefore it would help in preventing over-intake and eventually in maintaining the ideal body weight. fasting benefits in blood pressure table 1. benefit of fasting on human health article writer impact of fasting on human health trepanowski et al (trepanowski et al., 2017) increased hdl akaberi et al (akaberi, golshan, moojdekanlo, & hashemian, 2014) improved hdl, ldl/hdl ratio, tg/hdl ratio kul et al (kul et al., 2013) decreased body weight, fasting blood glucose and ldl at people healthy faris et al (faris et al., 2019) decreased biomarkers of inflammation (il-1, il-6, tnf-α) and decreased oxidative stress malondialdehyde (mda). salahuddin et al (salahuddin et al., 2014) can be used as complementary treatment for reducing blood pressure and body weight in people with hypertension mazurak et al (mazurak & gu, 2013) decreased body weight and cortisol diurnal profil iso et al (iso et al., 2014) decreased trygliceride asadi et al (asadi et al., 2015) decreased biomarkers of inflammation (serum amyloid a and protein carbonyl) radhakishun et al (radhakishun, blokhuis, vliet, & rosenstiel, 2014) decreased percentage of fat horne et al (horne et al., 2018) improved body weight and lower prevalence of cardiovascular disease sayedda et al (sayedda, kamal, & ahmed, 2013) decreased body weight, waist circumference and mean blood pressure (healthy) wei et al (wei et al., 2017) decreased body weight, waist circumference, body mass index, body fat and systole blood pressure (risk) id et al (id et al., 2019) decreased body weight marked by a decrease in waist circumference, and decreased blood pressure without hypotension complications ganesha (ganesan et al., 2018) decreased body weight, ldl and trygliceride youse et al (youse et al., 2014) increased vascular endothelial growth factor (vegf) and a decrease in the biomarker of endothelial dysfunction (asymmetric dimethylarginine) 3.293 papers excluded because they did not fulfill the inclusion criteria fasting, cardiovascular health. database scopus, science direct, proquest. title screening (n = 3.619) full text screening (n = 325) appropriate papers (n = 15) 310 papers excluded because they did not fulfill the inclusion criteria figure 1. flowchart of the research benefits of fasting to improve health conditions and disease prevention in relation to the cardiovascular system w.s. samudera, et al. 386 | pissn: 1858-3598  eissn: 2502-5791 a study (salahuddin et al., 2014) revealed that ramadhan fasting could be used as a nonpharmacological therapy to support antihypertension therapy in reducing blood pressure in a person with hypertension. this was proven by the result of the study, which showed a total of 15 hypertensive patients experienced a decrease in their systolic and diastolic blood pressure after fasting (salahuddin et al., 2014). another study stated that fasting was safe to be practiced to decrease blood pressure by not overly reducing it below the normal level. according to the study by (sayedda et al., 2013), a routine of 5 days spent fasting every month continually performed over 3 months in a row helped in the systolic reduction. fasting triggers the hunger sensation which produces a protective effect by preventing catecholamine release and minimizing blood flow in the veins. this mechanism results in reducing the sympathetic nerve impulse and causing a reduction in blood pressure and thus the arterial and cardiac output (salahuddin et al., 2014). thus, fasting is categorized as a non-pharmacological method for additional therapy to control blood pressure in hypertensive patients. furthermore, it has been proven to be a safe way to diet without initiating hypotension complications. the use of fasting towards ldl levels in the body fasting is one of the several ways to control the ldl level in the body. the results of the meta-analysis included 13 studies representing 740 healthy participants (500 men and 240 women). it showed that fasting is proven to be an effective way to decrease the ldl level in the body (kul et al., 2013). this result proved that the respondents who carried out ramadhan fasting experienced weight loss and a decrease in some of the biochemical parameters such as ldl level compared to before ramadhan. fasting shifts the dietary habits of people. for instance, someone who did ramadhan fasting ate just twice in a day; once before dawn and the remainder after sunrise. during ramadhan fasting, a muslim changes their lifestyle as well, such as their physical activities and dietary habits. the reduction of ldl level occurring as an effect of ramadhan fasting is the thing that is related to weight loss during fasting. it is basic proof that the use of fasting could be used for the prevention of disorders or diseases in the cardiovascular system. the use of fasting towards the vascular wall fasting is useful in relation to vascular wall function or endotel. the use of fasting can be seen from the previous results of the research. a total of 21 individuals who did fasting experienced an increase in the vascular endothelial growth factor (vegf) and a decrease in asymmetric dimethylarginine (adma) level. these are the markers that relate to dysfunctions of the vascular wall (endotel) (youse et al., 2014). the dysfunction of the vascular wall (endotel) is a systemic disorder that has became one of the factors tied into the pathogenesis of atherosclerosis. endotel dysfunction causes a decrease in the vasodilation ability of the vascular wall. it is caused by the imbalance between vasolidation and vasoconstriction as one of the symptoms of endotel dysfunction (youse et al., 2014). some research has showed that fasting can increase the nitric oxide level in the cardiovascular system which could influence the vascular wall. nitric oxide possesses links with the vascular endothelial growth factor and asymmetric dimethylarginine. vascular endothelial growth factor increases the nitric oxides used to maintain the elasticity of the endotel that causes endotel dysfunction endotel (youse et al., 2014). meanwhile, asymmetric dimethylarginine decreased the production of nitric oxide that could cause endotel dysfunction (youse et al., 2014). it showed that fasting contributed to maintaining the elasticity of vascular wall and thus it prevented endotel dysfunction. both are the main factors of high blood pressure or hypertension. conclusion fasting is a safe pharmacological treatment that can be safely done. it has some advantages such as helping to reduce weight, controlling or reducing blood pressure without causing hypotension complications, preventing endotel dysfunction and decreasing the ldl level. several advantages can be gained by a healthy individual without cardiovascular disease such as the prevention of cardiovascular disease. it can also help an individual with a high risk of or with cardiovascular disease. fasting can be used to repair one’s health condition by repairing the risk factors such blood pressure, being overweight and endotel dysfunction. references akaberi, a., golshan, a., moojdekanlo, m., & hashemian, m. (2014). does fasting in ramadan ameliorate lipid profile ? a prospective observational study. 30(4), 708–711. asadi, h., abolfathi, a. a., badalzadeh, r., majidinia, m., yaghoubi, a., & asadi, m. (2015). effects of ramadan fasting on serum amyloid a and protein carbonyl group levels in patients with cardiovascular diseases. 7(2), 55–59. https://doi.org/10.15171/jcvtr.2015.12 elbashir, m., awaisu, a., sa, m., hajj, e., & rainkie, d. c. (2019). research in social and administrative pharmacy measurement of health literacy in patients with cardiovascular diseases : a systematic review. (june 2018). https://doi.org/10.1016/j.sapharm.2019.01.00 8 faris, a. e., jahrami, h. a., obaideen, a. a., & madkour, m. i. (2019). journal of nutrition & intermediary metabolism impact of diurnal intermittent fasting during ramadan on in fl ammatory and oxidative stress markers in healthy people : systematic review and metaanalysis. journal of nutrition & intermediary metabolism, 15(august jurnal ners http://e-journal.unair.ac.id/jners | 387 2018), 18–26. https://doi.org/10.1016/j.jnim.2018.11.005 ganesan, k., habboush, y., & sultan, s. (2018). intermittent fasting : the choice for a healthier lifestyle methods. 10(7), 1–11. https://doi.org/10.7759/cureus.2947 horne, b. d., muhlestein, j. b., & anderson, j. l. (2018). health effects of intermittent fasting : hormesis or harm ? a systematic review 1. 102(2), 464– 470. https://doi.org/10.3945/ajcn.115.109553.1 id, d. t., grundler, f., bergouignan, a., drinda, s., & michalsen, a. (2019). safety , health improvement and well-being during a 4 to 21-day fasting period in an observational study including 1422 subjects. 341, 1–24. https://doi.org/10.1371/journal.pone.020935 3 iso, h., imano, h., yamagishi, k., ohira, t., hitsumoto, s., tanigawa, t., … investigators, c. (2014). fasting and non-fasting triglycerides and risk of ischemic cardiovascular disease in japanese men and women : the circulatory risk in communities study ( circs ). atherosclerosis, 237(1), 361–368. https://doi.org/10.1016/j.atherosclerosis.201 4.08.028 kul, s., savas, e., & ozturk, z. a. (2013). does ramadan fasting alter body weight and blood lipids and fasting blood glucose in a healthy. https://doi.org/10.1007/s10943-013-9687-0 mazurak, n., & gu, a. (2013). effects of a 48-h fast on heart rate variability and cortisol levels in healthy female subjects. 67, 401–406. https://doi.org/10.1038/ejcn.2013.32 radhakishun, n., blokhuis, c., vliet, m. van, & rosenstiel, i. von. (2014). intermittent fasting during ramadan causes a transient increase in total , ldl , and hdl cholesterols and hs-crp in ethnic obese adolescents. 14–17. https://doi.org/10.1007/s00431-014-2276-8 salahuddin, m., ah, s. a., sr, s., & km, b. (2014). effect of ramadan fasting on body weight , ( bp ) and biochemical parameters in middle aged hypertensive subjects : an observational trial. 8(3), 16–18. https://doi.org/10.1620/tjem.204.179. sayedda, k., kamal, s., & ahmed, q. s. (2013). effect of ramadan fasting on anthropometric parameters , blood pressure , creatine phosphokinase activity , serum calcium and phosphorus in healthy students of shri ram murti smarak institute of medical sciences , bareilly-up. 3(1), 48–52. https://doi.org/10.5455/njppp.2013.3.48-52 trepanowski, j. f., kroeger, c. m., barnosky, a., klempel, m. c., bhutani, s., hoddy, k. k., … varady, k. a. (2017). effect of alternate-day fasting on weight loss, weight maintenance, and cardioprotection among metabolically healthy obese adults a randomized clinical trial. 177(7), 930–938. https://doi.org/10.1001/jamainternmed.2017. 0936 wei, m., brandhorst, s., shelehchi, m., mirzaei, h., cheng, c. w., budniak, j., … longo, v. d. (2017). fasting-mimicking diet and markers / risk factors for aging , diabetes , cancer , and cardiovascular disease. 1(july 2015). youse, b., faghfoori, z., samadi, n., karami, h., ahmadi, y., badalzadeh, r., … ghavimi, h. (2014). the effects of ramadan fasting on endothelial function in patients with cardiovascular diseases. (february), 835–839. https://doi.org/10.1038/ejcn.2014.61 http://e-journal.unair.ac.id/jners | 247 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17123 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research japanese language interest on nursing students toward intention to work in japan at stikes pemkab jombang pepin nahariani, kikis widya ratna, kolifah kolifah, iin noviana and shanti rosmaharani nursing bachelor department of stikes pemkab jombang, indonesia abstract introduction: in indonesia, the working prevalence of nurses was that 95% worked in the country and 5% were working abroad. the government provides opportunities for nurses who want to work in japan through networking (indonesia japan economic partnership agreement). however, there isn’t a lot of interest due to the lack of knowledge of the japanese language. this study aimed to analyze the japanese language related to the nursing students’ interest concerning working in japan. methods: the design of the study was correlational research with a crosssectional approach which was conducted between may 31st and june 1st, 2016. the population consisted of nursing bachelor’s program students and the population totaled 41; the samples totaled as many as 37. the data collection used japanese observation test scores and questionnaires. results: the results showed that most of the 75.6% got a good score (b). nearly half (48.6%) of them were intending to work in japan and 2.7% got great scores, also with the intent to work japan. based on the test results, the statistical value = 0.798 that the ρ value> α (0.05). conclusion: this means that there is no correlation between the japanese language and the nurse’s working interest related to japan. the recommendation in this study is the implementation of an active japanese language course. further research should analyze the factors that affect the interests of indonesian nurses when it comes to working in japan. article history received: december 26, 2019 accepted: december 31, 2019 keywords japanese language; nursing students; intention contact pepin nahariani  pepin.nahariani@gmail.com  nursing bachelor department of stikes pemkab jombang, indonesia cite this as: nahariani, p., ratna, k. w., kolifah, k., noviana, i. & rosmaharani, s. (2019). japanese language interest on nursing students toward intention to work in japan at stikes pemkab jombang. jurnal ners, 14(3si), 247-251. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17123 introduction every aspect of health service delivery requires nursing staff and other professional health personnel in order to produce competent and quality health services. over the past 10 years, the international health workforce has increased for a variety of reasons (santric-milicevic et al., 2015). the shortage of nursing staff globally in developed countries has led to the active recruitment of nurses especially from developing countries, one of which is indonesia (efendi, mackey, huang, & chen, 2017). indonesia has a lot of nursing workforce resources that it can use to supply the world’s demands. in reality however, there is a gap between the number of nursing staff and the distribution within the country. indonesia is therefore experiencing a crisis of health access that should be sufficient for its own population. on the other hand, indonesia has established cooperative relations with japan in the indonesia japan economic partnership agreement (ijepa). in this cooperative agreement, the ijepa has facilitated the migration of indonesian nurses who want to work in japan. one of the facilities provided is japanese language training, conducted for approximately 1 year. however, there is qualitative evidence that shows that some indonesian nursing personnel have been returned because of their lack of japanese language skills. japanese is applied in the form of a kangoshi / nursing exam that uses japanese (efendi et al., 2017). in indonesia, the number of diploma and bachelor’s of nursing graduates in 2008 was 25,517. this then increased to 27,909 nurses in 2009. according to the data from the national agency for placement and protection of indonesian workers (bnp2tki), the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). p. nahariani, et al. 248 | pissn: 1858-3598  eissn: 2502-5791 demand for nurses to work abroad during 2010 2014 was for as many as 15,431 people. only 36.5% of this demand was fulfilled. the latest data from the east java province shows that there are 55 nursing diploma study programs and 53 bachelors of nursing study programs producing around 12,000 nursing staff per year. this number will be of great potential for indonesia when it comes to sending domestic nurses abroad to compete internationally (efendi et al., 2013). in jombang, around as many as 845 out of 1,115 people work as nursing staff (jombang health office, 2014). the crisis in the distribution of indonesian nursing staff is known from the health office in 2014, which reported that 10,370 nurses were in public hospitals and that 4,213 were in community health centers throughout indonesia. out of the total number of nurses produced in 2014, an estimated 60% of them were utilized domestically, 5% were overseas and the rest worked outside of their competence (efendi et al., 2017). from the results of a preliminary study that was conducted on 10 undergraduate students in 4th grade in semester viii of stikes jombang who participated in the japanese language course, it was found that 60% were interested in working in japan with passive foreign language skills. in the period of 2008 – 2011, the number of indonesian nurses returning from japan was many as 152 out of 363 nurses. the nurses returned to indonesia for a variety of reasons. about 11 out of 20 nurses decided to return to indonesia because they had completed the contract, 7 nurses returned for family reasons and the rest returned because they wanted to continue to pursue higher education. a report from the ministry of health shows that currently only a small number of prospective nursing staff are interested in returning to japan via ijepa. this is because they are worried about the long recruitment process and the risk of failing the nursing exam taken in the japanese language (efendi et al., 2013). the use of nurses abroad is an alternative policy in order to optimize the use of nurses in relation to the principle of mutual benefit, both in terms of indonesia and other countries that are partners, as well as between indonesian nurses and those who use them. one use of nurses abroad is through the indonesian japan economic partnership agreement (ijepa). the ijepa is part of the cooperation between indonesia and japan in reference to the placement of nurses and health workers that has been carried out since 2008 until now (dinkes, 2017). from the amount of available resources, indonesia should be able to send nursing staff abroad. in reality however, there are many indonesian nurses who are not interested in working abroad for various reasons. one important reason is their ability to speak a foreign language. thus, hard work is needed to increase the utilization of nurses abroad while paying attention to their domestic needs. working abroad can be a personal desire or a cultural motive as an expression of choice, freedom and their human rights (ham). it can also be the result of financial needs, job needs and challenges in order to face the nursing competition from others (anna kurniati e f, 2012). to work abroad, one must be able to speak the relevant foreign language well, especially in accordance with the country that you want to go to as a place of work. in this case, the student’s japanese language skills must be truly mastered to facilitate communication while increasing the quality of the foreign workforce itself. therefore ijepa has provided japanese language training for 6 months and also living in japanese society for more than 1 year. jombang is a part of east java that has many health workers. there are many health colleges in jombang, such as the faculty of health sciences in the university of darul ulum jombang, stikes pemkab jombang, stikes insan cendekia medika, stikes husada jombang and stikes bahrul ‘ulum jombang (dinkes, 2017). thanks to several universities in jombang, especially in the field of nursing, it opens up a great opportunity for prospective nursing staff in jombang to work in japan (dinkes, 2017). this study aims to determine the student’s japanese language ability and how much it affects the interest of the nursing bachelor’s students in stikes jombang regency when it comes to working in japan materials and methods the design of study was analytical and correlational with a cross-sectional approach. the population was all of the students in 4th grade who followed the japanese courses, totaling as many as 41 students. the sample was half of 4th grade students of stikes pemkab jombang who followed the japanese courses, totaling as many as 37 students. the study used purposive sampling. the independent variable was foreign language ability (japanese and arabic) and the dependent variable was the interest in and intention to work in japan. the instruments were an observation and a questionnaire that consisted of 12 questions from (efendi et al., 2013). the data collection technique started by the researcher submitting a research recommendation letter to the stikes pemkab jombang institution. the data was from the 4th semester nursing undergraduate students of stikes pemkab jombang. the prospective respondents of the study obeyed the rules that were given by the researcher. if they agreed to be a respondent, then they were welcomed to fill in the questionnaire. after all of the data had been obtained, the researcher analyzed the data. the analysis of the data used the spearman rank test α = 0.05 (hidayat a a a, 2011). jurnal ners http://e-journal.unair.ac.id/jners | 249 results the results gained both common and specific data. the common data consisted of sex and the desire to learn a foreign language. the specific data consisted of the ability to learn a foreign language and the students’ interest in working in japan. the study was focused on the class taking the japanese courses at stikes pemkab jombang from may 31st to june 1st 2016. common data; respondent characteristics based on sex and interest in a foreign language table 1. based on the gender statistic, it showed that out of the nursing bachelor students in the 4th grade who followed the japanese subject, there were as many as 23 female respondents (62,2%). according to the interest in foreign language, the results showed that out of the nursing bachelor students, 35,2 %, as many as 13 respondents, desired to learn english. specific data; the characteristics of the respondent based on foreign language ability. table 2 shows that the foreign language ability of the students on the nursing bachelor’s program in the 4th grade who joined the japanese courses, for as many as 28 respondents (75,6%), was a b. the characteristic of respondent based on the interest to work in japan table 3 shows that via the nursing bachelor’s program in the 4th grade and regarding who joined the japanese courses, as many as 25 respondent (67,5%) had a moderate interest. cross-tabulation of ability to speak a foreign language with the interest of the nursing students to work in japan the results showed that out of the 28 respondents who got a b, as many as 18 students, almost half the respondents (48.6%), were moderately interested. discussion ability to speak foreign languages table 2 showed that foreign language skills of 4th level of nursing undergraduate students who take japanese courses as many as 28 respondents, most of them (75.6%) get b. language ability is the ability of an individual to hear the speech delivered by the interlocutor, such as when speaking with the other person, reading messages conveyed in written form and writing messages both verbally and non-verbally (kepada, ilmu, dan, untuk, & syarat, 2014). the results of the study with the japanese final examination score measuring instrument showed that the majority of respondents got a b in a good category. this is as the value was contained of reading, writing and speaking. in the questionnaire, there was a checklist of questions on foreign language skills (japanese) related to their interest in working in japan. from the results of the study, the average respondent had a moderate interest (questions number 1 to 4) which could be a benchmark of the extent of their foreign language skills. it can thus be concluded that their foreign language skills could be seen in the assessment of reading, writing and speaking in the final japanese language test that has been carried out (efendi et al., 2013). the interest to work in japan table 3 shows that the 4th level nursing undergraduate students who participated in the japanese language courses totaled 25 respondents, most of whom (67.5%) had a moderate interest in working in japan. interest is a source of motivation that encourages people to do what they want so then they are free to choose. if they see something that will be profitable, they feel interested. this brings in satisfaction. their interest in the work will determine how much table 1. frequency distribution based on sex and foreign language (n=37) n % sex male 14 37.8 female 23 62.2 the interest of foreign language english japanese arabic 13 12 12 35.2 32.4 32.4 table 2. frequency distribution based on foreign language ability foreign language ability scoring frequency (%) a 100-76 1 (2.7) b 75-66 28 (75.6) c 65-56 8 (21.7) d 55-46 0 (0) e ≤ 45 0 (0) total 37 table 3. frequency distribution based on the desire to work in japan (n=37) the interest of work in japan n (%) high 12 32.5 moderate 25 67.5 low 0 0.0 table 4. cross-tabulation of the ability to speak a foreign language with the interest of the nursing students to work in japan japa nese lang uage exam value interest in working in japan total high moderat e low ∑ % ∑ % ∑ % ∑ % a 0 0.0 1 2.7 0 0.0 1 100 b 1 0 27 18 48.6 0 0.0 28 100 c 2 5.4 6 16.2 0 0.0 8 100 d 0 0.0 0 0.0 0 0.0 0 100 e 0 0.0 0 0.0 0 0.0 0 0 p. nahariani, et al. 250 | pissn: 1858-3598  eissn: 2502-5791 participation they put into a job. the stronger the interest and attention, the more concerned they are about the job.(anna kurniati e f, 2012) the results of study via the interest questionnaire measurement showed that most of the respondents had a moderate interest in working in japan. in the questionnaire, there was a checklist of questions about the interest in working in japan based on age, level of education, marital status, family income, their source of information, the type of decision, kinship and experience abroad in order to try and find out what triggered their interest in working in japan. from the results of the study, the average respondent had a moderate interest (questions number 5 to 12) which could be a benchmark for the extent of their interest in working in japan. thus, the interest in working in japan can be influenced by the above factors (mckenna & brooks, 2018). the correlation between foreign language ability for 4th level of nursing students of stikes pemkab jombang with the interest in working in japan the results of study was conducted at the 4th level of the nursing program in stikes jombang and it found that there was no relationship between foreign language proficiency and the interest in working in japan. table 4 shows that 28 respondents received a b, which is as many as 18 students. almost half of the respondents (48.6%) were moderate interested. the spearman rank statistical test results obtained significant numbers or a probability value of 0.798. this is higher than the significant standard 0.05 or (r ˃ a). thus, h0 was accepted and h1 was rejected, which means that there was no correlation between foreign language skills and the interest of the nursing undergraduate students in stikes pemkab jombang to work in japan. the results of study that was conducted relating to the return of indonesian nurses from japan showed that 18 out of 20 skilled migrants were unemployed and looking for new jobs. meanwhile, 2 returned to attend higher education. evidence from the interviews revealed that it seemed to be very challenging for them to live in their home and they struggled with real life. they were looking for vacancies and they were looking for the best one that matched their qualifications. in this study, the participants returned for various reasons (efendi et al., 2013). 11 of 20 nurses decided to emigrate back home because they had completed their contracts, 7 nurses returned for family reasons (hajj, planning to get married or to raise children, safety) and the rest were higher-level graduates. the concept of the theory by patricia benner explained that nurses develop skills and an understanding of patient care from time to time through a combination of basic strong education and personal experience. benner proposed that nurses could gain knowledge and skills without actually learning any of the theory involved. language is not a theory, but a skill. in this study, the student respondents included in the advanced beginner stage were still in first place. however, there was no effect on language skills according to imogene m. king's nursing theory, ‘human being’ which included perceptions, patient nurses and communication. this study focused on communication. communication is the means of delivering information in the form of language. in this study, almost all of the respondents had good language skills but this did not affect their interest in working in japan (anna kurniati e f, 2012). the results of the study indicate that there is no correlation between foreign language skills and the interest in working in japan. this is because the respondents in the japanese classes were more interested in english than in japanese and the highest score (a) in the exam was also very minimal. almost all of the respondents got a b. there may be other factors such as family, experience and the information provided about the opportunity to work in japan. the family was the main reason for making the decision to work abroad for reasons of considerable distance. this could thus affect their interest in working in japan. experience was also important because work experience gained in the country could be different from japan, which was seen of as more advanced technologically than indonesia and thus they need more time to adjust through special training. the experience of going abroad could be a barrier for a few different reasons. information about the opportunity to work in japan in indonesia had not been maximized, thus affecting the number of interested people. conclusion the foreign language ability (japanese) of the 4th level students in stikes pemkab jombang who followed the japanese language courses was increased, as most got 75.6%, which is a b and in the good category. in the institution, for the 4th level of nursing undergraduate students who took japanese courses, 67.5% were interested in working in japan and they had a higher motivation to do the job in japan. it has a good impact on the institution to reach an international vision. based on the explanation above, there was no correlation between foreign language skills and the interest of 4th level nursing undergraduate students of stikes pemkab jombang. references anna kurniati e f. (2012). kajian sdm kesehatan di indonesia. jakarta: medika salemba. dinkes. (2017). profil kesehatan kabupaten jombang tahun 2017. dinas kesehatan kabupaten jombang. efendi, f., mackey, t. k., huang, m. c., & chen, c. m. (2017). ijepa: gray area for health policy and international nurse migration. nursing ethics. https://doi.org/10.1177/0969733015602052 jurnal ners http://e-journal.unair.ac.id/jners | 251 efendi, f., purwaningsih, d., qur’aniati, n., kurniati, a., singka, e. j., & chen, c.-m. (2013). return migration of indonesian nurses from japan: where should they go? journal of nursing education and practice. https://doi.org/10.5430/jnep.v3n8p154 hidayat a a a. (2011). metodelogi penelitian keperawatan dan teknik analisis data. jakarta: medika salemba. kepada, d., ilmu, f., dan, t., untuk, k., & syarat, m. (2014). pengaruh kemampuan berbahasa asing (arab-inggris) tehadap prestasi belajar siswa. mckenna, l., & brooks, i. (2018). graduate entry students’ early perceptions of their future nursing careers. nurse education in practice. https://doi.org/10.1016/j.nepr.2017.11.010 santric-milicevic, m., matejic, b., terzic-supic, z., vasic, v., babic, u., & vukovic, v. (2015). determinants of intention to work abroad of college and specialist nursing graduates in serbia. nurse education today. https://doi.org/10.1016/j.nedt.2014.12.022 92 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.15213 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of health promotion intervention on anemia prevention behavior and haemoglobin level in pregnant women: based on health promotion model and selfdetermination theory mira triharini1, agus sulistyono2, merryana adriani3, and shrimarti rukmini devy3 1 faculty of nursing, universitas airlangga, indonesia 2 dr. soetomo general hospital surabaya, indonesia 3 faculty of public health, universitas airlangga, indonesia abstract introduction: anemia during pregnancy has an impact on pregnancy and fetus. pregnant women who have low iron status can affect the development of nerves and behavior of children. low self-determination in pregnant women will affect the commitment to prevent anemia. the objective of the study was to analyze the effect of health promotion model and self determination theory based intervention on anemia prevention behaviors and hemoglobin level in pregnant mothers. methods: this research was a quasi-experiment research with a preand posttest using a control group design. the samples were 30 pregnant women who did antenatal care in community health center of tanah kali kedinding surabaya. intervention through health education about anemia in pregnancy, family support and self-determination was held 3 times consisting of 1 meeting with health professionals, 1 meeting with pregnant mothers, and 1 meeting with pregnant women and their families through home visits. data were collected using questionnaires that consist of adherence to iron supplementation and behavioral prevention of intestinal worms, food recall in 2x24 hours, and laboratory test for hemoglobin level. paired t-test and independent t-test was used to analyze data in this study. results: there was an effect of health promotion model and self determination theory based intervention to anemia prevention behaviors and hemoglobin level (p = 0.013; p = 0.040). conclusion: health workers can use health promotion model and self determination theory based intervention to improve anemia prevention behavior. article history received: september, 10 2019 accepted: december, 4 2019 keywords anemia in pregnancy; behavior; self-determination; health promotion; prevention contact mira triharini  mira-t@fkp.unair.ac.id  faculty of nursing, universitas airlangga, indonesia cite this as: triharini, m., sulistyono, a., adriani, merryana., devy, s., r. (2019). the effect of health promotion intervention on anemia prevention behavior and haemoglobin level in pregnant women: based on health promotion model and self-determination theory. jurnal ners, 14(1),92-100. doi:http://dx.doi.org/10.20473/jn.v14i1.15213 introduction iron deficiency anemia is a major nutritional problem that occurs in many developing countries. in current study in pakistan showed 65.4% pregnant women were anemic. on the basis of hb level, 6.4% were severely anemic, 19.2% were moderately and 39.8% were mildly anemic (hameed et al., 2018). from the data of the indonesian basic health research in 2018 found that 48.9% of pregnant women in indonesia were anemic (ministry of health, 2018). anemia is considered to be one of huge public health challenge as population studies find that anemia prevalence is at 5.0% or higher (who, 2008). anemia during pregnancy may cause health problems in pregnant women and fetuses (huang, purvarshi, wang, zhong, & tang, 2015). anemia is associated with the incidence of low birth weight in newborns (aboye, berhe, birhane, & gerensea, 2018). the behavior of pregnant women in the prevention of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.15213 jurnal ners http://e-journal.unair.ac.id/jners | 93 anemia needs to be done through health promotion by looking at various internal and external factors of pregnant women. the health promotion model (hpm) as a nursing theory may be used as a theoretical basis to help patients conduct healthy behaviors (pender, 2011). physical and psychological changes experienced by mothers during pregnancy will have an impact on their ability to make efforts to prevent anemia, so a behavioral model for prevention of anemia with self-determination is needed that forms a high commitment. various health promotion efforts that have been carried out are expected to provide behavioral changes in pregnant mothers will last longer, if they are committed and have high intrinsic motivation from pregnant women themselves. there are various factors that affect the incidence of anemia in pregnant mothers, namely inadequate antenatal care, close birth spacing, and poor nutrition (singal, setia, taneja, & singal, 2018).the current high incidence of anemia may be influenced by the low behavior of mothers in preventing anemia, such as do not take the iron supplement tablets regularly. based on data from the indonesian basic health research in 2018, 61.9% of pregnant women in indonesia consumed fewer than 90 iron tablets (ministry of health, 2018). many pregnant women do not adhere in taking iron tablets because of the belief that iron tablets only need to be taken when they have health complaints. this was supported by studies of factors that influenced the adherence to iron tablets in pregnant women were the level of education and knowledge about anemia and iron tablets (taye, abeje, & mekonen, 2015). other studies showed that perceptions of benefits, barriers and family support affected maternal compliance in taking iron tablets (triharini et al., 2018). hpm is multidimensional which has an impact on health, individuals, environment and nursing. hpm also states that health behavior requires commitment based on cognition and affection factors. the concept of this model explain the uniqueness of individuals, families, and communities, as it explain the perceived benefits, perceived barrier and perceived self efficacy may influence individual’s health behavior (pender, 2011). this theory has been widely used in various research areas, for example a study had showed perceived benefits, perceived self efficacy, interpersonal influences, commitment to a plan of action have an effect on nutritional intake (dehdari, rahimi, aryaeian, & gohari, 2013). commitment of pregnant women in anemia prevention behavior would be better if the mother has a strong selfdetermination. with a strong commitment, pregnant women will be able to overcome the barriers in preventing anemia. in accordance with the self determination theory (sdt), the behavior is expected to be able to last longer when the patient is able to internalize the value and achieve satisfaction with the fulfillment of three psychological needs in health services, autonomy, competence, and relatedness (patrick & williams, 2012). sdt has been widely used in research to increase commitment and health behavior. satisfaction with fulfilling psychological needs improves health behaviors for eating healthy foods (ryan, patrick, deci, & williams, 2008). in an effort to increase the commitment of pregnant women to overcome the problem of preventing anemia, an intervention in the form of health education is needed based on the use of the hpm theory and sdt. this intervention is comprehensive because it involves several parties, who are expected to increase the commitment of pregnant mothers, including health professionals, pregnant mothers, families, and groups of pregnant mothers. the hpm and std model emphasizes several aspects, namely (1) the cognitive aspects of pregnant women, which include increasing perceived benefits, reducing the perceived barrier, and increasing self-efficacy; (2) the increase of environmental support, which includes health professionals, families and groups of pregnant mothers; (3) the increase of self-motivation for preventing anemia; and (4) the increase of the goal of pregnancy. there is no study conducted to explain hpm and sdt-based intervention to improve anemia prevention behavior. hence, this study was aimed to explain the effectiveness of interventions using hpm and sdt on the prevention behavior of anemia and hemoglobin levels in pregnant women. materials and methods this research used a quasi-experimental design with two groups, pre-test, and post-test, which were conducted from january to march 2018. the population was pregnant women attending antenatal care at puskesmas (the community health center) of tanah kali kedinding in surabaya, east java, indonesia. the inclusion criteria were pregnant women who were receiving iron supplementation from the community health center. the exclusion criteria were those who did not have anemia based on an examination of the community health center and with complication of diseases that required specific medical treatment. the samples that met the inclusion criteria were 30 mothers with 15 mothers for each group. data were collected using questionnaires, food recall in 2x24 hours, and hemoglobin level examination using the cyanmethemoglobin method. qualified nutritionists conducted the food recall in pregnant women to carry out data collection on consumption patterns. nutrition laboratory staff at universitas airlangga surabaya carried out hemoglobin level examination using the cyanmethemoglobin method. the questionnaires were focused on sociodemographic characteristics, and anemia prevention behavior. the sociodemographic characteristics of questions asked about age, parity, m. triharini et al. 94 | pissn: 1858-3598  eissn: 2502-5791 education and income. the questions about anemia prevention behavior consisted of adherence to iron supplementation and prevention of intestinal worms. the questionnaires were developed by researchers with items based on the theory of prevention of maternal anemia and the health-promotion model (hpm) (pender, 2011; sharma & shankar, 2010). while preparing the questionnaire contents, the researchers were assisted by two experienced nurses in the field of maternity nursing. translation was accomplished by a qualified translator from indonesia. before being used in data collection, the compiled questionnaires had been tested for validity and reliability on 20 pregnant women who attended antenatal care at community health center keputih surabaya. data collection on adequacy of energy, carbohydrates, protein, vitamin c, and iron of pregnant mothers was based on their age and gestational age. measurements were made with a questionnaire with a 2 x 24 hour food recall method the results of which were expressed in calories, grams and mg, compared with the recommended dietary allowance (rda) (ministry of health, 2013). the questions on adherence to iron supplementation focused on four items: regularity, time, reducing and increasing absorption process. the questionnaire consisted of four questions. each item was converted into a likert scale with the following options: always, often, sometimes, rarely and never. the total scores for this section were in the range of 4–20, with higher scores indicating higher levels of adherence to iron supplementation. the validity of the questionnaire on adherence to iron supplementation had a cronbach's α of 0.761 the questionnaire on behavioral prevention of intestinal worms consisted of two items: personal hygiene and environmental hygiene. each item was converted into a likert scale with the following options: always, often, sometimes, rarely and never. the total scores for this section were in the range of 6–24, with higher score indicating higher levels of behavioral prevention of intestinal worms. the validity and reliability test of the questionnaire on prevention of intestinal worms had a cronbach's α of 0.831. paired t-test was used to examine the differences between the pre-test and post-test scores for both the intervention group and control group. independent ttest was used to analyze the effect of health promotion model and self determination theory based intervention on anemia prevention behavior and hemoglobin level. descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to describe sociodemographic characteristics. in all statistical analyses, a p-value of < 0.05 was considered significant. all data were analyzed using spss software. after selecting respondents based on inclusion criteria, the researchers conducted a health education intervention on the topics of anemia prevention, selfdetermination and family support. anemia prevention material discusses the definition of anemia, the causes of anemia, the influence of anemia on pregnancy, and ways to prevent anemia, which includes procedures for taking iron tablets, dietary regulation, and prevention of intestinal worms. selfdetermination material discusses three psychological needs of pregnant women that need to be fulfilled and self-motivation in preventing anemia. family support material to prevent anemia includes the benefits of family support for pregnant women, forms of support given to pregnant women, and family support for pregnant women to have a strong determination in preventing anemia. intervention activities were held three times consisting of one meeting with health professionals, one meeting with pregnant mothers, and one meeting with pregnant women and their families through home visits. the first meeting was held for 1 x 60 minutes targeting health professionals with anemia health promotion to pregnant mothers. this meeting aimed to improve the understanding of health professionals about intervention. in this meeting, the researchers discussed the model of health education that needed to be provided based on hbm and selfdetermination, which aimed to increase the satisfaction of pregnant women in terms of psychological needs, including autonomy, competence, and relatedness. at the end of the session, the researchers gave the module to the health professionals. the second meeting was held for 1 x 60 minutes targeting the pregnant women in groups. this meeting aimed to improve the perceived benefit and reduce perceived barriers according to the hpm theory, to improve the orientation and goals of maternal pregnancy in implementing anemia prevention behaviors according to the theory of selfdetermination, and to support the groups of pregnant mothers. the researchers conveyed material about the concept of anemia of pregnancy, ways to prevent anemia through nutrition, adherence with iron supplementation and prevention of intestinal worms, the role of support for pregnant women groups, and the concept of self-determination. the researchers applied the concept of communication by paying attention to fulfilling the psychological needs of the mother according to the sdt theory, which included the needs of autonomy, competence, and relatedness. at the end of the meeting session, pregnant women were asked to plan the actions to be carried out. they were also given a form to record the adherence to iron supplementation. the researchers provided leaflets about anemia in pregnancy. in a group meeting of pregnant women there was a meeting between multigravida with primigravida mothers. researchers provided an opportunity for multigravida mothers to convey previous pregnancy experiences in carrying out anemia prevention behaviors and as role models for other pregnant women. the positive thing expressed by mothers is trying to keep taking iron tablets according to the advice of the midwife so that the baby is healthy, even jurnal ners http://e-journal.unair.ac.id/jners | 95 though sometimes they feel bored and nauseous. mothers stated that they were very happy when their labor was smooth and the baby was in good health. primigravida pregnant women can study the past experiences of other pregnant women and achieve the motivation and goals of their pregnancy. the third meeting was held for 1 x 60 minutes targeting the family members of pregnant women who lived at home. the purpose of this meeting was to increase family support to pregnant women in an effort to prevent anemia. the researchers delivered material about the concept of anemia, ways to prevent anemia, and the role of family support to pregnant mothers. the researchers also looked at the form of the results of record adherence to iron supplementation that had been made by pregnant women and discussed the obstacles that existed in carrying out prevention for anemia. post-test data collection was carried out after three months of intervention using questionnaires that consisted of adherence to iron supplementation and behavioral prevention of intestinal worms, food recall in 2x24 hours, and laboratory test for hemoglobin level. sampling was conducted after ethical approval from the health research ethics committee of the faculty of public health, airlangga university in surabaya (no 123-kepk). results table 1 shows that the majority of respondents were aged 25-35 years, both in the intervention group (66.7%) and the control group (53.3%). the majority of respondents had one parity in the intervention group (40.0%) and nullipara in the control group (46.7%). more than half of the intervention group (88.0%) and control groups (53.3%) had income of < 3 million rupiahs. more than half of the intervention group (60.0%) and the control group (79.9%) had secondary education levels. table 2 shows that there is an increased mean score after an intervention in the intervention group on the nutritional adequacy (15.67 ± 4.49), adherence to iron supplementation (21.47 ± 1.19), and prevention of intestinal worms (29.93±0.26). in the intervention group, the mean difference in nutritional adequacy score was 4.14, the difference in adherence to iron supplementation score was 1.20, and the difference in prevention of intestinal worms score was 0.40. the results of the t-test showed that p value < 0.05, indicating that there were significant differences of nutritional adequacy, adherence to iron supplementation and prevention of intestinal worms between before and after the intervention. table 3 shows that there is an increased mean score after an intervention in the intervention group on anemia prevention behavior (67.07±4.74) and hemoglobin level (12.87 ±1.04). in the intervention group, the mean difference in anemia prevention behavior score was 5.74. the results of the t-test showed that p value 0.004 < 0.05, indicating that there were significant differences of anemia prevention behavior between before and after the intervention. data show an increased score in anemia prevention behavior between before and after intervention in the intervention group. the results of the independent t-test between the intervention and control groups after the intervention obtained p value 0.013< 0.05, which means that intervention influenced the anemia prevention behavior. table 3 shows that, in the intervention group, the mean difference in hemoglobin level score was 0.68. the results of the t-test showed that p value 0.025 < 0.05, meaning that there were significant differences of hemoglobin level behavior between before and after the intervention. data show an increase in hemoglobin between before and after the intervention. the results of the independent t-test between the intervention and control groups after the intervention obtained p value 0.040 < 0.05, which means that intervention influenced the hemoglobin level. discussion interventions based on hpm and sdt influenced the anemia prevention behavior and hemoglobin level. anemia prevention behavior was measured by three indicators including: (1) consumption of energy, carbohydrates, protein, vitamin c, iron; (2) adherence to iron supplementation (3) intestinal worm prevention behavior. in this study, the results show that, after interventions based on hpm and sdt, there was an increase in the mean score on anemia prevention behavior and hemoglobin levels in the intervention group. there was a significant difference in anemia prevention behavior and hemoglobin level between before and after the intervention. this intervention may increase the self-determination of pregnant women so that they have a strong commitment to conduct behaviors to prevent anemia properly. pre-test scores on nutritional adequacy showed low results because there are still many pregnant women who are still in the deficit category based on food recall results. the cause of this is possible because there is still a lack of knowledge of mothers about the importance of adequate nutrition during pregnancy, so that pregnant women do not pay attention to the adequacy of their daily nutritional needs. this is supported by the number of respondents who have elementary education. economic factors also affect the ability of mothers to meet nutritional adequacy, where most respondents have an income of less than 3 million rupiah. this is supported by other research that shows there are many factors that affect the nutrition of pregnant women. socioeconomic factors (education level, employment status, monthly income, household m. triharini et al. 96 | pissn: 1858-3598  eissn: 2502-5791 assets and land ownership) have been shown to influence dietary diversity (kiboi, kimiywe, & chege, 2017). there are still many pregnant women with insufficient nutrition. the result revealed that the caloric intake was below the rda (85%), while calcium, iron, vitamins a, e, c and folate intake were respectively 28%, 47%, 25%, 9% 31% and 44% (yetunde & olubukunola, 2015). the presence of deficits in adequate iron was also caused by the irregularity of the mother in taking iron tablets. iron requirements during pregnancy were not enough to only be filled with daily food, but also must be added with iron tablet supplements. in this study, it was found that some pregnant women do not regularly take iron tablets because they feel side effects after taking them, forget and get bored because you have to drink them every day. the results showed that there was an increase in post-test scores on the adequacy of nutrition in the intervention group. in the post-test data, it was found an increasing adequacy of protein and iron. a good intake of iron needs showed the adherence of iron supplementation. some pregnant women who had experienced insufficient energy, carbohydrates and vitamin c would have a risk of anemia. this is supported by the results of related research that women with anemia show a low adequacy in energy, protein, folate, b12, iron, vitamin c and red meat (thomson et al., 2011). related research stated that there were several factors that influence the nutrition table 1.distribution of both groups regarding their sociodemographic characteristics no variable intervention control n % n % p value 1 age (yrs) 0,156 < 25 4 26.7 4 26.7 25-35 10 66.7 8 53.3 >35 1 6.7 3 20.0 2 parity 0,092 0 5 33,33 7 46.7 1 6 40,00 4 26.7 2 2 13.3 4 26.7 3 2 13.3 3 income (rupiah)a 0,275 <3 million 12 80.0 8 53.3 ≥ 3 million 3 20.0 7 46.7 4 education level 0,455 elementary 5 33.3 3 20,1 secondary 9 60.0 12 79. 9 university 1 6.7 a13.500 rupiahs equal to 1 us dollar (us$) table 2. distribution of intervention and control group regarding indicator of anemia prevention behavior in pre-post intervention anemia prevention behavior group pre test (mean ± sd) post test (mean ± sd) mean differences p value nutritional adequacy intervention 11.53 ± 5.33 15.67 ± 4.49 4.14 0.019 control 14.73±4.18 15.93±3.41 1.20 0.389 adherence to iron supplementation intervention 20.27 ± 0.96 21.47 ± 1.19 1.20 0.003 control 19.20±2.54 18.87±1.41 -0.33 0.642 prevention of intestinal worms intervention 29.53±0.52 29.93±0.26 0.40 0.009 control 29.53 ± 0.52 29.93 ± 0.26 0.40 0.009 table 2. distribution of intervention and control group regarding indicator of anemia prevention behavior in pre-post intervention anemia prevention behavior group pre test (mean ± sd) post test (mean ± sd) mean differences p value nutritional adequacy intervention 11.53 ± 5.33 15.67 ± 4.49 4.14 0.019 control 14.73±4.18 15.93±3.41 1.20 0.389 adherence to iron supplementation intervention 20.27 ± 0.96 21.47 ± 1.19 1.20 0.003 control 19.20±2.54 18.87±1.41 -0.33 0.642 prevention of intestinal worms intervention 29.53±0.52 29.93±0.26 0.40 0.009 control 29.53 ± 0.52 29.93 ± 0.26 0.40 0.009 jurnal ners http://e-journal.unair.ac.id/jners | 97 intake of pregnant mothers, namely gestational age, education, and family income (wang et al., 2015). in this study, more than 50% of respondents had secondary level of education and had income < 3 million. this could be an obstacle for some pregnant women to be able to make changes in their nutrition intake. nutrition during pregnancy is very important for fetal development and long-term health in infants. malnutrition and obesity during pregnancy may affect the condition of fetal development, growth and development of childhood and the risk of developing chronic diseases in adults (imdad, lassi, salaam, & bhutta, 2017). pre-test scores on adherence to iron supplementation have a low score. some pregnant women still stated that they had not routinely taken iron supplementation because of forgetfulness and nausea. this was supported by other studies about the causes of non-compliance of iron tablets in pregnant women, which are access to iron tablets, forms of vitamins, side effects, fear, forgetful behavior and feeling no need (galloway et al., 2002). post-test scores on adherence to iron supplementation increased after the intervention. to improve adherence to iron supplementation in this study, a mother was given a monitoring card for iron supplement. families who have received health education about prevention of anemia may help monitor the regularity of pregnant women in taking iron supplements. material about preventing anemia was also given to families so that they understood the importance of preventing anemia for pregnant women and provided support. in this intervention, the adherence to iron supplementation was also improved by providing information about the community's inappropriate perception of iron supplements. some inappropriate perception of iron supplements might cause obese babies and babies with disability, high blood pressure, or iron tablets consumed only when having health complaints. the correct understanding about wrong perceptions will increase compliance in taking iron supplements. a way to minimize forgetfulness in taking iron supplements is by increasing support of the family by reminding pregnant women to take iron tablets regularly. families also need to monitor whether pregnant mothers have taken iron tablets properly. to improve the family's ability to provide the support, this intervention also provides health education to families about prevention of anemia in pregnancy. the form of family support for pregnant mothers can be in the form of information support, emotional support, and instrumental support. information support can be provided by reminding pregnant women to take iron tablets regularly, have food that is nutritious and high in iron, and maintain hygiene. giving time to listen to their complaints and giving them encouragement can give emotional support. instrumental support can be given by giving them direct support, such as helping them with homework. most pregnant women had regularly taken iron supplementation of one tablet per day, but there were still many of them consumed it in an inappropriate manner so it was not absorbed optimally. they took iron supplements before tea, coffee and milk. some of them also did not understand that orange juice could be taken to reduce nausea after taking iron supplements. understanding the needs of pregnant mothers should be improved through health education. most pregnant women understood the importance of taking iron supplementation regularly, but they did not understand how to take it properly. the status of iron in the human body depends on the absorption of iron in food. iron absorption may be increased through sources of vitamin c, such as oranges, papaya and certain animal protein sources, such as beef, chicken and fish. vitamin c helps absorb non-heme iron by changing the shape of ferrous into ferro, which is easily absorbed. conversely, iron absorption may be inhibited by several inhibitors, including caffeine, tannin, oxalate, and phytate, which can be found in soy products, tea and coffee (masthalina, laraeni, & dahlia, 2015). the result of the study on the intestinal worm prevention behavior was an increase in scores in the intervention group compared to the control group, but the percentage change in scores in the intervention group was very small. on average, pregnant women have a good behavior in preventing anemia through maintaining personal and environmental hygiene. this shows that the behavior of maintaining cleanliness has become a habit of pregnant women and their family. behavior in preventing intestinal worms is related to hemoglobin levels of pregnant mothers. this is supported by several studies. there is a significant relationship between the incidence of worm infections with low iron reserves in the body in pregnant women (baidoo, tay, & abruquah, 2010). prevention of intestinal worms can be done by wearing sandals when going out of the house, washing hands before eating, washing vegetables and cooking them well, cleaning the floor of the house every day, using clean water for daily drinking purposes, and using a toilet to defecate. at present, there is no worm-screening program for pregnant mothers, so it will be difficult to know whether they have worms or not. taking precautions against intestinal worms are the best thing to anticipate worms in pregnant mothers. in the results of research on hemoglobin in pregnant mothers, there were significant differences between before and after intervention in the treatment group. the difference in hemoglobin value in the treatment group was 0.68 during the 3-month intervention in pregnant mothers. there are many factors that may affect hemoglobin levels, so it's quite difficult to get a large enough increase. iron reserves in the body are affected by the absorption and loss of iron. iron absorption is affected by food intake, while iron loss is affected by menstruation, pathological factors and worm conditions (sharma & shankar, m. triharini et al. 98 | pissn: 1858-3598  eissn: 2502-5791 2010). this is supported by the results of research related to nutritional interventions that increase hemoglobin levels in pregnant women in the 2nd to 3rd trimester by 0.35 points (al-tell, el-guindi, soliman, & el-nana, 2010). the study showed that the health promotion model and self determination theory-based intervention may improve anemia prevention behaviors and hemoglobin level. according to self determination theory (sdt), the expected behavior will be able to last longer if the patient is able to internalize the values and get satisfaction with the fulfilment of the three psychological needs in health services, autonomy, competence, and relatedness (gebremedhin, samuel, mamo, moges, & assefa, 2014). sdt theory is a framework in health services that focuses on patient care (podlog & brown, 2016). in this study, sdt was applied to increase the commitment of pregnant women to implement anemia prevention behaviors. increased autonomy was given by achieving the freedom to prevent anemia in accordance with the wishes and abilities possessed. competency enhancement was given by providing health education to improve perceptions of benefits and reduce perceptions of barriers among pregnant mothers. increased attachments were given with the involvement of families, health professionals and groups in providing support to pregnant mothers. the health promotion model theory is used to predict factors that influence health behavior, which, in this case, emphasizes that health behavior may be influenced by the commitment of pregnant mothers (pender, 2011). this intervention might identify the commitment of pregnant women and the factors that influence them in carrying out anemia prevention behavior. obstacle perceptions will be experienced by pregnant women in carrying out anemia prevention behaviors, both in terms of nutrition fulfilment, compliance with taking iron tablets, and prevention of intestinal worms. barriers perceived by the mother will reduce the behavior of pregnant women in preventing anemia, so this intervention also aims to provide understanding to pregnant women about the obstacles that can be found in the prevention of anemia and efforts that can be done to overcome them. obstacles that women feel in preventing anemia include nutritious foods that are expensive, iron tablets can cause nausea, iron tablets that must be taken every day during pregnancy cause boredom and forgetfulness, and washing hands and using footwear when going out is a nuisance. this intervention emphasized the selfdetermination of pregnant women in carrying out anemia prevention behaviors. health education delivered to pregnant women to increase selfdetermination was to explain three psychological needs of pregnant women, namely (1) autonomy or feeling free in carrying out pregnancy care, being free in making their own choices and decisions to take anemia prevention measures; (2) competence or feeling confident that they were able to prevent anemia by increasing their knowledge; and (3) relatedness or feeling close to family, friends and health professionals. the limitation of this study is that the selection of respondents did not address the condition of other chronic infections that can influence hemoglobin levels in pregnant women. the recommendation in future study is to examine serum transferrin to determine the condition of anemia in pregnant women. conclusion interventions based on hpm and sdt influenced the anemia prevention behavior and hemoglobin level. this intervention involves pregnant women, peer group and families. increased understanding of anemia will increase support, which strengthens selfdetermination in pregnant women. selfdetermination of pregnant women can strengthen commitment to prevent anemia. behavior to prevent anemia includes consumption patterns, adherence to taking iron supplements, and prevention of intestinal worms. consumption patterns include consumption of energy, carbohydrates, protein, vitamin c and iron. efforts to prevent anemia through these three things carried out simultaneously will be able to increase the hemoglobin level of pregnant mothers. health workers can implement interventions based on hpm and std in an effort to increase the determination of pregnant women to strengthen commitments in anemia prevention behavior. health education provided to pregnant women also needs to involve peer groups and families so that they can provide support. references aboye, w., berhe, t., birhane, t., & gerensea, h. (2018). prevalence and associated factors of low birth weight in axum town, tigray, north ethiopia. bmc research notes, 11(1), 684. https://doi.org/10.1186/s13104-018-3801-z al-tell, m. a., el-guindi, f. k., soliman, n. m., & el-nana, h. (2010). effect of nutritional interventions on anemic pregnant women ’ s health using health promotion model. medical journal of cairo university, 78(2), 109–118. baidoo, s. e., tay, s. c. k., & abruquah, h. h. (2010). intestinal helminth infection and anaemia during pregnancy: a community based study in ghana. african journal of microbiology research, 4(16), 1713–1718. https://doi.org/10.1080/0964056070140207 5 dehdari, t., rahimi, t., aryaeian, n., & gohari, m. r. (2013). effect of nutrition education intervention based on pender ’ s health promotion model in improving the frequency and nutrient intake of breakfast consumption among female iranian students. public health jurnal ners http://e-journal.unair.ac.id/jners | 99 nutrition, 17(3), 657–666. https://doi.org/10.1017/s136898001300004 9 fuseini, g., edoh, d., kalifa, b. g., hamid, a.-w., & knight, d. (2010). parasitic infections and anaemia during pregnancy in the kassenanankana district of northern ghana. journal of public health and epidemiology, 2(3), 48–52. galloway, r., dusch, e., elder, l., achadi, e., grajeda, r., hurtado, e., … stephen, c. (2002). women’s perceptions of iron deficiency and anemia prevention and control in eight developing countries. social science & medicine, 55(4), 529– 544. https://doi.org/10.1016/s02779536(01)00185-x gebremedhin, s., samuel, a., mamo, g., moges, t., & assefa, t. (2014). coverage , compliance and factors associated with utilization of iron supplementation during pregnancy in eight rural districts of ethiopia : a cross-sectional study. bmc public health, 14(1), 1–8. https://doi.org/10.1186/1471-2458-14-607 hameed, h., hameed, a., bashir, s., akram, s., arshad, m., & afzal, r. (2018). study of prevalence of anaemia among pregnant women and its correlation with different risk factors drug designing : open access. drug designing, 7(1), 1–5. https://doi.org/10.4172/21690138.1000158 huang, l., purvarshi, g., wang, s., zhong, l., & tang, h. (2015). the influence of iron-deficiency anemia during the pregnancy on preterm birth and birth weight in south china. journal of food and nutrition research, 3(9), 570–574. https://doi.org/10.12691/jfnr-3-9-2 imdad, a., lassi, z., salaam, r., & bhutta, z. a. (2017). prenatal nutrition and nutrition in pregnancy: effects on long-term growth and development. early nutrition and long-term health, 3-24. https://doi.org/10.1016/b978-008-100168-4.00001-x kiboi, w., kimiywe, j., & chege, p. (2017). determinants of dietary diversity among pregnant women in laikipia county, kenya: a cross-sectional study. bmc nutrition, 3(1), 12. https://doi.org/10.1186/s40795-017-0126-6 masthalina, h., laraeni, y., & dahlia, y. p. (2015). pola konsumsi (faktor inhibitor dan enhancer fe) terhadap status anemia remaja putri. jurnal kesehatan masyarakat, 11(1), 80–86. retrieved from http://journal.unnes.ac.id/nju/index.php/kem as%0ahttp://dx.doi.org/10.15294/ ministry of health. (2013). permenkes no 75 tahun 2013 tentang angka kecukupan gizi yang dianjurkan bagi bangsa indonesia. ministry of health. (2014). pmk no. 88 iron supplementation. kemenkes 2014, (1), 1–5. https://doi.org/10.1007/s13398-014-01737.2 ministry of health. (2018). indonesia basic health research 2018. patrick, h., & williams, g. c. (2012). selfdetermination theory: its application to health behavior and complementarity with motivational interviewing. international journal of behavioral nutrition and physical activity, 9(1), 18. https://doi.org/10.1186/1479-58689-18 pebri, v., thongpat, s., & nitirat, p. (2018). predictors of health-promoting behaviour among older adults with hypertension in indonesia. international journal of nursing sciences, 5(2), 201–205. https://doi.org/10.1016/j.ijnss.2018.04.002 pedreño, n. b., ferriz-morel, r., rivas, s., almagro, b., cervelló, e., & moreno-murcia, j. a. (2015). sport commitment in adolescent soccer players compromisso desportivo em atletas de futebol adolescentes, 11, 3–14. pender, n. j. (2011). heath promotion model manual. chicago: university of michigan. podlog, l. w., & brown, l. w. (2016). selfdetermination theory: a framework for enhancing patient-centered care. the journal for nurse practitioners, 12(8), 1–4. https://doi.org/10.1016/j.nurpra.2016.04.022 ryan, r. m., patrick, h., deci, e. l., & williams, g. c. (2008). original article facilitating health behaviour change and its maintenance : interventions based on self-determination theory. the european health psychologist, 10(march). shahroodi, m. v., & amin-shokravi, f. (2013). a survey on the effects of the pender ’ s health promotion model on prediction of the employees ’ physical activity. health education & health promotion (hehp), 1(1), 51–66. sharma, j. b., & shankar, m. (2010). anemia in pregnancy. jimsa, 23(4), 253–260. singal, setia, taneja, & singal. (2018). factors associated with maternal anaemia among pregnant women in rural india. bangladesh journal of medical science, 17(04), 583–592. https://doi.org/doi: http://dx.doi.org/10.3329/bjms.v17i4.38320 introduction singh, m. b., fotedar, r., & lakshminarayana, j. (2009). micronutrient deficiency status among women of desert areas of western rajasthan, india. public health nutrition, 12(5), 624–629. https://doi.org/10.1017/s136898000800239 5 m. triharini et al. 100 | pissn: 1858-3598  eissn: 2502-5791 susiloningtyas, i. (2012). pemberian zat besi (fe) dalam kehamilan oleh : is susiloningtyas. majalah ilmiah sultan agung, 50, 128. taye, b., abeje, g., & mekonen, a. (2015). factors associated with compliance of prenatal iron folate supplementation among women in mecha district, western amhara: a cross-sectional study. pan african medical journal, 20, 1–7. https://doi.org/10.11604/pamj.2015.20.43.48 94 thomson, c. a., stanaway, j. d., neuhouser, m. l., snetselaar, l. g., stefanick, m. l., arendell, l., & chen, z. (2011). nutrient intake and anemia risk in the women’s health initiative observational study. journal of the american dietetic association, 111(4), 532–541. https://doi.org/10.1016/j.jada.2011.01.017 triharini, m., nursalam, sulistyono, a., adriani, m., armini, n. k. a., & nastiti, a. a. (2018). adherence to iron supplementation amongst pregnant mothers in surabaya, indonesia: perceived benefits, barriers and family support. international journal of nursing sciences, 5(3), 243–248. https://doi.org/10.1016/j.ijnss.2018.07.002 wang, p.-y., liu, f.-l., zhang, y.-m., parés, g., reidy, k., zhao, w.-z., … zheng, y.-d. (2015). nutrient intakes of pregnant women and their associated factors in eight cities of china: a cross-sectional study. chinese medical journal, 128(13), 1778. https://doi.org/10.4103/03666999.159354 who. (2008). worldwide prevalence of anaemia 19932005: who global database on anaemia. yetunde, s.-l. m., & olubukunola, o. (2015). the nutrient adequacy of foods eaten by pregnant women attending antenatal clinic at traditional birth homes. iosr journal of nursing and health science ver. iii, 4(2), 2320–1940. https://doi.org/10.9790/1959-04236567 http://e-journal.unair.ac.id/jners | 199 jurnal ners vol. 14, no. 2, april 2019 http://dx.doi.org/10.20473/jn.v14i2.17212 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family support system as an effort to optimize coping mechanism of preschool children during hospitalization m. hasinuddin1, ulva noviana1 and fitriah fitriah2 1stikes ngudia husada madura, east java, indonesia 2poltekkes kemenkes surabaya, east java, indonesia abstract introduction: the condition of the child during hospitalization can experience stress due to environmental changes. child coping mechanism is very supportive of the adaptation process. the purpose of this study was to analyze the effect of family support system on coping mechanisms during hospitalisation. methods: it was quasi-experimental with pre-test post-test with control group design. the study population was preschool children who were treated in the hospital of bangkalan, east java province, indonesia. total sample was 60 respondents in treatment and control group and obtained consecutive sampling. the variables were family support system and coping mechanism. data collection used children’s coping behavior questionnaire and tested by paired t-test. results: the treatment group showed the coping mechanism was mostly maladaptive (mean=34.07) and after the intervention most of them had adaptive coping (mean=46.87). whereas in the control group before the intervention, the coping mechanism was mostly maladaptive (mean=36.22) and after the intervention most of the coping groups had maladaptive coping (mean=36.74). conclusion: family support systems play an important role in improving the adaptive coping of preschool children during hospitalisation. nurses should maximise family support as a strategy in interacting with children to enhance coping mechanisms to reduce the stress of hospitalisation. article history received: january 8, 2020 accepted: january 12, 2020 keywords family support system; coping; coping mechanism; stress hospitalisation contact m. hasinuddin  hasin3333.nhm@gmail.com  stikes ngudia husada madura, east java, indonesia cite this as: hasinuddin, m., noviana, u., & fitriah, f. (2019). family support system as an effort to optimize coping mechanism of preschool children during hospitalization. jurnal ners, 14(2), 199-204. doi:http://dx.doi.org/10.20473/jn.v14i1.17212 introduction hospital is a process for reasons of planning or emergency that requires children to stay in the hospital to undergo therapy and treatment (mcmahon & chang, 2020; rückholdt, tofler, randall, & buckley, 2019). thus, being treated at the hospital remains a big problem and causes fear and anxiety (chao & chiang, 2003). hospitality can also be interpreted as psychological changes that can be the cause of children being hospitalized (priyoto, 2014). disease and hospitalisation are often the first crisis children must be faced. especially during the early years, children are very vulnerable to disease crises and hospitalisations due to stress due to changes from normal healthy and environmental routines, and children have a limited amount of coping to deal with stress (stratta et al., 2014). in general, preschoolers show maladaptive coping behaviours when adapting to the hospitalisation they experienced, namely behavioural reactions such as protest, hopelessness, and regression. this is because children feel afraid if their body parts will be injured by health care workers(atkin & ahmad, 2001; sukoati & astarani, 2012). rejection from nursing care and treatment has become a phenomenon in hospitals (stratta et al., 2014). based on research conducted by psychologists in the last 30 years, it is stated that 1030% of children with hospitalisation have psychological disorders and as many as 90% of children feel disappointed and discouraged from https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.17212 m. hasinuddin et al. 200 | pissn: 1858-3598  eissn: 2502-5791 being hospitalized (evi, sri, & junaidi, 2013). from the results of a survey of preliminary studies, four of five preschool children (3-6 years old) who are being treated show maladaptive coping behaviours manifested by crying, anger, withdrawal by not wanting to talk, always asking to go home, asking to be held, and do not want to eat. preschoolers when they are hospitalised generally have a fear of both doctors and nurses, especially if the child has experienced such as immunized (palka et al., 2016). in his shadow, a nurse or doctor would hurt him by injecting. in addition, children also feel disturbed relations with parents or siblings. the environment at home is certainly different in an atmosphere with the tools in the treatment room (foster, mitchell, young, van, & curtis, 2019; foster, young, mitchell, van, & curtis, 2017). the first reaction of the child in addition to fear is the patient lacks an appetite and even cries, does not want to drink milk or eat the food provided (joosten & hulst, 2014; stremler, haddad, pullenayegum, & parshuram, 2017; whyte et al., 2011). the child's reaction is influenced by perceptions, age, previous experience of the process of illness and being treated and the support system available (nursalam & efendi, 2008). effective coping produces a permanent adaptation which is a new habit and an improvement from the old situation, while ineffective coping ends in maladaptive i.e. behaviour deviating from normative desires and can harm oneself or others or the environment (rasmun, 2014). one of the best approaches is to encourage parents to stay with their children and participate in care if possible (duzkaya, uysal, & akay, 2014; moghaddam, vashani, reihani, & zadegan, 2017; olsson, kenardy, de young, & spence, 2008). parents can provide effective care during hospitalisation of their children (konuk şener & karaca, 2017). it has been proven in several studies that children will feel safe when they are beside their parents, especially when facing invasive procedure (supartini, 2004). casey in (supartini, 2004)suggested that the principle of nursing services to children must focus on children and families, to meet the needs of children and their families (kudchadkar et al., 2019; moghaddam et al., 2017). the purpose of this study is to analyze the effect of family support systems on coping mechanisms of preschool children. materials and methods the research design used quasi-experimental with pre-test post-test with control group design. variables in this study were the family support system and coping mechanisms of preschool children. the population of this study was preschool children who were treated in the hospital of bangkalan, east java province, indonesia. the sample size was 30 respondents in the treatment group and 30 respondents in the control group. sampling technique using consecutive sampling. data collection used in the form of observation sheets of coping mechanisms for preschoolers using the children's coping behavior checklist designed by (hernandez, 2008). the implementation of the family support system intervention in the treatment group is based on the standard procedure that has been made, and each nurse carries out nursing care to patients from the first day to the third day. the steps in implementing the family support system include the pre-action stage, the orientation phase, the work phase and the termination stage. the study was conducted for three months (august october 2018). the intervention in the control group used standard therapy that was routinely carried out in the hospital of bangkalan, east java province, indonesia. the results of the study to determine differences in coping mechanisms before and after the intervention in the treatment and control groups were tested by paired t-test. this research has been conducted ethics due diligence by kepk stikes ngudia husada madura. results the age of children in the treatment group was mostly three years old (10.3%). in the control group, most of the age of nine years was 30 people (30%). based on the sex of the children in the treatment group, most of the male were 17 people (56.7%). in the control group, most of the male was 16 people (53.3%) (table 1). the coping mechanisms of respondents in the treatment group before the intervention were mostly maladaptive as many as 18 people (60%), after the intervention most of the coping mechanisms were quite adaptive as many as 20 people (66.7%). the coping mechanisms of respondents in the control group before the intervention were mostly maladaptive as many as 16 people (53.3%), after the intervention most of the coping mechanisms were maladaptive as many as 15 people (50%). in the treatment group, there was an increase in the mean coping mechanism before (34.07) and after (46.87) intervention family support system. whereas in the control group, there were less significant mean differences in coping mechanisms between before (36.22) and after (36.74) administration of the intervention. paired ttest results in the treatment group showed p-value table 1. characteristic respondents (n=60) characteristics treatment control n % n % age 3 year 10 33.3 9 30 4 year 8 26.7 7 23.3 5 year 7 23.3 8 26.7 6 year 5 16.7 6 20 gender male female 17 13 56.7 43.3 16 14 53.3 46.7 jurnal ners http://e-journal.unair.ac.id/jners | 201 (0.000) and in the control group p-value (0.065) with α (0.05). this indicates that there is an influence of the family support system on the coping mechanism of preschool children (table 2). discussion sickness and hospitalisation are the main crises seen in children. if a child is hospitalized, the child will be prone to crisis because the child will experience stress due to changes in both his health status and the environment in daily habits, and the child has a number of limitations in coping mechanisms to deal with problems and events that are of nature (almis, bucak, konca, & turgut, 2017). push. children's reaction in overcoming the crisis is influenced by the level of age development, previous experience of the process of illness and being treated, support systems available, and coping skills in dealing with stress (christian, 2018). effective coping produces a permanent adaptation which is a new habit and an improvement from the old situation, while ineffective coping ends in maladaptive ie behaviour deviating from normative desires and can harm oneself or others or the environment (rasmun, 2014). during early childhood, children understand that certain circumstances can arouse certain emotions, facial expressions indicate certain emotions, emotions affect behaviour, and emotions can be used to influence the emotions of others. at this stage of preschool age, stable concepts are formed, mental reasoning emerges, egocentrism begins to become strong and then weakens, as well as the formation of belief in the magical. based on piaget's theory, at this stage, the focus is on the limitations of children's thinking which refers to mental activities that allow children to think about the events or experiences they experience (duzkaya et al., 2014; hill et al., 2019). changes in coping patterns in children can be caused by environmental changes that are entirely meaningful for children. usually, children are at home with family or friends in a pleasant atmosphere. however, when a child is sick and has to undergo treatment in a hospital, the child must adapt to the environment and atmosphere that is foreign to him. besides that, the child's activity must also be limited unlike at home, it will make the child feel lost his strength. this situation tends to make children act aggressively with anger and rebellion (stremler et al., 2017). apart from environmental changes experienced by children, the absence of children who have adaptive coping mechanisms can also be caused by child development based on the child's age and physical condition of the child who is sick. preschoolers have not been able to reason, they are only able to perceive anything that makes them uncomfortable and make the pain in themselves as something that can threaten them at any time while the condition of illness experienced by children will worsen their perceptions about things that are considered threatening so that children become unable to cope well (christian, 2018). in helping coping mechanisms to be more adaptive in children during hospitalisation, the role of the family as a support provider is needed in the care of children while undergoing hospitalisation. the presence of a family for a child being treated in the hospital helps the child deal with the changes it receives, the child will adapt and try to learn and change their perceptions about things they feel are uncomfortable and afraid (smith, 2018). the coping mechanism of children is greatly influenced by good social support from families for sick children. the family plays an important supporting role during the child's recovery period. if this support is not available, the success of recovery decreases significantly (friedman & jones, 2010). one of the best approaches is to encourage parents to stay with their children and participate in care if possible (smith, 2018). family support system (family support system) is a support system provided by the family to family members in order to maintain the social identity of family members, provide emotional support, material assistance, provide information and services, or facilitate family members in making new social contacts with the environment. family support is obtained from people who have social relationships with individuals. the primary source of social support is the closest people such as parents, family and close friends. the foundation of children's social relations is the relationship between parents and children, where parents have an important role in the family as adults who provide a sense of security, love, protection and education. the social support that can be shown by the family includes giving more attention to children, but that does not mean spoiling and obeying all the wishes of the child. attention can be done by accompanying children table 2. distribution of coping mechanism of preschool children (n=60) coping mechanism treatment control before after before after n % n % n % n % adaptive enough maladaptive 0 12 18 0 40 60 8 20 2 26.7 66.7 6.6 0 14 16 0 46.7 53.3 1 14 15 3.3 46.7 50 paired t test mean = 34.07 mean = 46.87 p-value = 0.000 mean = 36.22 mean = 36.74 p-value = 0.065 significant: p-value < 0.05; insignificant: p-value > 0.05 m. hasinuddin et al. 202 | pissn: 1858-3598  eissn: 2502-5791 during treatment, inviting children to joke and play, providing understanding in language that children understand about the care and treatment provided during hospitalisation is a way to help the child recover quickly. family participation is significant for healing children because the family is the closest support system for children. support from the family is also verbal or non-verbal information, both in real/behavioural assistance provided by people who are familiar with children in their social environment or in the form of attendance and things that can provide emotional benefits. if the child gets good social support from the family or the people closest to him, the child will feel safe and comfortable and indirectly influence the use of children's coping during the treatment process (garro, thurman, kerwin, & ducette, 2005; hasegawa et al., 2015). the coping mechanism that children learn is very important in their ability to cope with disorders experienced by children. the positive effect of family social support is on adjusting for events in a stressful life(bordone, arpino, & aassve, 2017). support from the family can improve ways of dealing with problems or solve problems focused on reducing stress reactions through the attention, information and feedback needed (alcântara et al., 2016). the influence of family support on the use of coping mechanisms for preschoolers in principle, family support system intervention is one way that can be used to make children feel safe and comfortable and help children adapt during the treatment process in the hospital (helton & house, 2019; iio, hamaguchi, nagata, & yoshida, 2018). families usually know what makes their children feel comfortable, such as being held, stroked, or talked. children will be free to express their feelings when near the people closest to them. another case with children who do not get more attention from their families, children will seek a lot of attention with fuss and tend to act aggressively (weber & harrison, 2019). based on the results of existing research and theories, it can be done to help children adapt adaptively during hospitalisation by doing a family support system. in providing this intervention, the role of parents in assisting children is significant as supporting children, nurses and hospitals only act as facilitators so that if there are procedures for nursing care offered by nurses, parents must be actively involved and assist children and provide motivation to children (iio et al., 2018; tsitsi, charalambous, papastavrou, & raftopoulos, 2017). conclusion preschoolers (3-6 years old) who are treated have a good coping mechanism after an intervention using a family support system approach. the family especially the presence of parents, means to be able to improve coping mechanisms in children undergoing hospitalisation to help children reduce stress and the adverse effects of stress due to hospitalisation. nurses are expected to be able to involve the role of the family in providing nursing care to children especially preschool age to improve coping mechanisms and reduce the stress of hospitalisation. references alcântara, p. l., wogel, a. z., rossi, m. i. l., neves, i. r., sabates, a. l., & puggina, a. c. (2016). effect of interaction with clowns on vital signs and nonverbal communication of hospitalized children. revista paulista de pediatria (english edition), 34(4), 432-438. doi:https://doi.org/10.1016/j.rppede.2016.02.01 1 almis, h., bucak, i. h., konca, c., & turgut, m. (2017). risk factors related to caregivers in hospitalized children's falls. journal of pediatric nursing, 32, 3-7. doi:https://doi.org/10.1016/j.pedn.2016.10.006 atkin, k., & ahmad, w. i. u. (2001). living a ‘normal’ life: young people coping with thalassaemia major or sickle cell disorder. social science & medicine, 53(5), 615-626. doi:https://doi.org/10.1016/s02779536(00)00364-6 bordone, v., arpino, b., & aassve, a. (2017). patterns of grandparental child care across europe: the role of the policy context and working mothers' need. ageing and society, 37(4), 845-873. doi:10.1017/s0144686x1600009x chao, m.-l., & chiang, v. c. (2003). impact on and coping behaviours of a chinese mother with a child suffering from developmental dysplasia of the hip. journal of orthopaedic nursing, 7(4), 176183. doi:https://doi.org/10.1016/j.joon.2003.08.001 christian, b. j. (2018). translational research – the stress and uncertainty of hospitalization and strategies for pediatric nurses to improve the quality of care for children and families. journal of pediatric nursing, 41, 140-145. doi:https://doi.org/10.1016/j.pedn.2018.05.012 duzkaya, d. s., uysal, g., & akay, h. (2014). nursing perception of the children hospitalized in a university hospital. procedia social and behavioral sciences, 152, 362-367. doi:https://doi.org/10.1016/j.sbspro.2014.09.21 2 evi, h. h., sri, w., & junaidi. (2013). hubungan dukungan keluarga dan lingkungan rumah sakit dengan reaksi hospitalisasi pada anak usia sekolah di rsup dr. wahidin sudiro husodo makassar. jurnal keperawatan, 3(2). foster, k., mitchell, r., young, a., van, c., & curtis, k. (2019). resilience-promoting factors for parents of severely injured children during the acute hospitalisation period: a qualitative inquiry. injury, 50(5), 1075-1081. doi:https://doi.org/10.1016/j.injury.2018.12.011 foster, k., young, a., mitchell, r., van, c., & curtis, k. https://doi.org/10.1016/j.rppede.2016.02.011 https://doi.org/10.1016/j.rppede.2016.02.011 https://doi.org/10.1016/j.pedn.2016.10.006 https://doi.org/10.1016/s0277-9536(00)00364-6 https://doi.org/10.1016/s0277-9536(00)00364-6 https://doi.org/10.1016/j.joon.2003.08.001 https://doi.org/10.1016/j.pedn.2018.05.012 https://doi.org/10.1016/j.sbspro.2014.09.212 https://doi.org/10.1016/j.sbspro.2014.09.212 https://doi.org/10.1016/j.injury.2018.12.011 jurnal ners http://e-journal.unair.ac.id/jners | 203 (2017). experiences and needs of parents of critically injured children during the acute hospital phase: a qualitative investigation. injury, 48(1), 114-120. doi:https://doi.org/10.1016/j.injury.2016.09.034 friedman, m. m. b. v. r., & jones, e. g. (2010). family nursing textbook: research, theory, and practice. jakarta: egc. garro, a., thurman, s. k., kerwin, m. e., & ducette, j. p. (2005). parent/caregiver stress during pediatric hospitalization for chronic feeding problems. journal of pediatric nursing, 20(4), 268-275. doi:https://doi.org/10.1016/j.pedn.2005.02.015 hasegawa, k., ahn, j., brown, m. a., press, v. g., gabriel, s., herrera, v., . . . youngquist, s. (2015). underuse of guideline-recommended long-term asthma management in children hospitalized to the intensive care unit: a multicenter observational study. annals of allergy, asthma & immunology, 115(1), 10-16.e11. doi:https://doi.org/10.1016/j.anai.2015.05.004 helton, j. j., & house, n. g. (2019). children with chronic health conditions and maltreatment rereport. children and youth services review, 105, 104412. doi:https://doi.org/10.1016/j.childyouth.2019.1 04412 hernandez, b. c. (2008). the children’s coping behavior questionnaire: development and validation. loyola university new oerleans, hill, d. l., carroll, k. w., snyder, k. j. g., mascarenhas, m., erlichman, j., patterson, c. a., . . . feudtner, c. (2019). development and pilot testing of a coping kit for parents of hospitalized children. academic pediatrics, 19(4), 454-463. doi:https://doi.org/10.1016/j.acap.2018.11.001 iio, m., hamaguchi, m., nagata, m., & yoshida, k. (2018). stressors of school-age children with allergic diseases: a qualitative study. journal of pediatric nursing, 42, e73-e78. doi:https://doi.org/10.1016/j.pedn.2018.04.009 joosten, k. f. m., & hulst, j. m. (2014). nutritional screening tools for hospitalized children: methodological considerations. clinical nutrition, 33(1), 1-5. doi:https://doi.org/10.1016/j.clnu.2013.08.002 konuk şener, d., & karaca, a. (2017). mutual expectations of mothers of hospitalized children and pediatric nurses who provided care: qualitative study. journal of pediatric nursing, 34, e22-e28. doi:https://doi.org/10.1016/j.pedn.2017.02.004 kudchadkar, s. r., aljohani, o., johns, j., leroux, a., alsafi, e., jastaniah, e., . . . crainiceanu, c. (2019). day-night activity in hospitalized children after major surgery: an analysis of 2271 hospital days. the journal of pediatrics, 209, 190197.e191. doi:https://doi.org/10.1016/j.jpeds.2019.01.054 mcmahon, e., & chang, y.-s. (2020). from surviving to thriving parental experiences of hospitalised infants with congenital heart disease undergoing cardiac surgery: a qualitative synthesis. journal of pediatric nursing, 51, 32-41. doi:https://doi.org/10.1016/j.pedn.2019.12.010 moghaddam, e. z., vashani, h. b., reihani, t., & zadegan, s. n. (2017). the effect of spiritual support on caregiver's stress of children aged 8– 12 with leukemia hospitalized in doctor sheikh hospital in mashhad. journal of cellular immunotherapy, 3(1), 29-30. doi:https://doi.org/10.1016/j.jocit.2017.04.046 nursalam, & efendi, f. (2008). pendidikan dalam keperawatan. jakarta: salemba medika. olsson, k. a., kenardy, j. a., de young, a. c., & spence, s. h. (2008). predicting children's post-traumatic stress symptoms following hospitalization for accidental injury: combining the child trauma screening questionnaire and heart rate. journal of anxiety disorders, 22(8), 1447-1453. doi:https://doi.org/10.1016/j.janxdis.2008.02.00 7 palka, t., peura, c., verdi, m., kaplan, d., beresford, c. a., sannar, e. m., . . . grados, m. a. (2016). 3.30 sleep disturbance in hospitalized children with autism spectrum disorder: relationship to parent report and parental stress. journal of the american academy of child & adolescent psychiatry, 55(10, supplement), s151-s152. doi:https://doi.org/10.1016/j.jaac.2016.09.162 priyoto. (2014). konsep manajemen stress. jakarta: sagung seto. rasmun. (2014). stres, koping dan adaptasi. yogyakarta: nuha medika. rückholdt, m., tofler, g. h., randall, s., & buckley, t. (2019). coping by family members of critically ill hospitalised patients: an integrative review. international journal of nursing studies, 97, 4054. doi:https://doi.org/10.1016/j.ijnurstu.2019.04.0 16 smith, w. (2018). concept analysis of familycentered care of hospitalized pediatric patients. journal of pediatric nursing, 42, 57-64. doi:https://doi.org/10.1016/j.pedn.2018.06.014 stratta, p., capanna, c., carmassi, c., patriarca, s., di emidio, g., riccardi, i., . . . rossi, a. (2014). the adolescent emotional coping after an earthquake: a risk factor for suicidal ideation. journal of adolescence, 37(5), 605-611. doi:https://doi.org/10.1016/j.adolescence.2014. 03.015 stremler, r., haddad, s., pullenayegum, e., & parshuram, c. (2017). psychological outcomes in parents of critically ill hospitalized children. journal of pediatric nursing, 34, 36-43. doi:https://doi.org/10.1016/j.pedn.2017.01.012 sukoati, s., & astarani, k. (2012). aktivitas bermain mewarnai dapat meningkatkan mekanisme koping adaptif saat menghadapi stres hospitalisasi pada anak. jurnal stikes, 5(2). supartini, y. (2004). buku ajar konsep dasar https://doi.org/10.1016/j.injury.2016.09.034 https://doi.org/10.1016/j.pedn.2005.02.015 https://doi.org/10.1016/j.anai.2015.05.004 https://doi.org/10.1016/j.childyouth.2019.104412 https://doi.org/10.1016/j.childyouth.2019.104412 https://doi.org/10.1016/j.acap.2018.11.001 https://doi.org/10.1016/j.pedn.2018.04.009 https://doi.org/10.1016/j.clnu.2013.08.002 https://doi.org/10.1016/j.pedn.2017.02.004 https://doi.org/10.1016/j.jpeds.2019.01.054 https://doi.org/10.1016/j.pedn.2019.12.010 https://doi.org/10.1016/j.jocit.2017.04.046 https://doi.org/10.1016/j.janxdis.2008.02.007 https://doi.org/10.1016/j.janxdis.2008.02.007 https://doi.org/10.1016/j.jaac.2016.09.162 https://doi.org/10.1016/j.ijnurstu.2019.04.016 https://doi.org/10.1016/j.ijnurstu.2019.04.016 https://doi.org/10.1016/j.pedn.2018.06.014 https://doi.org/10.1016/j.adolescence.2014.03.015 https://doi.org/10.1016/j.adolescence.2014.03.015 https://doi.org/10.1016/j.pedn.2017.01.012 m. hasinuddin et al. 204 | pissn: 1858-3598  eissn: 2502-5791 keperawatan anak. jakarta: egc. tsitsi, t., charalambous, a., papastavrou, e., & raftopoulos, v. (2017). effectiveness of a relaxation intervention (progressive muscle relaxation and guided imagery techniques) to reduce anxiety and improve mood of parents of hospitalized children with malignancies: a randomized controlled trial in republic of cyprus and greece. european journal of oncology nursing, 26, 9-18. doi:https://doi.org/10.1016/j.ejon.2016.10.007 weber, a., & harrison, t. m. (2019). reducing toxic stress in the neonatal intensive care unit to improve infant outcomes. nursing outlook, 67(2), 169-189. doi:https://doi.org/10.1016/j.outlook.2018.11.0 02 whyte, j., jones, a., arias, a., yuhico, m., tellez, g., latorre, a., & ernst, m. (2011). decreasing stress in parents of children hospitalized in the cardiac intensive care unit. journal of pediatric nursing, 26(4), e24. doi:https://doi.org/10.1016/j.pedn.2011.01.274 https://doi.org/10.1016/j.ejon.2016.10.007 https://doi.org/10.1016/j.outlook.2018.11.002 https://doi.org/10.1016/j.outlook.2018.11.002 https://doi.org/10.1016/j.pedn.2011.01.274 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 298 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17150 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review factors related to sleep disorders in the elderly in tresna werdha madago tentena nurmawati s. lataima1 and novrin s. pasaju2 1faculty of nursing, universitas airlangga, surabaya, indonesia 2school of nursing, stikes husada mandiri, poso, central abstract background: sleep disorders are common things often experienced by the elderly. this will affect their quality of life. there are many factors that influence sleep needs in the elderly. the aim of this study was to determine the factors related to sleep disorders in the elderly. method: this study used a cross-sectional design with accidental sampling. the population in this study was the elderly at tresna werdha madago tentena. the data retrieval for this research was conducted between june july 2014. the analysis of the data was done using chi-square. the results from the 45 respondents showed that 61.3% had sleep disorders caused by their disease and that 65.6% had sleep disorders caused by an unconducive environment. result: this result showed that disease and an unconducive environment influenced sleep needs. conclusion: the recommendation for nurses and staff is to increase their attention span and the environmental comfort by dimming the lights when the patient is going to sleep and reducing noise. this means that the patient's sleep needs are fulfilled. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords sleep disorder; elderly; quality of life; comfort; sleep contact nurmawati s. lataima  nurmawati.s.lataima2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: lataima, n. s & pasaju, n. s. (2019). factors related to sleep disorders in the elderly in tresna werdha madago tentena. jurnal ners, 14(3si), 298-300. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17150 introduction increasing the economic life, increasing the variety of technology and improving on the health facilities has led to an number of improvements tied into human life expectancy(mubarak, 2008). the increase in life expectancy has an impact on the increasing number of elderly people (maryam, 2008). at present, the number of elderly people around the world is estimated to be more than 629 million (one in 10 people are over 60 years old). by 2025, the elderly population will reach 1.2 billion (menkokesra, 2008). in indonesia, there are 15.3 million, which is 7.4% of the population. in 2005, this number was estimated to have increased to / + 18.3 million (8.5%) (nugroho, 2008). as they age, the elderly will experience physical, psychosocial and spiritual changes(saputra, 2013). one of changes is their sleep patterns(saryono and widianti, 2010). according to the national sleep foundation, about 67% out of 1,508 elderly people in the united states aged 65 years and over reported experiencing sleep disorders (pirma siburian sp pd, 2009) and as many as 7.3% of the elderly complained of a disorder related to starting and maintaining sleep or insomnia (anderson, 2009). sleep quality in the poor elderly cannot be separated from the factors that influence it(stockslager, jaime l and schaeffer, 2008). a quiet environment, hot or cold temperature, car noise and other communication devices can disrupt sleep (immanuel, 2008). medical conditions and the physical changes related to old age also influence sleep(widuri, 2010). the pain at night will be more influential, it will take longer to fall asleep and the sleep is disrupted. the aim of this study was to determine the factors related to sleeps disorder in elderly (bandiyah, 2009). materials and methods research design, population and sample and variables this study used a cross-sectional design and accidental sampling. the population in this study was all of the elderly people at the tresna werda https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nurmawati.s.lataima-2018@fkp.unair.ac.id mailto:nurmawati.s.lataima-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 299 "madago" social institution in tentena, totaling about 85 people. from the results of the calculation above, the total sample was 45 people. this research was conducted in the poso of central sulawesi from june july 2014. the inclusion criteria of this research were as follows: 1) the elderly who live in the tresna social home werda "madago" tentena, 2) the elderly people who do not experience psychic disorders, 3) the elderly people who have no hearing loss and 4) the elderly who are willing to be used as a respondent. the independent variables in this study were accompanying diseases and the environment. the dependent variable was the need for sleep in the elderly. instruments this instrument used three types of questionnaire in the form of a disease disorder questionnaire, environmental questionnaire and the questionnaire on the needs of the elderly sleepers. research procedures and analysis the procedure for retrieving the data was the filling out of the questionnaires by the respondents with their approval. the study was conducted for 2 months in the madago tentena social institution. this research study received permission and passed the ethical review conducted by the ethics commission of the tresna werdha madago tentena on july 2nd 2014, certificate number 016/tu/pstw/vii/2014. the data was analyzed using ibm spss statistic 24. the statistical analysis used was the chi-square test. the confidence interval was 95% with an alpha value of (a)= 0.05. result the results of the analysis of the relationship between the dependent variables, namely the elderly sleep needs and disease, showed a value of p=0.013. this value is said to be significant because the value is p<0.05, which means that the hypothesis is accepted. this explains that there is a significant relationship between elderly sleep needs and disease. we can see from the or value of 5.806 (25.173-1.339) that the respondents with disease have a chance that is 5. 806 times more likely when it comes to not having fulfilled their sleep needs compared to the respondents without a disease [table 1]. the results of the analysis of the relationship between the dependent variables indicates that elderly sleep needs and environmental disorders showed a value of p=0.000. this value is said to be significant because the value is p<0.05 which means that the hypothesis is accepted. this explains that there is a significant relationship between the elderly sleep needs and environmental disorders. the or value is 22.909 (199.944-2.625), which shows that the respondents with an environmental disorder have 22.909 times more of a chance of unfulfilled sleep needs compared to the respondents without environmental disturbances [table 2]. table 1. the results of the analysis of the relationship between elderly sleep needs and disease in june-july 2014 variable needs sleep n fulfilled not fulfilled n % n % 31 14 45 with disease 12 38.7 19 61.3 without disease 11 78.6 3 21.4 total 23 51.1 76 48.9 chi-square p = 0.013 or = 5.806 table 2. the results of the analysis of the relationship between the elderly sleep needs and environment disorders in june july 2014 environmental needs sleep n fulfilled not fulfilled n % n % unconducive 11 34.4 21 65.6 32 conducive 12 92.3 1 7.7 13 total 23 51.1 76 48.9 45 chi-square p = 0.00 or = 22.909 discussion the results of the study on 45 respondents showed that the respondents who did not fulfill their sleep needs were 61.3% compared to the respondents without disruption to meeting their need for sleep, which amounted to 21.4%. for the respondents with environmental disorders, 65.6 did not meet their sleep needs compared to the respondents who did not have any disruption in their sleep by 7.7%. the results of the analysis in this study are based on the significance values which indicate that there is a significant relationship in relation to meeting the needs of the elderly, their sleeping, the disruption of disease and environmental disorders. this means that if there are accompanying diseases and environmental disorders, then the sleep needs of the elderly are not met. this is in accordance with what the respondents indicated in the results of this study. the disease experienced by the respondents was rheumatism. this caused the respondents to experience pain complaints, especially during their daily activities or when the temperatures too cold. pain is an unpleasant sensory and emotional experience due to actual or potential tissue damage(immanuel, 2008). pain stimuli are transmitted to the spinal cord, thalamus and midbrain(asmadi, 2008). from the thalamus fibers, there is the transmission of pain messages to the various areas of the brain including the sensory cortex, association cortex and limbic system. which will affect sleep (anderson, 2009). the response / complaint commonly experienced by the rheumatic clients was mild to severe pain, which can interfere with sleep. based on the results of a study by dament et al., it was reported that young people reported a sleeping efficiency of 80 to 90% while the elderly reported 67 to 70%. luce and segal revealed that in the elderly group (forty years), only 7% of cases complained about sleep problems (only n. s. lataima et al. 300 | pissn: 1858-3598  eissn: 2502-5791 able to sleep for no more than five hours a day). the same was found in 22% of cases in the age group who were 70 years old (woke up earlier than 5:00 a.m). in addition, 30% of the 70-year age group had awakened at night (bandiyah, 2009). environmental factors are factors that greatly influence the fulfillment of rest and sleep needs in the elderly. these factors include noise, temperature, lighting, circulation or ventilation systems and the room situation. the limitations in this study were the limited number of independent variables. there is also the cause of insomnia in the elderly to consider. conclusion the conclusion is that the respondents with disabilities and environmental disorders have not fulfilled their need for sleep. references anderson, e. t. and j. m. (2009). community nursing textbooks: theory and practice (3rd ed.). egc. asmadi. (2008). nursing procedures, concepts and kdm applications. salemba medika. bandiyah, s. (2009). elderly and gerontik nursing. nuha medika. immanuel, s. (2008). laboratory examination in anti aging medicine. cermin dunia kedokteran. maryam, r. s. (2008). get to know old age and care. salemba medika. menkokesra. present and future ages. , (2008). mubarak, w. i. (2008). textbooks for basic human needs. egc. nugroho, w. (2008). gerontik and geriatric nursing. egc. pirma siburian sp pd. (2009). fourteen health problems that often occur in the elderly. saputra, l. (2013). introduction to basic human needs. binarupa aksara. saryono and widianti, a. t. (2010). lecture notes basic human needs. nuha medika. stockslager, jaime l and schaeffer, l. (2008). geriatric nursing pocket book. egc. widuri, h. (2010). basic needs of human aspects of mobility and sleep rest. gosyan publishing. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 85 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.18863 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research exploring the influencing factors on breast self-examination among myanmar women: a qualitative study nyein moh moh myint1,2, nursalam nursalam1, and eka mishbahatul mar’ah has1 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 university of nursing, mandalay, myanmar abstract introduction: breast self-examination (bse) is the most sensitive and costeffective method to diagnose breast cancer at an early stage in healthcare resources’ limited setting. however, the practice of bse is low in myanmar. although various international studies were conducted to clarify the influencing factors in irregular bse practice, there is a range of different factors and the answer is not yet clear. hence, this study is aimed to explore the influencing factors on the practice of breast self-examination among myanmar women. methods: a qualitative exploratory-descriptive study was conducted on eight women through in-depth semi-structured interviews between february 2020 and march 2020. the samples were women who lived in the rural area of myanmar and purposive sampling technique was used. data were analyzed using colaizzi’s method, which consisted of seven stages. results: four themes emerged as the results of the in-depth interview, namely knowledge of breast cancer, knowledge regarding breast self-examination, barriers to performing regular bse and ways to improve bse practice. conclusion: this study showed that the women were inadequate in knowledge and practice regarding bse and breast cancer. some barriers of bse practice are rooted in the inadequate skill of bse and the women’s attitude. greater understanding about breast cancer and improving the confidence of women in bse will lead to better prognosis. hence, healthcare authorities and providers should encourage a formal health education program and the results from this study hope to be useful in future rural health education programs of bse practice. article history received: may 2, 2020 accepted: may 27, 2020 keywords breast self-examination; myanmar; rural women contact nyein moh moh myint nyeinmoh.1950@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: myint, n. m. m., nursalam, n., & has, e.m.m. (2020). exploring the influencing factors on breast selfexamination among myanmar women: a qualitative study. jurnal ners, 15(1). 85-90. doi:http://dx.doi.org/10.20473/jn.v15i1.18863 introduction breast self-examination (bse) is important to detect breast cancer early, especially in healthcare resources’ limited setting. it is the most sensitive and cost-effective method to diagnose breast cancer at an early stage (tiwari and naik, 2018). even though the women heard about bse, the majority of the women were low in bse practice and did not perform regular bse (win et al., 2019) (abolfotouh, banimustafa and mahfouz, 2015; ahmed, zahid and ladiwala, 2018). although various studies were conducted to clarify the influencing factors in irregular bse practice, there is a range of different factors and the answer is not yet clear. in myanmar, the government introduced the bse method as a primary healthcare level in the manual for package of essential non-communicable diseases (pen) (ministry of health and sports, 2017). in addition, the government encourages promoting regular bse practice by sharing information using pamphlets and through government websites (ministry of health and sports, 2019). if breast cancer (bc) detects late with low screening practice, it results in poor prognosis with a high mortality rate. to enhance bse practice and support the bse program, the contributing factors of bse need to be identified. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ n. m. m. myint, et al. 86 | pissn: 1858-3598  eissn: 2502-5791 bc is a serious health problem for both developed and developing countries (world health organization, 2018). according to the international agency for research on cancer (iarc), over 60,000 new cancer cases occur yearly in myanmar, with bc being the most common among women and 11 people per 100,000 population die of bc (international agency for research on cancer, 2018). early detection involves an essential role in breast cancer (bc). of breast cancer cased detected, 73.5% were by physical examination method, and there was evidence that bse can find tumors with 22.1mm in diameter (schwab et al., 2015). moreover, bse can help to diagnose over 90% of all breast cancers in an early stage (mohamed, ibrahim and lamadah, 2016). also, hassan, mahmoud and miller (2015) proved that bse could detect breast cancers at early stages (<3) and suggested it be applied as a useful screening test with high availability and low costs at the community level (hassan, mahmoud and miller, 2015). however, bse practice is still low in practice. a previous study conducted in myanmar showed that only 16.7% of the respondents could talk about bse, and only 13.3% of them performed it (win et al., 2019). the previous international studies identified the various impacting factors that can influence on bse. as socio-demographic factors, age, marital status, personal history of breast disease (vasishtaa et al., 2018), level of education (febriyanti et al., 2018), and work status (abolfotouh et al., 2015) have a significant relation with bse practice. according to a cross-sectional study conducted in bali, it described that those having good level of knowledge of bse, perceived benefits, perceived low barriers, and high level of self-efficacy were more likely to perform bse (febriyanti et al., 2018). also, the reasons for not performing bse included that they did not know how to do it, had no symptoms of breast cancer and worried about detecting breast cancer, respectively (vasishtaa et al., 2018). to organize an effective program in improving regular bse practice among women, understanding the impacting factors on bse practice plays a crucial role. hence, this study is aimed to explore the influencing factors on the practice of breast selfexamination among rural women in myanmar. materials and methods this research is a qualitative research using a descriptive exploratory approach. eight women who met the criteria were recruited by using purposive sampling. targeting criteria included women who wanted to share their experience for this research, women who had heard about bse and women aged between 20 to 45years. data collection was carried out at two villages of meiktilar township, myanmar between february 2020 and march 2020. the data were collected by using individual indepth interview until the data were saturated. openended semi-structured questions were used and the interview took 30 to 60 minutes at the respondents’ home or convenient place. before conducting the interview, the researcher firstly explained the purpose of the study and procedure. then, if the women desired to participate, took consent from all women. all interviews were audio-recorded and field notes taken after getting permission from respondents. the main guided items used in the interview were “what do you understand about breast cancer?” “what do you think of breast selfexamination?” “have you ever examined your breasts?” and “how can bse practice be improved?” ethical approval was obtained from the institutional review board, department of medical research, yangon, myanmar with the number (ethics/dmr/2020/004) and the research ethics committee of faculty of nursing, universitas airlangga with the number (no: 1799-kepk). interview data were transcribed from original recordings and field notes after data collection, and the accuracy checked to reduce mistakes in writing the transcript. then, data were analyzed using the colaizzi’s method, which consisted of seven steps. peer check and immersed data to ensure the rigor of the findings were used as well. four major themes emerged, namely, knowledge of breast cancer, knowledge regarding bse, barriers to performing regular bse, and ways to improve bse practice. results eight women from two villages of meiktilar township, myanmar, participated in this study. all of the women were buddhists and aged between 21 to 42 years. among them, two women had a history of excision of a breast lump, and one woman had a history of cyst in breast. all women had heard about bse. one of them performed bse every day, four of them sometimes and three of them never used bse. three women obtained information from healthcare providers, three from peers and two from audiovisual media. the characteristics of participants are shown in table 1, and then four major themes are described in detail with the respondents’ responses. knowledge of breast cancer the results showed that the women did not know about breast cancer well, especially in sign and symptoms, risk factors, screening and management. the majority of the women, except one, agreed that breast cancer was a painful lump. some of their responses were: “breast cancer is a serious and fatal disease. i am scared that i suffer from breast cancer. it is a painful lump and gradually increases in size and pain intensity” (p1). jurnal ners http://e-journal.unair.ac.id/jners | 87 “it is the lump in the breast that can disseminate to other parts of the body. if the lump has no pain, there is no need to worry. there is no problem. it is not breast cancer” (p3). “....it is a painful ulcer or lump, but i do not know well” (p4). “i do not know the symptoms…it is a lump and painful” (p5). regarding risk factors and causes, many different aspects appeared. they assumed that menopausal or unmarried women can suffer more breast cancer. some of the women believed they had no chance to experience breast cancer. some of their opinions were: “it is common in women after menopause and in spinsters. i believe that i cannot suffer from bc. i am not old age and already married” (p2). “i never think i can suffer breast cancer because i have no breast disease” (p4). although there was no scientific evidence on the relationship between wearing a bra and breast cancer (american cancer society, 2017), the women believed there was a relationship. two of the women believed wearing a nylon bra as a cause of breast cancer while one of them suggested removing the bra at free time. the women explained the following: “the women who always wear nylon bras suffer from breast cancer. so, i always wear cotton ones” (p3). “wearing a tight bra and nylon bra (that can feel hot and sweating) causes breast cancer and other breast diseases” (p7). “i think it (bra) maybe, but not sure. should remove at night and free to prevent bc” (p5). a controversial response was found in gripping or massaging of the breast by hand and breast cancer. the women said: “i don’t know the causes of bc. i think if there is an injury of the breast caused by handgrip of the breast during sexual intercourse. it will become breast cancer later. so, i always remind my husband” (p5). “i think it is not related to a handgrip on the breast. even if there is a lump, it will reduce by massaging” (p1). on screening method, all of them accepted that examination of the breast was a way to detect breast cancer. one woman recommended a regular checkup (every three years) whereas another woman answered there was no need for a regular check-up. all of them accepted that bse was a way to detect breast cancer. knowledge regarding bse the level of understanding of bse was inadequate among participants. although the women had already heard of and accepted bse as a way to detect breast cancer, they did not know the method accurately. their uncertainty was seen in the following responses: “….just heard about bse. women should perform bse. but it is not sure how to do it” (p2) (p4). “i heard about bse. ………………… but not know the way to do” (p7). “i heard about bse from the doctor who removed my breast lump. she taught me how to palpate the breast briefly, but now i forget the steps” (p1). the majority of the samples assumed that bse was the palpation of the breast by hand to find the lump and there was no need to inspect the breast. one of them described that she felt embarrassment with inspection. some of them thought that there was no need to palpate the axilla region. some of their responses were the following: “bse is squeezing of the breast thoroughly with hand in sitting position at the time of bathing, but not the axilla because of breast cancer” (p6). “bse is the palpation of the breast so see if there is a lump or not. i think there is no need to palpate the axilla region ….” (p8). “i palpate both the breast and the nipple, but never look at in the mirror. it makes me embarrassed” (p1). although regular practice in bse is important to find abnormal changes in the breast, the women table 1 characteristics of participants code.no age marital status religion education family history of bc history of breast disease bse practice sources of information p1 42 married buddhism graduate no breast lump sometimes healthcare person p2 21 single buddhism university no no never peer p3 40 single buddhism high school no cyst sometimes healthcare person p4 40 married buddhism graduate no no never healthcare person p5 25 married buddhism graduate no no never peer p6 31 single buddhism high school yes no always (everyday) audio-visual media p7 36 married buddhism middle school no no sometimes peer p8 39 married buddhism high school no lipoma sometimes audio-visual media *p=participant n. m. m. myint, et al. 88 | pissn: 1858-3598  eissn: 2502-5791 who participated in this study did not implement this. most of them performed bse when they felt something in the breast and before menstruation. some of their responses were: “if there is a pain in the breast, i sometimes perform the bse, but not regularly. as for me, there is no need to do a regular exam if there is no problem” (p1). “sometimes, i perform when i feel something in my breast. i think there is no need to do it regularly” (p8) “i do bse sometimes. if i suffer pain in the breast (usually before menstruation), i remember to take bse” (p3). on the other hand, one woman performed bse every day (sometimes, more than once a day). she stated that: “i always perform bse every day. sometimes, i palpate more than once a day. my aunt (father’s sister) suffered from breast cancer with a painful feeling and groaning before she died. i’m afraid of dying with breast cancer” (p6). moreover, some misunderstandings on the lump of bse had occurred. one of the women described that “bse is the palpation of the breast. the women should perform bse. if there is a painful lump immediately go to healthcare providers. the painless lump has no need to be a worry. it is not a problem.” the women assumed that only females need to perform bse. therefore, the women needed more information about bse, including who should perform, how to do it, when to do it, and which region should be performed. barriers to perform regular bse generally, the women had no regular bse practice. the majority of the participants reported that they did not know how to do bse correctly. some women performed bse sometimes when they felt something or had pain in the breast. the women who had never performed bse answered that they were busy; they did not have enough time to palpate, no history of a breast lump, no pain in the breast and assumed no need to do bse. their responses were as following: “… i have no history of breast disease. i do not feel pain in my breast. i think that i do not need to do breast examination” (p2). “… because i do not know how to do it, and i have no extra time to do it” (p4). “i rarely perform it because i have no problem with breast and usually go to an obstetrician and gynecologist (og) to get a child. nevertheless, i have never asked about breast cancer, and also she does not suggest me to perform bse” (p7). ways to improve bse practice based on the participants’ view, health education involves a crucial role. they stated that they are eager to learn how to do bse systematically, and they think that providing health education with practical sessions from the healthcare provider is effective. they also suggested that healthcare providers should be female, and group discussion should also be included. some of the samples described their concern to improve bse practice as follows: “if there are health talks about bse, i would like to join. i think it should include the explanations with the picture, the practical examination one by one. the practical session should be how to understand and classify the findings from other breast diseases” (p3). “do i need to perform bse? if someone explains the requirement of bse and teaches how to do it, i will perform it” (p5). “i think that health education with peer group discussion will get the chance to ask for the unclear points. besides, i always encourage others to palpate the breast if they have an interest” (p6). “to understand and perform bse well, i would like to learn the method of bse from female healthcare providers together with my peers. i can discuss and remember easily. if i forget something, i can ask my friends” (p7). discussion the present study was conducted with the aim to explore the contributing factors on regular bse practice. the samples who participated in this study were aged women between 21 to 42 years. this study revealed the perceptions of young women on bse because breast tumors in young female showed more aggressive and tended to be diagnosed in more advanced stage (radecka and litwiniuk, 2016). as a result of the recent study, four major themes emerged, namely, knowledge of breast cancer, knowledge regarding bse, barriers to performing regular bse, and ways to improve bse practice. the study results showed that women with a history of the breast-related disease and family history of breast cancer had more tendencies to do bse. this finding was in concordance with previous study (abolfotouh, banimustafa and mahfouz, 2015). the sample obtained the information mainly from healthcare providers and peers. similar results were also seen in the study by hanson, wyk and adejumo (2016), which described that healthcare workers were the primary source of health information in reproductive health issues (hanson, wyk and adejumo, 2016). in myanmar, basic health services in the rural area are provided primarily by the midwives and community health nurse. they should provide health information widely in the community and encourage women to perform bse regularly. although knowledge is the essential requirement to change behaviors, the understandings of breast cancer and bse among women were low in this study. khiyali, aliyan and kashf (2017) proved that improving the knowledge of bc and bse improved the bse behaviors which can reduce the mortality rate with breast cancer. jurnal ners http://e-journal.unair.ac.id/jners | 89 another study showed that there was a significant relationship between knowledge and bse practice (noor et al., 2018). in this study, some of the women knew about breast cancer and that it is common in women, but they denied that they had the chance to suffer from breast cancer with the reasons of young age and marital status. the women heard about bse from different sources and accepted that women should palpate the breast to find the breast lump. however, the results showed that the information that they obtained is not enough and it required an organized health education program, including basic knowledge about breast cancer and bse. the perceived low barrier is one of the significant factors that can influence on bse (febriyanti et al., 2018). in this study, the causes of failures to do bse practice were that they do not know the method of bse, no time to perform bse, busy and inadequate time to palpate, no history of a breast lump, no pain in the breast and assumed no need to do bse. similarly, another study showed that the women in myanmar had a negative attitude toward bse with embarrassment to do, time-consuming, fear of discovering tumors, and difficulties to do (myint, 2015). based on the results, the barriers that occurred among women were rooted in inadequate knowledge regarding bse, risk factors, and signs and symptoms of breast cancer. so, enhancing knowledge is considered to remove or reduce the perceptions of barriers. in this study, the majority of the women assumed that health education is essential to improve bse practice. the women were willing to learn about bse method with practical sessions until understanding how to interpret the findings. they also suggested using visual aids like diagrams to get precise information. similarly, a study conducted in malaysia proved that there was a significant increase in knowledge and performance of bse. health intervention of that study was carried out by different teaching methods such as powerpoint presentation, using educational videos, group discussion, and performing breast examination on models (masoudiyekta et al., 2017). similarly, previous studies proved that health education is essential to obtain awareness about bc and encourage performing bse practice. an educational intervention based on the health belief model (hbm) on bse behavior showed that it is effective in promoting bse behaviors (khiyali, aliyan and kashf, 2017). therefore, theory-based health education combined with different teaching methods should be considered in enhancing bse practice. conclusion this study showed that the women living in the rural area of myanmar were low in knowledge and practice regarding bse and breast cancer. some barriers that contribute to the bse practice were rooted in inadequate knowledge and skill of bse and the women’s attitude. by providing health education, the more the women understand about bc and bse, the earlier they detect breast cancer. consequently, the prognosis of breast cancer will be better and the mortality rate with breast cancer will reduce. hence, healthcare authorities and providers should develop a formal health education program on bc and bse. the results from this recent study hope to be useful in future health education programs in the rural area. references abolfotouh, m. a., banimustafa, a. a. and mahfouz, a. a. (2015). using the health belief model to predict breast self examination among saudi women. bmc public health, 15(1). doi: 10.1186/s12889-015-2510-y. ahmed, a., zahid, i. and ladiwala, z. f. r. (2018). breast self ‑ examination awareness and practices in young women in developing countries : a survey of female students in karachi , pakistan. journal of education and health promotion, 7, pp. 1–9. doi: 10.4103/jehp.jehp. american cancer society (2017). about breast cancer: breast cancer basics. available at: https://www.cancer.org/content/dam/crc/p df/public/8577.00.pdf (accessed: 29 october 2018). febriyanti, n. m. a., lubis, d., wirawan, d.n. and suariyani, p.. (2018). the determinants of early breast cancer detection via breast selfexamination ( bse ) in denpasar , bali. public health and preventive medicine archive (phpma), 6(1), pp. 37–41. doi: 10.15562/phpma.v6i1.7. hanson, v. f., wyk, b. van and adejumo, o. (2016). breast self-examination knowledge and practice among women in a rural community in southwest nigeria : a qualitative approach, midirs midwifery digest, 26(4), pp. 525–530. hassan, l. m., mahmoud, n. and miller, a. b. (2015). evaluation of effect of self-examination and physical examination on breast cancer. the breast, 24, pp. 487–490. doi: 10.1016/j.breast.2015.04.011. international agency for research on cancer (2018). myanmar data fact sheet. doi: https://gco.iarc.fr/today/fact-sheetspopulations. khiyali, z., aliyan, f. and kashf, s. h. (2017). educational intervention on breast selfexamination behavior in women referred to health centers: application of health belief model. asian pacific journal of cancer prevention, 18(10), pp. 2833–2838. doi: 10.22034/apjcp.2017.18.10.2833. masoudiyekta, l. dashtbozorgi, b., gheibizadeh, m., malehi, a.s. and moradi , m.. (2017). effect of education based on health belief model on the behavior of breast cancer screening in women. asia‑pacific journal of oncology nursing, 4(2), pp. 95–7. doi: n. m. m. myint, et al. 90 | pissn: 1858-3598  eissn: 2502-5791 10.4103/apjon.apjon. ministry of health and sports (2017). training of trainer manual for package of essential noncommunicable disease interventions (pen), ministry of health and sports, myanmar. nay pyi taw: ministry of health and sports, myanmar. doi: 10.1017/cbo9781107415324.004. ministry of health and sports (2019). breast selfexamination. nay pyi taw: ministry of health and sports, myanmar. mohamed, h. a. e. a., ibrahim, y. m. and lamadah, s. m. (2016). application of the health belief model for breast cancer screening and implementation of breast self-examination educational program for female students of selected medical and non-medical faculties at umm al qura university. life science journal, 13(5), pp. 21–33. doi: 10.7537/marslsj13051603.key. noor, s., hardiyanti, d., nursalam, yunitasari, e., tristiana, rr d. (2018).analysis of factors relating to practice of breast self-examination (bse) among women in indonesia. indian journal of public health research and development, 9(12), pp. 595–599. doi: 10.5958/0976-5506.2018.01902.2. radecka, b. and litwiniuk, m. (2016). breast cancer in young women. ginekologia polska, 87(9), pp. 659–663. doi: 10.5603/gp.2016.0062. schwab, f. d., huang, d.j.,schmid, s.m., schötzau, a. and güth,u. (2015). self-detection and clinical breast examination: comparison of the two “classical” physical examination methods for the diagnosis of breast cancer. the breast, 24(1). doi: 10.1016/j.breast.2014.11.008. tiwari, a. and naik, m. (2018). effectiveness of structured teaching program on knowledge and practice regarding breast self-examination among college girls in a selected college of bhilai , chhattisgarh, india. international journal of community medicine and public health, 5(9), pp. 4028–4036. win, t., aung, k.m.s.s., aung, k.o.s. and yee, m.m. (2019). a gap between knowledge and practice: breast cancer knowledge and practice of breast self-examination (bse) in community. available at: https://www.researchgate.net/publication/3 30661109_a_gap_between_knowledge_and_pr actice_breast_cancer_knowledge_and_practice _of_breast_selfexamination_bse_in_community (accessed: ). world health organization (2018). who | breast cancer. available at: http://www.who.int/cancer/prevention/diag nosis-screening/breast-cancer/en/ (accessed: 29 october 2018). 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 272 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17029 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review factors affecting burnout syndrome among nurses: a systematic review rizal tri ardiansyah, fetreo negeo putra, hari soebagiyo, and basilius yosepfus weu faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: burnout syndrome is due to the fatigue felt from work, both physically and mentally. work fatigue experienced by the health care team, especially the nurses, can threaten patient safety. there needs to be actions or policies put in place to decrease the level of nurse burnout syndrome. before setting the policies or actions, it is important to know the factors that affect the occurrence of burnout syndrome. the purpose of this paper is to analyze the factors that influence the occurrence and incidence of burnout syndrome. method: the authors specified the topics and keywords used to search the literature, which in turn allowed for the seeking and obtaining of the appropriate literature criteria. result: the search found 15 pieces of literature. there are several factors that cause burnout syndrome, but the most common factor in the working environment was the poor working conditions and motivation factors of nursing itself. conclusion: based on the results above, we can reduce burnout syndrome with modifications in the working environment or improving the nurse’s motivation through policies, dependent on the institution. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords burnout syndrome; nurse; working environment; nurse motivation contact rizal tri ardiansyah  rizal.tri.ardiansyah2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: ardiansyah, r. t, putra, f. n, soebagyo, h & weu, b. y. (2019). factors affecting burnout syndrome among nurses: a systematic review. jurnal ners, 14(3si), 272-276. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17029 introduction nursing is one profession that is not easy to do; one might say that it is rife with risks because it deals with the lives and safety of others, and even salvation itself. the magnitude of this workload could grow when not supported by the working environment, the health institution and the wages. some of the policies are increasingly adding to the problem and the burden must be shouldered by the. nurse not all immediately find a good coping system and not all of them have emotional intelligence; burnout syndrome can be the result of this (giorgi et al., 2016). burnout syndrome is defined as the effect of fatigue that is both physical and mental which develops the concept of self-negativity, a lack of concentration and negative work behavior. high levels of stress in a nurse can be caused by exhausting work routines, the number of patients who have to be serviced and pressure from their superiors who sometimes add to the burden on the mind of the nurses so as to cause a decline in the performance of the nurses. the nurse's role is very important in the primary health care services in the hospital; a nurse must be able to adapt quickly to high pressure and they should not be in a state of confusion when providing the nursing service (cheng, meng, & jin, 2015). the consequences arising from burnout in the nursing field are very diverse, including emotional exhaustion, depersonalization and a loss of individuality. practically, this can be seen in everyday nursing practices. one example is the length of the working hours (shift) that a nurse has as well as a large number of patients (fang, 2017). the longer the working hours of the nurses, the more that the risk of an error or accident in the workplace will grow. in addition to resulting indirectly in the service of nursing itself, burnout can also lead to an impact on the personal life of each nurse. one of the research studies shows the impact of burnout against family conflicts. when elaborated on further, the conflict is caused by the dimensions of time, stress and changes in behavior. therefore, there needs to be an action or https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 273 regulation to minimize the occurrence of burnout itself. nurses in various countries have different levels of workload and responsibility. this difference can be influenced by the social, cultural, environmental and market orientation, and particularly regarding the patients themselves. although different, some research suggests that there are always nurses suffering from burnout. in one of the articles, it set forth that referring to the nurses in china, 71% work more than 8 hours a day for 2 months ahead of reaccreditation and as many as 44% experienced severe saturation level (guo et al., 2016). there are many effects related to the incidence of burnout syndrome that affect the nursing service. nursing discontent at work will be increased when it has triggered a decline in performance and an even higher turnover of nurses themselves. it is important to take actions to reduce the risk of the occurrence of events where burnout starts from. materials and methods we chose to focus on burnout syndrome as the topic. factually, this specific condition has been an unsolved problem in management nursing studies up until now. furthermore, we determined some of the keywords used to find the literature, namely burnout syndrome, nursing stress and nursing workload. qualified international journals were involved to provide some of the information including scopus, science direct, pro quest and sage with the articles having been published between 2014 and up to the 2019 with the topic of nursing and burnout as the limitations. the search found 8,666 articles and 363 articles that were duplicates were removed; 8,203 out of the 8,303 were excluded by screening both the titles and abstracts. we found 100 articles. we shortened the list again to 15 using the type of study and the location of the research. from the articles chosen, they were classified based on the type of research, the subject of the research and the correlation between the factors affecting burnout syndrome and the incident of burnout syndrome. the respondents were healthcare personnel consisting of doctors and the nurses from several departments. result study methods based on all of the research reviewed, the number of samples totaled 15,857 respondents. the respondents were mostly nurses and a small portion were doctors. the respondents from other professions were found in the study in order to find a relationship between the level of intelligence and the level of burnout (giorgi et al., 2016). the instruments used in these studies mostly consisted of the maslach burnout inventory instrument as a measurement tool for the burnout level of the respondents in 11 articles. following this, 4 articles used different instruments (cheng et al., 2015; fang, 2017; khamisa, peltzer, ilic, & oldenburg, 2017; kim & yeom, 2018b). all of the articles were descriptive cross-sectional studies. burnout level is closely related to external factors, especially the working environment (năstasă & fărcaş, 2015) and work pressure (lee & ji, 2018; mehrabian, baghizadeh, & alizadeh, 2018). high work pressure can cause stress and it can be used as an initial predictor of burnout (akman, ozturk, bektas, ayar, & armstrong, 2016). other external factors related to burnout are the factors of leadership and organizational trust towards the nurses and vice versa (nwafor, immanel, & obi-nwosu, 2015). burnout levels can increase when the nurses are face with problems outside of work. the burnout level risk increases when experiencing problems within the family and this can decrease the level of support from the family (fang, 2017). in some articles, the internal factors that affect burnout include job satisfaction. it is stated that if the nurses often fail or feel dissatisfied with the results that are carried out continuously, then they will be prone to burnout (akman et al., 2016; nwafor et al., 2015). the moral stress experienced by the nurses will also cause burnout (fumis, junqueira amarante, de fátima nascimento, & vieira junior, 2017). when the nurses experience burnout, either directly or indirectly, this will have an impact on the quality of service provided to the patients (cheng et al., 2015). broadly speaking, all of the articles analyzed have been summarized in the following table. outcomes based on some of the investigations about burnout syndrome in 15 journals, we found that there are 9 dominant factors that influence the creation of burnout syndrome. work environment this is recognized as the biggest factor that predisposes an individual to burnout syndrome. there were 2 research studies that explained about the relationship between the environment and the incidence of burnout syndrome by zang et al in 2013 and ernold et al in 2011. a positive work environment will reduce burnout syndrome. on the contrary, a negative work environment will increase the incidence of burnout syndrome. emotional intelligent intelligence is an absolute attribute for everyone to allow them to make good preparations to become a success in terms of survival in all aspects of their life. there is no exception for nurses in their work. intelligence is divided into different parts including emotional, social and spiritual. in the research journal by natasha et al in 2014, they sought to discuss the role of the influence of emotional intelligence toward burnout syndrome in health workers, especially those in the nursing field. from their study, it was found that a higher level of nursing emotional intelligence will make for an easier adaptation to accept pressure and their work burden. as a result, burnout syndrome risk can be avoided. r. t. ardiansyah et al. 274 | pissn: 1858-3598  eissn: 2502-5791 figure 1. flowchart of review process distress morality it cannot be denied that the nurse’s involve feelings and empathy in their work. this will appear when they see the patients in a painful condition, especially in an emergency and terminal condition. these cases can also be met in an intensive care unit or a high care unit. based on research that conducted by furnis et al (2017)(fumis et al., 2017) implies that ethical dilemmas are a big problem for the nurses who work at icu or hcu. the failure to save lives in critical and terminal conditions sometimes will result in the morality burden predisposing the nurse to burnout syndrome risk. nurse self-concept the nurse’s ability to recognize their self concept is very important. it is needed to face their hard daily duties and to cope with many patients problems with many different characteristics of their own. nwafor et al in 2015 conducted research related to the nurse’s self concept. his conclusion was that the better the nurse’s self concept, the more it will reduce the possibility of them suffering from burnout syndrome. personal and work stress burnout syndrome may also appear to come from personal stress and work stress. in 2016, khamisa et al researched into the co-relationships between personal stress and work stress when related to burnout syndrome. it is clearly that the results inform us that personal stress has more of an influence on burnout syndrome than work stress. nursing organization. the nursing organization has a strategic position to decrease the burnout syndrome risk. this institution improves the media for the peer group of the nurses to interact with each other starting at the local, regional, national and even international scale. some of the research studies identified that the higher the level of trust that the nurse has toward the role of their professional institution, the more this will minimize the burnout syndrome risk. empowerment and motivation of nurse. motivation and empowerment are needed to maintain good performance and spirit to do well in the nursing job. there are two studies that explain that motivation has an important role when it comes to inducing good work performance and reducing the incidence of burn out syndrome. furthermore, these studies also mentioned that a higher and stronger nurse motivation toward their duties will lower the possibility of them getting burnout syndrome. the role of the institutional leader. the role of the leader in a professional institution and organization is very important. every policy from the leader has the power to influence whether the organization is more conducive or not. it is a must to create good leaders to create a conducive work environment to minimize burnout syndrome. one study conducted in seoul south korea implied that there is correlation between the role of the leader and the incidence of burnout syndrome; better leaders will reduce the condition of burnout syndrome among the nurses. spiritual well-being. the spiritual well-being side means different things for each individual. this can be influenced by age where the level of burnout is higher when experienced by those of a younger age, of no specific gender and when concerning work experience where the nurses who work for under five years experience higher levels of burnout (kim & yeom, 2018a) discussion the causes of burnout can be broadly grouped into two, namely external and internal factors. external factors are the organizations or institutions where nurses work. workplace organizations if specified can cover the work environment, workload, relationships with their leaders, coworkers, trust in the system in the organization and vice versa. external factors dominate the occurrence of burnout significantly but the external factors are relatively more difficult to modify. for the workload, the nurses individually cannot change or modify these factors. the workload itself can cover the tasks that must be done concerning both the main tasks and any additional tasks that add to their working hours (fang, 2017). there must be authority and power in changing what has become a burden and the main task of a nurse. relationships in the work environment can involve both leaders with the nurses and between the nurses. a good leader will always provide reinforcement to their staff members, strengthening through motivation and giving assignments that are proportional and fair to all members. the research shows that empowering leaders have a negative correlation with burnout (guo et al., 2016). a fair assignment also avoids job stress. job stress itself is associated with the occurrence of burnout jurnal ners http://e-journal.unair.ac.id/jners | 275 (mehrabian et al., 2018)(wu et al., 2014). when the nurses experience a lot of division regarding their tasks, the possibility of the results being obtained will not be optimal. the results of the work not being optimal causes reduced job satisfaction. the job satisfaction figures can be influenced by a number of things, namely among them a sense of failure in carrying out the task as well as possible. this can also be caused by an imbalance between workloads and in the awards received by the nurses. low job satisfaction values can be related to an increase in the incidence of burnout (zhang et al., 2014), (khamisa et al., 2017). the next organizational factor is the relationship with their fellow colleagues, both between the nurses or between the nurses with other professionals. in one organization, there is a sense of fair competition, especially in certain scientific disciplines. the competition will be good if it occurs within certain limits. the competition will be negative if there are no rules governing the situation. competition like this can lead to mutual dropping and even intimidation can occur. this intimidation also causes the work atmosphere to become uncomfortable and this can cause effects in the form of burnout (giorgi et al., 2016). the external factors are the factors that can be controlled by the stakeholder in an organization. a good top manager will understand that burnout can affect the quality of the service providers' output. the quality of the output of a nurse's service is caring. so when the nurses experience burnout, it can be ascertained that this will affect the nature of caring concerning the recipient of the service, namely the patients (cheng et al., 2015). it would be ideal if the top manager continually evaluates the state of the organization, especially the work environment, so then there is not a high level of burnout. the top manager is also expected to be able to make dynamic policies regarding a conducive work environment. burnout can also be caused by internal factors. from the articles reviewed, it was found that burnout was negatively correlated with emotional intelligence (năstasă & fărcaş, 2015), self-concept (nwafor et al., 2015) and spiritual well-being (kim & yeom, 2018a). this means that the better the emotional intelligence, self-concept and spiritual well-being of the nurses, the lower the risk of burnout. in addition to these three factors, burnout is also correlated with moral distress but the relationship between them is positive. to minimize this risk factor internally, it can be said to be an individual responsibility. the top manager is only supportive and facilitates the policies produced. conclusion exhaustion and fatigue are common. this condition can generate burnout syndrome and it is the cause of the decreasing work performance of the nurse. based on some of the research studies, there are many factors related to burnout syndrome, namely the work the environment, emotional intelligence, moral distress, self concept, communication ability, massive work load, the role of the professional organization, the role of the leader and motivation and empowerment. from all of the factors above, the work environment and motivation were the dominant factors that influence the incidence of burnout syndrome among the nurses. it is a must to create a work environment that is more conducive and to keep up the internal motivation for the nurse to eliminate burnout syndrome. the study results show that spiritual intelligence strengthened the beliefs and personality of the nurses. references akman, o., ozturk, c., bektas, m., ayar, d., & armstrong, m. a. (2016). job satisfaction and burnout among paediatric nurses. journal of nursing management. https://doi.org/10.1111/jonm.12399 cheng, f., meng, a. f., & jin, t. (2015). correlation between burnout and professional value in chinese oncology nurses: a questionnaire survey. international journal of nursing sciences. https://doi.org/10.1016/j.ijnss.2015.04.004 fang, y.-x. (2017). burnout and work-family conflict among nurses during the preparation for reevaluation of a grade a tertiary hospital. chinese nursing research. https://doi.org/10.25164/cnr201701010 fumis, r. r. l., junqueira amarante, g. a., de fátima nascimento, a., & vieira junior, j. m. (2017). moral distress and its contribution to the development of burnout syndrome among critical care providers. annals of intensive care, 7(1). https://doi.org/10.1186/s13613-017-0293-2 giorgi, g., mancuso, s., fiz perez, f., castiello d’antonio, a., mucci, n., cupelli, v., & arcangeli, g. (2016). bullying among nurses and its relationship with burnout and organizational climate. international journal of nursing practice, 22(2), 160–168. https://doi.org/10.1111/ijn.12376 guo, j., chen, j., fu, j., ge, x., chen, m., & liu, y. (2016). structural empowerment, job stress and burnout of nurses in china. applied nursing research. https://doi.org/10.1016/j.apnr.2015.12.007 khamisa, n., peltzer, k., ilic, d., & oldenburg, b. (2017). effect of personal and work stress on burnout, job satisfaction and general health of hospital nurses in south africa. health sa gesondheid. https://doi.org/10.1016/j.hsag.2016.10.001 kim, h. s., & yeom, h. (2018a). care unit nurses : a descriptive study. intensive & critical care nursing. https://doi.org/10.1016/j.iccn.2017.11.005 kim, h. s., & yeom, h. a. (2018b). the association between spiritual well-being and burnout in intensive care unit nurses: a descriptive study. intensive and critical care nursing. https://doi.org/10.1016/j.iccn.2017.11.005 r. t. ardiansyah et al. 276 | pissn: 1858-3598  eissn: 2502-5791 lee, e. k., & ji, e. j. (2018). the moderating role of leader–member exchange in the relationships between emotional labor and burnout in clinical nurses. asian nursing research. https://doi.org/10.1016/j.anr.2018.02.002 mehrabian, f., baghizadeh, k., & alizadeh, i. (2018). the relationship between empowerment, occupational burnout, and job stress among nurses in rasht medical education centers: a dataset. data in brief. https://doi.org/10.1016/j.dib.2018.08.176 năstasă, l.-e., & fărcaş, a. d. (2015). the effect of emotional intelligence on burnout in healthcare professionals. procedia social and behavioral sciences, 187, 78–82. https://doi.org/10.1016/j.sbspro.2015.03.015 nwafor, c. e., immanel, e. u., & obi-nwosu, h. (2015). does nurses’ self-concept mediate the relationship between job satisfaction and burnout among nigerian nurses. international journal of africa nursing sciences. https://doi.org/10.1016/j.ijans.2015.08.003 wu, h., liu, l., sun, w., zhao, x., wang, j., & wang, l. (2014). factors related to burnout among chinese female hospital nurses: cross-sectional survey in liaoning province of china. journal of nursing management. https://doi.org/10.1111/jonm.12015 zhang, l., you, l., liu, k., zheng, j., fang, j., lu, m., … zhu, x. (2014). the association of chinese hospital work environment with nurse burnout , job satisfaction , and intention to leave. nursing outlook, 62(2), 128–137. https://doi.org/10.1016/j.outlook.2013.10.010 http://e-journal.unair.ac.id/jners | 171 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17015 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review lactobacillus sp as a probiotic for the prevention of clostridium difficile associated diarrhea ulfa nur rohmah, saskiyanti ari andini, hendrik prayitno luawo, waluyo and yulia indah permata sari faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: antibiotic treatment can disturb the resistance of the gastrointestinal flora to colonization. this may result in complications, the most serious of which is clostridium difficile associated diarrhea (cdad). the aim of this study was to determine the effectiveness of probiotics for the prevention of cdad. method: the databases used were scopus, proquest, cinahl, medline, pubmed and sciencedirect, limited to having been published in the last 5 years. a literature review followed the keyword search. the keywords used were probiotics, clostridium difficile, associated, diarrhea, randomized, control and trial using "and" and “or”. twelve trials with 5102 participants were included. eight trials reported a preventive effect for cdad using a mixture of 2 strains of lactobacillus, a mixture of 4 combination strains, a mixture of lactobacillus and saccharomyces or a mixture of bifidobacterium, lactobacillus and saccharomyces. result: our findings indicate that probiotics may prevent cdad. most probiotics contain a singular strain. the combination with lactobacillus sp was the most effective at preventing cdad. conclusion: in addition, 6 out of 8 trials had an in relation to preventing cdad containing lactobacillus sp. four studies said that there were some factors that meant that the probiotic could not reduce or prevent the cdad. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords lactobacillus sp; probiotic; clostridium difficile; diarrhea contact ulfa nur rohmah  ulfa.nur.rohmah2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: rohmah, u. n, andini, s.a, luawo, h.p, waluyo & permatasari, y.i. (2019). lactobacillus sp as a probiotic for the prevention of clostridium difficile associated diarrhea. jurnal ners, 14(3si), 171-176. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17015 introduction a healthy body normally has clostridium difficile (cd) bacteria in the intestine. clostridium difficile (cd) is a gram positive anaerobic bacterium. the use of antibiotics for an unknown period showed that clostridium difficile disrupts the colonic microbiata, so then the growth of clostridium difficile is faster and produces toxins a and b. this causes an increase in pseudomembrane colitis with fever and diarrhea (mizui et al., 2013). the major cause of antibiotic associated diarrhea in hospitals is clostridium difficile(li et al., 2018). according this study, the antibiotics used included clindamycin, cephalosporins and fluoroquinolones. the use of these antibiotics is not obligatory (squellati, 2018). administering antibiotics as a treatment can interfere with the colonization of the normal flora in the digestive tract, resulting in various symptoms and effects, especially diarrhea. this process results in clostridium difficile associated diarrhea (cdad)(li et al., 2018). patients who have a sustained clostridium difficile infection can contract antibiotic associated diarrhea (aad). it is also known that clostridium difficile associated diarrhea is a trend that is currently evident, with more than 500,000 people exposed to clostridium difficile. it may cause major death with inflammation in patients and around 10% will die (squellati, 2018). the centers for disease control and prevention (cdc) conducted a survey about clostridium difficile in an infection-focused program. there was 34 countries that used 10 sites and other countries showed that cdad has increased by 453.000 with 29.300 deaths (approach, 2017) https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). u. n. rohmah, et al. 172 | pissn: 1858-3598  eissn: 2502-5791 figure 1. prisma flow diagram the complexity of diarrhea generally establishes whether a physician will discontinue or change the antibiotics, and whether a stool specimen needs to be analyzed for the appearance of clostridium difficile toxins. other nosocomial infections, long hospital stays, medical care costs, and diagnostic procedures can make the patient at risk for developing aad (xie, li, wang, li, & chen, 2015). probiotics can potentially prevent the development of cdad and it can make the growth of the normal gastrointestinal flora increased and compensate for the negative microbiota effects of antibiotics. therefore, probiotics have been greatly used to medicate a variation of conditions influencing the gastrointestinal tract, including diarrhea, inflammatory bowel disease, irritable bowel syndrome, bacterial overgrowth and especially clostridium difficile infection (xie et al., 2015). probiotics also help to take down clostridium difficile colonization by adhering to the epithelial and mucosal membranes in the colon. but probiotics should not be taken in the icu, because some patients have an unsuitable reaction as they are already compromised due to the patient’s underlying condition (squellati, 2018). probiotics are becoming advanced, existing as capsules and dairy-based food supplements sold in health food stores, medicine stores and on the modern market. if probiotics are effective, then the incidence of clostridium difficile becomes reduced and adverse events decline, meaning that the cost that the hospital pays is lower. probiotics make an attractive choice for the prevention of clostridium difficile associated diarrhea (johnston et al., 2013). we were guided by systematically reviewing the literature to determine the effectiveness and safety of probiotics (any strain or dose) for the prevention of clostridium difficile associated diarrhea and looking at the wellbeing of patients who were also receiving antibiotics. materials and methods research design the systematic review was used to determine the effectiveness of probiotics for the prevention of cdad. the use of studies was limited to the latest research, namely for the last 5 years and using the preferred reporting items for systematic reviews and meta-analyzes (prisma) approach. search strategy the literature search was carried out focused on several databases such as scopus, proquest, cinahl, medline, pubmed and science direct. the literature review used the following keywords: probiotics, clostridium difficile, associated, diarrhea, randomized, control and trial, in addition to using "and" and the keywords rct, randomized control and trial using “or”. after a number of articles were obtained, the researcher then selected them again according to the specified inclusion and exclusion criteria. inclusion and exclusion criteria the desired articles were published from 2013 to 2018, and the age restriction was applied, focusing on the keywords in the search for matching articles. the design method searched for was rcts that compared interventions based on a variety of strains where a combination of probiotics and doses were eligible. we scanned the lists of identified articles to obtained additional trial articles. articles with samples that did not focus on humans but that used rats or mice, the discussion of articles outside of the probiotics of clostridium difficile associated diarrhea, articles with design methods that were not rct, as well as articles that were systematic reviews, narrative reviews, theses, books or chapters, abstracts and editorials issued in this study were not included according to our exclusion criteria. article searching process the searching of the articles was done using the keyword ‘surgical scrubs’, ‘scrubbing’ and ‘microorganisms’ in accordance with the picot method that was determined and we also used the boolean logic search method on the ebscho, science direct, springer link, scopus and proquest databases with a time limitation of 2012 2018. in the search process, 189 articles were found and 11 articles were in accordance with the inclusion criteria to be articles that are relevant from the databases (n= 2282): proquest: 1451 cinahl: 404 medline: 279 science direct: 70 scopus: 30 pubmed: 48 articles selected for title and abstract review (n=1129) articles eligible for review (n=12) articles selected for full text review (n=176) article duplicates removed (n= 1153) excluded and removed (n= 953) exluded (n=162) animal studies: 69 not relavant: 83 not rct: 5 no available data 3 noenglish 2 jurnal ners http://e-journal.unair.ac.id/jners | 173 explored further. the complete explanation can be seen in table 1. results study selection and characteristics the initial literature search returned 2282 articles (1451 from proquest, 404 from cinahl, 279 from medline, 70 from science direct, 30 from scopus, 48 from pubmed). after reviewing the abstracts for relevance and matching them with the inclusion criteria, 1129 articles were selected for fulltext review and the researcher excluded 953 by title and abstract. there were 176 full text reviews, and then the articles included 29 animal studies; 83 were not relevant, 5 were not rcts, 5 had no available data, and 2 were in a different language and they were thus excluded. finally, 12 articles were chosen to review that met the inclusion criteria (figure 1). the studies included were homogenous design studies. there were 12 studies that used a randomized control trial design (table 1). the 12 studies were published between 2013 and 2018. there were 5102 participants across all of the studies and the studies were heterogeneous, with between 32 and 2981 participants per trial with an average sample size of 425 per trial. the age of the participants in the studies ranged between 18 and 70 years. the average age was adult. there were 7 studies that reported on a combination of genuses and 5 studies didn’t report what they used. the probiotics which prevented cdad were from 4 major genuses. there was lactobacillus sp, bifidobacterium sp, streptococcus sp and saccharomyces sp. the probiotics used included from within the lactobacillus sp genus included lactobacillus casei, lactobacillus acidophilus (cul60, cul21, la-5, nfcm), lactobacillus paracasei (lpc-37), lactobacillus helveticus r005, lactobacillus rhamnosus r0011, lactobacillus bulgarius and lactobacillus casei shirota. the probiotics used that were bifidobacterium sp included bifidobacterium bifidium (cul20, w23), bifidobacterium lactis (cul34, bi-07, b1-04, bb-12), bifidobacterium breve, bifidobacterium longum and bifidobacterium infantis. the probiotics used that were streptococcus sp included streptococcus thermophiles and streptococcus boulardii. the probiotics used that were saccharomyces sp included saccharomyces boulardii and saccharomyces cncm i-745. duration of probiotics giving in this studies was varies, it about from 7 days to several weeks. the doses of the probiotics in the studies varied, and they ranged from a minimum of 1.0 x 107cfu to a maximum dose of 6×1010cfu. other preparations include 93 ml, 2 techsules, 250 mg, 100 gm (97ml) and 2 sachets. the duration of the probiotics and antibiotics varied. diarrhea was defined as consisting of 2 main variations, which were ≥ 3 loose stools in 24 h and ≥ 2 loose or watery stools per day. probiotics affecting clostridium defficile associated diarrhea a combination probiotic treatment was associated with significant clostridium defficile associated diarrhea on these studies. eight trials reported a preventive effect against cdad with a mixture of lactobacillus casei and lactobacillus paracasei cncm i-1518(alberda, marcushamer, hewer, journault, & demetrios kutsogiannis, 2018) and a mixture of 4 strains containing lactobacillus acidophilus ncfm, lactobacillus paracasei lpc-37, bifidobacterium lactis bi-07 and b. lactis bl-04(barker et al., 2017)(ouwehand et al., 2014). there was also a mixture of lactobacillus helveticus r0052, lactobacillus rhamnosus r0011(evans, salewski, christman, girard, & tompkins, 2016) and saccharomyces boulardii cncm i-745 (sb) (kabbani et al., 2017). vsl#3 contains a mixture of bifidobacterium breve, bifidobacterium longum, bifidobacterium infantis, lactobacillus acidophilus, lactobacillus plantarum, lactobacillus paracasei, lactobacillus delbrueckii sub.sp., bulgaricus, table 1 multi strain or single strain probiotic genus author lactobacillus sp bifidobacterium sp streptococcus sp saccharomyces sp multi strain single strain (alberda et al., 2018) √ √ (allen et al., 2013) √ √ √ (barker et al., 2017) √ √ √ (chatterjee et al., 2013) √ √ √ (ehrhardt et al., 2016) √ √ (evans et al., 2016) √√ √ (kabbani et al., 2017) √ √ (mallina et al., 2018) √ √ √ (ouwehand et al., 2014) √ √ √ (selinger et al., 2013) √ √ √ √ (shan et al., 2013) √ √ (wong et al., 2014) √ √ u. n. rohmah, et al. 174 | pissn: 1858-3598  eissn: 2502-5791 streptococcus thermophiles(selinger et al., 2013), saccharomyces boulardii(shan et al., 2013) and lactobacillus casei shirota(wong et al., 2014). six studies reported that lactobacillus sp was the most effective probiotic at preventing clostridium defficile associated diarrhea (barker et al., 2017)(barker et al., 2017), (evans et al., 2016), (kabbani et al., 2017), (ouwehand et al., 2014), (selinger et al., 2013). across the 4 trials, it was reported there was no important impact on clostridium defficile associated diarrhea when using a mixture of 2 strains, namely lactobacillus acidophilus (cul600 and cul21) and two strains of bifidobacterium (bifidobacterium bifidum cul20 and bifidobacterium lactis cul34) (allen et al., 2013). there was also a mixture examined consisting of lactobacillus acidophilus la-5 and bifidobacterium bb-12(chatterjee et al., 2013), saccharomyces boulardii(ehrhardt et al., 2016) and actimel containing lactobacillus casei, lactobacillus bulgaricus and streptococcus thermophiles (mallina et al., 2018). discussion the result of this review found that the age group most affected by cdad was adults (the youngest being 6 months through to old age in the study overall), although this was not statistically significant. one study stated that being of an age >18 years old may increase the risk by about 2% concerning being infected by clostiridium defficile in the health care setting. however, the level of infection was neither studied nor evaluated deeply. old age individuals are more susceptible to clostridium defficile infection because it is related to their humoral immune response (patel, wieczorkiewicz, & tuazon, 2016). in addition, cdad infection often happens at an old age where, in the health care setting, they have consumed broad spectrum antibiotic (allen et al., 2013). based on the review, the duration of consumed probiotics in the studies varied and it was between a minimum of 7 days to a maximum of several weeks. the other studies said that a short treatment duration (<8 weeks) may be more effective than a long duration (≥8 weeks) in reference to bowel inflammation. this is related to the quality of the patient’s life because longer term or even the continuous supplementation of probiotics may be required to detect significant alterations in the symptoms (zhang et al., 2016). we found 4 journals that said that probiotics cannot reduce cdad. this was found because ineffective probiotic results were related to the limitations of the trial. for example, probiotics that were not according to a doctor’s recommended dosage. there were some patients who had not only received probiotics but they had also received a high dosage of antibiotics so the probiotics given at the time no longer have an effect (box, ortwine, & goicoechea, 2016). another thing to consider is that the number of study participants was 80.5% for those not eligible and the patients who were eligible may have been relatively healthy. one must consider a different design for the trial to get better results (ehrhardt et al., 2016). on the other hand, our review showed that the probiotics that can reduce cdad were from 4 different genuses. these were lactobacillus, bifidobacterium, streptococcus and saccharomyces. it also was explained by johnston and colleagues. their systematic review consisted of 20 rcts with 3818 patients to determine if probiotics are effective at preventing cdad. they found evidence that shows that probiotics reduce the chance of cdad to a large extent, with only a small percentage of adverse reactions. the probiotics used were bifidobacterium, lactobacillus, saccharomyces, and streptococcus(johnston et al., 2013). it was explained that probiotics are the most effective if given closer to the first antibiotic dose, with a decrement in efficacy for every day of delay in starting probiotics (shan et al., 2013). probiotics bifidobacterium, lactobacillus, saccharomyces, and streptococcus may have effects that can be attributed to its actions on intestinal immunity. they may improve the number of iga and other immunoglobulin secreting cells in the intestinal mucosa and it can also stimulate the local release of interferons. it could also function through the advancing of the barrier function, immunomodulation, and competitive adherence to the intestinal mucosa by avoiding or ameliorating various infective or inflammatory diseases (chatterjee et al., 2013). on the other hand, this review has shown that lactobacillus is a great species determinant for the prevention of cdad. for example, lactobacillus casei becomes practical when it is flavored. it was shown by alberda teams (alberda et al., 2018) said that 32 participants in trial. aad was documented in 12.5% of the probiotic lactobacillus casei drink group and 31.3% in the control group. most of the studies stated that probiotics were more effective against bacterial diarrhea. for instance, when the efficacy of lactobacillus gg was analyzed in a meta-analysis, as for separate etiologies, it was evident that this probiotic was most effective for rotavirus diarrhea(guandalini, 2011). one trial said that lactobacillus sp strains have been shown to survive passage through the gastrointestinal tract when healthy volunteers were given eubacteriaceae, causing diarrhea. in in-vitro studies, these strains have shown the ability to adhere to human epithelial cells, to maintain the gut barrier and to stimulate an anti-inflammatory response, in addition to blocking pathogen adhesion. it is feasible that these mechanisms have a role in reducing the duration of diarrhea events (evans et al., 2016). lactobacillus can also reduce cdad according to ouwehand et al. as seen in a trial. their result showed there to be a significant dose response effect in cdad with an incidence of 12.5, 19.6, and 24.6 with the high dose, low dose and placebo (p=0.02). they said that abdominal pain was reduced only in the high-dose jurnal ners http://e-journal.unair.ac.id/jners | 175 group, focusing on the diarrhea cases. only the lowdose group showed a trend for reduced abdominal pain. this reduction in pain is interesting, as l. acidophilus ncfm, one probiotic out of the components in the tested preparation shown earlier, was shown been able to increase the pain threshold in rats by inducing the expression of the µ opioid and canabinoid 2 receptor numbers. both the average of the liquid stools and the average duration of the diarrhea were significantly reduced by both the high and low doses compared to the placebo (ouwehand et al., 2014). the other study said that the average of the probiotics containing lactobacillus sp. had a preventive effect on cdad, with a pooled relative risk reduction of 75 (sinclair, xie, saab, & dendukuri, 2016). the limitation in this study was that statistical evidence was not provided to support the recommendations for the routine using of microbial preparations for cdad prevention. the most effective probiotics preparations or probiotic forms to prevent cdad still need to be investigated. conclusion this systematic review was used to determine the effectiveness of probiotics at preventing cdad. our findings indicate that probiotics may prevent cdad. most probiotics contain a singular strain, but it was the one that was in combination with lactobacillus sp that was the most effective at preventing cdad. in total, 6 out of 8 trials showed as having an effective effect when it comes to preventing cdad containing lactobacillus sp. four studies said that there were some factors that meant that the probiotic cannot reduce or prevent cdad: this includes giving probiotics that are not according to the doctor’s recommended dosage and not only consuming the probiotic but also high dosages of antibiotics. nursing implication the results of the review of many studies can be implicated in providing help to prevent cdad through the use of probiotics. the nurses can provide an intervention and structured management education for the patients in hospital or in a home care setting about using the right antibiotic, using probiotics and creating a comfortable and clean environment in both a hospital and home care setting. references alberda, c., marcushamer, s., hewer, t., journault, n., & demetrios kutsogiannis. (2018). feasibility of a lactobacillus casei drink in the intensive care unit for prevention of antibiotic associated diarrhea and clostridium difficile. https://doi.org/10.3390/nu10050539 allen, s. j., wareham, k., wang, d., bradley, c., hutchings, h., harris, w., … mack, d. (2013). lactobacilli and bifi dobacteria in the prevention of antibiotic-associated diarrhoea and clostridium diffi cile diarrhoea in older inpatients ( placide ): a randomised , double-blind , placebo-controlled , multicentre trial. the lancet, 6736(cdd), 1–9. https://doi.org/10.1016/s0140-6736(13)612180 approach, e. (2017). clinical update. 13(4), 238–241. barker, a. k., duster, m., valentine, s., hess, t., archbald-pannone, l., & guerrant, r. (2017). a randomized controlled trial of probiotics for clostridium difficile infection in adults ( pico ). (august), 3177–3180. https://doi.org/10.1093/jac/dkx254 box, m. j., ortwine, k. n., & goicoechea, m. (2016). no impact of probiotics to reduce clostridium difficile infection in hospitalized patients : a real-world experience. (table 1), 9–11. https://doi.org/10.1093/ofid/ofy192 chatterjee, s., kar, p., das, t., ray, s., ganguly, s., rajendiran, c., & mitra, m. (2013). randomised placebo-controlled double blind multicentric trial on efficacy and safety of lactobacillus acidophilus la-5 ® and bifidobacterium bb-12 ® for prevention of antibiotic-associated diarrhoea. 61(october), 708–712. ehrhardt, s., guo, n., hinz, r., schoppen, s., may, j., reiser, m., … lohse, a. w. (2016). saccharomyces boulardii to prevent antibiotic-associated diarrhea: a randomized, double-masked, placebocontrolled tria. 1–7. https://doi.org/10.1093/ofid/ofw011 evans, m., salewski, r. p., christman, m. c., girard, s., & tompkins, t. a. (2016). effectiveness of lactobacillus helveticus and lactobacillus rhamnosus for the management of antibioticassociated diarrhoea in healthy adults : a randomised , double-blind , placebo-controlled trial. 94–103. https://doi.org/10.1017/s0007114516001665 guandalini, s. (2011). probiotics for prevention and treatment of diarrhea. 45(december), 149–153. johnston, b. c., stephanie s.y. ma, m., z, j., goldenberg, bs., kristian thorlund, p., per o. vandvik, md, p., … gordon h. guyatt, m. (2013). review annals of internal medicine probiotics for the prevention of clostridium difficile – associated. (20). kabbani, t. a., pallav, k., dowd, s. e., villafuertegalvez, j., vanga, r. r., castillo, n. e., … kelly, c. p. (2017). prospective randomized controlled study on the effects of saccharomyces boulardii cncm i745 and amoxicillin-clavulanate or the combination on the gut microbiota of healthy volunteers. 0976. https://doi.org/10.1080/19490976.2016.12678 90 li, n., zheng, b., cai, h., chen, y., qiu, m., liu, m., … mb, l. (2018). accepted manuscript. https://doi.org/10.1016/j.jhin.2018.04.013 mallina, r., frcs, j. c., frcs, n. b., ahluwalia, v., frcp, j. c., & frcs, a. g. c. (2018). journal of infection and public health probiotic containing lactobacillus u. n. rohmah, et al. 176 | pissn: 1858-3598  eissn: 2502-5791 casei , lactobacillus bulgaricus , and streptococcus thermophiles ( actimel ) for the prevention of clostridium difficile associated diarrhoea in the elderly with proximal femur fractures. journal of infection and public health, 11(1), 85–88. https://doi.org/10.1016/j.jiph.2017.04.001 mizui, t., teramachi, h., tachi, t., tamura, k., shiga, h., komada, n., … aoyama, s. (2013). risk factors for clostridium difficile -associated diarrhea and the effectiveness of prophylactic probiotic therapy. 68. https://doi.org/10.1691/ph.2013.3552 ouwehand, a. c., donglian, c., weijian, x., stewart, m., ni, j., stewart, t., & miller, l. e. (2014). probiotics reduce symptoms of antibiotic use in a hospital setting : a randomized dose response study. vaccine, 32(4), 458–463. https://doi.org/10.1016/j.vaccine.2013.11.053 patel, u. c., wieczorkiewicz, j. t., & tuazon, j. (2016). journal of clinical gerontology & geriatrics evaluation of advanced age as a risk factor for severe clostridium dif fi cile infection. journal of clinical gerontology & geriatics, 7(1), 12–16. https://doi.org/10.1016/j.jcgg.2015.06.003 selinger, c. p., bell, a., cairns, a., lockett, m., sebastian, s., & haslam, n. (2013). probiotic vsl # 3 prevents antibiotic-associated diarrhoea in a double-blind , randomized , placebocontrolled clinical trial. journal of hospital infection, 84(2), 159–165. https://doi.org/10.1016/j.jhin.2013.02.019 shan, l., hou, p., wang, z., liu, f., chen, n., shu, l., … shang, y. (2013). prevention and treatment of diarrhoea with saccharomyces boulardii in children with acute lower respiratory tract infections. 4(december), 329–334. https://doi.org/10.3920/bm2013.0008 sinclair, a., xie, x., saab, l., & dendukuri, n. (2016). lactobacillus probiotics in the prevention of diarrhea associated with clostridium difficile: a systematic review and bayesian hierarchical metaanalysis. 4(4), 706–714. https://doi.org/10.9778/cmajo.20160087 squellati, r. (2018). e v i d e n c e b a s e d pr a c t i c e i n t he tre atm en t f o r antibiotic-associated diarrhea in the i ntensive care unit. 30, 87–99. https://doi.org/10.1016/j.cnc.2017.10.008 wong, s., jamous, a., driscoll, j. o., sekhar, r., weldon, m., yau, c. y., … forbes, a. (2014). a lactobacillus casei shirota probiotic drink reduces antibioticassociated diarrhoea in patients with spinal cord injuries : a randomised controlled trial british journal of nutrition. 672–678. https://doi.org/10.1017/s0007114513002973 xie, c., li, j., wang, k., li, q., & chen, d. (2015). sciencedirect probiotics for the prevention of antibioticassociated diarrhoea in older patients : a systematic review. travel medicine and infectious disease, 1–7. https://doi.org/10.1016/j.tmaid.2015.03.001 zhang, y., li, l., guo, c., mu, d., feng, b., zuo, x., & li, y. (2016). effects of probiotic type , dose and treatment duration on irritable bowel syndrome diagnosed by rome iii criteria : a. bmc gastroenterology, 1–11. https://doi.org/10.1186/s12876-016-0470-z http://e-journal.unair.ac.id/jners | 63 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18931 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors related to the utilization of the integrated health services center for the elderly sunik cahyawati1, windarti rumaolat1,2, nur sayid jalaludin rumi2 and wiwi rumaolat1 1 stikes maluku husada, indonesia 2 faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the health service center for elderly is a public health center program for the elderly so they can be are ready to face old age independently and healthy. the objective of the research was to find out if there was a relationship between the use of health services centers for the elderly and attitudes, family support, the role of cadres, and access distance to health services for elderly people. methods: the method used was quantitative with a cross-sectional design; the sample contained 121 respondents, elderly people aged over 60 , the study time was 4 weeks. the instrument used was a questionnaire. the variables were elderly people’s attitudes, cadre roles, family support and the distance to the health service. the analysis was done using chisquare with a significant p-value (α <0,05). results: the study obtained a significant relationship between the attitudes of the elderly p-value (0.001), family support p-value (0.00), the role of cadre p-value (0.00) and the use of the elderly health services center while the distance to the integrated health center was not significantly related p-value (0.513). conclusion: family support and the role of cadres is needed to support the interests and readiness of the elderly in building a positive attitude for the integrated health center, to the distance to the health services is not a problem. there is a relationship between the attitudes of the elderly, family support, the role of cadres to the use of elderly health services center while there is no relationship between the distance to access the health services center and the use of elderly. article history received: feb 27, 2020 accepted: april 1, 2020 keywords elderly; utilization; attitudes; cadre; family; health contact sunik cahyawati  sunikcahyawati87@gmail.com  stikes maluku husada, indonesia cite this as: cahyawati, s., rumaolat, w., rumi, n. s. j., & rumaolat, w. (2020). factors related to the utilization of the integrated health services center for the elderly. jurnal ners, special issues, 63-66. doi:http://dx.doi.org/10.20473/jn.v15i2.18931 introduction the development of science and technology has a positive impact on welfare and health, one of which can be seen from the level of life expectancy. add advanced age in the world. (purwadi et al., 2016). the united nations (un) estimates that the number of people ≥60 years will increase from 901 million in 2015 to 1.4 billion in 2030 globally, increasing by more than 56% in 15 years. an estimated 71% increase in the elderly population will occur in developing countries(guerra et al., 2015). indonesia, with the 4th largest population in the world of around 258 million in 2015, also faces the challenge of a rapidly increasing elderly population. the number of elderly increased by around 4.12 million from 2000 to 2015, because life expectancy in indonesia has increased from 67.25 to 70.8 years in the same period. with an increase in life expectancy and a decrease in fertility, it is expected that the rate at which contributions will age will also increase. by 2025, it is estimated that 11.8% of the population will be ≥60 years (madyaningrum et al., 2018) the increasing number of elderly people needs to be anticipated because it will have broad implications in the lives of families, communities, and countries. a https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. s. cahyawati et al. 64 | pissn: 1858-3598  eissn: 2502-5791 study showed that the elderly tend to have lower health status, more cases of comorbidity and polypharmacy (hajek et al., 2017). therefore, the elderly need to get attention in national development. it is necessary to improve the type and quality of health and nursing services, whether carried out by the elderly themselves or by their families or other institutions, one of which is the services of the elderly health services center, a forum for activities from the community and for communities supported by crosssectoral cooperation. the public health center provides support and technical guidance. the activities here especially in the area include preventive, promotive, curative and rehabilitative activities for the elderly (purwadi et al., 2016) . however, in reality, there are still many problems related to the low utilization of the elderly health services center by the elderly. this is because there are several factors including knowledge, the distance of the house from the location of the health services center, family support, facilities and infrastructure to support the implementation of the health service center, attitudes and behavior of the elderly, income, support from health workers (yang et al., 2014). from the observations in the field, researchers also found several factors related to the use of health services center for elderly people, namely: the attitude factor where the attitudes of elderly people who did not participate in elderly health service center activities were reminded of some health services center cadres when they did not go to a health services center; the role of the health professionnals as some are also not active in conducting health services at the center for the elderly or too lazy to call the elderly, while the encouragement factor of the family where elderly families do not participate in encouraging the elderly to go to the health services center for the elderly and also sending them to the health services center for the elderly because they are busy; the distance to access the health services center is also a factor when the health services center is located in the middle of the country settlement in front of the road and the distance that can be reached ≥ 1km for those who have a house far from the health services center location while having a house close to the health services center can be located in travel with a distance of ≤ 1 km. the data above shows that many elderly people do not visit the health services center. previous studies found a relationship between the attitude of the use of elderly health services center, family encouragement and the use of elderly health services center, and the role of the staff with the use of elderly health services center. the researchers were interested in exploring "factors associated with the utilization of elderly health services center in the elderly work area. materials and methods this research is quantitative with a cross-sectional approach, which is research that emphasizes the observational time of the independent and dependent variables only once at a time. this research was conducted for 4 weeks from 22 july to 17 august 2019 at the health services center elderly. the sampling technique used purposive sampling and the sample had 121 respondents. the inclusion criteria were elderly aged > 60 and above, the elderly who were present at the time of the study and were willing to become respondents. data collection techniques collected two types of data: primary data obtained directly from the elderly through questionnaires to find out the factors associated with the utilization of the health services center, and secondary data obtained from the records and reports to determine the number of elderly health services center registered. data processing: the analysis used is univariate and bivariate using chi-square statistical tests with significance (α = 0.05). results characteristics of the respondents the 121 respondents, elderly who visited the elderly lahahealth services center in the tawiripublic health tabel. 1 characteristics of the respondents (n=121) variable (n) (%) age 61-65 66-70 >70 61 53 7 50,4 43,8 5,8 gender male female 51 70 42,1 57,9 level of education primary school junior high school senior high school scholar 49 45 20 7 40,5 37,2 16,5 5,8 job retired entrepreneur housewife farmer fisherman 21 27 11 41 21 17,4 22,3 9,1 33,9 17,4 primary data source in 2019 tabel. 2 univariate analysis variable n (%) utilization good 49 40.5 poor 72 59.5 attitude good poor 63 58 52,1 47,9 family support good poor 47 74 38,8 61,2 the role of the staff good poor 62 59 51,2 48,8 distance to access easy difficult 71 50 58,7 41,3 primary data source in 2019 jurnal ners http://e-journal.unair.ac.id/jners | 65 center working area had the following characteristics. univariate analysis the univariate analysis conducted on the research variables will produce the frequency distribution and the percentage of each variable as follows. bivariate analysis the bivariate analysis is performed to determine whether there is a relationship between the dependent variable and the independent variable. discussion attitude is someone's readiness to act in certain situations. the attitude of the elderly is a form of their response to the use of the elderly health services center which includes several stages, namely, receiving responding, respecting and being responsible. the results of the study showed that the attitude of the elderly is still quite good and there is a relationship between the attitudes of the elderly towards the use of the elderly health services center . (notoatmodjo, 2012) according to the researchers' assumptions, a poorer attitude of the elderly, the less elderly they use the health services center compared to the elderly who behave well the elderly who have a bad attitude have a tendency to act not to use the health services center while the elderly who behave well have a high tendency to use the health services center. a behavior that cannot be directly seen is the readiness or willingness of the elderly to carry out health services center activities. personal assessment or good attitude towards the staff is the basis or readiness of the elderly to participate in health services center activities. while the elderly who has a good attitude in utilizing the health services center, indirectly the target of achieving the use of the elderly health services center is getting higher. (notoatmodjo, 2013) family support empowers the elderly to carry out activities. it also can increase the desire to know and use something that is still considered new or things that are rarely done by the elderly (yang et al., 2014). family support plays an important role in encouraging the interest or willingness of the elderly to participate in health services center for the elderly. the family can be a strong motivator if they always take the time to accompany or bring the elderly to the health services center, remind the elder if he forgets, schedule and try to help overcome all the problems.(setyorini, 2018) based on the results of the research, family support is closely related to the use of health service center because a better family support for the elderly means better use of health service center for the elderly and vice versa. family support has a great influence on the lives of the elderly. elders need support, motivation to feel cared for, valued, and loved by those closest to them. family support is interpreted to help them face an unpleasant situation in life. because they feel they have family support, emotionally elderly feel cared for, get advice or a pleasant impression on him and the behavior of an activity or activities that can be observed or not. (handayani & wahyuni, 2012). based on the above, we recommend elderly people’s families to always be given counseling about the benefits of the elderly health services center; the aim is to provide information to support parents in utilizing the elderly health services center. the staff are members of the community chosen from and by the community, willing and able to work together as volunteers sharing community activities. health staff are responsible for the local community, they work and act as an agent of the health system. they are responsible for the village head and supervisors appointed by government officials or service personnel. the presence of elderly cadres plays a very important role in utilizing the elderly health service center. if the cadres' attitudes and behavior are good, they will get a good assessment tabel. 3 bivariate analysis utilization of health services center independent variable poorly good total sig n % n % n % attitude p = 0,001 poor 44 36,4 14 11,6 58 47,9 good 30 24,8 33 27,3 63 52,1 total 74 61,2 47 38,8 121 100 family support p = 0.000 poor 64 52,9 10 8,3 74 61,2 good 10 8,3 37 30,6 47 38,8 total 74 61,2 47 38,8 121 100 the role of the staff p = 0.000 poor 51 42,1 8 6,6 59 48,8 good 23 19,0 39 32,2 62 51,2 total 74 61,2 47 38,8 121 100 distance to access p = 0.513 difficult 31 25,6 19 15,7 50 41,3 easy 43 35,5 28 23,1 71 58,7 total 74 61,2 47 38,8 121 100 primary data source in 2019 s. cahyawati et al. 66 | pissn: 1858-3598  eissn: 2502-5791 from the health service center participants (santjaka et al., 2013). access to a nearby health services center will make it easy for the elderly to come without having to experience physical fatigue due to decreased endurance or physical strength. the body that states it is easy but less active is caused by their physical condition, less supportive of visiting the health services center and the attitudes of the elderly who prefer to check their health at the health center and the hospital because they think the facilities are more adequate. based on the results of the research, distance to the health services center is not related to the use of the health services center (notoatmodjo.2005). according to the researchers' assumptions, network access is not related to the use of health services center for the elderly because access to the health services center is not difficult and transportation costs are cheap. when investigating the research questions about the reasons why elderly are too lazy to go to the health services center because, the reason is they tire easily. as a person grows older, his bodily functions will be reduced. but based on the analysis, the biggest obstacle is the poor attitude of the elderly, the absence of the family to take the elderly. a good use of health services center can also affect the elderly in utilizing health services center even though the distance between health services center and the respondent is short but the attitude of the elderly is not good in utilizing the place.(rusmin et al., 2017) conclusion the variables related to the utilization of the health services center for the elderly were the attitude, family support and the role of the health services center cadre, while there was no relationship to the distance to the elderly health services center. empowering the cadre to conduct training ionn increasing knowledge about the management of the elderly health services center. it is necessary to motivate health workers to provide information to the elderly who visit health facilities and their families about the benefits of the center. conflict of interest there is no conflict of interest. acknowledgement the author would like to thank the elderly for being willing to be respondents in this study, the leadership of the public health center laha who has allowed the author to conduct the research and also to colleagues who have helped in the research process. references guerra, m. l., singh, p. j., & taylor, n. f. (2015). early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. clinical rehabilitation, 29(9), 844–854. https://doi.org/10.1177/0269215514558641 hajek, a., bock, j. o., & könig, h. h. (2017). which factors affect health care use among older germans? results of the german ageing survey. bmc health services research, 17(1), 1–9. https://doi.org/10.1186/s12913-017-1982-0 handayani, d., & wahyuni, . (2012). hubungan dukungan keluarga dengan kepatuhan lansia dalam mengikuti posyandu lansia di posyandu lansia jetis desa krajan kecamatan weru kabupaten sukoharjo. gaster | jurnal ilmu kesehatan, 9(1), 49–58. http://jurnal.stikesaisyiyah.ac.id/index.php/gaster/article/view/32 madyaningrum, e., chuang, y. c., & chuang, k. y. (2018). factors associated with the use of outpatient services among the elderly in indonesia. bmc health services research, 18(1), 707. https://doi.org/10.1186/s12913-018-3512-0 notoatmodjo, (2012). s. public health, science and art. jakarta: health research methodology, jakarta: rineka cipta notoatmojo. (2013). health promotion and health behavior. jakarta: rineka cipta notoatmodjo (2005) health promotion theory and application. jakarta: rineka cipta. purwadi, h., hadi, h., & hasan, m. n. (2016). faktor yang mempengaruhi pemanfaatan posyandu lansia di imogiri kabupaten bantul. jurnal ners dan kebidanan indonesia, 1(3), 76. https://doi.org/10.21927/jnki.2013.1(3).76-81 rusmin, m., bujawati, e., & habiba, n. (2017). faktor faktor yang berhubungan dengan pemanfaatan posyandu lansia di wilayah kerja puskesmas somba opu kabupaten gowa tahun 2015. al-sihah public health journal, 9(1), 9–18. santjaka, h. i., walin, & handayani, r. (2013). proses menua. bidan prada: jurnal ilmu kebidanan, 4(1), 1. setyorini, a. (2018). hubungan self efficacy dengan self care management lansia yang menderita hipertensi di posyandu lansia padukuhan panggang iii binaan puskesmas panggang i gunungkidul. health sciences and pharmacy journal, 2(2), 58. https://doi.org/10.32504/hspj.v2i2.29 yang, f.-f., dengan pemanfaatan, b., sapta, d., stikes, a., & pekanbaru, p. n. (2014). the factors that deals with the utilization. an.nada, 1(2), 42–47. 99 model asuhan keperawatan berbasis knowledge management meningkatkan kepatuhan pasien dalam pengobatan tuberkulosis (knowledge-management-based-nursing care model improves patient adherence to tuberculosis treatment) ninuk dian k*, abu bakar*, eka m.mhas*, elida ulfiana*, erna dwi w*, laily hidayati*, hanik endang n*, retnayu pradanie*, kristiawati* *faculty of nursing universitas airlangga email: ndian.k@gmail.com abstrak pendahuluan. tb paru tetap menonjol sebagai salah satu masalah kesehatan masyarakat di dunia. pasien non-kepatuhan terhadap pengobatan merupakan kontributor yang signifikan untuk resistensi obat. penelitian ini bertujuan untuk mengembangkan dan menguji keampuhan model asuhan keperawatan untuk mencegah non-kepatuhan. metode penelitian ini terdiri dari dua tahap: tahap satu, pengembangan model, menggunakan analisis deskriptif, dan tahap dua, pengujian model, menggunakan desain kuasi-eksperimental. peserta, terdiri kedua pasien dan perawat di dua pusat kesehatan di surabaya, direkrut oleh consecutive sampling. data dikumpulkan melalui wawancara, dikelola sendiri-kuesioner, check-list dan diskusi kelompok terfokus. analisis data dilakukan dengan menggunakan kedua kuadrat terkecil parsial dan uji wilcoxon. hasil. model secara statistik efektif untuk meningkatkan hampir semua aspek kepatuhan pasien terhadap pengobatan tb (pengetahuan, disiplin dalam mengambil obat keteraturan kontrol, dan kemampuan untuk memantau hasil pengobatan dengan p <0,05), kecuali untuk kemampuan untuk mengatasi obat yang merugikan efek (p=1.000). hal ini dimungkinkan karena jarang melakukan pasien sadar akan efek samping obat, sehingga pengalaman mereka mungkin terbatas. diskusi. penelitian ini menyimpulkan bahwa model asuhan keperawatan km terbukti efektif untuk meningkatkan kepatuhan pasien terhadap pengobatan. studi di masa depan disarankan untuk mengevaluasi dampak dari model asuhan keperawatan km dalam populasi yang lebih besar. kata kunci: tuberkulosis paru, kepatuhan pasien, model pelayanan keperawatan, manajemen pengetahuan. abstract introduction. pulmonary tuberculosis remains prominent as one of public health problems in the world. patients’ non compliance to treatment is a significant contributor to drug resistance. this study aimed to develop and to test the efficacy of a nursing care model to prevent non-compliance. method this study consisted of two phases: phase one, model development, used a descriptive analytic, and phase two, model testing, employed a quasi-experimental design. participants, comprised both patients and nurses at two health care centres in surabaya, were recruited by consecutive sampling. data were collected by interview, self-administered-questionnaires, check-list and focused group discussion. data analyses were performed using both partial least squares and wilcoxon signed rank test. results. the model was statistically effective to improve nearly all aspects of patients’ compliance to tb treatment (knowledge, discipline in taking medications regularity of controls, and abilities to monitor the results of treatment with p < 0.05), except for abilities to cope with drug adverse effects (p = 1.000). this is possible because seldom do patients aware of the medication side effects, so their experiences were probably limited. conclusion. this study concludes that the km nursing care model was proven effective to improve patients’ adherence to treatment. future study is suggested to evaluate the impact of the km nursing care model in bigger population. keywords: pulmonary tuberculosis, patient compliance, nursing care model, knowledge management. ____________________________________________________________________________________________________ introduction tuberculosis (tb), primary a lung infection caused by mycobacterium tuberculosis, remains one of the most prominent public health worldwide. patients’ compliance to treatment is central to deter the disease from drug resistant. generally patients’ compliance is related to their psychological, perception, and motivational state. non-compliance behaviour was proven as the main contributor to the increase of multi drug resistant tb (mdr tb) cases. the world health organisation (who 2013) reports that in 2012 the total incidence of tb is about 8.6 million cases, and 1.3 million people have died from the disease. globally indonesia is ranked fourth as the most tb-burdened country (who 2013). the tb prevalence is around 730 thousand cases with the prevalence rate of 297 per 10.000 (who 2013). most of the cases are highly concentrated in jurnal ners vol. 11 no. 1 april 2016: 99-105 100 java, in which east java as the second-most burdened province from tb after west java province. surabaya, the capital city of east java, was reported to have the most prevalence among other regions in the province. that non-compliance to treatment behaviour is significant to the success of tb eradication, new nursing care model development is necessary. this article aims to report one of the developed nursing care model that is proven significant to improve patients’ adherence to pulmonary tuberculosis treatment. method study comprised of two phases, the first phase aimed to develop a model while the second phase was conducted to test the efficacy of the model. the design used in the first phase of the study was a descriptive approach that explored contributing factors to nursing care model for pulmonary tb patients in two health care centres (pusat kesehatan masyarakat = puskesmas) in surabaya. the model was developed through interviews with tb patients and community nurse, a focused group discussion and a discussion with tb expert. the data gained from the aforementioned activities were used to develop a nursing care model based on knowledge management. the developed model was then applied to patients using a quasi-experimental design of one group pre-post intervention test in the second phase of the study. this study involved tb patients who were select consecutively at two of the available primary-public health services in surabaya, and nurses who worked as the chair of tb programs at the two puskesmas. the data were collected in three months, and from 29 tb patients and 2 nurses. medical records of the patients were also accessed as supporting evidence for analysis. more than 50% of the respondents were male; mostly (76%) came from javanese background of culture where about 62% of them have monthly salary less than us$ 200. about 62% of the respondents were new patients and diagnosed with tb less than 6 months. the main mode of transport that was used by them were moped (83%). the most of respondents lived within the range of less than 5 kilometres away from the nearest puskesmas. all of nurses participated in the study were females, graduated from nursing academy and currently worked as managers of tb program for more than three years. their ages were mostly older than 40 years. nevertheless, none of the puskesmas known to have any nursing care standard for tb patients, partly because the nurses did not have the requirement to document the given care. given the two puskesmas have provided the standard to care for tb patients, the nurses’ knowledge about caring patients was 100% thorough. all of the controlled variable were analysed using partial least square, while patients’ adherence was measured using wilcoxon signed rank test and mann whitney u test with significant level of p<0,05. the ethical clearance of this study was obtained from the ethical committee at the faculty of public health universitas airlangga. ethical issues anticipated in this study were beneficence, justice, and humanity. result data obtained from questionnaires shows that nurses’ knowledge about knowledge management nursing care model were above average scores (>75%), except in the assessment. table 1 shows that 50% of nurse respondents already knew which patients’ capacity that is required to be evaluated, as to determine whether they have any tendency to comply with tb management. however, the nurses’ performance in preventing patients’ non-adherence behaviour were varied (table 2). in the aspect of assessment internalisation, most nurses (97%) were in average score. however, the nurses scored better in diagnosing, planning, and implementing care. however, most nurses reached good scores in three aspects, including socialisation (83%), combination (100%) and internalization (97%). instead, almost none of the nurses did proper phase in socialisation with patients (07%). the knowledge management based nursing care model intervention does impact patients’ adherence in taking tb medications (table 3). this nursing care model specifically improves patients’ knowledge (table 4), discipline in taking medicine (table 5), ability in countering the adverse effect of the medication (see table 6), and the ability in monitoring the medication results (see table 7). model asuhan keperawatan berbasis knowledge management (ninuk d.k,dkk.) 101 table 1. nurses’ knowledge about knowledge-management based nursing care model no nurses’ knowledge assessment knowledge level know (%) do not know (%) 1 first step in nursing care process 100 0 2 nursing care standard: assessment 75 25 3 assessment toward factors interfering patients’ adherence 100 0 4 patients capacity that affects adherence to treatment 50 50 5 assessment toward patients’ adherence indicators 100 0 6 defining assessment priority at the initial process with patients 50 50 7 nursing diagnosis components 75 25 8 intervention to improve patients’ adherence 100 0 table 2. nursing care performance before the implementation of knowledge management-based nursing care model no evaluated aspects knowledge management components category good (%) fair (%) poor (%) 1 assessment socialisation 0 38 62 externalization 66 34 0 combination 66 34 0 internalization 0 97 3 2 nursing diagnosis socialisation 0 97 3 externalization 69 0 31 combination 97 0 3 internalization 17 0 83 3 planning socialisation 7 93 0 externalization 72 28 0 combination 72 28 0 internalization 10 90 0 4 intervention implementation socialisation 0 97 3 externalization 0 83 17 combination 66 17 3 internalization 45 41 14 5 evaluation socialisation 83 0 17 externalization 0 100 0 combination 100 0 0 internalization 97 0 3 table 3. the comparison of the average of patients’ adherence toward tb management between intervention and control group group pre (%) post (%) intervention 86 100 control 86 91 table 4. the comparison of patients’ knowledge about tb medication, pre and post intervention of knowledge-management based nursing care model grade category intervention group control group pre intervention post intervention pre intervention post intervention f % f % f % f % 3 fully understand 10 62,5 16 100 4 80 2 40 2 moderately informed 3 18,75 0 0 1 20 3 60 1 do not know 1 18,75 0 0 0 0 0 0 total 16 100 16 100 5 100 5 100 jurnal ners vol. 11 no. 1 april 2016: 99-105 102 table 5. the comparison of patients’ self-discipline in taking tb medication before and after the intervention of knowledge management based nursing care model grade category intervention group intervention group pre intervention post intervention pre intervention post intervention f % f % f % f % 3 discipline 10 62,5 16 100 2 40 4 80 2 moderate discipline 5 31,25 0 0 3 60 1 20 1 non-discipline 1 6,25 0 0 0 0 0 0 total 16 100 16 100 5 100 5 100 table 6. the comparison of patients’ ability to counter the adverse effect of tb medications before and after the intervention of knowledge management based nursing care model grade category intervention group control group pre intervention post intervention pre intervention post intervention f % f % f % f % 3 sufficient 12 75 16 100 5 100 5 100 2 moderate 4 25 0 0 0 0 0 0 1 incapable 0 0 0 0 0 0 0 0 total 16 100 16 100 5 100 5 100 tabel 7. the comparison of patients’ ability to monitor the success of tb treatment, before and after before and after the intervention of knowledge management based nursing care model grade category intervention group control group pre intervention post intervention pre intervention post intervention f % f % f % f % 3 able to monitor 10 62,5 16 100 2 40 2 40 2 moderate ability 6 37,5 0 0 3 60 3 60 1 unable to monitor 0 0 0 0 0 0 0 0 total 16 100 16 100 5 100 5 100 as can be seen from table 3, prior the intervention using knowledge management model was given, patient’s adherence’s score in both groups to treatment was 86%, showing that both groups were homogeny before the intervention was given. however, after the intervention, the treatment group achieve 9% higher in adherence’s score as compare to the control group. table 4 shows that the majority of respondents in the control group (80%) were fully understand about tb medication program while in the intervention group only 62.5% of respondents who had fully understand about the program. table 4 describes that 75% respondents have already knew how to overcome the unpleasant effect of taking tb medications. on the other hand, all of the respondents in control group were able to counter the side effects of the medications. in terms of monitoring the results of the medication program, 40% of control group member were able to perform evaluate properly (see table 7). this number was 12.5% lower when compared to the respondents in the intervention group. improvements were reported in all respondents (100%) from intervention group, particularly in aspects of knowledge, oral and injection medication-taking self-discipline, countering medication’s adverse effects, and monitoring medication program results. on the other hand, the control group’s results were varied. in terms of knowledge, 20% of the respondents remained moderately informed, and their ability in countering the adverse effects of the medications remained unchanged. however, their self-discipline in taking medications was improved by 80%. the statistical assessment using the mann whitney u test showed that there was no difference between the two groups during the pre-intervention of knowledge-management based nursing model (p>0,05). instead, all measured aspect was shown to be significantly different between the two groups after the intervention. for instance, the mann whitney u test results in knowledge about tb medications (p=0,074), oral medication-taking self-discipline (p=0,074), regularity to control (p=0,001), and the ability in monitoring the medication results (p=0,074). however, there was no significant difference between the two groups in the aspects of countering the adverse effects of the medication (p=1,000). model asuhan keperawatan berbasis knowledge management (ninuk d.k,dkk.) 103 discussion nurses’ knowledge about the intervention (nursing care process) theory was sufficient. however, the implementation of their knowledge in assessing patients’ ability that contributes to their adherence toward the real situation was compromised. this is possibly related with the overloading administration and delegation tasks, while doctors had to take over their roles in assessing the patients. this finding infers that nurses may compromise the proper assessment process and hinder patients from a successful therapy. this finding adds the available behaviour theory that explains about knowledge as the main contributor to individual acts. theoretically, behavioural adaptation occurs through changing processes that involve aspects of knowledge, attitude, and practice (notoatmodjo 2010). previous research suggest that aspect of knowledge has a close relationship with behaviour (asna 2011; maseda et al. 2013; nugrahini et al. 2012). nurses’ performance in patients’ assessment, particularly in aspects of socialization, externalization, and combination was deficient. the deficiency was also found in the rest of nursing process, except in evaluation phase, the aspect of socialization. this result was suspected to relate with nurses’ insufficient knowledge about nursing assessment process. the result showed in table 4.4 implies that nurses’ skill and knowledge in prioritizing diagnosis and understanding in the need of adherence were insufficient. thus, it influences their skills in assessing patients. cross & cummings (2004) assert that nurses’ performance has a strong relationship with their knowledge. this statement was also highlighted in different literatures, such as one in suprapti (2010) that involved staff of department of water resource management in central java province (suprapti 2010). patients adherence is evaluated through five indicators, including: knowledge, and self-discipline about medication and management, ability in countering the adverse effect of medication, regularity in control and monitoring, and the ability in evaluating the result of treatment. this research result implies that knowledge management based nursing model could improve patients’ adherence toward tb medication program. this is possibly because the model reinforces nurses to encourage patient to adhere to treatment. during the assessment phase, nurses as respondents are empowered to assess patients that they will bee able to ensure the clinical decision-making, diagnosis, and care-plan development is patient-centred. thus, the patients are expected to be self-reliant. in the implementation phase, the nurses are ready to help patients solve their problems, and acts as either mentor or counsellor, while in the evaluation phase; the nurses are able to evaluate their patients without prejudice. these thorough process would improve patients to adhere to tb treatments (potter et al. 2013). nurses perform nursing care based on the knowledge, experience, attitudes, and standards. nursing care improve patient knowledge and attitudes, so that then change the desire and ability of patients to follow treatment as prescribed (potter et al. 2013). patients’ knowledge improvement can be explained in two ways: because they obtain adequate information from nurses, or because positive patient-nurses contact, all of which acts as driven factors. therefore, knowledge management based nursing care model is believed to facilitate quality patient-nurse interaction and improve patients’ comprehension toward treatments and medication management. through socialization, externalisation, combination, and internalisation process, knowledge management nursing model facilitates patients’ new perspective regarding medication adherence. nurses are expected to assist patients to access learning through dynamic, tacit, and explicit interactions; initiated from the initiation of knowledge identification, development, distribution, utilization and retention (setiarso et al. 2009). patients’ improvement in taking medication is partly because the nurses take their roles as educator, reliable source of information, trainer, and caregiver. thus, patients’ adherence improves. according to peplau’s interpersonal relationship theory, knowledge management nursing care model enables patients’ reliability in adherence to treatment, and transform patients from care receptor to as partner to nurses in achieving shared-defined goals (johnson & webber 2015). however, the result of this study does not indicate that the nursing model is able to empower patients in countering the side effects of tb medications. it is suspected that this jurnal ners vol. 11 no. 1 april 2016: 99-105 104 resulted from the short duration of the treatment, which was limited to two weeks of implementation. the limited time of implementation also causing patients’ ability to counter medication side effects cannot be assessed further, and the majority of the patients could not share their lived-experience in managing the side effects of medication. however, the nursing care model was proven to facilitate good relationship between patients and nurses, and improves patients’ knowledge that encourages their motivation in regular control. integrated health education within the nursing care model facilitates the clients in achieving better health outcomes. this comprehensive nursing care model does improve patients’ self-concept and reliability to treatment, which proper and routine health check are some of the examples (burton et al. 2013). knowledge management nursing care model was proven to be mutually beneficial for both party. the nurses are allowed to provide health education, act as consultant, encourage patients to actively participating in their care, trust their clients, and encourage their patients to be reliant, all of which is consistent to the principles of learning in the sphere of nursing (burton et al. 2013). conclusion and recommendation conclusion knowledge management nursing care model was proven effective in improving patients’ adherence to treatment; this includes patients knowledge and ability in managing their medications, and actions and attitude in taking medications. the patients improved their regularity in taking tb medication, accessing health services, and evaluating their medication progress. recomendation knowledge management based nursing care model can be adopted as a way to improve tb patients’ adherence to treatments. further research is suggested to evaluate the influence of this nursing care model within the larger population and using method of randomized control trial. referrence asna, k. (2011). hubungan antara pengetahuan dan sikap terhadap kesehatan reproduksi dengan perilaku seksual pra nikah pada siswa di sma negeri 14 kota semarang tahun 2010/2011. skripsi. retrieved 2 12, 2015, from digilib unnes: http://lib.unnes.ac.id/7559/1/10361.pdf burton, t. (2013). client education. in j. crisp, c. taylor, c. douglas, & g. reberio, fundamentals of nursing (4th ed) (pp. 217-243). chatswood: elsevier australia. cross, r., & cummings, j. (2004). tie and network correlates of individual performance in knowledge-intensive work. academic management journal, 47(6), 928-937. johnson, b., & webber, p. (2015). an introduction to theory and reasoning in nursing (4th ed). philladelphia: wolters kluwer lippincott williams & wilkins. maseda, d., suba, b., & wongkar, d. (2013). hubungan pengetahuan dan sikap tentang bahaya merokok dengan perilaku merokok pada remaja putri di sma negeri 1 tompasobaru. retrieved 2 12, 2015, from jurnal keperawatan universitas sam ratulangi: http://ejournal.unsrat.ac.id/index.php/jkp/ article/view/2176 notoatmodjo, s. (2010). metodologi penelitian kesehatan. bandung: rineka cipta. nugrahini, d., anna, a., & emaliyawati, e. (2012). hubungan tingkat pengetahuan dengan perilaku sadari pada mahasiswa fakultas ilmu keperawatan universitas padjadjaran. retrieved 2 12, 2015, from jurnal unpad: http://jurnal.unpad.ac.id/ejournal/article/v iewfile/729/775 potter, a., perry, a., stockert, p., & hall, a. (2013). fundamental of nursing (8th ed). canada: elsevier mosby. setiarso, b., harjanto, n., & subagyo, h. (2009). penerapan knowledge management pada organisasi. yogyakarta: graha ilmu. shi, songge, & jia. (2010). the application of socialization externalization combination internalization model in library knowledge management. international conference on mechanical engineering and automation advances in biomedical engineering, 10, pp. 359-363. suprapti, w. (2010, 5 30). pengaruh pengetahuan, ketrampilan dan sikap terhadap kinerja pegawai pada dinas pengelolaan sumber daya air propinsi jawa tegah. tesis. retrieved 1 20, 2015, from universitas diponegoro: http://eprints.undip.ac.id/12332/ model asuhan keperawatan berbasis knowledge management (ninuk d.k,dkk.) 105 who. (2013). stop tb partnership: the global plan to stop tb 2011-2015. retrieved agustus 13, 2013, from world health organisation: http://www.stoptb.org/assets/documents/ global/plan/tb_globalplantostoptb20 11-2015.pdf http://e-journal.unair.ac.id/jners | 161 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16956 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the effect of clinical supervision on nurse performance rahayu tri nuritasari, erfan rofiqi, tan nina fibriola and rizal tri ardiansyah faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the nursing department often incurs problems about the performance of the nurses in providing nursing care at the hospital. this condition must get the attention of the head of the room as the manager who is directly responsible for the nursing care provided by the implementing nurse. supervision is a part of the directional function that has the role of maintaining the department so then all programmed activities can be carried out properly and smoothly. methods: this systematic review was conducted to review the effect of clinical supervision on nurse performance. for the systematic review, a literature search of the pubmed, sage, science direct, and scopus databases using the keywords ‘nursing’, ‘clinical supervision’, ‘clinical performance’ and ‘nurse performance’ was conducted in february 2019. the search identified 15 relevant research articles from the 2.436 original articles and full texts published between 2013 and 2019. results: the results show that clinical supervision has the potential to improve staff performance, which will ultimately affect the successful attainment of the hospital. conclusion: support from the hospital nursing management in providing support and monitoring is critical to the continuity, sustainability and successful implementation of clinical supervision. clinical supervision activities conducted regularly in a scheduled manner will spur on the nurse’s performance. article history received: december 26, 2019 accepted: december 31, 2019 keywords clinical supervision; nurse; performance; contact rahayu tri nuritasari  rahayu.tri.nuritasari2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: nuritasari, r. t., rofiqi, e., fibriola, t. n. & ardiansyah, r. t. (2019). the effect of clinical supervision on nurse performance jurnal ners, 14(3si), 161-164. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16956 introduction nursing services in hospitals depend on the nursing care given to individuals, their family and the wider communities. the process of nursing care is a part of the health services that is used a mirror of success which can affect the image of the hospital. the nursing department often incurs problems with the performance of the nurses in relation to providing nursing care in the hospital. this condition must get the attention of the head of the room as the manager who is directly responsible for the nursing care provided by the implementing nurse. supervision is a part of the directional function that has the role of maintaining quality so then all of the programmed activities can be carried out properly and smoothly. supervision in nursing is not just about control. supervision activities include determining the conditions or personal and material requirements needed to achieve the objective of effective and efficient nursing care(nursing supervision, 2016). clinical supervision is becoming a standard practice for health professionals and it has been considered to be an important component of comprehensive clinical governance(pearce, phillips, dawson, & leggat, 2014). clinical supervision involves a supportive relationship between the supervisor and supervisee that facilitates reflective learning. it is a part of professional socialization. the model of nursing clinical supervision in indonesia is unclear as to the nature of the implementation in the hospital. up to this point, it is not yet known how appropriate and practical the model is that can be applied(yuswanto, ernawati, & rajiani, 2018a). researchers have developed methods to measure the effectiveness of clinical supervision using scales such as the manchester clinical supervision scale (mcss) based https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:rahayu.tri.nuritasari-2018@fkp.unair.ac.id mailto:rahayu.tri.nuritasari-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). r. t. nuritasari et al. 162 | pissn: 1858-3598  eissn: 2502-5791 on the commonly cited proctor’s model of clinical supervision which is a three function interactive model of the restorative, formative and normative aspects of the supervision relationship. scales such as mcss were designed to evaluate the processes and effectiveness of clinical supervision. however, they do not specifically evaluate the content of the sessions(pearce et al., 2014). some studies concluded that one of the factors that influences nursing performance is supervision. applying proper supervision will cause the implementing nurses to feel accepted, valued and involved so then there is a high commitment to advancing the nursing services as a whole(cruz, carvalho, & sousa, 2014). the aim of this systematic review was to evaluate the current evidence regarding the effect of clinical supervision on nurse performance. the results may contribute to improving the existing clinical supervision practices for the health professionals. materials and methods search strategies reviewer search for articles published from 2012 to 2019 using the pubmed, science direct, sage, and scopus databases. the keywords used were ‘supervision’, ‘clinical supervision’, ‘nurse performance’ and ‘clinical performance’. in addition, only studies written in english were used for the current study. the search results in the form of titles and abstracts were the responsibility of the author in terms of reading and selecting the articles that were relevant to the criteria set by the author. selection criteria the inclusion criteria were as follows: 1) including an increase in nursing services or a system developed as a part of nursing; 2) the subjects of the study were nurses, clinical supervision or nurse performance and 3) the location of the study was in a hospital or in education. the exclusion criteria were 1) focusing on the location in the community and 2) the research was a thesis or as part of a conference. data extraction from the 15 studies that we chose, we extracted the type of research, the research subjects and the research data sources. the research subject in the 15 studies could be on clinical supervision and nurse performance. in addition, we extracted the results of the articles that discussed the influence between clinical supervision and nurse performance. the discussion of the differences in the research results required consideration from the author. results selection of studies the initial search retrieved a total of 2.436 studies: 32% from pubmed, 29% from sciencedirect, 15% from sage and 24% from scopus. from this, 2234 or 92% of the articles were deleted. based on the inclusion and exclusion criteria, the author reviewed each article and reached a consensus regarding any exceptions. the review process for the selected articles developed in 3 stages; a title review, abstract review and full text review. we extracted 202 or 8% studies from the abstract titles and reviews and 102 or 4% studies from the full text review. finally, a total of 17 articles were selected for this study. the retrieval and screening process has been summarized in figure 1. study methods based on the research subject, there were 1808 respondents with the details available for as many as 1546 of the respondents. the supervisees totaled as many as 194; 23 had a bachelor’s degree, 10 had a master’s degree and the manager of nursing totaled as many as 68 respondents. based on the location of the study, we found 17 studies that were conducted in hospitals. based on the research design, we found 13 types of cross-sectional and reflective studies, in addition to randomized controlled trials, quasiexperiments, literature reviews, qualitative and comparative studies. we identified several instruments used to measure the reflective supervision, self-efficacy scales for supervisees (rssess), the manchester clinical supervision scale (mcss) and the brief personal survey (bps), amsn mentoring program-mentor guide book. discussion for this general hospital, the biggest influence on the nurses’ performance occurs if all of the variables are intervened simultaneously. ability contributes the most of the nurses’ performance, followed by motivation and the nurses’ health status. the supervision of the nursing services will benefit the nurses in terms of enhancing the feelings of support, reducing professional isolation, decreasing work and emotional fatigue, increasing job satisfaction and morale, and developing professional practices and support in practice. furthermore, the supervision of the nursing services can improve the relationship of the nurses when they are supervised by their supervisors as well as in their relationships with other nurses. having established that clinical supervision is an important feature in the practice of nursing, it is important to state that there are times when it will not be successful. the barriers to successful clinical supervision may include the personalities of the people involved, skill mixtures, staffing levels and nurse caseloads. clinical supervision is multifaceted and dynamic. its outcome is dependent on many factors. however, there is increasing evidence suggesting that advantages can be achieved when and where quality clinical supervision is encouraged. clinical supervision implementation is not only to monitor whether all nursing staff perform their duties as well as possible per the instructions or conditions outlined but it is also about how to improve the ongoing nursing process. jurnal ners http://e-journal.unair.ac.id/jners | 163 supervisors need to collaborate with the nurses when analyzing situations so then they can work together to be able to recognize, clarify and identify existing problems. in the identification stage, the supervisors and nurses work together when solving problems. the exploitation stage allows the nurse to feel that they have a quality relationship with their supervisor and they have a good perception of the supervisor. the supervisor can improve their knowledge and solve any problems faced by the nurses related to their nursing care documentation. the resolution stage explains that the nurse’s needs have been noticed and there is a collaborative effort between the supervisor and the executing nurse. supervision of nursing services will benefit the nurses in enhancing feelings of support, reducing professional isolation, decreasing work and emotional fatigue, increasing job satisfaction and morale, and developing professional practice and support in practice. furthermore, the supervision of nursing services can improve the relationship of the nurses supervised by their supervisors as well as their relationships with other nurses. this study has been able to identify the effect of clinical supervision on nurse performance. four out of the fifty research studies showed that clinical supervision can improve the performance of the nurses and the research also found that the use of select strategies in the application of clinical supervision can enhance the performance of nurses in terms of their care documentation. conclusion the study results show that the clinical supervision implementation is not only to monitor whether all nursing staff performs their duties as well as possible per the instructions or conditions outlined but it also shows how to improve the ongoing nursing process. the supervision of the nursing services will benefit the nurses in terms of enhancing their feelings of support, reducing professional isolation, decreasing work and emotional fatigue, increasing job satisfaction and morale and developing professional practice and support in practice. references aung, k. t., & jamal, n. q. a. b. (2018). nurse managers’ perspectives on nurses’ performance in mentorship program. enfemeria clinica, 28(suplement 1), 139–143. brunero, s., & stein-parbury, j. (2008). the effectiveness of clinical supervision in nursing : an evidenced based literature review. australian journal of advanced nursing, 25(3), 86–94. chaves, l., mininel, v., silva, j., alves, l., silva, m., & camelo, s. (2017). nursing supervision for care comprehensiveness. revista brasileira de enfermagem, 70(5), 1106–1111. cruz, s., carvalho, a. l., & sousa, p. (2014). clinical supervision: priority strategy to a better health. procedia social and behavioral sciences, 112(7), 97–101. https://doi.org/10.1016/j.sbspro.2014.01.1143 escrig-pinol, a., corazzini, k. n., blodgett, m. b., chu, c. h., & mcgilton, k. s. (2018). supervisory relationships in long ‐ term care facilities : a comparative case study of two facilities using complexity science. journal of nursing management, 27(2), 311–319. https://doi.org/10.1111/jonm.12681 estes, b. c. (2013). abusive supervision and nursing performance. nursing forum, 48(1), 3–16. fitzpatrick, s., smith, m., & wilding, c. (2012). quality allied health clinical supervision policy in australia : a literature review. australian health review, 36(4), 461–465. frosch, c. a., varwani, z., mitchell, j., caraccioli, c., & willoughby, m. (2018). impact of reflective supervision on early childhood interventionists’ perceptions of self-efficacy, job satisfaction, and job stress. infant mental health journal, 39(4), 385–395. https://doi.org/10.1002/imhj. leggat, s. g., & phillips, b. (2015). clinical supervision for allied health staff: necessary but not sufficient. australian health review, 40(4), 431–437. lyu, d., ji, l., zheng, q., yu, b., & fan, y. (2019). abusive supervision and turnover intention: mediating effects of psychological empowerment of nurses. international journal of nursing sciences, 6(2), 98–203. https://doi.org/10.1016/j.ijnss.2018.12.005 martin, p., copley, j., & tyack, z. (2014). twelve tips for effective clinical supervision based on a narrative literature review and expert opinion. medical teacher, 36(3), 201–207. https://doi.org/10.3109/0142159x.2013.85216 6 nancarrow, s. a., wade, r., moran, a., coyle, j., young, j., & boxall, d. (2014). connecting practice: a practitioner centred model of supervision. clinical governance: an international journal, 19(3), 235– 252. https://doi.org/10.1108/cgij-03-20140010 nikpeyma, n., saeedi, z. a., azargashb, e., & majd, h. a. (2014). problems of clinical nurse performance appraisal system : a qualitative study. asian nursing research, 8(1), 5–22. nursing supervision. (2016). 23(4), 7748. https://doi.org/10.7748/nop.2016.e815 pearce, p., phillips, b., dawson, m., & leggat, s. g. (2014). content of clinical supervision sessions for nurses and allied health professionals: a systematic review. clinical governance: an r. t. nuritasari et al. 164 | pissn: 1858-3598  eissn: 2502-5791 international journal, 18(2), 39–154. proctor, b. (2015). review : a randomised controlled trial of clinical supervision : selected findings from a novel australian attempt to establish the evidence base for causal relationships with quality of care and patient outcomes , as an informed contribution to mental he. journal of research in nursing, 15(2), 169–172. https://doi.org/10.1177/1744987109357819 saxby, c., wilson, j., & newcombe, p. (2015). can clinical supervision sustain our workforce in the current healthcare landscape ? findings from a queensland study of allied health professionals. australian health review, 39(4), 476–482. yuswanto, t. j. a., ernawati, n., & rajiani, i. (2018a). the effectiveness of clinical supervision model based on proctor theory and interpersonal relationship cycle (pir-c) toward nurses’ performance in improving the quality of nursing care documentation. indian journal of public health research & development, 9(10), 561–566. https://doi.org/10.5958/09765506.2018.01405.5 yuswanto, t. j. a., ernawati, n., & rajiani, i. (2018b). the effectiveness of clinical supervision model based on proctor theory and interpersonal relationship cycle (pir-c) toward nurses’ performance in improving the quality of nursing care documentation. indian journal of public health, 9(10), 562. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 19 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.16683 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research indicators and index of elderly well-being to support an age–friendly city pipit festi wiliyanarti1, hari basuki notobroto2, hamidah hamidah3, and erfan rofiqi4 1 faculty of health science, universitas muhammadiyah surabaya, surabaya, indonesia 2 faculty of public health, universitas airlangga, surabaya, indonesia 3 faculty of psychology, universitas airlangga, surabaya, indonesia 4 student, master in nursing programme, faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: increasing the life expectancy of the elderly raises complex problems concerning the life aspects of the elderly, family, community, and government. a well-being indicator for the elderly is needed as a measurement tool to facilitate indonesian elderly individuals to becoming more prosperous. the purpose of this study was to develop well-being indicators and to formulate the elderly well-being index. methods: this study used an explanatory research design with a quantitative approach. in total, 400 respondents were collected using multistage random sampling. the physical well-being variable used the mini-mental state examination (mmse) instrument, barthel’s index, and the disease complaint questionnaire. in addition, a psychology and social well-being instrument, social well-being instrument, and spiritual instrument were employed. confirmatory factor analysis was used to verify the factor structure of all of the observed variables. results: the results showed that the indicators for elderly well-being are demographic with the following factor loading: (λ) 0.32, social environment (λ)=0.51, health services (λ)=0.55, physical well-being (λ=0.36 psychological wellbeing (λ)=0.46, social well-being (λ)=0.45 and spiritual well-being (λ)=0.50. the indicators and index can be used as an effort to drive the program, so then the elderly can become productive, prosperous, and meaningful. conclusion: the elderly well-being index is expected to be a programmatic instrument that can measure and evaluate the welfare of the elderly. this will increase the elderly health program that is available to achieve more holistic wellbeing and an age-friendly city. article history received: dec 12, 2019 accepted: march 09, 2020 keywords age-friendly city; elderly; indicators; index; well-being contact pipit festi wiliyanarti  pipitfesti@fik.umsurabaya.ac.id  faculty of health science, universitas muhammadiyah surabaya, surabaya, indonesia cite this as: wiliyanarti, p. f., notoboroto, h. b., hamidah, h., & rofiqi, e. (2020). indicators and index of elderly wellbeing to support an age–friendly city. jurnal ners, 15(1), 19-25. doi:http://dx.doi.org/10.20473/jn.v15i1.16683 introduction a growing elderly population has an impact when trying to improve the quality of life. human wellbeing is one of the most popular fields of modern multidisciplinary research. the issue is topical due to the conclusions that it is on economic and social change. more than 25% of the world population will fall into the category of being elderly by 2050 (global age watch index, 2014). this also has an impact on the increasing growth of indonesia's elderly population. the increase in aging is estimated to reach 63.31 million in 2045, which is around 20% of the population (bps, 2018). elderly needs are not only related to meeting their physical and financial needs that are currently the focus, but it also refers to their overall needs in life. at present, the increase in the number of elderly residents is not accompanied by an increase in the well-being of the elderly (lifshitz, nimrod and bachner, 2019). the view of well-being lies in the approach used in interpreting well-being. well-being starts from the study of social and economic perspective approaches, where social well-being is a state of human life that is https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ p. f. wiliyanarti et al. 20 | pissn: 1858-3598  eissn: 2502-5791 created when facing various social problems that can be managed properly (fave et al., 2018). the wellbeing study in this research uses being 60 years of age and over to refer to the elderly, which includes their physical, psychological, social, and spiritual wellbeing. the elderly group that is the target of this development is also the concern of the surabaya city government (bps, 2018) of east java. at present, the problem of the elderly is the focus of a study conducted by the province of east java, especially the city of surabaya. one of the development goals in east java is to improve the well-being and quality of life of the people, including the elderly in east java. in line with that, the formulation and direction of development policies are aimed at empowering and improving well-being. however, the program's achievements are not yet clear. the concern for older individuals about their well-being is closely related to their health condition. as an individual get older, their health declines and may worsen due to the constraints faced when maintaining their health (ivankina and ivanova, 2016). at present, the indonesian government has launched an elderlyfriendly city program (hermawati, 2015). the acceleration program for achieving an elderlyfriendly city is one of the efforts undertaken to anticipate the explosion of the elderly in indonesia by 2035. the explosion will have an impact on the socioeconomic burden of the state (global agewatch insight, 2018). the indonesian government does not have any indicators, nor an index prepared to measure the well-being of the elderly. well-being indicators use individual income guidelines, but this was a different concept between welfare and well-being (wiliyanarti et al., 2017). the availability of appropriate indicators will help the indonesian government determine the scale of the priorities and targets of well-being development. if there are no indicators or well-being indexes available, the government will experience difficulties when trying to determine the well-being category of the elderly for certain individuals or regions (wiliyanarti, asri and putra, 2018). this will have an impact on the development of the elderly well-being program. it is important to understand that index numbers do not only measure a variable or indicator. they can measure several indicators at the same time. advances in technology and knowledge require an effective method to be able to find a change in relation to the welfare of the elderly (wiliyanarti, 2018). an index number is a simple statistical measure that can indicate a difference in the individual (elderly), so then the value and category of the index are known. based on the concept of health, according to fleuret and atkinson (2007), it conveys that wellbeing is a perfect state that includes physical, mental, social, and spiritual well-being. it does not mean being free from disease only. this indicator does not mention in detail the symbols used for each component, making it difficult to measure the achievement of well-being because it is still too general. the well-being of the elderly in various regions has not been measured using the same indicators. therefore, in order to be able to assess the level of well-being of the elderly, it is recommended to use the elderly well-being index as an additional method paired with the use of the existing indicators. the availability of appropriate indicators will assist the government in determining the scale of the priorities and targets of well-being development. if there are no indicators or well-being indexes, the government will have difficulty identifying the well-being categories of the elderly for certain individuals or regions. this will have an impact on the development of the elderly well-being program. the study aimed to develop the elderly well-being indicators and subsequently to formulate the elderly well-being index in surabaya. materials and methods this study aimed to develop indicators for the wellbeing of the elderly. the research was conducted in two stages. the first stage used a qualitative approach presented in the form of a descriptive exploration (burhan bungin, 2005). the study design used was an explanatory research study with a cross-sectional approach. the population was all of the elderly living with families— the study conducted in a selected village in the city of surabaya. the sample was in the working area of the primary health care services of surabaya (east, west, central, north, south), totaling as many as 400 respondents. the sampling method used in this study was multistage random sampling. the research variables were physical, psychological, social, and spiritual well-being. at the quantitative research stage, the research instruments were in the form of structured questionnaires. the instrument was created after the first research phase was completed when the indicators had been collected qualitatively. the indicators that were collected were used as material for instrument development. the instruments used were for physiological well-being (ryff, 2014), social well-being (ryff, 2014), and spiritual well-being (gomez and fisher, 2016). modifications in terms of the instrument theme studies are associated with elderly well-being. the indicators tested for validity and reliability were psychological well-being with a value of 0,691, social well-being with a value of 0.7, spiritual well-being with a value of 0.971, social environment with a value of 0.7 and the health service factor with a value of 0.8. the instruments that were not tested for validity and reliability were the indicators for the demographic factors and physical well-being. this study was approved by the ethics committee number 37-kepk in 2016. results based on table 1 above, it is known that the majority of the elderly were aged 60 69 at 68.3%, that women made up 80.8%, and that the percentage for those not jurnal ners http://e-journal.unair.ac.id/jners | 21 working was 78.3%. the percentage of those who had no income was 66.9%, and 63.5% were married. expenditures most commonly made up 41 % 60% of any income, and the most common level of education was 26.8% for elementary school. based on table 2, the factor loading value of the 27 valid indicators, the factor score was calculated (table 2). based on the data above, it can be seen that out of the seven indicators. all indicators have a factor loading value above 0.3. the confirmatory factor analysis (cfa) model for elderly well-being showed that the indicators that have the highest factor loading value were health services (x3=0.55) spiritual (y4=0.50), social services (x2=0.51), psychological (y2=0.46), social (y3=0.45), physical (y1=0.36), and demographics (x1=0.32). the results are known to all of the indicators with a factor loading value >0.4 or value of tλ> 1.96 (α = 5%). thus, be concluded that the seven indicators above are valid to use to measure the well-being of the elderly. based on the results of table 3, the elderly well-being index formulation can include the addition of 0,3(x1) + 0,51(x2) + 0,55(x3) + 0,36(y1) + 0,46(y2) + 0,45(y3) + 0,50(y4), after which the index value is categorized. the categorization of prosperity is 15.50 19.35, while well-being is sufficient 19.36-23.20, and prosperity is 23.21-27.05 (table 3). discussion the indicator of demographics can be explained by education and income. the education achieved by the elderly contributes to the perception of the elderly regarding well-being. the income of the elderly made it known that most of the elderly do not have an income. meeting their needs in everyday life is a cost borne by the family (bps, 2018). for the elderly individuals that do have an income, this shows that there are still elderly who are actively working to fulfill their daily needs, or just to fill their spare time. they may also have a pension fund (hyde, maher and elavsky, 2013). the ability of the elderly to meet their daily needs and to be able to help other families is an old formula for financial happiness (kirkwood and cooper, 2014). the elderly in the community have different well-being levels depending on if the elderly can adapt and go through the aging process. the health service indicators explained that health services had become one of the components in the well-being of the elderly. the factor loading meets the standard criteria. it can be stated that the social environment and service guarantees are the indicators of the well-being of the elderly. according to the research, the social environment being optimal is a condition that is needed by the elderly (burton, mitchell and stride, 2011). the environment determines the achievement of well-being for the elderly. health insurance is one of the health efforts that the elderly need. when the elderly individual becomes sick, fulfilling health insurance is needed. the elderly health services in indonesia are facilitated by the existence of the elderly health services post. the benefits of the health services post for the elderly that it was a community-based service effort, among others. it seeks to improve the health status of the elderly, increasing their independence, slowing the aging process, and allowing for the early detection of health problems and increasing their life expectancy (erpandi, 2015). the elderly way of life in the environment is very influential in the development of the elderly. the environmental conditions can provide support to increase the interest of the elderly to achieve a better sense of overall well-being (wiliyanarti, notobroto and asri, 2017). a thriving environment is an environment that can improve the physical health, psychological well-being and social needs of those within it (othman and fadzil, 2020) successful or optimal old age emphasizes that the elderly have three relevant components: avoiding disease, the ability to work, and the ability to interact socially. the existence of disease is an indicator of the physical well-being of the elderly. this was stated by several elderly (hyde, maher and elavsky, 2013). the physical condition is affected by the disease, which can reduce the life satisfaction of the elderly. physical functioning and elderly cognition are also indicators of physical well-being. changes in the organic and systemic systems vary greatly, both between individuals and within individuals as well (kirkwood and cooper, 2014). aging with chronic stress can table 1. characteristic of respondents (n=400) characteristics n % age 60 69 years old 273 68.3 70 79 years old 113 28.3 > 80 years old 14 3.5 gender man 77 19.3 woman 323 80.8 income status have an income 133 33.3 don’t have an income 267 66.8 expenditure expenditure 40% of income 135 33.8 expenditure 41% 60% of income 143 35.8 expenditure >60% of income 122 30.5 occupation working 87 21.8 un-employed 313 78.3 marital status married 254 63.5 divorced 14 3.5 widow/widower 128 32.0 un-married 4 1.0 education no education 27 6.8 elementary school 107 26.8 junior high school 96 24.0 senior high school 95 23.8 diploma 23 5.8 bachelor’s 51 12.8 p. f. wiliyanarti et al. 22 | pissn: 1858-3598  eissn: 2502-5791 reduce immune function, making the elderly more vulnerable to getting an infection. the digestive system can still be quite efficient even though the elderly are more at risk of malnutrition. the elderly have a heart functioning level that is slower and irregular, often due to the occurrence of obesity in the elderly. this also increases blood pressure (kirkwood and cooper, 2014). nevertheless, there are still many elderly individuals who do not pay attention to the changes in their systemic functions. the elderly abilities related to cognitive function also experience changes, but not all changes in the brain are destructive. changes in cognitive function are not fundamental, and they do not significantly affect cognition, although there are increased brain changes. cognitive decline tends to increase (papalia, olds and feldman, 2009). the physical activity carried out by the elderly is closely related to the level of well-being, normally referring to the activities carried out by individuals without assistance. however, this was different for each age group where the elderly experience physical decline (hyde, maher and elavsky, 2013). this was also stated by (roberts et al., 2017), who stated that the ability to carry out basic activities could be used to refer to the continuation of old age and the desire to remain independent and to have a good quality of life. the ability to work independently contributes significantly to the quality of life of the elderly, and it is associated with psychological well-being (fave et al., 2018). psychological well-being, in general, can be interpreted as a form of satisfaction with aspects of life to bring in or cause feelings of happiness and a feeling of peace in one's life. the standard of satisfaction in each person is different, so this is subjective. based on the results of the study, all of the indicators for psychological well-being can be used to measure psychological well-being, proving that the loading factor’s statistical value is above the standard value. (ryff, 2014) states that a positive attitude, which is a component of psychological well-being, is needed to recognize and accept the various aspects of the self, both positive and negative. they should have positive feelings about their past life. self-acceptance means that the elderly are able to reflect on the shortcomings that exist in their elderly self. it was included the weakness of the physical condition when aging. this should not be a thing that reduces happiness, but instead, it should result in the sense of acceptance in the form of gratitude. the purpose of life that is possessed by the elderly is also an indicator and component of psychological well-being. ryff formulates psychological well-being into a multidimensional model (ryff, 2014). each dimension describes the efforts made by someone to face different challenges, then the individual functions positively. individuals who are autonomous means that the individuals have a sense of selfdetermination and that they are free and able to overcome social problems by thinking and acting according to their beliefs. they regulate their behavior from within and evaluate themselves based on their standards. psychological well-being must be supported by mental health, which is not only about being without a mental illness. positive mental health involves psychological feelings of well-being that coexist with self-health (ryff, 2014). suggested health table 2. well-being indicators based on loading factor factors indicators factor loading (λ) demography 1. level of expenditure 2. occupation 3. marital status 4. education 0.41 0.71 0.30 0.49 social environment 1. social network 2. family and community environment 3. problems 0.78 0.68 0.59 health services 1. elderly services 2. access information 3. health insurance 0.80 0.69 0.73 physical well-being 1. independence 2. complaints of physical health 3. cognitive function 4. disease suffered 0.71 0.54 0.64 0.58 psychological well-being 1. self-acceptance 2. purpose of life 3. control of the environment 4. personal development 5. positive relationship 6. autonomy 0.76 0.49 0.68 0.59 0.60 0.59 social well-being 1. social acceptance 2. social actualization 3. social contributions 0.88 0.71 0.94 spiritual well-being 1. god 2. personal 3. the environment 4. communal 0.92 0.87 0.88 0.91 jurnal ners http://e-journal.unair.ac.id/jners | 23 and social policy approaches include supporting ameliorating an older adults’ disability stages which may also contribute to their improved social life and mental health. preventing functional decline may help to maintain regular social participation and independence in terms of mobility. (stage 0) seems to be crucial to mental well-being. psychosocial support should be allocated to individuals in higher adl stages because of their more significant mental health needs. the findings from this study emphasize the salience of the care coordination required to provide complete medical, rehabilitative, psychological, and social care (na and streim, 2017). the social changes that occur in the elderly are related to the physical and cognitive changes experienced by the elderly. entering a happy old age is the same as being prepared to face changes in all aspects of their life. social change can be a source of stress if it is not responded to positively (fave et al., 2018). many elderly can remain optimal in the social field, and they can achieve conditions that are said to be prosperous (elo and isola, 2011). the results of the social well-being confirmatory factor analysis model show that the indicator that has the highest factor loading value was a social contribution. a small loading value was excluded from the model, referring to social relations and social integration. the social well-being indicators are based on the statistical test results for social contribution, social relations, and social inclusion. the results obtained a loading factor result that was more than the standard indicator. based on these results, it appears that the elderly have both carried out their social roles in the application of daily life, and they have value in the community. the research conducted by seligman (diener and ryan, 2008) shows that the happiest people have good quality social relationships. relationships that are considered to be useful must include two of the following three social relationships, namely family, friends, and harmonious relationships. elderly social relations and social integration with the environment are positive behaviors in the environment (wiliyanarti, notobroto and asri, 2017). most of the elderly can fully interact in society, but the intensity of each individual’s interactions shows a difference in the sense that the social relations carried out by the elderly occur only when due to a program or association (wiliyanarti, notobroto and asri, 2017). it also found that the elderly who become cadres and who are active feel happy at being able to socialize. therefore social relations and social integration cannot yet be a measure to show that these indicators are the components of the social well-being indicators. elderly well-being is in line with the quality of life, as well as the amount of social relations experienced (ivankina and ivanova, 2016). spiritual activity is something that can be said to be synonymous with old age activities (gomez and fizer, 2016). in societies in various countries, some elderly are made spiritual leaders in various religions, including churches, muslim communities, and others. based on the results of research conducted looking into the characteristics of spiritual well-being, the aspect of approaching god and the personal, environmental and communal aspects are in the good category. in this case, it can be interpreted that almost all elderly have fulfilled the criteria for spiritual happiness. the results of the spiritual well-being model show that the well-being components above are declared to be valid. the highest factor loading value is the god indicator. this is in line with spiritual well-being, according to (gomez and fisher, 2016). they stated that something is felt about the positive reflections on their behavior and cognition relating to oneself, in addition to society, intuitive feelings and the environment, the ability of individuals to identify themselves alone, commitment, positive attitude, and hormones in life. they also state that the reason for participating in religious activities is related to one's well-being (diener and ryan, 2008). a religious belief system helps most people to deal with stress and loss across the life cycle, providing optimism that the later life problems that cannot be overcome today will be resolved. in line with the opinion of (diener and ryan, 2008), the relationship between religion and the practice of spirituality is paradoxical. a religious person tends to have a higher sense of well-being, and it is more specific about matters of participation in faithful service, affiliation, a relationship with god, and praying. older people get a better appreciation of the meaning of life from religion, as well as life satisfaction, self-esteem, and higher optimism (lifshitz, nimrod, bachrur, 2009). the use of this index can be preventive and part of an evaluation related to the well-being of the elderly in surabaya. the use of indices in both the municipal and central governments. it is useful for measuring the well-being categories of each region. the areas with low elderly well-being categories are to be used for an evaluation of the elderly well-being programs. based on the results of the study, it can be noted that the surabaya urban elderly well-being index has an average value. it can be declared that the elderly in table 3. significance of the cfa model on elderly well-being symbol & variables factor loading (λ) tλ 1-δ t1-δ x1. demography 0.32 4.49 0.90 13.47 x2. social environment 0.51 8.63 0.74 11.44 x3. health services 0.55 10.14 0.70 y1. physical well-being 0.36 6.20 0.87 y2 psychological well-being 0.46 7.63 0.79 12.15 y3. social well-being 0.45 7.50 0.80 12.23 y4. spiritual well-being 0.50 8.36 0.75 11.65 p. f. wiliyanarti et al. 24 | pissn: 1858-3598  eissn: 2502-5791 surabaya are in the prosperous category. based on the formulation of the well-being index of the elderly, it is known that the most significant contribution is that the elderly can be biased in terms of well-being, environmental factors, health services, and spiritual well-being. in line with (fleuret and atkinson, 2007), they state that achieving success with the well-being index of the elderly must be supported by all aspects of life. the elderly can prepare themselves to face old age in a manner that is prosperous, productive, and meaningful. the strategy to become a friendly city for the elderly in 2030 requires an improvement of the indicators that achieved low, which does not require a lot of money. the results of this study can be used as input in the data assessment. reconstruction is needed to plan towards having an elderly-friendly city (kemenkes ri, 2013). the limitations of the study were the sample consisted of the elderly, who live with their families. it did not include the elderly in nursing homes or the elderly who are being treated in hospitals. the measurement of the indicators for physical wellbeing is limited to the instruments of daily ability. psychological well-being also did not look at the level of depression in the elderly. conclusion based on the above results, the indicators of elderly well-being are demographics, the health services available, the social environment, physical well-being, psychological well-being, social well-being, and spiritual well-being. the well-being indicators are expected to be a measuring tool that is a component of the well-being index. this study was useful as an evaluation of the elderly wellbeing in a manner that can be applied to policies and programs to improve the health of the elderly in both the regional and central government areas. the results can be used as a tool for improvement related to the elderly program to make the age-friendly city more optimal. references bps, k. (2018) statistik penduduk lanjut usia. jakarta: badan pusat statistik. burhan bungin (2005) metodologi penelitian kuantitatif. jakarta: kencana. burton, e. j., mitchell, l. and stride, c. b. (2011) ‘good places for ageing in place : development of objective built environment measures for investigating links with older people ’ s wellbeing’, bmc public health. biomed central ltd, 11(1), p. 839. doi: 10.1186/1471-2458-11-839. diener, e. and ryan, k. (2008) ‘subjective well-being : a general overview’, 39(4), pp. 391–406. elo, s. and isola, a. (2011) ‘the physical , social and symbolic environment supporting the well-being of home-dwelling elderly people’, (february). doi: 10.3402/ijch.v70i1.17794. erpandi (2015) posyandu lansia mewujudkan lansia sehat, mandiri dan produktif. jakarta: egc. fave, a. d. et al. (2018) ‘promoting well-being in old age : the psychological benefits of two training programs of adapted physical activity’, 9(may), pp. 1–13. doi: 10.3389/fpsyg.2018.00828. fleuret, s. and atkinson, s. (2007) ‘well-being , health and geography : a critical review and research agenda’, pp. 106–118. global agewatch insight (2018) global agewatch insight. helpage international. gomez, r. and fisher, j. w. (2016) ‘development and validation of the spiritual well-being questionnaire . domains of spiritual well-being and development and validation of the spiritual well-being questionnaire’, 35(january 2003). doi: 10.1016/s0191-8869(03)00045-x. hermawati, i. (2015) kajian tentang kota ramah lanjut usia, kajian tentang kota ramah lanjut usia. yogyakarta. hyde, a. l., maher, j. p. and elavsky, s. (2013) ‘enhancing our understanding of physical activity and well-being with a lifespan perspective’, 3, pp. 98–115. doi: 10.5502/ijw.v3i1.6. ivankina, l. and ivanova, v. (2016) ‘social well-being of elderly( based on the survey results )’, 01046, pp. 1–5. kirkwood, t. b. l. and cooper, c. l. (2014) well-being: a complete reference guide, well-being in later life volume 4 dari well-being: a complete reference guide wiley clinical psychology handbooks. john wiley & sons. lifshitz, r., nimrod, g. and bachner, y. g. (2019) ‘spirituality and well-being in later life : a multidimensional approach spirituality and wellbeing in later life : a multidimensional approach’, aging & mental health. taylor & francis, 0(0), pp. 1–8. doi: 10.1080/13607863.2018.1460743. na, l. and streim, j. e. (2017) ‘psychosocial wellbeing associated with activity of daily living stages among community-dwelling older adults’. doi: 10.1177/2333721417700011. othman, a. r. and fadzil, f. (2020) ‘influence of outdoor space to the elderly well-being in a typical care centre’, procedia social and behavioral sciences. elsevier b.v., 170, pp. 320– 329. doi: 10.1016/j.sbspro.2015.01.042. papalia, d. e., olds, s. w. and feldman, r. d. (2009) human development international student edition. mcgraw-hill. roberts, c. e. et al. (2017) ‘effect of different types of physical activity on activities of daily living in older adults: systematic review and metaanalysis’, journal of aging and physical activity, 25(4), pp. 653–670. doi: 10.1123/japa.2016-0201. ryff, c. d. (2014) ‘psychological well-being revisited : advances in the science and practice of eudaimonia’, pp. 10–28. doi: 10.1159/000353263. wiliyanarti, p. f. et al. (2017) ‘family environment and public (social), independence elderly, the achievement of welfare of elderly’, in the proceeding of 8th international nursing conference “education, practice and research development in nursing”. jurnal ners http://e-journal.unair.ac.id/jners | 25 surabaya: fakultas keperawatan universitas airlangga, pp. 385–388. wiliyanarti, p. f. (2018) buku ajar gizi dan diet. surabaya: umsurabaya publishing. wiliyanarti, p. f., asri, a. and putra, k. w. r. (2018) ‘developing holistic care model: the physical well-being of elderly based on social support and characteristic’, public health of indonesia, 4(3), pp. 108–115. doi: 10.36685/phi.v4i3.147. wiliyanarti, p. f., notobroto, h. b. and asri, k. (2017) ‘the effect of social and participation environmental factors on achievement of the well-being for elderly’, 5(6), pp. 71–78. 40 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18907 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors related to vaccine hesitancy in anti-vaccine group on facebook aisyah nur izzati, budi utomo, retno indarwati faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the current controversial issue regarding the anti-vaccine movement is the biggest challenge in implementing immunization in indonesia because it influences the stagnation in the coverage of complete basic immunization. the world health organization (who) also states that the anti-vaccine group is one of the ten major threats to global health in 2019 since this phenomenon can cause rare diseases to become epidemic. this study aims at factors related to vaccine hesitancy in the anti-vaccine group on facebook. methods: this study used a descriptive correlational method with a quantitative approach. the sample in this study was 150 mothers who were members of the anti-vaccine group on facebook social media, selected using a purposive sampling technique. results: demographic characteristics include religion, ethnicity, education, and income. perceived susceptibility and perceived severity were assessed using hwang’s health belief model questionnaire, while vaccine hesitancy was assessed using saphiro’s vaccine hesitancy scale questionnaire, then analyzed using spearman rho (α<0.05). the results of this study showed that there was a correlation between perceived susceptibility and perceived severity of vaccine hesitancy (p=0.000), while demographic characteristics were not related to vaccine hesitancy. conclusion: certain religions and ethnicities which have caused concern have proven unrelated to parent’s hesitance in immunization, as well as the level of education and income. the vulnerability and severity of a disease emerged as most parents’ overriding concern when making decisions about vaccine article history received: feb 27, 2020 accepted: april 1, 2020 keywords perceived susceptibility; perceived severity; vaccine hesitancy; antivaccine contact retno indarwati  retno-i@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: izzati, a, n., utomo, b., & indarwati, r. (2020). factors related to vaccine hesitancy in anti-vaccine group on facebook. jurnal ners, special issues, 40-44. doi: http://dx.doi.org/10.20473/jn.v15i2.18907 introduction the controversial problem regarding vaccines, especially the recent vaccine hesitancy, is the biggest challenge in implementing immunization in indonesia (depkes ri, 2018). according to the strategic advisory group of experts (sage) vaccine hesitancy working group of who, vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite the availability of vaccine services. this certainly affects the stagnation of complete basic immunization coverage in indonesia. meanwhile, to be able to provide effective protection, immunization coverage must be maintained high and evenly distributed throughout the regions to avoid extraordinary events (klb) (depkes ri, 2018). the world health organization ( 2018) also stated that the anti-vaccine group is one of the ten major threats to global health in 2019 because this phenomenon can cause rare diseases to become epidemic again (who, 2018). the achievement of complete basic immunization must pass various challenges, one of which is the public’s trust in the immunization program. schalkwyk (2019)explained that most of the antivaccine group movement use social media to spread misleading information about vaccines to strengthen the hesitancy of others in giving vaccines to their children (schalkwyk, 2019). social media is chosen because it is the only media currently used by everyone to interact, search for information, and to become part of a community (joubert, 2019). the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:retno-i@fkp.unair.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 41 most widely used type of social media to spread antivaccine propaganda is the facebook group (chiou & tucker, 2018). indonesia is the fourth highest user of facebook social media in the world with 130 million active users per month (hootsuite and we are social, 2018). the results of the study by the ipsos-centre for international governance innovation (cigi) showed that 65%of internet and social media users in indonesia believe in the truth of the information in cyberspace without making confirmation beforehand. various arguments about the pros and cons of vaccination that are widely communicated on social media make ordinary people directly accept the information and are more influenced by counter statements about vaccination (sundoro et al., 2018). trust and legitimacy are crucial concepts for understanding why some sources of information on vaccination can lead to vaccine hesitancy because the fear of disease, which we term perception of susceptibility and severity, has been replaced by fear of vaccines for some people... the phenomenon that is happening in the midst of the community surely becomes a concern of all health workers in the world, including in indonesia. a number of studies on cons of vaccination have been examined in several other countries, but there are still very few studies in indonesia. the background underlies this study’s intent to analyze the hesitancy of basic immunization in the anti-vaccine groups on facebook social media. materials and methods the data of this study have been collected by distributing questionnaires through google form to 150 mothers who joined the anti-vaccine facebook group and were selected with a purposive sampling technique. a section of the questionnaire consists of religion, race disparities, level of education, level of income, perceived susceptibility, and perceived severity. a scale from one to four has been used in the questionnaires to determine the level of vaccine hesitancy. the questionnaires were distributed on the first of december 2019 and collected on the fifth of february 2020. after the questionnaires were collected, experts’ answers were extracted using coding method and transferred to an excel spreadsheet. the data were transferred to the coding excel spreadsheet and grouped to summarize similar opinions in tables to present the percentages. this study has received ethical approval from the research ethic committee, faculty of nursing universitas airlangga with letter of approval no: 1837-kepk. results the first section of this study explains basic information regarding age, area of residence, occupation, religion, ethnicity, education level, and income level of the respondents. the data show that 34% of the respondents are in the age range of 26-30 years, 31% of them are in the age range of 31-35 years, 21% of them are in the age range of 36-40 years, and the rest are under 25 years old. a of the respondents, 53.3% live in urban areas and the remaining 46.7% live in villages. housewives account for 56% of the respondents , 24% of them are selfemployed, 14% of them are civil servants, and the remaining 9% work as merchants. almost all of them are predominantly muslim with a percentage of 97.3%, 2% are christians, and the remaining 0.7% are catholics. the ethnicity of the respondents are quite diverse, but the majority or 88.7% of the respondents table 1. percentage distribution of demographic characteristics of the respondents demographic characteristics category n % age 18-25 years old 21 14 26-30 years old 51 34 31-35 years old 47 31.3 36-40 years old 31 20.7 religion islam 146 97.3 christian 3 2 catholic 1 0.7 ethnicity java 133 88.7 madura 4 2,7 batak 6 4 chinese 3 2 osing 2 1.3 bali 2 1.3 area of residence urban 80 53.3 rural 70 46.7 level of education primary school 2 1.3 junior high school 3 2 senior high school 53 35.4 college 92 61.3 occupation housewife 84 56 wiraswasta 36 24 pns 21 14 pedagang 9 6 level of income <2.500.000 70 46.7 >2.500.000 80 53.3 a. n. izzati et al. 42 | pissn: 1858-3598  eissn: 2502-5791 are javanese, 4% are bataknese, 2.7% are madurese, 2% are chinese, and the remaining 2.6% are osing and balinese. only 1.3% graduated from elementary schools, 2% graduated from junior high schools, 35.4% graduated from senior high schools, and the remaining 61.3% graduated from universities. having an income of above idr 2,500,000 accounted for 53.3% of the respondents and the remaining 46.7% have an income of below idr 2,500,000 (table 1). table 3 shows the results of bivariate analysis between the dependent variables and the independent variables, where if a p-value is less than 0.05 . it is statistically significant. there was no significant relationship between religion and vaccine hesitancy (p=0.148 r=-0.119), there was no significant relationship between ethnicity and vaccine hesitancy (p=0.127 r=0.125), between level of education and vaccine hesitancy (p=0.560 r=0.097), or between level of income and vaccine hesitancy (p=0.560 r=-0.048), but there was a significant relationship between perceived susceptibility and vaccine hesitancy (p=0.000 r=0.323), and between perceived severity and vaccine hesitancy (p=0.000 r=0.292). discussion the results of this study indicate that demographic characteristics do not affect immunization hesitancy in parents. a study conducted by calu in 15 countries showed lower immunization coverage among muslims than christians (calu et al., 2020) this phenomenon of vaccine refusal has also been recently reported in developed countries, such as in the united states with religious concerns being a major reason (review, 2016). however, a study carried out by larson in 2016 explained that studies on vaccine confidence showed that muslim faith itself is not always linked to low coverage, for example in saudi arabia (larson et al., 2016). this study revealed that religion is not related to vaccine hesitancy in the antivaccine group on facebook in indonesia. this is consistent with a study conducted by pelčić in 2016 which found that every religion has its own basic reasons for not giving immunizations to the children table 2. percentage distribution of the perceived susceptibility and severity of the respondents perceived susceptibility strongly agree agree disagree strongly disagree total my child is at risk for pd3i ((infectious disease that can be prevented by immunization) or vaccine-preventable diseases (tuberculosis, polio, hepatitis b, pertussis, diphtheria, measles and tetanus) 7 47 59 37 150 i am worried that my child will have pd3i or vaccinepreventable diseases (tuberculosis, polio, hepatitis b, pertussis, diphtheria, measles, and tetanus) 29 65 43 13 150 pd3i or vaccine-preventable diseases (tuberculosis, polio, hepatitis b, pertussis, diphtheria, measles and tetanus) are contagious diseases 41 82 19 8 150 pd3i or vaccine-preventable diseases (tuberculosis, polio, hepatitis b, pertussis, diphtheria, measles and tetanus) are dangerous for my child 63 73 11 3 150 pd3i or vaccine-preventable diseases (tuberculosis, polio, hepatitis b, pertussis, diphtheria, measles and tetanus) can cause serious health problems for my child 58 75 15 2 150 the provision of immunizations is important for maintaining the health of my child 23 40 79 8 150 the immunization program implemented by the government is very effective 18 45 75 12 150 if i provide immunizations for my child, it means i also take care of the health of the people around me 21 39 82 7 150 the immunization program provided by the government is expected to be very useful 19 42 79 10 150 the latest vaccine products are more dangerous than the old vaccines products 22 61 61 6 150 information about immunizations that i obtain from health workers can be trusted 14 66 61 8 150 immunization is the best way to protect my child from illness 20 40 78 12 150 i did what the doctor suggested to immunize my child 17 46 79 8 150 i am worried about the serious side effects caused by immunization 43 70 32 5 150 my child does not need immunizations for pd3i or vaccinepreventable diseases (tuberculosis, polio, hepatitis b, pertussis, diphtheria, measles, and tetanus) because the diseases are now rare 18 76 47 9 150 jurnal ners http://e-journal.unair.ac.id/jners | 43 (pelčić et al., 2016). basically, religion is not in contradiction with vaccination and public health. it is only individual parents or religious leaders and their questionable interpretations of religious practices that are opposed to vaccination since no religion has such intention. there have not been many studies linking the relationship of racial disparities and vaccine hesitancy. this study shows that ethnicity is not related to vaccine hesitancy. this is not in line with the results of a previous study conducted by crouse quinn in 2018 which stated that there are significant racial differences in vaccine attitudes, risk perception, trust, hesitancy and confidence. they concluded that racial factors can be a useful new tool for understanding and addressing attitudes toward vaccine behavior (crouse quinn et al., 2018). this study also explains that there is no relationship between education level and income on vaccine hesitancy. previous studies have reported that parents with low levels of education obtain less information about vaccines compared to parents with high levels of education (kumar et al., 2016). meanwhile, another study conducted by opel showed that parents with higher levels of education were nearly four times likely to be concerned about the safety of vaccines than those with lower levels of education. highly educated people may have thought seriously about vaccination issues from the internet and social media, in which anti-vaccination groups are abundant (dubé et al., 2013). this study shows that the immunization hesitancy is not affected by parental income levels as well. some studies revealed that parents of lower-income brackets have been shown in some studies to have greater levels of concern about the safety and necessity of vaccines compared to those with higher socioeconomic status. however, in another study, parents of higher-income brackets are more than two times likely to be concerned that injections might not be safe than parents of lower-income brackets. the apparent contradiction could be related to differing perceptions of what “vaccine safety” means among parents from different socioeconomic backgrounds (gowda & dempsey, 2013) this study suggests that the feeling of vulnerability to pd3i or vaccine-preventable diseases in parents and the belief that pd3i can have a serious impact on the health of their children is related to immunization hesitancy in parents. parents’ perceptions on the prevalence of disease influence parents’ decisions on whether or not to obtain a vaccine. the pd3i can affect anyone; therefore, according to them, infectious diseases that can be contagious should be prioritized for vaccination. it is the same for the severity of pd3i, in which the severity of a disease could be quantified by how long the child would be sick, or if the disease would result in disabilities or long-term effects. these results show that mothers who have a high awareness of the risk of pd3i require more compensation to accept vaccines than mothers who have less awareness of that issue. table 3. the results of univariate analysis independent variables vaccine hesitancy sig. coefficient correlation refuser hesitance acceptor religion 0.148 -0.119 islam 26 88 32 christian 2 1 catholic 1 ethnicity 0.127 0.125 java 21 80 32 madura 2 2 batak 2 3 1 chinese 2 1 osing 2 balinese 1 1 level of education 0.560 -0.097 sd 2 1 smp 1 sma 9 31 14 pt 18 57 17 level of income 0.560 0.048 <2.500.000 11 41 17 >2.500.000 15 48 17 perceived susceptibility 0.000 0.323 high 3 28 22 middle 16 44 9 low 7 18 3 perceived severity 0.000 0.292 high 16 74 33 middle 3 low 7 16 1 a. n. izzati et al. 44 | pissn: 1858-3598  eissn: 2502-5791 conclusion this study implies that what influences immunization hesitancy to parents is their perception of the possibility of pd3i and the seriousness of the disease. the results of the study assess decision-makers in the governmental organization and all health workers need to confirm to the community about the possibility of pd3i spread and the serious impacts that result from it because, in reality, demographic characteristics have no impact on immunization hesitancy. this study is just a first step into studying vaccine hesitancy in mothers who join the antivaccine group on facebook social media in indonesia. more studies are required to analyze other factors that can influence immunization hesitancy among mothers in other communities in the real world. conflict of interest no conflict of interest has been declared. acknowledgement authors of this study would like to thank the faculty of nursing and also master’s in nursing study programme, for providing the opportunity to present this study. references calu, j., weber, a. m., darmstadt, g. l., abdalla, s., & victora, c. g. (2020). religious affiliation and immunization coverage in 15 countries in subsaharan africa. 38, 1160–1169. https://doi.org/10.1016/j.vaccine.2019.11.024 chiou, l., & tucker, c. (2018). fake news and advertising on social media : a study of the antivaccination movement. 1–35. crouse quinn, s., jamison, a., freimuth, v., hancock, g., & musa, d. (2018). exploring racial influences on flu vaccine attitudes and behavior: results of a national survey of african american and white adults. 35(8), 1167–1174. https://doi.org/10.1016/j.vaccine.2016.12.046.e xploring depkes ri. (2018). pelaksanaan imunisasi mr masih ada tantangan. dubé, e., laberge, c., guay, m., bramadat, p., roy, r., & bettinger, j. (2013). vaccine hesitancy an overview. august, 1763–1773. gowda, c., & dempsey, a. f. (2013). the rise ( and fall ?) of parental vaccine hesitancy. august, 1755– 1762. hootsuite and we are social. (2018). digital in 2018 : essential insights into internet, social media, mobile, and e-commerce use around the world. joubert, m. (2019). why anti-vaccine beliefs and ideas spread so fast on the internet. medical press. kumar, d., chandra, r., mathur, m., samdariya, s., & kapoor, n. (2016). vaccine hesitancy : understanding better to address better. israel journal of health policy research, 1–8. https://doi.org/10.1186/s13584-016-0062-y larson, h. j., figueiredo, a. de, xiahong, z., schulz, w. s., verger, p., johnston, i. g., cook, a. r., & jones, n. s. (2016). ebiomedicine the state of vaccine con fi dence 2016 : global insights through a 67country survey. ebiom, 12, 295–301. https://doi.org/10.1016/j.ebiom.2016.08.042 pelčić, g., karačić, s., galina, l., kubar, o. i., leavitt, f. j., tai, m. c., & morishita, n. (2016). religious exception for vaccination or religious excuses for avoiding vaccination. 20, 516–521. review, c. (2016). association between vaccine refusal and vaccine-preventable diseases in the united states a review of measles and pertussis. 315(11), 1149–1158. https://doi.org/10.1001/jama.2016.1353 schalkwyk, f. van. (2019). new potentials in the communication of open science with non-scientific publics : the case of the anti-vaccination movement new potentials in the communication of open science with non ‐ scientific publics : the case of the anti ‐ vaccination movement by françois barend van schalkwyk. march. https://doi.org/10.13140/rg.2.2.28501.06888 sundoro, j., sulaiman, a., purwadianto, a., & wasisto, b. (2018). kampanye anti-vaksin oleh seorang dokter , apakah melanggar etik ? 2(1), 1–5. https://doi.org/10.26880/jeki.v2i1.8 who. (2018). immunization. 55 persepsi anak dan orang tua tentang kualitas hidup anak penderita diabetes mellitus tipe 1 (the type 1 diabetic children’s quality of life from children and parents perspective) n.agustini*, allenidekania*, mariam effendi** *departemen keperawatan fakultas ilmu keperawatan, universitas indonesia **rumah sakit umum pusat nasional cipto mangun kusumo e-mail : tufahati@ui.ac.id abstrak pendahuluan: jenis-1 diabetes mellitus (t1d) manajemen adalah penting untuk meningkatkan kualitas hidup pada anak-anak penderita diabetes. penelitian ini bertujuan untuk mengeksplorasi dan membandingkan orang tua dan anakanak perspektif dalam kualitas hidup terkait dengan t1d. metode cross sectional digunakan untuk 35 anak-anak angka dua (berusia 8-18 tahun) dan orang tua mereka. anak-anak telah terdaftar di atas rumah sakit rujukan di indonesia. mereka mengisi pedsql® modul diabetes 3.2 dengan laporan diri. data dianalisis dengan t-test. karakteristik responden terdiri dari anak-anak dan orang tua usia, panjang menjadi diagnosis dengan t1d dan jumlah kunjungan dalam 6 bulan terakhir. kualitas dimensi kehidupan diukur pada bulan lalu karena data yang dikumpulkan. ini terdiri dari tanda dan gejala, penyakit dan terapi, perhatian manajemen t1d terkait komplikasi dan komunikasi. hasil penelitian menunjukkan bahwa anak-anak usia rata-rata berusia 13,11 + 2,85 tahun dibandingkan dengan orang tua (berusia 41,03 + 8,34 tahun). rata-rata lama menjadi diagnosis dengan t1d adalah 4.54 2,87 tahun dan rata-rata jumlah kunjungan dalam 6 bulan terakhir adalah 5,8 + 1,79. total skor kualitas hidup dari perspektif orang tua dan anak-anak 64,41% + 10,97 dan 63,09% + 13,25. selain itu, analisis t-test menemukan bahwa ada perbedaan yang signifikan dalam perspektif orang tua dibandingkan dengan perspektif anak-anak mengenai kualitas hidup terkait dengan t1d. kesimpulannya, anak-anak memiliki persepsi yang relatif lebih rendah dalam mengevaluasi kualitas hidup mereka di t1d dibandingkan dengan orang tua. oleh karena itu, perlu bagi perawat untuk mengeksplorasi faktor-faktor yang mempengaruhi serta mekanisme yang berkaitan dengan manajemen t1d sehingga perawat dapat mengembangkan rencana keperawatan individu untuk meningkatkan kualitas anak-anak t1d tentang kehidupan mengatasi. keyword (s): kualitas hidup, type-1 diabetes mellitus, orangtua, anak-anak, perspektif abstract introduction: type-1diabetes mellitus (t1d) management is important to increase the quality of life in diabetic children. this research aimed to explore and to compare the parents and children perspective in the quality of life related to t1d. cross sectional method was used to 35 dyad children (8-18 years old) and their parents. children have been registered in top referral hospital in indonesia. they filled the pedsql® module diabetes 3.2 by self-report. data were analyzed by t-test. the characteristic of respondents consist of the children and parents age, length of being diagnoses with t1d and the number of visit in the last 6 months. quality of life dimensions were measured in the last month since data collected. it consists of sign and symptom, disease and therapy, t1d management concern related to complication and communication. the result showed that the children mean age was 13.11 + 2.85 years old compared to parents (41.03 + 8.34 years old). the average length of being diagnoses with t1d was 4.54 +2.87 years and the average number of visit in the last 6 months was 5.8 + 1.79. total score of quality of life from parents and children perspective were 64.41% + 10.97 and 63.09% + 13.25. moreover, t-test analysis found that there was significant difference in parent perspective compared to the children perspective regarding quality of life related to t1d. in conclusion, children have relatively lower perception in evaluating their quality of life in t1d compared to the parents. therefore, it is necessary for nurses to explore the influencing factors as well as coping mechanism related to t1d management so that nurses can develop individual nursing plan to increase the t1d children's quality of life. keywords: quality of life, type-1 diabetes mellitus, parents, children, perspective pendahuluan dm tipe 1 sering ditemui pada masa kanak-kanak, remaja dan semua umur. diabetes melitus tipe 1 merupakan salah satu penyakit kronis yang sampai saat ini belum dapat disembuhkan. diabetes melitus yang tidak mendapat tatalaksana yang baik dapat menyebabkan beberapa komplikasi, baik komplikasi jangka pendek seperti hipoglikemi dan hiperglikemi ataupun komplikasi jangka panjang berupa nefropati dan retinopati yang secara langsung akan mempengaruhi kualitas hidup (hockenbery, m., j., & wilson, 2013) penyakit kronik didefinisikan sebagai suatu kondisi yang memerlukan monitoring jangka panjang atau minimal selama 6 bulan dan memerlukan manajemen khusus untuk mengontrol gejala yang terjadi baik karena gangguan fisik, kognitif, psikososial maupun sosial (bowden, v.r., & 2 greenberg, 2010). salah satu penyakit kronik yang saat ini menjadi perhatian serius dalam pelayanan kesehatan indonesia adalah penyakit diabetes mellitus, khususnya diabetes mellitus tipe 1 (dm tipe 1). berdasarkan data dari persi, kasus diabetes di indonesia saat ini menduduki peringkat keempat terbanyak setelah amerika serikat, china dan india dengan jumlah penderita diabetes pada tahun 2003 adalah 13,7 juta orang dan pada tahun 2030 diperkirakan akan bertambah menjadi 20,1 juta penderita dengan tingkat prevalensi 14,7 persen untuk daerah urban dan 7,2 persen di rural, sementara itu, berdasarkan laporan, kasus diabetes tipe-1 pada anak di awal tahun 1990, dalam kurun waktu satu tahun ditemukan sekitar 10 kasus. sejak tahun 2000-an hampir setiap bulan terdapat kasus baru dm tipe 1 dan pada tahun 2009 setiap bulan terdapat lebih dari 2 kasus baru yang terdeteksi (izn, 2011; pulungan, 2009). pengelolaan dm tipe-1 berdasarkan konsensus nasional adalah mengoptimalkan kualitas hidup penderita. kompleksitas permasalahan yang terjadi pada anak dm tipe 1 dapat berakibat munculnya permasalah gangguan fisik, psikologis maupun sosial yang dapat mengganggu aktivitas anak baik di rumah maupun di sekolah. anak mungkin akan mengalami keterlambatan dalam mengikuti kegiatan di sekolah karena anak diharuskan istirahat di rumah. anak juga mungkin mengalami stres dan rendah diri karena memerlukan pengobatan insulin sepanjang hidupnya. (idai, 2009). penelitian tentang kualitas hidup anak penderita diabetes tipe-1 di indonesia masih jarang peneliti temukan, oleh karena itu penellitian ini sangat penting dilakukan sebagai bahan kajian yang komprehensif dalam memberikan asuhan keperawatan anak dengan diabetes tipe-1 beserta keluarganya. bahan dan metode penelitian ini menggunakan desain kuantitatif deskriptif analitik dengan pendekatan potong lintang (cross sectional) yang mengukur variabel bebas dan terikat dalam satu waktu. . variabel bebas pada penelitian ini adalah kualitas hidup anak berdasarkan persepsi anak dan variabel terikat adalah kualitas hidup anak berdasarkan persepsi orang tua. hipotesis yang ingin ditegakan adalah tidak ada perbedaan skor kualitas hidup anak antara yang dipersepsikan anak dan yang dipersepsikan oleh orangtua. populasi pada penelitian ini adalah anak semua anak yang mengidap diabetes mellitus tipe 1 dengan populasi terjangkaunya adalah anak usia sekolah dan remaja pengidap dm tipe 1 yang terdaftar di rs cipto mangunkusumo. sampel penelitian ini adalah sebagain anak dengan dm tipe 1 yang bersedia menjadi responden, yang dipilih secara konsekutif. kriteria inklusi adalah anak usia sekolah dan remaja (8-18 tahun), pasien rawat jalan, bersedia untuk berpartisipasi dalam penelitian, orangtua memberikan ijin mengikutkan anak dalam penelitian. jumlah sampel ditentukan berdasarkan rumus penelitian analitis numerik tidak berpasangan. simpang baku untuk kelompok ibu adalah 12.5 dan kelompok remaja 18.5 didapatkan dari penelitian oleh hillard (2010). simpang baku gabungan didapatkan hasil 18.09, peneliti menetapkan bahwa tipe kesalahan 1 adalah 5% (z=1.96) dan kesalahan tipe 2 adalah 10% (z=12.82) dan selisih minimal yang dianggap bermakna adalah 15 skor, maka jumlah sampel yang diperlukan dengan penambahan 10 % menjadi 35 anak penderita dm tipe-1dan 35 orang tuanya. proses pengumpulan data yang penelkiti lakukan meliputi beberapa tahapan yaitu uji etik penelitian didapatkan dari fakultas ilmu kedokteran ui, perijinan penelitian dari rs cipto mangunkusumo, mendata pasien anak pengidap dm tipe 1 usia 8-18 tahun berdasarkan hari kontrol senin dan kamis, membuat daftar responden yang memenuhi kriteria inklusi, menghubungi orangtua dan anak yang memenuhi kriteria inklusi dan menjelaskan tujuan, manfaat penelitian dan kegiatan penelitian serta mendapatkan persetujuan berpartisipasi dalam penelitian, terakhir dilakukan pengambilan data dengan meminta anak dan orang tuanya untuk mengisi kuesioner, bagi anak yang kesulitan membaca peneliti membantu anak dalam mengisi kuesioner dengan cara membacakan kuesioner dan meminta anak memilih jawaban berdasarkan pilihan dari kuesioner yang dibacakan. 57 alat ukur pada penelitian ini terdiri dari kuesioner a, mengukur karakteristik responden: usia, jenis kelamin, lama terdiagnosa, frekuensi kunjungan ke poli, pemantauan mandiri yang dikembangkan oleh peneliti berdasarkan tujuan penelitian. kuesioner b adalah pedsql™ diabetes module yang dibuat oleh varni (2003). kuesioner ini dibagi menjadi 2 yaitu kuesioner b1 yang diisi oleh anak dan kuesioner b2 yang diisi oleh orang tua, berupa laporan orang tua tentang kualitas hidup anaknya. kuesioner pedsql™ diabetes module dibedakan berdasarkan usia dari anak pra sekolah sampai dengan dewasa. pada penelitian ini kuesioner yang digunakan adalah kuesioner untuk anak usia 8-18 tahun dan orangtua dari anak usia 8-18 tahun. pernyataan dalam kuesioner terdiri dari 33 item, dengan 5 pilihan respon secara likert. pilihan 0 (hampir tidak bermasalah), 1 (agak bermasalah), 2 (kadang bermasalah), 3 (sering bermasalah), dan 4 (hampir selalu bermasalah). untuk analisis selanjutnya skor yang dipilih dibalik interpretasinya menjadi 0=100,1=75, 2=50, 3 =25 dan 4=0. makin tinggi skor maka kualitas hidup anak pengidap dm tipe 1 makin baik. alat ukur kualitas hidup anak dengan dm yang digunakan pada penelitian ini merupakan adaptasi dari alat ukur yang digunakan di luar indonesia. sebelum alat ukur ini digunakan, peneliti menerjemahkan dulu ke dalam bahasa indonesia, kemudian hasil terjemahan direview oleh dua orang pakar bahasa inggris untuk diterjemahkan kembali ke dalam bahasa inggris, berasarkan hasil review secara makna kuesioner asli sudah memiliki makna yang sama dengan hasil terjemahan bahasa indonesia, maka alat ukur yang sudah diterjemahkan tersebut dilakukan uji keterbacaan kepada 10 orang anak dengan dm tipe 1 dan orang tuanya. hasil ujicoba didapatkan kesulitan pemahaman pada kuesioner harapan untuk pertanyaan nomor 5 orang tua dan kuesioner pedsql nomor 5 dan 6 pada kolom pertanyaan pengobatan ii, baik kuesioner yang diisi oleh anak meupun orang tua. berdasarkan hasil ujicoba kemudian dilakukan revisi. kuesioner yang telah direvisi kemudian digunakan sebagai alat ukur dalam penelitian ini. hasil tabel 1. rerata responden berdasarkan karakteristik dan kualitas hidup anak variabel mean sd (min-max) usia anak 13,11 2,85 (7-18) orang tua 41,03 8,34 (29-71) lama terdiagnosa 4,54 2,87 (1-11) frekuensi kunjungan poli 5,80 1,79 (2-12) kualitas hidup penilaian anak 63,09 13.25 (28.79-87.88) penilaian orang tua 64,41 10.97 (37.12-82.88) tabel 2. distribusi frekuensi responden anak berdasarkan jenis kelamin dan pemantauan mandiri variabel n (%) jenis kelamin anak laki-laki perempuan 9 26 (25,7) (74,3) pemantauan mandiri rutin tidak rutin 30 5 (85,7) (14,3) tabel 3. perbedaan rerata skor kualitas hidup anak berdasarkan penilaian oleh anak dan penilaian orang tua kualitas hidup rerata sd nilai p perbedaan rerata (ik95%) penilaian oleh anak 63,09 13,25 0,000 (28.79-87.88) penilaian oleh orang tua 64,41 10,97 0,000 (37.12-82.88) 2 hasil penelitian menunjukkan bahwa rata-rata usia anak pada penelitian ini yaitu 13,11 tahun dengan usia terendah yaitu 7 tahun dan usia tertinggi yaitu 18 tahun dengan sebagian besar berjenis kelamin perempuan (74,3%) dan rutin dalam melakukan monitoring dula darah mandiri (85,7%). rerata usia orang tua yang memiliki anak dm tipe 1 pada penelitian ini yaitu 41,03 tahun dengan usia terendah adalah 29 tahun dan usia tertinggi adalah 71 tahun (lihat table 1 dan 2). rerata skor kualitas hidup anak yang diukur oleh dirinya sendiri adalah 63,09, sedangkan yang dipersepsikan oleh orang tua adalah 64,41.dianalisis secara univariat dan bivariat (lihat table 1). berdasarkan analisis secara bivariat didapatkan bahwa terdapat perbedaan bermakna skor kualitas hidup anak dm tipe-1 antara pengukuran yang dilakukan oleh diri anak sendiri dan yang dilakukan oleh orang tua dengan nilai p<0,05 (lihat tabel 3) pembahasan hasil penelitian menunjukan bahwa skor kualitas hidup anak yang dinilai oleh anak dan yang dipersepsikan oleh orang tua memiliki perbedaan yang bermakna (p = 0.00). nilai rata-rata skor kualitas hidup berdasarkan penilaian anak lebih rendah dari skor kualitas hidup anak yang dipersepsikan orang tua (63,09; 64,41). hasil penelitian skor kualitas hidup anak dalam penelitian ini berbeda dengan hasil penelitian yang dilakukan oleh froisland (2012) dan bas (2011). penelitian froisland menemukan bahwa skor kualitas hidup anak usia sekolah dan remaja yang dinilai orang tua memiliki skor lebih rendah dari yang dinilai oleh anak dan bas menjelaskan hasil penelitiannya menunjukkan bahwa penilaian skor kualitas hidup anak yang dinilai oleh anak maupun yang dipersepsikan oleh ibu memiliki skor yang sama secara bermakna. beberapa penelitian yang menjelaskan mengapa penilaian kualitas hidup dari orang tua lebih rendah daripada yang dilakukan oleh anak sendiri disebabkan oleh beberpa faktor, seperti: perasaan distress orangtua ketika anaknya didiagnosis dm tipe-1, ketakutan orang tua akan kejadian hipoglikemia pada anaknya (whittemore, r., jaser, s., chao, a., jang, m., & grey, 2012). penelitian yang menunjukkan penilaian skor kualitas hidup anak dm tipe-1 oleh orang tua lebih tinggi dari penilaian oleh anak sendiri belum teliti temukan. beberapa hal yang dapat dijadikan pertimbangan adalah status ekonomi dari responden (orang tua) dalam penelitian ini meskipun peneliti tidak analisis secara kuantitatif, namun berdasarkan wawancara dengan beberapa responden orang tua didapatkan informasi bahwa cek gd mandiri yang dilakukan di rumah tidak mengikuti jadwal dikarenakan keterbatasan ekonomi. kurang patuhnya orang tua dalam melakukan cek gula darah di rumah menunjukkan kurangnya rasa kekhawatiran orang tua akan komplikasi yang dapat terjadi pada anak, sehingga penilaian orang tua terhadap kualitas hidup anak menjadi lebih tinggi dari penilaian yang dilakukan anak sendiri. faktor lain yang juga dapat berkontribusi dalam kualitas hidup anak yang lebih rendah dari yang dipersepsikan oleh orangtuanya adalah adanya hambatan anak dalam berkomunikasi dengan tenaga kesehatan dan munculnya gangguan emosional yang terjadi pada anak selama menderita penyakit diabetes tipe-1. hal ini sejalan dengan penelitian yang dilakukan oleh lowes et al., (2015) yang menyatakan bahwa kemampuan komunikasi yang baik oleh tenaga kesehatan memberikan pengalaman klinik positif yang mendorong pengambilan keputusan bersama, seperti kesempatan belajar, meningkatkan kepercayaan pasien untuk mengelola diabetes. namun, ketika tenaga perawatan dan kesehatan menggunakan bahasa yang sulit (jargon) selama konsultasi klinik, anakanak dan remaja dilaporkan merasa bingung dan frustrasi, dan melihat sedikit manfaat saat datang ke klinik. keterampilan komunikasi yang buruk mengakibatkan anak dan remaja merasa tidak diperhatikan saat konsultasi, menjadi bingung tentang rejimen pengobatan, dan kehilangan kepercayaan dalam mengelola kondisi kesehatan mereka (lowes et al., 2015). hambatan anak dalam berkomunikasi dengan tenaga kesehatan dan munculnya masalah emosional pada anak merupakan gambaran akan kualitas hidup anak yang tidak baik, hal ini peneliti temukan pada sebagian besar anak yang menjadi responden 59 dalam penelitian ini. kualitas hidup berdasarkan alat ukur yang digunakan dalam penelitian ini merupakan gambaran dari beberapa komponen penilaian yaitu seberapa sering anak mengalami gejala, bagaimana anak dalam mematuhi program terapi, seberapa sering anak mengalami kekahawatiran akan masalah yang akan timbul serta bagaimana kesiapan anak dalam melakukan komunikasi tentang penyakit yang dirasakan kepada tenaga kesehatani. peneliti melakukan perubahan pada lembar jawaban yang semula dinyatakan dalam bentuk skala likert 0-4 (tidak pernah, hampir tidak pernah, kadang-kadang, selalu, dan sering) menjadi 2 kategori, yaitu skala tidak pernah dan hampir tidak pernah peneliti kategorikan 2 (berkualitas) dan skla lainnya peneliti kategorikan menjadi 1 (tidak berkualitas). berdasarkan perubahan skala ukur kemudian dilakukan analisis dari komponen-komponen kualitas hidup. berdasarkan hasil analisis didapatkan bahwa kualitas hidup intuk komponen gejala, kuatir akan masalah, dan komunikasi dengan tenaga kesehatan berdasarkan penilaian yang dilakukan anak sendiri dapat dikatakan tidak berkualiatas. kondisi ini dapat dilihat dari sebagian besar anak (>50%) menyatakan bahwa dalam 6 bulan terakhir kadangkadang, selalu, atau sering mengalami timbulnya gejala, merasakan kuatir akan masalah, dan merasa mengalami kesulitan berkomunikasi dengan tenaga kesehatan tentang penyakit yang dideritanya. hasil penelitian ini menemukan bahwa kualitas hidup anak berdasarkan penilaian anak memiliki skor lebih rendah dari penilaian orang tua. perbedaan penilaian ini dapat diartikan sebagai suatu disparitas antara realitas yang dirasakan anak dengan penilaian orang tua. anak mungkin merasakan penderitaan akan sakitnya namun orang tua sebagai support system terdekat tidak melihat kondisi tersebut. perawat perlu menggali lebih dalam tentang pengalaman anak selama menderita diabetes tipe-1 dan melakukan evaluasi terhadap pemahaman anak tentang penyakit, pengobatan dan manajemen perawatan mandiri yang telah dilakukan anak dan orang tua. simpulan dan saran simpulan berdasarkan penelitian yang telah dilakukan, dapat diambil kesimpulan bahwa jumlah responden yang terdiri dari 35 pasang anak penderita dm tipe-1 dan orang tuanya memiliki skor kualitas hidup yang berbeda, berdasarkan pengukuran yang dilakukan oleh anak dan orang tuanya, dengan penilaian orang tua terhadap skor kualitas hidup anak diabetes tipe-1lebih tinggi daripada penilaian yang dilakukan oleh anak sendiri. saran peneliti menyarankan agar dilakukan penelitian lebih lanjut tentang faktor-faktor yang mempengaruhi kualitas hidup anak diabetes tipe-1, agar perawat dapat melakukan asuhan keperawatan secara komprehensif. kepustakaan bowden, v.r., & greenberg, c. s. (2010). children and their families: the continuum of care. philadelphia: lippincott williams & wilkins. hockenbery, m., j., & wilson, d. (2013). wong’s esential of pediatric nursing. missouri: elsevier mosby. izn. (2011). perkembangan diabetes di indonesia. retrieved from http://www.pdpersi.co.id pulungan, a. & h. (2009). diabetes mellitus tipe-1: penyakit baru yang akan makin akrab dengan kita. majalah kedokteran indonesia, 59(10). whittemore, r., jaser, s., chao, a., jang, m., & grey, m. (2012). psychological experience of parents of children with type 1 diabetes. a systematic mixedstudies review. the diabetes educator, 38(4), 562–579. 2 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 301 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17151 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the impact of perceived organizational support (pos) for increasing the intention to stay: a systematic review mira melynda prakosa, nisa dewanti and sena wahyu purwanza faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: nurse turnover is a problem that occurs in hospitals. the high turnover of nurses in health facilities can have a negative impact on the needs of the patients and on the quality of the health services. the turnover of nurses thus becomes a serious challenge to the efficiency, effectiveness and productivity of the health services. the aim of the systematic review was conducted to examine the impact of perceived organization support when it came to increasing the intention to stay. method: a systematic search was conducted using articles from scopus, science direct and sage. the search identified 15 original articles and full texts published between 2014 and 2019. result: nurses with high perceived organizational support with their organization have a lower intention to leave the organization. pos is the key predictor of turnover intention. conclusion: pos can reduce turnover, especially for nurses. the positive perception of the organization can decrease turnover intention. pos that is felt strongly will affect the work performance of the nurses by increasing their intention to stay. this can the reduce hospital costs when it comes to having to recruitment new nurses. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords perceived organization support; turnover intention; intention to stay; intention to leave contact mira melynda prakosa  mira.melynda.prakosa2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: prakosa, m. m, dewanti, n & purwanza, s. w. (2019). the impact of perceived organizational support (pos) for increasing the intention to stay: a systematic review. jurnal ners, 14(3si), 301-.304 doi:http://dx.doi.org/10.20473/jn.v14i3(si).17151 introduction nurse turnover is a problem that occurs in hospitals. the turnover percentage of nurse is greater than in any other profession. the turnover of nurses became a serious challenge regarding the efficiency, effectiveness, and productivity of the health services. healthcare organizations need to keep the turnover rate among nurses low to maintain the quality of the nursing services that they provide (bobbio & manganelli, 2015). high turnover for the nurses in health facilities can have a negative impact on the needs of the patients and on the quality of the health services. the direct impact can be seen in the extra cost incurred i.e. personnel, recruitment, selection, and training costs (kalidass & bahron, 2015). nurse turnover complicates the human resources when it comes to sustaining or building a quality team of staff and this often leads to high costs for recruiting and training new nurses. nurse turnover also resulted in losses in the organization (yim, seo, cho, & kim, 2017). thus, we expect that perceived organizational support acts as a relationship mediator between turnover intention and organizational commitment, as well as for this relationship to be stronger when the employees perceive there to be high organizational support compared to when they perceive there to be low organizational support. perceived organizational support may be defined as the worker’s belief of the organization’s consideration regarding his/ her contributions, and the extent to which the organization is concerned about the worker’s wellbeing (bohle, 2016). based on where the employees’ expectations are not met by the organization, we propose the betrayal perspective to understand the influence of perceived organizational support on the relationship between job insecurity and affective organizational commitment (fernet, trépanier, demers, & austin, 2017). this concept has also been viewed as a relevant issue for perceived organization https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mira.melynda.prakosa-2018@fkp.unair.ac.id mailto:mira.melynda.prakosa-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). m. m. prakosa et al. 302 | pissn: 1858-3598  eissn: 2502-5791 support and employment relations, especially for nurses. this study can contribute to the understanding of how perceived organization support may be used to predict the nurse’s intention to leave their job. materials and methods the systematic search was conducted in scopus, science direct and sage. the studies were published from 2014 to 2019 with the keywords “perceived organization support” and “turnover intention” or “intention to stay” or “intention to leave”. with these terms, we also combined them with other keywords, such as (nurse * or nursing *) for nursing so then they can retrieve all of the relevant articles. the inclusion criteria of the articles were 1) including an increase in nursing services or a system developed as part of nursing; 2) original research; abstract; 3) the subjects of the study were nurses or employees and 4) the location of the study was a hospital or in industry. the exclusion criteria from the articles were 1) focusing on a location in the community and 2) the research is a thesis or part of a conference process. we extracted the different types of research, research subjects and the research data sources. the research subjects in the 15 studies could be either nurses and employees. in addition, we extracted the results of the articles that discussed the impact of perceived organization support when it comes to increasing the intention to stay. result figure 1: literature search flow selection of the studies the initial search retrieved a total of total of 10539 studies: 7647 (72,55%) from sage, 2292 (21,74%) from science direct, and 600 (5,69%) from scopus. based on the inclusion and exclusion criteria, the author reviewed each article and reached a consensus regarding the exceptions. the review process for the selected articles developed across three stages, including the title review, abstract review and full text review. we extracted 80 (100 %) studies from the abstract titles and reviews, while a total of 15 articles were selected for the study. the retrieval and screening process has been summarized in figure 1. study methods based on the research subject, we found that the number of respondents was 9233 total with nurses making up as many as 8103 respondents and employees making up as many as 1130 respondents. based on the location of the study, we found that 11 studies were conducted in hospitals and 4 studies were conducted in companies. based on the research design, we found 13 types of cross-sectional design and two quantitative studies with a descriptive correlation design. for data sources, questionnaires were the instrument used from all 15 articles. we identified several instruments used to measure perceived organizational support and turnover intention. perceived organizational support was measured using the questionnaires developed by eisenberger (1986) (abou hashish, 2017; bobbio & manganelli, 2015; bohle, 2016; caesens, stinglhamber, demoulin, de wilde, & mierop, 2019; fernet et al., 2017; filipova, 2011; kalidass & bahron, 2015; kim, lee, & shin, 2019; labrague, mcenroe petitte, leocadio, van bogaert, & tsaras, 2018; ross, 2017) eisenberger (1997) (robson & robson, 2016; shacklock, brunetto, teo, & farr-wharton, 2014) and ling (2006) (j. y. liu, yang, yang, & liu, 2015). one measurement was developed by perceived organizational supportsimplified version scale (pos-svs) (w. liu et al., 2018), turnover intention was measurement with questionnaire developed by camman (1979) (fernet et al., 2017) and the measurement was modified by becker (1992) and mobley (1982) (kim et al., 2019). intent to leave was created by camman (1979) (filipova, 2011), and the turnover intention inventory scale (tiis) (labrague et al., 2018) and intent to quit was created by meyer (1993) (robson & robson, 2016; shacklock et al., 2014). the intent to remain scale was developed by turnley and feidman (1993) (j. y. liu et al., 2015), the turnover intention scale was developed by lichtenstein (2004) (ross, 2017), and the turnover intention scale was developed by lee. the spiritual perceived organizational support questionnaire and the characteristics of the turnover intention questionnaire were tested for reliability using cronbach’s alpha and everything has been declared reliable. however, there are some instruments that have not been reported on in the validity test.. search term: perceived organization support and turnover intention intention to stay intention to leave sage: 72,55% science direct: 21,74% scopus: 5,69% 10.539 (100%) articles 80 (100%) full-text articles assessed for eligibility 15 articles retained jurnal ners http://e-journal.unair.ac.id/jners | 303 discussion the study results show that perceived organizational support impacts on the nurse’s intention to stay with their organization. high perceived organization support will be a profit for the organization because it can help them to improve the success of the organization, to defend and contribute toward the nurses and increase the productivity of the nurses in providing nursing care. high perceived organization support should be improved to increase the employee's intention to stay. what the organization can do is to fulfill the social-emotional needs of their nurses, to fulfill their promises, to increase their performance–reward expectations, and to create a healthy environment with job security, job satisfaction and autonomy. they should also signal the availability of help and support for their employees. such a need fulfillment produces a strong sense of belonging felt toward the organization in turn, and they expect more commitment related to the intention to stay (burke, 2003; rhoades & eisenberger, 2002). perceived organization support (pos) is defined as the social exchange relationship that results from the exchange between a nurse and their organization. nurses with high pos are less likely to seek out and accept jobs in alternative organizations. high pos lowers the nurse’s intention to leave the organization. apart from that, focusing on the concept of pos would be a key predictor of turnover intention (kalidass & bahron, 2015). a study conducted by ahmed (2012) suggested that organizations that possess and support the management will produce more work that benefits the organization (bashir ahmed, 2012). perceived organizational support can influence the employees to feel a sense of obligation, which can lead to them paying attention to their work and to the organization to help them achieve their goals. this has an effect on the organizational commitments so as to reduce the turnover intention. nurses have a high perception of organizational support and also the nurse’s commitment is settled within the organization. the review suggests that one of the keys to reducing the percentage of turnover intention in organization is that the human resource managers should be more supportive. there should be a responsible internal relationship between the employees and management, care should extend to the employees’ well-being and they should understand the values of achieving the organization’s goals together. therefore, there is a need to understand the important roles of pos i.e. the continuance of commitment, affective commitment and normative commitment in order to increase the intention to stay in the organization. the high employee perception of the organization will lower the turnover intention, so the related costs incurred by the organization can be minimized. conclusion of the fifteen articles reviewed, all showed the positive result that perceived organization support can increase the intention to stay of the nurse. the intention to stay of nurse can be increased if the organization can fulfill the social-emotional needs of their nurses, fulfill their promises an increase their performance–reward expectations, including providing a healthy environment, job security, job satisfaction, autonomy, and signaling the availability of help and support to their employees. high perceived organizational support will increase the profit of the organization because it can help them to improve the success of the organization, to defend and contribute to the nurses’ skills and increase the productivity of the nurses in providing nursing care. high employee perception of the organization rate will lower turnover intention so then the costs incurred in the organization can be minimized. references arshadi nasrin. the relationships of perceived organization support (pos) with organizational commitment, in role performance and turnover intention: mediating role of felt obligation. procedia social and behaviour science. 2016 bobbio andrea and anna maria. antecedents of hospital nurse’ intention to leave the organizatio: a cross sectional survey. international journal of nursing studies. 2015 bohle sergio, chambel m, medina f, cunha b. the role of perceived organizational support in job insecurity an performance. journal of business management. 2016 caesens gaetane, florence stinglhamber and stephanie demulin. perceived organizational support and workplace conflict: the mediating role of failure-related trust. frontiers in psychology.2019;9. fernet c, trépanier, s.-g, demers m and austin s. motivational pathways of occupational and organizational turnover intention among newly registered nurses in canada. nursing outlook. 2017;65(4): 444–454. filipova anna. relantionships among ethical climates, perceived organizational support, and intent to leave for licensed nurses in skilled nursing facilities. journal of applied gerontology. 2011;30(1): 44-66 hashish ebtsam and aly abou. relationship between ethical work climate and nurses perception of organizational support, commitment, job satisfaction and turnover intent. nursing ethic. 2015 kalidass a and arsiah b. the relationship between perceived supervisor support, perceived organizational support, organizational commitment and employee m. m. prakosa et al. 304 | pissn: 1858-3598  eissn: 2502-5791 turnover intention. international journal of business administration. 2015;6(5) kim,cheol young, joo han lee and soo young shin.why are your employees leaving the organization? the interaction effect of role overload, perceived organizational support, and equity sensitivity. sustainability journal. 2019;11(657) labrague l, michael l, kostantinos t. perception of organizational support and its impact on nurse job oucomes.wiley nursing forum. 2018 liu jing, ji-peng, y, yang y and yan-hui. the relationship among perceived organizational support, intention to remain, career succees and self esteem in cjinese male nurses. international journal of nursing sciences. 2015 liu wenhui. workplace violence, job satisfaction, burnout, perceived organizational support and their effect on turnover intention among chinese nurses in tertiary hospitals: a cross sectional study. bmj open. 2018 mosadeghrad ali mohammad. occupational stress and turnover intention: implication for nursing management. international journal of health policy and management 2018;1(2):169-176 piers ruth, d versluys, k devoghel, and j andre. interprofessional teamwork, quality of care and turnover intention in geriatric care: a cross-sectional study in 55 acute geriatric units. international journal of nursing studies. 2018 robson andrew and fiona r. investigation of nurses intention to leave: a study of a sample of uk nurses. journal of health organization and management . 2016;30(1) ross j. organizational support, workload, and intent to stay: work environment perceptions in perianesthesia nursing units. journal of perianesthesia nursing. 2017;32(4):287–294. shacklock kate, yvonne b, stephen t and rod f. the role of support antecendents in nurses intentions to quit: the case of australia. jan reseacrh. 2014 yim hy. mediating role of psychological capital in relationship between occupational stress and turnover intention among nurses at veterans administration hospitals in korea. asian nurs res. mar. 2017;11(1):6-12. ahmed b, shad i and mumtaz r. organizational ethics and job satisfaction: evidence from pakistan. afr j bus manag. 2012; 6(8): 29662973 burke r. nursing staff attitudes follow restructuring; the role of perceived organizational support, resctructuring processes and stressors. int j social policy. 2003; 23(8): 129-157 rhoades l and eisenberger r. perceived organization suppport; a review of the literature. j appl psychol. 2002; 87(4): 698-714 http://e-journal.unair.ac.id/jners | 141 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16945 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research deep breathing relaxation for decreasing blood pressure in people with hypertension rahmatul fitriyah, gratsia victoria fernandez, wahyu sukma samudera, hidayat arifin and shenda maulina wulandari faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: various non-pharmacological therapies can be used to reduce blood pressure. one of them is deep breathing relaxation. this study aimed to know the influence of deep breath relaxation to decrease the blood pressure of people with hypertension. methods: the design of this study was an pre-experimental one group pretest-post-test design which covered 30 respondents as the sample. they fulfilled the inclusion criteria and were chosen through purposive sampling. the independent variable in this study was deep breath relaxation and the dependent variable was blood pressure. the data collection technique was using the observation sheet of blood pressure measurement. data were analyzed using the paired t test. results: the findings of this study majority there were decrease blood pressure after deep breath. before doing the breath relaxation exercise, most of the respondents were hypertension level 1. nonetheless, after the deep breath relaxation had been executed, most found that their blood pressure decreased although several respondents were at hypertension level 2 with stable blood pressure. conclusion: there were differences in the blood pressure patients with hypertension before and after the deep breath relaxation. there were several points which influenced the decrease in blood pressure after implementing the deep breath relaxation such as stress, cigarettes etc. article history received: december 26, 2019 accepted: december 31, 2019 keywords deep breathing; blood pressure; hypertension contact rahmatul fitriyah  rahmatul.fitriyah2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: fitriyah,, r, gratsia victoria fernandez, g. v., samudera, w. s., arifin, h & wulandari, s. m. (2019). deep breathing relaxation for decreasing blood pressure in people with hypertension. jurnal ners, 14(3si), 141-145. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16945 introduction hypertension is a persistent elevation of the systolic blood pressure at a level of >140 mmhg and a diastolic blood pressure at a level of > 90 mmhg. hypertension must be controlled because it is related to myocardial infarction, stroke, renal failure and it is the main cause of death in united states(armstrong, 2014)(nice, 2011). cardiovascular disease is one of the main causes of death in the world. the development of cardiovascular disease is caused by the accompanying risk factors that are not immediately handled(du et al., 2016). data from the who in 2019 showed that raised blood pressure caused 7,5 million deaths or about 12,8% of the total deaths in the world. the number of people with uncontrolled hypertension has risen from 600 million in 1980 to nearly 1 billion in 2008(who (world health organization), 2019). in 2010, there was an estimated 1,39 billion people with hypertension (mills, 2016). the prevalence of raised blood pressure was highest in africa, as it was 46% for both genders. the lowest prevalence of raised blood pressure was in america, at 35%. in america, men had a higher prevalence (39%) than women (32%)(who (world health organization), 2019). the percentage of people with hypertension in indonesia had risen from 25,8% in 2013 to 34,1% in 2018. the highest prevalence of hypertension in indonesia was in north sulawesi at about 13,2% and the lowest prevalence was in papua (ri, 2018). in some age groups, the risk of cardiovascular disease increases twice for each increment of 20/10 mmhg of blood pressure. besides that, the complications of raised blood pressure include heart failure, peripheral vascular disease, renal https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). r. fitriyah et al. 142 | pissn: 1858-3598  eissn: 2502-5791 impairment, retinal hemorrhage and visual impairment(park & han, 2017). the lifestyle of the patients with hypertension must be controlled, for example, including a good diet (high fiber, low fat), a weight control program, physical exercise, drug therapy and reducing their psychological stress [1](park & han, 2017)(staffileno, tangney, & fogg, 2018). uncontrolled hypertension can cause serious problems for their overall health(park & han, 2017). it is important for the patients with hypertension to control their stress levels for the sake of their blood pressure management(park & han, 2017). one of the non-pharmacological interventions for controlling blood pressure approved by fda is deep breath relaxation (mahtani, beinortas, bauza, & nunan, 2016) in this study, the researchers wanted to know the influence of deep breath relaxation on decreasing the blood pressure of people with hypertension. materials and methods the design of this study was praeksperimental with a one group prepost-test design. there was one group of people with hypertension. before and after implementing the deep breath relaxation, the respondents had their blood pressure measured with a standardized sphygmomanometer. the aim of this research design was to compare the blood pressure measurement before and after implementing the deep breath relaxation. the population in this research was all of the patients with hypertension in the citizen’s association 05 of sawunggaling village, sub-district wonokromo, surabaya. this research was conduct on april 2nd 2015 with 109 individuals. the inclusion criteria in this research were 1) patients with hypertension diagnosed by a physician, 2) patients with hypertension aged 30 59 years old and 3) those who had given informed consent for the research. there were 30 respondents who fulfilled the inclusion criteria for the sample in this research. the independent variable in this study was deep breathing relaxation. the dependent variable was blood pressure. this study used a sphygmomanometer, stethoscope and observation sheet with the following guidance: 1) normotension: sbp (120-139) dbp (80-89), 2) hypertension stage 1: sbp (140-159) dbp (90-99) and 3) hypertension stage 2: sbp (≥160) dbp (≥100). this standard is based on that of joint national committee 8 (jnc 8). the patient’s blood pressure was measured by the researcher before implementing the relaxation. after that, the researcher accompanied them and gave the patients the instructions for the deep breath relaxation for about 15 minutes. after the procedure, their blood pressure was measured again to determine the results of the procedure. the data was analyzed using ibm spss statistic 16 with a paired t-test. this research was carried out in collaboration with jagir primary health service. this research passed the ethical review from the institute of health science katolik st. vincentius a paulo surabaya, certificate no. 072/7860/436.6.3/2015. results the characteristics of the respondents as seen in table 1 show that most of the respondents are the elderly and female. most of them had a family history of hypertension, they often ate salty food, were a nonsmoker, took their medicine regularly, did not consume alcohol and were not stressed. for physical exercise, they did it at least twice a week. before implementing deep breathing relaxation, none of the respondents had a normal blood pressure measurement. after implementing dbr, 33% of the respondents had normal blood pressure. the respondents with hypertension in stage 1 made up 73% before given dbr and this decreased to 47% after given dbr. the respondents with hypertension table 1. characteristics of the respondents who were patients with hypertension (n=30) characteristic result n % age adult (30-44) elderly (45-59) 4 26 13 87 sex male female 10 20 33 67 family with hypertension yes no 19 11 63 37 like salty food yes no 20 10 67 33 smoker yes no 8 22 27 73 kind of tobacco cigarettes filter 5 3 63 37 adherence to medicine yes no 23 7 77 23 have great problem yes no 5 25 17 83 physical exercise > 2x/week ≤ 2x/week seldom 7 18 5 23 60 17 alcohol consumption yes no 0 30 0 100 table 2. differences in blood pressure before and after the deep breathing relaxation (n=30) differences of blood pressure before and after dbr before after n % n % ht st 1 ht st 2 normal tension 22 8 0 73 27 0 14 6 10 47 20 33 total 30 100 30 100 jurnal ners http://e-journal.unair.ac.id/jners | 143 in stage 2 made up 27% before implementing dbr and this decreased to 20% after implementing dbr. discussion based on this study, before implementing deep breathing relaxation (dbr), most of the respondents had hypertension stage 1. in terms of age, most of the respondents were elderly. the incidence of hypertension increases with age (triyanto, 2014). this is caused by natural changes in the body that affects the heart, blood vessels and hormones. the structural and functional changes especially occur in the peripheral vascular system. these changes include atherosclerosis, a loss of connective tissue elasticity and a decrease in the relaxation of the vascular smooth muscles, which in turn decreases blood vessel distention and stretching ability, so the consequence is that the large aorta and arteries diminish in their ability to accommodate the volume of blood pumped by the heart, resulting in a decreased cardiac output and increased peripheral resistance. this causes an increase in blood pressure. uncontrolled hypertension could increase the risk of heart failure, coronary heart disease and major cardiovascular disease(ettehad d, 2016). besides that, there were a minority of respondents of a younger age who were suffering from hypertension. in terms of the demographic data, they had a family history of hypertension and they often ate salty food. the consumption of salty food can increase the blood pressure because salty food contains sodium. deep breathing relaxation consisted of breathing with slow breaths to a point of maximal inhalation before slowly exhaling. this could reduce the pain intensity, improve lung ventilation and increase blood oxygenation. slow deep breathing training is acceptable for older people (sangthong b, 2016). pharmacological treatment should be given when the systolic pressure is ≥ 150 mmhg and when the diastolic pressure is ≥ 90 mmhg and the target is 140/90 mmhg. slow deep breathing also effectively reduced the blood pressure in terms of the essential and isolated systolic hypertension, even in patients with conventional pharmacological treatments (sangthong b, 2016)(jones cu, 2010). in several studies there have been shown to be non-pharmacologic treatments that can decrease blood pressure such as yoga, meditation, etc. slow and deep breathing is important thing in yoga and meditation (bai et al., 2015)(posadzki, cramer, kuzdzal, lee, & ernst, 2014). slow breathing could reduce the systolic blood pressure (elliot w.j, 2004). yoga could reduce the sistolic blood pressure more significantly than meditation, especially in the elderly respondents (>60 years) (park & han, 2017). the results of study confirmed that 8 weeks of slow loaded breathing reduces the sbp and dbp by approximately 20 and 10 mm hg, map by 15 mm hg and hr by 12 bpm. the data also showed that the load (25% mip) was increased significantly in relation to the respiratory muscle strength, lung capacity, chest and abdominal expansion and arm exercise endurance(ublosakka-jones, tongdee, pachirat, & jones, 2018). based on this study, most of the respondents had decreased blood pressure after practicing the deep breath relaxation, even to the point of becoming normotension. this is in line with the research in other countries indicating that slow and deep breathing could their decrease blood pressure. the relaxation process could inhibit the autonomic nervous system and central nervous system, in addition to increasing the parasympathetic nervous system. the parasympathetic nervous system controls the digestive system, respiratory system and heart rate during the rest period. the autonomic nervous system influences the blood pressure through the arterial baroreceptors and pulmonary strech receptors (joseph c.n, 2005). deep breathing stimulates the stretch receptors, increases the vagal tone, decreases the sympathetic activity and the result is a decrease in blood pressure (misra et al., 2018). deep breathing could stimulate the stretch receptors, increase vagal tone and decreased sympathetic activity. this results in a decrease in blood pressure and heart rate[10](wan r, 2014). low breathing activates the hering-breuer reflex to improve baroreflex sensitivity and the result was a decreased heart rate and blood pressure(joseph c.n, 2005). fda recommends that breathing exercises should be an adjunct anti-hypertensive treatment that can be practiced at home, as published in 2002. there were several devices like a control box, headphones and a respiratory rate monitor in the form of a sensor belt around respondent’s chest. the instructions were for the respondents to practice slow and deep breathing at about 10 breaths per minute for at least 40 minutes per week with each session lasting for at least 10 minutes. device-guided breathing (dgb), such as breathing exercises, is recommended as an effective nonpharmacological treatment for hypertension. dgb guides the respondents to breathe 14 times/minute. this study was independent. the dgb results were a significant decrease in systolic and diastolic blood pressure(staffileno et al., 2018). there was also a study that confirmed that for every 3.6 mmhg reduction of the mean bp, the relative risk of total cardiovascular events, stroke, coronary events, cardiovascular deaths and total deaths were 0.86, 0.72, 0.91, 0.75, and 0.78 times, respectively, out of a 2.4 mm hg reduction. these results confirm that a reduction in bp is important for cardiovascular patients(zou et al., 2017). when viewed regarding a history of smoking, there were 8 smoker respondents, 5 respondents who had decreased blood pressure, 2 of them with increased blood pressure and 1 respondent had a constant blood pressure. r. fitriyah et al. 144 | pissn: 1858-3598  eissn: 2502-5791 for the respondents who did not have a smoking history, making up a total of 22 respondents, there were 14 respondents who had decreased blood pressure, 5 respondents whose blood pressure was constant and 3 respondents who had an increased blood pressure. the tar in cigarettes is a hydrocarbon substance that is sticky and irritates the lungs, thereby increasing the production of mucus in the lungs as a result. cigarette smokers have difficulty breathing because the airways into the lungs are blocked[11]. after the deep breath relaxation was performed on the respondents with a history of smoking, it decreased their blood pressure less than respondents who did not have a history of smoking. this is due to the accumulation of secretions in the lungs of people who smoke so then the deep breathing relaxation cannot be carried out optimally. in addition, the researchers argue that 3of the respondents who did not have a history of smoking still had an increased blood pressure. this is because the respondents had a history of experiencing problems. someone who has a problem is likely to cause an increase in blood pressure caused by an increase in the peripheral vascular resistance and cardiac output and due to the release of the hormone epinephrine (adrenaline) and norepinephrine (noradrenaline). this causes the blood vessels to constrict. conclusion before implementing the deep breathing relaxation, most of the respondents had hypertension stage 1. after implementing the deep breath relaxation, most of respondents had a decrease in blood pressure (categorized as hypertension stage 1 through to normal tension). there was one respondent with hypertension stage 2 after implementing the deep breathing relaxation. he was categorized in hypertension stage 2. there were differences in the blood pressure before and after implementing the deep breath relaxation. references andarmoyo, s. (2012). kebutuhan dasar manusia (oksigenasi). yogyakarta: graha ilmu. armstrong, c. (2014). practice guidelines jnc 8 guidelines for the management of hypertension. american family physician, 90(7), 503–504. https://doi.org/10.1002/hipo.22742 bai, z., chang, j., chen, c., li, p., yang, k., & chi, i. (2015). investigating the effect of transcendental meditation on blood pressure: a systematic review and meta-analysis. journal of human hypertension, 29(11), 653–662. https://doi.org/10.1038/jhh.2015.6 cernes, r., & zimlichman, r. (2015). resperate: the role of paced breathing in hypertension treatment. journal of the american society of hypertension, 9(1), 38–47. https://doi.org/10.1016/j.jash.2014.10.002 du, j., zhang, d., yin, y., zhang, x., li, j., liu, d., … chen, w. (2016). the personality and psychological stress predict major adverse cardiovascular events in patients with coronary heart disease after percutaneous coronary intervention for five years. medicine, 95(15), e3364. https://doi.org/10.1097/md.000000000000336 4 elliot w.j. (2004). graded blood pressure reduction in hypertensive outpatients associated with use of a device to assist with slow breathing. clin hypertens, 6, 553–561. ettehad d. (2016). blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. lancet, 387, 957–967. jones cu. (2010). an inspiratory load enhances the anti-hypertensive effects of home-based trainingwith slow breathing: a randomized trial. j. phys, 56, 179–186. joseph c.n. (2005). slow breathing improves arterial baroreflex sensitivity and decreases blood pressure in essential hypertension. hypertension, 46, 714–718. mahtani, k. r., beinortas, t., bauza, k., & nunan, d. (2016). device-guided breathing for hypertension: a summary evidence review. current hypertension reports, 18(4). https://doi.org/10.1007/s11906-016-0631-z mills, k. (2016). global disparities of hypertension prevalence and control. circulation, 134, 441–450. misra, s., smith, j., wareg, n., hodges, k., gandhi, m., & mcelroy, j. a. (2018). take a deep breath: a randomized control trial of pranayama breathing on uncontrolled hypertension. advances in integrative medicine. https://doi.org/10.1016/j.aimed.2018.08.002 nice. (2011). hypertension: the clinical management of primary hypertension in adults: update of clinical guidelines 18 and 34. london: royal college of physicians. park, s.-h., & han, k. s. (2017). blood pressure response to meditation and yoga: a systematic review and meta-analysis. the journal of alternative and complementary medicine, 23(9), 685–695. https://doi.org/10.1089/acm.2016.0234 posadzki, p., cramer, h., kuzdzal, a., lee, m. s., & ernst, e. (2014). yoga for hypertension: a systematic review of randomized clinical trials. complementary therapies in medicine, 22(3), 511– 522. https://doi.org/10.1016/j.ctim.2014.03.009 ri, k. k. (2018). riskesdas. sangthong b. (2016). breathing training for older patients with controlled isolated systolic hypertension. med. sci. sports exerc, 28, 147–158. satiti, a. (2011). strategi rahasia berhenti merokok. yogyakarta: datamedia. staffileno, b. a., tangney, c. c., & fogg, l. (2018). favorable outcomes using an ehealth approach to promote physical activity and nutrition among jurnal ners http://e-journal.unair.ac.id/jners | 145 young african american women. journal of cardiovascular nursing, 33(1), 62–71. https://doi.org/10.1097/jcn.000000000000040 9 triyanto, e. (2014). pelayanan keperawatan bagi penderita hypertensi secara terpadu. yogyakarta: graha ilmu. ublosakka-jones, c., tongdee, p., pachirat, o., & jones, d. a. (2018). slow loaded breathing training improves blood pressure, lung capacity and arm exercise endurance for older people with treated and stable isolated systolic hypertension. experimental gerontology, 108(march), 48–53. https://doi.org/10.1016/j.exger.2018.03.023 wan r. (2014). evidence that bdnf regulates heart rate by a mechanism involving increased brainstem parasympathetic neuron excitability. j neurochem, 129, 573–580. who (world health organization). (2019). raised blood pressure. zou, y., zhao, x., hou, y. y., liu, t., wu, q., huang, y. h., & wang, x. h. (2017). meta-analysis of effects of voluntary slow breathing exercises for control of heart rate and blood pressure in patients with cardiovascular diseases. american journal of cardiology, 120(1), 148–153. https://doi.org/10.1016/j.amjcard.2017.03.247 79 evaluasi psikometrik skala kualitas asuhan keperawatan pada anak dengan infeksi saluran pernafasan akut (psychometric evaluation of the quality of nursing care scale for children hospitalized with acute respiratory infection) dewi elizadiani suza fakultas keperawatan, universitas sumatera utara, indonesia email: elizadiani@hotmail.com abstrak pendahuluan: evaluasi psikometrik kualitas skala asuhan keperawatan adalah kunci penting dalam meningkatkan kualitas asuhan keperawatan bagi anak yang dirawat di rumah sakit dengan infeksi saluran pernapasan akut (ispa) untuk menurunkan angka kesakitan dan kematian anak dengan ispa, terutama di indonesia. metode: konstruksi validitas yang diidentifikasi dengan menggunakan eksploratori faktor analisis (efa), pendekatan kelompok kontras, dan reliabilitas. hasil: konstruksi validitas: 1) efa menemukan bahwa qncs-haric terdiri dari 37 item dengan empat faktor dan total variance explained dari 42.92% dan factor loadings berkisar .30-.70; 2) pendekatan kelompok kontras menemukan bahwa skor ratarata dari 37 item qncs-haric antara dua kelompok berbeda secara signifikan (t = -22,91; p = .000); dan 3) cronbach’s alpha coefficient dari total 37 item yang qncs-haric adalah .93. cronbach’s alpha coefficient faktor 1, 2, 3, dan 4 dari 37 item qncs-haric masing-masing adalah .87, .80, .77, dan .76. diskusi: meskipun model 37 item qncs-haric diterima, itu kurang representatif, terutama dalam dimensi sosial-budaya anak dengan ispa dan keluarga karena hanya terdiri dari 3 dari 10 item yang tidak bisa mengukur dimensi aspek sosio-budaya secara lengkap. kata kunci: evaluasi psikometrik, skala kualitas asuhan keperawatan, infeksi saluran pernafasan akut, anak abstract introduction: psychometric evaluation of the quality of nursing care scale is a vital key to improve the quality of nursing care for hospitalized acute respiratory infection (ari) children in order to decrease morbidity and mortality of ari children, especially in indonesia. method: construct validity was identified using the exploratory factor analysis (efa), contrasted group approach, and reliability. results: construct validity: 1) efa found that the qncs-haric consisted of 37 items with four factor and total variance explained of 42.92% and factor loadings ranged from .30 to .70; 2) contrasted group approach found that the mean scores of the 37 items qncs-haric between two groups were significantly different (t = -22.91; p = .000); and 3) cronbach’s alpha coefficient of the total 37 item qncs-haric was .93. cronbach’s alpha coefficients of factor 1, 2, 3, and 4 of the 37 item qncs-haric were .87, .80, .77, and .76, respectively. discussion: although the 37 items qncs-haric model was acceptable, it was less representative, especially in the socio-cultural dimension of ari children and family because it consisted of only 3 from 10 items which could not measure the complate dimension of the socio-cultural aspect. keywords: psychometric evaluation, quality of nursing care scale, acute respiratory infection, children ____________________________________________________________________________________________________ introduction one possible way to reduce the morbidity and mortality of acute respiratory infection (ari) children and increase quality of nursing care of ari children is to develop a scale to evaluate quality of nursing care for hospitalized ari children. the scale development will be based on the related concepts such as quality of nursing care, holistic care, nursing process, and holistic nursing care for ari children. quality of nursing care is measured by patients’ met needs in terms of physical, psychosocial, socio-cultural, and spiritual aspects as well as patient satisfaction with the care (kunaviktikul, w, anders, rl, srisuphan, w, chontawan, r, nuntasupawat, r & pumarporn 2001). quality of nursing care as the degree to which patients’ physical, psychosocial, and extra care needs were met (williams 1998). nurses’ response to patients’ needs would be used as an indicator for quality of nursing care and categorized the quality of nursing care indicators into three groups: structure, process, and outcome, which are related to the structure, process, and outcome of care (donabedian, 1997). the structure indicators were divided into four categories: 1) management, 2) facility, 3) resources, and 4) staff development (kunaviktikul, w, anders, rl, srisuphan, w, chontawan, r, nuntasupawat, r & pumarporn 2001). the process indicators were divided into two categories: 1) nursing practice and 2) professional characteristics (kunaviktikul., et mailto:elizadiani@hotmail.com jurnal ners vol. 11 no. 1 april 2016: 79-87 80 al. 2001). the outcome indicators were divided into six categories: 1) incidents and complications, 2) patient satisfaction, 3) satisfaction with information, 4) time, 5) satisfaction with pain management, and 6) satisfaction with symptom management (kunaviktikul, et al 2001). in this study, the quality of nursing care for ari children will be defined as the degree to which pediatric nurses provide nursing care to meet the needs of ari children in the physical, psychological, social-cultural, and spiritual dimensions. thus, one process indicator, namely nursing practice, will be implied as an indicator used to measured quality of nursing care for ari children. based on a literature review of studies from 1990 to 2010, no known quality of nursing care scale for hospitalized ari children was found. however, one study used the concept of holistic care and nursing process (lee, ll, hsu, n & chang 2007) to evaluate the quality of nursing care in orthopedic units. the nursing process and four aspects of holistic care, including physiological, psychological, socio-cultural, and spiritual aspects, were used as the conceptual framework to evaluate the quality of nursing care in orthopedic patients. other related studies were found in various populations. lynn, mcmillen, and sidani (2007) developed an instrument to measure nurses’ evaluation quality of patient care delivery in acute care setting, in the united states. they found that the components of quality of nursing care consisted of the following factors: interaction, vigilance, individualization, advocate, work environment, unit collaboration, personal characteristics, and mood. murphy ( 2007) explored nurses’ perceptions of the attributes of quality of care and the factors that facilitate or hinder high quality nursing care in longterm care in ireland. the findings indicated that nurses perceived quality of care for older people in ireland as holistic, individualized and focused on promoting independence and choice. from the overview of the literature review, it was found that these previous studies measured quality of nursing care in general were not specific to ari children. the definition of quality of nursing care for nurses who work with ari children has not been identified in the nursing literature. most of the studies were conducted with the different setting and diseases, and also offered the meaning/definition of quality of nursing care based on nurses in western countries. the complexity, subjectivity, and multidimensional concept of quality of nursing care is difficult to be defined and measured (attree 1996; kunaviktikul, w, anders, rl, srisuphan, w, chontawan, r, nuntasupawat, r & pumarporn 2001; norman, ij, redfern, sj, tomalin, da & oliver 1992). in addition, the issue related to measurement of quality of pediatric nursing care is usually associated with the lack of definition and evaluation of the concept of quality of care (leinokilpi, h & vuorenheimo 1994; pelander 2008; suhonen, r & valimaki 2003). the other problem is that there are few instruments developed especially for evaluating the quality of pediatric nursing care. furthermore, in indonesia, the quality of nursing care of children is the main issue in indonesian hospitals. the fifth target goal of the national development plan of indonesia is to reduce the under-five child mortality rate by two thirds from 1990 to 2015 ( mdgs-indonesia, 2008). the indonesian under-five child mortality rate in 1990 was 57/1000 live births and by 2015, this number should be reduced to 38/1000 live births to achieve the target (hernani, sudarti, agustina 2009) (the under-five child mortality rate in 2005 was 38/1000 live births (government of indonesia, 2005) and the major contributor was ari (mdgs-indonesia, 2008) the quality of nursing care is the main concern in a health care setting because of its impact on safety, incidence of pneumonia, length of stay, and mortality rate. also, low nurse performance related to high morbidity and mortality incidence rate of children is a major concern in indonesia, (hennessy, d, hicks, c, hilan, a & kowanal 2006). related to this matter, development and evaluation of the quality of nursing care scale is a vital key to improve the quality of nursing care for hospitalized ari children in order to decrease morbidity and mortality of ari children, especially in indonesia. this scale can used as a guideline for pediatric nurses to assess the quality of nursing care for ari children, to provide the high quality standard of ari nursing care, and also to identify the strength and weakness in the delivery of nursing care. material and method psychometric evaluation of the quality of nursing care scale for hospitalized acute respiratory infection children consisted of 1) evaluasi psikometrik skala kualitas asuhan keperawatan (dewi e.s) 81 administer the items to the development sample, 2) evaluate the items, and 3) optimize scale length (devellis 1991). the qncs-haric is formulated on the basis of the feedback and data received from the development of of the quality of nursing care scale for hospitalizad acute respiratory infection children of devellis process, the researcher administered the demographic data questionnaire, the qncs-haric, and the mcsds-c to 779 pediatric nurses at 39 pediatric wards from general hospitals in indonesia. this was done in order to test for internal consistency and stability of the questionnaire. after receiving the questionnaires back, construct validity were performed using exploratory factor analysis (efa) and the contrasted group approach. reliability was performed both internal consistency and stability. purposive sampling was used to recruit nurses who met the inclusion criteria. the inclusion criteria includes 1) pediatric nurses who have provided nursing care to ari children (age under-five) for at least 1 year, 2) are willing to participate in this study, and 3) are able to communicate in indonesian language. casey, fink, krugman, and propst (2004) found that graduate nurses felt that it took at least 12 months to feel comfortable and confident practicing in the acute care setting. an exploratory factor analysis was conducted with 779 pediatric nurses using the principle axis factoring (paf) extraction with varimax rotation. the data from the qncsharic was assessed for reliability (e.g., internal consistency and stability), factor structure (efa), and a contrasted group for construct validity evaluation. in addition, the mcsds-c will be used to examine for social desirability response bias affecting the validity of a questionnaire by using pearson’s productmoment correlation coefficient. results construct validity was identified using the efa and contrasted group approach. the reliability was evaluated in terms of internal consistency (cronbach’s alpha) and stability (testretest). the results of psychometric evaluation of the validity and reliability of the qncs-haric are as follows. construct validity of the qncs-haric before performing efa, all assumptions of efa were examined. the assumptions of efa consisted of type of data, sample size, normality, linearity, outliers, and multicollinearity. the details of assumptions for efa are as follows. efa requires an interval level of measurement. the qncs-haric has items that are assessed using a likert scale. although the response categories in likert scales have a rank order and should be viewed as ordinallevel measurement, it has become common practice to assume that likert-type categories constitute interval-level measurement as well as the intervals between values are equal. the sample size should be at least 1 to 10 cases per variable. in this study, the qncsharic consisted of 77 variables. thus, sample size should be 770. data were available initially from 807 pediatric nurses with no missing data and 1: 10.48 cases per variable. after deleting 28 outliers, the sample size was 779 and 1:10.1 cases per variable. thus, this assumption was met. the distribution of the 77 variables was examined for each item looking at skewness and kurtosis values. all 76 variables were normally distributed, except variable 70 which had a kurtosis value of 3.78. the box plot was used to detect outliers. after deleting the outliers item 70 had a normal distribution. the skewness values varied from 0.00-3.12, while the kurtosis values ranged from 0.513.26. thus, this assumption was met. linearity was assessed through inspection of scatter plots. the scatter plots of the residual against the predicted values provide information about possible non linearity. the scatter plots showed a positive linear relationship with all linear correlation. thus, this assumption was met. factor analysis is sensitive to outlier cases. outliers were assessed using boxplots and mahalanobis distance. using a criterion of pvalues equals to .001 with 77 df, critical x 2 = 121.11. twenty five outliers were found. the reseacher re-evaluated the variables several times until no outliers were detected by checking the boxplots and calculating mahalanobis distances. multicollinearity was detected using correlation matrices for the independent variables. in this study, multicolinearity was not found (r=.30-.82). thus, this assumption was met. demographic data of pediatric nurses seven hundred and seventy-nine pediatric nurse participants were involved in this study. most of the pediatric nurses were female (90.9%). their ages ranged from 25 to jurnal ners vol. 11 no. 1 april 2016: 79-87 82 48 years old and about less than fifty percent of them (44.3%) were an average of 30 to 40 years old (md = 35, qd = 6). the majority of the participants were muslim (73.8%) and one hundred ninety eight participants were christian (25.4%). the majority of the participants were married (78.7%). all participants had a bachelor degree (100%). more than fifty percent of the participants (60.6%) had more than six years of nursing experience (md = 10, qd = 6). less than fifty percent of the participants (41.8%) had more than six years of working experience with acute respiratory infection children (md = 6, qd = 3.5). less than fifty percent of the participants (41.1%) took care of ari children more than 10 cases per month (md = 10, qd = 3). before performing an efa, an item analysis (an item-total correlation) was conducted. the results showed that 28 items had low item-total correlations, ranging from .02 to .29 indicating that the items might be less consistent and less reliable to reflect the construct when compared with other items in the 77 item qncs-haric. therefore, nine items were eliminated from 77 item qncsharic. however, based on theoretically interpretation, 19 of 28 items were retained. thus, 68 items were used to perform the efa. the item-total correlations coefficients for factor 1 of the 77 item qncs-haric ranged from .04 to .54 whereas those of the 68 item qncs-haric ranged from .11 to .62. the item-total correlations coefficients for factor 2 of the 77 item qncs-haric ranged from .02 to .62 whereas those of the 68 item qncs-haric ranged from .04 to .62. the item-total correlations coefficients for factor 3 of the 77 item qncs-haric ranged from .33 to .55 whereas those of the 68 item qncsharic ranged from .22 to .55. the item-total correlations coefficients for factor 4 of the 77 item qncs-haric ranged from .09 to .58 whereas those of the 68 item qncs-haric ranged from .08 to .60. to determine the number of factors underlying the qncs-haric, an exploratory factor analysis was conducted with 779 pediatric nurses using the principle axis factoring (paf) extraction with orthogonal rotation by using varimax method. in this study, efa was performed several times with the 77 item qncs-haric. the final model consisted of 37 items. before interpretation of the results, the model fits of the 77 and 37 items qncs-haric were identified. kaisermeyer-olkin (kmo) indices of both models were satisfactory (.85-.86). bartlett’s tests of sphericity were significant. the eigenvalues showed in 4 to 22 factors and scree test showed 3-4 factors. the percentage of total variance explained was acceptable only for the model of 37 item qncsharic (40.92%). the percentages of variance explained per factor were acceptable only for the model of 37 item qncs-haric. based on the model fit evaluation, only the 37 item qncsharic model was acceptable. factors, items and factor loadings were interpret only the 37 items qncs-haric because it had a model fit. based on the 37 item qncs-haric consisted of 4 factors. factor 1 the physical dimension of ari children consisted of 14 items. the factor loading of all items of factor 1 were acceptable and significant (varied from .33 to .79, p = .000). the communalities of all items of factor 1 were acceptable (varied from .25 to .74). in factor 2, the psychological dimension of ari children and family consisted of 15 items. the factor loadings of all items were acceptable and significant (varied from .33 to .79, p = .000). the communalities of all items were acceptable (varied from .30 to .58). factor 3, the socio-cultural dimension of ari children and family consisted of 3 items. the factor loadings of all items were acceptable and significant (varied from .33 to .55, p = .000). the communalities of all items were acceptable (varied from .42 to .56). in factor 4, the spiritual dimension of ari children and family consisted of 5 items. the factor loadings of all items were acceptable and significant (varied from .54 to .75, p = .000). the communalities of all items were acceptable (varied from .41 to .64). results from contrasted group approach the independent t-test was used to examine the construct validity of the 77 and 37 item qncs-haric with nurses who had work experience with ari children less than six years (group 1, n = 271) and nurses having work experience six years or more (group 2, n=508). before testing, all assumptions of independent t-test were assessed and were met. the results showed that the mean scores of the 77 and 37 item qncs-haric of nurses who had work experience six years or more were significantly higher than those of nurses who had work experience less than six years. evaluasi psikometrik skala kualitas asuhan keperawatan (dewi e.s) 83 results from internal consistency cronbach’s alpha coefficient of the total 77 items qncs-haric was .92 whereas that of the 37 item qncs-haric was .93. cronbach’s alpha coefficients of factor 1, 2, 3, and 4 of the 77 item qncs-haric were .85, .79, .77, and .76, respectively whereas those of the 37 item qncs-haric were .87, .80, .77, and .76, respectively. the internal consistency of all two versions of the qncs-haric were acceptable. results from test-retest reliability b efo re p erfo rm ing a test -retest reliability, all assumptions of pearson product moment correlation were examined and were met. test-retest was administered twice within a 2 week interval between the tests to two groups of pediatric nurses. the results revealed that the mean score of the 77 item qncsharic measured at time 1 was positively significant and highly correlated with that of measured at time 2 (r =.75). the mean scores of each dimension measured at time 1 also were positively significant and highly correlated with those of measured at time 2 (r = .78, .77, .73, and .81). these high correlations indicate that the instrument is stable over time. results from social desirability before performing social desirability testing, all assumptions of pearson product moment correlation were examined and were met. the results revealed that the overall mean scores of the 77 items qncs-haric did not significantly correlate with the mean score of social desirability (r =.07, p =.06) whereas that of the 37 item qncs-haric did significantly correlate with mean score of social desirability (r =.08, p =.02). for each dimension/factor of the 77 item qncs-haric, the mean scores of factor 1 (physical dimension of ari children), factor 2 (psychological dimension of ari children and family), and factor 4 (spiritual dimension of ari children and family) did not significantly correlate with that of the social desirability (r =.06, p =.12; r =.07, p =.07; r =.04, p =.33, respectively) whereas the mean score of factor 3 (socio-cultural dimension of ari children and family) significantly correlated with that of the social desirability (r =.07, p =.05). for each dimension/factor of the 37 item qncs-haric, the mean scores of factor 1 (physical dimension of ari children) and factor 4 (spiritual dimension of ari children and family), did not significantly correlate with that of the social desirability (r=.01, p=.75; r=.02, p=.61, respectively) whereas the mean scores of factor 2 (psychological dimension of ari children) and factor 3 (socio-cultural dimension of ari children and family) significantly correlated with that of the social desirability (r =.10, p =.01; r =.17, p =.00, respectively). discussion exploratory factor analysis an exploratory factor analysis was conducted with 779 pediatric nurses using the principle axis factoring (paf) extraction with varimax rotation. the paf extraction was chosen because it is the best method of extraction in efa for non-normality distributed data (fabrigar, lr, wegener, dt, maccallum, rc & strahan 1999). paf will give reseacher the best results, depending on whether the data are generally normallydistributed or significantly non-normal, respectively (costello, ab & osborne 2005) the varimax rotation method was chosen because when using varimax rotation, rotated matrix is interpreted after orthogonal rotation and to maximize the factor coefficient for each variable on only one factor (weiner, ib, schinka, ja & velicer 2012) based on the item analysis of 77 item qncs-haric revealed that twenty-eight items had item-total correlation less than .30. the item-total correlation is a reflection of how well items measure what they are intended to be measured. correlations should be range from .30 to .70 (nunnally & bernstein, 1994). correlations that exceed .70 suggest item redundancy, while correlations less than .30 suggest the item is measuring an entirely different construct. according to ferketich (1991), a low item-total correlation is less likely to correlate with other items to form factor in factor analysis. the unexpected results of the efa occurred with the 77 items qncs-haric. although almost all of the criteria for the model fit of the 77 item qncs-haric were satisfactory, the total variance explained was only 32.11%. according to scherer, wiebe, luther, and adams (1988), the total variance explained for new instrument should be at least 40%. in this model, the total variance jurnal ners vol. 11 no. 1 april 2016: 79-87 84 explained was only 32.11% and thus indicates an unsatisfactory. t o p u r s u e a d i s t i n g u i s h a b l e a n d interpretable solution with sound psychometric evaluation for the qncs-haric, the researcher re-examined each item, assigned items to each factors according to the criteria for determining the number of factors included using the following: item-total correlation at least .30 (nunnally, jc & bernstein 1994), reliability of each factor at least .70 (devellis 1991), eigenvalues should be equal or more than 1 (hair et al., 1998), scree test criterion should be the data points above the break (tabachnick, bg & fidell 2007), percent of total variance explained at least 40% or more (scherer, rf, wiebe, fa, luther, dc, & adams 1988), percentage of variance should be equal or more than 5% of variance explained (hair, jf, anderson, re, tatham, rl & black 1998) factor loading at least .30 (hair, jf, anderson, re, tatham, rl & black 1998), and had theoretical interpretability of the item (hair, jf, anderson, re, tatham, rl & black 1998) after item reduction was completed, the number of items was reduced from 77 to 37. four factors were obtained from 37 items, which extracted 42.92% of the total variance explained. scherer, wiebe, luther, and adams (1988) state that the variance explained between 40% and 60% is considered sufficient in social sciences. in this model, the total variance explained was 42.92% which indicated that it was sufficient for a newly development instrument. the kmo was .86 and is acceptable (hair, jf, anderson, re, tatham, rl & black 1998) . bartlett's test of sphericity was significant (p = .000) indicating the suitability of the sample for factor analysis (hair et al., 1998). the eigenvalue for the first factor was 8.25; the second factor eigenvalue was 3.08; the third factor eigenvalue was 2.50, and the fourth factor eigenvalue was 2.05, and since they were all greater than 1.0 indicate a good fitting model (hair, jf, anderson, re, tatham, rl & black 1998) factor loading of all items were acceptable (varied from .30 to .70), indicating that the model fit was acceptable. in this model, all items had communalities greater than .20 indicating an acceptable fit and all items were retained. although the 37 items qncs-haric model was acceptable, it was less representative, especially in the socio-cultural dimension of ari children and family because it consisted of only 3 from 10 items which could not measure the complate dimension of the sociocultural aspect. based on the conceptual framework, the researcher expected that the quality of nursing care for acute respiratory infection children consisted of four dimensions. however, few items of the the socio-cultural dimension of ari children and family were loaded on factor 3, probably due to an unequal number of initial items between factor 3 and the others 3 factors. according to mroch and bolt (2003), the number of items per dimension is manipulated such that a test contains either the same number of items per dimension, or varying numbers of items per dimension. if there are an equal number of items per dimension, each dimension will have an equal proportion. thus, further study is needed to revise and balance the items in each dimension of the qncs-haric. when performing the contrasted group analysis, the overall mean scores of the 77, and 37 items of the qncs-haric of the nurses who had six or more years of work experience with ari children were significantly higher than those of the nurses having work experience with ari children for less than six years. this indicated that the construct measured by all 2 versions of the qncsharic could be distinguished between groups with extremely different characteristics (polit, df & beck 2004; waltz, cf, strickland, ol & lenz 2005) therefore, the researcher may claim some evidence for construct validity that is the instrument measures the attribute of interest (waltz, cf, strickland, ol & lenz 2005). the pediatric nurses who had more work experience with ari children would provide better quality of nursing care to ari children and family. reliability the internal consistency of total 77 and 37 item versions of the qncs-haric was excellent (cronbach’s alpha coefficients .92, .93, respectively). cronbach’s alpha coefficients of 77 and 37 items qncs-haric for factor 1 (physical dimension of ari children) were very good (.85, .86, respectively); factor 2 (psychological dimension of ari children and family) were acceptable (.79) and very good (.81), respectively; factor 3 social-cultural dimension of ari children and family were acceptable (.77, .77, evaluasi psikometrik skala kualitas asuhan keperawatan (dewi e.s) 85 respectively); and factor 4 (spiritual dimension of ari children and family) were acceptable (.76, .76, respectively). this indicated that internal consistency of total 77 and 37 items of the qncs-haric were acceptable. in general, a cronbach’s alpha of at least .70 is the criterion used to establish an acceptable level of internal consistency (nunnally, jc & bernstein 1994). a strong cronbach alpha coefficient scale provides useful information about the internal structure of the scale indicates that the items in the scale are quite correlated with each other ( w o r t h i n g t o n , r l & w h i t t a k e r 2 0 0 6 ) furthermore, the evidence of reliability is very important in the development of research as far as scale increases confidence that the items on the scale that produces consistent scores. for the test-retest of the 77 items of the qncs-haric, total mean scores from administering the qncs-haric on two separate occasions (two weeks apart) gave a correlation coefficient equaled to .75, (p <.001) indicating that the instrument is stable over time (devon, et al 2007) unfortunately, the test-retest was not performed with the 37 item of the qncs-haric. further performing the test-retest reliability with 37 item qncsharic is needed. social desirability the overall mean score of the 77 item qncs-haric did not significant correlate with that of the social desirability whereas the overall mean score of the 37 items of the qncs-haric significantly correlated with that of the social desirability. all mean scores of all dimensions of the 77 item qncsharic did not significantly correlate with that of the social desirability except the mean score of factor 3 socio-cultural dimension of ari children significantly correlated with that of the social desirability (r =.07, p =.05). for 37 item qncs-haric, the mean scores of factor 2 and factor 3 significantly correlated with that of social desirability whereas the other two factors did not. non-significant correlation indicates that social desirability is not a factor affecting the participants’ response to the instrument (crowne, dp, & marlowe 1960) the results of non-significant correlation of these two measures were similar to the study of konggumnerd, isaramalai, suttharangsee, and villarruel (2009) developed a scale to measure sexual health protective behavior in thai female adolescents and to examine its psychometric properties. the results indicated that there was no significant correlation between the mean scores of the sexual health protection scale and the marlow-crown social desirability scale, which means that participants answered the sexual health protection scale without social desirabiliy bias. in contrast, a significant correlation indicates that that social desirability is a factor affecting the participants’ response to the instrument (kassam, a, papish, a, modgill, g & patten 2012) . the results of significant correlation of these two measures were similar to the study of sriratanaprapat, chaowalit, and suttharangsee (2012) which was developed and determined the psychometric properties of the job satisfaction scale for thai nurses (tnjss). the results revealed that the correlation coefficient between social desirability and the tnjss was small (r =.12, p < .01) and significant probably due to large number of subjects (n= 963) (sriratanaprapat, j, chaowalit, a & suttharangsee n.d.) in this study, the sample size also was large (n= 779). paulhus (1991) suggested that researchers should try to reduce social desirability by employing representative subjects. another way, the researcher could administer the marlowe-crowne scale to identify individuals who tend to respond in a socially desirable way and eliminate them from the studies. no design, of itself, can control for motivation and response bias factors. further study, the researcher should use some strategies for minimizing social desirability including: 1) using do guess directions when multiplechoice measures are employed, 2) wording directions as clearly and concisely, 3) avoiding items formats that use fixed-response, 4) using items with a general rather than a personal difference, and 5) avoiding any words or actions that might communicate to subjects that the investigators would give certain responses (waltz, srickland, & lenz, 2005). conclusion and recommendation conclusion the 37 items the qncs-haric is not representative and cannot capture the sociocultural dimension of ari children because the number of items is few. jurnal ners vol. 11 no. 1 april 2016: 79-87 86 recommendation further research is needed to revise and balance the items in each dimension of the qncs-haric. references attree, m., 1996. towards a conceptual model of quality care. international journal of nursing studies, 33, pp.13–28. costello, ab & osborne, j., 2005. best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. practical assessment, research & evaluation, crowne, dp, & marlowe, d., 1960. a new scale of social desirability independent of psychopathology. journal of consulting psychology, 24, pp.349–354. devellis, r., 1991. scale development: theory and applications, newbury park, np: sage. devon, ha, block, me, moyle-wright, p, ernst, dm, hayden, sj, lazzara, dj, savoy, sm & kostas-polston, e., 2007. a psychometric toolbox for testing validity and reliability. journal of nursing scholarship, 39(2), pp.155–164. donabedian, a., 1977. evaluating the quality of medical care. milbank memorial fund quarterly. , 44, pp.106–206. fabrigar, lr, wegener, dt, maccallum, rc & strahan, e., 1999. evaluating the use of exploratory factor analysis in psychological research. psychological methods, hair, jf, anderson, re, tatham, rl & black, w., 1998. multivariate data analysis (5th ed.). upper saddle river, nj: prentice hall. hennessy, d, hicks, c, hilan, a & kowanal, y., 2006. the training and development needs of nurses in indonesia: paper 3 of 3. human resources for health, 4(10), pp.1–14. hernani, sudarti, agustina, t.& s., 2009. report on situation analysis of acute respiratory infection in children in indonesia, jakarta. available at: http://files.dcp2.org/pdf/dcp/dcp25.pd f [accessed january 12, 2011]. indonesia, m.d.g. of, 2008. current situation on mdg 4 and 5 in indonesia. available at: http://www.targetmdgs.org/download/m dg_report_2008_en.pdf [accessed january 10, 2011]. kassam, a, papish, a, modgill, g & patten, s., 2012. the development and psychometric properties of a new scale to measure mental illness related stigma by health care providers: the opening minds scale for health care providers (oms-hc. biomedicalcentral psychiatry, 12(62), pp.2–12. kunaviktikul, w, anders, rl, srisuphan, w, chontawan, r, nuntasupawat, r & pumarporn, o., 2001. development of quality nursing care in thailand. journal of advanced nursing, 36(6), pp.776– 784. lee, ll, hsu, n & chang, s., 2007. an evaluation of quality of nursing care in orthopedic units. journal of orthopaedic nursing, 11, pp.160–168. leino-kilpi, h & vuorenheimo, j., 1994. the patients perspective on quality: developing a framework for evaluation. international journal of quality health care, 6(1), pp.85–95. murphy, k., 2007. a qualitative study explaining nurses perceptions of quality care for older people in long-term care setting in ireland. journal of clinical nursing, 16, pp.477–485. norman, ij, redfern, sj, tomalin, da & oliver, s., 1992. developing flanagan’s critical incident technique to elicit indicators of high and low quality nursing care from patients and their nurses. journal of advanced nursing, 17(5), pp.590–600. nunnally, jc & bernstein, i., 1994. psychometric theory., new york: mcgraw-hill. pelander, t., 2008. the quality of paediatric nursing care-children’s perspective (doctoral dissertation). available at: https://www.doria.fi/bitstream/handle/ [accessed april 20, 2011]. polit, df & beck, c., 2004. nursing research: principles and practices 7th ed., philadelphia, pa: lippincott williams & wilkins. scherer, rf, wiebe, fa, luther, dc, & adams, j., 1988. dimensionality of coping: factor stability using the ways of coping questionnaire, sriratanaprapat, j, chaowalit, a & evaluasi psikometrik skala kualitas asuhan keperawatan (dewi e.s) 87 suttharangsee, w., development and psychometric evaluation of the thai nurses’ job satisfaction scale. pacific rim international journal nursing research., 16(3), pp.175–191. suhonen, r & valimaki, m., 2003. surveying patient satisfaction: challenging for nursing research. hong kong nursing journal, 39(2), pp.7–14. tabachnick, bg & fidell, l., 2007. using multivariate statistics 5, ed., new york, ny: harper collins. waltz, cf, strickland, ol & lenz, e., 2005. issue in nursing measurement. in. cf. waltz, ol. strickland & er. lenz (eds.), measurement in nursing research, philadelphia: pa: davis. weiner, ib, schinka, ja & velicer, w., 2012. handbook of psychology: research methods in psychology 2nd ed.)., hoboken, nj: john wiley. williams, a., 1998. the delivery of quality nursing care: a grounded theory study of the nurses perspective. journal of advanced nursing, 2, pp.808–816. worthington, rl & whittaker, t., 2006. scale development research: a content analysis and recommendations for best practices. the counseling psychologist, ners vol 10 no 2 okt 2015.indd 296 ekstrak getah pepaya sebagai autolitik debridement luka kronis (sap extract papaya for autolitic debridement chronic wound) tri johan agus yuswanto*, tanto hariyanto* *poltekkes kemenkes malang, jl. besar ijen no.77c, klojen, kota malang, jawa timur, 65119, tel. (0341) 551893 email: denbagusjohan@yahoo.co.id abstrak pendahuluan: mahalnya obat-obatan atau dressing luka yang spesifik untuk luka kronis yang minimal bisa sembuh dalam dua minggu bergantung pada stadium luka dan kadar gula darah. berdasarkan hal inilah perlu adanya suatu inovasi pengolahan sumber daya alam (sda) untuk menghasilkan suatu produk perawatan luka kronis yang bisa dijangkau oleh semua kalangan. salah satu yang sedang trend saat ini adalah dengan menggunakan enzim protease (ekstrak getah papaya) yang berfungsi sebagai autolitik debridement pada perawatan luka kronis. tujuan penelitian ini adalah mengidentifikasi karakteristik enzim protease yang terdapat dalam getah papaya. metode: desain penelitian yang digunakan merupakan deskriptif eksploratif dengan melakukan pure ekstrak enzim protease getah pepaya. hasil: hasil pengukuran berat molekul dengan menggunakan kit pre-stained protein markers (broad range) for sds page. nacalai tesque no produksi 02525 diperoleh hasil berat molekul yang homogen dengan gambaran diatas sedikit dari 28 kd. hasil pengukuran kadar enzim menggunakan kit nanodrop spectrophotometer nd-1000, dengan marker aquades, diperoleh hasil relatif homogen dengan rentang antara 43–61% dengan rata-rata 53,88%. hasil penambahan ekstrak papain ke dalam masing-masing tabung reaksi yang berisi 7 ml gelatin diperoleh hasil: kelompok kontrol terdapat penggumpalan sempurna pada gelatin; kelompok dengan penambahan 2 tetes (± 0,5 ml) didapatkan hasil, gelatin terhidrolisis 50%; kelompok dengan penambahan 4 tetes (± 0,5 ml) didapatkan hasil, gelatin terhidrolisis 75%. diskusi: aktivitas pure ekstraksi getah papaya (protease enzim) dalam menghidrolisis gelatin menunjukkan gambaran secara kualitatif dapat digunakan sebagai autolitik debridement. hasil identifikasi dapat dikatakan bahwa ektraksi getah papaya identik dengan enzim protease, maka perlu kiranya dilanjutkan dengan uji struktur dan aktivitas enzim dengan determinan yang lebih banyak (suhu, waktu, dan dosis). kata kunci: ekstraksi getah papaya, enzim protease abstract introduction: the high cost of drugs or specific wound dressings for chronic wounds can be healed at least in two weeks depending on the stage of the wound and blood sugar levels. hence the need for an innovative processing of natural resources (nr) to produce a chronic wound care products that are accessible to all people. one of the current trends is to use protease enzymes (sap extract papaya) that serves as autolitic debridement in the treatment of chronic wounds. the aims of this research was to indentify characteristics of protease enzyme present in sap of papaya. methods: this study was a descriptive exploratory that doing pure protease enzyme extract of papaya sap. results: molecular weight measurement using a kit pre-stained protein markers (broad range) for sds page, nacalai tesque no. 02525 showed a homogeneous molecular weight that slightly above 28 kd. measurements of the enzyme levels using nanodrop spectrophotometer nd kit-1000 (with a distilled water marker) showed a relatively homogeneous enzyme level with a range between 43–61% and 53,88% in average. the addition of papaya sap extract into each tube containing 7 ml gelatin obtained results: the control group there were clots perfectly on gelatin; groups with the addition of 2 drops (± 0.5 ml) obtained 50% hydrolyzed gelatin; and groups with the addition of 4 drops (± 0.5 ml) obtained 75% hydrolyzed gelatin. discussions: the results showed that papaya sap extraction synonymous with protease enzyme. papaya sap extraction activity (protease enzymes) on hydrolyzing gelatin shows a qualitative picture. therefore, it can be used as autholitic debridement. further, the following study is essential to identify structure and activity of the enzyme with a more determinant (temperature, time, and dose). keywords: sap papaya extraction, protease enzymes pendahuluan model d a n sen i per awat a n lu k a sesungguhnya telah lama di kembangkan yaitu sejak jaman prasejarah dengan pemanfaatan bahan alami yang diturunkan dari generasi ke generasi ber ik ut nya, yang ak hir nya perkembangan perawatan luka menjadi modern seiring ditemukannya ribuan balutan untuk luka. menurut carville (1998) tidak ada satu jenis balutan yang cocok atau sesuai untuk setiap jenis luka. pernyataan ini menjadikan kita harus dapat memilih balutan yang tepat untuk mendukung proses penyembuhan luka. 297 ekstrak getah pepaya sebagai autolitik (tri johan agus yuswanto dan tanto hariyanto) pemilihan balutan luka yang baik dan benar selalu berdasarkan pengkajian luka. p e r a w a t a n l u k a k r o n i s y a n g berkesinambungan dan intensif berimbas pada unit cost perawatan yang tidak dapat dijangkau oleh seluruh kalangan masyarakat, khususnya r umpun menengah ke bawah. mahalnya perawatan luka kronis disebabkan oleh dua hal, pertama karena total care pasien yang belum mandiri sehingga perawatannya mutlak perlu dilakukan oleh perawat, namun permasalahan ini bisa diselesaikan dengan memberikan edukasi pada keluarga atau pasien untuk meningkatkan kemampuan perawatan diri menjadi semi mandiri ( partial care) dan menuju keperawatan mandiri (self care). kedua, mahalnya obat-obatan atau dressing luka yang spesifik untuk luka kronis, luka kronis minimal bisa sembuh dalam 2 minggu atau lebih lama bergantung pada stadium luka dan kadar gula darah (dyah ayu, 2011). berdasarkan hal inilah perlu adanya suatu inovasi pengolahan sumber daya alam (sda) untuk menghasilkan suatu produk perawatan luka kronis yang bisa dijangkau oleh semua kalangan. pengembangan teknologi tepat guna dengan memanfaatkan kekayaan sumber hayati yang ada di wilayah negara indonesia sangat memungkinkan dapat digunakan sebagai pengganti peralatan dan bahan perawatan luka kronis. salah satu yang sedang trend saat ini adalah dengan menggunakan protease enzim yang berfungsi sebagai autolitik debridement pada perawatan luka kronis. protease selama ini sudah banyak berkembang untuk perawatan kulit dan beberapa kegiatan rumah tangga lainnya, namun belum dalam perawatan luka kronis. protease secara alamiah di negara kita dapat diambil dengan menggunakan getah pepaya (crude ekstrak papain). getah papaya yang sudah disadap dikeringkan dan langsung diaplikasikan untuk kegiatan rumah tangga. pepaya sangatlah mudah didapatkan di indonesia, khususnya di malang. kabupaten mala ng me r upa k a n sala h sat u sent r a perkebunan pepaya di jatim. menurut data dinas pertanian provinsi jawa timur, produksi pepaya di kabupaten malang 2005 mencapai 23.361 ton, meningkat dari tahun sebelumnya yang hanya 4.557 ton. di kabupaten malang, setidaknya terdapat 500 keluarga tani yang mengusahakan tanaman asal karibia ini meskipun kepemilikan lahan rata-rata hanya 0,3 hektar. penelitian ini sekaligus untuk mengoptimalkan kearifan sumber daya lokal sebagai solusi dalam permasalahan perawatan luka kronis pasien diabetes melitus dengan prinsip nekrotomi enzimatis dari kandungan enzim protease pada carica papaya. pe n el it i a n i n i b e r t uj u a n u nt u k mengidentifikasi karakteristik protease enzim yang terdapat dalam getah papaya, antara lain berat molekul protease enzim getah papaya, kadar protease enzim pada getah papaya, dan aktifitas enzim secara kualitatif. manfaat yang diharapkan antara lain dapat menambah pengetahuan tentang karakteristik protease enzim dalam getah pepaya, dapat digunakan sebagai salah satu dasar pengembangan penelitian lebih lanjut mengenai protease enzim pepaya sebagai autolitik debridement dalam perawatan luka kronis, sebagai dasar pengembangan metode perawatan pada luka kronis dengan tanpa melakukan nekrotomi pada jaringan nekrotiknya, dan sebagai asar pengembangan untuk penurunan unit cost dalam perawatan luka kronis. bahan dan metode desain penelitian yang digunakan mer upakan diskriptif eksploratif dengan melakukan pure ekstrak protease enzim getah pepaya, mengidentifikasi berat molekul, aktivitas kualitatif enzim dan kadar enzim dalam pure ekstraksi papain. penelitian dilaksanakan di laboratorium biokimia poltek kes kemen kes malang (ekst raksi papain dan aktivitas enzim secara kualitatif), laboratorium sentral ilmu hayati (analisis kadar protease) dan laboratorium sentral biomedik (analisis berat molekul) fakultas kedokteran universitas brawijaya malang mulai tanggal 5 september 2012 sampai dengan 26 nopember 2012. getah pepaya disadap dari buah pepaya dengan species paris kw 1 yang berusia 3–4 298 jurnal ners vol. 10 no. 2 oktober 2015: 296–300 bulan. pengambilan dilakukan pada pagi hari dengan melukai kulit buah papaya sedalam 1–2 mm. bertempat di perkebunan papaya wilayah kabupaten malang. sampel getah pepaya diambil dari species pepaya yang sama pada tempat dan waktu yang bersamaan pula. dalam penelitian eksploratif peneliti menggunakan besar sampel sebanyak 10 pohon pepaya dengan sepesies dan tempat lokasi penanaman yang sama. pemisahan protease enzim dari getah pepaya menggunakan metode kromatografi, ph isoelektrik papain 8,75. berat molekul diperoleh dengan mengukur lar utan dan endapan ekstraksi papain menggunakan kit pre-stained protein markers (broad range) for sds page. nacalai tesque no produksi 02525. kadar enzim diukur dengan menggunakan kit nanodrop spectrophotometer nd-1000, dengan marker aquades. pengujian aktivitas k ualit atif en zim dengan mengg u nakan larutan gelatin yang dipapar ekstraksi papain (penambahan ekstrak papain masing-masing 2 tetes dan 4 tetes ke dalam masing-masing tabung reaksi yang berisi 7 ml gelatin, kecuali pada kelompok kontrol tidak ditambah ekstrak papain). hasil hasil penyadapan diperoleh getah antara 3–5 ml sekali penyadapan pada pagi hari, dengan karakteristik warna putih bersih, konsistensi kental, bau segar khas getah papaya. hasil pengukuran berat molekul dengan menggunakan kit pre-stained protein markers (broad range) for sds page. nacalai tesque no produksi 02525 diperoleh hasil berat molekul yang homogen dengan gambaran diatas sedikit dari 28 kd. dapat disimpulkan bahwa dengan menggunakan metode kromatograf i yang telah peneliti modifikasi dapat diperoleh protease enzim dan sudah memisahkan dengan chemocine. h a si l p e ng u k u r a n k a d a r e n z i m menggunakan kit nanodrop spectrophotometer nd-1000, dengan marker aquades. diperoleh hasil relatif homogen dengan rentang antara 43– 61% dengan rata-rata 53, 88% (tabel 1). hasil penambahan ekstrak papain ke dalam masing-masing tabung reaksi yang , 28 kd 31 kd s.1 s.3 s.4 s.5 s.6 s.7 s.8 s.9 s.10 gambar 1. b e r a t m o l e k u l s u p e r n a t a n t ekstrak papain 28 kd 31 kd s.9 s.8 s.7 s.6 s.5 s.4 s.3 s.1 gambar 2. berat molekul endapan ekstrak papain tabel 1 kadar enzim dalam ekstraksi getah pepaya sampel kadar (%) s 1 50,98 s 3 61,93 s 4 56,34 s 5 49,36 s 6 43,46 s 7 61,02 s 8 52,71 s 9 56,08 berisi 7 ml gelatin. penambahan masingmasing 2 tetes dan 4 tetes, serta kelompok control tidak di tambah ekstrak papain diperoleh hasil pada kelompok control terdapat pengg u mpalan sempu r na pada gelatin, kelompok dengan penambahan 2 tetes (± 0,5 ml) didapatkan hasil, gelatin terhidrolisis 50%, dan kelompok dengan penambahan 4 tetes (± 0,5 ml) didapatkan hasil gelatin terhidrolisis 75%. 299 ekstrak getah pepaya sebagai autolitik (tri johan agus yuswanto dan tanto hariyanto) pembahasan metode kromatografi merupakan suatu cara yang tepat untuk memisahkan protease enzim dengan bahan lain yang terdapat pada getah papain. prinsip kromatografi yaitu salt in dan salt out dapat digunakan untuk memisahkan enzim dengan protein yang lain, namun sangat perlu diperhatikan kadar ph yang optimal untuk memindahkan enzim tersebut keluar dari sel getah papaya. berdasarkan beberapa kali percobaan dari ph netral diperoleh ph isoelektris yang dapat digunakan untuk memisahkan protease enzim yaitu sebesar 8,75. penggunaan ph isoelektris sangat menentukan untuk pemisahan enzim tersebut. berat molekul yang diperoleh dari peng u k u ra n d ala m k isa ra n 28 –30 k d menandakan bahwa molekul hasil pemisahan dari getah papaya tersebut adalah protease enzim. berat molekul hasil pemisahan sesuai dengan marker yang diambilkan dari berat molekul protease enzim. berat molekul ekstrak papain yang dipisahkan dengan kromatografi sesuai dengan berat enzim protease, maka ekstrak tersebut kemungkinan adalah enzim protease juga, dengan demikian ekstrak papain dapat dijadikan kandidat untuk pengobatan luka kronis yang bertujuan untuk autolitik debridement. penggunaan metode autolitik debridement dengan menggunakan ekstrak papain dimungkinkan akan dapat menekan unit cost perawatan luka kronis di samping dapat digunakan untuk meningkatkan nilai ekonomis papaya di dunia pengobatan. identifikasi kadar protein dari nano drop dapat diidentikkan dengan kadar enzim asalkan diikuti dengan identifikasi yang lainnya, yaitu: berat molekul dan aktivitas protein tersebut. hasil analisis kadar protein menunjukkan gambaran yang menakjubkan yaitu kadar rata rata 53,99%. nilai terendah kadar 43,46% dan tertinggi 61,93%. kadar enzim yang dapat dikatakan relative tinggi tersebut sangat mendukung untuk pengembangan ekstraksi getah pepaya untuk dunia kedokteran. sampai saat ini yang banyak diterapkan adalah crude ekstrak getah papaya (protease enzim dan chemocine) unt u k kepentingan indust r i makanan. penemuan pure ekstrak papain yang mirip (bahkan sama) dengan protease enzim sangat memungkinkan untuk pengembangan dalam pengobatan luka kronis yang banyak terdapat jaringan nekrotiknya. hasil penambahan ekstrak papain ke dalam masing-masing tabung reaksi yang berisi 7 ml gelatin dan juga hasil observasi pa d a kelomp ok kont rol me nu nju k k a n gambaran kualitatif yang bermakna, di mana ekstrak getah pepaya mampu menghidrolisis gelatin yang identik dengan karakteristik jaringan nekrotik. oleh karena itu, penelitian berikutnya perlu mengidentifikasi efektivitas dari aktivitas enzim protease dari ekstrak getah pepaya agar dapat dijadikan salah satu alternatif produk perawatan luka kronis yang murah dan terjangkau. simpulan dan saran simpulan pemisahan enzim protease dengan menggunakan metode kromatografi perlu memperhatikan kadar ph untuk mendapatkan hasil yang maksimal. berat molekul hasil ekstraksi getah papaya menunjukkan gambaran yang identik dengan berat molekul protease enzim di mana pada kisaran 28kd – 31 kd. kadar enzim protease pada getah pepaya relatif banyak yaitu lebih dari 50% dengan rata-rata 53,99%. berdasarkan hasil penelitian, aktifitas protease enzim dalam menghidrolisis gelatin menunjukkan gambaran secara kualitatif dapat digunakan sebagai autolitik debridement. saran perlu adanya penelitian lanjutan tentang uji str uktur dan aktivitas enzim dengan determinan yang lebih banyak (suhu, waktu, dan dosis). selain itu, diperlukan pula uji stabilisasi protease enzim dari ekstraksi getah papaya serta analisis formulasi protease enzim dari ekstrak getah pepaya agar dapat dibuat dan digunakan sebagai sediaan obat rawat luka. 300 jurnal ners vol. 10 no. 2 oktober 2015: 296–300 kepustakaan a nd r ew h., 1998, fr e que nt ly a ske d questions: alginate dressings, www. worldwidewounds.com berger, karen j., 1999. fundamental of nursing: collaborating for optimal health, 2nd edition, con necticut: appleton & lange. drenth,j., j.n.jansonius, r.koekoek, and b.g.wolthers. 1971. papain x-ray st r ucture. d alam p.d.boyer. t he enzymes. academic press, new york. gitarja, widasari s., 2002. penatalaksanaan perawatan luka. makalah disampaikan pada pelatihan wound dan stoma care ke-2 bagi perawat, rsup. dr. hasan sadikin bandung, 21–25 mei 2002 hartmann, 1999. compedium wounds and wound management. first hartmann medical edition. joanne t., 2002. wound management: a pain free and cost effecctive approach, convatec. disampaikan pada pelatihan wound dan stoma care ke-2 bagi perawat, rsup dr. hasan sadikin bandung, 21–25 mei 2002 perry, ag, dan potter, pa., 1994. pocket guide to basic skills and procedures 3rd edition, st louis, missouri: mosby yearbook. riset kesehatan dasar (riskesdas) 2007a. pe doma n pe wa wa ncara pe t uga s peng umpul data. jakar ta: badan litbangkes, depkes ri, 2007. riset kesehatan dasar (riskesdas), 2007b. laporan nasional 2007. jakarta: badan litbangkes. depkes ri. scrimgeour, k.g., 1977. chemistr y and control of enzyme reaction. academic press, new york. smeltzer, s.c., dan bare, b.g., 2005. brunner and suddart’s textbook of medical surgical nursing 10th edition. lippincot william & wilkins. smith s.f, duell d.j, martin b.c., 2004. clinical nursing skills – basic to advanced skills sixth edition. new jersey: pearson prentice hall. suhartono, m.t., 1992. protease. departemen pendidikandan kebudayaan, dirjen pe nd id i k a n ti ngg i, p u sat a nt a r universit as biotek nologi, instit ut pertanian bogor. tandra, h., 2008.segala sesuatu yang harus anda ketahui tentang diabete s. jakarta: pt gramedia pustaka utama. taylor, et al. 1989. fundamental of nursing – the art and science of nursing care. ph iladelph ia: j.b. lippincott co. http://e-journal.unair.ac.id/jners | 221 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17104 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research care, support and therapy service of hiv patients with the “sate krembung” application totok indarto1, arif rahman nurdianto2 and dyah ayu febiyanti3 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 primary health care of trosobo, sidoarjo, east java, indonesia 3 general hospital of sidoarjo, east java, indonesia abstract introduction: the prevalence and incidence of hiv and aids in sidoarjo is still high. today, the adherence of patients to several art services in sidoarjo is quite low and varied. therefore the researchers want to find out the effectiveness of registration using “the sate krembung” application in terms of service effectiveness, reducing the lost follow up (lfu) and increasing patient adherence in krembung primary health care. methods: the study was cross-sectional. the use of alternative art service modes was done via “the sate krembung” application as an integrated queue system. the patients who participated in this study were hiv patients at krembung primary health care who accessed art at krembung primary health care within the age range of 20 60 years. the total number of samples in this test was 16 patients. results: registration using “the sate krembung” application can reduce the waiting time for getting access to services for the hiv patients who plan on getting cst services and art collection. conclusion: service effectiveness due to the use of “the sate krembung” application can improve service quality, reduce the lost follow up (lfu) and increase the patient adherence in krembung primary health care’s art services. article history received: december 26, 2019 accepted: december 31, 2019 keywords care; support; hiv; sate krembung; contact totok indarto  totokindartoina@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: indarto, t., nurdianto, a. r. & febiyanti, d. a. (2019). care, support and therapy service of hiv patients with the “sate krembung” application. jurnal ners, 14(3si), 221-226. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17104 introduction human immunodeficiency syndrome (hiv) infection is an important public health problem in the worldwide population, especially in east java province which reached 8,204 patients in 2017. this is an iceberg phenomenon that can still increase along with the availability of the poly voluntary consulting test (vct) at each primary health service in the east java province. (kementerian kesehatan republik indonesia, 2018). there are several problems concerning the hiv cases in east java, in that the patients are not always from the key groups, that pregnant women are tested for hiv and that not all health services can carry out hiv testing and care, support and treatment (cst). not all hiv patients are willing to undergo therapy in the health services, adherence to art is still low, there are still hiv patients who have dropped out of treatment and not all cross-sectors of society are involved in handling hiv. (dinas kesehatan kabupaten sidoarjo, 2018). the cases of hiv and aids in sidoarjo regency up until july 2018 was estimated to total 5226 people; hiv patients totaled 2797 people (53%) and the patients who had aids conditions totaled 1432 people. of the 1432 patients with aids, the number of deaths from aids was recorded at 441 people (50%), the number of children with aids was 34 (3.5%) and the number of housewives with aids was 68 (6.6%). (dinas kesehatan kabupaten sidoarjo, 2018; kementerian kesehatan republik indonesia, 2018). since 2018, the district health office of sidoarjo has made a breakthrough in hiv-aids prevention in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). t. indarto, et al. 222 | pissn: 1858-3598  eissn: 2502-5791 the community. the transmission of hiv is not only through sexual contact, but it can also be through blood, syringes and breast milk. individuals who are infected play an important role in the spread of the disease, so contact with patients of hiv is one that needs attention.(widyaningsih, zahra, kurniawan, sutanto, & saputro, 2019) hiv treatment begins with the establishment of a health center that opened specifically for the care, support and treatment services of patients with hiv. the service was started by three major health centers in the sidoarjo regency, namely waru primary health care, krian primary health care and porong primary health care. the increasing number of patients in krembung primary health care center has made the services more crowded so the number of complaints regarding the speed of service being long has increased. queues and crowds are not uncommon.(dinas kesehatan kabupaten sidoarjo, 2018). efforts should also be made to investigate and compare the content development with that of other mobile modalities, such as smartphone applications. research on the prevalence of smartphone ownership required for a feasible sms intervention is also necessary. this could not only lead to improved collaborations and content but it could also facilitate learning and applications beyond hiv/aids.(kerrigan, kaonga, tang, jordan, & hong, 2019). krembung health center has an online queue system called "sate krembung" which can provide a service time. one of its doctors won an exemplary doctor award in 2018 and the primary health care provides art services for patients with hiv.(jawa pos, 2018; puskesmas krembung, 2018). based on the explanation above, the researchers in this study tried to find an alternative queuing model to increase the adherence to taking medication within the hiv patients in krembung primary health care with the use of the application "sate krembung". with this research, it is expected that there will be a new queuing model to increase the adherence to taking art drugs, to reduce the queue numbers and finally to be able to increase the lost follow up rate and the quality of health services in the sidoarjo district overall. materials and methods this research was conducted by making an online application that we named “sate krembung”. the present study involved both male and female patients at the poly vct krembung primary health care in sidoarjo regency who had been tested for hiv using three methods and who had been declared hiv reactive within the age range of 20 60 years old between july december 2018. the patients were divided into 11 men and 5 women. the patients will begin the registration treatment manually by taking a queue number at the counter along with the general patients and the elderly without special treatment. the clerk will calculate the time by recording the time taken from the patient taking the queue number at the counter up until the patient gets the medicine and goes home. at the next visit, the patient will be given education and information about “the sate krembung” application and taught to download and operate it online. the patients, on the second visit, will be asked to register online at the time specified by the officer for taking drugs online with “the sate krembung” application. the registration is done during the visit. when the patient arrives for the third visit, a time calculation will be made as done in the manual registration above. then the data obtained is recorded and the data processing and analysis is performed using spss version 21. the art services at krembung primary health care are initially carried out just like those of the general patients who have just arrived for treatment and who are not familiar with “the sate krembung” application. we recorded the time of service from when the patients queued up until they obtained the medical record collection services, including the waiting time for the doctor services until they were served by the doctors, the prescribing services from the time that the patients handed over the prescription to being given the drugs and the drug information itself. all service times were calculated one by one and then cumulatively. after that, the data in our patient's medical record was analyzed. the art therapy for the patients receiving queue treatment with “sate krembung” was in the form of a fixed dose combination (fdc) with a single dose taken at night. the fdc composition was tenofovir 300 mg, lamivudin 300 mg and efavirenz 600 mg.(peraturan menteri kesehatan republik indonesia momor 84 tahun 2014 tentang pedoman pengobatan antiretroviral, 2014) the material needed by this research was “the sate krembung” application that was available on google play store. how to get and operate the application is listed below: 1) the patient is directed to download “the sate krembung” application on the google play store and to install it on their android smartphone. in the privacy policy option, the patient is asked to give their agreement and then the patient logs in to the application. 2) an explanation of how to use the schedule message feature and others on the application is given. 3) the patients are asked to register on their visit with the application according to the schedule for taking arv control. then they need to save the queue receipt in the patient gallery which can be done automatically through the application. 4) patients come directly to the doctor's room without going in line according to the hours that the queue is served shown on the receipt. 5) patients enter the examination room and get seen to by the doctor. 6) patients submit their prescriptions to the krembung primary health service pharmacy, get jurnal ners http://e-journal.unair.ac.id/jners | 223 their medication and provide information about the drug. 7) each patient moves to where the officer records the time as needed 8) data is collected, analyzed and compared to the manual queuing services without the application use. results the cst services provided to the hiv / aids patients are services that may still be very taboo and that can cause stigma. our patients are very keen to maintain the confidentiality of their status so then the service must be carried out as confidential as possible. at present, there are 16 hiv patients in krembung primary health service consisting of 11 men and 5 women. characteristics of the patients the patients who contributed to this research are distinguished by sex; there are 11 men (69%) and 5 (31%) women as can be seen in figure 1. based on figure 1, there were 11 (69%) men and 5 (31%) women who were registered as patients with hiv at krembung primary health care in 2018. they were declared hiv reactive and were aged between 20 60 years old. they were patients between july december 2018. poly vct service with manual registration the duration of time regarding the poly vct service through manual registration at krembung primary health care as can be seen in the figure 2. from the observations of the 16 patients with hiv who received the services without using “the sate krembung” application, the average queue time obtained up until the patient's medical record was delivered to the doctor's office was 28 minutes. the waiting time to be called up to obtain the services of the doctor was 19 minutes, the waiting time from the first time hanging the script over to get the medicine and to get an explanation of the drug information amounted to 22 minutes and the obtained total time during the poly vct service at krembung primary health care without using “the krembung sate” application was 69 minutes poly vct service with the “sate krembung” application the duration of time taken using the poly vct service with “the sate krembung” application at krembung primary health care can be seen in the figure 3. from the observation of 16 patients with hiv who received services via “the sate krembung” application, the average queue time was obtained up until the patient's medical record was delivered to the doctor's room at 0 minutes. this was since the patient first arrived because the medical record was prepared a day before the patient arrived. the waiting time before being called up to getting the service by the doctor was 8 minutes. this is because with “the sate krembung” application, the patient can come up with an estimated period of time that has been printed on the application token. the waiting time from the first time putting the prescription in to getting the medicine and the explanation about the drug information is equal to 5 minutes. this is because the routine arv drug preparation has been done one day before and the drug officer only needs to add additional prescriptions if the doctor provides additional therapy. the total time taken to obtain the poly arv services at krembung health center using “the krembung sate application” was 13 minutes. difference in the time of the poly vct service between manual registration and registration with the “sate krembung” application. the differences in the duration of time through the poly vct service between manual registration and “the sate krembung” application at krembung primary health care can be seen in the figure 4. according to figure 4, it was found that the mean value of providing the medical records was 28 minutes by manual registration and 0 minutes by “the sate krembung” application. the doctor’s service was 19 minutes by manual registration and 8 minutes by “the sate krembung” application. the receipt service was 22 minutes by manual registration and 0 minutes by “the sate krembung” application. the total time was 69 minutes by manual registration and 13 minutes by “the sate krembung” application. based on the statistical analysis using the ibm spss statistical version 21 application with an independent sample t test, we obtained the significance (p) value and an f value of 22,033 which means that there were differences in the time service: 1) mr preparation (p) value of (0,0001) < α (0,05) between manual registration and registering using “the sate krembung" application 2) doctor service (p) value of (0,02) < α (0,05) between manual registration and registering using “the sate krembung" application 3) receipt (p) value of (0,0001) < α (0,05) between manual registration and registering using “the sate krembung" application 4) total time (p) value of (0,0001) < α (0,05) between manual registration and registering using “the sate krembung" application. based on the statistical analysis, there are differences in both of the services which could reduce the queue when providing medical records to the hiv table 1. results of the analyzed independent t test between manual registration and “the sate krembung” application at krembung primary health care in 2018. variable f sig (p) value medical record service 22.033 .000 time doctor service 6.082 .020 receipt time 39.201 .000 total time 23.217 .000 t. indarto, et al. 224 | pissn: 1858-3598  eissn: 2502-5791 patients who plan to take medicine at krembung primary health care. discussion looking at the long time needed to get access to the art services, we are trying to implement “the sate krembung” application service for patients alongside the art services in order to allow them to get fast and quality service on their next visit. there is a significant change in the service time with the use of “the sate krembung” application for all poly art service patients. another benefit that can be taken from using this application is that it can reduce the lost follow up (lfu) rate in hiv patients in krembung health center by 0%. when evaluating the patients with the interview technique, the lfu decline was found to be due to several factors. 1. the patient feels comfortable and more secure about their privacy 2. the patients do not need to linger for treatment (time efficiency) 3. the patients can order a schedule of controls for a month before within the application 4. the patient does not need to queue again 5. the clerk can remind them of the time of the patient's visit if the patient forgets through whatsapp this result can be compared with the lfu numbers on the art service users that have not used other online-based services. this can be seen in the results of the evaluation of the lfu art services in 4 large primary health care centres which provide art services in sidoarjo, porong primary health care at 20.6%, taman primary health care at 8.8%, waru primary health care at 0% and sidoarjo primary health care at 38.7%. in addition, the use of “the sate krembung” application can also increase adherence by up to 100% in the patients receiving the art services at krembung primary health care. this can be compared to the adherence to arts among the other art services in other sidoarjo regencies such as porong primary health care at 75%, krian primary health care at 79.2%, sidoarjo general hospital at 34.8% and waru primary health care at 90.5%. this number may still change again with the increase in the number of patients and others because of the factors that affect the level of adherence. however, it is expected that the use of this application can increase the patient's level of satisfaction and the comfort of the patients when it comes to accessing art regularly. based on the statistical analysis through the ibm spss statistical version 21 application, it was found that the mean total time for treatment for the hiv patients in krembung primary health care from the time that they arrived at the puskesmas through to obtaining drugs with the "sate krembung" application queue was 12,875 minutes. the total treatment time through the manual registration route amounted to 68,8125 minutes. the independent sample t test obtained a significance value of (p) 0.0001 < α=0.05 with an f value of 23.217. this means figure 1. characteristics of the patients by gender at krembung primary health care in 2018 figure 2. duration of time taken for the poly vct service through manual registration at krembung primary health care in 2018 figure 3. duration of time taken to obtain the poly vct service with “the sate krembung” application at krembung primary health care in 2018 figure 4. duration of time taken for the poly vct service between the manual registration and “the sate krembung” application in the krembung primary health care in 2018 jurnal ners http://e-journal.unair.ac.id/jners | 225 that there is difference in the total time of service between the manual registration and when using the "sate krembung" application. this can thus reduce the total treatment time for the hiv patients who plan to seek treatment at krembung primary health care. another analysis of the benefits of “sate krembung” application is that the level of adherence to the inh prophylaxis therapy (ipt) by the hiv patients in krembung primary health care focused on 4 people was also 100 percent following the patient’s adherence to art. therefore by utilizing this application, it is expected that inh prophylactic therapy can be achieved and that it can prevent infection from mycobacterium tuberculosis. this thus reduces the morbidity of hiv patients due to tuberculosis infection. for the ipt in tb incidence, it was found that ipt in people who are living with hivaids had a significant protective effect, where the incidence of tb in plhiv was 0.21 times (irr 0.21,95% ci 0.023-0.881, p 0.008) lower than nonexposed patients. in this study, ipt decreased the tb incidence rate by 79%.(satiavan et al., 2018) oral candidiasis and pulmonary tuberculosis were the most common opportunistic infections found in airlangga university hospital. (asmarawati, putranti, rachman, hadi, & nasronudin, 2018). with the use of this application, 5 patients with opportunistic infections (oi) were found in which 3 hiv patients with ois recovered and did not repeatedly contract the previous oi. in addition, with the use of this application, the level of adherence to taking oat in the hiv patients with category 1 tb can be controlled and the patients were thus not late taking the oat along with art. one patient, a hiv patient with category 2 oi tb undertaking oral streptomycin and oat injection therapy, also experienced 100 percent compliance levels even though in the oat therapy before this application, the patient experienced tb therapy failure twice. with the use of this application, the patients can also mention any complaints received due to art .they can mention it on the online form in the complaints column so then the doctors can anticipate the side effects of fdc drug use earlier, so the handling complaints of the drug side effects can be treated early. this is so then the level of adherence to art is also good. using this application, the hiv patients can use the features contained within the application such as reporting the presence of patients suspected of tuberculosis. this can increase the rate of hiv testing in krembung primary health care. this is due to a policy that requires the patients with tb to be tested for hiv so then it can be detected early and treated as soon as possible. in addition, hiv patients who have “the sate krembung” application can play an active role in promotive and preventive public health efforts through other features in the application conclusion the use of “the sate krembung" application in the hiv support and treatment care program in krembung primary health care could shorten the service time. this could improve the adherence of the patients with hiv aids in taking drugs, thus reducing the number of lost follow up (lfu). the “the sate krembung” application can improve the quality of service offered in krembung primary health care related to both public good services and private good services. acknowledgment this research was funded by the blud krembung primary health care to develop “the sate krembung” application. we would like to say thank you to all of the patients with hiv at krembung primary health care who were really cooperative in joining this research. we would also like to thank the head of krembung primary health care that supports this research well. references asmarawati, t. p., putranti, a., rachman, b. e., hadi, u., & nasronudin. (2018). opportunistic infection manifestation of hiv-aids patients in airlangga university hospital surabaya. iop conference series: earth and environmental science, 125(1). https://doi.org/10.1088/17551315/125/1/012061 dinas kesehatan kabupaten sidoarjo. (2018). profil dinas kesehatan kabupaten sidoarjo. jawa pos. (2018). hebat, dokter arif rahman berhasil pangkas waktu berobat. retrieved from https://www.jpnn.com/news/hebat-dokter-arifrahman-berhasil-pangkas-waktu-berobat kementerian kesehatan republik indonesia. (2018). laporan perkembangan hiv aids dan infeksi menular seksual (ims) triwulan iv 2017. retrieved from siha.depkes.go.id/portal/files.../laporan_hiv_aid s_tw_4_tahun_2017__1_.pdf. kerrigan, a., kaonga, n. n., tang, a. m., jordan, m. r., & hong, s. y. (2019). content guidance for mobile phones short message service (sms)-based antiretroviral therapy adherence and appointment reminders: a review of the literature. aids care psychological and socio-medical aspects of aids/hiv, 31(5), 636–646. https://doi.org/10.1080/09540121.2018.15497 23 peraturan menteri kesehatan republik indonesia momor 84 tahun 2014 tentang pedoman pengobatan antiretroviral. (2014). puskesmas krembung. (2018). profil puskesmas krembung. satiavan, i., hartantri, y., werry, b., nababan, y., wisaksana, r., & alisjahban, b. (2018). effect of isoniazid preventive therapy on tuberculosis incidence in people living with hiv-aids at hasan sadikin hospital. iop conference series: earth and t. indarto, et al. 226 | pissn: 1858-3598  eissn: 2502-5791 environmental science, 125(1). https://doi.org/10.1088/17551315/125/1/012006 widyaningsih, p., zahra, u. u., kurniawan, v. y., sutanto, & saputro, d. r. s. (2019). susceptible infected aids treatment (siat) model. iop conference series: earth and environmental science. https://doi.org/10.1088/17551315/243/1/012047 336 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17178 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review analysis of occupational therapy in schizophrenic patients siti khadijah, darni darni, and sitti sulaihah faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: nursing care in the rehabilitation phase is one which provides occupational therapy, which is one form of combination therapy between art and science to direct patients to selective activities, so that health can be improved and maintained, and prevent disability through work activities and training this study is to show evidence of the effectiveness of occupational therapy interventions: job training in schizophrenic patients at the mental hospital. methods: the method used in this systematic review consists of 5 stages: identification of instruments in the literature (database search); identification of relevant literature based on title and abstract; inclusion and exclusion criteria; obtaining full text literature; assessment based on literature component and analysis of selected instruments. the database used in the literature search was scopus, proquest, science direct, japan journal, cochrane by limiting the keywords "occupational therapy" and "schizophrenia", which were published in the years between 2012-2018. results: fifteen studies were included in the analysis, only 10 journals met the criteria to be included in the quantitative design. conclusion: from the results of this study it was found that occupational therapy was significant in improving cognitive, social, work, welfare, and contributing to the quality of life of patients. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords occupational therapy; cognitive; social; work, welfare contact siti khadijah  khadije1704@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: khadijah, s., darni, d., & sulaihah, s. (2019). analysis of occupational therapy in schizophrenic patients. jurnal ners, 14(3si), 336-339. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17178 introduction mental health is still one of the most significant health problems in the world, including in indonesia. the world health organization (who) estimates that more than 21 million people worldwide are living with schizophrenia. the median incidence of schizophrenia is estimated at 15.2 cases per 100,000 of the general population with lifetime prevalence estimated at 7.2 per 1000 of the general population (mcgrath 2008). prevalence is higher in males compared to females (rate ratio 1.4:1) and the mortality risk for people with schizophrenia is two to three times that of the general population, with an allcause standardized mortality ratio of 2.6:1. the number of mental disorders is still very high. one of the most common mental disorders is schizophrenia which is a disease that affects the brain and results in disorders of the mind, perception (hallucinations), emotions, and behavior (videbeck, sheila, 2008) schizophrenia produces experiences of loss of work, since suffering from the disease affects quality of life and has a high rate of recurrence, (singh, singh, & ., 2019) explains the results of his research on studies showing that people who suffer from schizophrenia have poor maintenance abilities, their personal hygiene, loss of interest in meeting people at the time of illness, poor communication skills (good skill deficits). scores also indicate that they lost their work skills since the disease began. nursing care at the rehabilitation stage is one of which provides occupational therapy which is a combination of art and science to direct patients to selective activities, so that health can be improved and maintained, and prevent disability through activities and work activities for mentally and physically handicapped people (badan penelitian dan pengembangan kesehatan, 2013). this is supported by research journals from d’amico, (2018) which confirms that every impact of psychosocial therapy and rehabilitation, neutralizes the causes of withdrawal of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 337 patients from social life. social skills training is needed in teaching patients to return to situations when they will be able to function properly in their environment (amico, jaffe, & gardner, 2018). materials and methods literature search strategy the literature used in this systematic review uses tracing through 6 (six) electronic databases, namely: scopus, science direct, proquest, which has been published in publications from 2012 to 2018. that is the key word used is occupational therapy and schizophrenia. furthermore, the method chosen was a study using randomized clinical trials (rcts) which discussed occupational therapy in schizophrenia. study design the study design became the inclusion criteria in this systematic review, the design is a random controlled trial (rct) published in english. population the population in this systematic review is all studies evaluated patients who received occupational therapy interventions with or without a control group, such as schizophrenic patients, productive age according to who (15 54 years), and rehabilitation patients, able to communicate well and cooperatively. intervention occupational therapy that has been found in the study of this literature is given by a combination of social management, psychosocial interventions on interpersonal functioning and personal and social, occupational goal intervention clinical results the main outcome of the main objective of this systematic review is that occupational therapy interventions have a significant impact on improving cognitive, social, occupational and patient welfare functions, contributing to the quality of life of patients and effective treatment in schizophrenic patients. study selection standard protocols are used for selecting studies as suggested in the systematic review method guide, prisma. the steps taken are duplicate eraser, examination independently for titles, abstracts, and keywords and citations that are not relevant according to the inclusion criteria, f the title and abstract are approved by the inclusion review meeting and are in accordance with the objectives of the systematic review, the next step is the selection of the journal with full text, the final step is to select a journal using a randomized controlled trial to reduce the possibility of bias data extraction data is extracted from each studio that meets the requirements. the extracted data adds research characteristics, characteristics of occupational therapy, characteristics of results and ranking of results. data analysis studies are grouped according to the effects of occupational therapy in improving cognitive, social, occupational and patient welfare functions, contributing to patients' quality of life and effective treatment in schizophrenic patients. if possible, the research was then grouped based on the time of follow-up and the type of control group. results picture 1. the search results and study selection follow the prisma guidelines (liberati et al., 2009). selection of journals was based on the keywords used to produce prequest 15,517 there are 2 corresponding journals and 15,515 journals issued because they do not meet the eligibility criteria, scopus 202 there are 5 appropriate journals and 197 journals issued because they do not meet the eligibility criteria. science direct has 1 journal that matches the criteria, japan journal of nursing science has 1 journal that is appropriate. in cochrane there is 1 corresponding journal. a total of 10 studies were selected for systematic review. the results of research show that social skills develop the potential to maintain socio-occupational skills personally with schizophrenia (singh & singh, 2018). the results of çakmak, et al, study that there are benefits from work activities, as indicated by improvements in all client psychiatry scores on personal and social performance scale (psp) compared to scores from the control group: patients who did not participate in this activity (çakmak, süt, öztürk, tamam, & bal, 2016). development of individual therapy occupational programs (iot) and impacts on neurocognition, symptoms and social functioning of patients with schizophrenia, shimada et al, is iot in psychiatric facilities can improve psychosocial treatment of figure 1. prisma of systematic review s. khadijah, et al. 338 | pissn: 1858-3598  eissn: 2502-5791 schizophrenia, improve cognition and symptoms in patients with schizophrenia (shimada, nishi, yoshida, tanaka, & kobayashi, 2016). the results of the shimada, et al study were mixed effect models, indicating that the occupational group therapy (got) + individual okupaei therapy (iot) shows a significant increase in verbal memory memory that works, verbal fluency, attention and composite score mmas-8 score (p <0.01) compared to got only. patients on got + iot showed a significant increase in the japanese version of the client satisfaction questionnaire-8 (csq-8j) (shimada, ohori, inagaki, & shimooka, 2018). independence of patients function tanaka, et al shows that early occupational therapy can improve functional independence in acute schizophrenic patients (tanaka, yotsumoto, tatsumi, maeda, & hashimoto, 2014). occupational therapy of daily activities (adl), eklund, et al, describes satisfaction with daily activity activities and selfassessed health, and functional grouping effects reduce dependence on improvement findings in symptoms. although the occupational therapy group adl was lower the results than the balance everyday life (bel) group (eklund, tjörnstrand, sandlund, & argentzell, 2017). discussion there are similarities in the results of research on the occupational occupational therapy program (iot) and occupational group therapy (got) better than got alone with significant results on improving cognitive function, including verbal memory, working memory, verbal ability. these findings provide preliminary support for the feasibility of applying iot and effectiveness to improve cognition and symptoms in patients with schizophrenia with the same measurement tools, namely short cognition assessment in japanese-schizophrenia (bacs-j), positive and negative syndrome scale (panss) . the research was carried out by the same author, but with different teams and at times there were additional assessments on the japanese version of intrinsic motivation inventory (imi-j), morisky-8 drug compliance scale (mmas-8), and the japanese version of the satisfaction questionnaire client-8 (csq-8j). there is a similarity in the provision of interventions, namely occupational therapy: work activities but with a positive impact on varied schizophrenic patients, namely increasing independence, social work, social skills (social performance, interpersonal function), and decreasing psychiatric symptoms both negative and positive symptoms with measuring instruments that are interpersonal function scale (ifs) and personal and social performance scale (psp), functional independence is measured using functional independence measurement (fim), psychiatric symptoms are also measured by the short psychiatric rating scale, social work function scale (sofs), and self-prepared checklist of social skills, behavioral assessment of dys-executive syndrome (bads) as the main outcome of executive function therapy occupational rehabilitation direct functional assessment (dafs-br) as well as the independent life skills survey (ilss-br) as a secondary outcome, the syndrome scale (panss) is used to monitor the severity of symptoms, scale for the assessment of positive and negative symptoms (sans, saps) there is 1 study that is different from occupational therapy results: lower work training in schizophrenic patient satisfaction than daily activity occupational therapy (adl), [6] describing the bel group increased more than the cau group from baseline to 16 weeks in primary outcomes in terms of activity involvement (p <0.001), activity level (p = 0.036) and activity balance (p <0.042), satisfaction with each day. the aim of a systematic review of occupational therapy is to review the clinical evidence of the effect of therapeutic occupational intervention in schizophrenia. based on the results of the analysis there are many effects resulting from various combinations of occupational therapy interventions. so that it can be continued in subsequent studies. based on a review of the differences in journals, it was found that occupational therapist interventions had a lot that stated that the benefits for schizophrenic patients such as improving cognitive, social, occupational and patient welfare functions contributed to the quality of life of patients and were effective for treatment in schizophrenic patients. expectations at health care facilities namely mental hospital maximize and develop occupational therapy so as to improve the quality of life for schizophrenic patients and reduce the rate of recurrence. there are several potential limitations that are subscribed to by a systematic review of occupational therapy that is a few journals are in accordance with the criteria, namely with a village-level, quasi-experimental controlled rct study with the limits of the last 5 years many journals were not in english. conclusion there are several occupational therapy journals explaining the benefits that are almost the same as having a positive effect on schizophrenic patients, and occupational therapy is more on the type of work training activities focusing on the recognition of existing abilities in patients by providing work skills training, and many are given in combination with other therapies such as social management, psychosocial interventions on interpersonal functioning and personal and social, occupational goal intervention. there is one therapeutic occupational journal with a different type, namely focusing on activity daily living (adl). occupational therapy interventions have some significant positive effects, especially in the treatment of schizophrenia. references amico, m. l. d., jaffe, l. e., & gardner, j. a. (2018). jurnal ners http://e-journal.unair.ac.id/jners | 339 evidence for interventions to improve and maintain occupational performance and participation for people with serious mental illness : a systematic review. badan penelitian dan pengembangan kesehatan. (2013). riset kesehatan dasar (riskesdas) 2013. laporan nasional 2013, 1–384. https://doi.org/1 desember 2013 çakmak, s., süt, h., öztürk, s., tamam, l., & bal, u. (2016). the effects of occupational therapy and psychosocial interventions on interpersonal functioning and personal and social performance levels of corresponding patients. (9), 234–240. https://doi.org/10.5152/npa.2015.10130 eklund, m., tjörnstrand, c., sandlund, m., & argentzell, e. (2017). effectiveness of balancing everyday life (bel) versus standard occupational therapy for activity engagement and functioning among people with mental illness a cluster rct study. bmc psychiatry, 17(1), 1–12. https://doi.org/10.1186/s12888017-1524-7 foruzandeh, n., & parvin, n. (2012). occupational therapy for inpatients with chronic schizophrenia : a pilot randomized controlled trial. https://doi.org/10.1111/j.17427924.2012.00211.x morris, k., syed, a., reid, g., & spencer, s. (2016). occupational therapy delivered by specialists versus nonspecialists for people with schizophrenia ( protocol ). (10). https://doi.org/10.1002/14651858.cd012398 .www.cochranelibrary.com shimada, t., nishi, a., yoshida, t., tanaka, s., & kobayashi, m. (2016). development of an individualized occupational therapy programme and its effects on the neurocognition , symptoms and social functioning of patients with schizophrenia. 425–435. https://doi.org/10.1002/oti.1445 shimada, t., ohori, m., inagaki, y., & shimooka, y. (2018). a multicenter , randomized controlled trial of individualized occupational therapy for patients with schizophrenia in japan. 1–18. singh, u., & singh, b. (2018). assessment and management of socio-occupational functioning of persons with chronic schizophrenia : effect of. 13(1), 189–198. singh, u., singh, b., & . s. (2019). assessment and management of socio-occupational functioning of persons with chronic schizophrenia: effect of social skills training. journal of psychosocial research, 13(1), 189–198. https://doi.org/10.32381/jpr.2018.13.01.18 tanaka, c., yotsumoto, k., tatsumi, e., maeda, k., & hashimoto, t. (2014). improvement of functional independence of patients with acute schizophrenia through early occupational therapy : a pilot quasiexperimental controlled study. 7–10. https://doi.org/10.1177/0269215514521440 videbeck, sheila, l. (2008). buku ajar keperawatan jiwa. jakarta: penerbit buku kedokteran egc. vizzotto, a. d. b., celestino, d. l., buchain, p. c., oliveira, a. m., oliveira, g. m. r., di sarno, e. s., … elkis, h. (2016). a pilot randomized controlled trial of the occupational goal intervention method for the improvement of executive functioning in patients with treatment-resistant schizophrenia. psychiatry research, 245, 148– 156. https://doi.org/10.1016/j.psychres.2016.05.0 11 378 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17219 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the implementation of therapeutic communications with postoperative patient satisfaction in islamic hospital of sultan agung semarang alif wahdatin, dyah wiji puspita sari and muh. abdurrouf departmen of nursing science, sultan agung islamic university, indonesia abstract introduction: weaknesses in applying therapeutic communication are still a problem for nurses. this affects the quality of nursing services that have an impact on patient satisfaction. the purpose of this study was to identify the relationship between therapeutic communication and postoperative patient satisfaction. methods: this research method was an analytical survey method used a cross sectional approach. respondents in this study were postoperative patients who were treated in rsisa inpatient ward with 127 patients. sampling technique that use was simple random sampling. the data analysis technique in this study used the spearman test. results: the results showed that the majority characteristics of respondents had female 61.4%, age 50-64 (33.8%), employment of private employees 24.4%, senior secondary education 37.0%. the results also showed that most therapeutic communication was in the good category (54.3%) and patient satisfaction in the category was very satisfied (52.8%). the results of this research showed that there was significant relationship between therapeutic communication and postoperative patient satisfaction with p-value 0,000 (p-value <0.05). conclusion: the implications of this research can be a reference in increasing the ability of nurse therapeutic communication so that patient satisfaction with nursing services increases. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords therapeutic; communication; postoperative; patient satisfaction contact dyah wiji puspita sari  daiyah_04@yahoo.com  departmen of nursing science, sultan agung islamic university, indonesia cite this as: wahdatin, a., sari, d.w.p., & abdurrouf, m. (2019). the implementation of therapeutic communications with postoperative patient satisfaction in islamic hospital of sultan agung semarang. jurnal ners, 14(3si), 378-382. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17219 introduction a hospital organization consists of various members whose communication with one another may result in conflicts. because of the typical urgency of tasks, smooth communications among departments and colleagues in relation to patients are essential in a hospital (kim, 2011; o’connell & gardner, 2012). nurses comprise most staff in most hospitals and come into contact with other hospital staff and departments most frequently. all activities related to patients, the main customers of a hospital, are conducted through nurses (dinh, walker, parameswaran, & enright, 2012). (lee, 2008) weakness in communication is still a problem for nurses and patients because the nursing process does not run optimally and causes patient discomfort. patients often complain about nursing services where service is unsatisfactory and makes patients angry, this is sometimes due to misunderstanding of communication with nursing staff who do not understand the intent of the message conveyed by the patient (sya’diyah, 2013). good nurse communication will enhance the image of professionalism in him. conversely, if nurse communication is not good, this will affect the client's assessment of the nurse. because in communication, especially therapeutic communication, there are several characteristics of a nursing staff needed to solve problems and facilitate therapeutic growth. honesty (trustworthy) which is owned by a nurse, expressive in delivering messages, is positive so that patients feel cared for by nurses, have an attitude of empathy and not sympathy, are able to see patient problems from the patient's point of view, sensitive to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 379 the patient's feelings, not affected by the past clients and nurses themselves. the result of the research from (park, jeoung, lee, & sok, 2015) show that affiliation and time of worse duty each had a significant impact on self-efficacy. positive correlations the degrees of communication competence and selfefficacy of er nurses were good, with higher scores than the median values. religious affiliation and previous participation in communication education each had a significant impact on communication competence. religious were identified among communication competence, self-efficacy, and job satisfaction (park et al., 2015). the difference in individual communication of each nurse has a direct impact on one's behavior (ivanovich, konopaske, & matteson, 2007). gibson in farida (2011) explains that there are three individual variables. the nurse's performance in question is one of them is the application of therapeutic communication. job performance decreases with age. age also affects a person in intrapersonal relationships. men and women have uniquely different communication styles. physically between men and women are different, parenting is different, the style of speech is different, even the tone of voice is different. education affects the individual mindset influences a person's behavior (asmadi, 2008). the duration of work influences nurses in developing communication skills because a lifetime experience will continue to grow throughout his professional career (sheldon, 2013). patient satisfaction is one of the important indicators that must be considered in health services. patient satisfaction is the result of assessment of patients on health services by comparing what is expected in accordance with the reality of health services received in a health order in the hospital (kotler, 2007). thus patient satisfaction at the hospital depends on how the service provided by the hospital. but the services provided are still not in accordance with what is desired by the patient and patient satisfaction is still not in accordance with the standard. measuring nursing care quality has been recognized as a priority for healthcare providers and policymakers. there are two critical factors indicating the need to measure nursing care quality. first, nurses represent the largest segment of healthcare professionals, and therefore measuring nursing care quality is critical to improving practice (freitas, silva, minamisava, bezerra, & sousa, 2014). second, measuring nursing care quality is a necessary step in determining the level of success that healthcare systems achieve in providing high-quality, high-value care in an equitable manner (freitas et al., 2014). the low number of patient satisfaction will have an impact on the development of the hospital. in patients who feel dissatisfied with health services received, the patient decides to move to another hospital that can provide better services (abdel maqsood, oweis, & hasna, 2012)(kotler, 2007). the results of darmawan's study (2009) with the title "the relationship between therapeutic communication implementation and client satisfaction in obtaining nursing services in emergency services at dr soedarso hospital pontianak west kalimantan" stated that most of the nurses in the emergency installation district general hospital dr. soedarso pontianak has implemented therapeutic communication and client satisfaction about nursing services is satisfied, there is a meaningful relationship between the implementation of therapeutic communication with the level of client satisfaction about nursing services. it is also in line with the research of nugroho and aryati (2009) about "therapeutic nurse communication relations with patient satisfaction in kendal islamic hospital. the results showed that the average value of patient satisfaction was 57.4%. materials and methods this research is a quantitative research that uses a cross sectional design where variables including risk factors and variables including effects factors are observed and related variables are measured and at the same time or at one time (chandra, 2008). respondents in this study were inpatients at least 3 days at sultan agung islamic hospital semarang. this research was conducted in november 2018 as many as 127 respondents. the instrument of this study used a demographic questionnaire, therapeutic communication questionnaire and patient satisfaction questionnaire. the demographic questionnaire contains the patient's identity which includes: gender, age, education, occupation, and length of stay. the patient satisfaction questionnaire consisted of 25 statements with favorable and unfavorable forms using a likert scale, ie each item was valued for a very dissatisfied answer (stp) value 1, dissatisfied (tp) value 2, quite satisfied (cp) value 3, satisfied (p) value of 4 and very satisfied (sp) value 5. result of assessment not satisfied: 25-58 satisfied: 59-92 very satisfied 93-125. therapeutic communication questionnaire consists of 13 statements where the statement has been tested for validity with no answer (tp) = 1, occasionally (sk) = 2, sometimes (kk) = 3, often (s) = 4, always (s) = 5. result of assessment: never: 1330, often: 31-47, always: 48-65. the validity and reliability test of this instrument was carried out at the sultan agung islamic hospital in 42 respondents. test the validity in this study using the pearson product moment technique. the validity test conducted by researchers on the research instrument shows that all statement items on the patient satisfaction instrument are valid. this is indicated by the results of r count greater than r table (0.304). whereas in therapeutic communication instruments, it is found that 7 (seven) invalid items are item no. 7, 8, 11, 12, 13, 15, 20, because r count is smaller than r table (0.304) so that the item is a. wahdatin, et al. 380 | pissn: 1858-3598  eissn: 2502-5791 declared not valid and cannot be used (deleted). reliability test using cronbach's alpa, the results obtained that the two valid instruments are indicated by the value of cronbach's alpa 0.971 for the patient satisfaction instrument, and 0.824 for therapeutic communication. results discussion table 1 shows that out of 127 respondents based on sex, the highest number of respondents was female with 78 respondents with 61.4% percentage while 49 respondents with the least number were male patients with 38.6% percentage. women are more emotional than men because women are more easily offended, easily affected, very sensitive, highlight feelings, and easily vent, while men are not emotionally very objective, not easily affected, easily separate between thoughts and feelings so that sometimes they are less sensitive and able to harbor feelings (dagun, 2002). men and women have differences in doing work and in communication, robbins (2008) revealed that there are differences in abilities between men and women in the relationship between humans where women have a higher sensitivity in interpreting signs of communication than men. the results of this study indicate that women are psychologically more sensitive than men, in communicating always use feelings, so that the power of emotion influences the way of self-control in showing ability and ability to foster a healing motivation within him. table 1 shows that from 127 respondents based on age the results of the highest respondents aged 50-64 years were 43 respondents with a percentage of 33.8% , while respondents who were at least 65 years old were as many as 11 respondents with a percentage of 8.7%. age is a person's life span until his last birthday (tampubolon, 2008). davis (2004) states that age> 35 years old is categorized as old age and age ≤35 years old. the results of this study indicate that age is very influential with postoperative term younger age because the modern lifestyle of an unhealthy society creates many diseases without realizing it. age has a very important role in determining the pattern of thinking, the higher the age of a person will be more mature in taking a decision or action to be carried out, where the early adult age still think has a responsibility and a big role in the family, thereby strengthening motivation to recover. table 1 shows that from 127 respondents based on work the results of the respondents were mostly private employees 31 with a percentage of 24.4% while the respondents were the least namely public servants 9 with a percentage of 7.1%. someone who has worked and in the work environment, there is work stress which is the tension that is often experienced by employees that can interfere with work situations and concentration in completing tasks. the emergence of these tensions is essentially influenced by three factors, namely the problem of the organization of the work environment, individual employee factors and other matters relating to the community (griffin, hogan, lambert, tucker-gail, & baker, 2010) robert, 2010 in eunike). characteristics of respondents table 1. respondent frequency distribution based on gender, age, work, and education patients in the ward on december 2018 (n = 127) variable frequency(f) percentage (%) gender female 78 61,4 male 49 38,6 age 17-24 15 11,8 25-34 19 15 35-49 39 30,7 50-64 43 33,8 65> 11 8,7 work students 16 12,6 goverment employees 9 7,1 private employees 31 24,4 laborer 17 13,4 traders 28 22 unemployment 26 20,5 education elementari school 35 27,6 junior high school 37 29,1 senior high school 47 37,0 diploma 3 2,4 bachelor 5 3,9 patient satisfaction table 2 respondent frequency distribution based on patient satisfaction in the ward on december 2018 (n = 127) patient satisfaction frequency (f) percentage (%) not satisfied 3 2,4 satisfied 57 44,9 very satisfied 67 52,8 total 127 100 therapeutic communication table 3 frequency distribution of respondents based on therapeutic communication in the ward on december 2018 (n = 127) therapeutic communication frequency (f) percentage (%) never 2 1,6 often 56 44,1 always 69 54,3 total 127 100 jurnal ners http://e-journal.unair.ac.id/jners | 381 the results of this study indicate that the majority of respondents work status as private employees because people who have worked have more tendency to utilize health services. in line with the concept, the results of this study some respondents work as private employees so they are more required to be creative with work pressure and higher stress burden. table 1 shows that out of 127 respondents based on education the results of the most respondents were high school educated as many as 47 respondents with a percentage of 37.0% while respondents the least educated diploma were 3 respondents with a percentage of 2.4%. people who are knowledgeable with less education, need more special attention to medical services. the low level of education can result in low community visits to health care services. someone who has high knowledge and education has some desire for goods and services so they try to fulfill according to the knowledge they have in achieving satisfaction, (tjiptoherijanto, 1994 in budiman, suhat, helina, 2010). the majority of the education of middle and upper secondary respondents have attention to his health is better when compared to the level of primary education so that if he is sick he will immediately seek treatment. the level of education influences the perception of satisfaction and utilization of health service facilities, the higher the level of education, the higher the intensity of the utilization of health services (sulistyorini, 2012 in fachrizal, 2014). the results of this study indicate that the number of respondents with high school education is more than the elementary school, junior high school, pt (college). one's education influences one's thinking and reasoning power where understanding something is someone who has a low education, this also influences the curiosity and use of available services such as health services, highly educated people better understand the use of existing services. table 2 shows that out of 127 respondents based on patient satisfaction, the majority of patients had patient satisfaction with the highest category of 67 respondents with percentage 52.8%, while patients who had the least category were not satisfied as many as 3 respondents with a percentage of 2.4%. patient satisfaction is related to the quality of hospital services. patient satisfaction with nursing care is considered a principal outcome indicator of quality of care (laschinger, hall, pedersen, & almost, 2005), and it is seen as an important aspect for evaluating and improving overall healthcare (dudkiewicz, 2014; koy, yunibhand, & angsuroch, 2016). as nurses provide the key aspects of healthcare, their contribution influences significantly the level of patient satisfaction with the overall healthcare services provided. (de-la-cueva-ariza et al., 2014; laschinger et al., 2005) providing satisfaction to patients can only be obtained if the company pays attention to things that are desired by patients (nursalam, 2011). paying attention to what the patient wants means the quality of service produced is determined by the patient. by knowing the level of patient satisfaction, hospital management can improve service quality in improving patient satisfaction (chahal, 2008). nurse therapeutic communication is indicated by four aspects, namely aspects of authenticity, aspects of empathy, aspects of respect or respect and concrete aspects (nurjannah, 2005). the higher each aspect, the higher therapeutic communication will be, therapeutic communication is not just verbal communication but also non verbal communication. in good therapeutic communication there are several stages namely pre-interaction, orientation stage, work phase and termination stage. in this research, therapeutic communication stages are discussed, namely at the orientation stage, here the researcher assesses how when the nurse first meets the patient and how the attitude shown by the nurse to the patient, so that the patient feels satisfied with the nurse's performance and therapeutic communication. this study concluded that communication would be very helpful not only for patients but also for medical staff. for medical staff information about patients is very important to determine the diagnosis and treatment. patients communicate can issue complaints that they face at the same time is a form of treatment, because not infrequently patients feel satisfied and relieved after channeling to the other side. the results of the cross table in table 4 found that therapeutic communication in the category never with patient satisfaction in the category of dissatisfaction of 2 respondents (1.6%), therapeutic communication in the category often with patient bivariate analysis table 4. cross table of relationships between therapeutic communication and post-operation patient satisfaction in the ward on december 2018 (n = 127) therapeutic communication patient satisfaction total not satisfied satisfied very satisfied f % f % f % f % never 2 1,6 0 0 0 0 2 1,6 often 0 0 50 39.4 6 4.7 56 44.1 always 1 0.8 7 5.5 61 48 69 54.3 total 3 2.4 57 44.9 67 52.8 127 100 a. wahdatin, et al. 382 | pissn: 1858-3598  eissn: 2502-5791 satisfaction in the satisfied category of 56 respondents (44.1%), and therapeutic communication in the category always with patient satisfaction in the very satisfied category of 69 respondents (54.3%). the results of the analysis of therapeutic communication relationship with postoperative patient satisfaction at sultan agung hospital in semarang obtained p value in the spearman rank test of 0,000 (p <0.05) which means that there is a relationship between therapeutic communication and postoperative patient satisfaction at rsi sultan agung semarang, while the correlation coefficient between the two variables is 0.552, meaning that the closeness between the two variables is moderate, where the increase in y value is followed by an increase in the value of x. it means the better therapeutic communication to the patient, the higher patient satisfaction, the lower the therapeutic communication patient about nursing therapeutic communication. conclusion therapeutic communication with postoperative satisfaction in sultan agung semarang islamic hospital has moderate closeness. having a meaningful positive relationship in the same direction if therapeutic communication is good, the satisfaction of postoperative patients can increase, this is true for the opposite, if postoperative satisfaction increases, therapeutic communication will also be good. high patient satisfaction is supported by good hospital services, especially therapeutic communication, so that patients feel comfortable. acknowledgment the author wish thank to nursing science faculty of sultan agung islamic university for the trust, support and for sponsoring the researcher to do this research. references abdel maqsood, a. s., oweis, a. i., & hasna, f. s. (2012). differences between patients’ expectations and satisfaction with nursing care in a private hospital in jordan. international journal of nursing practice. https://doi.org/10.1111/j.1440172x.2012.02008.x chahal, h. (2008). predicting patient loyalty and service quality relationship: a case study of civil hospital, ahmedabad, india. vision: the journal of business perspective. https://doi.org/10.1177/0972262908012004 05 dagun, m. s. (2002). psikologi keluarga (peranan ayah dalam keluarga). jakarta: pt rineka cipta. de-la-cueva-ariza, l., romero-garcía, m., delgadohito, p., acosta-mejuto, b., jover-sancho, c., ricart-basagaña, m. s. o. s. c. t., … solà-ribó, m. (2014). development of an instrument to measure the degree of critical patient’s satisfaction with nursing care: research protocol. journal of advanced nursing. https://doi.org/10.1111/jan.12184 dudkiewicz, p. b. (2014). utilizing a caring-based nursing model in an interdepartmental setting to improve patient satisfaction. international journal of human caring. https://doi.org/10.20467/1091-5710.18.4.30 freitas, j. s. de, silva, a. e. b. de c., minamisava, r., bezerra, a. l. q., & sousa, m. r. g. de. (2014). quality of nursing care and satisfaction of patients attended at a teaching hospital. revista latino-americana de enfermagem. https://doi.org/10.1590/01041169.3241.2437 griffin, m. l., hogan, n. l., lambert, e. g., tucker-gail, k. a., & baker, d. n. (2010). job involvement, job stress, job satisfaction, and organizational commitment and the burnout of correctional staff. criminal justice and behavior. https://doi.org/10.1177/0093854809351682 koy, v., yunibhand, j., & angsuroch, y. (2016). the quantitative measurement of nursing care quality: a systematic review of available instruments. international nursing review. https://doi.org/10.1111/inr.12269 laschinger, h. s., hall, l. m. g., pedersen, c., & almost, j. (2005). a psychometric analysis of the patient satisfaction with nursing care quality questionnaire: an actionable approach to measuring patient satisfaction. journal of nursing care quality. https://doi.org/10.1097/00001786200507000-00006 lee, h. s. (2008). relationships among communication competence, communication types, organizational commitment of nurses (unpublished master’s thesis). dankook university, cheonan-si, republic of korea. nurjannah, i. (2005). komunikasi terapeutik (dasardasar komunikasi bagi perawat). yogyakarta: mocomedia. park, m. s., jeoung, y., lee, h. k., & sok, s. r. (2015). relationships among communication competence, self-efficacy, and job satisfaction in korean nurses working in the emergency medical center setting. journal of nursing research. https://doi.org/10.1097/jnr.00000000000000 59 sheldon, k. . (2013). komunikasi untuk keperawatan: berbicara dengan pasien (2nd ed.). jakarta: erlangga. http://e-journal.unair.ac.id/jners | 45 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16976 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a review of personality type d on cardiovascular disease patients gratsia viktoria fernandez, rahmatul fitriyah, wahyu sukma samudera, hidayat arifin and shenda maulina wulandari faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the type of personality that a patient has as a psychosocial factor has been associated with the incidence and progression of cardiovascular disease. the aim of the study was to review the evidence and correlation between personality type and the development of cardiovascular disease. methods: articles were searched for using the prisma approach in the cinahl, science direct and scopus databases, limited to the last 5 years. the articles were from 2013 to 2018 and the language used was english. the studies focused on personality type d and cardiovascular disease, and the participants were above 18 years old. results: most of the findings of the studies showed that individuals with a type d personality have a relationship with more severe heart disease, which relates to several physiological factors, namely emotion increase, anxiety, stress, biological factors, cognitive decline and the decrease in quality of life. conclusion: individuals with type d personality have a higher level of stress, significant blood pressure, higher pulse and they experience an increase in cortisol compared to non-type d personalities. individuals who suffer from cardiovascular disease with personality type d tend to experience a more severe progression of the condition of cardiovascular disease. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords personality; type d; cardiovascular disease contact gratsia viktoria fernandez  gratsia.victoria.fernandez2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: fernandez, g. v., fitriyah, r., samudra, s., arifin, h., & wulandari, s. m. (2019). the current information on personality type d with cardiovascular disease: a systematic review.jurnal ners, 14(3si), 45-49. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16976 introduction cardiovascular disease is one of the main causes of death globally. the development of cardiovascular disease is caused by accompanying risk factors that are not immediately handled. in some of the research findings, it was found that there was a relationship between personality type and the development of cardiovascular disease (du et al., 2016). the development of heart disease has a link with the characteristics of a person’s personality. in the case of cardiovascular disease, psychological factors play a crucial role in the development of the disease condition. it is revealed by the results of a previous study that the level of depression and anxiety in a person with cardiovascular disease tends to be higher compared to another person without cardiovascular disease (du et al., 2016) . likewise, psychosocial factors such as poor social support and low socioeconomic status also have an influence or relationship with the risk of cardiovascular disease (bekendam et al., 2018). the increase of the cardiovascular disease risk mainly has a relationship with the social barriers possessed by a person, including being unable to interact with others. this makes the person tend to have self-restraint or they are not able to express their negative emotions. this can later lead to a disrupted physiological immune system (ogińskabulik, 2014). type d stands for distressed and it refers to a set of personality traits that involve things like feelings of worry, sadness, irritability, a pessimistic outlook, negative self-talk, an avoidance of social situations, a lack of self-confidence, fear of rejection, appearing gloomy and hopelessness. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:gratsia.victoria.fernandez-2018@fkp.unair.ac.id mailto:gratsia.victoria.fernandez-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). g. v. fernandez, et al. 46 | pissn: 1858-3598  eissn: 2502-5791 based on the results of several previous metaanalysis studies, it has been shown that someone with type d personality had twice the risk of worsening cardiac events and death in the context of patients with coronary heart disease (kupper & denollet, 2016). in this study, the researchers wanted to see the extent of the correlation between personality type d and the development of cardiovascular disease viewed in terms of psychology, biology and physiology. materials and methods this study used a systematic review design, with a questioning search focused on “what is the correlation between personality type d with the development of cardiovascular disease?” trials were included in the review identified through the electronic database searches conducted from the earliest available time through to march 2014 in the following databases: cinahl, science direct, ebsco and scopus using the keywords “personality type” and “cardiovascular disease”. the inclusion criteria in this review were both experimental studies and nonexperimental studies; studies that were published from march 2013 to 2018; where the participants were above 18 years old; where the language used was english and where they focused on personality type d and cardiovascular disease. the exclusion criteria were studies that did not involve patients with cardiovascular disease and that did not have information on personality type. based on the literature research from four databases (science direct, ebsco, cinahl, and scopus, there were a total of 1,675 papers. the detailed identification process of the paper selection can be seen in figure 1. this study reviewed 15 chosen articles. the articles came from sweden, turkey, italy, swiss, the netherlands, germany, belgium, spanish, america, china, and poland. results the review results show the factors caused by someone having a type d personality as presented in table 1. based on table 1, the researchers were able to determine the factors found in someone with a type d personality. there were two dominant factors found, namely increased stress and increased anxiety. other factors found were increased emotions, reduced cognitive function, endothelial dysfunction, increased lipids, increased c-reactive point levels, increased superoxide macrophage anions, increased troponin i, increased myocardial infarction, increased stress response, increased stress response, decreased influence positive, decreased quality of life and an increased risk of heart events. the measuring instrument used in assessing the personality types was ds14, made up of 14 items consisting of 7 negative affective components (na) and 7 components of social inhibition (si) coupled with the phq-9 (patient health questionnaire) questionnaire, bdi-ii (beck depression inventory second edition) and csss (chronic stress screening scale) to measure depression. anxiety was measured using gad-7 (generalized anxiety disorder scale), the spielberger state-trait anxiety inventories (staii and stai-ii), and the health anxiety inventory (hi). endothelial function was assessed using the flowmediated dilation (fmd) of the brachial artery, cognitive function was measured using the tol (tower of london), positive effects were measured using the gms (global mood scale), and satisfaction from and with life was evaluated using the life satisfaction questionnaire and blood biomarker measurements. discussion a person with type d personality has a higher level of stress compared to other personality types. this was found in the study of du et al, whose results showed that the respondents with type d personality had higher stress and anxiety levels and higher negative coping scores than those for positive coping (du et al., 2016). furthermore, in a study conducted by annagur et al patients with type d personalities had a higher frequency of hypertension, stress and psychiatric disorders, including depression and anxiety than nontype d personality patients (annagur, demir, avci, & uygur, 2017). this happens as when stressed, the body will release stress hormones that can narrow the blood vessels and accelerate the heart rate. this causes the blood pressure to easily increase. increased stress causes a decrease in immune competence (as a consequence of stress hormone secretion) as found in the blood examination of patients with coronary artery disease (cad) with type d personality. this results in an increase in the superoxide production of macrophages, resulting in the reactivation of systemic infections and the release of cytokines. the increased superoxide production of macrophages plays an important role in the figure 1. flowchart of the research on personality type with cardiovascular disease jurnal ners http://e-journal.unair.ac.id/jners | 47 pathogenesis of atherosclerosis (zuccarella-hackl et al., 2016). according to bibbey et al type d personalities had a higher stress level (bibbey, carroll, ginty, & phillips, 2015). people with type d personality have a significant increase in blood pressure, pulse and their amount of cortisol compared to non-type d personalities. stress is one of the risk factors for cardiovascular disease and it also has an association with increased systolic blood pressure. stress can trigger the release of catecholamine quickly which will later cause an increase in cardiac output and blood pressure. in addition, stressful conditions will activate the hypothalamus-pituitary-adrenal which will release adrenal glucocorticoids and cortisol. corticotropinreleasing hormone (crh) is released by the hypothalamus in response to stress, which then affects the anterior pituitary gland to prompt it to release adrenocorticotrophic hormone (acth). this in turn causes the adrenal cortex to release cortisol. the cortisol hormone caused the increased breakdown of protein and fat that will be converted into blood glucose, so this increases the blood sugar level. this increases the risk of cardiovascular disease due to an increase of fatty acid (bibbey et al., 2015). in the cardiovascular system, cortisol is required to protect the balance of blood pressure, heart function, and blood vessel responses. however, if the amount of cortisol increases, then the protection function of the heart is also impaired. in type d personality, the level of their emotions will increase, according to van monfort et al study (van montfort, mommersteeg, spek, & kupper, 2018). this proved that a person's emotional level is related to a combination where people have type d personalities and bad life experiences. this emotional level can be caused by a negative effect and high social barriers, which will affect their lifestyle. this is also in line with the research conducted by steca et al, which explained that a person with type d personality, especially men who do not have many friends, has a high level of anxiety and depression, low levels of optimism and self-esteem, and they have a bad lifestyle such as a poor diet, higher fat intake, smoking and poor adherence to treatment (steca et al., 2016). according to the research of wang et al, they showed that there was a relationship between type d personality and susceptibility to coronary plaque (wang et al., 2016). in type d personality, the respondents tend to have more lipid-rich plaques and macrophages. this is in line with the study of garcia et al, which revealed that respondents with type d personality who smoked had a high blood pressure systole and thus had poor lipid profile examination results, especially concerning hdl (garcia-retamero, petrova, & ram, 2016). an increase in lipids is caused by the lifestyle of patients with type d personality who are less healthy, such as a lack of exercise, smoking and not following the recommended diet (imbalzano et al., 2018). in addition, type d patients often lack social support, which can indirectly contribute to the failure to adopt a healthy lifestyle and lipid control. type d personality also affects the quality of life of cvd patients. this was found in a study conducted by oginska, which proved that the level of quality of life in respondents with type d personality was significantly lower than all of the components when compared to the respondents with a non-type d personality (ogińska-bulik, 2014). in measuring type d personality, the social obstacle component had a close correlation with the life quality level. it related to the interactions with other people. the more that people were socially isolated and often hid their emotions, the lower their life quality level was. accordingly, it was required that psychology rehabilitation should not only have the goal to overcome the stress but it should also increase their openness with other people, thus allowing them to identify and use social support. cognitive function also had an influence regarding type d personality. in the research conducted by unterainner et al, it was explained that type d personality had a relation with lower cognitive table 1. list of factors caused by someone having a type d personality authors factors caused by someone having a type d personality van montfort et al increased emotion unterrainer et al lowered cognitive, increased stress, increased anxiety denollet et al decreased flow mediated dilation (endothelial dysfunction) and increased stress garcia et al(garcia-retamero et al., 2016)(garcia-retamero et al., 2016) increased lipid, increased troponin i and increased myoglobin level annagur et al higher incidence, persistent of smokers, increased stress level, anxiety, and depression bekendam et al decreased in positive affect imbalzano et al higher incidence of smokers du et al increased stress level, anxiety and re-myocardial infarction bibbey et al increased stress response steca et al high levels of anxiety and depression ogińska-bulik lowered life quality kupper and denollet increased risk cardiac events wang et al increased c-reactive point level, thinned fibrous cap leu et al increased risk cardiac event (angina and revascularization) zuccarella-hackl et al increased macrophage superoxide anion production and increased stress g. v. fernandez, et al. 48 | pissn: 1858-3598  eissn: 2502-5791 function in the respondents with cvd (unterrainer et al., 2016). the downgrade of cognitive function was connected with the existence of cardiovascular disease which could lead to a lack of blood supply to the brain. moreover, people who had a high negative effect from their type d personality had high stress and a high anxiety level, which would influence their own cognitive function. the existence of endothelial dysfunction is also related to type d personality in patients with cvd. this could be proven by the research conducted by denollet et al, which explained that endothelial dysfunction is the key factor which was able to connect type d personality with the higher heart attack risk (denollet et al., 2018). negative affect and social obstacles could be the factors of endothelial dysfunction in type d personality. the increase of superoxide anion formation, stress oxide, tnf-α, and cortisol were part of a biological pathway where type d personality contributes to endothelial dysfunction. the stress level of type d personality also influences endothelial dysfunction. type d personality could be a predictive factor for the occurrence of major adverse cardiac events (mace) consisting of several components: death, myocardial infarction, coronary artery bypass surgery (cabg), percutaneous intervention (pci) or the development of coronary artery disease (cad). based on the research conducted by kupper and denollet, it was revealed that there was a correlation between type d personality and mace. this was indicated by the increased risk when under 70 years old (kupper & denollet, 2016). the biological mechanisms found in the type d personality were related to specific diseases such as the increase of the amount of plaque in the coronary arteries, the increase of macrophage activity, the increase of oxidative stress, endothelial dysfunction and the increase of cortisol, which could be a marker of heart disease risk. in older patients, the risk of death was higher than the risk of the younger patients due to the aging process, increased comorbidity and the decreased medication options. this is also in line with the research conducted by leu et al, which revealed that type d personality can be independently associated with an increased risk of future heart events (leu et al., 2018). in addition, the risk profile of type d personality is even more significant in women, older patients, patients with hypertension and patients with type 2 diabetes. meanwhile, in a study conducted by bekendam et al, it was explained that people with a positive affect can avoid cardiovascular disease (bekendam et al., 2018). positive affect generally refers to positive mood conditions such as enthusiasm, excitement, happiness, joy and satisfaction. however, further studies are required to prove that positive affect could provide a protective effect against cvd. conclusion individuals with cardiovascular disease who have a type d personality have a tendency to develop a more severe cardiovascular condition. this is related to several factors that are physiological, psychological and biological. through the systematic review, the author has tried to identify the disorders caused by type d personality. the physiological and biological disorders include increased lipids, increased troponin i, increased myoglobin, increased c-reactive point level, increased risk of a cardiac event (angina and revascularization, superoxide macrophages increased anion production and decreased endothelial function. the psychological disorders include increased emotions, increased levels of stress, anxiety, decreased positive affect and decreased quality of life. after learning of these factors, it is expected to be a reference to be able to modify the coping mechanisms of people with type d personality so then the disorder can be avoided and minimized. after recognizing the factors, it is expected that the results will a reference to be able to modify the coping mechanisms of people with type d personality so then the interference can be avoided and minimized. references annagur, b., demir, k., avci, a., & uygur, ö. (2017). impact of a type d personality on clinical and psychometric properties in a sample of turkish patients with a first myocardial infarction. journal of psychiatric practice, 23(1), 3–10. https://doi.org/10.1097/pra.00000000000002 01 bekendam, m. t., kop, w. j., barzilay, s., widdershoven, j. w., aarnoudse, w., denollet, j., & mommersteeg, p. m. c. (2018). the predictive value of positive affect and type d personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease. journal of psychosomatic research, 104(october 2017), 108–114. https://doi.org/10.1016/j.jpsychores.2017.11.00 3 bibbey, a., carroll, d., ginty, a. t., & phillips, a. c. (2015). cardiovascular and cortisol reactions to acute psychological stress under conditions of high versus low social evaluative threat: associations with the type d personality construct. psychosomatic medicine, 77(5), 599– 608. https://doi.org/10.1097/psy.000000000000019 4 denollet, j., van felius, r. a., lodder, p., mommersteeg, p. m., goovaerts, i., possemiers, n., … van craenenbroeck, e. m. (2018). predictive value of type d personality for impaired endothelial function in patients with coronary artery disease. international journal of cardiology, 259(2017), 205–210. https://doi.org/10.1016/j.ijcard.2018.02.064 du, j., zhang, d., yin, y., zhang, x., li, j., liu, d., … chen, w. (2016). the personality and psychological jurnal ners http://e-journal.unair.ac.id/jners | 49 stress predict major adverse cardiovascular events in patients with coronary heart disease after percutaneous coronary intervention for five years. medicine, 95(15), e3364. https://doi.org/10.1097/md.000000000000336 4 garcia-retamero, r., petrova, d., & ram, a. (2016). type d personality is related to severity of acute coronary syndrome in patients with recurrent cardiovascular disease. british journal of health psychology, 14, 111–119. https://doi.org/10.1111/bjhp.12196 imbalzano, e., vatrano, m., quartuccio, s., ceravolo, r., ciconte, v. a., rotella, p., … mandraffino, g. (2018). effect of type d personality on smoking status and their combined impact on outcome after acute myocardial infarction. clinical cardiology, 41(3), 321–325. https://doi.org/10.1002/clc.22865 kupper, n., & denollet, j. (2016). explaining heterogeneity in the predictive value of type d personality for cardiac events and mortality. international journal of cardiology, 224, 119–124. https://doi.org/10.1016/j.ijcard.2016.09.006 leu, h., yin, w., tseng, w., chang, k.-c., wang, j., & wu, c. (2018). impact of type d personality on clinical outcomes in asian patients with stable coronary artery disease. journal of the formosan medical association, 1–9. https://doi.org/10.1016/j.jfma.2018.08.021 ogińska-bulik, n. (2014). type d personality and quality of life in subjects after myocardial infarction. kardiologia polska, 72(7), 624–630. https://doi.org/10.5603/kp.a2014.0066 steca, p., d’addario, m., magrin, m. e., miglioretti, m., monzani, d., pancani, l., … greco, a. (2016). a type a and type d combined personality typology in essential hypertension and acute coronary syndrome patients: associations with demographic, psychological, clinical, and lifestyle indicators. plos one, 11(9), 1–28. https://doi.org/10.1371/journal.pone.0161840 unterrainer, j., michal, m., rahm, b., hadzibegovic, j., wild, p. s., schulz, a., … beutel, m. e. (2016). association of type d personality with cognitive functioning in individuals with and without cardiovascular disease the gutenberg health study. international journal of cardiology, 214, 256–261. https://doi.org/10.1016/j.ijcard.2016.03.221 van montfort, e., mommersteeg, p., spek, v., & kupper, n. (2018). latent profiles of early trauma & type d personality: sex differences in cardiovascular risk markers. comprehensive psychiatry, 83, 38–45. https://doi.org/10.1016/j.comppsych.2018.02.0 09 wang, y., zhao, z., gao, x., li, l., liu, g., chen, w., … lin, p. (2016). type d personality and coronary plaque vulnerability in patients with coronary artery disease: an optical coherence tomography study. psychosomatic medicine, 78(5), 583–592. https://doi.org/10.1097/psy.000000000000030 7 zuccarella-hackl, c., känel, r. von, thomas, l., kuebler, p., schmid, j., mattle, h. p., … wirtz, p. h. (2016). psychoneuroendocrinology higher macrophage superoxide anion production in coronary artery disease ( cad ) patients with type d personality. psychoneuroendocrinology, 68, 186– 193. https://doi.org/10.1016/j.psyneuen.2016.02.031 http://e-journal.unair.ac.id/jners | 193 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.16531 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research determinants of drug adherence on grade two and three patients with hypertension riza fikriana1, shrimarti rukmini devy1, ahsan ahsan2 and al afik3 1 faculty of public health, universitas airlangga, east java, indonesia 2 faculty of medicine, brawijaya university, east java, indonesia 3 faculty of medicine and health science, university of muhammadiyah yogyakarta, indonesia abstract introduction: compliance for taking medication has become an important activity for patients with hypertension. compliance is needed to control blood pressure and prevent complications. the purpose of this study was to analyse determinant drug adherence on grade two and three patients with hypertension. methods: the study design was a descriptive survey using a cross-sectional approach. the sample was 225 patients with hypertension grade two and three. the sampling technique was done using a multistage random sampling technique. the coping strategy is the independent variable and drug adherence is the dependent variable. the research instrument was in the form of a questionnaire which consisted of demographic, coping strategy used, cope inventory scale questionnaire, and drug adherence using the hypertension self-care profile questionnaire. data analysis was performed using the pearson test and linear regression. results: the results showed that patient adherence in taking medicine was 51.1% in the medium category. factors influencing the adherence were ages (p-value: 0.002), return to religion (p-value: 0.011), gender (p-value: 0.016) and suppressing competition activities (p-value: 0.063). conclusion: age, gender, return to religion and suppressing competition activities influence the taking of medication in patients with grade two and grade three hypertension. strengthening coping strategies with transporting to coping emotions is very important and will affect drug adherence in patients with grade two and grade three hypertension. article history received: december 06, 2019 accepted: december 30, 2019 keywords coping strategic; drug adherence; hypertension contact riza fikriana  riza_fikriana@stikeskepanjenpemkabmalang.ac.id  faculty of public health, universitas airlangga east java, indonesia cite this as: fikriana, r., devy, s. r., ahsan, a.. & afik, a. (2019). determinants of drug adherence on grade two and three patients with hypertension. jurnal ners, 14(2), 193-198. doi:http://dx.doi.org/10.20473/jn.v14i2.16531 introduction the development of the disease is now shifting from infectious diseases to non-communicable conditions. while the problem of infectious diseases has not been resolved, the prevalence of non-communicable diseases continues to increase (atiim, g., et al, 2015). hypertension is a non-communicable disease in which numbers continue to grow (bell kayce et al., 2015; bhagani, s., et al., 2018). in indonesia, the development of hypertension prevalence continues to grow throughout the year. the results of the riskesdas conducted by the ministry of health of the republic of indonesia found that the incidence of hypertension from 2013 to 2018 rose sharply from 25.8% to 34.1% (kemenkes ri, 2018). the increase should be a concern given the increase of complications due to hypertension, such as cardiovascular disease, stroke and kidney failure (fikriana, r., 2016; fikriana, r., et al, 2018). one of the causes of the increased risk of hypertension complications is due to non-compliance with hypertension treatment. non-compliance with treatment will cause uncontrolled blood pressure and lead to the risk of complications (fikriana, r., 2018). studies show that 51.6% of hypertension patients taking antihypertensive drugs include in unchecked hypertension (borghi, c., et al., 2016). blood pressure control is also deficient, at 22.3% (shafi, s. t.,et al, 2017). as a result, the increase of uncontrolled hypertension is correlated with an increased risk of heart disease (borghi, c., et al., 2016). hypertension https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.16531 r. fikriana et al. 194 | pissn: 1858-3598  eissn: 2502-5791 classification are optimal blood pressure, normal blood pressure, high-normal blood pressure, grade one hypertension, grade two hypertension, grade three hypertension, isolated systolic hypertension, white-coat hypertension and masked hypertension. in patients with grade two and three, hypertension has a very high risk of complications and organ damage (indonesian society of hypertension, 2019; bhagani, s., et al, 2018). the results of the study of adherence showed that 32.3% did not take medication regularly, 13.3% did not take medicine, and 54.4% take medicine daily. the reasons for not taking medicine are because they feel healthy (59.8%), are not routinely going to health service facilities (31.3%), taking traditional medicine (14.5%), often forgetting (11.5%), not being able to buy drugs regularly (8.1%), cannot stand the side effects of drugs (4.5%), medications do not exist in health care facilities (2.0%) and others (12.5%) (borghi, c., et al., 2016). patients with hypertension who take antihypertensive drugs for controlling blood pressure slightly increased by 32.3%. however, this value is also still classified as very low. low blood pressure control is positively correlated with increasing age, body mass index and occupational status (shafi, s. t.,et al, 2017; (fikriana, r., 2016; fikriana, r., et al, 2018). in a situation that is considered as stressful and requires an effort to overcome it, coping will have an effect on a person. coping strategies aim to manage stressors or regulate emotions arising from stressful situations (biggs, a., 2017; nursalam, 2017). coping strategies are related to a person's quality of life. coping strategies that are positively associated with the right psychosocial environment and which produce good physical health will improve the quality of life of a person (hernández-ledesma, a. l.,et al, 2018). situational assessment and conditions that occur will affect how coping strategies are effective in dealing with stress and be able to influence one's decision to perform certain behaviours. based on the transactional theory, coping is a continuous cognitive change and a person's behavioural effort in managing the existence of both internal and external demands that are judged to be beyond one's ability. coping is process-oriented, dynamic, and is done consciously and directed (biggs, a., 2017; nursalam, 2017). several factors influence the behaviour of hypertensive sufferers towards medication adherence. knowledge about medication, frequency and dosage of drugs has a role in influencing adherence (ramli, a., et al, 2012). the aim of the research was to analyse the determinant drug adherence on grade two and three hypertension patients. materials and methods this study was a cross-sectional design. the study was conducted from july to august 2019 in the malang district, indonesia. the sample was 225 people with hypertension. inclusion criteria: 1) hypertension patients with grade two and grade three hypertension criteria, 2) aged more than 30 years old. the exclusion criteria: 1) the patient is getting treatment in hospital, 2) patients were in the total and partial dependency level category. the sampling technique used multistage random sampling. this sampling technique uses three stages. the first step is to determine the five sub-districts in malang regency by simple random sampling. the second step was to determine each of the one regions from one district by simple random sampling. the third stage was to determine hypertension patients from each region by simple random sampling. variables in this study were coping strategic (independent variable) and drug adherence (dependent variable). the instrument used was a questionnaire. the questionnaire covers the demographic characteristics of the respondents, which include age, gender, family history of hypertension and a long duration of hypertension. the patient coping questionnaire was measured by examining problemfocused coping consisting of active coping, planning, restraint, suppression of competing activities, seeking instrumental and informational social support and reviewing emotion-focused coping consisting of positive reinterpretation, return to religion and seeking emotional, social support. the coping questionnaire was adopted from the cope inventory scale questionnaire (carver, c. s, 2013). respondents answered the coping questionnaire choices using a likert scale consisting of four answer choices that are never, sometimes, often and always. the data scale used numeric data. the drug adherence questionnaire was adopted from the hypertension self-care profile (hbp scp) questionnaire regarding adherence to taking antihypertensive medication ( han, et al, 2014). the drug adherence questionnaire used a likert scale of four answer choices that are never, sometimes, often and always. the questionnaire was tested for validity and reliability, with a cronbach alpha active coping value of 0.806 with four questions; planning value of 0.884 with four questions; restrain value of 0.700 with four questions; suppression of competing activities value of 0.737 with four questions; seeking instrumental and informational social support value of 0.921 with five questions; return to religion value of 0.884 with five questions; seeking social emotional social support value of 0.825 with five questions. prior to data collection, the researcher obtained informed consent for the study with each respondent. the researcher explains the purpose of the study, the benefits of the research and the procedure of conducting the research. respondents who agreed to be involved in the research process must sign an informed consent sheet. approval of research ethics has been carried out by the health research ethics committee of the faculty of nursing, universitas airlangga, surabaya, no. 1468-kepk. jurnal ners http://e-journal.unair.ac.id/jners | 195 data analysis of demographic characteristics, coping, and medication adherence characteristics variables were performed using frequency distribution. the data distribution is normal. to find out the relationship between demographic and coping characteristics with adherence to medication, use the pearson test. determinant drug adherence was analysed by using a linear regression test. results demographic characteristics the demographic characteristics of people with hypertension are described in terms of age, sex, family history of hypertension and long duration of hypertension. table 1 shows that the majority of respondents, 70.7% aged 56 65 years and 3.1% aged 26 35 years. a total of 83.1% were female and the majority, namely 79.1% of respondents had no family history of hypertension. in addition, it was found that more than half the respondents, 64% had hypertension for 1-3 years. coping of patients with hypertension people with hypertension are described as problemfocused coping and emotion-focused coping which is divided into eight types of coping done by the patient. the results in table 2 shows that planning, restraint, suppression of competing activities, positive reinterpretation and seeking emotional social support found that more than half of the respondents were in the poor category, namely 52.9%, 53.3%, 54.2%, 52.9%, and 54.2 %. whereas in the sufficient category, coping has a percentage of more than half the respondents is active coping (53.8%), seeking instrumental and informational social support (54.2%) and return to religion (51.1%). while coping is in a good category, all coping components are in a very low percentage of less than. drug adherence analysis of the frequency distribution of drug administration are 74 people (32.9%) low category, 115 people (51.1%) medium category and 36 (16%) is good enough. relationship between demographic and coping characteristics with drug adherence trial analysis using the pearson test according to table 3 obtained demographics and coping related to drug testing about type variables not related to drink or drug testing. return to religion was the variable that was most strongly associated with taking medication meetings (r = 0.322). effects of demographic characteristics and coping on medication adherence table 4 illustrates the results of the linear regression analysis of the variables that influence medication adherence. the results show that there are four variables that influence medication adherence, namely age, sex, suppression of competing activities and return to religion. the suppression of competing activities variable is retained by the model even though p-value> 0.05. these results indicate that coping strategies that are very influential on medication adherence in patients with grade 2 and grade 3 hypertension are emotion focused coping, especially return to religion and suppression of competing activities. table 1. demographic characteristics of patients with hypertension (n = 225) variable n % age 26 – 35 years old 36 – 45 years old 46 – 55 years old 56 – 65 years old > 65 years old 7 15 34 159 10 3.1 6.7 15.1 70.7 4.4 gender male female 38 187 16.9 83.1 family history yes no 47 178 20.9 79.1 long suffered < 1 years 1 – 3 years > 3 years 50 144 31 22.2 64.0 13.8 table 2. frequency distribution of hypertension patients' coping strategy (n = 225) variable n % active coping less enough good 68 121 36 30.2 53.8 16.0 planning less enough good 119 74 32 52.9 32.9 14.2 restraint less enough good 120 73 32 53.3 32.4 14.2 suppression of competing activities less enough good 122 77 26 54.2 34.2 11.6 seeking instrumental and informational social support less enough good 70 122 33 31.1 54.2 14.7 positive reinterpretation less enough good 119 84 22 52.9 37.3 9.8 return to religion less enough good 84 115 26 37.3 51.1 11.6 seeking emotional social support less enough good 122 71 32 54.2 31.6 14.2 r. fikriana et al. 196 | pissn: 1858-3598  eissn: 2502-5791 discussion hypertension is a significant risk factor for cardiovascular and kidney disease. although treatment for hypertension is available, only about 25% of people with hypertension have control of their blood pressure. effective management in patients with hypertension is recommended to assess the asymptomatic target organ damage and the risk of secondary causes. management of hypertension depends not only on the level of blood pressure but also on the risk of cardiovascular disorders (bhagani, s.,et al, 2018). people with hypertension must be responsible for taking care of themselves every day. this treatment includes blood pressure monitoring, diet management, maintaining physical activity, maintaining weight, stress management and medication adherence. appropriate treatment and lifestyle modification will be able to prevent and slow the occurrence of complications. blood pressure that is not well controlled will contribute to heart and kidney disease. so that self-regulation to achieve the desired blood pressure level is very important (visutyothin, y., 2018). the results of this study indicate that age, sex, return to religion and suppression of competing activities affect medication adherence in patients with grade 2 and grade 3 hypertension. these results illustrate that demographic characteristics also play a substantial role in adherence to taking drugs. besides, these results also indicate that the coping strategy in the emotion-focused coping category is the coping strategy that is most influential on sufferers. age is the most potent variable influencing medication adherence. the results show that the younger generation tends to have a better level of adherence compared to old age. this is possible because young sufferers feel a higher threat to their disease, so they try to take the drug regularly to avoid excessive blood pressure. whereas in elderly patients, long-term treatment that must be done is likely to have an impact on the emergence of boredom to consume drugs regularly. so that patients will prefer not to take medicine. gender also has an effect on medication adherence. patients with hypertension who are female have better adhesion compared to men. women tend to be more proactive in getting treatment for their condition. however, the results of other studies show that women have lower levels of medication adherence compared to men (granger, b. b.,et al, 2009; manteuffel, m., et al, 2017). this is possible because women experience more side effects that are felt due to the treatment received. so women decided to stop treatment (manteuffel, m., et al, 2017). this is also in line with other studies in which the suppression of competing activities affects the behaviour of sufferers who are under stress. patients in stressful situations more often use coping strategies in the form of avoidance and rejection rather than finding positive aspects of the stressful event that they are experiencing (orzechowska, a.,2013) return to religion reflects emotion-focused coping as a coping variable that influences medication adherence. this is supported by other studies that explain that emotion-focused coping is associated with the occurrence of dysmenorrhea (nursalam, n., et al, 2018). return to religion is an effort made to try and control the problems they are facing by multiplying prayers and getting closer to god. this strategy shows that the spiritual and religious dimensions of sufferers with chronic diseases become very important for their lives and affect the sufferer's representation of their health (perricone, g.,et al, 2013). spirituality has a significant relationship with disease prevention behaviour (rohman.,et al, 2019). spiritual beliefs possessed by a patient suffering from a chronic illness has the potential to support or hinder a person's ability to care for himself (drutchas, a., et al, 2014). religious needs are strongly related to beliefs, beliefs and positive emotions towards god, where this is also related to an individual's table 3. drug adherence (n = 225) variable n % drug adherence low medium good 74 115 36 32.9 51.1 16.0 table 4. relationship between demographic characteristics and coping on drug adherence variable medication adherence r p-value age -0.132 0.047 gender 0.023 0.730 family history -0.131 0.050 long suffered -0.129 0.054 active coping 0.212 0.001 planning 0.215 0.001 restraint 0.207 0.002 suppression of competing activities 0.295 0.000 seeking instrumental and informational social support 0.195 0.003 positive reinterpretation 0.170 0.011 return to religion 0.322 0.000 seeking emotional social support 0.205 0.002 table 5. linear regression analysis of factors affecting drug interactions variable b se β t p* constant 1.363 0.247 5.526 0.000 age 0.639 0.200 0.369 3.204 0.002 gender 0.584 0.240 0.284 2.430 0.016 suppression of competing activities 0.145 0.078 0.142 1.867 0.063 return to religion 0.182 0.071 0.200 2.575 0.011 jurnal ners http://e-journal.unair.ac.id/jners | 197 interpretation of his illness (büssing, a.,et al, 2015). in someone suffering from a chronic disease, religious needs are positively related to spiritual well-being and life satisfaction (bu ̈ssing, a., et al, 2013a). however, this is different from other research results where religious needs are not associated with high or low life satisfaction. however, this need refers more to the resources that are vital to them and relied on by them. this happens because of several underlying factors, namely their religious attitude, such as the attitude towards the strength of faith needed to survive in the difficult times they are going through. it is also based on their search for factors to find access to spiritual sources or sources of religiosity that may be useful to overcome the illness they experience which ultimately interprets their illness into something of value (büssing, a.,et al, 2015). in light of these conditions, the health worker has a duty to provide care to chronic patients, it is therefore necessary to conduct an assessment of their spiritual and religious needs. this is because the requirements for spirituality and religiosity play an essential role in the quality of life for sufferers (büssing, a.,et al, 2010). conclusion several factors influence adherence to taking the medication in patients with grade two and grade three hypertension. demographic characteristics, namely age and gender, and emotion-focused coping, namely religion and suppression of competing activities, have a significant effect on medication adherence. suggestions for further research include a qualitative research design to explore coping strategies for patients with grade two and grade three hypertension, especially in return to religion variables and suppression of competing activities. practice implications for this research is to increase drug adherence for patient hypertension grade two and grade three, strengthened coping strategies are very important. funding source sources of funding come from stikes kepanjen (kepanjen college of health science) and kemenristek dikti (ministry of research and higher education). acknowledgement the author would like to thank stikes kepanjen malang and airlangga university for their support in conducting this research. references atiim, g. a., & elliott, s. j. (2015). the global epidemiologic transition: noncommunicable diseases and emerging health risk of allergic disease in sub-saharan africa. health education and behavior, 43, 37s-55s. https://doi.org/10.1177/1090198115606918 bell kayce,twiggs june and olin bernie r. 2015.hypertension : the silent killer: updated jnc8 guideline recommendations. alabama pharmacy association bhagani, s., kapil, v., lobo, m. d. (2018). hypertension. medicine. 46 (9), 509–515. https://doi.org/10.1016/j.mpmed.2018.06.009 biggs, a., brough, p., drummond, s. (2017). the handbook of stress and health: a guide to research and practice, first edition. edited by cary l. cooper and james campbell quick. john wiley & sons, ltd. borghi, c., tubach, f., backer, g. de, dallongeville, j., guallar, e., medina, j., … halcox, j. p. (2016). lack of control of hypertension in primary cardiovascular disease prevention in europe : results from the eurika study ☆. international journal of cardiology, 218, 83–88. https://doi.org/10.1016/j.ijcard.2016.05.044 büssing, a., pilchowska, i., & surzykiewicz, j. (2015). spiritual needs of polish patients with chronic diseases. journal of religion and health, 54(5), 1524–1542. https://doi.org/10.1007/s10943014-9863-x bu ̈ssing, a., janko, a., baumann, k., hvidt, n. c., & kopf, a. (2013a). spiritual needs among patients withchronic pain diseases and cancer living in a secular society.pain medicine, 14, 1362–1373. büssing, a., & koenig, h. g. (2010). spiritual needs of patients with chronic diseases. religions, 1(1), 18– 27. https://doi.org/10.3390/rel1010018 carver, c. s. (2013). cope inventory : measurement instrument database for the social science. drutchas, a., & anandarajah, g. (2014). spirituality and coping with chronic disease in pediatrics. rhode island medical journal (2013), 97(3), 26–30. fikriana, r. (2016). faktor – faktor yang diduga menjadi prediktor terjadinya peningkatan tekanan darah sistolik pada penderita hipertensi, jurnal kesehatan mesencephalon, 2(4), 285-291 http://dx.doi.org/10.36053/mesencephalon.v2i4 .14 fikriana, r., & devy, s. r. (2018). the effect of age and body mass index on blood glucose, blood cholesterol, and blood pressure in adult woman. indian journal of public health research & development, 9(11), https://doi.org/10.5958/09765506.2018.01687.x fikriana, r. (2018). sistem kardiovaskuler. yogyakarta : deepublish han, hae-ra., lee, h., commodore-mensah, y., kim, m. (2014). development and validation of the hypertension self care profile : a practical tool to measure hypertension self care. journal of cardiovascular nursing. 29(3) doi:10.1097/jcn.0b013e3182a3fd46 granger, b. b., ekman, i., granger, c. b., ostergren, j., olofsson, b., michelson, e., … swedberg, k. (2009). adherence to medication according to sex and age in the charm programme. european journal of https://doi.org/10.1177/1090198115606918 https://doi.org/10.1016/j.mpmed.2018.06.009 https://doi.org/10.1016/j.ijcard.2016.05.044 https://doi.org/10.1007/s10943-014-9863-x https://doi.org/10.1007/s10943-014-9863-x https://doi.org/10.3390/rel1010018 http://dx.doi.org/10.36053/mesencephalon.v2i4.14 http://dx.doi.org/10.36053/mesencephalon.v2i4.14 https://doi.org/10.5958/0976-5506.2018.01687.x https://doi.org/10.5958/0976-5506.2018.01687.x r. fikriana et al. 198 | pissn: 1858-3598  eissn: 2502-5791 heart failure, 11(11), 1092–1098. doi:10.1093/eurjhf/hfp142 hernández-ledesma, a. l., rodríguez-méndez, a. j., gallardo-vidal, l. s., trejo-cruz, g., garcía-solís, p., dávila-esquivel, f. d. j., … querétaro, a. de. (2018). coping strategies and quality of life in mexican multiple sclerosis patients : physical , psychological and social factors relationship. multiple sclerosis and related disorders, 25(may), 122–127. https://doi.org/10.1016/j.msard.2018.06.001 indonesian society of hypertension. (2019). konsensus penatalaksanaan hipertensi 2019. jakarta : inash kemenkes ri. (2013). riset kesehatan dasar. jakarta: kemenkes ri. 88–90 kemenkes ri. (2018). laporan nasional riskesdas 2018. jakarta: kemenkes ri. 154–66 nursalam. (2017). metodotogi penelitian ilmu keperawatan : pendekatan praktis edisi 4. jakarta : salemba medika manteuffel, m., williams, s., chen, w., verbrugge, r. r., pittman, d. g., & steinkellner, a. (2014). influence of patient sex and gender on medication use, adherence, and prescribing alignment with guidelines. journal of women’s health, 23(2), 112– 119. https://doi.org/10.1089/jwh.2012.3972 nursalam, n., dwi, o.d.w., alit, a.n.k., ferry, e. (2018). analysis of the stressor and coping strategies of adolescents with dysmenorrhoea. indian journal of public health research & development, 9(10), 381-386. https://doi.org/10.5958/09765506.2018.01373.6 orzechowska, a., zajaczkowska, m., talarowska, m., & gałecki, p. (2013). depression and ways of coping with stress: a preliminary study. medical science monitor, 19, 1050–1056. https://doi.org/10.12659/msm.889778 perricone, g., guerra, m. p., cruz, o., polizzi, c., lima, l., morales, m. r., … fontana, v. (2013). maternal coping strategies in response to a child’s chronic and oncological disease: a cross-cultural study in italy and portugal. pediatric reports, 5(2), 43–47. https://doi.org/10.4081/pr.2013.e11 ramli, a., ahmad, n. s., & paraidathathu, t. (2012). medication adherence among hypertensive patients of primary health clinics in malaysia. patient preference and adherence, 6, 613–622. https://doi.org/10.2147/ppa.s34704 rohman., nursalam., titin, s., ali, a.r. (2019). the relationship between knowledge and spirituality with the prevention behavior of infection transmission in plwha. indian journal of public health research & development, 10(8), 28172822. https://doi.org/10.5958/09765506.2019.02300.3 shafi, s. t., & shafi, t. (2017). journal of epidemiology and global health a survey of hypertension prevalence , awareness , treatment , and control in health screening camps of rural central punjab , pakistan. journal of epidemiology and global health, 7(2), 135–140. https://doi.org/10.1016/j.jegh.2017.01.001 visutyothin, y., & boonmongkon, p. (2018). selfregulating blood sugar control in women with uncontrolled diabetes mellitus. kasetsart journal of social sciences, 1–5. https://doi.org/10.1016/j.kjss.2017.12.016 https://doi.org/10.1016/j.msard.2018.06.001 https://doi.org/10.1089/jwh.2012.3972 https://doi.org/ http://dx.doi.org/10.5958/0976-5506.2018.01373.6 http://dx.doi.org/10.5958/0976-5506.2018.01373.6 https://doi.org/10.12659/msm.889778 https://doi.org/10.4081/pr.2013.e11 https://doi.org/10.5958/0976-5506.2019.02300.3 https://doi.org/10.5958/0976-5506.2019.02300.3 https://doi.org/10.1016/j.jegh.2017.01.001 https://doi.org/10.1016/j.kjss.2017.12.016 310 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17170 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research self affirmation reduces the anxiety, ldh and troponin i in the clients with coronary heart disease (chd) padoli padoli1, joko suwito1, and tanto hariyanto2 1faculty of nursing surabaya health ministry polytechnic, indonesia 2faculty of nursing malang health ministry polytechnic, indonesia abstract introduction: positive self affirmation is one of the psychological interventions that can be applied to the treatment of coronary heart disease; its effect is currently unknown. the purpose of this study was to prove the effect of self affirmation on anxiety, troponin i and ldh in coronary heart disease patients. methods: the type and design of the study was quasi-experimental with a nonrandomized post-test control group design. thirty patients with coronary heart disease who were treated in the camelia room of dr soetomo hospital who had been selected were divided into 2 groups. the first group was given self affirmation twice / day for 20 minutes and the second group had standard care as the control group. after the intervention, anxiety measurements were taken, in addition to the measurement of troponin i and ldh. results: the results showed that self affirmation reduced anxiety (ρ = 0.03), decreased troponin i (ρ = 0.003) and decreased the lactate dehydrogenase (ldh) levels (ρ = 0.006). conclusion: self-affirmation improves the client’s emotions, preventing damage to the heart muscle cells. this is reflected by a decrease in the troponin i and ldh levels which are indicators of heart muscle damage. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords self affirmation; anxiety; troponin i; ldh; coronary heart disease contact padoli padoli1  padolipolteksby@yahoo.co.id  faculty of nursing surabaya health ministry polytechnic, indonesia cite this as: padoli, p, suwito, j, & hariyanto, t (2019). self affirmation reduces the anxiety, ldh and troponin i in the clients with coronary heart disease (chd). jurnal ners, 14(3si), 310-315 doi:http://dx.doi.org/10.20473/jn.v14i3(si).17170 introduction coronary heart disease (chd) is the single largest cause of death in the united states, western europe and many other countries including indonesia. observational studies indicate that psychosocial factors strongly influence the development of coronary heart disease and that they influence the prognosis post-mi. psychosocial factors in depression are a major problem in patients after they have experienced an acute heart attack, so psychological interventions specifically target these psychosocial risk factors to reduce the rate of recurrence of heart attacks (adverse cardiac events). in indonesia, the prevalence of chd is increasing every year. a regular household health survey (skrt) conducted by the ministry of health showed that heart disease contributed to 19.8% of all causes of death in 1993. this number increased to 24.4% in 1998. the 2001 skrt results for chd ranked first in reference to the main causes of death in indonesia(lestari, 2007). it is estimated that up to 20% of individuals experience depressive episodes within a few weeks of acute events. more than 25% experience minor depression or dysrhythmias, with an odds ratio of 2 3. the data of the patients treated in the camelia room in the rsud year 2008 in the dr. soetomo surabaya hospital showed 207 people (27.95%) out of 741 cases of coronary heart disease wre diagnosed with ima and in 2009, there were 243 (30.29%) ima patients out of 802 chd patients. in 2010 during the period from january to september, the number of ima patients numbered 199 people (35%) out of 553 patients with chd. psychological factors have been widely found to increase the risk and to worsen the prognosis of coronary disease. increased corticosteroids due to stress will induce hypercholesterolemia, hypertriglyceridemia and hypertension. other actions of induction due to atherosclerosis on steroids include injury to the endothelial blood vessel cells, intima and the inhibition of normal healing. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 311 morning plasma cortisol increases significantly, which is correlated with moderate to severe coronary atherosclerosis. sympatoadrenal hyperactivity contributes to the development of cardiovascular disease through the effects of catecholamines on the heart, blood vessels and platelets. some evidence suggests that the psychosocial factors in depression are a major problem in patients after experiencing an acute heart attack. depressed patients experience several social problems during the first year of healing. they report an impaired quality of life, are less adherent to treatment and are slower to return to work than non-depressed patients. several studies have shown that depression after an acute myocardial infarction is accompanied by an increase in the risk of future heart attacks and cardiac death(kristina orth-gome, 2009). stress and depression due to chd attacks requires psychological interventions to prevent this risk and to improve the prognosis of coronary disease. positive selfaffirmation interventions that control stress and that enhance the parasympathetic nervous system action are expected to reduce morbidity and to facilitate emotional and physical recovery after being discharged from the hospital. however, so far, apart from positive affirmations rarely being used, it has not been able to explain the improvement in healing in coronary heart disease patients. the interaction of various factors can significantly speed up the disease process (price, silvia, 2006). emotional factors and chronic stress experiences increase atherosclerosis and the risk of heart attacks. acute emotional stress in mice causes increased creatinine kinase (ck) activity and increased alanine aminotransferase (alt), aspartate aminotransferase (ast) and lactate dehydrogenase (ldh) in the plasma or serum. this increase in enzymes is thought to result from damage to the various tissues (nutr et al., 2009). acute anger is accompanied by twice the risk of myocardial infarction and mental stress, causing cardiac ischemia in 30 60% of patients with chd(kop,willem j., 2007). heart disease has a reciprocal relationship with emotional distress, psychosocial conditions and psychiatric disorders. the management of chd is focused on risk factor modification intensively through drugs, changes in lifestyle, physical exercise and diet. the results revealed that around 75% of all physical diseases stem from mental and emotional problems. unfortunately, most treatments rarely reach the source of this problem, namely the mind or emotions (w, 2007). cardiac rehabilitation services are comprehensive programs that involve education, training, risk factor modification and counseling, which are designed to limit the physiological and psychological effects of heart disease, reducing the risk of death or the recurrence of heart attacks, and increasing the client’s psychosocial and vocational status(contractor, 2011). self affirmation is very easy, fast and effective, reaching the subconscious mind, re-educating and healing the sick mind. self affirmation is one of the psychological interventions that works to improve the work of the parasympathetic nervous system. increased parasympathetic activity protects from the effects of electrical destabilization in the myocardium by increasing adrenergic tone. mind relaxation also counters the high response due to stress. the relaxation of the mind as a physiological responses will affect the hypothalamic pituitary adrenal (hpa) axis and the sympathetic-adrenalmedullary (sam) axis by decreasing the cortisol secretion in the adrenal gland of the cortex and decreasing the release of catecholamines through the sympathetic fibers in the medullary adrenal sympathetic axis. decreased levels of cortisol and catecholamines will reduce cardiac demand, induce an increase in plasma volume, increase the mean heart variability (hrv), prevent coronary contraception and reduce platelet / plaque activation and rupturing related to atherosclerosis. the purpose of this study was to explain the effectiveness of self-affirmation related to anxiety, ldh and troponin i in the clients with coronary heart disease. materials and methods coronary heart disease (chd) is the single largest cause of death in the united states, western europe and many other countries including indonesia. observational studies indicate that psychosocial factors strongly influence the development of coronary heart disease and that they influence the prognosis post-mi. psychosocial factors in depression are a major problem in patients after they have experienced an acute heart attack, so psychological interventions specifically target these psychosocial risk factors to reduce the rate of recurrence of heart attacks (adverse cardiac events). in indonesia, the prevalence of chd is increasing every year. a regular household health survey (skrt) conducted by the ministry of health showed that heart disease contributed to 19.8% of all causes of death in 1993. this number increased to 24.4% in 1998. the 2001 skrt results for chd ranked first in reference to the main causes of death in indonesia(lestari, 2007). it is estimated that up to 20% of individuals experience depressive episodes within a few weeks of acute events. more than 25% experience minor depression or dysrhythmias, with an odds ratio of 2 3. the data of the patients treated in the camelia room in the rsud year 2008 in the dr. soetomo surabaya hospital showed 207 people (27.95%) out of 741 cases of coronary heart disease wre diagnosed with ima and in 2009, there were 243 (30.29%) ima patients out of 802 chd patients. in 2010 during the period from january to september, the number of ima patients numbered 199 people (35%) out of 553 patients with chd. psychological factors have been widely found to increase the risk and to worsen the prognosis of p. padoli, et al. 312 | pissn: 1858-3598  eissn: 2502-5791 coronary disease. increased corticosteroids due to stress will induce hypercholesterolemia, hypertriglyceridemia and hypertension. other actions of induction due to atherosclerosis on steroids include injury to the endothelial blood vessel cells, intima and the inhibition of normal healing. morning plasma cortisol increases significantly, which is correlated with moderate to severe coronary atherosclerosis. sympatoadrenal hyperactivity contributes to the development of cardiovascular disease through the effects of catecholamines on the heart, blood vessels and platelets. some evidence suggests that the psychosocial factors in depression are a major problem in patients after experiencing an acute heart attack. depressed patients experience several social problems during the first year of healing. they report an impaired quality of life, are less adherent to treatment and are slower to return to work than non-depressed patients. several studies have shown that depression after an acute myocardial infarction is accompanied by an increase in the risk of future heart attacks and cardiac death(kristina orth-gome, 2009). stress and depression due to chd attacks requires psychological interventions to prevent this risk and to improve the prognosis of coronary disease. positive selfaffirmation interventions that control stress and that enhance the parasympathetic nervous system action are expected to reduce morbidity and to facilitate emotional and physical recovery after being discharged from the hospital. however, so far, apart from positive affirmations rarely being used, it has not been able to explain the improvement in healing in coronary heart disease patients. the interaction of various factors can significantly speed up the disease process (price, silvia, 2006). emotional factors and chronic stress experiences increase atherosclerosis and the risk of heart attacks. acute emotional stress in mice causes increased creatinine kinase (ck) activity and increased alanine aminotransferase (alt), aspartate aminotransferase (ast) and lactate dehydrogenase (ldh) in the plasma or serum. this increase in enzymes is thought to result from damage to the various tissues (nutr et al., 2009). acute anger is accompanied by twice the risk of myocardial infarction and mental stress, causing cardiac ischemia in 30 60% of patients with chd(kop,willem j., 2007). heart disease has a reciprocal relationship with emotional distress, psychosocial conditions and psychiatric disorders. the management of chd is focused on risk factor modification intensively through drugs, changes in lifestyle, physical exercise and diet. the results revealed that around 75% of all physical diseases stem from mental and emotional problems. unfortunately, most treatments rarely reach the source of this problem, namely the mind or emotions (w, 2007). cardiac rehabilitation services are comprehensive programs that involve education, training, risk factor modification and counseling, which are designed to limit the physiological and psychological effects of heart disease, reducing the risk of death or the recurrence of heart attacks, and increasing the client’s psychosocial and vocational status(contractor, 2011). self affirmation is very easy, fast and effective, reaching the subconscious mind, re-educating and healing the sick mind. self affirmation is one of the psychological interventions that works to improve the work of the parasympathetic nervous system. increased parasympathetic activity protects from the effects of electrical destabilization in the myocardium by increasing adrenergic tone. mind relaxation also counters the high response due to stress. the relaxation of the mind as a physiological responses will affect the hypothalamic pituitary adrenal (hpa) axis and the sympathetic-adrenalmedullary (sam) axis by decreasing the cortisol secretion in the adrenal gland of the cortex and decreasing the release of catecholamines through the sympathetic fibers in the medullary adrenal sympathetic axis. decreased levels of cortisol and catecholamines will reduce cardiac demand, induce an increase in plasma volume, increase the mean heart variability (hrv), prevent coronary contraception and reduce platelet / plaque activation and rupturing related to atherosclerosis. the purpose of this study was to explain the effectiveness of self-affirmation related to anxiety, ldh and troponin i in the clients with coronary heart disease. results the characteristics of the research subjects in the control group were that most were women (69,23,%), almost half were unemployed or private employees (23,08%), most suffered from an old miocardial infarction (omi) (46,15%) and the average age was 55.67 years. most of the subjects in the treatment group were male (64.71%), almost half were not working or they were private employees (29.41%) and they had suffered from an acute myocardial infarction (ima / 41.18%) and omi (41.18%) (table 1). anxiety the mean anxiety score in the control group was 9.07 ± 4.66 and in the treatment group it was 6.11 ± 2.49. the average anxiety scores in the treatment group were lower than in the control group. the data shows that self affirmation decreases anxiety more quickly than in the standard group of coronary heart disease clients (table 2). the results of the independent t test show a ρ value = 0.033 <α = 0.05, therefore h0 is rejected. this means that there are significant differences in the level of anxiety between the clients who are given self-affirmation and standard care. jurnal ners http://e-journal.unair.ac.id/jners | 313 when a threat or danger is perceived as excessive, the sympathetic nervous system input decreases and the parasympathetic system becomes more active. the 2 systems cannot operate together at the same time(herbert, 1975)(sapolsky, 1994a), so relaxation occurs when the sympathetic nervous system is more dominant. nerve impulses originating from the cortex stimulate the hypothalamus where the parasympathetic response begins. the hypothalamus sends instructions through the nerves to the rest of the body. the vagus nerve is responsible for most of the innervation in the internal organs. the vagus nerve sends a message to slow down the heart rate, to lower the blood pressure, to stimulate digestion and to normalize the blood sugar levels. this response was identified by herbert benson as a relaxation response (herbert, 1975). troponin i the mean troponin i level in the control group was 15.39 ng / ml ± 16.92 and in the treatment group it was was 1.76 ng / ml ± 4.13. the mean troponin i level in the treatment group was lower than in the control group. the results of the independent t test showed a value of p 0.003> (p = 0.05), meaning that there were differences in the levels of troponin i enzymes between the 2 groups, where for the coronary heart disease patients who got self-affirmation, the troponin i enzyme level tended to be lower than in the patients with standard care (table 3). lactate dehydrogenase the mean ldh value of the control group was 905.33 ± 652.26 and in the treatment group, it was 459.89 ± 145.04. the results of the independent t test showed a value of p 0.006> (p = 0.05), meaning that there were differences in the ldh enzyme levels between the two groups. the mean ldh in the treatment group was lower than in the control group. this shows that there are differences in the ldh values between the 2 groups. where the coronary heart disease patients were given self-affirmation, the ldh enzyme values tended to be lower than in the patients with standard care (table 4). discussion this study was a quasi-experimental study conducted on patients with coronary heart disease in the camelia room of dr. hospital. soetomo surabaya. the research design used was a post-test control group design because the researcher wanted to know the tendency of changes in anxiety, followed by the tendency of changes in heart cell function using the table . distribution of the characteristics of the coronary heart disease clients characteristics control group treatment group gender f % f % man 4 30,77 6 35,29 women 9 69,23 11 64,71 total 13 100,0 17 100,0 work f % f % irt/does not work 3 23,08 5 29,41 private 6 46,15 7 41,18 entrepreneurship 2 15,38 1 5,88 civil servants 2 15,38 4 23,53 total 13 100,0 17 100,0 medical diagnosis f % f % omi 6 46,15 7 41,18 nstemi 2 15,38 1 5,88 angina 2 15,38 2 15,38 ima 3 23,08 7 41,18 total 13 100 17 100 average age 55,67 years 51,33 years table 2. anxiety in the coronary heart disease clients after being given self affirmation variables group means sd sig. (2-tailed) anxiety control 9,07 ±4,66 0,03 treatment 6,11 ±2,49 table 3. troponin i in the coronary heart disease clients after being given self affirmation variables groups means sd sig. (2-tailed) troponin i control 15,39 ±16,92 0,003 treatment 1,76 ±4,13 table 4. ldh value in the coronary heart disease clients after being given self affirmation variable groups means sd sig. (2-tailed) ldh control 905,33 ±652,26 0,006 treatment 459,89 ±145,04 p. padoli, et al. 314 | pissn: 1858-3598  eissn: 2502-5791 parameters of troponin i and ldh levels. self affirmation iwas carried out twice a day for 20 minutes each session after the client returned from the iccu room. the retrieval of data for the anxiety variable was carried out twice before and after the treatment, while the values for the troponin i and ldh data were taken once, 3 days after giving the self affirmation in both the treatment and control groups. anxiety ischemic heart disease is a disease that causes death in developing countries throughout the world. psychosocial factors are known today to play a significant and independent role in the development of ischemic heart disease and its complications. mental stress has implications for triggering myocardial infarction (mi) and sudden death in patients with coronary artery disease[10]. a survey of the physical and psychological symptoms of chd client anxiety shows that anxiety correlates with physical factors such as palpitations without exercise, anger, redness in the face, an abnormal pulse and muscle tension. the psychological consequences of cardiovascular disease are known to affect recovery and quality of life. anxiety and depression are the main consequences of the incidence of sudden death accompanied by chd and cardiac arrhythmias (roest, martens, p, & denollet, 2010). self-affirmation triggers a psychological cascade of effects, such as paying increasing attention to threats, broadening the perspective, increasing the feelings of social connection and enhancing their coping resources (sapolsky, 1994b; sherman & hartson, 2011). the results of this study indicate that the average rating of anxiety in the client group given selfaffirmation (7.50) was lower than the group of clients who received standard care. although the results of the statistical tests showed no difference in the groups (ρ = 0.169> ɑ = 0.05), the results indicated there to be a tendency for self affirmation to reduce anxiety in the clients owith coronary heart disease. research states that self-affirmation plays an important role in increasing behavioral secretions (stone et al., 1999) and it can reduce the defensive response to information that threatens their health. the ventral striatum is a key region in the mesolimbic dopamine reward pathway which suggests that affirming important personal values is rewarding and it may lead to a cascade of effects associated with reward processing. self-affirmation increases ventral striatum activity. ventral striatum activity during self-affirmation activates a cascade of neural effects, including increased ventromedial prefrontal cortex activity, which in turn leads to psychological and behavioral changes. selfaffirmation reduces the threat and stress responses, improves performance, reduces defensiveness and alters social and health behaviors troponin i and lactate dehydrogenase (ldh) in myocardial necrosis, intracellular proteins will enter the interstitial space and go on to enter the systemic circulation via the local microvascular and lymphatic flow. therefore, myocardial necrosis can be detected by examining the proteins in the blood caused by cell damage. these proteins include aspartate aminotransferase (ast), lactate dehydrogenase, creatine kinase isoenzyme mb (ckmb), myoglobin, carbonic anhydrase iii (ca iii), myosin light chain (mlc) and cardiac troponin i and t (ctni and ctnt). increased serum levels of these proteins confirms the presence of myocardial infarction (stürmer, nigbur, schacht, & sommer, 2011). some elevation of the cardiac troponin levels in patients with st elevation mi, non-st elevation mi, unstable angina, congestive heart failure and chronic renal insufficiency are indicative of poor outcomes (sylvana, fransisca, & da, 2005). patients with a tnc elevation have higher mean cardiac mortality and they are more likely to have a coronary thrombus, more emboli in the coronary microvascular system and depression in their ventricular function (van koningsbruggen & das, 2008). the results of this study indicate that selfaffirmation reduced the troponin i levels in the clients with coronary heart disease (p = 0.011), in addition to the level of the enzyme lactate dehydrogenase (ldh) (p = 0.006). decreased levels of this enzyme indicates an improvement in relation to the myocardial infarction risk in clients with coronary heart disease. self-affirmation relies on similar neural mechanisms to reduce the threat response. there is evidence that rewards and a positive effect increases the correlates of error-related negativity eventrelated potentials, which might relate to an improved conflict adaptation[18]. self-affirming appears to encourage adaptive responses, reducing the responses that minimize the negative emotional impact of the information (fear control) and promoting responses that may eventually reduce the danger (danger control). in this case, it decreases anxiety, decreases the sympathetic activity and increases the parasympathetic response in chd patients thereby reducing the risk of myocardial ischemia, which is reflected in a decrease in the troponin i and lhd levels. conclusion based on the results of the self-affirmation study to reduce anxiety, lactate dehydrogenase and troponin i in chd clients, it can be concluded that self affirmation tends to reduce anxiety and prevent damage to the heart muscle cells. this is reflected by a decrease in the troponin i and lactac dehydrogenase (ldh) levels which are indicators of muscle damage in the heart. the results of this study suggest that self affirmation should be carried out on chd clients and that this can be initiated in the intensive care room after the patient's condition is stable until the healing period begins properly. nurses need to be equipped with the knowledge of self affirmation techniques as jurnal ners http://e-journal.unair.ac.id/jners | 315 a complementary therapy to provide effective patient services. references contractor, a. s. (2011). cardiac rehabilitation after myocardial infarction. 59(december), 51–55. herbert, b. (1975). the relaxation response. new york: harper collin publisher inc. kop,willem j., et al. (2007). psychoneuroimmunological pathways involved in acute coronary syndromes. psychoneuroimmunology. kristina orth-gome, n. s. h.-x. w. c. w. (2009). stress reduction prolongs life in women with coronary disease. circ cardiovasc qual outcomes. lestari. (2007). identifikasi risiko dan gejala penyakit jantung koroner. kantor berita indonesia, gemari. nutr, j. c. b., ohta, y., kaida, s., chiba, s., tada, m., teruya, a., & imai, y. (2009). japan stress in increases in the serum levels involvement of oxidative of various enzymes and components in rats with water-immersion restraint stress. (november), 347–354. price, silvia, et al. (2006). patofisiologi: konsep klinis proses-proses penyakit (from pathophysiology: clinical concepts of disease process). jakarta: penerbit buku kedokteran, egc. roest, a. m., martens, a. j., p, de j., & denollet, j. (2010). anxiety and risk of incident coronary heart disease: a meta-analysis. j am coll cardiol, 1. sapolsky. (1994a). why zebras don’t get ulcers. new york: henry holt and company. sapolsky. (1994b). why zebras don’t get ulcers. new york: henry holt and company. sherman, d. ., & hartson, k. . (2011). reconciling selfprotection with self-improvement: selfaffirmation theory (in m. alic). new york: guilford press. stone, p. h., krantz, d. s., & mcmahon, r. p. (1999). relationship among mental stress-induced ischemia and ischemia during daily life and during exercise. stürmer, b., nigbur, r., schacht, a., & sommer, w. (2011). reward and punishment effects on error processing and conflict control. frontiers in psychology, 2. https://doi.org/10.3389/fpsyg.2011.00335 sylvana, fransisca, & da, g. (2005). acute myocardial infarction. wijaya kusuma university medical school. van koningsbruggen, g. m., & das, e. (2008). don’t derogate this message! self affirmation promotes online, type 2 diabetes risk test taking. psychology and health, 24, 635–649. w, g. a. (2007). hypnotherapy, the art subconsious restructuring. jakarta: penerbit gramedia pustaka utama. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 252 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17125 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review efficacy of topical applications on reducing uremic pruritus: a systematic review gabriel wanda sinawang, rohmatul faizah, mohamad roni alfaqih and andrik hermanto faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: uremic pruritus is an unpleasant sensation that has been recognized as a frequent complication in patients with chronic kidney disease. this study was undertaken to determine the effect of topical applications for reducing pruritus. methods: a systematic review was conducted by searching science direct, scopus and google scholar to create an integrative 12 articles review focusing on a 10 year period from 2009 to 2018. the language used was english and the studies focused on pruritus, itching, hydration, chronic kidney disease and where the patient did not undergo a kidney transplant. the articles in this systematic review were experimental studies (pre-experimental, true experimental and quasi-experimental). results: most of the findings of the studies showed that a topical application for reducing uremic pruritus (clove oil, almond oil, cromolyn sodium 4%, baby oil, sweet almond oil, vinegar and avenasativa, glycerol and paraffin, sericin cream and chia seed oil) can be used as an adjuvant moisturizing agents for pruritis. conclusion: topical applications have a positive effect on itching and decreased pruritus. topical applications are simple, safe, inexpensive and easily applied, so it can be used on many people. article history received: december 26, 2019 accepted: december 31, 2019 keywords topical applications; uremic pruritus contact gabriel wanda sinawang  gabriel.wanda.sinawang2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sinawang, g. w., faizah, r., alfaqih, m. r., & hermanto, a. (2019efficacy of topical applications on reducing uremic pruritus: a systematic review. jurnal ners, 14(3si), 252-255. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17125 introduction pruritus is one of the most common skin disorders among patients with end-stage renal disease, which disturbs their mental and physical health status. for instance, it causes sleep disorders, although pruritus is not life-threatening, it can affect the quality of life of the patients (karadag et al., 2014). uremic pruritus is an unpleasant sensation that has been recognized as a frequent complication in patients with chronic kidney disease. it is one of the most common disabling symptoms in patients with end-stage renal disease. (aramwit et al., 2012) it has been found that 15% to 49% of patients with chronic kidney disease and more than 40% of patients undergoing hemodialysis suffer from chronic pruritus. pruritus frequency increases significantly alongside the deterioration of the disease and the treatment period. it can cause disturbances in the day and night rhythm, depression, sleeping disorders, anxiety and skin complications and it can also diminish quality of life (nakhaee et al., 2015).patients with hd are at a high risk of experiencing drug toxicity due to kidney failure in terms of excreting drug metabolites. non-chemical medications such as herbal medicines with low toxicity may be advised for such cases (mehri, afrasiabifar and hosseini, 2018). the topical application of a herbal substance can moisturize the skin and reduce pruritus and this treatment can minimize the effect of chemicals for the patient with renal disease. in this study, the researchers wanted to see the efficacy of topical applications when it comes to reducing uremic pruritus. materials and methods research design this study used a systematic review with a questionbased search: “what is the effect of topical applications on reducing pruritus?” https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 253 search strategy the trials to be included to the review were identified through electronic database searching from the earliest available time through to 2017 using the following databases: sciencedirect, scopus and google scholar by using the keywords “pruritus” and “chronic kidney disease”. inclusion and exclusion criteria the inclusion criteria in this review were experimental study and non-experimental studies that had been published from june 2009 to 2018, where the participants were 10 years old or more, where the language used was english and that focused on pruritus and chronic kidney disease. the exclusion criteria were studies that did not involve patients with chronic kidney disease and where there had been a transplant. article searching process this systematic review was conducted according to the prisma (preferred reporting items for systematic reviews and meta-analyses) guidelines. the database search was performed from 2009 to 2019. the literature research used three databases: sciencedirect, scopus and google scholar. the following key words were used: pruritus, itching, hydration, kidney disease and the patient did not undergo a kidney transplant. the limitations used in the literature search were that they had to be published in english. this study reviewed 12 articles. the articles come from iran, taiwan, prances, korea, cairo and thailand. results the review results showed the efficacy of the topical applications related to reducing uremic pruritus as presented in table 1. based on table 1, the researchers were able to determine the efficacy of topical treatments for reducing uremic pruritus. there were 2 dominant applications found through natural and pharmaceutical therapy. natural therapy from the 12 articles that reviewed, 9 articles used natural or non-pharmacological therapy as a comparison intervention. the interventions used baby oil, clove oil, sericin, chia seed and sweet almond oil. the applications were effective at moisturizing the skin because the substance was liquid paraffin (baby oil), contained essential fatty acids (sweet almond, chia seed), had moisturizing properties with a proinflamatory effect (sericin) and they contained natural oils (clove oil). pharmacological therapy from the 12 articles that were reviewed, 3 articles used the pharmacological therapy as a comparison intervention. the intervention used cromolyn sodium 4%, avena sativa and glycerol-parrafin. this application contains a chemical material that can decrease pruritus. cromolyn sodium acts as a mast cell stabilizer for patient dialysis, avena sativa has the effect of moisturizing, protective, soothing and being an anti-inflammatory and glycerol-paraffin results in hydration and it is an anti-irritant. this study was used to evaluate the efficacy of topical therapy using at least one of several instruments. the measuring instruments were iss (itch severity scale), the 5-d itch scale (duration, degree, direction, disability and distribution), vas (visual analogue scale), a corneometer (skin parameters for hydration), a mexameter (irritation and pigmentation), kdqol-sf (kidney disease quality of life short form), dermalab and skin surface phwas measured by the skin ph meter ph900. there was also the d-squame technique (the total surface area of all squames; [surft] the parameter measures the extent and density of the scales, the mean optical density without threshold and the [mod] parameter measures the thickness of the scales, generic scale short form-12 (sf-12) questionnaire, the dermatology life quality index (dlqi), psqi (the pittsburgh sleep quality index), the sf-36 quality of life scale (sf-36 qol), ods (overall dry scale), the questionnaire of pruritic score and itchyqol. discussion effectiveness of baby oil for treating uremic pruritus the severity of the itching was much lower in the participants treated with baby oil than those who were untreated. this was found in the study of (lin et al., 2012), where the severity of the itching did not significantly differ between the groups treated with chilled baby oil and those treated with un-chilled baby oil. chilled or un-chilled baby oil is effective as a cooling and soothing agent and moisturizing lotion. furthermore, in a study conducted by (karadag et al., 2014), itching improved the patient’s quality of life and it reduced the sleep problems of the hd patients. baby oil, which contains moisturizing raw coconut oil and oil with minerals, reduces itching through its effects such as stopping the transmission of the nerve fibers and decreasing chemical stimulus and inflammation. in another study (mokhtarabadi et al., 2017), baby oil had moisturizing properties and there are similarities between this compound and physiological lipids, endogenous cannabinoids and emollients containing high water content. effectiveness of topical clove oil for treating uremic pruritus chronic pruritus can be broadly categorized into four major groups: dermatologic causes, systemic causes, neuropathic causes and psychogenic cause. there are several modalities for the treatment of pruritus including topical therapy, systemic therapy, phototherapy and behavioral therapy (ibrahim et al., 2017). clove oil (eugenol) is a topical anesthetic in dentistry and it might possess the potential to replace benzocaine as a topical agent. this therapeutic option for chronic pruritus has excellent results and it is free from toxic side effects. g. w. sinawang i, et al. 254 | pissn: 1858-3598  eissn: 2502-5791 effectiveness of topical avena sativa, vinegar and hydroxyzine for treating uremic pruritus the study of (nakhaee et al., 2015) showed that avena sativa produced a protective moisturizing barrier on the skin which helped to soften and moisten the skin and heal tissue, hence reducing pruritus. vinegar has been reported to be useful for the treatment of pruritus. by maintaining the acidic ph of the skin’s surface, vinegar helps to preserve the skin’s barrier function and thus it reduces skin irritation. low ph topical therapies decrease pruritus by limiting the activity of serine proteases on the skin nerve fibers. on the other hand, pruritus is cause by the elimination of urea and sodium through the skin. a diluted vinegar solution can counteract the urea crystals and reduce pruritus. effectiveness of sericin cream for treating uremic pruritus the level of skin hydration in the patients’ extremities increased after treatment with sericin[3]. sericin cream and the cream base were used to prepare the sericin cream that increased moisture content of the stratum corneum. however, the level of hydration was significantly higher in the skin treated with sericin cream. effectiveness of topical chia seed oil for treating uremic pruritus skin capacitance, which represents the skin’s hydration, was below the normal values before the treatment and it gradually increased during the treatment time with the chia seed oil containing moisturizer (jeong et al., 2010). effectiveness of topical cromolyn sodium 4% for treating uremic pruritus this study found out that in the third and fourth week of the study, cs 4% cream was more effective at reducing pruritus than the placebo (maryam et al., 2013). the skin of the ckd patients with pruritus had a greater number of mast cells and also an increased plasma histamine level compared to those without table 1. list the efficacy of topical applications on reducing uremic pruritus no article writer efficacy of topical applications on reducing uremic pruritus 1. lin t, lai y, guo s, liu c, tsai j, guo h chilled or un-chilled baby oil is effective as a moisturizing lotion and cooling soothing agents. 2. ibrahim im, elsaie ml, mohey-eddin mh natural oil is free from toxic side effects. 3. aramwit p, keongamaroon o, siritientong t, bang n sericin cream can also significantly increase skin hydration and reduce skin irritation and skin pigmentation in patients. 4. jeong sk, ph d, park hj, ph d, park bd, ph d, et al chia seed oil is effective at treating pruritus and xerosis and it is also beneficial for skin moisturizing. 5. balaskas e, szepietowski jc, bessis d, ioannides d, ponticelli c, ghienne c. randomized the effective emollient treatment of uremic xerosis can also efficiently relieve uremic pruritus. 6. nakhaee s, nasiri a, waghei y vinegar and avena sativa lotion can be used for uremic pruritus. 7. karadag e, kilic sp, karatay g, metin o baby oil had short term positive effects on itching, sleep quality and quality of life in the hd patients who had itching complaints. 8. tricaesario c, widayati ri, oil a 4% almond oil cream is effective at increasing the skin’s moisture level. 9. maryam k, feily a, dormanesh b, ghorbani a cs 4% cream was more effective at reducing pruritus than the placebo. 10. mehri z, afrasiabifar a, hosseini n topical application of sweet almond oil improved itchiness in patient with uremic pruritus. 11. mokhtarabadi s, shahabinejad m, sadeghi t, kazemi m thermal changes in baby oil had no effect on assuaging pruritus severity, and the only effective factor was its moisturizing properties. 12. (ardashirafrasiabifar, et al sweet almond oil as a natural method without complications could be a non-invasive way to help patients to reduce uremic pruritus. figure 1. flowchart of the research on pruritus and chronic kidney disease jurnal ners http://e-journal.unair.ac.id/jners | 255 pruritus, so it is logical to use the mast cell stabilizing cs in the treatment of renal pruritus. effectiveness of topical glycerol and paraffin for treating uremic pruritus the results indicate that an effective emollient treatment of uremic xerosis can also efficiently relieve uremic pruritus (balaskas et al., 2011). the effects of an emollient and skin protective product combining glycerol 15% and paraffin 10% were rapid hydrating and a smoothing effect. effectiveness of sweet almond oil for treating uremic pruritus one of the natural agents believed to have a moisturizing effect is almond oil due to its occlusive and emollient properties (‘efektivitas krim almond oil 4% terhadap tingkat kelembapan kulit’, 2016). furthermore, in a study conducted by (mehri, afrasiabifar and hosseini, 2018), dry skin (xerosis) is introduced as a cause of uremic pruritus. topical agents such as sweet almond oil containing essential fatty acids such as linoleic acid may help in its relief through increasing the leukotrienes and prostaglandins, which moisturize the skin. in addition, essential fatty acids, by reducing the lymphokines and lymphocytes, may lead to the reduction of pruritus and dermatological inflammations. for instance, arachidonic and linoleic acids play a protective role in the skin and their deficiency in patients undergoing hd may lead to dermatological complaints such as pruritus. (afrasiabifar, mehri and hosseini, 2017) in justifying the effectiveness of sweet almond oil on the relief of uremic pruritus, it can be said that sweet almond contains essential fatty acids such as linoleic acid that have been shown to be effective in relieving pruritus. the implication toward practice by recognizing several of the topical treatments that can be given to patients with kidney failure who have uremic pruritus, nurses are expected to be able to carry out the role of nursing in collaboration with doctors and pharmacists in providing natural or chemical treatment options. conclusion pruritus is an effect of kidney disease which will affect the quality of life of the sufferer. topical therapy is one of the options for reducing the impact of pruritus. natural topical therapies and chemicals generally aim to hydrate by providing moisture to the skin of the patients with renal failure, who tend to dry out. some topical therapies have additional functions such as having an anti-irritating and anti-inflammatory effect. topical therapy is an invasive action and it is a simple therapy that can be applied independently. topical therapy (especially natural therapy) can be an option because it is effective, efficient and easily accessible by all groups. references afrasiabifar, a., mehri, z. and hosseini, n. (2017) ‘efficacy of topical application of sweet almond oil on reducing uremic pruritus in hemodialysis patients: a randomized clinical trial study’, iranian red crescent medical journal. doi: 10.5812/ircmj.34695. aramwit, p. et al. (2012) ‘sericin cream reduces pruritus in hemodialysis patients: a randomized, double-blind, placebo-controlled experimental study.’, bmc nephrology. doi: 10.1186/14712369-13-119. balaskas, e. et al. (2011) ‘randomized, double-blind study with glycerol and paraffin in uremic xerosis’, clinical journal of the american society of nephrology. doi: 10.2215/cjn.05490610. ‘efektivitas krim almond oil 4% terhadap tingkat kelembapan kulit’ (2016) jurnal kedokteran diponegoro. ibrahim, i. m. et al. (2017) ‘effectiveness of topical clove oil on symptomatic treatment of chronic pruritus’, journal of cosmetic dermatology. doi: 10.1111/jocd.12342. jeong, s. k. et al. (2010) ‘effectiveness of topical chia seed oil on pruritus of end-stage renal disease (esrd) patients and healthy volunteers’, annals of dermatology. doi: 10.5021/ad.2010.22.2.143. karadag, e. et al. (2014) ‘effect of baby oil on pruritus, sleep quality, and quality of life in hemodialysis patients: pretest-post-test model with control groups’, japan journal of nursing science. doi: 10.1111/jjns.12019. lin, t. c. et al. (2012) ‘baby oil therapy for uremic pruritus in haemodialysis patients’, journal of clinical nursing. doi: 10.1111/j.13652702.2011.03906.x. maryam, k. et al. (2013) ‘efficacy of topical cromolyn sodium 4 % on pruritus of uremic nephrogenic patients ; a randomized double blind study on 60 patients’, (march). doi: 10.5414/cp201629. mehri, z., afrasiabifar, a. and hosseini, n. (2018) ‘improved itchy quality of life following topical application of sweet almond oil in patients with uremic pruritus: a randomized, controlled trial’, jundishapur journal of chronic disease care. doi: 10.5812/jjcdc.68164. mokhtarabadi, s. et al. (2017) ‘the effect of administration of baby oil on the severity of pruritus in hemodialysis patients’, medicalsurgical nursing journal. doi: 10.15171/jrip.2017.22. nakhaee, s. et al. (2015) ‘comparison of avena sativa, vinegar, and hydroxyzine for uremic pruritus of hemodialysis patients a crossover randomized clinical trial’, iranian journal of kidney diseases. authors index volume 13 nomor 2 oktober 2018 abunyamin, 31 adriani, merryana, 156 afik, al, 42 agustiyowati, 150 alim, syahirul, 227 aprianti, riri, 122 arief, yuni sufyanti, 98 armini, ni ketut alit, 184 artsanthia, jintana, 57 aryanti, putu indraswari, 200 asih, susi wahyuning, 18 asmuji, 106 astuti, athanasia budi, 36 astutik, erni, 87 bakar, abu, 213 besral, 150 deswita, 190 devy, shrimarti rukmini, 98 dewi, desak made sintha kurnia, 87 dewi, putu dian prima kusuma, 114 dharmayanti, hanifa erlin, 194 erawati, erna, 207 faridah, 106 fikriana, riza, 42 fitriyani, poppy, 24 fitryasari, rizki, 72 handayani, luh titi, 106 hargono, rachmat, 64, 72 harmayetty, 80 hartini, sri, 9 harun, hasniatisari, 50 haryanto, joni, 200 haryanto, joni, 93 herliani, yusshy kurnia, 50 hsieh, pei-lun, 156 ibrahim, kusman, 50 indriyani, diyan, 18 istiqomah, zulaikah nur, 207 junaiti, sahar, 1 kurdi, fahruddin, 233 kurnia, iqlima dwi, 213 kurnia, theresia avila, 219 kurniawati, ninuk dian, 144 kusnanto, 171 kusnanto, 64, 93 kusnanto, hari, 227 kusumaningrum, arie, 178 kusumaningrum, tiyas, 122 lun hsieh, pei, 64 mandagi, ayik m., 87 mediarti, devi, 31 mei chan, chong, 72 mulyanti, sri, 36 mulyono, sigit, 1 nahariani, pepin, 233 natosba, jum, 178 ni'mah, lailatun, 171, 184 ningsih, warti, 9 nurachmah, elly, 1 nursalam, 144, 156 nursalam, 64, 72, 98 parut, anselmus aristo, 162 pradita, adelia, 178 prasetyo, sabarinah, 1 prawesti, ayu, 219 priyanti, ratna puji, 233 purwanta 9 purwanto, bambang, 194 puspikawati, septa indra, 87 putra, made mahaguna, 93 putri, mella gustriyani, 190 qomariah, siti nur, 213 rahmadiyah, dwi cahya, 24 refnandes, randy, 190 rehana, 31 riyono, bagus, 227 rohma, elfira fitria, 213 rtamagustini, ni nyoman trioka, 194 sari, gadis meinar, 122 sari, ni putu wulan purnama, 162 sari, ni putu wulan purnama, 57 sari, nilam yusika, 87 savage, eileen, 98 sebayang, susy k., 87 setiawan, agus, 24 setyawati, anita, 50 silviani, baiq selly, 184 sitorus, ratna, 150 stefani, oktaffrastya widhamurti, 80 suharto, 144 suharto, 80 sukartini, tintin, 93 sulistyono, agus, 156 sulistyorini, lantin, 128 susanti, retno dwi, 171 suyanta, 207 tri hapsari retno, 150 triharini, mira, 156 trisyani, yanny, 219 ugrasena, i dewa gede, 98 ulfiana, elida, 200 usuyanlfiana, elida, 93 utami, 227 waluyo, agung, 150 widiarta, gede budi, 114 widyawati, ika yuni, 64 wilandika, angga, 138 yusuf, ah, 72 zulkarnain, hakim, 171 subject index volume 13 nomor 2 oktober 2018 a acute respiratory tract infections, 213 adolescence, 207 adolescent, 122 age of menarche, 190 anaemia, 122 attitude, 9, 57 b belief, 122 breast milk, 213 buleleng district hospital, 114 c caregiver, 9 children aged 6-24 months, 24 children with physical disability, 9 chronic disease, 200 chronic kidney disease, 150 clinical learning environment, 233 coastal area, 87 collaboration, 1 college student, 194 community empowerment, 128 community nursing intervention, 24 competence, 50 complain, 184 complementary feeding, 24 coronary heart disease, 144 d dasawisma, 36 depression, 207 dialysis patient, 64 dietary adherence of dm, 171 discharge planning, 106 dreall, 178 e education, 31 elderly, 200 elderly, 57 empowerment, 98 evidence-based practice, 50 exclusively breastfed, 213 f family perceptions, 18 family stress predictors, 72 family, 72 family, 98 food safety, 1 functional disability, 200 g glicemic control, 171 grieving, 64 growth of infants, 18 growth, 24 h health education, 36 health locus of control, 171 health sciences university student, 162 health status, 128 heart disease, 42 hiv, 162 hiv/aids, 114 hiv-risk behaviour, 138 hospital, 227 i icu, 219 immune, 93 inpatient room, 106 instrument, 227 iron deficiency, 122 iron deficiency, 156 k knowledge, 162 knowledge, 9 l leptospirosis, 36 leukemia, 98 life writing therapy, 207 lifestyle behaviour, 42 lifestyle, 184 m maternal sensitivity models, 18 meditation healing exercise, 57 menopausal, 184 menstruation cycle, 194 metabolic response, 80 mind-body-spiritual, 144 module of leptospirosis, 36 motivation, 171 motivation, 31 muslim, 138 must, 80 n nrs 2002, 80 nurse, 219 nurse-patient interactions, 64 nurses, 31, 106 nursing care model, 144 nursing documentation, 31 nursing education, 233 nursing student, 50 nursing students, 233 nutrition intake, 156 nutritional status, 128 nutritional status, 190 o osteoarthritis, 200 p palliative care, 219 parents, 1 peer health education, 42 perceived benefits, 156 physiological adaptation response, 150 pornographic media exposure, 190 pre-dialysis, 150 pregnancy, 156 prevention, 138 psychological adaptation behavior, 150 q quality of nursing work life, 227 r random blood glucose, 87 red ginger massage, 200 reliability, 227 religiosity, 138 resfeed-play, 24 respiratory function, 93 risk of ari, 213 role of parents, 18 roy’s adaptation model, 150 s schizophrenia, 72 school age children, school health nursing, 1 self-care training, 9 self-efficacy, 138 self-efficacy, 219 self-efficacy, 50, 122 self-protection, 178 sexual abuse, 178 sexual education, 178 skill, 9 spiritual emotional breathing, 93 spirituality, 144 stiffness, 200 stress, 184 student, supplementary feeding, 128 survival analysis, 114 t toddler, 213 tourism, 87 trauma, 80 tuberculosis, 93 v validity, 227 vct, 162 w waist circumference, 194 willingness to participate in vct, 162 women, 184 7 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of: ▪ a highly respected journal in the nursing field. ▪ it is indexed in major databases: science and technology index (sinta), indonesian publication index (ipi), google scholar, bielefeld academic search engine (base), (doaj), worldcat, indonesia onesearch, ebsco, pkp index, index copernicus, isjd, asean citation index ▪ rapid initial screening for suitability and editorial interest. jurnal ners has been accredited by the ministry of science, research, technology and higher education of indonesia since 2010. ii. focus and scope the scope of this journal includes studies that intend to examine and understand nursing health care interventions and health policies which utilize advanced nursing research. the journal also committed to improve the high-quality research by publishing analytic techniques, measures, and research methods not exception to systematic review papers. policy concerns of this journal are as follows: fundamentals of nursing, management in nursing, medical-surgical nursing, critical care nursing, emergency and trauma nursing, oncology nursing, community health nursing, occupational health nursing, mental health nursing, holistic nursing, geriatric nursing, family nursing, maternity nursing, women's health nursing, pediatric nursing, education in nursing, nursing policies, legal nursing, advanced practice nursing, and nursing informatics please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. author information pack update: march 5, 2020 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing https://drive.google.com/file/d/0b5ormcrmctnwq0dix2dictffdlk/view?usp=sharing 8 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam m.nurs. (hons), (scopus id: 56660628500; h-index: 4); faculty of nursing, universitas airlangga, indonesia international advisory board reviewers 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740; h-index: 13); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200; h-index: 10); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, (scopus id: 8293647300; h-index: 12); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172; h-index: 2); college of nursing, university of the philippines manila, philippines 5. dr. nicola cornally, (scopus id: 36982904800; h-index: 13); school of nursing and midwifery, university college cork, ireland 6. dr. david pickles, (scopus id: 57190150026; h-index: 5); college of nursing & health sciences, flinders university, south australia, australia 7. dr. farhan alshammari, (scopus id: 57192298773; h-index: 3); college of nursing, university of hail, saudi arabia 8. dr. patricia leahy-warren, (scopus id: 55954181800; h-index: 11); school of nursing and midwifery, university college cork, ireland 9. dr. wendy abigail, (scopus id: 24467540600; h-index: 3); school of nursing and midwifery, flinders university, australia 10. dr. chong mei chan, (scopus id: 57189591887; h-index: 2); dept. of nursing faculty of health science, university of malaya, malaysia 11. dr. sonia reisenhofer, (scopus id: 16310818100; h-index: 4); school of nursing and midwifery, la trobe university, australia, australia editor: 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100; h-index: 3); faculty of nursing, universitas airlangga, indonesia 2. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756; h-index: 1); faculty of nursing, universitas airlangga, indonesia, indonesia 3. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 4. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); faculty of nursing, universitas airlangga, indonesia javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/454') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3472') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3469') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3098') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3458') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3784') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3783') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3708') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3657') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/1447') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/2992') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3034') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/509') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/632') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/155') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/510') 9 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 5. laily hidayati, s.kep., ns., m.kep., (scopus id: 57202743375); faculty of nursing, universitas airlangga, indonesia assistant editor: 1. hidayat arifin, s. kep., ns., (scopus id: 57211333166); faculty of nursing, universitas airlangga, indonesia 2. masunatul ubudiyah, faculty of nursing, universitas airlangga, indonesia 3. dluha maf'ula, faculty of nursing,. universitas airlangga, indonesia 4. rifky octavia pradipta, s.kep., ns, faculty of nursing, universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., (scopus id: 57201187775); faculty of nursing, universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/542') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/1605') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10192') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10193') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10603') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/2145') mailto:secretariat_jurnalners@fkp.unair.ac.id http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 10 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on apriori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and meta-analyses will be dealt with as original articles are, as far as the editorial process is concerned. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and postpublication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following: • introduction: one or two sentences on the background and purpose of the study. • method: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics). • results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals. • conclusions: should relate to the study aims and hypotheses. • keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. 11 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 acknowledgment (optional). acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below: • observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/ • qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq • quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/ • randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/ • study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/ • systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/ • systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 publication fee jurnal ners charges the author a publication fee amounted to idr 1.000.000 (indonesian author) and usd 100 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within two working days. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 12 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: ………………………………………………………………………………………………….. f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. 13 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 title page example vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 14 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 15 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: 𝐇′ = −∑ (𝑃𝑖)(log2 𝑃𝑖) 𝑠 𝑖=1 ………............................................................................................... (1) remarks: .............................................................................................................................................. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old type of care age groups (years) <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 16 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. https://www.mendeley.com/guides/harvard-citation-guide 17 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author, • hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language. • have read the final version of the manuscript and responsible for what is said in it. • have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website. • hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below. • acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk http://e-journal.unair.ac.id/jners | 13 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.17508 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research implementation of chest compression for cardiac arrest patient in indonesia: true or false rendi editya darmawan1, untung sujianto2 and nana rochana2 1health polytechnic of ministry of health surakarta, central java, indonesia 2department of nursing diponegoro university, central java, indonesia abstract introduction: the highest cause of death is cardiac arrest. proper manual chest compression will increase survival of cardiac arrest. the aim of this study was to know the implementation of chest compressions for cardiac arrest patient in indonesia. methods: this study used a descriptive quantitative design. the samples were nurse and code blue team when performing manual chest compression to 74 patients experiencing cardiac arrest. the sample have body mass index (bmi) more than 20. research was conducted in two hospitals in java, indonesia. implementation of chest compression is measured based on depth accuracy. depth accuracy of chest compressions was assessed based on the comparison of the number of r waves with a height >10 mv on the bedside monitor with the number of chest compressions performed. the data were analyzed descriptively (mean, median, mode, standard deviation, and variances). results: the mean of accuracy of compression depth is 75.97%. the result shows accuracy of compression depth on manual chest compression still under the american heart association (aha) recommendation of 80%, because chest compression rate are not standardized. chest compression rates are between 100-160 rates/minute, while aha’s recommendations are 100-120 rates/minute. high compression speed causes a decrease in accuracy of chest compressions depth. conclusion: the implementation of chest compressions in indonesia if measured based on accuracy of compression depth is not effective. nurses and the code blue team have to practice considering the use of cardiac resuscitation aids. article history received: january 22, 2020 accepted: december 30, 2020 keywords accuracy of compression depth; cardiac arrest; chest compression contact rendi editya darmawan  ndik_ners@yahoo.com  health polytechnic of ministry of health surakarta, central java, indonesia cite this as: darmawan, r. e., sujianto, u., & rochana, n. (2021). implementation of chest compression for cardiac arrest patient in indonesia: true or false. jurnal ners, 16(1). 13-16. doi:http://dx.doi.org/10.20473/jn.v16i1.17508 introduction cardiac arrest (ca) is an emergency condition with a high mortality rate, and patient survivors are low (perkins et al., 2015). the mortality rate of patients due to ca is high. perkins et al. (2015) and grunau et al. (2016) reported more than 90% of ca patients in the uk and north america dying. the incidence of cardiac arrest in indonesia is unknown. the biggest cause of ca is cardiovascular disease (70%), so if there are more than 5 million people with cardiovascular disease in indonesia, ca sufferers in indonesia are quite high (darmawan, sujianto, & rochana, 2018). the external factor affecting ca survivor is the quality of resuscitation (aha, 2015). the american heart association (aha) (2015) recommends cpr done at a speed of 100 to 120 compression rates per minute. rescuer must push chest wall with the depth of 5 to 6 cm. rescuer must allow full chest wall recoil, and to minimize interruptions (aha, 2015). rescuer in hospital often do not to do high quality cprs, especially related to compression rates and depths (coy & schultz, 2015; hasegawa, daikoku, saito, & saito, 2014; idris et al., 2012; monsieurs et al., 2012; ruiz de gauna, gonzález-otero, ruiz, & russell, 2016). appropriate chest compression speed, will provide the perfect depth of chest compressions (monsieurs et al., 2012). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ r. e. darmawan et al. 14 | pissn: 1858-3598  eissn: 2502-5791 the chest compression rate affects the depth of chest compression. monsieurs et al. (2012) concluded that chest compressions were high, resulting in low chest compressive depth. on the other hand, chest compression rate in indonesia is not standardized (monsieurs et al., 2012). darmawan and oktavianus (2013) reported that the rhythm of rule of five or two syllables has an average chest compression velocity of 125.7 x / min and the depth of chest compression that reaches 5 cm is 39.05%, while the rhythm of the rule of ten or one syllable produces chest compression speed 157 x / min, with a chest compression depth that reaches 5 cm which is 39.27%. unstandardized rhythm can decrease accuracy of compression depth (gauna et al., 2016). although the nurses and the code blue team have experience in performing chest compressions, in reality the rate of chest compressions taken by the aha has not been implemented properly. therefore, it is necessary to study how is the implementation of chest compressions in indonesia, so that the most effective method of chest compressions can be developed effectively in the future. the aim of this study was to know the implementation of chest compressions for cardiac arrest patient in indonesia, especially the accuracy of compression depth. materials and methods this study used a descriptive quantitative design. the researcher determined the number of samples using previous study methods that are sourced from idris et al.’s (2012) research. calculation results obtained 74 cardiac arrest patients. the researcher also selected rescuer as respondents using purposive sampling techniques. the researcher recruited enumerators, and taught them how to calculate the depth of chest compressions. when chest compressions are performed, the screen image of bedside monitor will show r waves. the researchers and enumerator recorded the number of r waves with the height more than 10 mv and the number of chest compressions (using hand counters). then, the number of r waves with the height more than 10 mv were divided with the number of chest compressions done to determine accuracy of chest compressions. data were analyzed by finding descriptive data, such as averages of accuracy of chest compressions, and other data, such as median, mode, standard deviation, and variances, using spss 25. the researcher established inclusion criteria as chest compressions on a solid surface, patients have heart electrical records using bedside monitor, cpr was done by medical personnel who have certified emergency training. rescuer must have weight more than 20 of body mass index (bmi). exclusion criteria were patients marked with do-not-resuscitate. the researcher obtained ethical clearance from the health research ethics committee of faculty of medicine, university of diponegoro (number :176 / ec / fk-rsdk / iv / 2017). the research was conducted in two hospitals in java, indonesia, by asking permission from the director of the hospital. the researcher asked permission from the patient’s family with giving informed consent. researchers and enumerators w waited for a patient to experience cardiac arrest, with a sign of a code blue call. results research results obtained74 patients having cardiac arrest that were given cardiopulmonary resuscitation with complete data, and according to the criteria. the characteristics of people who performed chest compressions are shown in table 1. characteristics of rescuers, as presented in table 1, show most respondents have experience more than 10 years in doing chest compressions (79.8%). the mean of body mass index of respondents is 23.436, with an intermediate range 21-26.4. all respondents are certified in emergency training. accuracy of chest compression can be seen in figure 1. based on figure 1, the accuracy of chest compressions is 29-96%, and the average accuracy of chest compressions is 75.97%. the result of the variance test showed the number 226,769. these data show a high variation among chest compressions. when viewed from the standard deviation of 15.059, it means that the range of variation in chest compression accuracy is quite wide. the median value shows 80.00, while the mode value shows the number 81. this condition indicates that most of the implementation of chest compressions is good and above the standard of aha. on the other hand, some rescuers did not successfully achieve proper chest compressions accuracy. discussion the implementation of chest compressions for cardiac arrest patient in indonesia has not been done optimally. this condition is shown from the data that accuracy of chest compressions is 75.97%. the mean of accuracy of compression depth needs to be improved. there is absence of a speed regulator to arrange compression rates making for faster of chest compression rates. chest compression rates in this study show a range 120-160 beat/minute. chest compression rates more than 120 beat/minutes cause fatigue in the helper, which, in turn, causes a decrease in strength of compressions, so that the accuracy of compression decrease (chung et al., 2012). chest compressions rate can affect compression depth. monsieurs et al. (2012) explain that the higher chest compressions rate affects decreased concentration, so that the rescuer cannot control the speed and depth of chest compressions. if we look at the data, mean of accuracy of chest compressions is 75.97%. this mean is below aha recommendation, jurnal ners http://e-journal.unair.ac.id/jners | 15 which is 80%. there needs to be an effort to improve accuracy of chest compressions. besides compression rates, weight rescuer factor can also be decisive of compression depth. the heavier rescue makes impact easier to get ideal compressions depth. aha explains that the high position of the bed will affect the accuracy of chest compressions (gauna et al., 2016). ideally the position of the bed is adjusted to the height of the helper. jantti, silfvast, turpeinen, kiviniemi, and uusaro, (2009) explain the surface under the patient must be firm, because it is a counter of pressure exerted on the patient’s chest. the accuracy of chest compressions has an impact to return of spontaneous circulation (rosc) and survival with good neurological function. accuracy of chest compressions is determined by chest compression rates, weight of rescuer, surface under the patients, as well as the number and duration of disturbances in compression (grunau et al., 2016). sometimes, we must stop compressions due to attaching intubation, or other tools. in most studies, chest compressions rate with 100-120 beats per minute is associated with an increased survival rate, and lower than 100 beats per minute is associated with a decreased survival rate. the rescuer should begin to adjust the compression rate and minimize distraction during compression (aha, 2015). during cpr, the rescuer must provide effective compression at speeds of 100 to 120x / minute, accuracy of chest compression higher than 80%, and the appropriate depth, minimizing the number and duration of disturbances in chest compressions. additional components of high-quality cpr include allowing full chest recoil after each compression and preventing excessive ventilation (graham et al., 2015). accuracy of chest compression must be increased to improve survival of cardiac arrest. other than compression rates, the weight of the rescuer is an important factor in the compression depth (hasegawa et al., 2014). respondents of this study have body mass index mean 23.436, with an intermediate range 21-16.4. it is ideal body for a rescuer to perform chest compressions. jäntti et al. (2009) find that bed height affects maximal compression forces, and affects accuracy of compression depth. dellimore and scheffer (2012) showed the surface under the patient may affect the cardiopulmonary resuscitation (cpr) quality. the limitation of this study is that there is not a large number of samples. in addition, researchers do not limit body weight in cardiac arrest patients, because body weight will affect the amount of pressure required for chest compressions. another factor affecting the accuracy of chest compression depth is the training gained. this study shows that all executor chest compressions are certified, but, when viewed from variations in the accuracy of chest compressions is 29-96%, then there is an abnormality. körber, köhler, weiss, pfister, and michels, (2016) reported differences in the quality of chest compressions between students and experienced medical personnel. it can be concluded that, when the reservoir is homogeneous, the table 1. distribution of characteristics’ respondents (n=74) variable (s) f % mean (sd) min-max long been a code blue team 2-5 years 5-10 years > 10 years 2 13 59 2.7 17.5 79.8 body mass index 23.436 (1.491) 21.00-26.4 have an emergency training certificate 74 100 figure 1. accuracy of chest compression 0 20 40 60 80 100 120 0 10 20 30 40 50 60 70 80 a c c u ra c y o f c h e st c o m p re ss io n ( % ) cases accuracy of chest compression r. e. darmawan et al. 16 | pissn: 1858-3598  eissn: 2502-5791 accuracy should be the same. the researcher is of the opinion that this occurs because there is no continuous renewal of science, so it is possible to forget the principles of chest compressions. conclusion the implementation of chest compressions for cardiac arrest patient in indonesia, based on accuracy of compression depth is lower than standard. helpers of cardiac arrest must control chest compression rate to improve accuracy of compression depth. future research can increase the number of samples and homogenize the type of ward. references aha. (2015). highlights of the 2015 american heart association guidelines update for cpr and ecc. in american heart association. chung, t. n., kim, s. w., you, j. s., cho, y. s., chung, s. p., & park, i. (2012). a higher chest compression rate may be necessary for metronome-guided cardiopulmonary resuscitation. the american journal of emergency medicine, 30(1), 226–230. https://doi.org/10.1016/j.ajem.2010.11.026 darmawan, r. e., sujianto, u., & rochana, n. (2018). effects of neo automatic code on the accuracy of chest compression depths in cardiac arrest patients. hiroshima journal of medical sciences, 67. darmawan r e, & oktavianus. (2013). pengaruh kompresi dada berdasarkan rule of five terhadap kedalaman dan frekuensi kompresi dada. jurnal kesehatan kusuma husada, 4(1), 47–56. dellimore, k. h., & scheffer, c. (2012). optimal chest compression in cardiopulmonary resuscitation depends upon thoracic and back support stiffness. medical & biological engineering & computing, 50(12), 1269–1278. https://doi.org/10.1007/s11517-012-0963-z gauna, s. r. de, gonzález-otero, d. m., ruiz, j., & russell, j. k. (2016). feedback on the rate and depth of chest compressions during cardiopulmonary resuscitation using only accelerometers. plos one, 11(3), 1–17. https://doi.org/10.1371/journal.pone.0150139 graham, r., coy, m. a. m., & andrea m schultz. (2015). strategies to improve cardiac arrest survival a time to act. wasington dc: the national academies press. grunau, b., reynolds, j., scheuermeyer, f., stenstom, r., stub, d., pennington, s., … christenson, j. (2016). relationship between time to rosc and survival in out of hospital cardiac arrest ecpr candidates: when is the best time to consider transport to hospital? prehospital emergency care : official journal of the national association of ems physicians and the national association of state ems directors, 20(5), 615–622. https://doi.org/10.3109/10903127.2016.11496 52 hasegawa, t., daikoku, r., saito, s., & saito, y. (2014). relationship between weight of rescuer and quality of chest compression during cardiopulmonary resuscitation. physiological anthropology, 33(16), 1–7. idris, a. h., guffey, d., aufderheide, t. p., brown, s., morrison, l. j., nichols, p., … nichol, g. (2012). relationship between chest compression rates and outcomes from cardiac arrest. circulation, 125(24), 3004–3012. https://doi.org/10.1161/circulationaha.111. 059535 jäntti, h., silfvast, t., turpeinen, a, kiviniemi, v., & uusaro, a. (2009). quality of cardiopulmonary resuscitation on manikins: on the floor and in the bed. acta anaesthesiologica scandinavica, 53(9), 1131–1137. https://doi.org/10.1111/j.13996576.2009.01966.x körber, m. i., köhler, t., weiss, v., pfister, r., & michels, g. (2016). quality of basic life support : a comparison between medical students and paramedics. journal of clinical and diagnostic research : jcdr, 10(7), oc33-7. https://doi.org/10.7860/jcdr/2016/19221.819 7 monsieurs, k. g., de regge, m., vansteelandt, k., de smet, j., annaert, e., lemoyne, s., … calle, p. a. (2012). excessive chest compression rate is associated with insufficient compression depth in prehospital cardiac arrest. resuscitation, 83(11), 1319–1323. https://doi.org/10.1016/j.resuscitation.2012.07. 015 perkins, g. d., lall, r., quinn, t., deakin, c. d., cooke, m. w., horton, j., … gates, s. (2015). mechanical versus manual chest compression for out-ofhospital cardiac arrest (paramedic): a pragmatic, cluster randomised controlled trial. lancet (london, england), 385(9972), 947–955. https://doi.org/10.1016/s0140-6736(14)618869 ruiz de gauna, s., gonzález-otero, d. m., ruiz, j., & russell, j. k. (2016). feedback on the rate and depth of chest compressions during cardiopulmonary resuscitation using only accelerometers. plos one, 11(3), e0150139. https://doi.org/10.1371/journal.pone.0150139 354 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17213 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family support on the activities of elderly hypertension patients in elderly gymnastics activities wachidah yuniartika and fauzan muhammad faculty of health science, universitas muhammadiyah surakarta, indonesia abstract introduction: the aging process results in decreased body resistance, physiological functions and diseases which attack the elderly, such as hypertension. elderly gymnastics is a mild exercise that is applied to the elderly. high family support will make the elderly more actively participate in elderly gymnastics activities, and vice versa. the aim of study was to determine the relationship of family support to the activity of elderly in pajang village. methods: the design of the study was quantitative research with a cross sectional approach. the population of the study was all elderly people with hypertension who were aged 60 years and over who participated in elderly gymnastics, with total sampling at 95 respondents. this was then analyzed using the kendall’s tau formula. results: the majority of family support was enough (38.8%) and the active category (63.2%), with bivariate analysis a value of 0.001 (<0.05), with a magnitude of 0.082. conclusion: families can help overcome the problems of the elderly and provide support for exercise activities. families can also increase selfconfidence to improve the health of the elderly. there is a significant relationship of family support for the activeness of elderly hypertension patients in elderly gymnastics activities in pajang village. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords aging; elderly; hypertension; family support; gymnastics activities contact wachidah yuniartika  wachidah.yuniartika@ums.ac.id  faculty of health science, universitas muhammadiyah surakarta, indonesia cite this as: yuniartika, w. & muhammad, f. (2019). family support on the activities of elderly hypertension patients in elderly gymnastics activities. jurnal ners,14(3si),354-357.doi:http://dx.doi.org/10.20473/jn.v14i3(si).17213 introduction increasing human life expectancy is one manifestation of the success of indonesia's development. projected data for the average life expectancy of indonesian citizens in 2015-2020 has increased to 71.7 years, while the data is projected in 2010-2015, which is 70.7 years (hasugian, lubis, & tukiman, 2012). data from the indonesian ministry of health in 2017, estimates that in 2017 there are 23.66 million elderly people in indonesia. the central java province entered the second rank and in surakarta alone there were 55 thousand elderly people. data from the 2013 riskesdas (health im, 2013), the health problems that arise in the highest elderly are hypertension. then according to ri law number 36 of 2009 concerning health, one of the goals of the health program for the elderly is to stay healthy, so that the government guarantees the availability of health service facilities by establishing elderly posyandu in each region. the elderly posyandu activities include elderly gymnastics (sunaryo, wijayanti r, 2016). elderly gymnastics is a mild exercise that is applied to the elderly with movements that are easy to do and which are not burdensome (widianti, 2018). this exercise will help the elderly to stay fit and fresh, exercise strong bones, encourage the heart to work optimally, eliminate free radicals in the body, inhibit the aging process, and increase immunity in the body. there are several factors that influence elderly visits, but the most influential is family support. family support for the elderly provides peace of mind and pleasure to the elderly as well as this facilitates the elderly to participate in elderly gymnastics activities. high family support will make the elderly more actively participate in elderly gymnastics activities, and vice versa (purnawati, 2014; susilowati, 2014). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners 355 | pissn: 1858-3598  eissn: 2502-5791 the role of the family has a big influence on the psychology of the elderly because it can provide peace of mind and happy feelings to the elderly and provides a safe sense of security in the elderly. elderly people will feel very cared for if there is a lot of support from the family. preliminary studies conducted in pajang village include 6 out of 10 elderly who are not actively participating in elderly gymnastics by reason of lack of family support, families do not deliver the elderly to take part in elderly exercises, do not remind elderly gymnastics activities, and families forbid elderly people from taking elderly exercise because of the elderly hypertension sufferers. the purpose of this study was to determine the relationship of family support to the activeness of elderly people with hypertension in elderly gymnastics activities. materials and methods this researcher is a type of quantitative research using a cross sectional approach. the population of the study were all elderly hypertension patients aged 60 years and over who participated in elderly gymnastics, at 95 respondents. sampling using total sampling, this research was conducted at pajang village on 8 october-8 november 2018. an instrument of the independent variable family support with a guide to the review of friedman theory at 12 questions with the likert scale and the dependent variable on the activity of the elderly using a documentation sheet that records the presence of the elderly in 1 year. the course of the research was by distributing questionnaires directly to the elderly who attended the elderly gymnastics and home visits when the elderly with hypertension were not present at public health. univariate analysis using a frequency distribution and analysis bivariate kendall’s tau formula. results the results of the study from table 1 are known that based on the characteristics of respondents family support shows that the majority of respondents received sufficient family support, namely 37 people (38.8%) and the active elderly people with the most hypertension, namely active with a number of 60 respondents (63.2%). the results of the analysis show that the significant value is 0.001 which is <0.05, then h0 is rejected. this means that there is a significant relationship with the magnitude of the relationship of 0.082, so that there is a relationship between family support and the activity of the elderly people with hypertension who are very strong. discussion the results showed that the majority of the elderly who participated in elderly gymnastics activities received adequate family support, namely 37 people (38.8%) and included an active category with 60 people (63.2%). family support plays an active role in encouraging the willingness of the elderly to take part in elderly exercise (panjaitan a., frelestanty e, 2017). family support given to the elderly is an important element to help in solving problems, especially in the context of health. the existence of family support will make the elderly feel more confident and have the motivation to deal with and maintain their health problems (padila, 2016). the family can also be a strong influence for the elderly in assisting the elderly, reminding the elderly and helping them to overcome various problems in participating in elderly gymnastics activities (hamalding h, 2017). the elderly can get information about the benefits of elderly gymnastics from their daily lives and based on personal experience. elderly people who attend the posyandu activities will certainly get health information about how to maintain a healthy lifestyle with all the problems or limitations they have, so that table 1. distribution of characteristics based on family support and activeness of the elderly no variable frequency percentage (%) 1 family support good 22 23,2% enough 37 38,8% less 36 37,9% 2 activeness of the elderly active 60 63,2% not active 35 36,8% total 95 100% table 2.analysis result activeness of the elderly family support kendall’s tau activeness of the elderly correlation 1.000 0.802 coefficient sig. (2-tailed) 0.000 n 95 95 family support correlation 0.802 1.000 coefficient sig. (2-tailed) 0.000 n 95 95 w. yuniartika, et al. 356 | pissn: 1858-3598  eissn: 2502-5791 based on experience and knowledge will make the interest of the elderly towards the activities carried out at the posyandu high, one of which is elderly gymnastics (novianti, 2018). being active is defined if its presence is more than 75%, or attendance is more than 9 times in one year (arikunto, 2010). the results of the bivariate analysis show that the significant value is 0.001 which is <0.05, then h0 is rejected. it means that there is a relationship between family support and the activity of elderly hypertension sufferers in participating in elderly gymnastics activities in pajang village. the size of the relationship is 0.082, which means the relationship of family support with the activity of elderly people with hypertension is very strong family support has an important role in encouraging the elderly to participate in elderly gymnastics activities (noviana, 2013). as well as the role of the family also has a big influence in the psychology of the elderly because it can provide peace of mind and feelings of pleasure in the elderly and provide a safe sense of security in the elderly. elderly people will feel very cared for if there is a lot of support from the family. so that the family has an important role in the lives of the elderly. this is supported by the opinion who said that support from the family can also increase self-confidence in the elderly, so that the elderly will tend to positive things, for example participating in elderly gymnastics activities to improve the health of the elderly (center im of hd&i, 2016). in addition, families play an important role in strengthening self-management (peñarrieta et al., 2015). the family has support functions in the form of information support, assessment support, instrumental support, and emotional support, as well as family support provided for families with diverse elderly. the family has information support that functions as an advocate, advice and guidance and provides information. family assessment support allows families to be supportive, useful, and caring. and the emotional support of functioning families as a safe and comfortable place to rest, and instrumental support put the family as a source of practical and concrete assistance. because basically the elderly need security and love from the family (flynn et al., 2013; novita & novitasari, 2017). in addition, family support can be described by giving attention to the elderly in reminding the elderly gymnastics activity schedule, bringing the elderly to follow elderly gymnastics, listening to the complaints of the elderly and giving awards to the elderly and motivation or encouragement of life for the elderly. conclusion the conclusion from the results of the study that there is a very strong and significant relationship between family support for the activeness of elderly people with hypertension in elderly gymnastics activities in pajang village. references arikunto, s. (2010). research procedure a practice approach. jakarta: rineka cipta. center im of hd&i. (2016). elderly situation in indonesia. retrieved from http://www.depkes.go.id/ flynn, s. j., ameling, j. m., hill-briggs, f., wolff, j. l., bone, l. r., levine, d. m., … boulware, l. e. (2013). facilitators and barriers to hypertension self-management in urban african americans: perspectives of patients and family members. patient preference and adherence. https://doi.org/10.2147/ppa.s46517 hamalding h, m. (2017). relationship between family support and quality of life (qol) in stroke events. jurnal kesehatan masyarakat, 7(2), 146–152. retrieved from https://media.neliti.com/ hasugian, f. h., lubis, n. l., & tukiman. (2012). hubungan perilaku lansia dan dukungan keluarga terhadap pemanfaatan posyandu lansia di wilayah kerja puskesmas darussalam tahun 2012. kebijakan, promosi kesehatan dan biostatistik. health im. (2013). indonesian health profile. retrieved from http://www.depkes.go.id/ noviana. (2013). factors associated with elderly visits to elderly in public health. jurnal keperawatan stikes ngudi waluyo ung. novianti, d. (2018). factors affecting elderly behavior in following elderly gymnastics in the public health working area. jurnal keperawatan silampari, 1(9), 123–138. novita, d. a., & novitasari, r. (2017). hubungan antara dukungan sosial dan kualitas hidup pada remaja berkebutuhan khusus. psikodimensia. https://doi.org/10.24167/psiko.v16i1.937 padila. (2016). family nursing. yogyakarta: nuhamedika. panjaitan a., frelestanty e, l. s. (2017). family support for active activities of elderly people in joining elderly public health at emparu health center. jurnal kesehatan stikes kapuas raya sintang, 3(2), 78–81. retrieved from http://ejournal.poltekkes-pontianak.ac.id/ peñarrieta, m. i., flores-barrios, f., gutiérrez-gómez, t., piñones-martínez, s., resendiz-gonzalez, e., & quintero-valle, l. maría. (2015). selfmanagement and family support in chronic diseases. journal of nursing education and jurnal ners 357 | pissn: 1858-3598  eissn: 2502-5791 practice. https://doi.org/10.5430/jnep.v5n11p73 purnawati, n. (2014). faktor faktor yang mempengaruhi kunjungan lansia dalam kegiatan posyandu di desa plumbon kec. mojolaban sukoharjo. muhammadiyah surakarta. sunaryo, wijayanti r, k. m. (2016). gerontik nursing care. yogyakarta: cv.andi offset. susilowati. (2014). faktor faktor yang mempengaruhi kunjungan lanjut usia ke posyandu lanjut usia desa tegalgiri nogosari boyolali. muhammadiyah surakarta. widianti, t. a. (2018). health gymnastics. yogyakarta: nuha medika. ners vol 10 no 2 okt 2015.indd 324 keselamatan pasien berbasis knowledge management seci sebagai peningkatan kompetensi mahasiswa keperawatan (patient safety based knowledge management seci to improve nusrsing students competency) joanggi wiriatarina harianto*, nursalam**, yulis setiya dewi** *stikes muhammadiyah samarinda, east borneo email: joanggiwh@gmail.com **fakultas keperawatan universitas airlangga surabaya abstrak pendahuluan: keselamatan pasien merupakan komponen penting dari kualitas pelayanan kesehatan, dan prinsipprinsip dasar dalam merawat pasien. mahasiswa keperawatan berpotensi melakukan suatu tindakan yang dapat membahayakan pasien, karena rumah sakit merupakan salah satu tempat praktek mahasiswa. tujuan dari penelitian ini adalah untuk meningkatkan kompetensi mahasiswa keperawatan dengan menggunakan pendekatan model keselamatan pasien berbasis knowledge management seci. metode: penelitian ini menggunakan survei eksplorasi, dan eksperimen kuasi. sampel adalah beberapa mahasiswa keperawatan yang sedang magang dari stikes muhammadiyah samarinda dipilih dengan menggunakan teknik simple random sampling, total 54 siswa. variabel penelitian ini adalah kompetensi mahasiswa keperawatan dan model keselamatan pasien berbasis knowledge management seci. data dikumpulkan dengan menggunakan kuesioner dan observasi. data dianalisis menggunakan partial least square (pls). hasil: hasil penelitian menunjukkan bahwa ada pengaruh yang signifikan setelah diterapkan model keselamatan pasien berbasis knowledge management seci dalam meningkatkan kompetensi mahasiswa keperawatan. diskusi: peningkatan kompetensi mahasiswa dalam keselamatan pasien menggunakan knowledge management seci dilakukan dalam empat tahap, yaitu sosialisasi, eksternalisasi, kombinasi, dan internalisasi. hasilnya adalah pengetahuan dapat meningkatkan kompetensi mahasiswa dalam keselamatan pasien. kata kunci: keselamatan pasien, knowledge management, seci, kompetensi abstract introduction: patient safety is an important component of health services quality,and basic principles of patient care. nursing students also have a great potential to make an action that could endanger the patient, because hospital is one of student practice area. the purpose of this study was to improve the nursing students competency in patient safety by using knowledge management seci approached. methods: the study used exploratory survey, and quasy experiment. the samples were some of nursing students of stikes muhammadiyah samarinda who were on internship programme that selected using simple random sampling technique, in total of 54 students. this research’s variables were the knowledge management seci based-patient safety and nursing student’s competency. the data were collected by using questionnaires and observation. the data were analyze by using partial least square (pls). results: the result showed that there were significant influence the implementation of a model patient safety based knowledge management seci on increased competence nursing students. discussions: improved student competency in patient safety using seci knowledge management was carried out in four phases, that is socialization, externalization, combination, and internalization. the result was a new knowledge related to patient safety that able to improve the student’s competency.. keywords: patient safety, knowledge management, seci, competency pendahuluan keselamatan pasien (patient safety) saat ini telah menjadi isu global dan nasional bagi rumah sakit, komponen penting dari mutu layanan kesehatan, prinsip dasar dari pelayanan pasien dan komponen kritis dari manajemen mutu world health organization (who) tahun 2004. rumah sakit sebagai salah satu lahan praktik klinik untuk mahasiswa keperawatan, tidak menutup kemungkinan mahasiswa melakukan kesalahan. mahasiswa keperawatan memiliki keterbatasan pengalaman klinis sehingga berisiko melakukan kesalahan dalam memberikan pengobatan atau tindakan kepada pasien, sehingga ketika memberikan tindakan atau pengobatan kepada pasien dapat membahayakan kondisi pasien ketika dilakukan dengan tidak sempurna atau salah dalam melakukan suatu prosedur (khasanah, 2012). 325 keselamatan pasien berbasis knowledge management seci (joanggi wiriatarina harianto, dkk.) k e s a l a h a n d a l a m m e m b e r i k a n pengobatan atau tindakan kepada pasien sehingga membahayakan kondisi pasien bertentangan dengan sasaran keselamatan pasien sesuai dengan yang ada dalam standar akreditasi rumah sakit (2011). kesalahan yang dilakukan oleh mahasiswa keperawatan saat sedang melaksanakan praktik sangat sulit didapatkan datanya. kesalahan yang dilakukan mahasiswa pada umumnya dibagi menjadi dua yaitu kesalahan dalam pemberian obat dan kesalahan dalam prosedur tindakan (khasanah, 2012). fokus dari keselamatan pasien adalah untuk meminimalkan risiko bahaya bagi pasien dan penyedia layanan baik melalui efektivitas sistem dan kinerja individu. pendidikan keperawatan di berbagai negara memiliki tantangan untuk memasukkan prinsip-prinsip penerapan keselamatan pasien ke dalam pendidikan klinik. mendorong mahasiswa keperawatan untuk mengaplikasikan standar nasional keselamatan pasien, berpikir kritis, dan perencanaan pelayanan keperawatan membantu untuk menyiapkan mahasiswa dengan dasar-dasar yang dibutuhkan untuk memberikan pelayanan yang aman bagi pasien (fura, et al., 2014). mahasiswa keperawatan dalam menempuh studinya dibagi ke dalam 2 tahap yaitu tahap akademik dan tahap profesi. lahan praktik mahasiswa keperawatan tidak hanya di laboratorium namun juga di rumah sakit. mahasiswa keperawatan pada saat dinas atau praktik di rumah sakit perlu untuk mengetahui tentang sasaran keselamatan pasien yang berlaku di rumah sakit. k n o w l e d g e m a n a g e m e n t s e c i (socialization, externalization, combination, and internalization) merupakan suatu cara u nt u k memba ng u n su at u penget a hu a n bar u unt uk menduk ung organisasi dari pengetahuan, pengalaman dan kreativitas para staf untuk perbaikan organisasi (nawawi, 2012). manajemen pengetahuan yang selama ini dibicarakan dalam kalangan akademik atau organisasi hanya sebatas manajemen informasi, organisasi dalam hal ini adalah institusi pendidikan, sedangkan staf adalah dari dosen internal, clinical educator dan mahasiswa sendiri. pengetahuan, pengalaman, informasi baik dari dosen, clinical educator, dan mahasiswa akan dilakukan konversi pengetahuan menggunakan model seci (socialization, externalization, combination and internalization). metode seci digunakan karena dengan metode ini fokus penciptaan pengetahuan baru untuk mengatasi masalah yang ada dimulai dari individu. pengetahuan tersebut dikumpulkan dan kemudian dibekukan dalam sebuah perusahaan sehingga dapat menjadi pengetahuan bagi orang lain. perusahaan dalam penelitian ini adalah institusi pendidikan tempat mahasiswa menempuh program praktik profesi ners. alasan kenapa yang dibentuk dalam penelitian ini adalah suatu pengetahuan adalah karena pengetahuan merupakan suatu dasar seorang individu dalam berpersepsi, bersikap yang pada akhir nya mendasari individu dalam ber perilaku (ivancevich, konopaske, matteson; 2009). pendekatan ini diharapkan mampu meningkatkan kompetensi mahasiswa keperawatan sehingga dapat meningkatkan keselamatan pasien di rumah sakit. bahan dan metode desain penelitian yang digunakan adalah eksploratif survey dengan pendekatan cross sectional untuk tahap pertama, dan quasy experiment untuk tahap kedua. populasi dalam penelitian sejumlah 62 mahasiswa stikes muhammadiyah yang menjalani program pendidikan profesi ners. sampel penelitian dipilih menggunakan simple random sampling sejumlah 54 orang. variabel dalam penelitian ini adalah keselamatan pasien berbasis k nowledge management seci dan kompetensi mahasiswa keperawatan. karakteristik demografi dalam penelitian ini yang diambil adalah jenis kelamin, usia, dan suku. variabel keselamatan pasien terdiri dari sub variabel ketepatan identifikasi pasien, peningkatan komunikasi yang efektif, peningkatan keamanan obat yang perlu diwaspadai, tepat lokasi, tepat prosedur, tepat pasien operasi, pengurangan risiko infeksi terkait pelayanan kesehatan, dan pengurangan risiko jatuh. masing-masing 326 jurnal ners vol. 10 no. 2 oktober 2015: 324–331 variabel keselamatan pasien dilihat dari setiap aspek knowledge management seci (socialization, externalization, combination, internalization). faktor psikologis yang diteliti dalam ada 5 sub variabel yaitu persepsi, sikap, kepribadian, belajar, dan motivasi, sedangkan untuk variabel organisasi yang dilihat hanya pada satu sub variabel yaitu desain pekerjaan. dat a di k u mpul kan mengg u na kan k uesioner dan obser vasi. a nalisis data menggunakan partial least square (pls). hasil b e r d a s a r k a n ke s el u r u h a n h a s i l pengujian hipotesis, maka dapat diketahui jalur signifikan, menggambarkan model hasil penelitian ini yaitu variabel kemampuan p si kolog i s s e r t a v a r i a b el o r g a n i s a si berpengaruh terhadap pencapaian kompetensi mahasiswa keperawatan dalam keselamatan pasien. hasil temuan menunjukkan ada dua indikator dari kemampuan psikologis meliputi sikap dan motivasi mempengaruhi kompetensi mahasiswa keperawatan dalam keselamatan pasien. pada variabel organisasi hanya ada satu faktor yaitu desain pekerjaan, dan desain pekerjaan ini mempengar uhi kompetensi mahasiswa keperawatan dalam keselamatan pasien. terdapat tiga indikator yang tidak valid yaitu persepsi, belajar dan kepribadian sehingga indicator tersebut direduksi karena nilai outer loading yang kurang dari 0,5. lima belas indikator yang lain dinyatakan valid di mana nilai outer loading yang dihasilkan telah sesuai dengan kriteria yang diharapkan yaitu di atas 0,5. hal ini menunjukkan bahwa indikator di dalam struktural telah memenuhi uji validitas. gambar 1. nilai outer loading untuk variabel penelitian dari hasil analisismenggunakan partial least square (pls) tabel 1. hasil uji hipotesis no variabel path coeffi cients standar error t-statistic ket 1. pengaruh faktor psikologis terhadap keselamatan pasien berbasis knowledge management seci 0,488 0,073 6,719 signifi kan 2. pengaruh faktor organisasi terhadap keselamatan pasien berbasis knowledge management seci. 0,431 0, 093 4,936 signifi kan 3. pengaruh model keselamatan pasien berbasis knowledge management seci terhadap k o m p e t e n s i m a h a s i s w a keperawatan 0,787 0,060 13,059 signifi kan 327 keselamatan pasien berbasis knowledge management seci (joanggi wiriatarina harianto, dkk.) va r iabel psi kologis d a n va r iabel organisasi secara umum mempengar uhi keselamatan pasien berbasis k nowledge m a n a g e m e n t s e c i y a n g a k h i r n y a me n i ng k at k a n komp et e n si m a h a siswa ke p e r awat a n . komp e t e n si m a h a si s wa yang berkaitan dengan keselamatan pasien tersebut adalah pemasangan gelang identitas, dok u me nt a si sba r , p e mbe r ia n obat , verifikasi pra intra dan post operasi, universal precaution, dan penilaian risiko jatuh pada pasien. pemasangan gelang identitas pasien berdasarkan hasil analisis pertama menggunakan wilcoxon signed rank test untuk uji coba modul 1 keselamatan pasien: terdapat perbedaan yang signifikan pada kompetensi pemasangan gelang identitas pasien pada kelompok perlakuan antara sebelum dan sesudah diberikan intervensi dengan nilai signifikansi sebesar p-value 0,008 < α (0,05). hasil analisis data mengg u nakan tek nik uji mann w hitney u pada saat sebelum diberikan perlakuan (pretest) pada kelompok kontrol dan kelompok perlakuan pada tabel dapat di lihat bahwa signifikansi sebesar p-value 0,342 > α (0,05), artinya tidak terdapat perbedaan yang signifikan pada saat pretest antara kelompok kontrol dan kelompok perlakuan sebelum intervensi. setelah diberikan perlakuan (post-test) nilai signifikansi p-value sebesar 0,042 < α (0,05), artinya terdapat perbedaan yang signifikan pada saat post-test antara kelompok kontrol dan kelompok perlakuan setelah intervensi. dokumentasi sbar berdasarkan hasil analisis pertama menggunakan wilcoxon signed rank test untuk uji coba modul 2 keselamatan pasien: terdapat perbedaan yang signifikan pada kompetensi dokumentasi sbar pada kelompok perlakuan antara sebelu m dan sesudah diber ikan intervensi dengan p-value 0,003 < α (0,05). hasil analisis data mengg u nakan tek ni k uji mann whit ne y u pada saat sebelum diberikan perlakuan ( pretest) pada kelompok kontrol dan kelompok perlakuan pada tabel dapat di lihat bahwa signifikansi sebesar p-value 0,542 > α (0,05), artinya tidak terdapat perbedaan yang signifikan pada saat pretest antara kelompok kontrol dan kelompok perlakuan sebelum intervensi. setelah diberikan perlakuan ( post-test) nilai signifikansi p-value sebesar 0,025 < α (0,05), artinya terdapat perbedaan yang signifikan pada saat post-test antara kelompok kontrol dan kelompok perlakuan setelah intervensi. pemberian obat berdasarkan hasil analisis pertama menggunakan wilcoxon signed rank test untuk uji coba modul 3 keselamatan pasien: terdapat perbedaan yang signifikan pada kompetensi pemberian obat pada kelompok perlakuan antara sebelu m dan sesudah diber ikan intervensi dengan p-value 0,005 < α (0,05). hasil analisis data mengg u nakan tek ni k uji mann whit ne y u pada saat sebelum diberikan perlakuan ( pretest) pada kelompok kontrol dan kelompok perlakuan pada tabel dapat di lihat bahwa signifikansi sebesar p-value 0,548 > α (0,05), artinya tidak terdapat perbedaan yang signifikan pada saat pretest antara kelompok kontrol dan kelompok perlakuan sebelum intervensi. setelah diberikan perlakuan ( posttest) nilai signifikansi p-value sebesar 0,026 < α (0,05), artinya terdapat perbedaan yang signifikan pada saat posttest antara kelompok kontrol dan kelompok perlakuan setelah intervensi. verifikasi pra intra dan post operasi berdasarkan hasil analisis pertama menggunakan wilcoxon signed rank test untuk uji coba modul 4 keselamatan pasien: terdapat perbedaan yang signifikan pada kompetensi verifikasi pra, intra dan post operasi pada kelompok perlakuan antara sebelum dan sesudah diberikan intervensi dengan p-value 0,005 < α (0,05). hasil analisis data menggunakan teknik uji mann whitney u pada saat sebelum diberikan perlakuan (pretest) pada kelompok kontrol dan kelompok perlakuan pada tabel dapat di lihat bahwa signifikansi sebesar p-value 0,317 > α (0,05), artinya tidak terdapat perbedaan yang 328 jurnal ners vol. 10 no. 2 oktober 2015: 324–331 signifikan pada saat pretest antara kelompok kontrol dan kelompok perlakuan sebelum inter vensi. setelah diberikan perlakuan ( post-test) nilai signifikansi p-value sebesar 0,002 < α (0,05), artinya terdapat perbedaan yang signifikan pada saat post-test antara kelompok kontrol dan kelompok perlakuan setelah intervensi. universal precaution berdasarkan hasil analisis pertama menggunakan wilcoxon signed rank test untuk uji coba modul 5 keselamatan pasien: terdapat perbedaan yang signifikan pada kompetensi universal precaution pada kelompok perlakuan antara sebelu m dan sesudah diber ikan intervensi dengan p-value 0,002 < α (0,05). hasil analisis data mengg u nakan tek nik uji mann w hitney u pada saat sebelum diberikan perlakuan ( pretest) pada kelompok kontrol dan kelompok perlakuan pada tabel dapat di lihat bahwa signifikansi sebesar p-value 0,317 > α (0.05), artinya tidak terdapat perbedaan yang signifikan pada saat pretest antara kelompok kontrol dan kelompok perlakuan sebelum intervensi. setelah diberikan perlakuan ( post-test) nilai signifikansi p-value sebesar 0,004 < α (0,05), artinya terdapat perbedaan yang signifikan pada saat post-test antara kelompok kontrol dan kelompok perlakuan setelah intervensi. penilaian risiko jatuh berdasarkan hasil analisis pertama menggunakan wilcoxon signed rank test untuk uji coba modul 6 keselamatan pasien: terdapat perbedaan yang signifikan pada kompetensi penilaian risiko jat uh pada kelompok perlakuan antara sebelum dan sesudah diberikan intervensi dengan p-value 0,002 < α (0,05). pembahasan pengaruh kemampuan psikologis terhadap keselamatan pasien berbasis seci sebagai upaya peningkatan kompetensi mahasiswa keperawatan ke m a mpu a n psi kolog is mel iput i persepsi, sikap, kepribadian, motivasi, dan belajar. dari hasil penelitian didapatkan bahwa faktor psikologis berkontribusi dalam penerapan keselamatan pasien berbasis knowledge management seci sebagai upaya peningkatan kompetensi mahasiswa. persepsi merupakan proses pemberian arti (kognitif ) terhadap lingkungan oleh se se or a ng. p rose s p e r se psi b e rk a it a n dengan kognitif atau dalam hal ini adalah pengetahuan. persepsi dalam penelitian ini adalah persepsi mahasiswa keperawatan terkait dengan keselamatan pasien. hasil penelitian sebagian besar pada kategori baik, dalam hal ini mengartikan bahwa pengetahuan yang selama ini diberikan atau diterima oleh mahasiswa telah menghasilkan persepsi baik. idealnya persepsi mahasiswa keperawatan tentang keselamatan pasien yang baik akan menghasilkan perilaku dan sikap yang baik atau positif. robbins (2007) mengartikan sikap sebagai per nyataan evaluatif baik yang menyenangkan maupun tidak menyenangkan terhadap objek, individu atau peristiwa. sebagai landasan dalam sikap adalah pengetahuan, dalam hal ini berkaitan dengan pengetahuan mahasiswa akan keselamatan pasien sehingga akan mempengaruhi sikap mahasiswa dalam memberikan tindakan yang berkaitan dengan keselamatan pasien. sikap negatif sebagian besar mahasiswa terkait keselamatan pasien bisa disebabkan oleh berbagai hal. kepribadian merupakan seperangkat k a r a k t e r i s t i k y a n g r e l a t i f m a n t a p , kecenderungan dan perangai yang sebagian besar dibentuk oleh faktor-faktor keturunan dan faktor-faktor sosial,kebudayaan, dan lingkungan (herman, 2007). pada penelitian didapatkan sebagaimana besar mahasiswa memiliki sikap ekstrovert. mahasiswa yang memiliki tipe kepribadian ekstrovert cenderung lebih terbuka, mudah bekerja sama, ramah, memiliki banyak teman, mudah bergaul, terbuka untuk menerima hal-hal baru, namun cenderung lebih agresif, tidak sabar dan hilang kontrol terhadap perasaannya sesuai dengan penelitian yang dilakukan farida (2007). latar belakang budaya yang menjadi pembentuk karakter kepribadian mahasiswa yang beragam juga berpengaruh dalam pemberian pelayanan kesehatan (burke, 2011). 329 keselamatan pasien berbasis knowledge management seci (joanggi wiriatarina harianto, dkk.) sub variabel belajar pada penelitian ini didapatkan bahwa sebagian besar mahasiswa be r a d a pa d a k at egor i cu k up. belaja r merupakan salah satu proses yang mendasari perilaku. sebagian besar perilaku dalam organisasi adalah perilaku yang diperoleh dengan belajar. tujuan dan reaksi emosional dapat dipelajari, arti penggunaan bahasa dapat dipelajari, persepsi dan sikap juga dapat dipelajari belajar dapat didefinisikan sebagai proses terjadinya perubahan yang relatif tetap dalam perilaku sebagai akibat dari praktek. kemampuan mempelajari suatu hal tidak dipengaruhi oleh jenis kelamin, di mana jenis kelamin sebagian besar mahasiswa adalah perempuan. laki-laki dan perempuan adalah sama dalam hal kemampuan belajar, daya ingat, kemampuan penalaran, kreativitas, dan kecerdasan. meskipun beberapa peneliti masih percaya adanya perbedaan kreativitas, penalaran, dan kemampuan antara pria dan wanita (gibson, 1987). faktor usia yang sebagian mahasiswa berada pada kategori remaja akhir juga mempengaruhi dalam kemampuan belajar. proses belajar juga akan berhasil dengan baik apabila metode yang digunakan tidak hanya satu namun bisa bervariasi. mot iva si u nt u k s e b a g i a n b e s a r mahasiswa masih berada pada kategori rendah. motivasi adalah karakteristik psikologis manusia yang memberi kontribusi pada tingkat komitmen seseorang. motivasi adalah perasaan atau pikiran yang mendorong seseorang melakukan pekerjaan atau menjalan kan kekuasaan, ter utama dalam ber perilaku (nursalam, 2014). hal ini sesuai dengan penelitian ebright (2006) bahwa motivasi yang melatarbelakangi mahasiswa keperawatan dalam melakukan yang akan mempengaruhi profesionalitas mereka sehingga akhirnya berpengaruh dalam kualitas pelayanan dan keselamatan pasien. mahasiswa dalam melakukan suatu tindakan tidak terlepas dari motivasi. motivasi ini bisa berupa motivasi internal maupun eksternal. motivasi internal pada mahasiswa bisa berupa keinginan untuk berprestasi, mendapatkan pengakuan dari orang lain, atau untuk kebanggaan diri. sedangkan untuk motivasi eksternal merupakan motivasi yang timbul dari luar misalnya penghargaan, pujian, atau hukuman yang diberikan oleh dosen, teman atau keluarga. motivasi individu pada umumnya hanya melakukan hal-hal yang menurutnya menyenangkan. prinsip itu tidak menutup kemungkinan bahwa dalam keadaan terpaksa seseorang mungkin saja melakukan sesuatu yang tidak disukainya (nawawi, 2000). motivasi mahasiswa dalam melakukan tindakan atau terlibat dalam keselamatan pasien yang rendah, bisa terjadi karena adanya faktor dari luar maupun dalam individu mahasiswa sendiri. motivasi tinggi diharapkan menimbulkan semangat untuk belajar dan menghasilkan prestasi baik pada akhirnya menjadi lulusan atau perawat berkualitas dan profesional. motivasi rendah seringkali disebabkan karena keinginan untuk menekuni bidang keperawatan bukan berasal dari diri mereka tapi karena paksaan dari orang tua sehingga sesuai dengan teori bila motivasi bukan t umbuh dalam diri sendiri akan cenderung lemah. selama proses pembelajaran berlangsung terkadang motivasi itu akan meningkat dengan sendirinya, tentu harapan dari pendidik di institusi adalah menghasilkan lulusan yang unggul yang mampu bersaing dan menjaga nama baik institusi. keselamatan pasien merupakan hal yang penting, sehingga t id a k bisa d iabai k a n. ke ce nde r u nga n ma ha siswa ma si h rend a h mot iva si nya dalam keselamatan pasien karena merasa kurang dilibatkan apabila berkaitan dengan keselamatan pasien justru akan memperlemah motivasi mahasiswa. pengaruh variabel organisasi terhadap keselamatan pasien berbasis knowledge m a n a g e m e n t s e c i s e b a g a i u p a y a peningkatan kompetensi mahasiswa keperawatan. desain pekerjaan pada penelitian ini didapatkan ada pada kategori yang sama antara cukup dan kurang. desain pekerjaan merupakan keputusan dan tindakan manajerial yang mengkhususkan kedalaman, cakupan, dan hubu ngan peker jaan yang objek tif guna memenuhi kebutuhan organisasi serta 330 jurnal ners vol. 10 no. 2 oktober 2015: 324–331 kebutuhan sosial dan individu pemegang pekerjaan. desain pekerjaan dikembangkan dengan menekankan pentingnya karakteristik pekerjaan inti seperti yang dipersepsikan oleh pemegang pekerjaan. pe r b e d a a n i n d iv id u m e r u p a k a n variabel utama dalam mendesain pekerjaan. pengalaman, kerumitan, kognitif, kebutuhan, nilai, dan persepsi tentang keadilan merupakan perbedaan individu yang mempengar uhi reaksi individu pemegang pekerjaan terhadap cakupan dan hubungan pekerjaan mereka. perbedaan individu tersebut menjadi tugas dari manajer untuk mengkaji cara meningkatkan persepsi positif terhadap keragaman, identitas, arti, dan balikan sehingga akan meningkatkan kemungkinan timbulnya prestasi kerja bermutu tinggi dan kepuasan kerja yang tinggi. dalam hal ini desain pekerjaan yang dimaksud adalah persepsi mahasiswa mengenai lahan praktik yang digunakan saat ini. latar belakang individu yang beragam juga menyebabkan cara pandang seseorang terhadap lingkungan tempat kerjanya juga berbeda. lingkungan kerja dalam hal ini adalah lahan praktik mahasiswa. lahan praktik mahasiswa yang merupakan fasilitas pelayanan kesehatan menyebabkan mahasiswa harus berinteraksi dengan berbagai macam karakter individu. harapan mahasiswa akan pencapaian yang diperoleh ketika memasuki lahan praktik juga akan berbeda-beda. penerapan model keselamatan pasien berbasis seci terhadap peningkatan kompetensi mahasiswa keperawatan pemberian model keselamatan pasien berbasis k nowledge management seci secara signifikan mempengaruhi kompetensi m a h a s i s w a ke p e r aw a t a n . k n o w l e d g e management seci yang terdir i dar i 4 tahapan yaitu socialization, externalization, combination, dan internalization merupakan suatu cara atau alat bagi sebuah perusahaan atau organisasi untuk membangun suatu pengetahuan, di mana pengetahuan nanti akan dig u nakan oleh organisasi u nt u k mengembangkan dirinya (nonaka, 2000). pengetahuan yang dikembangkan di sini adalah tentang keselamatan pasien. masingmasing tahapan memerlukan waktu untuk menghasilkan pengetahuan yang dapat secara langsung diaplikasikan oleh anggotanya. tahapan internalizaton adalah tahapan di mana pengetahuan baru akan secara otomatis diterapkan oleh anggota tanpa perlu diingatkan atau diawasi, yang ar tinya pengetahuan ini telah menjadi landasan individu dalam mela k u kan t i nd a ka n at au ber per ila k u. perilaku didasari oleh pengetahuan maka lebih langgeng daripada perilaku tidak didasari oleh pengetahuan (notoadmojo, 2015). hal tersebut sangat dipengaruhi oleh intensitas perhatian dan persepsi terhadap objek (notoatmodjo, 2007). faktor mempengaruhi pengetahuan diantaranya umur, pendidikan, pekerjaan, minat, pengalaman, kebudayaan dan informasi (mubarak, 2007). tahap akhir dari knowledge management seci merupakan penerapan pengetahuan baru yang diperoleh individu untuk melakukan suatu perilaku. perubahan perilaku individu dalam hal ini memerlukan waktu yang relatif cukup lama. simpulan dan saran simpulan model keselamatan pasien berbasis k nowledge management seci dibangun dari faktor psikologis dan faktor organisasi. model ini diterapkan untuk meningkatkan ko m p e t e n si m a h a si s w a ke p e r aw a t a n , kompetensi mahasiswa yang ditingkatkan denga n pengg u na a n model i n i ad ala h pemasangan gelang identitas, dokumentasi sbar, pemberian obat, verifikasi praintra dan post operasi, universal precaution, dan penilaian risiko jatuh. saran model keselamatan pasien berbasis k nowledge management seci ini dapat diterapkan oleh instusi dan r umah sakit untuk meningkatkan kompetensi mahasiswa ataupun perawat. penelitian selanjutnya disarankan untuk meneliti penerapan model knowledge management seci ini pada asuhan keperawatan. 331 keselamatan pasien berbasis knowledge management seci (joanggi wiriatarina harianto, dkk.) kepustakaan burke, patricia m. 2011. cultural competency of associate degree nursing faculty. 2011. capella university: proquest. ebright, patricia r., s. wendy., kooken, c a r t e r., m o o d y, r o s e a n n e c ., al-ishaq, moza a. latif hassan. mindful attention to complexity: implications for teaching and learning patient safety in nursing. 2006. anuual review of nursing education: proquest. farida, umi. 2007. hubungan tipe kepribadian ekstrovert dan introvert dengan perilaku agresif pada remaja (di sma widya dharma turen. skripsi: universitas islam negeri malang. fura, m.l., & rothenberger, m.c. 2014. integrating national patient safety initiatives into prelicensure clinical learning. journal of nursing education, 363–364. gibson, james l. 1987. organisasi perilaku, struktur,proses, jakarta: erlangga herman, sofyandi., gamiwa, iwa. 2007. perilaku organisasional. yogyakarta: graha ilmu ivancevich, j.m., konopaske, r., & matteson, m.t. 2007. perilaku dan manajemen o r g a n i s a s i . j a k a r t a : p e n e r b i t erlangga. kementerian kesehatan, r.i. 2011. standar ak reditasi rumah sak it. jakar ta: kementer ian kesehat an republi k indonesia. khasanah, u. 2012. tindakan error prosedur ke p e r awat a n: je n i s d a n fa k t or penyebabnya pada mahasiswa profesi ners program studi ilmu keperawatan fa k u lt a s ke d ok t e r a n d a n i l mu kesehatan uin syarif hidayatullah jakarta. jurnal ners, 191–200. mubarak, wahid iqbal. 2007. promosi kesehatan. jogjakarta: graha ilmu. nawawi, hadari. 2000. manajemen sumber daya manusia. yogyakarta: gadjah mada university press. nawawi, i. 2012. manajemen pengetahuan (knowledge management). bogor: ghalia indonesia. nonaka, i., toyama, r., & konno, n. 2000. seci, ba and leadership: a unified model of dynamic knowledge creation. long range planning elsevier, 5–34. nonaka, i., takeuchi, h.1 995.the knowledge creating company: how japanese companies create the dynamics of innovation. harvard business school press. boston. mass. nursalam. 2014. manajemen keperawatan: aplikasi dalam praktik keperawatan profesional edisi 4. jakarta: salemba medika. notoat modjo, soek idjo. 2005. promosi kesehatan dan ilmu perilaku. jakarta: pt. rineka cipta. notoatmodjo, soekidjo. 2007. kesehatan masyarakat: ilmu dan seni. jakarta: pt. rineka cipta. robbi n s , st e phe n , p. 20 07. pe r ila k u organisasi: edisi bahasa indonesia. jakarta: pt. prenallindo. 72 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.18572 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of nursing intervention-based levine conceptual model program on rehabilitation process among fracture patients henrianto karolus siregar , dudut tanjung , and nunung febriany sitepu faculty of nursing university of sumatera utara, sumatera utara, indonesia abstract introduction: the nursing intervention program is a strategy for the rehabilitation process among fracture patients the levine conceptual model program is a practical nursing theory using energy conservation, energy, structural integrity, personal integrity, and social integrity. the study aims to identify the effect of nursing intervention based on levine's theory of the rehabilitation process among fracture patients. methods: a quasi-experimental with equivalent control group design was applied in this study. sixty-two respondents were selected into the experimental group (n=31) and control group (n=31) by using a consecutive sampling technique. the patients' rehabilitation on fracture included sleep disorder, pain, anxiety, and family support as dependent variables. researchers used the sleep quality scale (sqs) instrument, the numeric rating scale, the hamilton anxiety rating scale, and the family support scale. data were analyzed using a wilcoxon signed rank test. results: the results showed a significant effect of patients' recovery on fracture among patients after receiving levine-based nursing intervention than before receiving the intervention (p <0.05). the results of research on the nursing intervention program are based on levine's conceptual model of sleep disorders, pain, anxiety, and family support (p <0.05). in conclusion, there was significantly different nursing intervention based on levine in energy conservation, energy, structural integrity, personal integrity, and social integrity. conclusion: the nursing intervention program based on levine's conceptual model could be part of independent nursing intervention to deal with recovery in fracture patients. based on this description, the researcher is interested in examining the effect of nursing intervention based on levine’s conceptual model program on rehabilitation process among fracture patients. article history received: april 8, 2020 accepted: may 15, 2020 keywords fracture patient; rehabilitation; levine conceptual model contact henrianto karolus siregar  henriantokarolussiregar @student.usu.ac.id  master program in faculty of nursing university of sumatera utara,sumatera utara, indonesia cite this as: siregar, h, k., tanjung, d., & sitepu, n, f. (2020). the effect of nursing intervention-based levine conceptual model program on rehabilitation process among fracture patients. jurnal ners, 15(1). 72-78. doi:http://dx.doi.org/10.20473/jn.v15i1.18572 introduction fracture condition is caused by pressure that exceeds the ability of the bone to withstand excessive stress on the bone. it could cause massive trauma and difficulty to perform activities (einhorn & gerstenfeld, 2015). fractures cause malfunctioning parts of the body that can result in permanent disability and even cause death after the trauma experienced. it can cause significant changes in a person's life, with the result of loss of independence. thereby, immediate treatment for fracture recovery is required (buza & einhorn, 2016). fracture recovery is a stage of the fracture healing process that starts from the beginning of the trauma until the fracture process, enabling the body to recover from the trauma experienced. fracture recovery from injury due to trauma requires a different recovery time, from a few weeks to months, depending on the type of trauma, location, and severity of the fracture (bhandari et al., 2008). data from the world health organization (who) in 2011 revealed fracture incidence of approximately 5.6 million people who died due to accidents, and 1.3 million people experienced permanent physical disabilities. in addition, basic health research in the republic of indonesia (2018) also showed that fractures had significant impacts on lower limbs https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:henriantokarolussiregar@student.usu.ac.id mailto:henriantokarolussiregar@student.usu.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 73 (67.9%), upper limbs (32.7%), head (11.9%), back (6.5%), chest (2.6%), and abdomen (2.2%). the prevalence of fractures in north sumatera was 864 people, which included lower limb fractures as many as 549 people (63.5%), upper limb fractures were 250 people (28.9%), pelvic fractures were 39 people (4.5%), and spinal fractures as many as 26 people (3.1%) (moesbar, 2013). a pilot survey conducted at h. adam malik hospital, medan in 2018, showed that of 196 people, lower limb fractures accounted for 94, upper limb fractures 45, shoulder and upper arm fractures31, and foot fractures 26. fractures patients often experience physical and psychological changes. the physical changes included sleeping disorder, pain, anxiety, and low family support (potter, perry, stockert, & hall, 2016), all of which could hinder the recovery process of fracture healing. factors associated with fracture recovery include age, length of hospitalization, and other complications (crowley, 2011). in maintaining the ability of fracture patients to resist obstacles, make appropriate adaptations, and deal with disabilities, a conceptual conservation model is required in this study. fracture patients often have complex problems, such as sleep disorders, pain, anxiety, and low family support. therefore, fracture patients have limited activities and are still dependent on other people around them (paech, 2007). the concept of the levine model is a nursing intervention program that has various conservation principles. levine's conceptual model has never been studied in fracture patients, so the researcher is interested to look at this phenomenon. thus, it could impact on functional of life among individuals even when faced with difficult challenges. levine's conceptual model aims to maintain the needs of individuals using the principle of energy conservation, conservation of structural integrity, conservation of personal integrity, and conservation of social integrity (abumaria et al., 2015). the conceptual model of the nursing intervention program is in accordance with operational standards of the procedure and the results of this study have a significant effect on the recovery of fracture patients. the complex problems previously stated can be overcome by carrying out nursing interventions based on levine's conceptual model. the novelties in this study were the intervention of levine's nursing intervention program among fracture patients and it aimed to identify the effect of nursing intervention based on the levine concept on fracture recovery among fracture patients. materials and methods a quasi-experimental study design was applied in this study to examine the effect of nursing intervention based on the levine conceptual model program on the rehabilitation process among fracture patients. in the intervention group, the nursing intervention program was carried out based on the levine conceptual model, while the control group was given hospital-based nursing interventions. nursing interventions based on levine's conceptual model consist of four programs: benson relaxation techniques, deep breathing relaxation techniques, progressive muscle relaxation techniques, and providing health education. the frequency of nursing interventions based on levine's conceptual model was carried out for six days and a duration of 40 minutes for each of the nursing problems. in the intervention group, levine's conceptual program action was taken from each nursing intervention and evaluated every day for six days, whereas the control group was not given a nursing intervention based on levine's conceptual model but only given based on hospital standards. the study was conducted in h. adam malik hospital, medan, between august 10th and october 29th, 2019. sixty-two samples consisted of 31 samples were allocated in the experimental group and 31 samples for the control group. allocation techniques in this study consisted of patients included in the inclusion criteria. we applied a nonprobability sampling with consecutive sampling to select the samples. this method is a strategy to choose all individuals found and who met with the inclusion criteria (polit & beck, 2015). the criteria inclusion included: (a) all hospitalized fracture patients aged between 17 to 65 years old, (b) patients with upper and lower limb fractures, (c) cooperative in discussion process, (d) rehabilitation length between 1 to 3 months. the data were gathered using a sleep quality scale (sqs) to measure sleeping disorders. hamilton anxiety rating scale (hars) was used to measure anxiety level (hamilton, 1959). hamilton anxiety rating scale (hars) was one of the first rating scales developed to measure the severity of anxiety symptoms and is still widely used today in both clinical and research settings. family support scale (fss) was used to measure family support (espe-sherwindt, 2008). before data collection process ethical consideration was approved by the ethics committee, faculty of nursing, north sumatera university with ethical clearance number 1874/viii/sp/2019. informed consent was signed by all respondents who were willing to participate in this study. results three experts validated those questionnaires with the validation scores reported as: sleep quality scale (sqs) 0.94, hamilton anxiety rating scale (hars) 0.97 and family support scale (fss) 0.98. test-retest was applied to measure the reliability of the questionnaire with cronbach's alpha of sleep quality scale (sqs) as 0.80, hamilton anxiety rating scale 0.86, and the family support scale 0.81. description of respondents' characteristics table 1 shows that the highest distribution of respondents' characteristics based on age among the intervention group was 17-25 years old (29.0%). h. k. siregar et al 74 | pissn: 1858-3598  eissn: 2502-5791 also, the control group showed that most respondents were 26-35 years old (32.3%). the distribution of respondents based on gender among the intervention group was 67.7% male, while the control group also showed that most of them were male (83.9%). regarding respondents' characteristics based on education, most of the respondents in the both the intervention group and control group were high school with 74.2% and77.4%, respectively. in regard to distribution of respondents based on occupation, both the intervention group (32.3%) and the control group (54.8%), were entrepreneurs. in terms of the distribution of respondents based on the duration of hospitalization, it showed that most of them were hospitalized from between one day to 1 week, accounting for 45.2% of the intervention group and 74.2% in the control group. analysis in the intervention group used the kolmogorov smirnov test while the analysis in the control group used the mann whitney test. rehabilitation of fracture patients table 2 shows that, in the distribution of patients' rehabilitation of fracture on sleep disorder among the intervention group before receiving the levine-based model of nursing intervention, the majority of sleep quality was poor, which is 26 respondents (83.9%). whereas among the control group before receiving the standard care from the hospital, all 31 respondents (100%) had poor sleep quality. for the distribution of respondents after receiving the levine-based nursing intervention, the majority of respondents had better quality of sleep (74.2%), and among the control group after receiving the standard intervention from the hospital, all respondents had a poor quality of sleep (100%). the results of the study showed that the distribution of patients' rehabilitation of fractures on the pain level among the intervention group before receiving the levine-based nursing intervention was 23 respondents (74.2%), while among the control group before receiving the standard intervention from the hospital, the majority of respondents with mild pain were 20 respondents (64.5%). for the distribution of respondents after receiving the levine-based nursing intervention, all 31 respondents (100%) were mild pain, whereas among the control group after receiving the standard table 1. the distribution of frequency and percentage of characteristic demographic data among the intervention and the control group (n=62) characteristics intervention control n % n % aged 17-25 years old 9 29.0 9 29.0 26-35 years old 6 19.4 10 32.3 36-45 years old 3 9.7 2 6.5 46-55 years old 6 19.4 5 16.1 56-65 years old 6 19.4 5 16.1 >65 years old 1 3.2 mean ± sd 38.68± 16.782 36.55± 15.714 gender male 21 67.7 26 83.9 female 10 32.3 5 16.1 mean ± sd 1.32± .475 1.16±.374 education junior high school 4 12.9 1 3.2 high school 23 74.2 24 77.4 diploma 3 1 3.2 3 9.7 bachelor 3 9.7 3 9.7 mean ± sd 4.10± .746 4.26±.682 occupation housewife 5 16.1 entrepreneur 10 32.3 17 54.8 private employees 5 16.1 5 16.1 farmer 1 3.2 4 12.9 student 8 25.8 5 16.1 civil servant 2 6.5 mean ± sd 3.10±1.640 2.90±1.165 duration of hospitalization one day to 1 week 14 45.2 23 74.2 2 to 3 weeks 10 32.3 6 19.4 1 to 2 months 6 19.4 2 6.5 three months 1 3.2 mean ± sd 1.81± .873 1.32± .599 jurnal ners http://e-journal.unair.ac.id/jners | 75 intervention from the hospital it showed that some of them were mild pain, with 23 respondents (74.2%). based on the results it shows that in regard to the distribution of patients' rehabilitation of fracture on anxiety among the intervention group before receiving the levine-based nursing intervention all 31 respondents (100%) had severe anxiety, whereas in the distribution of respondents after receiving the levine-based nursing intervention, the majority of them, as many as 30 respondents (96.8%) had severe anxiety and with 31 respondents (100%) among the control group after receiving the standard nursing intervention from the hospital. the effect of the levine-based nursing intervention on the rehabilitation of fracture patients among the intervention group and the control group based on table 3 of the bivariate analysis using the wilcoxon signed-rank statistical test, it was obtained the significance value of p-value in the intervention group before and after the nursing intervention table 2. the distribution frequency and percentage on patients' rehabilitation of fractures among the intervention group and the control group before receiving the nursing intervention based on the levine model (n=62) rehabilitation of fracture patients intervention control pre post pre post n % n % n % n % sleep disorder very poor 26 83.9 poor 5 16.1 31 100 31 100 good 8 25.8 very good 23 74.2 mean ± sd 66.10 ± 3.655 47.87 ± 6.328 90.55 ± 3.686 89.65 ± 4.294 min-max 59-73 38-56 85-99 80-99 pain light 8 25.8 31 100 20 64.5 23 74.2 mild 23 74.2 11 35.5 8 25.8 severe mean ± sd 3.71 ± 0.529 2.06 ± 0.512 3.19 ± 0.703 3.10 ± 0.651 min-max 2-4 1-3 2-4 2-4 anxiety light 1 3.2 mild 30 96.8 severe 31 100 31 100 31 100 mean ± sd 58.19 ± 3.240 29.52 ± 5.476 56.19 ± 3.902 55.52 ± 4.419 min-max 52-64 20-43 51-63 47-63 family support good 31 100 enough 24 77.4 poor 7 22.6 31 100 31 100 mean ± sd 38.81 ± 7.534 61.84 ± 1.508 56.19 ± 3.902 54.97 ± 3.071 min-max 27-58 57-64 51-63 49-62 table 3. the effect of the levine-based nursing intervention on rehabilitation of fracture patients among the intervention group and the control group (n=62) rehabilitation of fracture patients intervention control mean sd z p-value mean sd z p-value sleep disturbance pretest 88.77 4.318 -4.862 0.000 90.55 3.686 -2.032 0.042 posttest 47.87 6.328 89.65 4.294 pain pretest 3.71 0.529 -4.824 0.000 3.19 0.703 -1.732 0.083 post-test 2.06 0.512 3.10 0.651 anxiety pretest 58.19 3.240 -4.862 0.000 56.19 3.902 -1.604 0.109 posttest 29.52 5.476 55.52 4.419 family support pretest 38.81 7.543 -4.865 0.000 56.19 3.902 -1.486 0.137 posttest 61.84 1.508 54.97 3.071 h. k. siregar et al 76 | pissn: 1858-3598  eissn: 2502-5791 program based on the levine conceptual model for the recovery of fracture patients (sleep disturbance, pain, anxiety, and family support) α = 0.000 (p < 0.05). thus, it can be said that the nursing intervention program based on levine's conceptual model influences the recovery of fracture patients (sleep disorders, pain, anxiety, and family support) in patients who experience fractures. the results of the bivariate analysis using the wilcoxon signed-rank statistical test showed no effect on the control group on fracture patient recovery (sleep disturbance α = 0.042, p < 0.05, pain α = 0.083, p < 0.05, anxiety α = 0.109, p < 0.05, and family support α = 0.137, p < 0.05). thus, it can be said that there is no significant effect of an intervention on recovery among fracture patients. there are sleep disorders, pain, anxiety, and family support in the control group in patients who have fractures. discussion based on the study, results showed that the levinebased nursing intervention had a significant effect on sleep quality (α=0.000, p<0.05). the nursing intervention conducted in this study to improve sleep in fracture patients is benson's relaxation technique. this can improve sleep because it can stimulate endorphin hormone secretion. this hormone is related to the neurotransmitter serotonin, which has a role in the sleep process (rambod et al., 2013).benson and proctor (2000) state benson's relaxation techniques can be approved by a good environment. this finding showed significant effect on the sleep quality of the respondents (p-value 0.000). rahman, handayani, & sholehah(2019) stated that the benson relaxation technique could improve sleep quality among elderly patients. the levine-based nursing intervention also showed a positive effect on pain (α=0.000, p<0.05). the results of the bivariate analysis using the wilcoxon signed ranking statistical test showed no difference in the control group in pain (α = 0.083, p> 0.05). fracture patients with pain could use nonpharmacological management, such as deep breathing techniques (black &, 2014). this study implemented the deep breathing relaxation technique to reduce pain among fracture patients. based on the results, there is a significant effect on the intervention on pain among respondents (p-value 0.000). another study from sehono (2010) stated that deep breathing relaxation technique was effective in reducing pain post-operation for fracture. nursing intervention-based on the levine model could also provide a positive impact on anxiety (α=0.000, p<0.05). zhao et al. (2012) said that progressive muscle relaxation techniques can be used to reduce anxiety, which can suppress sympathetic nerves and suppress tension experienced by respondents reciprocally so that counter conditioning will arise. xie et al. (2016) state that progressive muscle relaxation techniques are effective in reducing anxiety in patients with limb fractures undergoing surgery. based on this intervention, it showed that there is a positive effect of the intervention on anxiety among respondents (p-value 0.000). a study from hardono & amirudin (2020) said that muscle progressive relaxation technique could reduce anxiety levels among pre operated fractures patients. in addition, another study from zhao et al. (2012) also said that muscle progressive relaxation technique could be used to reduce anxiety and that it could suppress the sympathetic nerves and the tension experienced by the respondents reciprocally so that there will be counter conditioning. other findings showed positive effect of the levine-based nursing intervention on family support (α=0.000, p<0.05). nursing interventions conducted in this study to improve family support in fracture patients were to provide health education. this family support can be in the form of task orientation that can be given to family, friends, and even neighbors (friedman, browden, & jones, 2010). the health education was implemented to educate fracture patients. this finding indicated that there is a significant difference in the intervention on family support among respondents (p-value 0.000). the result was consistent with previous study from helmi (2012) which said that there is a positive effect of health education on anxiety levels among preoperated patients. the limitation of this study is that it still takes a long time to provide nursing intervention for the recovery of fracture patients so that nursing intervention can be felt and utilized by patients suffering from fractures. conclusion there is a positive effect of levine-based nursing intervention on sleep disorder, pain, anxiety, and family support. the findings recommend applying the different instruments for measuring sleep disorder, pain, anxiety, and family support to identify the results effectively. further studies are also needed to conduct a similar study with longer and expected duration and frequency of levine-based nursing intervention. the results of this study can be an evidence-based nursing practice that can strengthen the body of knowledge of nursing, especially those related to the nursing intervention program based on levine's conceptual model. references abumaria, i. m., hastings-tolsma, m., & sakraida, t. j. (2015). levine's conservation model: a framework for advanced gerontology nursing practice. nursing forum. https://doi.org/10.1111/nuf.12077 benson, h., & proctor, w. (2000). keimanan yang menyembuhkan dasar-dasar respon relaksasi. bandung: kaifa. buza, j. a., & einhorn, t. (2016). bone healing in 2016. in clinical cases in mineral and bone metabolism. https://doi.org/10.11138/ccmbm/2016.13.2.1 jurnal ners http://e-journal.unair.ac.id/jners | 77 01 bhandari, m., busse, j. w., hanson, b. p., leece, p., ayeni, o. r., & schemitsch, e. h. (2008). psychological distress and quality of life after orthopedic trauma: an observational study. canadian journal of surgery. https://doi.org/10.1016/s02761092(09)79482-9 black, j. m. & h. (2014). keperawatan medikal bedah black vol 3.pdf. in 3. crowley, k. (2011). sleep and sleep disorders in older adults. in neuropsychology review. https://doi.org/10.1007/s11065-010-9154-6 donsu, j. d. ., & amini, r. (2017). perbedaan teknik relaksasi dan terapi musik terhadap kecemasan pasien operasi sectio caesaria. jurnal vokasi kesehatan. https://doi.org/10.30602/jvk.v3i2.113 einhorn, t. a., & gerstenfeld, l. c. (2015). fracture healing: mechanisms and interventions. in nature reviews rheumatology. https://doi.org/10.1038/nrrheum.2014.164 evi, n., rachmawati, i., & budiarti, t. (2020). levin's conservation model and unpleasant symptoms theory in nursing care of pregnant women with preeklamsia : a case study. journal of health sciences. https://doi.org/10.33086/jhs.v13i01.556 espe-sherwindt, m. (2008). family-centred practice: collaboration, competency and evidence. support for learning. https://doi.org/10.1111/j.14679604.2008.00384.x friedman, m. m., bowden, v. r., & jones, e. g. (2010). family nursing textbook: research, theory, and practice of. interpreter, akhir yani s. hamid, ed, 5. hamilton, m. a. x. (1959). the assessment of anxiety states by rating. british journal of medical psychology, 32(1), 50-55 hardono, wahyudi, d. a., & amirudin, ikhwan. (2020). pengaruh pendidikan kesehatan preoperasi terhadap tingkat kecemasan pada pasien preoperasi elektif mayor di rskb kurnia medical center pringsewu tahun 2019. jurnal inovasi kesehatan. karladani, a. h., granhed, h., kärrholm, j., & styf, j. (2001). the influence of fracture etiology and type on fracture healing: a review of 104 consecutive tibial shaft fractures. archives of orthopaedic and trauma surgery. https://doi.org/10.1007/s004020000252 lin, p. c., & lu, c. m. (2005). hip fracture: family caregivers' burden and related factors for older people in taiwan. journal of clinical nursing. https://doi.org/10.1111/j.13652702.2005.01130.x mirhadi, s., ashwood, n., & karagkevrekis, b. (2013). factors influencing fracture healing. trauma. https://doi.org/10.1177/1460408613486571 moesbar, n. (2013). pengendara dan penumpang sepeda motor terbanyak menderita patah tulang pada kecelakaan lalu lintas. paech, m. (2007). nursing theorists and their work (6th edn). contemporary nurse. https://doi.org/10.5172/conu.2007.24.1.106a polit, d.f.,& beck, c. t. (2015). nursing research: generating and assessing evidence for nursing practice 10th edition. in wolters kluwer health. https://doi.org/10.1007/s13398-014-0173-7.2 potter, p. a., perry, a. g., stockert, p., & hall, a. (2013). fundamentals of nursing, 8th edition. in notes. rahman, h. f., handayani, r., & sholehah, b. (2019). pengaruh terapi relaksasi benson terhadap kualitas tidur lansia di upt pelayanan sosial lanjut usia bondowoso. jurnal sainhealth. rambod, m., pourali-mohammadi, n., pasyar, n., rafii, f., & sharif, f. (2013). the effect of benson's relaxation technique on the quality of sleep of iranian hemodialysis patient: a randomized trial. complementary therapies in medicine, 21(6), 557-584. sehono, e. (2010). pengaruh teknik relaksasi guided imagery terhadap penurunan nyeri pada pasien pasca operasi fraktur di rsud dr. moewardi surakarta. electonic theses and disertation universitas muhammadiyah surakarta. smeltzer, s. c & barre, b. g. (2017). buku ajar keperawatan medikal-bedah brunner & suddarth. in journal of chemical information and modeling. https://doi.org/10.1017/cbo9781107415324. 004 swanson, c. m., shea, s. a., stone, k. l., cauley, j. a., rosen, c. j., redline, s., karsenty, g., & orwoll, e. s. (2015). obstructive sleep apnea and metabolic bone disease: insights into the relationship between bone and sleep. in journal of bone and mineral research. https://doi.org/10.1002/jbmr.2446 thomas, a. a., & d'silva, f. (2015). pain, anxiety & functional status of patients with lower limb fracture and dislocation after open reduction. nitte university journal of health science. whiteing, n. l. (2008). fractures: pathophysiology, treatment and nursing care. nursing standard (royal college of nursing (great britain) : 1987). https://doi.org/10.7748/ns2008.09.23.2.49.c6 671 world health organization. (2011). the global prevalence of fractute. who. xie, l. q., deng, y. l., zhang, j. p., richmond, c. j., tang, y., & zhou, j. (2016). effects of progressive muscle relaxation intervention in extremity fracture surgery patients. western journal of nursing research, 38(2), 155-168. zairin noor helmi. (2012). hubungan antara nyeri fraktur dengan kualitas tidur pasien yang di rawat inap.journalofchemicalinformationand modeling. https://doi.org/10.1017/cbo9781107415324. 004 zhao, l., wu, h., zhou, x., wang, q., zhu, w., & chen, j. (2012). effects of progressive muscular h. k. siregar et al 78 | pissn: 1858-3598  eissn: 2502-5791 relaxation training on anxiety, depression and quality of life of endometriosis patients under gonadotrophin-releasing hormone agonist therapy. european journal of obstetrics and gynecology and reproductive biology. https://doi.org/10.1016/j.ejogrb.2012.02.029 http://e-journal.unair.ac.id/jners | 227 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.10450 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the validity and reliability of quality of nursing work life instrument for hospital nurses utami utami1,4, hari kusnanto2, bagus riyono3 and syahirul alim2 1 doctoral candidate of public health programme, faculty of medicine, public health and nursing, universitas gadjah mada, yogyakarta, indonesia 2 faculty of medicine, public health and nursing, universitas gadjah mada, yogyakarta, indonesia 3 faculty of psychology, universitas gadjah mada, yogyakarta, indonesia 4 department of nursing, stikes abi surabaya, east java, indonesia abstract introduction: the validity and reliability of the quality of nursing work life (qnwl) instrument in hospitals that suitable to treatment needs include: trust, care, respect, learn, and contribute need, have to be assessed. therefore, in order to perform good care, it is necessary to notice qnwl aspect, which the implementation may be assessed by using valid and reliable instruments. this study aimed to evaluate the construct validity of the qnwl scale in hospital. methods: the research used a cross-sectional approach and the respondents were 100 experts in nursing and 400 nurses working in four hospitals in gresik, indonesia, who have been working for minimum one year. the sampling technique was purposive sampling. we analyzed the data using content analysis, the validity of item discrimination using pearson products moment, reliability with cronbach’s alpha, and construct validity with confirmatory factor analysis. results: the results based on content validity index qnwl instrument was 0.2075-0.915, with an average 0.7059 (high). item discrimination capacity was 0.339-0.79 (high), while the reliability was 0.9374 (very high) and the validity of the construct meets the goodness of fit criteria. conclusion: all constructs are able to explain and support the qnwl instrument model. this research can be used to measure the quality of work life of nurses in all classes of hospitals in indonesia. article history received: november 14, 2018 accepted: january 09, 2019 keywords validity; reliability; quality of nursing work life; instrument; hospital contact utami utami  tami_ola@yahoo.com  doctoral candidate of public health programme, faculty of medicine, public health and nursing, universitas gadjah mada, yogyakarta, indonesia cite this as: utami, u., kusnanto., h., riyono, b., & alim, s. (2018). the validity and reliability of quality of nursing work life instrument for hospital nurses. jurnal ners, 13(2), 227-232. doi:http://dx.doi.org/10.20473/jn.v13i2.10450 introduction quality of nursing work life (qnwl) is described as strength as well as motivating and increasing employee productivity at work environment in the organization. quality of nursing work life is a sustainable management approach directed for improving the quality of work, (hamim nur, et al, 2015). quality of nursing work life (qnwl) serves as a predictor of a nurse’s intent to leave and a hospital nurse turnover, since qnwl can be influenced by various factors, scholars and organizations have serious attention on how to scientifically assess the work conditions and mental statuses of nurses, (fu et al., 2015). qnwl is needed in the work environment at the hospital. through human resource management approach, the hospital must be able to create qnwl that can provide opportunities for self-development, which are welfare covering workers’ basic needs as well as a safe and comfortable work environment, in order to generate work morale as an effort to achieve goals https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:tami_ola@yahoo.com mailto:tami_ola@yahoo.com http://dx.doi.org/10.20473/jn.v13i2. http://dx.doi.org/10.20473/jn.v13i2. u. utami et al. 228 | pissn: 1858-3598  eissn: 2502-5791 better. quality means the ability to produce goods or services, marketed and to provide services constantly based on costumers’ needs. that way, the goods or services produced are able to compete and to succeed in seizing the market. qnwl instrument is basically looking for ways to improve the quality of life and to create better work results or to achieve high performance (kheradman, e, et al). however, qnwl measurement tools that have been validated for the implementation in indonesia have not been sufficient yet. past research indicates that quality work life is negatively associated with job stress (mosadeghrad, et al 2011; bragard, et al, 2012), turnover intention (mosadeghrad et al., 2011 and almalki, et al, 2012), and depression symptoms (wang, 2009), and positively related to productivity (nayeri, et al, 2011) and patient safety (mitchell ji, 2012). quality of nursing work life is a management approach that is continuously directed for improving the quality of work. thus, hospital management should care about the condition of its nurses in order to increase their loyalty to give better service which will ultimately improve employee performance. overall, the best quality of care provided by the nurse is influenced by qnwl, which is an important element in health care services, (clarke & brooks, 2010). the preliminary study found that the number of nurses was around 60% of the total hospital employees. in terms of intensity of interaction with patients, the nurse is also an element of human resources with the highest intensity of interaction with the patient. therefore, the quality of nursing work life (qnwl) instrument, especially in a hospital, need to be prepared based on the nurses’ needs of qnwl. it aims to achieve an effective work environment that brings the needs and values of the organization to the employee's personal need and value. qnwl also emphasizes the feeling perceived from the interaction between individual and work environment (mohamad m and mohamed w.n, 2012). effective and efficient services can be measured based on two aspects, namely the service process aspect and service output aspect. in the process aspect, the parameter can be known from the service process in general (for example, the service of the implementation and documentation of nursing care). if the service process aspect in a hospital is not good, it will result in low service performance (for example, a low bed occupancy ratio and incomplete filling of care document) (soejadi, 2010). research related to qnwl is important to determine the quality of nursing work life in every hospital. each hospital has different organizational systems and environments, so qnwl for their employee is different as well. this difference can be related to the state of the unit, the number and type of units, policies, and the environment in each unit (nursalam, et al, 2018). a better understanding of qnwl is fundamental to specific strategies to improve qnwl and organizational productivity. the effectiveness of specific strategies, including nurses’ participation in making a decision, removing non-nursing tasks, and building healthy environments, could be evaluated using this instrument. the greater achievement of qnwl may increase nurses’ job satisfaction and improve patient care as well as organizational productivity (fu et al., 2015). thus, it can be concluded that a valid and reliable quality of work life instrument can be used to assess organizational culture, which is oriented to a balance between productivity and employee welfare. in addition, welfare is defined as subjective wellbeing that has psychological dimensions such as trust, care, and mutual respect. meanwhile, productivity also includes attitude and behaviour that support the achievement of optimal work outcomes, namely the willingness to learn and the commitment to contribute. accordingly, this study aims to evaluate the constructed validity of qnwl scale in a hospital. materials and methods this study was a descriptive research study using a cross-sectional design. this research was conducted in five stages namely, first, preparing an initial draft of the instrument by determining the instrument's blueprint. based on the blueprint, we compiled a statement in accordance with the type of instrument and the amount specified in the blueprint; second, getting an assessment from the experts who at least had educational background of a master or a professional experienced in the scale of design in the fields of public health, clinical nursing, clinical care to generate a revised version; third, revising the draft instrument; fourth, performing the first and the second stage of testing; and, five, compiling the final draft. the number of respondents involved in this study was 100 experts in nursing, 50 nurses for the early stage of testing instrument, and 350 nurses for the final stages of the testing instrument. inclusion criteria were nurses working in a public hospital for at least one year in gresik, east java, indonesia, and nurses who agreed to participate in the present study and who were not on vacation. the adaptation of a scale into a different culture requires a group of at least 5–10 times greater than the number of scale items, (bryne, 2009). the desired minimum sample size required was 175 participants based on 35 items. without selecting a sample group for the study, the data was collected using questionnaires from a total of 350 nurses who agreed to participate in the study. qnwl questionnaire was developed by riyono (2012). therefore, the qnwl measurement instrument to be developed can be aligned with minnesota satisfaction questionnaire (msq) and job diagnostic survey (jds) as the standard organizational diagnostic tool, that became the parameters including psychological dimensions such as trust, care, respect, learn, and contribution. the sampling technique was purposive sampling. the qnwl developed by riyono (2012) was to determine jurnal ners http://e-journal.unair.ac.id/jners | 229 the quality of nursing work life. the scale consisted of 35 items and five subscales (trust, care, respect, learn, and contribution). each item in the original scale was scored by a 5-point likert scale ranging from “completely disagree (1 point)” and “completely agree (5 points)”. the 35 items were reverse coded on the scale. the minimum total score was 35 and the maximum was 175. higher total score indicated better quality of work life. this research had gone through a process of ethical feasibility research and had been approved by the medical and research ethics committee of faculty of medicine, universitas gadjah mada number ke/fk /0168/ec/ 2017. results in the initial stage, there were 50 items in the qnwl instrument. the initial test aimed to determine the item discrimination power, face validity. this test involved 50 nurses as respondents. the content validity index (cvi) of the qnwl instrument was range from 0.2075 to 0.915 with an average score of 0.7059 (high) according to expert judgment based on the aiken v formula validity score, (aiken, 2014). based on table 2, we found that 52% of items were very high, 18% criteria were high, 10% criteria were fair and 20% criteria were low, according to expert judgment. item number 4, 6, 7, 10, 18, 19, 20, 26, 27, 32, 37, 48, 44, 45, and 46 aiken v formula validity scores less than 0.7 so that the items were considered invalid and not can be used again for measuring the qnwl indicator. after deducting the number of invalid statements, the number of items reduced to 35 statements. the item discrimination test results in the initial stage trial using pearson product moment correlation obtained a validity score (r count) in the range 0.33 9 0.79 for 50 instrument items, while the r table was 0.279, so that items with r count were more the size of the r table, which means this validity score was sufficient reason to state that this qnwl instrument was valid. test construct validity with factor analysis using the r program, the data included in the factor analysis were the five qnwl constructs containing 13 indicators and 35 item statements. factor analysis involved 350 respondents who were nurses from four hospitals in gresik regency. test construct validity with factor analysis using the r program, the data included in the factor analysis were five qnwl constructs containing 10 indicators and 35 item statements. factor analysis involved 350 respondents who were nurses from four hospitals in gresik regency. construct validity with loading factor of all indicators above 0.50, namely trust table 1 initial draft and final results for the outline quality of nursing work life instrument construct indicator number of items initial draft final result trust 20% 1. trust of supervisor to subordinates by willing to delegate tasks that are quite risky to subordinates 10 7 2. share information about plans and problems in the organization 3. engaging subordinates in making important decisions care 23% 4. get involved in the organization in a responsible and caring manner 10 8 5. care for life dynamic of the organization 6. supervisor treat each subordinate as an individual and pay attention to their needs, abilities, feelings, and aspirations respect 17% 7. improve nurse's ability 10 6 8. getting deeper knowledge about other people than just tolerance, admiration, and interference with other individuals. learn 26% 9. there is a passion and willingness to learn continuously for all nurses 10 9 10. develop new skills and competencies, 11. add new knowledge so that it will encourage the emergence of positive attitudes in the organization. contribute 14% 12. providing the widest opportunity for each employee to channel the source of initiative and creativity in solving important problems faced by the organization, in developing the organization, 10 5 13. make the climate pleasant for the organization. total 50 35 table 2 the result of expert judgment based on content validity criteria validity criteria item’s number number of items very high (0.80 <v 00 1.00) 1, 2, 3, 5, 8, 9, 14, 15, 21, 23, 24, 25, 28, 29, 30,31 33, 35, 38, 39, 41, 42, 43, 47, 49, 50 26 high (0.60 <v ≤ 0.80) 11, 12, 13, 16, 17, 22, 34, 36, 40 9 fair (0.40 <v ≤ 0.60) 26, 27, 32, 37, 48 5 low (0.20 <v ≤ 0.40) 4, 6, 7, 10, 18, 19, 20, 44, 45, 46 10 very low (0.00 <v ≤ 0.20) none 0 u. utami et al. 230 | pissn: 1858-3598  eissn: 2502-5791 (0.755; 0.753; 0.721; 0.612; 0.794; 0.786; 0.727); car e (0.742; 0.590; 0.869; 0.766; 0.648; 0.681; 0.861; 0.766); respect (0.774; 0.655; 0.795; 0.855; 0.682; 0.534); learn (0.861; 0.923; 0.766; 0.698; 0.850; 0.816; 0.822; 0.915; 0.696); and contribute (0.708; 0.870; 0.846; 0.795). the results of this validity test were relevant to the t-test which showed the value of t count > 1.96, so it can be stated that all qnwl instruments were valid and able to explain the qnwl instrument model. the results of factor analysis with confirmatory factor analysis on each qnwl construct: trust, care, respect, learn, and contribute have met the established goodness of fit criteria. the probability value testing of the goodness of the index indicates a value of 0.996 and the value of rmsea 0.012. other model compatibility tests such as agfi, tli, and cfi also showed a value of ≥ 0.90, so it could be stated that existing construct can confirm the theory of qnwl which was the basis for developing instrument. discussion qnwl is an organizational behaviour variable that gets a lot of attention from practitioners and academics in the field of organizational behaviour. thus, it needs to be formulated more sharply based on the standard. during this time, the qnwl variable still has various meanings. qnwl is partly defined as matters related to physical welfare or work environment. meanwhile, there is also a definition stating qnwl as a variable associated with psychological well-being related to job satisfaction and calm at work. this study seeks to define qnwl as an organizational cultural value that creates a work atmosphere which is conducive to psychological wellbeing and nurse performance. qnwl is influenced by internal and external factors. internal factor is the environmental condition of nurses that come from individuals and nurse organizations, while the external factor is the condition of the quality of nursing work life that comes from outside the nurse organization. those factors are divided into three parts, namely patient demand on health system demand, health care policy or health policy, and labour market nursing. in this study, the instruments of qnwl we used were different from the previous research. the previous research used a theory of brook and anderson consisting of 42 items, and it has four subscales (home/work life; work organization/design; work condition/contention; and work world). in this study, dimensions were used according to riyono (2012) whose assessment was based on psychological aspects. these dimensions consisted of 35 items and five aspects including trust, care, respect, learn, and contribute (riyono, 2012), while the previous research was more about physical evaluation. this was because this study used a theory stating that qnwl was an organizational culture which was balance-oriented between productivity and employee benefits (subjective wellbeing). qnwl, in this case, is the employee's perception of the hospital or organization where the nurses work. qnwl is also quite individual because qnwl is how nurses in a hospital or organization assess the hospital or organization in paying attention to their welfare and work productivity. in qnwl, it is applied how hospitals are able to increase the productivity of nurses’ work, and the welfare of nurses is also fulfilled at the same time. thus, there is a balance in qnwl concept between nurse welfare and productivity. this is directly related to job satisfaction since job satisfaction is basically individual and personal, so the things that exist in qnwl concept itself affect employees' job satisfaction. simply, the higher the qnwl, the higher the job satisfaction of the nurse will be. testing of content validity index (cvi) using expert panels was commonly used in the process of organizing instruments as performed by (salimi and azimpour, 2013). the content validity index (cvi) in qnwl was between 0.2075 and 0.915, with very high criteria of 52% and high criteria of 18% according to the assessment of 100 experts at the scale of 1-5. in a study conducted by (sirin, 2015) in turkish, which used 11 experts in the nursing field, the cvi values were 0.91 with the scale of 1-4. instrument reliability (internal consistency) was applied in this study, the intention was that we tested the instrument once only, and then the data obtained from the trial was analyzed using cronbach α coefficient. this coefficient had a range of 0-1, which was used to obtain an estimation of internal consistency reliability (bryne, 2009). the research results of the reliability test of qnwl instruments using cronbach alpha was 0.9374, which was higher than the reliability test of a benchmark (azwar, 2012) stating that the minimum standard of the test was 0.90 with high takes. research conducted by fu xia, et al, (2015), has cronbach alpha value of 0,912, and research conducted by lee y.w, et al (2014) has cronbach alpha value of 0.72 0.89. in conclusion, the qnwl instrument cronbach α coefficient results are better than those of the previous studies. the test of discrimination power of items in the initial stage used pearson product moment correlation obtaining a validity score (r count) ranged from 0.33 9 0.79 for 50 instrument items, then the r table was 0.279. thus, the size of the item with r count was bigger than r table meaning that the validity score can be a sufficient reason to state that qnwl instrument was valid. in a study conducted by(lee et al., 2014) , the value of r = 0.72,which was contrary to a study conducted by xia fu, xu jiajia et al (2015) stating that there were 6 items with a low score in the pearson product moment correlation and were eventually removed from the model. the final results of testing qnwl instrument showed that there were 35 valid items out of 50 items. table 2 showed the initial and final drafts for the qnwl instrument. the construct validity of this research was expected to prove that the measurement results jurnal ners http://e-journal.unair.ac.id/jners | 231 obtained through item statement were highly correlated to the theoretical construct of qnwl instrument development. according to azwar (2012), the validity was conducted through three stages, namely articulating the theoretical concept and the relational principle, developing a way to measure the theoretic hypothetical construct, and empirically testing the hypothetical relationship between the construct and its manifestation, (devellis, 2012). this study used factor analysis with confirmatory factor analysis (cfa) to determine the validity of the constraints of qnwl instruments. the aim of cfa was first, to analyze the validity of the instruments, provided that if the load factor ( λ)> 0.3 then the instrument was valid; second, to identify the dimensions of the instrument in order to test whether these dimensions were confirmed as well as empirical data truly match. the results of factor analysis with confirmatory factor analysis on each qnwl construct were: trust, care, respect, learn and contribute, of which all results were well. evaluation of goodness of fit index based on the results of factor analysis showed that the constructs used to form the qnwl model have met the established criteria for goodness of fit index, (hair, f.h, et al, 2010). the probability value of testing the goodness of fit index was 0.996, and the value of rmsea was 0.012. the other model compatibility tests such as agfi, tli, and cfi also showed a value > 0.90, so that the existing construct on qnwl model could confirm the theory of qnwl, which was the basis for developing the instrument. it was in contrast to a research conducted by sirin & sokmen (2015) in turkish, showing that the probability value of testing the goodness of fit index was 0.91, and the value of rmsea is 0.06. likewise, a research conducted by fu xia, et al., (2015), showed that the probability value of testing the goodness of fit index was 0.74, and the value of rmsea was 0.091. conclusion quality of nursing work life instrument in hospitals has fulfilled the criteria of validity and reliability, which include: content validity, item discrimination power, instrument reliability and construct validity. his instrument is recommended to be used to measure the quality of nursing work life by nurses in all hospital classes in indonesia. references aiken, l. r. (2014). content validity and reliability of single items or questionnaires. educational and psychological measurement, 40(4), 955–959. https://doi.org/10.1177/00131644800400041 9 almalki, m. j., fitzgerald, g., & clark, m. (2012). quality of work life among primary health care nurses in the jazan region , saudi arabia : a cross-sectional study, 1–13. azwar, s. (2012). reliability dan validity (4th ed.). pustaka pelajar yogyakarta. bragard, i., dupuis, g., razavi, d., reynaert, c., & etienne, a. (2012). quality of work life in doctors working with cancer patients, (october 2011), 34–40. doi :10.1093/occmed/kqr149 bryne, b.m, (2009)., structural equation modeling with amos basic concepts, applications, and programming (2 nd). taylor and francis: group, ny. clarke, p. n., & brooks, b. (2010). quality of nursing worklife : conceptual clarity for the future, 23(4). doi :10.1177/0894318410380268 devellis, r. f. (2012). scale development second edition (second, vol. 26). sage publication. fu, x., xu, j., song, l., li, h., wang, j., wu, x., hu y., wei, l., gao l., wamh q., lin z., & huang h.(2015). validation of the chinese version of the quality of nursing work life scale, 605, 1–13. doi :10.1371/journal.pone.0121150 hair, f.h, william, c.b., barry, j.b., rolph, e.a., & ronald, l., (2010). multivariate data analysis (vol. 7 th).hamim, n., suwandi. t., and yusuf. a. (2015). caring behaviour nurse based on quality of nursing work life and self-concept in nursing nurses in hospital. international journal of development research, 5(10), 5808–5808. kheradman, e, valilou, m & lotfi, a. (2010). the relation between quality of work life and job performance. middle east journal of scientific research, 6 no 4, 317–323. lee, y. w., d, p., dai, y. t., i. linda ., mccreary., yao g., and brools b.a.(2014). psychometric properties of the chinese-version quality of nursing work life scale, nursing and health sciences, 298–306. doi : 10.1111/nhs.12099 mitchell ji. (2012). work life and patient safety culture in canadian healthcare : connecting the quality dot using national accreditation results., 15, 51–58.mohamad, m., & mohamed. w.n., (2012). a model of quality of work life , life satisfaction and service quality, asian journal of business research, 2(2), 38–51. mosadeghrad, a. m., ferlie, e., & rosenberg, d. (2011). a study of the relationship between job satisfaction , organizational commitment and turnover intention among hospital employees. doi :10.1258/hsmr.2011.011009 nayeri, n. d., salehi, t., & noghabi, a. a. a. (2011). quality of work life (qwl) and productivity among iranian nurses. contemporary nurse, 39(1), 106–118. doi :10.5172/conu.2011.39.1.106 nursalam, fardiana a, asmoro c.p., fadhilah h., & efendi. f. (2018). the correlation between the quality of nursing work life and job performance, 9(10). indian journal of public health research & development. doi :10.5958/0976-5506.2018.01364.5 riyono, b., hartati s., & fatdina (2012). pengembangan alat ukur quality of work life. psikologi universitas gadjah mada. yogyakarta. u. utami et al. 232 | pissn: 1858-3598  eissn: 2502-5791 salimi and azimpour. (2013). journal of caring science, 2, 269. sirin, m., and sokmen s.m. (2015). quality of nursing work life scale : the psychometric evaluation of the turkish version. international journal of caring sciences. 8(3), 543–554 soejadi. (2010). efisiensi pengelolaan rumah sakit, grafik baber jhonson sebagai salah satu indikator. jakarta: katiga bina. wang, x. (2009). impact of depressive symptoms on the work-life quality of financial workers in china. european psychiatry, 24, s688. doi :10.1016/s0924-9338(09)70921-6 pp. 93-102). malden, usa: blackwell publishing . ners vol 10 no 2 okt 2015.indd 233 tanda gejala dan kemampuan mengontrol perilaku kekerasan dengan terapi musik dan rational emotive cognitif behavior therapy (sign and symptom and ability to control violent behaviour with music therapy and rational emotive cognitive behaviour therapy) heri setiawan*, budi anna keliat**, ice yulia wardani ** *mahasiswa magister ilmu keperawatan kekhusussan keperawatan jiwa kampus fik ui, jl. prof. dr. bahder djohan, depok, jawa barat-16424 **kelompok keilmuan keperawatan jiwa fakultas ilmu keperawatan universitas indonesia email: herirsjs09@yahoo.com abstrak pendahuluan: angka perilaku kekerasan cukup tinggi pada klien gangguan jiwa yang dirawat di rumah sakit jiwa. dampak perilaku kekerasan dapat berakibat mencederai orang lain. penelitian ini bertujuan mengetahui efektivitas terapi musik dan rational emotive cognitive behaviour therapy (recbt) terhadap perubahan tanda gejala dan kemampuan klien mengontrol perilaku kekerasan. metode: desain penelitian quasi eksperimental, jumlah sampel 64 responden dengan purposive sampling. hasil: penelitian menunjukkan penurunan tanda gejala perilaku kekerasan dan peningkatan kemampuan mengontrol perilaku kekerasan lebih besar pada kelompok yang mendapatkan terapi daripada yang tidak mendapatkan. diskusi: terapi musik dan recbt direkomendasikan sebagai terapi keperawatan pada klien perilaku kekerasan. kata kunci: kemampuan, perilaku kekerasan, tanda gejala, terapi musik, recbt abstract introduction: prevalence of violence is highly occur in mental disorders clients at psychiatric hospitals. the impact is injure to others. this research aims to examine the effectiveness of music therapy and recbt to sign and symptom and ability to control violent behaviour. methods: quasi-experimental research design with a sample of 64 respondents. results: the study found a decrease symptoms of violent behaviour, ability to control violent behavior include relaxation, change negative thingking, irational belief, and negative behavior have increased significantly than the clients that did not receiving therapy. discussions: music therapy and recbt is recommended as a therapeutic nursing at the client’s violent behaviour. keywords: violent, sign and simptom, ability, music therapy, recbt pendahuluan data yang didapatkan dari who (2015) menunjukkan jumlah orang yang mengalami skizofrenia di seluruh dunia adalah 7 dari 1000 pendudu k di dunia yait u sebesar 21 juta orang, tiga dari empat kasus gejala yang muncul ter jadi pada usia 15 dan 34 tahun (stuart, 2013). data riskesdas tahun 2007 menunjukkan prevalensi nasional gangguan jiwa berat yaitu skizofrenia sebesar 0,46%, atau sekitar 1,1 juta orang atau 5,2% dari jumlah penderita skizofrenia di seluruh dunia. prevalensi skizofrenia di provinsi jawa tengah yaitu 0,33% penduduk, masih di bawah prevalensi skizofrenia di indonesia. data riset kesehatan dasar (2013) dengan responden yang diteliti adalah 1.027.763 art menunjukkan prevalensi gangguan jiwa berat nasional sebesar 1,7 per mill, sedangkan gangguan jiwa berat di provinsi jawa tengah yaitu 2,3 per mill. jumlah rasio penderita skizofrenia dengan jumlah penduduk di indonesia masih di bawah jumlah rasio penderita skizofrenia di dunia, akan tetapi masih tergolong cukup tinggi. sebagian kasus skizofrenia terjadi antara 20 –25 tahun, di mana tahap kehidupan. s e s e o r a n g m e n c a p a i k e m a n d i r i a n , m e n g e m b a n g k a n h u b u n g a n d e n g a n pasangan, mulai mengejar karir atau tujuan hidup akan berdampak pada keberhasilan sosial d a n p eke r ja a n seh i ng ga d apat m e n g h a n c u r k a n ke h id u p a n ( el a i n e , et al, 2005). prevalensi skizofrenia cukup tinggi dan terjadi pada usia produktif. 234 jurnal ners vol. 10 no. 2 oktober 2015: 233–241 penel it ia n ya ng t ela h d ila k u k a n menunjukkan bahwa ada keterkaitan antara pender it a sk izof ren ia dengan per ila k u kekerasan, meskipun tidak semua skizofrenia melakukan perilaku kekerasan. sistematik review untuk melihat adanya risiko perilaku kekerasan pada penyakit psikotik yait u terdapat 20 studi termasuk 18.423 individu dengan gangguan skizofrenia menunjukkan peningkatan r isiko per ilak u kekerasan, perilaku kekerasan yang dilakukan oleh klien dengan skizofrenia adalah 13,2% dibandingkan dengan populasi pada umumnya yaitu sebesar 5,3% (fazel, et al., 2009). prevalensi perilaku kekerasan yang dilakukan oleh orang dengan skizofrenia adalah 19,1% (swanson, 2006). penelitian lain menunjukkan bahwa data klien perilaku kekerasan pada berbagai seting, menunjukkan adanya perbedaan dari tiap negara. australia 36,85%, kanada 32,61%, jer man 16,06%, italia 20,28%, belanda 24,99%, norwegia 22,37%, kanada 32,61%, swedia 42,90%, amerika serikat 31,92% dan inggris 41,73%. studi dilakukan di berbagai setting mulai dari unit akut, unit forensik dan pada bangsal dengan tipe yang berbeda beda. penelitian dilakukan dengan jumlah total 69.249 klien dengan rata-rata sampel 581,9 klien (bowers, et al., 2011). angka tersebut tergolong cukup tinggi di berbagai negara di dunia. perilaku kekerasan dilakukan karena ketidakmampuan dalam melakukan koping terhadap stres, ketidakpahaman terhadap situasi sosial, tidak mampu untuk mengidentifikasi stimulus yang dihadapi, dan tidak mampu mengont rol dorongan unt uk melak ukan perilaku kekerasan (volavka & citrome, 2011). dampak dari perilaku kekerasan yang muncul pada skizofrenia dapat mencederai atau bahkan menimbulkan kematian, pada akhirnya dapat memengaruhi stigma pada klien skizofrenia (volavka, 2012). stigma yang berkembang di masyarakat dan penolakan terhadap orang dengan skizof renia dan gangguan mental lainnya menjadi penghalang dalam proses pemulihan, integrasi di dalam masyarakat, dan peningkatan kualitas hidup klien gangguan jiwa (ahmed, et al.,2014). stigma yang berkembang di masyarakat menimbulkan penilaian bahwa gangguan jiwa identik dengan perilaku kekerasan. orang lain menganggap bahwa klien gangguan jiwa berbahaya sehingga tidak mau untuk mendekati klien gangguan jiwa yang pernah melakukan tindakan perilaku kekerasan. u p a y a y a n g d i l a k u k a n u n t u k menurunkan tanda gejala dan peningkatan kemampuan mengontrol perilaku kekerasan adalah dengan terapi musik dan recbt. kombinasi terapi musik dan recbt akan memberikan dampak yang lebih luas pada tanda gejala yang dialami oleh klien perilaku keke r a sa n. te r api mu si k membe r i k a n kenyamanan pada klien dan mengalami proses relaksasi. terapi musik juga dapat menurunkan stimulus yang mengakibatkan tanda gejala perilaku kekerasan masih muncul (chlan, 2011). terapi musik dan recbt memberikan efek yang saling mendukung untuk menurunkan tanda gejala kognitif, afektif, fisiologis dan perilaku. dampak pada tanda gejala sosial adalah dampak sekunder dari pemberian terapi musik dan recbt, apabila k lien mempu nyai kema mpu a n menurunkan tanda gejala dengan relaksasi, mengubah pikiran negatif, keyakinan irasional dan perilaku negatif, maka akan berdampak pada kemampuan dalam hal sosialisasi dengan orang lain dengan menunjukkan perilaku yang positif. penelitian dilakukan di rsj prof dr soerojo magelang. rumah sakit ini merupakan rumah sakit vertikal tipe a kementerian kesehatan yang khusus merawat klien dengan gangguan jiwa dan napza sebagai salah satu pusat r ujukan klien gangguan jiwa di indonesia. kapasitas tempat tidur yang tersedia adalah 720 dan 680 tempat tidur diantaranya untuk klien dengan gangguan jiwa. jumlah klien yang dirawat di rsj prof dr soerojo magelang bulan september 2104 yaitu 249 klien, bulan oktober yaitu 231 klien, bulan november 2014 yaitu 224 klien dan bulan desember 2014 yaitu 306 klien, dengan rata-rata bor 40,5%. nilai bor menurun dikarenakan kebijakan lama rawat yang lebih singkat yaitu 35 hari. studi pendahuluan yang dilakukan pada 51 dokumen menunjukkan klien skizofrenia sebanyak 80,34% dengan 235 tanda gejala dan kemampuan mengontrol perilaku kekerasan (heri setiawan, dkk.) diagnosa keperawatan perilaku kekerasan sebanyak 46,34% (19 klien). selama bulan januari, rata-rata klien masuk dengan perilaku kekerasan 2-3 klien di bangsal putra dan 1–2 klien di bangsal putri. angka tersebut cukup tinggi. upaya yang dilakukan di rsj prof dr soerojo magelang adalah pemberian terapi generalis, rebt dan assertiveness training dan hasilnya belum optimal. berdasarkan latar belakang di atas maka peneliti tertarik untuk meneliti tentang pengaruh efektivitas terapi musik dan recbt terhadap tanda gejala dan kemampuan mengontrol perilaku kekerasan. bahan dan metode desain penelitian yang digunakan pada penelitian ini adalah quasi experiment with control group dengan perbandingan satu kelompok intevensi dan satu kelompok kontrol. dua kelompok intervensi yang mendapat terapi musik dan recbt tersebut antara lain: kelompok yang diberikan terapi kombinasi terapi musik dan recbt, dan kelompok kontrol yang tidak mendapat terapi musik dan recbt. metode pengambilan sampel dengan teknik purposive sampling. penelitian dilakukan untuk membandingkan perbedaan penurunan tanda dan gejala perilaku kekerasan ser t a kemampuan mengont rol per ilak u kekerasan (relaksasi, mengubah pikiran negatif, keyakinan irasional, dan perilaku negatif ) pada kelompok inter vensi yang mendapat terapi musik dan recbt dengan kelompok kontrol. pengukuran terdiri dari data demografi responden mer upakan k uesioner u nt u k mendapatkan gambaran faktor-faktor yang memengaruhi perilaku kekerasan pada klien yang terdiri dari usia, pendidikan, jenis kelamin, pekerjaan, stat us perkawinan, riwayat gangguan jiwa, frekuensi dirawat, terapi medik, anggota keluarga dengan gangguan jiwa, pengobatan sebelumnya dan putus obat < 6 bulan. pengambilan data ini menggunakan lembar kuesioner a yang terdiri dari 11 pertanyaan dengan cara mengisi pada pilihan jawaban yang tersedia terkait dengan karakteristik responden. pe ng u k u r a n p e r i l a k u ke ke r a s a n mengg u nakan k uesioner b dan lembar observasi. kuesioner b untuk mengukur perubahan gejala perilaku kekerasan pada klien yang meliputi kognitif, emosi, perilaku, fisiologis dan sosial. pengukuran perilaku kekerasan menggunakan instrument yang dapat mengukur perubahan perilaku pada klien (responden) yang meliputi kognitif, afektif (emosi), perilaku, fisiologis dan sosial. instrumen yang digunakan untuk mengukur perubahan tanda gejala perilaku kekerasan yaitu kuesioner b yang terdiri dari respons kognitif, emosi, sosial dan perilakunya. instrumen yang digunakan adalah kuesioner pengungkapan kemarahan yang digunakan terdiri atas 8 per nyataan untuk respons kognitif, 12 pernyataan untuk respons emosi, 7 pernyataan untuk respons sosial, 6 pernyataan untuk respons perilaku klien terhadap situasi yang dihadapinya, dan 6 pernyataan untuk respons fisiologis. instr umen ini menggunakan skala likert yaitu 4: selalu; 3: sering; 2: jarang; 1: tidak pernah. instrumen ini akan diisi oleh responden langsung dan bila ada yang tidak dimengerti maka peneliti akan menjelaskannya (putri, keliat, nasution & susanti, 2010). uji validitas 26 item pernyataan valid yaitu r hasil > r table (0,413). uji reliabilitas: instrumen dinyatakan reliabel jika koef isien alpha cronbach lebih besar dari nilai standar 0,6 (alpha = 0,6). hasil uji ditemukan nilai r alpha (0,765) lebih besar dibandingkan dengan nilai 0,6 maka 26 pernyataan dinyatakan reliable. instrumen yang digunakan kemudian dikembangkan menjadi 36 item pertanyaan, item k uesioner tambahan pada respons kognitif 2 item, respons emosi/ afektif 5 item, respons sosial 2 item, dan respons perilaku 1 item, dan aspek (fontaine, 2009; stuart, 2013). tambahan item pada instrumen penelitian akan lebih memberikan gambaran tanda gejala yang muncul pada klien perilaku kekerasan. pelaksanaan terapi musik dan recbt adalah sebagai berikut pertemuan pertama: terapi musik, identifikasi kejadian dan respons terhadap kejadian: perasaan yang muncul, me ng u k u r pe r a sa a n dg me ngg u na k a n ter mometer perasaan, mengidentif i kasi 236 jurnal ners vol. 10 no. 2 oktober 2015: 233–241 pikiran dan perilaku negatif. latihan melawan keyakinan irasional terhadap kejadian yang pertama. pertemuan kedua: terapi musik, diskusi dan latihan melawan keyakinan irasional terhadap kejadian yang kedua. pertemuan ketiga: terapi musik, diskusi dan latihan melawan pikiran negatif yang pertama. pertemuan keempat: terapi musik, diskusi dan latihan melawan pikiran negatif yang kedua. pertemuan kelima: terapi musik, diskusi dan mengubah perilaku negatif yang pertama. pertemuan keenam: terapi musik, diskusi dan mengubah perilaku negatif yang kedua. analisis data menggunakan komputer, analisis univariat digunakan untuk menganalisis variabel-variabel yang ada secara deskriptif dengan menghitung distribusi frekuensinya untuk data kategori dan tendensi sentral untuk data numerik. analisis bivariat adalah analisis untuk menguji hubungan antara dua variabel. uji yang digunakan adalah chi square untuk analisis kesetaraan pada data kategori dan data kategori, independent t test pada data numerik dan data numerik, independent t test pada uji hipotesis skala numerik dan korelasi pearson untuk mengetahui hubungan antara skala numerik. hasil karakteristik klien dengan perilaku keke r a sa n d ala m pe nel it ia n i n i lebi h banyak laki-laki 49 orang (76,6%). pada jenjang pendidikan, sebagian besar jenjang pendidikannya adalah sma 38 orang (59,4%). pada status pekerjaan, sebagian besar tidak beker ja 44 orang (68,8%). pada stat us pernikahan klien menunjukkan sebagian besar sudah menikah 30 orang (46,9%). pada pemberian terapi medis yang diberikan saat ini, sebagian besar adalah golongan typikal 25 orang (39,1%). berdasarkan riwayat anggota keluarga yang mengalami gangguan jiwa sebagian besar 56 (87,5%) orang tidak ada riwayat anggota keluarga yang mengalami gangguan jiwa 56 orang (87,5%). karakteristik berdasarkan keberhasilan pengobatan sebelumnya sebagian besar tidak berhasil yaitu sebesar 41 orang (64,1%). karakteristik klien berdasarkan riwayat putus obat menunjuk kan sebagian besar mengalami putus obat yaitu sebanyak 48 orang (75%). berdasarkan usia rata-rata klien berusia 32,26 tahun, analisis mengenai frekuensi dirawat klien dengan perilaku kekerasan ratarata klien dirawat sebanyak 3,21 kali, ratarata klien mengalami gangguan jiwa selama 2,53 tahun. per uba ha n t a nd a gejala per ila k u kekerasan pada kelompok intervensi yang mendapat terapi musik dan recbt yang mendapat terapi musik dan recbt dengan kelompok kontrol yang tidak mendapat terapi musik dan recbt dapat dilihat dari tabel 1. hasil penelitian menunjukkan bahwa total rata-rata komposit tanda gejala perilaku kekerasan pada kelompok intervensi yang mendapat terapi musik dan recbt sebelum dilakukan terapi musik dan recbt adalah 100,84 (67,32%) dan setelah dilakukan sebesar 46,06 (30,71%) sehingga diketahui selisih komposit tanda gejala perilaku kekerasan sebesar 54,78 (36,52%). hasil uji statistik menunjukkan ada perubahan yang bermakna tanda gejala kognitif sebelum dan sesudah diberikan terapi musik dan recbt (p value < 0,05). sedangkan pada kelompok kontrol diketahui bahwa total rata-rata komposit tanda gejala klien perilaku kekerasan pada kelompok kontrol sebelum dilakukan terapi musik dan recbt pada kelompok intervensi yang mendapat terapi musik dan recbt adalah 98,72 (65,81%) dan setelah dilakukan sebesar 70,75 (47,17%) sehingga diketahui selisih komposit tanda gejala sebesar 27,97 (18,14%). hasil uji statistik menunjukkan ada perubahan yang bermakna komposit tanda gejala pada kelompok kontrol sebelum dan sesudah kelompok intervensi yang mendapat terapi musik dan recbt diberikan terapi musik dan recbt (p value < 0,05). per ubahan kemampuan mengontrol perilaku kekerasan pada kelompok intervensi d an kelompok kont rol yang mend apat terapi musik dan recbt2, didapatkan data bahwa total rata-rata komposit kemampuan mengontrol perilaku kekerasan sebelum dilakukan terapi musik dan recbt adalah 53,20 (28,91%) dan setelah dilakukan sebesar 237 tanda gejala dan kemampuan mengontrol perilaku kekerasan (heri setiawan, dkk.) 139,94 (73,33%) sehingga diketahui selisih komposit kemampuan mengontrol perilaku kekerasan sebesar 86,84 (44,42%). hasil uji statistik menunjukkan ada perubahan yang bermakna komposit kemampuan mengontrol perilaku kekerasan sebelum dan sesudah diberikan terapi musik dan recbt (p value < 0,05). total rata-rata komposit kemampuan mengontrol perilaku kekerasan pada kelompok kontrol sebelum dilakukan terapi musik dan r ecbt pada kelompok inter vensi yang mendapat terapi musik dan recbt adalah 52,33 (34,89%) dan setelah dilakukan sebesar 80,06 (53.37%) sehingga diketahui selisih kemampuan mengontrol perilaku kekerasan sebesar 27,78 (18,48%). hasil uji statistik menunjukkan ada perubahan yang bermakna kemampuan mengontrol perilaku kekerasan pada kelompok kontrol sebelum dan sesudah diberikan terapi musik dan recbt pada kelompok intervensi yang mendapat terapi musik dan recbt (p value < 0,05). h u b u n g a n a n t a r a k e m a m p u a n mengontrol perilaku kekerasan dengan tanda gejala perilaku kekerasan di rsj prof dr soerojo magelang tahun 2015 menunjukkan bahwa ada hubungan yang k uat antara kemampuan mengontrol perilaku kekerasan dengan tanda gejala perilaku (p value < 0,05) semakin tinggi kemampuan maka tanda gejala perilaku kekerasan semakin menurun tanda gejala perilaku kekerasan (r= –0,908). pembahasan ha sil penelit ia n ya ng d ila k u k a n untuk mengetahui efektivitas terapi musik berpengaruh terhadap tanda gejala perilaku kekerasan, terjadi penurunan tanda gejala kognitif 34,15%, perilaku 13,5%, sosial 13,5%, fisiologis 25,8% (sulistyowati, keliat, hastono, 2009). sedangkan hasil penelitian yang dilakukan untuk mengetahui efektifitas r ecbt terhadap tanda gejala perilak u kekerasan, terjadi penurunan tanda gejala tanda gejala kognitif: 30,00% emosi 28,12%, perilaku 28,33%, sosial 34,28%, fisiologis. 30,00% (lelono, keliat, & besral, 2011). hasil penelitian menunjukkan pengaruh terapi musik dan recbt lebih besar dibandingkan dengan hanya pemberian terapi musik atau recbt. terdapat perbedaan dalam tindakan pada penelitian pemberian terapi musik yang dilakukan di rsjd soerakarta di mana terapi musik yang dilakukan terdiri dari 4 sesi, perubahan tanda gejala yang diukur yaitu kognitif, perilaku, sosial dan fisik, penelitian dilakukan di r uang akut sampai dengan maintenance (sulistyowati, keliat, hastono, 2009). pada penelitian tersebut belum ada suatu proses untuk melatih klien mengubah pikiran negatif, dan keyakinan irasional pada klien yang terjadi pada klien. sedangkan penelitian yang dilakukan mengenai efektivitas cbt dan rebt di rsj marzoeki mahdi bogor, diberikan latihan untuk mengubah pikiran negatif, keyakinan irasional dan perilaku negatif, penelitian dilakukan di r uangan maintenance (lelono, keliat, & besral, 2011). pada penelitian tersebut tidak diberikan terapi musik yang dapat memberikan manfaat terutama pada tanda gejala fisiologis klien perilaku kekerasan. pada penelitian ini pemberian terapi musik dilakukan terlebih dahulu kemudian dilanjutkan dengan r ecbt. kombinasi terapi musik dan recbt akan memberikan dampak yang lebih luas pada tanda gejala yang dialami oleh klien perilaku kekerasan. terapi musik memberikan kenyamanan pada klien ketika dilakukan recbt, klien mengalami proses relaksasi selama pemberian recbt. terapi musik juga dapat menurunkan stimulus yang mengakibatkan tanda gejala perilaku kekerasan masih muncul (dunn, 2010). terapi musik yang dikombinasikan dengan psikoterapi efektif untuk meningkatkan hasil dari psikoterapi yang dilakukan. terapi musik dan recbt memberikan efek yang saling mendukung untuk menurunkan tanda gejala kognitif, afektif, fisiologis dan perilaku. dampak pada tanda gejala sosial adalah dampak sekunder dari pemberian terapi musik dan recbt, apabila klien mempunyai kemampuan menurunkan tanda gejala dengan relaksasi, mengubah pikiran negatif, keyakinan irasional dan perilaku negatif, maka akan berdampak pula pada kemampuan dalam hal sosialisasi dengan orang lain dengan menunjukkan perilaku yang positif. 238 jurnal ners vol. 10 no. 2 oktober 2015: 233–241 terapi musik pada ak hir nya akan berdampak pada kondisi relaksasi pada klien, sedangkan recbt berdampak pada kognitif, emosi, dan perilaku klien. terapi musik adalah metode terapeutik dengan menggunakan musik yang membantu seseorang dengan gangguan jiwa berat untuk membangun suatu hubungan. aspek dari skizofrenia yang berkaitan dengan kehilangan untuk mengembalikan kreativitas, ekspresi emosi, hubungan sosial dan motivasi mungkin menjadi penting ketika dihubungkan dengan terapi musik. (gold, 2009 dalam mossler, 2013). sedangkan recbt secara signifikan dapat mengurangi kemarahan, perasaan bersalah dan harga diri yang rendah. aaron t. beck pada tahun 1960an juga menemukan bahwa kognisi klien memiliki dampak yang luar biasa terhadap perasaan dan perilakunya. beck menyatakan bahwa kesulitan emosional dan perilaku yang dialami seseorang dalam hidupnya disebabkan oleh cara mereka menginterpretasikan berbagai peristiwa yang dialami. sehingga terapi musik dan recbt berdampak pada relaksasi, mengubah keyakinan irasional, pikiran negatif dan perilaku negatif pada klien perilaku kekerasan. h a s i l p e n e l i t i a n m e n u n j u k k a n kemampuan mengontrol perilaku kekerasan pada kelompok intervensi yang mendapat terapi musik dan recbt sebesar 74,15% sedangkan pengaruh tindakan keperawatan sesuai dengan sak rumah sakit dalam men i ng kat ka n kema mpu a n mengont rol perilaku kekerasan pada kelompok kontrol sebesar 10,32%. kemampuan klien dalam me ngont r ol p e r i la k u keke r a s a n p a d a kelompok yang diberikan terapi musik dan recbt lebih tinggi dibandingkan dengan kelompok kontrol. kemampuan klien dalam relaksasi dilakukan selama sesi berlangsung sedangkan kemampuan mengubah pikiran negatif, keyakinan irasional, dan perilaku negatif selama proses pelaksanaan terapi selalu dimotivasi untuk melakukan latihan secara mandiri yang menjadi tugas rumah (home work) yang dievaluasi secara terus menerus dengan menggunakan jadwal kegiatan harian dan buku kerja. latihan merupakan hal yang sangat penting dalam proses pembelajaran. latihan adalah penyempur naan potensi tenaga-tenaga yang ada dengan mengulangulang aktivitas tertentu. latihan merupakan kegiatan yang nantinya diharapkan menjadi su at u p e mbia sa a n at au p e mbud aya a n ( notoatmojo, 2003). pembudayaan akan membuat klien menjadi mandiri ketika menghadapi kejadian atau peristiwa yang tidak menyenangkan termasuk kejadian yang dapat mencetuskan perilaku kekerasan. buku kerja yang diberikan kepada klien dapat berguna untuk mengevaluasi kemampuan klien dalam mengatasi masalahnya. pada kemampuan relaksasi, klien mampu relaks ketika mendengarkan musik yang sudah disiapkan oleh peneliti dan mampu menceritakan mengenai apa yang dirasakan setelah mendengarkan musik, dampak pada fisiologis, kognitif, emosi, perilaku dan sosial. musik berpengaruh pada impuls yang berada di otak dan dapat meningkatkan status relaks pada klien (chlan, 2011). diketahui bahwa aktif itas mental dan emosi dipengar uhi oleh sistem syaraf autonom, sistem syaraf autonom berdampak pada kardiovaskuler, neuroendokrin dan sistem imun. imunosupresi memengaruhi emosi yang negatif seperti kemarahan. musi k dapat memengar u hi mood dan status emosional seseorang, di mana akan terjadi perubahan pada sistem imun dan hormonal. pada kondisi relaks terjadi penurunan tekanan darah, nadi, dan ketegangan otot. tanda tanda kenaikan tekanan darah, nadi, dan ketegangan otot merupakan tanda gejala fisiologis pada klien perilaku kekerasan (chanda & levitin, 2013). kondisi relaks dapat meningkatkan kenyamanan pada seseorang. pada kemampuan mengubah keyakinan irasional, klien mencatat kejadian yang tidak menyenangkan dan perasaan yang muncul dari kejadian tersebut, keyakinan yang tidak rasional akan membawa individu pada emosi dan perilaku negatif yang tidak sehat seperti perilaku amuk (agresif ) dan rasa bersalah (jensen, 2010). dari hasil penelitian menunjukkan kemampuan yang dimiliki oleh klien dalam mengubah keyakinan irasional dapat menurunkan tingkat perasaan klien. pada kemampuan meng ubah keyakinan 239 tanda gejala dan kemampuan mengontrol perilaku kekerasan (heri setiawan, dkk.) irasional diawali dengan menuliskan peristiwa yang tidak menyenangkan dan perasaan yang muncul. terdapat satu klien menolak untuk menuliskan mengenai peristiwa yang tidak menyenangkan dan terjadi perubahan emosi pada klien. kemampuan klien dalam mengubah keyakinan irasional menggunakan prinsip abc, a-activating event: persepsi individu dan membuat kesimpulan dari peristiwa yang berdampak pada individu. b-beliefs: keyakinan rasional dan irasional pada individu yang yang menunjang pada peristiwa yang aktif, cconsequence, emotional and behavior consequence, konsekuensi emosi dan perilaku yang diakibatkan oleh peristiwa yang terjadi (ellis, 2000). kemampuan mengubah pikiran negatif, tindakan keperawatan untuk meningkatkan kemampuan berfokus pada masalah klien, berorientasi pada tujuan dan aktual saat ini. fokus dari tindakan untuk memberikan kemampuan berpikir adalah pendidikan dan membangun keterampilan klien. hubungan yang terapeutik klien dan perawat sangat penting untuk meningkatkan efektivitas dari tindakan keperawatan yang dilakukan (stuart, 2013). klien menuliskan pikiran otomatis negatif yang muncul. klien juga menuliskan latihan mengubah pikiran dan perilaku negatif menjadi pikiran dan perilaku positif. latihan mandiri yang dilakukan oleh klien dan dit uliskan dalam bu k u ker ja akan men i ng kat ka n kema mpu a n mengont rol perilaku kekerasan. dengan mengubah status pikiran dan perasaannya, klien diharapkan dapat mengubah perilaku negatif menjadi positif (oemarjoedi, 2003). buk u kerja dijadikan sebagai alat untuk melatih klien dalam kemampuan mengubah pikiran negatif klien menjadi sebuah pembudayaan atau kebiasaan. kemampuan yang keempat adalah kemampuan dalam mengubah perilaku negatif, banyak perilaku yang digunakan sebagai koping pada saat muncul perasaan atau pikiran yang negatif yang membuat individu merasa lebih baik dalam waktu jangka pendek (stuart, 2013). perilaku yang ditunjukan seringkali sesuai dengan pikiran negatif yang muncul atau perasaan negatif yang muncul, sehingga muncul perilaku yang negatif pada individu. dalam meningkatkan kemampuan m e ng u b a h p e r i l a k u n eg a t i f , p e n el it i menerapkan prinsip-prinsip teori perilaku dengan memberikan penguatan (reinforcement) posit if terhad ap per ila k u posit if yang dilakukan klien dan memberikan umpan balik negatif terhadap perilaku yang tidak diinginkan. videbeck (2008) menyatakan modifikasi perilaku merupakan suatu metode yang dapat digunakan untuk menguatkan per ilak u atau respons yang diingin kan melalui pemberian umpan balik baik positif maupun negatif. peneliti juga menerapkan prinsip tocen economy berupa memberikan hadiah sesuai dengan keinginan klien, jika perilaku yang diinginkan dilakukan oleh klien setelah mengumpulkan minimal 50% poin bintang selama 3 hari. hal tersebut dapat meningkatkan motivasi klien untuk mengubah perilaku yang negatif, dan pada kontrak awal klien dan perawat membuat kesepakatan bahwa reinforcement yang diberikan tidak selamanya didapatkan oleh klien. klien akan tetap mengubah perilaku negatif walaupun sudah tidak diberikan reinforcement. analisis hubungan antara kemampuan mengontrol perilaku kekerasan dengan tanda gejala perilaku kekerasan menunjuk kan bahwa koefisien korelasi antara kemampuan mengontrol perilaku kekerasan dengan tanda gejala perilaku kekerasan adalah – 0,908 uji statistik menggunakan korelasi pearson menghasilkan nilai sebesar 0,003 (p value < 0,05) yang menunjukkan adanya hubungan yang bermakna dan negatif antara kemampuan mengontrol perilaku kekerasan dengan tanda gejala perilaku kekerasan. nilai r menunjukkan negatif artinya semakin tinggi kemampuan maka tanda gejala perilaku kekerasan semakin menurun, dengan keeratan hubungan yang kuat (r > 0,5). hasil penelitian menunjukkan adanya perubahan tanda gejala komposit yang lebih tinggi pada kelompok intervensi yang mendapat terapi musik dan r ecbt dibandingkan dengan kelompok kontrol, di mana rata rata kemampuan dalam mengontrol perilaku 240 jurnal ners vol. 10 no. 2 oktober 2015: 233–241 kekerasan yang dimiliki oleh kelompok yang diberikan terapi musik dan recbt lebih tinggi dibandingkan dengan kelompok yang tidak diberikan terapi musik dan recbt. ketika klien mempunyai kemampuan yang lebih tinggi dalam mengontrol perilaku kekerasan, tanda gejala perilaku kekerasan lebih minimal. terapi musik dan recbt merupakan suatu bentuk psikoterapi. psikoterapi adalah interaksi yang sistemik antara klien dan terapis yang menerapkan prinsip untuk membantu klien ketika mengalami per ubahan pada perilaku, perasaan dan pikiran. teknik yang digunakan pada recbt dengan memberikan homework tujuannya adalah memampukan klien dalam kemampuan mengontrol perilaku kekerasan (st uar t, 2013). dalam proses psikoterapi terdapat proses pembelajaran terhadap keterampilan yang bar u dalam hal ini relaksasi, mengubah pikiran negatif, keyakinan irasional dan perilaku negatif. tujuan dari tindakan terapi musik dan recbt adalah terciptanya perilaku yang baru dalam hal mengontrol perilaku kekerasan. perbedaan pemberian psikofarmaka dan psikoterapi adalah pada psikofarmaka berfokus pada penurunan tanda gejala saja, tanpa memperhatikan mengenai kemampuan yang dimiliki oleh klien ketika muncul stressor yang dihadapi yang mengakibatkan perubahan dalam pikiran, perasaan, perilaku, sosial dan fisiologis. fokus tindakan pada terapi musik dan recbt adalah self control di mana klien membangun sendiri keterampilan dalam mengontrol perilaku kekerasan. respons maladaptif yang muncul disebabkan karena terjadinya perubahan dalam pikiran, perasaan dan perilaku (stuart, 2013). ketika pikiran yang negatif, perasaan yang irasional dan perilaku negatif dapat dikontrol secara mandiri oleh klien maka perilaku kekerasan akan dapat terkontrol dan tidak muncul lagi. simpulan dan saran simpulan terapi musik dan r ecbt efektif men i ng kat ka n kema mpu a n mengont rol perilaku kekerasan (relaksasi, mengubah pikiran negatif, keyakinan irasional dan perilaku negatif) sebesar 73,33%. analisis hubungan antara kemampuan mengontrol perilaku kekerasan dengan tanda gejala perilaku kekerasan menunjukkan bahwa adanya hubungan yang bermakna dan negatif antara kemampuan mengontrol perilaku kekerasan dengan tanda gejala perilaku kekerasan. nilai r menunjukkan negatif artinya semakin tinggi kemampuan maka tanda gejala perilaku kekerasan semakin menurun, dengan keeratan hubungan yang kuat (r > 0,5). saran perawat jiwa di rumah sakit diharapkan selalu memotivasi klien dan mengevaluasi kemampuan-kemampuan yang telah dipelajari dan dimiliki oleh klien sehingga latihan yang diberikan membudaya. apabila terjadi kemunduran pada klien hendaknya perawat ruangan mengkonsultasikan perkembangan kliennya yang telah mendapat terapi spesialis kepada perawat spesialis yang dimiliki rumah sakit. h a si l p e nel it ia n i n i he nd a k nya digunakan sebagai evidence based dalam mengembangkan terapi musik dan recbt baik pada individu maupu n kelompok, sehingga menjadi modalitas terapi keperawatan jiwa yang efektif dalam mengatasi masalah kesehatan jiwa dan meningkatkan derajat kesehatan jiwa. penelitian lebih lanjut perlu dilakukan pada klien dengan perilaku kekerasan dengan cohort untuk melihat pencapaian kemampuan dalam menurunkan gejala dan meningkatkan kemampuan mengontrol perilaku kekerasan (rela k sa si, meng uba h pi k i r a n negat if, keyakinan irasional dan perilaku negatif). 241 tanda gejala dan kemampuan mengontrol perilaku kekerasan (heri setiawan, dkk.) pe r l u n y a d i l a k u k a n p e n e l i t i a n lanjutan yang melihat pengaruh peningkatan kemampuan klien setelah terapi musik dan recbt terhadap penurunan tanda gejala perilaku kekerasan pada klien skizofrenia. perlu dilakukan penelitian mengenai kombinasi psikoterapi individu dengan psikoterapi yang diberikan pada keluarga. kepustakaan ahmed, ao. et al. 2014. cognition and other targets for the treatment of aggression in people with schizophrenia. scimed central. balitbang depkes r.i 2008. hasil riset kesehatan dasar 2007, jakarta: depkes ri. balitbang depkes ri. 2013. hasil riset kesehatan dasar 2013, jakarta: depkes ri. chanda, ml and levitin, dj. 2013. the neurochemistry of music. trends in cognitive sciences april 2013, vol. 17, no. 4. chlan, l, 2011. music helps reduce stress and anxiety. ventilator living assisted journal vol. 25. dunn, b. 2010. psychotherapy and music therapy. reprinted from victory review magazine. ellaine, js, et al, 2005. schizophrenia: etiology and course. a journal annualreviews. org. ellis, a. 2000. rational emotive behavioral approaches to childhood disorders theory, practice and research. springer science+business media, inc. fazel, s, et al. 2009. schizophrenia and violence: systematic review and metaanalysis. plos medicine. fontaine, kareen lee. 2009. mental health nursing 6th edition. new jersey: pearson education, inc. jensen, 2010. evaluating the abc models of rational emotive behaviour therapy theory: an analysis of the relationship between irrational thinking an guilt, thesis of science in psychology. the faculty of department psychology villanova university. united state. proquest llc. lelono, sk, keliat, ba dan besral. 2011. pengaruh cognitif behaviour therapy dan rat ional e mot ive beha vio ur therapy terhadap klien dengan perilaku kekerasan, halusinasi dan isolasi sosial di rumah sakit marzoeki mahdi bogor, tesis tidak dipublikasikan, tahun 2011. mozzler k, et al. 2013. music therapy for p e o p l e w i t h s c h i z o p h r e n i a a n d schizophrenia-like disorders (review). wiley. oemarjoedi, a,k,. 2003. pendekatan cognitive behavioral dalam psikoterapi. jakarta: kreativ media. sulistyowati, keliat, hastono dan susanti. 2011. pengaruh terapi musik terhadap klien perilaku kekerasan di rsjd surakarta. tesis tidak dipublikasikan. fik. ui. swanson, et al., 2006. a national study of violent behavior in persons with schizophrenia. arch gen psychiatry/ vol. 63, may 2006. stuart, gw. 2013. principles and practice of psychiatric nursing. (9th edition). st louis: mosby. videback, sl. 2008. buku saku keperawatan jiwa. egc: jakarta. volavka, j., 2012. violence in schizophrenia and bipolar disorder. psychiat ria danubina, 2013; vol. 25, no. 1, pp. 2 4–33. volavka, j & citrome, l. 2011. pathways to aggression in schizophrenia affect results of treatment. oxford journal. world health organization. 2015. improving health systems and services for mental health (mental health policy and service guidance package), geneva 27, switzerland: who press. ners vol 10 no 2 okt 2015.indd 208 uji validitas dan reliabilitas instrumen penilaian profesional behaviour mahasiswa keperawatan (validity and reliability assessment tool of nursing students professional behavior) fatikhu yatuni asmara* *jurusan keperawatan fakultas kedokteran universitas diponegoro, semarang email: unie_nuzul@yahoo.com abstrak pendahuluan: shieffield peer review assessment (sprat) adalah salah satu instrumen yang digunakan untuk menilai penampilan mahasiswa kedokteran dengan menggunakan metode multi source feedback (msf). penelitian terdahulu menyebutkan bahwa msf dengan sprat sebagai instrumen dapat diterapkan sebagai metode dan instrumen evaluasi untuk menilai professional behaviour (pb) mahasiswa keperawatan di setting klinik dan komunitas, namun membutuhkan modifikasi berupa tambahan item pernyataan. berdasarkan hal tersebut, perlu dilakukan uji validitas dan reliabilitas untuk memastikan tingkat validitas dan reliabilitas instrumen penilaian. metodologi: uji yang dilakukan adalah uji content dan construct untuk validitas, serta uji inter-rater dan item covariance untuk reliabilitas. partisipan yang terlibat terdiri atas 4 orang pembimbing klinik dan 116 orang mahasiswa. hasil: uji content validity menunjukkan perlunya item kedisiplinan dan kejujuran sebagai item no 22 dan 23. uji construct validity menunjukkan 5 dari 23 pernyataan di instrumen penilaian yang tidak valid karena memiliki nilai pearson correlation < 0,3, namun tetap menjadi item pernyataan dengan pertimbangan kepentingan terhadap pb mahasiswa. uji inter-rater dan item covariance reliability menunjukkan berturutturut instrumen reliabel dengan skor 0,460 dan 0,912. diskusi: instrumen penilaian dapat digunakan untuk menilai pb mahasiswa keperawatan karena valid dan reliabel. penelitian lebih lanjut diperlukan untuk mengetahui efektivitas dari form penilaian ini terhadap perbedaan pb mahasiswa keperawatan. kata kunci: validitas, reliabilitas, instrumen penilaian pb ( professional behaviour) abstract introduction: shieffield peer review assessment (sprat) is an instrument to assess medical student’s performance using multi source feedback (msf) method. the previous study stated that msf with sprat is an effective tool assessing professional behaviour (pb) of nursing students both in clinical setting and community setting. however it needs more items to be added. based on that explanation, it needs conducting validity and reliability test to make sure that the tool is valid and reliable. methods: there were two types of validity test used, content validity test and construct validity test as well as reliability test, namely inter-rater reliability test and item covariance test. participants were four clinical instructors and 116 nursing students. results: content validity test showed that two items must be added as part of assessment item, namely diciplines and faithness. furthermore construct validity test showed that five items were not valid since they had pearson correlation score < 0.3. however the items were included as consideration of nursing students’s pb. inter-rater reliability test and item covariance reliability test showed that the tool was reliable with score 0.460 and 0.912 respectively. discussions: the assessment tool can be applied to assess pb of nursing students since it valid and reliable. it needs to investigate the effectiveness of the tool in difference of pb of nursing students. keywords: validity, reliability, assessment tool of pb (professional behaviour) pendahuluan profesionalisme tenaga kesehatan sudah menjadi isu yang dibicarakan sejak lebih dari 25 tahun yang lalu ter masuk rumusan pengertian, capaian kompetensi, dan penilaian profesionalisme (hodges, et al., 2011). tenaga kesehatan seperti dokter dan perawat ditantang untuk memiliki kompetensi profesionalisme seperti komunikasi secara efektif, berorganisasi, bekerja dalam tim, dan profesional yang disebut soft skill. van tartwijk & driessen (2009) menyatakan bahwa di samping memiliki kemampuan klinis seperti memberikan perawatan kepada pasien atau yang disebut dengan hard skill, tenaga kesehatan harus memiliki kemampuan profesional atau yang disebut soft skill. aktivitas profesional yang dilakukan oleh dokter dan perawat sebagai tenaga kesehatan memerlukan kontribusi tiga aspek, yaitu: kognitif, psikomotor, dan soft skill atau profesionalisme atau professional behaviour (pb). ketiga komponen tersebut memiliki bobot yang sama (kuiper and balm, 2001 in 209 uji validitas dan reliabilitas instrumen penilaian (fatikhu yatuni asmara) speth-lemmens, 2009), dan menjadi salah satu kompetensi yang harus dicapai oleh mahasiswa selama proses pembelajaran. lebih lanjut lagi, speth-lemmens (2009) menyatakan bahwa meskipun belum ada definisi yang pasti untuk pb, banyak ahli merujuk pada sikap dan perilaku profesional dan pb dapat disupervisi, diajarkan dan dievaluasi. evaluasi pb mahasiswa khususnya mahasiswa keperawatan perlu dilakukan karena evaluasi tersebut dapat membantu mahasiswa mengidentifikasi aspek negatif (van mook, et al., 2009) sehingga dapat membantu pembimbing dalam memberikan feedback untuk meningkatkan pb mahasiswa (asmara, 2013a). hal ini berdasarkan pada kebutuhan akan tenaga perawat yang memiliki soft skill yang bagus di samping keterampilan memberikan asuhan keperawatan terhadap pasien atau hard skill (van taartwijk & driessen, 2009). multi source feedback (msf) adalah salah satu metode evaluasi yang menggunakan kuesioner dan melibatkan tenaga kesehatan lain serta pasien untuk memberikan feedback (davies & a rcher, 2005). penilai atau evaluator msf meliputi tiga source (sumber), yaitu peer (teman), pasien, dan mahasiswa itu sendiri (self ) (epstein, 2007). selama proses evaluasi, mahasiswa akan mendapatkan feedback dari evaluator, tergantung dari tipe evaluasi. feedback akan diberikan di tengah proses pembelajaran apabila evaluasi termasuk dalam formatif, sedangkan feedback diperoleh mahasiswa di akhir proses pembelajaran apabila evaluasi termasuk dalam sumatif (davis, et al., 2009). penelitian sebelumnya menyebutkan bahwa msf dapat diterapkan dan efektif sebagai metode evaluasi pb mahasiswa keperawatan baik di setting klinik dan komunitas, khususnya di program studi ilmu keperawatan fakultas kedokteran universitas diponegoro (psik fk undip) (asmara, 2013a; asmara, 2013b). alasan yang menyebutkan msf efektif adalah pelibatan berbagai sumber yang berinteraksi dengan mahasiswa seperti: pembimbing, kolega yait u perawat non pembimbing, mahasiswa non keperawatan, self and peer assessment. hal ini didukung oleh pernyataan dari lynch, et.al (2004) di dalam hodges, et al (2011) bahwa evaluasi pb menjadi lebih baik apabila melibatkan banyak evaluator seperti msf, cognitive assessment, dan kuesioner pada pasien. selama implementasi msf di psik fk undip, shieffield peer review assessment (sprat) digunakan sebagai form penilaian. form ini berisi 24 pertanyaan yang diturunkan dari good medical practice (gmp) yang meliputi tiga ranah aktivitas profesional yaitu kognitif, psikomotor, dan afektif atau pb. delapan pertanyaan meliputi kognitif dan psikomotor (pertanyaan no. 1, 2, 3, 6, 7, 8, 9, dan 10) sedangkan 16 pertanyaan lainnya tentang afektif atau pb (archer, 2008). namun sprat yang digunakan mengalami modifikasi berupa penambahan komponen penilaian seperti komponen berpikir kritis, menghargai kelebihan, caring, penampilan mahasiswa, dan kesopanan. komponen yang ditambahkan merupakan masukan dari responden dari penelitian sebelumnya dan disesuaikan dengan budaya indonesia, seperti kesopanan (asmara, 2013a). uji validitas dan reliabilitas diperlukan untuk memastikan apakah instrumen penilaian dapat digunakan, artinya instrumen tersebut mampu mengukur apa yang seharusnya diukur dan konsisten (dharma, 2011). uji validitas dilaksanakan untuk melihat kesesuaian, ketepatan suatu alat untuk menilai sesuatu (fraen kel & wallen, 2010), sedangkan reliabilit as su at u alat ditent u kan oleh konsistensi suatu alat untuk menilai sesuatu (fraenkel & wallen, 2010). selanjutnya, penelitian ini penting dilak u kan unt u k mengetahui tingkat validitas dan reliabilitas hasil modif ikasi for m penilaian spr at sebelum digunakan secara luas untuk menilai pb mahasiswa keperawatan. tujuan penelitian ini adalah untuk mengidentifikasi validitas dan reliabilitas instrumen penilaian pb pada mahasiswa keperawatan yang kemudian dijabarkan menjadi beberapa t ujuan k husus, yait u mengidentifikasi content validity instrumen penilaian, mengidentifikasi construct validity instrumen penilaian, mengidentifikasi interrater reliability instrumen penilaian, dan 210 jurnal ners vol. 10 no. 2 oktober 2015: 208–216 mengidentifikasi item covariance reliability instrumen penilaian. bahan dan metode penelitian ini berfokus pada identifikasi validitas dan reliabilitas instrumen penilaian pb m a h a si s wa ke p e r awat a n b e r ba si s pembelajaran klinik dan komunitas berupa modifikasi sprat. penelitian ini dilakukan dalam 4 tahap, yaitu 2 tahap uji validitas dan 2 tahap uji reliabilitas. tahap i per tama instr umen penilaian diuji validitasisi (content validity) dengan meminta ahli untuk mengevaluasi konten instrumen. dua orang perawat ahli dilibatkan dalam uji ini yaitu perawat yang memahami pb yang harus dimiliki oleh mahasiswa keperawatan. tidak ada batasan jumlah pakar yang dapat terlibat dalam uji content validity, yang pasti ada pembanding antar feedback yang diberikan (dharma, 2011). pada tahap ini, para ahli diminta untuk memberikan tanggapan atau masukan terhadap item pernyataan pada instrumen penilaian pb dengan memilih apakah masing-masing pernyataan relevan tanpa perbaikan, relevan dengan perbaikan, dan tidak relevan. ahli pertama menyatakan bahwa semua pernyataan, 21 per nyataan relevan. masukan unt uk pernyataan no 14 “mudah untuk dihubungi” perlu diper jelas apa kait an nya dengan perilaku profesional apabila deskripsinya adalah mahasiswa berada di tempat sesuai dengan jadwal dinas. begitu juga dengan ahli kedua yang menyatakan bahwa semua item pernyataan relevan, namun perlu ditambahkan item penilaian kejujuran dan kedisiplinan. tahap ii tahap selanjutnya adalah melakukan uji construct validity. pada tahap ini, instrumen penilaian yang sudah melalui uji content validity, dapat diujicobakan pada kelompok partisipan, yaitu mahasiswa keperawatan dan pembimbing. selanjutnya hasil uji construct validity akan dianalisis untuk dilihat tingkat validitasnya. subjek yang terlibat sebagai partisipan adalah 64 mahasiswa pada uji contruct validity i dan 54 mahasiswa pada uji construct validity ii, serta 2 orang pembimbing klinik yang dipilih secara acak dari populasi. pemilihan i n i d ipil i h k a rena d apat membe r i k a n kesempatan yang sama bagi setiap partisipan yang memenuhi kriteria untuk terlibat dalam penelitian (fraenkel & wallen, 2010). data yang diperoleh dianalisis dengan pearson product momen karena metode ini digunakan untuk menghubungkan skor setiap item pernyataan dengan skor total (dharma, 2011). nunnaly (1994) dalam dharma (2011) menyatakan bahwa hubungan antara skor item dengan skor total (item-total correlation) yang baik adalah lebih atau sama dengan 0,3 (r ≥ 0,3). berdasarkan hasil analisa ada 15 pernyataan yang memiliki skor pearson correlation ≤ 0,3 artinya ada 15 pernyataan yang tidak valid sehingga dilanjutkan dengan uji contruct validity ii. hasil analisa menyebutkan bahwa hanya 5 pernyataan yang tidak valid yaitu pernyataan no 3, 5, 7, 16, dan 17. tahap iii tahap ketiga adalah uji reliabilitas i, yaitu uji inter-rater reliability. terdapat dua tipe pada uji ini, yaitu tipe yang pertama adalah bertujuan untuk melihat konsistensi skor yang diberikan oleh dua atau lebih penilai terhadap penampilan atau hasil kerja mahasiswa, dan tipe kedua bertujuan untuk melihat konsistensi seorang penilai dalam memberikan nilai terhadap pekerjaan mahasiswa yang sama tetapi dalam waktu yang berbeda (mcaleer, 2009). dalam penelitian ini, tipe pertama yang digunakan, yaitu untuk melihat konsistensi dua penilai atau lebih terhadap pb mahasiswa. pada tahap ini, 2 orang pembimbing diminta untuk menilai pb satu orang mahasiswa kemudian hasilnya akan dihubungkan antara 1 pembimbing dengan pembimbing yang lain. dharma (2011) mengatakan bahwa penilaian terhadap persetujuan/kesamaan antara 2 orang penilai atau lebih terhadap suatu pengukuran disebut inter-rater reliability. selanjutnya korelasi antar 2 nilai atau lebih dapat dianalisis menggunakan pearson product momen. sama halnya dengan uji construct validity, nilai antar 211 uji validitas dan reliabilitas instrumen penilaian (fatikhu yatuni asmara) 2 pembimbing dikorelasikan dan dianalisa. hasil uji menunjukkan bahwa skor pearson correlation adalah 0.460 atau ≥ 0,3, sehingga instrument ini disebut sebagai intrumen yang reliabel. tahap iv tahap selanjutnya adalah reliabilitas tahap 2 berupa uji reliabilitas menggunakan item covariance, yaitu penggunaan instrumen pada mahasiswa untuk menilai dirinya sendiri (self assessment) dan kemudian dianalisis. tahap ini melibatkan 26 orang mahasiswa yang diminta untuk menilai pb dirinya sendiri menggunakan form penilaian. hasil penilaian ini akan dianalisis menggunakan cronbach alpha karena lebih sesuai untuk mengukur reliabilitas instrumen penilaian dengan skala likert. anastasi dan urbina (1997) dalam dharma (2011) mengatakan bahwa koefisien reliabilitas instrumen penilaian yang dapat diter ima adalah 0,8 ar tinya inst r u men penilaian bersifat reliabel apabila koefisien cronbach alpha lebih dari atau sama dengan 0,8. hasil analisa menunju k kan bahwa koefisien cronbach’s alpha adalah 0,912 atau ≥ 0,8 artinya instrument ini reliabel. hasil ada 23 pernyataan yang digunakan untuk menilai pb mahasiswa keperawatan. pernyataan no 22 dan 23 adalah tambahan pernyataan berdasarkan hasil uji content validit y (tahap i). berdasarkan hasil uji const r uct validit y i (t ahap 2), ada 15 pernyataan tidak valid yaitu pernyataan no 2, 3, 4, 5, 6, 7, 9, 10, 11, 13, 14, 16, 17, 20, dan 23. setelah dilakukan perbaikan dalam redaksi deskripsi dan rumusan pernyataan, dilakukan uji construct validity ii (tahap 2) dengan hasil 18 pernyataan valid dan 5 pernyataan tidak valid yaitu pernyataan no 3, 5, 7, 16, dan 17. tabel 2 dan 3 menunjukkan hasil skor pearson correlation pada uji construct validity. analisa dilanjutkan dengan tahap 3 yait u uji inter-rater reliabilit y yait u membandingkan nilai yang diberikan 2 orang pembimbing klinik pada 7 mahasiswa. hasil analisa disajikan dalam tabel 4 berikut ini. tabel 4 menunjukkan bahwa hasil skor pearson correlation adalah 0.460 atau lebih besar dari 0.3, artinya instrumen penilaian reliabel. selanjutnya, tabel 5 menunjukkan analisa tahap terakhir atau tahap 4, yaitu uji item covariance dengan menggunakan cronbach’s alpha untuk menganalisis hasil self assessment pada 23 responden. pembahasan uji validitas uji validitas dilakukan dua kali yaitu uji validitas i dan ii. hal ini disebabkan karena hasil uji validitas i kurang memuaskan, yaitu 15 dari 23 pernyataan tidak valid. sebelum diulang, deskripsi masing-masing pernyataan diperinci sehingga menjadi lebih jelas bagi responden. menurut fraenkel & wallen (2010), uji validitas dapat diulang apabila hasil uji validitas tidak sesuai dengan yang diharapkan. berdasarkan hasil uji validitas 2, ada 5 pernyataan yang tidak valid, yaitu pernyataan nomor 3 (kemampuan untuk manajemen waktu atau kemampuan memprioritaskan), nomor 5 (komitmen untuk belajar), nomor 7 (kemampuan untuk memberikan feedback: jujur, secara pribadi, dan membangun), nomor 16 (kemampuan untuk mengatur sesuatu/ manajemen), dan nomor 17 (berpikir kritis). kemampuan untuk manajemen waktu/ memprioritaskan (no. 3) dan kemampuan untuk mengatur sesuatu/manajemen (no. 16). apabila dilihat dari rumusan pernyataan, 2 kalimat ini memiliki makna yang sama yaitu kemampuan mengatur sesuatu namun berbeda dalam deskripsi, yaitu manajemen intrapersonal dan interpersonal. kemampuan manajemen yang sering dipraktekkan oleh mahasiswa dalam proses pembelajaran klinik adalah belajar dalam kelompok. rudland (2009) menyebutkan ada 4 tahap pembentukan kelompok, yaitu forming. storming, norming, dan performing. forming, atau pembentukan adalah waktu di saat beberapa individu berusaha memantapkan dirinya dalam kelompok. pada fase ini anggota kelompok sering berganti dan kekuatan serta kelemahan anggota kelompok akan teridentifikasi. 212 jurnal ners vol. 10 no. 2 oktober 2015: 208–216 tabel 1. daftar pernyataan penilaian pb no pernyataan deskripsi 1. kesadaran mahasiswa terhadap keterbatasan diri kemampuan mahasiswa untuk menyadari kekurangan dan keterbatasan yang perlu dikembangkan. 2. kemampuan untuk merespons a s p e k p s i k o s o s i a l p e n y a k i t pasien kemampuan mahasiswa untuk mengkaji, menentukan diagnosa, merencanakan intervensi, mengimplementasi dan mengevaluasi aspek psikososial penyakit pasien. 3. kemampuan untuk manajemen waktu/memprioritaskan kemampuan mahasiswa untuk mengatur waktu dan memprioritaskan tindakan terkait dengan diri sendiri. 4. kemampuan untuk bisa mengatasi stress kemampuan mahasiswa dalam mengidentifi kasi dan mengatasi stres atau masalah. 5. komitmen untuk belajar kemampuan mahasiswa untuk berkomitmen dalam belajar 6. keinginan dan keefektifitasan dalam belajar bersama kolega atau peer kemampuan mahasiswa untuk mengidentifi kasi kebutuhan belajar dalam kelompok. kemampuan mahasiswa belajar dalam kelompok dan kemampuan untuk mengambil manfaat belajar dalam kelompok. 7. kemampuan dalam memberikan feedback: jujur, secara pribadi, membangun kemampuan mahasiswa memberikan feedback yang membangun bukan mencela. 8. komunikasi dengan pasien kemampuan mahasiswa untuk berkomunikasi asertif dan terapeutik terhadap pasien. 9. komunikasi dengan keluarga pasien kemampuan mahasiswa untuk berkomunikasi asertif dan terapeutik terhadap keluarga pasien. 10. menghormati pasien dan hak rahasia mereka kemampuan mahasiswa untuk menyimpan rahasia terkait informasi pasien dan hanya menggunakan informasi tersebut untuk hal yang terkait perawatan pasien. 11. k o m u n i k a s i v e r b a l d e n g a n kolega kemampuan mahasiswa untuk menyampaikan hal/sesuatu secara verbal terhadap kolega, contoh: operan 12. k o m u n i k a s i t e r t u l i s d e n g a n kolega kemampuan mahasiswa untuk menyampaikan hal/sesuatu secara tertulis terhadap kolega, contoh: dokumentasi askep, rujukan 13. menyadari nilai dan distribusi nilai-nilai kemanusiaan antar sesama terutama pasien kemampuan mahasiswa untuk mengidentifi kasi dan menghormati nilai/value/keyakinan yang dimiliki pasien. 14. mudah untuk dihubungi mahasiswa berada di tempat sesuai dengan jadwal dinas, memiliki alat komunikasi (telepon, email) untuk komunikasi tidak langsung. 15. kemampuan menjadi pemimpin kemampuan mahasiswa untuk mengorganisasi kelompok, pernah menjadi pemimpin dalam kelompok. 16. kemampuan untuk mengatur sesuatu (manajemen) kemampuan mahasiswa untuk mengatur sesuatu di luar diri sendiri. 17. berpikir kritis kemampuan mahasiswa untuk menyelesaikan masalah secara ilmiah. 18. penampilan mahasiswa penampilan mahasiswa rapi, bersih, menarik, seragam sesuai aturan. 19. kesopanan mahasiswa menunjukkan sikap sopan, menghargai orang yang lebih tua, senang menyapa. 20. menghargai kelebihan kemampuan mahasiswa mengidentifi kasi dan menghargai kelebihan diri dan orang lain. 21. caring terhadap pasien, peer, dan kolega kemampuan mahasiswa bersikap caring dan peduli terhadap pasien, peer, dan kolega, ada saat di samping pasien secara fi sik dan jiwa. 22. kedisiplinan mahasiswa dating dan pulang dinas tidak terlambat, mematuhi jadwal dan mengumpulkan laporan sesuai waktu dan 23. kejujuran mahasiswa berkata benar, tidak berbohong dengan alasan apa pun, termasuk mampu menjaga kerahasiaan pasien 213 uji validitas dan reliabilitas instrumen penilaian (fatikhu yatuni asmara) tabel 2. hasil uji construct validity i (n = 64) pernyataan q 1 q 2 q 3 q 4 q 5 q 6 q 7 q 8 pearson correlation 0.394 0.287 0.295 0.282 0.294 0.250 0.275 0.322 pernyataan q 9 q 10 q 11 q 12 q 13 q 14 q 15 q 16 pearson correlation 0.274 0.252 0.245 0.340 0.269 0.252 0.300 0.276 pernyataan q 17 q 18 q 19 q 20 q 21 q 22 q 23 pearson correlation 0.219 0.324 0.350 0.291 0.318 0.306 0.254 tabel 3. hasil uji construct validity ii (n = 54) pernyataan q 1 q 2 q 3 q 4 q 5 q 6 q 7 q 8 pearson correlation 0.419 0.340 0.288 0.334 0.243 0.303 0.256 0.368 pernyataan q 9 q 10 q 11 q 12 q 13 q 14 q 15 q 16 pearson correlation 0.375 0.376 0.317 0.334 0.337 0.324 0.300 0.272 pernyataan q 17 q 18 q 19 q 20 q 21 q 22 q 23 pearson correlation 0.281 0.381 0.386 0.358 0.337 0.306 0.309 tabel 4. hasil uji inter-rater reliability (n = 7) evaluator 1 evaluator 2 evaluator 1 pearson corr. 1 0,460 evaluator 2 pearson corr. 0,460 1 tabel 5. hasil uji item covariance (n = 23) cronbachs’ alpha n 0.912 23 fase kedua adalah storming yaitu fase yang dikarakteristikkan dengan konf lik, ketidakpuasan, dan kompetisi, namun rasa kepercayaan bias terbentuk dalam fase ini. fase ketiga adalah norming, yaitu fase dimana kelompok mulai mengembangkan identitas kelompok dan rasa memiliki. fungsi kelompok mulai efektif dan mulai menyusun aturan perilaku dalam kelompok. fase terakhir adalah performing yang berfokus pada tugas dan kesadaran anggota kelompok terhadap tugas dan peran masing-masing. s e b elu m m e mb e nt u k kelom p ok , i nd iv id u h a r u s me m i l i k i m a n aje me n intrapersonal yang mampu mengenali tujuan individu yang ingin dicapai, persiapan materi terhadap isu atau topik yang akan dibicarakan, dan kemampuan untuk berkontribusi dalam kelompok (rudland, 2009). berdasarkan hal tersebut, manajemen i nt rapersonal d an i nter personal bu kan bagian yang terpisahkan. pernyataan tentang manajemen ini diperlukan sebagai pernyataan dalam form penilaian pb karena kemampuan manajemen penting bagi mahasiswa yang mengikuti pembelajaran klinik. komitmen untuk belajar me nu r ut ha rde n (20 09), prose s pembelajaran terdiri dari dua yaitu formal dan informal. seperti fenomena gunung es, pembelajaran informal mengambil porsi yang lebih besar dibanding pembelajaran formal. komitmen diperlukan oleh mahasiswa untuk terlibat dalam proses pembelajaran baik formal maupun informal. ada beberapa hal yang memengaruhi komitmen mahasiswa dalam belajar mandiri sebagai bagian dari pembelajaran informal, yaitu konten atau isi, 214 jurnal ners vol. 10 no. 2 oktober 2015: 208–216 ritme belajar, waktu, media, strategi belajar, dan tempat belajar (harden, 2009). apabila salah satu faktor yang memengaruhi tersebut tidak terpenuhi atau tersedia, maka komitmen untuk belajar sulit untuk ditegakkan. pernyataan tentang komitmen untuk belajar tidak valid dengan salah satu alasan yang mendasari adalah belum terbiasanya mahasiswa dengan belajar mandiri. beberapa mahasiswa menyampaikan bahwa waktu yang membatasi kesempatan untuk belajar mandiri. namun karena komitmen untuk belajar penting untuk dievaluasi sebagai bagian dari pb maka pernyataan ini tetap dimasukkan dalam form penilaian. selain itu, dengan adanya komponen evaluasi tersebut dapat memicu mahasiswa untuk dapat berkomitmen dalam belajar mandiri. kemampuan dalam memberikan feedback: jujur, secara pribadi, dan membangun. f e e d b a c k d a p a t m e m b e r i k a n keuntungan, baik untuk mahasiswa, dosen dan program. sebagai contoh: mahasiswa akan menerima masukan untuk penampilan yang kurang dan mendapatkan pujian bagi pencapaian yang bagus sehingga mahasiswa mampu menyusun strategi untuk meningkatkan pe ncapaia n. me nu r ut k r a ckov (20 09) memberikan feedback bukan hal yang mudah. ada beberapa hal yang dapat menghambat dalam pemberian feedback, yaitu waktu dan tempat, pemahaman dan kemampuan dosen dan mahasiswa dalam pemberian feedback, perbedaan persepsi tentang feedback seperti anggapan bahwa feedback adalah k ritik yang menyalahkan, dan budaya pemberian feedback. hambatan inilah yang membuat dosen dan mahasiswa tidak terbiasa memberikan feedback karena sebagian besar feedback hanya berasal dari dosen bukan dari teman ( peer) atau dari diri sendiri (self ) (asmara, 2013). feedback menjadi lebih berar ti apabila diberikan secara positif. ciri-ciri feedback yang positif adalah mendengarkan aktif, disampaikan dalam hubungan yang menguntungkan, spesifik, keinginan untuk menolong bukan menghakimi, serta waktu yang tepat dan cukup (krackov, 2009). memberikan feedback har us mulai dibiasakan pada mahasiswa terutama self and peer feedback sehingga per nyataan kemampuan memberikan feedback tetap menjadi bagian dari item penilaian dalam form penilaian pb mahasiswa keperawatan. selain itu memberikan feedback juga dapat melatih kemampuan komunikasi asertif mahasiswa yang merupakan bagian dari kemampuan profesional. berpikir kritis berpikir kritis dapat dicapai melalui ref leksi yang meliputi belajar mandiri, kolaborasi, dan interaksi dalam tim (lachman & pawlina, 2009), sedangkan menurut rudland (2009) ber pikir k ritis adalah asimilasi, inter pretasi, dan sintesis informasi yang diperoleh. berpikir kritis dapat terstimulasi pada saat mahasiswa belajar dalam kelompok seperti halnya pada saat mahasiswa mengikuti pembelajaran klinik. pada saat mahasiswa mengimplementasikan proses keperawatan, mulai dari pengkajian, penyusunan diagnosa keperawatan, merencanakan inter vensi, mengimplementasikan intervensi keperawatan, mengevaluasi implementasi yang sudah dilaksanakan, dan mendok u mentasikan proses keperawatan merupakan bagian dari berpikir kritis (pullen jr, 2005). semakin sering mahasiswa mengaplikasikan proses keperawatan maka kemampuan ber pikir kritis semakin terasah. sehingga walaupun pernyataan berpikir kritis pada form penilaian tidak valid dalam uji validitas, pernyataan ini tetap menjadi salah satu item penilaian pb mahasiswa. uji reliabilitas dua tahap uji reliabilitas menunjukkan hasil yang signifikan, yaitu 0,460 untuk inter-reater reliability dan 0,912 untuk item covariance reliability. hal ini memperlihatkan bahwa form penilaian pb reliabel dan dapat digunakan sebagai form penilaian. reliabilitas suatu form penilaian adalah konsistensi suatu skor yang diperoleh yaitu skor yang diperoleh seorang mahasiswa sama walaupun mahasiswa dinilai oleh dua atau lebih penilai dan skor 215 uji validitas dan reliabilitas instrumen penilaian (fatikhu yatuni asmara) yang sama saat mahasiswa tersebut dinilai pada waktu yang berbeda (fraenkel & wallen, 2010). simpulan dan saran simpulan uji validitas dan reliabilitas perlu dilakukan untuk memastikan suatu form penilaian secara valid untuk menilai suatu penampilan serta dapat digunakan dari waktu ke waktu. hasil uji validitas dan reliabilitas menunjuk kan bahwa for m penilaian pb mahasiswa keperawatan valid dan reliabel sebagai instrumen penilaian sehingga dapat digunakan secara luas. saran u n t u k m e m a s t i k a n e f e k t i v i t a s penggunaan instrumen penilaian terhadap pb mahasiswa, perlu dilakukan penelitian lanjutan tentang evaluasi aplikasi for m pen ilaia n pb ma hasiswa terhad ap pb mahasiswa keperawatan. selain itu perlu dilakukan uji beda pb sebelum dan sesudah dilakukan penilaian dengan form penilaian pb. sebelum dilakukan penelitian lanjutan, sosialisasi tentang penggunaan form penilaian pb harus dilakukan agar setiap mahasiswa, dosen dan institusi penyelenggara pendidikan keperawatan dapat memperoleh manfaat dari hasil penelitian ini. kepustakaan archer, j., 2008. the educational impact of the sheffi eld peer review assessment i n s t r u m e n t ( s p r at ) . t h e s i s dissertation. asmara, f.y., 2013a. the implementation of multi source feedback (msf) to assess professional behaviour (pb) of nursing students in clinical setting. [unpublished master thesis]. mastricht: maastricht university, the netherland. asmara, f.y., 2013b. implementasi multi s o u r c e fe e d b a c k ( m sf ) u nt u k mengevaluasi professional behaviour (pb) mahasiswa keperawatan berbasis k e p e r a w a t a n ko m u n i t a s . ti d a k dipublikasikan. semarang: universitas diponegoro. davies, h. & archer, j., 2005. multi source feedback: development and practical aspects. the clinical teacher 2 (2): 77–81. davis, m.h., ponamperuma, g.g. & wall, d., 2009. workplace-based assessment. in: dent, j.a & harden, r.m. (eds). a practical guide for medical teachers. edinburgh: elsevier limited. dharma, k.k., 2011. metodologi penelitian keperawatan: panduan melaksanakan dan menerapkan hasil penelitian. jakarta: trans info media. epstein, r.m., 2007. assessment in medical education. n engl j med, 356(4): 387–396. fraenkel, j.r. & wallen, n.e., 2010. how to design and evaluate research in education. 7th edition. new york: mcgraw-hill companies. harden, r.m., 2009. independent learning. in a practical guide for medical teacher. philadelphia: churchill livingstone. hodges, b.d., ginsburg, s., cr uess, r., delport, r., hafferty, f., ho, m.-j., holmboe, e., holtman, m., ohbu, s., rees, c., ten cate, o., tsugawa, y., van mook, w., wass, v., wilkinson, t. & wade, w., 2011. assessment of professionalism: recommendations from the ottawa 2010 conference. medical teacher. 33, 354–363. krackov, s.k., 2009. giving feedback. in a practical guide for medical teacher. philadelphia: churchill livingstone. lachman, n. & pawlina, w. 2009. basic science and curriculum outcomes. in a practical guide for medical teacher. philadelphia: churchill livingstone. mca le e r, 20 09. choosi ng a sse ssme nt inst r u ment. in a practical g uide for medical teachers. philadelphia: churchill livingstone. pullen jr, r.l., 2005. applying nursing process: a tool for critical thinking. nurse educator, 30 (6), 238–239. rudland, j.r., 2009. learning in small groups. in a practical guide for medical teacher. philadelphia: churchill livingstone. 216 jurnal ners vol. 10 no. 2 oktober 2015: 208–216 sp e t h -l e m me n s , i., 20 07. a s s e s si ng professional behaviour of students in preclinical and clinical setting [unpublished master thesis]. maastricht: un i ve r s i t y of m a a s t r i c h t , t h e netherlands. van mook, w.n.k.a., gorter, s.l., van luijk, s.j., o’sullivan, h., wass, v., schuwirth, l. w., van der vleuten, c. p. m., 2009. approaches to professional behaviour assessment: tools in the professionalism tool box. european journal of internal medicine, 20, e153– e157. van tartwijk, j. van & driessen, e.w. 2009. portfolios for assessment and learning: amee guide no. 45 medical teacher. 31, 790–801. http://e-journal.unair.ac.id/jners | 79 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.18291 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research hypnotherapy and yoga combination decrease the anxiety of patients in elective preoperative basir basir1, sidik awaludin2, and arif imam hidayat2 1student of school of nursing, faculty of health sciences, jendral soedirman university, purwokerto, indonesia 2lecturer of school of nursing, faculty of health sciences, jendral soedirman university, purwokerto, indonesia abstract introduction: surgery is an experience that can cause anxiety, which, if not treated well, will cause some side effects. one of the forms of nonpharmacological therapy is hypnotherapy and yoga combination therapy. this study aimed to determine the effect of hypnotherapy and yoga combination therapy on anxiety scores in elective preoperative patients. methods: this study used a quasi-experimental pretest and posttest with control group design. this study involved 17 respondents in the intervention group and 17 respondents in the control group. the sampling technique used consecutive sampling. data collection used the instruments of the amsterdam preoperative anxiety and information scale (apais). the statistical test used was the mannwhitney test. results: the average age of respondents was 36.65 years old. in a majority, they were junior high school graduates who worked as employee. the major type of operation was tumor excision. the average anxiety scores before treatment in the intervention group were 14.71 (moderate anxiety) and decreased after being given hypnotherapy and yoga combination therapy to 9.47 (mild anxiety). the average anxiety scores before treatment in the control group were 15.71 (moderate anxiety) and decreased after deep breathing therapy to 13.76 (moderate anxiety). the difference test in anxiety scores of the intervention and control groups obtained p-value 0.015. conclusion: hypnotherapy and yoga combination therapy can reduce anxiety scores in elective preoperative patients. article history received: march 18, 2020 accepted: may 8, 2020 keywords anxiety; deep breathing; hypnotherapy; preoperative; yoga contact basir basir  basirigd118@gmail.com  faculty of health sciences, jendral soedirman university, purwokerto, indonesia cite this as: basir, b., awaludin, s., & hidayat, a. i. (2020). hypnotherapy and yoga combination decrease the anxiety of patients in elective preoperative. jurnal ners, 15(1). 79-84. doi:http://dx.doi.org/10.20473/jn.v15i1.18291 introduction surgery is all medical treatments that use invasive methods by opening or displaying parts of the body to be treated (sjamsuhidajat & jong, 2010). the surgery phase consists of pre, intra and post operative. the pre-operative stage is the initial stage of the surgical procedure, including the decision on the operation until the act of operation itself (maryunani, 2014). world health organization (who) data shows a significant increase in the number of patients who are undergoing operations. data in 2011 recorded 140 million patients in all hospitals in the world, while data in 2012 increased to 148 million patients. in 2012, operation treatments were measured in indonesia and recorded 1.2 million patients (hartoyo, 2015). preoperative anxiety impacts physiological and psychological responses. if preoperative anxiety is not handled well, it has some side effects such as sweating and frequent urination, in addition to which the patient will also experience anxiety or tension, changes in hemodynamic status, and it can continue to postoperative which can affect the immune response, causing longer recovery and longer healing in the wound after surgery (gunawan & kristinawati, 2018; pereira, figueiredo-braga & carvalho, 2015). internal and external factors can affect preoperative patient anxiety. internal factors consist of gender, age, level of knowledge, personality type, environment, and situation, while external factors https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ b. basir et al. 80 | pissn: 1858-3598  eissn: 2502-5791 consist of the type of work, family, threats to the selfsystem, and threats to physical integrity (yusuf, fitryasari, & nihayati, 2015). anxiety management is generally managed with pharmacological and non-pharmacological therapy. hawari (2001) described antidepressants and antianxiety medicines (anxiolytic) as pharmacological treatments. the use of antidepressants and antianxiety medicines can help reduce anxiety, but it has negative effects such as drowsiness, breathing difficulty, and affects the recovery duration of operation patients (bradt, dileo, & shim, 2013). nonpharmacological therapies that can help reduce preoperative anxiety are hypnotherapy and yoga. research conducted by lestari and putri (2018) found that the combination of self-hypnosis and yoga exercises was effective in reducing anxiety. hypnotherapy physiologically makes the body relax so that it can increase endorphins, which can reduce anxiety. it also makes the body feel comfortable and calm, while yoga can increase gamma amino butyric acids (gaba) which function to reduce arousal and aggression, anxiety, and are active in the function of excitation (lestari & putri, 2018; yulinda, purwaningsih, & sudarta, 2017). hypnotherapy method is to change the patients’ ways of thinking using relaxation techniques, suggestions, while yoga uses the integration of a series of physical, mental health, mind movements, and is done continuously and regularly (, 2018; cahyadi 2017). hypnotherapy and yoga are therapies that both cause a relaxing effect. when the body relaxes, the endorphins increase, which is beneficial to reduce anxiety and to make the patient feel comfortable and calm. hypnotherapy is expected to retain suggestions that have long-term effects, so that the therapeutic effects of combination hypnotherapy and yoga can maximally handle anxiety. medical record data were from hj. anna lasmanah regional public hospital banjarnegara with 9916 patients treated in poly operation during 2018 and 27% of patients were scheduled elective operations from a poly operation. the results of a preliminary study of 10 elective operation patients showed that 90% of patients expressed anxiety in facing the planned operation. anxious feelings are such as fear of operation and fear of something unexpected happening during operation. anxiety management performed by nurses in preoperative patients was in using deep breathing techniques. from the results of the evaluation, seven patients said they were still anxious after being given deep breathing therapy. as the majority of patients still feel anxiety after deep breathing therapy, there is a need for new therapies that can help reduce anxiety. one of the therapies is a combination therapy of hypnotherapy and yoga which is expected to be more effective in reducing anxiety scores. this research combines hypnotherapy and yoga which are complementary therapies that must be developed in the field of nursing. based on the background phenomena above, it is necessary to study these. this study aimed to determine the effect of the combination of hypnotherapy and yoga on anxiety scores in elective preoperative patients at hj. anna lasmanah regional public hospital banjarnegara. materials and methods the study design used a quasi-experimental pre and posttest control group design. the population of this study was elective preoperative patients at hj. anna lasmanah regional public hospital banjarnegara. the sampling technique was consecutive, which refers to the inclusion and exclusion criteria set by the researcher. inclusion criteria: re elective surgery patients from surgical polyclinic, do not have a hearing problem, ages range from 18 65 years old, have composite consciousness and not experiencing mental disorders, willing to be a respondent, firsttime experience operation, and their last education backgrounds are elementary and junior high school. exclusion criteria: the patient is experiencing a worsening condition and requires immediate surgery, the patient resigns from being a respondent during the research process, and the patient experiences moderate to severe pain during the research process. the sample size was 34 respondents with 17 respondents as the intervention group and 17 respondents as a control group. this study used the amsterdam preoperative anxiety and information scale (apais) instrument, which had been tested for validity and reliability by firdaus (2014) on 102 preoperative respondents with the following results: the validity test of the apais instrument showed the r value for question 1 (0.864), 2 (0.773), 3 (840), 4 (0.868), 5 (829) and 6 (849). question correlation had a good total value of r> 0.7. apais instrument reliability showed consistent internal results (cronbach’s alpha). cronbach's alpha value for anxiety component (questions 1, 2, 4, and 5) obtained 0.825, while cronbach's alpha value for information necessity component (questions 3 and 6) was obtained as 0.863. good cronbach's alpha value ranged from 0.7 to 0.9. researchers conducted an anxiety assessment pretest to respondents using apais questionnaire, the experimental group received a combination of hypnotherapy and yoga therapy one by one, then respondents received therapy for 25 minutes, including yoga for 10 minutes and hypnotherapy for 15 minutes, while, in the first control group, they received deep breathing therapy jurnal ners http://e-journal.unair.ac.id/jners | 81 for five times after the two groups did an anxiety score posttest assessment for respondents using the apais questionnaire. this study received ethical approval from the faculty of health sciences, jenderal soedirman university, number: 242 / ec / kepk / xii / 2019. univariate data analysis was performed on the two research variables and produced data presented in the form of frequency distributions namely gender, education, job, and age using central tendency. bivariate data analysis was performed using the mann-whitney test. the data normality test results obtained data were not normally distributed in the posttest intervention, p = 0.021. homogeneity tests for the pre-groups of both groups using the levine test results obtained p = 0.554, which means data similarity was homogenous. results the distribution of respondents based on the gender of the majority were men (52.9%), the education of the majority of respondents was junior high school education (55.9%), the majority of respondents' jobs were employees (38.2%), the majority of operation types were excision tumor biopsy (29.4%) and the average age of respondents was 36.65 years old. based on the table, there were no differences in the characteristics of respondents (gender, education, job, type of operation, and age) between the intervention and control groups. based on table 1, it can be seen that the p-value is to determine the homogeneity of each respondent's characteristics (table 1). the mean score of anxiety before treatment in the intervention and control groups using the unpaired ttest obtained p = 0.554. anxiety scores in both groups belonged to the moderate anxiety category (13-18). these data indicate there was no statistical difference in the mean score of anxiety scores before treatment in the intervention and control groups (table 2). the anxiety score in the intervention group showed the pretest with a median value of 15, on the posttest with a median value of 8 and a significance value of 0.001 (p <0.005). this meant that there were differences in anxiety scores before and after hypnotherapy and yoga combination therapy in the intervention group. the anxiety score in the control group showed that the pretest with a mean value of 15.71, the posttest with a mean value of 13.76, the average difference of 1.95, and the significance value of 0.002 (p <0.005). this meant that there were differences in anxiety scores before and after deep breathing therapy in the control group (table 2). the anxiety score in the intervention group was lower than the control group. mann-whitney test results obtained a p-value of 0.015 (p <0.05), then ho was rejected, which meant there was an effect of table 1. respondents’ characteristics (n=34) characteristics intervention control p-value n (%) n (%) gender male female 8 9 44.4 56.2 10 7 55.6 43.8 0.492 education elementary school junior high school 7 10 46.7 52.6 8 9 53.3 47.4 0.730 job farmer housewife employee 4 6 7 40 54.5 53.8 6 5 6 60 45.5 46.2 0.753 surgery type mama tumor biopsy excision bph prostatectomy appendectomy tumor biopsy excision hernia repair 4 2 3 6 2 50 40 50 60 40 4 3 3 4 3 50 60 50 40 60 0.938 mean sd p-value age 36.65 13.919 0.338 table 2. description of anxiety mean scores anxiety mean (sd) median min-max p-value pretest intervention (n = 17) 14.71 (4.135) 15 6-22 0.554 pretest control (n = 17) 15.71 (5.520) 17 6-24 pretest intervention (n = 17) 14.71 (4.135) 15 6-22 0.001 posttest intervention (n = 17) 9.47 (3.223) 8 6-15 pretest control (n = 17) 15.71 (5.520) 17 6-24 0.002 posttest control (n = 17) 13.76 (5.142) 14 6-24 posttest intervention (n = 17) 9.47 (3.223) 8 6-15 0.015 posttest control (n = 17) 13.76 (5.142) 14 6-24 b. basir et al. 82 | pissn: 1858-3598  eissn: 2502-5791 hypnotherapy and yoga combination therapy on the reduction of anxiety scores in elective preoperative patients (table 2). discussion the age range of respondents in this study was between the ages of 18-65 years old (n = 34) with the average age of respondents in both groups 36.65 years old. respondents in this study were classified as adults according to (indonesian ministry of health (2016). the results of this study were supported by the research of sulastri, cahyanti, and rahmayati (2019) showing the majority of preoperative respondents aged 36-45 years old. age can determine a person's ability to make decisions in how they behave (diananda, 2019). the majority of respondents in this study were male. this result was supported by research conducted by nurdin (2018) which stated that the majority of preoperative patients were male. in contrast, research conducted by usnadi, rahayu, and praptiwi (2019) explained that the majority of respondents were female. medical record data of hj. anna lasmanah regional public hospital banjarnegara showed the proportion of elective operation patients in 2019 male and female patients was 58:42. men and women have different levels of anxiety in which women are more easily offended, very sensitive, and emphasize feelings, whereas men have masculine characteristics that tend to be dominant, such as active, more rational, and they are not emphasizing feelings (niken, armiyanti & arif, 2014). this study showed that the majority of respondents had a junior high school education and was supported by the research of usnadi, rahayu, and praptiwi (2019) that the majority of respondents had elementary and junior high school education. this was different from research conducted by sulastri, cahyanti, and rahmayati (2019) who found that the majority of respondents had an elementary school education. the difference in the results of this study was because one's education does not affect perceptions that can cause anxiety in facing operation (vellyana, lestari, & rahmawati, 2017). this study showed that most of the respondents were employees and was supported by the research of rizki and hartoyo (2019) who found that the majority of respondents’ jobs were employees. this was different from the research of usnadi, rahayu, and praptiwi (2019) where the majority of respondents were housewives. this difference was due to the majority of respondents in this study. the type of job that has an unstable income can affect the behavior of respondents in determining treatment, buying medicine, paying hospital costs, and paying high medical costs which will increase respondents' anxiety (rizki & hartoyo, 2019). similar results were also conducted by vellyana, lestari, and rahmawati (2017) who stated that anxiety can be triggered by low-income levels and economic status. this study showed most types of surgery as with excision of tumor biopsy. excision biopsy was performed at hj. anna lasmanah regional public hospital to strengthen the diagnosis of patients with tumors or cancer. the type of operation affects the duration of postoperative care, the seriousness of the disease, the affected body part, and the duration of recovery (rahmayati, asbana, & aprina, 2017). the results of this study indicated that the average value of anxiety in respondents before the application of hypnotherapy and yoga combination therapy did not differ statistically compared to respondents before applying deep breathing therapy. anxiety score in both groups belongs to the moderate anxiety category. this study was supported by the research of rismawan, rizal, and kurnia (2019) in that the majority of respondents who experienced preoperative anxiety were at moderate anxiety levels. anxiety is an emotion or feeling that arises due to the first response to psychological stress and threatens values that are meaningful to patients (azizah, zainuri, & akbar, 2016). physical responses arising in preoperative patients who experienced moderate levels of anxiety include sweating, frequent urination, restless sleep, and waking up at night (rismawan, rizal, & kurnia, 2019). the results of this study indicated there were significant differences between anxiety scores in patients before and after hypnotherapy and yoga combination therapy in the intervention group. research conducted by potié et al. (2016) explained that hypnotherapy sessions were very effective in reducing anxiety before an operation. the results of this study reinforce the research conducted by téllez et al. (2016) who explained that hypnosis sessions for 15 minutes before an operation can increase relaxation and significantly reduce preoperative anxiety levels. deep breathing therapy is a nursing therapy procedure at hj. anna lasmanah regional public hospital banjarnegara as an independent nursing intervention in overcoming preoperative anxiety. the results of this study indicated that there were differences in anxiety scores before and after deep breathing therapy in the control group. other studies related to deep breathing therapy in nurdin's research (2018) where there were differences in anxiety levels in patients with preoperative appendicitis after doing deep breathing therapy. research conducted by rokawie, sulastri, and anita (2017) showed that there were differences in average anxiety scores before and after deep breathing in abdominal preoperative patients. this is in line with the theory of smeltzer and bare (2002) which stated the purposes of deep breathing relaxation were to maximize the work of alveoli ventilation, to accelerate gas exchange, to prevent lung atelectasis, to improve cough efficiency, and to reduce stress both physical stress (pain) and emotional (anxiety). the results of this study indicated that there was an effect of decreasing anxiety scores between respondents who were given hypnotherapy and yoga jurnal ners http://e-journal.unair.ac.id/jners | 83 combination therapy with respondents given deep breathing therapy. this study showed hypnotherapy combination therapy, yoga and deep breathing therapy, could all reduce anxiety scores, but for the reduction score in the intervention group using hypnotherapy and yoga combination therapy was higher than the control group using deep breathing therapy. hypnotherapy and yoga combination therapy were given for 25 minutes and deep breathing therapy given for five times. both therapies were effective in reducing anxiety. the advantage of hypnotherapy and yoga combination therapy was the process of uniting aspects in human beings, such as physical, psychological, and spiritual, by giving positive suggestions; even after the hypnosis session had finished the suggestion was still recorded in the patient's subconscious mind (kinasih, 2010; syaripudin, 2018). deep breathing is a procedure for treating anxiety in the hj. anna lasmanah regional public hospital banjarnegara so that researchers took deep breathing as a control. a deep breathing is as effective as hypnotherapy and yoga combination in dealing with anxiety, but the duration of the effectiveness of relaxation is longer because hypnotherapy and yoga are cognitive therapies. research conducted by niken, armiyanti, andarif (2014) explained that there was the effect of reducing anxiety after being given deep breathing therapy within four hours before the patient entered the operating room and measuring anxiety again 45 minutes before the patient entered the operating room, as such an increase in anxiety scale was obtained due to external and internal stimuli that could affect preoperative patient anxiety. the study limitation was not yet controlling overall factors that influenced preoperative anxiety, such as the type of surgery and personality type. conclusion in conclusion, respondents’ ages in this study were averaged 36.65 years old, the gender majority was male, the education majority was junior high school, the job majority was employee, and the type of operation was tumor excision. the average anxiety score before the intervention was 14.71, while in the control group was 15.71. anxiety scores in both groups belonged to the moderate anxiety category. there were differences in anxiety scores before and after hypnotherapy and yoga combination therapy in the intervention group. there were differences in anxiety scores before and after deep breathing therapy in the control group. there was a significant decrease in anxiety scores after the application of hypnotherapy and yoga combination therapy. the researcher suggests future research to examine the effective duration of hypnotherapy and yoga combination therapy in preoperative patients. references asli, d.l. 2018, kontekstualisasi ajaran yoga sutra patanjali pada masyarakat, jayapangus pres, bali. azizah, l.m., zainuri, i., & akbar, a. 2016, buku ajar keperawatan kesehatan jiwa, indomedia pustaka, yogyakarta. bradt, j., dileo, c., & shim, m. 2013, ‘music interventions for preoperative anxiety ( review )’, nursing and health professions, 6, 2. cahyadi, a. 2017, ‘metode hipnoterapi dalam merubah perilaku’, jurnal ilmiah syi’ar, 17(2),73. diananda, a. 2019, ‘psikologi remaja dan permasalahannya’, journal istighna, 1(1),116– 133. firdaus, m.f. 2014, ‘uji validitas konstruksi dan reliabilitas instrumen the amsterdam preoperative anxiety and information scale (apais) versi indonesia’, fakultas kedokteran universitas indonesia, program studi anestesiologi dan intensif terapi, universitas indonesia. gunawan, y., & kristinawati, w. 2018, ‘regulasi emosi menghadapi kecemasan pada pasien pre operasi mayor’, jurnal psikohumanika, 10(1) 42–61. hartoyo, e.p. 2015, ‘hubungan antara karakteristik demografi dengan pengetahuan mobilisasi dini pada pasien post operasi laparatomi di rs pku muhammadiyah bantul’, universitas muhammadiyah yogyakarta. hawari, d. 2001, manajemen stres cemas dan depresi, fakultas kedokteran universitas indonesia, balai penerbit fkui, jakarta. kinasih, a.s. 2010, ‘pengaruh latihan yoga terhadap peningkatan kualitas hidup’, bulutin psikologi, 18, 1–12. lestari, p., & putri, r.a. 2018, ‘kombinasi self hypnosis dan senam yoga terhadap tingkat nyeri dan kecemasan saat menstruasi’, indonesia journal of midwifery,1, 94–98. maryunani, a. 2014, asuhan keperawatan perioperatif pre operasi, trans info media, jakarta timur. niken, p., armiyanti, y., & arif, s. 2014, ‘efektifitas waktu penerapan teknik relaksasi nafas dalam terhadap penurunan kecemasan pada pasien pre operasi bedah mayor abdomen di rsud tugurejo semarang’, jurnal ilmu keperawatan dan kebidanan, 1–9. nurdin, r.o. 2018, ‘pengaruh teknik relaksasi nafas dalam dan aromaterapi lavender untuk penurunan tingkat kecemasan pasien pre operasi apendiksitis’, jurnal media kesehatan, 11(1),79– 84. pereira, l., figueiredo-braga, m., & carvalho, i.p. 2015, 'preoperative anxiety in ambulatory surgery : the impact of an empathic patientcentered approach on psychological and clinical outcomes', patient education and counseling, 6, 7– 12. potié, a., roelants, f., pospiech, a., momeni, m., & watremez, c. 2016, hypnosis in the perioperative management of breast cancer surgery : clinical benefits and potential implications, 2016, 1–8. b. basir et al. 84 | pissn: 1858-3598  eissn: 2502-5791 rahmayati, e., al asbana, z., & aprina 2017, ‘faktorfaktor yang berhubungan dengan lama perawatan pasien pasca operasi di ruang rawat inap bedah rumah sakit’, jurnal keperawatan, xiii,(2), 195– 202. rismawan, w., rizal, f.m., & kurnia, a. 2019, ‘tingkat kecemasan pasien pre-operasi di rsud dr. soekardjo kota tasikmalaya’, jurnal ilmu keperawatan, 19, 65–70. rizki, f.a., & hartoyo, m. 2019, 'health education using the leaflet media reduce anxiety levels in pre-operation patients', jendela nursing journal, 3(1), 49–57. rokawie, a.o.n., sulastri, s., & anita, a. 2017, ‘relaksasi nafas dalam menurunkan kecemasan pasien pre operasi bedah abdomen’, jurnal kesehatan, 8,(2), 257. sjamsuhidajat, r., & de jong, w. 2010, buku ajar ilmu bedah, penerbit buku kedokteran. jakarta: egc. smeltzer, s., & bare, b. 2002, ‘buku ajar keperawatan medikal bedah brunner & suddarth, edisi' 8, egc : jakarta. sulastri, cahyanti, a.i., & rahmayati, e. 2019, perilaku caring menurunkan kecemasan pasien preoperasi, 10( november), 382–389. syaripudin, a. 2018, hipnoterapi aplikasi keperawatan komplementer, in media, bogor. téllez, a., sánchez-jáuregui, t., juárez-garcía, d.m., & garcía-solís, m. 2016, ‘breast biopsy : the effects of hypnosis and music’, international journal of clinical and experimental hypnosis, 4, 456–467. usnadi, u., rahayu, u., & praptiwi, a. 2019, ‘kecemasan preoperasi pada pasien di unit one day surgery (ods)’, jurnal keperawatan ’aisyiyah, 6, 75–87. vellyana, d., lestari, a., & rahmawati, a. 2017, ‘faktor-faktor yang berhubungan dengan tingkat kecemasan pada pasienppreoperative di rs mitra husada pringsewu’, jurnal kesehatan, 8(1), 108. yulinda, purwaningsih, d., & sudarta, c.m. 2017, ‘latihan yoga dapat menurunkan tingkat kecemasan pada siklus mentruasi remaja puteri’, jurnal ners dan kebidanan indonesia. yusuf, a., fitryasari, r., & nihayati, h.e. 2015, buku ajar keperawatan kesehatan jiwa, salemba medika, jakarta selatan. http://e-journal.unair.ac.id/jners | 1 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18894 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review managing cancer and living meaningfully for advanced cancer: a systematic review shenda maulina wulandari, esti yunitasari, tiyas kusumaningrum faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: managing cancer and living meaningfully (calm) is a supportive-expressive psychotherapy designed to address such barriers and to facilitate communication of mortality-related concerns in patients facing advanced disease and their primary caregivers. the study was meant to review the benefits of the calm psychotherapy on patients with advanced or metastatic cancer and caregivers. methods: this study was done through a systematic review with the preferred reporting items for systematic reviews and meta-analysis (prisma) approach. it broadly used scopus, science direct, and proquest database. the search utilized the boolean phrases “cancer”, “living meaningfully”, and “psychotherapy” throughout the title, abstract, or keywords. the consideration criteria in the literature study were: an original article, the source from journals, article in english, and available in full text. we obtained 97 articles, and 11 were considered relevant for this systematic review. results: the findings from the results of this study are that calm has several psychological benefits for patients with advanced cancer, including: can reduce anxiety and depression, relieve distress, promote psychological growth and well-being, and improve quality of life. based on these findings, it can be concluded that the calm psychotherapy has many benefits for patients with advanced cancer and their caregivers and can be used as additional therapy to improve the quality of life to face the end-oflife. conclusion: calm may be a feasible intervention to benefit patients with advanced cancer. it may help them overcome obstacles in communication and alleviate death-related distress. article history received: feb 27, 2020 accepted: april 1, 2020 keywords advanced cancer; managing cancer and living meaningfully; psycho-oncology; psychotherapy contact esti yunitasari  esti-y@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: wulandari, s, m., yunitasari, e., & kusumaningrum, t. (2020). managing cancer and living meaningfully for advanced cancer: a systematic review. jurnal ners, special issues, 1-8. doi:http://dx.doi.org/10.20473/jn.v15i2.18894 introduction the world health organization describes cancer as a large group of diseases that can start in almost any organ or tissue of the body when abnormal cells grow uncontrollably, go beyond their usual boundaries to invade adjoining parts of the body and/or spread to other organs. the latter process is called metastasizing and is a major cause of death from cancer. cancer is the second leading cause of death globally, accounting for an estimated 9.6 million deaths, or one in six deaths in 2018 (who, 2020). advanced cancer is related to fears and provokes identified disease progression and symptom burden, dependency and disability, suffering, and worry about dying and death (an et al., 2017). the diagnosis of advanced cancer may trigger colossal trouble and the challenge of living meaningfully in the face of progressive disease. people right now face the burden of physical suffering, the threat of dependency and impending mortality, and the difficulty of making treatment decisions that have life-and-death implications while navigating a complex health care system (rodin et al., 2019). early palliative care for such individuals has been shown to produce better outcomes, but the psychological dimensions of such care are much less systematized than those focused on symptom control https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:esti-y@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. s. m. wulandari et al. 2 | pissn: 1858-3598  eissn: 2502-5791 and advanced care-planning. these undermine confidence and any sense of meaning, may disrupt individual relationships and generate emotional distress. the psychological consequences of an advanced cancer diagnosis may include increased suicide rates. there is evidence to suggest that psychological distress may surpass physical side effects in terminally ill patients (rodin et al., n.d.). therefore research related to psychological care in patients with advanced cancer needs to be developed to help cancer survivors improve their quality of life. the aims of the study was to review the benefits of the calm psychotherapy on patients advanced or metastatic cancer and their caregivers. materials and methods strategy for searching studies articles published in english were searched in scopus (medical and nursing subject category), science direct and proquest databases. the relevant literature was searched from march 25, 2015 to february 19, 2019. the publication date was limited to 2011 – 2019. the search utilized the boolean phrases "managing cancer and living meaningfully" and/or "cancer" and/or"living meaningfully" and/or "psychotherapy" and/or "advance cancer" throughout the title, abstract, or keywords. this article used a systematic study review, compiled based on prisma (preferred reporting items for systematic reviews and meta-analyzes) (figure 1). study selection the data obtained were then analyzed and synthesized based on inclusion and exclusion criteria. in this systematic review, the inclusion criteria are (1) respondents ≥ 18 years of age, (2) respondents are in stage 3 – 4 of cancer or advanced cancer, (3) using the calm intervention program, (4) in english, (5) original articles. the exclusion criteria were respondents with major communication difficulties, or/and cognitive impairment, or/and currently under psychiatric or psychological treatment, or/and unwillingness. the articles used are not limited to the type of study design. the articles must comply with the inclusion and exclusion criteria. the abstracts and the full text must be compatible and explain the calm intervention of psychotherapy. the early literature search obtained in 97 articles, 26 from scopus, 46 from science direct and 25 from proquest. the articles found were then reviewed in the abstract, relevance to the theme and adjusted for inclusion and exclusion criteria. finally, 11 articles were considered relevant for this systematic review. results the findings from the results of this study suggest that calm has several psychological benefits for patients with advanced cancer, including: reducing anxiety and depression, relieving distress, promoting psychological growth and well-being, it may help patients with advanced cancer overcome obstacles in communication and alleviate death-related distress (table 1). discussion from the journals obtained and examined according to the theme, the articles previously used were screened according to the inclusion and exclusion criteria. psychological therapy such as cancer and living meaningfully (calm) intervention can decrease depression, anxiety, and death-related distress, which can improve the quality of life. cancer created a lot of negative and stressful emotions for patients and their family and supportive care programs were critical in helping patients cope with their journey (rodin, 2017). one of the stressful emotions for a patient with advanced cancer is deathrelated distress (an et al., 2017). therefore, psychotherapy is needed to reduce anxiety and depressive symptoms. the researchers propose a psychotherapeutic manualized, individual, semi-structured intervention to relieve distress and promote psychological wellbeing in advanced cancer patients. this intervention is called cancer and living meaningfully (van der spek et al., 2018)(s. hales et al., 2017)(s. hales et al., 2015)(obesity et al., 2015), according to canadians professor of psychiatry, gary rodin, and psychiatrist sarah hales of toronto’s princess margaret cancer centre. it is designed to help manage the “practical and profound” challenges people with advanced disease and their families face. rodin and hales shared their work on calm with about 50 palliative care and oncology clinicians, including nurses, 86 articles were excluded analyzed using prisma with the keywords: "cancer”, “cancer”, “living meaningfully”, and/ or “psychotherapy” in databases: scopus, science direct, and proquest the total paper identified: 97 articles excluded with reasons: meaning centered individual therapy was not an original article the source is not from journals does not available in full text. respondents with cancer are not in an advanced stage. the language was used is not english. more than time limitation (2015 to 2020) total articles that match inclusion criteria (n=11) figure.1. flowchart of the research on managing calm for advanced cancer jurnal ners http://e-journal.unair.ac.id/jners | 3 table 1. theoretical mapping of research on managing calm for advanced cancer title, author, year type of study participan t intervention control outcome time managing cancer and living meaningfully ( calm ): a randomized controlled trial of a psychological intervention for patients with advanced cancer [3] rodin et al., 2019 randomized controlled trial 305 participant s between august 3rd, 2012 until march 2016 in the princess margaret cancer centre (pm), the university health network in toronto, ontario, canada. calm psychother apy sessions usual care only, which included routine oncology treatment and follow-up and clinicbased distress screening. calm is an effective intervention that provides a systematic approach to alleviating depressive symptoms in patients with advanced cancer and addresses the predictable challenges these patients face and no adverse effects were identified. 8-week intervention and follow-up scheduled 1 week after the intervention, and 3 and 6 months thereafter. from evidence to implementati on: the global challenge for psychosocial oncology [16] rodin, 2017 speaker presentation more than 20 countries to have calm implement ed routinely in cancer care emotion and symptomfocused engagemen t (ease), and a managing cancer and living meaningfull y (calm) usual care showed in a large rct that calm improves depression, distress related to dying and death and preparation for the end of life (eol) managing cancer and living meaningfully (calm): randomized feasibility trial in patients with advanced cancer [10] lo et al., 2016 randomized feasibility trial 60 adult patients with advanced cancer at the princess margaret cancer centre calm interventio n usual care assessment of feasibility included rates of consent, randomization, attrition, intervention noncompliance, and usual care contamination. primary outcome: depressive. secondary outcomes: major depressive disorder (mdd), generalized anxiety, death anxiety, spiritual well-being, attachment anxiety and avoidance, self-esteem, experiential avoidance, quality of life (qol) and post-traumatic growth. both groups were given intervention or control followed by 3 and 6 months follow-up managing cancer and living meaningfully: study protocol for a randomized controlled trial [11] lo et al., 2015 study protocol for a randomized controlled trial the site is the princess margaret cancer centre, part of the university health network, in toronto, canada. eligibility criteria include: ≥ 18 years of age; interventio n plus usual care usual care alone the primary outcome is the frequency of depressive symptoms and the primary endpoint is at 3 months. secondary outcomes include diagnosis of major or minor depression, generalized anxiety, death anxiety, spiritual wellbeing, qol, demoralization, attachment security, posttraumatic growth, communication with partners, and satisfaction with clinical interactions. it is delivered over a 3–6 month period s. m. wulandari et al. 4 | pissn: 1858-3598  eissn: 2502-5791 title, author, year type of study participan t intervention control outcome time english fluency; no cognitive impairment ; and diagnosis of advanced cancer managing cancer and living meaningfully (calm): phase 2 trial of brief individual psychotherap y for patients with advanced cancer [17] lo et al., 2014 trial research – phase 2 intervention only 50 patients with advanced or metastatic cancer assessed at 3 months (t1) assessed at 6 months (t2) calm may be a feasible intervention to benefit patients with advanced cancer. the results are encouraging, despite attrition and small effect sizes, and support further study these were assessed at 3 months and 6 months managing cancer and living meaningfully (calm): a qualitative study of a brief individual psychotherap y for individuals with advanced cancer [18] nissim et al., 2011 qualitative with semistructured interviews patients were recruited from a large urban regional cancer center in toronto, canada. the 10 interviewee s included seven women and three men. all had completed between three to six calm sessions before the interview. five interrelate d benefits of calm interventio n were identified: (1) a safe place to process the experience of advanced cancer; (2) permission to talk about death and dying; (3) assistance in managing the illness and navigating the healthcare system; (4) resolution of relational strain; and (5) an opportunit y to ‘be seen as a whole person’ within the healthcare system. these findings from a qualitative study suggest that the calm intervention provides substantial benefits for patients with advanced cancer before the end of life. findings informed the development of an rct to evaluate the effectiveness of this intervention. jurnal ners http://e-journal.unair.ac.id/jners | 5 title, author, year type of study participan t intervention control outcome time benefits were regarded by participant s as unique in their cancer journey. mentalization in calm psychotherap y sessions: helping patients engage with alternative perspectives at the end of life [19] shaw et al., 2018 conversation analysis total of 7 therapy sessions and 5 hours, 24 minutes of data the analysis identifies one subtle way a patient is invited to consider an alternative perspective relating to their disease progressio n. the analysis reveals a skillful way in which therapists can cautiously and collaboratively introduce a patient to alternative perspectives concerning end-of-life, without invalidating the patient’s perspective on this particularly delicate context. 5 hours and 24 minutes of data inviting endof-life talk in initial calm therapy sessions: a conversation analytic study [14] shaw et al., 2016 conversation analysis data was collected as part of a phase iii rct of calm at the princess margaret cancer centre open questions about the patients’ experience s, feelings or understand ing in the context of talk about their troubles, were found to regularly elicit talk concerning end-of-life. the analysis shows that therapists provide patients with the opportunity to talk about eol in a way that is supportive of the therapeutic relationship. the patients’ readiness to engage in eol talks displays the salience of this topic, as well as the reflective space provided by calm therapy. practice implications: the results provide important insight into the process of calm therapy, which can be used to guide training. sessions lasting approximately one hour death talk and relief of death-related distress in patients with advanced cancer [2] an et al., 2017 qualitative research 17 patients with advanced cancer managing cancer and living meaningfull y (calm) patients with advanced cancer perceive barriers to effective communication of death distress to be related to their own reluctance, as well as the reluctance of their loved ones to address such fears. calm therapy may help patients with advanced cancer \ overcome obstacles in communication and \ alleviate death-related distress. 6-month period efficacy of a brief manualized intervention managing cancer and living meaningfully (calm) singleblinded randomizedcontrolled trial: study protocol managing cancer and living meaningfull y (calm) supportive psychooncological interventio n (spi). this study will contribute important statistical evidence on whether calm can reduce depression and existential distress in a german sample of advanced and highly distressed cancer patients 6 months s. m. wulandari et al. 6 | pissn: 1858-3598  eissn: 2502-5791 title, author, year type of study participan t intervention control outcome time adapted to german cancer care settings: study protocol for a randomized controlled trial [13] scheffold et al., 2015 “double awareness” in psychotherap y for patients living with advanced cancer[15] colosimo et al., 2017 task analysis managing cancer and living meaningfull y (calm) calm therapists are trained to facilitate meaning-making by providing patients with opportunities to mentalize their experience, for instance by using gentle questioning to invite the patients to explore a variety of perspectives. finally, when the individual feels safe and has had an opportunity to construct and deepen meanings related to life and death, the therapist can help the patient bridge these dimensions by synthesizing meanings. this bridging process helps the patient see life and death as interconnected possibilities. existential distress may not be eliminated, but it can be managed in this process. calm: cancer and living meaningfully; rct: randomized controlled trial; eol: end of life; mdd: major depressive disorder; qol: quality of life psychiatrists, social workers and physicians from new zealand and australia, in a two-day workshop in auckland in march (rodin, 2017). this short-term intervention was originally developed for advanced cancer patients. “managing cancer and living meaningfully (calm)” is built up by 3–8 sessions (duration about 45–60 min) (oberstadt et al., 2018) and optimally delivered in over 6 months (an et al., 2017). this intervention focuses on six dimensions: (1) symptom management and communication with healthcare providers, (2) changes in self and relations with close others, (3) spirituality, sense of meaning and purpose (4) thinking of the future, hope, and mortality (5) communication skills, and (6) emotional expression and control (oberstadt et al., 2018). each participant’s primary caregiver (e.g., partner, adult son, or daughter) is invited to attend sessions when this is desired by the patient (an et al., 2017) (oberstadt et al., 2018) in one or more of the therapy sessions, as deemed appropriate by the therapist (oberstadt et al., 2018). based on the relational, attachment, and existential theory, calm provides a therapeutic relationship and reflective space, with attention to the following domains: symptom management and communication with health care providers, changes in self and relations with close others, spiritual wellbeing and the sense of meaning and purpose, and mortality and future-oriented concerns (rodin et al., n.d.). outcomes that can be measured were depressive symptoms (an et al., 2017; s. j. hales et al., 2015; lo et al., 2015, 2016; rodin et al., n.d.; scheffold et al., 2015), death anxiety, attachment security, spiritual well-being and psychological growth (an et al., 2017; s. j. hales et al., 2015; lo et al., 2015, 2016), quality of life, post-traumatic growth (lo et al., 2015, 2016), major depressive disorder (mdd), generalized anxiety, avoidance, self-esteem, experimental avoidance (lo et al., 2016), demoralization, communication with partner and satisfaction with clinical interaction (lo et al., 2015; shaw et al., 2016). all over outcomes that provide a huge impact in alleviating depressive symptoms. jurnal ners http://e-journal.unair.ac.id/jners | 7 during calm therapy, the psychotherapist and the patient explore the meanings of the patient’s life history, including achievements and failures, as well as the disease itself (oberstadt et al., 2018), by using gentle questioning to invite the patients to explore a variety of perspectives (colosimo et al., 2017). finally, when the individual feels safe and has had an opportunity to construct and deepen meanings related to life and death, the therapist can help the patient bridge these dimensions by synthesizing meanings (colosimo et al., 2017). thereby, the whole life trajectory of the patient, his/her aims, the experience of suffering, and death/dying play important roles in the therapy (oberstadt et al., 2018). in the therapeutic contact, the therapist can explore how the patient makes sense of his or her situation and help the patient see life and death as interconnected possibilities and facilitate meaningmaking as an adaptive way of coping with a situation beyond one's control. the distress that arises may not be eliminated, but it can be managed in this process. one qualitative study demonstrates that individuals with advanced cancer are preoccupied with concerns related to dying and death and find relief in the opportunity to communicate this distress. participants experienced the calm therapist as a secure base who supported communication of deathrelated distress both within the therapy and in their close relationships. open discussion of fears was commonly perceived by participants as therapeutic as it could be accepted by their therapist or family without causing perceived distress or discomfort in them. calm therapy facilitated communication of death-related distress within families whether or not caregivers participated in the therapy sessions. although health professionals and families may be reluctant to discuss such topics, patients facing mortality may find relief from being able to discuss fears that cannot be eliminated from awareness. support for a wide range of healthcare providers to engage in a more open discussion of mortality-related concerns with patients with advanced disease is needed (an et al., 2017). conclusion based on the findings of the study, it can be concluded that calm has several psychological benefits for patients with advanced cancer and their caregivers, including: reducing depressive symptoms, death anxiety, attachment security, promoting spiritual well-being and psychological growth, improving quality of life, alleviating post-traumatic growth, major depressive disorder (mdd), generalized anxiety, avoidance, self-esteem, experimental avoidance, demoralization, increasing communication with partner and satisfaction with clinical interaction. some of these studies found one of the biggest impacts calm therapy has is on alleviating the depressive symptom and thus it can be used as additional therapy to improve the quality of life to face the end-of-life. calm may be a feasible intervention to benefit patients with advanced cancer. it may help patients with advanced cancer overcome obstacles in communication and alleviate death-related distress and no adverse effect was identified. conflict of interest no conflicts of interest have been declared. acknowledgement the author of this study would like to thank the master of the nursing study programme and the faculty of nursing universitas airlangga for providing the opportunity to present this study. references an, e., wennberg, e., nissim, r., lo, c., hales, s., & rodin, g. (2017). death talk and relief of death related distress in patients with advanced cancer. bmj supportive & palliative care, 0, 1–7. https://doi.org/10.1136/bmjspcare-2016001277 colosimo, k., nissim, r., pos, a. e., hales, s., zimmermann, c., rodin, g., & colosimo, k. (2017). “double awareness” in psychotherapy for patients living with advanced cancer. journal of psychotherapy integration. hales, s., chiu, a., panday, t., malfitano, c., jung, j., rydall, a., li, m., nissim, r., zimmermann, c., & rodin, g. (2017). health and medicine palliative and supportive care ; recent findings in palliative and supportive care described by researchers from university health network [ managing cancer and living meaningfully ( calm ): randomised feasibility trial in patients w. 1–3. hales, s. j., jung, a., chiu, t., panday, a., rydall, r., nissim, c., malfitano, d., petricone-westwood, c. z., & rodin, g. (2015). psychotherapy ; findings from university health network update understanding of psychotherapy [ managing cancer and living meaningfully ( calm ): phase 2 trial of a brief individual psychotherapy for patients with advanced cancer ]. 95, 2–4. hales, s., rydall, a., panday, t., chiu, a., malfitano, c., jung, j., li, m., nissim, r., zimmermann, c., & rodin, g. (2015). clinical research ; researchers from princess margaret cancer center report new studies and findings in the area of clinical trials and studies [efficacy of a brief manualized intervention managing cancer and living meaningfully ( calm ) adapted to german. 2–4. lo, c., hales, s., chiu, a., panday, t., malfitano, c., jung, j., rydall, a., li, m., nissim, r., zimmermann, c., & rodin, g. (2016). managing cancer and living meaningfully ( calm ): randomised feasibility trial in patients with advanced cancer. 1–10. https://doi.org/10.1136/bmjspcare-2015000866 lo, c., hales, s., rydall, a., panday, t., chiu, a., malfitano, c., jung, j., li, m., nissim, r., s. m. wulandari et al. 8 | pissn: 1858-3598  eissn: 2502-5791 zimmermann, c., & rodin, g. (2015). managing cancer and living meaningfully : study protocol for a randomized controlled trial. trials, 1–8. https://doi.org/10.1186/s13063-015-0811-1 oberstadt, m. c. f., esser, p., classen, j., & mehnert, a. (2018). alleviation of psychological distress and the improvement of quality of life in patients with amyotrophic lateral sclerosis: adaptation of a short-term psychotherapeutic intervention. frontiers in neurology, 9(apr). https://doi.org/10.3389/fneur.2018.00231 obesity, i., week, w., & sep, a. a. (2015). clinical research ; study results from university of toronto in the area of clinical trials and studies reported ( managing cancer and living meaningfully : study protocol for a randomized controlled trial ). 1–3. rodin, g. (2017). managing cancer and living meaningfully critical care : nursing initiatives highlighted. 23(4). rodin, g., lo, c., rydall, a., shnall, j., mal, c., chiu, a., panday, t., watt, s., an, e., nissim, r., li, m., zimmermann, c., & hales, s. (2019). managing cancer and living meaningfully ( calm ): a randomized controlled trial of a psychological intervention for patients with advanced cancer. american society of clinical oncology, 36(23). https://doi.org/10.1200/jco.2017.77.1097 scheffold, k., philipp, r., engelmann, d., schulzkindermann, f., rosenberger, c., oechsle, k., härter, m., wegscheider, k., lordick, f., lo, c., hales, s., & rodin, g. (2015). efficacy of a brief manualized intervention managing cancer and living meaningfully ( calm ) adapted to german cancer care settings : study protocol for a randomized controlled trial. bmc cancer, 1–10. https://doi.org/10.1186/s12885-015-1589-y shaw, c., chrysikou, v., davis, s., gessler, s., rodin, g., & lanceley, a. (2016). inviting end-of-life talk in initial calm therapy sessions : a conversation analytic study. patient education and counseling. https://doi.org/10.1016/j.pec.2016.08.024 van der spek, n., jansen, f., holtmaat, k., vos, j., breitbart, w., van uden-kraan, c. f., tollenaar, r. a. e. m., cuijpers, p., coupé, v. m. h., & verdonckde leeuw, i. m. (2018). cost-utility analysis of meaning-centered group psychotherapy for cancer survivors. psycho-oncology, 27(7), 1772– 1779. https://doi.org/10.1002/pon.4726 who. (2020). cancer. http://e-journal.unair.ac.id/jners | 67 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18946 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the correlation of spiritual status and anxiety level in patients with pulmonary tuberculosis merina widyastuti, puji hastuti, sukma ayu candra kirana, and nevinda hervi farendita stikes hang tuah surabaya, indonesia abstract introduction: pulmonary tuberculosis (tb) is an infectious disease caused by the mycobacterium tuberculosis. the increasing prevalence of tuberculosis and infectious disease overall is causing patients to experience anxiety. someone who experiences anxiety will find support in their religious beliefs. the purpose of this research was to analyze the relationship between spirituality and the anxiety level of patients with pulmonary tuberculosis. methods: the study design was analytical observational research with a cross-sectional approach. the independent variable was spirituality and the dependent variable was anxiety. the population of this research was 55 people with pulmonary tuberculosis. the sample totaled 49 people. the retrieval of the data was conducted on 1-31 may 2018 using the simple sampling random technique. the research instrument used the anxiety questionnaire dass 21 and spiritual questionnaire dses and the results were tested using spearman rho correlations results: the statistical results with ρ = 0.01 with ρ ≤ 0.05. the results of this study show that the majority of the anxiety levels experienced are normal and that the spiritual outcomes for the majority are at a high level. this shows the relationship between the anxiety level and the spirituality of the patients with pulmonary tuberculosis at puskesmas perak timur surabaya. conclusion: the result of the correlation coefficient was 0.552. the implication that the research indicates is that high spiritual intelligence causes someone to reduce their anxiety. expected health workers can provide more education about the treatment o further reduce the anxiety levels of pulmonary tuberculosis patients. article history received: feb 27, 2020 accepted: april 1, 2020 keywords anxiety; pulmonary tb; spiritual contact merina widyastuti  merinawidyastuti@gmail.com  stikes hang tuah surabaya, indonesia cite this as: widyastuti, m., hastuti, p., kirana, s.a.c., dharmayanti, n., fatimawati, i., & farendita, n.h. (2020). the correlation of spiritual status and anxiety level in patients with pulmonary tuberculosis. jurnal ners, special issues, 67-71. doi:http://dx.doi.org/10.20473/jn.v15i2.18946 introduction pulmonary tuberculosis (tb) is an infectious disease caused by mycobacterium tuberculosis. pulmonary tuberculosis is currently a major health problem globally(sari, mubasyiroh, & supardi, 2017). the increasing prevalence of tb patients will have an impact on both the patients and their families. some of the anxiety experienced by the family includes a decrease in the quality of life of the sufferers, the transmission of disease, the risk of complications and the risk of death. anxiety reactions in families of tb patients can reduce the ability of the families to care for the patients(rohmi, soeharto, & lestari, 2015). anxiety is a natural human attitude as a form of bodily response when facing threats (luana na, sahala panggabean, joyce vm lengkong, 2012). one effort to overcome anxiety is to get closer to one's religious beliefs. thus the patient is expected to accept the condition of his illness even when there is a long healing process and uncertain results(perdana & niswah, 2011). according to nuraeni et al (2015), spiritual needs are needed by the patients with a chronic disease. however, how the relationship https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. m. widyastuti et al. 68 | pissn: 1858-3598  eissn: 2502-5791 between anxiety levels and spirituality in tuberculosis patients still requires in-depth study. according to the world health organization's global tuberculosis report (2017), tuberculosis is one of the 10 diseases with the highest mortality worldwide. in 2017, indonesia was third in the ranking on the most cases of tb. the east java province showed that the number of tb cases had reached 41,404 cases. surabaya city has the most tb cases in east java totaling 3990 (kemenkes ri, 2018) followed by jember regency with 3334 cases(ariyani, 2016). in the perak timur health center, the number of tuberculosis patients from march to june 2017 numbered 89 patients while in october 2017 to march 2018, there were 55 patients. the complications of tb can have serious effects on other organs and parts of the body including the bones and brain (suhaidah, 2013). continuous anxiety will lead to depression with feelings of uncertainty and helplessness (riskesdas, 2018). one effort to overcome anxiety is to increase the patient’s spiritual beliefs. spiritual intelligence is one solution that offers spiritual calm. spiritual intelligence is the intelligence used to face and solve life problems. it is an intelligence that manifests in ways of behaving and living in a broader context of life (husain, dearman, chaudry, rizvi, & waquas waheed, 2008). the development of a good spiritual aspect can make someone more able to interpret their life and have a level of self-acceptance of their condition so as to provide a positive response to changes in his health (sadipun, dwidiyanti, & andriany, 2018). up until now, spirituality as a part of therapy is still on a limited basis. nurses have not optimally provided the patient with a way to meet their spiritual needs. most nurses still perceive that spiritual fulfillment can only be done in the form of religious worship facilities. thus the results of this study are expected to provide an overview of the relationship between anxiety and the spiritual level of tuberculosis patients. materials and methods this study used an observational analytic research design with a cross-sectional approach. this research was carried out in the period 1st-31st may 2018 at the puskesmas perak timur surabaya. the population was tuberculosis patients. the sample of this study was 49 tuberculosis patients in the puskesmas perak timur surabaya. the sampling technique used was simple random sampling. the inclusion criteria were tuberculosis patients who could communicate. respondents were excluded if they were not in place when collecting the data and if they were younger than 18 years old. the spiritual instrument in this study was the dses (daily spiritual experience scale) questionnaire and the anxiety instrument used was the dass questionnaire consisting of 21 questions. all of the respondents in this study were given an explanation of the purpose and benefits of the study. the explanation was given both orally and in writing. this research has been ethically approved by the health research ethics commission stikes of hang tuah surabaya number pe/07/v/2018/kepk/sht. results based on table 1, out of the 49 respondents, 17% were aged 46-55 years while based on gender, 53.1% were male. as many as 40.8% of the respondents had a high school education level. based on employment status, the majority of respondents were entrepreneurs (59.2%). for the treatment category of less than 6 months, 93.1% of the 49 study respondents fitted here. based on marital status, the majority of the respondents were married at 71.4%. table 2 shows that of the 49 respondents, the majority at 30 respondents had a high spiritual level. from the 30 respondents with a high spiritual level, 16 people did not experience anxiety. only 4 respondents experienced severe anxiety. out of the 30 respondents who have a high spiritual level, 9 people are in the age range of 36-45 years old. for level of education and gender in the group of respondents with high spirituality, there was no significant difference. the results of the data show that of the 30 respondents with a high spiritual level, 22 respondents were married and 18 had been in the tb treatment category for less than 6 months. the results in table 2 show that out of the 49 respondents, there were 20 respondents who did not experience anxiety. of the 20 respondents, 8 had an age distribution of 36-45 years and 12 were male. in addition, from the 20 respondents, there were 18 respondents in the treatment category of less than 6 months. table 2 also shows that out of the 49 tb respondents, 20 respondents did not experience anxiety and 16 of them had high spiritual levels. the spearman rho test analysis results obtained a ρ value = 0.01 with a significance level <α = 0.05. thus the results show that there is a relationship between spiritual level and anxiety level. the correlation coefficient is -0.708 which means that the higher the spiritual level, the lower the anxiety level. discussion this study aims to analyze the relationship between spiritual level and anxiety in pulmonary tb patients in puskesmas perak timur surabaya. based on the results of this study, it showed that there was a relationship between spiritual level and anxiety level. the negative correlation coefficient indicates that the higher the spiritual level, the lower the anxiety level. tuberculosis is a contagious disease that most often occurs in the lungs(tosepu, 2016). tb is chronic and the cure takes a long time. the healing of pulmonary tb is influenced by the adherence to taking medication and the immune system. the complaints due to pulmonary tb such as shortness of breath, chest pain and decreased appetite will increase the level of anxiety felt. this is in line with jurnal ners http://e-journal.unair.ac.id/jners | 69 the results of the research conducted in pakistan on 108 pulmonary tb patients who showed symptoms of anxiety and depression associated with the symptoms and complaints experienced (husain et al., 2008). anxiety and depression will cause the tb patients to experience a decrease in motivation, a reduction in compliance with medication and a worsening of their condition. severe anxiety will affect the hypothalamus. the anterior pituitary gland will be prompted to produce acth. acth will produce cortisol. cortisol will reduce the body's immune system so then the patients with tb will experience subsequent complications(santos, lazzari, & silva, 2017). anxiety indicates uncertain feelings, panic, fear and the inability of to understand the source of their fear. anxiety arises because of several situations that threaten their integrity as a social being. in this case, pulmonary tb patients sometimes get a negative stigma from the community because it can be contagious, so the patients will increasingly feel helpless and this will increase their anxiety. suhaidah (2013) revealed that the factors that influence anxiety are age, cultural values, spirituality, education, physical condition, coping responses, social support, stages of development, past experience and knowledge. age greatly affects one's psychology. the older someone is, the better their level of emotional maturity and the better their ability to deal with various problems. anxiety is connected to feelings of helplessness and uncertainty. based on the results of this study, the majority of respondents were aged 46-60 years. this is consistent with the previous research which states that tb is often experienced by patients in the age range of 46-60 years. this age group is vulnerable due to the aging process as it decreases the body’s immunity (sadipun et al., 2018). hope is related to uncertainty in life and it is an interpersonal process that is built through trusting relationships with others, including with god. hope is very important for individuals to maintain life. without hope many people become depressed and they are more likely to get sick. the results of this study indicate that the majority of the respondents did not experience anxiety and that this was correlated with a high spirituality level. a high spiritual level can reduce the anxiety in patients with pulmonary tb. individuals with a high spiritual level can build good coping mechanisms to deal with their anxiety. the factors that influence the coping mechanisms used include hope, age, and social support. good coping mechanisms can be obtained through a spiritual approach such as meditation and this shows the improved emotional control of the tb table 1. characteristics of the respondents based on their sociodemographic details (n=49) characteristic frequency (%) age 17-25 26-35 36-45 46-55 56-65 66-70 6 9 11 17 4 2 12,2 18,4 22,4 34,7 8,2 4,1 gender male female 26 23 53,1 46,9 education no school primary school junior high school senior high school bachelor 2 13 10 20 4 4,1 26,5 20,4 40,8 8,2 occupation housewife unemployed entrepreneur 17 3 29 34,7 6,1 59,2 treatment term category category 1 (<6 month) category 2 (>6 month) 36 3 93,9 6,1 marital status single married widower widow 11 35 2 1 22,4 71,4 4,1 2,0 table 2. anxiety level and spiritual level of the pulmonary tuberculosis patients in puskesmas perak surabaya (n = 49) anxiety level spiritual low (n=6) moderate (n=13) high (n=30) normal 0 4 (8,2%) 16(32,7%) mild anxiety 0 0 5(10,2%) medium anxiety 0 0 2 (6,7%) serious anxiety 0 1 (2%) 3 (6,1%) very severe anxiety 6 (12,2%) 8 (16,3%) 4 (8,2%) total 6 13 30 the spearman rho test ρ = 0.01 r correlation = -0.708 m. widyastuti et al. 70 | pissn: 1858-3598  eissn: 2502-5791 patients (sadipun et al., 2018). this result is consistent with the research(karomah, 2015) which shows that the spiritual level also affects the emotional control of the tb patients. in addition, spiritual beliefs have a strong effect on psychological functioning. religious spiritual activities paired with physiological activities reduce stress, result in the participant not being afraid of death and becoming more resilient in the face of the disease process (marsinova bakara et al.,2013). spiritual therapy will improve the quality of life of tb patients (kusnanto, pradanie, & alifi karima, 2016). this is needed to cure the tb patients. anxiety will reduce one's thinking power so as to further reduce the body's resistance through the effect of increased cortisol. spiritual intelligence is the foundation needed to enable individuals to function with intellectual and emotional intelligence(lesmana, 2014). the results of this study indicate that the anxiety is severely experienced by the majority of the women. anxiety in women is caused by taking care of the household as well as being the backbone of the family (yuliani & purwanti, 2013). the anxiety experienced by menopausal women can be reduced by seft spiritual therapy for 3 weeks. although the study did not examine the anxiety felt by tb patients, the similarities showed that anxiety was experienced by many women and it also showed that spirituality can reduce the respondent’s anxiety level. these results are also consistent with the results of the research conducted by marsinova bakara et al (2013). out of the 23 respondents with ska, it was demonstrated that spiritual therapy can reduce the levels of anxiety, stress and depression. culture and spirituality influence the way that an individual thinks. individuals who have high spiritual intelligence have the confidence that they can utilize the conditions that they experience as a gift from god. they will take wisdom from their situation. this makes the individuals with high spirituality always think positively. they try to optimize the healing process so as to accelerate and support their healing. spiritual intelligence when thinking will lead individuals to a better quality life (kusnanto, haryanto, sukartini, ulfiana, & putra, 2018). the power that arises in the individual will help them to realize the meaning and purpose of life. this will make the individual view his life experience as a positive experience, in addition to them gaining optimism about the future where their life goals become clearer. the feeling of knowing the meaning of life, which is sometimes identified with feeling close to god, will be a positive experience social and environmental support can also be a source of coping. husain et al (2008) believes that the presence of other people can help someone to reduce their anxiety. the environment can also affect one's thinking. however in this study, the researcher did not examine the role of the pmo in the respondent so it is not known exactly how the social support obtained by the respondent is also related to their anxiety other than the existence of a spiritual level. the role of the nurse is also very important when handling pulmonary tb patients, especially in psychological terms. developing guidelines and training the health workers in tb clinics is useful to screen and treat the depression and anxiety present among tb patients(duko, gebeyehu, & ayano, 2015). this can be considered in subsequent studies. the sample size is small. however, one of the strengths of this study is that we used validated and recognized measures. conclusion based on the research conducted on 49 respondents with pulmonary tb, it can be concluded that their level of spirituality is related to their level of anxiety. the implication is that nurses can direct the patients to increase their spirituality level in an effort to reduce their anxiety and support the patient's recovery. conflict of interest no potential conflicts of interest relevant to this article have been reported. acknowledgement we would like to acknowledge the support from the stikes hang tuah surabaya. the funding source was for internal research from stikes hang tuah surabaya. references ariyani, h. (2016). hubungan tingkat pengetahuan dengan kepatuhan pada pengobatan penderita tuberkulosis paru di puskesmas pekauman kota banjarmasin , kalimantan selatan. 03(02), 23–28. duko, b., gebeyehu, a., & ayano, g. (2015). prevalence and correlates of depression and anxiety among patients with tuberculosis at wolaitasodo university hospital and sodo health center, wolaitasodo, south ethiopia, cross sectional study. bmc psychiatry. https://doi.org/10.1186/s12888-015-0598-3 husain, m. o., dearman, s. p., chaudry, i. b., rizvi, n., & waquas waheed. (2008). the relationship between anxiety , depression and illness perception in tuberculosis patients in pakistan. clinical practice and epidemiology in mental health, 4(4), 1–5. karomah, n. n. (2015). hubungan tingkat spiritual dengan kecemasan terhadap kematian pada lansia yang memiliki penyakit kronis. kemenkes ri. (2018). laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2018. riset kesehatan dasar 2018, 182–183. kusnanto, k., haryanto, j., sukartini, t., ulfiana, e., & putra, m. m. (2018). the effectiveness of spiritual emotional breathing towards respiratory function and immune response of tuberculosis jurnal ners http://e-journal.unair.ac.id/jners | 71 patients. jurnal ners, 13(1), 93. https://doi.org/10.20473/jn.v13i1.8373 kusnanto, k., pradanie, r., & alifi karima, i. (2016). spiritual emotional freedom technique (seft) terhadap kualitas hidup penderita tuberkulosis paru. jurnal keperawatan padjadjaran, v4(n3), 213–224. https://doi.org/10.24198/jkp.v4n3.1 lesmana, d. (2014). kecerdasaan spiritual dengan kecemasan menghadapi masa pensiun. journal imiah psikologi terapan, 02(01), 168–183. luana na, sahala panggabean, joyce vm lengkong, i. c. (2012). hubungan kecemasan pada penderita penyakit ginjal kronik yang menjalani hemodialisis di rs universitas kristen indonesia. marsinova bakara, d., ibrahim, k., & sriati, a. (n.d.). volume 1 nomor 1 april 2013 48 efek spiritual emotional freedom technique terhadap cemas dan depresi, sindrom koroner akut. 1(april 2013), 1–8. perdana, m., & niswah, z. (2011). pengaruh bimbingan spiritual terhadap tingkat kecemasan pada pasien pre operatif di ruang rawat inap rsud kajen kabupaten pekalongan. riskesdas, k. (2018). hasil utama riset kesehata dasar (riskesdas). journal of physics a: mathematical and theoretical, 44(8), 1–200. https://doi.org/10.1088/17518113/44/8/085201 rohmi, f., soeharto, s., & lestari, r. (2015). pengaruh psikoedukasi keluarga terhadap tingkat kecemasan dan kemampuan keluarga dalam merawat penderita tb di puskesmas sumbermanjing wetan kecamatan sumbermanjing kabupaten malang. 5(2), 255– 270. sadipun, d. k., dwidiyanti, m., & andriany, m. (2018). effect of spiritual based mindfullness intervention on emotional control in adult patients with pulmonary tuberculosis. belitung nursing journal, 4(2), 226–231. https://doi.org/10.33546/bnj.357 santos, a.paula cere dos, lazzari, tassia kirchmann, & silva, d. rossato. (2017). health related quality of life, depression and anxiety in hospitalized patients with tuberculosis. tuberculosis and respiratory disease, 80, 69–76. https://doi.org/10.1088/1751-8113/44/8/085201 https://doi.org/10.1088/1751-8113/44/8/085201 256 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16957 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review analysis of the restraint model for mental disorder clients in health care facilities: a systematic review sitti sulaihah, siti khadijah and darni darni faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the reduction or elimination of restraint for psychiatric patients continues to be an area of concern and debate. the lack of accessible alternatives to restraint shows that nurses need to use restraints. the aim of the study was to gain insights from the restraint model used by mental disorder client nurses in health care facilities. methods: the method used was the identification of interventions in the literature, the identification of the relevant literature by topic and title, obtaining the literature in full-text form and the analysis of the results from the various interventions used in the literature. we systematically searched scopus, proquest and science direct by including keywords such as ‘restraint models’ and ‘clinical restraint’. the years were limited to 4 (20152018). results: from the 80 potentially relevant articles, 15 met our eligibility criteria with qualitative and quantitative designs; all discussed restraint interventions. the restraint models for mental disorder clients were physical, mechanical and chemical. conclusion: this study reports on the latest experience that restraint cannot be eliminated from use. nurses tended to disagree if the restraint method was removed. restraint with physical, chemical, and mechanical solutions could be tailored to the client's case in health care facilities. the results of this review should be considered when developing interventions aimed at reducing the use of restraint. article history received: december 26, 2019 accepted: december 31, 2019 keywords restrain; mental disorder; psychiatric; contact sitti sulaihah  sitti.sulaihah2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sulaihah, s., khadijah, s., & darni, d. (2019). analysis of the restraint model for mental disorder clients in health care facilities: a systematic review. jurnal ners, 14(3si), 256-259. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16957 introduction the reduction or elimination of restraint for psychiatric patients continues to be an area of concern and debate. the lack of accessible alternatives to restraint and exile shows that nurses believe that there are no effective and accessible alternatives to this collective practice (muircochrane e c, baird j and mccann t v, 2015). three related themes contribute to this perception. first, is that adverse interpersonal environments contribute to restraint and isolation, which are both associated with the undesirable consequences of poor staff-topatient relationships. second, the unfavorable physical environment contributes to aggression and restraint and the use of exile. third, the practice environment influences the adoption of controllers and exile (eskandari et al, 2018). the omnibus budget reconciliation act (obra) guidelines define physical restraint as "any physical or mechanical method or device, material or equipment installed or adjacent to the body of an individual that the individual cannot remove easily, and limits freedom of movement (standing, walking, lying down, turning, sitting) or normal access to one's body" (winokur, e. j, loucks, j and raup g.h, 2018). the finding of the previous study that has been done contributes to the limited evidence of psychiatric nurse’s experiences and if they would reduce or remove restraint. policy reduction or the elimination of restraint needs to be accompanied by broad initiatives to deal with aggression, including providing appropriate education and support and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 257 addressing ethical cultural issues and workplace attitudes around these practices (eskandari et al, 2018). several approaches have been commonly carried out but they are not effective. a quantitative survey aimed to describe the attitude of the nurses using different questionnaires to investigate the relationship between the attitudes of the nurses and other factors. for example, the use of physical restraint, the education level of the nurses and the characteristics of the facility and/or country. the results of this study are inconsistent; no clear association has been identified. a comparative survey in three countries showed that the nurses 'attitudes differ depending on the nurses' definition of physical restraint and their national and cultural affiliation (lan s h et al, 2017). to gain an insight from the restraint model used by mental disorder client nurses in health care facilities, the systematic analysis of both qualitative and quantitative studies is needed to investigate the restraint model used by nurses. materials and methods this systematic review was made with the aim of gaining insights from the restraint model used by odgj client nurses in health care facilities. the articles were analyzed using pico. the literature search was carried out on several databases such as scopus, proquest and sciencedirect by including keywords such as restraint models and clinical restraint. the year limit used was 4 years (2015 2018) according to the inclusion criteria for qualitative and quantitative designs that discussed restrain interventions in health care facilities and mental disorder clients. there was no age limit for the participants in the article. this is because the focus of the search was on the model or restraint intervention used. articles were excluded if the results of the study did not explain the estimated effects of the intervention provided. the method used in preparing this systematic review was to identify interventions in the literature, to identify the relevant literature based on both topics and titles, to obtain the literature in the full-text form and to analyze the results from various interventions in the literature. from 80 potentially relevant articles, 15 met our eligibility criteria. furthermore, the articles that met the criteria were analyzed using the pico method. results in their clinical practice, nurses who feel the need to use physical restraint in a number of situations and for various reasons explained some of the strategies used to overcome their moral conflicts, which come from these differences. nurses do not question the use of physical restraints in general, and it seems that the nurses consider physical restraints to be the usual nursing intervention (winokur, e. j, loucks, j and raup g.h, 2018). it is felt that it is necessary to use physical restraints in daily practice in everyday practice, nurses are faced with situations where they experience the need to use restraint. the need to use restraint includes situations where the nurses are required to guarantee the safety of the clients and the officers themselves, to fulfill other tasks, to prevent themselves from being harmed by those at risk or they must comply with decisions being made regarding the use of restraint. in addition, a lack of knowledge about alternatives to using restraint increases the perceived need to use physical restraint. restrain model for mental disorder clients in health facilities physical restraint psychiatric nurses have a positive attitude and adequate practice towards the use of physical restraint as an alternative management for psychiatric patients. it is important for psychiatric nurses to recognize that physical restraint must be carried out as a last resort (rose d, perry e, rae s and good n, 2017). physical restraints can include belts, gloves, vests, bedrails, geriatric chairs and other devices. the use of such devices has been under close supervision. this is because physical restraint can result in anxiety, confusion, de=conditioning, pressure ulcers, strangulation, death and adverse psychological effects (cunha m et al 2016). mechanical restraint mechanical isolation or restraint is seen of as a last resort to keep the staff safe. nurses likely to disagree if detention methods are eliminated (gerace, a and muir-cochrane e, 2018). chemical restraint there were no specific journals describing chemical restraints that only focused specifically on physical figure 1. flowchart of the study selection process. s. sulaihah, et al. 258 | pissn: 1858-3598  eissn: 2502-5791 control (which is usually followed by chemical control) (visaggio, n et al, 2018). synthesis of the qualitative and quantitative studies the results of the qualitative and quantitative studies are difficult to compare because only a small number of items were assessed by the aspects of the nurse's attitudes described in the qualitative research. regarding the nurses' feelings about the use of physical restraints, the qualitative results and those of the quantitative studies were inconsistent. the qualitative studies described negative feelings especially on the use of physical restraint. the quantitative surveys showed inconsistent results regarding the nurses' feelings. a level of agreement was shown regarding the reasons for using physical restraint. in qualitative research, the nurses describe the perceived need to use physical restraints to ensure the safety of both their clients and fellow officers. it is felt to be necessary to use physical restraint as confirmed by the quantitative surveys, which describes the safety issues, especially in terms of preventing falls and injuries and maintaining medical care. there is also evidence in qualitative research as well as in several quantitative surveys that nurses consider physical restraint to be an 'ordinary' nursing intervention. discussion the restraint models for mental disorder clients were physical, mechanical and chemical. responding to the lack of studies that focus more on physical control, this study reports on the latest collective experience indicating that restraint cannot be eliminated. the nurses tended to disagree if the restraint method was removed. restraint with physical, chemical and mechanical solutions could be tailored to the client's case in health care facilities. the results of this review should be considered when developing interventions aimed at reducing the use of restraint. policies addressing these measures need to be accompanied by wide-ranging initiatives to deal with aggression, including providing appropriate education and support and addressing the ethical and workplace cultural issues surrounding these practices. the nurses use physical restraint as one of the main strategies to control psychiatric patients, and despite having negative consequences, it is extensively used. given the risks and challenges of using physical restraint, nursing education should find alternative methods. some techniques used as an effort to develop a restraint model can be used as a basis for consideration in an effort to reduce physical restraint use. the choice of intervention can be adjusted to the client's case and the objectives that are to be achieved. conclusion the restraint models for mental disorder clients in health care facilities were physical, mechanical, and chemical. this study reports on the latest experience that it turns out that restraint cannot be eliminated. specialized psychiatric emergency services and emergency departments, because of their treatment primarily of acute patients, may not be able to entirely eliminate the use of seclusion and restraint. restraint through physical, chemical and mechanical solutions could be tailored to the client's case in health care facilities. references care, t., beckett, p., holmes, d., phipps, m., patton, d., molloy, l., & hons, m. n. (n.d.). trauma-informed care and practice. cunha, m., andré, s., bica, i., ribeiro, o., dias, a., & andrade, a. (2016). chemical and physical restraint of patients. procedia social and behavioral sciences, 217, 389–399. https://doi.org/10.1016/j.sbspro.2016.02.109 eskandari, f., abdullah, k. l., zainal, n. z., & wong, l. p. (2018). the effect of educational intervention on nurses’ knowledge, attitude, intention, practice and incidence rate of physical restraint use. nurse education in practice, 32(april 2017), 52–57. https://doi.org/10.1016/j.nepr.2018.07.007 espinosa, l., harris, b., frank, j., armstrong-muth, j., brous, e., moran, j., & giorgi-cipriano, j. (2015). archives of psychiatric nursing milieu improvement in psychiatry using evidence-based practices : the long and winding road of culture change. archives of psychiatric nursing, 29(4), 202–207. https://doi.org/10.1016/j.apnu.2014.08.004 gerace, a., & muir-cochrane, e. (2018). perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: an australian survey. int j ment health nurs, (october 2017). https://doi.org/10.1111/inm.12522 lan, s. h., lu, l. c., lan, s. j., chen, j. c., wu, w. j., chang, s. p., & lin, l. y. (2017). educational intervention on physical restraint use in long-term care facilities – systematic review and meta-analysis. kaohsiung journal of medical sciences, 33(8), 411– 421. https://doi.org/10.1016/j.kjms.2017.05.012 mahmoud, a. s. (2017). psychiatric nurses’ attitude and practice toward physical restraint. archives of psychiatric nursing, 31(1), 2–7. https://doi.org/10.1016/j.apnu.2016.07.013 muir-cochrane, e. c., baird, j., & mccann, t. v. (2015). nurses’ experiences of restraint and seclusion use in short-stay acute old age psychiatry inpatient units: a qualitative study. journal of psychiatric and mental health nursing, 22(2), 109–115. https://doi.org/10.1111/jpm.12189 perez, d., peters, k., wilkes, l., & murphy, g. (2018). physical restraints in intensive care–an jurnal ners http://e-journal.unair.ac.id/jners | 259 integrative review. australian critical care. https://doi.org/10.1016/j.aucc.2017.12.089 rhodes, k., & rhodes, a. (2017). aggression and violent behavior the pursuit of homeostasis : closing the gap between science and practice in the treatment of aggression and violence. aggression and violent behavior, 34, 9–19. https://doi.org/10.1016/j.avb.2017.03.003 rose, d., perry, e., rae, s., & good, n. (2017). service user perspectives on coercion and restraint in mental health. bjpsych. international, 14(03), 59– 61. https://doi.org/10.1192/s2056474000001914 shrestha, y. (2017). archives of psychiatric nursing knowledge and attitude of family member of mentally ill patient regarding restraint , 2016. archives of psychiatric nursing, (november), 0–1. https://doi.org/10.1016/j.apnu.2017.11.018 visaggio, n., phillips, k. e., kichefski, k., mcelhinney, j., idiculla, t. b., blair, e. w., … young, s. c. (2018). archives of psychiatric nursing is it safe ? the restraint chair compared to traditional methods of restraint : a three hospital study. archives of psychiatric nursing, (march), 0–1. https://doi.org/10.1016/j.apnu.2018.04.003 winokur, e. j., loucks, j., & raup, g. h. (2018). use of a standardized procedure to improve behavioral health patients’ care: a quality improvement initiative. journal of emergency nursing, 44(1), 26–32. https://doi.org/10.1016/j.jen.2017.07.008 wu, w. w. k. (2015). psychosocial correlates of patients being physically restrained within the first 7 days in an acute psychiatric admission ward : retrospective case record review. 47–57. 260 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17030 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review information technology-based interventions for health care support in patients with chronic kidney disease: a systematic review inda rian patma putri, nursalam nursalam and ninuk dian kurniawati faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: self-management and support in managing therapeutic regimens is very important for patients with ckd. information technologybased interventions are increasingly being used to support the selfmanagement of patients with ckd. this study aimed to conduct a systematic review to evaluate information technology-based interventions in relation to the support of the health management of patients with ckd. method: we conducted a systematic review using electronic databases (scopus, science direct, proquest) limited to the last 8 years from 2010 to 2018 with the relevant keywords. the studies included used rct, pilot and case-control methods focusing on patients with ckd stage 1-5 and that reported on at least one outcome from the health management of patients with ckd. out of the 7.852 studies taken, 13 studies fulfilled the inclusion criteria. result: the interventions in this systematic review are multifaceted, including smartphone/pda (6/13), telematics devices (2/13), internet/web (3/13) and a combination of several interventions (2 studies). in total, 12 (92%) out of the 13 studies showed a positive outcome from the intervention, 7 studies showed improved outcomes in the clinical points, 3 studies had improved adherence and 2 studies improved knowledge. conclusion: this evidence indicates the potential of it-based interventions (i.e. smartphone/pda, computer, internet/web, telematic device) to support the health management of patients with ckd. the variety of interventions in this systematic review requires further research on which interventions are best applied. article history received: december 26, 2019 accepted: december 31, 2019 keywords information technology; health care support; chronic kidney disease; selfmanagement contact inda rian patma putri  inda.rian.patma2017@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: putri, i. r. p., nursalam, n., & kurniawati, n. d. (2019). information technology-based interventions for health care support in patients with chronic kidney disease: a systematic review. jurnal ners, 14(3si), 259265. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17030 introduction the prevalence of chronic kidney disease is increasing around the world. this has a major impact on the health system resources related to care. hemodialysis is the main alternative therapy for modalities to help increase the survival of patients with chronic kidney disease (chiou & chung, 2012). studies have stated that the success of hemodialysis is related to patient compliance, both to the therapeutic regimen and to the fluid and dietary restrictions (kim, evangelista, phillips, pavlish, & kopple, 2010). personal involvement is needed to integrate the complex recommendations about compliance with the lifestyle modifications (diamantidis & becker, 2014). self-management is about how individuals know their illness, how they manage their symptoms, how they monitor themselves at home and how they implement daily care plans including following a complex treatment regimen, diet and fluid restrictions, even for those who do dialysis as in (bonner et al., 2018). innovation and efficient ways to improve the health behavior in patients with chronic kidney disease are needed. at present, the use of the internet and mobile devices in providing health care is growing rapidly (lin, wang, jing, & chang, 2014). technological developments provide convenience and access to various health information applications and it helps the service patients with chronic diseases (diamantidis & becker, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 261 2014). in the current phenomenon, the application of mobile computing related to health will increasingly play a role for chronic disease patients and even elderly users (diamantidis & becker, 2014). the development of electronic health implementations is very promising to increase access to the relevant health information, to improve the quality of services and to support the management of self-care and positive health behavior (ong et al., 2016) the aim of this study was to conduct a systematic review of the effectiveness of information technologybased interventions for self-care support in patients with chronic kidney disease. the results of this systematic review are expected to be applicable to the relevant health services. this systematic review is presented in the form of articles consisting of an abstract, introduction, method, results, picot, discussion, implications for practice, conclusions and a bibliography. materials and methods this systematic review was conducted and reported according to the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. search strategies the systematic search using the picot framework utilized electronic databases through keywords. the first step was to search the electronic databases based on the determined keywords according to the topics contained in the picot framework (science direct, sage journals, scopus, proquest) to identify the relevant studies published from 2010 1018. the search strategy included a combination of keywords related to it (such as information technology, mhealth, e-health, monitoring) and also chronic kidney disease (such as kidney disease, renal transplant, hemodialysis). eligibility criteria the selection criteria in this study were determined based on population, intervention, results and study design. the inclusion criteria included: 1) it-based interventions in chronic kidney disease with stage 35 chronic kidney disease, patients undergoing hemodialysis and kidney transplant patients, 2) information technology with mobile health (smartphones, pdas), e-mail, internet / web, computers, telematics / electronic transmission devices, 3) the research design included rcts, pilot studies and quasi-experiments and 4) they were in the english language. the exclusion criteria were: 1) studies where the health care providers were the users, 2) studies that only offer the feasibility or validity of the it-based interventions, 3) pediatric patients and 4) peritoneal dialysis patients. selection of articles this systematic review used the prisma method for systematic reviews followed by selection including figure 1. searching for the articles following tthe prisma flow. removing duplicates. then, three reviewers chose the titles, abstracts and keywords, then they deleted any studies that were irrelevant according to the selection criteria. the three reviewers independently screened the titles and abstracts including the reasons for choosing the study and the selection of the inclusion and exclusion criteria through an electronic search. the full text of all articles were taken and assessed. differences in opinion about the relevance of any articles were resolved through a discussion. after the article was completed, the record sheet was prepared for systematic data extraction. the data was extracted by the first reviewer and then the other reviewers examined and verified the accuracy and identified any information that might be missing. result this study reviewed the 13 selected articles from various countries. overall, 12 out of the 13 studies (92%) indicated that using technology-based interventions was effective at supporting health care in ckd patients (an, 2011; blakeman et al., 2014; cicolini et al., 2014; cottrell, chambers, & connell, 2012; cueto-manzano et al., 2015; gordon et al., 2016; mcgillicuddy et al., 2013; neumann et al., 2013; ogna et al., 2014; ong et al., 2016; rifkin et al., 2013; welch et al., 2013). this review contained several studies on chronic kidney disease: stage 3-4 chronic kidney disease (cottrell et al., 2012), kidney transplant (cueto-manzano et al., 2015; mcgillicuddy et al., 2013) and patients undergoing hemodialysis (ogna et al., 2014; welch et al., 2013). the number of samples i. r. p. putri et al. 262 | pissn: 1858-3598  eissn: 2502-5791 varied between 20-436 respondents. this systematic review included several study designs including rcts (blakeman et al., 2014; gordon et al., 2016; mcgillicuddy et al., 2013; neumann et al., 2013; ogna et al., 2014; rifkin et al., 2013; sevick et al., 2015), experimental queries (an, 2011; cottrell et al., 2012) and pilot studies (cueto-manzano et al., 2015; welch et al., 2013) which are intended to get a broad picture of the coverage of it-based interventions. some of the information technology-based interventions used in this study included smartphone/pda, computers and internet/web (cueto-manzano et al., 2015; mcgillicuddy et al., 2013; ong et al., 2016; sevick et al., 2015; welch et al., 2013). overall, 12 out of the 13 studies showed that the use of information technology-based interventions was effective at improving self-health management in patients with chronic kidney disease as indicated by the positive results in the clinical, compliance and knowledge values (an, 2011; blakeman et al., 2014; cicolini et al., 2014; cottrell et al., 2012; cueto-manzano et al., 2015; gordon et al., 2016; mcgillicuddy et al., 2013; neumann et al., 2013; ogna et al., 2014; ong et al., 2016; rifkin et al., 2013; welch et al., 2013) . the study (3 out of 10) used telematics devices as interventions (neumann et al., 2013; ogna et al., 2014; rifkin et al., 2013), four studies used pdas and smartphone technology (applications/software/ sms) (cueto-manzano et al., 2015; neumann et al., 2013; ong et al., 2016; sevick et al., 2015; welch et al., 2013), two studies used interactive messaging services (cottrell et al., 2012), 1 study used a combination of smartphones with electronic devices (mcgillicuddy et al., 2013), and 1 study used the web and e-mail (an, 2011; blakeman et al., 2014; gordon et al., 2016). most studies reported high values of satisfaction and acceptance of the interventions, as well as effective results related to managing patient health. some of the studies using interventions in the form of telematics tools (drug monitoring, blood pressure monitoring, weight monitoring) showed good results related to the clinical results in the form of idwg, blood pressure and medication adherence (neumann et al., 2013; ogna et al., 2014; rifkin et al., 2013). in addition, the intervention used involved a combination of other modalities such as the presence of web-based applications which were found to have positive results (gordon et al., 2016). other interventions with the internet were combined with telematics devices (electronic drug tray that records the real time when the bottle was opened connected to the internet to automatically transmit data) and blood pressure monitoring devices. they showed success in the indicators of adherence to the treatment regimens and decreased blood pressure (neumann et al., 2013; ogna et al., 2014; rifkin et al., 2013). in the study using the m-health intervention in the form of the smartphone application, in addition to the improvement in terms of the results of the indicators of compliance, it was also reported that there was satisfaction in the patients (welch et al., 2013). the advantages that can be observed in interventions using smartphone applications are related to its interesting features (ong et al., 2016). smartphone applications have the potential to overcome the complexity of non-compliance behaviors related to lifestyle with respect to complete, unique and interesting features (ong et al., 2016). another study using pdas stated that there was no significant difference in idwg changes but that there were difference in sodium intake (sevick et al., 2015). m-health (smartphones, pdas) several studies evaluating interventions using smartphones/pdas included using applications (software) (sevick et al., 2015; welch et al., 2013), automatic text messaging and electronic monitoring. the development of smartphones has made apps a potential tool for increasing the adherence to treatment (santo et al., 2017). several studies using interventions with smartphone applications have shown positive results regarding the indicators of health and self-management behavior in patients with chronic kidney disease (cottrell et al., 2012; cueto-manzano et al., 2015; mcgillicuddy et al., 2013). a pilot study conducted on 23 kidney transplant patients using text messaging applications and reminders that contained information on the risk factors for kidney disease, a healthy lifestyle diet and medication adherence have been reported to have the potential to influence the patients' health behavior and clinical outcomes (cueto-manzano et al., 2015). in another study, research conducted over 6 months in canada with an mhealth intervention, namely a smartphone application including data servers for information management combined with wireless blood pressure monitoring devices (with bluetooth), on 47 stage 4 and 5 ckd patients showed good results regarding the clinical results of blood pressure monitoring and their access to care resources (ong et al., 2016). the application allows for feedback to be sent to the service provider (via email) when the patient's clinical value is at the threshold(welch et al., 2013). another randomized study of 20 kidney transplant patients for 3 months was with an intervention using a smartphone (automatic text message) combined with a blood pressure measurement device (automatically sent via bluetooth to a cellphone) and an electronic drug tray. this showed significant results in relation to medication adherence and systolic blood pressure in the intervention group (mcgillicuddy et al., 2013). an rct study with an intervention using an automatic text messaging application that was connected to a server to deliver reminders to take their blood pressure measurements applied to 490 ckd patients showed significant results in terms of their blood pressure reduction (ogna et al., 2014). the mhealth of electronic diet monitoring (dima) applications used on pdas gave positive results regarding patient idwg (9). not all of the interventions with mhealth jurnal ners http://e-journal.unair.ac.id/jners | 263 showed significant results. randomized research in pennsylvania with electronic diet monitoring interventions through pda and diet counseling with 179 patients undergoing hemodialysis stated that there were no significant differences in the idwg changes. however, positive results were seen in the behavior related to sodium intake, although this behavior was maintained in the short term (16 weeks during the intervention) (sevick et al., 2015). internet / web interventions with web-based education were conducted in chicago with 63 hispanic kidney patients who underwent dialysis. it was found that the internet can effectively improve the knowledge of kidney transplants. most stated that interventions through the web could increase the patients' knowledge of kidney transplants, and so the interventions were declared feasible and accepted (gordon et al., 2016). another study was conducted on 436 stage 3 ckd patients randomly for 6 months by giving them an intervention in the form of providing information through the internet (interactive website) with a combination of telephone access guides. there were positive results on the patient's quality of life by 26.3% (eq-5d), blood pressure control and their positive involvement in life (heiq). the patients stated that they accessed the website and 62% of patients said that this intervention encouraged them to be more active in their daily activities (blakeman et al., 2014). other studies showed that the use of interventions with the e-mailing of information in 40 patients undergoing hemodialysis had results that were effective in terms of reducing stress levels. this was indicated by a lower level of serum cortisol and lower epinephrine results compared to the control group, in addition to increased compliance with fluid restrictions in the patients (an, 2011). telematics / wireless devices interventions were carried out on 120 patients undergoing hemodialysis with telematics measuring the weight transferred by telemetry daily to their mobile phones, which were automatically connected to e-mail. they showed there to be a significant difference in the patient's idwg (neumann et al., 2013). this study states that interventions with technology can be accepted for patient selfmonitoring as the telematics tool has the potential to be one method to optimize idwg and ultrafiltration (neumann et al., 2013). although it does not affect the idwg, it can reduce the intake of sodium in the diet (neumann et al., 2013). interventions using electronic drug devices in 50 patients undergoing hemodialysis had significant results regarding the increase in cinacalcet adherence, making it possible to reduce the dose of cinacalcet and to increase the number of patients, thus reaching the target (ong et al., 2016). the intervention with wireless blood pressure monitoring devices connected to the internet (web server) conducted in the elderly with stage 3 ckd with hypertension that was not controlled showed good results regarding their blood pressure (rifkin et al., 2013). m-health (smartphones, pdas) several studies evaluating interventions using smartphones/pdas included using applications (software) (sevick et al., 2015; welch et al., 2013), automatic text messaging and electronic monitoring. the development of smartphones has made apps a potential tool for increasing the adherence to treatment (santo et al., 2017). several studies using interventions with smartphone applications have shown positive results regarding the indicators of health and self-management behavior in patients with chronic kidney disease (cottrell et al., 2012; cueto-manzano et al., 2015; mcgillicuddy et al., 2013). a pilot study conducted on 23 kidney transplant patients using text messaging applications and reminders that contained information on the risk factors for kidney disease, a healthy lifestyle diet and medication adherence have been reported to have the potential to influence the patients' health behavior and clinical outcomes (cueto-manzano et al., 2015). in another study, research conducted over 6 months in canada with an mhealth intervention, namely a smartphone application including data servers for information management combined with wireless blood pressure monitoring devices (with bluetooth), on 47 stage 4 and 5 ckd patients showed good results regarding the clinical results of blood pressure monitoring and their access to care resources (ong et al., 2016). the application allows for feedback to be sent to the service provider (via email) when the patient's clinical value is at the threshold(welch et al., 2013). another randomized study of 20 kidney transplant patients for 3 months was with an intervention using a smartphone (automatic text message) combined with a blood pressure measurement device (automatically sent via bluetooth to a cellphone) and an electronic drug tray. this showed significant results in relation to medication adherence and systolic blood pressure in the intervention group (mcgillicuddy et al., 2013). an rct study with an intervention using an automatic text messaging application that was connected to a server to deliver reminders to take their blood pressure measurements applied to 490 ckd patients showed significant results in terms of their blood pressure reduction (ogna et al., 2014). the mhealth of electronic diet monitoring (dima) applications used on pdas gave positive results regarding patient idwg (9). not all of the interventions with mhealth showed significant results. randomized research in pennsylvania with electronic diet monitoring interventions through pda and diet counseling with 179 patients undergoing hemodialysis stated that there were no significant differences in the idwg changes. however, positive results were seen in the behavior related to sodium intake, although this behavior was maintained in the short term (16 weeks during the intervention) (sevick et al., 2015). i. r. p. putri et al. 264 | pissn: 1858-3598  eissn: 2502-5791 internet / web interventions with web-based education were conducted in chicago with 63 hispanic kidney patients who underwent dialysis. it was found that the internet can effectively improve the knowledge of kidney transplants. most stated that interventions through the web could increase the patients' knowledge of kidney transplants, and so the interventions were declared feasible and accepted (gordon et al., 2016). another study was conducted on 436 stage 3 ckd patients randomly for 6 months by giving them an intervention in the form of providing information through the internet (interactive website) with a combination of telephone access guides. there were positive results on the patient's quality of life by 26.3% (eq-5d), blood pressure control and their positive involvement in life (heiq). the patients stated that they accessed the website and 62% of patients said that this intervention encouraged them to be more active in their daily activities (blakeman et al., 2014). other studies showed that the use of interventions with the e-mailing of information in 40 patients undergoing hemodialysis had results that were effective in terms of reducing stress levels. this was indicated by a lower level of serum cortisol and lower epinephrine results compared to the control group, in addition to increased compliance with fluid restrictions in the patients (an, 2011). telematics / wireless devices interventions were carried out on 120 patients undergoing hemodialysis with telematics measuring the weight transferred by telemetry daily to their mobile phones, which were automatically connected to e-mail. they showed there to be a significant difference in the patient's idwg (neumann et al., 2013). this study states that interventions with technology can be accepted for patient selfmonitoring as the telematics tool has the potential to be one method to optimize idwg and ultrafiltration (neumann et al., 2013). although it does not affect the idwg, it can reduce the intake of sodium in the diet (neumann et al., 2013). interventions using electronic drug devices in 50 patients undergoing hemodialysis had significant results regarding the increase in cinacalcet adherence, making it possible to reduce the dose of cinacalcet and to increase the number of patients, thus reaching the target (ong et al., 2016). the intervention with wireless blood pressure monitoring devices connected to the internet (web server) conducted in the elderly with stage 3 ckd with hypertension that was not controlled showed good results regarding their blood pressure (rifkin et al., 2013). discussion self-management support is seen of as a priority for people with long-term health problems. the effective management of health and ckd can prevent the development of the disease and reduce the risk of the complications of cardiovascular disease(ong et al., 2016). this review provides evidence regarding the effectiveness of it-based interventions in the health management of ckd patients related to clinical, compliance and knowledge values. substantial advancements in information and mobile technology, as well as the increasingly widespread mobile-health, has become a promising new alternative tool for improving health services by increasing the adherence to treatment therapy(santo et al., 2017). interventions using monitoring/reminders are mainly based on the principles of learning behavior(welch et al., 2013). the techniques used in self-care programs include the use of cellphones, computer networks and web-based tools. this is very useful especially in developing countries as mobile phones have high penetration and can even reach large areas(diamantidis & becker, 2014). this study provides evidence related to the shortterm effectiveness (<6 months) of electronic reminder interventions in terms of improving treatment compliance in patients with chronic kidney disease (clark-cutaia, ren, hoffman, burke, & sevick, 2014; gordon et al., 2016; mcgillicuddy et al., 2013; neumann et al., 2013). it-based interventions here included a smartphone / pda (as well as a combination with telematics), internet / web (combination with e-mail) and telematics / wireless devices (cueto-manzano et al., 2015; mcgillicuddy et al., 2013; neumann et al., 2013; ong et al., 2016; sevick et al., 2015). in this study, blood pressure and idwg values were the clinical outcomes that were assessed and they showed significant improvements in most studies. another outcome that was assessed was adherence to treatment, which can help in the treatment of patients with chronic kidney failure. in several of the studies reviewed, it-based interventions allow the providers to manage patient data remotely so then they can monitor and provide the direction needed by the patients. telematics equipment, which allows for the direct wireless transmission of patient data to the central system, can reduce the risk of errors caused by manual entry (human error). there are some potential limitations related to this systematic review; (1) the heterogeneity of study design and (2) this review has diversity in its results and in the interventions reviewed, so further research is needed regarding which interventions are best applied. based on the results of the study, the use of interventions with smartphones / pdas can support health management, especially for medication adherence as well as clinical values of blood pressure and idwg in patients with chronic kidney disease. smartphone applications have the potential to overcome the complexity of non-compliance behaviors related to lifestyle with respect to complete, unique and interesting features. jurnal ners http://e-journal.unair.ac.id/jners | 265 conclusion it-based interventions can be an alternative in interventions to improve the health management olf patients with chronic kidney disease. technological advances make it-based interventions a promising alternative but more research is needed in terms of evidence-based outcomes, especially in developing countries. by knowing some it-based interventions, it can be used as a consideration in terms of the alternative interventions suggested by the health providers. this study shows that it-based interventions can improve self-management and patient empowerment as in blood pressure control, idwg and medication compliance. it-based interventions can therefore be used in further clinical practices, like a combination of smartphones and health devices. references an, g. j. (2011). effect of e-mail education on stress and compliance in korean elderly on hemodialysis. hong kong journal of nephrology, 13(2), 68–73. https://doi.org/10.1016/j.hkjn.2011.10.002 blakeman, t., blickem, c., kennedy, a., reeves, d., bower, p., gaffney, h., … rogers, a. (2014). effect of information and telephone-guided access to community support for people with chronic kidney disease: randomised controlled trial. plos one, 9(10). https://doi.org/10.1371/journal.pone.0109135 bonner, a., gillespie, k., campbell, k. l., coroneswatkins, k., hayes, b., harvie, b., … havas, k. (2018). evaluating the prevalence and opportunity for technology use in chronic kidney disease patients: a cross-sectional study. bmc nephrology, 19(1), 4–11. https://doi.org/10.1186/s12882-018-0830-8 chiou, c. p., & chung, y. c. (2012). effectiveness of multimedia interactive patient education on knowledge, uncertainty and decision-making in patients with end-stage renal disease. journal of clinical nursing, 21(9–10), 1223–1231. https://doi.org/10.1111/j.13652702.2011.03793.x cicolini, g., simonetti, v., comparcini, d., celiberti, i., di nicola, m., capasso, l. m., … manzoli, l. (2014). efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: a randomized controlled trial. international journal of nursing studies, 51(6), 833–843. https://doi.org/10.1016/j.ijnurstu.2013.10.010 clark-cutaia, m. n., ren, d., hoffman, l. a., burke, l. e., & sevick, m. a. (2014). adherence to hemodialysis dietary sodium recommendations: influence of patient characteristics, self-efficacy, and perceived barriers. journal of renal nutrition, 24(2), 92–99. https://doi.org/10.1053/j.jrn.2013.11.007 cottrell, e., chambers, r., & connell, p. o. (2012). using simple telehealth in primary care to reduce blood pressure : a service evaluation. https://doi.org/10.1136/bmjopen-2012-001391 cueto-manzano, a. m., gallardo-rincón, h., martínezramírez, h. r., cortés-sanabria, l., rojas-campos, e., tapia-conyer, r., … medina, m. (2015). a pilot study of a mobile phone application to improve lifestyle and adherence of patients with kidney disease. journal of telemedicine and telecare, 21(2), 119–120. https://doi.org/10.1177/1357633x14566591 diamantidis, c. j., & becker, s. (2014). health information technology (it) to improve the care of patients with chronic kidney disease (ckd). bmc nephrol, 15, 7. https://doi.org/10.1186/14712369-15-7 gordon, e. j., feinglass, j., carney, p., vera, k., olivero, m., black, a., … caicedo, j. c. (2016). a website intervention to increase knowledge about living kidney donation and transplantation among hispanic/latino dialysis patients. progress in transplantation, 26(1), 82–91. https://doi.org/10.1177/1526924816632124 kim, y., evangelista, l. s., phillips, l. r., pavlish, c., & kopple, j. d. (2010). the end-stage renal disease adherence questionnaire (esrd-aq): testing the psychometric properties in patients receiving incenter hemodialysis. nephrology nursing journal, 37(4), 377–393. lin, h. w., wang, y. j., jing, l. f., & chang, p. (2014). mockup design of personal health diary app for patients with chronic kidney disease. studies in health technology and informatics, 201, 124–132. https://doi.org/10.3233/978-1-61499-415-2124 mcgillicuddy, j. w., gregoski, m. j., weiland, a. k., rock, r. a., brunner-jackson, b. m., patel, s. k., … treiber, f. a. (2013). mobile health medication adherence and blood pressure control in renal transplant recipients: a proof-of-concept randomized controlled trial. jmir research protocols, 2(2), e32. https://doi.org/10.2196/resprot.2633 neumann, c. l., wagner, f., menne, j., brockes, c., schmidt-weitmann, s., rieken, e. m., … schulz, e. g. (2013). body weight telemetry is useful to reduce interdialytic weight gain in patients with endstage renal failure on hemodialysis. 480–486. https://doi.org/10.1089/tmj.2012.0188 ogna, v. f., pruijm, m., zweiacker, c., wuerzner, g., tousset, e., & burnier, m. (2014). clinical benefits of an adherence monitoring program in the management of secondary hyperparathyroidism with cinacalcet : results of a prospective randomized controlled study clinical benefits of an adherence monitoring program in the management of second. (july 2013). https://doi.org/10.1155/2013/104892 ong, s. w., jassal, s. v., miller, j. a., porter, e. c., cafazzo, j. a., seto, e., … logan, a. g. (2016). integrating a smartphone–based self– i. r. p. putri et al. 266 | pissn: 1858-3598  eissn: 2502-5791 management system into usual care of advanced ckd. clinical journal of the american society of nephrology, 11(6), 1054–1062. https://doi.org/10.2215/cjn.10681015 rifkin, d. e., abdelmalek, j. a., miracle, c. m., low, c., barsotti, r., rios, p., … agha, z. (2013). linking clinic and home : a randomized , controlled clinical effectiveness trial of real-time , wireless blood pressure monitoring for older patients with kidney disease and hypertension. 8–15. https://doi.org/10.1097/mbp.0b013e32835d12 6c santo, k., chow, c. k., thiagalingam, a., rogers, k., chalmers, j., & redfern, j. (2017). medication reminder apps to improve medication adherence in coronary heart disease ( medapp-chd ) study : a randomised controlled trial protocol. 1–10. https://doi.org/10.1136/bmjopen-2017-017540 sevick, m. a., piraino, b. m., st-jules, d. e., hough, l. j., hanlon, j. t., marcum, z. a., … stone, r. a. (2015). no difference in average interdialytic weight gain observed in a randomized trial with a technologysupported behavioral intervention to reduce dietary sodium intake in adults undergoing maintenance hemodialysis in the united states : primary outcomes of . 1–10. https://doi.org/10.1053/j.jrn.2015.11.006 welch, j. l., astroth, k. s., perkins, s. m., johnson, c. s., connelly, k., siek, k. a., … scott, l. l. (2013). using a mobile application to self-monitor diet and fluid intake among adults receiving hemodialysis. research in nursing and health, 36(3), 284–298. https://doi.org/10.1002/nur.21539 search strategies eligibility criteria selection of articles m-health (smartphones, pdas) internet / web telematics / wireless devices m-health (smartphones, pdas) internet / web telematics / wireless devices http://e-journal.unair.ac.id/jners | 69 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.15700 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the comparison of progressive muscle relaxation frequency on anxiety, blood pressure, and pulse of haemodialysis patients kusnanto kusnanto1, maulana arif murtadho2, lilik herawati3 and hidayat arifin2 1 faculty of nursing, universitas airlangga, east java, indonesia 2 master of nursing program, faculty of nursing, universitas airlangga, surabaya, indonesia 3 faculty of medicine, universitas airlangga, surabaya, indonesia abstract introduction: haemodialysis is one of the kidney replacements therapies, but, as it cannot wholly replace kidney function, it still causes complications such as increased blood pressure and pulse which can lead to anxiety for the patient. the purpose of this study was to explain the effect of progressive muscle relaxation (pmr) on anxiety, blood pressure and pulse in haemodialysis patients. methods: the study design was a true pre-post-test control group design experiment. the total sample was 105 haemodialysis patients taken by purposive sampling technique and divided into two intervention groups and one control group. the independent variable was pmr, and the dependent variables were anxiety, blood pressure and pulse. data were obtained using a questionnaire and analysed using the kruskal wallis test and mann-whitney u test with a significance level <0.05. results: the results of the pmr two times per week group analysis for one month showed a significant influence on anxiety (p=0.000), blood pressure (p=0.000), and pulse rate (p=0.000). mann-whitney u test results showed a significant effect on anxiety (p=0.004), blood pressure (p=0.000), and pulse (p=0.000). conclusion: haemodialysis patients who performed pmr interventions showed a promising outcome on a decrease in anxiety, blood pressure and pulse. the regular application of pmr interventions can control vital signs in patients undergoing haemodialysis article history received: october 16, 2019 accepted: december 02, 2019 keywords haemodialysis; progressive muscle relaxation; anxiety; blood pressure; pulse contact kusnanto kusnanto  kusnanto@fkp.unair.ac.id  faculty of nursing, universitas airlangga east java, indonesia cite this as: kusnanto, k., murtadho, m. a., herawati, l., & arifin, h. (2019). the comparison of progressive muscle relaxation frequency on anxiety, blood pressure, and pulse of haemodialysis patients. jurnal ners, 14(1), 69-74. doi:http://dx.doi.org/10.20473/jn.v14i1.15700 introduction chronic kidney disease (ckd) is a problem that is often found in the community; in its journey, if it reaches to stage five, it will require kidney replacement therapy in the form of kidney transplantation or dialysis (kdigo, 2013; tomson & taylor, 2015). between the two types of replacement therapy, dialysis is a standard therapy carried out and haemodialysis (hd) is a procedure that results in the rest of metabolism, and excess fluid is removed from the blood through the artificial kidney (amini, goudarzi, masoudi, ahmadi, & momeni, 2016). haemodialysis cannot heal and is unable to compensate for the loss of metabolic or endocrine activity carried out by the kidneys, so that patients continue to experience complications, including increased blood pressure and pulse that cannot be controlled. studies estimating ckd prevalence with hd in general populations worldwide found a consistent rate estimated of 11-13% (li, jiang, wu, xu, & miao, 2017; qureshi, lorch, & navaneethan, 2017; rahimlu, shab-bidar, & djafarian, 2017; trapp et al., 2014; valika & peixoto, 2016). the complication raises new more complex problems, including anxiety (kokoszka et al. 2016). anxiety in patients who do hd often lacks people’s attention, even though the psychological burden experienced by hd patients can affect health and treatment (li et al., , , 2016). anxiety is a major factor that can reduce the health of hd patients. in our study site location, the interventions are given to patients to reduce anxiety with health education, and there are no additional interventions. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ k kusnanto et al. 70 | pissn: 1858-3598  eissn: 2502-5791 further efforts are needed to reduce anxiety, blood pressure and pulse experienced by hd patients. the proportion of the global population with anxiety disorders in 2015 was estimated at 3.6%. depression and anxiety disorders are more common in women than men (4.6% compared to 2.6% at the global level). the data showed the prevalence of emotional, and mental diseases as indicated by symptoms of depression and anxiety for ages 15 years and older, reaching around 14 million people or 6% of the total population of indonesia (riskesdas, 2018). in the blood pressure and pulse rate of 100 haemodialysis patients, an estimated 80 patients experienced changes in both. one of the essential intradialytic complications to evaluate is cardiovascular problems because it causes an increase in morbidity and mortality in ckd patients undergoing routine haemodialysis (shin, yeo, hong, hwang, & kim, 2018). cardiovascular complications can include blood pressure and pulse that cannot be controlled. in increased blood pressure often associated with renin, fluid overload and sympathetic nerves, these sympathetic nerves also affect the pulse rate in haemodialysis patients. (li et al, 2017). all complications arising will increase the anxiety felt by the patient. the anxiety in sedentary hd patients can contribute to disease progression and worsen the prognosis (li et al., 2016). the intervention to minimise complications is usually pharmacological and non-pharmacological therapies, but, due to a disruption in kidney function, an alternative that can be used is non-pharmacological therapy. pmr is a relaxation technique through two processes, namely tensing and relaxing the muscles of the body, which is a combination of breathing and movement exercises (mhaske, poovishnu devi, & jagtap, 2018). pmr can reduce anxiety for five times per week (ramasamy, panneerselvam, govindharaj, kumar, & nayak, 2018); improved physical function (ublosakka-jones, tongdee, pachirat, & jones, 2018); sleeping disorder seyedi chegeni, gholami, azargoon, hossein pour, birjandi, & norollahi, 2018), mental (li et al., 2015); and quality of life (ramasamy et al., 2018). implementation of pmr for five times per week can reduce patient anxiety in the hospital (amini, goudarzi, masoudi, ahmadi, & momeni, 2016; ramasamy, panneerselvam, govindharaj, kumar, & nayak, 2018), while research conducted by li et al. (2015) states giving it three times per week can reduce anxiety. the success of an exercise is also determined by the frequency performed. based on the explanation above, research is needed to analyse the effect of the comparison of pmr frequency two times per week for one month and one time per week on anxiety, blood pressure and pulse frequency in hd patients. materials and methods the research was true-experimental with pre-posttest control group design. the population was 192 haemodialysis patients at “x” hospital in east java province. the total samples were 105 people obtained by purposive sampling with inclusion criteria 1) conscious and cooperative patients (compos mentis) and cooperative; 2) aged >18 years; 3) having hd for >2 months, and undergoing hd twice per week; 4) systolic blood pressure between 120 160mmhg, and diastole between 80-110mmhg before hd; and 5) pulse between 70-100 x per minute before hd. the exclusion criteria included: 1) the patient having chronic unstable heart disease; 2) the patient experiences neuromusculoskeletal system disorders such as chronic injuries, fractures, increased intracranial pressure, severe coronary artery disease, and is pregnant; and 3) being weak (haemoglobin (hb)<8). the dropout criteria: 1) respondents resign during the study; 2) respondents are not cooperative in answering the questionnaire given; 3) respondents who did not follow the intervention more than three times in a row and did not take the post-test; and 4) respondents move haemodialysis. the independent variable was the progressive muscle relaxation intervention and the dependent variables were the change in anxiety, blood pressure and pulse. anxiety was measured with the covi anxiety scale (lipman & covi, 1981) which consists of a quantitative anxiety assessment. blood pressure was measured using an automatic tensiometer, and a pulse with palpation which was then documented on the observation sheet. the collected data were analysed by kruskal wallis to analyse differences between groups (treatment 1, treatment 2, and control) and wilcoxon signed rank test to find out the difference between pre-test and post-test in each group. the researchers assessed the anxiety score using the covi anxiety scale questionnaire sheet in order to obtain an initial score before the intervention. then, the researchers conducted a matching technique based on the level of scoring results to try to maintain the homogeneity of respondents and divide respondents into treatment 1 (pmr group two times per week for one month) with 35 respondents, treatment 2 (pmr group once per week for one month) with 35 respondents, and the control group with 35 respondents. after four weeks of intervention, a post-test was conducted on both groups as an evaluation using the covi anxiety scale questionnaire. this study has obtained ethical eligibility from the health research ethics committee of “x” hospital with number 893.3/1873/438.6.7/2019. results the results of studies on the variables anxiety, blood pressure (systole and diastole) and pulse can be seen in table 1 with 105 respondents. the results of the study on anxiety variables found a significant difference in the significance of anxiety changes in treatment 1 with the control group, obtaining a p=0.004 which means that treatment 1 was a change in anxiety compared with the control group. whereas jurnal ners http://e-journal.unair.ac.id/jners | 71 in treatment 2 compared to the control group, it could be interpreted that there was no significant difference because of obtaining a p-value of 0.05. in the comparison of treatment 1 and treatment 2 it can be interpreted that there was no significant difference, with p-value 0.05. treatment 1 affects anxiety; this is indicated by the difference in anxiety values in treatment 1, treatment 2 and control group. the results of the study are that blood pressure systole variable showed differences in systolic blood pressure in treatment 1 with the control group obtaining a p=0.000. this means that treatment 1 was a change in systolic blood pressure compared to the control group. with treatment 2 compared to the control group, it can be interpreted that there was a significant difference, with p=0.019, whereas in the comparison of treatment 1 and treatment 2, it can be interpreted that there was a significant difference, with p=0.000. treatment 1 was the most effective in changes in systolic blood pressure compared to treatment 2; this is indicated by the difference in anxiety values in treatment 1, treatment 2 and the control group. the results of the study on the blood pressure diastole variable obtained significant diastole blood pressure differences in the three groups. it showed a significant difference with p=0.000, which means that treatment 1 was the best group in diastolic blood pressure changes compared to treatment 2 and control. thus, it can be concluded that implementation of treatment 1 has an effect on diastolic blood pressure; this is indicated by the difference in the value of diastolic blood pressure in treatment 1, treatment 2 and the control group. the results of the study on the pulse variable obtained a significant difference in the pulse rate in the three groups and showed a significant difference with a value of p<0.000, which means that treatment 1 affected the change in pulse rate of haemodialysis patients compared to treatment 2 and the control group. thus, it can be concluded that implementation of treatment 1 was the most effective against changes in pulse; this is indicated by the difference in the value of pulse changes in treatment 1, treatment 2 and the control group. discussion anxiety variable change in anxiety in the progressive muscle relaxation group two times per week for one month showed a significant decrease, which means there was an influence of pmr two times per week for one month compared to the control group. the progressive muscle relaxation group one time per week for one month showed no significant decrease, which means there was no effect of pmr one time per week for one month compared to the control group. whereas the comparison of the progressive muscle relaxation group two times per week for one month and the progressive muscle relaxation group one time per week for one month showed a nonsignificant decrease, which means that the administration of pmr two times per week for one month and pmr one time per week for one month were both effective on anxiety changes in haemodialysis patients. however, the pmr group two times per week for one month showed a more effective value when compared to the pmr group one time per week for one month and the control group. the results of this study are consistent with other studies that show that progressive muscle relaxation can reduce anxiety. research conducted by ramasamy, panneerselvam, govindharaj, kumar, and nayak (2018) states that progressive muscle table 1. the intervention of progressive muscle relaxation two times per week for one month (treatment 1) and one time per week for one month (treatment 2) for changes in anxiety, blood pressure (systole and diastole) and pulse. variables pre p* post p* delta p* mean ± sd p** p*** anxiety treatment 1 9.91 ± 2.120 0.000 9.31 ± 2.153 0.017 -0.60 ± 0.497 0.000 -0.60 ± 0.497 0.015 0.004 treatment 2 9.91 ± 2.120 0.000 9.51 ± 2.049 0.025 -0.40 ± 0.497 0.000 -0.40 ± 0.497 0.207 control 9.91 ± 2.120 0.000 9.66 ± 2.169 0.001 -0.26 ± 0.443 0.000 -0.26 ± 0.443 0.009 systole blood pressure treatment 1 144.86 ± 12.455 0.004 138.14 ± 12.25 0.064 -8.14 ± 4.864 0.000 -8.14 ± 4.864 0.000 0.000 treatment 2 139.14 ± 11.973 0.000 135.57 ± 11.09 0.007 -3.57 ± 3.109 0.000 -3,57 ± 3,109 0.019 control 140.86 ± 11.973 0.000 139.00 ± 9.985 0.001 -1.86 ± 2.451 0.000 -1.86 ± 2.451 0.000 diastole blood pressure treatment 1 93.14 ± 7.960 0.000 86.14 ± 6.427 0.000 -7.00 ± 4.236 0.000 -7.00 ± 4.236 0.000 0.000 treatment 2 89.71 ± 6.636 0.000 85.71 ± 5.959 0.017 -4.00 ± 4.166 0.000 -4,00 ± 4,166 0.005 control 88.00 ± 9.010 0.000 86.43 ± 7.130 0.004 -1.57 ± 2.913 0.000 -1.57 ± 2.913 0.006 pulse treatment 1 83.83 ± 1.706 0.001 80.63 ± 1.262 0.000 -3.20 ± 1.828 0.000 -3.20 ± 1.828 0.000 0.000 treatment 2 83.14 ± 2.074 0.000 81.37 ± 1.800 0.000 -1.77 ± 1.516 0.000 -1,77 ± 1,516 0.009 control 82.29 ± 2.177 0.000 81.43 ± 1.720 0.000 -0.86 ± 1.115 0.000 -0.86 ± 1.115 0.001 treatment 1: pmr two times per week for one month treatment 2: pmr once per week for one month p* normality test, shapiro wilk (normal p-value 0.05) p** kruskal wallis (p-value 0.05) p*** wilcoxon signed rank test (p-value 0.05) k kusnanto et al. 72 | pissn: 1858-3598  eissn: 2502-5791 relaxation two times a day for 5-6 days per week can reduce anxiety in leprosy patients who are hospitalised. mhaske, poovishnu devi, and jagtap (2018) state that progressive muscle relaxation two times a day for five days per week can reduce anxiety and depression in patients with chronic obstructive pulmonary disease. progressive muscle relaxation interventions were more effective in reducing anxiety, fatigue and improving the sleep quality of patients with chronic kidney failure undergoing haemodialysis (seyedi chegeni et al. 2018). progressive muscle relaxation is effective in reducing anxiety, depression and improving mental health in patients with pulmonary arterial hypertension. progressive muscle relaxation causes contraction of skeletal muscle fibres which leads to a sensation of muscle tension. in this case, the central nervous system involving the sympathetic nerves and the parasympathetic nervous system. some organs are affected by these two nervous systems between sympathetic and parasympathetic work reciprocity. the activity of the parasympathetic nervous system is also called trophotropic, which can cause feelings of wanting to rest and physical repair of the body. the parasympathetic response includes a decrease in pulse and blood pressure, increased blood flow and suppression of tension and anxiety. therefore, progressive muscle relaxation exercises can bring a relaxation response so that it can achieve a state of calm and stress will decrease. comfortable feelings are passed on to the hypothalamus to produce corticotropin-releasing factor (crf). the crf stimulates the pituitary gland to increase the production of endorphin, enkephalin and serotonin which can ultimately increase patient comfort. feeling comfortable and relaxed can cause anxiety to decrease (smeltzer, bare, & hinkle, 2015). in this study, demographic characteristics between groups are the same. thus it does not affect the results. the researchers believe that the change in anxiety in this study occurred due to the influence of progressive muscle relaxation two times per week for one month, which stimulates the pituitary gland to increase endorphin production, which can ultimately increase patient comfort. this comfortable and relaxed feeling can cause a decrease in anxiety, blood pressure and pulse rate (smeltzer et al., 2015). in the control group, most respondents did not experience changes in anxiety, this is because respondents in the control group only received health education and the absence of interventions that could increase comfort caused anxiety in most patients in the control group to not decrease. blood pressure in the variable changes in blood pressure, the progressive muscle relaxation group two times per week for one month showed a significant decrease, which means there was an influence of pmr two times per week for one month compared to the control group. the progressive muscle relaxation group one time per week for one month showed a significant decrease, which means there was an effect of pmr one time per week for one month compared to the control group. whereas the comparison of the progressive muscle relaxation group two times per week for one month and the progressive muscle relaxation group one time per week for one month showed a significant decrease, meaning that the administration of pmr two times per week for one month was more effective when compared to the pmr one time per week for one month in regard to changes in blood pressure in haemodialysis patients. the results of this study are consistent with other studies that show that progressive muscle relaxation can reduce blood pressure. research conducted by rosdiana and cahyati (2019) states that progressive muscle relaxation once a day for seven days can lower blood pressure in hypertensive patients ). herawati and azizah (2016) stated that progressive muscle relaxation two times a day for seven days can reduce systolic blood pressure in hypertensive patients. with progressive muscle relaxation interventions, blood pressure in hypertensive patients are more likely to fall than without progressive muscle relaxation (sulaeman, 2018). progressive muscle relaxation is effective in reducing blood pressure in hypertensive patients (arisjulyanto, 2019). this comfortable and relaxed feeling can cause blood pressure to decrease (herawati & azizah, 2016). in this study, the demographic characteristics between the pmr groups of the control group were the same, so that they did not affect the results. the researchers believe that changes in blood pressure in this study occurred because of the effect of progressive muscle relaxation that stimulates the pituitary gland to increase endorphin production, which can ultimately increase patient comfort. this comfortable and relaxed feeling can cause a decrease in blood pressure (herawati & azizah, 2016). in the control group, most of the respondents did not experience changes in blood pressure; this is because respondents in the control group only received health and the absence of interventions that can increase the sense of comfort and relaxation caused blood pressure in most patients in the control group to not decrease. pulse in the variable pulse change, the progressive muscle relaxation group two times per week for one month showed a significant decrease, which means there was an influence of pmr two times per week for one month compared to the control group. the progressive muscle relaxation group one time per week for one month also showed a significant decrease, which means there was an effect of pmr one time per week for one month compared to the control group. whereas the comparison of the progressive muscle relaxation group two times per week for one month and the progressive muscle relaxation group one time per week for one month showed a significant decrease, meaning that the administration of pmr two times per week for one month was more effective jurnal ners http://e-journal.unair.ac.id/jners | 73 when compared to the pmr one time per week for one month on changes in pulse in haemodialysis patients. the results of this study are in agreement with other studies that show that progressive muscle relaxation can reduce the pulse rate. research conducted by khanna (2007) states that progressive muscle relaxation once a day for ten consecutive days can reduce the pulse rate in women with high-stress levels (khanna, paul, & sandhu, 2007). progressive muscle relaxation interventions two times per week can reduce the pulse rate in surgical patients (ko & lin, 2012). intervention of progressive muscle relaxation, two times per week for one month meant the pulse rate and stress in students decreased (shinde, kini, naik, & desousa, 2015). high pulse in haemodialysis patients can be caused by anxiety experienced. anxiety occurs due to the stimulation of the endocrine and autonomic systems. hyperactivity to stimulants in the autonomic nerve due to anxiety can affect several organs and results in other symptoms, such as increased pulse rate. in this study, the demographic characteristics between the pmr groups of the control group were the same, so that they did not affect the results. the researchers believe that the change in pulse rate in this study occurred due to the effect of progressive muscle relaxation which stimulates the pituitary gland to increase endorphin production, which can ultimately increase patient comfort. this feeling of comfort and relaxation can cause a decrease in pulse (herawati & azizah, 2016). in the control group, most respondents did not experience a change in pulse, and this is because respondents in the control group only received health education and the absence of interventions that could increase the sense of comfort and relaxation which caused the pulse rate in most patients in the control group to not decrease. conclusion from the results of the study it can be concluded that increasing the intensity of pmr interventions can have a positive effect on reducing anxiety levels, controlled blood pressure and regular pulse. it is hoped that further researchers will be able to develop pmr methods that can be effective and be used to resolve health problems in haemodialysis patients or others. the contribution of the study is in affording new information and techniques to maintain anxiety, blood pressure and pulse of haemodialysis patients. the application of pmr interventions can be given by nurses regularly to patients undergoing haemodialysis so that vital signs, including anxiety, blood pressure and pulse, can be controlled. limitation limitations in this study are that it only uses the progressive muscle relaxation group two times per week for one-month, progressive muscle relaxation one times per week for one month and the control group. thus, it was necessary to add sufficient interventions as a comparison to see the effectiveness of progressive muscle relaxation therapy. references amini, e., goudarzi, i., masoudi, r., ahmadi, a., & momeni, a. (2016). effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis. international journal of pharmaceutical and clinical research, 8(12), 1634–1639. arisjulyanto, d. (2019). the effect of progressive muscle relaxation techniques to decrease blood pressure for patients with hypertension in mataram. primary health care open access, 08(04), 10–13. https://doi.org/10.4172/21671079.1000309 herawati, i., & azizah, s. n. (2016). effect of progressive muscle relaxation exercise to decrease blood pressure. international conference on health and well-being (ichwb), 405–412. kdigo, (kidney disease: improving global outcomes). (2013). kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney international supplements, 3(1), 4–4. https://doi.org/10.1038/kisup.2012.76 khanna, a., paul, m., & sandhu, j. s. (2007). efficacy of two relaxation techniques in reducing pulse rate among highly stressed females.calicut medical journal, 5(5), 6–8. ko, y. l., & lin, p. c. (2012). the effect of using a relaxation tape on pulse, respiration, blood pressure and anxiety levels of surgical patients. journal of clinical nursing, 21(5–6), 689–697. https://doi.org/10.1111/j.13652702.2011.03818.x kokoszka, a., leszczyńska, k., radzio, r., daniewska, d., łukasiewicz, a., orzechowski, w., … gellert, r. (2016). prevalence of depressive and anxiety disorders in dialysis patients with chronic kidney disease. archives of psychiatry and psychotherapy, 18(1), 8–13. https://doi.org/10.12740/app/61977 li, x., jiang, q., wu, w., xu, x., & miao, l. (2017). nighttime blood pressure and pulse wave velocity in dialysis patients. clinical and experimental nephrology, 22(1), 173-178. https://doi.org/10.1007/s10157-017-1464-z li, y.-n., shapiro, b., kim, j. c., zhang, m., porszasz, j., bross, r., … kopple, j. d. (2016). association between quality of life and anxiety, depression, physical activity and physical performance in maintenance hemodialysis patients. chronic diseases and translational medicine, 2(2), 110– 119. https://doi.org/10.1016/j.cdtm.2016.09.004 li, y., wang, r., tang, j., chen, c., tan, l., wu, z., … wang, x. (2015). progressive muscle relaxation improves anxiety and depression of pulmonary arterial hypertension patients. evidence-based complementary and alternative medicine, 2015, 1– k kusnanto et al. 74 | pissn: 1858-3598  eissn: 2502-5791 8. https://doi.org/10.1155/2015/792895 lipman, r., & covi l, d. r. (1981). pharmacotherapy of anxiety and depression. psychopharmacology bulletin, 17(3), 91–103. mhaske, m. m., poovishnu devi, t., & jagtap, v. k. (2018). comparison of the effectiveness of visual imagery technique and progressive relaxation technique on anxiety and depression in subjects with moderate chronic obstructive pulmonary disease. asian journal of pharmaceutical and clinical research, 11(6), 318–323. https://doi.org/http://0dx.doi.org.wam.leeds.ac.uk/10.22159/ajpcr.2018. v11i6.25067 qureshi, s., lorch, r., & navaneethan, s. d. (2017). blood pressure parameters and their associations with death in patients with chronic kidney disease. current hypertension reports, 19(11), 92. https://doi.org/10.1007/s11906-017-0790-6 rahimlu, m., shab-bidar, s., & djafarian, k. (2017). body mass index and all-cause mortality in chronic kidney disease : a dose – response metaanalysis of observational studies. journal of renal nutrition, 27(4), 225–232. https://doi.org/10.1053/j.jrn.2017.01.016 ramasamy, s., panneerselvam, s., govindharaj, p., kumar, a., & nayak, r. (2018). progressive muscle relaxation technique on anxiety and depression among persons affected by leprosy. journal of exercise rehabilitation, 14(3),, 375–381. riskesdas. (2018). riset kesehatan dasar 2018. kementrian kesehatan republik indonesia, 1–100. https://doi.org/1 desember 2013 rosdiana, i., & cahyati, y. (2019). effect of progressive muscle relaxation (pmr) on blood pressure among patients with hypertension. international journal of advancement in life sciences research, 2(1), 28–35. https://doi.org/10.31632/ijalsr.2019v02i01.005 seyedi chegeni, p., gholami, m., azargoon, a., hossein pour, a. h., birjandi, m., & norollahi, h. (2018). the effect of progressive muscle relaxation on the management of fatigue and quality of sleep in patients with chronic obstructive pulmonary disease: a randomized controlled clinical trial. complementary therapies in clinical practice, 31, 64–70. https://doi.org/10.1016/j.ctcp.2018.01.010 shin, j., yeo, s., hong, j. y., hwang, j. h., & kim, s. h. (2018). impact of intradialytic blood pressure changes on cardiovascular outcomes is independent of the volume status of maintenance hemodialysis patients. journal of the american society of hypertension, 12(11), 779-788. https://doi.org/10.1016/j.jash.2018.06.011 shinde, v., kini, r., naik, r., & desousa, a. (2015). a study on the effect of relaxation techniques and shavasana on stress and pulse rates of medical students. journal of exercise science and physiotherapy, 11(2), 123. https://doi.org/10.18376//2015/v11i2/67711 smeltzer, s.c., bare, b.g., hinkle, j.l., & kerry, h. c. (2015). brunner & suddarth. brunne-suddarth infermieristica medico-chirurgica. sulaeman, r., muhasidah, -, purnamawati, d., zulkifli, -, jafar, s. r., & suiraoka, i. p. (2018). progressive muscle relaxation using video aids reduces blood pressure of hypertension patients. international journal of health sciences, 2(3), 33–42. https://doi.org/10.29332/ijhs.v2n3.214 tomson, c., & taylor, d. (2015). management of chronic kidney disease. medicine (united kingdom), 43(8), 454–461. https://doi.org/10.1016/j.mpmed.2015.05.004 trapp, m., trapp, e. m., egger, j. w., domej, w., schillaci, g., avian, a., … baulmann, j. (2014). impact of mental and physical stress on blood pressure and pulse pressure under normobaric versus hypoxic conditions. plos one, 9(5), 1–7. https://doi.org/10.1371/journal.pone.0089005 ublosakka-jones, c., tongdee, p., pachirat, o., & jones, d. a. (2018). slow loaded breathing training improves blood pressure, lung capacity and arm exercise endurance for older people with treated and stable isolated systolic hypertension. experimental gerontology, 108(december 2017), 48–53. https://doi.org/10.1016/j.exger.2018.03.023 valika, a., & peixoto, a. j. (2016). hypertension management in transition: from ckd to esrd. advances in chronic kidney disease, 23(4), 255– 261. https://doi.org/10.1053/j.ackd.2016.02.002 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 177 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17016 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the management of diabetic foot ulcers using the wound treatment techniques of modern dressing: a systematic review mohamad roni alfaqih, gabriel wanda sinawang, rohmatul faizah, and andrik hermanto faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: one of the complications caused by diabetes mellitus is the problem of diabetic foot ulcers (dfu). the management of the dfu problem can be carried out through the wound care focused on the foot using modern dressings. this research was to determine the effectiveness of modern dressings on the healing process of diabetic foot ulcers. method: the methods used in arranging this systematic review were (1) the identification of interventions in the literature, (2) the identification of relevant literature based on the topic and title, (3) obtaining the literature in full-text form and (4) the analysis of the results from the various interventions in the literature. the literature search was carried out in several databases such as scopus, google scholar and pubmed. the samples in this article wee research about the effect of modern dressings in the treatment of diabetic foot ulcers. result: a total of 22 evidence bases found 10 studies using the preexperimental method, 3 rcts, 2 quasi-experiments, 2 articles / systematic reviews, 2 perspective studies, 1 medical report, 1 case study and 1 vitro and vivo study. conclusion: based on the review, it explains that the research on modern dressings using nanocrystalline silver ion and curcumin can improves wound recovery by increasing the transformation rate of the ß1 growth factor, which is a protein involved in cell growth and proliferation. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords diabetic foot ulcer; wound; treatment; modern dressing; healing process contact mohamad roni alfaqih  mohamad.roni.al2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: alfaqih, m. r, sinawang, g.w, faziah, r, & hermanto, a. (2019). the management of diabetic foot ulcers using the wound treatment techniques of modern dressing: a systematic review. jurnal ners, 14(3si), 176-180. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17016 introduction diabetes mellitus can be defined as a metabolic disorder in the human body. this metabolic disorder is caused by a lack of insulin production. the insulin deficiency in diabetes mellitus patients can be caused by excessive glucose in the bloodstream or the low production of insulin(tavakkoli-kakhki & motavasselian, 2017). patients with diabetes mellitus have reached 150 million in the world today. it is estimated that by 2025, there will be a two fold increase in the number of patients currently (world health organization, 2017). in indonesia, the survey results of the number of people with diabetes mellitus reached approximately 12 million people with a proportion of 6.9% (kemenkesri, 2014). the complications of diabetes mellitus are grouped into 2, namely microvascular and macrovascular complications. one of the complications caused by diabetes mellitus is diabetic foot ulcers (dfu) which includes into microvascular complications(nasiri et al., 2015). the latest method in managing dfu is by designing new wound care techniques. the principle use for wound care is managing the moist wound condition. (liu, zhou, gao, & zhai, 2018). if the moisture of the wound is managed properly, then it will speed up the healing process. the area of the wound will be easily diminished and it will not easily get infected. the management of the dfu problem can be conducted via treatments using modern dressings (tavakkolikakhki & motavasselian, 2017). modern dressings are effective at accelerating the wound healing process.. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). m. r. alfaqih, et al. 178 | pissn: 1858-3598  eissn: 2502-5791 materials and methods this systematic review was compiled with the aim of identifying the effect of modern dressing therapy on diabetes mellitus wounds. the methods used in arranging the systematic review was (1) the identification of the interventions in the literature, (2) the identification of the relevant literature based on the topic and title, (3) obtaining the literature in a fulltext form and (4) the analysis of the results from the various interventions in the literature. the literature search was carried out on several databases such as scopus, google scholar, pubmed and so on by including the keywords of ‘modern dressing’, ‘wound care management’, ‘diabetes mellitus’, ‘diabetic foot ulcers’ and ‘wound care treatments’. the year limit used was in the last 10 years, with the diabetic foot ulcer inclusion criteria according to a randomized controlled trial study (rcts). the review included cluster rcts, a quasiexperimental design, pre-experiment, case studies, systematic reviews and medical records. there was no age and gender limitation for the participants in the article. the sample in this article consisted of 23 articles about the effect of modern dressing treatments on diabetic foot ulcers. the analysis was focused on modern dressing therapy with various combinations of interventions for diabetic foot ulcers patients and the side effects of the interventions. the criteria were excluded if the results of the study did not explain the effect of the modern dressing on the wounded patients. the instruments used were observation sheets, standard operating procedures (sop) and the laboratory test results of the diabetic mellitus ulcers. results the sources obtained from the 15 studies focused on modern dressing therapy for diabetic foot ulcers is found 10 studies with experimental methods, 1 quasiexperimental, 1 article / systematic review, 1 medical report, 1 case study and 1 vitro and vivo study. there were several comparative interventions as described in table 1. discussion natural polymers have better biocompatibility such as lower immune degradation and resistance while synthetic polyesters have easier electrospinning with excellent mechanical strength such as flexibility and rigidity. to obtain the maximum benefit of these ingredients, it is highly recommended to use a mixed strategy. bixin-load pcl nanofibers reduce the length of time of wound closure more than the pcl nanofibers. other natural curcumin compounds derived from turmeric have many biological activities that have been proven such as anti-tumor, antioxidant, and anti-inflammatory(liu et al., 2018). nanocrystalline silver ion, curcumin, improves wound recovery by increasing the transformation rate of the ß1 growth factor, which is a protein involved in cell growth and proliferation (shaikh et al. 2009). moreover, these compounds also protect the skin cells from oxidative damage. skin histological studies for the test group (with phylum curcumin) show that the area of hair follicles and sebaceous glands in the dermis layer of the skin is protected(tong et al., 2018). nanocrystalline silver ion is an effective antimicrobial barrier consisting of a core to maintain an optimal moist environment for wound healing. moreover, the outer layer of a silver dressing polyethylene net prevents wound contamination and has a bactericidal effect. silver ions show faster wound contractions due to the accelerated proliferation and differentiation of fibroblasts to myofibroblasts(gupta, kakkar, gill, gill, & gupta, 2018). silver gauze oil, when the bandage is exposed to the wound exudate, means that the silver ions are released immediately, binding and effectively killing the bacteria (dong & liu, 2017). topical olive oil consists of 98% triglycerides, including oleatmonounsaturated acid, whose antiinflammatory properties have been completely and crucially proven for skin care as these properties are similar to ibuprofen (the current study links it to oleocanthal). it possibly accelerates recovery and the healing process of the ulcer. furthermore, because of the high concentration of polyphenols, the natural antioxidants included in the olive oil medicate the inflammatory process and increase blood flow so then they help with ulcer healing(nasiri et al., 2015). there is also the topical application of bee honey. propolis has an antibacterial effect that has been proven in this study. the bacterial load (cfu) in propolis-treated ulcers decreased by 26% in terms of the diabetic wound fluid after 10 days compared with b 1% in the published control subgroup. our laboratory study found that the number of growing bacteria predicts poor wound healing in a neuropathic ulceration, which is the dominant type of ulcer in this study (xu et al., 2007)(tavakkoli-kakhki & motavasselian, 2017). sucrose octasulfate and sulfate ligosaccharide are known to have many biological activities, particularly the potassium salts of sucrose octasulfate, which have been shown to inhibit the matrix of metalloproteases22. it also interacts with the growth factors and restores their biological functions since they have a high charge density (edmonds et al., 2017). fr integra flowable wound, the use of biomaterials in expert hands and in selected patients allows for the rapid natural healing of lesions and it also allows for the reduction of major amputations caused by complications in more distal amputations in the lower limbs (f. campitiello et al, 2017) the development of wound healing in diabetes mellitus patients with a variety of simple alternatives can be used by both health workers and the patients as an effort to treat and prevent the complications of dfu. the choice of intervention can be adjusted according to the available health facilities and services in the surrounding environment. jurnal ners http://e-journal.unair.ac.id/jners | 179 table 1. study of the systematic review production author type of study variable result (liu et al., 2018)(liu et al., 2018) article review 1. electrospun nanofibers as a wound dressing to treat diabetic foot ulcers the nanofiber dressing is able to absorb moisture well, and it helps the oxygen exchange process and has an antibacterial effect. (nasiri et al., 2015)(nasiri et al., 2015) quasiexperimental 1. topical olive oil for wound healing in dm 2. treatment of wounds in accordance with the protocol 3. ulcer wound healing in diabetes mellitus type 2 olive oil is able to diminish the area of the ulcer and it also reduces the depth of the ulcer. there is no side effect from the research intervention. (tavakkoli-kakhki and motavasselian, 2017)(tavakkolikakhki & motavasselian, 2017) case study 1. the success of improving diabetic foot ulcers with honey-based treatment honey-based treatment is good for wound healing. the wound will be diminished from the wide area of the wound and it also becomes antibacterial so then it can prevent infection, especially in diabetic foot ulcers. (henshaw et al., 2014)(henshaw et al., 2014) prospektive study 1. tolerance of topical applications from a honeycomb 2. improved healing of diabetic foot ulcers topical propolis is a therapy which increases the wound covering in diabetic foot ulcers. (tsang et al., 2015)(tsang et al., 2015) experimental 1. the anti-inflammatory effect of nanocrystalline silver and manuka honey. 2. the anti-bacterial effects of nanocrystalline silver and manuka honey. the findings from the in vitro and animal studies show that both agents have effective antibacterial actions. the anti-inflammatory actions and the impact related to the wound healing are not clear. overall, the high-quality clinical human study is supported by the findings from molecular science concerning the lack of use of manuka honey or nanocrystalline silver. (dong and liu, 2017)(dong & liu, 2017) experimental 1) group 1: silver ion, 2) group 2: oil gauze silver 3) wound healing process wound healing using oil gauze silver was faster than using silver ions. (edmonds et al., 2017)(edmonds et al., 2017) experimental: double blind 1) intervention group: gauze with sucrose octasulfate 2) control group: gauze without sucrose octasulfate wound surface healing was faster in the intervention group than in the control group which reached 20 weeks. the life quality of both groups was bad. (f. campitiello et al, 2017) experimental: simple random sampling 1) intervention group: integra flowable wound matrix 2) control group: controlled dressing 1) the average duration of wound healing in the integra flowable wound matrix group was faster. (ramarao and ramu, 2017)(ramarao & ramu, 2017) experimental: simple random sampling 1) intervention group: nanocrystalline ionic silver dressing 2) control group: daily dressing by giving gauze soaked in nacl the wound healing for the nanocrystalline silver ion dressing needed less time. (jung, yoo and han, 2016)(jung, yoo, & han, 2016) medical record 1) intervention group: hydrophilic polyurethane dressing 2) saline dressing total wound healing occurred in 87 patients (polyurethane dressing group) and in 28 patients in the control group within 12 weeks. (xu et al., 2018)(xu, min, guo, liao, & fu, 2018) experimental: random sampling 1) efg (epidermal grow factor) group 2) afgf (acidic fibroblast growth factor) 3) combination of efg and afgf 4) normal saline new tissue granulation at grades 2 and 3 needed less treatment time than in the combination group. m. r. alfaqih, et al. 180 | pissn: 1858-3598  eissn: 2502-5791 conclusion research on modern dressings has been abundantly done but of the results obtained, only a few have provided benefits related to the healing of diabetic foot ulcers. some provide benefits as antibiotics that can reduce infection and others provide benefits that can accelerate reducing the wound area, maintaining the moisture and reducing the duration of the wound healing process. references dong, c. y., & liu, w. j. (2017). effect of oil gauze silver dressings on diabetic foot ulcers in the elderly. (october). edmonds, m., lázaro-martínez, j. l., alfayate-garcía, j. m., martini, j., petit, j., rayman, g., & lobmann, r. (2017). articles sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers ( explorer ): an international , multicentre , double-blind , randomised , controlled trial. 8587(17), 1–11. https://doi.org/10.1016/s2213-8587(17)304382 gupta, v., kakkar, g., gill, a. s., gill, c. s., & gupta, m. (2018). comparative study of nanocrystalline silver ion dressings with normal saline dressings in diabetic foot ulcers. journal of clinical and diagnostic research, (june 2017), 1–4. https://doi.org/10.7860/jcdr/2018/36691.115 90 henshaw, f. r., bolton, t., nube, v., hood, a., veldhoen, d., pfrunder, l., … twigg, s. m. (2014). journal of diabetes and its complications topical application of the bee hive protectant propolis is well tolerated and improves human diabetic foot ulcer healing in a prospective feasibility study. journal of diabetes and its complications, 28(6), 850–857. https://doi.org/10.1016/j.jdiacomp.2014.07.012 jung, j., yoo, k., & han, s. (2016). evaluation of the efficacy of highly hydrophilic polyurethane foam dressing in treating a diabetic foot ulcer. 29(12), 546–555. kemenkesri. (2014). pusat data dan informasi. liu, y., zhou, s., gao, y., & zhai, y. (2018). electrospun nanofibers as a wound dressing for treating diabetic foot ulcer ✩. asian journal of pharmaceutical sciences, 000, 1–14. https://doi.org/10.1016/j.ajps.2018.04.004 nasiri, m., fayazi, s., jahani, s., yazdanpanah, l., haghighizadeh, m. h., & jundishapur, a. (2015). the effect of topical olive oil on the healing of foot ulcer in patients with type 2 diabetes : a doubleblind randomized clinical trial study in iran. author type of study variable result (niederauer, michalek and armstrong, 2017)(niederauer, michalek, & armstrong, 2017) analysis of a randomized, balanced, double blind, shamcontrolled, parallel group clinical trial evaluating the use of the cdo device for dfus continuous diffusion oxygen (cdo) therapy this research showed that oxygen continuously spreading on the wound significantly caused a higher and faster level of wound closure. (tong et al., 2018)(tong et al., 2018) in vitro and in vivo the efficiency of nanocrystal cellulose film as an anti-microbe medication system in diabetic wound dressing. film-charged curcuma significantly improved the hair follicles and sebaceous skin glands. this result showed that curcuma nanocrystal film could be used for the application of diabetic wound healing. (ramarao and ramu, 2017)(ramarao & ramu, 2017) experimental 1) group a (n: 30) used 1 cc of normal saline and 10 iu of insulin for every 10 cm2 of wound. 2) group b (n:30) used normal saline for the wound treatment. insulin topical dressing gave advantageous results for the patients with a diabetic foot ulcer. there was a significant decrease on the wound’s surface compared to the normal saline dressing. (rahayu et al., 2018)(rahayu, ramlan, anwar, sri, & pujiastuti, 2018) experimental 1. control group received the intervention with modern antibacterials (calcium alginate, cutimed sorbact, aquacel, dalethyne, and iodosorb powder) 2. intervention group received the same wound treatment using modern antibacterial and ozone therapy with 60.100µg / ml concentration for 15 minutes. calcium alginate lowered the wound’s size better than the other dressing. jurnal ners http://e-journal.unair.ac.id/jners | 181 niederauer, m. q., michalek, j. e., & armstrong, d. g. (2017). a prospective, randomized, double-blind multicenter study comparing continuous diffusion of oxygen therapy to sham therapy in the treatment of diabetic foot ulcers. journal of diabetes science and technology, 11(5), 883–891. https://doi.org/10.1177/1932296817695574 rahayu, u. m., ramlan, d., anwar, m. c., sri, r. r., & pujiastuti, e. (2018). combination of modern dressing and bagging ozone therapy for speed up the process of wound healing of grade ii diabetic ulcer patients. (november 2017), 1–5. ramarao, k., & ramu, l. (2017). comparative study between the effect of topical insulin and normal saline dressing in healing of diabetic foot ulcers. 4(6), 1337–1339. tavakkoli-kakhki, m., & motavasselian, m. (2017). successful repair of diabetic foot ulcer with honey-based treatment : a case report. 19(3). https://doi.org/10.5812/ircmj.41939.case tong, w. y., bin abdullah, a. y. k., binti rozman, n. a. s., bin wahid, m. i. a., hossain, m. s., ring, l. c., … tan, w. n. (2018). antimicrobial wound dressing film utilizing cellulose nanocrystal as drug delivery system for curcumin. cellulose, vol. 25, pp. 631–638. https://doi.org/10.1007/s10570017-1562-9 tsang, k., kwong, e. w., woo, k. y., to, t. s., chung, j. w., & wong, t. k. (2015). the anti-inflammatory and antibacterial action of nanocrystalline silver and manuka honey on the molecular alternation of diabetic foot ulcer : a comprehensive literature review. 2015. world health organization. (2017). media centre who diabetes mellitus. xu, j., min, d., guo, g., liao, x., & fu, z. (2018). experimental study of epidermal growth factor and acidic fibroblast growth factor in the treatment of diabetic foot wounds. 5365–5370. https://doi.org/10.3892/etm.2018.6131 106 kejadian diarrhea pada pasien kanker serviks setelah penatalaksanaan kemoterapi (the incident of diarrhea among cervical cancer patients post chemoterapy treatment) masfin muhayanah*, ni ketut alit armini*, aria aulia nastiti* *faculty of nursing universitas airlangga email: nk.alita@fkp.unair.ac.id abstrak pendahuluan. kanker serviks merupakan penyakit terbanyak kedua yang diderita oleh perempuan. kemoterapi merupakan pengobatan utama untuk kanker serviks. kemoterapi mempunyai beberapa efek samping, salah satunya adalah diarrhea. diarrhea menyebabkan penderita kanker serviks lebih menderita. penelitian ini bertujuan untuk menganalisis faktor yang yang menyebabkan diarrhea pada penderita kanker serviks setelah mendapatkan kemoterapi. metode. penelitian ini menggunakan metode analitik deskriptif dengan desain retrospektif. populasi dalam penelitian ini adalah pasien yang telah menjalani kemoterapi pertama. sampel didapatkan sebanyak 21 orang dengan teknik pusposive sampling. variabel independen meliputi obat kemoterapi, jenis kemoterapi, stadium kanker, stress, dan makanan. variabel dependen adalah diarrhea. data dikumpulkan dengan menggunakan kuesioner, kemudian dianalisis menggunakan chi square dengan tingkat signifikansi α≤0,05. hasil. uji statistik menunjukkan bahwa obat dan jenis kemoterapi tidak berhubungan dengan kejadian diarrhea (p:0,598 dan p:0,336). sedangkan faktor yang berhubungan dengan kejadian diarrhea yaitu stadium kanker (p:0,022), stress dan jenis diet (p:0,00). diskusi. dapat disimpulkan bahwa kejadian diarrhea pada pasien kanker serviks pasca kemoterapi dipengaruhi oleh faktor stadium kanker, stress, dan makanan. berdasarkan hasil tersebut diperlukan pendidikan kesehatan tentang jenis makanan yang dapat menyebabkan diarrhea, prosedur kemoterapi dan efek sampingnya, dan peningkatan dukungan untuk pasien dengan kanker serviks. kata kunci: kanker serviks, kemoterapi, diarrhea abstract background: cervical cancer is second most diseases suffered by women. chemotherapy is primary treatment for cervical cancer. chemotherpy has some side effect, and one of them is diarrhea. diarrhea make cervical cancer sufferred more. the purpose of this research was to analyze the factors that caused diarrhea among cervical cancer patients after chemotherapy. method: this research uses descriptive analitic method with retrospective design. the population in this research is all patients who had post first chemotherapy. sample in this study were 21 respondents, with purposive sampling. variable independent were type of chemotherapy drugs, character of chemotheraphy, staging, stress and dietary. variable dependent was diarrhea. data collected using quesionare. data were analyzed using chi square test with level of significant α≤0,05. results: the result of the study reveals that the type of the chemotherapy drug and the character of chemotherapy has no correlation with the incident of diarrhea with p value (p:0,598 and p:0,336). the factors that has correlation with diarrhea were stage of cancer (p:0,022), stress and dietary (p:0,00). conclusion: it can be concluded that incident of diarrhea was related to staging, stress and dietary. thus, very important to give health education about dietary causing diarrhea, chemotherapy procedural and it’s sides effects, and also increase supports for patient with cervical cancer. keyword: cervical cancer, chemotherapy, diarrhea ____________________________________________________________________________________________________ introduction indonesia is one of developing countries which have sufficient serious problems about cancer. two types of cancer with the highest incidence on women are breast cancer and cervical cancer. cervical cancer management requires integrated treatments of various disciplines, clinical basis, in terms of diagnosis and therapy. chemotherapy is the treatment of cancer using drugs or hormones (rasjidi 2007). chemotherapy is effective towards spreading or even localized disease. treatment with chemotherapy manage to increase the cure rate of cancer, but there are some therapeutic effect accompaniments such as bone marrow depression, gastrointestinal reactions, impaired liver and kidney function, cardiotoxicity, pulmotoxicity, neurotoxicity, allergic reactions, alopecia, melanosis, and thrombophlebitis. in long term, the effects could lead to carcinogenesis and infertility (wan desen sun yatsen university, cancer center (2008). the research reported about 7% to 10% of cancer patients admitted to hospital due to diarrhea post therapy (ferrell et al. 2010). the diarrhea during post-chemotherapy has not been well managed because diarrhea occurred at home. diarrhea on cervical cancer patients post chemotherapy can not be underestimated because it threatens patient’s lives, if it is left unchecked and will worsen the patient's medical condition as well. factors related to the incidence of diarrhea in patients jurnal ners vol. 11 no. 1 april 2016: 106-111 107 with post-chemotherapy for cervical cancer can’t be explained yet. in the world wide, cervical cancer still have a huge number of cancer incidents among women after breast cancer. cervical cancer is the leading cause of cancer death in women of reproductive age in developing countries (rasjidi 2007). based on data from who (2010), a woman dies from cervical cancer every two minutes in the world, or about 30 people per hour. cancer incidence in indonesia is not yet known with certainty, because there has been no population-based registry. globocan (2002), the iarc (international agency for research on cancer) estimates the incidence of cervical cancer is 16 per 100,000 women (dinkes 2012). according kuntarti (2011), in indonesia every 1 hour a woman dies from cervical cancer, this is because in indonesia more than 70% of cervical cancers are found after entering an advanced stage iib or above (oagin, 2011). data of east java health office shows increase in the numbers of patients with cervical cancer last three years. distribution of cervical cancer hospitalized in 2011 were as many as 790 cases and the death number were 29 patients (dinkes 2012). dr. soetomo general hospital is a type a hospital which has good and adequate facilities for the treatment of cancer. cervical cancer patients who were treated at dr. soetomo general hospital generally in stage iia upwards so that they need chemotherapy. the results of interviews in 5 patients with cervical cancer who received chemotherapy show that, all of patients complained about nausea, vomiting, hair loss, fatigue, and diarrhea. majority of patients said they had suffered diarrhea at homes around three days post chemotherapy. diarrhea is generally classified into six categories: secretory, exudative, dysmotilitiy, osmotic, malabsorbtive, and diarrhea due to side effects of treatment (benson, b., & stein 2009). diarrhea in chronic diseases could be due to medication, diet, tumor, radiotherapy, intestinal obstruction, concomitant diseases such as ibs (inflammatory bowel disease), malabsorption, infections (rasjidi 2010a). other factors can cause diarrhea due to stress trigger chemicals such as serotonin which affects the brain when you're anxious and it can alter bowel movements. cervical cancer patients are vulnerable to the stress. the incidence of stress in patients with cervical cancer can be caused by cervical cancer disease or long and painful treatment procedures. chemotherapy increases the stress of cervical cancer patients because it has various side effects (wan desen (sun yatsen university, cancer center 2008). diarrhea associated with chemotherapy is called cid (chemotherapy-induced diarrhea). it can cause exudative diarrhea due to damage of the intestinal mucosa (bisanz 2010). some type of chemotherapy used in patients with cervical cancer monotherapy are cisplatin, carboplatin, 5-fluorouracil (5-fu®), methotrexate, paclitaxel, gemicitabine, doxetal (rasjidi 2007). drug types 5 fluorouracil (5-fu®) does have toxicity, especially in the gastrointestinal mucositis and stomatitis, and diarrhea resulting. other types of chemotherapy drugs that can cause diarrhea is xeloda, irinotekan (cpt-11), and iressa (gefitinib). series of chemotherapy regiments depending on the stage of cervical cancer and patient performance status (rasjidi 2010a). the effect of diarrhea appears as a result of toxicity of chemotherapy drugs (benson, b., & stein 2009). the involvement of relevant agencies and medical personnel are needed as well as public awareness so that, the incidence and mortality of cervical cancer can be minimized, especially by changing the pattern of lifestyle and early detection screening. cancer can happen to everyone, on any part of the body but it can be prevented. there are some concrete actions cancer prevention, for instance avoiding cigarette smoke, limit alcoholic drinks, increasing exercise, eating healthy foods. chemotherapy is the main alternative for the treatment of cervical cancer whether they are curative, palliative or adjuvant. some various negative side effects caused by chemotherapy are unavoidable. diarrhea can cause the patient not able to move outside the home, increasing weakness, dehydration, and contribute to a feeling of lack of control and depression all of which affect the self-care of patients, and causes the of decrease patients quality of life (qol) and it go worse into life threatening if it is untreated. the role of nurses could be very important to recognize, educate and manage diarrhea and manifestations (ferrell et al. 2010). it is important for nurses to recognize the onset of diarrhea in patients post chemotherapy. the purpose of this study was kejadian diarrhea pada pasien kanker serviks (masfin muhayanah, dkk.) 108 to analyze factors associated with the incidence of diarrhea in cervical cancer patients post chemotherapy. the factors examined included: types of chemotherapy, drugs of chemotherapy, stage of cancer, stress, and diet. method this research used descriptive analytic design. the population in this study were patients with cervical cancer who received chemotherapy in merak ward dr. soetomo general hospital. samples in this study were 21 respondents based on the inclusion and exclusion criteria taken by purposive sampling. the independent variable were type of chemotherapy, chemotherapy drug, stage of cancer, stress, and diet. the dependent variable was the incidence of diarrhea. the study was conducted at merak ward dr. soetomo general hospitals for 2 months between january to february 2013. the research instrument was a questionnaire with enclosed statement. tests to measure the level of stress are the questionnaire dass 42 (depression anxiety stress scale 42)(lovibond 1995). the data were analyzed using fisher's exact test and chi square. result table 1 characteristic of demography demography category f % age 20-30 years old 1 5 31-40 years old 2 10 40-50 years old 11 52 >50 years old 7 33 marrital status married 20 95 widow 1 5 job housewife 5 24 officials 2 10 farmer 11 52 private 3 14 education elementray 15 71 yunior high school 2 10 senior high school 4 19 child number 1-2 3 14 >2 18 86 contraception pills 3 14 iud 8 38 injection 5 24 none 5 24 n 21 100 demographic data showed most respondents were aged 40-50 years (52%), and married (95%). the majority of respondents worked as farmers (52%), with primary level of education background (71%), the number of their children >2 (86%), and mostly they used iud (38%). table 2 analysis of chemotherapy drugs and incident diarrhea chemotherapy drug diarrhea (-) diarrhea (+) ∑ % f % f % cisplatin 12 57 4 19 16 76 paclitaxel and carboplatin 3 14 2 10 5 24 total 15 71 6 29 21 100 fisher’s exact test : p = 0,598 the types of drugs are given based on clinical cervical cancer cells to the mechanism of action of anti-tumor drugs. results of the analysis of fisher's exact test was obtained p = 0.598 (α <0.05), it means there is no relationship between the type of chemotherapy with diarrhea. table 3 analysis type of chemotherapy and incident diarrhea type of chemotherapy diarrhea (-) diarrhea (+) ∑ % f % f % neoadjuvant 7 33 1 5 8 38 primary 8 38 5 24 13 62 total 15 71 6 29 21 100 fisher’s exact test : p = 0,336 chemotherapy is given based on the purpose and timing of chemotherapy drugs. results of the analysis of fisher's exact test was obtained p = 0.336 (α <0.05), it means there is no relationship between the nature of chemotherapy with diarrhea. table 3 analysis of cancer stadium and incident diarrhea cancer stadium diarrhea (-) diarrhea (+) ∑ % f % f % stadium ii 9 43 0 0 9 43 stadium iii 6 28 5 24 11 52 stadium iv 0 0 1 5 1 5 total 15 71 6 29 21 100 chi square p = 0,022 koefisien kontingensi = 0,516 cervical cancer staging by histopathologic and clinical characteristic cervical cancer cells. results of the analysis of chi square p = 0.022 contingency coefficient = 0.516, it means there is a relationship between the stage of the cancer with the incidence of diarrhea. table 5 analysis stress and incident diarrhea stress diarrhea (-) diarrhea (+) ∑ % f % f % normal 9 43 0 0 9 43 mild 6 29 5 23 11 52 moderate 0 0 1 5 1 5 jurnal ners vol. 11 no. 1 april 2016: 106-111 109 severe 0 0 2 10 2 10 total 15 71 6 29 21 100 chi square p = 0,000 koefisien kontingensi = 0,685 stress is not specific response to the of the body disrupted and impact on physical, psychological, intellectual, social and spiritual from cervical cancer and its treatment procedure. results of the analysis of chi square p = 0.000, contingency coefficient = 0.685, it means there is a relationship between stress and the incidence of diarrhea table 5 analysis diet type and incident diarrhea type of diet diarrhea (-) diarrhea (+) ∑ % f % f % low risk 15 71 1 5 16 76 moderate risk 0 0 3 14 3 14 high risk 0 0 2 10 2 10 total 15 71 6 29 21 100 chi square p = 0,000 koefisien kontingensi = 0,662 dietary risk of diarrhea in patients post chemotherapy include high fiber foods, spicy foods, high-fat foods, food contains a lot of gas. results of the analysis of chi square p = 0.000, contingency coefficient = 0.662, it means there is a relationship between the type of diet with diarrhea. discussion type of drug does not determine the incidence of diarrhea after chemotherapy. 4 of 16 respondents who use cisplatin experienced diarrhea. 2 of 5 respondents using paclitaxel + carboplatin, have diarrhea. according to hoff at. all., (2011) in bizans et al. (2010), there are several types of chemotherapy drugs that cause diarrhea including paclitaxel group as much as 38% (bisanz 2010). type of drug cisplatin has no direct effect on gastrointestinal. the side effects of cisplatin include: nefrotosik, ototoxicity, hypomagnesemia, nausea, vomiting, anaphylactic reaction, myelosuppression and anemia (rasjidi 2007). cisplatin can cause diarrhea if the gift exceeded the limits of patient toxicity (benson, b., & stein 2009). almost all classes of antitumor drug (antimetabolite, antibiotic class, metabolite protein inhibitors, topoisomerase inhibitors, hormone class, class of molecular targets) are toxic chemical structure and a different mechanism. chemotherapy cause immunosuppression and weaken the general condition of the patient due to side effects of the type of chemotherapy drugs given so that affect the metabolism of the gastrointestinal tract and also lead to parasitic infections (giardia lamblia, entamoeba histoliytica, crytosporidium), fungi (candida), bacteria (clostridium difficile, shigella, salmonella) , viruses (rotavirus, cytomegalovirus, herpes simplex, hepatitis, norwalk virus) into the gastrointestinal thus causing diarrhea. there are more respondents who did not experience diarrhea, perhaps because most of them used the chemotherapy drug cisplatin than the respondents who received the chemotherapy drug paclitaxel + carboplatin types. this is because cisplatin (ddp) is the primary drug of cervix cancer (rasjidi 2009). the amount of the percentage of respondents who experienced diarrhea after receiving carboplatin + paclitaxel compared with cisplatin literacy accordance with the theory that the chemotherapy drug paclitaxel causes diarrhea incidence by 38% (bisanz 2010). respondents who use chemotherapy first series, indirectly related to drug toxicity type of cisplatin which is still low and can be tolerated by the patient. drug characteristics do not determine the incidence of diarrhea post chemotherapy. 1 of 8 respondents with neoadjuvant chemotherapy has diarrhea. 5 of 13 respondents with primary chemotherapy characteristic get diarrhea from 13 respondents. chemotherapy characteristics based on the objective type of chemotherapy treatment of cervical cancer, is adjuvant, neo adjuvant or primary. there are more respondents with primary chemotherapy have diarrhea because primary chemotherapy characteristic is curative so that it has high toxicity. there are fewer respondents who obtained neo adjuvant chemotherapy suffer have diarrhea, this may be because the majority of respondents with neo adjuvant cervical cancer stage ii so that the general condition is better than those who received primary chemotherapy with stage of cancer. the higher the stage of cervical cancer, the more increasing incidence of diarrhea post chemotherapy. respondents with stage ii were 9 respondents, none had diarrhea. one respondent with stage iv experienced diarrhea. 5 respondents with cervical cancer stage iii have diarrhea. according to research, stage is an estimate of the possible spread of disease (benson, c. r., & pernoll 2009). based on the figo, stage iii carcinoma has spread to kejadian diarrhea pada pasien kanker serviks (masfin muhayanah, dkk.) 110 the pelvic wall, whereas in stage iv tumors have spread far (dunleavy 2009). cervical cancer stage iii to iv relating to the general condition of the patient that is drop of patients health due to the decrease metastasis of cancer cells to other organs so that will affect a patient's ability to tolerate the side effects of chemotherapy drugs and immune suppression due to infection that occurs easily after chemotherapy. advanced-stage patients will experience tortured feeling by the disease. patients experience physical weakness, as well as the side effects of the therapy include diarrhea post chemotherapy. the higher stress, the incidents of diarrhea will more increase. respondents in normal level of stress, have no diarrhea. a total of 6 respondents experience stress postchemotherapy and 100% had diarrhea, that is 1 person with mild stress, 3 people with moderate stress, and 2 people with severe stress. higher stress experienced by respondents at the younger age category 20-30 years and 31-40 years. the stress totally impact on individuals against physical, psychological, intellectual, social, and spiritual, stress can also disturb physiological equilibrium (hawari 2011). stress experienced by patients with cervical cancer can trigger the production of serotonin in the brain that can improve the work of the gastrointestinal tract, bowel movements increase and eventually cause diarrhea. chemotherapy can be a source of stress for cervical cancer patients, (wan desen (sun yatsen university, cancer center 2008). if the patient has severe anxiety towards chemotherapy then psychological response after chemotherapy appears to be more severe. stress has a direct effect on diarrhea, and side effects of chemotherapy drugs can also cause stress to the patient. respondents suffering from stress express that they are fear to undergo their first chemotherapy and reactions afterwards. measurement of patient stress was measured using the dass. item of statements often expressed respondents with stress is irritable because of trifles. the lack of family support towards a widow stress of chemotherapy, causing diarrhea post chemotherapy. the more risky type of diet consumed, the more increasing incidence of diarrhea post chemotherapy. there are some respondents whose diet is at risk of diarrhea, 1 of 15 respondents with low risk and moderate risk diet have diarrhea. while all respondents who have heavy risk diet experienced diarrhea. one of the causes of diarrhea patients with cancer is diet (benson, b., & stein 2009) (rasjidi 2010b). stern (2003) suggest diet foods to avoid cervical cancer patients post chemotherapy, such as: milk, cheese, yogurt, ice cream, coffee, tea, soft drinks, chocolate, glucose, acidic juices, juice sorbitol, high-fiber foods, and cause gas, irritation, highcholesterol foods, spicy foods, and pasta (ferrell et al. 2010). these various kinds of food are classified to facilitate the respondents and the social conditions of the respondent. the higher the dietary risks of respondents, the higher the risk of diarrhea will be experienced by respondents. great number of respondents who experienced diarrhea with diet high risk because patients do not know the foods to avoid post-chemotherapy. respondents educational background were mostly graduates of elementary, relates to the ability of respondents receive information diarrhea prevention and treatment of postchemotherapy. generally, people had diarrhea after being at home. consumption of food to distract post chemotherapy nausea, such as spicy foods and acidic taste can trigger diarrhea. conclusion and recommendation conclusion types of drugs, and the nature of the chemotherapy drugs are not associated with the incidence of diarrhea post chemotherapy. the higher the stage of cancer of the cervix, the more increasing the incidence of diarrhea post chemotherapy. stress experienced by patients increases the incidence of diarrhea post chemotherapy. type of risky diet that is consumed, increase the incidence of diarrhea post chemotherapy. recomendation it should be given continuous information on cervical cancer patients about management of diarrhea, health education about cervical cancer, chemotherapy procedures, and the side effects there of, and taking care patients with diarrhea post chemotherapy. patients need to get emotional support in anticipation of the psychological needs. patients need to consume a diet that is not at jurnal ners vol. 11 no. 1 april 2016: 106-111 111 risk to prevent diarrhea. hospital need to improve cross-sectoral cooperation between health centers on palliative care by conducting home visit to anticipate problems after chemotherapy. for further research can investigate other side effects experienced by patients after chemotherapy with larger samples and the method of cohort. references benson, b., & stein, r., 2009. cancer and drug discovery development: supportive care in cancer therapy d. s. ettinger, ed., totowa, nj: human press. benson, c. r., & pernoll, l.m., 2009. buku saku: obstetri & ginekologi 9th ed., jakarta: egc. bisanz, a., 2010. summary of the causative and treatment factors of diarrhea and the use of a diarrhea assessment and treatment toll to improve patient outcomes. nursing center, 33(4). dinkes, 2012. kegiatan pengendalian kanker di jawa timur (ppkm, trans.), surabaya. dunleavy, r., 2009. cervical cancer: a guide for, chichester: john willey & sons. sons ltd. ferrell, b.r., coyle, n. & judith, p., 2010. oxford textbook of palliative nursing third., new york: oxford university press. hawari, 2011. manajemen stres, cemas dan depresi 2nd ed., jakarta: balai penerbit fkui. lovibond, l.&, 1995. manual for the depression anxiety stres scale 2nd ed., sydney: psychology foundation, australia centre for post traumatic mental health. available at: www.psy.ed.au/groups. rasjidi, i., 2007. chemotherapy kanker ginekologi dalam praktik sehari – hari, jakarta: sagung seto. rasjidi, i., 2009. deteksi dini dan pencegahan kanker pada wanita 1st ed., jakarta: sagung seto. rasjidi, i., 2010a. imaging ginekologi onkologi, jakarta: sagung seto. rasjidi, i., 2010b. perawatan paliatif suportif dan bebas nyeri pada kanker, jakarta: sagung seto. wan desen (sun yatsen university, cancer center, g., 2008. buku ajar onkologi klinis, jakarta: fkui. http://e-journal.unair.ac.id/jners | 45 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18909 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family factors and their relation to the treatment adherence of pulmonary tb patients in surabaya dhian satya rachmawati1,2, dwi priyantini2, qurrotul aini2 1 doctoral student, faculty of public health, universitas airlangga, surabaya, indonesia 2 stikes hang tuah, surabaya, indonesia abstract introduction: pulmonary tb is a chronic disease of which is one of the keys to its successful management is the quality of the patient's family support system. the family has a role in the psychological wellbeing of sick family members in the care process. the purpose of this study was to look for the effects of family factors (family stress level and family resilience) with treatment adherence of pulmonary tb patients in north surabaya. methods: the design of this research was analytic observational research design with cross-sectional approach. a sample of 284 respondents was taken using proportional random sampling technique from 990 patients with pulmonary tb in the north surabaya area. the instrument used was a questionnaire that had been tested for validity and reliability. data were analyzed using pearson correlation test at α ≤ 0.05. results: the results showed that family stress level was mostly in the normal category (86.6%), family resilience was mostly in the good category (79.9%), and tb medication adherence was in the moderate category (39.8%). the pearson correlation test results obtained family stress level associated with tb medication adherence (p = 0.004) and family resilience has a relationship with tb medication adherence (p = 0.001). conclusion: families can work to reduce stress and increase the resilience of their families to increase adherence with tb treatment in family members suffering from pulmonary tb article history received: feb 27, 2020 accepted: april 1, 2020 keywords adherence; family resilience; stress; pulmonary tb; tuberculosis contact dhian satya rachmawati  dhian.satya.rachmawati2017@fkm.uniar.ac.id  faculty of public health, universitas airlangga, surabaya, indonesia cite this as: rachmawati, d, s., priyantini, d., & aini q. (2020). family factors and their relation to the treatment adherence of pulmonary tb patients in surabaya. jurnal ners, special issues, 45-49 doi: http://dx.doi.org/10.20473/jn.v15i2.18909 introduction a global tuberculosis report in 2017 indicated that indonesia had taken the third biggest position in the number of tb patients (who, 2017). tuberculosis is a disease that attacks the lungs, so it is called pulmonary tb. pulmonary tb disease is a large problem for society, especially in developing countries and has become one of the leading causes of death globally, regionally, nationally, and locally among a wide variety of infectious diseases (firdaufan et al., 2015), pulmonary tb is an infectious disease that requires long-term treatment and may have an impact on treatment adherence (rr dian tristiana et al., 2019). in general, cases of pulmonary tb in indonesia have increased every year. the number of new cases of pulmonary tb in indonesia were as many as 420, 994 cases in 2017(pusdatin kemenkes ri, 2016), tb case detection bta + new cases in east java in 2015 ranked second in indonesia. the score indicated as many as 23,183 people with a discovery case detection rate (cdr) of 56% whereas the target is at least 70% (kemenkes ri, 2017) in 2016, the number of pulmonary tb patients who were treated was as many as 47,478 cases while the estimated number of cases amounted to 123,414. based on reports from 63 community health centers in the city of surabaya, the number of patients with pulmonary tb in surabaya increased by 6,488 people. a global tuberculosis report in 2017 indicated that indonesia had taken the third biggest position in the number of tb patients (who, 2017). tuberculosis https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:dhian.satya.rachmawati-2017@fkm.uniar.ac.id mailto:dhian.satya.rachmawati-2017@fkm.uniar.ac.id d. s. rachmawati et al. 46 | pissn: 1858-3598  eissn: 2502-5791 is a disease that attacks the lungs, so it is called pulmonary tb. pulmonary tb disease is a large problem for society, especially in developing countries and has become one of the leading causes of death globally, regionally, nationally, and locally among a wide variety of infectious diseases (firdaufan et al., 2015), pulmonary tb is an infectious disease that requires long-term treatment and may have an impact on treatment adherence (rr dian tristiana et al., 2019). in general, cases of pulmonary tb in indonesia have increased every year. the number of new cases of pulmonary tb in indonesia were as many as 420, 994 cases in 2017(pusdatin kemenkes ri, 2016), tb case detection bta + new cases in east java in 2015 ranked second in indonesia. the score indicated as many as 23,183 people with a discovery case detection rate (cdr) of 56% whereas the target is at least 70% (kemenkes ri, 2017) in 2016, the number of pulmonary tb patients who were treated was as many as 47,478 cases while the estimated number of cases amounted to 123,414. based on reports from 63 community health centers in the city of surabaya, the number of patients with pulmonary tb in surabaya increased by 6,488 people. materials and methods this study design was analytical observational with cross-sectional approach whereby the researchers took measurements and observations of the dependent variable, tb treatment adherence, and the independent variables included family stress level and family resilience. measurements were made simultaneously. the study population was 990 tuberculosis patients' families in north surabaya undergoing treatment, of which 284 persons met the following criteria: families willing to study and fill out the consent form, age 17-70 years old, families who have a family member with positive smear, pulmonary tb patients newly diagnosed and undergoing treatment at least two months, respondents who live in surabaya with family registered chard. there are families who share the same home (parents / husband / wife / son /daughter), with immediate family members caring for patients with pulmonary tb. the study used probability sampling with proportional random sampling technique in three community health centers representing community health centers in the city of surabaya. the family stress instrument in this study used a stress measurement questionnaire adopted from dass-42 (depression anxiety stress scale 42) to measure family resilience used the family resilience assessment scale (fras) instrument, while the instrument for tb lung treatment adherence used mmas-8 (morisky medication adherence scale). all of the instruments had been already tested for validity and reliability in a pilot study consisting of 25 respondents. each item in the statements reached validity (r>0.514) and each questionnaire reached reliability as well (>0.8). results general data of research respondents the result of this study showed 181 respondents (63.7 %) living in nuclear family type, and 104 respondents (36.6 %) at senior high school in their level education, and 122 respondents (43%) working as a private employee. the position in the family of respondents is mostly as husband / wife with 135 respondents (47.5%); research shows that among 268 patients with pulmonary tb (94.4%) family members act as supervisors to take medication. effects of family stress on adherence with pulmonary tb treatment research shows data that, from 284 respondents, there are 246 respondents in the category of normal stress with normal stress levels and having a high level of medication adherence, as many as 107 people (43.5%) who have normal stress levels, those having moderate levels of medication adherence as many as 92 people (37.4%), and those whose stress level is normal and have a low level of adherence as many as 47 people (19.1%). furthermore, out of 284 respondents, there were 26 respondents in severe levels who had severe stress levels and a high level of adherence with five people (19.2%), those with severe stress levels and moderate adherence levels were 15 people (57.7%), and those who had severe stress levels and low adherence rate were six people (23.1%). of the 284 respondents, there were six people in the category of mild and moderate stress, those with mild stress levels and had moderate adherence levels were six people (100%), and those with moderate stress levels and low adherence rates were people (100%). based on the pearson statistical test, the results were ρ = 0.004 where α = ≤ 0.05. this means that there is an influence between family stress level and pulmonary tb treatment adherence in north surabaya. effects of family resilience on adherence with pulmonary tb treatment the study showed data from 284 respondents who had good family resilience and high levels of adherence as many as 101 people (44.5%), those with good family resilience and moderate levels of adherence as many as 90 people (39.6%), those with good family resilience and low levels of adherence as many as 36 people (15.9%), those with adequate family resilience and high levels of adherence 11 people (21.6%), those with adequate family resilience and moderate levels of adherence 17 people (33.3%), those with sufficient family resilience and low levels of adherence 23 people (45.1 %), and lack of family resilience and moderate level of adherence 6 people (100%). based on the pearson statistical jurnal ners http://e-journal.unair.ac.id/jners | 47 test, the results were ρ = 0.001 where α = ≤ 0.05, which means that there is an influence between family resilience with pulmonary tb treatment adherence in north surabaya. discussion the results showed that families with normal stress levels and high adherence were 107 respondents (43.5%). a good coping mechanism will affect the family in dealing with stressors, which come from inside or outside the family. adaptive attitude will have a positive impact on patient adherence in undergoing pulmonary tb treatment, so that patients will achieve a high level of adherence. families with normal stress levels and moderate adherence were 92 (37.4%) and families with normal stress levels and low adherence were 47 (19.1%). stable family stress condition does not guarantee that the patient is fully obedient in taking medicine. researchers assume that, in addition to family, sufferers also need support from external factors, namely the environment. feeling bored and fed up is also a factor in causing a patient's low adherence to treatment. when associated with adherence of pulmonary tb treatment, stress will greatly affect the patient's family. the duration of pulmonary tb treatment that requires a long period of time can be a stressor for the family. when the family is unable to cope with the stressor, it will affect the continuity of the pulmonary tb treatment process, which can be seen from the level of patient adherence. this can be seen from the results of the study, where there are still sufferers table 1. general data of research respondents characteristics n % family type nuclear family extended family 181 103 63.7 36.3 education level elementary 97 34.2 junior high school 46 16.2 senior high school 104 36.6 college 26 9.2 other 11 3.9 occupation government employees 5 1.8 entrepreneur 61 21.5 private 122 43 other 96 33.8 family member position husband /wife 135 47.5 child 67 23.6 parents of husband / wife 82 28.9 the supervisor took the medicine health careers 6 2.1 health workers 10 3.5 family 268 94.4 table 2. effects of family stress on adherence with pulmonary tb treatment family stress level pulmonary tb treatment adherence total high moderate low n % n % n % n % normal mild moderate severe 107 0 0 5 43.5 0.0 0.0 19.2 92 6 0 15 37.4 100 0.0 57.7 47 0 6 6 19.1 0.0 100 23.1 246 6 6 26 100 100 100 100 total 112 39.4 113 39.8 59 20.8 284 100 pearson correlation: 0.004 (p=0.05) table 3. effects of family resilience on adherence with pulmonary tb treatment family resilience pulmonary tb treatment adherence total high moderate low n % n % n % n % good adequate lack of 101 11 0 44.5 21.6 0.0 90 17 6 39.6 33.3 100 36 23 0 15.9 45.1 0.0 227 51 6 100 100 100 total 112 39.4 113 39.8 59 20.8 284 100 pearson correlation: 0.001 (p=0.05) d. s. rachmawati et al. 48 | pissn: 1858-3598  eissn: 2502-5791 who are included in low adherence as many as 59 people (20.8%) and moderate adherence as many as 113 people (39.8%). the presence of stressors is interpreted by the family as a burden of care. families try to optimize the family's strength, called family structure, as a resource for managing stressors, but if the family thinks that the stressors are threatening to the family stability, then this may result in a family burden. this situation brings families into stressful situations. the findings of the study have proven that the patient’s frequency of relapse, stigma, the burden of care, and family structure can predict the stress experienced by the families (rizky fitryasari et al., 2018)(sulistyono et al., 2020). the study also showed that, out of 227 families included in the category of good resilience, there were high levels of adherence of 101 people (44.5%), moderate adherence of 90 (39.6%), and low adherence of 36 people (15.9%). the adaptation process in the family as a functional unit allows the family to mediate stress and overcome a prolonged crisis (walsh, 2012). families who see difficulties as common challenges and natural things that happen in life are able to survive and rise from these difficulties. it is also driven by the view that the difficulties experienced can be explained and predicted; the availability of resources needed to overcome the difficulties experienced is something that is valuable for family security. thus, when a family member is sick, the rest of the family feel this as a burden (rr dian tristiana et al., 2018). this is in line with the results of previous studies that showed that the burden of care felt by the family is related to confusion about the illness, emotions, physical, time, and financial and social burdens. this leads to a decrease in the quality of life of family and family functionality. there are opportunities for negative outcomes in relation to family resilience (rizki fitryasari et al., 2018). the problem for the families of tb sufferers is the misunderstanding of the family and community, which leads to discrimination related to the disease (rachmawati et al., 2019)(sulistyono et al., 2019). discrimination felt at the beginning of the diagnosis is one of the causes of depression in tb patients and their families (li‐yun lee, heng‐hsin tung, shu‐ching chen, 2017). the results of the analysis from previous studies indicate that the acceptance stage of the family endurance stage ranks first, with a structural equation which states that it has a 0.94 effect on family endurance in the family of pulmonary tb patients. this shows that, when family members suffer from pulmonary tb, the family tries to adapt to new sources of stress in the family (rachmawati et al., 2019). according to (walsh, 2012) , the family resilience framework explains that family resilience is built including three components, namely: family beliefs, organizational patterns, and communication processes. the researcher assumes that one of the families suffering from pulmonary tb in north surabaya has an open communication pattern, where most of the people in north surabaya are classified as nuclear family. the key to family resilience is evidenced by the existence of endurance when one family member experiences a chronic illness and is able to complete treatment to completion. the higher the family's resilience, the higher the level of adherence with pulmonary tb treatment. readiness is the key to family security. families must be encouraged to be proactive in anticipating life's challenges. declining family resilience researchers are the most valuable resource, providing not only care but also a sense of security and comfort that goes on in an emotional bond. conclusion from the results of the study it can be concluded that the lower the level of family stress, the adherence of patients carrying out the treatment program of pulmonary tb will be better, and the higher the resilience of the family, the higher the patient's adherence implementing the pulmonary tb treatment program. conflict of interest this research does not have a conflict of interest acknowledgement acknowledgment to stikes hang tuah surabaya and airlangga university in compiling research and publishing research results references firdaufan, santoso, hartanto, r., hendratno, sumardiyono, sutisna, e., & syahril, m. (2015). evaluasi program pengendalian tuberkulosis dengan strategi dots di eks karesidenan surakarta. jurnal kedokteran indonesia, vol. 1 no., 199–208. fitryasari, rizki, yusuf, a., dian, r., & endang, h. (2018). international journal of nursing sciences family members ’ perspective of family resilience ’ s risk factors in taking care of schizophrenia patients. international journal of nursing sciences, 5(3), 255–261. https://doi.org/10.1016/j.ijnss.2018.06.002 fitryasari, rizky, nursalam, n., yusuf, a., hargono, r., & chan, c.-m. (2018). predictors of family stress in taking care of patients with schizophrenia. jurnal ners, 13(1), 72–79. https://doi.org/http://dx.doi.org/10.20473/jn.v 13i1.7762 kemenkes ri. (2017). profil kesehatan provinsi jawa timur tahun 2016. dinas kesehatan provinsi jawa timur. li‐yun lee, heng‐hsin tung, shu‐ching chen, c. f. (2017). perceived stigma and depression in initially diagnosed pulmonary tuberculosis patients. journal of clinical nursing, 26(23–24), jurnal ners http://e-journal.unair.ac.id/jners | 49 4813–4821. https://doi.org/10.1111/jocn.13837 louw, j. s., mabaso, m., & peltzer, k. (2016). change in health-related quality of life among pulmonary tuberculosis patients at primary health care settings in south africa : a prospective cohort study. research article, 1–14. https://doi.org/10.1371/journal.pone.0151892 pusdatin kemenkes ri. (2016). tuberkulosis. kemenkes ri. rachmawati, d. s., nursalam, n., & amin, m. (2019). developing family resilience models : indicators and dimensions in the families of pulmonary tb patients in surabaya. 14(2), 165–171. rachmawati, d. s., nursalam, n., wibowo, a., budiarti, a., & agustin, r. (2018). family factors associated with quality of life in pulmonary tuberculosis patients in surabaya, indonesia. indian journal of public health research & development, 9(11), 91–95. sulistyono, r. e., susanto, t., & tristiana, r. d. (2019). barriers in tuberculosis treatment in rural areas (tengger, osing and pandalungan) in indonesia based on public health center professional workers perspectives: a qualitative research. jurnal ners, 14(1), 62–68. https://doi.org/http://dx.doi.org/10.20473/jn.v 14i1.10270 sulistyono, r. e., susanto, t., & tristiana, r. d. (2020). patients experience and perception in preventing tuberculosis transmission in rural areas: a qualitative research. jurnal keperawatan padjadjaran, 8(1). https://doi.org/10.24198/jkp tristiana, rr dian, kumalasari, r., & makhfudli, m. (2019). pengalaman klien tb paru yang menjalani pengobatan fase intensif di puskesmas taji kabupaten magetan. indonesian journal of community health nursing, 8(1). https://doi.org/http://dx.doi.org/10.20473/ijch n.v8i1.12353 tristiana, rr dian, yusuf, a., fitryasari, r., wahyuni, s. d., & nihayati, h. e. (2018). perceived barriers on mental health services by the family of patients with mental illness. international journal of nursing sciences, 5(1), 63–67. https://doi.org/10.1016/j.ijnss.2017.12.003 walsh, f. (2012). successful aging and family resilience. spinger publishing company. who. (2017). global tuberculosis report 2017. in who. https://doi.org/who/htm/tb/2017.23 wong, p., hons, b. n., & clinnursed, g. (2019). the impact of social support networks on family resilience in an australian intensive care unit : a constructivist grounded theory. journal of nursing scholarship, 68–80. https://doi.org/10.1111/jnu.12443 http://e-journal.unair.ac.id/jners | 23 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.12125 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors correlated to job stress among icu nurses yulis setiya dewi1, rachmat hargono2 and ainur rusdi3 1 faculty of nursing, universitas airlangga, east java, indonesia 2 faculty of public health, universitas airlangga, east java, indonesia 3 soetomo general hospital, east java, indonesia abstract introduction: job stress is a major barrier to the attainment of safety, health, and wellness among nurses. understanding factors job stress among nurses is very important to provide alternatives solution to ease the stress in the future. however, there are limited studies with respect to factors related to stress in intensive care unit (icu) nurses particularly in indonesian context. this study aimed to identify factors correlated to job stress among icu nurse in three public hospitals. methods: a correlational study was carried on icu nurses who hands-on icu nursing care. data were collected using questionnaires. descriptive statistic and spearman correlation were used to analyze the correlation between perceived job burden, working condition, quality of nursing work life, perceived organizational support, and stress among icu nurses. results: a total of 91 respondents (32 male and 59 female) were involved to the study comprises of two different educational backgrounds (59 diploma iii and 32 bachelor degree). the statistical analysis using pearson correlation found that workload (0.003), working condition (0.000), quality of nursing work life (0.000), perceived organizational support (0.000) significantly correlated to job stress among icu nurses. conclusion: all studied factors correlated to job stress among icu nurses. all factors had moderate correlation with nurses’ job stress and working condition has highest strong correlation compare to the other factors. its implies from the result that management of the hospital may provide more attention to job stress among nurses to maintain optimum performance to provide nursing care for patients particularly critically ill patients in icu. article history received: feb 25, 2019 accepted: may 12, 2019 keywords icu; job stress; nurses; qnwl; organisational support; working condition, workload contact yulis setiya dewi  yulis.sd@fkp.unair.ac.id  faculty of nursing, universitas airlangga, east java, indonesia cite this as: dewi, y.s., hargono, r., & rusdi, a. (2019). factors correlated to job stress among icu nurses in surabaya indonesia. jurnal ners, 14(1),23-27. doi:http://dx.doi.org/10.20473/jn.v14i1.12125 introduction the icu nurses are confronted with the unpleasant facts every day and it is very difficult to avoid the source of stress. on the other hand nurses are required to always perform caring behaviour not only for patients but also for the patient's family. previous studies revealed major stressor among icu nurses include consistent contact with dying, interaction between patients’ and family members, conflict with supervisors, uncertain condition and health progress of patients (burtson and stichler, 2010; sarafis et al., 2016). research in one hospital in east java found that there was a relationship between job stress and caring behaviour where nurses did not provide caring behaviour optimally (74%) because they experienced stress at moderate and severe levels (desima, 2013). while other studies at the intensive care unit showed that nurses indicate stressful behaviour (43.1%), experienced physical stress (43.7%), and experienced emotional stress (46.7%) (amiyanti, 2000). a study found that critical care nurses experience greater level of stress compare to internal surgical unit in tehran (zaher, vafaei and abianeh, 2016). consistent contact with the events of death, interactions with patients and their families, conflicts with supervisors and uncertainty about therapy caused much higher stress in icu nurses (burtson and stichler, 2010; sarafis et al., 2016) the characteristics of the icu and the high need for care can cause stress-related symptoms, namely post-traumatic stress disorder (ptsd), anxiety, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.121253 y. s. dewi et al. 24 | pissn: 1858-3598  eissn: 2502-5791 depression and burnout syndrome (cavalheiro, moura junior and lopes, 2008; mealer et al., 2012, 2018; zhang, huang and guan, 2014; siffleet et al., 2015). all the problems faced drain the energy, mind, concentration, physical and psychological health conditions of the nurse in various forms, for example being cynical and indifferent to patients, often ditching, often feeling dizzy, wanting to always change their jobs, and apathy towards the future of themselves. the results of the preliminary study through unstructured interviews in march 2018 with the head of the intensive care unit and reanimation in one of the government hospitals in surabaya were in 2010 found that 34% of nurses requested for job rotation to another ward. in the period januarymarch 2018, there were 4 people (out of 44 icu nurse) who asking for job rotation to other wards due to many factors including health issues. stress may cause more severe psychological problems and this can have an impact on nurses’ interactions with other health workers, nurses’ jobs performance, and institution's reputation (mariani, 2013). it is important to understand factors correlated to nurses’ stressors in icu including perceived job burden, working condition, quality of nursing work life, perceived organizational support. this result may provide a solution for the nurse manager to ease level of stress among icu nurses. materials and methods research design this study is a part of bigger study conducted by researcher and become preliminary steps for constructing a model to develop resilience model. a correlational design was used to reveal relationship between job stress including quality of nursing worklife, job burden, and stress among icu nurses. the factors were namely perceived job burden, working condition, quality of nursing work life, perceived organizational support were identified to correlated with stress of icu nurses. this study conducted at soetomo general hospital, universitas airlangga teaching hospital, and hajj general hospital surabaya, east java, indonesia. respondents the respondents were recruited from three different hospitals using total population sampling method. the population included all staff nurses. this means that all nurses were involved to the study but not with those who in managerial level such as nurse unit manager and nurse unit coordinator. a total of 95 nurses were voluntary participated to the study but only 91 nurses completed all questionnaires. those who did not fill in the questionnaire completely considered as drop out from the study. measurement tools the data collection tools were single questionnaires on socio-demographic characteristic were designed by researcher. in addition, the questionnaires for all variables were adopted from existing questionnaire. researcher made some adjustment on the questionnaire and tested the validity and reliability of the questionnaires on april, 15 – may 3, 2018 to 26 at icu nurses in darmo hospital, surabaya. validity test was using pearson product-moment with coefficient correlation > 0.5. item no 13 on working condition tool was not considered valid. researcher made modification on the sentence structure and diction to make it readable since this is an important question. tools on perceived job burden, working condition, job stress and qnwl were considered reliable with result 0.936, 0.819, 0.732 and 0.840 respectively after tested using alfa cronbach. however tool for perceived organisational support was not reliable. researcher reviewed and made modification before it was used. translation was accomplished by researcher and proofread by journal development team from faculty of nursing, universitas airlangga, surabaya indonesia. measurement tools to explore demographic data was developed by researcher based on current characteristic of nurses in public hospital in surabaya. the demographic data included ages, work experience, gender, and level of education. tools for job stress was adopted form nursing job stress questionnaire from nursalam (2015) consisted of 30 items. likert scale was occupied using 4 scales from always to never choices. tools for nursing workload was also adopted from nursalam (2015) which is consisted of 12 question and using likert scales with 4 scales from always to never choices. in addition for qnwl (quality of nursing work life was adopted from brook (2001, cited from (nursalam, 2015)) consisted of 42 statements and the chosen answers used likert scales from very agree to very disagree. organizational support questionnaire was adopted from perceived organizational support (eisenberger and huntington, 1996) using likert scale with very agree to very disagree choices for 25 statements. data collection data was collected at july-september 2018. a questionnaire was completed with description of the study, consent procedure, response confidentiality and researcher’s contact details. the questioner was completed independently by the respondents and collected by researcher in the same day. it took about two months to reached all respondents from three different hospitals and due to shift schedule and administrative process in the hospitals . data analysis original data were inputted into excel spreadsheet and checked by researcher. all data were analyzed using the spss 20.00 software. descriptive analysis included frequency, percentages, means and standard deviation were used to provide descriptive data. data was analysed using pearson correlation to identify the influence between workload, working condition, jurnal ners http://e-journal.unair.ac.id/jners | 25 quality of nursing work life, perceived organizational support, and stress among icu nurses. in this study the statistical level of significance was set at p< 0.05 for two sides. ethical consideration ethical approval was obtained from the ethic committee of the three hospitals i.e dr. soetomo hospital (no. 0325/kepk/v2018), hajj general hospital (no. 073/11/kom.etik/2018) dan universitas airlangga teaching hospital (no. 145/keh/2018). voluntary, confidentially, fair and harmless ethical principles were occupied in this study. we explained carefully the purpose, benefits and risk to the respondents before they asked to participate to our study. all respondents who agree to involved in the study had been asked to sign the written informed consent freely. respondent received tea set as a reward from researcher for their time and willing to participate to the study. significance of the study job stress can lead to an important impact on individual icu nurses and their activities such as lack of concentration, decrease job motivation, emotionally vulnerable to patients and conflict with other health care worker. this situation may impair their job performance, decrease their job satisfaction and leads to medication errors. thus, it is important to identify factors may correlated to job stress among icu nurses. results sociodemographic characteristic of respondents a total of 95 questionnaires were distributed but 91 were completed and the rest was considered incomplete and invalid therefore indicating 94,8% returned rate. the majority of the respondent age at the range of 23 – 54 years. level of education was dominated at d3 level (64,8%) with work experience at 1-5 yrs (40.7%). a total 0f 64.8 % was female nurses. table 1 provide the other demographic data of the respondents. characteristic of respondents the characteristic of respondent described in the table 1. the vast majority of respondent were between 25-35 years old. most of the respondents had work experience under 10 years where 37 % were under 5 years. female were dominant staff compare to male staff. respondents were mostly had diploma degree and none of them were graduated from post graduate degree and above. variable description all variables of the study have been stated in the table 2. the averages perceived job burden was 27,86 (sd=7.62). the working condition was in the average of 43.30 (sd=7.034) where as quality of nursing work life was in the average of 146.48 (sd=17.36). organisational support has been perceived by the icu nurse was an average of 69.36 (sd=7.531). the total average job stress among icu nurses reached 93.24 (sd=11.33) as provided in table 3. all variables of the study have been stated in the table 2. the averages perceived job burden was 27,86 (sd=7.62). the working condition was in the average of 43.30 (sd=7.034) where as quality of nursing work life was in the average of 146.48 (sd=17.36). organisational support has been perceived by the icu nurse was an average of 69.36 (sd=7.531). the average job stress among icu nurses reached 93.24 (sd=11.33). table 1. sociodemographic characteristic of respondents (n=91) variable n % age (years) <25 3 3.3 25-30 35 38.5 31-35 19 20.9 36-40 8 8.8 41-45 14 15.4 46-50 6 6.6 51-55 6 6.6 work experience (yrs) <1 7 7.7 1-5 37 40.7 6-10 19 20.9 11-15 9 9.9 16-20 11 12.1 21-25 5 5.5 26-30 3 3.3 sex male 32 35.2 female 59 64.8 level of education diploma 3 59 64.8 bachelor 32 35.2 table 2. description of independent and dependent variables variable mean sd independent perceived job burden 27.87 7.627 working condition 43.31 7.034 qnwl 146.48 17.363 working support 69.36 7.531 dependent physical stress 32.29 4.483 psychological stress 60.94 7.625 job stress 93.24 11.33 table 3. correlation of job stress among icu nurses (pearson’s correlation) variable job stress of icu nurses r p-value perceived job burden 0.310 0.003 working condition 0.432 0.000 qnwl 0.389 0.000 perceived organisational support 0.420 0.000 y. s. dewi et al. 26 | pissn: 1858-3598  eissn: 2502-5791 discussion correlation between job stress and variables was analyzed using pearson’s correlation. the result showed that there was correlation between perceived job burden, working condition, qnwl and perceived support and nursing job stress. perceived job burden perceived job burden correlated with job stress among icu nurses. this result is in line with previous study in pakistan (johan, sarwar and majeed, 2017) that job burden correlated with kind of stress among icu nurses. intensive care unit is considered as a high demand of care where nurses have to provide total care using sophisticated equipment such as ventilator, continuous renal replacement therapy infusion pump, syringe pump, portable x-ray and a lot of life-saving tools and medicines. this situation need more concentration and extra energy from nurses. in addition, in three public hospital in surabaya, the ratio between nurse and patients is remain inappropriate to the standard in which based on observation of researcher frequently 2 nurses have to handle 3-4 ventilated patients. according to ministry of health of indonesia (2006) ratio nurse – patient for ventilated patients is 1:1 and 1: 2 for unventilated patients. however, in this three hospital this ideal ratio was difficult to apply due to nursing shortages in each hospital particularly in soetomo hospital. soetomo hospital provides tertiary icu care and as referral hospital in eastern part of indonesia. meanwhile, from the researcher observation, nurse also had to handle other administrative task such as patient’s billing, and etc. as the consequence, nurse workload was high and correlated with level of stress. working condition working condition was correlated with job stress among icu nurses. it has been known that working in icu it takes a thoughtful task, quick thinking, and dedication to achieve the advanced skills necessary for the job. handling difficult patients is a frequent cause of stress for icu nurses (vahedian-azimi et al., 2017). the results of this study support previous studies that work conditions are related to the stress level of icu nurses (andolhe et al., 2016). in surabaya, unpleasant working condition in icu may include alarms, restricted area, sophisticated machines which may not all nurses able to operate, fluid body secretion, limited time to communicate with other staff and health care worker, un-cooperative patient’s relatives, unstable and unpredicted situation. in this study, most of nurses had work experience at under 10 years (more than 69.2%) and under 5 years (37 %) and they still in the journey of mastering all equipment which is not easy and may find it difficult to adapt with. some of the nurses were also still learn about such procedures and also may not confidence to communicate with patients’ family and other health care professional, especially those who experienced under 1 year. quality of nursing work life quality of nursing work life correlated to job stress of icu nurses. this result was in accordance with present study that there was a correlation between job stress and qnwl (roshangar et al., 2017). it has been widely accepted that staff nurse are challenging with relatively stressful work environment including irregular scheduling or shifting and socio-emotional pressures related to the patients and their own family almost every day (jaafarpour, khani and mahmodian, 2015). in addition, due to the complex nature of working in critical care, nurses in the icu encounter more pressure and stress than general ward nurse. this situation may be worsen when the nurse relates the distress from a patient’s situation with one in his/her own personal life. furthermore another study found that nurse’s high work pressure declines qwl. thus, nurses often are deprived of energy and are not able to stabilize their work life and family life (roshangar et al., 2017). based on the characteristic of respondents of this study, the majority (59,4 %) of them are in the productive ages (25-35 year old) where they are just starting a family and busy with domestic chores and taking care of their children. it could be understood that nurses are still struggling to balancing between working-life and personal-life. perceived organizational support this study revealed that there was correlation between perceived organizational support and nursing job stress. this result was in the contrary with recent study that there was a negative relationship between nurses’ job stress and organizational support (roshangar et al., 2017). this different result may be due to different participant of the study. this study was for icu nurses whereas another study conducted for all type of nurses. however, a research found that there was correlation between organizational support and job stress among nurses at saudi public hospital (al-homayan et al., 2013). the study also confirmed that nurses who received organizational support performed a better job than being stressed at work by mitigating the effect of job stress on job performance (al-homayan et al., 2013). icu nurses who provide total care for critically ill patients have to adapt to a fast-paced and stressful environment by functioning within their own culture. therefore organizational support is needed to keep nurses work on their best performance and lighten adversity in the workplace. conclusion the result of this study revealed that most of the participant had work experience less than 10 years and most of them were at the age of under 35 years. there were significant correlation between workload, working condition, qnwl and perceived jurnal ners http://e-journal.unair.ac.id/jners | 27 support and nursing job stress. based on the study result, it is important for the management of hospital to provide more attention on the nurses’ psychological and personal aspect to help them bounce back from difficult situation in the workplace. such of education or training is required to help nurses adapt with difficult situation in a better way. another research id also needed to develop method with respect to the requisite of the education or training. acknowledge the author are grateful to educational fund management institution (lpdp), ministry of finance of republic indonesia which funded this research, rector of universitas airlangga and last but not least all icu nurses from soetomo general hospital, universitas airlangga teaching hospital, and the hajj general hospital surabaya, east java indonesia who participated to this study. references al-homayan, a. m. et al. (2013) ‘effects of job stress and organizational support on the relationship between job demand resources and nurses ’ job performance in saudi public hospitals’, australian journal of basic and applied sciences, 7(10), pp. 7– 19. amiyanti, l. (2000) analysis factors related to stress among staff nurse at emergency unit, dr. tjipto mangukusumo national hospital. andolhe, r. et al. (2016) ‘estresse, coping e burnout da equipe de enfermagem de unidades de terapia intensiva: fatores associados’, journal of school of nursing, 49(spe), pp. 58–64. doi: 10.1590/s0080623420150000700009. burtson, p. l. and stichler, j. f. (2010) ‘nursing work environment and nurse caring: relationship among motivational factors’, journal of advanced nursing, 66(8), pp. 1819–1831. doi: 10.1111/j.1365-2648.2010.05336.x. cavalheiro, a. m., moura junior, d. f. and lopes, a. c. (2008) ‘stress in nurses working in intensive care units’, revista latino-americana de enfermagem, 16(1), pp. 29–35. doi: 10.1590/s010411692008000100005. desima, r. (2013) ‘tingkat stres kerja perawat dengan perilaku caring perawat’, jurnal keperawatan, 4(1), pp. 43–55. doi: https://doi.org/10.22219/jk.v4i1.2380 eisenberger, r. and huntington, r. (1996) ‘perceived organisational support’, journal of applied psychology, 71(3), pp. 500–5007. doi: 10.1037//0021-9010.87.4.698 jaafarpour, m., khani, a. and mahmodian, m. r. (2015) ‘evaluation of the quality of nursing work life and its association with job burnout in isfahan university of medical sciences’, international journal of epidemiologic research, 2(1), pp. 30–39. johan, s., sarwar, h. and majeed, i. (2017) ‘to identify the causes of stress among nurses working in intensive care unit of ittefaq hospital lahore’, international journal of social sciences and management, 4(2), pp. 96–109. doi: 10.3126/ijssm.v4i2.17159. mariani, b. u. (2013) ‘faktor-faktor personal sebagai prediktor terhadap resiliensi perawat di rumah sakit penyakit infeksi’, journal of infectious disease, 1(1), pp. 14–21. doi: oi 10.32667/ijid.v1i01.3 mealer, m. et al. (2012) ‘the presence of resilience is associated with a healthier psychological profile in intensive care unit (icu) nurses: results of a national survey’, international journal of nursing studies, 49(3), pp. 292–299. doi: 10.1016/j.ijnurstu.2011.09.015. mealer, m. et al. (2018) ‘designing a resilience program for critical care nurses’, advanced critical care nursing, 28(4), pp. 359–365. doi: 10.4037/aacnacc2017252.designing. nursalam (2015) metodologi penelitian ilmu keperawatan: pendekatan praktis. 5th edn. jakarta: salemba medika. roshangar, f. et al. (2017) ‘job stress and quality of nurse’s work life’, pharmacophore, 8(6s), pp. 1–8. sarafis, p. et al. (2016) ‘the impact of occupational stress on nurses ’ caring behaviors and their health related quality of life’, bmc nursing. bmc nursing, 15(56), pp.1–9. doi: 10.1186/s12912-016-0178-y. siffleet, j. et al. (2015) ‘delivering best care and maintaining emotional wellbeing in the intensive care unit : the perspective of experienced nurses’, applied nursing research, 28, pp. 305–310. doi: 10.1016/j.apnr.2015.02.008. vahedian-azimi, a. et al. (2017) ‘effects of stress on critical care nurses : a national cross-sectional study’, journal of intensive care medicine, xx(x), pp. 1–12. doi: 10.1177/0885066617696853. zaher, s. j., vafaei, m. and abianeh, e. e. (2016) ‘comparing depression , anxiety and stress among thenurses in the critical care and internal surgical units at the selected hospitals of the social security organization of tehran in 2016’, international journal of medical research & health sciences, 5(9s), pp. 254–261. zhang, x., huang, d. and guan, p. (2014) ‘job burnout among critical care nurses from 14 adult intensive care units in northeastern china : a cross-sectional survey’, bmj open, 3(e004813). doi: 10.1136/bmjopen-2014-004813. 108 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16991 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review correlation of picky eating in children’s growth: a systematic review dona muji fitriana, risna nur pradany and apriana rahmawati faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: picky eating is a problem that is now common in children, characterized by not trying or limiting variations in food, especially vegetables and fruit. picky eating has an important role in the development of children, both physically and emotionally, so that it becomes a concern for the parents. method: this systematic review aims to explain the correlation of picky eating on a child's growth using prisma approach from two database: scopus and proquest limited to the last 5 years; from 2015-2019 and obtained 15 articles that selected. identification of articles using keywords ('picky eating' and 'children' and 'weight' or 'growth'). result: according to the findings, it was found nine articles that mentioned picky eating had an effect on growth and six articles mentioned no effect. limitation of this study is that there are other factors that influence picky eating in selected articles. conclusion: the most of the result from the studies show the behavior of picky eating in children can affect the growth of both body weight and height, and can also affect nutritional status, emotional status, physical activity and health status. nurses can provide education about the effects of picky eating behavior on children in parents. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords picky eating; children; growth; body weight contact dona muji fitriana dona.muji.fitriana2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: fitriana, d. m, pradany, r, n and rahmawati, a. (2019). correlation of picky eating in children’s growth: a systematic review. jurnal ners, 14(3si), 108-111. doi:http://dx.doi.org/10.20473/jn.v14i1.16991 introduction parents often complain about their child's poor diet by picky eating. it's as a normal feature of development, children sometimes experience decreased appetite and decrease the rate of growth (peterson et al., 2017) between 2 and 6 years of age (cohen, irby, brown, vander schaaf, & skelton, 2016). picky eating is the behavior of rejecting some unfamiliar foods or ingredients (thompson, cummins, brown, & kyle, 2015). further, it can result in long-term eating disorders in adolescence and early adulthood (li et al., 2017). especially on fruits and vegetables, and this requires important attention for parents. picky eating so far has not been understood the effect on body weight and height in children, where the problem can be at risk for nutritional status in children (ghosh et al., 2018). in southeast asia there is a prevalence of overweight 4.2% from 19.9 million in asia and 15.1% of 86.5 million in asia experiencing stunting (united nations children’s fund, organization, & bank, 2017). growth in children who can be at risk for these problems is likely to be influenced by the eating behavior of children who are picky on food and more often consume unhealthy foods. picky eating can also only be a concern for parents who are overweight, and have nothing to do with the problem of nutritional status in children (berger, hohman, marini, savage, & birch, 2016). it is necessary to discuss whether the behavior of picky eating in children is related to growth in children. this study aims to explain the correlate of picky eating on a child's growth. where children with picky eating have a greater risk of experiencing changes in body weight, either overweight, underweight or even obesity and changes in height are even at risk for stunting in childhood and adolescence. we hypothesize that children with picky eating will have a tendency to experience problems with their growth, both weight and height. materials and methods search strategy this systematic review was conducted and reported as per the guidelines from prisma (preferred reporting items for systematic reviews and metaanalyses) and we search in two database such as scopus and proquest without study design and publication status restrictions. studies were includes https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1. jurnal ners http://e-journal.unair.ac.id/jners | 109 if reported result on children aged less than 18 years, publish in english, and limited to the last 5 years; from 2015 to 2019. identification of articles using keywords picky eating, children, body weight and growth.. eligibility criteria this systematic review was aimed to identify correlate of picky eating in children growth. we compile search results based on the results of screening titles and abstracts, removed duplicates to identify studies relevant to the objectives of this review abastracts were not included if studyes evaluated the following data included after screening the articles that have been found, the data is extracted based on the research design, number of samples used, language used and growth status in children. this type of analysis of this review requires a theme that is relevant to the purpose of the review. the theme groups used for the review and form of the unit of analysis are: study design, the age of population, sample size, and correlation of picky eating in children's growth. results study characteristics figure 1. result and selection procedure characteristics of the 15 selected articles are different. of the studies included in analysis, 6 were cross-sectional, 5 were cohort study, and 3 randomized controll trial. participant age ranged from 6 months to 17 years. sample size varied from 153 to 5.700 children or mothers with their children. correlate picky eating in children growth of the 15 studies reviewed, 9 articles were found which mentioned a positive relationship between eating and growth and the 6 articles mentioned were not related. from 9 articles that positively related to the growth of children, 3 articles mentioned the correlation in increasing body weight and 6 articles mentioned the correlation between the occurrence of weight loss (chao, 2018; galloway, watson, pitama, farrow, & llewellyn, 2018; kwon, shim, kang, & paik, 2017; viljakainen, figueiredo, rounge, & weiderpass, 2019; volger et al., 2017). 6 articles that are negatively related, mention that the growth of children remains stable or normal but only related to diet or nutritional intake is even just an excessive concern by parents. discussion there is no clear correlation between picky food behavior and children's growth including 15 articles included in this study. our findings indicate a wide range of the not same evidence, with results like no association between picky eating and weight status, to associations with either overweight or underweight. in addition, results of some individual studies were mixed, with many varying found depending on baseline bmi, gender, or the persistence of picky eating or when the kids are choose their meal. the definitions of picky eating varied significantly between studies, varying from parental referral to a subspecialist due to picky eating behaviors that interfered with daily routines. these inconsistencies in the conceptualization and measurement of picky eating contribute in reported prevalence of picky eating and association with weight. most of the studies in this review were cross-sectional. it is especially important to note that the odds ratios are not comparable in magnitude across study designs-for example, one study finding that overweight kids are five times as likely to be picky does not mean that picky kids are five times as likely to be over or under weight. even in studies that found a relationship between picky eating and overweight like the article that made by (taylor, steer, hays, & emmett, 2018) also, most studies did not clearly report possible effect modifiers e.g., types of foods offered to the child, parenting styles, oral nutritional supplementation, growth (ghosh et al., 2018), nutritional status, development, physical activity, and health (chao, 2018), sosioeconomy (galloway et al., 2018) parent weight status) that could affect the relationship between eating behaviors and weight status. other limitations that may affect the cumulative evidence in this systematic review include publication bias and the risk of selective reporting records identified through database searching (n = 88) scopus : n = 32, proquest : n = 56 in c lu d e d e li g ib il it y id e n ti fi c a ti o n records after duplicates removed (n = 82) records screened by tittle/abstract assessed for eligibility (n = 27) full-text articles excluded (n = 12 ) tittle/ abstract articles excluded (n = 55 ) studies included in this review (n = 15) d. m. fitriana et al. 110 | pissn: 1858-3598  eissn: 2502-5791 within studies. 15 studies in this review included children younger than 17 years old, 5 of these were cohort studies. our finding that severe or persistent picky eating is associated with increased odds of underweight suggests that these studies are describing different eating behaviors than many of the other studies like a recent article by rohde et al. (rohde et al., 2017). a study conducted in china said that small children with picky eating and heavy low-for-height behaviors have a less optimal diet and are at risk of significant food and nutritional deficiencies (volger et al., 2017). this information would indeed help clinicians in appropriately classifying pediatric patients and providing counsel for parents. the existing literature supports that food neophobia is common in children and does not put children at increased risk for being underweight (viljakainen et al., 2019). however, given the variety of available definitions for picky eating, it is unclear if this finding would stand up for all. a more uniform definition of picky eating and a better understanding of the pathology of picky eating in various age groups are needed to clarify this literature. further research also is warranted to examine how picky eating affects the timing of the bmi. in addition, more information is needed regarding the role of environment as a determinant of parents and children’s food preferences and whether these environmental influences are responsible for maladaptive nutrition practices during childhood. the sistematic review has several limitations. first, in sistematic review the study used has many study designs. second, some studies found not only focus on the behavior of picky eating. third, the systematic review of studies comes from various countries. conclusion there is no resolution that can be used for the whole or general for all literature obtained. this is because there are very different conclusions about the prevalence of picky eating and this affects the status of nutrients, micro and macronutrients that enter the body, growth, development, height and weight, and future health. parents play an important role in this matter from early childhood to adolescence, but old parents are used as respondents in this literature. the results of picky eating who have a habit of choosing foods that can lack substances actually needed by the body. there are a number of articles that discuss issues that cause the body not easy, but some articles will also discuss how to make more children than obese bodies. references antoniou, e. e., sleddens, e. f. c., thijs, c., roefs, a., kremers, s. p. j., gubbels, j. s., & jansen, a. (2015). picky eating and child weight status development: a longitudinal study. journal of human nutrition and dietetics, 29(3), 298–307. https://doi.org/10.1111/jhn.12322 berger, p. k., hohman, e. e., marini, m. e., savage, j. s., & birch, l. l. (2016). girls’ picky eating in childhood is associated with normal weight status from ages 5 to 15 y1,2. american journal of clinical nutrition, 104(6), 1577–1582. https://doi.org/10.3945/ajcn.116.142430 chao, h.-c. (2018). association of picky eating with growth, nutritional status, development, physical activity, and health in preschool children. frontiers in pediatrics, 6(february), 1–9. https://doi.org/10.3389/fped.2018.00022 cohen, g. m., irby, m. b., brown, c. l., vander schaaf, e. b., & skelton, j. a. (2016). association of picky eating and food neophobia with weight: a systematic review. childhood obesity, 12(4), 247– 262. https://doi.org/10.1089/chi.2015.0189 galloway, a. t., watson, p., pitama, s., farrow, c. v, & llewellyn, c. h. (2018). socioeconomic position and picky eating behavior predict disparate weight trajectories in infancy. frontiers in endocrinology, 9(september), 1–9. https://doi.org/10.3389/fendo.2018.00528 ghosh, a. k., kishore, b., shaikh, i., satyavrat, v., kumar, a., shah, t., … huynh, d. t. t. (2018). continuation of oral nutritional supplementation supports continued growth in nutritionally atrisk children with picky eating behaviour: a postintervention , observational follow-up study. https://doi.org/10.1177/0300060518766982 kwon, k. m., shim, j. e., kang, m., & paik, h. (2017). association between picky eating behaviors and nutritional status in early childhood : performance of a picky eating behavior questionnaire. mdpi. https://doi.org/10.3390/nu9050463 li, z., horst, k. van der, edelson-fries, l. r., yu, k., you, l., zhang, y., … wang, j. (2017). perceptions of food intake and weight status among parents of picky eating infants and toddlers in china : a crosssectional study. appetite, 108, 456–463. https://doi.org/10.1016/j.appet.2016.11.009 peterson, k. e., ball, s. c., brown, c. l., lumeng, j. c., perrin, e. m., horodynski, m. a., … contreras, d. (2017). association of picky eating with weight status and dietary quality among low-income preschoolers. academic pediatrics, 18(3), 334– 341. https://doi.org/10.1016/j.acap.2017.08.014 rohde, j. f., trærup, m., stougaard, m., olsen, n. j., mortensen, e. l., heitmann, b. l., & händel, m. n. (2017). relationship between pickiness and subsequent development in body mass index and diet intake in obesity prone normal weight preschool children. plos one, 12(3), e0172772. https://doi.org/10.1371/journal.pone.0172772 sandvik, p., ek, a., somaraki, m., hammar, u., eli, k., & nowicka, p. (2018). picky eating in swedish preschoolers of different weight status: application of two new screening cut-offs. international journal of behavioral nutrition & physical activity, 15(1), n.pag-n.pag. https://doi.org/http://dx.doi.org/10.1186/s129 66-018-0706-0 jurnal ners http://e-journal.unair.ac.id/jners | 111 taylor, c. m., steer, c. d., hays, n. p., & emmett, p. m. (2018). growth and body composition in children who are picky eaters: a longitudinal view. european journal of clinical nutrition, 1–10. https://doi.org/10.1038/s41430-018-0250-7 thompson, c., cummins, s., brown, t., & kyle, r. (2015). what does it mean to be a “picky eater”? a qualitative study of food related identities and practices. appetite, 84, 235–239. https://doi.org/10.1016/j.appet.2014.09.028 united nations children’s fund, organization, w. h., & bank, t. w. (2017). levels & trends in child malnutrition. https://doi.org/10.1016/s02666138(96)90067-4 viljakainen, h. t., figueiredo, r. a. o., rounge, t. b., & weiderpass, e. (2019). picky eating – a risk factor for underweight in finnish preadolescents. appetite, 133(march 2018), 107–114. https://doi.org/10.1016/j.appet.2018.10.025 volger, s., sheng, x., tong, l. m., zhao, d., fan, t., zhang, f., … yao, m. (2017). nutrient intake and dietary patterns in children 2 . 5-5 years of age with picky eating behaviours and low weight-forheight. asia pacific jurnal clinical nutrition, 26(august 2015), 104–109. https://doi.org/10.6133/apjcn.102015.02 xue, y., lee, e., ning, k., zheng, y., ma, d., gao, h., … zhang, y. (2015). prevalence of picky eating behaviour in chinese school-age children and associations with anthropometric parameters and intelligence quotient. a cross-sectional study. appetite, 91, 248–255. https://doi.org/10.1016/j.appet.2015.04.065 xue, y., ma, d., szeto, i. m. y., cai, l., wang, p., zhao, a., … zhang, y. (2015). growth and development in chinese pre-schoolers with picky eating behaviour: a cross-sectional study. plos one, 10(4), e0123664. https://doi.org/10.1371/journal.pone.0123664 included eligibility identification ners vol 10 no 2 okt 2015.indd 301 model asuhan keperawatan komunitas untuk percepatan mdgs sektor perilaku sanitasi kesehatan (model of community health nursing care to accelerate mdgs on health sanitation behavior sector) martono*, satino* *jurusan keperawatan politeknik kesehatan surakarta jl. letjend sutoyo mojosongo, surakarta email: must_ton@ymail.com abstrak pendahuluan: upaya promosi kesehatan memiliki peran penting dalam proses untuk meningkatkan kemandirian masyarakat dalam kesehatan dan hidup sehat yang juga dipengaruhi oleh kondisi lingkungan sosial budayanya. tujuan dari penelitian ini adalah untuk mengetahui kontribusi keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat pada sektor perilaku sanitasi kesehatan, sehingga dapat mempercepat pencapaian mdgs. metode: penelitian berdesain explanatory research dengan pendekatan cross sectional. sejumlah 99 orang direkrut menjadi sampel penelitian. variabel independen dalam penelitian ini meliputi keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat. sementara, variabel terikatnya yaitu perilaku sanitasi kesehatan. alat ukur yang digunakan untuk pengumpulan data dalam penelitian ini adalah kuesioner. data dianalisis dengan teknik analisis regresi. hasil: hasil uji statistik menunjukkan bahwa secara bersama-sama keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat memiliki kontribusi positif terhadap perilaku sanitasi kesehatan (25,4%). sementara, secara parsial hasil keaktifan kader (0,2%), pemberdayaan keluarga (15,3%), dan persepsi budaya sehat (9,9%). diskusi: kesuksesan sanitasi kesehatan di masyarakat memerlukan partisipasi dan kesadaran dari keluarga serta masyarakat itu sendiri. perawat kesehatan komunitas harus melakukan upaya promosi kesehatan untuk meningkatkan pemahaman individu, keluarga, dan masyarakat dalam berperilaku hidup sehat. kata kunci: posdaya, keaktifan kader kesehatan, pemberdayaan keluarga, persepsi budaya sehat abstract introduction: health promotion have an important role in order to improve community’s independency on health and healthy lifestyle which influenced by socio-cultural around them. the purpose of this study was to examine the contribution of health volunteer activeness, family empowerment, and healthy lifestyle perception on health sanitation behavior sector, so that can help to accelerate mdgs acheivement. methods: this was explanatory research with cross sectional approach. ninety nine people were recruited as research samples. independent variables were health volunteer’s activeness, family empowerment, and health lifestyle perception. while, the dependent variable was health sanitation behavior. data were collected by using questionnaire. data were then analyzed by using regression technique. results: result had showed that together health volunteer’s activeness, family empowerment, and healthy lifestyle perception have positive contribution to health sanitation behavior (25.4%). while partially, health volunteer’s activeness has result (0.2%), family empowerment (15.3%), and healthy lifestyle perception (9.9%). discussions: the successfullness of health sanitation on community needs participation from family and community itself. community health nurses should conduct health promotion as an effort to improve community’s knowledge about health behavior. keywords: posdaya, health volunteer’s activeness, family empowerment, and healthy lifestyle perception pendahuluan ke s e p a k a t a n g lob a l ya ng t el a h dituangkan dalam millenium development goals (mdgs) tidak dapat dipisahkan dengan arah pembangunan kesehatan nasional, yang membuat di setiap sektor pelayanan kesehatan harus bekerja lebih efektif dan efisien untuk meningkatkan derajat kesehatan masyarakat yang optimal. sejalan dengan komitmen pemer int ah u nt u k mencapai millenium development goals (mdgs) tahun 2015 tersebut, maka telah dicanangkan gerakan pembangunan berwawasan kesehatan yaitu dengan kegiatan operasional, yaitu program sanitasi total berbasis masyarakat (stbm) (depkes ri, 2008). st udi indonesia sanitation sector development program (issdp) tahun 2006, menunjukkan bahwa perilaku masyarakat dalam mencuci tangan dilakukan setelah 302 jurnal ners vol. 10 no. 2 oktober 2015: 301–307 buang air besar 12%, setelah membersihkan tinja bayi dan balita 9%, sebelum makan 14%, sebelum memberi makan bayi 7%, dan sebelum menyiapkan makanan 6% (depkes ri, 2008). kondisi tersebut berkontribusi terhadap tingginya angka kejadian penyakit akibat sanitasi lingkungan di indonesia. hal ini terlihat dari angka kejadian diare nasional pada tahun 2006 sebesar 423 perseribu penduduk pada semua umur dan 16 provinsi mengalami kejadian luar biasa (klb) diare dengan case fatality rate (cfr) sebesar 2,52. strategi untuk mengubah perilaku tersebut, pemerintah telah memberikan perhatian di bidang hygiene dan sanitasi dasar dengan menetapkan open defecation free dan peningkatan perilaku hidup bersih dan sehat. hal tersebut membuat propinsi jawa tengah berupaya lebih meningkatkan kesejahteraan masyarakat terutama dalam hal kesehatan, dengan dibent uk nya pos pemberdayaan keluarga (posdaya) sesuai wewenang dan tanggung jawab masing-masing kota atau kabupaten. berdasarkan studi pendahuluan yang dilakukan pada juli 2014, diketahui bahwa perilaku masyarakat dalam cuci tangan setelah buang air besar 18%, setelah membersihkan tinja bayi dan balita 12%, sebelum makan 16%, sebelum memberi makan bayi 6%, dan sebelum menyiapkan makanan 11%, perilaku buang air besar sembarangan 10%, perilaku pengelolaan air minum rumah tangga merebus air untuk mendapatkan air minum 13%, perilaku mengelola limbah rumah tangga dengan aman 12%, dan perilaku membuang sampah dengan benar 2%. keadaan tersebut mendorong masyarakat kauman polanharjo kabupaten k laten berkom it men u nt u k memeli hara d an meni ng katkan derajat kesehatan melalui posdaya dengan kegiatan salah satunya sanitasi kesehatan dasar. keluarga semakin penting setelah lahirnya posdaya sebagai salah satu bentuk upaya kesehatan bersumber daya keluarga yang merupakan wujud nyata peran serta keluarga dalam pembangunan kesehatan. posdaya merupakan salah satu alternatif untuk mendorong terciptanya perilaku dan kualitas kesehatan keluarga di bidang kesehatan yang diawali dari rumah tangga atau keluarga. perilaku dan kualitas kesehatan keluarga yang tinggi merupakan jembatan dalam menjawab jaminan kualitas pelayanan kesehatan dasar di tingkat desa. per ilak u sanitasi kesehatan dasar terhadap lingkungan kesehatan sesorang dipengaruhi oleh banyak faktor. faktor tersebut dapat berasal dari orang itu sendiri, orang lain yang dapat mendorong untuk berperilaku baik atau buruk, maupun kondisi lingkungan sekitar yang dapat mendukung terhadap berubahnya perilaku. selama ini upaya yang dilak ukan masyarakat unt uk mengatasi masalah kesehatan, masih berorientasi pada penyembuhan penyakit yang artinya apa yang dilakukan masyarakat dalam bidang kesehatan hanya untuk mengatasi penyakit yang telah terjadi atau menimpanya, di mana hal ini dirasa kurang efektif karena banyak mengeluarkan biaya. upaya promosi kesehatan mempunyai peran yang sangat penting dalam proses pemberdayaan masyarakat yait u melalui pembelajaran dari, oleh dan bersama masyarakat sesuai dengan lingkungan sosial budaya setempat, agar masyarakat dapat menolong dirinya sendiri di bidang kesehatan. pelaksanaan pemberdayaan warga masyarakat di bidang kesehatan memerlukan kerja sama dari beberapa pihak terkait diantaranya perangkat desa, tokoh masyarakat, kader kesehatan, pemuda, lsm, dan seluruh warga masyarakat pada umumnya. (syafr udin, hamidah, 2009). upaya tersebut diharapkan dapat mewujudkan perilaku sanitasi dasar kesehatan untuk mencegah penyakit akibat sanitasi lingkungan. u n t u k m e w u j u d k a n k o m i t m e n pemerintah dalam mencapai target millennium development goals (mdgs) tahun 2015, betapa pentingnya menaruh perhatian yang lebih ser ius terhadap per ilak u sanitasi kesehatan dasar, agar tercapainya derajat kesehatan masyarakat yang optimal. bahan dan metode penelitian ini menggunakan rancangan explanatory research dengan pendekatan cross sectional yang bertujuan untuk menjelaskan 303 model asuhan keperawatan komunitas untuk percepatan (martono dn satino) prediksi besarnya kontribusi variabel bebas yang meliputi keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat. sementara, variabel terikatnya yaitu per ila k u sa n it asi kesehat a n. seju m la h 99 responden direk r ut menjadi sampel penelitian. alat ukur yang digunakan untuk pengumpulan data dalam penelitian ini adalah kuesioner. untuk memprediksi besar nya variasi, dan menentukan arah dan besarnya kontribusi antara variabel bebas dengan variabel terikat menggunakan teknik analisis regresi. nilai keyakinan yang dipahami dalam uji statistik pada penelitian adalah 95%. hasil hasil penelitian menunjukkan dari 99 responden, sebagian besar keaktifan kader kesehatan dikategorikan sedang yaitu sebesar 47 (47,5%), kategori rendah sebesar 35 orang (35,4%), dan tinggi sebesar 17 orang (17,1%) (lihat tabel 1). sebagian besar pemberdayaan keluarga dikategor ikan tinggi yait u 54 (54,5%), kategori sedang sebesar 45 (45,5%) dan kategori rendah sebesar 0 (0%) (lihat tabel 2). sebagian besar persepsi budaya sehat dikategorikan tinggi yaitu 89 (89,9%), kategori sedang sebesar 10 (10,1%) dan kategori rendah sebesar 0 (0%) (lihat tabel 3). sebagian besar perilaku sanitasi kesehatan dikategorikan tinggi yaitu 97 (98,0%), kategori sedang sebesar 2 (2,0%) dan kategori rendah sebesar 0 (0%) (lihat tabel 4). berdasarkan perhitungan uji normalitas sampel mengg u nakan uji jarque bera diperoleh nilai probability jarque bera sebesar 0,160 dengan tingkat signifikansi 95%. dengan mendasarkan pada kaidah data dinyatakan normal, jika nilai probability jarque bera > 0,05, maka perbandingan 0,160 adalah lebih besar dari 0,05. dengan demikian data penelitian yang diperoleh berdistribusi normal. berdasarkan hasil uji statistik diperoleh perbandingan ρ > 0,05, sehingga data penelitian yang diperoleh dinyatakan linier. hasil perhitungan uji linieritas dijelaskan pada tabel 5. berdasarkan hasil uji multikolinieritas, dapat dijelaskan bahwa nilai yang diperoleh r square model complete > dari r square auxilary regressive, dengan demikian data yang diperoleh tidak terjadi multikolinieritas. hasil perhitungan uji klein’s dapat dijelaskan pada tabel 6. hasil uji heterokedastisitas pada tabel 7, dapat dijelaskan bahwa nilai ρ spearman”s rho > dari 0,05. dengan demikian data penelitian ini tidak terjadi heterokedastisitas. berdasarkan hasil uji statistik menunjukkan bahwa ada pengaruh yang positif variabel pemberdayaan keluarga sebesar 0,304, variabel keaktifan kader kesehatan sebesar 0,239, dan variabel persepsi budaya sehat sebesar 0,503 terhadap perilaku sanitasi kesehatan. tabel 1. distribusi frekuensi keaktifan kader kesehatan keaktifan frekuensi % rendah 35 35,4 sedang 47 47,5 tinggi 17 17,1 jumlah 99 100 tabel 2. distribusi frekuensi pemberdayaan keluarga pemberdayaan frekuensi % rendah 0 0 sedang 45 45,5 tinggi 54 54,5 jumlah 99 100 tabel 3. distribusi frekuensi persepsi budaya sehat persepsi frekuensi % rendah 0 0 sedang 10 10,1 tinggi 89 89,9 jumlah 99 100 tabel 4. distribusi frekuensi klasifikasi perilaku sanitasi responden perilaku frekuensi persentase rendah 0 0 sedang 2 2,0 tinggi 97 98,0 jumlah 99 100 304 jurnal ners vol. 10 no. 2 oktober 2015: 301–307 berdasarkan hasil perhitungan uji f, diperoleh nilai fhitung=10.768 dan ftabel(0,01;3; 95)=4.04. karena nilai fhitung=10,768 lebih besar dari nilai ftabel=4.04, maka harga fhitung=10.768 berada di daerah penolakan ho atau menerima ha, yang artinya secara simultan variabel keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat dapat menjelaskan perilaku sanitasi. berdasarkan uji statistik, diperoleh perbandingan harga t1hitung=1.973>ttabel=1.6 60; t2hitung=3.421>ttabel =1.660; dan t3 hitung= 3.106>ttabel=1.660 dengan derajat kepercayaan 95%, sehingga ho ditolak dan ha diterima atau keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat secara parsial memberikan pengaruh yang signifikan terhadap perilaku sanitasi. hasil uji t dapat dilihat pada tabel 9. tabel 5. rangkuman hasil uji linieritas variabel ρ kriteria ket x1y 0,134 ρ > 0,05 linier x2y 0,640 ρ > 0,05 linier x3y 0,124 ρ > 0,05 linier tabel 6. r a n g k u m a n h a s i l u j i multikolinieritas variabel r square ket r2 mc r2 ar x1*x3 x2 0,223 0,105 tidak ada multikolinieritas x2* x1 x3 0,223 0,053 tidak ada multikolinieritas x3*x2 x1 0,223 0,066 tidak ada multikolinieritas tabel 7. hasil uji heterokedastisitas variabel a b s o l u t residual kriteria keterangan x1 0,569 ρ > 0,05 tidak ada heterokedastisitas x2 0,402 ρ > 0,05 tidak ada heterokedastisitas x3 0,054 ρ > 0,05 tidak ada heterokedastisitas tabel 8. hasil analisis regresi berganda variabel koef regresi t hitung x1 0.239 1.973 x2 0.304 3.421 x3 0.503 3.106 konstanta 45.182 3.204 r 0.504 r2 0.254 f 10.768 tabel 9. rangkuman hasil uji t variabel harga t keterangan t-hitung t-tabel x1y 1.973 1.660 signifi kan x2y 3.421 1.660 signifi kan x3y α = 0.05: n = 99 3.106 1.660 signifi kan nilai hasil uji statistik regresi (keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat) menunjukkan nilai r2 sebesar 0,254 yang artinya sebesar 25,4% variabel keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat menjelaskan perilaku kesehatan. sisanya sebesar 74,6% diterangkan oleh variabel lain di luar model yang digunakan. untuk mengetahui besa r va r ia si ma si ng-ma si ng va r iabel independen dalam menerangkan perilaku sanitasi, perlu dilakukan penghitungan r2 masing-masing variabel independen (keaktifan kader kesehatan, pemberdayaan keluarga, dan persepsi budaya sehat) terhadap perilaku sanitasi. hasil perhitungan statistik diperoleh r 2 total dari prediktor keaktifan kader kesehatan (x1), pemberdayaan keluarga (x2) dan persepsi budaya sehat (x3) = 25,4%. r 2 dari prediktor variabel persepsi budaya sehat (x3) = 9,9% dan r 2 dari prediktor variabel keaktifan kader kesehatan dan persepsi budaya sehat (x1 dan x3) = 10,1%, maka r 2 masingmasing variabel independen terhadap perilaku sanitasi adalah r2 x3,y = 9,9%, r 2 x1,y = 10,1%–9,9% = 0,2% dan r2 x2,y = 25,4% –10,1% = 15,3%. 305 model asuhan keperawatan komunitas untuk percepatan (martono dn satino) pembahasan keaktifan pemberdayaan keluarga, persepsi budaya sehat, dan kader kesehatan secara simultan ber pengar uh positif dan signifikan terhadap perilaku sanitasi sebesar 25,4%. sedangkan besarnya pengaruh masingmasing variabel pemberdayaan keluarga, persepsi budaya sehat, dan kader kesehatan dalam menjelaskan variabel perilaku sanitasi adalah besarnya pengaruh variabel keaktifan kader kesehatan sebesar 0,2%, pemberdayaan sebesar keluarga 15,3%, dan persepsi budaya sehat sebesar 9,9%. dengan demikian variabel yang paling tinggi pengaruhnya terhadap perilaku sanitasi adalah variabel pemberdayaan keluarga sebesar 15,3%, kemudian variabel persepsi budaya sehat sebesar 9,9% dan keaktifan kader kesehatan 0,2%. variabel pemberdayaan keluarga memiliki pengaruh yang lebih besar terhadap perilaku sanitasi dibandingkan dengan variabel keaktifan kader kesehatan maupun variabel persepsi budaya sehat. hal ini menggambarkan bahwa perilaku kesehatan di lingkungannya lebih dominan dipengaruhi oleh pemberdayaan keluarga. keberhasilan masyarakat untuk melakukan sanitasi kesehatan di lingkungannya tidak lepas dari peran dan partisipasi keluarga sebagai unsur dari masyarakat. dengan pemberdayaan keluarga diharapkan unsur yang ada dalam keluarga tersebut mendapat kontrol internal dari kepala keluarga yang mengarahkan untuk berperilaku kesehatan di lingkungannya. kontrol perilaku dari kepala keluarga bila didukung dengan persepsi yang baik tentang budaya sehat dan keaktifan kader kesehatan masyarakat akan lebih mengarahkan untuk mencapai tujuan. berdasarkan hasil penelitian di atas, bahwa untuk meningkatkan kontribusi warga dalam rangka berperilaku untuk melakukan sanitasi di bidang kesehatan seyogyanya diik uti oleh pengembangan sumber daya manusia (warga) itu sendiri. hal ini dapat dipahami bahwa semua kegiatan masyarakat untuk mencapai tujuannya adalah sangat tergantung sumber daya manusianya. h a l i n i s e s u a i p e n d a p a t y a n g disampaikan syafrudin dan hamidah (2009), ya ng menjelaska n ba hwa pela k sa na a n pemberdayaan warga masyarakat di bidang kesehatan memerlukan kerja sama dari beberapa pihak terkait diantaranya perangkat desa, tokoh masyarakat, kader kesehatan, pemuda, lsm, dan seluruh warga masyarakat pada umumnya. dengan upaya tersebut diharapkan dapat mew ujudkan perilaku sanitasi dasar kesehatan untuk mencegah penyakit akibat sanitasi lingkungan. keaktifan kader kesehatan merupakan salah satu daya dukung untuk mewujudkan pelaksanaan pengembangan program sanitasi total berbasis masyarakat baik secara internal di dalam desa sendiri ataupun antar desa. upaya ini dapat memantapkan kerja sama dan sebagai wahana untuk menumbuhkan kesadaran warga akan pentingnya sanitasi kesehatan, dan ber t u kar pengalaman memecah kan masalah yang dihadapi masyarakat secara bersama termasuk sanitasi kesehatan warga. berdasarkan hasil uji statistik variabel keaktifan kader kesehatan terhadap perilaku sanitasi diperoleh nilai koef isien regresi sebesar 0.239 artinya setiap kenaikan 5% keaktifan kader kesehatan dengan menganggap bahwa variabel pemberdayaan keluarga dan persepsi budaya sehat dikendalikan, maka diikuti dengan kenaikan perilaku sanitasi kesehatan sebesar 23,9%. faktor keaktifan kader kesehatan dalam penelitian ini secara parsial terbukti mampu memberikan kontribusi yang signifikan dalam mempengaruhi perilaku sanitasi kesehatan yaitu sebesar 0,2%. hal ini berarti dapat dijelaskan bahwa aspek-aspek keaktifan kader kesehatan yang meliputi kesiapan dan keyakinan kader kesehatan terhadap kemampuan menguasai tugasnya, keaktifan kader kesehatan dalam kegiatan, dan kedisiplinan kader kesehatan mampu membentuk perilaku yang positif dan mempunyai kontribusi dalam meningkatkan perilaku sanitasi kesehatan. hasil penelitian ini sesuai dengan pendapat yang di sampaikan syafrudin dan hamidah (2009), yang menjelaskan bahwa keaktifan kader kesehatan merupakan salah satu kunci keberhasilan dalam pengembangan program pelaksanaan ukbm (upaya kesehatan berbasis masyarakat). kader kesehatan diberi kesempatan dalam mengembangkan 306 jurnal ners vol. 10 no. 2 oktober 2015: 301–307 kreativitasnya dan melakukan pemantauan serta evaluasi. dalam hal ini, kader kesehatan t e rl ibat se ca r a la ngs u ng p e ngelola a n pengembangan program sanitasi total berbasis masyarakat). kegiat an yang dilak u kan oleh kader kesehatan salah satunya adalah penyuluhan perilaku hidup bersih sehat). dengan demikian, semakin banyak kader kesehatan yang aktif berperan serta dalam kegiatan stbm di desa, maka semakin tinggi pula perilaku sanitasi kesehatan masyarakat. pemberdayaan keluarga di bidang ke seh at a n me ng h a si l k a n p e n i ng k at a n k e m a m p u a n t e r m a s u k k e m a m p u a n keluarga dalam mengidentifikasi masalah kesehatan yang ada di masyarakat dan cara pemecahan nya. dengan demi k ian pemberdayaan keluarga dapat memberikan kontribusi terhadap perilaku sanitasi kesehatan dalam meningkatkan derajat kesehatan masyarakat. berdasarkan hasil uji statistik var iabel pemberdayaan keluarga dalam memprediksi perilaku sanitasi kesehatan diperoleh nilai koefisien regresi sebesar 0.304 artinya setiap kenaikan 5% pemberdayaan keluarga dengan menganggap bahwa variabel keaktifan kader kesehatan, dan persepsi budaya sehat dikendalikan, maka diikuti dengan kenaikan perilaku sanitasi kesehatan sebesar 30.4%. hal ini berarti aspek-aspek yang meliputi sense of self determination, sense of meaning, sense of competence, dan sense of impact telah membentuk pemberdayaan keluarga yang baik. hasil penelitian ini sesuai dengan penelitian yang dilakukan sulistiyani (2004), yang menjelaskan bahwa keluarga merupakan faktor paling mendukung dalam pelaksanaan perilaku hidup bersih dan sehat. hal ini juga diperkuat hasil penelitian yang dilakukan oleh sinaga, marhaeni, dan mubasyir (2004), yang menjelaskan bahwa rendahnya cakupan perilaku hidup sehat disebabkan oleh belum optimalnya pemberdayaan keluarga. dengan demikian, perilaku sanitasi kesehatan dapat tercapai bila dilakukan dengan pendekatan i nd iv idu , kelu a rga , kelomp ok sa mpai masyarakat. persepsi adalah terjadinya tanggapan yang didahului oleh penginderaan terhadap stimulus, kemudian diorganisasikan, diartikan, dievaluasi dan ditanggapi dengan tindakan. dengan demikian faktor persepsi budaya sehat mempunyai kontribusi dalam meningkatkan perilaku sanitasi kesehatan di masyarakat. berdasarkan hasil uji statistik variabel persepsi budaya sehat terhadap perilaku sanitasi diperoleh nilai koefisien regresi sebesar 0.503 artinya setiap kenaikan 5% persepsi budaya sehat dengan menganggap bahwa variabel pemberdayaan keluarga dan keaktifan kader kesehatan dikendalikan, maka diikuti dengan kenaikan perilaku sanitasi kesehatan sebesar 50,3%. faktor persepsi budaya sehat dalam penelitian ini terbukti secara parsial mampu memberikan kontribusi yang signifikan dalam mempengaruhi perilaku sanitasi kesehatan yaitu sebesar 9,9%. hal ini berarti aspekaspek persepsi budaya sehat yang meliputi tanggung jawab terhadap buang air besar, mencuci tangan sebelum dan sesudah makan, mengelola air minum dan makanan yang aman, mengelola sampah dengan benar, mengelola limbah cair r umah tangga dengan aman mampu membentuk perilaku yang positif dan mempunyai kontribusi dalam meningkatkan kinerja. hasil penelitian ini sesuai dengan pendapat yang disampaikan gibson (1997), menjelaskan bahwa per ilak u seseorang dipengaruhi oleh faktor psikologis yang salah satunya adalah persepsi seseorang. persepsi individu akan mempengaruhi proses dalam pengambilan suatu keputusan, dan dengan adanya suatu keputusan seseorang akan terdorong untuk melakukan suatu kegiatan untuk mencapai tujuannya. dengan tindakan yang didasarkan atas persepsi tersebut, akan menimbulkan sebuah perilaku yang nyata yaitu perilaku sanitasi kesehatan. simpulan dan saran simpulan aspek pemberdayaan keluarga, persepsi budaya sehat, dan keaktifan kader kesehatan secara simultan memberikan kontribusi yang positif dalam mengubah perilaku sanitasisanitasi kesehatan sebesar 25,4%. secara parsial pemberdayaan keluarga memberikan 307 model asuhan keperawatan komunitas untuk percepatan (martono dn satino) kontribusi sebesar 15,3%, persepsi budaya sehat sebesar 9,9%, dan keaktifan kader kesehatan sebesar 0,2%. saran saran yang diberikan dalam rangka upaya percepatan mdgs sektor sanitasi kesehatan di masyarakat adalah dengan memfungsikan posdaya (pos pemberdayaan keluarga) sebagai wadah yang representatif untuk duduk bersama dalam rangka urun rembug mengenal, mengidentifikasi, dan memecahkan masalah perilaku kesehatan untuk meningkatkan derajat kesehatan dengan memberdayakan masyarakat k hususnya kelu a rga, seh i ngga terbent u k per ila k u yang dapat membawa anggota keluarganya berkreativitas dan mempunyai pengetahuan dan sikap dalam berperilaku sanitasi kesehatan sesuai yang diharapkan, dan melibatkan warga masyarakat serta memberikan kesempatan yang lebih luas kepada warga untuk bertindak atas inisiatif sendiri sesuai kemampuannya. kepustakaan depkes ri. 2008. buku paket pelatihan kader kesehatan dan tokoh masyarakat dalam pengembangan desa siaga. klaten: depkes ri. gibson, jl., ivancevich, jm, dan donelly, jr. 1997. organizations behavior structure processes. united states of america: van hoffmann press. kemenkes ri. 2008. strategi nasional sanitasi total berbasis masyarakat. jakarta: kemenkes ri. sulistiyani, t. 2004. kemitraan dan modelmodel pemberdayaan. yogyakar ta: gava media. syafrudin dan hamidah. 2009. kebidanan komunitas. jakarta: egc. http://e-journal.unair.ac.id/jners | 305 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17152 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of foot massage on decreasing peripheral neuropathy diabetic complaints in the patients with type 2 diabetes mellitus ni luh putu inca buntari agustini, nadya treesna wulansari, yustina ni putu yusniawati and ni wayan sintia bachelor of the nursing faculty, the institute of technology and health sciences bali, indonesia abstract background: peripheral neuropathy diabetic is a problem that will be experienced by almost all patients with type 2 diabetes mellitus (t2dm). one of the non-pharmacological therapies that can be done to reduce the complaints of peripheral neuropathy diabetic is foot massage. the purpose of this study was to determine the effect of foot massage on decreasing peripheral neoropathy diabetic complaints. method: the research design was a one group pretest-post-test design (foot massage) as the treatment given to the patients with t2dm. the population in this study was the patients with t2dm who had peripheral neuropathy diabetic. seventy-two participants were involved as the sample of the study selected through simple random sampling. the data was collected using the questionnaire of the michigan neuropathy screening instrument. result: the results were analyzed using the wilcoxon sign rank test with a significance level was set at α = 0.05. conclusion: the foot massage had a significant effect at reducing the complaints of peripheral neuropathy diabetic in patients with t2dm (p=0,000 < ɑ 0.05). the patients with t2dm are expected to practice foot massage independently. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords foot massage; peripheral neuropathy; type 2 diabetes mellitus contact ni luh putu inca buntari agustini  inca.stikesbali@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: agustini, n. l. p. i. b, wulansari, n. t, yusniawati, y. n. p & sintia, n. w. (2019). the effect of foot massage on decreasing peripheral neuropathy diabetic complaints in the patients with type 2 diabetes mellitus . jurnal ners, 14(3si), 305-309. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17152 introduction diabetes mellitus (dm) is one of the most feared health issues of the current age. metabolic and endocrine disorders occur in the pancreas, especially in the beta langerhans cells. this means that the production of the hormone insulin will be disrupted (achmad rudijanto, agus yuwono, alwi shahab, 2015; azura, 2012). the disruption of the work of insulin causes an increase in the blood sugar level (hyperglicemia) which triggers various complications and even the poor management of dm. this often contributes to disability and even death (achmad rudijanto, agus yuwono, alwi shahab, 2015). the world health association (who) predicts an increase in the number of people with dm in indonesia from 8.4 million in 2000 to around 21.3 million in 2030. this report shows there to be an increase in the number of people with dm by 2-3 times by 2035. in addition, the international diabetes federation (idf) predicts an increase in the number of people with diabetes in indonesia from 9.1 million in 2014 to 14.1 million in 2035 (achmad rudijanto, agus yuwono, alwi shahab, 2015). the high incidence of dm shows that it is essential to handle it to prevent new problems occurring in the form of complications in people with dm. peripheral diabetic neuropathy is a problem that will be experienced by almost all people with type 2 diabetes mellitus (t2dm). the complaints include cramps, muscle aches, feeling thick and a feeling of burning or coldness in the legs. the peripheral frequency of diabetic neuropathies in t2dm is quite high at 57.81%, most of whom have had t2 dm for more than 10 years (hutapea, 2016). the complaints of peripheral neuropathy had a prevalence of 7.5% when found in someone newly diagnosed with t2 dm. it would appear that it had an incidence of more than 50% in patients who’d had t2 dm for more than 25 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:inca.stikesbali@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). n. l. p. i. b. agustini et al. 306 | pissn: 1858-3598  eissn: 2502-5791 years. it is estimated that 15% of patients with t2 dm will experience foot ulcers during their lifetime, where 70% will be at risk of relapse and where 85% will end with amputation (dy sm, bennett wl, sharma r, zhang a, waldfogel jm, nesbit sa & chelladurai y, feldman d, wilson lm, 2017; gilg, 2016). amputation is an action that can have a negative impact not only physically but also psychologically and socially. the loss of part of the body means that the people with t2 dm who undergo amputation experience stress and the disruption of their bodily image (gilg, 2016). stress that continues directly will be a trigger factor for increased blood sugar levels and this means that the patients are not obedient to the offered treatment (nursalam, 2016). the prevention of amputation must begin with the treatment of peripheral neuropathy. the handling of this is a part of the functions and role of the nurses, one of which is being a caregiver for patients with peripheral neuropathy. this is evidenced from their experience in the field. however, nurses usually only pay attention to wound care rather than controlling the factors that slow the wound itself. the wounds will continue to develop until necrotic tissue forms, which must be amputated. the peripheral prevention of diabetic neuropathy versus the incidence of diabetic ulcers requires much lower maintenance costs compared with treatment after the occurrence of diabetic ulcers (shaw, 2015). the preventive measures that can be taken to overcome peripheral diabetic neuropathy include foot exercises and pharmacological therapy. the results of a study conducted by putri (2016) stated that diabetic foot gymnastics did not fully improve peripheral neuropathy in diabetics. another effort that can be done is by handling pharmacology but pharmacological approaches that are ongoing for a long time will cause side effects (achmad rudijanto, agus yuwono, alwi shahab, 2015). researchers should thus make an effort to prevent peripheral neuropathy through doing foot massage. foot massage is another method that can be chosen when providing nursing care for patients with t2dm with complaints of peripheral neuropathic diabetic. foot massage is done by giving gentle pressure to the feet which will hopefully increase blood flow so that it can improve blood flow. good blood flow will support the supply of oxygen and nutrients to the nerve cells so then the nerves will work optimally and reduce the peripheral neuropathic diabetic complaints (tschakovsky, n.d.). the repair of blood vessels in the form of an increase in the ankle brachial index has also been shown. the results of this study indicate that the better the abi value, the lower the peripheral degree of diabetic neuropathy experienced by dm patients. the results of the different study conducted by harnaya (2014) emphasize further the effect of foot massage on lowering the sensation of foot protection and the scores of the type 2 dm patients, which is related to one of the peripheral symptoms of diabetic neuropathy. this study showed there to be a significant effect of foot massage on sensory and neuropathic protection (harmaya, 2014). related research on the effect of foot massage at reducing the complaints of peripheral neuropathic diabetes has not been widely performed. diabetic peripheral neuropathy was examined by the researcher more fully and not only with 10g monofilament. the researcher used the michigan neuropathy screening instrument (mnsi) questionnaire. it contained two parts in the form of the history of the disease with 4 questions and a physical examination. physical examinations performed included an examination of the muscular damage, sensory damage and motor damage. based on these descriptions, it is important that the nurses pay attention to the prevention of peripheral diabetic neuropathies so then complications can be prevented. one of the nonpharmacological nursing interventions that can be done to reduce the peripheral complaints of diabetic neuropathy is foot massage. however, this intervention still needs to be investigated, therefore this study examines peripheral neuropathy more fully and not only with 10g monofilament. materials and methods the research design was a one group pretest-posttest design (foot massage) as the treatment given to the patients. the population in this study was all of the t2 dm patients in phc 2 north denpasar. seventy-two respondents were selected using simple random sampling. a data collection tool in the form of foot massage protocol was used by adopting the foot massage theory from the journal of intermountai health care (2016). each participant in this study performed a foot massage twice a week for 4 weeks starting from the lower leg, stroke, down to the bottom of the foot, thumb stroke, to the top of the foot, thumb stroke with a toe stretch and then repeating the lower leg stroke. for each massage, they took approximately 15 minutes. the michigan neuropathy screening instrument (mnsi) consisted of two parts in the form of a history of the disease with 4 questions and a physical examination. the physical examination included an examination of the muscular damage, sensory damage and motor damage. mnsi was validated and has good internal consistency. the cronbach’s alpha for this instrument was 0.703. the wilcoxon sign rank test was used for the analysis of the changes in the dependent variables before and after the exercise. all of the differences with p < .05 were accepted as statistically significant (pallant, 2010). approval and permission to conduct the study obtained from the board for national unity and from the peoples’ protection of bali province (070/00932/dpmptsp-b/2018). in addition, permission to conduct the study was obtained from the head of phc 2 north denpasar sub-district, bali. jurnal ners http://e-journal.unair.ac.id/jners | 307 the participants signed the inform consent form, thus indicating their permission and willingness to participate in the study. the researchers maintained the anonymity and confidentiality regarding the participants’ identity and responses. the result findings were presented in aggregate. table 1. general characteristics of the respondents (n = 72) characteristic of age median (range) age (years) 56 (51-68) gender (male/female) 27/4 peripheral neuropathy pre 14.5 (6-39) post 6.5 (0-27) table 2. the results of the effect of foot massage on decreasing the peripheral neuropathy diabetic complaints of the patients with t2dm wilcoxon sign rank test result negative ranks positive ranks ties p value 72 0 0 0,000 result as shown in table 1, the average age was 63 years old. in terms of the peripheral neuropathic diabetic level, it changed from moderate peripheral neuropathy to mild peripheral neuropathy. table 2. the results of the effect of foot massage on decreasing the peripheral neuropathy diabetic complaints of the patients with t2dm. table 2 shows the results of the wilcoxon sign rank test statistical analysis which indicated that for the 72 negative ranks that showed after being given the foot massage intervention, the 72 respondents had a decreased complaint of peripheral neuropathy. the results of the positive ranks was 0; this indicates that after being given the foot massage intervention, no respondents experienced an increase in the complaint of peripheral neuropathy. tie 0 indicates that none of the respondent’s scores remained the same before and after the intervention. from the results of the wilcoxon sign rank test statistical test, p = 0,000 <ɑ 0.05 was obtained. this shows that there was a significant effect from foot massage on a decrease in peripheral neuropathic diabetic complaints in type 2 dm patients in the north denpasar health center ii working area. the results showed that the distribution of peripheral neuropathic in diabetics before the foot massage in type 2 dm patients in the north denpasar health center ii working area had a range of 6-39. the most dominant respondents belonged to mild neuropathy for as many as 36 respondents (50%) and those with severe neuropathies totaled as many as 9 respondents (12.5%) discussion peripheral diabetic neuropathy is a nervous disorder especially focused in the peripheral area with symptoms such as pain, tingling or a loss of feeling in the hands, arms and legs (robert, 2009). the peripheral symptoms of diabetic neuropathy can occur in various places in the body but most of the complaints are mostly felt in the legs. some of the symptoms include pain, a burning sensation in the legs and tingling. these symptoms are in accordance with the examination that was carried out on the respondents using the michigan neuropathy screening instrument (mnsi) questionnaire. moreover, pharm (2014) stated that as for the factors that affect peripheral neuropathic diabetics, namely age, the aging process will be increasingly visible. age will affect nerve damage due to dm (davies, k., pharm, d., pharmacy, p. g. y., & resident, n.d.). azura et al. (2012), concluded that there was a positive correlation of age with the incidence of peripheral diabetic neuropathy (azura, 2012). this prevalence increased with age, from 5.6% in the participants aged less than 40 years up to 51.8% in patients over 60 years. hypertension also affects peripheral diabetic neuropathy. according to pharm (2014), many diagnoses are comparable to peripheral diabetic neuropathy other than diabetes. hypertension is an important factor to be considered because it is shown to be significantly associated with peripheral diabetic neuropathy (davies, k., pharm, d., pharmacy, p. g. y., & resident, n.d.). according to the center for disease control and the prevention of smoking and health office (cdc) (2017), smokers have a 30 40% risk of developing dm compared to non-smokers. cigarettes also trigger the release of oxidative stress and they reduce the oxygen intake to the cells which ultimately trigger cell damage and the inflammatory process. this process will accelerate nerve damage due to hyperglycemia in the dm patients. from the results of the examinations conducted by the researchers, the respondents who have more than 60 years of age experience severe neuropathic complaints. the respondents who have a history of smoking and hypertension also experienced severe neuropathic complaints. one of the peripheral symptoms of diabetic neuropathy is neuropathic pain. this is supported by the research conducted by putri (2016), which showed that 93.8% of respondents were found to complain of diabetic neuropathic pain (putri, m. c., widodo, s., 2013). the results of another study conducted by hutapea (2016) found that out of 140 dm patients, 83 of them (59.2%) had neuropathies. the symptoms of peripheral diabetic neuropathy that can occur along with the promotion of dm are known as sensory neuropathies (hutapea, 2016). the results showed that the frequency distribution of the peripheral neuropathic diabetic complaints after the foot massage in type 2 dm n. l. p. i. b. agustini et al. 308 | pissn: 1858-3598  eissn: 2502-5791 patients in the puskesmas ii north denpasar work area with the score neuropathic respondents in the range of 0 27. the dominant respondents were those with moderate neuropathies which were as many as 33 respondents (45.8%) and the lowest number of respondents were those with severe neuropathies, totaling 6 respondents (8.3%). reducing peripheral neuropathic symptoms can be done by pharmacological or non-pharmacological approaches. in this study non-pharmacological interventions played a role in reducing complaints of peripheral neuropathic diabetic. besides treatment is a very important part. peripheral neuropathic diabetic patients need to care for their feet carefully. the nerves to the legs are the longest in the body and they are the ones most often affected. one should avoid risk factors such as smoking and the consumption of alcohol. various other foot exercises such as acupuncture, foot massage and other therapies can be an alternative in the context of care (putri, m. c., widodo, s., 2013). from the results of the examination carried out, the results showed that there was a decrease in neuropathic scores after being given the intervention. the results of this study indicate that all of the respondents surveyed experienced a decrease in neuropathic complaints. from the data collection, it showed that the decrease in neuropathic complaints was found the most in relation to autonomic nerve damage. in the post-test, the autonomic nerve damage data in the respondents all decreased to a score of 0. the autonomic nerve examination included dry skin, cracked skin and calluses/callus. during the foot massage, they used olive oil. by using the oil, the skin will become moister so then the respondent's skin will not be cracked. the calluses will be moist and loose. the declining complaints of peripheral neuropathic diabetes according to the researchers are effective when paired with foot massage. gentle pressure during the foot massage can increase blood flow. according to the researchers, the increase in blood flow can be seen from the change in the color of the respondent's feet when the massage changes it from pale to more reddish. the effect of foot massage is not only from the gentle pressure but also from the oil used during the massage. the decrease was also seen in sensory nerve damage. this result is in line with the research conducted by harmaya et al (2014) which shows that there is an effect of foot massage on the sensory protection of dm patients (harmaya, 2014). these results are in accordance with the theoretical massage done by applying gentle pressure to the feet which is expected to increase and improve blood flow. good blood flow will support the supply of oxygen and nutrients to the nerve cells so then the nerves will work optimally by increasing the work of sensory nerves (tschakovsky, n.d.). the results of the study were based on an analysis of the effect of foot massage on decreasing the peripheral neuropathic diabetic complaints in patients with type 2 dm in the north denpasar community health center ii working area using the wilcoxon sign rank test statistical test which obtained a result of negative rank 72. this indicates that following the foot massage intervention, 72 patients experienced a decrease in peripheral neuropathic diabetic complaints. while the results of the positive ranks were 0, this indicates that after being given the foot massage intervention, none of the respondents experienced an increase in their complaint of peripheral neuropathic diabetes. this means that after being given the intervention, the results of the wilcoxon sign rank test statistical test were p = 0,000 <ɑ 0,05. this shows that there is a significant effect of foot massage on the decrease in peripheral neuropathic diabetic complaints in patients with type 2 diabetes in the working area of north denpasar health center ii. foot massage is another method that can be chosen when providing nursing care for patients with type 2 diabetes with complaints of peripheral neuropathy. the foot massage is done by applying gentle pressure to the feet which is expected to increase the blood flow. good blood flow will support the supply of oxygen and nutrients to the nerve cells so then the nerves will work optimally and reduce the rate of peripheral neuropathic diabetic complaints (tschakovsky, n.d.). with foot massage interventions, they are not only effective at reducing the complaints of peripheral neuropathic diabetics but they can also provide a comfortable feeling because the patient's foot massage will make them more comfortable. the effect of this relaxation, according to the researchers, is very important. some of the respondents said that they felt comfortable when doing the foot massage. this feeling of comfort is good, as the researchers hope to reduce the stress. it is expected that with reduced stress, the dm patients will be more obedient in the management of diabetes in terms of diet, exercise and pharmacological / non-pharmacological therapies. the repair of the blood vessels is in the form of an increase in the ankle brachial index. the results of this study indicate that the better the abi value, the lower the peripheral level of diabetic neuropathies experienced by the dm patients. different research results were found in the study conducted by harnaya (2014), which further emphasized the effect of foot massage on peripheral diabetic neuropathies. this study showed a significant effect of foot massage on the sensory and neuropathic processes (harmaya, 2014). conclusion from the results of the study, it can be concluded that there was an effect of foot massage on the decrease in peripheral neuropathic diabetic complaints in patients with type 2 diabetes in the working area of north denpasar health center ii. the results of the data collection showed that the neuropathic scores of the respondents before being given the foot massage intervention were in the range of 6 39. the jurnal ners http://e-journal.unair.ac.id/jners | 309 respondents with mild neuropathies were as many as 12 responses (50%) and the least with severe neuropathies by 3 respondents (12.5%). after giving the intervention, there was found to be a decrease in the neuropathic output of the respondents. the data showed that the respondents' neuropathic scores after being given intervention were in the range off 027. the respondents with moderate neuropathies were as many as 11 respondents (45.8%) and the responders with severe neuropathies were as many as 2 respondents (8.3%). references achmad rudijanto, agus yuwono, alwi shahab, a. m. (2015). pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. pengurus besar perkumpulan endokrinologi indonesia (pb perkeni). azura. (2012). risk factor of peripheral neuropathy among newly diagnosed type 2 diabetic patients in primary care clinic. 4(11), 1858–1867. davies, k., pharm, d., pharmacy, p. g. y., & resident, p. (n.d.). diabetic neuropathy. ohio northern university objectives. dy sm, bennett wl, sharma r, zhang a, waldfogel jm, nesbit sa, y. h., & chelladurai y, feldman d, wilson lm, r. k. (2017). preventing complications and treating symptoms of diabetic peripheral neuropathy. comparative effectiveness review. gilg, a. c. (2016). the impact of amputation on body image. harmaya. (2014). pengaruh masase kaki terhadap sensasi proteksi pada kaki pasien diabetes melitus tipe ii dengan. coping (community of publishing in nursing), 2(1). hutapea, f. (2016). gambaran klinis neuropati pada pasien diabetes melitus di poliklinik. 4. nursalam. (2016). metodologi penelitian ilmu keperawatan. jakarta: salemba medika. pallant. (2010). spss survival manual: a step by step guide to data analysis using spss. step by step guide to data analysis using spss. putri, m. c., widodo, s., & s. (2013). pengaruh senam kaki diabetik terhadap intensitas nyeri neuropati diabetik pada penderita diabetes melitus tipe 2. stikes telogorejo semarang. robert, t. (2009). diabetic peripheral neuropathy: painful or painless. (december). shaw, g. b. (2015). diabetic foot ulcers – prevention and treatment table of contents. minneapolis: coloplast corp. tschakovsky, w. and v. (n.d.). massage impairs postexercise muscle blood flow and “lactic acid” removal. medicine & science in sports & exercise., 42(6), 1062–1071. https://doi.org/0.1249/mss.0b013e3181c9214f http://e-journal.unair.ac.id/jners | 181 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.16741 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the impact of self efficacy on the foot care behavior of type 2 diabetes mellitus patients in indonesia nuh huda1, tintin sukartini1 and nadya wahyu pratiwi2 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 sekolah tinggi ilmu kesehatan hang tuah surabaya, east java, indonesia abstract introduction: diabetes mellitus (dm) often causes complications, one of which is diabetic foot ulcers (dfus). one of the factors involved in preventing diabetic foot injuries is performing foot care behavior. to improve patient behavior in terms of performing foot care is to improve self-efficacy. the purpose of this study was to determine the effect of the self-efficacy of diabetes patients on foot care behavior. methods: this study used a descriptive correlational design to reveal the correlative relationships between the variables with a sample of 106 respondents using probability sampling in the form of cluster random sampling. the data was collected using questionnaires, the foot care confidence scale (fccs), and the foot care behavior scale for diabetes (fcbs for diabetes). the independent variable of this study was the self-efficacy of dm sufferers and the dependent variable of this study was the behavior of foot care. the data analysis used the spearman rho correlation test (α=0.05). results: spearman rho correlation test showed there to be a relationship between the self-efficacy of people with diabetes mellitus and foot care behavior p value = 0.001 (p<0.05), r= -0.542. conclusion: the implication of this study is that a high self-efficacy in people with diabetes mellitus will improve the behavior related to foot care, thereby reducing the risk of behaviors that damage the feet. article history received: dec 18, 2019 accepted: jan 13, 2020 keywords diabetes mellitus; foot care behavior; self-efficacy contact nuh huda  nuh.huda-2018@fkp.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: huda, n., sukartini, t., & pratiwi, n, w. (2019). the impact of self efficacy on the foot care behavior of type 2 diabetes mellitus patients in indonesia. jurnal ners, 14(2), 181-186. doi:http://dx.doi.org/10.20473/jn.v14i2.16741 introduction dm has complications that have a great chance of causing death. dfu is one of the most common complications of dm which is the main cause of many hospitalizations due to a lack of foot care behavior. this subsequently leads to the amputation of the lower extremities (pourhaji et al., 2016). foot care behavior is often neglected, especially by adults and the elderly. foot care education is one of the best tools available to increase the awareness of people with diabetes mellitus on the matter of proper foot care behavior (zaman, shah and hussein, 2018). some of the most common cases of dm include the problem of dfu every year. the number of people suffering from dm is increasing due to limitations in terms of self foot care behavior. one of the limitations is that the health workers have counseled them about diabetes mellitus but without any follow up, it is uncertain whether the dm sufferers have understood and are convinced of what is being delivered by the health workers. many dm sufferers seem to have not cut their nails straight, the skin of dm sufferers' feet looks dry and some of the sufferers are not sure that they can take care of the feet because of the lack of a support system from their family and the environment around them. there needs to be a support system when a patient forgets. it is expected that they will have someone to remind and convince them that they are able to take preventive behavior steps in relation to their illness. if proper foot care is not carried out, then certain chronic complications of diabetes mellitus, especially diabetic foot ulcers, can occur in people with dm. the existence of these limitations is influenced by self-efficacy. this is one's belief in their ability to perform a behavior that is expected to change one's health behavior (sharoni et al., 2018). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nuh.huda-2018@fkp.ac.id n. huda, et al. 182 | pissn: 1858-3598  eissn: 2502-5791 the who (world health organization) estimates that 108 million people live with dm. this number increased in 2015 to 415 million people, while the estimates for 2017 2045 according to the idf showed a total of 7.5-9.5 billion world population. the prevalence of diabetes is 425 628.6 million people around the world. according to the who data in 2017, the prevalence of dm sufferers with neuropathic disorders reached 50% and those with leg injuries reached 15 25% (international diabetes federation (idf), 2017). the results of research conducted in arabic states that 70% of lower extremity amputations are dm sufferers with leg injuries (al-hariri et al., 2017). indonesia ranks 7th in the world with the highest number of dm sufferers and the estimates reach 6.7 11.1 million sufferers. the results of the 2018 riskesdas survey showed that the prevalence of dm in the indonesian population aged > 15 years old has increased to 8.5%. east java ranks 5th in the number of dm sufferers in indonesia at 7.6% (depkes ri, 2018). dm patient data from the surabaya district/city health office in 2018 for the working area of the puskesmas in wonocolo district, namely siwalankerto puskesmas, showed that there were 1,140 dm patients and for sidosermo puskesmas, there were 2,790 dm patients (dinas kesehatan kota surabaya, 2018). behavior is very much involved in preventing the complications of dm. behavior is a complex process and it is influenced by several factors such as knowledge, self-confidence, attitudes, skills, motivation and social support. this is needed to make improvements in self-care behavior. one of the determining factors in achieving a behavior is selfefficacy (self-confidence). self-efficacy is a person's self-confidence in their ability to perform a behavior that needs to be done to achieve goals, tasks, and challenges set. self-efficacy describes the interaction between the behavioral, personal, and environmental factors in the context of health and chronic diseases. this is also a belief that affects people with diabetes mellitus concerning whether they are able to perform health behaviors. people with high self-efficacy believe that they are able to do difficult tasks well, as something that must be mastered is not something that should be avoided. it can be estimated that the dfu risk will decrease with the increase in foot care behavior (hamedan, hamedan and torki, 2012). the purpose of this study was to determine the impact of diabetes self-efficacy on foot care behavior in surabaya. materials and methods this study used a descriptive correlational design that reveals the correlative relationship between variables, which is related to getting to know the relationship between the self-efficacy of diabetics and foot care behavior. this research was conducted in the working area of wonocolo district health center (uptd siwalankerto health center and sidosermo health center) in may july 2019. the population consisted of 3,930 respondents. the sampling technique in this study was probability sampling where the cluster random sampling approach was done twice, first based on the number of villages and second based on age range. a sample of 106 respondents was finally obtained. the instrument used in this study was the foot care confidence scale (fccs) questionnaire (sloan, 2002) used to measure the self-efficacy of diabetics consisting of 12 questions. the interpretation of the results was that high scores indicate high self-efficacy and low scores indicate low self-efficacy. after testing the reliability and validity by calculating the coefficient between the item scores and total scores in the range of 0.30 and 0.70, cronbach’s alpha was 0.90 for the 12 question items. they showed strong content validity and construction when performing foot care behavior based on the confidence scale (pourhaji et al., 2016). the fcbs for diabetes (foot care behavior scale for diabetes) questionnaire was used to measure foot care behavior consisting of 17 questions evaluating two behaviors, namely prevention and risk behavior with the interpretation of the high score results indicating the risk of high destructive behavior and with a low score indicating that the damage risk was low (garcía-inzunza et al., 2015). the data collection was carried out using a questionnaire addressed to all type 2 dm patients in the community. the previous respondents received an explanation of self-efficacy and foot care behavior, so it was hoped that the questionnaire would be filled in correctly. the authors found 126 people willing to become respondents, although 20 people resigned for the reason of not being able to do foot care because of their age, weakness and moving out of town. we got 106 respondents in total. the inclusion criteria were as follows: dm type 2 sufferers, control done at the puskesmas and aged 15-60 years. the exclusion criterion were that the patient dropped out before the end of the study, there were complications regarding their leg injury, mental disability and decreased health/awareness. the analytical test used was the spearman rho correlation test (α = 0.05) with spss v-23. a statement of medical research ethics was issued by the health research ethics commission (kepk) of stikes hang tuah surabaya in accordance with number: pe/38/v/2019/kepk/sht. results based on the table 1, the characteristics of the respondents in this study included age, sex, last education stage, occupation, duration of diabetes mellitus, understanding every month, and had received counseling. it can be explained that the characteristics of the respondents showed that most were aged 51-60 years (52.8%) and most were female sex (65.1%). the majority were also educated at the high school/equivalent level (34.9%), in private employment (54.7%), had suffered from diabetes mellitus 2-3 years (40.6%), had a monthly income of jurnal ners http://e-journal.unair.ac.id/jners | 183 2-4 million idr (56.6%), and had never received counseling (60.4%) regarding foot care behavior. based on table 2, it shows that out of 106 respondents, people with diabetes mellitus with low self-efficacy were as many as 21 respondents (19.8%). those with high self-efficacy were as many as 85 respondents (80.2%). dm sufferers with low self-efficacy were as many as 21 respondents out of the total of 106 respondents. the results of the questionnaire showed that the respondents mostly had low self-efficacy because they were not sure after washing the feet if they had to dry the feet between the toes. having wet feet can cause a fungus, resulting in damage to the cells of the feet. the respondents were not sure that they should cut their nails straight. they preferred to follow the shape of the nails if they were done often. this can cause lesions and infections that we usually call ‘slants’. this shows that out of the 106 respondents, there are people with diabetes mellitus who have a low risk of destructive behavior (as many as 83 respondents; 78.3%) and those who have a high risk of destructive behavior (as many as 23 respondents; 21.7%). the dm sufferers who have a low risk of destructive behavior totaled 83 respondents. discussion the respondents were less confident when examining the inside of their shoes before using it. this can harm their feet as there may be foreign objects that can cause lesions on the feet. patients who have low selfefficacy tend to doubt their abilities and they encounter difficult problems because they usually assume that any problem is a threat (bahador et al., 2017). someone with low self-efficacy tends to be slow at getting their self-efficacy back when it causes them to fail to deal with problems (d’souza et al., 2017). someone with low self-efficacy does not think of the best way to deal with the tasks that must be done, especially foot care in order to prevent complications. they will be disturbed by doubts about their abilities and they will easily give up when faced with difficulties doing the task. chronic illness can be a trigger for low self-efficacy because the longer the illness is suffered from, the more problems will be faced by the sufferers. someone who has low self-efficacy is usually busy thinking about deficiencies in themselves. they quickly give up when faced with problems. there were 21 respondents with low self-efficacy, there were 14 respondents also with a high risk of destructive behavior and 7 have a low risk of damage. this will be much influenced by table 1. characteristic of respondents (n=106) characteristics of the respondents n % age 15-23 years old 1 0.94 24-32 years old 4 3.77 33-41 years old 8 7.55 42-50 years old 37 34.91 51-60 years old 56 52.83 sex male 37 34.91 female 69 65.09 educations primary school 11 10.38 junior high school 35 33.02 senior high school 37 34.91 bachelor 23 21.70 work not working 2 1.89 private 58 54.72 employee 20 18.87 others 26 24.53 duration suffering from dm <1 years 1 0.94 >1-2 years 30 28.30 2-3 years 43 40.57 4-5 years 24 22.64 >6 years 8 7.55 income <1 million (idr) 7 6.60 >1-2 million (idr) 22 20.75 2-3 million (idr) 30 28.30 3-4 million (idr) 30 28.30 4-5 million (idr) 17 16.04 counselling yes 42 39.62 no 64 60.38 n. huda, et al. 184 | pissn: 1858-3598  eissn: 2502-5791 the behavior that is often done in their daily lives. they can gain experience because of discussing things with fellow sufferers or seeing related topics through mass media. the daily behavior that has been done will affect the behavior when someone is in a state of experiencing an illness. the results of the questionnaires showed that some of the respondents chose behavior used for prevention, namely the frequent checking of the feet, often washing their feet and drying them using a small towel, often checking the inside of their shoes before using them and measuring their foot size first before buying new shoes. good behavior in terms of foot care can be done in several ways: 1) clean, dry and gentle foot care, 2) skin care, 3) nail care and 4) using the right shoes (heitzman, 2010). a low risk of destructive behavior can occur when the respondent already knows and can perform good foot care behavior in the way that is available. based on these results, the dm sufferers said that they already knew how to take care of their feet and some of them had applied this well. for the results of filling in the fcbs for diabetes questionnaire, many of the respondents answered question no. 2 about how often they had wash their feet in the past week; some of the respondents answered 2x/day while in reality, other respondents washed feet 5-10x/day. this is done by the respondents when they feel that their feet are dirty and dry. they do so to moisturize their feet. they prefer washing their feet instead of using foot lotion, which according to them means that their feet will feel more comfortable, not dry, fresh, and clean. after washing their feet, the respondents did not forget to dry them with a small towel. the most frequent statement within the category of risky behavior done by the respondents was walking barefoot in the room. according to them, if they are in their house, then they do not have to use footwear because the house is clean and has a ceramic floor. thus there is no need to use footwear inside the house, except when performing prayer at the time of ablution when they usually use footwear from the bathroom through to the place of prayer in the house (maslakpak, 2017). correlation coefficient(r) shows the result of -,542 * which means that there is a significant relationship between the two variables. this shows that there is a negative correlation, so the higher the self-efficacy, the lower the risk of destructive behavior and vice versa. the lower the self-efficacy, the more that the risk of destructive behavior will be high. the negative sign indicates that the direction of the correlation is the opposite, which means that the higher the selfefficacy of people with diabetes mellitus, the lower the risk of destructive foot care behavior. self-efficacy is known as one of the resources used by someone when carrying out their personal tasks. self-efficacy is not related to the skills possessed by individuals but it instead relates to individual beliefs in the things done (brown, malouff and schutte, 2013). the results of this study are supported by the research which has revealed that patients who have higher self-efficacy will have good self-care behavior. other studies support this research (sharoni et al., 2018). these studies have revealed the existence of a self-efficacy program that can improve the self-care foot behavior in relation to the program delivered. research by (pourhaji et al., 2016) concludes that the belief in performing foot care by improving the physical selfconcept can help to improve the foot care behavior among people with diabetes mellitus. according to researchers, the existence of good self-care behavior can reduce the risk of destructive behavior. the selfefficacy of diabetics in foot care is needed to maximize the foot care behavior to prevent diabetes mellitus complications. patients are expected to be able to apply self-efficacy optimally through foot care behavior. perceived self-efficacy can also have an impact on the efforts made when handling a task or problem, especially health problems. health education must continue to be done to improve sufferers' self-efficacy of foot care behavior. the characteristics of individuals who have high selfefficacy include where they feel able to deal effectively with the events and situations faced, that they persevere in completing their existing tasks, that they are always confident in their abilities and that they view difficult situations as challenges rather than as threats. this is in addition to designing their own goals , increasing their strong commitment to themselves increasing the strong effort to do everything, increasing the effort needed to deal with failure, thinking to strategize in the face of adversity, quickly restoring the sense of being able to fail, and being able to deal with stressors. out of the sample, 23 dm sufferers have a high risk of destructive behavior. this can be interpreted as poor foot care behavior. the respondents stated that table 1. impact of self-efficacy on diabetic foot care behaviors (n=106) self-efficacy of dm patients foot care behavior total low risk destructive behaviors high risk destructive behavior low self-efficacy n 7 14 21 % 6.6 13.2 19.8 high self-efficacy n 76 9 85 % 71.6 8.4 85.8 total n 91 15 106 % 78.3 21.7 100 spearman’s rho test; 0,001(ρ < 0.05) correlation coefficient; -0.542* jurnal ners http://e-journal.unair.ac.id/jners | 185 they sometimes walked barefoot outside of the room, that they often wore shoes without socks and that they sometimes use tape on the feet to remove calluses. according to the research, it revealed that the low foot care behavior may occur when people with diabetes mellitus have difficulty checking feet; help from others may be needed (cousart and handley, 2017). the results of the respondents ignoring doing their routine foot care for several reasons is that they often forget, are lazy, do it in a manner that is not in accordance with what is usually done, and they feel uncomfortable in the way that it is given. one of these behaviors is where they rarely cut their nails straight to avoid lesions; some of them prefer to cut their nails according to their shape. meanwhile, 85 other respondents had high selfefficacy. the respondents said that they were confident in terms of protecting their feet, examining their feet every day to check for cuts, scratches, blisters, redness, or dry feet, and choosing good and suitable shoes without relying on having a suitable feeling. patients who have high self-efficacy usually tend to choose being directly involved in solving problems even though the problems faced are difficult. this is because people with a high selfefficacy look more at the problem rather than at the threat that must be avoided (d’souza et al., 2017). someone with high self-efficacy can overcome their problems effectively and they will try hard to deal with all of the difficulties encountered. they will persist in carrying out a task when they already have the prerequisite skills in accordance with the existing rules. previous research by d'souza (2017) on foot care behavior shows that positive behavior correlates with a positive attitude and awareness of diabetes management. patients are able to behave better in the prevention of foot injuries through the use of footwear by 47.14%, using foot moisturizer by 44.29%, walking without a pedestal by 53.57%, inspecting their shoes before use by 49.29% and cutting the nails by 60.71%. this study recommends an increase in self-efficacy that involves families in the prevention of diabetic foot injuries (d’souza et al., 2017). one of the determining factors in achieving behavior is self-efficacy. another study stated that self-efficacy improvement programs are able to improve foot-care behavior and they recommend that the theory of self-efficacy be included in dm education programs to improve foot-care behavior (sharoni et al., 2018). behavior arises because of the intention to behave. intentions can be predicted from attitudes, subjective norms and the perception of selfcontrol the greater the intention to take preventative measures, the greater the chance of improving the health behavior (nursalam, 2015). self-efficacy is the human belief in their ability to perform an expected behavior, in particular control of the self-function to achieve the expected results. self-efficacy is different from the aspirations or ideals that describe something that can be achieved, as it is more due to the belief in one's abilities. self-efficacy is a construct based on social cognitive theory. human actions have a reciprocal relationship where there are individuals, the environment and behavior (chin, huang and hsu, 2012). most respondents have the assumption that with positive thinking patterns and self-confidence in their ability to deal with every problem, there is the existence of motivation and support among the family members which can increase their confidence. self-efficacy is an individual's belief in their ability to exercise control over various self-functions and events in their environment. the ability of the individuals to improve their motivation, cognitive resources and actions is needed to meet the demands faced. efficacy refers to the belief that an individual is able to estimate his or her ability to carry out tasks in order to achieve the expected results. efficacy always develops continuously in someone who is in line with the ability and number of experiences or events that they experience (bandura, 1997). conclusion the higher the self-efficacy of people with diabetes mellitus, the better their foot care behavior. they will have a lower risk of potentially damaging behavior related to foot care. references al-hariri, m. t. et al. (2017) ‘descriptive study on the knowledge, attitudes and practices regarding the diabetic foot’, journal of taibah university medical sciences, 12(6), pp. 492–496. doi: 10.1016/j.jtumed.2017.02.001. bahador, r. s. et al. (2017) ‘the impact of three-month training programme on foot care and self-efficacy of patients with diabetic foot ulcers’, journal of clinical and diagnostic research, 11(7), pp. ic01– ic04. doi: 10.7860/jcdr/2017/29025.10261. bandura (1997) ‘self efficacy: toward a unififying theori of behavioral change psycological review’. brown, l. j., malouff, j. m. and schutte, n. s. (2013) ‘self-efficacy theory’, pp. 13–38. chin, y., huang, t. and hsu, b. r. (2012) ‘impact of action cues , self-efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy’, (259), pp. 61–68. doi: 10.1111/j.13652702.2012.04291.x. cousart, t. h. and handley, m. (2017) ‘implementing diabetic foot care in the primary care setting’, journal for nurse practitioners. elsevier, 13(3), pp. e129–e132. doi: 10.1016/j.nurpra.2016.11.009. d’souza, m. s. et al. (2017) ‘self-efficacy and self-care behaviours among adults with type 2 diabetes’, applied nursing research. elsevier inc., 36, pp. 25– 32. doi: 10.1016/j.apnr.2017.05.004. depkes ri and depkes (2018) riskesdas 2018. dinas kesehatan kota surabaya (2018) profil kesehatan kota surabaya 2017. available at: http://www.depkes.go.id/resources/download/ profil/profil_kab_kota_2016/3578_jatim_kot n. huda, et al. 186 | pissn: 1858-3598  eissn: 2502-5791 a_surabaya_2016.pdf. garcía-inzunza, j. a. et al. (2015) ‘validity of the mexican version of the combined foot care confidence / foot-care behavior scale for diabetes’, 38(1), pp. 35–41. hamedan, maryam shabani, hamedan, marzieh shabani and torki, z. (2012) ‘relationship between foot-care self-efficacy beliefs and self care behaviors in diabetic patients in iran (2011)’, journal of diabetes & metabolism, 3(9). doi: 10.4172/2155-6156.1000220. heitzman, j. (2010) ‘foot care for patients with diabetes’, topics in geriatric rehabilitation, 26(3), pp. 250–263. international diabetes federation (idf) (2017) idf diabetes atlas 8th edition, idf.org. doi: 10.1289/image.ehp.v119.i03. maslakpak (2017) ‘preventing and managing diabetic foot ulcers: application of orem’s self-care model’, international journal of diabetes in developing countries. international journal of diabetes in developing countries, 38(2), pp. 165–172. doi: 10.1007/s13410-017-0570-5. nursalam (2015) motodologi penelitian ilmu keperawatan. edisi 4. jakarta: salemba medika. pourhaji, f. et al. (2016) ‘foot-care self-efficacy beliefs, physical self-concept and actual footcare behavior in people with diabetes mellitus’, international journal of musculoskeletal pain prevention, 1(3), pp. 101–107. sharoni, s. k. a. et al. (2018) ‘the effects of selfefficacy enhancing program on foot self-care behaviour of older adults with diabetes: a randomised controlled trial in elderly care facility, peninsular malaysia’, plos one, 13(3), pp. 1–23. doi: 10.1371/journal.pone.0192417. sloan, h. l. (2002) ‘developing and testing of the foot care confidence scale’, journal of nursing measurement, 10(3), pp. 207–218. doi: 10.1891/jnum.10.3.207.52564. suharsono, y. and istiqomah (2014) ‘validitas dan reliabilitas skala self-efficacy’, jurnal ilmiah psikologi terapan, 02(01), pp. 144–151. zaman, k., shah, m. and hussein (2018) ‘knowledge and practice of foot care among diabetic elderly in ukm medical centre (ukmmc)’, the malaysian journal of nursing, 9(3), pp. 6–12. http://e-journal.unair.ac.id/jners | 195 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17056 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review factors affecting the organizational commitment of nurses in comprehensive health services: a systematic review erfan rofiqi1, rahayu tri nuritasari1 and pipit festi wiliyanarti2 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 faculty of health sciences, muhammadiyah university of surabaya, surabaya, indonesia abstract introduction: organization commitment is an important variable in understanding employee behavior that has a serious effect on organizational performance. employees not only have to have expertise, empowerment and competence, but they also have to have organizational commitment. therefore, the level of attachment and commitment of the nurses to their organization can influence their clinical competence. the research was conducted to identify the factors that influence nursing organizational commitment. methods: the literature review employed the scopus, sciencedirect, pubmed, ebsco and cinahl databases to retrieve original articles published between 1999 and 2017. the method used to arrange the literature review started with the topic selection and then the reviewer determined the following keywords: organization commitment, commitment, nursing, health and factors of commitment. out of the 2.134 articles found, there were 15 journals with a crosssectional study design that discussed the organizational commitment of nurses. results: the organizational commitment of care is influenced by many factors, both internal and external. these factors include leadership style, compensation, career development, organizational culture /climate, spiritual health and learning organizations. conclusion: the factors found above can increase the commitment of nurse organizations in comprehensive health services. article history received: december 26, 2019 accepted: december 31, 2019 keywords organizational commitment; health services; nursing contact erfan rofiqi  erfan.rofiqi-2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: rofiqi, e., nuritasari, r. t., & wiliyanarti, p. f. (2019). factors affecting the organizational commitment of nurses in comprehensive health services: a systematic review. jurnal ners, 14(3si), 195-198. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17056 introduction in today's modern world, the role of human resources in developing a country is very important. in addition, they believe that the most important capital of any organization is its human resources. in this case, nurses are counted as the largest and most important human resource in health organizations(yang, liu, chen, & pan, 2014). nursing is one of the most important professions in the hospital which is influenced by several factors, one of which is organizational commitment. organizational commitment is an important variable in understanding employee behavior that has a serious effect on organizational performance(labrague et al., 2018). we have defined organizational commitment as a psychological relationship between the employees and/or organizations where there is a small possibility of them voluntarily leaving the organization. the commitment model has 3 components that have been built as interpretations of the existing research. the component models are as follows: affective commitment, ongoing commitment and normative commitment(amin, barati, & ghoroghchian, 2016). each component is associated with an appropriate psychological state. affective commitment refers to a positive emotional relationship between the employees and the organization. from an organizational aspect, this is the type of relationship that is liked by the employees because an employee who is committed affectively wants to remain a part of the organization. thus, they accept the organizational goals. continuous commitment refers to the psychological state in which the employee has the choice to stay or leave the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:erfan.rofiqi-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). e. rofiqi, et al. 196 | pissn: 1858-3598  eissn: 2502-5791 organization. this choice is not the result of a sense of association with the organization but from the fact that staying in the organization is more beneficial than leaving the organization. normative commitment refers to the psychological state of the employees where they feel obligated to remain in the organization. this three-component model of organizational commitment is the most widely accepted model. to achieve the health system goals, the workforce not only involves expertise, empowerment and competence but also a high level of attachment, organizational commitment and the willingness to engage in outside activities and predetermined tasks. therefore, the level of attachment and the commitment of nurses to the organization can influence their clinical competence(j. zhou et al., 2018). in order to achieve a satisfactory level of health organization management, one must consider employee job satisfaction and organizational commitment. these two factors must be continuously measured and monitored, starting from the recruitment of new staff. in addition to continued measurements and monitoring, it is necessary to identify the other factors that directly or indirectly affect employee job satisfaction and organizational commitment(erdogan & yildirim, 2018). there are several things that can affect employee commitment, i.e. compensation, career development and organizational culture. materials and methods the literature review employed the scopus, sciencedirect, pubmed, ebsco and cinahl databases to retrieve the original articles published between 1999 and 2017. the method used in arranging literature review started with the topic selection. then the determined keywords were used: organization commitment, commitment, nursing, health and the factors of commitment. out of the 2.134 found, there were 15 journals with a crosssectional study design that discussed the organizational commitment of the nurse. the journals that met the inclusion criteria were collected and examined systematically. results based on the search results, we obtained as many as 15 journals that were in accordance with the objectives of the study. we then carried out screening based on eligibility in accordance with the inclusion and exclusion criteria for further review. after a study of the quality of the 15 articles was carried out, then the data extraction was conducted. data extraction was done by analyzing the data based on the name of the author, the design, population, intervention and results. the total number of respondents in this review was 6,903 nurses who worked in hospitals, both primary nurses and executive nurses. the area in this study was a hospital. discussion based on the journal analysis, it was found that organizational commitment was influenced by several things that are closely related to one another in the service process, especially in the field of nursing. several studies have been conducted to identify the factors that influence the nurses in organizational commitment. for example, leadership style, compensation, career development, organizational culture, supervisor support and so on. in this systematic review, we will discuss the comparison between each of these factors in terms of increasing nurse organization commitment. leadership style significant relationships were found between the organizational commitment of the nursing staff and its correlation with transformational leadership, which indicates that the staff became more committed to their hospital when their manager displayed the characteristics of transformational leadership. the effective leadership style influences the response of the individual nurses in the workplace and their organizational commitment(alyami, galdas, & watson, 2018). transformational leadership style has a positive and direct relationship with the level of organizational commitment and retention, with a significant impact on patient outcomes and the survival of the health organizations(al-yami et al., 2018) compensation, career development there was a direct impact from compensation, career development and organizational culture on the commitment of the nurses at suaka insan hospital simultaneously. the coefficient of determination was 0.945, which meant that 94.5% of the nurses' commitment was influenced by compensation and career development. hani handoko (2005) stated that compensation was important for the employees because the amount of it reflected the quantity of their working performance, and it supported their families and communities. compensation was defined as a form of reward given to the employees as a form of remuneration for the contribution they made to the organization. career development variables could be measured by the indicators as according to keith davis and werther, w.b in mangkuprawira (2002) i.e. their study of a group of employees revealed there to be 5 related aspects such as fairness in their career, attention with supervision, an awareness of opportunities, interest in the workers and career satisfactional. organizational culture the efforts to improve the organizational culture could be a valuable strategy for increasing organizational commitment(amin et al., 2016). thus, managers must try to understand the organizational culture and its factors in order to increase the organizational commitment of their staff. managers jurnal ners http://e-journal.unair.ac.id/jners | 197 could create a positive and desired culture for the staff in order to increase their responsibility to the organization, to try to achieve the organizational goals (normative commitment), to create emotional ties and to enjoy being in the organization (affective commitment). in addition, because change starts from oneself, the managers had to be familiar with the goals of the organization and they had to be committed to achieving it. thus it became a good example for the staff to create influence and motivation with their behavior. our research confirmed the correlation between organizational culture and some aspects of organizational commitment, which had to be considered regarding the planning of human resource management strategies in hospitals. spiritual health the results of all of the hypotheses put forward in this study showed that spiritual health had an effect on the nurses' attitudes towards spiritual care, professional commitment and caring itself. indeed, the attitude of the nurses in our study focused on spiritual care increased professional commitment and their ability to care. nurses who had a more positive attitude towards spiritual care tended to have better professional commitment and caring abilities. in addition, we proved that the nurses' attitudes towards spiritual care could mediate their spiritual health, spiritual commitment and spiritual health relationship(j. zhou et al., 2018; y. zhou et al., 2014). learning organization we found there to be a statistically significant positive correlation between internal marketing and the existence of learning organizations. through statistical analysis, we also found that internal marketing mediates between the existence of organizational learning and commitment. thus, when hospitals promote learning in the organizational culture, internal marketing was very positive and helpful in terms of influencing the nurse’s organizational commitment. we therefore suggest that hospital managers have to practice internal marketing to support the creation and ongoing existence of learning organizations(tsai, 2014). conclusion the organizational commitment of caring was influenced by many factors both internal and external. the factors included leadership style, compensation, career development, organizational culture, spiritual health, learning organizations and so on. the factors found above can increase the commitment of nurse organizations in comprehensive health services. references al-yami, m., galdas, p., & watson, r. (2018). leadership style and organisational commitment among nursing staff in saudi arabia. journal of nursing management, 26(5), 531–539. https://doi.org/10.1111/jonm.12578 amin, m., barati, o., & ghoroghchian, m. (2016). role of organizational climate in organizational commitment : the case of teaching hospitals. osong public health and research perspectives, 7(2), 96–100. https://doi.org/10.1016/j.phrp.2015.11.009 ayaz-alkaya, s., yaman-sözbir, ş., & bayrakkahraman, b. (2018). nurse education today the e ff ect of nursing internship program on burnout and professional commitment. 68(april), 19–22. chiang, y., lee, h., chu, t., han, c., & hsiao, y. (2016). the impact of nurses ’ spiritual health on their attitudes toward spiritual care , professional commitment , and caring. 64(261), 215–224. erdogan, v., & yildirim, a. (2018). sciencedirect sciencedirect healthcare professionals ’ exposure to mobbing behaviors and relation of mobbing with job satisfaction and organizational commitment. procedia computer science, 120, 931–938. https://doi.org/10.1016/j.procs.2017.11.328 hossein, m., naghneh, k., tafreshi, m. z., naderi, m., shakeri, n., bolourchifard, f., … beheshti, s. (2017). electronic physician ( issn : 2008-5842 ). (july), 4835–4840. karami, a., farokhzadian, j., & foroughameri, g. (2017). nurses ’ professional competency and organizational commitment : is it important for human resource management ? 1–15. labrague, l. j., petitte, d. m. m., tsaras, k., jonas, p., colet, p. c., & gloe, d. s. (2018). perceptions of organizational commitment and turnover intention among rural nurses in the philippines: implications for nursing management. international journal of nursing sciences. https://doi.org/10.1016/j.ijnss.2018.09.001 ruiller, c., & heijden, b. i. j. m. van der. (2016). socioemotional support in french hospitals : effects on french nurses ’ and nurse aides ’ affective commitment. applied nursing research, 29, 229– 236. https://doi.org/10.1016/j.apnr.2015.06.006 tsai, y. (2014). learning organizations , internal marketing , and organizational commitment in hospitals. veli, v. m. (2014). organizational commitment and job satisfaction among nurses in serbia : a factor analysis. 62, 415–427. https://doi.org/10.1016/j.outlook.2014.05.003 yang, j., liu, y., chen, y., & pan, x. (2014). the effect of structural empowerment and organizational commitment on chinese nurses ’ job satisfaction. applied nursing research, 27(3), 186–191. https://doi.org/10.1016/j.apnr.2013.12.001 zhou, j., yang, y., qiu, x., yang, x., pan, h., ban, b., … wang, w. (2018). serial multiple mediation of organizational commitment and job burnout in the relationship between psychological capital and anxiety in chinese female nurses : a crosssectional questionnaire survey. international journal of nursing studies, 83(157), 75–82. https://doi.org/10.1016/j.ijnurstu.2018.03.016 e. rofiqi, et al. 198 | pissn: 1858-3598  eissn: 2502-5791 zhou, y., lu, j., liu, x., zhang, p., & chen, w. (2014). effects of core self-evaluations on the job burnout of nurses : the mediator of organizational commitment. 9(4), 2–5. https://doi.org/10.1371/journal.pone.0095975 http://e-journal.unair.ac.id/jners | 397 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17180 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review effectiveness of self-management education based on information technology (it) in chronic kidney disease patients innani wildania husna, qolbi nur qoidah yahya, masita widiyani, and sholihin sholihin faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: chronic kidney disease (ckd) has a slow progression in the treatment process. the use of it (information technology) media as an innovation to support health education in patients with chronic kidney failure to improve their knowledge and self-management nowadays is becoming a trend. methods: we analyzed the literature to identify the effectiveness of it using as education media on chronic kidney disease patients. articles were obtained by prisma approach from scopus, sciencedirect, cinahl, pubmed, and proquest limited to the 5 years; from 2013 to 2018 and obtained 12 articles with rcts design study. we identified interventions based on it devices such as smartphones, pdas (personal digital assistant), computer-based applications, telehealth, film, sms, and website-based applications. results: this studies assessed 12 journals. according to the outcomes, there were 38 outcomes in total which are divided into three groups. they were 13 clinical outcomes, 14 caring process outcomes, and 11 usability and feasibility outcomes. conclusion: overall, the percentage of intervention which had a positive effect on the outcomes was about 47%. smartphone and computer-based technologies are the most effective to help the patient find information about aspects related to caring, self and disease management which are recommended by the health care team. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords chronic kidney disease; selfmanagement; computer-based technologies; caring contact innani wildania husna  innani.wildania.husna2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: husna, i. w., yahya, q.n.q., widiyani, m., & sholihin, s. (2019). effectiveness of self-management education based on information technology (it) in chronic kidney disease patients. jurnal ners, 14(3si), 397-401. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17180 introduction chronic kidney disease (ckd) is associated with agerelated kidney function accelerated in hypertension, diabetes, and obesity. ckd is a prolonged disease that affects 13.4% of the population worldwide, with indicators of damage to the results of kidney imaging or marked by proteinuria and decreased kidney function (glomerulus filter rate / gfr lower than serum creatinine). poor treatment of ckd causes kidney failure that requires expensive treatments such as dialysis or transplantation (asl, lakdizaji, ghahramanian, & seyedrasooli, 2018). repairing ckd is very slow, so it requires health education to be able to self-managed from patients and routine monitoring of blood sugar, physical activity, eating and drinking patterns, and compliance with taking medicines (barahimi et al., 2017). improved information technology as a means of health education has developed at this time, information technology (it) based interventions help improve health information and help communication with health care providers so as to be able to help patients in self-management (diamantidis et al., 2015). new technology is increasingly developing with the many media applications for health information for patients via the internet and smartphones, such as sms services, video conferencing, telephone contacts. it offers an understanding of the disease and a good way of self-management (diamantidis et al., 2012). this review explores it media as an innovation supporting education to inform, engage and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). i. w. husna, et al. 398 | pissn: 1858-3598  eissn: 2502-5791 communicate with patients suffering from kidney failure so that patients are able to improve their knowledge and self-management. there are many effective interventions to improve self-management in ckd patients by using it media, but some do not provide positive results. although health education through it can improve patient self-management, there are some disadvantages to using it media, namely indirect discussion between patients with experts, limited communication, and human error. there is no systematic review that explains the most effective it media to improve self-management in ckd patients. several questions have been evaluated from several articles: what type of intervention is given? what are the uses for each media? what are the results of the intervention? and what are the most effective media used to improve self-management in ckd patients? materials and methods we focus our analysis on studies which evaluate the effectiveness of information technology to increase self-management on a patient with chronic kidney disease because media intervention has positive effect interventions and negative effect interventions. data source and strategy we use four steps to identify and select articles that meet the criteria specified in this review. first, a comprehensive search was conducted at scopus, science direct, cinahl, pubmed, and proquest to identify relevant research published in the last 5 years (2013-2018). search strategies include using combinations related to information technology (such as smartphone, mobile application, website, telehealth, e-learning, and the internet) and also kidney disease (such as chronic kidney failure, dialysis). the second, screening articles, we read each title and abstract and focus on three main criteria: the articles population is patients with chronic kidney failure stage 1-5, the articles focus on effectiveness of information technology for health education to increase self-management, the articles report the result of self-management on chronic kidney disease (ckd). the third, to identify eligible articles that include the criteria required and are read and understood to consider further inclusion criteria. in detail the articles must be: it-based interventions in patients with stage 1 to 5 chronic kidney disease (ckd), more than 18 years of age, patient can apply all type of it-based tools, such as mobile phones, tablets, computers, internet, web cameras that support intervention, design of randomized controlled trial (rct) studies, and patient have control groups that accept health education standards without it system. the exclusion criteria in the study were intervention studies with the direct involvement of health care providers with patients (telephone, sms, and direct email) and the study that did not compare between groups, study protocols, before and after trials. last, articles are considered to be eligible for review and analysis. all of them focus on the effectiveness of information technology health education to increase self-management on the patient with chronic kidney disease. article analysis for each article that meets the requirements. the process of nursing outcomes affects patients with the increasing provision of health care information and interactions between patients and the health team. according to research (elliott et al., 2016) interventions are classified as follows: a smartphone or digital device (application / sms) used to provide information from a health care provider, devices that can be used to assess health according to independence (such as weight scales, bp monitors), computerized systems: information systems provided by patients via the internet or devices to healthcare providers. the results of the interventions were classified into four parts: statistically significantly positive, positive without statistical arguments, no statistical influence, and mixed effects (positive and non-effect). results study selection a total of 1857 articles from initial searches were retrieved from various databases. out of 1445 nonduplicate studies in the title and abstract screening process, 1422 studies were omitted due to lack of relevance. of the remaining 23 studies, 12 met the eligibility criteria. of 11 excluded studies because haven’t control groups that accept health education without an it media (figure 1). effects of intervention on the outcomes this systematic review assessed 12 articles that have outcomes for health education (table 1). table 2 shows the effects of the intervention on the outcome in the included studies. according to the outcomes, there were 38 outcomes in total which are divided into three groups. they were 13 clinical outcomes, 14 figure 1: flowchart of the study selection process jurnal ners http://e-journal.unair.ac.id/jners | 399 caring process outcomes, and 11 usability and feasibility outcomes. overall, the percentage of intervention which had a positive effect on the outcomes was about 47%. otherwise, the percentage of intervention which had no significant effect on the outcomes was about 56%. clinical outcomes the total clinical outcomes which are summarized on some studies had eight outcomes. they were hemoglobin (one study), gfr (one study), hba1c (one study), lipoprotein (one study), triglyceride (one study), weight (two studies), waist size (one study), bmi (one study), map (one study), serum phosphate (one study) and blood pressure (two studies), whereas the most commonly studied outcome was weight (n=2). for overall, the percentage of clinical outcomes which resulted from positive effects from given intervention was 31 % (n=4). the percentage of clinical outcomes which resulted in no significant effect from given intervention was 69% (n=9). for the type of intervention most used in studies and could result from a positive effect on the clinical outcome was a smartphone (n=2). otherwise, the website based intervention did not give a significant effect on the clinical outcome (n=7). caring process outcomes in the caring process, there were ten outcomes assessed. those ten outcomes were knowledge (four studies), dietary adherence (two studies), qol (one study), hrqol (one study), attitude tendency toward health (one study), drugs identification ability (one study), decreasing inpatient visit (one study), decreasing emergency unit visit (one study), decreasing professional nurse clinic visit (one study), homecare dialysis experience (one study). from its outcome, knowledge became the most studied outcome in some journals (n=4). from overall outcomes, there was 28% (n=4) intervention which gave a positive effect to the participants while 71% (n=10) of the intervention did not give any significant effect. from the total of 28% intervention which gave a positive effect, knowledge became the most effective outcome which is a taken effect toward the intervention (100%, n=4). for the most effective intervention type, movie media became the most used intervention in the caring process outcome category. while website based media became the most ineffective intervention in some studies. usability and feasibility outcomes in this outcome, there were five outcomes assessed. the most used outcome to measure the usability and feasibility was participant satisfaction toward the media intervention (n=5). overall, the percentage of outcome which results in a positive effect on the participant was 99% (n=10) and 1% did not result in a significant effect. for the media type can be accepted by participants and gives a lot of usefulness for them was computer-based media intervention. discussion systematic review conducted by groups regarding effective information technology is used to provide health promotion to ckd patients. health promotion based on information’s technology has increased the patient's independence in controlling his condition table 1. list of outcome health education based on the information technology article writer outcome kiberd et al (forster, allem, mendez, qazi, & jennifer, 2015) there were no statistically significant differences in the baseline hrqol score for those who participate in the web-based ehealth portal and those who don't ong et al (he, liu, li, wu, & liu, 2016) increased level of patient compliance given the schedule of taking medication diamantidis et al (heapy et al., 2015) patient satisfaction in accessing and obtaining information from the "safe kidney care" website lee o et al (hill et al., 2016) increased patient satisfaction in e-prom (patient reported outcome measures) against hrqol diamantidis et al (ishani et al., 2016) increasing patient knowledge about the safe use of drugs in mobile-based ckd patients asl et al (jeddi & nabovati, 2017) there was no difference in qol between the messaging groups and face to face, a significant increase in knowledge in the group face to face barahimi et al (kiberd et al., 2018) changes in serum high-density lipoprotein levels elliott et al (lee et al., 2018) satisfaction in the intervention group uses an online wiki sevick et al (murali, arab, vargas, & rastogi, 2013) controlling body weight and fluid ishani et al (ong et al., 2016) able to control blood pressure, proteinuria, dm, fluid volume status, lipid levels, depression, and patient activity murali et al (sevick et al., 2017) ckd patients have high motivation and desire to use the application. knowledge of diet and adherence to k / doqi guidelines for sub-optimal ckd patients forster et al (vegesna, tran, angelaccio, & arcona, 2017) increasing patient knowledge and behavior with telenovela design i. w. husna, et al. 400 | pissn: 1858-3598  eissn: 2502-5791 while at home. at the journal review, we have done, our group focuses on three components, there are clinical outcome, treatment process category, and usability, and feasibility category. the results of the study showed that it intervention had a positive effect of 28% of the total studies. the positive effect was observed from the results of the treatment process, namely increasing the knowledge of ckd patients by using smartphones, films, text messages and website based (forster et al., 2015; he et al., 2016; jeddi & nabovati, 2017; vegesna et al., 2017). therefore, it can be concluded that itbased interventions are appropriate interventions to increase knowledge in self-management in ckd patients. in this study, blood pressure and weight regulation are the most frequently considered in the self-management of ckd patients, and clinically itbased interventions help patients regulate and control blood pressure and weight, so patients can improve their antihypertensive medication regimen and improve awareness of patients in a sense of control of blood pressure and weight (he et al., 2016; ishani et al., 2016). the study in this article states that the it media used has the ease of access and understanding of information because patients do not need other skills in accessing the internet, only by reading can patients understand information (ishani et al., 2016). the development of the current digital era using smartphones is an appropriate intervention to improve self-management skills, this is included in the strategy of increasing patient education resources. it has recently become a trending issue in research, as did ishani who provided information and self-management by controlling blood pressure, proteinuria, fluid volume status, lipid levels and patient activity (ong et al., 2016). strength of the study the study had several strengths and limitations. the strengths include the extensive search strategy used, which led to the extraction of a large number of studies and therefore made the relevance of missing studies very small. moreover, only rcts were included in the study and other types of studies were not included. implication for practice this study shows that health promotion based on it can lead to the independence of ckd patients in controlling their disease. therefore, the use of information technology is recommended to be used in clinical settings to further empower patients and increase patient care for their disease. the implication for further research the result of research is required to develop features in smartphones, not only in health promotion, but also health prevention, and health intervention. for example making features: how to calculate and control fluid balance, complicating alarms, diets menu for ckd patients, and so on. educational materials used can also be improved, for example, spiritual emotion or undergoing ckd with a smile on ckd disease. the limitations in this study are the exclusion of studies presented not in full text, which means the potential loss of some relevant studies. conclusion it-based intervention for ckd client such as smartphone, pda, computer-based application, telehealth, movie, sms, and website based intervention could help patients to seek information about caring, self-management, and disease management recommended by the health care team. good coordination and active involvement between clients, technology developer and healthcare team are also being the main point for the using of it-based intervention. application socialization should be actively encouraged not only for middle to the upper class but also middle to lower class. in addition, the client's willingness to access technology should be improved too. from the aspect of usefulness through a usability test, it can be concluded that the client could get a lot of benefit from the it-based application. references asl, p. t., lakdizaji, s., ghahramanian, a., & seyedrasooli, a. (2018). effectiveness of text messaging and face to face training on improving knowledge and quality of life of patients undergoing hemodialysis : a randomized clinical trial. tabriz university of medical sciences, 7(2), 95–100. https://doi.org/10.15171/jcs.2018.015 barahimi, h., zolfaghari, m., abolhassani, f., foroushani, a. r., mohammadi, a., & rajaee, f. (2017). e-learning model in chronic kidney disease management a controlled clinical trial. 11(4), 280–285. diamantidis, c. j., ginsberg, j. s., yoffe, m., lucas, l., prakash, d., aggarwal, s., … fink, j. c. (2015). article remote usability testing and satisfaction with a mobile health medication inquiry system in ckd. 10. https://doi.org/10.2215/cjn.12591214 diamantidis, c. j., zuckerman, m., fink, w., hu, p., yang, s., & fink, j. c. (2012). article usability of a ckd educational website targeted to patients and their family members. 1553–1560. https://doi.org/10.2215/cjn.03690412 elliott, m. j., straus, s. e., pannu, n., ahmed, s. b., laupacis, a., chong, g. c., … hemmelgarn, b. r. (2016). a randomized controlled trial comparing in-person and wiki-inspired nominal group techniques for engaging stakeholders in chronic kidney disease research prioritization. bmc medical informatics and decision making, 1–12. https://doi.org/10.1186/s12911-0160351-y forster, m., allem, j., mendez, n., qazi, y., & jennifer, b. (2015). evaluation of a telenovela designed to jurnal ners http://e-journal.unair.ac.id/jners | 401 improve knowledge and behavioral intentions among hispanic patients with end-stage renal disease in southern california. 7858(november). https://doi.org/10.1080/13557858.2015.1007 119 he, t., liu, x., li, y., wu, q., & liu, m. (2016). remote home management for chronic kidney disease : a systematic review. 0(0), 1–11. https://doi.org/10.1177/1357633x15626855 heapy, a. a., higgins, d. m., cervone, d., wandner, l., fenton, b. t., & kerns, r. d. (2015). special topics series a systematic review of technology-assisted self-management interventions for chronic pain looking across treatment modalities. 31(6), 470–492. https://doi.org/10.1097/ajp.0000000000000 185 hill, n. r., fatoba, s. t., oke, j. l., hirst, j. a., callaghan, a. o., lasserson, d. s., & hobbs, f. d. r. (2016). global prevalence of chronic kidney disease – a systematic review and meta-analysis. 1–18. https://doi.org/10.5061/dryad.3s7rd.funding ishani, a., christopher, j., palmer, d., otterness, s., clothier, b., nugent, s., & nelson, d. (2016). original investigation telehealth by an interprofessional team in patients with ckd: a randomized controlled trial. 68(1), 41–49. https://doi.org/10.1053/j.ajkd.2016.01.018 jeddi, f. r., & nabovati, e. (2017). features and effects of information technology-based interventions to improve self-management in chronic kidney disease patients : a systematic review of the literature. https://doi.org/10.1007/s10916017-0820-6 kiberd, j., khan, u., stockman, c., radhakrishnan, a., phillips, m., kiberd, b. a., … tennankore, k. k. (2018). effectiveness of a web-based ehealth portal for delivery of care to home dialysis patients : a single-arm pilot study. https://doi.org/10.1177/2054358118794415 lee, o., kyte, d., cockwell, p., marshall, t., dutton, m., walmsley-allen, n., … calvert, m. (2018). development and usability testing of an electronic patient-reported outcome measure ( eprom ) system for patients with advanced chronic kidney disease. computers in biology and medicine, 101(august), 120–127. https://doi.org/10.1016/j.compbiomed.2018.0 8.012 murali, s., arab, l., vargas, r., & rastogi, a. (2013). internet-based tools to assess diet and provide feedback in chronic kidney disease stage iv : journal of renal nutrition, 23(2), e33–e42. https://doi.org/10.1053/j.jrn.2012.05.001 ong, s. w., jassal, s. v, miller, j. a., porter, e. c., cafazzo, j. a., seto, e., … logan, a. g. (2016). article integrating a smartphone – based self – management system into usual care of advanced ckd. 1–9. https://doi.org/10.2215/cjn.10681015 sevick, m. a., woolf, k., mattoo, a., sierra, a., williams, s. k., & goldfarb, d. s. (2017). the healthy hearts and kidneys (hhk) study: design of a 2×2 rct of technology-supported self-monitoring and social cognitive theory-based counseling to engage overweight people with diabetes and chronic kidney disease in multiple lifestyle changes. 64, 265–273. https://doi.org/https://doi.org/10.1016/j.cct. 2017.08.020 vegesna, a., tran, m., angelaccio, m., & arcona, s. (2017). remote patient monitoring via noninvasive digital technologies: a systematic review. telemedicine and e-health, 23(1), 3–17. https://doi.org/10.1089/tmj.2016.0051 50 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16978 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the quality of life of patients with hiv/aids undergoing antiretroviral therapy: a systematic review putri irwanti sari, rts netisa martawinarti, nurmawati s. lataima, and vivi meiti berhimpong faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: quality of life (qol) is one of the most important things for a patient with hiv/aids. good qol will improve the adherence to treatment, especially antiretroviral therapy. the purpose of this study was to explore about the quality of life of the patients with hiv/aids undergoing antiretroviral therapy. methods: the data was collected through a literature review from electronic databases such as scopus, proquest, google scholar and springerlink journal. the keywords were "quality of life", "hiv/aids", "quality of life of patients with hiv/aids" or "quality of life and hiv/aids and antiretroviral therapy". results: the researcher obtained 15 articles based on the inclusion criteria. several research articles that were analyzed showed that the quality of life of hiv/aids patients undergoing antiretroviral therapy was not all good. this is caused by the side-effects of using antiretroviral therapy and the side-effects that were physical, psychological, social and environmental. conclusion: the impact of the side effects of antiretroviral therapy has caused the clients with hiv/aids to choose other therapies such as art replacement therapy to improve the quality of life for patients with hiv/aids. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords antiretroviral; hiv//aids; quality of life contact puteri irwanti sari  putri.wanti.sari2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sari, p. i., martawinarti, r. n., lataima, n. s., & berhipong, v. m. (2019). the quality of life of patients with hiv/aids undergoing antiretroviral therapy: a systematic review.jurnal ners, 14(3si), 50-54. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16978 introduction recently, hiv infection has been considered to be a chronic disease because the effective dissemination of antiretroviral therapy has lengthened the life expectancy of people living with hivwho. it has been noted that since aids was discovered and up until the end of 2014, 34 million people had died and in 2014, 1.2 million people died of the virus. there were 36.9 million people living with hiv in the world at the end of 2014. the goal of sustainable development goals (sdg) is to stop the hiv / aids epidemic in the world by 2030. in 2016, around 36.7 million people were living with hiv around the world. indonesia was ranked as having the third largest number of people living with hiv (plwha) in the asia and pacific region (ortblad, lozano, & murray, 2013). many hiv patients in lowand middle-income countries do not immediately start antiretroviral therapy (art) despite being eligible for art(daniels et al., 2018). the results of the study by linlin lindayani meant that the overall whoqol-hiv score was 78.9 (sd = 9.08; range; 46-101). there were no significant differences in the whoqol-hiv domain scores at various stages of the disease after controlling for potential confounders (lindayani, chen, wang, & ko, 2018). health-related quality of life (hrqol) is a broad concept that reflects the patients' general subjective perceptions of the effects of disease or interventions on the physical, psychological and social aspects in their daily lives. hrqol among hiv-infected patients has become an important indicator of the impact of the disease and treatment outcomes. a crosshttps://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:putri.wanti.sari-2018@fkp.unair.ac.id mailto:putri.wanti.sari-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 51 sectional survey was conducted at the chitungwiza central hospital, zimbabwe, to assess the hrqol in patients with hiv / aids who received antiretroviral therapy (art) using two validated instruments. the targeted quality of life for hiv / aids (hat-qol) and the euroqol five-dimensional three-level instruments (eq-5d-3l) were used to assess hrqol (mafirakureva, dzingirai, postma, van hulst, & khoza, 2016). therefore, it is necessary to further analyze the quality of life of patients undergoing antiretroviral therapy to determine the effects of antiretroviral therapy for patients with hiv / aids. materials and methods the systematic review was conducted using a standard methodology as published by iop introductory guide for authors. we followed the preferred reporting item for systematic reviews and meta-analyses (prisma) guidelines. this systematic review was made in such a way to get answers about the quality of life of hiv/aids patient undergoing antiretroviral therapy. the process used to conduct the systematic review involved reviewing several research articles published through electronic databases. the electronic databases used were scopus, proquest, google scholar and springerlink. the keywords for the journals in english were "quality of life", "hiv/aids", "quality of life of patients with hiv/aids" or "quality of life and hiv/aids and antiretroviral therapy". the search results found in proquest totaled 87.223 journals, and scopus had 1,302 journals and google scholar had 75,800 journals so the total journals found were 164.325. the journals found were specified based on the inclusion criteria. after adjusting for the inclusion criteria, the missing articles made up 843 documents. we then selected the same article (duplicate article) published from scopus, proquest and springerlink, selected based on the suitability of the article title with the aim of systematic review. we then filtered based on the research where one of the samples in the study must be adults or couples > 18 years; 40 articles were then obtained. of the 40 articles selected, 15 were analyzed. studies meeting the following criteria were included in the systematic review: (1) full-text articles published in english, (2) research articles from the period 2013-2018, (3) different types of quantitative research, (4) articles where the main content was hiv/aids patients undergoing antiretroviral therapy and (5) the samples in the study must be adults or couples > 18 years. the exclusion criteria in the systematic review were (1) a wrong study design, (2) no relevant outcomes and (3) unpublished full-text or unable to obtain the full text. results the total respondents in this review were 45,377 people with the disease (hiv/aids) who received antiretroviral therapy. the area in this study was hospitals and communities. of the 15 articles selected, research was conducted in indonesia, south africa (kwazulu-natal, cape town), botswana, the republic of zimbabwe, zambia, ethiopia, india and kenya. all of the articles analyzed according to the type of research are quantitative approaches (n = 15). the most widely used research design was correlation with a cross-sectional approach (n = 13) and a prospective cohort (n = 2). in connection with the year of publication, the research articles were published in the range of 2013-2018. all of the samples in the study were hiv / aids patients who were on antiretroviral therapy (art). the most figure 1. prisma p. i. sari, et al. 52 | pissn: 1858-3598  eissn: 2502-5791 widely used research instruments when assessing the quality of life of patients with hiv / aids was the euro quality of life instrument, the functional assessment of hiv infection (fahi) instrument, whoqol-hiv bref, euro quality visual analog scale (eq-5d vas), hat -qol, hrqol (eq 5d), mos-hiv, dass-21, hiv tsqs, others use whoqol-bref, hrql sf 36, mcs, and pcs. several of the research articles that were analyzed showed that the quality of life of hiv/aids patients undergoing antiretroviral therapy was not good across the board. this is caused by the side effects of using antiretroviral therapy and the side effects include physical, psychological, social and environmental factors. the impact of the side effects of antiretroviral therapy has caused the clients with hiv/aids to use other therapies such as nucleoside reverse transcriptase inhibitor (nrti) replacement to non-nucleoside reverse transcriptase inhibitor (nnrti) therapy to improve the quality of life for patients with hiv/aids. discussion the systematic review of the quality of life of patients with hiv/aids who are undergoing antiretroviral therapy is very necessary to improve their understanding of the quality of life of patients as the most widely used instruments. the factors that affect table 2. studies that formed the basis of the systematic review author type of study respondents instrument outcome (maiese, johnson, bancroft, goolsby hunter, & wu, 2016) cohort study 134 clients with hiv mos-hiv dass-21 hiv tsqs the patient has improved an quality of life after replacing the antiretroviral therapy regimen (lindayani et al., 2018) epidemiology 215 respondents whoqol-bref the main priority was the sleep problem art can improve quality of life (mafirakureva et al., 2016) epidemiology 257 clients with hiv/aids hrqol hat-qol eq-5d-3l euro qol vas higher levels of hrqol are positively and significantly related to income, education and employment. (munene & ekman, 2014) epidemiology 421 clients with hiv sf-36 hrqol pcs antiretroviral therapy is negatively related to hrqol (narsai, jinabhai, taylor, & stevens, 2016) descriptive 600 respondents eqsd eq-vas use of antiretroviral therapy the majority of the respondents were young women (ndubuka, lim, ehlers, & van der wal, 2017) descriptive 456 hiv clients on art whoqol-hiv bref the domain of the environment got the lowest score the quality of life for plwha is bad (nglazi, 2014) descriptive 903 hiv clients on art hrqol eq-5d eq-5d-vas there is no significant relationship between the groups for most eq-5d domains (amanuel, abebe, mulusew, & hailay, 2015) descriptive 494 hiv clients on art whoqolbref family support for the clients with low art (thomas et al., 2017) descriptive 38691 respondents, 19750 from zambia, and 18941 from south africa hrqol eq-5d-5l hrqol there is no difference between hiv-positive and hiv-negative hrqol (tomita, garrett, werner, burns, mpanza, et al., 2014) cohort 160 clients with hiv/aids fahi hrqol increases (tomita, garrett, werner, burns, ngcobo, et al., 2014) cohort 160 clients with art cohorts (n=51 and non-initiating art (n=191) hrqol fahi non-initiation art hrqol was higher than cohort art (vo et al., 2016) descriptive 1180 clients with hiv hat-qol hrqol low life satisfaction (torres, harrison, la rosa, lavenberg, et al., 2018) descriptive 512 clients with hiv qol based quality of life there is art failure compliance with treatment decreasing the virus load (torres, harrison, la rosa, cardoso, et al., 2018) descriptive 512 clients with hiv qol based quality of life can be improved (pokhrel, gaulee pokhrel, neupane, & sharma, 2018) descriptive 682 clients using art whoqol-hivbref scale compliance with art treatment qol jurnal ners http://e-journal.unair.ac.id/jners | 53 quality of life and the complaints most often felt by patients can be the input for medical personnel including nurses in improving the quality of life of patients undergoing antiretroviral therapy. besides that, it also helps other medical personnel to collaborate to improve the patients' quality of life. some articles show that the patients experience problems when using antiretroviral therapy. this can affect the quality of life of the patients. quality of life is the concept of the analysis of individuals to get a normal life related to the individual perceptions of the goals, expectations, standards and special attention to life experienced by being influenced by cultural values in the individual environment. there are four domains that are used as parameters to determine quality of life, and each domain is described in several ways: the physical health domain, psychological domain, social relations domain and environmental domain. good quality of life will improve the adherence to therapy. adherence is very important in antiretroviral treatment because if the drug do not reach the optimal concentration in the blood, then it allows for the development of resistance. taking the medication doses on time and correctly can prevent resistance. level of adherence is highly correlated with the success of maintaining viral suppression. things that must be considered are the reduction of mutations and resistance. hiv has a unique mutation characteristic. the virus can double to 1 billion per day. for people on art, if they are not adherent to the treatment, then the virus can multiply and there will be a choice of resistant hiv types. the only way to prevent mutations is to suppress the complete multiplication of the virus which ensures that no new mutants are produced. for resistance in the nnrti group, only one hiv mutation makes the patient resistant to all drugs in one class, while the other arv class requires several mutations to become resistant. in the case of failed therapy, second-line regimens should replace nnrtis with protease inhibitors (pi) such as nelfinavir (nfv), indinavir (idv), squinavir (sqv) and loponavir/ritonavir (lpv/r). nurses need to monitor the successes and failures of the therapy, which also affects the quality of life of patients with hiv. there are times when the patient and the accompanying doctor must revise the therapy that has been done so far. there is a critical moment when the therapy for plhiv patients must be replaced. regarding the reasons for drug replacement, virological failure and drug resistance are characterized by an increased viral load, drug toxicity, patient tolerance and non-compliance with treatment. the more often that patients change their treatment, for example due to therapy failure, the more often it is that the success rate of the next regimen will be lower than the previous regimen. the probability of success is lower than the previous regimen. the best treatment success in the first regimen is determined by the 4ss, namely start, substitute, switch and stop. conclusion various countries have examined the quality of life of hiv/aids patients undergoing antiretroviral therapy and the results of their research show that not all of the patients' quality of life is good. this was due to the side effects of the antiretroviral therapy. therefore the clients with hiv choose to use other therapies as art replacement therapy to improve their quality of life with hiv/aids. we found that hiv patients whose regimen was switched due to treatment-related sideeffects experienced an improvement in qol. further research is needed on the effects of art and art replacement therapy and into the client's experience with art on quality of life. the findings in this study suggest that physicians should take the potential impact of qol into consideration when making decisions on a switch in art regimen, particularly when the patients are intolerant of their current treatment. references amanuel, t., abebe, g., mulusew, g., & hailay, a. (2015). gender differences in health related quality of life among people living with hiv on highly active antiretroviral therapy in mekelle town, northern ethiopia. biomed research international, 2015(article id 516369), 1–9. https://doi.org/http://dx.doi.org/10.1155/2015 /516369 daniels, j., marlin, r., medline, a., wilson, g., rosengren, l., huang, e., & klausner, j. d. (2018). getting hiv self-test kits into the home for young african american msm in los angeles : a qualitative report. journal of the association of nurses in aids care, 29(1), 115–119. https://doi.org/10.1016/j.jana.2017.09.015 lindayani, l., chen, y. c., wang, j. der, & ko, n. y. (2018). complex problems, care demands, and quality of life among people living with hiv in the antiretroviral era in indonesia. journal of the association of nurses in aids care, 29(2), 300–309. https://doi.org/10.1016/j.jana.2017.10.002 mafirakureva, n., dzingirai, b., postma, m. j., van hulst, m., & khoza, s. (2016). health-related quality of life in hiv/aids patients on antiretroviral therapy at a tertiary care facility in zimbabwe. aids care psychological and socio-medical aspects of aids/hiv, 28(7), 904–912. https://doi.org/10.1080/09540121.2016.11736 39 maiese, e. m., johnson, p. t., bancroft, t., goolsby hunter, a., & wu, a. w. (2016). quality of life of hiv-infected patients who switch antiretroviral medication due to side effects or other reasons. current medical research and opinion, 32(12), 2039–2046. https://doi.org/10.1080/03007995.2016.12277 76 munene, e., & ekman, b. (2014). does duration on antiretroviral therapy determine health-related quality of life in people living with hiv? a crossp. i. sari, et al. 54 | pissn: 1858-3598  eissn: 2502-5791 sectional study in a regional referral hospital in kenya. global health action, 7(1). https://doi.org/10.3402/gha.v7.23554 narsai, p., jinabhai, c. c., taylor, m., & stevens, f. (2016). the health related quality of life of hiv positive respondents on antiretroviral treatment and hiv negative living in lower socio-economic housing in kwazulu-natal, south africa. social indicators research, 127(2), 851–863. https://doi.org/10.1007/s11205-015-0970-1 ndubuka, n. o., lim, h. j., ehlers, v. j., & van der wal, d. m. (2017). health-related quality of life of patients on antiretroviral treatment in botswana: a cross-sectional study. palliative and supportive care, 15(2), 214–222. https://doi.org/10.1017/s1478951516000638 nglazi, m. d. w. s. j. d. j. a. l. n. s. l. e. v. (2014). quality of life in individuals living with hiv/aids attending a public sector antiretroviral service in cape town, south. bmc public health; 2014, 14(676). ortblad, k. f., lozano, r., & murray, c. j. l. (2013). the burden of hiv: insights from the global burden of disease study 2010. aids, 27(13), 2003–2017. https://doi.org/10.1097/qad.0b013e328362ba 67 pokhrel, k. n., gaulee pokhrel, k., neupane, s. r., & sharma, v. d. (2018). harmful alcohol drinking among hiv-positive people in nepal: an overlooked threat to anti-retroviral therapy adherence and health-related quality of life. global health action, 11(1). https://doi.org/10.1080/16549716.2018.14417 83 thomas, r., burger, r., harper, a., kanema, s., mwenge, l., vanqa, n., … hughes, e. (2017). differences in health-related quality of life between hiv-positive and hiv-negative people in zambia and south africa: a cross-sectional baseline survey of the hptn 071 (popart) trial. the lancet global health, 5(11), e1133–e1141. https://doi.org/10.1016/s2214-109x(17)303674 tomita, a., garrett, n., werner, l., burns, j. k., mpanza, l., mlisana, k., … karim, s. s. a. (2014). healthrelated quality of life dynamics of hiv-positive south african women up to art initiation: evidence from the caprisa 002 acute infection cohort study. aids and behavior, 18(6), 1114– 1123. https://doi.org/10.1007/s10461-0130682-y tomita, a., garrett, n., werner, l., burns, j. k., ngcobo, n., zuma, n., … abdool karim, s. s. (2014). impact of antiretroviral therapy on health-related quality of life among south african women in the caprisa 002 acute infection study. aids and behavior, 18(9), 1801–1807. https://doi.org/10.1007/s10461-014-0800-5 torres, t. s., harrison, l. j., la rosa, a. m., cardoso, s. w., zheng, l., ngongondo, m., … hughes, m. d. (2018). quality of life improvement in resourcelimited settings after one year of second-line antiretroviral therapy use among adult men and women. aids (vol. 32). https://doi.org/10.1097/qad.00000000000017 38 torres, t. s., harrison, l. j., la rosa, a. m., lavenberg, j. a., zheng, l., safren, s. a., … hughes, m. d. (2018). quality of life among hiv-infected individuals failing first-line antiretroviral therapy in resourcelimited settings. aids care, 0(0), 1–9. https://doi.org/10.1080/09540121.2018.14272 07 vo, q. t., hoffman, s., nash, d., el-sadr, w. m., tymejczyk, o. a., gadisa, t., … elul, b. (2016). gender differences and psychosocial factors associated with quality of life among art initiators in oromia, ethiopia. aids and behavior, 20(8), 1682–1691. https://doi.org/10.1007/s10461-016-1396-8 http://e-journal.unair.ac.id/jners | 413 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17220 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review development the national institutes of health stroke scale (nihss) for predicting disability and functional outcome to support discharge planning after ischemic stroke agit putra pratama, tejo tresno, and sena wahyu purwanza faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: a discharged stroke patients with disability from hospital need special identify in order to obtain a meaningful quality of life, to improve the functional status of patient’s life quality can be started immediately at admission patient in health sevices. the initial discharge planning was carried out to explore patient’s needs during inpatient and discharge with the national institutes of health stroke scale (nihss). nihss as a predictor model to discharge stroke patient with disability , need to identify effectivity of it to improve the functional status of patient’s life quality with stroke. methods: search of journal articles used pecot framework in the database; sciencedirect, cinahl, elseiver, sage, scopus, ebscohost, and medline with limitations of publication time is in the last 15 years (2004-2019) by including keywords natioanal institutes of health stroke scale, discharge planning, ischemic stroke. results: there are 10 journals according specified criteria design that discuss the interventions of discharge planning model patient stroke. conclusion: nihss can be applied to predicting disability and functional outcome status of patient’s life quality with stroke. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords discharge planning; ischemic stroke; nihss contact agit putra pratama  agitputra@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: putra. p. a., tresno, t., & wahyu, p.s. (2019). development the national institutes of health stroke scale (nihss) for predicting disability and functional outcome to support discharge planning after ischemic stroke jurnal ners, 14(3si), 413-417. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17220 introduction stroke is one of the major causes of disability and mortality all over the world , it given major socioeconomic burden (al-weshahy, el-sherif, abd, selim, & heikal, 2017), there are arround 15 million people worldwide experiencing strokes is year (visvanathan, 2019), this disease is the third largest cause of permanent disability in the world, resulting in significant burdens and costs on the health system (kushner, peters, & johnson-greene, 2016). discharge disposition is a health issue at the participation level and an important health outcome which increasingly gathers attention. for stroke patients, the first and crucial disposition happens after discharge from post-acute inpatient rehabilitation ward. failure to return home may compromise the quality of lives of stroke patients and families. understanding its predicting factors helps health professionals to provide counseling and helps policy makers in improving case referral and long term care systems (hsieh, chien, weng, & chiang, 2017). discharge planning is an important component in hospital care, so it must be given immediately when new patients enter the care facility. it aims to prepare for further treatment, reduce the length of treatment, optimize the use of beds, and improve coordination with home care services. discharge planning is a process used to decide what patients need to do to improve their health. this process begins when the patient enters and does not end until the patient is discharged, discharge from the hospital does not mean that the patient has fully recovered. this only means that the doctor has determined that the patient's condition is stable enough to treat at home (kamalakannan et al., 2016). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). p. a. putra, et al. 414 | pissn: 1858-3598  eissn: 2502-5791 the national institutes of health stroke scale (nihss) is a 15-item impairment scale used to measure stroke severity. it was originally developed in 1989 and is now a widely used outcome measure in the recombinant tissue plasminogen activator stroketrials. in the current national stroke foundation guidelines, the nihss is recommended as a valid tool to assess stroke severity inemergency departments. the original 15-item nihss remains the mostwidely accessible, although several versions have been developed(such as the 5-, 8and 11-item modified nihss) and are avail-able in many languages (kwah & diong, 2014). today, payers and regulators demand reportable data on patient outcomes, and such outcomes must be adjusted for baseline severity: the nihss has become the de facto metric for regulatory compliance. the joint commission, as part of its certification program for primary stroke centers, now requires an nihss score within 12 hours of admission for all stroke patients; this assessment is to be done by a certified examiner (lyden p, 2017). it is a quantitative measure of stroke-related neurological deficit that has proven intrarater and interrater reliability and has predictive validity for longterm stroke outcome. it includes items to assess level of consciousness, gaze, visual fields, facial palsy, motor strength, ataxia, sensation, language, dysarthria, and extinction or inattention. it is widely used, easy to learn, and can be performed rapidly on admission. prior studies have found that the nihss score could be used to predict disposition (schlegel, tanne, demchuk, levine, & kasner, 2004). every clinical trial in vascular neurology prevention, acute treatment, recovery requires a severity assessment, and the nihss became the gold standard for stroke severity rating after the first successful trial in acute stroke therapy as part of the trial, detailed and rigorous training/certification procedures were created for the nihss that facilitate wider use of the scale outside of research (lyden et al., 2009). severity of neurological deficits can be measured by the nihss at admission and has previously been identified to independently predict clinical outcomes in stroke patients. nihss often changes during the first 24 hours, and the relationship between the neurological examination and long-term functional outcome strengthens after the first few hours and then begins to plateau (rangaraju, jovin, frankel, schonewille, et al., 2016). the nihss’ strong ability to predict outcomes after stroke helpsclinicians provide accurate information to patients, set realisticgoals for therapy and plan for discharge. the nihss captures bothmotor and non-motor impairments of stroke, and provides a goodoverview of people’s deficits (kwah & diong, 2014). this study aim to identify of nihss for predict disability and functional outcome to determine the criteria. materials and methods this systematic review was made with the aim identify of nihss for predict disability and functional outcome as a determine the criteria of discharge planning after ischemic stroke. the methods used in preparing this systematic review are (1) identification of interventions in the literature, (2) identification of relevant literature based on topics and titles, (3) inclusion and exclusion criteria, (4) obtaining literature in full text form, and (5) analysis of the results of various interventions in the literature. literature searches using the picot framework in databases such as scopus, cinahl, medline, ebscohost, sciencedirect, google scholar and sage by including keywords nihss, discharge planning, ischemic stroke, disability and functional outcome. the year limit used is 9 (2004 2019) in the last year, with the criteria for implementing to determine of disability and fuctional outcome with nihss for discharge planning after ischemic stroke. the picot / pecot framework is: population : patient with ischemic stroke trated at hospital, nursing facility and rehabilitation. intervention : stroke severity measure with the national institute health stroke scale related to disability and functional outcome. outcomes : the scale disability and functional patient when discharge. based on the determination of keywords according to the topics contained in the picot framework, and equipped with boolean logic methods (sciencedirect, scopus, and sage jurnal) the the keywords in english used are “the national institute health stroke scale” and “discharge planning” and “ischemic stroke”. results the inclusion criteria in this study are articles on using nihss for criteria disability and functional outcome to discharge patient after ischemic stroke. design this articles are using cohort study, retrospective and quasy experiment. exclusion figure 1 : prisma scheme figure 1 : prisma scheme initial search (n = 1072) scopus (n = 617) sage (n = 322) sciencedirect (n = 525) remaining studies after title screening (n = 516) studies exclude after title screening ( n = 456) full-text articles assessed for eligibility (n = 145) studiesincluded in the systematic review (10) full text articles excluded n = 371 duplicates removed jurnal ners http://e-journal.unair.ac.id/jners | 415 criteria is an article about giving intervention use nihss but not related to discharge planning. the literature search flow in total 1072 records was identified, consist of scopus (n = 617), sage jurnal (n = 322), sciencedirect (n = 525). than exclude studies with title screening that remaining n = 516 articles, we filter remain articles with full-text assessed for eligibility n = 145, than duplicates removed articles include in the systematic review n = 10. discussion the predictive power of the 24to 48-hour nihss for 1-month mortality and confirmed high predictive power supporting the possibility that 24to 48-hour nihss is likely to have high predictive value for outcomes at later time points as well. twenty-fourto 48-hour nihss accurately predicts 1-month poor outcome and mortality and represents a clinically valuable prognostic tool for the care of basilar artery occlusion patients.(rangaraju, jovin, frankel, & schonewille, 2016). study conducted by (schlegel et al., 2004) found that increasing stroke severity, particularly with nihss scores greater than 10, increased the likelihood of discharge to rehabilitation or nursing homes instead of to home. this multinational community and academic center–based table 1. baseline characteristics of all patients and subgroups of patients at baseline table 2. univariate analysis of predictors for los p. a. putra, et al. 416 | pissn: 1858-3598  eissn: 2502-5791 study reinforces the usefulness of the nihss score as a predictor of disposition after stroke. the nihss score can predict discharge disposition when thrombolysis is used, although possibly with less precision than in patients not given this treatment (schlegel et al., 2004). more than two-thirds of those who are initially non-ambulant recover independent ambulation, but less than half of those who initially lack upper limb function recover functional use of their upper limbs six months after stroke. prediction models using age and nihss can predict independent ambulation and upper limb function six months after stroke, although these models require external validation. (kwah, harvey, diong, & herbert, 2013) the 114 stroke survivors who were unable to ambulate initially, 80 (70%, 95% ci 62 to 79) were able to do so at six months. of the 51 stroke survivors who were unable to move a cup across the table initially, 21 (41%, 95% ci 27 to 55) were able to do so at six months. of the 56 stroke survivors who were unable to feed themselves with a spoonful of liquid initially, 25 (45%, 95% ci 31 to 58) were able to do so at six month (kwah et al., 2013) table 2 summarizes predictors of longer stay in the univariate analysis. the overall asymptomatic and symptomatic hemorrhage rates at 36 hours were 10.4% and 4.1%, respectively. five patients (2.3%) with symptomatic intracranial hemorrhage died. the presence of symptomatic or any kind of bleeding was not associated with longer stay (p_0.79 and 0.20, respectively). forty patients (18%) were treated outside the time window (180 minutes). there was no statistically significant difference in the los between those patients treated within or outside 180 minutes of symptom onset (p_0.29). a total of 118 patients (55%) had poor outcome (mrs 3 to 5 or death) at 90 days. the frequency of longer stay was significantly higher among patients with poor outcome at 3 months (74% versus 39.5%; p_0.001). (saposnik, webster, o’callaghan, & hachinski, 2005). conclusion need to know early on about the severity of ischemic stroke using the nihss, as evaluation to provide intervention as early as possible in order to reduce the days of hospitalization of patients ischemic stroke, patients with low nihss scale indicates the level readiness to discharge to home so as to reduce maintenance costs by contrast the higher the scala nihss as patients are yet to show ability and functional outcome to be discharged. therefore the nihss was able to become one of the reference criteria for the return of patients with ischemic stroke. references al-weshahy, a., el-sherif, r., abd, k., selim, a., & heikal, a. (2017). the egyptian journal of critical care medicine short term outcome of patients with hyperglycemia and acute stroke. the egyptian journal of critical care medicine, 5(3), 93–98. https://doi.org/10.1016/j.ejccm.2017.11.003 hsieh, s. f., chien, k. l., weng, c. h., & chiang, y. p. (2017). having more daughters independently predicts home discharge in stroke patients admitted to inpatient rehabilitation ward. international journal of gerontology. https://doi.org/10.1016/j.ijge.2017.07.005 kamalakannan, s., gudlavalleti venkata, m., prost, a., natarajan, s., pant, h., chitalurri, n., … kuper, h. (2016). rehabilitation needs of stroke survivors after discharge from hospital in india. archives of physical medicine and rehabilitation. https://doi.org/10.1016/j.apmr.2016.02.008 kwah, l. k., & diong, j. (2014). national institutes of health stroke scale ( nihss ). journal of physiotherapy, 60(1), 61. https://doi.org/10.1016/j.jphys.2013.12.012 kwah, l. k., harvey, l. a., diong, j., & herbert, r. d. (2013). models containing age and nihss predict recovery of ambulation and upper limb function six months after stroke: an observational study. journal of physiotherapy. https://doi.org/10.1016/s18369553(13)70183-8 lyden, p., raman, r., liu, l., emr, m., warren, m., & marler, j. (2009). national institutes of health stroke scale certification is reliable across multiple venues. stroke, 40(7), 2507–2511. https://doi.org/10.1161/strokeaha.108.532 069 lyden p. (2017). using the national institutes of health stroke scale a cautionary tale. 513–519. https://doi.org/10.1161/strokeaha.116.015 434 rangaraju, s., jovin, t. g., frankel, m., & schonewille, w. j. (2016). neurologic examination at 24 to 48 hours predicts functional outcomes in basilar artery occlusion stroke. 2534–2540. https://doi.org/10.1161/strokeaha.116.014 567 saposnik, g., webster, f., o’callaghan, c., & hachinski, v. (2005). optimizing discharge planning: clinical predictors of longer stay after recombinant tissue plasminogen activator for acute stroke. stroke, 36(1), 147–150. https://doi.org/10.1161/01.str.0000150492. 12838.66 schlegel, d. j., tanne, d., demchuk, a. m., levine, s. r., & kasner, s. e. (2004). prediction of hospital disposition after thrombolysis for acute ischemic stroke using the national institutes of health stroke scale. archives of neurology. https://doi.org/10.1001/archneur.61.7.1061 visvanathan, v. (2019). early supported discharge services for people with acute stroke: a cochrane review summary. international journal of nursing studies. https://doi.org/10.1016/j.ijnurstu.2018.07.00 7 jurnal ners http://e-journal.unair.ac.id/jners | 417 362 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17214 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the role of family as a caregiver in caring for family members that are suffering from pulmonary tuberculosis beti kristinawati1, annisa muryadewi1, and ana dwi irianti2 1school of nursing, universitas muhammadiyah surakarta, solo, indonesia 2center public hospital, klaten, indonesia abstract introduction: families have an important role in the successful treatment of people with pulmonary tuberculosis. the purpose of this study was to obtain an overview of the role of the family as a caregiver in caring for family members suffering from pulmonary tuberculosis. methods: the phenomenological qualitative design was chosen to obtain indepth information by interviewing thirteen family members who cared for pulmonary tuberculosis patients determined through a purposive technique. results: the content of collaizi's analysis produced five themes, namely: 1) nonpharmacological therapy is given by the family to treat symptomatic pulmonary tuberculosis 2) efforts to cut transmission was carried out by the family to prevent transmission of disease, 3) nutrition support provided by families in treating patients, 4) instrumental support given by families in caring for pulmonary tuberculosis patients, 5) emotional support given by families in treating pulmonary tuberculosis sufferers. conclusion: the family provides physical and psychological care to support the successful treatment of pulmonary tuberculosis. a program is recommended to increase family knowledge in caring for family members suffering from pulmonary tuberculosis. words are sorted alphabetically. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords pulmonary tuberculosis; phenomenological; family; support; knowledge contact beti kristinawati  bk354@ums.ac.id  school of nursing, universitas muhammadiyah surakarta, solo, indonesia cite this as: kristinawati, b., muryadewi, a., & irianti, a. d. (2019). the role of family as a caregiver in caring for family members that are suffering from pulmonary tuberculosis. jurnal ners, 14(3si), 362-366. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17214 introduction tuberculosis is an infectious disease caused by mycobacterium tuberculosis and usually attacks the lung organs or other organs of the body. tuberculosis that attacks other parts of the body can be caused by incomplete treatment (brunner & suddarth, 2013). data from the world health organization / who, there was an increase in cases of pulmonary tb, which amounted to 6.3 million cases from 6.1 million cases in 2015. this number is equivalent to 61% of the estimated incidence of 10.4 million cases of pulmonary tb, where 56% are in five countries, namely india, indonesia, china, the philippines, and pakistan (world health organization, 2017). the prevalence of tb in the world in 2015 was 10.4 million new cases of tuberculosis or 142 cases / 100,000 populations, with 480,000 cases of multidrug-resistance. indonesia is a country with the second largest number of new cases in the world after india. 60% of new cases occur in 6 countries, namely india, indonesia, china, nigeria, pakistan and south africa (world health organization / who, 2016). globally, in 2017, the tb mortality rate in the world is 16% (world health organization, 2017). data in indonesia shows that deaths from tuberculosis are estimated at 1.4 million. this number increased with tb comorbidities. this number increased with tb comorbidities of 0.4 million in 2016 (kaulagekarnagarkar, dhake, & jha, 2012). the high incidence and mortality, due to tuberculosis, encourages the indonesian state to improve the treatment and care of tuberculosis patients. treatment of good tb patients can help speed healing (friedman, mm, bowden, vr, & jones, 2010). in the treatment of pulmonary tuberculosis, the role of the family is needed, especially in providing care and support. family contributions to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 363 the treatment of tuberculosis can be in the form of support and care (samal, 2017). treatment is not only physical care but psychosocial treatment. actions that can be taken by the family in caring for family members, for example by monitoring patients in taking medicine regularly, fulfilling nutritional needs, and increasing nutritional intake to increase the immune system of people with tuberculosis r(indyah rachmawati, s, & isabella, 2015). care provided by the family can be in the form of providing motivation to fight the disease, not despairing, and not thinking negatively thought such as suicide or leaving home (ministry of health, 2017). there is enough research about the role of families in caring for pulmonary tuberculosis patients, but the conclusions obtained from these studies are still not uniform, so researchers assume that exploration is still needed on the role of families as caregivers in treating pulmonary tuberculosis patients. the results of this study are expected to have the effect of increasing the ability of families as a caregiver in treating pulmonary tuberculosis patients. this study aimed to explore the role of families as caregivers in caring for family members who suffer from tb. materials and methods design this study is a qualitative study with a phenomenological approach carried out in the pajang surakarta health center work area. data was collected by interviewing participants who had family members suffering from pulmonary tuberculosis. participants the number of participants in qualitative research is determined based on the focus or depth of information expected by the researcher. in this study, the number of participants was determined according to the saturation of data. thirteen participants were included in this study. participants involved in the study were selected by purposive sampling technique. determination of participants based on predetermined criteria, namely; over eighteen years old, family as caregiver who treats family members with pulmonary tuberculosis, families with experience caring for tuberculosis sufferers for aminimum of six months and living in one house. data collection participants who were selected and willing to participate in the study were given a questionnaire containing demographic data and followed by indepth interviews. open-ended questions were used in interviews to explore family experiences in caring for family members suffering from pulmonary tuberculosis. interviews were conducted face to face for 45-60 minutes in a place desired by the participants and agreed upon by the researchers. when conducting interviews, researchers used interview guidelines that contained research topics, and if any, the information presented by participants needed to be explored more deeply, the researchers used probes. during the interview process, the researcher records a general description of the participant's nonverbal response into the note field. the researcher bracketing, intuiting, analyzing, and describing to obtain information that comes from truly natural participants. the interview guide used in this study is explained in table 1. ethical considerations this research was approved by the universitasmuhammadiyah surakarta committee, faculty of medicine. a number of ethical certificate 96/i/hrec/2019. researchers protect and guarantee the confidentiality of participants involved in research by maintaining the confidentiality of the participant's identity. in addition, only certain data will be reported and published with permission from the participants. the results of the interviews and verbatim transcripts were only known by researchers and participants. data analysis the seven stages of the colaizzi method (1978) are applied to analyze information obtained from interviews. this method was chosen because, at the end of the analysis, there is a final validation activity that must be carried out by the researcher to ensure trustworthiness. the stages of data analysis use the colaizzi method which includes reading repeatedly verbatim transcripts that contain descriptions of participants about the phenomenon being studied, identifying specific statements conveyed by the participants and then making them as keywords. this specific statement will be given a code(coding) by giving colour to specific words. the next stage is to formulate the meaning of each specific statement and proceed with grouping the meanings that have been made into categories, identifying the relationships of each category and grouping them into themes. after the theme is formed, the researcher carries out final validation on the participant, and if new data is found at the end of the validation, it will be combined with a complete description. the validity of the data from this research is maintained.the validity of the data from this research table 1 interview outline 1. how is your experience while caring for family members who suffer from pulmonary tuberculosis 2. please tell us about the actions that have been taken to prevent transmission of the disease while caring for family members suffering from pulmonary tuberculosis? 3. what is your role in treating pulmonary tuberculosis suffered by family members? 4. what are your efforts in meeting nutritional needs when caring for family members suffering from pulmonary tuberculosis? 5. please tell me about the support that has been given to family members who suffer from pulmonary tuberculosis b. kristinawati, et al. 364 | pissn: 1858-3598  eissn: 2502-5791 is maintained by researchers by applying the principles of credibility, transferability, dependability and confirmability. the degree of credibility is attempted by including verbatim quotes from the results of interviews. second, the possibility of research results can be applied to other groups with different conditions (transferability) conducted by researchers by providing descriptions of data that support the research process. third, data stability (dependability) is maintained by auditing the research process by means ofan audit trail of listening to the results of multiple interviews, checking verbatim transcripts made and examining the results of the interpretation of the data obtained. fourth, confirmability is carried out by researchers by means of researchers explaining conclusions and interpreting the data obtained to reflect the family plan as caregiver in treating tuberculosis sufferers. results demographic data on the characteristics of participants are described in table 2. based on the verbatim analysis, a detailed description of the family performance as a caregiver who cared for families suffering from pulmonary tuberculosis was obtained. the categories, abstracted to themes that emerged from the analysis process is shown in table 3. the table above shows that the results of the analysis based on the colaizzi data analysis stage formed six categories which have been drawn down into five broad themes. discussion theme: nonpharmacological therapy is given by the family to treat symptomatic pulmonary tuberculosis tb disease suffered by patients often causes symptoms that cause sufferers to feel uncomfortable. the family stated in handling the initial symptoms by administering nonpharmacological therapy. families interpret nonpharmacological therapy as a first aid measure in reducing symptomatic arising. symptomatic arises in the form of shortness of breath and coughing. families take non-pharmacological table 2. demographic characteristic of the participants characteristics number % gender male 3 23,1 female 10 76,9 age 24-40 year 4 30,8 41-57 year 9 69,2 job housewife 6 46,2 private sector 6 46,2 civil servant 1 7,7 education level primary school 3 23,1 junior high school 1 7,7 high school 7 53,8 bachelor 2 15,4 treatment period 6 month 8 61,5 8month 1 7,7 9 month 2 15,4 10 month 2 15,4 table 3. analysis of the content of the role of families as care giver in caring for family members who have pulmonary tuberculosis coding category theme nonpharmacological therapy is given by family nonpharmacological therapy nonpharmacological therapy is given by the family to treat symptomatic pulmonary tuberculosis dyspnea management complementary therapy prevent the risk of transmission tuberculosis family strategy in preventing tb transmission efforts to cut transmission was carried out by the family to prevent transmission of disease giving nutrition food fulfilment of nutrition intake by the family nutrition support provided by families in treating patients remind taking medication families provide information to patients informational support is given by families in caring for pulmonary tuberculosis patients make use of health services controlling emotions family coping behaviour in caring for family members who suffer from pulmonary tuberculosis emotional support is given by families in treating pulmonary tuberculosis sufferers accept condition family motivational actions psychological support from the family jurnal ners http://e-journal.unair.ac.id/jners | 365 actions in the form of giving eucalyptus oil. here are some participant statements: “coughing, then i will use oil to make it warm... and i use massage oil to reduce it..." (p11) "it's covered with oil... i use eucalyptus oil so that the patient feels warm..." (p12) family is the leading health care unit in improving health status. and having the function of providing health care aims to maintain the health condition of family members. the family also performs its role in preventing health problems and caring for sick family members (suprajitno, 2012). health care carried out by the family is influenced by family actions or behaviour towards stimuli related to illness and disease (friedman, mm, bowden, vr, & jones, 2010). family efforts to reduce symptoms of shortness of breath in tb patients can use pharmacological therapy and non-pharmacological therapy. the results showed the effect of aromatherapy on mint leaves with simple inhalation on decreasing shortness of breath in pulmonary tuberculosis patients. mint leaves containing essential menthol can loosen breathing (shrivastava, shrivastava, & ramasamy, 2015). 4.2. theme: efforts to cut transmission was carried out by the family to prevent transmission of disease the attempt to cut the transmission of tb transmission is meant that participants take actions that can prevent the risk of tb transmission. prevention of tb transmission by families in accordance with the recommendations of health workers. actions carried out by the family, such as using a mask, not throwing phlegm anywhere and separating the eating equipment and drinking the patient. besides, family business in preventing tb transmission by providing an understanding of tuberculosis sufferers. the following is a quote from the participant's expression: “next..ee... prepare a mask... father must be selfaware if he is sick. i am afraid the disease will be contagious, so the father is given an understanding of the importance of using his mask "(p4) "the spit is placed in a closed place... a special place for saliva and given karbol, so that the germs die..." (p5) "the glass used is separated... to prevent transmission" (p4) prevention is an effort to protect patients from health threats. prevention efforts are carried out so that everyone is spared from contracting a disease and preventing the spread of disease (febriansyah, 2017). according to ali in 2010, prevention of transmission of diseases carried out by families was included in the form of duties or family roles. one of the tasks of the family is to care for sick family members and prevent transmission to healthy family members (ali, 2010) 4.3.theme: nutrition support provided by families in treating patients participants interpret nutritious food as a family effort to meet the nutritional needs of tuberculosis patients. the family said that providing nutrition will help the healing process of family members who suffer from tuberculosis at home. the family provides nutrients in the form of protein (milk) and fruits during the treatment process. milk is given in sufficient quantities with frequent frequency while fruits are given approximately one to three times a week. the following is a quote from the participant "almost everyday milk is made... goat milk" (p3) “i give bananas, grapes... essentially everyday fruit is provided "(p12) adequate nutrition can help increase endurance. endurance can decrease when poor nutrition conditions so that the ability to defend themselves against infection decreases (gupta, gupta, atreja, verma, & vishvkarma, 2009). other research shows that 51.3% of tuberculosis sufferers have poor nutritional status. poor nutritional status increases the risk of tuberculosis (arsunan, a. a., wahiduddin, & ansar, 2013). 4.4. theme: informational support given by families in caring for pulmonary tuberculosis patients participants interpret informational support as family actions in supporting or supporting treatment for family members suffering from tuberculosis. information provided by the family is in the form of reminding sick members to take medicine and accompanying control to health services. the following is a quote from the participant's statement: "i always remind you to... the medication should not forget, later... repeat the treatment" (p3) "so i also reminded myself to take medicine... for six months i reminded myself to recover" (p11) the family is the first person who knows about the condition of the patient and the person who is closest and communicates every day with the patient. families have an important role in the treatment process of patients. the family can be used as a pmo (superintendent of swallowing drugs) because the family is trusted, known, and approved by health workers and sufferers as well as staying close or one house with patients (ministry of health, 2017). 4.5. theme: families give emotional support in treating pulmonary tuberculosis sufferers b. kristinawati, et al. 366 | pissn: 1858-3598  eissn: 2502-5791 emotional support means that the family as the closest person to the patient gives motivation to family members who are sick during the treatment process. tuberculosis sufferers need considerable time for treatment, so, patients need the motivation to minimise the negative response to treatment. the following is the expression of the participant's statement: "in my daily life, i support patients... so that they can have the spirit of treating" (p3) "eee... i really motivate him... support him" (p12) motivation is a basic impulse that moves and directs someone to act to achieve certain goals. the results of encouragement and movement are manifested in the form of behaviour. own behaviour is formed through a certain process and takes place in the interaction of a person with his environment (donsu, 2017). motivation is interpreted as a force or factor contained in someone who raises and moves his behaviour. conclusion the role of the family as caregiver in caring for family members is illustrated in five themes, namely; 1) family experience in preventing disease transmission while caring for family members suffering from tuberculosis, which is accommodated by the theme of efforts to cut transmission carried out by families to prevent disease, 2) family role in treating tuberculosis sufferers accommodated by the theme of nonpharmacological therapy given by families to overcome symptomatic pulmonary tuberculosis the family's role in fulfilling nutritional needs in caring for family members sufferingfrom tuberculosis is accommodated by the theme nutrition support provided by families treating patients, 4) social support provided when caring for family members suffering from tuberculosis is accommodated by the theme of informational support given to families in caring for tuberculosis patients and the theme of emotional support is given by the family in caring for tuberculosis patients. references ali, z. (2010). introduction to family nursing. jakarta: egc. arsunan, a. a., wahiduddin, & ansar, j. (2013). overview of nutritional substance and nutritional status of patients with pulmonary tb in makassar city. hasanuddin. brunner & suddarth. (2013). textbook for medicalsurgical nursing (1st ed.). jakarta: egc. donsu, j. d. t. (2017). nursing psychology aspects of psychology basic concepts psychology theory of human behavior. yogyakarta: new library press. febriansyah, r. (2017). hubungan tingkat pengetahuan keluarga dengan upaya pencegahan penularan tuberkulosis paru pada keluarga di wilayah kerja puskesmas sukoharjo. universitas muhammadiyah surakarta. friedman, mm, bowden, vr, & jones, e. (2010). family nursing textbook: research, theory, and practice. jakarta: egc. gupta, k., gupta, r., atreja, a., verma, m., & vishvkarma, s. (2009). tuberculosis and nutrition. lung india. https://doi.org/10.4103/0970-2113.45198 indyah rachmawati, n., s, s., & isabella, c. (2015). kebutuhan psikososial keluarga yang mempunyai anggota keluarga menderitatb paru. jurnal keperawatan padjadjaran, v3(n1), 25–32. https://doi.org/10.24198/jkp.v3n1.4 kaulagekar-nagarkar, a., dhake, d., & jha, p. (2012). perspective of tuberculosis patients on family support and care in rural maharashtra. indian journal of tuberculosis. ministry of health. (2017). indonesian health profile 2016. jakarta: ministry of health of the republic of indonesia. samal, j. (2017). family perspectives in the care and support of tuberculosis patients: an indian context. the journal of association of chest physicians. https://doi.org/10.4103/23208775.202899 shrivastava, s., shrivastava, p., & ramasamy, j. (2015). scope of family in public health: an epidemiologist′s perspective. muller journal of medical sciences and research, 6(1), 101. https://doi.org/10.4103/0975-9727.146480 suprajitno. (2012). family nursing care: application in practice. jakarta: egc. world health organization. (2017). global tuberculosis report. france. http://e-journal.unair.ac.id/jners | 227 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17107 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review work environment, spiritual, and motivational factors affecting job satisfaction among hospital nurses: a systematic review ida yanriatuti, tan nina fibriola, kornelis nama beni and fitriyanti patarru' faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: patient services at the hospital cannot be separated from the role of the nurse. therefore, nurses must work professionally to provide better nursing care. there are several factors that can affect the performance of the nurses, one of which is job satisfaction. the purpose of a systematic review is to understand the factors that influence the job satisfaction of nurses in hospitals. methods: for a systematic review, the search was focused on the pubmed, science direct and scopus database literature with the keywords ‘job satisfaction’ and ‘nurses’. the search identified 15 relevant research articles from the 10,530 original articles that were full texts published between 2015 and 2018. results: the results showed that the job satisfaction of the nurses was influenced by their leadership, work environment, career path, the relationship with their co-workers, salary, the relationship between the organizations, appreciation, communication, opportunity, organizational commitment, work schedule, work stress, empowerment and work rotation. the results also indicated that high job satisfaction leads to lowering nurse retention and burnout, in addition to an improved quality of patient care. conclusion: the nurse’s job satisfaction needs to get serious attention from hospital management because it plays an important role in improving the health care service quality in the hospital. article history received: december 26, 2019 accepted: december 31, 2019 keywords work environment; spiritual; motivational contact ida yanriatuti  ida.yanriatuti2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: yanriatuti, i., fibriola, t. n., beni, k. n., & patarru', f. (2019). review work environment, spiritual, and motivational factors affecting job satisfaction among hospital nurses: a systematic review. jurnal ners, 14(3si), 227-230. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17107 introduction job satisfaction is an important factor in the healthcare setting. it is a predictor of patient care quality and safety internationally. improving the nurses' job satisfaction and reducing their intention to leave is crucial to the stability of the nursing workforce (biegger, de geest, schubert, & ausserhofer, 2016). as advances have been made in medicine and technology recently, patient care has become more complex. nurses needed specialized knowledge, skills and health care delivery mechanisms to evolve and support the patients' needs for continuous monitoring and treatment(abduelaal abduelazeez & mohammed nouri, 2016). dissatisfaction with the work can cause poor job performance, lower productivity, staff turnover and increased costs to the organizations (akman, ozturk, bektas, ayar, & armstrong, 2016). the nurse managers and policy makers should ensure adequate staffing, supplies and equipment to provide a positive and healthy practice environment, which is crucial to job satisfaction. the outcomes should provide important insights for policy makers on how to improve job satisfaction and other stakeholders in order to provide a deeper understanding of the factors that can influence job satisfaction. this is so then strategies can be developed on how best to manage the nursing workforce in the face of increasing pressure (atefi, abdullah, wong, & mazlom, 2014). previous research on the factors affecting nurse job satisfaction has been conducted. for this systematic review, job satisfaction has been represented by three main factors: the work environment, spirituality and motivational factors. we chose to conduct a systematic review to identify https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). i. yanriatuti, et al. 228 | pissn: 1858-3598  eissn: 2502-5791 and summarize the currently available factors affecting nurse job satisfaction the aim of this systematic review is to understand the factors that influence the job satisfaction of the nurses in the hospitals. materials and methods design this systematic review was conducted using the following steps based on the prisma statement, which were as follows: (biegger et al., 2016) formulating a research question, (abduelaal abduelazeez & mohammed nouri, 2016) selecting the relevant search terms and formulating search phrases by consulting an information specialist in the field of health sciences, (akman et al., 2016) planning a search strategy, (atefi et al., 2014) agreeing on the inclusion and exclusion criteria, (moher et al., 2009) conducting a systematic search in electronic databases, (boamah, spence laschinger, wong, & clarke, 2018) selecting eligible research articles and (alostaz, 2016) performing a quality appraisal of the studies selected for the review (moher et al., 2009). for a systematic review, the search of te pubmed, science direct and scopus database literature was done with the keywords ‘job satisfaction’ and ‘nurses’. the search identified 15 relevant research articles from the 10,530 original articles and full texts published from 2015 2018. the research articles were in pdf format, were a full text, were free to download and used english. figure 1 shows the prisma flow chart. searching strategy and inclusion criteria a systematic search was conducted in the pubmed, science direct and scopus databases in february 2019 resulting in 10,530 articles. the search was performed by employing combinations of the terms job satisfaction and nurses. in order to be eligible for this study, the reviews had to be cross-sectional, longitudinal, qualitative or a literature review in terms of their research design and they had to answer the research questions. there were inclusion criteria related to the factors affecting job satisfaction and nurses. there was no limitation on the type of work and regarding the location of the participant’s data collection because the focus of the search was to define the factors affecting job satisfaction among the nurses in the hospital. the articles were excluded if the results of the study did not define the factors affecting the job satisfaction of the nurses and if the study was not conducted in a hospital setting. in terms of reducing bias, all of the selected article results were based on a statistic test, the inclusion and exclusion criteria, and the reliability and validity of the instruments used. results the total literature in this review consisted of 15 published articles with a total of 16,657 respondents and 1 literature review related to the factors affecting job satisfaction among the nurses in the hospital. several studies have been conducted to define factors affecting job satisfaction among nurses in hospital. job satisfaction job satisfaction is defined as the feelings that an individual has about his/her job is an important nursing outcome that is affected by the quality of the work environment (boamah et al., 2018). there were 7 questionnaires identified in this systematic review, 5 open question journals, 1 minnesota job satisfaction scale journal, 1 jss journal, 2 journals using the general satisfaction sub scale of the job diagnostic survey, 1 index of work satisfaction journal, 2 mmss journals and 1brayfiel and rothe’s index of job satisfaction nursing job satisfaction scale journal. work environment there were three studies that examined work environment but only one study suggested that the work environment has an effect on job satisfaction. the work environment factors include teamwork, benefits and rewards, working condition, lack of medical resources, unclear nursing responsibilities at different levels, patient and doctor perceptions, poor leadership skills and discrimination at work (atefi et al., 2014). the studies showed that the nurses were satisfied with their teamwork and their relationships with other staff nurses. these are important factors related to the nurses’ job satisfaction. the brisbane practice environment scale was used to measure the work environment. transformational leadership was measured using the multifactor leadership questionnaire. resonant leadership was measured using the resonant leadership scale. the cweq-ii questionnaire was developed by laschinger et al. (2001) and it was used to measure structural empowerment. years of experience and level of qualification figure 1. prisma flow chart (moher et al. 2009) screening eligibility records screen (n=1,146) 1. pdf 2. full text 3. english 4. free download 5. year 2015-2018 records excluded based on title and abstract (n=148) full-text articles assessed for eligibility (n=15) identificatio n searching for literature from database. key words: job satisfaction, nurses (n=10,530) systematic review (n= 15) included jurnal ners http://e-journal.unair.ac.id/jners | 229 it was found that years of experience and level of qualification were not influencing factors in relation to the level of job satisfaction. nurse to patient ratio the relation between the nurse-to-patient ratio and job satisfaction was significant. burnout there were two articles that examined burnout. all of them used the maslach burnout inventory (mbi). the results showed there to be a significant relationship between burnout and job satisfaction. future career intentions only one study assessed future career intention and job satisfaction. the results showed that most of the respondents agreed that they intended to continue with their nursing career. spiritual feeling this theme emerged from the eight fgs during which nurses described factors affecting their job satisfaction. nurses highlighted a spiritual feeling when taking care of patients. this includes helping sick people and being involved in patient care. motivation factors the motivation factors included the task requirements, professional development and a lack of clinical autonomy. job stress there were two studies that assessed job stress as a factor affecting job satisfaction. the studies used the nursing stress scale and the nurse job stressor questionnaire was developed in chinese by li and liu to measure job stress. both of the studies showed there to be no significant relation between job stress and job satisfaction. horizontal violence only one study assessed to see if horizontal violence affected job satisfaction. the results showed no significant relation between them. the negative acts questionnaire-revised (naq-r) was used to measure horizontal violence. discussion the findings of this systematic review suggest that nurse job satisfaction is influenced by many factors. they are including the work environment, the nurse to patient ratio, future career intentions, spiritual feelings and motivation factors. the work environment factors included teamwork, benefits and rewards, the working conditions, a lack of medical resources, unclear nurse responsibilities at different levels, patient and doctor perceptions, poor leadership skills and discrimination at work. spiritual feelings include helping sick people and their involvement in patient care. motivation factors include task requirements, professional development and a lack of clinical autonomy (atefi et al., 2014). there was no significant relation between job stress, years of experience, level of qualification and horizontal violence on job satisfaction. the present study shows that the environmental factors affect the nurses’ satisfaction. the environmental factors show that the nurses who were satisfied with the level of teamwork, who had a relationship with their co-workers in good working conditions, with benefits and rewards, good medical resources, clear nursing responsibilities, good leadership skills and who faced no discrimination at work will increase the nurses’ job satisfaction. however, several studies reported that nurses are still dissatisfied about the medical resources and benefit and reward system factors in the hospitals. for the spiritual factors, they show that the nurse were satisfied when helping the patient and being involved in patient care. last, for motivational factors, they show that opportunities for promotion and development will contribute to the nurses to have higher job satisfaction. the limitation of the study was the variation in measurement instruments and the number of samples that made the comparison difficult. nurse managers and policy makers should improve the nurse’s job satisfaction and provide a deeper understanding of the factors that can influence job satisfaction. this is so then strategies can be developed to provide the best way to manage the nursing workforce in the face of increasing pressures. conclusion the results of this review have identified some of the key factors that affect job satisfaction. the result also indicated that high job satisfaction leads to lowering nurse retention and burnout, and it also improves the quality of patient care. however, there were several studies that reported that not all hospitals pay attention to the factors affecting the nurses’ job satisfaction. nurse managers and policy makers play an important role in providing nursing job satisfaction in hospitals. references abduelaal abduelazeez, a. e., & mohammed nouri, m. (2016). job satisfaction and related factors among intensive care nurses in governmental hospitals at khartoum state sudan. journal of community & public health nursing. https://doi.org/10.4172/2471-9846.1000114 akman, o., ozturk, c., bektas, m., ayar, d., & armstrong, m. a. (2016). job satisfaction and burnout among paediatric nurses. journal of nursing management. https://doi.org/10.1111/jonm.12399 alghamdi, m. g., topp, r., & alyami, m. s. (2018). the effect of gender on transformational leadership and job satisfaction among saudi nurses. journal of advanced nursing. https://doi.org/10.1111/jan.13385 alostaz, z. (2016). job satisfaction among critical i. yanriatuti, et al. 230 | pissn: 1858-3598  eissn: 2502-5791 care nurses in al baha, saudi arabia: a crosssectional study. gulf medical journal. ashley, c., peters, k., brown, a., & halcomb, e. (2018). work satisfaction and future career intentions of experienced nurses transitioning to primary health care employment. journal of nursing management. https://doi.org/10.1111/jonm.12597 atefi, n., abdullah, k. l., wong, l. p., & mazlom, r. (2014). factors influencing registered nurses perception of their overall job satisfaction: a qualitative study. international nursing review. https://doi.org/10.1111/inr.12112 bawafaa, e., wong, c. a., & laschinger, h. (2015). the influence of resonant leadership on the structural empowerment and job satisfaction of registered nurses. journal of research in nursing. https://doi.org/10.1177/1744987115603441 biegger, a., de geest, s., schubert, m., & ausserhofer, d. (2016). the “magnetic forces” of swiss acute care hospitals: a secondary data analysis on nurses’ job satisfaction and their intention to leave their current job. nursingplus open. https://doi.org/10.1016/j.npls.2016.01.002 boamah, s. a., spence laschinger, h. k., wong, c., & clarke, s. (2018). effect of transformational leadership on job satisfaction and patient safety outcomes. nursing outlook. https://doi.org/10.1016/j.outlook.2017.10.004 déry, j., clarke, s. p., d’amour, d., & blais, r. (2018). scope of nursing practice in a tertiary pediatric setting: associations with nurse and job characteristics and job satisfaction. journal of nursing scholarship, 50(1), 56–64. https://doi.org/10.1111/jnu.12352 douglas, c., & bonner, a. (2015). haemodialysis nurse satisfaction , stress and burnout work environment , job satisfaction , stress and burnout among haemodialysis nurses bronwyn hayes rn , mhlthsci , clint douglas rn , phd and ann bonner rn , phd school of nursing , queensland universit. https://doi.org/10.1111/jonm.12184/abstract. fallatah, o. k., & mahran, s. (2017). nursing practice environment and job satisfaction from the perspective of staff nurses. 6(6), 82–86. https://doi.org/10.9790/1959-0606078286 halcomb, e., smyth, e., & mcinnes, s. (2018). job satisfaction and career intentions of registered nurses in primary health care: an integrative review. bmc family practice, 19(1). https://doi.org/10.1186/s12875-018-0819-1 moher, d., liberati, a., tetzlaff, j., altman, d. g., altman, d., antes, g., … tugwell, p. (2009). preferred reporting items for systematic reviews and meta-analyses: the prisma statement. annals of internal medicine, vol. 151, pp. 264–269. https://doi.org/10.7326/0003-4819-151-4200908180-00135 purpora, c., & blegen, m. a. (2015). job satisfaction and horizontal violence in hospital staff registered nurses: the mediating role of peer relationships. journal of clinical nursing. https://doi.org/10.1111/jocn.12818 wu, x., li, j., liu, g., liu, y., cao, j., & jia, z. (2018). the effects of emotional labor and competency on job satisfaction in nurses of china: a nationwide cross-sectional survey. international journal of nursing sciences. https://doi.org/10.1016/j.ijnss.2018.08.001 128 psikoedukasi menurunkan tingkat depresi, stres dan kecemasan pada pasien tuberkulosis paru (psycho education decrease the level of depression, anxiety and stress among patient with pulmonary tuberculosis) suryani, efri widianti*, taty hernawati*, aat sriati* *fakultas keperawatan unpad, jalan raya jatinagor km 21, jatinanor, sumedang email: suryani@unpad.ac.id abstrak pendahuluan: tuberkulosis paru (tb paru) meupakan penyakit paru – paru kronis yang berdampak secara fisik dan psikososial pada pasien. hingga saat ini program – program pemerintah dalam mengatasi penyakit ini masih berfokus pada pengobatan dan pencegahan penularan. belum ada program yang ditujukan untuk mengatasi masalah psikososial pasien padahal dampak psikososial mempunyai pengaruh yang besar pada kepatuhan berobat dan prognosa penyakit pasien tb. metode: penelitian ini merupakan penelitian quassi eksperimen untuk membuktikan efek psikoedukasi terhadap tingkat depresi, cemas dan stress pada pasien yang mengalami tb paru. sebanyak 74 pasien tb paru terlibat dalam penelitian ini yang terdiri dari 37 orang masuk kedalam kelompok intervensi dan 37 orang masuk kelompok control. hasil: hasil penelitian menunjukkan bahwa psikoedukasi efektif menurunkan tingkat depresi, cemas dan stress pasien tb paru. diskusi: psikoedukasi sebaiknya diberikan kepada penderita tb paru yang berobat ke puskesmas. kata kunci : intervensi, psikoedukasi, tuberculosis paru abstract introduction: pulmonery tuberculosis is a chronic pulmonary disease that affects physicallly and psychosocially for the patients. until now, the government’s programs in overcoming this disesase still focus on treatment and prevention of infection. the programs has not yet to lead to a psychosocial problem of the patients whereas the psychosocial impact has a big influence on treatment compliance and prognosis of patients with pulmonery tuberculosis. method: this study was quassy experiment to test the effect of psychoeducation on the level of stress, anxiety and depression of patients with pulmonary tuberculosis. 74 patients with pulmonery tuberculosis involved in this study divided into two group (37 involved in intervention and 37 involved as control group). result: the result of the study showed that psychoeducation was effective in reducing stress, anxiety and depression of the patients with pulmonery tuberculosis. discussion: psycho education should be provided for patients with pulmonary tuberculosis at the community health center. keywords: intervention, psychoeducation, pulmonary tuberculosis ____________________________________________________________________________________________________ pendahuluan jumlah penderita tb paru di indonesia cukup besar dan menduduki peringkat kelima di dunia (who 2010), dengan jumlah penderita tbc sebesar 429.000 orang. angka kematian karena tb paru diperkirakan sebesar 27 per 100.000 penduduk per tahun. dalam rangka mengatasi permasalahan tb paru di indonesia, pemerintah telah melakukan berbagai upaya dengan berbagai macam program yang terkait pengobatan dan pencegahan penularan penyakit tb paru. akhir–akhir ini pemerintah melakukan sebuah program yang dikenal dengan programmatic managament of drug resistance tb (pmdt). pmdt tahun 2011-2014 bertujuan untuk melaksanakan secara bertahap diagnosis dan pengobatan multidrug resistance tuberculosis (tb mdr). beberapa program yang telah dikembangkan dan dilakukan oleh pemerintah belum ada program yang bertujuan untuk mengatasi masalah psikososial yang dihadapi penderita tb paru, padahal dampak psikososial ini sangat besar pengaruhnya terhadap kepatuhan berobat dan prognosa penyakit penderitanya. dampak psikososial menurut jong (2011) antara lain adalah adanya masalah emosional berhubungan dengan penyakitnya seperti merasa bosan, kurang motivasi, sampai kepada gangguan jiwa yang cukup serius seperti depresi berat. masalah psikososial lainnya adalah adanya stigma di masyarakat, merasa takut akan penyakitnya yang tidak dapat disembuhkan, merasa dikucilkan dan tidak percaya diri, serta masalah ekonomi (aye´ et al. 2011). bagi penderita yang mengalami depresi dan putus asa terhadap penyakitnya, mereka tidak mau minum obat, resikonya jurnal ners vol. 11 no. 1 april 2016: 128-133 129 adalah penderita tidak sembuh dan tentu akan menularkan penyakit mereka pada orang lain disekitarnya. pada penelitian kami sebelumnya sudah ditemukan kebutuhan psikososial penderita tb paru (suryani et al. 2014), sehingga diperlukan upaya intervensi untuk mengatasinya. psikoedukasi adalah pendidikan kesehatan pada pasien baik yang mengalami penyakit fisik maupun gangguan jiwa yang bertujuan untuk mengatasi masalah psikologis yang dialami mereka. penyakit fisik disini bisa berupa hipertensi, kanker, penyakit kulit, tbc dan sebagainya. sedangkan gangguan jiwa bisa berupa depresi, kecemasan dan skizofrenia. terapi psikoedukasi ini bisa berupa pasif psikoedukasi seperti pemberian informasi dengan leaflet atau melalui email atau website dan juga bisa berupa aktif psikoedukasi berupa konseling atau pemberian pendidikan kesehatan secara individu atau kelompok. hasil sistematic review terhadap 9010 abstrak penelitian dari cochrane, psycinfo and pubmed yang dilakukan oleh donker et al. (2009) di netherland menunjukkan bahwa psikoedukasi pasif berupa pemberian leaflet pada penderita depresi dan distress psikologi dapat menurunkan gejala tersebut secara signifikan. penelitian lain dengan metode randomized multicenter dari bauml et al. (2006) di jerman yang meneliti tentang pengaruh psikoedukasi pada penderita skizofrenia dan keluarganya menunjukkan bahwa terapi psikoedikasi bisa menurunkan hospital rate dari 58% menjadi 41 %. berdasarkan latar belakang masalah yang sudah diuraikan di atas, maka efektifitas intervensi psikoedukasi dalam mengatasi masalah psikososial berupa depresi, cemas dan stress pada penderita tb paru belum dapat dijelaskan. metode jenis penelitian yang digunakan adalah quasi experimental (pretest and posttest design with control group). hipotesis dalam penelitian ini adalah terdapat pengaruh intervensi psikoedukasi terhadap tingkat depresi,cemas dan stres penderita tb paru. pengambilan sampel dalam penelitian ini menggunakan teknik nonprobability sampling dengan metode consecutive sampling yaitu teknik sampling dimana setiap responden yang datang dan memenuhi kriteria pemilihan sampel dimasukkan dalapenelitian sampai jumlah subyek yang diperlukan terpenuhi atau sampai waktu yang telah ditentukan (dahlan 2011). adapun kriteria khusus dalam pemilihan sampel ini antara lain: menderita tuberkulosis paru, termasuk kategori usia dewasa, masih dalam proses pengobatan ke puskesmas,dan bisa membaca dan menulis. semua pasien yang datang berobat baik ke puskesmas garuda maupun babakan sari dan memenuhi kriteria dalam penelitian ini diambil sebagai sampel. setelah 5 bulan penelitian (april–september) diperoleh sampel sebanyak 52 orang dari puskesmas garuda dan 22 orang dari puskesmas babakan sari. jadi total sampel berjumlah 74 orang, yang terbagi menjadi 2 kategori, 37 orang kelompok intervensi dan 37 orang kelompok kontrol. kelompok intervensi mendapatkan psikoedukasi sedangkan kelompok kontrol hanya mendapatkan pengarahan seperti yang biasa dilakukan di puskesmas. setelah selesai penelitian, kelompok kontol juga diberikan psikoedukasi. psikoedukasi yang diberikan berupa psikoedukasi aktif dan pasif. psikoedukasi aktif yang dilakukan yaitu dengan konseling, sedangkan psikoedukasi pasif dengan cara pemberian booklet kepada responden setelah diberikan konseling. pemberian psikoedukasi pasif dimaksudkan untuk melengkapi psikoedukasi aktif atau konseling yang telah dilakukan, dengan tujuan agar responden bisa mempelajari kembali apa yang suda h didiskusikan di puskesmas. pengumpulan data dilakukan dengan menggunakan kuesioner depression anxiety stress scale (dass). pengumpulan data dilakukan 2 kali, pertama sebelum dilakukan psikoedukasi. pengumpulan data kedua dilakukan 1 minggu setelah dilakukan intervensi. pada penelitian ini analisis yang digunakan analisa univariat dan bivariat. teknik analisis univariat dilakukan untuk mengetahui distribusi, frekuensi, dan persentase dari karakteristik responden yang meliputi usia, jenis kelamin, dan pendidikan serta tingkat stres, cemas dan depresi dgn kriteria: 0–29 = normal, 30–59 = tingkat stress ringan, 60–89 = tingkat stress sedang, 90–112 = tingkat stress berat, dan > 120 = tingkat stress sangat berat analisis kedua adalah analisis bivariat. pada penelitian ini, sebelum dilakukan analisa bivariat, terlebih dahulu dilakukan uji normalitas data. analisis yang digunakan untuk pengujian skor stres pretest pada kelompok intervensi dan kelompok kontrol menggunakan uji t test karena data terdistribusi normal. selanjutnya untuk pengujian beda antara skor depresi pre psikoedukasi menurunkan tingkat depresi (suryani, dkk.) 130 dan posttest pada kelompok intervensi menggunakan uji t berpasangan, hal tersebut dikarenakan data yang dikumpulkan adalah data numerik dan dilakukan pada kelompok yang sama dengan menghitung pre dan post test nya (berpasangan) (dahlan 2011). hasil hasil pada tabel 1 menunjukkan bahwa sebelum dilakukan psikoedukasi sebagian besar responden (64,9 %) mengalami tingkat stres, cemas dan depresi (yang diukur dengan dass) tingkat ringan. hampir setengahnya dari responden (35,1%) mengalami .tingkat stres, cemas dan depresi tingkat sedang. setelah diberikan terapi psikoedukasi sebagian besar responden (75,7 %) mengalami tingkat stres, cemas dan depresi normal (dalam batas norma) dan hanya sebagian kecil saja yang masih mengalami stres, cemas dan depresi, itupun tingkat ringan. tabel 2 menunjukkan bahwa pada pengukuran pertama sebagian besar responden (62,2 %) mengalami tingkat stres, cemas dan depresi (yang diukur dengan dass) tingkat ringan dan hampir setengahnya dari responden (35,1%) mengalami stres, cemas dan depresi tingkat sedang. pada pengukuran kedua sebagian besar responden (75,7 %) masih mengalami tingkat stres, cemas dan depresi ringan, hanya sebagian kecil saja yang menjadi normal dan sebagian yang lain malah tetap mengalami stres, cemas dan depresi tingkar sedang. hasil penghitungan kolmogorov smirnov untuk kelompok intervensi didapatkan d hitung = 0.11 < d tabel 0.1581, dengan taraf nyata 5%, ternyata h0 diterima, artinya data (kelompok intervensi) berasal dari populasi yang berdistribusi normal. untuk kelompok kontrol didapatkan d hitung = 0.09 < d tabel 0.1581, dengan taraf nyata 5%, ternyata h0 diterima. artinya data (kelompok kontrol) berasal dari populasi yang berdistribusi normal. uji normalitas data berdistribusi normal maka digunakan uji t, untuk pengujian karena kita ingin membandingkan tingkat stress penderita tb paru kelompok intervensi dan kontrol maka dibandingkan pre pada kelompok kontrol dengan pre pada kelompok intervensi dan post pada kelompok kontrol dengan post pada kelompok intervensi. tabel 1. prosentase tingkat strss, cemas dan depresi dari responden kelompok intervensi sebelum dan sesudah dilakukan intervensi psikoedukasi no tingkat stres, cemas dan depresi sebelum intervensi sesudah intervensi jumlah prosentase jumlah prosentase 1 normal 28 75,7 2 ringan 24 orang 64,9 % 9 24,3 3 sedang 13 orang 35,1 % tabel 2. prosentase tingkat strss, cemas dan depresi dari responden kelompok kontrol no tingkat stres, cemas dan depresi pengukuran pertama pengukuran kedua jumlah prosentase jumlah prosentase 1 normal 3 8,1 2 ringan 23 62,2 28 75,7 3 sedang 14 orang 37,8 6 16,2 tabel 3. perhitungan nilai t mengunakan ms. excel dan didapatkan nilai t sebagai berikut : t-test: paired two sample for means intervensi(pre) kontrol(pre) mean 54.02702703 54.10810811 variance 142.5825826 282.9324324 observations 37 37 pearson correlation -0.101389018 hypothesized mean difference 0 df 36 t stat -0.022840948 p(t<=t) one-tail 0.490951641 t critical one-tail 1.688297694 p(t<=t) two-tail 0.981903282 t critical two-tail 2.028093987 kriteria uji : tolak h0 jika t hitung > t table jurnal ners vol. 11 no. 1 april 2016: 128-133 131 nilai t hitung diatas yaitu t stat = -0.022840948 < t tabel diatas yaitu = 2.028093987 maka h0 di terima. sampel diatas dapat diketahui bahwa rata –rata tingkat stress penderitas tb paru pada kelompok intervensi sebelum diberikan terapi psikoedukasi sama dengan rata –rata tingkat stress penderita tb paru kelompok kontrol sebelum diberikan terapi psikoedukasi dengan taraf signifikansi 5%, artinya tidak ada perbedaan tingkat stress penderita tb paru pada kelompok intervensi dan kontrol sebelum diberikan terapi psikoedukasi. hasil analisis menggunakan uji t diatas dapat kita ketahui bahwa tidak terdapat perbedaan tingkat stress penderita tb paru sebelum diberikan terapi psikoedukasi pada kelompok interverensi dan kelompok kontrol. kemudian ketika penderita tb paru diberikan terapi psikoedukasi dapat kita lihat bahwa terdapat perbedaan tingkat stress penderita tb paru yang diberikan terapi psikoedukasi (kelompok intervensi) dengan penderita tb paru yang tidak diberikan terapi psikoedukasi (kelompok kontrol), dapat kita lihat pada hasil perbandingan t hitung dengan t tabel juga selain itu dapat kita lihat dari nilai mean tingkat stress penderita tb paru setelah diberikan terapi psikoedukasi (kelompok intervensi) sebesar 27.05405405 sedangkan nilai mean penderita tb paru yang tidak diberikan terapi psikoedukasi = 47.72972973, semakin kecil nilai mean tingkat stress penderita tb paru maka semakin baik untuk kondisi psikologis penderita tb paru. jadi, pemberian terapi psikoedukasi memberikan pengaruh yang signifikan terhadap tingkat depresi, cemas dan stress pada penderita tb paru sehingga pemberian terapi psikoedukasi sangat berguna dan baik untuk diterapkan kepada penderita tb paru untuk mengurangi tingkat depresi, cemas dan stress penderita. pembahasan berdasarkan hasil penelitian diperoleh data bahwa tingkat depresi, cemas, dan stres, yang diukur dengan dass, baik pada kelompok intervensi maupun kelompok kontrol sebagian besar mengalami tingkat ringan, dan hampir setengahnya mengalami tingkat sedang. hal tersebut menunjukkan bahwa penderita tb paru mengalami masalah psikososial yang cukup signifikan yang termanifestasi dalam bentuk stres, cemas dan depresi. hasil penelitian ini mendukung hasil penelitian sebelumnya yang dilakukan oleh padayatchi et al. (2010) di india yang menemukan bahwa sampai dua tahun setelah terdiagnosa tb paru, penderita masih mengalami stres, cemas dan depresi. hasil penelitian ini juga mendukung temuan dari venkatraju & prasad (2013) di india yang menggali masalah psikososial yang dialami penderita tb dengan menggunakan metode kualitatif. salah satu hasil penelitian penelitian mereka adalah bahwa penderita merasa cemas dan takut dalam menjalani hidup dengan tb paru. untuk mengatasi masalah psikososial yang dihadapi oleh penderita tb paru, pada penelitian ini telah dilakukan psikoedukasi (psikoedukasi aktif dan pasif). psikoedukasi merupakan pendidikan kesehatan untuk mengatasi masalah psikososial bagi pasien baik yang mengalami penyakit fisik maupun gangguan jiwa (donker et al. 2009). psikoedukasi ini terdiri dari psikoedukasi aktif dan pasif. psikoedukasi aktif dilakukan dengan melakukan konseling bagi pasien yang mengalami masalah psikososial terkait penyakit yang dialaminya sedangkan psikoedukasi pasif dilakukan dengan memberikan booklet, pamplet, website atau video tentang bagaimana mengatasi masalah psikososial yang biasanya dialami oleh penderita tb. pada penelitian ini dilakukan kombinasi keduanya sehingga diharapkan dapat lebih efektif dalam mengatasi masalah pasien. pasien terdiagnosa tb paru mengalami banyak masalah psikososial. selama mereka mencari pertolongan atau berobat kepuskesmas, menurut hasil penelitian tahap 1 (satu) kami, terdapat 5 aspek kebutuhan psikososial yang tidak terpenuhi antara lain kebutuhan akan tenaga profesional kesehatan, kebutuhan emosional dan spiritual, kebutuhan informasi, kebutuhan dukungan jaringan dan kebutuhan praktis (suryani et al. 2014). sebagian besar responden (62%) pada penelitian tahap satu menyatakan bahwa tidak ada pelayanan pendukung yang dapat memberikan dukungan psikososial bagi mereka. sehingga masalah psikososial yang dialami mereka tidak pernah teratasi. karena itu pada penelitian tahap dua kami peneliti meneliti tentang terapi yang kemungkinan besar bisa mengatasi masalah psikososial yang mereka alami agar penderita mempunyai strategi koping yang konstruktif sehingga dapat mengatasi berbagai masalah psikososial yang mereka alami dan terbebas dari stres, cemas maupun depresi. psikoedukasi menurunkan tingkat depresi (suryani, dkk.) 132 hasil penelitian tahap dua menunjukkan bahwa psikoedukasi efektif dalam menurunkan tingkat stres, cemas dan depresi yang dialami penderita tb paru. hasil penelitian ini sejalan dengan hasil penelitian sebelumnya yang dilakukan oleh donker et al. (2009) di netherland yang menyimpulkan bahwa terapi psikoedukasi pasif berupa pemberian leaflet efektif dalam menurunkan gejala depresi dan stres. hasil penelitian ini juga mendukung hasil penelitian sebelumnya yang dilakukan oleh kaliakbarova et al. (2013) di india yang menemukan bahwa terapi kelompok psikososial support yang diberikan kepada pasien dapat menurunkan frekuensi putus obat pada pasien tb. terapi psikoedukasi yang telah dilakukan kepada kelompok intervensi berupa gabungan dari psikoedukasi aktif dan psikoedukasi aktif. pemberian terapi gabungan (aktif dan pasif) ini didasarkan pada temuan sebelumnya oleh moult et al. (2004) bahwa informasi kesehatan yang diterima oleh seorang pasien bisa terlupakan dalam beberapa menit setelah mereka mendapatkan informasi, karena itu diperlukan booklet supaya penderita bisa mengulang di rumah apa yang telah dibicarakan sebelumnya dengan perawat. penderita tb yang datang ke puskesmas yang masuk kedalam kelompok intervensi diberikan konseling tentang masalah psikososial yang mereka hadapi, kemudian diberikan booklet yang berisi tentang cara–cara mengatasi masalah psikososial yang biasa dialami penderita tb. kombinasi kedua pendekatan psikoedukasi (pasif dan aktif) ini sangatlah efektif dalam mengatasi masalah psikososial penderita tb, terbukti dengan hasil penelitian yang signifikan dimana terdapat perbedaan yang bermakna dari tingkat depresi, cemas dan stres kelompok intervensi dan kelompok kontrol. simpulan dan saran simpulan hasil penelitian dapat disimpulkan bahwa terapi psikoedukasi terbukti efektif menurunkan tingkat stres, cemas dan depresi pada penderita tb paru. pada penelitian ini juga dapat disimpulkan bahwa dalam memberikan terapi psikoedukasi haruslah mempertimbangkan latar belakang pendidikan dari penderita. pada umumnya mereka yang menderita penderita tb paru adalah mereka yang berlatar pendidikan rendah dan miskin, karena itu psikoedukasi baik pasif maupun aktif harus dilakukan menggunakan bahasa awam, bukan bahasa ilmiah. saran saran kepada perawat puskesmas penanggung jawab pengobatan tb paru di rumah sakit dan puskesmas untuk selalu mengkaji masalah psikososial penderita tb. perawat juga diharapkan melakukan terapi psikoedukasi bagi mereka dengan bahasa yang dimengerti oleh penderita. kepada kepala puskesmas disarankan untuk membuat ruangan pojok konseling bagi penderita tb dan memperbanyak booklet mengatasi masalah psikososial pada penderita tb yang dihasilkan pada penelitian ini untuk dibagikan pada penderita yang datang berobat ke puskesmas kepustakaan (who), w.h. organization, 2010. multidrug and extensively drug-resistant tb (m/xdr-tb): 2010 global report on surveillance and response., geneva. aye´, r. et al., 2011. factors determining household expenditure for tuberculosisand coping strategies in tajikistan. tropical medicine and international health, 16(3), pp.307–313. b., v. & s., p., 2013. psychosocial trauma of diagnosis: a qualitative study on rural tb patients’ experiences in nalgonda district, andhira pradesh. indian journal of tuberculosis, 60, pp.162 – 167. bauml et al., 2006. psychoeducation: a basic psychotherapeutic intervention for patients with schizophrenia and their families. schizophrenia bulletin, pp.s1– s9. dahlan, s.m., 2011. statistik untuk kedokteran dan kesehatan. deskriptif, bivariat, dan multivariat dilengkapi aplikasi dengan menggunakan spss (d.j. ishardini, ed) 5th ed., jakarta: salemba medika. donker, t. et al., 2009. psychoeducation for depression, anxiety and psychological distress: a meta-analysis. bmc medicine, 7(1), p.79. available at: http://www.biomedcentral.com/17417015/7/79. jong, k., 2011. psychosocial and mental heanth interventions in areas of massive violence 2nd ed., medecins san frontier. amsterdam: rozenberg publishing services. jurnal ners vol. 11 no. 1 april 2016: 128-133 133 kaliakbarova, g. et al., 2013. psychosocial support improves treatment adherence among mdr-tb patients: experience from east kazakhstan. the open infectious diseases journal, 7, pp.60–64. moult, b., franck, l. & h., b., 2004. ensuring quality information for patients: development and preliminary validation of a new instrument to improve the quality of written healthcare material. health expectations, 7(2), pp.165–173. padayatchi, a. et al., 2010. case series of the long-term psychosocial impact ofdrug resistant tuberculosis in hiv-negative medical doctors. international journal tuberculosis lung disesase, 14(8), pp.960–966. suryani et al., 2014. psychosocial need analysis of patients with pulmonary tuberculosis. makara journal of health research, 18(3). http://e-journal.unair.ac.id/jners | jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.17599 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the risk of mortality on patients with traffic accidents of emergency department at dr. soebandi regional hospital, jember regency baskoro setioputro, indah listiyawati, kholid rosyidi muhammad nur jember university, east java, indonesia abstract introduction: the number of deaths due to traffic accidents has become a global burden. in addition sdgs 2030 has set a target to decrease the number of fatalities and global injuries due to traffic accidents. the purpose of this study was to analyse the risk of mortality due to traffic accidents in the emergency department (ed) of dr.soebandi hospital regional, jember regency. methods: a retrospective observational study was carried out in the ed by studying medical records of the traffic accident patients aged ≥16 years. the sampling technique was simple random sampling with sample size 250. the study collected data with modified rapid emergency medicine score. this study result was analyzed with frequency distribution and chi-square test. results: the result showed respondents who experienced traffic accidents were mostly 20-29 years old (19.6%). the majority of the patients were men (68.4%). the riders of two/three-wheeled vehicles who suffered traffic accidents reached 73.2%. most of the accidents occurred between 06.00-11.59am, 37.6%. generally, traffic accidents occur to drivers as much as 68.4% and the number of types of head trauma as much as 57.2%. this study showed that 94.8% patients were at low risk of mortality. there was significant relationship between risk of mortality and the role in vehicle use (p-value = 0.043). conclusion: almost all patients have a low risk of mortality in the ed of dr. soebandi hospital jember regency. article history received: january 27, 2020 accepted: april 26, 2020 keywords risk of mortality; emergency department (ed); traffic accident. contact baskoro setioputro  bsetioputro@gmail.com  jember university east java, indonesia cite this as: setioputro, b., listiyawati, i., & nur, k. r. m. (2020). the risk of mortality on patients with traffic accidents of emergency department at dr. soebandi regional hospital, jember regency. jurnal ners, 15(1), x-x. doi:http://dx.doi.org/10.20473/jn.v15i1.17599 introduction traffic accidents can increase mortality rates for vulnerable road users, such as bicycle riders, motor riders and pedestrians. mortality rate due to traffic accidents is still a global burden and the 3.6th target of the sustainable development goals 2030 program (sdgs) is to reduce half of global mortality and injury rates by 2020 (who, 2018; ilo, 2018). during the period 01 january to 30 december 2018, the number of traffic accidents in indonesia reached 108,873 accidents with a total mortality of 25,511 people (national traffic police, 2019). one of the provinces contributing mortality rates due to traffic accidents is east java. the number of traffic accidents in east java during the period 01 april to 30 june 2019 reached 423 accidents with a total mortality of 104 victims (national traffic police, 2019). on the other hand, jember police data revealed that traffic accidents in 2018 reached 1,260 accidents with a total mortality of 379 victims (wahyunik, 2019). traffic accidents can cause emergency condition for the victim (ministry of health of the republic of indonesia, 2016). therefore it requires treatment within the first hour or what is often called as the golden period to save the victim (korlantas polri, 2019). one of the initial steps to save victims is determining risk of mortality in prioritizing victim care in health facilities. the rapid emergency medicine score (rems) observation sheet can be used to determine patient’s risk of mortality (seak et al., 2017). based on research by nakhjavan-shahraki, bikpour, youseifard, nikhseresht, razaz, faridaalaee, and hossein (2017), rems can predict mortality events and adverse effects on patients in the emergency department. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i1.175991 b. setioputro et al. | pissn: 1858-3598  eissn: 2502-5791 however, rems has a lower validity value than the modified rapid emergency medicine score (mrems) in determining the incidence of mortality in trauma patients. rems validity value is 91.1% and 92.1% for mrems. in addition, mrems is suitable to apply in trauma cases. mrems is better than some other trauma scores, such as the mechanism of glasgow coma scale and arterial pressure (mgap), revised trauma score (rts), injury severity score (iss), shock index (iss), and shock index si). mrems score range is between 0 and 26. patients who have mrems score 0 to 2 reached 70 mortalities (0.03%) out of 221,684 victims, while trauma patients having mrems score 22 to 26 reached 1,781 mortality (91.2%) out of 1,952 victims. the higher the value of mrems, the higher the mortality rate of patients with trauma (miller et al., 2017). the mrems instrument consists of age, systolic blood pressure (sbp), heart rate (hr), respiratory rate (rr), oxygen saturation, and glasgow coma scale (gcs). these variables are needed by the ems (emergency medical service) officer or triage officer to check the patient's health status in making the decision to transport the victim to the most appropriate facility (miller et al., 2017). thus, it is important to know the score of the mrems at the hospital ed, which is the first emergency service. emergency services are expected to prevent the risk of disability and mortality in patients (to save life and limb) (korlantas polri, 2019). emergency departments experience an increase in the number of patient visits each year (deviantony et al., 2017). based on data from the dr. soebandi regional hospital emergency department there were 2,402 patients with traffic accident in 2018. therefore, it is important to know the patient's condition in preventing mortality, especially in the hospital emergency department. the assessment of mortality scores with mrems is unknown in the dr. soebandi regional hospital emergency department. this study aimed to analysis the risk of mortality patients with traffic accidents in the dr. soebandi regional hospital emergency department, jember regency materials and methods quantitative research with retrospective approach was used in this study. retrospective observational research is a research conducted on events that have occurred to see the risk factors of the causes of these events (nursalam, 2015). this research was conducted for one month (december 2019-january 2020) using a variable risk level of patient mortality due to traffic accidents and the risk factors for mortality in the dr. soebandi regional hospital, emergency department, jember regency. the population in this study is the data of medical records of patients with traffic accidents in the dr. soebandi regional hospital, emergency department, jember regency in january to december 2018; there were 2,402 population while the number of samples used in the study was 250. this study used probability sampling, which is a sampling technique by giving equal opportunities to each population to be selected as a sample (sastroasmoro & ismael, 2014). the technique in sampling used simple random sampling by randomization. this technique is a random sampling technique without considering strata in the population (sugiyono, 2015). the instrument used in this study was the mrems observation sheet. the mrems component consists of age, sbp, hr, rr, spo2 and gcs that are measured when the patient is in the first triage or during the primary survey. the auc value of mrems has been tested for validity and reliability by miller, nazir, mcdonald and cannon (2017) of 0.967 (95% ci (confidence interval): 0.9630.971) which means that the validity level of mrems is 96.7% to predict mortality of trauma patients in the hospital. mrems had three categories in the risk of mortality: low risk (score 0-8), moderate risk (score 9-17), and high risk (18-26) (miller et al., 2017). this study employed univariate analysis of patient characteristics (such as age, education, gender, and occupation), season, day of traffic accident, time of traffic accident, type of road, role of patient using vehicle, type of trauma, patient information and level risk of mortality. the component is analyzed by percentage and frequency distribution. this study also employed bivariate analysis with chi-square test. the chi-square test was used for relationship between categorical variables with the risk of mortality (p<0.05). the research ethics were approved on october 21, 2019, by the ethics committee of the faculty of dentistry, university of jember based on a certificate of ethical qualification number 594 / un25.8 / kepk / dl / 2019. results respondent characteristic, risk factors, and risk of mortality of traffic accident patients were analyzed in this present study. table 1 shows that the highest data of traffic accident patients characteristic in the dr. soebandi regional hospital, emergency department, jember regency, in 2018 was age group of 20-29 years with 49 patients (19.6%), and 171 male patients (68.4%) with 94 high school education level patients (37.6%). based on the type of employment often involved in crashes are farmers with 57 patients (22.8%). table 1 shows that the characteristics of respondents’ age, gender, education, and job had no significant relationship with risk of mortality. table 2 shows that, according to type of user, 2/3wheeled motorized vehicles with about 183 patients (73.2%) became the highest case. based on the distribution of the day, the highest accident occurrence was on wednesday as many as 46 patients (18.4%) and sunday as many as 40 respondents (16%), while based on the time of the incident there were 94 patients (37.6%) who had an accident at 06.00-11.59am. there were 134 respondents (54.0%) who had accidents in the dry season jurnal ners http://e-journal.unair.ac.id/jners | dominated by drivers as many as 171 respondents (68.4%). the most types of trauma were head trauma of 143 respondents (57.2%) out of 250 respondents and referral patients were 158 respondents (63.2%). table 2 found significant relationship in the role in vehicle use between risk of mortality (p = 0.043 <0.05), but there wasn’t a significant relationship in type of road, the day of occurrence, time of occurrence, season, type of trauma and patient information between the risk of mortality. table 3 illustrates the level of risk of mortality of patients due to traffic accidents in the dr. soebandi regional hospital emergency department in jember regency that in 2018 there were 237 patients (94.8%) who had a low risk of mortality. the high risk of mortality is 12 patients (4.8%) and the lowest level risk of mortality is a high risk of one patient (0.4%) discussion this study analyzed 250 medical records from patients with traffic accident in the dr. soebandi regional hospital, emergency department, jember regency. most of the study samples or 237 patients (94.8 %) had a low risk of mortality. trauma patients death reached 6.0% with the highest proportion of head /spinal trauma patients (67%) (eaton et al., 2017). in addition, other studies also showed 4.5 % deaths in motorbike traffic accident, treated in ward (82.5%) and icu (13%) (fouda et al., 2016). the high risk of mortality was caused by traffic accident. traffic accidents can cause casualties to become an emergency (ministry of health of the republic of indonesia, 2016). an emergency case is a situation that can threaten a victim's life. emergency case requires immediate treatment to reduce the table 1. the relationship between the characteristics of patients with the risk of mortality in the ed of dr. soebandi hospital, jember regency, in 2018 (n = 250) characteristics of respondents risk of mortality frequency totals low risk moderate risk high risk n % n % n % n % age 16-19 43 95.6 2 4.4 0 0 45 100 20-29 48 98 1 2 0 0 49 100 30-39 31 100 0 0 0 0 31 100 40-49 45 93.8 3 6.2 0 0 48 100 50-59 35 94.6 2 5.4 0 0 37 100 60-69 27 87.1 3 9.1 1 0,1 31 100 >69 8 88.9 1 11.1 0 0 9 100 totals 237 94.8 12 4.8 1 0.4 250 100 chi-square test p = 0.427 gender man 164 95.9 6 8.2 1 0,6 171 100 woman 73 92.4 6 7.6 0 0 79 100 totals 237 94.8 12 4.8 1 0.4 250 100 chi-square test p = 0.299 education not schooling 16 84.2 3 15.8 0 0 19 100 primary school 84 94.4 4 4.5 1 0,4 89 100 middle school 28 93.3 2 6.7 0 0 30 100 senior high school 92 97.9 2 2.1 0 0 94 100 college 17 94.4 1 5.6 0 0 18 100 totals 237 94.8 12 4.8 1 0.4 250 100 chi-square test p = 0.380 job not working 6 100 0 0 0 0 6 100 government employees 11 100 0 0 0 0 11 100 general employees 40 90.9 3 6.8 1 2.3 44 100 entrepreneur 47 97.9 1 2.1 0 0 48 100 housewife 19 82.6 4 17.4 0 0 23 100 farmer 54 94.7 3 5.3 0 0 57 100 student 48 98 1 2 0 0 49 100 etc (driver, pedicab and wood driver, fisherman, trader ) 12 100 0 0 0 0 12 100 totals 237 94.8 12 4.8 1 0.4 250 100 chi-square test p = 0.301 * a statistically significant (p < 0.05) b. setioputro et al. | pissn: 1858-3598  eissn: 2502-5791 threat of life and an emergency situation needs to be handled quickly and appropriately to avoid the threat of life and disability in the limbs of the victim (musliha, 2010). thus, this requires treatment in the first hour, or what is often called the golden period, to save the victim's condition (kartikawati, 2012). there are trimodal mortality patterns in trauma. the first periode is the risk of mortality caused by disorders of the heart, large blood vessels, brain and spinal cord system. the second periode is is the risk of mortality table 2. the relationship between the type of road, day of occurrence, time of occurrence, season, role in vehicle use, type of trauma and patient information with the risk of mortality in the ed of dr. soebandi hospital, jember regency, in 2018 (n = 250) variable risk of mortality frequency totals low risk moderate risk high risk n % n % n % n % type of road pedestrian 47 87 6 11.1 1 0,2 100 non-motorized vehicle users 8 100 0 0 0 0 8 100 user of 2/3-wheeled motorized vehicles 177 96.7 6 3.3 0 0 183 100 motorized vehicles ≥ 4-wheeled motor 5 100 0 0 0 0 5 100 totals 237 94.8 12 4.8 1 0.1 250 100 chi-square test p = 0.122 day of occurrence monday 29 87.9 4 12.1 0 0 33 100 tuesday 32 94.1 2 5.9 0 0 34 100 wednesday 44 95.7 2 4.3 0 0 46 100 thursday 33 100 0 0 0 0 33 100 friday 25 92.6 2 7.4 0 0 27 100 saturday 35 94.6 2 5.4 0 0 37 100 sunday 39 97.5 0 0 1 0,4 40 100 totals 237 94.8 12 4.8 1 0.1 250 100 chi-square test p = 0.350 time of occurrence 06.00-11.59 am (morning) 89 94.7 5 5.3 0 0 94 100 12.00-17.59 am (noon) 69 95.8 3 4.2 0 0 72 100 18.00-23.59 am (night) 61 95.3 3 4.7 0 0 64 100 00.00-05.59 am (early day) 18 90 1 5 1 5 20 100 totals 237 94.8 12 4.8 1 0.1 250 100 chi-square test p = 0.070 season dry 129 95.6 5 3.7 1 0.7 135 100 rain 108 93.9 7 6.1 0 0.4 115 100 totals 237 94.8 12 4.8 1 0.1 250 100 chi-square test p = 0.448 role in vehicle use pedestrian 47 87 6 11.1 1 1.9 54 100 driver 166 97 5 2,9 0 0 171 100 passenger 24 96 1 4 0 0 25 100 totals 237 94.8 12 4.8 1 0.1 250 100 chi-square test p= 0.043 type of trauma head trauma 130 90.9 12 8.4 1 0.7 143 57.2 facial trauma 32 100 0 0 0 0 32 12.8 neck and spinal trauma 4 100 0 0 0 0 4 1.6 chest trauma 5 83.3 1 16.7 0 0 6 2.4 abdomen and pelvic trauma 5 100 0 0 0 0 5 2 upper extremity of trauma 52 98.1 1 1.9 0 0 53 21.2 lower extremity trauma 95 95 4 4 1 1 100 40 totals 323 129.2 18 7.2 2 0.8 343 137.2 chi-square test p = 0.689 patient information tranfer patient 147 93 10 6.3 1 0.6 158 100 non-transfer patient 90 97.8 2 2.2 0 0 92 100 totals 237 94.8 12 4.8 1 0.1 250 100 chi-square test p = 0.245 * a statistically significant (p < 0.05) jurnal ners http://e-journal.unair.ac.id/jners | caused by intracranial bleeding, pelvic fracture and tears in solid organs bleeding. the third periode is the risk of mortality caused by sepsis, failure of some respiratory organs or other complications (american college of surgeons, 2018; kartikawati, 2012; sheehy, 2013 ). this study showed one referral patient experienced the highest risk of mortality with an mrems score 25. patient had traffic accident between pedestrians and motorbikes on sunday at 04.00am. the traffic accident was in early morning with vehicle tending to speeding because there are not many vehicles on the road. according to rompis, mallo, and tomuka (2016), the slower the vehicle on the road, the higher the severity of the patient's condition due to traffic accidents. on the other hand, this 68-yearold patient was also diagnosed with brain hemorrhage and open fracture femur, systolic blood pressure (78mmhg), heart rate (39 x/min), respiratory rate (5x/min), spo2 (74) %), and gcs (3). hemorrhagic brain can increase intracranial pressure, which increases the risk of cerebral hypoxia (lack of oxygen), cerebral necrosis, cerebral ischemia, brain tissue edema, and brain herniation. open fracture femurs can cause massive bleeding according to the location of the fracture and its trauma ( sheehy, 2013; ulya et al., 2017). these conditions can increase patient’s risk of mortality. in addition to the types of trauma above, the patients' vital signs are in the abnormal range. according to ha et al. (2017), the vital signs of patients experiencing the risk of mortality are patients with abnormal vital signs and as much as 5% risk of mortality with respiratory distress from the first eight hours to 48 hours. systolic blood pressure, gcs, and rr also affect the risk of mortality. the lower the value of systolic blood pressure, gcs, and rr the higher risk of mortality (ristanto et al., 2016). sbp (<90mmhg) can predict the risk of patient mortality (liu et al., 2012). if the spo2 is lower (<90%), it can increase the risk of mortality within 24 hours (ha et al., 2017).age also plays a role in determining the level of risk of mortality in trauma patients. lingsma, roozenbeek, steyerberg, murray, and maas (2010), showed that the older the age of the patients, the worse their condition. this was caused by decreased neurological function and disability conditions increased. the role in vehicle use has significant relationship with risk of mortality (p = 0.043). the role in vehicle use as drivers often experiences traffic accidents (68.4%). drivers had the risk of mortality (67.8 %) due to traffic accident in tomohon. this incident was caused by an undisciplined driver using a seat belt, on the motorist’s helmet and completeness of the letter, the condition of the driver who was tired, drunk (or the influence of alcohol and drugs) and / or sleepy (rompis et al., 2016). drivers had 66,2% experience of traffic accidents (angela et al., 2013). thus, researchers assume that drivers have higher risk of mortality due to traffic accidents. the age group of 20-29 years often experiences traffic accidents (19.6%). generally traffic accidents at guilan province medical center occur in the age group of 20-29 years (32.2%) (amiri et al., 2016). other studies show that ages 21-30 years dominate traffic accidents (33.46%) (yogesh, 2015). so it can be seen that the productive age group and adult contribute in the occurrence of traffic accidents. this is because these age groups have anger and are less stable. as a result, there is lack level of caution and discipline in using vehicles and roads (rompis et al., 2016). researchers assume that traffic accidents often occur in the age group 21-29 years with status as students and workers due to the time when the accident happened; 6 am to 11.59am is the time where students go home and go to school. however, based on chi-square test, there is no significant relationship between the age group and risk of mortality (p = 0.427). type of road user who frequently experience traffic accidents are 2-wheeled or 3-wheeled motor riders (73.2%). motorcycle users often experience traffic accidents (53.78%) (wicaksono et al, 2014). another study explained that the number of motorcycle users who experienced traffic accidents was 65% (herawati, 2014). this is due to an increase in the number of motorized vehicles, which in developing countries sees an increase occurred in two-wheeled motor vehicles and buses (nugroho & yulianti, 2016). on the other hand, drivers and passengers of motorized vehicles are not protected by security as are car drivers (rompis et al., 2016). researchers assume that two or three-wheeled motorized vehicle users have a vulnerability to traffic accidents due to lack of safety driving behavior. however, the chi-square test showed no significant relationship between type of vehicle and the risk of mortality (p = 0.122> 0.05). traffic accident patients at the ed of dr. soebandi regional hospital, jember regency, in 2018 often occurred from 06.00-11.59am (morning) (37.6%). this research is in line with the results of herawati's research (2014), stating that the highest number of traffic accidents occurred 06.00-12.00am and 12.0018.00pmeach as much as 31%. most traffic accidents occurred at 12.00-18.00pm (31.74%) (wicaksono et al., 2014). other research also explains that 12.0018.00pmis a time that often occurs traffic accidents, by 44% (saputra, 2017). this is because at 06.00table 3. overview risk of mortality of traffic accident patients (n = 250) mortality risk frequency (n) percentage (%) low risk moderate risk high risk 237 12 1 94.8 4.8 0.4 total 250 100 b. setioputro et al. | pissn: 1858-3598  eissn: 2502-5791 11.59am and 12.00-17.59pmare the peak of outdoor activities, which means that people tend to go out at the same time, either for going to school or having lunch, so that the level of traffic accidents is greater (rompis et al., 2016). although traffic accident tends to increase in a specific time, there is no significant relationship between time of traffic accident and risk of mortality (chi-square test p = 0.070 > 005). furthermore, the number of male patients in the ed of dr. soebandi regional hospital due to traffic accidents reached 68.4%. but the gender does not have significant relationship with risk of mortality (p = 0.299 > 0.05). male dominates the incident of traffic accidents by 88.5% (katageri et al., 2015). the fatalities were primarily male (98.5%) (kotwal et al., 2019). the ratio of injuries due to traffic accidents between men and women is 8.4: 1 (hosseinpour et al., 2017). furthermore, traffic accident victims who experienced mortality in the city of tomohon for the 2012-2014 period were 84.75% men (84.75%) (rompis et al., 2016). gender which frequently experiences traffic accidents is men. factors that cause an increase in traffic accidents in men are behavior patterns in driving, mobility levels, and male dominance on the road (oktavianti, 2016; rompis et al., 2016). in this study, traffic accident patients experienced head trauma (57.2%), and lower limb trauma (40.0%). lower extremities consist of femur, tibia, fibula, patella, tarsal, metatarsal, and phalanges (ros & wilson, 2014). other studies also explained that head trauma due to traffic accidents reached 87.8% and external trauma as much as 92.8% (nugroho& yulianti, 2016). the type of trauma that usually occurs in traffic accident victims is extremity trauma as much as 28% (yogesh et al ., 2015). generally, head and neck trauma is experienced by victims of traffic accidents by 26.4% (amiri et al., 2016). head trauma is caused due to negligence in the use of helmets. the use of helmets can reduce the incidence of severe head injuries by 70%. traumatic injuries also often occur due to traffic accidents because of primary impact or secondary impact; secondary impact is caused by a collision with an opposing vehicle and / or highway (oktavianti, 2016). the highest mortality rates occur in patients with chest trauma (22.2%) and head trauma (14.7%) (fouda et al., 2016). this research result showed no significant relationship between type of trauma and risk of mortality (p = 0.689). the limitation of this study was it only analyzed medical record patients in one year and only in one hospital. this study cannot show risk of mortality trend due to regulation change that makes patients go to first referral hospitals. conclusion the conclusion of this research was that almost all patients with traffic accident in the ed dr.soebandi regional hospital (94.8%) had low risk of mortality. traffic accidents often occured in the age group of 20 to 29 years (19.6%) and the male group (68.4%). traffic accidents were often experienced by riders of 2 or 3-wheeled motor vehicles (73.2%), while the highest type of trauma in traffic accident patients was head trauma (41.7%). there was a significant relationship between the role in vehicle use with the risk of mortality. future studies can focus on the prevention risk of mortality for patients due to traffic accidents according to role in vehicle use. the clinical implication of this research is a source of data for health workers to make clinical decisions at various levels risk of mortality for patients with traffic accidents. this is expected to prevent worsening in the patient's condition. references amiri, z. m., dastgiri, s., davoudi-kiakalyeh, a., imani, a., & mollarahim, k. (2016). an epidemiological study of road traffic accidents in guilan province, northern iran in 2012. bull emerg trauma, 4(4), 230–235. deviantony, f., ahsan, & setyoadi. (2017). analisis faktor yang berhubungan dengan waktu tunggu pasien setelah keputusan rawat inap diputuskan di zona kuning instalasi gawat darurat rsd dr.iskak tulungagung. 2(2). eaton, j., grudziak, j., bilal, a., chisenga, w. c., hadar, e., & charles, a. (2017). the effect of anatomic location of injury on mortality risk in a resourcepoor setting. journal injury, 48(7), 1432–1438. https://doi.org/10.1016/j.injury.2017.05.023 fouda, e. y., youssef, m., & emile, s. h. (2016). pattern of major injuries after motorcycle accidents in egypt : the mansoura pattern of major injuries after motorcycle accidents in egypt : the mansoura emergency hospital experience. journal sage, 19(june), 39–45. https://doi.org/10.1177/1460408616652924 ha, d. t., dang, t. q., tran, n. v, pham, t. n. t., nguyen, n. d., & nguyen, t. v. (2017). development and validation of a prognostic model for predicting 30day mortality risk in medical patients in emergency department (ed). nature publishing group, (march). https://doi.org/10.1038/srep46474 herawati. (2014). karakteristik dan penyebab kecelakaan lalu lintas di indonesia tahun 2012. warta penelitian perhubungan, 26, 133–142. hosseinpour, m., mohammadian-hafshejani, abdollahesmaeilpour aghdam, m. m., & mahdi maleki, f. (2017). trend and seasonal patterns of injuries and mortality due to motorcyclists traffic accidents; a hospital-based study. journal emerg trauma, 5(1), 47–52. ilo. (2018). tujuan pembangunan millenium; referensi manual serikat pekerja pada agenda untuk pembangunan berkelanjutan 2030. jakarta: organisasi perburuhan internasional. katageri, s., sharma, r. b., govindaraju, h. c., & singh, a. k. (2015). pattern of injuries in road traffic accidents at chitradurga karnataka: an autopsy jurnal ners http://e-journal.unair.ac.id/jners | based study. journal of indian academy of forensic medicine, 37(2), 173–175. https://doi.org/10.5958/09740848.2015.00042.1 korlantas polri. (2019). korlantas polri. lingsma, h. f., roozenbeek, b., steyerberg, e. w., murray, g. d., & maas, a. i. (2010). early prognosis in traumatic brain injury: from prophecies to predictions. the lancet neurology, 9(5), 543–554. https://doi.org/10.1016/s1474-4422(10)70065x liu, y., liu, j., fang, z. a., shan, g., xu, j., qi, z., … yu, x. (2012). modified shock index and mortality rate of emergency patients. world j emerg med, 3(2), 114–117. miller, r. t., nazir, n., mcdonald, t., & cannon, c. m. (2017). the modified rapid emergency medicine score : a novel trauma triage tool to predict inhospital mortality. injury, 8. https://doi.org/10.1016/j.injury.2017.04.048 nugroho, a. a., & yulianti, k. (2016). karakteristik luka pada korban kecelakaan lalu lintas di instalasi kedokteran forensik rsup sanglah pada tahun 2012. e-jurnal medika, 5(3). nursalam. (2015). metodologi penelitian ilmu keperawatan: pendekatan praktis. jakarta: salemba medika. oktavianti, p. h. (2016). prevalensi dan gambaran pola luka korban kecelakaan sepeda motor di instalasi forensik rsup sanglah denpasar tahun 2013 putu herlin oktavianti program studi pendidikan dokter , fakultas kedokteran universitas udayana abstrak kecelakaan lalu lintas merupak. directory of open access journals, 7(1), 33–41. https://doi.org/e-issn: 2503-3638 ristanto, r., indra, m. r., poeranto, s., & setyorini, i. (2016). kata kunci : mortality, pasien cedera kepala, rts. jurnal kesehatan hesti wira sakti, 4, 76–90. rompis, a., mallo, j., & tomuka, d. (2016). kematian akibat kecelakaan lalu lintas kota tomohon tahun 2012-2014. jurnal e-clinic, 4(1). https://doi.org/10.35790/ecl.4.1.2016.10837 saputra, a. d. (2017). studi tingkat kecelakaan lalu lintas jalan di indonesia berdasarkan data knkt ( komite nasional keselamatan transportasi ) dari tahun 2007-2016. warta penelitian perhubungan, 29(2), 179–190. sastroasmoro, s., & ismael, s. (2014). dasar-dasar metodologi penelitian klinis (5th ed.). jakarta: cv. sagung seto. seak, c., yen, d. h., ng, c., & wong, y. (2017). rapid emergency medicine score : a novel prognostic tool for predicting the outcomes of adult patients with hepatic portal venous gas in the emergency department. 1–9. sugiyono. (2015). statistik untuk penelitian. bandung: alfabeta. wahyunik, s. (2019). laka lantas di jalan basuki rahmat jadi kasus kecelakaan pertama yang terjadi di jember pada 2019 tribun madura. jember. who. (2018). global status report on road safety 2018. wicaksono, d., fathurochman, r. a., & riyanto, b. (2014). analisis kecelakaan lalu lintas. jurnal karya teknik sipil, 3, 203–213. yogesh, g. (2015). pattern of injuries in fatal road traffic accidents : autopsy based study. journal of evidence based med & hlthcare, 2(4), 321–327. http://e-journal.unair.ac.id/jners | 267 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17146 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review analysis of the nurse’s behavior toward helping a patient with a mental health problem: a systematic review darni darni, siti khadijah and sitti sulaihah faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: nurses have the role of helping in the healing process of patients through their knowledge, attitudes and actions. several studies have shown that nurses frown when serving patients and this worsens the patient’s condition. the aim of this study was to analyze about nurse behavior towards people with mental disorder. method: the articles were obtained from a search through the scopus, google scholar, science direct and proquest database. result: article searches began in 2014 until 2018 and found 8 article which match the inclusion criteria. after the articles were obtained, a study was then carried out up until the stage of making a systematic review. conclusion: the behavioral interventions of the mental health nurse will improve and accelerate the recovery of the patients with mental disorders. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords nurse behaviour; mental health; mental disorder; recovery contact darni  darni.resky86@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: darni, d., khadijah, s., & sulaihah, s. (2019). analysis of the nurse’s behavior toward helping a patient with a mental health problem: a systematic review. jurnal ners, 14(3si), 267-271. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17146 introduction mental health is an integral part of overall health and health efforts need to be increasingly in line with the progress of society, namely by the presence of urbanization, industrialization and modernization. someone who has a mental disorder will experience the inability to function optimally in their daily lives. a person's behavior is considered to be abnormal and this is thought to be disturbed by their soul if this occurs for no reason that is reasonable or of it is excessive, lasts for a long time and causes hendaya towards the individual over others (maramis, 2018). a mental disorder is a disorder of thoughts, feelings or behaviors that cause suffering and disruption of daily functions. to deal with mental patients, the nurses have a big role to help in the healing process of the patients, namely with their knowledge, attitudes and actions. the attitude of the nurses is usually displayed in the form of empathy and being willing to listen to patient complaints, while the form of action is to provide physical therapy to the patients so then the patients will immediately experience an increased awareness of their attitude and the act of giving therapy such as group therapy and other forms of therapy for the patients. this is considered to be very good at helping to speed up the healing process of mental health patients (ri ministry of health, 2018). the nurses must create an environment in such a way that the patients feel safe, comfortable, accepted, protected and get attention. the nurses should also play a most important role as an an intermediary between the patients and doctors. everything must be done with full softness, sincerity and compassion to alleviate the suffering of the patients. some of the studies focused on the quality of the care personnel services indicate that poor service quality is caused by the nurses who are sullen when serving their patients. how deft and professional the nurse is in carrying out the nursing care can cause a deterioration of the state of the mental patients or not. success in meeting customer satisfaction is not only seen from the ability of the nurses to carry out their duties in accordance with their professionalism but their success can be reviewed through the attitude and empathy of the nurses as people who need sufficient attention in accordance with what is needed. the nurses are demanded not only to have the skill of creating a therapeutic environment and to establish a relationship of mutual trust with the patients, but they also must provide quality services and improve the image of the profession and the image of the hospital where the nurse https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). darni et al. 268 | pissn: 1858-3598  eissn: 2502-5791 works(moleong, 2018). however, in reality and according to the results of the observations, the researchers indicated that the quality of care, especially the nursing care that was implemented or carried out, was still very poorly marked by the large number of patients living and engrossed in their own world or sitting alone without a nurse, family or other patients. because of that, nursing care should be more focused on the patients, not only to restore the patient's condition but with the aim of developing and improving the patient's ability to deal with their own problems (ri, 2018). this systematic review aims to identify and summarize the main focus based on scientific evidence about the burden of nurses as the providers of care for people with mental disorders, as well as the behavior, knowledge, attitudes and actions of the nurses themselves. materials and methods literature search strategy the literature used in this systematic review was via 3 (three) electronic databases, namely scopus, sciencedirect and proquest. the articles were published within the limits of 2014 through to 2019. the keywords used were "nurse behavior" and "caring" or "mental disorder". furthermore, the method chosen was qualitative. criteria for inclusion and exclusion the study designs focused on were those with a qualitative design published in english. the population of the systematic review was both male and female nurses. clinical results the main result, which was the main goal of the systematic review, was to see the themes used in the systematic review. the research used was without any time limit. study selection the standard protocol for selecting the studies is as suggested in the systematic review method guide, known as prisma. the steps taken were (1) removal of duplications; (2) the independent examination of the titles, abstracts and keywords. citations were deleted if they were not relevant according to the inclusion criteria; (3) if the title and abstract seem to meet the inclusion criteria and they are in accordance with the objectives of the systematic review, the next step is the selection of the journals according to their full text; (5) the final step was the selection of the journals using the randomized controlled trial approach to reduce the risk of bias. the data was extracted from each study that fulfilled the requirements. the data extracted includes the characteristics of the study, the characteristics of mindfulness, the characteristics of the results and the summary of the results. for the data analysis, the studies were grouped according to the nature of the qualitative studies, the nurse’s behavior, caring and mental disorder. figure 1. diagram of prisma result literature search and study selection searching for the literature in accordance with the keywords in the scopus database found 42 articles, while there were 53 articles in science direct and 38 articles in bmc (health services). in total, 53 articles were the same and there were 48 potential articles according to the criteria. after selection according to the abstract, 37 were considered to be irrelevant. the remaining 8 articles that met the inclusion criteria were part of the systematic review. the sample size of 11 studies involved 23 people. the condition of the patients sampled in this study included the nurse’s behavior towards their patients. analysis of themes for collaizzi's method, there were 7 methods written by zintle, ali fakhr-movahedil, mrs. sevecen, renate amm kieft, frances ree, jane e. hyde, dr. linda carman copel phd. van mannen has 1 method written by louise ward. theme findings the themes were positive job aspects, an unsafe working environment, a challenging working environment, compromised clinical care, challenging experiences (sobekwa & arunachallam, 2015), storytelling, treatment and recovery, taking responsibility and safeguarding (ward & gwinner, 2015). the majority indicated a strong desire to be scopus (n=42) sciencedirect (n=53) bmc (n=38) database records (n=133) records excluded • not relevant (n=78) • published in chinese language (n=20) • duplication (n=12) • number of respondent < 20 (n=15) studied included (n=8) jurnal ners http://e-journal.unair.ac.id/jners | 269 able to provide care for people with mental health problems (reed & fitzgerald, 2005). there is also the patient's need-based communication to consider (graneheim, jansson, & lindgren, 2015). the barriers to the physical healthcare theme included the barriers related to the patients, their illness and treatment, the barriers related to the patients' caregivers, the barriers related to health professionals and the barriers related to the healthcare system. the physical health care practices theme included common physical health problems and current nursing practices (ra, bb, al, & dm, 2014). the motivators theme included the desire to see positive changes in the patient, receiving positive feedback, feeling useful and happy, having a sense of conscience and feeling satisfied with their profession (ra et al., 2014). the need for better physical healthcare theme included the nurses' recommendations for better physical healthcare (vizzotto et al., 2016). actions should be taken to foster positive attitudes towards people with mental illness, such as evaluating ways to do this in the nursing curricula as well as incorporating programs to promote better knowledge of mental health among practicing nurses, particularly general nurses (ramalisa et al., 2013). the findings suggest that the value of the caring encounter process leads to recommendations indicating that the use of the caring encounter can be implemented in larger hospital settings and in the physician’s clinical setting (the effects of assertiveness training in patients with schizophrenia: a randomized, single-blind, controlled study, 2013). from all of the themes obtained, 5 themes were the same according to the theme of positive work aspects (sobekwa & arunachallam, 2015). the theme of motivators included the desire to see positive changes in the patients, receiving positive feedback (paper, 2008), fostering a positive attitude towards people with mental illness and fostering a positive attitude towards people with mental illness (vizzotto et al., 2016)(paper, 2008)(eklund, tjörnstrand, sandlund, & argentzell, 2017)(ward & gwinner, 2015). the needs related to the better physical health theme included the nurses' recommendations for better physical health (vizzotto et al., 2016). themes that did not have the same theme were patient-based communication (graneheim et al., 2015) and the barriers to the theme of physical health care including the barriers related to patients, illness and care, the barriers associated with patient caregivers, the barriers associated with health professionals and the barriers related to the health care system. the theme of physical health care practices included general physical health problems and current nursing practices, as according to frances reed. the findings show the value of the caring encounter process which leads to the recommendation that the use of the caring encounter should be implemented in larger hospital settings and in the doctor's clinical setting (hyde, innes, ph, mccord, & ph, 2016). discussion the objective of this study was to describe the lived experiences and feelings of the nurses who care for mhcus in an acute admission unit at a psychiatric hospital in the western cape province. both positive and negative experiences were reported. positive experiences were the recovery of the patients, teamwork and a passion for caring. the main focus of this research was to comprehend the views of dutch nurses on how their work and their working environment contributed to positive patient experiences, clinically competent nurses, collaborative working relationships, autonomous nursing practice, adequate staffing, control over nursing practice, managerial support and patientcentered culture. they also mentioned several inhibiting factors such as the cost-effectiveness policy and transparency goals for external accountability. the purpose of this quantitative correlational study was to determine the attitudes of the omani nurses toward people with mental illness and the factors that influence their attitudes when providing health care in the ministry of health (moh) institutions. in this study, the omani nurses were asked to answer a survey consisting of three questionnaires, which were the opinions about mental illness scale (omi), the opening minds scale for health care providers (omshc) and the demographic characteristics questionnaire. the similarity of the three themes across the journals is possible because the characteristics of the respondents who were identified as participants were the same. intensive treatment in facilities is available to people experiencing acute psychiatric distress. the aim of this study was to determine the mental health nurses' opinions of physical health care for the individuals with mental illness. four main themes were determined. there were 2 themes that were the same but different from the theme above as seen in the terms related to knowledge and education. the barriers to physical healthcare theme included the barriers related to the patients, their illness and treatment, barriers related to the patients' caregivers, barriers related to the health professionals and barriers related to the healthcare system, the physical health care practices theme included common physical health problems and current nursing practices. the motivator theme included the desire to see positive changes in a patient, receiving positive feedback, feeling useful and happy, having a sense of conscience and feeling satisfied with their profession,. the need for a better physical healthcare theme included the nurses' recommendations for better physical healthcare, exploring the role of the nurse in patient-nurse relationships, identifying the patient’s needs and communicative behavior in the face of the patient’s darni et al. 270 | pissn: 1858-3598  eissn: 2502-5791 needs. “identifying the patient’s needs” was related to “the type of the patient’s problem”, “the patients’ inquiring about their health status” and “monitoring the patient’s health status”. positive experiences promoted through education and support is required for the nurses to improve care and attitudes. in spite of the negative attitudes expressed by 50% of participants, the majority indicated a strong desire to be able to provide care for people with mental health problems in their own community hospital. this study expects that use of the proposed caring encounter can improve the patients’ views and the hcahps scores for nursing communication and the overall rating of the hospital. two tailed ttests and ztests were conducted on the survey data. the findings demonstrate that there were some statistically significant improvements in the patients’ views of the caring post and caring encounter, compared with the patients who had not experienced the encounter. there are 3 differences from these themes; there are the obstacles when doing care, the problems regarding the nursing practice and the nursing processes in the hospitals being influenced by the doctors. the themes found that all of the studies have similarities. some have nothing in common because of the different number of samples; there were 24 samples by zintle c. sobekwa(sobekwa & arunachallam, 2015), 52 samples by louise ward(ward & gwinner, 2015), 23 samples by ali fakhr-movahedi(graneheim et al., 2015), 24 samples by renate amm kieft(paper, 2008), 60 samples by mrs. sevecen(vizzotto et al., 2016), 62 samples by frances reed(reed & fitzgerald, 2005), 65 samples by amal h gani(9) and 62 samples by hyde(hyde et al., 2016). there were different characteristics related to the respondents, such as the research by zintle c. sobekwa(sobekwa & arunachallam, 2015) on knowledge. there was also educational research by louise ward(ward & gwinner, 2015), the state by aii fakhr-movahedi(graneheim et al., 2015), and knowledge. educational research was done by frances reed(reed & fitzgerald, 2005), knowledge research was done by renate amm kieft(paper, 2008), state research by mrs. sevecen and educational research by frances reed(the effects of assertiveness training in patients with schizophrenia: a randomized, single-blind, controlled study, 2013). jane conducted knowledge-based research (hyde et al., 2016). there are several potential limitations associated with this systematic review, namely (1) the search is limited to published research, which might introduce the risk of publication bias; (2) it is possible that bias is introduced by the way that the studies are chosen or the search criteria and 3) what we consider to be the main outcome of the nurse’s behavior in psychiatric patients is not always the same as in other studies. for future research, another theme must be found and there is always the need to develop more interventions to help patients with mental health problems. conclusion this systematic review found there to be 5 themes, including the theme of positive work aspect. the theme of motivator includes the desire to see positive change in the patients, to receive positive feedback to foster a positive attitude towards people with mental illness and to foster a positive attitude towards people with mental illness. this includes their need for a better physical health theme including related to the nurses' recommendations for better physical health. in total, 3 themes were found that are not the same, namely patient-based communication, barriers to the theme of physical health care including barriers related to the patients, illness and their care, barriers associated with the patient’s caregivers, barriers associated with health professionals and barriers relating to the health care system. the theme of physical health care practices includes general physical health problems and current nursing practice. the findings of this theme show the value of the caring encounter process which leads to the recommendation that the use of a caring encounter should be implemented in larger hospital settings and in the doctor's clinical setting. references eklund, m., tjörnstrand, c., sandlund, m., & argentzell, e. (2017). effectiveness of balancing everyday life (bel) versus standard occupational therapy for activity engagement and functioning among people with mental illness a cluster rct study. bmc psychiatry, 17(1), 1–12. https://doi.org/10.1186/s12888-017-1524-7 graneheim, u. h., jansson, l., & lindgren, b. m. (2015). hovering between heaven and hell: an observational study focusing on the interactions between one woman with schizophrenia, dementia, and challenging behaviour and her care providers. issues in mental health nursing, 36(7), 543–550. https://doi.org/10.3109/01612840.2015.10075 40 hyde, j. e., innes, d., ph, d., mccord, j., & ph, d. (2016). improving patient experiences and patient views by submitted in partial fulfillment of the requirements for the degree of doctor of philosophy in leadership studies at marian university , fond du lac , wisconsin dissertation committee jon nicoud , ph . d . (december). maramis, w. . (2018). ilmu kedokteran jiwa,. surabaya: unair. moleong, l. (2018). metode penelitian kualitatif. bandung: pt. remaja rosdakarya. paper, o. (2008). the development of needs in a group of severely mentally ill. 705–713. https://doi.org/10.1007/s00127-008-0356-7 ra, k., bb, de b., al, f., & dm, d. (2014). how nurses and their work environment affect patient experiences of the quality of care: a qualitative study. bmc health services research, 14, 249. jurnal ners http://e-journal.unair.ac.id/jners | 271 ramalisa, r. j., plessis, e., koen, m. p., africa, s., africa, s., & ramalisa, r. (2013). increasing coping and strengthening resilience in nurses providing mental health care : empirical qualitative research. 1–10. reed, f., & fitzgerald, l. (2005). the mixed attitudes of nurse’s to caring for people with mental illness in a rural general hospital. international journal of mental health nursing, 14(4), 249–257. https://doi.org/10.1111/j.14400979.2005.00389.x ri, d. (2018). pedoman penggolongan diagnosa gangguan jiwa,. jakarta. ri ministry of health. (2018). guidelines for classifying psychiatric disorders. jakarta. sobekwa, z. c., & arunachallam, s. (2015). experiences of nurses caring for mental health care users in an acute admission unit at a psychiatric hospital in the western cape province. curationis, 38(2), 1–10. https://doi.org/10.4102/curationis.v38i2.1509 the effects of assertiveness training in patients with schizophrenia: a randomized, single-blind, controlled study. (2013). https://doi.org/10.1111/jan.12142 vizzotto, a. d. b., celestino, d. l., buchain, p. c., oliveira, a. m., oliveira, g. m. r., di sarno, e. s., … elkis, h. (2016). a pilot randomized controlled trial of the occupational goal intervention method for the improvement of executive functioning in patients with treatment-resistant schizophrenia. psychiatry research, 245, 148–156. https://doi.org/10.1016/j.psychres.2016.05.011 ward, l., & gwinner, k. (2015). have you got what it takes ? nursing in a psychiatric intensive care unit. 10(2), 101–116. https://doi.org/10.1108/jmhtep-08-2014-0021 http://e-journal.unair.ac.id/jners | 165 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.16549 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research developing family resilience models: indicators and dimensions in the families of pulmonary tb patients in surabaya dhian satya rachmawati1, nursalam nursalam2, muhammad amin3 and rachmat hargono1 1 faculty of public health, universitas airlangga, east java, indonesia 2 faculty of nursing, universitas airlangga, east java, indonesia 3 faculty of medicine, universitas airlangga, east java, indonesia abstract introduction: family resilience is the process of adaptation and coping in the family as a functional unit. a lack of family involvement in the care programs for tb sufferers is one of the factors of concern. the purpose of this study was to analyze the indicators of the family resilience of patients with pulmonary tb. methods: this study used an observational analytical method with a crosssectional approach. the study population was the families of new pulmonary tb sufferers in the surabaya area, taken using the rule of the thumb guideline with a sample of 130 respondents. the sampling technique using was systematic random sampling. the variables in this study were the stages of family resilience: survival, adaptation, acceptance, growing stronger and helping others, which were measured using a questionnaire. the data was analyzed using second cfa. results: the results showed that the family resilience model is also the fit model. this refers to the results of the goodness of fit test. family resilience = 0.724 survival, family resilience = 0.762 adaptation, family resilience = 0.945 acceptance, family resilience = 0.783 growing stronger and family resilience = 0.879 helping others. conclusion: the results of this study provide information on the stages of family resilience and the ability of each stage so then it can be used as a reference when developing family nursing care plans for patients with pulmonary tb. article history received: december 09, 2019 accepted: january 06, 2020 keywords family resilience; tuberculosis; cfa; adaptation; acceptance contact dhian satya rachmawati  dhian.satya.rachmawati2017@fkm.unair.ac.id  faculty of public health, universitas airlangga east java, indonesia cite this as: rachmawati, d. s., nursalam, n., amin, m., & hargono, r. (2019). developing family resilience models: indicators and dimensions in the families of pulmonary tb patients in surabaya. jurnal ners, 14(2), 165-171. doi:http://dx.doi.org/10.20473/jn.v14i2.16549 introduction the family has a very important role in maintaining optimal levels of patient health in the face of illness (samal, 2016). the family support received by the pulmonary tb patients plays an important role in improving treatment adherence. lack of family and social support predicts poor treatment adherence (py et al., 2013). good support and care from the family becomes a consideration when paying special attention to the daily routine of patients with pulmonary tb, especially in terms of medication adherence (kaulagekar-nagarkar, dhake, & jha, 2012). the family as a system can cause problems and at the same time, be effective in overcoming problems (friedman, 2010). family resilience is the process of adaptation and coping in the family as a functional unit. resilience involves dynamic processes that help them adapt to significant problems. it is this strength and the available resources that enable individuals and families to successfully face crises and problems. it is important to learn the stages of family resilience related to the pulmonary tb sufferers as well as the strength or ability in each stage of family resilience itself. in the previous studies that have discussed the stages of family resilience, they did not test the indicators of each stage tuberculosis (tb) is the leading cause of death in the world. an estimated 10.4 million people became ill with tb in 2016 of which 90% were adults, 65% were men, 10% were people living with hiv (74% in africa) and 56% were in the following five countries: https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.16549 d. s. rachmawati et al. 166 | pissn: 1858-3598  eissn: 2502-5791 india, indonesia, china, the philippines and pakistan (who, 2017). the detection rate of tb cases, also known as the case detection rate (cdr), in indonesia in 2020 is estimated to be > 70% while the success rate of tb treatment, or the success rate, is estimated to be (sr) >85%, even though indonesia is still included in the ten countries that contribute to tb cases in the world. the number of tb sufferers in indonesia ranks third in the world after india and china (who, 2017). surabaya is the second largest city in indonesia. in 2015, the number of new cases of pulmonary tb disease in surabaya was 2,330 patients, the cure rate of bta+ was 70.43%, and the success rate of the treatment provided was 79.21% (dinkes, 2015). data from the surabaya city health office in 2016 showed that the total number of tb patients in the surabaya city area was 5,389 patients, with 3,421 patients were reported by 63 public health centers and 1,968 patients reported by 33 public and private hospitals in the surabaya city area (sitt data source online version 10.04). family resilience is expected to be able to increase the independence of the family when caring for family members suffering from pulmonary tb with the end result expected that the patients will have a support system in the form of their family during the treatment process. family resilience through the 5 stages or processes indicates that when the family is faced with various problems that simultaneously occur in the family, the family will go through 5 phases of resilience. the first stage of the family resilience process is survival (survival). the second stage is where the family begins to adapt to the problems that occur, the third stage is where the family begins to accept the problems and family condition and the next stage is where the family will become stronger because they have experience handling problems. the fifth stage is where the families are able to help others who face the same problems (lietz & strength, 2016). every family going through the stages of family resilience does not always follow a sequential process. when the family has stepped into the next phase, it is possible to be thrown back to the initial phase when a new crisis occurs. in addition, in this phase, not every family will be in the same phase to begin with. the accuracy of knowing the current phase of the family and the strength of the family itself helps the family to adapt and to develop in relation to their needs (lietz & strength, 2016). family resilience shows that the family is able to be independent when caring for the family member suffering from pulmonary tb with the expected result that the patient will have a support system in their family which complies with the care process. the purpose of this study was to analyze the development of a family resilience model in the family of pulmonary tb patients. materials and methods table 1. variables and sub variables variable sub-variable survival (b) b .1 respect the family b .2 worship b .3 resolve the problem yourself b .4 dependent b .5 consulting each other b .6 strong when facing problems b .7 strong faith b .8 mutually keep feeling b .9 family will help when there is a problem b .10 be aware that the family presence is important b .11 seeking advice from religious experts adaptation (a) a .1 families can overcome things that are not desirable a .2 open minded to new ways in the family a .3 understanding among the family members a .4 asking for clarification if there are things not understood a .5 sharing responsibility a .6 awakened family confidence a .7 trying new ways to solve problems acceptance (p) p .1 accept tb disease-related difficulties as a part of life p .2 belief that they can overcome the problem and this becomes a family commitment p. 3 honest to the family p. 4 compromise if there is a problem p. 5 communicating in a relaxed and warm, even humorous, way p .6 can ask the purpose of the message that is conveyed by the family related to the success of the treatment p .7 solve the problem by discussion p .8 discussing the problem until there is a solution that can be completed and there is successful treatment p .9 open to expressing their opinion to get insights p .10 have the power to solve the problem p .11 hearing honest information p .12 understand the intentions of the other family members growing stronger (g) g. 1 becoming part of a complete family g .2 making important decisions related to the treatment of disease, especially in the family g .3 able to cope with pain and to mutually understand the effects of the disease jurnal ners http://e-journal.unair.ac.id/jners | 167 analytical observational research with a crosssectional approach was used in this study. the population in this study was the families of pulmonary tb patients who had just been diagnosed in the data collection period in the working area of the public health center in the city of surabaya. samples were taken through systematic random sampling and calculated using the rule of the thumb with a total sample of 130 respondents. the research instrument used was a questionnaire. the variables in this study are the following dimensions of the family resilience: survival (b), adaptation (a), acceptance (p), growing stronger (g) and helping others (h) as well as the dependent variable (y) of family resilience. the indicators of each dimension (sub-variable) are as follows: the data was analyzed using second confirmatory factor analysis (2cfa). this study has received the recommendation to carry out the research from the national unity, politics and community protection agency of surabaya city. it obtained ethical approval from the health research ethics commission of the faculty of nursing, airlangga university results g .4 able to adapt to the demands that befall them as a family in the presence of disease g .5 able to solve problems due to the disease correctly g .6 able to resolve the issue positively helping others (h) h .1 helping each other with the neighbors who have pulmonary tb h .2 able to survive if other problems are encountered h .3 interacting with the family and others h .4 sincerity to help others h.5 feel secure living in the family and in the social environment h .6 feel free when becoming a family member and in the social environment h .7 mutual learning from mistakes and sharing with others h .8 participate in social activities h .9 providing assistance to those in need h .10 caring for their family members and others h .11 caring for the family members of others h .12 the family is a place that is good for the members of the family family resilience (y) table 2. demographics of the respondents (n=130) indicator n % family type nuclear 88 67.7 extended 27 20.7 other type 15 11.6 socioeconomic family high 3 2.3 medium 30 23.1 low 97 74.6 position in the family husband 20 15.4 wife 47 36.2 children 31 23.8 other 32 24.6 supervisor the taking of medicine (pmo) family 93 71.5 other 37 28.5 figure 1. family resilience measurement model table 3. results of testing the family resilience model criteria cut-off value calculati on results information chi-square expecte d to be small 796.978 2 with df = 754 is 818,991 well significance probability 0.05 0.135 well rmsea 0.08 0.039 well gfi 0.90 0907 well agfi 0.90 0838 pretty good cmin / df 2.00 1,057 well tli 0.90 0.921 well cfi 0.90 0.927 well d. s. rachmawati et al. 168 | pissn: 1858-3598  eissn: 2502-5791 the results of the study focused on 130 families of pulmonary tb sufferers showed the follow results. table 2 shows that the most family type is that of a nuclear family (67.7%). most families of the pulmonary tb patients have a low socioeconomic level (74.6%). the position of the family members who were the respondents was mostly that of a wife (36.6%). the majority were the supervisors of the patients with pulmonary tb when taking their medicine (71.5%) the indicator description includes the minimum, maximum, average and standard deviation value of each indicator as presented in table 3. cfa modeling requires multivariate normally distributed data. the results of the analysis show that the cr multivariate value of 0.07 lies between the -1.96 values up to 1.96, thus showing the multivariate normal distribution of the data (table 4). next, the 2cfa modeling is presented in the following figure. the results of testing the measurement model with the complete amos program can be seen in the following table. table 3 shows that the 7 (seven) criteria used to assess the feasibility of the model were good. it can be said that the measurement model for 2cfa is acceptable, which means that there is a match between the model and the data. from the appropriate model, each path coefficient can be interpreted. the path coefficients are the hypotheses in this study which can be presented in the following structural equation: family resilience = 0.724 survival family resilience= 0.762 adaptation family resilience= 0.945 acceptance family resilience= 0.783 growing stronger family resilience= 0887 helping others discussion the families who were respondents in this study were the families of pulmonary tb patients recently diagnosed with pulmonary tb. the analysis shows that most of the families were in the ‘acceptance’ and ‘helping others’ phases. this proves that not all families undergo the series of family endurance stages sequentially. previous studies discussed the stages of the resilience of the families but they did not test the indicators of each stage. the indicators in the family resilience stages will be explained in the following discussion. survival when a family faces a crisis, loss or trauma, they will usually experience a period of time in which the family members only try to do the minimum of what is needed throughout the day. in this phase, the family has not been able to make adjustments and accept reality. the family is only trying to survive. the survival phase is the phase where the family is only able to get through the problem as it comes every day. many families explained that before making adaptations to their family life, they just have to find a way to survive. the main family strength in this phase is spiritual power and social support (lietz & strength, 2016). the results show that the respondents stated the spiritual and religious strength of the family was their most important ability in terms of overcoming and finding meaning in their struggle. during this phase, many families stated that prayer and worship were an important part of survival in the beginning of the crisis. the loading factor of each indicator shows that there are behaviors among the family members who care for each other's feelings, who feel strong when facing problems and who feel the presence of their family. this is a translation of family support and the indicator of asking for help from religious leaders had a greater value than the other indicators. following this, 67,7 % of respondents with a nuclear family type had a positive impact on family support. when an individual in a family experiences illness, all of the family members are affected because they are connected. the effect on each family member varies in terms of intensity and quality. during the survival phase, emotional support is very important. social support in this phase is more about getting help from outside of the family system, including from the extended family, friends, support groups and professionals. in this stage, the family feels an increase in the burden on the family, especially if the sick individual is the husband or wife. the results showed that 47 respondents (36.2%) were husbands. the husband, as the head of the family, has the main role of providing a decent life for their family so when the husband is sick, it will have an impact on the family. thus when a family member is sick, the rest of the family feel this as a burden. this is in line with the results of previous studies that showed that the burden of care felt by the family is related to confusion about the illness, emotions, physical, time, and financial and social burdens. this leads to a decrease in the quality of life of family and family functionality. there are opportunities for negative outcomes in relation to family resilience (fitryasari, yusuf, dian, & endang, 2018). in this stage, the family needs support from outside of the family, especially from the environment and health workers, to help the family to identify the burden of care and to improve their coping as a part of recovering from adversity. the problem for the families of tb sufferers is the misunderstanding of the family and community which leads to discrimination related to the disease (kaulagekar-nagarkar & aarti, 2012). discrimination felt at the beginning of the diagnosis is one of the causes of depression in tb patients and their families (li‐yun lee, heng‐hsin tung, shu‐ching chen, 2017). social support from the community will be meaningless if there is still stigma and discrimination felt by the tb patients and their families. fear of contracting tb is often the reason for this discrimination. in subsequent studies, this will be further investigated in terms of the effect of stigma on family resilience. in this study, the indicator which states that families are interdependent when others jurnal ners http://e-journal.unair.ac.id/jners | 169 keep away for fear of contracting the disease has no significance. this shows that at this stage, the family is still oriented towards the impact of any problems internally. this is where the family is more focused on surviving with the problems that they face, which are related to one family member suffering from pulmonary tb. the results of the analysis of the survival stage provide a 0.72 effect on family resilience in the families of pulmonary tb patients. adaptation phase this phase refers to the time that the families need to readjust their lives in order to accommodate the crisis that they face. at this time, the family may not really accept new challenges and they begin to find that they need to immediately start making changes. the adaptation phase is the time when changes are made, even before the family really accepts the nature of their current situation. the most relevant family strengths during this period were initiative, flexibility/creativity, and limitation management. initiative refers to the willingness of the families to take responsibility and to handle situations while the management of restrictions refers to the ability of the families to separate themselves from unhealthy influences (lietz & strength, 2016) family creativity is the ability to find several solutions to a problem. flexibility is the desire of families to try new things when dealing with problems or crises in the family. the results showed that all of the indicators can significantly measure the adaptability of families of the pulmonary tb patients. at this stage, the biggest loading factor value is the family clarifying a problem that is not understood (0,80). other indicators that have a large enough value include starting to understand each other (0.77), starting to try new things (0.63) and solving problems (0.73). at this stage, the family in this study by as much as 36.2% shows that the representation of the wife is in accordance with the culture in the surabaya region. this is how most of the javanese tribes will act after obtaining approval from the husband as the head of the family who is given authority by the family as decision maker. the analysis shows that the adaptation stage ranks fourth with the structural equation stating that adaptation has an effect of 0.76 on family resilience in the families of patients with pulmonary tb. acceptance the family strengths in this stage include commitment, insight, communication, and humor. family commitment refers to the dedication and strong desire of the family as a whole. the family is the first priority. when the family faces difficulties, the strength of the family commitment will make it easier for the family to keep trying to get out of trouble. the provision of interventions that facilitate social support from the family's internal system will foster close relationships and commitment among the family members, especially families at risk. insight refers to the ability of the families to gain an understanding of the problems that they face. when the families discuss accepting their situation, they identify communication as a family strength that helps them to achieve acceptance. affective communication includes expressions of love and attention. attention and is very important to foster a sense of family cohesiveness. a sense of humor is a family strength that refers to the family's ability to be light in the face of adversity. humor is discussed as something that helps them to accept their difficulties. similar to communication, this is also a sign that the reception phase is in progress. families can make their situation light. this activity reduces their pain while also showing that they are starting to accept what they are facing. the results showed that indicators p4, p6, and p10 were not significant in terms of measuring the acceptance of the family resilience stage. the indicators show that the family can be compromised if there is a problem, that they can ask for the purpose of the message delivered by the family related to the success of care, and that the family has the power to solve the problem. the four indicators above show that at this stage, the family does not have power. the indicators showing commitment, openness to discussion and communication have a great value. when the families discuss in order to accept their situation, they identify communication as a family power that helps them to achieve acceptance while also showing that acceptance does occur (walsh, 2017). the results of the analysis show that the acceptance stage ranks first with the structural equation stating that it has an effect of 0.94 on family resilience in the families of pulmonary tb patients. growing stronger growing stronger is when the families acknowledge and experience reinforcement related to the changes they have made so far. the most important family strength during this stage is assessment. when the families experience loss and difficulties but also find meaning in them, they seem to be better able to avoid the negative consequences that are usually associated with high risk situations. this stage is seen when the families move from their initial anger and fear to acceptance, and finally to a place where they can assess the situation positively. the results showed that all indicators that were built can significantly measure the phase of family growth. all of the competencies that show the strength of the family when taking on a positive decision to solve a problem, to accept pain and the impact of pain, and to beginning to feel that they have the ability to resolve the issue properly as a family unit intact. each indicator above has a value of a loading factor that is almost the same. according to mccubbin (1996) cited by (chapin, 2015), positive movements are referred to by mccubbin as "bonadaptation”, namely behavior that shows changes that move towards growth and maturation. growing the family resilience ability is not an easy effort. the family should be able to identify any risk factors and manage them in order to achieve a dynamic family situation. in the stage of d. s. rachmawati et al. 170 | pissn: 1858-3598  eissn: 2502-5791 resilience, there is the ability of families to cope with stressors from outside the family, known as risk factors. they respond using the family strength, family resources, and the ability to solve problems within the family, which are collectively referred to as protective factors (taylor & distelberg, 2016).the results of the analysis showed that the stage of growing stronger ranks third with the structural equation stating an effect of 0.78 on the family resilience of the families of patients with pulmonary tb. helping others when families can assess their difficulties in a positive way, the family reaches a point where they want to help others. some suggest that altruistic prosocial behavior helps families to find meaning in adversity (lietz, 2018). in other words, the families describe their participation in some pro-social behaviors as an effort to help others while also helping themselves. families have a major contribution towards the pulmonary tb patients. when the nuclear family and extended family provide mutual support, the family resources of education, employment and socioeconomic level also influence this support in accordance with the previous research which states there is a significant relationship between the family factors of family type, level of education, employment, income, healthy home and stressors in the family with the quality of life of pulmonary tb patients (rachmawati, 2018). providing social support is a family strength associated with this phase. the process of resilience grows from the survival stage where families are desperate to receive social support where they help others in turn to give back. the results show that indicators h6, h8, and h9 which state that the family feels free to be a family member in the social environment , that they provide assistance and gifts for neighbors in need, that they show love and concern for their family members are not significant in terms of measuring the stage of helping others. this is because the three indicators are still focused on the abilities of the family internally. more precisely, when the family needs support while in this stage, it is more to provide support to others who have similar problems to those experienced by the family. the indicators that show the ability of the families to help others who have similar problems while continuing to show internal efforts to strengthen the family resources, in addition to a sense of security and comfort in the family and environment, plus the social relationships. these are all indicators with high loading values. the results of the analysis show that the stage of growing stronger ranks second with the structural equation stating an effect of 0.88 for the family resilience of the families of pulmonary tb patients. conclusion based on the results of this study, it can be concluded that the family resilience model is a fit model. this refers to the results of the goodness of fit test. the indicators of each phase of family resilience, which is the development of indicators in the family resilience model as the observed variables in the model, are valid based on the results of the validity test conducted on the measurement model. the construct as described by the observed variable is reliable. the construct of family resilience can be measured clearly using its dimensions or phases which are, sequentially from the greatest value, as follows: acceptance, helping others and growing stronger. following these three, the adaptation and survival phases have a relatively similar value. the results also showed that not all of the families passed the family resilience stage. references chapin, m. g. (2015). deployment and families : hero stories and horror stories smith college studies in social work, (july 2009). https://doi.org/10.1080/00377310903130316 dinkes. (2015). profil kesehatan tahun 2015. surabaya. fitryasari, r., yusuf, a., dian, r., & endang, h. (2018). international journal of nursing sciences family members â€tm perspective of family resilience â€tm s risk factors in taking care of schizophrenia patients. international journal of nursing sciences, 5(3), 255–261. https://doi.org/10.1016/j.ijnss.2018.06.002 friedman, m. (2010). buku ajar keperawatan keluarga; risert, teori, dan praktik. (e. tiar, ed.) (edisi 5). jakarta: egc. kaulagekar-nagarkar, aarti, d. d. and p. j. (2012). perspective of tuberculosis patients on family support and care in rural maharasthra. indian journal of tuberculosis, 59(655), 224–230. kaulagekar-nagarkar, a., dhake, d., & jha, p. (2012). perspective of tuberculosis patients on family support and care in rural maharashtra, 411007, 224–230. li‐yun lee, heng‐hsin tung, shu‐ching chen, c. f. (2017). perceived stigma and depression in initially diagnosed pulmonary tuberculosis patients. journal of clinical nursing, 26(23–24), 4813–4821. https://doi.org/10.1111/jocn.13837 lietz, c. a. (2018). theoretical adherence to family centered practice : are strengths-based principles illustrated in families â€tm descriptions of child welfare services ?, (february). https://doi.org/10.1016/j.childyouth.2010.12.01 2 lietz, c. a., & strength, m. (2016). stories of successful reunification : a narrative study of family resilience in child welfare, (june). https://doi.org/10.1606/1044-3894.4102 py, k., sv, a., rm, m., js, b., banerjee, a., & ad, k. (2013). non ‐ adherence of new pulmonary tuberculosis patients to anti ‐ tuberculosis treatment, (march). https://doi.org/10.4103/2141-9248.109507 jurnal ners http://e-journal.unair.ac.id/jners | 171 rachmawati, hian satya; nursalam nursalam; wibowo arief; budiarti astrida; a. r. (2018). family factors associated with quality of life in pulmonary tuberculosis patients in surabaya, indonesia. indian journal of public health research & development, 9(11), 1772–1776. retrieved from http://www.indianjournals.com/ijor.aspx?target =ijor:ijphrd&volume=9&issue=11&article=292 samal, j. (2016). role of families in tuberculosis care : a case study, (july), 5–8. https://doi.org/10.4103/0975-9727.185020 taylor, s. d., & distelberg, b. (2016). predicting behavioral health outcomes among low-income families : testing a socioecological model of family resilience determinants. journal of child and family studies, 25(9), 2797–2807. https://doi.org/10.1007/s10826-016-0440-7 walsh, f. (2017). the concept of family resilience : crisis and challenge special section family resiliance : a concept and its application the concept of family resilience : crisis and challenge, (november). who. (2017). global tuberculosis report. geneva: who. 388 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17171 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a clinical decision support system as a tool to improve the accuracy of nursing diagnoses wikan purwihantoro sudarmaji, sholihin sholihin, roby aji permana, agustina soares, and yanuar aga nugraha faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: nursing diagnosis is an important part of the nursing process and it influences the quality of nursing care. accuracy in establishing nursing diagnoses is one of the factors that determines the accuracy of the nursing intervention program and the speed of healing of the patients. the clinical decision support system is an information system built to assist health workers in making clinical decisions including the enforcement of nursing diagnoses. through this systematic review, the author wants to explain the clinical decision support system as a tool to increase the accuracy of the enforcement of nursing diagnoses. methods: the search for journals using the picot framework was conducted in the scopus, proquest, pubmed and cinahl databases with a 10year publication time limit (2008 2018). there were 8 international journals reviewed in full. results: generally the journals reviewed stated that the use of the clinical decision support system in establishing nursing diagnoses has been shown to improve the accuracy of nursing diagnoses. conclusion: this systematic review concludes that the use of clinical decision support systems can help nurses or nursing students in establishing accurate nursing diagnoses. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords nursing diagnosis; nursing care; clinical decision support system contact wikan purwihantoro sudarmaji wikan.purwihantoro.sudarmaji201 8@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sudarmaji, w.p., sholihins s., permana, r. a., soares, a.,& nugraha, y.a. (2019). a clinical decision support system as a tool to improve the accuracy of nursing diagnoses. jurnal ners, 14(3si), 388-392. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17171 introduction nursing documentation is one of the factors that affects patient safety. the lack of standardized nursing language use in nursing documentation can pose a risk to the patients. the nursing process includes nursing studies, the enforcement of nursing diagnoses, the selection of nursing interventions and the determination of the results to be achieved based on scientific-based nursing classifications (müllerstaub, 2016). professional standards, service standards, standard operational procedures and codes of ethics are references that can be used as a basis for implementing nursing practices such as the process of nursing diagnoses enforcement. to achieve effective and high-quality nursing practice, terminology and its definitions should be based on a standard used to formulate nursing problems to determine the appropriate nursing interventions and to evaluate the results of nursing care as needed (mynaříková & žiaková, 2014). nursing diagnoses is the result of a human's interpretation related to health in establishing nursing diagnoses; clinical decision making based on the data sourced from the patients with a low risk of mistaken accuracy in the diagnoses is needed (jensen, silveira, ortega, & de moraes lopes, 2012). the accuracy of the nursing diagnoses is an assessment of the relevance level, specificity, signs, symptoms and manifestations that appear in the patients (de oliveira azevedo matos & de almeida lopes monteiro da cruz, 2009). to improve the accuracy of the diagnoses, identifying the correct signs and symptoms, the etiology of the disease and the patient's actual condition is necessary. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:wikan.purwihantoro.sudarmaji2018@fkp.unair.ac.id mailto:wikan.purwihantoro.sudarmaji2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 389 the confirmation of all diagnoses found is important for identifying and obtaining optimal nursing interventions (jensen et al., 2012). the clinical decision support system is a system that assists doctors in developing clinical services by increasing practitioner compliance in implementing practices that are in accordance with the standardized clinical guidelines (ahamed et al., 2016). vetter 2012 in his article stated that the clinical data included in the clinical decision support system (cdss) can be used as information sources for managing patients, as a new knowledge source that can be utilized in research and treatment and as a support for enforcing diagnoses (vetter, 2015). cdss is designed to assist clinical decision making. cdss uses the characteristics of each patient to produce patient-specific recommendations. cdss involves embedded base knowledge that contains boundaries and logical statements that summarizes knowledge based on the particular needs of clinical decision making, so it can produce specific recommendations which are in accordance with the characteristics of each patient (lee, 2013). the purpose of this study is to explain the correlation between using a clinical decision support system as a tool with increasing the accuracy of nursing diagnoses. materials and methods research design this study used a systematic review design with a question-based search: “what is the correlation between using a clinical decision support system as a tool with increasing the accuracy of the enforcement of nursing diagnoses?” search strategy the picot framework was used for searching for the articles which were in accordance with the theme of the systematic reviews. the picot framework could be described as follows: population: nursing; intervention: clinical decision support system; control: -; outcome: accuracy of nursing diagnoses; time: 2008 2018, using the keywords “clinical decision support system”, “accuracy diagnosis” and “nursing”. inclusion and exclusion criteria the inclusion criteria in this review covered both experimental studies and non-experimental studies published between 2008 and 2018 were the participants were in nursing, where the language used was english and that focused on clinical decision support system and accuracy in the nursing diagnosis. the exclusion criteria were studies that did not involve a clinical decision support system and that did not have information on the accuracy of the nursing diagnosis. article searching process the search for the articles used the keywords ‘clinical decision support system’, ‘accuracy diagnoses’ and ‘nursing’ in accordance with the picot method that has been determined. the search also used the boolean logic search method in the scopus, proquest, pubmed and cinahl databases with a time limitation of between 2008 and 2018 for the year of publication. in the search process, 287 articles were found and 8 articles were in accordance with the inclusion criteria to be explored further. results eight international journals that were in accordance with the systematic theme of the review were found and further examined by the authors. from the 8 international journals, the research design was obtained: 2 journals used a randomized control trial design, 1 journal used a pre-experimental design, 1 journal used a cross-sectional descriptive study, 1 journal used a cross-sectional quantitative study, 1 journal used a case study design, 1 journal used a randomized cross-over trial design and 1 journal did not mention the research design used. the research conducted by chunmei, hualing and haihua 2018 showed that there was a significant increase in the accuracy of the nursing diagnoses after using the clinical decision support system (cdss) based on structured emr (electronic medical record). the data was taken from 300 medical records before using nursing cdss and 300 medical records after using nursing cdss (chunmei, hualing, & haihua, 2018). the research conducted by aziz, hidayat and uliyah 2018 showed that there was no difference between all of the nursing diagnoses enforced by expert systems and all of the diagnoses enforced by the expert nurses. this study took 30 pediatric patients as the respondents with medical diagnoses of bronchopneumonia, bronchitis, typhoid fever, fever, gastroenteritis, upper respiratory infections, febrile seizures and morbillie. the developed expert system was able to identify the 58 nursing diagnoses that figure 1. flowchart of the research on clinical decision support systems, accuracy of diagnosis and nursing 257 papers excluded because they did not fulfil the inclusion criteria 22 papers excluded because they did not fulfil the inclusion criteria clinical decision support system, accuracy of the diagnosis, nursing databases: scopus, pub med, proquest, cinahl title screening (n = 287) full text screening (n = 30) appropriate paper (n = 8) w. p. sudarmaji, et al. 390 | pissn: 1858-3598  eissn: 2502-5791 were enforced. the diagnoses enforced by the expert systems were compared with the diagnoses enforced by the expert nurses for the same patients and the results showed a 100% similarity in the nursing diagnoses (aziz, hidayat, & uliyah, 2018). peres 2016 conducted a cross-sectional descriptive study with 17 nursing students in the seventh semester as the respondents. all of the respondents were asked to make diagnoses using a paper-based record and the procenf-usp® software. the scale for the accuracy of nursing diagnoses (sand) version 2 was used as the instrument to assess the accuracy of the diagnoses made. according to the wilcoxon test, there were no statistical differences found in determining high accuracy diagnoses (p = 0.013). the following table showed the differences in the nursing diagnoses accuracy by the nursing students when using procenf-usp® and the paper-based system (n = 17)(peres, 2016). zega, agostino and bowles 2014 used 2 stages in developing the nursing assessment form (naf). the first stage of naf was developed by 4 expert nurses by identifying the structure, content and links and the second stage of the naf was validated by a panel of 11 expert nurses. in conducting the content validation, the experts examined each item proposed in each diagnosis and they evaluated the relevance of the item to the suitability of the diagnostic identification. the experts used questionnaires with an ordinal rating scale of 4 points (1 = irrelevant items, 2 = little bit relevant items, 3 = fairly relevant items, and 4 = very relevant items) to give their responses. on the validity of the naf items, phase 1 obtained good validity above 80%. the diagnostic validity test showed that 37 of 44 diagnoses were claimed in accordance with a 90% or more level of conformity (zega, agostino, & bowles, 2014). liao, hsu and chu 2015 carried out the research by examining 216 medical records from 105 patients. they examined the use of artificial intelligence to enforce the nursing diagnoses. a back propagation neural network (bpn) was used in determining the accuracy of the enforced nursing diagnoses. the bpn estimation model was made for 123 training data sets using the clementine software and it used 93 patient datasets for testing purposes. the test results using clementine stated that the accuracy level was 87.41 percent in predicting nursing diagnoses (liao, hsu, & chu, 2015). the study was conducted by emille et al 2016 on 56 nursing students by involving 13 expert nurses with clinical and research expertise in each nanda-i domain. there was no correlation between the academic level and the number of correct answers. this indicated that students may not be exposed to nanda-i classifications or they are exposed to it but in a shallow manner. the students were asked to determine the characteristics and the factors related to the case, in addition to establishing nursing diagnoses using the software prototypes. the percentage of correct answers to the related factors was 65.7%, followed by 62.2% for the characteristics limit and 60.5% for the nursing diagnosis (emille et al., 2016). a randomized crossover trial was conducted by kurashima et al. 2008 involving 42 nurses as the subjects divided into 2 groups. the first group used a computer-aided nursing (can) diagnosis system in the enforcement of nursing diagnoses and the second group used nursing diagnoses. the determination of the nursing diagnoses accuracy used lunney's 7-point interval scale. statistically, there was no significant difference in the correct answer between the group that used the can system and the group that did not use the can system (p = .341 in case 1 and p = .758 in case 2). the correct answer for the group that used the can system in diagnosing case 1 was 47.6% and it was 42.9% in case 2. the correct answers for the group that did not use the can system were 28.6% for case 1 and 52.4% for case 2. the accuracy of the nursing diagnoses was not significantly different between the group that used the can system and those that did not, with p = .220 in case 1 and p = .230 in case 2. the diagnosis accuracy of the can system was 3.0 (0.5.3.5) in case 1 and 4.0 (2.0, 3.5) in case 2. the group that did not use can system had an accuracy of 2.0 (2.0,5.0) in case 1 and 1.0 (0.0.4.5) in case 2 (kurashima, kobayashi, toyabe, & akazawa, 2008). helena et al. 2012 conducted a study using the fuzzy cognitive map (fcm) which was implemented in microsoft visual c ++ ® edition 2005, used in 195 real cases. the diagnosis enforced by the fcm system was compared to the diagnosis enforced by 3 expert nurses. the diagnosis enforced by the fcm system compared with table 1.comparison of the degree of accuracy of the nursing diagnoses indicated by the nursing students in the procenf-usp® and paper-based systems (n=17) degree of accuracy of the nursing diagnoses paper-based procenf-usp® p-value med (min-max) med (min-max) null accuracy low accuracy moderate accuracy high accuracy 1.5 0 1.0 1.0 (1.0-5.0) (0-0) (0-4.0) (0-4.0) 1.5 0 2.0 3.0 (1.0-4.0) (0-0) (0-4.0) (0-4.0) 0.916 0.361 0.013 jurnal ners http://e-journal.unair.ac.id/jners | 391 those established by the expert nurses had very good (kappa = 0.92, p <0,0001) and moderate suitability (kappa = 0.42, p <0,0001) (helena et al., 2012). discussion documentation in the form of electronic medical records can be used for clinical purposes. there are several methods for assessing the quality of the documentation. the development of technology use in health systems changes the way that health workers do documentation, namely by using electronic medical records that might be related to the use of software applications (nurjannah & warsini, 2016). an expert system is a program that has been used in various health and hospital fields and it is a solution to solve problems in the same way as experts. this is because expert systems adapt human knowledge into the form of software in a computer (aziz et al., 2018). chunmei, hualing and haihua in 2018 stated in their article that the databases of nursing knowledge related to nursing plans and routines can be used as the basis for making cdss. there is a decrease in the time required to document nursing, increased nursing diagnoses accuracy and a reduced risk of unexpected events after cdss use in nursing practices (chunmei et al., 2018). the use of cdss in nursing has become a trend in the development of information systems in hospitals. the assessment of patient problems is a dynamic process, and a useful digital instrument for managing clinical data was found and it is growing. however, the specific skills needed to perform diagnostic reasoning cannot be replaced by cdss (zega et al., 2014). cognitive skills such as clinical reasoning, problem solving and decision making in nursing could be improved by using the decision support system in nursing education. based on the analysis of the diagnostic accuracy, students who used the procenfusp® software were better at determining the nursing diagnoses with high accuracy than the students who enforced the nursing diagnoses by manual or paper-based methods (peres, 2016). expert systems were built by facilitating the application of theory to the practical level and with a high accuracy to enforce diagnoses. some of the steps of the expert systems application include first entering the medical diagnosis that is appropriate for the patient's condition. this is used to generate the focus questions related to the diagnosis. second, the nurse should enter the signs, symptoms and risk factors experienced by the patient based on the physical assessment, laboratory test results and the interview with the patients. third, there is the search for diagnosis types related to the symptoms and risk factors, calculating the number of minimal signs and symptoms found in the patients according to the number of minimal signs and symptoms needed to establish the diagnosis (aziz et al., 2018). the use of can systems could reduce the time needed to enforce nursing diagnoses without reducing their accuracy. this efficiency was obtained from the computerized diagnostic nursing processes (kurashima et al., 2008). the nursing information system application is developing toward something that can be used as a support in clinical decision making. the use of clinical decision support systems can support the nurse practitioners and nursing students in enforcing nursing diagnoses. the use of clinical decision support systems can make the time needed by the nurses to enforce nursing diagnoses more efficient, so the nurses have more time to do other work. the increased accuracy of diagnoses from cdss use has an impact on the selection of more appropriate interventions (kurashima et al., 2008). the nurses' ability to make clinical decisions, prevent mistakes, improve care quality, increase accuracy in nursing diagnoses and the achievement of predetermined nursing care can be improved by cdss in the context of providing care to the patients (mary jo vetter, dnp, rn, 2015) (chunmei et al., 2018). conclusion patient care safety is influenced by several factors, one of which is nursing documentation. nursing documentation, including nursing diagnoses which do not meet the standards, will cause the treatment outcome targets that have been set to not be achieved. the use of cdss in nursing practices can improve the quality of nursing care. this system can facilitate the nurses in analyzing the clinical data sourced from the patients and it can help to validate the accuracy of nursing diagnoses effectively and efficiently. high diagnostic accuracy will improve the suitability of nursing action selection based on the patient's needs. the treatment outcome targets can therefore be achieved more optimally. references ahamed, t., lederman, r., bosua, r., verspoor, k., buntine, w., & hart, g. (2016). towards a methodology for nursing-specific clinical decision support systems (cdss). journal of decision systems. https://doi.org/10.1080/12460125.2016.11873 87 aziz, a., hidayat, a., & uliyah, m. (2018). analysis of nursing diagnosis using an expert system in paediatric patients. 9(8), 17–26. chunmei, r., hualing, h., & haihua, z. (2018). design and application of nursing cdss b ased on structured emr. 3(2014), 2014–2015. https://doi.org/10.3233/978-1-61499-872-3238 de oliveira azevedo matos, f. g., & de almeida lopes monteiro da cruz, d. (2009). development of an instrument to evaluate diagnosis accuracy. revista da escola de enfermagem. https://doi.org/10.1590/s008062342009000500013 w. p. sudarmaji, et al. 392 | pissn: 1858-3598  eissn: 2502-5791 emille, v., sousa, c. de, venícios, m., lopes, d. o., keenan, g. m., & lopez, k. d. (2016). developing and testing of a software prototype to support diagnostic reasoning of nursing students. 00(0), 1– 9. helena, m., moraes, b. de, regina, n., ortega, s., sérgio, p., silveira, p., … fátima, h. de. (2012). fuzzy cognitive map in differential diagnosis of alterations in urinary elimination : a nursing approach. international journal of medical informatics, 82(3), 201–208. https://doi.org/10.1016/j.ijmedinf.2012.05.012 jensen, r., silveira, p. s. p., ortega, n. r. s., & de moraes lopes, m. h. b. (2012). software application that evaluates the diagnostic accuracy of nursing students. international journal of nursing knowledge. https://doi.org/10.1111/j.20473095.2012.01212.x kurashima, s., kobayashi, k., toyabe, s., & akazawa, k. (2008). accuracy and efficiency of computer-aided nursing diagnosis. 19(3), 95–101. https://doi.org/10.1111/j.1744618x.2008.00088.x lee, s. (2013). features of computerized clinical decision support systems supportive of nursing practice: a literature review. cin computers informatics nursing. https://doi.org/10.1097/01.ncn.0000432127.99 644.25 liao, p., hsu, p., & chu, w. (2015). applying artificial intelligence technology to support decisionmaking in nursing : a case study in taiwan. https://doi.org/10.1177/1460458213509806 mary jo vetter, dnp, rn, a.-b. a. (2015). theinfluenceofclinicaldecisionsupporton diagnostic accuracy in nurse practitioners.pdf. müller-staub, m. and w. p. (2016). a standard for nursing process clinical decision support systems (np-cdss). 225, 810–811. mynaříková, e., & žiaková, k. (2014). the use of nursing diagnoses in clinical practice. central european journal of nursing and midwifery. https://doi.org/10.15452/cejnm.2014.05.0006 nurjannah, i., & warsini, s. (2016). validity and reliability of end-user computing satisfaction in indonesian language to measure digital nursing assessment tool. 070001. https://doi.org/10.1063/1.4958496 peres, h. h. c. (2016). assessment of diagnostic accuracy in nursing : paper versus decision support system. 29(2), 218–224. vetter, m. j. (2015). the influence of clinical decision support on diagnostic accuracy in nurse practitioners. worldviews on evidence-based nursing. https://doi.org/10.1111/wvn.12121 zega, m., agostino, f. d., & bowles, k. h. (2014). development and validation of a computerized assessment form to support nursing diagnosis. 25(1). http://e-journal.unair.ac.id/jners | 165 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16958 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review prevention of the stigma of mental disorders in the community retno puji astuti, antonia rensiana reong, fakhrun nisa' fiddaroini and m. elyas arif budiman faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the stigma felt towards clients with mental disorders is still negative in community. health education programs are run by health workers in order to reduce the stigma for clients with mental disorders in the community. these programs have been widely implemented but there has been a low impact on the community thus far. the aim of this study was to gain an insight into the stigma focused on clients with mental disorders in the community. methods: the databases used were scopus, proquest, sage and science direct in order to identify potential articles. the articles were limited to being published in a range of 5 years from 2013 to 2018. the keywords used in the literature review were “stigma” and “community” and “mental disorder”. results: this study reports on the latest experience of stigma in relation to clients with mental disorders. the stigma is given from the community to the client with a mental disorder at 4 levels, namely labeling, stereotype, exclusion and discrimination. this makes the social life of the clients disturbed. stigma and the prevention of it must therefore be further developed in the community. conclusion: from this systematic review should be considered to reduce and prevent stigma in clients with mental disorders. article history received: december 26, 2019 accepted: december 31, 2019 keywords mental disorder; stigma; prevention; contact retno puji astuti  retno.puji.astuti2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: astuti, r. p., reong, a. r., fiddaroini, f. n., & budiman, m. e. a. (2019). prevention of the stigma of mental disorders in the community. jurnal ners, 14(3si), 165-170.doi:http://dx.doi.org/10.20473/jn.v14i3(si).16958 introduction stigma has been linked to adverse experiences for people with mental disorder as it acts as a barrier to help-seeking and it can affect all aspects of a person’s life (corker et al., 2015)(subramaniam et al., 2017). stigma is referred to as a social construct comprised of 4 interrelated components including: 1) people distinguish and label human differences as a knowledge problem; 2) labeled people are caused damage by negative stereotypes as a attitude problem; 3) labeled people are placed in exclusion and 4) labeled people have a lost status and are discriminated against in terms of behavior problems (svensson & hansson, 2016)(reavley, morgan, & jorm, 2017). a stigmatized attitude was related to the mental disorder itself (zhuang, wong, cheng, & pan, 2017). the stigma of mental health has a detrimental effect because the sufferers tend to be hesitant to reveal a psychiatric diagnosis, meaning that there is a decrease in mental health-seeking behavior and decreased medication adherence, which potentially worsens the disease prognosis (ndetei et al., 2016)(subica et al., 2019). when studying the public stigma of people with mental disorder, several factors such as gender, age, socioeconomic status, knowledge of mental disorder and contact or familiarity with individuals with a mental disorder should be considered (lien & kao, 2019). some of studies state that culture influences experience, expression and the determinants of stigma and the effectiveness of the various approaches to reducing stigma. a meaningful intervention to combat stigma must, therefore, consider the cultural context (ikwuka et al., 2016). an indigo schizophrenia study involved 732 individuals diagnosed with schizophrenia in 27 countries where 47% of participants experienced discrimination when making or maintaining friends, 43% experienced discrimination from their family members and 29% found keeping work to be difficult. the same group examined the discrimination experienced by 1087 people who were diagnosed with major depressive disorder in 35 countries and found that 79% of participants experienced https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:retno.puji.astuti-2018@fkp.unair.ac.id mailto:retno.puji.astuti-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). r. p. astuti et al. 166 | pissn: 1858-3598  eissn: 2502-5791 discrimination in at least one area of life in indonesia (farrelly et al., 2014). recent research more often investigates the level of stigma and discrimination using direct reports from the users of mental health services where the results of these studies show a high level of stigma and discrimination, regardless of the type of diagnosis (corker et al., 2015). public stigma is still high despite efforts to improve public knowledge and attitudes and to reduce discrimination (aznar-lou, serranoblanco, fernández, luciano, & rubio-valera, 2016). several recent studies on reducing stigma have found that most programs aim to increase awareness of the mental disorder and to improve mental health literacy. countries that have carried out anti-stigma campaign activities have proven there to be positive results in terms of reducing the negative attitudes towards people with a mental disorder (corker et al., 2015). one study showed that there is a positive effect from the anti-stigma campaign over a 2-year multimedia-based period where the standardized tools captured data on knowledge, attitude and the behavior towards mental health as well as the perceptions related to help-seeking for a mental disorder (maulik et al., 2019). attitudes toward someone with a mental disorder can be improved by providing information continuously related to said mental disorder (schomerus et al., 2016). the aim of this systematic review should be considered to reduce and prevent stigma in clients with a mental disorder. materials and methods data sources and search the journal search strategy begins with asking research question “what stigma of mental disorder in the community?” it was reviewed in actions to reduce stigma in clients with mental disorders in the community. the databases used were scopus, proquest, sage and science direct. the articles were limited to a publishing range of 5 years from 2014 to 2019 within the areas of nursing, psychology and medicine in english language journals. the keyword used in the literature review were “stigma” and “community” and “mental disorder”. article selection criteria the feasibility of this study was assessed using the picot approach. the population was clients with mental disorders. the intervention used was an antistigma health education campaign. there was no comparison. the expected output was a positive effect in terms f an increase in people's knowledge, attitudes and behavior in terms of stigmatizing clients with mental disorders. the inclusion criteria were 1) all articles related to the act of reducing the stigma of clients with mental disorders in the community; 2) the population in the article was the clients with mental disorders and the community; 3) the actions taken in the articles are health education interventions that can reduce stigma and 4) the results measured in the article show an increase in the positive effects of anti-stigma campaigns. exclusion data the exclusion criteria for this study were non-health education interventions and journals published before 2014. research design most of the 15 articles in the review used a crosssectional design. data items the following information will be collected from each paper: (1) author(s); (2) year of publication; (3) journal title; (4) summary or journal paper; (5) design and setting; (6) country; (7) study objective(s); (8) theory and/or hypothesis; (9) definitions of stigma; (10) instruments for data collection; (11) samples of demographic information (age, gender, etc.) and (12) the type of participants, sample size and the time of the data collection. risk of bias in individual studies the credibility of the synthesis can be compromised by reporting on the bias that arises when the results of the study are influenced by the nature of the results of the study. for example, there may be bias because of selective publication, such as where a study is only published if the findings are considered to be interesting(page, mckenzie, & higgins, 2018). risk of bias was considered during the search for research and during the quantitative synthesis of the research selected(larkings & brown, 2018). no formal assessment of risk of bias was undertaken due to the limited articles available that explored the relationship between an anti-stigma campaign and stigma among people with mental illness in community. instead, all of the articles that met the inclusion criteria were included, and several factors that influence the risk of bias were discussed throughout the results and discussion sections in the present study, such as the characteristics of the included studies, the steps used for reducing stigma and the multiple terms and definitions used for stigma, people with mental illness, and the antistigma campaign itself (larkings & brown, 2018). data synthesis in the final report, we will present a domain of the definitions in the form of a list with various subgroups. the papers will be divided into these subgroups on the basis of healthy people, at risk people and people with mental disorders where the participants came from both men and women, and teenagers and adults. we will examine the anti-stigma campaigns used to reduce stigma in the community. we will record the various stigmas in our table of results. the various anti-stigma campaigns will then be compared and contrasted. the collected data will also be used to demarcate the various chronological trends within the anti-stigma campaigns. subsequently, the data will be combined and jurnal ners http://e-journal.unair.ac.id/jners | 167 categorized based on the procedure mentioned above. results results of search the researcher identified 2.354 citations, with 354 being through the initial stages of feasibility assessment using study type, title and abstract. the first step that the researchers did was to examine the various articles manually that were related to the research title. of the 354 potentially relevant articles, only 28 were selected for further assessment. detailed reviews of the remaining 24 articles were carried out and 4 further articles were excluded because they had the same title. overall, articles were excluded for the following reasons: they did not involve an anti-stigma health campaign for the clients with mental disorders and there was no positive effect from the intervention. of the 24 remaining papers, a total of 15 studies were examined in detail that met the expected criteria. sample characteristics the samples used came from various countries where the participants were taken from those aged 18 and above. the participants from the various communities were healthy people, at risk people and people with mental disorders. the participants were both men and women and both teenagers and adults. all of the participants provided written informed consent including parental written consent where appropriate (xu et al., 2016)(townley, brusilovskiy, & salzer, 2017). articles were included in this review if they focused on evaluating the stigma toward adults and/or children with a diagnosis of mental disorder included quantitative or qualitative measures of public stigma. they also had to be written in english. types of interventions the results of the review of the research articles that met the inclusion criteria showed that there are various types of intervention to know or prevent stigma in the community, such as questionnaires, interviews and mental health first aid (mhfa). the settings from the 15 research articles were in the community. from the review of the 15 research articles, there was 1 research article that was quasiexperimental and 14 research articles that were cross-sectional. procedures most of the research was carried out in europe and asia. the quantitative studies used questionnaires developed by the authors or adaptations of instruments previously designed. the qualitative studies collected information from interviews, both face to face and over the telephone. the standardized tool captures looked at the knowledge, attitude and behavior towards mental health as well as the perceptions related to help-seeking for mental disorder patients. relation with a mental disorder in this study, the community was divided into 2 types, namely people who have direct contact with an md (family, friends, health worker) and people who are not directly related to an md (knowing of mds through lessons or the news). one study showed that relating to someone with md is associated with a better attitude and behavior (aznar-lou et al., 2016). the criterion for the participants was also based on education being divided into two, namely the participants with low education (zero to secondary education) and the participants with higher education (postsecondary education). marriage status was also identified as married and unmarried respectively. type of questionnaire the questionnaires used in the study were community attitudes to mental illness (cami), the reported and intended behavior scale (ribs), the discrimination and stigma scale (disc-12), mental illness-related investigations on discrimination (miriad), the depression literacy questionnaire, the table 1. literature search summary id e n ti fi ca ti o n scopus proqu est sage scie nce dire ct explanation n= 1339 n = 585 n= 279 n= 151 the sources were identified by searching the selected databases. s cr e e n in g types, titles and abstracts the articles were listed in the reference sections of the reviews in addition to the screened articles. n = 101 n = 83 n = 92 n = 78 same title n = 4 e li g ib il it y full-text article all of the articles obtained in the research were full text articles. n = 24 in cl u d e d after reading adjusted to the inclusion criteria 15 articles were examined in detail and met the expected criteria n = 15 after reading adjusted to the exclusion criteria 9 did not expected criteria n = 9 r. p. astuti et al. 168 | pissn: 1858-3598  eissn: 2502-5791 perceived devaluation discrimination questionnaire, the stigma stress scale and the positive and negative syndrome scale. discussion attitudes towards people with mental disorders are varied(aznar-lou et al., 2016). people tend to hesitate to express their mental disorder to their family and friends because they are worried whether their family and friends will understand and accept the situation. this has an effect on the increasing duration of the disease which will increase the experience of discrimination(corker et al., 2015). for example, people with a diagnosis of their first depressive episode reported experiencing discrimination in areas of life that were far more significant than the participants diagnosed with schizophrenia(svensson & hansson, 2016). higher levels of discrimination experienced by people with a disorder other than depression or anxiety are consistent. this shows that people are more likely to have a stigmatizing attitude towards people with schizophrenia because of the duration of the disease(farrelly et al., 2014). the general public regards depression as a less serious condition. it is seen of as an old disease that is not worth getting care and assistance for as much as other types of mental disorder. the behavior of people diagnosed with depression may be less supportive and more discriminatory(farrelly et al., 2014). this can be considered negative and discriminatory by the participants with a diagnosis of depression. the higher discrimination of participants with depression can also be explained by the duration and/or severity of the disease. the public stigma present means that other people will view it negatively if they seek treatment and this is associated with a reluctance to seek professional help(lien & kao, 2019). anti-stigmatic interventions should aim to directly influence emotions and to increase the social acceptance of those affected. emotional reactions that are stronger predict discrimination rather than stereotypes. there are several ways to fight authoritarianism such as contact-based education or education to increase knowledge, attitudes, mental health literacy and to reduce stereotypes, in addition to the desire for interpersonal distance(aznar-lou et al., 2016). social contact is considered to be the most effective intervention used as a part of anti-stigma campaigns(maulik et al., 2019). younger people are more tolerant and less stigmatized because of the changing knowledge and perceptions of mental disorder. young people at risk of psychosis tend to seek professional help because they may not want to be labeled as a mental disorder patient and suffer prejudice and discrimination (subramaniam et al., 2017). this could also be due to the fact that younger people know more about the causes, treatment and results of mental disorder as a result of campaign exposure in their place of education, as well as through social media. those who have personal contact with someone who has a mental disorder have a better understanding and they are more sensitive to stigma and discrimination against people with mental disorders(svensson & hansson, 2016). those with a higher education level have more knowledge and a better understanding of people with mental disorders(farrelly et al., 2014). if they have family members who suffer from a mental disorder, then they will likely experience stigmatization which leads to empathy and nonstigma. social contact with people with mental disorder is an effective anti-stigma intervention as well. working with mentally disturbed individuals is very important to encourage them to identify and access the community resources that facilitate activity participation and community involvement. one method is utilizing peer support and strengthening social support networks. this helps individuals to identify opportunities to participate in their environment. this systematic review provides evidence about the effectiveness of anti-stigma campaign interventions as one of health education steps in preventing and reducing the stigma felt by the clients with mental disorders. the results of the review explain that one effective way that can be used to carry out the anti-stigma campaign is used multimedia. the results of this review are useful for both clinical nurses and community mental nurses. the results of this review can be implicated in providing anti-stigma campaigns where the campaign is effective at preventing the stigma that develops in the community with clients with mental disorders. health workers can provide structured education to ordinary people about the importance of supporting mental health improvement, so the clients can socialize within the community and get maximum care. nurses can implement health interventions to reduce stigma by using technology, especially social media. better conditions in the application of health education can prevent the emergence of stigma and improve the quality of social life of clients with mental disorders, for example, in terms of work and family. several studies have explained that anti-stigma campaigns should be carried out with regard to the local culture. a positive attitude towards someone with a mental disorder can be improved by providing information from the anti-stigma campaigns continuously in a manner that is related to mental disorders. a limitation of this research is that the data is not representative of any of the participating countries, so it can thus carry a higher risk of bias. this is because the culture, social life and the level of stigma in each region is different. further research is essential to explore the utilized programs in order to increase the self-awareness of the risk of mental disorders without stigmatizing connotations as well as strategies to reduce the stigma for people at risk of mental disorders. jurnal ners http://e-journal.unair.ac.id/jners | 169 conclusion the results of the systematic reviewing of 15 research journals related to the stigma of clients with mental disorders in the community were that the implementation of nursing services can be used to reduce stigma in the form of an anti-stigma campaign. this has been proven to reduce discrimination relating to the neighbor’s life, dating, education, marriage, religious activities and the health of the client with a mental disorder. future actions aimed at reducing stigma in mental health must be directed at reducing the component of authoritarianism from the stigma itself. public campaigns can be an important way to combat stigma in mental health and the campaigns can have a greater impact by targeting older people, people who have a lower educational attainment and people who have no contact with someone with a mental disorder. references aznar-lou, i., serrano-blanco, a., fernández, a., luciano, j. v., & rubio-valera, m. (2016). attitudes and intended behaviour to mental disorders and associated factors in catalan population, spain: cross-sectional population-based survey. bmc public health, 16(1), 1–12. https://doi.org/10.1186/s12889-016-2815-5 corker, e. a., beldie, a., brain, c., jakovljevic, m., jarema, m., karamustafalioglu, o., … thornicroft, g. (2015). experience of stigma and discrimination reported by people experiencing the first episode of schizophrenia and those with a first episode of depression: the fedora project. international journal of social psychiatry, 61(5), 438–445. https://doi.org/10.1177/0020764014551941 farrelly, s., clement, s., gabbidon, j., jeffery, d., dockery, l., lassman, f., … thornicroft, g. (2014). anticipated and experienced discrimination amongst people with schizophrenia, bipolar disorder and major depressive disorder: a cross sectional study. bmc psychiatry, 14(1), 157. https://doi.org/10.1186/1471-244x-14-157 ikwuka, u., galbraith, n., manktelow, k., chen-wilson, j., oyebode, f., & muomah, r. c. (2016). attitude towards mental illness in southeastern nigeria: the contradictions of a communitarian culture. journal of community psychology, 44(2), 182–198. https://doi.org/10.1002/jcop.21749 larkings, j. s., & brown, p. m. (2018). do biogenetic causal beliefs reduce mental illness stigma in people with mental illness and in mental health professionals? a systematic review. international journal of mental health nursing, vol. 27, pp. 928– 941. https://doi.org/10.1111/inm.12390 lien, y. j., & kao, y. c. (2019). public beliefs and attitudes toward schizophrenia and depression in taiwan: a nationwide survey. psychiatry research, 273(january), 435–442. https://doi.org/10.1016/j.psychres.2019.01.062 maulik, p. k., devarapalli, s., kallakuri, s., tripathi, a. p., koschorke, m., & thornicroft, g. (2019). longitudinal assessment of an anti-stigma campaign related to common mental disorders in rural india. british journal of psychiatry, 214(2), 90–95. https://doi.org/10.1192/bjp.2018.190 ndetei, d. m., mutiso, v., maraj, a., anderson, k. k., musyimi, c., & mckenzie, k. (2016). stigmatizing attitudes toward mental illness among primary school children in kenya. social psychiatry and psychiatric epidemiology, 51(1), 73–80. https://doi.org/10.1007/s00127-015-1090-6 page, m. j., mckenzie, j. e., & higgins, j. p. t. (2018). tools for assessing risk of reporting biases in studies and syntheses of studies: a systematic review. bmj open, vol. 8, pp. 1–16. https://doi.org/10.1136/bmjopen-2017-019703 reavley, n. j., morgan, a. j., & jorm, a. f. (2017). predictors of experiences of discrimination and positive treatment in people with mental health problems: findings from an australian national survey. social psychiatry and psychiatric epidemiology, 52(3), 269–277. https://doi.org/10.1007/s00127-016-1301-9 schomerus, g., angermeyer, m. c., baumeister, s. e., stolzenburg, s., link, b. g., & phelan, j. c. (2016). an online intervention using information on the mental health-mental illness continuum to reduce stigma. european psychiatry, 32, 21–27. https://doi.org/10.1016/j.eurpsy.2015.11.006 subica, a. m., aitaoto, n., sullivan, j. g., henwood, b. f., yamada, a. m., & link, b. g. (2019). mental illness stigma among pacific islanders. psychiatry research, 273(january), 578–585. https://doi.org/10.1016/j.psychres.2019.01.077 subramaniam, m., abdin, e., picco, l., pang, s., shafie, s., vaingankar, j. a., … chong, s. a. (2017). stigma towards people with mental disorders and its components a perspective from multi-ethnic singapore. epidemiology and psychiatric sciences, vol. 26, pp. 371–382. https://doi.org/10.1017/s2045796016000159 svensson, b., & hansson, l. (2016). how mental health literacy and experience of mental illness relate to stigmatizing attitudes and social distance towards people with depression or psychosis: a cross-sectional study. nordic journal of psychiatry, 70(4), 309–313. https://doi.org/10.3109/08039488.2015.11091 40 townley, g., brusilovskiy, e., & salzer, m. s. (2017). urban and non-urban differences in community living and participation among individuals with serious mental illnesses. social science and medicine, 177, 223–230. https://doi.org/10.1016/j.socscimed.2017.01.05 8 xu, z., müller, m., heekeren, k., theodoridou, a., dvorsky, d., metzler, s., … rüsch, n. (2016). selflabelling and stigma as predictors of attitudes towards help-seeking among people at risk of psychosis: 1-year follow-up. european archives of psychiatry and clinical neuroscience, 266(1), 79– r. p. astuti et al. 170 | pissn: 1858-3598  eissn: 2502-5791 82. https://doi.org/10.1007/s00406-015-0576-2 zhuang, x. y., wong, d. f. k., cheng, c. w., & pan, s. m. (2017). mental health literacy, stigma and perception of causation of mental illness among chinese people in taiwan. international journal of social psychiatry, 63(6), 498–507. https://doi.org/10.1177/0020764017719303 ners vol 10 no 1 april 2015.indd 48 respons dan koping pasien penderita kanker servik terhadap efek kemoterapi (response and coping on physically to side effect cemotherapy in women suffered cervical cancer) winarsih nur ambarwati*, erlinda kusuma wardani* *program studi ilmu keperawatan fakultas ilmu kesehatan universitas muhammadiyah surakarta jl. a yani pabelan, kartasura, telp. 0271-711774, tromol pos 1, surakarta 57102 email: winarsih.ambarwati@ums.ac.id abstrak pendahuluan: kanker serviks adalah kanker yang menyebabkan sebagian besar kematian terutama di negara-negara berkembang. manajemen untuk kanker yang umum adalah kemoterapi. tujuan dari penelitian ini untuk mengembangkan konsep respon dan koping pasien kanker serviks yang menerima kemoterapi. metode: desain penelitian menggunakan metode kualitatif dengan fenomenologi. subjek penelitian adalah wanita dengan kanker serviks dirawat dengan kemoterapi di rumah sakit dr moewardi surakarta. teknik pengambilan sampel purposive sampling. instrumen penelitian yaitu wawancara, observasi, alat tulis dan rekaman perangkat, dan catatan lapangan. analisis data dilakukan dengan menggunakan analisis kualitatif. hasil: respons fi sik pasien kanker serviks kemoterapi termasuk mual, muntah, sembelit, neuropati perifer, kelelahan, penurunan berat badan, alopecia, toksisitas kulit, nafsu makan menurun, nyeri, perubahan rasa di lidah. koping pasien menggunakan cara-cara tradisional, dan sangat sedikit farmakologis yang digunakan untuk menyelesaikan masalah. analisis dan diskusi: kemoterapi memberikan efek nyata terhadap fi sik. pasien pada umumnya mengatasi dengan cara tradisional dan non-farmakologis. saran: hasil penelitian dapat digunakan sebagai dasar dalam melakukan penelitian lanjutan dalam hal pengembangan intervensi untuk meningkatkan kualitas hidup pasien kanker. kata kunci: respons, koping, fi sik, kemoterapi abstract introduction: the cervical cancer is a cancer that causes most deaths especially in developing countries. the management for most cancer is chemotherapy. chemotherapy has many impacts in many areas of life, among others, the impact lays on the physical and psychological. lack of information about the side effects of chemotherapy treatments cause the quality of life of patients continued to decline. the objective of the research: it: is to develop the concept of responses and coping physically of the cervical cancer patients who received the chemotherapy. methods: the study design was designed using qualitative methods. the approach used was qualitative research of the phenomenology study. the subjects of the research were the women with cervical cancer treated by chemotherapy in hospital of dr. moewardi of surakarta. the sampling technique was the purposive sampling. the research instruments were interview guidelines, observation guidelines, stationery and recording devices, and fi eld notes. the data analysis would be conducted by using qualitative analysis. result: the physical response of cervical cancer patients on chemotherapy include nausea, vomiting, constipation, peripheral neuropathy, fatigue, weight loss, alopecia, skin toxicity, decreased appetite, pain, change in taste on the tongue. the coping of the patients generally use traditional ways or leave it, and very few pharmacological were used to resolve the problem. discussion: chemotherapy give real effect to the physical. patients in general were coping by traditional and non-pharmacological means. suggestion: the results of the research can be used as evidence-based research in the treatment of cervical cancer patients with chemotherapy and used as the basis for the development of interventions to improve the life quality of the patients. keywords: response, coping, physical, chemotherapy pendahuluan kanker serviks merupakan penyakit kanker yang menimbulkan kematian terbanyak terutama di negara berkembang. setiap tahun lebih dari 270.000 wanita meninggal karena kanker servik, 85% dari kematian ada pada negara dengan pendapatan menengah ke bawah (who, 2013). kanker serviks menempati peringkat pertama penyebab kematian pada wanita dengan kasus keganasan kanker. berdasarkan catatan dari buku registrasi rekam medik di rsud (rumah sakit umum daerah) dr. moewardi surakarta jumlah kasus kanker serviks pada tahun 2012 sejumlah 841 kasus. tahun 2013 terjadi peningkatan jumlah penderita kanker serviks menjadi 1.757 kasus. penatalaksanaan untuk kanker serviks alternatif pengobatan utama adalah kemoterapi. 49 respons dan koping pasien penderita kanker servik (winarsih nur ambarwati, dkk.) kemoterapi memiliki dampak yang nyata dalam berbagai bidang kehidupan antara lain dampak terhadap fi sik dan psikologis. banyak sekali ditemukan bahwa program terapi yang direncanakan seringkali tidak selesai-selesai karena setiap kali pasien harus kemoterapi terpaksa harus ditunda karena kondisi pasien yang tidak memenuhi syarat untuk kemoterapi. rata-rata disebabkan karena keadaan umum yang jelek seper ti h b rendah, kondisi memburuk, pasien sakit-sakitan karena daya tahan pasien menurun akibat pengaruh obat kemoterapi, pasien tidak mau melanjutkan program kemoterapi karena merasa sudah sembuh atau drop out. kondisi ini disebabkan karena pasien tidak mendapat informasi yang adekuat tentang penyakit, penatalaksanaan dan perawatan efek samping kemoterapi dan minimnya informasi dari tenaga kesehatan. kondisi ini menyebabkan kualitas hidup pasien terus menurun. pasien penderita kanker servik dengan kemoterapi merupakan suatu pengalaman yang sangat individual dan berbeda antar wanita satu dengan lainnya. melihat fenomena di atas, dan masih terbatasnya penelitian mengenai respons dan koping pada wanita yang menderita kanker servik dengan kemoterapi terhadap efek samping secara f isik maka peneliti tertarik untuk melakukan penelitian kualitatif studi fenomenologi untuk mengidentifi kasi kualitas yang essensial dari pengalaman kesadaran dilakukan dengan mendalam dan teliti. secara umum tujuan dari penelitian ini adalah mengembangkan konsep respons dan mekanisme koping wanita menderita kanker servik yang mendapat kemoterapi terhadap fi sik. bahan dan metode d e s a i n p e n e l i t i a n d i r a n c a n g menggunakan metode kualitatif. pendekatan yang digunakan adalah penelitian kualitatif studi fenomenologi. subjek penelitian adalah wanita penderita kanker serviks dengan kemoterapi di rsud dr. moewardi surakarta. partisipan diambil dengan menggunakan teknik purposive sampling. instrumen dalam penelitian kualitatif ini adalah pedoman wawancara, pedoman observasi, alat tulis dan juga alat perekam untuk merekam dan mendokumentasikan (handphone lenovo a516 dan kamera digital samsung e91) serta catatan lapangan (fi eld note). teknik pengumpulan data pada tahap pertama akan dilakukan dengan wawancara mendalam pada pasien penderita kanker servik untuk meng ident if i ka si respons d a n kopi ng. observasi dilakukan untuk mendapatkan data tentang perubahan fi sik pasien setelah diberikan kemoterapi. analisa data akan dilakukan menggunakan analisa kualitatif. prinsip etik yang digunakan adalah respect for persons, benefi cence, justice, and respect for communities. hasil dan pembahasan karakteristik partisipan jumlah partisipan dalam penelitian ini ada 8 orang wanita penderita kanker servik. deskripsi dari partisipan sebagai berikut: partisipan berusia 42, 49, 54, 55, 58, 60 dua orang dan 62 tahun. stadium kanker servik iib 6 orang, iii a 1 orang dan iiib 1 orang. telah menjalani kemoterapi tiga kali 2 orang, empat kali 1 orang, lima kali 4 orang dan enam kali 1 orang. pendidikan terakhir semua sd. pekerjaan sebagai ibu rumah tangga 5 orang, wiraswasta 2 orang sebagai buruh 1 orang. agama islam 7 orang, dan budha 1 orang. respons dan koping wanita menderita kanker servik yang mendapat kemoterapi terhadap fi sik adalah sebagai berikut: mual dan muntah “sekitar 1 sampai 2 jam setelah dikemo terus merasa mual dan muntah...cuma mual saja tidak sampai muntah...hilang timbul” (p1). “sekitar setengah jam setelah diberi kemo...mual setiap kemo apa saja yang masuk muntah...masakan dari rumah sakit” (p2). “saat diberi obat ya merasa mual mbak... hilang timbul...setiap 5 menit sekali merasa mual dan muntah...bau gorengan, bau makanan manis-manis dan minuman manismanis” (p3).”saat diberi obat kemo mual tapi ga sampai muntah...mual terus...bau sayur sop, sayur terik atau sayur bersantan, 50 jurnal ners vol. 10 no. 1 april 2015: 48–60 bau soto dan bau pesing” (p4). “mual aja ga sampai muntah...2 jam sampai di rumah terus mual...sekitar 2 sampai 3 hari baru hilang... hilang timbul... kalo makan yang lembek-lembek.. telor yang amis-amis itu sama makanan yang lembek” (p5). “ waktu diberi obat kemonya saja mbak. masuk obat itu terus mual... sampai muntah” (p6).” iya mbak waktu obatnya masuk aja” (i6). “saat dikasih kemo itu mbak... biasanya kalo dapat makanan dari rumah sakit mbak langsung mual” (i7). “kalo obat kemonya habis sudah tidak mual dan muntah mbak rasanya mual saat dikasih obat aja... mual saja mbak jarang muntah” (p7). berdasarkan hasil observasi terhadap pasien penderita kanker ser viks dengan kemoterapi, ditemukan data pasien nampak lemas, sering meludah saat wawancara. kemudian dari hasil catatan lapangan (fi eld note), peneliti menemukan bahwa selama wawancara p4 menghirup bau minyak kayu putih. serta selama wawancara partisipan tidak merasa mual dan muntah. respons fi sik berupa mual dan muntah munculnya bervariasi yaitu pada saat selama pemberian kemoterapi, setiap lima menit, setengah sampai 2 jam setelah pemberian kemoterapi dan bahkan mual dan muntah dapat terjadi sehari, dua dan tiga hari setelah pemberian kemoterapi. sensasi yang dirasakan ada mual atau mual dan muntah. munculnya gejala mual dan muntah ada yang hilang timbul dan terus menerus. menurut gralla, grunberg dan messner (2008), mual dan muntah akut terjadi pada 24 jam pertama setelah kemoterapi sedangkan mual dan muntah yang terlambat merupakan efek samping yang terjadi sehari setelah kemoterapi atau bahkan beberapa hari setelah kemoterapi. pasien sering tidak mengetahui bahwa hal tersebut adalah efek samping dari kemoterapi. r e s p o n s m u a l d a n m u n t a h diklasifi kasikan menjadi akut, terlambat, dan antisipatif. akut terjadi kurang dari 24 jam setelah kemoterapi, terlambat terjadi 24 jam atau lebih setelah kemoterapi. muntah dapat diinduksi oleh berbagai zat kimia, obat sitostatik dan yang diperantai melalui chemoreceptors trigger zone (ctz). ctz berlokasi di medulla yang berperan sebagai chemosensor. area ini kaya akan berbagai reseptor neurotransmitter. contoh dari reseptor-reseptor tersebut antara lain reseptor kolinergik dan histamin, dopaminergik, opiate, serotonin, neurokinin dan benzodiazepine. agen kemoterapi, metabolitnya, atau komponen emetik lain menyebabkan proses muntah melalui salah satu atau lebih dari reseptor tersebut. mual dan muntah antisipatif merupakan respons yang timbul karena riwayat mual dan muntah yang tidak terkontrol. ini mungkin dipicu oleh selera, bau, pikiran, atau kecemasan yang berhubungan dengan kemoterapi. mual terdiri dari dorongan untuk muntah. ini bisa disertai dengan gejala otonom seperti pucat, takikardia, diaphoresis dan mukosa bibir kering (hawkins & grunberg, 2009). faktor pemicu rasa mual dan muntah meliputi aroma masakan dari rumah sakit, makanan yang berminyak, makanan yang berlemak, makanan dan minuman yang manis, bau yang menyengat (pesing), makanan dengan tekstur yang basah/lembek, makanan yang berbau amis, masakan yang bersantan. menurut hawkins & grunberg (2009), mual dan muntah dapat dipicu oleh bau, pikiran dan kecemasan terkait dengan kemoterapi. koping terhadap mual dan muntah “makan apel, pepaya atau jeruk... karena suka jenis buah itu...waktu makan buah ya tidak merasa mual mbak” (p2). “makan buah apa saja yang penting tidak terlalu manis...kalau jeruk terlalu manis saya juga tidak mau...ya karena saya suka buah itu saja... iya ada perbedaan rasanya menjadi tidak mual lagi” (p3). “ini mbak menghirup minyak kayu putih...karena saya tau sendiri...iya mbak rasa mualnya jadi berkurang”(p4). “minum air putih saja...tidak ada yang memberitahu karena saya tahu sendiri...rasanya jadi enak dan jadi hilang rasa mualnya jadi pengen makan” (p5). “makan buah pepaya atau apel yang penting tidak terlalu manis...ya karena saya suka jenis buah itu...jadi berkurang mual dan muntahnya” (p7). koping pasien dalam menghadapi rasa mual muntah di antaranya adalah memberikan makanan yang disukai pasien, menghirup aromaterapi, makan buah-buahan seperti apel, jeruk, pepaya, duku, pir dan minum air putih. 51 respons dan koping pasien penderita kanker servik (winarsih nur ambarwati, dkk.) dalam menghadapi rasa mual dan muntah pasien lebih memilih dengan cara mereka sendiri berdasarkan pengalaman, informasi dari tetangga atau teman sedikit yang secara inisiatif pribadi meminta dokter memberikan obat antimual. berbeda dengan orang barat yang memiliki kecenderungan yang tinggi permintaan pendekatan farmakologi. caracara yang dilakukan ternyata cukup efektif. berdasarkan sumber dari cancer care caracara untuk mengurangi mual muntah dapat dilakukan dengan menghindari makanan manis, gorengan, makanan berlemak dan makanan yang terlalu ekstrem baunya. jenis makanan yang memenuhi kriteria di atas adalah di antaranya buah-buahan. karena buah memiliki aroma yang segar tidak menyebabkan rasa mual, merupakan sumber gula alami yang baik dan kaya akan serat dan air. selain itu minum air yang adekuat juga sangat dianjurkan untuk menghindari dehidrasi selama mendapat kemoterapi (gralla, grunberg dan mesner, 2012). orang jawa juga sangat senang menggunakan minyak seperti minyak kayu putih, minyak telon, minyak-minyak tradisional lain yang sangat banyak untuk dioles atau dihirup. menurut loprinzi & messner (2012) penanganan mual dan muntah selain dengan perawatan medis yaitu makan dan minum perlahan, makan makanan kecil sepanjang hari sebagai pengganti sarapan, makan siang dan makan malam. hindar i makanan yang manis, makanan yang digoreng atau makanan yang berlemak, serta makanan dengan bau yang kuat, makan makanan dingin atau pada suhu kamar bisa membantu menghindari bau yang kuat, minum air yang cukup. konstipasi “sekitar seminggu, hanya sekali dan sedikit-sedikit...bentuknya keras juga sulit dikeluarkan” (p1). “setelah kemoterapi ada sekitar 1 minggu...keras sekali seperti tai kambing, keras dan mringkil-mringkil” (p3). “ini sudah 2 hari belum bab, mringkil – mringkil gitu dan ada darahnya...warnanya hitam” (p4) “di elus-elus punggung bagian belakang...karena keinginan saya sendiri... iya jadi bisa keluar tapi ya masih meringkilmeringkil gitu” (p4).. “ya sampai rumah juga belum bisa bab... ya ada seminggu... keras, tapi ya ga keras sekali, mringkil” (p6). “sampai di rumah sekitar 1 minggu baru bisa keluar bab nya mbak... keras sekali... sedikitsedikit” (p7). “sekitar 5 hari sampai 1 minggu mbak... keras..iya sulit” (p8). respons fisik pada sistem eliminasi yang dirasakan responden yaitu berupa feses yang keluar dengan jumlah yang sedikit, teksturnya keras, rasa tidak nyaman, kecilkecil, seperti feses kambing dan ada darahnya berwarna hitam. konstipasi terjadi selama kurang lebih lima sampai satu minggu. defi nisi konstipasi menur ut wgo (2007) adalah memenuhi kriteria buang air besar kurang dari tiga kali seminggu, feses keras lebih dari 25%, perasaan tidak puas atau tidak lengkap pengeluaran feses, diperlukan mengejan yang kuat. menurut avila (2004), pasien dengan kanker terutama dengan kanker stadium lanjut memiliki beberapa faktor yang menyebabkan konstipasi yaitu penggunaan analgesik opioid (opioid bekerja dengan menurunkan peristaltik dan meningkatkan tonus spincter pada katup ileocaecal sehingga perjalanan usus menjadi pelan memungkinkan meningkatnya absorpsi cairan, juga dapat mengurangi sekresi cairan pada usus dan mengurangi sensitivitas rektum untuk diregang), berkurangnya intake makanan dan minuman, mobilitas yang berkurang, usia lanjut dan terkait kondisi keganasan dari kanker itu sendiri. selain opioid, terdapat juga golongan obat yang dapat menyebabkan konstipasi seper ti agen kemoterapi, anti kolinergik (antidepresan trisiklik, fenotiazin), kalsium atau aluminium yang mengandung antasida dan antiemetik. sitotoksik agen kemoterapi dapat menghambat fungsi neurologis atau otot saluran cerna, terutama pada usus besar menyebabkan makanan masu k ke usus dengan sangat lambat. akibatnya air terlalu banyak diserap usus, maka feses menjadi keras dan kering. seseorang yang mengalami kanker dikatakan mengalami konstipasi atau sembelit apabila frekuensi buang air besar kurang dari 3 kali dalam seminggu setelah pemberian kemoterapi dengan konsistensi keras. pasien dengan kanker terutama yang 52 jurnal ners vol. 10 no. 1 april 2015: 48–60 memiliki kanker stadium lanjut memiliki faktor yang menyebabkan konstipasi yaitu penggunaan analgesik opioid, berkurangnya intake makanan dan minuman, berkurangnya mobilitas, usia lanjut, atau kondisi keganasan terkait misalnya obstr uksi usus parsial, hiperkalsemia yang berhubungan dengan tumor, dan akibat kemoterapi (avila, 2004). koping terhadap konstipasi “makan kates sama makan sayur juga” (p1). “makan kates dan pisang...ya saya kirakira saja dari pengalaman yang dulu-dulu itu kok setelah mengkonsumsi kates atau pisang itu bab nya jadi lancar...iya merasakan perubahannya bab nya jadi bisa keluar” (p3). “di elus-elus punggung bagian belakang... karena keinginan saya sendiri...iya jadi bisa keluar tapi ya masih meringkil-meringkil gitu” (p4). “makan pepaya...ada yang memberitahu dari tetangga kalo pepaya bisa melancarkan bab...iya jadi bisa keluar bab nya” (p6). “makan pepaya...ya suster dan dokter yang memberitahu kalo pepaya bisa melancarkan bab...kadang ya iya bisa keluar kadang ya tidak” (p7). “makan pepaya...banyak yang memberitahu teman-teman pasien disini juga memberitahu...ya jadi lebih mudak keluarnya bab nya” (p8). kopi ng pa sie n d ala m me ngat a si kelu ha n konst ipasi mengg u na ka n ca ra tradisional, informasi tentang cara tersebut diperoleh dari teman dan tetangga. caracara yang ditempuh pada umumnya jarang menggunakan pendekatan farmakologi. upaya yang dilakukan dalam mengatasi konstipasi yaitu mengonsumsi makanan tinggi serat seper ti buah pepaya dan pisang, say ur, melakukan teknik distraksi untuk mengatasi nyeri saat bab seper ti dimasage pada punggung belakang. dengan minum cukup air dan makanan berserat akan membantu pergerakan feses dan membuat feses menjadi lebih lunak. peningkatan aktivitas fi sik juga akan membantu dalam mengatasi konstipasi. cancer care (2012) merekomendasikan cara untuk mengatasi konstipasi adalah dengan minum air adekuat, diet high fi ber, exercise and hati-hati penggunaan laksatife. neuropati perifer “pa s cuacanya dingin aja ter us kesemutan...kalo cuacanya sudah panas lagi ya sudah hilang...cuma beberapa jam” (p3). “gemetar semenjak 2 bulan yang lalu...kalo tangan pas kecapean...agak sulit digerakkan jarinya... hilang timbul...kalo kecapekan jalan juga di kaki” (p4). “waktu kepanasan itu mbak langsung gemetar dan pusing” (p5). “kemarin kemo yang kelima itu mbak mulai jimpe... setiap hari mbak... ini di jari tangan dan jari kaki” (p7). “saat tiduran itu tiba-tiba terasa kesemutan jimpe... ga terus menerus mbak, dikit-dikit ya hilang nanti... semenjak dikemo itu mbak terus kesemutan... di tangan sampai lengan dan terkadang di kaki” (p8). berdasarkan hasil observasi, peneliti menemukan bahwa tangan bagian kanan p4 bergetar dan sulit menggerakkan jari tangan dan skala otot tangan kanan 4. berdasarkan hasil catatan lapangan (fi eld note) didapatkan data bahwa selama wawancara p4 menekankan t a nga n nya pa d a t e mpat t idu r supaya mengurangi gemetar di tangannya. keluhan pada saraf yang dirasakan adalah kesemutan, gemetar, sulit digerakkan pada tangan (jari-jari), lengan sampai kaki. lebih sering timbul pada cuaca yang dingin dan kelelahan, munculnya hilang timbul. neuropati perifer adalah seperangkat gejala yang disebabkan oleh kerusakan pada saraf yang lebih jauh dari otak dan sumsum tulang belakang. saraf perifer berfungsi membawa sensasi ke otak dan mengontrol pergerakan lengan, kaki, kandung kemih dan usus. beberapa obat kemoterapi yang d ig u n a k a n u n t u k m e n go b a t i k a n ke r menyebabkan neuropati perifer. gejala yang umum terjadi adalah kesemutan, penurunan kemampuan u nt u k merasakan tekanan, sent u han, panas dan dingin, kesulit an menggerakkan jari jari untuk mengambil dan menjatuhkan sesuatu dan kelemahan otot. neuropati perifer dapat terjadi setiap saat setelah pengobatan dimulai dan akan semakin parah sei r i ng ber jalan nya pengobat an. beb e r apa fa k t or ya ng me mp e nga r u h i neuropati perifer adalah usia pasien, intensitas kemoterapi, dosis obat, durasi pemberian kemoterapi dan penggunaan bersamaan 53 respons dan koping pasien penderita kanker servik (winarsih nur ambarwati, dkk.) dengan agen kemoterapi neurotoksik lainnya, dan kondisi yang sudah ada seperti diabetes dan pecandu alkohol (wolf et al., 2008). “diolesi fresh care...ya tidak ada yang memberitahu supaya hangat saja...iya mbak berkurang rasa kesemutannya kalo diberi fresh care” (p3). “tangannya saya tekankan pada kasur mbak...iya mbak jadi berkurang gemetarnya” (p4). “saya buat istirahat duduk atau mencari tempat yang tidak panas...iya mbak gemetarnya menjadi hilang” (p5). upaya untuk mengatasi rasa kesemutan dengan cara masage dengan minyak supaya hangat, istirahat, mencar i tempat yang nyaman. toksisitas kulit “ini sampai sekarang kulit gosongnya belum hilang...biasanya ga sampe panjang dan lama seperti ini” (p1). “hanya di bagian lengan tidak di tubuh...3 hari langsung hilang” (p2). “di infus kemo itu jadi agak hitam gosong gini, dulu juga pernah seperti ini” (p6). “kemo kemarin juga seperti itu mbak. tapi 2 hari sudah hilang” (i6). berdasarkan hasil observasi, didapatkan data terjadinya perubahan warna vena menjadi lebih gelap di bagian tangan kanan p1 dengan panjang ± 7 cm, dan pada bagian tangan kiri p6 dengan panjang ± 4 cm. berdasarkan hasil pemeriksaan fi sik didapatkan data tidak ada nyeri tekan. respon fisik berupa toksisitas kulit sebagian besar ber upa per ubahan war na vena menjadi lebih gelap yang terjadi pada sepanjang vena daerah sekitar lokasi pemberian kemoterapi. waktu terjadinya perubahan warna vena adalah saat pemberian kemoterapi dan akan hilang sekitar 2 sampai 3 hari. menurut aydogan et al (2004), efek samping sistemik kemoterapi pada kulit dapat berupa eritema atau garis hiperpigmentasi yang menyebar di sepanjang jaringan vena superfi sial di anterior lengan kanan dan lengan kiri bagian distal. gejala ini dapat muncul 24 jam sampai 15 hari setelah pemberian kemoterapi dan akan menghilang secara spontan setelah satu sampai tiga minggu. sedangkan menurut american cancer societ y (2013), ketika obat kemoterapi diberikan melalui infus, obat kemoterapi tertentu dapat menggelapkan kulit sepanjang vena. perubahan warna ini biasanya dapat menghilang dari waktu ke waktu setelah perawatan berakhir. toksisitas k ulit tidak mengancam kehidupan tetapi memperburuk kualitas hidup pasien. agen sitotoksik seperti siklofosfamid, klorambusil, busulfan, prokarbazin dapat menyebabkan efek samping pada rambut dan kuku (alopecia, paronychia, melanonychia) pada barier kulit (ruam kulit, kulit kering, hiperpigmentasi) dan mukosa (steven johnson syndrome dan nekrolisis epidermal toksik). i n hibitor t ransdu ksi sinyal, k hususnya antagonis egfr adalah kelas bar u agen kemoterapi, yang mengakibatkan efek samping dalam praktek klinis dermatologi. paling sering dilaporkan efek kulit beracun yang berasal dari obat ini adalah ruam folikular papulo pustular yang didefi nisikan sebagai bentuk jerawat karena melibatkan atas semua wajah dan daerah seboroik, kulit kepala serta dada. tetapi sangat jarang terjadi di daerah ekstremitas dan punggung. gejala pada kulit tersebut muncul selama dua minggu pertama pengobatan. disertai dengan pruritus yang sangat rentan terhadap infeksi bakteri (fabbrocini et al., 2012). koping terhadap toksisitas kulit “d i b i a r k a n s a j a n a n t i h i l a n g sendiri..(p1) minum air putih yang banyak... dokter yang bilang kalo kemo itu harus banyak minumnya...iya mbak gosongnya jadi hilang” (p2) “ minum air putih...(p6). upaya untuk mengatasi per ubahan pada pembuluh darah vena adalah minum air putih, anjuran ini di dapatkan dari dokter. pada umumnya tidak banyak yang dilakukan, pasien yang mengalami efek samping ini membiarkannya dan mengikuti anjuran dokter unt uk minum air putih. walaupun tindakan ini tidak mengatasi secara langsung tetapi intake air yang adekuat akan memberikan kesegaran, mencegah dehidrasi dan meningkatkan fungsi-fungsi metabolisme dalam tubuh. sangat sedikit referensi yang melaporkan cara mengatasi toksisitas kulit ini aydogan et al (2004) menyarankan cara 54 jurnal ners vol. 10 no. 1 april 2015: 48–60 untuk meminimalkan efek tersebut adalah dengan penatalaksanaan obat kemoterapi yang baik dan hati-hati. pasien dapat menggunakan lotion untuk melembabkan kulit. alopecia (kerontokan rambut) “saya sisir langsung brol banyak penuh, saya tarik langsung ketut semua...habisnya rontok itu kurang lebih satu bulan rontok habis semua rambutnya...ga cuma rambut sini tapi semua rambut di badan habis. rambut alis, ketiak... saya kasih jadam itu mbak lidah buaya itu mbak setiap hari...satu bulan baru mau tumbuh...hitam mbak...jadi lebih kasar” (p2). “rontok sedikit-sedikit gitu...iya jadi lebih kasar” (p3). “hanya sedikit – sedikit... jadi lebih kasar” (p4). “waktu tidur itu rontok. disisir juga rontok... panjang – panjang gitu banyak sekali... sudah sedikit rambutnya” (p5). “waktu cuci selimut itu sampai selimutnya juga saya sisir karena banyak rambutnya yang rontok disana” (i5). “sekitar 1 minggu setelah kemo yang pertama... tapi ya dikit – dikit... kalo disisir itu ya rontok” (p6). “sekitar 2 bulan setelah kemo yang pertama... pertama ya buanyak buanyak gitu mbak sekarang sampai habis gini... rambut di kemaluan bawah juga rontok mbak” (p7). “habis dikemo itu terus rontok tapi ya sedikit-sedikit rontoknya... jarang-jarang rambutnya dan gak nambah panjang-panjang mbak rambutnya” (p8). dari hasil observasi didapatkan data distribusi rambut tidak merata, rambut tipis, rambut di bagian atas lebih sedikit dan tekstur rambut lebih kasar dan sebagian besar pasien yang mengalami kerontokan rambut saat tidur dan disisir. waktu terjadinya kerontokan rambut beragam yaitu 1 minggu sampai 2 bulan setelah pemberian kemoterapi yang pertama. jumlah rambut yang mengalami kerontokan juga beragam yaitu sedikit demi sedikit dan langsung banyak. kerontokan rambut yang terjadi berlangsung sekitar 1 bulan sampai rambut benar-benar habis. selain itu, setelah menjalani kemoterapi tekstur rambut juga berubah menjadi lebih kasar, mudah patah dan pertumbuhan rambut menjadi lebih lambat. menurut trueb (2009), karakteristik utama dari folikel rambut anagen yang mengalami proliferasi dengan sel-sel matriks yaitu dengan menunjukkan aktivitas proliferasi terbesar dalam membangun batang rambut. selain itu juga penghentian mendadak aktivitas mitosis menyebabkan melemahnya sebagian keratin di bagian proksimal dari batang rambut, penyempitan, dan selanjutnya ker usakan kanal rambut. kerontokan rambut dapat terjadi 1 sampai 3 minggu dan selesai 1 sampai 2 bulan setelah dimulainya kemoterapi. diikuti dengan kerontokan rambut yang menyebar, perubahan yang khas terjadi pada akar rambut yait u pen ipisa n ya ng t aja m. menu r ut luanpitpong & rojanasakul (2012), alopecia mulai terjadi 2 sampai 4 minggu dan akan selesai 1 sampai 2 bulan setelah dimulainya kerontokan. efek berbeda pada rambut yang dapat dilihat adalah perubahan penampilan r a mbut, t i ng kat per t u mbu ha n r a mbut. kerontokan rambut dapat terjadi sebagian atau lengkap. bagian tubuh lain yang mengalami kerontokan selain di bagian kepala yaitu di bagian ketiak, kemaluan dan alis. namun, wak t u ter jadinya kerontokan ada yang bersamaan dan ada yang tidak. menurut luanpitpong & rojanasakul (2012), kemoterapi jangka panjang juga dapat mengakibatkan kerontokan pada rambut kemaluan, ketiak, rambut dan wajah. per t umbuhan rambut bar u ter jadi sekitar 1 bulan setelah kerontokan rambut s ele s a i. pe r t u mbu h a n r a mbut t e r ja d i setela h mengg u na ka n ca ra t rad isional yaitu mengoleskan lidah buaya setiap hari di kulit kepala. rambut baru yang tumbuh teksturnya menjadi lebih kasar dan berwarna hitam. menurut trueb (2009), kerontokan rambut biasanya bersifat reversibel dengan pertumbuhan kembali rambut pada umumnya 3 sampai 6 bulan setelah pengobatan berakhir. rambut baru menunjukkan perubahan pada warna. tekstur atau struktur, dalam beberapa kasus kepadatan rambut akan berkurang setelah terjadinya kerontokan rambut akibat kemoterapi. alopecia atau rambut rontok yang disebabkan oleh kemoterapi adalah efek samping pada kulit yang paling umum. tingkat alopecia tergant ung pada jenis 55 respons dan koping pasien penderita kanker servik (winarsih nur ambarwati, dkk.) kemoterapi, regimen dosis dan cara pemberian. hampir semua kemoterapi menyebabkan alopecia tetapi berbagai tingkat keparahan dan frekuensi. kemoterapi jangka panjang juga dapat mengakibatkan kerontokan pada rambut kemaluan, ketiak, rambut dan wajah. sebagian besar rambut baru berwarna abuabu yang mencerminkan adanya distorsi proses pigmentasi. rambut baru biasanya menunjukkan beberapa perubahan dalam struktur rambut seperti tekstur rambut menjadi lebih kasar, pertumbuhan rambut menjadi lebih lambat (luanpitpong & rojanasakul, 2012). koping terhadap alopecia “saya kasih jadam atau lidah buaya itu setiap hari.. terus 1 bulan kemudian saat saya pegang itu kok kasar-kasar gitu ternyata sudah tumbuh” (p2). saya biarkan saja, tidak saya apa-apakan, katanya pak dokter nanti tumbuh lagi (p3). saya biarkan saja…nanti rak tumbuh lagi….saya diberi tahu pasien yang pernah kemo juga mba(p6) pasien pada umum nya cender ung membiarkan saja, ada yang mencoba mengatasi dengan cara tradisional, mereka memperoleh informasi dari sesama penderita dan informasi dari perawat dan dokter bahwa rambut akan tumbuh lagi sehingga mereka tidak terlalu kawatir. upaya untuk mengatasi rambut yang rontok yaitu dengan menggunakan cara mengoleskan aloevera ke kulit kepala setiap hari. lidah buaya atau aloe vera merupakan tanaman tradisional yang dipercaya secara turun temurun dalam masyarakat jawa banyak ber manfaat unt uk rambut. lidah buaya ternyata mengandung banyak vitamin dan mineral yang efektif untuk mengobati rambut rontok. aloe vera adalah kondisioner rambut alami yang memiliki efek pendinginan dapat meningkatkan pertumbuhan rambut dengan mengoleskan gel atau jus lidah buaya pada kulit kepala dan melembapkan rambut dan membuatnya jadi lebih mudah ditata serta untuk mengobati ketombe secara alami. penurunan berat badan “dulu 38 mbak...sekarang 34...kurang makan..susah makan” (p4). “sebelum kemo 53 kg mbak... 42 kg mbak... bertahap, setiap kontrol kan di timbang mbak. turunnya sekitar 2 sampai 3 kg... ya makannya itu kan kurang mbak” (p6). “sebelum kemo 50 kg... sekarang sekitar 43 kg” (p7). “iya mbak makannya dikit” (i7). “sebelum kemo 65 kilo... setelah makan 60 kilo.. ga doyan makan” (p8). dari hasil observasi didapatkan data penurunan berat badan dalam persen meliputi p4 mengalami penurunan sebanyak 10,53%, p6 sebanyak 20,75%, p7 sebanyak 14% dan p8 sebanyak 7,69%. respon fi sik berupa penurunan berat badan ditemukan data bahwa penurunan berat badan berkisar 4 kilogram sampai 11 kilogram. penurunan berat badan tersebut mulai terjadi saat pasien mendapatkan terapi kemoterapi dan penurunan berat badan terjadi secara bertahap. salah satu faktor penyebab penurunan berat badan adalah intake nutrisi yang kurang. dan penurunan berat badan dalam persen sekitar 7,69% sampai 20,75%. menurut lara et al (2012), penurunan berat badan dapat terjadi 6 bulan terakhir atau 2 minggu terakhir setelah dimulainya kemoterapi. sebagian besar penderita mengalami penurunan berat badan sekitar 5% sampai 15% dari berat badan sebelum menjalani kemoterapi. penurunan berat badan bisa terjadi karena beberapa faktor di antaranya adalah penurunan nafsu makan yang disebabkan oleh mual, muntah, dan mukositis yang dialami oleh pender it a kan ker ser vi ks dengan kemoterapi. sebagian besar penderita mengalami penurunan 5% dari berat badan sebelum menjalani kemoterapi. deteksi dini malnutrisi pada pasien kanker sangat penting dan dapat meningkatkan kelangsungan hidup dan meningkatkan kualitas hidup. skrining nutrisi termasuk anthropometric parameters (bmi dan persentase penurunan berat badan) dan parameter biokimia. bmi normal adalah antara 18,5–24,9. penurunan berat badan merupakan parameter yang lebih baik untuk mengetahui status malnutrisi pada pasien kanker dengan kemoterapi. sebagian besar penurunan berat badan adalah 6–15% dari berat badan sebelum menjalani kemoterapi. skrining rutin malnutrisi pada pasien kanker harus mencakup faktor-faktor masalah yang timbul terkait dengan gangguan gastrointestinal (gi) 56 jurnal ners vol. 10 no. 1 april 2015: 48–60 yang mencakup gejala yang mempengaruhi asupan makanan (lara et al., 2012). koping terhadap penurunan berat badan berusaha mengatasi mual muntah biar bisa makan sedikit-dikit (p4)makan sebisanya, la gimana mau makan tidak nafsu…(p6)“ya dipaksa makan terus mbak supaya berat badannya tidak terus turun” (p8). upaya untuk mengatasi penurunan berat badan dengan memaksa dirinya untuk makan dengan mengatsi mual dan muntah. upaya memaksa dirinya untuk makan adalah sebagai bentuk upaya atau ihtiar bahwa manusia harus berupaya sekuat tenaga untuk memperoleh hal yang diinginkan. kelelahan (fatigue) “saya merasa cepat lelah 1 sampai 2 minggu setelah kemoterapi...jalan sebentar kaki sudah teklok...mau duduk juga lelah sekali, mau ke kamar mandi juga lelah sekali” (p2). “mulai lelah saat terdiagnosis kanker... kalo berjalan 5 meter itu sudah ga kuat” (p4). “ya rasanya pegel...semenjak sakit... jadi tambah lelah... kalo jalan tanjakan itu saya ga kuat” (p5). “ya lelah ga kayak dulu... nyapu sebentar itu sudah lelah, capek terus mbak, masak juga ya cepet capek... ya capek sekali itu di badan pegel-pegel” (p6). “ga enak,capek, pegal semua di seluruh badan... cuman ga bekerja selalu merasa capek. paling cuma nyayur kalo kuat... ya kalo jalan – jalan gitu kan juga terus merasa capek juga” (p7). “rasanya lelah mbak pengen tidur, jalan sebentar gitu sudah ngos-ngosan... semenjak dikasih kemo... duduk, tidur, berjalan, nyuci, masak” (p8). dari hasil observasi, peneliti menemukan bahwa saat p1 dan p4 berjalan ke kamar mandi anggota keluarga lain menuntun atau memapah partisipan dan selama wawancara partisipan lebih memilih berbaring. kemudian berdasarkan catatan lapangan (field note) peneliti menemukan bahwa saat wawancara akan berakhir partisipan menyatakan capek, sehingga ingin mengakhiri wawancara. respon fi sik berupa kelelahan (fatigue) dapat terjadi 1 sampai 2 minggu setelah pemberian kemoterapi. kelelahan ( fatigue) muncul saat berjalan dan melakukan kegiatan rumah tangga seperti menyapu, mencuci dan memasak. gejala fi sik yang dirasakan meliputi perasaan lelah, capek, rasa tidak kuat, sesak napas. fatique adalah keluhan yang paling sering dilaporkan oleh pasien kanker di mana masalah ini dapat mempengaruhi kualitas hidup pasien. fatique dapat di tandai dengan kekurangan energi secara umum, gangguan kognitif, somnolence dan gangguan mood atau kelemahan otot. masalah ini dapat timbul akibat kanker itu sendiri dan efek dari terapi kanker yang tidak hilang dengan istirahat atau tambahan tidur (vitkauskaite et al., 2011). menurut ream, richardson dan dann (2006), kelelahan dapat terjadi karena kebutuhan nutrisi yang kurang sehingga kebutuhan energi dalam tubuh tidak tercukupi. kelelahan dapat muncul beberapa hari setelah pengobatan kemoterapi dan akan terus akan semakin memburuk. sedangkan menurut vitkauskaite et al (2011), kelelahan dapat disebabkan banyak faktor seperti anemia, gangguan tidur, nyeri, gangguan emosi, efek pengobatan dari kanker dan disfungsi organ. kelelahan dapat terjadi karena anemia dan kebutuhan nutrisi yang kurang yang terjadi akibat penurunan nafsu makan. efek kemoterapi menyebabkan adanya pelepasan zat-zat sitokin seperti tnf (tumor nekrosis faktor) dan interleukin yang menyebabkan hipotalamus bereaksi dengan menurunkan rasa lapar mengakibatkan pasien kemoterapi mengalami penurunan nafsu makan, sehingga kebutuhan energi dalam tubuh tidak tercukupi. kelelahan dapat muncul beberapa hari setelah pengobatan kemoterapi. penyebab umum lainnya dari kelelahan terkait kanker antara lain karena kanker itu sendiri, kehilangan nafsu makan, anemia (rendahnya jumlah sel darah merah), nyeri yang tidak terkontrol, depresi, kurang tidur atau insomnia, obatobatan, kurangnya olahraga, nutrisi yang tidak memadai. sebagian besar orang yang menerima pengobatan kanker mengalami kelelahan dan beberapa penderita kanker yang selamat, mengalami kelelahan selama berbulan-bulan dan bahkan bertahun-tahun setelah menyelesaikan pengobatan kanker. kelelahan sering mengakibatkan dampak 57 respons dan koping pasien penderita kanker servik (winarsih nur ambarwati, dkk.) negatif yang mempengaruhi keseluruhan fi sik, psikologis, sosial dan ekonomi. ada banyak penyebab kelelahan yang berhubungan dengan kanker termasuk pengobatan kanker (ream, richardson, dann, 2006). koping terhadap kelelahan “kalo kecapean langsung ga jalan terus berhenti disitu...rasa capeknya jadi berkurang” (p2). “istirahat saja mbak...iya jadi berkurang rasa lelahnya” (p4). “kalo capek ya terus istirahat duduk lagi gitu terus minum atau makan kletik-kletik yang renyah itu seperti jagung goreng atau kacang goreng... rasa lelahnya jadi berkurang” (p5). “di buat istirahat tidur gitu...iya kemudian rasanya terus ga lelah lagi. hilang rasa lelahnya” (p6). “dengan istirahat atau tidur gitu...iya lelahnya jadi berkurang rasanya” (p7). “ya istirahat dengan tidur atau duduk...iya kemudian rasa lelahnya menjadi hilang” (p8). upaya unt u k mengatasi kelelahan adalah istirahat dengan berbaring, duduk atau tidur, makan atau minuman ringan. beberapa cara yang dapat digunakan untuk mengatasi kelelahan (fatigue) adalah sebagai berikut tidur siang singkat atau istirahat di kursi yang nyaman bukan di tempat tidur, berjalan-jalan atau melakukan beberapa latihan ringan jika memungkinkan ( l opr i n z i & messner, 2012). fat ique merupakan negatif efek yang diakibatkan berbagai masalah dan kondisi bukan karena efek samping kemoterapi itu sendiri tetapi secara umum oleh kondisi fi sik, psikologi, sosial, ekonomi dan kesejahteraan yang berhubungan dengan kan ker. unt uk it u manajemen fatique harus dilakukan secara komprehensif. menurut vitkauskaite et al (2011) manajemen fatigue harus interdisipliner yang melibatkan unsur klinik, psykologi dan faktor sosial. penurunan nafsu makan “ya tetep makan mbak tapi porsinya berkurang... tapi waktu kemo aja kalo ga kemo ya ga mbak” (p3). “makannya itu kalo lagi pengen makan aja... makan tapi porsinya berkurang” (p5). “ga mau makan sama sekali...semenjak kemo saja, kalo uda di rumah uda ga pahit mulutnya ya makan seperti biasa” (p8). berdasarkan hasil observasi, peneliti menemukan bahwa terdapat sisa makanan, berdasarkan catatan lapangan ( field note) p e nel it i me ne mu k a n ba hwa kelu a rga membawakan sendiri jenis makanan yang disukai oleh partisipan agar partisipan mau makan. respons fi sik berupa penurunan nafsu makan setelah menjalani kemoterapi dan bahkan tidak mau makan sama sekali selama pemberian kemoterapi serta frekuensi makan yang menjadi tidak teratur. menurut cherwin (2012), kurangnya nafsu makan terkait kanker dapat terjadi karena sinyal rasa lapar yang berasal dari hipotalamus berkurang dan sinyal kenyang yang dihasilkan oleh melacortins diperkuat. kurangnya nafsu makan juga dapat semakin memburuk saat pasien menerima kemoterapi yang berhubungan dengan mual atau perubahan rasa. koping terhadap perunurunan nafsu makan “minum air degan atau air kelapa muda sehari sekali...hanya air degannya saja tidak dicampur gula...ya mengetahui menggunakan air degan itu dari saya sendiri dan ternyata saya coba ya betul...nafsu makannya langsung bertambah” (p3). “makan yang saya suka... tahu sama tempe...iya kalo makan tahu sama tempe jadi nafsu makan lagi” (p5). “ makannya kalo sudah tidak pahit, kalo sudah di rumah (p8). upaya unt uk meningkatkan nafsu makan dengan memberikan makanan yang disukai pasien, dengan memberikan air kelapa muda dicampur gula, makan saat rasa pahit sudah tidak ada. american cancer society merekomendasikan cara untuk mengatasi per ubahan nafsu makan adalah makan sedikit tapi sering, mencoba makanan baru, membuat makanan yang disajikan secara bervariasi, jalan-jalan sebelum makan agar merasa lapar, makan bersama teman atau keluarga. air kelapa mengandung cytokinin yang dipercaya sebagai bahan anti penuaan dan anti kanker, sumber eletrolit alami yang steril dan mengandung kadar kalium, khlor, serta klorin yang tinggi airnya yang segar dan dingin dapat menghilangkan rasa mual 58 jurnal ners vol. 10 no. 1 april 2015: 48–60 dan meningkatkan nafsu makan. cancer care (2012) merekomendasikan cara untuk meningkatkan nafsu makan dengan membuat suasana makan yang menyenangkan (dengan musik, hiasan bunga, hias makanan). makan sedikit tapi sering, makan snack yang sehat, pertahankan pola makan dan makan snack yang teratur, sediakan camilan, pada betulbetul tidak berminat makan, maka makanlah makanan yang paling disukai, jika tidak cukup makan, maka dapat dipilih minuman yang tinggi kalori, tinggi protein dapat dikonsultasikan dengan dokter. nyeri “ya kencang terus... bagian bawah sampe punggung belakang... hilang timbul... kalo terlalu banyak di gerakkan itu sakit... itu mbak 5” (p2). “ini nyerinya di perut bagian bawah ini... senut-senut rasanya... kumatkumatan mbak... kalo aktivitas berat kayak nyuci gitu.. kira-kira 3 mbak.” (p7). “biasanya kalo selesai dikemo itu ga terasa sakit mbak tapi nanti lambat laun sakit lagi”(i7). “nyeri di per ut bagian ba wah...hilang timbul kayak diupek gt. slengking-slengking...kalo kecapekan mbak..ya 2 gitu mbak kira-kira” (p8). berdasarkan hasil catatan lapangan (fi eld note), peneliti menemukan bahwa selama wawancara partisipan tidak banyak bergerak. dari hasil pemeriksaan fi sik ditemukan data adanya nyeri tekan pada daerah yang nyeri. rasa nyeri timbul pada bagian perut bawah dan punggung, dengan munculnya hilang timbul, diperberat oleh aktivitas fi sik yang berat atau kecapekan, setelah kemoterapi selesai nyeri berkurang. rasa nyeri dapat timbul akibat kanker serviks itu sendiri dan dapat juga karena pengobatan kemoterapi. neurofi siologi nyeri pada kanker merupakan suatu hal yang kompleks yang meliputi mekanisme infl amatory, neuropathy, iskemik, dan kompresi termasuk faktor psikososial dan spiritual. penggunaan obat opiod yang lama dapat meningkatkan toleransi, hperalgesia, ketergantungan dan kecanduan. koping terhadap nyeri “ diseko air hangat... nyerinya jadi berkurang” (p2). “minum obat nyeri dari sini sampai habis kemudian juga diseko air hangat pake botol...suster sini yang memberitahu... rasa nyerinya jadi berkurang” (p7). nyeri diatasi dengan cara lapor dokter untuk mendapat obat, teknik distraksi seperti diseka air hangat. sesuai dengan sikap dan pandangan orang jawa bahwa hidup itu harus kuat, prihatin, jangan suka mengeluh membuat orang jawa sangat kuat dalam menahan sakit. keyakinan akan sakit adalah ujian, hidup itu sudah ada garisnya sehingga yang perlu dilakukan harusnya banyak berdoa, sehingga sangat sedikit yang menyelesaikannya dengan pendekatan farmakologis. perubahan rasa “ga nafsu makan karena ga enak di mulut, rasanya pahit...ya itu pengennya makan apa gitu” (p1). “pas dikemo rasanya pahit di mulut, jadi males” (p4). “iya itu mbak rasanya ga enak di mulut. pahit rasanya... ya tetep makan mbak tapi sedikit – sedikit. porsinya jadi sedikit... pokoknya tetap makan seadanya mbak” (p6). “iya mbak ga enak di mulut... pahit rasanya” (p7). “ya pahit mbak... setiap dikemo..makan apa saja itu rasanya pahit... dikasih kemo ini saja” (p8). berdasarkan hasil observasi, peneliti menemukan data bahwa terdapat sisa makanan baik dari rumah sakit. perubahan rasa pada lidah terasa pahit (rasa tidak enak di mulut dan rasa pahit di mulut) hampir dirasakan oleh semua pasien. menurut hong et al (2009), efek samping dari pengobatan kanker dan juga kanker itu sendiri dapat menyebabkan disfungsi persepsi sensorik pada pasien. gangguan rasa dan bau dapat meliputi perubahan ketajaman rasa (ageusia dan hypogeusia), kualitas (dysgeusia dan phantogeusia), gangguan persepsi penciuman, dan sindrom mulut kering (xerostomia). pasien yang diberikan kemoterapi sering mengeluhkan perubahan dalam persepsi rasa (changes in taste quality), perubahan persepsi rasa yang 59 respons dan koping pasien penderita kanker servik (winarsih nur ambarwati, dkk.) paling banyak dikeluhkan adalah rasa pahit atau rasa metal. kualitas rasa juga berkurang yang dideskripsikan sebagai sensasi rasa tidak enak di mulut atau mual. faktor lain yang berpengaruh adalah kurangnya perawatan mulut, infeksi, gastrointestinal refl ux. koping terhadap perubahan rasa “ya dituruti pengennya apa gitu.. apa jus sirsak, jambu merah atau jus apel” (p1). “makan makanan yang saya suka seperti sayur asem tahu tempe...ya rasanya jadi enak” (p4). “ngemil singkong...jadi agak enak rasanya” (p7). perubahan rasa diatasi dengan cara memberikan yang diinginkan seperti minum jus sirsak, jus jambu merah atau jus apel, makan camilan yang disukai. perubahan rasa diatasi dengan minum jus karena jus memberikan kesegaran, menghilangkan rasa mual dan banyak manfaatnya. ravasco (2005) dalam hong et al (2009) merekomendasikan cara untuk mengatasi perubahan rasa adalah dengan menghindari penggunaan peralatan makan dan minum dar i metalik u nt u k mengurangi rasa logam, mengurangi konsumsi makanan rasa logam atau pahit seperti daging merah, kopi, teh, dan meningkatkan konsumsi tinggi protein seperti ayam, ikan, dan telur. menambahkan bumbu dan rasa pedas untuk meningkatkan rasa bila terjadi hypogeusia atau hyposmia. menyajikan makanan dalam suhu dingin untuk mengurangi bau yang tidak enak. melakukan perawatan mulut dengan baik, termasuk sikat gigi dan menggunakan pencuci mulut. kepustakaan aydogan., kavak, a., parlak, h. a., alper, m., annakkaya, n. a., erbas, m. 2004. persistent ser pentine supravenous hyperpigmented eruption associated with docetaxel. journal of european a c a d e m y o f d e r m a t o l o g y a n d venereolog y, (doi: 10.1111/j.1468., diakses tanggal 15 juni 2014, jam 10.00 wib) american cancer society. 2013. understanding chemotheraphy: a guide forpatients and families. (online), (www.cancer. org. diakses tanggal 4 juni 2014, jam 11.309 wib) avila, g.j. 2004. pharmacologic treatment of constipation in cancer patients. journal of departement of pharmacy, vol. 11, no.3, ht t p://moff it t.org /3083.2005.01088.x., diakses tanggal 20 juni 2014, jam 09.00 wib cherwin, h. c. 2012. gatrointestinal symptom represent at ion i n cancersy mptom clusters: a synthesis of the literature. journal of oncologynursing society, doi: 10.1188/12.onf.157-165 fabbrocini, g., cameli, n., romano, c.m., mariano, m., panariello, l., bianca,d., monfrecola, g. 2012. chemotherapy and skin reaction. journal of experimental a n d cli n i c a l ca n c e r re se a r c h, 31:50.(online), (http://www.jeccr.com/ content/31/50, diakses tanggal 25 mei 2014, jam 13.00 wib) gralla, j.r., grunberg, m.s., messner, c. 2012. coping with nausea a vomiting from chemotheraphy. www.cancercare. com hawk i n s, r ., & g r u nb e rg, s. 20 09. chemotherapy induced nausea and vomiting: challenges and opportunities for i mproved pat ient s outcomes. journal of oncology nursing or the oncology nursing society. vol. 13, no. 1, doi:10.118/09.cjon,55-64 hong, h.j., ozbek, o.p., stanek, t.b., dietrich, m.a., d u nca n , e.s., l ee, w.y., lesser, g. 2009. taste and odor abnor malities i n cancer patients. t h e j o u r n a l o f s u p p o r t i v e oncology, 7:58-65. (online), (www. supp or t ive o ncolog y.net , d ia k se s tanggal 24 mei 2014, jam 12.30 wib) lara, s.k., morales, u.e., kuba, m.d., green, d. 2012. gastrointestinal symptoms and weight loss in cancer patients receiving chemotherapy. british journal of nutrition, 894-897. doi: 10.1017/ s0007114512002073 luanpitpong, s., & rojanasakul, y. 2012. chemotherapy induced alopecia topicsin cancer survivorship. journal of europe: in tech. isbn: 978 953-3078946,www. intechopen.com ream, e., richardson, a., dann, a.c. 2006. supportive intervention for fatigue in 60 jurnal ners vol. 10 no. 1 april 2015: 48–60 patients undergoing chemotherapy. jo u r n a l o f pa i n a n d s y m p t o m management, vol. 31, no. 2. doi: 10.1016/j.jpainsymman.2005.07.003 trueb, m.r. 2009. chemotheraphy induced alopecia. journal of departement of dermatology university hospital of zurich, doi:10.1016/j.sder.2008.12.001 vitkauskaite, e., juozaityte, e., drukteniene, j., bunevicius, r. 2011. a systematic review of cancer related fatigue. biological psychiatry and psychopharmacology. vol. 13. wolf, s., ba r ton, d., kot t schade, l., g rot hey, a., lopr i n zi, c. 20 08. chemotherapy induced per ipheral neuropathy prevention and treatment strategies. european journal of cancer, 1 5 0 7 – 1 5 1 5 . d o i : 1 0 . 1 0 1 6 / j.ejca.2008.04.018, (online), (www. ejconline.com, diakses tanggal 23 juni 2014, jam 13.00 wib) 82 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18943 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the relationship between internet addiction and insomnia in student class ix la rahmat wabula1, m. taufan umasugi1, wa ode nurlina2, angga miftakhul nizar2, and restiyana agus2 1 nursing study programme stikes maluku husada, indonesia 2 faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: internet addiction can cause unfulfilled hours of sleep, which if left unchecked will lead to disruption of sleep patterns often called insomnia. the purpose of the research was to determine the relationship between internet addiction and insomnia. methods: the design of the research was descriptive-analytic with a crosssectional approach. the population in the research consisted of as many as 217 respondents with a sample size of 141 respondents. the variables used in the research were insomnia as the dependent variable and internet addiction as the independent one. the instrument used was a questionnaire with a univariate and bivariate analysis. results: the results of the study used the spearman rho test with a value of p = 0,000. conclusion: from these results, it could be concluded that there is a relationship between internet addiction and the incidence of insomnia. internet addiction can cause unfulfilled hours of sleep, which if left unchecked will lead to disturbed sleep patterns often called insomnia. the research suggests that students pay more attention to their health by limiting or reducing the use of the internet for unimportant issues as it can reduce learning productivity and academic value and cause insomnia. article history received: feb 27, 2020 accepted: april 1, 2020 keywords insomnia; internet addiction; students contact wa ode nurlina  wa.ode.nurlina-2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: wabula, l, r., umasugi, m. t., nurlina, w.o., nizar, a.m., & agus, r. (2020). the relationship between internet addiction and insomnia in student class ix. jurnal ners, special issues, 82-85. doi:http://dx.doi.org/10.20473/jn.v15i2.18943 introduction the development of science, technology, and information is rapidly increasing at this time, making people inseparable from the use of the internet. along with the development of the internet, the development of social media is also widely spread in the community. the rapid development of the internet and social media has a significant impact on all communities throughout the world (sumedi, t., & kuswati, 2010) data from the ministry of communication and information technology (kemenkominfo) states that internet users in indonesia in 2013 reached 63 million people. of that number 95 per cent use the internet to access social networks. the most accessed social networking sites are facebook and twitter. indonesia ranks 4th as the country with the most facebook users in the world, with 65 million active users after the usa, brazil, and india. indonesia ranks fifth as the country with the most twitter users in the world, with 19.5 million active users after the usa, brazil, japan, and the united kingdom. in addition to facebook and twitter, other social networks known in indonesia is path with 700,000 users in indonesia, line with 10 million users, google+ 3.4 million users and linkedin with 1 million(kominfo., 2015). the results of the social survey conducted in singapore in 2017 showed that the indonesian population using social media reached 106 million out of a total population of 262 million. the popularity of the internet as a medium of communication has made it a part of everyday life for many people and led to an increase in the use of the internet by individuals. the number of internet users in indonesia in 2017 reached 143.26 million from a https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 83 total of 262 million people. this means that 54.68% of indonesians are internet users (supratman, 2018). globally, the highest prevalence of internet addiction is in the middle east (10.9%) and the lowest is in northern and western europe (2.6%). an internet addiction (supratman, l. p., & wahyudin, 2017) the experts agree that the use of the internet deserves serious attention given its usage in adolescents where there is an increasing tendency which tends to be excessive, and in the long run can lead to mental disorders in users such as antisocial disorders, anxiety disorders, and stress disorders (dewi, n & trikusumaadi, 2017; raj, 2017) internet addiction can cause unfulfilled hours of sleep, which if left unchecked will lead to disturbed sleep patterns often called insomnia. case studies from young also found that people with internet addiction could spend up to 70 hours a week accessing the internet (nur rahmawati, 2018).. most internet users are educated people, namely students. the development of the current era of globalization is encouraging the next generation, especially students as agents of change to keep abreast of the times. the inevitability of the internet as study equipment and job aids makes it play a role in the way humans think, communicate, relate, recreate, behave, and make decisi(linda pradani agesti, rizki fitryasari, ni ketut alit armini, 2019)[8]ons[8]. ironically, this useful tool also raises quite a number of problems for internet users (lombogia, b. j., kairupan, b. h. r., & dundu, 2018). the study aims to determine the relationship between internet addiction with insomnia. materials and methods this study used a descriptive-analytic research design where the researcher makes direct observations on respondents and distributes questionnaires using a cross-sectional approach to determine the relationship between internet addiction and insomnia in students class ix. this research was conducted at one of the campuses in maluku on 728 august 2019. this study uses a stratified random sampling technique, which was a random sample selection concerning strata levels in the population, namely students of class ix, amounting to 141 people. the data collection technique used primary data obtained directly from the use of a structured questionnaire with alternative answers provided and secondary data, that is supporting information obtained from the nursing study program which contains data about students. the data analysis consisting of univariate and bivariate analysis used the spearman rho statistical test with a significance level of p <0.05. the ethical principles implemented in this study include the recruitment of respondents with awareness, without coercion, with informed consent, benefits for the subject, and confidentiality, results table 1 shows that of the 141 respondents, the majority were respondents age 21 with a total of 63 respondents (44.7%), and the least were respondents age 22 with a total of 5 respondents (3.5%). there were 51 male respondents (36.2%) and 90 female respondents (63.8%). table 2 shows that of the 141 respondents studied, the respondents belonging to normal internet use were 28 (19.9%), as many as 56 respondents (39.7%) were classified as light , 53 as medium (37.6%) and 4 were severe (2.8%). there were 69 (48.9%) respondents who experienced insomnia and 72 (51.1%) other respondents who did no. 28 respondents used the internet normally, whereas 2 (7.1%) experienced insomnia and as many as 26 (92.9%) other respondents did not experience. 56 respondents were addicted to the internet, categorized as mild; there were 17 (30.4%) respondents who experienced insomnia and as many as 39 (69.6%) other respondents who did not. of the 53 respondents who were addicted to the internet in the middle category, there were 46 (86.8%) respondents who experienced insomnia and 7 table 1. respondents’ characteristics (n=141) characteristics category n % age 19 year 21 14,9 20 year 52 36,9 21 year 63 44,7 22 year 5 3,5 gender man 51 36.2 woman 90 63.8 source: primary data 2019 table 2. relationship between internet addiction and insomnia (n=141) internet addiction incident insomnia p-value insomnia no insomnia total n % n % n % normal 2 26 28 mild 17 39 56 intermediate 46 7 53 0.000 severe 4 0 4 totally 69 48.9 72 51.1 141 100 source: primary data 2019 l. r. wabula et al. 84 | pissn: 1858-3598  eissn: 2502-5791 (13.2%) did not. 4 respondents who were in the severe category were known to have overall insomnia. based on the results of the spearman rho test, the value of sig (2-tailed) is value = 0,000 which indicates p <α or 0,000 <0.05. the analysis shows that there is a significant relationship between internet addiction and the incidence of insomnia in class ix students. discussion there is a significant relationship between internet addiction and the incidence of insomnia experienced by students of class ix. internet addiction can cause unfulfilled hours of sleep, which if left unchecked will lead to disturbed sleep patterns often called insomnia. there were 28 respondents with a normal use of the internet, 2 (7.1%) respondents experienced insomnia and as many as 26 (92.9%) others did not. teenagers have an unstable and egocentric behavior so teens have not been able to filter out good or bad things from the internet which means adolescents are vulnerable to its negative effects. among the negative effects of internet use are decreased adolescent learning discipline, stress and anxiety, and loss of self-concept(altamiranobustamante & altamirano-bustamante, 2016; sumter, bokhorst, steinberg, & westenberg, 2009). of the 56 respondents who were addicted to the internet categorized as mild, 17 (30.4%) experienced insomnia and as many as 39 (69.6%) did not. of the 53 respondents who were addicted to the internet in the middle category, 46 (86.8%) experienced insomnia and as many as 7 (13.2%) did not. whereas 4 respondents who were in the severe category were known to have overall insomnia. the progress of science and technology is currently a very big influence in the community, especially among adolescents. the cell phone features that are often used by teenagers are video calls, social media and various social media sites such as facebook which are very helpful as multifunctional tools, because these multifunctional teens use technology positively or negatively(griffiths, 2000; landtblom & engström, 2014). there is a relationship between the duration of social media use and the incidence of insomnia in adolescents in public senior high school manado(lombogia, b. j., kairupan, b. h. r., & dundu, 2018). suggestions include reducing the use of social media and being able to manage sleep time. one of the internet addiction effects was smartphone behavior, being restless when not using a smartphone, and selfefficacy can be influenced by an anxious behavior. academic achievement is influenced by environmental factors, and one of them is social media.(linda pradani agesti, rizki fitryasari, ni ketut alit armini, 2019) the biggest indicator of smartphone addiction is overuse. respondents use smartphones excessively and uncontrollably. this excessive use can make students not concentrate on learning and lose motivation (young, 1998). internet addiction has become a serious problem and is considered a psychological one. internet addicts are individuals addicted to the internet with a strong tendency to carry out activities that are only solitary and limit social activities. pathological internet use refers to psychological dependence on the internet(dewi, n & trikusumaadi, 2017; nur rahmawati, 2018). conclusion there was a relationship between internet addiction and the incidence of insomnia in class ix students. most respondents were in the moderate internet addiction category; however, some were included in the severe category. the higher the level of internet addiction, the higher the problem of insomnia experienced by adolescents. further research needs to be done with a qualitative approach on the experience of families with teenagers who are internet-addicted. conflict of interest the authors declare that there is no conflict of interest. acknowledgement the authors would like to thank the faculty of nursing and stikes maluku husada for providing the opportunity to present this study. references altamirano-bustamante, n., & altamiranobustamante, m. m. (2016). teenager. gaceta medica de mexico. https://doi.org/10.4324/9780429485336-5 dewi, n & trikusumaadi, s. k. (2017). bahaya kecanduan internet dan kecemasan komunikasi terhadap karakter kerjasama pada mahasiswa. jurnal psikologi, 43(3), 220. https://doi.org/https://doi.org/10.22146/jpsi.1 6829 griffiths, m. (2000). does internet and computer “addiction” exist? some case study evidence. cyberpsychology and behavior. https://doi.org/10.1089/109493100316067 kominfo. (2015). pengguna internet di indonesia capai 82 juta. kementrian komunikasi dan informatika republik indonesia. jakarta: kemkominfo. landtblom, a. m., & engström, m. (2014). the sleepy teenager diagnostic challenges. frontiers in neurology. https://doi.org/10.3389/fneur.2014.00140 linda pradani agesti, rizki fitryasari, ni ketut alit armini, a. y. (2019). relationship of smartphone addiction and self-efficacy with academic achievement in adolescent. psychiatric nursing journal, 1(1), 1–6. lombogia, b. j., kairupan, b. h. r., & dundu, a. e. (2018). hubungan kecanduan internet dengan jurnal ners http://e-journal.unair.ac.id/jners | 85 kualitas tidur pada siswa sma kristen 1 tomohon. urnal medik dan rehabilitasi (jmr), 1(1), 1–8. nur rahmawati, a. i. (2018). internet addiction pada remaja pelaku substance abuse: penyebab atau akibat? buletin psikologi, 26(1), 64–70. https://doi.org/https://doi.org/10.22146/buleti npsikologi.31164 raj, a. a. (2017). perilaku kecanduan internet terhadap interaksi sosial pada remaja di lingkungan kos. fakultas psikologi. sumedi, t., & kuswati, a. (2010). pengaruh senam lansia terhadap penurunan skala insomnia ada lansia di panti wredha dewanata cilacap. soedirman journal of nursing, 5(1), 13–20. sumter, s. r., bokhorst, c. l., steinberg, l., & westenberg, p. m. (2009). the developmental pattern of resistance to peer influence in adolescence: will the teenager ever be able to resist? journal of adolescence. https://doi.org/10.1016/j.adolescence.2008.08.0 10 supratman, l. p., & wahyudin, a. (2017). digital media literacy to higher students in indonesia. international journal of english literature and social sciences, 2(5), 51–58. supratman, l. p. (2018). penggunaan media sosial oleh digital native. jurnal ilmu komunikasi, 15(1), 47–60. https://doi.org/https://doi.org/10.24002/jik.v1 5i1.1243 young, k. s. (1998). internet addiction: the emergence of a new clinical disorder. cyberpsychology and behavior, 1(3), 237–244. https://doi.org/https://doi.org/10.1089/cpb.19 98.1.237 45 model kesehatan keselamatan kerja berbasis agricultural nursing: studi analisis masalah kesehatan petani (occupational health nursing model-based agricultural nursing: a study analyzes of farmers health problem) tantut susanto*, retno purwandari**, emi wuri wuryaningsih*** * departemen keperawatan keluarga dan komunitas, psik universitas jember. ** departemen keperawatan dasar dan manajemen keperawatan, psik universitas jember. ***) departemen keperawatan jiwa, psik universitas jember. email: tantut_s.psik@unej.ac.id abstrak pendahuluan: mayoritas tenaga kerja indonesia di daerah pedesaan bekerja di sektor pertanian yang berisiko untuk masalah kesehatan yang berkaitan dengan interaksi petani dan lingkungan. hal ini diperlukan untuk mendekati keselamatan kesehatan berdasarkan pada perawatan kesehatan primer untuk mencegah dan mengurangi risiko kecelakaan atau penyakit. studi ini mengidentifikasi masalah kesehatan petani dan faktor mereka untuk mengembangkan kerja keperawatan pertanian berbasis model keperawatan kesehatan di daerah pedesaan jember. metode: penelitian cross-sectional dari 169 petani dilakukan untuk menyelidiki sosiodemografi, gaya hidup, lingkungan hidup dan bekerja, status kesehatan dan masalah kesehatan. data yang dikumpulkan oleh kuesioner diberikan diri, penilaian fisik, dan tes darah. analisis deskriptif dan komparatif meliputi tes chi-square dan analisis regresi ogistic dan multinomial digunakan untuk menilai hubungan antara faktor kehadiran masalah kesehatan. hasil: ada perbedaan antara sosiodemografi, lingkungan hidup dan bekerja dan masalah kesehatan petani (p <0,05). hampir 37,9% dari petani adalah penyakit. di antara 28,5% dari berat badan dan 9,5% dari kelebihan berat badan yang berhubungan dengan usia, minum kopi, dan kelebihan seharian bekerja. 62,6% dari anemia yang berhubungan dengan gender dan kebiasaan merokok. sementara itu, 45,2% hipertensi sistolik dan 35,8% hipertensi diastolik yang disebabkan oleh bekerja overload. selanjutnya, 50,3% dari nyeri pada bergabung dan tulang yang berhubungan dengan usia dan reses bekerja. diskusi: masalah kesehatan petani ditandai masalah gizi, anemia, hipertensi, dan rasa sakit yang terkait dengan lingkungan sosiodemografi biologis, psikologis, dan bekerja. model keperawatan pertanian bisa mengembangkan untuk assessesment faktor terkait yang dirumuskan diagnosa masalah kesehatan pada petani di daerah pedesaan. kata kunci: keperawatan pertanian; keperawatan kesehatan kerja; petani; masalah kesehatan abstract introduction: the majority of indonesian labor force at rural area works in the agricultural sector that risk for health problems related to interaction of farmer and environment. it is necessary to approach health care safety based on primary health care for to prevent and reduce the risks of accidents or illness. this study identifies farmer’s health problem and their factors for developing occupational health nursing model-based agricultural nursing at rural area of jember. methods: a cross-sectional study of 169 farmers was done to investigate sociodemographic, lifestyles, environment of living and worked, health status and health problem. data collected by the self administered questionnaire, physical assessment, and blood test. the descriptive and comparative analyses include chi-square tests and ogistic and multinomial regression analyses were used to assess the relationships between factors to the presence of health problems. results: there was differences between sociodemographic, environment of living and worked and the health problems of farmers (p<0.05). almost 37.9% of farmers is illness. among 28.5% of underweight and 9.5% of overweight that related to age, drink of coffe, and exc ess day of work. 62.6% of anemia that related to gender and smoking habit. meanwhile, 45.2% of sistolic hypertension and 35.8% diastolic hypertension that caused by worked of overload. furthermore, 50.3% of pain on join and bone related to age and recess of worked. discussion: the health problems of farmers was characterized of nutritional problem, anemia, hypertension, and pain that related to sociodemographic environment of biologic, psychologic, and worked. agricultural nursing model could be develop for assessesment of related factors that formulated diagnoses of health problems on farmers at rural area. keywords: agricultural nursing; occupational health nursing; farmer; health problem ____________________________________________________________________________________________________ pendahuluan hasil survei bps kabupaten jember dominasi penggunaan lahan adalah kegiatan pertanian yakni seluas 5.099,283 ha atau 51,47% dari total luas wilayah (badan pusat statistik, 2014). pertanian dilihat sebagai suatu yang potensial dalam kontribusinya terhadap perekonomian di indonesia dan juga dinilai dapat memiliki berbagai macam resiko kesehatan dalam pelaksanaan, hal tersebut dikarenakan pekerjaan petani masih belum memiliki standart keselamatan dan kesehatan kerja (k3). laporan international labor organitation (ilo), 6.000 kasus k3 fatal terjadi setiap harinya dan setiap 100.000 tenaga kerja terdapat 20 orang terkena kasus k3 fatal di indonesia. kerugian yang harus ditanggung akibat kecelakaan mailto:tantut_s.psik@unej.ac.id jurnal ners vol. 11 no. 1 april 2016: 45-50 46 kerja di negara berkembang mencapai 4% dari gross national product (gnp) (depnakertrans, 2012). sementara itu, rata-rata 2,2 juta orang meninggal per tahun akibat sakit atau kecelakaan yang berkaitan dengan pekerjaan mereka (suardi, 2005). pekerja sektor informal di indonesia dilaporkan terkena berbagai masalah kesehatan seperti malnutrisi, penyakit akibat parasit (misalnya cacingan), asma, alergi kulit, kanker, keracunan bahan kimia, keracunan makanan, gangguan otot dan tulang, gangguan saluran pernafasan, penyakit kelenjar getah bening, dan penyakit darah. risiko bahaya yang dihadapi di tempat kerja antara lain meliputi kebisingan, vibrasi, radiasi panas, kurangnya pencahayaan, pemasangan alat berbahaya tanpa menggunakan alat perlindungan diri (apd) untuk aspek keselamatan, menghirup debu dan terkena bahan kimia berbahaya, serta ergonomik yang buruk (markkanen, 2004). k3 dinilai dapat mengurangi resiko munculnya penyakit akibat kerja (pak). program k3 di terapkan dalam bentuk unit kesehatan kerja (ukk) di setiap puskesmas (zaenal, et al., 2008) dengan mengenali hal-hal yang berpotensi menimbulkan kecelakaan dan penyakit akibat kerja serta tindakan antisipatif terjadinya kecelakaan dan penyakit akibat kerja (lestari, 2007). pendekatan perawatan kesehatan dan keselamatan kerja (pk3) berbasis agricultural nursing di puskesmas bertujuan untuk peningkatan pelayanan kesehatan kerja untuk lebih diarahkan pada partisipasi masyarakat. pendekatan ini diharapkan dapat memenuhi kebutuhan untuk membentuk atau mendirikan unit perawatan kesehatan primer dalam masyarakat melalui pelayanan kesehatan yang bersifat promotif, preventif, kuratif dan rehabilitatif melalui pendekatan asuhan keperawatan di komunitas dengan pendekatan pada kelompok khusus pekerja. berdasarkan paparan tersebut diatas, penelitian ini bertujuan untuk: 1) mengidentifikasi faktor-faktor yang mengakibatkan masalah kesehatan petani; 2) mengidentifikasi prevalensi masalah kesehatan petani; dan 3) menyusun model perawatan kesehatan keselamatan kerja berbasis agricultural nursing yang difokuskan pada pengkajian faktor dan masalah kesehatan di area rural kabupaten jember. bahan dan metode penelitian ini menggunakan desain studi cross-sectional pada 169 petani di dua wilayah kerja puskesmas dengan dominasi sektor pertanian di daerah rural yang menerapkan ukk dengan binaan kelompok tani di kabupaten jember. penelitian ini berlangsung selama 3 bulan (juni-agustus 2015). sampel diambil secara multi stage random sampling. penelitian ini merupakan penelitian multi tahun, dimana pada tahun pertema ini peneliti berfokus pada identifikasi faktor dan masalah sehingga dapat dirancang model perawatan k3 dengan menekankan pada pengkajian dan masalah. data penelitian dikur dengan menggunakan kuesioner untuk mengukur setiap variabel yang mempengaruhi permasalahan kesehatan petani dan masalah penyakit yang ditimbulkannya. data sosial demografi (umur, jenis kelamin, suku, dan pendidikan), gaya hidup (merokok, minum kopi, dan makanan berlemak), lingkungan tempat tinggal (kondisi rumah, ventilasi dan sirkulasi, keadaan air, mck, dan lingkungan sekitar), lingkungan psikologis (lama tinggal dan kenyamanan tinggal), dan lingkungan dan keadaan di tempat kerja petani (lama kerja, istirahat, hari kerja, beban kerja, apd, posisi kerja atau ergonomis) diukur dengan menggunakan kuesioner. status sehat sakit diukur dengan melakukan pengkajian fisik langsung. masalah kesehatan terkait status nutrisi diukur melalui tinggi badan (m 2 ) dan berat badan (kg) dengan menggunakan timbangan digital dari omron yang kemudian dikonversi menjadi indeks masa tubuh (imt). hasil imt diklasifikasikan untuk menentukan status nutrisi (underweight: imt kurang dari 18.5; normal: imt 18.5-24.9; overweight: imt 25-27; dan obesity: imt lebih dari 27; kemudian, overweight and obesity dikelompokkan menjadi satu yaitu overweight. pengukuran tekanan darah dilakukan untuk mengidentifikasi hipertensi baik sistolik dan diastolik dengan menggunakan tensi meter air raksa dari omron. pengukuran tekanan darah sistolik dan diatolik (mmhg) dikategorikan berdasarkan jnc vii untuk menentukan status hipertensi, yaitu: hipertensi sistolik (normal <120 mmhg; pre hipertensi 120-139 mmhg; hipertensi stage i 140-159 mmhg dan hipertensi stage ii >160 mmhg). hipertensi diastolik (normal < 80 mmhg; pre hipertensi 80-89 mmhg; hipertensi stage i 90-99 mmhg dan hipertensi stage ii >100 mmhg). pengukuran kadar hb dilakukan untuk mengetahui status anemia diukur dengan model kesehatan keselamatan kerja berbasis agricultural nursing (tantut susanto, dkk.) 47 hemocue. anemia dikategorikan berdasarkan hasil pegukuran kadar hb (anemia: hb kurang dari 12 gr/dl dan normal jika hb lebih dari 12 gr/dl). pemeriksaan fisik sendi dan tulang ekstremitas atas dan bawah serta tulang belakang dilakukan untuk mengetahui nyeri tulang dan sendi. hasil pengukuran dikategorikan nyeri apabila mengalami keluhan nyeri pada tulang dan sendi kurang lebih 1 minggu terakhir atau tidak. peralatan pengukuran berat badan dan tinggi badan, tekanan darah, dan kadar hb telah dilakukan uji kalibrasi terlebih dahulu sebelum digunakan. adapun kriteria sampel penelitian ini adalah petani yang berusia lebih dari 17 tahun, bekerja sebagai petani minimal satu tahun di wilayah kerja puskesmas penelitian berlangsung dan terdaftar sebagai anggota kelompok tani serta bersedia menjadi responden. prosedur pengumpulan data dilakukan dengan terlebih dahulu menjelaskan tujuan penelitian kepada partisipan dan dilanjutkan dengan pemberian inform consent apabila bersedia menjadi partisipan. pengambilan data dilakukan di balai kelompok tani di lingkungan terdekat partisipan. setelah responden bersedia kemudian diberikan kuesioner untuk responden isi terkait dengan data sosial demografi, gaya hidup, karakteristik lingkungan tempat tinggal dan lingkungan pekerjaan. setelah responden selesai mengisi kuesioner dilakukan pemeriksaan fisik, dan pengukuran tinggi badan dan berat badan, tekanan darah, dan kadar hb di rungan pemeriksaan yang telah disiapkan oleh peneliti. pengambilan data dari awal sampai selesai dibutuhkan waktu kurang lebih 30 menit untuk setiap responden. dalam penelitian ini telah mendapatkan ijin dari lembaga penelitian universitas jember dan dinas kesehatan kabupaten jember dengan tetap mempertahankan prinsip etika penelitian terkait dengan kejujuran, kerahasiaan, dan keteradilan, dan kemanfaatan penelitian. data dianalisis secara univariat, bivariat, dan multivariat. analisis univariat berupa statistik deskriptif, seperti frekuensi dan prosentase digunakan untuk menganalisis data kategorik, sedangkan mean dan standard deviasi digunakan untuk menganalisis data kontinyu, sehingga dapat diketahui prevalensi masalah kesehatan petani. analisis bivariat berupa analisis comparatif digunakan uji chisquare tests dalam mengidentifikasi variabel yang berhubungan dengan kesehatan petani. analisis multivariat digunakan analisis regersi logistik dan multinomial untuk menggambarkan model perawatan kesehatan kerja (pengkajian dan diagnosis atau masalah kesehatan). hasil berdasarkan hasil penelitian didapatkan data prevalensi masalah kesehatan beserta dengan faktor-faktor yang berhubungan dengan munculnya masalah kesehatan. petani yang mengalami gizi kurus adalah 28.5% dengan karakteristik usia lebih dari 60 tahun (43.1%) dan mengkonsumsi kopi (60.8%) yang berhubungan dengan jumlah hari kerja yang lebih dari lima hari per minggu (58.8%) dan karakteristik lingkungan fisik yang tidak sehat. petani yang mengalami gizi lebih adalah 9.5% dengan usia 41-59 tahun (58.8%) yang berhubungan dengan jumlah hari kerja yang kurang dari 5 hari per minggunya (76.5%). petani yang mengalami anemia adalah 62.6% dengan jenis kelamin laki-laki (81.3%) dan merokok (46.8%) yang berhubungan dengan jumlah hari kerja yang lebih dari 5 hari per minggu (64.3%) dan posisi atau sikap kerja yang tidak ergonomi (57.1%). permasalahan tekanan darah atau hipertensi sistolik adalah pre hipertensi sistolik (20.1%) dan hipertensi sistolik grade 1 dan 2 (25.1) serta hipertensi diastolik grade 1 dan 2 (35.8%) yang berkaitan dengan gaya hidup merokok (55.6%), makanan berlemak (55.6%) dan tinggi garam (60%) serta berhubungan dengan beban atau stress kerja (58.3%) dan tidak menggunakan apd (64.4%). petani yang mengalami nyeri persendian dan tulang sebanyak 50.3% yang berhubungan dengan usia antara 41-59 tahun (44.4%), istirahat kerja yang kurang dari 30 menit tiap bekerja (70%) dan posisi kerja yang tidak ergonomis (54.4%). petani yang mengalami sakit sebesar 39.7% dengan karakteristik tidak bersekolah (53.5%) dan merokok (56.3%) serta berhubungan dengan lingkungan kerja seperti stress kerja (57.7%) dan lingkungan tempat tinggal yang tidak sehat, seperti kualitas air minum yang tidak sehat (88.7%). didapatkan data bahwa faktor risiko dan faktor pencegah masalah gizi kurang dan lebih, anemia, nyeri tulang dan sendi, serta status sakit pada petani. hasil regresi multonominal (status gizi normal sebagai reference) memperlihatkan bahwa petani yang berusia lebih dari 60 tahun berisiko 3.57 kali (1:0.28) dan yang berusia 40 – 60 tahun berisiko 4 kali (1:0.25) serta mengkonsumsi kopi berisiko jurnal ners vol. 11 no. 1 april 2016: 45-50 48 2.78 kali (1:0.36) untuk mengalami gizi kurus. sementara itu, petani yang beristirahat lebih dari 30 menit setiap bekerja berisiko 14.28 kali (1:0.07) dan bekerja kurang dari 5 hari per minggu berisiko 16.67 kali (1:0.06) mengalami gizi lebih. hasil regersi logistik menunjukkan bahwa petani yang berusia 40-60 tahun berisiko 0.39 dan berjenis kelamin laki-laki berisiko 0.10 lebih rendah mengalami anemia. model ini memprediksi sebesar 68.2% untuk terjadinya anemia padapetani. tabel 3 juga memperlihatkan bahwa petani yang berusia lebih dari 60 tahun berisiko 2.48 dan yang berusia 40-60 tahun berisiko 2.41 serta yang beristirahat kuran dari 30 menit selama bekerja akan mengalami nyeri sendi dan tulang. model ini memprediksi sebesar 63.7% petani untuk mengalami nyeri sendi dan tulang. selain itu, petani akan berisiko mengalami permasalahan kesehatan atau status kesehatan sakit sebesar 4 kali pada petani yang tidak sekolah tetapi hal ini dapat dicegah apabila petani tidak mengalami stress kerja maka akan berisiko sebesar 0.54 kali lebih rendah untuk mengalami sakit. model perawatan kesehatan kesalamatan kerja berbasis agricultural nursing yang merupakan sintesis dari model tersebut menunjukkan komponen pengkajian dan masalah kesehatan (diagnosis masalah) petani. pengkajian digambarkan adanya fakor-faktor yang mempengaruhi sehat-sakit petani, kemudian masalah kesehatan digambarkan dengan munculnya masalah gizi (kurus dan lebih), anemia, hipertensi, nyeri tulang dan sendi. masalah petani tersebut digambarkan dengan adanya karakteristik penyebab yang berhubungan dengan munculnya permasalahan, baik pada faktor sosioal demografi, gaya hidup, lingkungan kerja, dan lingkungan tempat tinggal. pembahasan penelitian ini menganalisis faktor-faktor yang mempengaruhi kesehatan petani dan kemudian mencoba menyusun suatu model perawatan kesehatan dan kesalamatan kerja berbasis agricultural nursing. hasil penelitian menunjukkan bahwa banyak faktor yang mempengaruhi kesehatan petani sehingga mengakibatkan masalah gizi, anemia, hipertensi, dan nyeri pada tulang dan persendian. prevalensi gizi kurang pada penelitian ini lebih tinggi bila dibandingkan dengan angka nasional yaitu 8.7% (ministry of health indonesia, 2013). hal ini berkaitan dengan usia lanjut (ks & ty, 2004) pada petani dan riwayat mengkonsumsi kopi (susanti, et al., 2011) yang akan mempengaruhi penyerapan makanan didalam lambung sehingga memicu terjadinya gizi kurang. masalah kesehatan lingkungan dan sanitasi juga mengakibatkan masalah gizi kurang pada petani, hal tersebut revelan dengan studi bahwa agen bakteri dan virus pada lingkungan akan berpengaruh masalah kecacingan yang berdampak pada gizi kurang (markkanen, 2004). hal ini sangat menggambarkan keadaan daerah rural pertanian di indonesia yang mengalami masalah gizi kurang akibat kesenjangan standar hidup, keadaan sosial ekonomi, dan gaya hidup yang akan memnegaruhi kesehatan petani. masalah gizi lebih padapenelitian ini lebih rendah dari angka nasional yaitu gizi lebih 13.5% dan obesitas 15.4% (ministry of health indonesia, 2013). petani yang mengalami gizi lebih dikarenakan kurangnya jumlah hari kerja tiap minggunya. permasalahan gizi lebih umumnya berkaitan dengan kurangnya aktivitas fisik dan akan berdampak pada penyakit kronis (silva, et al., 2014). petani lebih berisiko mengalami gizi kurang daripada gizi lebih yang menggambarkan tingginya jam kerja yang tidak diimbangi dengan peningkatan konsumsi nutrisi pada petani di daerah rural. hal ini akan berdampak pada produktivitas kerja petani (jurakic, et al., 2014) dan mengarah pada status sehat sakit petani. petani berjenis kelamin laki-laki dan memiliki riwayat merokok berisiko untuk mengalami anemia. hal ini sesuai dengan riset sebelumnya bahwa, lelaki berisiko menderita masalah kesehatan akibat tuntutan sosial ekonomi (kaleta, et al., 2012), prevalensi anemia pada petani dalam penelitian ini lebih tinggi dari angka nasional yaitu 20% (ministry of health indonesia, 2013) . kondisi anaemia defisiensi zat besi dalam penelitian ini diakibatkan karena faktor merokok dan beban kerja yang terlalu tinggi, hal ini mengakibatkan penurunan ikatan oksigen dan fe karena adanya zat rokok didalam darah sehingga mengganggu transpor oksigen dalam darah kemudian berdampak pada kelelelahan yang muncul pada petani dan ditunjang dengan beban kerja petani yang terlalu tinggi. model kesehatan keselamatan kerja berbasis agricultural nursing (tantut susanto, dkk.) 49 petani yang berusia lebih tua mengalami nyeri sendi dan tulang, karena pada masa lansia umumnya muncul penyakit metabolik degeneratif yang ditandai dengan berkurangnya massa tulang dan risiko patah tulang yang mengakibatkan hilangnya mobilitas sendi (rafiah, et al., 2014). hal ini relevan dengan studi sebelumnya bahwa pekerja di pertambangan menderita sakit terutama di punggung bawah, tangan, lutut, pergelangan tangan, bahu, dan leher (das, 2014). masalah nyeri sendi pada petani diakibatkan posisi kerja yang tidak ergonomis dan masa istirahat dalam berkerja yang terlalu singkat (tella, et al., 2013), karena petani bekerja dari pagi sampai malam tanpa waktu yang cukup untuk mengambil waktu istirahat akan mengakibatkan nyeri pada tulang dan sendi akibat penggunaan dan pemakaian masa otot dan tulang yang melebihi dari kapasitas kerja. hal ini akan mengakibatkan nyeri punggung bawah setelah melebihi dari beban kerja (gupta & nandini, 2015). permasalahan hipertensi pada petani teridentifikasi pada petani dengan gaya hidup yang tidak sehat, seperti merokok, mengkonsumsi makanan tinggi lemak dan garam. hal ini sesuai dengan dengan riset sebelumnya bahwa empat faktor risiko terjadinya non communicabel diseases adalah merokok, konsumsi alkohol, aktivitas fisik yang tidak memadai dan diet yang tidak sehat (low, et al., 2015). masalah hipertensi pada petani juga berhubungan dengan beban kerja dan stress kerja, dimana makin besar stress kerja akan menunjang tingkat kematian pada pekerja yang sudah berusia lanjut (tobiasz-adamczyk, et al., 2013). hal ini dikarenakan stress kerja dan beban kerja pada petani yang tinggi akibat tuntutan pekerjaan dalam produktivitas pertanian dari bercocok tanam, memanen, dan menjual hasil pertanian mengakibatkan sistem cardiorespirasi bekerja lebih tinggi sehingga akan berdampak pada kenaikan tekanan darah. sementara itu, pola hidup yang tidak sehat, seperti merokok dan makanan berlemak akan memicu terjadinya resistensi tahanan perifer dan berdampak pada kenaikan tekanan darah. faktor risiko utama status kesehatan petani yang sakit adalah pendidikan petani yang tidak sekolah. hal ini berkaitan dengan rendahnya pengetahuan dan pemahaman petani terhadap program ketrampilan hidup sehat (pkhs). karakteristik umum dari kondisi sakit dalam penelitian ini ditandai dengan lingkungan sanitasi tempat tinggal yang tidak sehat seperti tipe rumah yang tidak permanen, ventilasi dan pencahayaan rumah, manajemen sampah dan mck, serta kualitas air minum yang tidak sehat. hal ini berkaitan dengan lingkungan sebagai media vektor penyakit yang akan berdampak baik secara langsung maupun tidak langsung terhadap masalah kesehatan dan promosi kesehatan individu, kelompok, dan komunitas (pender, et al., 2014). hal ini memerlukan perhatian antara keseimbangan faktor petani, agen, lingkungan dan kesehatan dalam mencegah masalah kesehatan pada petani. simpulan dan saran simpulan model perawatan kesehatan dan keselamatan kerja berbasis agricultural nursing yang disusun dalam penelitian ini dikembangkan berdasarkan analisis faktor sosial demografi, gaya hidup, faktor lingkungan fisik, psikososial, dan lingkungan kerja yang disusun menjadi karakteristik untuk diidentifikasi dalam pengkajian keperawatan komunitas pada kelompok petani. masalah kesehatan yang teridentifikasi beserta faktor penyebabnya dapat menjadi diagnosis atau masalah kesehatan kerja pada petani. saran penelitian berikutnya perlu dilakukan uji coba model dengan melakukan beberapa intervensi keperawatan mandiri dan terapi modalitas kelompok sehingga dampak dari penerapan model perawatan kesehatan kesalamatan kerja berbasis agricultural nursing ini dapat dievaluasi. kepustakaan badan pusat statistik, 2014. berita resmi statistik no. 33/05/th.xv.7 mei 2012. [online]. das, b., 2014. assessment of occupational health problems and physiological stress among the brick field workers of west bengal, india. international journal of occupational medicine and environmental health, 27(3), pp. 413425. depnakertrans, 2012. pusat data dan informasi ketenagakerjaan badan penelitian, pengembangan, dan jurnal ners vol. 11 no. 1 april 2016: 45-50 50 informasi kementrian tenaga kerja dan transmigrasi ri. [online] available at: http://pusdatinaker.go.id [accessed 2014]. gupta, g. & nandini, n., 2015. prevalence of low back pain in non working rural housewives of kanpur, india. international journal of occupational medicine and environmental health, 28(2), pp. 313-320. jurakic, d., golubic, a., pedisic, z. & pori, m., 2014. patterns and correlates of physical activity among middle-aged employees: a population-based, crosssectional study. international journal of occupational medicine and environmental health, volume 3, pp. 487-497. kaleta, d., makowiec-dabrowska, t., dziankowska-zaborszczyk, e. & fronczak, a., 2012. prevalence and socio-demographic correlated of daily cigarette smoking in poland: results from the global adults tobacco survey (2009–2010). international journal of occupational medicine and environmental health, 25(2), pp. 126136. ks, y. & ty, l., 2004. sociodemographic factors associated with nutrients intake of elderly in korea. korean journal nutrition, 37(3), pp. 210-222. lestari, t., 2007. hubungan keselamatan dan kesehatan kerja (k3) dengan produktivitas kerja karyawan (studi kasus : bagian pengolahan ptpn viii gunung mas, bogor). [online] available at: http://repository.ipb.ac.id/bitstream/hand le/123456789/17179/h07tle.pdf [accessed 2014]. low, w.-y., lee, y.-k. & samy, a. l., 2015. non communicable diseases in the asia-pacific region: prevalence, risk factors, and community based prevention. international journal of occupational medicine and environmental health, 28(1), pp. 20-26. markkanen, p. k., 2004. kesehatan dan keselamatan kerja di indonesia (health and work safety in indonesia), manila, philippines: iternational labour organization, subregional office for south-east asia and the pacific. ministry of health indonesia, 2013. riset kesehatan dasar 2013/riskesdas 2013 (basic health research 2013), jakarta: badan penelitian dan pengembangan kesehatan. pender, n., carolyn, l. & mary, a., 2014. health promotion in nursing practice. 7rd edition. stamford: appleton & lange. rafiah, s., rieuwpassa, i. e., bahrun, u. & bahri, m., 2014. low density lipoprotein sebagai faktor prediktor terhadap penurunan densitas mineral tulang pada osteoporosis. [online]. silva, f. c. d. et al., 2014. anthropometric indicators of obesity in policeman: a systematic review of observational study. international journal of occupational medicine and environmental health, 27(6), pp. 891901. suardi, 2005. sistem manajemen keselamatan dan kesehatan kerja. jakarta: ppm. susanti, a., briawan, d. & urip, v., 2011. dyspepsia risk factors of university students in bogor agricultural university. jurnal kedokteran indonesia, 2(1), pp. 80-91. tella, b. a., sunday rufus akinwumi akinbo, s. a. a. & gbiri, c. a., 2013. prevalence and impacts of low back pain among peasant farmers in southwest nigeria. international journal of occupational medicine and environmental health, 26(4), pp. 621627. tobiasz-adamczyk, b., brzyski, p., florek, m. & brzyska, m., 2013. job stress and mortality in older age. international journal of occupational medicine and environmental health, 26(3), p. 349 – 362. zaenal, a., tri, w. & ishandono, d., 2008. hubungan perilaku keselamatan dan kesehatan kerja dengan dosis radiasi pada pekerja reaktor kartini. jurnal stt batan, pp. 1-10. authors index volume 14 nomor 1 april 2018 adriani, merryana, 92 lestari, desy indah nur, 28 afriyani, 55 lukmanulhakim, 55 ahsan, 1 mahiroh, hodimatum, 16 andriani, merryana, 82 murtadho, maulana arif, 69 annas, jimmy yanuar, 101 nursalam, 1, 10 anwar, syamsul, 75 oducado, ryan michael flores, 47 arifin, hidayat, 69 pradana, fiqih ardi, 82 asmoro, candra panji, 82 prasetyo, yoyok bekti, 1 astuti, erlina suci, 10 pratama, rochmad ardiansyah, 16 astutik, erni, 16 rachmawati, praba diyan, 28 bakar, abu, 87 ramdan, iwan muhamad,33 devy, shrimarti rukmini, 10, 92 rusdi, ainur, 23 dewi, yulis setiya, 23 sipahutar, muhammad adil, 41 ermalia, helen, 101 soedirham ,oedojo, 87 etika, risa, 10 sukartini, tintin, 82 hadisuyatmana, setho, 41 sulistyono, agus, 92 handayani, samsriyaningsih, 101 sulistyono, r endro, 62 hargono, rahmat, 1, 23 supriyati, yetti, 75 hariawan, hamdan, 87 susanto, tantut, 62 haryani, ani, 55 tolla, burhanuddin, 75 herawati, lilik, 69 triharini, mira, 92 krisnana, ilya, 41 tristiana, rr dian, 62 kusnanto, 69 yunitasari, esti, 28 subject index volume 14 nomor 1 april 2019 a anaemia, 28 anemia in pregnancy, 92 anxiety, 69 attitude, 75, 87 attitude about lapms, 101 attitude friends support, 28 avoidant restrictive food intake disorder, 1 b behavior, 92 blood pressure, 69 bmi, 16 c caring behavior, 55 caring efficacy, 55 cb, 82 children, 41 clinical nursing student, 82 critical patients, 55 e emotional intelligence, 82 empowerment, 47 f family support, 1, 10 h haemodialysis, 69 hamilton anxienty rating scale, 33 health efforts, 28 health facility, 28 health promotion, 92 health provider, 62 hypertension, 16 i icu, 23, 41 ifls, 16 immunization compliance, 41 independence of the mother, 10 individual coaching, 87 intelligence quotient, 82 intention, 41 j job stress, 23 k knowledge, 10, 28, 87 knowledge of lapms, 101 l leader empowering behaviors, 47 leadership, 47 long-acting and permanent methods of contraception (lapms), 101 low birth weight, 10 m media, 101 mother, 41 muslim, 87 n nurses, 23, 33 nursing empowerment, 47 o organisational support, 23 p peer-education, 101 physical activity, 16 preceptee, 75 preceptor, 75 preceptorship, 75 prevention, 92 progressive muscle relaxation, 69 psychological empowerment, 47 pulse, 69 q qnwl, 23 qualitative research, 62 r reliability, 33 rural, 62 s salat, 87 self-determination, 92 sociodemography, 1 spiritual intelligence, 82 stake’s countenance, 75 t taking care, 55 tuberculosis, 62 v validity, 33 w working condition, 23 workload, 23 work-related stress, 33 4 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of: ▪ a highly respected journal in the nursing field. ▪ it is indexed in major databases: science and technology index (sinta), indonesian publication index (ipi), google scholar, bielefeld academic search engine (base), (doaj), worldcat, indonesia onesearch, ebsco, pkp index, index copernicus, isjd, asean citation index ▪ rapid initial screening for suitability and editorial interest. jurnal ners has been accredited by the ministry of science, research, technology and higher education of indonesia since 2010. ii. focus and scope the scope of this journal includes studies that intend to examine and understand nursing health care interventions and health policies which utilize advanced nursing research. the journal also committed to improve the high-quality research by publishing analytic techniques, measures, and research methods not exception to systematic review papers. policy concerns of this journal are as follows: fundamentals of nursing, management in nursing, medical-surgical nursing, critical care nursing, emergency and trauma nursing, oncology nursing, community health nursing, occupational health nursing, mental health nursing, holistic nursing, geriatric nursing, family nursing, maternity nursing, women's health nursing, pediatric nursing, education in nursing, nursing policies, legal nursing, advanced practice nursing, and nursing informatics please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. author information pack update: march 5, 2020 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing https://drive.google.com/file/d/0b5ormcrmctnwq0dix2dictffdlk/view?usp=sharing 5 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam m.nurs. (hons), (scopus id: 56660628500; h-index: 4); faculty of nursing, universitas airlangga, indonesia international advisory board reviewers 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740; h-index: 13); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200; h-index: 10); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, (scopus id: 8293647300; h-index: 12); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172; h-index: 2); college of nursing, university of the philippines manila, philippines 5. dr. nicola cornally, (scopus id: 36982904800; h-index: 13); school of nursing and midwifery, university college cork, ireland 6. dr. david pickles, (scopus id: 57190150026; h-index: 5); college of nursing & health sciences, flinders university, south australia, australia 7. dr. farhan alshammari, (scopus id: 57192298773; h-index: 3); college of nursing, university of hail, saudi arabia 8. dr. patricia leahy-warren, (scopus id: 55954181800; h-index: 11); school of nursing and midwifery, university college cork, ireland 9. dr. wendy abigail, (scopus id: 24467540600; h-index: 3); school of nursing and midwifery, flinders university, australia 10. dr. chong mei chan, (scopus id: 57189591887; h-index: 2); dept. of nursing faculty of health science, university of malaya, malaysia 11. dr. sonia reisenhofer, (scopus id: 16310818100; h-index: 4); school of nursing and midwifery, la trobe university, australia, australia editor: 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100; h-index: 3); faculty of nursing, universitas airlangga, indonesia 2. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756; h-index: 1); faculty of nursing, universitas airlangga, indonesia, indonesia 3. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 4. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); faculty of nursing, universitas airlangga, indonesia javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/454') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3472') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3469') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3098') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3458') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3784') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3783') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3708') 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nursing, universitas airlangga, indonesia 2. masunatul ubudiyah, faculty of nursing, universitas airlangga, indonesia 3. dluha maf'ula, faculty of nursing,. universitas airlangga, indonesia 4. rifky octavia pradipta, s.kep., ns, faculty of nursing, universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., (scopus id: 57201187775); faculty of nursing, universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/542') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/1605') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10192') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10193') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10603') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/2145') mailto:secretariat_jurnalners@fkp.unair.ac.id http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 7 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on apriori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and meta-analyses will be dealt with as original articles are, as far as the editorial process is concerned. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and postpublication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following: • introduction: one or two sentences on the background and purpose of the study. • method: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics). • results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals. • conclusions: should relate to the study aims and hypotheses. • keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. 8 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 acknowledgment (optional). acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below: • observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/ • qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq • quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/ • randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/ • study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/ • systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/ • systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 publication fee jurnal ners charges the author a publication fee amounted to idr 1.000.000 (indonesian author) and usd 100 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within two working days. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 9 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: ………………………………………………………………………………………………….. f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. 10 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 title page example vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 11 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 12 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: 𝐇′ = −∑ (𝑃𝑖)(log2 𝑃𝑖) 𝑠 𝑖=1 ………............................................................................................... (1) remarks: .............................................................................................................................................. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old type of care age groups (years) <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 13 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. https://www.mendeley.com/guides/harvard-citation-guide 14 | a u t h o r i n f o r m a t i o n p a c k m a r c h 6 , 2 0 2 0 vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author, • hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language. • have read the final version of the manuscript and responsible for what is said in it. • have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website. • hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below. • acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk ners vol 10 no 2 okt 2015.indd 343 analisis keselamatan dan kesehatan kerja perawat dalam penanganan pasien di rumah sakit benyamin guluh kabupaten kolaka (analysis of nurse’s occupational health in managing patients in benyamin guluh hospital kolaka regency) tukatman*, sulistiawati**, purwaningsih***, nursalam***, *akper pemda kolaka. jln. pintu selatan km. 3 no. 17 kolaka sultra 93517 ** fakultas kedokteran universitas airlangga kampus a jalan prof. dr. moestopo no. 47 surabaya 60131 *** fakultas keperawatan universitas airlangga kampus c unair jalan mulyorejo surabaya 60115 email: nstukatman@yahoo.co.id abstrak pendahuluan: keselamatan dan kesehatan kerja adalah kegiatan yang dirancang untuk menjamin keselamatan dan kesehatan di tempat kerja. perawat berisiko terhadap kecelakaan dan penyakit akibat pekerjaan. tujuan penelitian ini menganalisis pengaruh faktor predisposing, enabling, reinforcing dan core-care terhadap keselamatan dan kesehatan kerja pada perawat dalam penanganan pasien. metode: penelitian ini explanatori, desain cross sectional dilaksanakan di rsbg kab. kolaka. pengambilan sampel proporsional random (consecutive sampling) berjumlah 100 responden. variable yang diteliti adalah faktor predisposing (pengetahuan, sikap, kepercayaan dan nilai), faktor reinforcing (petugas yang menjadi contoh), faktor enabling (fasilitas, aturan), core (hubungan interpersonal), care (kepedulian), serta keselamatan dan kesehatan kerja. data dianalisa dengan menggunakan partial least square (pls). hasil: faktor predisposing (pengetahuan, sikap, nilai dan kepercayaan) berpengaruh terhadap keselamatan dan kesehatan kerja (t-htung 2,82 > t-tabel 1,96), faktor reinforcing (petugas yang menjadi contoh) tidak berpengaruh terhadap keselamatan dan kesehatan kerja (t-htung 1,098 < t-tabel 1,96), faktor enabling (fasilitas keamanan/keselamatan, hukum/aturan) jugs berpengaruh (t-htung 2,39 > t-tabel 1,96), faktor core, care ( hubungan interpersonal, peduli) berpengaruh terhadap keselamatan dan kesehatan kerja pada perawat dalam penanganan pasien di rsbg kabupaten kolaka (t-htung 1,963 > t-tabel 1,96). diskusi: pengembangan teori perilaku dan grand teori keperawatan terhadap keselamatan dan kesehatan kerja nilai r-square 39,5% yang berarti faktor predisposing, enabling, core-care hanya berkontribusi 39,5% sedangkan 60,5% dipengaruhi oleh faktor lain sehingga diharapkan pengembangan model ini masih perlu perbaikan dan peningkatan, agar menjadi model yang baik. kata kunci: k3, perawat, perilaku, keperawatan abstract introduction: occupational health and safety are a system designed to ensure a good safety and health in the workplace. nurses have a higher risk of accidents and occupational diseases due to managing patients the goal of analyze the relationship or the influence of predisposing, enabling and reinforcing factors, and the concept of core and care in nurses’ safety and occupational health issue nurs in managing patient. methods: type of study is explanatory research using cross sectional design. proportional random was chosen by consecutive sampling technique amounted to 100 respondents based on criteria. the variables measured were predisposing factors (knowledge, attitudes, beliefs and values), reinforcing factor (officers who became a role model), enabling factors (facilities, rules/regulation), core-care (interpersonal, concern), as well as safety and occupational health. data were analyzed using partial least square (pls). result: predisposing factors affecting safety and occupational health, value by t-count of 2.82 > t-table of 1.96. reinforcing factors do not significantly affect occupational health and safety by t-count of 1.098 < t-table of 1.96. enabling factors affecting occupational health and safety by t-count of 2.39 > t-table of 1. factors of core and care factors affecting nurses’ safety and occupational health in managing patients in benyamin guluh hospital, kolaka regency have t-count of 1.963 > t-table of 1.96. discussion: development of behavioral and nursing theories to nurses’ occupational health and safety showed r-square value of 39.5%. the new model structure are: predisposing factors (knowledge, attitudes, beliefs and values), enabling factors (facilities, rules / regulation), core (interpersonal relationships) and care (concern). keywords: occupational health, behavior, nursing 344 jurnal ners vol. 10 no. 2 oktober 2015: 343–347 pendahuluan perawat adalah tenaga kesehat an yang paling besar jumlahnya dan paling lama kontak dengan pasien, sehingga sangat berisiko dengan pekerjaannya, namun banyak perawat tidak menyadari terhadap risiko yang mengancam dirinya, melupakan keselamatan dan kesehatan kerja (k3). data who (2004): dari 35 juta pekerja kesehatan bahwa 3 juta terpajan patogen darah (2 juta terpajan virus hbv, 0.9 juta terpajan virus hbc dan 170.000 terpajan virus hiv/ aids). probabilitas penularan hiv setelah luka tusuk jarum suntik yang terkontaminasi hiv 4: 1000. risiko penularan hbv setelah luka tusuk jarum suntik yang terkontaminasi hbv 27–37: 100. penelitian terhadap perawat perinatologi di rsud tugurejo semarang, dalam satu tahun terakhir perawat mengalami kecelakaan kerja (tertusuk jarum) tertinggi 14 kali (kurnia, 2013). perawat dan pekarya kesehatan di rsi malang, 100% tidak menggunakan handscoen saat mengambil sampel dahak, dan 90% tidak menggunakan sarung tangan (handscoen) saat memasang infuse (heny, 2005). penyakit akibat kerja (pak) dan kecelakaan kerja (kk) pada petugas kesehatan dan non kesehatan di indonesia belum terekam dengan baik, data kecelakaan di rumah sakit belum ada laporannya. hasil survei nopember 2014, dalam rentang tahun 2009 sampai tahun 2011, terdapat 2 orang perawat di ruangan interna menderita penyakit hepatitis, diduga tertular dari pasien, kemudian dilanjutkan dengan survei pada bulan januari 2015 di ruang icu dan interna, pada 10 perawat hasilnya pencapaian rata-rata keselamatan dan kesehatan kerja perawat di rumah sakit benyamin guluh kab. kolaka adalah 56%, yang artinya k3rs belum optimal (standar kemenkes mfk dan ppi 100%). penelitian tentang k3rs sudah banyak dilakukan namun analisis k3rs pada perawat dalam penanganan pasien dengan pendekatan teori precede-proceed dan teori model core, care dan cure belum per nah dilakukan, sehingga dengan pengembangan ini diharapkan keperawatan lebih berkembang lebih maju dalam kaitannya keselamatan perawat dan keselamatan pasien. bahan dan metode desain penelitian ini adalah cross sectional yaitu desain penelitian analitik yang bertujuan mengetahui hubungan antar variabel independen dan variabel dependen. dilaksanakan di rsbg kab. kolaka dari tanggal 12 maret sampai dengan 12 april 2015. populasi penelitian ini adalah seluruh perawat yang bekerja di rsbg kabupaten. kolaka. penarikan sampel secara proposional random sampling dengan kriteria inklusi dan inklusi. sampel terdiri dari 100 orang perawat. pengukuran variabel independen dan dependen faktor predisposing (pengetahuan, sikap kepercayaan dan nilai), faktor reinforcing (petugas yang menjadi contoh k3rs), faktor enabling (fasilitas dan aturan) serta faktor corecare (hubungan interpersonal dan kepedulian diukur dengan menggunakan kuesioner. variabel dependen yaitu k3rs (mencuci tangan, memakai handscoen, memakai masker, memakai apron, pengelolaan benda tajam dan pengelolaan lingkungan) diukur dengan kuesioner. data dianalisis secara multivariat dengan menggunakan program pls-smart versi 3.0 untuk mengetahui pengaruh faktor predisposing, reinforcing, enabling dan corecare terhadap keselamatan dan kesehatan kerja pada perawat. dan menguji hipotesis. hasil uji validitas konstruk dengan indikator formatif dapat dilakukan dengan melihat tstatistics pada outer weight, di mana suatu indikator dikatakan valid jika memiliki nilai tsattistics > t-tabel, dengan alfa 5% (two-tailed) diketahui nilai t-tabel adalah 1,96. berikut adalah nilai t-statistics dari masing-masing indikator pada variabel penelitian. hasil nilai outer weigh menunjukkan bahwa ada satu indikator yaitu kepedulian yang memiliki nilai t-statistics < 1,96 sehingga konstruk care tidak lulus uji validitas konstruk, namun indikator ini merupakan indikator refleksif, walaupun tidak memenuhi 345 analisis keselamatan dan kesehatan kerja perawat (tukatman, dkk.) uji validitas konstruk (yaitu terdapat salah satu atau lebih indikator yang tidak signifikan) indikator tersebut tetap dapat dilanjutkan dalam model struktural, karena perubahan i ndi kator ref lek t if t id a k menyebabkan perubahan konstruk, serta menghilangkan satu indikator tidak akan mengubah makna konstruk (ghozali, 2012). pembahasan fa k t o r p r e d i s p o s i n g ( p e n c e t u s) (pengetahuan, sikap. kepercayaan dan nilai) pada perawat terhadap k3rs yaitu memiliki hubungan yang sangat berpengaruh terhadap keselamatan dan kesehatan ker ja pada perawat dalam penanganan pasien di rsbg kab. kolaka, bahkan faktor ini bila dilihat dari nilainya merupakan faktor yang paling dominan mempengaruhi k3rs, berdasarkan hasil uji pls nilai dari seluruh komponen berkorelasi sangat baik, sedangkan nilai tertinggi pada indikatornya adalah komponen kepercayaan, artinya bahwa kepercayaan memiliki nilai yang sangat baik dan memiliki pengaruh yang sangat baik terhadap perilaku seseorang, sedangkan nilai untuk pengetahuan adalah yang paling rendah. kepercayaan mer upakan keyakinan terhadap sesuatu, gambar 1. d i a g r a m j a l u r h u b u n g a n p re d i s p o s i n g , re i n f o rc i n g , enabling, core, care dengan keselamatan dan kesehatan kerja pada perawat. kepercayaan bersifat abstrak, sebagai contoh seseorang yang memiliki agama yaitu mereka percaya dan yakin bahwa suatu saat akan ada yang disebut kiamat, walaupun belum pernah melihat dan merasakan mereka yakin bahwa hal itu ada, maka dengan demikian mereka berusaha untuk berbuat yang terbaik untuk menghadapi hal tersebut. kepercayaan inilah yang mendasari perilaku perawat bahwa k3 sangat penting dan sangat berarti untuk dirinya, sehingga mereka berperilaku yang baik terhadap pelaksanaan k3rs. fa k t o r r e i n fo r c i ng ( p e n d o r o n g) (petugas yang menjadi contoh) pada perawat terhadap k3rshasil uji statistik nilai faktor reinforcing (petugas yang menjadi contoh) ini tidak berpengaruh terhadap keselamatan dan kesehatan kerja pada perawat dalam penanganan pasien di rsbg kabupaten kolaka, dengan nilai t-hitung 1,098 < ttabel 1,96 ar tinya secara kesahihan dan keandalan instrument sebagai alat ukur sudah memenuhi syarat namun sebagai veriabel yang mempengaruhi perilaku keselamatan dan kesehatan kerja tidak berpengaruh, hal ini mungkin terjadi karena petugas yang bertanggung jawab kurang melaksanakan tugas k3 sebagai akibat tugas rangkap, maka bila telah dilaksanakan dengan kesadaran sendiri faktor pendorong kurang berarti, sehingga tidak berpengaruh terhadap keselamatan dan kesehatan kerja. perawat di rsbg kolaka menganggap bahwa petugas k3 yang bekerja saat ini tidak memiliki kontribusi terhadap keselamatan dan kesehatan kerja. faktor enabling (fasilitas keamanan dan keselamatan, hukum/aturan) pada perawat terhadap k3rs. faktor enabling berpengaruh terhadap k3 pada perawat dalam penanganan pasien di rsbg kab. kolaka nilai t-hitung 2,388 > t –tabel 1,96, sebagai faktor yang memungkinkan suatu proses perilaku, maka faktor ini memiliki kedudukan yang cukup strategis di mana per ubahan tidak dapat terjadi bila faktor ini tidak disiapkan fasilitas pendukungnya. nilai yang paling tinggi pada faktor enabling berada pada komponen hukum/aturan karena pada prinsipnya perilaku seseorang dipengaruhi oleh aturan yang ada di lingkungannya, sebagai contoh seseorang 7,936 15,015 21,256 10,283 2,816 pengetahuan sikap kepercayaan nilai 2,388 255,92 312,823 petugas referensi fasilitas hukum/atura 0,00 1,098reinforcing 1,963 25,149 1,709 interpersonal peduli mencuci tangan 5,794 7,794 7,089 24,692 11,072 11,072 masker handscoen apron keselamatan & kesehatan kerja pengelolaan benda tajam pengelolaan lingkungan predis posing core & care enabling 346 jurnal ners vol. 10 no. 2 oktober 2015: 343–347 yang bekerja sebagai prajurit maka ia harus menaati peraturan dan disiplin terhadap aturan bila tidak maka ia akan terkena hukuman. kebiasaan dalam menaati aturan ini menjadi kebiasaan yang baik sehingga ia tidak akan melanggar aturan karena kebiasaan disiplin dan sanksi dari aturan tersebut. factor core and care. faktor core, and care (hubungan interpersonal dan kepedulian) ber pengar uh terhadap keselamatan dan ke seh at a n ke r ja pa d a p e r awat d ala m penanganan pasien di rsbg kab. kolaka, nilai t-hitung 1,963 > t-tabel 1,96. core, and care, namun pada hasil outer wight nilai yang paling tinggi adalah core, sedangkan care tidak signif ikan, hal ini mungkin dipengaruhi oleh indikator care yang kurang variasi dalam pertanyaan dalam instrument indikator kepedulian tidak mempunyai nilai yang bermakna. simpulan dan saran simpulan faktor predisposing merupakan faktor dominan yang menentukan keselamatan dan kesehatan kerja pada perawat, sedangkan kepercayaan merupakan indikator yang sangat dominan berpengaruh. pada faktor predisposisi i n i dibandi ng yang lai n. fa k tor tid a k mempengaruhi keselamatan dan kesehatan kerja pada. faktor enabling mempengaruhi keselamatan dan kesehatan ker ja pada perawat. faktor core-care kurang dominan mempengaruhi keselamatan dan kesehatan kerja pada perawat dalam penanganan pasien di rsbg kab. kolaka, di mana pada indikator care (peduli) tidak bermakna dalam kontruk core-care. rekomendasi pengembangan teori precede-proceed dan core, care, and cure terhadap k3rs, yang dapat dilanjutkan melibatkan faktor predisposing, enabling, core and care. saran koordinator k3rs dan pengendalian infeksi yang telah ditunjuk oleh direktur rsbg kab. kolaka melaksanakan tugas k3rs dengan baik agar program ini dapat men i ng kat ka n mut u , k u alit a s laya na n dan akreditasi rumah sakit, dan perawat diharapkan tetap menjaga dan meningkatkan pengetahuan, sikap, kepercayaan, nilai, hubungan interpersonal, serta tetap peduli pada keselamatan dan kesehatan kerja, untuk menjaga dan meningkatkan keselamatan dan kesehatan diri agar tetap sehat, selamat dan produktif. peneliti selanjutnya dapat melanjutkan penelitian ini dengan model keperawatan safety yaitu safety perawat dan safety pasien sebagai pengembangan ilmu keperawatan. daftar pustaka alligod, t., 2010. nursing theorists and their work. (edisi 7). usa: mosby. inc, elsevier. depkes ri, 2009. standar kesehatan dan keselamatan di rumah sakit. dirjend bina kesehatan masyarakat. jakarta. frestianiasari & fenti., 2008. pengetahuan dan sikap perawat tentang pelaksanaan k3-rs di bapelkes (rsud) genteng bany uwangi. jurnal unair adln perpustakaan unair. ghozali i, latan h., 2012. partial least squares konsep, metode dan aplikasi badan penerbit universitas diponegoro. semarang. green, l., 2000. health promotion planning a n d e d u c a t i o n a l e n v i r o n m e n t approach, second edition kesehatan dan keselamatan kerja, mayf ied publising company. montain view, usa. nursalam. 2013. metodologi penelitian ilmu keperawatan: pendekatan praktis. edisi 3. salemba medika. jakarta. nursalam. 2014. manajemen keperawatan, aplikasi dalam praktik keperawatan profesional. edisi 4. salemba medika. jakarta. permana, l,w, adisasmito, w., 2004. analisis pelaksanaan tugas dan fungsi panitia pengendalian infeksi nosokomial pelayanan kesehatan st carolus jakarta. jurnal k3 02 juni 2005. 347 analisis keselamatan dan kesehatan kerja perawat (tukatman, dkk.) sholihah, h,h. 2005, pelaksanaan universal precautions oleh perawat dan pekarya kesehatan (studi kasus di rumah sakit islam malang unisma) jurnal pusat penelitian pengembangan teknologi surabaya. rat ulangi, a, & josephus, j,b,s. 2013. hubungan pengetahuan, sikap dengan tindakan terhadap k3rs pada perawat di siloam hospital manado. junal fkm unsrat. wijayanti, k. 2013, hubu ngan prak tik penerapan standar operating prosedure (sop) dan pemakaian (apd) dengan kejadian kecelaka an ker ja pada perawat unit perinatologi di rsud tug u rejo sema rang htt p:ui.ac.id/ fi le?fi le=digital/125852-s-5820-.pdf. http://e-journal.unair.ac.id/jners | 33 jurnal ners vol. 14, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.10673 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research reliability and validity test of the indonesian version of the hamilton anxiety rating scale (ham-a) to measure work-related stress in nursing iwan muhamad ramdan department of occupational health and safety, faculty of public health, mulawarman university, samarinda, indonesia abstract introduction: specific work characteristics have placed nurses as one of the professions with a high level of work-related stress. if not managed properly, work-related stress can cause adverse effects. signs of stress can be seen in people's behavior, thinking or physical symptoms. one of a subjective measurement tool that is widely used to measure work-related stress is the hamilton anxiety rating scale (ham-a), however, the literature that discusses the results of the ham-a translation, validity and reliability test in the nurse profession is still limited. this study aims to translate ham-a into the indonesian version, then test its validity and reliability in nurses. methods: a cross-sectional study with stratified random sampling method was conducted on 98 nurses from july to august 2018. the english version of ham-a consists of 14 items has been a translation into indonesian version. pearson product moment correlation was used to evaluate the construct validity and cronbach's alpha scores were used to assess the internal consistency reliability of the indonesian version of ham-a. results: item construct validity based on the pearson correlation ranged from 0.529 to 0.727, cronbach’s alpha reliability was obtained at 0.756. conclusion: the indonesian version of the ham-a fulfills the criteria of a reliable (fair acceptable criteria) and valid (good criteria) assessment tool to assess the work-related stress in the nursing profession. article history received: december 07, 2018 accepted: august 30, 2019 keywords work-related stress; nurses; hamilton anxiety rating scale; reliability; validity contact iwan muhamad ramdan  iwanmuhamadramdan@gmail.com  department of occupational health and safety, faculty of public health, mulawarman university, samarinda, indonesia cite this as: ramdan, i. m. (2019). reliability and validity test of the indonesian version of the hamilton anxiety rating scale (ham-a) to measure work-related stress in nursing. jurnal ners, 14(1), 33-40. doi:http://dx.doi.org/10.20473/jn.v14i1.10673 introduction work-related stress is the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope (world health organization, 2007)(international labour organization, 2016). previous research concluded that work-related stress is associated and increase an individual’s vulnerability to burnout, job satisfaction and physical as well as mental health outcomes (piko, 2006; pillay, 2009). other health problems related to the effects of work stress include: cardiovascular disorders (li, loerbroks, bosma, & angerer, 2016), gastrointestinal disorders (huerta-franco, 2013), musculoskeletal disorders (nafeesa, vidhya, vijayalakshmi, & rajkumar, 2017), anxiety and depression (fan, blumenthal, watkins, & sherwood, 2015), work fatigue (rose et al., 2017), insomnia (deguchi et al., 2017), alcohol abuse (moore, sikora, grunberg, & greenberg, 2007), decrease marital quality (obradović & čudina-obradović, 2013) and disruption of social interaction (la torre et al., 2018). specific work characteristics such as working time, length of interaction with patients, emotional nature of patient demands and inter-professional relationships are prone to conflict (khamisa, peltzer, ilic, & oldenburg, 2017). sources of work-related stress of nursing consist of working environment (physical, psychological and social environment factors), interpersonal relationships, nature of nursing, organizational factors, role characteristics and individual characteristics (moustaka & constantinidis, 2010). work-related stress if not https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:iwanmuhamadramdan@gmail.com i. m. ramdan 34 | pissn: 1858-3598  eissn: 2502-5791 managed properly can cause adverse effects, including emotional disturbances, behavioral problems, biochemical and neurohormonal changes, presenting added risks of mental or physical illness. conversely, well managed work-related stress will create a feeling of mastery and self-confidence; increases motivation, working capacity and satisfaction; and improves health (vernekar & shah, 2018). signs of stress can be seen in people's behavior changes. acute responses to stress may be in the areas of feelings (for example, anxiety, depression, irritability, fatigue), behavior (for example, being withdrawn, aggressive, tearful, unmotivated), thinking (for example, difficulties of concentration and problem solving) or physical symptoms (for example, palpitations, nausea, headaches). if stress persists, there are changes in neuroendocrine, cardiovascular, autonomic and immunological functioning, leading to mental and physical ill health (for example anxiety, depression, heart disease) (michie, 2002). anxiety symptoms are serious and critical problems in the occupational context and they can be associated with stress (vignoli, muschalla, & mariani, 2017). one subjective measurement tool that is often used to measure work-related stress is the hamilton anxiety rating scale (ham-a) (thompson, 2015). ham-a was one of the first rating scales developed to measure the severity of anxiety symptoms, being considered one of the most popular assessment instruments widely used rating scales both clinical and research settings/general health psychology, has been widely translated into various languages in the world and is widely used to measure work stress in various types of work (lópez-pina, sánhez-meca, & rosa-alcázar, 2009; thompson, 2015). research using ham-a to assess work-related stress among others: karanikola et al (2016) who examined anxiety symptoms and quality of interaction among greek oncology nurses, and craiovan (2015) which examines burnout, depression, and quality of life among the romanian employees working in nongovernmental organizations. the ham-a has been translated into cantonese for china, french, urdu, and spanish, however, the literature that discusses the results of the ham-a translation, validity and reliability test in the nurse profession in the indonesian version is still limited. to make the ham-a accessible for the use in an indonesian setting, especially in the nursing profession, this study aims to translate ham-a into the indonesian version, then test its validity and reliability among nurses in indonesia. materials and methods design of study and participants a cross-sectional study was conducted among 98 nurses at one of the government hospitals in east kalimantan from july to august 2018. the research sample was taken stratified randomly from all departments (operation room, hemodialysis room, emergency room, internist room, pulmonary room, surgery care room, medical checkup, and polyclinics). determination of respondents using random sampling method (singh & masuku, 2014). all members of the nurse population are given a serial number, the serial number is written on small paper and rolled up, then inserted into a closed glass which is given a small hole, the researcher then shakes the glass, each number that comes out is made a respondent. instruments the english version of hamilton anxiety rating scale (ham-a) consists of 14 items, each defined by a series of symptoms, and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety) (hamilton, 1959; maier, buller, philip, & heuser, 1988). the dimension of ham-a consist of: (1) anxious mood: worries, anticipation of the worst, fearful anticipation, irritability; (2) tension: feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax; (3) fears: of dark, of strangers, of being left alone, of animals, of traffic, of crowds; (4) insomnia: difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors; (5) intellectual: difficulty in concentration, poor memory; (6) depressed mood: loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing; (7) somatic (muscular): pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone; (8) somatic (sensory): tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation; (9) cardiovascular symptoms: tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat; (10) respiratory symptoms: pressure or constriction in chest, choking feelings, sighing, dyspnea; (11) gastrointestinal symptoms: difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation; (12) genitourinary symptoms: frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence; (13) autonomic symptoms: dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair; (14) behavior: fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc. each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where <17 indicates mild severity, 18–24 mild to moderate severity and 25–30 moderate to severe(maier et al., 1988). ham-a is comprised of a psychic and a somatic subscale. the psychic subscale (items 1-6 and 14) jurnal ners http://e-journal.unair.ac.id/jners | 35 addresses the more subjective cognitive and affective complaints of anxiety (e.g., anxious mood, tension, fears, difficulty concentrating), and is particularly useful in assessing the severity of general anxiety disorders (gad). the somatic component (items 713) emphasizes the features of gad such as autonomic arousal, respiratory, gastrointestinal and cardiovascular symptoms (katherine shear et al., 2001). cross-cultural process of daptation and translation the questionnaire was translated according to the guidelines for cross-cultural adaptation of self-report measures by beaton et al (2000). the guidelines consists of five stages: (1) translation by two bilingual translators (native indonesian), then they discuss and identify the selection of appropriate words so that they can reflect clinical symptoms and the language used by the general population; (2) synthesis, both translators and an observer discuss to get a combined translation; (3) back translation by two bilingual translators (native english), the results of a combined translation in indonesian are translated back into english by two translators with the aim of checking the validity of the translation process and ensuring the translated version reflects the same meaning as the original version; (4) evaluation by a team of experts consisting of forward and backward translators, epidemiologists and health professional experts, this was intended to consolidate all versions of the instrument and develop a prefinal version of the instrument for use in field testing; (5) pre-testing in a group of 98 nurses in operation rooms, hemodialysis rooms, emergency rooms, internist rooms, pulmonary rooms, surgery care rooms, medical checkups, and polyclinics. the final results of the hars translation into indonesian can be seen in table 2. pre-testing in a group of 98 nurses in operation room, hemodialysis room, emergency room, internist room, pulmonary room, surgery care room, medical checkup, and polyclinics. the final results of the translation into indonesian can be seen in table 2. statistical analyses data were analyzed by the statistical package for the social sciences (spss ver. 21, chicago, il, usa), in order to describe continuous and qualitative variables, mean, standard deviation (sd) and percentage frequency were used respectively. the minimum, maximum and variance were also reported for each item of the questionnaire. validity and reliability pearson product moment correlation was used to evaluate the construct validity of each item to the total score. ham-a test correlations were considered as ‘good to excellent’ when r ≥ 0.75, as ‘good’ when r ranged between 0.5 and 0.7, as ‘fair’ when r ranged between 0.25 and 0.50, and as ‘little or no relationship’ when r was less than 0.25 (kline, 2000; portney & watkins, 2009; terwee et al., 2007). cronbach's alpha scores with split half method were used to assess the internal consistency reliability of the ham-a questionnaire. a value below 0.70, the questionnaire is ‘unacceptable’ a value between 0.70 and 0.79 is considered ‘fair’, a value between 0.80 and 0.89 considered ‘good’, and a value 0.90 and above considered ‘excellent’ (cicchetti, 1994; nunnally & bernstein, 1994; michalopoulos et al. 2015; taber, 2018). results respondent characteristics the majority of respondents in this study were 20-30 years old (46.9%), the majority of respondents were women (77,6%), mostly married (82.7%), worked more than 5 to 10 years (45.9%) and mostly graduated from diploma iii in nursing (80.6%) ( table 1). the result of validity and reliability test of hama indonesian version as is shown in table 3, the mean of the total ham-a score was 10,58 (± 5,82). the 4th item on “insomnia (difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors)” showed the highest score (1,11, ± 0,73), whereas the 10th item on “respiratory symptoms (pressure or constriction in chest, choking feelings, sighing, dyspnea)” had the lowest score (4,1 ± 0,64). the largest and smallest variance was also observed in item 2 and item 4 (0,53) and item 1 (0,37), respectively. the smallest pearson correlation value is 0.529 (item number 11 on “gastrointestinal symptoms (difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation)”, and the largest pearson correlation is 0.727 (item number 6 on “depressed mood: loss of interest, lack of pleasure in hobbies, table 1. characteristics of respondents (n=98) characteristics n % ages 20-30 46 46.9 >30-40 43 43.9 >40-50 9 9.2 gender male 22 22.4 female 76 77.6 marital status married 81 82.7 not married 15 15.3 ever married 2 2 working experience 0-5 35 35.7 >5-10 45 45.9 >10-15 13 13.3 >15-20 5 5.1 level of education diploma iii in nursing 79 80.6 strata 1 in nursing 19 19.4 total 98 100 i. m. ramdan 36 | pissn: 1858-3598  eissn: 2502-5791 depression, early waking, diurnal swing”). based on the previous criteria, it can be concluded that all of the ham-a items in indonesian version are declared "fair" or in this study called as a valid because pearson correlation (r) ranged between 0.5 and 0.7. if item question number 2 “tension: feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax” is deleted this can increase cronbach's alpha coefficient by 0.753, if item question number 12 “genitourinary symptoms (frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence)” is deleted this can increase cronbach's alpha coefficient by 0.745 and if item question number 5 “intellectual (difficulty in concentration, poor memory)” is deleted this can increase cronbach's alpha coefficient by 0.744. to get the indonesian version of ham-a with the highest level of reliability, it is recommended that item number 2 “tension: feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax” be omitted so that cronbach's alpha coefficient becomes 0.753. but in general, the combination of all 14 items of ham-a has shown the fair reliability (or table 2. the hamilton anxiety rating scale (ham-a): original (english)(hamilton, 1959) and translated (indonesian) version. original version indonesian version item 1 anxious mood (worries, an anticipation of the worst, fearful anticipation, irritability) perasaan cemas (merasa khawatir, firasat buruk, takut akan fikiran sendiri, lekas marah atau mudah tersinggung) item 2 tension (feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax) ketegangan (merasa tegang, merasa lelah, respon yang mengejutkan, mudah meneteskan air mata, merasa gemetar, merasa gelisah, tidak mampu untuk bersantai) item 3 fears (of dark, of strangers, of being left alone, of animals, of traffic, of crowds) ketakutan (takut terhadap gelap, takut terhadap orang asing, takut ditinggalkan sendirian, takut pada hewan, takut pada keramaian lalu lintas, takut pada kerumunan orang banyak) item 4 insomnia (difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors) insomnia (kesulitan tidur, tidur tidak memuaskan, merasa lelah saat bangun, mimpi buruk, terbangun tengah malam) item 5 intellectual (difficulty in concentration, poor memory) intelektual (sulit berkonsentrasi, sulit mengingat) item 6 depressed mood (loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing) perasaan depresi (kehilangan minat, kurangnya kesenangan dalam hobi, perasaan bersedih, sering terbangun dini hari saat tidur malam) item 7 somatic (muscular) (pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone) gejala somatik (otot) (nyeri atau sakit otot, kedutan, otot terasa kaku, gigi gemertak, suara tidak stabil, tonus otot meningkat) item 8 somatic (sensory) (tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation) somatik (sensorik) (telinga terasa berdenging, penglihatan kabur, muka memerah, perasaan lemah, sensasi ditusuk-tusuk) item 9 cardiovascular symptoms (tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat) gejala-gejala kardiovaskular (takikardi, palpitasi, nyeri dada, denyut nadi meningkat, perasaan lemas/lesu seperti mau pingsan, denyut jantung serasa berhenti sekejap) item 10 respiratory symptoms (pressure or constriction in chest, choking feelings, sighing, dyspnea) gejala pernapasan (nafas terasa sesak/dada terasa ditekan, perasaan tercekik, sering menarik nafas dalam, nafas pendek/tersengal-sengal) item 11 gastrointestinal symptoms (difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation) gejala gastrointestinal (kesulitan menelan, nyeri perut, perut terasa kembung, sensasi terbakar, perut terasa penuh, merasa mual, muntah, sukar buang air besar/bab, kehilangan berat badan, konstipasi) item 12 genitourinary symptoms (frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence) gejala genitourinari (frekuensi berkemih meningkat, tidak dapat menahan air seni, tidak datang bulan, darah haid lebih banyak dari biasanya, gairah sex menurun, ejakulasi dini, kehilangan libido, impotensi) item 13 autonomic symptoms (dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair) gejala otonom (mulut kering, muka kemerahan, muka pucat, sering berkeringat, merasa pusing, kepala terasa berat, merasa tegang, rambut terasa menegang) item 14 behavior (fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc.) tingkah laku (gelisah, tidak tenang/sering mondar-mandir, tangan gemetar, alis berkerut, wajah tegang, sering mendesah atau pernapasan cepat, wajah pucat, sering menelan ludah, dll.) jurnal ners http://e-journal.unair.ac.id/jners | 37 in this study called as a reliable) with cronbach’s alpha coefficient of 0,756. this result generally shows the indonesian version of ham-a is reliable to measure work-related stress in nurses. discussion validity expresses the degree to which a measurement measures what it purpose to measure. validity tests are categorized into two broad components namely; internal and external validities. internal validity refers to how accurately the measures obtained from the research was actually quantifying what it was designed to measure whereas external validity refers to how accurately the measures obtained from the study sample described the reference population from which the study sample was drawn (bolarinwa, 2015). reliability is the extent to which a measurement of a phenomenon provides stable and consist result (taherdoost, 2016), and cronbach's alpha is an accurate estimate of reliability and the spearman-brown formula is an accurate method to calculated reliability coefficient (eisinga, grotenhuis, & pelzer, 2013). according to ursachi, horodnic, & zait (2015), the cronbach alpha coefficient between 0.6-0.7 indicates an acceptable level of reliability, and 0.8 or greater a very good level. the finding of the present study indicates that the indonesian version of the ham-a has a high enough internal and external validity, which can reveal the causal relationship between independent and dependent variables related to work-related stress in nursing with generalized results. this can be seen from the correlation coefficient (r) of the pearson product moment between the item score and the total score ranging from 0.529 (min) to 0.967 (max) with a significant positive correlation (p = 0.000). in accordance with bryman's (2001 ) opinion that internal validity is common to refer to the factor that has a causal impact as the independent variable and the effect as the dependent variable, and mc dermot's (2011) opinion that external validity refers to the generalizability of findings from a study, or the extent to which conclusions can be applied across different populations, settings, treatments, and outcomes in this study, the english version of ham-a was translated into indonesian language and the reliability and validity of the indonesian version of the ham-a were investigated using a representative sample of nurses from various aspect i.e department/care rooms, age, marital status, educational level, and work experience, the finding indicates that the ham-a in indonesian version has satisfactory psychometric properties with adequate validity and reliability, so that it can be used to measure work-related stress on nurses. similar to this study, translation of ham-a into another language version has been done several times and getting valid and reliable results. in clinical research settings, ham-a is a reliable and valid measure for the assessment of global anxiety in the adolescent population (clark & donovan, 1994); ham-a are reliable and valid instruments that can be used among end-stage renal disease (esrd) patients undergoing hemodialysis (hd)(gencoz, gencoz, & soykan, 2007); ham-a is a valid and reliable instrument for the assessment of depression in the urdu language (hashmi, naz, asif, & khawaja, 2016); in indian language with video recorded interview, ham-a inter-rater reliability has found excellent to asses patients with major depressive disorder (mdd) (prasad et al., 2009). in general/workers setting, this study supports the results of previous studies, among others: hars in the arabic version is valid and reliable to measure work-related stress among working women in gaza strip (aqel & thabet, 2017), the ham-a showed good internal consistency to assess the romanian employees working in non-governmental organizations (craiovan, 2015), ham-a can be used globally and is valid and reliable to measure workrelated stress on students (gupta et al., 2014), hama has a high-reliability index to measure anxiety oncology nursing in athens, greece (karanikola et al., 2016) and the hars in greek language was reliable to assess work-related stress in emergency nursing table 3. descriptive characteristics and the pearson correlation of each data for internal consistency of indonesian version of the ham-a questionnaire (n=98) item mean sd pearson correlation (r) p corrected item/total correlation cronbach’s alpha if item deleted item 1 0.64 0.613 0.599 0.000 0.586 0.743 item 2 0.96 0.731 0.697 0.000 0.702 0.753 item 3 0.66 0.657 0.537 0.000 0.574 0.742 item 4 1.11 0.731 0.600 0.000 0.587 0.740 item 5 0.87 0.715 0.550 0.000 0.565 0.744 item 6 0.86 0.603 0.727 0.000 0.750 0.743 item 7 0.88 0.703 0.672 0.000 0.673 0.738 item 8 0.72 0.662 0.629 0.000 0.640 0.738 item 9 0.46 0.715 0.629 0.000 0.702 0.738 item 10 0.41 0.645 0.562 0.000 0.651 0.741 item 11 0.83 0.589 0.529 0.000 0.618 0.741 item 12 0.82 0.626 0.693 0.000 0.526 0.745 item 13 0.82 0.648 0.569 0.000 0.714 0.737 item 14 0.55 0.628 0.569 0.000 0.562 0.743 total score 10.58 5.82 1 i. m. ramdan 38 | pissn: 1858-3598  eissn: 2502-5791 personnel in greece (stathopoulou, karanikola, panagiotopoulou, & papathanassoglou, 2011). conclusion the result of the study demonstrates that the indonesian version of the ham-a fulfils the criteria of a reliable (fair acceptable criteria) and valid (good criteria) assessment tool to assess the work-related stress in the nursing profession. this scale showed good psychometric properties in the nursing profession with different education, gender, work experience, and different department. the high internal consistency and construct validity support the application of the ham-a as an easy-administered tool to asses work-related stress in the nursing profession. acknowledgments the authors are very grateful to the hospital management for giving research permission, all nurses participated in this study, and expert committee (translators, epidemiologist and health professionals expert). references aqel, n. a., & thabet, a. (2017). work and family stressors , depression , and anxiety among working women in gaza strip. global journal of intellectual & develompental disabilities (gjidd), 555615(november), 001–006. beaton, d. e., bombardier, c., guillemin, f., ferraz, m. b., borsa, j. c., wamser, g. h., … schoemaker, m. m. (2000). guidelines for the process of crosscultural adaptation of self-report measures. spine, 25(24), 3186–3191. https://doi.org/10.1111/cch.12124 bolarinwa, o. a. (2015). principles and methods of validity and reliability testing of questionnaires used in social and health science researches. nigerian postgraduate medical journal, 22(4), 195–201. doi: 10.4103/1117-1936.173959 bryman, a. (2001). social research methods. new york: oxford university press inc. cicchetti, d. v. (1994). guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. psychological assessment, 6(4), 284– 290. https://doi.org/10.1037/1040-3590.6.4.284 clark, d. b., & donovan, j. e. (1994). reliability and validity of the hamilton anxiety rating scale in an adolescent sample. journal of the american academy of child & adolescent psychiatry, 33(3), 354–360. doi: 10.1097/00004583-19940300000009 craiovan, p. m. (2015). burnout, depression and quality of life among the romanian employees working in non-governmental organizations. procedia social and behavioral sciences, 187, 234–238. https://doi.org/10.1016/j.sbspro.2015.03.044 deguchi, y., iwasaki, s., ishimoto, h., ogawa, k., fukuda, y., nitta, t., … inoue, k. (2017). relationships between temperaments, occupational stress, and insomnia among japanese workers. plos one, 12(4), 1–13. https://doi.org/10.1371/journal.pone.0175346 eisinga, r., grotenhuis, m. te, & pelzer, b. (2013). the reliability of a two-item scale: pearson, cronbach, or spearman-brown? international journal of public health, 58(4), 637–642. https://doi.org/10.1007/s00038-012-0416-3 fan, l. b., blumenthal, j. a., watkins, l. l., & sherwood, a. (2015). work and home stress: associations with anxiety and depression symptoms. occupational medicine, 65(2), 110–116. https://doi.org/10.1093/occmed/kqu181 gencoz, f., gencoz, t., & soykan, a. (2007). psychometric properties of the hamilton depression rating scale and other physician-rated psychiatric scales for the assessment of depression in esrd patients undergoing hemodialysis in turkey. journal psychology, health & medicine, 12(4), 450–459. doi: 10.1080/13548500600892054 gupta, r., punia, a., mathur, s., gupta, r., kawatra, a., & verma, k. (2014). assessment of psychological stress in first year students of a private indian journal of basic and applied medical research. indian journal of basic and applied medical research, 1956(march), 437–443. hamilton, m. (1959). the assessment of anxiety states by rating. the british journal of medical psychology, 32(1), 50–55. doi: 10.1111/j.20448341.1959.tb00467.x hashmi, a. m., naz, s., asif, a., & khawaja, i. s. (2016). urdu translation of the hamilton rating scale for depression: results of a validation study. pakistan journal of medical sciences, 32(6), 1479–1483. https://doi.org/10.12669/pjms.326.11399 huerta-franco, m.-r. (2013). effects of occupational stress on the gastrointestinal tract. world journal of gastrointestinal pathophysiology, 4(4), 108. https://doi.org/10.4291/wjgp.v4.i4.108 international labour organization. (2016). workplace stress. world day for safety and health at work. turin italy: international labour organization. https://doi.org/10.1017/cbo9781107415324.0 04 karanikola, m. n. k., giannakopoulou, m., kalafati, m., kaite, c. p., patiraki, e., mpouzika, m., … middleton, n. (2016). anxiety symptoms and quality of interaction among oncology nurses: a correlational, cross-sectional study. revista da escola de enfermagem, 50(5), 800–807. https://doi.org/10.1590/s0080623420160000600013 katherine shear, m., bilt, j. vander, rucci, p., endicott, j., lydiard, b., otto, m. w., … frank, d. m. (2001). reliability and validity of a structured interview guide for the hamilton anxiety rating scale (sigh-a). depression and anxiety, 13(4), 166–178. https://doi.org/10.4103/1117-1936.173959 https://doi.org/10.1097/00004583-199403000-00009 https://doi.org/10.1097/00004583-199403000-00009 https://doi.org/10.1080/13548500600892054 https://doi.org/10.1111/j.2044-8341.1959.tb00467.x https://doi.org/10.1111/j.2044-8341.1959.tb00467.x jurnal ners http://e-journal.unair.ac.id/jners | 39 https://doi.org/10.1002/da.1033 khamisa, n., peltzer, k., ilic, d., & oldenburg, b. (2017). effect of personal and work stress on burnout, job satisfaction and general health of hospital nurses in south africa. health sa gesondheid, 22, 252–258. https://doi.org/10.1016/j.hsag.2016.10.001 kline, p. (2000). the handbook of psychological testing (second). london and new york: routledge. la torre, g., sestili, c., mannocci, a., sinopoli, a., de paolis, m., de francesco, s., … de giusti, m. (2018). association between work related stress and health related quality of life: the impact of sociodemographic variables. a cross sectional study in a region of central italy. international journal of environmental research and public health, 15(1), 159. https://doi.org/10.3390/ijerph15010159 li, j., loerbroks, a., bosma, h., & angerer, p. (2016). work stress and cardiovascular disease: a life course perspective. journal of occupational health, 58(2), 216–219. https://doi.org/10.1539/joh.15-0326-op lópez-pina, j. a., sánhez-meca, j., & rosa-alcázar, a. i. (2009). the hamilton rating scale for depression: a meta analytic reliability generalization study. international journal of clinical and health psychology, 9(9), 143–159. maier, w., buller, r., philip, m., & heuser, i. (1988). the hamilton anxiety rating scale: reliability, validity and sensitivity to change in anxiety and depresive disorders. j affect disord, 14(1), 61–68. doi:10.1016/0165-0327(88)90072-9 mcdermott, r. (2011). internal and external validity. in j. n. druckman, d. p. green, j. h. kuklinski, & a. lupia (eds.), cambridge handbook of experimental political science. cambridge: cambridge university press. https://doi.org/10.1017/cbo9780511921452.0 03 michalopoulos, l. t. m., murray, l. k., kane, j. c., van wyk, s. s., chomba, e., cohen, j., … bolton, p. a. (2015). testing the validity and reliability of the shame questionnaire among sexually abused girls in zambia. plos one, 10(4), 1–17. https://doi.org/10.1371/journal.pone.0123820 michie, s. (2002). causes and management of stress at work. occupational environ med, 59, 67–72. https://doi.org/10.1136/oem.59.1.67 moore, s., sikora, p., grunberg, l., & greenberg, e. (2007). work stress and alcohol use: examining the tension-reduction model as a function of worker’s parent’s alcohol use. addict behav, 32(12), 3114–3121. https://doi.org/10.1016/j.immuni.2010.12.017.t wo-stage moustaka, e., & constantinidis, t. c. (2010). sources and effects of work-related stress in nursing. health science journal, 4(4), 210–216. nafeesa, m., vidhya, v., vijayalakshmi, p., & rajkumar, p. (2017). annals of musculoskeletal disorders central perceived work-related psychosocial stress and musculoskeletal disorder complaints among call centre workers in india – a cross sectional study. ann musc disord, 1(1), 1–6. retrieved from https://www.jscimedcentral.com/musculoskelet aldisorders/musculoskeletaldisorders-11005.pdf nunnally, j. c., & bernstein, i. h. (1994). psychometric theory (3rd ed.). usa: mcgraw-hill, inc. https://doi.org/10.1177/014662169501900308 obradović, j., & čudina-obradović, m. (2013). work stress and marital quality in dual earner couples: a test of three mediation models. drustvena istrazivanja, 22(4), 673–691. https://doi.org/10.5559/di.22.4.06 piko, b. f. (2006). burnout, role conflict, job satisfaction and psychosocial health among hungarian health care staff: a questionnaire survey. international journal of nursing studies, 43(3), 311–318. https://doi.org/10.1016/j.ijnurstu.2005.05.003 pillay, r. (2009). work satisfaction of professional nurses in south africa: a comparative analysis of the public and private sectors. human resources for health, 7(15), 1–10. https://doi.org/10.1186/1478-4491-7-15 portney, l., & watkins, m. (2009). foundations of clinical research: applications to practice pearson education. new jersey: upper saddle river. prasad, k. m., udupa, k., kishore, k., thirthalli, j., sathyaprabha, t., & gangadhar, n. (2009). interrater reliability of hamilton depression rating scale using video-recorded interviews — focus on rater-blinding. indian journal of psychiatry, 51(3), 191–194. doi: 10.4103/0019-5545.55085 rose, d. m., seidler, a., nübling, m., latza, u., brähler, e., klein, e. m., … beutel, m. e. (2017). associations of fatigue to work-related stress, mental and physical health in an employed community sample. bmc psychiatry, 17(1), 1–8. https://doi.org/10.1186/s12888-017-1237-y singh, a. s., & masuku, m. b. (2014). sampling techniques & determination of sample size in applied statistics research: an overview. international journal of economics, commerce and management, 2(11), 1–22. doi: 10.12691/jpar-31-8. stathopoulou, h., karanikola, m., panagiotopoulou, f., & papathanassoglou, e. (2011). anxiety levels and related symptoms in emergency nursing personnel in greece. j emerg nurs, 37(4), 314– 320. doi: 10.1016/j.jen.2010.03.006 taber, k. s. (2018). the use of cronbach’s alpha when developing and reporting research instruments in science education. research in science education, 48(6), 1273–1296. https://doi.org/10.1007/s11165-016-9602-2 taherdoost, h. (2016). validity and reliability of the research instrument ; how to test the validation of a questionnaire / survey in a research. international journal of academic research inmanagement (ijarm), 5(3), 28– https://doi.org/10.1016/0165-0327(88)90072-9 https://doi.org/10.1017/cbo9780511921452.003 https://doi.org/10.1017/cbo9780511921452.003 https://doi.org/10.1177%2f014662169501900308 https://doi.org/10.4103/0019-5545.55085 https://doi.org/10.1016/j.jen.2010.03.006 i. m. ramdan 40 | pissn: 1858-3598  eissn: 2502-5791 36. http://dx.doi.org/10.2139/ssrn.3205040 terwee, c. b., bot, s. d. m., de boer, m. r., van der windt, d. a. w. m., knol, d. l., dekker, j., … de vet, h. c. w. (2007). quality criteria were proposed for measurement properties of health status questionnaires. journal of clinical epidemiology, 60(1), 34–42. https://doi.org/10.1016/j.jclinepi.2006.03.012 thompson, e. (2015). hamilton rating scale for anxiety (ham-a). occupational medicine, 65(7), 601. https://doi.org/10.1093/occmed/kqv054 ursachi, g., horodnic, i. a., & zait, a. (2015). how reliable are measurement scales? external factors with indirect influence on reliability estimators. procedia economics and finance, 20(15), 679–686. https://doi.org/10.1016/s2212-5671(15)001239 vernekar, s. p., & shah, h. (2018). a study of workrelated stress among nurses in a tertiary care hospital in goa. international journal of cummunity medicine and public health, 5(2), 657– 661. doi: http://dx.doi.org/10.18203/23946040.ijcmph20180246 vignoli, m., muschalla, b., & mariani, m. g. (2017). workplace phobic anxiety as a mental health phenomenon in the job demands-resources model. biomed research international, 1–10. https://doi.org/10.1155/2017/3285092 world health organization (who). (2007). stress at the workplace. geneva. retrieved from http://www.who.int/occupational_health/topics /stressatwp/en https://dx.doi.org/10.2139/ssrn.3205040 http://dx.doi.org/10.18203/2394-6040.ijcmph20180246 http://dx.doi.org/10.18203/2394-6040.ijcmph20180246 ners vol 10 no 1 april 2015.indd 1 peningkatan nutrisi ibu hamil di indonesia: pentingnya peran bidan di desa dan kader (improving the nutrition of pregnant village women in indonesia: the important roles of village midwives and cadres) setyowati* *fakultas ilmu keperawatan universitas indonesia, kampus ui depok 16424, indonesia email: watisetyowati@yahoo.com.au atau wati123@ui.ac.id abstrak pendahuluan: angka kematian ibu di negara berkembang seperti di indonesia masih tinggi. tiga penyebab kematian adalah perdarahan, infeksi, dan eklampsia. beberapa kondisi tersebut disebabkan secara tidak langsung oleh anemia kekurangan zat besi. banyak program nutrisi yang sudah dilakukan oleh pemerintah indonesia, tetapi nutrisi pada wanita hamil masih merupakan masalah yang besar di indonesia. penelitian ini menggali status nutrisi ibu hamil di daerah pedesaan di propinsi banten serta mengidentifi kasi intervensi yang sesuai untuk mengatasi masalah nutrisi ibu hamil di pedesaan. metode: desain yang digunakan adalah studi deskripsi longitudinal dengan pendekatan studi operasional dengan memberdayakan bidan desa dan kader untuk memberikan intervensi nutrisi ibu hamil di desa. pengukuran yang dilakukan adalah mengukur kadar anemia, indeks masa tubuh, dan berat badan. tiga tahap telah dilakukan dengan pendekatan community development sebagai intervensi. hasil: hasil penelitian menunjukkan bahwa beberapa perubahan dalam praktek bidan terjadi setelah dilakukan intervensi dan juga kader lebih baik dalam berkomunikasi tentang nutrisi dengan masyarakat. namun demikian intervensi ini belum cukup untuk dapat merubah status nutrisi ibu hamil secara keseluruhan dan intervensi tidak mempengaruhi kesehatan komunitas dalam jangka waktu yang pendek di desa intervensi. perubahan keadaan ini memerlukan waktu yang cukup lama. analisis dan diskusi: rekomendasi dari hasil penelitian ini adalah kepada pemerintah dan institusi pendidikan untuk meningkatkan kompetensi dari pemberi pelayanan kesehatan dalam pelayanan kesehatan pada ibu hamil khususnya nutrisi dan cara keterampilan komunikasinya. kata kunci: community development, indonesia, status nutrisi, ibu hamil, perawatan di komunitas desa. abstract introduction: the maternal mortality remains high in developing countries such as indonesia. three most common reasons for this incidence are hemorrhage, infection, and eclampsia. some of these conditions can be infl uenced by iron defi ciency anemia (ida). a lot of programs for nutrition have been provided by indonesian government, but the nutritional condition of pregnant women still be big problem in indonesia. this study explored the nutritional status of pregnant village women in banten province, indonesia and assessed interventions in dealing with nutrition problems among pregnant women especially in the rural area. method: the design was a longitudinal descriptive study with operational study by empowering village midwives and cadre to intervene pregnant women nutrition in rural area. the measurements were focused on the rate of anemia, body mass index (bmi), and weight. three stages were applied in this study with community development as intervention. result: this study reported some changes in the midwife practises after intervertion, while cadres more talkative when explaining about nutrition after intervention. however, the intervention did not affect the overall nutritional status of the pregnant women and the intervention was not able to infl uence the community’s health in the medium term in the intervention villages. analysis and discussion: this study recommend the government and educational institutions to improve the competencies of health care providers especially in communication skill. keywords: community development, indonesia, nutritional status, pregnant women, rural nursing. pendahuluan a ng k a ke m at ia n ibu d i nega r a berkembang masih terus tinggi, seperti di indonesia walaupun segala upaya telah dilak u kan seper ti perat u ran-perat u ran, p e l a k s a n a a n p r o g r a m p r o g r a m d a n aktivitasnya. tiga penyebab utama dari kematian ini adalah terjadinya perdarahan, infeksi dan eklampsia. beberapa dari kondisi tersebut dapat disebabkan anemia karena defi siensi zat besi (ida) yang terjadi kurang lebih 51% dari wanita di indonesia (who, 1994 & kodyat et al.). risiko kematian akan lebih tinggi pada wanita dengan anemia yang berat (hb < 70 atau 80 gm/l) (un/accscn, 1997, kodyat et al., 1998, & depkes ri, 2007). pemerintah indonesia mulai program 2 jurnal ners vol. 10 no. 1 april 2015: 1–8 pemberian rutin untuk wanita hamil pada pertengahan tahun 1970-an. di samping itu pemerintah indonesia juga mengidentifi kasi kemungkinan memberdayakan masyarakat lokal dalam aktivitas promosi kesehatan (ber man, 1984; depkes ri, 2011). para perempuan di komu nitas yang dikenal sebagai kader dilatih sebagai penyuluh nutrisi di samping tugas-tugas program kesehatan lain nya dalam posisinya sebagai kader kesehatan. kader kesehatan terlihat mempunyai pengaruh yang sedikit untuk menurunkan prevalensi anemia pada wanita hamil yang tetap sekitar 64% pada tahun 1988 dan sampai sekarang masih sekitar 60% (kodyat et al., 1998; kosen et al., 1998; who, 1998). namun demikian sudah ada beberapa keberhasilan dari beberapa program pemerintah misalnya angka kematian bayi turun menjadi 32/1000 kelahiran hidup berdasarkan survey rumah tangga tahun 2008 karena peningkatan ekonomi dan pelayanan (w ho, 2002). meskipun demikian, pemberian suplemen zat besi tidak menunjukkan hasil yang efektif. oleh sebab itu ada kebutuhan yang mendesak untuk mengkaji ulang bagaimana sebetulnya cara yang sesuai untuk menurunkan anemia pada ibu hamil di indonesia. penelitian ini menjelaskan bagaimana peran yang harus dilakukan oleh bidan yang bekerja di desa dan kader-kader untuk meningkatkan status nutrisi ibu hamil yang dilakukan melalui intervensinya ke komunitas. intervensi yang ber upa pelatihan pendekatan komunitas dan memberdayakan komunitas melalui komunikasi yang efektif khususnya dalam nutrisi dan pemberian zat besi. intervensi yang dilakukan berdasarkan pada model green’s health promotion (green & kreuter, 2005). pengukuran status nutrisi dilakukan sebelum dan sesudah intervensi tujuan utama dari penelitian ini adalah untuk mengidentifi kasi efektivitas dari program intervensi dengan partisipasi/pemberdayaan komunitas terhadap status nutrisi ibu hamil di pedesaan. metode dan bahan penelit ia n i n i d ila k u k a n denga n menggunakan desain studi operasional dengan pendekatan kuantitatif (cross sectional untuk survey status nutrisi) dan didukung dengan data kualitatif (studi etnografi). penelitian dilakukan di provinsi banten jawa barat dengan 4 desa di serang sebagai lokasi penelitian dan 4 desa di cilegon sebagai desa pembanding. perlakuan diberikan kepada petugas bidan desa dan kadernya. karena kedua daerah ini berdekatan tetapi dapat dicegah untuk kontak masing –masing subjek penelitian karena jarak geografi s yang jauh namun budaya dan sumber-sumber makanan sama. keluasan dan jumlah penduduk kedua daerah sama. penelitian mengg u nakan 3 tahap. tahap pertama digunakan pendekatan cross sectional dalam pengambilan data terhadap kadar haemoglobin, basal metabolisme index (bmi) dan perubahan berat badan pada setiap ibu hamil di desa tempat penelitian selama tiga bulan. terdapat rerata 18 ibu hamil per desa dalam sebulan yang melakukan pemeriksaan antenatal. pada tahap pertama pengumpulan data dilakukan bersama di 8 desa. jumlah ibu hamil yang menjadi calon responden sebanyak 312 diperoleh dengan cara pendekatan melalui bidan dan kader desa. ibu hamil yang telah diidentifi kasi diberikan penjelasan dan diminta untuk ikut dalam riset dengan menandatangani informed consent. hanya 70% (210) dari ibu hamil yang setuju menjadi responden, sehingga ada 121 sampel ibu hamil di desa perlakuan dan 89 di desa pembanding. ibu hamil diminta untuk mengisi data demografi (umur, pendidikan, status sosial dan pekerjaan) dan data kehamilan (u mu r kehamilan, riwayat abortus, pernah/tidak perdarahan, riwayat kematian janin, dan komplikasi yang dialami). data status nutrisi dikumpulkan yaitu mengukur berat badan yang dibedakan pada kunjungan pertama dan berat badan sekarang, tinggi badan, tinggi fundus uterus (berat badan diukur dengan memakai baju dengan menggunakan timbangan seca yang telah dikaliberasi dan dicocokkan dengan timbangan di puskesmas sebelum penelitian). pengukuran tinggi badan dengan meter line di mana ibu hamil berdiri menempel di tembok tanpa sepatu. pengukuran bmi dikalkulasi dengan formula (berat badan dalam 3 peningkatan nutrisi ibu hamil di indonesia (setyowati) kilogram dibagi dengan kuadrat dari tinggi badan dalam meter. ibu hamil dikategorikan sebagai di bawah normal bila bmi kurang dari 20, normal bila antara 20-24.9 dan kelebihan bila lebih besar dari 25. kenaikan berat badan dikalkulasi dengan menghitung selisih berat badan sebelumnya/sebelum hamil dengan berat badan saat ini. ibu hamil dengan peningkatan berat badan lebih dari standar deviasi di bawah rerata berat badan diklasifi kasikan sebagai kenaikan berat badan rendah. peningkatan berat badan ibu hamil lebih dari satu standar deviasi di atas rata-rata kenaikan berat badan ibu hamil dikategorikan sebagai kenaikan berat badan yang tinggi dan sisanya yaitu yang sesuai dengan rerata kenaikan disebut normal. pengukuran haemoglobin dilakukan sebagai data dasar lainnya untuk mengukur stat us nut r isinya dengan mengg u nakan metode cyanmethemoglobin dengan sahli haemometer. alat ini umumnya digunakan untuk test diagnostik anemia di puskesmas di indonesia. tahap satu pada pengumpulan data mengindikasikan bahwa wanita hamil di daerah perlakuan tinggi anemia dan bmi rendah dan peningkatan berat badan rendah. kondisi ini diperparah dengan kenyataan bahwa bidan dan kader serta para wanita di desa tersebut pengetahuan sangat kurang tentang bagaimana nutrisi yang baik bagi wanita hamil dan bagaimana meningkatkan nutrisi ibu hamil. masyarakat desa mempunyai keyakinan sehubungan dengan nutrisi, beberapa larangan tentang makanan ibu hamil, juga nilai dan keyakinan mereka bahwa wanita atau istri itu makan harus terakhir dan paling sedikit, demikian juga ibu hamil harus mengurangi makanan selama hamil supaya bayi tidak besar serta dilarang makanan protein hewani tertentu. wanita hamil di desa yang diteliti tidak patuh dalam minum suplemen tablet besi yang diberikan bidan desa dan tidak dijelaskan tentang nutrisi tambahan yang diperlukan selama kehamilan oleh bidan dan kader. hasil ini menunjukkan bahwa diperlukan segera peningkatan pengetahuan dan kapasitas bidan desa, kader dan para wanita serta ibu hamil di desa dalam nutrisi. pelatihan tentang pengembangan masyarakat dilaksanakan dengan berdasarkan pada model green’s health promotion. pertama adalah identifi kasi kebutuhan komunitas. program dikembangkan dengan desain bottom-up, di mana bidan desa, kader dan ibu hamil diberdayakan untuk mengidentifi kasi isu-isu yang spesifi k yang mempengaruhi nutrisi ibu hamil dan juga mengusulkan rencana pemecahan masalah yang cocok dan sesuai. kedua dengan mengikutsertakan bidan desa dan kader. prinsip tahap ini adalah membentuk program yang mengikut sertakan bidan desa dan kader dalam membuat program. mereka dianjurkan untuk mengidentifi kasi berbagai faktor yang mempenga r u h i u nt u k mengemba ng ka n komunitas misalnya: kekuasaan pimpinan/ kepala suku/adat/agama dan identif ikasi strategi untuk menggunakannya. kemudian dilanjutkan dengan memperkuat hubungan antara bidan desa, kader dan ibu hamil. kader dan bidan desa diminta untuk melihat dan memberdayakan faktor-faktor lain yang mempengaruhi pengembangan komunitas misalnya peran dukun bersalin di desa dan mereka har us dapat memberdayakan hal tersebut. desai n i nter vensi d i kemba ng ka n melalui konsultasi dengan bidan desa, kader dan ibu hamil (melalui diskusi kelompok dan interview individu). telah dikembangkan yang sesuai dengan menyesuaikan dengan kerangka nasional dan komitmen untuk mengatasi masalah dengan memberdayakan sumber yang ada. bidan dan kader diundang untuk ikut berpartisipasi dalam pelatihan u nt u k meningkatkan keterampilan dan mengembangkan strategi dalam meningkatkan status nutrisi ibu hamil. akses dan fasilitas dari proyek diberikan oleh bidan pengawas dan berkoordinasi dengan puskesmas setempat. dalam pelatihan juga diberikan feedback dari hasil pengambilan data tahap satu, untuk meningkatkan pemahaman partisipan. konsep pengembangan komunitas, komunikasi dan nutrisi diperkenalkan kepada bidan desa dan kader di 4 desa perlakuan. pelatihan menggunakan metode diskusi kelompok, demonstrasi dan aktivitas percobaan seperti mengembangkan dan mempraktekkan strategi unt u k meningkatkan nut r isi ibu hamil. 4 jurnal ners vol. 10 no. 1 april 2015: 1–8 beberapa contoh strategi yang digunakan adalah pendekatan kepada pimpinan agama atau ketua adat, penyuluhan kesehatan secara individual, dan menggunakan poster yang ditempelkan pada tempat yang mudah dilihat masyarakat. di desa pembanding tidak dilakukan pelatihan tetapi hanya diambil data yang sama untuk membandingkan dengan desa dilakukan perlakuan pada bidan dan kader. setelah satu tahun dilakukan intervensi, dilakukan pengumpulan data kembali di 8 desa (perlakuan dan pembanding). pengambilan data dilakukan sama dengan pada tahap satu, yaitu data demografi , kehamilan, umur kehamilan, komplikasi termasuk perdarahan, berat badan sebelum hamil dan saat ini, tinggi dan berat badan saat ini dan hemoglobin. etika penelitian komite etik dari uts telah menyetujui dan juga komite etik dari ui. sebagai tambahan ijin dari badan kesatuan bangsa, politik dan perlindungan masyarakat banten dan kanwil kesehatan propinsi banten. informed consent telah ditandatangani oleh semua partisipan dan responden setelah penjelasan penelitian. hasil penjelasan karak ter istik obstet r ik dari sampel sebelum dan sesudah intervensi terlihat pada tabel satu yaitu 69% (144) dari responden adalah ibu hamil multipara. dua puluh satu persen (45 orang) dari responden telah mengalami keguguran pada kehamilan sebelumnya. sedangkan 7% (14 dari 210) mengala m i kela h i ra n ja n i n men i nggal sebelumnya. tidak ada perbedaan yang berarti sebelum intervensi antara kedua kelompok desa. sebanyak 32% (56 dari 210) wanita hamil pada trimester satu, 32% (68 dari 210) pada trimester dua dan 41% (86 dari 210) pada trimester tiga. ada proporsi besar ibu hamil di desa perlakuan pada kehamilan trimester tiga (47%) dan di desa pembanding (33%) tetapi perbedaan tidak bermakna secara statistik (χ2 = 4.63, p >.05). hanya 5% (10 dari 210) ibu hamil mengalami perdarahan ante natal selama kehamilan ini. tujuh persen tabel 1. karakteristik obstetrik responden di kelompok desa perlakuan dan desa pembanding (sebelum dan sesudah intervensi) di banten jawa barat variabel desa pembanding (%) desa perlakuan (%) kehamilan: trimester i [0–16 weeks] trimester ii [17–28 weeks] trimester iii [> 28 weeks] 26 (29.2) – 27 (30.3) 34 (38.2) – 32 (36) 29 (32.6) – 30 (33.7) 30 (24.8) – 34 (34) 34 (28.1) – 43 (43) 57 (47.1) – 23 (23) riwayat kehamilan: primipara multipara [1–5 lahir] grand multipara [>5 kelahiran] 25 (28.1) – 23 (25.8) 56 (62.9) – 57 (64) 8 (9) – 9 (10) 41 (33.9) – 45 (45) 65 (53.7) – 51 (51) 15 (12.4) – 4 (4) riwayat abortus: no abortion 1-3 abortions lebih 3× abortus still birth 69 (77.5) – 62 (69.7) 19 (21.3) – 20 (20.2) 1 (1.2) – 1 (1) 8 (9) – 6 (6.7) 96 (79.3) – 90 (90) 24 (19.8) – 10 (10) 1 (0.8) – 0 (0) 6 (5) – 1 (1) komplikasi kehamilan: tidak ada perdarahan antenatal risiko lahir premature tekanan darah tinggi infeksi vagina lainnya 71 (79.8) – 71 (79.8) 5 (5.6) – 5 (5.6) 10 (11.2) – 9 (10) 3 (3.4) – 0 (0) 1 (1.1) – 1 (1) 4 (4.5) – 8 (9) 105 (86.8) – 91 (91) 5 (4.1) – 0 (0) 5 (4.1) – 0 (0) 3 (2.5) – 0 (0) 1 (0.8) – 0 (0) 7 (5.8) – 9 (9) 5 peningkatan nutrisi ibu hamil di indonesia (setyowati) (15 dari 210) ibu hamil terancam lahir prematur untuk kehamilan ini. tiga persen (6 dari 210) ibu hamil mengalami tekanan darah tinggi. komplikasi ini tidak berbeda antara desa perlakuan dan desa-desa pembanding. terdapat kejadian yang tinggi dari anemia (62%, n = 125) dari seluruh sampel walaupun perbedaan antara dua kelompok tidak banyak (tabel 1). dua persen dari masing-masing kelompok mengalami anemia berat (< 7 gm/l). terdapat rentang kadar haemoglobin yang besar pada dua kelompok. proporsi ibu hamil yang anemia pada desa pembanding sangat tinggi (71% pada desa c3) dan yang terendah proporsi anemia ibu hamil adalah 46% pada desa c4). secara tidak diperkirakan proporsi anemia menurun semakin tua kehamilannya pada kelompok perlakuan dan kelompok pemba nd i ng. ba nya k ibu ha m il ya ng mengalami anemia pada kehamilan trimester satu (67% sampai 73%) dari pada ibu hamil di trimester dua dan tiga (52% to 58%). beberapa penelitian menunjukkan bahwa pada pengukuran haemoglobin turun semakin tua kehamilan trimester dua karena adalanya haemodilution (hadijono et al., 2010; rahardjo, 2000). bmi pada ibu hamil dikategorikan rendah, normal dan tinggi menurut pengukuran yang ditetapkan world health organization (who 1979; who 1994; u n-acc/scn 1997). secara keseluruhan ada 48% (101 dari 210) ibu hamil memiliki bmi rendah, 46% (97 dari 210) dari ibu hamil pada bmi yang normal dan 6% (12 dari 210) pada bmi tinggi. pada desa intervensi terlihat memiliki proporsi ibu hamil dengan bmi rendah yaitu 53% (64 dari121) dibandingkan desa pembanding yaitu 42% (37 dari 89). variasi proporsi ibu hamil dengan bmi yang rendah antara 35dan 66%, tetapi hanya dua desa di kelompok perlakuan yang mempunyai 50% ibu hamil dengan bmi rendah. kenaikan berat badan pada ibu hamil sudah ditetapkan sesuai dengan beberapa aturan yang ada (15). kenaikan berat badan di kategor i kan menjadi kenai kan berat badan jelek, normal dan tinggi, dan sesuai dengan usia kehamilan dan nilai bmi. secara keseluruhan, 68% ibu hamil (143 dari 210) mengalami kenaikan berat badan yang jelek, 26% ibu hamil mengalami kenaikan berat badan yang normal dan hanya 6% ibu hamil yang mengalami kenaikan berat badan yang tinggi menurut usia kehamilan dan bmi-nya. desa-desa di kelompok perlakuan memiliki proporsi yang besar pada kenaikan berat badan yang jelek 72% dibandingkan dengan kelompok desa pembanding 62%, tetapi perbedaannya tidak bermakna. range proporsi ibu hamil yang mengalami kenaikan berat badan yang jelek selama hamil bervariasi setiap desa antara 54%-77%. ku ra ng lebi h sat u t a hu n setela h i n t e r ve n s i , d a t a d a r i d e l a p a n d e s a dikumpulkan lagi dengan menggunakan metode yang sama pada data dasar di tahap satu sebelum intervensi. pada tahap tiga umumnya responden di kelompok perlakuan pada kehamilan trimester satu dan dua. ada perbedaan dengan tahap satu di mana diperoleh lebih banyak responden pada trimester tiga. tidak ada perbedaan dalam umur kehamilan responden pada tahap satu dan tahap tiga di desa pembanding. proporsi anemia di kelompok perlakuan ada 54% dan di kelompok desa pembanding ada 46% pada tahap tiga. proporsi anemia turun sedikit dari 60% di tahap satu menjadi 54% di tahap tiga pada kelompok desa perlakuan. pada kelompok desa pembanding proporsi anemia sebelum intervensi di kelompok desa perlakuan sebesar 64% dan 46% setelahnya. ibu hamil pada trimester satu turun proporsi anemia nya pada kedua kelompok. ibu hamil pada trimester satu hanya kontak sedikit dengan bidan tidak banyak ditemukan perbedaannya. keseluruhan pada kelompok desa pembanding memilki ibu hamil dengan anemia ringan baik pada tahap satu maupun tahap tiga. meskipun terjadi peningkatan yang tidak diperkirakan (64% sebelum dan 46% sesudah intervensi). variabel yang diukur lainnya yang mengidentifi kasikan status nutrisi ibu hamil adalah tingkat bmi. terdapat proporsi yang tinggi dari ibu hamil dengan bmi rendah (44% di kelompok desa pembanding dan 53% di kelompok desa perlakuan). proporsi ibu hamil dengan bmi rendah pada tahap satu dan tiga 6 jurnal ners vol. 10 no. 1 april 2015: 1–8 tidak berubah baik pada tahap satu maupun tahap tiga baik di kelompok desa perlakuan maupun pembanding. secara keseluruhan kedua kelompok desa perlakuan dan pembanding turun proporsi ibu hamil dengan kenaikan berat badan jelek. kelompok desa pembanding mempunyai proporsi ibu hamil dengan kenaikan berat badan yang rendah sedikit lebih rendah dari pada tahap satu dan tahap tiga. sedangkan pada kelompok desa perlakuan tetap memiliki proporsi yang tinggi pada ibu hamil dengan kenaikan berat badan yang jelek pada tahap tiga (60%). pembahasan hasil penelitian menunjukkan bahwa terjadi per ubahan sedikit dari proporsi anemia, kenaikan berat badan dan bmi baik di kelompok desa perlakuan dan kelompok desa pembanding. secara keseluruhan tidak ada perubahan proporsi bmi dari masing-masing kelompok pada tahap tiga. meskipun terjadi penurunan yang sedikit proporsi bmi yang jelek pada dua kelompok desa perlakuan, tetapi dampak dari penelitian pada status bmi dari ibu hamil di kelompok desa perlakuan tidak efektif. terdapat hal yang tidak diperkirakan yaitu waktu yang tidak cukup sejak intervensi dilakukan dan intensitas serta strategi yang digunakan tidak berpengaruh. faktor yang mempenga r u h i terha d ap bm i, se per t i status ekonomi, keamanan dan kemudahan memperoleh berbagai jenis makanan. dampak dari intervensi pada status nutrisi ibu hamil tidak efektif, hal ini disebabkan keterbatasan waktu dan logistik serta pendidikan dasar dari target group (abel et al., 2000; david, 2009). intervensi tidak dapat mempengaruhi kesehatan komunitas dalam jangka panjang di kelompok desa perlakuan. hal ini sesuai dengan pendapat tones (2010) yang berpegang pada indikator epidemiologikal (misalnya mortalitas dan morbiditas) sebaiknya tidak digunakan unt uk mengkaji dan menilai program promosi kesehatan (david, 2009; green & kreteur, 2005; hadijono et al., 2010; tones, 2010). pertimbangan dari waktu terjadi antara input dan output secara epidemiologi. secara terbalik dampak dari penelitian pada proporsi kenaikan berat badan sepertinya lebih efektif pada kelompok desa pembanding. pada tiga desa pembanding proporsi kenaikan berat badan yang jelek turun tanpa intervensi. k it a berasu msi ba hwa perhat ia n yang lebih dari petugas kesehatan yang ber pengetahuan pada pentingnya nutrisi mempengaruhi hasil ini. hal ini menjelaskan bahwa dengan kualitas pendidikan yang lebih baik dan praktik bidan di desa tersebut diingatkan akan pentingnya nutrisi bagi ibu hamil setelah selesai mengisi kuesioner. selanjut nya hal i ni membant u mereka m e n i ng k a t k a n p r a k t i k ny a . me s k ipu n demikian pengaruh sosial dan budaya serta kepercayaan dan kurang kuatnya posisi wanita di keluarga dalam mengontrol intake gizinya harus dipahami betul oleh petugas kesehatan dalam rangka meningkatkan pelayanannya di tempat praktik. hal dari hasil ini terlihat bahwa peningkatan kualitas dari komunikasi tentang nutrisi serta memberikan dorongan dan pengetahuan tentang suplemen tablet besi kepada ibu hamil akan membuat ibu mau minum suplemen tablet besi yang diberikan. di segi lain kemiskinan (tidak mampu membeli makanan) dan budaya (perbedaan gender dan status wanita di keluarga) akan menghambat akses ibu hamil untuk mendapatkan nutrisi yang baik. dampak dari isu ini tidak bisa terlepas dari kader dan bidan desa di mana karena tingkat pendidikan mereka rendah. pada kenyataannya mereka lebih berfokus pada perhatiannya pada pekerjaan rutin seharihari seperti memberi obat dan pelayanan lainnya, mereka merasa lebih kompeten d iba nd i ng k a n me mb e r i k a n p elaya n a n keperawatan/kebidanan. meskipun demikian sebaliknya terlihat hasil studi etnografi terdapat penemuan yang penting dengan terjadinya perubahan cara komunikasi dan pendekatan yang digunakan oleh bidan di desa dan kader setelah intervensi. bidan dilaporkan lebih baik dan kader berbicara lebih banyak tentang nutrisi pada pertemuan-pertemuan setelah intervensi. dengan mereka memahami dan bekerja dengan budaya akan meningkatkan perilakunya dan cara komunikasinya dalam praktik sehari-hari, kemungkinan untuk 7 peningkatan nutrisi ibu hamil di indonesia (setyowati) meningkatkan dan mempengaruhi perilaku pasien terhadap input nutrisi yang akhirnya meningkatkan status kesehatan pasien. namun pengar uh cara komunikasi di kelompok intervensi pada status nutrisi ibu hamil tidak berhasil efektif pad waktu yang pendek. penelitian ini juga mempunyai beberapa keterbatasan. meskipun sampel penelitian ini relatif kecil, peneliti telah mengembangkan kuesioner dengan nilai validasi dan reliabilitas yang minimum serta mengurangi bias. namun ada beberapa yang masih harus diperhatikan pada penelitian ini. desa pembanding masih terlalu dekat dengan desa perlakuan (5 km) dapat menghasilkan bias meskipun peneliti mencoba u nt u k memi n i malisi r dengan melakukan intervensi di desa yang jauh dan ter pencil dan tidak diketahui oleh bidan maupun kader di desa pembanding. namun karena peraturan pemerintah yang mewajibkan semua pemberi pelayanan kesehatan harus berkumpul satu kali sebulan maka hal ini dapat mempengaruhi hasil dengan kemungkinan adanya transfer pengetahuan dan pengalaman antar petugas di desa-desa tersebut. simpulan simpulan hasil penelitian menunjukkan bahwa tidak ada penurunan proporsi ibu hamil dengan anemia di kelompok desa perlakuan setelah intervensi. di kelompok desa pembanding justru presentasi ibu hamil dengan anemia turun dari 60% ke 46% persen meskipun tidak dilakukan intervensi. secara keseluruhan tidak ada perubahan dalam proporsi bmi pada semua kelompok di tahap tiga. dapat disimpulkan bahwa waktu pemberian intervensi tidak cukup untuk menur unkan proporsi bmi yang jelek. tidak terjadi penurunan proporsi kenaikan berat badan ibu hamil yang jelek pada kedua kelompok setelah intervensi. hal tersebut karena keterbatasan waktu dan logistik serta pendidikan dasar dari kelompok target. intervensi tidak mampu mempengaruhi kesehatan komunitas pada jangka panjang di kelompok intervensi. meskipun demikian penemuan yang berbeda terjadi pada studi etnografi , di mana poin yang penting adalah terjadinya perubahan cara komunikasi dan pendekatan yang digunakan bidan dan kader setelah intervensi. tabel 2. data status nutrisi responden di kelompok desa perlakuan dan desa pembanding (sebelum dan sesudah intervensi) di banten jawa barat variabel desa pembanding [freq (%)] desa perlakuan [freq (%)] anemia level: severe i [< 7 gm/l] moderate [7-10.9 gm/l] normal [> 11 gm/l] 2 (2) – 2 (2) 55 (62) – 39 (44) 32 (36) – 48 (54) 2 (2) – 2 (2) 70 (58) – 52 (52) 49 (41) – 46 (46) anemia* gestation: trimester 1 trimester 2 trimester 3 19/26 (73) – 10/27 (37) 19/34 (56) – 14/32 (44) 15/29 (52) – 17/30 (57) 20/30 (67) – 17/34 (50) 19/34 (56) – 25/43 (58) 33/57 (58) – 12/23 (52) bmi rate level: bmi rendah bmi normal bmi tinggi 37 (42) – 39 (44) 49 (55) – 47 (53) 3 (3) – 3 (3) 64 (53) – 53 (53) 48 (40) – 45 (45) 9 (7) – 2 (2) kenaikan berat badan jelek normal tinggi 55 (62) – 49 (55) 29 (33) – 27 (30) 5 (6) – 13 (15) 88 (73) – 60 (60) 25 (21) – 36 (36) 8 (7) – 4 (4) 8 jurnal ners vol. 10 no. 1 april 2015: 1–8 saran pengaruh cara komunikasi terhadap status nutrisi ibu hamil di kelompok intervensi tidak terlihat bila dilaksanakan dengan jangka pendek, direkomendasikan beberapa hal yaitu perlunya peningkatan pendidikan bidan di desa dan fokus pada ilmu kebidanan dan promosi kesehatan, dan perlu pemahaman budaya dan bekerja dalam budaya untuk meningkatkan stat us nutrisi ibu hamil di pedesaan di indonesia. kepustakaan abel, r., rajaratnam, j., kalaimani, a., kirubakaran,s., 2000. can iron status be improved in each of the three trimesters? a community based study. european journal of clinical nutrition, 54(6): 490–493. berman, p.a. 1984. village health workers in java, indonesia: coverage and equity. social science and medicine. 19(4): 411–422. david h. peters et al., 2009. improving health service delivery in developing countries: from evidence to action; washington dc. the world bank publication. green, l. and kreuter. m., 2005. health promotion planning: an educational and ecological approach (4th ed.). mo u nt a i n vie w, ca : m ay f ield publishers. hadijono, r., pramono, s., soeyono, a. 2010. kesehatan reproduksi di indonesia. semarang: department obstetri dan ginekologi, fak ultas kedok teran, universitas diponegoro. semarang indonesia. henderson, c., jones, k. 2005. essential midwifery. london: mosby company. departemen kesehatan republik indonesia. 2007. prof il kesehatan indonesia. jakarta: pusat data kesehatan dep, kes. ri. kodyat, b., kosen, s., de pee, s., 1998. iron defi ciency in indonesia: current situation and intervention. nutrition research; 18(12): 1953–1963. kosen, s., kodyat, b., muhilal., karyadi, d., gross, r., 1998. suggested actions for iron defi ciency control in indonesia. nursing research; 18(12): 165–197. tones, k., green, j. 2010, health promotion: planning and strategies, london: sage publications ltd. kementrian kesehatan republik indonesia. 2001. pedoman umum pengelolaan posyandu. jakarta, indonesia. rahardjo, p. 2000. indonesia: posyandu managerial support for grassroots community delivery, usaid, country health statistical profi le for indonesia sloan, n., jordan, e., winikoff, b., 2002. effects of iron supplementation on maternal haematological status in pregnancy. american journal of public health, 92(2): 288–292. stephansson, o., dickman, p., 2001. maternal weight, pregnancy, weight gain and the risk of antepartum stillbirth. american journal of obstetrics and gynaecology; 184 (3): 463–470. un-acc/scn. 1997. control and prevention of ida: current status of programs geneva.un-acc/scn. usa i nst it ute of med ici ne. ef fect of gestational weight gain on outcome in singleton pregnancy. nutrition during pregnancy. usa, national academies press; 176–435. who. 2000. protein and energy requirements: a joint fao/ w ho memorandum. bulletin of world health organization; 1979; 57(1): 65-79. who. 1994. indicators and strategies for iron defi ciency and anaemia programmes geneva, switzerland. who/unicef/ unu; 6–10. who. 2002. indonesia. making pregnancy safer in indonesia. who indonesia. 2009. country health system profi le. mother and child health.. http:// www.ino.searo.who.int/en/section3_ 158.htm diakses tanggal 23 desember 2010. 182 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17017 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review telerehabilitation system in nursing post stroke a systematic review dimas hadi prayoga, bernadetta germia aridamayanti, ida trisnawati and maria fransiska ronalia faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: stroke is currently the main cause of disability worldwide. telerehabilitation is a rehabilitation approach that can be used to repair the damage to motor, sensory and cognitive functions. this can also substantially reduce the travel time for the health workers and therefore increase the number of patients who are consulted in a day. method: a search using specific keywords was done in both the journal articles and in the database. in total, 119 articles were from scopus, 45 articles were from pubmed, 87 articles were from science direct, 52 articles were from ebsco and 97 articles were from proquest. result: there were 15 articles that matched the inclusion criteria. most of the available literature only refers to short-term results and most of the research is of low quality. evidence of the relative effectiveness was found in the types of videos, vr, cellphones and computer use. the location of the network support and technological progress are still obstacles that must be addressed immediately. based on the current scientific evidence, only a few telerehabilitation methods can be recommended for wider use. the rehabilitation to a safe and proper condition for the sufferers due to telerehabilitation can encourage the patients to stay in rehabilitation care at home so then the patients do not need to leave home to do the rehabilitation. this can cause long-term disruption. conclusion: the telerehabilitation system can provide long-term therapy, meet the patient needs and save the health resources needed to minimize the severity of the patients’ condition. the application of telerehabilitation is used by the nurses to optimize their role in improving patient health and telerehabilitation will answer the problem of penetrating the distance dimension. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords telerehabilitation system; nursing; post stroke; rehabilitation; long-term therapy contact dimas hadi prayoga  dimas.hadi.prayoga2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: prayoga, d. h, aridamayanti, b.g, trisnawati, i, & ronalia, m. f. (2019). telerehabilitation system in nursing post stroke a systematic review. jurnal ners, 14(3si), 182-187. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17017 introduction heart disease and cancer. every year, 15 million people worldwide suffer from a stroke. telerehabilitation is one of the most important factors that must be considered as an effort to achieve the goals tailored to the needs of the patients (dasilva et al., 2018). the impact that can occur in poststroke patients include damage to their motor function (joint contractures, the subluxation of the shoulder joint, syndrome shoulder and the dropping of the leg), in addition to their sensory and cognitive function [10]. another impact that also occurs in poststroke patients is aphasia (da-silva et al., 2018). the merger between the use of technology and remote communication is appropriate to change conventional rehabilitation into more modern rehabilitation. rehabilitation alternatives using telerehabilitation enable the stroke survivors to undergo physical therapy exercises without being accompanied by a therapist as they under their guidance remotely through a consultant. as a result, telerehabilitation can encourage the patients to stick with the treatment rehabilitation and it can help them to improve the recovery of their physical function due https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 183 to the stroke having resulted in a long-term disorder that can interfere with the patient’s daily activities (yamamoto, 2017). the telerehabilitation program (tr) was carried out to improve the patient’s daily life activities and to minimize the dependence of the stroke patients. telerehabilitation provides a strategy for the rehabilitation, evaluation and supporting strategies that improve the patient’s capacity from other parties. telerehabilitation shows evidence of the satisfaction and acceptance of the patients, their families and health workers (sarfo et al., 2018). telerehabilitation is a rehabilitation service for patients using information and communication technology that can be carried out by the patients from afar, this can substantially reduce the travel time for the health workers and therefore increase the number of patients who they can consult in a day (da-silva et al, 2018). the use of information technology in rehabilitation care can help the patients with their needs and allow them to provide care for their own patients (sarfo et al., 2018). materials and methods the search strategy relevant to the topic of the study was done using a database search. the databases used were scopus, pubmed, science direct, ebsco and pro quest. the keywords used were "stroke", "telerehabilitation", "telemedicine" and "online counseling". full text articles and abstracts were reviewed to choose a theme that fits the criteria. the articles or journals used a randomized controlled trial. the minimum intervention duration was one month. the journal articles were published between january 2015 and september 2018. the language of the journals was english. selection criteria the pico framework (population, intervention, control, outcome) was designed and its elements were used as the selection criteria. articles were deemed potentially eligible if they met all of the criteria. the respondents in this study were diagnosed post-stroke as being either ischemic or hemorrhagic for <24 months with deficits in their motor, sensory, cognitive and function. the interventions related to the criteria for inclusion in the literature review were that they were telerehabilitation (video, virtual reality, robotics, sms, mobile phones, computers and video games). 2.2 selection method we examine each independently titles and abstracts of potentially eligible reports using endnote. a total of 400 articles found, came from five databases: 119 articles in scopus, 45 articles in pubmed, 87 article in science direct, 52 articles in the ebsco, 97 articles in proquest. the results of the selection were in accordance with the inclusion criteria. in total, 15 articles were found and then they were given a serial number. then the articles were analyzed. there are seven media types used in telerehabilitation, namely video, virtual reality, robotics, sms, phones, computers and video games. all of the research articles were prepared and used a randomized controlled trial (rct). data extraction in this systematic review, the studies eligible for inclusion were if they tested telerehabilitation for the recovery of motor function (measured by means of different scale) in patients affected by any kind of disturbance or disease. the data extraction and management were recorded in a predesigned form with the details of the study as follows; the details of the citations that include the title, author and year of publication, the participants who met the inclusion and exclusion criteria that had been set, the participant characteristics including age, gender, the location of the stroke, time since stroke onset and their level of disability, the quality of the methodology and the telerehabilitation intervention including a description of the action procedures, the medical personnel involved, the duration of the intervention, the dose and the comparison intervention. the results of the interventions included the measures that were used and by whom, when they were given and how they were provided (directly or through information and communication technology). data collection and analysis we filter out the article title and abstract of notes taken from the search strategy and selection criteria applying predetermined. the full text of the notes that may qualify were taken and analyzed for inclusion in this systematic review. any disagreements can be resolved through discussion. we will extract the data from the studies and incorporate them into a d. h. prayoga, et al. 184 | pissn: 1858-3598  eissn: 2502-5791 summary table. the experimental intervention and control participants have been reported in detail. quality assessment the quality assessment study focused on areas that may overestimate the effectiveness of telerehabilitation. the quality of the randomized controlled trials varies. unclear randomization procedures might raise questions about a potential selection bias. it provides a greater transparency than the previous approach. there is a constant uncertainty and large variations in practice, about how to assess potential biases in this particular domain of experimentation, including how to summarize biased assessments across the domains and how to incorporate biased assessments into the meta-analysis processing. the reliability of the tool has not been studied extensively, although it has been observed that there is a greater risk of bias compared to a low risk bias study. studies selection the search through the database found 400 articles from the five databases: 119 articles in scopus, 45 articles in pubmed, 87 articles in science direct, 52 articles in the ebsco and 97 articles in proquest. moreover, the information was also added through the records identified through other sources. in the filtering stage, there was the removal of the duplicate articles totaling 124 articles. the text displayed in accordance with the searched keywords totaled 98 articles. then the researcher proceeded to determine the full text and they assessed the results for eligibility, totaling 63 articles. the results of the selection in accordance with the inclusion criteria resulted in 15 articles, which were then given a serial number. there were seven media forms used in telerehabilitation, namely video, virtual reality, robotics, sms, phones, computers and video games. all of the research articles used randomized controlled trials (rcts). result characteristics of the included studies the total respondents in this review were 1,432 people with post-stroke complications that were either ischemic or hemorrhagic suchas hemiplagia, hemiparesis, cognitive barriers, aphasia and depression. several studies have been conducted to identify telerehabilitation as one of the best interventions based on high technology. examples include the use of telemedia video, virtual reality, robotics, sms, mobile phone, computers and video games or any combination thereof. this systematic review will compare each intervention used. telerehabilitation post-stroke patients telerehabilitation refers to the delivery of rehabilitation services through information and communication technologies. clinically, this term covers a wide range of rehabilitation and telerehabilitation services that include assessment, monitoring, prevention, intervention, supervision, education, consultation and counseling. the telerehabilitation services provided to adults and children by various professionals may include but are not limited to physical therapists, speech-language pathologists, occupational therapists, audiologists, rehabilitation physicians and nurses, rehabilitation engineers, technology assistants, teachers, psychologists and dieticians. the other personnel such as the professionals, family members and caregivers can help during the telerehabilitation sessions. for the purpose of this document, the term 'professional' will be used to refer to the telerehabilitation professional service providers. the term 'client' is used to refer to all recipients of the telerehabilitation services and it is meant to include both the patients in medical settings, and the children and adults who receive the services outside of the medical sphere, for example, in school or at home(caves et al., 2015). telerehabilitation has the capacity to provide services throughout the patient’s lifetime and in all care settings. the point of service may include health care settings, clinics, home, school, workplace or it may be community-based. the terminology used to describe telerehabilitation is also coextensive. some of the terms are used specifically to refer to individual rehabilitation disciplines, such as telespeech (speech language pathology) and tele ot (occupational therapy). more general terms, such as teletherapy and telepractice are also used, allowing for a broader focus on populations and activities, such as setting up education and health promotion in addition to rehabilitation. it is not the intention of this document to resolve a debate about terminology. rather, its purpose is to provide consistency across the applications, regardless of the vocabulary used. for the purpose of this document, the term 'telerehabilitation' will be used and the reader is reminded that the terminology may vary according to the application and location(linder et al., 2015). the total respondents in this review consisted of 1,432 people with post-stroke complications such as eitherischemia or that were hemorrhagic like hemiplagia, hemiparesis, cognitive barriers, aphasia and depression. the necessary interventions are continuous effective to alleviate the workload of health workers. several studies have been conducted to identify telerehabilitation as one of the best interventions based on high technology. examples include the use of telemedia videos, virtual reality, robotics, sms, mobile phones, computers and video games or any combination thereof. this systematic review will discuss the comparison of each intervention telemedia used(da-silva, moore, & price, 2018). video from the 15 articles, there were 4 articles that used sms reminders as their intervention of choice. speech therapy intervention through video is more effective at improving the process of speech and the jurnal ners http://e-journal.unair.ac.id/jners | 185 pronunciation of words in post-stroke patients with aphasia (øra et al., 2018), a similar study also explained that with the help of telerehabilitation using video, not only the patients themselves but also their families and caregivers can facilitate effective communication. video can also better the adherence to exercise and it can allow for the remote control of the therapist(caves et al., 2015). virtual reality modality therapy with motor rehabilitation encourages the participation and motivation of patients with upper limb weakness in the virtual reality (e.-k. kim et al., 2014)(j. kim et al., 2016) using vr as an intervention for patients with upper extremity hemiparesis. the patients were trained in the supination and pronation of the forearm, extension and flexion of the elbow and shoulder, abduction and adduction, internal rotation and ekstrenal shoulder using the application of "guru virtual" and by giving visual feedback both positive and negative. this provides online information about the quality and performance of the patient's motor skills. a similar study using vr recording through the jintronix system was used to monitor the progress of the patient’s exercise (hernandez et al., 2015). robot this intervention was carried out by linder m. et al. and fuentes et al. it used hmp (hand mentor pro) using a pneumatic pump to facilitate the active assisted movement of the wrist and fingers. each participant using the robot’s movements will have their results recorded into a computer. telerehabilitation with robotics is a good intervention and it has become a practical approach to provide post-stroke care with limited resources. however, the results of chen et al’s study explain that the home-based rehabilitation telesupervising is as effective as conventional outpatient rehabilitation at improving the functional recovery of stroke patients. it can ease the burden of the families and caregivers of patients during the treatment(jin et al., 2015; linder et al., 2015). sms, mobile phone and computer some interventions combine telemedia, which is smsmobile and mobile-computers. sarfo et al. used an intervention device ua-767 plus bluetooth and smartphones to monitor and report the measurement of blood pressure and the patient’s compliance with medication schedules. the patient takes the medication for 3 months and then gives feedback. other interventions include a mobile-based computer-aided prevention system (capsys) control used to monitor blood pressure and the risk of stroke in patients. the system uses text to speech software (tts) in capsys to read the blood pressure and to provide direct feedback. the system lifestyle in the form of computerized telephone-based coaching can support the usual treatment in reducing the risk factors of cerebro-cardiovascular damage (sarfo et al., 2018; spassova, vittore, droste, & rösch, 2016). video game motor interventions, such as constraint-induced movement therapy (ci therapy)=based video game outpatient rehabilitation for stroke (vigorous), increase the intensity of training and the techniques to carry-over post-stroke patients and to improve their brain repair. however, this approach is less intense and less effective if used as a clinical treatment. in addition, many barriers to access to care are due to differences in the cognitive differences of each patient when getting the intervention (gauthier et al., 2017). discussion the results of this systematic review and analysis show that the use of telerehabilitation has a significant influence on the process of long-term care in stroke patients. in practice, the treatment of stroke patients in the outpatient unit is very difficult to facilitate especially for people who live in areas that are far outside of urban areas. the existence of the current inpatient rehabilitation and outpatient care should be sustainable. many forms telerehabilitation as a form of post-stroke intervention may show promising results (van de ven, schmand, groet, veltman, & murre, 2015). by using the telerehabilitation system, it is possible to provide rehabilitation services at the patient's home or in the form of community-based technology, allowing the healthcare professionals to monitor a patient's health status and to identify the conditions that require improvement before ill effects occur (j. kim et al., 2016; van de ven et al., 2015). telerehabilitation involves the provision of rehabilitation through information and communication technologies. thus it involves the role of nurses as educators, collaborators and consultants to provide nursing care through high-tech intervention requires interdisciplinary collaboration between different health professionals. on the other hand, it is easy for the nurses do a "home care" visit albeit with limited resources. from the review of the articles as done by some of the researchers, there are several drawbacks that may occur in the application of telerehabilitation in patients post-stroke. telerehabilitation enables for remote communication and the use of tools. the use of technology in telerehabilitation can be applied to countries that are still experiencing keterbelakangaan . however, some of them still lack the support of the internet and a good signal for accessing the telerehabilitation itself. the level of a country's economy is also very influential in the implementation of the technology-based rehabilitation model. prolonged use will also impose a small cost, so individual economic factors also become an obstacle to implementing the rehabilitation using telerehabilitation. studies have d. h. prayoga, et al. 186 | pissn: 1858-3598  eissn: 2502-5791 been done that indicate that there are limitations related to the lack of knowledge of the use of tools used by the post-stroke patients in the rehabilitation process, hence this can affect the outcome and use of telerehabilitation in post-stroke patients. for further research, it is advised to provide complete information on how to use the rehabilitation equipment for both medical personnel and the patients so as to not cause bias in the research. conclusion this systematic review does not provide final evidence about the efficacy of telerehabilitation in the recovery of the patient's motor function. the rehabilitation in this systematic review refers to the form of the clinical application of therapeutic services including counseling, prevention and diagnostics through two-way interactive telecommunications technology. this intervention provides an alternative to routine outpatient rehabilitation services such as post-stroke patients with motor, sensory and psychiatric barriers in the form of video, virtual reality, robotics, sms, telephone, computers and video games. this intervention is also an alternative to the rehabilitation method of "home care", which requires a therapist, nurse or doctor who needs to make a trip to the patient's home. the rehabilitation of a safe and appropriate condition for the patients due to telerehabilitation can encourage the patients to stay on the course of rehabilitation care at their home. this means that the patients do not need to leave home to do the rehabilitation which can cause long-term disruption. however, the application of telerehabilitation must consider increasing the workload of the nurses in each country's national health system. in addition, there needs to be support from all parties in the development of innovative internet-based rehabilitation service infrastructure, trial use and an analysis of the cost-effectiveness is also needed. references caves, k., png, c., tay, a., kumar, y., koh, y. s., chen, c., … hoenig, h. (2015). singapore tele-technology aided rehabilitation in stroke (stars) trial: protocol of a randomized clinical trial on telerehabilitation for stroke patients. bmc neurology, 15(1), 1–14. https://doi.org/10.1186/s12883015-0420-3 da-silva, r. h., moore, s. a., & price, c. i. (2018). selfdirected therapy programmes for arm rehabilitation after stroke: a systematic review. clinical rehabilitation, 32(8), 1022–1036. https://doi.org/10.1177/0269215518775170 gauthier, l. v., kane, c., borstad, a., strahl, n., uswatte, g., taub, e., … mark, v. (2017). video game rehabilitation for outpatient stroke (vigorous): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis. bmc neurology, 17(1), 1–18. https://doi.org/10.1186/s12883-017-0888-0 hernandez, a., kaizer, f., raz, a., kairy, d., veras, m., archambault, p., … levin, m. f. (2015). maximizing post-stroke upper limb rehabilitation using a novel telerehabilitation interactive virtual reality system in the patient’s home: study protocol of a randomized clinical trial. contemporary clinical trials, 47, 49–53. https://doi.org/10.1016/j.cct.2015.12.006 jin, w., chen, j., shi, f., yang, w., zhang, y., liu, y., … ren, c. (2015). home-based tele-supervising rehabilitation for brain infarction patients (htrbip): study protocol for a randomized controlled trial. trials, 16(1), 1–8. https://doi.org/10.1186/s13063-015-0585-5 kim, e.-k., jang, s.-h., choi, y.-h., lee, k.-s., kim, y.-j., kim, s.-h., & lee, h.-k. (2014). effect of an oral hygienic care program for stroke patients in the intensive care unit. yonsei medical journal, 55(1), 240. https://doi.org/10.3349/ymj.2014.55.1.240 kim, j., pyun, s.-b., eun, s.-d., yoon, b., lee, m., & son, j. (2016). comparison of individualized virtual realityand group-based rehabilitation in older adults with chronic stroke in community settings: a pilot randomized controlled trial. european journal of integrative medicine, 8(5), 738–746. https://doi.org/10.1016/j.eujim.2016.08.166 linder, s. m., rosenfeldt, a. b., bay, r. c., sahu, k., wolf, s. l., & alberts, j. l. (2015). improving quality of life and depression after stroke through telerehabilitation. american journal of occupational therapy, 69(2), 1–11. https://doi.org/10.5014/ajot.2015.014498 øra, h. p., kirmess, m., brady, m. c., winsnes, i. e., hansen, s. m., & becker, f. (2018). telerehabilitation for aphasia protocol of a pragmatic, exploratory, pilot randomized controlled trial. trials, 19(1), 1–10. https://doi.org/10.1186/s13063-018-2588-5 sarfo, f., treiber, f., gebregziabher, m., adamu, s., patel, s., nichols, m., … ovbiagele, b. (2018). pings (phone-based intervention under nurse guidance after stroke) interim results of a pilot randomized controlled trial. stroke, 49(1), 236–239. https://doi.org/10.1161/strokeaha.117.0195 91 spassova, l., vittore, d., droste, d. w., & rösch, n. (2016). randomised controlled trial to evaluate the efficacy and usability of a computerised phone-based lifestyle coaching system for primary and secondary prevention of stroke. bmc neurology, 16(1), 1–9. https://doi.org/10.1186/s12883-016-0540-4 van de ven, r. m., schmand, b., groet, e., veltman, d. j., & murre, j. m. j. (2015). the effect of computerbased cognitive flexibility training on recovery of executive function after stroke: rationale, design and methods of the tapass study. bmc neurology, 15(1), 1–12. https://doi.org/10.1186/s12883015-0397-y jurnal ners http://e-journal.unair.ac.id/jners | 187 yamamoto, y. (2017). health informatics. https://doi.org/10.1177/1460458212462077 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 ners vol 10 no 2 okt 2015.indd 289 kepatuhan pasien tb paru berdasarkan teori sistem interaksi king (adherence in pulmonary tuberculosis patients based on king’s interacting systems theory) tintin sukartini*, ratna sitorus**, agung waluyo*, ede surya darmawan*** *faculty of nursing universitas airlangga **faculty of nursing university of indonesia *** faculty of public health university of indonesia email: tintin_bios@yahoo.com abstrak pendahuluan: indonesia merupakan salah satu negara penyumbang kasus tb terbesar di dunia. salah satu penyebab tingginya kasus tb paru di indonesia adalah ketidakpatuhan pasien tb paru dalam pengobatan. berdasarkan hal tersebut, maka perlu dikembangkan suatu model untuk meningkatkan kepatuhan pasien tb paru dalam pengobatannya. langkah awal yang diperlukan adalah menggali kepatuhan pasien berdasarkan teori sistem interaksi king. penelitian ini bertujuan untuk menggali pengalaman pasien yang menyebabkan mereka tidak mematuhi program pengobatan berdasarkan teori sistem interaksi king. metodologi: penelitian ini merupakan penelitian kualitatif dengan pendekatan deskriptifeksploratif. sampel diambil melalui metode purposive sampling. partisipan yang terlibat dalam penelitian sebanyak 8 orang yang telah memenuhi kriteria inklusi penelitian. partisipan yang terlibat adalah pasien tb paru yang telah menjalani pengobatan selama 5–6 bulan. hasil: penelitian ini menghasilkan 12 tema tentang kepatuhan pasien tb paru, antara lain: (1) persepsi yang positif atau benar tentang tb paru; (2) kesadaran diri; (3) pertumbuhan dan perkembangan yang optimal; (4) gambaran diri yang positif; (5) lingkungan yang sehat; (6) meminum obat dengan disiplin; (7) koping yang efekktif; (8) komunikasi yang terbuka dengan tenaga kesehatan dan keluarga; (9) berperan secara optimal; (10) menyeimbangkan stres selama sakit; (11) mengetahui birokrasi pelayanan kesehatan; (12) mampu mengambil keputusan. diskusi: 12 tema di atas menjelaskan bahwa kepatuhan pasien melibatkan interaksi beberapa sistem, yaitu sistem personal, sistem interpersonal, dan sistem sosial. kata kunci: kepatuhan, tuberkulosis paru, teori sistem interaksi king abstract introduction: indonesia is one of largest contributor countries to pulmonary tb cases in the world. one of the factors that cause it is no adherence in the treatment. it is necessary to develop a model in order to improving compliance in patient. for an initial step, it is necessary to explore patient’s adherence that based on king’s interacting systems theory. the objective of this study was to explore the patients experience that cause them obedient the treatment based on king’s interacting systems theory. methods: this research was a qualitative research with descriptive explorative approach. the samples were selected through purposive sampling method. participants in this study were 8 patients who met the inclusion criteria. in this study, participants were pulmonary tb patients who have undergone treatment for 5–6 months. results: there were 12 themes in patients compliance based on king’s interacting systems theory; (1) true perception of pulmonary tuberculosis, (2) self-awareness, (3) optimal growth and development, (4) positive self-image, (5) a healthy environment, (6) discipline to take medication, (7) effective coping, (8) open communication with the patient’s health workers and family, (9) to perform its role optimally, (10) balancing stress during illness, (11) knowing the health care bureaucracy and (12) able to take decisions. discussions: the 12 themes describe that adherent patients have interaction systems that were personal systems, interpersonal systems and social systems. keywords: compliance, pulmonary tuberculosis, king’s interacting systems theory introduction in done sia i s the fo u r th la rge st contributor to tuberculosis (tb) in the world in 2012, the number of new cases of approximately 400,000–500,000 cases, after india (2.0 million-2.5 million), china (900,000– 1100,000) and south africa (400,000 – 600,000) cases. in many studies of pulmonary tuberculosis obtained results indicate that patients are disobediently in treatment. the studies was conducted at polyclinic of ahmad muchtar hospital bukit tinggi showed that noncompliance patients in treatment were 31% while the study by aisha (2003) in health 290 jurnal ners vol. 10 no. 2 oktober 2015: 289–295 care center jatinegara indicated that noncompliance patients in treatment were 26.1%. from the above results it can be concluded that non-compliance in the treatment of patients still high. king’s interacting systems model is used to improve the interaction of nurses and patients to improve medication adherence to achieve a good recovery. as a first step needs to be done research to explore the patient’s compliance based on king’s interacting systems theory. king’s interacting systems is a dynamic system that consists of personal, interpersonal and social systems. personal systems according to king describe the individual characteristics and the individual is seen as an open system[4]. interpersonal system describes the interaction of two or more like the relationship between patient and nurses. social systems are the interaction that describes the broader of interpersonal relationship such as the relationship between patient and nurse with the family or community. king saw man as a personal system that consists of the concept of perception, self, growth and development, self-image, learning, time, space and coping. interpersonal system is formed when two or more individuals in interaction, two (dyad) or three people (triads). to understanding the interpersonal systems, it is required knowledge about communication, interaction, roles, stress, stressors and transactions. materials and methods this study was a qualitative research phenomenology. phenomenological method focus on fact-finding on a social phenomenon and trying to understand human behavior based on the perspective of the participants[5]. phenomenological method chosen for this study was to explore the experience of patients that compliance in carrying out the treatment of pulmonary tuberculosis. the samples were selected through purposive sampling method. participants in this study were 8 patients who met the inclusion criteria. in this study, participants were pulmonar y tb patients who have undergone treatment for 5–6 months. research has obtained ethical approval from the ethics committee of the faculty of nursing, university of indonesia and the ethics committee of haji general hospital surabaya. results theme 1: positive or true perception of pulmonary tuberculosis po s i t i v e p e r c e p t i o n t h e m e s o f pulmonary tuberculosis identified through pulmonary tuberculosis treatment, infection prevention and proper nutrition to support healing. subtheme pulmonary tb treatment consists of a category of causes of pulmonary tuberculosis, duration of treatment, how to take the medication, side effects of medication and cured if the doctor who said recovered. subtheme prevention of transmission identified through coughing and sneezing category means and how to dispose of sputum. subtheme right nutrients to support recovery were identified through food categories that help healing and foods were prohibited. subtheme treatment of pulmonar y tuberculosis in the categor y of causes supported by the statement: “yes, the disease because germs...” (p2) “because germs...” (p3) “bacterial cause, should maintain a healthy”, (p7) category duration of treatment was supported by the statement: “6 months to 9 months” (p1) “yes it is 6 to 9 months” (p5) “... treatment should be routinely 6 to 9 months” (p8) categories how to take medicine supported by the statement: “once directly 3 tablets” (p2) “3 tablets once a drink” (p4) categories of adverse effects of drugs supported by the statement: “... i forgot to explain, if not one of nausea, vomiting and skin redness, if i do not feel anything” (p1) “....i do not feel anything, normal body even more preferably” (p6) 291 kepatuhan pasien tb paru berdasarkan teori (tintin sukartini, dkk.) categories cured if the doctor who declared cured supported by the statement: “... reminded cured if the doctor says it should not by themselves or others.” (p2) “.... recover it must be said the doctor....” (p4) subtheme prevention of transmission in the category of waste phlegm by coughing and supported by the statement: “... communication with masks, cough must be closed, the exhaust phlegm not inept” (p1) “...coughing and sneezing should be closed, sputum discharged into drains “(p2) “yes, if talking with distance 1.5 meters...” (p5) “if coughing and sneezing must close the mouth, sputum discharged into waterways” (p6) theme 2: self-awareness the theme of self-awareness through the categories identified sure pulmonary tb was curable and routinely treatment despite having to come alone. category sure to recover supported by the statement: “yes because i have no desire to heal, because there are ideals which have not been achieved” (p2) “it must be recovered, so the future is easier” (p3) “yes, i want to recover, where people who do not want to heal anyway, own consciousness” (p7) “.... the desire to heal, maybe not like this again in the future” (p8) categories come alone to the hospital: “yes by myself” (p3) “the fi rst three months of hell had escorted by father, now i already came alone, the father was ordered to work”. (p8) theme 3: optimal growth and development themes optimal growth and development was divided into two sub-themes; sub-theme of hope that a better future and subtheme able to perform tasks in an optimal development. subtheme hope of a better future was supported by the statement: “... there are ideals which have not been achieved” (p2) “.... i still have a long future” (p3) “... yes, i still want to have children” (p4) subtheme able to carry out the task of development was supported by the statement: “... beside go to the school i play football” (p3) “.... yes as usual at home taking care of her husband, follow recitation” (p4) theme 4: positive body-image theme was capable of receiving a positive body-image changes divided into categories: not ashamed to wear a mask and not ashamed to lose weight. encouraged by the statement: “no, i never feel shame, i never give up, i am confi dent” (p2) “no, it is common, there is tolerance” (p3) “i ever shame, but from it i want to recover...” (p8) theme 5: a healthy environment themes healthy environment consist of pulmonary poly with comfortable environment and a healthy home environment. s u b th e m e p u l m o n a r y p ol y w ith comfortable environment supported by the statement; “.... quite spacious and comfortable” (p3) “.... so good, the space was in the corner near the bathroom, if i want to dispose of sputum stay straight to the bathroom” (p5) subtheme healthy home environment was supported by the statement: “... i still rent a one room, every morning the sunlight entered into the room anyway, from backyard also entered” (p2) “…the nurse told to make glass tile, fi nally my husband make the glass tile” (p4) “...the sunlight coming through the window” (p5) theme 6: discipline taking medication themes discipline to take medication consisted of categories of time to take medication 1 hour before meals and use an alarm as a reminder. categories t ime tak ing medicine supported by the statement: 292 jurnal ners vol. 10 no. 2 oktober 2015: 289–295 “taking medication should be routine, drinking at 6 pm 1 hour before meals” (p1) “.... 6 pm after sunset” (p2) “6 o’clock in the afternoon” (p3) categories using the alarm as a reminder supported by the statement: “... i use the alarm…” (p2) “the alarm use hp” (p3) “my concept in alarm” (p8) theme 7: effective coping effective coping themes for treatment of pulmonary tuberculosis consists of a subtheme accept the conditions experienced and positive thinking. s ubtheme accepts the conditions e x p e r i e n c e d w e r e s u p p o r t e d b y t h e statement: “yes, i pray a lot... what can we do, it is given problem, i must be patient, must be closer to god, sometimes i fell bored to taking medication but the recovery would be, to be sincere, ask to the god to healed quickly and given patience”(p1) “must to be patient and sincere, it should be routine. given sick from god, have to patient”(p2) subtheme positive thinking is supported by the statement: “no, i consider this is just life problem” (p3) “....insyaallah, i can heal if i routine do the treatment” (p4) theme 8: open communication patient with the health workers and family the theme was open communication between patient and health workers and family, it was identif ied through open communication patients with health workers and sub-themes of open communication with the patient’s family subtheme open communication between patient and health workers supported by the statement: “…yes, it is fl uent. nurse often given notice the schedule of treatment, drink the medicine should be routine, a little to eat but often so that add its weight” (p1) “…everything is good, if there is trouble the nurse aided and described” (p3) “... if i not understand, i can ask” (p6) “... yes, doctors usually give out”, nurse does certainly give out, if all for our goodness, so we just according to” (p7) subtheme open communication between patient and family was supported by the statement: “yes, i must to pray, there is the wisdom of life, during the treatment i should be patient” (p1) “father and mother are working, they remind for treatment” (p3) “... yes, it is common, given the sick must be patient and do the treatment” (p4) “my wife said, ” for the future, be careful, keep the condition” (p5) “every day come to the home back, the home adjacent” (p6) theme 9: running role optimally theme running role during illness was divided into sub-themes perform daily work and activities in the community. subthemes perform daily work with the category of school, working as usual and do homework that was supported by the statement: “yes may permit” (p2) “yes, in school may permit” (p3) “... after the sick, i sell at home and take care of the mosque” (p6) “i be off sick one month but is considered on leave, now i am working again” (p8) subtheme conducts activities in the community were supported by the statement: “...when my body feels healthy, i attended recitation at the mosque again” (p1) “...join recitation, participated in neighborhoods gathering” (p4) theme 10: balancing stress during illness theme balancing the stress experienced during the illness was divided into three subthemes; the stress experienced by the weight loss category, saturated and unsaturated take medicine back and forth to the hospital, cause of stress by long treatment time and handling stress by recreation, discuss with their family and discuss with fellow patients. subtheme stress experienced was supported by the statement: 293 kepatuhan pasien tb paru berdasarkan teori (tintin sukartini, dkk.) “....yes, sometimes feel bored go to hospital” (p2) “…saturated taking medication but i would recover, so be patient” (p5) “... the beginning of stress due to weight loss, but it spurred me to get well soon so i’m not skinny anymore” (p8) s ubthe me st re ssors with a long treatment time category were supported by the statement: “...because the treatment so long…so long take medicine but i must be patient” (p6) “…the treatment so long and must go back and forth to hospital” (p8) subtheme stress management was supported by the statement: “... yes, i considered it be recreational” (p2) “....saturated but it must be sincere, i want to recover” (p6), “... saturated reasonable anyway, but it’s okay, too ordinary for long” (p8) theme 11: knowing the health care bureaucracy themes determine the health care bureaucracy consists of subtheme knowing pulmonary polyclinic service organizations, know the authorities in pulmonary polyclinic and aware of their status as a patient in pulmonar y polyclinic. subtheme k nows polyclinic service organizations consist of categories: hospital-owned facilities, human resources and hospital admissions in poly groove, it was supported by the statement: “.... he said the doctor is kind, facility anywhere near any place so back and turning fast and not hard “(p2) “.... my son said facility here more complete than in health centers....”. (p6) “if treated here early days are still confused, but soon can memorized the rules here” subtheme knowing authority consisting of pulmonary poly administration of dot appropriate category of government programs supported by the statement: “from the beginning has been explained if sick lungs as i entered the government program and will be monitored continuously”. (p2) “... the beginning the sick is recorded by nurse that it is incoming government programs, supervised continuously, if not back to the hospital to be sought” (p6) “... drugs are expensive but given free so must be willing to seek treatment” (p7) subthemes aware of the status of hospitalized patients with category abide by the rules of the hospital were supported by the statement: “…the treatment follows the schedule, tuesday and wednesday” (p1) “.... if treatment every tuesday-wednesday”, “if go out of town, the nurse said i should come before the time control on the tuesday or wednesday” (p2) “if suddenly i can’t come, the family may come to consult a doctor and take medication, but do not be too often” (p7) theme 12: able to make decisions themes able to take a decision consist of categories: treatment in pulmonary poly and categories referred to else, it was supported by the statement: “... it is my intention from the beginning of treatment in hospital” (p3) “... first i want to move the clinic, but the nurse said if treatment here would move must wait 2 months before the new allowed, fi nally i feel good here so i do not be moved”. (p4) discussion according to the results there were 12 themes of patient compliance based on king’s interacting systems theory. adherent patients were patients who 1) have a true perception of pulmonary tuberculosis; 2) have selfawareness to heal; 3) have optimal growth and development; 4) have a positive self-image; 5) have a healthy environment; 6) discipline to take medication; 7) have effective coping; 8) have open communication with families and health workers; 9) able to perform the role optimally; 10) able to balance the stress; 11) determine the health care bureaucracy and 12) were able to take a decision. perception of pulmonary tb patients is inf luenced by the level of education and information received during the patient’s treatment. the results showed that the majority 294 jurnal ners vol. 10 no. 2 oktober 2015: 289–295 of patients had a high school education so easy to receive information delivered by nurses. some participants perceive that pulmonary tb disease is caused by bacteria, can be contagious and can be cured if treated daily for 6-9 months. overall participants said that they seek treatment because they want to recover and sure can recover if treated with routine. it is proved that the participants have the knowledge and self-awareness or confidence to recover. this is consistent with research from chani (2010) who explains that the lack of knowledge will improve of non-compliance the treatment in patients with pulmonary tuberculosis, increase self-efficacy will increase the motivation of pulmonary tb patients to adhere to treatment. environmental conditions of the house owned by the participants support the healing process of patients and prevent transmission to others. this is supported by research fatimah (2008) that there is a relationship incidence of pulmonary tuberculosis with lighting, ventilation, where the window is opened, humidity, temperature and type of wall[7]. one of the things that make compliance patient is a participant in this research discipline in taking medication and always uses an alarm as a reminder to take medication. this is consistent with research lukito (2012) who explains that the required solution as a reminder not to forget because it felt well enough, get busy or lazy. solutions offered lukito is android smartphone as a reminder. some participants said that sometimes feel bored attended the treatment because they have often alternating to hospital but because of a desire to recover, they still undergoing treatment. coping does is to closer to god, more patient, sincere and steadfast undergoing trials given. with this their attitude may be more accepting of pain conditions and in the end have a high motivation for routine treatments. this is consistent with research namawejje (2011) who explains that the treatment without stress would be more effective. the provision of health education is done to reduce the level of stress that affects the patient’s recovery. health education should be emphasized because it enhances the effects of the individual in treatment adherence. in line with the research muttaqqin (2009) who explains that the coping mechanisms used in the pulmonary tb patients underwent 6 months of treatment in the form of a religious approach, confide and discussion. open communication bet ween the patient and the family or health worker is an important factor in patient compliance. participants more freely and quietly in asking or being with a nurse so that more discipline and obedient treatment because of the good service of nurses. this is in line with research nepal, et al (2012) who explains that communication skills training for health care providers can improve patient compliance with treatment. in addition to the above factors whole adherent participants have optimal growth and development and the roles for pain such as school, work or take care of the household. participants were not ashamed even lost weight and had to wear a mask when communicating with others. participants also learned about the obedient bureaucracy hospital services so that no diff iculty during treatment in pulmonary poly and patients were able to take a decision to carry out the treatment in the hospital with the consideration that the health workers in hospitals expert in his field and a short distance from the residence. this is in line with research naing et al (2001) that the distances from the facility can cause nonadherent patient treatment. conclusion and recommendation conclusion there were 12 themes in compliance in pulmonary tuberculosis patient based on king’s interacting systems theory. it can be described that adherent patients have interaction systems that were personal, interpersonal and social systems. 295 kepatuhan pasien tb paru berdasarkan teori (tintin sukartini, dkk.) recommendation based on the research f indings of compliance based on king’s interacting systems theory, the themes can describe how the system interaction in adherent patients. it can be used as initial data to develop a model of intervention for pulmonary tb patients to improving adherence in therapy. references a i s y a h , 2 0 0 3. h u b u n g a n pe r s e p s i , pengetahuan tb paru dan pmo dengan kepatuhan berobat pasien tb paru di puskesmas kecamatan jatinegara jakarta timur tahun 2001. tesis, fkmui. alligood, m.r & tomey, a.m, 2006. nursing theory: utilization & application. missouri: mosby inc. chani, k., 2010. factors affecting compliance to tuberculosis treatment in andara kavango region namibia. d e p k e s , 2 0 0 7. p e d o m a n n a s i o n a l penanggulangan tuberkulosis. jakarta: depkes fat i ma h , s., 20 08. fa k t or ke sehat a n lingkungan rumah yang berhubungan dengan kejadian tb paru di kabupaten ci la cap ta hu n 20 08. dise r t a si. universitas diponegoro. lukito, h., 2012. analisis dan perancangan kebutuhan produk kontrol gula darah bagi penderita diabetes menggunakan aplikasi android. doctoral dissertation. binus. muttaqin, h., 2009. mekanisme koping penderita tbc paru menghadapi penyakitnya di wilayah puskesmas b e r g a s. d o c t o r a l d i s s e r t a t i o n . universitas diponegoro. naing, n.n., d’este, c., isa, a.r., salleh, r., bakar, n., & mahmod, m.r., 2001. factors contributing to poor compliance with anti-tb treatment among tuberculosis patients. southeast asian j trop med public health, 32 (2). namawejje, h., 2011. modelling the effect of stress on the dynamics and treatment of tuberculosis. dissertation for the degree of master of science, university of dar es salaam, tanzania. nepal, a.k., shiyalap, k., sermsri, s., & keiwkar nka, b. 2012. compliance w it h dots a mong tubercu losis patients under community based dots strategy in palpa district, nepal. international journal of infection and microbiology, 1 (1), 14–19. streuebert, h.j & carpenter, d.r. 2003. qualitative research in nursing: advancing humanistic imperative. (3rd ed). philadelphia: lippincott. who, 2012. global tuberculosis report 2012. isbn 978 92 4 156450 2. http://e-journal.unair.ac.id/jners | 9 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18897 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review effectiveness of mobile app-based interventions to support diabetes selfmanagement: a systematic review dia amalindah, agnestria winarto, anggun hidayatur rahmi faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: diabetes is a major health problem worldwide due to its rapidly growing prevalence and high disease burden. nowadays, the evolution of mobile technology provides a large number of health-related mobile applications (apps) mainly focusing on the self-management of diabetes. the aim of this paper is to systematically review the effectiveness of mobile app-based self-management interventions on clinical and/or psychological outcomes in patients with type 1 and type 2 diabetes. methods: a systematic search of four databases (scopus, medline, cinahl, and proquest) was conducted using the terms "diabetes" and "self-management" and "mobile applications" or "mobile based" or “smartphone”. studies published in english from 2016 to 2020 were considered. only randomized controlled trials (rcts) for patients with type 1 and type 2 diabetes that reported any of the study outcomes were included. using our search strategies, we identified 4339 articles. after removing duplicate studies, a total of 12 articles met the inclusion and exclusion criteria included in the review. results: the majority measured self-monitoring of blood glucose monitoring frequency, glycated hemoglobin (hba1c) and/or psychological or cognitive outcomes. the most positive findings were associated with mobile app-based health interventions as a behavioral outcome, with some benefits found for clinical and/or psychological diabetes self-management outcomes for patients with type 1 and type 2 diabetes mellitus. conclusion: therefore, more research with larger and longer studies to develop the ideal mobile-app based self-management tool for diabetes is needed. article history received: feb 27, 2020 accepted: april 1, 2020 keywords diabetes mellitus; self-management; mobile applications contact dia amalindah  dia.amalindah-2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: amalindah, d., winarto, a., & rahmi, a, h. (2020). effectiveness of mobile app-based interventions to support diabetes self-management: a systematic review. jurnal ners, special issues, 9-18. doi: http://dx.doi.org/10.20473/jn.v15i2.18897 introduction diabetes mellitus (dm) is a major health problem worldwide due to its rapidly growing prevalence and high disease burden (binte et al., 2019). worldwide, diabetes mellitus has been diagnosed in 415 million people. according to the international diabetes federation (idf), by 2045 this number will rise to 629 million (international diabetes federation, 2019). the prevalence of dm has resulted in a substantial financial burden on medical systems, families, and societies (chao et al., 2019). currently, in the united states, only 50% of diabetes patients are achieving the recommended target glycosylated hemoglobin (a1c, %) level of 7% or below (casagrande et al., 2013). uncontrolled diabetes leads to deleterious complications, such as retinopathy, neuropathy, and nephropathy(fox et al., 2004). its complications are a global health emergency. annual global health expenditure on diabetes is estimated at around usd 760 billion. it is projected to reach usd 825 billion by 2030 and increase to usd 845 billion by 2045 (international diabetes federation, 2019). furthermore, the who projects that diabetes will be the seventh leading cause of death in 2030 (mathers & loncar, 2006). as the prevalence of type 1 and type 2 diabetes continues to rise worldwide, more individuals and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:dia.amalindah-2019@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2.18897 d. amalindah et al. 10 | pissn: 1858-3598  eissn: 2502-5791 families are living with the challenge of integrating an exhausting, complex, and long term regimen into their lives to control their progressive illness and prevent diabetes complications (gonzalez et al., 2016). indeed, the management of diabetes mellitus is challenging for both patients and clinicians. to successfully self-manage, diabetes patients must have high levels of health literacy and numeracy. clinicians often advocate lifestyle change including diet, exercise, interpreting blood glucose trends, adjusting medication doses within brief clinic visits and sometimes engaging with patients who may have a limited understanding of their condition or treatment plan (shan et al., 2019). long-term medication use and lifestyle changes are necessary for the successful management of both type 1 and type 2 dm (gonzalez et al., 2016). the diverse lifestyle changes requirements for the selfmanagement of diabetes including regular medication taking, selfmonitoring of blood glucose (smbg), changes in diet and physical activity, foot self-care, and visits with health care providers are detailed elsewhere in this issue (gonzalez et al., 2016). traditionally, self-management support for diabetic patients comprised face-to-face patient education using printed materials, demonstrations or videos (binte et al., 2019). therefore, effective tools to support patients in their self-management to enhance the quality of life and help to reduce complications are needed. the rise of mobile-based applications (apps) over the past decade has led to increasing interest in using this technology to assist patients or clinicians in chronic disease management such as diabetes mellitus. diabetes mobile-based applications as an emerging set of technologies are a promising tool for self-management. this technology combines the functions of the mobile phone, wireless network for data transmission, and sometimes hcps for providing feedback (hou et al., 2016). accordingly, the american diabetes association (ada) has stated that mobile apps may be a useful element of effective lifestyle modification to prevent diabetes (american diabetes association, 2017). the purpose of diabetes apps is increasing the patient’s self-management skills by storing personal data, such as glucose, hemoglobin a1c or glycated hemoglobin (hba1c), blood pressure, body weight etc., and facilitating them in making treatment decisions by utilizing pre-stored validated algorithms (doupis et al., 2020). most of them provide services such as glucose and meal tracker, insulin calculator, planned physical activity, and health education presented in the form of diaries, pictures, videos or animations (doupis et al., 2020; veazie et al., n.d.). some applications have facilitated real-time communication between a healthcare professional and the patient (diabetes diary (skrøvseth et al., 2015), diabetes interactive diary (rossi et al., 2013), d-partner (doupis et al., 2020), diabeo (jeandidier et al., 2018), diabetes pal (bee et al., 2016b), and bluestar (agarwal et al., 2019)). however, most of them have not been approved by the us food and drug administration (fda) or other corresponding regulatory authorities and bluestar was the first mobile app-based in the usa to be given fda approval as a mobile prescription therapy (doupis et al., 2020). there was current uncertainty on the clinical and psychological effectiveness of diabetes apps and limited research on the mechanisms of patient engagement, including use by specific populations. previous studies have shown that the use of diabetes applications is currently limited because they fail to assess patient engagement among older adults with diabetes (quinn et al., 2015). so, the aim of this paper is to systematically review the effectiveness of mobile app-based self-management interventions on clinical and/or psychological outcomes in patients with type 1 and type 2 diabetes. materials and methods data sources and search strategy the prisma statement and checklist was followed. five databases were used in the searching process: scopus, medline, cinahl, and proquest for studies published between 1 january 2016 and 1 january 2020. the terms "diabetes mellitus" and "selfmanagement" and "mobile applications" or "mobile based" or “smartphone” were used during the search. inclusion and exclusion criteria we included studies that were randomized controlled trials (rcts) and that met the following inclusion criteria. 1) study participants were patients who were age 14 years and above with a confirmed diagnosis of type 1 and type 2 diabetes mellitus. 2) studies evaluated the effectiveness of the mobile appbased self-management interventions. 3) studies separated participants into at least one group receiving mobile app-based self-management interventions and one group receiving usual care. 4) studies that investigated at least one of the following outcomes: self-efficacy, self-care activities, healthrelated quality of life and/or clinical outcomes, such as glycated hemoglobin (hba1c), fasting blood glucose, body mass index (bmi), and blood pressure. we excluded studies wherethe participants were pregnant women who required different therapeutic strategies. we also excluded studies that used qualitative data as an outcome measure, were not written in english, and did not use mobile app-based technology for diabetes self-management purposes. study selection the results of the systematic searches were imported into a reference manager, mendeley software. duplicates were removed using the software and manual. then, we independently screened the titles and abstracts of the studies and categorized them into jurnal ners http://e-journal.unair.ac.id/jners | 11 those that meet, potentially meet or do not meet the eligibility criteria. studies with titles and abstracts deemed irrelevant and that did not meet the eligibility criteria were thus removed. the full texts of those that met or could potentially meet the eligibility criteria were retrieved. risk of bias assessment the quality of the studies in this review was analyzed by reviewers. the risk of bias was assessed using the cochrane risk of bias tool for randomized controlled trial (cochrane, 2016). we used a study’s overall risk of bias as a determinant measure for three quality categories: low risk of bias meant a study was likely high quality, a moderate risk of bias meant a study was likely moderate quality, and a high risk of bias meant a study was likely low quality. results these studies examined only type 1 diabetes, only type 2 diabetes or both type 1 and type 2 diabetes. the main characteristics of the 12 studies identified in this systematic review are summarized in table 1. study and participant characteristics we identified two studies from the twelve evaluating mobile applications only for type 1 diabetes mellitus (agarwal et al., 2019; garg et al., 2017), eight studies evaluating mobile applications only for type 2 diabetes mellitus (agarwal et al., 2019; anzaldocampos et al., 2016; bee et al., 2016b; boels et al., 2019; chao et al., 2019; dugas et al., 2018; franc et al., 2019; kusnanto et al., 2019), two evaluating mobile applications for both type 1 and type 2 (gunawardena et al., 2019; l. zhang et al., 2019). the size of the study ranged from 29 to 330 participants. participants ranged in mean age from 14 to 80 years old and had had diabetes for an average of no more than 3 years. average of baseline hba1c more than 7.0 was measured with laboratorium standard method or a single automated glycohemoglobin analyzer then the result was recorded in the application. study length and length of time that participants used the apps and also an evaluation of the interventions ranged from 3 to 12 months. for most studies, the intervention group used the app with additional support from a clinician doctor or nurse diabetes educator. the control group typically received usual care, standard education, or use of a paper diary and the comparison group (intervention group) used diabetes mobilebased apps. risk of bias of the 12 rct studies, nine were found to have low to moderate risk of bias (agarwal et al., 2019; anzaldocampos et al., 2016; boels et al., 2019; castensøeseidenfaden et al., 2018; chao et al., 2019; dugas et al., 2018; gunawardena et al., 2019; kusnanto et al., 2019; l. zhang et al., 2019), and 3 had a high risk of bias (bee et al., 2016a; garg et al., 2017; jeandidier et al., 2018) features common features of apps for diabetes management included the ability to track health data such as blood glucose, diet programs, prescriptions, and exercise, patient feedback such as reminders to take medication or measure blood glucose, and diabetes education such as foot care. impact on hba1c all studies assessed changes in hba1c as the main outcome of interest and showed a reduction on hba1c level but five studies were not statistically significant (agarwal et al., 2019; bee et al., 2016b; boels et al., 2019; chao et al., 2019; dugas et al., 2018). diasocial app has no significant statistic in lowering hba1c between-group comparison (dugas et al., 2018). impact on lipid or total cholesterol two studies assessed the impact of diabetes application on lipid or total cholesterol (anzaldocampos et al., 2016; l. zhang et al., 2019). those studies had better control of hdl or ldl level at month 3 and 6 (all p<.05) but no significant differences were observed (all p>.05). records identified through database searching (n = 4339) cinahl : n = 1024, scopus : n = 2135, proquest: n = 1004, medline: n=176 in c lu d e d e li g ib il it y id e n ti fi c a ti o n records after duplicates removed (n = 3085) abstracts assessed for eligibility (n = 56) articles excluded, with reasons (n = 44) ▪ intervention ▪ outcomes ▪ method full text downloaded (n = 12) studies included in review (n = 12) records excluded based on inclusion and exclusion criteria (n = 3029) figure 1. prisma flowchart of included studies. d. amalindah et al. 12 | pissn: 1858-3598  eissn: 2502-5791 impact on body mass index three studies assessed the impact of diabetes application on body mass index (bmi) (anzaldocampos et al., 2016; boels et al., 2019; l. zhang et al., 2019). no significant differences were founded for bmi in all those studies in this review (all p>.05). impact on hypoglycemia event three studies assessed the impact of diabetes application on hypoglycaemia events (bee et al., 2016b; boels et al., 2019; castensøe-seidenfaden et al., 2018). the hypoglycemic event was marginally lower in the intervention group, but this difference was also not statistically significant and no severe hypoglycemia was reported. impact on psychological aspects we identified four studies from twelve that assessed psychological aspects such as self-efficacy, depression, quality of life, knowledge, and adherence (agarwal et al., 2019; anzaldo-campos et al., 2016; chao et al., 2019; kusnanto et al., 2019). the impact of self-efficacy has increased through the use of dmcalendar apps and there was improved behavior of good self-management referred from national standards diabetes self-management education (dsme) (funnell et al., 2010; kusnanto et al., 2019). a significant interaction effect was also observed for diabetes knowledge but not for any of the other selfreported outcomes: self-efficacy, depression, lifestyle, and quality of life (all p values >0.05) (anzaldocampos et al., 2016). but other studies stated that the results of the case group was better than those of the control group, especially those for knowledge score (p=.05) (chao et al., 2019). participants at a high risk indicated a high motivation to change and to achieve high scores in the self-care knowledge assessment. discussion our findings suggest the significant glycated haemoglobin (hba1c) reduction associated with sgm was probably due to the app’s ability to continuously engage the participants in the dietary and exercise advice given by diabetes educators (castensøeseidenfaden et al., 2018; franc et al., 2019; l. zhang et al., 2019). patient engagement with technology, educational content and self-care behaviors influence outcomes of mobile app-based interventions. people living with diabetes are more likely to check their mobile phones or smartphones more than once a day (gunawardena et al., 2019). this allows the mobile app to maintain the attention of an individual while managing symptoms of their illness to prevent further adverse outcomes or complications associated with diabetes such as retinopathy, neuropathy, nephropathy, foot ulcers, and other morbid conditions such as cardiovascular disease, chronic kidney disease, functional and cognitive decline, and even mortality. another reason for this may be that patients generally show interest or enthusiasm toward treatment through mobile app advances that ease the burden imposed by traditional strategies to manage diabetic symptoms and complications. we believe this might be the driving reason for a more prominent effect of apps on a1c levels after 3 months of the trial. in the other point of view, clinicians often direct patients to attend in-person diabetes selfmanagement classes, which may be burdensome and this may be partly responsible for the low attendance rates (national center for chronic disease prevention and health promotion, 2015). mobile-based application interventions for education and selfmanagement generally provide holistic content, are targeted towards patients with type 1 or type 2 diabetes, and are informed by behavioral change theories (orsama et al., 2013), such as the information-motivation-behavioral skills model, social cognitive theory (arora et al., 2014), motivational interviewing (block et al., 2015) or the theory of planned behavior (holmen et al., 2014). patients are encouraged to monitor glucose, diet, insulin dosages, and exercise regularly, and this data can be used to adjust feedback messages sent through the application (y. zhang et al., 2018). the content of the messages includes diabetes education, health promotion, motivational messages, reminders for medications and, self-monitoring blood glucose, or specific behavioral changes to implement, which are table 1. general characteristic of selected studies (n=12) category n % year of publishing 2016 2 16.6 2017 1 8.3 2018 2 16.6 2019 7 58.3 type of dm t1dm 2 16.6 t2dm 8 66.6 t1dm and t2dm 2 16.6 participants age adolecense 4 33.4 adult 8 66.6 *dm: diabetes mellitus: t1dm: type 1 diabetes mellitus: t2dm: typ2 2 diabetes mellitus jurnal ners http://e-journal.unair.ac.id/jners | 13 table 2. summary of selected studies author type of dm design sample variable result (anzaldocampos et al., 2016) t2dm randomized controlled trial 301 participants were enrolled in the study and were allocated randomly: 99 to project dulce-only (pd) 102 to project dulce technology enhanced with mobile tools (pdte), 100 to standart care/control group (cg) clinical: 1. glycated haemoglobin (hba1c) 2. total cholesterol, low-density lipoprotein cholesterol (ldl-c), highdensity lipoprotein cholesterol (hdl-c), triglycerides 3. systolic blood pressure (sbp) 4. diastolic blood pressure (dbp) 5. body mass index (bmi) self-reported: 1. self-efficacy 2. depression 3. lifestyle 4. quality of life 5. diabetes knowledge hba1c reductions from baseline to month 10 were significantly greater in intervention groups. significant improvement in diabetes knowledge when compared with control. no statistically significant differences were detected between pd and pd-te on these indicators. several within-group improvements were observed on other clinical and self-report indicators but did not vary significantly across groups. (gunawardena et al., 2019) t1dm and t2dm randomized clinical trial 67 participants were randomized: smart glucose manager sgm (n = 27) control group (n = 25). glycated hemoglobin (hba1c) at the 6-month follow up, the sgm group had significant lower a1c levels than the control group. for both groups, a1c values decreased from baseline to the 3 months. from 3 months to 6 months, the sgm group showed further improvement of a1c, whereas the control group did not. a1c improvement was positively correlated with sgm usage. (dugas et al., 2018) t2dm randomized control trial 29 participants were randomized: usual care group (n = 5) intervention group (n = 24) 1. glycated hemoglobin (hba1c) 2. adherence there were no differences in adherence levels across treatment conditions. between group comparisons detected no significant effects on hba1c change over time. (boels et al., 2019) t2dm open two-arm multicenter parallel randomized controlled superiority trial 330 participants were randomized: intervention group (n=115) control group (n=115) 1. hba1c 2. hypoglycemic event 3. body mass index 4. glycemic variability 5. dietary habits 6. quality of life. hba1c level was slightly lower in the intervention group in both the unadjusted and the adjusted analysis, but this difference was not statistically significant. there was no effect on secondary outcomes included dietary habits and quality of life. no adverse events were reported. d. amalindah et al. 14 | pissn: 1858-3598  eissn: 2502-5791 author type of dm design sample variable result (l. zhang et al., 2019) t1dm and t2dm prospective randomized controlled trial 276 participants were randomized: control group (group a) (n=78) app selfmanagement group (group b) (n=78) app interactive management group (group c) (n=78) 1. hba1c 2. fasting plasma glucose (fpg) 3. body weight 4. lipid at months 3 and 6, all 3 groups showed significant decreases in hba1c levels. patients in the app interactive management group had a significantly lower hba1clevel than those in the app selfmanagement group at 6 months. (franc et al., 2019) t2dm randomized controlled trial 191 participants were randomized: group 1 (standard care, n = 63) group 2 (g2, interactive voice response system, n = 64) group 3 (g3, diabeo-bi app software, n = 64). 1. hba1c levels 2. fasting blood glucose (fbg) hba1c levels decreased significantly more in patients from the intervention than in the control. hba1c decreases from baseline were also significantly higher in g2 and g3 compared with the control. the glycaemic control target (hba1c < 7.0%) was achieved in twice as many patients as in the control. (chao et al., 2019) t2dm randomized controlled trials 121 participants were stratified randomized: case-group patients participated (n=62) control-group patients (n=59) 1. hba1c 2. self-knowledge 3. self-care the associated clinical outcomes in the case group with the mobile-based intervention were slightly better than in the control group. in addition, 86% (42/49) of the participants improved their health knowledge through the mobile-based app and information and communications technology. (garg et al., 2017) t1dm randomized controled trial 100 participants were stratified randomized: control group (n=50) intervention grup (n=50) 1. a1c 2. complete metabolic panel 3. complete cell counts there was a decrease in a1c among both the control and intervention groups at 3 months, although the amount of change in a1c was not different between groups. however, at 6 months, there was a significant decrease in a1c from baseline only in the intervention group. (kusnanto et al., 2019) t2dm randomized controlled trial 30 participants were randomized: control group (n=15) intervention group (n=15) 1. self-efficacy 2. hba1c education with dmcalendar media has increased the perception of self-efficacy and improved the behavior of good selfmanagement that can be seen from changes in controlled hba1c level, lipid profile and insulin. (agarwal et al., 2019) t2dm multicenter pragmatic randomized controlled trial 240 participants were randomized: immediate treatment group (itg) (n=110) 1. hba1c 2. patient selfmanagement 3. experience of care the results of an analysis of covariance controlling for baseline hba1c levels did not show evidence of intervention impact on hba1c levels at 3 months. similarly, there was no jurnal ners http://e-journal.unair.ac.id/jners | 15 author type of dm design sample variable result control group (n=113) 4. self-reported health utilization intervention effect on secondary outcomes measuring diabetes selfefficacy, quality of life, and health care utilization behaviors. (castensøeseidenfaden et al., 2018) t1dm randomized controlled trial 151 participants were randomized: intervention group (n=76) control (n=75) 1. hba1c 2. hypoglycemia 3. hospitalizations at 12 months, hba1c was significantly higher in the intervention group. the apps did not improve hba1c, but it may be a useful tool for complementing selfmanagement in young people with t1dm. this finding did not occur when comparing app users with nonusers. most young people and half of the parents reported that the apps helped them. (bee et al., 2016b) t2dm a pilot randomized controlled trial 66 participants were randomized: intervention group (n =33) control group (n=33) 1. fasting plasma glucose 2. hba1c 3. hypoglycemia reductions from baseline were numerically greater in the intervention group at allthree follow-ups, mean reduction of hba1c from baseline was numerically greater in the intervention group than the control group with no significant difference between groups. usually sent automatically according to an algorithm (schramm, 2018; shan et al., 2019). previous studies showed that performance expectancy had the strongest direct effect on behavioral intention (y. zhang et al., 2019). furthermore, novel mobile apps should aim to initiate behavioral changes and treatment adjustments in a positive way for both clinical and psychological outcomes, considering that diabetes is a chronic and complicated disease in which glycemic management alone may not be enough to improve health outcomes (modzelewski et al., 2018). other evidence indicates that the use of some mobile apps with additional support from a healthcare provider or study staff may be useful in improving short-term outcomes, especially hba1c, compared with controls for both type 1 and type 2 diabetes (veazie et al., n.d.). this study suggests that mobile apps have the potential to improve diabetes self-management skills in patients with diabetes mellitus both type 1 or type 2. but, there is limited evidence that the use of apps improves other important outcomes such as quality of life, depression, blood pressure, weight, or body mass index (bmi) (holmen et al., 2014), (pramanik et al., 2019). emerging evidence shows that mobile apps provide benefits for diabetes treatment after an average of 3 months. similar with we have found in this review, previous studies by osborn et al. found that both type 1 and type 2 diabetes patients reported a mean a1c reduction over 4 months using an app called one drop (osborn et al., 2017). however, this reduction was detected not in a randomized trial design but an observational setting. in addition, diabetes-related complications such as neuropathy, retinopathy, or hypertension were not measured, so we could not determine if the use of the apps reduced their incidence or severity and also assess what components of the mobile-apps based were most associated with long-term compliance to the management of diabetes. so, further research must explore many aspects that have not been reviewed in previous studies both clinical and psychological output. conclusion most of the reviewed mobile-app-based diabetes management tools have been shown to positively effect outcomes, including hba1c levels, hypoglycemia rates, cholesterol level, self-efficacy, quality of life, diabetes knowledge and more. giving that, now the need for individualized or self-care management for patients with diabetes is more evident than ever. the development and evaluation of more comprehensive mobile apps that allow logging of glucose readings, calculation of carbohydrates and insulin doses, incorporate reminders for medication, support education to prevent complications, and provide feedback are warranted and should incorporate both patient and clinician feedback on d. amalindah et al. 16 | pissn: 1858-3598  eissn: 2502-5791 lifestyle or workflow integration, respectively, as well as usability and content. thus, further long-term, multicenter studies are necessary to prove the longterm impact of the available applications today, while continuing efforts should target the development of the ideal mobile-app based self-management tool for diabetes. hence, guidelines from scientific organizations and authorities in the field of mobile health are also necessary to successfully carry on the programs. conflict of interest no conflict of interest has been declared by the authors. acknowledgement the authors acknowledge the faculty of nursing universitas airlangga especially the master committee of the nursing programme for lending their suggestions to this article. references agarwal, p., mukerji, g., desveaux, l., ivers, n. m., bhattacharyya, o., hensel, j. m., shaw, j., bouck, z., jamieson, t., onabajo, n., cooper, m., marani, h., jeffs, l., & sacha bhatia, r. (2019). mobile app for improved self-management of type 2 diabetes: multicenter pragmatic randomized controlled trial. journal of medical internet research, 21(1), 1–13. https://doi.org/10.2196/10321 american diabetes association. (2017). comprehensive medical evaluation and assessment of comorbidities. sec. 3. in standards of medical care in diabetes. diabetes care, 40, 25– 32. anzaldo-campos, m. c., contreras, s., vargas-ojeda, a., menchaca-díaz, r., fortmann, a., & philistsimikas, a. (2016). dulce wireless tijuana: a randomized control trial evaluating the impact of project dulce and short-term mobile technology on glycemic control in a family medicine clinic in northern mexico. diabetes technology and therapeutics, 18(4), 240–251. https://doi.org/10.1089/dia.2015.0283 arora, s., peters, a. l., burner, e., lam, c. n., & menchine, m. (2014). trial to examine text message-based mhealth in emergency department patients with diabetes (text-med): a randomized controlled trial. annals of emergency medicine, 63(6), 745-54.e6. https://doi.org/10.1016/j.annemergmed.2013.1 0.012 bee, y. m., batcagan-abueg, a. p. m., chei, c.-l., do, y. k., haaland, b., goh, s.-y., lee, p. c., chiam, p. p. s., ho, e. t. l., & matchar, d. b. (2016a). a smartphone application to deliver a treat-totarget insulin titration algorithm in insulinnaive patients with type 2 diabetes: a pilot randomized controlled trial. diabetes care, 39(10), e174–e176. https://doi.org/10.2337/dc16-0419 bee, y. m., batcagan-abueg, a. p. m., chei, c. l., do, y. k., haaland, b., goh, s. y., lee, p. c., chiam, p. p. s., ho, e. t. l., & matchar, d. b. (2016b). a smartphone application to deliver a treat-totarget insulin titration algorithm in insulin-naive patients with type 2 diabetes: a pilot randomized controlled trial. diabetes care, 39(10), e174– e176. https://doi.org/10.2337/dc16-0419 binte, h., jiao, n., jiang, y., hong, j., & wang, w. (2019). international journal of nursing studies effectiveness of smartphone-based selfmanagement interventions on self-ef fi cacy , selfcare activities , health-related quality of life and clinical outcomes in patients with type 2 diabetes : a systematic revie. international journal of nursing studies, 103286. https://doi.org/10.1016/j.ijnurstu.2019.02.003 block, g., azar, k. m. j., romanelli, r. j., block, t. j., hopkins, d., carpenter, h. a., dolginsky, m. s., hudes, m. l., palaniappan, l. p., & block, c. h. (2015). diabetes prevention and weight loss with a fully automated behavioral intervention by email, web, and mobile phone: a randomized controlled trial among persons with prediabetes. journal of medical internet research, 17(10). https://doi.org/10.2196/jmir.4897 boels, a. m., vos, r. c., dijkhorst-oei, l. t., & rutten, g. e. h. m. (2019). effectiveness of diabetes selfmanagement education and support via a smartphone application in insulin-treated patients with type 2 diabetes: results of a randomized controlled trial (trigger study). bmj open diabetes research and care, 7(1), 1–4. https://doi.org/10.1136/bmjdrc-2019-000981 casagrande, s. s., fradkin, j. e., saydah, s. h., rust, k. f., & cowie, c. c. (2013). the prevalence of meeting a1c, blood pressure, and ldl goals among people with diabetes, 1988-2010. diabetes care, 36(8), 2271–2279. https://doi.org/10.2337/dc12-2258 castensøe-seidenfaden, p., husted, g. r., jensen, a. k., hommel, e., olsen, b., pedersen-bjergaard, u., kensing, f., & teilmann, g. (2018). testing a smartphone app (young with diabetes) to improve self-management of diabetes over 12 months: randomized controlled trial. jmir mhealth and uhealth, 6(6). https://doi.org/10.2196/mhealth.9487 chao, d. y. p., lin, t. m. y., & ma, w. y. (2019). enhanced self-efficacy and behavioral changes among patients with diabetes: cloud-based mobile health platform and mobile app service. journal of medical internet research, 21(5). https://doi.org/10.2196/11017 cochrane. (2016). the rob 2 . 0 tool ( individually randomized , parallel group trials ). 1–21. doupis, j., festas, g., tsilivigos, c., & efthymiou, v. (2020). smartphone-based technology in diabetes management. diabetes therapy. https://doi.org/10.1007/s13300-020-00768-3 jurnal ners http://e-journal.unair.ac.id/jners | 17 dugas, m., crowley, k., gao, g. g., xu, t., agarwal, r., kruglanski, a. w., & steinle, n. (2018). individual differences in regulatory mode moderate the effectiveness of a pilot mhealth trial for diabetes management among older veterans. plos one, 13(3), 1–21. https://doi.org/10.1371/journal.pone.0192807 fox, c. s., sullivan, l., d’agostino, r. b., & wilson, p. w. f. (2004). the significant effect of diabetes duration on coronary heart disease mortality: the framingham heart study. diabetes care, 27(3), 704–708. https://doi.org/10.2337/diacare.27.3.704 franc, s., joubert, m., daoudi, a., fagour, c., benhamou, p. y., rodier, m., boucherie, b., benamo, e., schaepelynck, p., guerci, b., dardari, d., borot, s., penfornis, a., d’orsay, g., mari, k., reznik, y., randazzo, c., & charpentier, g. (2019). efficacy of two telemonitoring systems to improve glycaemic control during basal insulin initiation in patients with type 2 diabetes: the telediab-2 randomized controlled trial. diabetes, obesity and metabolism, 21(10), 2327–2332. https://doi.org/10.1111/dom.13806 funnell, m. m., brown, t. l., childs, b. p., haas, l. b., hosey, g. m., jensen, b., maryniuk, m., peyrot, m., piette, j. d., reader, d., siminerio, l. m., weinger, k., & weiss, m. a. (2010). national standards for diabetes self-management education. diabetes care, 33(suppl. 1). https://doi.org/10.2337/dc10-s089 garg, s. k., shah, v. n., akturk, h. k., beatson, c., & snell-bergeon, j. k. (2017). role of mobile technology to improve diabetes care in adults with type 1 diabetes: the remote-t1d study ibgstar® in type 1 diabetes management. diabetes therapy, 8(4), 811–819. https://doi.org/10.1007/s13300-017-0272-5 gonzalez, j. s., tanenbaum, m. l., & commissariat, p. v. (2016). psychosocial factors in medication adherence and diabetes self-management: implications for research and practice. american psychologist, 71(7), 539–551. https://doi.org/10.1037/a0040388 gunawardena, k. c., jackson, r., robinett, i., dhaniska, l., jayamanne, s., kalpani, s., & muthukuda, d. (2019). the influence of the smart glucose manager mobile application on diabetes management. journal of diabetes science and technology, 13(1), 75–81. https://doi.org/10.1177/1932296818804522 holmen, h., torbjørnsen, a., wahl, a. k., jenum, a. k., småstuen, m. c., årsand, e., & ribu, l. (2014). a mobile health intervention for self-management and lifestyle change for persons with type 2 diabetes, part 2: one-year results from the norwegian randomized controlled trial renewing health. jmir mhealth and uhealth, 2(4), e57. https://doi.org/10.2196/mhealth.3882 hou, c., carter, b., hewitt, j., francisa, t., & mayor, s. (2016). do mobile phone applications improve glycemic control ( hba 1c ) in the selfmanagement of diabetes ? a systematic review , meta-analysis , and grade of 14 randomized trials. 39(november), 2089–2096. https://doi.org/10.2337/dc16-0346 international diabetes federation. (2019). idf diabetes atlas (9 th). jeandidier, n., chaillous, l., franc, s., benhamou, p.-y., schaepelynck, p., hanaire, h., catargi, b., farret, a., fontaine, p., guerci, b., reznik, y., penfornis, a., borot, s., serusclat, p., kherbachi, y., d’orsay, g., detournay, b., simon, p., & charpentier, g. (2018). diabeo app software and telemedicine versus usual follow-up in the treatment of diabetic patients: protocol for the telesage randomized controlled trial. jmir research protocols, 7(4), e66. https://doi.org/10.2196/resprot.9154 kusnanto, widyanata, k. a. j., suprajitno, & arifin, h. (2019). dm-calendar app as a diabetes selfmanagement education on adult type 2 diabetes mellitus: a randomized controlled trial. journal of diabetes and metabolic disorders, 18(2), 557– 563. https://doi.org/10.1007/s40200-01900468-1 mathers, c. d., & loncar, d. (2006). projections of global mortality and burden of disease from 2002 to 2030. plos medicine, 3(11), e442–e442. modzelewski, k. l., stockman, m. c., & steenkamp, d. w. (2018). rethinking the endpoints of mhealth intervention research in diabetes care. journal of diabetes science and technology, 12(2), 389– 392. https://doi.org/10.1177/1932296817733007 national center for chronic disease prevention and health promotion. (2015). emerging practices in diabetes prevention and control: medicaid coverage for dsme. orsama, a. l., lähteenmäki, j., harno, k., kulju, m., wintergerst, e., schachner, h., stenger, p., leppänen, j., kaijanranta, h., salaspuro, v., & fisher, w. a. (2013). active assistance technology reduces glycosylated hemoglobin and weight in individuals with type 2 diabetes: results of a theory-based randomized trial. diabetes technology and therapeutics, 15(8), 662–669. https://doi.org/10.1089/dia.2013.0056 osborn, c. y., van ginkel, j. r., marrero, d. g., rodbard, d., huddleston, b., & dachis, j. (2017). one drop | mobile on iphone and apple watch: an evaluation of hba1c improvement associated with tracking self-care. jmir mhealth and uhealth, 5(11), e179. https://doi.org/10.2196/mhealth.8781 pramanik, b. k., angelin, j. j., mathai, v. j., mathai, s., korula, s., & simon, a. (2019). smartphone app as motivational intervention to improve glycemic control in adolescents with type 1 diabetes. indian journal of pediatrics, 86(12), 1118–1123. https://doi.org/10.1007/s12098-019-03035-x quinn, c. c., khokhar, b., weed, k., barr, e., & gruberbaldini, a. l. (2015). older adult self-efficacy study of mobile phone diabetes management. d. amalindah et al. 18 | pissn: 1858-3598  eissn: 2502-5791 diabetes technology & therapeutics, 17(7), 455– 461. https://doi.org/10.1089/dia.2014.0341 rossi, m. c., nicolucci, a., lucisano, g., pellegrini, f., di bartolo, p., miselli, v., anichini, r., & vespasiani, on behalf of the did st, g. (2013). impact of the “diabetes interactive diary” telemedicine system on metabolic control, risk of hypoglycemia, and quality of life: a randomized clinical trial in type 1 diabetes. diabetes technology & therapeutics, 15(8), 670–679. https://doi.org/10.1089/dia.2013.0021 schramm, w. (2018). digital diabetes selfmanagement: a trilateral serial. journal of diabetes science and technology, 12(3), 709–711. https://doi.org/10.1177/1932296818761973 shan, r., sarkar, s., & martin, s. s. (2019). digital health technology and mobile devices for the management of diabetes mellitus: state of the art. diabetologia, 62(6), 877–887. https://doi.org/10.1007/s00125-019-4864-7 skrøvseth, s. o., årsand, e., godtliebsen, f., & joakimsen, r. m. (2015). data-driven personalized feedback to patients with type 1 diabetes: a randomized trial. diabetes technology & therapeutics, 17(7), 482–489. https://doi.org/10.1089/dia.2014.0276 veazie, s., winchell, k., gilbert, j., paynter, r., ivlev, i., eden, k. b., nussbaum, k., weiskopf, n., guise, j., & helfand, m. (n.d.). rapid evidence review of mobile applications for self-management of diabetes. 2, 1167–1176. https://doi.org/10.1007/s11606-018-4410-1 zhang, l., he, x., shen, y., yu, h., pan, j., zhu, w., zhou, j., & bao, y. (2019). effectiveness of smartphone app-based interactive management on glycemic control in chinese patients with poorly controlled diabetes: randomized controlled trial. journal of medical internet research, 21(12), 1– 10. https://doi.org/10.2196/15401 zhang, y., li, x., luo, s., liu, c., liu, f., & zhou, z. (2018). exploration of users’ perspectives and needs and design of a type 1 diabetes management mobile app: mixed-methods study. jmir mhealth and uhealth, 6(9), 1–20. https://doi.org/10.2196/11400 zhang, y., liu, c., luo, s., xie, y., liu, f., li, x., & zhou, z. (2019). factors influencing patients’ intention to use diabetes management apps based on an extended unified theory of acceptance and use of technology model: web-based survey. journal of medical internet research, 21(8), 1–20. https://doi.org/10.2196/15023 86 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16992 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review stigma in family patients who have a psychiatric disorder: a systematic review antonia rensiana reong and retno puji astuti faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the stigma in families who are caring for patients who experience mental illness in the modern era is high. some of the experiences of patients with mental illness reveal that they are still stigmatized. this is not just the patients but also the families that care for them. the aim of this study was to conduct a systematic review relating to the stigma felt by the families of the patients experiencing mental illness. methods: the database used to identify the potential articles was scopus. the articles were limited to a range of 5 years from 2014 through to 2018. the keywords used in the literature review were "stigma family" and "mental illness". results: fifteen articles from eight countries were evaluated. the families were confirmed as experiencing stigma: labeling, stereotyping, separation and discrimination. stigma means that the families face psychological, social and intrapersonal consequences which can reduce the family quality of life and family functioning. conclusion: there are opportunities for negative outcomes related to the family resilience. one of the results of the study revealed that psychoeducation programs using education interventions can be an alternative intervention to reduce stigma. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords stigma; family; psychiatric disorder contact antonia rensiana reong  antonia.rensiana.reong2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: reong, a. r., & astuti, r. p. (2019). stigma in family patients who have a psychiatric disorder: a systematic review.jurnal ners, 14(3si), 86-90. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16992 introduction schizophrenia is one type of mental health disorder that is still a complicated problem. the prevalence of severe mental illnesses, including schizophrenia, based on riskesdas 2013 is present in 1.7 per 1000 people, which means that more than 400,000 people suffer from severe mental disorders in indonesia. the incidence of schizophrenia is difficult to decrease due to the high recurrence rates. the recurrence rate of schizophrenia patients in indonesia was 50%e 80%, 57% within 3 years and 70%e82% over the first five year (rizki fitryasari, yusuf, nursalam, tristiana, & nihayati, 2018). mental health stigma may have a detrimental effect on people due to their hesitation to disclose their psychiatric diagnoses, as well as decreased help-seeking attitudes and treatment compliance, potentially worsening prognosis (ndetei et al., 2015). stigma has been linked to adversity for people with a mental disorder as it acts as a barrier to help-seeking and it can affect all aspects of a person's life. stigma is referred to as a social construct comprised of four interrelated components that include: 1) people distinguish and label human differences as a knowledge problem; 2) labeled people incur damage through negative stereotypes as an attitude problem; 3) labeled people are placed in exclusion; and 4) labeled people lost their status and are discriminated against. a stigmatized attitude was related to the reason people consider mental disorder itself. the stigma of mental health has a detrimental effect on people because they tend to hesitant to reveal a psychiatric diagnosis, display a decrease in mental healthseeking attitude, and a decreased medication adherence potentially worsens the disease prognosis. stigma and discrimination related to mental health not only affects the people living with schizophrenia but also their entire family. reducing stigma and discrimination is the key to responding to the unmet needs of people with mental illness. local contexts are very important in this effort because their stigma https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:antonia.rensiana.reong-2018@fkp.unair.ac.id mailto:antonia.rensiana.reong-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 87 and manifestations depends on the specific conditions of the target population and across cultures and settings (krupchanka et al., 2018). stigma modulates what is revealed in the disclosure of depression, the life experiences of people who experience psychiatric disorders after the disclosure, and how striving for health services becomes stigmatized (brijnath & antoniades, 2018). stigma basically hides the mental illness from the community and puts pressure on the families to provide support who may not have the expert knowledge needed by the clinical consumers. the caring and continuous nature of caring can cause the caregivers to develop stigmatic attitudes and attitudes (sawrikar & muir, 2018). shame focuses on stigma as a form of social responsibility and it is a socio-psychological consequence of mental illness (subandi & good, 2018). affiliate stigma often refers to the stigma that is internalized among the family members of stigmatized individuals (zhang et al., 2018). the stigma associated with mental illness, which permeated the context of chinese culture, had a good effect on people with schizophrenia and their family caregivers (wong, kong, tu, & frasso, 2018). internalized stigma is a barrier to mental health care in china, and stigma reduction is expected to encourage the use of treatment, especially for mood disorders and schizophrenia (smith et al., 2018). some people with mental illness in china do not receive treatment. this proves how stigma and family obligations affect the accessibility of social support for patients with depression in china and the potential acceptance of peer support programs (yu, kowitt, fisher, & li, 2018). generally, people blame the family members for the development of their mental illness and they may expect them to assume the responsibility of caring for their sick relatives. for example, parents can be accused of causing illness; siblings and spouses are blamed for ignorance (chang et al., 2018). the inability of the family to control emotions, and the existence of stressful family life problems, means that continuous criticism from the family is the cause of the recurrence of patients with mental disorders. this phenomenon shows that the family has not been able to care for the family members who have schizophrenia. there is the inability to be influenced by various stressors. stressors involve many types of care burden, negative perceptions or stigma and a lack of support from the surrounding environment. the stressors experienced by the families may be mediated by resilience, the family's ability to survive and rise to determine what they will do, and the ability to care for family members who suffer from schizophrenia (r. fitryasari, yusuf, nursalam, tristiana, & nihayati, 2018). family plays an important role in the way that an individual manages the emotions of psychiatric disorders experienced by individuals. families play a role in providing social support through family communication (flood-grady & koenig kellas, 2018). family communication around the sufferers suffering from mental illness is not uniformly positive. family interactions precede, and sometimes worsen, the members' experiences with mental illness, and their relationship with members who experience psychiatric disorders can expose them to stigma (flood-grady, kellas, & flood-grady, 2018). the families of people with mental illness are considered to be important resources rather than as contributors to their mental illness. however, these families not only experience the burden of care but also the social stigma and discrimination in various aspects of their lives. their psychosocial needs tend to be neglected (hyun, nam, & kim, 2018). one study showed that one of the interventions to reduce stigma, namely using the family psycho-education program, showed a reduction in post-intervention stigma by using contact interventions and educational interventions which had a small-medium direct effect on stigma (morgan, reavley, ross, too, & jorm, 2018). the purpose of this systematic review must be considered to reduce and prevent stigma in clients with mental disorders. materials and methods the database search focused on the scopus online journal database and the publication media therein. the keywords included were "family stigma" and "mental illness"; 989 related articles were found. from the related articles, 15 articles were taken that met the inclusion criteria. the articles included in the summary of this literature were (1) articles published in scopus indexed journals, (2) articles focusing on the assessment of stigma in adults or children whose children are concerned with health and change, (3) quantitative or qualitative research methods related to stigma in general, self-stigma, and stigma on the families, (4) articles within the last 5 years from 2014-2018 and (5) articles written in english. the initial search results totaled 989 articles, abstracts and the full texts n = 55 articles. the issuance of the selected articles (main article selected) after the abstract titles and collections n = 934 articles, articles that do not comply with the inclusion criteria n = 40 articles; 34 were entered under the general stigma in 6 criteria, focused on the stigma of mental illness. publication according to the inclusion criteria articles n = 15 articles, while the publications that included systematic reviews n-15. results stigma in people who experience psychiatric disorders is not only attached to the sufferer but to their whole family. this sometimes becomes an obstacle to improving the quality of life of people who experience psychiatric disorders, whereas we know that families play an important role as a support system for their quality of life. stigma and emotional expression are the factors that exacerbate social interaction in both the family and society, in the form of family communication in meeting the psychological a. r. reong, et al. 88 | pissn: 1858-3598  eissn: 2502-5791 needs of the patients and their families as support systems through interaction (khoirunnisa, syuhaimie hamid, & catharina daulima, 2018). patients with mental illness report barriers that prevent them from (a) receiving treatment and (b) relying on informal social support from family members, including stigma, somatization, and community norms. peer support (support from others with depression) is seen by the patients as an acceptable means of exchanging information and relying on others for support (yu et al., 2018). in this literature study, the family experiences of the patients experiencing psychiatric disorders will be discussed. the burden of care felt by the family is related to confusion about the illness, emotional burden, physical problems, time constraints, and financial and social problems, which cause a decrease in the quality of family life. families also experience stigma through labeling, stereotyping, separation and discrimination. stigma means that families face psychological, social and intrapersonal consequences. this decreases the family quality of life and family functioning, and there are opportunities for negative outcomes related to family resilience. health workers, especially psychiatric nurses, must review the burden of care and stigma to develop nursing interventions so then the families can achieve resilience (r. fitryasari et al., 2018). the experience of stigma of 25 different family members related to people living with schizophrenia included four levels of the respondents' lives (macro, micro, and intro-level). the overall issues were (1) a lack of general understanding and misunderstandings about mental illness; (2) structural discrimination and a lack of government and public support systems; (3) the burden of "pervasive and unlimited" care and an inability to live independently (krupchanka et al., 2018) . overall, it was found that their 'stories' were very different from each other, which caused high stigma in the family. in short, the widespread stigma associated with mental illness in society affects the people from gaining in-depth knowledge about it and therefore the ability to recognize the initial symptoms and to provide the empathy needed. it also impacts on the capacity of the health professionals to provide holistic care and not only to depend on 'medical models'. providing adequate funding to ensure that a formal mental health system has the right infrastructure to meet consumer needs. stigma basically hides the mental illness from the community and puts pressure on the families to provide support, who may not have the expert knowledge needed by clinical consumers. the continuous and stressful nature of caring can cause the caregivers to develop stigmatic attitudes. this is intensified by the misperceptions of consumer control related to their mental illness, the uneven distribution of attention in the household, and low consumer insight into the caregiver experiences. this can also lead to the development of their own trauma which requires formal assistance. to overcome these complex problems, stigma is a major problem that requires improvement (sawrikar & muir, 2018). most caregivers of individuals with mental illness experience affiliate stigma in singapore. the four qol domains are significantly related to affiliate stigma (zhang et al., 2018). the thematic analysis of the data showed that the participants experienced shame in three different ways. first, is as a cultural index of disease and recovery. the family members identify their family member’s illness when they lose their shame. if the patient shows an attitude that shows the reappearance of shame, the family sees this as an indication of recovery. second, is as an indication of recurrence. third, is as a barrier to recovery (subandi & good, 2018). people with schizophrenia and their caregivers have both internalized negative judgments from their social networks and reduced their involvement in society. the participants with schizophrenia expressed shame and inferiority, talked about being a burden to their family, and expressed self-disappointment as a result of their psychiatric diagnosis. the caregivers reveal a high level of emotional stress due to mental illness in the family. the family figures vary as far as internal stigma experienced by patients and caregivers goes. the family plays a central role in treating people with mental illness in china (wong et al., 2018). discussion family stigma is low in the early stages of a psychotic disorder, with the families endorsing many supportive statements. for example, the patients are often encouraged to vote and the patients want to work. the family members express a belief that mental illness should be protected legally as a disability and that parity should exist in insurance coverage. one characteristic of family stigma is social isolation. the members of the families keep to themselves and they usually do not invite others into the home or tell them what is happening (khoirunnisa et al., 2018). the implementation of family duties requires the skill and ability of all members of the family to achieve the highest degree of health. establishing and maintaining good relationships with the patients is an important aspect of the treatment and healing process (khoirunnisa et al., 2018). in order to better identify which aspects of the interventions are associated with effectiveness, the studies should aim to report the intervention characteristics in more detail. these include implementation characteristics (e.g. dose and fidelity) as well as the characteristics drawn from the intergroup contact theory that have been proposed as important (e.g. for contact interventions, the type of interaction and comparative status of participants and the person with lived experience; for education interventions, the type of information including experiences of recovery, stigma, and how to provide support). a greater emphasis on how interventions reduce stigma, such as the role of knowledge, anxiety and empathy, would also advance the literature. jurnal ners http://e-journal.unair.ac.id/jners | 89 the results of one study on a family psychoeducation program showed a reduction in stigma after the intervention, namely by using combination interventions; contact interventions and educational interventions have a small-medium direct effect on stigma (morgan et al., 2018). in addition, this can be utilized by peer support communication (i.e., support from fellow mental illness patients). it is seen by the patients as an acceptable means to exchange information and to support each other in the process of undergoing treatment therapy (yu et al., 2018). in addition, a therapeutic communication approach is made in an effort to motivate the patient's family in a joint effort to reduce fear, shame, burden, and emotional stress and to develop a culture of respect and attention to people with psychiatric disorders. conclusion the family is an internal support system that plays an important role in achieving the expected quality of life, especially in patients who experience psychiatric disorders. however, even in this modern global era, there are still many people who stigmatize not only the patients with psychiatric disorders but also their families. this is a serious obstacle to the successful improvement of the positive quality of life expected in mental illness patients because of the loss of important internal supporting factors, namely their family. this can increase the recurrence in patients; therefore, it is necessary to design an effective and efficient therapeutic communication intervention method to minimize the stigmatization in mental illness in order to improve the quality of life of mental illness patients by involving their families. the family psychoeducation program shows a reduction in stigma after the intervention, namely by using a combination of interventions; contact interventions and educational interventions have small-medium direct effects on stigma, but further research is needed to investigate how to sustain the benefits in the long term and how to support the interventions to maximize their effectiveness (morgan et al., 2018). in addition, peer support (support from fellow mental illness patients) is seen by the patients as an acceptable means to exchange information and to support each other in the process of undergoing treatment therapy (yu et al., 2018). references brijnath, b., & antoniades, j. (2018). what is at stake? exploring the moral experience of stigma with indian-australians and anglo-australians living with depression. transcultural psychiatry, 55(2), 178–197. https://doi.org/10.1177/1363461518756519 chang, c. c., su, j. a., chang, k. c., lin, c. y., koschorke, m., & thornicroft, g. (2018). perceived stigma of caregivers: psychometric evaluation for devaluation of consumer families scale. international journal of clinical and health psychology, 18(2), 170–178. https://doi.org/10.1016/j.ijchp.2017.12.003 fitryasari, r., yusuf, a., nursalam, tristiana, r. d., & nihayati, h. e. (2018). family members’ perspective of family resilience’s risk factors in taking care of schizophrenia patients. international journal of nursing sciences, 5(3). https://doi.org/10.1016/j.ijnss.2018.06.002 fitryasari, rizki, yusuf, a., nursalam, tristiana, r. d., & nihayati, h. e. (2018). family members’ perspective of family resilience’s risk factors in taking care of schizophrenia patients. international journal of nursing sciences, 5(3), 255–261. https://doi.org/10.1016/j.ijnss.2018.06.002 flood-grady, e., kellas, j. k., & flood-grady, e. (2018). sense-making , socialization , and stigma : exploring narratives told in families about mental illness sense-making , socialization , and stigma : exploring narratives told in families about mental illness. health communication, 00(00), 1–11. https://doi.org/10.1080/10410236.2018.14310 16 flood-grady, e., & koenig kellas, j. (2018). sensemaking, socialization, and stigma: exploring narratives told in families about mental illness. health communication, 00(00), 1–11. https://doi.org/10.1080/10410236.2018.14310 16 hyun, m.-s., nam, k. a., & kim, h. (2018). effects of a brief empowerment program for families of persons with mental illness in south korea: a pilot study. issues in mental health nursing, 0(0), 1–7. https://doi.org/http://dx.doi.org/10.1080/0161 2840.2018.1453000 khoirunnisa, m. l., syuhaimie hamid, a. y., & catharina daulima, n. h. (2018). family experiences in communicating with family members experiencing social isolation after hospitalization. enfermeria clinica, 28, 116–121. https://doi.org/10.1016/s1130-8621(18)300494 krupchanka, d., chrtková, d., vítková, m., munzel, d., čihařová, m., růžičková, t., … sartorius, n. (2018). experience of stigma and discrimination in families of persons with schizophrenia in the czech republic. social science and medicine, 212, 129–135. https://doi.org/10.1016/j.socscimed.2018.07.01 5 morgan, a. j., reavley, n. j., ross, a., too, l. s., & jorm, a. f. (2018). interventions to reduce stigma towards people with severe mental illness: systematic review and meta-analysis. journal of psychiatric research. https://doi.org/10.1016/j.jpsychires.2018.05.01 7 ndetei, d. m., mutiso, v., maraj, a., anderson, k. k., musyimi, c., & mckenzie, k. (2015). stigmatizing attitudes toward mental illness among primary school children in kenya. social psychiatry and a. r. reong, et al. 90 | pissn: 1858-3598  eissn: 2502-5791 psychiatric epidemiology. https://doi.org/10.1007/s00127-015-1090-6 sawrikar, p., & muir, k. (2018). toward a familyoriented treatment approach for consumers and carers of mental illness. international journal of mental health, 47(2), 158–183. https://doi.org/10.1080/00207411.2017.13674 48 smith, m. l., yang, l. h., huang, d., pike, k. m., yuan, c., & wang, z. (2018). measuring internalized stigma of mental illness among chinese outpatients with mood disorders. international journal of culture and mental health, 0(0), 1–14. https://doi.org/10.1080/17542863.2018.14424 84 subandi, m. a., & good, b. j. (2018). shame as a cultural index of illness and recovery from psychotic illness in java. asian journal of psychiatry, 34(2010), 33–37. https://doi.org/10.1016/j.ajp.2018.04.005 wong, y. l. i., kong, d., tu, l., & frasso, r. (2018). “my bitterness is deeper than the ocean”: understanding internalized stigma from the perspectives of persons with schizophrenia and their family caregivers. international journal of mental health systems, 12(1), 1–15. https://doi.org/10.1186/s13033-018-0192-4 yu, s., kowitt, s. d., fisher, e. b., & li, g. (2018). mental health in china: stigma, family obligations, and the potential of peer support. community mental health journal, 54(6), 757–764. https://doi.org/10.1007/s10597-017-0182-z zhang, y., subramaniam, m., lee, s. p., abdin, e., sagayadevan, v., jeyagurunathan, a., … chong, s. a. (2018). affiliate stigma and its association with quality of life among caregivers of relatives with mental illness in singapore. psychiatry research, 265, 55–61. https://doi.org/10.1016/j.psychres.2018.04.044 50 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18910 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research perceptions of working mothers toward breastfeeding self-efficacy sylvia dwi wahyuni1, budi santoso2, mira triharini1, novri susan1,3 1 faculty of nursing, university of airlangga, surabaya indonesia 2 faculty of medicine, university of airlangga, surabaya indonesia 3 faculty of social science and politics, universitas airlangga, surabaya abstract introduction: the benefits of exclusive breast feeding are welldocumented; however, in indonesia, breast feeding rates fall well below global recommendations. one of the factors contributing to the low breastfeeding rates is the economic need for many mothers to work and workplaces not providing an adequate environment in which to do so. the aim of the research was to explore the meaning of breastfeeding selfefficacy from the working mothers’ perspective. methods: the methodology is phenomenology; hence, it is qualitative in nature. the study was conducted in an outpatient’s department in a hospital in surabaya, indonesia. participants: 8 working mothers working outside the home 40 hours a week, attend lactation class, indonesian, children ages 7 months to 2 years, and baby born healthy. results: there were six main themes identified in the women’s stories that related to self-efficacy and breastfeeding: 1) the source of breastfeeding self-efficacy, 2) the benefits of breastfeeding, 3) another woman's experience, 4) perception of workplace control, 5) estimated ability of self-confidence, and 6) decision of breastfeeding. the participants who decided to breastfeed for at least two years tended to think positively about breastfeeding. conclusion: the women had realistic expectations of the commitment that breastfeeding entailed even though they were faced with many workplace obstacles. this research provides the basis for recommendations for medical personnel, employers, government organizations and community centers to support breast feeding women who work with specific interventions so that these women can increase their breastfeeding self -efficacy and thereby increase the overall rates of breastfeeding women in indonesia. article history received: feb 27, 2020 accepted: april 1, 2020 keywords breastfeeding; self-efficacy; working mother; phenomenology contact sylvia dwi wahyuni  sylvia.dwiwahyuni@fkp.unair.ac.id  faculty of nursing, university of airlangga, surabaya indonesia cite this as: wahyuni, s, d., santoso, b., triharini, m., & susan, n. (2020). perceptions of working mothers toward breastfeeding self-efficacy. jurnal ners, special issues, 50-56. doi: http://dx.doi.org/10.20473/jn.v15i2.18910 introduction breastfeeding self-efficacy is an important thing in breastfeeding. breastfeeding self-efficacy is related to exclusive breastfeeding (dwi rahayu, 2018; rohani dwi ratnasari, 2018). it can show breastfeeding behavior by predicting: 1) whether a mother will breastfeed her infant or not, 2) how great are the efforts of a mother in order to be able to breastfeed her infant, 3) whether it can form a constructive or destructive mindset, 4) how a mother emotionally responds to every possible obstacle in breastfeeding activity (dennis, 2010). the impact of self-efficacy that is formed is the individual response and includes: choice of behavior, effort and persistence, thought patterns, and emotional reactions (dennis, 2010). then, the individual responses will determine the behavior to be taken by the mother, starting from the initiation of breastfeeding, breastfeeding actively to maintain lactation consistently. however, breastfeeding self-efficacy in women working in indonesia is still unexplained until now. the number of female workers in indonesia tends to increase every year. based on data from the central https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:sylvia.dwiwahyuni@fkp.unair.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 51 bureau of statistics in 2012, it is known that, from the total of 112 million workers in indonesia, 43 million are women. furthermore, most of the women who work in urban areas work as laborers/employees, amounting to 50.88% in 2018 (kementrian pemberdayaan perempuan dan badan pusat statistik, 2018). the working women also include women with the possibility of pregnancy, childbirth, and are in lactation. the 20th world breastfeeding week from 1-7 august, 2012, stated that the scope of exclusive breastfeeding targets by 2025 was at least 50% in infants aged 0-6 months. however, attainment of exclusive breastfeeding globally in 2016 was only around 38% (indonesia, 2018). meanwhile, the scope of exclusive breastfeeding in indonesia presented by the ministry of health in 2010 was 80%. however, the national coverage of exclusive breastfeeding is still far from the target. this is reinforced by the data from the directorate general of public health and, the ministry of health of the republic of indonesia in 2018 that exclusive breastfeeding in indonesia was 65.16% (kementrian kesehatan ri, 2018). moreover, the coverage of exclusive breastfeeding in east java was under 55% (kementrian kesehatan, 2018). the low exclusive breastfeeding rate in working mother is due to many factors. factors affecting breastfeeding are occupation, the role of health workers, and the promotion of formula milk (oktora, 2013). there is a significant relationship between breastfeeding self-efficacy and the success of exclusive breastfeeding in postpartum mothers (dwi rahayu, 2018). in addition, difficulties encountered during the working time are not having flexible rest time, rest time is too short, overlapping roles, and access to space maintaining a low privacy. the impacts force many working mothers to switch to formula and stop breastfeeding exclusively (weber et al., 2011). meanwhile, the maternity protection convention no.183 & 191 states that women have a right to a rest period of more than once a day or obtain permanent working hours to breastfeed their baby or express breast milk. it is also supported with government regulation no 33, 2012 about exclusive breastfeeding, chapter 30, section 3, which explains the workplace committee is obliged to provide special facilities for breastfeeding and/ or expressing breast milk according the company’s ability. giving breast milk is highly recommended. breast milk composition is suitable for the growth and development of the baby. the who recommends exclusive breastfeeding during the first six months and, along with a certain quality of complementary food, for breast milk to continue until two years or more as desired by mother and baby. the research shows that duration of breastfeeding has a great effect on the survival of babies in indonesia. babies having breastfeed duration of six months or longer have a survival rate 33.3 times greater than babies who are breastfed for less than four months and babies who are breastfed 4-6 months have a survival rate 2.6 times better than babies who are breastfed less than four months (besral, 2008). therefore, the kendangsari mother and child hospital, which is pro-breastfeeding, has a special program to support successful breastfeeding. the working mothers who attend classes will gain knowledge about lactation, including how to give breast milk. according to the theory of breastfeeding self-efficacy it is submitted that verbal persuasion of a lactation counselor will increase breastfeeding selfefficacy (dennis, 2010). based on the above, it can be concluded that working mothers should have the effort to exclusive breastfeeding. the effort is comparable to breastfeeding self-efficacy. meanwhile, research on breastfeeding self-efficacy in indonesia is still very little and is done quantitatively. thus, the researchers are interested in conducting research with qualitative methods to explore more about breastfeeding selfefficacy in working mothers. materials and methods this study used a qualitative method with phenomenological approach, paying attention to the emphasis on the subjective aspect of human behavior by trying to enter into the world of the conceptual subject in order to understand how and what meaning they related to the construction of breastfeeding self-efficacy in working mothers. type of phenomenology chosen was descriptive, which is a method to directly explore, analyze and describe certain phenomena, as free as possible of the estimated untested. the population in this study was eight working mothers who attend lactation classes in kendangsari mother and child hospital surabaya in april september 2013. the sampling technique was purposive sampling. participants in this study were selected based on the following inclusion criteria: 1) work outside the home 78 hours a day or 40 hours a week, 2) having children aged 7 months-2 years, 3) attend lactation classes in kendangsari mother and child hospital, 4) can communicate in indonesian, 5) babies are born healthy, and 6) are willing to become a participant by filling out a statement and sign the consent form, after being read and explained the purpose of the study by the researcher. researcher used mp3 recorder to collect data from participants, interview guides in the form of an official statement of semi-structured interview to help research questions addressing the purpose of research, field notes to record the response of nonverbal and conditions affecting the process of the interview and the researcher’s own self as a research instrument. this research was done by using in-depth interview with semi-structured questions. the use of open-ended questions is selected because the participants can use their own words. research used nine steps data interpretation according to colaizzi (creswell, 2007). s. d. wahyuni et al. 52 | pissn: 1858-3598  eissn: 2502-5791 results participants in this study were eight people with an age range of 28 years to 34 years. the work of participants varied, namely four civil servants, two private employees, one lecturer, and one bank employee. most participants (87.5%) have undergraduate education and one participant has a postgraduate level of education. the tribes of the participants varied, javanese (75%), madurese (12,5%), and bugis (12,5%). the religion of seven participants is islam and one christian. all participants had one child ranging in age from nine months to 22 months. the study identified six themes as the results after analysis. various themes will be elaborated based on research purpose. the sources of breastfeeding self-efficacy the sources of breastfeeding self-efficacy found as a result of this research are the role, physical condition, emotional state, socio-cultural, religious belief, support, and exposure to information from the mass media. the role delivered by participants is divided into four categories, namely: parental obligations, children's rights, affection, and emotional closeness. these can be illustrated in the following interview excerpts: “ breastfeeding is an obligation on parents ...” (p1). “the right of a child to get breast milk from a mother." (p6). "... our affection with him, we hug him, look at him ... he smiles every time he feeds his milk while looking at his eyes, hold his hand ..." (p5). "... breastfeeding brings the emotions of the child and the mother because if we breastfeed it feels like holding the child calm ..." (p4). emotional conditions and physical conditions experienced by working mothers were divided into four categories, namely depression, anxiety, inner conflict, and despair. this condition is illustrated in the following interview transcript: "... so i'm always pumping here (living room), pumping in the middle of the night. i tried to divert my thoughts by watching. suddenly not until a few seconds suddenly red, it's red ... it turns out blood ... bleeding. crying for me that's god that's my struggle ... "(p3). "... i doubt if the milk is sufficient or not, i doubt the caregiver at home to give breast milk, how much temperature should be according to body temperature because if it is too hot the child is not strong and his tongue can be white." (p5). "actually, i sometimes feel uncomfortable with office friends because they are busy, but i have to pump breast milk. i am not prohibited from pumping breast milk, but psychologically feel uncomfortable." (p2). "physical fatigue, because i am very tired with the trip about 1 hour and traffic jams when i have to go home and depart as well." (p1). the socio-cultural sub-theme is divided into two forms, namely: abstinence and suggestion. abstinence from ethnic groups is divided into two categories of food and activities. "you can't eat spicy foods, you can't eat spicy foods, you can't eat raw foods, if most spicy foods make your stomach hurt ..." (p3) "... the old people say that they eat a lot of vegetables, for example katuk ..." (p4) religious beliefs related to breastfeeding for working mothers are divided into two categories, namely: the role of mothers and determination. " i remember my child still in the womb, i opened the qur'an, read it yourself, weaning your child for up to two years."(p3) "breastfeeding is natural. as much as possible breastfeeding." (p2) benefits of breastfeeding the benefits of breastfeeding for children found in this study fall into three categories, namely: nutrition, immunity, and health. "... breast milk is said to be better than formula milk huh, the vitamin ..." (p8) "... the antibody is antibody, the breast milk content is also said to adjust to the age of the baby the womb is also different. it's hard to find milk like that, isn't it?" (p2) "... that breast milk is defeating medicine. suppose that breast milk is supported continuously, the impact so far is good." (p7) another woman’s experiences motivational behavior that emerged in the mothers was based on the experiences of other women in the form of reinforcement through recommendation. "there is a patient, dr. d, she also cannot breastfeed for a year, but she only feeds for up to six months. try to feed you for a long time. his son does not want to leave him pre-service. finally it can stop by itself."(p5) "... ms. k (p3) inspired me ..." (p7) perceptions of workplace control breastfeeding facilities are divided into two forms, namely: means and infrastructure. means of supporting breastfeeding in the workplace is in the form of a lactation room. "... there is no refrigerator in the office so bring a cooler bag." (p4) "... wear a lid (breastfeeding apron)." (p5) "... if in this workplace actually there are no nursery room support facilities, but i work here so i know the points where i can pump (smile)." (p1) "at first, i always pumped in the toilet, fortunately, the toilet in the office was clean and jurnal ners http://e-journal.unair.ac.id/jners | 53 the toilet was dirty. i'm in a clean toilet, but still the toilet category.” (p3) estimated ability of self-confidence participants' self-estimation is in the form of belief that they continue to breastfeed. the belief is divided into two categories, namely: optimistic and pessimistic. "i have to be able to breastfeed for up to two years." (p5) "... maybe it's true that it depends on our mindset if we can be optimistic, god willing, it will come out." (p7) "my child does not want to breastfeed even though the breast milk is still out, forced it still does not want ... when suckling is released because it does not come out much, i also pump, it finally stops by itself for a long time." (p8). decision of breastfeeding there are three categories according to the revelation of the participants, namely: giving only breast milk, breastfeeding and formula, and formula feeding alone. "if you want to give breast milk when the desire is there you must persevere, you can't be lazy." ((p3) “"basically, i am exclusively breastfeeding for 4.5 months. then, after that, mixed breast milk with formula milk." (p6) "now add formula milk ..." (p5) discussion source of breastfeeding self-efficacy there was one theme as to the source of breastfeeding self-efficacy, namely the significance of breastfeeding was stated as the owned concept of breastfeeding. motives of breastfeeding found as a result of this research are the role, physical condition, emotional state, socio-cultural, religious belief, support, and exposure to information from the mass media the role is divided into four, namely: the obligation of parents, children's rights, affection, and emotional closeness. motive of breastfeeding is as an obligation of parents in accordance with government regulations. the regulation states the obligation mothers to breastfeed their babies from birth until the baby is 6 months old (peraturan pemerintah ri no.33 tahun 2012, 2012). breastfeeding in the category of children's rights was stated by participants one and six according to the child protection law chapter i article 1 no. 12 and chapter ii, article 2 which explains that children's rights are part of human rights which must be guaranteed, protected and fulfilled by parents, families, communities, governments and the state. the children's rights include (1) non-discrimination, (2) the best interests of the child, (3) right to survival, and (4) development and respect for the child's opinion. in the law of the republic of indonesia number 36 year 2009 on health, article 128 paragraph 1, it reads that every baby is entitled to exclusive breastfeeding from birth for 6 (six) months, except on medical indication. in the breastfeeding category of affection felt by the participants, this means that emotional closeness is the meaning conveyed by most participants in this study. participants felt that by breastfeeding it enabled them to be closer to children. this is in accordance with the opinion of worthington-roberts (1993 , cited in bobak, 2004) that breastfeeding has many advantages, one of which is to improve maternal-child contact. in addition, the secretion of prolactin increases relaxation and prolactin and oxytocin enhance the mother-child attachment. emotional state experienced by working mothers is divided into four categories, namely depression, anxiety, inner conflict, and despair. maternal emotional conditions greatly affect milk production. bahiyatun (2009) stated that feelings of stress, distress, and discomfort experienced by a mother can hinder the amount of milk that comes out (bahiyatun, 2009). workplace can be a source of tension for working mothers. anxiety category found in this study is a psychological symptom of stress (gusti yuli asih, hardani widhiastuti, 2018). the phenomenon that first occurs in the working mother is that the mother is worried and thinks that her breast milk is not sufficient for the baby while she works. some working mothers who are breastfeeding are faced with a conflict between work and family roles. conflicts of roles found in this study are time-based conflicts and conflicts due to maternal anxiety in their role as employees and mother. mothers felt uncomfortable when having to pump breast milk during work time because mothers feel they are consuming work time for their personal interests. moreover, women also feel guilty when leaving the child all day at home and cared for by others. physical stress is a physical condition that felt by five participants. this is in accordance with the research from danso (2014) that 90.5% of the respondents said that the main challenge that hinders exclusive breastfeeding practice is their working status (danso, 2014). moreover, more than half of the respondents (51%) said they leave their children at home to their families due to work pressure and go to breastfeed their children when they have break or family members regularly bring the children to the workplaces for them to breastfeed their babies. furthermore, 30.5% of the respondents said they do not have adequate time to breastfeeding their children and 17.5% said there are no proper facilities for them to breastfeed their children at their various workplaces (danso, 2014). based on the research results, it was found foods most recommended by java tribal beliefs are vegetables, especially leaf katuk, with the aim of facilitate the production of breast milk. the belief is in s. d. wahyuni et al. 54 | pissn: 1858-3598  eissn: 2502-5791 accordance with the results of research conducted by juliastuti (2019) that there was significant effect of administration of katuk leaf decoction toward breastfeeding(juliastuti, 2019). seven of the eight participants are muslim and one participant is christian. the latter conveyed no particular religious beliefs related to breast-feeding children. the role of mothers and religious statutes in accordance with islamic teachings are contained in the koran, the holy book of muslims. the explanation is contained in paragraph 14 of the letter to luqman. support for working mothers is obtained from family, friends, and a lactation counselor while the shape of the support is provided in the form of emotional support, esteem support and informational support. emotional support and informational support are the most widely available according to participants in this study. the support findings in this study are similar to kahn and antonoucci's opinion (cited in orford, 1992), that sources of social support are divided into three categories, namely: a) support that comes from the individual who is always there throughout their life, who are always together and supportive, for example, close relatives, spouse (husband / wife) or close friends, b) support from other individuals that play only a small role in their life and tend to change according to the time. these sources include co-workers, neighbors, relatives and sepergaulan, c) support that comes from another individual who very rarely gives social support and has a rapidly changing role s. where appropriate, the source of support is the supervisor, expert /professional and family. forms of support identified in this study are also almost the same as those identified by house (in smet, 1994),that there are four types or dimensions of social support: emotional support, esteem support, which occurs through the expression of respect (appreciation), instrumental support, and support information. the internet is most frequently accessed by the participants in this study by reason of ease and speed of getting information sought about breastfeeding. benefits of breastfeeding the benefits of breastfeeding for children found in this study fall into three categories, namely: nutrition, immunity, and health. results were in accordance with roesli (2007) regarding the seven benefits of breastfeeding for babies. the first three benefits are as follows: 1) as a single food to satisfy all the growing needs of babies up to age 6 months, 2) improved endurance because it contains immunity factors so the child will be less sick, 3) protecting children from an allergy attack. the benefits of breastfeeding for mothers were found in the health category and are in accordance with the third point, namely: 3) to decrease the risk of premenopausal breast cancer, especially if the first lactation occurs before the age of 20 years and for at least 6 months (roesli, 2007). moreover, breastfeeding for at least up to 6 months reduces the likelihood of a mother suffering from breast cancer, uterine cancer, and ovarian cancer. protection against breast cancer is in accordance with the length of breastfeeding (roesli, 2009). breastfeeding can protect the baby from several infectious, atopic and cardiovascular diseases as well as leukemia, necrotizing enterocolitis, celiac disease, and inflammatory bowel disease. moreover, it has a positive impact on neurodevelopment, improving iq, reducing the risk of attention deficit disorder, and generalized developmental and behavioral disorders (brahm, 2020). additionally, the effect of breastfeeding on internalizing pathology likely represents a biosocial and holistic effect of physiological, and nutritive, and maternal-infant bonding benefits (liu et al., 2014) other women’s experiences motivational behavior that emerges in the mother based on the experiences of other women is in the form of reinforcement through recommendation. in this research, other women’s experience in motivating mothers to breastfeed comes from sister – in-law and friends of mothers who gave birth in kendangsari hospital . the experience of such persistence in breastfeeding, even though there are many obstacles and failure of breast-feeding because of the impact of separation of mother and baby when the mother works on duty outside the city, is positive. according to the research, diana (2007) women’s experience will affect the attitude of women in relation to breast-feeding in the future. a woman in the family or the environment having a habit of often seeing women who breastfeed their babies on a regular basis would then have a positive view of breastfeeding in accordance with everyday experience. perceptions of workplace control breastfeeding facilities are divided into two forms, namely: means and infrastructure. means of supporting breastfeeding in the workplace is in the form of a lactation room. in the job agency act no. 13 of 2003 article 83 of law no.13 of 2003 on labor it states, “entrepreneurs are under an obligation to provide proper opportunities to female workers/ labourers whose babies still need breastfeeding to breast-feed their babies if that must be performed during working hours..”this was further strengthened by act 36 of 2009 section 128 subsection (3), which states, "the provision of special facilities referred to in paragraph (2) is held in workplaces and public facilities." however, in reality, many workplaces do not provide space for female employees who are in the phase of lactation. in this study, a workplace that provides a lactation room was only obtained one participant. thus, working mothers have to find a place that can be utilized to express their breast milk. places used include toilets, rooms, warehouses, empty room or expressing breast milk from underneath a table. such conditions can disturb jurnal ners http://e-journal.unair.ac.id/jners | 55 the process of expressing breast milk because the mother needs a quiet and comfortable atmosphere when doing so. this is consistent with research that female workers do not obtain adequate information or support about breastfeeding and continued lactation after returning to work. workplace lactation facilities and programs are still insufficient, which could hinder lactation practice (hendarto et al., 2018). opportunity to express breast milk at the workplace is divided into two, namely: time and frequency, allowing flushing time during recess and in the afternoon before returning home. the frequency is divided into two times, three times, and more than three times, the highest frequency being twice to express the milk. in this study, the opportunity of working mothers to express milk was identified in break time and evening before leaving work. however, the mothers complained of difficulty to divide their time between prayers, lunch, and expressing breast milk. mothers does not get a special time or be allowed to cut working hours to express the milk. this is contrary to ilo convention no. 183 of 2000 article 10 of the breastfeeding stating that: 1) "a woman shall be provided with the right to one or more daily breaks or a daily reduction of hours of work to breastfeed her child" and 2) "the period during which nursing breaks or the reduction of daily hours of work are allowed, their number, the duration of nursing breaks and the procedures for the reduction of daily hours of work shall be determined by national law and practice. these breaks or the reduction of daily hours of work shall be counted as working time and remunerated accordingly." estimated ability of self-confidence confidence is divided into two categories, namely: optimism and pessimism. participants were optimistic to breastfeed for two years, always think positive, think realistic and take concrete action in an effort to achieve these goals despite the many obstacles. however, despite optimism in women to breastfeed for two years, effort is required to overcome various obstacles. in addition, mothers who were optimistic also had a relationship of friendship with fellow nursing mothers through group communication about breast milk, shared breastfeeding experiences, and in seeking the support of those closest and friends to encourage successful breastfeeding in children even though the mother had to work. mothers who were pessimistic that they could can breastfeed for up to two years looked resigned and desperate and decided to give formula in children. decision of breastfeeding behavioral choice is the decision of breastfeeding in children. according to the participants’ answers, there are three categories, namely: giving only breast milk, breastfeeding and formula, and formula feeding alone. mother's occupational status factors cause exclusive breastfeeding to be not achieved (timporok, 2018). in addition, the relationship of lactation with working performance and productivity does not motivate employers to invest in a workplacebased lactation promotion facility or program (hendarto et al., 2018). effort and failure conducted by the mother is in the category of firmness. in the context of this theme, firmness shows the intent of a working mother’s provision in maintaining breastfeeding a child. it can be seen from the persistence of the participants in this study. the third participant continued breastfeeding even though her breasts began to blister and bleed when pumped. although she had to endure pain when breastfeeding or pumping breast milk, these conditions were not sufficient to stop breastfeeding. meanwhile, five participants tried to pump breast milk by hand when on their way out of town and had left the pump breast behind, even though pumping breast milk by hand had never been done before. this was shown by the five participants patiently learning stimulating their nipples which have become small with frequent breastfeeding and pumping. the mindset that appears in the mothers is included in the category of commitment and perception. results of this experiment found three participants committed to breastfeeding children for up to two years. commitment of mothers to breastfeeding is one factor contributing to the success of breastfeeding in working mothers and makes mothers adapt and find solutions to any problems encountered related to breastfeeding because they have a strong desire to breastfeed children until the age of two years. this is in accordance with roesli (2007), who said factors of success in breastfeeding are: (1) commitment of mothers to breastfeed, (2) breastfeeding early (early initiation) that begins at birth, (3) engineering and nursing positions are correct for both mother and baby (4) breastfeeding on infant demand (on demand), and (5) breastfeeding granted exclusively (roesli, 2007). in this study, maternal perception identified is the perception that breast milk was in accordance with her mindset and a mothers’ state of state anxiety reduces the chances of exclusive breastfeeding(jalal et al., 2017). conclusion based on the research and analysis discussed in the previous chapter, it can be concluded that the source of breastfeeding self-efficacy in working mothers is the meaning of breastfeeding, such as the meaning of the role, emotions, physical condition, socio-cultural, religious beliefs, social support, and exposure to information from the mass media. meanwhile, the confidence to breastfeed the child in terms of positive and negative form of the benefits of breastfeeding is divided into two, namely: in the category of benefits for child nutrition, immunity, and health and maternal benefits in the form of health categories, namely avoiding breast cancer. s. d. wahyuni et al. 56 | pissn: 1858-3598  eissn: 2502-5791 motivation to behave is based on the views of others in the form of the experience of other women, while the perceptions of control are divided into three, namely: 1) amenities for breastfeeding lactation f, 2) the availability to breastfeed in the form of time and frequency flushing in the workplace, and 3). estimating the self-ability in the form of the categories of optimism and pessimism. the impact on maternal breastfeeding selfefficacy is as follows: 1) choice of feeding behavior is divided into three categories, namely: breastfeeding, breastfeeding and formula, and formula feeding, 2) effort and persistence in breastfeeding, and 3) the mindset that appears in the form of commitment and perception categories. identified commitment is a commitment to breastfeed a baby until two years. perceptions that arise in working mothers is that the mother's breast milk is out of the appropriate mindset. mindset is divided into two, namely: the mindset of reduced milk supply and not enough for the child and the mindset that breastfeeding mothers can still meet the needs of children. in addition, participants were optimistic about being able to breastfeed for two years, always think positive, think realistic and take concrete action in order to achieve the goal of breastfeeding until the child is aged two, although there are many obstacles. conflict of interest the author(s) declared no conflict of interest. acknowledgement thanks for universitas airlangga and also kendangsari mother and child hospital who gave permission to do this research. references bahiyatun. (2009). buku ajar asuhan kebidanan nifas normal. egc. besral, n. dan. (2008). durasi pemberian asi terhadap ketahanan hidup bayi. 12(2), 47– 52. brahm, p. (2020). benefits of breastfeeding and risks associated with not breastfeeding beneficios de la lactancia materna y riesgos de no amamantar. 88(1), 15–21. creswell, j. . (2007). qualitative inquiry and research design choosing among five approaches. sage publication. danso, j. (2014). examining the practice of exclusive breastfeeding among professional working mothers in kumasi metropolis of ghana. 1(1), 11– 24. dennis, c. l. (2010). mothering transitions research. dwi rahayu. (2018). hubungan breastfeeding self efficacy dengan keberhasilan pemberian asi eksklusif. jurnal ilmu kesehatan, 7(1), 247–252. gusti yuli asih, hardani widhiastuti, r. d. (2018). stres kerja (1st ed.). semarang university press. hendarto, a., soemarko, d. s., sungkar, a., khoe, l. c., & vandenplas, y. (2018). challenges and supports of breastfeeding at workplace in. 21(4), 248–256. indonesia, i. bidan. (2018). pekan asi sedunia (world breastfeeding week). jalal, m., dolatian, m., mahmoodi, z., & aliyari, r. (2017). the relationship between psycological factors and mayernal social support to breastfeeding process. electronic physicianlectronic physician, 9(1), 3561–3569. juliastuti. (2019). efektivitas daun katuk (sauropus androgynus) terhadap kecukupan asi pada ibu menyusui. indonesian journal for health science, 3(1), 1–5. kementrian kesehatan, r. (2018). riskesdas. kementrian kesehatan ri. (2018). data-daninformasi_profil-kesehatan-indonesia-2018.pdf. kementrian pemberdayaan perempuan dan badan pusat statistik. (2018). profil perempuan indonesia 2018. liu, j., leung, p., & yang, a. (2014). breastfeeding and active bonding protects against children’s internalizing behavior problems. 76–89. https://doi.org/10.3390/nu6010076 oktora, r. (2013). gambaran pemberian asi eksklusif pada ibu bekerja di desa serua indah , kecamatan jombang , tangerang selatan description of exclusive breastfeeding among working mother in serua indah village , jombang subdistric , tangerang selatan rasti oktora. jurnal kesehatan reproduksi, 1(1), 30–40. peraturan pemerintah ri no.33 tahun 2012, (2012). roesli, u. (2007). mengenal asi eksklusif. trubus agriwidya. roesli, u. (2009). panduan praktis menyusui. pustaka bunda, grup puspa swara. rohani dwi ratnasari. (2018). kepercayaan diri ibu pada pemberian asi eksklusif di wilayah desa sentolo kulonprogo yogyakarta. universitas ’aisyiyah. timporok, a. g. a. (2018). hubungan status pekerjaan ibu dengan pemberian puskesmas kawangkoan. 6, 1–6. weber, d., janson, a., nolan, m., wen, l. m., & rissel, c. (2011). female employees ’ perceptions of organisational support for breastfeeding at work : findings from an australian health service workplace. international breastfeeding journal, 6(1), 19. https://doi.org/10.1186/1746-4358-619 142 model pembelajaran reproduksi sehat melalui kelompok sebaya pada remaja putri (reproductive health learning model through adollecent peer) awatiful azza*, cipto susilo* *fakultas ilmu kesehatan universitas muhammadiyah jember. email: awatiful.azza@yahoo.com abstrak pendahuluan: masalah remaja merupakan kondisi yang perlu diperhatikan dalam pembangunan nasional di indonesia. masalah remaja terjadi, karena mereka tidak dipersiapkan mengenai pengetahuan tentang aspek yang berhubungan dengan masalah peralihan dari masa anak ke dewasa. salah satu masalah yang dihadapi oleh remaja saat ini adalah tentang kesehatan remaja terutama terkait dengan kesehatan reproduksi. metode: penelitian ini menggunakan pendekatan kuantitatif pra eksperimen dengan pendekatan pre – post test design, dengan tujuan menyusun model pembelajaran reproduksi sehat melalui kelompok sebaya di pesantren tradisional dan menganalisis aplikasi dari pembelajaran melalui kelompok sebaya terhadap pengetahuan santriwati tentang reproduksi sehat. sampel penelitian ini adalah santriwati yang ada di pesantren gunung sepikul berjumlah 50 santriwati, dengan tehnik purposive sampling. hasil analisis dengan menggunakan uji spearman’s rho didapatkan nilai p value 0,00 dimana nilai tersebut < lebih kecil dari 0,05 sehingga dapat disimpulkan bahwa ada pengaruh pembelajaran reproduksi sehat melalui kelompok sebaya terhadap pemahaman santriwati. diskusi: pondok pesantren perlu memberikan kurikulum tentang kesehatan reproduksi agar meningkatkan pemahaman santriwati dalam berperilaku hidup sehat terkait dengan organ reproduksinya. kata kunci: pesantren, tutor sebaya, kesehatan reproduksi abstract introduction: teen problems are conditions that need to be considered in national development in indonesia. teenagers problems occur, because they are not prepared regarding knowledge of aspects related to the problem of transition from childhood to adulthood. one of the problems faced by teenagers today is about the health of adolescents, especially related to reproductive health. method: this study uses a quantitative approach pre experiment with pre post test design, the purpose of research, construction of models of healthy reproductive learning through peer groups in traditional schools and analyze the application of learning through peer group against knowledge female students about reproductive health. the sample was female students in pesantren gunung sepikul amounted to 50 female students, with purposive sampling technique. result: of analysis using spearman's rho test ,p value of 0.00 obtained value where the value is < less than 0.05 so it can be concluded that there is a learning effect of reproductive health through peer groups for knowledge female students. discussion: boarding schools need to provide curriculum on reproductive health in order to improve the understanding of female students in healthy living behavior associated with reproductive organs. keywords: boarding school, peer tutors, reproductive health _______________________________________________________________________________________________ pendahuluan permasalahan kesehatan reproduksi remaja saat ini menjadi acuan standar tentang perilaku remaja dalam menjaga reproduksinya. data menunjukkan bahwa kondisi remaja saat ini baik di perkotaan maupun perdesaan tidak jauh berbeda terkait dengan peningkatan perilaku negative terutama dalam hal kesehatan reproduksi. perilaku negatif yang dimaksud adalah semakin maraknya seks pra-nikah. namun, menarik dipertanyakan adalah apakah mereka memahami resiko-resiko seksual yang menyertainya? berdasarkan studi di 3 kota jawa barat (2009) tentang penyebab perilaku seks pra nikah adalah remaja putri lebih takut pada resiko sosial (antara lain: takut kehilangan keperawanan/ virginitas, takut hamil di luar nikah karena jadi bahan gunjingan masyarakat) dibanding resiko seksual, khususnya menyangkut kesehatan reproduksi dan kesehatan seksualnya (iriyanti 2003). padahal kelompok usia remaja merupakan usia yang paling rentan terinfeksi hiv/aids dan penyakit menular seksual (pms) lainnya. bahkan, dalam jangka waktu tertentu, ketika remaja putri menjadi ibu hamil, maka kehamilannya dapat mengancam kelangsungan hidupnya atau janin yang dikandungnya (azza 2009). di dunia dewasa ini jumlah orang yang terinfeksi hiv/aids mencapai 39,4 juta, dari data tersebut perempuan cenderung berpeluang besar tertular hiv/aids yaitu sekitar 17,6 juta penderita. data yang ada di indonesia menunjukkan jumlah penularan hiv/aids jurnal ners vol. 11 no. 1 april 2016: 142-146 143 perhari 14 ribu, dan 6.000 kasus dialami oleh perempuan (hutapea 2003). data lain dari dinas kesehatan kabupaten jember jawa timur menetapkan status merah terhadap penyebaran hiv/aids. status ini ditetapkan karena terus meningkatnya penderita hiv/aids tiap tahunnnya (azza 2009) pada dasarnya, kerentanan perempuan, bukan hanya karena faktor biologisnya, namun juga secara sosial dan kultural kurang berdaya untuk menyuarakan kepentingan/haknya pada pasangan seksualnya demi keamanan, kenyamanan, dan kesehatan dirinya. kepasipan dan ketergantungan sebagai karakter feminin yang dilekatkan pada perempuan juga melatari kerentanan tersebut. faktor ekonomi juga mengkondisikan kerentanan perempuan. model pembelajaran reproduksi sehat melalui teman sebaya yang tersusun secara sistematis dan sebagai strategi dalam pembangunan kesehatan merupakan upaya untuk membangun sumber daya generasi muda serta untuk membangkitkan kesadaran akan potensi yang dimilikinya dalam upaya untuk meningkatkan status kesehatan reproduksinya. bahan dan metode penelitian ini menggunakan pendekatan partisipatif yang dilakukan dalam 2 (dua) tahap yaitu; 1) mengidentifikasi dukungan pengelola pesantren, dan masyarakat tentang kurikulum kesehatan reproduksi di pesantren tradisional dan menguatkan peran tutor sebaya dalam pembelajaran reproduksi sehat di pesantren tradisional putri dengan menggunakan metoda participatory action research (par), hasil identifikasi tersebut digunakan untuk menyempurnakan model pembelajaran kesehatan reproduksi melalui teman sebaya 2) dilanjutkan dengan pelaksanaan uji coba model yang komprehensif dan kompleks yang melibatkan seluruh remaja putri serta pengelola pesantren dan pendampingan kelompok sebaya oleh tim peneliti dan pendampingan pelaksanaan model. selanjutnya peneliti melakukan evaluasi hasil pengembangan model pembelajaran reproduksi sehat yang berkelanjutan untuk peningkatan kesehatan fisik dan sosial bagi remaja putri. penelitian ini dilakukan di pondok pesantren tradisional putri di kabupaten jember yaitu pesantren miftahul hasan gunung sepikul pakusari jember, dengan melibatkan remaja putri di pondok pesantren tradisional miftahul hasan gunung sepikul pakusari kabupaten jember dengan jumlah 50 orang, pengelola pondok pesantren tradisional dengan jumlah 5 orang. kegiatan ini dilakukan bekerjasama dengan kementrian agama, dan dinas pendidikan kabupaten jember. data yang dikumpulkan dalam penelitian ini meliputi data primer dan data sekunder. data primer diperoleh secara langsung sebagai sumber data yaitu melalui observasi, kuesioner dan wawancara yang dilakukan kepada remaja putri. penelitian ini juga membutuhkan data sekunder. data sekunder diperoleh dari tokoh masyarakat, pengelola pondok pesantren melalui hasil focus group discussion (fgd), selain itu peneliti juga membutuhkan sumber lain yang relevan dengan kebijakan serta program terkait dengan kesehatan reproduksi remaja. data sekunder yang dikumpulkan meliputi: 1) pemahaman pengelola pesantren tradisional tentang kurikulum kesehatan reproduksi dalam pendidikan pesantren, 2) peran serta masyarakat dalam mendukung pembelajaran reproduksi sehat di pesantren tradisional, 3) peran pemerintah daerah (kementrian agama dan dinas pendidikan) dalam mendukung pemberian edukasi tentang kesehatan reproduksi bagi remaja. terkait kebijakan pemerintah tentang kesehatan reproduksi, maka peneliti melakukan identifikasi dan analisa data pada dinas kesehatan kabupaten serta dinas sosial. pada pelaksanaan penelitian, 50 sampel santriwati dibagi menjadi 5 kelompok dengan masing-masing kelompok teridiri dari 10 santriwati. selanjutnya tiap kelompok ditunjuk satu sebagai tutor bagi kelompoknya. peneliti memberikan kuesioner kepada seluruh sampel sebelum perlakuan dan kemudian dilanjutkan dengan pelatihan tutor oleh peneliti untuk bisa menjadi tutor bagi kelompoknya. tutor yang dipilih adalah santriwati yang cakap, mudah bergaul,mampu menyampaikan informasi dan mempunyai wawasan yang luas. selanjutnya pelaksanaan tutor sebaya tentang kesehatan reproduksi berlangsung selama 1 bulan dengan pendampingan peneliti. dan setelah itu peneliti membagikan kuesioner untuk dilakukan analisis setelah tindakan pada 50 sampel. pengolahan dan analisa data yang diperoleh baik secara dokumenter maupun dari lapangan dianalisa secara kuantitatif dan kualitatif. untuk mengetahui pengaruh teman sebaya terhadap pemahaman santriwati di pesantren tentang kesehatan reproduksi analisis model pembelajaran reproduksi sehat (awatiful azza, cipto susilo) 144 yang dilakukan dengan menggunakan uji sperman rho. sedangkan untuk temuan data melalui fgd dianalisis secara kualitatif. hasil data tentang usia pertama kali santriwati di pesantren miftahul hasan mengalami menarche berdasarkan kuesioner pada sampel didapatkan bahwa dari 50 sampel, sebagian berusia 12 tahun (50%). jika dilihat dari rentang usia santriwati yang berada di pondok pesantren miftahul hasan berkisar antara 11-16 tahun dan kebanyakan santriwati berusia 14 tahun yaitu sebanyak 18 santriwati (36 %). lama santriwati berada di pesantren berkisar antara 14 tahun, dari data penelitian ditemukan bahwa sebagian santri berada di pesantren selama 3 tahun (50%). ada tiga katagori pengetahuan yang berdasarkan analisis terhadap responden yitu pengetahuan baik, cukup dan kurang. hasil cross tabulasi pada kelompok sebelum diberi perlakuan didapatkan bahwa pengetahuan santriwati adalah 20% pengetahuan baik, 68% pengetahuan sedang dan 12% pengetahuan kurang. untuk pengetahuan pada kelompok setelah diberi perlakuan didapatkan pengetahuan baik 70%, pengetahuan cukup 20% dan pengetahuan kurang 10%. hasil uji menggunakan spearman’s rho menunjukkan nilai 0,00 dimana nilai tersebut lebih kecil dari 0,05 sehingga dapat ditarik kesimpulan bahwa ada pengaruh pembelajaran reproduksi sehat terhadap pemahaman santriwati. berdasar temuan tersebut maka model pembelajaran reproduksi sehat menjadi penting untuk diterapkan di pesantren tradisional. untuk keeratan hubungan atau koefisien korelasi pada penelitian ini didapatkan bahwa berada pada 0,627 artinya berada pada korelasi yang tinggi. sehingga dapat disimpulkan bahwa pengetahuan santriwati 62,7 % dipengaruhi oleh tutor sebaya, dan sisanya dipengaruhi oleh faktor lain. pembahasan kesehatan reproduksi menyangkut proses, fungsi dan system reproduksi pada seluruh tahap kehidupan. untuk mendapatkan reproduksi yang sehat dan bertanggung jawab memerlukan bimbingan moral yang baik (crow 2004). dalam kaitannya pemasyarakatan kehidupan reproduksi yang sehat dibutuhkan tidak hanya kekuatan lembaga (melalui tokoh), namun juga sangat ditentukan ketepatan materi yang disampaikan, cara penyampaian dan kepada siapa materi itu disampaikan. santri di pesantren merupakan remaja yang membutuhkan pengetahuan serta pendidikan mengenai seksualitas dan kesehatan reproduksi. tabel 1. pengetahuan sebelum dan sesudah pembelajaran reproduksi sehat di pesantren miftahul hasan pengatahuan sebelum pengetahuan sesudah spearman's rho pengatahuan sebelum correlation coefficient 1.000 .627 ** sig. (2-tailed) . .000 n 50 50 pengetahuan sesudah correlation coefficient .627 ** 1.000 sig. (2-tailed) .000 . n 50 50 **correlation is significant at the 0.01 level (2-tailed). tutor sebaya santriwati santriwati santriwati santriwati jurnal ners vol. 11 no. 1 april 2016: 142-146 145 gambar 1: model pembelajaran reproduksi sehat melalui tutor sebaya di pesantren miftahul hasan jember hasil penelitian di pesantren salaf ini menunjukkan bahwa pembelajaran kesehatan reproduksi ini kebanyakan hanya diberikan melalui media kitab kuning. pembelajaran seksualitas melalui media kitab kuning lebih banyak memberikan pendidikan normatif syari’ah, akhlak dan belum terkait dengan kesehatan reproduksi. pembelajaran seksualitas lewat kitab kuning ini diberikan kepada santri dengan materi seksualitas dan kesehatan reproduksi melalui kitab risalatul mahid. materi-materi yang dijelaskan dalam kitab risalatul mahid yaitu sebagian besar membahas mengenai haid, nifas dan wiladah serta cara bersucinya setelah mengalami haid, nifas ataupun wiladah. di dalamnya juga dijelaskan mengenai tata cara hubungan suami istri tetapi hanya dijelaskan garis besarnya saja. data tentang dukungan pengelola pesantren didapatkan melalui kegiatan wawancara dengan ustadz dan pimpinan pesantren, serta melalui diskusi dalam kegiatan fgd. hasil temuan peneliti didapatkan gambaran bahwa sistem pembelajaran yang ada dalam pondok pesantren tradisional mempunyai keunikan dibandingkan dengan sistem yang diterapkan dalam pendidikan pada umumnya. tidak ada kurikulum baku yang dikembangkan dalam pesantren tradisional atau salaf. masing-masing pesantren diberi kewenangan untuk menyusun kurikulum sesuai kebutuhan santriwati. penelitian yang dilakukan di tempat pondok pesantren salaf ini menunjukkan hasil yang tidak jauh berbeda tentang pengelolaan pesantren, yaitu: 1) memakai sistem tradisional yang mempunyai kebebasan penuh dibandingkan dengan sekolah modern, sehingga terjadi hubungan dua arah antara santri dan kiyai; 2) kehidupan di pesantren menempatkan semangat demokrasi karena mereka praktis bekerja sama mengatasi problema non-kurikuler mereka; 3) para santri tidak mengharap penghargaan kependidikan yaitu perolehan gelar dan ijazah, karena sebagian besar pesantren tidak mengeluarkan ijazah, sedangkan santri dengan ketulusan hatinya masuk pesantren tanpa adanya ijazah tersebut. hal itu karena tujuan utama adalah mencari keridlaan allah swt dan ilmu untuk diamalkan. namun ada temuan yang berbeda dengan pesantren miftahul hasan, pengelola pesantren memberikan kebebasan santrinya untuk mengikuti kegiatan ujian paket c, karena sesuai dengan tuntutan kebutuhan santri setelah keluar dari pesantren, yaitu: a) sistem pondok pesantren mengutamakan kesederhanaan, idealisme, persaudaraan, persamaan, rasa percaya diri, dan keberanian hidup; b) pembelajaran kesehatan reproduksi selama ini dipelajari di media kitab kuning; c) hal-hal yang telah dipelajari lebih banyak memberikan pendidikan normatif syari’ah, akhlak dan belum terkait dengan kesehatan reproduksi. pembelajaran seksualitas lewat kitab kuning ini diberikan kepada santri dengan materi seksualitas dan kesehatan reproduksi melalui kitab risalatul mahid. materi-materi yang dijelaskan dalam kitab risalatul mahid yaitu sebagian besar membahas mengenai haid, nifas dan wiladah serta cara bersucinya setelah mengalami haid, nifas ataupun wiladah. di dalamnya juga dijelaskan mengenai tata cara hubungan suami istri tetapi hanya dijelaskan garis besarnya saja. hasil fgd pengelola pesantren bersama masyarakat menunjukkan bahwa pengelola pesantren setuju dimasukkan pembelajaran kesehatan reproduksi, namun harus di sampaikan dengan pendekatan yang santun dan tidak terlalu vulgar. selama ini santri belum mendapatkan materi khusus tentang kesehatan reproduksi. santriwati hanya mendapatkan pelajaran kesehatan reproduksi berdasar tinjauan hukum islam. kelompok sebaya adalah sekelompok siswa yang telah tuntas terhadap bahan pelajaran, memberikan bantuan kepada siswa yang mengalami kesulitan dalam memahami bahan pelajaran yang dipelajarinya. bantuan belajar oleh teman sebaya dapat menghilangkan kecanggungan. bahasa teman sebaya lebih mudah dipahami selain itu dengan teman sebaya tidak ada rasa enggan, rendah diri, malu, dan sebagainya, sehingga diharapkan siswa yang kurang paham tidak segan-segan untuk mengungkapkan berbagai kesulitan yang dihadapinya (desmita 2009). tutor sebaya merupakan salah satu strategi pembelajaran untuk membantu memenuhi kebutuhan peserta didik. ini merupakan pendekatan kooperatif bukan kompetitif. rasa saling menghargai dan mengertu dibina diantara peserta didik yang bekerjasama. pondok pesantren memiliki karakteristik unik dari lembaga-lembaga model pembelajaran reproduksi sehat (awatiful azza, cipto susilo) 146 pendidikan lainnya,dan karekateristik ini tidak dimiliki oleh lembaga pendidikan lain selain pesantren. ada beberapa metode pengajaran yang diberlakukan di berbagai pesantren, diantaranya adalah: sorogan, weton/bandungan, halaqoh, hafalan, hiwar, bahtsul masa’il, fathul kutub, dan muqoronah (nurhasannah 2006) dalam perkembangannya santri belajar dengan menggunakan banyak sumber (dian 2010). dalam proses pendidikan kesehatan reproduksi di pesantren, ustadzah bukan satusatunya sumber yang dapat dijadikan pedoman oleh santri. hal ini berarti santri harus mandiri, tidak tergantung dan tidak mengandalkan materi pendidikan kesehatan reproduksi dari ustadzah semata. dengan memanfaatkan berbagai sumber belajar yang tersedia santri berusaha aktif mencari sumber belajar yang berkaitan dengan materi pendidikan kesehatan reproduksi. metode pembelajaran tutor sebaya mampu meningkatkan pemahaman santri tentang kesehatan reproduksi secara mandiri dan lebih bertanggung jawab. simpulan dan saran simpulan pesantren tradisional merupakan pendidikan non formal yang mempunyai andil cukup besar dalam membantu meningkatkan kecerdasan bangsa. tidak adanya kurikulum yang baku tentang kesehatan reproduksi menyebabkan sebagian besar santriwati belum mendapatkan pemahaman yang benar tentang kesehatan reproduksi, selama ini mereka hanya mempelajara kesehatan reproduksi berdasar pada tinjauan agama. pengetahuan santriwati sebelum dilakukan pembelajaran reproduksi sebagian besar cukup dan setelah dilakukan pembelajaran reproduksi sehat di pesantren miftahul hasan mayoritas menjadi baik. ada pengaruh pembelajaran reproduksi sehat yang diberikan dipesantren tradisional terhadap pemahaman santriwati. saran perlu kerjasama lintas program dan sektor dalam meningkatkan sosialisasi kesehatan reproduksi pada remaja baik dilingkungan umum maupun di pesantren. perlu diberikan penguatan bagi pengelola pesantren agar pembelajaran kesehatan reproduksi menjadi materi yang disampaikan di pesantren tidak hanya dari tinjauan agama, namun juga tinjauan bio-psiko dan sosial. kepustakaan azza, a., 2009. beban perempuan penderita hiv/aids dalam perspektif gender. fakultas ilmu kesehatan universitas muhammadiyah jember. crow, 2004. educational psychology. american book company, new york. desmita, 2009. model teman sebaya sebagai media pembelajaran, jakarta: rineka cipta. dian, 2010. pondok pesantren dalam persepektif pendidikan islam indonesia. skripsi. stain jember. hutapea, r., 2003. no title, jakarta: rineka cipta. iriyanti, 2003. no title, jakarta: egc. nurhasannah, 2006. pola pendidikan pesantren: studi terhadap pesantren sekota pekanbaru. fakultas tarbiyah dan keguruan uin suska riau. 10 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.12734 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research knowledge, family support and self-reliance capital when caring for low birth weight babies erlina suci astuti1, nursalam nursalam2, shrimarti rukmini devy1 and risa etika3 1 faculty of public health, universitas airlangga, east java, indonesia 2 faculty of nursing, universitas airlangga, east java, indonesia 3 department of neonatology, dr. soetomo general hospital surabaya, east java, indonesia abstract introduction: low birth weight (lbw) infants are very susceptible to illness. lbw treatment with the principle of preventing infection is very important at home. the purpose of this study was to determine the relationship between maternal knowledge and family support with the prevention of infection at home. methods: this study used a correlation design. the samples were 160 mothers who had low birth weight infants with inclusion criteria mothers give birth to babies weighing less than 2,500 grams with ages 0-2 months. the samples were obtained through purposive sampling. the dependent variable was the mother's ability to prevent infection while the independent variable was the mother's knowledge and family support. the instruments used were questionnaires. this research analyzed using spearman rho. results: the results showed that there was a strong correlation between knowledge and the ability to prevent infection in treating low birth weight (r = 0.696; p = 0.00) and that there was a moderate correlation between family support and infection prevention ability when treating a low birth weight (r = 0.54. p = 0.000). conclusion: factors of maternal knowledge about infection prevention and family support need to be considered in increasing the ability of mothers to care for babies with lbw. the factor of maternal knowledge about prevention of infection has a strong correlation value when compared to family support factors. further research is needed on the model of increasing maternal knowledge about lbw infants during home care. article history received: april 10, 2019 accepted: may 29, 2019 keywords low birth weight; family support; knowledge; independence of the mother contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga east java, indonesia cite this as: astuti, e. s., nursalam, n., devy, s. r., & etika, r. (2019). knowledge, family support and self-reliance capital when caring for low birth weight babies. jurnal ners, 14(1), 10-15. doi:http://dx.doi.org/10.20473/jn.v14i1.12734 introduction low birth weight (lbw) babies are babies born with a body weight of less than 2,500 grams. the number of low birth weight infants in indonesia is also quite high. riskesdas in 2013 showed that the percentage of low birth weight of infants was 10.2%. the birth rate of low birth weight infants in east java was 11.2%, which is slightly higher than the national figure (ri ministry of health, 2014; who, 2014). the high prevalence of low birth weight babies in java, especially east java because in addition to the large population resulting in a high number of births, the culture of women in java as workers to help the family economy where most respondents have less family income, fatigue due to work, psychological conditions, maternal age at pregnancy and maternal nutritional factors during pregnancy. the physiological condition of low birth weight has an impact on various health problems that arise such as hypothermia, the lack of ability to consume nutrients and infection (ri ministry of health, 2010; world health organization, 2011; akter, dawson and sibbritt, 2016). infection and sepsis are health problems related to a low birth weight during the neonatal period that can lead to death. the incidence rate of infection in the neonatal period can reach 17% (respiratory infections) and the incidence rate of sepsis can reach 22%. low birth weight babies are the second leading https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.127343 jurnal ners http://e-journal.unair.ac.id/jners | 11 cause of neonatal death in indonesia, which is 32% (ri ministry of health, 2014). the survey results in hospitals in malang, east java, found that 10.4% of the total lbw infants treated in the perinatology room were lbw infants who experienced re-hospitalization, meaning that after returning from the neonatology room before they were one-month-old, the baby had to be hospitalized again because of serious health problems. health problems that often occur in lbw infants are being febrile, infection, dehydration, shortness of breath, vomiting, and diarrhea. the health condition of a low birthweight after returning from home care must be maintained properly. mothers, as the primary care providers for lbw, must be able and independent both in knowledge, attitude and actions when it comes to caring for their babies, especially in terms of the prevention of infection. the ability and independence of the mother in treating lbws is determined by their knowledge, mental readiness and skills when carrying out baby care. the results of the research showed that the mother's knowledge about the care of the baby at home found that the mother's knowledge in relation to the effort to prevent infection was 44.45% with less knowledge (rita et al., 2008). infection is the main cause of death in lbw infants. infection in lbws at home can be due to the inability of the mothers to care for babies cleanly, as well as environmental factors such as exposure to infection in both the human and living environment. the risk of infection in lbws is also due to the body's immunity factor which is still lacking. the body is not able to defend itself against any infections that enter the body. mothers who have lbw babies often experience obstacles in relation to carrying out their roles. one of the obstacles is family support. family support is very important when the mothers experience role changes, stress and further care problems when at home (singer et al., 2017; jilian ireland et al., 2016; mehler et al., 20 14). mothers need knowledge, information and care support from the environment from both health and family officers in the first 6 months after birth (warren, 2005). family support is very important in order to improve the ability and confidence of the mothers in caring for babies however, family support in relation to the care of lbw babies is sometimes less than optimal. dewi purwanti et al (2012), in her study, said that family support for independence and the role of mothers when caring for lbw babies was less supportive (53%). a lack of maternal knowledge about lbw, an unstable psychological condition and lbw conditions that require special care and family support will all have an impact on the ability of the mothers when it comes to caring for lbw. lbw treatments that are not particularly good at preventing infection will cause the babies to get sick. the purpose of this study was to provide information on maternal knowledge about the prevention of lbw infection and its relationship with family support and the ability of the mothers to prevent infection. materials and methods this study used a correlation research design that explains the relationship between knowledge and family support with the ability of the mothers to prevent infection when treating an infant with lbw. this research was conducted between september to november 2018 in malang, east java. this study involved 160 respondents obtained by purposive sampling from 190 respondents. the inclusion criteria were mothers who gave birth to lbw babies (body weight less than 2,500 grams with a baby aged 0-2 months and infants without any congenital defects). the dependent variable was the mother's ability to provide infection care while the independent variable was the mother's knowledge and family support. the data was obtained through a questionnaire. the demographic data was assessed using one item that covered age, education, employment, childbirth history related to a previous low birth weight infant, family income and information on low birthweight care. the data was measured using a closed questionnaire. the mother's knowledge of preventative care for their infant was measured using a modified questionnaire on low birth weight care (ministry of health, 2014). ten questions were used to assess family knowledge related to the definition, causes, signs and symptoms, ways and effects of the prevention of infection when treating lbw babies. the scale of the data in this questionnaire was ordinal with 1 (less) to 3 (good). the family support variable instrument was compiled based on a measurement questionnaire by gareth d. mercer (2015) with modifications adjusted to fit families who had infants with low birthweight. this instrument consisted of statements about information support, assessment, instrumentality or means, emotional support and social network support with an ordinal data scale from 1 (less) to 3 (good). the instrument of the ability of the mothers to take preventive measures was measured through observations and interviews based on lbw care books and health manuals (ministry of health of the republic of indonesia, 2016; ministry of health, 2010) with 6 items focused on maternal activities. the collected data was categorized into ordinal data scales from 1 (less) to 3 (good). all instruments were tested for validity and reliability in a pilot study consisting of 15 respondents. each item in the statements had validity (r> 0.529) and each questionnaire also achieved reliability (> 0.8). descriptive analysis was used for the characteristics of the respondents. the analysis of the relationship of the dependent variables independently was done using spearman rho with a statistical significance level set at p <0.05. ethical e. s. astuti et al. 12 | pissn: 1858-3598  eissn: 2502-5791 clearance was provided by the faculty of public health ethics team number 504kepk on september 3rd, 2018. results characteristics of the respondents the characteristics of the respondents have been presented in table 1. the majority of respondents were aged between 20 and 35 years old. the most common education obtained was that of junior high school. the job of housewife was the most common the monthly family income was most commonly less than rp. 2 .000.000. most of the respondents had had children with a previous low birthweight. description of the variables the description of the variables has been explained in table 2. the average maternal knowledge about the prevention of infection in neonates was 2.75 (sd = 0.49). the average family support felt by the respondents was 2.51 (sd = 0.61). the ability of the mother to prevent infection when treating lbws at home averaged 2.73 (sd = 0.49). variable correlation the calculated correlation between infection prevention and the ability to treat an infant with a low birth weight as well as the correlation between family support and infection prevention care for infants with a low birth weight. the test results show that there was a relationship between family support and infection prevention in lbws (r = 0.54; p = 0.000). there is a relationship between a low birth weight and the prevention of care and between family support and infection prevention for low birth weight infants (table 3). the test results show that there was a relationship between family support and infection prevention ability (r = 0.54; p = 0.000). discussion knowledge is the basic foundation of behavior. the knowledge of baby care for mothers is very important so then the mothers are able to care for their babies well. the research findings showed that in relation to the mothers' knowledge of infection prevention, 78.8% at a good level and the practice of infection prevention in caring for babies was also good at 76.3%. the results of good knowledge from 78.8% of the respondents showed that the awareness of and willingness to seek out information in the sample of mothers who had lbw infants was very high because 42.5% of respondents did not get the information needed. the results of extracting information when the data was collected were obtained even though the mother had not received good information regarding lbw care from the health workers. when preparing to go home, not all hospitals did a good discharge planing method of low-weight baby care at home obtained from the results of the questionnaire, only some mothers received the information from the sick hospital who cared for it, not all mothers during treatment waited for their singers first allowed to go home while their baby is still in the hospital so if there is counseling at home the baby does not know. almost all mothers had mobile communication media access that enabled access to the internet in addition to asking neighbors or relatives who had given birth for help. this data is known when interviewing data retrieval mothers have cellphones with internet services. the mothers consider that information about baby care is the main requirement for postpartum table 1. characteristics of the respondents variable n % age <20 years old 20-35 years > 35 years old 14 115 31 8.8 71.9 19.4 education elementary school junior high school senior high school college 40 57 38 15 25.0 41.9 23.8 9.4 work farmer laborers employers housewife 10 42 24 84 6.3 26.3 15.0 52.5 family income <1 million 1-2 million 3-5 million > 5 million 63 76 20 1 39.4 47.5 12.5 0.6 history of low birthweight yes no 101 59 63.1 36.9 information about low birthweight care yes no 92 68 57.5 42.5 table 2. description of the variables variable n % mean sd independent knowledge well enough less family support well enough less 126 29 5 92 58 10 78.8 18.1 3.1 57.5 36.3 6.3 2.75 2.73 0.49 0.49 dependent ability to prevent infection well enough less 122 34 4 76.3 21.3 2.5 2.73 0.49 table 3. spearman rho analysis variable correlation coefficient sig. (2tailed) knowledge -ability family support -ability 0.696 0.540 0.000 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 13 mothers (arzani et al., 2015; slomian et al., 2017). there are four postpartum maternal needs, namely: information needs, psychological support needs, the need to share experiences and practical and material support needs. a mother needs more and sometimes different information from other mothers because they sometimes have a different focus on the problems that can arise (misgna, gebru and birhanu, 2016; slomian et al., 2017). less knowledge will make the mother feel confused and not know what to do to care for her baby. this condition will make the mothers stressed and even depressed. the stressful condition of the mother will disrupt their daily activities, including the task of caring for the baby (offiah, o’donoghue and kenny, 2012). the results of the research that supports this was conducted in canada. it found that the mothers of premature babies experience increased levels of psychological stress that is more severe in the neonatal period than mothers of fullterm infants. the confusion, stress and anxiety of mothers stands out when they are discharged from the hospital (singer et al., 2017) this psychological pressure will be weighed on by the family environmental factors, such as a low family income and a large number of family members that are dependent on the same pool of living costs (suplee, gardner and borucki, 2014). the results of this study indicate that 86.9% of the respondents came from families with an income of less than 2 million per month, which is an income level far from the regional minimum wage of malang (2.7 million / month). the mother's knowledge was, overall, relatively good, even though some of the mothers had not received information about lbw care at home supported by the experience factor of having a low birth weight baby before and their age. the results showed that 63.1% of respondents had a history of giving birth to lbw infants beforehand, so that they were familiar with the health conditions and care of lbw babies. the age of the respondents in this study was that 71.9% were of a productive age or they were women of childbearing age who had the duty to care for their children. the health information in this study was partly provided by the health workers (57.5%). correct information about lbw care both during childbirth and on their return to the hospital from a health worker in charge of the community will increase the level of maternal knowledge. visits by community health workers have been shown to increase the interaction and communication of mothers and health workers so then they are able to solve any baby health problems well, especially in the first month (horowitz et al., 2013). health education has been shown to increase the mother's confidence in caring for her baby (gilmer et al., 2016). babies with problems or high-risk babies are vulnerable groups who must get special care and assistance such as visits so then the mothers are not too stressed and are able to independently care for their babies (haugan, innstrand and moksnes, 2013). this is done because lbw babies have serious problems regarding the risk of infection, their lack of nutrient intake and hypothermia. infections that arise as a result of poor treatment, such as not washing one’s hands properly when treating a baby, avoiding exposure to infection at home, using non-sterile devices for direct care, sterile cord care etc. can trigger infection and sepsis (rice, 2001; marilyn and wong, 2004; yadav, chaudhary and shrestha, 2011). the results of the study show that the knowledge of mothers about the prevention of infection in lbws has a significant effect (p = 0,000) on the ability of the mothers to prevent infection in relation to the care of their babies. village midwives actively provide counseling and assistance. the results related to maternal knowledge were that 18.1% had sufficient knowledge and that 3.1% were incompetent, which means that the baby has the potential for infection and illness. this is in accordance with boykova and kenner's (2012) study which found that 30% of lbw babies will experience pain after being taken care of at home. the high birth rate of lbws and premature babies puts a burden on the parents and also creates a public health burden because of the impact of morbidity and mortality (offiah et al, 2012). family support is something that cannot be ignored in relation to helping the cognitive and behavioral abilities of the mother to care for her baby. the family support given to the mother to care for her baby is given the most by the biological mother or mother-in-law who lives close to the mother of the baby, support by the husband, especially in the nuclear family. support for the mother is not given as whole care but it is very helpful for the mother to care for her baby. the biggest support is psychological support for funds to provide baby care facilities. a family atmosphere that is harmonic, that fulfills the material needs of the mother, that is involved in infant care and that provides support for other treatments will improve the mother's psychology. mothers, in both the antenatal and postpartum period of ten, do not feel that they are informed enough about this difficult part of their life span; they need support from their family. they feel that they are not sufficiently supported, not only from a psychological point of view but also from a more practical perspective. for example, this can include help with domestic work. mothers need to share their life experiences, they need to be convinced and they need to feel understood. family support is done by providing for the needs of the mother and trying to prevent the risk of postpartum psychological distress during the postpartum period (hookway and everson, 2011; ingram et al., 2016). the results showed that family support for mothers who carried out lbw care at home was 57.5, which is good, with there being a number of significant relationships from maternal behavior to preventing infection in the medium category. in carrying out the role of a mother, a harmonious e. s. astuti et al. 14 | pissn: 1858-3598  eissn: 2502-5791 relationship between husband and mother-baby and with other family members is the most important factor (alligood, 2014). family support increases people's confidence. the family is a source of power that is owned by the family in order to regulate their values, communication patterns and the role of the family as a lifestyle. this is so then the families are able to carry out their functions well (friedman, 2003). the results showed that the treatment and behavior required to prevent infection in infants was 76.3%, and therefore was at a good level. good care and the supervision of lbw babies is derived from knowledge and family support. this shows that the preparation for the transition from the hospital setting is quite good. preparation for this period still requires commitment from the health workers, mothers and their families (murch and smith, 2016). monitoring the condition of the baby and mentoring the mother is very important in order to maintain a conducive situation for the health of lbw babies and their mothers (schönbauerová and boledovičová, 2015; mahanta et al., 2016). conclusion factors of maternal knowledge about infection prevention and family support need to be considered in increasing the ability of mothers to care for babies with low birth weight. the factor of maternal knowledge about prevention of infection has a strong correlation value when compared to family support factors. further research is needed on the model of increasing maternal knowledge that is optimal so that babies with low birth weight do not have health problems during home care. references akter, t., dawson, a. and sibbritt, d. (2016). ‘the determinants of essential newborn care for home births in bangladesh’.public health. 141, pp. 7–16. doi: 10.1016/j.puhe.2016.08.004. alligood, m. r. (2014).nursing theorists and their work. st. louis, missouri. doi: 10.5172/conu.2007.24.1.106a. arzani, a. et al. (2015). ‘mothers’ strategies in handling the prematurely born infant: a qualitative study’.journal of caring sciences, 4(1), pp. 13–24. doi: 10.5681/jcs.2015.002. boykova, m. and kenner, c. (2012). ‘transition from hospital to home for parents of preterm infants’. the journal of perinatal & neonatal nursing, 26(1), pp. 81–87. doi: 10.1097/jpn.0b013e318243e948. friedman, m. m. (2003).family nursing research, theory & practice, fifth edition. new jersey: pearson education, inc.p. gareth d. mercer b.sc. (2015). ‘do fathers care ? measuring mothers’ and fathers’ perceptions of fathers’ involvement in caring for young children in south africa by’, (july), pp. 1–295. gilmer, c. et al. (2016). ‘parent education interventions designed to support the transition to parenthood: a realist review’.international journal of nursing studies, 59, pp. 118–133. doi: 10.1016/j.ijnurstu.2016.03.015. gray, p. h. et al. (2013). ‘parenting stress in mothers of very preterm infants influence of development, temperament and maternal depression’.early human development, 89(9), pp. 625–629. doi: 10.1016/j.earlhumdev.2013.04.005. haugan, g., innstrand, s. t. and moksnes, u. k. (2013). ‘the effect of nurse-patient interaction on anxiety and depression in cognitively intact nursing home patients’.journal of clinical nursing, 22(15–16), pp. 2192–2205. doi: 10.1111/jocn.12072. hookway, l. and everson, b. (2011). ‘first familycentred care coordinators appointed to support families through the difficult and stressful time of having a baby in neonatal care’.journal of neonatal nursing, 17(6), pp. 216–218. doi: 10.1016/j.jnn.2011.09.004. horowitz, j. a. et al. (2013). ‘nurse home visits improve maternal/infant interaction and decrease severity of postpartum depression’.jognn journal of obstetric, gynecologic, and neonatal nursing, 42(3), pp. 287– 300. doi: 10.1111/1552-6909.12038. ingram, j. c. et al. (2016). ‘does family-centred neonatal discharge planning reduce healthcare usage ? a before and after study in south west england’, pp. 1–10. doi: 10.1136/bmjopen-2015010752. jilian ireland, minesh khashu, luisa cescutti-butler, edwin van teijlingen, j. h.-t. (2016). ‘experience of father with babies admitted to neonatal care units’.journal of neonatal nursing. doi: dx.doi.org/10.1016/j.jnn.2016.01.006. kementerian kesehatan ri. (2010).buku saku pelayanan kesehatan neonatal esensial. kementerian kesehatan ri. (2014).profil kesehatan indonesia tahun 2013. satu, jakarta: kementerian kesehatan ri. satu. edited by m. e. drg. vensya sitohang, m. dr. drh. didik budijanto, m.kes boga hardhana, s.si, and m. k. a. drg. titi aryati soenardi. jaakarta. doi: 351.770.212 ind p. kementrian kesehatan republik indonesia. (2016).buku kesehatan ibu dan anak, buku kesehatan ibu dan anak. doi: 362.198.2.ind b. lakshmanan, a. et al. (2017). ‘the impact of preterm birth < 37 weeks on parents and families : a crosssectional study in the 2 years after discharge from the neonatal intensive care unit’. health and quality of life outcomes, pp. 1–13. doi: 10.1186/s12955-017-0602-3. mahanta, t. g. et al. (2016). ‘effectiveness of introducing home-based newborn care (hbnc) voucher system in golaghat district of assam’.clinical epidemiology and global health, 4(2), pp. 69–75. doi: http://dx.doi.org/10.1016/j.cegh.2015.08.002. marilyn, h.-e. and wong, l. d. (2004).wongs clinical manual of pediatric. 6th edn. st. louis, missouri: mosby. jurnal ners http://e-journal.unair.ac.id/jners | 15 mehler, k. et al. (2014) ‘increased rate of parental postpartum depression and traumatization in moderate and late preterm infants is independent of the infant’s motor repertoire’, early human development, 90(12). doi: 10.1016/j.earlhumdev.2014.09.008 misgna, h. g., gebru, h. b. and birhanu, m. m. (2016). ‘knowledge, practice and associated factors of essential newborn care at home among mothers in gulomekada district, eastern’.bmc pregnancy and childbirth, pp. 1–8. doi: 10.1186/s12884-0160931-y. murch, t. n. and smith, v. c. (2016). ‘supporting families as they transition home’.newborn and infant nursing reviews, 16(4), pp. 298–302. doi: 10.1053/j.nainr.2016.09.024. offiah, i., o’donoghue, k. and kenny, l. (2012).preterm birth mother and child. doi: 10.5772/1284. rice, r. (2001).home care nursing practice, concepts and application. 3th ed. st louis, missouri: mosby year book. riset, b. and dasar, k. (2012). ‘dukungan sosial keluarga dan hubungannya dengan kecemasan ibu primipara dalam merawat bayi berat badan lahir rendah’, pp. 249–254. rita magdalena br, tarigan, restuning widiasih, e. (2008). ‘pengetahuan ibu tentang penatalaksanaan perawatan bayi bblr di rumah di rskia kota bandung’, pp. 1–15. schönbauerová, a. and boledovičová, m. (2015). ‘the role of paediatric nurse in home visiting of newborns and infants in the past literary survey’.kontakt, 17(4), pp. e211–e218. doi: 10.1016/j.kontakt.2015.09.003. singer, l. t. et al. (2017). ‘parenting stress after the birth of a very low-birth-weight infant’, 281(9), pp. 799–805. slomian, j. et al. (2017). ‘identifying maternal needs following childbirth : a qualitative study among mothers, fathers and professionals’. bmc pregnancy and childbirth, pp. 1–13. doi: 10.1186/s12884-017-1398-1. suplee, p. d., gardner, m. r. and borucki, l. c. (2014). ‘low‐income, urban minority women’s perceptions of self‐ and infant care during the postpartum period’.journal of obstetric, gynecologic & neonatal nursing, 43(6), pp. 803– 812. doi: 10.1111/1552-6909.12506. warren, p. l. (2005). ‘first-time mothers: social support and confidence in infant care’.journal of advanced nursing, 50(5), pp. 479–488. doi: 10.1111/j.1365-2648.2005.03425.x. who. (2014). ‘wha global nutrition targets 2025: low birth weight policy brief’.w.h.o publication, pp. 1–7. doi: who/nmh/nhd/14.3. world health organization. (2011). ‘guidelines on optimal feeding of low birth-weight infants in lowand middle-income countries.’geneva: who, pp. 16–45. yadav, d. k., chaudhary, u. and shrestha, n. (2011). ‘risk factors associated with low birth weight.’journal of nepal health research council, 9(2), pp. 159–164. doi: https://doi.org/10.33314/jnhrc.v0i0.266 widhiarso, w. (2005). mengestimasi reliabelitas. fakultas psikologi ugm. yogyakarta. https://doi.org/10.33314/jnhrc.v0i0.266 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 199 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17059 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review effectiveness of physical exercise on the glycemic control of type 2 diabetes mellitus patients: a systematic review yulia kurniawati, hurin’in aisy baridah, made dian kusumawati and irfan wabula faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: type 2 diabetes mellitus (t2dm) is one of the main causes of increasing global health morbidity and mortality for diabetes cases. increasing the glycemic control in patients with t2dm is not enough if it is only treated with anti-hyperglycemic drugs. physical exercise is an activity that is planned, structured and carried out to improve health or physical fitness and it is an effective way to improve glycemic control. the aim of this study was to search and review the research on effectiveness of physical exercise on glycemic control in t2dm. methods: we searched the scientific literature on t2dm and physical exercise in the sciencedirect, proquest, scopus, ebsco and pubmed databases for original research studies and then we reviewed them systematically. of the 1145 articles retrieved, 14 studies were obtained by the prisma (preferred reporting items for systematic reviews and metaanalyses) method results: aerobic physical exercise improved the glycemic control of t2dm and it was widely used and significant for glycemic control. the schedule of 3 times a week for 60 minutes per session over 2 months was widely used and significant when it came to reducing blood glucose and hemoglobin a1c (hba1c). conclusion: this systematic review could be used as evidence when carrying out aerobic physical exercise interventions for the purpose of glycemic control. article history received: december 26, 2019 accepted: december 31, 2019 keywords physical exercise; glycemic control; diabetes mellitus contact yulia kurniawati  yulia.kurniawati2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: kurniawati, y., baridah, h. a., kusumawati, m d., & wabula, i. (2019). effectiveness of physical exercise on the glycemic control of type 2 diabetes mellitus patients: a systematic review.jurnal ners, 14(3si), 199-204. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17059 introduction t2dm is one of the main causes of increasing global health morbidity and mortality for 80-90% of all diabetes cases(dixit, maiya, & shastry, 2017). the increasing prevalence of t2dm is followed by some of the most influential factors such as age, obesity and a sedentary lifestyle (lazarevic et al., 2006). the factors that affect the increase of t2dm over a long period of time leads to a variety of abnormalities in various organs, including microvascular, macrovascular, neurological and infectious complications (a, najafipoor, aliasgarzadeh, niafar, & mobasseri, 2012). the world health organization (who) and the international diabetes federation (idf) reported that the number of patients with diabetes worldwide was projected to increase to more than 300 million people in 2025 and 366 million by 2030. this is up from 171 million in 2000 (animaw & seyoum, 2017). different associations such as the american diabetes association (ada), the american college of physicians (acp) and the international diabetes federation (idf) assumed that the goal of glycemic control was to decrease the hba1c level, as shown by the epidemiology analysis where each decrease by 1% in hba1c is associated with a 14% reduction in the risk of myocardial infarction (mi), a 21% reduction in mortality associated with t2dm and a 37% reduction in microvascular complications (a et al., 2012). t2dm is caused by insulin resistance which affects the process of carbohydrate metabolism. this is because glucose transporters in cells or glut-4 can https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:yulia.kurniawati-2018@fkp.unair.ac.id mailto:yulia.kurniawati-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). y. kurniawati, et al. 200 | pissn: 1858-3598  eissn: 2502-5791 go to the plasma membrane if the corresponding insulin present. insulin is a hormone made up of small proteins produced from the beta cells of the pancreas’ islets of langerhans and it has an important role in saving energy (fabricio, chango, cezar, & mathias, 2016). blood glucose level and hba1c decreased rapidly and significantly after physical exercise (bruce, kriketos, cooney, & hawley, 2004). physical exercise as an intervention to maintain glycemic control in t2dm is widely used and it has been frequently reported on to date. many studies have focused on the effect of physical exercise in t2dm related to its actions, laboratory parameters and organ damage (thent, das, & henry, 2013). the aim of the present study was to search and review the findings from the randomized or non-randomized scientific published literature studies focusing on the t2dm patients’ used types of exercise and their effect on glycemic control. materials and methods searching strategy this study employed a systematic review on the effectiveness of the physical exercise for glycemic control done by t2dm patients. a comprehensive literature search was conducted using the sciencedirect, proquest, scopus, and pubmed journal databases. this study began with determining the topic, searching for original articles and seeing if they matched with the inclusion criteria. the keywords used were type 2 diabetes mellitus, physical exercise, glycemic control, blood glucose and hba1c. inclusion and exclusion criteria the inclusion and exclusion criteria used for this study have been presented in table 1. data extraction and quality assessment the title, abstract and the article were reviewed independently. the information was taken from each study using a collection form that consisted of the authors, the date of the study, the population, the exercise type, the outcome measures, the study design and the duration of the intervention and its intensity. the quality assessment for each selected study was conducted using the prisma method. results the results of the data search identified 1145 relevant studies, but 885 studies were excluded after the title and abstract analysis. therefore, 260 full-text articles were assessed for eligibility after excluding 155 duplicates. in the final stage of the eligibility assessment, 141 articles were excluded and the remaining 14 studies were included in this review. a flow diagram of the prisma method of search and selection has been shown in figure 1. all of the 14 selected studies were published in english. the population was t2dm patients and the majority were published after 2004. all of the participants were aged between 18 years and 70 years old without complications. three studies used female participants only and 11 studies used mixed participants. all of the participants were people with diabetes mellitus without insulin dependence. the interventions that were used were aerobic exercise, resistance exercise and a combination of exercises that were both aerobic and resistance. four studies used an aerobic only intervention. one study used a resistance only intervention. four studies used a combination of aerobic and resistance exercises. four studies used an aerobic exercise, in addition with tension and combination exercises. one study used a combination of exercises. the intensity of physical exercise ranged from 2 to 3 times a week for 30 to 60 minutes. the intervention was targeted at reducing hba1c and glucose level. samples for the examination of blood sugar and hba1c were obtained both before exercise and after the administration of the intervention. the length of the re-examination of the blood glucose levels and hba1c varied. all of the results of the study stated that aerobic and resistance studies gave significant results for glycemic control, blood sugar levels and hba1c. aerobic was the most widely used and modest exercise used to maintain glycemic control. the main characteristics of the included studies have been summarized in table 2. discussion the previous study pointed that there were 3 types of physical exercise; aerobic exercise, resistance exercise and flexibility and balance exercise. these can be done by the t2dm patients as an intervention for glycemic control (colberg et al., 2016). another study also stated that aerobic exercise was the most commonly done for maintaining glycemic control and resistance exercise was number two (services, 2018). the study’s result before was related to the results of the current study in that aerobic exercise, resistance exercise and a combination of aerobic and resistance exercise were the most common types of physical exercise used for maintaining glycemic control respectively. compared with supervised aerobic or supervised resistance exercise alone, combined exercise showed there to be more of an improvement in hba1c levels. aerobics is a form of exercise that involves the repeated and continuous movement of large muscle groups. aerobic activities include walking, cycling, jogging, and swimming (t. et al., 2018). aerobic exercises consist of many different types of exercise. exercise is performed at moderate levels of intensity, so they can be undertaken for extended periods of time that maintain an increasing heart rate. activities such as cycling, swimming, jogging, rowing, crosscountry skiing and aerobic dancing require oxygen to produce atp (adenosine tri-phosphate). aerobic exercise improves oxygen consumption and it also increases the functioning of the cardiovascular and respiratory systems (thent et al., 2013). jurnal ners http://e-journal.unair.ac.id/jners | 201 resistance exercises are exercises that have to be performed against resistance (facility et al., 2015). resistance exercise includes exercises with free weights, weight machines, body weights or elastic resistance bands. unlike aerobic exercise, resistance exercises rely on the equipment used (colberg et al., 2016). diabetes mellitus is a chronic endocrine disorder that needs definite treatment. several complications are associated with diabetes and a lack of treatment can result in a life-threatening condition. many researchers have explained that exercise played a crucial role in maintaining t2dm glycemic control. exercise not only maintained glycemic control but it also improved their insulin sensitivity and lessened the diabetes-associated complications such as cardiovascular damage, which is considered to be one of the major complications (services, 2018). based on the past data, the present systematic review has table 1. inclusion and exclusion criteria inclusion criteria exclusion criteria 1. the study design specifically evaluated the effect of physical exercise on glycemic control such as hba1c and glucose level 2. this study focused on t2dm patients 3. studies that were published in english 4. the study had one of the following study designs: randomized controlled trial, non-randomized controlled trial and a before-after trial 1. studies that evaluate the effect of physical exercise on other chronic diseases 2. studies that evaluate the effect of physical exercise on children or mothers with gestational diabetes 3. patient with complications or another disease table 2. summary of the main characteristics of the included studies year sample size type of exercise intensity of exercise finding/ conclusion refe-rence 2004 9 combination (aerobics and resistance) 2 times/week, 16 weeks hba1c significantly reduced (tokmakidis, zois, & touvra, 2004) 2007 251 aerobics, resistance, combination (aerobics and resistance) 3 times/week, 22 weeks hba1c showed a significant reduction in the 3 types of exercise (sigal et al., 2007) 2009 20 aerobics and resistance 4 times/week, 16 weeks both exercise modes have a positive effect on glycemic control (zois et al., 2009) 2010 60 aerobics and resistance 3 times/week, 50 minutes, 8 week resistance exercise has similar effects to aerobic exercise in terms of reducing hba1c (ng et al., 2010) 2011 48 aerobics, resistance and combination (aerobics and resistance) 3 times/week, 60 minutes, 12 week exercise training has a positive effect on the glycemic parameter (luiza et al., 2011) 2012 13 aerobics 60 minutes, 7 days aerobics reduced blood glucose (mikus et al., 2015) 2012 60 aerobics and resistance, combination (aerobic and resistance, control) 3 times/week, 60 minutes, 52 weeks the mean hba1c showed a significant reduction in the training groups. all training groups improved in terms of postprandial glucose, blood pressure, vo2max and muscular percentage. (najafipour et al., 2017) 2012 30 aerobics 3 times/week, 50 minutes, 8 weeks aerobics significantly reduced hba1c concentration (no title, 2012) 2015 30 aerobics and resistance 50 minutes, 6 weeks both exercises reduced hba1c and blood glucose significantly (farias, santoslozano, urra, & cristi-montero, 2015) 2016 20 aerobics and resistance 30 minutes, 7 days the glycemic response did not differ between the exercise modes (brett, stephen, richard, & benson, 2016) 2016 20 aerobics 3 times/week, 8 weeks aerobics significantly reduce hba1c and blood glucose (mahmoudnejad, 2016) 2016 52 aerobics and resistance, combination (aerobics and resistance) 3 times/week, 10 weeks blood glucose significant reduce on three type exercise (siavoshy & heidarianpour, 2017) 2017 65 aerobics 3 times/week, 8 years aerobics reduced hba1c significantly (a et al., 2012) 2018 60 resistance 3 times/week, 3040 minutes, 12 weeks resistance exercise significantly reduced hba1c and blood glucose (article, 2018) y. kurniawati, et al. 202 | pissn: 1858-3598  eissn: 2502-5791 summarized the extent and types of exercise conducted among the t2dm population. the current systematic review revealed that physical exercise can be used as an intervention for maintaining glycemic control in t2dm. aerobic was mostly done, followed by resistance or a combination of exercises. the fact that has to be of concern was that resistance exercise depends on the use of equipment. it could be costly and proper supervision is needed (thent et al., 2013). many other aspects have to be concerned with related to resistance exercises such as the knowledge of exercise, the economic aspect of exercise and the sustainability of the exercise(training, the, & of, 2006). on the other hand, aerobic exercise is devoid of using equipment (segal et al., 2018). in this systematic review, the authors reviewed 14 research articles about physical exercise (aerobics, stretching, and a combination of aerobics and stretching) as it relates to glycemic control (blood sugar and hba1c). the result of this review were the same as the previous study, in that aerobics significantly reduce blood glucose and hba1c through increased insulin sensitivity (harrison, shields, taylor, & frawley, 2016). during exercise, muscle contraction stimulates an increase in ampk activity (amp-activated protein kinase). this activation then stimulates glut4 translocation into the cell membrane, thereby increasing the glucose uptake (bird & hawley, 2017). in t2dm, there are deficiencies in the insulin receptors which results in impaired glucose uptake and glut4 translocation. however, exercise therapy could restore the defects of insulin by providing gltu4 translocation (bird & hawley, 2017). the provision of aerobic exercise in terms of evidence and theory can reduce blood sugar and hba1c levels. this was in accordance with the systematic results of this review, in that the most common intervention that was significant at reducing sugar levels and hba1c was aerobics. in theory, there were more optimal and significant exercises which reduced the blood sugar levels and hba1c and it is recommended by the ada and the american college of sports medicine that these are used in combination rather than just aerobics (activity, 2004). this could be done through two mechanisms. increasing insulin sensitivity is a result of exercise-specific adaptations. increased lean body mass (hypertrophy) is associated with resistance training, which contributes to increased glucose disposal. the problem with the authors when conducting the systematic review was that there has been only a small amount of research evaluating the benefits of aerobic combination training and resistance in the diabetic population. resistance exercise developed proper glucose control and less insulin resistance among the t2dm patients. resistance exercises are an exercise that has to be performed against resistance. examples of resistance exercises include weight lifting. unlike aerobic exercise, resistance exercises rely on equipment. similar to aerobic exercise, resistance exercises are useful therapeutic tools in the management of t2dm. in addition, it was also proven to be safe and efficacious for the elderly insulin resistant diabetic patients. resistance exercise has been reported to enhance insulin sensitivity, daily energy expenditure and quality of life. furthermore, resistance training has the potential to increase muscle strength, lean muscle mass and bone mineral density, which could enhance both functional status and glycemic control. the schedule of carrying out exercises for between 30 60 minutes 3 times/week was reasonable; this consisted of 1 hour of physical exercise 3x/week to reduce the capillary glucose level. at least 150 minutes/week of physical activity and dietary changes resulting in a weight loss of 5%– 7% is recommended to prevent or delay the onset of t2dm in populations at high risk and in those with pre-diabetes. not allowing more than 2 days to elapse between exercise sessions is recommended to enhance insulin action (services, 2018). the limitation of this study was the variation of the intervention’s duration. two studies had an intervention duration that was for 7 days. the other studies were done over more than 8 weeks conclusion the present systematic review revealed the effectiveness of physical exercise on glycemic control. from the published data, it can be concluded that exercise-based research on a schedule of 3 times a week for 60 minutes per session over 2 months was figure 1. flow diagram of the search and selection article process articles identified through database searching (n=1145) full text articles and abstract reviewed (n=1145) abstract excluded (n=835): 350-condition did not meet the inclusion criteria 380-outcome did not meet the inclusion criteria 155-duplicate studies full text articles assessed for eligibility (n=260) full text excluded (n=141): 98-population did not meet the inclusion criteria 43-study design did not met inclusion full text articles included in the systematic review jurnal ners http://e-journal.unair.ac.id/jners | 203 widely used and significant at reducing blood glucose and hemoglobin a1c (hba1c). this systematic review could be used as evidence when carrying out aerobic physical exercise interventions for the purpose of glycemic control. references a, a. y., najafipoor, f., aliasgarzadeh, a., niafar, m., & mobasseri, m. (2012). effect of aerobic exercise , resistance training or combined training on glycaemic control and cardio vascular risk factors in patients with type 2 diabetes. 135–143. https://doi.org/10.5604/20831862.990466 activity, p. (2004). physical activity / exercise and diabetes. 27. animaw, w., & seyoum, y. (2017). increasing prevalence of diabetes mellitus in a developing country and its related factors. 1–11. article, o. (2018). home-based resistance training improves glycemic control and body fat content in patients with type 2 diabetes mellitus: experience from a tertiary care hospital in sri lanka. 1(1), 1– 4. bird, s. r., & hawley, j. a. (2017). update on the effects of physical activity on insulin sensitivity in humans. (3), 1–26. https://doi.org/10.1136/bmjsem2016-000143 brett, a., stephen, a. g., richard, r. b., & benson, m. a. c. (2016). ac ce t. journal of science and medicine in sport. https://doi.org/10.1016/j.jsams.2016.01.004 bruce, c. r., kriketos, a. d., cooney, g. j., & hawley, j. a. (2004). disassociation of muscle triglyceride content and insulin sensitivity after exercise training in patients with type 2 diabetes. 23–30. https://doi.org/10.1007/s00125-003-1265-7 colberg, s. r., sigal, r. j., yardley, j. e., riddell, m. c., dunstan, d. w., dempsey, p. c., … tate, d. f. (2016). physical activity / exercise and diabetes : a position statement of the american diabetes association. 39(november), 2065–2079. https://doi.org/10.2337/dc16-1728 dixit, s., maiya, a., & shastry, b. a. (2017). effect of moderate-intensity aerobic exercise on glycosylated haemoglobin among elderly patients with type 2 diabetes & peripheral neuropathy. (january), 129– 132. https://doi.org/10.4103/ijmr.ijmr fabricio, g., chango, a., cezar, p., & mathias, d. f. (2016). environmental contaminants and pancreatic beta-cells. 8(3), 257–263. facility, c. b., inan, z., depkes, gurgand, m., afsa, c., briant, p., … world health organisation. (2015). nih public access. sleep, 4(1), 213–223. https://doi.org/10.1086/513446.iijima farias, t. y., santos-lozano, a., urra, p. s., & cristimontero, c. (2015). effects of training and detraining on glycosylated haemoglobin , glycaemia and lipid profile in type-ii diabetics. 32(4), 1729–1734. https://doi.org/10.3305/nh.2015.32.4.9341 harrison, a. l., shields, n., taylor, n. f., & frawley, h. c. (2016). exercise improves glycaemic control in women diagnosed with gestational diabetes mellitus : a systematic review. journal of physiotherapy, 62(4), 188–196. https://doi.org/10.1016/j.jphys.2016.08.003 lazarevic, g., antic, s., cvetkovic, t., vlahovic, p., tasic, i., & stefanovic, v. (2006). a physical activity programme and its effects on insulin resistance and oxidative defense in obese male patients with type 2 diabetes mellitus. 583–590. luiza, m., pereira, m., neves, v., oliveira, d., maria, n., ferreira, l., … geloneze, b. (2011). the effects of aerobic , resistance , and combined exercise on metabolic control , inflammatory markers , adipocytokines , and muscle insulin signaling in patients with type 2 diabetes mellitus. metabolism, 60(9), 1244–1252. https://doi.org/10.1016/j.metabol.2011.01.006 mahmoudnejad, m. h. (2016). effects of aerobic training on fbs , hba1c , fructosamine and plasma lipid profile in male with type 2 diabetes. 27–33. mikus, c. r., physiology, e., oberlin, d. j., physiology, e., libla, j., physiology, e., … physiology, e. (2015). hhs public access. 55(5), 1417–1423. https://doi.org/10.1007/s00125-012-24908.glycaemic najafipour, f., mobasseri, m., yavari, a., nadrian, h., aliasgarzadeh, a., abbasi, n. m., … sadra, v. (2017). effect of regular exercise training on changes in hba1c , bmi and vo 2 max among patients with type 2 diabetes mellitus : an 8-year trial. 1–7. https://doi.org/10.1136/bmjdrc-2017-000414 ng, c. l. w., goh, s., malhotra, r., østbye, t., tai, e. s., qspmmf, n., … usjbm, b. s. (2010). minimal difference between aerobic and progressive resistance exercise on metabolic profile and fitness in older adults with diabetes mellitus : a randomised trial. journal of physiotherapy, 56(3), 163–170. https://doi.org/10.1016/s18369553(10)70021-7 no title. (2012). segal, k. r., tomas, m. b., edano, a., abalos, a. m. y., pisunyer, f. x., blando, l., … pi-, f. x. (2018). effect of exercise training on insulin sensitivity and glucose metabolism in lean , obese , and diabetic men. services, h. (2018). 2018 physical activity guidelines y. kurniawati, et al. 204 | pissn: 1858-3598  eissn: 2502-5791 advisory committee scientific report to the secretary of health and human. siavoshy, h., & heidarianpour, a. (2017). effects of three type exercise training programs on fbs and hba1c of elderly men with type 2 diabetes. 9(1), 8– 13. sigal, r. j., kenny, g. p., boule, n. g., wells, g. a., prud, d., fortier, m., … jaffey, j. (2007). annals of internal medicine article effects of aerobic training , resistance training , or both on glycemic control in type 2 diabetes. t., r., l., b., p., b., m., m.-b., p., f., s., k., … ii, b. a. b. (2018). penatalaksanaan fisioterapi pada penyakit paru obstruktif kronis (ppok) di bbkpm surakarta. laporan nasional 2013, 18(4), 213– 223. https://doi.org/10.1086/513446.iijima thent, z. c., das, s., & henry, l. j. (2013). role of exercise in the management of diabetes mellitus : the global scenario. 8(11), 1–8. https://doi.org/10.1371/journal.pone.0080436 tokmakidis, s. p., zois, æ. c. e., & touvra, a. (2004). the effects of a combined strength and aerobic exercise program on glucose control and insulin action in women with type 2 diabetes. 437–442. https://doi.org/10.1007/s00421-004-1174-6 training, r., the, f. o. r., & of, m. (2006). for the management of. 29(8). https://doi.org/10.2337/dc05-1981 zois, c. e., tokmakidis, s. p., volaklis, k. a., kotsa, k., eleni, a. t., & ioannis, d. (2009). lipoprotein pro w le , glycemic control and physical w tness after strength and aerobic training in post-menopausal women with type 2 diabetes. 69100. https://doi.org/10.1007/s00421-009-1104-8 ners vol 10 no 2 okt 2015.indd 348 kemampuan merawat pada ibu pascaseksio sesarea dan hubungannya dengan nilai budaya (caring ability of postcaesarean mothers and it’s association with cultural value) atik hodikoh*, setyowati** *program studi keperawatan bogor, politeknik kesehatan kemenkes bandung jl. dr. sumeru no 116 bogor, 16111 **fakultas ilmu keperawatan universitas indonesia. kampus ui depok jawa barat 16424 email: atik.hodikoh@gmail.com abstrak pendahuluan: kemampuan merawat pada ibu pascaseksio sesarea dipengaruhi berbagai faktor seperti karakteristik ibu, pengetahuan dan nilai budaya. ibu pascaseksio sesarea memiliki tingkat ketergantungan yang tinggi dalam melakukan perawatan diri dan perawatan bayinya. penelitian ini bertujuan untuk mengidentifikasi kemampuan merawat diri pada ibu pascaseksio sesarea dan hubungan dengan karakteristik, pengetahuan, nilai budaya yang dianut dan perilaku budaya terkait perawatan ibu pospartum. metode: penelitian ini menggunakan rancangan cross-sectional dengan purpossive sampling terhadap 66 ibu pascaseksio sesarea di lima rumah sakit di jawa barat. instrumen yang digunakan terdiri dari instrumen karakteristik ibu meliputi umur, paritas, pekerjaan, penghasilan, pengetahuan, nilai budaya, perilaku budaya dan instrumen observasi kemampuan merawat. hasil: terdapat hubungan bermakna antara karakteristik pekerjaan dan nilai budaya ibu dengan kemampuan merawat dengan korelasi r 0,295 dan 0,355 (nilai p = 0,003). diskusi: perawat harus melakukan pendekatan budaya dalam memfasilitasi ibu untuk merawat diri dan merawat bayi sesuai dengan nilai budaya mereka, sehingga ibu dapat melakukan perawatan secara optimal. kata kunci: kemampuan merawat, nilai budaya, pekerjaan, perawatan pascaseksio abstract introduction: ability to care of postcaesarean mother affected by multifactor; moternal characteristic, knowledge and cultural values. postcaesarean mother has high level of dependency in performing selfcare and baby care. the aim of this study was to identified of selfcare and baby care and relation with that factors and cultural behaviour associaated pospartum care. methods: this study used cross sectional design with a purpossive sampling of 66 post caesarean mother ini five hospital in west java. instrumen used consisted of maternal characteristic including ages, parity,job, income, knowledge, cultural values, cultural behaviour and observasional instruments of the ability to care. results: there was a significant relationship between job characteristic and cultural values with the ability to care, for the correlation r 0.295 an 0.355 (p value = 0.003). discussions: nurses must perform a cultural approach in facilitating the mother to care for themselves and care for the baby in accordance with their cultural values, so that the mother can perform optimally care. keywords: ability to, cultural values, job, postcaesarean care pendahuluan seksio sesarea adalah suatu prosedur tindakan pembedahan untuk mengeluarkan bayi dari abdomen dengan melakukan insisi pada abdomen dan uterus ibu (lowdermilk, perry & bobak, 2005). pertolongan persalinan melalui tindakan pembedahan atau seksio sesarea dapat menimbulkan komplikasi fisik dan psikosial pada ibu nifas, meskipun tindakan seksio sesarea merupakan tindakan yang paling aman dibandingkan dengan tindakan bantuan persalinan yang lain, namun tidak berarti tindakan seksio bebas dari risiko dan komplikasi yang menyertai (pilliteri, 2003), termasuk tingkat ketergantungannya terhadap bantuan orang lain. t i n g k a t k e t e r g a n t u n g a n d a n kemampu an merawat di r i dipenga r u h i berbagai faktor antara lain usia, jenis kelamin, tingkat perkembangan, status kesehatan, pengalaman hidup, orientasi sosial kultural dan sumber daya yang ada akan menentukan apakah individu mampu merawat diri atau tidak. orem menjelaskan bahwa kemampuan merawat dan memenuhi kebutuhan diri dapat dipelajari dan ditransfer dari satu individu ke individu yang lain, ditunjukkan dengan kemampuan mengatur dan menyesuaikan 349 kemampuan merawat pada ibu pascaseksio (atik hodikoh dan setyowati) diri dengan lingkungan untuk mencapai derajat kesehatan yang optimal selama siklus kehidupannya (tomey & alligood, 2006). kondisi pascaseksio menggambarkan kondisi dengan tingkat ketergantungan tinggi terutama pada hari pertama pascaoperasi, sehingga ibu membutuhkan bantuan perawat untuk memfasilitasi pemenuhan kebutuhan diri dan bayinya dan mendukung pencapaian kemandirian secara bertahap sampai ibu dapat memenuhi kebutuhan diri dan bayinya secara optimal tanpa bantuan orang lain. nilai budaya sebagai salah satu bagian yang tidak ter pisah kan dar i kehidupan masyarakat sangat erat kaitannya dengan kesehatan ibu nifas termasuk ibu pascaseksio sesarea, terlebih pada kondisi operasi seksio yang dipandang secara budaya sebagai kondisi persalinan yang tidak normal. indonesia yang dikenal sebagai negara multikultur menunjuk kan bahwa keragaman budaya sangat mempengaruhi pengetahuan, sikap dan perilaku masyarakat termasuk keyakinan dan per ilak u kesehatan terkait dengan perawatan kehamilan, persalinan dan nifas. peran sakit meliputi ekspektasi interpersonal, sosial dan kultural terhadap orang lain seperti keluarga, dokter, perawat dan terapis lainnya serta harapan dan bantuan yang diberikan orang lain terhadap dirinya sebagai bentuk koping dalam menyelesaikan masalahnya (winkelman, 2009). perilaku sakit, peranan sakit dan peranan pasien dipengaruhi oleh kelas sosial, perbedaan suku bangsa dan budaya, sehingga ancaman kesehatan yang sama yang ditentukan secara klinis akan menimbulkan reaksi berbeda di kalangan pasien (foster & anderson, 2006). fa k t or bud aya at au k u lt u r juga sangat ber pengar uh terhadap perawatan ibu masa pasca partum selain masalah fisik dan psikososial, yang selanjut nya akan mempengaruhi kesehatan ibu dan bayinya. nilai budaya dan praktik budaya akan berpengaruh terhadap kesehatan ibu dan bayi, terlebih pada kondisi operasi seksio yang dipandang secara budaya sebagai kondisi persalinan yang tidak normal. berbagai penelitian tentang perawatan pospartum pada berbagai latar belakang budaya sudah banyak dilakukan, dari hasil penelitian tersebut dapat di kelompok kan menjadi dua, budaya yang positif dan mendukung kesehatan seperti: 1) perawatan pemeliharaan kebersihan diri, meliputi: mandi wajib nifas, irigasi vagina dengan menggunakan rebusan air daun sirih, dan menempeli perut sampai vagina dengan menggunakan daun sirih, 2) perawatan untuk mempertahankan kesehatan tubuh, meliputi: perawatan dengan pemakaian pilis, pengurutan, walikdada, dan wowongan, 3) perawatan untuk menjaga keindahan tubuh, meliputi: perawatan dengan pemakaian parem, 4) melakukan kusuk (pijat), memakai gurita, minum jamu, sale dan memakai batu hangat. nilai kebiasaan dan perilaku budaya negatif dan kurang mendukung atau bertentangan dengan kesehatan seperti: 1) duduk sender, tidur dengan posisi setengah duduk, 2) pemakaian gurita, dan minum jamu kemasan, 3) perawatan khusus, minum kopi dan minum air jamu wejahan, 4) tuum (tutup) mata (manurung, 2010; rina, 2010). peran perawat sangat penting dalam memfasilit asi ibu pascasek sio sesa rea memenuhi kebutuhannya. perawat maternitas dapat memberikan pelayanan secara holistik meliputi pelayanan fisik, psikososial, dan spiritual (ladewig, p.w., et al., 2002). perawat sebagai orang pertama yang melakukan kontak dengan ibu, penting memahami metode dan pendekatan dalam perawatan ibu dan bayi, hanya dengan memahami dan menghargai keyakinan dan nilai budaya setiap ibu pascaseksio sesarea, perawat dapat membuat perencanaan sesuai dengan kondisi mereka (wong, perry, & hockenberry, 2002). tujuan dari penelitian ini adalah mengidentifikasi karakteristik kemampuan merawat diri pada ibu pascaseksio sesarea dan hubungannya dengan karakteristik ibu. bahan dan metode d e s a i n p e nel it ia n me ng g u n a k a n cross sectional dengan teknik pengambilan sampel purpossive sampling, besar sampel me ngg u n a k a n r u mu s e st i m a si pre sisi relatif, berdasarkan data survey nasional tahun 2007 didapatkan data angka kejadian 350 jurnal ners vol. 10 no. 2 oktober 2015: 348–354 seksio sebanyak 22,8%, presisi relatif 10% dan derajat kepercayaan 95% sebanyak 66 orang. untuk mengantisipasi drop out, sampel ditambah 10%, jadi total sampel sebanyak 73 orang. cara menetapkan sampel berdasarkan dengan kriteria inklusi: ibu pascaseksio, hari kedua, kondisi ibu dan bayi sehat, bersedia menjadi responden, mampu membaca dan menulis serta mampu berbahasa indonesia secara baik. alat pengumpulan data menggunakan instrumen yang dikembangkan oleh peneliti berdasarkan teori dan konsep yang terkait dengan variabel yang akan diteliti. instrumen berupa kuesioner terdiri dari: karakteristik ibu (umur, pendidikan, penghasilan, paritas, agama dan suku, pengetahuan), kuesioner pengetahuan tentang perawatan pascaseksio yang terdiri dari 25 per tanyaan dengan rentang skor 0 –25, kuesioner kemampuan merawat diri dan bayi pada ibu seksio berisi 25 pertanyaan dengan rentang skor 0 –25, kuesioner nilai budaya dan kebiasaan budaya terkait perawatan pascaseksio berisi 25 item per nyataan dengan rentang skor 25–100 dan lembar observasi kemampuan merawat berisi 25 item butir kegiatan ibu pascaseksio yang diobser vasi. metode pengumpulan data dengan membagikan kuesioner kepada responden, menjelaskan tujuan penelitian, cara pengisian kuesioner, dan meminta responden mengisi kuesioner sesuai dengan pemahaman responden. a nalisis d at a u n iva r iat terhad ap variabel karakteristik ibu pascaseksio dan kemampuan merawat meliputi: mean, median, standar deviasi dan proporsi. analisis bivariat menguji hubungan antara karakteristik ibu, pengetahuan, nilai budaya dan perilaku budaya dengan kemampuan merawat diri dan bayinya pada ibu pascaseksio menggunakan uji independen t-test, uji anova dan uji korelasi pearson. analisis multivariat untuk mengetahui hubungan pekerjaan dan nilai budaya dengan kemampuan merawat, menggunakan uji statistik regresi linier ganda. hasil penelitian a n al isis u n iva r iat me nu nju k k a n karakteristik responden memiliki rerata umur 29,79 tahun, rerata skor pengetahuan 15,08, nilai budaya 77,23, kebiasaan perilaku responden 63,03 dan kemampuan merawat responden 11,82. proporsi ibu pascaseksio dengan pendidikan tinggi 84,8%, tidak bekerja 84,8%, penghasilan terbanyak diatas 850.000 (68%), sebagian besar suku sunda (59,5%), agama islam (95,5%) dan sebagian besar paritas 2–4 (57,6%). tabel 2 menunjukkan hubungan antara karakteristik umur (p = 0,058), pandangan dan nilai budaya (p = 0,002), pekerjaan (p = 0,003), dan paritas (p = 0,147) dengan kemampuan tabel 1. d i s t r i b u s i f r e k u e n s i u m u r , pengetahuan, nilai kebiasaan, perilaku ibu dan kemampuan melakukan perawatan diri pada ibu pascaseksio sesarea (n:66) karakteristik ibu nilai umur mean 29,79 median 30,00 sd 5,484 pengetahuan mean 15,08 median 15.00 sd 2,165 nilai budaya mean 77,23 median 77.00 sd 6,876 k e b i a s a a n perilaku mean 63,03 median 63.00 sd 5,689 k e m a m p u a n merawat mean 11,82 median 12,00 sd 4,739 pendidikan rendah 15,2% tinggi 84,8% pekerjaan tdk bekerja 84,8% bekerja 15,2% penghasilan ≤ 850.000 38,8% >850.000 68,2% suku/ras sunda 59,1% non sunda 40,9% agama islam 95,5% non islam 4,5% paritas 1 37,9% 2-4 57,6% >4 4,5% 351 kemampuan merawat pada ibu pascaseksio (atik hodikoh dan setyowati) merawat. variabel tersebut untuk selanjutnya dilakukan uji multivariat regresi linier ganda. b e r d a s a r k a n p e m o d e l a n a k h i r multivariat, didapatkan data bahwa faktor yang mempengaruhi kemampuan merawat adalah pekerjaan ibu dan nilai budaya ibu pascaseksio dengan koefisien determinasi (r square) 0,193 yang berarti bahwa model dapat menjelaskan 19,3% variasi variabel kemampuan merawat. persamaan regresi adalah: kemampuan merawat = -6,349–2,941 pekerjaan +0,295 pandangan dan nilai budaya. r square 0,193 atau 19,3%. m o d e l d a p a t m e m p e r k i r a k a n kemampuan merawat dengan menggunakan variabel pekerjaan dan nilai budaya. setiap kenaikan satu poin kemampuan merawat akan menur unkan 2,941 poin pekerjaan setelah dikontrol dengan nilai budaya artinya ibu yang tidak bekerja mempunyai peluang kemampuan merawat lebih baik dibandingkan ibu yang bekerja dan setiap kenaikan satu poin kemampuan merawat akan meningkatkan nilai budaya sebesar 0,295 setelah dikontrol oleh variabel pekerjaan. h a si l p e m o d el a n a k h i r d e ng a n mengg u na ka n reg resi li n ier d iperoleh determinan (faktor penentu) utama kemampuan merawat dan bayi adalah faktor pandangan dan nilai budaya yakni sebesar 35,5%. pembahasan budaya sebagai perilaku yang dipelajari adalah seluruh bagian praktik, keyakinan, institusi, adat istiadat, kebiasaan, mitos, dan tabel 2. hasil uji korelasi pearson antara umur ibu, pengetahuan, pandangan dan nilai budaya, dan kebiasaan perilaku dengan kemampuan merawat pada ibu pascaseksio (n.66) variabel mean sd r t p value umur 29,79 5,484 0,236 0,058 pengetahuan 15,08 2,165 0,072 0,566 pandangan dan nilai budaya 77,23 6,876 0,379 0,002 kebiasaan/perilaku budaya 63,03 5,689 0,068 0,588 pendidikan rendah 12,80 4,050 0,71 0,481 tinggi 11,64 4,863 pekerjaan tdkbekerja 12,34 4,506 2,17 0,03 bekerja 8,90 5,195 penghasilan ≤ 850.000 11,52 4,512 -0,34 0,773 >850.000 11,96 4,885 suku/ras sunda 11,31 4,674 -1,053 0,296 non sunda 12,56 4,822 agama islam 11,87 4,824 0,43 0,670 non islam 10,67 2,517 paritas 1 11,36 4,172 1,98 0,1472–4 11,71 4,981 >4 17,00 4,359 * uji korelasi pearson ** uji chi square *** uji anova tabel 3. hasil pemodelan akhir hubungan karakteristik pekerjaan dan nilai b u d a y a d e n g a n k e m a m p u a n merawat karakteristik ibu b beta r square pvalue pekerjaan tidak bekerja bekerja -2,349 -0,224 0,193 0,053 nilai budaya 0,295 0,355 0,003 constant -6,349 *variabel dependen kemampuan merawat 352 jurnal ners vol. 10 no. 2 oktober 2015: 348–354 seterusnya yang dibangun oleh manusia dan diwariskan dari generasi ke generasi. sphigel (2005), mendef inisikan budaya sebagai perilaku yang dipelajari, sebagai sistem praktik, sebagai simbol, sebagai institusi dan pembentukan makna, sebagai kreativitas dan agensi. leininger (2001) menjelaskan asumsi dari model keperawatan transkultural menyatakan bahwa kebudayaan atau kultual merupakan suatu hal yang dipelajari, dibagi dan dipindahkan. aspek budaya meliputi nilai, norma dan cara hidup yang membimbing mereka berpikir, memutuskan dan bertindak sesu ai denga n pola /ca r a ya ng d ipil i h (leininger, 2001; andrew & boyle, 2003). sehingga asuhan keperawatan seyogyanya dapat diberikan sesuai dengan tata cara, kebiasaan dan tradisi yang dapat diterima oleh masyarakat sesuai budaya yang dianut. ca mbe rlai n (20 05), me njela sk a n bahwa budaya menggambarkan nilai, norma dan tradisi yang mempengaruhi persepsi, pemikiran, interaksi dan pembuatan keputusan individu tentang suatu hal. individu yang terlahir dalam lingkungan kompetensi budaya yang baik akan dapat mengembangkan kompetensi budaya untuk dirinya, keterampilan budaya digambarkan sebagai kemampuan menjadi contoh, menyediakan waktu sebanyak mungkin untuk memahami budaya orang lain. pemahaman tentang kompetensi budaya dapat diaplikasikan pada semua area termasuk keperawatan. hubungan antara asuhan keperawatan dan budaya menurut leininger adalah bahwa keperawatan dan budaya merupakan dua hal yang saling terikat dan tidak terlepas. konsep mayor yang mendasari keperawatan transkultural yaitu konsep care (asuhan) dan culture (kebudayaan). kebudayaan (culture) didefinisikan sebagai pengetahuan tentang nilai, keyakinan, norma dan cara hidup yang dipelajari, dibagi dan dipindahkan, juga sebagai suatu hal yang dipelajari secara turun-temurun (andrew & boyle, 2003). asuhan keperawatan peka budaya adalah asuhan keperawatan yang diberikan dengan mempertimbangkan budaya klien dan memfasilitasi klien untuk mempertahankan dan meningkatkan kesehatan sehingga menghasilkan bentuk asuhan yang kreatif dan bermakna yang merupakan bagian dari kualitas pelayanan kesehatan (leininger, 2001; tomey & alligood, 2006). pada dasar nya perilaku dan ritual budaya yang mendukung tidak bertentangan dengan kesehatan diperbolehkan sebagai suatu keragaman budaya yang mewarnai tahapan kehidupan wanita pada masa kehamilan, persalinan dan nifas. studi fenomenologi hodikoh (2011), tentang nilai budaya dan kebiasaan ibu pascaseksio sesarea menyatakan ada lima tema, yaitu 1) pandangan ibu terhadap persalinan operasi seksio merupakan persalinan yang tidak normal, 2) pantangan makanan dan perilaku selama masa nifas yang dianut sesuai dengan nilai budaya yang mendominasi ibu pascaseksio selama nifas, 3) anjuran makanan dan perilaku yang harus diikuti tentang perawatan pascaseksio sesuai dengan nilai budaya yang mendominasi ibu, 4) kebutuhan infor masi dan pendidikan kesehat an tent ang perawat an di r i d an perawatan bayi pada ibu pascaseksio dan 5) ibu pascaseksio lebih tergantung pada keluarga untuk merawat ibu dan bayinya menjadi orang tua adalah suatu proses pencapaian peran dan transisi peran yang dimulai dari masa kehamilan sampai bayi lahir dan terbentuknya peran ibu dalam pola asuh. transisi peran berakhir ketika orang tua mengembangkan sikap nyaman dan percaya diri menampilkan perilaku peran sebagai orang tua yang terdiri dari dua komponen yaitu: 1) kemampuan dan keterampilan dalam aktivitas merawat bayi seperti menggendong, memberi makan, memakaikan baju, memandikan dan melindungi bayi dar i bahaya, dan 2) internalisasi nilai, sikap dan kesadaran terhadap kebutuhan dan keinginan bayi (lowdermilk, perry & bobak, 1999; 2002). kemampuan ibu unt uk memenuhi kebutuhannya dipengar uhi oleh berbagai faktor antara lain; usia, jenis kelamin, tingkat perkembangan, status kesehatan pengalaman hidup, orientasi sosial kultural dan sumber daya yang ada yang akan menentukan apakah individu mampu menjadi agen self care bagi dirinya atau tidak (alligood &marriner – tomey, 2006). faktor yang mempengaruhi status fungsional ibu pascapartum antara 353 kemampuan merawat pada ibu pascaseksio (atik hodikoh dan setyowati) lain; 1) paritas, 2) kesehatan selama hamil, 3) lama dan jenis persalinan, 4) temperamen bayi, 5) metode pemberian makanan bayi, 6) status pendidikan dan social ekonomi, 7) kepuasan terhadap perilaku keibuan dan peran sebagai ibu, dan 8) besarnya dukungan sosial (may & mahlmeister, 2003). peran perawat dalam memfasilitasi kompetensi ibu untuk mencapai rasa percaya diri menjalani perannya sebagai ibu dan mengesampingkan e g o n y a u n t u k k e p e n t i n g a n b a y i n y a (lowdermilk, perry & bobak, 1999). simpulan dan saran simpulan hasil penelitian ini membuktikan bahwa nilai budaya dan pandangan masyarakat berhubungan erat dengan kemampuan ibu dalam merawat diri dan merawat bayinya. sesuai dengan peran perawat sebagai fasilitator, edukator, konselor dan mitra bagi ibu, seyogianya dapat memfasilitasi ibu pascaseksio mencapai peran yang diharapkan sebagai ibu. kelu a rga sebagai sistem pendukung utama dan masyarakat sebagai satu kesatuan system termasuk didalamnya nilai dan praktik budaya memungkinkan asuhan keperawatan diberikan secara holistik dan komprehensif. saran perawat maternitas dapat memberikan asuhan keperawatan secara holistik dengan mempertimbangkan keragaman nilai budaya ibu pascaseksio dan memberikan intervensi berbasis budaya untuk mencapai kesehatan ibu dan bayi secara optimal. kepustakaan andrew & boyle, 2003. transcultural concept in nursing care, fourth edition, new york: lippincott williams & wilkins. callister, lc., semenic, s., foster, jc., 2001. cultural and spiritual meanings of childbirth, orthodox jewish and mormon women, (online), (http://jhn. sagepub.com/content/17/3/280.abstract, diakses tanggal 12 maret 2011) coffman, marren j., 2004. cultural caring in nursing practice: a meta-synthesis of qualitative research. journal of cultural diversity, september 22, 2004, (online), (http://www.highbeam.com/doc/1g1125337671.html, diakses tanggal 22 mei 2011) doseey, bm., keegan, l., 2009. holistic nursing, a handbook for practice, 5th edition, usa: jones and bartlett publishers, llc. jeffreys, mr., 2006. teaching cultural competence in nursing and health care: inquiry, action and innovation, new york: spr i nge r p ubl ish i ng company. kemenkes, 2009. draft standar pelayanan k e p e r a w a t a n , j a k a r t a : t i d a k dipublikasikan. lowdermilk, dl., perry, s.e., bobak, i.m., 2005. maternity and women health care, 7th ed, philadelpia: mosby. m a c h m u d a h , s e t y o w a t i , r a h m a h , n u r a h m a w a t i , 2 010. pe n g a r u h persalinan dengan komplikasi terhadap kemungkinan terjadinya postpartm blues di kota semarang, manuscript, tidak dipublikasikan manurung, yd., 2010. perawatan pospartum menur ut perspektif budaya jawa, (online), (http://repository.usu.ac.id/ ha nd le/123456789/1720 0, d ia k ses tanggal 14 maret 2011). murray & mckinney. 2007. foundation of matrnal-newborn nursing, singapore: elseiver. nababan, 2010. tingkat kemandirian ibu post seksio sesarea dalam merawat diri dan bayinya selama early postpartum di rsup adam malik medan, (online), (http://repositor y.usu.ac.id/handle/ 123456789/20014, diakses tanggal 16 maret 2011). nurachmawati, a., anggraeni, i., 2010. trad isi kepercaya a n masya ra kat pesisir menangani kesehatan ibu di desa tanjang limau muara badak kalimantan timur tahun 2008, jurnal kesehatan reproduksi, vol. 1 no. 1, desember 2010. 354 jurnal ners vol. 10 no. 2 oktober 2015: 348–354 pilliteri, a., 2003. maternal and child health nuirsing, care of childbearing and childrearing family, philadelphi: lippincott. williams & wilkins. rina, 2010. perawatan pospartum menurut perspektif budaya aceh, (online), ( h t t p : / / r e p o s i t o r y . u s u . a c . i d / handle/123456789/19116, diakses tanggal 13 februari 2011). srivastava, r h. 2007. the health care profesional, guide to clinical cultural p e te n c e , usa: ca n a d a , mosbyelseiver. swasono, mf., 1998. kehamilan, kelahiran, perawatan ibu dan bayi dalam konteks budaya, jakarta: ui-press. tomey, am., alligood, mr., 2006. nursing theory, utilization and application, usa; philadephia. 310 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17153 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors influencing the incidence of dengue haemorrhagic fever trijati puspita lestari, siti sholikhah and nurul hikmatul qowi university of muhammadiyah lamongan abstract background: dengue hemorrhagic fever (dhf) is a contagious disease that is still a community problem in indonesia. the purpose of this study was to analyze the factors related to the incidence of dengue fever in deket village. method: this study was an observational analytical study with a case control design. the data that was collected used interviews and questionnaires. the sample consisted of 39 for the case group and 39 for the control group. the variables used were 3m behavior (covering the water container, draining the water container, burying unused things) and the incidence of dhf. this study used the chi-square test. result: the results showed that there was a relationship between the habitual draining of the water reservoirs with dengue fever, where p=0.000 (p<0.005). there was a relationship between the habit of closing the water reservoirs with dengue fever; p=0.000 (p<0.005). there was a relationship between the habits of thrift burial with dengue hemorrhagic fever; p=0.000 (p<0.005). conclusion: based on these results, it is expected that the health cadres should control the implementation of 3m in the community. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords dengue hemorrhagic fever; peripheral draining; water reservoir; thrift burial contact trijati puspita lestari  pipid.puspita@gmail.com  university of muhammadiyah lamongan cite this as: lestrai, t. p., sholikhah, s., & qowi, n. h. (2019). factors influencing the incidence of dengue haemorrhagic fever. jurnal ners, 14(3si), 310-313. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17153 introduction dengue is a disease related to the environment (kesetyaningsih, andarini, sudarto, & pramoedyo, 2018; rasjid, yudhastuti, & notobroto, 2016) that spreads rapidly (kesetyaningsih et al., 2018). dengue fever (df) is considered as one of the diseases that occur in most of the world's tropical regions (ferreira et al., 2018; islam, haque, hossain, & rochon, 2019; kemenkes ri, 2010) and subtropics in the world (ferreira et al., 2018), one of which is in indonesia. dengue hemorrhagic fever (dhf) in indonesia has an increased incidence and declines in mortality (kemenkes ri, 2010). increasing and increasing areas of dhf distribution are in line with increasing community mobility and density (kemenkes ri, 2016; rasjid et al., 2016). based on the review of the articles, the most cases of dengue were in the southeast asian region (62 cases), the western pacific region (20 cases) and the united states (31 cases) (banno et al., 2018). the who noted that indonesia became the country with the highest number of dhf cases in southeast asia from 1968 2009 (kemenkes ri, 2010). in 2015, there were 126,675 dhf sufferers in the 34 provinces in indonesia and 1,229 of them died (kementrian kesehatan ri pusat data dan informasi, 2016). in lamongan city, the incidence of dhf in 2017 was 248 cases. dengue hemorraghic fever can be caused by climate change and a low awareness of maintaining environmental cleanliness (kementrian kesehatan ri pusat data dan informasi, 2016). the knowledge and behavior of the community at reducing the density of the aedes aegyepti mosquito larvae has a relationship with the presence of standing water (kesetyaningsih & ulfabriana, 2016; rasjid et al., 2016). mosquito vector control measures can be carried out at the shelter as a potential place for mosquito breeding (islam et al., 2019). vector control can be done by using, removing and recycling the water reservoirs properly (islam et al., 2019). in indonesia, the mosquito vector eradication program is run through the 3m plus program which includes the movement of draining the water reservoirs, closing the water reservoirs and recycling goods that can hold water (kementrian kesehatan ri pusat data dan informasi, 2014). not all regions in indonesia do this program https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:pipid.puspita@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 311 well, so the incidence of dhf still cannot be prevented optimally. the purpose of this study was to identify the 3m factors related to the incidence of dengue in the deket area, lamongan. materials and methods design this study was an observational analytical study with a case control design, conducted by comparing the case groups and control groups based on their exposure status. the subjects diagnosed with the disease were called cases while the subjects who did not suffer from the disease were called the controls. the variables used were the 3m behaviors (covering the water container, draining the water container and burying unused things) as the independent variables and the incidence of dhf as the dependent variable. participant the population in this study was all of the people living in the village of deket lamongan who had been diagnosed with dhf. the sample size in each group was 39 samples. the total sample total in this study was 78 people. the sampling method used in this study was simple random sampling. data collection the data was collected from november 2018 to january 2019 in deket village using a questionnaire created by ariyanti (2005) about 3m behavior. the reliability test was cronbach’s alpha and the result was 0.927. the primary data covering the 3m behavior was obtained through a questionnaire on people who had had dhf. the data of the dengue patients in 2018 was confirmed by the primary health care center of each sub-district. data analysis the relationship between the variable of 3m behavior with the variable of dhf incidence was analyzed using the chi-square test using spss version 22. result for the respondents in this study, most were in the age range of 24-34 years in the case group (46%), and 35-45 years in the control group (33%). the most common sex was women at 69% in the case group and 74% in the control group. the highest educational level was the low level (elementaryjunior high school), which was 51% in the case group and 59% in the control group. most of the respondents worked; 62% in the case group and 51% in the control group (table 1). the results of the study were the relationship between the behavior of covering the water container and the incidence of dhf (p=0.000; or=0.021), the behavior of draining the water containers with the incidence of dhf (p=0.000; or=0.000) and burying unused things with dhf (p=0.000; or=0.064). the 3m steps in terms of preventing dhf are part of a government program that has been implemented since 1992. in 2002, it was developed into 3m plus by using larvacide, maintaining the fish and preventing mosquito bites (table 2). table 1. respondent’s characteristics respondent's characteristics case group control group n % n % age 24 to 34 18 46% 11 28% 35 to 45 12 31% 13 33% 46 to 56 6 15% 10 26% >56 3 8% 5 13% sex male 12 31% 10 26% female 27 69% 29 74% educational level low (elementaryjunior high school) 20 51% 23 59% moderate (high school) 15 38% 16 41% high (college) 4 10% 0 0% occupy worker 24 62% 20 51% not worker 15 38% 19 49% table 2. relationship between the 3m behavior with the incidence of dhf discussion closing the water reservoir is an effort to prevent dengue fever. this is supported by the results of this study which shows that there is a significant relationship between the behavior of the water reservoir covering and the incidence of dhf. the results of this study support the recent research, namely that there is a need to close the landfill poorly. there is an increase in the risk of developing dengue variable case group control group p or n % n % covering the water container 0,000 0,021 yes 4 10% 33 85% no 35 90% 6 15% draining the water container 0,000 0,000 yes 27 69% 39 100% no 12 31% 0 0% burying unused things 0,000 0,064 yes 17 44% 36 92% no 22 56% 3 8% t.p. lestari et al. 312 | pissn: 1858-3598  eissn: 2502-5791 fever 9 times greater than the respondents who do not practice closing the landfill well (rahmawati, nurjazuli, & dangiran, 2016). the results of observations in several cities in indonesia shows that water shelters such as drums, bottles, toilets and buckets have the potential to be a breeding ground for mosquitoes (rasjid et al., 2016). poor behavior has an impact on the increasing number of containers available for breeding mosquitoes which can increase the incidence of dengue cases (azlina, adrial, & anas, 2016; widagdo, husodo, bhinuri, & dkk, 2008). burying used goods is one of the psn's efforts. this is supported by the results of this study which showed that there is a significant relationship between the drainage behavior concerning the water reservoirs and the incidence of dhf. the results of this study support the recent research, which is related to the behavior of using or recycling used goods. this is not good, as the risk of dengue fever is 5 times greater than the behavior of recycling used goods properly (rahmawati et al., 2016). changes in people's behavior in the form of using, disposing and recycling of containers properly is very important to do in places that are potential mosquito breeding sites (islam et al., 2019). increasing the incidence of dhf is influenced by various factors which include the climatic factor (khairunisa, wahyuningsih, suhartono, & hapsari, 2018). the rainy season causes environmental changes such as puddles in several places. gutters which still contain puddles and used cans which still contain puddles are accompanied by the community phbs which, if not maximized, could increase the incidence of dhf (artana, 2018). closing the containers, exposing the landfill and burying the used goods are some of the efforts that can be done in terms of the psn activities. the good implementation of psn in areas with a high dhf incidence is very influential in decreasing the dhf rate (kesetyaningsih & ulfabriana, 2016). the poor implementation of the 3ms involves 6 times the risk of getting dengue fever than those who do not have good 3m practices (“hubungan faktor lingkungan dan praktik pemberantasan sarang nyamuk (psn) dengan kejadian demam berdarah dengue (dbd) di kecamatan ngawi,” 2016). this effort to prevent dengue fever can be improved with the role of “jumatik” (astuti et al., 2017) or through the larva monitoring health center that has been formed in each village. conclusion there was a relationship between the influence of the 3m's of behavior with the incidence of dhf in deket lamongan village. the behavior of covering the water container, draining the water container, and burying unused things had relationship with the dhf incidence. community participation as an effort to prevent the occurrence of dhf is needed through the health cadres that have been formed by the public health center. coordination with the health centers and health offices should be related to the government programs for preventing dhf as needed. the community needs to be given health education concerning the signs and symptoms of dhf as the first form of detection and as the first line of treatment that needs to be done. references artana, i. w. (2018). demam berdarah dengue (dbd) di banjar tegal, tegallalang gianyar. journal center of research publication in midwifery and nursing. https://doi.org/10.36474/caring.v2i1.11 astuti, a. p., wijaya, e., hilyati, f., darmawan, i., wartati, s., nurzamzami, a., & amri, z. (2017). factor contributing to high dengue incidence in pulogadung subdistrict, jakarta, 2016: a community diagnosis. advanced science letters. https://doi.org/10.1166/asl.2017.9433 azlina, a., adrial, & anas, e. (2016). hubungan tindakan pemberantasan sarang nyamuk dengan keberadaan larva vektor dbd di kelurahan lubuk buaya. jurnal kesehatan andalas. banno, k., huu, l., minh, n., eltobgy, a., lam, l., tai, t., … reda, y. (2018). dengue hemophagocytic syndrome : a systematic review and meta ‐ analysis on epidemiology , clinical signs , outcomes , and risk factors. (march), 1–11. https://doi.org/10.1002/rmv.2005 ferreira, r. a. x., kubelka, c. f., velarde, l. g. c., de matos, j. p. s., ferreira, l. c., reid, m. m., … de oliveira, s. a. (2018). predictive factors of dengue severity in hospitalized children and adolescents in rio de janeiro, brazil. revista da sociedade brasileira de medicina tropical. https://doi.org/10.1590/0037-8682-0036-2018 hubungan faktor lingkungan dan praktik pemberantasan sarang nyamuk (psn) dengan kejadian demam berdarah dengue (dbd) di kecamatan ngawi. (2016). jurnal kesehatan masyarakat (e-journal), 4(4), 992–1001. islam, s., haque, c. e., hossain, s., & rochon, k. (2019). role of container type, behavioural, and ecological factors in aedes pupal production in dhaka, bangladesh: an application of zero-inflated negative binomial model. acta tropica. https://doi.org/10.1016/j.actatropica.2019.02.0 19 kemenkes ri. (2010). deman berdarah dengue. jakarta: buletin jendela epidemiologi vol 2 agustus 2010 issn 2087-1546. kemenkes ri. (2016). buku data dasar puskesmas kondisi desember 2015. pusat data dan informasi kementerian kesehatan ri. https://doi.org/351.770.212 ind p kementrian kesehatan ri pusat data dan informasi. (2014). situasi demam berdarah dengue di indonesia. kementrian kesehatan ri pusat data dan informasi. (2016). stop dbd di indonesia. jakarta: pusdatin pusat data dan informasi kemenkes ri. jurnal ners http://e-journal.unair.ac.id/jners | 313 kesetyaningsih, t. w., andarini, s., sudarto, & pramoedyo, h. (2018). determination of environmental factors affecting dengue incidence in sleman district, yogyakarta, indonesia. african journal of infectious diseases. https://doi.org/10.2101/ajid.12v1s.3 kesetyaningsih, t. w., & ulfabriana, a. (2016). knowledge, behavior and socio-economic status of community in dengue endemic areas with increase and stable trends in sleman district, yogyakarta, indonesia. aip conference proceedings. https://doi.org/10.1063/1.4953533 khairunisa, u., wahyuningsih, n. e., suhartono, & hapsari. (2018). impact of climate on the incidence of dengue haemorrhagic fever in semarang city. journal of physics: conference series. https://doi.org/10.1088/17426596/1025/1/012079 rahmawati, n. d., nurjazuli, n., & dangiran, h. l. (2016). hubungan kondisi lingkungan fisik, biologi dan praktik pemberantasan sarang nyamuk (psn) dengan kejadian demam berdarah dengue (dbd) di wilayah kerja puskesmas ngawi (studi kasus di wilayah kerja puskesmas ngawi, kecamatan ngawi, kabupaten ngawi). jurnal kesehatan masyarakat universitas diponegoro. rasjid, a., yudhastuti, r., & notobroto, h. b. (2016). relationship of environmental condition, container and behavior with the existence of aedes aegypti mosquito larvae in an endemic area of dengue hemorrhagic fever, makassar. pakistan journal of nutrition. https://doi.org/10.3923/pjn.2016.295.298 widagdo, l., husodo, b. t., bhinuri, & dkk. (2008). kepadatan jentik aedes aegypti sebagai indikator keberhasilan pemberantasan sarang nyamuk (3m plus): di kelurahan srondol wetan, semarang. makara kesehatan. design participant data collection data analysis 82 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.12154 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the factors related to the caring behavior of clinical nursing students tintin sukartini, candra panji asmoro and fiqih ardi pradana faculty of nursing, universitas airlangga, east java, indonesia abstract introduction: the cb of clinical nursing students is very important but they are still in the implementation phase of the theory from when it was learned in college. this study aims to describe the correlation between intelligence quotient (iq), emotional intelligence (ei) and spiritual intelligence (si) with caring behavior (cb). methods: this study was descriptive and correlational with a cross-sectional approach. the respondents of this research were all of the clinical nursing students (166 respondents) via the simple random sampling technique. the data was collected using questionnaires and analyzed using the spearman-rho test with a level of significance ≤ 0.05. results: the results showed that cb had a correlation with iq (p=0.019, r=0.211), ei (p=0.048, r=0.178) and si (p=0.000, r=0.456). conclusion: iq, ei, and si have a correlation with cb. a higher quotient will produce a higher cb. future research is expected to be able to analyze the other factors related to cb among clinical nursing students. article history received: feb 27, 2019 accepted: nov 22, 2019 keywords intelligence quotient; emotional intelligence; spiritual intelligence; cb; clinical nursing student contact candra panji asmoro  candra.panji.a@fkp.unair.ac.id  faculty of nursing, universitas airlangga, east java, indonesia cite this as: sukartini, t., asmoro, c.p., & pradana, f.a. (2019). the factors related to the caring behavior of clinical nursing students. jurnal ners, 14(1), 82-86. doi:http://dx.doi.org/10.20473/jn.v14i1.12154 introduction clinical nursing students are fully implemented in practical health settings such as hospitals, health centers, maternity hospitals, nursing homes, families, communities and societies (nursalam, 2015). the practice of student clinics has so far been deemed to lack the caring attitude of prospective professional nurses. unlike the nurses who already have the full authority to treat patients, students are often required to behave in the same caring manner as professional nurses. therefore, studies are needed to explain what factors influence the cb of students in their clinical practice in hospitals. caring is a special form of performance made by the nurses and the clinical nursing students who are enrolled on the nursing profession program of education. swanson (swanson, 1991) stated that caring is a nursing technique in relation to the value of one's feelings about commitment and responsibility. in the theory of the middle range theory of caring, swanson (swanson, 1991) found that the five processes of caring involve becoming more practical. they are maintaining belief, knowing, being with, doing for (active component) and enabling (possible component). gibson (gibson, j. l., ivancevich, j. m., & donnely, 1987) stated that a person's behavior and performance is influenced by three factors. these factors are individual factors, psychological factors and organizational factors. gibson et al (gibson, j. l, ivancevich, j. m, donnelly, j. h., & konopaske, 2012) found that the variables of ability and skill under the individual factors are the main factors that influence a person’s behavior and performance. according to hawari, the skill of intelligence is divided into four kinds of intelligence. these kinds are iq, ei, si, and creative quotient (hawari, 2006). iq is the cognitive ability that is interpreted as iq where the ability includes achievement in learning and problem solving (behling, 1998). iq refers to being smart, intelligent and clear-minded based on the knowledge that can be described as including academic and nonacademic learning achievements (ministry of education and culture, 2000). the knowledge of nursing can be seen in the behavior of caring (swanson, 1993). nursing students are potential nurses in the future that will have academic qualifications. they will also have the right to cb (murphy, f. & robert, 2009). rhodes identified that the intellectual level of a student will challenge his https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 83 intellect as a part of gaining their nursing knowledge and skills (rhodes, m. k., lazenby, r., & moris, 2011). ei is the ability to motivate yourself and to survive when facing problems. it is about relying on the spirit and not being too excessive in terms of pleasure. it is also about managing one’s moods, avoiding stress, the ability to think, to empathize and to pray (goleman, 2015). the elements of ei were self-awareness, selfmanagement, motivation, empathy and social skills. si is a set of mental capacities that including taking responsibility for awareness, integration, and the non-material aspects of adoption used. it is the things that are realized in the transcendent area (king, 2008). there are four aspects that can be observed in si, each of which represents the measurements within the si self-report inventory questionnaire (sisri-24). they were critical existential thinking (cet), personal meaning production (pmp), transcendental awareness (ta) and conscious state expansion (cse). the purpose of this study is to describe the correlation between iq, ei, and si with cb. materials and methods this study was descriptive and correlational with a cross-sectional approach. the study was conducted in the faculty of nursing (fon) universitas airlangga (ua) between october and december 2018. the independent variables in this study were iq, ei and si. the dependent variable of this study was cb. the population of this study consisted of the clinical nursing students of the fon ua 2018. the total sample in this study was 123 people chosen using simple random sampling. the procedure of the data collection in this study was divided into two stages, namely preparation and implementation. the preparation stage involved licensing and two tests, namely ethical testing and the validity and reliability test focused on the questionnaire. the first step was where the researcher tested the validity and reliability of the questionnaire. the researcher adopted the questions on each variable from the previous research conducted in indonesia (within a span of five years). the ethical test phase was carried out at the ethics committee of the fon ua. the results of the ethical test were that the study had an ethical score of 1187-kepk. the researcher received a research permit from the fon ua. the next stage was implementation. this stage was the step used for collecting the research data from the respondents. the researcher obtained a list of clinical nursing students from fon ua. this was used by the researchers to conduct sampling according to the criteria previously set. the questionnaires were distributed to the respondents and they filled out the informed consent sheet after the researcher explained the purpose and benefits of the research. next, the researcher calculated the score from each questionnaire by summing up each answer to the questions. the final results were obtained by the total score used to analyze the data. this was done using the spearman rho test with a p value <0.05. the academic workload questionnaire was adapted from wijaya (wijaya, a., 2015). iq was taken from the academic score data. the ei questionnaire adopted was a questionnaire by iswanto (2014) (rifai, 2017). the si questionnaire was adopted from wulandari (2013). the cb questionnaire was taken from the caring, professional scale (cps), which is the standard questionnaire. all of the questions were tested for validity and reliability. results table 1 shows that most of the respondents were women. for the age of the respondents, nearly half of them were aged 22 years old. the majority of the respondents were force a14. most of the respondents almost half exist in the category of stage management. table 2 indicates that the iq of the respondents can be viewed from their academic score. most of the academic scores were in the range of 2.76 to 3.50 with honors. the ei clinical nursing students in 2018 at the fon ua, universitas airlangga, were found mostly to be in the medium category. the si clinical nursing students in 2018 at the fon ua were mostly found to be in the medium category. the clinical nursing students and cb nurses in 2018 from fon ua were found to be mostly in the high category. table 3 shows that iq has a correlation with cb although the strength of the correlation is weak. ei has a correlation with cb and the strength of the correlation is very weak. si has a correlation with cb with a medium correlation strength. discussion the correlation between iq and cb iq has a weak correlation with the caring behavior done by the students. this means that the higher iq that the students have, the higher the caring behavior of the clinical nursing students. this is in line with the research conducted by wijaya (wijaya, a., 2015). the results of his study stated that iq (gpa) has a relationship with a moderate correlation. the number of respondents figure 1 significance of si and ei on the cb of nurses: a simple model of four intelligences by gardner 1983 (kaur & sambasivan, 2015). si ei iq physical intelligence t. sukartini et al. 84 | pissn: 1858-3598  eissn: 2502-5791 totaled 26 respondents with the level of caring in the medium range. the category of iq of the respondents was found to be very satisfying/moderate. it was also stated by murphy (murphy, f. & robert, 2009),that the higher the educational qualifications or academic achievements of the students, the better the quality of caring by the nurses. the higher the intelligence of the individual, the lower the level of human error related to the caring done by the nurses. this could increase the quality of the behavior related to the caring of an individual. according to gibson (gibson, j. l., ivancevich, j. m., & donnely, 1987), the factors that influence performance are the abilities and skills where intelligence is one of the main factors associated with individual behavior and performance. swanson (swanson, 1991) found out that the first domain associated with cb refers to a person's capacity to pay attention. iq or intelligence (iq) can be defined as the ability to work in a theoretical way using ideas, symbols, logical relationships and theoretical concepts. this is the ability to recognize, learn and use these preliminary concepts. the ability to solve problems belongs to a new issue (hawari, 2006). rhodes stated that the intellectual level of a student relates to the challenge to his intellect in order for them to gain the knowledge, abilities and skills involved in nursing (rhodes, m. k., lazenby, r., & moris, 2011). a high intellectual ability will make it easier for the students to remember and use their knowledge in performance, which is called cb. increasing the level of cb done by the clinical nursing students belongs to knowledge, as does studying with the lecturers and benefiting from their guidance while in the practical settings. the more iq that the individual has, the students will be able to understand and apply the theory more. a high iq score means that the students are expected to have a good memory. while the students use their theory knowledge, they can minimize the human error factor of performance and caring. it is expected that the students can improve their performance and caring in order to be better. the correlation between ei and cb ei has a correlation with cb, although it is a very weak correlation. this has the meaning that the higher the ei, the higher the cb that the students have. in the research conducted by rifai (rifai, 2017), it was found that there was a significant relationship between ei and the caring behavior of the nurses. while implementing the factors of recognizing selfemotion, controlling self-emotion, motivating oneself, and establishing relationships and empathy in the process of nursing, it will lead to a good cb in the patients. according to kaur and sambasivan (kaur, d. & sambasivan, 2015), they stated that ei has a highly significant relationship with the cb of the nurse. ei is not obtained instantly. it is obtained through the mechanisms of training, education and other things that enhance the comprehension of their nursing knowledge. in addition, according to nightingale et al. (nightingale, s., hsiang, c.p., & eng, 2018) in his research, it was found that the more that the nurses develop their ei, the more they can increase the cb of the nurses spontaneously. the more that the ei of the nurses' increases, the more that the nurses will be professional when doing cb, including being smart when solving problems and increasingly being able to lead when it comes to solving nursing problems. goleman (goleman, 2015) stated that ei is the ability to motivate oneself and how to survive when facing problems, including relying on spirit and not being too excessive in terms of pleasure, to manage their moods, to avoid stress and the inability to think, to empathize and to pray. the aspect of ei is closely related to cb in nurses. it can be seen that aspects of ei become an important component in influencing the nurses’ behavior. swanson (swanson, 1993) stated that cb is closely related to empathy. the nurses who are able to do caring well will show empathy to their patients. the nature of empathy is the main element of ei. besides that, holding in anger in the area of nursing is also closely related to optimal caring. ei is a non-academic intelligence that must be learnt by the students in order for them to be able to do caring properly. for the factor of self-awareness, the clinical nursing students must be careful when carrying out nursing care. they must be able to adapt to the practice environment and they must be able to innovate if there is a gap between theory and practice. we have then focused on the self-regulation factors that influences caring. clinical nursing students are required to be able to withstand emotions if there are undesirable things encountered in the professional practice environment. this is because it will greatly interfere with the process of the client's recovery and the performance of the nursing care services. empathy is the closest factors of ei to cb. the level of empathy held by each individual is different. at the lowest level, empathy requires the ability to feel other’s emotions. at the highest level, empathy table 1. characteristics of the respondents (n=123) characteristics f % gender man 25 20.3 woman 98 79.7 age 21 17 13.8 22 52 42.3 23 31 25.2 24 17 13.8 25 6 4.9 class b19 54 43.9 a14 69 56.1 stage management 36 29.3 emergency 17 13.8 geriatric 5 4.1 child 17 13.8 soul 4 3.3 community 17 13.8 maternity 20 16.3 medical-surgical 7 5.7 jurnal ners http://e-journal.unair.ac.id/jners | 85 requires someone to feel while responding to someone else’s needs or feelings that are not described in words. then there are the factors related to the social skills that influence cb. the main meaning of social skills is the art of dealing with the other’s emotions. this is the basics of several skills such as the medical devices used in doing cb, being able to communicate therapeutically with patients and their colleagues and being able to manage any problems faced so then it does not appear again during the process of caring. the last factor is the motivation that influences cb. managing emotions such as paying attention, motivating and knowing oneself, and being creative are all very important things in order to achieve the goals before them. the correlation between si and cb si has a correlation with the cb of clinical nursing students with a moderate correlation. this means that the higher the si that the students have, the better that the clinical nursing students behave in terms of caring. these results are in line with the study of hossein (hossein, 2015) which stated that si with cb and clinical competence results in a good quality of caring. this is in line with the increasing number of nurses with good clinical competence who will also deal with cb and si. it was also stated by moradnezhad that increasing si will improve the spiritual care provided, in addition to cb and the quality of care given by the university students. the nurses' spirituality can also reduce their stress level in their job (moradnezhad, 2017). according to king (king, 2008), si is defined as a set of mental capacities that contribute to the awareness, integration, and application of adaptive non-material aspects to consider in the area of the transcendent, leading to results such as deep existential meaning improvement, the recognition of self-transcendence, and mastery of the spiritual arena. this is supported by the theory of si put forward by zohar & marshall (zohar, d. & marshall, 2010). si is the intelligence that is created to deal with and solve some of the problems present in meaning and value. subjects sometimes get confused because there is still a difference between religious and spiritual concepts. the subjects must have a good spiritual level to be able to perform their service tasks optimally. nursing and cb services are very important when looking to get positive results on the health and well-being of clients (swanson, 1991). caring is not merely just doing the action so then it is finished. it must also present a caring nature that works together with the nurse's spirituality focused towards the client. si is the highest intelligence that can be possessed by humans. si can control individual behavior to encourage them to take action according to the right thing to do. therefore, the nurses’ and clinical nursing students’ spirituality should be established in order to achieve good cb. for the existential critical thinking factors that influence cb, clinical nursing students must be able to understand the reality that they are facing which is dealing with individuals who need help, treatment rooms that have many patients, time to reflect on or think and then interventions to carry out limited nursing care and death. the more capable their existential critical thinking, the more it is hoped that this will increase the cb that is possessed. in forming the self-perception of factors that affect caring, the components included are the elements of the adaptability of the meaning and purpose of life and the reason to live, the meaning of failure, making decisions in accordance with the purpose of life, and the meaning and purpose of daily events. from the components above, it is expected that the respondent can learn the meaning in order to be able to do cb properly. in the transcendental intelligence factor or the ability to perceive the spiritual dimension of life, it is about reflecting what was previously described as feeling a more tangible, wider spread presence and our special senses. the last factor is the development of the area of consciousness. self-awareness is the main differentiator between people who have a high level of spirituality and those who do not. people who have high awareness will always think several times before responding to each situation, and taking a moment to understand what is hidden or real before doing the initial response. they always act in a manner that is calculated, considered and cautious. moreover, the clinical nursing students, are required to think more deeply when facing each situation so then they are not mistaken when carrying out nursing. table 2. iq, ei, si and cb clinical nursing students (n=123) variables f % iq (gpa score) 2.00 to 2.75 (excellent) 1 0.8 2.76 to 3.50 (honors) 83 67.5 3.50 to 4.00 (cum laude) 39 31.7 ei low 1 0.8 medium 79 64.2 high 43 35.0 si low 2 1.6 medium 86 69.9 high 35 28.5 cb low 4 3.3 medium 51 41.5 high 68 55.3 table 3. workload, academic relations, iq, ei and si of the cb clinical nursing students (n=123) independent dependent cb iq p value: 0,019 r: 0211 ei p value: 0,048 r: 0.178 si p value: 0,001 r: 0.456 t. sukartini et al. 86 | pissn: 1858-3598  eissn: 2502-5791 conclusion iq has a correlation with cb. the high score of iq can be seen from the high gpa that makes for good cb. ei has a correlation with cb. a higher ei will make for good cb. si has a correlation with cb. a higher si will make for good cb. the clinical nursing students are expected to maintain their cb. for students who have cb at a moderate level, they are expected to improve their quality of cb by increasing their self-regulation, motivation, social skills, critical thinking, the shaping of their personal perception, transcendental awareness and the development of other areas of awareness in order to become clinical nursing students after finishing their education. for institutions, it is necessary to provide people who have competence in religion to teach nursing and to provide emotional training for the clinical nursing students. for further research, this study could be developed further in order to be able to analyze the other factors related to the cb of clinical nursing students. references behling, o. (1998). employee selection: will intelligence and conscientiousness do the job. gibson, j. l, ivancevich, j. m, donnelly, j. h., & konopaske, r. (2012). organization: behavior, structure, processes (14th ed.). new york: mcgraw-hill. gibson, j. l., ivancevich, j. m., & donnely, j. h. (1987). organisasi: perilaku, struktur, proses (1st editio). jakarta: binarupa aksara. goleman, d. (2015). hbr’s 10 must reads on ei. jakarta: gramedia pustaka utama. hawari, d. (2006). iq, eq, cq dan sq: kriteria sdm (pemimpin) berkualitas. jakarta: fkui. hossein, k. m. (2015). relation between spiritual intelligence and clinical competency of nurses in iran. iranian journal of nursing and midwifery research, 20(6), 665. https://doi.org/10.4103/1735-9066.170002 kaur, d. & sambasivan, m. (2015). significance of spiritual (si) and emotional intelligence (ei) on the caring behavior of nurses. journal of community and public health nursing, 1(2), 2–4. https://doi.org/10.4172/2471-9846.1000101 king, d. b. (2008). rethinking claims of spiritual intelligence: a definition, model, and measure. trent university. moradnezhad, m. (2017). nursing practice today. journal of medical ethics and history of medicine, 4(4), 170–179. murphy, f. & robert, s. (2009). the impact of nurse education on the caring behaviours of nursing students. nurse education today, 29(2), 254–264. doi: 10.1016/j.nedt.2008.08.016. nightingale, s., hsiang, c.p., & eng, c. j. (2018). the impact of emotional intelligence in health care professionals on caring behaviour towards patients in clinical and long-term care settings : findings from an integrative review. international journal of nursing studies, 80, 106–117. doi: 10.1016/j.ijnurstu.2018.01.006. nursalam. (2015). manajemen keperawatan: aplikasi dalam praktik keperawatan profesional (edisi 5). jakarta: salemba medika. rhodes, m. k., lazenby, r., & moris, a. h. (2011). nursing at its best: competent and caring. the online journal of issues in nursing, 16(2). rifai, f. (2017). hubungan kecerdasan emosional dengan perilaku caring pada perawat di ruang marwah rs haji surabaya. universitas airlangga. swanson, k. m. (1991). empirical development of a middle range theory of caring’. journal of nursing scholarship, 40(3). swanson, k. m. (1993). n as informed caring for the well-being of others. journal of nursing scholarship, 25(4), 352–357. doi: 10.1111/j.15475069.1993.tb00271.x wijaya, a., et al. (2015). indonesian nursing students in caring behavior. journal of nursing and health care, 2(2), 1–4. https://doi.org/10.5176/20104804_2.2.75 zohar, d. & marshall, i. (2010). si: kecerdasan spiritual (edisi 7). bandung: mizan media utama. ners vol 10 no 2 okt 2015.indd 308 perilaku kesehatan dan indikator klinis pasien dengan infark miokard di indonesia (health behaviors and clinical outcomes among patients with myocardial infarction in indonesia) yusshy kurnia herliani*, yaowarat matchim*, charuwan kritpracha* * faculty of nursing, prince of songkla university, hat-yai, songkhla, thailand, 90112, telp. 66-74-28-6520, fax: 66-74-28-6421 e-mail: yusshy_cute@yahoo.com abstrak pendahuluan: perilaku kesehatan sangat penting untuk mencegah kemungkinan terjadinya serangan jantung serta menjaga kesehatan pasien dengan infark miokard. selain itu, pemeriksaan indikator klinis juga sangat penting untuk mengoptimalkan program pengobatan dan memonitor adanya faktor risiko serangan jantung. berdasarkan hal tersebut, penelitian ini bertujuan untuk (1) menjelaskan perilaku kesehatan dan indikator klinis pasien dengan infark miokard di indonesia; dan (2) menganalisis hubungan perilaku kesehatan pasien dengan indikator klinis dan variabel lain yang telah ditentukan. metode: penelitian ini merupakan penelitian deskriptif korelasional dengan melibatkan 60 pasien dengan infark miokard. hasil: sebagian besar pasien berada pada tingkat cukup/sedang untuk perilaku kesehatan secara keseluruhan, perilaku berolahraga, perilaku diet, dan manajemen stres. sebagian besar pasien juga memiliki tingkat kepatuhan yang tinggi terhadap pengobatan dan berhenti merokok. selain itu, tekanan darah dan indeks massa tubuh (imt) pasien dengan infark miokard juga berada pada level normal. sebaliknya, lebih dari separuh pasien dengan infark miokard memiliki kadar gula darah dan kolesterol yang tinggi, serta hdl yang rendah. selain itu, hampir setengah pasien menunjukkan kadar ldl dan trigliserida yang tinggi. lebih lanjut, perilaku olahraga menunjukkan hubungan yang negatif terhadap kolesterol total dan ldl, namun jenis kelamin menunjukkan hubungan yang positif dengan perilaku kesehatan secara keseluruhan dan perilaku berhenti merokok. selain itu, penghasilan pasien per bulan menunjukkan hubungan yang positif terhadap perilaku olahraga dan diet; frekuensi hospitalisasi menunjukkan hubungan yang positif dengan tekanan darah sistolik; dan program pengobatan infark miokard menunjukkan hubungan yang positif dengan perilaku kesehatan, perilaku berhenti merokok, dan tekanan darah. diskusi: program rehabilitasi jantung sebaiknya juga mengikutsertakan perilaku kesehatan dan indikator klinis didalamnya sehingga dapat mencegah terjadinya serangan jantung dan menjaga status kesehatan pasien dengan infark miokard. kata kunci: infark miokard, perilaku kesehatan, indikator klinis abstract introduction: health behaviors are necessary for preventing possible cardiac events and maintaining health for mi patients. in addition to health behaviors, measuring clinical outcomes is a critical element for optimizing treatment and monitoring the risk factors of a cardiac event. the aims of this study were to (1) describe health behaviors and clinical outcomes among patients with myocardial infarction (mi) in indonesia; and (2) investigate the relationship between their health behaviors, clinical outcomes, and other selected variables. methods: sixty hospitalized mi patients participated in this descriptive correlational study. data were analyzed using descriptive and correlational statistics. results: the majority of mi patients in this study had a moderate level of total health behaviors, exercise behaviors, dietary behaviors, and stress management. interestingly, most of the patients had a high level of medication adherence, and smoking cessation. also, their blood pressure (bp) and body mass index (bmi) of mi patients were at the normal level. in contrast, more than half the patients had a high level of fasting blood glucose and total cholesterol, and a low level of hdl. moreover, nearly half of the patients presented a high level of ldl, and triglyceride. exercise behaviors have a negative relationship with total cholesterol, and ldl. interestingly, gender showed a positive relationship with total health behaviors, and smoking cessation. in addition, monthly incomes show a positive relationship with exercise behavior, and dietary behaviors. the number of times hospitalized appeared to have a positive relationship with systolic bp. surprisingly, mi treatments showed a positive relationship with total health behaviors, smoking cessation, and bp. discussions: in conclusion, cardiac rehabilitation should involve health behaviors and clinical outcomes to prevent recurrent cardiac events and maintain health for mi patients. keywords: myocardial infarction, health behaviors, clinical outcomes 309 perilaku kesehatan dan indikator klinis pasien (yusshy kurnia herliani, dkk.) introduction myocardial infarction (mi) is a leading cause of morbidity and mortality in the united states and other developed countries (cabrera & kornusky, 2014) and is one of the leading causes of disease burden in developing countries as well as indonesia (gaziano, bitton, anand, abrahams-gessel, & murphy, 2010). therefore, health behaviors are necessary for preventing possible cardiac events and maintaining health for mi patients. health behaviors are the individual’s activities performed in order to promote health, prevent disease, detect, and control symptoms of the disease (edelman & mandle, 2010). based on the american heart association (aha)’s recommendations, the health behaviors consisted of medication adherence, exercise, dietary modification, stress management, and smoking cessation (balady et al., 2007). health behaviors are important aspect for preventing hospital admissions as well as decreasing mortality among people who survive a mi (boyde et al., 2014). in addit ion to health behaviors, measuring clinical outcomes is a critical element for opt imizing t reat ment and monitoring the risk factors of a cardiac event (balady et al., 2007). savage, sanderson, brown, berra, and ades (2011) reported that clinical outcomes will provide critical information to guide the treatment and support the program development. aha recommended the control and maintenance of body weight, cholesterol, blood pressure, and blood glucose level (balady et al., 2007; hariadi & ali, 2005) as strategies for modifying the risk factors of adverse cardiac events (leif heit-limson et al., 2013). nevertheless, existing educational program for mi patients still provide general information rather than consider in patient’s information needs that cause patients failed to achieve the behavioral change and clinical goals recommendations (boyde et al., 2014). therefore, assessing information related to characteristic of health behavior and clinical characteristics among mi patients are important to provide effective primary and secondary prevention of mi. despite there are few studies have investigated health behaviors and clinical characteristics of mi patients, previous researches were mostly conducted in western countries and were still limited in indonesia. moreover, the relationship between health behaviors, clinical outcomes, and mi patient’s demographic data are not clear yet. therefore, the aims of this study were to (1) describe health behaviors and clinical outcomes among patients with myocardial infarction (mi) in indonesia; and (2) investigate the relationship between their health behaviors, clinical outcomes, and other selected variables among mi patients in indonesia. method and materials the sample of this study consisted of 60 mi patients admitted into the cicu (cardiac intensive care unit) and the hccu (high cardiac care unit) of hasan sadikin hospital, indonesia. hasan sadikin hospital is a tertiary hospital located in west java province, indonesia. convenience sampling was used as sampling procedure of this study. the patients who met the inclusion criteria were approached to determine their willingness to participate in the study. t h e i n c l u s i o n c r i t e r i a w e r e : (1) age >18 years; (2) confirmed diagnosis of mi; (3) have no cognitive impairment; (4) agree to participate in the study; (5) be able to communicate in indonesian language; (6) have stable hemodynamic levels; and (7) have no chest pain or dyspnea. the instruments used to collect data in this study were the demographic data and health related questionnaire (ddhq), a n d mo d i f ie d m y o c a r d i a l in fa r c t i o n health behaviors questionnaire (modified mihbq). the ddhq was used to collect the patient’s demographic and health related data. the ddhq was developed by the researcher. it included age, gender, marital status, educational level, monthly incomes, occupation, number of times hospitalized, types of mi, and treatments. the modified 310 jurnal ners vol. 10 no. 2 oktober 2015: 308–317 mihbq is a self-reported health behaviors questionnaire. it was modif ied from the mihbq that was developed by ahyana (2013) based on cardiac rehabilitation and a secondary prevention guideline established by the aha. the modified mihbq is composed of 34 questions which cover 5 subscales including medication adherence, exercise behavior, dietary behavior, stress management, and smoking cessation. the score for each question ranged from one to four points. 1 = never (never perform the activity), 2 = sometimes (3–4 times per month), 3 = often (3–4 times per week), and 4 = routinely (5–7 times per week). for some negative questions, the score was reversed. the total score ranges from 34 to 136, higher scores indicate more frequent performance of health behaviors. cronbach’s alpha coefficient revealed a reliability score of.81. the clinical outcomes assessed in this study consisted of blood pressure (bp), serum lipid (total cholesterol, hdl, ldl, triglyceride), fasting blood glucose, and body mass index (bmi). bp was measured by a mercury sphygmomanometer as recommended by the aha as the gold standard for clinical measurement of blood pressure. to measure blood glucose and serum lipid, the patients were instructed to take nothing orally except water and medication for 12 hours before the tests. blood glucose and serum lipid were measured at a standardized hospital biochemistry laboratory. bmi was calculated by measuring the height and the weight without shoes, with light clothing, and after urination. body weight was measured using digital weight scale. this study was also approved by the research ethics committee of faculty of nursing, prince of songkhla university, thailand, and hasan sadikin hospital, indonesia. the researcher explained to the potential subjects the purpose of the study, that participation in this study was voluntary, and that their anonymity would be ensured; the data would remain confidential and they had the right to refuse to participate in the study or withdraw at any time without any negative consequences. patients who agreed to participate signed the consent form before starting data collection. data were analyzed using descriptive and correlational statistics. descriptive statistics were used to describe characteristics of the sample by using frequency, percentage, mean, and standard deviation. preliminary testing was done to meet the assumption of parametric testing prior to running the parametric tests. pearson’s product-moment table 1. frequency, percentage, means, and standard deviations of the patients’ demographic data (n = 60) characteristic n % age (range 37–79 years) mean = 56.33 sd = 9.25 gender male 47 78.3 female 13 21.7 marital status married 57 95.0 widower/ widow 3 5.0 educational level no schooling 5 8.3 elementary school 11 18.3 junior high school 9 15.0 high school 24 40.0 college or higher 11 18.3 monthly incomes < 1million idr (< 76.97 usd) 16 26.7 1–2 million idr (76.97– 153.93 u sd) 17 28.3 2–4 million idr (153.93– 307.87 usd) 12 20.0 > 4million idr (> 307.87 usd) 15 25.0 occupation entrepreneur 20 33.3 government employee 7 11.7 private sector employee 6 10.0 farmer 1 1.7 retired 7 11.7 unemployed 19 31.7 number of times hospitalized 1 39 65.0 2 12 20.0 3 5 8.3 >3 4 6.7 types of mi stemi 49 81.7 nstemi 11 18.3 mi treatment medication 19 31.7 pci 41 68.3 311 perilaku kesehatan dan indikator klinis pasien (yusshy kurnia herliani, dkk.) correlation statistic (r) was calculated to examine the relationship between health behaviors, clinical outcomes, and other selected variables among mi patients. results the majority of patients were men (78.3%), and married (95%) with a mean age of 56.33 years (ranging from 37 to 79 years). a high number of patients (28.3%) had monthly incomes of 1–2 million idr (76.97–153.93 usd), followed by 26.7% who had monthly incomes of less than 1 million idr (< 76.97 usd). forty percent of the patients had a high school education and 56,6% were working in various sectors of commerce. the number of those who were hospitalized due to mi varies: 65% of the patients were diagnosed for the first time with mi and the rest had been hospitalized twice or more. in addition, 81,7% of the subjects were diagnosed with stemi of which 68,3% of the patients had undergone percutaneous coronary intervention (pci). the health behaviors scores among mi patients in this study ranged from 63 to 121, with the mean score of was 94.42 (sd = 12.43). the mean scores of health behaviors subscales are presented in table 2, which are: medication adherence (m = 20.83), exercise behaviors (m = 20.10), dietary behaviors (m = 22.30), stress management (m = 17.88), and smoking cessation (m = 19.63). table 3 presents the frequency and percentage of level of health behaviors and each subscale. the majority of mi patients had a moderate level of total health behaviors (75%). each subscale of health behaviors was reported differently. most of the patients had a high level of medication adherence (76.7%), and smoking cessation (73.3%). the majority of the patients appeared to exhibit a moderate level of exercise behaviors (53.3%), dietary behaviors (43.3%), and stress management (55%). the clinical outcomes of mi patients in this study are presented in table 4. the majority of mi patients in this study showed a normal level of blood pressure (70%), and body mass index (63.3%). in contrast, more than a half of the patients (61.7%) had a high level of fasting blood glucose. approximately 41.7% had a high value of total cholesterol, 78.3% had a high level of ldl, 80% had a low level of hdl, and 46.7% had a high value of triglyceride. the results of the bivariate correlational analysis using pearson correlation coefficients table 2. range, mean and standard deviation of health behaviors (n = 60) health behaviors range mean sd level total health behaviors 63–121 94.42 12.43 moderate medication adherence 14–24 20.83 3.04 high exercise behaviors 9–29 20.10 4.97 moderate dietary behaviors 9–30 22.30 5.29 moderate stress management 12–24 17.88 2.99 moderate smoking cessation 6–24 19.63 5.72 high table 3. frequency and percentage of level of health behaviors (n = 60) health behaviors low moderate high n % n % n % total health behaviors 2 3.3 45 75.0 13 21.7 medication adherence 0 0 14 23.3 46 76.7 exercise behaviors 16 26.7 32 53.3 12 20.0 dietary behaviors 11 18.3 26 43.3 23 38.3 stress management 1 1.7 33 55.0 26 43.3 smoking cessation 10 16.7 6 10.0 44 73.3 312 jurnal ners vol. 10 no. 2 oktober 2015: 308–317 table 4. frequency and percentage of clinical outcomes (n = 60) clinical outcomes n % blood pressure normal 42 70.0 hypertension (systolic >140) (diastolic >90) 12 20.0 hypotension 6 10.0 fasting blood glucose normal 23 38.3 diabetes (>100) 37 61.7 total cholesterol normal 35 58.3 hypercholesterolemia (> 200 mg/dl) 25 41.7 ldl normal 13 21.7 high ldl (> 100 mg/dl) 47 78.3 hdl normal 12 20.0 low hdl (< 50 mg/dl) 48 80.0 triglyceride normal 32 53.3 high triglyceride (>150 mg/ dl) 28 46.7 bmi normal (1824) 38 63.3 overweight ≥ 25 kg/m2 19 31.7 obese (≥ 30 kg/m2) 1 1.7 underweight (<18) 1 1.7 (r) are presented in table 5. the results showed that exercise behaviors had a statistically negative relationship with total cholesterol (r = -0.27, p < 0.05), and ldl (r = -.31, p < 0.05). other subscales of total health behaviors did not show any significant correlation with each clinical outcome. table 6 provides correlation data between health behaviors, clinical outcomes, and selected variables among mi patients. the results revealed that age, marital status, education, occupation, and types of mi did not have any significant relationship with health behaviors. interestingly, gender showed a positive statistically relationship with total health behaviors (r = 0.33, < 0.01), and smoking cessation (r = 0.28, p < 0.05). in addition, monthly incomes show a positive significant relationship with exercise behavior (r = 0.33, p <.01), and dietary behaviors (r = 0.29, p <.05). number of times hospitalized appeared as a statistically positive relationship with systolic blood pressure (r = 0.31, < 0.05). surprisingly, mi treatments that are divided into pci and medication, showed a statistically positive relationship with total health behaviors (r = 0.53, < 0.01), smoking cessation (r = 0.37, < 0.01), systolic blood pressure (r = 0.27, < 0.05), and diastolic blood pressure (r = 0.34, < 0.01). table 5. correlation (r) between health behaviors and clinical outcomes among mi patients sys dias fbg tc ldl hdl trig bmi total health behaviors -.02 .21 -.09 -.12 -.17 -.06 -.04 .08 medication adherence .04 -.01 .24 -.04 -.07 -.01 .09 -.04 exercise behavior .14 .07 .05 -.27* -.31* .18 -.07 -.14 dietary behavior .09 .15 .04 -.18 -.24 .20 -.06 -.08 stress management .02 -.04 -.12 -.12 -.01 -.01 -.14 .17 smoking cessation .20 .24 -.11 -.20 -.15 -.05 -.22 .15 ** correlation is signifi cant at the 0.01 level (2-tailed) * correlation is signifi cant at the 0.05 level (2-tailed) note: sys = systolic blood pressure, dias = diastolic blood pressure, fbg = fasting blood glucose, tc = total cholesterol, ldl = low density lipoprotein cholesterol, hdl = high density lipoprotein cholesterol, trig = triglyceride, bmi = body mass index. 313 perilaku kesehatan dan indikator klinis pasien (yusshy kurnia herliani, dkk.) table 6 correlation (r) between health behaviors, clinical outcomes, and selected variable among mi patients variable age g m i e o h tm treat total health behaviors .19 .33** .05 .14 .03 .06 .01 .01 .53** medication adherence -.01 .08 .24 .09 .18 .11 .02 -.03 .12 exercise behavior -.14 -.06 .07 .33** .17 -.18 .14 .05 .11 dietary behavior .01 -.10 .19 .29* .19 -.21 .19 -.13 .13 stress management .05 -.02 -.07 .06 .04 .12 .12 -.05 .21 smoking cessation .09 .28* .11 .17 .09 -.09 .23 .13 .37** systolic -.06 .09 .18 -.13 .02 .05 .31* .23 .27* diastolic -.01 .23 .07 .08 .25 -.04 .20 -.18 .34** fasting blood glucose .01 .09 .08 .06 -.11 .04 -.08 .01 -.14 cholesterol .02 .09 .00 -.09 .17 .21 -.25 -.06 -.09 ldl -.01 -.01 .06 -.13 .06 .25 -.18 -.01 -.11 hdl .08 -.10 -.19 .14 -.01 .07 -.11 .17 .11 triglyceride -.19 .14 .01 .09 .11 -.05 -.07 -.16 -.13 bmi -.12 -.07 -.10 .17 .24 -.17 -.09 -.14 .21 ** correlation is signifi cant at the 0.01 level (2-tailed). * correlation is signifi cant at the 0.05 level (2-tailed). note: age, g = gender, m = marital status, i = incomes, e = education, o = occupation, h = number of times hospitalized, tm = types of mi, treat = mi treatment. discussion most of the patients in this study were men, and married with an average age of 56.33 years, ranging from 37 to 79 years. these results were supported by a previous study conducted in indonesia, which noted that more than half of the patients were men with a mean age of 55.16 years (ahyana, kritpracha, & thaniwattananon, 2014). of the 81.7% who had been diagnosed with stemi, 68.3% had undergone percutaneous coronary intervention (pci). in the last two years, pci was reported as the most common treatment for coronary heart disease (venturini &testa, 2014). the results of this study are congruent with a previous study of mahgoub, mohamed, mohammed, abdel-aziz, and kishk (2013) who reported that the majority patients with mi who had undergone pci were males in the age group between 50 to 60 years. the subjects in this study had middle and low monthly incomes. the majority of the patients had graduated from high school, and worked in various commercial sectors. the patients studied varied in terms of frequency of hospitalization and 35% had been hospitalized twice or more due to mi. this finding is similar with what was reported by kikkert et al. (2014) that 21.2% of patients still have a recurrent mi after receiving treatment. in addition, ahyana et al. (2014) also reported that 53.1% of the subjects had been hospitalized twice. this finding revealed that secondary prevention was not performed optimally to prevent recurrent mi. in regards to health behaviors, the majority of mi patients had a moderate level of total health behaviors. each subscale of health behaviors was reported differently. the majority of the patients appeared to exhibit a moderate level of exercise behaviors, dietary behaviors, and stress management. interestingly, most of the patients had a high level of medication adherence, and smoking cessation. these results differed from a previous study conducted by ahyana et al. (2014) that revealed the level of total health behaviors and all the subscales including taking medication, exercise, dietary modification, and stress management were at a high level. however, in the study of ahyana et al. (2014), smoking cessation was not investigated. 314 jurnal ners vol. 10 no. 2 oktober 2015: 308–317 mi patients had a high level of compliance in taking medication regularly because most of the subjects had more than one comorbid disease (hypertension, hypercholesterolemia, and diabetes mellitus) (ahyana et al., 2014). the patients who had a history of smoking within the past 30 days were categorized as current smokers. the clinical outcomes investigated in this study consisted of blood pressure, fasting blood glucose, serum lipid, and bmi. hypertension was defined as systolic blood pressure > 140 mmhg or diastolic blood pressure > 90 mmhg. obesity was defined as a body mass index (bmi) > 30 kg/m2 and overweight was bmi >25 kg/m2 (leif heitlimson et al., 2013). in addition, diabetes was defined as fasting blood glucose levels is more than 100 mg/dl (go et al., 2014). the majority of mi patients in this study showed a normal level of blood pressure, and body mass index (bmi). in contrast, more than half of the patients had a high level of fasting blood glucose. these findings are in agreement with those of gaziano et al. (2010) who reported that indonesia is in the top 10 in high absolute number of diabetics which indicates that asian populations have a higher risk for developing dm even at a lower bmi due to a greater tendency of abdominal obesity. hypercholesterolemia was def ined as total cholesterol > 200 mg/dl, an ldl cholesterol level greater than 100 mg/dl, or an hdl cholesterol level less than 50 mg/dl, and a triglyceride greater than 150 mg/dl (national heart, lung, and blood institute [nhlbi], 2014). in the present study, more than a half of the patients had a high level of total cholesterol, and a low level of hdl. moreover, nearly half of the patients in the present study had a high level of ldl, and triglyceride. total cholesterol was positively associated with ischemic heart disease mortality at all blood pressure levels (zodpey, shrikhande, negandhi, ughade, & joshi, 2015). moreover, high cholesterol levels are estimated to cause 56% of ischemic heart disease worldwide (gaziano et al., 2010). lipids concentration is changed with mi. serum lipid will increase over the first 24 hours following mi. patients with mi had the highest level of serum lipids than other types of cad such as stable and unstable angina pectoris (ornek et al., 2011). the results of the present study showed that exercise behaviors have a statistically negative relationship with total cholesterol, and ldl. the findings are in agreement with those of which gaziano et al. (2010) who reported that decreased exercise causes higher plasma cholesterol level. a lack of exercise can worsen other chd risk factors, such as high blood cholesterol and triglyceride levels, high blood pressure, diabetes and obesity (nhlbi, 2014). these findings indicate that exercise lowers the levels of total cholesterol and ldl. other subscales of total health behaviors did not show any significant correlation with each clinical outcome. the results revealed that age, marital status, education, occupation, and types of mi did not have any significant relationship with health behaviors, and the clinical outcomes that were investigated in this study. these results were analyzed differently by ahyana et al. (2014), who noted health behavior related with the age, and marital status. however, compared to the study of ornek et al. (2011), serum lipids were not influenced by gender and age. interestingly, in the present study, gender showed a positive statistically relationship with total health behaviors, and smoking cessation. in general, men are more likely to smoke than women are. smoking is now more common in the developing countries such as indonesia with more than 60% male prevalence (gaziano et al., 2010). a history of prior smoking was more strongly associated with mi in men compared to that in women (anand et al., 2008), also it was reported that a woman controls smoking easier than a man (nhlbi, 2014). these findings indicate that gender is more likely to influence a person’s behavior to avoid smoking, which results in a better level of total health behaviors. therefore, female patients are more likely to have better health behaviors due to the better level of smoking cessation behaviors. 315 perilaku kesehatan dan indikator klinis pasien (yusshy kurnia herliani, dkk.) in addition, monthly incomes showed a positive significant relationship with exercise behavior, and dietary behaviors. these results are congruent with previous study which revealed that patients with higher income were more confident in adhering to exercise and maintain exercise behavior even when barriers were present (lapier, cleary, & kidd, 2009). in the present study, the majority of the subjects had middle and low monthly incomes which affected exercise and dietary behavior. number of times hospitalized appeared as a statistically positive relationship with systolic blood pressure. surprisingly, mi treatments that are divided into pci and medication showed a statistically positive relationship with total health behaviors, smoking cessation, systolic blood pressure, and diastolic blood pressure. a previous study revealed similar findings with this study and noted that the risk factors for patients who underwent pci were smoking, hypertension, and hyperlipidemia. better control of these risk factors might potentially improve outcomes in these patients (damman et al., 2013). conclusion and recommendations conclusion the majority of mi patients had a moderate level of total health behaviors, exercise behaviors, dietary behaviors, and stress management. interestingly, most of the patients had a high level of medication adherence, and smoking cessation. the majority of mi patients in showed a normal level of bp, and bmi. in contrast, more than 50% of the patients had a high level of fasting blood glucose. more than half of the patients had a high level of total cholesterol, and a low level of hdl. moreover, nearly half of the patients in the present study had a high level of ldl, and triglyceride. exercise behaviors had a negative relationship with total cholesterol, and ldl. this result indicates that the more a person exercises, the lower of total cholesterol and ldl he/she will have. other subscales of total health behaviors did not show any significant correlation with each clinical outcome. the results revealed that age, marital status, education, occupation, and types of mi did not have any significant relationship with total health behaviors, and all the clinical outcomes that investigated in this study. interestingly, gender showed a positive relationship with total health behaviors, and smoking cessation in addition, monthly incomes showed a positive significant relationship with exercise behavior, and dietary behaviors. number of times hospitalized appeared as a positive relationship with systolic blood pressure. surprisingly, mi treatments that are divided into pci and medication showed a positive relationship with total health behaviors, smoking cessation, and blood pressure. recommendation cardiac rehabilitation should involve health behaviors and clinical outcomes to prevent recurrent cardiac events and maintain health for mi patients. references ahyana., 2013. the effect of self-efficacy enhancing cardiac rehabilitat ion program on health behaviors among patients with myocardial infarction in aceh, indonesia (master’s thesis). prince of songkla university, thailand. ahyana., kritpracha, c., & thaniwattananon, p., 2014. health behaviors among patients with myocardial infarction in aceh, indonesia. songklanagarind journal of nursing, 34, 109-118. anand, s.s., islam, s., rosengren, a., franzosi, m.g., steyn, k., yusufali, a.h., yusuf, s., 2008. risk factors for myocardial infarction in women and men: insights from the interheart study. european heart journal, 29, 932–940. doi:10.1093/eurheartj/ehn018 balady, g.j., williams, m.a., ades, p.a., bittner, v., comoss, p., foody, j.m., southard, d., 2007. core components 316 jurnal ners vol. 10 no. 2 oktober 2015: 308–317 of cardiac rehabilitation/secondar y prevention programs: 2007 update: a scientifi c statement from the american heart association exercise, cardiac r e h a b i l i t a t i o n , a n d p r e ve n t i o n committee, the council on clinical c a r d i o l o g y ; t h e c o u n c i l s o n cardiovascular nursing, epidemiology and prevention, and nutrition, physical activity, and metabolism; and the american association of cardiovascular a n d p u l m o n a r y r e h a b i l i t a t io n . circulation, 115, 2675-2682. doi:10.1161/ circulationaha.106.180945 boyde, m., grenfell, k., brown, r., bannear, s., lollback, n., witt, j., aitken, l., 2014. what have our patients learnt after being hospitalised for an acute myocardial infarction? australian critical care, 1–6. doi: http://dx.doi. org/10.1016/j.aucc.2014.05.003 cabrera, g & kornusky, j., 2014. acute myocardial infarction. in d. pravikoff & d. pravikoff (eds.), (pp. 2p). glendale, c a l i fo r n i a : ci n a h l i n fo r m a t io n systems. damman, p., woudstra, p., kuijt, w.j., k i k k e r t , w. j., h o e f , t. p.v. d., grundeken, m.j., winter, r.j.d., 2013. shortand long-term prognostic value of the timi risk score after primary percutaneous coronary intervention for st-segment elevation myocardial infarction. journal of interventional cardiology, 26(1), 8–13. doi: 10.1111/ j.1540-8183.2012.00763.x edelman, c.l., & mandle, c.l., 2010. helath promotion throghout the life span (7th ed.). philadelphia, pa: mosby elsevier. gaziano, t.a., bitton, a., anand, s., abrahamsgessel, s., & murphy, a., 2010. growing epidemic of coronary heart disease in lowand middle-income countries. current problems in cardiology, 35(2), 72–115. doi: http://dx.doi.org/10.1016/ j.cpcardiol.2009.10.002 go, a.s., mozaffarian, d., roger, v.l., benjamin, e. j., berry, j. d., blaha, m. j., turner, m. b., 2014. heart disease and stroke statistics—2014 update: a report from the american heart association. circulation, 129, e28-e292. doi:10.1161/01.cir.0000441139.02102.80 hariadi & ali., 2005. hubungan obesitas dengan beberapa faktor risiko penyakit jantung koroner di laboratorium klinik prodia makassar tahun 2005 [correlation bet ween obesit y and multiple risk factors of coronary heart disease in prodia clinical laboratories makasar in 2005], 1–14. retrieved from: http://arali2008.fi les.wordpress. com /2008/09/obesitas-dan-jant ungkoroner. kikkert, w.j., hoebers, l.p., damman, p., lieve, k.v., claessen, b.e., vis, m.m., henriques, j.p., 2014. recurrent myocardial infarction after primary percutaneous coronary intervention for st-segment elevation myocardial i n fa rct ion. a me r ica n jou r nal of cardiology, 113, 229–235. doi:10.1016/ j.amjcard.2013.08.039. lapier, t.k., cleary, k., & kidd, j., 2009. e xe r c i s e s el fef f ic a c y, h a bit u a l physical activity, and fear of falling in patients with coronary heart disease. cardiopulmonary physical therapy journal, 20(4), 5–11. leif heit-limson, e.c., spertus, j.a., reid, k. j., jones, s.b., vacca r i no, v., krumholz, h.m., & lichtman, j.h., 2013. prevalence of traditional cardiac risk factors and secondary prevention among patients hospitalized for acute myocardial infarction (ami): variation by age, sex, and race. journal of women’s health (15409996), 22(8), 659– 666. doi: 10.1089/jwh.2012.3962 mahgoub, a.a., mohamed, w.y., mohammed, m.a., abdel-aziz, m.a., & kishk, y.t., 2013. impact of knowledge about early ambulation on patients’ satisfaction post percutaneous coronary intervention, at assiut university hospital. medical journal of cairo university, 81(2), 97– 104. national heart, lung, and blood institute., 2014. lower heart disiease risk: what are the risk factors of heart disease. retrieved from http://www.nhlbi.nih. gov/ health /educat ional / hea r t t r uth / lower-risk/risk-factors.htm ornek, e., murat, s., duran, m., turfan, m., kurtul, a., demircelik, m.b.,akdemir, 317 perilaku kesehatan dan indikator klinis pasien (yusshy kurnia herliani, dkk.) r., 2011. the relationship between lipoprotein(a) and coronar y ar ter y disease, as well as its variable nature follow i ng myoca rd ial i n fa rct ion. clinical & investigative medicine, 34(1), e14-e14. savage, p.d., sanderson, b.k., brown, t.m., berra, k., & ades, p.a., 2011. clinical research in cardiac rehabilitation and secondar y prevention: looking back and moving forward. journal of cardiopulmonary rehabilitation and prevention, 31, 333–341. doi:10.1097/ hcr.0b013e31822f0f79 venturini, e., & testa, r., 2014. cardiac r eh a bi l it at ion a nd p e r c ut a ne ou s coronary intervention: together against global burden of cardiovascular disease. journal of cardiology and therapy, 1(1), 3–11. doi:10.6051/j.issn.23096861.2014.01.9. zodpey, s.p., shrikhande, s.n., negandhi, h. n., ug hade, s. n., & josh i, p.p., 2015. risk factors for acute myocardial infarction in central india: a case-control study. indian journal of community medicine, 40(1), 19–26. doi: 10.4103/0970-0218.149265 http://e-journal.unair.ac.id/jners | 59 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.13689 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research fear of falling among the elderly in a nursing home: strongest risk factors anastasia putu martha anggarani and raditya kurniawan djoar stikes katolik st. vincentius a paulo, surabaya, indonesia abstract introduction: the aging process causes a decrease in physical abilities which can cause fall events. fall events are influenced by fear of falling. some risk factors of fear of falling were age, gender, balance while walking, use of a walker, depression and a history of previous falls. this study aim was to identify risk factors related to fear of falling among the elderly in nursing home. methods: a cross-sectional study was used in this study. respondents were elderly aged ≥60 years, can communicate well, able to read and write and not being sick which causes balance disorders and pain when walking. respondents totaled 155 obtained by proportional random sampling. a questionnaire was used to retrieve data such as age, gender, use of a walker, depression, previous fall history and balance walking. results: the results showed a significant relationship between all of these risk factors with the fear of falling (p <0.05) and the power of significance for each variable was different. the age variable was power significance 0.228, gender c = 0.2, previous fall history c = 0.374, use of a walker c = 0.367, balance walking c = 0.355 and depression rs = 0.196. there are three risk factors most closely associated with fear of falling in terms of balance walking (b = 1.424 exp(b) = 4,153), use of a walker (b = 1,365 exp(b) = 3,914) and previous fall history (b = 1.425 exp(b) = 4.159). these factors had strength of 27%. conclusion: balance walking, use of a walker and previous fall history were the strongest risk factors. article history received: june 17, 2019 accepted: april 30, 2020 keywords elderly; fear of falling; nursing home contact raditya kurniawan djoar  radit_stikvinct@yahoo.com  stikes katolik st. vincentius a paulo, surabaya, indonesia cite this as: djoar, r.k., & anggraini, a. p. m. (2020). fear of falling among the elderly in a nursing home: strongest risk factors. jurnal ners, 15(1). 59-65. doi:http://dx.doi.org/10.20473/jn.v15i1.13689 introduction the aging process causes a decrease in physical ability and further can cause the incidence of fall, especially for the elderly. the number of falling in the elderly is quite high, at least 28% -35% of 65year-old people fall every year and the number increases to 32% -42% in the elderly over 70 years (world health organization, 2007). fall events are influenced by several factors, one of which is the personal factor of fear of falling. as to psychological status of fear of falling, up to 70% of recent fallers and up to 40% of those not reporting recent falls acknowledge the fear of falling (25,38,55). up to 50% of people who are fearful of falling restrict or eliminate social and physical activities because of that fear (who, 2004). fall events are influenced by several factors, one of which is the personal factor of fear of falling. fear of falling is an internal phenomenon or anxiety associated with falls that can affect a person's level of dependence which results in a decrease in function when doing activities. fear of falling is a residual symptom of falling, but can also occur in people who have never fallen. this incident occurs above 60% in the elderly aged 60-79 years (howland, 1998). fear of falling can affect quality of life for the elderly and increase the risk of falling through the reduction of physical activity, confidence, strength, and balance. fear of falling can reduce balance control and reduced the confidence to prevent falls, further increasing the incidence of falls for the elderly (public health agency of canada, 2005). fear of falling is feeling anxious when walking or mobilizing normally or normally, it can cause falls (greenberg, 2011). the current study showed around 26% -55% of elderly people living in the community were fearful of falling, and 40% -73% of the elderly who had fallen had fear of falling (howland, 1998). in many ways, the fear of falling potentially causes restrictive movement, especially https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ r. k. djoar et al. 60 | pissn: 1858-3598  eissn: 2502-5791 for the elderly. that condition can decrease the independence of the elderly in daily activities (murphy, 2002), decreased quality of life of elderly and decreased social interaction (austin et al., 2007). the prevalence of fear of falling is in line with age (scheffer et al., 2008). aging will lead to physiological changes in the body's systems, such as the musculoskeletal, cardiovascular, respiratory, nervous, sensory and other organ functions (narinder & verma, 2007). because of physiological changes during the aging process, the elderly will have difficulty maintaining balance while performing activities. this situation can produce fear of falling during a functional activity. several studies of fear of falling have identified the prevalence of more women (susan et al., 2002). in one study conducted on 1000 women over three years, more than one-third of the samples reported fear of falling and increased 45% after three years (lach, 2005). the fear of falling is also influenced by the ability to maintain balance while walking (jacobs & fox, 2008). people with impaired balance have lost confidence to rest with the feet, especially when walking (fletcher & hirdes, 2004; kumaret al., 2008)) so that it will increase the fear of falling. psychological conditions, especially depression, also become one of the risk factors in fear of falling. depression has a strong relationship with the fear of falling and can cause the limitations of physical and social activity (jung, 2008). when the ability to do activity is decreased, elderly people will feel not confident and increase further fear of falling. depression can also make people less secure about their physical abilities, thus causing fear of falling (legters, 2002). several studies have shown a positive relationship between fear of falling and a previous fall history. a person who often experiences a fall will increase the incidence of fear of falling (jung, 2008). elderly people who have fallen are also more difficult to maintain balance as they perform their functional activities for fear of falling (kumaret al., 2008). elderly people who feel fear of falling will protect themselves by using walking aids to reduce the fear (victorian quality council, 2004). however, the elderly dependency on walking aids will also increase the fear of falling. several factors have a positive relationship with fear of falling; therefore, through this study, we want to identify the strongest risk factors that have been mentioned. so, it will be very helpful in determining the intervention, especially sports activities appropriate for the elderly who can support the maintenance of independence, function, health, and safety for them so it can be used as a preventive effort to reduce the incidence rate of fall in the elderly (greenberg, 2011). materials and methods this study was carried out at private and government nursing homes, st yosef nursing home, surya nursing home, usia nursing home, griya wredha nursing home, anugerah surabaya nursing home, and yayasan cinta kasih ibu teresa, between 1 march and 29 may 2016. the study protocol was approved by the ethical committee on health research, faculty of medicine, airlangga university, indonesia. informed consent was obtained from all of the respondents. this study was conducted at 155 elderly determined by a proportional random sampling technique. independent variables in this study are age, gender, previous fall history, use of a walker, depression status, and balance ability, while the dependent variable is fear of falling. the data were obtained by using questionnaire. the questionnaire containing questions about age, gender, previous fall history and use of a walker. to fill in the age data, the respondents fills his / her age in the questionnaire in year, gender, for the data of previous fall history, respondents select "yes" or "no" items in the questionnaire, and for the data of the use of the walker, respondents select item "yes" or "no" in the questionnaire. to obtain the fear of falling data, we used the questionnaire modified fall efficacy scale indonesia version with content validity item in the range of 0.857 1 (valid value> 0.78), while the sum-content validity index obtained the result 0.93 (valid value> 0. 9) with cronbach's alpha value 0.948), and to obtain depression data we used the indonesian version of the geriatrics depression scale (gds) questionnaire with cronbach’s alpha value of 0.88 (himawan, rinawaty, & wirawan, 2014), in addition, we used the time up and go test (tugt) with interrater of 0.94 and intra rater of 0.95 to obtained balance walking data (asnandra, 2009). the data were recapitulated, entered into the spss program and analyzed. spearman test was used to identify correlation for age, depression, and fear of falling and the other data used contingency coefficient to identify the correlation between gender, previous falls history, use of a walker, balance ability with fear of falling. to identify the risk factor, binomial logistic regression was used. results characteristics of respondents in this research are average 76 years with a percentage equal to 70.3% and female. of the 155 respondents it was found 58.1% had experienced a fall. as many as 65.2% are not depressed. respondents in this study, as many as 65.8%, had a risk of falling and 74.2% of them did not use a walker. a total of 49.7% of respondents have high concerns about falling (table 1). jurnal ners http://e-journal.unair.ac.id/jners | 61 spearman test was used to identify correlation for age, depression, and fear of falling and the other data used contingency coefficient to identify the correlation between gender, previous fall history, use of a walker, and balance ability with fear of falling. the correlation analysis in this study showed that there was a moderate correlation between the previous fall history and the fear of falling (c = 0.374; p = 0.000), the use of walking aids with fear of falling (c = 0.367, p = 0.000) and the balance walking with fear of falling (c = 0.355; p = 0.000) (table 2) multivariate analysis in this study used a binomial logistic regression test. we used this test because the correlation test of risk factors fear of falling to fear of falling is not strongly related and we assume the possibility of any relationship between each risk factor. the previous fall history, the use of walkers and the current balance is the strongest risk factor for fear of falling (cox & snell r square = 0.276). respondents experiencing one of these three risk factors risk an average of four times more with high fears of falling (exp (b) = 3,9144,159) (table 3). respondents who do not have a risk of falling, do not use walking aids and do not have a previous fall history still have a chance of fear of falling by 10.76%. respondents who are at risk of falling, using walking aids and having a previous fall history have a high probability of falling 89.07%. to identify the chance of power independent variable to the dependent variable, the researcher using the formula p:1/1+e¯ʸ. (y= -2,116+1,425 balance ability+1, and use of a walker +1, previous fall table 1. demographics (n: 155) variable sub group mean±sd/n(%) age 76.3±8.02 gender male 46 (29.7%) female 109 (70.3%) previous fall history yes 90 (58.1%) no 65 (41.9%) use of a walker yes 40 (25.8%) no 115 (74.2%) balance walking 22.3±14.6 risk of falls 102 (65.8%) no risk of falls 53 (34.2%) depression 8.5±5.1 normal 101 (65.2%) mild depression 50 (32.3%) moderate depression 4 (2.6%) table 2. correlation analysis variable fear of falling rs c age 0.228** gender 0.200* previous fall history 0.374*** use of a walker 0.367*** balance walking 0.355*** depression 0.196* *p< .05;**p< .01;***p< .001 table 3. binomial logistic regression test analysis b sig. exp(b) 95% c.i.for exp(b) cox & snell r square lower upper previous fall history 1.424 0.000 4.153 1.913 9.016 use of a walker 1.365 0.006 3.914 1.474 10.395 balance walking 1.425 0.001 4.159 1.820 9.501 constants -2.116 0.000 0.276 table 4. chance of fear of falling risk of falls use of a walker previous fall history % chance of fear of falling no no no 10.76% no yes no 32.06% no no yes 33.36% yes no no 33.39% no yes yes 66.23% yes no yes 67.57% yes yes no 66.23% yes yes yes 89.07% r. k. djoar et al. 62 | pissn: 1858-3598  eissn: 2502-5791 history. the formula used by researchers has a precision of 74.8%. equation: ……….......................... ............................................................. (1) remarks: ................................................................................ discussion this study showed 58.1% of respondents had a history of previous falls. the result of the correlation analysis p = 0.000 r = 0.374 indicating that the previous fall history has a moderate strength relationship with fear of falling. the logistic regression analysis test showed the result of significance p = 0.000 with the positive direction indicated by the value of b = 1.423. this is by the theory that a person who often experiences a fall will increase the incidence of fear of falling (jung, 2008). when viewed from the chances of respondents who have a history of falling and experiencing high fears they will fall, this obtained data of 33.3% and 76.62% of respondents who have a history of falls have high worries they will fall. other studies with elderly respondents also reported that there was a significant correlation between previous fall history and fear of falling (lopes, costa, santos, castro, & bastone, 2009). the fear of falling can be described depending on the experience of the previous fall and the increased fear of falling with the fall type (arken et al., 1994). fall events that cause serious injury further increase the fear of falling (salkeld et al., 2000). elderly people who have experienced a previous fall not only impact on their physical condition, but have an impact on the psychological conditions in which they will feel traumatized by such unpleasant events and afraid to fall again when they do the activity. this condition will have an impact on the decline in social activity and confidence. this study has the result explain that although respondents who never fall but they have risk of falls and using a walking aid, they have a chance 66.23% fear of falling (table 4). this is in line with previous research by lopes et al. (2009) where the incidence of fear of falls occurred by 12% -65% in the elderly who live in the community, aged over 60 years and have no previous fall history. the results obtained in this study indicate that most respondents who have a fear of falling do not have a previous fall history (lopes et al., 2009). this condition can occur because the fear of falling is a multifactor event, so that not only the previous fall history can cause fear of falling. elderly people who do not have a previous fall history may experience fear of falling. this fear can be a safeguard to be more careful to avoid the risk of falling, but also can be a risk when it results in limitations and lack of confidence when doing activities. the previous fall history is one of the biological factors of fear of falling. to determine the appropriate intervention in this risk factor, it is necessary to examine the type of activity, the time of the fall, the frequency of fall, the injury suffered and the symptoms at the time of fall. if the elderly have a history of falling due to unsafe environmental causes for the elderly to walk, then appropriate intervention is to change the environment to be safe for the elderly, for example: to give a handle in every aisle used by the elderly to walk so that the elderly remain confident not to fall. interventions that can be done in the elderly with a history of previous fall include trying to stay active, always positive thinking, take care of yourself and do relaxation exercises (shaw, 2010). for these three things, balance is one of the key moves (allison, 2001). balance, strength, and flexibility are needed to maintain good posture. these three elements are the basis for realizing a good road pattern for each individual. important mechanisms for each individual to have a good balance involve the peripheral nervous system, proprioceptive (sense of joint position), vestibular and cerebral and visual (vision) (skelton, 2017), otherwise known as postural control, which is the ability to maintain balance and orientation in the gravitational environment. according to lopes et al. (2009), postural control consists of three components, peripheral sensory system, central system, and effector system, and the elderly will experience a decrease in function, as well as peripheral nerves. central processing runs slowly as well as in the interpretation and sensory information of the system and recruitment of motor planning, and careful environmental responses. peripheral nerves, skeletal muscle mass and muscle strength decrease in function causing postural control to be slower and weaker. this decrease in function will disturb the balance, which will ultimately lead to a greater risk of falling (jette, 2012). in this study data obtained 65.8% of respondents have the risk of falling. the result of the correlation analysis is p = 0.000 r = 0.355, which shows that the current balance has a medium relationship with the strength of the relationship. the logistic regression analysis test showed the result of significance p = 0.001 with the positive direction indicated by the value of b = 1.425. research conducted by boyd and stevens (2009) shows a relationship between decreasing balance and fear of falling. posture control, voluntary movement stability, and reaction maintain balance when being subjected to outside interference is the basis for maintaining balance. postural control involves the integration of sensory, nervous, and musculoskeletal systems, so the center of mass remains at bases of support and center of gravity moves along with a change in the base of support so that balance can be formed (miyamoto, lombardi, berg, ramos, & natour, 2004). another study reported that 78.91% of respondents experienced partial independence during transfer, 50.34% indicated a fear of falling through the tandem gait test (correlation r = 0.457) jurnal ners http://e-journal.unair.ac.id/jners | 63 and 31.39% decreased equilibrium (correlation r = 0.44248) (lopes et al., 2009). this is in line with this study that there is a relationship between the current balance and the fear of falling. fear of fall is the result of the recruitment of agonist and antagonist muscle work while maintaining poor posture, abnormal road patterns, poor balance strategy, depending on assistive devices that ensure stability and increased risk of falls in the elderly. when a person is feeling unbalanced when doing activities, especially walking, this will directly make the individual afraid to perform activities because of changes in the balance that can consciously cause a fall when forced to move. likewise, in the elderly, physical changes are closely related to the balance in walking. the chance of respondents experiencing high concerns they will fall in respondents who have a risk of a fall is 33.39%. medical conditions associated with a disturbance of equilibrium greatly affect the increased fear of falling because people with impaired balance have lost the confidence to rest with the foot, especially when walking (kumar, venu vendhan, awasthi, scholar, & tiwari, 2008). therefore, it is necessary to identify the main factors causing the imbalance so that appropriate interventions can be given to improve the balance of the elderly. to determine the appropriate intervention of this risk factor, an examination consisting of a path pattern examination, balance and joint function on the lower extremities is required. one of the interventions that can improve balance is tai chi gymnastics. this is shown in a study conducted by scheffer, schuurmans, van dijk, van der hooft, and de rooij (2007) which found that there is an increase in balance during activity. tai chi is a sport that contains slow, rhythmic movements, many involving trunk movements, weight transfer, coordination, and pedestrian refinement. this gymnastic activity is performed for 60-90 minutes for two sessions per week. this study shows 25.8% of respondents using road aids. the result of the correlation analysis p = 0.000 r = 0.367 indicates that the use of the walker has a relation with the medium strength of the relationship. the logistic regression analysis test showed the result of significance p = 0.006 with the positive direction indicated by value b = 1.365. opportunities of respondents using of road aids experienced high concerns about falling (32.06%). the elderly use walking aids for various reasons, namely as a therapeutic tool to train post-injury walking skills, the elderly with neurological disorders, and to further reduce the fear of falling (world health organization, 2007). the use of a walker has a protective effect on falls in the elderly as it helps elderly people with mobility limitations when engaging in activities with disturbances from the environment (rayel, land, & gutheil, 1999). elderly using a walker already have concerns about falling if they do activities. this is in line with the theory so they compensate by using a walker to reduce the fear of falling. this is in line with research conducted by multani andc verma (2007) in 43 elderly people (≥ 60 years) where 22 people (51%) used a walker at least one year. the reason for the respondents using the walker was because they were afraid of falling as much as 54.5%, while the other reason was finding security (27.3%), and habituation following surgery/injury (18.2%). this study also obtained the data of respondents who do not use a walker, but have a high concern they will fall, as many as 45 people (58.44%). elderly do not use walkers because they feel embarrassed / considered disabled, elderly and feel by using a walker it will restrict its activity because the use of a walker can affect the pattern of the road by inhibiting swing pattern, affect posture, reduce road speed, step length and swing time, and stance time (world health organization, 2007). it will cause more fear of falling. besides, the elderly judge that the environment around them does not support them to use the walker. another thing that causes those who do not use the walker, but still experience high worries they will fall, with 32 respondents have a history of falling before, 32 people have a risk of falling, and 22 people have a history of previous fall and have the risk of falling. some elderly people have difficulty when using a walker. therefore, the should be trained in advance in the use of a walker, especially in the elderly, on how to use the right aids so that the elderly are confident in using the tool so that the fear of falling can be reduced (bradley & hernandez, 2011). this study reported that the probability of experiencing heightened fear of fall over those who do not have a risk of falling / balancing when walking well, not having a previous fall history and not using a walker is 10.76%. this concern can be a protective order to be more careful to avoid the risk of falling during the move. opportunities experiencing heightened concerns they will fall over those who have had a previous fall history and use the walker is 66.23%. one study reported that, from 199 respondents, 56 respondents (28.4%) often experienced a fall in the last 12 years, eight respondents (4.1%) had experienced a fall of one time to cause injury and 32 respondents (16.2%) never experienced a previous fall without causing injury. respondents who had experienced the fall using a walker and experienced fear of falling (roman de mettelinge & cambier, 2015). the elderly who have experienced a fall have low confidence when doing activities for fear of falling owned. to increase confidence to feel a sense of security while doing activities and avoid the risk of falling back, some elderly use a walker because it helps to maintain balance while on the move. people who have a risk of falling / balancing on a bad run and using a walker have a chance of high worries will fall by 67.57%. the use of a walker indicates the occurrence of a balance disorder or r. k. djoar et al. 64 | pissn: 1858-3598  eissn: 2502-5791 may cause one to lose balance due to an increase in attention requirement (public health agency of canada, 2005), and it can cause fear of falling. people who have a risk of falling/balancing on a bad run and having a previous history of falling have a chance of high worries they will fall by 66.23%. ability to maintain balance while on the move/walking is done by several systems in the body. when considering elderly experiencing a decline in anatomical and physiological functions, the ability will be reduced, resulting in the elderly often experiencing a fall during the move. therefore, the elderly who have often experienced a fall because of balance going bad will experience the fear of falling to a higher extent. according to this study, if people have a risk of falling / balancing when walking is bad, having a history of previous falls and using a walker, they will have a chance of experiencing high worries they will fall by 89.07% (table 4). this is because of the three things are the most dominant factors in the fear of falling. the elderly having a poor balance will feel insecure when using foot as a pedestal. this causes an increased risk of falling in the elderly. the elderly who had fallen had a sense of trauma and confidence reduction during the move, so used a walker. the use of a walker will also cause the elderly to have unusual road patterns, reduce swing while walking, affect posture, reduce road speed, length of step and stance time, and then will increase worries of fall. conclusion the strong predictor of the fear of falling in the elderly was the use of walkers, balance and previous fall history. therefore, based on this study people who have responsibility in the nursing home have to provide regularly activities such as gymnastics which can improve the balance of the elderly, also provide consultation for the elderly to be able to increase self-confidence, especially for those who have a history of previous falls, and modify the environment to add handrails in the area used by the elderly to reduce fears of falling. references allison l., f. k. (2001). balance and vestibular disorder, neurogical rehabilitation (4th ed.). mosby. arken, c. l., lach, h. w., birge, s. j., & miller, j. p. (1994). the prevalence and correlates of fear of falling in elderly persons living in the community. american journal of public health, 84, 565–570. asnandra, n. (2009). uji reliabilitas time up and go test pada lansia perempuan. politeknik kesehatan surakarta. austin, n., devine, a., dick, i., prince, r., & bruce, d. (2007). fear of falling in older women: a longitudinal study of incidence, persistence, and predictors. journal of the american geriatrics society, 55(10), 1598–1603. https://doi.org/10.1111/j.15325415.2007.01317.x boyd, r., & stevens, j.a. (2009). falls and fear of falling : burden , beliefs and behaviours. oxford journal, 38, 423–428. https://doi.org/10.1093/ageing/afp053 bradley, s. m., & hernandez, c. r. (2011). geriatric assistive devices. american family physician, 84(4), 405–411. c.scheffer, a., j.schuurmans, m., dijk, n. van, hooft, t. van der, & de rooij, s. e. . (2008). fear of falling : measurement strategy , prevalence , risk factors and consequences among older persons. age and ageing, 37, 19–24. https://doi.org/10.1093/ageing/afm169 fletcher, p. c., & hirdes, j. p. (2004). restriction in activity associated with fear of falling among community-based seniors using home care services. age and ageing, 33(3), 273–279. https://doi.org/10.1093/ageing/afh077 friedman, s.m. (2002). falls and fear of falling: which comes first? a longitudinal prediction model suggests strategies for primary and secondary prevention. journal of the american geriatrics society, 50:1329-1335. greenberg, s. a. (2011). assessment of fear of falling in older adults : the falls efficacy scaleinternational ( fes-i ). hartford institute for geriatric nursing, 45(29). https://doi.org/10.1159/000320054.kempen himawan, k. ., rinawaty, w., & wirawan, h. . (2014). effect of reminiscence group therapy on depressive symptoms of the nursing home elderly residents in tangerang, indonesia: a pilot study. the guidance journal, 45(1), 1–22. howland, j. (1998). covariates of fear of falling and associated activity curtailment. gerontologist, 38(5). jacobs, m., & fox, t. (2008). using the “ timed up and go / tug ” test to predict risk of falls. assisted living consult, (april). jette, a. m. (2012). fear-of-falling in older persons. fear of falling in older persons. jung, d. (2008). fear of falling in older adults: comprehensive review. asian nursing research, 2(4), 214–222. https://doi.org/10.1016/s19761317(09)60003-7 kumar, s., awasthi, s., sharma, v.p., vendhan, g.h,, & tiwari, m. (2008). relationship between fear of falling, balance impairment and functional mobility in community dwelling elderly. indian journal of physical medicine and rehabilitation, 19(482), 48–52. lach, h. w. (2005). incidence and risk factors for developing fear of falling in older adults. public health nursing, 22(1), 45–52. legters, k. (2002). fear of falling. physical therapy (journal of the american physical therapy association, 82 no.3, 264–272. retrieved from https://www.msconnection.org/blog/novembe r-2013/fear-of-falling lopes, k.t., costa, d.f., santos, l.f., castro, d.p., & jurnal ners http://e-journal.unair.ac.id/jners | 65 bastone, a.c. (2009). prevalence of fear of falling among a population of older adults and its correlation with mobility , dynamic balance, risk and history of falls. revista brasileira de fisioterapia, 13(june), 223–229. miyamoto, s. t., lombardi, i., berg, k. o., ramos, l. r., & natour, j. (2004). brazilian version of the berg balance scale. brazilian journal of medical and biological research, 37(9), 1411–1421. https://doi.org/10.1590/s0100879x2004000900017 murphy, s. l. (2002). characteristics associated with fear of falling and activity restriction in community-living older persons. j am geriatr soc, 50 (3). multani, n.k., & verma, s. k. (2007). principles of geriatric physiotherapy. public health agency of canada. (2005). report on seniors’ falls in canada. canada: minister of public works and government services canada. rayel, m. g., land, w. b., & gutheil, t. g. (1999). dementia as a risk factor for homicide. jforensic-sci, pp. 565–567. roman de mettelinge, t., & cambier, d. (2015). understanding the relationship between walking aids and falls in older adults: a prospective cohort study. journal of geriatric physical therapy (2001), 38(3), 127–132. https://doi.org/10.1519/jpt.00000000000000 31 salkeld, g., cameron, cumming, r. g., easter, s., seymour, j., kurrle, s. e., & quine, s. (2000). quality of life related to fear of falling and hip fracture in older women: a time trade off study. british medical journal, 320, 341–346. scheffer, a. c., schuurmans, m. j., van dijk, n., van der hooft, t., & de rooij, s. e. (2007). fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. age and ageing, 37(1), 19–24. https://doi.org/10.1093/ageing/afm169 shaw, g. b. (2010). fear of falling and anxiety. retrieved from http://www.catounbound.org/2010/04/07/richard-thaler/fearof-falling/ skelton, t. (2017). risk factors for falls. national center for injury prevention and control, 12. victorian quality council. (2004). minimising the risk of falls & fall-related injuries. melbourne victoria: metropolitan health and aged care services division. who. (2004). what are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls ? (march). world health organization. (2007). who global report on falls prevention in older age who global report on falls prevention in older age. perancis: who. http://e-journal.unair.ac.id/jners | 345 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17182 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research music therapy and bibliotherapy to reduce child anxiety when given intravenous therapy heryyanoor heryyanoor1, muhsinin muhsinin2, rahmawati rahmawati3, fitriyanti patarru'1, febrina secsaria handini1, and basilius yosepfus weu1 1faculty of nursing, universitas airlangga, surabaya, indonesia 2faculty of nursing and health sciences muhammadiyah university, banjarmasin, indonesia 3 health polytechnic ministry of health, banjarmasin, indonesia abstract introduction: children often experience anxiety when undergoing the treatment process at the hospital. efforts to reduce such anxiety can be done with music therapy and bibliotherapy. this study aims to analyze the differences in the effectiveness of music therapy and bibliotherapy in reducing anxiety in children before getting intravenous therapy. methods: the research design was quasi-experimental, with the pretest and posttest approach. the population was 178 with 32 samples, each of the 16 respondents were given music therapy and bibliotherapy using a purposive sampling technique. data were collected with observation sheets from the adoption of the ham-a scale, analyzed by the wilcoxon test and independent t test at a significance level of p ≤ 0.05. results: there were differences in children's anxiety when getting intravenous therapy before and after music therapy and bibliotherapy with p = 0.001 (p <0.05), and there was no difference in the effectiveness of the two p values = 0.91 (p> 0.05), but the average bibliotherapy reduced anxiety by 65%, and music therapy by 57%. conclusion: bibliotherapy can be given as complementary therapy in children before intravenous therapy. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords music therapy; bibliotherapy; anxiety; anxiety; intravenous therapy contact heryyanoor heryyanoor  heryyanoor-2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: heryyanoor, h., muhsinin, m., rahmawati, r.,, patarru', f., handini, f.s., & weu, b.y. (2019). music therapy and bibliotherapy to reduce child anxiety when given intravenous therapy. jurnal ners, 14(3si), 345-353. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17182 introduction children are individuals who are in a range of developments ranging from babies to teenagers and who have specific physical, psychological, social, and spiritual needs that are different from adults. these needs must be fulfilled so that they are successful and healthy, because if the illness affects the growth, physical, psychological, intellectual, social, and spiritual development that increases in the hospitalization process (yupi supartini . msc, 2004). hospitalization is a process that requires children to stay in the hospital, evaluate therapy and care to return home (yupi supartini . msc, 2004). hospitalization is the main cause of stress for patients, including pediatric patients who cause concern (ghabeli, moheb, & hosseini nasab, 2014) anxiety is a difficult, handled, and anxiety situation in response to stress or uncertain movement (scholten & randall, 2013). children's anxiety is manifested by feelings of discomfort or care in the most basic response, given when given invasive medical therapy such as intravenous therapy and blood sampling which is the initial example of admission to hospital. giving intravenous therapy causes a trauma response in children, especially children aged 3-12 years who usually express as moaning and whining, angry, withdrawn, and hostile reactions that can be expressed verbally (wilson, 2016). the next process of action in the hospital treatment process, especially when given intravenous drug delivery therapy or other actions, causes the child to be uncooperative, because the child's memory of previous pain https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). h. heryyanoor, et al. 346 | pissn: 1858-3598  eissn: 2502-5791 experience when given intravenous therapy (gosia m. brykczynska, 2011), and the fear of children for recurring pain in something that hurts his body (debra l. price, msn, rn, cpnp and julie f. gwin, mn, 2012). the last two decades the prevalence of children admitted to hospitals has rapidly increased and has more serious and complex problems compared to previous years (donna l. wong [et.all], 2008). in the united states, it is estimated that more than 5 million children experience hospitalization and more than 50% of these children experience anxiety and stress (kain zn1, mayes lc, caldwell-andrews aa, karas de, 2006). interviews conducted at 6 children in hospitals in the uk found that children aged 10-13 years with various chronic conditions revealed fear of invasive procedures, injections, surgery, fear of death, loss of control and freedom. of the 17 children aged 7-16 years in 3 hospitals in ireland with 7 children suffering from chronic diseases and 10 of children suffering from acute illness reported anxiety about injection procedures, blood tests and pain (gosia m. brykczynska, 2011). in indonesia 30% of 180 children aged 3-12 years have experience with hospitals and an estimated 35 per 1000 children undergo hospitalization. the results of the national health survey, morbidity rate for children aged 5-12 years were 14.91% or around 14.44% of the total population of 237,641,326 people. the data was supported by the 2012 annual unicef (united nations children's fund) report which explained that the child poverty rate in indonesia was around 44.4 million or more than 50% of all children, even greater than the adult poverty rate. child health problems that are common in indonesia and which remain high are diseases caused by environmental problems such as dengue hemorrhagic fever, diarrhea, intestinal worms, and acute respiratory infections and adverse reactions to food due to poor sanitation and food security (judarwanto, 2005). the survey results on the 25th and 26th of september 2014 in the children's room of ratu zalecha martapura public hospital found that the number of pediatric patients in 2012 was 2343 and in 2013 as many as 2039. in 2014 from january to september 24 2014 there were 1758. children treated since in last 3 months (july to september) amount to 643, and specifically in july to september 24, 2014 the number of preschoolers (3-5 years) 441 and school age (6-12 years) total 92 or an average of 147 and 31 patients every month. the observation of 15 children who were given intravenous drug treatment, 46.7% (7 children) cried loudly and rebelled by trying to avoid, 0.06% (1 child) crying and restless, and 46.7% (7 children) ) frown. verbal expressions spoken by children before being given therapy include "what for? ; what are you doing, mama? ; pain ", while nonverbal refused to be touched, cried when touched and woke up from sleep, and embraced his parents when he just met the nurse. the results of interviews conducted on 5 of the 15 children observed, 100% complained of pain when given intravenous drug delivery therapy and expressed the desire to go home soon. this condition is a manifestation of children's anxiety as a result of hospitalization. anxiety that occurs in children when given intravenous drug administration therapy is due to trauma over previous experience when given intravenous therapy that causes pain. they do not understand why they should be treated and the unpreparedness of the child to face something new, a foreign environment that has never been encountered before, which is different from the atmosphere of the house and the unknown care provider. as a result children feel insecure and comfortable, feel lost something that is usually experienced, different habits, or separation from peers, and family and nursing actions that are very painful for children (yupi supartini . msc, 2004). these conditions if not addressed properly can cause tension, fear and can cause emotional or behavioral disorders that ultimately affect recovery and the child's illness journey during hospitalization. attempts to process the environment can be done by nurses to be able to minimize stress on children so that it does not become a crisis, especially when giving a medical action. this is because preparing the psychological condition of a child prior to nursing action is very important. many methods can be used by nurses to minimize anxiety, including using music therapy and bibliotherapy. music therapy is a complementary therapy that is used in the health sector to evaluate and treat patients with emotional, physical, cognitive, and social function disorders (maratos, gold, wang, & crawford, 2008) . the use of music as a health therapy or treatment is because music has a therapeutic aspect by stimulating stimulation, where the music enters the mind through an auditory sensation with a soft voice that can reduce stress, pain perception, anxiety and feelings of isolation. the results of the study found that the successor nerves of the music and the successor nerves of pain were the same (musbikin, 2009), and confirmed by the results of nurul sri wahyuni (2004) that there was an effect of music therapy on the decrease in anxiety levels with a value (p = 0,000) and the average decrease in anxiety level is 4.05. bibliotherapy is an action that is projected by using thematic books or any reading such as biography, novels, poetry, short stories to help children overcome changes, emotional and mental problem (lucas & soares, 2013). bibliotherapy helps children to think and understand the situation they experience, in other words being able to act as a therapeutic treatment (nicki l. potts, 2011) the tendency of children to identify the characters in the story, making bibliotherapy become a tool that has full strength to help normalize the feeling of loss and pain experienced (austin, 2010). this provides an example of coping in the hope that children will get joy again and reduce anxiety during the hospitalization process, especially when they will be given nursing action. this is supported by the results jurnal ners http://e-journal.unair.ac.id/jners | 347 of the study of anita apriliawati (2011) who concluded that there was an influence of bibliotherapy on the decrease in anxiety levels with a value (p = 0,000) with an average decrease in anxiety level of 5.33. based on the urain it can be concluded that music therapy and bibliotherapy can reduce anxiety in children who undergo the hospitalization process, especially when they will be given nursing action. both methods can be easily implemented by nurses in providing hospital services by involving families and or parents of children in order to increase the intensity of service time, because basically the intensity of service to pediatric patients is 20-45% more than adults (aidar, 2011) the effectiveness between the two methods is not much different only around 1.28, so it needs to be further investigated to be applied in a simple manner in the hospital as one of the interventions in providing nursing services to children who, as far as the researchers know, have not yet done so. especially with the statement of 3 (three) nurses in the children's room of ratu zalecha martapura hospital who said that "music therapy and bibliotherapy have never been given to pediatric patients, we only provide play therapy such as drawing and coloring, writing, and playing dolls". based on this, the researchers argue that this research can be applied in hospitals later. materials and methods the design of this research is quasy experimental with pretest and posttest design. population 178 with a sample of 32, each 16 respondents were given classical music therapy with a choice of titles: 1) helps baby relax & fall asleep fast; 2) relaxing sunrise with meditation music; 3) this mozart for baby does not make my baby sleep like an angel. bibliotherapy by projecting children's perceptions of the hospitalization process accompanied by book 50 stories of world fable stella ernes or tales of the kancil and her friends, fatiharifah and nisa yustisia. sampling uses purposive sampling. data were collected by observation sheet of the results of the adoption of the ham-a scale (hamilton anxiety rating scale) that has been modified / adopted into 6 situations, namely: 1) children try to avoid when the nurse comes over / anticipates fear; 2) the child jerks when the hand is touched by the nurse; 3) children's voices falter when given nursing intervention; 4) does not show interest in activities / invited to interact (looks weak); 5) rapid breathing / choking when given nursing intervention; and 6) crying loudly / groaning when given intravenous therapy. analysis with wilcoxon test and independent t test with significance level p ≤ 0.05. results the results of the study were based on the respondents' characteristics as many as 32 samples taken through purposive sampling techniques by considering inclusion criteria with parental consent of a population of 178 (table 1). based on the table above shows that the majority of respondents aged 6-12 years as many as 21 pediatric patients (65.6%), male sex as many as 18 pediatric patients (56.2%), first time treated as many as 15 patients children (46.9%), while the majority of medical diagnoses were febrile as many as 11 pediatric patients (34.4%), children accompanied by both parents (father and mother) were 25 pediatric patients (78.1%) and had undergone treatment on the second day there were 12 pediatric patients (37.5%). the results of the study are based on differences in the effectiveness of anxiety in patients with children aged 3-12 years when given intravenous therapy before and after music therapy and bibliotherapy are given in table 2. from the data it is known that out of 16 respondents who will be given intravenous therapy before being given music therapy, all (100%) experience severe anxiety with a score range of 4-6 and an average score of anxiety 4.94. after being given music therapy, respondents who experienced severe anxiety became 6 children (37.5%) with a score range of 0-3 and an average of 2.13. this means that there was a decrease in the average anxiety of 2.81 (57%) after being given music therapy. the decrease in anxiety that occurs specifically is seen in the situation. children do not avoid when the nurse comes over / anticipates fear with a percentage of 100%, the child's breathing pattern becomes regular / no longer choked with a 66.7% decrease in the child. percentage decrease of 57.1%, crying loudly / groaning when given intravenous therapy 56.2%, children do not show interest in activities / invited to interact (looks weak) with a percentage decrease of 50%, and children's voices faltering / frowning when given nursing intervention 49 , 9%. analysis by wilcoxon test p = 0.001 (p <0.05) which means h berarti is rejected. so it was concluded that there was a difference in anxiety between 3-12 year olds when given intravenous therapy in the queen room of ratu zalecha martapura hospital before and after being given music therapy, meaning music therapy had an effect on reducing child anxiety when they were given intravenous therapy. in addition to these data it is also known that of the 16 respondents who will be given intravenous therapy before being given bibliotherapy, 11 children (68.8%) experienced severe anxiety with a score range of 4-6 and an average score of anxiety of 4.25. after being given music therapy, respondents who experienced severe anxiety became 5 children (31.2%) with a score range of 0-3 and an average of 1.5. this means there is a decrease in the average anxiety of 2.75 (65%) after being given bibliotherapy. the decrease in anxiety that occurs specifically seen in the child's situation does not flinch when his hand is touched by the nurse and shows interest in activities / invited to interact 93.8%, the child does not avoid when the nurse comes over / anticipates h. heryyanoor, et al. 348 | pissn: 1858-3598  eissn: 2502-5791 fear with an 80.1% percentage, crying loudly / whimpering when given 60% intravenous therapy, the child's breathing pattern becomes regular / no longer choking with a percentage decrease of 58.4%, and the child's voice faltering / frowning when given a 40% nursing intervention. statistical analysis with the wilcoxon test obtained a value of p = 0.001 (p <0.05) which means hₒ was rejected. so it can be concluded that there is a difference in anxiety between 3-12 year old children when given intravenous therapy in the queen zalecha martapura hospital children's room before and after the bibliotherapy was given, meaning bibliotherapy has an effect on reducing child anxiety when given intravenous therapy. the average percentage decrease in the anxiety of the given bibliography is 2.75 (65%), or given music therapy which is 2.81 (57%). the statistical analysis using the independent sample test obtained p = 0.91 (p> 0.05) which means hₒ is accepted. so it can be concluded that there is no difference between therapy and those given by bibliotherapy. the therapy is in the children's room of the queen zalecha martapura hospital table. 1. distribution of respondents based on the characteristics of children of the age 3-12 years who were given intravenous therapy in the children's room of ratu zalecha martapura hospital in 2015. no. karakteristik n kategori f person (%) 1. age 32 3-5 years 11 34,4 6-12 years 21 65,6 2. gender 32 man 18 56,2 women 14 43,8 3. nursing experience 32 the first time 15 46,9 second 11 34,4 third 4 12,5 fourth 2 6,2 4. type of disease 32 asthma 1 3,1 dengue hemorrhagic fever 6 18,8 febris 11 34,4 gastrointestinal 2 6,2 febrile convulsion 4 12,5 typhoid 8 25 5. parent's side by side 32 accompanied by father 2 6,2 accompanied by mother 5 15,6 accompanied by father and mother 25 78,1 6. nursing day 32 first 11 34,4 second 12 37,5 third 9 28,1 table. 2. anxiety distribution of 3-12 year-old children patients who were given intravenous therapy before and after were given music therapy in the children's room of ratu zalecha martapura hospital in 2015. res treatment with music therapy res treatment with bibliotherapy before after differen ce decline before after differe nce decline score category score category score category score category 1 4 weight 0 light 4 1 6 weight 4 weight 2 2 6 weight 0 light 6 2 6 weight 4 weight 2 3 5 weight 4 weight 1 3 4 weight 0 light 4 4 4 weight 0 light 4 4 6 weight 2 light 4 5 4 weight 1 light 3 5 3 light 0 light 3 6 5 weight 4 weight 1 6 6 weight 4 weight 2 7 5 weight 5 weight 0 7 5 weight 0 light 5 8 5 weight 3 light 2 8 4 weight 0 light 4 9 5 weight 4 weight 1 9 4 weight 1 light 3 10 4 weight 1 light 3 10 3 light 0 light 3 11 4 weight 0 light 4 11 4 weight 4 weight 0 12 6 weight 4 weight 2 12 5 weight 1 light 4 13 5 weight 1 light 4 13 3 light 0 light 3 14 6 weight 4 weight 2 14 2 light 0 light 2 15 5 weight 0 light 5 15 5 weight 4 weight 1 16 6 weight 3 light 3 16 2 light 0 light 2 me an 4,94 2,13 2,81 (57%) mean 4,25 1,5 2,75 (65%) uji wilcoxon : p = 0,001 uji wilcoxon : p = 0,001 uji independent sample t test : p = 0,91 jurnal ners http://e-journal.unair.ac.id/jners | 349 discussion an overview of the characteristics of respondents based on age, gender, previous treatment experience, type of illness, assisted parents, day of care for children aged 3-12 years in general, the number of respondents was 32 children, each of which 50% of children were given music therapy and were given bibliotherapy. the majority of children aged 6-12 years as many as 65.6%, male sex 56.2%, and the first time undergoing treatment at the hospital 46.9%, the type of disease (diagnosis) febris 34.4%, accompanied both parents (father and mother) 78.1%, and second day care 37.5%. all respondent characteristics are factors that influence children's anxiety during the hospitalization process. decreased anxiety of respondents given bibliotherapy before children were given intravenous therapy by 65% and those given music therapy by 57%. this is influenced by the characteristics of the respondents themselves. respondents aged 6-12 years experienced severe anxiety of 47.6% compared to 3-5 years of age of only 9.1%. this is not in accordance with the opinion of mansur (2007) which states that the older a person is, the better he is in controlling his emotions. respondents male sex 56.2% majority experienced severe anxiety 38.9% compared to women who only 28.6%. this is because women in responding to external stimuli or stimuli are more sensitive than men, so they influence their coping mechanisms (kurniawan, 2008). respondents with first-time experience in hospital care were 46.9% basically experiencing severe anxiety 40% compared to subsequent experiences, but this condition could also occur in respondents who had already undergone hospital treatment. this is influenced by various other factors such as the type of disease, parental assistance, and children's perceptions in responding to pain responses. the most types of diseases / medical diagnoses experienced by respondents were febris 34.4%, but those who experienced severe anxiety were 50% of children with dhf (dengue fever). this is because dengue is a relatively severe disease, this dengue virus infection caused by the aedes agypty mosquito causes fever, bleeding, shock, and can even lead to death. parental facilitation affects children's anxiety during hospitalization, respondents who were only accompanied by their father 100% more experienced severe anxiety, compared to children accompanied by their mothers with a weight of only 20%. this is because the mother is the closest figure to the child compared to the father. the length of the treatment day affected anxious children, in this study children with care on the third day experienced severe anxiety 55.6% or increased on the first day of treatment 18.2% and secondly 33.3%. this is due to trauma factors over the treatment of intravenous therapy, especially those that are invasive and the perception of children who consider the hospitalization process to be a punishment for him. anxiety of children patients aged 3-12 years who were given intravenous therapy in the children's room of ratu zalecha martapura hospital in 2015 before and after being given music therapy. anxiety of children patients aged 3-12 years who were given intravenous therapy based on the anxious response of children before being given music therapy 100% experienced severe anxiety with a score range of 4-6. while the average anxiety score of children from 6 situations / anxiety is 4.94. the child's anxiety is seen in the situation when the nurse will provide intravenous therapy. the response that occurs is: the child does not show interest in the activity / invited to interact (looks weak) and crying loudly / moaning when given intravenous therapy shows anxiety 100%, rapid breathing / choking when given nursing intervention 93.8%, the child jerks when his hand is touched nurses, children's voices faltered when given a nursing intervention of 87.5%, and the child tried to avoid when the nurse came over / anticipated fear by 25%. this is in accordance with the theory that physical symptoms that appear in anxious states such as fatigue, rapid heartbeat, sweating (especially on the palms), muscle tension, shortness of breath / increased frequency of breathing, choking (scholten & randall, 2013). according to carpenito (2007) symptoms of anxiety can be seen from situations of fear, helplessness, nervousness, loss of control, apparent tension seen in children with excessive anger, loud crying, and rebellion. the child's behavior is a symptom of anxiety, especially for children who have undergone hospitalization for the first time in the study as much as 46.9% and experience severe anxiety about 40%, so the effects of trauma will be very meaningful and make the hospital environment including health workers a threat to him . this situation occurs because the child feels threatened when given intravenous therapy which is usually manifested by feeling uncomfortable or painful as the most basic response, especially when given invasive medical therapy such as intravenous therapy (infusion) and blood sampling that becomes initial action when the child is admitted to the hospital. giving intravenous therapy causes a trauma response in children, especially children aged 3-12 years who usually express moaning and whining, angry, withdrawn, and hostile reactions that can be expressed verbally (hockenbery & wilson, 2009). in the next process in the hospital treatment process, especially when given intravenous drug treatment and other actions, children tend to be uncooperative. this is supported by the child's memory of previous pain experiences when given intravenous therapy (brykczyinska & simons, 2011) and the existence of expressions of fear of children over recurring pain in something that hurts their body (price & gwin, 2008). h. heryyanoor, et al. 350 | pissn: 1858-3598  eissn: 2502-5791 efforts to reduce anxiety related to situations that occur in children when intravenous therapy will be given in this study, namely before children are given classical music therapy with a slightly slower tempo, 50 70 beats / minute, using a quiet rhythm (schou, 2007), and with the minimum time range for giving is 10 minutes to 1 hour using speakers or cellphones. this is very easy for nurses to involve parents of children, because in principle therapists do not always need special skills (suryana, 2012). providing music therapy to children undergoing hospitalization before intravenous therapy has been shown to reduce anxiety. the results of this study indicate that the anxious response of children aged 3-12 years after being given music therapy who experienced severe anxiety became 37.5% with a score range of 0-3 and an average of 2.13. this shows that there was a decrease in the average anxiety of 2.81 (57%) after being given music therapy. the decrease in anxiety that occurs specifically also occurs in situations where children do not avoid when nurses come over / anticipate fear with a percentage of 100%, the child's breathing pattern becomes regular / no longer choked with a 66.7% drop in percentage, the child does not jerk when the hands are touched by the nurse and showing interest in activities / invited to interact 57.1%, children not crying loudly / moaning when given intravenous therapy 56.2%, and the sound of children not wavering / not frowning when given nursing intervention 43.7%. the results of statistical analysis using the wilcoxon test, of the 16 respondents it was known that there were 15 respondents (94%) experienced a decrease in anxiety after being given music therapy, and 1 respondent whose anxiety remained. the value of p = 0.001 (p <0.05) which means hₒ is rejected. so it can be concluded that there is a difference in anxiety decrease in children aged 3-12 years when given intravenous therapy in the children's room of ratu zalecha martapura hospital in 2015 before and after being given music therapy. this means that music therapy is effective in reducing anxiety in children aged 3-12 years when intravenous therapy is given. the results of this study are in accordance with the results of previous studies conducted by nurul sri wahyuni (2004) that there is an effect of music therapy on the decrease in anxiety levels with a value (p = 0,000) and an average decrease in anxiety level of 4.05. the use of classical music as a health therapy in medicine is because music has a therapeutic aspect by stimulating stimulation, where the music enters the mind through auditory sensations with a soft voice that can reduce stress, pain perception, anxiety and feelings of isolation (de laune & ladner, 1998 ) this is because from the results of the study it was found that the successor nerves of the music and the successive nerves of pain are the same (musbikin, 2009). in addition, classical music has a rhythm similar to the heart rhythm compared to pop music, disco, rock and roll, and other anapestic beat music (2005) in suryana (2012). so that it can affect the body and mind, especially in children aged 3-12 years who undergo the hospitalization process. classical music produces rhythmic stimuli which are then captured through the auditory organs and processed in the nervous system of the body and glands in the brain and then reorganizes sound interpretations into the internal rhythm of the listener. this internal rhythm affects the body's metabolism so that the process takes place better. good metabolism will be able to build a better immune system, so that the body becomes more resilient to the possibility of disease attacks (satiadarma, 2002). these physiological changes occur due to the activity of two neuroendocrine systems controlled by the hypothalamus, namely the sympathetic system and the adrenal cortex system (prabowo & regina, 2007). the hypothalamus is also called the brain stress center because of its dual function in an emergency. its first function is to activate the sympathetic branches and autonomic nervous system. the hypothalamus delivers nerve impulses to the nuclei in the brain stem that control the functioning of the autonomic nervous system. the sympathetic branch of the autonomic nervous system reacts directly to smooth muscles and internal organs to produce several body changes such as an increase in heart rate and blood pressure as a response to anxiety. the sympathetic system also stimulates the adrenal medulla to release the hormone epinephrine (adrenaline) and norepinephrine into the blood vessels, thus impacting increasing heart rate and blood pressure, while norepinephrine indirectly through its action on the pituitary gland releases sugar from the liver. adrenal corticotropin hormone (acth) stimulates the outer layer of the adrenal gland (the adrenal cortex) which causes the release of hormones (one of the main ones is cortisol / hormone that affects anxiety) which regulates glucose levels and certain minerals (primadita, 2011). one of the benefits of music as a therapy is selfmastery, the ability to control yourself. music contains energy vibrations, these vibrations also activate cells in a person, so that by activating these cells a person's immune system is more likely to be active and increase its function. in addition, music can increase serotonin and the growth of hormones that are as good as reducing the hormone acth (satiadarma, 2002). giving classical music therapy makes a person relax, creates a sense of security and well-being, releases feelings of joy and sadness, releases pain and lowers stress levels, so that it can cause a decrease in anxiety (musbikin, 2009). this happens because of a decrease in ardenal corticotropin hormone (acth) which is a stress hormone (djohan, 2006). decreased anxiety experienced by children after being given music therapy due to various factors. these factors include age, gender, previous treatment experience, type of illness, and parental assistance jurnal ners http://e-journal.unair.ac.id/jners | 351 that has been explained previously on the characteristics of respondents. it is evident from this study that these factors affect children's anxiety when given intravenous therapy. boys experience anxiety weighing 38.9% compared to women who are only 28.6%. this is because women in responding to external stimuli or stimuli are more sensitive than men, so they influence their coping mechanisms (kurniawan, 2008). the first experience was basically treated with anxiety 40% compared to subsequent experiences, but this condition can also occur in respondents who have had treatment at the hospital. this is influenced by various other factors such as the type of disease, parental assistance, and children's perceptions in responding to pain responses. severe diseases, such as dhf (dengue hemorrhagic fever) result in 50% of children experiencing severe anxiety. this is because dhf is a disease of dengue virus infection caused by the aedes agypty mosquito which causes various clinical symptoms such as fever, bleeding, shock, and even death. parental facilitation affects children's anxiety during hospitalization, respondents who were only accompanied by their father 100% more experienced severe anxiety, compared to children accompanied by their mothers with a weight of only 20%. this is because the mother figure is the closest figure to the child compared to the father. anxiety in children patients aged 3-12 years who were given intravenous therapy in the children's room of ratu zalecha martapura regional hospital in 2015 before and after being given a bibliotherapy. anxiety of children patients aged 3-12 years who were given intravenous therapy based on the anxious response of children before being given a bibliotherapy 68.8% experienced severe anxiety with a score range of 4-6. while the average anxiety score of children from 6 situations / anxiety is 4.25. the child's anxiety is apparent in the situation when the nurse will provide intravenous therapy. the response was specifically, 100% of children showed no interest in activities / invited to interact (looking weak), crying loudly / moaning when given 93.8% intravenous therapy, rapid breathing / choking when given 75% nursing intervention, the child jerks when his hand touched by the nurse, the child's voice faltered / frowned when given 62.5% nursing intervention, and the child tried to avoid when the nurse came over / watched fear 31.2%. the response above is a situation that describes children's anxiety during the hospitalization process, this is in accordance with wong's opinion (2009) which is included in the child's protest phase. in this phase observable behaviors such as crying, screaming, avoiding and refusing eye contact with strangers last several hours to several days before the child enters the phase of despair, and the phase of release. factors affecting child anxiety in addition to the trauma response when given intravenous therapy, especially those that are invasive, among others, according to moersintowarti (2008), namely: hospital environment, typical smell of drugs, medical devices, and health workers who are not known by child. bibliotherapy is proven to be able to reduce anxiety in children, even though it is done simply with or without involving parents directly. the results of this study indicate that the anxious response of children aged 3-12 years after being given a bibliotherapy who experience severe anxiety becomes 31.2% with a score range of 0-3 and an average of 1.5. this shows that there was a decrease in the average anxiety of 2.75 (65%) after being given bibliotherapy. the decrease in anxiety that occurs specifically also occurs in situations where children do not flinch when their hands are touched by nurses and show interest in activities / invited to interact 93.8%, children do not avoid when nurses come over / anticipate fear with a percentage of 80.1%, children not crying loudly / groaning when given 60% intravenous therapy, the child's breathing pattern becomes regular / no longer choked with a percentage decrease of 58.4%, and the child's voice is not shaky / not frowning when given a 40% nursing intervention. the results of statistical analysis using the wilcoxon test, of the 16 respondents it was known that there were 15 respondents (94%) who experienced a decrease in anxiety after being given bibliotherapy, and 1 respondent (6%) whose anxiety remained. value p = 0.001 (p <0.05) which means h berarti is rejected. so that it can be concluded that there is a difference in the anxiety decrease in children aged 3-12 years when given intravenous therapy in the children's room of ratu zalecha martapura hospital in 2015 before and after being given the bibliotherapy. the results of this study are in accordance with the results of previous studies by anita apriliawati (2011) which states that there is an influence of bibliotherapy on the decrease in anxiety levels in children undergoing hospitalization with a value (p = 0,000) and an average decrease in anxiety level of 5.33. bibliotherapy is able to reduce anxiety because it is projection, especially by using imaginative or creative short stories referring to the presentation of human behavior in a dramatic way related to the situation of hospitalization experienced by children combined with illustrated fairy tales. this is in accordance with the opinion of austin (2010) that bibliotherapy aims to support children's needs in processing difficult personal experiences such as painful and confusing experiences for children. so that it can help overcome emotional problems / anxiety and mental children (lucas & soares, 2013). bibliotherapy also affects children's perceptions of the nursing process in the hospital by describing that all actions given to children are not a thing to hurt and punish, but to help children recover from their illness immediately and be able to return home so they can play back with friends -friend. this is h. heryyanoor, et al. 352 | pissn: 1858-3598  eissn: 2502-5791 important, because children aged 3-12 years are still in the process of growth and development, and are included in the stage of play. mansur (2007) argues that children use basic movement skills (running, walking, climbing, jumping, etc.), are able to communicate better with other children, enjoy playing real-life situations as part of their play. decreasing anxiety through bibliotherapy due to using approach techniques using therapeutic communication that can involve parents directly. this is like playing for children, where children can express their imagination through seeing pictures contained in the book and listening to the stories read by the child's nurse / parents. differences in the effectiveness of music therapy with bibliotherapy on decreasing anxiety in 3-12 year-old children patients given intravenous therapy in the children's room of ratu zalecha martapura hospital in 2015 the results of the statistical analysis with the independent sample t test obtained the value of t count 0.12 and the value of p = 0.91 (p> 0.05) which means hₒ is accepted, so it can be concluded that there is no difference in anxiety decreases in children aged 3-12 intravenous therapy was given at the children's room of ratu zalecha martapura regional hospital in 2015 which had previously been given music therapy with those given by bibliotherapy. but on average bibliotherapy is able to reduce child anxiety by 65% compared to 57% music therapy. various anxiety responses that occur in the child such as trying to avoid when the nurse comes over / anticipates fear, the child jerks when his hand is touched by the nurse, the child's voice is shaky / and or crying when given nursing intervention, does not show interest in interacting (looks weak) , rapid breathing / choking when given a nursing intervention, and showing facial expressions that fear is expected not to occur when the child is given intravenous therapy. because it can cause tension, fear and can cause emotional or behavioral disorders that ultimately affect healing and the journey of the child's illness while being hospitalized (posted, 2009). bibliotherapy is better able to reduce anxiety due to direct contact between nurses and pediatric patients, so that communication takes place more effectively therapeutically in both parents and children. it is important to change the child's view of what the nurse does just to cure the sick. this is in accordance with the study of nelko, greta j.p, and franl (2013) regarding the relationship between nurse communication and stress of hospitalization in children aged 6-12 years. therapeutic communication also involves many senses that are used by children to project what is dismissed by nurses, especially when given bibliotherapy with almost the same situation experienced by children, compared to music therapy which only involves the sense of hearing. this is in accordance with associative learning theory which states that the more senses (stimulus) are involved in the learning process, the child will be better able to understand the situation they are experiencing. the age factor of the respondents who were given bibliotherapy, the majority of 6-12 years, 68.8% were more able to understand the meaning of the stories conveyed by the researchers. this is in accordance with the theory that states children aged 6-12 years get the basics of knowledge that are considered important for the success of self-adjustment in adult life, learn certain important skills, both curricular and extra-curricular skills (wong, 2009). the results of this study can be applied in hospitals as a complementary therapy to reduce children's anxiety during the hospitalization process. the results of this study can also be used as reference material for future researchers to be able to use more samples and different research designs such as using religious music or transcultural aspects of nursing. conclusion bibliotherapy can reduce anxiety in children who will be given intravenous therapy compared to music therapy. the results of this study can be applied in hospitals as complementary therapies to reduce children's anxiety during the hospitalization process and can be used as reference material for future researchers to be able to use more samples and different research designs such as using religious music or transcultural aspects of nursing. the next researcher can further examine the use of music therapy and bibliography for anxiety, pain, cooperative level by considering the same characteristics of the child and the support system of the child's parents. references aidar, n. (2011). relationship between the role of families and the anxiety level of school-age children (6-12 years old) who have hospitalization in room iii of the general hospital dr. pirngadi medan. debra l. price, msn, rn, cpnp and julie f. gwin, mn, r. (2012). pediatric nursing, 11th edition. saunders. donna l. wong [et.all]. (2008). wong volume 2 pediatric nursing textbook. jakarta: egc. ghabeli, f., moheb, n., & hosseini nasab, s. d. (2014). effect of toys and preoperative visit on reducing children’s anxiety and their parents before surgery and satisfaction with the treatment process. journal of caring sciences, 3(1), 21–28. https://doi.org/10.5681/jcs.2014.003 gosia m. brykczynska, j. s. (2011). ethical and philosophical aspects of nursing children and young people. wiley-blackwell. judarwanto, w. (2005). the general health problems of school-age children are presented at scientific seminars on popular health in school-age children. kain zn1, mayes lc, caldwell-andrews aa, karas de, jurnal ners http://e-journal.unair.ac.id/jners | 353 m. b. (2006). preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. pediatrics, 2. https://doi.org/10.1542/peds.2005-2920 lucas, c. v., & soares, l. (2013). bibliotherapy: a tool to promote children’s psychological well-being. journal of poetry therapy, 26(3), 137–147. https://doi.org/10.1080/08893675.2013.8233 10 maratos, a., gold, c., wang, x., & crawford, m. (2008). music therapy for depression cochrane database of systematic reviews. (1.art). https://doi.org/10.1002/14651858.cd004517 .pub2 musbikin, i. (2009). greatness of music for sharpening children’s intelligence. diva press. nicki l. potts, b. l. m. (2011). pediatric nursing: caring for children and their families. cengage learning; 3 edition. scholten & randall. (2013). anxiety disorders (chronic free-floating anxiety). wilson, m. h. c. r. d. (2016). wong’s essentials of pediatric nursing 10th edition. mosby. yupi supartini . msc. (2004). textbook for basic concepts of child nursing. jakarta: egc. ners vol 10 no 2 okt 2015.indd 250 visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis (visual schedule towards the decline of behavioral problems in feeding activities and defecation in children with autism) sandu siyoto* *progam studi pendidikan ners stikes surya mitra husada kediri jl. manila sumberece no. 37 kediri email: siyotos@yahoo.com abstrak pendahuluan: autis merupakan gangguan perkembangan perpasif pada anak yang ditandai dengan adanya gangguan dan keterlambatan dalam bidang kognitif, bahasa, perilaku (behavior), komunikasi dan interaksi sosial. salah satu cara bagi anak autis yaitu dengan visual schedule. visual schedule merupakan metode pembelajaran yang berupa informasi dalam bentuk visual yang mengomunikasikan serangkaian aktivitas. penelitian ini bertujuan untuk mengetahui pengaruh visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri. metode: desain yang di gunakan pra eksperimental one group pre post test desaign, jumlah populasi 30 responden, menggunakan tehnik purposive sampling didapatkan sampel sebanyak 16 responden. hasil: hasil penelitian menunjukkan nilai signifikan p = 0,011 < 0,05 dengan menggunakan uji statistik wilcoxon, yang berarti ada pengaruh visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri tahun 2014. diskusi: visual schedule dapat diterapkan sebagai terapi pada anak autis yang memiliki behavior problem, karena teknik tersebut dapat memberikan pengaruh pada anak autis untuk dapat menurunkan behavior problem. kata kunci: visual schedule, penurunan behavior problem, anak autis abstract introduction: autism is a pervasive developmental disorder in children that is characterized by the disruption and delays in cognitive, language, behavior, communication and social interaction. one of the ways for children with autism is the visual schedule. visual schedule is a learning method in the form of information in a visual form that communicates a series of activities. this study aimed to determine the effects of a visual schedule to decrease problem behaviors when feeding activity and defecation in children with autism in the foundation board of christian education wetan jawi (ybpk) kediri. methods: research design was one group pre post test design, with a population of 30 respondents, used the purposive sampling technique obtained a sample of 16 respondents. when the reseachon april 16 until mei 17, 2014. results: the results showed obtained asymp significant p = 0.011 < 0.05 with wilcoxon statistical test, which means that ho was rejected and h1 accepted schedule. it means there were visual effects on reducing behavioral problems in feeding activity and defecation in children with autism in the foundation board of christian education wetan jawi (ybpk) kediri in 2014. discussions: the visual schedules can be applied in the treatment of autistic children who have behavior problems, because these techniques can provide influence on autistic children to be able to decrease behavior problems. keywords: visual schedule, decline in behavior problems, children with autism pendahuluan a u t i s m e m e r u p a k a n g a n g g u a n perkembangan per pasif pada anak yang ditandai dengan adanya gangg uan dan keterlambatan dalam bidang kognitif, bahasa, perilaku (behavior), komunikasi dan interaksi sosial. autisme merupakan kelainan yang terjadi pada anak yang tidak mengalami perkembangan normal, khususnya dalam hubungan dengan orang lain. anak autis menggunakan bahasa lain yang tidak normal, bahkan sama sekali tidak dapat dimengerti. anak autis pada umumnya berkelakuan compulsive (memberontak) dan retualistik yang artinya anak autis melakukan tindakan berulang yang kemungkinan besar akibat proses perkembangan yang biasanya tampak jelas sebelum anak mencapai usia 3 tahun (winarno, 2013). mayoritas anak autis menunjukkan per ilak u (behavior) yang tidak pantas. istilah alat bantu visual digunakan untuk 251 visual schedule terhadap penurunan behavior problem (sandu siyoto) mengga mba rk a n ber aga m bend a ya ng membantu anak autis agar lebih mudah berkomunikasi dan menjaga perilakunya. gambar adalah alat bantu visual yang efektif dalam berkomunikasi. gambar juga membantu anak untuk mengetahui apa yang ada dalam dunianya ketika dia berupaya memahami rangsangan yang diterimanya (kidd, 2011). hampir semua anak autis mengalami behavior problem, hanya intensitas dan keluasannya yang berbeda. bantuan-bantuan atau strategi visual dapat diterapkan untuk mereduksikan permasalahan perilaku/behavior problem yang biasa terjadi pada anak autis tersebut (winarno, 2013). prevalensi autis pada anak berkisar 2–5 penderita dari anak 10.000 anak-anak di bawah 12 tahun. apabila retardasi (keterbelakangan mental) berat dengan beberapa gambaran aut isme d i ma su k k a n , ma k a a ng k a nya meningkat menjadi 20 penderita dari 10.000 anak. rasio perbandingan 3:1 untuk anak lakilaki dan perempuan. dengan kata lain, anak laki-laki lebih rentan menyandang sindrom autisme dibanding anak perempuan. bahkan diprediksikan oleh para ahli bahwa kuantitas autisme pada tahun 2015 akan mencapai 60% dari keseluruhan populasi anak di seluruh dunia. organisasi kesehatan dunia (who) menyatakan perkembangan anak autis semakin bertambah dari tahun ke tahun. prevalensi autis berkisar 1–2 per 1000 penduduk dengan distribusi pada laki-laki lebih banyak dari pada wanita (4:1). hal ini menjadi bukti bahwa kebutuhan akan layanan anak autis semakin meningkat bersamaan dengan jumlah anak autis (hasdianah, 2013). berdasarkan studi pendahuluan yang dilakukan oleh peneliti pada tanggal 22 oktober 2013 di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri, d ila k u k a n de nga n wawa nca r a ke pa d a pengajar dan secara observasi kepada anak autis didapatkan 2 anak mempunyai behavior problem saat aktivitas buang air dan 1 anak mempunyai behavior problem saat aktivitas makan. hal ini membuktikan bahwa ratarata anak autis di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri mengalami behavior problem saat aktivitas makan dan buang air. anak autisme mengalami gangguan perkembangan yang sangat kompleks, yang disebabkan oleh adanya ker usakan pada otak sehingga mengakibatkan gangguan dalam bidang perkembangan, perkembangan interaksi dua arah, perkembangan interaksi timbal balik, dan perkembangan perilaku (hasdianah, 2013). anak autis memiliki sensasi yang berbeda tentang tubuhnya. oleh sebab itu anak autis tidak dapat belajar buang air seperti anak normal. perbedaan proses pengindraan ini juga yang membuat anak autis menjadi sosok yang sangat pemilih dalam hal makanan dan tidak mau buang air kecil atau besar di toilet. selain pemilih dalam hal makanan anak autis juga tidak dapat menjaga perilakunya pada saat makan, misalnya melompat-lompat, naik ke atas meja. oleh karena itu mereka membutuhkan alat bantu visual untuk menggambarkan beragam benda yang dapat membantu anak autis agar lebih mudah berkomunikasi dan menjaga perilakunya (kidd, 2011). visual schedule mer upakan suat u i n for m a si d ala m be nt u k v isu al ya ng mengomunikasikan serangkaian aktivitas. visual schedule dapat membantu meningkatkan perhatian dalam memahami perintah, aturan, dan kegiatan pada anak autis. visual schedule sebuah metode yang penting untuk mengatasi, mencegah dan mereduksi kecemasan pada anak autis, apabila harapan dan tuntutan lingkungan sosial tidak dapat mereka mengerti maka anak autis akan merasakan kecemasan, sehingga dapat memunculkan permasalahan perilaku. visual schedule dapat membantu anak autis menjadi mandiri dalam melakukan kegiatan sehari-hari, karena mengajarkan pada anak untuk mengikuti visual schedule tanpa instruksi atau bantuan verbal (yuliana, 2011). bahan dan metode desain penelitian yang dibuat dalam penelitian ini adalah one group pra post test design. pada penelitian ini populasinya adalah seluruh siswa-siswi di yayasan badan 252 jurnal ners vol. 10 no. 2 oktober 2015: 250–255 pendidikan kristen jawi wetan (ybpk) kota kediri, sampel yang memenuhi kriteria inklusi. teknik sampling yang digunakan adalah purposive sampling. instrumen pengumpulan data pada penelitian ini menggunakan lembar observasi. prosedur pengolahan data dengan cara editing, coding, skoring, dan tabulating. uji statistik yang digunakan dalam penelitian ini adalah uji wilcoxon. hasil tabel 1. karakteristik subjek penelitian berdasarkan umur, jenis kelamin, kelas, frekuensi behavior problem sebelum pemberian visual dan frekuensi behavior problem setelah pemberian visual no karakteristik n % 1 usia umur 6–10 th umur 10–12 th umur 13 th total 8 5 3 16 50 31 19 100 2 jenis kelamin laki-laki perempuan total 11 5 16 69 31 100 3 kelas kelas 1 kelas 2 kelas 3 kelas 4 kelas 5 kelas 6 total 2 2 4 4 3 1 16 12 13 25 25 19 6 100 4 frekuensi behavior problem sebelum pemberian visual schedule baik cukup kurang total 1 7 8 16 6,2 43,8 50 100 5 frekuensi behavior problem sebelum pemberian visual schedule baik cukup kurang total 2 13 1 16 12,5 81,2 6,2 100 sumber: data primer, tahun 2014. berdasarkan tabel 1 diatas diketahui bahwa sebagian besar responden berusia <10 tahun yaitu sebanyak 8 responden (50%). diketahui bahwa sebagian besar berjenis kelamin laki-laki yaitu sebanyak 11 responden (69%), sebagian besar responden kelas iii yaitu sebanyak 4 responden (25%) dan kelas iv yaitu sebanyak 4 responden (25%), behavior problem pada saat aktivitas makan dan buang air kriteria baik sebesar (6,2%) dan kriteria cukup sebesar (43,8%) sedangkan kriteria kurang sebesar (50%). behavior problem sesudah pemberian visual schedule pada saat aktivitas makan dan buang air kriteria baik sebesar (12,5%) dan kriteria cukup sebesar (81,2%) sedangkan kriteria kurang sebesar (6,2%). distribusi hasil analisis pengar uh visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri tahun 2014 didapatkan behavior problem post test < behavior problem pre test yaitu sebanyak 9 responden dan behavior problem post test > behavior problem pre test yaitu sebanyak 1 responden, sedangkan behavior problem post test = behavior problem pre test yaitu sebanyak 6 responden. dari hasil uji statistik wilcoxon untuk menget a hu i penga r u h visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan pendidikan kristen jawi wetan kota kediri tahun 2014 didapat nilai signifikan asymp. sig (2-tailed) atau p = 0,011 < 0,05 yang h0 ditolak dan h1 diterima artinya ada pengaruh visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan pendidikan kristen jawi wetan kota kediri tahun 2014. pembahasan behavior problem saat aktivitas makan dan buang air pada anak autis sebelum diberikan visual schedule berdasarkan dari data yang didapat selama penelitian bahwa dari 16 responden didapatkan responden behavior problem 253 visual schedule terhadap penurunan behavior problem (sandu siyoto) saat aktivitas makan dan buang air sebelum diberikan visual schedule k riteria baik sebesar (6%) dan kriteria cukup sebesar (44%) sedangkan kriteria kurang sebesar (50%). a u t i s m e m e r u p a k a n g a n g g u a n perkembangan per pasif pada anak yang ditandai dengan adanya gangg uan dan keterla mbat a n d ala m bid a ng kog n it if, bahasa, perilaku (behavior), komunikasi dan interaksi sosial (winarno, 2013). anak autisme mengalami gangguan perkembangan yang sangat kompleks, termasuk gangguan pada perilakunya (behavior) yang disebabkan oleh adanya kerusakan pada otak, sehingga mengakibatkan gangguan dalam bidang perkembangan, perkembangan interaksi dua arah, perkembangan interaksi timbal balik (hasdiana, 2013). anak autis memiliki sensasi yang berbeda tentang tubuhnya. oleh sebab itu anak autis tidak dapat belajar buang air seperti anak normal. perbedaan proses pengindraan ini juga yang membuat anak autis menjadi sosok yang sangat pemilih dalam hal makanan dan tidak mau buang air kecil atau besar di toilet. selain pemilih dalam hal makanan anak autis juga tidak dapat menjaga perilakunya pada saat makan, misalnya melompat-lompat, naik ke atas meja. oleh karena itu mereka membutuhkan alat bantu visual untuk menggambarkan beragam benda yang dapat membantu anak autis agar lebih mudah berkomunikasi dan menjaga perilakunya (kidd, 2011). dari uraian di atas, peneliti berpendapat bahwa sebelum diberikan visual schedule, sebagian besar dari anak autis yang ada di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri memiliki behavior problem saat aktivitas makan dan buang air yang kurang. yang artinya sebagian besar anak autis mengalami masalah dalam perilaku (behavior problem). faktor yang memengaruhi behavior problem anak autis yang sebagian besar adalah kurang di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri yaitu karena faktor emosi, yang ditunjuk kan dengan per ubahan perilaku dalam beraktivitas sehari hari, salah satunya ditunjukkan pada saat aktivitas makan dan buang air. beberapa perubahan perilaku yang timbul yaitu seperti rasa marah, gembira, bahagia, takut dan benci. sebagian besar responden berusia kurang dari 10 tahun, akan tetapi dapat ditemukan pula penyandang autis pada tahap pendidikan taman kanak-kanak. hal ini menunjukkan bahwa gangguan autis bisa terjadi saat usia di bawah 4 tahun bahkan sebelum usia 2,5 tahun. behavior problem saat aktivitas makan dan buang air pada anak autis sesudah diberikan visual berdasarkan dari data yang didapat selama penelitian bahwa dari 16 responden didapatkan responden yang mengalami behavior problem saat aktivitas makan dan buang air sesudah terapi visual schedule kriteria baik sebesar (12,5%) dan kriteria cukup sebesar (81,2%) sedangkan kriteria kurang sebesar (6,2%). autisme merupakan jenis gangguan yang berkelanjutan dan paling umum terjadi dalam prevalensi dari setiap 10.000 anak dan terjadi 2-4 kali lebih sering pada anak laki-laki dibandingkan perempuan. autisme berbeda dari mental retardation, meskipun banyak anak autis juga mengalaminya (winarno, 2013). visual shedule adalah suatu informasi dalam bentuk visual yang mengomunikasikan serangkaian aktivitas yang akan datang. visual schedule dapat membantu meningkatkan perhatian dalam memahami perintah, aturan, dan kegiatan pada anak autis. visual schedule sebuah metode yang penting untuk mengatasi, mencegah dan mereduksi kecemasan pada anak autis, apabila harapan dan tuntutan lingkungan sosial tidak dapat mereka mengerti maka anak autis akan merasakan kecemasan, sehingga dapat memunculkan permasalahan perilaku (yuliana, 2011). pada penelitian yuliana (2011) mengatakan bahwa permasalahan perilaku anak autis dapat direduksikan yang awalnya memiliki persentase 76% menjadi 61%. berdasarkan uraian di atas, peneliti berpendapat bahwa behavior problem anak autis setelah diberikan visual schedule sebagian besar adalah cukup. hal ini sama dengan sebelum pemberian visual schedule, akan tetapi setelah pemberian visual schedule ini terdapat penurunan behavior problem di 254 jurnal ners vol. 10 no. 2 oktober 2015: 250–255 mana sebelum pemberian visual schedule behavior problem pada anak autis yang kurang sebanyak 8 responden, setelah visual schedule menjadi 1 responden, dan behavior problem baik sebelum visual schedule 1 responden, setelah visual schedule menjadi 2 responden. hal ini membuktikan bahwa visual schedule efektif untuk menangani behavior problem saat aktivitas makan dan buang air pada anak autis. dengan visual schedule akan membantu me ngat a si, me ncega h d a n me re du k si kecemasan pada anak autis. apabila suatu harapan tidak dapat dimengerti oleh anak autis maka akan menyebabkan munculnya suat u kecemasan. dari hasil penelitian ditemukan 6 orang anak autis yang mengalami behavior problem tetap dan 1 orang anak autis mengalami peningkatan behavior problem. hal ini kemungkinan disebabkan oleh derajat kerusakan saraf atau derajat autisme anak tersebut lebih parah. kemungkinan penyebab yang lain adalah kurangnya peran serta orang tua dalam pemberian visual schedule dan pencegahan timbulnya behavior problem ketika berada di rumah sehingga pemberian visual schedule ketika berada di sekolah tidak memberikan pengar uh dalam penur unan behavior problem pada beberapa anak autis tersebut. analisis pengaruh visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air behavior problem saat aktivitas makan dan buang air pre test dengan behavior problem saat aktivitas makan dan buang air post test dari 16 responden post test menunjukkan behavior problem pre test pada anak autis kriteria baik sebanyak 1 responden (6,2%), kriteria cukup sebanyak 7 responden (43,8%) dan kriteria kurang sebanyak 8 responden (50%). behavior problem saat aktivitas makan dan buang air pada anak autis kriteria baik sebanyak 2 responden (12,5%), kriteria cukup sebanyak 13 responden (81,2%), kriteria kurang sebanyak 1 responden (6,2%). hasil uji statistik wilcoxon, pengaruh visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri tahun 2014 didapat nilai signifikan asymp. sig (2-tailed) atau p = 0,011 < 0,05 yang berarti h0 di tolak dan h1 artinya ada pengaruh visual schedule terhadap penurunan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan pendidikan kristen jawi wetan (ybpk) kota kediri tahun 2014. ha si l p e nel it ia n t e r sebut se su ai dengan penemuan para peneliti bahwa visual schedule dapat membantu dalam memahami adanya peralihan-peralihan atau perubahan aktivitas. anak autis diberikan pengertian melalui visual schedule dengan tujuan untuk mengomunikasikan bahwa akan ada perubahan atau peralihan aktivitas yang memungkinkan dapat mengatasi permasalahan-permasalahan perilaku tersebut. demikian juga bahwa ke m a mpu a n belaja r a n a k aut is d apat ditingkatkan dengan menggunakan visual schedule, karena anak dengan gangguan autisme lebih mampu berpikir secara visual, sehingga anak lebih mudah mengerti apa yang dilihat daripada apa yang didengar, oleh karena itu visual schedule dipilih agar anak autis lebih mudah memahami berbagai hal yang ingin disampaikan (yuliana, 2011). berdasarkan uraian di atas peneliti ber pendapat bahwa terdapat penur unan behavior problem saat aktivitas makan dan buang air pada anak autis melalui visual schedule, di mana terdapat 8 responden yang sebelum diberikan visual schedule memiliki behavior problem yang kurang dan sesudah diberikan visual schedule memiliki behavior problem yang cukup, serta 7 responden yang sebelum diberikan visual schedule memiliki behavior problem yang cukup dan sesudah diberikan visual schedule memiliki behavior problem yang baik. simpulan dan saran simpulan visual schedule dapat menurunkan behavior problem saat aktivitas makan dan buang air pada anak autis di yayasan badan 255 visual schedule terhadap penurunan behavior problem (sandu siyoto) pendidikan kristen jawi wetan (ybpk) kota kediri. saran diharapkan orang tua juga menerapkan visual schedule saat aktivitas makan dan buang air di rumah secara kontinyu untuk membantu mengurangi behavior problem pada anaknya. sebagai salah satu pedoman bagi tenaga profesional kesehatan yang memberikan asuhan pelayanan kesehatan pada penderita autis, terutama dalam hal melakukan intervensi keperawatan terapi visual schedule sebagai salah satu alternatif terapi yang dapat membantu penurunan behavior problem anak autis. kepustakaan hasdianah. 2013. autis pada anak pencegahan, p e r a w a t a n , d a n p e n g o b a t a n . yogyakarta: nuha medika. kidd, susan larson. 2011. anakku autis, aku harus bagaimana?. jakarta: pt bhuana ilmu populer. winarno, 2013. autisme dan peran pangan. jakarta: pt gramedia pustaka utama. yuliana, elisa. 2011. visual schedule untuk menurunkan behavior problem pada autis. tesis. semarang: universitas katolik soegijapranata. 340 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17263 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the influence of diabetic foot exercise in sensory peripheral neuropathy with monofilament test on diabetes mellitus clients tintin sukartini, candra panji asmoro and putri nandani alifah faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: peripheral neuropathy is a long-term complication that attacks the nerves and loses the sensation of protection which affects about 50% of people with diabetes mellitus (dm). diabetic foot exercises can help blood circulation, especially in the legs or lower limbs. this researched aimed to analyze the effect of diabetic foot exercise on sensory peripheral neuropathy in dm clients. method: the study design used quasi-experimental pre-post test with control group. samples were 28 respondents using purposive sampling and divided into two groups of 14 respondents each. the independent variable is diabetic foot training, and the dependent variable is peripheral sensory neuropathy. interventions are carried out 3 times a week for 4 weeks. the research instrument was weinstein monofilament 10 g semmes and a diabetic foot training checklist. data analysis using the wilcoxon-signed rank test and mann whitney test with α≤0.05. result: the wilcoxon-signed rank test in the treatment group showed differences in sensory peripheral neuropathy after treatment (p=0,000) and no difference in the control group (p=0.564). the mann whitney test results showed differences in sensory peripheral neuropathy between the treatment group and the control group after treatment p=0.039. conclusion: diabetic foot exercises can be used as an alternative measure to improve sensory peripheral neuropathy. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords sensory peripheral neuropathy; diabetic foot exercises; monofilament test contact tintin sukartini  tintin-s@fkp.unair.ac.id  faculty of nursing universitas airlangga, surabaya, indonesia cite this as: sukartini, t., asmoro, c. p., & alifah, p. n. (2019). the influence of diabetic foot exercise in sensory peripheral neuropathy with monofilament test on diabetes mellitus clients. jurnal ners, 14(3si), 340-344. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17263 introduction international diabetes federation (idf) in 2017 stated that indonesia ranks 6th in the number of diabetics in the world (nam han cho., 2017). in 2017 the number of diabetics in indonesia reached 10.3 million people and among them 73.7% were unaware that they had diabetes. the prevalence of diabetes mellitus (dm) in indonesia has reached 9.1 million people. idf estimates that the number of diabetics in indonesia will continue to soar to reach 16.7 million in 2045 (perkeni, 2015). increased prevalence of dm patients can increase complications such as heart disease, nephropathy, retinopathy, diabetic foot injury, and neuropathy. neuropathy is one of the long-term complications that affects about 50% of people with diabetes. peripheral neuropathy is a broad and potentially disabling pathological condition that includes more than 100 different forms and manifestations of nerve damage. the diverse pathogenesis of peripheral neuropathy affects autonomic, motor and / or sensory neurons, and symptoms that describe these conditions are abnormal skin sensations, muscle dysfunction and, especially, chronic pain (dobson, mcmillan, & li, 2014). neuropathy is strongly associated with the duration and severity of hyperglycemia. disease prevalence increases with increasing duration of dm and poor glycemic control (chawla, chawla, & jaggi, 2016). about 11.9 million adults in the united states aged> 40 years have been diagnosed with diabetes and among them, 3.9 million (32.7%) have diabetes neuropathy and 1.6 million (13.1%) have comorbid neuropathy and retinopathy (ahmad & mittal, 2015). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:tintin-s@fkp.unair.ac.id.com http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 341 the prevalence of diabetic peripheral neuropathy ranges from 16% to 66%. amputation in diabetics is 10 to 20 times more common than non-diabetes (federation, 2017). patients with diabetic neuropathy are more often hospitalized than other diabetes complications. diabetic neuropathy increases in patients within 5-10 years after the onset of this disease. diabetic peripheral neuropathy (dpn) has a strong association with other complications such as diabetic retinopathy (67% versus 21%) and micro albuminuria (51% vs 41%). it has been observed that 56% of patients with dm less than 5 years have moderate / severe dpn (chawla et al., 2016). as many as 1,785 dm patients in 2008 to 2009 in indonesia experienced 63.5% of neuropathy complications, 42% diabetic retinopathy, 73% nephropathy, 16% spectacular, and 27.6% microvascular complications (soewondo et al., 2010). research in persadia units at dr. soetomo hospital surabaya showed that 30.8% of 26 respondents who did not experience diabetes ulcers complained of neuropathy (widyawati, irawaty, & sabri, 2010). one of the factors that trigger diabetic foot ulcers is neuropathy. international diabetes federation reports that 1 in 6 diabetics will experience diabetes ulcers during their lifetime (international diabetes federation, 2017). diabetic foot exercises are activities or exercises carried out by dm patients to help blood circulation, especially in the legs or lower leg (francia, gulisano, anichini, & seghieri, 2014). based on a preliminary study at the gedongan community health center in mojokerto, east java, dm was included in the list of the 10 biggest diseases in the last 3 years. people with dm every year always experience an increase, in 2015 there were 2,434 patients, in 2016 there were 3,085 patients, in 2017 there were 3,343 patients. in march 2018 there were 32 dm patients with neuropathy. observations and interviews during preliminary studies with outpatients at the gedongan community health center with dm showed that 7 out of 12 patients complained of frequent leg pain, calluses, and dry feet. the gedongan community health center in mojokerto has not yet intervened specifically in diabetic neuropathy to reduce the incidence of foot ulcers. the intervention given to dm patients is to schedule control patients, health education, and antidiabetes drugs on a regular basis according to the doctor's advice. most cases of peripheral neuropathy cannot be fully treated because the underlying cause is unknown or incurable, so the main goal associated with the treatment of most forms of peripheral neuropathy is to control or correct troublesome symptoms (nathan, 2014). exercise is known to increase several metabolic factors that can affect nerve health (nimmo, leggate, viana, & king, 2013). based on previous reviews, researchers were interested in conducting research on the effects of diabetic foot exercise on sensory peripheral neuropathy in dm patients at gedongan health center, mojokerto city. materials and methods the research design used was quasy experiment (prepost test with control design) and the project was approved by the health research ethics committee of faculty of nursing universitas airlangga (ethical number 989-kepk). the sample in this study was dm clients at gedongan health center, mojokerto. the sample size in this study were 28 clients who were divided into two groups. the sampling technique used in this study was purposive sampling. the instrument used was a 10 g monofilament type type diabetes test semmes-weinstein monofilament neuropathy measuring 10 g with a thickness of 5.07 and a checklist for diabetic foot exercises. retrieval of data in this study was conducted at gedongan community health center, mojokerto city, then followed up and routinely intervened through clients' home visits. samples were divided into treatment groups and the controls were matched pairs. the researcher explained the objectives, benefits, procedures, and research time in detail to the respondents. after that, the researchers asked the respondents for their consent to participate by signing an agreement letter in the study. at the first home visit the researchers conducted a pre test to determine the initial value of the dependent variable by examining the value of sensory neuropathy using a 10 g monofilament device in the treatment and control groups. foot gymnastics interventions were carried out every 3x / week for 4 weeks, referring to harmaya (2014) in the treatment group while intervention was not carried out in the control group (harmaya, sukawana, & lestari, 2014). at the end of the fourth week the researchers conducted a post test to determine the final value of the dependent variable, namely the value of sensory peripheral neuropathy with 10 g monofilament in the tre the research analysis was carried out with the help of spss v16 software. bivariate analysis used the mann whitney test statistical test using the degree of significance α ≤ 0.05 to compare the results of the treatment and control groups. the wilcoxon signed rank statistical test compared the results of the pretest and posttest in the intervention group and the control group. result most of the respondents were women (71.4%). the majority of respondents were in the range of the early elderly and the late elderly (92.85%); age of 46-55 years (46.43%) and age 56-65 (46.43%). most of the patients who participated in this study were diagnosed for less than 5 years (39.28%). most of them do not have job (46.43%). in the treatment group before diabetic foot exercise, the average value of sensory peripheral neuropathy was 2.64, which meant that the dm patients in the treatment group had sensory t. sukartini et al. 342 | pissn: 1858-3598  eissn: 2502-5791 peripheral neuropathy on average. after diabetic foot exercise, the mean sensory peripheral neuropathy showed a decrease to 1.64, meaning that sensory peripheral neuropathy scores improved. the results of statistical tests showed that there were significant differences between the values of sensory peripheral neuropathy before and after diabetic foot exercise in the intervention group (p = 0,000) while in the control group it meant that there were no differences in sensory peripheral neuropathy (p = 0.564). whereas in the post-intervention results there were differences in sensory peripheral neuropathy between the treatment and control groups (p = 0.039). discussion patients with diabetes and neuropathy are associated with low nerve conduction due to demyelination and loss of large myelin fibers, and decreased potential for nerve action due to loss of axons (charles et al., 2010; kobori et al., 2017). in patients with peripheral diabetic neuropathy, loss of sensation in the foot causes recurrent minor injuries (calluses, nails, foot deformities) or external causes (shoes, burns, foreign objects) that are not detected at that time and consequently can cause foot ulceration. this can be followed by ulcer infection, which can eventually cause amputation of the foot, especially in patients with peripheral arterial disease (alexiadou & doupis, 2012). in diabetic patients, regular physical activity reduces weight, increases blood glucose control and insulin sensitivity which all lead to a reduced risk of developing neuropathy (francia et al., 2014). the results of this study indicate that diabetic foot exercise can reduce sensory peripheral neuropathy. exercise positively influences other pathological factors associated with diabetic peripheral neuropathy, by promoting microvascular function and fat oxidation, by reducing oxidative stress and increasing neurotropic factors (colberg et al., 2010; kluding et al., 2012). exercise-induced neurotrophin3 (nt3) increases are associated with increased peripheral nerve conduction velocity and reduction in neuropathic pain (li et al., 2012). neurotrophin-3 (nt-3) is known to promote the survival and differentiation of existing neurons and to encourage the growth of new synapses and neurons. foot and toes exercises are one of the exercises that can modulate the level of sorbitol in the body so as to prevent a decrease in blood flow in the endoneural blood flow (dixit, maiya, & shastry, 2014). providing stimulation in the form of exercise or leg exercises can produce potential action resulting in depolarization which results in increased na + / k + atp activity, axonal transport is increased, patients feel sensory sensations / sensory responses. foot exercises can help smooth and improve blood circulation in the legs. it also helps in the process of wound healing in diebetes foot ulcer (eraydin & table 1. characteristics of respondents characteristics of respondents treatment group (n=14) control group (n=14) n % n % gender men 4 28,6 4 28,6 woman 10 71,4 10 71,4 age 36-45 years 0 0,0 2 14,3 46-55 years 9 64,3 4 28,6 56-65 years 5 35,7 8 57,1 duration diagnosed with dm <5 years 5 35,7 6 42,9 5-10 years 5 35,7 2 14,3 >10 years 4 28,6 6 42,9 profession do not have job 8 57,1 5 35,7 pensionary 1 7,1 2 14,3 civil servants 1 7,1 2 14,3 entrepreneur 3 21,4 2 14,3 other 1 7,1 3 21,4 table 2. sensory peripheral neuropathy before and after diabetic foot exercises in the treatment and control groups groups mean p value wilcoxon signed rank test p value mann-whitney test pretest posttest pretest posttest treatment group 2,64 1,64 0 0,541 0,039 control group 2,57 2,64 0,564 jurnal ners http://e-journal.unair.ac.id/jners | 343 avşar, 2018). in addition to this effect, the main reason for a large increase in blood flow during exercise is a decrease in oxygen in the tissues, which is one of the chemical factors found in diabetic patients. the decrease in oxygen causes dilation because of its direct effect on muscle arterioles. muscles consume oxygen quickly during exercise, and the amount of oxygen in the tissue decreases. in the absence of oxygen, the arteriolar wall cannot continue to contract, and lack of oxygen causes the release of vasodilators. this causes vasodilation of local arterioles so that all capillaries are open and blood flow increases. blood circulation that smoothly carries oxygen and nutrients to the tissues and nerve cells that will affect the metabolic process of schwann cells so that axon function can be maintained. the optimal function of nerve cells in dm patients will maintain sensory function of their feet (han, sin, & yoon, 2013). foot exercises play a role in controlling blood glucose levels to improve peripheral blood circulation which can be seen from the value of the ankle brachial index (abi) in dm patients (barone gibbs, dobrosielski, althouse, & stewart, 2013). decreasing glucose levels in the blood will improve myelin nerve function and axons so that dm patients will be able to feel pain, heat, vibration, and pressure. in other words, the nerve endings of patients experience increased conduction and recurrent sensitivity in protection against risky conditions, which are detected by examining the sensation of protection using monofilament 10 g.. conclusion dm patients who perform foot exercises will experience a decrease in the value of peripheral sensory neuropathy because foot exercise movements can improve myelin nerves and axon function so that nerve endings undergo improved conduction and sensitive return detected by monofilament 10 g. there was a decrease in sensory peripheral neuropathy in the intervention group and there was no decrease in the value of sensory peripheral neuropathy in the control group proving the theory above that foot exercise can help smoothen so as to improve blood circulation and sensitivity to prevent numbness. community health nurses can provide education about foot exercise to dm patients, especially patients with peripheral neuropathy. dm patients are able to do leg exercises independently at home to improve the status of sensory peripheral neuropathy so that it can prevent the occurrence of ulcers. references ahmad, s., & mittal, m. (2015). diabetic neuropathies. jimsa, 28(1), 51–53. alexiadou, k., & doupis, j. (2012). management of diabetic foot ulcers. diabetes ther, 3(4). https://doi.org/10.1007/s13670-015-0133-x barone gibbs, b., dobrosielski, d. a., althouse, a. d., & stewart, k. j. (2013). the effect of exercise training on ankle-brachial index in type 2 diabetes. atherosclerosis, 230(1), 125–130. https://doi.org/10.1016/j.atherosclerosis.2013.0 7.002 charles, m., soedamah-muthu, s. s., tesfaye, s., fuller, j. h., arezzo, j. c., chaturvedi, n., & witte, d. r. (2010). low peripheral nerve conduction velocities and amplitudes are strongly related to diabetic microvascular complications in type 1 diabetes: the eurodiab prospective complications study. diabetes care, 33(12), 2648– 2653. https://doi.org/10.2337/dc10-0456 chawla, a., chawla, r., & jaggi, s. (2016). microvasular and macrovascular complications in diabetes mellitus: distinct or continuum? indian journal of endocrinology and metabolism, vol. 20, pp. 546– 553. https://doi.org/10.4103/22308210.183480 colberg, s. r., sigal, r. j., fernhall, b., regensteiner, j. g., blissmer, b. j., rubin, r. r., … braun, b. (2010). exercise and type 2 diabetes: the american college of sports medicine and the american diabetes association: joint position statement. diabetes care, 33(12). https://doi.org/10.2337/dc10-9990 dixit, s., maiya, a. g., & shastry, b. a. (2014). effect of aerobic exercise on peripheral nerve functions of population with diabetic peripheral neuropathy in type 2 diabetes: a single blind, parallel group randomized controlled trial. journal of diabetes and its complications, 28(3), 332–339. https://doi.org/10.1016/j.jdiacomp.2013.12.006 dobson, j. l., mcmillan, j., & li, l. (2014). benefits of exercise intervention in reducing neuropathic pain. frontiers in cellular neuroscience, 8(1 apr), 1–9. https://doi.org/10.3389/fncel.2014.00102 eraydin, ş., & avşar, g. (2018). the effect of foot exercises on wound healing in type 2 diabetic patients with a foot ulcer. journal of wound, ostomy and continence nursing, 45(2), 123–130. https://doi.org/10.1097/won.00000000000004 05 federation, i. d. (2017). idf diabetes atlas eighth: eighth edition 2017. in international diabetes federation. idf diabetes atlas, 8th edn. brussels, belgium: international diabetes federation, 2017. http://www.diabetesatlas.org (8th ed.). https://doi.org/http://dx.doi. org/10.1016/s0140-6736(16)31679-8. francia, p., gulisano, m., anichini, r., & seghieri, g. (2014). diabetic foot and exercise therapy: step by step the role of rigid posture and biomechanics treatment. current diabetes reviews, 10(2), 86–99. https://doi.org/10.2174/157339981066614050 7112536 han, j. w., sin, m. y., & yoon, y. s. (2013). cell therapy for diabetic neuropathy using adult stem or progenitor cells. diabetes and metabolism journal, t. sukartini et al. 344 | pissn: 1858-3598  eissn: 2502-5791 37(2), 91–105. https://doi.org/10.4093/dmj.2013.37.2.91 harmaya, d. p., sukawana, i. w., & lestari, m. (2014). pengaruh masase kaki terhadap sensasi proteksi pada kaki pasien diabetes melitus tipe ii dengandiabetic peripheral neuropathy. coping (community of publishing in nursing), 2(3). international diabetes federation. (2017). idf diabetes atlas 8th edition. brussels, belgium. kluding, p. m., pasnoor, m., singh, r., jernigan, s., farmer, k., rucker, j., … wright, d. e. (2012). the effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy. journal of diabetes and its complications, 26(5), 424–429. https://doi.org/10.1016/j.jdiacomp.2012.05.007 kobori, m., yagihashi, s., shiina, n., shiozawa, n., haginoya, a., ojima, m., … osonoi, t. (2017). fouryear sequential nerve conduction changes since first visit in japanese patients with early type 2 diabetes. journal of diabetes investigation, 8(3), 369–376. https://doi.org/10.1111/jdi.12583 li, h., shen, z., lu, y., lin, f., wu, y., & jiang, z. (2012). muscle nt-3 levels increased by exercise training contribute to the improvement in caudal nerve conduction velocity in diabetic rats. molecular medicine reports, 6(1), 69–74. https://doi.org/10.3892/mmr.2012.897 nam han cho. (2017). eighth edition 2017. in idf diabetes atlas, 8th edition. https://doi.org/http://dx.doi. org/10.1016/s0140-6736(16)31679-8. nathan, d. m. (2014). the diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview. diabetes care, 37(1), 9–16. https://doi.org/10.2337/dc13-2112 nimmo, m. a., leggate, m., viana, j. l., & king, j. a. (2013). the effect of physical activity on mediators of inflammation. diabetes, obesity & metabolism, 15 suppl 3, 51–60. https://doi.org/10.1111/dom.12156 perkeni. (2015). pengolahan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. https://doi.org/10.1017/cbo9781107415324.0 04 soewondo, p., soegondo, s., suastika, k., pranoto, a., soeatmadji, d. w., & tjokroprawiro, a. (2010). the diabcare asia 2008 study – outcomes on control and complications of type 2 diabetic patients in indonesia. medical journal of indonesia, 235. https://doi.org/10.13181/mji.v19i4.412 widyawati, i. y., irawaty, d., & sabri, l. (2010). latihan active lower range of motion menurunkan tanda dan gejala neuropati diabetikum. jurnal ners, 5(2), 107–117 editorial internationally, academic nurses face increasing pressure to publish their research in high quality and esteemed journals. publication is important for disseminating research findings that can be adopted to influence the delivery of health care, but also influences rankings and prestige of universities and the professional standings of individual researchers. however, there are many challenges in making it to successful publication, particularly for novices. internationally, journals are under growing pressure having a limited scope on how many manuscripts they can publish in any one issue and annually. as academics are under pressure to publish more, numbers of manuscripts being submitted to each journal increases every year. this means that the number rejected by each journal also increases. many of these manuscripts may not be poorly written or present bad research, they are just not prioritised by editors as material they want to publish. it is, therefore, important to submit manuscripts that present work that an editor wants to publish in their journal. making it through the initial editor screening can be challenging, but there are strategies that can assist with increasing the likelihood of successful publication. when developing your manuscript for publication, it is important to write specifically according to the journal you are planning to publish in. often, researchers will write their manuscript and then try to fit it into a particular journal. this strategy may not be very successful. journals all have different styles, audiences and manuscript guidelines. it is important when writing the manuscript to consider all of these factors. it is easy to forget you are writing for a particular audience, not just writing to get published. researchers need to be clear about the audience who read the particular journal, and who is likely to benefit from the research outcomes being reported. it is important to carefully choose journals to publish work in and use the journal’s specific author guidelines to develop the manuscript. many papers are rejected by journal editors because they have not been developed according the actual journal guidelines. in preparing for publication, it is important that researchers identify and highlight the new knowledge that their research adds to the existing knowledge base. a lot of research conducted in nursing is very localised to a particular practice or educational setting or geographical location. researchers need to consider the international scope of their findings if they want to publish in international journals that have readers from around the world. such considerations need to include how research methodologies or findings could be used by others in international settings or the uniqueness or new knowledge within the paper needs to be highlighted. overall, it is important that the manuscript is relevant to a broad, international readership as much as possible, and that this relevance is clear. there is an additional challenge for nurse researchers whose first language is not english. most of the highly ranked journals in nursing are published in the english language. not only are they competing for publication space, these researchers face rejection because of issues relating to english expression, grammar and tense. collaborations with other researchers whose first language is english may be one strategy for increasing possibility of acceptance through improving the english language in manuscripts submitted to journals. furthermore, collaborating with researchers who have established publication records means that there are members of the writing team who have expertise in being successful at navigating the many publication challenges. ethics is also an important component in reporting on research conducted. in publishing their work, researchers are required to address ethical issues related to their studies. as editors, we often see papers where ethical considerations comprise only one statement that the research had ethical approval. however, there is more to reporting on ethics than merely acquiring ethical approval, which does not necessarily mean that the research was actually conducted in an ethical manner. in particular, it is important to discuss aspects relating to issues such as informed consent and how this was managed, as well as recruitment strategies demonstrating there was no pressure placed on potential participants or power imbalances between researcher and participants (mckenna & gray, 2018). overall, there is a need for more transparent reporting of ethical processes in research. the growth in predatory journals further complicates the publication process, particularly for novice researchers. predatory journals are most often money-making scams. each year, many good research papers are caught up in predatory journals that may not even exist, essentially becoming lost work that cannot be published anywhere else. it is very important for researchers to be aware of how to avoid losing their valuable work to these entities (darbyshire et al., 2016). it is not uncommon to receive emails daily from so-called journals to publish with them. they often promise a quick turnaround, sometimes in a few days which is impossible for peer review to be conducted. many have names similar to legitimate journals so you may think they are the real journal. it is very important to carefully check that a journal is legitimate before submitting any work to it. usually, a lot of work has gone into developing a manuscript for publication and it is vital not to lose that effort. the need to publish nursing research is increasing. however, this has also increased the competition and number of manuscripts submitted to international journals each year. being successful in publishing is complex but necessary and empowering. researchers need to consider a range of strategies they can use to increase the possibility of successful publication in appropriate journals. professor lisa mckenna head, school of nursing and midwifery, la trobe university, australia adjunct professor, airlangga university, indonesia l.mckenna@latrobe.edu.au dr. sonia reisenhofer director of international school of nursing & midwifery, la trobe university, australia adjunct professor, airlangga university, indonesia s.reisenhofer@latrobe.edu.au http://e-journal.unair.ac.id/jners | 55 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16979 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a diabetes self-management education/support (dsme/s) program in reference to the biological, psychological and social aspects of a patient with type 2 diabetes mellitus: a systematic review novita fajriyah, tria anisa firmanti, ainul mufidah and nita tri septiana faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: various efforts have been made to improve the self-care management of patients with type 2 diabetes mellitus (t2dm). one of them is by using a diabetes self-management education and support (dsme/s) program. dsme/s produces positive effects in relation to patient behavior and health status. this is a systematic review of randomized controlled trials published where the aim was to evaluate the impact of the dsme/s program in term of biological. psychological and social aspects. methods: the articles were searched for using the prisma approach from within scopus, sage journal, proquest, google scholar and pubmed to identify the relevant english publications on dsme over the last 5 years (2013-2018). in total, 15 studies met the inclusion criteria. results: the articles included at least one result that covered the biological, psychological, and social aspects that are more general and relevant for t2dm patients who received the dsme program. dsme had a positive impact on t2dm, namely the reduction of hba1c, blood glucose, ldl, cholesterol, blood pressure, weight, waist circumference, decreased distress, anxiety and increased self-efficacy and self-empowerment. conclusion: it can increase the social and family support, improve selfmanagement motivation, increase knowledge and improve the behavior of t2dm patients. the findings of our review showed that dsme has a positive impact on the biological, psychological and social aspects of type 2 diabetes mellitus. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords diabetes self-management education and support; type 2 diabetes mellitus; biological; psychological; social contact tria anisa firmanti  tria.anisa.firmanti2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: fajriyah, n., firmanti, t. a., mufidah, a., & septiana, n. t. (2019). a diabetes self-management education / support (dsme/s) program in reference to the biological, psychological and social aspects of a patient with type 2 diabetes mellitus: a systematic review.jurnal ners, 14(3si), 55-64. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16979 introduction one of the health challenges of society in this world is diabetes mellitus (dm). this is the fifth most common cause of death in high-income countries, and it is rapidly becoming an epidemic in lowand mediumincome countries. expensive diabetes care can cause serious complications such as kidney failure, myocardial infarction, stroke, blindness and the amputation of limbs (kumah, sciolli, toraldo, & murante, 2018). one of the diseases that has become an epidemic in the world and its prevalence in terms of increase is type 2 diabetes. according to the who in 2016, the biggest percentage of diabetes is type 2 diabetes, which is 95% with weight loss problem and psychological disorders. approximately 415 million diabetics are aged 2079 years and according to the international diabetes federation in 2015, this number will increase to 642 million in 2040. according to the who in 2011, there are 12.3 million diabetics in southeast asia and this is estimated to increase to 19.4 million in 2040. according to the who in 2009, the prevalence of diabetics was 8,246,000. in 2000, indonesia was ranked first in southeast asia and it is estimated to increase by 2.5 times, which is as many as 21,257,000 by 2030. according to the ministry of health 2013, the highest symptoms of dm prevalence were found in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:tria.anisa.firmanti-2018@fkp.unair.ac.id mailto:tria.anisa.firmanti-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). n. fajriyah, et al. 56 | pissn: 1858-3598  eissn: 2502-5791 central celebes 3.7%, north celebes 3.6%, south celebes 3.4% and east nusa tenggara 3.3%. based on the doctor's diagnosis, the highest prevalence of dm was found in di yogyakarta 2,6%, dki jakarta 2.5%, north celebes 2.4% and east borneo 2.3%. the proportion of the indonesian population aged> 15 years with dm is 6.9% (kementrian kesehatan ri, 2018). type 2 diabetes mellitus is a type of diabetes that is characterized by an increase n blood sugar due to a decrease in insulin secretion by the pancreatic beta cells and / or impaired insulin function (insulin resistance). type 2 diabetes mellitus can be seen from the increased blood sugar levels during fasting, glycemic control and significant weight loss. incorrect perceptions due to a lack of knowledge of type 2 diabetics causes psychological effects and an inability to treat themselves, so many patients experience depression (farhangi, 2017). epidemiological trends indicate that the prevalence of type 2 diabetes mellitus is expected to increase continuously in the coming years due to unhealthy behavior, the enhancement of urbanization, the reduction of physical activity, dietary changes and increased obesity. the risk factors that cannot be changed are gender, age and genetic factors. the changeable risk factors are smoking, alcohol consumption, physical activity, knowledge and obesity. if good management is not focused on these risk factors, then it can cause nursing problems in the biological, psychological and psychosocial aspects (costa, 2016). the self-care management education program is a systematic intervention involving active patient participation in self-monitoring and / or decision making, providing diabetic patients with the knowledge and skills needed to carry out self-care behavior, allowing them to manage crises and to make effective lifestyle changes (cai & hu, 2016). several empirical studies have shown that the dsme / s program has a beneficial effect on patient health, health behavior and the utilization of health services which reduces the medical costs for treating diabetics. a systematic review also showed an improvement of the outcomes such as better glycemic control, increased weight loss, increased knowledge, the reduction of blood pressure, the increase in diet and exercise habits, and the reduction of the need for diabetes medication. in a research article entitled ‘2017 national standards for diabetes self-management education and support’, dsme / s is stated as being a process that facilitates the knowledge, skills and abilities of diabetics to care for themselves. the activities that are described refer to the help from others that can support them in their daily needs in terms of regulating their condition continuously from the baseline to the end or even when outside of the selfmanagement training.(beck et al., 2018) the available evidence indicates that early diagnosis and effective management can improve the prevention of complications, and improve the client's condition, especially in the biological, psychological and social aspects (garcía, brown, horner, zuñiga, & arheart, 2014). among the management strategies, patient education programs are considered to be the components of effective and efficient care for type 2 diabetes as a prevention strategy against complications (busch et al., 2015; cai & hu, 2016; chrvala, sherr, & lipman, 2016). evidence from the randomized controlled trials and observational studies suggest that dsme is costeffective at improving the lifestyle, clinical, and psychosocial outcomes (azami et al., 2018). it is associated with favorable changes in knowledge (albikawi, petro-nustas, & abuadas, 2016; cai & hu, 2016; garcía et al., 2014), clinical outcomes (ku & kegels, 2014), self-efficacy, self-management and other psychosocial outcomes (cai & hu, 2016; chai et al., 2018; habibzadeh, sofiani, alilu, & gillespie, 2017; yuan et al., 2014), in addition to quality of life (cai & hu, 2016; chai et al., 2018; kim et al., 2015; ku & kegels, 2014). several studies were used as systematic reviews related to dsme / s and type 2 diabetes as an effort to improve glycemic control, blood sugar, psychological problems such as stress, anxiety, and distress, and to improve knowledge, the self-care ability and to improve patient perceptions about the disease. this was a systematic review of the randomized controlled trials published to evaluate the impact of the dsme program in terms of the biological, psychological, and social aspects. materials and methods we focused our analysis on studies that evaluated the effectiveness of diabetes self-management education /support (dsme/s) and the holistic aspects of type 2 diabetes. this is because the program is known to produce more positive effects that counter the risk of long-term complications. we used four steps to identify and select journals that met the criteria specified in this review (figure 1). firstly, we conducted a major search on the chosen databases (scopus, sage journal, proquest, science direct, and pubmed) to identify the relevant english works published in the last 5 years (2013-2018). for this review, we used the following search string: (diabetes* or diabetes mellitus) and (diabetes selfmanagement education* dsme* or * diabetes self management support* or dsms*) and (patient * or person *) and (benefit * or effectiveness * or results *) and (self-management education* or self management support* or education* or intervention * or program*) and (glucose level * or hba1c* or self-efficacy* or quality of life* or glycemic control * or stress* or distress* or psychology * or behavior*). the search identified a total of 1325 articles but the number of articles was reduced to 885 after removing the duplicate results. secondly, to identify eligible journals, we carefully read each title and abstract of the 885 journals. we focused on three main criteria, namely as the journal jurnal ners http://e-journal.unair.ac.id/jners | 57 population compiled consisted of type 2 diabetes mellitus patients. the journals focused on the effectiveness of the diabetes self-management education (dsm) program and diabetes selfmanagement support (dsms), and the journal reported the results of the diabetes self-management education (dsme) and diabetes self-management support (dsms). after this, 841 journals were to be included in the next stage of the review, because the journals had to be sure that they would meet all of the criteria needed. third, the remaining 44 journals were read and understood to be considered further for the inclusion criteria. in detail, the journal must not to be a review / report / protocol article, it must exclusively refer to type 2 diabetes mellitus, it must report at least one result which includes the biological, psychological, and social aspects that are more general and relevant for type 2 diabetes mellitus patients who receive the diabetes self-management education (dsme) program and diabetes self-management support (dsms), such as hemoglobin glycated (hba1c), body mass index (bmi), diet, physical activity (diabetic foot exercises, etc.), mental health (psychology, stress, distress), self-efficacy, quality of life) and the utilization of the health services (glycemic control etc). the study should also be from an indexed and reputable journal. after the third step, 29 articles were eliminated. the reason for exclusion was due to the complications of other chronic diseases. they did not report on the effectiveness of diabetes self-management programs on one specific holistic aspect. it was a type of qualitative research. finally, the remaining 15 journals were considered to be eligible for review and analysis. all of them focused on the effectiveness of the diabetes self-management education / support (dsme/s) program for type 2 diabetes mellitus patients focused on the biological, psychological, and social aspects. for each journal that meets the requirements, the research team drew information about the study design, participant / sample, the type of intervention, the name of the diabetes self-management education / support (dsme / s) program, the results of the study, the length of the program, the professional leader, the doctors, endocrinologists, nutritionists, pharmacists, registered dietitians and community health workers (chws) involved, the psychologists, public health experts, peer leaders, community health workers, registered dietitian nutritionists (rdn), physicians, medical teams, psychology and public health staff involved, and the location of the study (country). in our analysis, we only considered the results of the diabetes self-management education / support (dsme / s) program which included the biological, psychological, and social aspects. the effects of increase (+) and decrease (-) in terms of yield from dsme/s have been shown in each reported result. results the sample used in the study varied with the minimum sample being 19 with the maximum being 250 participants. the place where the research was conducted was in asia for as many as four countries (indonesia, hong kong, china, and philippines). three studies were located in the united states (usa), three studies were located in iran and one study was located in iraq, canada, and latin america. the complete explanation can be seen in table 1. there were eight studies about pure dsme program, comparison between dsme and diabetes care standards and other programs. the leader program was carried out by professionals, while five studies were conducted by professional nurses, three studies were conducted by nurses who collaborated with other health professionals such as endocrinologists, nutritionists, pharmacists, registered dietitians, and community health workers, three studies were conducted by peer educators, and one of them was in collaboration with community health workers (chws). two studies were conducted by a certificated nutritionist and a registered nutritionist (rdn), two studies were conducted by physicians, one study was conducted by a multidisciplinary team from the medicine, psychology, and public health sections. the duration of the intervention varied with the shortest being 2 months and the longest being 12 months. the details of each study have been explained in table 1. problem based learning (pbl) program. the problem based learning (pbl) program is a program based on specific problem learning especially for patients with type 2 diabetes mellitus. this program can reduce anxiety, depression, decrease fasting blood glucose levels and hba1c, and it improve figure 1. literature search flow n. fajriyah, et al. 58 | pissn: 1858-3598  eissn: 2502-5791 diabetes self-management and health for patients with type 2 diabetes mellitus (chai et al., 2018). nurse-led dsme intervention. it is an educational program led by nurses as the educators. in this case, the patients were educated regarding selfmanagement in the self-care of patients with type 2 diabetes mellitus. the main outcome of the program was that it can reduce the hba1c values. the secondary results were changes in blood pressure, body weight, lipids, self-efficacy, self-management behavior, quality of life, social support and psychology (azami et al., 2018). self-help intervention program was designed for diabetes management. the intervention was designed to help type 2 diabetes mellitus patients to perform treatments independently. the aim of this program was to help the patients achieve better glycemic control and to restore their confidence in the table 2. experimental studies and rcts of dsme/s type 2 diabetes mellitus as the basis of the systematic review author type of study participant intervention name of program program leader outcome and effect of dsme/s (+/increase and -/decrease) time (chai et al., 2018) completel y randomiz ed design 118 (intervention n = 63 control n = 55) dsme problem based learning (pbl) professional nurse educator 1.primary result: hemoglobin a1c (-) glucose (-) 2.secondary result psychosocial (+) diabetes selfmanagement and health education (+) 6 months (cai & hu, 2016) quasiexperime ntal design 57 (intervention n= 29 control n= 28) family-based selfmanagement educational dsme the first writer is a nurse (rn) diabetes knowledge (+) self-efficacy diabetes (+) self-care activities (+) quality of life (+) 3 months (kargar jahromi et al., 2014) rct n=90 (experimental and control) dsme self-care education the researchers are nurses quality of life (+) 2 3 months (azami et al., 2018) rct n=142 (intervention= 71 control n=71) a nurse-led dsme nurse-led dsme intervention nurse and team (endocrinolo gists, nutritionists, nurses, and pharmacists ) clinical: hba1c (-) sekunder: blood pressure (-) weight (-) lipid profile (-) self-efficacy (expectation of success and expected results) (+) self-management behavior (+) quality of life (+) social support (+) psychology (+) 2 months (abdulah et al., 2018) a doublearm posttest interventi on study. n=45(experim ental arm (n = 22) and control arm (n = 23) selfmanagement education selfmanagement health education (face to-face group session) nurses physical activity(+) dm diet(+) hba1c (-) 3 months (kim et al., 2015) rct n = 250 (intervention group n = 120, control group n = 130) self-help based community (ship-dm): self-help intervention program for diabetes management (ship-dm) self-help intervention program was designed for diabetes management (ship-dm) nurses team and community health workers clinical: hemoglobin a1c (-) glucose (-) total cholesterol (-) ldl (-) secondary psychosocial (+) self-management behavior (+) quality of life (+) self-efficacy (+) compliance with therapy (+) 12 months (rusdian a et al., 2018) quasiexperime ntal (one group pretestposttest design) n = 80 dsme dsme program medical team, psychology, public health. hba1c level (-) 3 months jurnal ners http://e-journal.unair.ac.id/jners | 59 management of diabetes, thereby reducing dmrelated mortality and morbidity and improving their quality of life. the main results of the program were a decrease in hba1c, glucose, cholesterol, and ldl and to promote an increase in self-management behavior, quality of life, self-efficacy and self-management compliance(nguyen et al., 2015). table 2. experimental studies and rcts of dsme/s type 2 diabetes mellitus as the basis of the systematic review (continue) author type of study participant intervention name of program program leader outcome and effect of dsme/s (+/increase and -/decrease) time (yuan et al., 2014) rct n = 76 patients (intervention n= 36, control n= 40) dsme dsme program a certificated nutritionis t short term education (+) knowing dsme in metabolic and parameter cases aterosclerotic: hba1c (-) obesity (-) 3 months (garcía et al., 2014) rct 72 patient (36 intervention group, 36 control group) dsme dsme nurses clinical: hba1c (-) clinical symptoms (-) lipid levels (-) blood pressure (-) cholesterol (-) ldl (-) bmi (body mass index) (+) psychosocial diabetes knowledge (+) self efficacy(+) empowerment (+) positive behavior changes (+) quality of self management(+) quality of life (+) 2 – 6 months (habibza deh et al., 2017) rct 90 patients (45 intervention, 45 control) group discussion group discussionbased education on selfmanagement nurses self-management (+) 3 months (adam et al., 2018) mixed methods (pretest/ post-test design) n=21 (cm intervention n=10 te intervention n=11) cm – te intervention traditional education (te) canadian conversation maps (cms) nurses clinical : hba1c (-) psychosocial : knowledge of dm management (+) attitude(+) 3 months (ku & kegels, 2014) prospecti ve quasiexperime ntal n=164 (108 in batac city and 59 in pagudpud) fildcare project dsme/s fildcare project dsme/s the lghu nurse the fildcare project nurse clinical hba1c (-) waist circumference (-) psychosocial knowledge of dm management (+) attitude(+) diet compliance (+) 12 months (spencer et al., 2018) comparat ion n=222 (chw+pl n=60, chw only n=89, euc n=73) dsme dsme and enhanced usual care (euc) communit y health workers (chws) peer leaders (pls) clinical hba1c (-) psychosocial distress (-) social support(+) dm knowledge (+) 6 – 18 months (pazpacheco et al., 2017) prospecti ve, education interventi on trial n=19 (intervention n=9 control n=10) dsme : 1. peer educator dsme content dsme program and standard care peer educators hba1c level (-) 3-6 months (albikaw i et al., 2016) rct n=149 (intervention n=76, control n=73) diabetes self efficacy intervention package dseeip: diabetes self efficacy intervention package the dm clinic physicians clinical hba1c (-) psychosocial depression (-) social support (+) knowledge of dm management (+) distress (-) 2 weeks-3 months n. fajriyah, et al. 60 | pissn: 1858-3598  eissn: 2502-5791 fildcare project dsme/s. this program is the first diabetes treatment with a self-management modification specifically for type 2 diabetes mellitus patients. this program produces an improvement n clinical and psychosocial status, namely the improvement of hba1c, waist circumference, increased knowledge and compliance (kumar s, nayak rr, 2015). diabetes self efficacy intervention package. it is a package of self-efficacy interventions designed for patients with type 2 diabetes mellitus which emphasizes increasing self-efficacy and goal-setting skills to improve self-efficacy and to change people's behavior. dseeip can promote the level of self-care management behavior at two weeks and three months after intervention (albikawi et al., 2016). traditional education (te) canadian conversation maps (cms). traditional education from canada specifically designed for patients with type 2 diabetes mellitus can improve clinical and psychosocial status, namely the improvement of hba1c, waist circumference, increased knowledge and compliance (adam, o’connor, & garcia, 2018). education has a positive effect when it comes to improving the health status of the patients with type 2 diabetes. twelve studies reported improvements in the clinical status of hba1c. for example, a study by (chai et al., 2018) revealed that the hba1c levels among the participants decreased significantly [7.20% (6.40%, 9.10%)] in the first and [6.20% (580%, 6.60%)] in the sixth month p <0.00 after the educational intervention was given for six months. several studies have shown there to be improvements in blood glucose status, cholesterol, lipid levels, ldl, bmi (body mass index) blood pressure, waist circumference and body weight. for example, in the study conducted by (chai et al., 2018), the weight loss was (.11.19 ± 1.39kg versus (−0.61 ± 2.04kg; 𝑃<0.05) in the group intervention to be compared with the control group. in a study by (chai et al., 2018), referring to patients in the intervention group, there was a significant reduction in hba1c level and body weight in the follow-up examinations compared with the baseline examinations (𝑃<0.05). the hba1c changes and body weight after 3 months were significantly greater in the intervention group than in the control group (𝑃<0.05). for both the intervention and control groups, there was a significant reduction in total cholesterol, ldl, and bmi in the follow-up examination (𝑃<0.05). in another study that was conducted(ku & kegels, 2014), after a year of fild self care management and support intervention, the analysis of the median values showed a significant decrease in hba1c (p <0.001), waist circumference (p = 0.007) and waist base ratio (p <0.001). five studies reported that the results of the research related to improving the quality of life of people with type 2 diabetes. for example, in a study by (kargar jahromi, ramezanli, & taheri, 2014), there was a significant difference between the two groups (p = 0.012) after being given a diabetes selfmanagement program intervention for 2 and 3 months. in other words, the training session increased the qol score (quality of life) in the experimental group (p <0.001) compared to the control group (p = 0.5). the study resulted in an intervention group that showed a statistically significant increase in self-efficacy related to diabetes and quality of life compared to the control group, as well as improvements in quality of life and medication adherence(nguyen et al., 2015). significant physical activity reported that the frequency and duration of activities was significantly and statistically higher among the patients assigned to the experiment compared to the patients in the control group; 7.0 1.0 vs. 4.0 7.0 days / week (p = 0.004) and 120 60 vs. 30 60 minutes / day (p = 0.001)(abdulah, hassan, saadi, & mohammed, 2018). the proposal analysis of the study stated that there was significant increase in treatment compliance (p = 0.001) and exercise adherence (p <0.001) but a significant reduction in dietary compliance (p <0.001)(ku & kegels, 2014). the research performed stated that there was an increase in knowledge in the first study session. after a 2-week evaluation, there was a significant increase in knowledge in the cms group (p = 0.0023) (adam et al., 2018). the findings from the study (habibzadeh et al., 2017) indicated that a group discussion is an effective method for improving the self-management of diabetics (paz-pacheco et al., 2017). furthermore, the use of the group discussion method can be an effective approach for holding active training sessions, for improving self-management and for facilitating the learning process in the real environment. the study carried out, after a full year of fild self care management and education support, an analysis of the median scores that showed significant perceptual support from families and friends (p <0.001), a significant increase in the correct answers from the knowledge tests ( p <0.001), the ability to perceive sugar control (p = 0.036), the ability to perceive diet control and exercise (p = 0.022), and the ability to perceive fear of the disease (p <0.001) (ku & kegels, 2014). discussion type 2 diabetes mellitus is a type of diabetes that is characterized by an increase in blood sugar due to the decrease of insulin secretions by the pancreatic beta cells and / or impaired insulin function (insulin resistance)(chai et al., 2018). type 2 diabetes mellitus requires high-quality clinical care and the effective involvement of patients by improving their self-management skills. this is because diabetics experience problems related to the biological, psychological and social aspects of their life. poorly controlled blood glucose leads to serious complications which will impose a large economic burden on the individual and on the healthcare system. jurnal ners http://e-journal.unair.ac.id/jners | 61 the caring of patients with diabetes is of growing importance to the public health sector. for the proper control of diabetes mellitus, it is essential for the patients to actively participate in their own management such as having an appropriate diet, level of physical activity, blood glucose monitoring and adherence to medication. professional health workers are responsible for providing clinical care for patients with type 2 diabetes mellitus. some selfmanagement programs and support for diabetics are given to improve the patient's skills in managing their diabetes symptoms and / or risk factors. diabetes self-management (dsm) refers to the concept that each person systematically has to be involved in the management of their medical and non medical conditions (abdulah et al., 2018). the assessment process is collaboratively conducted by a health care professional with the participant to identify their needs and potential self-management support strategies. the health care professional uses the information gleaned from the assessment to determine the appropriate educational and behavioral interventions, including enhancing the participant’s problem-solving skills (beck et al., 2018) (chrvala et al., 2016). many leaders have participated in several programs such as dsme as they are professional nurses(abdulah et al., 2018; adam et al., 2018; cai & hu, 2016; chai et al., 2018; garcía et al., 2014; habibzadeh et al., 2017; kargar jahromi et al., 2014; ku & kegels, 2014). the nurses collaborated with other health professionals, including endocrinologists, nutritionists, pharmacists, registered dietitians, community health workers (azami et al., 2018; kim et al., 2015), peer educators and one of them collaborated with community health workers (chws) (paz-pacheco et al., 2017; spencer et al., 2018), a certificated nutritionist and a registered dietitian nutrition. there were also (rdn) (yuan et al., 2014), physicians collaborated with (albikawi et al., 2016) and one study was conducted by a multidisciplinary team from medicine, psychology and public health (rusdiana, m., & r., 2018). the usual self-management education activities aim to provide information about the disease process, its pathophysiology and instructions about selfmanagement behavior which can include diet, physical activity, monitoring, medication, risk reduction, problem solving and coping. several published individual articles and a meta-analysis of the tests evaluating the effectiveness of dsme have demonstrated the efficacy of dsme for diabetics in terms of improving glycemic control, knowledge, selfmanagement behavior, the psychological aspects and self-management behavior. the arrangements, techniques and types of interventions used in the dsme program vary and involve a combination of a number of providers including at least three of the following: medical specialists, dieticians, psychologists, managers and pharmacists apart from primary care doctors, nurses and community-based health workers. several different types of diabetes self-care education management programs have their own innovations. a problem based learning (pbl) program is a program based on specific problem learning in patients with type 2 diabetes mellitus. this program can reduce anxiety and depression, decrease the fasting blood glucose levels and hba1c, and improve the diabetes self-management and health of patients with type 2 diabetes mellitus (chai et al., 2018). nurse-led dsme interventions are an educational program led by nurses as educators. this is done by educating the patients related to the selfmanagement and self-care of type 2 diabetes mellitus patients (azami et al., 2018). the self-help intervention program was designed for diabetes management. this intervention is designed to help type 2 diabetes mellitus patients in carrying out self care independently. the aim of this program is to help the patients to achieve better glycemic control and to bring back their confidence in the management of diabetes mellitus (kim et al., 2015).the diabetes self efficacy intervention package is a package of selfefficacy interventions designed for patients with type 2 diabetes mellitus that emphasizes on increasing self-efficacy to change the person's behavior (albikawi et al., 2016). traditional education (te) canadian conversation maps (cms) are a form of traditional education from canada specifically designed for patients with type 2 diabetes mellitus that can improve the patient’s clinical and psychosocial status (adam et al., 2018). the dsme study was carried out for more than 6 months and up to 1 year in order to have a positive impact on type 2 diabetes mellitus. generally, the results of the dsme/s program showed positive results. there were no research reports that stated the patient's condition was getting worse after participating in the dsme/s program. twelve studies reported that the dsme/s program had a positive impact on the biological aspects, namely a statistically significant decrease in the hba1c levels. two studies reported a decrease in the glucose levels of patients with type 2 diabetes. other studies showed an improvement in the clinical outcomes related to total cholesterol, ldl, severe body, blood pressure, bmi (body mass index) and waist circumference. the basic targets in the treatment of t2dm are the normalization of blood glucose, blood pressure control and lipid management. studies have shown that good glycemic control is associated with a significant reduction in the risk of many complications (chai et al., 2018). the control of diabetes is affected by both lifestyle factors and pharmacological treatments. the management of diabetes is largely the responsibility of those affected. the role of education is to improve the patients’ understanding of diabetes mellitus and to enhance their self-management practices. meanwhile, active collaboration with the caregivers can improve their clinical outcomes and quality of life. the administration of dsme/s resulted in a simple but significant weight loss, which in turn led to a n. fajriyah, et al. 62 | pissn: 1858-3598  eissn: 2502-5791 significant reduction in hba1c and blood pressure (azami et al., 2018). there are numerous factors that can lead to changes in these variables, but lifestyle modifications are the key factor in the management of diabetes. changes in lifestyle and dietary habits may have led to a weight reduction over time. similarly, the mental health of patients with diabetes cannot be ignored. patients with type 2 diabetes mellitus are closely related to psychological problems, which has an impact on their health status and quality of life. some studies have shown that both depressive disorders and anxiety disorders have a close relationship with type 2 diabetes (busch et al., 2015). the reality is that diabetes affects the lives of patients. the mere presence of diabetes worsens a person's quality of life (qol). when diabetes coexists with other chronic diseases, the effect is even worse (trikkalinou, ak, & a, 2017). studies have reported that patients who went on the dsme/s program after a minimum of two months had a positive impact on improving the patients' quality of life (azami et al., 2018; chai et al., 2018; garcía et al., 2014; kargar jahromi et al., 2014; kim et al., 2015). besides, distress in the patients also decreased significantly (albikawi et al., 2016; spencer et al., 2018). this is supported by the existence of support systems, family and social support that can increase motivation, empowerment, knowledge and self-efficacy. this is so then the patients with type 2 diabetes are able to implement diabetes care management independently. for example, the patient adheres to the treatment and control of glycemia and their routine exercise activities. these results demonstrated that the psychosocial intervention was very effective in relation to the treatment of t2dm patients with depression and anxiety. in addition, the improvement of anxiety and depression can also indirectly affect blood glucose. the improvement of depression and anxiety plays an active role in the control of blood glucose. as it is known, there are many factors influencing the level of blood glucose. there is no denying that the improvement of blood glucose has been impacted by professional education. through the systematic learning of diet, physical activity, diabetic medications and complications, the patients have gained a better understanding from their previous state. they have become capable of tackling diabetes and they are also confident when it comes to the proper self-management of diabetes. pathophysiologically, there is a relationship between depression and blood glucose level. chronic stress activates the hypothalamus – pituitary – adrenal axis (hpa-axis) and the sympathetic nervous system (sns), increasing the production of cortisol in the adrenal cortex and the production of adrenalin and noradrenalin in the adrenal medulla (kyrou & tsigos, 2009). chronic hypercortisolemia and prolonged sns activation promotes insulin resistance and visceral obesity, and it leads to metabolic syndrome and dm2 (chrousos, 2009). excess cortisol disturbs the neurogenesis in the hippocampus, which is a region involved in depression as well as in dm2 (moulton, costafreda, horton, ismail, & fu, 2015). seeing the negative effects caused by psychological problems that can worsen the condition of patients with type 2 diabetes mellitus, self-efficacy (expectations of success and expected results) and social support from other people is needed, such as support from one’s spouse, family, community and health workers. this shows that the dsme/s program was intensively very significant for the psychological and social aspects of type 2 diabetes mellitus patients. quality diabetes care must include the involvement of dsme/s because it is beneficial to the biological, psychological, and social aspects of the patient. an effective dsme must integrate practical and feasible educational interventions that can be implemented in a variety of settings. our results show that dsme has the potential to achieve a clinically significant a1c reduction, reduce psychological stress and increase social support by reducing the risk of complications produced. health workers must refer their patients to diabetes self-management education using a diabetes education algorithm to improve the patient's health status. conclusion the findings of our review showed that dsme had a positive impact on the biological, psychological and social aspects of type 2 diabetes mellitus. for the biological aspects, it can decrease hba1c, blood glucose, ldl, cholesterol, blood pressure, weight and waist circumference. for the psychological aspects, it can reduce distress, anxiety and increase self-efficacy, and self-empowerment. the social aspects of the dsme/s program can increase the social and family support so then there is an improvement in the motivation, knowledge and self-management behavior of diabetes mellitus. there are some limitations regarding this systematic review. there is no unique protocol for evaluating the journals homogeneously, but we observed the differences in the sample dimensions, in the procedures for recruiting / selecting the journals and in the inclusion and exclusion criteria for the patients. the journal literature that we have included in this systematic review are not directed at the holistic aspects of how the researchers sorted through the sub-categories of biological, psychological and social aspects so then the readers can deeply understand the benefits of the dsme program in all three aspects. references abdulah, d. m., hassan, a. b., saadi, f. s., & mohammed, a. h. (2018). impacts of selfmanagement education on glycaemic control in patients with type 2 diabetes mellitus. diabetes and metabolic syndrome: clinical research and reviews, 12(6), 969–975. https://doi.org/10.1016/j.dsx.2018.06.007 jurnal ners http://e-journal.unair.ac.id/jners | 63 adam, l., o’connor, c., & garcia, a. c. (2018). evaluating the impact of diabetes selfmanagement education methods on knowledge, attitudes and behaviours of adult patients with type 2 diabetes mellitus. canadian journal of diabetes, 1–8. https://doi.org/10.1016/j.jcjd.2017.11.003 albikawi, z. f., petro-nustas, w., & abuadas, m. (2016). self-care management intervention to improve psychological wellbeing for jordanian patients with type two diabetes mellitus. issues in mental health nursing, 37(3), 190–201. https://doi.org/10.3109/01612840.2015.11221 18 azami, g., soh, k. l., sazlina, s. g., salmiah, m. s., aazami, s., mozafari, m., & taghinejad, h. (2018). effect of a nurse-led diabetes self-management education program on glycosylated hemoglobin among adults with type 2 diabetes. journal of diabetes research, 2018, 1–12. beck, j., greenwood, d. a., blanton, l., bollinger, s. t., butcher, m. k., condon, j. e., … wang, j. (2018). 2017 national standards for diabetes selfmanagement education and support. diabetes educator, 44(1), 35–50. https://doi.org/10.1177/0145721718754797 busch, m., kahl, k. g., schweiger, u., correll, c., conrad, m., bauer, m., & schwarz, p. (2015). depression , anxiety disorders , and metabolic syndrome in a population at risk for type 2 diabetes mellitus, 1, 1–7. https://doi.org/10.1002/brb3.306 cai, c., & hu, j. (2016). effectiveness of a family-based diabetes self-management educational intervention for chinese adults with type 2 diabetes in wuhan, china. diabetes educator, 42(6), 697–711. https://doi.org/10.1177/0145721716674325 chai, s., yao, b., xu, l., wang, d., sun, j., yuan, n., … ji, l. (2018). the effect of diabetes self-management education on psychological status and blood glucose in newly diagnosed patients with diabetes type 2. patient education and counseling, 101(8), 1427–1432. https://doi.org/10.1016/j.pec.2018.03.020 chrousos, g. p. (2009). reviews stress and disorders of the stress system. nature publishing group, 5(7), 374–381. https://doi.org/10.1038/nrendo.2009.106 chrvala, c. a., sherr, d., & lipman, r. d. (2016). patient education and counseling diabetes selfmanagement education for adults with type 2 diabetes mellitus : a systematic review of the effect on glycemic control. patient education and counseling, 99(6), 926–943. https://doi.org/10.1016/j.pec.2015.11.003 costa, d. s. et al. (2016). prevalence of subclinical hypercortisolism in type 2 diabetic patients from the rio de janeiro type 2 diabetes cohort study. of diabetes and its complications, 30(6), 1032– 1038. farhangi, m. a. et al. (2017). a randomized controlled trial on the efficacy of resistant dextrin, as functional food, in women with type 2 diabetes: targeting the hypothalamic–pituitary–adrenal axis and immune system. clinical nutrition, 37(4), 1216–1223. garcía, a. a., brown, s. a., horner, s. d., zuñiga, j., & arheart, k. l. (2014). home-based diabetes symptom self-management education for mexican americans with type 2 diabetes. health education research, 30(3), 484–496. https://doi.org/10.1093/her/cyv018 habibzadeh, h., sofiani, a., alilu, l., & gillespie, m. (2017). the effect of group discussion-based education on self-management of adults with type 2 diabetes mellitus compared with usual care: a randomized control trial. oman medical journal, 32(6), 499–506. https://doi.org/10.5001/omj.2017.95 kargar jahromi, m., ramezanli, s., & taheri, l. (2014). effectiveness of diabetes self-management education on quality of life in diabetic elderly females. global journal of health science, 7(1), 10– 15. https://doi.org/10.5539/gjhs.v7n1p10 kementrian kesehatan ri. (2018). hasil utama riset kesehatan dasar jawa timur 2018. jakarta: badan penelitian dan pengembangan kesehatan, kementrian kesehatan republik indonesia, 1–82. kim, m. t., kim, k. b., huh, b., nguyen, t., han, h. r., bone, l. r., & levine, d. (2015). the effect of a community-based self-help intervention: korean americans with type 2 diabetes. american journal of preventive medicine, 49(5), 726–737. https://doi.org/10.1016/j.amepre.2015.04.033 ku, g. m. v., & kegels, g. (2014). effects of the first line diabetes care (fildcare) self-management education and support project on knowledge, attitudes, perceptions, self-management practices and glycaemic control: a quasi-experimental study conducted in the northern philippines. bmj open, 4(8). https://doi.org/10.1136/bmjopen2014-005317 kumah, e., sciolli, g., toraldo, m. l., & murante, a. m. (2018). the diabetes self-management educational programs and their integration in the usual care : a systematic literature review. health policy, 122(8), 866–877. https://doi.org/10.1016/j.healthpol.2018.06.003 kumar s, nayak rr, d. s. (2015). effectiveness jacobson’s progressive muscle relaxation technique (pmrt) to relieve anxiety among alcoholic patients mhi, scb, cuttack, odisha. j nurs health sci, 4, 1–6. kyrou, i., & tsigos, c. (2009). stress hormones : physiological stress and regulation of metabolism, 787–793. https://doi.org/10.1016/j.coph.2009.08.007 moulton, c. d., costafreda, s. g., horton, p., ismail, k., & fu, c. h. y. (2015). meta-analyses of structural regional cerebral effects in type 1 and type 2 diabetes. https://doi.org/10.1007/s11682-0149348-2 nguyen, t., levine, d., kim, k. b., huh, b., bone, l. r., kim, m. t., & han, h.-r. (2015). the effect of a n. fajriyah, et al. 64 | pissn: 1858-3598  eissn: 2502-5791 community-based self-help intervention. american journal of preventive medicine, 49(5), 726–737. https://doi.org/10.1016/j.amepre.2015.04.033 paz-pacheco, e., sandoval, m. a., ardena, g. j. r., paterno, e., juban, n., lantion-ang, f. l., … bongon, j. (2017). effectiveness of a community-based diabetes self-management education (dsme) program in a rural agricultural setting. primary health care research and development, 18(1), 35– 49. https://doi.org/10.1017/s1463423616000335 rusdiana, m., s., & r., a. (2018). the effect of diabetes self-management education on hba1c level and fasting blood sugar in type 2 diabetes mellitus patients in primary health care in binjai city of north sumatera, indonesia. open access macedonian journal of medical sciences, 6(4), 715– 718. https://doi.org/10.3889/oamjms.2018.169 spencer, m. s., kieffer, e. c., sinco, b., piatt, g., palmisano, g., hawkins, j., … funnell, m. (2018). outcomes at 18 months from a community health worker and peer leader diabetes selfmanagement program for latino adults, 1–9. trikkalinou, a., ak, p., & a, m. (2017). type 2 diabetes and quality of life. world journal of diabetes, 8(4), 120–129. yuan, c., lai, c. w., chan, l. w., chow, m., law, h. k., & ying, m. (2014). the effect of diabetes selfmanagement education on body weight, glycemic control, and other metabolic markers in patients with type 2 diabetes mellitus. j diabetes res, 2014, 789761. https://doi.org/10.1155/2014/789761 http://e-journal.unair.ac.id/jners | 117 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17036 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effects of handgrip relaxation on decreasing blood pressure in patients with hypertension moomina siauta1, selpina embuai1 and hani tuasikal2 1 universitas kristen indonesia maluku, indonesia 2 akper rumkit tk iii dr. j. a. latumeten ambon, indonesia abstract introduction: hypertension is a leading cause of death if it is not properly treated. handgrip relaxation is an intervention that can be used to reduce the blood pressure in patients with hypertension. the purpose of this study was to determine the effects of handgrip relaxation on decreasing blood pressure in patients with hypertension. methods: this study used a pre-test-post-test design with a control group and it was conducted at rsud dr. m. haulussy, ambon. the sample consisted of 14 patients aged 18 to 75 who suffered from hypertension type 1 and 2. the sampling method was consecutive sampling and the patients were divided into the intervention (n=7) and control group (n=7). handgrip relaxation was administered to the patients in the intervention group. the data was analyzed using a one-way anova test. results: the results showed a decrease in the systolic and diastolic blood pressures on the 3rd day with the highest mean value found in the intervention group and the control group had a significance value of 0.003 (p<0.05) and 0.014 (p<0.05). conclusion: handgrip relaxation had an effect on the decrease of systolic and diastolic blood pressures in patients with hypertension. handgrip relaxation that was given for fifteen minutes over three days can be recommended as a nursing intervention to decrease the blood pressure of hypertensive patients. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords handgrip; relaxation; blood pressure; hypertension contact moomina siauta  moominasiauta@gmail.com  universitas kristen indonesia maluku, indonesia cite this as: siauta, m., embuai, s., & tuasikal, h. (2019). effects of handgrip relaxation on decreasing blood pressure in patients with hypertension.jurnal ners, 14(3si), 117-120. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17036 introduction hypertension or high blood pressure is a common condition which occurs in almost one-third of the population in the world. hypertension has been one of the leading causes of mortality (klabunde, 2015). the world health organization (who) in 2012 reported that the number of hypertension cases worldwide reached 839 million. it is estimated that the number will increase to approximately 1.15 billion in 2025 or 29% of the total world population. the cases of hypertension are mostly found in women by as much as 30% and in men by as much as 29%. this number will especially increase by 80% in developing countries (triyanto, 2015; triyanto, iskandar, & saryono, 2012). the prevalence of hypertension in people aged 18 years old and over in indonesia in 2013 is 9.4% and 25.8% based on the diagnosis of health workers and blood pressure measurement respectively. the highest prevalence of hypertension based on the diagnosis of health personnel was found in bangka belitung by as much as 30.9%. the lowest was found in papua province by as much as 16.8%. furthermore, sulawesi and kalimantan are reported to have a sufficient prevalence of hypertension. hypertension is a risk factor for cardiovascular disease and it is the third most common cause of death after stroke and tuberculosis. the number reached 6.8% out of the death causes for all ages in indonesia (kementerian kesehatan republik indonesia, 2014). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:moominasiauta@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). m. siauta, et al. 118 | pissn: 1858-3598  eissn: 2502-5791 the prevalence of hypertension in rsud dr. m. haulussy ambon is quite high. there were 635 cases of hypertension reported in the last three years. in 2013, the prevalence was 30.86%. there was an increase in the percentage of hypertensive patients by 36.86% in 2014 and a decrease with a percentage of 32.27% in 2015 (rekamedik rsud dr. m. haulussy ambon, 2016). interviews with the nurses in both the male and female patient medical wards, and on the male and female patients’ surgical wards revealed that deep breathing relaxation was an independent nursing intervention given to patients in the early stages of treatment. however, this intervention is not routinely carried out as it is only taught at the beginning of the therapy administration. next, pharmacological therapy is then used to reduce the blood pressure and headaches that the patients have. increased blood pressure in the arteries can occur in multiple stages. at first, the heart will contract more strongly so then there will be more blood flow every second. as a result, large arteries will lose their flexibility and become stiff so then they cannot expand in the process of blood pumping through the arteries. the blood will be forced to pass through narrow vessels and this causes increased pressure. such a condition happens to some elderly people, in which the artery walls are stiff due to arteriosclerosis. increasing the circulatory fluid can cause increased blood pressure. this happens if there are abnormalities in kidney function, as the kidneys are unable to remove a certain amount of blood and water from the body. the volume of blood in the body increases and so does the blood pressure. in contrast, if the heart relaxes then the arteries will experience widening, causing lots of fluid to get out of circulation. thus, the blood pressure will decrease. in this context, the kidneys and the autonomic nervous system (a part of the nervous system that regulates various bodily functions automatically) are responsible for adapting to these factors (mortimer & mckune, 2011). an appropriate management method for hypertension is needed to reduce the impact of pharmacological therapy and non-pharmacological therapy. one of the alternatives of nonpharmacological treatments which can be implemented is the relaxation technique. relaxation is one of the self-management techniques based on the working of the sympathetic and parasympathetic nervous system (kaplan, 2002) (ferguson, 1982). this study aimed to investigate the effects of handgrip relaxation on reducing blood pressure in patients with hypertension in dr. rsud. m. haulussy ambon. materials and methods this study employed a pre-post-test quasiexperimental research design. the sample consisted of 50 patients with hypertension in the medical polyclinic of rsud dr. m. haulussy ambon who were assigned to the intervention group (n=25) and the control group (n=25). consecutive sampling was used to recruit the samples. the intervention of handgrip relaxation was given to the patients in the intervention group. the data was collected through blood pressure measurements before and after the intervention. handgrip relaxation is an easy way to manage feelings and emotions and to develop emotional intelligence. along the fingers, there are energy channels or meridians that are connected to various organs and emotions. reflection points on the hands provide spontaneous stimulation (reflex) when an individual grasps his fingers (liana, 2008). at first, the patients were tested for their initial blood pressure and then they were given time to rest for 5 10 minutes. after that, the patients in the intervention group were given handgrip relaxation for 15 minutes. a short break was also given before the final blood pressure measurement was conducted. an observation sheet for the blood pressure measurement was used in this study. the collected data was then analyzed using a one-way anova test (nursalam, 2016). results table 1 shows the highest decrease in systolic blood pressure and diastolic blood pressure on the third day in the intervention group with a significance value of 0.003 (<0.05) and 0.014 (<0.05) respectively. the result of the anova test showed that handgrip relaxation was considered to be the most effective intervention at reducing blood pressure on the third day. the mean difference test showed a significant decrease in diastolic pressure between the pre and post-tests, indicating that the intervention could effectively decrease blood pressure. discussion the respondents in this study were patients with hypertension who visited the medical polyclinic at table 1. data analysis using one-way anova variable control group intervention group chi square significance mean sd mean sd systolic pressure day 1 day 2 day 3 0.000 0.000 0.000 0.000 0.000 0.000 1.429 5.714 5.000 3.631 5.136 5.189 4.231 20.091 13.657 0.238 0.000 0.003 diastolic pressure day 1 day 2 day 3 1.429 0.000 -3.571 5.714 0.000 11.507 5.345 8.571 7.143 6.462 6.630 6.113 7.009 24.805 10.560 0.072 0.000 0.014 jurnal ners http://e-journal.unair.ac.id/jners | 119 rsud dr. m. haulussy ambon. the patients were aged from 41 to 70 years, indicating that they were middle adults. most of the respondents (28.6%) were in the age range of 41 50. this study is in line with the theory that blood pressure in adults increases with age. in the elderly, systolic blood pressure increases along with decrease in blood vessel elasticity (carlson et al., 2016). in this study, 53.6% of the respondents were women. this is different from a theory which states that the incidence of hypertension is higher in men than in women up to the age of 55 years. the risk of hypertension is almost the same between the age of 55 – 74. women are at a higher risk after the age of 74. kaplan (2002) stated that women have a better tolerance than men to hypertension (muhadi, 2016). clinically, there is no significant difference in blood pressure between men and women. after puberty, men tend to have higher blood pressure and women after menopause tend to have a higher blood pressure than men at the same age (kozier, b., erb, g., 1997). the majority of respondents (75%) had a family history of hypertension. hypertension is caused by polygenics and many other factors in which some genes may interact with the environment, causing blood pressure to increase in the future (pinandita, purwanti, & utoyo, 2012). genetic predisposition in families is more acceptable in hypertension. this may be related to increased intracellular sodium and a decreased ratio of potassium and sodium that often occurs in black people. in this study, 53.6% of respondents had a history of smoking. in smokers, co and nicotine in cigarettes can damage the endothelial cells and cause the blood vessels and their branches to become stiff. such substances also increase norepinephrine, catecholamine, fibrinogen, platelet aggregation and the number of lipids that cause the blood pressure to rise. this study revealed that handgrip relaxation produced an impulse sent through the nonnociceptive afferent nerve fibers. these nonnociceptor nerve fibers will close the gate in the thalamus so then the stimulus to the cerebral cortex is blocked. as a result, the intensity of the pain can be reduced. the result of the anova test in this study showed that handgrip relaxation is effective at reducing blood pressure. handgrip relaxation was most effective at reducing blood pressure on day 3. the mean difference test between the preand posttests indicated that there was a significant decrease in diastolic blood pressure. thus, it can be concluded that the intervention of handgrip relaxation caused a decrease in blood pressure. it has been stated that relaxation techniques effectively reduce heart rate, blood pressure and muscle tension, improve well-being and reduce symptom pressure in individuals who experience various situations (triyanto & iskandar, 2012). according to the theory, handgrip relaxation is able to free the locked energies called safety energy so then the energy can flow smoothly (hill, 2011). handgrip relaxation is an easy way to manage emotions and develop emotional intelligence. this technique helps the body, mind and soul to achieve a relaxed state. this relaxation technique is also an action to free the mind and body from tension and stress to increase tolerance to pain. various relaxation methods are used to reduce anxiety and muscle tension, which results in a decreased heart rate, decreased blood pressure, decreased respiration and decreased muscle tension. this relaxation can be learned easily by any individual to help them achieve regular and relaxed breathing and to release endorphins in the body under normal circumstances. based on the results in this study, it could be concluded that handgrip relaxation is able to reduce high blood pressure and headaches in people with hypertension. the results also showed a difference in the decrease in blood pressure and headaches in the intervention group on days 4 and 3 when the intervention was administered. conclusion handgrip relaxation had an effect on the decrease of systolic and diastolic blood pressure in patients with hypertension. handgrip relaxation that was given for fifteen minutes over three days can be recommended as a nursing intervention to decrease the blood pressure in hypertensive patients. references carlson, d. j., inder, j., palanisamy, s. k. a., mcfarlane, j. r., dieberg, g., & smart, n. a. (2016). the efficacy of isometric resistance training utilizing handgrip exercise for blood pressure management: a randomized trial. medicine (united states), 95(52). https://doi.org/10.1097/md.000000000000579 1 ferguson, c. l. (1982). effects of education and relaxation training with essential hypertension patients. hill, r. y. (2011). nursing from the inside-out: living and nursing from the highest point of your consciousness. london: jones and barlett publishers. kaplan, n. m. (2002). kaplan’s clinical hypertension (8th ed.). philadelphia: lippincott williams & wilkins. kementerian kesehatan republik indonesia. (2014). situasi kesehatan jantung. klabunde. (2015). konsep fisiologi kardivaskular. jakarta: egc. kozier, b., erb, g., b. (1997). profesional nursing practice : concept and perspective. california: addison wesley longman, inc. liana, e. (2008). teknik relaksasi : genggam jari untuk keseimbangan emosi. mortimer, j., & mckune, a. j. (2011). effect of shortterm isometric handgrip training on blood pressure in middle-aged females. cardiovascular journal of africa, 22(5), 257–260. https://doi.org/10.5830/cvja-2010-090 m. siauta, et al. 120 | pissn: 1858-3598  eissn: 2502-5791 muhadi. (2016). jnc 8 : evidence-based guideline penanganan pasien hipertensi dewasa. cermin dunia kedokteran, 43(1), 54–59. nursalam. (2016). metodologi penelitian ilmu keperawatan (4th ed.). jakarta: salemba medika. pinandita, i., purwanti, e., & utoyo, b. (2012). pengaruh teknik relaksasi genggam jari terhadap penurunan intensitas nyeri pada pasien post operasi laparatomi. jurnal ilmiah kesehatan keperawatan, volume 8, no. 1, februari 2012 perk, 8(1), 44–56. rekamedik rsud dr. m. haulussy ambon. (2016). jumlah penderita hipertensi di rsud dr. m. haulussy ambon. triyanto, e. (2015). penderita hipertensi secara terpadu. yogyakarta: graha ilmu. triyanto, e., & iskandar, a. (2012). pengaruh aplikasi health promotion model terhadap peningkatan kualitas kelompok peduli hipertensi. soedirman journal of nursing, 7(2), 109–115. triyanto, e., iskandar, a., & saryono. (2012). pengaruh aplikasi health promotion model terhadap peningkatan kualitas kelompok peduli hipertensi. jurnal keperawatan soedirman, 7(2), 109–115. https://doi.org/10.20884/1.jks.2012.7.2.3634 http://e-journal.unair.ac.id/jners | 231 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17108 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the role of the nurse unit manager function on nursing work performance: a systematic review fitriyanti patarru', basilius yosepfus weu, febrina secsaria handini and heryyanoor heryyanoor faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: the role of nurse unit manager is to improve the nurses’ performance in the context of their professional services. this role consists of planning, organizing, actuating and controlling. the aim of this systematic review was to determine the influence of the nurse unit manager’s management functions related to the nurses’ performance. methods: the literature search was conducted in the pubmed, scopus, proquest, science direct and sage databases with the keywords ‘head nurses’, ‘management function’ and ‘nurse performance’. the articles were reviewed using the inclusion criteria, which was that the title and abstract was in accordance with the desired topic, that the article aimed to analyze the influence of the nurse unit manager’s management functions related to the nurses’ performance and that it was explained in english. the exclusion criteria were that the title, abstract and purpose of the article was not in accordance with the topic of focus. the search identified 15 relevant journals from the 276.303 articles published between 2014 and 2019. results: the results indicate a significant relationship exists between the role of the nurse unit manager and nursing work performance. conclusion: to improve the management function of the nurse unit manager, it is necessary to conduct training for the nurse unit manager to allow them to better understand the functions and role of the nurse unit manager. article history received: december 26, 2019 accepted: december 31, 2019 keywords nurse unit manager; nursing work performance; role contact fitriyanti patarru'  fitriyanti.patarru2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: patarru', f patarru', f., weu, b. y., handini, f.s. & heryyanoor, h. (2019). the role of the nurse unit manager function on nursing work performance: a systematic review. jurnal ners, 14(3si), 231-235. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17108 introduction the evaluation of the nurses’ activity when providing nursing care for the patients is the most important factor when taking care of the patients and their satisfaction regarding the care is an important indicators (fateme & enayatollah, 2016). nursing, as a service field, is highly labor-intensive. this makes nursing management particularly challenging because of the wide variety of experience and educational backgrounds of the employees in the health care setting. the type of work, as well as the workers themselves, challenge the nurse manager to create the kind of environment that facilitates quality nursing practices. the nurse unit manager has specific responsibilities to the organization and to the staff. the staff, in turn, have responsibilities to the organization and to their manager. the beginning nurse will contribute to the success of the unit’s efficiency by being aware of the manager’s role (rashed, al torky, & morsey, 2015). the phenomenon that occurs in several hospitals is that there are still many nurse unit managers who have not implemented management functions, thus affecting the performance of the team leader and having a further impact on the quality of the nursing services. the principles of management can be categorized into the four major functions of planning, organizing, leading and controlling (the p-o-l-c). the four functions are highly integrated when they are carried out in the day-to-day realities of running an organization. planning is the function of management that involves setting objectives and determining a https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). f. patarru', et al. 232 | pissn: 1858-3598  eissn: 2502-5791 course of action for achieving those objectives. it is required that the managers are aware of the environmental conditions faced by their organization and that they are able to forecast future conditions. organizing is the function of management that involves developing an organizational structure and allocating human resources to ensure the accomplishment of the objectives. leading involves the social and informal sources of influence used to inspire the actions taken by others. if the managers are effective leaders, then they will inspire their subordinates to enthusiastically exert their efforts to achieve the common organizational objectives. controlling involves ensuring that performance does not deviate from the standards set (miri, mansor, alkali, & chikaji, 2014). all managers, irrespective of where or what they manage, need to develop several competencies that will enable them to effectively perform the four generic functions of planning, organizing, leading and controlling. the head nurses’ performance plays an important role in the successful operation of the hospital. the identification and prioritization of managerial competencies required for the supervisors and for the evaluation of their performance on this basis is necessary (moghaddam et al., 2019). in general, job performance relates to an organizations’ success. however, it is more than simply one person doing their job well because they want to. performance is an organizational behavior. in a work environment that is strained by financial constraints and organizational changes, nurse leaders and managers remain accountable for the success of the organization as a whole. performance evaluation analyses the managers' skills and performance by determining their strengths and weaknesses. performance evaluation also counts as a tool for developing managerial skills (h. m. ousav. isfahani, aryankhesal, & haghani, 2015). the aim of this systematic review is to determine the influence of the management functions of the nurse unit manager on the performance of the nurses. materials and methods design a systematic review was prepared following a statement based on the preferred reporting items for systematic reviews and meta-analyses (prisma). this involved: 1) the identification of the literature through searching the databases using the selected keywords, 2) the screening of the literature based on both the inclusion and exclusion criteria, 3) the eligibility of the literature in full text form and 4) the final chosen articles being included in the systematic review. search strategies and inclusion criteria the literature search was carried out on several databases such as pubmed, scopus, proquest, science direct and sage with the journal search resulting in 276.303 articles. the search was done by entering the keywords ‘management function’, ‘nurse unit manager’ and ‘performance’. the year limit used was 2014 2019, with the inclusion criteria being that the title and abstract were in accordance with the desired topic. the article had to aim to determine the effect of the management function of the nurse unit manager on the performance of the nurses and the article must be original research that has been reviewed and explained in english. the search resulted in 15 articles that corresponded to the criteria. the exclusion criteria were if the results of the study did not explain the approximate relationship between the role of the management functions of the nurse unit manager and the nurse's performance, if the title and abstract did not match the desired topic and if the article was not explained in english. results this systematic review used 15 articles published with 3,059 respondents in total. the independent variable was the nurse unit manager’s management function. the dependent variable was the nurses’ performance. several studies have been previously conducted that support the role of the nurse unit manager. there were several variables found in the discussion about the management function of nurse unit managers and in relation to the performance of the nurses. the results showed that the nurse unit manager’s management function was evaluated using three different instruments. three management function questionnaires were used to measure the management functions of the head nurse managers. the three categories included 34 responsibilities: 1) clinical practice with 11 items, 2) managerial with 17 items and 3) educational with 6 items. nursing activity analysis was the observation of the nurses done by monitoring the actual time of patient care every 15 minutes for 6 days during the period of the data collection. this was used to calculate the productivity of the staff nurses (rashed et al., 2015). the questionnaires that were distributed to the nurses also used the planning, organizing, staffing, actuating and controlling (posac) approach (rina figure 1. prisma flow chart jurnal ners http://e-journal.unair.ac.id/jners | 233 karmila et al., 2018). this was in the form of a qality assessment and validity tool used in correlational studies. the study was focused on the role of first line nurse managers flnms (management and clinical skills) (miri et al., 2014). the data was collected via a checklist of the nurse unit manager’s managerial skills based on the bars principles. we found there to be a significant relationship between the nurse unit manager’s management functions as the independent variable with nurse performance as the dependent variable. in this systematic review, the results of several articles were obtained. overall, 27 managerial competencies required for nurse unit manager were identified and categorized in the 4 main categories relating to management functions, namely planning, organizing, leadership and controlling (moghaddam et al., 2019). there is a correlation between the nurse unit manager’s management functions and nursing productivity in the medical unit, surgical unit, postoperative icu and casualty intensive care unit in assiut university hospital. this was found using a structured interview questionnaire about the management functions of first-line nurse managers. the results of the present study revealed that, there is a statistically significant relation between the staffing element and the quality of patient care. about two thirds of the head nurses were applying most activities on an acceptable level as the staffing and controlling process, while they were unacceptable for planning, organizing and directing generally. this was analyzed using a self-administered questionnaire for the head nurses and observation checklists for the patients (elmoghith et al., 2014). in the planning function, it was found that there was no specific policy regarding the implementation of the nursing shift handover. this was obtained based on the results of documentation studies and interviews with the head of nursing. the results of the interviews with the head nurse from 8 inpatient wards also showed there to be a lack of guidance and standard operating procedures regarding patient handover between nursing shifts. this resulted in the unstructured implementation of the nursing shift handover. this was assessed using a questionnaire distributed to the nurses using the planning, organizing, staffing, actuating, and controlling (posac) approach. the first questionnaire was about the nurses' perceptions of the ward heads associated with surrender and implementation and the second questionnaire was related to the implementation of the nursing shift by the nurses (rina karmila et al., 2018). from the 15 articles reviewed, the results show that the role of the management function of the nurse unit manager has an influence on the performance of the nurses. the management functions of the nurse unit manager include planning, organizing, staffing, actuating and controlling. to see whether there is an effect of the management function from the nurse unit manager on the nurses' performance, this was measured using a questionnaire that was distributed to the implementing nurses to assess the competence of the nurse unit manager. from this article, it was also found that not all of the nurse unit managers performed their roles and functions properly. discussion this systematic review focuses on the discussion of the role of the management functions of the nurse unit manager in influencing nurse performance. from the 15 articles found, not all of the nurse unit managers performed their functions properly. there were still those who have not implemented their functions fully which can have a negative impact on the performance of the nurses in the hospitals. the head nurses' roles is that of the front line firefighting service of nursing care. it is the most challenging nursing role that involves a detailed description of the tasks involved. the head nurse has three main areas that constitute their role. these are patient care management to ensure that the patient’s total needs are met, staff management to utilize, guide, evaluate and correct the staff nurses in their nursing practice and unit management to ensure its smooth running to fulfill the hospital goals (rashed et al., 2015). managerial competencies can be categorized in four main functions (including planning, organizing, leadership and control) as previously identified (moghaddam et al., 2019). planning practices include drawing up plans. this is the first and perhaps most important step in the management process and the findings showed that the practice was almost universal (95 percent). only three (5 percent) participants did not use the approach in their wards. in one study, the managerial level of the managers was low. these results follow the same conclusion. this indicates that the managerial skills of the managers are an important factor for improving the work proficiency. a lack of these skills causes disorder in the organization. this study also emphasizes the importance of developing managerial skills by the nursing managers (h. m. ousav. isfahani et al., 2015). supervision or direction is important to improve the staff motivation when implementing an activity so then their performance becomes better. supervision activities can increase the employee’s motivation, enthusiasm and confidence, causing the employees to be more driven and to improve their performance. supervision is important to improve motivation, spirit and the performance of nurses in terms of performing activities including handover (rina karmila et al., 2018). in general, these findings suggest that there is an important relationship between nursing leadership and nurse performance. nurse leaders play a key role in fostering autonomy, building relationships and managing resources, which are the very factors that nurses state they require to effectively perform. based on carpenter’s management principles, the roles involve duties and skills. these can be clustered into three categories planning, organizing and leadership (miri et al., 2014). the nurse leaders both indirectly and directly f. patarru', et al. 234 | pissn: 1858-3598  eissn: 2502-5791 influence their subordinates’ performance and thereby the goals of the healthcare organization that they represent. the limitation in this systematic review was the number of articles that are still lacking according to the topic, as well as due to variations in the instruments and measurements. conclusion the findings from the 15 articles show that there is an influence from the role of the management function of the head of the room on the performance of the implementing nurses. management functions can be categorized into four main functions: planning, organizing, leading/actuating and controlling (p-o-lc/p-o-a-c). nursing management plays a key role in today’s healthcare organizations, thus there is a need for a further discussion of the nurse managers’ leadership and management competencies. in fact, head nurses in hospitals not only need to accomplish their clinical practices but they are also required to carry out the administrative tasks that are entrusted to them as part of their management responsibilities. in order to carry out the task effectively, the nurse unit manager must have competence that can guide well so as to improve the nurse’s performance. the responsibility of the nurse unit manager in improving nurse performance is by carrying out the management function of the nurse unit manager with full responsibility in term of leading and guiding the nurses. this can improve the performance of the nurses by having a positive impact on their satisfaction with the hospital services. they should also conduct training for the nurse unit manager to allow them to better understand the competencies. references barkhordari-sharifabad, m., ashktorab, t., & atashzadeh-shoorideh, f. (2018). ethical competency of nurse leaders: a qualitative study. nursing ethics. https://doi.org/10.1177/0969733016652125 denker, a. l., sherman, r. o., hutton-woodland, m., brunell, m. lou, & medina, p. (2015). florida nurse leader survey findings: key leadership competencies, barriers to leadership, and succession planning needs. journal of nursing administration. https://doi.org/10.1097/nna.00000000000002 22 divshali, m. &firouuzkouhi. (2015). evaluation of scales and barriers of managerial performance of head nurses based on bars performance evaluation model in rasht , 2011. (january). elmoghith, n. g. a. b. d., sc, m., hamouda, s. i., sc, d. n., ibrahim, s. a., & sc, d. n. (2014). the effect of nursing management process applied by head nurses on quality of patient care in the main mansoura university hospital. 82(1), 583–590. fateme, k., & enayatollah, s. (2016). the study of nurses ’ performance from the viewpoints of head nurses in the special and general wards of the instructional hospitals of zahedan in 2015. (9), 212–216. huang, c. y., weng, r. h., & chen, y. t. (2016). investigating the relationship among transformational leadership, interpersonal interaction and mentoring functions. journal of clinical nursing. https://doi.org/10.1111/jocn.13153 isfahani, h. m., aryankhesal, a., & haghani, h. (2015). the relationship between the managerial skills and results of " performance evaluation " tool among nursing managers in teaching hospitals of iran university of medical science. 7(2), 38–43. https://doi.org/10.5539/gjhs.v7n2p38 isfahani, h. m. ousav., aryankhesal, a., & haghani, h. (2015). the relationship between the managerial skills and results of "performance evaluation "tool among nursing managers in teaching hospitals of iran university of medical science. global journal of health science. https://doi.org/10.5539/gjhs.v7n2p38 kantanen, k., kaunonen, m., helminen, m., & suominen, t. (2017). leadership and management competencies of head nurses and directors of nursing in finnish social and health care. journal of research in nursing. https://doi.org/10.1177/1744987117702692 kovačič, h., & rus, a. (2015). leadership competences in slovenian health care / vodstvene kompetence v slovenskem zdravstvu. slovenian journal of public health. https://doi.org/10.1515/sjph-2015-0002 lee, m., & chung, k. (2016). a study on the classification and development of pattern designs represented in luggage. journal of the korean society of costume. https://doi.org/10.7233/jksc.2016.66.1.135 matlakala, m. c., bezuidenhout, m. c., & botha, a. d. h. (2014). challenges encountered by critical care unit managers in the large intensive care units. curationis. https://doi.org/10.4102/curationis.v37i1.1146 miri, s. a., mansor, n. n. a., alkali, a., & chikaji, a. (2014). the role of first line nurse manager. review of european studies. https://doi.org/10.5539/res.v6n4p31 moghaddam, n. m., jame, s. z. b., rafiei, s., sarem, a. a., ghamchili, a., & shafii, m. (2019). managerial competencies of head nurses: a model and assessment tool. british journal of nursing. https://doi.org/10.12968/bjon.2019.28.1.30 rashed, s. a. e., al torky, m. a. m., & morsey, s. m. (2015). performance of head nurses management functions and its effect on nurses’ productivity at assiut university hospital. iosr journal of nursing and health science (iosr-jnhs). https://doi.org/10.9790/1959-04523849 rina karmila et al., r. k. et al. . (2018). description of nursing shift handover implementation in one of provincial public hospitals in dki jakarta province. international journal of medicine and jurnal ners http://e-journal.unair.ac.id/jners | 235 pharmaceutical sciences, 8(2), 39–48. https://doi.org/10.24247/ijmpsapr20187 http://e-journal.unair.ac.id/jners | 367 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17215 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effectiveness of cognitive behavioral therapy to reduce depression, anxiety and stress among hospitalized patients with congestive heart failure in central java dian hudiyawati and ajie maulana prakoso faculty of nursing, universitas muhammadiyah surakarta, indonesia abstract introduction: psychological problems in patients with heart failure are the result of a combination of the influence of behavior and interactions with physiological responses, which if not handled properly will contribute to worsening clinical symptoms and have a higher risk of rehospitalization. the objective of the study was to evaluate the effects of cognitive behavior therapy (cbt) on psychological symptoms among chf patients. methods: this was a quasi-experimental, pretest-posttest control study that applying a cbt to overcome depression, anxiety, and stress. thirty eligible respondents were recruited and were randomly divided into a case group and waiting list group. psychological symptoms of respondents were measured using depression, anxiety and stress scale – 21 questionnaires (dass-21). chi-square was used to compare demographic data between groups and t-test analysis was used to describe changes in mean scores between and within groups. both groups had similar characteristics and psychological symptoms level at baseline. results: the mean score of depression, anxiety and stress showed a significant difference within the group after the intervention (p<0.05). conclusion: a recent study found that cbt was effective to reduce psychological symptoms among chf patients. based on the study results it can be highlighted that it is important for nurses to provide brief cbt to hospitalized patients in an effort to reduce short term psychological symptoms. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords heart failure; psychological problems; cbt; depression; anxiety; stress contact dian hudiyawati  dian.hudiyawati@ums.ac.id  faculty of nursing, universitas muhammadiyah surakarta, indonesia cite this as: hudiyawati, d& prakoso, a.j. (2019). effectiveness of cognitive behavioral therapy to reduce depression, anxiety and stress among hospitalized patients with congestive heart failure in central java. jurnal ners, 14(3si), 367-373. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17215 introduction congestive heart failure is a clinical syndrome in which the heart is inadequate in pumping blood to meet the body's needs (ponikowski et al., 2014). heart failure is a major cause of hospitalization with high mortality and rehospitalization rates, which increases the high economic burden on the nation's health system due to the high cost of care (parissis, fountoulaki, paraskevaidis, & kremastinos, 2005). in developed countries, it is estimated that one in five people will experience heart failure (lloyd-jones et al., 2002). about 26 million adults worldwide suffer from heart failure, so it should be made as a global health priority. in the us, around 5.8 million people suffered from heart failure in 2012, and it is predicted will increase to 8.5 million by 2030 (ponikowski et al., 2014). other contributing factors in increasing the prevalence of heart failure are improving the survival rates of patients with heart attacks or other cardiovascular diseases, due to improvement in diagnosis and medical management. in addition, in some countries the majority of the population are elderly people who are expected to increase the number of heart failure patients (hobbs, korewicki, cleland, eastaugh, & freemantle, 2005). in economically developing countries, such as indonesia, the number of patients with heart failure has also risen. this incidence is a result of transformation culture related to western-type lifestyles and its related diseases, for example, conditions such as diabetes increase the risk of heart failure (sato, 2015). in recent years, heart failure patients were hospitalized with complications from https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). d. hudiyawati, et al. 368 | pissn: 1858-3598  eissn: 2502-5791 other diseases, resulting in a longer length of stay in a hospital. moreover, patients will experience rehospitalization repeatedly because of their condition (sasayama, 2008). this situation represents that heart failure is a global healthcare burden in indonesia. heart failure greatly affects the physiological condition of the patient, such as anxiety and depression. the association between heart failure and depression symptoms has been revealed in several studies (sohani & samaan, 2012). based on the previous studies around 9% to 60% of heart failure patients experience depression (vaccarino, kasl, abramson, & krumholz, 2001). heart failure patients who experience psychological symptoms have a higher risk of hospitalization and death compared to those who are free from depression (jeyanantham, kotecha, thanki, dekker, & lane, 2017; parissis et al., 2005). the exact mechanism that psychological problems cause worse results in patients with heart failure is not clear but are estimated by a combination of the influence of behavior and interactions with physiological responses (o ’ connor, 2018). moreover, the influence behavior of psychological issues can reduce the possibility of treatment compliance and lifestyle behavior modification, which may subsequently contribute to poor prognosis (pihl, jacobsson, fridlund, strömberg, & mårtensson, 2005). lately, depression and anxiety in patients with chronic diseases are targeted by many psychoeducation programs. this statement is supported by research from dusseldorp et al. who conducted a meta-analysis of psychoeducation programs for coronary heart disease patients. the results of the study found a reduction in mortality and recurrence of myocardial infarction, respectively by 34% and 29%, and contributed to changes in better self-care management (dusseldorp, van elderen, maes, meulman, & kraaij, 1999). cognitive behavioral therapy (cbt) is presently suggested to overcome anxiety and depression by the national institute for health and care excellence (nice) in the united kingdom (nice, 2014). cognitive behavioral approaches are based on the concept that psychological problems such as depression, anxiety, and stress are often exacerbated by overthinking. cbt practitioners, then, will help the patients identify their mindsets and change their traits using evidence and logic. cbt seems to be effectual for rectifying psychological health. the objective of cbt training is to assist patients to identify maladaptive behavior and irrelevant pattern of thought through directed discussion and organized behavior. based on the description above, it might conclude that a cbt program could help heart failure patients in reducing depression, anxiety, and stress by teaching coping strategies that focus on problems. therefore, the objective of the present study was to investigate the short session of cognitive behavioral therapy in reducing depression, anxiety, and stress among hospitalized patients with congestive heart failure. materials and methods a quasi-experimental study using simple randomization was allocated comparing administered brief cbt interventions with the usual care for treating psychological problems. thirty (30) eligible respondents from a cardiovascular unit in moewardi hospital, central java were conducted in a recent study. the inclusion criteria included heart failure patients who admitted with aged ≥ 18 years, had an nyha classification i-iv, hemodynamically figure 1. research design as per the consort guidelines, 2010 jurnal ners http://e-journal.unair.ac.id/jners | 369 stable and concurred to follow the study procedure. exclusion criteria included patients with antidepressant medication, the experience of psychotic illness or mental disorder. the estimated sample size of 30 respondents was based on a formula of two independent mean groups and parameters used were from essa, et al (essa, ismail, & hassan, 2017). fifteen (15) respondents were conducted into the study and wait-list control groups. eligible respondents in the study groups received cognitive behavioral therapy (cbt) training from cbt practitioners who were formally trained in cbt. the respondents were given instructions on the steps of the cbt session while those in the wait-list control groups only received the intervention after completion of the study. this research design scheme is based on consort 2010 and presented in (figure 1) (schulz, altman, & moher, 2011). the cbt group was individual training consisting of five sessions of cbt, 20-30 minutes during each session over 3 days. the session commenced with exploring and discussion problems faced by patients. content included formulating problems as the focus of therapy goal (session 1), activity planning (session 2), structured problem solving (session 3), strategies to improve motivation (session 4), evaluate new strategies (session 5). finally, respondents in the intervention and control groups were re-evaluated on their depression, anxiety and stress level using the same set of a questionnaire of dass 21. cbt procedure first day. first session (8 am), asking patient problems (what, when, why and how) and exploring problems to be formulated (with patients) to be agreed upon as the focus of therapy. second session (1 pm), examine and formulate behavioral consequences or somatic reactions (perhaps the main problem of the patient) so that patients need help or treatment (c), check or explore events that might be the originator or cause of the patient's problems (a), recognizing a patient's negative cognitive status (b) in the form of an irrational belief system, reaching the belief or belief relationship with the consequences of that belief. the second day. third session (8 am), an irrational or negative examination of beliefs and prepare rational or positive beliefs. fourth session (1 pm), encourage learning to practice new beliefs.the third day. fifth session (8 am), evaluating new beliefs. the instrument for outcome measure all respondents from cbt group and usual care groups were assessed for their depression, anxiety and stress level using a set of pre-tested, selfadministered and validated questionnaires which involve depression, anxiety, stress scale 21 (dass 21) in the indonesian language as a baseline measure prior to the implementation of the intervention and post-intervention. dass-21 consists of total of 21 items comprised of 3 domains which measuring depression, anxiety, and stress. each domain has 7 items that reflect symptoms related to those 3 psychological measures. patients are asked to score each item on a scale of 0 (not valid for me at all) to 3 (applied to me very much). the total score is calculated by summing the scores on the per (sub) scale items then multiplied by 2. the sum of the total dass scale ranges from 0 120, and the scores for each subscale range from 0 42. the cut-off score 60 is used for the score total dass, while the cut-off 21 is utilized for each sub-scale items (tran, tran, & fisher, figure 2. pre-post anxiety level data histogram between the control group and intervention group 0 1 2 3 4 5 6 7 8 pre post pre post normal mild modarete severe extremely severe kelompok intervensi kelompok kontrol d. hudiyawati, et al. 370 | pissn: 1858-3598  eissn: 2502-5791 2013). the dass sub-scale severity ratings suggested for this study are shown in table 1. dass-21 has good validity and internal consistency in indonesian studies and cronbach's alpha value from dass-21 in this study is 0.914. ethics consideration the study obtained ethical approval from the hospital ethics committee and all respondents provided informed consent and signed it prior to the study. the respondents from the wait-list group were given an option to undergo the cbt training after completion of the study. the respondents were also ensured that confidentiality was maintained throughout the study period. statistical analysis the data was analyzed using a computer program. frequency, percentage, mean and standard deviation were used in the descriptive analysis. chi-square test was used to compare the demographic variables between intervention and control groups. independent t-test was used to compare the mean depression, anxiety and stress scores between groups, while paired t-test was used to evaluate the short session cbt in reducing depression, stress, and anxiety after an intervention. the significance level was set at 0.05 (p<0.05). results respondents’ demographic characteristics are presented in table 1. there were no significant differences found on any of the personal characteristic of the respondents between the short session cbt group (n = 15) or the usual care group (n = 15) (p > 0.05). a total of 30 eligible respondents were included in the recent study. the majority of the final sample was male (67%) and in the mean age 63 years (age group 52-60 years old; 33%). table 2 shows the comparison of mean scores of depression, anxiety and stress between intervention table 1. depression anxiety and stress 21 sub-scale severity ratings suggested for australian severity dass21-d dass21-a dass21-s normal 0-9 0-7 0-14 mild 10-13 8-9 15-18 moderate 14-20 10-14 19-25 severe 21-27 15-19 26-33 extremely severe 28+ 20+ 34+ table 2. baseline comparison of socio-demographic characteristics between intervention and control groups variable intervention group control group p value (n=15) % (n=15) % age (years old) a. 18-30 b. 31-40 c. 41-50 d. 51-60 3 3 4 5 20.00 20.00 26.67 33.33 2 2 5 6 13.33 13.33 33.33 40.00 0.882 gender a. men b. women 5 10 33.33 66.67 6 9 40.00 60.00 0.786 education level a. no school b. grade school c. junior high school d. high school 0 6 4 5 0.00 40.00 26.27 33.33 1 4 7 3 6.67 26.67 46.67 20.00 0.324 nyha level a. i b. ii c. iii 3 4 8 20.00 26.67 53.33 5 3 7 33.33 20.00 46.67 0.801 *significant level p < 0.05 table 3. total score (mean) of the intervention group and the control group item intervention group (n=30) control group (n=30) p value* mean±sd mean±sd depression pre-test 26.13± 9.870 28.27± 10.306 0.567 post-test 14.27± 7.005 22.93± 8.481 0.005 anxiety pre-test 25.20±11.608 26.80±9.792 0.686 post-test 15.20±8.029 21.47± 8.331 0.045 stress pre-test 26.80± 9.792 27.07± 10.552 0.943 post-test 15.07± 8.713 22.13± 9.456 0.042 *significant level p < 0.05 jurnal ners http://e-journal.unair.ac.id/jners | 371 and control groups at baseline (pre-test) and after an intervention (post-test). there was no significant difference in mean scores of depression (p=0.567), anxiety (p=0.686) and stress (p=0.946) between intervention and control groups at baseline. meanwhile, the mean scores of depression (p=0.005), anxiety (p=0.045) and stress (p=0.042) between both groups significantly different after intervention. table 2 shows the comparison of mean scores of depression, anxiety and stress between intervention and control groups at baseline (pre-test) and after intervention (post-test). there was no significant difference in mean scores of depression (p=0.691), anxiety (p=0.743) and stress (p=0.546) between intervention and control groups at baseline. meanwhile, the mean scores of depression (p=0.001), anxiety (p=0.001) and stress (p=0.001) between both groups were significantly different after intervention. discussion the present study found that half of the respondents were male. this result is in line with the study from kao, et al. who stated that the number of chf patients is higher in males (54.4%) than females (45.6%) (kao et al., 2014), which the result was repeated in the study conducted by gottlieb, et al that states chf is more prevalent in male than female (gottlieb ss, khatta m, friedmann e, einbinder l, katzen s, baker b, 2004). the framingham study also states that the prevalence increases notably with advancing age, rising to 6.6% and 7.9% in male and female, respectively (lloyd-jones et al., 2002). the majority of the chf patients from this study were in the age group of 51-60 years old (37%). this finding concurs with the previous study from bui, et al. which argued that the growing prevalence of chf might reflect an aging population (gaviţa, david, bujoreanu, tiba, & ionuţiu, 2012). in other words, the older person will have a higher risk of heart failure. depression, anxiety and stress among congestive heart failure patients high levels of depression, anxiety, and stress were reported in the recent study. this result is similar to the study conducted by castillon, at al. found that almost 50% of chf patients have suffered psychological problems especially depression (guallar-castillón et al., 2006). this result also supported by pihl, et al., it was revealed that around 60% of chf patients experienced depression symptoms (lefteriotis, 2013). depression, anxiety, and stress symptoms were found to be related by the uncertainty experienced by patients in regards to their disease progression and long-term care (jeyanantham et al., 2017). effectiveness of cbt in depression, anxiety, and stress the average depression score in the cbt group was statistically significantly decreased compared to the usual care group score after the cbt program. this finding was supported by a previous study that examined 193 implantable cardioverter defibrillator (icd) patients, it was found that 96 respondents in the cbt group experienced greater improvement of depression symptoms. the instrument used in this study was the hospital anxiety and depression scale. whereas, the current study used a depression subscale from dass-21. it is seen that whatever questionnaire is used, cognitive behavioral therapy is consistently found to reduce depression scores (sheu, irvin, lin, & mar, 2003). the mean anxiety score in the experimental group was also statistically lower than usual cardiac care after the application of cognitive behavioral therapy. this result is in line with the study result conducted by valsaraj, et al., the finding was found that cbt was significant for reducing anxiety and depression in the hemodialysis patients (valsaraj, bhat, & latha, 2016). both studies used the dass-21 anxiety subscale, but the follow-up of the cbt program in the previous study was longer. however, in the short sessions measurements between the two studies also showed a significant reduction in the mean anxiety score. the study also found that the average stress score was significantly lower in the intervention group than in the control group after the intervention. this finding is supported by a study from gavita et al., who examined 97 romanian foster parents with the results that the cbt group significantly reduced parental emotional distress (gaviţa et al., 2012). previous studies used “the profile of emotional distress”, meanwhile in the recent study used the stress subscale from dass-21. apart from the different questionnaires in both of studies, the mean stress score decreased significantly after the cognitive behavioral therapy program. in all previous research and current research, the contents of cognitive behavioral therapy sessions, number of sessions, and administration and session procedures differed. in addition, this study differs in a number of samples, sample size, presence or absence of a control group, number of variables, data collection methods, and methods of data analysis. however, if cbt is carried out appropriately and according to the concept and the principle will be able to help patients in dealing with stress, anxiety, and depression. however, the results of the present study were limited by the small sample sizes and lack of long term follow-up. the true random allocation of the respondents is also limited, therefore may contribute to the selection bias. the blinding process is also limited as the process of masking the intervention was not possible. in view of these limitations, future research is suggested to include multiple study locations and the study design would take into account the true randomization and blinding process. larger and more robust rcts are needed to ascertain the long-term benefits and costeffectiveness of a cbt intervention for depression, anxiety, and stress in congestive heart failure patients. conclusion d. hudiyawati, et al. 372 | pissn: 1858-3598  eissn: 2502-5791 in conclusion, brief cbt is identified to be more effective than usual care at reducing depression, anxiety and stress symptoms in congestive heart failure patients. future studies can formulate cbt programs into a simple package that can be applied by a health care providers in a hospital. references ponikowski p, anker sd, alhabib kf, cowie mr, force tl, hu s, et al. 2014 heart failure: preventing disease and death worldwide esc heart failure. available from: http://dx.doi.org/10.1002/2055-5822.12005 parissis jt, fountoulaki k, paraskevaidis i, kremastinos d 2005 depression in chronic heart failure: novel pathophysiological mechanisms and therapeutic approaches. expert opinion on investigational drugs informa healthcare 14 567–77. available from: http://dx.doi.org/10.1517/13543784.14.5.5 67 lloyd-jones dm, larson mg, leip ep, beiser a, d’agostino rb, kannel wb, et al. 2002 lifetime risk for developing congestive heart failure circulation 106 3068–72. available from: http://dx.doi.org/10.1161/01.cir.000003910 5.49749.6f hobbs fdr, korewicki j, cleland jgf, eastaugh j, freemantle n 2005 the diagnosis of heart failure in european primary care: the improvement programme survey of perception and practice european journal of heart failure 7 768–79. available from: http://dx.doi.org/10.1016/j.ejheart.2005.01. 018 sato n 2015 epidemiology of heart failure in asia. heart failure clinics 11 573–9. available from: http://dx.doi.org/10.1016/j.hfc.2015.07.009 sasayama s 2008 heart disease in asia circulation 118 2669–71. available from: https://doi.org/10.1161/circulationaha. 108.837054 sohani zn, samaan z 2012 does depression impact cognitive impairment in patients with heart failure? cardiology research and practice 1–9. available from: http://dx.doi.org/10.1155/2012/524325 vaccarino v, kasl sv, abramson j, krumholz hm 2001 depressive symptoms and risk of functional decline and death in patients with heart failure journal of the american college of cardiology 38 199–205. available from: http://dx.doi.org/10.1016/s07351097(01)01334-1 jeyanantham k, kotecha d, thanki d, dekker r, lane da 2017 effects of cognitive behavioral therapy for depression in heart failure patients: a systematic review and metaanalysis heart failure reviews 22 731–41. available from: http://dx.doi.org/10.1007/s10741-0179640-5 o’connor cm 2018 depression in heart failure jacc: heart failure 6 885–6. available from: http://dx.doi.org/10.1016/j.jchf.2018.08.004 pihl e, jacobsson a, fridlund b, strömberg a, måtensson j 2005 depression and healthrelated quality of life in elderly patients suffering from heart failure and their spouses: a comparative study european journal of heart failure 7 583–9. available from: http://dx.doi.org/10.1016/j.ejheart.2004.07. 016 dusseldorp e, van elderen t, maes s, meulman j, kraaij v 1999 a meta-analysis of psychoeducational programs for coronary heart disease patients health psychology 18 506–19. available from: http://dx.doi.org/10.1037/02786133.18.5.506 nice 2014 chronic kidney disease in adult: assessment and management. available from: nice.org.uk/guidance/cg182 essa rm, ismail niaa, hassan ni 2017 effect of progressive muscle relaxation technique on stress, anxiety, and depression after hysterectomy journal of nursing education and practice 7 77. available from: http://dx.doi.org/10.5430/jnep.v7n7p77 schulz kf, altman dg, moher d 2010 consort 2010 statement: updated guidelines for reporting parallel group randomised trials trials 11. available from: http://dx.doi.org/10.1186/1745-6215-11-32 tran td, tran t, fisher j 2013 validation of the depression anxiety stress scales (dass) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern vietnamese women. bmc psychiatry 13. available from: http://dx.doi.org/10.1186/1471-244x-13-24 kao c-w, chen t-y, cheng s-m, lin w-s, friedmann e, thomas sa 2013 gender differences in the predictors of depression among patients with heart failure european journal of cardiovascular nursing 13 320–8. available from: http://dx.doi.org/10.1177/1474515113496 493 gottlieb ss, khatta m, friedmann e, einbinder l, katzen s, baker b, et al. 2004 the influence of age, gender, and race on the prevalence of depression in heart failure patients acc current journal review 13 36. available from: http://dx.doi.org/10.1016/j.accreview.2004. 07.048 gaviţa oa, david d, bujoreanu s, tiba a, ionuţiu dr 2012 the efficacy of a short cognitive– behavioral parent program in the treatment of externalizing behavior disorders in romanian foster care children: building parental http://dx.doi.org/10.1002/2055-5822.12005 http://dx.doi.org/10.1517/13543784.14.5.567 http://dx.doi.org/10.1517/13543784.14.5.567 http://dx.doi.org/10.1161/01.cir.0000039105.49749.6f http://dx.doi.org/10.1161/01.cir.0000039105.49749.6f http://dx.doi.org/10.1016/j.ejheart.2005.01.018 http://dx.doi.org/10.1016/j.ejheart.2005.01.018 http://dx.doi.org/10.1016/j.hfc.2015.07.009 https://doi.org/10.1161/circulationaha.108.837054 https://doi.org/10.1161/circulationaha.108.837054 http://dx.doi.org/10.1155/2012/524325 http://dx.doi.org/10.1016/s0735-1097(01)01334-1 http://dx.doi.org/10.1016/s0735-1097(01)01334-1 http://dx.doi.org/10.1007/s10741-017-9640-5 http://dx.doi.org/10.1007/s10741-017-9640-5 http://dx.doi.org/10.1016/j.jchf.2018.08.004 http://dx.doi.org/10.1016/j.ejheart.2004.07.016 http://dx.doi.org/10.1016/j.ejheart.2004.07.016 http://dx.doi.org/10.1037/0278-6133.18.5.506 http://dx.doi.org/10.1037/0278-6133.18.5.506 http://dx.doi.org/10.5430/jnep.v7n7p77 http://dx.doi.org/10.1186/1745-6215-11-32 http://dx.doi.org/10.1186/1471-244x-13-24 http://dx.doi.org/10.1177/1474515113496493 http://dx.doi.org/10.1177/1474515113496493 http://dx.doi.org/10.1016/j.accreview.2004.07.048 http://dx.doi.org/10.1016/j.accreview.2004.07.048 jurnal ners http://e-journal.unair.ac.id/jners | 373 emotion-regulation through unconditional selfand child-acceptance strategies children and youth services review 34 1290–7. available from: http://dx.doi.org/10.1016/j.childyouth.2012. 03.001 guallar-castillón p, del mar magariños-losada m, montoto-otero c, tabuenca ai, rodríguezpascual c, olcoz-chiva m, et al. 2006 prevalence of depression and associated medical and psychosocial factors in elderly hospitalized patients with heart failure in spain. revista española de cardiología 59 770–8. available from: http://dx.doi.org/10.1016/s18855857(07)60042-5 lefteriotis c 2013 depression in heart failure patients heal sci j 7 349–55 sheu s, irvin bl, lin h-s, mar c-l 2003 effects of progressive muscle relaxation on blood pressure and psychosocial status for clients with essential hypertension in taiwan holistic nursing practice 17 41–7. available from: http://dx.doi.org/10.1097/00004650200301000-00009 valsaraj bp, bhat sm, latha ks 2016 cognitive behavior therapy for anxiety and depression among people undergoing haemodialysis: a randomized control trial journal of clinical and diagnostic research 10 vc06-10. available from: http://dx.doi.org/10.7860/jcdr/2016/18959 .8383 http://dx.doi.org/10.1016/j.childyouth.2012.03.001 http://dx.doi.org/10.1016/j.childyouth.2012.03.001 http://dx.doi.org/10.1016/s1885-5857(07)60042-5 http://dx.doi.org/10.1016/s1885-5857(07)60042-5 http://dx.doi.org/10.1097/00004650-200301000-00009 http://dx.doi.org/10.1097/00004650-200301000-00009 http://dx.doi.org/10.7860/jcdr/2016/18959.8383 http://dx.doi.org/10.7860/jcdr/2016/18959.8383 146 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16950 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the effect of exercise on postpartum women’s quality of life ni putu dian ayu anggraeni1, lucky herawati2, melyana nurul widyawati1 and i komang leo triandana arizona3 1 health polytechnic, ministry of health, mataram, indonesia 2 health polytechnic, ministry of health, yogyakarta, indonesia 3 faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: postpartum mothers are vulnerable to several problems during the puerperium, such as fatigue, sleep disorders, anxiety, depression, sexual problems, physical functioning and dissatisfaction with partner support that can affect their quality of life. the aim of this systematic review is to explore the effect of exercise on postpartum women’s quality of life methods: comprehensive searches including experimental studies (including rcts and non-randomized trials) from several databases, namely scopus, pubmed, and science-direct, were used to search for scientific contributions published between 2009 and 2019. the articles are identified using the relevant keywords. this systematic review is guided by prisma. fourteen of the 636 articles met both the inclusion and exclusion criteria results: the postpartum exercises found in this study were yoga, pelvic floor muscle training (pfmt), pilates, postnatal exercise, aerobic exercise and progressive muscle relaxation (pmr). this review cannot provide definitive conclusions about the best form of exercise, the suggested duration or the timing needed to improve the quality of life for postpartum women. conclusion: yoga and pilates are proven to effectively improve maternal well-being because this exercise focuses on increasing the physical, psychological and social support during the postpartum period. further research is needed to provide evidence and to strengthen the results of this systematic review. article history received: december 26, 2019 accepted: december 31, 2019 keywords exercise; postpartum; women’s quality of life contact ni putu dian ayu anggraeni  niputudianayu@gmail.com  health polytechnic, ministry of health, mataram, indonesia cite this as: anggraeni, n. p. d. a., herawati, l., widyawati, m. n., & arizona, i. k. l. t. d. (2019). the effect of exercise on postpartum women’s quality of life. jurnal ners, . jurnal ners, 14(3si), 146-154. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16950 introduction the postpartum period starts after labor and lasts for about six weeks. this period is characterized by physiological, physical, social and emotional changes for the mothers and their families that require the members therein to take on new roles and responsibilities(ahmadi et al., 2014). most problems occur in the first days of this period and last for six weeks and up to one year after delivery (martínezgaliano et al., 2019). the symptoms include fatigue, sleep disorders, nausea, anxiety, depression, sexual problems, physical function and dissatisfaction with partner support (bahrami, karimian, & bahrami, 2014; insana, costello, & montgomery-downs, 2011; medina, lederhos, & lillis, 2009; parker et al., 2015). however, given the impact and risk on postpartum mothers, it is not surprising that the quality of life of the mother can decrease. the main reason for the decline in the quality of life of postpartum mothers is that women have physical, psychological and social problems during this period (rezaei et al., 2016). in the united states, researchers found that 4495% of postpartum mothers experienced postpartum fatigue (milligan, parks, kitzman, & lenz, 1997). the phenomenon of postpartum fatigue often starts immediately after giving birth and reaches maximum severity within 36 hours. it can even last for a long time after giving birth (dennis & ross, 2005; lee, 2004). the literature review by groër et al reported that more than 80% of mothers complained of postpartum fatigue and that about 70% occurred among women who had given birth 1-2 months earlier (corwin, brownstead, barton, heckard, & https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:niputudianayu@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 147 morin, 2005; groër et al., 2005). during the postpartum period, most women experience significant disturbances in their sleep patterns due to hormonal changes and the responsibility for the care of the newborn (farzaneh ashrafinia et al., 2013; heh, huang, ho, fu, & wang, 2008). postpartum sleep quality is a critical health index and sleep deprivation is the main source of stress or anxiety for postpartum women (hardianti, amir, & balqis, 2013; hunter, rychnovsky, & yount, 2009; li, chen, li, gau, & huang, 2011; yang, yu, & chen, 2013). the prevalence of postpartum anxiety ranges from 0.5% to 2.9%, and for panic disorders, it can be up to 6.1% -7.7% for generalized anxiety disorders. in addition, 10-15% of women suffer from postpartum depression (guille, newman, fryml, lifton, & epperson, 2013; wenzel & stuart, 2011). about 90% of women start sexual activity after 6 weeks of giving birth. of this total, 83% experienced sexual problems in the first 3 months and 64% experienced problems in the first 6 months after giving birth (acele & karaçam, 2012; nikpour, javaheri, yadavar nikravesh, & jamshidi, 2006). during this time, there were also cases of urinary incontinence where the incidence reached 6-38%, which increased with the number of births. in the primiparas who gave birth normally, this can cause a decrease in pelvic muscle strength by 22-35% between pregnancy and the postpartum period (dinc, kizilkaya beji, & yalcin, 2009; morkved & bo, 1999). these problems have a significant effect and they can have a negative impact on their physical, emotional, and social health, breastfeeding, relationships with the family, community, baby care, and homework (bahrami et al., 2014; parker et al., 2015). postpartum physical and psychological problems can interfere with the ability of the new mothers to care for their babies and this can adversely affect their quality of life (lovell, huntsman, & hedley‐ward, 2015; werner et al., 2016). quality of life (qol) is a multidimensional concept that affects individual performance in the physical, psychological, social and spiritual aspects of life. assessing quality of life in the postpartum period will allow a woman to conduct a self-evaluation of her own postpartum situation and this will help the health care providers with the further promotion of the health of women and their infants (al thobaity, plummer, & williams, 2017). according to the literature, maternal quality of life is declining due to many problems in relation to women's self-care and infant care (parker et al., 2015). to improve the maternal quality of life in the postpartum period, non-pharmacological methods, such as health education, exercise and relaxation therapy during pregnancy and the postpartum period can be used (dritsa, da costa, dupuis, lowensteyn, & khalifé, 2008). one intervention that is often recommended as a part of postpartum maternal care is exercise (davies, wolfe, mottola, & mackinnon, 2003). exercise refers to any bodily movements that cause an increase in energy consumption, including planned and structured systematic movements based on frequency, intensity and duration to maintain or improve health-related outcomes (wolin, schwartz, matthews, courneya, & schmitz, 2012). therefore, the aim of this systematic review is to explore the effects of exercise on postpartum women’s quality of life and to provide references for future research. materials and methods this systematic review used a guide based on the preferred reporting item for systematic review and meta-analysis (prisma)(liberati et al., 2009; moher, tetzlaff, altman, liberati, & group, 2009). the journal articles were published in english from january 2009 to february 2019. the search strategy used the pico framework to identify the keywords. all of the studies were experimental studies (including rct and non-randomized experimental trial) that studied the effectiveness of postpartum exercises on the quality of life of postpartum mothers.the studies reviewed included normal postpartum mothers aged> 18 years, not limited by the number of births. all types of exercise interventions given to postpartum mothers were included. exercise refers to any bodily movement that causes an increase in energy consumption, including planned and structured systematic movements, based on frequency, intensity and duration to maintain or improve health-related outcomes. the control group received treatment as usual/regular postpartum care, waiting list controls or no treatment. quality of life and/or the problems that occur in postpartum mothers include anxiety, postpartum depression, urine incontinence, sleep disorders and other problems related to the quality of life of postpartum mothers. the studies were identified by searching electronic databases and scanning the reference lists of any relevant articles. three databases were systematically searched including scopus, science direct and pubmed. the search terms in the database using a combination of keywords: (1) postpartum or (2) postnatal and (3) exercises and (4) quality of life. the protocol standard for selecting the research studies is as suggested in the prisma method for systematic reviews followed by screening to remove duplicates. two reviewers (npdaa and iklta) then chose the titles, abstracts and keywords, and then deleted irrelevant articles. the selection of the research studies was recorded by two reviewers and then these were compared with one another to adjust the feasibility to the criteria set. the full text of the article was obtained if the title and abstract meet the inclusion criteria or if the feasibility study was clearly completed following a joint discussion between the reviewers. n. p. d. a. anggraeni et al. 148 | pissn: 1858-3598  eissn: 2502-5791 the following data was extracted: author, year, journal, country, the setting of the study and the main result. two authors (npdaa and iklta) were involved in the data extraction, and after organizing the results in a table, the findings were discussed and reviewed again. one review author extracted the following data from the included studies and the other author checked the extracted data. any disagreement was resolved by a discussion between the authors. the information that was extracted from each included study was on (1) the study identity (including the author's name, year of publication and origin of the study); (2) the study arrangements (including participant characteristics, interventions, the presence of control groups as a comparison, intervention time, modality, frequency, setting and implementation); (3) outcomes, measurements and tools and (4) major findings relevant to the review. two reviewers independently evaluated the quality and risk of bias of each study in accordance with the cochrane risk of bias tool. for research using the rct design, the assessment used rob 2.0 which consists of 5 domains, namely (1)randomization process, (2) deviations from the intended interventions, (3) missing outcome data, (4) the measurement of the outcome and (5) the selection of the reported results(higgins, savovic, page, & sterne, 2018). the non-randomized studies were assessed using the robins-i(j. a. sterne et al., 2016). the robins-i tool covers seven domains through which bias might be introduced into non-randomized studies or interventions (nrsi). the first two domains discussed the problem before the interventions began to be compared, the third domain discussed the classification of the intervention itself and the other four domains addressed the problem after the intervention began(j. sterne, higgins, elbers, reeves, & the development group for robins-i., 2016). the reviewers crosschecked their final assessments and resolved any disagreements through discussion. the studies were grouped according to the intervention used and the study population. where possible, the studies were thereafter grouped according to the time of follow-up and the type of control group. all studies were individually rated for evidence level using the national health and medical research council (nhmrc) hierarchy of evidence guidelines (iv-i, with i being the strongest level of evidence). meta-analysis was not possible as the studies were too heterogeneous in design and methodology, namely in relation to the types of intervention, the type of control group, the outcome measures used and the time of follow-up. results study selection a total of 14 articles were identified to be included in this systematic review. searching through the scopus, science direct and pubmed databases, 636 articles were found. after duplication screening, there were 620 articles left. of these, 575 articles were eliminated because of being on an irrelevant topic. the full text article stage identified and eliminated as many as 31 articles on the grounds that it was a review article, the publication was not in english, the research design was not experimental and the outcome was irrelevant (see the flow diagram in figure 1). study characteristics for the summary of the characteristics of the studies, see appendix a. in total, 14 studies were finally selected for review. these consisted of 12 randomized controlled trials, 1 single-center prospective cohort study and 1 single group pre-post experimental study design. the included studies involved 945 participants. the sample size of the included studies ranged from 18 140 participants, involving female participants (pregnant women and postpartum mothers) from 8 different countries. the studies were conducted in turkey (n=3), usa (n=2), ireland (n=1), sweden (n=1), south korea (n=1), iran (n=4), india (n=1) and taiwan (n=1). the average age of the participants ranged from 18 45 years. table 1 represents the characteristics and content of the intervention of the 14 low-risk studies related to postpartum exercises. one study evaluated progressive muscle relaxation (gökşin & ayazalkaya, 2018), 2 studies evaluated yoga (buttner, brock, o’hara, & stuart, 2015), 6 studies evaluated pelvic floor muscle training (dinc et al., 2009; gagnon, boucher, & robert, 2016; golmakani, zare, khadem, shareh, & shakeri, 2015; gutke, sjödahl, & öberg, 2010; kim, kim, & oh, 2012; pourkhiz, mohammadalizadeh-charandabi, mirghafourvand, haj-ebrahimi, & ghaderi, 2017; sut & kaplan, 2016), 2 studies figure 1. flow diagram records identified through database searching (n = 636) scopus: n = 98, pubmed: n = 62, science direct: n = 476, records screened after removing duplicates (n = 620) records excluded based on title and abstract not relevant topic (n = 575) full-text articles assessed for eligibility full-text articles excluded, with reasons (n = 31) 1. review 2. not in the english language 3. no relevant study design. 4. no relevant outcome studies included in qualitative synthesis (n = 14) 14 studies included in systematic review s c r e e n in g i n c lu d e d e li g ib il it y i d e n ti fi c a ti o n jurnal ners http://e-journal.unair.ac.id/jners | 149 evaluated the pilates exercise (f ashrafinia et al., 2015; farzaneh ashrafinia et al., 2013), 1 study evaluated postnatal exercises (mahishale, ulorica, & patil, 2014) and 1 study evaluated aerobic gymnastic exercise (yang & chen, 2018). each study examined the problems in the puerperium associated with the quality of life of postpartum mothers. the timing of the results ranged from 1 week to 3 months after birth. there were 3 studies starting from 20 34 weeks of pregnancy through to 6 8 weeks postpartum. the follow-up period in several studies was determined relative to the time since starting or completing the treatment. to measure the postpartum quality of life, the studies used the maternal postpartum quality of life questionnaire (mapp-qol) and the patient health questionnaire (phq-9, short-form health survey (sf-36) and health-related quality of life (eq-5d). depression, stress and anxiety were measured using the hamilton depression rating scale (hdrs), the inventory of depression and anxiety symptoms (idas), the stress perception scale and the edinburgh postnatal depression scale. sleep quality was measured using the pittsburgh sleep index (psqi). postpartum sleep quality was measured using the postpartum fatigue scale and the multidimensional fatique inventory questionnaire (mfi-20). pain was measured using the oswestry disability index. muscle symptom, function satisfaction and urinary incontinence were measured using the bristol female lower urinary tract symptoms questionnaire. sexual function was measured using perineometer vaginal function, self-efficacy sexual and the brink scale. risk of bias the risk of bias in the judgments of each paper was summarized in appendix b. the 12 randomized control trials were assessed using rob-2 (see appendix table b1). five studies (41,67%) had a low risk of bias and 7 studies (58,33%) had a risk of bias with some concerns. inadequate randomization methods were the main source of bias. two nonrandomized studies consisting of interventions were assessed using robins-i (see appendix table b2). one article has a risk of serious bias and one article had a moderate risk of bias. result of individual studies there were various types of exercise intervention found, including pelvic floor muscle training (n=7), progressive muscle relaxation (pmr) (n=1), yoga (n=2), postnatal exercise (n=1), pilates exercises (n=2) and aerobic gym exercises (n=1). each intervention was grouped and described separately related to its effect on the quality of life of postpartum mothers (table 1). discussion summary of the evidence this systematic review investigated the effectiveness of postpartum exercises on the quality of life of postpartum women. fourteen studies were included and analyzed. the trials included were very heterogeneous, differing in the outcome measures, the type of intervention, the type of control group and the duration of the follow-up. five studies reported that pfmt can improve the quality of life of postpartum women in pelvic floor muscle strength and as an intervention for urinary incontinence treatment (dinc et al., 2009; gagnon et al., 2016; golmakani et al., 2015; kim et al., 2012; sut & kaplan, 2016). two of the five studies were carried out from pregnancy through to postpartum(dinc et al., 2009; sut & kaplan, 2016). one study related to the pfmt exercise reported that kegel exercises carried out during the postpartum period can improve selfefficacy (pourkhiz et al., 2017). six studies reported that pfmt, pmr, postnatal exercises, pilates, and yoga have been shown to significantly improve the quality of life for postpartum women(f ashrafinia et al., 2015; gagnon et al., 2016; gökşin & ayaz-alkaya, 2018; mahishale et al., 2014; sut & kaplan, 2016; timlin & simpson, 2017). four studies including aerobic exercise, pilates and yoga can improve the well-being of psychology in postpartum women(f ashrafinia et al., 2015; buttner et al., 2015; timlin & simpson, 2017; yang & chen, 2018). other studies reporting on pilates and aerobics also reduced the fatigue and can improve the sleep quality of postpartum women(farzaneh ashrafinia et al., 2013; yang & chen, 2018). although the results of the various studies varied as a whole, this review provided evidence that exercise is a viable, acceptable and effective intervention to improve the quality of life for women during pregnancy and through to the postpartum period. there are several important findings regarding efficacy, or a lack thereof, for several types of interventions, which will now be discussed in detail. pelvic floor muscle training is beneficial for women with or without incontinence in the postpartum period. pfmt that is carried out for 8 weeks can increase sexual self-efficacy, contribute to a significant increase in pelvic function and result in an increased quality of life for pregnant women and postpartum women(dinc et al., 2009; kim et al., 2012; sut & kaplan, 2016). some studies reported that exercises to strengthen pelvic floor muscles can increase a woman's ability to achieve optimal orgasm, the duration and intensity of her orgasms, the number of orgasms, and the vaginal sensations felt during intercourse(bø, talseth, & vinsnes, 2000). therefore, the increase in female sexual self-efficacy after doing the pelvic floor strengthening exercises was proven in this study. this is different from gutke, sjödahl dan öberg#s (2010) research, where the majority of the respondents after being given specific muscle stabilization exercises still experienced pain and some back-related disability for up to 9 months after giving birth. some women may need more than training as a part of their care (gutke et al., 2010). pelvic floor exercises applied during pregnancy to the postpartum period increased the pelvic floor n. p. d. a. anggraeni et al. 150 | pissn: 1858-3598  eissn: 2502-5791 muscle strength and prevented the worsening urinary symptoms, decreased he urinary system factors and improved the quality of life in both pregnancy and postpartum (sut & kaplan, 2016). in gagnon’s study (2016), the study design used a prospective cohort study in which the design limited the ability to accurately measure the impact on pelvic floor function as a result of the intervention. without evidence from the control group, it is possible that the improvement in the pelvic floor function and the strength of the mos is more due to time than due to the pfmt program (gagnon et al., 2016). five other studies were reported to have physical and psychological benefits related to improving the quality of life for postpartum mothers; they involved pmr, yoga and pilates(f ashrafinia et al., 2015; farzaneh ashrafinia et al., 2013; buttner et al., 2015; gökşin & ayaz-alkaya, 2018; timlin & simpson, 2017). the pmr effect on the postpartum quality of life of women in both the intervention group and the control group was investigated, revealing an increase in the mean mapp-qol score after pmr which was found to be statistically significant. pmr has physiological and psychological benefits related to improving the quality of life for postpartum women. this technique promotes the systematic relaxation of the body's main muscle groups with the aim of physical and mental relaxation, reducing the response to stress, reducing the contraction of the skeletal muscles and reducing the sensation of pain(mcguigan & lehrer, 2007). pmr applied in the postpartum period will have a positive impact on improving the quality of life for women by increasing their overall ability to overcome any problems that may be encountered during this period. pmrs are thus recommended to be taught to women who are being treated in midwifery clinics and as outpatients. this can be continued during home visits to expand on the use of pmr(gökşin & ayaz-alkaya, 2018). the two studies related to yoga reported that women in the yoga group, by 78%, had at a much lower rate of depression and anxiety and better scores for well-being and health-related quality of life (hrqol) compared to the control group (wlc)(buttner et al., 2015). other studies have found that dru yoga programs significantly reduce stress, negative coping and dysfunctional focus. they are a form of coping that focus on emotions and positive influences(timlin & simpson, 2017). in accordance with the previous research, there is a growing interest in the role of yoga as a type of cam therapy for emotional and physical health(cramer, lauche, langhorst, & dobos, 2013; kuan-yin, yu-ting, kingjen, lin, & tsauo, 2011), especially during the perinatal and postpartum periods(bershadsky, trumpfheller, beck, pipaloff, & yim, 2014). quality of life improvement was also reported when the pilates exercises were carried out by primiparous postpartum women for 8 weeks. it significantly improved their subjective sleep quality, sleep latency and daytime dysfunction. however, there were no differences in sleep duration, sleep efficiency and sleep disorders between the groups(farzaneh ashrafinia et al., 2013). in another study conducted by ashrafinia et al (2015), it was shown that the pilates exercises performed at home were proven to reduce general fatigue, physical and mental and increase activity and motivation, physical fatigue, reduced activity, reduced motivation and mental fatigue. physical exercise can significantly reduce the fatigue of postpartum women for all subscales. reducing fatigue and the risk of depression is an effective step toward improving maternal and infant health. therefore, more attention is needed to be given as an effective intervention, especially concerning physical exercise, to reduce fatigue (f ashrafinia et al., 2015). in accordance with the research findings conducted by eyigor et al. (2010), pilates exercises are a healthy and effective method for improving functional capacity, flexibility, fatigue, depression and the quality of life for breast cancer patients (eyigor, karapolat, yesil, uslu, & durmaz, 2010). one study reported that the postpartum women who received postnatal training immediately after giving birth had been shown to be shown to have better physical well-being and an improved quality of life(mahishale et al., 2014). the results of the exploratory studies conducted by carolyn et al also showed that by exercising, postpartum women can avoid decreasing their usual level of activity and increase their physical and psychological benefits felt by postpartum women (sampselle, seng, yeo, killion, & oakley, 1999). another type of exercise reported in this systematic review was aerobic exercise. aerobic exercise performed three times a week (15 minutes per section) for three months had a positive and significant effect on the stress perception, fatigue and sleep quality of the postpartum women. in addition, changes in sleep inefficiency associated with physical symptoms after 12 weeks of gymnastics training decreased significantly after aerobic exercise(yang & chen, 2018). in general, physical exercise has been well documented to be important and beneficial to overall women's health during the postpartum period(adeniyi, ogwumike, & bamikefa, 2013; daley, jolly, & macarthur, 2009). limitations there are several potential limitations associated with this systematic review. (1) the heterogeneity of the research design makes it difficult to collect the data and to draw quantitative conclusions. (2) what we consider to be the main outcome (quality of life) is not always the same as in the original research. (3) the research instruments used were subjective assessment tools, and there is still a lack of objective measurement variables such as biomarkers (hormonal). (4) the results of the study only explored the short-term effects of exercise on the quality of life of women during the postpartum period and they ignored the long-term effects and (5) some studies were limited to primipara / nulliparous women and those who experienced vaginal delivery. jurnal ners http://e-journal.unair.ac.id/jners | 151 special training programs for postpartum women may be more conducive to increasing their acceptance and adherence to sports. in addition, it is recommended that health care providers should encourage postpartum women to carry out postpartum exercise in the early weeks of labor to improve their quality of life as early as possible. therefore, future research is expected to explore alternative or additional variables such as qol biomarkers to quantitatively predict or evaluate the quality of life of postpartum women. future research should focus on implementing follow-ups and emphasizing the importance of exercise in order to have a long-term impact on women's quality of life during the postpartum period. in addition, further research is needed by using large-scale replication studies and this should be carried out for all postpartum women including primiparas and multiparas. conclusion this systematic review explains that the postpartum exercises found in this review (yoga, pelvic floor muscle training (pfmt), pilates, postnatal exercise, aerobic exercise and progressive muscle relaxation (pmr)) have a positive impact on the quality of life of postpartum mothers. this is in the prevention and treatment of problems during the puerperium, including pelvic floor muscle strength, depression, stress, anxiety, sleep quality, fatigue, pain, urinary incontinence and sexual function. however, this review cannot provide definite conclusions about the best form of exercise, including its duration or timing to improve the quality of life for postpartum women. out of the exercises, yoga and pilates were found to be effective at improving maternal well-being during the postpartum period. both of these exercises focus on improving psychological well-being, helping to speed up the recovery of physical strength after giving birth, and providing social support to the mothers. in particular, the yoga and pilates exercises must be considered by the midwives and obstetricians to improve physical and mental health during the postpartum period. further research is needed to provide evidence and to strengthen the results of this systematic review. references acele, e. ö., & karaçam, z. (2012). sexual problems in women during the first postpartum year and related conditions. journal of clinical nursing, 21(7‐8), 929–937. adeniyi, a. f., ogwumike, o. o., & bamikefa, t. r. (2013). postpartum exercise among nigerian women: issues relating to exercise performance and self-efficacy. isrn obstetrics and gynecology, 2013. ahmadi, s. e., montazeri, a., mozafari, r., azari, a., nateghi, m. r., & ashrafi, m. (2014). health-related quality of life and primi-gravid: a comparative study of natural conception and conception by assisted reproduction technologies (arts). international journal of fertility and sterility, 8(2), 167–174. al thobaity, a., plummer, v., & williams, b. (2017). what are the most common domains of the core competencies of disaster nursing? a scoping review. international emergency nursing, 31, 64– 71. https://doi.org/10.1016/j.ienj.2016.10.003 ashrafinia, f, mirmohammadali, m., rajabi, h., kazemnejad, a., sadeghniiat haghighi, k., & amelvalizadeh, m. (2015). effect of pilates exercises on postpartum maternal fatigue. singapore medical journal, 56(3), 169–173. ashrafinia, farzaneh, mirmohammadali, m., rajabi, h., ph, d., kazemnejad, a., ph, d., … ph, d. (2013). the effects of pilates exercise on sleep quality in postpartum women. journal of bodywork & movement therapies, 1–10. https://doi.org/10.1016/j.jbmt.2013.09.007 bahrami, n., karimian, z., & bahrami, s. (2014). comparing the postpartum quality of life between six to eight weeks and twelve to fourteen weeks after delivery in iran. iranian red crescent medical journal, 16(7). https://doi.org/10.5812/ircmj.16985 bershadsky, s., trumpfheller, l., beck, h., pipaloff, d., & yim, i. s. (2014). the effect of prenatal hatha yoga on affect , cortisol and depressive symptoms. complementary therapies in clinical practice, 20(2), 106–113. https://doi.org/10.1016/j.ctcp.2014.01.002 bø, k., talseth, t., & vinsnes, a. (2000). randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women. acta obstetricia et gynecologica scandinavica, 79(7), 598–603. buttner, m. m., brock, r. l., o’hara, m. w., & stuart, s. (2015). efficacy of yoga for depressed postpartum women: a randomized controlled trial. complementary therapies in clinical practice, 21(2), 94–100. https://doi.org/10.1016/j.ctcp.2015.03.003 corwin, e. j., brownstead, j., barton, n., heckard, s., & morin, k. (2005). the impact of fatigue on the development of postpartum depression. journal of obstetric, gynecologic, & neonatal nursing, 34(5), 577–586. cramer, h., lauche, r., langhorst, j., & dobos, g. (2013). yoga for depression: a systematic review and meta-analysis. depression and anxiety, 30(11), 1068–1083. https://doi.org/10.1002/da.22166 n. p. d. a. anggraeni et al. 152 | pissn: 1858-3598  eissn: 2502-5791 daley, a., jolly, k., & macarthur, c. (2009). the effectiveness of exercise in the management of post-natal depression: systematic review and meta-analysis. family practice, 26(2), 154–162. davies, g. a. l., wolfe, l. a., mottola, m. f., & mackinnon, c. (2003). exercise in pregnancy and the postpartum period. journal of obstetrics and gynaecology canada, 25(6), 516–522. https://doi.org/https://doi.org/10.1016/s17012163(16)30313-9 dennis, c., & ross, l. (2005). relationships among infant sleep patterns, maternal fatigue, and development of depressive symptomatology. birth, 32(3), 187–193. dinc, a., kizilkaya beji, n., & yalcin, o. (2009). effect of pelvic floor muscle exercises in the treatment of urinary incontinence during pregnancy and the postpartum period. international urogynecology journal, 20(10), 1223–1231. https://doi.org/http://dx.doi.org/10.1007/s001 92-009-0929-3 dritsa, m., da costa, d., dupuis, g., lowensteyn, i., & khalifé, s. (2008). effects of a home-based exercise intervention on fatigue in postpartum depressed women: results of a randomized controlled trial. annals of behavioral medicine, 35(2), 179–187. https://doi.org/10.1007/s12160-008-9020-4 eyigor, s., karapolat, h., yesil, h., uslu, r., & durmaz, b. (2010). effects of pilates exercises on functional capacity, flexibility, fatigue, depression and quality of life in female breast cancer patients: a randomized controlled study. eur j phys rehabil med, 46(4), 481–487. gagnon, l.-h., boucher, j., & robert, m. (2016). impact of pelvic floor muscle training in the postpartum period. international urogynecology journal, 27(2), 255–260. https://doi.org/10.1007/s00192-015-2822-6 gökşin, i̇., & ayaz-alkaya, s. (2018). the effectiveness of progressive muscle relaxation on the postpartum quality of life: a randomized controlled trial. asian nursing research, 12(2), 86–90. https://doi.org/https://doi.org/10.1016/j.anr.20 18.03.003 golmakani, n., zare, z., khadem, n., shareh, h., & shakeri, m. t. (2015). the effect of pelvic floor muscle exercises program on sexual self-efficacy in primiparous women after delivery introduction. iranian journal of nursing and midwifery research, 20(3), 347–353. groër, m., davis, m., casey, k., short, b., smith, k., & groër, s. (2005). neuroendocrine and immune relationships in postpartum fatigue. mcn: the american journal of maternal/child nursing, 30(2), 133–138. guille, c., newman, r., fryml, l. d., lifton, c. k., & epperson, c. n. (2013). management of postpartum depression. journal of midwifery & women’s health, 58(6), 643–653. gutke, a., sjödahl, j., & öberg, b. (2010). original report specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy : a randomized , controlled clinical trial. journal rehabilitation medic, 42, 929–935. https://doi.org/10.2340/16501977-0615 hardianti, u., amir, m. y., & balqis. (2013). faktor yang berhubungan dengan mutu pelayanan antenatal di puskesmas pattingalloang kota makassar tahun 2013. 2(2), 1–11. https://doi.org/10.1007/s00340-005-1803-8 heh, s., huang, l., ho, s., fu, y., & wang, l. (2008). effectiveness of an exercise support program in reducing the severity of postnatal depression in taiwanese women. birth, 35(1), 60–65. higgins, p., savovic, h., page, m., & sterne, j. (2018). revised cochrane risk-of-bias tool for randomized trials (rob 2.0). rob 2.o development group, (march). hunter, l. p., rychnovsky, j. d., & yount, s. m. (2009). a selective review of maternal sleep characteristics in the postpartum period. journal of obstetric, gynecologic & neonatal nursing, 38(1), 60–68. insana, s. p., costello, c. r., & montgomery-downs, h. e. (2011). perception of partner sleep and mood: postpartum couples’ relationship satisfaction. journal of sex & marital therapy, 37(5), 428–440. kim, e.-y., kim, s.-y., & oh, d.-w. (2012). pelvic floor muscle exercises utilizing trunk stabilization for treating postpartum urinary incontinence: randomized controlled pilot trial of supervised versus unsupervised training. clinical rehabilitation, 26(2), 132–141. https://doi.org/http://dx.doi.org/10.1177/0269 215511411498 kuan-yin, l., yu-ting, h., king-jen, c., lin, h.-f., & tsauo, j.-y. (2011). effects of yoga on psychological health, quality of life, and physical health of patients with cancer: a meta-analysis. evidence based complementary and alternative medicine, 2011. https://doi.org/http://dx.doi.org/10.1155/2011 /659876 lee, s.-h. (2004). effects of aroma inhalation on fatigue and sleep quality of postpartum mothers. korean journal of women health nursing, 10(3), 235–243. jurnal ners http://e-journal.unair.ac.id/jners | 153 li, c.-y., chen, s.-c., li, c.-y., gau, m.-l., & huang, c.-m. (2011). randomised controlled trial of the effectiveness of using foot reflexology to improve quality of sleep amongst taiwanese postpartum women. midwifery, 27(2), 181–186. https://doi.org/https://doi.org/10.1016/j.midw. 2009.04.005 liberati, a., altman, d. g., tetzlaff, j., mulrow, c., gøtzsche, p. c., ioannidis, j. p. a., … moher, d. (2009). the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions : explanation and elaboration. 6(7). https://doi.org/10.1371/journal.pmed.1000100 lovell, g. p., huntsman, a., & hedley‐ward, j. (2015). psychological distress, depression, anxiety, stress, and exercise in a ustralian and n ew z ealand mothers: a cross‐sectional survey. nursing & health sciences, 17(1), 42–48. mahishale, a. v, ulorica, l. p. a. m., & patil, h. s. (2014). effect of postnatal exercises on quality of life in immediate postpartum mothers: a clinical trial. journal of safog, 6(1), 11–14. https://doi.org/10.5005/jp-journals-100061258 martínez-galiano, j. m., hernández-martínez, a., rodríguez-almagro, j., delgado-rodríguez, m., rubio-alvarez, a., & gómez-salgado, j. (2019). women’s quality of life at 6 weeks postpartum: influence of the discomfort present in the puerperium. international journal of environmental research and public health, 16(2), 1–9. https://doi.org/10.3390/ijerph16020253 mcguigan, f. j., & lehrer, p. m. (2007). progressive relaxation. principles and practice of stress management, 57. medina, a. m., lederhos, c. l., & lillis, t. a. (2009). sleep disruption and decline in marital satisfaction across the transition to parenthood. families, systems, & health, 27(2), 153. milligan, r. a., parks, p. l., kitzman, h., & lenz, e. r. (1997). measuring women’s fatigue during the postpartum period. journal of nursing measurement. moher, d., tetzlaff, j., altman, d. g., liberati, a., & group, p. (2009). preferred reporting items for systematic reviews and meta-analyses : the prisma statement. 339(august). https://doi.org/10.1136/bmj.b2535 morkved, s., & bo, k. (1999). prevalence of urinary incontinence during pregnancy and postpartum. international urogynecology journal, 10(6), 394– 398. nikpour, s., javaheri, i., yadavar nikravesh, m., & jamshidi, r. (2006). study of sexual problems resulting from delivery in primiparous women referred to outpatient clinics in west of tehran. razi journal of medical sciences, 13(50), 189–196. parker, l., ahn, h., bernardo, e. b. r., de oliveira, m. f., almeida, p. c., de oliveira, m. f., … antezana, f. j. (2015). maternal predictors for quality of life during the postpartum in brazilian mothers. health, 07(03), 371–380. https://doi.org/10.4236/health.2015.73042 pourkhiz, z., mohammad-alizadeh-charandabi, s., mirghafourvand, m., haj-ebrahimi, s., & ghaderi, f. (2017). effect of pelvic floor muscle training on female sexual function during pregnancy and postpartum: a randomized controlled trial. iranian red crescent medical journal, 19(10). https://doi.org/10.5812/ircmj.63218 rezaei, n., azadi, a., zargousi, r., sadoughi, z., tavalaee, z., & rezayati, m. (2016). maternal health-related quality of life and its predicting factors in the postpartum period in iran. scientifica, 2016, 1–7. https://doi.org/10.1155/2016/8542147 sampselle, c. m., seng, j., yeo, s., killion, c., & oakley, d. (1999). physical activity and postpartum well‐ being. journal of obstetric, gynecologic, & neonatal nursing, 28(1), 41–49. sterne, j. a., hernán, m. a., reeves, b. c., savović, j., berkman, n. d., viswanathan, m., … higgins, j. p. (2016). robins-i: a tool for assessing risk of bias in non-randomised studies of interventions. bmj, 355, i4919. https://doi.org/10.1136/bmj.i4919 sterne, j., higgins, j., elbers, r., reeves, b. c., & the development group for robins-i. (2016). risk of bias in non-randomized studies of interventions (robins-i): detailed guidance. (updated 12 october 2016), 1–53. sut, h. k., & kaplan, p. b. (2016). effect of pelvic floor muscle exercise on pelvic floor muscle activity and voiding functions during pregnancy and the postpartum period. neurourology and urodynamics, 35(3), 417–422. https://doi.org/10.1002/nau.22728 timlin, d., & simpson, e. e. a. (2017). a preliminary randomised control trial of the effects of dru yoga on psychological well-being in northern irish first time mothers. midwifery, 46, 29–36. https://doi.org/https://doi.org/10.1016/j.midw. 2017.01.005 wenzel, a., & stuart, s. c. (2011). anxiety in childbearing women: diagnosis and treatment. american psychological association. werner, e. a., gustafsson, h. c., lee, s., feng, t., jiang, n., desai, p., & monk, c. (2016). prepp: n. p. d. a. anggraeni et al. 154 | pissn: 1858-3598  eissn: 2502-5791 postpartum depression prevention through the mother–infant dyad. archives of women’s mental health, 19(2), 229–242. wolin, k. y., schwartz, a. l., matthews, c. e., courneya, k. s., & schmitz, k. h. (2012). implementing the exercise guidelines for cancer survivors. journal of supportive oncology, 10(5), 171–177. https://doi.org/10.1016/j.suponc.2012.02.001 yang, c.-l., & chen, c.-h. (2018). effectiveness of aerobic gymnastic exercise on stress, fatigue, and sleep quality during postpartum: a pilot randomized controlled trial. international journal of nursing studies, 77, 1–7. https://doi.org/10.1016/j.ijnurstu.2017.09.009 yang, c.-l., yu, c.-h., & chen, c.-h. (2013). development and validation of the postpartum sleep quality scale. journal of nursing research, 21(2), 148–154. http://e-journal.unair.ac.id/jners | 283 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17147 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review minimizing the use of restraint in patients with mental disorders at a mental hospital: a systematic review achmad syamsudin, fakhrun nisa fiddaroini and maulidiyah junnatul azizah heru faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: restraint in the psychiatric unit is a common practice but it is very controversial and it has undergone a poor evaluation according to methodological investigations. using restraint is a common problem and has a significant impact on patients, families and health care staff. therefore, this systematic review will discuss the important reasons as to why restraint should be reduced. it will also explain several alternative treatments for aggressive patients in mental hospitals. method: the database searches were used to identify potential articles: scopus and proquest were the focus. the search was limited to those published in the range of the last 5 years from 2013 to 2018. the keywords that were used were ‘restraint in the hospital’, ‘restraint reduction’, ‘the elimination of restraint’ and ‘physical restraint’. result: only 15 articles met the inclusion criteria. the results suggest that restraint is considered to be a violation of human rights and that it traumatizes the patients. it is inhuman and degrading. besides this, restraint can result in physical complications in the form of lacerations, asphyxia, thrombosis and death. restraint is permitted when other methods fail and in emergency conditions. conclusion: some of the ways to reduce the use of restraint are by constant monitoring and through the control of individual behavior, including verbal management and attitudes, reducing the environmental risks, and administering drugs. some of the efforts to avoid restraint are the "positive and safe in calderstones" program, sensory modulation and peer advice and support. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords restraint at the hospital; restraint reduction; elimination of restraint; physical restraint contact achmad syamsudin  achmadsyamsudin43@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: syamsudin, a, fiddaroini, f. n & heru, m.j.a (2019). minimizing the use of restraint in patients with mental disorders at a mental hospital: a systematic review. jurnal ners, 14(3si), 283-287. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17147 introduction using restraint is a common problem and it has a significant impact on the patients, families and health care staff (scheepmans, dierckx de casterlé, paquay, van gansbeke, & milisen, 2017). therefore, it is necessary to look for alternative treatment and appropriate strategies for aggressive patients. restraint is one of the actions that is often used in health care for people who are aggressive in a manner that can harm themselves and others. mental disorders are defined as the behavioral or psychological patterns shown by individuals that can cause dysfunction and distress and that can decrease the quality of life. it shows that there is the presence of psychobiological dysfunction that is not as a result of the conflict of public or social deviation. the persistence and severity of some mental disorders affects and causes stress for the families, individuals, communities and the wider health care system (stuart, 2016). the world health organization (who) estimated that there are approximately 450 million people who have mental disorders in the world. the results of riset kesehatan dasar (riskesdas) in 2013 showed that the prevalence of severe mental disorders in the indonesian population was 0.17%. meanwhile, mental emotional disorders stood at 6%. the highest prevalence of mental disorders was central sulawesi (11.6%) while the lowest province was lampung https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:achmadsyamsudin43@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). a. syamsudin et al. 284 | pissn: 1858-3598  eissn: 2502-5791 (1.2%). the prevalence of mental disorders in east java, for severe mental disorders (psychosis / schizophrenia), was 0.22% and for mental/emotional disorders, it stood at6.5% (penelitian & pengembangan, 2013)(badan penelitian dan pengembangan kesehatan, 2013). the main symptom that appears in patients with mental disorders is violent behavior. violent behavior is a form of expression of anger is not appropriate in which a person acts in a manner that injures themselves, other people and that even damages the environment (prabowo, 2014). one of the treatments for violent behavior is restraint. restraint in a psychiatric unit is a common practice but it is very controversial and poorly evaluated according to the methodological investigations. cultural issues, professional perceptions and attitudes are substantial contributors to the increasing frequency of using restraints (vedana et al., 2018). therefore, this systematic review will discuss important reasons as to why restraint should be reduced and it goes on to suggest several alternative treatments for aggressive patients in mental hospitals. materials and methods the method used was a systematic review of the literature with the aim of several studies suggesting that restraint needs to be reduced or that it needs to be kept as a last alternative to treat patients who are aggressive. this can endanger both the patients themselves and the nursing staff. the database search used the scopus and proquest database with a range from 2013 2018. the search for a systematic review begins with the selection of topics and the keywords were determined to search for the journals that used english. the keywords used in the search were "seclusion", "restraint reduction", "elimination of seclusion and restraint" and "physical restraint". after obtaining the database through scopus and proquest, it was then reviewed until the stage of making a systematic review. the inclusion criteria was the research related to minimizing the use of restraint on patients who were receiving hospital care. the exclusion criteria was if there was no relationship found with minimizing the use of restraint in patients with mental disorders in hospitals and journals published before 2014. the data to be extracted started from the general information including the author, the research design and the method used. the journals and abstracts that will be reviewed have been included in the journal feasibility assessment sheet. the journal feasibility test was seen in full text in a pdf format based on the inclusion criteria that have been set. the journals were in accordance with the original empirical research criteria of each review which was carried out in the form of critical appraisal analysis. data synthesis was done by summarizing the results of the study in the narrative and then discussing it. result definition seclusion and restraint is focused on restricting a consumer’s movement using environmental, physical or mechanical means. it is a containment methods used in inpatient settings and emergency departments to prevent and manage the risk of harm because of behaviors such as aggression, violence and self-injury (adam gerace & muir-cochrane, 2018) restraint may encompass the use of bodily force (physical restraint) or a device (mechanical restraint) to control a person’s freedom of movement. (brophy, roper, hamilton, tellez, & mcsherry, 2016). restraint (restricting patients’ freedom of movement by physical, mechanical, chemical and/or emotional means and seclusion (confining patients alone in rooms with locked doors and windows) may be used to address aggression but it can have deleterious effects on the patient (muir-cochrane, baird, & mccann, 2015). seclusion and restraint has its origins in the inhumane treatment of individuals with psychiatric disorders in the 18th century and earlier. during this period, service users were locked up in unclean rooms with little daylight and/or held in restraints. towards the end of the 18th century, there were improvements for the individuals confined to the asylums such as banning the use of manacles and chains. from a pragmatic perspective, seclusion can be defined as the voluntary or involuntary short-term isolation of a service user in either a specifically designed room, usually low-stimulating, bare or sparsely decorated (seclusion room), locked from the outside with a window for observation (green, shelly, gibb, & walker, 2018). prevalence it has been estimated that 12% of uk mental health patients have experienced physical restraint but its use varies both within the uk and internationally. chemical restraint is when medication is prescribed pro re nata (prn) as a reaction to agitated or aggressive behavior for the purpose of sedation (wilson, rouse, rae, & kar ray, 2017). studies performed in the psychiatric hospitals of two brazilian cities estimated that physical restraint was used in 13%–36% of admissions and that it was more common in the patients presenting with agitation/aggressive behavior (vedana et al., 2018). in the usa, decreases in the seclusion and restraint rates have been reported in the 70 facilities that have used these strategies. the reductions range from 47 to 92% (kinner et al., 2017). in the netherlands, restraint is recorded at 115.8 per 100 000 total population per year. although seclusion rates for non-māori and non-pacific island people in new zealand around this time was 59 events per 100 000 total population per year, the crude population rate for māori, the indigenous people of new zealand, was 258 seclusion events per 100 000 population per year (the highest populationjurnal ners http://e-journal.unair.ac.id/jners | 285 based rate reported internationally) (w. m. julie et al., 2016). type of restraint the term ‘restraint’ may encompass the use of bodily force (physical restraint) or a device used to control a person’s freedom of movement (mechanical restraint) and/or the use of medication to control a person’s behavior rather than to treat a mental disorder (chemical restraint) (kinner et al., 2017). chemical restraint in the uk often comes hand in hand with physical restraint as the patients are physically restrained in order to receive prn medication (wilson et al., 2017). some service users reported that during hospitalization, they were given strong doses of medication such as haloperidol. this is a medication whose significant side effects (apathy, somnolence, loss of consciousness and of memory and extra-pyramidal symptoms) can continue for hours and even days.(gagnon, desmartis, dipankui, gagnon, & st-pierre, 2013). parts involved regarding the restraint measures, the brazilian federal care council states that nurse assistants can only use mechanical restraints under the direct supervision of nurses, except in emergency situations. maintenance control is also needed by the doctors (vedana et al., 2018). the department of emergency of southern california states that handling patients should be done as part of a multidisciplinary collaboration. the team consists of emergency room staff nurses, emergency department leadership and doctors (kinner et al., 2017). reasons for using restraint research shows that restraint is seen of as the last resort method of staff and nurses. the study also shows that initiatives at various levels are needed to help the nurses to maintain security and to minimize / reduce and, if possible, eliminate the use of restraints (a gerace & muir-cochrane, 2018). most of the interviewees expressed the belief that restraint was needed and that it could not or should not be completely eliminated on the basis of security for all parties and with restraint being used as a last resort (wilson et al., 2017). the use of physical restraint shows that restraint is a challenging subject and that it can be considered an acceptable tool with various objectives, such as control, additional care, therapeutic measures and preventing damage (vedana et al., 2018). discussion restraint can cause physical and psychological injury to the patient. this is in accordance with a study conducted in australia on the patient’s families who had performed restraint and the patients themselves. it was found that restraint was a violation of human rights and that it was traumatizing, inhuman, degrading and limiting recovery (brophy et al., 2016)and that it could result in physical complications such as laceration, asphyxia, thrombosis and death (wilson et al., 2017). the restraint intervention is considered to be a difficult and potentially dangerous procedure for the patients, staff and others. they report on the negative consequences of restraint, including fractures, abrasions, cuts, bruises, bites, circulatory problems and contact with bodily fluids. bodily injuries among the staff and nurse assistants is another risk. physical restraint is a forced and traumatic procedure that is only permitted in very specific circumstances as a last alternative(vedana et al., 2018). however, many participants, especially professionals, also believe that seclusion and restraint actions tend to be beneficial, namely for increasing the safety of the patients and increasing the safety of the staff and others (kinner et al., 2017). the need for reduced or eliminated restraint and sectional action is because of the risk of physical health concerns associated with tension, including accidental injury and impaired respiratory function. some patients may also become physically depressed because of the long periods of restraint (green et al., 2018). restraint is not a therapeutic intervention because it not only has negative consequences for the patient but also for the staff as well. this is in accordance with a study called ‘the national mental health & caregivers forum’ (2009) that indicates that isolation and restraint is not therapeutic. it is not ‘generally related to human rights violations' because it can cause short-term and long-term emotional damage to patients (a gerace & muir-cochrane, 2018). prolonged restraint can be considered to be a violation of human rights (vedana et al., 2018). although it has been debated that control is needed for patient and staff safety, its use has negative consequences. the patients and staff report feeling depressed, scared, angry, anxious and frustrated (wilson et al., 2017). there is a strong agreement that the use of seclusion and restraint is dangerous, that it violates human rights and that it jeopardizes the therapeutic relationship and trust between the mental health service providers and patients (kinner et al., 2017). efforts to avoid restraint are by the constant monitoring and control of individual behavior, verbal management and attitudes, reducing the environmental risks and administering drugs (vedana et al., 2018). calderstones’ partnership and the nhs foundation trust have established the "positive and safe in calderstones" program which consists of three project group constituencies. the first of these, safewards, aims to create the most conducive culture possible and an environment that may be within the limits of specialist services. the second, positive behavioral support, focuses on workforce development, shifting the emphasis to more preventive techniques through increasing the staff competencies supported by relevant training. third, monitoring, reporting and review, is focused on the use of high-quality data (riding, 2016). one of https://www.emeraldinsight.com/keyword/positive+behavioural+support a. syamsudin et al. 286 | pissn: 1858-3598  eissn: 2502-5791 the ways to reduce the use of seclusion and restraint is through sensory modulation. the use of sensory modulation that is culturally appropriate includes the use of certain cultural prayers, songs, messages and dances. peer advice and support can support recovery by sharing personal stories, personal approaches and skills (w. julie et al., 2016)(bryson et al., 2017)(w. m. julie et al., 2016). constant observation seems to be an acceptable alternative to seclusion if there is also communication between the service users and individuals. listening and communicating are the main approaches that are spontaneously proposed as an alternative to restraint and seclusion (gagnon et al., 2013). conclusion restraint and seclusion are not therapeutic interventions related to human rights violations because they can cause emotional damage and physical injury. however, restraint and seclusion may be used in mental hospitals as a last alternative. it is necessary to reduce the use of restraint because it is deemed not to be humane and it has various adverse consequences. there needs to be an appropriate strategic alternative in terms of handling aggressive and furious patients in order to reduce and ultimately eliminate restraint. some of the ways to reduce the use of restraint are by constant monitoring and the control of individual behavior, including through verbal management and the observation of their attitude, reducing the environmental risks and administering drugs. some of the efforts to avoid restraint include the "positive and safe in calderstones" program, which consists of three project group constituencies including sensory modulation and peer advice and support. listening and communicating are the main approaches that are spontaneously proposed as an alternative to restraint and seclusion. references badan penelitian dan pengembangan kesehatan. (2013). riset kesehatan dasar (riskesdas) 2013. laporan nasional 2013, 1–384. https://doi.org/1 desember 2013 brophy, l. m., roper, c. e., hamilton, b. e., tellez, j. j., & mcsherry, b. m. (2016). consumers’ and their supporters’ perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings. australian health review, 40(6), 599–604. https://doi.org/10.1071/ah15128 bryson, s. a., gauvin, e., jamieson, a., rathgeber, m., faulkner-gibson, l., bell, s., … burke, s. (2017). what are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? a realist systematic review. international journal of mental health systems, 11(1), 1–16. https://doi.org/10.1186/s13033-017-0137-3 gagnon, m. p., desmartis, m., dipankui, m. t., gagnon, j., & st-pierre, m. (2013). alternatives to seclusion and restraint in psychiatry and in long-term care facilities for the elderly: perspectives of service users and family members. patient, 6(4), 269–280. https://doi.org/10.1007/s40271-013-0023-2 gerace, a, & muir-cochrane, e. (2018). perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: an australian survey. int j ment health nurs, (october 2017). https://doi.org/10.1111/inm.12522 gerace, adam, & muir-cochrane, e. (2018). perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments: an australian survey. international journal of mental health nursing, (october 2017). https://doi.org/10.1111/inm.12522 green, r., shelly, c., gibb, j., & walker, t. (2018). implementing seclusion in forensic mental health care: a qualitative study of staff decision making. archives of psychiatric nursing, (december 2017), 0–1. https://doi.org/10.1016/j.apnu.2018.04.008 julie, w., erana, c., nick, w., trudie, f., jason, h., mike, t., … brian, m. (2016). strategies to reduce the use of seclusion with t ā ngata whai i te ora ( m ā ori mental health service users ). 258–265. https://doi.org/10.1111/inm.12219 julie, w. m., erana, c., nick, w., trudie, f., jason, h., mike, t., … brian, m. (2016). strategies to reduce the use of seclusion with tāngata whai i te ora (māori mental health service users). international journal of mental health nursing, 25(3), 258–265. https://doi.org/10.1111/inm.12219 kinner, s. a., harvey, c., hamilton, b., brophy, l., roper, c., mcsherry, b., & young, j. t. (2017). attitudes towards seclusion and restraint in mental health settings: findings from a large, community-based survey of consumers, carers and mental health professionals. epidemiology and psychiatric sciences, 26(5), 535–544. https://doi.org/10.1017/s2045796016000585 muir-cochrane, e. c., baird, j., & mccann, t. v. (2015). nurses’ experiences of restraint and seclusion use in short-stay acute old age psychiatry inpatient units: a qualitative study. journal of psychiatric and mental health nursing, 22(2), 109–115. https://doi.org/10.1111/jpm.12189 penelitian, b., & pengembangan, d. a. n. (2013). riset kesehatan dasar. prabowo, e. (2014). konsep & aplikasi asuhan keperawatan jiwa. nuha medika. riding, t. (2016). exorcising restraint: reducing the use of restrictive interventions in a secure learning disability service. journal of intellectual disabilities and offending behaviour, 7(4), 176– 185. https://doi.org/10.1108/jidob-06-20160007 jurnal ners http://e-journal.unair.ac.id/jners | 287 scheepmans, k., dierckx de casterlé, b., paquay, l., van gansbeke, h., & milisen, k. (2017). restraint use in older adults receiving home care. journal of the american geriatrics society, 65(8), 1769– 1776. https://doi.org/10.1111/jgs.14880 stuart, g. w. (2016). prinsip dan praktik keperawatan kesehatan jiwa stuart. jesika pasaribu. vedana, k. g. g., da silva, d. m., ventura, c. a. a., giacon, b. c. c., zanetti, a. c. g., miasso, a. i., & borges, t. l. (2018). physical and mechanical restraint in psychiatric units: perceptions and experiences of nursing staff. archives of psychiatric nursing, 32(3), 367–372. https://doi.org/10.1016/j.apnu.2017.11.027 wilson, c., rouse, l., rae, s., & kar ray, m. (2017). is restraint a ‘necessary evil’ in mental health care? mental health inpatients’ and staff members’ experience of physical restraint. international journal of mental health nursing, 26(5), 500–512. https://doi.org/10.1111/inm.12382 http://e-journal.unair.ac.id/jners | 321 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17173 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the difference between the conventional warm compress and tepid sponge technique warm compress in the body temperature changes of pediatric patients with typhoid fever aulya kartini dg karra1, muh. aswar anas2, muh. anwar hafid2, and rosdiana rahim2 1faculty of nursing, universitas airlangga, surabaya, indonesia 2faculty of medicine and health sciences, alauddin state islamic university makassar, south sulawesi, indonesia abstract introduction: the use of warm compresses and warm sponge techniques as a modality therapy for the management of fever in typhoid children has a good influence. the purpose of this research was to learn of the differences between conventional warm compress and the tepid sponge technique as related to the body temperature changes of pediatric patients with typhoid fever. a fever that does not get a good standard of treatment can cause dehydration, neurological damage and febrile seizures. methods: the research design was quasi-experiment with two groups prepost test. the population was taken from the kampili community health center while the 20 samples were taken using the purposive sampling technique. conventional warm compresses were placed on the forehead, while warm tepid sponges were compressed and placed on the forehead, armpits and the folds of the thighs simultaneously. results: . the data of the results were significance tested using the general linear model repeated measure (p value 0.03 for conventional warm compresses and p value 0.01 on a warm compress tepid sponge technique). conclusion: statistically, the warm compress tepid sponge technique is more meaningful and qualitatively, the temperature change is better after the compression. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords typhoid; children; warm; compresses; warm sponge; fever contact aulya kartini dg karra  aulya.kartini.dg2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: karna, a.k.d., anas, m.a., hafid, m.a., & rahim, r. (2019). the difference between the conventional warm compress and tepid sponge technique warm compress in the body temperature changes of pediatric patients with typhoid fever. jurnal ners, 14(3si),321-326. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17173 introduction typhoid fever is a systemic infection caused by gram negative bacteria salmonella typhi. this bacteria are on food or drinks associated with poor hygiene and areas with poor sanitation. typhoid fever is a serious health problem and it is a major cause of infant morbidity and mortality in developing countries (almeida & almeida, 2008). fevers that do not get a good treatment can cause dehydration, neurological damage and febrile seizures (arbianingsih, 2011). a report from the who revealed that 21 million cases and > 600,000 deaths every year worldwide are due to typhoid fever. developing countries have the highest number of typhoid fever cases caused by the rapid population growth, increased urbanization and limited water and health service hygiene (gebreyesus & negash, 2015) areas with high endemicity include central asia, south asia, southeast asia and south africa (almeida & almeida, 2008). a study conducted in urban areas in some asian countries focused on children aged 5 15 years showed that the incidence of positive blood cultures reached 180-194 per 100,000 children in south asia in those aged 5-15 years. it was 400–500 per 100,000 population in southeast asia and in northeast asia, it was less than 100 cases per 100,000 population (burnside dan m.c glynn, 2014). in indonesia, typhoid fever should get serious attention from various parties because this disease is endemic and threatens public health. the problem is increasingly complex with increasing career cases (carrier) or relapse and resistance to the drugs used, thus making it more difficult for treatment and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). a. k. d. karra, et al. 322 | pissn: 1858-3598  eissn: 2502-5791 prevention efforts to respond. in 2008, typhoid morbidity in indonesia was reported to be 81.7 per 100,000 population, with the distribution according to the age group being 0.0 / 100,000 population (0–1 years), 148.7 / 100,000 population (2-4 years), 180, 3 / 100,000 (5-15 years) and 51.2 / 100,000 (= 16 years). this figure shows that the highest number of sufferers is in the 2-15 years old age group (kemenkes, 2006) one effort to reduce fever is with a warm compress. according to the research, a warm compress can be used as an independent act by the nurses to help to reduce the patient’s body temperature (surakarta & ambarwati, n.d.) conventional warm compresses (forehead area) can reduce the body temperature but warm compresses on the forehead produce insignificant decreases in temperature (edbor, arora, & mukherjee, 2011). another action used to reduce heat is a tepid sponge. tepid sponging is a procedure used to improve the control of body heat loss through evaporation and conduction, which is usually done in patients who have a high fever. the purpose of the tepid sponge action is to reduce the body temperature in patients who have hyperthermia (gebreyesus & negash, 2015). the tepid sponge technique is more effective at lowering the body temperature in the first 15 minutes. the research carried out combining mothers with the tepid sponge technique showed that it can reduce the body temperature better than just using profen mothers only (hidayati, 2014). according to a study conducted by (kania, 2015), the reduction of the body temperature using a warm sponge with antipyretic drugs was significantly faster than using only antipyretics and paracetamol. however, the effects of discomfort were milder. based on the background phenomenon of the above problems, the researchers wanted to examine the difference between a conventional warm compress and the tepid sponge technique related to the body temperature changes of pediatric patients with typhoid fever. materials and methods this research was conducted using a quasiexperimental technique. a quasi-experiment explains the relationship used as a basis to predict a phenomenon (kanj et al., 2015). the types of design used were two groups of pre-test post-tests. the sample totaled 20 people, consisting of 10 in the conventional warm intervention groups and 10 people in the group for the tepid sponge technique. the sample in the research were children aged 3 12 years old (preschool and school years) who had been admitted to the kampili health center inpatient room, who had typhoid fever based on a medical diagnosis (temperature; 37,20c – 39,50c) and who had received fluid therapy and antipyretic therapy. this study used the research instrument of observation sheets for the body temperature research method, in addition to conventional warm compress equipment, tepid sponge warm compress equipment, a wrist watch, stationery and a mercury thermometer for the axillary measurements. measuring the body temperature was done using a mercury thermometer because it has a 99% accuracy rate. mercury responds to body temperature and it is not related to other factors such as battery usage or damage as might happen to a digital thermometer machine. the location of this study was in the inpatient room of the kampili community health center, pallangga district, gowa regency. to determine the effect of the conventional warm compress and tepid sponge technique warm compress on the body temperature changes of pediatric patients with typhoid fever, the data was analyzed using the general linear model-univariate test. in addition, the general linear model repeated measure test was also used to determine whether there were significant differences in the variables that were measured repeatedly. results based on the results of the research conducted on the 20 respondents using a conventional warm compresses and the tepid sponge technique, [table 1] shows the demographic data, namely the distribution of respondents based on the highest age at 7 12 years especially in reference to the tepid sponge techniques (60.0%). conventionally, those between the ages of 3-6 years old and 7-12 years old were comparable (50% each), while the distribution of respondents by sex was that (70%) were women in the conventional warm compress group while the sexes were split by 50% each in the tepid sponge technique. the variable data on the form and duration of the fever suffered after 4-6 days of compressing was so for as many as 13 respondents (65%), which is the duration of fever suffered the most. the distribution of the respondents based on length of the treatment performed was 1 day of treatment for 13 respondents (65%), which was the most common treatment time. [table 2] shows that the distribution of the respondents based on the level of fever was, for the conventional warm compresses in the pre-test measurements, at the highest febrile level, namely 38.50c. the highest sub-febrile value was 37.90c. for the tepid sponge technique, the highest score was 38.60c and the highest sub-febris was 38.20c. the highest temperature compressed in this research was 38.60c compressed with the tepid sponge technique. [table 3] after the general linear model-repeated measure test is carried out the following results: temperature changes between the pre-test and posttest in the conventional warm compress groups were as follows: in the 5 minutes after compressing, the p value was 0.07 (p> α) or 0.07> 0.05, which means that conventional warm compresses are not statistically significant but they are able to reduce the average body temperature by 0,150c in quality. at 15 minutes, the p value was 0.01 (p <α) or 0.01 <0.05, which jurnal ners http://e-journal.unair.ac.id/jners | 323 means that conventional warm compresses in the 15th minute after compressing caused a decrease in body temperature. at 30 minutes, the p value was 0, 78 (p> α) or 0.78> 0.05, which means that there is no decrease in body temperature and it even tends to increase from the pre-test value. at 60 minutes, we got a p value of 0.21 (p> α) or 0, 21> 0.05, which means that conventional warm compresses 60 minutes after the compression do not lower the body temperature and it even tends to increase from the pre test value. the temperature changes between the pre-test and post-test in the warm compress group for the tepid sponge technique were as follows. in the 5 minutes after compressing, it got a p value of 0.01 (p <α) or 0.01 <0.05, which means that the tepid sponge technique affects the decrease in body temperature. at 15 minutes, p value 0.01 was obtained (p <α) or 0.01 <0.05, which means that the tepid sponge table 1. distribution of the respondents based on their demographic data respondent’s characteristics conventional warm warm compress tepid sponge frequency (%) frequency (%) age 36 years 5 50.0 4 40.0 7-12 years 5 50.0 6 60.0 total 10 100 10 100 gender male 330.0 5 50.0 female 770.0 5 50.0 total 10 100 10 100 old fever suffered frequency percentage (%) 1 3 days 7 35.0 4 – 6 days 13 65.0 total 20 100 duration of treatment frequency percentage (%) 1 day 13 65.0 2 days 7 35.0 total 20 100 table 2. respondent’s frequency distribution based on the dependent variables warm compress warmth level highest value pre-test (0c) conventional febris subfebris 38,5 37,9 febris sub-febris 38.6 38,2 table 3. effect of compression on changes in body temperature at every time of measurement technique transfer temperature change p value conventional pre-test-minute ke 5 0,07 (p value 0,03) pre-test-minute ke 15 0,01 pre-test-minute ke 30 0,78 pre-test-minute ke 60 0,21 tepid sponge pre-test minute ke 5 0,01 (p value 0,01) pre-test-minute ke 15 0,01 pre-test-minute ke 30 0,02 pre-test-minute ke 60 0,11 table 4. effect of compression on changes in body temperature multivariate analysis warm technique temperature change p value conventional pillai's trace ,003 wilks' lambda ,003 hotelling's trace ,003 roy's largest root pillai's trace ,003 0,01 tepid sponge wilks' lambda 0,01 hotelling's trace 0,01 roy's largest root 0,01 a. k. d. karra, et al. 324 | pissn: 1858-3598  eissn: 2502-5791 technique has an effect on decreasing the body temperature in the 15 minutes after compressing. in the 30 minutes after compressing, the p value was 0.02 (p> α) or 0.02> 0.05, which means that the tepid sponge technique is not statistically significant but it is able to reduce the average body temperature by 0.110 c 30 minutes after compressing. at 60 minutes, the p value was 0.11 (p> α) or 0.11> 0.05, which means that the tepid sponge technique does not reduce the body temperature 60 minutes after compressing, which is even higher than the pre test value [table 4]. the effect of the compress on changes in body temperature analyzed using multivariate analysis was done to find out whether the mean of the post-test measurements differed significantly. multivariate tests were carried out by looking at table 4.8. from all of the tests, it was concluded that they all rejected ho because all of the tests produced the same p-value, which was 0.03 <0.05. there was a significant difference in the changes in body temperature with the conventional warm compresses. for the tepid sponge technique, all tests produced the same p-value, that is 0.01 <0.05. there was a significant difference in the changes in body temperature. of the two types of compresses based on the analysis, the tepid sponge technique was more statistically significant because the p value was lower than that of the conventional warm compresses (0.01 <0.03). the multivariate tests included pillai's trace test, wilks' lamda, hotelling's trace and roy's largest root; the values of the 4 tests were also used to strengthen the results of the hypothesis. discussion a heat or fever conditions is where the brain fixes the body temperature above the normal setting, which is above 380c. however, true heat is when the temperature is > 38.50c. as a result of the increasing demand, the body will produce heat. infection is the entry of microorganisms (microorganisms or very small living things that are generally not visible to the eye) into the body. the entry of microorganisms does not necessarily cause us to fall sick, depending on many things. among others, it depends on how strong our immune system is. if our immune system is strong, then we may not get sick. even if we are sick, our body then forms immune substances (antibodies). microorganisms can include germicidal bacteria, viruses and fungi. in children who have an infection, the signs of an elevated body heat often appear. it has been proven that a fever is deliberately made by our body as an effort to help the body get rid of infection. when attacked by an infection, the body must eradicate it. the trick is by deploying the immune system. commanding the forces to fight infection are the white blood cells. in carrying out their duties to be effective and on target, white blood cells cannot be alone. support is needed by many parties including pyrogens. pyrogens have a complex role in the regulatory mechanism that exists in the human body. pyrogens have 2 missions: 1. deploy the white blood cells or leukocytes to the site of infection and 2. cause a fever that will kill the virus. this is because viruses do not deal well with high temperatures. the typhoid virus thrives at low temperatures (djuwariyah, 2011). the occurrence of fever when someone has an infection in one of his organs, for example, is not a negative sign like it is in typhoid. typhoid fever has the typical symptom of a continuous fever. this is a fever that persists with a maximum fluctuation of 0,40c over a 24 hour period (kemenkes, 2006). typhoid fever is more common in school-aged children (nasution, 2015). in typhoid fever patients, there is a fever that is not too high and that lasts for 3 weeks. the first week is where there is an increase in fluctuating body temperature. usually the body temperature increases at night and decreases in the morning (nurrochmadc & williams, 2014). the first step in managing the fever is to make the diagnosis as precise as possible before establishing treatment modalities that are not necessarily drugs (pujiarto, 2008). one effort to reduce fever is warm compresses that cause the body temperature to warm up. the body will interpret that the temperature is quite hot and eventually the body will reduce the temperature control in the brain so as not to increase the body's temperature further. warmer temperatures make the vessels carrying the peripheral blood widen and vasodilate, so the skin pores will open and facilitate heat dissipation. changes in body temperature will therefore occur (djuwariyah, 2011). a warm compress on the skin can inhibit shivering and the resulting metabolic effects. in addition, a warm compress also induce peripheral vasodilation, thereby increasing the amount of body heat coming out (purba & wandra, 2016). a warm compress can be made by coating the surface of the skin with a towel soaked in warm water. the results of the research conducted proved that a compress of wet warmth is effective at lowering the body temperature in fever patients diagnosed with typhoid fever (purwanti & ambarwati, 2008). the nonpharmacological treatment of fever that can be done includes compressing. the compress techniques that can be used come in the form of a conventional warm compress or the tepid sponge technique. warm water compresses are more effective by 74.6% at reducing the body temperature of pediatric patients with a fever than compress plasters (yuliani, 2006). the tepid sponge is one of the warm compress techniques that combines a block technique related to the superficial large vessels with the seka technique throughout the body. the results of the research conducted shows there to be a significant comparison of effectiveness between a tepid sponge compress and warm water compress toward the body temperature reduction in typhoid fever children with hyperthermia. the tepid sponge compress show a greater reduction in numbers compared to the warm water compress (susanti, 2012). child nursing uses jurnal ners http://e-journal.unair.ac.id/jners | 325 the principle of a family care center that there is a family partner in contact related to child care. the associated nurse provides appropriate information for them to make decisions, assesses the family needs and gathers the families to help them learn of appropriate resources in their environment (suyanto, 2011). this research was carried out for 3 weeks by compressing 1 respondent for 15 20 minutes (to avoid the rebound phenomenon). the respondents were children who had typhoid fever in the inpatient ward of the kampili health center, totaling 20 respondents. the respondents in this study each received parenteral fluid therapy in the form of ivfd ringer lactat and antiperetic therapy. none of the respondents had any secondary diseases. this was based on the medical diagnoses concluded from the clinical examinations and laboratory examinations (widal test). the researchers also first examined for the existence of a wound,; if no wound was found, then compressing could be done. the average value of the respondent's body temperature before being compressed (pre test) was 37.80c for the conventional warm compresses whereas for the tepid sponge technique, it was 38.040c. from the differential univariate-general linear model and the general linear model-repeated measure test, it is known that conventional warm compresses and the tepid sponge technique significantly influence body temperature changes. based on the results of the testing using the univariate-general linear model, it showed a value of p <α (0,03<0,05) which concluded that there was a difference between conventional warm compresses and the tepid sponge technique (h0 rejected). based on the general linear model-repeated measure test, the p value for conventional warm compresses was obtained after compressing: after 5 minutes (0.07)> 0.05, the average effect given was a decrease in body temperature of 0,150c, in 5 minutes and up to 15 (0.01) <0.05, the average effect given was a decrease in body temperature of 0.280c, at 30 minutes (0.78)> 0.05, the average effect given was a decrease in body temperature of 0.010 c and at 60 minutes (0.21)> 0.05, the average effect given was an increase in body temperature of 0.690c from the initial temperature of the compress. based on the results of the statistical tests on the changes in body temperature after being compressed, the decrease was only found in the 5 to 15 minute period for the conventional warm compresses while the tepid sponge technique decreased the temperature for between 5 to 30 minutes; 60 minutes after both types of compress were used, there was an increase in temperature again. because this research was only empirical, the researchers assume that it is influenced by the placement of the compression cloth. conventional warm-sensitive neurons are less sensitized because the compress is only placed at 1 point. impulses from afferent nerve fibers received by the hypothalamus to control body temperature are determined by the receptors. unlike what is the case with warm compresses, the tepid sponge technique and the placement of the compress cloth at 3 points of afferent nerve fibers allows for the stimulus to the receptor to be stronger which allows for decrease in temperature for longer, up to 30 minutes after compressing. conclusion based on the results of the study, it was obtained that the average for the conventional warm compress pretest body temperature was 37.830c while the average tepid sponge technique warm compress pre-test body temperature was 38.040c. changes in the body temperature fluctuated in both the conventional warm compresses and tepid sponge technique. from the different univariate-general linear model test, it is known that both the conventional warm compresses and tepid sponge technique significantly influence changes in body temperature p = 0.03. the tepid sponge technique is better used for fever management in children with typhoid fever than conventional warm compresses because the decrease in body temperature occurs from 5 minutes through 30 minutes while the conventional warm compresses’ decrease in body temperature only lasts for 15 minutes after compressing. references almeida, m. de, & almeida, m. de. (2008). tepid sponging plus dipyrone versus dipyrone alone for reducing body temperature in febrile children. 126(2), 107–111. arbianingsih. (2011). keperawatan anak: konsep dan prosedur tindakan. makassar: alauddin press. burnside dan m.c glynn. (2014). diagnosis fisik adam edisi 17. jakarta: egc,. djuwariyah. (2011). efektivitas penurunan suhu tubuh menggunakan kompres air hangat dan kompres plester pada anak dengan demam di ruang kanthil rumah sakit umum daerah banyumas. retrieved from http://digilib.ump.ac.id/files/disk1/16/jhptu mp-a-djuwariyah-758-1-efektivi-.pdf. edbor, a. j., arora, a. k., & mukherjee, p. s. (2011). early management of fever: benefits of combination therapy. 53(4), 702–705. gebreyesus, a., & negash, l. (2015). international journal of infectious diseases diagnosis and treatment of typhoid fever and associated prevailing drug resistance in northern ethiopia. international journal of infectious diseases, 35, 96–102. https://doi.org/10.1016/j.ijid.2015.04.014 hidayati. (2014). no title. jakarta: penerbit erlangga. kania. (2015). upaya peningkatan kualitas tumbuh kembang anak. (pustaka unpad). kanj, s. s., kanafani, z. a., shehab, m., sidani, n., baban, t., baltajian, k., … matar, g. m. (2015). epidemiology , clinical manifestations , and molecular typing of salmonella typhi isolated a. k. d. karra, et al. 326 | pissn: 1858-3598  eissn: 2502-5791 from patients with typhoid fever in lebanon. (2015), 159–165. kemenkes. (2006). pedoman pengendalian demam typoid. nasution, r. d. (2015). no 主観的健康感を中心とし た在宅高齢者における健康関連指標に関する 共分散構造分析title. 3(2), 54–67. nurrochmadc, a., & williams. (2014). fakultas ilmu kesehatan universitas muhammadiyah surakarta 2014. hubungan antara peningkatan angka persalinan seksio caesar dengan program jampersal di rsud moewardi surakarta, 6. pujiarto, p. s. (2008). demam pada anak. majalah kedokteran indonesia. http://indonesia.digitaljournals.org/index.php /idnmed/article/download/900/899. purba, i. e., & wandra, t. (2016). program pengendalian demam tifoid di indonesia : tantangan dan peluang. (february 2017). https://doi.org/10.22435/mpk.v26i2.5447.99108 purwanti, s., & ambarwati, w. n. (2008). pengaruh kompres hangat terhadap perubahan suhu tubuh pada pasien anak hipertermia di ruang rawat inap rsud dr. moewardi surakarta. berita ilmu keperawatn, 1(2), 81–86. retrieved from https://publikasiilmiah.ums.ac.id/xmlui/bitstr eam/handle/11617/484/2f.pdf?sequence=1&i sallowed=y%0ahttp://journals.ums.ac.id/inde x.php/bik/article/download/3741/2410 surakarta, r. m., & ambarwati, w. n. (n.d.). tubuh pada pasien anak hipertermia di ruang rawat inap. 81–86. susanti, n. (2012). efektivitas kompres dingin dan hangat pada penatalksanaan demam. http://download.portalgaruda.org/article.php ?article=115578&val=5285. suyanto. (2011). metodologi dan aplikasi penelitian keperawatan. yogyakarta: nusa medika. yuliani, s. dan r. (2006). asuhan keperawatan pada anak. jakarta: cv sagung seto. 188 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18968 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effect of health education on mothers’ knowledge in the prevention of acute respiratory infection in toddlers in waimital village, maluku ira sandi tunny1, idham soamole1,2, suhendra a. wibowo2, ira purnamasari2, wiwi rumaolat1 1institute of health science maluku husada, maluku, indonesia 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: acute respiratory infection (ari) is a disease caused by infectious agents that are usually toddlers, so it is expected that the family, especially the mother, plays a role in terms of having good knowledge about the prevention of ari transmission. health education through visual aid leaflets is very effective to increase knowledge and understanding in preventing ari disease. the aim of this study was to determine the effect of health education on the level of maternal knowledge in the prevention of ari in children under. methods: the research design used was a pre-experiment with one group and a pretest-posttest design approach. intervention was carried out by way of house visits on a sample of 129 people. the research instrument used was questionnaire data analysis using the wilcoxon test at a significance of (α <0.05). results: before doing health education, good knowledge was seen in 2 respondents or 1.6% and after the action of health education using leaflets, good knowledge was seen in 33 respondents or 25.6%. statistical analysis of respondents' knowledge after treatment obtained an average value for knowledge of 68.84; the lowest value was 30 and the highest was 100, significant with a p-value = 0.000 (α <0.05). conclusion: health education using leaflets can increase mothers' knowledge so that it encourages self-efficacy and self-management and increases awareness in the prevention of disease. there is an influence of health education on the level of maternal knowledge in the prevention of ari among children under five. article history received: feb 27, 2020 accepted: april 1, 2020 keywords acute respiratory infection; health education; knowledge contact ira sandi tunny  irasandi.99@gmail.com  institute of health science maluku husada, maluku, indonesia cite this as: tunny, i. a., soamole, i., wibowo, s. a., purnamasari, i., & rumaolat, w. (2020). effect of health education on mothers’ knowledge in prevention of acute respiratory infection in toddlers in waimital village, maluku. jurnal ners, special issues, 188-192. doi:http://dx.doi.org/10.20473/jn.v15i2(si).18968 introduction acute respiratory infection (ari) is an acute infection that attacks one part/more than one part of the airways from the nose to the alveoli including adnexa (sinus, middle ear cavity, pleura). this infection is caused by viruses, fungi, and bacteria. ari will attack the host if the immune system or immunity decline. (dharmayanti & tjandararini, 2018). the highest prevalence of ari occurs in toddlers. according to who (world health organization), ± 13 million children under five in the world die every year and most of these deaths occur in developing countries in asia and africa such as india (48%), indonesia (38%), ethiopia (4,4%), pakistan (4.3%), china (3.5%), sudan (1.5%), and nepal (0.3%) (putra & wulandari, 2019). in maluku province, the number of ari cases among under-fives ranks first out of 10 in terms of most cases of the disease. and western spooky districts in 2018 the number of ari cases in toddlers was 12,171 and in waimital care health centers in 2018, the number of cases of ari in toddlers was 1,576 (profil_kesehatan_2018_1 6.pdf, n.d.). there are several risk factors that cause ari in toddlers including incomplete immunization, exposure to cigarette smoke and dust, lack of breastfeeding, mother's educational background and lack of mother's knowledge about toddler care. the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ about:blank http://dx.doi.org/10.20473/jn.v15i2(si). jurnal ners http://e-journal.unair.ac.id/jners | 189 increasing frequency of ari events in children has caused socio-economic concerns and burdens for parents, especially mothers, so many of them have consulted health practitioners, especially doctors in prescribing antibiotics (bham et al., 2016). to reduce the increase in prevalence, it is necessary for there to be a family role in the prevention of ari in toddlers, especially among mothers. one of the preventive management techniques is the implementation of health education interventions to transmit information to mothers about how to properly care for and prevent ari in toddlers (saleh faidah et al., 2019). health education interventions are very effective in increasing one's awareness and motivation in preventing risk factors for the disease especially in rural areas such as west seram district waimital. therefore health education must be delivered through visual aids such as brochures or leaflets to encourage willingness and increase knowledge and understanding in preventing an illness (mohebi et al., 2018) . health education using leaflets can help respondents improve self-efficacy and self-management and increase respondent awareness in the prevention of disease (karuniawati et al., 2019). this is supported by research conducted by kayalli in 2016, which was conducted on 486 patients, with patients wanting to receive information verbally and in writing. more than half of the patients (60%) read leaflets and found useful resources in them (kayyali, 2016). for ari that occurs in the west seram community, one of the triggering factors is the lack of parental knowledge of the importance of obtaining information to prevent and overcome ari events in toddlers. based on preliminary studies obtained by researchers on june 14, 2019, from one of the waimital community health centers, officials stated that the ispa problem that occurs in waimital village is the lack of parental knowledge about it. as evidenced by a survey conducted in the village of waimital, in which it was found that out of the 20 surveys carried out, 11 parents had toddlers who experienced ari and lacked knowledge. the purpose of this study was to determine the effect of health education on the level of maternal knowledge in the prevention of ari among children under five years of age in waimital village, kairatu district, west seram district. materials and methods this research was a type of pre-experimental research with an on-group pre-post-test design approach that reveals cause and effect by involving one group of subjects. the subject group was observed before the intervention and then observed again after the intervention. (nursalam 2017). this research was conducted for 5 weeks from july 8 to august 10, 2019, in the village of waimital, kairatu district, west seram district, maluku province. the sampling technique used was consecutive sampling, with a large sample of 129 respondents. respondents were mothers who have children under five who live in the village of waimital, kairatu sub-district. this study did not go through an ethical test because there were no ethics commissions formed at the educational institutions, but before conducting the study, informed consent was sought from respondents. data collection techniques in this study were obtained through direct interviews with respondents using a research instrument in the form of a questionnaire with home visits. the questionnaire consisted of 10 closed questions surrounding the concept of the disease. before the intervention, respondents filled out a questionnaire about the concept of ari. furthermore, respondents were given health education interventions on ari disease material assisted with visual media in the form of leaflets containing information on understanding, causes, signs and symptoms, risk factors and prevention. the intervention was only carried out for one session for 20-30 minutes. the intervention was not done in groups but with each individual through a home visit. after 1 hour, it was evaluated by giving the same questionnaire to the respondent. after the data, retrieval was done and the data were obtained; the data processing was then performed which included several parts, namely: editing, coding, processing, cleaning, and tabulating. then the data were analyzed using spss version 21 computer software. the analyses used were: univariate and bivariate analysis using wilcoxon nonparametric statistical tests with significance levels (α = 0.05). results characteristics of respondents the 129 respondents, mothers who had children under five in the village of waimital, had the following characteristics: univariate analysis knowledge of respondents in waimital village before and after the health education intervention was given in table 2. based on table 2, prior to the intervention, respondents who had good knowledge totaled only 2 people (1.6%), just 6 people (4.7%) had sufficient knowledge and as many as 121 people (93.8%) had less knowledge. after the intervention, the respondents' knowledge increased to 33 people (25.6%) with good knowledge, 90 people (69.8%) with enough knowledge and those with less knowledge were only 6 people (4.7%). normality test the normality test used was kolmogorov-smirnov because the sample was above 50 respondents. based on the results of the normality test, data from the variables were not normally distributed because they i. s. tunny et al. 190 | pissn: 1858-3598  eissn: 2502-5791 had a p-value <0.05. because the requirements for normal data are p-value > 0.05, the test used was the wilcoxon nonparametric test. bivariate analysis result bivariate analysis aims to determine the effect of health education on the level of maternal knowledge in the prevention of ari among children under five. based on table 3, it can be seen that the median knowledge of respondents before treatment was 20.85. the lowest value was 10 and the highest was 100. while the analysis of respondents' knowledge after treatment obtained an average value of knowledge of 68.84, the lowest value was 30 and the highest was 100. a significant p-value of 0.000 (α < 0.05) was obtained, thus it can be concluded that there is a health effect of education at the level of maternal knowledge in the prevention of ari among children under five. discussion from the results of the study, there was still a lack of knowledge of respondents before health education was conducted even though most mothers had secondary education. but interestingly 2 (1.6%) of the respondents had good knowledge because their education level was bachelor's level given that the higher the level of one's education, the better one's knowledge and attitudes and behavior (notoatmodjo 2014). but an increase in knowledge is not absolutely obtained from formal education but can also be obtained through non-formal education such as the role of health education and access to information from various media which is still lacking (karimah et al., 2014). as is known, prevention of ari is a very important problem because of the high incidence of ari in children, especially among toddlers. parents, especially mothers, play an important role in preventing ari by avoiding risk factors, especially cigarette smoke and dust, ensuring environmental cleanliness and avoiding other risk factors. one of the factors is how much health education is given (alexandrino et al., 2017) the results of the study show that, after being given an intervention in the form of health education, the knowledge of respondents increased by 25.6% in the good knowledge category and sufficient knowledge increased to 69.8%. this is because health education guidance was carried out in this study by visiting house to house with visual aids, namely leaflets. the results of this study were supported by karuniawati in an article which stated that health education via house-to-house guidance using visual media was more effective and better at increasing respondents' knowledge in understanding both disease prevention or adherence to treatment. visual media leaflets are needed to make it easier for table 1. characteristics of respondents (n=129) characteristics of respondents n % age 19-23 24-28 29-33 34-39 12 46 36 35 9,3 35,7 27,9 27,1 level of education primary school junior high school senior high school diploma 3 scholar 1 17 28 78 3 3 13,2 21,7 60,5 2,3 2,3 job government employees entrepreneur housewife farmer 5 27 91 6 3,9 20,9 70,5 4,6 primary data source in 2019 table 2. respondents’ knowledge knowledge pre-test post test (n) (%) (n) (%) good sufficient less 2 6 121 1,6 4,7 93,8 33 90 6 25,6 69,8 4,7 total 129 100 129 100 primary data source in 2019 table 3. wilcoxon test knowledge of respondents before and after being given health education about acute respiratory infections knowledge (n) mean (min-max) pvalue pre-test post-test 129 129 20.71 68.84 (10-100) (30-100) 0.000 0.000 primary data source in 2019 jurnal ners http://e-journal.unair.ac.id/jners | 191 patients to get information related to disease prevention (karuniawati et al., 2019). in addition to counseling, mothers can read leaflets about the concepts of the disease listed so that they can immediately ask questions about what they do not understand. a person's knowledge of an object involves two aspects, namely positive aspects and negative aspects. these two aspects will determine a person's attitude; the more positive aspects and objects that are known, the more positive attitudes towards an object (andarias et al., 2018). a positive attitude can turn negative if you do not receive guidance in the form of education or education and vice versa because of the attitude of having valence; a positive attitude can also be increased to be more positive (kamaljeet singh, 2017). but from the results of the study, there were still 4.7% of respondents who lack knowledge; this is because there were 5.4% of respondents who had a primary school education: the higher the level of one's education, the better one's knowledge and attitudes and behavior and vice versa notoatmodjo (2015). knowledge can encourage someone to try to get more information about something that is deemed necessary to be understood further or is considered important. such knowledge encourages parents to develop attitudes that lead to action as a result or output of knowledge about things that are the right of children, one of which is to be nurtured. there was a significant relationship between the mother's level of knowledge with care efforts for toddlers with ari. this result is reinforced by the opinion of notosiswoyo in muhammad who stated that a low level of knowledge and skills in the family, especially mothers, is one of the triggers of ari in toddlers (andarias et al., 2018). from the wilcoxon test results with α <0.05, pvalue = 0.000, this means that there is an influence of health education on the level of maternal knowledge in the prevention of ari in children under five so that h0 is rejected and ha is accepted. based on this theory, health education is an effort aimed at influencing others and providing learning to the community so that healthy living behavior is applied in an effort to improve their health. one health education technique is the use of leaflets to make it easier for respondents to immediately read anywhere and anytime. in addition, leaflets can help respondents improve self-efficacy and selfmanagement and increase respondent awareness in disease prevention (karuniawati et al., 2019). this is supported by research conducted by kayalli, conducted on 486 patients, who wanted to receive information verbally and in writing. more than half of the patients (60%) read the leaflets and found useful resources (kayyali, 2016). health education affects a person's level of knowledge. knowledge is the result of human sensing or the result of knowing something about objects through the senses. factors that influence a person's level of knowledge include education, information/mass media, social, cultural, and economic, environment, experience, and age. the level of knowledge will be a provision to be more selective in looking after toddlers (andarias et al., 2018). however, limited knowledge can affect family health care, especially among toddlers. so it is demanded of parents, especially mothers, to always increase their knowledge so that they can take good care of their children. conclusion the solution in preventing the emergence of ari in a toddler is to conduct health education with the help of visual leaflets for parents, especially mothers. the leaflet medium helps mothers to understand because it can be read immediately wherever and whenever. this method has a significant positive impact on increasing knowledge and awareness in terms of changing attitudes and behaviors to care for toddlers. from the results of the study, after being given an intervention, mothers who had children under five showed an increase in the prevention of ari so that there was an influence of health education on the level of maternal knowledge in the prevention of ari in children under five in waimital village, maluku province. it is recommended that additional similar research is conducted using group intervention so that the group and individual method can be compared for efficacy. conflict of interest the authors report no conflicts of interest. the authors alone are responsible for the content and writing of the paper. acknowledgement the authors would like to thank the mothers who have toddlers for being willing to be respondents in this study, to the village head of waimital and the head of the waimital village public health center who helped and especially to mrs. ira sandi tunny for her guidance so that this research could be completed. references alexandrino, a. m. f. d. s., dos santos, r. i. g. v., de melo, m. c. d. a., & bastos, j. a. m. (2017). designing and evaluating a health education session on respiratory infections addressed to caregivers of children under three years of age attending day-care centres in porto, portugal: a community-based intervention. european journal of general practice, 23(1), 43–50. https://doi.org/10.1080/13814788.2016.1240777 andarias, m., darwis, & hanis. (2018). gambaran pengetahuan orang tua dan lingkungan keluarga dengan kejadian ispa di wilayah kerja puskesmas batua kota makasar. jurnal ilmiah kesehatan diagnosis, 12(6), 630–634. bham, s. q., saeed, f., & shah, m. a. (2016). knowledge, attitude and practice of mothers on acute respiratory infection in children under five years. pakistan journal of medical sciences, 32(6), i. s. tunny et al. 192 | pissn: 1858-3598  eissn: 2502-5791 1557–1561. https://doi.org/10.12669/pjms.326.10788 dharmayanti, i., & tjandararini, d. h. (2018). identifikasi indikator dalam indeks pembangunan kesehatan masyarakat (ipkm) untuk meningkatkan nilai sub-indeks penyakit menular. jurnal keperawatan padjadjaran, 5(3), 249–257. https://doi.org/10.24198/jkp.v5i3.647 kamaljeet singh, deepak sharma. (2017). effect of health education on awareness obout oral cencer and oral selfexamination. 1–6. https://doi.org/10.4103/jehp.jehp karimah, d. n., kurniawati, n. d., & hidayati, l. (2014). pendidikan kesehatan dengan metode syndicate group meningkatkan pengetahuan tentang pencegahan ispa pada remaja putri di pondok pesantren. universitas airlangga, 3(1), 31–41. karuniawati, h., putra, o. n., & wikantyasning, e. r. (2019). impact of pharmacist counseling and leaflet on the adherence of pulmonary tuberculosis patients in lungs hospital in indonesia. indian journal of tuberculosis, 66(3), 364–369. https://doi.org/10.1016/j.ijtb.2019.02.015 kayyali, r. (2016). patients perceptions of medication counselling from community pharmacies. pharmacy & pharmacology international journal, 4(2), 334–337. https://doi.org/10.15406/ppij.2016.04.00071 mohebi, s., parham, m., sharifirad, g., & gharlipour, z. (2018). social support and self ‑ care behavior study. 1–6. https://doi.org/10.4103/jehp.jehp notoatmodjo (2014). ilmu perilaku kesehatan, jakarta: rineka cipta. notoatmodjo (2015) pendidikan dan perilaku kesehatan. jakarta: rineka cipta nursalam (2017). metodologi penelitian ilmu keperawatan. penerbit salemba medika: jakarta. profil_kesehatan_2018_1 6.pdf. (n.d.). putra, y., & wulandari, s. s. (2019). faktor penyebab kejadian ispa. jurnal kesehatan, 10(1), 37. https://doi.org/10.35730/jk.v10i1.378 saleh faidah, h., haseeb, a., yousuf lamfon, m., mohammad almatrafi, m., abdullah almasoudi, i., cheema, e., hassan almalki, w., e elrggal, m., mohamed, m. a., saleem, f., mansour algethamy, m., pervaiz, b., khan, t. m., & azmi hassali, m. (2019). parents’ self-directed practices towards the use of antibiotics for upper respiratory tract infections in makkah, saudi arabia. bmc pediatrics, 19(1), 1–9. https://doi.org/10.1186/s12887-019-1391-0 144 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.16561 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research analysis of sociodemographic and information factors on family behaviour in early detection of high-risk pregnancy ika mardiyanti1, shrimarti rukmini devy1, ernawati ernawati2 1 faculty of public health, universitas airlangga, surabaya, east java, indonesia 2 faculty of medicine, universitas airlangga, east java, indonesia abstract introduction: pregnancy and childbirth are physiological processes experienced by women, but they sometimes have risky conditions. there are still many pregnant women and their families who are unable to detect a highrisk of pregnancy early. this study aims to determine family behaviour in conducting early detection of a high-risk of pregnancy in terms of sociodemographic and information factors. methods: this study uses an explanatory survey design with a cross sectional design. the sample size of this study was 146, with simple random sampling. the independent variables were sociodemographic factors (age, gender, ethnicity, education, income and religion) and information factors (experience, and media exposure) while the dependent variable is family behaviour. the instrument with the questionnaire used the likert scale. the data was analysed using partial least square. results: the results showed that structural equation modelling-partial least square (sem-pls) statistical analysis, through confirmatory factor analysis (cfa), obtained sociodemographic factors on family behaviour of 1,999, and information factors on family behaviour of 13,78. the value of the influence of sociodemographic factors (0.102) and the value of the influence of information factors (0.754). r2 (0.63) and q2 value of 0.65. conclusion: sociodemographic factors and information factors significantly influenced family behaviour factors in early detection of high-risk of pregnancy. information factors have a greater effect on family behaviour than sociodemographic factors. midwives as health service providers at the health care centre need to optimize family empowerment through health information efforts in health promotion efforts. further research requires the involvement of other factors to improve family behaviour, especially in the ability of families to detect early high-risk pregnancies. article history received: december 09, 2019 accepted: december 26, 2019 keywords behaviour; family; high-risk; pregnancy contact ika mardiyanti  ika.mardiyanti2017@fkm.unair.ac.id  faculty of public health, universitas airlangga, surabaya, east java, indonesia cite this as: mardiyanti, i., devy, s. r., & ernawati. (2019). analysis of sociodemographic and information factors on family behaviour in early detection ff high-risk pregnancy. jurnal ners, 14(2), 144-150. doi:http://dx.doi.org/10.20473/jn.v14i2.16561 introduction pregnancy and childbirth are physiological processes experienced by a woman, but sometimes there are risky conditions (holness, 2018). the ability of pregnant women to detect early high-risks is still below the average, which is one of the causes of complications that can endanger the welfare of the mother and foetus (lee, ayers, & holden, 2016). for this reason there is a need for social support from family, friends, colleagues and health care providers to provide support to pregnant women, especially in risky conditions. this is especially important given the importance of maternal mental health during pregnancy (wei et al., 2018). national maternal mortality rate (mmr) from 1991-2015 has fluctuated. the results of the indonesian demographic and health survey (idhs) 2017 showed a decrease in mmr during the 1991https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.1 jurnal ners http://e-journal.unair.ac.id/jners | 145 2007 period from 390 to 228 per 100,000 kh, in 2012 it increased to 359 per 100,000 kh, in 2015 it decrease to 305 per 100,000 kh. results of the 2015 intercensal population survey (supas) again showed a decline in mmr to 305 per 100,000 kh. the reduction in mortality has not yet reached the mdgs (millennium development goals) target of reducing mmr to 102 per 100,000 kh in 2015 and is still far from sdgs (sustainable development goals) output to reduce mmr to 70 per 100,000 kh in 2030 (ministry of health republic indonesia, 2017). surabaya city is the highest regency / city in east java with pregnant women experiencing obstetric complications of 9,496 out of 47,480 pregnant women in 2016 (health office of east java province, 2017). the number of high-risk pregnant women in 2015-2017 continued to increase, in 2015 amounted to 17,656 pregnant women, in 2016 amounted to 17,928 pregnant women, and in 2017 amounted to 19,698 pregnant women (health office of surabaya, 2017). the phenomenon in the community at this time is that there are still many pregnant women and their families who do not and are not able to perform early detection of a high-risk pregnancy. this is proven by the low coverage of early detection of high-risk by the community. lack of community participation in early detection of high-risk of pregnancy is due to low levels of education and family knowledge, behaviour that is less supportive such as social position, economic ability and thus causes families to experience powerlessness in carrying out early detection of high-risk pregnancy (khadijah & ., 2018). the factors affecting individuals as well as family, act among other things: personal factors (general attitudes, personality traits, values of life, emotions and intelligence), sociodemographic factors (age, gender, ethnicity, education, income and religion) and information factors (experience, knowledge, and media exposure) (nursalam, 2017). sociodemographic factors such as income and education can influence the condition of pregnant women and even depression (biaggi, conroy, pawlby, & pariante, 2016). the impact of early detection of highrisk pregnancy is not done optimally by the family, among others, is the occurrence of delays called 3 late. the first is late in recognizing danger signs of pregnancy and childbirth, the second is too late to make decisions, the third is too late to get to the hospital or referral is late. 3 late results in a higher maternal mortality rate (mmr) and infant mortality rate (imr) (fatkhiyah, kodijah, & masturoh, 2018). the family is expected to act as the closest support system for pregnant women, because in the family there are strong emotions to help take care of the mother during her pregnancy including in detecting abnormalities and danger signs (joyce, tully, kirkham, dicker, & breathnach, 2018). early detection of symptoms and danger signs during pregnancy is the best effort to prevent the occurrence of serious disruption to pregnancy and maternal safety. conducting early recognition of risk factors in pregnancy and childbirth as far as possible by pregnant women themselves, their husbands and families (klugman, li, barker, parsons, & dale, 2019). family behaviour in terms of sociodemographic factors and information can improve the ability of families, in this case the husband to participate in the care of pregnant women in recognizing the high-risk of pregnancy, and important aspects in caring for these pregnant women, as well as increasing family involvement in family empowerment. the purpose of this study was to determine family behaviour in conducting early detection of a high-risk of pregnancy in terms of sociodemographic and information factors. materials and methods in this study, the design is an explanatory survey design with a cross sectional design. the population and sample are family. the independent variables are sociodemographic factors (age, gender, ethnic, education, income and religion) and information factors (experience, and media exposure) while the dependent variable is family behaviour. the sample size of 146 respondents from the population pregnant women in the area around the dupak health center is obtained by simple random sampling. this research was conducted in august to september 2019 in puskesmas dupak health center surabaya, east java. with the inclusion criteria of families who live together with pregnant women, and who play an important role in family decision maker. the questionnaire used the likert scale. exogenous variables (sociodemographic and information) and endogenous variables (family behaviour). valid indicators of social factors are education (0.76) and income (0.91), religious indicators (0.22) and gender (0.22) are quite valid. education and income indicators have a significant effect on sociodemographic factors, religious and gender indicators also have a significant effect. information factors are validly explained by experience indicators (1.00) and media exposure (0.30). so, the indicators of experience and media exposure have a significant effect on the information factor. based on the composite reliability and cronbach alpha values above which are worth more than 0.6 for sociodemographic factors (0.61), information (0.75) and family behaviour (1.0), it can be concluded that these factors are reliable (reliable) or consistent. data collection is done directly / primary data, and analysed by sem-pls, through cfa (confirmatory factor analysis). ethical clearance has i. mardiyanti, et al. 146 | pissn: 1858-3598  eissn: 2502-5791 been issued by the airlangga university faculty of nursing ethics team no. 1752-kepk in august 2019. results data obtained from 146 respondents are presented in the distributed table. table 1 shows that the age of the respondents spread in all groups. where the most age groups are 36-45 years and 26-35 years, respectively 35.6% and 30.8%. the gender of the majority of male respondents was 89%, education was spread at all levels, with the highest level of education being elementary education (sd-smp) as much as 56.8% and secondary education (high school) as much as 31.5%. the ethnic origin of respondents are almost entirely javanese at 76%, then madura at 23.3%. the income of the respondents is almost entirely in the sufficient category which is 80.8%; and the religion practiced by almost all islam/muslims is 83.6%. related information variables with experience indicators (54.8%) had received counselling and for indicators of media exposure almost all (89.7%) were exposed to media in the form of posters. in regard to family behaviour related to actions taken by family members in carrying out family tasks in early detection of a high-risk of pregnancy, it is known that the achieved or positive behaviour is 52.7%, while that which is not achieved or the behaviour towards negative is 47.3%. analysis of measurement models the process of analysing the measurement model is done by testing the validity and reliability of the factor variables. indicator criterion indicators concluded valid measuring the factor variables, if the loading factor value has the value of t-statistics ≥ ttable or if the value of t-statistics of the weight of influence ≥ t-table = t (n-1; 5% / 2) = t (92; 0.025) = 1.96. while it is concluded invalid if the factor loading value and the influence weight value both have tstatistic values <1.96. the next tests the consistency / reliability of the factor variables by using composite reliability and alpha cronbach values. the criterion that the factors concluded reliable is explained by the indicator variables, if the composite value > 0.7 then the consistency of the factors is good, and if the value of 0.6 to 0.7 is still acceptable. it is known that all indicator variables have t-statistics values more than t-table values = 1.96. there are only 2 indicators that do not reach 1.96 and are still above 1, so the conclusion is quite significant. indicators of valid sociodemographic factors are education and income, religious and gender indicators are valid enough to explain sociodemographic factors. education and income indicators have a significant effect on sociodemographic factors, religious and gender indicators have a significant effect. information factors are explained validly by indicators of experience and media exposure. so, it can be concluded that the indicators of experience and media exposure significantly influence the information factor. based on the value of composite reliability and cronbach alpha. which are worth more than 0.6 for sociodemographic factors, information and family behaviour, it can be concluded that the factors mentioned above are reliable (reliable) or consistent. analysis of structural model testing analysis of the structural model testing to evaluate several criteria, namely the significance criteria of the coefficient of influence of exogenous variables (sociodemographic and information) of the endogenous variable (behavioural family), then the criteria of the coefficient of determination (r2), and predicted relevance (q2). significance criteria of the coefficient of influence of sociodemographic factors and information factors on family behaviour factors, table 1. frequency distribution of sociodemographic, information, and family behaviour variables (n=146) indicator sub indicator n % sociodemographic age (years old) 17-25 16 11.0 26-35 45 30.8 36-45 52 35.6 46-55 27 18.5 56 65 5 3.4 >65 1 0.7 gender male 130 89.0 female 16 11.0 education basic 83 56.8 intermediate 46 31.5 high 17 11.6 ethnic java 111 76.0 madura 34 23.3 china 1 0.7 batak 0 0 income high 28 19.2 enough 118 80.8 religion islam 122 83.6 christian 24 16.4 catholic 0 0 hindu 0 0 buddha 0 0 experience ever 80 54.8 not yet 66 45.2 media exposure poster 131 89.7 leaflet 7 4.8 not exposed 8 5.5 family behaviour family behaviour reached 77 52.7 not achieved 69 47.3 jurnal ners http://e-journal.unair.ac.id/jners | 147 by testing using t-statistics values which are then compared with t-table values. the results of testing the effect of the coefficient of influence between sociodemographic factors and information factors on family behaviour in early detection of high-risk of pregnancy, that the tstatistics between sociodemographic factors on family behaviour is 1.999 where above the t-table value of 1.96, it is concluded that sociodemographic factors have a significant effect towards family behaviour. furthermore, the t-statistic value of the information factor on family behaviour is 13.78 where above the t-table value of 1.96 it is concluded that the information factor has a significant effect on family behaviour. the value of the influence of sociodemographic factors on family behaviour is 0.102, where the value of the influence is linear in the same direction which means that if sociodemographic factors are increased by 1 unit it will increase family behaviour in the early detection of high-risk of pregnancy, with the effect of an increase of 0.102 times. the value of the influence of information factors on family behaviour is 0.754, where the value of the influence is linear in the direction which means that if the information factor is increased by 1 unit it will increase family behaviour in the early detection of high-risk of pregnancy, with the effect increasing by 0.754 times. results of processing coefficient of determination (r2) of the influence of sociodemographic factors and factors of information on family behavioural factors in the early detection of high-risk pregnancies, amounting to 0.63. so this value is included in the criteria both in terms of large variations of endogenous factors (family behaviour) that can be explained by exogenous factors (sociodemographic and information). the processing results obtained q2 value of 0.65. this value is included in the criteria of having a good ability (relevant) in predicting. discussion the sociodemographic factors examined in this study concern age, sex, education, ethnicity, income and religion. sociodemographic factors have the effect of increasing family behaviour in the detection of highrisk of pregnancy by 0.102 times and the information factor has the effect of increasing family behaviour in the detection of high-risk of pregnancy by 0.754 times. in this study almost half in the late adult age group 36-45 years (35.6%) and early adults 26-35 years (30.8%). in family members who are old enough the level of maturity and strength of the family will be more mature in thinking and acting. this is seen from the experience and maturity of his soul. age is one of the factors that influence one's health behaviour (lin, broström, nilsen, & pakpour, 2018). support obtained from husbands, families and health workers is very important in recognizing the symptoms and responses felt by pregnant women (zand et al., 2017). in this research, in the majority of respondent families, 89% were accompanied by their husband. husband support is particularly beneficial in reducing anxiety and complications in pregnancy (abdollahpour, ramezani, & khosravi, 2015). support, especially from couples, is very influential in making decisions (alemayehu & meskele, 2017). family education is mostly elementary education (elementary-junior high) at 56.8%. the lack of community participation in the early detection of high-risk of pregnancy is due to low levels of education and knowledge, and low income resulting in unsupportive behaviour. education is one way for families to receive knowledge about antenatal care, with high education and good knowledge which will make families easy to receive information and conduct early detection of high-risk pregnancies (mehta, zheng, & myrskylä, 2019). table 2. convergent validity of latent variables latent variable indicator convergent validity loading factor (λ) t statistics validity sociodemographic religious 0,22 1,06 valid enough gender 0,22 1,25 valid enough education 0,76 4,44 valid income 0,91 5,42 valid information exposure media 0,30 2,64 valid experience 1,00 139,92 valid figure 1. value of loading factor and t-statistics value of the model i. mardiyanti, et al. 148 | pissn: 1858-3598  eissn: 2502-5791 the origin of respondents is almost entirely javanese 76% and madura 23.3%. indigenous peoples' knowledge about health advice can be good information in supporting education and behaviour for pregnant women of certain ethnicities. for example, in madura many dietary restrictions and food suggestions are applied for pregnant women. this affects the patterns of habits and behaviour of pregnant women and their families (diana et al., 2018). culture has a strong influence on decision making. family participation in perinatal care is very important (tobing, afiyanti, & rachmawati, 2019). income shows that almost all (80.8%) respondents have a sufficient income level. it is important for financial income to meet the daily needs of households in the community, specifically with financing, then someone will be able to utilize the existing health facilities such as treatment and control that can still maintain the health of pregnant women. this income is very influential on family behaviour, including pregnant women. a good level of income allows family members to meet better needs, for example in the fields of education, health, career development and so on. health care professionals should carefully assess the state of family empowerment of primary caregivers who are younger and those with low education, low household income, high burden of child-rearing, and ties are fragile among the members of the family. home visits and institutional services for the provision of care and services are well coordinated (wakimizu, fujioka, nishigaki, & matsuzawa, 2018). religion, at almost 83.6%, is almost entirely muslim. religion is published about life in humans, published in humans. the existence of such rules can provide guidance to families in how to care for and respond to families who are pregnant. spirituality strongly influences muslims in supporting spiritual values during pregnancy and childbirth, nurses must be sensitive to women's spirituality and integrate this element in providing maternal nursing care (budiati & setyowati, 2019). the information factors examined in this study include experience and media exposure. most respondents (54.8%) had the experience of respondents from the study results who had received counselling about risky pregnancy. in addition, most respondents consider themselves experienced when children also have experiences about other people who have already been pregnant. a collaborative education model using multi-disciplines for patient education will be very important to provide information related to assistance provided to support maternal mortality and morbidity (jain & moroz, 2017). in this study nearly half (89.7%) of respondents were exposed to the media related to high-risk pregnancies in poster form. respondents obtained information about high-risk pregnancies from posters or leaflets provided at puskesmas, as well as electronic media, and counselling by health workers. media information about the detection of high-risk of pregnancy can affect one's knowledge (dewi, 2017). the results of this study showed the majority of family behaviour reached 52.7%. information factors have a greater effect on family behaviour in the detection of high-risk of pregnancy. information about high-risk pregnancies provided by health workers both print and electronic media will increase the knowledge of pregnant women and their families about the importance of early detection of high-risk pregnancies so that they can be encouraged to do so. the role of health workers in providing information about high-risk pregnancies is very important (widarta, cahya laksana, sulistyono, & purnomo, 2015). the role of the government in providing information about high-risk pregnancies greatly helps pregnant women and families to obtain better information (waryana, supadi, & haryani, 2016). the information factor on family behaviour is 0.754 greater than the sociodemographic factor. a more proactive approach to providing information may be valuable not only for those who have a clear desire for more information, but also for those who are unsure of what information they might have missed (baron et al., 2017). the behaviour of the family in performing early detection of high-risk pregnancies in influenced by a person's health beliefs (health belief) in theory hbm (health belief model). hbm (health belief model) is used to identify several important priority factors that have an impact on behaviour (huang, dai, & xu, 2020). table 3. path coefficients: effect of sociodemographic and information on family behaviour indicators original sample (o) sample mean (m) standard deviation standard error tstatistics religious <sociodemographic 0.215 0.210 0.203 0.203 1.058 gender <sociodemographic 0.225 0.212 0.180 0.180 1.248 exposure media <information 0.304 0.299 0.115 0.115 2.643 education <sociodemographic 0.764 0.713 0.172 0.172 4.439 experience <information 0.999 0.994 0.007 0.007 139.917 income <sociodemographic 0.909 0.865 0.168 0.168 5.424 information ->family behaviour 0.754 0.752 0.0555 0.0555 13.78 sociodemographic ->family behaviour 0.102 0.110 0.051 0.051 1.999 jurnal ners http://e-journal.unair.ac.id/jners | 149 azwar (2013) stated that according to the theory of planned behaviour, among the various beliefs, the availability of opportunities and resources are the reason to determine intention and attitude. this belief can be derived from the experience, and also it can be influenced by indirect information about behaviour, for example by looking at the experience of a friend or someone else. it is also influenced by several other factors that reduce or increase the effect of the difficulty committing acts. human behaviour occurs through a stimulusorganism-response process. the behaviour in question is family behaviour in the early detection of high-risk pregnancies in which behaviour is associated with factors of age, education, income, knowledge, experience and media exposure. in fact, the role of the husband and the family also influences pregnant women in supporting the behaviour or actions of pregnant women in utilizing health services (chou et al., 2018). a person's health behaviour is determined, among other things, by the presence or absence of support from the surrounding social support, in this case midwives are the main health care providers during pregnancy, they should ideally emphasize the availability of questions during antenatal examinations (baron et al., 2017). people who live in an environment that upholds health aspects will be more enthusiastic in maintaining their health (yeh, ma, huang, hsueh, & chiang, 2016). maternal and child health needs to be improved, so in an effort to improve the holistic and integrative approach is not only limited to the medical sector, but also economically, educationally and socio-culturally (asmuji. & indriyani, 2016). the involvement of families as caregivers is to improve their health status (chimowitz, gerard, fossa, bourgeois, & bell, 2018). the limitation in this research is that it only relates to sociodemographic and information factors. while there are other factors that also influence family behaviour in detecting early high-risk pregnancies. conclusion there are social factors and information factors that need to be considered to improve family behaviour in pregnancy care. the information factor has a larger comparison than sociodemographic factors. family problems can improve the quality of the family in approval of danger signs or problems experienced in the family. midwives as health service providers at the health care centre need to optimize family empowerment through health information efforts in health promotion efforts. further research needs an optimal family empowerment model that makes families need help during pregnancy and participates in preventing the presence of maternal and infant applications. references abdollahpour, s., ramezani, s., & khosravi, a. (2015). perceived social support among family in pregnant women. international journal of pediatrics. https://doi.org/10.22038/ijp.2015.4703 alemayehu, m., & meskele, m. (2017). health care decision making autonomy of women from rural districts of southern ethiopia: a community based cross-sectional study. international journal of women’s health. https://doi.org/10.2147/ijwh.s131139 asmuji., & indriyani, d. (2016). model family centered maternity care sebagai strategi optimalisasi competent mothering. ners airlangga. https://doi.org/http://dx.doi.org/10.20473/jn.v 11i12016.17-28 azwar, s. (2013). sikap manusia: teori dan pengukurannya. sikap manusia: teori dan pengukurannya. https://doi.org/10.1038/cddis.2011.1 baron, r., heesterbeek, q., manniën, j., hutton, e. k., brug, j., & westerman, m. j. (2017). exploring health education with midwives, as perceived by pregnant women in primary care: a qualitative study in the netherlands. midwifery. https://doi.org/10.1016/j.midw.2017.01.012 biaggi, a., conroy, s., pawlby, s., & pariante, c. m. (2016). identifying the women at risk of antenatal anxiety and depression: a systematic review. journal of affective disorders. https://doi.org/10.1016/j.jad.2015.11.014 budiati, t., & setyowati. (2019). the influence culture and maternal care on exclusive breastfeeding practice in post caesarean section mothers. enfermeria clinica. https://doi.org/10.1016/j.enfcli.2019.04.121 chimowitz, h., gerard, m., fossa, a., bourgeois, f., & bell, s. k. (2018). empowering informal caregivers with health information: opennotes as a safety strategy. joint commission journal on quality and patient safety. https://doi.org/10.1016/j.jcjq.2017.09.004 chou, j. l., pierce, k. j., pennington, l. b., seiler, r., michael, j., mc namara, d., & zand, d. (2018). social support, family empowerment, substance use, and perceived parenting competency during pregnancy for women with substance use disorders. substance use and misuse. https://doi.org/10.1080/10826084.2018.14674 56 dewi, r. g. a. i. (2017). pengaruh kemampuan ibu hamil dalam melakukan deteksi dini risiko preeklamsia terhadap paritas, pengetahuan dan keterpaparan informasi. medical technology and public health journal. https://doi.org/10.33086/mtphj.v1i1.275 diana, r., rachmayanti, r. d., anwar, f., khomsan, a., christianti, d. f., & kusuma, r. (2018). food taboos and suggestions among madurese pregnant women: a qualitative study. journal of ethnic foods. https://doi.org/10.1016/j.jef.2018.10.006 fatkhiyah, n., kodijah, k., & masturoh, m. (2018). i. mardiyanti, et al. 150 | pissn: 1858-3598  eissn: 2502-5791 determinan maternal kejadian preeklampsia: studi kasus di kabupaten tegal, jawa tengah. jurnal keperawatan soedirman. https://doi.org/10.20884/1.jks.2016.11.1.642 health office of east java province. (2017). profil kesehatan jawa timur 2017. in profil kesehatan jawa timur. health office of surabaya. (2017). profil dinas kesehatan kota surabaya. in dinas kesehatan. holness, n. (2018). high-risk pregnancy. nursing clinics of north america. https://doi.org/10.1016/j.cnur.2018.01.010 huang, x., dai, s., & xu, h. (2020). predicting tourists’ health risk preventative behaviour and travelling satisfaction in tibet: combining the theory of planned behaviour and health belief model. tourism management perspectives. https://doi.org/10.1016/j.tmp.2019.100589 jain, j., & moroz, l. (2017). strategies to reduce disparities in maternal morbidity and mortality: patient and provider education. seminars in perinatology. https://doi.org/10.1053/j.semperi.2017.04.010 joyce, n. m., tully, e., kirkham, c., dicker, p., & breathnach, f. m. (2018). perinatal mortality or severe neonatal encephalopathy among normally formed singleton pregnancies according to obstetric risk status:” is low risk the new high risk?” a population-based cohort study. european journal of obstetrics and gynecology and reproductive biology. https://doi.org/10.1016/j.ejogrb.2018.06.010 khadijah, s., & . a. (2018). upaya deteksi dini resiko tinggi kehamilan ditentukan oleh pengetahuan dan dukungan tenaga kesehatan. jurnal sehat mandiri. https://doi.org/10.33761/jsm.v13i1.2 klugman, j., li, l., barker, k. m., parsons, j., & dale, k. (2019). how are the domains of women’s inclusion, justice, and security associated with maternal and infant mortality across countries? insights from the women, peace, and security index. ssm population health. https://doi.org/10.1016/j.ssmph.2019.100486 lee, s., ayers, s., & holden, d. (2016). risk perception and choice of place of birth in women with high risk pregnancies: a qualitative study. midwifery. https://doi.org/10.1016/j.midw.2016.03.008 lin, c. y., broström, a., nilsen, p., & pakpour, a. h. (2018). using extended theory of planned behavior to understand aspirin adherence in pregnant women. pregnancy hypertension. https://doi.org/10.1016/j.preghy.2018.04.001 mehta, n. k., zheng, h., & myrskylä, m. (2019). how do age and major risk factors for mortality interact over the life-course? implications for health disparities research and public health policy. ssm population health. https://doi.org/10.1016/j.ssmph.2019.100438 ministry of health republic indonesia. (2017). profile kesehatan indonesia 2017. ministry of health indonesia. https://doi.org/10.1002/qj nursalam. (2017). metodologi penelitian ilmu keperawatan: pendekatan praktis. in metodologi penelitian iimu keperawatan: pendekatan praktis. tobing, v. y., afiyanti, y., & rachmawati, i. n. (2019). following the cultural norms as an effort to protect the mother and the baby during the perinatal period: an ethnographic study of women’s food choices. enfermeria clinica. https://doi.org/10.1016/j.enfcli.2019.04.125 wakimizu, r., fujioka, h., nishigaki, k., & matsuzawa, a. (2018). family empowerment and associated factors in japanese families raising a child with severe motor and intellectual disabilities. international journal of nursing sciences. https://doi.org/10.1016/j.ijnss.2018.09.006 waryana, w., supadi, s., & haryani, w. (2016). empowering women’s organizations for anemia prevention and control in trimurti village, srandakan sub-district, bantul, yogyakarta, indonesia. belitung nursing journal. https://doi.org/10.33546/bnj.36 wei, d. m., au yeung, s. l., he, j. r., xiao, w. q., lu, j. h., tu, s., … qiu, x. (2018). the role of social support in family socio-economic disparities in depressive symptoms during early pregnancy: evidence from a chinese birth cohort. journal of affective disorders. https://doi.org/10.1016/j.jad.2018.06.014 widarta, g. d., cahya laksana, m. a., sulistyono, a., & purnomo, w. (2015). deteksi dini risiko ibu hamil dengan kartu skor poedji rochjati dan pencegahan faktor empat terlambat. majalah obstetri & ginekologi. https://doi.org/10.20473/mog.v23i1.2100 yeh, h. y., ma, w. f., huang, j. l., hsueh, k. c., & chiang, l. c. (2016). evaluating the effectiveness of a family empowerment program on family function and pulmonary function of children with asthma: a randomized control trial. international journal of nursing studies. https://doi.org/10.1016/j.ijnurstu.2016.04.013 zand, d. h., chou, j. l., pierce, k. j., pennington, l. b., dickens, r. r., michael, j., … white, t. (2017). parenting self-efficacy and empowerment among expectant mothers with substance use disorders. midwifery. https://doi.org/10.1016/j.midw.2017.03.003 14 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.17628 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research self-efficacy and health status in coronary artery disease patients wantiyah wantiyah, mochamad riko saputra, and fitrio deviantony faculty of nursing, universitas jember, east java, indonesia abstract introduction: coronary artery disease (cad) impairs all aspects of the patient's life due to the decrease in physical function and lower quality of life, indicating an overall decreased health status. self-efficacy as a psychological factor plays an important role in individuals maintaining a healthy lifestyle and improving their health status. the aim of this study was to analyze the correlation between selfefficacy and the health status of coronary artery disease patients. methods: this study used an observational analytic research design with a crosssectional approach. this study involved 112 respondents who were coronary artery disease patients in rsd dr. soebandi jember obtained through the incidental sampling method. the data was collected using cardiac self-efficacy (cse) and seattle angina questionnaire (saq). the data analysis used the spearman rank test with a 95% ci. results: the results showed that there was a significant relationship between selfefficacy and health status (p = 0,001, r = 0.307, α = 0,05). self-efficacy was in good category (71,41 points) while health status was also in the good category (79,56 points). conclusion: the low positive correlation between the two variables shows that the higher the value of self-efficacy, the higher the value of health status. good selfefficacy through healthy living behaviors can increase the health status of coronary heart disease patients. it is important for nurses to improve the psychological aspect of the patients including self-efficacy when optimizing their self-care and health status. article history received: january 21, 2020 accepted: february 24, 2020 keywords coronary artery disease; self-efficacy; health status contact wantiyah wantiyah  wantiyah.psik@unej.ac.id  faculty of nursing, universitas jember, east java, indonesia cite this as: wantiyah, w., saputra, m, r., & deviantony, f. (2020). self-efficacy and health status in coronary artery disease patients. jurnal ners, 15(1), 14-18. doi:http://dx.doi.org/10.20473/jn.v14i1.17628 introduction coronary artery disease (cad) is one of the most prevalent killer diseases in the world. the most common manifestations of underlying coronary heart disease are the presence of angina and myocardial infarction. patients often experience symptoms of distinctive pain in the chest that spreads to the neck, jaw, ears, arms, and wrists, and possibly to the shoulder blades, back or abdomen. in connection with the effects of pain that are felt to be subjective, this can lead to psychological limitations such as anxiety arising from the sudden onset of illness and a fear of sudden death (beltrame, 2017). due to the feeling of pain, the physical restrictions, social disability, anxiety and depression, cad patients are very vulnerable to a decline in health status (de smedt et al., 2015; le, dorstyn, mpfou, prior, & tully, 2018). the symptom-based burden of cad becomes the focus of attention because it is an impact that is felt directly by the patient (stahle & cider, 2018). the impact of the symptoms can cause physical limitations in terms of walking, climbing the stairs and other daily activities (suputra, 2015). healthy behavior must still be applied in order to maintain the stability of the health status of patients with heart disease (nuraeni, 2016). because cad threatens the lives of sufferers in an ongoing manner, it needs there to be a good management of health continuously. cad can be prevented through healthy lifestyle behaviors (hendiarto, 2014). the psychosocial construct that plays a role in healthy behavior is self-efficacy. it is a strong predictor of the ability to adopt healthy https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.17628 jurnal ners http://e-journal.unair.ac.id/jners | 15 lifestyle changes (bailey, kashani, eliasson, & vernalis, 2013). cardiac self-efficacy in cardiac patients is a specific measure of a patient's confidence in his capacity to perform activities that may be affected by the symptoms and complications of cardiovascular disease (barham, ibraheem, & zyoud, 2019). self-efficacy makes a difference in how individuals feel, think and act. the level of specific self-efficacy in cardiovascular health is related to important behavioral determinants of cardiovascular health such as a high-fat diet, physical activity, smoking cessation and high blood pressure control through active stress management (wigger, 2011). in this case, self-efficacy can influence health behavior and chronic disease management in many chronic disease settings (sarkar, ali, & whooley, 2007). healthy behavior, as a major factor, can reduce the risk of disease from becoming more severe and increase the success of any treatment and surgery that is to be performed (nuraeni, 2016) research findings in the united states show that on average, cad patients have less self-efficacy. this low level of self-efficacy is associated with the risk of poor health management (sarkar, ali, & whooley, 2009). poor health management behavior is also indicated by poor dietary arrangements and irregular control after returning home following hospitalization (wantiyah, 2010). cad patients with lower initial self-efficacy are more likely to be hospitalized for heart failure. in fact, with each standard deviation (22%), the decrease in the participants' self-efficacy is 40% more likely to resulting in them being hospitalized with heart failure and they are 30% more likely to die (sarkar et al., 2009). in addition, low self-efficacy involves many of the risk factors for existing heart disease. this is indicated by the research involving 71 respondents; 81.6% of the respondents (as many as 58) had low self-efficacy with many of the risk factors (bailey et al., 2013) coronary artery disease is a chronic disease that lasts for the duration of a patient's life that is able to cause fluctuations in their health status from optimal function through to dropping dramatically due to recurrence. this can be life threatening (wantiyah, 2010). this disease requires complex treatment management including not only medication adherence but also a healthy lifestyle. self-efficacy is important in the management of cad because it comes from the individual who feels the impact of the disease. this is improved through the motivation to change into having a good level of health management and decision making in reference to their care (hendiarto, 2014; riegel et al., 2017). the ability to manage their lifestyle as a form of good self-efficacy is needed, especially when managing their exposure to risk factors. people tend to ignore this and have unhealthy lifestyles such neglecting to lessen the sodium in their diet and eating high-lipid foods. these both have an impact on the development of cardiovascular disease. this study hypothesis is that self-efficacy has a correlation with perceived health status among patients with cad. materials and methods this study used an observational analytical design with a cross-sectional approach. the sample used in this study consisted of cad patients post-outpatient treatment in the heart clinic of rsd dr. soebandi jember. in total, 112 patients with cad were selected as the research participants according to the criteria established by the researcher. the measurement of the sample size used the application of g * power with a power analysis of 0.90. the sampling technique used in this research was incidental sampling. this sampling technique determined the sample based on coincidence, where anyone who incidentally meets the researcher and who fits the inclusion and exclusion criteria can be sampled (nursalam, 2017; sugiyono, 2016). the data table 1. characteristics of the respondents (n=112) characteristics of the respondents n % gender men women 91 21 81.25 18.75 age <45 years old 45-54 years old 55-64 years old 65-74 years old > 74 years old 4 15 61 27 5 3.57 13.39 54.47 24.11 4.46 education no school graduated from elementary school graduated from middle school graduated from high school college 7 17 17 45 26 6.25 15.18 15.18 40.18 23.21 occupational status does not work labor farmers general employees entrepreneur civil servants indonesian national army/ indonesian republic police 53 9 8 12 17 11 2 47.32 8.04 7.14 10.71 15.18 9.82 1.79 income <rp 2,000,000 ≥ rp 2,000,000 49 63 43.75 56.25 marital status single married widowed 0 104 8 0 92.9 7.1 smoking history never ever 35 77 31.2 68.8 disease history do not have hypertension (high blood pressure) stroke diabetes mellitus (sugar disease) have others 48 48 0 14 2 42.86 42.86 0 12.5 1.78 history of chest pain (angina) in the past month no chest pain there is chest pain 81 31 72.3 27.7 w. wantiyah et al. 16 | pissn: 1858-3598  eissn: 2502-5791 collection process was carried out in january 2020 in the heart outpatient ward of rsd dr. soebandi jember. the process of taking the data used an instrument in the form of a demographic characteristic questionnaire. the self-efficacy measurement was done using the cardiac selfefficacy (cse) questionnaire by sullivan translated and adapted to bahasa indonesian. this was found to be valid and reliable with a cronbach’s alpha reliability of 0.77 (wantiyah, 2010). the health status measurement was done using the indonesian version of seattle angina questionnaire (saq). the validity and reliability values in general for the saq questionnaire were in the range of 0.477-0.577 and the cronbach’s alpha value was 0.866 (nurhalimah, 2016). the data analyses used a spearman rank test with a 95% ci by using spss 26 to determine the relationship between the two variables, namely selfefficacy and health status in patients with cad. this study was declared to have passed the ethical test conducted by the health research commission of the faculty of dentistry at the university of jember with ethics committee approval number no. 706/un25.8/kepk/dl/2019. all of the respondents in this study were given informed consent. the study respondents had the right to refuse to participate without penalty if they wished to do so. results the respondent’s demographic characteristics including age, gender, education, occupational status, income, marital status, history of disease and history of heart attack in the past month have collectively been displayed in table 1. based on table 1, most of the respondents (81.25%) were men. the respondents were dominated by those in the age range of 55-64 years, totaling 61 respondents (54.47%). the most common educational history of the respondents was having graduated senior high school, totaling 45 respondents (40.18%). most respondents did not work, totaling 53 respondents (47.32%). in relation to this, 63 respondents (56.25%) earn more than rp. 2,000,000.00. almost all of the respondents are married (92.9%). the respondents' smoking history shows that 77 respondents (68.8%) have a history of smoking and that 48 respondents (42.86%) have hypertension. chest pain experienced by the respondents during the past month showed that as many as 81 respondents (72.3%) did not complain of a heart attack in the past month. in table 2, the self-efficacy measurement by cse shows an average value of 71.41 (sd: 5.45). in table 3, the health status measurement by saq shows an average value of 79.56, which indicates that the average health status of cad patients is included in the good category because the criteria value ≥ 72.03 is the natural cut-off point. the median value is 80.39 with a minimum value of 49.06 and a maximum value of 95. it is known that the indicator with a high average score has a symptom load of 89.9 with a minimum value of 20 and a maximum value of 100. the indicator with the lowest average value was physical limitations, equal to 68.4 with a minimum value of 20 and a maximum value of 100. table 4 shows that there is a correlation between self-efficacy and health status in cad patients. the spearman rank test correlation coefficient value of 0.307 shows that the correlation category of the relationship between the two variables is low. the direction of the relationship shows there to be a positive value which means that the higher or better the self-efficacy, the higher or better the health status of the cad patients. discussion this study found that there is a relationship between self-efficacy in reference to the ability to manage the changeable risk factors with health status. the study findings show that good self-efficacy has a positive effect on the perception of the health status of cad patients. this can impact their condition and any improvements. the improvement is indicated by the low complaint of angina recurrence and other symptoms of a heart attack. the level of specific selfefficacy on cardiovascular health is related to the important behavioral determinants of cardiovascular health such as a high-fat diet, physical activity, smoking cessation and high blood pressure control through active stress management (wigger, 2011). the statistical analysis results show that there is a relationship between the self-efficacy variable with the variable of the health status of cad patients. the correlation category shows that the relationship between the two variables has a low correlation. the relationship between the two variables has a positive relationship. the nature of the relationship shows that good self-efficacy associated with health table 2. the value of self-efficacy in cad patients in rsd dr. soebandi jember (n = 112) variable mean sd self-efficacy 71.41 5.45 table 3. health status value in cad patients in rsd dr. soebandi jember (n = 112) variable mean median min-max physical limitations 68.44 67.78 20-100 symptoms burden 89.94 96.67 20-100 treatment satisfaction 84.41 86.25 47.50-100 quality of life 79.57 83.33 33.33-100 health status 79.56 80.39 49.06-95 table 4. the correlation between self-efficacy and health status in cad patients in rsd dr. soebandi jember (n = 112) variable p r self-efficacy 0.001 0.307 health status jurnal ners http://e-journal.unair.ac.id/jners | 17 management will have an impact on the better health status of the cad patients. this is supported by the research by ahn, song, & choi, (2016) which shows that there is a relationship between the variables, where self-efficacy, self-health behavior and the risk factors that can be changed have an important role in improving the quality of life of cad patients through the better and effective management of cardiovascular risk factors. research by sarkar, ali, & whooley (2007) shows that among patients with cad, low cardiac self-efficacy is associated with poor health status, independent of cad severity and depressive symptoms. the lack of self-efficacy in cardiac patients is associated with good selfacceptance. individuals who have good selfacceptance can mean that they can accept both their weaknesses and strengths with realistic expectations. they can respect themselves. individuals claim to be able to accept their conditions in various aspects positively and be able to live life well (puspita, 2018). according to bandura (1994), good self-efficacy is able to bring in adaptive behaviors, especially in the prevention of a health problem. preventive efforts that are intended are efforts to reduce or control the risk factors that are detrimental to health. these efforts include being physically active, maintaining blood pressure, and developing various ways to manage stress (buchanan, 2016). the low correlation of the two variables as indicated by the findings of the study in some patients showed good self-efficacy but a poor level of health status. these results are irrelevant because the patient's self-efficacy began to be high after they were diagnosed with cad, especially in new patients. it is known that cad is a disease that is caused by a long period of exposure to the risk factors. a drastic change in self-efficacy when the patient changes his behavior in terms of health management and risk exposure does not show significant results in terms of improving their health status immediately. conclusion based on the research findings and discussion, it can be concluded that there is a relationship between selfefficacy and health status in patients with coronary heart disease at a low correlation level. the results showed that the better the self-efficacy of the patients with coronary heart disease, the better their health status. prospective studies can explore, using qualitative methods, matters related to self-efficacy and health status including the patient perceptions related to the symptoms and limitations in terms of cad given how the opinions, ideas and assumptions will be broader than just the symptoms themselves. references ahn, s., song, r., & choi, s. w. (2016). effects of selfcare health behaviors on quality of life mediated by cardiovascular risk factors among individuals with coronary artery disease: a structural equation modeling approach. asian nursing research, 10(2), 158–163. https://doi.org/10.1016/j.anr.2016.03.004 american thoracic society. (2007). key concept: health status, and health perceptions. retrieved october 19, 2019, from https://qol.thoracic.org/sections/keyconcepts/health-status-health-perceptions.html bailey, k., kashani, m., eliasson, a., & vernalis, m. (2013). low self-efficacy correlates with increased cardiovascular disease risk. circulation cardiovascular quality and outcomes, 6(a626). bandura, a. (1994). self-efficacy. in v. s. ramachaudran (ed.), encyclopedia of human behavior. new york: academic press barham, a., ibraheem, r., & zyoud, s. h. (2019). cardiac self-efficacy and quality of life in patients with coronary heart disease: a cross-sectional study from palestine. bmc cardiovascular disorders, 19(1), 1–12. https://doi.org/10.1186/s12872-019-01281-7 beltrame, j. f. (2017). impact of chronic stable angina on health status. medicographia, 39(1), 11–16. buchanan, j. (2016). albert bandura: self-efficacy for agentic positive psychology. retrieved october 26, 2019, from positive psychology website: https://positivepsychology.com/bandura-selfefficacy/ de smedt, d., clays, e., annemans, l., pardaens, s., kotseva, k., & de bacquer, d. (2015). selfreported health status in coronary heart disease patients : a comparison with the general population. european journal of cardiovascular nursing, 14(2), 117–125. https://doi.org/10.1177/1474515113519930 hendiarto, y. (2014). hubungan antara self-efficacy dengan perilaku sehat pada penderita jantung koroner. jurnal psikologi klinis dan kesehatan mental, 03(02), 85–89. hidayat, a. (2017). pilihan uji normalitas berdasarkan software-jumlah sample. retrieved november 11, 2019, from http://statistikian.com/ le, j., dorstyn, d. s., mpfou, e., prior, e., & tully, p. j. (2018). health-related quality of life in coronary heart disease: a systematic review and metaanalysis mapped against the international classification of functioning, disability, and health. quality of life research, 27(10), 2491– 2503. https://doi.org/10.1007/s11136-0181885-5 nuraeni, a. (2016). faktor yang memengaruhi kualitas hidup pasien dengan penyakit jantung koroner. jurnal keperawatan padjadjaran, 4(2), 107–116. https://doi.org/10.24198/jkp.v4n2.1 nurhalimah, a. (2016). hubungan kesejahteraan spiritual dengan kualitas hidup pasien sindrom koroner akut di poliklinik jantung rsup dr. hasan sadikin bandung. skripsi, sumedang, fakultas keperawatan universitas padjadjaran. nursalam. (2017). metodologi penelitian ilmu keperawatan pendekatan praktis (4th ed.). jakarta: salemba medika. w. wantiyah et al. 18 | pissn: 1858-3598  eissn: 2502-5791 polit, d. f., & beck, c. t. (2010). essentials of nursing research seventh edition appraising evidence for nursing practice (7th ed.). https://doi.org/10.1017/cbo9781107415324.0 04 puspita, r. d. (2018). hubungan antara self efficacy dengan penerimaan diri pada pasien penyakit jantung. skripsi, sleman, program studi psikologi universitas islam indonesia. riegel, b., moser, d. k., buck, h. g., dickson, v. v., dunbar, s. b., lee, c. s., … webber, d. e. (2017). self-care for the prevention and management of cardiovascular disease and stroke. journal of the american heart association, 6(9). rumsfeld, j. s., alexander, k. p., goff, d. c., graham, m. m., ho, p. m., masoudi, f. a., … zerwic, j. j. (2013). cardiovascular health : the importance of measuring patient-reported health status a scientific statement from the american heart association. circulation, 127, 2233–2249. https://doi.org/10.1161/cir.0b013e3182949a2 e sarkar, u., ali, s., & whooley, m. a. (2007). selfefficacy and health status in patients with coronary heart disease: findings from the heart and soul study. psychosomatic medicine, 69(4), 306–312. https://doi.org/10.1097/psy.0b013e3180514d5 7 sarkar, u., ali, s., & whooley, m. a. (2009). selfefficacy as a marker of cardiac function and predictor of heart failure hospitalization and mortality in patients with stable coronary heart disease : findings from the heart and soul study. health psychology, 28(2), 166–173. https://doi.org/10.1037/a0013146 stahle, a., & cider, a. (2018). physical activity in the prevention of treatment and disease. in coronary artery disease (pp. 283–299). sweden: swedish research council. sugiyono. (2016). metode penelitian kuantitatif, kualitatif dan r&d. bandung: alfabeta. suputra, p. a. (2015). latihan fisik pada penderita koroner. proceedings seminar nasional fmipa undiksha v, 342–346. wagner, j., knaier, r., infanger, d., arbeev, k., briel, m., dieterle, t., … schmidt-trucksäss, a. (2019). functional aging in health and heart failure: the complete study. bmc cardiovascular disorders, 19(1), 1–17. https://doi.org/10.1186/s12872019-1164-6 wantiyah. (2010). analisis faktor-faktor yang mempengaruhi efikasi diri pasien penyakit jantung koroner dalam konteks asuhan keperawatan di rsd dr. soebandi jember. thesis, depok, fakultas ilmu keperawatan universitas indonesia. wigger, e. (2011). self-efficacy and heart disease. in psychological risk factor. retrieved october 18, 2019, from https://unhealthywork.org/psychological-riskfactors/self-efficacy-and-heart-disease/ https://unhealthywork.org/psychological-risk-factors/self-efficacy-and-heart-disease/ https://unhealthywork.org/psychological-risk-factors/self-efficacy-and-heart-disease/ 86 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16970 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research development of detection instrument models for mobility impairment in the older adults based on a mobile health nursing application in a public health center riksa wibawa resna1, lutfan lazuardi2, sri werdati3 and wasilah rochmah4 1 college of health sciences of banten, indonesia 2 university of gadjah mada, yogyakarta, indonesia 3 university of alma ata, yogyakarta, indonesia 4 medical faculty, university of gadjah mada, yogyakarta, indonesia abstract introduction: mobility impairment is a problem in the older adults who have decreased in mobility as it may affect their daily activity. the development of a detection model to identify the problem of mobility impairment in older adults has become a solution that can increase the health care for older adults. this study aimed to develop a health detection instrument models using a mobile health nursing application to detect mobility impairment in older adults. methods: this study used action research through a purposive sampling method involving three nurses and twenty-seven cadres to perform the detection process of mobility impairment focused on one hundred and seventy-five older adults in three public health centers in two provinces using an m-health application. results: based on direct observation and questionnaires addressed to the user of the m-health nursing application, 80% stated that the information contained in the mobile health nursing application was appropriate. in terms of speed, only 43.33% stated that the application worked fast, but overall, 66.67% of users stated that they were delighted with the application-based of the instrument model and that they were helped in detecting the mobility disorders that occurred in the older adults. conclusion: these applications can be developed into a model that can help nurses, older adults and their family to detect other older adult problems in addition to mobility problems like cognitive function etc. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords mobility impairment; telenursing; mobile health nursing contact riksa wibawa resna  riksawibawa@stikesbanten.ac.id  college of health sciences of banten, indonesia cite this as: resna, r. w., lazuardi, l., werdati, s., & rochmah, w. (2019). development of detection instrument models for mobility impairment in the older adults based on a mobile health nursing application in a public health center. jurnal ners, 14(3si), 86-92. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16970 introduction indonesia, as one of the countries with a high population growth rate for the older adult percentage, is estimated to be included in the top 5 countries with an older adult population of 18.1 million or around 9.6% of the total population. this number will continue to increase up to 28.8 million people or around 11.34% of the total population in indonesia in 2020 (kementerian koordinator bidang kesejahteraan rakyat ri, 2013).the increase in the number of older adult people will also have an impact on increasing the dependency ratio, where indonesia in 2008 was at the level of 0-17%. this number will continue to increase year to year. in the years 20202030, dependence between productive and nonproductive ages will reach 44%(department of economic and social affairs (desa) united nations, 2013). health problems are problems that cannot be avoided by older adults. the health problems of the older adults are characterized by various complaints that are multi-pathologic, thus being caused by the multiple impairments suffered by older adults. this can have an impact on the occurrence of dysfunction, disability, disease and complications(boehlke, 2015). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:riksawibawa@stikesbanten.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 87 based on the data from the basic health research (riskesdas) of the ministry of health of the republic of indonesia, it showed that the most common cause of death in older adult people over the age of 65 years was a stroke, with an occurrence of 20.6% in men and 24.4% in women(kementerian kesehatan ri, 2018). the impairment of the musculoskeletal system of older adults is one of the problems faced by the older adults. difficulty walking, stiffness in the lower legs and soreness are some of the problems that are often reported. some of these complaints are associated with several joint degenerative diseases such as rheumatoid arthritis, polymyalgia rheumatic and osteoarthritis. the biggest problem of mobility experienced by the older adult majority is in the lower body functions, where the older adults have difficulties walking. the level of difficulty in walking is essential in measuring the health status of the older adults. the older adults who cannot walk are indicated as older adults with a poor health status and they have worse overall functions compared to those who do not experience mobility problems(satariano et al., 2016). seeing the magnitude of the impact caused by the occurrence of impairments in older adults, the role of health workers is essential so then the process of impairment experienced by the older adults does not continue to worsen. the role of the health services starts from the level of the most basic health care, which is the primary health care level. it is indispensable at performing the early detection of problems. in indonesia, efforts to detect impairment in older adults have not been made even at the level of primary care. older adult services refer to a service that cannot be considered easy that is especially related to the function and role of the health center which aims to provide promotive and preventive services. the problems and organ function decline experienced by the older adults, until now, had not received special attention in the majority of health centers in indonesia so the services provided by the health center are still complained about. the absence of a system that functions to detect the setbacks that occur in the older adults is an unusual concern for researchers, considering that the decline process experienced by the older adults will have a considerable impact on the older adults themselves. the occurrence of various organ dysfunctions will have an impact on the inability of older adults to function, as they may experience pain and various complications. the purpose of this study is to develop a system of services and further health protection by using information systems and technology applications called m-health nursing. the prototype software that will be made is expected to assist the officials in the primary health center as primary health care is able to conduct the early detection of mobility impairment in older adults. the m-health nursing prototype is expected to be used independently by the public health center officers to detect older adult mobility problems directly in the community. materials and methods this research was carried out to detect the deterioration problem of the musculoskeletal system that occurs in older adults by using an instrument developed based on several instruments that have been used in general. the development of these instruments is expected to assist the health workers at the primary service level such as nurses and cadres in order for them to carry out early detection, monitoring and alertness in the process of the mobility impairments experienced by the older adults. the development of a software prototype application to detect the mobility impairments experienced by the older adults requires several stages, where at each stage, an evaluation will be carried out to achieve the desired results. in the first stage, the researchers conducted a preliminary study on the locations that were used as the research sites to carry out the process of observing and recording the activities carried out by the officers when providing services to the older adults at the public health center and posyandu. at this stage, the researcher aimed to look at the process that had been carried out by the public health center officers in detecting the problems of mobility experienced by the older adults such as moving disorders, walking disorders or the ability to perform their daily activities. in the second stage, the researcher created an early detection system model by compiling instruments made by researchers based on the older adult health cards issued by the indonesian ministry of health, icf checklist version 2.1a, the older adult mobility scale, and the barthel index modified instruments. in the third stage, a trial of the implementation of the compiled instrument model was conducted to measure the effectiveness of the instrument model in the effort to detection mobility impairments in older adults. in this stage, the instruments were analyzed for validity and reliability in order to assess the feasibility of the instruments. the fourth stage, the implementation of the early detection instrument model, was evaluated to translate the findings that can be applied into the trial phase carried out in the next stage in the form of a software prototype. the fifth stage, after the software prototype was assessed to see if it was able to function to translate the information collected by the officers in the early detection of the mobility impairments experienced by the older adults, the prototype software will be applied in the mobile health nursing application system. in the sixth stage, the researcher evaluated the effectiveness of the use of the m-health nursing application by comparing the effectiveness and efficiency between the users. the entire research process was carried out in two different provinces, namely gamping 1 health center in the special region of yogyakarta, pondok ranji health center and serpong 1 health center located in the south tangerang city area. the sample in the study consisted of three nurses and twenty-seven r. w. resna, et al. 88 | pissn: 1858-3598  eissn: 2502-5791 posyandu cadres who were responsible for implementing the older adult program in the community. the sample in the study identified mobility impairments using m-health nursing for one hundred seventy-five older adults in the community. results based on the results of the validity and reliability tests conducted as many as two times, the tests carried out show that all items in the instrument applied to the table 1. validity and reliability test results of the m-health nursing instrument questionnaire variable item r-value (nurse) r-value (cadres) history of falls question 1 0.904 0.972 question 2 0.990 0.998 alpha-cronbach 0.667 0.686 history of the disease question 1 0.917 0.807 question 2 0.988 0.974 alpha-cronbach 0.720 0.608 history of smoking question 1 0.869 0.944 question 2 0.999 0.975 question 3 0.999 0.966 question 4 0.999 0.657 alpha-cronbach 0.941 0.856 rest pattern question 1 0.973 0.858 question 2 0.995 0.995 question 3 0.998 0.995 alpha-cronbach 0.882 0.837 exercise pattern question 1 0.885 0.813 question 2 0.704 0.791 question 3 0.737 0.769 question 4 0.925 0.874 question 5 0.674 0.806 question 6 0.566 0.806 alpha-cronbach 0.781 0.867 current complaints question 1 0.972 0.997 question 2 0.828 0.788 question 3 0.683 0.841 question 5 0.722 0.476 question 6 0.811 0.936 question 7 0.976 0.996 alpha-cronbach 0.815 0.776 mobility assessment on bed question 1 0.788 0.738 question 2 0.79 0.74 question 3 0.867 0.817 question 4 0.896 0.846 question 5 0.885 0.835 question 6 0.58 0.53 alpha-cronbach 0.685 0.612 mobility assessment while standing question 1 0.763 0.737 question 2 0.763 0.682 question 3 0.763 0.694 question 4 0.999 0.998 question 5 0.923 0.895 question 6 0.937 0.885 question 7 0.939 0.889 alpha-cronbach 0.884 0.865 mobility assessment in walk question 1 0.886 0.873 question 2 0.803 0.802 question 3 0.887 0.987 question 4 0.877 0.988 alpha-cronbach 0.689 0.792 activity daily living assessment question 1 0.761 0.892 question 2 0.701 0.892 question 3 0.701 668 question 4 0.701 0.892 question 5 0.701 0.892 question 6 0.701 0.892 question 7 0.987 0.995 question 8 0.974 0.988 question 9 0.958 0.955 alpha-cronbach 0.774 0.841 jurnal ners http://e-journal.unair.ac.id/jners | 89 m-health nursing application meet the requirements. the development of instrument models that have been tested for validity and reliability in software prototype m-health nursing has been carried out by involving the programmer in the data flow diagram (dfd) created by the researcher. once dfd is completed by the researcher, the researcher then scores for each question that will be displayed on the software. this scoring functions is so then the researchers and programmers can summarize the overall results of the observations and the filling in of the nurses and cadres of the medical history, lifestyle, current health conditions and assessment of mobility in older adults. from the total 48 items that will be presented in m-health nursing, only 11 items were used as the basis for scoring for the m-health nursing application, while the 37 other items were additional information for the health workers. the use of m-health applications in the medical world is not a new thing. some countries have even made use of this technology for a long time. the research conducted by moore, holaday, meehan, & watt (2015) shows that the use of m-health technology is one of the most promising new advances in the field of nursing. the effectiveness of the use of technology engaged in health, in addition to being used to collect data and information about the patients, is that it can now also be used to provide timely and appropriate interventions that are interactive and adaptive so then efforts to deal with one's health condition can be made more quickly. in this study, the 66.67% level of satisfaction of the users after using the m-health nursing system shows that this m-health-based mobility impairment detection model has exceeded user expectations. the satisfaction of these users is not without reason. because the evaluation of the m-health nursing system is related to information content, accuracy, format, convenience, speed, and renewability; most of it has been adjusted to the user's input during the preparation of the instrument. some things are perceived as lesser by the user because there is still some feedback needed from the users to further develop it. some of these inputs, among others, include that this application has not usually applied to the ios operating system, the addition of client photos as an identifier and the client's location positioning using a global positioning system (gps). based on this study, we propose a new model of posyandu services that combines the concept of health center program services with an application following m-health nursing. table 2. user evaluation of the ability of the m-health nursing application aspects evaluated nurse cadre % % m-health nursing system: not in line with expectations less in line with expectations in line with expectations exceed expectations 0 33 67 0 7 34 52 7 information content not in line with expectations less in line with expectations in line with expectations exceed expectations 0 67 0 33 4 11 81 4 accuracy not in line with expectations less in line with expectations in line with expectations exceed expectations 0 33 67 0 0 4 92 4 form not in line with expectations less in line with expectations in line with expectations exceed expectations 0 67 33 0 0 19 77 4 ease of use not in line with expectations less in line with expectations in line with expectations exceed expectations 0 33 67 0 4 15 59 22 timeliness not in line with expectations less in line with expectations in line with expectations exceed expectations 0 33 67 0 0 15 59 26 the speed of the system not in line with expectations less in line with expectations in line with expectations exceed expectations 67 0 33 0 22 8 59 11 r. w. resna, et al. 90 | pissn: 1858-3598  eissn: 2502-5791 discussion the older adult health program is a development program in the public health center area where the health services not only provide services related to curative efforts but where they also focus on promotive and preventive efforts. this shows that the rate of development of health centers that provide older adults health services and the formation of older adults groups is not in line with expectations with an even distribution(kemenkes ri, 2015). the mechanism for organizing the older adults posyandu itself is done by collecting the older adults into one particular place to check their health. based on previous studies, it was shown that many older adult people did not want to come to the posyandu because of the location being far from their homes. ideally, health workers will go to the older adult people to check their health, especially those who do not go to the older adult posyandu, but they come back again because of the limited number of health workers in the public health center and the uneven distribution of older adult people, making this impossible(syahid, 2015). based on the observations within preliminary studies conducted at three public health center, it was found that the services provided at the posyandu included only the measurements of height and weight, in addition to blood pressure checks and noting the general complaints of the older adults. it shows that the treatment of older adults in indonesia is still focused on treatment; there are no preventive health measures and a comprehensive promotion for the older adults to use to keep themselves productive and happy. another problem found is that the services of the older adults’ posyandu are only done once a month; this is due to the limited human and material resources in the services of the posyandu itself. with increasing age, functional disorders will increase as indicated by disability. basic health research reported in 2013 that mild disability is measured by the ability to carry out daily living activities or activity of daily living (adl) and that this is experienced by 51% of older adults. according to the phenomenon, older adult health services should prioritize promotion and prevention with the support of quality curative and rehabilitative services. this is because the efforts and programs that have been provided by the indonesian government are not enough to deal with the problems of the older adults related to immobilization. one program in the life cycle approach system is older adult health by screening or early detection. the implementation of early detection related to the older adults is considered to be capable of maintaining the health condition of older adults and furthermore it is expected to prevent the occurrence of disease or further complications of illness in the older adults. the use of information technology in the present condition is something that cannot be avoided in the development of a detection system. the research conducted by wang & bai, (2013) shows that the application of technology has begun to be able to identify the risk of older adults falling. research conducted by aran, sanchez-cortes, do & gaticaperez (2016) developed the use of computerized applications to build smart homes that aim to improve the quality of everyday life for older adults. research conducted by hou, lu, liang, chen & xu (2016) developed a system that can monitor the daily lives of older adults. this system can detect and activate alarms when the parents fall. this system can detect the ability to balance in older adults to prevent them from becoming senile. based on several models that have been developed, it shows that prevention or screening efforts with a notification system against figure 1. model posyandu with m-health nursing applications jurnal ners http://e-journal.unair.ac.id/jners | 91 the possibility of risks to the older adults are a significant concern. the development of this model is the basis for researchers to develop other detection models that aim to be able to detect mobility problems in older adults, which will have an impact on the possibility of other risks in older adult decreasing, including the risk of falling. the development of the detection model of mobility impairments conducted by the researchers aims to enable older adult people to recognize mobility problems that the families and older adults may not be aware of themselves. the development of the research instruments was carried out by adopting several instruments. after carrying out the development, a draft instrument for mobility impairment was produced in the form of a manual instrument that was then discussed with the puskesmas officers. after the discussion, the researchers made changes to the instrument by including items that explored the ability of the older adults in carrying out their daily movements and activities. to facilitate data collection in conducting the trial instruments made, the researchers collected data online with the help of a google form. based on the results of the preparation and trial of several instruments used in general to be able to detect problems with mobility impairments in older adults, the results of the validity and reliability tests are as follows in table 1. after the m-health nursing software prototype was completed and could be appropriately used, the researchers conducted socialization and education focused on the nurses and cadres who will use the mhealth nursing application. based on the results of the training and the use of m-health nursing to detect mobility impairments as carried out by the posyandu nurses and cadres on one hundred seventy-five older adult people, the researchers evaluated the users. this evaluation aimed to determine the function of the m-health nursing prototype to help in the early detection of mobility impairments experienced by older adults and the ease of the data presented by the nursing m-health prototype will be used to be easily understood and operationalized when used. the evaluation was conducted using the method of enduser computing satisfaction. apart from user input, another limitation felt by the researchers was that the application has not been able to thoroughly identify all impairment problems faced by the older adults. further development is needed concerning the content and interface aspects of this application. the researchers also realize that this application still has to be tested more extensively to be able to see the various shortcomings that exist and so then it can also accommodate the various needs desired by the users when detecting impairment problems in older adults. conclusion the use of mobile technology in the detection of mobility impairment is a choice of model that can be applied in a variety of situations including through mechanisms and the utilization of the cadres’ role directly in the community. prototype m-health nursing can help the nurses and cadres in detecting older adult mobility impairment faster, allowing them to be able to provide recommendations for the nurse and cadres in an intervention for older adults. based on the results of this study, it showed that m-health nursing applications can be used as one method of detection that can be developed to maintain and improve the health of older adult people in indonesia. this application is expected to be a basis for the development of other application models that can be used to detect various health problems for older adults. the development of nursing mhealth applications is expected to participate in the national health insurance program so then efforts to improve the health status of the older adults can be more comprehensive and integrated into the national health insurance system to help reduce the health budget nationally. references aran, o., sanchez-cortes, d., do, m. t., & gatica-perez, d. (2016). anomaly detection in elderly daily behavior in ambient sensing environments. in lecture notes in computer science (including subseries lecture notes in artificial intelligence and lecture notes in bioinformatics) (vol. 9997 lncs, pp. 51–67). https://doi.org/10.1007/978-3-31946843-3_4 boehlke, j. (2015). problems with elderly health care. department of economic and social affairs (desa) united nations. (2013). world population prospects the 2012 revision. hou, z. j., lu, z. q., liang, j. z., chen, c., & xu, y. (2016). a healthy monitor system for fall and balance detection of elderly. journal of mechanical engineering research and developments, 39(2), 364–372. kemenkes ri. (2015). pelayanan dan peningkatan kesehatan lansia. kementerian kesehatan ri. (2018). riskesdas 2018. jakarta: kementerian kesehatan republik indonesia. kementerian koordinator bidang kesejahteraan rakyat ri. (2013). jumlah lansia indonesia, lima besar terbanyak di dunia situs resmi kementerian koordinator bidang kesejahteraan rakyat  moore, s. e., holaday, b., meehan, n., & watt, p. j. (2015). exploring mhealth as a new route to bridging the nursing theory-practice gap. research and theory for nursing practice, 29(1), 38–52. https://doi.org/10.1891/1541-6577.29.1.38 satariano, w. a., kealey, m., hubbard, a., kurtovich, e., ivey, s. l., bayles, c. m., … prohaska, t. r. (2016). mobility disability in older adults: at the intersection of people and places. gerontologist, r. w. resna, et al. 92 | pissn: 1858-3598  eissn: 2502-5791 56(3), 525–534. https://doi.org/10.1093/geront/gnu094 syahid, a. (2015). kualitas pelayanan kesehatan ( studi deskriptif tentang kualitas pelayanan kesehatan pada pasien usia lanjut. jurnal kebijakan dan manajemen publik, 3(3), 131–137. wang, y., & bai, x. y. (2013). research of fall detection and alarm applications for the elderly. in proceedings 2013 international conference on mechatronic sciences, electric engineering and computer, mec 2013 (pp. 615–619). https://doi.org/10.1109/mec.2013.6885137 http://e-journal.unair.ac.id/jners | 277 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review trends of early marriage in developing countries: a systematic review suhariyati suhariyati, joni haryanto and ririn probowati faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: early marriage is being increasingly recognized globally as a fundamental violation of human rights and a major obstacle to sustainable development. early marriage occurs globally to varying degrees, especially in developing countries. the purpose of this article was to identify the determinants and impact of early marriage in developing countries. method: a systematic search for studies published from 2014 up to 2019 was conducted via scopus, proquest, elsevier, science direct, sage journal, springerlink and ebsco. a total of 10 studies met the inclusion criteria. these were independently extracted by two reviewers. result: education and place of residence were the most commonly studied determinants of early marriage. only a few of them reported results concerning the age difference between the spouses, access to media information and self-efficiency. early marriage has a relationship with both the mother's and child's health. however, the significance of these associations was often small or inconsistent. conclusion: this review summarizes the best available evidence for local policymakers and public health practitioners so then they can consider incorporating these findings into the development of intervention protocols for the prevention of early marriage. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords early marriage; developing countries; education; contact suhariyati  suhariyati-2017@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: suhariyati, s., haryanto, j., & probowati, r. (2019). trends of early marriage in developing countries: a systematic review. jurnal ners, 14(3si), 277-282. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17019 introduction globally, nearly 15 million girls under age 18 are married every year (antarini, rhadiyah, permata, marcely, & montovani, 2016). around 750 million women alive today were married in childhood, and unless progress is accelerated, that number will remain at least as high through to 2030. this shows that early marriage is a human rights violation on a vast scale and a major obstacle to sustainable development (berliana et al., 2018). the violation was outlined in the 1989 convention on the rights of the child (crc). the right was included not to be separated from their parents against their will (article 9), the right to freedom of expression (article 13), the right to education (articles 28 and 29), the right to rest and leisure and engagement in play and recreational activities (article 31) and the right to protection from sexual exploitation and abuse (article 34) (efevbera, bhabha, farmer, & fink, 2017). early marriage have been reported and is a trend among adolescent women to varying degrees across many countries, especially in developing countries like indonesia, egypt, pakistan, turkey, viet nam, india, bangladesh and countries in sub-saharan africa (goli, rammohan, & singh, 2015; hamed & yousef, 2018; hong le, tran, nguyen, & fisher, 2014; sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015; unicef-unfpa, 2017; united nations, 1989; wells, 2017; yuksel-kaptanoglu & ergocmen, 2014). the age at first marriage varies from one area to another in the world. however, there are many women who have married before 18 years in developing countries. marriage before this age is called ‘child’, or more commonly, ‘early marriage’ (sanjaya et al., 2018). although many countries have decided on a legal minimum age of marriage of 18, some countries are struggling to change their policy, like indonesia (goli et al., 2015). marriage, for many people, is the most enduring and intimate bond of all close relationships (hamed & yousef, 2018). high quality marriages amplify https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:suhariyati-2017@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). suhariyati et al. 278 | pissn: 1858-3598  eissn: 2502-5791 psychological functioning and problematic marriages can take a toll on one’s emotional and psychological health (hamed & yousef, 2018). one of the many aspects that can affect quality of marriage, and subsequently psychological functioning, is the timing of matrimony (hamed & yousef, 2018). women married before 18 years are more exposed to physical, psychological and sexual violence than those married after 18 years (hamed & yousef, 2018; sanjaya et al., 2018; united nations, 1989). adolescent pregnancy at a time when women are not biologically mature increases the risk of damaging the reproductive tract and pregnancy-related complications such as anemia, pregnancy-induced hypertension, preterm labor, cephalo-pelvic disproportion (cpd), maternal mortality, perinatal and neonatal mortality, low birth weight and stunting (hong le et al., 2014; wells, 2017). additionally, available evidence from developing countries has shown that early marriage and childbearing affects a women’s nutritional status both directly and indirectly (hong le et al., 2014). adolescent pregnant girls do not gain weight during pregnancy and lactation, but rather, they lose weight (hong le et al., 2014). a number of researchers have reported the factors associated with early marriage in the global context (shaud & asad, 2018). lower socio-economic attainment, i.e. a lower educational degree and income degree (sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015; united nations, 1989; yukselkaptanoglu & ergocmen, 2014). considering the numerous maternal and child health risks associated with early marriage, this issue is worth studying. therefore, this study will enrich the current situation on early marriage in developing countries. the purpose of this article was to identify the determinants of early marriage in developing countries. in addition, this review will also look into the impact of early marriage on maternal and child health. materials and methods our systematic review followed a defined protocol to reduce bias and ensure replicability. the preferred reporting items for systematic reviews and metaanalyses (prisma) was used to search for concepts in the literature and to increase its integrity. our simplified prisma flow diagram has been included in figure 1. data sources one reviewer implemented the search strategy to search for relevant articles published from 2014 up to 2019 in scopus, proquest, elsevier, science direct, sage journal, springerlink and ebsco. one reviewer then independently screened the identified studies against the inclusion criteria before extracting the data. the search strategy was inclusive and concentrated on the keywords "early marriage". study selection this systematic review included studies using any quantitative methodologies so long as they met the other criteria. the analysis of the systematic reviews was required. the inclusion criteria were: (i) reported on the determinants of early marriage and/or reported on the impact of early marriage; (ii) involved women who were early married and/or children born to mothers with an early marriage and (iii) the place of study in developing countries. the studies were excluded based on the following criteria: (i) articles that were only abstracts and (ii) where the outcome not the determinants and/or impact of early marriage. one reviewer identified the appropriate studies. all of the titles and the abstracts were retrieved through the database searches. then an initial screening of the title and abstract were conducted by two reviewers against the above mentioned exclusion criteria. next, an evaluation of the full text of the articles was conducted by the two reviewers to refine the results based on the inclusion criteria. disagreements between the reviewers were resolved through a discussion. among the 32 studies that were initially captured, 22 studies were excluded because they reported on the abstract only, the outcome did not include the determinants and/or impact of early marriage and where the place of research was not a developing country. data extraction the quality assessment was carried out using a structured format which drew on the recommendations of the modified newcastle-ottawa scale for both cohort and cross-sectional studies. it was developed to assess the quality of studies in three domains related to the selection of the study groups, to boost the comparability of the groups and to assist in the ascertainment of exposure and outcomes. two reviewers conducted pilot testing of the quality assessment tools independently on the included studies and then completed the evaluation of the quality of the remaining studies independently. where there were disagreements, the two reviewers discussed the issues until consensus was achieved. the studies were determined as being good, fair or poor. good quality studies consisted three or four stars in the selection domain, one or two stars in the comparability domain and two or three stars in the outcomes domain. fair quality consisted of two stars in the selection domain, one or two stars in the comparability domain and two or three stars in the outcomes domain. poor quality consisted of zero or one stars in the selection domain, zero stars in the comparability domain, and zero or one stars in the outcomes domain[14]. the data was extracted by the two reviewers in excel with characteristics like the author, the year of publication, sample size, the participant’s demographics (e.g. age, country) and the outcomes. the association significantly assessed the p-value compilation in this study, which was <0.05. only the bivariate and multivariate results were jurnal ners http://e-journal.unair.ac.id/jners | 279 accessed in this review. there was an initial agreement rate of over 95%. result figure 1. flow diagram of the literature search used to identify the determinants and impacts of early marriage in developing countries the initial search of the database resulted in a total of 761 items of literature without the help of searching the other sources. from this, 10 were included in the systematic review (figure 1). figure 1 provides a summary of each study. from the table, it can be seen that the sample sizes of the studies ranged from 164 339 respondents. duplicate literature items were deleted, after which there were 310 remaining literature items. only the abstracts were excluded, if the results were not determinants, where the impact of early marriage was excluded and where the place of research in developed countries was excluded. the results of the review found 10 literature items from a total of 761literature items originally found. this review was conducted in 22 developing countries, including indonesia (n=3), pakistan (n=1), india (n=1), egypt (n=1), turkey (n=1), vietnam (n=1), bangladesh (n=1) and developing countries in sub-africa (n=16). where the determinant was measured, this was done using questionnaires that included bps’s classifications (n = 1), the household questionnaire (n=1), an individual questionnaire (n=1) and a questionnaire designed by the author (n=1). as for impact, this was determined using the zscore (n=2), ddst ii (n=1), demographic information sheet (n=1), short marital adjustment test (n=1), convergence communication scale (n=1), kessler psychological distress scale (n=1), bmi (n=1), and early childhood development index (n=1). the rest of the studies (n=3) did not specify the questionnaire used. one of the studies used the hb level in a decilitre of blood. based on the quality assessment criteria, only one study was rated as good (wells, 2017) while the others were rated as being of fair quality (table 1). determinants of early marriage table 2 summarizes the associations between early marriage and the determinants of early marriage. the factors related to early marriage were investigated in 6 studies. the outcomes were grouped into 10 categories: age difference between the spouses, place of residence, region, religion, education, economy, access to media information, ethnicity and selfefficiency. education and place of residence were the most commonly assessed determinants of early marriage. age difference between the spouses. only one study investigated the significant correlation of there being an age difference between the spouses in which the component was the husband being older by 5-9 years or the husband being older by 10+ years. age difference between the spouses is an important indicator of power relations and it is significantly related to being married at an early age. the risk of being a child bride is much higher for women whose husbands are older than themselves by 5-10 years or more (uddin, 2015). place of residence. five studies investigated the association between early marriage and place of residence. this was significantly higher among rural adolescents compared to their urban counterparts (sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015). one study showed that place of residence was significantly higher matrilocal residential pattern (yukselkaptanoglu & ergocmen, 2014). there was only one study that showed there to be no significant relationship between early marriage and place of residence, include rural and urban (united nations, 1989). education. five studies examined the association between early marriage and education, in which the components were less than secondary, secondary or more, illiterate, literate, junior high school primary and incomplete primary were found to have a significant association (sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015; united nations, 1989; yukselkaptanoglu & ergocmen, 2014). religion. two studies investigated the association between early marriage and religion and found it to be a nonsignificant correlate, including islam, christianity, buddhism, no religion and other (sanjaya et al., 2018; united nations, 1989). suhariyati et al. 280 | pissn: 1858-3598  eissn: 2502-5791 economy. two studies examined the association between early marriage and economy level. it was found to be a significant correlate, including low income, middle income, the poorest 20%, 21%-40%, 41%-60% and 61%-80% and the highest 20% (shaud & asad, 2018; united nations, 1989). access to media information. only one study examined the association between early marriage and access to media information, and found it to be a significant correlate, including radio and newspaper/magazines. however, there was no association between early marriage and access to media information for the television (shaud & asad, 2018). ethnicity. two studies examined the associations between early marriage and ethnicity. one study showed a significant correlate among santal and muslim (yuksel-kaptanoglu & ergocmen, 2014). one study showed a significant correlate with kinh. however, there was no association between early marriage and any other ethnicities (united nations, 1989). region. only one study examined the associations between early marriage and region. however, there was no significant correlate between early marriage and region in turkey (1978 and 2008), including the south, central, north and east (uddin, 2015). self-efficiency. only one study examined the association between early marriage and self-efficiency, including vicarious experience and emotional arousal. the analytical results obtained that there was a very weak negative correlation between vicarious experiences and the emotional arousals factor with early marriage (unicef-unfpa, 2017). impact of early marriage table 3 summarizes the associations between early marriage and the impact of early marriage. the impacts related to early marriage were investigated in 5 studies. the impacts of early marriage were grouped into 2 categories: the mother’s health and the child’s health. mother’s health. three studies examined the association between early marriage and the mother’s health as a significant correlate in which the components of psychological distress (early vs. late) and the mother’s nutritional status (thin, anemia and risk of experiencing ipv) came into play (hamed & yousef, 2018; shaud & asad, 2018; united nations, 1989). child’s health. two studies examined the associations between early marriage and the child's health, including child development and the child’s nutritional status. two studies showed a significant correlate between early marriage and child development (goli et al., 2015; wells, 2017). however, 1 study showed as being a non-significant correlate with the child’s nutritional status (goli et al., 2015), and one study showed a significant correlate with the child’s nutritional status if there was stunting (wells, 2017). discussion this systematic review identified 10 studies for the determinants of early marriage and the impacts of early marriage in developing countries. this review clearly demonstrates that for many of the variables, the evidence is insufficient and this is mainly due to the limited number of studies conducted. this review found that most of the early marriage determinants focused on education and place of residence, but place of residence was still a gap. only a few of them reported results concerning the economy, ethnicity, the age difference between the spouses, access to media information and self-efficiency. the most common impact of early marriage identified by this review was child development. only a few of them reported results concerning the mother’s health: psychological distress, thin, anemia and risk of experiencing ipv and the child’s health: child’s nutrition. it was not possible to establish any strong relationships between some of the significant associated factors of the mother’s health because these were evaluated in only 1 study. it was also not possible to examine the child’s nutrition because these were significant only in 1 study too.. the studies focused on (sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015; united nations, 1989; yuksel-kaptanoglu & ergocmen, 2014) five developing counties reported that female education is an important determinant of early marriage. the study in egypt showed that women with secondary or higher education had a lower prevalence than those with less than secondary education (sanjaya et al., 2018). this relationship might be reciprocal in that young women who have little education might view marriage as a pathway to adult privileges that cannot be reached through formal education and conversely that early marriage reduces the opportunities to complete their schooling (united nations, 1989). this indicates the importance of female education in reducing early marriage. in this study, the prevalence was lower in urban than in rural areas (sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015; yuksel-kaptanoglu & ergocmen, 2014). this is in contrast with the data from vietnam (united nations, 1989) which showed that no relation was present between early marriage and the place of residence, including rural and urban. high early marriage in rural areas was reported in many studies from different developing countries, included indonesian, bangladesh, egypt and turkey (sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015; yukselkaptanoglu & ergocmen, 2014). early marriage is associated with the lower wealth, lower education levels, and higher labor force participation that are jurnal ners http://e-journal.unair.ac.id/jners | 281 more common in rural areas (sanjaya et al., 2018). living in rural areas where access to public information and prevention programs is much more limited may lead adolescents to be married early (sanjaya et al., 2018; shaud & asad, 2018; uddin, 2015; yuksel-kaptanoglu & ergocmen, 2014). improved educational levels among urban females increased the age of first marriage (shaud & asad, 2018). this indicates the importance of female education, of female employment and of prevention programs in both rural and urban areas. in pakistan, the study results showed that age at marriage (early vs. late), marital adjustment and convergent communication patterns together explained the significant variance for psychological distress while low marital adjustment and the greater use of interpersonal deference communication styles emerged as significant predictors of psychological distress. research evidence indicates that women with an early marriage mostly got married to much older men and this age difference affects the level of mutual understanding, the level of communication and their social status within a family. women who marry young find their husbands to be more controlling and dominating. depressive symptoms are more commonly found among women with early marriages. an undeveloped girl who is still struggling to comprehend her own body structure is forced to make marital relations. this often leads to psychological distress and despair due to her insufficient role performance and the handling of domestic chores (hamed & yousef, 2018). early marriage is likely to have adverse consequences on the health of women. our study (hong le et al., 2014) suggests there to be a large adverse effect from early marriage on the nutritional status of women in india. a large proportion of women who were married before the legal age and who were consequently exposed to early pregnancy were found to be undernourished (thin) relative to the women who were married at a later age. the analyses also show that across all of our models, women who married at 25 years and above had the highest likelihood of having a normal nutritional status. similar results were also found with regard to the prevalence of anemia among women. thin and anemic women were typically from rural areas, and they were also commonly illiterate and from poor economic status households. the study in vietnam (united nations, 1989) showed that all of the large proportion of the young women who had experienced sexual violence perpetrated by their intimate partner did not consider this to be a type of sexual abuse. this revealed a lack of awareness about and the limited nomenclature for these experiences among young people. young women who were married before the age of 18 in vietnam were nearly twice as likely to experience ipv compared with those who did not. family background, in which children witnessed ipv between their parents, or who were affected by their parents’ traditional gender role stereotypes, may magnify the belief among adolescent brides that ipv is a part of marriage in vietnam. the studies in indonesian and sub-saharan africa (goli et al., 2015; wells, 2017) showed that children born to women who marry before they are aged 18 had significantly higher developmental disorders than those whose mothers married later. importantly, contextual factors including the mother’s completion of primary education and geographic location, which may create enabling environments for early marriage, explained most of this relationship and it may also explain the differences observed by country. lower levels of maternal education and living in a rural setting have been associated with a higher likelihood of early marriage. living in an urban setting may result in the increased availability of health facilities, antenatal and postnatal care and early education opportunities, all of which can positively influence child development. our review also found evidence in sub-saharan africa that a small part of the relationship between early marriage and child stunting was explained by early childbearing (wells, 2017). this is in contrast with the data from indonesian that showed that there to be no relation between early marriage and the child’s nutritional status (goli et al., 2015). this may be the result of a young mother’s physiological immaturity. however, some issues and limitations should be considered when interpreting the findings. first, the majority of studies relied on self-reported data and it was therefore difficult to judge the validity and reliability of the determinants and impacts of early marriage that were used to collect the data because this information was not reported in several of the studies. in addition, the literature reviewed presented very heterogeneous and inconsistent results with regard to the correlates of the determinants and impacts of early marriage. furthermore, this inconsistency remained even when the results of the previous reviews were compared with those of this review. additionally, many studies used samples that were non-representative or that were only representative of a limited geographical area. the majority of studies focused on specific countries such as indonesia, egypt, pakistan, turkey, vietnam, india, bangladesh and countries in subsaharan africa. this indicates that the development of scientific research on the determinants and affects of early marriage in developing countries has yet to cover all regions of the developing countries. we recommend that future research make better use of a wider range of methods to understand the dynamics of the determinants and impacts of early marriage on maternal and child health. conclusion this systematic review was conducted first to summarize the determinants and impacts of early marriage in developing countries. education and place of residence were the most commonly studied suhariyati et al. 282 | pissn: 1858-3598  eissn: 2502-5791 correlates of the determinants of early marriage. additionally, child development disorder was the most commonly studied correlate that was an impact of early marriage. however, the significance of these associations was often small or inconsistent. this review highlights that there is a lack of research to support the causal role of the specific factors in improving early marriage and the impact of early marriage in developing countries. this review summarizes the best available evidence for local policymakers and public health practitioners so then they can consider incorporating these findings into the development of an intervention for the prevention of early marriage. references antarini, rhadiyah, p., permata, t., marcely, r., & montovani, d. (2016). adolescent ’ s selfefficacy for early marriage in south bangka regency , indonesia. international journal of public health science, 5(4), 427–432. berliana, s., kristinadewi, p. a. n., rachmawati, p. d., fauziningtyas, r., efendi, f., & bushy, a. (2018). determinants of early marriage among female adolescent in indonesia. international journal of adolescent medicine and health, 1– 6. https://doi.org/10.1515/ijamh-2018-0054 efevbera, y., bhabha, j., farmer, p. e., & fink, g. (2017). girl child marriage as a risk factor for early childhood development and stunting. social science and medicine, 185, 91–101. https://doi.org/10.1016/j.socscimed.2017.05.02 7 goli, s., rammohan, a., & singh, d. (2015). the effect of early marriages and early childbearing on women’s nutritional status in india. maternal and child health journal, 19(8), 1864–1880. https://doi.org/10.1007/s10995-015-1700-7 hamed, a. f., & yousef, f. m. a. (2018). prevalence , health and social hazards , and attitude toward early marriage in evermarried women , sohag , upper egypt. journal of the egyptian public health association, 92(4), 228–234. https://doi.org/10.21608/epx.2018.22044 hong le, m. t., tran, t. d., nguyen, h. t., & fisher, j. (2014). early marriage and intimate partner violence among adolescents and young adults in viet nam. journal of interpersonal violence, 29(5), 889–910. https://doi.org/10.1177/0886260513505710 sanjaya, a., narendra, m. b., irwanto, suryawan, a., irmawati, m., & efendi, f. (2018). early marriage and its relationship with child development. indian journal of public health research & development, 9(9), 193–198. https://doi.org/doi number: 10.5958/09765506.2018.00993.2 shaud, s., & asad, s. (2018). marital adjustment , convergent communication patterns , and psychological distress in women with early and late marriage. uddin, m. e. (2015). family socio-cultural values affecting early marriage between muslim and santal communities in rural bangladesh. international journal of sociology and social polic, 35(3/4), 141–164. https://doi.org/10.1108/ijssp-06-2014-0046 unicef-unfpa. (2017). join us in ending child marriage. (september). united nations. (1989). convention on the rights of the child. general assembly resolution 44/25 of 20 november 1989. (november 1989). wells, j. c. k. (2017). the new “obstetrical dilemma”: stunting, obesity and the risk of obstructed labour. anatomical record, 300(4), 716–731. https://doi.org/10.1002/ar.23540 yuksel-kaptanoglu, i., & ergocmen, b. a. (2014). early marriage : trends in turkey , 1978-2008. journal of family issues, 35(12), 1017–1724. https://doi.org/10.1177/0192513x14538025 issn 0000-0000 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. technical editor: gading ekapuja aurizki, s.kep., ns. lingga curnia dewi, s.kep., ns., m.kep. layouter: masunatul ubudiyah, s.kep., ns. dluha maf’ula, s.kep., ns. hidayat arifin, s.kep., ns. rifky octavia pradipta, s.kep., ns. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. p-issn: 1858-3598 e-issn: 2502-5791 acknowledgment to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 14 no. 1 april 2019. 1. dr. abu bakar., s.kep., ns., m.kep., sp.kep.mb universitas airlangga, indonesia 2. dr. ah. yusuf, s.kp., m.kes universitas airlangga, indonesia 3. anna kurniati, s.km, ma, phd bppsdmk, ministry of health, indonesia 4. agus sudaryanto universitas gajah mada, indonesia 5. dr. chong mei chan university of malaya, malaysia 6. hilmi yumni poltekkes kemenkes surabaya, indonesia 7. dr. ika yuni widyawati, s.kep., ns., m.kep., ns.sp.kep.mb universitas airlangga, indonesia 8. kumboyono, m.kep., sp. kom universitas brawijaya, indonesia 9. kusman ibrahim, s.kp., m.ns., phd universitas padjajaran, indonesia 10. dr. kusnanto, s.kp., m.kes universitas airlangga, indonesia 11. li yoong tang university of malaya, malaysia 12. dr. mira triharini, s.kp., m.kes universitas airlangga, indonesia 13. dr. muhammad miftahussurur., m.kes., sp.pd., phd universitas airlangga, indonesia 14. ni ketut alit armini, s.kp., m.kes universitas airlangga, indonesia 15. dr. retno indarwati, s.kep., ns., m.kep. universitas airlangga, indonesia 16. rista fauziningtyas, s.kep., ns., m.kep universitas airlangga, indonesia 17. dr. rizki fitryasari p.k, s.kep., ns., m.kep universitas airlangga, indonesia 18. rr. dian tristiana, s.kep., ns., m.kep universitas airlangga, indonesia 19. suci ratih, s.km., m.km., mph universitas jenderal soedirman, indonesia 20. dr. yuni sufyanti arief, s.kp., m.kes universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 table of content 1. socio-demographic determinants and the family ability to care for children with avoidant restrictive food intake disorder (arfid) yoyok bekti prasetyo, nursalam nursalam, rahmat hargono, ahsan ahsan 1-9 2. knowledge, family support and self-reliance capital when caring for low birth weight babies erlina suci astuti, nursalam nursalam, shrimarti rukmini devy, risa etika 10-15 3. the association of body mass index, physical activity, and hypertension in indonesia hodimatum mahiroh, erni astutik, rochmad ardiansyah pratama 16-22 4. factors correlated to job stress among icu nurses in surabaya indonesia yulis setiya dewi, rachmat hargono, ainur rusdi 23-27 5. effort to prevent anaemia during menstruation among female adolescent in islamic boarding school esti yunitasari, praba diyan rachmawati, desy indah nur lestari 28-32 6. reliability and validity test of the indonesian version of the hamilton anxiety rating scale (ham-a) to measure work-related stress in nursing iwan muhamad ramdan 33-40 7. factors influencing mothers’ intention to immunize children younger than five years of age: a case study in west borneo setho hadisuyatmana, ilya krisnana, muhammad adil sipahutar 41-46 8. leader empowering behaviors and psychological empowerment as perceived by young hospital staff nurses: a pilot study ryan michael flores oducado 47-54 9. caring efficacy and nurse caring behavior in taking care of critical patients lukmanulhakim lukmanulhakim, afriyani afriyani, ani haryani 55-61 10. barriers in tuberculosis treatment in rural areas (tengger, osing and pandalungan) in indonesia based on public health center professional workers perspectives: a qualitative research r endro sulistyono, tantut susanto, rr dian tristiana 62-68 https://e-journal.unair.ac.id/jners/article/view/12735 https://e-journal.unair.ac.id/jners/article/view/12735 https://e-journal.unair.ac.id/jners/article/view/12734 https://e-journal.unair.ac.id/jners/article/view/12734 https://e-journal.unair.ac.id/jners/article/view/12811 https://e-journal.unair.ac.id/jners/article/view/12811 https://e-journal.unair.ac.id/jners/article/view/12125 https://e-journal.unair.ac.id/jners/article/view/9928 https://e-journal.unair.ac.id/jners/article/view/9928 https://e-journal.unair.ac.id/jners/article/view/10673 https://e-journal.unair.ac.id/jners/article/view/10673 https://e-journal.unair.ac.id/jners/article/view/9406 https://e-journal.unair.ac.id/jners/article/view/9406 https://e-journal.unair.ac.id/jners/article/view/15056 https://e-journal.unair.ac.id/jners/article/view/15056 11. the comparison of progressive muscle relaxation frequency on anxiety, blood pressure, and pulse of haemodialysis patients kusnanto kusnanto, maulana arif murtadho, lilik herawati, hidayat arifin 69-74 12. evaluation of clinical nursing practice programme with preceptorship supervision (stake’s countenance evaluation model) syamsul anwar, yetti supriyati, burhanuddin tola 75-81 13. the factors related to the caring behavior of clinical nursing students tintin sukartini, candra panji asmoro, fiqih ardi pradana 82-86 14. the individual coaching improves spiritually muslim patients hospitalized hamdan hariawan, oedojo soedirham, abu bakar 87-91 15. the effect of health promotion model and self determination theory based intervention on anemia prevention behavior and haemoglobin level in pregnant women mira triharini, agus sulistyono, merryana adriani, shrimarti rukmini devy 92-100 16. effect of health lecture using media and peer-education on long acting and permanent methods of contraception helen ermalia, jimmy yanuar annas, samsriyaningsih handayani 101-105 17. diabetic foot spa implementation in early neuropathy diagnosis based on blood glucose levels, foot sensitivity and the ankle brachial index in patients with diabetes erika martining wardani, chilyatiz zahroh, nur ainiyah 106-110 18. the effectiveness of auditory stimuli from murottal quran to improve comfort and weight in low birth weight infants: randomized controlled trial desriati devi, yeni rustina, defi efendi 111-117 ners vol 10 no 1 april 2015.indd 9 produksi asi ibu dengan intervensi acupresure point for lactation dan pijat oksitosin (the difference in breastmilk production between acupresure point for lactation and oxytocin massage) dwi rahayu*, budi santoso**, esti yunitasari*** *akademi keperawatan dharma husada kediri jalan penanggungan no. 41a kota kediri **rsud dr. soetomo surabaya/fk universitas airlangga surabaya ***fakultas keperawatan universitas airlangga email: alfarezapriyoputra@yahoo.com abstrak pendahuluan: menyusui merupakan salah satu proses adaptasi yang dialami ibu postpartum. bila seorang ibu dibantu dengan baik pada saat mulai menyusui, ibu akan berhasil untuk terus menyusui. produksi asi yang sedikit pada harihari pertama melahirkan menjadi kendala dalam pemberian asi. acupressure points for lactation merupakan solusi untuk mengatasi ketidaklancaran produksi asi. tindakan tersebut membantu memaksimalkan reseptor prolaktin dan oksitosin, serta meminimalkan efek samping dari tertundanya proses menyusui. tujuan penelitian ini adalah membuktikan perbandingan antara acupressure points for lactation dan pijat oksitosin dalam meningkatkan comfort dan produksi asi pada ibu postpartum. metode: desain penelitian ini adalah quasi eksperimen dengan rancangan pre-post test design with control group. teknik pengambilan sampel adalah consecutive sampling, sebanyak 27 ibu postpartum primipara, dibagi 3 kelompok. kenyamanan diukur dengan gcq (general comfort questionarre), produksi asi diukur dengan weighing test. data diukur sebelum dan sesudah dilakukannya tindakan, kemudian dianalisa dengan anova dengan α = 0,05. hasil: hasil analisa untuk comfort didapatkan nilai p: 0.035 yang berarti ada perbedaan comfort yang signifi kan antara acupressure points for lactation, pijat oksitosin dan kelompok kontrol. hasil pengukuran produksi asi didapatkan nilai p = 0.000 yang berarti ada perbedaan produksi asi yang signifi kan antara acupressure points for lactation, pijat oksitosin dan kelompok kontrol. analisis dan diskusi: hasil penelitian dapat disimpulkan bahwa acupressure points for lactation dapat meningkatkan comfort dan produksi asi pada ibu postpartum di rsud kabupaten kediri. tindakan ini dapat digunakan sebagai intervensi alternatif dalam melakukan perawatan pada ibu postpartum,. perawat perlu mengajarkan teknik ini kepada ibi postpartum agar lebih mandiri dalam mengatasi masalah laktasi. kata kunci: acupressure points for lactation, kenyamanan, produksi asi abstract introduction: breastfeeding is the adaptation process experienced by postpartum mothers. if she has assisted carlier in breastfeeding, the mothers will succeed to continue breastfeeding. in reality milk ejection very little on the fi rst days after birth is a constraint in early breastfeeding. acupressure points for lactation can increase milk production, help maximize prolactin and oxytocin receptors and minimize the side effects of delaying in the breastfeeding process. the objective of this study was to prove the difference effect of acupressure points for lactation and oxytocin massage to increase milk production and comfort on postpartum mothers. method: this study used a quasy-experiment design with pre-post test design with control group. the sample of this study was recruited using consecutive sampling, consist of 27 mother postpartum primiparous, divided into 3 groups. comfort was measured with gcq, and milk production measured with weighing test. data measured before and after the intervention, and analyzed by anova with α = 0.05. results: the results showed there was a signifi cant difference in comfort between the acupressure points for lactation, oxytocin massage and control group (p = 0.035). and there was a a signifi cant difference in milk production between the acupressure points for lactation, oxytocin massage and control group (p = 0013). analysis and discussion: conclusion, acupressure points for lactation effective to increase comfort and milk production in postpartum mothers in kediri district hospital. this technique should be used as an alternative intervention in treatment of postpartum mothers. nurses need to teach these techniques to postpartum mothers to be more independent in reduxing the problem of lactation. keywords: acupressure points for lactation, comfort, milk production pendahuluan air susu ibu (asi) merupakan makanan yang paling direkomendasikan untuk bayi sedikitnya pada 6 bulan pertama kehidupan (kramer & kakuma, 2002). ketidakcukupan produksi asi merupakan alasan utama seorang ibu untuk penghentian pemberian asi secara dini, ibu merasa dirinya tidak mempunyai kecukupan produksi asi untuk memenuhi kebutuhan bayi dan mendukung kenaikan 10 jurnal ners vol. 10 no. 1 april 2015: 9–19 berat badan bayi yang adekuat (binns, 2002), sehingga hal tersebut menjadikan menyusui merupakan hal yang dapat menimbulkan stress bagi seorang ibu post partum (anamed, 2012). pemberian asi secara eksklusif selama 6 bulan dan diteruskan sampai usia 2 tahun di samping pemberian makanan pendamping asi (mp asi) secara adekuat terbukti merupakan salah satu intervensi efektif dapat menurunkan angka kematian bayi (akb) (sitaresmi, 2010). target nasional untuk pemberian asi eksklusif adalah 80%, sedangkan dari data didapatkan bahwa ibu yang berhasil memberi asi secara eksklusif tercatat sebesar 61,5% pada tahun 2010. sementara di jawa timur, ibu yang memberi asi sebesar 64.08% pada tahun 2012 dan di kabupaten kediri ibu yang memberikan asi sebesar 65,25% (seksi gizi dinas kesehatan proponsi jawa timur, 2013) dari hasil wawancara dengan kepala ruang bersalin rsud kabupaten kediri didapatkan data bahwa pelaksanaan inisiasi menyusu dini (imd) belum bisa dilakukan secara optimal dan pemberian asi seringkali ter t unda diakibatkan ibu enggan unt uk menyusui karena produksi asi-nya belum keluar dan kuatir bayinya kurang asi, sehingga bayi tersebut diberi susu formula. dari hasil pengkajian pada 7 ibu postpartum hari i yang sedang dirawat di ruang bersalin rsud kabupaten kediri didapatkan, sebanyak 5 (71,43%) ibu postpartum hari i yang asi-nya belum keluar. saat terpenting waktu menyusui adalah beberapa hari pertama setelah melahirkan. bila seorang ibu dibantu dengan baik pada saat ia mulai menyusui, kemungkinan ibu tersebut akan berhasil untuk terus menyusui (siregar a, 2004). kenyataan di lapangan menunjukkan produksi dan ejeksi asi yang sedikit pada hari-hari pertama setelah melahirkan menjadi kendala dalam pemberian asi secara dini. menurut cox (2006) disebutkan bahwa ibu yang tidak menyusui bayinya pada hari-hari pertama menyusui disebabkan oleh kecemasan dan ketakutan ibu akan kurangnya produksi asi serta kurangnya pengetahuan ibu tentang proses menyusui. dua puluh empat jam setelah melahirkan adalah saat yang sangat penting untuk keberhasilan menyusui selanjutnya. pada jam-jam pertama setelah melahirkan, dikeluarkan hormon oksitosin dan prolaktin yang bertanggung jawab terhadap kelancaran produksi asi, jadi pada jam-jam pertama tersebut bayi har us tetap disusui (idai, 2010) penurunan produksi asi pada harihar i per tama setelah melahirkan dapat disebabkan oleh k urangnya rangsangan hormon prolaktin dan oksitosin yang sangat berperan dalam kelancaran produksi asi. penelitian yang dilakukan oleh blair (2003) menunjukkan bahwa pada 95 ibu postpartum yang menyusui bayinya ditemukan produksi asi-nya menurun jika rangsangan hisapan bayi menurun atau berkurang. demikian pula penelitian yang dilakukan oleh pace (2001) menunjukkan bahwa penurunan hisapan bayi juga menurunkan stimulasi hormon prolaktin dan oksitosin. a d a b e b e r a p a f a k t o r y a n g mempengar uhi keberhasilan laktasi baik faktor internal maupun faktor eksternal. pada hakikatnya semua wanita dapat menyusui. jarang ada wanita yang tidak dapat menyusui karena kelainan patofi siologis (who, 2003). menurut who diperkirakan 97% wanita subur mempunyai kemampuan untuk menyusui (iglesias, 2011). kegagalan dalam proses menyusui sering disebabkan karena timbulnya beberapa masalah, baik masalah pada ibu maupun pada bayi. masalah pada ibu yang timbul selama menyusui dapat dimulai sejak sebelum persalinan (periode antenatal), pada masa pasca-persalinan dini, dan masa pascapersalinan lanjut. masalah menyusui dapat pula diakibatkan karena keadaan khusus. ibu mengeluhkan bayinya sering menangis atau menolak menyusu yang kemudian diartikan bahwa asi-nya tidak cukup atau tidak baik sehingga menyebabkan diambilnya keputusan untuk menghentikan menyusui (widiasih, 2008). r a s a c e m a s y a n g d i s e b a b k a n oleh perasaan takut yang tidak berdasar akan gagalnya meny usui (tidak mampu menghasilkan asi) dan tidak memiliki asi yang cukup adalah suatu alasan yang paling 11 produksi asi ibu dengan intervensi acupresure point for lactation (dwi rahayu, dkk.) sering dikemukakan oleh ibu yang mulai gagal menyusui, berhenti menyusui terlalu cepat, atau memulai pemberian makanan tambahan sebelum makanan itu dibutuhkan. dukungan psikologis akan membant u memperkuat keyakinan dari ibu bahwa dia dapat berhasil menyusui (who, 2003). sampai sa at i n i t id a k ad a bu k t i bahwa terapi konvensional untuk mengatasi ketidakcukupan produksi asi yang tidak menimbulkan efek samping. lebih dari ribuan tahun yang lalu akupuntur telah dipromosikan untuk peningkatan produksi asi. pada saat ini, banyak penelitian tentang traditional chinese acupuncture (tca) untuk mengatasi ketidakcukupan produksi asi, akan tetapi semua penelitian tersebut tidak menggunakan kelompok kontrol. untuk evaluasi klinik yang lebih kredibel, diperlukan kelompok kontrol dalam penelitian ini (watson, 1991). dalam penelitian ini, peneliti melakukan intervensi acupressure point for lactation dan pijat oksitosin unt uk meningkatkan produksi asi dengan pendekatan comfort theory dari kolcaba. teknik acupressure points for lactation merupakan salah satu solusi untuk mengatasi ketidaklancaran produksi asi (anamed, 2012). tindakan tersebut dapat membantu memaksimalkan reseptor prolaktin dan oksitosin serta meminimalkan efek samping dari tertundanya proses menyusui oleh bayi (evariny, 2008). acupressure points for lactation juga dapat meningkatkan perasaan rileks pada ibu postpartum. acupressure points for lactation melalui titik meridian sesuai dengan organ yang akan dituju dapat membantu mengurangi rasa ketidaknyamanan. akupresur akan meningkatkan kadar endorfi n dalam darah maupun sistemik. stimulasi akupresur dapat membawa hubungan subtansi untuk pelepasan zat yang mampu menghambat sinyal rasa sakit ke otak. efek rangsangan titik akupresur dapat melalui saraf dan dapat melalui transmiter humoral yang belum dapat diterangkan dengan jelas (garret et al. 2003, dalam apriany, 2010;saputra, 2000). teori neurotransmitter yang menghasilkan endorfi n yaitu dengan mempengaruhi area otak, menstimulasi sekresi beta-endorphin dan enkepalin pada otak dan spinal cord. pelepasan neurotransmitter mempengaruhi sistem imu n dan sistem antinoceptive. (saputra, 2000). endorfi n merupakan opiat tubuh secara alami dihasilkan oleh kelenjar pituitary yang berguna untuk mengurangi nyeri, mempengaruhi memori dan mood yang kemudian akan memberikan perasaan rileks (tuner, 2010 dalam apriany, 2010). pijat oksitosin adalah pemijatan pada sepanjang tulang belakang (vertebrae) sampai tulang costae kelima keenam dan merupakan usaha untuk merangsang hormon prolaktin dan oksitosin setelah melahirkan (biancuzzo, 2003; yohmi & roesli, 2009). pijatan ini berfungsi untuk meningkatkan hormon oksitosin yang dapat menenangkan ibu, sehingga asi pun otomatis keluar. peningkatan rasa nyaman merupakan salah satu tujuan dari comfort theory yang d i kemba ng k a n oleh kolcaba. kolcaba m e nya t a k a n b a hwa p e r awat a n u nt u k meningkatkan kenyamanan memerlukan sekurangnya tiga tipe intervensi comfort yaitu: teknis pengukuran kenyamanan, coaching (mengajarkan) dan comfort food for the soul (kolcaba, 2011). pada penelitian ini, intervensi yang digunakan oleh penelti adalah comfort food for the soul, terapi untuk kenyamanan pasien yang meliputi pemijatan. dalam hal ini peneliti mengaplikasikan teknik acupressure point for lactation dan pijat oksitosin untuk membe r i k a n st i mu la si k ut a neu s ya ng diharapkan akan meningkatkan kenyamanan pasien, merangsang keluar nya oksitosin, sehingga terjadi peningkatan produksi asi. bahan dan metode desain penelitian ini adalah quasi eksperimen dengan rancangan pre-post test with control group. teknik pengambilan sampel adalah consecutive sampling, sebanyak 27 ibu postpartum primipara, dibagi 3 kelompok (kelompok acupressure points for lactation, pijat oksitosin, dan kelompok kontrol) dengan kriteria inklusi: 1) bayi tidak diberikan susu formula pada saat dilakukan penelitian; 2) refl ek hisap bayi baik (dilakukan penilaian dengan instrumen latch), 3) bb bayi > 12 jurnal ners vol. 10 no. 1 april 2015: 9–19 2500 gram; 4) ibu dan bayi dirawat dalam 1 ruang (rawat gabung), 5) bentuk puting pada kedua payudara ibu menonjol. kriteria eksklusi dalam penelitian ini adalah: 1) ibu mengalami komplikasi persalinan (misalnya perdarahan postpartum, infeksi postpartum), 2) ibu postpartum dengan gangguan anatomi payudara (misalnya puting masuk/datar), 3) bayi yang dilahirkan meninggal. peng u mpula n d at a mengg u na ka n general comfort questionarre (gcq) untuk kenyamanan dan weighing test untuk produksi asi. pre-test dilakukan pada kelompok kontrol terlebih dahulu dengan melakukan pengukuran kenyamanan, setelah itu dilakukan follow up tiap 2 hari selama 2 minggu, setelah itu dilakukan post-test pada kelompok kontrol. pada kelompok pijat oksitosin dan acupressure points for lactation, sebelumnya dilakukan pengukuran kenyamanan dan produksi asi, setelah itu dilakukan tindakan (pijat oksitosin dan acupressure points for lactation pada tiap-tiap kelompok) tiap 2 hari sekali selama 2 minggu (6 kali tindakan), setelah tindakan selesai dilakukan pengukuran kenyamanan dan produksi asi. hasil usia mer upakan salah sat u faktor f isiologis yang seca ra langsu ng d apat mempengar uhi proses pengeluaran asi. berdasarkan tabel 1 dapat diketahui bahwa dari 27 responden, sebagian besar berada pada rentang usia 21-30 tahun yaitu sebanyak 77,78%, di mana pada usia ini merupakan usia produktif dan waktu yang tepat untuk hamil dan melahirkan serta merupakan usia yang paling baik dalam memproduksi asi (biancuzzo, 2003). dalam penelitian ini, seluruh responden berada dalam rentang usia produktif untuk memproduksi asi. tabel 1. distribusi frekuensi karakteristik responden karakteristik kontrol pijat oksitosin acupressure points for lacatation uji homogenitas kontrol pijat oksitosin acupressure points for lacatation f % f % f % usia p = 0.122 ≤ 20 tahun 2 22 3 33 2 22 21–30 tahun 7 78 6 67 7 78 pendidikan p = 0.750 sd 2 22 2 22 1 12 smp 2 22 4 44 4 44 sma 5 56 3 34 4 44 imt p = 0.331 normal 7 78 5 56 3 33 overweight 2 22 4 44 6 67 bbl (gram) p = 0.648 2500–3000 2 22 4 44 5 56 3001–3500 6 67 4 44 2 22 3501–4000 1 11 1 12 2 22 tabel 2. tabel distribusi frekuensi peningkatan kenyamanan pada responden no kel resp mean stdev p 1 kontrol 9 0,44 9,44 p = 0.0352 pijat oksitosin 9 7,22 7,32 3 acupressure points for lactation 9 13 11,55 13 produksi asi ibu dengan intervensi acupresure point for lactation (dwi rahayu, dkk.) tabel 3. perbedaan kenyamanan antara kelompok responden dengan uji lsd kelompok yang dibandingkan nilai signifi kansi kelompok kontrol p = 0,147 kelompok pijat oksitosin kelompok kontrol p = 0,011 kelompok acupressure points for lactation kelompok pijat oksitosin p = 0,214 kelompok acupressure points for lactation berdasarkan uji homogenitas usia responden antara kelompok kontrol, kelompok pijat oksitosin dan kelompok acupressure points for lactation menggunakan anova didapatkan distribusi usia responden antara kelompok kontrol dan perlakuan homogen, sehingga variasi faktor usia dianggap tidak berpengaruh terhadap variabel dependen. pendidikan merupakan salah satu faktor yang secara tidak langsung mempengaruhi laktasi terkait dengan latar belakang sosial budaya. hal ini berkaitan dengan kemampuan ibu untuk menerima informasi yang nantinya berpengaruh secara langsung dalam proses pengeluaran asi. faktor langsung yang terkait psikologis ibu meliputi persepsi ibu mengenai keuntungan dan ker ugian menyusui dan pengetahuan tentang menyusui (biancuzzo, 2003). berdasarkan tabel 1 dapat diketahui bahwa dari 27 responden didapatkan sebagian besar responden pada tiap-tiap kelompok berpendidikan sma. tingkat pendidikan dan pengetahuan tentang asi pada responden hampir seluruhnya baik, terbukti dengan adanya motivasi untuk memberi asi eksklusif pada bayinya. selain itu, latar belakang pendidikan ini juga sangat membantu peneliti dalam memberikan intervensi. berdasarkan uji homogenitas pendidikan responden antara kelompok kontrol dan kelompok perlakuan menggunakan kruskall walis didapatkan p = 0,750 yang berarti bahwa distribusi pendidikan antara kelompok kontrol dan kelompok perlakuan homogen, sehingga variasi faktor pendidikan pada kelompok responden dianggap tidak berpengaruh terhadap variabel dependen. faktor fi siologis status kesehatan ibu, nutrisi, asupan cairan mer upakan faktor yang secara langsung dapat mempengaruhi p r o s e s p e ngelu a r a n a si ( bi a nc u z z o, 2003). dalam penelitian ini diambil data mengenai status gizi ibu sebelum hamil berdasarkan imt. hal ini dikarenakan status gizi orang dewasa cenderung konstan jika diukur melalui anthropometri. selain itu, berdasarkan wawancara, seluruh responden tidak mempunyai pantangan makanan setelah melahirkan dan selur uh responden juga mengonsumsi diet tinggi kalori dan tinggi protein. imt sebelum hamil juga berpengaruh terhadap inisiasi dan durasi menyusui (jm, 2011). berdasarkan uji homogenitas pendidikan responden antara kelompok kontrol dan kelompok perlakuan menggunakan kruskall walis didapatkan p = 0,331 yang berarti bahwa distribusi status nutrisi antara kelompok kontrol dan kelompok perlakuan homogen, sehingga variasi faktor status nutrisi pada kelompok responden dianggap tidak ber pengar u h terhadap variabel dependen. salah satu faktor tidak langsung dalam proses menyusui adalah faktor bayi yaitu berat badan bayi saat lahir, temperamen bayi, status kesehatan bayi. hubungan berat badan lahir bayi dengan volume asi berkaitan dengan kekuatan untuk menghisap, frekuensi, dan lama penyusuan dibanding bayi yang lebih besar. bayi yang dilahirkan seluruh responden termasuk dalam kategori bayi normal dengan apgar score baik dan bb antara 25004000 gram, sehingga faktor berat badan bayi dianggap tidak berpengaruh terhadap variabel dependen. berdasarkan uji homogenitas berat badan bayi saat lahir responden antara kelompok kontrol dan kelompok perlakuan menggunakan kruskall walis didapatkan p = 0,648 yang berarti bahwa distribusi berat 14 jurnal ners vol. 10 no. 1 april 2015: 9–19 badan bayi saat lahir antara kelompok kontrol dan kelompok perlakuan homogen, sehingga variasi faktor berat badan bayi saat lahir pada kelompok responden dianggap tidak berpengaruh terhadap variabel dependen. dari hasil uji statistik dengan uji statistik parametrik anova pada tabel 2 didapatkan ada perbedaan antara kelompok acupressure points for lactation, pijat oksitosin dan kelompok yang tidak dilakukan perlakuan dengan nilai p = 0,035 (p < 0,05). untuk mengetahui kelompok mana yang berbeda dilanjutkan dengan uji lsd pada tabel 3 yang menunjukkan ada perbedaan kenyamanan yang signifi kan antara kelompok kontrol dan kelompok acupressure points for lactation, dengan nilai p: 0.011 (p < 0,05). namun, antara kelompok kontrol dan pijat oksitosin serta pijat oksitosin dengan kelompok acupressure points for lactation tidak ada perbedaan yang signifi kan. tabel 5 menunjukkan hasil uji statistik perbedaan peningkatan produksi asi antara 3 kelompok, yang didapatkan bahwa ada perbedaan yang signifi kan antara kelompok kontrol dan kelompok acupressure points for lactation, dengan didapatkan nilai p = 0,004 (p < 0,05). hasil yang tidak signifi kan antara kelompok kont rol dan kelompok pijat oksitosin, dengan nilai p = 0.349 (p > 0.05), dan perbedaan yang signifi kan antara kelompok acupressure points for lactation dan kelompok pijat oksitosin, dengan nilai p = 0.037 (p < 0,05). pembahasan pe n g u k u r a n k e n y a m a n a n y a n g d ila k u k a n ke pa d a responden sebelu m diber i kan tindakan pijat oksitosin dan acupressure points for lactation didapatkan peningkatan kenyamanan pada responden. akan tetapi ada sebagian responden yang mengalami penurunan kenyamanan hal ini dikarenakan ibu mengalami puting lecet. pada kelompok kontrol terdapat 3 responden yang mengalami penurunan kenyamanan karena ibu mengalami puting lecet dan ibu mengatakan setiap kali menyusui merasakan sakit pada putingnya ibu. puting lecet merupakan salah satu faktor ketidaknyamanan pada ibu yang secara tidak langsung mempengaruhi produksi asi. ibu sering berhenti menyusui karena hal tersebut, sehingga angsangan isapan bayi berkurang dan berdampak pula pada produksi asi yang semakin menurun (suradi, 2004). bila ibu yang menyusui mengalami stres, maka akan terjadi suatu blokade dari refl eks let down. ini disebabkan oleh pelepasan dari adrenalin (epinefrin) yang menyebabkan vasokonstriksi dari pembuluh darah alveoli, sehingga oksitosin yang dapat mencapai target organ mioepitelium hanya sedikit. selain itu tabel 4. perbedaan peningkatan produksi asi no kelompok responen mean stdev p 1 kontrol 9 27,22 18,21 p = 0,013 2 pijat oksitosin 9 34,44 15,50 3 acupressure points for lactation 9 51,11 14,09 tabel 5. perbedaan peningkatan produksi asi dengan uji lsd no kelompok mean p 1 kelompok kontrol 27,22 p = 0,349 kelompok pijat oksitosin 34,44 2 kelompok kontrol 27,22 p = 0,004 kelompok acupressure points for lactation 51,11 3 kelompok acupressure points for lactation 51,11 p = 0,037 kelompok pijat oksitosin 34,44 15 produksi asi ibu dengan intervensi acupresure point for lactation (dwi rahayu, dkk.) akan terjadi pula pelepasan noradrenalin pada sistem syaraf pusat, sehingga aktivitas kedua substansi kimia ini akan menyebabkan terhambatnya milk ejection refl ex (riordan & auerbach, 2010). refl eks let down yang tidak sempurna akan berakibat bayi yang haus menjadi tidak puas. ketidakpuasan ini akan menyebabkan tambahan stres bagi ibu. bayi yang haus dan tidak puas ini akan berusaha untuk mendapatkan asi yang cukup dengan cara menambah kuat hisapannya, sehingga tidak jarang menimbulkan luka-luka pada puting susu yang menyebabkan rasa sakit pada ibu. hal ini juga akan menambah stres pada ibu, sehingga akan terbentuk suatu lingkaran setan (circulus vitiosus) dengan akibat kegagalan dalam menyusui (machfuddin, 2004). sesuai dengan teori bahwa prolaktin yang dihasilkan selama proses menyusui telah diteliti mempunyai efek relaksasi yang menyebabkan ibu menyusui merasa tenang bahkan mempunyai efek euforia, sehingga semakin tinggi kadar prolaktin, dapat mencegah kejadian postpartum blues (riordan & auerbach, 2010). meny usui juga melindungi ibu dengan menginduksi ketenangan, mengurangi reaktivitas ibu untuk stres. menyusui memiliki efek perlindungan pada kesehatan mental ibu yang disebabkan karena st res dengan cara melemah kan dan memodulasi respon inf lamasi melalui penurunan kortisol, acth, epinefrin dan norepinefrin. ketika meny usui berjalan dengan baik, kadar proinfl ammatory cytokine akan turun dalam batas normal, sehingga menurunkan reaksi infl amasi yang menjadi underlying risk factor terjadinya depresi, hal ini akan melindungi ibu dari stres dan menjaga suasana hati ibu (tackett, 2007). me nu r ut kolcaba , 2011 comfor t diartikan sebagai suatu keadaan yang dialami oleh seseorang yang dapat didef inisikan sebagai suatu pengalaman yang menjadi sebuah kekuatan melalui kebutuhan akan keringanan (relief ), ketenangan (ease), and (transcedence) yang dapat terpenuhi dalam empat kontexks pengalaman yang meliputi aspek f isik, psi kospi r it u al, sosial d a n li ng k u nga n. kenyamanan yang dirasakan responden pada penelitian ini masuk dalam tipe comfort yang kedua yaitu ease, yang berarti suatu keadaan yang tenang dan kesenangan yang dirasakan oleh seseorang. dalam penelitian ini responden merasakan ketenangan dan perasaan senang setelah dilakukan tindakan acupressure points for lactation maupun pijat oksitosin. pengukuran produksi asi pada ibu sebelum diberikan tindakan pijat oksitosin dan acupressure points for lactation didapatkan peningkatan produ ksi asi yang sangat bermakna, terutama pada responden yang dilakukan acupressure points for lactation. pada kelompok kontrol, responden tidak mengalami peningkatan produksi asi pada pengukuran pertama dan pengukuran yang terakhir (pengukuran produksi asi ke-6). pad a hasil penelit ia n d id apat ka n bahwa semua responden memiliki usia yang tergolong usia reproduktif (rerata 21-30 tahun), di mana pada usia ini produksi asi masih sangat banyak. usia merupakan salah satu faktor fi siologis yang secara langsung dapat mempengaruhi proses pengeluaran asi (biancuzzo, 2003). usia merupakan salah satu faktor yang mempengaruhi produksi asi pada ibu. ibu yang berusia kurang dari 35 tahun lebih banyak memproduksi asi dibandingkan dengan ibu yang lebih tua, tetapi ibu yang sangat muda (kurang dari 20 tahun) produksi asi-nya juga kurang banyak karena dilihat dar i tingkat kemat uran nya (biancuzzo, 2003). ibu yang menghasilkan cukup asi pada penelitian pudjiaji (2005) yaitu ibu yang berumur 19–23 tahun dibandingkan dengan ibu-ibu yang usianya lebih dari 35 tahun. hasil penelitian ini diperkuat oleh suraatmadja (2009) menyatakan bahwa ibu yang umurnya lebih muda lebih banyak memproduksi asi dibandingkan dengan ibu yang lebih tua. penjelasan di atas memberikan gambaran bahwa dalam penelitian ini, salah satu faktor yang berpengaruh terhadap produksi asi adalah faktor usia. ibu-ibu postpartum dalam penelitian ini tinggal di kalangan yang sudah cukup modern dan tidak mengenal mitos-mitos mengenai hal-hal u nt u k memperbanyak produ ksi asi. makanan yang disediakan oleh pihak rumah sakit dikonsumsi oleh ibu. namun dalam penelitian ini tidak dilihat kadar yang 16 jurnal ners vol. 10 no. 1 april 2015: 9–19 terkandung dalam makanan yang dikonsumsi oleh ibu. setelah dilakukan follow up di rumah sampai dengan 6 kali kunjungan selama 2 minggu, didapatkan hasil bahwa seluruh responden tidak membatasi makanan tertentu, makanan yang dikonsumsi oleh responden termasuk makanan yang tinggi kalori dan tinggi protein, di mana jenis makanan ini juga merupakan salah satu faktor yang dapat meningkatkan produksi asi. hasil penelitian didapatkan bahwa pada kelompok responden yang dilakukan tindakan acupressure points for lactation terdapat peningkatan comfort yang signifi kan dibandingkan dengan kelompok yang lain. hal ini dikarenakan pada kelompok yang dilakukan akupresur akan menjadi lebih rileks dan merasa lebih nyaman. acupressure points for lactation melalui titik meridian sesuai dengan organ yang akan dituju dapat membantu mengurangi rasa ketidak nyamanan. akupresur akan meningkatkan kadar endorfi n dalam darah maupun sistemik. stimulasi akupresur dapat membawa hubungan subtansi untuk pelepasan zat yang mampu menghambat sinyal rasa sakit ke otak. efek rangsangan titik akupresur dapat melalui saraf dan dapat melalui transmiter humoral yang belum dapat diterangkan dengan jelas (garret et al., 2003, dalam apriany, 2010; saputra, 2000). hal tersebut didu k u ng oleh teor i gate control, di mana dalam teori tersebut menjelaskan bahwa perangsangan pada suatu titik acupoint pada suatu jalur meridian akan diteruskan oleh serabut saraf a-beta berdiameter besar menuju saraf spinal yang kemudian dalam medulla spinalis terdapat subtansi gelatinosa bekerja sebagai gate control sebelum diteruskan oleh serabut saraf aferen menuju sel-sel transmisi, sel transmisi menyalurkan ke sistem saraf pusat dengan menurunkan rasa ketidaknyamanan (hakam, krisna & tutik, 2009). pijatan yang dilakukan dalam akupresur akan menghilangkan ketegangan dan dapat menyebabkan relaksasi otot tubuh (gach, 1990; hongzhu, 2002). hal ini akan memberi rasa enak dan nyaman yang berarti secara psikis memberi dampak positif bagi rasa tenang, nyaman, rileks dan stres yang menurun (adikara, 1998). gach (1990) menyatakan bahwa pijatan akupresur akan menstimulasi peningkatan morphin tubuh yaitu endorfi n. suasana yang nyaman, tenang dan rileks akan mendatangkan emosi positif yang dapat meningkatkan sekresi neurotransmiter endorphin melalui pomc yang berfungsi sebagai penghilang rasa sakit dan pengendali sek resi cr f secara berlebihan (sholeh, 2006). respons positif ini melalui jalur hpa akan merangsang hipotalamus menurunkan sek re si cr f ya ng d i i k ut i pe nu r u na n acth, dan medula adrenal akan merespons dengan menurunkan sekresi katekolamin, kemudian tahanan perifer dan cardiac output akan menu r un sehingga tekanan darah menurun (putra, 2005). keadaan relaksasi yang dirasakan oleh ibu tersebut akan meningkatkan kenyamanan ibu sehingga semakin meningkatkan refl ek let down dan meningkatkan jumlah hormon prolaktin dan oksitosin. acupressure points for lactation m e r u p a k a n t i n d a k a n y a n g b e r f u ng si merangsang diproduksinya hormon prolaktin dari otak. hormon ini yang mempengaruhi banyak sedikitnya asi. dengan dilakukannya acupressure points for lactation di titik-titik tertentu yang sesuai dengan acupoints pada tindakan akupunktur akan bisa merangsang produksi hormon prolaktin. titik-titik pijatan yang utama untuk memperlancar asi, menurut daris, berada di bagian payudara sendiri. tiga titik utama untuk dilakukan pemijatan di pay udara adalah satu titik di atas puting, tepat di puting payudara, dan titik di bawah puting. jika ini dilakukan secara rutin dan benar, upaya ini bisa memperlancar produksi asi. selain titiktitik di payudara, titik di bawah lutut (titik st 36) juga akan membantu memperlancar asi. terapi akupresur dapat merangsang titik sentral dan lokal untuk asi. terapi akupresur akan memberikan rangsangan pada titik meridian untuk memberikan fungsi kerja yang maksimal dengan menuju target organ yang berhubungan dengan organ tersebut. rangsangan tersebut dapat melewati jalur saraf, somatovisceral, garis meridian dan reaksi 17 produksi asi ibu dengan intervensi acupresure point for lactation (dwi rahayu, dkk.) lokal. rangsangan dengan perpaduan beberapa titik akupresur yang menuju sentral terutama hipofi sis dan pituitari akan mempengaruhi perbaikan kerja fungsi dari hormon yang ber t ujuan mening katkan produ ksi asi dengan yang diberikan rangsangan dalam waktu tertentu, selain itu titik lokal (seperti titik lambung) juga membant u aktifnya terbentuknya asi dalam jumlah yang cukup. titik yang akan distimulasi dengan pijat akupresur adalah tangan, kaki dan titik lokal payudara yang akan membantu jumlah asi secara maksimal. gangguan yang paling umum terjadi selama masa nifas adalah hambatan dalam meridian. merangsang acupoints sepanjang saluran dengan akupresur dapat membantu menghilangkan penghalang, merevitalisasi mer id ia n, d a n memba nt u memuli h ka n kesehatan. akupresur juga dapat merangsang pelepasan oksitosin dari kelenjar hipofi sis, yang secara langsung merangsang kontraksi rahim untuk proses involusi uteri dan merangsang produksi asi. karena itu akupresur dapat merangsang acupoints dapat membant u mengatur proses involusi uteri dan pengeluaran asi dan mengembalikan keseimbangan selama masa post partum (chung, hung, kuo & huang, 2003). st i mulasi ber upa teka na n d ala m akupresur dapat melancarkan jalur energi dalam tubuh melalui titik dan meridian akupunktur. tujuan sebuah terapi akan dicapai apabila diberikan rangsangan yang tepat pada titik akupunktur sesuai organ yang dituju. menurut kaidah pengobatan tradisional china, kondisi sehat tercipta apabila terjadi keseimbangan yang harmonis antara unsur yin (unsur dalam yang tidak bisa diukur) dan yang (unsur tubuh yang dapat diukur), sebaliknya apabila terjadi ketidakseimbangan antara keduanya akan mengakibatkan kondisi sakit. teori yin dan yang digunakan untuk menunjukkan hubungan dua hal unsur alami yang saling berlawanan tetapi saling berhubungan, unsur yin dapat ditemukan dalam unsur yang dan unsur yang dapat ditemukan dalam yin sehingga terjadi keseimbangan. teori fi losofi s yang lain dalam pengobatan tradisional ini adalah komposisi dan perkembangan tubuh manusia dilambangkan dengan unsur alam yang mempunyai kesamaan karakter yang disebut lima unsur dalam kesehatan. kelima unsur tersebut adalah api yang mempunyai sifat panas mewakili jantung dan usus kecil, kayu mempunyai sifat lemah lembut mewakili hati dan kandung empedu, air bersifat dingin dan lembab mewakili ginjal dan kandung kemih, tanah bersifat membendung air mewakili limpa dan lambung, logam bersifat bersifat bersih dan mengeluarkan suara nyaring mewakili paru dan usus besar. kelima unsur tersebut saling mendukung dan menentang satu sama lain untuk mempertahankan keseimbangan (nanjing university of traditional chinese medicine, who, 2007). titik yang dilakukan pemijatan pada acupressure points for lactation ini adalah titik lokal pada area payudara yang meliputi titik st 17 (ruzhong), st 18 (rugen) yang termasuk meridian lambung (stomach – st) di mana pemijatan pada titik lokal pada area payudara ini bertujuan untuk meningkatkan produksi hor mon pralaktin dan hor mon oksitosin. selain itu dari meridian lambung, juga dilakukan pemijatan pada titik st 36 (zusanli), di mana pada titik ini bertujuan untuk meningkatkan penyerapan nutrisi yang merupakan bahan dasar pembentukan asi. unt u k meningkatkan kenyamanan secara umum pada ibu postpartum dilakukan pemijatan pada meridian limpa (spleen – sp) yaitu titik sp 6 (sanyinjiao) serta pada meridian usus besar (large intentine – li): li 4 (hegu) di mana titik ini bertujuan untuk meningkatkan energi dan kondisi rileks pada ibu postpartum. dengan kondisi yang nyaman dan rileks pada ibu postpartum akan meningkatkan refl eks let down serta hormon prolaktin, sehingga dapat meningkatkan produksi maupun pengeluaran asi. simpulan dan saran simpulan acupressure points for lactation dan pijak oksitosin dapat meningkatkan kenyamanan pa d a pa d a ibu p ost pa r t u m sek al ig u s meningkatkan produksi dan pengeluaran asi. ibu yang dilakukan acupressure points for 18 jurnal ners vol. 10 no. 1 april 2015: 9–19 lactation mempunyai tingkat kenyamanan yang lebih besar dan produksi asi yang lebih banyak dibandingkan ibu yang mendapat pijat oksitosin. namun, pijat oksitosin lebih efektif meningkatkan kenyamanan dan produksi asi pada ibu postpartum dibandingkan ibu yang tidak mendapat intervensi apa pun. saran acupressure points for lactation dapat dijadikan bahan kajian secara ilmiah dan dikembangkan dalam pendidikan khususnya keperawatan maternitas untuk memberikan bekal intervensi alternatif kepada para peserta didik. acupressure points for lactation dapat dijadikan sebagai intervensi alternatif secara non farmakologis (keperawatan komplementer) yang efektif untuk meningkatkan produksi asi tanpa efek samping, selain itu terapi acupressure points for lactation merupakan tindakan yang bisa dilakukan perawat secara mandiri. penelitian ini bisa dikembangkan lebih lanjut tentang pengaruh acupressure points for lactation terhadap hormon yang berperan dalam proses laktasi (prolaktin dan oksitosin) sehingga memperkuat penjelasan ilmiah tentang terapi komplementer ini. kepustakaan adikara, rts. 1998. teknik tekanan mekanis pada pengobatan akupunktur. majalah akupunktur indonesia. vol. 5, no 1. paksi, hal. 48–51. anamed, 2012. insufi sient lactation. ana-med acupuncture. diakses di website www. ana-med.co.nz. tanggal 18 september 2013. apriany, d. 2010. pengaruh terapi music terhadap mual muntah lambat akibat kemoterapi pada anak usia sekolah yang menderita kanker di rsup dr. hasan sadikin bandung. thesis: magister universitas indonesia. fakultas ilmu keperawatan. biancuzzo, m. 2003. breastfeeding the newborn: clinical strategies for nurses. st. louis: mosby. binns, c., scott, j 2002. breastfeeding: reason for starting, reason for stopping and problems along the way, breastfeeding review, volume 10, no 2, pp. 13–19. blair, t. 2003. suckling of lactation mother, http://www.ncbi.nlm.nih.gov/entrez/ quory.fcgi?db=pubmed&cdm=search& itol=pubmedabstract, diakses tanggal 17 november 2013. bobak, lowdermilk & jensen, 2004. buku ajar keperawatan maternitas. alih bahasa. jakarta: egc. chung, l., hung, l., kuo, s., huang, c. 2003. effects of li4 and bl 67 acupressure on labor pain and uterine contractions in the first stage of labor. journal of nursing research vol. 11, no. 4, 2003. cox, s. 2006. breastfeeding with confi dence: panduan untuk belajar menyusui dengan percaya diri (gracinia, penerjemah.). jakarta: gramedia. dinas kesehatan provinsi jawa timur, seksi gizi. 2013. data capaian program giziasi eksklusif. evariny, a. 2008. agar asi lancar di awal masa menyusui, http://www.hypnobirthing. web.id/?, diakses tanggal 15 november 2013. gach m.r 1990. acupressur’s potent points. toronto: a bantam book edition. garret et. al. 2003. treating nausea and vomiting in palliative care: a review. clinical intervention; (6). 243–295. hakam, m., krisna dan tutik. 2009. intervensi spiritual emotional freedom technique (seft) untuk mengurangi rasa nyeri pasien kanker. makara, kesehatan, 13 (2), 95–99. hongzhu, j. 2000. chinese tuina (massage). c h i n a : sh a n g h a i un ive r sit y of traditional chinese medicine. iglesias s. m. gonzales, cuesta, argelles, zarnello, riva. 2011. effectiveness of an implementation strategy for a breastfeeding guideline in primary care: cluster randomized trial. bmc family practice, 1–8. indriyani, d. 2006. pengaruh menyusui dini dan teratur terhadap produksi asi pada ibu post partum dengan sectio caesarea di rsud dr. soebandi jember dan dr. h. koesnadi bondowoso. tesis. depok: fik ui. jm, w. 2011. maternal prepregnancy body mass index and initiation and duration of 19 produksi asi ibu dengan intervensi acupresure point for lactation (dwi rahayu, dkk.) breastfeeding: a review of the literature, journal women health, 341–7. king, f.s. 2003. nutrition for developing countries. new york: oxfort university press inc kolcaba, 2011. comfort theory kolcba. http. currentnursing.com. diakses pada tanggal 26 september 2013. kramer, m, kakuma, r. 2002. the optimal duration of exclusive breastfeeding. a systematic review, who, switzerland. lawrence, r.a. 2004. breastfededing a guide for the medical profession. st louis: cv mosby. li n kages, 20 09. melahirk an , memulai pemberian asi dan tujuh hari pertama setelah melahirkan. diambil dari http:// w w w.lin kagesproject.org. diakses tanggal 26 september 2013. moore, e. r., coty, m.b. 2006. prenatal and postpartum focus groups with primiparas, breastfeeding attitudes, support, barriers, self-efficacy, and intention. journal pediatrics health care, 20, 35–46. novianti, r. 2009. cara dahsyat memberikan asi untuk bayi sehat dan cerdas. yogyakarta: octopus. pace, b. 2001. breastfeeding. the journal of the american medical association. poedianto, 2002. kiat sukses menyusui. jakarta: aspirasi pemuda. pudjiadi, 2005. ilmu gizi klinis pada anak. edisi 4. jakarta: fk ui p ut ra, s.t 2005. psikoneuroimunologi kedokteran. surabaya: graha masyarakat ilmiah kedokteran fakultas kedokteran universitas airlangga press. riordan j & aurbach, k. g, 2010. breastfeeding and human lactation. london: jones an barlett publishers international. saputra, k. 2000. akupunktur dalam ilmu kedok teran. su rabaya: a i rla ngga university press. saputra dkk, 2000. akupunktur klinis. cetakan i. surabaya: airlangga university press. sholeh, m. 2006, pelatihan sholat tahajud: menyembuhkan berbagai penyakit. cetakan xxi. november 2006. mizan medika utama. bandung. siregar. 2004. pemberian asi eksklusif dan faktor-faktor yang mempengaruhinya. diakses tanggal 27 april 2013 http:// repository.usu.ac.id/bitstream/1234567 89/32726/1/f km-arifi n4.pdf tackett, k. 2007. a new paradigm for depression i n new mot hers: t he control role of infl ammation and low breastfeeding and anti-inf lammatory treatments protect maternal mental health. international breastfeeding journal, 2–6. watson, k, 1991. the philosophical basis of traditional chinese medicine and the implication of its clinical evaluation. journal of chinese medicine. (36). 199: 14–17. welford, h. 2009. menyusui bayi anda. jakarta: dian rakyat w ho, 2003. protecting promoting and supporting breastfeeding: the special role of maternity services. a join who/ unicef statement. genewa: world health organization. widiasih, r, 2008. masalah-masalah dalam menyusui. seminar manajemen laktasi. (pp 1-11). bandung fakultas ilmu keperawatan universitas padjajaran. issn 0000-0000 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep technical editor: gading ekapuja aurizki, s.kep., ns. nadia rohmatul laily, s.kep., ns., m.kep. lingga curnia dewi, s.kep., ns., m.kep. layouter: masunatul ubudiyah, s.kep., ns. dluha maf’ula, s.kep., ns. hidayat arifin, s.kep., ns. rifky octavia pradipta, s.kep., ns. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. p-issn: 1858-3598 e-issn: 2502-5791 acknowledgment to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 13 no. 2 october 2018. 1. dr. abu bakar, s.kep., ns., m.kep., sp.kep.mb. universitas airlangga, indonesia 2. prof. angeline bushy, phd, rn, phcnsbc, faan university of central florida, united states 3. anna kurniati, s.km, ma, phd bppsdmk, ministry of health, indonesia 4. awatiful azza, m.kep., sp.kep.mat universitas muhammadiyah jember, indonesia 5. bayhakki phd, rn universitas riau, indonesia 6. dr. chong mei chan university of malaya, malaysia 7. dr. farhan alshammari university of hail, saudi arabia 8. henny suzana mediani, mng., phd universitas padjadjaran, indonesia 9. dr. hilmi yumni, s.kep., ns., m.kep., sp.mat poltekkes kemenkes surabaya, indonesia 10. josefina a. tuazon, drph, rn university of the philippines manila, the philippines 11. khatijah lim abdullah, phd university of malaya, malaysia 12. koen westen, bsn, msw avans hogeschool, netherlands 13. dr. linda sweet flinders university, australia 14. linlin lindayani, phd stikep ppni jawa barat, indonesia 15. dr. mardiana mansor, msc universiti sultan zainal abidin, malaysia 16. dr. meidiana dwidiyanti universitas diponegoro, indonesia 17. muhammad arsyad subu, phd gulf medical university, united arab emirates 18. prof. dr. nursalam, m.nurs (hons) universitas airlangga, indonesia 19. peter hoegen, bsn, msc., phd (cand.) avans hogeschool, netherlands 20. dr. retno indarwati, s.kep., ns., m.kep. universitas airlangga, indonesia 21. rr. dian tristiana, s.kep., ns., m.kep universitas airlangga, indonesia 22. saldi yusuf, mhs, phd universitas hasanuddin, indonesia 23. saryono, s.kp., m.kes universitas jenderal soedirman, indonesia 24. susy katikana sebayang, phd universitas airlangga, indonesia 25. dr. vimala ramoo university of malaya, malaysia p-issn: 1858-3598 e-issn: 2502-5791 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 table of content 19. structural equation modelling on effects of community empowerment and supplementary feeding on health status and nutritional status of pregnant women lantin sulistyorini 128-137 20. religiosity and self-efficacy in the prevention of hiv-risk behaviours among muslim university students angga wilandika 138-143 21. development of the mind-body-spiritual (mbs) nursing care model for coronary heart disease patients ninuk dian kurniawati, nursalam nursalam, suharto suharto 144-149 22. the effectiveness of roy’s adaptation model for patients with chronic kidney disease undergoing pre-dialysis in indonesia tri hapsari retno agustiyowati, ratna sitorus, agung waluyo, besral besral 150-155 23. perceived benefits and intakes of protein, vitamin c and iron in preventing anemia among pregnant women mira triharini, nursalam nursalam, agus sulistyono, merryana adriani, pei-lun hsieh 156-161 24. hiv/aids-related knowledge and willingness to participate in voluntary counselling and testing among health sciences university students ni putu wulan purnama sari, anselmus aristo parut 162-170 25. the correlation between motivation and health locus of control with adherence dietary of diabetes mellitus kusnanto kusnanto, retno dwi susanti, lailatun ni'mah, hakim zulkarnain 171-177 26. improving self-protection knowledge against sexual abuse by using dreall healthy and animation video adelia pradita, arie kusumaningrum, jum natosba 178-183 27. complaints in menopausal women and its correlation with lifestyle and stress ni ketut alit armini, lailatun ni'mah, baiq selly silviani 184-189 28. the association of pornographic media exposure and nutritional status with early menarche deswita deswita, randy refnandes, randy refnandes, mella gustriyani putri, mella gustriyani putri 190-193 29. waist circumference as a predictor for menstrual cycle disturbance among college student bambang purwanto, ni nyoman trioka rtamagustini, hanifa erlin dharmayanti 194-199 30. red ginger (zingiber officinale var. rubrum) massage reduces stiffness and functional disability in elderly with osteoarthritis putu indraswari aryanti, joni haryanto, elida ulfiana 200-206 31. life writing therapy decreases depression in late adolescent zulaikah nur istiqomah, erna erawati, suyanta suyanta 207-212 32. exclusive breastfeeding associated with the reduction of acute respiratory tract infections in toddlers with high-risk factors abu bakar, elfira fitria rohma, iqlima dwi kurnia, siti nur qomariah 213-218 33. factors associated with nurses’ self-efficacy in applying palliative care in intensive care unit theresia avila kurnia, yanny trisyani, ayu prawesti 219-226 34. validity and reliability of quality of nursing work life instrument for hospital nurses utami utami, hari kusnanto, bagus riyono, syahirul alim 227-232 35. the perception of indonesian nursing students on the learning environment in clinical practice pepin nahariani, fahruddin kurdi, ratna puji priyanti 233-238 editorial indonesia is experiencing a crisis of sexual abuse. the cases of sexual abuse are currently increasing but sound policies have still not been made to deal with it. this problem is not just an individual and family responsibility. this is a global problem that touches on the realms of both law and health. this situation has a significant negative impact, especially on the quality of adolescent development and it demonstrates the quality of the community health services as the frontline in preventing community health problems. the indonesian child protection commission (icpc) recorded, in two months, 223 cases of sexual abuse at the end of 2018 and every year, the national commission on violence against women recorded more than 250,000 reports. the high incidence rate showed that this is a problem that requires priority handling. sexual abuse that continues to occur has implications for the emergence of various major problems namely mental health and reproductive health issues such as sexually transmitted infections (stis). melissa hall and joshua hall in ‘the long-term effects of sexual childhood abuse’ explained that the long-term consequences of sexual abuse include depression, guilt, shame, self-blame, eating disorders, somatic problems, anxiety, dissociative rejection, sexual problems and social issues. the effort that has been made by the government is to make the draft law on the elimination of sexual violence, but this has not had a significant impact. the incidence rate of sexual abuse is undeniable and it will continue to increase and develop from a small community problem to becoming a national and international problem. the health sector, especially community nurses, have an essential role in promotive and preventive efforts through early reproductive education to educate the public. the legal role of policymakers is needed to provide smart solutions to overcome and reduce the incidence rate of sexual abuse. jurnal ners seeks to provide support in decision making through the latest research that can be used as material for consideration related to existing policy decisions. we hope that this effort can help community nurses take on sexual abuse promotive and preventive interventions and that they assist the government considering policy making. http://e-journal.unair.ac.id/jners | 305 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3.17166 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research management of shivering in post-spinal anesthesia using warming blankets and warm fluid therapy arina qona’ah1 ,novi enis rosuliana2, i made amartha bratasena2, and wahyu cahyono2 1faculty of nursing, universitas airlangga, surabaya, indonesia 2sekolah tinggi ilmu kesehatan mataram, mataram, indonesia abstract introduction: hypothermia is a common and serious complication of spinal surgery and it is associated with many harmful perioperative outcomes. the aim of this study was to compare the effectiveness of warming blankets and warm fluid therapy to manage shivering. methods: a quasi-experiment with a non-equivalent control group was applied as the research design. there were 60 patients involved in the study. the instrument of this study was a warmer fluid modification, a warming blanket and a cotton blanket. the data was analyzed using an applied paired t-test and independent t-test. results: after 60 minutes of the intervention, the mean and sd of body temperature of the patients receiving warm fluids was 36.71 ± 0.18, a warming blanket was 36.12 ± 0.35, and the control group was 35.76 ± 0.22. the p values were 0,000. conclusion: warm fluid therapy and warming blankets are significant in terms of increasing the body temperature of post-spinal anesthesia patients. warm fluids are more effective than warming blanket. warming blankets and warm fluid therapy can be used as a way to increase the body temperature of patients with hypothermia. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords warm fluid therapy; warming blankets; hypothermia contact arina qona’ah  arina-qonaah@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: qona’ah, a.., rosuliana, n.e., bratasena, i.m.a & cahyono, w. (2019). management of shivering in post-spinal anesthesia using warming blankets and warm fluid therapy. jurnal ners, special issues, 305-309. doi:http://dx.doi.org/10.20473/jn.v14i3.17166 introduction hypothermia often occurs in postoperative patients. around 40-60 minutes after anesthesia, the body temperature decreases intensively(moysés, trettene, navarro, & ayres, 2014). hypothermia occurs when the body temperature is less than 360c at the perioperative point in time and during anesthesia. hypothermia is caused by a cold operating room, decreased metabolism, the length and type of operation, body cavity exposure, the type of anesthesia and the fluids used in the operative processes(de figueiredo locks, 2012). based on the results of a survey conducted on 564 patients, 45.7% experienced hypothermia(aksu, kus, gurkan, solak, & toker, 2014). harahap (2014) said that the number of patients who experienced hypothermia in the recovery room was 113 people (87.6%). in the patients receiving spinal anesthesia, the incidence rate of hypothermia was higher than that for general anesthesia (52%)(shaw, steelman, deberg, & schweizer, 2017). hypothermia is an independent factor in the occurrence of death due to interference various organs of the body and produce shivering in the post-operative period(harahap, kadarsah, & oktaliansah, 2014)(okeke, 2007). hypothermia triggers shivering where oxygen demand increases 500%(zaman, rahmani, majedi, roshani, & valiee, 2018). shivering is the body's protection mechanism by increasing heat production through muscle contractions. muscle contractions can increase heat production, oxygen consumption, and carbon dioxide production. this can lead to a risk of complications in patients with cardiovascular and pulmonary disorders(de figueiredo locks, 2012). shivering occurs in 50% of operating patients with a body temperature of 35.50c and 90% in patients with a body temperature of 34.50c (harahap et al., 2014). shivering is more common in surgical patients who https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3. a. qona’ah et al. 306 | pissn: 1858-3598  eissn: 2502-5791 use spinal or epidural anesthesia(tarmey & white, 2009). the intervention for the treatment of postoperative hypothermia is oxygen, intravenous thermal elements, warming blankets and wool caps. therapy with warm fluids is given intravenously where previously the liquid is warmed to 370c. warm fluids are used to reduce heat dissipation and to avoid iatrogenic cooling in the body(nayoko, 2016). the active warming fluid infusion given to patients with spinal anesthesia has a significant impact on reducing the incidence of hypothermia and shivering(sultan, habib, cho, & carvalho, 2015). other than that, hypothermia can be controlled with active external installation. for example, a warming blanket. warming blankets can protect the body after it has experienced hypothermia so then it is not exposed to the surrounding air which has a lower temperature(jin & chung, 2001). during spinal anesthesia, giving the patient a passive warming (cotton blankets, reflective blankets) is less effective than active warming (forced air warming, underbody conductive heat mat, circulating water mattress, and a radiant warmer)(shaw et al., 2017). a combination of several devices in managing the shivering can be more effective at controlling body temperature during the operative periods(ihn et al., 2008). this study aims to determine the effectiveness of warm fluid therapy and warming blankets to increase body temperature in post-spinal anesthesia patients. materials and methods the study design used in this study was a time series with a non-equivalent control group design with a population of 200 patients from october to november 2017.this research was conducted in the recovery room of yatofa hospital. the inclusion criteria on this study were patient operatives who’ had spinal anesthesia, aged from 18-65 years old and who experienced shivering. the total sample was 60 respondents divided into 40 respondents in the intervention groups divided into warm fluid therapy (infusion fluid warmed up to 37 – 400c) and a warming blanket. meanwhile, 20 respondents in the control groups were given therapy according to the hospital procedures performed post-spinal anesthesia; a blanket was provided. the instrument in this study was a warmed fluid infusion, a warmed blanket and a cotton blanket. for the warmed fluid infusion, we used a box of 27cmx25cmx40cm with 800 grams weight, voltage 110 / 220 v equipped with 40 watt light bulbs (2 lamps). the specifications of the warmed blanket are that it was made from fine cotton and had a plain blue motif, while being 1 kg in weight, 150 cm in length, 2m in width and with a thickness of 5cm. the body temperature measurements were taken using an axillary thermometer and observation sheet. the patient's body temperature was divided into four criteria; mild hypothermia (32-360c), moderate hypothermia (28-320c), severe hypothermia (<280c) and normal body temperature (36-37,50c). body temperature measurements after the intervention were carried out four times, namely at the 15, 30, 45and 60minutes. the collected data was analyzed using a paired ttest and independent t-test. the paired t-test was used to measured the differences before and after the treatment in the respective groups. to find out which treatment had the most influence on changes in body temperature, an independent t-test was conducted. this research was conducted by upholding ethical principles and getting approval from the research location. results the total patients used in this study were 60 patients. the patients were grouped into an intervention group and a control group. the intervention group was given warm fluids and warming blankets. the control group was given a blanket. the average age of the patients in this study was 41.8 years (41.8 in the warm fluid intervention group, 44.5 in the group treating with warming blankets and 39.10 in the control group). there were 28 male patients (46.7%) and 32 female patients (53.3%). the average body temperature of the patient before the intervention was 35.370c and body temperature after the intervention was 35.550c at 15 minutes, 35.790c at 30 minutes, 36.060c at 45 minutes and 36.170c at 60th minutes (table 1). there was a significant difference in body temperature before and after the intervention in both the intervention and control groups (p-value <0.05) (table 2). the results of the independent t-test showed that there were significant temperature differences between the warm fluid and the warming blanket at 30, 45 and 60 minutes; at 30t and 45 minutes in the comparison between warm fluid and the control group and at 60t minutes at the and of the warm blanket and control group comparison (table 3). discussion shivering is part of the body's defense mechanism by regulating the center of heat in the body which can produce harmful effects in terms of systemic oxygen consumption, oxygen in the brain tissue and intracranial pressure. spinal and general anesthesia can cause shivering. spinal anesthesia causes heat redistribution from the center of the body to the periphery because spinal anesthesia induces vasodilation(a., 2017). a rapid decrease in core body temperature due to shifting body heat from the core to the perimeter can cause vasodilation. after that, the reduction slows down the core temperature, causing heat loss due to excessive heat production(zaman et al., 2018). hypothermia is more common in the elderly compared to adults. based on the results of this study, 46.7% of patients who experienced hypothermia were aged 41-65 years, while those aged 18-25 years had an incidence rate of 13.3%. in the elderly, spinal anesthesia causes hypothermia and jurnal ners http://e-journal.unair.ac.id/jners | 307 slows recovery(mendonça, lucena, quirino, govêia, & guimarães, 2019). a. qona’ah et al. 308 | pissn: 1858-3598  eissn: 2502-5791 shivering is controlled with warm fluids more table 1. demographic data (mean ± sd) of the patients shivering after spinal anesthesia variabel groups (mean ± sd) all respondents (mean ± sd) intervention control warm fluid warming blanket patient age 41,85 ± 14,87 44,55 ± 12,28 39,10 ± 14,98 41,83 ± 14,04 patient sex 10 (male) 10 (female) 8 (male) 12 (female) 10 (male) 10 (female) 28 (male) 32 (female) body temperature before intervention 35.43 ± 0.22 35.34 ± 0.26 35.34 ± 0.25 35.37 ± 0.24 body temperature after 15 minutes 35.67 ± 0.22 35.49 ± 0.27 35.49 ± 0.26 35.55 ± 0.26 body temperature after 30 minutes 35.99 ± 0.16 35.68 ± 0.27 35.74 ± 0.32 35.79 ± 0.30 body temperature after 45 minutes 36.35 ± 0.18 35.91 ± 0.31 35.96 ± 0.42 36.06 ± 0.38 body temperature after 60 minutes 36.71 ± 0.18 36.12 ± 0.35 35.76 ± 0.22 36.17 ± 0.48 table 2. test results of the paired t-test in shivering patients post-spinal anesthesia mean ± sd ci 95% p intervention group: warm fluid before and after warm fluid for 15 minutes 0.24 ± 0,59 0,21-0,26 0,00 before and after warm fluid for 30 minutes 0,56 ± 0,11 0,51-0,61 0,00 before and after warm fluid for 45 minutes 0,93 ± 0,16 0,85-0,99 0,00 before and after warm fluid for 60 minutes 1,28 ± 0,26 1,15-1,40 0,00 intervention group: warming blanket before and after warming blanket for 15 minutes 0,15 ± 0,06 0,12-0,17 0,00 before and after warming blanket for 30 minutes 0,34 ± 0,09 0,29-0,38 0,00 before and after warming blanket for 45 minutes 0,57 ± 0,13 0,50-0,63 0,00 before and after warming blanket for 60 minute s 0,77 ± 0,18 0,68-0,86 0,00 control group before and after blanket for 15 minutes 0,14 ± 0,24 0,03-0,25 0,015 before and after blanket for 30 minutes 0,39 ± 0,34 0,23-0,56 0,00 before and after blanket for 45 minutes 0,62 ± 0,43 0,41-0,82 0,00 before and after blanket for 60 minutes 0,41 ± 0,35 0,24-0,58 0,00 table 3. the results of the independent t test on shivering patients post-spinal anesthesia n mean ± sd p warm fluid thermal blanket before intervention 20 35,43 ± 0,22 35,34 ± 0,26 0,345 15 minutes after intervention 20 35,67 ± 0,22 35,49 ± 0,27 0,156 30 minutes after intervention 20 35,99 ± 0,16 35,68 ± 0,27 0,010 45 minutes after intervention 20 36,35 ± 0,18 35,91 ± 0,31 0,004 60 minutes after treatment 20 36,71 ± 0,18 36,12 ± 0,35 0,001 warm fluid control before intervention 20 35,43 ± 0,22 35,34 ± 0,25 0.579 15 minutes after intervention 20 35,67 ± 0,22 35,49 ± 0,26 0.405 30 minutes after intervention 20 35,99 ± 0,16 35,69 ± 0,34 0.025 45 minutes after intervention 20 36,35 ± 0,18 35,93 ± 0,44 0.002 60 minutes after intervention 20 36,71 ± 0,18 35,70 ± 0,18 1.000 warming blanket control before intervention 20 35,34 ± 0,26 35,34 ± 0,25 0,701 15 minutes after intervention 20 35,49 ± 0,27 35,49 ± 0,26 0,601 30 minutes after intervention 20 35,68 ± 0,27 35,69 ± 0,34 0,705 45 minutes after intervention 20 35,91 ± 0,31 35,93 ± 0,44 0,236 60 minutes after intervention 20 36,12 ± 0,35 35,70 ± 0,18 0,001 jurnal ners http://e-journal.unair.ac.id/jners | 309 effectively than a warming blanket or cotton blanket. warm fluids significantly controlled shivering after 30 minutes. all patients who were given warm fluids for 60 minutes experienced changes in their body temperature from hypothermia to normothermia. the warm liquid was given to the post-spinal anesthesia patients who experienced shivering and it worked through the mechanism of heat conduction. warm liquids can increase the tolerance of the regulatory systems when shivering occurs. warm fluids given through intravenous lines aim to maintain core body temperature by activating the reflex and semi-reflex thermoregulation mechanisms in humans so then there are otonomsomatic, endocrine and behavioral changes(nayoko, 2016). giving a warming blanket to post-spinal anesthesia patients can increase the body temperature to normothermia in almost half (30%) of the patients. warming blankets can protect the body from exposure to low room temperatures. giving blankets to post-operative patients can minimize body heat loss due to incision wounds and the effects of hypothermia during surgery. when the hypothermia of the body experiences vasoconstriction, this can cause a loss of heat so the blankets act as heat insulators to prevent excessive heat loss(ihn et al., 2008). blankets can be used to reduce cutaneous heat loss. a sheet of insulator (blanket) can reduced heat loss by 30%(lopez, 2018). maintaining hemodynamic stability during the perioperative period is important to ensure a balance between delivery and oxygen demand. in the early post-operative stage, mild hypothermia can increase the concentration of norepinephrine and peripheral vasoconstriction which contributes to cardiovascular ischemia and arrhythmias. hypothermia also increases blood loss during surgical procedures, while also increasing the risk of infection, decreasing drug metabolism and causing prolonged hospitalization time(jin & chung, 2001). the intervention that can be taken to maintain hemodynamic stability is the giving of warm fluids and warming blankets. the limitation of this research was that the instrument used to warm the fluid was still manual. conclusion shivering due to hypothermia in post-operative patients having used spinal anesthesia can be treated using warm fluids and warming blankets. warm fluid therapy has proven to be more effective at boosting the body temperature to normal compared to a warming blanket. controlling hypothermia should be carried out starting from the time that the patient is in the operating room and it should continue into the recovery room (perioperative). the management of hypothermia in postoperative patients can be done in a simple way. nurses can use the available resources to make a tool that can be used to warm up intravenous fluids. references a., p. (2017). control of intraoperative shivering under spinal anaesthesiaa prospective randomized comparative study of butorphanol with tramadol. journal of krishna institute of medical sciences university, 6(1), 57–65. aksu, c., kus, a., gurkan, y., solak, m., & toker, k. (2014). survey on postoperative hypothermia incidence in operating theatres of kocaeli university. turkish journal of anesthesia and reanimation, 42(2), 66–70. https://doi.org/10.5152/tjar.2014.15010 de figueiredo locks, g. (2012). incidence of shivering after cesarean section under spinal anesthesia with or without intrathecal sufentanil: a randomized study. revista brasileira de anestesiologia, 62(5), 676–684. https://doi.org/10.1016/s00347094(12)70166-6 harahap, a. m., kadarsah, r., & oktaliansah, e. (2014). the incidence of hypothermia and duration of care in the recovery room on postoperative geriatric patients at dr. hasan sadikin hospital bandung during october 2011–march 2012. jurnal anestesi perioperatif, 2(1), 36–44. ihn, c. h., joo, j. d., chung, h. s., choi, j. w., kim, d. w., jeon, y. s., … choi, w. y. (2008). comparison of three warming devices for the prevention of core hypothermia and post-anaesthesia shivering. journal of international medical research, 36(5), 923–931. https://doi.org/10.1177/1473230008036005 08 jin, f., & chung, f. (2001). minimizing perioperative adverse events in the elderly. british journal of anaesthesia, vol. 87, pp. 608–624. https://doi.org/10.1093/bja/87.4.608 lopez, m. b. (2018). postanaesthetic shivering – from pathophysiology to prevention. romanian journal of anaesthesia and intensive care, 25(1), 73–81. https://doi.org/10.21454/rjaic.7518.251.xum mendonça, f. t., lucena, m. c. de, quirino, r. s., govêia, c. s., & guimarães, g. m. n. (2019). risk factors for postoperative hypothermia in the post‐ anesthetic care unit: a prospective prognostic pilot study. brazilian journal of anesthesiology, 69(2), 122–130. https://doi.org/10.1016/j.bjan.2018.10.001 moysés, a. m., trettene, a. dos s., navarro, l. h. c., & ayres, j. a. (2014). hypothermia prevention during surgery: comparison between thermal mattress and thermal blanket. revista da escola de enfermagem, 48(2), 226–232. https://doi.org/10.1590/s0080623420140000200005 nayoko. (2016). perbandingan efektifitas pemberian cairan. jurnal keperawatan muhammadiyah, 1(1), 86–92. okeke, l. i. (2007). effect of warm intravenous and irrigating fluids on body temperature during a. qona’ah et al. 310 | pissn: 1858-3598  eissn: 2502-5791 transurethral resection of the prostate gland. bmc urology, 7, 5–7. https://doi.org/10.1186/1471-2490-7-15 shaw, c. a., steelman, v. m., deberg, j., & schweizer, m. l. (2017). effectiveness of active and passive warming for the prevention of inadvertent hypothermia in patients receiving neuraxial anesthesia: a systematic review and metaanalysis of randomized controlled trials. journal of clinical anesthesia, 38, 93–104. https://doi.org/10.1016/j.jclinane.2017.01.00 5 sultan, p., habib, a. s., cho, y., & carvalho, b. (2015). the effect of patient warming during caesarean delivery on maternal and neonatal outcomes: a meta-analysis. british journal of anaesthesia, vol. 115, pp. 500–510. https://doi.org/10.1093/bja/aev325 tarmey, n., & white, l. a. (2009). section 3: shivering. in risks associated with your anaesthetic (pp. 1– 3). zaman, s. s., rahmani, f., majedi, m. a., roshani, d., & valiee, s. (2018). a clinical trial of the effect of warm intravenous fluids on core temperature and shivering in patients undergoing abdominal surgery. journal of perianesthesia nursing, 33(5), 616–625. https://doi.org/10.1016/j.jopan.2016.12.010 http://e-journal.unair.ac.id/jners | 209 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17060 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the impacts of depression treatment on health-related quality of life in cancer patients: a systematic review andrik hermanto, gabriel wanda sinawang, mohamad roni alfaqih and rohmatul faizah faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: cancer diagnosis can have a profound negative impact on the health-related quality of life (hrqol) of cancer patients. cancer patients also suffer from psychological pressures including sadness, depression, hopelessness, anxiety and worry. the literature review was employed to determine the effects of depression on health-related quality of life (hrqol) in cancer patients. methods: a systematic review was conducted by searching the science direct, scopus and google scholar databases. the integrative review of the 10 articles was focused on the 10 years period from 2008 to 2018. the language used was english and the search was conducted using predefined keywords. results: all of the journals discussed the impact of depression treatment on health-related quality of life in cancer patients. based on all of the journals, depression can be reduced by health education, physical activity and medicine therapy conclusion: despite the treatment for depression, the patient’s hrqol did not improve during the measurement timeframe. quality of life is a priority health outcome in cancer treatment but the clinical approaches to ameliorate depression in cancer patients appear to be suboptimal. article history received: december 26, 2019 accepted: december 31, 2019 keywords depression; quality of life; cancer; treatment contact andrik hermanto  andrik.hermanto2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: hermanto, a., sinawang,, g. w., alfaqih, m. r., & faizah, r. (2019). the impacts of depression treatment on health-related quality of life in cancer patients: a systematic review. jurnal ners, 14(3si), 209-212. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17060 introduction a cancer diagnosis in adults is frequently accompanied by a negative impact on mental health, such as changes in body image and function, persistent pain, distress and anxiety, a fear of cancer recurrence and death, due to which there is an increased risk of depression among adults with cancer. in fact, 25% to 38% of adults with cancer have reported experiencing depression. comorbid depression in adults with cancer is negatively associated with health-related quality of life (hrqol), which, in turn, may decrease survival. for instance, 16% of breast cancer survivors were reported to be depressed and depression was inversely associated with hrqol. health-related quality of life (hrqol) has been defined as the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient themselves. to improve hrqol and hence survival in this vulnerable group, adults with cancer and comorbid depression should be offered pharmacological or psychological treatment for depression. the importance of detecting and treating depressive illness in cancer patients lies not only in the relief of the psychological distress and its impact on quality of life but also on the consequent health service and societal costs. in addition, depression has been associated with the increased impairment of the human immune response and thus, poorer survival. a more recent systematic review and metaanalysis examining the use of antidepressants for treating depression in cancer patients reported that only one study included quality of life as an outcome. another systematic review of the effect of cognitive behavioral therapy and health education on depression in adult cancer survivors reported an improved quality of life through the therapy. an rct of the collaborative care management of depression among cancer patients showed an improvement in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:andrik.hermanto-2018@fkp.unair.ac.id mailto:andrik.hermanto-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). a. hermanto, et al. 210 | pissn: 1858-3598  eissn: 2502-5791 hrqol, although the study may not be broadly generalizable as it focused on low income and predominantly hispanic patients. few studies that have evaluated the impact of depression treatment on hrqol have specifically focused on a particular type of cancer. for instance, studies on women with breast cancer reported that the treatment of depression, either by pharmacological agents or psychosocial interventions, improves quality of life and longevity. furthermore, the majority of studies evaluated quality of life, which is a broad and distinctive construct measuring overall general well-being, whereas hrqol, which may evaluate the physical, social and mental health dimensions, specifically describes a health construct using functioning and well-being. this study aims to determine the effects of pharmacological and non-pharmacological therapies on reducing the depression in cancer patients so as to increase hrqol. materials and methods the literature review was employed according to the prisma (preferred reporting items for systematic reviews and meta-analyses) guidelines. the database search was performed in march 2019 for articles dated in the last 5 years, which included those in the scopus, science direct and ebscho databases. the keywords used were alone or in combination as follows: cancer, cancer depression, health related quality of life and cancer treatment. the limitations used in the literature search were published in the last 5 years and they were also english-only articles. once all of the articles were found, duplicate articles were removed. the criteria for inclusion in this review included the following: (1) the studies that involved cancer patients that had been received or that were still receiving therapy and (2) studies that involved cancer therapy as their intervention for increasing depression. the criteria for exclusion included the following: (1) studies that did not have information on cancer and depression, (2) the language used was not english and (3) outside of the time limitation of september 2013 to 2018. results the articles that were used in this review used a randomized controlled trial in addition to quantitative, qualitative and experimental study. the research took place in the usa, china, spain, korea and taiwan. a total of 10 articles are met the inclusion criteria for this review. total respondents in this review are 4197 cancer patients who received pharmacological and nonpharmacological therapy. there is 3 journal that using a pharmacological therapy for cancer patient and 7 journals that using a non-pharmacological therapy. pharmacological therapy from the 10 articles that were reviewed, 4 articles used the pharmacological therapy as a comparison intervention [2, 8-10]. these interventions support the chemotherapy undergone by the cancer patients directly. in this intervention, the patients were not given any therapy other than the specified treatment before undergoing chemotherapy. the treatment usually given in cancer patients is paroxetine and fluoxetine. paroxetine is effective at reducing major depression in cancer patients with malignant melanomas who are to receive a high-dose of interferon alpha therapy. paroxetine was found to be effective at reducing the depressive symptoms of breast, lung, hematological, gynecological and gastrointestinal cancer patients who reported fatigue in their second chemotherapy cycle. fluoxetine was not effective at reducing caseness for depression in a trial that included patients with breast, gynecological or hematological cancer who presented with major depressive disorder. non-pharmacological therapy from the 10 articles that were reviewed, 6 articles used non-pharmacological therapy as a comparison intervention [1, 3-7]. the interventions provided included health education and physical therapy. health education is important in order to understand the information needs of the cancer patients to better address their needs and thus, to improve health care delivery. many of the fears and uncertainties surrounding cancer treatment and outcomes may be lessened with changes in the information sharing patterns between breast cancer patients. physical activity has similar benefits for depressive symptoms. implementing physical activity during and posttreatment, could preempt the decline in cancer survivors. specifically, moderate to vigorous physical activity in cancer survivors has been shown to have a complimentary effect on information processing speed. this suggests that physical activity may be a figure 1. flowchart of the research on depression in cancer patients total articles that matched the inclusion criteria (n=10) keywords: “cancer”, “cancer depression”, “health related quality of life” and/or “cancer treatment” databases: scopus, science direct and ebscho articles exluded with reasons: • studies that did not have information on cancer depression • language used was not english • more than the time limitation (september 2013 to 2018) 4197 cancer patients jurnal ners http://e-journal.unair.ac.id/jners | 211 preventative measure for cognitive decline in breast cancer survivors. impact of depression treatment on health-related quality of life health-related quality of life (hrqol) is an important outcome measure of chronic illness management and treatment, including anticancer treatment. hrqol is particularly important for patients with cancer because the survival time of this disease is likely to be short and its treatments are expected to be toxic and limited in efficacy. a number of factors including age, marital status, income, cancer stage, treatment regime and cell type are found to be significantly associated with poor qol in patients with cancer. the effect of depression on the hrqol of patients with cancer has not been investigated, although there is convincing evidence that depression negatively affects the hrqol of the general population. discussion this systematic review indicates that there is limited trial data available on the efficacy/tolerability of pharmacological and non-pharmacological interventions for patients with cancer and depression. the reviewed studies varied in the type of pharmacological interventions employed, in the characteristics of the studied populations, in the type, grade and stage of the subject’s cancer, in the treatments being received and in the trial design, including the outcome measures used. pharmacological therapy pharmacological interventions reported on the efficacy of antidepressants in terms of change in caseness for clinical depression as opposed to changes in the scores indicating the level of depressive symptoms. paroxetine was found to be effective at reducing major depression in patients with malignant melanomas who were to receive highdose interferon alpha therapy and at reducing the caseness for depression in breast cancer patients receiving chemotherapy. fluoxetine was not effective at reducing caseness for depression in a trial that included patients with breast, gynecological or hematological cancer. paroxetine and fluoxetine were both effective at reducing depressive symptoms in 3 trials that included patients with a range of cancers (breast, lung, hematological, gynecological and gastrointestinal) and the tetracyclic antidepressant mianserin was also shown to be effective at reducing depressive symptoms in breast cancer. pharmacological therapy can effectively to reduce anxiety in cancer patients. however, pharmacological therapy includes side effects such as an elevation in blood pressure, dry mouth, blurred vision, constipation, urinary retention, cardiac arrhythmia, tachycardia, sedation, postural hypotension, dizziness and headache. health education health education showed that increased access to health information enhanced the chances of better health outcomes such as decreased depression and anxiety, which in turn result in an improved quality of life among the cancer patients. the findings regarding the impact of access to healthcare information on depression, anxiety and quality of life could be attributed to uncertainties that characterize the patient’s perceptions about treatment outcomes and prognosis. thus, increased access to health information may serve to alleviate the levels of depression and anxiety associated with living with cancer patients which in turn result in an improved quality of life. even though one would expect that in some cases, factual information about negative treatment outcomes may heighten the levels of anxiety and depression among the patients, this was not the case in this study. these findings highlight the importance of the information needs of cancer patients as the evidence suggests that access to health information leads to better mental and physical health outcomes. access to health information did not have any significant direct influence on the quality of life of the participants. this finding is consistent with the previous studies that did not find there to be any significant direct influence from access to health information on the quality of life among cancer patients. however, the results showed that there was an indirect impact from access to information on quality of life through short-term health outcomes such as decreased depression and anxiety. physical therapy physical activity was effective at improving cognition in those who did not receive chemotherapy. those who did showed only minimal improvements in cognition with increasing levels of moderate physical activity. the results of our study suggest that the effects of chemotherapy on the brain may not be mitigated by moderate levels of physical activity. applying more targeted exercise protocols may be necessary to show improvements in cognition and depressive symptoms in those who received chemotherapy. cancer treatment requires a combination of pharmacology and non-pharmacology. the role of the nurses, in addition to helping to provide treatment, helps in the non-pharmacological treatment as well so then the depression in cancer patients can be reduced. conclusion the sparse number of studies on the pharmacological interventions used for cancer patients with depression provides some evidence that antidepressants are effective at reducing depression/depressive symptoms in cancer patients. although more data is needed regarding the safety and efficacy of antidepressants, there is some evidence that cancer patients with depression are a. hermanto, et al. 212 | pissn: 1858-3598  eissn: 2502-5791 responsive to treatment. overall, the small number of trials related t pharmacological interventions for cancer patients with depression/depressive symptoms, the high dropout rates in some trials and a lack of reporting of adverse events/tolerability should be used as a caution against drawing definitive conclusions about which antidepressants are the most effective or well-tolerated by cancer patients in general or by patients with specific types of cancer. there is limited trial data on the efficacy of nonpharmacological interventions in treating depression/depressive symptoms in cancer patients. cognitive behavioral therapy appears to be effective at reducing the depressive symptoms in cancer patients. references bedillion, m. f., ansell, e. b., & thomas, g. a. (2019). cancer treatment effects on cognition and depression: the moderating role of physical activity. breast, 44, 73–80. https://doi.org/10.1016/j.breast.2019.01.004 calderon, c., carmona-bayonas, a., hernández, r., ghanem, i., castelo, b., martinez de castro, e., … jimenez-fonseca, p. (2019). effects of pessimism, depression, fatigue, and pain on functional healthrelated quality of life in patients with resected non-advanced breast cancer. breast, 44, 108–112. https://doi.org/10.1016/j.breast.2019.01.012 gu, w., xu, y.-m., zhu, j.-h., & zhong, b.-l. (2017). depression and its impact on health-related quality of life among chinese inpatients with lung cancer. oncotarget, 8(62), 104806–104812. https://doi.org/10.18632/oncotarget.21001 kugbey, n., meyer-weitz, a., & oppong asante, k. (2018). mental adjustment to cancer and quality of life among women living with breast cancer in ghana. international journal of psychiatry in medicine. https://doi.org/10.1177/0091217418805087 lin, h. y., lai, h. l., chen, c. i., & huang, c. y. (2017). depression and health-related quality of life and their association with resourcefulness in survivors of prostate cancer. archives of psychiatric nursing, 31(4), 407–413. https://doi.org/10.1016/j.apnu.2017.04.014 merakou, k., tsoukas, k., stavrinos, g., amanaki, e., daleziou, a., kourmousi, n., … barbouni, a. (2019). the effect of progressive muscle relaxation on emotional competence: depression–anxiety– stress, sense of coherence, health-related quality of life, and well-being of unemployed people in greece: an intervention study. explore, 15(1), 38– 46. https://doi.org/10.1016/j.explore.2018.08.001 mishra, s. i., rishel brakey, h., kano, m., nedjat-haiem, f. r., & sussman, a. l. (2018). health related quality of life during cancer treatment: perspectives of young adult (23–39 years) cancer survivors and primary informal caregivers. european journal of oncology nursing, 32(june 2017), 48–54. https://doi.org/10.1016/j.ejon.2017.11.007 park, s. j., rim, s. j., kim, c. e., & park, s. (2019). effect of comorbid depression on health-related quality of life of patients with chronic diseases: a south korean nationwide study (2007–2015). journal of psychosomatic research, 116(november 2018), 17–21. https://doi.org/10.1016/j.jpsychores.2018.11.00 4 vyas, a., babcock, z., & kogut, s. (2017). impact of depression treatment on health-related quality of life among adults with cancer and depression: a population-level analysis. journal of cancer survivorship, 11(5), 624–633. https://doi.org/10.1007/s11764-017-0635-y wang, z., yin, g., & jia, r. (2019). impacts of self-care education on adverse events and mental health related quality of life in breast cancer patients under chemotherapy. complementary therapies in medicine, 43(january), 165–169. https://doi.org/10.1016/j.ctim.2019.01.027 98 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16995 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of ergonomic gymnastics on joint pain in community-dwelling elderly martha lowrani siagian1, anggi hanafiah syanif1, andreas wojtyla sukur2, beatric maria dwijayanti baga2, and ni ketut emi rayuni2 1faculty of nursing, universitas airlangga, surabaya, indonesia 2institute of health science, william booth, surabaya, indoensia abstract background: the aging process that occurs in the elderly is characterized by a decreasing immune system and physical impairment. the most common complaint is joint pain. the aim was to determine the effect of ergonomic gymnastics on the elderly who experienced joint pain. method: the samples totaled 110 respondents who had joint pain at krembangansurabaya obtained through the total sampling technique. the data was collected through observation sheets with one group pre-post-test design, and it was analyzed through the wilcoxon text. the result showed that after 9 sessions of 60 minutes each for two months found that ergonomic gymnastics could influence the reduction of joint pain with a significance level of 0.00 (p<0.05). discussion: there were a decreasing number of respondents that felt moderate pain (82 to 44) and this automatically meant that there was an increasing number of mild pain respondents (28 to 66). conclusion: exercising regularly and with the correct methods could provide an excellent benefit to maintain bodily health, especially to reduce joint pain in the elderly. it is expected that all health care providers in primary health services or in a private clinics should know and be able to conduct ergonomic gymnastics using the correct methods. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords ergonomic gymnastics; joint pain; community dwelling, elderly contact martha lowrani siagian martha.lowrani.siagia n-2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: siagian, m. l, syarif, a. h, sukur, a. w, baga, b. m. d, and rayuni, n. k. e. (2019). the effect of ergonomic gymnastics on joint pain in community-dwelling elderly. jurnal ners, 14(3si), 98-102 doi:http://dx.doi.org/10.20473/jn.v14i1.16995 introduction the increasing elderly population needs to get attention because the elderly group is a high-risk group that experiences an increase of various health problems, especially degenerative diseases(ri, 2006).the emergence of various diseases increases because of someone's age and because of that the body’s immune system getting slightly down, that’s why our body easily gets ill, becomes fatigued and can’t do heavier or regular activity anymore. old age is a natural process that cannot be avoided. the aging process that occurs in the elderly is characterized by biological deterioration that is seen by the symptoms of physical deterioration, among others including the skin begins to relax, wrinkles, gray hair, teeth begin to fall out, hearing and sight loss, and being more easily tired. one disease that often occurs in old age is joint pain. joint pain is a result of bone calcification or it can be due to other diseases (muttaqin, 2010). joint disorders in general provide symptoms in the form of pain that can disturb the patient, so the patients cannot work or move comfortably. some of the factors that cause joint pain include the mechanisms of immunity, metabolic factors, age, excessive and repeated joint burden, genetic factors and environmental trigger factors (uliya, s., soempeno, b., 2007). elderly people who experience joint pain disorders should exercise across a range of active motion so then there is no decrease in the range of motion in the elderly or no decrease in their muscle strength(stanley, m & beare, 2010). based on this problem, the researcher wanted to find some other ways to increase the independence of the elderly people by reducing the number of joint pain. one of the exercises for active motion is by doing ergonomic exercises. ergonomic gymnastics is one method that is practical and effective at maintaining https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:martha.lowrani.siagian-2018@fkp.unair.ac.id mailto:martha.lowrani.siagian-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i1. jurnal ners http://e-journal.unair.ac.id/jners | 99 bodily health. ergonomic gymnastic movements are movements that are in accordance with the rules of creation of the body and this movement is like a prayer movement. ergonomic gymnastics can directly open, cleanse and activate all body systems such as the cardiovascular, urinary and reproductive systems (liu, wan, zhou, feng, & shang, 2017). ergonomic gymnastics consists of movements that resemble prayer movements so then the elderly can easily apply these gymnastic movements in their daily life (gerais, 2017). based on the preliminary study at the wredha mojopahit orphanage, mojokerto regency, it was obtained that 80 elderly individuals had joint disease (joint pain) by around 70%. there are several service researchers at the krembangan health center that are concerned with the elderly people who have joint pain. based on the research conducted by wratsongko, there is the effect of ergonomic exercise on pain complaints referring to the increasing range of motion in elderly people who have experience of rheumatic pain at the bhakti dharma in surakarta hospital(wratsongko, 2010). according to the world health organization (who), they reported that 20% of the world's population is affected by joint pain. from the study on the socio-economic and health conditions of the elderly carried out by the national commission on elderly in 10 provinces in 2006, it became known that the majority of illnesses suffered by the elderly were 69.39% for joint pain, after which came hypertension, anemia, and cataracts (walker, sibley, carter, & hurley, 2017). according to the district health office data in 2010, the number of elderly people suffering from joint disease was 2.3%. based on the results of a recent study about the prevalence of joint pain in indonesia, it has reached 23.6% to 31.3%. based on health diagnosis and symptoms, the national prevalence of joint disease is 30.3%, and the prevalence of joint disease in east java specifically is 30.9% (zeng, q.y., chen, r., darmawan, 2008). therefore the authors are interested in conducting research on the effect of ergonomic exercise on the elderly who experience joint pain in the krembangan health center for the elderly. materials and methods research design, population, sample, and variables the design used was one group pre-post test design. the population of this research was all of the elderly that visited the primary heath service regularly for routine activities or to check their health condition. the sample obtained was 110 respondents through the total sampling technique. this research was conducted at the elderly care service in krembangan (integrated health service for an elderly) from september 3rd october 29th, 2018. the inclusion criteria in this research were as follows: 1) elderly patients with an average age < 60 years old and >71 years old, 2) all genders (male and female), 3) elderly with moderate and mild pain, 4) all levels of education (from elementary up until a bachelor’s degree), 5) all working statuses (private/public employee or retired), 6) they were able to communicate verbally well, and they were able to read, and write and 7) they were willing to participate and had a strong commitment to join us for two months. the exclusion criteria were 1) the elderly who had severe pain and 2) the elderly who visited the elderly care service centre irregularly. the independent variable was the application of ergonomic gymnastics and the dependent variable was joint pain. instruments the research used a leaflet module as the media that was given to the respondents. the module consisted of information about the aging process, diet, common behaviors for the elderly, bein elderly with regular activity or elderly with less activity, and elderly nutrition status (underweight, normal, overweight, obese). this was in addition to simple instructions about ergonomic exercise. other instruments that were used included an observation sheet that contained how long the elderly had to be able to follow the instructions and vds (verbal descriptor scale) for measuring the joint pain scale(walker et al., 2017), which was modified and translated into the indonesian language. the respondents were asked to show how severe their joint pain was on a 1-10 scale and this scale indicated mild pain, moderate pain, and severe or uncontrolled pain. after we finished the interviews and the observation, we demonstrated ergonomic exercise, and asked them to follow it step by step. research procedures and analysis this research was carried out in collaboration with krembangan, surabaya primary health service in order to increase the knowledge of the elderly people surrounding the public health service and to encourage the elderly to be more active when visiting through empowerment and health education. the research passed the ethical review and obtained an ethical approval certificate, which was no. 197/stikeswb/ppm/2018 issued by the health research ethics committee of institute of health science for the nursing department, william booth surabaya in east java province, indonesia. the research was conducted with one treatment group by providing some leaflets and demonstrate ergonomic exercises with some observations and interviews (questions about their pain scale) within a module for 9 meetings across 2 months, which were conducted once a week for 60 minutes, with an evaluation before and after the treatment (pre-post test design).the first week was the introduction to the programs, and an ergonomic gymnastics demonstration and leaflet were given to the respondents. weeks 2 8 provided the health education, explored the elderly comprehension of being elderly and all the related problems, ergonomic gymnastics were demonstrated and there was an observation of the pain scale. week m. l. siagian et al. 100 | pissn: 1858-3598  eissn: 2502-5791 9 was monitoring evaluation and ergonomic gymnastic demonstration. data were analyzed by using ibm spss statistic 24. the statistical analysis used the wilcoxon signed rank test. the confidence interval was 100% with p = 0.00. results characteristics of the respondents as shown in table 1. the majority of the respondents were aged 61-70 years, female, educated to elementary level and unworking/retired. from the data, we can assume that this is typical of the elderly people in krembangan; this may influence how their thinking and interpretation about pain. all of the participants 110 elderly in total were very pleasant toward the program. it can be seen that the results of the research at elderly care service in krembangan surabaya before the ergonomic exercise for all of the elderly respondents was that those in mild pain totaled 28 people and that those with moderate pain totaled 82 people. after the implementation of ergonomic gymnastics, mild pain was experienced by 66 people and moderate pain was experienced by 44 people. the data was analyzed using the wilcoxon statistical test with a significance degree of p <0.05 and a significance level of p = 0.00. thus, h1 was accepted, where the conclusion was that there is some effect from doing ergonomic gymnastics on the elderly who experienced joint pain at the elderly care service in krembangan, surabaya. discussion the vds scale with observations and an interview approach explains the basic principles of the prevention of joint pain in the elderly(lincoln, radford, game, & jeffcoate, 2008) to prevent a higher risk of injury. it is highly dependent on the elderly people by giving them solutions and interventions focused on reducing joint pain by providing integrated health education and ergonomic gymnastics demonstration(schaper, van netten, apelqvist, lipsky, & bakker, 2017). the aging process will cause anatomical, physiological, and biochemical changes in the body so this affect the body's functions and abilities as a whole (primana, 2006). all systems in the body experience setbacks, including the musculoskeletal system, in which the elderly often experience rheumatism, gout, joint pain and lumbar pain (pudjiastuti, s.s., & utomo, 2003). one of the other factors in the musculoskeletal system is the bone loss in terms of density and the more fragile knee and wrist movements. the wrist and finger movements become limited, the joints enlarge and become stiff, the tendons constrict, and they experience sclerosis and an atrophy of muscle fibers (muscle fibers shrinking). movement becomes sluggish, as the muscles become cramped and tremor. a common disease that often occurs in old age is joint pain. there was evidence of this happening when the researcher engaged in the the observation-interview with the respondent to look or find out the scale of the pain in the elderly at the elderly care service focused on in krembangan-surabaya. when the researchers asked the respondents questions, mostly the elderly people answered as to when they had joint pain. ordinarily, they just let it go and rested for a while, minimizing their activity. the respondents who were younger than 60 years old totaled 8 people (7%), those aged 61-70 years old totaled 79 people (72%) and those who were more than 71 years old totaled 23 people (20%). almost 8% of people aged 50 years and over had complaints about their joints, especially rheumatic pain and aches. all of the elderly people often suffered from pain in the joints. this is because the musculoskeletal system decreases in its functions due to changes in the collagen. the impact of this change decreases joint flexibility in addition to the erosion of the joint capsules resulting in decreased joint movement and pain(albargawi, snethen, gannass, & kelber, 2017). the majority gender in this study was mostly female, amounting to 84 people (76%). women are susceptible to severe osteoarthritis caused by a decrease in the estrogen hormone during menopause. hormones play a role in the loss of bone mass which results in joint pain sensations in the elderly(sanou et al., 2018). other research shows that the incidence rate of joint pain is greater in women, which is caused by a dramatic decrease in estrogen hormone levels. meanwhile in men, the hormone estrogen decreases very slowly. the decrease in the hormone estrogen plays an important role in maintaining bones. the protection from pain also diminishes as women get table 1. characteristics of the respondents characteristics treatment group n % age < 60year 61-70 year > 71 year 8 79 23 7.3 71.8 20.9 gender male female 26 84 23.6 76.4 level of education elementary junior high senior high diploma bachelor 34 10 28 25 13 30.9 9.09 25.4 22.7 11.9 working status yes (private) yes (public) no 14 3 93 12.7 2.7 84.6 table 2. effect of ergonomic gymnastics on joint pain in the elderly variable pre post joint pain n (%) n (%) mild pain moderate pain 28 82 26 74 66 44 60 40 total 110 100 110 100 statistic test results wilcoxon p=0 jurnal ners http://e-journal.unair.ac.id/jners | 101 older. in women, the hips are more shaped so the buildup of fat in the hips increases the burden of the joints and muscles in the legs. this causes joint pain, while men have a straighter posture and it is the male tendency to maintain an ideal posture(vivi meliana sitinjak, maria fudji hastuti, 2016). for level of education, 34 of the elderly were elementary school graduates (30%), 1 graduated junior high school (10%), 3 were senior high school graduates (25%), 25 (22.7%) had a diploma and 13 (12%) had an undergraduate program background. education status affects the opportunity to obtain information about the management of disease. elderly people who have a low level of knowledge can influence the limited information available when getting the knowledge to prevent the disease, to protect themselves, and on how to manage their own pain to improve their health status. this is what causes the elderly who experience joint pain to be supportive of the daily activities that are needed [16]. the level of education of a person is very influential on changes in their attitude and the behaviors related to healthy living. higher levels of education will make it easier for a person or community to absorb information and to implement it in daily behavior and lifestyle, especially in terms of health. based on the information obtained by the researchers through questions and answers with the respondents, the respondents said that they always tried to maintain or lessen the level of their joint pain by exercising. looking into working status found that most of the elderly people were not working, although some of them were house-wives, totaling as many as 93 people (85%) out of the 110 respondents. according to (muttaqin, 2010), activity will also activate the immune system and prevent inflammation in the joints. one of the factors that impacts on joint pain in the elderly is physical exercise, as it trains the body to move which will have an impact on the production of synovial fluid which functions as a lubricant and prevents friction in the joints. this shows that if the elderly do not carry out activities such as exercise or gymnastics, then the lubricant in the joint will decrease and cause stiffness. conversely, if the elderly often exercise, then the synovial fluid will increase and reduce the risk of injury, which will prevent joint pain in the elderly. it is very important to maintain health by doing bodily exercises safely to avoid injury. at the time that the aging process happens, their physical activity level will be decreasing due to physical deterioration and this could promote bone calcification in the long term if there are no interventions. exercise is very beneficial for improving blood circulation, losing weight and producing synovial fluid to reduce joint pain in the elderly. physical activity is included in research such as ergonomic gymnastics to maintain blood circulation and to prevent bone contracture. maintaining physical activity will increasing the sensitivity of the insulin receptors in the active muscle(vivi meliana sitinjak, maria fudji hastuti, 2016). the main problem that occurs in the elderly is the occurrence of joint pain, which is caused by the aging process and the loss of synovial fluid from the joint. this means that the bones rub easily against each other. when a person performs physical activity, there will be a muscle contraction which will eventually make it easier for glucose to enter the cell(jankowska-polaska et al., 2015). this means that when a person engages n physical activity, it will reduce their insulin resistance and eventually reduce blood sugar levels. there are other factors that influence blood sugar levels. in addition to sgfdp implementation, there are several things that cause blood sugar to rise, namely a lack of exercise, an increased amount of food consumed, increased stress and emotional factors, weight gain and age, and the impact of treatment from drugs, such as steroids(iljaž, brodnik, zrimec, & cukjati, 2017). the driving factor is that obtained from the closest person and social support given to the individual such as their family, friends and teachers, and especially in this case, the health workers who can strengthen the behavior of the elderly. with the support provided by their closest people, it is expected to encourage behavior change(nursalam, 2016). in the prevention of joint pain in the elderly, ergonomic gymnastics can be one of the solutions that consist of the identification of the risk of joint pain. routine examinations of their exercise and giving health education to the patients about diet and all of the problems related to being elderly will increase the meaning of life of an elderly person. conclusion ergonomic exercises can cause a decrease in joint pain in the elderly in the care service provided in krembangan surabaya. elderly people experience joint pain due to their synovial fluid being reduced due to the aging process. sharing information and the attention given by the nurses with regular meetings can increase their knowledge and cause behavior changes in the elderly to encourage them to take positive actions. this proved that ergonomic gymnastic can prevent or reduce joint pain in the elderly by doing this type of exercise regularly. family with elderly members inside should maintain a good lifestyle including good food, a balanced diet, and routine exercise and activities. the next researchers should be able to improve the treatment of joint pain in the elderly based on their culture and by evaluating the qualitative data. references albargawi, m., snethen, j., gannass, a. al, & kelber, s. (2017). relationship between person ’ s health beliefs and diabetes self-care management regimen. journal of vascular nursing, 1–6. https://doi.org/10.1016/j.jvn.2017.07.002 gerais, m. (2017). ergonomics posture and movement analyses of supermarket checkout operators in m. l. siagian et al. 102 | pissn: 1858-3598  eissn: 2502-5791 the city of. 123–135. iljaž, r., brodnik, a., zrimec, t., & cukjati, i. (2017). ehealthcare for diabetes mellitus type 2 patients – a randomised controlled trial in slovenia ezdravstvena oskrba bolnikov s sladkorno boleznijo tipa ii – randomizirana kontrolirana raziskava v sloveniji. 56(3), 150–157. jankowska-polaska, b., fal, a. m., uchmanowicz, i., sen, m., polanski, j., & kurpas, d. (2015). influence of organized diabetic education on self-control and quality of life of patients with type 2 diabetes. international journal of diabetes in developing countries, 35, 79–87. https://doi.org/10.1007/s13410-014-0253-4 lincoln, n. ., radford, k. ., game, f. ., & jeffcoate, w. . (2008). education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. diabetologia, 51, 1954–1961. liu, c., wan, q., zhou, w., feng, x., & shang, s. (2017). factors associated with balance function in patients with knee osteoarthritis: an integrative review. international journal of nursing sciences. https://doi.org/10.1016/j.ijnss.2017.09.002 muttaqin, a. (2010). buku ajar asuhan keperawatan klien dengan gangguan sistem imunologi. jakarta: salemba medika. nursalam. (2016). metodologi penelitian ilmu keperawatan. jakarta: salemba medika. primana, d. a. (2006). fleksibilitas sendi lanjut usia pada berbagai kompensasi tubuh. jurnal knowledge management (jkm), 06–01, 1–12. pudjiastuti, s.s., & utomo, b. (2003). fisioterapi pada lansia. jakarta: egc. ri, d. (2006). pharmaceutical care untuk hipertensi. jakarta. sanou, a. s., diallo, a. h., holding, p., nankabirwa, v., engebretsen, i. m. s., ndeezi, g., … kashalaabotnes, e. (2018). association between stunting and neuro-psychological outcomes among children in burkina faso, west africa. child and adolescent psychiatry and mental health, 12(1), 1–10. https://doi.org/10.1186/s13034-018-0236-1 schaper, n. c., van netten, j. j., apelqvist, j., lipsky, b. a., & bakker, k. (2017). prevention and management of foot problems in diabetes: a summary guidance for daily practice 2015, based on the iwgdf guidance documents. diabetes research and clinical practice, 124, 84– 92. https://doi.org/10.1016/j.diabres.2016.12.007 stanley, m & beare, p. . (2010). buku ajar keperawatan gerontik (2nd ed.). jakarta: egc. uliya, s., soempeno, b., & k. b. m. w. (2007). pengaruh latihan range of motion (rom) terhadap fleksibilitas sendi lutut pada lansia di panti wreda wening wardoyo ungaran. jurnal media ners, 1.2, 72–79. vivi meliana sitinjak, maria fudji hastuti, a. n. (2016). pengaruh senam rematik terhadap perubahan skala nyeri pada lanjut usia dengan osteoartritis lutut. jurnal keperawatan padjajaran, 4(2), 139–150. walker, a., sibley, f., carter, a., & hurley, m. (2017). improving access to better care for people with knee and / or hip pain : service evaluation of allied health professional ‐ led primary care. 1– 11. https://doi.org/10.1002/msc.1189 wratsongko, m. (2010). senam ergonomik dan pijat getar saraf. jakarta: egc. zeng, q.y., chen, r., darmawan, j. (2008). rheumatic diseasesi in china. arthritis research and theraphy, 10. research design, population, sample, and variables http://e-journal.unair.ac.id/jners | 1 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.12735 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research socio-demographic determinants and the family ability to care for children with avoidant restrictive food intake disorder (arfid) yoyok beksi prasetyo1, nursalam nursalam2, rahmat hargono1 and ahsan ahsan3 1 faculty of public health, universitas airlangga, east java, indonesia 2 faculty of nursing, universitas airlangga, east java, indonesia 3 faculty medicine, universitas brawijaya malang, east java, indonesia abstract introduction: the ability of families to care for avoidant restrictive food intake disorder children is still low. there are only a few studies that examined the relationship between family factors and ability to care for children with avoidant restrictive food intake disorder. the purpose of this study was to identify the influence of socio-demographic factors on the ability of families to care for children with avoidant restrictive food intake disorder. methods: this study design was cross-sectional, with 245 participants. the sampling technique used was multistage sampling. data were collected by using questionnaire. we then conducted an analysis of the univariate data using frequency distribution, while for the bivariate data, we used the chi-square technique. all of the data was processed using ibm spss 23.0 statistics. results: the results showed that the ability of care from the families (health promotion behavior) of children with avoidant restrictive food intake disorder was influenced by the socio-demographic factors, namely maternal age (p= 0.010), the number of children (p= 0.047) and education (p= 0.036). conclusion: young mothers need appropriate guidance and direction through good health education. good health education in young mothers can reduce the pressure faced by the mothers when caring for their children with avoidant restrictive food intake disorder. health promotion behavior is influenced by maternal education and maternal age. through good mother's education, the mother will be able to provide a good pattern of care to children who experience avoidant restrictive food intake disorder. article history received: april 10, 2019 accepted: may 21, 2019 keywords sociodemography; family ability; avoidant restrictive food intake disorder contact nursalam nursalam  nursalam@fkp.ac.id  faculty of nursing, universitas airlangga, east java, indonesia cite this as: prasetyo, y.b, nursalam, n, hargono, r, and ahsan, a. (2019). socio-demographic determinants and the family ability to care for children with avoidant restrictive food intake disorder (arfid). jurnal ners, 14(1), 1-9. doi:http://dx.doi.org/10.20473/jn.v14i1.12735 introduction the ability of families to care for children with avoidant restrictive food intake disorder (arfid) is still low. the low family capacity means that there is a disruption of care from the family to care for children with arfid. this is indicated by neglect and abuse in the family (mairs and nicholls, 2016). neglect or maltreatment in children is indicated by the tension between parents and children between 13 82% (skovgaard væver, smith-nielsen, and lange, 2016). skills in relation to providing a positive feeding style are a major problem (blaine, kachurak, davison, klabunde, & fisher, 2017; kerzner et al., 2016; van der horst & sleddens, 2017). some of the problems related to this are forcing the food to run out at the age of infancy (67.9%) and at the toddler stage (77.4%), forcing food before the child feels hungry at the age of infancy (26.3%) and at the toddler stage (53.9%), giving sweet foods (ice cream, cakes, sweets) as much as at infancy (12.5%) and at the toddler stage (52%) and providing fast food as much as 8.9% at the age of infancy and 47.6% at the toddler stage (baby et al., 2015). forcing children to try new foods was 56.1% in infancy and 79.1% at the toddler stage (baby et al., 2015). avoidant restrictive food intake disorder is a new term for describing infant and toddler feeding disorders with the following characteristics: refusing https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.12735 y. b. prasetyo et al. 2 | pissn: 1858-3598  eissn: 2502-5791 to eat, poor mealtime schedules, low eating skills that are not in accordance with the child's development stage (davies et al., 2006), a lack of interest in eating, avoidance based on sensory food including the appearance of food, the smell and taste of the food, fear that occurs when eating such as dysphagia and a fear of swallowing food (davies et al., 2006; fisher et al., 2014; kostro, lerman, & attia, 2014; nicely, lane-loney, masciulli, hollenbeak, & ornstein, 2014). the distinctive difference from other eating disorders is that in arfid, there are also psychological disorders such as anxiety and a lack of good parenting (strandjord et al., 2016; zimmerman & fisher, 2017). children with arfid were reported to be at 11% (nakai et al., 2017), 12, 4% (fisher et al., 2014), 22.5% (nicely et al., 2014) and 5% 23% (mairs & nicholls, 2016; strandjord et al., 2016). problems related to difficulty eating in children is largely determined by family factors, especially those of the mother or caregiver (allen et al., 2015), where there is a dysfunctional mother and lacking in mother and child interaction (goulding et al., 2014; gueron-sela, atzaba-poria, meiri, & yerushalmi, 2011; kröller & warschburger, 2009; sacrato, pellicciari, & franzoni, 2010; squires, lalanne, murday, simoglou, & vaivredouret, 2014), concerning the environmental and socio-cultural influences and any psychological tensions (campbell & peebles, 2014; de luca & napoletani, 2015; strandjord, sieke, richmond, & rome, 2015). parenting problems such as neglect and abuse are important factors for families with arfid children (mairs & nicholls, 2016). the prevalence of affection tension between parents was between 13 82% depending on the risk factors in the family such as neglected or maltreatment (skovgaard væver, smith-nielsen, & lange, 2016). the problem of arfid will have a serious impact on children's growth and development so that it can cause stunting and wasting. a serious problem is a disruption in the life cycle in the future (ágh et al., 2015; campbell & peebles, 2014; segovia, 2015; uher & rutter, 2012), such as stunting and wasting. indonesia has a fluctuating trend and has increased against stunting in the period 2007 2010. this is indicated by stunting data in indonesia: 36.8% in 2007, 35.6% in 2010 and 37.2% in 2013 (badan penelitian dan pengembangan kesehatan, 2013; kementerian koordinator bidang kesejahteraan rakyat, 2013). nutritional problems in children are influenced by the socio-demographic factors of the families, especially the mothers (allen et al., 2015). the social demographic factors that cause the children to experience difficulty eating are dysfunctional mother and child interactions (allen et al., 2015; goulding et al., 2014; gueron-sela et al., 2011; kröller & warschburger, 2009; sacrato et al., 2010), environmental and socio-cultural influences and psychological tensions (campbell & peebles, 2014; de luca & napoletani, 2015). the education level of the mother determines the nutritional status of the child (habibi, zahra, aguenaou, & doukkali, 2018). the good education of the mother will have an impact on the pattern of giving good food to the child (do, eriksson, tran, petzold, & ascher, 2015). paying attention to social and demographic characteristics is an important factor for improving the child's nutritional status (holbrook, white, heyman, & wojcicki, 2013). there is still very little research related to arfid in indonesia. this study had the main objective of analyzing determinant factors of socio-demography in relation to the ability of families to care for children with arfid. the secondary objective was to compare the socio-demographic characteristics of the mothers and the nutritional status of the children, namely between mothers who worked and mothers who did not work and the ability of their families to care for children with arfid. the purpose of this study was to identify the influence of socio-demographic factors on the ability of families to care for children with arfid. materials and methods the research location was in malang regency. malang regency has 69 integrated health posts divided into six regional coordinators (korwil); singosari, tumpang, turen, pujon, pagak, and bantur. the singosari regional office was determined to be a population area because of the presence of nutritional problems for infants, easy access, ease of transportation and relatively cheaper costs. the singosari regional office included pakis, karangploso, singosari health center, ardimulyo, and lawang community health center (there were five community health centers). the study design was cross-sectional. the sample size is determined using the rule of thumb in structural equation modeling (sem), which is the number of parameters estimated multiplied by 5 or 10 (azman, 2017). there are 10 parameters so that the sample size is 10 x 10 = 100 participants (minimal). in this study, a sample of 245 participants was used. this research was conducted from december 2018 march 2019. the sampling technique was multistage sampling, namely gradual sampling (taherdoost, 2018). phase one determines the puskesmas then in stage two chooses the posyandu (n = 229). in this study, 20% of posyandu (n = 46) were determined by simple random sampling. in the third stage, families with arfid children were determined with a sample of 245 families with arfid children. participant inclusion criteria included children experiencing arfid (<5 years), children who were not ill with chronic diseases, not experiencing congenital defects on the eating path. the data collection was assisted by eight research assistants. the data collection was carried out through a survey using a questionnaire, both in community health centers and in the homes of jurnal ners http://e-journal.unair.ac.id/jners | 3 residents. the demographic characteristics questionnaire was developed by the researchers. the socio-demographic characteristics focused on the number of children, the age of the child, the mother's age, the mother's level of education and family income. the nutritional status of the children was determined by the anthropometry measurement, which refers to the who standard in 2005. the ability of families to care for children with arfid have indicators of ability related to managing eating disorders and the ability to take health promotion actions (good category score = x> mean + sd; enough = mean-sd≤ x ≤ mean + sd; less = x <mean sd). independent variables are maternal and child demographic factors while the dependent variable is the family's ability to care for arfid. family ability consists of two sub-variables, namely the ability to manage eating disorders and the ability to show promotive behavior. the eating disorder management questionnaire consists of 9 items of statements with indicators: 1) cooperation with the health team, 2) cooperation with family members, 3) stepping positive relationships, 4) monitoring vital sign, 5) monitoring fluid output intakes, 6) setting appropriate expectations, 7) use behavior modification, 8) discuss with the health team, 9) take responsibility. using a 5 point likert scale (1: never, 2: rarely, 3: sometimes, 4: often, 5: always). the questionnaire has been tested for validity and reliability. validity test results show valid with a value of> 0.4 and the reliability value of managing eating disorder (cronbach's alpha = 0.888). the promotive behavior questionnaire consisted of 11 items of questions, with indicators: 1) asking appropriate questions, 2) completing assignments, 3) showing early examinations, 4) contacting health personnel, 5) showing ability, 6) explaining behavior change strategies, 7) obey strategy, 8) show healthy behavior, 9) seek health information, 10) explain strategies for maximizing health, 11) explain individual development strategies. using a 5 point likert scale (1: never, 2: rarely, 3: sometimes, 4: often, 5: always). test the validity of all question items> 0.4 and reliability values (cronbach's alpha = 0.830). the analysis of the univariate data used frequency distribution, while for bivariate data, we used the chi-square technique. all of the data was processed using ibm spss 23.0 statistics. this research was carried out with the approval of the declaration of helsinki. ethical approval as granted by the research ethics committee of the faculty of public health, airlangga university number 333kepk. all participants filled an informed consent form with their signature. the privacy and confidentiality of the data were highly guaranteed. results table 1 shows that the average maternal age between working and non-working (w / nw) groups was 30 years old. the average age of children with arfid between the two groups w / nw = 2.25 / 2.05 years (toddler age). the average number of w / nw children was the same (2/2). the sex of the children was mostly female both in group w / nw (60% / 53.7%). the income per month between 2 groups also did not have a significant difference with the majority of the income falling between 1 2 million / month. demographic factors for maternal age, age of children, number of children, the gender of the child, income per month, no significant differences were found between groups of working mothers and non-working (p value> 0.05). the mother's education in the working group was higher than in the group of mothers who did not work. this can be seen from the highest education category, namely college (w / nw = 23.6% / 9.5%; p = 0.019). the anthropometric characteristics include height (h) and body weight (w) with the categories of w /u. h/ u. w / h are presented in table 2. the mean w of children between the two groups was w / nw = 11.9 / 11.2 kg. the average h of the children between the two groups was n / nw = 86.9 / 84.4 cm. the nutritional status of the children based on w / u in both groups was lacking and they had a very poor nutritional status (w = 7.3% and 1.8%; nw = 18.4% and 3.2%). the nutritional status based on h / u also contained stunting conditions in both groups. this stunting condition can be seen from the presence of short and very short categories (w= 10.9% and 16.4%; nw= 16.8% and 21.6%). nutritional status based on w / h involved a wasting condition in both groups. this wasting condition can be seen from the thin and very thin categories (w = 5.5% and 3.6%; nw = 10.5% and 2.6%). table 3a shows that the family's ability to treat (manage eating disorder) children with arfid is influenced by sociodemographic factors: maternal age (p = 0.006) and a number of children (p = 0.001). table 3a shows most of the family's ability to manage eating disorders in the category was quite good in the group of mothers who were under 30 years old (71.9%) or in the group of women who were over 30 years old (68.4%). the largest percentage of the family's ability to manage eating disorders, including the poor categories, was based on socio-demographics such as maternal age (≥ 31 years: 22.2%), the number of children (3-4 children: 34.9%), income (<1 million: 23.2%), education (basic: 22%). and work (working: 20%). y. b. prasetyo et al. 4 | pissn: 1858-3598  eissn: 2502-5791 table 3b shows that the caring ability of the families (health promotion behavior) of children with arfid is influenced by socio-demographic factors, namely maternal age (p = 0.010), the number of children (p = 0.047) and education (p = 0.036). most of the family's ability to behave in health promotion was quite good in the group of women who were under 30 years of age (74.2%) or in the group of women who were over 30 years old (68.4%). health promotion behavior in the good category is based on socio-demography with a higher percentage in maternal age ≤ 30 years: 17.2%), the number of children (1-2 children: 15.9%), the equal income between those who earn > 2 million and the groups that earn 1-2 million (14.3%), those with an education (middle-high: 14.9%) and work (not working: 14.2%). discussion the average age of the mothers was in the productive age with the ability to manage eating disorders and health promotion behavior; this differed between the groups of mothers under or equal to 30 years old. mothers who are of a younger table 1. socio-demographic characteristics between the working mother (w) and non-working (nw) groups characteristics w n (%) or m (sd) n = 55 nw n (%) or m (sd) n =190 total n (%) or m (sd) n = 245 p value* mother's age 30 (6) 30 (6) 30 (6) 0.905 child's age 2.28 (1.24) 2.05 (1.07) 2.10 (1.11) 0.183 number of children 2 (1) 2 (1) 2 (1) 0.400 gendera man 22 (40) 88 (46.3) 110 (44.9) 0.407 women 33 (60) 102 (53.7) 135 (55.1) income monthb above 2 million 18 (32.7) 45 (23.7) 63 (25.7) 0.397 1 2 million 26 (47.3) 100 (52.6) 126 (51.4) under 1 million 11 (20) 45 (23.7) 56 (22.9) educationc college 13 (23.6) 18 (9.5) 31 (12.7) 0.019 high school 13 (23.6) 76 (40) 89 (36.3) junior high school 17 (30.9) 58 (30.5) 75 (30.6) elementary school 12 (21.8) 38 (20) 50 (20.4) note w (works). nw (not working). m (mean). sd (standard deviation) a gender of child b family income in 1 month c mother's education level * level of significance is 0.05 table 2. characteristics of the anthropometry of children between working and non-working mothers characteristics w n(%) or m(sd) n = 55 nw n(%) or m(sd) n =190 total n(%) or m(sd) n = 245 p value* weight (kg)a 11.9 (2.8) 11.2 (2.7) 11.4 (2.7) 0.119 height (cm)a 86.9 (10.3) 84.4 (10) 85 (10.1) 0.109 weight/ub overweight 0 (0) 2 (1.1) 2 (0.8) 0.161 normal 50 (90.9) 147 (77.4) 197 (80.4) underweight 4 (7.3) 35 (18.4) 39 (15.9) very underweight 1 (1.8) 6 (3.2) 7 (2.9) height/ub tall 2 (3.6) 6 (3.2) 8 (3.3) 0.500 normal 38 (69.1) 111 (58.4) 149 (60.8) short 6 (10.9) 32 (16.8) 38 (15.5) very short 9 (16.4) 41 (21.6) 50 (20.4) weight/hb overweight 3 (5.5) 24 (12.6) 27 (11) 0.260 normal 47 (85.5) 141 (74.2) 188 (76.7) underweight 3 (5.5) 20 (10.5) 23 (9.4) very underweight 2 (3.6) 5 (2.6) 7 (2.9) note: n (works). nw (not working). m (mean). sd (standard deviation) a w and h data obtained from a notebook in the integrated health post b the determination of the category was done through the z-score value * level of significance is 0.05 jurnal ners http://e-journal.unair.ac.id/jners | 5 age have the ability to treat eating disorders better than the mothers over the age of 31 years old. relatively younger mothers will learn to recognize themselves and learn to be responsible for their children if they experience arfid. responsible learning is shown through affection, responsiveness, and responsibility when it comes to caring for their child (dlamini, 2016). this sense of responsiveness is indicated by the acceptance of the signs/signals that the child shows. they need to interpret signals well and provide the appropriate response as indicated by voice, facial expressions and touch (esposito, manian, truzzi, & bornstein, 2017; lavallée, aita, bourbonnais, & de clifford-faugère, 2017). sensitive responses from the parents include accuracy, consistency and the appropriate response from the parents concerning the signs of affection that come from the child (troutman, 2015). responsiveness is a dimension related to parental responsiveness in terms of guiding a child's personality regarding assertiveness, self-regulation and the fulfillment of special needs (kasy, 2017). in addition to the above factors, relatively younger mothers who live within large families such as where grandparents are present will get full support from their families (financial, emotional and care support) (easterbrooks, chaudhuri, bartlett, & copeman, 2011). family support is very much needed in childcare to provide protection and direction (cismaru & le pioufle, 2016). children experience arfid on average in the toddler age group. arfid symptoms at the age of infancy and in the toddler stage include refusing to eat, a bad meal schedule and low eating skills (davies et al., 2006). children aged 6 months 3 years will experience infantile anorexia which is characterized by rejecting a number of foods, the inability to control hunger and fullness, environmental disturbances and experiencing growth and development disorders. this is because toddler-age children experience a transition to the habit of being fed themselves. new dynamics also table 3a. socio-demographics and the family’s ability to manage their child’s eating disorder characteristic ability to manage an eating disorder p-value less n (%) enough n (%) well n (%) mother age ≤ 30 years 12 (9.4) 92 (71.9) 24 (18.8) 0.006 ≥ 31 years 26 (22.2) 80 (68.4) 11 (9.4) number of children 1 – 2 child 23 (11.4) 145 (72.1) 33 (16.4) 0.001 3 – 4 child 15 (34.9) 26 (60.5) 2 (4.7) income < 1 millions 13 (23.2) 36 (64.3) 7 (12.5) 0.255 1 – 2 millions 19 (15.1) 91 (72.2) 16 (12.7) > 2 millions 6 (9.5) 45 (71.4) 12 (19) education elementary school 11 (22) 34 (68) 5 (10) 0.278 midlle college 27 (13.8) 138 (70.8) 30 (15.4) job working 11(20) 37 (67.3) 7(12.7) 0.569 no working 27 (14.2) 135 (71.1) 28 (14.7) table 3b. socio-demographics and the family caring ability (health promotion behavior) characteristic ability to show promotive behavior p-value less n (%) enough n (%) well n (%) mother age ≤ 30 years 11(8.6) 95 (74.2) 22 (17.2) 0.010 ≥ 31 years 25 (21.4) 80 (68.4) 12 (10.3) number of children 1 – 2 child 25 (12.4) 144 (71.6) 32 (15.9) 0.047 3 – 4 child 10 (23.3) 31 (72.1) 2 (4.7) income < 1 millions 15 (26.8) 34 (60.7) 7 (12.5) 0.055 1 – 2 millions 16 (12.7) 92 (73) 18 (14.3) > 2 millions 5 (7.9) 49 (77.8) 9 (14.3) education elementary school 13 (26) 32 (64) 5 (10) 0.036 middle high 23 (11.8) 143 (73.3) 29 (14.9) job working 7 (12.7) 41 (74.5) 7 (12.7) 0.839 no working 29 (15.3) 134 (70.5 ) 27 (14.2) y. b. prasetyo et al. 6 | pissn: 1858-3598  eissn: 2502-5791 occur between the children and their caregivers. the child learns to put food in their own mouth. the children learn to feel the sensation of hunger and fullness while the caregivers always try to keep on forcing the food. the impact is that their children will feel depressed while eating (merwin, advisor, & gray, 2010) the education level of the mothers in the working mother's group was higher. mothers who have a higher education level will have the chance to get a better job position. better work will help the family financially when it comes to providing facilities that support children's growth and development (putri & gutama, 2018). the challenge for mothers when it comes to working on their parenting is to provide warmth, attention, and care for their children. the mothers are able to provide attachment to their children on the sidelines of their busy life so then the closeness is still intertwined with the interconnection of positive feelings that will have a positive impact on the child's development (dewi, 2016). good communication can create a harmonious family atmosphere, such as being open to each other and having trust. this warm interaction will have an impact on children's health. mothers who have good interactions with their children, mothers will be able to provide good care shown by being able to manage their children's health and be able to carry out health promotion actions (panico, 2012). working mothers will also get additional information. the knowledge and networking are better than those of the mothers who don't work. this will increase the confidence of their individual beliefs when dealing with children's problems related to arfid. confidence is the basis that determines someone as being able to take preventive action against diseases and health promotion activities (akey, rintamaki, & kane, 2013). this explains why someone changes or maintains specific health behaviors (akey et al., 2013; james, pobee, oxidine, brown, & joshi, 2012; poortaghi et al., 2015) and it also explains why someone can fail to participate in activities aimed at detecting or preventing disease (borowski & tambling, 2015). this helps to predict if someone will take actions in relation to prevention, screening and controlling illness conditions (glanz, rimer, & viswanath, 2008). children with arfid experience stunting and wasting (campbell & peebles, 2014). stunting and wasting problems occur due to the failure to meet their appropriate nutritional needs and/or energy requirements (katzman, stevens, & norris, 2014). next, it will cause one or more signs of significant weight loss, caused by a lack of nutrition. children are very dependent on nutrition, oral supplements and the presence of psychosocial functions (berlin, davies, silverman, & rudolph, 2011; sharp, volkert, scahill, mccracken, & mcelhanon, 2017). this causes physical health problems and has an impact on social, emotional and cognitive development (goudet et al., 2018). if it continues until adolescence, then there will be a disruption of identity and self-esteem (mairs & nicholls, 2016). impaired identity and selfesteem are associated with a body shape that is too thin, giving rise to shame and insecurity (king, urbach, & stewart, 2015). having a smaller number of children, between 12 children, correlates associated with the better ability to manage eating disorders and the ability to conduct better health promotion behaviors. this is when compared with families that have 3 to 4 children. mothers with fewer children will be able to maintain warmer mother-child interactions. this is due to the availability of sufficient time to interact. this warm interaction will affect children's health. mothers who have good interactions with their children will be able to provide good care as shown by being able to manage the health of their children and being able to take health promotion actions (panico, 2012). the ability of mothers to take health promotion actions is determined by the mother's education. maternal education is linear to the ability of the mothers of health promotion behavior. the mother's education is one of the factors that determine the success of the parenting patterns present when feeding their children(do et al., 2015; goulding et al., 2014). in contrast, low maternal education results in poor health promotion behavior (mulyani, 2016). conclusion the ability to care for children with avoidant restrictive food intake disorder children is impacted on by the maternal socio-demographic factors. eating disorders are regulated by maternal age. young mothers can get the right guidance and direction through good health education when caring for children with avoidant restrictive food intake disorder children. health promotion behavior is influenced by maternal education and maternal age. through good mother's education, the mother will be able to provide a good pattern of care to children who have avoidant restrictive food intake, disorder children. the quality of the mother's interaction and will be a very important part. increasing mother and child interaction is one of the keys to the implementation of nursing to provide nursing care to children who experience arfid. references ágh, t., kovács, g., pawaskar, m., supina, d., inotai, a., & vokó, z. (2015). epidemiology, health-related quality of life and economic burden of binge eating disorder: a systematic literature review. eating and weight disorders : ewd, 20(1), 1–12. https://doi.org/10.1007/s40519-014-0173-9 akey, j. e., rintamaki, l. s., & kane, t. l. (2013). health belief model deterrents of social support seeking among people coping with eating disorders. journal of affective disorders, 145(2), jurnal ners http://e-journal.unair.ac.id/jners | 7 246–252. https://doi.org/10.1016/j.jad.2012.04.045 allen, s. l., smith, i. m., duku, e., vaillancourt, t., szatmari, p., bryson, s., … zwaigenbaum, l. (2015). behavioral pediatrics feeding assessment scale in young children with autism spectrum disorder: psychometrics and associations with child and parent variables. journal of pediatric psychology, 40(6), 581–590. azman, a. h. n. (2017). structural equation modeling (sem): confirmatory factor analysis (cfa), 72(1), 1–11. https://doi.org/10.13140/rg.2.2.25615.38565 baby, c., sacc, n. a. p., blaine, r. e., davison, k. k., hesketh, k., taveras, e. m., … neelon, s. e. b. (2015). child care provider adherence to infant and toddler feeding recommendations: findings from the baby nutrition and physical activity self-assessment for child care (baby nap sacc) study. childhood obesity journal, 11(3). https://doi.org/10.1089/chi.2014.0099 badan penelitian dan pengembangan kesehatan. (2013). riset kesehatan dasar (riskesdas) 2013. laporan nasional 2013, 1–384. https://doi.org/1 desember 2013 berlin, k. s., davies, w. h., silverman, a. h., & rudolph, c. d. (2011). assessing family-based feeding strategies, strengths, and mealtime structure with the feeding strategies questionnaire. journal of pediatric psychology, 36(5), 586–595. https://doi.org/10.1093/jpepsy/jsp107 blaine, r. e., kachurak, a., davison, k. k., klabunde, r., & fisher, j. o. (2017). food parenting and child snacking : a systematic review. international journal of behavioral nutrition and physical activity, 14(146), 1–23. https://doi.org/10.1186/s12966-017-0593-9 borowski, s. c., & tambling, r. b. (2015). applying the health belief model to young individuals’ beliefs and preferences about premarital counseling, 23(4), 417–426. https://doi.org/10.1177/1066480715602221 campbell, k., & peebles, r. (2014). eating disorders in children and adolescents: state of the art review. pediatrics, 134(3), 582–592. https://doi.org/10.1542/peds.2014-0194 cismaru, m., & le pioufle, a. (2016). helping families affected by depression: incorporating prosocial and caregiving literature. international business research, 9(12), 23. https://doi.org/10.5539/ibr.v9n12p23 davies, w. h., satter, e., berlin, k. s., sato, a. f., silverman, a. h., fischer, e. a, … rudolph, c. d. (2006). reconceptualizing feeding and feeding disorders in interpersonal context: the case for a relational disorder. journal of family psychology, 20(3), 409–417. https://doi.org/10.1037/0893-3200.20.3.409 de luca, g., & napoletani, m. (2015). premonitory symptoms of feeding and eating disorders in pediatric age. italian journal of pediatrics, 41(suppl 2), a25. https://doi.org/10.1186/18247288-41-s2-a25 dewi, e. m. p. (2016). pengasuhan ibu berkarir dan internalisasi nilai karir pada remaja. jurnal ilmiah psikologi terapan, 3(1), 165–183. dlamini, n. (2016). teenage mothers ’ experiences of motherhoodschooling , stigma and learned responsibility : a case study of teenage mothers of school going age in a peri-urban area in kwa-zulu natal . stellenbosch university. do, l. m., eriksson, b., tran, t. k., petzold, m., & ascher, h. (2015). feeding of preschool children in vietnam: a study of parents’ practices and associated factors. bmc nutrition, 1(1), 16. easterbrooks, m. a., chaudhuri, j. h., bartlett, j. d., & copeman, a. (2011). resilience in parenting among young mothers: family and ecological risks and opportunities. children and youth services review, 33(1), 42–50. esposito, g., manian, n., truzzi, a., & bornstein, m. h. (2017). response to infant cry in clinically depressed and non-depressed mothers. plos one, 12(1), 1–16. https://doi.org/10.1371/journal.pone.0169066 fisher, m. m., rosen, d. s., ornstein, r. m., mammel, k. a., katzman, d. k., rome, e. s., … walsh, b. t. (2014). characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in dsm-5. journal of adolescent health, 55(1), 49–52. glanz, k., rimer, b. k., & viswanath, k. (2008). health behavior and health education: theory, research, and practice. john wiley & sons. goudet, s., griffiths, p. l., wainaina, c. w., macharia, t. n., wekesah, f. m., wanjohi, m., … kimanimurage, e. (2018). social value of a nutritional counselling and support program for breastfeeding in urban poor settings, nairobi. bmc public health, 18(1), 424. goulding, a. n., rosenblum, k. l., miller, a. l., peterson, k. e., chen, y.-p., kaciroti, n., & lumeng, j. c. (2014). associations between maternal depressive symptoms and child feeding practices in a cross-sectional study of low-income mothers and their young children. international journal of behavioral nutrition and physical activity, 11(1), 75. gueron-sela, n., atzaba-poria, n., meiri, g., & yerushalmi, b. (2011). maternal worries about child underweight mediate and moderate the relationship between child feeding disorders and mother-child feeding interactions. journal of pediatric psychology, 36(7), 827–836. https://doi.org/10.1093/jpepsy/jsr001 habibi, m., zahra, f., aguenaou, h., & doukkali, l. (2018). international journal of pediatrics and the impact of maternal socio-demographic characteristics on breastfeeding knowledge and practices : an experience from. international journal of pediatrics and adolescent medicine, y. b. prasetyo et al. 8 | pissn: 1858-3598  eissn: 2502-5791 5(2), 39–48. https://doi.org/10.1016/j.ijpam.2018.01.003 holbrook, k. e., white, m. c., heyman, m. b., & wojcicki, j. m. (2013). maternal sociodemographic characteristics and the use of the iowa infant attitude feeding scale to describe breastfeeding initiation and duration in a population of urban, latina mothers: a prospective cohort study. international breastfeeding journal, 8(1), 1–14. https://doi.org/10.1186/1746-4358-8-7 james, d. c. s., pobee, j. w., oxidine, d., brown, l., & joshi, g. (2012). using the health belief model to develop culturally appropriate weightmanagement materials for african-american women. journal of the academy of nutrition and dietetics, 112(5), 664–670. https://doi.org/10.1016/j.jand.2012.02.003 kasy, s. (2017). pengasuhan anak pada orangtua yang menikah usia dini di kabupaten konawe selatan provinsi sulawesi tenggara. program studi psikologi fpsi-uksw. katzman, d. k., stevens, k., & norris, m. (2014). redefining feeding and eating disorders : what is avoidant / restrictive food intake disorder ? paediatrics child health, 19(8), 445–446. diambil dari http://www.cpsp.cps.ca/uploads/publications/h ighlights-avoidant-restrictive-food-intakedisorder.pdf kementerian koordinator bidang kesejahteraan rakyat. (2013). kerangka kebijakan gerakan nasional percepatan perbaikan gizi dalam rangka seribu hari pertama kehidupan (gerakan 1000 hpk), 71. kerzner, b., milano, k., maclean, w. c., berall, g., stuart, s., & chatoor, i. (2016). a practical approach to classifying and managing feeding difficulties. pediatrics, 135(2), 70. https://doi.org/10.1542/peds.2014-1630 king, l. a., urbach, j. r., & stewart, k. e. (2015). illness anxiety and avoidant/restrictive food intake disorder: cognitive-behavioral conceptualization and treatment. eating behaviors, 19, 106–109. https://doi.org/10.1016/j.eatbeh.2015.05.010 kostro, k., lerman, j. b., & attia, e. (2014). the current status of suicide and self-injury in eating disorders: a narrative review. journal of eating disorders, 2, 19. https://doi.org/10.1186/s40337-014-0019-x kröller, k., & warschburger, p. (2009). maternal feeding strategies and child’s food intake: considering weight and demographic influences using structural equation modeling. the international journal of behavioral nutrition and physical activity, 6, 78. https://doi.org/10.1186/1479-5868-6-78 lavallée, a., aita, m., bourbonnais, a., & de cliffordfaugère, g. (2017). effectiveness of early interventions for parental sensitivity following preterm birth: a systematic review protocol. systematic reviews, 6(1), 62. https://doi.org/10.1186/s13643-017-0459-x mairs, r., & nicholls, d. (2016). assessment and treatment of eating disorders in children and adolescents, 1168–1175. https://doi.org/10.1136/archdischild-2015309481 merwin, s., advisor, c., & gray, j. (2010). feeding disorders of infants and toddlers : a follow-up to the treatment of infantile anorexia. mulyani, s. (2016). pengaruh konseling menyusui terhadap sikap menyusui ibu postpartum yang dirawat. jambi medical journal, 4(1), 28–38. nakai, y., nin, k., noma, s., hamagaki, s., takagi, r., teramukai, s., & wonderlich, s. a. (2017). clinical presentation and outcome of avoidant/restrictive food intake disorder in a japanese sample. eating behaviors, 24, 49–53. https://doi.org/10.1016/j.eatbeh.2016.12.004 nicely, t. a., lane-loney, s., masciulli, e., hollenbeak, c. s., & ornstein, r. m. (2014). prevalence and characteristics of avoidant/ restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. journal of eating disorders, 2(2 suppl. 1), s38. https://doi.org/10.1016/j.jadohealth.2012.10.09 2 panico, l. (2012). family structure and child health. university college london. poortaghi, s., raiesifar, a., bozorgzad, p., golzari, s. e. j., parvizy, s., & rafii, f. (2015). evolutionary concept analysis of health seeking behavior in nursing: a systematic review. bmc health services research, 15(1), 523. https://doi.org/10.1186/s12913-015-1181-9 putri, r. a., & gutama, t. a. (2018). strategi pasangan suami istri dalam menjaga keharmonisan keluarga wanita karir (studi kasus wanita karir di desa pucangan, kelurahan pucangan, kecamatan kartasura). journal of development and social change, 1(1), 1–8. diambil dari https: //jurnal.uns.ac.id/jodasc sacrato, l., pellicciari, a., & franzoni, e. (2010). emergent factors in eating disorders in childhood and preadolescence. italian journal of pediatrics, 36, 49. https://doi.org/10.1186/1824-7288-3649 segovia, m. j. g. (2015). psychological and psychological impairment in preschoolers with selective eating. acta pediatrica espanola, 73(9), 240. https://doi.org/10.1542/peds.2014-2386 sharp, w. g., volkert, v. m., scahill, l., mccracken, c. e., & mcelhanon, b. (2017). a systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: how standard is the standard of care? the journal of pediatrics, 181, 116–124. skovgaard væver, m., smith-nielsen, j., & lange, t. (2016). copenhagen infant mental health project: study protocol for a randomized controlled trial jurnal ners http://e-journal.unair.ac.id/jners | 9 comparing circle of security–parenting and care as usual as interventions targeting infant mental health risks. bmc psychology, 4, 57. https://doi.org/10.1186/s40359-016-0166-8 squires, c., lalanne, c., murday, n., simoglou, v., & vaivre-douret, l. (2014). the influence of eating disorders on mothers’ sensitivity and adaptation during feeding: a longitudinal observational study. bmc pregnancy and childbirth, 14, 274. https://doi.org/10.1186/1471-2393-14-274 strandjord, s. e., sabik, j., nahra, a., abdulkader, z., sieke, e. h., worley, s., & rome, e. s. (2016). avoidant/restrictive food intake disorder: treatment choice and outcome in the outpatient setting. journal of adolescent health, 58(2), s37– s38. https://doi.org/10.1016/j.jadohealth.2015.10.08 8 strandjord, s. e., sieke, e. h., richmond, m., & rome, e. s. (2015). avoidant/restrictive food intake disorder: illness and hospital course in patients hospitalized for nutritional insufficiency. journal of adolescent health, 57(6), 673–678. https://doi.org/10.1016/j.jadohealth.2015.08.00 3 taherdoost, h. (2018). sampling methods in research methodology; how to choose a sampling technique for research. ssrn electronic journal, (january 2016). https://doi.org/10.2139/ssrn.3205035 troutman, b. (2015). integrating behaviorism and attachment theory in parent coaching., xv, 126. https://doi.org/10.1007/978-3-319-15239-4 uher, r., & rutter, m. (2012). classification of feeding and eating disorders: review of evidence and proposals for icd-11. world psychiatry, 11(2), 80–92. https://doi.org/10.1016/j.wpsyc.2012.05.005 van der horst, k., & sleddens, e. f. c. (2017). parenting styles, feeding styles and food-related parenting practices in relation to toddlers’ eating styles: a cluster-analytic approach. plos one, 12(5), e0178149. zimmerman, j., & fisher, m. (2017). avoidant/restrictive food intake disorder (arfid). current problems in pediatric and adolescent health care, 47(4), 95–103. 210 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.10863 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the relationship between partner support and interdialytic weight gain (idwg) hemodialysis patient mundakir mundakir, nur fadillah, retno sumara, asri asri and yuanita wulandari muhammadiyah university of surabaya, surabaya, indonesia abstract introduction: patients undergoing hemodialysis experience an influence in terms of the biological, psychological, social and spiritual problems that they encounter. in particular, there are biological aspects that affect weight gain between dialysis sessions. in terms of the psychological aspect, there is an influence on emotional vulnerability, such as anxiety, fear and despair. they need family support, especially as part of a couple. this study aimed to determine the relationship between partner support and idwg in hemodialysis patients. methods: this study used a descriptive cross-sectional design. the population consisted of 60 hemodialyzed people. the sample was recruited using purposive sampling, resulting in 42 respondents who met the inclusion criteria. the study was conducted in a private hospital in surabaya. the independent variable was partner support and the dependent variable was the idwg in the hemodialysis patient. the data was collected through a questionnaire and it was analyzed using the spearman test. results: the results show that there was a relationship between partner support and idwg hemodialysis patients with p = 0.025 (α ≤0.05). conclusion: good partner support reduces the low idwg in hemodialysis patients. therefore, determining the level of family support especially that given by a partner of a idwg hemodialysis patients will positively support better idwg hemodialysis patients, thus preventing them from the potential side effects of idwg such as hypotension, muscle cramps, shortness of breath and cardiovascular problems. article history received: dec 19, 2019 accepted: jan 13, 2020 keywords partner support; idwg; hemodialysis contact mundakir mundakir  mundakir.ners@fik.umsurabaya.ac.id  muhammadiyah university of surabaya, surabaya, indonesia cite this as: mundakir, m., fadillah, n., sumara, r., asri. a., & wulandari, y. (2019). the relationship between partner support and interdialytic weight gain (idwg) hemodialysis patient. jurnal ners, 14(2), 210-214. doi:http://dx.doi.org/10.20473/jn.v14i2.10863 introduction one of the problems experienced by hemodialysis patients is weight gain between the two sessions of dialysis, which is called uncontrolled inter-dialysis weight gain (idwg). weight gain between the dialysis sessions is a manifestation of the amount of fluid intake between dialysis sessions. idwg additions that are too high can have negative effects on the body such as hypotension, muscle cramps, difficulty breathing, and cardiovascular problems. idwg > 4% increases the frequency of hospitalization and idwg exceeding 5.7% increases the mortality of patients (wong et al., 2017). in the nkf kdoqi guidelines (2002), it is mentioned that the weight gain interdialysis should not exceed 4.8% of dry weight. this is because excessive ultrafiltration can give rise to problems in terms of hemodynamics and cardiovascular disorders (kurniawati, 2012). the research conducted by istanti (2011) showed that social and family support as well as self-efficacy were related to two through to five factors that contributed to idgw incidents. one of strategies that have been suggested to limit idgw is behavioral interventions. this strategy was developed to improve the adherence of fluid restriction, the improvement of xerostomia and the use of lower dialysate sodium concentration (bossola, pepe, & vulpio, 2018). excessive salt consumption will increase ecf osmolality, which stimulates thirst. behavioral interventions are applied to increase the compliance with the fluid restrictions. this behavioral intervention uses an approach to increase motivation, knowledge and understanding in order to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id mailto:mundakir.ners@fik.um-surabaya.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 211 improve the level of obedient behavior towards fluid restrictions. the phenomenon of reduced salivary flow or xerostomia in hemodialysis patients is caused by the atrophy and fibrosis of the salivary glands. therefore, finding strategies to stimulate the salivary glands is a solution to improve xerostomia. the high concentration of sodium dialysate stimulates thirst in hemodialysis patients. this is because the sodium dialysate concentration reduces sodium loss. the feeling of thirst will make the patient drink excess water. in this situation, the role of the family is very important to succeed in the implementation of a behavioral intervention. the source of family support that was the most instrumental was that of a couple (husband, wife). this is because the interaction of the individual first and foremost is the nearest person, which is often a partner. the purpose of this study was to determine the relationship between the supports from the partners with the idwg of the patients undergoing hemodialysis. materials and methods the study was a descriptive correlation with a crosssectional approach. the population was all of the patients with chronic kidney disease (ckd) undergoing routine hemodialysis in a private hospital in surabaya in january 2018, which is as many as 60 people. the sampling technique was total sampling. the inclusion criteria were patients who had underwent hemodialysis > 3 months, who were undergoing regular hemodialysis 2 times a week, who had a life partner, who had a stable hemodynamic condition and who were willing to participate as respondents. the exclusion criteria were patients who passed through the hemodialysis schedule, and the patients who could not measure their own weight. the patients who passed through the hemodialysis schedule were excluded. it is because in this study, idwg is defined as patient weight gain between two sessions of dialysis due to excess fluid / food volume. if the respondents came to the hemodialysis therapy more than two weeks after the previous schedule, then the data from the respondents might be effect the research results. we assume that the weight gain of the respondents who underwent hemodialysis every two weeks was different from that of the respondents who received hemodialysis that was more than two weeks apart. the respondents who were unable to stand on their own to measure their weight found the data collection process difficult. the samples obtained from this study totaled 42 respondents. the independent variable was support from the spouse and the dependent variable was idwg. this study used questionnaires to obtain the demographic and spousal support data. the support spouse questionnaire was developed by pratita (2012). this questionnaire consists of 17 questions which measure the 4 spousal support dimensions. the four dimensions of support provided by the spouse are the emotional dimension, valuation dimension, instrumental dimension, and informational dimension. the score of the spousal support questionnaire was calculated by calculating the cumulative number of the respondents' answer scores divided by the number of question items. the test results on the reliability and validity were obtained. in the end, the spouse-focused questionnaire concluded that there was good support (>3-4), enough support (2-3), and poor support (<2). weight scales and a self-developed observational checklist were used to measure idwg. the researchers collected the data by themselves. the data collection procedures carried out during the two periods of hemodialysis. the first period of the data collection was done with the questionnaire respondents focused on their demographics and the spousal support data. then their weight was measured after the completion of hemodialysis and the results were documented on the observational checklist. in the second period (scheduled with the hemodialysis respondents) of the data collection, the respondents’ weight was collected before the respondents underwent hemodialysis. because the data had a normal distribution, we used the median score to create the level of idgw. the idwg level was mild, moderate and heavy. spss 25 statistical analysis was used to determine the characteristics of the demographic data of the respondents. since, both of the data scales were continuous and the data had a normal distribution, the pearson product moment test was selected in order to determine the relationship between the independent variables and the dependent variable. this study passed the institutional review board of muhammadiyah university of surabaya. the research permit was issued by the department of education and research of the hospital as the chosen research setting. the whole process of submission took one and half months. results the majority of the respondents in terms of gender were male (64.3%) and a small percentage were female (35.7%). the average age of the respondents was 50.74 years old with a standard deviation of 10.883. the youngest age was 27 years old and the oldest was 74 years old. most of the respondents had a high school education (40.5%) and a small percentage was un-educated (4.8%). most of the respondents were un-employed (45.2%) and a small percentage were private officers (4.8%) (table 1). based on table 2, the spousal support level was good for the majority (57.1%) and only 11.9% experienced less support. the majority of the respondents who underwent hemodialysis had done so for more than 12 months (90.5%) and a small portion had been undergoing hemodialysis for ≤12 months (9.5%). the mean idgw value was 2.89 (95% ci = 2.74-3.04) while the mean value of spousal support was 2.45 (95% ci = 2.21-2.64). the mean m. mundakir, et al. 212 | pissn: 1858-3598  eissn: 2502-5791 value of the length of hemodialysis was 47.61 (95% ci = 43.72 57.09). this is based on the statistical spearmen test result with a significant p-value of 0.025 (α≤ 0.05). thus, p is smaller than α [0.025 <0.05] so therefore there is a relationship between the support of the spouses with the interdialytic weight gain (idwg) experienced by hemodialysis patients in hospital al-irsyad surabaya. discussion identification of the spousal support in the patients undergoing hemodialysis therapy the results showed that 57.1% of respondents have good life partner support and only 11.9% had less. it can be said that the majority of respondents in this study are supported in an optimal way. in the patients undergoing hemodialysis, indispensable support from their spouses is evidenced because the actions of hemodialysis are done for life. these actions can cause stress and boredom for the patients otherwise. support from their spouse can increase a patient's life in relation to adherence. juárez-ramírez et al (2015) also stated that a greater level of social support mainly comes from partner-related compliance. it serves to reduce the adverse effects of stress and to help in the management of the disease. the level of support provided by the spouses of the respondents in these studies can be influenced by religious factors, as the majority of the respondents’ were muslim (95.2%). islam teaches that in marriage (husband / wife), there must be mutual affectionate support and mutual help. there is a sense of responsibility as part of a pair where there is mutual support against any state experienced, including accepting the condition or disease suffered by the partner, and giving in to god. this is in accordance with the hadith of the prophet muhammad who said that the best man is the one who is the most kind to his family. supportive spouses will make for a more harmonious relationship and it can also increase the happiness felt because they will give their help voluntarily and on the basis of love to cure their ailing spouse. this was also supported by pratita (2013) who explained that in a marriage, two people as one have a mutual sense of desire, unity, interdependence, mutual service, mutual encouragement and support. prasetyawati et al (2012) identified that spousal support may come in one of four forms: emotional, appraisal, informational, and instrumental. emotional support given to the couples in this study is in the form of encouragement in terms of the treatment, giving them the motivation to comply with the rules of eating / drinking and giving attention to their partner. thus the hemodialysis patients feel less alone because of the people watching them. according to friedemann, newman, buckwalter, & montgomery (2014), support can be provided through the assessment of the positive expressions of couples, approval of the idea of support and the feeling that your partner can help with troubleshooting. support ratings were given through the expression of praise when no medical progress was made, when overseeing the implementation of the rules of eating / drinking, and when they were either happy or angry if the respondent violated the rules related to eating / drinking as set by the doctor. thus the respondents sought to maintain an table 1. the respondent characteristic distribution by demographic data (n=42) demographic characteristics n % gender male female 27 15 64.3 35.7 age 27-34 years old 35-42 years old 43-50 years old 51-58 years old 59-66 years old 67-75 years old 3 6 12 10 9 2 7.1 14.3 28.6 23.8 21.4 4.8 education background un-educated elementary school junior high school senior high school bachelor 2 6 9 17 8 4.8 14.3 21.4 40.5 19.0 occupational un-employed public service officer private officer entrepreneur retired 19 3 2 13 5 45.2 7.1 4.8 31.0 11.9 jurnal ners http://e-journal.unair.ac.id/jners | 213 appropriate fluid intake because the doctor who recommended it was the one watching. informational support refers to the guidance, advice or explanation related to how couples behave and how they try to find a way out of the problem. in this case, this is the regulation of body weight over time while on dialysis. support is given in the form of advice given to the couples to encourage them to abide by the rules about drinking, including telling them about the consequences of excessive drinking, and informing them about all of the information passed on from the doctor or nurse to the respondent. this is so then the respondents understand the consequences if they break the rules of eating / drinking that are set. instrumental support is given in the form of practical and concrete help as needed. the support of this instrument is in the form of a couple who prepare their food / beverages together according to the rules set both in the home and at hospital. during the study, it can be observed that the respondents who underwent hemodialysis were facilitated in this by their life partner, such as by delivering the respondents to the hospital and even bringing in food and drinks according to the rules set by the doctor. thus the results of the respondents support that the most couples are a form of instrumental support. identification of idwg in hemodialysis patients the results showed that the lowest idwg respondents had a result of 0%. the highest idwg found was 33.3%. this is contrary to other research which states that weight gain between the dialysis sessions of zero ml would not be possible (yosi suryarinilsih, 2010). idwg is an increase in the volume of fluid that is manifested by an increase in body weight as the basis used to determine the amount of fluid intake during the inter-dialitic period. the patients were routinely measured in terms of weight before and after hemodialysis in order to determine the condition of the fluid in the patient's body. idwg was calculated based on their dry weight after hemodialysis (istanti, 2013). weight gain due to too much fluid has become one of the prognoses of kidney failure, which affects survival time. the greater the weight gain, the lower the level of patient safety (kurniawati, 2012). most of the respondents know the result of excess idwg due to the information received from their doctors and nurses during hemodialysis. the respondents’ knowledge about the consequences of excessive idwg can be influenced by the respondents' education, which for 17 respondents (40.5%) was that of high school level. according to arnold (2008) and suryarinilsih (2010), they said that the higher the level of education of a person, the better they tend to behave. this is because education is obtained in order to lay the foundations of understanding (comprehension) and behavior in a person. during the course of hd, patients with ckd are always given good insights by the doctors or nurses to encourage them to reduce their fluid intake. this is because this will have an impact on the patient’s idgw. when at home, the respondents receive support from their spouse in the form of emotional support, appraisal, information and instrumental assistance so then the patients can better adhere to the drinking rules that must be followed. this encourages there to be no heavy idwg. this is in line with the research conducted by pratita (2012) who found that married couples can persuade or seduce their partners to encourage them to comply with some of the things that have been recommended by doctors including the eating and drinking rules. the results of these studies showed that the average hd duration experienced by the respondents ranged from 43.72 months to 57.09 months. the longer the patients underwent hemodialysis therapy for, the more knowledge they acquired. this allowed them to be more positive concerning their compliance with the liquid diet that can affect their idwg. this is in line with the results of the study by mustikasari (2017) which states that the duration of hemodialysis (> 1 year) has an influence on knowledge, attitude and the patient’s compliance with the restrictions concerning fluid intake. each patient requires a different time period within which to improve their knowledge and attitude. the relationship between the support of their spouses with idwg in hemodialysis patients in hospital al-irsyad surabaya the relationship between idgw and spousal support in the hemodialysis unit produced a p-value of significance of 0.025 with α ≤0.05. the obtained p is smaller than α [0.025 <0.05], thus supporting the hypothesis maintained by the researchers that there is a relationship between the support of the spouses table 2. idwg relationship with spousal support and the length of hemodialysis (n=42) variables n % mean sd min-max 95% ci p idwg 2.89 1.472 0-6.5 2.74-3.04 0.025 mild moderate heavy 17 22 3 40.5% 52.4% 7.1% spouse support 2.45 0.705 1-4 2.21-2.64 poor moderate good 5 13 24 11.9 31.0 57.1 length of hemodialysis 47.61 32.70 4-126 43.72 -57.09 ≤ 12 months >12 months 4 38 9.5 90.5 m. mundakir, et al. 214 | pissn: 1858-3598  eissn: 2502-5791 and idwg in hemodialysis patients in hospital alirsyad surabaya. the longest period of time in terms of the respondents undergoing hemodialysis was 126 months while the shortest was 4 months. according to the investigators, the longer that the patients undergo hemodialysis for and the more that the patients are obedient in terms of undergoing hemodialysis, the more that they increasingly recognize their own bodies when it feels uncomfortable. istanti (2011) states that one of the causes of weight gain is fluid intake. the respondents initially did not know about the causes of idwg and this condition might have an impact due to their lack of knowledge. the lack of knowledge of the respondent was caused by only a small proportion of respondents having a college-level education (8 respondents; 19%). the remaining respondents' education level was below that. this is in line with the research results by suryarinilsih (2010) which state that the higher a person's education level, the better their level of knowledge when it comes to seeking treatment and care. the analysis in this study showed that most of the respondents were aged 43-50 years old, totaling 12 respondents (28.6%). the age of the respondents is among those who are still very eager to seek treatment to improve their health. age could also affect the compliance of the respondents when conducting hemodialysis and refer to keeping the weight gain between dialysis sessions at a level that is not too heavy. based on these results, the majority of the respondents have the support of a life partner (24 respondents; 57.1%). delianty (2015) states that support from their life partner is the effort made by the married couple mentally, physically, and socially. according to researchers, the spouse as well as those closest to the respondents serve as a support system for their partner. they noticed that the people who are supportive are always ready to provide assistance if needed, either in the form of thoughts when making the decision to undergo hemodialysis or providing the motivation to want to comply with the drinking rules that must be followed for the convenience of their partner. this is in line with the research conducted by pratita (2012) showing that spousal support can improve patient compliance in terms of the therapy offered for chronic diseases, which in this case is hemodialysis and problems. spousal support during the hemodialysis process is essential in order to maintain and improve the quality of life of the patient partner as well as to reduce the risk of health problems such as hypotension, muscle cramps, shortness of breath, and cardiovascular problems. conclusion there is a significant relationship between the support given by the spouse and idwg in hemodialysis patients. good partner support reduces the idwg in hemodialysis patients. therefore, determining the level of family support, especially that given by the partner of the idwg hemodialysis patients, will positively support a better level of idwg. this prevents them from experiencing the potential negative side effects of idwg such as hypotension, muscle cramps, shortness of breath, and cardiovascular problems. for further research to be referenced and developed in relation to conducting further research, it should be focused on the factors that affect the support of the spouses given to the patients on hemodialysis. references arnold, t. (2008). predicting fluid adherence in hemodialysis patients via the illnessperception questionaire revided. counseling and psychological services dissertations. bossola, m., pepe, g., & vulpio, c. (2018, september 1). the frustrating attempt to limit the interdialytic weight gain in patients on chronic hemodialysis: new insights into an old problem. journal of renal nutrition, vol. 28, pp. 293–301. https://doi.org/10.1053/j.jrn.2018.01.015 delianty, anggita puspita. (2015). hubungan dukungan pasangan terhadap kepatuhan diet pada penderita diabetes melitus tipe 2 di wilayah kerja puskesmas munjul. friedemann, m. l., newman, f. l., buckwalter, k. c., & montgomery, r. j. v. (2014). resource need and use of multiethnic caregivers of elders in their homes. journal of advanced nursing, 70(3), 662– 673. https://doi.org/10.1111/jan.12230 istanti, yuni permatasari. (2011). faktor-faktor yang berkontribusi terhadap interdialytic weight gains pada pasien chronic kidney diseases yang menjalani hemodialisis. jurnal kedokteran dan kesehatan. istanti, yuni permatasari. (2013). hubungan antara masukan cairan dengan interdialytic weight gains (idwg) pada pasien chronic kidney diseases di unit hemodialisis rs pku muhammadiyah yogyakarta | semantic scholar. kurniawati, yosy. (2012). hubungan antara dukungan sosial dengan stres pada mahasiswa fakultas ekonomi universitas negeri jakarta | kumpulan contoh laporan evaluasi. mustikasari, i. (2017). faktor-faktor yang mempengaruhi nilai interdialytic weight gain pasien hemodialisa di rsud panembahan senopati bantul. jurnal kesehatan, 15(1), 78–86. https://doi.org/10.30787/gaster.v15i1.139 pratita, nurina dewi. (2012). hubungan dukungan pasangan dan health locus of control dengan kepatuhan dalam menjalani proses pengobatan pada penderita diabetes mellitus tipe-2 neliti. suryarinilsih, yosi. (2010). hubungan penambahan berat badan antara dua waktu dialisis dengan kualitas hidup pasien hemodialisis di rumah sakit dr. m. djamil padang tesis . 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 172 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 2, april 2019 http://dx.doi.org/10.20473/jn.v14i2.12229 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors influencing the success of the national nursing competency examination taken by the nursing diploma students in yogyakarta yulia wardani department of nursing, school of health sciences of panti rapih, yogyakarta, indonesia abstract introduction: yogyakarta is a province with the highest percentage of achievements over the past five years. it is argued that it has been affected by many factors. this study was conducted to analyze the factors that influence the success in the national nursing examination of the 3-year nursing diploma students in yogyakarta. methods: this study was a descriptive correlation design with a total sample of 755 participants. the variables in this study were mental preparedness and the learning strategy used by the examinees before the exam (internal factors). this is in addition to the management strategy used three months before the exam, the learning methods used within the 3-year process and the environment where the exam is done (external factors) and also the results of the national nursing competency examination. the questionnaire used in this study was developed by the researcher with a cronbach’s alpha = 0.82. the data was analyzed with the frequency distribution, pearson correlation and r2 for the determinant analysis unit obtained. results: this study found that the management strategy and exam room/environment were significantly correlated with the results of the exam (p=0.05). the learning methods used were also correlated with the results of the exam (p=0.00). the learning strategies used before the exam was a significant factor influencing the success of the national competency examination with a higher coefficient value. conclusion: various factors are related to the success of the national nursing competency examination in yogyakarta. this study implies that the nursing diploma management and the students should manage the learning strategies used before the exam to achieve better results in the national nursing competency examination. article history received: may 5, 2019 accepted: january 7, 2020 keywords learning strategy; national competency examination; factors contact yulia wardani  danygirlspu@gmail.com  department of nursing, school of health sciences of panti rapih, yogyakarta, indonesia cite this as: wardani, y. (2019). factors influencing the success of the national nursing competency examination taken by the nursing diploma students in yogyakarta. jurnal ners, 14(2), 172-180. doi:http://dx.doi.org/10.20473/jn.v14i2.12229 introduction the implementation of the mutual recognition arrangement (mra) affects the dynamics of the association of south east asia nations (asean) and the economic community (ajccn forum, 2016). the global competitiveness index in 2017-2018 shows that indonesia was in 36th place from among 137 countries globally (world’s economic forum, 2018). nursing and tourism are some of the free flowing services ready to compete in the free market competition. the current global situation of the nursing workforce is experiencing an undersupply of nursing staff (marc, bartosiewicz, burzynka, chmiel, and januszewicz, 2018). the increasing elderly population and decreasing number of births, which influences health policies and health care systems around the world, will affect the human resource demand of nursing. to deal with this condition, some nursing institutions should adapt their strategies to manage their institutions. nurses who graduate within a similar nursing education system who want to work overseas will take a nursing competency examination and gain professional certification or recertification in order to update their professional competencies to meet the standards of the origin country. this certification can be achieved through bridging programs and certain nursing courses. it ends in the nursing licensure examination (covell, primeau, kilpatrick, and st.pierre, 2017). unfortunately, indonesia, while producing a great number of nurses each year, has not been able to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.12229 jurnal ners http://e-journal.unair.ac.id/jners | 173 fulfill the demands of the market yet. the government should be aware that after five years of the national examination for the health care profession ongoing, it still has a big problem. the facts indicate that from the first results of the examination until 2018, the results did not meet expectations. about half of the students who came from many different health education institutions who participated in the examination still failed. the low pass rate of the national nursing examination is a burden for many nursing institutions and the government. some of the nursing institutions in the west and east provinces of indonesia even had a 0% 25% passing grade. another problem is the mental preparedness of the re-taker examinees who have still failed the examination many times. almost 50% of the participants in the national competency examination were found to be incompetent (re-taker participants) at the time of the study (pnuk, nakes, 2018) this performance still needs to be increased significantly in order to be able to reach a higher level of nursing passing grade in the national examination, thus increasing the level of the competency of the nursing students. a higher level passing grade will reflect the level of competency of the graduate nursing students. if this higher passing grade is achieved well, then hopefully the indonesian nurses can compete with the other asean countries, particularly singapore and the philippines. the indonesian ministry of health is mandating all nurses who work in the healthcare services to have a registration document that can be obtained through the national nursing examination after finishing all credits in the degree program (indonesian ministry of health, 2014). responding to this situation, nursing education in indonesia has changed the curricula into a competence-based curriculum based on kerangka kualifikasi nasional indonesia (kkni), or the indonesian national qualification framework, in order to have equal parameters of competency that are synchronous and equivalent in the asean scope. the national competency examination for the health profession is an examination held by the national competency examination committee. it consists of elements from the indonesian national nurse association, the association of nursing education institution, the ministry of research, technology, and higher education, the ministry of health, and stakeholders. this examination is a requirement to obtaining a nursing certificate. it is conducted three times a year in the form of paper-based and computer-based examinations. every student must pass the examination. the examination is taken after the nursing students finish their education and before they apply for work. the conclusion on the passing grade of the examination is determined by the agreement of the expert panel. they are all wellestablished and independent scientists with over 10 years of professional and multidisciplinary experience in health (kemenristekdikti, 2016). the performance and results of the competency examination are influenced by several variables and predictors related to either the internal factors inside of the participants or to the external factors. the internal factors, such as the psychological or mental readiness of the students, the learning strategies used to face the examination several months before until a night before the exam day and the physical conditions of the students while taking the examination are believed to be the important factors affecting the examination score. the demographic profiles of the students such as gender, academic achievements and the cognitive ability of the students, especially their problem-solving ability and critical thinking are also important internal predictors that influence the examination score. shin, kim, suh, jung, kim, and yim (2017) stated that construct analysis and a validity test might be significant contributors that affect success in the national competency examination. in order to have a clear understanding of the question, students need to have ability to understand the test construction in many steps of the case reviews. some external factors can also influence success in the nursing competency examination. these factors, such as the role of the management in developing the competency test, the registration process, miscommunications and the absence of specific strategies in preparing the students, need to be explored more seriously in order to achieve the best score in the competency examination performance. kim, nikstaitis, park, amstrong and mark (2019) said that some students predicted that they will succeed in the nursing licensure exam because they took review courses, made aggressive use of the practice questions and studied hard. a strategic review is done by many nursing institutions at the end of the nursing program stimuli by the student to collect and form an early understanding of the essential nursing courses. robert (2018) also supported the statement that an accomplishment in all of the essential nursing subjects will lead the students to achieve a higher grade in the national nursing licensure examination. palompon, ong and banico (2012) found that many variables such as their college entrance examination performance in the iq test, their college grade point average and their preboard examination performances had a correlation with licensure examination performance. the last two variables significantly predicted their licensure nursing examination score. y. wardani 174 | pissn: 1858-3598  eissn: 2502-5791 other external factors include support from their family, peers, friends or classmates, the class room environment where the examination is held, the behavior of the lecturers, and the weather. the quality of the clinical instructors, lecturers and the learning methods provided along the program and the location where the competency examination is held are also important variables that affect the examination process (okanga, ogur and arudo, 2017). considering that there are so many factors affecting the performance of graduate nurses, especially in the national examination process, the researcher is interested in exploring the variables and predictors that affect the results of the national nursing competency examination of the 3-years nursing diploma in yogyakarta. yogyakarta was chosen because it is a province that has always had the highest performance in the nursing competency examination in the country since the first time when the examination was held. although yogyakarta has only 9 institutions that offer a nursing diploma, this province is always the best province that achieves the highest score and highest percentage in the national nursing diploma competency examination. it also had the highest passing grade of more than 98% from 2015 until 2018 (pnuk,nakes, 2018). materials and methods this quantitative research used a descriptivecorrelative analytical design. the first description was to determine the demographic profile of the participants, the results of the examination, the mental strategies and examination strategies of the participants, the strategies of the managers in preparing the examination and the environment during the examination. this descriptive process was then followed by the correlative analysis process and the analysis of the impact value of the variables in order to explore the most significant predictors of the examination results more deeply and to see the correlations between and among the variables that affect the results of the national competency examination3-year. the independent variables in this study were mental preparedness, learning strategies, management strategies (preparation of the management), learning methods, and the environment/room where the competency test was held. the dependent variable was the results of the competency examination. the research was conducted in the special region of yogyakarta, indonesia, and the target population was all of the students participating in the national competency examination at that time. through the total sampling technique, 766 students doing the 3year nursing diploma participating in the national competency examination in yogyakarta were chosen as the sample. the instrument used in this research was a questionnaire that was developed by the researcher consisting of 100 items or statements as follows: 1) the first segment consisted of 20 items exploring the physical, mental, and cognitive preparation of the students before taking the national nursing competency examination; 2) the second segment contained 20 items used to explore the learning strategies of the students when facing the examination in which every statement led to the steps and readiness of the students to face the national competency examination; 3) the third segment, consisting of 20 items, showed the strategies of the managers of the study program in preparing the students to do the final exam; 4) the fourth segment of the instrument consisted of 20 items that explored the types of learning method experienced by the students alongside the learning process of the three-year nursing diploma program table 1. the demographic profile of the participants (n=755) variable n % gender male female 165 590 21.9 78.1 age 20 – 24 years old 25 – 29 years old 30 – 34 years old 35 – 39 years old 40 – 44 years old 45 – 49 years old 689 16 3 13 23 11 91.3 2.1 0.4 1.7 3.0 1.5 province of origin south sumatera 14 1.9 west sumatera 1 0.1 bengkulu 3 0.4 lampung 13 1.7 banten 2 0.3 dki jakarta 3 0.4 west java 7 0.9 central java 102 13.5 yogyakarta 515 68.2 east java 11 1.5 bali 22 2.9 west nusa tenggara 14 1.8 east nusa tenggara 14 1.8 west kalimantan 14 1.8 east kalimantan 4 0.5 central kalimantan 9 1.2 south kalimantan 2 0.3 north maluku 1 0.1 papua 4 0.5 senior high school background natural sciences social sciences health vocational high school non-health vocational high school 336 261 50 108 44.4 34.6 6.6 14.3 gpa 2.00 – 2.99 3.00 – 3.99 24 731 3.1 96.9 types of housing private house/with parents boarding house rented house student dormitory 493 210 36 16 65.2 27.9 4.8 2.1 jurnal ners http://e-journal.unair.ac.id/jners | 175 and 5) the last segment had 20 items that explored the condition of the place or room where the examination took place. every sentence in the questionnaire was filled in by the participants using dichotomy/ binary category scales. this means that the participants could only answer ‘yes’ or ‘no’. yes had a value of 1 and no had a value of 0. to make sure that the instruments reliable and valid, a pilot study was performed to test the questionnaire. the results of the reliability test showed that cronbach’s alpha = 0.82. every participant was asked to fill in a document of agreement stating that they were willing to participate in the study. this study implemented ethical principles of human research such as confidentiality, justice and beneficence. the data collection was carried out in two steps. the first was when the researcher gained a permit for the research from the institutions and when they gathered information from the management of 3-year nursing diploma. the second was at the event briefing for the examination, which was the day before the real examination was held in october 2016. the data was collected by the researcher and a research assistant at poltekkes kemenkes, yogyakarta (a place chosen as a site for the national 3-year nursing diploma examination). the secondary data was collected from the formal announcement of the results of the national nursing competency examination from the committee of the national competency examination. in total, 766 examinees from 9 institutions administering the 3-3year nursing diploma in yogyakarta filled the questionnaires. after the data were sorted, 755 eligible questionnaires were analyzed; 10 participants did not fill in the questionnaires completely, so the data could not be used. to describe the data through a frequency distribution, the data was then analyzed using spss 20 and descriptive analysis. multiple linear regression was employed to examine the predictors of success in the national competency examination. results the characteristics of the demographic profile of the participants are presented as follows. the results of the univariate analysis conducted in table 1 indicates that 590 (78.1%) of the participants were female. the most dominant age range was of 20–24 years old for as many as 689 participants (91.3%). for province, 515 participants (68.2%) came from yogyakarta and 419 participants (55.4%) had an educational background of senior high school in a non-science program. the gpas of 731 participants (99%) were between 3.00 and 3.99. as many as 493 participants (65.2%) stayed in their parents’ house. the results regarding the variables that affect the students when facing the examination are presented in the table below. table 2 shows the predictors affecting the results of the examination. in terms of the mental preparedness of the participants, 395 participants (51.3%) said that they did not feel ready to take the examination while 397 participants (52.6%) used good learning strategies before the exam. on the other hand, 400 institutions (53 %) had bad management when preparing for the examination. in addition to this, 457 participants (60.5%) used bad learning methods in their 3-year study in campus and 491 places (65%) or the rooms used for the examination were unconducive. after the demographic profile of the participants was tabulated, the data on the correlation of the results of the national nursing competency examination with mental preparedness, learning strategies, management strategies, and learning methods in the bivariate statistical data has been presented as follows. from table 3, it can be seen that the variable of learning strategies has a significant correlation with the mental preparedness of the participants when facing the examination with a p value = .01. the correlation exists at the moderate level with a value of r = .092 *. the learning strategies also have a significant correlation with the preparations performed by the director of the 3-year nursing diploma program with a p-value = .000 and an r value = .225 ** the data also shows that the variable of the environment during the examination also has an important role in the success of the students facing the competency test. this variable is significantly correlated with mental preparedness with a p value = .000 and an r value = .144 **, along with the learning strategies (p value = .000 and r value = .246 *), management strategies (p value =, 000 and r value =, 255 **) and learning methods (p value = .000 and r value = .476 **). the results show that the learning strategies before the examination are accepted as the dominant predictor affecting the nursing competency examination. table 2. the distribution of the levels of mental preparedness, learning strategies, management strategies, learning methods, and the environment/room used by the participants (n=755) variable n % mental preparedness ready not ready 395 360 52.3 47.7 learning strategies effective 397 52.6 ineffective 358 47.4 management strategies helpful 355 47.0 unhelpful 400 53.0 learning methods used suitable 298 39.5 unsuitable 457 60.5 condition of the room conducive unconducive 264 491 35.0 65.0 y. wardani 176 | pissn: 1858-3598  eissn: 2502-5791 discussion this study has identified that the extrinsic factors correlated with success in the national nursing competency examination are management capability, the learning methods used in the learning process and the environment where the exam is done. the first extrinsic factor is the ability of the managers/directors of the 3-years nursing diploma program in preparing the students from the first semester through to the last semester. these abilities include their inspirational value, enthusiasm, the clarity of the materials used, the plan, the organizational skill materials, the method of learning, and the method of judging and evaluating the learning processes. the capabilities of the managers in strengthening the learning strategies (including the learning processes and the accurate use of learning methods/strategy) are important keys to passing the final competency examination. nursing managers are also required to be advanced in terms of providing good facilities and infrastructures in the learning process, to employ up-to-date information technology and to update the learning resources used. pence and wood (2018) underline that using software and being skillful at managing information technology in the examination will also lead the students to success in the examination, especially in the computer-based test (cbt) examination. murphy, goossen, and weber (2015) also said that educators should have a vision to focus on confirming what informatics competencies are applicable and needed for helping the students in their study and their examination. the other ability of the manager is planning, managing, and evaluating the learning process of the lecturers. okanga, ogur, and arudo (2017) emphasize that the experience of the faculty has a significant correlation with success in the competency examination. mcdonald (2017) adds that nursing educators should provide the students with many opportunities to master the knowledge required for the licensure. finkelman (2017) also adds that lecturers should be able to serve as a partner for the managers in preparing the nurses for the future. pulito (2017) states that in order to be successful in the licensure/competency examination, deep learning is important. deep learning can be achieved by choosing suitable and accurate learning methods. the deep learning level of the students will be affected by the style of the nursing management used to direct the faculty in teaching and constructing the evaluation/examination. learning methods are how a person learns something as a part of achieving a certain competency and they are usually designed by the lecturers to achieve a learning outcome in particular course/subject (mc donald, 2017). stojanovic et all (2018) said that students need professional help and support to increase their understanding of some clinical nursing subjects. this idea is supported by quin, smolinsky and peters (2018) who emphasized the role of the nursing faculty is to take steps to prepare the nursing students for success on this difficult examination. the role of the nursing lecturer starts at the beginning of the nursing program and it is focused on the fundamental nursing courses through to the advanced nursing courses at the end semester of the program. the mastery in clinical nursing subject through appropriate learning methods designed by the lecturers and clinical instructors will build a good understanding and mental capacity in the students. proper learning methods utilized from table 3. the correlation of mental preparedness, learning strategies of the students, management strategies, learning methods and the environment (room condition) with the results of the national nursing competency examination in yogyakarta examination results mental preparedness learning strategies management strategies learning methods enviro nment results of the examination pearson correlation 1 -.05 .06 .05 .02 .05 sig.(2-tailed) .14 .06 .11 .44. .12 mental preparedness pearson correlation -.05 1 .09* .03 .15* .14* sig.(2-tailed) .14 .14 .01 .28 .00 .00 learning strategies pearson correlation .06 .09* 1 .22* .21* .24* sig.(2-tailed) .06 .01 .00 .00 .00 management strategies pearson correlation .05 .03 .22* 1 .20* .25* sig.(2-tailed) .11 .28 .00 .00 .00 learning methods pearson correlation .02 .15* .21* .21* 1 .47 sig.(2-tailed) .44. .00 .00 .00 .00 environment pearson correlation .05 .14* .24* .25* .47 sig.(2-tailed) .12 .00 .00 .00 .00 1 * the correlation is significant at the 0.05 level (2-tailed) **the correlation is significant at the 0.01 level (2-tailed) jurnal ners http://e-journal.unair.ac.id/jners | 177 first year will increase their verbal and critical thinking skills. the capability to verbalize and understand some of the courses critically builds the mental and emotional capabilities of the students. suitable and accurate learning methods can cultivate curiosity and their manner of being proactive and communicative. students can also learn to develop their arguments and reasoning, and ability to see correlations (associations), including the ability to see cause and effect. therefore, the management skills used to arrange their learning methods are needed. the management skills could also cover the management activity, person, finances and facilities of the successful exam. park et al (2017) states that the quality of the question items in the examination is influenced by the methods used to develop the test items. thus, it needs there to be workshops, brainstorming, verification, and content validity from the experts in order to create quality question items. the nursing education field in indonesia has enforced many nursing institutions to allow them to have the capability to develop items or questions as part of the basic material of the examination package. for reference, one package of items/questions in the examination book consists of 180 items. after the lecturers write the question items, professional nurses review the questions and send them to the panel expert meeting for them to determine the national passing grade. the quality of the test items determines the quality of the test item package. if the quality of the test items improves, then the possibility of having a good passing grade will increase and thus their chance to pass the exam will be higher. shin, kim, suh, jung, kim, and yin (2017) explain that management should also consider using simulators or a standardized patient-based method as the most suitable format to increase the students’ understanding of the patients’ condition. simulations and patient-based methods in a nursing laboratory practicum or in a clinical nursing setting, such as a hospital and primary health care services, will increase the nursing students’ communication abilities and nursing care skills, especially when conducting a nursing assessment about the patients’ health problems. communication, critical thinking, clinical judgment, and competency in relation to their nursing skills/procedures are the key components for success in the nursing competency examination. critical thinking and clinical judgment are very important skills for nursing students. the second factor that influenced the results of the examination was the learning methods used by the lecturers in the teaching and learning process. unsuitable learning methods in the process of education (from the first year up until the third year of the nursing diploma program) leads to failure when doing the competency examination. some of the learning methods used in nursing education that emphasize critical thinking and clinical judgment are case studies, simulations, problem-based learning, project based learning, debriefing, the ability to reflect, peer review scenarios, writing skills and clinical experience/experimental (kaddaura, flint, van dyke,yang and chiang, (2017), synder (2018) and caputi (2019)). zapko et all (2018) emphasizes that serial simulation and having the student’s experience a simulation more than once in consecutive years is the best way to increase their clinical practice in the context of nursing education. on the other hand, a lack of experience in using the learning methods focused on student activities (students centered learning), poor case study methods, and a lack of ability and clinical practices will blunt the abilities of the students in terms of making good inferences and reflecting low critical thinking and clinical judgment skills. it is urgent to reform the nursing program by enhancing the learning methods in terms of clinical judgment and critical thinking. these skills can be achieved through practicing and applying clinical judgment and critical thinking in some thinking competencies. hence the case study method and real practices in the real field become important factors in these processes, but not all students can generate the meaning of the experience well. in addition, the satisfaction of the students when they engage in experiential learning in the clinical practice area can increase their self-confidence and their ability to resolve their duties and tasks in the examination. cowen, hubbard, and hancokck (2018) identify that having enough experience to communicate effectively with patients and other health professionals, and their experience of many skills/nursing procedures and observations through clinical courses, will increase their critical thinking and clinical judgment. the third extrinsic factor that was correlated with success in the nursing examination results was the environment where the exam was done. a conducive environment is a significant factor in terms of increasing the mental preparedness of the examinees which will lead to success in the examination (sanches, costa, agea, izguerdo, and rodriquez (2018). the environment or the room for the examination must be well prepared and meet the standards as follows: the room should have good circulation, and the distance between the students should at least be 1 m2. the room must also have a clear and visible clock/timer that can be seen by all of the participants during the examination (pnuknakes, 2018). in addition, the room should facilitatee a good, calm, and conducive environment, which means that the room should be quiet, as well as being clean, and comfortable with enough lighting and ventilation. good circulation will facilitate the examinees in terms of having enough oxygen. the oxygen inhaled will be distributed via the blood flow in the body including to the brain of the person. this will increase the brain’s metabolic rate and this will increase the work of the brain in terms of y. wardani 178 | pissn: 1858-3598  eissn: 2502-5791 concentrating, recall and memorizing, in addition to understanding and reasoning in the examination. the cognitive activities in the brain contribute to the mental preparedness of the examinees. this mental state in the examination is very important to attain success. another standard of the environment refers to clear directions and information about the building which will affect success in the examination. when the examinees do not know the location or the room for the test, they will be confused and anxious. moreover, when the examinees are late and get lost, they might panic and be more stressed. the anxiety and panic will affect their mental cognitive capacity and capability to understand the test which will influence the results of the examination. the position of the toilet is also important. the examinees should know the location of the toilet. the anxious feeling of the examinees while they are taking the examination will trigger them to urinate more often than usual. the location, cleanliness, and comfort of the toilet will help them to reduce their tension. appropriate lockers for storing their goods, including handphones, is also an important environmental factor that contributes to success in the exam indirectly (pnuknakes, 2018). in fact, on the day of the examination, the examinees often find that the room is still dirty and hot because of poor ventilation, poor lighting and noise. the noise sometimes comes from the neighborhood of the campus such as the music from a wedding party, motorcycles on the main road, and building construction going on around the campus. the noise will disturb the concentration of the examinees and this will influence the results of the exam indirectly. they cannot concentrate on the examination. hence, the environment will influence the results of the competency examination indirectly. the intrinsic factors that were found in this study include mental status and the learning strategies before the exam were used by the examinees. the good mental status of students will decrease their anxiety as well as expand and strengthen their personal competency when the nursing students face the examination. good psychological wellbeing and emotional security affects cognitive capacity and this can lead to better achievements in the examination. when the students have mental preparedness to face the examination, the chance for them to be successful in the competency test will be higher. students need help and support to expand and strengthen their psychological wellbeing in terms of improving the level of their competencies. sanchez, costa, agea, izquierdo, and rodriquez (2018) explained that social-emotional competencies consist of communication skills, the ability to cope with stress, and engagement in both learning activities and self-efficacy. the process of building their critical thinking and clinical judgment in accurate and suitable learning methods correlates with the mental construction of the nursing students. nursing students who have a firm mental capacity will have a good emotional security and sense of psychological wellbeing. psychological wellbeing is an important factor in the examination. some aspects of psychological wellbeing include good motivation, confidence, the state of being free of panic and anxiety, and the willingness or strong desire to pass the examination. the examinees should be free from anxiety because this will influence their performance in the examination (stojanovic et all, 2018). students who have good motivation to become nurses will do their best to pass the examination. the higher their motivation, the better the results of the examination. a person with good motivation will have more enthusiasm and effort and they will struggle more to graduate as soon as possible and to pass the final competency examination. the calling to become a professional nurse and the desire to serve humanity is the highest motivation needed to attain good results in the nursing examination and finally, to become a professional nurse. another intrinsic factor was the learning strategies used when facing the exam. it refers to the strategies used by the nursing students to prepare themselves to face the examination from three months up until the day before the competency examination. the learning strategies chosen by the students are a kind of intrinsic factor that can be very specific and personal in the short-term before the examination. learning only some days before the examination will not fully help the students to pass the nursing competency test. individuals who use good learning strategies to face the examination are slightly higher in terms of result than those who have poor learning strategies. a few students still did not understand the tips and tricks used to pass the examination. trying to learn all of the materials in only one night is not a smart strategy. instead, students can have a course resume, discuss the test questions in a group, attend nursing review classes, and try to answer the test questions on the computer (cbt test questions). most students will attend the review class delivered by the management on a very strict schedule several weeks before the examination. kim, nikstaitis, park, amstrong and mark (2019) said that some students predicted that they would succeed at the nursing licensure exam because they took review courses, which makes aggressive use of practice questions paired with studying hard. the health education system inc (hesi) test is frequently used as a standardized test in nursing programs. many students stated that the review course provided by hesi is helpful for achieving a higher passing grade in the nursing licensure examination. taking review courses seems to be rarely done in indonesia. the lecturer gave the questions before the exam happened. some institutions gave them within a week, some within one, two or three months. at the end of the review session, the student did their test taking package and some of them used a computerbased test. the student should be afforded many opportunities to engage in remediation, test taking jurnal ners http://e-journal.unair.ac.id/jners | 179 and any other support associated with tutoring. these question review methods helped the students to deal with the questions and as a result, they got a higher passing grade in the nursing exam. robert (2018) also supported the finding that there was a significant correlation between the preadmission examination scores and success in the nclex-rn (national council licensure examination – registered nurse) on the first attempt. program completion had also a positive correlation with their pre-admission science grade and hesi score. students who had a higher grade in their preadmission science course were significantly accomplished in all of the essential nursing subjects and this leads them to achieve a higher grade in the national nursing licensure examination. czekanski, mingo and piper (2018) noted that the preparation strategy for success in the nursing licensure examination consists of at least content review and test-taking strategy. a content review will lead the student to have more of a deep understanding of the essential nursing subjects and it will stimulate their critical thinking and clinical judgment when answering the questions. the test-taking strategy will sharpen the student’s skills in terms of managing their time, choosing the best answers and managing stress alongside the examination processes themselves. the preparation reviewstrategy needs to begin from the early semester of the nursing program and continue until after program completion. the learning strategy will improve the students’ understanding of the test questions. the better the learning strategies used by the students, the better their mental preparedness and psychological well-being, thus better results in the examination can be achieved. conclusion this study concludes that the factors that influence the success of the nursing students in achieving high results in the nursing competency examination are the learning methods used in the 3-year nursing program, the environment (conducive rooms/places where the examination is held, the direction of the building, and a comfortable room), the strategies of the nursing diploma managers/directors in preparing the examination, and the learning strategies employed by the students from three months up until the day before the examination. the factors of mental preparedness and the learning strategies used from the first semester until the last semester are also important factors that contribute indirectly to success in the national competency examination. the learning strategies used should be considered a critical aspect in achieving the best results in the national nursing exam. the study then recommends that the nursing students who take the competency examination should have effective learning strategies (personally or institutionally) implemented at least three months before the examination. the institution should improve the learning methods taught during the 3-year nursing program, have a special preparation strategy or treatment available before the examination, and provide a conducive environment/room for the examination which meets the standards as a place of examination. references caputi, l. j. (2019). reflections on the next generation nclex with implications for nursing programs. nursing education perspectives (wolters kluwer health), 40(1), 2. https://doi.org/10.1097/01.nep.000000000000 0439 cormack, c. l., jensen, e., durham, c. o., smith, g., & dumas, b. (2018). the 360-degree evaluation model: a method for assessing competency in graduate nursing students. a pilot research study. nurse education today, 64, 132–137. https://doi.org/10.1016/j.nedt.2018.01.027 covell, c. l., primeau, m.-d., kilpatrick, k., & stpierre, i. (2017). internationally educated nurses in canada: predictors of workforce integration. human resources for health, 15(1), 26. https://doi.org/10.1186/s12960-017-0201-8 dean j, fischer s, saint petersburg junior coll. f. nursing predictors study, phase one. [serial online]. july 20, 1992;available from: eric, ipswich, ma. accessed october 13, 2017. doe, p. f., oppong, e. a., & sarfo, j. o. (2018). students’ demographic, academic characteristics and performance in registered general nursing licensing examination in ghana. european journal of contemporary education, 7(1), 73–81. retrieved from http://search.ebscohost.com/login.aspx?direct=t rue&authtype=cookie,ip,cpid&custid=ns134184 &db=eric&an=ej1172931&site=ehostlive&scope=site eyikara, e., & baykara, z. g. (2017). the importance of simulation in nursing education. world journal on educational technology: current issues, 9(1), 2-7. finkelman (2017). professional nursing concepts: competencies for qualaity leadership. jones & bartlett learning. murphy,j., goossen, w.,& weber,p (2017). forecasting informatics competencies for nurses in the future of connected health. ios press, amsterdam, berlin, washington, dc kaddoura, m. a., van dyke, o., & yang, q. (2017). correlation between critical thinking skills and national council licensure examination for registered nurses success in accelerated y. wardani 180 | pissn: 1858-3598  eissn: 2502-5791 bachelor nursing students. teaching & learning in nursing, 12(1), 3–7. https://doi.org/10.1016/j.teln.2016.08.004 kaddoura, m. a., flint, e. p., van dyke, o., yang, q., & chiang, l.-c. (2017). academic and demographic predictors of nclex-rn pass rates in firstand second-degree accelerated bsn programs. journal of professional nursing, 33(3), 229–240. https://doi.org/10.1016/j.profnurs.2016.09.005 kavanagh, j. m., & szweda, c. (2017). a crisis in competency: the strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. nursing education perspectives (wolters kluwer health), 38(2), 57– 62. https://doi.org/10.1097/01.nep.000000000000 0112 mcdonald (2017). guide to assessing leraning outcome. 4th ed. jones & bartlett learning. park, in sook, yeon ok suh, hae sook park, so young kang, kwang sung kim, gyung hee kim, yeonhee choi, and hyun-ju kim. 2017. “item development process and analysis of 50 casebased items for implementation on the korean nursing licensing examination.” journal of educational evaluation for health professions 14 (september): 20. doi:10.3352/jeehp.2017.14.20. pence, j., & wood, f. (2018). using computeradaptive quizzing as a tool for national council licensure examination success. nursing education perspectives (wolters kluwer health), 39(3), 164. https://doi.org/10.1097/01.nep.000000000000 0289 pnuknakes (2018). blueprint uji kompetensi program diii keperawatan. https://ukperawat.ristekdikti.go.id/index.php/p rosedur_pendaftaran pnuknakes (2018). pedoman persiapan uji kompetensi nasional program studi diii keperawatan. https://drive.google.com/drive/folders/1jqbyes wuzbwlk_ebj0uaxxs2c8gbsptq pulito, j. (2017, january 1). associate degree nursing graduates perceptions of nclex performance. proquest llc. proquest llc. retrieved from http://search.ebscohost.com/login.aspx?direct=t rue&authtype=cookie,ip,cpid&custid=ns134184 &db=eric&an=ed580066&site=ehostlive&scope=site okanga, a. a., ogur, j. o., & arudo, j. (2017). institutional characteristics influencing bachelor of science nursing student performance in the nursing council of kenya licensure examinations in kenya. journal of education and e-learning research, 4(1), 28–36. retrieved from http://search.ebscohost.com/login.aspx?direct=t rue&authtype=cookie,ip,cpid&custid=ns134184 &db=eric&an=ej1148429&site=ehostlive&scope=site quinn, b. l., smolinski, m., & peters, a. b. (2018). strategies to improve nclex-rn success: a review. teaching & learning in nursing, 13(1), 18–26. https://doi.org/10.1016/j.teln.2017.09.002 ristekdikti, (2016). panduan pelaksanaan uji kompetensi program diploma iii kebidanan, diploma iii keperawatan dan profesi ners april tahun 2016 sánchez expósito, j., leal costa, c., díaz agea, j. l., carrillo izquierdo, m. d., & jiménez rodríguez, d. (2018). socio-emotional competencies as predictors of performance of nursing students in simulated clinical practice. nurse education in practice, 32, 122–128. https://doi.org/10.1016/j.nepr.2018.07.009 shin, s. j., kim, y. k., suh, s.-r., jung, d. y., kim, y., & yim, m. k. (2017). perception survey on the introduction of clinical performance examination as part of the national nursing licensing examination in korea. journal of educational evaluation for health professions, 14, 26. https://doi.org/10.3352/jeehp.2017.14.26 snyder, t. l. (2018, january 1). the relationship between admission requirements, academic performance measures and undergraduate nursing student success. proquest llc. proquest llc. retrieved from http://search.ebscohost.com/login.aspx?direct=t rue&authtype=cookie,ip,cpid&custid=ns134184 &db=eric&an=ed587641&site=ehostlive&scope=site stojanovic, g., vasiljevic-blagojevic, m., stankovic, b., terzic, n., terzic-markovic, d., & stojanovic, d. (2018). test anxiety in pre-exam period and success of nursing students. serbian journal of experimental & clinical research, 19(2), 167– 174. https://doi.org/10.1515/sjecr-2017-0060 world economic forum (2018). the global competitiveness report 2018. retrive from reports.weforum.org/global-competitivenessreport-2018/dowloads/ http://e-journal.unair.ac.id/jners | 57 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18911 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research analysis of implementation of perioperative care instrument based on standards of nursing diagnosis, intervention and outcomes in indonesia haris widodo, nursalam nursalam, erna dwi wahyuni faculty of nursing, university of airlangga, surabaya, indonesia abstract introduction: perioperative nursing care has been widely applied in either various hospitals or other healthcare facilities. the purpose of this study was to analyze the implementation of a perioperative care instrument based on the indonesian nursing diagnosis standards (sdki, the indonesian nursing intervention standards (siki), and the indonesian nursing outcome standards (slki) in the operating room in a teaching hospital, east java. methods: this research design was a descriptive study. the study population was the perioperative nursing care instrument in the medical records of patients with fracture cases. the research sample consisted of 106 medical records with total sampling. the dependent variable of this study was the implementation of the perioperative nursing care instrument based on sdki, slki, and siki. data were collected using observation sheets and analyzed using descriptive analysis. results: applying the diagnosis of nursing care according to the standard the risk of infection is (27.36%), acute pain (20.75%), and the risk of injury (2.83%). the application of nursing outcomes according to standards is the infection rate (27.36%), pain level (20.75%) and fluid balance (2.83%). conclusion: the nursing interventions, implementation, and evaluation of nursing are not according to the indonesian nursing intervention standards (siki). the application of perioperative nursing care instruments, which includes titles, diagnoses, and outcomes, is partly following sdki and slki standards. nursing interventions, implementation, and evaluation of nursing are not according to standards. article history received: feb 27, 2020 accepted: april 1, 2020 keywords perioperative nursing; nursing diagnosis; nursing intervention; nursing outcome contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, university of airlangga, surabaya indonesia cite this as: widodo, h., nursalam, n., & wahyuni, e, d. (2020). analysis of implementation of perioperative care instrument based on standards of nursing diagnosis, intervention and outcomes in indonesia. jurnal ners, special issues, 57-62 doi: http://dx.doi.org/10.20473/jn.v15i2.18911 introduction standard nursing language in nursing services is now a global trend in the nursing profession that arises to unite the terminology used in nursing practice (gusen, 2017). in providing nursing care standardization of care is needed which includes diagnostic standards, output standards, clear standards of intervention and terminology so that nursing care can be uniform, accurate, and unambiguous to guarantee continuity and quality of service (dpp ppni, 2017). in various countries, standards for nursing care plans have not been widely explained comprehensively in the nursing literature (johnson et al., 2018). although there are already several internationally recognized nursing care standards, because these standards have not been developed with due regard to cultural disparities and the uniqueness of nursing services in indonesia, these standards are deemed inappropriate for indonesia (dpp ppni, 2017). the indonesian national nurses association (ppni) as a professional nurse organization in indonesia has developed nursing care standards in indonesia by publishing the indonesian nursing diagnosis standards (sdki), indonesian nursing intervention standards (siki) and indonesian nursing outcomes standards (slki) (dpp ppni, 2017). the use of standardized nursing care is essential in improving the quality of nursing care https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nursalam@fkp.unair.ac.id h. widodo et al. 58 | pissn: 1858-3598  eissn: 2502-5791 (olatubi et al., 2019). several factors affect the quality of nursing documentation, including documentation according to the nursing process, the use of standard terminology and documentation instruments, electronic documentation and documentation instruments that vary according to nursing practice (de groot et al., 2019). instrument documentation according to standards is one of the factors that influence the quality and integration of nursing documentation (de groot et al., 2019). research conducted by linden, karen and jo-ann (2017) explains that the use of standardization in providing nursing care is essential in the successful integration of nursing documentation. nursing documentation instruments must also be prepared based on established clinical practice standards (de groot et al., 2019). according to the indonesian ministry of health, in 2015, limb fractures had the highest prevalence among other fractures, which was around 46.2% . based on research conducted by rachmania and yunitasari (2016) in a hospital in east java, it was explained that, before using the development of documentation, instruments that meet the standards obtained complete documentation of 100% assessment data, 62.55% diagnosis, 62.5% intervention, 50% implementation, and 50% evaluation. the average document filling is around 65% of the recorded documentation (rachmania & yunitasari, 2016). the purpose of this study was to analyze the implementation of perioperative nursing care instrument based on the indonesian nursing diagnosis standards (sdki), the indonesian nursing intervention standards (siki) and the indonesian nursing outcome standards (slki). materials and methods literature review literature review related to the application of diagnostic standards, outcomes and nursing orders has been carried out. the development of diagnostic and intervention instruments based on established standards was carried out by diana in 2015. the results of the development of the diagnostic and intervention instruments are valid and reliable (rachmania & yunitasari, 2016). other studies have also been carried out by sartika on developing clinical pathways using indonesian nursing diagnosis standards. the result showed that the appropriate nursing diagnosis based on the clinical pathway of diabetes mellitus was: unstable glucose level, activity intolerance, a deficit of nutrition. for thrombotic stroke, the nursing diagnoses were decrease of adaptive intracranial capacity, physical mobility impairment, and ineffective breathing pattern. for pneumonia, the nursing diagnoses were ineffective airway clearance, activity intolerance, and hyperthermia. for acute myocardial infarction, the nursing diagnoses were decreased cardiac output, activity intolerance, spontaneous, circulation impairment (sartika, 2017). the use of nursing standards can also improve the quality of nursing documentation. research conducted by adubi,. olaogun, and adejumo on 270 medical records related to the use of nursing standards found that the existence of programs related to the use of nursing standards, in general, had a significant effect on the quality of nursing documentation (adubi et al., 2018). nursing intervention standards can also be relied upon to assess and evaluate clinical competencies, especially table 1. evaluation of nursing diagnosis in operating room (n=106) evaluation of nursing diagnosis indonesian nursing diagnosis standard total (%) results worry anxiety 49 (46.23%) not appropriate risk infection risk infection 29 (27.36%) appropriate acute pain acute pain 22 (20.75%) appropriate risk of lack of fluid volume risk of fluid imbalance 3 (2.83%) not appropriate risk of injury risk of injury 3 (2.83%) appropriate table 2. evaluation of nursing outcomes in operating room (n=106) evaluation of nursing outcomes indonesian nursing outcomes standards total (%) results distress level self-control of anxiety anxiety level level of agitation 49 (46.23%) not appropriate infection rate infection rate skin and tissue integrity control of risk infection 29 (27.36%) appropriate pain level pain control pain level physical mobility 22 (20.75%) appropriate fluid balance hydration status fluid balance hydration status 3 (2.83%) appropriate physical injury level tissue integrity: skin and mucous membranes falling rate level of injury 3 (2.83%) not appropriate jurnal ners http://e-journal.unair.ac.id/jners | 59 in competency systems for nursing practice (iglesiasparra et al., 2015). the use of nursing standards can also be used to minimize ambiguity and identify the terminology used in nursing practice (c. m. g. carvalho et al., 2017). research conducted on 122 medical records in the period before and after accreditation found that there was an improvement in the quality of diagnoses, interventions, and outcomes in nursing (nomura et al., 2016). other studies also state that the use of nursing care standards can improve the quality of diagnoses, interventions and nursing outcomes that can be assessed using q-dio instruments (linch et al., 2015). data collection this study uses a descriptive research design to describe events systematically and emphasizes factual data rather than conclusions (nursalam, 2017). this research was conducted between may 2019 and november 2019 at a teaching hospital in east java. this research was conducted by observing 106 medical records in fracture patients of perioperative nursing care instruments obtained in total sampling. the inclusion criteria in this study were 1) patients undergoing open reduction internal fixation (orif) surgery, 2) with a single operation, and 3) patients aged 18 to 70 years. meanwhile, the exclusion criterion in this study was patients who had multiple fracture surgeries. data obtained through observation sheets were conducted by researchers on perioperative nursing care instruments in the patient's medical record. this observation sheet to evaluate the perioperative nursing care instruments includes the instrument title, diagnosis, outcomes, interventions, implementation, and evaluation of nursing. this research protocol was declared to have passed the ethics test by the universitas airlangga hospital ethics commission with an ethics certificate number no: 185 / keh / 2019 on november 5, 2019. data analysis descriptive statistics on evaluating diagnosis are shown in table 1. descriptive statistics on evaluating the determination of nursing outcomes are shown in table 2. descriptive statistics on evaluating nursing interventions are shown in table 3 and descriptive statistics on evaluating nursing interventions are shown in table 4. this evaluation was carried out on 106 medical records of perioperative patients with fracture cases. results evaluation of nursing diagnosis based on evaluation of 106 medical records that have been analyzed (table 1), the diagnosis most often made in perioperative patients is anxiety (46.23%), and what is rarely established is the risk of lack of table 3. evaluation of nursing intervention in operating room (n=106) evaluation of nursing interventions indonesian nursing intervention standards total (%) results reducing anxiety distraction technique relaxation therapy anxiety reduction surgical preparation soothing techniques relaxation therapy 49 (46.23%) not appropriate control of intra-action infections incise / puncture access treatment prevention of infection treatment of incision area 29 (27.36%) not appropriate pain management provision of analgesics help control patient analgesics pain management provision of analgesics 22 (20.75%) not appropriate vital sign monitoring fluid and electronic management intravenous therapy bleeding reduction fluid monitoring urinary catheterization 3 (2.83%) not appropriate intraoperative position regulation skin surveillance surgical precaution temperature regulation: perioperative fall prevention environmental safety management sedation management installation of safety devices 3 (2.83%) not appropriate table 4. evaluation of perioperative care instruments in operating room (n=106) component of perioperative care instruments category total (%) appropriate (%) not appropriate (%) standard of title 51 (48.11) 55 (51.89%) 106 (100%) standard of nursing diagnoses 54(50.94%) 52(100%) 106 (100%) standard of nursing outcomes 54 (50.94%) 52 (100%) 106 (100%) standard of nursing intervention 0 (0) 106 (100%) 106 (100%) standard of implementation 0 (0) 106 (100%) 106 (100%) evaluation of nursing care 0 (0) 106 (100%) 106 (100%) h. widodo et al. 60 | pissn: 1858-3598  eissn: 2502-5791 fluid volume (2.83%) and risk of injury (2.83%). the diagnosis has been established and, following the indonesian nursing diagnosis standards (sdki), the risk of infection is (27.36%), acute pain (20.75%) and risk of injury (2.83%). evaluation of nursing outcomes based on evaluation of 106 medical records that have been analyzed (table 2), the nursing outcomes that have been determined and are in accordance with the slki are the level of infection (27.36%), the level of pain (20.75%), and fluid balance (2.83%). evaluation of nursing interventions based on evaluation of 106 medical records that have been analyzed (table 3), all of the specified nursing interventions that have been determined are not in accordance with indonesian nursing intervention standards (siki). evaluation of perioperative care instruments based on evaluation of 106 medical records that have been analyzed (table 4), the majority of the intervention, implementation and evaluation of nursing are following the standards. however, the titles of instruments, diagnoses, and outcomes of nursing are still not following established standards. discussion evaluation of perioperative nursing care instruments in fracture cases in the operating room of the educational hospital in east java was measured using an observation sheet based on diagnosis standards, outcome standards and intervention standards as well as implementation and evaluation that have been determined by nursing professional organizations (ppni). the instrument title is based on the problem/label on the component of the nursing diagnosis. the perioperative nursing care instruments currently in use are five instruments, including instruments of anxiety, acute pain, risk of infection, risk of lack of fluid volume and risk of injury to the perioperative position. however, this instrument is still based on nanda, noc and nic has not been based on sdki-slki-siki since it was first created in 2012, and there has been no change until now. the results of the evaluation of the perioperative nursing care instruments on 106 medical records found that the title of the instrument was according to the established standards of 48.11%. nursing diagnoses and nursing outcomes that have been set at 50.94% are in accordance with the sdki and slki. nursing interventions, implementation and evaluation of nursing that have been set are not in accordance with established standards. the title of the instrument matches the label/problem in the component of diagnosis. standard diagnosis includes an actual diagnosis consisting of problems, etiology, major/minor signs and symptoms. standard outputs include primary and additional outputs. intervention standards include observation, therapeutic, education and collaboration (dpp ppni, 2018). patient development records can be seen from the evaluation of diagnoses, interventions and nursing outcomes (myklebust, 2017). law no. 38 of 2014 concerning nursing emphasizes that nursing practice must be based on a code of ethics, service standards, professional standards, and operational procedure standards (presiden ri, 2014). on 29 december, 2016, ppni established nursing care standards by publishing the indonesian nursing diagnosis standards book (sdki), then proceeding with the issuance of indonesian nursing output standards (slki) and the indonesian nursing intervention standards (siki)(dpp ppni, 2018). the accuracy in the nursing diagnosis can be caused by the standardization of nursing care that has been determined (e. c. de carvalho et al., 2016). the use of standardization in nursing can also improve patient safety and nursing care provided (florin et al., 2016). research conducted by linden, karen and jo-ann (2017) explains that the use of standardization in providing nursing care is vital in the successful integration of nursing documentation (johnson et al., 2018). nursing documentation instruments must also be prepared based on established clinical practice standards (de groot et al., 2019). standardization of nursing care is very important in improving the quality of nursing care. in the current era of healthcare, the use of standardized language terminology in providing patient care is needed to improve patient care, patient safety and patient outcomes (oreofe & oyenike, 2018). the nursing law also regulates the matter mandated by professional organizations. standardization of care can increase the continuity of nursing care. this standardization of care must, of course, adhere to the standards of professional organizations, not from foreign standards. although there are already several internationally recognized nursing care standards, because these standards have not been developed with due regard to cultural disparities and the uniqueness of nursing services in indonesia, these standards are deemed inappropriate for indonesia (dpp ppni, 2017). the use of documentation instruments that are not in accordance with the standards can cause discrepancies in the nursing care provided so that it can affect the quality of documentation. the use of documentation instrumentation can also cause incompleteness in documentation due to differences in terminology, different understandings, and differences in the enforcement of nursing diagnoses. this research is limited to the perioperative nursing care instruments in fracture cases, thus, it is necessary to do more research related to other cases. jurnal ners http://e-journal.unair.ac.id/jners | 61 conclusion the application of nursing care that includes the standard title, diagnosis, and nursing outcomes in the perioperative nursing care instrument is almost in accordance with the sdki and slki. the application of nursing diagnoses in accordance with the idhs is the risk of infection, acute pain and risk of injury. the application of nursing outcomes in accordance with slki is the level of infection, the level of pain and fluid balance. conflict of interest no conflicts of interest have been declared acknowledgement acknowledgments to all research respondents and the medical records section who were willing to take the time, energy and information support to complete this research data. references adubi, i. o., olaogun, a. a., & adejumo, p. o. (2018). effect of standardized nursing language continuing education programme on nurses’ documentation of care at university college hospital, ibadan. nursing open, 5(1), 37–44. https://doi.org/10.1002/nop2.108 carvalho, c. m. g., cubas, m. r., & nóbrega, m. m. l. da. (2017). terms of the specialized nursing language for the care of ostomates. revista brasileira de enfermagem, 70(3), 461–467. https://doi.org/10.1590/0034-7167-2015-0058 carvalho, e. c. de, helena, a., eduardo, a., romanzini, a., simão, t. p., zamarioli, c. m., garbuio, d. c., & herdman, t. h. (2016). correspondence between nanda international nursing diagnoses and outcomes as proposed by the nursing outcomes classification. international journal of nursing knowledge, 29(1), 1–13. https://doi.org/10.1111/2047-3095.12135 de groot, k., triemstra, m., paans, w., & francke, a. l. (2019). quality criteria, instruments, and requirements for nursing documentation: a systematic review of systematic reviews. journal of advanced nursing, 75(7), 1379–1393. https://doi.org/10.1111/jan.13919 dpp ppni. (2017). standar diagnosis keperawatan indonesia. dpp ppni. (2018). standar luaran keperawatan indonesia,edisi 1. 2. florin, j., jansson, i., strandberg, e., ehrenberg, a., & björvell, c. (2016). cross-mapping diagnostic nursing concepts between the icnp and the icf for expressing nursing in the health care record. studies in health technology and informatics, 225, 1016. https://doi.org/10.3233/978-1-61499658-3-1016 gusen, n. j. et al. (2017). nurses’ knowledge attitude and practice of standardized nursing language in pssh, jos. west african journal of nursing. iglesias-parra, m. r., garcía-guerrero, a., garcíamayor, s., kaknani-uttumchandani, s., leóncampos, á., & morales-asencio, j. m. (2015). design of a competency evaluation model for clinical nursing practicum, based on standardized language systems: psychometric validation study. journal of nursing scholarship, 47(4), 371–376. https://doi.org/10.1111/jnu.12140 johnson, l., edward, k. l., & giandinoto, j. a. (2018). a systematic literature review of accuracy in nursing care plans and using standardised nursing language. collegian, 25(3), 355–361. https://doi.org/10.1016/j.colegn.2017.09.006 linch, g. f. da c., rabelo-silva, e. r., keenan, g. m., moraes, m. a., stifter, j., & m??ller-staub, m. (2015). validation of the quality of diagnoses, interventions, and outcomes (q-dio) instrument for use in brazil and the united states. international journal of nursing knowledge, 26(1), 19–25. https://doi.org/10.1111/20473095.12030 myklebust, k. k. (2017). nursing documentation in inpatient psychiatry: the relevance of nursepatient interactions in progress notes. a focus group study with mental health staff. journal of clinical nursing, 38(1), 27 (3-4). https://doi.org/10.1111/ijlh.12426 nomura, a. t. g., silva, m. b. da, & almeida, m. de a. (2016). quality of nursing documentation before and after the hospital accreditation in a university hospital. revista latino-americana de enfermagem, 24, e2813. https://doi.org/10.1590/1518-8345.0686.2813 nursalam. (2017). metodologi penelitian ilmu keperawatan: pendekatan praktis. metodologi penelitian ilmu keperawatan: pendekatan praktis. olatubi, m. i., oyediran, o. o., faremi, f. a., & salau, o. r. (2019). knowledge, perception, and utilization of standardized nursing language (snl) (nnn) among nurses in three selected hospitals in ondo state, nigeria. international journal of nursing knowledge, 30(1), 43–48. https://doi.org/10.1111/2047-3095.12197 oreofe, a., & oyenike, a. (2018). transforming practice through nursing innovative patient centered care: standardized nursing languages. international journal of caring sciences, 11(2), 1319–1322. presiden ri. (2014). undang-undang ri no.38 tahun 2014 tentang keperawatan. departemen kesehatan ri. rachmania, d., & yunitasari, e. (2016). pengembangan instrumen diagnosis & intervensi keperawatan berbasis standardized nursing language (nanda-i, noc, nic) (development of nursing diagnosis & intervention instrument based on standardized nursing language (nanda-i, noc,nic)). 9(2). h. widodo et al. 62 | pissn: 1858-3598  eissn: 2502-5791 sartika, n. and e. (2017). developing format of clinical pathway using nursing diagnosis based on indonesian nursing diagnosis standard ( standar diagnosis keperawatan indonesia : sdki ). 3(inc), 87–89. 26 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.17286 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the relationship between fulfilment of basic needs with the incidence of stunting in toddlers endang surani and endang susilowati sultan agung islamic university, semarang, central java, indonesia abstract introduction: the prevalence of toddlers who very short and short at the age of 0-59 months in indonesia is still high. one cause of stunting is lack of nutrition, mainly in the first 1000 days of life. the purpose of this study was to identify the relationship between the fulfilment of basic needs with the incidence of stunting in toddlers. methods: a quantitative analytic research methods using cross-sectional approach was applied on this study. the sample was100 toddlers collected by purposive sampling technique. the questionnaires were used to measure the fulfilment of the basic needs of children and included questions about physical, emotion and stimulation. the data were analysed using chi-square. results: there was a relationship between fulfilment of the basic needs in physical and emotion category with stunting (p value of 0.000), while there was no relationship between fulfilment of basic needs in the category of stimulation with stunting (p value of 0.090). conclusion: the fulfilment of the basic needs of physical and emotion affects the condition of toddlers with stunting. thus, all of children should get exclusive breastfeeding, appropriate complementary feeding, early childhood education programme, attend an integrated healthcare centre routinely, have adequate access to immunisation services. article history received: january 23, 2020 accepted: march 30, 2020 keywords basic needs of children; toddler; stunting contact endang susilowati esusilowati@unissula.ac.id  sultan agung islamic university, semarang, central java, indonesia cite this as: surani, e., & susilowati, e. (2020). the relationship between fulfilment of basic needs with the incidence of stunting in toddlers. jurnal ners, 15(1), 26-30. doi:http://dx.doi.org/10.20473/jn.v15i1.17286 introduction more than two million deaths of children under 5 years in the world are directly related to malnutrition, especially wasting and stunting. according to data released by unicef, there are around 195 million stunted children who live in poor and developing countries (wiyogowati, 2012). the world health organization (who) placed indonesia as the third country with the highest stunting prevalence rate in asia in 2017, reaching 36.4%. however, in 2018, the figure continued to decline by 23.6%. from the same data, it is also known that stunting in children under five in indonesia dropped to 30.8%. in indonesia in 2017, the prevalence of toddlers was very short and short at the age of 0-59 months by around 9.8% and 19.8%, respectively and, in 2018, around 30.8% of toddlers were in the very short and short categories while in central java province in 2018 it was around 31.22% (riskesdas, 2018). stunting is a syndrome in which linear growth failure functions as a marker of several pathological abnormalities associated with increased morbidity and mortality, loss of potential for physical growth, reduced nerve development and cognitive function and increased risk of chronic disease in adulthood (kemenkes, 2018). stunting can occur as a result of malnutrition, especially in the first 1000 days of life. there are multidimensional factors that cause stunting, including poor parenting practices, limited health services including ante natal care, lack of access to nutritious food, lack of access to clean water and sanitation (kemenkes, 2018). the nutritional status of children less than five years old is very influential in the process of growth and development. in stunting children there is a growth failure (growth faltering) that starts in the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 27 womb and lasts until the child is 2 years old. this problem can occur due to lack of protein energy as one of the main nutritional problems that occur in toddlers and which is very influential on the child's growth and development process (unicef, 2010). one treatment that can prevent the occurrence of stunting in children is to meet the basic needs during growth and development, namely fostering, caring and homing needs; these basic needs affect nutritional status. basic needs greatly affect the nutritional status is the fulfilment of fostering needs because it is directly related to the physical environment of children (maria & adriani, 2009). parenting is a way parents treat their children by looking after, caring for, and educating them. from the way the parents treat them it will reflect their own characteristics which will affect the child's attitude patterns later on. basic needs are very necessary to support the growth and development of children. these basic needs can be grouped into three, namely “asih, asah, and asuh” (soetjiningsih, 2013). the purpose of this study was to determine whether there is a relationship between meeting basic needs with the incidence of stunting toddlers. materials and methods this research used observational analytic research with cross-sectional approach. the research was conducted in a village of demak regency for eight months from may december 2019. the population in this study were 155 toddlers who were stunted. the sampling technique in this study was purposive sampling method. the inclusion criterion was minimum age of 2 years and a maximum of 5 years. samples obtained were 100 respondents. the instrument used in this study was questionnaires containing the child's identity, mother identity and 41 questions about fulfilment of the basic needs of children, which included 25 questions for physical, 10 questions for emotion, and six questions for stimulation. the independent variable in this study was the fulfilment of the basic needs of children and the dependent variable was stunting. this study has received ethical approval from the medical/health research from the commission of the faculty of medicine in unissula with no. 642 / x / 2019 / bioethics commission. results based on table 1, it can be seen that 63.0% of respondents are included in the high-risk age category, 81.0% have basic education, 51.0% are housewives, 92.0% earn below the minimum wage payment, 60.0% are male, 50.0% were in short status and 50.0% were very short. the results of the study (table 2) found that 70.0% of respondents in the low risk category had toddlers with a short status and 56.0% were very short, respondents with basic education 80.0% had short toddlers and 82.0% were very short, respondents as housewives, 50.0% had short toddlers and 52.0% were very short; income less than mwp, 90.0% had short toddlers and 94.0% were very short while for gender of stunting in toddlers 54.0% are short and 66.0% are very short occurring in boys under five. the characteristics of respondents had no significant relationship with stunting in toddlers (p value> 0.05), but there was a significant relationship between fulfilment of the basic needs, including physical, emotion and stimulation with the incidence of stunting in toddlers (p value 0.000 <.05). discussion the fulfilment of the basic needs of physical and emotion affects the condition of toddlers with stunting. according to the director of the budget in the field of human and cultural development in 2018, stunting is caused by multidimensional factors including bad child care practices, meaning children aged 0-6 months are not getting exclusive breastfeeding and children aged> 6-24 months do not get the appropriate complementary feeding, while children aged 3-6 years old are not registered in an early childhood education programme, show decreased level of attendance in integrated healthcare centres, and do not get adequate access to immunisation services (direktur anggaran bidang pembangunan manusia dan kebudayaan, 2018). the results showed that for toddlers with both short and very short status, neither physical nor emotional needs were met. based on the questionnaire, it is known that the majority of infants do not get exclusive breastfeeding and have received complementary feeding before the age of 6 months. the complementary feeding given is not suitable for the baby's age, whereas in children aged 12 60 months the feeding does not meet balanced nutrition. this includes bad parenting and child care needs not being met. this is in line with the research of rahmayana, ibrahim, and darmayati (2014) which stated there was a significant relationship between feeding practices with stunting in toddlers. feeding infants and children is an important foundation in the growth process. globally, around 30% of children under five years who are stunted are a consequence of poor feeding practices and recurrent infections (rahmayana et al., 2014). maternal nutrition knowledge in mimika regency was found to be 80% of respondents in good category and 20% in less category. the level of maternal education also determines the convenience of mothers in absorbing and understanding the nutritional knowledge gained. this can be the basis for distinguishing the appropriate extension methods. from the family's nutritional importance, e. surani et al. 28 | pissn: 1858-3598  eissn: 2502-5791 education is needed so that a person, especially mothers, is more responsive to the nutritional problems in the family and can take action as soon as possible. high maternal knowledge is able to provide a balanced nutritional intake for families and children. higher maternal knowledge is more prevalent in well-educated mothers than in poorly educated mothers. good maternal nutritional knowledge does not always mean a child experiences optimal growth; in cases where the mother is wellknowledgeable ,m17.5% of children have stunting (silas, rantetampang, tingginehe, & mallongi, 2018). the association between education, in general, and health education in particular, with the level of stunting even after controlling for other socioeconomic factors underlines the need for customised health/nutrition education to make it more relevant to the existing situation and table 1. respondents’ characteristics (n=100) variables n % age of respondent low risk 37 37.0 high risk 63 63.0 mother’s education primary education 81 81.0 secondary education 18 18.0 higher education 1 1.0 mother’s occupation housewife 51 51.0 labourers 23 23.0 private employee 26 26.0 family income < mwp 92 92.0 > mwp (minimum wage payment) 8 8.0 gender of toddlers male 60 60.0 female 40 40.0 status of stunting short 50 50.0 very short 50 50.0 table 2. relationship of characteristics, fulfilment of basic needs with stunting toddler events variables stunting p value short % very short % age of respondent low risk high risk 35 15 70.0 30.0 28 22 56.0 44.0 0.214 mother’s education primary education secondary education higher education 40 9 1 80.0 18.0 02.0 41 9 0 82.0 18.0 0 0.603 mother’s occupation housewife labourers private of employment 25 12 13 50.0 24.0 26.0 26 11 13 52.0 22.0 26.0 0.969 family income below the minimum wage payment above the minimum wage payment 45 5 90.0 10.0 47 3 94.0 06.0 0.715 gender of toddler male female 27 23 54.0 46.0 33 17 66.0 34.0 0.307 physical fulfilled not fulfilled 3 47 6.0 94.0 emotion fulfilled not fulfilled 12 38 24.0 76.0 stimulating fulfilled not fulfilled 7 43 14.0 86.0 jurnal ners http://e-journal.unair.ac.id/jners | 29 underscores the need to fulfil the right to education. importantly, children born of young mothers are at increased risk for stunting as these age groups are more active and involved in various income generating activities while the age of their children reflects a period of high risk. similarly, the children from households having no access to irrigation and livestock are likely to be at a higher risk of stunting. this substantiates the longstanding fact that livestock and irrigation are critical components of food security in this community. the findings suggest that children from households that practise inappropriate child eating habits and food taboos are at increased risk for underweight and wasting. this complements the results of a pocket study in the country (unpublished), which found that children from households practising the old age traditional feeding habits are twice as likely to be malnourished. this finding underscores the importance of feeding the child separately and confirms its usefulness in avoiding the risk of child malnutrition. in terms of the right to nutrition security, 44.5% of the children exposed by the study were found as having chronic malnutrition. this is a type of malnutrition that reflects an extended period of deprivation. the study also captured violations of a short-term nature which affected 9% of the children as depicted by prevalence of wasting. the need to have an enabling environment in which individuals can provide for their own and their families’ needs are stressed in the voluntary guidelines that provide a rich and very detailed set of recommendations and an agenda for action for the progress to realisation of the right to food (hidar & abate, 2005). emotional needs are children's need for the development of love, spirituality, independence, security, comfort, and sense of belonging. emotional needs can provide a sense of security if physical and psychological contact is fulfilled as early as possible by the mother (soetjiningsih, 2013). one of the needs that can be done immediately after birth is for the mother to hold the baby (skin to skin contact). the results showed that there was a significant relationship between fulfilment of the needs of caring for the incidence of stunted toddlers; based on a questionnaire given to respondents, there were things related to the success of breastfeeding, namely the question of early breastfeeding initiation. eighty per cent of respondents stated that when giving birth to a baby they were not immediately held to the breast of the mother or had no early breastfeeding experience. early initiation is the beginning of breastfeeding activities within the first hour after the baby is born. early initiation can also be interpreted as a way for babies to breastfeed the first hour after birth with their own efforts, in other words selfbreastfeeding instead of being breastfed. the way the baby initiates breastfeeding early is called the breast crawl or crawl looking for breasts. one of the benefits of imd is that the baby is more successful at breastfeeding exclusively and will be breastfed longer (roesli, 2008). one of the factors causing stunting is that the baby does not get exclusive breastfeeding (kemenkes, 2018). this is in line with (mawaddah, 2018) who states that there is a relationship between the ebm (early breastfeeding initialization) variable and exclusive breastfeeding. the odd ratio 9.17 (95% ci) shows that respondents who were not given breastfeeding initiation were 9.17 times more at risk of not getting exclusive breastfeeding compared with respondents who were initiated into early breastfeeding (mawaddah, 2018). stimulation needs are very important to support the growth and development of children. the more often the child gets stimulation, their development is faster than children who get little stimulation. during pregnancy, stimulation can be done from when the child is in the womb and after the child is born by giving breastmilk as early as possible. the child also needs stimulation as early as possible to develop motor skills, sensory awareness, social-emotional skills, language, cognitive processes, independence, creativity and leadership, and become moral and spiritual children (kemenke, 2018). based on the questionnaire, 88% of respondents did not provide stimulation to children. stimulation is stimulus that is carried out from newborn (even preferably when in the womb) and is carried out every day to stimulate all the sensory systems (hearing, vision, touch, smell, smell). in addition, it must also stimulate rough and smooth motion of feet, hands and fingers, invite communication, and stimulate feelings that delight babies and children. stimulation is important in children's growth and development. the results showed that children who lack of love and lack of stimulation will experience obstacles in their growth and development as well as difficulties in interacting with others. stimulation given to children during the first three years (golden age) will provide an enormous influence on the development of the brain and become the basis for forming life to come (setiawan, 2019). conclusion age, education, occupation and family income do not influence the occurrence of stunting in under five children, while the pattern of the fulfilment of the basic needs, which includes exclusive breastfeeding, e. surani et al. 30 | pissn: 1858-3598  eissn: 2502-5791 complementary feeding, emotional needs (early breastfeeding initiation and early stimulation) have a significant relationship with the incidence of stunting in toddlers. references direktur anggaran bidang pembangunan manusia dan kebudayaan. (2018). penanganan stunting terpadu tahun 2018. j. hidar, abate, g., kogi-makau, w., & sorensen, p. (2005). risk factors for child under-nutrition with a human rights edge in rural villages of north wollo, ethiopia. east african medical journal, 82(12), 625–630. kemenkes r.i. (2018). preventing of stunting is crucial. warta kermas kementrian kesehatan republik indonesia, 02(2018), 1–27. maria, f. n., & adriani, m. (2009). hubungan pola asuh, asih, asah dengan tumbuh kembang balita usia 13 tahun . the indonesian journal of public health, 6 (1): 24−29 mawaddah, s. (2018). hubungan inisiasi menyusu dini dengan pemberian asi ekslusif pada bayi. jurnal info kesehatan, 16(2), 214–225. rahmayana, ibrahim, i. a., & darmayati, d. s. (2014). hubungan pola asuh ibu dengan kejadian stunting anak usia 24-59 bulan di posyandu asoka ii wilayah pesisir kelurahan barombong kecamatan tamalate kota makassar tahun 2014. public health science journal, vi(2), 424–436. riskesdas. (2018). riset kessehatan dasar 2018. kementerian kesehatan republik indonesia. https://doi.org/10.1017/cbo9781107415324.0 04 roesli, u. (2008). inisiasi menyusu dini plus asi eksklusif. jakarta: pustaka bunda. setiawan. (2019). pengertian stimulasi, tujuan dan manfaat menurut para ahli. retrieved november 10, 2019, from https://www.gurupendidikan.co.id/pengertianstimulasi/ silas, l., rantetampang, a. l., tingginehe, r., & mallongi, a. (2018). the factors affecting stunting child under five years in sub province mimika. international journal of science & healthcare research, 3(2), 99–108. soetjiningsih. (2013). tumbuh kembang anak. jakarta: egc. unicef. (2010). asia-pacific regional workshop on the reduction of stunting through improvement of complementary feeding and maternal nutrition. wiyogowati, c. (2012). kejadian stunting pada anak berumur dibawah lima tahun tahun (0-59 bulan) di provinsi papua barat tahun 2010 (analisis data riskesdas 2010). universitas indonesia. ners vol 10 no 2 okt 2015.indd 256 pemberdayaan pasien berbasis experiential learning terhadap perilaku pencegah:an komplikasi akut dan kadar glukosa darah pasien dm (patients empowerment based on experimential learning to behavior of acute compilation prevention and blood glucose levels of patients dm) nunung ernawati*, suharto**, yulis setiya dewi** *poltekes rs dr. soepraoen malang, jl. sudanco supriyadi no. 22 malang. email: kinan_sweet@yahoo.com **fakultas keperawatan universitas airlangga, kampus c mulyorejo abstrak pendahuluan: komplikasi akut sering terjadi pada pasien diabetes mellitus (dm), sehingga untuk meningkatkan perilaku pencegahan komplikasi dan kontrol kadar gula darah, pasien perlu dibekali dengan pengetahuan tentang proses penyakit untuk membentuk sikap yang positif dan perilaku yang baik. tujuan dari penelitian ini adalah untuk menganalisis pengaruh pemberdayaan pasien berbasis experiential learning terhadap perilaku pencegahan komplikasi dan kadar gula darah pasien dm. metode: penelitian ini menggunakan desain quasi eksperimen dengan pendekatan pre-post test menggunakan kelompok kontrol. sampel pasien dm yang melakukan kontrol di poli rs mardi waluyo blitar yang diseleksi menggunakan consecutive sampling sebanyak 46 orang. data dikumpulkan menggunakan kuesioner dan checklist recall. analisa data menggunakan paired t test, wilcoxon signed rank test dan mann whitney. hasil: pemberdayaan pasien berbasis experiential learning mempunyai dampak yang signifikan terhadap perilaku pencegahan komplikasi. diskusi: metode experiential learning dapat diterapkan untuk meningkatkan self care pada pasien, terutama yang pernah mengalami komplikasi akut, sehingga pasien lebih mudah untuk mengimplementasikan perilaku pencegahan komplikasi dan mengontrol kadar gula darah. kata kunci: pemberdayaan pasien, experiential learning, perilaku pencegahan, kadar gula darah. abstract introduction: acute complications are common in patients with diabetes mellitus (dm). to improve the behavior prevention of complications and control blood sugar levels, patients need to be equipped with knowledge about the disease process to built a positive attitude and good behavior. the aim of this study was to analyze the effect of patient empowerment based on experiential learning behavior on the prevention of complications and blood sugar levels. methods: this study used a quasi-experimental design with pre-post test approach using control groups. samples were 46 diabetic patients who take control in poly rs mardi waluyo blitar taken by consecutive sampling. data were collected using a questionnaire and checklist recall. data were analyzed using paired t test, wilcoxon signed rank test and mann whitney. results: the patient empowerment-based experiential learning have a significant impact on the behavior of prevention of complications. discussions: methods of experiential learning can be applied to improve the self-care of patients, especially those who have experienced an acute complications, so the patient is easier to implement behavioral prevention of complications and control blood sugar levels. keywords: patient empowerment, experiential learning, behavioral prevention, blood glucose pendahuluan diabetes mellitus (dm) merupakan penyakit kronis yang sering menimbulkan komplikasi, sehingga pasien membutuhkan dukungan edukasi terkait perawatan dan pengobatan jangka panjang pada penderita dm, khususnya untuk mengurangi risiko timbulnya komplikasi. di rumah sakit mardi waluyo kota blitar program promosi kesehatan masyarakat di rumah sakit (pkmrs) belum berjalan secara optimal. komunikasi informasi edukasi (kie) yang dilakukan oleh pihak gizi saat penderita rawat inap masih kurang berkesinambungan dan belum dilakukan evaluasi/tindak lanjut dari kegiatan tersebut. program pelaksanaan kegiatan pkmrs yang tidak optimal dapat berdampak pada peningkatan jumlah pasien yang mengalami komplikasi. prevalensi kejadian diabetes mellitus di jawa timur berdasarkan laporan profil ke sehat a n propi n si jawa ti mu r 2012 menjelaskan bahwa dari 24 rumah sakit tipe 257 pemberdayaan pasien berbasis experiential learning (nunung ernawati, dkk) b kasus terbanyak masih tergolong penyakit degeneratif peringkat 2 adalah dm (102,339 kasus) dan kasus rawat jalan terbanyak juga penyakit dm (35.028 kasus). rumah sakit mardi waluyo merupakan salah satu rs daerah tipe b yang mempunyai catatan peningkatan kunjungan pasien dm. hasil st udi pendahuluan berdasarkan catatan rekam medis igd rs mardi waluyo kota blitar selama tahun 2014 tercatat kunjungan pasien yang mengalami kedaruratan diabetik yaitu hipoglikemia sejumlah 223 kasus dan hiperglikemia sejumlah 106 kasus. sedangkan catatan medis poli penyakit dalam tercatat kunjungan pasien dm selama tahun 2014 tercatat 2485 pasien, sedangkan tahun 2015 per 1 pebruari sudah mencapai angka kunjungan 1035 (data rekam medis poli penyakit dalam rs mardi waluyo kota blitar, 2015). menurut perkeni (2006) salah satu pilar dalam penanganan dm adalah pendidikan kesehatan. menurut tomey dan alligood (2010) bahwa perawat dapat memberikan bantuan kepada pasien yang mengalami health deviation of self care requisites yaitu kebutuhan akan self care yang muncul karena seseorang dalam keadaan sakit atau terluka, mempunyai bentuk patologis yang spesifik ter masu k ketidak mampuan dan berada pada diagnosis dan penatalaksanaan medis tertentu. perawat sebagai nursing agency dapat memberikan kebutuhan edukasi pada pasien dm tentang pengelolaan dan pengendalian penyakit dm. pengelolaan penyakit dm menur ut perkeni, 2011 terdiri dari 5 pilar antara lain pengaturan diet, latihan fisik, obat, monitoring glukosa dan edukasi. penyakit dm merupakan penyakit yang membut uhkan perawatan jangka panjang dan keterlibatan keluarga sehingga membutuhkan strategi perawatan, salah satunya melalui pemberdayaan pasien. pemberdayaan (empowerment) ber tujuan membentuk individu masyarakat menjadi mandiri yang meliputi kemandirian bertindak dan mengendalikan apa yang mereka lakukan demi penyelesaian pemecahan masalah yang dihadapi dengan menggunakan daya atau kemampuan yang dimiliki (sulistiyani, 2004). model pembelaja ran e xper ient ial mendefinisikan pembelajaran sebagai sebuah proses yang didapatkan melalui kombinasi antara memperoleh pengalaman (grasping e x p e r i e n c e) d e ng a n m e nt r a n sfo r m a si pengalaman (transformation of experience) (adam, et al., 2004). proses pembelajaran bermula dari adanya suatu pengalaman yang diobservasi dan direfleksikan. dari hasil proses tersebut, individu akan membentuk konsepkonsep abstrak yang kemudian dicobakan pada berbagai situasi baru. mencoba menerapkan pada situasi baru suatu konsep abstrak yang telah dibentuk, memberikan suatu pengalaman baru lagi bagi individu, demikian seterusnya proses pembelajaran berlangsung, seperti sebuah siklus (achmat, 2005). bahan dan metode desain penelitian ini menggunakan quasy experiment pre post tes with control group design. populasi dalam penelitian ini adalah seluruh pasien dm yang kontrol ke poli penyakit dalam rs mardi waluyo kota blitar. sampel penelitian ini sejumlah 46 responden dibagi menjadi 23 responden kelompok perlak uan dan 23 responden kelompok kontrol. variabel dalam penelitian terdiri dari variabel dependen yaitu perilaku pencegahan komplikasi akut dan kadar glukosa darah, sedangkan var iabel independen adalah pemberdayaan berbasis experiential learning. instrumen penelitian menggunakan kuesioner untuk mengukur pengetahuan, rating scale questions untuk mengukur skala sikap dan lembar observasi recall untuk mengukur t i nd a ka n ser t a alat glucometer u nt u k pemeriksaan kadar glukosa darah puasa dan glukosa darah 2 jam post prandial. penelitian dilakukan di poli penyakit dalam rs mardi waluyo kota blitar setiap hari selasa dan kamis, selama 4 minggu. intervensi pada kelompok perlakuan dilakukan dengan memberikan pemberian materi tentang konsep diabetes, pencegahan d a n p e n a n g a n a n h i p o g l i k e m i a d a n hiperglikemia dilakukan oleh peneliti dan trainer, pelatihan tentang pengaturan diet oleh 258 jurnal ners vol. 10 no. 2 oktober 2015: 256–264 tim gizi dan teknik pemeriksaan darah secara mandiri difasilitasi oleh peneliti dan perawat poli penyakit dalam, peneliti memberikan kalender kesehatan untuk setiap responden. sedangkan pada kelompok kontrol perlakuan dilakukan setelah selesai proses penelitian. pengolahan data menggunakan analisis deskriptif dengan persentase, mean, median, standar deviasi dan kooef isien var iasi. pengujian hipotesis menggunakan analisis inferensial dengan uji paired t-test, wilcoxon signed rank test dan analisis antar kelompok menggunakan mann-whitney. hasil tidak ada perbedaan yang signifikan antara pengetahuan, sikap dan tindakan responden pada kedua kelompok penelitian sebelum diberikan pemberdayaan pasien dm berbasis experiential learning pada kelompok perlakuan (tabel 1). hasil uji wilcoxon menunjukkan ada perbedaan yang signifikan pada tindakan responden kelompok perlakuan sebelum dan sesudah dilakukan pemberdayaan pasien berbasis experiential learning (tabel 2). hasil uji mann whitney didapatkan perbedaan yang signifikan pada tindakan responden setelah diberikan perlakuan pada kedua kelompok penelitian (tabel 3). tabel 4 menunjukkan bahwa tidak ada perbedaan yang signifikan kadar glukosa puasa dan 2 jam post prandial sebelum diberikan pemberdayaan berbasis experiential learning. kadar glukosa 2 jam post prandial menunjukkan perbedaan yang signifikan antara sebelum dan sesudah diberikan pemberdayaan berbasis experiential learning pada kelompok perlakuan seperti yang ditunjukkan pada tabel 5. sedangkan pada tabel 6 terlihat tidak ada perbedaan yang signifikan pada kelompok perlak uan dan kelompok kont rol kadar glukosa puasa dan 2 jam post prandial sesudah diberikan pemberdayaan berbasis experiential learning. tabel 1. pengaruh pemberdayaan pasien berbasis experiential learning terhadap pengetahuan, sikap dan tindakan sebelum diberikan perlakuan pada kelompok penelitian di poli penyakit dalam rumah sakit mardi waluyo kota blitar bulan mei–juni 2015 no variabel kel. perlakuan kel. kontrol hasil uji mann whitney mean sd mean sd p value 1. pengetahuan pre 21,56 3,64 pre 19,17 3,36 0,104 2. sikap pre 61,04 7,94 pre 47,2 6,23 0,559 3. tindakan pre 12,83 3,24 pre 11,35 2,77 0,135 tabel 2. pengaruh pemberdayaan pasien berbasis experiential learning terhadap pengetahuan, sikap dan tindakan sebelum dan sesudah diberikan perlakuan pada kelompok penelitian di poli penyakit dalam rumah sakit mardi waluyo kota blitar bulan mei–juni 2015 no variabel kel. perlakuan kel. kontrol mean sd mean sd 1. pengetahuan pre 21,56 3,64 pre 19,17 3,36 post 23,61 1,77 post 20,22 2,61 hasil uji wilcoxon þ-value 0,257 þ-value 0,046 2. sikap pre 61,04 7,94 pre 47,2 6,23 post 72,86 6,98 post 46,9 6,29 hasil uji wilcoxon þ-value 0,157 þ-value 0,317 3. tindakan pre 12,83 3,24 pre 11,35 2,77 post 14,95 2,91 post 11,61 2,76 hasil uji wilcoxon þ-value 0,018 þ-value 0,317 259 pemberdayaan pasien berbasis experiential learning (nunung ernawati, dkk) tabel 6. pengaruh pemberdayaan pasien berbasis experiential learning terhadap kadar glukosa sesudah diberikan perlakuan di poli penyakit dalam rumah sakit mardi waluyo kota blitar bulan mei–juni 2015 no variabel kel. perlakuan kel. kontrol hasil uji mann whitney mean sd mean sd þ-value 1. glukosa puasa post 151,7 65,3 post 164,8 69,3 0,385 2. g l u k o s a 2 j a m post prandial post 171,7 68,14 post 169,3 51,69 0,733 tabel 3. pengaruh pemberdayaan pasien berbasis experiential learning terhadap pengetahuan, sikap dan tindakan sesudah diberikan perlakuan pada kelompok penelitian di poli penyakit dalam rumah sakit mardi waluyo kota blitar bulan mei –juni 2015 no variabel kel. perlakuan kel. kontrol hasil uji mann whitney mean sd mean sd þ-value 1. pengetahuan post 23,61 1,77 post 20,22 2,61 0,154 2. sikap post 72,86 6,98 post 46,9 6,29 0,374 3. tindakan post 14,95 2,91 post 11,61 2,76 0.000 tabel 4. pengaruh pemberdayaan pasien berbasis experiential learning terhadap kadar glukosa sebelum diberikan perlakuan di poli penyakit dalam rumah sakit mardi waluyo kota blitar bulan mei–juni 2015 no variabel kel. perlakuan kel. kontrol hasil uji mann whitney mean sd mean sd p value 1. glukosa puasa pre 179,7 77,02 pre 146,3 35,49 0,191 2. glukosa 2 jam post prandial pre 231,8 153,6 pre 193,2 65,3 0,629 tabel 5. pengaruh pemberdayaan pasien berbasis experiential learning terhadap kadar glukosa sebelum dan sesudah diberikan perlakuan di poli penyakit dalam rumah sakit mardi waluyo kota blitar bulan mei–juni 2015 no variabel kel. perlakuan kel. kontrol mean sd mean sd 1. glukosa puasa pre 179,7 77,02 pre 146,3 35,49 post 151,6 65,3 post 164,8 69,3 hasil uji paired t-tes þ-value 0,059 wilcoxon þ-value 0,584 2. g l u k o s a 2 j a m p o s t prandial pre 231,8 153,6 pre 193,2 65,3 post 171,7 68,1 post 169,3 51,69 hasil uji wilcoxon test þ-value 0,012 paired t-test þ-value 0,068 260 jurnal ners vol. 10 no. 2 oktober 2015: 256–264 pembahasan hasil penelitian didapatkan tidak ada perbedaan yang signifikan pada pengetahuan responden kelompok perlakuan sebelum dan sesudah dilakukan pemberdayaan pasien berbasis experiential learning. hasil penelitian pemberdayaan berbasis experiential learning ini bertolak belakang dengan teori yang dikemukakan oleh roger (1974) dalam effendi dan makhfudli (2009) yang menyatakan bahwa pengkondisian pembelajaran akan terjadi perubahan perilaku seseorang dimulai dari perubahan tingkat pengetahuan. selain itu juga hasil penelitian ini tidak mendukung hasil penelitian-penelitian sebelumnya seperti hasil penelitian dari laili (2012) yang menyatakan bahwa setelah dilakukan dsme mengenai meal planning, responden menjadi tahu jenis makanan yang dikonsumsi banyak dan makanan yang sebaiknya dikurangi. perubahan pengetahuan pada responden kelompok perlakuan kurang bermakna karena pengetahuan sebelum dilakukan pemberdayaan berbasis experiential learning mayoritas sudah baik 20 responden (86,9%) dan sesudah diberikan pemberdayaan berbasis experiential learning mayoritas pengetahuan baik sejumlah 22 (95,6%). menurut notoatmodjo, 2003, menyatakan bahwa pengetahuan dipengaruhi berbagai faktor seperti usia, pendidikan dan pengalaman. faktor lain yang menjadi penyebab tidak signifikannya pengetahuan responden adalah tingkat pendidikan responden mayoritas adalah lulusan pergur uan tinggi sejumlah 10 responden (43,5%), seluruh responden mayoritas sudah per nah ter papar infor masi baik petugas kesehatan, majalah/koran, televisi maupun dari teman/saudara dan dari segi sosial ekonomi mayoritas responden adalah golongan pekerja baik pns maupun swasta dengan pendapatan minimal 2–4 juta/bln, hal diatas mengandung makna bahwa kemampuan responden dalam menyediakan sarana prasarana fasilitas kesehatan dan informasi sangat terjangkau dan mendukung responden memiliki pengetahuan yang baik mengenai pencegahan komplikasi akut dm. pada pengukuran akhir yang dilakukan pada kelompok perlakuan masih terdapat 1 orang (4,4%) responden memiliki pengetahuan yang cukup, hal ini dapat disebabkan karena faktor usia di mana pada kelompok perlakuan ada beberapa responden berada pada rentang usia presenil yaitu (46–55 tahun) usia yang mulai menunjukkan penurunan fungsi ingatan, daya tangkap dan pola berpikir, pada usia ini individu lebih mengutamakan ketenangan jiwa daripada kesehatan. peningkatan pengetahuan dari kategori cukup ke kategori baik pada kelompok kontrol dapat saja dikarenakan kelompok kontrol tidak mendapat pemberdayaan berbasis experiential learning tetapi responden tetap terpapar oleh berbagai informasi baik dari petugas kesehatan, majalah, koran, televisi maupun teman/saudara, kebebasan mengakses informasi dan mayoritas usia produktif di mana, pada rentang usia ini individu lebih aktif dan lebih banyak menggunakan waktunya untuk mengakses segala macam informasi demi mempersiapkan kesuksesannya dihari tua. b e r d a s a r k a n h a l d i a t a s d a p a t disimpulkan bahwa metode experiential learning menjadi kurang tepat jika diterapkan pad a i ndividu-i ndividu yang mem ili k i pengetahuan baik karena prinsip metode experiential learning lebih ditekan kan pada proses pengintegrasian pengalamanpengalaman yang dimiliki individu menjadi suatu pengalaman dan pengetahuan baru, yang dapat mereka gunakan untuk memecahkan masalah-masalah yang mereka hadapi, sehingga tingkat pengetahuan yang sudah baik tersebut akan lebih mendukung terbentuknya sikap dan tindakan responden. berdasarkan hasil penelitian didapatkan tidak ada perbedaan yang signifikan pada sikap responden kelompok perlakuan sebelum dan sesudah dilakukan pemberdayaan pasien berbasis experiential learning. hasil penelitian ini tidak mendukung teori yang dikemukakan oleh azwar (2003) yang menyatakan bahwa edukasi kesehatan mer upakan suatu bentuk persuasi dalam usaha melakukan perubahan sikap dengan 261 pemberdayaan pasien berbasis experiential learning (nunung ernawati, dkk) memasukan ide, pikiran, atau fakta melalui pesan komunikasi. pesan tersebut secara sengaja disampaikan untuk menimbulkan kontradiksi dan in konsistensi di antara komponen sikap sehingga menggangg u kestabilan sikap dan membuka peluang terjadinya perubahan sikap yang diharapkan. per ubahan si kap responden pada kelompok perlakuan kurang bermakna karena sebelum diberikan pemberdayaan berbasis experiential learning mayoritas responden kelompok perlakuan sudah memiliki sikap positif sejumlah 12 responden (52,2%) dan sesudah diberikan pemberdayaan terdapat perubahan sikap positif menjadi 15 responden (65,2%), hal ini dapat disebabkan karena pengetahuan yang baik dari responden maka akan terbentuk sikap yang lebih baik pula karena konsistensi kognisi dapat membantu individu dalam melakukan pertimbangan akan hal yang baik/buruk dan kematangan pribadi seseorang. duk ungan keluarga juga semakin memperk uat terbent uk nya sikap positif responden, hal ini terbukti saat dilakukan kunjungan rumah anggota keluarga mayoritas sangat terbuka dengan kehadiran petugas/ peneliti dan aktif bertanya. di samping itu pengalaman pribadi yang melibatkan emosional seperti pengalaman responden mengalami kejadian hiperglikemia dan hipoglikemia, mayoritas responden pada kelompok perlakuan pernah mengalami kejadian hiperglikemia dan hipoglikemia > 3 kali, pengalaman yang tidak menyenangkan bagi pasien ini akan meninggalkan kesan kuat sehingga lebih mudah membentuk sikap yang positif terhadap pencegahan komplikasi akut dm. pada pengukuran akhir pada kelompok perlakuan masih didapatkan sikap negatif seju mlah 8 responden (34,8%) hal ini dimungkinkan karena masih ada beberapa responden yang masih kurang mempunyai pengalaman dalam menangani kejadian komplikasi akut dm, serta masih ada beberapa responden yang hanya mengandalkan informasi yang diberikan oleh petugas kesehatan, hal ini bisa menjadi penyebab terbatasnya pengetahuan responden karena pengaruh berbagai sumber informasi dapat mengarahkan opini seseorang untuk membentuk suatu pandangan positif atau negatif terhadap suatu objek tertentu. perubahan yang terjadi pada kelompok kont rol t id a k sebesa r pa d a kelompok perlakuan kemungkinan karena masih ada responden yang tidak mendapat dukungan dari keluarganya dan mungkin pula ada dukungan keluarga yang tidak berkelanjutan dan mayoritas pengalaman tentang kejadian hiperglikemia dan hipoglikemia masih kurang berkisar 1-3 kali. b e r d a s a r k a n h a l d i a t a s d a p a t m e m b e r i k a n m a k n a b a h w a m e t o d e experiential learning k urang tepat jika diterapkan pada individu-individu yang memiliki tingkat pengetahuan baik karena semakin baik pengetahuan seseorang dapat menunjang pembentukan sikap terhadap self care mengenai pengendalian kadar gula darah menjadi lebih baik sehingga komplikasi dapat dicegah berdasarkan hasil penelitian pada kelompok perlakuan didapatkan ada perbedaan ya ng sig n if i k a n t i nd a k a n pencega ha n kompli kasi ak ut sebelu m dan sesudah diberikan pemberdayaan pasien dm berbasis experiential learning. hal ini ditunjukkan dengan adanya perubahan tindakan sesudah diberikan pemberdayaan pada kelompok perlakuan yaitu baik 10 responden (43,5%) dan cukup 12 responden (52,2%). hasil penelitian ini sesuai dengan hasil penelitian dari laili (2012) yang menyatakan bahwa ada edukasi dengan pendekatan prinsip dsme berpengaruh terhadap tindakan dalam mematuhi diet. hasil penelitian ini juga mendukung teori yang dikemukakan oleh skinner dalam notoatmodjo (2003) bahwa perilaku merupakan respons seseorang terhadap stimulus atau objek, namun dalam memberikan respons tergantung dari karakteristik dan faktor-faktor lain individu tersebut. penerimaan perilaku baru harus didasari oleh pengetahuan sehingga perilaku tersebut bersifat langgeng (long lasting). secara teori memang perubahan perilaku atau mengadopsi perilaku baru itu mengikuti tahap-tahap yaitu melalui proses perubahan: pengetahuan (knowledge)-sikap 262 jurnal ners vol. 10 no. 2 oktober 2015: 256–264 (attitude)-tindakan (practice). namun beberapa penelitian menunjukkan bahwa proses tersebut tidak selalu seperti teori diatas (k-a-p), bahkan dalam praktek sehari-hari terjadi sebaliknya, artinya seseorang telah berperilaku baik/ positif meskipun pengetahuan dan sikapnya masih negatif. selain itu menurut lawrence green dalam notoatmodjo (2007) menyatakan bahwa perilaku ditentukan oleh 3 faktor yaitu faktor predisposisi (pengetahuan, sikap, nilai dan keyakinan), faktor pemungkin (sarana dan prasarana/fasilitas untuk terbentuknya perilaku sehat) dan faktor penguat (dukungan keluarga/teman/tokoh/kelompok, petugas kesehatan, jaminan kesehatan dan pengambil keputusan). proses pemberdayaan pasien berbasis experiential learning dilakukan secara bertahap melalui pemberian materi mengenai penyakit dan penanganannya, pelatihan pengaturan dan penyediaan diet dm, tata cara pemeriksaan dan monitoring kadar glukosa darah puasa dan 2 jam post prandial, diskusi antar responden d an pet ugas dengan mengi nteg rasi kan pengalaman responden mengenai tindakan pencegahan dan penanganan hiperglikemia dan hipogikemia, hal ini dapat memperkuat pema ha ma n d a n keya k i na n responden dalam bertindak mengatur diet, latihan fisik, pemeriksaan kadar glukosa sendiri. pelatihan dengan pendekatan experiential learning ini sangat tepat dilakukan pada individu yang sudah mempunyai pengalaman-pengalaman mengalami komplikasi akut dm karena responden dapat aktif bertukar informasi antar responden sehingga dapat meningkatkan internalisasi pengalaman dan pengetahuan baru menjadi suatu bentuk tindakan yang positif dalam meningkatkan kemampuan self care responden. fasilitas kalender kesehatan yang diberikan peneliti dapat membantu ingatan responden dalam pengaturan diet, pencegahan dan penanganan komplikasi akut dalam jangka waktu yang lama. faktor penguat yang ada pada kelompok perlakuan adalah seluruh responden mendapat dukungan keluarga, di mana keluarga sebagai sumber support sistem yang penting bagi penyandang dm, hampir seluruh 20 responden (86,9%) sudah memiliki jaminan kesehatan baik berupa bpjs maupun swasta, pengaruh tokoh sangat penting dalam perubahan perilaku seseorang ke arah yang lebih sehat, dari data hasil penelitian seluruh responden (100%) tokoh yang berpengaruh adalah petugas kesehatan, kemudian keberadaan dan keterjangkauan fasilitas kesehatan juga sangat mendukung terlaksananya perubahan perilaku, mayoritas ketersediaan dan keterjangkauan pelayanan kesehatan dari r umah responden adalah ≤ 5 km, sehingga sangat memungkinkan untuk mencapai layanan fasilitas kesehatan. pa d a peng u k u r a n a k h i r sesud a h diberikan pemberdayaan berbasis experiential learning pada kelompok perlakuan juga m e nu nju k k a n b a hw a m a si h t e r d a p a t tindakan cukup 12 (52,2%) dan 1 responden (4,3%) tindakannya masih kurang, hal ini kemungkinan dikarenakan kebiasaan dari beberapa responden yang mengakui bahwa masih sering lupa mematuhi prinsip diet jika ada undangan yasinan ataupun selamatan, budaya malu membawa bekal makanan saat perjalanan di luar r umah dan tidak mengonsumsi oho ataupun insulin sesuai jadwal saat sedang perjalanan karena ada kek hawatiran akan mengalami kejadian hipoglikemia di jalan. perubahan tindakan pada kelompok kontrol tidak terlalu bermakna, hanya terjadi pada kategori cukup dan kurang, hal ini kemungkinan disebabkan pada kelompok kontrol tidak mendapat pemberdayaan berbasis experiential learning dan tidak mendapat fasilitas kalender kesehatan selama proses penelitian, sehingga informasi partial yang diterima dapat menyulitkan responden dalam menerapkan informasi yang diterima ke dalam bentuk tindakan nyata berdasarkan hasil penelitian didapatkan tidak ada perbedaan yang signifikan kadar glukosa darah 2 jam post prandial pada kelompok perlakuan dan kelompok kontrol sebelum dan sesudah diberikan pemberdayaan berbasis experiential learning. hasil penelitian ini sesuai dengan teori menurut perkeni, 2011, yang menjelaskan bahwa penanganan pasien diabetes mellitus berpedoman pada 5 pilar penanganan dm 263 pemberdayaan pasien berbasis experiential learning (nunung ernawati, dkk) antara lain diit, latihan f isik, program pengobatan, monitoring kadar glukosa dan edukasi pada penderita diabetes mellitus. monitoring glukosa pada penderita dm dilakukan dengan pemeriksaan glukosa puasa, glukosa 2 jam setelah makan ( post prandial), untuk monitoring 2 jenis pemeriksaan diatas dilakukan setiap bulan sedangkan untuk kadar glukosa hb a1c dilakukan setiap 3 bulan sekali. kadar glukosa dalam darah dipengaruhi oleh banyak faktor antara lain asupan makanan/diit, latihan fisik, obat-obat yang dikonsumsi. terdapat peningkatan pengukuran akhir kadar glukosa 2 jam post prandial sesudah diberikan pemberdayaan rata-rata 171,7 namun hal ini masih diambang batas normal, hal ini didukung oleh pengetahuan responden tentang pencegahan komplikasi mayoritas baik, sikap responden terhadap pencegahan komplikasi akut mayoritas positif, kedua hal diatas membantu terbentuknya perilaku responden dalam pencegahan komplikasi akut juga mayoritas baik, sehingga pencapaian 5 pilar penanganan dm dapat terlaksana yang dibuktikan dengan kadar glukosa darah baik glukosa puasa maupun glukosa 2 jam post prandial sebelum dan sesudah diberikan pemberdayaan cukup terkontrol. perubahan kadar glukosa 2 jam post prandial ini dipengaruhi oleh banyak hal antara lain: konsumsi obat-obatan dm, sebagian besar mendapatkan obat kombinasi antara oho dan insulin dengan terapi kombinasi ini diharapkan pasien memperoleh kendali glukosa darah yang baik, tentunya dilakukan bersamaan dengan pengaturan diit dan kegiatan jasmani. pengendalian kadar glukosa darah pada kelompok perlakuan ini juga didukung oleh sebagian besar melaksanakan diet dm 18 responden (78,2%) penyandang dm harus melakukan diet sesuai jumlah kalori yang masuk ke dalam tubuh menentukan kadar glukosa darah. prinsip penanganan dm pada hakikatnya adalah perubahan gaya hidup atau lifestyle ke arah yang lebih sehat, seperti berupaya mencapai berat badan ideal, mengik uti diet khusus diabetes, makanan atau diet merupakan factor utama yang berhubungan dengan peningkatan kadar glukosa darah pada pasien diabetes terutama setelah makan, sebagian responden melakukan latihan fisik 1-2×/minggu sejumlah 12 orang (52,2%) latihan fisik yang dilakukan oleh penderita dm dapat membantu tubuh melakukan peningkatan penggunaan energi/pemecahan penggunaan karbohidrat. sela m a mela k u k a n lat i h a n ot ot menjadi lebih aktif dan terjadi peningkatan p e r me abi l it a s me mbr a n se r t a a d a nya peningkatan aliran darah akibatnya membran kapiler lebih banyak yang terbuka dan lebih banyak reseptor insulin yang aktif dan terjadi pergeseran penggunaan energi oleh otot yang berasal dari sumber asam lemak ke penggunaan glukosa dan glikogen otot. aktivitas fisik meningkatkan transport glukosa melalui glucose transporter-4 (glut4) ke dalam membran sel yang memungkinkan terjadinya mekanisme peningkatan amp otot. amp kinase menyebabkan perubahan metabolisme termasuk metabolisme glukosa. hampir selur uh responden mendapatkan du k u ngan keluarga dalam pengobat an. keluarga mer upakan sistem yang paling penting dalam perawatan pasien, dukungan yang berkesinambungan dapat meningkatkan minat pasien dalam pengendalian kadar glukosa darah simpulan dan saran simpulan pemberdayaan berbasis experiential learning mampu meningkatkan tindakan pencegahan komplikasi akut pasien diabetes mellitus. saran peneliti yang akan d at ang dapat melakukan penelitian dengan metode kohort sehingga dapat mengamati perubahan perilaku pencegahan komplikasi akut dan dengan waktu yang lebih lama dapat diperoleh data tentang pengendalian kadar glukosa darah secara lebih valid. 264 jurnal ners vol. 10 no. 2 oktober 2015: 256–264 kepustakaan adam, a.b., kayes, d.c. & kolb, d.a., 2004. experiential learning in teams. [online] available at: http://www.learning from experience.com/research_llibrary azwar, s., 2011. sikap manusia, teori, dan pengukurannya. yogyakarta: pustaka karya. achmat, z., 2005. efektif itas pelatihan penge mbangan ke pr ibadian dan kepemimpinan dalam meningkatkan kepercayaan diri mahasiswa baru umm tahun 2005/2006. laporan penelitian. malang: lembaga penelitian universitas muhamadiyah malang universitas muhamadiyah malang. data rekam medis poli penyakit dalam rs mardi waluyo kota blitar, 2015. effendi, f & makhfudli. 2009. keperawatan kesehatan komunitas: teori dan praktik dalam keperawatan. jakarta: salemba medika. laili, n.r., dewi, y.s. & widyawati, i.y., 2012. edukasi dengan pendekatan prinsip diabetes self management education (dsme) meningkatkan perilaku kepatuhan diet pada penderita diabetes mellitus tipe 2. jurnal ners unair, 8. notoatmodjo, s., 2003. pendidikan dan perilaku kesehatan. jakarta: pt. rineka cipta. notoatmodjo, s., 2005. promosi kesehatan. jakarta: pt. rineka cipta. nursalam, 2013. metodologi penelitian ilmu keperawatan. jakarta: salemba medika. perkeni, 2008. pedoman teknis dan tata laksana penyakit diabetes mellitus. [online] departemen kesehatan ri. perkeni, 2011. pedoman teknis dan tata laksana penyakit diabetes mellitus. [online] departemen kesehatan ri. sulistiyani. 2004. kemitraan dan modelmodel pemberdayaan. yogyakarta: gala media. bibliography \l 1057 tomey, a.m. & alligood, m.r., 2010. nursing theorists and their work. vii ed. missiouri: mosby elsevier. 236 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17110 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review predictive risk factors of smartphone addiction in adolescents: a systematic review abdul fauzi1, ah. yusuf1 and mundakir mundakir2 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 faculty of health science, universitas muhammadiyah surabaya, indonesia abstract introduction: smartphone addiction often occurs in adolescents. the purpose of this systematic review was to identify the predictors of smartphone addiction in adolescents. methods: the method used in this systematic review consisted of 5 stages: (1) the identification of the instruments used in the literature (database search); (2) the identification of the relevant literature based on the title and abstract; (3) the inclusion and exclusion criteria; (4) getting the full-text literature and (5) grading based on the literature component and the analysis of the selected instruments. the databases used in the literature search were scopus, pubmed, science direct and springer link from 2013 2018. the criteria for the included articles were that they used a crosssectional design and involved adolescents as the sample. results: 17 of 829 articles met the inclusion criteria. the predictors of smartphone addiction were broadly divided into 3, namely personal factors, interpersonal factors and behavioral factors. these 3 factors are related to one another. conclusion: it is necessary to do further research within a case-control study to strengthen this systematic review. article history received: december 26, 2019 accepted: december 31, 2019 keywords addiction; adolescents; risk factors; smartphone contact abdul fauzi  abdul.fauzi-2017@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: fauzi. a., yusuf, a., & mundakir, m. (2019). predictive risk factors of smartphone addiction in adolescents: a systematic review. jurnal ners, 14(3si), 236-241. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17110 introduction smartphone addiction is a problem that has received serious attention in recent years (h. lee, kim, & choi, 2017). smartphone addiction is more common in adolescents than in adults (haug et al., 2015). this is inseparable from the culture inherent in asian countries regarding adolescents and smartphone use (bbc, 2015). based on the research conducted by lee (2017) in south korea, the prevalence of smartphone addiction was found to total 35% of adolescents (c. lee & lee, 2017). problems with smartphone use more often occur from social networking sites, online games and chatting applications (s. j. lee, lee, & lee, 2016). the influence of smartphone addiction in adolescents was found to deplete academic performance(samaha & hawi, 2016). the number of smartphone users in indonesia is one of the largest in asia. the country ranked second after china, with the total of 100 million smartphone users (kominfo, 2014). adolescents comprise 30% out of 80% of the total citizen in indonesia (the percentage of internet users out of the total population) (kominfo, 2014). previous research conducted by palupi (“hubungan ketergantungan smartphone terhadap kecemasan pada mahasiswa fakultas diponegoro,” 2018) showed that as many as 71.5% of adolescent smartphone-users were moderately addicted, 16.8% were mildly addicted and 11.7% were severely intolerance. smartphone addiction in adolescents will have a negative effect on psychology and daily activities. evidence of the bad influence of smartphone addiction is the cause of decreased sleep quality, decreased academic achievement, depression and conflict (lian, you, & huang, 2016). another picture of teenage smartphone addiction is aggressive policies, low prices and poor communication with others (j. lee et al., 2018). the main prevention in reducing smartphone addiction in adolescents is by increasing self-control in the most important way in order to identify the factors that cause smartphone addiction (sun, liu and yu, 2018). the purpose of this https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 237 systematic review was to find out the predictors of smartphone addiction. materials and methods this systematic review followed the preferred reporting item for systematic reviews and metaanalyzes (prisma) guidelines (liberati et al., 2009b). search strategy the search for potential articles was conducted through electronic databases, namely scopus, pubmed, sciencedirect and springer link. the papers included a human model and were published in the english language. those that were published between 2013 2018 were included in this review. the keywords used were “smartphone addiction” and “adolescent” or “factor” or “predictor”. furthermore, cross-sectional research related to smartphone addiction was also searched for. only the studies that were related to smartphone addiction in adolescents were included. inclusion and exclusion criteria the inclusion criteria in the systematic review included the research design, research population and research outcomes. the research design here was a cross-sectional design. the population in this study was adolescents who experienced smartphone addiction. all of the variables were related to the incidence of smartphone addiction in adolescents. data extraction and quality of appraisal a total of 16 studies were selected and reviewed that met all of the eligibility criteria. the standard protocol used as a guideline for this systematic review was prisma as shown in figure 1 below (liberati et al., 2009a). the steps taken included (1) the removal of duplications, (2) the independent examination of the titles, abstracts and keywords, then removing the excerpts that were not relevant in accordance with the inclusion criteria (3), thetitles and abstracts that appear to meet the inclusion criteria and that were in accordance with the objectives of the systematic review were chosen if the journal had full text available and (4) the selection of cross-sectional study articles to reduce the risk of bias. the quality assessment of the articles used the jbi critical appraisal tools. systematic reviews that combine the process of critique and the assessment of the research evidence aim to assess the methodological quality of a given study and seek to determine the extent to which a study has discussed the possible bias in the criteria, research subjects, exposure measured, confounding factors, outcome measures and the statistical analysis used. there were as many as 8 items in the list of jbi critical appraisal tools for cross-sectional studies. the choice of answers consisted of "yes", "no", "unclear" and "not applicable". the allocation of each article was based on how many "yes" or “no” answers, which was very good. this assessment was combined with that of the other reviewers. if there were differences of opinion among the reviewers then this was completed in the next discussion phase. the allocation of scores for each article reviewed was based on how many "yes" or more answers were given, referring to the quality of the article that was very good. the purpose of this quality assessment was not to distinguish between the different levels of quality for the articles but to refer to systematic and standard processes that can help to provide high-quality reviews based on the existing topics. results study selection figure 1 summarizes the search results and the selection of the studies following the prisma guidelines (liberati et al., 2009b). the selection of journals based on the keywords used produced 829 articles; 664 articles found after duplication screening. following this, 542 were eliminated because of being irrelevant studies based on their titles and abstracts. a total of 122 articles with full text were taken and 106 were studies excluded because they did not meet the inclusion criteria. the results of the 16 studies were used to carry out a systematic review. study characteristic regarding teh 16 included studies, 12 were conducted in asia and 4 were conducted in europe. the included studies involved 1301 participants, consisting of 332 (25%) men and 969 (75%) women. the majority of studies recruited participants aged 10 to 29 years old. all of the studies adopted a crosssectional design. the total number of respondents in the selected literature were 29,534 and the respondents were aged between 10-29 years old. figure 1. literature search following the prisma diagram a. fauzi, et al. 238 | pissn: 1858-3598  eissn: 2502-5791 risk of bias the risk of bias judgment for each paper used the jbi appraisal tools. the results of the critical appraisal shows that 10 papers (62.5%) were considered to have a low risk of bias, 4 (25%) had a moderate risk of bias and 2 (12,5%) had a high risk of bias. the less obvious inclusion and exclusion criteria were the causes of the first source of bias. other than that, the confounding factors have not been identified as the other risk factors for bias. result of synthesis personal the personal factors in smartphone addiction include personality (cocorada, maican, cazan, & maican, 2018; gao, xiang, zhang, zhang, & mei, 2017), psychological problems such as anxiety, depression (chen et al., 2017; long et al., 2016), somatization and hostility symptoms (fırat et al., 2018), quality of life (kumcagiz, 2019), self-esteem (j. lee et al., 2018), stress (haug et al., 2015; long et al., 2016) and income (chen et al., 2017). based on the research conducted by cocorada (2018)(cocorada et al., 2018) on adolescents in romania, they stated that personalities with high neuroticism will increase the risk factors for smartphone addiction. high neuroticism tends to lead to difficulties when building relationships with other people. neurotics are not able to communicate with the people around them, so this will cause depression and decrease their quality of life (gao et al., 2017). according to chen's (2017) (chen et al., 2017) research, the risk factors for smartphone addiction significantly include anxiety, depression and sleep quality. the use of smartphones in adolescents who experience anxiety is done as an effort to reduce or eliminate the feelings of anxiety and depression in order to get pleasure (long et al., 2016). anxiety and depression also affect smartphone addiction through being able to adjust the frequency of the use of the smartphone (elhai, levine, dvorak, & hall, 2017). addiction will increase along with the frequency of using the smartphone (cocoradă, maican, cazan, & maican, 2018). psychological problems such as anxiety and depression are also related to emotional intelligence and coping styles (sun, liu, & yu, 2019). adolescents with low emotional intelligence and destructive coping styles will not be able to solve the problems faced day to day and they will seek to improve the behaviors that are considered to make themselves happy like playing on the smartphone (sun et al., 2019). smartphone addiction is also found in teens with low self-esteem. the use of smartphones is used as an effort to gain intimacy in the virtual world as an effort to build new self-confidence (j. lee et al., 2018). besides that, quality of life was found to be negatively correlated with smartphone addiction. the use of smartphones is used as an effort to improve the quality of life (kumcagiz, 2019). another personal factor is income. based on the research conducted by long et al. (2016)(long et al., 2016) on teens in china, smartphone addiction is related to the family income. this is related to the lifestyle of the adolescents. adolescents with a high family income tend to experience smartphone addiction. there are no financial restrictions that tend to increase the addictive behavior in adolescents (long et al., 2016). interpersonal the interpersonal factors that cause smartphone addiction include their relationships with their parents (fırat et al., 2018; c. lee & lee, 2017) and social support such as their school life (c. lee & lee, 2017). smartphone addiction will increase in teens who have problems with their parents. adolescents who have experienced domestic violence and parental addiction will increase their likelihood of smartphone addiction because of their exposure to the surrounding environment (kim & koh, 2018). in addition, smartphone addiction occurs in students who are far from their parents (haug et al., 2015). the loss of the role of the parents when it comes to controling adolescent behavior increases the risk of smartphone addiction (c. lee & lee, 2017). interpersonal relations with their peers whenn carrying out activities in school can improve individual satisfaction. individuals who take part in school activities with their friends will prefer real life rather than busying themselves with smartphones (c. lee & lee, 2017). based on the research conducted by lee and lee (2017)(c. lee & lee, 2017) on adolescents in korea, it was found that good peer support would reduce the smartphone addiction rate in adolescents. therefore, maintaining good relationships with their peers and schoolmates can prevent smartphone addiction in adolescents. low self-esteem also mediates peer relationships and smartphone addiction. self-esteem becomes a form of social control for determining good relations between peers (y. li, wang, yin, li, & li, 2018). behavior behavior in this systematic review included the duration and frequency of smartphone use (cha & seo, 2018; cocorada et al., 2018), the process of smartphone use (chen et al., 2017; cocoradă et al., 2018; elhai et al., 2017; s. j. lee et al., 2016), avoidant attachment (kim & koh, 2018), positive attitudes toward smartphone use (cocorada et al., 2018), motivation (c. lee & lee, 2017), reporting lower physical activity (haug et al., 2015), aggressive behavior (j. lee et al., 2018) and the need to belong (wang et al., 2017). the behavior of smartphone use is related to smartphone addiction (elhai et al., 2017). a longer duration of smartphone use will increase the risk of addiction (cha & seo, 2018). increased smartphone usage is also influenced by the motivation behind the smartphone use (c. lee & lee, 2017). the motive for using smartphones is, for men, to play games, watch videos and listen to music. for women, the motive for using smartphones is more related to the function of jurnal ners http://e-journal.unair.ac.id/jners | 239 communication and social media (chen et al., 2017). in addition, the assumption of smartphones being a need increases the risk of smartphone addiction. this need also moderates peer relationships with smartphone addiction. the high demand for smartphones will assume that smartphones have a positive impact, especially in relation to improving their social relationships with their peers (wang et al., 2017). this statement is consistent with the research conducted by cocoradă (2018), in that a positive assessment of smartphones is positively related to smartphone addiction. the duration of the smartphone usage, the positive assessment of smartphone usage and the motive behind using the smartphone also mediates the relationship between personality and smartphone addiction (cocorada et al., 2018). based on the research by haug (2015), smartphone addiction is more common in adolescents with little physical activity. reduced physical activity can be caused by the avoidance of other people. this is consistent with the research conducted by kim (2018), indicating that avoidant attachments are done to keep a distance from others and to avoid close relationships. increased activity actually occurs in terms of smartphone use such as user applications and online sites (j. lee et al., 2018). discussion this systematic review aimed to identify the predictors of smartphone addiction in adolescents. the articles used a homogeneous research design. there are several findings related to the predictor factor of smartphone addiction. smartphone addiction can be divided into 3, namely personal factors, interpersonal relationships and behavior. there are several important findings regarding the predicting factors of smartphone addiction in adolescents that will now be discussed in detail. interpersonal factors such as peer support both from their peers and parents greatly influence the personality and abilities of the adolescents. adolescents who have bad relationships with their peers will look for something to meet their interpersonal needs (c. lee & lee, 2017). in addition, the role of the parents is very important. parents who always give attention and affection and who supervise the adolescents will prevent the adolescents from reactions such as smartphone addiction. conversely, adolescents who are always blamed by their parents and parents who have great hopes for their children will hinder the growth and development of the adolescents. young children can become depressed both physically and psychologically. adolescents can experience disorders such as anxiety, depression and low selfesteem, which can go on to affect the coping system and personality of the adolescents (x. li, li, & newman, 2013). personalities with high neuroticism will increase the risk factors for smartphone addiction (gao et al., 2017). a closed individual will feel anxious when there is no access to the smartphone (cocorada et al., 2018). this is because a smartphone is a tool to meet their needs (wang et al., 2017). low emotional intelligence and destructive coping systems will not be able to effectively overcome emotional problems. this low emotional intelligence also increases the interpersonal problems in the individuals. adolescents with low emotional intelligence and emotion-focused coping styles will experience smartphone addiction in an effort to meet their social needs. they will more often use the internet facilities of smartphones as a way to fulfil their social needs anytime and anywhere (sun et al., 2019). motivation, the attitude related to and the duration of smartphone use will mediate the personal factors concerning smartphone addiction. strong motivation lies at the core of the problem at hand but there may be different contributions in terms of different abilities and opportunities within different situations (michie, van stralen, & west, 2011). the ability to engage in behavior also influences the motivation to be involved in it. a systematic review of the factors that cause smartphone addiction started from the interpersonal factors and personal factors, through to adolescent behavior. the limitations of this study do not present a risk bias table and some of the studies do not describe in detail the confounding factors in each study. in addition, there were several journals that were difficult to read. conclusion this systematic review explains that smartphone addiction is influenced by personal, interpersonal and behavioral factors. the interpersonal factors related to the people around them will trigger smartphone addiction. this is exacerbated if the adolescents have problems within themselves such as coping, anxiety, depression, low self-esteem, poor quality of life and a lack of emotional intelligence. the inability of adolescents to overcome their problems will increase their motivation and excessive use of smartphones. studies with case-control are needed to strengthen these systematic results. references bbc. (2015). asia’s smartphone addiction. cha, s. s., & seo, b. k. (2018). smartphone use and smartphone addiction in middle school students in korea: prevalence, social networking service, and game use. health psychology open. https://doi.org/10.1177/2055102918755046 chen, b., liu, f., ding, s., ying, x., wang, l., & wen, y. (2017). gender differences in factors associated with smartphone addiction: a cross-sectional study among medical college students. bmc psychiatry. https://doi.org/10.1186/s12888-0171503-z cocorada, e., maican, c. i., cazan, a. m., & maican, m. . a. fauzi, et al. 240 | pissn: 1858-3598  eissn: 2502-5791 (2018). assessing the smartphone addiction risk and its associations with personality traits among adolescents. children and youth services review 93, 345–354. cocoradă, e., maican, c. i., cazan, a. m., & maican, m. a. (2018). assessing the smartphone addiction risk and its associations with personality traits among adolescents. children and youth services review. https://doi.org/10.1016/j.childyouth.2018.08.00 6 elhai, j. d., levine, j. c., dvorak, r. d., & hall, b. j. (2017). non-social features of smartphone use are most related to depression, anxiety and problematic smartphone use. computers in human behavior. https://doi.org/10.1016/j.chb.2016.12.023 fırat, s., gül, h., sertçelik, m., gül, a., gürel, y., & kılıç, b. g. (2018). the relationship between problematic smartphone use and psychiatric symptoms among adolescents who applied to psychiatry clinics. psychiatry research. https://doi.org/10.1016/j.psychres.2018.09.015 gao, t., xiang, y. t., zhang, h., zhang, z., & mei, s. (2017). neuroticism and quality of life: multiple mediating effects of smartphone addiction and depression. psychiatry research. https://doi.org/10.1016/j.psychres.2017.08.074 haug, s., paz castro, r., kwon, m., filler, a., kowatsch, t., & schaub, m. p. (2015). smartphone use and smartphone addiction among young people in switzerland. journal of behavioral addictions. https://doi.org/10.1556/2006.4.2015.037 hubungan ketergantungan smartphone terhadap kecemasan pada mahasiswa fakultas diponegoro. (2018). jurnal kedokteran diponegoro. kim, e., & koh, e. (2018). avoidant attachment and smartphone addiction in college students: the mediating effects of anxiety and self-esteem. computers in human behavior. https://doi.org/10.1016/j.chb.2018.02.037 kominfo. (2014). kementerian komunikasi dan informatika. kumcagiz, h. (2019). quality of life as a predictor of smartphone addiction risk among adolescents. technology, knowledge and learning. https://doi.org/10.1007/s10758-017-9348-6 lee, c., & lee, s. j. (2017). prevalence and predictors of smartphone addiction proneness among korean adolescents. children and youth services review. https://doi.org/10.1016/j.childyouth.2017.04.00 2 lee, h., kim, j. w., & choi, t. y. (2017). risk factors for smartphone addiction in korean adolescents: smartphone use patterns. journal of korean medical science. https://doi.org/10.3346/jkms.2017.32.10.1674 lee, j., sung, m.-j., song, s.-h., lee, y.-m., lee, j.-j., cho, s.-m., … shin, y.-m. (2018). psychological factors associated with smartphone addiction in south korean adolescents. the journal of early adolescence, 38(3), 288–302. https://doi.org/10.1177/0272431616670751 lee, s. j., lee, c., & lee, c. (2016). smartphone addiction and application usage in korean adolescents: effects of mediation strategies. social behavior and personality. https://doi.org/10.2224/sbp.2016.44.9.1525 li, x., li, d., & newman, j. (2013). parental behavioral and psychological control and problematic internet use among chinese adolescents: the mediating role of self-control. cyberpsychology, behavior, and social networking. https://doi.org/10.1089/cyber.2012.0293 li, y., wang, k., yin, y., li, y., & li, s. (2018). relationships between family resilience, breast cancer survivors’ individual resilience, and caregiver burden: a cross-sectional study. international journal of nursing studies. https://doi.org/10.1016/j.ijnurstu.2018.08.011 lian, l., you, x., & huang, j. (2016). who overuses smartphones? roles of virtues and parenting style in smartphone addiction among chinese college students. computers in human behavior, 65, 92– 99. https://doi.org/https://doi.org/10.1016/j.chb.20 16.08. 027 liberati, a., altman, d. g., tetzlaff, j., mulrow, c., gøtzsche, p. c., ioannidis, j. p. a., … moher, d. (2009a). the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. plos medicine. https://doi.org/10.1371/journal.pmed.1000100 liberati, a., altman, d. g., tetzlaff, j., mulrow, c., gøtzsche, p. c., ioannidis, j. p. a., … moher, d. (2009b). the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. bmj (clinical research ed.). https://doi.org/10.1136/bmj.b2700 long, j., liu, t.-q., liao, y.-h., qi, c., he, h.-y., chen, s.b., & billieux, j. (2016). prevalence and correlates of problematic smartphone use in a large random sample of chinese undergraduates. bmc psychiatry, 16(1), 408. https://doi.org/10.1186/s12888-016-1083-3 michie, s., van stralen, m., & west, r. (2011). the behaviour change wheel: a new method for characterising and designing behaviour change interventions’. implementation science 6, p. 42. samaha, m., & hawi, n. s. (2016). relationships among smartphone addiction, stress, academic performance, and satisfaction with life. computers in human behavior. https://doi.org/10.1016/j.chb.2015.12.045 sun, j., liu, q., & yu, s. (2019). child neglect, psychological abuse and smartphone addiction among chinese adolescents: the roles of emotional intelligence and coping style. computers in human behavior. https://doi.org/10.1016/j.chb.2018.08.032 jurnal ners http://e-journal.unair.ac.id/jners | 241 wang, p., zhao, m., wang, x., xie, x., wang, y., & lei, l. (2017). peer relationship and adolescent smartphone addiction: the mediating role of selfesteem and the moderating role of the need to belong. journal of behavioral addictions. https://doi.org/10.1556/2006.6.2017.079 ners vol 10 no 1 april 2015.indd 61 pengalaman orang tua dalam penggunaan pengobatan alternatif pada anak yang menderita kanker di jakarta (parents experiences using alternative medicine on children suffering cancer in jakarta) hermalinda, yeni rustina**, enie novieastari** stikes nan tongga lubuk alung, d/a jalan raya padang bukittinggi km 32 lubuk alung, sumatera barat, telp. (0751) 96440, faks. (0751) 96971. email: ns_ilin@yahoo.com ** fakultas ilmu keperawatan universitas indonesia abstrak pendahuluan: pengobatan alternatif saat ini menjadi popular sebagai terapi yang diyakini dapat membantu mengobati kanker. metode: penelitian fenomenologi ini bertujuan untuk mengidentifi kasi pengalaman orang tua dalam penggunaan pengobatan alternatif pada anak yang menderita kanker. pengumpulan data dilakukan dengan wawancara mendalam terhadap delapan orang tua dan dianalisis dengan metode colaizzi. tema pada penelitian ini adalah dampak penyakit pada anak, upaya yang dilakukan orang tua, gambaran penggunaan pengobatan alternatif, efek pengobatan alternatif pada anak, makna penggunaan pengobatan alternatif dan harapan orang tua. hasil: tidak ada perubahan dan adanya efek jera dalam penggunaan pengobatan alternatif merupakan hal baru yang teridentifi kasi dalam penelitian ini. pembahasan: diharapkan tenaga kesehatan profesional dapat menyadari tentang penggunaan pengobatan alternatif pada anak dan memberikan informasi yang adekuat kepada orang tua tentang keefektifan dan efek merugikan dari pengobatan alternatif. kata kunci: pengalaman orang tua, pengobatan alternatif, anak yang menderita kanker abstract introduction: alternative medicine are very popular today as a therapy that are believed to treat cancer. a phenomenology study was carried out to identify the experince of parent’s in using alternative medicine for children with cancer. method: the method of data collection was indepth interview to eigth parents and data was analyzed by colaizii’s method. themes of this research are the impact of illness to children, parent’s effort, description of alternative medicine, the effect of alternative medicine for children, meaning of using alternative medicine and parents expectation. result: no benefi t effect for children and detterence effect in using alternative medicine are current fi ndings in this research. discussion: healthcare professional should concerned about using alternative medicine in children and providing adequate information regarding effectiveness and adverse effects of alternative medicine. keywords: parents experiences, alternative medicine, children with cancer pendahuluan kanker adalah salah satu penyakit kronis pada anak. kanker merupakan penyakit proliferasi sel-sel tumor yang mempengaruhi pertumbuhan sel normal, di mana terdapat gen penga k t iva si t u mor ya ng ma mpu menyebabkan proliferasi sel tidak terkendali jika ditransmisikan ke sel normal dan dapat mempengaruhi fungsi fi sik dan sosial dalam waktu yang lama (muscari, 2005). menurut national care institute (nci ) pada tahun 2007 di amerika lebih kurang 10.400 anak yang berusia di bawah lima tahun terdiagnosa kanker, dan sekitar 1.545 anak meninggal karena kanker. di indonesia, berdasarkan data registrasi pasien rawat inap di rumah sakit cipto mangunkusumo jakarta pada tahun 2010, dari 2435 anak yang dirawat tercatat sebanyak 933 (38,3%) kasus kanker pada anak usia 0–17 tahun. kasus terbanyak adalah leukemia dengan jumlah kasus sebanyak 664 (27,3%), 85 (3,5%) kasus lymphoma malignum, 81 (3,3%) kasus retinoblastoma, 53 (2,2%) kasus rabdomiosarkoma, 50 (2,1%) kasus neuroblastoma. masalah fi sik yang sering muncul pada anak dengan kanker di antaranya adalah kelelahan, nyeri, cachexia, anemia dan infeksi (ball & bindler, 2003). anak akan menyesuaikan diri dengan masalah f isik yang dialami akibat penyakit dan terapi yang diterimanya. selama beradaptasi dengan kondisi fisiknya, anak tetap berhubungan dengan teman, keluarga, pemberi perawatan kesehatan dan lingkungan sekitar (enskar & von essen, 2000). kegagalan dalam beradaptasi 62 jurnal ners vol. 10 no. 1 april 2015: 61–73 dengan kondisi fi sik dan pengobatan dapat mempengaruhi fungsi psikososial anak dan dapat memberikan respons yang berbeda-beda pada keluarga. efek penyakit kanker yang diderita anak bagi orang tua menimbulkan respons psikologis yang sangat penting dikaji dan pada akhirnya secara langsung dapat mempengaruhi reaksi anggota keluarga lain dan koping anak itu sendiri (hockenberry & wilson, 2009). keyakinan terhadap penyebab sakit dan pemeliharaan kesehatan merupakan bagian integral dari warisan budaya keluarga yang tidak bisa dipisahkan dengan keyakinan agama yang dianut. dalam konteks budaya, setiap individu akan mempertahankan tradisi lama dalam mempertahankan kesehatan yang salah satunya adalah dengan penggunaan pengobatan komplementer dan alter natif (niska & snyder dalam snyder & lindquist, 2006). pe n g o b a t a n k o m pl e m e n t e r d a n alternatif pada saat ini menjadi popular pada anak dengan kanker. pada umumnya atau sekitar 40–77% orang tua menggunakan satu atau lebih jenis pengobatan komplementer dan alternatif di western turkey, di mana pengg u naan herbal mer upakan metode yang paling banyak digunakan (gozum, arikan, & buy ukavci, 2007; karadeniz et al., 2007; genc et al., 2009). penggunaan pengobatan komplementer dan alter natif dapat memberikan perspektif yang berbeda di antara beberapa orangtua. penelitian yang dilakukan oleh fletcher dan clarke tahun 2004 mengidentifi kasi beberapa tema yaitu adalah: 1) orangtua tidak mendukung penggunaan pengobatan komplementer dan alter natif pada anak kanker; 2) orangtua mendukung pengg u na an pengobat an komplementer dan alternatif pada anak kanker; 3) bahwa dokter juga memberikan pandangan tentang penggunaan pengobatan komplementer dan alternatif pada anak kanker. pengobatan alternatif seperti dijelaskan di atas dimaksudkan sebagai pengobatan pengganti atau alternatif dari pengobatan medis yang sudah ada atau penggunaannya pada anak diber ikan tanpa pengobatan medis. hal ini harus dievaluasi oleh tenaga kesehatan karena saat ini belum ada standar dari kualitas produk pengobatan alternatif di indonesia. beberapa produk yang ada belum diketahui secara bermakna keamanan dan ke efektifannya terhadap penderita kanker, karena belum banyak diteliti secara ilmiah. menggali informasi dari orang tua atau care giver tentang perawatan pada anak yang menderita kanker terutama pengalaman menggunakan pengobatan alternatif pada anak merupakan hal yang penting untuk mengidentifi kasi dan merencanakan asuhan keperawatan yang dibutuhkan oleh keluarga dan anak dengan kanker. pengalaman tentang suatu tindakan atau fenomena merupakan hal yang unik, berbeda pada masing-masing individu dan tidak dapat diukur secara kuantitatif. metode penelitian ini bertujuan untuk menggali secara lebih mendalam tentang pengalaman orang tua dalam penggunaan pengobatan alternatif pada anak yang menderita kanker. rancangan penelitian adalah metode kualitatif dengan pendekatan fenomenologi deskriptif. delapan orang partisipan berpartisipasi dalam penelitian ini yang diseleksi dengan teknik purposive sampling. penelitian dilaksanakan di wilayah jakarta dan sekitarnya dengan mengambil partisipan yang menemani anak menjalani pengobatan di ruang perawatan anak departemen kesehatan anak rscm ja ka r t a. dalam mela k u kan penelit ian, peneliti menggunakan prinsip-prinsip dasar etik penelitian yaitu: respect for human dignit y seper ti autonomy, benef icience, nonmalefi cience, atau anonymity dan justice. wawancara mendalam dipilih dalam penelitian ini agar dapat mengeksplorasi secara mendalam mengenai penggunaan pengobatan alternatif pada anak dengan kanker. pertanyaan inti yang akan diajukan adalah dengan metode open-ended question seperti: “bisakah ibu menceritakan kepada saya ketika ibu pertama kali menggunakan pengobatan alternatif pada anak?. alat bantu yang digunakan selama pengumpulan data adalah tape recorder atau mp4, panduan wawancara, dan fi eld note. 63 pengalaman orang tua dalam penggunaan pengobatan alternatif (hermalinda, dkk.) a nalisis data pada penelitian ini menggunakan analisis tematis dengan metoda colaizzi (1978 dalam streubert & carpenter, 2003). tahapan analisis yang per t ama dilakukan adalah membaca semua deskripsi partisipan sebanyak tiga sampai empat kali sampai peneliti merasa yakin dan mengutip pernyataan signifi kan (kata kunci) dari data yang telah dikumpulkan. selanjutnya peneliti mencoba mencari makna dari setiap kata kunci untuk membentuk ketegori. dari kategori yang telah dirumuskan, peneliti kemudian mengorganisir makna yang berhubungan kedalam kelompok tema. berdasarkan tema awal yang didapatkan peneliti kemudian menemu i pa r t isipa n u nt u k mela k u ka n validasi. tahapan akhir dari analisis yaitu menggabungkan hasil validasi ke dalam deskripsi hasil analisis. hasil berdasarkan hasil deskripsi partisipan melalui wawancara mendalam, teridentifi kasi delapan tema yang selanjutnya akan dijelaskan tentang tema yang teridentifi kasi berdasarkan tujuan khusus yang diharapkan. respons dan keluhan anak sehubungan dengan penyakit tema 1: dampak penyakit pada anak kondisi sakit akan mempengar uhi ke m a m pu a n a n a k u nt u k b e r a d a p t a si d ala m mela k u ka n a k t ivit as d a n t ugas perkembangan nya. pad a penelit ian i n i setiap partisipan mengungkapkan dampak penyakit baik pada fi sik maupun psikologis anak. masalah fi sik yang dikeluhkan anak pada orang tua selama sakit mencakup nyeri, masalah muskolosketal, kelemahan, penurunan berat badan, pembesaran kelenjar dan jaringan, masalah hematologi, dan penurunan daya tahan tubuh. masalah fi sik yang dikeluhkan anak seperti terlihat pada pernyataan orang tua berikut ini: “...kalau dari sono udah ga karuan, sakitnya ngerasain kalau malam begitu.. sak it nya pokok nya semua badan sak it semuanya ya s..” (p4) “...lemes, udah lemes.. memang anaknya udah lemes kondisinya, udah loyo, udah tiduran aja.. trus itu, ya lemes juga banyak tiduran..” (p3)“...terakhir aja dia drop drop, putih semua (menunjuk ke seluruh tubuh an m dengan mengayunkan tangan), jadi ga ada, tangannya putih (menyentuh tangan).. (loh kok pada putih)...” (p7) selain masalah fi sik, partisipan juga mengungkapkan adanya masalah psikologis pada anak selama menjalani penyakitnya seperti malu, sedih, masalah sekolah, menarik diri dan emosi yang labil. beberapa pernyataan partisipan yang menyatakan hal ini adalah: “...habis mandi dijemur, dijemur matahari pagi.. ntar mau, nta ga.. makin lama makin kesini ga mau lagi, katanya (puyeng lagi ma, ga apa-apa ga dijemur).. apa malu kayaknya, saya liat dia lemes aja..” (p3) “...yo kawan-kawannyo biaso-biaso sajo.. cuman nyo jarang kalua.. nyo jarang kalua (cuma dia jarang keluar) soalnyo badan lagi gapuak tu malehnyo kalua...” (p8) upaya yang dilakukan orang tua pada saat pertama kali anak sakit dan saat menjalani pengobatan medis saat ini tema 2: reaksi orang tua saat pertama kali anak sakit reaksi orang tua pada waktu pertama kali anak sakit digambarkan oleh tiga sub tema yang diantaranya adalah membiarkan keluhan anak untuk sementara waktu, membawa anak ke pengobatan tradisional atau alternatif dan mencari bantuan pelayanan kesehatan. reaksi partisipan tersebut tergambar dalam pernyataan-pernyataan berikut ini: “...tapi kita ya namanya orang kampung ya, kita fi kirnya (ah kayanya gondongan biasa doang gitu), udah dibiarin seminggu, dah seminggu kok ga ilang gitu..” (p2) “...sebelum dirawat di rumah sakit, ni saya gendong ke tempat rumah dukun, trus diobatin ni, semua diobatin..” (p1) “...kalau malam bangun jam dua, jam satu tuh nangis.. kalau saya kan tidur di bawah, dia tuh di atas.. jadi sama saya tuh dibawa ke klinik dua puluh empat jam.. “ (p4) 64 jurnal ners vol. 10 no. 1 april 2015: 61–73 tema 3: upaya yang dilakukan orang tua selama anak menjalani pengobatan saat ini beber apa upaya ya ng d ila k u k a n a d ala h me mb e r i mot iva si, me me nu h i kebutuhan nutrisi anak, mencari informasi, memberikan kenyamanan dan menggunakan terapi pendukung (komplementer). berikut pernyataan partisipan mengenai hal ini: “...kita pasti kasi dukungan, kamu pasti kuat.. masa kamu kalah sama penyakit, jangan kalah dong sama penyakit.. kaya y dulu juga sampai guling-gulingan dia, tapi dia musti makan, dia cuma berdo’a (tuhan, tolong y)..” (p2) “...kebanyakan konsul, kebanyakan nanya gitu sih.. kita harus rajin nanya.. apa lagi kalau ada dokter gizinya.. (gimana dok, anak saya ga mau makan.. gini gini.., gimana jagain dia supaya jangan aplasti),, (gini buk yang penting makan ini, makan ini).. saya turutin..” (p7) “...(makan yah tong ya), kata saya gitu, trus (mak suapin ya,. mamak beliin itu dah, beli bakso), bakso kuahnya doang tuh, airnya, ga pakai bawang, ga apa...” (p1) “...kan itu kato urang ubek-ubek kaya gitu kan ndak ado efek sampingnyo do.. itu kan daun senyo ndak ado efek sampiang nyo doh, kaya susu kan ndak ado efek sampingnyo, daun sirsak tu kan tu ndak ado efek sampiangnyo do.. setelah wak diagiah ubek dokter diawak ditambah lo kan.. jadi itu...” (p8). (kan kata orang obat-obat seperti itu tidak ada efek sampingnya, itu kan cuma daun saja, jadi tidak ada efek sampingnya, seperti susu itu tidak ada efek samping, daun sirsak juga tidak ada efek samping, jadi setelah kita diberi obat sama dokter, nanti kita tambahkan dengan obat lain red). g a m b a r a n p e n g g u n a a n p e n g o b a t a n alternatif pada anak tema 3: gambaran pengunaan pengobatan alternatif pada anak sub tema yang teridentifi kasi tersebut adalah sebutan pada penyembuh, bahan yang digunakan untuk obat, cara pemberian obat, metode pengobatan alternatif, alasan memilih pengobatan alternatif, informasi yang diterima dari penyembuh, dan keyakinan tentang penyakit. sebutan pada penyembuh adalah “...ya dukun patah tulang..” (p3). bahan yang digunakan untuk obat terdiri dari empat kategori yaitu tumbuh-tumbuhan, bahan mineral, substansi hewan dan bahan kimia. “...kalau kita di m sih ngomongnya daun balontas (beluntas), ga tau yang disini ya, trus sama ada tiga macam yang diminum sama rumput yang baru..” (p2) “...diginiin ama dia ada minyaknya ada apa gitulah, diginiin tuh yang tinggi..” (p3) “...ih pokoknya obat yang diminum udah, semuanya udah diminum.. kali tahi babi doang yang belum diminum.. iya, cacing mah, cacing kadal, cecak.. “ (p1) “...dia udah terlanjur panas-panas, dulunya dikasi spritus.. ada juga orang yang berobat pakai spritus itu baik katanya..” (p6) cara pemberian obat ada 2 yaitu topikal dan oral. “...di obat pinang muda lagi, pinang muda diparut.. dilekat-lekatkan (gerakan menekan-nekankan telapak tangan pada paha) ternyata kering..” (p6) “...ada ya rumput namanya apa.. ga tau juga.. pokoknya itu ada tiga macam,.. diminum.. ditumbuk, diperas airnya diminum.. tapi kayaknya ga ada efeknya..” (p2) metode pengobatan alternatif k u m p u l a n s u b s u b t e m a y a n g membentuk sub tema metoda pengobatan di antaranya adalah terapi biologi, manipulasi pada tubuh, pengobatan pada tubuh dan fi kiran dan terapi energi. “...aaa di anu.. ado yang dirandang di kampuang, dirandang tu (cacing red) sampai anguih (sampai hangus red) aa tu kan sampai co anu tu cooo kopi, tu beko di masuakan ka aia anu.. diseduh tu aianyo diminum...” (p8) “...diginiin ama dia ada minyak ada apa gitulah (sambil mengusap-usap paha) diginiin tuh yang tinggi (menekan paha dengan telapak tangan) sreett udah lempeng, bagus, pegang begini kasi apa gitu.. trus dilibetin itu perban..” (p3) “...ya alternatif mah, kalau kata orang kampung mah jampe-jampe gitu ya, udah ga ada sama sekali suster ga ada, yang ketahuan banget yah disini..” (p5) 65 pengalaman orang tua dalam penggunaan pengobatan alternatif (hermalinda, dkk.) “...cuman dipegang, dijampein ya gitu doang.. ga diurut ga aapa.. namanya juga dia kan punya ilmu tenaga dalam gitu, dibacain doa doang ntar dia tu (s berasa ga?) sambil mengangkat kedua tangan lurus kedepan) (ya enak) gitu..” (p5) beberapa alasan yang menjadi subsub temanya yaitu alasan psikologis, alasan ekonomis, alasan informatif, alasan spritual dan alasan fi sik. “...ga ada satu orang pun dokter yang ngejelasin penyaki a apa, penyakit ini itu, yang dokter yang operasi itu, waktu diperiksanya katanya bilangnya kelenjer aja...” (p5) “...di rujuk ke rs g, di g sebulan tuh pemulihan doang.. gitu, sebulan tuh pemulihan doang, udeh, dari mau awal puasa ampe akhir pemulihan doang, disitu suruh kontrol ga kontrol..” (p4) “...emang kan kalau dia baru bisa belajar berjalan kan sering jatuh, jadi diurut, tapi ga apa-apa, trus sembuh..” (p7) “...dah dapet informasi lagi gini.. saya.. apa.. (kenapa anaknya?) orang pada nanyakan,. (itu patah).. (oo, sana bawa ke p.. bawa lah ke p, disono bagus, menurut informasi remuk-remuk aja pada bisa).. udah baek, bagus, patah, engsel, keseleo..” (p3) “...tapi kan saya dengar dari orangorang kalau kemoterapi katanya ga bagus.. begini begini, pasti deh anaknya bisa ini bisa begitulah, namanya saya ini, saya jadi takutkan.. uhhhh takut banget, ihhh begini.. kayaknya serem banget gitu...” (p7) “...ya namanya kita syari’at ya, dari mana aja ya kita mah percaya aja.. gitu.. ya namanya apa itu.. yang.. yang nyembuhinnya itu kan bukan kita.. bukan manusia, yang menyembuhkan kan allah ya.. kita kan syari’at.. ya saya percaya aja, kali barang kali di sana kali jodohnya berobatnya kesitu...” (p5) “...ga ada efek sampingnya kalau menurut saya.. ga ada diare, ga ada mual, ee’ knya biasa, bisa main-main.. tapi pas setelah saya kasi obat yang lain-lain, dia jadi itu...” (p7) informasi dari penyembuh “...kata dukunnya penyakit buatan orang.. kata dukun itu.. ah ga percaya.. iya.. saya salah apa saya, salah apa anak saya ma si w.. kalau ditenun mah kalau punya hartanya banyak.. nah saya?? kata dukun kampung kena guna-guna, tapi saya ga percaya...” (p1) “...( ya ini mah bener patah).. trus bahasa sononya (ya potes) katanya.. (emang patah ya bu), (iya potes) kata dia gitu.. trus dilibet perban gitu...” (p3) “...cuman ya kata ini yang di bekam tuh, tu penyakitnya pada keluar, biarin, gapapa.. emang dia juga ngerasain enak, gitu...” (p4) keyakinan tentang penyakit anak “...kalau kata orang kita mah, kali ada roh.. ada yang ganggu ada yang nyolek, ada yang ganggu, kan suka ada yang ngomong gitu ya... ada yang bilang (si r kok ga mau diobatin ya, jangan-jangan ada yang nempelin, ada yang nyolek), ada begitu.. kalau saya sih percaya ga percaya..” (p3) tema 4: efek pengobatan alternatif pada anak pengobatan alter natif yang per nah dijalani anak memberikan efek yang tidak jauh berbeda dari masing-masing partisipan, pada umumnya partisipan mengungkapkan bahwa tidak ada perubahan yang dialami anak selama menjalani pengobatan alternatif. “...pokoknya itu ada tiga macam,.. diminum.. ditumbuk, diperas airnya diminum.. tapi kayaknya ga ada efeknya, mungkin karna penyakitnya y udah dikatakan stadium empat deh kan...” (p2) partisipan juga mengungkapkan tentang respon emosional anak pada saat menjalani pengobatan alternatif tersebut. “...diobatin pakai apa.. pakai kapur, kapur ma minyak.. diolesin lagi tuh sekujur badan yang benjol-benjol.. (men unjuk keseluruh badan) malah gegerungan, nangis...” (p1) di antara partisipan ada yang merasa kecewa karena pengobatan alternatif tersebut menimbulkan efek yang mer ugikan bagi kesehatan anak. “...kata saya sih gitu, nangis melulu, saya yang capek ngedengerinnya, alternatif dia kaga mau mah.. apa w sakit melulu sih,. katanya ngentek, malah kaga bisa jalan diterapi...” (p1) 66 jurnal ners vol. 10 no. 1 april 2015: 61–73 walaupun demikian, ada juga partisipan yang mengungkapkan tentang manfaat yang dirasakan anak baik fi sik maupun psikologis selama menjalani pengobatan alternatif. “...mau sih, mau dia.. kan dia agak mau gitu, kan manis-manis kaya bubur bayi, kalau kita makan rasanya enak gitu ya.. trus dia kasi beras apa.. kaya gandum.. ada satu lagi gandum, mau dia makan.. biarpun dua sendok itu udah mencukupi kebutuhan dia...” (p7) makna penggunaan pengobatan alternatif bagi orang tua tema 5: respons orang tua selama anak menjalani pengobatan alternatif ketidakberhasilan terapi dan lamanya waktu dalam pengobatan alternatif pada anak memberikan respons yang berbeda-beda pada masing partisipan berupa respons fi sik, respons psikologis dan respons ekonomi. perasaan orang tua ini tergambar dalam pernyataan berikut: “...saya dapat capeknya doang, mondar mandir, ongkos kesono kesini kesono kesini tapi ga ada hasilnya (ekspresi kekecewaan, kepala digelengkan, kening berkerut, mimik wajah menjadi serius)...” (p5) “...dari situ kita udah kebingungan, ga tau lagi mau ngapain, udah bingung pokoknya.. trus akhirnya kita sudahlah kita ke jakarta...” (p2) “...penyakit begini, waras.. sabar… atas cobaan ini.. saya gitu yah.. bagaimana dulu saya juga udah berusaha, kesono kemari.. kesono kemari..” (p4) “...seharusnya kalau dari pertama ga begitu parah.. ini tulangnya udah habis, ga ada tulanngnya (menerawang, mata mulai terlihat bening atau berkaca-kaca, suara agak serak)..” (p3) “...saya kan mau.. cuman biayanya.. mau diobatin ke alternatif sono, tapi saya ga punya.. biayanya.. sekian-sekian, aduhhh duit dari mana saya juga.. kan kalau kemanamana kalau ga punya duit kan, kan ga jalanjalan...” (p5) tema 6: makna penggunaan pengobatan alternatif efek jera “...pelajarannya sih ini ya.. apa sih, jangan sembarangan gitu.. sekarang kan orang kasi apa ini.. ayo, orang kasi apa ayo, sekarang sih percaya deh ama dokter.. kan dokter yang udah banyak ininya.. alternatif sih bagus, cuman kalau dicampur-campur gitu kayaknya aduh saya udah ga berani lagi.. keluar darahnya itu.. ga usah dengar-dengar deh kata orang...” (p7) langsung berobat ke fasilitas kesehatan “...kalau ada.. kalau.. saya sih, kalau ada penyakit gitu.. tumbuh, cepat-cepatlah diobatkan sama periksakan, kalau kata dokternya operasi ya dioperasi,..” (p6) sebagai terapi pendukung untuk pengobatan medis “...in yo k a n bi sa di se mb uh k a n .. disembuhkan tujuah puluh persen katonyo kan.. aa mungkin nan tigo puluah persen urang tuo lah yang bisa manolong, aa tu lah diambiak.. jadi contohnyo tadi susu kuda liar tambahnyo kan.. sabananyo kan ubek-ubek herbal tu kan ndak samo jo kemo do...” (p8) (... penyakit ini kan bisa disembuhkan tujuh puluh persen, mungkin yang tiga puluh persen lagi orang tua lah yang bisa membantu seperti susu kudaliar sebagai tambahannya. sebenarnya, obat-obat herbal itu kan tidak sama dengan obat kemoterapi...red). harapan orang tua harapan partisipan dalam pengobatan anak pada saat ini mencakup hal-hal yang diinginkan oleh partisipan baik terhadap penyakit anak, terhadap pelayanan kesehatan, dan terhadap fasilitas kesehatan. harapan terhadap anak: “...eee. dia bisa sembuh, dia bisa s e k ol a h ,..b i s a b e r m a i n s a m a t e m a n temannya...” (p2) 67 pengalaman orang tua dalam penggunaan pengobatan alternatif (hermalinda, dkk.) harapan terhadap pelayanan kesehatan: p a d a u m u m n y a p a r t i s i p a n mengharapkan pen i ng kat an pelayanan kesehatan meliputi sikap tenaga kesehatan, dukungan pengobatan, kemudahan dari rumah sakit dan kebutuhan informasi termasuk informasi tentang pengobatan alternatif pada anak yang menderita kanker. “...biar dia kasi.. anak saya dikasi pengobatan yang bisa bikin sembuh lah.. biar bisa ketawa lagi, bisa sekolah.. bisa main ama temen (menahan suara dan air mata yang sudah dipelupuk) kesana kemari..” (p3) “...saya sih maunya dipermudahkan semuaaa.. (tersenyum).. mudah obatnya gitu.. trus mudah cari kamarnya...” (p7) “..kalau dokter ko kan ado pulo kode etiknyo, mungkin dalam penelitian ka pasien kan alun ado lai.. dokter manyabuik tu.. ndak ado pernah dokter mendukung ko (susu kuda liar dan daun sirsak red) rancak, ndak ado..” (p8). (kalau dokter kan juga ada kode etiknya, mungkin belum ada penelitiannya ke pasien, kan belum ada dokter mengatakan seperti itu, tidak pernah dokter mendukung obatnya bagus, tidak ada red) harapan terhadap fasilitas kesehatan “...tapi untuk mendukung c nya supaya lebih bagus.. trus anak-anak tidak terlambat masuk obat.. ada baiknya kalau ke… apaaa..? tempatnya.. bangsalnya itu ditambah lagi.. biar anak-anak semua bisa.. bisa untuk berobat tepat pada waktunya...” (p2) pembahasan pa d a p e n el it i a n i n i o r a n g t u a mengungkapkan tentang dampak penyakit pada anak baik masalah fi sik maupun masalah psikologis. masalah fisik yang dikeluhkan anak pada penelitian ini tergantung pada jenis penyakit yang diderita. nyeri merupakan tanda utama yang diakibatkan oleh obstruksi baik langsung atau tidak langsung jaringan tumor terhadap reseptor saraf (reseptor nyeri). jaringan neoplasma dapat menyebabkan reaksi peradangan, kerusakan jaringan, dan tekanan pada organ. selain itu cachexia juga dapat menjadi keluhan fi sik pada anak yang dikarakteristikkan dengan anoreksia, penurunan berat badan, kelemahan, dan rasa cepat bosan (ball & bindler, 2003). selain itu, masalah fi sik yang diakibatkan oleh penyakit seperti pembesaran kelenjar dan jaringan mempengaruhi fungsi fi sik, body image dan konsep diri anak. perubahan emosional yang terjadi dapat ringan sampai berat, tergantung pada keseriusan dan tipe penyakit, tingkat ketergantungan dan perkiraan lama waktu sakit (potter & perry, 2005). friedmen (2010) menjelaskan keluarga ber t angg u ng jawab u nt u k member i kan perawatan dir i, motivasi keluarga, dan kompetensi aktual dalam menangani masalah kesehatan anggota keluarga yang sakit. dalam penelitian ini, orang tua membiarkan keluhan anak untuk sementara waktu sebagai upaya dalam melakukan fungsi perawatan kesehatan keluarga. selain membiarkan keluhan anak untuk sementara waktu, orang tua bereaksi terhadap keluhan anak dengan mencari bantuan pengobatan non medis atau dengan kata lain pengobatan tradisional. menurut hockenberry dan wilson (2009), dalam hal pencegahan dan pengobatan penyakit, terdapat banyak kesamaan di antara budaya. masing-masing budaya mempunyai cara dan tipe pengobatan tradisional dan perawatan di rumah sebelum mencari batuan orang lain. adanya persepsi bahwa sakit dapat mengganggu aktivitas sehari-hari menyebabkan kecenderungan bagi seseorang untuk mencari bantuan kesehatan dan mematuhi terapi yang diberikan (potter & perry, 2005). sama halnya dengan orang tua pada penelitian ini yang bereaksi langsung mencari bantuan kesehatan untuk mengatasi keluhan yang dirasakan anak karena cemas terhadap kesehatan anak. hasil penelitian ini respons adaptif orang tua yang tergambar sebagai upaya yang dilakukan pada anak selama menjalani pengobatan medis saat ini di antaranya adalah pemenuhan kebutuhan psikologis dan fi sik anak. mencari informasi merupakan hal yang esensial dilakukan oleh orang tua. hal yang sama juga teridentifi kasi pada pasien dewasa yang menderita kanker, di mana salah satu upaya dilakukan pasien dalam menjalani penyakitnya adalah dengan mencari informasi tentang pengobatan kanker baik tentang 68 jurnal ners vol. 10 no. 1 april 2015: 61–73 pengobatan konvensional medis maupun pengobatan alternatif dari berbagai sumber misalnya pustaka, toko buku, internet, chat rooms, pelayanan informasi kanker, ahli pengobatan alternatif, praktisi pengobatan komplementer dan alternatif, dokter, teman dan support group (verhoef & white, 2002). menggunakan pengobatan alternatif sebagai terapi pendukung pada saat anak menjalani kemoterapi juga dilakukan oleh orang tua. hal ini diyakini orang tua dapat membantu mempertahankan kestabilan fi sik anak selama menjalani kemoterapi. dalam penelitian fletcher dan clarke (2004), orang tua yang setuju dengan penggunaan pengobatan komplementer dan alter natif pada anak juga memberikan berbagai bentuk terapi pendukung pada anak mereka selama menjalan i kemoterapi seper t i vit am i n, suplemen diet dan herbal. pada penelitian ini orang tua menyebut penyembuh tradisional dengan sebutan dukun, tabib, orang “pintar”, dan ahli alternatif. dukun dalam pandangan budaya dikenal sebagai orang yang mempunyai kekuatan untuk menyembuhkan dan dianggap mendapat anugrah sebagai penyembuh dari t uhan (potter & perry, 2005). yader (1972 dalam potter & perry, 20 05) menjelaska n ba hwa pengobat a n r a k yat me r upa k a n sala h sat u b e nt u k praktek tradisional pada masyarakat yang menggunakan lingkungan alamiah seperti herbal, tumbuhan, mineral dan substansi hewan u nt u k mencegah dan mengatasi penyakit. pada penelitian ini juga terlihat adanya bentuk praktek pengobatan tradisional dengan menggunakan berbagai bahan alamiah sebagai obat untuk penyakit anak. bahan obat yang digunakan pun bervariasi tergantung dari jenis penyakit, daerah asal dan tempat pengobatan alternatif. bahan obat tersebut di antaranya adalah tumbuh-tumbuhan, bahan mineral, substansi hewan dan bahan kimia. di antara bahan obat yang digunakan bersifat alamiah, namun bahan obat tersebut belum tentu mengindikasikan aman dikonsumsi atau digunakan pada anak, karena terdapat berbagai jenis zat atau substansi kimia didalamnya yang dapat menimbulkan risiko pada tubuh jika pemberian dan pengolahannya tidak tepat. walaupun bahan obat yang digunakan dalam pengobatan alternatif bersifat alamiah, namun cara pemberiannya hampir sama dengan preparat obat yang digunakan oleh pelayanan kesehatan sebagai terapi, penyembuhan, penurunan atau pencegahan penyakit. rute pemberian obat oleh orang tua dalam penelitian ini adalah melalui oral dan topikal. rute oral adalah rute yang paling mudah dan paling umum digunakan. obat diberikan melalui mulut dan ditelan. rute ini lebih dipilih karena tidak menimbulkan nyeri. obat yang diberikan melalui kulit dan membran mukosa pada prinsipnya menimbulkan efek lokal, dengan mengoleskannya pada daerah kulit tertentu, memberi balutan basah, merendam bagian tubuh atau mandi dengan larutan obat (potter & perry, 2005). penelitian sebelumnya mengidentifikasi penggunaan pengobatan komplementer dan alternatif pada anak, di mana sebagian besar obat herbal diberikan secara oral (diminum atau dimakan) dan hanya sebagian kecil yang menggunakan obat ini secara eksternal (gozum, arikan, & buyukavci, 2007). penelitian ini mengidentifi kasi beberapa bentuk metode pengobatan yang digunakan oleh orang tua untuk membantu mengurangi ketidaknyamanan anak karena penyakit. metode pengobatan alternatif yang banyak digunakan adalah terapi yang bersifat biologis, manipulasi pada tubuh, pengobatan pada tubuh dan pikiran dan terapi energi. nccam (2007) mengklasifi kasikan pengobatan komplementer d a n alter nat if sebagai ber i k ut: sistem pengobatan alternatif (alternative medicine systems), intervensi tubuh dan fi kiran (mindbody interventions), terapi biologis (biologic based therapy), metode manipulasi tubuh (manipulative-bodybased therapy) dan terapi energi. dalam penelitian yang dilakukan oleh gen, et al. (2009) dapat dilihat bahwa jenis pengobatan yang banyak digunakan adalah terapi biologi yang mencakup herbal, jelatang, salvin offi cinalis, vitamin atau suplemen, kurakura atau darah katak dan jenis lainnya seperti 69 pengalaman orang tua dalam penggunaan pengobatan alternatif (hermalinda, dkk.) tepung lebah, madu dan jeruk. manipulasi chiropraksi dari struktur tulang, manipulasi osteoperatif dari sistem muskuloskeletal dan manipulasi terapi pijat dari jaringan lunak merupakan metode manipulasi pada tubuh (nccam, 2007). pijat selain berguna untuk mengurangi nyeri dan kekakuan, juga untuk meningkatkan mobilitas, rehabilitasi otot yang cedera dan mengurangi nyeri kepala dan punggung (sinclair, 2005). bentuk pengobatan yang dilakukan pada anak dalam penelitian ini dengan metode intervensi tubuh dan fi kiran adalah berdo’a atau prayer (gen, et al. 2009). orang tua berespons secara psikologis terhadap penyakit anak. kecemasan dan stres pada orang tua muncul sehubungan dengan penyakit anak seperti ketidakpastian tentang penyakit dan pengobatan pada anak dan ketidakpuasan terhadap pelayanan kesehatan. di samping perasaan cemas, orang tua pada penelitian ini juga mengungkapkan ke nya m a n a n k a re n a ke m a nju r a n d a r i pengobatan alternatif yang pernah dijalani sebelumnya (gen, et al. 2009). beberapa studi lain mengidentifikasi bahwa tidak adanya kemajuan dari pengobatan yang dijalani dapat menimbulkan ketidakpuasan terhadap pengobatan medis atau pelayanan kesehatan. hal ini juga menjadi alasan dalam memilih pengobatan komplementer dan alter natif (van der weg & streuli, 2003; chao, et al, 2006; jean & cyr, 2007; gozum, arikan, & buyukavci, 2007; evans, et al. 2007; chen, et al., 2009; erez, et al., 2009). pengg unaan pengobatan alter natif diasumsikan oleh pengg unanya sebagai bent u k terapi dengan biaya yang lebih murah dibandingkan dengan pengobatan medis (debas, laxminarayan, & straus, 2006). adanya sumber informasi baik dari teman ataupun orang lain serta kurangnya penget ahuan tent ang penyak it menjadi alasan bagi orang tua untuk membawa anak berobat ke tempat pengobatan alternatif (tan, uzun, & akcay, 2004; jean & cyr, 2007; chen, et al., 2009; erez, et al., 2009; lu, tsay, & sung, 2010). keyakinan agama dan keyakinan terhadap pengobatan alternatif juga merupakan faktor yang mempengaruhi pasien atau keluarga memilih pengobatan alternatif (debas, laxminarayan, & straus, 2006; chao, et al., 2006; chen, et al., 2009). alasan alamiah dari bahan dan metode pengobatan alternatif yang digunakan juga termasuk kedalam alasan pemilihan pengobatan alternatif (erez, et al., 2009). pe r b e d a a n ya ng me nc olok d a r i penyembuh tradisional dengan dokter adalah pada teknik komunikasi, di mana dukun tradisional lebih dapat memper tahankan hubungan informal dan efektif dengan seluruh anggota keluarga. selain itu dalam menentukan penyakit dan jenis pengobatan yang akan dilakukan, dukun akan menginformasikannya kepada keluarga dengan bahasa yang mudah d ipa ha m i, be r sa haja d a n me mba ng u n pengharapan untuk kesembuhan (potter & perry, 2005). berdasar konteks keluarga, keyakinan tentang penyakit dan pemulihan kesehatan merupakan bagian integral dari budaya yang mempengaruhi perilaku dan koping keluarga terhadap masalah kesehatan dan bagaimana b e re s p on s t e rh a d ap t e n aga ke seh at a n (hockenberry & wilson, 2009). selain itu adanya keyakinan dari budaya tertentu bahwa penyakit dapat disebabkan oleh orang yang mempunyai kemampuan untuk menyebabkan orang lain sakit, sehingga orang yang meyakini hal ini harus melakukan ritual tertentu untuk melindungi diri mereka (potter & perry, 2005). tujuan pengobatan alternatif pada anak menurut orang tua adalah untuk membantu mengobati atau melawan kanker pada anak, mengurangi gejala akibat penyakit dan efek samping obat dan sebagai dukungan pada saat menjalani terapi medis (genc, et al., 2009; bishop et al., 2010; masky & wallerstedt, 2006), membersihkan darah (genc, et al., 2009), meningkatkan kenyamanan fi sik dan psikologis pasien serta ketenangan diakhir kehidupan (masky & wallerstedt, 2006). berbeda dengan hasil-hasil penelitian sebelumnya, pengobatan alternatif menurut orang tua dalam penelitian ini tidak memberikan efek yang bermanfaat pada fi sik anak. sebu a h s y ste m a t i c r i v i e w ya ng dilakukan oleh ernst (2003) tentang efek serius dari terapi unconventional pada anak dan 70 jurnal ners vol. 10 no. 1 april 2015: 61–73 remaja. hasil analisis menunjukkan bahwa beberapa jenis obat herbal dapat berbahaya bagi anak karena efek toksiknya, kontaminasi dengan logam berat, atau ketidakaslian obat tersebut. ernst mengidentifi kasi bahwa efek merugikan dari obat herbal adalah bradikardi, kerusakan otak, shok kardiogenik, koma diabetik, ensefalopati, ruptur jantung, hemolisis intravaskular, kegagalan hepar, kegagalan pernapasan, toksik hepar dan kematian. selain itu, pengobatan alternatif seperti obat herbal dapat memberikan efek yang merugikan bagi kesehatan apabila dikombinasikan dengan pengobatan yang diresepkan dokter (tan, uzun, & akcay, 2004). terapi alter nat if t id a k d isa ng kal orang tua dapat memberikan manfaat dalam pemenuhan kebutuhan fi sik ataupun psikologis anak. seperti manfaat fi sik yang dirasakan anak setelah terapi pijat dan diet (terapi biologi). anak merasakan nyeri berkurang, bengkak berkurang, nafsu makan membaik dan ketahanan f isik meningkat setelah menjalani terapi tersebut. sebuah systematic review dilakukan oleh hughess, et al. tahun 2008 melalui pubmed, referensi online, laporan pemerintah yang dipublikasikan, dan mengambil artikel bibliografi , ulasan, dan buku-buku tentang pijat dan kanker. penelitian ini merekomendasikan pijat sebagai terapi modalitas noninvasif yang dapat diintegrasikan dengan aman sebagai intervensi tambahan untuk mengelola efek samping dan kondisi psikologis yang terkait dengan pengobatan antineoplastik pada anakanak. kurangnya energi selama merawat anak dan menjalani pengobatan alternatif merupakan respons fi sik yang pada umumnya diungkapkan oleh orang tua pada penelitian ini. selanjutnya respons fi sik ini saling bersinergi dengan respons psikologis (seperti bingung, kepasrahan, kebosanan, merasa bersalah, kesedihan dan kekhawatiran) dan respons ekonomi. respons ini muncul ber ulangulang dan tergantung pada kondisi anak. namun demikian, orang tua mengungkapkan kepasrahan yang dikaitkan dengan nilai dan keyakinan yang dimiliki. menurut who (2008), beban anggota keluarga dalam merawat anggota keluarga yang mengalami gangguan jiwa mencakup pada dua hal yaitu beban yang bersifat subjektif dan objektif. perasan yang dirasakan di dalam diri keluarga mengandung makna subjektif seperti adanya perasaan kehilangan, sedih, cemas, malu, stres dan frustasi. sementara itu dampak psikologis yang mempengaruhi keluarga dalam berhubungan dengan lingkungannya dipandang sebagai beban objektif yang di antaranya adalah gangguan hubungan antar anggota keluarga, keterbatasan hubungan sosial dan aktivitas kerja, kesulitan fi nansial dan dampak negatif terhadap kesehatan fi sik anggota keluarga. efek jera merupakan suatu hal yang belum teridentifi kasi pada penelitian-penelitian sebelumnya. beban yang dialami orang tua selama menemani anak menjalani pengobatan alternatif baik fi sik, psikologis dan ekonomi memberikan ar ti yang cukup mendalam sehingga orang t ua memut uskan unt u k tidak menggunakan pengobatan alternatif lagi pada anak. selain itu, adanya trauma dan efek yang merugikan pada anak akibat pengobatan alternatif yang pernah digunakan membentuk persepsi negatif pada orang tua dan mengungkapkan penolakan terhadap pengg unaan pengobatan alter natif pada anak. adanya efek jera pada orang tua dalam menggunakan pengobatan alternatif seperti dijelaskan di atas, mempengaruhi orang tua untuk membawa anak ke fasilitas kesehatan yang tersedia dan mengikuti berbagai regimen terapi pada anak, karena orang tua merasakan adanya perubahan yang dialami anak setelah menjalani pengobatan medis secara rutin. pada penelitian sebelumnya yang meneliti tentang sikap keluarga terhadap penggunaan pengobatan rakyat (tradisional) pada anak yang dirawat di taiwan. di dalam penelitian tersebut didapatkan data bahwa partisipan menyatakan keyakinan terhadap keefektifan pengobatan konvensional medis. partisipan dalam penelitian ini mengungkapkan bahwa pengobatan rakyat seperti alternatif tidak lebih efektif jika dibandingkan dengan pengobatan medis (chen, et al., 2009). pengalaman yang positif terhadap pengobatan alternatif dapat memberikan makna bagi orang tua bahwa pengobat an alter natif dapat dig u nakan 71 pengalaman orang tua dalam penggunaan pengobatan alternatif (hermalinda, dkk.) sebagai terapi pendukung dalam pengobatan medis kanker seperti kemoterapi. selain itu alasan dalam memilih pengobatan tradisional seperti qigong atau obat herbal adalah karena pengobatan medis kanker juga mempunyai keterbatasan dalam mengobati penyakit walaupun mereka yakin bahwa operasi dan kemoterapi dapat member ikan manfaat terhadap penyakit kanker (lu, tsay, & sung, 2010). tiga hal yang teridentifikasi dalam penelitian ini yang menunjukkan harapan orang t ua terkait dengan penyakit dan pengobatan anak. pada umumnya orang tua mengharapkan anak sembuh dan dapat kembali ke keadaan normalnya sebelum sakit seperti bertumbuh dan berkembang serta memainkan peranannya di kehidupan sosial. orang tua juga meng ungkapkan harapan terhadap peningkatan pelayanan kesehatan pada anak mereka termasuk sikap tenaga kesehatan, kemudahan dalam pelayanan kesehatan dan kebutuhan informasi serta tersedianya fasilitas kesehatan yang memadai dan mendukung selama pengobat an anak. nahalla dan fitzgerald (2003), menggambarkan tentang harapan orang tua dengan anak yang menderita talasemia mencakup empat hal yaitu efi siensi pelayanan, harapan anak sembuh, pengobatan terbaru dan perawatan yang memadai. simpulan dan saran simpulan orang tua menggunakan satu atau lebih jenis pengobatan alternatif pada anak. jenis yang paling populer digunakan adalah terapi biologi yang menggunakan bahan alamiah sebagai obat. salah satu faktor yang penting dan menjadi alasan dalam pemilihan pengobatan alternatif pada anak adalah karena faktor ketidakpuasan terhadap p elaya n a n ke seh at a n. pa d a u mu m nya orang t ua mengungkapkan bahwa tidak ada perubahan yang dialami anak selama menjalani pengobatan alternatif. namun, jenis pengobatan alternatif tertentu seperti pijat dan intervensi pada tubuh dan pikiran berupa pengobatan megisoreligius ( prayer) dapat memberikan manfaat baik pada fi sik maupun psikologis anak. diharapkan tenaga perawat profesional dapat mengaplikasikan teori keperawatan culture care theory of diversity and universality, terutama dalam hal penggunaan terapi komplementer pada pasien anak yang menderita kanker berdasarkan pada evidence based practice. saran be rd a sa r ha sil pe nel it ia n , ma k a disarankan perawat dapat menggunakan pendekatan transcultural nursing dalam m e l a k s a n a k a n a s u h a n k e p e r a w a t a n . perawat dapat memperoleh informasi agar dapat menentukan jenis perawatan yang diinginkan oleh pasien dari pemberi pelayanan kesehatan. kepustakaan american cancer society. 2008. cancer statistics presentation 2008. diakses dari http://www. cancer. org/docroot/ lpro/pada tanggal 13 januari 2011. ball, j.w., & bindler, r.c. 2003. pediatric of nursing: caring for children. new jersey: pearson education, inc. bishop, f.l., prescott, p., chan, y.k., saville, j., von elm, e., & lewith, g.t. 2010. prevalence of complementary medicine use in pediatric cancer: a systematic review. pediatrics, 125, p. 768–776. chen, l.l., huang, l.c., lin, s.c., smith, m., & liu, s.j. 2009. use of folk remedies among familes of children hospitalized in taiwan. journal of clinical nursing, 18, p. 2162–2179. debas, h.t., laxminarayan, r., & straus, s.e. 2006. complementary and alternative medicine: in disease control priorities in development countries. diakses dari www.dep2.org pada tanggal 01 juni 2011, jam 10.00 wib. enskar, k. et al. 2000. important aspect of care and assistance for children with cancer. journal of pediatric oncology nursing, 17(4), p. 239–249. enskar, k., & von essen, l. 2008. physical problems and psychosocial function in children with cancer. pediatric nursing, 23(3),p. 37–41. 72 jurnal ners vol. 10 no. 1 april 2015: 61–73 erez, c., reuveni, h., freud, t., & peleg, r. 2009. reasons for refferals of children and addolescents to alternative medicine in southern israel. the journal of alte r n a t i ve a n d com ple m e n ta r y medicine, 15 (6), p. 681–684. evans, m.a., et al. 2007. men with cancer: is their use of complementary and alternative medicine a response to needs unmet bu conventional care?. european journal of cancer, 16, 517–524. fletcher, p.c., & clarke, j. 2004. the use of complementar y and alter native medicine among pediatric patients. cancer nursing, 27 (2), p. 93–89. friedmen, m.m. 2010. buku ajar keperawatan keluarga: riset, teori, dan praktik/ mar ylin m . friedmen., vick y r. bowden., elane g. jones., alih bahasa, akhir yani s. hamid …. [et al]; ed 5, jakarta, egc. genc, r.e., senol, s., turgay, a.s., & kantar, m. 2009. complementery and alternative medicine used by pediatric patients with cancer in western turkey. oncology nursing forum, 36(3), p. e159-e164. gozum, s., arikan, d., & buyukauci, m. 2007. complementary and alternative use in pediatric oncology patient in eastern turkey. cancer nursing, 30 (1), p. 38–44. hockenberry, m.j & wilson, d. 2009. wong’s essentials of pediatric nursing (hlm. 51–64). st louis: mosby inc. hughes, d., ladas, e., rooney, d., & kelly, k. 2008. massage therapy as a supportive care inter vention in children with cancer. oncology nursing forum, 35(3), p. 432–442. jean, s., & cyr, c. 2007. use of complementary and aletrnative medicine in general pediatric clinic. pediatric, 120,p. e138e141. karadeniz, c., pinarli, f.g., oguz, a., gursel, t., & canter, b. 2007. complementary/ alternative medicine use in a pediatric oncology unit in turkey. pediatric blood and cancer, 42 (1), p. 106–108. leininger, m., & mcfarland, m.r. 2002. transcultural nursing; concepts, theories, research and practice. st. louis: mcgraw-hill companies. lu, j.h., tsay, s.l., & sung, s.c. 2010. taiwaness adult cancer patient’s reports of using complementar y therapies. cancer nursing, 33 (4), p. 320–326. malassiotis, a., & cubbin, d. 2004. “thinking outside the box”: complementary and alternative theapies use in pediatric oncology patients. european journal of oncology nursing, 8, p. 50–60. mansky, p.j., & wallestedt, d.b. 2006. complementary medicine in palliative care and cancer symptom management. the cancer journal, 12 (5), 425–431. montazeri, a., sajadian, a., ebrahim, m., haghighat, s., & harirchi, i. factors predicting the use of complementary and alternative therapies among cancer patients in iran. european journal of cancer, 16, p. 144–149. muscari, m. e. 2005. panduan belajar: keperawatan pediatric. jakarta: egc. nahalla, c,k., & fitzgeral, m. 2003. the impact of regular hospitalization of children living with thalasemia on their parents in srilangka: a phenomenological study, 9, 131–139. national cancer institute. 2007. cancer incidence and survival among children and adolescence united states seer program 1975 to 1995. diakses pada tangal 13 januari 2011, dari http://seer. cancer. gov/publications/childhood. national center for complementary and alternative medicine. 2007. cam use and children. diakses dari http://nccam. niv.gov.healthpada tanggal 16 februari 2001. nursalam. 2005. asuhan keperawatan bayi dan anak. jakarta: salemba medika. potter, p.a., & perry, a.g. 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktek/patricia a potter, anne griffi n perry; alih bahasa, yasmin asih et al. editor edisi bahasa indonesia, devi yulianti, monica ester, (hal 461– 471). jakarta: egc. sinclair, m. 2005. pediatric message therapy, 2nd edition. philadelphia: lippincott williams & wilkins. streubert, h.j., & carpenter, d.r. 2003. q ualitative re search in n ursing. philadelphia: lippincott, williams & wilkins. 73 pengalaman orang tua dalam penggunaan pengobatan alternatif (hermalinda, dkk.) tan, m., uzun, o., & ackay, f. 2004. trends in complementar y and alter native medicine in eastern turkey. the journal of alternative and complementar y medicine, 10 (5), p. 861–865. van der weg., & streuli, r.a. 2003. use of alternative medicine by patient with cancer in rural area of switzerland. swiss med wkly, 133, 233–240. diakses dari www.sww.ch pada tanggal 13 maret 2011. velez, i.c., clavarino, a., barnett, a.g., & e a s t w o o d , h . 2 0 0 3 . u s e o f c o m p l e m e n t a r y a n d a l t e r n a t i v e medicine and quality of life: change at the end of life. palliative medicine, 17, p. 695–703. verhoef, m.j., & white, m.a. 2002. factors i n ma k i ng the decision to forgo conventionalcare treatment. american cancer society, 10 (4), p. 201–207. wat t, l., et al. 2011. perception about complementary and alternative medicine use among chinese immigrant parent of child with cancer. suppor care cancer, diakses dari www.ncbi.gov/pubmed pada tanggal 06 juni 2011 pukul 10.11. world health organization. 2008. investing in mental health. geneva: who. yang, c., chien, l.y., & tai, c.j. 2008. use of complementary nursing and alternative medicine among patient with cancer receiving outpatient chemotherapy in taiwan. the journal of alternative and complementary medicine, 14(4), p. 413–41. 402 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17216 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review why we have to develop instruments of our caring measurement based on an indonesian perspective candra panji asmoro1,2, rr tutik sri hariyati1, and andri setiya wahyudi2 1faculty of nursing, universitas indonesia, depok, indonesia 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: caring is the core or focus in nursing as a form of professional nursing practice. the current caring instrument is an original instrument that measures the attitudes or behavior of nurses, has not paid attention to the administrative and environmental aspects of the hospital. the use of an instrument that does not yet contain certain characteristics gives rise to improper measurement results. the purpose of this study was to explain the importance of developing caring measurement instruments with an indonesian perspective. methods: systematic reviews were carried out from database articles on sciencedirect, scopus, google scholar, springerlink, wiley online, proquest, and ebscohost. criteria for articles were articles published in the last 10 years, national and international research locations, and in indonesian and english. 15 references were obtained from 2100 references that met the predetermined criteria. the development of a caring behavior instrument based on an indonesian perspective does not yet exist. results: the results found that development on the basis of linguistics, cultural adjustment, and according to the prevalence of disease in a country because the epidemiology of the disease differs on the climate region. conclusion: specific caring instruments in an indonesian perspective is expected that the research results will be more accurate. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords caring; linguistics; cultural adjustment contact candra panji asmoro  candra .panji.a@fkp.unair.ac.id  faculty of nursing, universitas indonesia, depok, indonesia cite this as: asmoro, c.p., hariyati, r.t. s., & wahyudi, a.s.. (2019). why we have to develop instruments of our caring measurement based on an indonesian perspective. jurnal ners, 14(3si), 402-407. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17216 introduction caring is at the core of humanity. the basis for providing nursing care for patients by nurses is caring behavior (alligood, m.r. tomey, 2014). nurses who meet caring criteria in attitudes and behaviors will guarantee excellent nursing services at the hospital (fawcett, 2005). nurse caring behavior can influence patients in quality services (prompahakul, c., nilmanat, 2011). in some previous studies, there were still caring attitudes and behaviors that nurses perceived were lacking by patients or by other nurses in the hospital. the current caring instrument is an original instrument that measures the attitudes or behavior of nurses, this has not paid attention to the administrative and environmental aspects of the hospital. the use of non-specific instruments results in incorrect measurement results. research on caring instruments has given birth to instruments that can measure caring according to the desired dimensions and aspects (suroso, 2016). the development of caring instruments based on the characteristics of the indonesian nation has never been done. the results of the literature study conducted by researchers found a study of developing caring instruments to be used in emergency nursing services. meanwhile, most of the research on caring in indonesia adopts instruments from other countries, of course, there are elements that are different from ours, for example, language. in addition to language, there are aspects that need to be considered to develop caring instruments in indonesia, namely nurse career paths, which are systems to improve performance and professionalism in the field of work through competencies that produce professional performance (kementrian kesehatan ri, 2017). by https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:dopaminsirup@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 403 developing caring instruments that are tailored to the characteristics of the indonesian nation, it is expected that caring measurements carried out in indonesia can be more specific and unbiased. several studies on caring nurses have been carried out with various caring parameters used or various kinds of caring questionnaires themselves. chen, s. y. conducted a validity study of the caring questionnaire namely the caring assessment report evaluation qsort (careq) in china. chen compared the level of nurse caring behavior seen from two sides, namely based on nurses' perceptions themselves and patient perceptions. this study provides information that there are significant differences in the level of caring between the assessments made by nurses and patients (chen, s.y., 2018). the validity and reliability study of the caring behavior questionnaire was also conducted by ayala, r.a. and calvo, m.j. this study examines the reliability of the asset assessment caring behavior (cba) questionnaire to be used in chile in spanish (ayala & calvo, 2017). fleming, r. developed a japanese version of the care planning assessment tool (j-cpat) whose original instrument was developed in australia for people with dementia (fleming, nagashio, kanegae, ichimaru, & koizumi, 2009). instrument development was carried out because then 2 million japanese people experienced dementia. a comprehensive assessment is vital in providing appropriate services and for improving the quality of life for elderly people with dementia. jcpat is valid and reliable for planning care in japan (fleming et al., 2009). this shows that there are differences in the assessment of caring behavior between countries so that adjustments are needed so that the questionnaire is more representative in its use. according to jean watson, caring is central to nursing practice because caring is a dynamic approach, where nurses work to further raise their concern for clients. the key to the quality of nursing care services is caring, empathy and caring. this is in accordance with the demands of the community at this time, namely to expect quality nursing services (muhlisin, 2008). with the caring instrument in accordance with the conditions and characteristics in indonesia, researchers in indonesia do not need to adopt caring instruments from other countries. it is hoped that more research on caring will result in better results because the instruments are more specific. the results of the literature study conducted by researchers obtained articles that developed caring instruments according to the conditions or characteristics of the nation or country. ayala research, r.a., and calvo, m.j develop caring instruments by prioritizing linguistic and cultural adjustment aspects (semantic disambiguation, morphosyntax, and language). one example of the difference in the original instrument at the different cba if applied in spanish is the parameter "know what they are doing" by analysis of the far difference. meanwhile, in fleming's research, the cpat adaptation process in japanese included: translation into japanese, item evaluation and modification if necessary, re-translation and comparison with the original, creating final results, assessing validity and reliability. there are additional items "the person interacts with the family" needed on the social interaction sub-scale. family interaction is an important care factor in japan where traditional family-based care is still expected. based on preliminary studies conducted by researchers through interviews with the nursing committee regarding the implementation of credentials in a large hospital, information was obtained that they had difficulty assessing nurses' caring behavior. according to them, caring evaluation parameters between clinic nurses and patients are sometimes in the instrument, but there are other activities from the nurse which are not caring behaviors but which are not in the instrument. while from the nurses' side when they filled out a questionnaire about caring behavior it stated that some of their caring activities were not on the instrument, such as doing caring by adjusting the ethnicity of the patient's culture. this states that caring assessment parameters do not reflect the actual conditions in the field. besides that, there is also no caring instrument that matches the characteristics of indonesian people which can be used for caring assessment. the nursing assessments are that the skills of nurses do care for patients increasingly trained with a large number of cases and patients and varied. based on the description above it is understandable the importance of developing caring instruments with an indonesian perspective. materials and methods systematic reviews or reviews are more widely used than descriptive reviews because they use systematic, explicit methods and reduce the effects of bias. the quality of the studies conducted can also be assessed and concluded based on the methodology used and the most votes (b’far, 2005). in this study, a systematic review methodology was used to identify, assess and compile evidence from research to develop caring measurement instruments; indonesian perspective. the stages in conducting a systematic review consist of 5 stages, namely (fling, 2009) are (1) question mapping. the problem to be analyzed must be specific, clear and the researcher prepares structured questions before the review. why do we have to develop caring instruments according to the indonesian perspective? what is the appropriate caring instrument to be applied in indonesia? how can the development of caring instruments be accepted and applied directly to indonesia?, (2) identification of relevant publications. a comprehensive literature search for literature published between 2009 and 2019 was carried out using several search engines including sciencedirect, c. p. asmoro, et al. 404 | pissn: 1858-3598  eissn: 2502-5791 scopus, google scholar, springerlink, ebscohost, proquest, wiley online. other criteria in search are articles with english and indonesian, accredited journals, theses, and dissertations. the search term is broadly determined with the aim of finding as much relevant literature as possible. the inclusion of one or more keywords or text terms is also determined with the aim of focusing the results on the desired topic. the keywords used are caring instruments, development of an instrument to measure care. of the 2100 articles obtained in the search results, researchers determined 15 articles that met the inclusion criteria, (3) assessing the quality of research. preparation of research questions (stage 1) and study selection criteria (stage 2), the next step is to describe the minimum acceptable design level. study designs were received from observation to experiment. another article is a book, domestic legislation that supports a systematic review of why we should develop caring measurement instruments with an indonesian perspective, (4) summarize the evidence. data synthesis consists of a tabulation of study characteristics, quality and results and also statistical methods to explore differences between studies and combined results. in this study, the search results were categorized in themes related to the development of caring measurement instruments with indonesian perspectives to be concluded based on the evidence found, (5) interpretation of findings. issues found in each of these stages must be met and the risk of bias or potential bias must be explored. exploration of heterogeneity can help determine whether general conclusions are reliable or high-quality research observations are needed to make conclusions. recommendations are generated based on the strength and weakness of the evidence or data found (khan, k.s., kunz, r., kleijnen, j., antes, 2003). the systematic review process as shown in figure 1. each article or abstract is read by the researcher with reference to the questions that have been mapped. systematic reviews or reviews are more widely used than descriptive reviews because they use systematic, explicit methods and reduce the effects of bias. the quality of the studies conducted can also be assessed and concluded based on the methodology used and the most votes (b’far, 2005). in this study, a systematic review methodology was used to identify, assess and compile evidence from research to develop caring measurement instruments; indonesian perspective. the stages in conducting a systematic review consist of 5 stages, namely (fling, 2009) : (1) question mapping, the problem to be analyzed must be specific, clear and the researcher prepares structured questions before the review. why do we have to develop caring instruments according to the indonesian perspective? what is the appropriate caring instrument to be applied in indonesia? how can the development of caring instruments be accepted and applied directly to indonesia? (2) identification of relevant publications. a comprehensive literature search for literature published between 2009 and 2019 was carried out using several search engines including sciencedirect, scopus, google scholar, springerlink, ebscohost, proquest, wiley online. other criteria in search are articles with english and indonesian, accredited journals, theses, and dissertations. the search term is broadly determined with the aim of finding as much relevant literature as possible. the inclusion of one or more keywords or text terms is also determined with the aim of focusing the results on the desired topic. the keywords used are caring instruments, development of an instrument to measure care. of the 2100 articles obtained in the search results, researchers determined 15 articles that met the inclusion criteria. (3) assessing the quality of research. preparation of research questions (stage 1) and study selection criteria (stage 2), the next step is to describe the minimum acceptable design level. study designs received from observation to experiment. another article is a book, domestic legislation that supports a systematic review of why we should develop caring measurement instruments with an indonesian perspective. (4) summarize the evidence. data synthesis consists of a tabulation of study characteristics, quality and results and also statistical methods to explore differences between studies and combine results. in this study, the search results were categorized in themes related to the development of caring measurement instruments with indonesian perspectives to be concluded based on the evidence found. (5) interpretation of findings. issues found in each of these stages must be met and the risk of bias or potential bias must be explored. exploration of heterogeneity can help determine whether general conclusions are reliable or highquality research observations are needed to make conclusions. recommendations are generated based on the strength and weakness of the evidence or data found (khan, k.s., kunz, r., kleijnen, j., antes, 2003). the systematic review process as shown in figure 1. each article or abstract is read by the researcher with reference to the questions that have been mapped. results search results are analyzed and categorized in large themes. in general, the theme is related to why we should develop caring measurement instruments jurnal ners http://e-journal.unair.ac.id/jners | 405 with the perspective of indonesians grouped into caring instrument development, cultural factors that influence the development of caring instruments, benefits of developing caring instruments, validity and reliability of the development of caring instruments. the results of the literature study conducted by researchers found several studies that used the cultural influence of a country in developing caring instruments. the research conducted by ayala, et al (2017) reports on the process of cultural adaptation from the caring behavior assessment tool for spanish. the results of the development of the instrument are considered valid and reliable and will facilitate caring measurements in countries with spanish (ayala & calvo, 2017). fleming, r. developed a japanese version of the care planning assessment tool (j-cpat) whose original instrument was developed in australia for people with dementia (fleming et al., 2009). instrument development was carried out because at that time around 2 million japanese people experienced dementia. a comprehensive assessment is very important in providing appropriate services and for improving the quality of life for elderly people with dementia. jcpat is valid and reliable for planning care in japan (fleming et al., 2009). the study conducted by piredda, et al developed and conducted psychometric testing of caring behavior scale nurses who speak italian. patient's perception of nurse caring behavior is a predictor of quality from care. caring behavior is culture-specific, but there is no instrument to measure the patient's performance regarding the caring behavior of nurses in italy. most measurements of caring behavior are very long, showing unclear psychometric performance, failing to assess actual behavior or not being widely used with different caring theories. the study aims to contribute to caring nurse investigations. the scale of caring behavior of nurses who speak italian is a measure with good construct validity and strong reliability in assessing the perception of hospitalized patients in italy on nurse behavior. this study contributes to the operationalization of caring and provides instruments that can be used regardless of the caring model in nursing practice. the nursing caring behavior scale (ncbs) shows excellent psychometric performance (piredda, m., ghezzi, v., fenizia, e., marchetti, a., mannis, m.g.de., sili, 2017). discussion andres's research aims to evaluate the validity and reliability and measure the technical competence of nurses in colombia with the spanish version of technological competency as caring in nursing instrument (tccni). tccni is translated into spanish. the spanish version of tccni shows consolidated validity, being a viable and reliable instrument for measuring nurse technology competencies in colombia. some dimensions of the spanish version of tccni; knowing is caring, professional and disciplinary values of nursing, care, and ethics, technological competency, healing (álvarez & díaz, 2017). the burbank study, et al shows that ageism has become an issue in the u.s. and also globally reflected in nurses' attitudes towards older patients. most research in this field measures the attitudes of the elderly differently from the feelings of nurses about caring in the elderly. the purpose of the study was to determine the reliability and validity of 24 perspective on caring for older patients (pcop) items and develop a scale using a tool that is useful for measuring nurses' perspectives on caring for the elderly at the u.s. and internationally (burbank, burkholder, & dugas, 2018). joseph s. et al reported the results of his research that many children, adolescents, and young people were involved in parents, siblings or other relatives who had an illness, disability, mental health problems or other needs for care or supervision. this study aims to develop two new instruments to be used in research with young carers to examine caring activities and psychological effects on them. the multidimensional assessment of caring activities checklist (maca-yc18) is a self-report measurement with 18 items used to provide a total index of caring activities by young people. the positive and negative outcomes of caring scales (panoc-yc20) is a self-report measurement with 20 items used to provide positive and negative results from caring (joseph, becker, becker, & regel, 2009). suhonen examines about adapting the scale of individual care for cross-cultural comparisons. cross-cultural comparison studies use instruments of reliability and validity that can increase awareness of differences and similarities between the ability of health workers to respond to individual patient needs in different health systems. the purpose of this study was to explain the process of translation and adaptation of the individualized care scale (ics) and test the reliability and validity of the study of cultural litas. given that ics has been proven to be a useful measure for assessing patients' perceptions of individualized nursing care in finland, greece, sweden and the united kingdom, additional populations are needed to establish the normative characteristics of the instrument (rn, r.s., adjunct, d.m., rnt, 2010). the results of the study by c. p. asmoro, et al. 406 | pissn: 1858-3598  eissn: 2502-5791 salimi show that nurses' caring behavior may be influenced by many variables. the purpose of this study was to develop an initial form of the instrument for evaluating the determinants of nurse caring behavior. the instrument uses a simple scale with good reliability and validity that provides comprehensive information about the determinants of caring behavior in a short time (salimi, s., azimpour, 2013). steele-moses examined the caring assessment for care givers (cacg). cacg revisions are reliable and valid and are useful for use in organizations. specially designed to measure the reigniting the spirit of caring program (steele-moses, koloroutis, & ydarraga, 2011). karhe, l., et al studied about the caring loneliness scale (carlos). this article assesses the constraints and constructs validity of the scale designed to measure patient experiences of loneliness in the relationship of professional care. this finding supports the reliability and validity of carlos for assessment of breast cancer and heart surgery but because of all the instruments, further validation is needed (karhe, l., kaunonen, m., koivisto, 2016). chen, et al conducted research on caring which aims to examine the validity and reliability of the chinese version of the caring assessment report evaluation q-sort (care-q). the results indicate high reliability and good content validity. the original instrument was translated into chinese and tested in taiwan. the scoring was modified using a likert scale between 1 and 7. several modifications were made to the chinese version of care-q. the instrument is made with 50 items on six factors. some of the factors modified, among others, comfort becomes anticipates and comfort, anticipates being respects, trusting relationship becomes a helping and trust relationship (chen, s.y., 2018). research galvin’s describes the qualitative development of tools that are sensitive to the dimension of human care informed by a life-world philosophical orientation. this tool can be applied to align staff with the human care dimension and offer items pointing to examples of humanizing and inhuman practice features in ways that have not been fully captured in caring literature (galvin et al., 2018). ‘caring for country 'by burges' is defined as indigenous participation in activities that are interrelated with the aim of promoting ecological and human health. ecological services on land owned by indigenous peoples attract several institutional investments. however, health outcomes related to the participation of indigenous people in 'caring for the country' activities have never been investigated. this study shows initial support for the validity of caring for the country concept and a questionnaire designed to measure it. the study also highlights the importance of investigating customary health promotion activities. further research in the same population is feasible to test generalizations from this questionnaire and to explore the relationship with other important indigenous health outcomes (burgess, c.p., berry, h.l., guntorpe w., baili, 2008). he t., et al investigated perceptions of caring in china. this research was conducted in mainland compare the perception of nurses and patients about nurses caring behavior. the concept of caring is important for patients and caregivers. if patients and caregivers feel differently caring behavior, patients may not have their needs met or will not be satisfied with nursing. the gap between the two groups showed that nurses need to improve their understanding of and response to the needs and expectations of the patient's actual and perceived. in china, patients need more support from nurses about their psychological needs (he, t., ms, y du, wang, l., zhong, z.f., y, xc., ms, 2013). dellamonica's study on the nurse caring patient development scale has two purposes. first, metasynthesis of qualitative studies on the perception of nurses, students and patients on nursing care to produce new definitions of care and the development and psychometric analysis of the new instrument the nurse caring patient scale (ncps). the second objective of this research is the development and testing of new instruments that measure the patient's perception of feeling cared for by a nurse. item for ncps is derived from descriptors meeting nurse-patient by the patient. ncps, an instrument valid reliable, can provide a means to measure aspects of nursing care that is not visible in addition to the current measures for quality and satisfaction, and it can provide a cross-cultural comparison to the differences so as to provide a response to the call for evidence-based practice and patient-centric care. ncps are also able to provide a more comprehensive evaluation of patient satisfaction with nursing care by assessing the patient's perception of nurses who currently hidden, and not measured (della-monica, 2008). conclusion the basis for providing nursing care for patients by nurses is caring behavior. nurse caring behavior can have an effect on quality services to patients. caring is the essence of nursing. in indonesia, there is a caring assessment for nurses based on nurse career paths that still need to be developed because it is still jurnal ners http://e-journal.unair.ac.id/jners | 407 not appropriate. research on caring has been carried out in indonesia by using instruments adopted from other countries. meanwhile, indonesia has its own characteristics that cannot be equated with other countries so that caring instruments need to be developed to be more suitable for use in indonesia. references alligood, m.r. tomey, a. m. (2014). nursing theoriest snd their work. usa: mosby elsavier. álvarez, d. a. r., & díaz, l. c. (2017). validity and reliability of the spanish version of the technological competency as caring in nursing instrument. investigacion y educacion en enfermeria, 35(2), 154–164. https://doi.org/10.17533/udea.iee.v35n1a04 ayala, r. a., & calvo, m. j. (2017). cultural adaptation and validation of the caring behaviors assessment tool in chile. nursing and health sciences, 19(4), 459–466. https://doi.org/10.1111/nhs.12364 b’far, r. (2005). mobile computing principle. new york: cambridge university press. burbank, p. m., burkholder, g. j., & dugas, j. (2018). development of the perspectives on caring for older patients scale: psychometric analyses. applied nursing research, 43(july), 98–104. https://doi.org/10.1016/j.apnr.2018.07.002 burgess, c.p., berry, h.l., guntorpe w., baili, r. s. (2008). development and preliminary validation of the â€tm caring for country â€tm questionnaire : measurement of an indigenous australian health determinant. international journal for equity in health, 7(26), 1–14. chen, s.y., et al. (2018). a chinese version of the caring assessment report evaluation q-sort scale for measuring patients perception on nurses caring behavior: reliability and validity assessment. international journal nursing practise, 18(4), 388–395. della-monica, n. r. (2008). development and psychometric evaluation of the nurse caring patient scale. boston collage. fawcett, j. (2005). analysis and evaluation of nursing models and theories (2nd ed). philadelphia: davis company. fleming, r., nagashio, t., kanegae, s., ichimaru, n., & koizumi, s. (2009). development of a japanese version of the care planning assessment tool. australasian journal on ageing, 29(1), 27–32. https://doi.org/10.1111/j.17416612.2009.00379.x fling, b. (2009). mobile design and development. usa: o’reilly. galvin, k. t., sloan, c., cowdell, f., ellis-hill, c., pound, c., watson, r., … brooks, s. (2018). facilitating a dedicated focus on the human dimensions of care in practice settings: development of a new humanised care assessment tool (hcat) to sensitise care. nursing inquiry, 25(3), 1–14. https://doi.org/10.1111/nin.12235 he, t., ms, y du, wang, l., zhong, z.f., y, xc., ms, x. (2013). perceptions of caring in china : patient and nurse questionnaire survey. international nursing review, 60(71073169), 487–493. joseph, s., becker, s., becker, f., & regel, s. (2009). assessment of caring and its effects in young people: development of the multidimensional assessment of caring activities checklist (maca-yc18) and the positive and negative outcomes of caring questionnaire (panocyc20) for young carers. child: care, health and development, 35(4), 510–520. https://doi.org/10.1111/j.13652214.2009.00959.x karhe, l., kaunonen, m., koivisto, a. (2016). development and validation of the caring loneliness scale. journal nursing meas, 24(3), 114e-129e. kementrian kesehatan ri. (2017). peraturan menteri kesehatan republik indonesia nomor 40 tahun 2017 tentang pengembangan jenjang karir profesional perawat klinis. jakarta. khan, k.s., kunz, r., kleijnen, j., antes, g. (2003). five steps to conducting a systematic review. j r soc med, 3(96), 118–121. muhlisin, a. (2008). aplikasi model konseptual caring dari jean watson dalam asuhan keperawatan. ber ilmu keperawatan, 1(3), 147–150. piredda, m., ghezzi, v., fenizia, e., marchetti, a., mannis, m.g.de., sili, a. (2017). development and psychometric testing of a new instrument to measure the caring behaviour of nurses in italian acute care settings. j adv nurs, 73(june), 3178–3188. potter, p.a., perry, a. g. (2009). fundamentals of nursing : fundamental keperawatan (edisi 7). jakarta: salemba medika. prompahakul, c., nilmanat, k. (2011). factors relating to nurses caring behaviors for dying patients. journal nurs, 1(1). respati, r. d. (2012). studi diskriptif perilaku caring perawat berdasarkan ruang rawat inap. universitas indonesia. rn, r.s., adjunct, d.m., rnt, a. b. (2010). adapting the individualized care scale for cross-cultural comparison. j caring scinece, 24, 269–278. salimi, s., azimpour, a. (2013). determinants of nurses ’ caring behaviors ( dncb ): preliminary validation of a scale. j caring scinece, 2(4), 269–278. steele-moses, s., koloroutis, m., & ydarraga, d. m. (2011). testing a “caring assessment for care givers” instrument. creative nursing, 17(1), 43–50. https://doi.org/10.1891/10784535.17.1.43 suroso, j. (2016). pengembangan instrumen caring pelayanan keperawatan gawat darurat rumah sakit. universitas gajah mada. swanson. (1991). empirical development of a middle c. p. asmoro, et al. 408 | pissn: 1858-3598  eissn: 2502-5791 range theory of caring. nurs res, 3(40), 161-166. watson, j. (1979). the philosophy and science of caring. boston: little brown. wolf, z.r., colahan, m., costello, a. (1998). relationship between nurse caring and patient satisfaction. med surg nurs, 2(7), 99–105. 126 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17046 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research implementation of the cipp evaluation model in indonesian nursing schools yakobus siswadi, grace solely houghty and triulan agustina universitas pelita harapan, jakarta, indonesia abstract introduction: the implementation of the indonesian national nursing competency test (innct) has faced several challenges, especially related to the low pass rate. the pass rate has decreased over time, but the number of examinees has increased. the aim of this study was to evaluate the nursing schools’ performance in innct using the context input process product (cipp) evaluation model. methods: a quantitative description was used in this study. the performance evaluation of nursing program questionnaire based on cipp was developed and used to collect the data. the participants in this study were faculty members and alumni from the nursing schools that were a member of ainec within region v. the variables of this study were the nursing school pass rate and the school’s performance. results: 320 participants were involved in this study. the passing rate of the nursing school in innct was in the moderate category. the cipp evaluation shows that out of the four aspects, there were two (2) aspects, namely “context and input” that were in the category of having met the requirements and two (2) aspects, namely “process and product”, were in the category exceeding the requirements. conclusion: nursing schools have fulfilled the government regulation based on the cipp evaluation and the nursing schools need to make a strategic plan to improve their performance and to increase their pass rate in innct. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords context input process product; model; implementation; model contact yakobus siswadi  yakobus.siswadi@uph.edu  universitas pelita harapan, jakarta, indonesia cite this as: siswadi, y., houghty, g. s., & agustina, t. (2019). implementation of the cipp evaluation model in indonesian nursing schools.jurnal ners, 14(3si), 126-131. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17046 introduction the indonesian national nursing competency test (innct) has been implemented since 2014. the innct is part of a standardization of registration and practices for nurses in indonesia. the innct has been developed as a computer-based test. all indonesian nursing students must take this test at the end of their program to get their nursing license. the indonesian government expecting that by implementing innct, this will increase the quality (ristekdikti, 2016). the implementation of the nnct has been beset with several challenges, especially the declining passing rate. the passing rate in the period iv/2015 was 53.61% or 6,222 out of 10,571 examinees and in the period xi/2018, it was 41.41%, where 5,957 had passed out of the 14,383 examinees (ristekdikti, 2018). low exam pass rates in the licensure examination have the potential for serious negative adverse effects on the school’s reputation, student body, accreditation and the continuity of a school’s program (brown-o’hara, 2013; grant, 2015; wade, 2011). the quality of a nursing education program is evidenced by the performance of its graduates on the licensure examination (bahari, 2015). from the indonesian perspective, a low passing rate indicates that there are gap and disparities in the performance of nursing education. on other hand, this will impact on the availability of nurses to fulfill the needs of the country. a low passing rate will impact on the availability of nurses to fulfill the needs of the country. indonesia has a lack of nurses; there is gap between the target and reality in term of nurses and the population ratio. the ministry of health stated that the nurse : population ratio was 158/100.000 in 2014 but the reality was that it was 87.65/100.000 in 2015. this means that there was a lack of 70.35 nurses. in 2019, the target is 180/100.00 (ministry of health of the republic of indonesia, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:jalina@ppukm.ukm.edu.my http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 127 2016). failures in the innct potentially add to the number of unemployed and this could be a burden for both their family and country. based on this background, there is a pressing need to evaluate the indonesian nursing school performance in the innct. the purpose of this study was to provide an insight into the indonesian nursing school performance focused on the indonesian national nursing competency test (innct) using the cipp evaluation model. materials and methods a descriptive quantitative design was used in this study. the population of this study consisted of the faculty staff and alumni from the nursing schools who were a member of ainec within region v. the convenience sample included all faculty staff and alumni who took part in the innct in the period 2017 through to 2018 and who either failed or passed. variables of the study were the nursing school passing rate and school performance in innct. the performance evaluation of nursing program questionnaire (penpq) based on the cipp evaluation model was developed and used as an instrument in the data collection. the results are categorized based on mean score: exceeded requirement = 3.26-4.00; met requirement = 2.51 – 3.25; partially met requirement = 1.76 – 2.50; and did not meet requirement = 1.00 – 1.75. the validity test of the instrument showed that the cronbach’s alpha value was .977. the data collection was done by surveymonkey. the link to the instrument was sent to the faculty and alumni coordinator or person in charge as assigned by the nursing school administrator through sms or whatsapp. the informed consent form was done electronically. the participants were required to fill out the informed consent form by clicking on the “agree” button on the screen after reading the research information and before being given full access to the instrument. the data was analyzed using the frequency, percentage and mean. the study was approved by the institutional review board of the mochtar riady institute of nanotechnology (mrin) protocol number 04.1807188. table 1. frequency and percentage distribution of the socio-demographics of the participants according to faculty (n=56) characteristics n % sex: male female 7 49 12.50 87.50 age: 25 year and below 26 – 35 years old 36 – 45 years old 46 – 55 years old 56 – 65 years old 66 years and above 1 29 14 7 3 2 1.78 51.78 8.13 12.50 5.34 3.57 education background: bachelor (s1) master (s2) doctor (s3) 10 42 4 17.85 75.00 7.15 teaching experience: 5 years and below 6 – 10 years 11 – 19 years 20 years and above 22 18 8 8 39.28 32.14 14.29 14.29 table 2. frequency and percentage distribution of the socio-demographic qualities of the participants who were alumni (n=264) characteristics n % sex: male female 51 213 19.31 80.69 age: 25 year and below 26 – 35 years old 36 – 45 years old 46 – 55 years old 209 41 12 2 79.17 15.53 4.54 .76 alumni type: regular non-regular 226 38 85.60 14.40 innct status: pass fail 201 63 76.13 23.87 y. siswadi, et al. 128 | pissn: 1858-3598  eissn: 2502-5791 results a total of 320 participants from six different nursing schools were involved in this study. the participants were both faculty staff (17.50%) and alumni (82.50%). most of the faculty staff were female (49 or 87.50%). the age of the majority of the participants ranged from 26 – 35 years old 29 (51.78%. only 2 or 3.57% were 66 years old and above. in terms of educational background, most of the participants had finished a master’s degree or s2 with 42 (75%); 4 or 7.15% hadf inished a doctorate, or s3. with regard to teaching experience, 22 or 39.28% had experience of 5 years and below, followed by 18 participants or 32.14% who had 6 – 10 years. see on table 1. the table shows that that the majority of the participants were 213 (80.69%). the majority of the alumni were 25 years old and below (209 or 79.17%). the alumni-participants were mostly of the regular type (226 or 85.60%) and the non-regular type consisted of 38 or 14.40%. the majority of them had passed the nnct (201 or 76.13%), while 63 or 23.87 failed (table 2). table 3 shows there were two (2) nursing schools in the high category for their passing rate and four (4) nursing schools who were in the moderate category. the highest average passing rate was 91.07% and the lowest was 37.80%. table 4 shows that the overall mean of the aspects “context” and “input” were in the met requirement category, while the aspects of “process” and “product” were in the exceeded requirement category. the sub aspect of “input”, such as leadership, student, faculty staff and the facility, were in the met requirement category. discussion the results of the study show that the majority (four; 66.66%) of the nursing schools were at a moderate level in terms of the average passing rate of innct. the highest passing rate was 91.07% and the lowest was 37.80%. these results show that there are disparities in terms of the passing rate and the gap was 56.5%. these disparities corroborate that there is still variety in the process of learning and in the education standard for every nursing program. the government, professional organization and nursing school association have released guidance or regulations such as the national standard of education and the blue print of innct as the basis for running a nursing program. the results also show that there were many retakes because of failure in the innct. this means that there were those who cannot work as professional nurses who could be potentially be an unemployed person. a strategy plan could be performed to support and help those who fail the nnct and the nursing school should have the responsibility to help them. the preview studies confirm that many contributing factors are involved in the licensure examination. these factors can be categories sorted into academic and non-academic. the academic factors include cumulative gpa (cgpa). cgpa significantly contributes to the success of the licensure examination (amankwaa, agyemangdankwah, & boateng, 2015; foley, 2016; grant, 2015; penprase, meghan harris, & qu, 2013; ristekdikti, 2018; siswadi y, 2018). moreover, the nursing subject grade was a significant predictor for licensure examination (breckenridge, wolf, & roszkowski, 2012; mcgahee, gramling, & reid, 2010; schooley & dixon kuhn, 2013; simon, mcginniss, & krauss, table 3. percentage distribution of the nursing school grouped according to passing rate school passing rate average category 2017-1 2017-2 2018-1 a 94.03 81.58 93.65 91.07 high b 59.09 28.57 45.83 45.63 moderate c 50.38 62.26 53.76 moderate d 30.77 32.73 43.37 37.80 moderate e 93.18 81.07 75.00 82.17 high f 63.16 53.13 37.14 54.29 moderate table 4. mean distribution of the assessment of the participants with respect to school performance based on cipp evaluation aspect mean category alumni faculty overall context 3.17 3.17 3.17 met requirement input: 3.25 2.23 3.24 met requirement curriculum 3.30 3.35 3.32 exceeded requirement leadership 3.26 3.22 3.24 met requirement student 3.25 3.23 3.24 met requirement faculty 3.23 3.19 3.21 met requirement facility 3.25 3.18 3.22 met requirement process 3.29 3.24 3.27 exceeded requirement product 3.23 3.38 3.30 exceeded requirement jurnal ners http://e-journal.unair.ac.id/jners | 129 2013). other studies found differently, in that there were no significant correlations between cgpa and academic achievement (siswadi y, sommers l c, 2017; ukpabi, 2008). non-academic factors that contribute to the licensure examination include sociodemography, which includes gender, age and the educational background of the parent (amankwaa et al., 2015; breckenridge et al., 2012). school accreditation level also contributed to the performance of the licensure examination (dator, 2016; gutierrez n p, 2016). the results of the cipp evaluation showed that two aspects (50%) such as “context” and “input” were in the met requirement category. the aspect “context” was the focus on the vision, mission and objective of the study program. clarity and socialization of the vision, mission and objectives to all civitas academica is needed to ensure the school’s achievements. vision helped the administrator and their team to become inspired and committed concerning a shared goal. the vision was a strong driving force for ongoing and systematic practice development and thus it established a culture that favored quality and safety improvement in patient care (martin, mccormack, fitzsimons, & spirig, 2014). the finding implies that the nursing school has not yet reached the highest standard or exceeded requirements. the aspect “input” includes the curriculum, administrator, students, faculty and facilities. four (4) sub aspects such as the administrator, students, faculty and facilities were rated as having met the requirements, and only curriculum exceeded requirements with a mean score 3.32. the category mean of the students and faculty was closed (3.25:3.23). the majority, or 4 out of 5, category means of the alumni were higher compared to the category mean of faculty. the overall category mean of the aspect “input” was 3.24 or met requirement. these findings corroborate that nursing schools have a problem in the majority sub aspect of “input”. the previous studies utilized the aspect of “input” and the relevant evaluation data for several proposes, such as to make decisions regarding subsequent program implementation regarding end-of-life education program (lippe m, 2017), for structuring decisions (patil y, 2015), and to help prescribe a project to address the identified needs (“using the context, input, process, and product evaluation model (cipp) as a comprehensive framework to guide the planning, implementation, and assessment of service-learning programs,” 2011). moreover, this evaluation was used as the bases for the recommendation of revising the course's curriculum and for increasing the facilities that included a library (mohebbi, akhlaghi, yarmohammadian, & khoshgam, 2011). the aspect “process” covers the implementation of the program either in the classroom activities, in the class laboratory and or in clinical practice; it also covers the monitoring, documentation and evaluation of the implementation of the program. there were 19 items used to evaluate the implementation of the process. the category mean was 3.27, or exceeded requirement. this finding implies that the nursing schools have exceeded the requirements of the national standard in terms of the aspect of “process”. the program evaluation monitors the project implementation process to help the staff carry out activities and for users to be able to judge the program’s performance (stufflebeam, 2003). the “process” evaluation is important in order to provide feedback to allow the program to be implemented correctly, to improve the program and to verity accountability in the work plan (chinta, kebritchi, & ellias, 2016; kahn et al., 2014; o’sullivan, 2013; pfitzinger m, 2016). in addition, another researcher explained that the “process” evaluation concerns the link between theory and practice and the implementation of the curriculum (stavropoulou & stroubouki, 2014). the aspect “product” is focused on the graduation rate, cgpa, passing rate and employment rate. there were 6 items reated to the ‘product’ aspect where the overall category mean was 3.30, or exceeded requirement. this implies that the aspect “product” was evaluated as having exceeded requirements but there was still problems related to the passing rate on the innct. the majority of the passing rates of innct were moderate. the passing rate is an indicator of the school’s quality. the quality of a nursing education program is evidenced by the performance of its graduates on the licensure examination (bahari, 2015). a nursing school’s reputation and standing with the national board can be at risk; students have a lot of money invested in their education and they may have to wait to gain employment (wade, 2011). the cipp evaluation model has been accepted worldwide and it is used in several settings. a clear picture and detailed explanation of the application of the cipp evaluation model in the nursing education setting was presented (singh, 2004). a limitation is that since the data collection used an online survey, it was a challenge to encourage the participants to participate in this study. not all alumni were a part of the whatsapp group or other social media in related groups. conclusion the nursing schools have been fulfilling the national standard of education based on the cipp evaluation model. there are areas of cipp that need to be improved in order to provide a higher level of standard, especially for the aspects of “context” and “input”. nursing schools should make a strategic plan to increase the pass rate of innct. references amankwaa, i., agyemang-dankwah, a., & boateng, d. (2015). previous education, sociodemographic characteristics, and nursing cumulative grade point average as predictors of success in nursing y. siswadi, et al. 130 | pissn: 1858-3598  eissn: 2502-5791 licensure examinations. nursing research and practice. https://doi.org/10.1155/2015/682479 bahari, g. m. (2015). a plan to promote nclex-rn success of saudi arabian nurse graduates. austin jpurnal of nursing & health care, 2(1), 1–8. breckenridge, d. m., wolf, z. r., & roszkowski, m. j. (2012). risk assessment profile and strategies for success instrument: determining prelicensure nursing students’ risk for academic success. journal of nursing education. https://doi.org/10.3928/01484834-2012011303 brown-o’hara, p. (2013). the influence of academic coaching on: baccalaureate nursing students’ academic success, perceptions of the academic coaching relationship, perceived nclex-rn exam readiness and success on the nclex-rn exam. chinta, r., kebritchi, m., & ellias, j. (2016). a conceptual framework for evaluating higher education institutions. international journal of educational management. https://doi.org/10.1108/ijem-09-2015-0120 dator, w. (2016). accreditation and its relationship to the performance in the nurse licensure examination of higher education institutions in the philippines. international journal of evidencebased healthcare. https://doi.org/10.1097/01.xeb.0000511624.93 121.49 foley, d. m. (2016). predicting student success: factors influencing nclex-rn rates in an urban university’s pre-licensure programs. grant, a. r. (2015). nclex-rn predictor test scores and nclex-rn success for first attempt test takers. available from proquest dissertations & theses global. gutierrez n p. (2016). level of accreditation and board performance on the colleges of nursing in the national capital region. international education & research journal, 2(5), 21–29. kahn, k. l., mendel, p., weinberg, d. a., leuschner, k. j., gall, e. m., & siegel, s. (2014). approach for conducting the longitudinal program evaluation of the us department of health and human services national action plan to prevent healthcareassociated infections: roadmap to elimination. medical care. https://doi.org/10.1097/mlr.00000000000000 30 lippe m, c. p. (2017). using the cipp model to assess nursing education program quality and merit. teaching and learning in nursing, 1–5. martin, j., mccormack, b., fitzsimons, d., & spirig, r. (2014). the importance of inspiring a shared vision. international practice development journal. mcgahee, t., gramling, l., & reid, t. (2010). nclexrn success: are there predictors. southern online journal of nursing research. ministry of health of the republic of indonesia. (2016). indonesian health profile 2015. mohebbi, n., akhlaghi, f., yarmohammadian, m. h., & khoshgam, m. (2011). application of cipp model for evaluating the medical records education course at master of science level at iranian medical sciences universities. procedia social and behavioral sciences. https://doi.org/10.1016/j.sbspro.2011.04.287 o’sullivan, c. a. m. (2013). evaluation of a successful high risk nursing student assistance program: one adn program’s journey. patil y, k. s. (2015). cipp model for school evaluation. scholarly research journal for humanity science & english language, 2(2), 2615– 2619. penprase, b. b., meghan harris, m. h., & qu, x. (2013). academic success: which factors contribute signifycantly to nclex-rn success for asdn students? journal of nursing education and practice. https://doi.org/10.5430/jnep.v3n7p1 pfitzinger m. (2016). evaluating baccalaureate curriculum end-of-life care content based upon end of life nursing education consortium (elnec) guidelines. the university of texas at austin. retrieved from https://repositories.lib.utexas.edu/bitstream/ha ndle/2152/39604/pfitzinger-dissertation2016.pdf?sequence=1 ristekdikti. (2016). implementasi uji kompetensi nasional bidang kesehatan sebagai langkah konkrit penjaminan mutu pendidikan tinggi kesehatan. ristekdikti. (2018). no title. retrieved from http://ukners.dikti.go.id/pages/statistik_lulus# schooley, a., & dixon kuhn, j. r. (2013). early indicators of nclex-rn performance. journal of nursing education. https://doi.org/10.3928/01484834-2013081908 simon, e. b., mcginniss, s. p., & krauss, b. j. (2013). predictor variables for nclex-rn readiness exam performance. nursing education perspectives. https://doi.org/10.5480/1536-5026-34.1.18 singh, m. d. (2004). evaluation framework for nursing education programs: application of the cipp model. international journal of nursing education scholarship. https://doi.org/10.2202/1548-923x.1023 siswadi y, sommers l c, h. g. s. (2017). faktor-faktor prediksi keberhasilan uji kompetensi nasional. in penguatan sistem uji kompetensi dalam meningkatkan kualitas profesi tenaga kesehatan untuk memperkuat daya saing bangsa di era global. bandung: lpuk-nakes and unpad. siswadi y, t. a. (2018). determinants of nursing licensure examination performance: a literature review. in h. malimi, k. abdullah, j. mcfarlane, j. evans, & y. sari (eds.), strengthening research capacity and disseminating new findings in nursing and public health. london: group, taylor & francis. stavropoulou, a., & stroubouki, t. (2014). evaluation of educational programmes the contribution of history to modern evaluation thinking. health jurnal ners http://e-journal.unair.ac.id/jners | 131 science journal, vol. 8, pp. 193–204. technological educational institute of athens. stufflebeam, d. l. (2003). the cipp model for evaluation. in international handbook of educational evaluation. https://doi.org/10.1007/978-94-010-0309-4_4 ukpabi, c. v. (2008). predicotrs of successful nursing education outcomes: a study of the north carolina central universit’s nursing program. educational research quarterly. using the context, input, process, and product evaluation model (cipp) as a comprehensive framework to guide the planning, implementation, and assessment of servicelearning programs. (2011). journal of higher education outreach and engagement, 15(4), 57– 84. wade, r. j. (2011). predicting nclex-rnreg pass rates: a regional study in the united states. http://e-journal.unair.ac.id/jners | 75 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.13908 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research evaluation of clinical nursing practice programme with preceptorship supervision (stake’s countenance evaluation model) syamsul anwar¹, yetti supriyati² and burhanuddin tolla2 1 student doctoral program, education research and evaluation, universitas negeri jakarta & lecture, faculty nursing, universitas muhammadiyah jakarta 2 lecture, doctoral program, universitas negeri jakarta abstract introduction: preceptorship is clinical education for nursing students by conducting constructive partnerships between nurse educators and practitioners. therefore, the purpose of this study was to find out the effectiveness of the preceptorship programme using the stake model evaluation programme in terms of aspects antecedents, transactions, outcomes and behaviours. methods: this study uses descriptive design with quantitative and qualitative approaches. the sample consists of 131 students, 22 clinical preceptors and 22 academic preceptors. the quantitative data were collected using questionnaires, observation and document studies. qualitative study was conducted using an interview. descriptive analysis uses mean, standard deviation, percentage, frequency distribution and qualitative analysis using a content analysis. results: the study evaluation found that at antecedent stage. about 68.2% to 90.9% clinical preceptors had a good preparation on the student preparation stages as perceived by the academic preceptor and preceptee. while in the stage of transaction, preceptors are able to teach nursing care and students to perform nursing care from simple to complex in accordance with the competencies achieved. only less than half (45.5%) of students had good implementation of nursing care, including assessment, diagnosis, planning, implementation and evaluation. however, more than 68% of them showed good professional attitudes and communication. the outcome phase obtained consistency in the result of the practice phase with the national competency test with value from 76.2% to 97.4%. conclusion: the majority of the antecedent, transaction stage, and outcome showed an average condition which requires an improvement in order to provide a good quality education programme. future studies may also need to design an alternative approach for students’ supervision in clinic. article history received: june 24, 2019 accepted: nov 23, 2019 keywords attitude; preceptee; preceptor; preceptorship; stake’s countenance contact syamsul anwar  syamsul_nisa@yahoo.co.id  faculty nursing, universitas muhammadiyah jakarta, jakarta, indonesia cite this as: anwar, s., supriyati, y., tolla, b. (2019). evaluation of clinical nursing practice programme with preceptorship supervision (stake’s countenance evaluation model). jurnal ners, 14(1),75-81. doi:http://dx.doi.org/10.20473/jn.v14i1.13908 introduction clinical learning with a preceptorship learning model is carried out by pairing between experienced nurses (preceptors) and nursing students (preceptees) over a certain period of time which has been previously determined. preceptorship aims to develop personal skills, communication, clinical skills, competence and self-confidence of nursing students when implementing nursing care (al-hussami, saleh, darawad, & alramly, 2011; jordan & farley, 2008; kim, 2007; mason & davies, 2013; yueju, 2005). preceptorship also teaches ethical dimensions and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1. s. anwar et al. 76 | pissn: 1858-3598  eissn: 2502-5791 integrates both theory and practice (bengtsson & carlson, 2015). preceptorship is also effective in achieving teaching goals so that ultimately the knowledge, skills and attitudes needed for nursing care are obtained (mcclure & black, 2013;varley, macnamara, & mannix-macnamara, 2012). the clinical teaching programme also teaches students to organise patient care and be able to build good communication with other staff. in the clinical setting, clinical nurses help the process in integrating and applying the role of professional nursing (murphy, 2014). clinical nurses also provide supervision to students and help them to apply the theoretical values obtained in academic studies(azizah & ropyanto, 2012; moyle, rickard, chambers, & chaboyer, 2015). during the process of the ongoing programme, clinical nurses in conducting supervision must have good skills, good nursing care abilities and clinical experience so that the learning process become effective (dahlia, harun, & usman, 2013). thus, by promoting a constructive partnership between nurse educators and clinical nurses, the knowledge transfer process during the preceptorship will run well (kaviani & stillwell, 2000). the preceptorship supervision model conducted by faculty of nursing muhammadiyah university in jakarta obtained a preliminary study which showed that supervision conducted by clinical supervisors was not optimal due to limited time to supervise. furthermore, 80% of the preceptors have many duties to do besides being preceptors; they are also care givers to their patients, so the supervision given to the students becomes ineffective. thus, the preceptors also work in shifts (morning, evening and night), so, in some cases, the supervision is represented by a staff nurse. the preliminary studies obtained that 45% of students said that they had not been optimal in nursing care, 55% were able to do nursing care, 75% of students’ skills were good and 25% had sufficient skills (fik umj, 2015). another study related to the effect of motivation from nursing supervisors towards students’ readiness to carry out clinical practice showed that 41.5% of students have good motivation and are ready to practice in the hospital and 58.5% are not ready (p = 0.008, p< 0.005) (pertiwi & ermayani, 2017). according to the results of preliminary studies and previous studies, we need evaluation to gather information about the implementation of the preceptorship on policies, the process carried out and the results of the programme (arikunto, 2008). the evaluation is needed to provide suggestions to policymakers so that these can be followed up in the future. thus, future prepared programmes can be useful for the recipient (ayurestianti, 2017). evaluation of this study used the evaluation process analysis designed by stake in 1967 (stufflebeam & coryn, 2014). this model also considers various dimensions and factors which have an impact on teaching and learning, quantitative and qualitative approaches (joseph & juwah, 2012). materials and methods the method used in this study is descriptive evaluation study approach with quantitative and qualitative approaches since the result of the study assessed the implementation of the preceptorship on policies, the process carried out and the results of the programme (brannen & brannen, 2017; nasional departemen pendidikan, 2008,). descriptive evaluation study is a research that has an aim to provide information for decision-makers (policy makers) related to a power or strength of a programme, seen from its effectiveness, cost, device, etc. descriptive research studies are designed to obtain the nature of the situation as it exists at the time of the study. thus, the aim of descriptive research is to describe what exists (ary, 1990). evaluation of this model consists of three stages, contexts (antecedents), processes (transactions) and results (outcomes). the evaluation format was developed by the team through extensive literature review and expert discussion. antecedents were focussed on preparation through preclinical test stage, curriculum and assessment of the facilities and infrastructure. transaction was related to the implementation of the supervision process from preceptors to students, competency achievement, implementation of nursing care, professional attitude, outcome and the results of a try out test conducted by aipni. this study was approved by the institutional review board and research and development from the affiliated university and information passed the ethics test number 0397a /f.9-umj /v/ 2016. data collection techniques used for quantitative study were questionnaire observation, documentation and attitude test scale (sukardi, 2014). qualitative study used an interview to explore more about the situation according to the informants’ experience and point of view. sample of this study consists of 131 students, 22 clinical preceptors and 22 academic preceptors. this study took place at islamic alliance hospital jakarta from may 2016 to november 2016. qualitative data were analysed using a content analysis, while quantitative data were described using a proportion for categorical data and mean and standard deviation for continuous data. table 1. antecedent evaluation (n = 131) indicator f % clinical preceptor sufficient 7 31.8 good 15 68.2 total 22 100.0 academic preceptor sufficient 2 9.1 good 20 90.9 total 22 100.0 preceptee (students) sufficient 24 18.3 good 107 81.7 total 131 100.0 jurnal ners http://e-journal.unair.ac.id/jners | 77 results antecedents the foundation of the professional nurse programme the results of interview with dean of faculty of nursing muhammadiyah university jakarta are reported as follows: “the clinical learning programme with preceptorship supervision model referred to the competency-based curriculum (curriculum basic competency) in 2010 which implements a professional programme inseparable from the academic programme by strengthening all the competencies.” students’ preparation through preclinical test stage the result of the preclinical test showed the average score of 131 students was 74.00. the evaluation of students’ preparation at antecedent stage was done by clinical preceptors, academic preceptors and students themselves by filling in questionnaires. table 1 shows the clinical preceptor assessment of students in the antecedent stage as preparation of preceptorship in the hospital, showing 68.2% with good evaluation. the assessment of academic preceptors to students showed 90.9% with good evaluation. thus, 81.7% students assessed them themselves with good evaluation. curriculum interview with dean of faculty of nursing muhammadiyah university jakarta “the education curriculum consists of the academic and professional stages curriculum, covering 60% of the core curriculum and 40% of the institutional curriculum. the institutional curriculum represents the speciality of each institution, which consists of 50% global ability and 50% intuitional ability. the output of professional nurses’ education curriculum must guarantee the achievements of competencies in accordance with the indonesian national qualification framework (iqf) rank 7.” the curriculum used refers to the study programme curriculum, which refers to the core curriculum of indonesian professional nurse education with indonesian national qualification framework at 7th level, which consists of two stages of education, academic stage and professional nurse stage. assessment of facilities and infrastructure this assessment used an observation sheet which includes the assessment of hospital land facilities (�̅�) = 68 with maximum score of 80%, and then categorised with the normal distribution model �̅� ≥ (𝜇 + 1,0𝑑) = �̅� ≥ 62.33. the conclusion category is good hospital and academic facilities. transactions implementation process the results of the implementation process of the preceptorship programme activities are obtained as follows: student orientation; the interview is conducted to the clinical supervisors who conduct orientation to students. … students who have been introduced have begun to participate in orientation activities. the implementation began with three students divided based on their competences, (p5) …when they got instructions from the campus, the contract continued to the implementation phase, where the clinical supervisors held orientation as part the requirement for students to practice in the hospital (p7) clinical preceptors are required to carry out the orientation process to students because the students need to be introduced to the hospital profile, both its vision and mission, its rooms, operational standard procedures, target of competencies, patient safety and nurse safety while give nursing care to patients. supervision process from preceptors in regard to students interview with the dean of faculty of nursing muhammadiyah university jakarta about the implementation process: …students meet the clinical supervisors and conduct a learning contract with them so both sides know their needs from each other in this learning programme. academic preceptors in collaboration with clinical preceptors provide gradual implementation, not carried out sporadically, from simple to complex activities. interview with academic preceptors about their supervision. … the supervision process is certainly applied in preceptors’ activities where the learning process is from simple to complex. students are also taught how to do one simple procedure, from understanding the procedure to how to perform it. learning from simple to complex is a part of the learning programme which moves from the easy part to the difficult part. this programme helps students to develop their ability from the cognitive and psychomotor side. furthermore, it can increase their self-confidence in managing cases. competency achievement interview with academic supervisors about competencies attained by students .... students are asked to make learning contracts, which explain competencies and what will be completed. academic supervisors prepare bpkm for students and supervisors. s. anwar et al. 78 | pissn: 1858-3598  eissn: 2502-5791 besides competencies and evaluation, bpkm also contains implementation of supervision and evaluation … (p1) …usually in a hospital, there are several wards where we will move students around and, for some wards, we cannot write down students’ competencies targets because it is determined on the majority of cases there…. the achievement of student competencies is written structurally in the students’ activity guidebook. besides the list of students’ competencies, the guideline book also contains the programme contract between students and clinical supervisors and then students and the academic supervisor regarding the competency targets to be achieved. but, if it is constrained, the clinical supervisor will roll out the students so they can get the competencies in other wards. thus, if there is no competency in the wards, it will be dealt with in discussion activities or case study presentation in the campus. implementation of nursing care implementation of nursing care evaluated by the academic supervisors can be seen in table 2. table 2 is obtained from assessment of 22 academic supervisors in regard to students’ nursing care implementation. in general, 50% of students are categorised with good ability with formulation, 45.5% with good ability of formulating diagnosis, 81.8% with good ability of planning the interventions, 68.2% with good ability to implement their interventions, and 59.1% with good evaluation. thus, the result of students’ assessment (131 students) to their performance shows 80.9% students with good ability, 73.3% can formulate diagnosis well, 85.5% can make good nursing care plans, 79.4% can implement the interventions well, and 75.6% perform good evaluation. during the interview, students said; … when carrying out our clinical practice, the head nurse gave us several case to take and manage. we were given the opportunity to follow and observe the preceptors’ while performing nursing care. then, after the preceptor thought we were capable enough to perform nursing care, she/he let us do the intervention and achieve our competency targets. (p6). the implementation of preceptorship makes the preceptors become mentor and supervisor to the students to perform nursing care to patients. they helped students by providing examples of implementing nursing care and gave students chances to perform nursing intervention (still under supervision). professional attitude the result for assessment of professional attitudes and communication performed by students, clinical preceptors and academic preceptors are obtained at table 3. the results of the assessment of professional attitudes and communication by 131 preceptees on themselves reached good values, 94.7% and mean average 16.6 assessment of communication was good at 84% and mean attitude of communication 20. assessment of professional attitudes and communication of 22 academic preceptors towards students achieving good grades was 77.3% with mean average professional attitude. communication assessment was 81.8% with mean communication table 2. nursing care implementation evaluation preceptor assessment diagnosing planning implementation evaluation f % f % f % f % f % academic sufficient 11 50 10 45.5 4 18.2 7 31.8 9 40.9 good 11 50 12 45.5 18 81.8 15 68.2 13 59,1 total 22 100 22 100 22 100 22 100 22 100 clinic sufficient 7 31.8 10 45.5 6 27.3 8 36.4 12 54.5 good 15 68.2 12 45.5 12 72.7 14 63.6 10 45.5 total 22 100 22 100 22 100 22 100 22 100 students sufficient 7 19.1 35 26.7 19 14.5 27 20.6 32 24.4 good 106 80.9 96 73.3 112 85.5 104 79.4 99 75.6 total 131 100 131 100 131 100 131 100 131 100 table 3. evaluation of professional attitudes and communication respondents evaluation competence score category professional attitude communication f % mean sd f % mean sd students sufficient 20 15.3 16.6 2.2 21 16 20 2.52 good 111 94.7 110 84 total 131 100 131 100 academic preceptors sufficient 5 22.7 16 2.44 4 18.2 28 3.44 good 7 77.3 18 81.8 total 22 100 22 100 clinical preceptors sufficient 7 31.8 15.7 2.46 9 40.9 26.54 2.46 good 15 68.2 13 59.1 jurnal ners http://e-journal.unair.ac.id/jners | 79 attitudes 28. the assessment of professional attitudes and communication of 22 clinical preceptors on students reached a good score of 68.2% with a mean professional attitude of 15.7. communication assessment was 59.1% with mean communication attitudes 26.54. outcome final evaluations of the preceptorship programme are from odd semester and even semester in academic year 2016/2017. graph 1 shows the distribution of average score from students of odd semester academic year 2016/2017 with the highest score obtained by the nursing seminar course with a score of 4.0, while the lowest average score was obtained by the emergency nursing with a score of 3.16. thus, for students in the even semester, the highest average score belongs to community health nursing with a score of 3.88 and the lowest average score is in emergency nursing with a score of 3.33. furthermore, the highest gpa for the odd semester was 4 and the lowest was 3.14, average gpa 3.47. the highest gpa for even semester was 4 and the lowest gpa was 3, average gpa 3.53. result of try out test conducted by aipni the result of a try out test held on february 4, 2017 by the indonesian nursing higher education association obtained results with the highest score of 72.2 in 2017 and the lowest score of 26.1. the competency test results of the preceptors' programme in odd semester and 2016/2017 academic year were even obtained with graduations of 76.2% and the odd semester 2016/2017 academic year were obtained by graduating 97.4% discussion the professional nurse programme with a preceptorship programme uses a competency-based curriculum (cbc or kbk) 2010, whereby students will be transplanted to senior nurses, namely preceptors. grafting students in this programme secures the supervision of their senior nurses. the aim of the clinical programme is to develop the knowledge, understanding and skills of new nurses to meet the requirements to work at a hospital. the progress and experience of new nurses can be monitored by ensuring their competence and satisfaction during their first year in clinical practice (forde-johnston, 2017). this process is called the transition phase, then, to facilitate this transition, preclinical programmes need to be implemented to encourage professional socialisation and help students achieve a level of trust in practice. preclinical exams or training will enhance the full-time practical experience with clinical preceptors (bourbonnais & kerr, 2007). students in their clinical practice need preceptors in order to obtain the competency skills needed to carry out care in safely, competently and with professional ethics in providing nursing care at the hospital. nursing care can improve student competences and increase knowledge about clinical teaching ( al-hussami et al., 2011; kim, 2007). on the other hand, to be preceptors, there are several criteria needed, including attitudes and behaviours, which include positive, patient and supportive behaviour, in addition to having the desire to motivate and inspire (anderson, 2008; moh, 2004; smedley, 2008; zilembo & monterosso, 2008 cited in haggerty, holloway, & wilson, 2013). the implementation process begins with the experience of students providing care to patients or assigned clients and having assistance, guidance and support from the supervisor. when competencies gradually increase, students assume more responsibility until they are able to carry out nursing tasks that are on par with a graph 1. students average score odd semester and even semester academic year 2016/2017 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 average score odd semester 2016/2017 average score even semester 2016/2017 s. anwar et al. 80 | pissn: 1858-3598  eissn: 2502-5791 novice practitioner in the chosen setting (bourbonnais & kerr, 2007). this study found that students’ preparation through preclinical test stage had a good preparation ranged from 68.2% to 90.9% as perceived by the academic preceptor and preceptee. the transition from classroom to clinical commonly makes a student feel fear or uncertainty (ham, 2004). to deal with this situation, nursing education should set the academic process or learning process that could facilitate students to have an opportunity to apply and refine the cognitive ability with affective and psychomotor skills. clinical training takes place in a complex social sense in which an educator takes care of the needs of patients, students and clinicians. however, previous study suggested that there were factors influencing the clinical preparation of nursing student interns, namely educator incompetency, nursing staff technical ability and a non-conducive learning environment (cheraghi, 2008). therefore, in designing clinical preparation for nursing practice there is need to consider competency of educators, technical ability and learning environment. this study also provides information on the ability of nursing students about the implementation of nursing care, including assessment, diagnosis, planning, implementation and evaluation. less than half of students showed good performance on these aspects. nursing students in particular often question why developing care plans is such an integral part of their education and training. this condition could happen due to nursing documentation covering a wide variety of issues, topics and systems; therefore, different hospitals or wards could have different styles or formats. given the problems of designing a care planning system that works well for nurses alone, it is understandable why it is much more difficult to build integrated systems that support interdisciplinary plans. conclusion this study discusses the evaluation of the preceptorship programme in the faculty of nursing, muhammadiyah jakarta, which includes antecedents, transaction and output/evaluation. the first stage, antecedents (context preparation), includes student evaluation, academic supervisors, clinical supervisors, curriculum, programme foundation, facilities and infrastructure. next is the transaction (process) and the guidance process is carried out following the clinical supervisor; the supervisor carries out activities customised to suit the competencies to be achieved by the student. in the process, the supervisors carry out the process of delegation; the stages carried out consist of student orientation and academic supervisors collaborating with clinical supervisors to provide supervision for students. the third stage, output / evaluation, is where evaluation conducted includes cognitive assessment, skills and competency tests, professional attitudes and communication, and behavioural attitudes. those objects of evaluation have criteria and standards which have been established from the beginning of evaluation and clinical behaviour as indicators to rank for clinical competencies (e.g. accountability, attitudes, judgements, communication). finally, the supervisors evaluate the students based on those evaluation criteria and ultimately ensure accuracy and consistency between student evaluations. this study suggested that, in designing clinical preparation for nursing practice, there is need to consider competency of educators, technical ability and learning environment. to improve the implementation of nursing care for students during their clinical practices, it is required to develop or create a new model in classroom teaching, for example, using virtual reality or using an actual case to help students have an overview about clinical situations and what they have to do as nurse. future studies may also need to design an alternative approach for students’ supervision in clinic. references al-hussami, m., saleh, m. y. n., darawad, m., & alramly, m. (2011). evaluating the effectiveness of a clinical preceptorship program for registered nurses in jordan. the journal of continuing education in nursing, 42(12), 569– 576. https://doi.org/10.3928/0022012420110901-01 arikunto, s. (2008). evaluasi program pendidikan. pt bumi aksara. https://doi.org/10.1109/tevc.2004.826389 ary, d. (1990). introduction to research in education 4th edn. ny: harcourt brace college publishers. ayurestianti. (2017). evaluasi pelayanan kesehatan dan pendidikan program keluarga harapan (pkh). masyarakat, jurnal pemberdayaan pemikiran, media pembangunan, dakwah, 1(2), 423–442. https://doi.org/10.14421/jpm.2017.012-10 azizah, l. k., & ropyanto, c. b. (2012). tingkat kepuasan bimbingan klinik mahasiswa. journal of nursing studies, 1(1), 219–224. bengtsson, m., & carlson, e. (2015). knowledge and skills needed to improve as preceptor: development of a continuous professional development course – a qualitative study part i. bmc nursing, 1–7. https://doi.org/10.1186/s12912-015-0103-9 bourbonnais, f. f., & kerr, e. (2007). preceptoring a student in the final clinical placement: reflections from nurses in a canadian hospital. journal of clinical nursing, 16(8), 1543–1549. https://doi.org/10.1111/j.13652702.2006.01828.x brannen, j., & brannen, j. (2017). mixing methods: the entry of qualitative and quantitative approaches into the research process.international journal of social research methodology, 8(3), 173-184, https://doi.org/10.1080/13645570500154642 jurnal ners http://e-journal.unair.ac.id/jners | 81 cheraghi, m. a, salasli, m, & ahmadi,f. (2008). factors influencing the clinical preparation of bs nursing student interns in iran. international journal of nursing practice, 14 (1), 26-33. doi: 10.1111/j.1440-172x.2007.00664.x. dahlia, s., harun, c. z., & usman, n. (2013). the performance of clinical instructor toward nursing internship students at mental hospital of aceh government. idea nursing journal, iv(1), 8– 17. forde-johnston, c. (2017). developing and evaluating a foundation preceptorship programme for newly qualified nurses. nursing standard, 31(42), 42–52. https://doi.org/10.7748/ns.2017.e10413 haggerty, c., holloway, k., & wilson, d. (2013). how to grow our own: an evaluation of preceptorship in new zealand graduate nurse programmes. contemporary nurse, 43(2), 162–171. https://doi.org/10.5172/conu.2013.43.2.162 ham, k, & o’rourke, e. (2004). clinical preparation for beginning nursing students: an experiential learning activity. nurse educator, 9 (4), 139-141. doi: 10.1097/00006223-200407000-00006 jordan, r., & farley, c. l. (2008). the confidence to practice midwifery: preceptor influence on student self-efficacy. journal of midwidery and women's health, 53(5), 413-420 https://doi.org/10.1016/j.jmwh.2008.05.001 joseph, s., & juwah, c. (2012). using constructive alignment theory to develop nursing skills curricula. nurse education in practice, 12(1), 52– 59. https://doi.org/10.1016/j.nepr.2011.05.007 kaviani, n., & stillwell, y. (2000). an evaluative study of clinical preceptorship. nurse education today, 20(3), 218–226. https://doi.org/10.1054/nedt.1999.0386 kim, k. h. (2007). clinical competence among senior nursing students after their preceptorship experiences. journal of proffesional nursing, 23(6), 369–375. https://doi.org/10.1016/j.profnurs.2007.01.019 mason, j., & davies, s. (2013). a qualitative evaluation of a preceptorship programme to support newly qualified midwives. evidence-based midwifery, 11(3), 94–98. mcclure, e., & black, l. (2013). the role of the clinical preceptor: an integrative literature review background. journal of nursing education,52(6), 335–341. https://doi.org/10.3928/0148483420130430-02 moyle, w., rickard, c. m., chambers, s. k., & chaboyer, w. (2015). the partnering with patients model of nursing interventions. healthcare (basel),3(2), 252–262. https://doi.org/10.3390/healthcare3020252 murphy, b. e. (2014). positive precepting: preparation can reduce the stress. medsurg nursing, 17(3), 183-188. nasional departemen pendidikan (2008). pendekatan, jenis, dan metode penelitian pendidikan. direktorat jenderal peningkatan kependidikan, pendidik dan tenaga nasional, departemen pendidikan. retrieved from stufflebeam, d.l, & coryn, c. l. s. (2014). evaluation theory, models & application (2nd edn.). san francisco: jossey-bass. varley, l., macnamara, c., & mannix-macnamara, p. (2012). preceptorship: exploring the experiences of final year student nurses in an acute hospital setting.journal of hospital aministration, 1(2), 42–53. https://doi.org/10.5430/jha.v1n2p42 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 111 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.14823 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effectiveness of auditory stimuli from murottal quran to improve comfort and weight in low birth weight infants: randomized controlled trial desriati devi, yuni rustina and defi efendi department of child, faculty of nursing, universitas indonesia, west java, indonesia abstract introduction: low birth weight (lbw) infants who have been hospitalized are exposed to various conditions that provoke discomfort, which could trigger a stress response and growth disorders. this study aimed to identify the effects of auditory stimuli from murottal quran when it comes to the comfort and weight of lbw infants. methods: this study used a clinical randomized controlled trial design involving 52 low birth weight infants. the infants were randomly assigned to either the intervention group (n=26) or the control (n=26). the intervention of murottal quran was given using a speaker 4 times a day for 20 minutes every 3 hours. this intervention was conducted for three days. results: the results of this study show that there is a significant difference in the comfort of low birth weight infants after murottal qur’an on the first, second, and third days between the intervention and control groups (p=0.014; <0.001; <0.001). there was no significant difference in the weight between the intervention and control groups in the first, second, and third days (p=0.481; 0.481; 0.464). conclusion: the auditory stimuli of murottal quran can help to improve the comfort level of low birth weight infants during hospitalization. it can therefore be used as a supportive therapy to facilitate low birth weight infant and premature infant development. article history received: august 13, 2019 accepted: december 16, 2019 keywords murottal quran; comfort; weight, low birth weight infants contact yeni rustina  y_rustina@ui.ac.id  department of child, faculty of nursing, universitas indonesia, west java, indonesia cite this as: devi, d, rustina, y, and efendi, d. (2019). the effectiveness of auditory stimuli from murottal quran to improve comfort and weight in low birth weight infants: randomized controlled trial. jurnal ners, 14(1), 111-117. doi:http://dx.doi.org/10.20473/jn.v14i1.14823 introduction hospitalized infants exposed to diverse environmental stressors can experience negative effects (majidipour et al., 2018; boxwell, 2010). environmental stress from varied medical devices and procedures causes discomfort in neonates (bouza, 2009). the increased stress response can lead to acute or prolonged effects (anderson & patel, 2018; hall & sanders, 2018). the stress response to physiological function could increase the risk of growth disorders, abnormal sleep patterns, hearing disorders, and developmental delay (almadhoob & ohlsson, 2015). loud sounds from medical devices could disrupt the respiratory system, affect oxygen consumption, cause an irregular heartrate (brown, 2009; wachman & lahav, 2011) and increase the energy consumption of hospitalized infants (wachman & lahav, 2011). this could disrupt their growth (valizadeh, hosseini, alavi, asadollahi, & kashefimehr, 2013; wachman & lahav, 2011). in one such study, pickler et al. (2013) showed that environmental stressors, like loud sounds, increased their nutritional intake compared to loud sound. this could disrupt the optimal nutritional fulfillment of hospitalized infants. one of the auditory stimuli that could be performed to reduce the stress response in neonates is murottal therapy, i.e. quran recitation (majidipour et al., 2018). murottal quran has indicated positive effects on the preterm infants’ vital stability (eskandari et al., 2012; marofi et al., 2018; qolizadeh, myaneh, & rashvand, 2018). it has been found to reduce their pain response during treatment in a neonatal intensive care unit (marofi et al., 2018). according to majidipour et al (2018), murottal could increase the physiological response https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.14823 d. devi et al. 112 | pissn: 1858-3598  eissn: 2502-5791 in neonates during painful invasive procedures. another study (rilla, ropi, & sriati, 2014) showed that murottal qur’an had more of an effect when it comes to reducing pain compared to music therapy. research studies related to murottal therapy given to infants in nicu are still very limited, therefore further research is needed as an evidencebased practice for improving the quality of the nursing care provided to neonates. majidipor et al (2018) and marofi et al (2018) conducted research to measure the effects of quran therapy on the physiological response to pain, but they did not look into the effects regarding comfort and weight. this made the writer interested in conducting research in order to identify the effects of auditory stimuli from murottal quran on the comfort and weight in lbw infants. materials and methods this study used a clinical trial incorporating randomization within a controlled trial conducted in parallel between two groups, namely the murottal quran intervention group and routine care group. this study was conducted in one of the hospitals in indonesia from march to may 2019. the number of samples was determined based on the previous study conducted by qolizadeh et al (2018). the standard deviation for the intervention and control groups was 13.6 and 10.8 respectively where the total respondents for each group was 32 and the combined standard deviation was 12.3. the researcher set 5% for error type 1 and 20% for error type 2 (power 80%). the calculation resulted in 50 samples. the number of samples involved in this study was 52 lbw infants who were treated in perinatology. the intervention and control groups were determined through block randomization (block size of four) using a random number table. the sample was chosen according to a random number table based on the sequence of lbws entering the perinatology. the total sample for each group was 26 lbw infants selected randomly (figure 1). the inclusion criteria consisted of: a birth weight of less than 2500 grams, did not have a hearing disorder based on the medical records, did not have congenital anomalies such as a congenital heart defect, not suffering from diarrhea, exhibited a stable physiological function i.e. pulse frequency 120-160 pulses per minute, respiratory rate 30-60 times per minute and body temperature 36.5-37.5 °c (rustina, 2015), possible for them to be weighed every day, age of 0-28 days, muslim, and the mother allowed her baby to be the respondent. the exclusion criteria were the babies who received sedative therapy during the intervention, who exhibited respiratory distress syndrome, and where the mother did not allow her baby to be a respondent. the outcome from this study focused on comfort and weight. comfort was measured using the observation sheet of the comfortneo scale (van dijk et al, 2009) consisting of alertness, calmness/agitation, respiratory response, crying, body movement, facial tension, and muscle tone. this instrument has never been used in indonesia before, therefore the researcher translated it into indonesian using the back-translation method. in this study, inter-rater reliability was executed and it involved 3 experts in order to check the agreement among the observers using the comfortneo scale. the agreement among the observers showed there to be a strong relationship or reliable based on the intraclass correlation coefficients, i.e. 0.982. this score indicated a very good or very satisfying inter-rater reliability (koo & li, 2016). the weights were measured using digital scales that had been calibrated in advance. figure 1. enrollment and random allocation flowchart randomly allocated into two groups (72 lbw infants) allocated to the intervention group (39 lbw infants) allocated to the control group (33 lbw infants) • discharged before the intervention was completed (12 lbw infants) • decreased fisiological responses (1 lbw infant) discharged before the intervention was completed (7 lbw infants) analyzed (26 lbw infants) analyzed (26 lbw infants) jurnal ners http://e-journal.unair.ac.id/jners | 113 the interventions of auditory stimuli from murottal quran given to the lbw infants were surah ar-rahman and yasin using an mp3 and a mini-portable speaker 4 times a day for 20 minutes every 3 hours in 3 days. the intervention was started after touching time (changing diapers, giving drink/breast milk or another routine intervention, and interaction with the parents) by playing the murottal quran through the mp3 player and speaker placed in the incubator. the speaker was placed 10-15 cm from the baby’s head (efendi, caswini, rustina, teguh, & iskandar, 2018). the first intervention was started at 9.3010.30 wib, the second intervention was started at 12.30-13.00 wib, the third intervention was started at 15.30-16.30 wib, and the fourth intervention was started at 18.30-19.30 wib. the weight was assessed at pre-intervention (baseline) on day 1 in intervention and control group. the infants’ weight was measured on days 2, 3 and 4 after the intervention and on days 1 to 3 for the intervention and control groups. the precomfort assessment was assessed before the first intervention in two groups using a video recorder for two minutes on days 1, 2, and 3. the video were taken within a distance of 30-40 cm. the post-comfort assessment was conducted right after the fourth intervention of murottal quran on days 1, 2 and 3. the comfort was assessed by 3 experts with a master's degree in pediatric nursing who have more than 3 years of experience of working in perinatology. the comfort observation sheet was completed after 3 days of the intervention. this research was approved by ethics committee of nursing faculty, universitas indonesia, no. 16/un2.f12.d/hkp.02.04/2019. before conducting the research on lbws that met the inclusion criteria, the researchers first met the parents and provided an explanation of the objectives, procedures and interventions that will be given to the lbws. if the parents were willing, the researcher asked for approval and offered them an informed consent form. a computer device was used to facilitate the data analysis in this study. the data normality test was measured using shapiro wilk. the analysis table 1. respondent’s characteristics and the homogeneity between the two groups variable intervention (n=26) control (n=26) p value sex male 14 12 1.000 female 12 14 nutrient type breast milk 0 0 0.224 formula milk 7 7 mix 19 19 birth weight (mean) 1620.96 (305.59*) 1552.31 (313.42*) 0.918 age (mean) gestasional age 32.50 (1.77*) 32.96 (2.29*) 0.381 chronological age 5.65 (5.78*) 8.69 (8.33*) 0.024 intervention (mean) pain procedure before intervention day 1 0.96 (1.11*) 0.73 (0.78*) 0.394 pain procedure before intervention day 2 0.65 (0.98*) 0.50 (0.58*) 0.228 pain procedure before intervention day 3 0.65 (0.85*) 0.38 (0.49*) 0.090 *levene’s test table 2. comfort and weight difference after the intervention of murottal quran between the two groups variable intervention group (n=26) control group (n=26) p value median min-max median min-max comfort day 1 day 2 day 3 weight day 1 day 2 day 3 9.50 7.50 7.00 1530.00 1535.00 1545.00 6-19 6-21 6-19 1140-2120 1270-2130 1250-2120 13.50 13.00 16.50 1445.00 1465.00 1460.00 6-30 6-29 6-30 1070-1920 1090-1920 1100-1980 0.014* <0.001* <0.001* 0.481 0.481 0.464 repeated mann-whitney test note: *significant at α (0.05) d. devi et al. 114 | pissn: 1858-3598  eissn: 2502-5791 between the groups was generated using a repeated mann whitney test for the non-parametric testing (dahlan, 2014). results the data for this study came from 52 lbw infants selected randomly for the intervention group (n=26) and control group (n=26). the respondents’ characteristics for this study comprised of sex, birth weight, gestational age, chronological age, nutrient type, and treatment before the intervention. the findings show that the number of male respondents was 14 in the intervention group and that the number of females was 14 in the control group. the most frequent nutrient type was a mixture of breast milk and formula, while the average birth weight in intervention and control group were 1620.96 grams and 1552.31 grams respectively. the average gestational age in both the intervention and control groups was 32.50 weeks and 32.96 weeks respectively. the average chronological age in the intervention and control groups was 5.65 days and 8,69 days respectively. the pain procedure before the intervention in the intervention group indicated an average of 0.96 on day 1, 0.65 on day 2, and 0.65 on day 3. meanwhile, in the control group, the average was 0.73 on day 1, 0.50 on day 2, and 0.38 on day 3. the characteristics between the groups showed a homogenous variation with a p value greater than 0.05. the characteristics and homogeneity can be seen in table 1. the result of the repeated mann-whitney test on comfort and weight in the intervention and control group on days 1, 2 and 3 after the intervention in the murottal group can be seen in table 2. the results showed there to be a significant difference in the comfort scale after the intervention between the intervention and control groups (p>0.05) with a median score in the intervention group that was less than the median score in the control group. the analysis from the repeated mann-whitney test on the infant’s weight between the intervention and control group on days 2, 3 and 4 did not show any significant difference after the intervention of murottal quran (p>0.05). discussion the effects of murottal quran to comfort murottal quran is a therapy that can reduce the level of stress because listening to and reading the quran increases the alpha waves in the brain. this gives more of a relaxation effect than classical music (zulkurnaini, shilawani, kadir, murat, & isa, 2012). the results of this study showed there to be a significant difference in comfort between the intervention and control group after the auditory stimuli from murottal quran was conducted for three days. this finding was in line with the research conducted by marofi et al (2018) who found there to be a significant difference in the pain intensity average in the neonates after being given murottal quran between the intervention and control groups in an intensive care unit. the treatment in an intensive care unit affects the brain, with one of the responses being triggering a stress response. the stress response activates the sympathetic nervous system and hypothalamus gland, in addition to the pituitary and adrenals (anderson & patel, 2018). according to anderson and patel (2018), the neonates in nicu that were exposed to music showed benefits related to the hypothalamus gland, pituitary, and adrenal (hpa). the sound of music could reduce the hpa stimuli by decreasing the cortisol level (yamasaki et al., 2012). this finding was supported by qiu et al (2017), who assessed 62 preterm infants related to the effect of music therapy on the infant pain profile, cortisol level, and β-endorfin. they showed there to be a decrease in pain score and increased β-endorfin after the music therapy was conducted for 2 weeks. another research study by loewy, stewart, dassler, telsey, and homel (2013) involving 272 infants resulted in an improvement in their sleep condition and a quiet period for those who received music therapy. keith, russell, and weaver (2009) conducted research on 22 infants in nicu and found that lullaby music significantly reduced the crying period after the music played. studies on the effect of quran recitation on the physiological responses of neonates have also been conducted by other researchers. several studies have showed there to be a significant difference in the physiological responses after receiving murottal quran therapy in neonates treated in nicu (eskandari et al., 2012; majidipour et al., 2018; qolizadeh et al., 2018). the sound of the quran could reduce the sympathetic nervous system activity in neonates, which can increase relaxation, reduce stress, and improve physiological responses such as the vital signs. listening to murottal quran is one of the alternatives for neonates as jurnal ners http://e-journal.unair.ac.id/jners | 115 it is a distraction from the varied stimuli in the nicu (qolizadeh et al., 2018). the effects of murottal quran on weight according to (yamasaki et al., 2012), music could influence the metabolic process due to the activation of the hpa system. this activation plays an important role in metabolism and energy balance. the cortisol produced by the hpa system triggers gluconeogenesis and glycogenesis that can trigger protein, fat, and carbohydrate catabolism. stress hormones can reduce the gastric activity and motility, which then prolongs gastric emptying and disturbs nutrient absorption. music could reduce their cortisol level, which decreases hpa activity, alters the catabolism process, and increases the amount of growth hormones (yamasaki et al., 2012). a similar thing was also stated by (lin et al., 2007) who found that there was an increase in gastric myoelectric activity in the respondents who listened to music, which increased their gastric motility and speeded up gastric emptying. this study showed no significant difference of weight between lbw infants who received auditory stimuli from murottal quran and those who did not. this finding was supported by farhat, amiri, karbandi, and esmaily (2010), who conducted research involving 44 very low weight birth infants with a gestational age of less than 34 weeks. they were given lullaby music over 8 days every day for 20 minutes. his study did not show there to be a significant difference in weight between the intervention and control groups. another study (standley, 2012) also supported the results of this study, which found that there was no significant weight difference in babies who received music therapy based on the meta-analysis effect of music therapy for babies in nicu. this finding was different from the study by auto, amancio, and lanza (2013) who conducted an analysis of the weight difference between the infants receiving music therapy over a 7 day intervention. in this study, the intervention was given over 3 days. a literature review related to the effect of music therapy in preterm babies showed that one of the positive effects of music on preterm babies was an increase in daily weight (neal & lindake, 2008). the increase in their daily weight did not show a significant difference in this study because the average age was 5.65 days. according to clark, spitzer, and olsen (2014), at 5-10 days old, the weight tended to remain the same and it would increase at 10-56 days old. the average of the respondent’s age was less than 10 days. this is one of the reasons why this study did not yield significant results. the study by auto, amancio, and lanza (2013) using a sample of 10-56 day old infants showed that there was a significant difference between the intervention and control group. according to standley (2012), birth weight was related to the effect of music therapy in neonates. this is based on the meta-analysis of music therapy on neonates in nicu. her research showed that music therapy was not significant on infants with a birth weight above 1500 grams. this was in line with the finding of this study where the average birth weight of the respondents was 1552 grams and 1620 grams for the two groups. the analysis yielded no significant differences between the intervention and control group after receiving auditory stimuli in the form of murottal quran. conclusion the finding of this study showed that auditory stimuli in the form of murottal quran is effective at improving the comfort of lbw infants treated in perinatology. in terms of weight, there was no significant difference. the auditory stimuli of murottal quran could improve the comfort of lbw infants during hospitalization. the result of this study can be used as one of the supportive therapies to facilitate low birth weight and premature infant development. further research should consider the infants’ age and weight, and making the intervention duration more than 3 days in order to yield more significant result. references almadhoob, a., & ohlsson, a. (2015). sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. cochrane database of systematic reviews, 1, cd010333. https://doi.org/10.1002/14651858.cd010333.p ub2 anderson, d. e., & patel, a. d. (2018). infants born preterm , stress , and neurodevelopment in the neonatal intensive care unit: might music have an impact ? developmental medicine & child neurology, 60(3), 256-266. https://doi.org/10.1111/dmcn.13663 auto, l., amancio, o. m. s., & lanza, f. de c. (2013). the effect of music on weight gain of preterm infants older than 32 weeks: a randomized https://doi.org/10.1002/14651858.cd010333.pub2 https://doi.org/10.1002/14651858.cd010333.pub2 d. devi et al. 116 | pissn: 1858-3598  eissn: 2502-5791 clinical trial. rev paul pediatr, 31(3), e293-299. http://dx.doi.org/10.1590/0103-058231369512 bouza, h. (2009). the impact of pain in the immature brain. the journal of maternal and neonatal medicine, 22(9), 722–732. https://doi.org/10.3109/14767050902926962 boxwell, g. (2010). neonatal intensive care nursing (2nd). usa: taylor & francis elibrary brown, g. (2009). nicu noise and the preterm infant. neonatal network, 28(3), 165–173. https://doi.org/10.1891/0730-0832.28.3.165 clark, r. h., spitzer, a. r., & olsen, i. e. (2014). assessment of neonatal growth in prematurely born infants. clinics in perinatology, 41(2), 295307. https://doi.org/10.1016/j.clp.2014.02.001 dahlan, m.s. (2014). statistik untuk kedokteran dan kesehatan: deskriptif, bivariat, dan multivariat, dilengkapi aplikasi menggunakan spss edisi 6. jakarta: epidemiologi indonesia efendi, d., caswini, n., rustina, y., teguh, r. a., & iskandar, p. (2018). combination of mother therapeutic touch ( mtt ) and maternal voice stimulus ( mvs ) therapies stabilize sleep and physiological function in preterm infants receiving minor invasive procedures, 24, 318324. https://doi.org/10.1016/j.jnn.2018.08.001 eskandari, n., keshavars, m., ashayeri, h., jahdi, f., & hosseini, a. f. (2012). quran recitation: short term and related factor in preterm newborn. research journal of medical sciences, 6(3), 148153. doi: 10.3923/rjmsci.2012.148.153 farhat, a., amiri, r., karbandi, s., & esmaily, h. (2010). the effect of listening to lullaby music on physiologic response and weight gain of premature infants . journal of neonatal-perinatal medicine, 3, 103–107. https://doi.org/10.3233/npm-2010-0101 hall, s. l., & sanders, m. r. (2018). trauma-informed care in the newborn intensive care unit : promoting safety , security and connectedness. nature publishing group, 38(1), 3–10. https://doi.org/10.1038/jp.2017.124 keith, d. r., russell, k., & weaver, b. s. (2009). the effects of music listening on inconsolable crying in premature infants medical center of central georgia. journal of music therapy, 46(3), 191– 203. doi: 10.1093/jmt/46.3.191 koo, t. k., & li, m. y. (2016). a guideline of selecting and reporting intraclass correlation coefficients for reliability research. journal of chiropractic medicine, 15(2), 155–163. https://doi.org/10.1016/j.jcm.2016.02.012 lin, h., chang, w., chu, h., huang, t., chao, y., & hsieh, t. (2007). effects of music on gastric myoelectrical activity in healthy humans. international journal of clinical practice, 61(7), 1126–1130. https://doi.org/10.1111/j.17421241.2006.01090.x loewy, j., stewart, k., dassler, a., telsey, a., & homel, p. (2013). the effects of music therapy on vital signs , feeding , and sleep in premature infants. pediatrics, 131(5), 902–918. https://doi.org/10.1542/peds.2012-1367 majidipour, n., nirouzad, f., madmoli, y., sarrafzade, s., aghababaeian, h., & borujeni, s. h. (2018). the effect of holy quran recitation on the physiological responses of premature infants during phlebotomy : a randomized clinical trial. international journal of pediatrics, 6(55), 7869– 7881. https://doi.org/10.22038/ijp.2017.24203.2038 marofi, m., abedini, f., shirazi, m., badiei, z., baghersad, z., & nikobakht, f. (2018). effect of the sound of the holy quran on the physiological responses and pain caused by blood sampling from the heels of hospitalized neonates at the neonatal intensive care unit. iranian journal of neonatology, 9(3), 57–63. https://doi.org/10.22038/ijn.2018.28102.1376 neal, d. o., & lindak, i. i. (2008). music as a nursing intervention for preterm infants in the nicu. neonatal network, 27(5), 319–327. doi: 10.1891/0730-0832.27.5.319 pickler, r., mcgrath, j. m., reyna, b. a., tubbs-cooley, h. l., best, a. m., lewis, m., … wetzel, p. a. (2013). effects of the neonatal intensive care unit environment on preterm infant oral feeding. research & reports in neonatology, (3), 15-20. https://doi.org/10.2147/rrn.s41280 qiu, j., jiang, y., li, f., tong, q., rong, h., & cheng, r. (2017). effect of combined music and touch intervention on pain response and β -endorphin and cortisol concentrations in late preterm infants. bmc pediatrics, 17(38),1–7. https://doi.org/10.1186/s12887-016-0755-y qolizadeh, a., myaneh, z. t., & rashvand, f. (2018). investigating the effect of listening to the holy qur’an on the physiological responses of neonates admitted to neonatal intensive care unit: a pilot study. advances in integrative medicine. article in press. https://doi.org/10.1016/j.aimed.2018.08.004 rilla, e. v., ropi, h., & sriati, a. (2014). terapi murottal efektif menurunkan tingkat nyeri. jurnal keperawatan indonesia, 17(2), 74–80. rustina, y. (2015). bayi prematur: perspektif keperawatan. jakarta: cv sagung seto. standley, j. m. (2012). music therapy research in the nicu: an updated meta-analysis. neonatal network, 31(5), 311–316. doi: 10.1891/07300832.31.5.311 valizadeh, s., hosseini, m. b., alavi, n., asadollahi, m., & kashefimehr, s. (2013). assessment of sound levels in a neonatal intensive care unit in tabriz. j caring sci, 2(1), 19–26. https://doi.org/10.5681/jcs.2013.003 van dijk, m., roofthooft, d. w. e., & anand, k. j. s. (2009). taking up the challenge of measuring prolonged pain in ( premature ) neonates the comfortneo scale seems promising. clin j pain, 25(7), 607–616. doi: 10.1097/ajp.0b013e3181a5b52a http://dx.doi.org/10.3923/rjmsci.2012.148.153 http://dx.doi.org/10.1093/jmt/46.3.191 http://dx.doi.org/10.1891/0730-0832.31.5.311 http://dx.doi.org/10.1891/0730-0832.31.5.311 https://doi.org/10.1097/ajp.0b013e3181a5b52a jurnal ners http://e-journal.unair.ac.id/jners | 117 wachman, e. m., & lahav, a. (2011). the effects of noise on preterm infants in the nicu. arch dis child fetal neonatal ed, 96(4), f305–9. https://doi.org/10.1136/adc.2009.182014 yamasaki, a., booker, a., kapur, v., tilt, a., niess, h., & keith d lillemoe, andrew l warshaw, c. c. (2012). the impact of music on metabolism. nutrition, 28(11–12), 1075–1080. https://doi.org/10.1016/j.nut.2012.01.020 zulkurnaini, n. a., shilawani, r., kadir, s. a., murat, z. h., & isa, r. m. (2012). the comparison between listening to al-quran and listening to classical music on the brainwave signal for the alpha band. ieee computer society, 181–186. https://doi.org/10.1109/isms.2012.60 http://e-journal.unair.ac.id/jners | 19 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18899 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review education-based mobile apps platform in patients undergoing surgery: a systematic review sariati sariati, esti yunitasari, laily hidayati faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: providing sufficient information during a pre-operative helps patients understand their condition and plan of care, to identify and manage potential complications, and to reduce hospital readmission. new innovation mobile application platforms put education in the hands of patients and their families. the aim of study was to investigate the effect of mobile application education in patients undergoing surgery. methods: a systematic review study was based on prisma (preferred reporting items for systematic reviews and meta-analyzes) with article sources using the scopus, science direct, pubmed and proquest databases. limited to the last 5 years (2015-2020) using english as well as full-text articles. this was done using a combination of keywords and boolean operators (and and or). keywords used in searching are “education” “pre-operative education”, "perioperative", "mobile application", “smartphone”, “multimedia” and "surgery". results: total article found were 438 articles and we just included 15 articles which related to topic. the design rct was 10 articles, 2 quasiexperimental articles, 1 cohort study, and 2descriptive study. mobile application platform has multiple benefit and challenges to effective delivery of health information to patients, new models of health care demand patient empowerment and so are fundamentally dependent on success with patient education. patients indicated they understood of the content prior to discharge. conclusion: additionally, patient demonstrated mobile application advances allow delivery of both individualized and ‘‘just-in-time’’ education. our findings indicate that education based mobile application platform have a positive effect on patients undergoing surgery. article history received: feb 27, 2020 accepted: april 1, 2020 keywords patient’s education; mobile application; surgery patients contact esti yunitasari  esti-y@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sariati, s., yunitasari, e., & hidayati, l. (2020). education-based mobile apps platform in patients undergoing surgery: a systematic review. jurnal ners, special issues, 19-24. doi: http://dx.doi.org/10.20473/jn.v15i2.18899 introduction surgical patients often experience pre-operative related problems such as anxiety and lack of knowledge (lin et al., 2016)(mundi et al., 2015). patients undergoing surgery are often faced with complex treatment decisions without sufficient information regarding the association of these choices with outcomes that matter most to them (panda et al., 2019).perioperatively, patient education helps patients understand their condition and the plan of care, to identify and manage potential complications, and to reduce hospital re admission. this type of information reduces healthcareassociated costs through decreased length of stay and improved self-management after discharge. effective patient education has multiple requirements; some relate to the form, content, and mode of delivery required for adults, whereas other contingencies are patient-sided challenges related to illness and hospitalization. finally, there are multiple requirements of providers. the format and delivery of education can impact a patient’s ability to learn and act. information acquisition is affected by the approach to education (type of setting, presenter), mode of delivery (written, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:esti-y@fkp.unair.ac.id s. sariati et al. 20 | pissn: 1858-3598  eissn: 2502-5791 electronic, face-to-face, etc.), and how often information is presented (tomaszek et al., 2019). adult education is most effective when the content is individualized, when multiple delivery means are utilized, and when delivery occurs in multiple sessions (stamenkovic et al., 2018). although perioperative education is critical, hospitalization creates patientdependent education barriers. surgery may result in pain, fatigue, and nausea; sleep deprivation, alteration of sleep wake cycles, medication effects, and cognitive impairment are also common, particularly in older adults (lee et al., 2014).there are also provider-dependent factors relevant to effective patient education. post-operative patient education has traditionally been delivered through writing (e.g., pamphlets), verbal instruction by a nurse, or a combination of these. with verbal education, nurses are typically responsible for the selection of topics that they perceive as important (cakmak et al., 2018).limitations of this approach include provider-dependent inconsistencies, disconnection between patient needs and the provider’s appraisal, providing too much information in written format, and information that may not correlate with patients’ knowledge level(hoon et al., 2013). furthermore, verbal only instructions are frequently forgotten or remembered inaccurately, and timing dyssynchrony between nurse and patient availability/readiness is common. educational topics may not be available, content inconsistencies are common, and keeping content up to date is difficult (patel et al., 2016). new approaches to patient education are required. there is a current growing movement in mobile technologies and applications that collaborate to build a new modality of healthcare (sousa & turrini, 2019).advances in mobile telecommunication, improved mobile internet and affordability have led to a significant increase in smartphone use within medicine (patel et al., 2016).mobile applications on smartphones have played an increasingly significant role in patientcentered health and medicine (panda et al., 2019). smartphone mobile apps have been developed to target both consumers and healthcare professionals in myriad scenarios and settings, such as health, fitness and lifestyle education and management apps, ambient assisted living apps, continuing professional education tools, and apps for public health surveillance (lalloo et al., 2017).e-learning on mobile applications is slowly becoming the standard of teaching in many fields because of multiple advantages, such as lack of physical barrier, flexibility, and options of asynchronous learning. technological innovations will continue to bring new solutions, but also new challenges at the same time (roy et al., 2019).the aim of this study was to identify the use of mobile application platforms in perioperative surgery. materials and methods this paper reported on a complementary intervention in the nursing area since 2015-2020. the study adopted a systematic literature review methodology to clarify the advantages of mobile applications on perioperative care in surgery patients. by systematically reviewing the literature, we were able to synthesize the existing literature and empirical evidence in a transparent and replicable way in order to identify areas where the knowledge is still scarce and to point out future research questions to academics, practitioners and policymakers. from a range of 438 papers in total, we identified 38 papers that need to be thoroughly revised and, after we decided on the inclusion criteria, it limited the papers down to 15 focused on mobile application and related multimedia innovation for perioperative care on patient undergoing surgery. figure 1. flow diagram s c re e n in g in c lu d e d e li g ib il it y id e n ti fi c a ti o n 438 studies identified through keywords and database searching 20 studies excluded due to duplication and not being relevant (titles and abstracts) 38 full–text studies assessed for eligibility 23 studies excluded due to the research methodology 10rcts, 2 in quasiexperimental, 1 cohort study, and 2 descriptive studies 15 studies included in the systematic review full-text articles assessed for eligibility (n = 58) jurnal ners http://e-journal.unair.ac.id/jners | 21 data collection the study uses a systematic review study based on prisma (preferred reporting items for systematic reviews and meta-analyzes), in searching for article sources using the scopus, science direct, pubmed and proquest databases. article search is limited to the last 5 years (2015-2020), articles that use english as well as full-text articles. this was done using a combination of keywords and boolean operators (and and or). keywords used in searching are “education” “pre-operative education” "perioperative", "mobile application", “smartphone”, “multimedia” and "surgery". study selection and data extraction the inclusion criteria of the research were 1) experimental and non-experimental studies (including descriptive study), 2) research conducted from 2015 to 2020 and 3) research samples or respondents who were patients undergoing surgery or related point of view about surgery. there was no age limitation for the participants in the article, because the focus of the search was on the mobile application usefulness and implication. the articles were clarified if the results of the study did not explain the estimated effects of the intervention and studies focusing only on describing the use of mobile application in educating patients. the steps of the data selection and extraction are reported in figure 1. results the results of the review of 15 journal articles used in this study are related to the benefits of mobile application and other kind multimedia innovation for surgery patient. the total number of respondents in this review was 1341 participants. the researcher found three articles that did not mention the number of participants. discussion the literature review showed that researchers have been analyzing mobile application benefit based on patient point of view. only limited study showed both advantages for patient and surgeon or physician point of view (patel et al., 2016)(uesugi et al., 2013).new models of mobile apps platforms demand patient empowerment and so are fundamentally dependent on success with patient education. remarkable advances in technology and information systems create previously unknown opportunities to achieve. in aging population having an average age over 60 years undergoing very major surgery, patients still utilize very aggressive education programs. furthermore, patients indicated they understood the content prior to discharge(roy et al., 2019). education tools and helping patient in making a decision mobile application can complement teaching techniques and educational tools in patient undergoing surgery (roy et al., 2019). in addition, it can potentially be used as a platform for helping patient in making a decision regarding appropriate recovery or dietary programs. the approach to education (setting, educator), mode of delivery (written, electronic, face-to-face, etc.), and timing may affect patient’s ability to retain information. education is most effective when the content is personalized, when multiple delivery means are utilized, and when delivery occurs in multiple sessions, the addition of multimedia material is associated with greater patient satisfaction and maximizes information gain (pecorelli et al., 2018). providing insight into the recovery of patients providing consultation may allow for considerable advances in shared decision-making, recovery monitoring, and patient engagement (panda et al., 2019).there has been remarkable growth in smartphones use among surgeons. apps are being developed for every conceivable use (patel et al., 2016). favorable experience patients reported favorable experience with app usage, reporting that it fits easily into their existing life pattern, while helping them prepare for surgery. the app accomplished the primary intent of costeffectively educating, assessing, and engaging patients (mundi et al., 2015).patients participating in the trial reported high usability and satisfaction with the app; most of them felt that the app was very helpful to understand and achieve their recovery goals and motivate them to recover from surgery (pecorelli et al., 2018). decreased anxiety levels the reduction in anxiety can be attributable to the audiovisual presentation, indicating that it might be easier to understand a video presentation than a purely verbal briefing (lin et al., 2016)(shao et al., 2019).patient anxiety may result from lack of information in the pre-operative period. the ‘fear of feeling ill’ component of anxiety was assessed by measurements. the pre-operative video addressed these two dimensions and described the experience that patients should expect during the perioperative period. previous studies of surgical patients indicate that pre-operative anxiety is reduced by having had positive experiences in previous surgery, feeling a sense of security and caring, being well-informed and having positive expectations. s. sariati et al. 22 | pissn: 1858-3598  eissn: 2502-5791 table 1. the studies included in the systematic review author type of study participants intervention outcome (bouwsma et al., 2018) rcts 433 participants an internet-based care program return to work (rtw) duration (lalloo et al., 2017) descriptive study 10 applications characterize, evaluate functionality of apps. character, content, and function of application (lin et al., 2016) rcts 100 participants educational anesthetic video anxiety, experimental effect, and satisfaction (mundi et al., 2015) rcts 30 participants algorithmic ema text messages satisfaction, behavior (panda et al., 2019) cohort study 139 participants application of accelerometer data post-operative physical activity (patel et al., 2016) descriptive study useful apps specifically helpful in the perioperative care of microsurgical reconstruction application on smartphone communication, storage, educational, flap monitor (pereira et al., 2019) rcts patients who underwent upper or lower extremity microsurgical reconstruction augmentation of reality for microsurgical planning with a smartphone (armps) information regarding vascular anatomy (roy et al., 2019) rcts 271 participants smartphone application as an educational tool effectiveness for teaching method (shao et al., 2019) rcts 128 participants multimedia-based pre-operative nursing visit stai score, vas scores and vital signs (pecorelli et al., 2018) rcts 45 participants mobile device application validity and usability (soh et al., 2019) rcts 44 patients mobile technology of incentive spirometer (is) (go-breath) performance rates of is count, active coughing, and deep breathing (sousa & turrini, 2019) quasiexperiment 30 participants educational mobile application usability and user satisfaction (rauwerdink et al., 2019) rcts patients undergoing elective colorectal surgery patient-centered mobile application compliance, health-related quality of life, physical activity, and patient satisfaction (pulijala et al., 2015) rcts 50 participants a mobile app with interactive 3d animations efficacy of sur-face (yang et al., 2016) quasi experiment 61 participants smartphone text messaging knowledge, anxiety supporting self-management of postoperative pain education was the most common self-management feature offered (lalloo et al., 2017). individually tailored pre-operative education and perioperative pain management planning, the use of validated pain assessment tools to track response to pain interventions and inform treatment adjustments as needed, as well as the use of evidence-based, nonpharmacological pain management (e.g., cognitive, behavioral strategies, physical modalities) in conjunction with indicated pharmacological modalities. a complex myriad of surgical, psychological, socio-environmental, and patientrelated risk factors have been shown to influence postsurgical pain experience. preand postsurgical psychological factors associated with increased pain include anxiety, depression, low self-efficacy, and the tendency to catastrophize about pain. apps that are designed to pair psychological and physical pain selfmanagement strategies with goal setting may be particularly effective for reducing pain and enhancing postsurgical outcomes. enhancing post-operative recovery in the days after surgery, patients receiving the intervention returned to work faster (bouwsma et al., 2018). implementation of mobile application through internet-based care program targeting the patient’s self-management leads to accelerated post-operative recovery following surgery. the majority of patients benefited greatly from the care program. patients reported slightly better on the outcomes recoveryspecific quality of life and pain (both intensity score and disability score) at two weeks following surgery. the differences disappeared with longer follow-up. jurnal ners http://e-journal.unair.ac.id/jners | 23 issues of confidentiality, consent, storage and data retention although, the benefits of smartphone apps to a microsurgical breast reconstructive surgeon are evident, the issues of confidentiality, consent, storage and retention warrant attention. there must be some caution with regard to storing and transferring patient’s sensitive data. there are both ethical and legal factors when processing this type of data, although guidance varies between countries. a clinical smartphone application, and collected data, used for patient care is likely to be considered part of a patient’s medical record, even when stored electronically. doctors should be aware of the applicable health records legislation within the country in which they practice. in addition, it is usual for local freedom of information legislation to give patients access their own clinical photographs if and when requested (patel et al., 2016). although there are multiple challenges to effective delivery of health information to patients, new models of healthcare demand patient empowerment and so are fundamentally dependent on success with patient education. additionally, we demonstrated that computing and technology advances allow delivery of both individualized and ‘‘just-in-time’’ education. finally, we showed that patients can quickly learn and consume education delivered with new, but user-friendly, technology. conclusion mobile computing allows for highly effective delivery of customizable, and, therefore, relevant, patient education. relevance is increased when the education is ‘‘just-in-time’’ and linked to the patients’ daily care experience. the potential for extending this health education model and the implications are profound, as we move toward care models where patients are informed, empowered participants in their healthcare. conflict of interest author was an independent researcher and declared no conflict of interest on this study. this study was not supported by any part of institutions or organization. no third party of mobile application or smartphone vendor endorsed the author. acknowledgement we thank our colleagues who provided insight and expertise that greatly assisted the research, although they may not agree with all of the interpretations of this paper. references bouwsma, e. v. a., huirne, j. a. f., van de ven, p. m., vonk noordegraaf, a., schaafsma, f. g., schraffordt koops, s. e., van kesteren, p. j. m., brölmann, h. a. m., & anema, j. r. (2018). effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation. bmj open, 8(1). https://doi.org/10.1136/bmjopen-2017017781 cakmak, m., kose, i., zinzircioglu, c., karaman, y., tekgul, z. t., pektas, s., balik, y., gonullu, m., & bozkurt, p. s. (2018). effect of video-based education on anxiety and satisfaction of patients undergoing spinal anesthesia. brazilian journal of anesthesiology (english edition), 68(3), 274–279. https://doi.org/10.1016/j.bjane.2018.01.004 hoon, l. s., chi sally, c. w., & hong-gu, h. (2013). effect of psychosocial interventions on outcomes of patients with colorectal cancer: a review of the literature. european journal of oncology nursing, 17(6), 883–891. https://doi.org/10.1016/j.ejon.2013.05.001 lalloo, c., shah, u., birnie, k. a., davies-chalmers, c., rivera, j., stinson, j., & campbell, f. (2017). commercially available smartphone apps to support postoperative pain self-management: scoping review. jmir mhealth and uhealth, 5(10), e162. https://doi.org/10.2196/mhealth.8230 lee, j. h., jung, h. k., lee, g. g., kim, h. y., park, s. g., & woo, s. c. (2014). effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients. korean journal of anesthesiology, 65(6), 508–518. https://doi.org/10.4097/kjae.2013.65.6.508 lin, s. y., huang, h. a., lin, s. c., huang, y. t., wang, k. y., & shi, h. y. (2016). the effect of an anæsthetic patient information video on perioperative anxiety. european journal of anaesthesiology, 33(2), 134–139. https://doi.org/10.1097/eja.00000000000003 07 mundi, m. s., lorentz, p. a., grothe, k., kellogg, t. a., & collazo-clavell, m. l. (2015). feasibility of smartphone-based education modules and ecological momentary assessment/intervention in pre-bariatric surgery patients. obesity surgery, 25(10), 1875–1881. https://doi.org/10.1007/s11695-015-1617-7 panda, n., solsky, i., huang, e. j., lipsitz, s., pradarelli, j. c., delisle, m., cusack, j. c., gadd, m. a., lubitz, c. c., mullen, j. t., qadan, m., smith, b. l., specht, m., stephen, a. e., tanabe, k. k., gawande, a. a., onnela, j. p., & haynes, a. b. (2019). using smartphones to capture novel recovery metrics after cancer surgery. jama surgery, 02114, 1–7. https://doi.org/10.1001/jamasurg.2019.4702 patel, n. g., rozen, w. m., marsh, d., chow, w. t. h., vickers, t., khan, l., miller, g. s., hunter-smith, d. j., & ramakrishnan, v. v. (2016). modern use of s. sariati et al. 24 | pissn: 1858-3598  eissn: 2502-5791 smartphone applications in the perioperative management in microsurgical breast reconstruction. gland surgery, 5(2), 150–157. https://doi.org/10.3978/j.issn.2227684x.2016.02.02 pecorelli, n., fiore, j. f., kaneva, p., somasundram, a., charlebois, p., liberman, a. s., stein, b. l., carli, f., & feldman, l. s. (2018). an app for patient education and self-audit within an enhanced recovery program for bowel surgery: a pilot study assessing validity and usability. surgical endoscopy, 32(5), 2263–2273. https://doi.org/10.1007/s00464-017-5920-3 pereira, n., kufeke, m., parada, l., troncoso, e., bahamondes, j., sanchez, l., & roa, r. (2019). augmented reality microsurgical planning with a smartphone (arm-ps): a dissection route map in your pocket. journal of plastic, reconstructive and aesthetic surgery, 72(5), 759–762. https://doi.org/10.1016/j.bjps.2018.12.023 pulijala, y., ma, m., & ayoub, a. (2015). design and development of sur-face: an interactive mobile app for educating patients regarding corrective surgery of facial deformities. springer international publishing switzerland, 1, 3–12. https://doi.org/10.1007/978-3-319-19126-3 rauwerdink, a., jansen, m., de borgie, c. a. j. m., bemelman, w. a., daams, f., schijven, m. p., & buskens, c. j. (2019). improving enhanced recovery after surgery (eras): eras apptimize study protocol, a randomized controlled trial investigating the effect of a patient-centred mobile application on patient participation in colorectal surgery. bmc surgery, 19(1). https://doi.org/10.1186/s12893-019-0588-3 roy, m., dip, f., rosales, a., roche, m., & hutchins, r. r. (2019). smartphone application as an education platform in hepato-pancreato-biliary surgery. surgical innovation, 26(5), 613–620. https://doi.org/10.1177/1553350619848210 shao, j., xiao, t., shi, m., zhou, x., wang, z., lin, t., xu, r., ni, h., & zhang, a. (2019). effect of multimediabased nursing visit on perioperative anxiety in esophageal squamous cell carcinoma patients undergoing video-assisted thoracoscopic surgery. psychology, health and medicine, 24(10), 1198–1206. https://doi.org/10.1080/13548506.2019.15956 87 soh, j. y., lee, s. u., lee, i., yoon, k. s., song, c., kim, n. h., sohn, t. s., bae, j. m., chang, d. k., & cha, w. c. (2019). a mobile phone–based self-monitoring tool for perioperative gastric cancer patients with incentive spirometer: randomized controlled trial. journal of medical internet research, 21(2), 1–11. https://doi.org/10.2196/12204 sousa, c. s., & turrini, r. n. t. (2019). development of an educational mobile application for patients submitted to orthognathic surgery. revista latino-americana de enfermagem, 27. https://doi.org/10.1590/1518-8345.2904.3143 stamenkovic, d. m., rancic, n. k., latas, m. b., neskovic, v., rondovic, g. m., wu, j. d., & cattano, d. (2018). preoperative anxiety and implications on postoperative recovery: what can we do to change our history. minerva anestesiologica, 84(11), 1307–1317. https://doi.org/10.23736/s03759393.18.12520-x tomaszek, l., cepuch, g., & fenikowski, d. (2019). influence of preoperative information support on anxiety, pain and satisfaction with postoperative analgesia in children and adolescents after thoracic surgery: a randomized double blind study. biomedical papers, 163(2), 172–178. https://doi.org/10.5507/bp.2018.060 uesugi, y., hayashi, s., fujishiro, t., kanzaki, n., & nishiyama, t. (2013). effectiveness of distance education intervention using video footage in postoperative patients after total hip arthroplasty. international journal of orthopaedic and trauma nursing, 17(2), 91–98. https://doi.org/10.1016/j.ijotn.2013.01.002 yang, j. y., lee, h., zhang, y., lee, j. u., park, j. h., & yun, e. k. (2016). the effects of tonsillectomy education using smartphone text message for mothers and children undergoing tonsillectomy: a randomized controlled trial. telemedicine and e-health, 22(11), 921–928. https://doi.org/10.1089/tmj.2016.0019 288 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17148 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of early mobilization on intestinal peristaltics in patients after a cesarean section in kendari city hospital andi herman1, budi santoso2 and esty yunitasari1 1faculty of nursing, universitas airlangga, surabaya, indonesia 2 faculty of medicine, universitas airlangga, surabaya, indonesia abstract background: cesarean section (cs) is the most significant surgical intervention that affects the central nervous system and that slows down the bowel movement after cs. intervention in the early period after cs is needed to improve bowel function. this study aims to determine the effect of early mobilization on intestinal peristalsis after cesarean section. method: this quasi-experimental study was conducted on 72 patients divided into two groups of 36 for the intervention group at dewi sartika public hospital and for the control group at kendari public hospital. a paired t-test was used for the data analysis. result: after the intervention, there was a significant improvement in intestinal peristalsis in the intervention group (p<0,05). conclusion: early mobilization is an effective intervention to improve intestinal peristalsis in patients after cesarean section. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords early mobilization; cesarean section; intestinal peristaltics contact andi hermawan  andi.herman2017@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: herman, a, santoso, b & yunitasari, b. (2019). the effect of early mobilization on intestinal peristaltics in patients after a cesarean section in kendari city hospital. jurnal ners, 14(3si), 288-291. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17148 introduction cesarean section is a major and common surgical procedure. sc is directly related to postoperative changes in the autonomic nervous system, which causes a decrease in bowel movements, which in turn causes several problems (ledari, barat, delavar, banihosini, & khafri, 2013). potential complications in post-sc patients include paralytic ileus, atelectasis, infection wounds, urinary retention and urinary tract infections (i̇zveren & dal, 2011). the average rate of sc is around 10-15% per 1000 births in the world (who, 2015). sc deliveries in the uk from 2008 to 2009 showed that the sc number increased by 24.6%, which in 2004 was around 24.5%. in australia in 2007, there was a 31% increase which in 1980 was only 21% (afriani, desmiwarti, & kadri, 2013). in indonesia, the rate of labor with sc reached 9.8% and in yogyakarta, the prevalence of labor with sc reached 15%. this prevalence is quite high, seeing as the highest prevalence occurring in jakarta is presently 19.9%. postoperatively, the anesthesia given to patients can affect the digestive tract by decreasing intestinal mobility. as a result of decreased mortality, peristalsis also decreases. decreased motility results in changes in the pattern of elimination, namely constipation (buhimschi et al., 2007; komariyah et al., 2013). post-sc mothers need intensive supervision to reduce the complications due to surgery by way of early mobilization (ung et al., 2010). early mobilization can influence the mother after cesarean section physically, as it has an effect on the cardiovascular system by increasing the cardiac output, strengthening the heart muscle, ensuring smooth circulation, improving the bodily metabolism regulation, restoring the physical work functions and keeping the vital signs within normal limits which will accelerate the wound healing process so then the risk of infection does not occur. otherwise, this trains the muscles and joints after surgery to prevent stiffness. in the digestive system, it increases gastric mobility and improves the abdominal muscle tolerance (brunner & suddarth, 2002; taylor et al., 2006). early mobilization is a policy that focuses on, as soon as possible, guiding the clients out of bed and guiding them as soon as possible to walk (ambarwati & wulandari, 2010). however, there are still many post-sc mothers who do not want to do early mobilization because the mother feels pain or https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:andi.herman-2017@fkp.unair.ac.id mailto:andi.herman-2017@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 289 because she is lazy because she is afraid of losing stitches on the 2-3 sc day (suhartini, heaven, & banks, 2014). research conducted in america shows that postoperative cesarean complications can rupture the uterine wall or cause homeostasis in the blood circulation resulting in bleeding and infection with 46% of all mothers being treated. this complication can be prevented by carrying out physical monitoring and early mobilization actions in postoperative cesarean section mothers (alanis, villers, law, steadman, & robinson, 2010; hartati & afiyanti, 2015). the early mobilization of the cesarean section can carried out by the mother several hours postchildbirth following a cesarean delivery. to prevent post-operative ssc complications, the mother must immediately be mobilized. after experiencing sc, the mother is advised not to be lazy and to move. the faster the move the better, but early mobilization must be carried out carefully as well (astriana, 2016). based on the description above, the researchers were interested in conducting a study on the effect of early mobilization on increased intestinal peristalsis in post-caesarean patients in kendari city hospital. materials and methods this study used a pretest-post-test quasiexperimental design with a control group. the sample consisted of 72 post-cesarean section patients divided into 2 groups; 36 for the early mobilization group in dewi sartika hospital and 36 in the control group in the municipal general hospital of kendari. the sampling technique used was non-probability sampling, specifically consecutive sampling. for the inclusion criteria, the conscious patients (compos mentis) aged between 20-40 years who were in the postpartum term, who were first-time cesarean section surgery patients, elective cesarean section patients and who were post-cesarean section patients who had undergone spinal anesthesia. the exclusion criteria were patients with a history of diseases such as hypothyroidism and neurological disorders, patients with a history of abdominal surgery other than a cesarean section, patients who have a history of digestive system disorders due to labor and patients with an inability to intervene. the intervention group began to be given after the patients were aware of the effects of anesthesia or 4 hours post-cesarean section starting with leg exercises. this intervention was carried out two times during the 10 hour period post-cesarean section (hours 4 and 7) or 3 hours by moving the legs through bending the knees and raising the legs-hold for a few seconds, then straightening the legs and lowering the bed. this was done 5 times for one leg and then repeated on the other leg. then they made a circle with the legs bent downward in close proximity to each other, before moving them upwards and then repeating this movement 5 times. the post-cesarean section change exercise was done once 10 hours posttable 1 respondents’ frequency distribution based on age, education level, profession and the indications of the post-caesarean patients' sectional section in kendari general hospital distribution of respondents n percentage (%) homogeneity test age 20 30 years 46 63,9 0,342 31 – 40 years 26 36,1 education primary school 6 8,3 0,293 junior high school 5 6,9 senior high school 47 65,3 bachelor 14 19,4 work housewife 49 68,1 0,212 entrepreneur 11 15,3 government employees 10 13,9 college student 2 2,8 indication of cesarean section cephalopelvic disproportion 43 59,7 0,310 breech location 19 26,4 location of buttocks 3 4,2 big baby 7 9,7 table 2 paired t-test test effect of early mobilization on increased intestinal peristalsis in post-cesarean patients in kendari city hospital variable early mobilization delta ∆ p value control delta ∆ p value pre post pre post mean + sd mean + sd mean + sd mean + sd intestinal peristaltics 11,31+1,489 15,81+1,849 4,500 0,000 11,31+1,470 14,22+1,290 2,917 0,000 a. herman, et al. 290 | pissn: 1858-3598  eissn: 2502-5791 caesarean section. the regulated position was lying on the right/left side, with the arm under the body flexed in front of the head or on the pillow. a pillow can be placed under the head and shoulders to support the sternocleidomastoid muscle. a pillow can also be placed under the hand to prevent the arm and shoulder from rotating inward. a pillow can be placed underneath it to prevent the thighs from forming and rotating inward and another pillow can be placed under the upper leg,while the upper leg is set slightly bent forward. this is carried out for 5 minutes and carried out alternately. the control group received standard therapy in the kendari regional general hospital room, namely concerning the early mobilization of patients 8 hours post-cesarean section for 15 minutes and up to 10 hours post-cesarean section. objective and subjective measurements were performed before and after the intervention. the collected data was analyzed using the paired t-test. the study was approved by the research ethics committee of the faculty of nursing, universitas airlangga and by the hospital where the study took place. all of the respondents were informed of the purpose of the study and consented to their participation in the study. result based on table 1, it shows the characteristics of the respondents based on age. the majority of the respondents had an age of 20 30 years by as many as 46 respondents (64.6%). the demographic data on the age of respondents in both groups showed a homogeneous data variant with a p-value = 0.342. for the characteristic of education, the highest number of respondents had a high school level education, as many as 47 respondents (65.3%). the demographic data on the education level of the respondents of the two groups showed a homogeneous data variant with a p-value = 0.293. for the job characteristics, most of them, totaling 49 respondents (68.1%), were housewives (irt). the demographic data on the profession of the respondents in both groups showed a homogeneous data variant with a p-value = 0.212. the characteristics of the indications of cesarean section showed that the highest number of respondents had cpd for as many as 43 respondents (59.7%). the demographic data indications of cesarean section in both groups showed a homogeneous data variant with a value of p = 0.310. intestinal peristalsis in the post-cesarean patient's section before and after getting an early mobilization intervention 3 times at the 4th hour, the 7th hour and the 10th hour post-cesarean section was obtained. the results were then tested using a paired t-test to see the results of the pre-test hour difference compared to the post-test at the 3rd hour and 12th hour. based on table 2, it shows that in the early mobilization group, there was an intestinal peristaltic enhancement of 4,500 and that the control group had an intestinal peristaltic increase of 2,917. after testing the data analysis using the paired test (α 0,05) in the early mobilization group, it obtained a p value of 0,000 which means that there is an effect from chewing gum on intestinal peristalsis in the postcesarean patients in kendari city hospital. discussion the early intervention group had an intestinal peristaltic enhancement of 4,500 and the control group had an intestinal peristaltic enhancement of 2,917. this study supports the study stating the effect of early mobilization on intestinal peristalsis in postlaparotomy patients who said that early mobilization can accelerate the function of intestinal peristalsis (ningrum, katuuk, & masi, 2018). early mobilization is carried out through exercises on the bed such as the left sloping right tilt and moving the extremities, thus making the air bubbles move from the lower right up to the hepatic plexus, leading to the left spleen flexus and down to the lower left towards the rectum. this can expel the flatus expenditure and stimulate intestinal peristalsis. early mobilization is an important aspect related to the patient’s physiological functions because it is essential to maintaining independence. early mobilization is an effort to maintain independence as early as possible by guiding the sufferers in maintaining their physiological function. the concept of early mobilization originates from early ambulation, which is a gradual return to the previous mobilization stage to prevent complications (windiarto, 2010). early mobilization in patients post-cesarean section is a non-pharmacological therapy that can be used to improve peristaltic intestine accelerating flatus time in a post-cesarean section patient. this is in line with (smeltzer & bare, 2002), who said that gastrointestinal dysfunction such as postoperative distension, decreased peristalsis and stool hardening can be prevented by increasing hydration and having an adequate level of activity. according to (iswati, 2010), moving will stimulate intestinal peristalsis to return to normal. activities will also help speed up the body's organs to work as before and the patients will feel healthier and stronger with early ambulation. with ambulation, the abdominal and pelvic muscles will return to normal so then the abdominal muscles become strong again. this can reduce the level of pain so then the client feels healthy. this can help them to gain strength, accelerate healing (buhimschi et al., 2007). moving will stimulate intestinal peristalsis to return to normal. this activity also helps to speed up the organs of the body to work as before. most patients still have concerns that if the body is moved into a certain position postsurgery then it will affect the unhealed surgical wound that has just been completed. almost all types of operations require mobilization or body movements as early as possible. as long as the pain can be restrained and the balance of the body is no longer a nuisance, by moving, the recovery period to reach the level of condition presurgery can be shortened. this, of course, will reduce jurnal ners http://e-journal.unair.ac.id/jners | 291 the time in the hospital, reduce financing and it can also reduce psychological stress (rahma, kasim, & angriani, 2011). early mobilization can be affected by an increase in intestinal peristalsis and in post-cesarean section patients in kendari city hospital. this is because early mobilization can stimulate the nerves of the sympathetic intestinal muscles, resulting in a wave of intestinal motility with an increase in the sympathetic work of the nerves. this will cause a release of acetylcholine so then there is an increase in acoustic wave conduction along the intestinal wall which can increase intestinal motility. conclusion the early intervention of mobilization has an influence on increasing intestinal peristalsis in postcesarean patients in kendari city hospital. early mobilization interventions can be used as self-care interventions to improve intestinal peristalsis in postcesarean section patients. references afriani, a., desmiwarti, d., & kadri, h. (2013). kasus persalinan dengan bekas seksio sesarea menurut keadaan waktu masuk di bagian obstetri dan ginekologi rsup dr. m. djamil padang. jurnal kesehatan andalas, 2(3), 116–121. alanis, m. c., villers, m. s., law, t. l., steadman, e. m., & robinson, c. j. (2010). complications of cesarean delivery in the massively obese parturient. american journal of obstetrics and gynecology, 203(3), 271-e1. ambarwati, e. r., & wulandari, d. (2010). asuhan kebidanan nifas. yogyakarta: nuha medika, 154. astriana, w. (2016). pengeluaran lochea rubra ditinjau dari mobilisasi dini pada ibu pasca operasi sectio caesarea. jurnal aisyah: jurnal ilmu kesehatan, 1(2), 67–70. brunner, s., & suddarth, d. (2002). buku ajar keperawatan medikal bedah. egc, jakarta. buhimschi, c. s., bhandari, v., hamar, b. d., bahtiyar, m.-o., zhao, g., sfakianaki, a. k., … norwitz, e. r. (2007). proteomic profiling of the amniotic fluid to detect inflammation, infection, and neonatal sepsis. plos medicine, 4(1), e18. hartati, s., & afiyanti, y. (2015). faktor-faktor yang mempengaruhi ibu postpartum pasca seksio sesarea untuk melakukan mobilisasi dini di rscm. jurnal keperawatan, 5(2), 192–197. iswati, n. (2010). gambaran penatalaksanaan mobilisasi dini oleh perawat pada pasien post appendiktomy di rs pku muhammadiyah gombong. jurnal ilmiah kesehatan keperawatan, 6(2). i̇zveren, a. ö., & dal, y. d. d. ü. (2011). abdominal cerrahi girişim uygulanan hastalarda görülen erken dönem sorunları ve bu sorunlara yönelik hemşirelik uygulamaları. hacettepe üniversitesi hemşirelik fakültesi dergisi, 18(2), 36–46. komariyah, k., adyani, a., st, s., kes, m., ainiyah, n. h., & st, s. (2013). asuhan kebidanan kehamilan, persalinan, nifas pada ny. v di bpm afah fahmi, amd. keb surabaya. universitas muhammadiyah surabaya. ledari, f. m., barat, s., delavar, m. a., banihosini, s. z., & khafri, s. (2013). chewing sugar-free gum reduces ileus after cesarean section in nulliparous women: a randomized clinical trial. iranian red crescent medical journal, 15(4), 330. ningrum, d. s., katuuk, m. e., & masi, g. n. m. (2018). pengaruh mobilisasi dini terhadap peristaltik usus pada pasien pasca laparatomi di rsu gmim pancaran kasih manado. jurnal keperawatan, 6(1). rahma, n., kasim, j., & angriani, s. (2011). hubungan mobilisasi dini terhadap kesembuhan luka pada pasien sectio caesarea di rskd ibu dan anak siti fatimah makassar. jurnal ilmiah kesehatan keperawatan. smeltzer, s. c., & bare, b. g. (2002). buku ajar keperawatan medikal bedah. jakarta: egc, 1223, 21. suhartini, s., heaven, s., & banks, c. j. (2014). comparison of mesophilic and thermophilic anaerobic digestion of sugar beet pulp: performance, dewaterability and foam control. bioresource technology, 152, 202–211. taylor, n., prescott, n., perry, g., potter, m., le sueur, c., & wathes, c. (2006). preference of growing pigs for illuminance. applied animal behaviour science, 96(1–2), 19–31. ung, c. y., lam, s. h., hlaing, m. m., winata, c. l., korzh, s., mathavan, s., & gong, z. (2010). mercuryinduced hepatotoxicity in zebrafish: in vivo mechanistic insights from transcriptome analysis, phenotype anchoring and targeted gene expression validation. bmc genomics, 11(1), 212. windiarto, n. (2010). perbedaan lama waktu pemulihan peristaltik usus pada pasien bedah dengan anestesi umum yang dilakukan ambulasi dini rom aktif dan pasif di rumah sakit bhakti wira tamtama semarang. universitas diponegoro. http://e-journal.unair.ac.id/jners | 91 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).18970 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research mental-emotional disorder among post-earthquake responders in ambon maluku cut mutia tatisina1, hamdan hariawan1, ahmad an naufal2 1polithechnic of health, ambon, maluku, indonesia 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: earthquake causes disruption of physical and mental health, such as stress. the government the assists the needs of victims of the earthquake to prevent disruption. the purpose of this study was to explain the factors related to mental-emotional disorder among postearthquake responders in ambon, maluku. methods: the design was observational analytics with a crosssectional approach. respondents were 174 people living near the epicenter and taken by simple random sampling. the independent variables were age, sex and work status, damage to the residence, the family members dying from earthquakes, and assistance from the government. the dependent variable was mental-emotional disorders. data of mental-emotional disorder were collected using the srq 20 (self-reported questionnaire) and analyzed using logistic regression (α <0.05). results: the results showed 69% of respondents experienced mentalemotional disorders. communities who were 17-25 years (or = 0.05; 95% ci = 0.005 0.491) tend to experience mental-emotional disorders. communities with moderate category of residence damage (or = 0.313; ci95% = 0.115 0.856) tend to experience mental-emotional disorders. communities with family members dying from earthquakes (or = 2,616; ci95% = 1,228 5,577) tend to experience mentalemotional disorders. communities who did not get residence compensation (or = 2,575; ci95% = 1,073 6,177) tend to experience mental-emotional disorders. conclusion: there were factors related to mental-emotional disorder among post-earthquake victims, such as teenagers who were 17-25 years old, community with residence damage and injured or died family members, and those who did not get assistance. assisting still needs to be done to prevent mental-emotional disorders of people affected by earthquake. article history received: feb 27, 2020 accepted: april 1, 2020 keywords mental-emotional disorder; postearthquake contact ahmad an naufal  ahmad.an.naufal-2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: tatisina, c. m., hariawan, h., & naufal, a. a. (2020). mental-emotional disorder among post-earthquake responders in ambon maluku. jurnal ners, special issues, 91-95. doi:http://dx.doi.org/10.20473/jn.v15i2(si).18970 introduction indonesia is known as one of the countries with high seismic activity because it is located in a circle of fire. indonesia is also flanked by three tectonic plates, namely the eurasian plate, the indo-australian plate, and the pacific plate. these geographical conditions increase the number of natural disasters in indonesia. disasters have an impact both physically and psychologically. one of the psychological effects of natural disasters is the emotional distress of disaster victims (kusdiah gemeliarini & helmi, 2018). earthquake was one of the recent natural disasters in ambon, maluku indonesia. the earthquake that occurred on september 29, 2019, produced a considerable impact on the community. a total of 247,437 residents were affected by the 6.8 m earthquake and as many as 30 people died, 83 were https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2(si). c. m. tatisina et al. 92 | pissn: 1858-3598  eissn: 2502-5791 seriously injured, and 85 people were slightly injured. physical impact in the form of damage to dwellings was also unavoidable, consisting of 59 heavily damaged houses, 45 moderately damaged houses, and 67 lightly damaged houses (aha centre, 2019; maipark, 2018). given the impact of the earthquake, the government provided logistical assistance along with guarantees for housing repairs according to the level of damage (ocha indonesia, 2018). although considerable assistance has been given by the government, earthquakes that occur can always affect the socioeconomic status of the victims, which can be psychological distress or mental-emotional disorders. the term mental-emotional disorders is used as an indicator of the mental health of the indonesian population with the aim that the public knows that the measuring instrument used is srq (self reporting questionnaire) (furukawa, takeuchi, yano, & muto, 2015; idaiani, prihatini, suryaputri, & indrawati, 2014). signs and symptoms of people who experience mental-emotional disorders after a disaster can be anxiety, depression, and ptsd. other psychological problems that can cause a person to experience mental-emotional disorders caused by an earthquake can be in the form of anxiety and fear of aftershocks and fears of occupying a place after an earthquake (ampuero, goldswosthy, delgado, & j, 2015; asim et al., 2019). mental-emotional disorders after a disaster depend on the size of the impact of the disaster caused. several previous studies mention the factors associated with post-disaster mental-emotional disorders can be in the form of demographic factors, community networks, living conditions, and employment status. many earthquake victims have lost family members, friends, and their homes after the disaster. in addition, job losses are also felt by many earthquake victims. therefore the purpose of this study is to determine the factors associated with mental-emotional disorders for earthquake-affected populations in ambon, maluku (furukawa et al., 2015; yamanouchi et al., 2017). table 1. potential factors correlated to mental-emotional disorder potential factors correlates n % gender male 59 34 female 115 66 total 174 100 age 17-25 years old 77 44.3 25-45 years old 36 20.7 46-65 years old 47 27 >65 years old 14 8 total 174 100 change in work status yes 109 62.6 no 65 37.4 total 174 100 loss of family yes 115 66 no 59 34 total 174 100 residence damage mild 86 49.4 moderate 47 27 severe 41 23.6 total 174 100 residence compensation yes 113 65 no 61 35 total 174 100 mental-emotional disorder yes no 120 54 69 31 total 174 100 table 2. analysis of potential factors correlated to mental-emotional disorder potential factors correlates or 95%ci p-value age (17-25 years old) 0.050 0.005-0.491 p = 0.010 change in work status 0.777 0.351-1.719 p = 0.533 died or injured family 2.575 1.073-6.177 p = 0.034 residence damage (moderate damage) 0.313 0.115-0.856 p = 0.024 residence compensation (no) 2.616 1.228-5.577 p = 0.013 jurnal ners http://e-journal.unair.ac.id/jners | 93 materials and methods this research was a descriptive analysis research with cross-sectional approach. the subjects in this study were the earthquake-affected population in ambon. the sample was 174 respondents with inclusion criteria 17-75 years and taken from one earthquake-affected region. the dependent variable is mental-emotional disorders while independent variables are potential correlates which include personal factors including gender, age, work status, loss of family, residence damage, and residence compensation. residence compensation was housing assistance from the government based on community answers through questionnaires. data were collected using the srq-20 (self-reported questionnaire) questionnaire from the ministry of health of the republic of indonesia which consisted of 20 questions. srq determines a person experiencing mental-emotional disorders through the accumulation of answers "yes" more or equal to 6 (rifati, 2012). the statistical tests used in this study are the chisquare test and the logistic regression test. chi-square test is performed to determine potential correlates that can be tested by logistic regression with α < 0.05. potential correlates not included in logistic regression are gender. this study has obtained ethical approval from the kepk poltekkes maluku ministry of health, the number of certificate lb.02.03/6.2/3045/2020. data collection the dependent variable is mirror therapy in combination with cylindrical grip and the independent variable is the self-care of post-stroke patients. the treatment group received mirror therapy combined with cylindrical grip while the control group received mirror therapy alone. interventions in each group involved as many as 2 sessions, 1 session with a duration of 15 minutes with intervals between sessions of 5 minutes, 3 times a week for a month. data were obtained through a questionnaire modified for the level of patient independence based on the theory of self-care from orem for assessing post-stroke patients’ self-care. twenty questions were used to assess post-stroke patients' self-care relating to each of the sub-variables eating, dressing, bathing/toileting and dressing. answers were categorized as follows: independence = 20, mild dependence = 12-19, moderate dependence = 9-11, heavy dependence = 5-8, total dependence = 0-4. this instrument was tested for validity on 15 stroke patients at banjarmasin hospital, and each question item had validity (r> 0.514) so that the instrument or question items correlated significantly to the total score (declared valid). the reliability test used cronbach's alpha with a value of 0.875> suggesting all items were reliable and all tests had consistently strong reliability. demographic data included gender, age, hands with hemiparesis, education, employment status and marital status. descriptive analysis was used for respondent characteristics. analysis of influence was undertaken using the wilcoxon sign rank test statistical test. this research protocol was declared to have passed an ethical test by the health research ethics commission of the faculty of nursing, airlangga university on october 14, 2019 with a certificate of ethics number 1786-kepk in an effort to protect human rights and patient welfare from therapy. results table 1 shows the characteristics of respondents which are also factors that can influence mentalemotional disorders. most of them were female (66%), aged 17-25 years (44.3%), and the change of work status to being unemployed after the disaster (62.6%). it was also found that most of the family members had become victims after the disaster (66%), both dead and seriously injured. and most of the population was affected by the earthquake with lightly damaged housing conditions (49.4%) with 65% received shelter compensation. as many as 69% of respondents experienced mental-emotional disorders. table 2 shows the results of the analysis of statistical test factors related to post-disaster mentalemotional disorders. statistical test results showed that sex was not associated with mental-emotional disorders because the chi-square results obtained were p = 0.352. factors related to post-disaster mental-emotional disorders based on statistical test results are communities who were 17-25 years (or = 0.05; 95% ci = 0.005 0.491), communities with moderate category of residence damage (or = 0.313; ci95% = 0.115 0.856), communities with family members died or injured from earthquake (or = 2,575; ci95% = 1,073 6,177), and communities who did not get residence compensation (or = 2,616; ci95% = 1,228 5,577). discussion this research shows that several factors have the potential to influence the occurrence of mentalemotional disorders in earthquake victims. these factors are age, the presence of family members who were injured or died, damage to housing, getting help from the government in the form of residence compensation. residence compensation is the respondent's answer through an interview with a questionnaire who claimed that he did not receive certainty as to whether he would be a recipient of compensation or not, while the data collection process related to disaster victims who are entitled to receive compensation which is still carried out by the government. however, the results of this study did not show gender differences affecting mentalemotional disorders. this is in contrast to previous studies which mention that women are more prone to c. m. tatisina et al. 94 | pissn: 1858-3598  eissn: 2502-5791 experiencing mental illness or psychological distress after a disaster (lawrence, lin, lipton, & birkhead, 2019). the same was found with changing job status. this study shows results that are different from previous studies which state that changes in the status of work during a disaster are associated with psychological distress that can lead to mental-emotional disorders. ambonese people are known as coastal communities, so most of them work as fishermen. after the earthquake, many of the victims of the disaster did not carry out activities as fishermen, but some of them temporarily switched to gardening for income. this can cause changes in work status and do not affect the occurrence of mental-emotional disorders (mendelson, turner, & tandon, 2010; pollack, weiss, & trung, 2016). the results of this study are following some previous studies which state that factors that can affect mental-emotional disorders include living conditions, loss of family members, and work status. in addition, the age group of children and adolescents are also more prone to experiencing emotional disorders after the disaster than the adult age group (asim et al., 2019). stress or mental-emotional disorders are affected by age. those aged 17-25 years with emotional instability have an impact on the readiness of coping mechanisms in dealing with a problem. this can be the cause of the age range of adolescents who are more prone to experiencing mental-emotional disorders in the aftermath of a disaster (allison, jessica, & brown, 2017). damage to housing also affects the mental and emotional victims of the earthquake disaster. but previous research says it is uncertain whether it is the damage to their homes or the conditions that require them to occupy their damaged homes are related to psychological stress (furukawa et al., 2015). on the other hand, providing socioeconomic support and compensation for housing can reduce psychological stress after a disaster. social and economic support can be considered a protective factor in the initial post-disaster phase. social support also provides long-term outcomes and reduces levels of anxiety or symptoms of excessive depression for those who are grieving and survivors of a disaster (thoresen, birkeland, arnberg, wentzel-larsen, & blix, 2019). not only damage to their homes, but earthquake victims with family members who died or were injured are also affected mentally and emotionally. people who feel lost or afraid of losing family members due to a disaster will be at risk of experiencing post-traumatic stress disorder, which is part of mental-emotional disorders. thus, people who have lost family members or have family members injured due to disasters require immediate psychiatric treatment (allison et al., 2017). mental-emotional disorders can also occur as a result of the emergence of post-disaster physical health problems. increased health problems after a disaster need to be given more attention to avoid factors that aggravate the emergence of mentalemotional disorders. therefore, we need the response of health workers to address public health problems holistically to improve health and prevent mental health problems (kajihara, munechika, sano, kaneko, & jin, 2017; kc, fitzgerald, & chhetri, 2019; saulnier, brolin ribacke, & von schreeb, 2017). earthquake causes a lot of doubts experienced by the victim, emotionally being the biggest loss. mentalemotional decline, due to the earthquake makes the stress level higher. psychological victims of the earthquake will feel they have lost many things, such as home and family and trauma persists for a long time. psychological development plays an enormous role in the coping mechanism of victims, age and experience are predisposing factors in the level of mental-emotional disorder. factors that influence the relationship between mental-emotional disorder are interrelated with loss of home, loss of family, loss of work, age and socioeconomic support. age is the main focus in the development of mental-emotional disorders, especially adolescents because the growth stage is still unstable and can be traumatized and loss of family and economy damaged by the earthquake. socioeconomic assistance and mental assistance from the government when there is a disaster can reduce the impact of mental-emotional disorder. the most important thing is to prepare early on about disaster learning because of the high level of disasters in indonesia; it is hoped that all people are ready and not experiencing severe mental-emotional disorder. conclusion one of the earthquake impacts is mental-emotional disorder. there are factors related to mentalemotional disorder, such as the presence of family members who were injured or died, as well as damage to the residence in regard to the assistance obtained. those injured or had family members died due to disaster will be at risk of post-traumatic stress disorder as mental-emotional disorder sign. socioeconomic support such as compensation for residence damage can prevent mental-emotional disorder post-disaster. conflict of interest no conflicts of interest have been declared acknowledgement the authors of this study would like to thank to polithechnic of health ambon (maluku) for providing the opportunity to present this study. references aha centre. (2019). m 6.5 earthquake in ambon, indonesia. jakarta. allison, g., jessica, w., & brown, l. m. (2017). disaster mental health services review of care for older persons after disasters. disaster medicine and jurnal ners http://e-journal.unair.ac.id/jners | 95 public health preparedness, 1–7. https://doi.org/10.1017/dmp.2017.60 ampuero, d., goldswosthy, s., delgado, l. e., & j, c. m. (2015). using mental well-being impact assessment to understand factors influencing well-being after a disaster. impact assessment and project appraisal, 33(3), 184–194. https://doi.org/10.1080/14615517.2015.10235 64 asim, m., ahammed, m., sathian, b., elayedath, r., kumar, r., simkhada, p., & teijlingen, e. van. (2019). post-traumatic stress disorder among the flood affected population in indian subcontinent. nepal journal of epidemiology, 9(1), 755–758. https://doi.org/10.3126/nje.v9i1.24003 furukawa, h., takeuchi, t., yano, e., & muto, s. (2015). factors influencing psychological distress after the great east japan. journal ofcommunity psychology, 43(5), 521–526. https://doi.org/10.1002/jcop idaiani, s., prihatini, s., suryaputri, i. y., & indrawati, l. (2014). mental emotional disorder pattern of indonesian population: a study of national basic health research 2007 and 2013. j indon med assoc, 64(april), 170–176. kajihara, c., munechika, m., sano, m., kaneko, m., & jin, h. (2017). changes in the functions for continued healthcare services during a disaster. prehospital and disaster medicine, 32(s1), s54– s55. https://doi.org/10.1017/s1049023x17001510 kc, j. k., fitzgerald, g., & chhetri, m. b. p. (2019). health risks and challenges in earthquake responders in nepal : a qualitative research. prehospital and disaster medicine, 34(3), 275– 281. https://doi.org/10.1017/s1049023x19004370 kusdiah gemeliarini, i. g. a., & helmi, m. (2018). earthquake capacity assessment based on geospatial model at north lombok, west nusa tenggara. e3s web of conferences, 73, 03014. https://doi.org/10.1051/e3sconf/20187303014 lawrence, w. r., lin, z., lipton, e. a., & birkhead, g. (2019). after the storm: short-term and longterm health effects following superstorm sandy among the elderly. disaster medicine and public health preparedness, 13(1), 28–32. https://doi.org/10.1017/dmp.2018.152 maipark. (2018). statistical report on catastrophic event: ambon earthquake 2019. jakarta. mendelson, t., turner, a. k., & tandon, s. d. (2010). social class as moderator of the relationship between (dis)empowering processes and psychological empowerment. journal of community psychology, 38(5), 607–621. https://doi.org/10.1002/jcop ocha indonesia. (2018). 7.0m earthquake lombok, indonesia. pollack, a. a., weiss, b., & trung, l. t. (2016). mental health, life functioning and risk factors among people exposed to frequent natural disasters and chronic poverty in vietnam. bjpsych open, 2(3), 221–232. https://doi.org/10.1192/bjpo.bp.115.002170 rifati, l. (2012). higher risk of probable mental emotional disorder in low or severe vision subjects. health science journal of indonesia, 2(1 apr), 9–13. https://doi.org/10.22435/hsji.v2i1apr.55.9-13 saulnier, d. d., brolin ribacke, k., & von schreeb, j. (2017). no calm after the storm: a systematic review of human health following flood and storm disasters. prehospital and disaster medicine, 32(5), 568–579. https://doi.org/10.1017/s1049023x17006574 thoresen, s., birkeland, m. s., arnberg, f. k., wentzellarsen, t., & blix, i. (2019). long-term mental health and social support in victims of disaster : comparison with a general population sample. bjpsych open, 5(2), 1–6. https://doi.org/10.1192/bjo.2018.74 yamanouchi, t., hiroshima, m., takeuchi, y., sawada, y., takahashi, m., & amagai, m. (2017). factors associated with worsened or improved mental health in the great east japan earthquake survivors. archives of psychiatric nursing. https://doi.org/10.1016/j.apnu.2017.10.005 98 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.16262 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research cardiovascular risk estimation in patients with hypertension: a crosssectional study nyayu nina putri calisanie, santi susanti, and linlin lindayani sekolah tinggi ilmu keperawatan ppni west java, bandung, west java, indonesia abstract introduction: cardiovascular disease is a disease caused by the misfunctioning of the heart and blood vessels. atherosclerosis is the main cause of cardiovascular disease. prevention and control of cardiovascular disease can be done with early detection through screening activities. framingham risk score using body mass index (frs bmi) risk assessment is very useful and easy, which is used without using lipid indicator. this study aims to estimate the risk of cardiovascular disease on patients with hypertension with framingham risk score bmi. methods: the study used a descriptive method with cross-sectional design. the samples in this study were 130 respondents who were selected using consecutive sampling and retrieval technique by using frs bmi application questionnaire. results: there were 11.5% respondents in low risk of cvd, 22.7% respondents at moderate risk and 60.8% respondents in higher category of cardiovascular disease 10 years later. conclusion: majority of patients with hypertension showed a high risk of cvd for the next 10 years. patients’ sex and age also play an important role to increase the risk, whereby men show a higher risk of cvd for the next ten years. the hospital management and health worker should pay more attention and educate the patient about the prevention of heart disease for the next 10 years, especially for those with high risk of cvd based on frs bmi measurement. article history received: november 25, 2019 accepted: june 24, 2020 keywords cardiovascular disease; framingham risk score bmi; hypertension contact linlin lindayani  linlinlindayani@gmail.com  sekolah tinggi ilmu keperawatan ppni jawa barat, jawa barat, indonesia cite this as: calisanie, n. n. p., susanti, s., & lindayani, l. (2020). cardiovascular risk estimation in patients with hypertension: a crosssectional study. jurnal ners, 15(1). 98-104. doi:http://dx.doi.org/10.20473/jn.v15i1.16262 introduction hypertension has become a global disease, both in developed and developing countries. hypertension is also referred to as a "silent killer" because, in some cases, it can appear without symptoms but suddenly result in death (nuraini, 2015). the development of hypertension is gradual so it is often not realized by the sufferers. hypertension is defined as an increase in systolic blood pressure of more than 140mmhg and diastolic blood pressure of more than 90mmhg at two measurements between a five minute interval in a good condition (kemenkes, 2014). hypertension which lasts for a long time (persistent) can cause damage to the kidneys, heart and brain (west java health office, 2016). according to data from dhungana et al. (2018), the prevalence of hypertension worldwide is around 972 million or 26.4% of people. the number is likely to increase to 29.2% in 2025. from 972 million cases of hypertension, 333 million occurred in developed countries and the remaining 639 million were in developing countries, including indonesia (yonata, satria, & pratama, 2016). meanwhile, based on the results of the 2018 baseline health research report, hypertension increased from 2013 as much as 25.8% to 34.1% from the results of measurements on the population aged over 18 years (badan penelitian & pengembangan kesehatan, 2018). by 2016 in west java 790,382 cases of hypertension (2.46% of the population ≥18 years) were found with a total of 8,029,245 cases examined in 26 districts or cities (west java health office, 2016). according to whelton et al. (2018), the prevalence of hypertension in stage 1 showed more https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:linlinlindayani@gmail.com jurnal ners http://e-journal.unair.ac.id/jners | 99 men with hypertension than women, while, in stage 2, it affects more women. women more than 55 years are more at risk of suffering hypertension than men. complications of hypertension cause around 9.4 million deaths worldwide each year. hypertension causes at least 45% of deaths due to heart disease and 51% of deaths due to stroke (kemenkes, 2014). increasing age and increasing numbers of hypertensive patients raise major problems associated to cardiovascular disease. cardiovascular disease is caused by impaired heart and blood vessel function who (2019). globally, among non-infectious diseases, the number one cause of death annually is cardiovascular disease (kemenkes, 2014). according to the who (2019), around 17.5 million people worldwide die from cardiovascular disease and the disease accounts for 31% of deaths worldwide. deaths caused by cardiovascular disease, especially coronary heart disease and stroke, are expected to keep increasing, reaching 23.3 million in 2030 (kemenkes, 2014). hypertension is a factor that plays a role in the pathogenesis process of cardiovascular disease through atherosclerosis process. according to budiman, sihombing, and pradina, (2015), the process of atherosclerosis in artery walls will facilitate the formation of blood clots and weaken the blood vessels of patients. so that the effects that occur in the heart arteries continuously cause damage to the arterial blood system leading to a hardening or stiffness process. according to frostegård (2013), atherosclerosis is a major cause of cardiovascular disease. atherosclerosis is a chronic inflammatory condition in blood vessels that can cause plaque in artery walls (aha, 2019). cardiovascular disease or atherosclerosis cardiovascular disease includes cardiovascular disease coronary heart disease, myocardial infarction, and stroke (lloyd-jones et al., 2019). plaque can be formed from cholesterol, fatty substances, calcium and fibrin. when plaque builds up, it can narrow the channels in the arteries, partially or completely, in the heart arteries (aha, 2019). efforts to prevent and control cardiovascular disease can be done with early detection through screening activities, so that the possibility complications risk, such as coronary heart disease, myocardial infarction, and stroke, can be prevented. health screening for disease prevention has long been used as the most important healthcare strategy to provide patients with early diagnosis and treatment, improvement in quality of life, and preventing premature death (bell et al., 2017). currently, there are many global researches developed on how much a person is affected by cardiovascular disease, one of which uses framingham risk score using body mass index (frs bmi)application. according to emor, panda, and pangemanan (2017), this can be done as primary prevention in patients who already have risk factors, but have never experienced cardiovascular disease. the result of frs bmi is a calculation of the risk of atherosclerotic cardiovascular disease in the next 10 years (lloyd-jones et al., 2019). this frs bmi application measures the risk of cardiovascular disease with indicators of age, sex, systolic blood pressures, hypertension treatment, smoking status, diabetes mellitus, and bmi. risk assessment using frs bmi is very useful and practical to use without using the measured lipid indicators, making it easier to detect early in controlling cardiovascular disease risk factors, among which are systolic blood pressure, smoking habits and body mass index. the results of emor et al's (2017) study regarding the prediction of the risk of atherosclerotic cardiovascular disease in patients seeking treatment at internal medicine clinics in rsup prof. dr. rd kandaou manado shows the results of the number of patients (n=100) with the predicted risk level of the next ten years for atherosclerotic cardiovascular disease;(n=42) patients have a low risk level of 42%, moderate 27% and high 31% based on framinghan risk score. this study also states that patients with systolic blood pressure ≥160mmhg were not found with low and moderate risk, but high risk. hassan et al. (2018) conducted a research on the prediction of atherosclerotic cardiovascular disease in the population of pakistan, and found that smoking history, diabetes type 2 and hypertension are the main potential risk factors underlying ascvd (atherosclerotic cardiovascular disease) in individuals in pakistan. no study has been conducted in indonesia to explore the risk of cardiovascular disease in hypertensive patients using frs bmi, which is considered as a useful tool. the purpose of this study was to estimate cardiovascular disease in hypertensive patients in indonesia. materials and methods the research design used in this study was quantitative descriptive, with cross-sectional approach. the study population was hypertension patients in hospitals in west java. the sample size in this study was determined using g-power software version 3. 1. 9. 2 (cohen, 1992) to determine the estimated frequency of cardiovascular risk in hypertensive patients using the exact test and statistical test, that are the proportion difference from constant (binominal test, one sample case) assuming α = 0.05, medium effect size = 0.15, power level = 0.95 and constant proportion = 0.5; the maximum total sample recruited is 119 people. to avoid data error, the number of respondents was n. n. p. calisanie et al. 100 | pissn: 1858-3598  eissn: 2502-5791 added by 10% for researcher errors and for sample errors measured. therefore, the total sample recruited in this study was 130 people. the inclusion criteria of this study were hypertension patients who have hypertension systolic, documented height and body weight (to measure the body mass index), and aged above 35 years old according to the recommendation from using framingham risk score bmi (for aged above 25 years old), and have been diagnosed with hypertension for more than one year. the exclusion criteria were patient already diagnosed with cardiovascular disease and other medication, chronic kidney disease, tuberculosis, cancer-related disease, and pregnant women. consecutive sampling technique was used to take all respondents that met the inclusion criteria until the sample size was fulfilled. the instrument used for this research was the application of frs bmi (framingham risk score using body mass index) developed by agostino et al. (2008) in collaboration with boston university and the national herat, lung, and blood institute. indicators assessed gender, age, systolic blood pressure, treatment of hypertension, current smoking, diabetes mellitus status and bmi. cardiovascular disease outcomes include stroke, chronic heart disease, myocardial infarction, and peripheral arterial disease and heart failure. risk assessment can be calculated using the following formula (agostino et al., 2008). reliabilities of the original framingham function and of the best cox model fit with the study data were similar in men (area under the receiver operator characteristic curve 0.68 and 0.69, respectively, p=0.273), whereas the best cox model fitted better in women (0.73 and 0.81, respectively, p=0.001) (marrugat et al., 2007). note: where s0 (t) is the baseline survival at follow-up time t (t = 10 years; see table 3. 1), βi is estimated regression coefficient (log hazard ratio; see table 3. 1), xi is logtransformed value of risk factors, x ̅ i is the corresponding mean, and shows the amount of risk factors. the 10-year cvd risk can be calculated as follows: the risk for women 1-0.95012exp (σßx 26.1931). the risk for men 1-0.88936exp (σßx 23.9802) (agostino et al., 2008). ethical permission was conducted from the affiliated university (iii/12/kepk/stikep/jabar/2019). in the implementation phase of the research for data collection, respondents used the application questionnaire. selection of respondents was by means of patients who came that day, but researchers first looked at the criteria. researchers looked at hypertensive patients from the patient's medical record to see that the respondents were indeed hypertensive patients. after that, the names of hypertensive patients were noted. after the respondent was summoned to the blood pressure measurement room by a nurse in the internal medicine clinic to be checked for blood pressure, weight and height, the researcher introduced themselves and provided a simple explanation of the purpose and objectives of this study. questionnaires and informed consent were read by researchers to respondents. respondents just answered questions from the researchers, then the researchers calculated the patient's bmi and frs bmi score. blood pressure, body weight, and tb data were obtained from the patient's medical record. for the stage of hypertension, this was seen from the doctor's diagnosis in the medical record. results table 1 shows that more than half of respondents (60.8%) have a high-risk category for the cvd in the next ten years particularly among hypertensive patients. on the other hand, a small proportion of respondents (11.5%) have a low category. table 2 shows that the majority of respondents (70.8%) were female with an average age of 61.3 years (sd 8.74). less than half of respondents (35.4%) work as housewives with last education for less than half of respondents (42.3%) was high school. table 3 shows that the average sbp stage is hypertension 142.20mmhg. hypertension patients without smoking habit have a greater percentage table 1. estimated cvd risk for hypertensive patients (n = 130) risk estimation n (%) low medium high 15 (11.5) 36 (22.7) 79 (60.8) table 2. characteristics of respondents (n = 130) variable n (%) gender male female 38 (29.2) 92 (70.8) age mean ± sd min ± max 36-45 years old 46-55 years old 56-65 years old >65 years old 61.3 ± 8.74 40 ± 74 8 (6.2) 24 (18.5) 46 (35.4) 52 (40.0) occupation unemployed labor trader private sector (employee) civil servant house wife retired 10 (7.7) 4 (3.1) 8 (6.2) 5 (3.8) 30 (23.1) 46 (35.4) 27 (20.8) education uneducated elementary school junior high school senior high school college 1 (0.8) 26 (20.0) 29 (23.3) 55 (42.3) 19 (14.6) jurnal ners http://e-journal.unair.ac.id/jners | 101 than those who smoke (80.0%). as regard diabetes status, more than half of respondents (66.9%) did not suffer from diabetes mellitus and the average bmi in hypertensive patients was 25.13 (sd 13.18). comorbidity in hypertensive patients showed that more than half of the respondents (63.8%) did not have concomitant diseases. the duration of htn treatment and length of htn suffered was an average of 6.21 years. table 4 shows the majority of respondents (94.7%) were men at high risk of cvd in the next 10 years with a p value of 0.000. the age of hypertensive patients at high risk of cvd in the next 10 years was less than half of respondents (46.8%) with age> 65 years. then, for the stage of hypertension, most respondents (84.2%) had a high risk of cvd in the next 10 years with a p value of 0.001. more than half of the respondents (68.4%) were obese bmis with a high risk of cvd in the next 10 years. the length of htn and htn treatment duration was more than half of respondents (64.7%) or> 10 years of high-risk cvd in the next 10 years with p value 0.180. discussion the data show that more than half of respondents (60.8%) were in high risk category in hypertensive patients to have cvd in the next 10 years. the results of this study are in line with the study of sa’adeh et al. (2018), who stated that hypertensive patients with high knowledge scores and high attitude scores are significantly associated with high practice scores on the prevention of chronic kidney disease (ckd). chronic kidney disease is a serious disease, but can be prevented with a three-level strategy, including education, modifying risk factors and screening. this research shows that the high risk of cvd in hypertensive patients is influenced by high blood pressure. increased blood pressure is a heavy burden on the heart, causing hypertrophy in the left ventricle or myocardial infarction. high and persistent blood pressure will cause direct trauma to the walls of the coronary arteries, making it easier for coronary atherosclerosis t occur. this causes angina pectoris (anwar, 2004). high blood pressure continuously causes damage to the arterial system of the arteries, with the artery slowly also affected by increased cholesterol levels in the blood; this process constricts the lumen in the blood vessels so that blood flow becomes obstructed. this study shows the results that the majority of respondents (94.7%) of high-risk cvd in the next 10 years were men more than women. this is supported by marso et al. (2016) who stated that the risk of cvd is greater in men than in women. women are somewhat more resistant to this disease until the age after menopause and then become as vulnerable as men; this is because men do not have protective hormones like women, called the hormone estrogen, which functions as protection of the heart until before menopause. however, this study not only describes the sex, but, in terms of age, it depicted that as regard the age of hypertensive patients less than half the respondents were > 65 years of high-risk cvd in the next 10 years. this is supported by marleni and alhabib (2017) at siti khadijah hospital in palembang who found that cardiovascular disease sufferers are more common in the age group> 45 years. according to research conducted by endah, patriyani, and purwanto (2016) 75% of chd occurred at the age of> 40 years. the american heart association (aha) explains that age is an irreversible risk factor and the majority of people die from coronary heart disease aged 65 years or more (arnett et al., 2019). age is a risk factor for coronary heart disease where increasing age will increase the risk of coronary heart disease, the older the age the greater the emergence of plaque that sticks to the walls of blood vessels and causes disruption of blood flow through it. age factor has been shown to be related to death from coronary heart disease. signs and symptoms of coronary heart disease are often found in older individuals (ghani et al., 2016). based on the results of this study and supported by theory and previous research, the researchers argue that coronary heart disease currently occurs considerably in old age, where the physiological physiology of the human body has decreased. that is because there are other trigger factors, especially in terms of lifestyle. for stage of hypertension or sbp most of the respondents (84.2%) have a high risk of cvd in the next 10 years. other studies also reinforce that respondents with high risk of hypertension experience chd 10.09 times compared with those table 3. clinical information of respondents (n = 130) variable n (%) hypertensive stage (sbp) mean ± sd min ± max 142.20 ± 13.18 130 ± 200 currently smoking status yes no 26 (20.0) 104 (80.0) diabetes mellitus yes no 43 (33.1) 87 (66.9) bmi mean ± sd min ± max 25.13 ± 4.13 16.70 ± 38.70 comorbidity no comorbidity ckd dm tb 83 (63.8) 3 (2.3) 43 (33.1) 1 (0.8) length of treatment mean ± sd min ± max 6.21 ± 6.91 1 ± 49 length of hypertension mean ± sd min ± max 6.21 ± 6.91 1 ± 49 n. n. p. calisanie et al. 102 | pissn: 1858-3598  eissn: 2502-5791 without hypertension (ghani et al., 2016). according to perry and potter (2010),the elderly usually experience an increase in systolic blood pressure associated with decreased elasticity of blood vessels and this increases the risk of diseases associated with hypertension. in addition, structural and functional changes in the peripheral vascular system are responsible for changes in blood pressure that occur in old age. these changes include atherosclerosis, loss of elasticity of the connective tissue, and reduction in relaxation of vascular smooth muscle. consequently, the aorta and large arteries are reduced in the ability to anocytate the volume of blood pumped by the heart (stroke volume), resulting in decreasing cardiac output and increasing peripheral resistance (brunner & suddarth, 2002). based on the above explanation, the researchers assume that hypertension increases the risk factors for cardiovascular disease. that is because the current pattern of human life which prefers to consume instant food or junk and fatty food, and has smoking habits increasingly makes the heart workload increase. so, if someone with hypertension needs to control blood pressure in order to reduce the risk of cardiovascular disease, she or he needs to adopt a healthier lifestyle. based on this study, it is known that the body mass index in hypertensive patients shows more than half of respondents (68.4%) have bmi obese status with high risk of cvd in the next 10 years. this can be explained as that the effect of obesity on coronary heart disease does not always stand alone, but is usually exacerbated by other factors. previous study using framingham risk score for lipid showed that for every 10% increase in body weight, systolic blood pressure rises by 6.5mmhg, plasma cholesterol is 12mg/dl and blood glucose level is 2mg/dl (djafri, monalisa, elytha, & machmud, 2017). this is supported by jneid and thacker (2001) who proved a significant relationship between obesity and coronary heart disease with a pooled rr of 1.81 (95% ci 1.56-2.10). there is a significant relationship between obesity and coronary heart disease because obesity can increase blood pressure, triglyceride levels, cholesterol, glucose resistance, and blood clotting. increased blood pressure makes blood vessels vulnerable to thickening and narrowing. if this occurs in the coronary arteries, it will cause coronary heart disease. duration of htn and duration of htn treatment show that more than half (64.7%) or >10 years of respondents are at high risk of cvd in the next 10 years. this is supported by novriyanti and usnizar (2014) that hypertension duration shows risk factors for chd with 11-15 years hypertension category dominating by 47.9%. this shows that the longer the hypertension, the higher the risk of chd. increased blood pressure over a long period of time will result in structural changes in blood vessels. these include changes in macro and microvascular structure. changes in macrovascular arteries become stiff and changes in amplification are central to peripheral pressure. microvascular changes are in the form of changes in the ratio of blood vessels and lumen in large arterioles, vasomotor tone abnormalities and 'structural rarefaction' meaning loss of microvascular blood flow does not flow to all microvascular to maintain perfusion to certain capillaries. changes in structure will interfere with tissue perfusion, so that, in the long term, hypertension can result in damage to body organs. table 4. frequency distribution based on demographic characteristics differences of hypertensive patients at the hospital polyclinic in west java (n = 130) variable n (%) estimated cvd risk for the next 10-years p value low n (%) medium n (%) high n (%) sex male female 38 (29.2) 92 (70.8) 0 15 (16.3) 2 (5.3) 34 (37.0) 36 (94.7) 43 (46.7) 0.000 age 36-45 years old 46-55 years old 56-65 years old >65 years old 8 (6.2) 24 (18.5) 46 (35.4) 52 (40.0) 6 (40.0) 7 (46.7) 1 (6.7) 1 (6.7) 2 (5.6) 5 (13.9) 15 (41.7) 14 (38.9) 0 12 (15.2) 30 (38.0) 37 (46.8) 0.000 blood pressure <142,2 >142,2 92 (70.8) 38 (29.2) 15 (16.3) 0 30 (32.6) 6 (15.8) 47 (51.1) 32 (84.2) 0.001 body mass index (bmi) underweight normal overweight obese 3 (2.3) 64 (49.2) 44 (33.8) 19 (14.6) 0 8 (12.5) 5 (11.4) 2 (10.5) 2 (66.7) 14 (21.9) 16 (36.4) 4 (21.1) 1 (33.3) 42 (65.6) 23 (52.3) 13 (68.4) 0.462 length of treatment <10 years >10 years 110 20 14 (14.6) 1 (2.9) 25 (26.0) 11 (32.4) 57 (59.4) 22 (64.7) 0.180 length of hypertension <10 years >10 years 110 20 14 (14.6) 1 (2.9) 25 (26.0) 11 (32.4) 57 (59.4) 22 (64.7) 0.180 jurnal ners http://e-journal.unair.ac.id/jners | 103 this causes myocardial infarction, stroke, heart failure, and kidney failure (hall et al., 2015; neter et al., 2003: :yannoutsos et al., 2014). in this research, limitations are that measurement of blood pressure was not carried out twice , difficulty to get respondents and the short time in the selection of respondents. conclusion prevalence of the estimated risk of cvd in the next 10 years in hypertensive patients results in a high category (60.8%). differences in demographic data in hypertensive patients showed men are at high risk of developing cvd in the next 10 years compared to women with an average age of 61.3 years. furthermore, hypertension with an average of 142.2mmhg showed high risk of cvd in the next 10 years. for bmi status, obese status estimation was with high category. duration of hypertension and length of treatment of high-risk hypertension cvd in the next 10 years have significant differences. it is expected that hospitals can pay attention to patients with obesity to obtain treatments or education related to obesity about prevention of heart disease in the next 10 years. future research can be done, such as the factors that influence the risk of cvd in hypertensive patients. references agostino, r. b. d., vasan, r. s., pencina, m. j., philip, a., cobain, m., massaro, j. m., & kannel, w. b. (2008). general cardiovascular risk profile for use in primary care. journal of the american heart association. https://doi.org/10.1161/circulationaha.107. 699579 aha. (2019). atherosclerosis. retrieved may 27, 2020, from https://www.heart.org/en/healthtopics/cholesterol/aboutcholesterol/atherosclerosis anwar, t. (2004). angina pektoris tak stabil (universitas sumatra utara). retrieved from https://www.researchgate.net/publication/4232 1445_angina_pektoris_tak_stabil arnett, d. k., blumenthal, r. s., albert, m. a., buroker, a. b., goldberger, z. d., hahn, e. j., … ziaeian, b. (2019). 2019 acc/aha guideline on the primary prevention of cardiovascular disease: a report of the american college of cardiology/american heart association task force on clinical practice guidelines. circulation, 140(11), e596–e646. https://doi.org/10.1161/cir.000000000000067 8 badan penelitian dan pengembangan kesehatan. (2018). hasil utama riskesdas 2018. retrieved from https://www.kemkes.go.id/resources/download /info-terkini/hasil-riskesdas-2018.pdf bell, n. r., singh, h., grad, r., moore, e. a., dickinson, j. a., kasperavicius, d., & kretschmer, k. l. (2017). prevention in practice. canadian family physician, 63, 521–524. brunner, s., & suddarth, d. (2002). buku ajar keperawatan medikal bedah. egc, jakarta. budiman; sihombing, rosmariana;pradina, p. (2015). hubungan dislipidemia, hipertensi dan diabetes melitus dengan kejadian infark miokard akut. jurnal kesehatan masyarakat andalas, 32–37. cohen, j. (1992). quantitative methods in psychology. 112(1), 155–159. dhungana, r. r., thapa, p., devkota, s., banik, p. c., gurung, y., mumu, s. j., … ali, l. (2018). prevalence of cardiovascular disease risk factors: a community-based cross-sectional study in a periurban community of kathmandu, nepal. indian heart journal, 70, s20–s27. https://doi.org/10.1016/j.ihj.2018.03.003 djafri, d., monalisa, elytha, f., & machmud, r. (2017). efek modifikasi faktor risiko modifiable penyakit jantung koroner: a hospital-based matched case control study. jurnal kesehatan masyarakat andalas, 11(94), 93–99. emor, engelin; panda, agnes; pangemanan, j. (2017). prediksi tingkat risiko penyakit kardiovaskuler aterosklerotik pada pasien yang berobat di poliklinik penyakit dalam rsup prof . dr . r . d . kandou manado. jurnal e-clinic (eci), 5(2). https://doi.org/https://doi.org/10.35790/ecl.5.2 .2017.18284 endah, r., patriyani, h., & purwanto, d. f. (2016). faktor dominan risiko terjadinya penyakit jantung koroner (pjk). jurnal keperawatan global, 1, 23–30. frostegård, j. (2013, may 1). immunity, atherosclerosis and cardiovascular disease. bmc medicine, vol. 11, p. 117. https://doi.org/10.1186/1741-7015-11-117 ghani, l., dewi, m., & novriani, h. (2016). faktor risiko dominan penyakit jantung koroner di indonesia. buletin penelitian kesehatan, 44(3), 153–164. hall, j. e., carmo, j. m., silva, a. a., wang, z., & hall, m. e. (2015). obesity-induced hypertension interaction of neurohumoral and renal mechanisms john. circulation research, 991– 1007. https://doi.org/10.1161/circresaha.116.3056 97 hassan, k., mohydin, b., fawwad, a., waris, n., iqbal, s., & jawaid, m. (2018). predicting the risk of atherosclerotic cardiovascular disease ( ascvd ) in pakistani population. clinical epidemiology and global health, (february), 0–1. https://doi.org/10.1016/j.cegh.2018.04.002 jneid, h & thacker, h. l. (2001). coronary artery disease in women : different , often undertreated. cleveland clinic journal of medicine, 68(5), 441–448. kemenkes ri. (2014). infodatin: situasi kesehatan jantung. jakarta: pusat data dan informasi kementerian kesehatan ri. n. n. p. calisanie et al. 104 | pissn: 1858-3598  eissn: 2502-5791 lloyd-jones, d. m., braun, l. t., ndumele, c., smith, s., sperling, l., virani, s., & blumenthal, r. (2019). use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease. 73(24). https://doi.org/10.1016/j.jacc.2018.11.005 marleni, l., & alhabib, a. (2017). faktor risiko penyakit jantung koroner di rsi siti khadijah palembang. jurnal kesehatan, viii(3), 478–483. marrugat, j., subirana, i., comı, e., cabezas, c., vila, j., elosua, r., … gene, j. (2007). validity of an adaptation of the framingham cardiovascular risk function : the verifica study. j epidemiol community health, 61, 40–47. https://doi.org/10.1136/jech.2005.038505 marso, s. p., mcguire, d. k., zinman, b., poulter, n. r., emerson, s. s., pieber, t. r., … buse, j. b. (2016). design of devote (trial comparing cardiovascular safety of insulin degludec vs insulin glargine in patients with type 2 diabetes at high risk of cardiovascular events) – devote 1. american heart journal, 179, 175–183. https://doi.org/10.1016/j.ahj.2016.06.004 neter, j. e., stam, b. e., kok, f. j., grobbee, d. e., & geleijnse, j. m. (2003). influence of weight reduction on blood pressure a meta-analysis of randomized controlled trials. 878–884. https://doi.org/10.1161/01.hyp.0000094221.86 888.ae novriyanti, i. d., & usnizar, f. (2014). pengaruh lama hipertensi terhadap penyakit jantung koroner di poliklinik kardiologi rsup . dr . mohammad hoesin palembang 2012. 1(1), 55–60. nuraini, b. (2015). risk factors of hypertension. majority, 4(5), 10–19. perry, & potter. (2010). potter & perry’s fundamentals of nursing. retrieved may 27, 2020, from https://books.google.co.id/books?id=vfnsc9hwzwc&pg=pt3476&lpg=pt3476&dq=pe rry+potter+elderly+hypertension&source=bl&ots =relzeg65is&sig=acfu3u0vwpot3oodxlscqvp_ __bsazicmw&hl=en&sa=x&ved=2ahukewiamak1 39ppahusu30khaxab5sq6aewanoecaoqaq#v =onepage&q=perry pot sa’adeh, h. h., darwazeh, r. n., khalil, a. a., & zyoud, s. h. (2018). knowledge , attitudes and practices of hypertensive patients towards prevention and early detection of chronic kidney disease : a cross sectional study from palestine. clinical hypertension, 1–13. https://doi.org/https://doi.org/10.1186/s40885 -018-0091-7 west java health office. (2016). laporan kinerja instansi pemerintah (lkip) 2016 dinas kesehatan jawa barat. jawa barat. whelton, p. k., carey, r. m., aronow, w. s., casey, d. e., collins, k. j., himmelfarb, c. d., … gentile, f. (2018). clinical practice guideline 2017 acc / aha / aapa / abc / acpm / ags / apha / ash / aspc / nma / pcna guideline for the prevention , detection , evaluation , and management of high blood pressure in adults a report of the american college of cardiology / . https://doi.org/10.1161/hyp.00000000000000 65 who. (2019). ethics and health: templates for imformed consent forms. yannoutsos, a., levy, b. i., safar, m. e., slama, g., & blacher, j. (2014). pathophysiology ofhypertension: interactions between macro andmicrovascular alterations through endothelial dysfunction. jhypertension, 32(2), 216–224. https://doi.org/10.1097/hjh.000000000000002 1 yonata, a., satria, a., & pratama, p. (2016). hipertensi sebagai faktor pencetus terjadinya stroke. majority, 5(september 2016), 17–21. http://e-journal.unair.ac.id/jners | 327 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17175 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the relationship between family support and quality of life improvement of patients with diabetes mellitus in semarang iskim luthfa, moch aspihan, and muhammad rifqi lathif sultan agung islamic university, semarang, indonesia abstract introduction: diabetes mellitus (dm) is known as the silent killer, where sufferers often do not realize its signs and symptoms and are frequently diagnosed during another health complication. to maintain quality of life, the family is required to provide support, therefore, this study aims to determine the relationship between family and the patient through observational analytic research. methods: 120 people with dm make up the research sample using an accidental sampling technique, and data analysis was carried out using the spearman rank test. the results found that 62 respondents (51.7%) agreed to their families providing good support, and 102 (85%) were satisfied with their quality of life. results: the spearman test resulted in a p value of 0,000 and r of 0.334. this means the higher the support provided by the family, the greater the increase in quality of life. conclusion: the suggestions proposed from this study is for health workers to advocate and encourage family in the planning management of dm sufferers in order to improve their quality of life. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords quality of life; diabetes mellitus; good support contact iskim luthfa  iskimluthfa@unissula.ac.id  sultan agung islamic university, semarang, indonesia cite this as: luthfa, i., aspihan, m., & lathif, m.r. (2019). the relationship between family support and quality of life improvement of patients with diabetes mellitus in semarang. jurnal ners, 14(3si), 327-330. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17175 introduction diabetes mellitus (dm) is a disease where the incidence rate increases every year (idf, 2015). up to 2030, indonesia is predicted to rank fourth for the highest number of dm patients in the world (wild, roglic, green, sicree, & king, 2004). dm sufferers are predicted to decline in life expectancy, however the benchmark is still uncertain as it is a prolonged disease. the results of a study conducted by loukine, waters, choi, & ellison (2012) found that a person aged 55 years and suffering from dm will lose 6 years off of their life expectancy. on average, complications are experienced 11 years are diagnosis (ludirdja, kencana, kurniawan, adyana, & aryana, 2010), including one, or a combination of, retinopathy, neuropathy, nephropathy, and heart disease (restada, 2016). the american heart association (2018) states that 68% of dm patients aged 65 die from heart disease and stroke, and not as a result of their diabetes. isa & baiyewu (2006) reported that dm has a negative impact on quality of life. of the 251 dm patients, 52 (20.7%) agreed they had a good quality of life, 164 respondents (65.4%) had fairly good, and 35 respondents (31.9%) had low. according to taylor (2006), quality of life is related to a person's ability to adapt to a disease, as indicated by their physical, social, psychological, and occupational functions. some factors include the ability to perform self-care (chaidir, wahyuni, & furkhani, 2017), nutritional status (setiyorini & wulandari, 2017), ability to do physical activities (timisela, ratag, & kalesaran, 2017), and the avoidance of psychological conditions such as stress (zainuddin, utomo, & herlina, 2015). in addition to these factors, family support is important in improving quality of life (nuraisyah, kusnanto, & rahayujati, 2017), where assistance is provided by families to other members who suffer illnesses to maintain and improve their health status (luthfa, 2016). according to (hensarling, 2009), there are four dimensions available to help families, which are emotional, appreciative, instrumental and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). i. luthfa, et al. 328 | pissn: 1858-3598  eissn: 2502-5791 informational. the purpose of this study was to determine the relationship between family support and the quality of life for dm patients in the city of semarang. materials and methods this was an observational analytic study with a cross sectional approach. 225 dm patients treated at the semarang bangetayu health center were respondents. samples were taken using the accidental sampling method (sastroasmoro, 2014), and 120 respondents were obtained. the sample criteria in this study includes dm patients who live with their families and were having treatment at the semarang public health center. the research instrument to measure family support included the hensarling diabetes family support scale (hdfss). meanwhile, the instrument to measure the quality of life for dm patients was diabetic quality of life (dqol). the processed data was then analyzed in both univariate and bivariate. the univariate analysis uses the frequency distribution, whereas the bivariate utilizes the spearman rank test. results respondent characteristics table 1 shows that the majority of respondents were female, at 67 respondents (55.2%), most of them were aged 46-80 years at 107 respondents (89.2%), most of them had a low education level, 103 respondents (85.8% ), most of them get support from the family with a good category, 62 respondents (51.7%), and most were satisfied with the quality of life, 102 respondents (85%). relationship between family support and the quality of life table 2 results of the spearman rank test shows a pvalue of 0,000 (p-value <0.05) and a spearman rank correlation value of 0.334, meaning that there is a relationship between family support and quality of life. the higher the support given by the family, the better quality of life for people with dm. discussion the majority of respondents were female, as they are more at risk of gestational diabetes due to pregnancy. they also experience an increase in bmi that leads to obesity after pregnancy. these conditions cause dm to be more common among women than men. table 1 also shows that 107 respondents (89.2%) were aged 46-80, with 54 being the classifier for early stages of being elderly. someone of old age will experience a decrease in producing the insulin hormone in the pancreas, thus increasing the risk of dm. furthermore, table 1 also indicates that 103 respondents (85.8%) had a low level of education, which usually produces an increase in cognitive, affective and psychomotor abilities (notoatmodjo, 2003). highly educated people tend to have more knowledge and understanding in maintaining their health, while people those who are limited in their education have minimal access to that information, making it difficult to recognize the signs of dm (fahra, widayati, & sutawardana, 2017). it is also shown that 62 respondents (51.7%) received good support from their family, and 102 (85%) felt satisfied with their quality of life. family support is a process of giving assistance to other members who suffer health issues that impact physical and psychological comfort (sepulveda, poihos, ribeiro, freitas, & carvalho, 2015), this is recommended to improve the quality of life of people with dm. the results of the spearman rank test in table 2 showed that the higher the support provided by the family, the greater the increase in quality of life. the results of this study are consistent with the research conducted by fatusin, agboola, shabi, bello, & elegbede (2016). family has a positive correlation with the quality of life for people with dm, with an improvement through emotional, appreciative, instrumental and informational support (nuraisyah et al., 2017). the first dimension is emotional support: friedman, bowden, & jones (2010) state that it is included in the affective function of the family, as families provide support for psychological issues experienced by dm sufferers, such as stress and anxiety. giving emotional support will encourage people with type 2 diabetes to control their emotions and be aware of complications that will arise in the future. the support provided by the family will have a positive impact on the growth and development of table 1. frequency distribution of respondent characteristics. variable (f) (%) sex male female 53 67 44,2 55,2 age 26-45 46-80 13 107 10,8 89,2 education elementary school junior high school senior high school 103 16 1 85,8 13,4 0,8 family support : good very good 62 58 51,7 48,3 quality of life satisfied not satisfied 102 18 85 15 table 2. relationship between family support and the quality of life of patients with dm. variable n p value r family support quality of life 120 0.000 0.334 jurnal ners http://e-journal.unair.ac.id/jners | 329 family members (friedman et al., 2010), and can reduce despair, inferiority and limitations due to physical disabilities experienced (felpina, wiyono, & maryah, 2016). the second dimension is appreciation. this is feedback given by the family based on the condition of the patient. appraisal support is considered to increase enthusiasm, motivation, and self-esteem as sufferers will still feel useful and meaningful to their family (ferawati, hasibuan & wicaksono, a., 2014). the third dimension is instrumental support, where real and direct assistance is provided in the form of personnel assistance, facilities and funds, including free time to serve and listen to complaints (bomar, 2004; sandra j.peterson, 2017). the last dimension is information support. it is very important, yet sometimes difficult, for families to provide support because they do not have enough information in managing diabetes (luthfa, 2016). they should look at diet, potential physical activity, conditions or symptoms of complications of dm, and how to treat it. the four dimensions of family support above should be given as a whole by the family to help sufferers in the management of dm treatment. correct and regular management, as well as support from the family, can make patients feel unencumbered and uplifted in the process of treatment and activities. this will improve the quality of life for people with dm physically, psychologically and socially (nuraisyah et al., 2017). conclusion most dm patients have support from families in good categories and are left satisfied with their quality of life. family support has a positive correlation to quality of life, the more support provided by the family, the more satisfied they are. health workers have to encourage families in planning management of dm patients in order to improve their quality of life. references ada. (2018). american heart association and american diabetes association launch landmark health initiative—know diabetes by heart. bomar, p. . (2004). promoting health in families: applying family research and theory to nursing practice. saunders: lippincot. chaidir, r., wahyuni, a. s., & furkhani, d. w. (2017). hubungan self care dengan kualitas hidup pasien diabetes melitus. endurance, 2(june), 132–144. fahra, r. u., widayati, n., & sutawardana, j. h. (2017). hubungan peran perawat sebagai sebagai edukator dengan perawatan diri pasien diabetes mellitus tipe 2 di poli penyakit dalam rumah sakit bina sehat jember. nurseline journal, 2(1), 61–72. fatusin, a. ., agboola, s. ., shabi, o. ., bello, i. ., & elegbede, o. . (2016). relationship between family support and quality of life of type-2 diabetes mellitus patients attending family medicine clinic, federal medical centre, ido– ekiti. nigerian journal of family practice, 7(2). federation, i. d. (2015). diabetes atlas. felpina, d. ., wiyono, j., & maryah, v. (2016). hubungan dukungan keluarga dengan kemandirian lansia dalam pemenuhan adl di kelurahan tlogomas kota malang. nursing news, 1(2), 101–114. friedman, bowden, & jones. (2010). buku ajar keperawatan keluarga: riset, teori dan praktik. jakarta: egc. hensarling, j. (2009). development and psychometric testing of hensarling’s diabetes family support scale. isa, b. ., & baiyewu, o. (2006). quality of life patient with diabetus melitus in a nigerian teaching hospital. hongkong jurnal psychiatry, 16, 27–33. loukine, l., waters, c., choi, b. c. k., & ellison, j. (2012). impact of diabetes mellitus on life expectancy and health-adjusted life expectancy in canada. jurnal boimed central, 10(1), 1–10. https://doi.org/10.1186/1478-7954-10-7 ludirdja, j. ., kencana, l., kurniawan, k., adyana, m. ., & aryana, i. . (2010). rerata durasi penderita diabetes melitus terkena nefropati diabetik sejak terdiagnosis diabetes melitus pada pasien di poliklinik geriatri rsup sanglah. jurnal iptekma, 2(1), 1–4. luthfa, i. (2016). family support pada penderita diabetes mellitus tipe 2 di puskesmas bangetayu semarang, analisis rasch model. jurnal keperawatan dan pemikiran ilmiah nurscope, 2(2), 1–12. notoatmodjo, s. (2003). pendidikan dan perilaku kesehatan. jakarta: rineka cipta. nuraisyah, f., kusnanto, h., & rahayujati, t. (2017). dukungan keluarga dan kualitas hidup pasien diabetes mellitus. journal of community medicine and public health, 33(1), 55–65. restada, e. . (2016). hubungan lama menderita dan komplikasi diabetes melitus dengan kualitas hidup pada penderita diabetes melitus di wilayah puskesmas gatak sukoharjo. sandra j.peterson, t. s. b. (2017). middle range theories; application to nursing research and practice. in wolters kluwer (fourth edi). philadelphia: wolters kluwer. sastroasmoro, s. (2014). dasar-dasar metodologi penelitian klinis (5th ed.). jakarta: sagung seto. sepulveda, e., poihos, r., ribeiro, j. p., freitas, p., & carvalho, d. (2015). health-related quality of life in type 1 and type 2 diabetic patients in a portuguese central public hospital. diabetes, metabolic syndrome and obesity: target and therapy, 8(maret), 219–226. setiyorini, e., & wulandari, n. a. (2017). hubungan status nutrisi dengan kualitas hidup pada lansia penderita diabetes mellitus tipe 2 yang berobat di poli penyakit dalam rsd mardi waluyo blitar. jurnal ners dan kebidanan, 4(2), 125– i. luthfa, et al. 330 | pissn: 1858-3598  eissn: 2502-5791 133. https://doi.org/10.26699/jnk.v4i taylor, s. . (2006). health psychology. sixth edition. singapore: mc grow hill book company. timisela, j. ., ratag, b. ., & kalesaran, a. f. . (2017). hubungan aktivitas fisik dengan kualitas hidup pasien dm tipe ii di rsu pancaran kasih. 1–6. wild, s., roglic, g., green, a., sicree, r., & king, h. (2004). global prevalence of diabetes: estimates for the year 2000 and projections for 2030. jurnal diabetes care, 27(5), 1047–1053. zainuddin, m., utomo, w., & herlina. (2015). hubungan stres dengan kualitas hidup penderita diabetes mellitus tipe 2. jom, 2(1), 890–898. 66 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.17793 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effects of acceptance and commitment therapy (act) on depression in tb-hiv co-infection patients avin maria1, untung sujianto2, and niken safitri dyan kusumaningrum2 1master program in nursing, diponegoro university, stikes panti rapih, jogjakarta, indonesia 2lecturer of nursing department, faculty of medicine, diponegoro university, semarang, indonesia abstract introduction: the most common psychological problem in tb-hiv coinfection patients is depression. acceptance and commitment therapy (act) is an intervention that encourages participants to change their relationships with their thoughts and physical sensations through mechanisms of acceptance and valuebased action. this present study has been carried out to investigate the effectiveness of act in treating tb-hiv coinfection patients. methods: this research was a quasi-experiment. this study involved 62 respondents diagnosed tb-hiv coinfection by doctor, experienced mild depression to severe depression, able to communicate well and have not hearing loss. act was given by a researcher with six sessions) one session per day) held in the intervention group. data were collected using beck depression inventory (bdi) questionnaires. data analysis use paired t-test to determine the differences in value of depression on pre-test and post-test in each group. data were analyzed using the independent t-test to determine the effect of act on depression. results: the majority of respondents were male (66.1%). most of the early adult and older adult respondents had moderate depression, while middle-aged adult mostly had severe depression (50%). the fully unemployed respondents had severe depression (100%). the analysis results showed that there was a more significant decrease in depression in the intervention group given act compared to the control group (p value =0.00). conclusion: act has an effect on reduce depression of tb-hiv coinfection patients. act is recommended to be developed as a nursing intervention that can be given to patients who are depressed. article history received: february 7, 2020 accepted: may 9, 2020 keywords depression; tb-hiv coinfection; aceptance and commitment therapy contact avin maria maria.avin@gmail.com  master program in nursing, diponegoro university, stikes panti rapih, jogjakarta, indonesia cite this as: maria, a., sujianto, u., & kusumaningrum, n.s.d. (2020). the effects of accepance and commitment therapy (act) on depression in tb-hiv co-infection patients. jurnal ners, 15(1). 66-71. doi:http://dx.doi.org/10.20473/jn.v15i1.17793 introduction hiv/aids is one of the most devastating illness that people have ever faced (bhatia & munjal, 2014). hiv/aids is still a global health problem (tran et al., 2019). prevalence of people with hiv/aids in the world until end 2018 was recorded as many as 37.9 million people (unaids, 2019). hiv/aids will cause the immune system to weaken so that the cd4 count will decrease. as a result, hiv/aids patients become more susceptible to various diseases, especially infectious diseases (opportunistic infections). opportunistic infections that most often occur in people living with hiv/aids is tuberculosis (tb). tb remains the leading cause of death among people living with hiv, accounting for around one in three aids related deaths. the tb virus will actively develop when the immune system damage gets heavier when the condition of patients with hiv/aids have a cd4 count below 200 (maartens et al., 2014). in the individual host, the two pathogens, mycobacterium tuberculosis and hiv, potentiate each other, accelerating the deterioration of immunological functions. both tb and hiv are heavily stigmatized diseases, and diagnoses may lead to poor psychological health outcomes (bruchfeld et al., 2015). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 67 depression is the most common psychological disorder with tb-hiv (larson et al., 2017). depression characterized by persistent sadness and a loss of interest in activities that people normally enjoy, accompanied by an inability to carry out daily activities, poor concentration, pessimistic thoughts and biological symptoms (poor appetite and sleep difficulties) (kim et al., 2015; tran et al., 2019). the incidence of depression in tb-hiv patients is 28% (deribew et al., 2013). despite its prevalence, depression is commonly underdiagnosed and consequently untreated in general medical population (bhatia & munjal, 2014). depression causes patients to be less likely to adhere to the consultation schedule, poor hiv treatment outcomes, not adhere to therapeutic doses, drug, and alcohol abuse (gebrezgiabher et al., 2019; todd et al., 2017; uthman et al., 2014). this will cause the patient's immune status to decrease. the final impact, the mortality rate will increase (larson et al., 2017). interventions to deal with depression have been carried out, namely cognitive behavior therapy (cbt) (mohamadian et al., 2018), internet-based intervention (karyotaki, 2018), logo therapy (mohammadi et al., 2014), psychotherapy and exercise study (lofgren et al., 2018). acceptance and commitment ther apy (act) is one of the interventions for reduce depression that has been developed by zettle & hayes in 1986. act helps someone to reduce the problems experienced by increasing the patients awareness and abilities of what they want in their life and aims to improve functioning and quality of life by increasing psychological flexibility (bramwell & richardson, 2018). act is as effective as other established psychological interventions in treating depression (atjak et al., 2015). in act, depression is conceptualized as a secondary emotion that arises from struggling to avoid normal and adaptive emotional reactions to distressing life events, for example, loss (far, gharraee, birashk, & habibi, 2017). the core difference between act and other interventions is the central proposition that diagnostically distinct clinical disorders may be established and maintained through common processes that are rooted in the capacity for language. these common processes include psychologically deleterious experiential avoidance (bai, luo, zhang, wu, & chi,, 2020), which has been defined as an unwillingness to experience feelings, physiological sensations, and thoughts, especially those that are negatively evaluated, as well as attempts to alter the form or frequency of these events and the contexts that occasion them (twohig, 2012). a recent meta-analysis concluded that act was effective to reduce depression in personality disorder patient, mental disorder patient, cancer patient, male smokers, and university students. in this study, act was given between four weeks until 16 weeks. the session was given once or twice per week (bai et al., 2020). there have been several studies of act to reduce depression, especially in mental disorder outpatients. however, study about act on tb-hiv patients has never been done before. therefore, in the present study, the aim is to investigate the effectiveness of acceptance and commitment therapy (act) in treating depression in tb-hiv coinfection inpatients. materials and methods this study was a quasi-experimental method with a pre-test and post-test design with comparison group design, which was conducted from december 2018 until february 2019. before data collection, this study obtained ethics approval from aisyiyah university, yogyakarta (no. 727/kep-unisa/xii/2018). the population in this study was tb-hiv coinfection patients who were hospitalized in yogyakarta regional public hospital and sleman regional public hospital. the sample was selected through the consecutive sampling method and divided into two groups, the experimental group and the control group. the inclusion criteria were patients who have been diagnosed tb-hiv coinfection by doctor, experienced mild depression to severe depression, and able to communicate well. the exclusion criterion was patients who have hearing loss. the number of people in each group was 31 people. the experimental group members participated in six sessions (one session per day). each session was given in 60 minutes. they were also given act module. no intervention was done in the control group by the researcher. however, the control group still received usual care from hospital. after data collection was done, the control group was also explained about act and given the act module. it was expected that this study has applied the principle of justice. the act sessions are 1) acceptance (willingness to open fully to unwanted experiences such as difficult thoughts, memories, or emotions); 2) cognitive defusion (being able to step back from unwanted experiences without getting stuck in them); 3) present moment (being mindful and aware of one's experiences); 4) self as a context (maintaining perspective about oneself within one's experiences); 5) valuing (staying connected to personal values or areas of life that are important) and 6) commitment (engaging in actions that move toward important aspects of life). data were collected using beck depression inventory (bdi) indonesia version questionnaires that consist of cognitive, affective and somatic a. maria et al. 68 | pissn: 1858-3598  eissn: 2502-5791 depression symptoms with content validity item in the range of 0.51 and cronbach's alpha value 0.90. the data were recapitulated, entered into spss program and analyzed. one way anova test was used to identify homogeneity of respondents’ characteristics. data analysis using paired t-test was used to determine the differences value of depression on pre-test and post-test in each group. data analysis using independent t-test was used to determine the effect of act on depression in both groups. results characteristics of respondents in this research are majority was male (66.1%) in both the experimental group and the control group. the majority of respondents were early adult, both in the experimental group (64.5%) and the control group (58.1%). based on the marital status, the majority of respondents had single status (46.7%). based on education, majority respondents had a senior high school education. based on the presence of disease complications, more than half of the control group (80.6%) and experimental group (74.2%) had no complications of the disease. all of the respondents' characteristics have p value > 0.05, which means that both groups are homogeneous (table 1). table 2 shows the results of the analysis of bdi scores on pre-test and post-test which found a significant reduction in depression symptoms in the experimental group that was equal to 8.09 (p=0.00). a greater reduction was found in the experimental group where the bdi scores mean before the act intervention was at 20.38 (moderate depression) and after the intervention, the bdi scores mean decreased to 12.29 (mild depression). the control group had a bdi score mean of 21.38 (moderate depression) on pre-test and the average actually increased to 21.67 (moderate depression) on post-test. the average value actually increased by 0.29 with p value = 0.329 (> 0.05). based on these table 1. distribution of both groups regarding their sociodemographic characteristics characteristics intervention (n=31) control (n=31) total (n=62) p n (%) n (%) n(%) gender 0.125 male 19 (61.3%) 22 (71%) 41(66.1%) female 12 (38.7%) 9 (29%) 21(33.9%) age 0.425 early adult (18-40 years) 20 (64.5%) 18 (58.1%) 38(61,2%) middle adult (41-60 years) 7 (22.6%) 11 (35.5%) 18(29.1%) late adult (>60 years) 4 (12.9%) 2 (6.5%) 6(9.67%) marital status 0.932 single 13 (41.9%) 16 (51.6%) 29(46.7%) widow/widower 8 (25.8%) 7 (22.6%) 15(24.2%) married 10 (32.3%) 8 (25.8%) 18(29.1%) education 0.353 elementary school 5 (16.1%) 3 (9.7%) 8(13%) junior high school 5 (16.1%) 5 (16.1%) 10(16.1%) senior high school 14 (45.2%) 15 (48.4%) 29(46.7%) college 7 (22.6%) 8 (25.8%) 15(24.2%) last job 0.893 not yet working 2 (6.5%) 1 (3.2%) 3(4.8%) housewife 5 (16.1%) 6 (19.4%) 11(17.7%) laborer 8 (25.8%) 8 (25.8%) 16(25.8%) entrepreneur 7 (22.6%) 7 (32.6%) 14(22.7%) pns/tni/polri 2 (6.5%) 0 (0%) 2(3.2%) private 7 (22.6%) 9 (29.0%) 16(25.8%) complications of the disease 0.233 yes 8 (25.8%) 6 (19.4%) 14(22.7%) no 23 (74.2%) 25 (80.6%) 48(77.3%) table 2. difference in bdi scores on pre-test and post-test of experimental group and control group variable group mean sd p value depression experimental group pre-test 20,38 6,34 0,000 post-test 12,29 control group pre-test 21,38 1,50 0,293 post-test 21,67 table 3. distribution of experimental and control group regarding indicator of bdi in post-test variable experimental group control group p value mean sd mean sd depression 12.29 4.93 21.67 4.52 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 69 data, it can be concluded that there was a significant change in the condition of depression pre-test and post-test only in the experimental group. the effect of acceptance and commitment therapy (act) for reducing depression can be seen from the mean post-test scores in the intervention group and the control group )table 3). table 2 shows the difference in bdi scores in the control and experimental group after getting act. it can be said that there is a significant difference in the experimental and control groups among depression (p = 0.000). given the size of this effect, the rate is significant. therefore, it can be said that acceptance and commitment therapy (act) significantly reduces depression in tb-hiv coinfection patients. discussion in the current study, the effectiveness of acceptance and commitment therapy to reduce depression was investigated and the finding was positive. this result is consistent with the findings of previous studies. heydari, masafi, jafari, saadat, and shahyad. (2018) showed that acceptance commitment therapy for razi psychiatric center staff had a positive effect on decreasing anxiety and depression (heydari et al., 2018). other study found that act was positive for relieving depression for patients with mild depression and depressed adults; depressive symptoms reduced significantly immediately after the intervention as well as at the three months of follow up (bai et al., 2020). in acceptance and commitment therapy, depression conceptualization is emotions related to past events, such as death or losing something, which prevents normal reactions and adaptation to stressful life events. in the above approach, the content of a depressed person’s negative thoughts is not considered. the act intervention led to statistically significant reduction in depressive symptomatology. moreover, mediational analysis showed that the improvement of acceptance during the intervention mediated the effects of the intervention on depressive symptomatology at follow-up (bohlmeijer, fledderus, rokx, & pieterse, 2011). the decrease in bdi scores in the experimental group could be caused by act. this could occur because, through act, respondents were asked to make commitments. the commitment states what is important to the individual and when making a commitment the respondent will underline the choices made, thereby committing to influence the emotional response and coping of individual to react to the presence of stressors (hayes & waltz, 2010). this is in accordance with the results of the research obtained where, after receiving act treatment, the mean of bdi scores decreased up to 11.08. majority respondents were in moderate level of depression on pre-test, while on post-test, majority respondents were in mild level of depression. the mean of bdi score in the control group actually increased before and after treatment, from 21.38 to 21.67. according to observations, the level of depression increase that occurred in the control group respondents could be due to the length of stay. in the control group respondents, the majority underwent hospitalization for 8-10 days. this is consistent with previous research which states that depression can occur because of the length of stay of hospitalization. when patients undergo lengthy hospitalization, they experience conditions that result in a person's inability to relate interpersonally. depression can be felt if individuals have a sensitivity to the environment. the existence of conditions such as separation from the closest person or loss of something can cause a person to experience depression (nasronudin, 2012). evaluation of the level of depression after giving act was done by giving a questionnaire to the respondents and observations made directly by the researcher. according to observations, when act was first performed, the majority of respondents avoided telling stories or meeting face-to-face with researchers. the avoidance of being able to be open in conveying the burden and the problem experienced (experiential avoidance) can be caused by cognitive defusion in that the environment will be judged poorly if it conveys its burden too far. this is an indicator of the absence of psychological flexibility (the ability to think with several different concepts) in respondents. without realizing it, avoiding behavior chosen as a strategy used, but is not effective for the long term. this is reflected in the reaction of respondents who are increasingly depressed because they feel alone in dealing with their illness (bai et al., 2020). in the third session ‘present moment’, the psychological knowledge of subjects was added. this means that the individuals were aware of all mental states, thoughts, and behavior in the present moment. fourth session, ‘self as a context’, involved efforts to reduce the excessive focus on visualization or personal story (as victims) that the individuals had made for themselves. fifth, ‘valuing’, was about helping the individuals to understand their basic personal values and identify them to convert to specific behavioral goals (to clarify the values). finally, the last session ‘commitment’, involved motivating them to act responsibly toward the goals and values of the activities identified with the adoption of mental experiences. (farb et al., 2018; montgomery, kim, & franklin,, 2011). because of these conditions, the act is important. act made it clear to respondents that it was important to provide space for themselves to accept unpleasant feelings and experiences so that they did not need to be avoided, and appreciation of other people's judgments that were not necessarily attached to them. act also made the respondents aware of the important things and expectations in life, and that it can change the perspective of the respondent in seeing the situation, and reduce the attachment to negative thoughts and feelings (rauwenhoff, peeters, bol, & van heugtenvan, 2019). a. maria et al. 70 | pissn: 1858-3598  eissn: 2502-5791 this was proven in that, after the second meeting to the end, respondents felt happy and more open. with the growing willingness to face and undergo the consequences obtained through act, there is a change in the cognition process where appraisal of situations that cause depression is no longer seen as something negative. when the meaning changes, which initially becomes negative neutral, the appraisal will change and the level of depression will also decrease. act also directs to improve their perspective to be more positive in dealing with problems through coping changes based on the emotions felt. the aim of act is to change the functions and context of behavior and thoughts; symptom reduction is not a treatment outcome (hayes & waltz, 2010). through act, the respondents were not only invited to accept, but were also facilitated to be able to set steps to overcome their problems along with the acceptance of the consequences. with the establishment of these measures, perceived resources can more reach demands as tb-hiv coinfected patients. thus, this can reduce the level of depression experienced (syndrome, maghsoudi, razavi, razavi, & javadi, 2019). this study has some limitations. first, these findings are based on self reporting of people. second, this study did not have follow–up period. third, the lack of large sample size of the population and only at two hospitals could be mentioned as other potential limitation. finally, further studies with larger sample sizes in multi-centers are suggested to clarify the results of this study. follow-up post-test in longer period is needed, for example within one month after intervention. this is intended to know whether act has an effect on reducing depression in the long term. investigating the effects of act on other patient outcomes such as quality of life, coping, adherence to treatment is recommended as is analyzing the patterns of all aspects of act on depression. it can be concluded that acceptance and commitment therapy could reduce depression. conclusion there was a significant difference between the value of depression in the experimental group after being given acceptance and commitment therapy compared to the control group. this means that act has the effect of reducing depression in tb-hiv coinfection patients. act is recommended to be developed as a nursing intervention that can be given to patients who are depressed. nurses can now directly use act to intervene according to the actual situation, so as to improve service efficiency and effects. references a-tjak, j.g., davis, m.l., morina, n., powers, m.b., smits, j.a.j., & emmelkamp, p.m.g. (2015). a meta analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. psychotherapy and psychosomatics, 84, 30–36. https://doi.org/10.1159/000365764 bai, z., luo, s., zhang, l., wu, s., & chi, i. (2020). acceptance and commitment therapy (act) to reduce depression: a systematic review and meta-analysis. journal of affective disorders, 260(may 2019), 728–737. https://doi.org/10.1016/j.jad.2019.09.040 bhatia, m.s., & munjal, s. (2014). prevalence of depression in people living with hiv/aids undergoing art and factors associated with it. journal of clinical and diagnostic research, 8(10), 1–4. https://doi.org/10.7860/jcdr/2014/7725.4927 bohlmeijer, e.t., fledderus, m., rokx, t. a.j.j., & pieterse, m.e. (2011). efficacy of an early intervention based on acceptance and commitment therapy for adults with depressive symptomatology : evaluation in a randomized controlled trial. behaviour research and therapy, 49(1), 62–67. https://doi.org/https://doi.org/10.1016/j.brat.2 010.10.003 bramwell, k., & richardson, t. (2018). improvements in depression and mental health after acceptance and commitment therapy are related to changes in defusion and values-based action. journal of contemporary psychotherapy, 48(1), 9–14. https://doi.org/10.1007/s10879-017-9367-6 bruchfeld, j., correia-neves, m., & kallenius, g. (2015). tuberculosis and hiv coinfection. cold spring harbor perspectives in medicine, 5(7), 1–15. https://doi.org/10.1101/cshperspect.a017871 deribew, a., deribe, k., reda, a.a., tesfaye, m., hailmichael, y., & maja, t. (2013). do common mental disorders decline over time in tb/hiv coinfected and hiv patients without tb who are on antiretroviral treatment? bmc psychiatry, 13(1), 1. https://doi.org/10.1186/1471-244x-13-174 far, s.t., gharraee, b., birashk, b., & habibi, m. (2017). effectiveness of acceptance and commitment therapy and cognitive therapy in patients with major depressive disorder. iranian journal of psychiatry and behavioral sciences, 11(4). https://doi.org/10.5812/ijpbs.3459 farb, n., anderson, a., rayindran, a., hawley, l., irving, j., mancuso, e,… segal, z.v. (2018). prevention of relapse/recurrence in major depressive disorder with either mindfulnessbased cognitive therapy or cognitive therapy. journal of consulting and clinical psychology, 86(2), 200–204. https://doi.org/https://doi.org/10/1037/ccp00 00266 gebrezgiabher, b.b., abraha, t.h., hailu, e., siyum, h., mebrahtu, g., gidey, b.,… angesom, t. (2019). depression among adult hiv/aids patients attending art clinics at aksum town, aksum, ethiopia: a cross-sectional study. depression research and treatment, 2019. https://doi.org/10.1155/2019/3250431 jurnal ners http://e-journal.unair.ac.id/jners | 71 hayes, s., & waltz, t. (2010). acceptance and commitment theraphy in cognitive behavioral therapy in clinical practice. the guilford press. heydari, m., masafi, s., jafari, m., saadat, s.h., & shahyad, s. (2018). effectiveness of acceptance and commitment therapy on anxiety and depression of razi psychiatric center staff. public health, 15. https://doi.org/10.3889/oamjms.2018.064 karyotaki, e. (2018). internet based interventions for people wih hiv and depression. lanset, 5(9), 474 475. https://doi.org/10.1016/s23523018(18)30172-3 kim, j.l., cho, j., park, s., & park, e.c. (2015). depression symptom and professional mental health service use. bmc psychiatry, 15(1), 1–12. https://doi.org/10.1186/s12888-015-0646-z larson, h., moverman, h., saito, s., frederix, k., pitt, b., maime, m., & howard, a.a. (2017). depressive symptoms and hazardous/harmful alcohol use are prevalent and correlate with stigma among tb-hiv patients in lesotho. physiology & behavior, 176(1), 139–148. https://doi.org/10.1016/j.physbeh.2017.03.040 lofgren, s.m., nakasujja, n., & boulware, d.r. (2018). systematic review of interventions for depression for people living with hiv in africa. aids and behavior, 22(1), 1–8. https://doi.org/10.1007/s10461-017-1906-3 maartens, g., ceum, c., & lewin, s.r. (2014). hiv infection: epidemiology, pathogenesis, treatment, and prevention. lanset, 384, 2014 258-271. https://doi.org/10.1016/s01406736(14)60164-1 mohamadian, f., bagheri, m., hashemi, m.s., & komeili sani, h. (2018). the effects of cognitive behavioral therapy on depression and anxiety among patients with thalassemia: a randomized controlled trial. journal of caring sciences, 7(4), 219–224. https://doi.org/10.15171/jcs.2018.033 mohammadi, f., fard, f.d., & heidari, h. (2014). effectiveness of logo therapy in hope of life in the women depression. social and behavioral sciences, 159, 643 – 646. https://doi.org/10.1016/j.sbspro.2014.12.440 montgomery,k.l., kim, j, s., & franklinc. (2011). acceptance and commitment therapy: for physiological and psychological illness. national association of social worker. nasronudin. (2012). hiv & aids. pendekatan biologi molekuler, klinis dan sosial. airlangga university press. rauwenhoff, j., peeters, f., bol, y., & van heugten, c. (2019). the brain act study : acceptance and commitment therapy for depressive and anxiety symptoms following acquired brain injury : study protocol for a randomized controlled trial. bmc, 20(773), 1–10. https://doi.org/10.1186/s13063019-3952-9 syndrome, m., maghsoudi, z., razavi, z., razavi, m., & javadi, m. (2019). efficacy of acceptance and commitment therapy for emotional distress in the elderly with type 2 diabetes : a randomized controlled trial. dovepress, 12, 2137–2143. https://doi.org/10.2147/dmso.s221245 todd, j.v., cole, s.r., pence, b.w., lesko, c.r., bacchetti, p., cohen, m. h., & adimora, a.a. (2017). effects of antiretroviral therapy and depressive symptoms on all-cause mortality among hiv-infected women. american journal of epidemiology, 185, 869–878. https://doi.org/10.1093/aje/kww192 tran, b.x., ho, r.c.m., ho, c.s.h., latkin, c.a., phan, h.t., ha, g.h.h., … zhang, m.w.b. (2019). depression among patients with hiv/aids: research development and effective interventions. environment research public health, 16, 1–15. https://doi.org/10.3390/ijerph16101772 w twohig, m. (2012). acceptance and commitment therapy. cognitive and behavioral practice, 19, 499–507. https://doi.org/10.1016/j.cbpra.2012.04.003 unaids. (2019). global hiv & aids statistics. uthman, o.a., magidson, j.f., safren, s.a., & nachega, j.b. (2014). depression and adherence to antiretroviral therapy in low-, middleand highincome countries: a systematic review and metaanalysis. current hiv/aids reports, 11, 291–307. https://doi.org/10.1007/s11904-014-0220-1 358 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17184 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effects of cold compress on the heguous point of meridian large intestine on pain before giving immunization in infants indra tri astuti, kurnia wijayanti, laila nuraini, nopi nur khasanah, and herry susanto faculty of nursing, sultan agung islamic university, semarang, indonesia abstract introduction: in basic immunizations received by infants 90% are given by injection. the immunization given by injection is a source of pain which can cause anxiety and trauma not only in infants but also for their families. thus, it is necessary to deal with the pain with appropriate management. one nonpharmacological therapy that can be used to reduce pain is by providing cold compresses. the aim of this study was to determine the effects of cold compress on the heguous point of meridian large intestine on pain before giving immunization. methods: this study used the quasi experimental method of posttest design with control group. this study used the instruments of face, legs, activity, cry and consolability (flacc) behavioral pain assessment scale to measure the pain. the sample was 42 people taken by consecutive sampling. the research data were analyzed by using the mann whitney test. the results obtained a p value equal to 0.023 (<0.05). results: this indicates that there were significant differences in pain scores between the two groups, meaning that there is a significant effect of giving cold compresses to the pain score before giving immunization. conclusion: this result explains that cold compresses carried out at the heguous point can be used as an alternative for management for nonpharmacological pain in infants during immunization. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords immunizations; non-pharmacological pain; cold compress; children contact indra tri astuti  indra@unissula.ac.id  faculty of nursing, sultan agung islamic university, semarang, indonesia cite this as: astuti, i.t, wijayanti, k., nuraini, l., khasanah, n.n., & susanto, h.. (2019). effects of cold compress on the heguous point of meridian large intestine on pain before giving immunization in infants. jurnal ners, 14(3si), 358-361. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17184 introduction immunization is one of the effective ways to prevent disease transmission and is very instrumental in tackling health problems (hadianti et al., 2014). the importance of immunization is based on the health paradigm which statesthat preventive efforts become the most important thing in improving health status as an effort to achieve the sustainable development goals (sdg) ((idai), 2018). 90% of basic immunization which is given to infants in their first year of life is carried out by injection. this kind of immunization can also cause a direct reaction such as pain, swelling and rednessat the injection site. meanwhile, there are also some indirect reactions such as fear, dizziness, and nausea, which make children and parents traumatized to give immunization in the future (kemenkes ri, 2015). the infancy immunization by injection is the most important source of pain and suffering that can cause anxiety and trauma, not only in children but also in families. untreated pain can have serious effects, both short-term such as memory of pain, hyper-sensitivity of pain, response to prolonged pain, and long-term pain which includes increased prevalence of neurological deficits, psychosocial problems and resistance to human contact (wong, hockenberry, wilson, winkelstein, & schwartz, 2009). one of the ways to reduce the impact of pain can be done by using non-pharmacological therapy. non-pharmacological therapies which can be applied as pain management are arranged in various modalities including physical modalities (physical exercise, massage, vibration, cutaneous stimulation, needling, and so on), cognitive modalities-behavioral (distraction, relaxation, spiritual approaches, and others) and psychotherapy modalities (wardani, 2014). pain is reduced when the acupressure https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 359 meridian of large intestine (li-4) area between the index finger and thumb is done with an ice compress (jayaraman & jose, 2018). cold compresses are used to relieve pain by slowing the speed of nerve conduction, causing numbness and working as a counterirritant (berman, shirlee, kozier, barbara, & glenora, 2009). based on a preliminary study conducted by researchers using the interview method on september 17, 2018 in banget ayu semarang public health center, the data ofthe immunized babies in the last 3 months were obtained, hb0, dpt, ipv immunization, polio infants at the age of 0-9 months who were immunized with intra-muscular (im) accounted for in june at 60 infants, in july at 55 infants, and in august at 52 babies. the coverage of complete immunizationsince the last year in bangetayu semarang health center has showed the number of hb 0 (100%), hepatitis (106%), bcg (119%), polio 1 (112%), polio 2 (97%), dpt 1 (99% ), dpt 2 (99%), dpt 3 (101%), mr (104%), measles (106%). banget ayu semarang public health center at the time of immunization has used warm compresses to reduce the pain of immunization and stated that its effectiveness could reduce the pain caused bythe injection of immunization, but has never used cold compresses before to reduce immunization pain. the parents' response to trauma from the effects of immunization such as fever, crying, fear, and others does not traumatize the parents of infants to giveimmunization for the next time. thus, it is necessary to deal with the pain with appropriate management. one non-pharmacological therapy that can be used to reduce pain is by providing cold compresses. the aim of this study was to determine the effects of cold compress on the heguous point of meridian large intestine on pain beforegiven immunization. materials and methods this study is a quantitative study of quasiexperimental research design by using posttest with control group design. posttest only with control group design is a study that examines an intervention in a group of subjects with a compared group but there is no randomization which is done to put subjects into treatment in control groups (dharma, 2011). the respondents in this study were infants who would be immunized intramuscularly (im) and started from the ages of 0-9 months. this research was conducted from november 2018 to january 2019 with 42 respondents. the intervention was carried out in groups of babies given ice packs (ice cubes wrapped in cotton cloth) on the compressing area on acupressure point hegu li-4 which is between the thumb and index finger. the ice compress was given 5 minutes before the immunization, and applied 3 minutes after the immunization for 30 seconds duration, rested for 60 seconds, given an ice pack again for 30 seconds. the pain measurement instruments cover face, legs, activity, cry, and consolability (flacc) behavior scale and observation sheet (wong et al., 2009). the data were analyzed by mann-whitney statistical test (dahlan, 2015). this test was chosen because it compares numerical data with abnormal distribution from two groups. results table 1 shows the results of the study that the mean age of the control group was 4.33 (1,906), and the intervention group was 4.05 (1,284). table 2 shows the results of the study that the highest sexes were 24 for female (57.1%). table 3 shows the results of the study that the pain score in the control group was 5.00 (1,673)higher than the pain score of the intervention group which was 4.19 (1,078). table 4 is the results of the mann-whitney statistical test which shows the value was equal to 0.023 (<0.05). these results mean that there are significant differences in pain scores in the control group and the intervention group. from the results, it can be concluded that the administration of ice compresses at the hegu li-4 acupressure point can reduce pain during immunization in infants aged from 0 to 9 months in bangetayu public health center. discussion judha and sudarti (2012) stated that pain is an unpleasant sensation which is located at a part of the body. pain is the body's defense mechanism, existing when there is damaged tissue .this will cause the individual to react by moving the pain stimulus. pain in children is one thing that can be seen from the emotions and behavior of individuals, subjective, and is a common thing. pain can also be interpreted as a feeling that is uncomfortable and often experienced by individuals (andarmoyo, 2013). the results of the study in bangetayu health center showed that the average pain score was lower in the intervention group accounted for 4.19, compared to the pain score in the control group which showed 5.00. giving cold compresses can reduce pain and relax muscles by the way of reducing prostaglandin which strengthens the sensitivity of other pain and subcutaneous receptors in the injury site by inhibiting the inflammatory process (kozzier et al, 2010). the physiological effects of cold therapy can reduce the temperature of the skin and the underlying tissue and cause vasoconstriction. vasoconstriction decreases blood flow to the affected area and then can reduce oxygen supply and metabolic capacity, as well as the rate of removal of waste substances and cause pale and cold on skin. the mechanism of giving cold compresses can increase the release of endorphins which block the transmission of pain stimuli and also stimulate nerve fibers that have large betadiameters, thereby i. t. astuti, et al. 360 | pissn: 1858-3598  eissn: 2502-5791 reducing transmission of pain impulses through small delta fibers and c nerve fibers (anugerah, purwandari, & hakam, 2017). cold compresses using ice slow the conduction of peripheral nerve fibers and reduce the release of inflammatory mediators and nociceptors, thereby causing relatively rapid effects of skin anesthesia (waterhouse, liu, & wang, 2013). according to (wong, 2009), cold compresses will cause numbness which is rightly used as a local anesthetic because it can stimulate the skin. hegu point li-4 is chosen because that point is known as the point of pain in the body. the hegu li-4 point is also a source point (yuan), the point where qi is actually radiated in the meridian when stimulated and it will cause energy twice stronger than the other points (kebudayaan, 2014). conclusion the duty of nurses in the health services to clients is to avoid undesirable things such as trauma, pain, and fear. the conclusions which can be taken from the results of this study show that there are significant effects of ice compresses on injection at the pain scores during immunization in infants aged from 0 to 9 months. thus, ice compress can be used as an alternative pain management due to its easiness and low cost of use. bangetayu health center can use this study as the basis for the head of bangetayu health center to issue new policy in the matter of reducing the pain of immunization by using an ice pack before the immunization is carried out because ice compresses have proven to be effective to reduce the pain of immunization. for the community, the ice compresses to reduce pain can also be done independently. references (idai), i. d. a. i. (2018). seputar pekan imunisasi dunia 2018. andarmoyo, s. (2013). konsep dan proses keperawatan nyeri. yogyakarta: arruz media. anugerah, a. p., purwandari, r., & hakam, m. (2017). pengaruh terapi kompres dingin terhadap nyeri post operasi orif ( open reduction internal fixation ) pada pasien fraktur di rsd dr . h . koesnadi bondowoso pain in patients orif fracture in rsd dr . h . koesnadi. e-jurnal pustaka kesehatan, 5(2), 247–252. berman, a., shirlee, j. s., kozier, barbara, e. r. ., & glenora. (2009). buku ajar praktik keperawatan klinis. jakarta: egc. dahlan, s. (2015). statistik untuk kesehatan. jakarta: salemba medika. dharma, k. (2011). metodologi penelitian. jakarta: cv. trans info media, jakarta. hadianti, d. n., mulyati, e., ratnaningsih, e., sofiati, f., saputro, h., sumastri, h., & dkk. (2014). buku ajar imunisasi. jakarta: pusdiknakes kementrian kesehatan ri. jayaraman, u., & jose, j. (2018). jissy jose , umarani j , effect of ice application in reducing pain perception of toddlers during immunization . table 1. frequency distribution of respondents based on the age group mean lowest age highest age standard deviation control 4.33 2 8 1.906 intervention 4.05 2 8 1.284 table 2. frequency distribution of respondents based on the gender gender frequency percentage (%) male 18 42.9 female 24 57.1 42 100 table 3. frequency distribution of respondents based on the pain score group mean lowest pain score highest pain score standard deviation control 5.00 0 7 1.673 intervention 4.19 2 6 1.078 table 4. effect of ice compress test on immunization injection pain score in infants aged from 0 (zero) to 9 (nine) months (n = 42) n z p value control 21 -2.270 .023 intervention 21 jurnal ners http://e-journal.unair.ac.id/jners | 361 international journal of recent scientific effect of ice application in reducing pain perception of toddlers during. 4(may 2013), 3–7. judha, m., & sudarti, f. a. (2012). teori pengukuran nyeri dan nyeri persalinan. yogyakarta: nuha medika. kebudayaan, d. p. k. dan p. d. j. p. a. u. d. n. dan i. k. p. dan. (2014). teori meridian akupunktur. jakarta. kemenkes ri. (2015). pengendalian penyakit dan penyehatan lingkungan. jakarta: balitbang kemenkes ri. kozzier, b., & et, a. (2010). fundamental keperawatan konsep, proses dan praktik (7 volume 2). jakarta: egc. wardani, n. p. (2014). manajemen nyeri akut. 57–69. waterhouse, m. r., liu, d. r., & wang, v. j. (2013). cryotherapeutic topical analgesics for pediatric intravenous catheter placement, ice versus vapocoolant spray. pediatric emergency care, 29(1), 8–12. wong, d. . (2009). buku ajar keperawatan pediatric (1st ed.). jakarta: egc. wong, d. l., hockenberry, m., wilson, d., winkelstein, m. l., & schwartz, p. (2009). buku ajar keperawatan pediatrik (6 volume 2). jakarta: egc. ners vol 10 no 2 okt 2015.indd 355 seduhan biji kurma (phoenix dactylifera) memperkuat membran sel sperma untuk menurunkan kadar malondialdehid (date seeds steeping (phoenix dactylifera) strengthen sperm cells membrane and reduce malondialdehyde level) saryono*, retnani h**, santoso d** *jurusan keperawatan, fakultas ilmu kesehatan, universitas jenderal soedirman, purwokerto. jalan dr. soeparno purwokerto 53122 **prodi keperawatan, sekolah tinggi ilmu kesehatan muhammadiyah gombong email: sarbiokim@gmail.com abstrak pendahuluan: infertilitas pada pria semakin sering terjadi dan umumnya disebabkan oleh tingginya kadar radikal bebas akibat makanan, merokok maupun polusi. stress oksidatif dapat diturunkan dengan antioksidan, namun sumber antioksidan eksogen umumnya mahal. biji kurma diketahui banyak mengandung antioksidan. tujuan penelitian ini adalah untuk mengetahui pengaruh seduhan biji kurma terhadap kadar mda dan jumlah sperma pada tikus putih yang diinduksi monosodium glutamate (msg). metode: penelitian ini menggunakan metode eksperimen murni dengan menggunakan post test only with control group design. jumlah kelompok perlakuan sebanyak 4 kelompok. biji kurma yang digunakan berjenis deglet noor, dicuci dan dikeringkan sebelum disangrai dan dihaluskan. jumlah sperma dihitung sesuai penelitian rahmanisa dan maisuri, (2013) dan pemeriksaan mda dengan metode tbars c-18 (thiobarbituric acid reactive substances). analisis data menggunakan oneway anova dilanjutkan uji post hoc. hasil: terdapat perbedaan kadar mda dan jumlah sperma pada masing-masing kelompok. seduhan biji kurma 10,5 mg/gbb secara signifikan dapat menurunkan kadar malondialdehid dan meningkatkan jumlah sperma pada kelompok perlakuan setelah induksi msg diskusi: kandungan f lavonoid dan fenolik dalam biji kurma terbukti dapat menurunkan kadar malondialdehid pada hewan coba setelah dipapar msg. kata kunci: radikal bebas, biji kurma, malondialdehide, jumlah sperma, infertilitas abstract introduction: infertility in men is becoming more frequent and are usually caused by high levels of free radicals as a result of diet, smoking or pollution. oxidative stress can be reduced by antioxidants, but a source of exogenous antioxidants are generally expensive. date seed known contain a lot of antioxidants. the purpose of this study was to determine the effect of date seed steeping against mda levels and sperm counts in rats model induced of monosodium glutamate (msg). methods: this study was a pure experimental method using a post-test only with control group design. the treatments were grouped into 4 groups. deglet noor of date seed were used, washed and dried before roasting and smoothed. sperm count is calculated in accordance research of rahmanisa and maisuri, (2013) and mda examination with the c-18 method of tbars (thiobarbituric acid reactive substances). data were analyzed by one way anova and continued with post hoc test. results: there were differences in mda levels and sperm counts between various groups. giving date seed steeping 10.5 mg/gbw can decrease malondialdehyde levels in experimental animals after msg induced significantly. the number of sperm increased significantly after the experimental animals were given a dose of date seed steeping 10.5 mg/g. discussion: flavonoid and fenolic substances of date seeds reduce malondialdehyde level on after msg exposed keywords: free radicals, date seeds, malondialdehyde, sperm count, infertility. pendahuluan kond isi ya ng me n a k ut k a n bag i pasangan baru yang telah berhubungan seksual secara teratur dalam periode yang lama adalah tidak terjadinya kehamilan (infertile). kondisi infertile akhir-akhir ini semakin meningkat, 64% umumnya terjadi pada wanita dan 36% terjadi pada pria. pada pasangan usia subur, kejadian infertile dapat mencapai 15–20%. menurut perkiraan badan kesehatan dunia, akan semakin banyak terjadinya peningkatan infertil di masa mendatang yaitu sekitar 2 jutaan. banyak faktor yang menjadi penyebab infertil, diantaranya adalah kuantitas sperma (dahlan, m.s. dan tjokronegoro, a., 2012). kuantitas sperma dipengaruhi oleh berbagai hal seperti makanan, gaya hidup, stress, olahraga dan obesitas, penyakit, 356 jurnal ners vol. 10 no. 2 oktober 2015: 355–359 lingkungan polusi yang bur uk dan lainlain. faktor lain yang sering terjadi adalah penolakan sperma suami oleh antigen dalam vagina ist ri (bambang, 2006). paparan radikal bebas dalam jangka waktu tertentu juga dapat menyebabkan penurunan fertilitas akibat penurunan berat testis, peningkatan peroksidasi lipid, penur unan antioksidan (vitamin c) dan kerusakan oksidatif. oksigen reaktif pada tikus wistar jantan dewasa di dalam testis dapat menyebabkan st ress oksidatif sehingga kemampuan testis menurun (nayanatara dan vinodini, 2008; dahlan, m.s. dan tjokronegoro, a., 2012). sumber radikal bebas yang umum pada seorang laki-laki adalah rokok, pengawet/perasa pada makanan, pembakaran tidak sempurna dan polusi di tempat kerja. pada kondisi normal, spesies oksigen r e a k t i f ( ros) b e r a d a d a l a m ju m l a h sedikit dihasilkan oleh spermatozoa, yang diperlukan untuk regulasi sperma, kapasitasi sperma dan reaksi akrosom. namun dalam jumlah besar, ros dapat mengoksidasi sel normal khususnya sperma sehingga dapat menu r u n ka n t i ng kat kesubu ra n a k ibat peningkatan kematian sel sperma (apoptosis) dan kerusakan asam deoksiribonukleat (dna). proses spermatogenesis dapat terganggu akibat paparan radikal bebas, yang dapat merusak membrane sel sehingga dapat terjadi gangguan morfologi sel sperma. paparan ros terus menerus dapat menyebabkan disfungsi seluler, apoptosis dan nekrosis (brittenham, 2011). salah satu cara untuk melindungi dinding sel sperma dari kerusakan oksidatif a d a l a h d e ng a n m e n i ng k a t k a n i nt a ke antioksidan. sumber antioksidan vitamin e dan c umumnya cukup mahal sehingga perlu diberikan makanan alternative tinggi antioksidan, salah satunya biji kurma. apalagi banyak masyarakat khususnya laki-laki yang menyukai minuman kopi dan biji kurma terbuang percuma setelah dikonsumsi daging buahnya. biji kurma banyak mengandung antioksidan, karena mengandung senyawa fenolik, yang diduga dapat menur unkan radikal bebas. biji kurma juga mengandung vitamin c, senyawa polifenol dan flavonoid. biji k u r ma ba nya k menga ndu ng senyawa fenolik, yang bermanfaat sebagai antioksidan (takaeidi, et al., 2014). biji k ur ma mengandung komponen bioaktif seperti polifenol dan serat dalam jumlah yang besar, yang bersifat protektif bagi kesehatan (habib et al., 2013). senyawa pektin dalam biji kurma sebagai komponen serat (al-shahib & marshall, 2003), mampu menghambat absorpsi kolesterol di usus halus. penelitian sebelumnya menunjukkan bahwa pemberian vitamin c 10 mg/kg bb secara intraperitoneal mampu mengurangi kadar malondialdehid (mda) dalam testis dan peningkatan jumlah sperma disertai penur unan persentase sper ma abnor mal (acharya dan mishra, 2006). penelitian lain juga memberikan bukti bahwa pemberian vitamin c sampai dosis 0.20 mg/grbb/ hari dapat mengurangi jumlah kerusakan spermatozoa (wibisono, 2011). banyak senyawa ak tif dalam biji kurma yang diduga berperan sebagai sumber antioksidan untuk menurunkan radikal bebas dalam tubuh, tetapi mekanisme pastinya belum jelas sehingga diperlukan penelitian lebih lanjut. oleh sebab itu, peneliti tertarik untuk melakukan penelitian tentang pengaruh seduhan biji kurma terhadap kadar mda dan status sperma pada tikus putih model. tujuan penelitian ini adalah untuk mengetahui pengaruh seduhan biji kurma terhadap kadar mda dan jumlah sperma pada tikus putih model yang diinduksi monosodium glutamate (msg). bahan dan metode metode penelitian yang digunakan a d a l a h e k s p e r i m e n m u r n i d e n g a n menggunakan post test only with control group design. perlakuan dikelompokkan menjadi 4 kelompok yaitu kelompok kontrol negatif = dosis seduhan 0 mg/g/bb dan tanpa msg; kelompok 1 (kontrol positif)= diberi msg 4,2 mg/g bb selama 11 hari selanjutnya dibiarkan sampai hari ke-25; kelompok 2 = diberi msg 4,2 mg/gbb selama 11 hari dan selanjutnya seduhan biji kurma dosis 3,5 mg/g 357 seduhan biji kurma (phoenix dactylifera) memperkuat membran sel sperma (saryono, dkk.) bb selama 14 hari; kelompok 3 = diberi msg 4,2 mg/gbb selama 11 hari dan selanjutnya seduhan biji kurma dengan dosis 10,5 mg/g bb selama 14 hari. biji kurma yang digunakan berjenis deglet noor, dicuci dan dikeringkan sebelum disangrai dan dihaluskan. jumlah sperma dihitung sesuai penelitian rahmanisa dan maisuri, (2013) dan pemeriksaan mda dengan metode tbars c-18 (thiobarbituric acid reactive substances). analisis data menggunakan oneway anova dilanjutkan uji post hoc. hasil kadar mda pada masing-masing kelompok menunjukkan adanya perbedaan (gambar 1). kadar mda tertinggi terjadi pada kelompok yang dipapar msg selama 11 hari sedangkan kadar terendah terdapat pada kelompok 3 yaitu kelompok tikus yang diberi seduhan biji kurma dengan dosis 10,5 mg/gbb pada tikus. hasil uji oneway anova diperoleh nilai f sebesar 114,01 (p < 0,05), hal ini menunjukkan bahwa terdapat perbedaan kadar mda di antara kelompok setelah perlakuan secara bermakna (tabel 1). pemberian seduhan biji kurma terbukti dapat menurunkan produk peroksidasi lipid berupa mda. berdasarkan uji post hoc duncan, keempat kelompok berada dalam subset yang berbeda, yang artinya bahwa keempat kelompok masing-masing berbeda secara bermakna. kelompok 3 yaitu yang diberi seduhan biji kurma 10,5 mg/g bb mempunyai rerata kadar mda paling rendah bila dibandingkan dengan kelompok lainnya. rerata jumlah sperma pada masingmasing kelompok menunjuk kan adanya perbedaan. rerata jumlah sperma tertinggi terdapat pada kelompok 3 setelah pemberian seduhan biji kurma, sedangkan jumlah sperma terendah terdapat pada kelompok 2 yaitu kelompok tikus yang diinduksi msg. hasil uji oneway anova diperoleh nilai f sebesar 87,55 (p < 0,05), hal ini menunjukkan bahwa terdapat perbedaan secara bermakna jumlah sperma di antara berbagai kelompok perlakuan. pemberian seduhan biji kurma terbukti dapat meningkatkan jumlah sperma pada hewan coba setelah terpapar msg. hasil uji post hoc duncan menunjukkan bahwa kelompok yang diberi seduhan biji kurma dosis 10,5 mg/g bb mempunyai rerata jumlah sperma tertinggi disbanding kelompok lainnya secara signifikan. kelompok yang gambar 1. distribusi kadar mda setelah perlakuan diantara berbagai kelompok. gambar 2. distribusi jumlah sperma pada beberapa kelompok perlakuan. tabel 1. rerata kadar mda masing-masing kelompok setelah periode perlakuan kelompok mda sd uji anova p kontrol 1,34 0,08 114,01 0,000 1 2,01 0,11 2 1,08 0,078 3 0,81 0,10 358 jurnal ners vol. 10 no. 2 oktober 2015: 355–359 hanya terpapar msg mempunyai jumlah sperma terendah. pembahasan kandungan flavonoid dan fenolik dalam biji kurma terbukti dapat menurunkan kadar malondialdehid pada hewan coba setelah dipapar msg. kandungan fenolik pada biji kurma yaitu asam galat, asam protokatekuat, p-hidroksibenzoat, asam vanili, asam kafeat, asam p-kumarat, m-kumarat, dan o-kumarat (takaeidi, et al., 2014). kandungan fenolik pada biji kurma sekitar 48.64 mg/100 g (ardekania et al., 2010. selain fenolik, biji kurma juga mengandu ng f lavonoid (sat u hu, 2010). senyawa f lavonoid telah terbukti memiliki banyak manfaat, yaitu sebagai antioksidan, a nt i-k a r si noge n i k , a nt i m i k roba , a nt imutagenik, anti-inf lamasi, dan mengurangi risiko penyakit kardiovaskular (al-farsi & lee, 2007). kombinasi flavonoid dan fenolik secara bersama-sama membantu mencegah terjadinya oksidasi lipid oleh radikal bebas. stress oksidatif pada sper matozoa merupakan penyebab terbanyak disfungsi spermatozoa. stress oksidatif diakibatkan oleh tingginya senyawa oksigen reaktif (ros), yang sebenarnya dalam jumlah sedikit dibutuhkan regulasi fungsi sperma. kandungan antioksidan biji kurma lebih tinggi dibanding daging buahnya (ardekania et al., 2010). oleh karena itu membrane sel sperma menjadi kuat dan tidak mudah rusak, sehingga jumlah sperma banyak. reactive oxygen species (ros) yang meningkat dapat menyebabkan gangguan pada proses spermatogenesis sehingga dapat menyebabkan adanya kelainan pada morfologi sel spermatozoa, kerusakan membran sel, penurunan motilitas, penurunan viabilitas dan kemampuan membuahi (twigg dan fulton, 2008). spesies oksigen reaktif dari msg dapat menyebabkan gangguan perkembangan testis, sel sertoli dan sel leydig pada masa prapuber tas. stres oksidatif msg dapat merusak integritas dna inti spermatozoa sehingga merangsang terjadinya apoptosis, akibatnya jumlah sperma menurun (archarya & mirshra, 2006; lamarinde, 2007). spermatozoa mudah rusak oleh induksi stress oksidatif karena membran selnya banyak mengandung asam lemak tidak jenuh ganda (dahlan, m.s. dan tjokronegoro, a., 2012). selain oksidasi membran sel, ker usakan mitokondria sperma juga dapat menyebabkan penurunan ketersediaan energi yang dapat berakibat pada menurunnya motilitas sperma. keberadaan mitokondria bagi sel sangat penting karena energi banyak dihasilkan dari metabolism aerob di mitokondria. ketika mitokondria rusak, energi yang dihasilkan akan menurun. simpulan dan saran simpulan pemberian seduhan biji kurma 10,5 mg/g bb dapat menurunkan kadar malondialdehid pada hewan coba setelah diinduksi msg secara bermakna. jumlah sperma meningkat signifikan setelah hewan coba diberi seduhan biji kurma dosis 10,5 mg/g bb. terdapat perbedaan kadar mda dan jumlah sperma yang signifikan antar berbagai kelompok. saran perlu penelitian lebih lanjut efek penggunaan seduhan biji kurma dalam jangka waktu lebih lama, sehingga dapat dijamin keamanannya jika digunakan pada manusia. respon pada manusia juga perlu diteliti untuk melihat efek yang lebih nyata. kepustakaan acharya, u. dan mishra, m., 2006. testicular dysfunction and antioxidative defense system of swiss mice after chromic acid exposure. reprod toxicol. 22, 87–91. tabel 2. jumlah sperma pada masing masing kelompok setelah perlakuan kelompok jumlah sperma (juta/ml) sd uji anova p kontrol 20,81 0,87 87,55 0,000 1 7,5 1,02 2 32,68 9,51 3 108,0 16,67 359 seduhan biji kurma (phoenix dactylifera) memperkuat membran sel sperma (saryono, dkk.) al-farsi, m.a., & lee, c.y., 2007. optimization of phenolics and dietary fibre extraction from date seeds. elsevier journal, 108 (3), 977–985. al-shahib, w., & marshall, r.j., 2003. the fruit of the date palm: its possible use as the best food for the future? international journal of food sciences and nutrition, 54 (4), 247–295. a r d e k a n i a , m . r . , k h a n a v i a , m . , hajimahmoodib, m., jahangiria, m., & hadjiakhoondi, a., 2010. comparison of antioxidant activity and total phenol contents of some date seed varieties from iran. iranian journal of pharmaceutical research, 9 (2), 141–146. brittenham, g.m., 2011. iron-chelating t he r apy for tr a n sf u sion a l i ron overload. n engl j med, 364, 146– 156. dahlan, m.s. dan tjokronegoro, a., 2012. oxidative stress and male infertility. pathophisiology and clinical implication. jurnal kedokteran yarsi, 10(1), 50. habib, h.m., plat at, c., meudec, e., cheynier, v., & ibrahim, wh., 2013. polyphenolic compound in date fruit seed characterization and quantifi cation by using uplc-dad-esi-ms. whiley online library. doi:10.1002/jsfa.6387. lamarinde, e., 2007. reactive oxygen species and sper m physiology. review of reproduction, 2, 48–54. nayanatara, a., dan vinodini, n. 2008. role of ascorbic acid in monosodium glutamat mediated effect on testicular weight, sperm morphology and sperm count, in rat testis. journal of chinese clinical medicine, 3, 1–5. rahmanisa, s. dan r.a. maisuri, 2013. pengar uh pemberian ekstrak jahe merah (zingiber offi cinale roxb. var rubrum) dan zinc (zn) terhadap jumlah, motilitas dan morfologi spermatozoa pada tikus putih (rattus norvegicus) jantan dewasa strain sprague dawley. jurnal kedokteran unila, 3 (2), 33–7. sat u hu , s., 2010. kur ma , kasiat dan olahannya. jakarta: penebar swadaya takaeidi, m.r., jahangiri, a., khodayar, m.j., siahpoosh, a., yaghooti, h., rezaei, s., et al., 2014. the effect of date seed (phoenix dactylifera) extract on paraoxonase and a r ylesterase activities in hy percolesterolemic rats. jundishapur journal national pharmacology, 9(1), 30–34. twigg, j., dan fulton, n., 2008. analysis of the impact of intracellular reactive oxygen species generation on structural and functional integrity of human spermatozoa: lipid peroxidation, dna fragmentation and effectiveness of antioxidants. human reproduction, 13, 1429–36. wibisono, 2001. pemanfaatan vitamin c untuk meningkatkan jumlah spermatozoa pada mus musculus yang dipapar gelombang ultrasonik. jurnal media medika, 12(3), 20. http://e-journal.unair.ac.id/jners | 65 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16982 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the use of health technology to enhance the adherence of tuberculosis treatment: a systematic review dwi uswatun sholikhah, gevi melliya sari, cahya mustika narendri, sariati sariati and nora dwi purwanti faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: disobedience in the context of tb treatment is one of the major problems around the world. many efforts have been made to improve the adherence to tb treatment; one of them is the utilization of health technology such as digital technology. the aim of the study was to identify the effectiveness of the use of health technology such as digital technology to improve treatment compliance. methods: the literature review was used to identify the interventions and then the identification of the relevant literature was done by topic and title, obtaining the literature in full text form. the analysis of the results was drawn from the many interventions in the literature. there were 15 articles found from the systematic search performed in the scopus, proquest, science direct, spingerlink and sage databases with an rcts design. this was conducting by entering the keywords of adherence, promoting adherence, improving adherence, tuberculosis treatment, chronic disease, health technology, digital technology, mhealth and self-reminders. results: the search was limited to journals from 2013 to 2018, with the inclusion criteria being the use health technology such as digital technology to improve the adherence to chronic disease treatment (tb treatment). conclusion: there are several uses of health technology when it comes to improving the adherence to tb treatment that can be used as a promotive and preventive effort during the treatment of tb. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords biomedical technology; medication adherence; tuberculosis therapy contact gevi melliya sari  gevi.melliya.sari2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sholikhah, d. u., sari, g. m., narendri, c. m., sariati, s., & purwanti, n. d. (2019). the use of health technology to enhance the adherence of tuberculosis treatment: a systematic review.jurnal ners, 14(3si), 65-70. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16982 introduction disobedience on chronic disease treatment like on tb treatment, is a major problem around the world. patient with tb are expected to have an adherence rate of more than 90% to support healing process. the failure of the healing process caused progression risk of disease such as medicine resistance, and continuity of disease transmission in community. these may cause the rise of morbidity and mortality (adane, alene, koye, & zeleke, 2013). tuberculosis remains the biggest problem in the world. the disease causes illness in 10 million people each year and it is one of the top ten causes of mortality in the worldwide (world health organization, 2017). in 2015, the new cases of tb were estimated to be around 10,4 million globally, of which 5,9 million (56%) were men, 3,5 million (34%) were women and 1,0 million (10%) were children (who, 2016). in 2016, the incidence rate of tb did not experience a decline and remained the same at10,4 million (around 8,8 million to 12,2 million cases). there were around 140 cases per 100.000 populations. most estimates of the number of cases in 2016 occurred in southeast asia (45%), africa (25%), the western pacific region (17%), the eastern mediterranean (7%), europe (3%) and america (3%). the 4 countries that have the largest incidence rate in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:tria.anisa.firmanti-2018@fkp.unair.ac.id mailto:tria.anisa.firmanti-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). d. u. sholikhah, et al. 66 | pissn: 1858-3598  eissn: 2502-5791 the world are india, indonesia, china and the philippines (world health organization, 2017). the high incidence rate of tb is caused by unsuccessful tb treatment which is related to the adherence of tb treatment. the long treatment duration (6 months), the medication side effects, maladaptive coping mechanisms, social and economic factors, and the presence of stigma may affect the adherence of tb treatment. adherence to the treatment is very important, because when the treatment process is completed with good adherence, it can be very effective at preventing medicineresistant tb, thus curing the disease and preventing the transmission of the disease to others (guixcomellas et al., 2017). there are many steps that can be taken to improve the adherence to tb treatment: (1) helping clients deal with social problems that might hinder their abilities during the treatment process, (2) to increase effective cooperation and communication between the care workers and (3) the supervision of the clients directly and indirectly through pmo, through the care workers and through the family who act as self reminders for the clients (oren, bell, garcia, perezvelez, & gerald, 2017). these steps can be realized with the existing innovations that are accessible, convenient, flexible and able to empower the clients. one of the utilizations of health technology is in the form of digital technology. the use of digital technology is considered to improve the adherence to a treatment program for the patients of tb. the purpose of this systematic review was to identify health-related digital technology that can be used to improve the adherence to tb treatment. the method used to prepare the systematic review consisted of (1) the identification of interventions in the literature, (2) the identification of the relevant literature by topic and title, (3) obtaining the literature in full text form and (4) the analysis of the results from many interventions in the literature. materials and methods this paper reported about the interventions used to improve the treatment adherence of patients with tb. the study adopted the systematic review methodology to clarify how diverse digital technology can be used to improve the adherence of tb patients. this paper reported on the first stage of the systematic review from a range of 1824 studies that were obtained by keyword searching. after the removal of duplicates and irrelevant studies, 35 studies that were full text articles were identified and then 20 studies were excluded due to not meeting the inclusion criteria. the remaining 15 randomized studies were considered in this review. the focus of this review was digital technology. the total respondents in this review consisted of 5,013 people with chronic disease (tuberculosis, hiv, asthma) that required adherence to long-term treatment. the research area was in the hospital and in the community. literature searches were conducted in multiple databases such as proquest, scopus, sciencedirect, spingerlink and sage by entering the keywords of adherence, promoting adherence, improve adherence, tuberculosis treatment, chronic disease, health technology, digital technology, m-health and self-reminders. the criteria used to include and exclude studies were defined and applied to the set of 1824 studies that were written in english. the criteria of the participants in this study were that they were people with a chronic disease who required long-term treatment, as adherence is necessary during the process of treatment. the use of health technology to improve the adherence to treatment within a longterm intervention period was therefore the focus. a given intervention such as sms reminders, videoobserved treatment, electronic reminders, mobile interactive supervised therapy or electronic monitoring devices were used to increase adherence in the treatment process. in this review, three articles did not have a comparison intervention. we limited the search range to 5 years (2013 to 2018) with the inclusion criteria being the use of health technology such as digital technology to improve the adherence to chronic disease treatment (tb treatment). the design of the studies were randomized controlled trial study (rcts), including cluster rcts and quasircts. there was no age limitation for the participant in the articles, because the focus of the search was on the chronic disease suffered by the participants. results based on the database search, the related studies of this review totaled 15 articles that met the conclusion figure 1. flow diagram jurnal ners http://e-journal.unair.ac.id/jners | 67 and exclusion criteria. a total of 1824 studies were obtained through the keyword search. after the removal of duplicates and irrelevant studies, 35 studies consisting of full text articles were identified and then 20 studies were excluded due to not meeting the inclusion criteria. the remaining 15 randomized studies were considered in this review. the research explained about digital technology intended to improve adherence for patients with tb. articles (bediang, stoll, elia, abena, & geissbuhler, 2018), (fang et al., 2017) (mohammed, glennerster, & khan, 2016), (johnston et al., 2018), (iribarren et al., 2013), (farooqi, ashraf, & zaman, 2017), (van der kop et al., 2014), (nhavoto, gronlun, & klein, 2017) explained about the use of sms reminders, article (molton et al., 2016) explained about mobile interactive supervised therapy, article (orrell et al., 2015) (liu et al., 2015), explained about the use of electronic monitoring based on the wisepil device and article (chan et al., 2015) explained about audio visual devices. article (oren et al., 2017) focused on sms reminders and phone cell reminders, (vasbinder et al., 2016) explain about real time medication monitoring and article (sinkou et al., 2017) explained about video observed treatment. the articles awere clarified if the results of the study did not explain the estimated effects of the intervention provided. the steps of the data selection and extraction were as reported in figure 1. for each study, the data from the full texts was extracted including publication year, title and the key words, including the authors, research questions, methodology and main results. they were then subject to a thematic analysis focused on the use of digital technology. see on table 1. discussion the use of digital technology can help to achieve success in the treatment on a patient with a chronic disease, such as tuberculosis. this chronic condition requires a long-term commitment to the treatment process (molton et al., 2016). many studies have been table 1. the randomized controlled trial studies which were included in the systematic review. author type of study participants intervention outcome (bediang et al., 2018) rcts 297 participants with tb disease sms reminder the proportion of client recovery the success of treatment adherence to treatment control timely (sinkou et al., 2017) rcts 10 participants with tb disease video-observed treatment adherence to treatment (fang et al., 2017) rcts 350 participants with tb disease sms reminders complete treatment adherence to treatment (mohammed et al., 2016) rcts 2.207 participants with tb disease sms reminders the success of the treatment self-reported adherence to treatment (johnston et al., 2018) rcts 358 participants with ltbi sms reminders completed treatment adherence to treatment quality of life self-reported (liu et al., 2015) cluster rcts 119 participants with tb disease electronic reminders (sms and medication monitor/mm) the success of the treatment follow up adherence to treatment (iribarren et al., 2013) rcts 37 participants with tb disease sms reminders feasibility of the use of the application adherence to treatment the result of the sputum examination was negative (farooqi et al., 2017) rcts 148 participants with tb disease sms reminders adherence to treatment (oren et al., 2017) rcts 40 participants with ltbi sms reminders and phone call reminders adherence to treatment awareness for control no loss of medicine dosage (van der kop et al., 2014) rcts 350 participants with ltbi sms reminder completed treatment adherence to treatment treatment is completed on time quality of life (nhavoto et al., 2017) rcts 404 participants with tb and sms reminders adherence to treatment giving motivation health education (molton et al., 2016) rcts 42 participants with tb disease mist (mobile interactive supervised therapy) adherence to treatment (orrell et al., 2015) rcts 230 participants with hiv electronic monitoring based on the wisepil device concern for the disease adherence to treatment decreased viral load (vasbinder et al., 2016) rcts 219 participants with asthma real time medication monitoring (rtmm) using sms reminders adherence to treatment control of disease quality of life (chan et al., 2015) rcts 220 participants with asthma electronic monitoring device with an audiovisual reminder adherence to treatment. control of disease d. u. sholikhah, et al. 68 | pissn: 1858-3598  eissn: 2502-5791 conducted to identify whether the use of digital technology is effect at improving medication adherence in clients with chronic disease. for example, through the use of sms reminders, videoobserved treatments, electronic reminders, mobile interactive supervised therapys and electronic monitoring. in this systematic review, we have discussed the comparison of each intervention given in improving medication adherence. sms reminders. of the 15 articles, there were 8 articles that used sms reminders as the intervention of their choice. the intervention was carried out by sending a reminder message to the patient according to the prescribed medication time. if the patient does not respond, then a second reminder message will be sent back until the patient responds. the success of the intervention from each article varied; 4 articles explained an increase in tb treatment adherence after being given the intervention and the 4 other articles did not. the failure can be caused by many factors that are limited in the study. for example, the use of sms reminders that only allows for one-way communication, the inability to verify whether the message really has reached the respondent and the likelihood of the respondents to change their phone number at any time during the research taking place. sms reminders and phone call reminders. oren’s research (2017) explained that, in this study, the tb patients will receive automatic messages from the system containing reminders related to taking the medication. the previous patient’s telephone number has been entered into the web platform which later can be used to verify whether the client received the message or not. each patient is required to respond to the system in response to receiving the reminder message. if the client does not provide a response, then it will continue with a telephone call. the results of the analysis obtained that the use of sms reminders and phone call reminders can significantly improve the adherence of latent tb patients which is measured by increasing the rate of completion of the treatment, higher self-reporting, reduced doses of the medicine were missing and a shorter treatment. video-observed treatment. video-observed treatments as an intervention were found to improve the treatment adherence of tb patients. adherence monitoring is done using video calls via a smartphone for each patient. video monitoring is considered to be more effective at increasing the level of adherence with the tb treatment. in conclusion, 8 of the 10 respondents said that it was more convenient to control via video rather than direct control by going to the clinic (sinkou et al., 2017). electronic reminder (sms and mm). this intervention uses sms reminders and communication monitoring (mm) in the form of medicine monitor boxes to improve the adherence of tb patients (liu et al., 2015). in sms reminders, the patient will receive a message to take the medication according to a predetermined schedule. the message will be resent if the client does not respond. in addition, the medicine monitor box equipped with an audio device will also sound according to the patient's medication schedule. the medicine monitoring box will not stop ringing until the patient has taken the medicine. based on the results of the analysis, sms reminders cannot improve adherence when it comes to taking the tb medicine but medication monitoring in the form of medicine monitoring boxes can significantly improve the adherence to the tb treatment. mist (mobile interactive supervised therapy). mist is a system consisting of 2 components; web-based and smartphone -based. the web-based component of the system allows for the administrators to manage the time needed to take the medication that is needed every day. this is selected according to the frequency of the therapy and the patient’s preferences. after the medication is determined, the system will send a notification for them to take the medication via sms 30 minutes before the specified schedule with repeated reminders every 15 minutes until the patient sends a video of himself taking the medicine. the video will then be uploaded to the web-based component according to the date and time of taking the medication. if the video has been uploaded successfully, then the video will be automatically deleted from the smartphone. web-based and smartphone mist increased the adherence of the tb patients to taking the medicine (molton et al., 2016). real time medication monitoring (rtmm). rtmm is a medication compliance monitoring tool for patients with asthma that is directly linked to the inhaled corticosteroids owned by the patient. this tool will monitor the patient’s provisions in relation to taking the medicine accompanied by sms reminders. the device can improve adherence to the asthma treatment but it cannot control the asthma itself or related exacerbations (vasbinder et al., 2016). electronic monitoring device with audiovisual reminders. there are audiovisual reminders to improve medication adherence in patients with asthma (chan et al., 2015). the audiovisual reminder consists of 14 audio reminders with different ringtones. the date, time and number of doses of the medicine administration are recorded in the visual display. conclusion the use of health technology such as digital technology provides many benefits, especially in the health sector. for example, for the treatment of chronic diseases such as tb that require long-term treatment, health technology can be used to improve the adherence to taking the tb medicine with a reminder system consisting of sms reminders, electronic reminders, video-observed treatments, medication monitors and so on. some health technologies that are used as an effort to improve the adherence to tb treatment can be used as a basis for consideration in the promotion and prevention efforts related to tb. the selection of interventions jurnal ners http://e-journal.unair.ac.id/jners | 69 can be adjusted to the objectives that are to be achieved. references adane, a. a., alene, k. a., koye, d. n., & zeleke, b. m. (2013). non-adherence to anti-tuberculosis treatment and determinant factors among patients with tuberculosis in northwest ethiopia, 8(11). https://doi.org/10.1371/journal.pone.0078791 bediang, g., stoll, b., elia, n., abena, j. l., & geissbuhler, a. (2018). sms reminders to improve adherence and cure of tuberculosis patients in cameroon (tb-sms cameroon): a randomised controlled trial. bmc public health, 18(1), 1–14. https://doi.org/10.1186/s12889-018-5502-x chan, a. h. y., stewart, a. w., harrison, j., camargo, c. a., black, p. n., & mitchell, e. a. (2015). the effect of an electronic monitoring device with audiovisual reminder function on adherence to inhaled corticosteroids and school attendance in children with asthma: a randomised controlled trial. the lancet respiratory medicine, 3(3), 210– 219. https://doi.org/10.1016/s22132600(15)00008-9 fang, x.-h., guan, s.-y., tang, l., tao, f.-b., zou, z., wang, j.-x., … pan, h.-f. (2017). effect of short message service on management of pulmonary tuberculosis patients in anhui province, china: a prospective, randomized, controlled study. medical science monitor, 23, 2465–2469. https://doi.org/10.12659/msm.904957 farooqi, r. j., ashraf, s., & zaman, m. (2017). the role of mobile sms-reminders in improving drugs compliance in patients receiving anti-tb treatment from dots program. journal of postgraduate medical institute, 31(2), 156–162. guix-comellas, e. m., rozas-quesada, l., morín-fraile, v., estrada-masllorens, m., galimany-masclans, j., & sancho-agredano, r. (2017). educational measure for promoting adherence to treatment for tuberculosis. procedia social and behavioral sciences, 237(june 2016), 705–709. https://doi.org/10.1016/j.sbspro.2017.02.047 iribarren, s., beck, s., pearce, p. f., chirico, c., etchevarria, m., cardinale, d., & rubinstein, f. (2013). texttb: a mixed method pilot study evaluating acceptance, feasibility, and exploring initial efficacy of a text messaging intervention to support tb treatment adherence. tuberculosis research and treatment, 2013, 1–12. https://doi.org/10.1155/2013/349394 johnston, j. c., van der kop, m. l., smillie, k., ogilvie, g., marra, f., sadatsafavi, m., … lester, r. t. (2018). the effect of text messaging on latent tuberculosis treatment adherence: a randomised controlled trial. european respiratory journal, 51(2), 1701488. https://doi.org/10.1183/13993003.01488-2017 liu, x., lewis, j. j., zhang, h., lu, w., zhang, s., zheng, g., … fielding, k. l. (2015). effectiveness of electronic reminders to improve medication adherence in tuberculosis patients: a clusterrandomised trial. plos medicine, 12(9), 1–18. https://doi.org/10.1371/journal.pmed.1001876 mohammed, s., glennerster, r., & khan, a. j. (2016). impact of a daily sms medication reminder system on tuberculosis treatment outcomes : a randomized controlled trial, 11, 1–14. https://doi.org/10.7910/dvn/hvj2cm.funding molton, j. s., pang, y., wang, z., qiu, b., wu, p., rahmanshepherd, a., … paton, n. i. (2016). prospective single-arm interventional pilot study to assess a smartphone-based system for measuring and supporting adherence to medication. bmj open, 6(12). https://doi.org/10.1136/bmjopen-2016014194 nhavoto, j. a., gronlun, a., & klein, g. o. (2017). mobile health treatment support intervention for hiv and tuberculosis in mozambique : perspectives of patients and healthcare workers. plos one, 1–13. https://doi.org/10.1371/journal.pone.0176051 oren, e., bell, m. l., garcia, f., perez-velez, c., & gerald, l. b. (2017). promoting adherence to treatment for latent tb infection through mobile phone text messaging: study protocol for a pilot randomized controlled trial. pilot and feasibility studies, 3(1), 1–9. https://doi.org/10.1186/s40814-017-01289 orrell, c., cohen, k., mauff, k., bangsberg, d. r., maartens, g., & wood, r. (2015). a randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. jaids-journal of acquired immune deficiency syndromes, 70(5), 495–502. https://doi.org/10.1097/qai.000000000000077 0 sinkou, h., hurevich, h., rusovich, v., zhylevich, l., falzon, d., de colombani, p., … skrahina, a. (2017). video-observed treatment for tuberculosis patients in belarus: findings from the first programmatic experience. european respiratory journal, 49(3), 1–3. https://doi.org/10.1183/13993003.02049-2016 van der kop, m. l., memetovic, j., patel, a., marra, f., sadatsafavi, m., hajek, j., … lester, r. t. (2014). the effect of weekly text-message communication on treatment completion among patients with latent tuberculosis infection: study protocol for a randomised controlled trial (weltel ltbi). bmj open, 4(4), 1–9. https://doi.org/10.1136/bmjopen-2013-004362 vasbinder, e. c., goossens, l. m. a., rutten-van mölken, m. p. m. h., de winter, b. c. m., van dijk, l., vulto, a. g., … van den bemt, p. m. l. a. (2016). emonitoring of asthma therapy to improve compliance in children (e-matic): a randomised controlled trial. european respiratory journal, 48(3), 758–767. https://doi.org/10.1183/13993003.01698-2015 d. u. sholikhah, et al. 70 | pissn: 1858-3598  eissn: 2502-5791 who. (2016). who | global tuberculosis report 2016. who 2016, (1), 1–204. https://doi.org/isbn 978 92 4 156539 4 world health organization. (2017). global tuberculosis report 2017. world health organizacion report 2017. https://doi.org/who/htm/tb/2017.23 http://e-journal.unair.ac.id/jners | 215 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.16592 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research analysis of the sociodemographic and psychological factors of the family caregivers’ self-management capabilities for type 2 diabetes mellitus rondhianto rondhianto1,2, nursalam nursalam3, kusnanto kusnanto3, soenarnatalina melaniani1, ahsan ahsan4 1faculty of public health, universitas airlangga, surabaya, indonesia 2faculty of nursing, universitas jember, jember indonesia 3faculty of nursing, universitas airlangga, surabaya, indonesia 4faculty of medicine, universitas brawijaya, malang, indonesia abstract introduction: the successful management of type 2 diabetes mellitus is determined by the role of the family in self-management as a family caregiver. many factors influence the capability of the family caregivers to carry out diabetes self-management. the purpose of this study was to analyze the factors that influence the family caregiver capability of performing diabetes self-management in people with type 2 diabetes mellitus. methods: the study design was an analytical observation using a cross-sectional approach. the sample was 220 family caregivers of people with type 2 diabetes mellitus in jember regency, east java province, indonesia. the multistage random sampling technique was used as the sampling technique. the research instrument was a questionnaire. the questionnaires used in this study were the diabetes management self efficacy scale, the spoken knowledge in low literacy patients with diabetes questionnaire, the motives for caregiving scale, the spirituality index of well-being, the sense of coherence scale, the coping scale, the hensarling diabetes family support scale, and the family caregiver's perception of the role of the nurse questionnaire. the data analysis was performed using the pearson correlation test, the spearman rank test, and the multiple linear regression test. results: the results of the pearson correlation test and spearman rank test showed that the sociodemographic factors associated with diabetes self management were age (p=0.000), gender (p=0.016), education (p=0.000), income (p=0.000), and kinship (p=0.000). the psychosocial factors associated with diabetes self management were diabetes knowledge (p=0.000), motivation (p=0.000), coping skills (p=0.000), spirituality (p=0.000), family coherence (p=0.000), family support (p=0.000) and the role of the nurses (p=0.000). the multiple linear regression test showed that the factors associated with diabetes self management were diabetes knowledge (β=0.047), motivation (β=0.094), coping (β=0.188), spirituality (β= -0.082), family coherence (β= −0.043), family support (β= 0.296) and the role of the nurses (β= 0.512). conclusion: efforts to increase the family caregiver’s capabilities in terms of diabetes self-management should pay attention to the socio-demographic and psychosocial factors to prevent complications and to improve the health status, and quality of life of people with type 2 diabetes mellitus. article history received: dec 19, 2019 accepted: jan 14, 2020 keywords diabetes self management; family caregiver capabilities; psychosocial; sociodemographic factors; type 2 diabetes mellitus contact rondhianto rondhianto  rondhianto2017@fkm.unair.ac.id  faculty of public health, universitas airlangga, surabaya, indonesia cite this as: rondhianto, r., nursalam, n., kusnanto, k., melaniani, s., ahsan, a. (2019). analysis of the sociodemographic and psychological factors of the family caregivers’ self-management capabilities for type 2 diabetes mellitus. jurnal ners, 14(2), 215-223. doi:http://dx.doi.org/10.20473/jn.v14i2.16592 introduction type 2 diabetes mellitus is a chronic disease that cannot be cured. it requires proper medical management, ongoing self-management, and collaboration between the diabetic individual, their family and any associated health workers. this is because the family plays an essential role in the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ r. rondhianto et. al 216 | pissn: 1858-3598  eissn: 2502-5791 successful management of type 2 diabetes mellitus (world health organization [who], 2016). the successful management of type 2 diabetes mellitus is determined by the role of the family in selfmanagement as a family caregiver can help the person with diabetes to manage the disease (pierce & lutz, 2012). this is by helping them to carry out a series of diabetes self-management actions (powers et al., 2015). however, not all families can play a role as a family caregiver. as a result, this can lead to failure in diabetes self-management (world health organization [who], 2016). the majority of families (53.33%) were unable to carry out their role as family caregivers related to caring for the type 2 diabetes mellitus patients (putri, yeni, & handayani, 2013). other studies showed that the family caregivers who care for people with diabetes have health problems themselves or physical and psychological disorders. this has the impact of them having a decreased ability to carry out the health task of caring for people with diabetes (badriah, wiarsih, & permatasari, 2017). furthermore, the failure of a family caregiver in terms of diabetes self management has an impact on their health status. it also increases the complications of people with diabetes (international diabetes federation [idf], 2017). the problem also can increase the care needed in the health care institutions which has an impact in terms of increasing the health cost (world health organization [who], 2016), decreasing quality of life, reducing life expectancy and increasing the mortality rate (international diabetes federation [idf], 2017). diabetes is an incurable disease. it requires continuous care in the long term that can deplete the family's economic resources and disrupt the roles, functions, and regulations in the family. diabetes also has a negative impact on the other family members in the form of physical and psychological disorders, social disruption and disturbances in the economic stability of the family. these all impact on their capability to carrying out caring actions related to the disease (pierce & lutz, 2012). families can participate in diabetes self-management to prevent the negative effects of the disease (world health organization [who], 2018). they can also provide emotional support to the people with diabetes, help them to develop healthy behaviors and promote diabetes self management. this can improve their blood sugar control, reduce the complications of the disease and improve the quality of life of diabetics (hu et al., 2014; matrook et al., 2018). therefore, it is essential for the health care provider to understand the critical role of the family in managing the disease and to seek to improve the family's capability of managing the disease independently. several studies have shown that many factors can affect the capability of the family caregivers in terms of self-management. sociodemographic factors including age, sex, marital status, socioeconomic status, ethnicity, and kinship can influence how a person conducts independent management of the disease (friedman, bowden,& jones, 2010; pierce & lutz, 2012). in addition, several studies show that a person's psychosocial condition such as their knowledge, motivation, coping, family coherence, and aspects of religiosity can also affect how a person should behave in relation to managing the disease of their family members (antonovsky & sourani, 1988; friedman, bowden & jones, 2010; pierce & lutz, 2012; rabinowitz et al., 2009; sakanashi & fujita, 2017). the family caregiver perception factors related to the resources that can be used in efforts to care and support the health services will also determine the ability of the family caregiver to carry out the caregiving role (friedman, bowden, & jones, 2010; grant & ferrell, 2012; pierce & lutz, 2012). understanding the interaction between the sociodemographic factors and psychosocial factors with the ability of the family caregivers to manage type 2 diabetes mellitus can provide insights to improve diabetes management comprehensively. this step was taken to be able to provide positive results in the management of diabetes, namely increased glycemic control and reduced disease complications, and to improve the quality of life of people with type 2 diabetes mellitus. materials and methods the study design was an analytical observation with a cross-sectional approach conducted from october 28th until november 28th 2019 in 10 public health centers in jember regency, east java province, indonesia. the sample size was 220 family caregivers of type 2 diabetic patients. this study used multistage random sampling with the following inclusion criteria: (1) spouse or adult children who have a parent with type 2 diabetes mellitus, (2) living together with people with type 2 diabetes mellitus, (3) the families of people with type 2 diabetes mellitus who have been diagnosed with type 2 diabetes mellitus within a minimum of 1 year and (4) the family has health insurance. the variables in this study are the family caregiver’s diabetes self-management capabilities as the dependent variable and the sociodemographic and psychosocial factors as the independent variables. the sociodemographic factors included age, gender, education level, income level, marital status, kinship with diabetes, diabetes duration and the complications of diabetes. the psychosocial factors included diabetes knowledge, motivation, coping skills, spirituality, family coherence, family support, and the perception of the role of the nurses. the instruments used in this study were questionnaires. all of the questionnaires were tested for validity and reliability, and all of the research variable question items have been declared to be valid and reliable. the family caregiver diabetes self-management capabilities were measured by the diabetes management self efficacy scale by van der bijl et al. jurnal ners http://e-journal.unair.ac.id/jners | 217 (2001). this questionnaire consists of 20 items with a likert scale of 1-5 which contains beliefs about the ability to regulate type 2 dm type 2 diets, the regulation of physical activity of patients with type 2 dm, the use of medication, blood sugar monitoring, and foot care. the sociodemographic factors were measured using questionnaires consisting of questions focused on age, gender, education level, income level, marital status, kinship with diabetics, and also diabetes duration and the complications experienced by people with diabetes. the spoken knowledge in low literacy patients with diabetes questionnaire by rothman et al. (2005) was used to measure the diabetes knowledge variables. this questionnaire contains questions on the knowledge of the signs, symptoms, and management of diabetes. this questionnaire consisted of 20 question items; a correct answer was given a score of 1 while a wrong answer was given a score of 0. the range of scores was 0-20. the motives for caregiving scale by kolmer et a. (2008) was used to measure the motivation of the family caregiver when caring for patients with diabetes. this questionnaire contains the aspects of responsibilities and obligations, feeling happy, being the right person and hope. this questionnaire consists of 12 question items with a score of yes (1) and no (0). the score range was 0-12. the spirituality index of well being by daaleman & frey (2004) was used to measure the aspects of family caregiver spirituality, which consists of their self-confidence in life and life schemes. this questionnaire consisted of 12 items with a likert scale of 1-5. the score range is 12-60. the sense of coherence scale by holmefur et al. (2014) was used to measure the family caregiver perception of family coherence. the questionnaire consisted of 13 items with a likert scale of 1-7 so the score range was 1391. the coping scale by hamby, grych, & banyard (2015) was used to measure the family caregiver coping skills that contained an assessment of their abilities to overcome problems. the questionnaire consisted of 13 items with a likert scale of 1-4 so the value range was 13-52. the hensarling diabetes family support scale by hensarling (2009) was used to measure the family caregiver perceptions of family support received in the form of information, an assessment and emotional and instrumental support. the questionnaire consisted of 29 items on a scale of 1-4, so the score range was 29 – 116. the perception of the family care groups of the health services was measured using a questionnaire compiled based on the concept of the role of the nurses of empowering the family (imanigoghary et al., 2017). this questionnaire consisted of 25 question items that measured the family perceptions on the role of nurses in helping people with diabetes and their families, in the form of enabling (9 items), reinforcing (8 items), and supporting (7 items) with a likert scale of 1-4, so the range of scores was 24-96. the data collection in the study was carried out with the help of research assistants. before the data collection, the researcher got informed consent for the study from each respondent. the researcher explained the purpose and benefits of the research, the procedure of conducting the research, and the risk of participating in the research. after it was explained, the researcher sought approval from each of the prospective respondents in order for them to become research respondents by signing an informed consent sheet. the data was analyzed using both a univariate and multivariate analysis test. the baseline sociodemographic characteristics of age, diabetes duration, the complications of diabetes, and other numerical research variables were described using both mean and standard deviation (sd). the categorical data of gender, education level, income level, marital status and kinship of the diabetes patients were described using frequency and constituent ratios. the correlation tests, namely the pearson correlation test and the spearman rank test, were used to determine the relationship between the characteristics of the respondents with diabetes selfmanagement. the multiple linear regression test was used to analyze the factors that influence the family caregiver’s diabetes self-management capability. a 2sided p <0.05 was considered to be statistically significant. this study passed the ethical review of the health research ethics commission of the faculty of nursing universitas airlangga and it received approval of the research protocol number 1795kepk. results the demographic characteristics of the respondents have been presented in table 1. the average age of the respondents in this study was 49.49 years old. the majority of the respondents were female (67.2%), married (91.4%), and had an education level of junior high school (33.8%) with a level of income under the regional minimum wage (69.8%). the average diabetes duration of illness was 48.08 months and they did not have any complications (83.6%). the respondent characteristics based on the psychosocial factors have been presented in table 2. the majority of respondents (63.18%) had a good knowledge of diabetes and they were highly motivated to care for their family members with diabetes (79.09%). the coping skills of the respondents were, for the majority, in the high category (61.36%) as were the aspects of spirituality (67.27%). the majority of respondents had family coherence that was in the good category (79.09%) and they received high family support from the rest of the family (74.09%). however, the respondents' perceptions of the role of the nurses in providing services was in the middle category for the majority (65.55%) and the majority of the respondents’ r. rondhianto et. al 218 | pissn: 1858-3598  eissn: 2502-5791 abilities in terms of managing diabetes was in the middle category (48.18%). table 2 also shows that there are significant differences based on gender, where the average male respondent had diabetes table 1. respondents’ sociodemographic characteristics (n=220) variable mean ±sd or n (%) age (years) 49.49 ± 9.516 gender female 156 67.2 male 64 27.6 level of education elementary school 56 24.1 junior high school 78 33.6 senior high school 70 30.2 college 16 6.9 income under minimum wage 162 69.8 above minimum wage 58 25.0 marital status unmarried 2 0.9 married 212 91.4 widow/widower 6 2.6 kinship children 36 15.5 husband 53 22.8 wife 131 56.5 diabetes complications no 194 83.6 present 26 11.2 diabetes duration (month) 48.0818 ±23.6336 table 2. respondent characteristics based on the psychosocial factors (n = 220) variable n % mean ± sd (minmax) mean difference p value female male diabetes knowledge 11.6364± 2.80322 (5.00– 17.00) 11.0769 ±2.77207 13.0000± 2.39709 0.000 poor 81 36.82 good 139 63.18 motivation 9.3636± 1.87377 (5.00 – 12.00) 9.0833± 1.95088 10.0469± 1.47390 0.000 low 0 0 middle 46 20.91 high 174 79.09 coping skills 39..318± 7.02207(22.00– 50.00) 38.1731± 7.21125 42.1562± 5.66027 0.000 low 13 5.91 middle 72 32.3 high 135 61.36 spirituality 47.1500± 7.23893 (28.00–59.00) 46.0769± 7.46825 49.7656± 5.92745 0.000 low 0 middle 72 32.73 high 148 67.27 family coherence 72.8500± 8.23348 (46.00–88.00) 71.8654± 8.66367 75.2500± 6.53683 0.002 poor 0 0 fair 46 20.91 good 174 79.09 family support 95.0818± 13.87526 (56.00–116.00) 93.0385± 14.73766 1.0006e2± 9.96641 0.000 low 0 0 medium 57 25.91 high 163 74.09 role of nurses 69.4682± 8.91840 (50.00–88.00) 68.4295± 9.01906 72.0000± 8.19601 0.007 poor 0 0 fair 142 65.55 good 78 35.45 diabetes self-management 71.0818± 10.55460 (43.00– 90.00) 69.3782± 10.98817 75.2344± 8.09221 0.000 poor 11 5 fair 106 48.18 good 103 46.82 jurnal ners http://e-journal.unair.ac.id/jners | 219 knowledge, motivation, coping skills, spirituality, family coherence and family support that was better than that of the female respondents. table 3 shows that there are three factors, namely marital status, diabetes complications and diabetes duration, that are not related to their diabetes self-management capability. all of the psychosocial factors were associated with diabetes self-management capability. according to table 4, it can be seen that only the coping variables, family support, and the perception of the role of the nurses partially influenced the ability of the family caregivers in terms of the diabetes selfmanagement capability (p-value <0.05). the f test of the model had an f value = 184,360, p =0,000 <α = 0.05. this explains that the variables of knowledge, motivation, coping, spirituality, family support, and the family caregiver perceptions of the nurses jointly influenced the family caregiver’s diabetes selfmanagement capability. it can be concluded that the estimated linear regression model is feasible to use to explain the impact of the variables on the independent management of type 2 diabetes mellitus by the family caregivers. discussion the results show that the majority of family caregivers have an ability of diabetes selfmanagement that is in the middle category (48.18%). however, there are a small proportion of family caregivers who have diabetes self-management capabilities in the poor category (5%). this is important and it should be a concern of the health care providers. this is because the inability of the families to carry out diabetes self-management can have an impact on the behavior of diabetics, their health status and the emergence of disease complications that can trigger a decrease in quality of life and an early death (international diabetes federation [idf], 2017). the family-focused approach is likely to maximize the effectiveness of the intervention. interventions that involve families can provide a new structure for table 3. relationship between the sociodemographic and psychosocial factors on diabetes self management capability (n=220) variable diabetes self-management capability sociodemographic factors r p value age -0.212** 0.000 gender 0.262** 0.000 education level 0.453** 0.000 income 0.207** 0.002 marital status 0.057 0.397 kinship -0.311** 0.000 diabetes complications -0.024 0.724 diabetes duration 0.022 0.745 psychosocial factors diabetes knowledge 0.774** 0.000 motivation 0.808** 0.000 coping skills 0.808** 0.000 spirituality 0.759** 0.000 family coherence 0.648** 0.000 family support 0.817** 0.000 role of nurses 0.865** 0.000 **. correlation is significant at the 0.01 level (2-tailed). table 4. effect of the psychosocial factors on diabetes self management capability variable coefficient model reliability test non-standardized coefficients standardized coefficients f test b se β t p f p constant -0.912 3.774 -.242 .809 184.360 0.000 diabetes knowledge 0.176 0.203 0.047 0.868 0.386 motivation 0.529 0.682 0.094 0.775 0.439 coping skills 0.283 0.092 0.188 3.059 0.003 spirituality -0.120 0.119 -0.082 -1.003 0.317 family coherence -0.055 0.056 -0.043 -0.972 0.332 family support 0.225 0.079 0.296 2.846 0.005 role of nurses 0.606 0.045 0.512 13.336 0.000 model r r square adjusted r square se of the estimate i 0.927a 0.859 0.854 4.02952 a. predictors: (constant), role of nurses, family coherence, diabetes knowledge, spirituality, coping skills, family support, motivation r. rondhianto et. al 220 | pissn: 1858-3598  eissn: 2502-5791 the family by adjusting their roles and expectations as needed to ensure optimal patient self-care (matrook et al., 2018; pierce & lutz, 2012). the empowerment of the family caregivers as an effort to improve the ability of the independent management of diabetes needs to be developed as a preventive promotion effort when managing diabetes (hu et al., 2014; international diabetes federation [idf], 2017; matrook et al., 2018). the influence of sociodemographic factors on diabetes self-management capability age the age of the family caregivers can affect diabetes self-management capability. the results of the study, as listed in table 1, show that the average age of the family caregivers was 49.9 years old. the role of a person as a family caregiver in the long-term care of a disease shows different levels and types of responsibility according to the age of the family caregiver (pierce & lutz, 2012). age is related to the experience and skills possessed in terms of self-care. in general, an increase in age will increase the experience and skills possessed. this is one of the strong contributors to the development of skills in self-care. however, the results of the study, as shown in table 3, also show that age has a negative relationship with diabetes self-management capability where the older a person is, the more that it will reduce their diabetes self-management capability. this is likely related to their functional and cognitive capacity where at an older age, there is a decrease in the cognitive function. this can affect their ability to perform self-care (riegel, jaarsma, & strömberg, 2012). gender the results of the study, as listed in table 1, show that the majority of family caregivers were women (67.2%). this is consistent with the previous study which states that women are more likely to carry out their role as a family caregiver (pierce & lutz, 2012). the results of the study, as shown in table 2, show that gender differences influence diabetes selfmanagement capability. the average family caregiver needs to have knowledge, motivation, coping skills, spirituality, the perception of family coherence, and family support as well as the perception of the role of the nurses. in this respect, the male caregivers have higher values than the female family caregivers. there needs to be attention paid by the health care providers in terms of their health promotion efforts because, as is well known, the majority of family caregivers are women. marital status the results of the study, as listed in table 1, show that the majority of the family caregivers are married with a life partner (91.4%). the results showed that marital status did not correlate with diabetes selfmanagement skills (table 3). this is likely due to the fact that some of the family caregivers do not have a life partner but they still get adequate support from their other family members. this is shown in table 2 where the majority of the respondents (74.09%) get support from their families in the high category, meaning that they can still develop their diabetes self management skills. however, it must still be a concern that someone who has a spouse will find it easier to get help from their family in the form of information, assessments, instruments and emotional support (hensarling, 2009). a healthy spouse will automatically assume themselves to be the caregivers of their partner (pierce & lutz, 2012). socioeconomic status the results of the study in table 1 show that the majority of respondents had a junior high school education level (33.8%), with an income level below the regional minimum wage (69.8%). health promotion efforts in the prevention of diabetes complications need to be developed on a massive scale because the inability to manage diabetes independently will have an impact on disease complications. this can cause increased health care costs (world health organization [who], 2016). variations in socioeconomic status affect the role of the family caregiver, especially in reference to longterm care. families from the higher socioeconomic groups show better care than those from the low socioeconomic groups (pierce & lutz, 2012). kinship the results in table 1 show that the majority of family caregivers who treat people with diabetes are their life partners (79.30%), especially wives (56.5%). this is consistent with the previous opinion that for patients who are adults, a spouse or adult child is their primary caregiver (pierce & lutz, 2012). adult children have a filial obligation to take care of their parents (jones, winslow, lee, burns, & zhang, 2011). however, kinship as a life partner shows a stronger relationship in care compared to other kinship relationships (friedman, bowden, and jones, 2010). kinship as a life partner involves a stronger emotional relationship than an adult children-parent relationship. adult children who care for their parents have a double obligation, namely the filial obligation to care for their parents and the responsibilities related to taking care of their own families (wife/ husband and children).the results in table 3 show that there is a significant relationship between kinship and diabetes self-management capability. the kinship relationship determines the caregiving process. the kinship relationship will determine the family caregiver’s motivation when caring for people with type 2 diabetes mellitus (pierce & lutz, 2012). the influence of psychosocial factors on diabetes self-management capability the results of the study show that psychosocial factors influence the ability of the family caregivers in relation to diabetes self-management. the correlation test results in table 3 show that diabetes knowledge, motivation, coping skills, spirituality, family jurnal ners http://e-journal.unair.ac.id/jners | 221 coherence, family support, and the perception of the role of the nurses have a significant effect on diabetes self-management capability. based on the results of modeling through multiple linear regression as listed in table 4, it can be seen that the psychosocial variables of knowledge, motivation, coping skills, spiritual aspects, family support, and the family caregiver perception of the nurses jointly affects diabetes self-management capability. based on table 4, it also can be seen that the r-value of 0.927 shows that there are multiple correlations (knowledge, motivation, coping, spirituality, family support, and family caregiver perceptions of nurses) with the ability to independently manage diabetes by the family caregiver. the adjusted r square value of 0.854 shows that the magnitude of the role or the contribution of the variables of knowledge, motivation, coping, spirituality, family support, and the family caregiver perceptions of the nurses is able to explain the variable ability of independent management in reference to type 2 diabetics by 85.4%. the results of this study are consistent with the previous research which states that the factors of social status, psychological conditions, and social support can affect the ability of self-care and in turn, quality of life (walker et al., 2014). diabetes knowledge the results in table 3 show that knowledge of diabetes has a significant positive relationship with diabetes self-management capability (r = 0.77; p = 0.000). providing the right education needs to be done in order to improve the ability of the family caregivers in terms of their diabetes self-management capability. the results of the study in table 2 further show that there are still family caregivers who have poor diabetes knowledge (36.8%). some of the families show helplessness when helping the sufferers to manage and master adaptive tasks related to their health problems. this is due to the lack of information held by the family and a lack of understanding and even incorrect information given to the family about the health problems that they face. ignorance related to the treatment process will cause excessive stress for the family caregivers, thereby reducing their motivation, influencing coping and affecting their ability to treat diabetes (sakanashi & fujita, 2017). motivation the results show that the majority of family caregivers (79.09%) have high motivation when treating their diabetic family members. the motivation owned by someone will encourage them to achieve their goals. the results of the study in table 3 show that motivation has a significant positive relationship with diabetes self-management capability (r = 0.808; p = 0.000). the higher the motivation, the more that their diabetes selfmanagement capability will increase in quality. this is due to the abilities of the family caregiver being influenced by their motivation when caring for their sick family member. the high motivation that comes from the expectations related to the results of the care process will increase their commitment to caring for their ill family members (friedman, bowden & jones, 2010). coping skills the results in table 2 show that the majority of the family caregivers have high coping skills (61.36%). the results of the study, as listed in table 3, show that coping skills have a positive and significant relationship with diabetes self-management capability (r = 0.808; p = 0.000) where the better the coping skills, the better the independent management of diabetes by the family caregiver. ineffective coping is marked by destructive behavior that can appear in the family caregiver. there is also the inability of the caregivers to manage the stressors that arise due to the limitations in their social activities and free time, violations of privacy, the disruption of the household and work routines, the demand for dual roles, a lack of social support and assistance from other family members, disruptions in their family relationships and the lack of aid from humanitarian service agencies and health professionals (friedman, bowden & jones, 2010). spirituality the results in table 2 show that the majority of family caregivers have a high spiritual aspect (67.27%). table 3 shows that the spirituality aspect has a positive and significant relationship with diabetes self-management capability (r = 0.759; p = 0.000), where the higher the spirituality aspect, the better the independent management of diabetes by the family caregiver. the results of this study correspond to those of the previous studies which state that the spirituality aspects of the caregiver affects the general health and well-being of the caregiver overall (rabinowitz et al., 2009). spirituality affects the coping mechanisms used by encouraging the caregiver to be more constructive (chang, noonan, & tennstedt, 1998). it also increases the commitment of the family caregivers when caring for their family members (sakanashi & fujita, 2017). family coherence the results of the study in table 2 show that the majority of the family caregivers have a good perception of family coherence (79.09%). there is a positive and significant relationship between family coherence and diabetes self-management capability (r = 0.648; p = 0.000), where the better the perception of family coherence, the better the independent management of diabetes by the family caregivers (table 3). the results of this study are consistent with those of the previous studies which state that family coherence can help to support the positive assessment of family caregivers related to the demands of care, thus facilitating effective coping and the management of care (jones et al., 2011). family coherence is related to the ability of the family r. rondhianto et. al 222 | pissn: 1858-3598  eissn: 2502-5791 members to adapt when dealing with stressful life events (antonovsky & sourani, 1988). family support the results of the study, as listed in tables 2 and 3, show that the majority of family caregivers have family support that is in the good category (74.09%). there is a positive and significant relationship between family coherence and diabetes selfmanagement capability (r = 0.817; p = 0.000) where the higher the family support received, the better the independent management of diabetes by the family caregiver. the results of this study are consistent with the previous study, which states that family support will increase the empowerment of the family caregivers (sakanashi & fujita, 2017). social support from other family members will reduce the negative impact and improve the positive aspects of caregiving (jones, winslow, et al., 2011). a lack of social support and assistance from other family members will reduce the resources of the family caregiver in turn (friedman, bowden, & jones, 2010). role of nurses the results of the study, as listed in table 3, show that the majority of family caregivers have a strong perception related to the role of the nurses (65.55%). this is not something extraordinary. it should be a common concern to ensure that the family caregiver's perception of the role that has been performed by the nurses in helping to treat people with diabetes is in the quite good category. more serious efforts are needed to increase the role of the practitioners in managing diabetes. there is a positive and significant relationship between family coherence and diabetes self-management capability (r = 0.648; p = 0.000) as listed in table 3. the better the perception of the role of the nurses, the better the independent management of diabetes by the family caregiver. support from health professionals has been proven to prevent the depression symptoms that appear in the family caregivers. the social support of the caregivers has a positive effect in the form of feelings of satisfaction, love, and pride (imanigoghary et al., 2017). the majority of respondents in this study believe that caregiving makes them stronger, more patient, more appreciative of the time spent with their family and less judgmental of others. the results showed that the role of the nurses in providing support to the caregivers was through providing advocacy education. advocacy is needed to improve the service support of the family caregivers through family education and through the preparation of the skills required by the caregivers (grant & ferrell, 2012). conclusion the results showed that the demographic and psychosocial factors together influence diabetes selfmanagement capability. sociodemographic factors such as age, gender, socioeconomic status, and kinship relations have a positive relationship with the ability of the family caregivers in the independent management of type 2 diabetes mellitus. there are also psychosocial factors such as knowledge, motivation, coping skills, spirituality, family support, and the perceptions of the family caregivers of the nurses. these together affect diabetes selfmanagement capability. this study indicates that health care providers, in the promotion and prevention of type 2 diabetes mellitus, should understand the interaction between the demographic factors, knowledge, the environment, and other diabetes-related factors. paying attention to the sociodemographic and psychosocial factors can provide insights to improve glycemic control and health status, to prevent complications and premature death, and also to improve the quality of life of people with type 2 diabetes mellitus. further research is needed with a qualitative research design in order to explore the family caregivers when they are carrying out the independent management of diabetes. further research in the form of experimental research by way of empowerment interventions evaluating the psychosocial factors should be done to prove the effectiveness of the involved factors concerning the ability of independent management of type 2 diabetes mellitus. references antonovsky, a., & sourani, t. (1988). family sense of coherence and family adaptation. journal of marriage and the family, 50(1), 79–92. https://doi.org/10.2307/352429 badriah, s., wiarsih, w., & permatasari, h. (2017). pengalaman keluarga dalam merawat lanjut usia dengan diabetes mellitus. jurnal keperawatan indonesia, 17(2), 57–64. https://doi.org/10.7454/jki.v17i2.401 chang, b.-h., noonan, a. e., & tennstedt, s. l. (1998). the role of religion/spirituality in coping with caregiving for disabled elders. gerontologist, 38(4), 463–470. daaleman, t. p., & frey, b. b. (2004). the spirituality index of well-being : a new instrument for health-related quality of life research. annals of family medicine, 2(5), 499–503. https://doi.org/10.1370/afm.89.department friedman, m.m., bowden, v.r., jones, e.g (2010) family nursing; research, theory, and practice.terjemahan oleh achir yani s. hamid, dkk 2010.. buku ajar keperawatan keluarga; riset, teori dan praktik. edisi 5.jakarta: egc grant, m., & ferrell, b. (2012). nursing role implications for family caregiving. seminars in oncology nursing. https://doi.org/10.1016/j.soncn.2012.09.011 hamby, s., grych, j. h., & banyard, v. (2015). coping scale. tn: life paths research program. https://doi.org/10.13140/rg.2.1.3094.0001 hensarling, j. (2009). development and psychometric testing of hensarling’s diabetes family support jurnal ners http://e-journal.unair.ac.id/jners | 223 scale. texas woman’s university. holmefur, m., sundberg, k., wettergren, l., & langiuseklo, a. (2014). measurement properties of the 13-item sense of coherence scale using rasch analysis measurement properties of the 13-item sense of coherence scale using rasch analysis. quality of life research, (november). https://doi.org/10.1007/s11136-014-0866-6 hu, j., wallace, d., mccoy, t., & amirehsani, k. (2014). nih public access. diabetes educator, 40(1), 48– 59. https://doi.org/10.1177/0145721713512682 imanigoghary, z., peyrovi, h., nouhi, e., kazemi, m., nouhi, e., & kazemi, m. (2017). the role of nurses in coping process of family caregivers of vegetative patients: a qualitative study. international journal of community based nursing and midwifery, 5(1), 70–81. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28097 180%0ahttp://www.pubmedcentral.nih.gov/a rticlerender.fcgi?artid=pmc5219567 international diabetes federation [idf]. (2017). idf diabetes atlas eighth edition 2017. international diabetes federation. idf diabetes atlas, 8th edn. brussels, belgium: international diabetes federation, 2017. http://www.diabetesatlas.org. https://doi.org/http://dx.doi. org/10.1016/s0140-6736(16)31679-8. jones, p. s., winslow, b. w., lee, j. w., burns, m., & zhang, x. e. (2011). development of a caregiver empowerment model to promote positive outcomes. journal of family nursing, 17(1), 11– 28. https://doi.org/10.1177/1074840710394854 kolmer, d. b. genaamd, tellings, a., gelissen, j., garretsen, h., & bongers, i. (2008). ranked motives of long-term care providing family caregivers. scandinavian journal of caring sciences, 22, 29–39. matrook, k. a., cowman, s., dovey, s. m., smith, s. m., mcgilloway, s., & whitford, d. l. (2018). familybased interventions for adults with type 2 diabetes mellitus. cochrane database of systematic reviews, (7), 1–19. https://doi.org/10.1002/14651858.cd013064 pierce, l. l., & lutz, b. j. (2012). family caregiving. in i. m. lubkin & p. d. larsen (eds.), chronic illnes: impact and intervention (8th ed, pp. 245–288). burlington, ma: jones & bartlett learning, llc, an ascend learning company. https://doi.org/10.1177/1742395312443692 powers, m. a., bardsley, j., cypress, m., duker, p., funnell, m. m., fischl, a. h., … vivian, e. (2015). diabetes self-management education and support in type 2 diabetes: a joint position statement of the american diabetes association, the american association of diabetes educators, and the academy of nutrition and dietetics. clinical diabetes, 34(2), 70–80. https://doi.org/10.2337/diaclin.34.2.70 putri, h., yeni, f., & handayani, t. (2013). hubungan peran keluarga dengan pengendalian kadar gula darah pada pasien diabetes melitus di wilayah kerja puskesmas pauh padang. ners jurnal keperawatan, 9(2), 133–140. https://doi.org/10.25077/njk.9.2.136142.2013 rabinowitz, y. g., mausbach, b. t., atkinson, p. j., & gallagher-thompson, d. (2009). nih public access. aging ment health, 13(6), 788–798. https://doi.org/10.1080/1360786090304644 6 riegel, b., jaarsma, t., & strömberg, a. (2012). a middle-range theory of self-care of chronic illness. advances in nursing science, 3(35), 194– 204. https://doi.org/http://dx.doi.org/10.1097/an s.0b013e318261b1ba rothman, r. l., malone, r., bryant, b., wolfe, c., padgett, p., dewalt, d. a., … pignone, m. (2005). the spoken knowledge in low literacy in diabetes scale: a diabetes knowledge scale for vulnerable patients. diabetes educator, 31(2), 215–224. https://doi.org/10.1177/0145721705275002 sakanashi, s., & fujita, k. (2017). empowerment of family caregivers of adults and elderly persons : a concept analysis. international journal of nursing practice, e12573(may), 1–9. https://doi.org/10.1111/ijn.12573 van der bijl, j., van poelgeest‐eeltink, a., shortridge‐ baggett, l. (2001). the psychometric properties of the diabetes management self‐efficacy scale for patients with type 2 diabetes mellitus. journal of advanced nursing; 30 (2). https://doi.org/10.1046/j.13652648.1999.01077.x walker, r. j., gebregziabher, m., martin-harris, b., & edege, l. e. (2014). independent effects of socioeconomic and psychological social determinants of health on self-care and outcomes in type 2 diabetes. gen hosp psychiatry, 36(6), 662–668. https://doi.org/10.1016/j.genhosppsych.2014. 06.011.independent world health organization [who]. (2016). global report on diabetes.world health organization (vol. 58). geneva. https://doi.org/10.1128/aac.03728-14 world health organization [who]. (2018). noncommunicable diseases country profiles 2018. world health organization. geneva: world health organization. https://doi.org/10.1056/nejmra1109345 wu, s.-f. (2007). effectiveness of self-management for persons with type 2 diabetes following the implementation of a selfefficacy enhancing intervention program in taiwan. queensland university of technology. retrieved from http://eprints.qut.edu.au/ 26 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i13(si).16971 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review family burden for the caregivers of people with mental disorders: a systematic review aplonia nenobais, atika jatimi and muh jufriyanto faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the main caregivers of people with mental disorders are their family members. families as the caregivers of people with mental disorders is associated with a significant burden. this systematic review aims to identify and summarize the main focus based on the scientific evidence about family burden as the caregivers of people with mental disorders. methods: the databases used were scopus, science direct and sage journal with the keywords ‘burden’, ‘family’, ‘caregiver’, ‘mental’, ‘health’, ‘illness’, ‘disorder’ and they were limited to 2014 – 2018 from within nursing and health science journals. one hundred and four full text articles were reviewed. the 14 articles that fulfilled the inclusion criteria were analyzed using narrative synthesis followed the joanna briggs methodology model for the qualitative systematic review to find the main themes of each article. results: seven main themes were found to be related to family burden as the caregivers of a family member with mental disorders. the 7 themes were knowledge, emotional burden, physical burden, medication, financial burden, social burden, health services and government support. conclusion: the findings suggest that the family burden on the caregivers was diverse and that this has an effect on the ability of the family to care for patients with mental disorders. family burden has become an important indicator for the provision of mental health services. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords family burden; caregivers; mental disorder contact aplonia nenobais  aplonia.nenobais2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: nenobais,a., jatimi, a., & jufriyanto, m. (2019). family burden for the caregivers of people with mental disorders: a systematic review. jurnal ners, 14(3si), 26-34. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16971 introduction family members are the main caregivers of people with mental illness. family plays an important role in caring for people with mental disorders such as monitoring their mental state and treatment, accompanying them to a hospital or clinic, offering emotional support and helping them with their finances. the family also plays a significant role in making sure that the patient adheres to the treatment while tolerating changes in patient behavior such as aggressiveness (venkatesh, andrews, parsekar, singh, & menon, 2016). people with chronic mental disorders generally live with their families (bademli, lök, & kılıc, 2017). the patients' families are the major source of support and caregiving for psychiatry patients and most of the patients live with their families. being a caregiver is something that cannot be chosen or planned, so the caregivers are required to be able to adapt to these situations. this situation causes the other family members to experience the feeling of being burdened (kizilirmak & küçük, 2016). caring for people with mental disorders with other routine activities makes the family members as caregivers experience negative experiences and consequently this leads to substantial stress or burden. constant stress or burden has a negative effect on the physical, psychological and social health of the caregivers, and the caregivers must adjust to the situation(venkatesh et al., 2016). studies on caregivers living with mental illness patients have found that they experience high levels https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:aplonia.nenobais-2018@fkp.unair.ac.id mailto:aplonia.nenobais-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 27 of burden. caregiver burden, especially tension, is associated with the caregivers' use of maladaptive coping strategies, poor quality of life and higher levels of psychological morbidity (bademli et al., 2017). family burden is also related to tradition and culture (von kardorff, soltaninejad, kamali, & eslami shahrbabaki, 2016). in addition, stigma and discrimination against mental health problems not only affects people with mental disorders but it also burdens the family (varghese, pereira, naik, balaji, & patel, 2017). the purpose of this study was to explore and summarize the caregivers’ burdens when related to people with mental disorders. the specific research question was: ‘based on qualitative research literature, how does the family as the caregivers of people with mental disorders describe their burden?’ materials and methods this systematic review is a narrative synthesis following the joanna briggs methodology (jbi) model for qualitative systematic review(the joanna briggs institute, 2014). qualitative evidence synthesis (qes) integrates the findings from qualitative studies by finding existing themes. the jbi methodology allows the researchers to answer a specific research question through reviewing the evidence in a systematic manner. the databases used were scopus, science direct and sage journal with the keywords “burden, family, caregiver, mental, health, illness and disorder”. furthermore, the inclusion and exclusion criteria were determined to find eligible articles. the inclusion criteria were that they had to be qualitative or mixed methods studies with a standalone qualitative piece, full text articles published in english and within the last five years (2014 – november 2018). the exclusion criteria were that the caregivers were not family members, that the articles were without direct quotes, that the articles were published in any other language and outside of the last five years or they were not available online. unpublished or grey literature, abstracts, theses, dissertations, books and conference summaries were excluded. see on figure 1. after searching the literature with the keywords, we found 382 articles in the scopus database, 435 articles in science direct and 403 articles in sage journal. in total, 585 potential articles met the criteria, 336 articles were similar, and 249 articles matched the criteria. after selecting the abstracts, 145 articles were deemed to be irrelevant and inaccessible. finally, 104 full articles were selected, 89 were excluded and the remaining 14 articles fulfilled the inclusion criteria. extracting and synthesizing the data from the selected study used a summary table containing the data of the author, the year of publication, country, purpose, the method of data collection and the method of the data analysis. the results of the study were then synthesized by categorizing each theme that was found. results according to the review of the selected studies, seven main themes were found to be related to family burden as the caregivers of the family member with a mental disorder. the seven themes were knowledge, emotional burden, physical burden, medication, financial burden, social burden, health services and government support. insufficient knowledge insufficient knowledge about the treatment of people with mental disorders makes the family as the caregivers always wonder when the patients will recover and they were confused about the patients’ constantly changing behavior (fitryasari et al., 2018; krupchanka et al., 2018). the majority of the caregivers did not have enough information about the disease or the treatment (von kardorff et al., 2016). when i faced this illness, i did not know about the illness. i did not know what i should do. i did not know what schizophrenia is about (von kardorff et al., 2016). ...but even when he recovered, he relapsed again, our family does not understand this disease (schizophrenia) (fitryasari et al., 2018) ...he (first-born son) decided that schizophrenia is infectious. so, he is careful and does not keep in touch with x at all (krupchanka et al., 2018). in addition, a lack of information is caused by the absence of information from the nurses and doctors about the disease(ebrahimi et al., 2018; von kardorff et al., 2016). no one has ever spoken to me about my daughter’s illness or explained anything to me yet. i don’t understand what is going on. they (health care team) are always too busy to give me an opportunity to share my problems with them (ebrahimi et al., 2018). emotional burden an emotional burden is felt by almost all family members such as sadness and shame due to the uncontrolled patient behavior, fearing that the patients can be harmful to the environment and figure 1. search tree diagram a. nenobais, et al. 28 | pissn: 1858-3598  eissn: 2502-5791 worrying about the future of the patients. this can make the emotional burden of the family increase (fitryasari et al., 2018; krupchanka et al., 2018; tlhowe et al., 2017). ...i'm afraid he will hit me or damage the house …when he relapses … he can go out without wearing clothes, go anywhere … as his mother, i am very ashamed …i feel annoyed almost every day, and when i can't stand it, i hit her (patient) (fitryasari et al., 2018). my sister was undressing in the street and this was really embarrassing, i could not even walk freely at the mall (tlhowe et al., 2017) i feel anxious now when i am talking about that because they started avoiding me because they were afraid(krupchanka et al., 2018). emotional burdens also make the family blame themselves, lose hope and worry about the future (fitryasari et al., 2018; krupchanka et al., 2018). the caregivers also think that the patients can only table 1. joanna briggs institutecheck list for qualitative research criteria dicé, federico, & zoena (2017) fitryasari, yusuf, nursalam, tristiana, & nihayati (2018) hernandez and barrio (2015) krupchanka et al. (2018) 1 is there congruity between the stated philosophical perspective and research methodology? yes yes yes yes 2 is there congruity between the research methodology and the research question or objectives? yes yes yes yes 3 is there congruity between the research methodology and the methods used to collect data? unclear yes yes yes 4 is there congruity between the research methodology and representation and analysis of data? yes yes yes yes 5 is there congruity between the research methodology and interpretation result? yes yes yes yes 6 is there a statement locating the researcher culturally or theoretically? yes yes yes yes 7 is the influence of the researcher on the research, and viceversa, addressed? yes yes yes yes 8 are participants, and their voices, adequately represented? yes yes yes yes 9 is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body? unclear yes yes yes 10 do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data? yes unclear unclear unclear total 8 9 9 9 criteria mccann, bamberg, & mccann (2015) radfar, ahmadi, and fallahi khoshknab (2014) radfar et al. (2014) tristiana et al ( 2018) varghese, pereira, naik, balaji, & patel (2017) 1 is there congruity between the stated philosophical perspective and research methodology? yes yes yes yes yes 2 is there congruity between the research methodology and the research question or objectives? yes yes yes yes yes 3 is there congruity between the research methodology and the methods used to collect data? yes yes yes yes yes 4 is there congruity between the research methodology and representation and analysis of data? yes yes yes yes yes 5 is there congruity between the research methodology and interpretation result? yes yes yes yes yes 6 is there a statement locating the researcher culturally or theoretically? unclear unclear yes yes yes 7 is the influence of the researcher on the research, and vice-versa, addressed? yes yes unclear unclear yes 8 are participants, and their voices, adequately represented? yes yes yes yes yes 9 is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body? yes yes yes yes unclear 10 do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data? yes yes yes yes yes total 9 9 9 9 9 jurnal ners http://e-journal.unair.ac.id/jners | 29 depend on them (dicé et al., 2017; von kardorff et al., 2016). concern about the patients’ current and future condition is because the family feels powerless to control the future, even though they know that they have to consider the patients as people who have the right to live as they wish. the families are still worried about the inability of the patients to have normal lives (gater et al., 2014; radfar et al., 2014). i will not be here forever (krupchanka et al., 2018) every moment, i can't escape thinking of him … his future, his fate …(fitryasari et al., 2018). ...he always needs somebody to help him, to care for him, and to give him affection, warmth, attention. because if he's left alone even 5-10 minutes, he panics, freaks out...(dicé et al., 2017) i can’t go anywhere. i can’t go on a trip. i must always accompany her and look after her. whenever i go out, i have to come back early (von kardorff et al., 2016). the family expressed their concern about the future of their members with mental disorders. the families also felt worried about who will take care of the patients if they died (radfar et al., 2014). what if i die! who will take care of her? i worry about compliance with the medication. i worry about her ability to be independent in future...(radfar et al., 2014). concerned about them being raped, the family members had to take their female members with mental disorders with them whenever they left home. in addition, cognitive problems and social interaction problems cause abuse. this is considered to be contrary to religious and cultural doctrine (radfar et al., 2014). she went to the park. instead of sitting on the bench, she laid on the grass. this is not a good behavior for a girl (radfar et al., 2014). for a spouse, being depressed because of changes in the relationship made the partner feel like a widow (mccann et al., 2015). i have depression. i don’t want to admit it to myself that i was depressed and i was eating like a ‘horse’ (eating excessively). i put on a lot of weight, because i just sat in front of the tv, eating. leaving my husband depresses me more because he is mentally and physically ill and he doesn’t respond (to me) anymore (mccann et al., 2015). treatment burden they also feel burdened because of the long lasting treatment (dicé et al., 2017)and because of the difficulty in managing the treatment according to time and the patient’s condition (von kardorff et al., 2016) he doesn’t take his drugs on time or puts it under his tongue and then throws it out. i have big problems with medication adherence with my patient (von kardorff et al., 2016). the treatment of mental patients is often late due to stigma in society. families are habitually in denial of having a family member who is mentally ill(venkatesh et al., 2016). table 1. joanna briggs institutecheck list for qualitative research (continue) criteria venkatesh et al (2016) von kardorff, soltaninejad, kamali, & eslami shahrbabaki (2016) ebrahimi et al (2018) gater et al. 2014) prevo et al. (2018) 1 is there congruity between the stated philosophical perspective and research methodology? yes yes yes yes yes 2 is there congruity between the research methodology and the research question or objectives? yes yes yes yes yes 3 is there congruity between the research methodology and the methods used to collect data? yes yes yes yes yes 4 is there congruity between the research methodology and representation and analysis of data? unclear yes yes yes yes 5 is there congruity between the research methodology and interpretation result? yes yes yes yes yes 6 is there a statement locating the researcher culturally or theoretically? yes yes unclear yes yes 7 is the influence of the researcher on the research, and vice-versa, addressed? unclear yes yes unclear yes 8 are participants, and their voices, adequately represented? yes yes unclear yes yes 9 is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body? no no yes yes unclear 10 do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data? yes no yes yes no total 7 9 8 9 8 a. nenobais, et al. 30 | pissn: 1858-3598  eissn: 2502-5791 physical burden a physical burden is also experienced by the family due to more time needing to be devoted to taking care of the patients. they do not have time to rest and there is a lack of social interactions (fitryasari et al. 2018; tristiana et al. 2018). the caregivers also feel very tired, lose energy and often have sleeping disorders (von kardorff et al., 2016). chest pain and increased blood pressure are also felt by the caregivers (hernandez & barrio, 2015). having the responsibilities associated with being caregivers, they often suffer from chronic physical and mental fatigue(prevo et al., 2018; radfar et al., 2014). i have been affected by thousands of somatic pains, such as backache, headache, lumbar disc and leg pains (von kardorff et al., 2016). high blood pressure…at times i feel a pain in my chest. i know that it is due to the sadness that i have, the pressure (hernandez & barrio, 2015). i don’t remember such a day as i’m tired today. i feel really tired(radfar et al., 2014). i feel it in my body... bending, lifting and even moving are all becoming more difficult (prevo et al., 2018). table 2. study characteristics (country, title & purpose) author (year) country title purpose dicé, federico, & zoena (2017) italy loneliness and family burden: an exploratory investigation on the emotional experiences of caregivers of patients with severe mental illness to conduct a descriptive investigation into the needs of the caregivers of patients with severe mental illness (smi) referring to a mental health service fitryasari et al. (2018) indonesia family members' perspective of family resilience's risk factors in taking care of schizophrenia patients rizki conducted to illustrate the risk factors of family resilience when taking care of patients with schizophrenia. hernandez and barrio (2015) amerika serikat perceptions of subjective burden among latino families caring for a loved one with schizophrenia to explore the perceptions of subjective burden among latino family members providing care for a loved one with schizophrenia krupchanka et al. (2018) republik ceko experience of stigma and discrimination in families of persons with schizophrenia in the czech republic explores the practice of stigma and discrimination in families with schizophrenia mccann, bamberg, & mccann (2015) australia family carers’ experience of caring for an older parent with severe and persistent mental illness to understand the lived experience of the primary caregivers of older people with severe and persistent mental illness, and to explore what, if anything, helps to sustain them in their caring role. radfar, ahmadi, & fallahi khoshknab (2014) iran turbulent life: the experiences of the family members of patients suffering from depression to explore and describe the experiences of the family members of patients suffering from depression on the impact of provision of care to the patients. tlhowe, du plessis, & koen (2017) south africa strengths of families to limit relapse in mentally ill family members to explore and describe the strengths of family members in assisting mental health care users to limit relapses tristiana, yusuf, fitryasari, wahyuni, & nihayati (2018) indonesia perceived barriers on mental health services by the family of patients with mental illness to identify the perceived barriers on mental health services by families whose members suffers from mental illness. varghese, pereira, naik, balaji, & patel (2017) india experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in india to describe the experiences of stigma and discrimination of people living with schizo phrenia (pls) in three sites in india and to identify factors influencing negative discrimination venkatesh, andrews, parsekar, singh, & menon (2016) india stigma and mental healthcaregivers' perspective: a qualitative analysis to understand the perception of caregivers of mentally ill patients von kardorff, soltaninejad, kamali, & eslami shahrbabaki (2016) jerman family caregiver burden in mental illnesses: the case of affective disorders and schizophrenia – a qualitative exploratory study to explore the specific burdens experienced by caregivers of patients with schizophrenia and affective disorders. ebrahimi et al (2018) iran barriers to family caregivers’ coping with patients with severe mental illness in iran to explore the barriers to coping with people who have severe mental illness as perceived by their family caregivers. gater et al. (2014) amerika serikat ‘‘sometimes it’s difficult to have a normal life’’: results from a qualitative study exploring caregiver burden in schizophrenia to investigate the subjective experiences of caregivers of people with schizophrenia as a means of understanding “caregiver burden” in this population prevo et al. (2018) belanda exploring informal caregivers’ views on their perceived burden to explore information about relationship fac tors, positive effects of caregiving, and coping strategies as factors influencing the physical or mental burden that caregivers perceive jurnal ners http://e-journal.unair.ac.id/jners | 31 financial burden the financial burden is also felt by the family. a lot of money is needed for medical expenses including education, regular visits to the health care centers, transportation costs to the hospitals, food, and for their daily needs (fitryasari et al., 2018; gater et al., 2014; tristiana et al., 2018; von kardorff et al., 2016). we should sell our motorbikes, sometimes sell our bird collection … yes, for treatment for him (patient), his meals and daily needs … (fitryasari et al., 2018). i've spent a lot for the travel costs …(tristiana et al., 2018). well, financially, because, um, sometimes we need people to, uh, to stay with her, to watch her, you know, medical bills for certain things at times (gater et al., 2014). families need high financial support because the patients cannot live independently (krupchanka et al., 2018). the financial situation is not good. i would say that without the help of relatives, we could not live in... we know that many of our friends with mental disorders still live with their parents, they do not have enough money to become independent...(krupchanka et al., 2018) social burden social burden as a stigma does not only come from the community but it can also come from the closest members of the family. they do not get support including visits from other family members, neighbors or relatives (fitryasari et al., 2018; tristiana et al., 2018; von kardorff et al., 2016). stigma and discrimination are the heaviest burdens, so much so that they often trigger another family burden (financial, physical or emotional) (krupchanka et al., 2018). mostly people do not want to go near us because of being scare or they are afraid of being beaten … the stigma experienced by the families is categorized into four types: labeling, stereotyping, separation and discrimination. labeling hurts the family because the people with mental disorders are called “madman” and they cannot be cured. stereotypes come from other people’s opinion that the patients can hurt others. separation is when the neighbors keep their distance from them. the families are discriminated against because they cannot join in with social activities due to unpredictable behavior of the patients (fitryasari et al., 2018). the neighbor sometimes calls him (patient) … “madman”’ (labeling) (fitryasari et al., 2018). table 3. study characteristics (design, data collection method & data analysis method) author (year) design data collection method data analysis method dicé, federico, & zoena (2017) phenomenological approach semi-structured interview thematic-categorical analysis fitryasari, yusuf, nursalam, tristiana, & nihayati (2018) phenomenological approach semi-structured interview thematic-categorical analysis hernandez & barrio (2015) grounded theory approach(glaser and strauss 1967; strauss and corbin 1990) open-ended section of the family burden interview schedule (fbis; pai and kapur 1981) data were sorted and coded using the qualitative software program atlas.ti, version 7 krupchanka et al (2018) phenomenological approach semi-structured in-depth interviews thematic analysis mccann, bamberg, & mccann ( 2015) hermeneutics, phenomenology, and idiography (smith et al. 2009). semi-structured, audio-recorded interviews were interview transcripts were analyzed in accordance with the ipa approach outlined by smith and osborn (2008). radfar, ahmadi, & fallahi khoshknab (2014) phenomenological approach unstructured interviews content analysis approach tlhowe, du plessis, & koen(2017) phenomenological design unstructured interviews thematic analysis tristiana, yusuf, fitryasari, wahyuni, & nihayati (2018) phenomenological design semi-structured in-depth interviews. thematic analysis varghese, pereira, naik, balaji, & patel ( 2017) mixed methods in-depth-interviews thematic analysis venkatesh, andrews, parsekar, singh,& menon ( 2016) phenomenological approach in-depth interview manual thematic content analysis von kardorff, soltaninejad, kamali, & eslami shahrbabaki (2016) grounded theory semi-structured interviews deductive and inductive content analysis ebrahimi et al(2018) phenomenological approach semi-structured, in-depth interviews four step qualitative content analysis method; graneheim and lundman (2004) gater et al. (2014) grounded theory semi structured, qualitative interviews qualitative analysis software package (atlas. ti) prevo et al.(2018) phenomenological approach semi-structured interviews interpretative phenomenological analysis approach a. nenobais, et al. 32 | pissn: 1858-3598  eissn: 2502-5791 people often do verbal bullying with nicknames of crazy person or insane... (tristiana et al., 2018). his behavior is sometimes strange … all day sitting on the edge of the trench in front of the house while daydreaming... when he relapses … he will be dangerous, sometimes uncontrollable (stereotype) (fitryasari et al., 2018). neighbors who do not dare come here (to the house)… afraid of him (separation) (fitryasari et al., 2018). we are rarely invited to public events, if invited, they (neighbor) always order us to come alone, and that my father (patient) should stay at home (discrimination) (fitryasari et al., 2018). negative comments and actions from the public and their extended family as well as criticism and the beliefs about the cause of the disorder adds to the family burden (dicé et al., 2017; hernandez & barrio, 2015; prevo et al., 2018). people hear schizophrenia is a mental illness, and run away. they just run away (dicé et al., 2017) the families as the caregivers also felt avoided by society. the families that have members with mental disorders felt separated from the community, with the patients unable to get the right treatment and at the right time. it is not as easy to visit a psychiatrist as it is to visit a cardiologist (venkatesh et al., 2016). ...every person should have freedom to say boldly ‘i am visiting a psychiatrist’ like how they say, without any hesitation, that i am visiting a cardiologist(venkatesh et al., 2016). health service and government support problems related to the health services and government support are strongly felt by the families including insurance, transportation and the distance to the health services (ebrahimi et al., 2018; krupchanka et al., 2018; tristiana et al., 2018; von kardorff et al., 2016). distant health care means that the families spend more money on transportation. the unavailability of medication and psychiatric help as well as mental health nurses in the community health centers means that the family have to travel a considerable distance to the hospital (tristiana et al., 2018). i’m the one who should manage all of these. who would help me out? the government doesn’t help. the hospital doesn’t care how to provide care for my husband. no help, no advice ... nothing ma’am, nothing. there is no support when we are in crisis. i perceive myself as being abandoned in the caregiving role (ebrahimi et al., 2018). we found it different between the health centre and mental health hospital; in the mental health hospital, there were examinations, hospitalization and treatment but not in the health centre; so there should be a referral to the mental health hospital... (tristiana et al., 2018). discussion the lack of knowledge about the disorder and treatment has been illustrated in three of the studies reviewed. a lack of information about mental disorders makes the caregivers more anxious. sufficient knowledge can reduce caregiver anxiety and emotional burden. the knowledge of patient care and treatment can improve family self-efficacy. studies conducted by (durmaz & okanli, 2014) show that family burden decreases when family selfefficacy is improved. the families of patients suffering from mental disorders have the symptoms of emotional burden. financial problems, stigma, family support, governmental and society factors are closely related to the emotional burden of the family. this was confirmed by the quantitative study conducted by (alzahrani, fallata, alabdulwahab, alsafi, & bashawri, 2017)which showed a feeling of tension, anxiety and rush experienced by the caregivers. the quantitative study by (kizilirmak & küçük, 2016)showed that 67.49% caregivers are at risk of experiencing depression and anxiety and that 43.3 % of caregivers are at a high risk of depression and anxiety. emotional burdens such as being impatient, feeling guilty, feeling shameful and feeling sinful are also shown in the quantitative studies by(alzahrani et al., 2017). the study conducted by (zanetti et al., 2018)shows that an increase in family emotional expression increases the family burden significantly. they also have feelings of shame and low self-esteem. most family caregivers are embarrassed because the community often looks down on and insults their family members who are suffering from a mental disorder (azman, jamir singh, & sulaiman, 2017). the physical burden experienced by the caregivers is caused by the amount of time spent caring for the patient. the physical burden becomes higher when it is associated with the amount of time spent caring for the family members (alzahrani et al., 2017). other quantitative studies described that the time spent treating patients with mental disorders was between 4-8 hours a day (mulud & mccarthy, 2017) and 16-17 hours a day (zanetti et al., 2018). other studies(dicé et al., 2017)showed that the caregivers’ burden increased if the intensity of contact with the patients increased. in addition, more time devoted to taking care of the patients reduces the social interactions of the caregivers (mulud & mccarthy, 2017). the financial burden described in 4 studies reviewed showed that financial burden is caused by the complete dependency of the patients on their caregivers. many caregivers do not have a job because they have to take care of the patient. the loss of productivity caused by the patients with mental disorders has an impact on the financial burden of the family. the burden of caregivers who experience financial problems is higher than those who do not experience it(kizilirmak & küçük, 2016). the economic burden experienced by families was jurnal ners http://e-journal.unair.ac.id/jners | 33 claimed (agboola, esan, afolabi, & soyinka, 2018) in his study conducted in nigeria. this indicates that the families are responsible for financing the care of people with mental disorders (68%) and that only 4% of respondents were financed by insurance. finances are also needed to fulfill the patients’ basic needs such as buying clothes and diapers for one’s parents with mental disorders (azman et al., 2017). social burden, in this case stigma and discrimination, is illustrated by all studies of the reviewed. stigma is the social burden felt by families. stigma damages family and community relations (park & seo, 2016). stigma and discrimination are the heaviest burden that is faced by the families. it leads to an emotional and physical burden for the caregivers. studies conducted (chai, mahadevan, ng, chan, & md dai, 2018) showed a significant relationship between stigma and depression in the caregivers. the study conducted by (varghese et al., 2017)highlights the need for interventions that address the family needs such as providing knowledge about schizophrenia, which can affect the stigmatization process both positively and negatively. educational interventions need to consider more specific contextual factors when choosing the antistigma messages that are to be delivered. this study shows that messages such as “recovery is possible” and “no one is blamed” might be more useful for reducing stigma than for focusing on bio-medical knowledge. problems related to government support and the availability of health services were revealed in 4 of the studies. the study concluded (nurjannah, mills, park, & usher, 2015) that institutional policies are important in the process of treating mental disorders. legal rules are needed to protect the human rights of mental disorder caregivers. limitation some of the articles found were not relevant to the problem of family burden as caregivers because some of the journal articles that supported the review were inaccessible. in addition, the articles used only represent twelve countries with the largest number of participants in the qualitative study being 64 people. conclusion the burden of the family as the caregivers of people with mental disorders is very diverse and it has an effect on the ability of the family to treat patients with mental disorders. family burden has become an important indicator for the provision of mental health services. cultural differences in each country affect the burden experience by each family as caregivers. families need support when caring for patients. families as caregivers need service and support for their own mental and physical health so then they are able to maintain their nurturing role. references agboola, a. a., esan, o. t., afolabi, o. t., & soyinka, t. a. (2018). economic burden of the therapeutic management of mental illnesses and its effect on household purchasing power, 1–13. alzahrani, s. h., fallata, e. o., alabdulwahab, m. a., alsafi, w. a., & bashawri, j. (2017). assessment of the burden on caregivers of patients with mental disorders in jeddah, saudi arabia. bmc psychiatry, 17(1), 1–8. https://doi.org/10.1186/s12888-0171368-1 azman, a., jamir singh, p. s., & sulaiman, j. (2017). the mentally ill and their impact on family caregivers: a qualitative case study. international social work, 2001(act 615). https://doi.org/10.1177/0020872817731146 bademli, k., lök, n., & kılıc, a. k. (2017). relationship between caregiving burden and anger level in primary caregivers of individuals with chronic mental illness. archives of psychiatric nursing, 31(3), 263–268. https://doi.org/10.1016/j.apnu.2016.12.001 chai, y. c., mahadevan, r., ng, c. g., chan, l. f., & md dai, f. (2018). caregiver depression: the contributing role of depression in patients, stigma, social support and religiosity. international journal of social psychiatry, 002076401879258. https://doi.org/10.1177/0020764018792585 dicé, f., federico, n., & zoena, f. (2017). loneliness and family burden : an exploratory investigation on the emotional experiences of caregivers of patients with severe mental illness, 22(7), 1781– 1791. durmaz, h., & okanli, a. (2014). investigation of the effect of self-efficacy levels of caregiver family members of the individuals with schizophrenia on burden of care. archives of psychiatric nursing, 28(4), 290–294. https://doi.org/10.1016/j.apnu.2014.04.004 ebrahimi, h., seyedfatemi, n., namdar areshtanab, h., ranjbar, f., thornicroft, g., whitehead, b., & rahmani, f. (2018). barriers to family caregivers’ coping with patients with severe mental illness in iran. qualitative health research, 28(6), 987– 1001. https://doi.org/10.1177/1049732318758644 fitryasari, r., yusuf, a., nursalam, tristiana, r. d., & nihayati, h. e. (2018). family members’ perspective of family resilience’s risk factors in taking care of schizophrenia patients. international journal of nursing sciences, 5(3), 255–261. https://doi.org/10.1016/j.ijnss.2018.06.002 gater, a., rofail, d., tolley, c., marshall, c., abetzwebb, l., zarit, s. h., & berardo, c. g. (2014). “sometimes it’s difficult to have a normal life”: results from a qualitative study exploring caregiver burden in schizophrenia. schizophrenia research and treatment, 2014, 1–13. https://doi.org/10.1155/2014/368215 a. nenobais, et al. 34 | pissn: 1858-3598  eissn: 2502-5791 hernandez, m., & barrio, c. (2015). perceptions of subjective burden among latino families caring for a loved one with schizophrenia. community mental health journal, 51(8), 939–948. https://doi.org/10.1007/s10597-015-9881-5 kizilirmak, b., & küçük, l. (2016). care burden level and mental health condition of the families of individuals with mental disorders. archives of psychiatric nursing, 30(1), 47–54. https://doi.org/10.1016/j.apnu.2015.10.004 krupchanka, d., chrtková, d., vítková, m., munzel, d., čihařová, m., růžičková, t., … sartorius, n. (2018). experience of stigma and discrimination in families of persons with schizophrenia in the czech republic. social science and medicine, 212, 129–135. https://doi.org/10.1016/j.socscimed.2018.07.01 5 mccann, t. v., bamberg, j., & mccann, f. (2015). family carers’ experience of caring for an older parent with severe and persistent mental illness. international journal of mental health nursing, 24(3), 203–212. https://doi.org/10.1111/inm.12135 mulud, z. a., & mccarthy, g. (2017). caregiver burden among caregivers of individuals with severe mental illness: testing the moderation and mediation models of resilience. archives of psychiatric nursing, 31(1), 24–30. https://doi.org/10.1016/j.apnu.2016.07.019 nurjannah, i., mills, j., park, t., & usher, k. (2015). human rights of the mentally ill in indonesia. international nursing review, 62(2), 153–161. https://doi.org/10.1111/inr.12153 park, k., & seo, m. (2016). care burden of parents of adult children with mental illness: the role of associative stigma. comprehensive psychiatry, 70, 159–164. https://doi.org/10.1016/j.comppsych.2016.07.0 10 prevo, l., linssen, e., hajema, k. j., kremers, s., crutzen, r., & schneider, f. (2018). exploring informal caregivers’ views on their perceived burden. home health care management and practice, 30(2), 47–53. https://doi.org/10.1177/1084822317746958 radfar, m., ahmadi, f., & fallahi khoshknab, m. (2014). turbulent life: the experiences of the family members of patients suffering from depression. journal of psychiatric and mental health nursing, 21(3), 249–256. https://doi.org/10.1111/jpm.12077 souza, a. l. r., guimarães, r. a., de araújo vilela, d., de assis, r. m., de almeida cavalcante oliveira, l. m., souza, m. r., … barbosa, m. a. (2017). factors associated with the burden of family caregivers of patients with mental disorders: a cross-sectional study. bmc psychiatry, 17(1), 1–10. https://doi.org/10.1186/s12888-017-1501-1 the joanna briggs institute. (2014). joanna briggs institute reviewers, manual-2014. south australia 5005: the joanna brggs institutei. tlhowe, t. t., du plessis, e., & koen, m. p. (2017). strengths of families to limit relapse in mentally ill family members. health sa gesondheid, 22, 28–35. https://doi.org/10.1016/j.hsag.2016.09.003 tristiana, r. d., yusuf, a., fitryasari, r., wahyuni, s. d., & nihayati, h. e. (2018). perceived barriers on mental health services by the family of patients with mental illness. international journal of nursing sciences, 5(1), 63–67. https://doi.org/10.1016/j.ijnss.2017.12.003 varghese, m., pereira, j., naik, s., balaji, m., & patel, v. (2017). experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in india. social science and medicine, 178, 66–77. https://doi.org/10.1016/j.socscimed.2017.01.06 1 venkatesh, b. t., andrews, t., parsekar, s. s., singh, m. m., & menon, n. (2016). stigma and mental healthcaregivers’ perspective: a qualitativeanalysis. clinical epidemiology and global health, 4(1), 23– 27. von kardorff, e., soltaninejad, a., kamali, m., & eslami shahrbabaki, m. (2016). family caregiver burden in mental illnesses: the case of affective disorders and schizophrenia a qualitative exploratory study. nordic journal of psychiatry, 70(4), 248– 254. https://doi.org/10.3109/08039488.2015.10843 72 zanetti, a. c. g., souza, t. m. p. de, tressoldi, l. de s., de azevedo-marques, j. m., corrêa-oliveira, g. e., silva, a. h. s. da, … gherardi-donato, e. c. da s. (2018). expressed emotion and family burden in relatives of patients in first-episode psychosis. archives of psychiatric nursing, 32(3), 390–395. https://doi.org/10.1016/j.apnu.2017.12.003 editorials: improving resilience and nurse caring behavior nurses encounter many risk factors in their work life and have to provide professional care for and relieve the patients under unpleasant conditions in any case in the same time. a number of adverse events or antecedents can pose a significant threat to the wellbeing of nursing staff, such as workplace violence, fatigue, lack of resources, intimidation at work, and lack of capacity that can affect service to patients (cusack et al., 2016). these situation leads to abroad arrays of occupational stress which is happened in daily life. when stressors exceed nurse’s coping skills, their functional capacity becomes impaired. a study in a teaching hospital in surabaya in july 2017 found that nurses showed symptoms of stress characterized by frequent sleep disturbances (40%), loss of concentration and thinking small things were too detailed (40%), irritable and tension when interacting with other health workers (70%) (dewi, hargono, & rusdi, 2019). several methods were implemented to improve coping of nurses but not their resilience (icn, 2016). arguably, resilience skills are needed by nurses to provide a better care to patients and their family. resilience is a term that we are hearing a lot lately. there is no single definition of resilience approved by experts. however, a common theme in various definition of resilience is strength, ability to overcoming challenging obstacles and bounce back from adversities (çam, 2017). in this editorial, we discuss ways of engaging the nurses to resilience skill in order to improve their caring behaviour. resilience is the result of the accumulation of various factors and characteristics possessed by individuals, namely personality traits, protective factors, and experiences collected through life in the process and / or developing as a result. these internal and external factors can predispose to "protect" or put individuals "at risk" that cause resilience or maladaptation (garcia-dia, dinapoli, garcia-ona, jakubowski, & o’flaherty, 2013). subsequently, there are 2 concepts in the organization that can emerge simultaneously in building nurse resilience, namely support and development. support is defined as an intervention in the workplace that directs and provides opportunities for nurses to withstand the pressures at work. development is defined as an intervention in the workplace that empowers nurses to enhance their professional, practice and personal potential. furthermore, in each organizational concept there are three domains i.e personal, practice and professional. the personal domain covers the welfare of individual nurses. the practice domain consists of skills, abilities, and special competencies from the profession. the professional domain is about the service ideal which includes lifelong learning and adherence to ethical behavior patients (cusack et al., 2016; hsieh, hung, wang, ma, & chang, 2016). in addition, three conditions that affect caring namely matters relating to patients, nurses themselves and the organization (hospital) (tonges & ray, 2011). the organizational factors highlighted are leadership, compensation and reward and professional relations. this component will build a healthy work environment that supports the ability and commitment of nurses displaying caring behavior. as widely known that patients in the hospital need a care where nurse have to provide comprehensively in terms of bio-psycho-social-spiritual care. furthermore, caring is not only a set of attitudes that can be identified such as sympathy or support, nor does it consist of all activities undertaken by nurses (warelow & edward, 2007). professional nursing care is determined by the way a nurse can use knowledge and skills to value client uniqueness and be physically and emotionally and require resilience within the nurse (warelow & edward, 2007). resilient nurses are able to display professional nursing care, in this case is caring behavior. nurse resilience is a nurse's ability to positively adapt to adversity, and can be applied to build personal strengths of nurses through several strategies namely building positive professional relationships, maintaining positivity, developing emotional insight, achieving life balance and spirituality, and becoming more reflective (jackson, firtko, & edenborough, 2007). it can be concluded that resilient nurse will be able to help patients in any situation with nurse’s professional manner. several studies have been carried out to develop nurse resilience potential, namely through stress control workshops and resilience development interventions (pipe et al., 2012), a workbased educational intervention (mcdonald, jackson, wilkes, & vickers, 2012), mindfulness-based stress reduction intervention (mbsri ) (foureur, besley, burton, yu, & crisp, 2013) , multimodal resilience training program (mealer, conrad, evans, jooste, solyntjes, rothbaum, et al., 2014), mindful self-care and resilience intervention (mscr) (craigie et al., 2016), and stress management and resiliency training (smart) (chesak et al., 2015), a pilot integrative coping and resiliency program (tarantino, earley, audia, d’adamo, & berman, 2013), aware compassionate communication: an experiential provider training series (accepts) (gerhart et al., 2016). the latest model was developed by author using a model of resilience for caring enhancement (more care) and focused for icu nurses (dewi, nursalam, & hargono, 2019). however the result is still inconsistent and influenced by various factors. in general, strategies for building or developing resilience include a) building good relationships in teams; b) provide education and training to develop behaviors that help control or limit the intensity of stress, or help recovery; and c) help in processing emotions and learning from experience. although individuals must be responsible for developing personal strategies to help coping and resilience, organizational support is an integral part of equipping individuals to face work related challenges (adams, 2015). resilient nurses have greater potential to be able to provide professional (caring) nursing services. in accordance with the resilience process (lietz, julien-chinn, geiger, & hayes piel, 2016) individuals reach the stage of resilience fully when able to provide assistance to others (helping others). from the various explanations above, it can be highlighted that nurse resilience influences caring behavior in general. the concept of resilience is very important in the field of care because resilience plays an important role in nursing longevity and retention. nursing leaders should be knowing how resilience can be applied to nurses and how to improve and maintain this concept in other fields (turner, 2014). therefore, it is very important to build and strengthen resilience of nurses in a stressful work environment in daily basis. this editorial has touched briefly on the method of resilience capacity improvement and how this may mitigate the impact of work place stress on nurses by involving nurse as individual and organisation as where nurse have support. dr. yulis setya dewi, s.kp., m.ng faculty of nursing yulis.sd@fkp.unair.ac.id http://e-journal.unair.ac.id/jners | 93 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16952 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review spiritual intelligence roles to improve the quality of nursing care: a systematic review kornelis nama beni, nisa dewanti, ida yanriatuti, mira melynda prakosa, and sena wahyu purwanza faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the quality of nursing care is the biggest predictor of patient satisfaction in care. but the fact is that nurses have not shown an increase in the quality of nursing care. lack of sense of responsibility, sincerity, self-awareness and professionalism is an indicator of the poor quality of nursing care in the health care system. the aim of the systematic review was conducted to examine the role of spiritual intelligence to improve the quality of nursing care. methods: a systematic search was conducted in pub med, science direct, research gate, and emerald insight data based. the search was identified 15 relevant original articles and full text published between 2013 until 2018. results: the result showed that spiritual intelligence can be improving the quality of nursing care. nurse with high spiritual intelligence have more competence, personal meaningful about caring, moral performance, personal excellence and flexibility were effective in increasing the quality of care. conclusion: spiritual intelligence was strengthened the beliefs and personality of nurses and the desire to grow and learn, work more professionally in improving the quality of nursing care. because there was a lack in the reviewed studies used the crosssectional and correlation, well-designed such as randomized controlled trials or queasy experiment should be conducted to more objectively evaluated the effect of spiritual intelligence to improve the quality of nursing care. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords spiritual intelligence, quality of nursing care contact kornelis nama beni kornelis.namabeni2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: beni, k. n, dewanti, n, yanriatuti, i, prakosa, m.m, and purwanza, s. w. (2019). spiritual intelligence roles to improve the quality of nursing care: a systematic review. jurnal ners, 14(3si)special issues, 93-97. doi:http://dx.doi.org/10.20473/jn.v14i1.16952 introduction quality of nursing care is influenced by several factors including spirituality, organizational commitment, and general health. this results in greater commitment and an improvement in service quality or productivity (khandan, eyni, & koohpaei, 2017). therefore, organizations recognize the importance of individual emotional and spiritual intelligence in improving the quality of nursing care (sunaryo, nirwanto, & manan, 2017). spiritual intelligence facilitates interaction among the logical thinking processes; emotional intelligence can lead to personal growth and changes. spiritual intelligence is one of the effective factors involved in improving the quality of nursing services. it can play a fundamental role in the observance of the patient’s rights because it provides the nurses with the ability to deal with stressful situations (khandan et al., 2017). nurses must have goals and meanings in relation to providing their nursing services. nurses providing services without purpose and meaning make people dissatisfied and cause the organizations to struggle to create something with an identity in the market. they also contribute less to the community that they serve (koražija, 2016). spiritual intelligence allows the nurses to find a meaning and purpose from all physical and mental experiences, including the ability to create and dominate life goals, and to produce individual meanings. nurses with high spiritual intelligence not only have the ability to respond appropriately in special circumstances but they also have the ability to understand why they are in that position, how to use that position and how to make the situation more suitable. spiritual intelligence also includes the highest levels of growth in various https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:kornelis.namabeni-2018@fkp.unair.ac.id mailto:kornelis.namabeni-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i1. k. n. beni et al. 94 | pissn: 1858-3598  eissn: 2502-5791 cognitive, ethical, emotional, and interpersonal fields, and it helps people to coordinate with the phenomena around them and to achieve internal and external integrity. the most important application of spiritual intelligence in the workplace was to create peace of mind, mutual understanding, and an understanding among one’s colleagues and, as a result, job satisfaction and job stress reduction. the characteristic of high-quality nursing care is focused on patient rights and the responsibility of all treatment nurses. communication competencies can be learned and by improving one’s learning communication skills, people can use various kinds of communication approaches to answer the different needs that arise of the patients in different situations. this includes patient safety, patient satisfaction, caring in nursing, performance and fulfilling patient needs (alireza faghihi & bafghi, 2016). the quality of patient nursing care can be improved through the personal characteristics and beliefs of the nurses who help through effective role-playing, which can affect the nursing process. improving the quality of nursing care by skilled nurses can be done both from the mental, communication, and social aspects because a nurse is involved in the holistic aspect of human life. this can tie into the biological, mental, social and spiritual aspects. the effects of the spirituality of the nurses and that coming from the nurses who use spiritual intelligence make it possible to approach and resolve their problems with a spiritual attitude approach, which can achieve better self-actualization and well-being (rani, abidin, rashid, & hamid, 2013). based on the description of the background, the aims of the article review used to identify the role of spiritual intelligence in increasing the quality of nursing care based on nursing service characteristics through an article review. materials and methods a systematic search was conducted in the pub med, science direct, research gate, and emerald insight databases for articles published from 2013 to 2018 with the keywords “spiritual intelligence and “nursing care” or “nursing delivery”. with these terms, we also combined other keywords, such as (nurse * or nursing *) to retrieve all relevant articles. the inclusion criteria of the articles sought were 1) including an increase in nursing services or a system developed as a part of nursing; 2) original research; abstract; 3). the subjects under study are nurses, employees, or leaders and 4) the location of the study was in a hospital or education setting. the exclusion criteria of the articles sought were those 1) focusing on a location in the community and 2) research that was a thesis or as part of the conference process. we extracted the types of research, research subjects, and research data sources. the research subjects in fifteen of the studies were nurses, leaders, and employees. in addition, we extracted the results of the articles that discussed the relationship between spiritual intelligence and improving the quality of nursing care. results selection of studies the initial search retrieved a total of 1,058 studies: 7 articles from pub med, 540 articles from research gate, 27 articles from science direct, and 484 articles from emerald insight. from this, 923 articles were deleted. based on the inclusion and exclusion criteria, the author reviewed each article and reached a consensus regarding the exceptions. the review process for the selected articles was developed in three stages, including a title review, abstract review and a full text review. we extracted 84 studies from the abstract titles and reviews and 69 studies from the full text review. finally, a total of 15 articles were selected for this study. the retrieval and screening process has been summarized in figure 1. study methods based on the research subject, we found that the number of respondents was 3218 respondents with as many as 2878 respondents finally detailed. the employees made up as many as 280 respondents, and the leaders made up as many as 100 respondents. based on the location of the study, we found 12 studies conducted in a hospital, 2 studies conducted in a company and 1 study conducted in a university. based on the research design, we found ten quantitative studies with the type of descriptive correlation and five that were cross-sectional. for the data sources, the questionnaire was the instrument used in the fifteen articles. we identified several of the figure1. prism flow chart 135 articles screened at title and abstract review 51 articles excluded 84 full-text articles assessed for eligibility 69 articles excluded: location not in hospital/education subject not nurse, leadership and employee 15 articles included pub med: 7 articles science direct: 27 articles emerald insight: 484 articles research gate: 540 articles 1.058 articles 923 articles removed jurnal ners http://e-journal.unair.ac.id/jners | 95 instruments used to measure spiritual intelligence and the components of nursing services. spiritual intelligence was measurement with a questionnaire developed by badie et.al (2010) (alireza faghihi & bafghi, 2016), (kaur, sambasivan, & kumar, 2013), (miri kh , keshavarz a, shirdelzadeh s, 2015), known as the integrated spiritual intelligence scale (isis) (koražija, 2016, khandan et al., 2017 and rani et al., 2013), abdullah zadeh et all questionnaires was developed and involved 29 articles scored using the likert method (quite agree, agree, partly agree, opposite of, quite opposite of) (fashi, 2017), king’s spiritual intelligence questionnaire (sunaryo et al., 2017), (mohsenimaram, naji, & zarea, 2018), (karimi, 2016) on (barghandan s. khalatbari j., 2017), spiritual intelligence had four indicators developed by zohar and marshall and agustian (haryono, rosady, & mdsaad, 2018), spiritual intelligence questionnaire contains 97 questions which evaluated the eight aspects (karimi-moonaghi et al., 2015), known as the spiritual intelligence self-report inventory (sisri) (arsang-jang, khoramirad, pourmarzi, & raisi, 2017). we identified the characteristics of quality nursing care as measured by kioalpak instrument for nursing care quality. for work satisfaction, we used the job descriptive index (jdi) by smith, kendall, & hulin on work satisfaction, a questionnaire on patient satisfaction (koražija, 2016). peterson’s job performance questionnaire (khandan et al., 2017), a demographic questionnaire, and richard walton’s quality of work life were developed by mathis and jackson and focused on output quality, output quantity, output period, work attendance and cooperative attitude (kaur et al., 2013). the questionnaire for emotional intelligence had five indicators as developed by goleman: self-awareness, self-adjustment, motivation, empathy and social skills (karimi-moonaghi et al., 2015). there are three indicators related to organizational commitment as described by meyer and allen (1984): affective, continuance and normative. the ethical performance questionnaire of dehqani nurses was used to assess the ethical performance. the applied questionnaires included qualpac regarding the nurses’ quality of care, the nurses’ ethical decision making assessed using the nursing dilemma test (ndt) and the nurse’s work performance measured using the schwirian six-d scale (rani et al., 2013). the nursing care quality questionnaire included two parts. part one includes the individual specifications and the second part includes three social and mental dimensions including 28 questions. the physical dimension includes 24 questions and finally, the communicational dimension includes 13 questions (alireza faghihi & bafghi, 2016). the spiritual intelligence questionnaire and the characteristics of the quality of nursing care services questionnaire were tested for reliability using cronbach’s alpha and everything has been declared reliable. there were, however, some instruments that did not report the validity test. from the fifteen journals, we found that the analysis tests were done using the pearson correlation coefficient, independent-samples t-test, sem, anova, t-test, independent t-test, mann–whitney, kruskal wallis, and pearson and spearman correlation coefficients and multivariate regression model, and multivariable linear regression tests. table 1 summarizes the studies methods as can be seen in supplementary file. outcomes measure from the results of the review of the fifteen articles, it was found that spiritual intelligence can directly or indirectly improve the quality of care. spiritual intelligence can improve the quality of patient care by mediating the nurses' beliefs and personalities (alireza faghihi & bafghi, 2016)]. spiritual intelligence with emotional intelligence can improve the quality of nurse caring behavior. spiritual intelligence, emotional intelligence, psychological ownership and the burnout of nurses play a significant role in terms of the effect of the caring behavior of the nurse (kaur et al., 2013). at the same time, spiritual intelligence correlates significantly with decreasing the burnout of nurses (sunaryo et al., 2017). the results of our study found there to be a significant positive relationship between spiritual intelligence and job satisfaction for employees, which has an impact on patient satisfaction (fashi, 2017). therefore, considering the spiritual dimension in the staff can improve the quality of care and patient satisfaction. the production of personal meanings and the conscious status of the dimensions of si expansion have a significant impact on the respect for others and guaranteed human presence dimensions related to the caring of the nurses. spiritual intelligence leads to changes in the patient attitudes, behavior and support among nurses. the promotion of si can help to improve the nurses' mental health status to allow them to better respond to patient needs, patient safety and organizational efficiency. there is a significant correlation between spiritual intelligence and the quality of work life in nurses in oncology departments (mohsenimaram et al., 2018); this relates to psychological well-being (ahoei, faramarzi, & hassanzadeh, 2017). emotional intelligence and spiritual intelligence were found to have positive and significant effects on organizational commitment. subsequently, organizational commitment has a positive and significant effects on the temporary nurses’ performance and it positively mediates the relationship between emotional intelligence and spiritual intelligence on the temporary nurses’ performance (haryono et al., 2018). moral performance has a direct relationship with spiritual intelligence, so individuals with high spiritual intelligence have higher moral scores(m & mojtaba, 2018) . there was a significant relationship found between spiritual intelligence with quality of work life and work engagement (barghandan s. khalatbari k. n. beni et al. 96 | pissn: 1858-3598  eissn: 2502-5791 j., 2017). a significant correlation was found between spiritual intelligence, clinical competency and quality of care (karimi-moonaghi et al., 2015). there was a positive significant correlation between spiritual intelligence and the nurses’ quality of care. improving spiritual intelligence can help in increasing the patients’ quality of care due to encouraging the nurses’ beliefs and personality (miri kh , keshavarz a, shirdelzadeh s, 2015). spiritual intelligence plays a positive role in the ethical decision making of nurses (arsang-jang et al., 2017). a positive correlation was found between spiritual intelligence and work performance. the result shows that nurses with higher spiritual intelligence perform more in their work (rani et al., 2013). table 2 shows the outcomes of the role of spiritual intelligence related to improving the quality of nursing care as can be seen in supplementary file. discussion the study results show that spiritual intelligence reinforces beliefs and personality and that it improves the quality of patient care. spiritual intelligence has strengthened the beliefs and personality of the nurses and their desire to grow and learn, and to work more professionally in improving the quality of nursing care. nurses who have strength in good beliefs and personalities will have the ability to continue to grow and learn when providing quality nursing care. the use of spiritual intelligence in the workplace is to create peace and mutual understanding from and in the nurses within their duties and responsibilities to improve nursing care (alireza faghihi & bafghi, 2016). spiritual intelligence is directly related to moral performance. nurses with high moral functions can improve the spiritual intelligence of their personnel in certain dimensions (communication with the source of life). one aspect of nursing care is communication. if the nurse has good communication, then it will have an impact on the quality of care (shigeko izumi, 2011). it can be said that the more that the nurses adhere to spiritual values, the more that they will show honesty towards the patients. with the presence of spiritual intelligence and good moral performance, the nurses strive to improve the quality of patient care at a higher level, reducing the incidence of disease problems. the nurses will show that they have good ethics when carrying out nursing care (m & mojtaba, 2018). spiritual intelligence affects performance but it must go through organizational commitment. this indicates that someone who carries the meaning of spirituality in his work will feel secure in his own life and work, and they will also have more meaning which will form a strong organizational commitment. establishing organizational commitment will encourage and motivate the individuals to make various efforts n the progress of the organization. spiritual intelligence will create commitment because the individuals will have skills in dealing with stress so this will produce success in the organization. with the presence of spiritual intelligence, it will increase critical thinking and creativity in finding the right solutions in patient care (haryono et al., 2018), (arsang-jang et al., 2017). spiritual dimensions can increase the quality of care and patient satisfaction. spiritual intelligence has four main components forming the spiritual intelligence: critical existential thinking, personal meaning production, transcendental awareness, and conscious state expansion. spiritual intelligence can be regarded as a personality attribute such as personality characteristics that build character and that can be used to identify the purpose of all physical and mental experiences, including the ability to create important goals and meanings for life and other contemplations of existence. personal meaning describes the transcendental quality which includes everything expressed in a perceptive and effective way, contributing and being conducive to creativity, self-development and producing life goals and meaning. with the purpose and meaning of life known, the nurse can improve their service in caring for patients as a part of their purpose and meaning in life (shammout & abu-eita, 2015). spiritual intelligence plays a positive role in the ethical decision making of nurses. spiritual intelligence is a combination of an individual's ability to solve problems effectively with the adaptation of spiritual resources. spiritual intelligence implies cognitive, moral and interpersonal development. with this intelligence, it will help the nurses to adjust to their environmental phenomena and to achieve internal and external integration. this intelligence provides a general view of life with spiritual experience and resources that can be used in important decision making (karimi-moonaghi et al., 2015). there is a positive effect of emotional and spiritual intelligence on caring behavior. spiritual intelligence is a set of mental capacities that deal with awareness, integration and the application of transcendental and spiritual (immaterial) aspects of the individual. spiritual intelligence is the ability of the individuals to behave through reasoning with compassion if they maintain their inner and outer calm in different situations. spiritual intelligence is a series of activities which, in addition to subtlety and flexibility in behavior, lead to self-awareness and a deep insight into life. such that goals are drawn beyond the material world (mohsenimaram et al., 2018). nursing care with a spiritual intelligence approach is a multidimensional concept where in practices, the nurses must respect, maintain patient privacy, listen carefully to the patient and help the patient to understand the treatment procedures. nurses, in meeting the primary needs of the patients, must build relationships, provide interventions and have the ability to work together on the care tasks. if the nurses are able to build relationships that are appropriate to the patient, the quality of nursing care will increase and they have an impact on increasing patient satisfaction (karimi-moonaghi et al., 2015). jurnal ners http://e-journal.unair.ac.id/jners | 97 conclusion among fifteen articles reviewed, all showed positive results that spiritual intelligence can improve the quality of nursing care. the quality of nursing care was generated and grouped into four domains: competence, caring, professionalism and demeanor. spiritual intelligence in the clinical environment can be applied to improve the function and role of nurses in improving nursing. due to the impact of the nurses' spiritual intelligence on their job performance, spiritual intelligence training courses should be incorporated into in-service training for nurses and other healthcare workers. spiritual intelligence leads to changes in attitude, behavior and patient support among the nurses. spiritual intelligence in the nurses increased the nurses 'clinical competence and quality of care, it is advisable to develop the nurses' spiritual intelligence during nursing education. references ahoei, k., faramarzi, m., & hassanzadeh, r. (2017). the relationship between spiritual intelligence and psychological well-being in women with breast cancer, 18(10), 4–9. https://doi.org/10.5812/semj.15103.research alireza faghihi, h. h.-f., & bafghi, and m. j. a. determining the relation between nurses spiritual intelligence and nursing care quality in estahban city imam khomeini hospital, vol-7 international journal of advanced biotechnology and research (ijbr) pp843-848 (2016). retrieved from http://www.bipublication.com arsang-jang, s., khoramirad, a., pourmarzi, d., & raisi, m. (2017). relationship between spiritual intelligence and ethical decision making in iranian nurses. https://doi.org/10.1177/0022167817704319 barghandan s. khalatbari j. (2017). the corelation beetwen cognitive emotion regulation and spiritual intelligence with quality of life among emergency department nurses. iran journal of nursing, 46–54. fashi, f. m. (2017). studying the relationship between spiritual intelligence of nurses and patients ’ satisfaction with nursing care, 6(3), 539–542. https://doi.org/10.15562/bmj.v6i3.542 haryono, s., rosady, f., & mdsaad, m. s. (2018). effects of emotional and spiritual intelligence on job performance among temporary nurses at abdul riva ’ i regional general hospital , berau district , east kalimantan province , indonesia. management issues in healthcare system, 4, 42–54. retrieved from www.aimijournal.com karimi-moonaghi, h., gazerani, a., vaghee, s., gholami, h., salehmoghaddam, a. r., & gharibnavaz, r. (2015). relation between spiritual intelligence and clinical competency of nurses in iran. iranian journal of nursing and midwifery research, 20(6), 665–669. https://doi.org/10.4103/1735-9066.170002 karimi, z. k. (2016). the structural model of relationship between spiritual intelligence and emotional intelligence with quality of work life and work engagement of employees. int. j. management in education, 10(3), 278–292. kaur, d., sambasivan, m., & kumar, n. (2013). effect of spiritual intelligence , emotional intelligence , psychological ownership and burnout on caring behaviour of nurses : a cross-sectional study. journal of clinical nursing, 22, 3192–3202. https://doi.org/10.1111/jocn.12386 khandan, m., eyni, z., & koohpaei, a. (2017). relationship between spiritual intelligence and job performance: a case study of nurses and nursing aids in the main university hospital of qom, iran. health spiritual med ethics, 4(3), 8–13. koražija, m. (2016). the relationship between spiritual intelligence and work satisfaction among leaders and employees. naše gospodarstvo/our economy, 62(2), 51–60. https://doi.org/10.1515/ngoe-2016-0012 m, h. m., & mojtaba, z. (2018). the relationship between spiritual intelligence and moral function of nurses in jahrom university of medical sciences. pharmacophore, 8(6), 4. miri kh , keshavarz a, shirdelzadeh s, p. p. (2015). the relationship beetwen nurses spiritual intelligence and quality of nursing care based on nurses and patients viewpoints. the journal of urmia nursing and midwifery faculty, 13(6). retrieved from mirikheizaran@yahoo.ie mohsenimaram, m., naji, s., & zarea, k. (2018). the relationship between spiritual intelligence and quality of work life in nurses in oncology departments of ahwaz hospitals. asian journal of pharmaceutics, 12(2), 1–5. retrieved from a_naji@ khuisf.ac.ir rani, a. a., abidin, i., rashid, m., & hamid, a. (2013). the impact of spiritual intelligence on work performance: case studies in government hospitals of east coast of malaysia. the macrotheme review, 2(3), 46–59. retrieved from anitarazali@gmail.com shammout, n. a., & abu-eita, j. d. (2015). the relationship between spiritual intelligence and personality traits among jordanian university students. psychology research and behavior management, 8, 89–97. https://doi.org/http://dx.doi.org/10.2147/prb m.s76352 shigeko izumi, j. g. b. (2011). quality nursing care for hospitalized patients with advanced illness: concept development. res nurs health, 33(4), 299–315. https://doi.org/10.1002/nur.20391.quality sunaryo, h., nirwanto, n., & manan, a. (2017). the effect of emotional and spiritual intelligence on nurses ’ burnout and caring behavior. international journal of academic research in business and social sciences, 7(september). https://doi.org/10.6007/ijarbss/v7-i12/3753 316 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17167 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review support factors of self foot care for diabetes mellitus patients rohmatul faizah, gabriel wanda sinawang, andrik hermanto, and mohamad roni alfatih faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: diabetes mellitus is a chronic disease of the endocrine system that has numerous complications such as diabetic foot ulcers. amputation is the last frontier for the treatment of diabetic foot ulcers but they can be prevented through proper self-foot-care behavior. the aim of this study was to explain the support factors of self foot care for diabetes mellitus patients. methods: the methods used were self-foot-care identification in the literature, with the relevant literature identification based on the topics and titles obtained from scopus, sciencedirect and proquest. this was as well as analysis of the results from examining the various behaviors that support self-foot-care behavior in the literature. the references included was the research conducted from 2013 2019 as follows: 2 descriptive correlation studies, 3 descriptive studies, 2 prospective studies, 1 prospective cohort study, 1 pre-experimental study, 3 quasi-experimental studies, 1 case study and 3 cross-sectional studies. results: all of the journals included discussed foot care behavior. education programs regarding foot care are a major factor that supports foot care behavior. conclusion: all of the journals that were obtained stated that there was a positive influence on the diabetic foot condition where routine foot care behavior was implemented. self-foot-care behavior also requires other supporting factors to obtain the maximum results. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords self foot care; foot care behavior; diabetic foot; diabetes mellitus contact rohmatul faizah  rohmatul.faizah2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: faizah, r., sinawang, g., alfaqihand, m., & hermanto, a. (2019). support factors of self foot care for diabetes mellitus patients. jurnal ners, 14(3si), 316-320. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17167 introduction diabetes mellitus is a chronic disease in the endocrine system, which occurs due to the disruption of glucose metabolism in the body. the disorder of glucose metabolism is caused by several factors. previously, it was known that glucose breakdown in the body requires the insulin hormone and that this hormone is produced by the pancreas gland(moradi, alavi, salimi, nouhjah, & shahvali, 2019). there is quite a large number of diabetes mellitus patients globally. according to the who (2015), there are 415 million adults with diabetes mellitus. the number has increased each year and it is predicted to reach 642 million in 2040. indonesia ranked 6thin south east asia for the mortality rate of people with diabetes mellitus. the results from riskesdas (2018) stated that people with diabetes mellitus in indonesia have increased by 3.4% since 2013 [3]. in general, there are 2 major factors causing diabetes mellitus; disorders of the pancreatic organs or a lifestyle disorder. for the pancreatic gland disorders, the problem is that the amount of the insulin hormone is insufficient for the body's requirement to carry out glucose metabolism. for lifestyle disorder, the problem is the excessive amount of glucose in the body, causing it to not be fully metabolized. diabetes mellitus is a noncommunicable disease. regardless, this disease still requires appropriate treatment. the treatment given to patients with diabetes mellitus is a life-long treatment, therefore compliance is required to achieve optimal results. the treatment of diabetes mellitus consists of 5 key principles(cousart & handley, 2017). uncontrolled diabetes mellitus can lead to complications. one problem that is often found as a complication is diabetic feet. the complication of poorly-treated diabetic feet is amputation. the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 317 intervention measure used to handle diabetic foot problems is proper foot care. diabetic feet could be prevented with proper self-foot-care behavior (al sayah, soprovich, qiu, edwards, & johnson, 2015). the systematic review will discuss appropriate foot care behavior and its supporting factors. the limitation of the self foot care of diabetes mellitus patients at home is that the nurse can’t accompany the patient 24 hours around the clock. therefore the ability to self foot care is needed by the patient and their family. the literature explained that the supporting factors for independent self foot care came from education, the media used to provide health education and health education in accordance with culture. materials and methods research design this study used a systematic review by finding out the support factors of self foot care for diabetes mellitus patient. this study explained the results drawn from the research published in journals internationally. search strategy this research reviews the support factors of self foot care through the process of electronic database searching which was limited to between2013 and 2019. the literature was used from scopus, sciencedirect and proquest. the keywords used in the literature search were self foot care and diabetes mellitus disease. inclusion and exclusion criteria the inclusion criteria of the research in this systematic review were: 1) experimental and nonexperimental studies, 2) there were no limitation regarding age and the amount of participants in the literature collection and 3) the research was conducted from 2013 2019. meanwhile, for the exclusion criteria, it was 1) the research samples or respondents with diabetic foot problems. article search process this research article was obtained from scopus, science direct, and proquest. this research found 6.679 articles during search. a detailed process of the mechanism for selecting research can be seen in the table below. results there were 16 literature studies obtained: 2 descriptive correlation studies, 3 descriptive studies, 2 prospective studies, 1 prospective cohort study, 1 pre-experimental study, 3 quasi experimental studies, 1 case study and 3 cross sectional studies. there were also interventions that were used as comparisons or combinations as described in table 1. all of the literature taken stated that that there was success concerning the diabetes mellitus patients and self foot care as indicated by either the patient or their family. ten items of literature explained that the main factor of the success of foot care was the health education provided. health education can be a success with the right education media. two literature items explained about using electronic media for health education such as a handphone, television and radio. the health education took on the form of a short message service (sms) or a message post using a social media account. health education through a social media account resulted in 45,7% posts being categorized as useful out of 103 posts. the limitation of health education through electronic media is that the patient may not be able to operate a handphone. so, the patients need support from their family. there were 3 items of literature that explained about health education aligned with culture and that self efficacy has an influence on the increase of self foot care. one literature explain that the sdfq-uma questionnaire was a valid tool that could be used to evaluate foot care in dm patients. discussion good foot care behavior in diabetes mellitus patients is needed. the main factor in the development of diabetic foot care behavior is health education. the health education provided to diabetes mellitus patients can be done using various media. health education health education is defined as efforts starting from the planning stage which eventually aim to affect people on different levels (i.e. individuals, groups or communities). health education is carried out in the hope that the targets could implement the knowledge that is obtained. health education addresses health issues ranging from health promotion through to treatment techniques. health education has important elements, including input, the process itself and output. the input in health education is the targets and the educators, while the process is the r. faizah et al. 318 | pissn: 1858-3598  eissn: 2502-5791 effort planned to exert an influence on others. the output is to do what has been given in the process element. in general, the results expected in health education are health behaviors or behaviors undertaken to maintain and improve conductive health in the target(notoatmodjo, 2012). besides having 3 important elements in health education, it should be known that the methods used in health education also need to be considered. there are 2 ways of giving health education; face-to-face in person or by using a certain media type. media in health education can influence the success of the material that is delivered. the educational media that can be used includes electronic media (radio, tv, internet, telephone, cellphones, social media, etc.), print media (leaflets, posters, booklets, newspapers, magazines, etc.) and other media (letters). the determination of health education media is adjusted according to the number of targets, the geographical conditions, the characteristics of the participants and their supporting resources(nursalam & efendi, 2008). health education is the starting point that can be initiated by health workers to have a good influence. one of the examples is providing health education to diabetes mellitus patients regarding proper foot care behavior. health education through electronic media electronic media is one of the media types that can be table 1. systematic review of the established studies author writer result of literature wendling and beadle (wendling & beadle, 2015) there was no significant correlation between the level of self-efficacy and foot care behavior. however, foot care behavior had significant results with gender, which was higher in men. vedhara et al (vedhara et al., 2014) the patient's beliefs in the illness that they experienced, which is a diabetic foot ulcer, became an important supporting factor in improving foot care behavior. sharoni et al (sharoni, abdul rahman, minhat, shariff ghazali, & azman ong, 2017) a self efficacy education program could increase the elderly patients’ improvement related to foot care behavior due to the enhancement of acceptance level, expectations of foot care behavior, foot care knowledge, quality of life, fbg, foot hygiene and anhydrosis li et al (li et al., 2014) foot care behavior was dependent on and had a positive correlation with individual knowledge level. the affecting factors include education, a long diabetes mellitus diagnosis, periodic examinations and education regarding dm complications navarro-flores et al (navarroflores, morales-asencio, cervera-marín, labajosmanzanares, & gijon-nogueron, 2015) the sdfq-uma questionnaire was a valid tool that could be used to evaluate foot care in dm patients. d’souza et al (d’souza et al., 2016) foot care behavior had a positive correlation with high income, high education, low weight, positive attitude and a high awareness of diabetes as well as its management. indrayana et al (indrayana, guo, lin, & fang, 2019) disease perception, local beliefs such as consequences, personal control, treatment control and coherence had a good contribution when it came to improving patient behavior in relation to foot care. adarmouch et al(adarmouch et al., 2017) there was an increase in foot care after the intervention in the form of health education tailored to the culture was given. al sayah et al (al sayah et al., 2015) dm patients with diabetic feet need to carry out self-care and monitor their clinical conditions regularly, so then dm can be controlled. moradi et al (moradi et al., 2019) sms increased the knowledge and behavior of diabetic foot ulcer prevention effectively. hicks et al (hicks et al., 2019) the costs for dfu maintenance are very large and it also had a high profitability effect. cousart and handley (cousart & handley, 2017) diabetic foot care in primary care was very effective and proved to be beneficial for preventing and healing process foot problems in diabetes mellitus patients. rumana et al (rumana et al., 2017) facebook has proven to be effective to provide correct information regarding diabetic foot care by seeing the positive likes and comments. fan et al (fan, sidani, cooperbrathwaite, & metcalfe, 2013) the self-foot-care education interventions were acceptable, feasible and had good effects for treating the skin of the feet and toenails. stolt et al (stolt et al., 2013) foot care in diabetes mellitus patients performed by home nurses must also have its associated scientific information updated. this should be done to obtain better results, especially in foot care. vatankhah et al (vatankhah et al., 2009) health education with a simple face-to-face method was an effective and implemented method to increase the knowledge regarding foot care. jurnal ners http://e-journal.unair.ac.id/jners | 319 used to provide health education. electronic media is an assembled device that has a machine to support its operations. the development of an increasingly modern era affects the sophistication level of electronic media. electronic media circulating in the community includes television, radio, cellphones etc. within the development era, mobile phones have become one of the electronic media items owned by nearly everyone. cellphones are now the main tool for people to find out the latest information, because each individual sees and holds cellphones almost every hour. electronic media can establish two-way communication, not only by receiving but also by responding. in addition, electronic media can receive responses from an unlimited amount of sources and it can be used to exchange information (garcia, 2011). these changes and developments can be utilized in the health sector. the health teams are also required to think forward by using mobile electronic media for providing health education. one of the examples of health education is proper foot care behavior education for diabetic foot ulcer prevention. an example of a type of electronic media that can be used and that has been extensively studied is the use of social media and information delivery via sms. these media types can have a positive effect on improving foot care behavior in diabetes mellitus patients. health education through direct method/face-toface the direct method of health education or the face-toface method is one of the most commonly used media. this media has various advantages and disadvantages. the advantage of the face-to-face media is that the health information providers can meet and provide direct feedback in person. however, the weakness of this media is the time and number of targets. in using this method, the counseling needs to be done at certain times and planned in advance. the targets must also spare a sufficient amount of time to attend the counseling. in addition, the amount of targets will be limited due to the small capacity of the counseling space (musfiqon, 2012). health education using the face-to-face method requires the targets to pay full attention during the counseling. despite many weaknesses of this media form, it is still an option for providing health education. some of the studies stated that this method had good results, such as increasing the adherence to foot care behavior in diabetes mellitus patients for the prevention of gangrene and even amputation. health education in accordance with cultures culture is a form of habit by humans as members of a particular community containing knowledge, beliefs, art, morals, law, habits and other complex skills. the first time that nursing emerged in health context, it discussed the culture associated with nursing. there is a theory in nursing that is focused on learning about culture, referred to as the theory of transcultural nursing, namely leininger's theory. the theory stated that the nursing practice as a whole needs to pay attention to the culture adopted and that it needs to provide information tailored to the content that is according to the culture as health workers (aini, 2018). numerous research studies have also been done by developing the theories of leinenger. health education, especially on foot care behavior is also connected, with theory. this study found that health education conducted by paying attention to the cultural contexts adopted can increase the willingness of the patient and trust in the information conveyed. therefore, giving health education in accordance with the local cultures can be a good influence on the diabetes mellitus patients when it comes to performing foot care behavior. the behavior of diabetic foot care performed by diabetes mellitus patients is indispensable. diabetic foot care behavior can prevent foot problems in diabetes mellitus patients. foot problems in diabetes mellitus patients are the most common complications. the complications of diabetic feet can result in amputation, which can affect various aspects of the patient’s life. therefore, diabetes mellitus patients need to understand and implement foot care behavior. nurses can help in foot care behavior education and they can assist in the development of techniques in terms of providing health education effectively to diabetes mellitus patients. conclusion foot care behavior is required to prevent diabetic foot complications. foot care behavior has a positive impact if it is done properly. health education regarding foot care behavior is also needed. performing education and media selection is an aspect which needs to be taken into consideration. examples of the media that can be selected and studied are sms, social media and the face to face method. health education using the right media will result in the improvement of foot care behavior in diabetes mellitus patients. thus, it can also prevent the occurrence of diabetic foot complications leading to amputation. the limitation of this systematic review was that it only found 16 supporting literature items. thus it could not explain all of the influential factors of self foot care and it could only explain the most important factor and related aspects. references adarmouch, l., elyacoubi, a., dahmash, l., el ansari, n., sebbani, m., & amine, m. (2017). short-term effectiveness of a culturally tailored educational intervention on foot self-care among type 2 diabetes patients in morocco. journal of clinical and translational endocrinology, 7, 54–59. https://doi.org/10.1016/j.jcte.2017.01.002 r. faizah et al. 320 | pissn: 1858-3598  eissn: 2502-5791 aini, n. (2018). teori model keperawatan. malang: umm press. al sayah, f., soprovich, a., qiu, w., edwards, a. l., & johnson, j. a. (2015). diabetic foot disease, selfcare and clinical monitoring in adults with type 2 diabetes: the alberta’s caring for diabetes (abcd) cohort study. canadian journal of diabetes, 39(3), s120–s126. https://doi.org/10.1016/j.jcjd.2015.05.006 cousart, t. h., & handley, m. (2017). implementing diabetic foot care in the primary care setting. journal for nurse practitioners, 13(3), e129– e132. https://doi.org/10.1016/j.nurpra.2016.11.009 d’souza, m. s., ruppert, s. d., parahoo, k., karkada, s. n., amirtharaj, a., jacob, d., … al salmi, n. m. d. (2016). foot care behaviors among adults with type 2 diabetes. primary care diabetes, 10(6), 442–451. https://doi.org/10.1016/j.pcd.2016.04.002 fan, l., sidani, s., cooper-brathwaite, a., & metcalfe, k. (2013). feasibility, acceptability and effects of a foot self-care educational intervention on minor foot problems in adult patients with diabetes at low risk for foot ulceration: a pilot study. canadian journal of diabetes, 37(3), 195– 201. https://doi.org/10.1016/j.jcjd.2013.03.020 garcia, i. (2011). social media integration theory model. spanish: human media. hicks, c. w., canner, j. k., karagozlu, h., mathioudakis, n., sherman, r. l., black, j. h., & abularrage, c. j. (2019). quantifying the costs and profitability of care for diabetic foot ulcers treated in a multidisciplinary setting. journal of vascular surgery, 1–8. https://doi.org/10.1016/j.jvs.2018.10.097 indrayana, s., guo, s. e., lin, c. l., & fang, s. y. (2019). illness perception as a predictor of foot care behavior among people with type 2 diabetes mellitus in indonesia. journal of transcultural nursing, 30(1), 17–25. https://doi.org/10.1177/1043659618772347 li, r., yuan, l., guo, x. h., lou, q. q., zhao, f., shen, l., … sun, z. l. (2014). ethe current status of foot self-care knowledge, behaviours, and analysis of influencing factors in patients with type 2 diabetes mellitus in china. international journal of nursing sciences, 1(3), 266–271. https://doi.org/10.1016/j.ijnss.2014.05.023 moradi, a., alavi, s. m., salimi, m., nouhjah, s., & shahvali, e. a. (2019). the effect of short message service (sms) on knowledge and preventive behaviors of diabetic foot ulcer in patients with diabetes type 2. diabetes and metabolic syndrome: clinical research and reviews, 13(2), 1255–1260. https://doi.org/10.1016/j.dsx.2019.01.051 musfiqon. (2012). pengembangan media dan sumber pembelajaran. jakarta: pt. prestasi pustakarya. navarro-flores, e., morales-asencio, j. m., cerveramarín, j. a., labajos-manzanares, m. t., & gijonnogueron, g. (2015). development, validation and psychometric analysis of the diabetic foot self-care questionnaire of the university of malaga, spain (dfsq-uma). journal of tissue viability, 24(1), 24–34. https://doi.org/10.1016/j.jtv.2014.11.001 notoatmodjo, s. (2012). promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta. nursalam, & efendi, f. (2008). pendidikan dalam keperawatan. jakarta: salemba medika. rumana, n., abedin, t., al mamun, m., turin, t. c., shommu, n., lasker, m. a. a., & ahmed, s. w. (2017). social media as a platform for information about diabetes foot care: a study of facebook groups. canadian journal of diabetes, 41(1), 97–101. https://doi.org/10.1016/j.jcjd.2016.08.217 sharoni, s. k. a., abdul rahman, h., minhat, h. s., shariff ghazali, s., & azman ong, m. h. (2017). a self-efficacy education programme on foot selfcare behaviour among older patients with diabetes in a public long-term care institution, malaysia: a quasi-experimental pilot study. bmj open, 7(6), 1–11. https://doi.org/10.1136/bmjopen-2016014393 stolt, m., suhonen, r., puukka, p., viitanen, m., voutilainen, p., & leino-kilpi, h. (2013). nurses’ foot care activities in home health care. geriatric nursing, 34(6), 491–497. https://doi.org/10.1016/j.gerinurse.2013.08.0 03 vatankhah, n., khamseh, m. e., jahangiri noudeh, y., aghili, r., baradaran, h. r., & safai haeri, n. (2009). the effectiveness of foot care education on people with type 2 diabetes in tehran, iran. primary care diabetes, 3(2), 73–77. https://doi.org/10.1016/j.pcd.2009.05.003 vedhara, k., dawe, k., wetherell, m. a., miles, j. n. v., cullum, n., dayan, c., … campbell, r. (2014). illness beliefs predict self-care behaviours in patients with diabetic foot ulcers: a prospective study. diabetes research and clinical practice, 106(1), 67–72. https://doi.org/10.1016/j.diabres.2014.07.018 wendling, s., & beadle, v. (2015). journal of clinical & translational endocrinology the relationship between self-ef fi cacy and diabetic foot self-care. 2, 37–41. https://doi.org/10.1016/j.jcte.2015.01.001 http://e-journal.unair.ac.id/jners | 213 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17061 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review of excessive social media use: has it really affected our mental health? apriana rahmawati, dona muji fitriana and risna nur pradany faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: social media use has been rapidly increasing over the past few years. research and practice have mostly focused on the positive impacts of social media, intending to understand and support the various opportunities afforded by this particular technology era. however, it is increasingly observable that social media also involves enormous risks for individuals, communities, firms and even for society as a whole. this systematic review aimed to establish the negative impacts on mental health related to the excessive use of social media. methods: as many as 15 articles were generated from scopus, sciencedirect and ebscohost. the reviewers independently screened the titles and abstracts in addition to assessing the studies. the study design varied in rigorousness over the quantitative as well as qualitative studies. results: the result for this study are that having an average daily screen time (more than 2 hours a day) is positively associated with social media addiction. avoidant attachment was associated with more problematic social media use. conclusion: avoidant attachment was associated with more problematic social media use. thus, an abstinence of several days from social media consumption can caused a reduction in perceived stress. article history received: december 26, 2019 accepted: december 31, 2019 keywords social media; mental health; depression; quality of life contact apriana rahmawati  apriana.rahmawati2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: rahmawati, a., fitriana, d. m., & pradany, r. n. (2019). a systematic review of excessive social media use: has it really affected our mental health?. jurnal ners, 14(3si), 213-216. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17061 introduction regardless of the numerous opportunities that social media offers, an increasing number of incidents show that there is undoubtedly a negative impact from social media. chamath palihapitiya, a former facebook executive, stated that he regrets that some of the tools he helped to create “are ripping apart the social fabric of how society works” (baccarella et. al. 2018). additional studies have examined the association between technology addictions and stress, anxiety, depression and psychological well-being, which all had negative impacts on satisfaction in life (hawi n, et. al, 2019). problematic social media use refers to being preoccupied with social media, having a strong motivation to use social media and spending an excessive amount of time on social media leading to impairments in their social, personal and/or professional life, as well as psychological health and well-being (kircaburun k, et al, 2018). the excessive use of technological devices and apprehensive concern can trigger stress because of losing the ability to control their mobile activities and being unable to limit the incoming communications. excessive social media use is linked with the distraction and alleviation of psychological suffering, mental exhaustion and attention deficiency (dhir a, et al, 2018). based on the global digital report 2018, the growth in internet users has been driven by more affordable smartphones and mobile data plans. more than 200 million people got their first mobile device in 2017 and two-thirds of the world’s 7.6 billion inhabitants now have a mobile phone. more than half of the handsets in use today are ‘smart’ devices too, making it easy for people to enjoy a rich internet experience wherever they are. social media use continues to grow rapidly, and the number of people using the top platforms available in each country has https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:apriana.rahmawati-2018@fkp.unair.ac.id mailto:apriana.rahmawati-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). a. rahmawati, et al. 214 | pissn: 1858-3598  eissn: 2502-5791 increased by almost 1 million new users every day over the past 12 months. more than 3 billion people around the world now use social media each month, with 9 out of 10 of those users accessing their chosen platforms via mobile devices. the essential headlines for the digital age in 2018 were that the number of internet users in 2018 was 4.021 billion, up 7 percent year-on-year. the number of social media users in 2018 was 3.196 billion, up 13 percent year-on-year. the country-based average numbers of hours that social media users spend using social media each day are the philippines with 3 h 57, brazil 3h 39 m, while in third place is indonesia with 3h 23m. excessive social media use (esmu) is defined as an excessive behavioral pattern of social media use that has adverse effects on the individuals by producing addiction-like symptoms, including salience, withdrawal, mood modification, relapse, conflict and tolerance. it can be viewed as a subcategory in the broader spectrum of the problematic excessive use of the internet. esmu can manifest in an imbalance between the reward and inhibition brain systems, which results in impaired decision making such that a person emphasizes short-term reinforcing rewards over larger long-term utilitarian rewards. such disadvantageous decisions underlie many excessive behaviors (he q, turel o, bechara a, 2018). experiencing addiction-related symptoms in the context of technology use can be stressful, and so is the mere use of a social networking site. one line of research in the literature thus far has examined various possibly stressful outcomes of excessive sns use, including reduced wellbeing, mental health and social and academic functioning (turel o, cavagnaro dr, meshi d, 2018). in this systematic review, we bring attention to the duality of social media. for the many positive sides of social media, there are also negative impacts that need to be explored so then we become more conscious of their potential risks and make betterinformed decisions. materials and methods this study used a systematic review to analyze the negative impact on the mental health of excessive social media use. the methods used in preparing this systematic review were generated literature from the scopus, sciencedirect and ebscohost databases. the search study began using the words social media and social media impacts, limited to 2015-2019. we checked for references lists through an in-depth manual search using google and remotex unair to identify any un-assured literature. as for the journal search, the inclusion criteria were excessive social media use and its negative impact on mental health. the exclusion criteria were if the study did not discuss a negative impact on mental health from excessive social media use. during the screening stage, no distinction was made in terms of the research design and the population’s age, including studies on adults, adolescents and children. only studies regarding the negative impacts of social media were included. the initial phase of the article search was conducted with the specified keywords. we then obtained 35 articles from scopus, sciencedirect and ebscohost. we adjusted the inclusion criteria and the restrictions for the year and found 21 articles. for the second screening, the publications were downloaded. from these 21, 6 publications were excluded after reading the full text. after the second screening, 15 articles are selected for the systematic review. the selection of studies was conducted in accordance with the prisma (preferred reporting items for systematic review) guidelines. the idea when writing this systematic review is that our consciousness of the increase in social media use is directly proportional with the disturbed psychological well-being of the social media user. results the result identified 15 articles that were eligible to be included in the systematic review. fifteen studies were selected. there were 3 articles that discussed about mental health and psychological well-being. they concluded that average daily screen time and psychopathy were positively associated with social media addiction. every additional hour of screen time was associated with an increased risk of poor psychosocial well-being. in terms of gender, females appeared to be more prone to being addicted to social media. indeed, there was evidence showing that the excessive use of social media is more common in females than males. as many as 6 articles were selected, thus it can be concluded that there was an association between social media dependence and depressive symptoms. excessive social media use leads to anxious behavior. as many as 2 articles that we selected showed that maltreatment during childhood on problematic social media use was mediated through anxious attachment. interactions between loneliness and excessive gambling were positively significant and correlated with compulsive internet use. other problematic social media use includes the narcissistic tendency for acquiring attention and validation, in addition to cyberbullying and body dissatisfaction. an article that we selected about narcissistic tendencies showed that the relationship between narcissism and psmu was fully mediated by cyberstalking among women, while cyberbullying and cyberstalking fully explained the association between machiavellianism and psmu among men. girls endorse some appearance concerns and social comparison, particularly with their peers. discussion the results of this systematic review show that the average daily screen time is positively associated with social media addiction, with such an excessive use manifested by being consumed by social media, increasing the use to gain pleasure from it, using jurnal ners http://e-journal.unair.ac.id/jners | 215 social media to trigger positive alterations in their emotional states, failure in terms of attempts to control themselves, experiencing distress if unable to use social media, and neglecting other important aspects of life due to its use (chung kl, et al, 2018). compulsive media use significantly triggers social media fatigue, which later results in elevated anxiety and depression. compulsive use behavior refers to an abnormality in controlling behavioral consumptions where an individual is unable to rationally manage his/her routine performances (dhir a, et al, 2018). anxiety includes the effects of entertainment and social interaction motivations in excessive smartphone use. people with high anxiety are more likely to use smartphones to protect themselves from their negative feelings, which may lead to a higher degree of problematic outcomes, indicating that the effect of the motivation related to excessive smartphone use depends on the level of the user’s psychological well-being (shen x, et al. 2019). narcissism is one personality factor that might be connected to the excessive or problematic use of social media and smartphones. there is a study that showed that narcissism is repeatedly reflected in their social media behavior such as being positively linked to having more friends on social networking sites, spending more time on social media and more frequently posting selfies, status updates and selfpromotional content (hawk st, et al, 2019). excessive social media use is associated with changes in the brain, including deficits in interhemispheric connection and in the communication along the ventral semantic path. excessive social media use can observable in terms of the imbalance between the reward and inhibition brain systems, which results in impaired decision making such that a person emphasizes short-term reinforcing rewards over larger long-term utilitarian rewards (he q, turel o, bechara a, 2018). previous studies have concluded that the relationship between facebook use and depressive symptoms is curvilinear. for the different levels of facebook use, the depressive symptoms may differ in terms of direction. this may be a reflection of the different kinds of user interactions possible on facebook. for example, if the users are actively using facebook to keep in contact with their friends, then they could have lower depressive symptoms than someone who uses facebook to simply view other’s profiles (nisar tm, et al. 2019). the internet provides for the formation of online gambling subcultures and the identity generation therein. it is relatively easy to find others who share similar gambling interests and values through the internet (sirola a et al, 2019). experiencing addiction-related symptoms in the context of technology use can be stressful. short-term abstinence from social media use leads to a reduction in stress. the research by turel (2018) supports the hypothesis that was tested with absolute stress reduction, although the results for relative stress reduction were inconclusive. this suggests that temporarily quitting social networking can be rewarding in terms of absolute stress reduction. a short abstinence from online networking suggests that if people with strong sns addiction-like symptomatology can be convinced to abstain from social media use, then they may have much to benefit from in terms of stress reduction (turel o, cavagnaro dr, meshi d, 2018). conclusion excessive social media use can leads to problematic social media use, which can causes impaired mental health such as anxiety and social media fatigue heading to depressive symptoms. references baccarella, c. v., wagner, t. f., kietzmann, j. h., & mccarthy, i. p. (2018). social media? it’s serious! understanding the dark side of social media. european management journal, 36(4), 431–438. https://doi.org/10.1016/j.emj.2018.07.002 chung, k. l., morshidi, i., yoong, l. c., & thian, k. n. (2019). the role of the dark tetrad and impulsivity in social media addiction: findings from malaysia. personality and individual differences, 143(february), 62–67. https://doi.org/10.1016/j.paid.2019.02.016 dhir, a., yossatorn, y., kaur, p., & chen, s. (2018). online social media fatigue and psychological wellbeing—a study of compulsive use, fear of missing out, fatigue, anxiety and depression. international journal of information management, 40(february), 141–152. https://doi.org/10.1016/j.ijinfomgt.2018.01.012 hawi, n., & samaha, m. (2019). identifying commonalities and differences in personality characteristics of internet and social media addiction profiles: traits, self-esteem, and selfconstrual. behaviour and information technology, 38(2), 110–119. https://doi.org/10.1080/0144929x.2018.15159 84 hawk, s. t., van den eijnden, r. j. j. m., van lissa, c. j., & ter bogt, t. f. m. (2019). narcissistic adolescents’ attention-seeking following social rejection: links with social media disclosure, problematic social media use, and smartphone stress. computers in human behavior, 92(october 2018), 65–75. https://doi.org/10.1016/j.chb.2018.10.032 he, q., turel, o., & bechara, a. (2018). association of excessive social media use with abnormal white matter integrity of the corpus callosum. psychiatry research neuroimaging, 278(january), 42–47. https://doi.org/10.1016/j.pscychresns.2018.06.0 08 kircaburun, k., jonason, p. k., & griffiths, m. d. (2018). the dark tetrad traits and problematic social media use: the mediating role of cyberbullying and cyberstalking. personality and individual differences, 135(july), 264–269. a. rahmawati, et al. 216 | pissn: 1858-3598  eissn: 2502-5791 https://doi.org/10.1016/j.paid.2018.07.034 nisar, t. m., prabhakar, g., ilavarasan, p. v., & baabdullah, a. m. (2019). facebook usage and mental health: an empirical study of role of nondirectional social comparisons in the uk. international journal of information management, 48(september 2018), 53–62. https://doi.org/10.1016/j.ijinfomgt.2019.01.017 shen, x., wang, h. z., rost, d. h., gaskin, j., & wang, j. l. (2019). state anxiety moderates the association between motivations and excessive smartphone use. current psychology. https://doi.org/10.1007/s12144-019-0127-5 sirola, a., kaakinen, m., savolainen, i., & oksanen, a. (2019). loneliness and online gamblingcommunity participation of young social media users. computers in human behavior, 95(july 2018), 136–145. https://doi.org/10.1016/j.chb.2019.01.023 turel, o., cavagnaro, d. r., & meshi, d. (2018). short abstinence from online social networking sites reduces perceived stress, especially in excessive users. psychiatry research, 270(november), 947– 953. https://doi.org/10.1016/j.psychres.2018.11.017 88 psycoeducative family therapy mempengaruhi pengetahuan, dukungan keluarga dan stigma kusta psycoeducative family therapy influence of knowledge, family support and leprosy stigma mega arianti putri*, harmayetty*, budi utomo** fakultas keperawatan-universitas airlangga kampus c mulyorejo surabaya 60115, fakultas kedokteran universitas airlangga email: arianti.mega89@gmail.com abstrak pendahuluan: seseorang dengan kusta mengalami kecacatan dan lesi yang disebabkan oleh kerusakan persyarafan. tanpa pengobatan, kusta secara permanen dapat merusak kulit, kaki dan mata. data menunjukkan bahwa stigma sosial pasien kusta mengakar di masyarakat. hal ini berupa sikap dan kayakinan yang negatif terhadap pasien kusta. stigma negatif terhadap kusta tidak hanya terhadap individu yang terkena tetapi juga anggota keluarga mereka. tujuan penelitian ini adalah untuk menganalisis pengaruh psycoeducative family therapy terhadap pengetahuan, dukungan keluarga dan stigma kusta. metode: desain penelitian ini adalah quasy experiment. sampel kelompok intervensi dan kelompok pembanding masing-masing 30 responden. sampel terdiri dari responden dan keluarga responden. teknik pengambilan sampel menggunakan purposive sampling. instrumen penelitian yang digunakan adalah dengan menggunakan kuesioner. hasil: hasil penelitian menunjukkan bahwa tidak hanya psychoeducative keluarga berpengaruh terhadap pengetahuan, dukungan keluarga dan stigma diri. faktor lain adalah karakteristik keluarga dan karakteristik responden. hasil statistik menunjukkan bahwa hubungan yang signifikan antara psychoeducative keluarga dengan pengetahuan (p = 0,000), dukungan keluarga (p = 0,000) dan stigma kusta (p = 0,004). diskusi: tingkat pengetahuan, dukungan keluarga dan stigma diri memiliki hubungan satu sama lain. keluarga yang memiliki pengetahuan kurang tentang kusta akan berpengaruh terhadap dukungan yang diberikan pada pasien kusta. penderita kusta yang memiliki stigma diri yang tinggi disebabkan oleh kurangnya pengetahuan dan mereka merasa ada tidak simpati, perhatian dan dukungan dari keluarga mereka. kata kunci: kusta, psychoeducative keluarga, self-stigma abstract introduction: a person with leprosy present disability and lesions caused by related nerve damage. without treatment leprosy can permanently damage skin, feet and eyes. leprosy-related documents show that stigma is typically a very deep rooted social process. it refers to unfavourable attitudes and beliefs directed toward someone or something. the stigma against leprosy not only burdens the affected individuals but also their family members. this research aims was to analyze the influence of family on knowledge psychoeducative intervention, family support and the self stigma. method: the design was a quasy experiment. the samples were the intervention and the comparison group each of 30 respondents. the sample consisted of respondent and respondent's family. sampling technique is using purposive sampling. the research instrument was a questionnaire used by researchers. result: the result showed that not only psychoeducative family influence level of knowledge, support family and self stigma. the other factor are family characteristics and respondent characteristics. the statistical result shown that a significant relationship between psychoeducative family with knowledge (p=0,000), family support (p=0,000) and the stigma of leprosy (p=0,004). discussion: level of knowledge, family support and self stigma have relations to each other. families who have less knowledge about leprosy will influence to be given family support. leprosy patients who have high self stigma caused by lack of knowledge and they feel there have not symphaty, attention and support from their families. keywords: leprosy, psychoeducative family, self-stigma ____________________________________________________________________________________________________ pendahuluan kusta adalah infeksi kronis pada kulit dan saraf tepi yang disebabkan oleh mycobacterium leprae. klien kusta mengalami cacat tubuh , kulit, kaki, tangan dan jari-jari karena hilangnya pelindung sensasi nyeri (roosta, black 2013). lesi kulit yang progresif dan cacat fisik yang permanen memicu isolasi secara fisik dan psikologis pada klien kusta (tsutsumi,a, izutsu, t, islam, a, amed, j,nakahar,s, takagi, f& wakai 2014). hal tersebut akan memberikan kesan negatif pada klien kusta. kesan negatif yang diterima klien kusta berlangsung seumur hidup bahkan setelah klien sembuh. klien kusta diperlakukan seperti orang buangan di masyarakat karena kusta dianggap sebuah penyakit yang menakutkan atau dengan kata lain menjijikkan dan memalukan (rafferty 2005). stigma diri pasien maupun stigma masyarakat membuat klien kusta tidak berada pada sebuah posisi untuk menjalankan peran dan kewajiban yang mereka harapkan didalam jurnal ners vol. 11 no. 1 april 2016: 88-98 89 lingkungan sosial dan keluarga (koparty, 1998). stigma pada klien kusta seperti ini tentu mempengaruhi pemahaman penyakit dan penerimaan diri bagi klien kusta (rafferty 2005). para peneliti menunjukkan bahwa stigma kusta berpengaruh luas pada kehidupan klien mulai dari perkawinan, pekerjaan, hubungan antar pribadi serta hubungan dengan lingkungan (brakel 2003). hasil penelitian menunjukkan bahwa dari 140 klien kusta 87,9% dikucilkan oleh keluarga. pengalaman klien kusta juga menunjukkan adanya perilaku yang menyakitkan dari keluarga (85%) (tsutsumi,a., et, al 2014). penemuan kasus menunjukkan bahwa satu dari tiga klien kusta ditinggalkan oleh pasangannya (smith, d. 2000). pada penelitian koparty (1998) menjelaskan bahwa seorang suami yang menderita kusta dengan lesi di kaki dan tangan diberikan tempat tersendiri didalam rumah, tidak diikutkan didalam pengambilan keputusan dan kegiatan didalam keluarga serta interaksi dengan anggota keluarga yang lain dibatasi. kecacatan pada klien kusta menjadikan suatu penghambat dalam penerimaan klien kusta. klien kusta yang mengalami cacat sebanyak 70% dikucilkan dan tidak diterima didalam keluarga (koparty, 1998). masalah kesehatan mental pada klien kusta telah terbukti menunjukkan prevalensi yang lebih tinggi dari masalah kejiwaan (tsutsumi et., al 2014). penelitian yang dilakukan pada 77 klien kusta menunjukkan 90,9% mengalami kecemasan dan 58,4% kehilangan harga diri (ajibade et al. 2013). hasil penelitian thilakavathi menunjukkan 55 dari 72 klien kusta memiliki penerimaan diri yang buruk (thilakavati, s, manickam, p & mahendale 2012). d a t a y a n g d i d a p a t k a n d a r i s t u d i pendahuluan yang dilakukan di kabupaten madiun angka kejadian kusta baru cukup tinggi. klien kusta di kabupaten madiun pada saat ditemukan sudah dalam keadaan cacat (dinkes, 2015). 4 dari 6 klien kusta mengalami penerimaan diri yang kurang baik. klien merasakan kehilangan peran didalam keluarga karena kusta yang diderita. angka kecacatan klien kusta yang tinggi di kabupaten madiun disebabkan karena perasaan takut, malu karena stigm a k ust a d im as ya ra kat, kur an gn y a pengetahuan, kesadaran diri, dan kepedulian keluarga terhadap anggota keluarga yang sakit. klien kusta cenderung mengurung diri dirumah karena merasa malu dan tidak memiliki harga diri dimasyarakat. dukungan keluarga yang didapatkan klien kusta cenderung kurang. penelitian (andayani 2006) bahwa keluarga yang merawat anggota keluarga dengan penyakit kusta merasakan beban baik secara psikologis mengenai pandangan masyarakat dan beban fisik karena pengobatan klien kusta memakan waktu hingga berbulan-bulan. klien kusta merasa bahwa keluarga kurang dapat memberikan dukungan baik secara fisik maupun psikologis. keluarga tidak bisa memberikan penguatan bagi klien untuk menghadapi masalahnya (rahayu, d. 2011). ilmu keperawatan sudah banyak mengembangkan penanganan klien dengan masalah psikologi yang disebabkan oleh beberapa penyakit melalui pendekatan kepada keluarga. komunikasi atau interaksi yang baik didalam keluarga dapat membantu mengurangi masalah psikologi yang dialami klien. hasil penelitian (clausson & berg 2008) menjelaskan bahwa dengan menggunakan pendekatan teori calgary yaitu calgary family assessment model (cfam) dan calgary family intervention model (cfim) memberikan dampak perubahan perilaku didalam keluarga dalam menjalankan fungsi keluarga dalam merawat anggota keluarga dengan keluhan kesehatan. penelitian tersebut dilakukan pada sekolah anak dengan gangguan mental. penelitian dengan pendekatan calgary juga dilakukan fráguas & soares (2007) dalam menangani koping keluarga pada klien diabetic nephropathy. penelitian ini menunjukkan hasil bahwa setiap keluarga memiliki sumber daya untuk mengurus anggotanya yang dihadapkan dengan masalah kesehatan. pemerintah telah melakukan upaya dan pengembangan program dalam penanganan penyakit kusta sejak tahun 1950 dengan berbagai kebijakan diantaranya kegiatan pengendalian kusta yang terintegrasi dalam pelayanan kesehatan umum, pengobatan tersedia secara gratis, regimen terapi mengikuti rekomendasi who, orang yang terkena kusta tidak boleh diisolasi sampai pemberian kredit mikro pada klien kusta. program pemerintah tersebut bertujuan untuk memberantas penyakit kusta dan meminimalisasi dampak psikososial yang dialami klien kusta. program dari pemerintah sudah dilaksanakan namun stigma masih terus melekat pada klien kusta (pppl 2014). data yang didapatkan menunjukkan bahwa pemerintah kabupaten madiun khususnya wilayah kerja puskesmas balerejo juga telah melaksanakan berbagai kegiatan yang bertujuan untuk mengurangi stigma kusta dimasyarakat. kegiatan tersebut meliputi pencegahan kecacatan psychoeducative family therapy (mega arianti putri, dkk.) 90 dengan pelatihan perawatan diri klien kusta dan penyuluhan pada masyarakat serta psikoedukasi keluarga klien kusta namun klien masih memiliki perasaan merasa malu dan tidak memiliki harga diri dimasyarakat. berdasarkan latar belakang tersebut peneliti tertarik untuk memberikan alternatif solusi untuk mengoptimalkan dukungan adalah dengan menggunakan psychoeducative family therapy. psychoeducative family therapy berarti memfasilitasi struktur lokal sosial (keluarga, kelompok, dan komunitas) yang kemungkinan sudah tidak berfungsi lagi sehingga dapat kembali memberikan dukungan yang efektif kepada orang yang membutuhkan terkait pengalaman hidup yang membuat stress klien kusta dalam mengurangi stigma kusta dengan metode pendekatan calgary. bahan dan metode jenis penelitian yang digunakan dalam penelitian ini adalah quasy experiment. penelitian dilakukan di puskesmas balerejo kabupaten madiun pada 30 maret sampai dengan 4 mei 2015. populasi dalam penelitian ini adalah semua klien kusta dan keluarga keluarga yang berada pada wilayah kerja puskesmas balerejo kabupaten madiun pada 3 tahun terakhir (2012-2014). teknik sampling yang digunakan adalah purposive sampling dengan kriteria inklusi yaitu klien berusia 20-50 tahun dengan minimal pendidikan terakhir sd dengan jenis kusta mb dan cacat tipe 2, menderita penyakit kusta lebih dari 1 tahun, tidak memiliki penyakit lain atau komplikasi, bisa diajak berkomunikasi, klien kusta yang berdomisili di wilayah kerja puskesmas balerejo dan tinggal satu rumah bersama keluarga. sampel yang didapat sebesar 60 responden yang dibagi kedalam dua kelompok yaitu intervensi dan pembanding. jumlah responden pada masing-masing kelompok adalah 30 responden. variabel independen dalam penelitian ini adalah intervensi psycoeducative family. sedangkan variabel dependennya adalah pengetahuan, dukungan keluarga dan stigma pada klien kusta. instrument penelitian untuk intervensi psycoeducative family adalah satuan acara kegiatan (sak) dan lembar observasi setiap sesi. pengukuran pengetahuan dan dukungan keluarga menggunakan kuesioner. pengukuran stigma (self stigma) menggunakan internalized stigma of mental illness scale (ismi) yang terdiri dari 28 pertanyaan. kuesioner tersebut telah dimodifikasi oleh peneliti untuk memudahkan subyek penelitian dalam menjawab pertanyaan. uji validitas dilakukan kepada 10 pasien kusta diluar subyek penelitian dengan kriteria inklusi penelitian yang sesuai. nilai r tabel yang digunakan adalah 0,632 dengan signifikansi 5% dan didapatkan hasil bahwa seluruh item pertanyaan dalam penelitian ini valid. uji reliabilitas dilakukan terhadap item pertanyaan yang valid saja. didapatkan nilai cronbach alpha yaitu sebesar 0.964 dibandingkan nilai r tabel 0,7, dengan nilai sebesar ini maka dapat ditarik suatu kesimpulan bahwa item-item pertanyaan adalah reliabel dan memiliki reliabilitas yang tinggi karena memiliki nilai mendekati 1. s e b e l u m d i l a k u k a n i n t e r v e n s i psycoeducative family, 60 responden penelitian yang memenuhi kriteria inklusi dilakukan pretest dengan mengisi kuesioner pengetahuan, dukungan keluarga dan internalized stigma of mental illness scale (ismi) dan dilakukan pengkajian keluarga berdasarkan calgary. setelah itu responden penelitian diberi perlakuan intervensi psycoeducative family selama 5 sesi, masing-masing sesi dilakukan setiap satu minggu sekali. kelompok pembanding tidak diberikan intervensi psycoeducative family. peneliti juga mempersiapkan lembar observasi untuk mengobservasi subyek penelitian pada setiap sesi. setelah 5 minggu (5 sesi) dilakukan intervensi psycoeducative family, responden penelitian diberikan posttest dengan mengisi kuesioner pengetahuan, dukungan keluarga dan internalized stigma of mental illness scale (ismi). statistik deskriptif digunakan untuk mengetahui identitas dan data demografi dari subyek penelitian. uji wilcoxon sign rank digunakan untuk mengetahui perbedaan hasil pretest dan posttest intervensi psycoeducative family. uji man whitney dilakukan untuk mengetahui pengaruh signifikan antar kelompok intervensi dan pembanding. nilai α=0.05 dengan tingkat kepercayaan 95%. hasil sebelum dilakukan intervensi psycoeducative family, mayoritas responden memiliki tingkat pengetahuan cukup pada kelompok intervensi. kelompok pembanding memiliki tingkat pengetahuan yang lebih baik dari kelompok intervensi. tingkat pengetahuan kelompok intervensi lebih baik dibandingkan kelompok pembanding setelah dilakukan intervensi (tabel 1). jurnal ners vol. 11 no. 1 april 2016: 88-98 91 tabel 1. tingkat pengetahuan responden tingkat pengetahuan kelompok intervensi kelompok pembanding pretest posttest pretest posttest baik 8 20 14 20 cukup 17 8 12 7 kurang 5 2 4 3 wilcoxon sign rank test, p=0,001 wilcoxon sign rank test, p=0,01 mann whitney test, p=0,000 . tabel 2. dukungan keluarga responden dukungan keluarga kelompok intervensi kelompok pembanding pretest posttest pretest posttest baik 1 2 0 9 cukup 29 28 30 21 kurang 0 20 0 0 wilcoxon sign rank test, p=0,001 wilcoxon sign rank test, p=0,001 mann whitney test, p=0,000 tabel 3. stigma (self stigma) responden stigma (self stigma) kelompok intervensi kelompok pembanding pretest posttest pretest posttest tinggi 13 4 7 5 cukup 0 0 1 1 rendah 17 26 22 24 wilcoxon sign rank test, p=0,001 wilcoxon sign rank test, p=0,07 mann whitney test, p=0,004 tabel 4. distribusi tingkat pengetahuan keluarga pengetahuan keluarga kelompok intervensi kelompok pembanding pretest posttest pretest posttest baik 15 26 5 23 cukup 12 4 22 6 kurang 3 0 3 1 wilcoxon sign rank test, p=0,001 wilcoxon sign rank test, p=0,001 mann whitney test, p=0,000 mayoritas responden memiliki dukungan keluarga yang cukup sebelum dilakukan intervensi p ad a kelompo k intervensi. k elompok pembanding memiliki dukungan keluarga yang sama dengan kelompok intervensi. dukungan keluarga kelompok intervensi lebih rendah dibandingkan kelompok pembanding setelah dilakukan intervensi (tabel 2). mayoritas responden memiliki tingkat stigma (self stigma) yang rendah pada kelompok intervensi sebelum dilakukan psycoeducative family, sedangkan kelompok pembanding memiliki tingkat stigma (self stigma) tinggi yang lebih rendah dari kelompok intervensi. perubahan tingkat stigma (self stigma) kelompok intervensi lebih baik dibandingkan kelompok pembanding setelah dilakukan intervensi. (tabel 3). tingkat pengetahuan keluarga responden kelompok intervensi lebih baik dari kelompok pembanding sebelum dilakukan intervensi psycoeducative family. tingkat pengetahuan keluarga responden setelah dilakukan intervensi psycoeducative family pada kelompok pemanding lebih baik dari kelompok ientervensi (tabel 4). pembahasan hasil penelitian tingkat pengetahuan responden pada kelompok intervensi sebelum dilakukan intervensi psychoeducative family menunjukkan bahwa sebagian besar masuk kedalam kategori cukup yaitu sejumlah 17 responden. pada sesi pertama didapatkan bahwa sebagian besar responden dan keluarga tidak mengetahui tentang penyakit dan pengobatan penyakit kusta. strategi yang menekankan pada pengetahuan dan pendalaman pengetahuan dilakukan terutama pada sesi kedua. pada sesi pertama didapatkan bahwa sebagian besar responden tidak mengetahui tentang penyebab dan prognosis kusta. strategi yang menekankan pada pengetahuan dan pendalaman pengetahuan dilakukan terutama pada sesi kedua. pada sesi kedua diberikan psikoedukasi tentang kusta, program pengobatan yang harus dijalani oleh pasien dan cara perawatan diri untuk mencegah kecacatan. pengetahuan tentang kusta akan membuat pasien mengerti sehingga termotivasi untuk berusaha kuat untuk sembuh dan mencegah terjadinya kecacatan. t i n g k a t p e n g e t a h u a n r e s p o n d e n meningkat dalam kategori baik yaitu sejumlah 20 responden setelah dilakukan intervensi psychoeducative family. pegetahuan tentang kusta yang paling besar peningkatannya ada pada pengetahuan tentang pengobatan. masih ditemukan 2 responden yang memiliki tingkat pengetahuan yang kurang setelah dilakukan intervensi psychoeducative family. keluarga responden pada kelompok intervensi sebelum dilakukan intervensi psychoeducative family menunjukkan bahwa sebagian besar masuk kedalam kategori baik yaitu sejumlah 15 responden dan setelah dilakukan intervensi psychoeducative family tingkat pengetahuan psychoeducative family therapy (mega arianti putri, dkk.) 92 responden dengan kategori baik meningkat yaitu sejumlah 26 responden. pada sesi pertama didapatkan bahwa sebagian besarkeluarga responden tidak mengetahui tentang penyebab, prognosis dan pengobatan kusta. strategi yang menekankan pada pengetahuan dan pendalaman pengetahuan dilakukan terutama pada sesi kedua. pada sesi kedua diberikan psikoedukasi tentang kusta, program pengobatan yang harus dijalani oleh pasien dan cara perawatan diri pada pasien kusta untuk mencegah kecacatan. pengetahuan tentang kusta akan membuat keluarga mengerti sehingga termotivasi untuk membantu dan mendampingi anggota keluarga dalam mengatasi masalah yang timbul akibat kusta. masih ditemukan 4 responden yang memiliki tingkat pengetahuan yang cukup setelah dilakukan intervensi psychoeducative family. responden pada kelompok intervensi masih memiliki tingkat pengetahuan yang kurang walaupun keluarga responden memiliki tingkat pengetahuan yang baik tentang kusta. rendahnya tingkat pengetahuan responden disebabkan karena 2 responden pada kelompok intervensi memiliki karakteristik yaitu berjenis kelamin perempuan dan berada dalam rentang usia 56-65 tahun dengan tingkat pendidikan smp. pekerjaan responden sebagai irt membuat responden jarang terpapar informasi dengan dunia luar. tipe keluarga extended dengan jumlah anggota keluarga lebih dari 5 orang juga akan mempengaruhi komunikasi dan interaksi antar anggota keluarga responden. pekerjaan keluarga responden sebagai buruh tani juga berpengaruh terhadap interaksi dalam penyampaian informasi dengan aanggota keluarga karena lebih banyak berada diluar rumah dibandingkan didalam rumah. hasil pengkajian juga menunjukkan bahwa komunikasi antara responden dan anggota keluarga lain menunjukkan komunikasi yang maladaptif. tidak adanya perhatian dan dukungan terhadap anggota keluarga yang sakit. keluarga responden kurang memberikan informasi mengenai penyakit yang diderita oleh anggota keluarga. hasil penelitian pada 2 responden tidak sesuai dengan teori psikoedukasi yang menyatakan psikoedukasi yang dilakukan pada keluarga klien akan meningkatkan pengetahuan keluarga tentang kemampuan cara merawat dan kemampuan koping terhadap stress dan beban yang dialami (wiyati 2010). nurhidayah (2010) juga berpendapat bahwa strategi dan metode pendidikan kesehatan untuk meningkatkan pengetahuan dipengaruhi oleh berbagai faktor. hasil penelitian yang tidak sesuai disebabkan karena beberapa hal yang berkaitan dengan karakteritik responden. hasil penelitian diatas ditunjang oleh pernyataan (stuart & laraia 2005) yang menyatakan bahwa pendidikan menjadi suatu tolak ukur kemampuan seseorang dalam berinteraksi dengan orang lain secara efektif. penelitian widianti (2007) juga menyebutkan bahwa seseorang yang berpendidikan lebih tinggi akan mempunyai pengetahuan yang lebih luas dibanding dengan seseorang yang tingkat pendidikannya rendah. pernyataan diatas juga ditunjang dengan pendapat erfandi (2009) yang menyatakan bahwa pengetahuan adalah suatu pembentukan yang terus menerus oleh seseorang yang setiap saat mengalami reorganisasi karena ada pemahaman baru. peningkatan pengetahuan pada keluarga dapat dipengaruhi karena setiap anggota keluarga selalu berinteraksi dengan orang lain, sehingga dimungkinkan melalui interaksi tersebut keluarga mendapatkan pemahamanpemahaman baru. pengetahuan yang menetap atau hanya mengalami kenaikan yang tidak signifikan pada kelompok kontrol dapat dipengaruhi oleh daya ingat seseorang. gagne (1988) dalam information processing learning theory berpendapat bahwa dalam pembelajaran terjadi proses penerimaan informasi, untuk kemudian diolah sehingga menghasilkan keluaran dalam bentuk hasil belajar. pemrosesan informasi melalui interaksi antara kondisi internal dan kondisi eksternal individu. untuk mengingat sesuatu manusia harus melakukan 3 hal yaitu mendapatkan informasi, menyimpannya dan m engeluarkan kembali. nasrun (2007) menyatakan bahwa ingat an seseorang dipengaruhi oleh tingkat perhatian, minat, daya konsentrasi, emosi dan kelelahan. pada aplikasi psychoeducative family therapy terdapat beberapa hal yang dapat mengganggu tingkat konsentrasi keluarga dalam mempelajari kusta, diantaranya adalah ketika anak rewel, keluarga dalam kondisi lelah dan kondisi emosionalnya yang tidak stabil. hal ini sejalan dengan jensen & markowitz (2002) bahwa kinerja ingatan secara keseluruhan bisa berada dalam retang kondisi baik ataupun buruk, tergantung pada keadaan fisik dan emosi. hasil penelitian yang menunjukkan usia responden berada pada rentang usia 56-65 jurnal ners vol. 11 no. 1 april 2016: 88-98 93 tahun tidak sesuai dengan teori yang dikemukakan wong (1995) dalam (potter, p.a, perry 2005) yang menjelaskan bahwa usia mampu menujukkan kemampuan belajar dan perilaku seseorang. edelman dan manle (1994) dalam (potter, p.a, perry 2005) menjelaskan bahwa kemampuan kognitif dan kemampuan perilaku sangat dipengaruhi oleh tahap perkembangan usia seseorang. jumlah anggota keluarga yang terlalu banyak dan pekerjaan yang memerlukan banyak waktu diluar rumah akan mempengaruhi pola komunikasi dan interaksi dalam keluarga sehingga penyampaian informasi juga tidak berjalan dengan baik. hasil penelitian diatas ditunjang dengan pernyataan wahidah (2010) yang menjelaskan bahwa dengan komunikasi didalam keluarga seseorang dapat menyampaikan informasi, ide pemikiran, pengetahuan konsep kepada anggota keluarga lain secara timbal balik, baik sebagai penyampai maupun sebagai penerima komunikasi. fungsi komunikasi yang berjalan dalam keluarga akan menghasilkan komunikasi yang efektif didalam keluarga. (notoadmodjo 2010) menjelaskan bahwa pengetahuan juga dipengaruhi oleh faktor penghasilan walaupun tidak secara langsung, jika seseorang berpenghasilan cukup maka akan mampu untuk menyediakan atau membeli fasilitas sumber informasi. hasil penelitian tingkat pengetahuan responden pada kelompok pembanding terdapat 6 responden yang mengalami peningkatan dan 24 responden tidak mengalami peningkatan. tingkat pengetahuan keluarga responden pada kelompok pembanding yang mengalami peningkatan sebanyak 18 responden. responden pada kelompok pembanding dengan tingkat pengetahuan yang baik tanpa diberikan intervensi psikoedukasi disebabkan karena sebagian besar berjenis kelamin perempuan dan berada dalam rentang usia 4655 tahun dengan tingkat pendidikan sma. responden sebagian besar tidak bekerja. status pernikahan responden adalah cerai dan janda. status pernikahan responden yang cerai dan janda mengatakan bahwa mereka sudah tidak memiliki tanggungan dirumah sehingga sering mengisi waktu luang untuk berobat ke puskesmas dan mengikuti paguyuban kusta. responden mengalami sakit selama lebih dari 3 tahun sehingga memiliki banyak pengalaman mengenai perawatan kusta dan pengetahuan mengenai kusta. tingkat pengetahuan responden yang baik juga ditunjang dengan tingkat pengetahuan keluarga responden yang baik dan keluarga responden memiliki pendidikan terakhir sma dan sebagian besar memiliki pekerjaan sebagai irt sehingga memiliki banyak waktu dirumah dan intensitas berkomunikasi dengan anggota keluarga lebih banyak. hasil penelitian diatas ditunjang dengan penelitian mahanani (2013) bahwa jenis kelamin berkaitan dengan peran kehidupan dan perilaku yang berbeda antara laki-laki dan perempuan dalam masyarakat. nurhidayah (2010) berpendapat bahwa pendidikan kesehatan sangat dipengaruhi oleh motivasi individu untuk berubah, kemampuan untuk mendapatkan pendidikan kesehatan tergantung pada faktor fisik dan kognitif, tingkat perkembangan dan proses berfikir intelektual. hersey& blanchard, 1997 dalam endah, (2003) menyatakan bahwa dalam teori berubah perubahan yang paling mudah adalah pengetahuan. penelitian djaali (2007) juga menyatakan bahwa semakin bertambahnya umur akan semakin berkembangnya daya tangkap dan pola pikirnya, sehingga pengetahuan yang yang diperolehnya semakin baik. dalam menjaga kesehatan biasanya kaum perempuan lebih menjaga kesehatannya dibanding laki-laki. notoadmodjo (2010) yang menyatakan bahwa tingkat pengetahuan seseorang dipengaruhi oleh beberapa hal diantaranya adalah pengalaman, tingkat pendidikan dan fasilitas. pengalaman berkaitan dengan usia dan tingkat pendidikan seseorang, yang berarti pendidikan yang tinggi akan mempunyai pengalaman yang lebih luas demikian juga dengan umur yang semakin bertambah maka pengalaman seseorang juga bertambah. pendidikan dapat membawa wawasan atau pengetahuan seseorang, secara umum seseorang yang berpendidikan lebih tinggi akan mempunyai pengetahuan lebih luas dibandingkan dengan seseorang yang tingkat pendidikannya lebih rendah. fasilitas-fasilitas sebagai sumber informasi dapat mempengaruhi pengetahuan seseorang seperti televisi, radio, leaflet dan sebagainya. pernyataan sadiman (2008) juga mengemukakan bahwa status pendidikan mempengaruhi kesempatan memperoleh informasi mengenai penatalaksanaan penyakit. penelitian mahanani (2013) juga menjelaskan bahwa tingkat pendidikan secara signifikan mempengaruhi tingkat pengetahuan tentang penyakit, sehingga mempengaruhi pola respon. perbedaan tingkat pendidikan mempengaruhi tingkat pengetahuan seseoarang dan kemampuan dalam menerima informasi baru. psychoeducative family therapy (mega arianti putri, dkk.) 94 pendidikan seseorang merupakan salah satu proses perubahan tingkah laku, semakin tinggi pendidikan seseorang maka dalam memilih tempat pelayanan kesehatan semakin diperhitungkan. hasil penelitian dukungan keluarga responden pada kelompok intervensi sebelum dilakukan intervensi psychoeducative family menunjukkan bahwa sebagian besar masuk kedalam kategori cukup yaitu sejumlah 29 responden dan setelah dilakukan intervensi psychoeducative family dukungan keluarga responden meningkat dalam kategori baik yaitu sejumlah 2 responden. dukungan keluarga yang didapatkan sebagian besar responden adalah cukup sejumlah 28 responden setelah dilakukan intervensi psychoeducative family. pada sesi pertama ditemukan masalah berupa keluarga kurang memperhatikan responden. keluarga responden saat dilakukan pengkajian merasa sudah bosan dan lelah dengan anggota keluarga yang menderita kusta dan tidak kunjung sembuh walaupun sudah dilakukan pengobatan. keluarga responden sebagian besar hanya memberikan dukungan secara informasional dari 4 komponen dukungan keluarga. dukungan yang paling rendah diberikan adalah dukungan emosional dan instrumental. pada pelaksanaan psychoeducative family therapy, terutama pada sesi tiga dan empat yaitu manajemen stress keluarga dan manajemen beban keluarga, keluarga dapat membagi tugas untuk selalu memberikan dukungan kepada anggota keluarga yang sakit sehingga responden senantiasa dapat terkontrol. dukungan keluarga dapat bersifat internal seperti dukungan dari suami atau istri atau dukungan dari saudara kandung dan dukungan eksternal misalnya dukungan dari sanak keluarga dan masyarakat. keberadaan dukungan keluarga yang adekuat terbukti berhubungan dengan menurunnya mortalitas, lebih mudah sembuh dari sakit, dan dikalangan kaum tua, fungsi kognitif, fisik dan kesehatan emosional. pengaruh positif dari dukungan ini akan dapat mudah menyesuaikan terhadap kejadian dalam kehidupan (friedman 2010). faktor yang dapat mempengaruhi dukungan keluarga meliputi beberapa hal antara lain faktor internal. faktor internal merupakan faktor yang muncul dari diri indvidu tersebut, yaitu emosi berkaitan dengan keadaan psikologis seseorang, dalam hal ini terkait dengan dua jenis dukungan keluarga yaitu dukungan emosional dan harga diri, dan faktor pendidikan dan tingkat pengetahuan berkaitan dengan seberapa besar pengetahuan tentang suatu penyakit. data yang didapatkan juga menunjukkan responden pada kelompok intervensi sebagian besar memiliki dukungan keluarga yang cukup disebabkan karena sebagian besar responden berjenis kelamin perempuan dan berada dalam rentang usia 46-55 tahun dengan tingkat pendidikan smp. pekerjaan responden sebagai irt dengan penghasilan kurang dari 1 juta setiap bulannya. status pernikahan responden adalah menikah. responden mengalami sakit selama lebih dari 3 tahun. dukungan keluarga dalam kategori baik yang masih kurang dibuktikan dengan sebagian besar keluarga responden hanya memberikan dukungan informasional saja tanpa di imbangi dengan dukungan penilaian, instrumental dan emosional. keluarga responden jarang mengantar responden berobat, hanya mengingatkan responden untuk minum obat tanpa mengetahui obat apa saja yang harus diminum. keluarga yang merawat responden sebagian besar berada pada rentang usia 17-25 tahun yang sebagian besar adalah istri responden. hasil wawancara dan pengkajian menunjukkan bahwa keluarga responden yang sebagian besar adalah istri responden merasa terbebani karena responden yang berperan sebagai kepala keluarga semenjak sakit kusta tidak bekerja lagi yaitu lebih dari 3 tahun sehingga istri merasa peran suami dalam perekonomian keluarga tidak terpenuhi. kelas perekonomian keluarga dan tingkat pendidikan juga mempengaruhi dukungan keluarga. bentuk keluarga extended dengan jumlah anggota keluarga lebih dari 5 orang juga mempengaruhi dukungan yang diberikan. hasil penelitian di atas didukung oleh pendapat feiring dan lewis (1984) dalam friedman (2010), ada bukti kuat dari hasil penelitian yang menyatakan bahwa keluarga besar dan keluarga kecil secara kualitatif menggambarkan pengalaman-pengalaman perkembangan yang berarti keluarga kecil dengan anggota keluarga yang berjumlah sedikit lebih mendapatkan perhatian dan dukungan dibandingkan keluarga besar. friedman (1998) dalam friedman (2010) juga menyatakan bahwa anggota keluarga (istri) yang masih muda cenderung untuk lebih tidak bisa merasakan atau mengenali kebutuhan anggota keluarganya dan juga lebih egosentris jurnal ners vol. 11 no. 1 april 2016: 88-98 95 dibandingkan ibu yang lebih tua. faktor yang mempengaruhi dukungan keluarga lainnya adalah kelas ekonomi. dukungan keluarga terhadap anggota keluarga dipengaruhi oleh kemampuan keluarga dalam mencukupi kebutuhan anggota keluarga. kemampuan pemenuhan kebutuhan tersebut berhubungan dengan tingkat pendapatan atau tingkat sosial ekonomi keluarga, dimana keluarga dengan tingkat sosial ekonomi menengah memiliki kemampuan memenuhi kebutuhan keluarga lebih baik dibandingkan keluarga dengan tingkat sosial ekonomi rendah. pernyataan di atas sesuai dengan fakta yang ditemukan didalam hasil penelitian yaitu sebagian besar keluarga responden memiliki penghasilan yang rendah yaitu kurang dari satu juta rupiah per bulannya dengan status kepala keluarga yang tidak bekerja karena menderita kusta. pernyataan di atas juga ditunjang oleh pendapat ariyanta (2013) yang menyatakan bahwa dukungan yang diberikan oleh keluarga dipengaruhi oleh beberapa faktor seperti tingkat pendidikan seseorang, tingkat ekonomi. hasil penelitian yang didapatkan tidak sesuai dengan hasil penelitian zulfitri (2006) yang menemukan tingginya dukungan keluarga mayoritas diberikan oleh perempuan sebesar 64,6%. zulfitri membahas bahwa perempuan dan laki-laki memiliki respon yang berbeda dalam menghadapi masalah, laki-laki cenderung tidak perduli, tidak memperhatikan kesehatan sedangkan perempuan lebih banyak ditemukan untuk memeriksakan kesehatannya. hasil penelitian dekungan keluarga responden pada kelompok pembanding mengalami peningkatan sejumlah 9 responden. kelompok pembanding menunjukkan dukungan keluarga yang lebih baik dari kelompok intervensi disebabkan karena responden sebagian besar berjenis kelamin perempuan dan berada dalam rentang usia 46-55 tahun dengan tingkat pendidikan sma. responden sebagian besar tidak bekerja dengan penghasilan kurang dari 1 juta setiap bulannya. status pernikahan responden adalah cerai dan janda. responden mengalami sakit selama lebih dari 3 tahun. keluarga responden yang memiliki tingkat pengetahuan baik sebagian besar berjenis kelamin perempuan dengan rentang usia 36-45 tahun. seluruh keluarga responden memiliki pendidikan terakhir sma dan sebagian besar memiliki pekerjaan sebagai irt. hubungan keluarga dengan responden sebagian besar adalah sebagai istri dari responden. hasil penelitian ditunjang dengan hasil penelitain zulfitri (2006) yang menemukan tingginya dukungan keluarga mayoritas diberikan oleh perempuan sebesar 64,6%. zulfitri membahas bahwa perempuan dan laki-laki memiliki respon yang berbeda dalam menghadapi masalah, laki-laki cenderung tidak perduli, tidak memperhatikan kesehatan sedangkan perempuan lebih banyak ditemukan untuk memeriksakan kesehatannya. jenis pekerjaan juga secara umum akan berpengaruh dalam pemberian dukungan keluarga, baik dukungan emosional, dukungan informasi, dukungan instrumental dan dukungan penilaian dalam merawat anggota keluarga dengan masalah kesehatan, keluarga yang tidak bekerja tentunya mempunyai waktu luang yang cukup untuk merawat anggota keluarga dibandingkan dengan keluarga responden yang bekerja. hasil penelitian diatas juga sesuai dengan pernyataan notoadmodjo (2010) yang menjelaskan bahwa usia yang dianggap optimal dalam mengambil keputusan adalah usia yang diatas umur 20 tahun. tingkat pendidikan keluarga responden sebagian besar adalah sma. luecknotte. a. g. (2000) menjelaskan bahwa tingkat pendidikan seseorang dapat mempengaruhi kemampuan untuk menyerap informasi, menyelesaikan masalah, dan berperilaku baik. pendidikan rendah berisiko ketidakmampuan dalam merawat kesehatannya (who 2003). hasil penelitian stigma (self stigma) responden pada kelompok intervensi sebelum dilakukan intervensi psychoeducative family menunjukkan bahwa stigma (self stigma) responden tinggi yaitu sejumlah 13 responden dan setelah dilakukan intervensi psychoeducative family stigma (self stigma) responden menjadi rendah dalam yaitu sejumlah 26 responden. masih ditemukan 4 responden yang memiliki stigma (self stigma) yang tinggi setelah dilakukan intervensi psychoeducative family. responden pada kelompok intervensi dengan tingkat pengetahuan yang kurang berjenis kelamin perempuan dan berada dalam rentang usia 56-65 tahun dengan tingkat pendidikan smp. pekerjaan responden sebagai irt dengan penghasilan kurang dari 1 juta setiap bulannya. empat responden pada kelompok intervensi dengan stigma (self stigma) tinggi masih memiliki tingkat pengetahuan yang kurang dan responden berlatar belakang psychoeducative family therapy (mega arianti putri, dkk.) 96 pendidikan smp. tingkat pengetahuan responden yang kurang menyebabkan responden memiliki persepsi bahwa kusta merupakan penyakit menular dan menimbulkan luka yang menjijikkan sehingga responden merasa malu dan takut dijauhi masyarakat ataupun keluarga. responden yang malu membuat enggan untuk berobat sehingga memperparah keadaan dan responden menjadi cacat. pekerjaan responden sebagai irt membuat responden juga menyebabkan jarang terpapar informasi dengan dunia luar. tipe keluarga extended dengan jumlah anggota keluarga lebih dari 5 orang juga akan mempengaruhi komunikasi dan interaksi antar anggota keluarga responden. pekerjaan keluarga responden sebagai buruh tani juga berpengaruh terhadap interaksi dalam penyampaian informasi dengan aanggota keluarga karena lebih banyak berada diluar rumah dibandingkan didalam rumah. hasil pengkajian juga menunjukkan bahwa menunjukkan bahwa bentuk dukungan keluarga yang diberikan sebatas kebutuhan sehari-hari pasien. keluarga cenderung hanya memberikan motivasi untuk patuh terhadap pengobatan dan mengingatkan jadwal berobat, dan tidak pernah mengantarkan pasien berobat puskesmas dikarenakan harus bekerja. berdasarkan hal tersebut terkadang pasien merasakan kurang mendapatkan perhatian dan dukungan dari anggota keluarganya sendiri. hasil penelitian diatas ditunjang oleh pernyataan mahendra dkk (2006) yang menyatakan bahwa self stigma dipengaruhi oleh beberapa hal yaitu pengetahuan, tingkat pendidikan, dukungan keluarga serta keyakinan atau kepercayaan seseorang. pendapat lain dari susanto (2006) yang menyebutkan bahwa pengetahuan responden mengenai kusta sangat bergantung pada tingkat pendidikan, dimana semakin tinggi tingkat pendidikan sesorang akan mempengaruhi proses atau pola berpikir terhadap sesuatu hal. hasil penelitian stigma (self stigma) responden pada kelompok pembanding menunjukkan penurunan jumlah responden yang memiliki stigma yang tinggi. stigma (self stigma) responden pada kelompok pembanding yang tinggi sejumlah 5 responden disebabkan karena informasi kesehatan yang didapatkan oleh responden baik melalui media cetak ataupun elektronik hanya akan merubah perilaku sasaran agar berperilaku sehat terutama pada aspek kognitif yang meliputi pengetahuan dan pemahaman sasaran, sasaran dari penyuluhan kesehatan adalah individu, keluarga dan masyarakat yang rawan terhadap masalah kesehatan (maulana 2009). pada kelompok intervensi bisa terjadi perubahan tingkat stigma (self stigma) disebabkan karena goldenberg (2004) menyatakan bahwa psikoedukasi adalah terapi yang diberikan untuk memberiakan informasi terhadap keluarga yang mengalami distress, memberikan pendidikan pada mereka untuk meningkatkan ketrampilan, untuk dapat memahami dan meningkatkan koping akibat gangguan kesehatan yang dapat mengakibatkan masalah pada keluarga. meningkatnya koping keluarga dan keterampilan keluarga dalam merawat anggota keluraga yang sakit akan berpengaruh kepada pemahaman kebutuhan anggota keluarga yang sakit dan berdampak pada perhatian serta dukungan keluarga yang akan diberikan dalam merawat anggota keluarga yang sakit. penelitian (lawrence & veronika 2002) menunjukkan hasil terjadi peningkatan 33% pada kelompok klien skizofrenia setelah diberikan terapi psikoedukasi keluarga, karena dalam psikoedukasi keluarga berisi tentang: peningkatan hubungan yang positif antara anggota keluarga, meningkatkan stabilitas keluraga, menajemen stess keluarga, kemampuan motorik keluarga. pernyataan diatas juga ditunjang oleh suny dan win-king (2007) yang menyatakan bahwa terapi psikoedukasi keluarga sangat efektif karena memberikan informasi tentang prefentif dan promotif, ketrampilan koping, kognitif, tingkah laku dan ketrampilan bagi keluarga. simpulan dan saran simpulan intervensi psychoeducative family yang diberikan kepada keluarga penderita kusta di puskesmas balerejo kabupat en madiun memiliki pengaruh yang signifikan terhadap pengetahuan, dukungan keluarga dan stigma (self stigma) kusta. saran intervensi psychoeducative family dapat dijadikan dalam penatalaksanaan komunitas bagi pasien kusta sehingga dapat meningkatkan pengetahuan keluarga tentang kemampuan cara merawat dan kemampuan koping terhadap stress dan beban yang dialami keluarga dan pasien. jurnal ners vol. 11 no. 1 april 2016: 88-98 97 kepustakaan ajibade, b.., okunlade, j.. & olawale, f., 2013. prevalence, management and percieved psychological impact of leprosy disease in national tuberculosis and leprosy training centre, saye village, zaria (2005-2010). journal of pharmacy and biological sciences, 8 (4), pp.9– 12.availableat: ttp://iosrjournals.org/iosrjpbs/papers/vol8issue4/c0840912.pdf?id=7389. andayani, e., 2006. hubungan tingkat kecemaan keluarga tentang penularan penyakit kustadan peran keluarga dalam perawatan penyakit kusta. universitas diponegoro. ariyanta, f., 2013. “hubungan antara dukungan keluarga dengan konsep diri penderita kusta di desa bangklean kabupaten blora,” brakel, w.h. van, 2003. measuring leprosy stigma a preliminary review of the leprosy literature. international jurnal of leprosy and other mycobacterial, 71(3), pp.190–197. clausson, e. & berg, a., 2008. family intervention sessions: one useful way to improve schoolchildren’s mental health. journal of family nursing, 14(3), pp.289–313. available at: http://jfn.sagepub.com/cgi/doi/10.1177/1 074840708322758. djaali, 2007. psikologi pendidikan., . jakarta.: bumi aksara. fráguas, g.s.& s.m., 2007. coping of diabetic nephropathy in the family: an approach in perspective calgary family assessment model. a qualitative study. objn, 6(3). friedman, 2010. buku ajar keperawatan keluarga : riset, teori dan praktek, jakarta: egc. goldenberg, h. goldenberg, i., 2004. family therapy: an overview,. cangage learning. lawrence & & veronika, 2002. understanding families in their own context : schizophrenia and structural family therapy in beijing. jurnal of family therapy. luecknotte. a. g., 2000. gerontologic nursing 2nd ed., missoury,: mosby. mahanani, n., 2013. faktor-faktor yang berhubungan dengan perawatan diri kusta pada penderita kusta di puskesmas kunduran kecamatan blora tahun 2011. universitas negeri semarang. available at: lib.unnes.ac.id/18240/1/6450406030.pdf. maulana, h., 2009. promosi kesehatan, jakarta: egc. notoadmodjo, 2010. pengantar ilmu perilaku kesehatan, jakarta: badan penerbit kesehatan masyarakat fakultas kesehatan masyarakat. universitas indonesia. nurhidayah, 2010. ilmu perilaku dan pendidikan kesehatan untuk perawat, medan: usu press. potter, p.a, perry, a.., 2005. buku ajar fundamental keperawatan : konsep, proses, dan praktik. 4th ed., jakarta: egc. pppl, 2014. kegiatan program ppml ditjen pp dan pl dan hasil yang dicapai tahun 2013. ditjen pengendalian peyakit dan penyehatan lingkungan, depkes ri. available at: pppl.depkes.go.id/berita?id=1250. rafferty, j., 2005. curing the stigma of leprosy. lepr rev, 76, pp.119 – 126. available at: https://www.lepra.org.uk/platforms/lepra/ files/lr/june05/150523.pdf. rahayu, d., a., 2011. pengaruh psikoedukasi keluarga terhadap dukungan psikososial keluarga pada anggota keluarga dengan penyakit kusta di kabupaten pekalongan. universitas indonesia. available at: http://download.portalgaruda.org/article.p hp?article=4463&val=426. roosta, black, ds & r., 2013. a comparison of stigma among patients with leprosy in rural tanzania and urban united states: a role for public health in dermatology. international journal dermato. available at: http://www.ncbi.nlm.nih.gov/pubmed/23 451850. sadiman, 2008. pendidikan kesehatan untuk meningkatkan kepatuhan berobat penderita tb paru di rsu jendral psychoeducative family therapy (mega arianti putri, dkk.) 98 a.yani. universitas gajah mada. smith, d., s., 2000. the psychosocial needs of leprosy patients. leprosy review, 71. stuart & laraia, 2005. buku saku keperawatan jiwa 5th ed., jakarta: egc. thilakavati, s, manickam, p & mahendale, s., 2012. awareness, social acceptance and community views on leprosy and its relevance for leprosy control, t amil nadu. indian j lepr, 84, pp.233–240. tsutsumi,a, izutsu, t, islam, a, amed, j,nakahar,s, takagi, f& wakai, h., 2014. depresive status of leprosy patients in bangladesh : association with selfperception of stigma. jurnal of leprosy, (1), pp.1–5. available at: www.lepra.org.uk/platforms/lepra/files/ir /mar04/lep57_56. wahidah, f., 2010. faktor-faktor yang berhubungan dengan praktik ibu dalam memberikan makanan pendamping asi pada bayi usia 0-4 bulan di desa gubug, semarang. available at: digilib.unimus.ac.id/files/disk1/121/jtptun imus-gdl-murtipurna-6002-4.pdf. who, 2003. evidance and health information. available at: www.who.int. widianti, e., 2007. remaja dan permasalahannya : bahaya merokok, penyimpangan seks pada remaja dan bahaya penyalahgunaan minuman keras atau narkoba. available at: elib.unikom.ac.id/files/disk1/461/jbptunikomp b-gdl-frianindra-23005-8-daftarp-a.pdf. wiyati, r., 2010. pengaruh psikoedukasi keluarga terhadap kemampuan keluarga dalam merawat klien isolasi sosial. jurnal keperawatan soedirman, 5 (2). zulfitri, r., 2006. hubungan dukungan keluarga dengan perilaku lanjut usia hipertensi dalam mengontrol kesehatannya di wilayah kerja puskesmas melur pekanbaru. universitas indonesia. available at: www.digilib.ui.ac.id/file?file=pdf/ab strak-95790.pdf. http://e-journal.unair.ac.id/jners | 1 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16933 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of blended learning on nursing students’ knowledge ni gusti ayu eka , grace solely houghty and juniarta faculty of nursing, universitas pelita harapan, tangerang, indonesia abstract introduction: blended learning is assumed to improve the students’ understanding of learning at nursing school especially in the current industrial revolution 4.0 era. the combination of classroom and online activities is expected to provide better study outcomes. this research aimed to compare the knowledge scores of the nursing students in blended learning concerning a research and statistics course at a private faculty of nursing. methods: the knowledge scores resulted from the student’s score in their mid and final examinations (0-100). a total of 474 respondents who were third year students involved in the study. this study applied a preexperimental design. due to the data having a significant non-normal value (p value < 0.001), this study further compared the mean-rank of the students’ score using a wilcoxon test analysis. results: the results of this study revealed that there was a significant difference (p value < 0.0001) between the students’ score in the mid (median 72.5; sd 9.82) and final exam examinations (median 86.66; sd 4.75). this means that the students had a better score in their final exam. conclusion: applying a blended learning method was a positive experience for the nursing students in terms of knowledge. it is needed to explore the students’ understanding and interest in their learning process using blended learning. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords blended learning; nursing; student; knowledge contact ni gusti ayu eka  gusti.eka@uph.edu  faculty of nursing, universitas pelita harapan, tangerang, indonesia cite this as: eka, n. g, a., houghty, g., & juniarta. (2019). the effect of blended learning on nursing students’ knowledge. jurnal ners, 14(3si), 1-4. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16933 introduction today’s era of the fourth industrial revolution where human and technology are connected has had impact on all sectors, including the health system and higher education (wef & schwab, 2017). regarding higher education, the current era is also known as higher education 4.0 (he 4.0). the he 4.0 requires changing skills in the industry which demands a learning system alteration in the universities (jhingan, 2017). universities should provide comprehensive resources based on technology that supports the students’ development related to problem solving and decision-making skills in order to follow along with the globalization of education(muawiyah, yamtinah, & indriyanti, 2018). the method of teaching also changes due to the current era, which it is important to consider regarding the instruments to aid the education process such as devices for supporting the teaching and learning process, such as massive open online courses (moocs) applications and using of blended learning (xing & marwala, 2017). the term “blended learning” is argued as being a new term in relation to the era of he 4.0 (wright, 2017). blended learning is a combination of face-toface traditional learning and online learning methods which suits the students by using various multimedia(dziuban, graham, moskal, norberg, & sicilia, 2018; wright, 2017). a previous study reported that 35% of courses in higher education are using a blended learning design and that 12% of 12.2 million online teaching materials are included in the blended courses (dziuban et al., 2018). blended learning could improve the clinical competencies of health students as reported by rowe and their colleagues (rowe et al., 2012) using a systematic review. mccutcheon and their colleagues (mccutcheon, lohan, & traynor, 2016) further claimed in their systematic review study that there is https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). n. g. a. eka et al. 2 | pissn: 1858-3598  eissn: 2502-5791 a minimum evaluation of blended learning needed in nursing education. both of these systematic reviews were limited to some areas of health education and there is no study in regard to blended learning effectiveness in health professions using a quantitative synthesis. to fill in these gaps, liu and their colleagues (shang & liu, 2018) conducted a systematic review to identify the effectiveness of blended learning for health professionals. liu’s study also compared blended learning with non-blended learning. liu’s study concluded that blended learning could have a positive effect in comparison with no intervention. blended learning was also more effective than non-blended learning for knowledge achievement in health professions. however, due to the enormous heterogeneity of the chosen studies in liu’s study, the above conclusion should be interpreted with caution. to become involved in the era of he 4.0, the faculty of nursing (fon) in universitas pelita harapan (uph) tangerang, supported by the directorate of higher education in indonesia that known as dikti, developed a blended course called research and statistics (rs). this course is one of the mandatory nursing courses for students in their third year at fon uph. the rs course is designed to encourage the students to understand the interrelationship between theory, research, and practice based on scientific evidence in the development of nursing knowledge and in the improvements in the quality of the nursing services. students are given the opportunity to develop an understanding of the stages of the research process, to gain knowledge, to apply critical thinking skills in research within the scope of nursing, and to apply skills in the development of research in an ethical way. in order for the course to be sustainable learning, a number of appropriate assessments are required in the blended learning design. the rs course provides four main assessments including a weekly quiz, mid-term exam, critique paper and final exam. however, in this study, we only compared the students’ scores between the mid and final exams. the reason for this is that both scores assessed the students’ knowledge in an equal time span (half semester). to pass the course, the students should get 70 or a bfor their final score. this study aims to compare the knowledge scores of the nursing students in the blended learning of their research and statistics course at fon uph. materials and methods blended learning was applied using a learning management system (lms), moodle, provided by the universitas pelita harapan website (http://learn.uph.edu/). the lms provides online course management, in this case, a research and statistics course which contains learning sources such as the course outline, videos, articles and assessments. the participants were the third-year students at the faculty of nursing in universitas pelita harapan. there were 474 students registered on the research and statistics course. thus, the respondents of this study were all of the students who were involved in the teaching-learning of the rs course. the students were informed of the study and agreed verbally. the students were divided into 10 groups and then, were divided into three big groups for classroom activities. the following are the learning activities in the blended learning. to achieve the objective of the current study, a pre-experimental research design was applied(polit & beck, 2012). a two times-test was employed to measure the students’ knowledge in the mid and final examinations. the mid examinations consisted of 40 multiple choice questions which were developed by the teaching team. the questions had been developed and revised over the past three years by evaluating each item using its facility index in the lms. the final examination score was the result of team work by developing a proposal in a group of 10 students. the rubric for the proposal evaluation was developed by team teaching, which had been evaluated over the past three years. in this study, the knowledge scores resulted from the students’ score in their mid and final examinations (0-100). since the data distribution of the students’ knowledge scores was abnormal, a wilcoxon test was conducted to compare the mean rank of the students’ scores(field, 2013). the wilcoxon test aimed to identify whether the mean rank of the two-times test was significantly different after experiencing blended learning (polit & beck, 2012). regarding the ethical considerations, the mochtar riady institute for nanotechnology ethics committee provided approval for this study (no. 016/mrinec/ecl/x/2018). in addition, the private faculty of nursing in which the study took place also gave permission for this study to be conducted. results the 474 students completed their mid-term and final exams. the results of the students’ knowledge score can be seen in table 1. the result of this study revealed that there was a significant difference (z= 18.43; p value < 0.0001) between the students’ score in the mid-term examination (median 72.5; standard deviation 9.82) and their score in the final examination (median 86.66; standard deviation 4.75). this also means that the students had a better score in their final-term exam. this study also calculated the approximate effect size manually (r= z/√n) (field, 2013). the effect size of this study was above moderate (r= -0.85). the result shows that blended learning had a large influence on the students’ knowledge. however, the final exam score was the result of team work by developing a proposal in a group of 10 students. meanwhile, the mid-term exam was from an individual multiple choice test. this condition could be a possible difference of jurnal ners http://e-journal.unair.ac.id/jners | 3 individual contributions (gagnon, gagnon, desmartis, & njoya, 2013) that might further influence the students’ achievements. discussion this study showed that blended learning had an influence on the nursing students’ achievements over the course of the research and in the statistics (p value < 0.0001).the findings of a previous systematic review study with a meta-analysis (kang & seomun, 2018) are consistent with the current study that blended learning increased the participants’ knowledge in nursing education. this achievement could not be separated from the learning process of the students. the process of the student’s learning included watching videos, weekly quizzes and article reading before the class meeting. a previous systematic review of blended learning in clinical practice informed us that blended learning has been implemented in many different approaches using many different tools(rowe et al., 2012). the study further mentioned that the chosen tools in blended learning should be the best to achieve the learning outcomes(rowe et al., 2012). a comparison study between blended learning and traditional learning within one nursing program in china also supported that 68% of the student participants favored the blended course over the traditional face-to-face course(shang & liu, 2018). in addition, the final examination results revealed that the students’ scores in the blended course were significantly better than students in the traditional classroom (p value < 0.01) (shang & liu, 2018). however, blended learning was not always evident in better scores but it can improve the clinical skills of the students(rowe et al., 2012). this also means that using the blended learning approach could bridge the knowledge gap between theory and practice in nursing education. moreover, contrary to the findings of the current study, a randomized control trial study focused on one nursing program in canada (gagnon et al., 2013) revealed that the blended teaching method did not affect the students’ knowledge directly. it was further mentioned that the learners motivation should be involved in the learning. motivation and learning are interconnected(schiefele, 1991), in which motivation affects the individual’s ability to learn as well as the intensity and length of the individuals’ learning (bandura, 1991). interestingly, a comparative study of the students’ motivation between traditional faceto-face learning and online learning revealed that the students who did online learning had stronger intrinsic motivation than the students in traditional face-to-face classes(rovai, ponton, wighting, & baker, 2007). however, there were no significant differences for the students’ extrinsic motivation and amotivation(rovai et al., 2007). moreover, gagnon and their colleagues conducted a study of motivation (one-time measurement) and suggested that less motivated students could get an advantage from elearning(gagnon et al., 2013). conclusion this study indicates that blended learning has influenced the students’ knowledge. the most important thing to be aware of is the process of the students learning using mixed teaching methods. this means that blended learning could accommodate the student’s learning by providing multiple sources. blended learning is also a positive experience for the nursing students in term of knowledge. further study is needed to explore the students’ understanding and interest in the teaching-learning process using blended learning. references bandura, a. (1991). human agency the rhetoric. table 1. learning activities in blended learning steps blended learning prior to lesson students view specific presentations relevant to the upcoming tutorial via the university’s learning management system (lms) designated lesson lecturer facilitates discussion with the students on the key concepts that are to be covered in the module students are divided into small groups post lesson lecturers facilitates discussion based on the content raised in the specific activity prior to lesson students view specific presentations relevant to the upcoming tutorial via the university’s lms designated lesson lesson repeated as per stage 2 (with new content) table 2. data description of students knowledge score (n=474) data measurement mid exam score final exam score wilcoxon test results mean 71.38 86.75 z = -18.43 p value < 0.0001 r = -0.85 median 72.50 86.38 mode 72.50 86.38 std. deviation 9.82 2.58 variance 96.55 6.70 minimum 45.00 81.75 maximum 95.00 92.50 n. g. a. eka et al. 4 | pissn: 1858-3598  eissn: 2502-5791 dziuban, c., graham, c. r., moskal, p. d., norberg, a., & sicilia, n. (2018). blended learning: the new normal and emerging technologies. international journal of educational technology in higher education, 15(1), 1–16. https://doi.org/10.1186/s41239-017-0087-5 field, a. (2013). discovering statistics using ibm spss statistics (4th ed.). sage publications ltd. gagnon, m., gagnon, j., desmartis, m., & njoya, m. (2013). the impact of blended teaching on knowledge, satisfaction, and self-directed learning in nursing undergraduates: a randomized, controlled trial, 34(6), 377–383. https://doi.org/10.5480/10-459 jhingan, a. (2017). leapfrogging to student at the core, (november). kang, j., & seomun, g. a. (2018). evaluating webbased nursing education’s effects: a systematic review and meta-analysis. western journal of nursing research, 40(11), 1677–1697. https://doi.org/10.1177/0193945917729160 mccutcheon, k., lohan, m., & traynor, m. (2016). a systematic review protocol on the use of online learning versus blended learning for teaching clinical skills to undergraduate health professional students. higher education pedagogies, 1(1), 82–88. https://doi.org/10.1080/23752696.2015.11342 04 muawiyah, d., yamtinah, s., & indriyanti, n. y. (2018). higher education 4.0: assessment on environmental chemistry course in blended learning design. journal of physics: conference series, 1097(1), 0–7. https://doi.org/10.1088/17426596/1097/1/012058 polit, d. f., & beck, c. t. (2012). nursing research, generating and assessing evidence for nursing practice. baltimore: wolters kluwer health. rovai, a. p., ponton, m. k., wighting, m. j., & baker, j. d. (2007). a comparative analysis of student motivation in traditional classroom and elearning courses proquest. international journal on elearning, 6(3), 413–432. rowe, m., frantz, j., bozalek, v., rowe, m., frantz, j., & bozalek, v. (2012). the role of blended learning in the clinical education of healthcare students: a systematic review the role of blended learning in the clinical education of healthcare students: a systematic review. https://doi.org/10.3109/0142159x.2012.64283 1 schiefele, u. (1991). perspektiven interest, learning, and motivation. educational psychologist, (april 2013), 37–41. shang, f., & liu, c.-y. (2018). blended learning in medical physiology improves nursing students’ study efficiency. advances in physiology education, 42(4), 711–717. https://doi.org/10.1152/advan.00021.2018 wef, & schwab, k. (2017). the fourth industrial revolution, by klaus schwab | world economic forum. world economic forum, 1–5. https://doi.org/978-1-5247-5886-8 wright, b. m. (2017). blended learning: student perception of face-to-face and online efl lessons. indonesian journal of applied linguistics, 7(1), 64. https://doi.org/10.17509/ijal.v7i1.6859 xing, b., & marwala, t. (2017). implications of the fourth industrial age on higher education, 10– 15. http://e-journal.unair.ac.id/jners | 103 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17010 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review summary of the prevention of catheter-associated urinary tract infection in an intensive care unit waluyo, yulia indah permata sari, ulfa nur rohmah, saskiyanti ari andini, and hendrik prayitno luwao faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: catheter-associated urinary tract infection is the most common type of nosocomial infection in an intensive care unit. the aim of this study was to examine the existing evidence of preventative measures against catheterassociated urinary tract infection being implemented to reduce urinary tract infection in intensive care units. method: databases were used to identify potential articles, namely scopus, pubmed, ebsco and proquest, limited to those published within the last 5 years from 2013 to 2018. the literature review used the keyword prevention, cauti and icu. in the article search using “and”, only 14 studies met the inclusion criteria. across the 14 studies, 42486 participants and a mean 3540 per trial were included. discussion: nursing round, cauti bundle, bacitracin and cranberry, nursedriven protocol, protocol by team/ developmental protocol, surveillance of cauti, education, performance feedback, and general cultural practices alongside the american college of critical care medicine and the infectious disease society of america present guidelines that recommend cauti preventive practices that can be implemented to reduce the incidence of cauti in icus. conclusion: from the several strategies used to prevent cauti, the most effective is the multidimensional approach because this approach combines several interventions and it also involves other practitioners. a multidimensional approach is more effective than a single dimensional approach in icu. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords cauti; icu; nosocomial infection; multidimensional approach contact waluyo  waluyo-2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: waluyo, w. l, sari, i. p, rohmah, u. n, andini, s. a, and luwao, h. p. (2019). summary of the prevention of catheter-associated urinary tract infection in an intensive care unit. jurnal ners, 14(3si), 103-107. doi:http://dx.doi.org/10.20473/jn.v14i1.17010 introduction catheter-associated urinary tract infections (cautis) are among the most common device-associated healthcare-acquired infections in intensive care units (icus)(navoa-ng et al., 2013). cautis are responsible for prolonged hospital lengths of stay, bacterial resistance, morbidity and increased healthcare costs(navoa-ng et al., 2013). if cauti is not immediately treated, it will cause urosepsis and can even cause death. it is estimated that 17% 69% of cauti can be prevented by applying infection prevention practices based on proven evidence. this means that the 380,000 infections and 9,000 deaths associated with cauti every year can be prevented by implementing this(gould, umscheid, agarwal, kuntz, & pegues, 2017). cautis increase the cost of treatment and length of stay. there is growing concern over the health care cost, especially in terms of preventable problems(underwood, 2015). cauti prevention efforts have been implemented in healthcare facilities and icus globally. however, standardization of the interventions and protocols used is lacking. a review of the literature has shown that some icus have implemented interventions and protocols that have been successful in decreasing cauti, and yet others who have done so have not been as fortunate. (leblebicioglu et al., 2013). the previous method for preventing complications from installing a urinary catheter only delayed the infection process without preventing problems and without even giving prophylactic antibiotics (cortese, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:waluyo-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i1. waluyo et al. 104 | pissn: 1858-3598  eissn: 2502-5791 wagner, tierney, devine, & fogarty, 2018)this may eventually lead to the development of required national and international cauti prevention standards and protocols. the implementation of preventative measures for cauti such as educational strategies, catheter avoidance, policies for catheter insertion, catheter selection, daily necessity review and limiting catheter days have been reported to be associated with decreased cauti rates in the icu(chenoweth & saint, 2013). the identification of the interventions with the greatest positive impact on cauti rates would be an asset to the healthcare professionals caring for patients with an in-dwelling catheter and for the clinic nurses developing policies. the aim of this study was to examine the existing evidence on the preventative interventions and protocols being implemented in icus and the impact that they have on the cauti rates and ultimately, patient outcomes. materials and methods research design a systematic review was the chosen research design, resulting from the latest research for the last 5 years. this study used the preferred reporting items for systematic reviews and meta-analyzes (prisma) approach. study heterogeneity the process of searching for the articles was conducted electronically. the data was obtained from scopus, pubmed, ebsco and proquest. the literature review used the keywords ‘prevention’, ‘cauti’ and ‘icu’; “and” was also used. after a number of articles was obtained, the researcher then selected them again according to the specified inclusion and exclusion criteria. inclusion and exclusion criteria the desired articles were articles published between 2013 and 2018, and articles in english focusing on the selected keywords. the inclusion criteria involved databases which could reveal the effect of the cauti bundle on reducing the cauti incidence rate, various interventions that can reduce or prevent cauti events, actions that can have an effect on reducing cauti events, the steps or procedures that can prevent cauti occurrences, and the research sites – namely the icus – where the studies were carried out. the exclusion criteria consisted of databases in the form of interventions that can reduce cauti but that use pharmacology, select research sites, where the patients studied are not in the icu or where the patients do not have the same character as the patients in the icu. article search process the article search process was carried out between august and october 2018. the search for the articles was done by using the keywords that had been determined by the researchers and within the limits provided by the inclusion and exclusion criteria. the data obtained was then selected one by one by the researchers to determine the suitability of the articles. duplicates were deleted. after obtaining the articles that were in accordance with what was set by the researchers, the articles were analyzed one by one and grouped to get the results. the next step was to discuss each intervention used to prevent the cauti. results study selection the initial literature search returned 183 abstracts (39 from scopus, 47 from proquest, 13 from ebschohost and 84 from pubmed). after reviewing the abstracts for relevance and matching them with the inclusion criteria, 31 articles were selected for a full-text review. there were 17 full-text articles excluded; 10 articles were not interventions and 7 articles were not set in the icu. finally, 14 articles were chosen to be reviewed, as listed in figure 1. study heterogeneity the studies were heterogeneous. there were 6 cohort studies, 4 retrospective cohort studies, 3 interventional prospective studies and 1 quasiexperimental case control study. the duration of the cauti prevention strategy interventions in this study also varied, ranging from 5 months to several years. the age in this study began from 0 years to> 65 years with an adult age being the average. the total respondents in this review were 42.486 patients with an average of 3,540 participants per study. strategy of prevention cauti in icu from the 14 studies reviewed, all had an effects concerning reducing the incidence of infection in the urinary tract. there are several strategies used in terms of preventing cauti such as nursing rounds, cauti bundle, bacitracin, nurse-driven protocol, protocol by team / developmental protocol, surveillance of cauti, education, performance feedback, general culture or culturing practices within the acccm and idsa guidelines. in this study, to reduce the incidence of cauti, there were 12 studies using a multi-dimensional approach strategy(al-hameed et al., 2018; düzkaya, bozkurt, uysal, & yakut, 2016; galiczewski, 2016; galiczewski & shurpin, 2017; gao et al., 2015; kanj et al., 2013; khamis et al., 2014; leblebicioglu et al., 2013; mullin et al., 2017; navoa-ng et al., 2013; tyson et al., 2018; underwood, 2015) and 2 other studies used a oneapproach strategy (davies et al., 2018; thomas, 2016) discussion patients in the icu are affected by critical conditions that are complex and that can change quickly. they are given treatment with invasive devices which reduces their immunity level. these factors make the jurnal ners http://e-journal.unair.ac.id/jners | 105 patients vulnerable to being infected, especially with opportunistic infections, in the hospital. studies have reported that patients in icus are more likely to be infected than those in other departments (gao et al., 2015). urinary catheter insertion is a necessary and important procedure for patient care and management in icu (al-hameed et al., 2018). the risk factors for the colonization of the periurethtral area by potential pathogens and cauti include invasive device insertion, catheterization time, severity of the underlying disease, the use of antibiotics, experience of the catheter insertion personnel, closed system problems, catheter blockage, renal dysfunction, and active infection in other body regions (düzkaya et al., 2016). various prevention strategies have been suggested to decrease the incidence of cautis in hospitalized patients. improvements in urinary catheter aseptic insertion technique and maintenance practices have been shown to decrease the incidence of cautis in multiple studies. studies have shown that a bundle for preventing and controlling cauti could effectively decrease the incidence of cauti, which was decreased from 7.6‰ to 5.0‰ using such a method (gao et al., 2015). bundles for cauti are a set of standard measures that, when applied during the care of the patients, are confirmed to reduce the incidence of cauti. the advantage of the performance and checking of the elements of a bundle is that it acts a complete and consistent reminder system for the prevention of cauti (khamis et al., 2014). the prevention bundle is focused on optimizing the technical aspects of urinary catheterization, including appropriate indications, insertion and maintenance techniques, and timely discontinuation, while concurrently standardizing urine culturing practices (davies et al., 2018) the international nosocomial infection control consortium (inicc) multi-dimensional infection control approach included the following items: (1) a bundle of infection control interventions; (2) education; (3) outcome surveillance; (4) process surveillance; (5) feedback on cauti rates and (6) performance feedback on the infection control practices (leblebicioglu et al., 2013). the inicc multidimensional approach for controlling cauti included the following elements. first, an infection prevention bundle was implemented based on the guidelines published by shea and idsa (navoa-ng et al., 2013), which provides evidence-based recommendations and cost-effective infection control measures that can be feasibly adapted to the icu setting in developing countries. second, the health care workers (hcws) were educated on infection preventive measures. third, the cauti outcomes were monitored by applying the definitions for cauti as developed by the us cdc/nhsn (navoa-ng et al., 2013). fourth, the cauti processes were monitored for compliance with easily measurable infection control measures, including hand hygiene performance. fifth, feedback was provided on the cauti rates. sixth, performance feedback was given on process surveillance, particularly by reviewing and discussing the chart results at the monthly infection control meetings. nurse-driven protocols generally require a physician’s documentation for catheter criteria, including the specific need for prolonged catheterization. appropriate indications for catheter use include acute urinary retention or bladder outlet obstruction, the need for accurate monitoring in critically ill patients, peri-operative catheter need following urologic or genitourinary surgery or for 24 hours after non-genitourinary surgery, for the protection of open sacral or perineal wounds in patients with urinary incontinence, prolonged immobilization due to unstable spine fractures or multiple pelvic fractures, or as an end-of-life comfort care measure. urinary incontinence or prolonged postoperative catheterization with no other indications is an insufficient indication for catheterization. under these protocols, nursing staff are encouraged to assess patients for the need for ongoing catheterization and to remove urinary catheters when they no longer meet the criteria (thomas, 2016) the nurse-driven protocols promoting early catheter removal in conjunction with improved catheter care and maintenance and improved urine culture ordering and collection practices can result in measurable decreases in both in-dwelling urinary catheter utilization and cauti rates in the sticu setting. in an era of quality improvement and patientcentered outcomes, this protocol represents a relatively low-cost resource which can serve as a useful adjunct for infection prevention in the sticu setting (tyson et al., 2018). cranberry (vaccinum macrocarpon) is thought to decrease the incidence of urinary tract infections through its many bioactive compounds. these include type-a proanthocyanins (pacs), fructose (known to decrease adhesions of fimbriated e-coli to the bladder epithelium), ascorbic acid, hydroxybenzoic records after duplicates removed (n=31) rec ords identified through database searchin g, sc opus (n= 39) records screened (n =14) records iden tified through database searc hing proquest (n =47), ebsc hohost (n =13), pubmed (n =84) rec ords excluded (n = 17) s c re e n in g id e n ti fi ti o n full-text articles exc luded (n =17): • not in terven tion (n =10) • the location n ot in ic u (n =7) full-text articles assessed for eligibility (n = 14) e li g ib il it y studies in cluded (n= 14) • in tervention with bundle cauti (n =5) • in tervention with multiple dimension s (n =4) • in tervention with driven-protoc ol (n=2) • in tervention with sterilisation procedure (n =3) in c lu d e d figure 1. flow diagram showing the selection of the studies waluyo et al. 106 | pissn: 1858-3598  eissn: 2502-5791 acid and favonols, which are known to exert antioxidant effects. it also contains ainulin, which is a prebiotic that enhances the growth of commensal ecoli in the rectum. vitamin c and hippuric acid in the urine decrease urine ph and may act as a bacteriostatic agent, although its effectiveness is thought to be minimal. bacitracin ointment, though active only against gram-positive bacteria, may serve to prevent an ascending infection which plays an important role in the pathogenesis of recurrent uti (sorour et al., 2016). the addition of cranberry product (cp) and bacitracin metal care to the cdc cauti prevention bundle is associated with a reduction in cauti incidence. cranberry products have previously demonstrated promise in reducing uti incidence. two meta-analyses have evaluated cp in preventing non-catheter-associated uti with mixed results. with respect to cauti, the use of cp in a single randomized controlled trial resulted in a reduction in cauti in women following gynecological surgery. topical antibiotics seem to have an intuitive mechanism but they have been scarcely studied, and prior evidence has not supported routine use. currently, the use of cranberry and topical bacitracin is not approved by the fda for use in preventing urinary tract infections (sorour et al., 2016). conclusion the present review shows that there are several strategies that are used such as nursing rounds, cauti bundles, bacitracin and cranberry, nursedriven protocol, protocol through a team / developmental protocol, the surveillance of cauti, education, performance feedback and general cultural practices alongside the american college of critical care medicine and the infectious disease society of america guidelines, making up a multidimensional approach for the prevention and evaluation of incidences of cauti in icu. a multidimensional approach is more used than a single dimensional approach in the icu. references al-hameed, f., ahmed, g., alsaedi, a., bhutta, m., alhameed, f., & alshamrani, m. (2018). applying preventive measures leading to significant reduction of catheter-associated urinary tract infections in adult intensive care unit. saudi medical journal, 39(1), 97–102. https://doi.org/10.15537/smj.2018.1.20999 chenoweth, c., & saint, s. (2013). preventing catheter-associated urinary tract infections in the intensive care unit. critical care clinics, 29(1), 19–32. https://doi.org/10.1016/j.ccc.2012.10.005 cortese, y. j., wagner, v. e., tierney, m., devine, d., & fogarty, a. (2018). review of catheter-associated urinary tract infections and in vitro urinary tract models. journal of healthare engineering, 2018, 1– 16. davies, p. e., daley, m. j., hecht, j., hobbs, a., burger, c., watkins, l., … brown, c. v. r. (2018). effectiveness of a bundled approach to reduce urinary catheters and infection rates in trauma patients. american journal of infection control, 46(7), 758–763. https://doi.org/10.1016/j.ajic.2017.11.032 düzkaya, d. s., bozkurt, g., uysal, g., & yakut, t. (2016). the effects of bundles on catheterassociated urinary tract infections in the pediatric intensive care unit. clinical nurse specialist, 30(6), 341–346. https://doi.org/10.1097/nur.00000000000002 46 galiczewski, j. m. (2016). interventions for the prevention of catheter associated urinary tract infections in intensive care units : an integrative review. galiczewski, j. m., & shurpin, k. m. (2017). an intervention to improve the catheter associated urinary tract infection rate in a medical intensive care unit: direct observation of catheter insertion procedure. intensive and critical care nursing, 40, 26–34. https://doi.org/10.1016/j.iccn.2016.12.003 gao, f., wu, y., zou, j., zhu, m., zhang, j., huang, h., & xiong, l. (2015). impact of a bundle on prevention and control of healthcare associated infections in intensive care unit. journal of huazhong university of science and technology [medical sciences], 35(2), 283–290. https://doi.org/10.1007/s11596-015-1425-2 gould, c. v, umscheid, c. a., agarwal, r. k., kuntz, g., & pegues, d. a. (2017). guideline for prevention of c atheter associated urinary tract infections 2009. kanj, s. s., zahreddine, n., rosenthal, v. d., alamuddin, l., kanafani, z., & molaeb, b. (2013). impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in an adult intensive care unit in lebanon: international nosocomial infection control consortium (inicc) findings. international journal of infectious diseases, 17(9), e686–e690. https://doi.org/10.1016/j.ijid.2013.01.020 khamis, a. e., amine, omar, m., helal, m., mohamed, w., & bakr, k. (2014). evaluation of an intervention program to prevent hospitalacquired catheter-associated urinary tract infections in an icu in a rural egypt hospital evaluation eines interventionsprogramms zur prävention nosokomialer. gms hygiene and infection control, 9(2), 1–10. leblebicioglu, h., ersoz, g., rosenthal, v. d., nevzatyalcin, a., akan, ö. a., sirmatel, f., … bacakoglu, f. (2013). impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of turkey: international nosocomial infection control consortium findings (inicc). american journal of infection control, 41(10), 885– 891. https://doi.org/10.1016/j.ajic.2013.01.028 mullin, k. m., kovacs, c. s., fatica, c., einloth, c., jurnal ners http://e-journal.unair.ac.id/jners | 107 neuner, e. a., guzman, j. a., … fraser, t. g. (2017). a multifaceted approach to reduction of catheterassociated urinary tract infections in the intensive care unit with an emphasis on stewardship of culturing. infection control and hospital epidemiology, 38(2), 186–188. https://doi.org/10.1017/ice.2016.266 navoa-ng, j. a., berba, r., rosenthal, v. d., villanueva, v. d., tolentino, m. c. v, genuino, g. a. s., … mantaring, j. b. v. (2013). impact of an international nosocomial infection control consortium multidimensional approach on catheter-associated urinary tract infections in adult intensive care units in the philippines: international nosocomial infection control consortium (inicc) fi. journal of infection and public health, 6(5), 389–399. https://doi.org/10.1016/j.jiph.2013.03.002 sorour, k., care, c., nuzzo, e., resident, i. m., tuttle, m., chief, i. m., … medical, d. (2016). addition of bacitracin and cranberry to standard foley care reduces catheter-associated urinary tract infections. canadian journal of infection control, 31(3), 166–168. thomas, k. l. (2016). reduction of catheterassociated urinary tract infections through the algorithm and the implementation of. j wound ostomy continence nurs, 43(april), 183–187. https://doi.org/10.1097/won.00000000000002 06 tyson, a. f., campbell, e. f., spangler, l. r., ross, s. w., reinke, c. e., passaretti, c. l., & sing, r. f. (2018). implementation of a nurse-driven protocol for catheter removal to decrease catheterassociated urinary tract infection rate in a surgical trauma icu. journal of intensive care medicine, xx, 1–7. https://doi.org/10.1177/0885066618781304 underwood, l. (2015). series / quality performance improvement the effect of implementing a comprehensive unit-based safety program on urinary catheter use. urologic nursing, 35(6), 271–279. https://doi.org/10.7257/1053816x.2015.35.6.271 http://e-journal.unair.ac.id/jners | 345 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si). 17313 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research attitude of nurses related to the implementation of patient safety in the intensive care unit hanik endang nihayati1, gunawan gunawan2, erna dwi wahyuni1, sena wahyu purwanza1, and hidayat arifin1 1faculty of nursing, universitas airlangga, surabaya, indonesia 2intensive care nurses, pelindo husada citra hospital, surabaya, indonesia abstract introduction: the error events in the intensive care unit (icu) were caused by nurses focusing more towards collaborative intervention with other medical staff and workload documentation which was not optimal. the purpose of this study was to determine the predisposing factors related to the implementation of patient safety in the icu. methods: this study was a descriptive analytic correlational study. sample size was determined by purposive sampling and obtained 26 nurses. the independent variables were the predisposing factors and the dependent variable was the implementation of patient safety. instruments used were a questionnaire and observation sheet. analysis was performed using spearman's rho and logistic regression. results: spearman’s rho showed there was a significant correlation between knowledge (p=0.019) and attitude (p=0.040) towards implementation of patient safety. there was no significant of motivation (p=0.073) towards the implementation of patient safety. logistic regression showed the dominant factor in implementation of patient safety was attitude. conclusion: predisposing factors, that include knowledge and attitude, had a significant effect on the implementation of patient safety, but still required high motivation in the implementation of patient safety. in addition to knowledge and good attitude, nurses are expected to improve motivation in the implementation of patient safety. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords patient safety; attitude; knowledge; attitude contact sena wahyu purwanza  sena.wahyu.purwanza2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: nihayati, h.e., gunawan, g., wahyuni, e.d.,, purwanza, s.w., & arifin, h. (2019). attitude of nurses related to the implementation of patient safety in the intensive care unit. jurnal ners, 14(3si), 345-350. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17313 introduction predisposing factors on emergency patients in the intensive care unit (icu) occur in the first 48 hours. the incidence of errors in the intensive care unit (icu) is because nurses are more focused on handling and collaborating with other medical personnel so that nursing documentation is not optimal. this occurs because nurses experience an increase of workload so that they make errors when carrying out their job (roque, tonini, & melo, 2016). error events in the icu in terms of documentation can occur due to nurse communication (documentation) that running poorly which can caused errors in documentation that are not accordance with the standards (nursalam, 2018). these error events can cause unexpected events (ue) including misidentification of patients, errors in communication when nursing handover and receiving advice from other health workers, errors in administration of drugs, especially high alert drugs, and the incidence of infections that occur in the icu room(dhabi, 2008); (international, 2014);(nursalam, 2018)). based on data from the ministry of health in indonesia the incidence of violations of patient safety carried out by nurses is 28.3% (kementrian kesehatan, 2013). reports of patient safety incidents in indonesia there were 55 cases (37.9%) occurring in the dki jakarta area, while based on their type https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). h. e. nihayati, et al. 346 | pissn: 1858-3598  eissn: 2502-5791 there was a prevalence of knc types (near injury events) as many as 69 cases (47.6%), 67 cases (46 , 2%), and others 9 cases (6.2%). error events that occur in hospitals is decreasing quality of nurses due to stress caused by an increase in workload by 74% (muthmainah, 2012). according to the health ministry of regulation clause 8 no. 1691 of 2011 concerning hospital patient safety which includes the accuracy of patient identification, improvement of effective communication, increased safety of drugs that need to be watched out, nurses ensure the right location, the right procedure, the right patient when the surgery is carried out, reduction the risk of infection related to health services, and reduction of patient falls risk. however, based on the preliminary survey data obtained by researchers in the icu room at the phc hospital in surabaya, there were still nurses who did not implement the patient safety program. preliminary data carried out by researchers in the icu of phc hospital surabaya conducted in november 2016 was obtained through observations related to patient safety actions, of the 10 morning shift nurses there were 4 who did not wash their hands before touching patients, 3 nurses did not identify patients and 3 nurses who do not put up a patient indicator of the risk of falling in bed. health services provided by health and non-health workers are increasingly complex along with the development of science and technology. this allows unwanted events to occur if the complexity is not managed properly. error events occur a lot on nurses because of the high workload and collaboration with other health workers. this can cause unwanted event which can have an impact on patient safety. the consequences of patient safety that do not do correctly and precisely are the occurrence of infection in patients, errors in drug administration and interventions that can caused disability and even death in patients (caesarityanti, 2011). efforts to prevent the occurrence of ue resulting in patient safety, it is necessary to make standard procedure operation (spo) and the culture of "seven steps towards patient safety" which are expected to reduce the patient's safety rate. the application of spo in principle is part of the performance and behavior of individuals in working accordance with their duties in organization and this is usually related to the compliance of nurses in carrying out nursing actions based on spo that has been determined. the researcher used guidelines from the implementation of hospital accreditation commission patient safety in conducting observations, that is identifying of patients correctly, improving effective communication, increasing drug safety, ensuring the right location, right procedures, appropriate patients, reducing the risk of infection and reducing the risk of falls. one of the factors that influence a person's compliance is knowledge, age, education, and motivation (notoadmodjo, 2012). this is in accordance with lawrence green's theory which analyzes human behavior from the level of health, which suggests that behavior is formed by several factors, one of them is predisposing factors which include knowledge, attitudes, and motivation. based on the description above, nurses have an important role in providing comprehensive care, one of which is through the implementation of patient safety. therefore, researchers wanted to know the predisposing factors with the implementation of patient safety in the icu room at the phc hospital surabaya. materials and methods this study was described correlational analytic design. the population in this study were all nurse who had work in intensive care unit phc hospital, which were 32 nurse. the sample in this study were nurse work in icu phc hospital with inclusion and exclusion criteria and obtained 26 nurse. inclusion criteria in this study include; 1) nurses who work in icu phc hospital at least 1 year, 2) nurses who have attended patient safety socialization. while the inclusion criteria include: 1) nurses during maternity leave, 2) nurses who currently attending patient safety training or outside education phc hospital surabaya. the sampling technique in this study used a non-probability sampling technique with the type of purposive sampling. the independent variable were the nursing factor (factor predisposing) which include knowledge, attitudes and nurses motivation, while the dependent variable was implementation of patient safety. knowledge questionnaire the knowledge questionnaire in this study was about implementation of patient safety of 15 questions. if the respondent answers the question correctly, it will get a value of 1 and if the respondent answers wrongly gets a value of 0. then the researcher makes a classification of the level of knowledge from the respondent's answer, namely: good: 76-100 %, sufficient: 56 75%, and less: ≤ 56 %. attitudes questionnaire the attitude instrument used in this study was a questionnaire about nurses' attitudes towards the implementation of patient safety in 30 questions. if the respondent answers correctly, he gets a score of 1 and 0 if the answers incorrect. then, the researcher will classify the attitude classification, namely good attitude> 75 and less good attitude <75. motivation questionnaire the motivational instrument in this study was using a questionnaire about nurses' motivation towards the implementation of patient safety in 15 questions. scores for positive questions: ss = 4, s = 3, ts = 2, sts = 1. scores for negative questions: ss = 1, s = 2, ts = 3, sts = 4. then, researchers will classify the classification of motivation levels, namely strong motivation: 76% -100%, moderate motivation: 56% 75% and weak motivation ≤ 55%. jurnal ners http://e-journal.unair.ac.id/jners | 347 instrument of patient safety implementation the instrument of patient safety implementation in this study uses an observation sheet about the implementation of patient safety. the number of components observed is 17 components. respondents will get 1 score when they doing patient safety and 0 if patient safety is not done. then, the researcher will classify the classification of patient safety implementation, which is good implementation:> 76% and less implementation <75%. procedures data collection was done by determining the population of 32 nurses in the icu of phc hospital surabaya, then selecting samples according to inclusion criteria and obtained a sample of 26 nurses, followed by sharing informed consent to respondents, then distributing questionnaires to a sample of 26 respondents in the room icu surabaya phc hospital. the questionnaire was distributed at the time of respondent's rest hour, then the respondent was asked to fill out the questionnaire accompanied by the researcher so that there was no bias (cheat sheet when filling out the questionnaire). after the results were obtained from the questionnaire, then the researchers began to observe at least 2 nurses related to the implementation of patient safety which includes the accuracy of patient identification, increased effective communication, increased drug safety to watch out for, nurses ensure the right location, right procedure, right patient before surgery, reduction the risk of infection related to health services, and reduction of the risk of falling patients performed in the icu phc hospital in one shift as much as twice, so that researchers make observations on morning or afternoon shifts. analysis this study uses a data analysis test to analyze related factors to the implementation of patient safety programs in the icu room at phc surabaya hospital. the scale obtained is ordinal through a questionnaire. the data obtained will be collected and analyzed by statistical tests using the spearman rank (rho) correlation test to determine whether there is a relationship between predisposing factors and the implementation of patient safety. the basis of decision making is based on 95% confidence level or α = 0.05.). the strength of the relationship is expressed in the magnitude of the coefficient correlation p ≤ α (0.05) which means that there is a meaningful relationship between the two measured variables, namely predisposing factors with the implementation of patient safety. if p ≤ α (0,05) then h0 is rejected and h1 is accepted. ethical consideration this research will begin by carrying out several procedures related to research ethics including informed consent, anonymity, confidentiality. the committee of ethical approval in the faculty of nursing universitas airlangga give approved the above mentioned protocol with number 264-kepk. results the results of the knowledge of respondents with the implementation of patient safety from 26 respondents. the majority of respondents' knowledge with sufficient knowledge categories can do patient safety in a good category. however, there are still respondents with sufficient knowledge in the implementation of patient safety is still not good. the results show there are respondents with less knowledge, but in the implementation of good patient safety. the relationship between the level of respondents 'knowledge about patient safety towards the implementation of patient safety and the spearmen's rho test shows that there is a relationship between respondents' knowledge of the implementation of patient safety in the intensive care unit (icu) in phc surabaya hospital with a moderate correlation level and a positive correlation coefficient indicating that there is a relationship between the variable that is in the same direction with the same high value. the results of the attitudes of respondents with the implementation of patient safety from 26 respondents. the majority of respondents with good attitude in the implementation of patient safety are also good. meanwhile, there are respondents with a bad attitude, but in the implementation of patient safety in the good category. the relationship of the respondent's attitude towards the implementation of patient safety with the spearmen's rho test shows that there is a relation between the respondent's attitude towards the implementation of patient safety in the intensive care unit (icu) room of phc hospital with a moderate correlation level and a positive correlation coefficient that shows the relationship between the two variables in the same direction the same height value. the results between the motivations of respondents with the implementation of patient safety from 26 respondents. the majority of respondents with strong motivation in implementing patient safety are in a good category, but there are still respondents with strong motivation, but with poor implementation of patient safety. the relationship of respondents 'motivation towards the implementation of patient safety with the spearmen's rho test showed that there was no correlation between respondents' motivation towards the implementation of patient safety in the intensive care unit (icu) room of the surabaya phc hospital with a low correlation level and a positive correlation coefficient that showed a relation between two directional variables with the same high value. the results of candidate selection were carried out using a simple logistic regression test. the requirement to enter the multivariate analysis model h. e. nihayati, et al. 348 | pissn: 1858-3598  eissn: 2502-5791 is p-value ≤ 0.25. the results show that predisposing factors (knowledge, attitude, and motivation) meet the requirements to enter the multivariate analysis model. the results showed that attitude was the most influential factor with the implementation of patient safety in the intensive care unit (icu) room of the surabaya phc hospital 13,940 times influential in patient safety implementation. discussion respondents' knowledge about patient safety in the intensive care unit (icu) room of the surabaya phc hospital was mostly at a sufficient level, but there were also those who lacking knowledge. the more advanced of science and technology that continues to evolve, the learning process to increase knowledge must be continue. the intensive care unit (icu) is equipped with adequate mechanical facilities and equipment, so that the existence of respondents as health workers must really master the operation of tools, care, willingness to always learn to increase knowledge and creativity and change the behavior of respondents as health workers in the better direction is needed in the implementation of patient safety. table 1. distribution of results between the categories of knowledge and implementation of safety patient knowledge value patient safety implementation ∑ good less good f(x) % f(x) % f(x) % 1. good 2. sufficient 3. less 4 14 1 15.4 53.8 3.8 0 5 2 0 19.2 7.7 4 19 3 15.4 73.1 11.5 ∑ 19 73.1 7 26.9 26 100 (p): 0.019 ≤ 0.05 (r): 0.457 table 2. results distribution between attitude categories and implementation of safety patient attitude value patient safety implementation ∑ good less good f(x) % f(x) % f(x) % 1. good 2. not good 17 2 65,4 7,7 2 5 7,7 19,2 19 7 73,1 26,9 ∑ 19 73,1 7 26,9 26 100 (p): 0,040 ≤ 0,05 (r): 0,405 table 3. results distribution between motivation categories and implementation of safety patient nilai motivasi patient safety implementation ∑ good less good f(x) % f(x) % f(x) % 1. strong 2. sufficient 3. weak 10 9 0 38,5 34,6 0 2 4 1 7,7 15,4 3,8 12 13 1 46,2 50 3,8 ∑ 19 73,1 7 26,9 26 100 (p): 0,073 ≥ 0,05 (r): 0,358 table 4. factors predisposing distribution of candidate selection to the implementation of patient safety variable p-value knowledge 0,082 attitude 0,006 motivation 0,147 table 5. significant levels of independent variables against dependent variables distribution predisposing factor wald p-value or knowledge 0.93 0.760 1.507 attitude 3.811 0.051 13.940 motivation 0.527 0.468 2.166 constant 3.317 .069 .002 jurnal ners http://e-journal.unair.ac.id/jners | 349 knowledge or cognitive is a very important domain in the formation of a person's actions (overt behavior). knowledge is defined as intellectually knowledge with facts, truths / principles added to observations, and experiences and reporting (notoadmodjo, 2012). the learning process is not only directly obtained from formal education or informal education. lack of knowledge can be caused by the process of acceptance and understanding of the information obtained that still not maximal. one of the way that can be done to increase knowledge that is useful is, doing conducting socialization to improve the effectiveness in achieving the work results set for safety and satisfaction. patient safety socialization is included in the policy of implementing patient safety at surabaya phc hospital through education, training and research. the results of research conducted by researchers showed a significant relation between attitudes towards the implementation of patient safety. this is supported by data distribution of attitude categories which shows that most respondents have good attitude towards the implementation of patient safety, as well as length of work data majority of the respondents have working experience for 6-10 years, so that they have enough experience in implementing patient safety. however, there are still some respondents in the sufficient category during the implementation of patient safety, this may be influenced by culture, quality of life, influence of people who are considered important, or may be influenced by the personal experience of respondents based on the length of time in the intensive care unit (icu) surabaya phc hospital. lawrence green's (1980) theory which states that one of the factors that influence behavior is attitude as a predisposing factor. walgito (2003) expressed his opinion that in order to change attitudes, people generally will change their cognitive components first so that the affective component will eventually change. some other factors that influence attitudes according to are personal experience, culture, other people who are considered important, mass media, educational institutions or institutions, religion, and individual factors (azwar, 2002). data distribution of respondents' motivation categories obtained by researchers shows that the majority of respondents' motivation are in the sufficient category, and most of the respondents' motivation is in the strong category. this is very different from the opinion which says that good motivation will be followed by a change in good attitude, in this case the implementation of patient safety. meanwhile, respondents' motivation was good but there was no relationship with the implementation of patient safety in the intensive care unit (icu) room of the phc hospital in surabaya. this can be caused by respondents show different performance in providing nursing services due to motivation. this is also included in the implementation of patient safety. respondents are motivated by physiological needs, safety, attention and love, self-esteem and self-actualization. respondents were also affected by co-cognitive needs for knowledge (kanagasabai, 2013). according to the theory of needs, the motivation of someone comes when they have not reached a certain level of satisfaction in their lives. satisfied needs will no longer be a motivator. the results of the analysis using multiple logistic regression tests showed that attitude was the most influential factor with the implementation of patient safety in the intensive care unit (icu) room of the surabaya phc hospital with 13,940 influential times in the implementation of patient safety. lawrence green's (1980) theory which states that factors that influence behavior one of them is attitude as a predisposing factor. zimbardo & ebbesen in ahmadi (1999) states that attitudes are a predisposition to an individual, an object that contains components cognitive, affective, and behavioral components. the limitations of this study are that questionnaires from questionnaires conducted by respondents were directed by the researcher directly, allowing respondents to experience pressure when filling out questionnaires, as well as data retrieval techniques carried out in a momentary manner, making it less representative of the research results. conclusion predisposing factors (knowledge and attitude) have a significant relationship with patient safety implementation in intensive care unit (icu) room phc hospital surabaya. but good predisposing factors (motivations) do not necessarily influence the implementation of patient safety in intensive care unit (icu) room phc hospital surabaya, this can be caused by several factors such as knowledge and length of work experience. the most dominant and influential predisposing factor of the implementing patient safety is the attitude of nurses. the implication of the research to increase patient safety implementation and quality nursing care. h. e. nihayati, et al. 350 | pissn: 1858-3598  eissn: 2502-5791 references azwar, s. (2002). sikap manusia, teori dan pengukurannya. yogyakarta: pustaka pelajar. caesarityanti, a. . (2011). faktor predisposing yang berhubungan dengan pelaksanaan patient safety di ruang hemodialisa. universitas airlangga. dhabi, h. a. a. (2008). hospital standart. abu dhabi: health authority. international, j. c. (2014). joint commission international accreditation standards for hospital 5th edition. kanagasabai, p. s. (2013). effect of multisensory stimulation on neuromotor development in preterm infants. indian j pediatr, 6(80), 460– 464. https://doi.org/10.1007/s12098-0120945-z kementrian kesehatan, r. (2013). riset kesehatan dasar 2013. jakarta. muthmainah, i. (2012). faktor faktor penyebab stres kerja di ruangan icu pelayanan jantung terpadu dr. cipto mangunkusumo jakarta. universitas indonesia. notoadmodjo, s. (2012). promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta. nursalam. (2018). manajemen keperawatan aplikasi dalam praktik keperawatan profesional (5th ed.; p. lestari, ed.). jakarta: salemba medika. roque, k. e., tonini, t., & melo, e. caetano p. (2016). adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study. cad. saúde pública, rio de janeiro, 32(10). https://doi.org/e00081815 http://e-journal.unair.ac.id/jners | 187 jurnal ners vol. 14, no. 2, oktober 2019 http://dx.doi.org/10.20473/jn.v14i2.10873 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research content validity and the reliability of technological competency as caring in the nursing instrument_indonesian version (tccni_iv) ignata yuliati, ni luh agustini purnama and sri winarni institute of health science katolik st vincentius a paulo, surabaya, indonesia abstract introduction: the tccni has not been used to conduct a study in indonesia previously. the researcher has thus conducted a study on technological competency as a caring in nursing instrument indonesian version (tccni_iv). this study aims to examine the content validity and reliability of the tccni_iv. methods: an exploratory sequential mixed method research design was used in this study. the researcher used closed-ended question asked of five (5) experts on the content of tccni-iv. the researcher explored the expert’s opinion about each statement of tccni_iv, and they required suggestions for the statements that were not relevant. furthermore, the researcher analyzed and rewrote the statements according to the expert’s input. there are twenty-five (25) items in the tccni_iv involving technological knowledge and technological caring as an expression of caring in the nursing dimension. furthermore, the researcher used the tccni_iv to gain quantitative data from the 135 nurses in the nursing wards of the hospitals. based on a finite population of 208 nurses, a total of 135 samples (nurses) participated in the quantitative study. the selection of the participants was through simple random sampling. there were 135 nurses from the nursing wards in the hospitals (n=135) with experience of at least 1 year in nursing practice. the item content validity (i-cvi) and scale content validity (s-cvi) was tested. the reliability was determined using cronbach’s alpha α. results: the “item content validity of the tccni_iv ratings ranged from .60 to 1.0. the scale content validity index (s-cvi) was 0.936. the cronbach’s alpha coefficient of .980 indicates there to be good reliability. conclusion: the technological competency as a caring in nursing instrument indonesian version (tccni_iv) is thus found to be valid and reliable. it is recommended that the developed instrument needs to be further tested for its reliability and validity in a larger setting. article history received: december 25, 2018 accepted: january 10, 2020 keywords instrument development; validation; technological competency; tccni_iv. contact ignata yuliati  ignatayuli@gmail.com  institute of health science katolik st vincentius a paulo, surabaya, indonesia cite this as: yuliati, i., purnama, n.l.a., & winarni, s. (2019). content validity and the reliability of technological competency as caring in the nursing instrument_indonesian version (tccni_iv). jurnal ners, 14(2), 187192. doi:http://dx.doi.org/10.20473/jn.v14i2.10873 introduction technological advancement dominates global health care, transcribing and advancing nursing as an independent practice in human health care (biswas, s., kongsuwan, w., & matchim, 2016). technology plays an important role in health care and it helps the nurses to provide comprehensive nursing care to the patients. another study explains that in order to sustain the life of the patient, the nurses need to use machine technology (biswas, s., kongsuwan, w., & matchim, 2016). furthermore, nurses are required to know and use this technology in order to provide nursing care. the tccni_iv has undergone a crosscultural adaptation study with 6 steps. the process adapted by the study is based on the translation, adaptation, and validation of the instruments or scales for cross-cultural health care in the research of sousa and rojjanasrirat (sousa & rojjanasrirat, 2011). in this research, the researcher would like to examine the validity test and reliability test of tccni_iv. the experts evaluated the tccni-iv using a rating scale: 1 = not relevant, 2 = unable to assess or in need of so much revision that it would no longer be https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.10873 i. yuliati et. al 188 | pissn: 1858-3598  eissn: 2502-5791 relevant, 3 = quite relevant and 4 = highly relevant. from these ratings, the item (i-cvi) and scale (s-cvi) statistics were calculated. i-cvi represents the “proportion of content experts giving each item a relevance rating of 3 or 4,” whereas s-cvi is strictly delimited by universal agreement (ua) this reflects the “proportion of items on a scale that achieves a relevance rating of 3 or 4 by all the experts”(denise f. polit, 2008). the reliability test was examined through the internal consistency and stability test. tccni-iv was administered to 135 nurses for the purpose of determining the internal reliability. the ability of nurses in terms of using technology has become necessity because with this ability, the nurses can improve the quality of their nursing care. technology as a part of caring in nursing has been introduced in several theories, such as the theory developed by locsin (2005) in “the middle-range theory of technological competency as an expression of caring in nursing”. in indonesia, technology has also been growing rapidly in health care and in all units of the hospital setting. the use of technology such as medical devices has increased rapidly and there is no tool that has been developed to assess the technological competency of caring in nursing. locsin (1999) developed the technological competency as caring in nursing instrument (tccni) and this instrument was revised by andrew parcel (parcells, & locsin, 2011). the tccni instrument originally contained 30 items (locsin, 1999). the instrument was modified based on written theory expert feedback and expert suggestions related to the clinical utility with associate and baccalaureate-prepared nurses in future investigations. therefore, the final instrument version with 25 items had an s-cvi/ua of .72 (parcells, & locsin, 2011). furthermore, the crosscultural adaptation of tccni into the indonesian version (tccni_iv) was conducted by using the process recommended by sousa & rojjanasrirat (2011). the process is described in 6 steps. first, there is the forward translation. step 2 is the comparison of the two translated versions of the instrument (tl1 and tl2) in synthesis i. step 3 is the back translation. step 4 is the comparison of the two back-translated versions of the instrument (b-tl1 and b-tl2), namely synthesis ii. step 5 is where the preliminary psychometric evaluation of the scale will be done with a monolingual sample. step 6 is the last step used to establish the initial full psychometric properties of the newly translated, adapted and crossvalidated instrument with a sample of the target population of interest. in indonesia, technology has also been growing rapidly in the health care sector and in all units of the hospital setting. the use of technology such as medical devices has increased rapidly. therefore, the researcher wants to examine the content validity and reliability of the technological competency as caring in nursing instrument indonesian version (tccni_iv) to see if the tccni-iv can be used in indonesia. this study aims to examine the content validity and reliability of the tccni_iv. materials and methods research design an exploratory sequential mixed method research design was used in this study. the researcher combined the qualitative method and the quantitative method, in order to gain comprehensive, valid, reliable, and objective data. the researcher used closed-ended question put to five (5) experts and to ask them to evaluate the tccni_iv using a rating scale: 1 = not relevant, 2 = unable to assess or in need of so much revision that it would no longer be relevant, 3 = quite relevant and 4 = highly relevant. there are twenty-five (25) items consist in the tccni_iv. the reliability test of tccni-iv was measured using the internal consistency and stability test. the technological competency as a caring in nursing instrument indonesian version (tccni-iv) was administered to 135 nurses for the purpose of finding the internal reliability. the measurement scales of tccni used a likert scale with 5 categories ranging from 1novice to 5expert. the total score of each category ranged from 25 to 125. each range was categorized according to benner’s level of competency (benner ’ s stages of clinical competence stage 1 : novice stage 2 : advanced beginner stage 3 : competent stage 4 : proficient stage 5 : the expert, 2011). participants of the study the participants of the study comprised of 5 nurse experts who participated in the qualitative study. one of them was a doctor of nursing, while the other experts had a master’s degree in nursing science and were the chief nurse of the hospitals. based on a finite population of 208 nurses, a total of 135 nurses participated in the quantitative study. the selection of the participants was done through simple random sampling. the inclusion criteria consisted of nurses from the nursing ward of the hospital with experience totaling at least 1 year in nursing practice. the exclusion criteria consisted of pediatric department’ nurses. the participants were recruited from two private hospitals in surabaya. research instruments the original questionnaire is from the revised item tccni which contained of 25 items. the tccni_iv with a likert scale ranging from novice to expert used to measure the responses of the participants for each item. data collection procedure prior to this study, approval of the research ethics committee of st. vincent de paul was obtained. after approval, the researcher worked on the recommendations. permission from the directors and administrators of the hospitals was gained to conduct the study, and so the packet containing the letter from the ethics committee, the questionnaire, and the jurnal ners http://e-journal.unair.ac.id/jners | 189 informed consent was presented to the nurse coordinator in the nursing wards of the hospitals. the participants who met the inclusion criteria were informed of the purpose of the study, its benefits, and finally, informed consent from the participants was obtained. furthermore, no force or harm followed when and if the participants decided to withdraw their participation from the research out of respect to their human dignity and rights. the researcher also informed the participants that there will be no direct benefit regarding their participation in this study. the data collection was done in august 2018. data analysis a sequential mixed method analysis was undertaken to analyze the data. the researcher analyzed the qualitative data over the quantitative data. the expert panel was asked to evaluated each item of the instrument for content equivalence (content-related validity) using the following scale: 1-not relevant, 2=unable to assess relevance, 3= relevant but needs minor alteration and 4=very relevant and succinct. items classified as 1 (not relevant) or 2 (unable to assess relevance) have to revised and the panel’s experts were asked to provide suggestions. from these ratings, the item (i-cvi), scale (s-cvi) and kappa coefficient of the agreement statistics were calculated. the quantitative data were analyzed using the statistical package for the social sciences (spss) version 24. the reliability was determined using cronbach’s alpha. the data was gathered from the sample of 135 nurses. the likert scale used 5 categories ranging from 1novice to 5expert. the total score of each category ranged from 25 to 125. results the results of the study have been divided into two parts: qualitative and quantitative. the qualitative part the results of the study in the qualitative part consist of the item content validity (i-cvi) and scale content validity (s-cvi) of tccni_iv. table 1 shows that there were 20 items with an i-cvi 1.00 (items no: 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 17, 19, 20, 23, 24 and item no.25). there were 4 items with i-cvi 0.80: item no: 2 (technology helps the nurses to know the "who" and "what" of each person), 16 (nurses need to assess the patient regarding his or her knowledge to him or herself and the care that he or she received), 18 (competent nurses do follow up his or her tasks and emotions creatively when meeting patient needs) and item no: 21 (concern in the nursing process can happen in a learning and teaching situation between the nurse, patient and family member). there was 1 item (item no.15) with an i-cvi 0.60 (nurses need to train his or her caring perspective when assessing and interpreting the health service data). the result also shows that the s-cvi of tccni_iv is 0.936. the quantitative part the results of the study in this quantitative part consist of the reliability test of tccni_iv. this was measured using internal consistency and a stability test. table 2 shows that the cronbach’s alpha of technological competency in the caring in nursing instrument indonesian versus tccni_iv is .980. discussion qualitative part the researcher computed two types of cvis, namely the content validity of individual items (i-cvi) and the content validity of the overall scale (s-cvi). for the first type of cvis is the i-cvi. there was considerable agreement about how to compute the item-level cvi. the content validity index (cvi) illustrates the degree of agreement between the expert raters (andreou, papastavrou, lemonidou, mattheou, & merkouris, 2015). this study shows that tccni-iv has an adequate and representative content validity (i-cvi) for all items. the criteria for item acceptability should be 1.00 when there are five or fewer judges. however, lynn recommended that the i-cvi’s criteria should be no lower than .78. (denise f. polit, 2008). therefore, the i-cvi of tccni_iv in this study provides the information to guide the researcher for the next study focused on revising, deleting and substituting items, specifically items with an i-cvi less than 1.00. most of the items of the tccni_iv have an i-cvi 1.00. this means that the items are adequate and representative of all items. this feasibly refers to the content validity of the technological competency. the caring in nursing instrument indonesian version (tccni_iv) was examined by experts and it additionally underwent the cross-cultural translation process. moreover, tccni was investigated by theory and practice experts until the instruments consisted of 25 statements that originally consisted of 30 items. the item statements were revised or eliminated based on the quantitative content validity indices and specific expert feedback (parcells, & locsin, 2011). furthermore, the content validity of tccni_iv confirms that the items in the questionnaires are acceptable and understandable among nurses. several factors could influence the understanding of the nurses related to each item in the questionnaire such as the nurse playing a major role in the use of technology in the health field and in daily care (cargnin, ottobelli, barlem, 2016). the nurse’s use the information technology tools is frequent in their practice (barbara, victoria, & carol, 2003). critical to this nursing practice is the understanding of the meaning of the experience of a living human while being cared for and dependent on technologies for the purpose of human care (koszalinski, & locsin, 2015). the limitation of this study is that the i-cvi questionnaire is less than 1.00 and it was not further analyzed. i. yuliati et. al 190 | pissn: 1858-3598  eissn: 2502-5791 although there are experts that indicate that the table 1: the content validity index (i-cvi) and scale content validity index (s-cvi) of tccni_iv no items expert panel total item agreement cvi 1 2 3 4 5 1 nursing as an important part of the health service which focuses on human service 4 4 4 4 3 5 1.00 2 technology helps the nurses to know the "who" and "what" of each person. 3 3 2 4 4 4 0.80 3 the final destinations of the nursing activity is healing, saving lives and increasing independence 4 4 4 3 4 5 1.00 4 nurses use unique ways to serve their patients 4 4 4 4 4 5 1.00 5 caring attitude is an interesting thing because there is mercy, physical attendance, a sense of comfort and personal appreciation 4 4 4 4 4 5 1.00 6 technology and a caring attitude help to encourage self-esteem when it is used appropriately 4 4 4 4 4 5 1.00 7 to know what and who the patient is can mean there is an appreciation of the patient and not only his or her physical performance. 3 4 3 3 4 5 1.00 8 nursing is a unique area of knowledge, skill and the ability to care 3 3 3 3 4 5 1.00 9 a caring attitude in nursing means there is a will to listen, to cooperate and to stay beside the patient 4 4 4 4 4 5 1.00 10 nurses need to balance the dependency on technology usage and their ability to take care of the patient 3 3 4 4 4 5 1.00 11 taking care means knowing the physical and emotional condition of the patient while handling them. 4 4 3 4 4 5 1.00 12 nurses should involve the patient when arranging the nursing plan to guarantee the accuracy and completeness of the patient caring process 4 3 4 3 4 5 1.00 13 an ability in using technology is a skill to use machines in caring the patient 4 4 4 4 4 5 1.00 14 nurses should honor the hope and dreams of every patient although it may change every time 2 3 4 4 4 4 1.00 15 nurses need to train his or her caring perspective when assessing and interpreting the health service data 2 3 2 4 4 3 0.60 16 nurses need to assess the patient regarding his or her knowledge of him or herself and the care he or she has received 3 3 2 3 4 4 0.80 17 nurses should build a relationship with his or her patient when creating a safe and comfortable situation 3 4 4 4 4 5 1.00 18 competent nurses follow up his or her task and emotions creatively when meeting patient needs 3 2 4 4 4 4 0.80 19 to understand the patient means to honor the patient as an individual every time 4 4 4 4 4 5 1.00 20 competent nurses can anticipate patient needs and respect the patient’s trust system at once. it is focused on the patient healing process 4 4 4 4 4 5 1.00 jurnal ners http://e-journal.unair.ac.id/jners | 191 item is unable to assess the relevance (item no.15: icvi 0.60), this is most probably because in reality, the nurses’ caring perspective when assessing and interpreting health service data is a fundamental practice conducted by all nurses. therefore, the nurses do not need to train his or her caring perspective when assessing and interpreting the health service data. the nurses acknowledge that caring is at the core of the nursing profession. selfawareness helps to improve the nurses’ caring behavior and understanding of themselves in respect to their own values and beliefs in order to understand the client’s perspectives (biswas, s., kongsuwan, w., & matchim, 2016). the second type of cvis is scale content validity (s-cvi). the s-cvi is defined as the proportion of items given a rating of 1 not relevant and 2 unable to assess the relevance by the experts involved. the items were given a rating of 3 relevant but needs minor alteration and 4 very relevant quite/very relevant by the experts involved. according to many writers, the s-cvi’s acceptable level is .80 or higher (denise f. polit, 2008). in this study, the s-cvi of tccni_iv is 0.93, which means that the items are adequate and representative for all items in order to measure the construct of interest. the use of technology plays a significant role in the nursing service. the nurses will be able understand their patients as a whole through the help of technology. thus the nurses require an enormous amount of technical skills, effort and competency when managing technologies harmoniously with the intention being to result in positive human health perspectives. quantitative part the quantitative part consisted of the reliability test of tccni_iv. it was measured using internal consistency and a stability test. cronbach’s alpha was the measure used to determine the reliability (internal consistency) of the items in the questionnaire. the range from 0.70 and 0.95 is an acceptable value for cronbach’s alpha (beck & gable, 2001). another researcher used the internal consistency to refer to the interrelatedness of the items. they distinguished internal consistency from homogeneity by claiming that homogeneity refers to the uni-dimensionality of a set of test items (tang, cui, & psychology, 2009). in this study, the results show that the cronbach’s alpha of tccni_iv is .980, representing a good value (al hadid, abu hasheesh, & al momani, 2011). this result means that the questionnaire is considered to have high reliability. this is most probably because each item has been examined by experts before being administered to the participants. furthermore, the tccni_iv underwent both development and psychometric testing. table 1: the content validity index (i-cvi) and scale content validity index (s-cvi) of tccni_iv no items expert panel total item agreement cvi 1 2 3 4 5 21 concern in the nursing process can happen in a learning and teaching situation between the nurse, patient and family member 3 3 2 4 4 4 0.80 22 concern in caring may reduce the anxiety in the nurse-patient relationship 4 4 4 4 4 5 1.00 23 a sincere commitment to the patient’s needs, hope and dreams is a kind of concern. 3 4 3 4 4 5 1.00 24 as a nursing concern, the ability to use technology in many ways is to know and understand one another, between patient and nurse 2 3 4 3 3 4 1.00 25 nurses use technology and human touch together when building relationships completely, focusing their concern 4 4 4 4 4 5 1.00 total agreement 0.88 0.96 0.84 1 1 s-cvi 0.936 table 2. the reliability test of the technological competency of the caring in nursing instrument indonesian versus (tccni_iv). reliability statistics cronbach's alpha n of items .980 25 i. yuliati et. al 192 | pissn: 1858-3598  eissn: 2502-5791 conclusion the technological competency of the caring in nursing instrument indonesian version (tccni_iv) is found to be both valid and reliable. it is recommended that the developed instrument is further tested for its reliability and validity in a larger setting. it is also recommended that the questionnaire can be used in a nursing ward hospital with nursing students as the sample. references al hadid, l. a., abu hasheesh, m., & al momani, m. (2011). validating a tool that explores factors influencing the adoption of principles of evidence-based practice. journal of nursing education, 50(12), 681–687. https://doi.org/10.3928/0148483420110930-03 andreou, c., papastavrou, e., lemonidou, c., mattheou, k., & merkouris, a. (2015). adaptation and validation of the learning style inventory version 3.1 in greek language: a methodological study. journal of nursing measurement, 23(2), 88e – 111. https://doi.org/10.1891/1061-3749.23.2.e88 barbara, j., victoria, l., & carol, j. (2003). nursing information technology knowledge , skills , and preparation of ... beck, c. t., & gable, r. k. (2001). ensuring content validity: an illustration of the process. journal of nursing measurement, 9(2), 201–215. benner ’ s stages of clinical competence stage 1 : novice stage 2 : advanced beginner stage 3 : competent stage 4 : proficient stage 5 : the expert. (2011). (1984), 2011. biswas, s., kongsuwan, w., & matchim, y. (2016). technological competency as caring in nursing as perceived by icu nurses in bangladesh and its related factors. songklanagarind journal of nursing , 36(1), 1–20. cargnin, ottobelli, barlem, c.-v. (2016). technology in nursing care and workload in an icu. j nurs ufpe on line., recife, 10(suppl. 2):903-7. denise f. polit, c. t. b. (2008). the content validity index: are you sure you know what’s being reported? critique and recommendations. research in nursing & health, 31(4), 341–354. https://doi.org/10.1002/nur koszalinski, r. s., & locsin, r. c. (2015). persons who dependent upon technologies for care: lived experience of being cared for following lower limb amputation. international journal of human caring, 19(4), 38–43. https://doi.org/10.20467/1091-5710.19.4.38 locsin, r. c. (1999). development of an instrument to measure technological caring in nursing. nursing & health sciences, 1, 27–34. parcells, d. a., & locsin, r. c. (2011). development and psychometric testing of the technological competency as caring in nursing instrument. international journal of human caring, 15(4), 8– 13. https://doi.org/10.20467/10915710.15.4.8 sousa, v. d., & rojjanasrirat, w. (2011). translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. journal of evaluation in clinical practice, 17(2), 268–274. https://doi.org/10.1111/j.13652753.2010.01434.x tang, w., cui, y., & psychology, e. (2009). internal consistency : do we really know what it is and how to assess it ? 2(2), 1–16. http://e-journal.unair.ac.id/jners | 157 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.18925 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research what do our nurses know about managing patient with permanent pacemakers? muhamad al muizz ismail1, nor marini ibrahim2 and muhammad kamil che hasan3 1 coronary care unit, hospital universiti sains malaysia, kelantan, malaysia 2 open university malaysia, kelantan, malaysia 3 department of medical-surgical nursing, kulliyyah of nursing, international islamic university malaysia, pahang, malaysia abstract introduction: the number of patients with pacemaker implant is increasing in the health services sector in malaysia, which requires nurses to have expertise in patient care with pacemaker implantation. therefore, this study was conducted to analyse the level of knowledge among nurses regarding the management of patients with pacemaker implantation. methods: a cross-sectional study was conducted through purposive sampling among all nurses working at the critical care unit, intensive care unit, cardiac rehabilitation ward, investigation clinical laboratory, and non-invasive clinical laboratory in a public hospital in kelantan. a questionnaire consisted of demographic data and nurses’ knowledge was distributed. data were analysed for descriptive analysis and using pearson correlation test. results: results from all respondents (n=70), show 48.6 % of the respondents had moderate knowledge about patient management with pacemaker implantation, 32.9 % had a low level of knowledge and only 13.6% had high knowledge regarding management of patient with pacemaker implantation. there is a significant difference between the level of knowledge and demographic data, that is between the level of education (p=0.027), age (p=0.011) and length of service (p=0.015). there is no significant relationship between knowledge and demographic data, such as gender (p=0.481), marital status (p=0.315), and post-basic (p=0.067). conclusion: level of knowledge among nurses about the management of patient with pacemaker implantation is low to moderate. additional education and exposure among nurses are needed to enhance the knowledge of nurses and improve the quality of care among patients with pacemaker implant. article history received: may 02, 2020 accepted: august 08, 2020 keywords knowledge; management; nurses; pacemaker contact muhammad kamil che hasan  mkamil@iium.edu.my  department of medicalsurgical nursing, kulliyyah of nursing, international islamic university malaysia, pahang, malaysia cite this as: ismail, m. a. m., ibrahim, n. m., & hasan, m. k. c. (2020). what do our nurses know about managing patient with permanent pacemakers?. jurnal ners, 15(2), 157-161. doi:http://dx.doi.org/10.20473/jn.v15i2.18925 introduction according to the world health organization (who), in 2016, an estimated 17.9 million deaths worldwide are caused by cardiovascular disease (who, 2020). in malaysia, in 2012, statistical data showed that 295.8% of deaths per 100,000 population in malaysia were due to cardiovascular disease (who | global health observatory (gho) data, 2019). it is also estimated that around 450,000 deaths worldwide are caused by sudden cardiac death (stecker et al., 2014). a poor electrical conduction system of the heart is seen as a critical issue and can result in death or cause complications such as congestive heart failure (burri & varma, 2013). currently, the problem of heart rhythm can be treated with the use of a permanent pacemaker (ppm) which helps the heart when the rate of heart rhythm drops below 60 per minute. it acts as an artificial sino-atrial node and helps drain the heart's electrical system to raise the heart rate to 60 beats per minute (boink, christoffels, robinson, & tan, 2015). nurses should play a role in caring for patients with ppm, through updating knowledge of pacemaker by attending continuous training and education to ensure comprehensive care (humphreys, 2013). the knowledge of pacemaker management is very crucial, and a key factor to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2.189251 m. a. m. ismail et al. 158 | pissn: 1858-3598  eissn: 2502-5791 ensure that the patients are fully informed and understand about the pacemaker. nurses are reported to have a key role to liaise with the multidisciplinary team in providing information to patients and family members before surgery (riley, 2015). the pacemaker will be part of the patient's life expectancy and, therefore, the assessment of patient and caregiver knowledge is important to prevent early complications and dysfunction and that immediate treatment can be provided (hatchett & thompson, 2002). the pacemaker is also reported to induce musculoskeletal attention of the diaphragm, the pectoral or the intercostal muscles due to normal extracardiac stimulation (rasmussen & pareek, 2014). the implantation of pacemaker is also reported in reducing the incidence of falls, fall-related fractures and fall-related injuries among patients with sinus node dysfunction (brenner et al., 2017). these ongoing updates and challenges among patients with pacemaker indicate the need for nurses to update their knowledge. currently, there is no research on nurses’ knowledge of pacemaker management in the local context. it is very crucial to identify the basic information related to the knowledge of nurses to provide ongoing awareness of the updated information of pacemaker. therefore, this study was conducted to measure the level of knowledge among nurses regarding the management of patients with pacemaker implantation. materials and methods a descriptive cross-sectional study was conducted. all nurses at cardiology related clinical area (coronary care, intensive care, cardiac rehab ward, invasive cardiac catheterization lab, and non-invasive cardiac lab) were purposively sampled to determine their levels of knowledge concerning pacemaker in one of the hospitals in kelantan. the questionnaires used in this study were adapted from hadiatiyah ( 2016) through back and forward translation process by a group of three content experts to ensure the reliability and validity of the questionnaire. the questionnaire contained two parts: part a, sociodemographic data; part b, knowledge. for demographic data, gender, age, marital status, education level, job placement, level of qualification and length of service in years were asked. the part b questions (10 items) were related to nurses' knowledge, including the basic concepts of pacemaker, information on pacemaker and temporary pacemaker (tpm) as well as basic nursing knowledge. responses to the statements were measured using a 5-point likert scale: “strongly agree,” “agree,” “not sure,” “disagree,” and “strongly disagree.” a pilot study was conducted to determine whether the instrument used in the measurement has high reliability and validity. the pilot study was conducted using 10 nurses and revealed a cronbach’s alpha value of 0.7. if the cronbach’s alpha value reaches 0.5 and above, it shows that the research questions are appropriate and applicable (bowling, 2002). the higher the value of the reliability of a measuring item, the better the outcome is. data collection procedure: after obtaining ethical approval [oum/5.7/2.1.1/469.3/303-17(006)], we executed the study for six months beginning february 2017. all nurses aged 20 years and above with a minimum of six months of clinical experience were purposively selected in the respective area and approached to participate in this study. we used krejcie and morgan sample size scheduling as a means of calculating sample size for this study (krejcie & morgan, 1970). according to the table, the sample size is based on the study population (70 nurses) and the sample size required is 59 people. the researcher distributed the questionnaire to 70 respondents and all respondents returned the completed questionnaire in response. before the data collection, written consent was obtained from respondents. the respondents answered the questionnaire themselves, which took about seven to ten minutes. the respondents returned the completed questionnaires to the researcher, who checked them. all data collected were kept confidential. the data were analysed using spss version 24, and the descriptive analysis results were presented in tables as frequency and percentage for the distribution of the data. pearson's correlation coefficient was used to measure the relationship between knowledge and demographic characteristics. the results for associations between variables are also presented in tables, interpreted based on the significant p-value of α = 0.05. results table 1. sociodemographic data of respondents (n = 70) variable (n) (%) gender male 28 40.0 female 42 60.0 age 20-34 38 54.3 35-54 32 45.7 marital status single 45 64.3 married 25 35.7 level of education diploma 48 68.6 bachelor’s degree 17 24.3 master’s degree 5 7.1 specialisation course with post-basic 32 45.7 without post-basic 38 54.3 length of service <5 years 4 5.7 5-10 years 29 41.4 11-20 years 27 36.6 >21 years 10 14.3 jurnal ners http://e-journal.unair.ac.id/jners | 159 table 1 presents the detailed distribution of sociodemographic data among the respondents. this study included a total of 70 respondents, more than the required by the estimated minimum sample size of 59. there were 42 female respondents (60%), age range from 20-34 years was 38 (54.3%). for the level of education, 48 respondents obtained diploma (68.6%) while 32 (45.7%) respondents have specialisation certificate in cardiac nursing. for distribution of service, this was less than five years (n=4, 5.7%), five to ten years (n=29, 41.4%), 11-20 years (n=27, 36.6%) and more than 21 years (n=10, 14.3%). meanwhile, regarding knowledge of pacemaker, a questionnaire with a total of ten questions measured the level of knowledge on pacemaker. as presented in table 2, almost half of the respondents have a moderate score (n=13, 48.6%), while a total of 13 respondents achieved a high score (18.6), and 23 respondents (32.9%) has a low score, particularly in information on the device. table 3 shows the results of sociodemographic data and level of knowledge in detail. based on the data analysis using a pearson correlation test, there was a significant association between age and knowledge: r = 0.301, p = 0.011; level of education and knowledge: r=0.265, p= 0.027; and length of service: r=0.289, p=0.015, while gender, marital status and specialisation course have no association with the level of knowledge regarding pacemaker among nurses. discussion this study indicated that the level of knowledge among nurses about the management of pacemaker is low to moderate. most nurses in this study generally need to increase their knowledge about patient management with pacemakers, particularly information about the device, as compared to another study in iraq (hadiatiyah, 2016). nurses need to educate the management of a patient with a cardiac problem, including a pacemaker. the development of professionalism is an activity that enhances the level of competence in terms of knowledge, skills and attitudes and the effectiveness of an individual's role in performing any given any task (mohd yusoff, firdaus, jamaludin, & che hasan, 2019). continuous education is needed to enhance the level of knowledge, skills and competencies in the treatment of patients. similar to a study in egypt, nurses’ knowledge and practices related to patient management and cardiac implantation devices are still unsatisfactory, while nurses' knowledge levels are low (ali, youssef, mohamed, & hussein, 2014). the study has concluded that the source of knowledge of nurses regarding cardiac implantation device in relation to the topic is inconsistent with the nursing curriculum and has a profound impact on nurses' knowledge of cardiac implantation. meanwhile, the lack of exposure and co-operation between each of the team disciplines led to the failure of nurses to have extensive knowledge of management of a patient with cardiac implantation devices. in addition, most nurses had low knowledge prior to the tests and satisfactory results after the tests on nurses as reported (mahramus et al., 2013). moreover, it is important for nurses to have the knowledge and skills of cardiac implantation and specific care for patients with cardiac implantation (ali et al., 2014). this finding is supported by faisal in which he also recognised that nurses' knowledge and skills play a key role in providing counselling and care to patients requiring cardiac implantation so as to enable nurses to meet the complex needs (ameen, 2017). therefore, the need for nurses to receive ongoing training and education is very crucial. through bivariate analysis, this study also revealed that age and length of service play a significant role in influencing nurses' knowledge for the management of patients with pacemaker. most nurses are from the age group of 2034 years and have less work experience. this is supported by another study where, through their research on the practice and perception of delirium in intensive care units in egypt, studies show 75% of respondents are within the range of this study (ali elfeky & shoeib ali, 2013). from the findings, we recommended some strategies to improve nurses' knowledge of management of patients with pacemaker. firstly, table 2. level of knowledge regarding pacemaker (n=70) level frequency (f) percentage (%) high 13 18.6 moderate 34 48.6 low 23 32.9 table 3. correlation between knowledge score and sociodemographic data knowledge score coefficient, r p-value mean standard deviation (sd) gender 0.86 0.481 1.60 0.49 age 0.301* 0.011 2.45 0.5 marital status -0.122 0.315 1.36 0.48 level of education 0.265* 0.027 1.38 0.62 specialisation course -0.220 0.067 1.54 0.50 length of service 0.289* 0.015 2.61 0.80 *. correlation is significant at the 0.05 level (2-tailed). m. a. m. ismail et al. 160 | pissn: 1858-3598  eissn: 2502-5791 continuous nursing education regarding pacemaker among nurses with the collaboration of cardiologists to help further understandings of the nature of pacemaker and its relatedness. this could promote the development of a positive patient safety culture among healthcare professionals (nurumal, sabran, hamid, & hasan, 2020). researchers involved in the study also should consider cultural context as, in malaysia, many issues involving cultural surroundings were reported (aris, sulaiman, & che hasan, 2019; mohd sharif, che hasan, che jamaludin, & zul hasymi firdaus, 2018). secondly, interprofessional learning activities could also be done to engage with the understanding of the management of pacemaker in the different fields, namely cardiovascular technologist, pharmacy, nutrition and therapist. such instances could lead the nurses to understand and be able to adjust the mode of pacemaker and the process of checking the specific pacemaker function, maintenance and follow-up of pacemakers and routine checks for patients. thirdly, regular assessment for nurses regarding the care of patients with cardiovascular problems, particularly pacemaker, in all cardiology-related units. it could lead to provide good practice of working, improve skills, and update the knowledge from time to time. limitation of this study could be the small number of sample size and focusing only on one hospital. conclusion as a conclusion, the level of knowledge among nurses regarding pacemaker is moderate which requires a numbers of actions to increase the level. level of education and length of service indicated the need for continuous education to promote understanding of the management of patients with pacemaker in general and provide full support to patients in need. further bigger scale research in different settings also is suggested to generalise the findings. references ali elfeky, h., & shoeib ali, f. (2013). nurses’ practices and perception of delirium in the intensive care units of a selected university hospitals in egypt. journal of education and practice, 4(19), 61-70. retrieved from www.iiste.org ali, n. s., youssef, w., mohamed, a., & hussein, a. (2014). nurses’ knowledge and practice regarding implantable cardiac devices in egypt. british journal of cardiac nursing, 10(1), 551-557. https://doi.org/10.12968/bjca.2015.10.1.34 ameen, f. (2017). knowledge of cardiology nurses, regarding care of patients with permanent pacemakers and implantable cardioverter defibrillators in karachi pakistan. prehospital and disaster medicine, 32(1), s148-s149. https://doi.org/10.1017/s1049023x17004095 aris, a., sulaiman, s., & che hasan, m. k. (2019). the influence of music therapy on mental well-being among postoperative patients of total knee arthroplasty (tka). enfermeria clinica, 29(2), 1623. https://doi.org/10.1016/j.enfcli.2019.04.004 boink, g. j. j., christoffels, v. m., robinson, r. b., & tan, h. l. (2015). the past, present, and future of pacemaker therapies. trends in cardiovascular medicine, 25(8), 661-673. https://doi.org/10.1016/j.tcm.2015.02.005 bowling, a. (2002). research methods in health : investigating health and health services. open university press. brenner, r., ammann, p., yoon, s.-i., christen, s., hellermann, j., girod, g., … kühne, m. (2017). reduction of falls and fractures after permanent pacemaker implantation in elderly patients with sinus node dysfunction. europace : european pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the european society of cardiology, 19(7), 1220–1226. https://doi.org/10.1093/europace/euw156 burri, h., & varma, n. (2013). remote device management in patients with cardiac complaints. cardiac electrophysiology clinics, 5(3), 337-347. https://doi.org/10.1016/j.ccep.2013.05.005 hadiatiyah, h. m. d. h. (2016). nurses, knowledge concerning an implantation pacemaker for adult patients with cardiac rhythm disorder at alnassirrhyia heart center. hatchett, r. p., & thompson, d. r. (2002). cardiac nursing : a comprehensive guide. humphreys, m. (2013). nursing the cardiac patient. blackwell. https://doi.org/10.1002/9781118785331 krejcie, r. v., & morgan, d. w. (1970). determining sample size for research activities. educational and psychological measurement, 30(3), 607-610. mahramus, t. l., penoyer, d. a., sole, m. lou, wilson, d., chamberlain, l., & warrington, w. (2013). clinical nurse specialist assessment of nurses’ knowledge of heart failure. clinical nurse specialist, 27(4),198-204. https://doi.org/10.1097/nur.0b013e31829557 35 mohd sharif, n. a., che hasan, m. k., che jamaludin, f. i., & zul hasymi firdaus, m. k. (2018). the need for first aid education for adolescents. enfermería clínica, 28(supplement 1), 13–18. https://doi.org/10.1016/s1130-8621(18)300287 mohd yusoff, n. s., firdaus, m. k. z. h., jamaludin, f. i. c., & che hasan, m. k. (2019). the need for educating healthcare professionals regarding good musculoskeletal health practice. enfermería clínica, 29(2),579-584. https://doi.org/10.1016/j.enfcli.2019.04.089 nurumal, m. s., sabran, n. m., hamid, s. h. a., & hasan, m. k. c. (2020). nurses’ awareness on patient safety culture in a newly established university hospital. jurnal keperawatan indonesia, 23(2). https://doi.org/10.7454/jki.v0i0.1088 rasmussen, i. k. b., & pareek, m. (2014). a video demonstration of pacemaker-induced pectoral jurnal ners http://e-journal.unair.ac.id/jners | 161 muscle stimulation. bmj case reports. https://doi.org/10.1136/bcr-2013-200697 riley, j. (2015). the key roles for the nurse in acute heart failure management. cardiac failure review, 1(2), 123-127. https://doi.org/10.15420/cfr.2015.1.2.123 stecker, e. c., reinier, k., marijon, e., narayanan, k., teodorescu, c., uy-evanado, a., … chugh, s. s. (2014). public health burden of sudden cardiac death in the united states. circulation: arrhythmia and electrophysiology, 7(2), 212–2 . https://doi.org/10.1161/circep.113.001034 who. (2020). cardiovascular diseases (cvds). retrieved from world health organisation website: https://www.who.int/news-room/factsheets/detail/cardiovascular-diseases-(cvds) who | global health observatory (gho) data. (2019). who. 73 deteksi dini derajat kesadaran menggunakan pengukuran nilai kritis mean artery pressure (detection of the degree of awareness using the measurement of critical value mean artery pressure on nursing care) martono*, sudiro*, satino* *keperawatan politeknik kesehatan surakarta jl. letjend sutoyo mojosongo surakarta, 0271-856929. fax. 0271-855388 email: must_ton@ymail.com abstrak pendahuluan: dampak trauma cranio cerebral dapat mempengaruhi gangguan autoregulasi volume intrakranial yang terdiri dari otak, cairan serebrospinal dan darah dalam pembuluh darah. perubahan salah satu volume tersebut tanpa diikuti respon kompensasi dari faktor yang lain akan menimbulkan perubahan tekanan intrakranial dan jumlah aliran darah dari sirkulasi sistemik yang diperlukan untuk memberi oksigen dan glukosa yang adekuat untuk metabolisme otak. salah satu hal yang sangat penting dalam asuhan keperawatan pada pasien dengan cidera kepala adalah menjaga kecukupan mean arteri pressure serebral. penelitian ini bertujuan untuk mengetahui kecukupan nilai kritis mean artery pressure dalam mendeteksi tingkat kesadaran pada pasien yang mengalami cidera kepala. metode: penelitian ini menggunakan disain explanatory research dengan pendekatan cross sectional yang menjelaskan pengaruh dan prediksi kecukupan nilai kritis mean arteria pressure terhadap derajat kesadaran pada pasien cidera kepala yang berjumlah 34 sampel. uji statistik penelitian ini menggunakan regresi sederhana. hasil: hasil penelitian menunjukkan bahwa ada pengaruh yang positif nilai kritis mean artery pressure terhadap derajat kesadaran yang ditunjukkan nilai p=0.00<0.05 dan nilai mean artery pressure ma mpu mendeteksi tingkat kesadaran pasien cidera kepala sebesar 77.8%. diskusi: peningkatan nilai kritis mean arterial pressure lebih dari 65 mmhg dapat memperbaiki mikrosirkulasi dan autoreglasi otak, sehingga mencegah terjadinya penurunan kesadaran pada pasien cidera kepala. kata kunci: mean artery pressure (map), kesadaran, cidera kepala abstract introduction: the impact of the trauma cranio cerebral can affect the volume autoregulation disorders any intracranial disease that consists of the brain and cerebrospinal fluid and the blood in the veins. the changes one of the volume without followed the response of compensation from the other factors will cause overt increased intracranial pressure changes and the amount of blood flow from the systemic circulation required to give oxygen and glucose intake to the metabolism of the brain. one of the things that is very important in nursing nursery on patients with injury head is to maintain the adequacy of mean artery pressure cerebral. this research aims to know the adequacy of critical value mean artery pressure in detecting the level of consciousness in patients who suffered injury on the head. method: this research using explanatory design research with cross sectional approach that explains the influence and the prediction of the adequacy of the critical value mean arteria pressure against the degree of awareness in patients with injury head which numbered 34 samples. this research statistics tests using simple regression. result: the results of the study showed that there is a positive influence critical value mean artery pressure against the degree of awareness that indicated the value of p=0.00<0.05 and value of mean artery pressure is able to detect the level of consciousness patients injury head of 77.8%. discussion: increased critical value mean arterial pressure is more than 65 mmhg can improve mikrosirkulasi and autoreglasi brain, so that prevent the decline of awareness in patients with wounds of the head. keywords: mean artery pressure (map), consciousness injury head ____________________________________________________________________________________________________ pendahuluan kecelakaan lalu lintas merupakan salah satu masalah kesehatan masyarakat yang dapat mempengaruhi semua sektor kehidupan dan salah satu penyebab utama trauma cranio cerebral. dampak trauma craniocerebral tersebut dapat mempengaruhi gangguan autoregulasi volume intrakranial yang terdiri dari otak, cairan serebrospinal dan darah dalam pembuluh darah. perubahan salah satu volume tersebut tanpa diikuti respon kompensasi dari faktor yang lain menimbulkan tekanan intrakranial dan jumlah aliran darah dari sirkulasi sistemik yang diperlukan untuk memberi oksigen dan glukosa yang adekuat untuk metabolisme otak. salah satu hal yang sangat penting dalam asuhan keperawatan pada pasien dengan cidera kepala adalah menjaga kecukupan tekanan perfusi serebral. jika jumlah aliran darah dari sirkulasi sistemik yang diperlukan untuk memberi oksigen dan glukosa yang adekuat mailto:must_ton@ymail.com jurnal ners vol. 11 no. 1 april 2016: 73-78 74 untuk metabolisme di otak diatas 100 mmhg, maka potensial terjadi peningkatan tekanan intrakranial dan sebaliknya jika nilai tekanan perfusi serebral kurang dari 60 mm hg, aliran darah ke otak tidak adekuat sehingga hipoksia, gangguan kesadaran dan kematian sel otak dapat terjadi. sedangkan jika mean arterial pressure dan intrakranial pressure sama, berarti tidak ada tekanan perfusi serebral dan perfusi serebral berhenti (black, j.m. & matassarinjacobs, 1993), sehingga tekanan perfusi otak dapat dijadikan sebagai prediktor keluaran tingkat defisit neurologis dan tigkat kesadaran. laporan hasil penelitian sebelumnya yang dilakukan oleh howard d. sesso, meir j. stampfer, bernard rosner, charles h. hennekens, j. michael gaziano, joann e. manson (2000), menjelaskan bahwa tekanan sistole dan diastole, mean arterial pressure mampu memprediksi cardicasculer desease pada orang muda, sedangkan baik sistole atau rata-rata denyut nadi memprediksi cardicasculer desease pada orang dan memberikan saran apakah mean arterial pressure ada kaitannya korelasikan dengan tekanan sistole dan diastole lebih lebih baik. upaya yang dapat dilakukan untuk memprediksi adanya gangguan kesadaran akibat ketidakcukupan tekanan perfusi serebral yaitu dengan melakukan pengukuran lebih awal kecukupan tekanan rata-rata aliran darah ke otak. (price, sylvia a., & wilson, 2006) menjelaskan bahwa mekanisme autoregulator otak sangat berperan dalam mempertahankan aliran darah ke otak dalam rentang fisiologik 60 mmhg-160 mmhg tekanan arteri rata rata dibawah kondisi tekanan darah arteri yang selalu berubah-ubah. tekanan arteri rerata (mean artery pressure/map) merupakan mekanisme kompensasi dalam memepertahankan tekanan perfusi serebral yaitu dengan meningkatkan tekanan arteri rerata tersebut. untuk itu, sangat penting menjaga kestabilan pasokan aliran darah otak agar tidak terjadi kerusakan lebih lanjut. kecukupan rata-rata aliran darah ke otak merupakan bahan kajian yang penting dalam asuhan keperawatan pada pasien dengan cidera kepala. kegagalan mengidentifikasi dan mengetahui tanda dan gejala tekanan perfusi otak dan kecukupan rerata arteri pasien dengan cidera kepala lebih awal merupakan resiko yang paling besar karena dapat menyebabkan kerusakan otak yang irreversibel sampai kematian. bahan dan metode p e n e l i t i a n i n i d i l a k u k a n u n t u k menjelaskan pengaruh dan prediksi kecukupan nilai kritis mean arteria pressure terhadap derajat kesadaran pada pasien cidera kepala menggunakan rancangan explanatory research dengan pendekatan cross sectional. populasi pada penelitian ini adalah semua semua pasien yang mengalami yang mengalami cidera kepala yang dirawat di unit perawatan bedah rumah sakit pku muhammadiyah delanggu kabupaten klaten yang berjumlah 34 sampel dengan pengambilan sampel menggunakan pu rpo sive samp ling . u ji statistik yang digunakan untuk melihat sejauh mana pengaruh variabel nilai kritis mean arterial pressure dalam mendeteksi tingkat kesadaran menggunakan uji regresi dengan tingkat signifikansi yang dipahami 95 %. hasil sebaran jenis kelamin pasien cidera kepala dari 34 orang pada penelitian ini sebagian besar perempuan yaitu sebesar 18 orang (52.9%) dan sisanya laki-laki sebesar 16 orang (47.1%). sebaran tingkat pendidikan pada pasien cidera kepala dari 34 orang yang diteliti sebagian besar sma yaitu sebesar 13 orang (38.3%), sd sebesar 12 orang (35.3%), smp sebesar 6 orang (17.6%), dan sisanya perguruan tinggi sebesar 3 orang (8.8%). sebaran umur pada pasien cidera kepala dari 34 responden pada penelitian ini sebagian besar lanjut usia yaitu sebesar 20 orang (58.8%), usia tua sebesar 13 orang (38.3%), dan sisanya remaja sebesar 1 orang (2.9%). sebaran tekanan sistole pada pasien cidera kepala dari 34 orang yang diteliti sebagian besar dengan kategori normal dan pra hipertensi yaitu masing-masing sebesar 9 orang (26.5%), hipertensi stadium i sebesar 6 orang (17.6%), hipertensi stadium ii sebesar 4 orang (11.8%) dan sisanya dengan kategori rendah dan hipertensi parah yang masing-masing sebesar 3 orang (8.8%). sebaran tekanan sistole pada pasien cidera kepala dari 34 orang yang diteliti sebagian besar mempunyai tekanan diastole dengan kategori normal dan hipertensi stadium i yaitu masingmasing sebesar 10 orang (29.4%), kategori rendah sebesar 6 orang (17.6%), pra hipertensi sebesar 4 orang (11.8%), hipertensi stadium ii sebesar 3 orang (8.8%) dan sisanya dengan kategori hipertensi parah sebesar 1 orang (2.9%). sebaran kecukupan mean artery deteksi dini derajad kesadaran (martono. dkk.) 75 pressure pada pasien cidera kepala dari 34 responden yang diteliti sebagian besar dengan kategori normal sebesar 20 orang (58.8%), kategori tinggi sebesar 8 orang (23.6%), dan sisanya dengan kategori kurang sebesar 6 orang (17.6%). sebaran tingkat kesadaran pada pasien cidera kepala dari 34 responden yang diteliti sebagian besar mempunyai tingkat kesadaran dengan kategori somnolen yaitu sebesar 13 orang (38.3%), kategori koma dan apatis masing-masing sebesar 8 orang (23.5%), dan sisanya dengan kategori komposmentis sebesar 6 orang (14.7%). prediksi nilai rata-rata variabel kecukupan mean artery pressure terhadap tingkat kesadaran pada pasien cidera kepala pada penelitian ini menggunakan persamaan regresi yang digunakan adalah kesadaran=10.552+1.012x + e. tabel 1. rangkuman hasil analisis regresi linier sederhana tabel 2. nilai prediksi tingkat kesadaran tabel 3. rangkuman hasil uji t variabel harga t keterangan thitung ttabel x1y 6.961 2.042 ada pengaruh α = 0,05 : n = 34 (df) n-k-1 berdasarkan tabel 1 dapat diperoleh perbandingan signifikansi uji f hitung sebesar 0.00<0.05 artinya persamaan garis regresi yang telah digunakan mampu melakukan prediksi dengan baik (nilai mean artery pressure (map) mampu memprediksi atau mendeteksi tingkat kesadaran pasien). sedangkan koefisien regresi variabel mean artery pressure (x) sebesar 1.012, hal ini menunjukkan bahwa jika mean artery pressure mengalami kenaikan 1, maka tingkat kesadaran (y) akan mengalami peningkatan sebesar 1.012. hasil uji koefisien regresi pada peneltian ini diperoleh bernilai positif artinya terjadi hubungan yang positif antara mean artery pressure dengan tingkat kesadaran, yang artinya semakin nilai mean artery pressure meningkat maka semakin meningkatkan tingkat kesadaran. pada tabel 2, didapatkan nilai residual (unstandardized residual) pada penelitian ini diperoleh semakin mendekati nilai 0. dengan demikian model regresi yang digunakan pada penelitian ini mampu melakukan prediksi dengan baik (nilai map mampu memprediksi atau mendeteksi tingkat kesadaran pasien). nilai tingkat kesadaran yang diprediksi dapat dilihat pada kolom predicted value. hasil perhitungan uji t diperoleh derajat kebebasan (df) n-k-1=34-2-1=31 dengan pengujian 2 sisi (signifikansi = 0,025), maka perbandingan harga t hitung = 6.961> t tabel = 2.042 dengan tingkat signifikansi 95%. dengan demikian ho ditolak dan ha diterima, artinya bahwa ada pengaruh secara signifikan antara nilai kritis mean artery p r e s s u r e d e n g a n t i n g k a t k e s a d a r a n . berdasarkan hasil uji statistik diperoleh nilai r square sebesar 0.778, artinya nilai kritis mean artery pressure mempunyai pengaruh terhadap kesadaran pasien sebesar 77.8% dan sisanya dipengaruhi variabel lain. rangkuman hasil uji t disajikan pada tabel 10. hasil uji statistik uji r 2 diperoleh nilai r square sebesar 0.778, artinya nilai kritis mean artery pressure mempunyai kontribusi terhadap tingkat kesadaran pasien sebesar 77.8% dan sisanya sebesar 22.2% dipengaruhi variabel lain. variabel koefisien regresi hasil uji signifikansi koefisien regresi map 1.012 t=7.648 0.000 konstanta 10.552 =1.157 0.114 r 0,870 r 2 0,778 f f=38.717 0.000 jurnal ners vol. 11 no. 1 april 2016: 73-78 76 pembahasan karakteristik pasien cidera kepala sebaran data jenis kelamin cidera kepala dari 34 responden pada penelitian ini sebagian besar perempuan yaitu sebesar 52.9% dan sisanya laki-laki sebesar 47,1%. hal ini bertolak belakang dengan laporan penelitian nurfaise., moh. zainuddin (2012) yang menjelaskan bahwa jenis kelamin laki-laki terdata sebagian besar mengalami cidera kepala, yaitu sebanyak 73,3%, sedangkan perempuan adalah sebanyak 26,7%. namun demikian, dapat dijelaskan bahwa jenis kelamin perempuan pada penelitian terdata sebagian besar mengalami cidera kepala karena pelanggaran lalulintas dan kurangnya ketrampilan mengendarai sepeda motor sehingga mengakibatkan kecelekaan. sebaran umur pada pasien cidera kepala dari 34 responden pada penelitian ini sebagian besar adalah lanjut usia sebesar 58.8%, usia tua sebesar 38.3%, dan sisanya remaja sebesar 2.9%. di laporkan sebelumnya melalui penelitian yang dilakukan oleh nurfaise., moh. zainuddin., wicaksono (2012) yang menjelaskan bahwa kelompok usia pasien cedera kepala tersering adalah kelompok usia 15 60 tahun yaitu sebanyak 81,2%. kelompok usia pasien cedera kepala yang paling sedikit yaitu kelompok umur lebih dari 60 tahun sebesar 2%, sedangkan untuk 5-14 tahun adalah sebanyak (16,8%). dengan melihat perbandingan data penelitian kejadian cidera kepala tersebut secara umum ada kesamaan angka kejadian cidera kepala, yang membedakan kategori kelompok umur. pembagian kelompok umur ada penelitian ini adalah usia anak (2-17 tahun), remaja (18-21 tahun), subur (22-35 tahun), tua (36-45 tahun), dan usia lanjut >45 tahun). usia lanjut pada penelitian merupakan prevalensi yang aling banyak hal ini terjadi disebakan usia tersebut merupakan risiko penurunan fungsi saraf, dan berkurangnya fungsi panca indera. tekanan darah dalam kehidupan seseorang bervariasi secara alami. bayi dan anak-anak secara normal memiliki tekanan darah yang jauh lebih rendah daripada dewasa. tekanan darah juga dipengaruhi oleh aktivitas fisik, dimana akan lebih tinggi pada saat melakukan aktivitas dan lebih rendah ketika beristirahat. tekanan darah dalam satu hari juga berbeda; paling tinggi di waktu pagi hari dan paling rendah pada saat tidur malam hari. kenaikan tekanan arteri pada usia tua biasanya dihubungkan dengan timbulnya arteriosklerosis. pada penyakit ini, tekanan arteri yang terutama meningkat; pada kira-kira sepersepuluh dari semua orang tua akhirnya meinngkat di atas 200 mmhg. tekanan darah seseorang dapat lebih atau kurang dari batasan normal. jika melebihi nilai normal, orang tersebut menderita tekanan darah tinggi/hipertensi. sebaliknya, jika kurang dari nilai normal, orang tersebut menderita tekanan darah rendah /hipotensi. sejalan dengan bertambahnya usia, hampir setiap orang mengalami kenaikan tekanan darah. tekanan sistolik terus meningkat sampai usia 80 tahun dan tekanan diastolik terus meningkat sampai usia 55 – 60 tahun, kemudian berkurang secara perlahan atau menurun drastis. pada hipertensi sistolik terisolasi, tekanan sistolik mencapai 140 mmhg atau lebih, tetapi tekanan diastolik kurang dari 90 mmhg dan tekanan diastolik masih dalam keadaan normal. hipertensi ini sering ditemukan pada usia lanjut. hal ini sesuai pendapat yang disampaikan potter, p.a & perry (2005) yang menjelaskan bahwa tekanan darah dewasa cenderung meningkat seiring dengan pertambahan usia. perubahan tingkat kesadaran biasanya dimulai dengan adanya gangguan fungsi diensefalon yang ditandai kebuntuan, kebingungan, letargi dan akhirnya stupor. penurunan kesadaran yang berkelanjutan terjadi pada disfungsi otak tengan dan ditandai dengan semakin dalamnya keadaan stupor. akhirnya dapat terjadi disfungsi medula dan pons yang menyebabkan koma. penurunan progresif kesadaran ini digambarkan sebagai perkembangan rostal-kaudal. volume intrakranial yang kaku berisi jaringan otak (1400g), darah (75ml), dan cairan serebro spinalis (75ml), volume dan tekanan pada ketiga komponen ini selalu berhubungan dengan keadaan keseimbangan. adanya peningkatan salah satu dari komponen ini menyebabkan perubahan pada volume yang lain. keadaan patologis seperti lesi, epileptik, stroke, infeksi dan bedah intrakranial dapat mengubah hubungan antara volume intrakranial dan tekanan.sehingga dapat menyebab kan gangguan pada batang otak /diensefalon. ketika terjadi gangguan kompensasi intracronial gagal dan terjadi peningkatan tekanan intrakranial (tik). peningkatan tekanan intrakranial secara singnifikan dapat menurunkan aliran darah dan menyebabkan iskemia. bila terjadi iskemia komplet dan lebih dari 3 sampai 5 menit, otak akan menderita kerusakan yang tidak dapat di perbaiki. hal ini terjadi di sebabkan oleh deteksi dini derajad kesadaran (martono. dkk.) 77 penurunan perfusi serebral yang mempengaruhi perubahan keadaan sel dan mengakibatkan hipoksia serebral. pada fase-fase ini menunjukkan perubahan status mental dan tanda – tanda vital bradikardi, tekanan denyut nadi melebar dan perubahan pernafasan (smeltzer, suzanne c & bare, 2005). prediksi tingkat kesadaran pasien dengan cidera kepala melalui pengukuran nilai kritis mean artery pressure nilai mean artery pressure pada penelitian menjadi estimator secara tidak langsung terhadap tingkat kesadaran pada pasien cidera kepala. kecukupan mean artery pressure di otak memberikan kontribusi berat ringannya gangguan kesadaran pada pasien cidera kepala. hasil penelitian ini didukung laporan penelitian yang dipublikasikan oleh jing-yuan xu, siqing ma, chun pan, hong-li he, shi-xia cai, shu-ling hu, ai-ran liu, ling liu, ying-zi huang, feng-mei guo (2015) yang menjelaskan bahwa peningkatan mean arterial pressure lebih dari 65 mmhg dapat memperbaiki mikrosirkulasi pada pasien shock septic. selain itu penelitian yang dilakukan oleh marc leone, pierre asfar, peter radermacher, jean-louis vincent (2015) dijelaskan bahwa map sekitar 75 hingga 85 mm hg dapat mengurangi perkembangan cidera ginjal akut pada pasien hipertensi arteri kronis. akan tetapi, hasil penelitian ini bertolak belakang dengan penelitian sebelumnya yang dilakukan oleh balgis desy, joni wahyuhadi, (2011) tentang hubungan antara tekanan intrakranial dan tekanan intraokular, tekanan intraokular dan mean arterial pressure pada pasien dengan cedera otak, dimana ditemukan korelasi yang signifikan antara tekanan intraokular pre dan pasca operasi juga tekanan intrakranial pre dan pasca operasi. namun, korelasi antara tekanan intraokular dan tekanan intrakranial, dengan mean arterial pressure tidak signifikan. namun demikian, dapat dijelaskan bahwa pasien dengan ceidera kepala secara patofisiologi memungkinkan terjadinya kerusakan jaringan otak (cereberal) dan peningkatan tekanan intrakranial, sehingga sistem autoregulasi di otak sebagai susunan saraf pusat juga mengalami ganguan. pada cidera kepala, terganggunya mekanisme autoregulasi otak akan berakibat aliran darah ke otak secara pasif tergantung pada mean arterial pressure, yang seanjutnya akan diikuti oleh turunnya tekanan perfusi otak (tpo) dan aliran darah ke otak (guyton & hall, 2005). selain itu, menurut hayens (2003) menjelaskan bahwa tekanan darah dikontrol oleh otak, sistem saraf otonom, ginjal beberapa kelenjar endokrin, arteri dan jantung. otak merupakan pusat pengontrol tekanan darah di dalam tubuh. serabut saraf adalah bagian sistem saraf otonom yang membawa isyarat dari bagian tubuh untuk menginformasikan kepada otak perihal tekanan darah, volume darah dan kebutuhan khusus semua organ. semua informasi ini diproses oleh otak dan hasilnya dikirim melalui saraf menuju organ-organ tubuh termasuk pembuluh darah, yang ditandai dengan mengempis atau mengembangnya pembuluh darah. sistem reflek neuronal ini yang mengatur mean arterial pressure bekerja dalam suatu rangkaian umpan balik negatif terdiri dari detektor, berupa baroreseptor yaitu suatu reseptor regang yang mampu mendeteksi peregangan dinding pembuluh darah oleh peningkatan tekanan darah, dan kemoreseptor, yaitu sensor yang mendeteksi perubahan po2, pco2 dan ph darah, neuronal aferen pusat kendali di medula oblongata. neuronal eferen yang terdiri dari sistem saraf otonom serta efektor, yang terdiri dari alat pemacu dan selsel otot jantung, sel-sel otot polos di arteri, vena dan medula adrenal. gangguan pada susunan saraf pusat dan tekanan intrakranial mengakibatkan penurunan aliran darah ke otak dan kerusakan otak yang selanjutnya mengakibatkan penurunan kesadaran. simpulan dan saran simpulan hasil penelitian menunjukkan bahwa ada pengaruh yang positif nilai kritis mean artery pressure terhadap derajat kesadaran pasien cidera kepala dan nilai mean artery pressure mampu mendeteksi tingkat kesadaran pasien cidera kepala sebesar 77.8%. hambatan pelaksanaan penelitian ini adalah kesulitan mengetahui langsung riwayat dan teknik pertolongan awal yang dilakukan oleh masyarakat sebelum pasien tersebut dibawa di unit gawat darurat rumah sakit karena hal tersebut dapat mempengaruhi nilai mean artery pressure dan berat ringannya cidera kepala . saran p e n e n t u k e b i j a k a n ( p o l i c y m a k e r ) hendaknya meningkatkan informasi tentang pertolongan pertama pada pasien cidera kepala 78 bagi tenaga kesehatan khususnya teknik ambulasi pasien cidera kepala dan perlunya protap alogaritma atau prosedur tata urutan penanganan kegawatandaruratan pada pasien cidera kepala. perlunya memberdayakan kepada masyarakat untuk menjadi awam khusus yang diharapkan mampu memberikan penanganan kegawatandaruratan pasien cidera kepala dengan cara memberikan pendidikan dan pelatihan karena masyarakat sangat menentukan saat pertama kali menemukan korban. kepustakaan balgis desy, joni wahyuhadi, m. (2011). hubungan antara tekanan intraokuli, tekanan intrakranial dan mean arterial pressure pada penderita cedera otak berat. surabaya. black, j.m. & matassarin-jacobs, f. (1993). luckmann and sorensen’s medicalsurgical nursing: a psychophysiologic approach. (4, ed.). philadelphia: w.b. saunders company. guyton & hall. (2005). buku ajar fisiologi kedokteran. jakarta: egc. hayens, b. (2003). buku pintar menaklukan hipertensi. jakarta: ladang pustaka dan intimedia. howard d. sesso, meir j. stampfer, bernard rosner, charles h. hennekens, j. michael gaziano, joann e. manson, r. j. g. (2000). systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure as predictors of cardiovascular disease risk in men. hypertension aha journal, 36, 801–807. jing-yuan xu, si-qing ma, chun pan, hong-li he, shi-xia cai, shu-ling hu, ai-ran liu, ling liu, ying-zi huang, feng-mei guo, y. y. and h.-b. q. (2015). a high mean arterial pressure target is associated with improved microcirculation in septic shock patients with previous hypertension: a prospective open label study” yang hasilnya bahwa increasing mean arterial pressure from 65 mmhg to normal levels is a. critical care journal, 19(1), 130. marc leone, pierre asfar, peter radermacher, jean-louis vincent, and c. m. (2015). optimizing mean arterial pressure in septic shock: a critical reappraisal of the literature. critical care journal, 19(1), 101. nurfaise., moh. zainuddin., a. w. (2012). hubungan derajat cedera kepala dan gambaran ct scan pada penderita cedera kepala. universitas tanjungpura pontianak. potter, p.a, perry, a. . (2005). buku ajar fundamental keperawatan : konsep, proses, dan praktik (edisi 4). price, sylvia a., & wilson, l. . (2006). pathofosiologi: konsep klinis proses– proses penyakit. jakarta: egc. smeltzer, suzanne c & bare, b. g. (2005). buku ajar keperawatan medikal bedah brunner & suddarth. jakarta: egc. 118 acceptance and commitment therapy (act) meningkatkan kualitas hidup pasien kanker (acceptance and commitment therapy improve the quality of life patients suffering cancer) saverinus suhardin*, kusnanto*, ilya krisnana* program studi pendidikan ners fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya 60115 telp(031)5913752 ,5913754 ,fax. (031)5913257 email: saverinussuhardin@gmail.com abstrak pendahuluan: kanker adalah penyakit kronis yang mempengaruhi dimensi fisik, psikologis, sosial, dan ekonomi kehidupan individu sehingga berpengaruh terhadap kualitas hidup. psikoterapi penting dalam meningkatkan kulitas hidup penderita kanker salah satu psikoterapi yang dapat diberikan adalah dengan penerapan act (acceptance and commitment therapy). penelitian ini bertujuan untuk menganalisis penerapan act dalam meningkatkan kualitas hidup penderita kanker di puskesmas pacarkeling surabaya. metode: metode yang digunakan dalam penelitian ini adalah pra-eksperimental dengan rancangan one group pre-post test design. populasinya penderita kanker yang terdaftar di puskesmas pacar keling. sampel yang berpartisi 12 orang yang ditentukan berdasarkan kriteria inklusi. variabel independennya berupa penerapan act dan variabel dependennya kualitas hidup. pengumpulan data dan penerapan act dilaksanakan di puskesmas serta melakukan kunjungan rumah. data yang terkumpul kemudian dianalisis menggunakan uji paired t test dengan tingkat kemaknaan α=0,05. hasil: hasil penelitian menunjukkan adanya perubahan peningkatan kualitas hidup pasien kanker secara signifikan setelah dilakukan penerapan act. hasil uji statistik paired t-test menunjukkan kualitas hidup pasien mempunyai tingkat signifikansi atau nilai p=0,000. hasil tersebut menunjukkan nilai p < 0,05, sehingga hipotesis penelitian diterima. pembahasan: berdasarkan hasil penelitian act dapat meningkatan kualitas hidup pasien kanker di puskesmas pacar keling surabaya, sehingga perawat perlu menguasai pelaksanaan act sebagai salah satu terapi modalitas. kata kunci: kanker, kualitas hidup (qol), acceptance and commitment therapy (act). abstract introduction: cancer is a chronic disease that affects physical, psychological, social, and economic life of individual and then contributes to life quality. psychotherapy is important in improving the life quality of cancer patients . one of psychotherapy that can be given is the implementation of act (acceptance and commitment therapy). the aim of this study is to analyze the application of act in improving the life quality of cancer patients at the puskesmas pacarkeling surabaya. method: this research method used pre-experimental with one group pre-post test design. the population of cancer patients enrolled in the puskesmas pacar keling. samples were 12 people whom are determined based on the inclusion criteria. the independent variable is application of act and the dependent variable is life quality. data collection and implementation of act were conducted in puskemas and home visits. the collected data was analyzed by paired t test with significance level α=0.05. result: result showed that there was change in increasing life quality of cancer patients significantly after giving implementation of the act. the result of paired t-test showed the life quality of patients had a significance level of p=0.000. these result demonstrate the value of p <0.05, so the research hypothesis is accepted. discussion: it can be concluded that the application of act can improve the life quality of cancer patients. health workers (nurses) need to master the implementation of the act as a therapeutic modality. keywords: cancer, quality of life (qol), acceptance and commitment therapy (act). ____________________________________________________________________________________________________ pendahuluan penyakit kanker merupakan momok bagi setiap orang. hal ini terjadi akibat dampak yang dialami oleh penderita dan keluarganya. terjadinya kanker dikarenakan adanya pertumbuhan sel yang tidak terkontrol dan terjadi tanpa batas dan tanpa tujuan bagi penderitanya. kanker merupakan pertumbuhan sel abnormal yang cenderung menyerang jaringan di sekitarnya dan menyerang ke organ tubuh lain yang letaknya jauh (corwin 2009). kanker adalah penyakit kronis yang mempengaruhi dimensi fisik, psikologis, sosial, dan ekonomi kehidupan individu. diagnosis kanker dapat disertai gangguan emosional dan perubahan gaya hidup atau kebiasaan seharihari (smeltzer 2001). setelah seseorang dinyatakan menderita kanker, secara khas akan mengalamai ketakutan, kecemasan, depresi dan ketidakberdayaan (feist. 2007). kemajuan diagnosis dan terapi, mendukung penderita kanker yang bertahan hidup lama. bentuk utama terapi penyembuhan kanker (operasi, kemoterapi, terapi hormon, terapi radiasi), biasanya mengakibatkan efek samping jangka panjang yang tidak diharapkan mailto:saverinussuhardin@gmail.com jurnal ners vol. 11 no. 1 april 2016: 118-127 119 pada jaringan dan organ tubuh serta mengganggu tingkat kesehatan dan kualitas hidup seseorang baik dalam bentuk kecil maupun besar (potter & perry 2009). psikoterapi penting, khususnya dalam meningkatkan kulitas hidup penderita kanker (feist. 2007). salah satu terapi yang dapat diberikan adalah dengan melakukan terapi act. act dikatakan sangat efektif dalam menciptakan penerimaan, perhatian dan lebih terbuka dalam mengembangkan kemampuan yang dimiliki pada klien depresi, ansietas, penyalahgunaan narkoba, nyeri kronik, ptsd, anoreksia dan skizofrenia serta sangat efektif dalam pelatihan diri (widuri 2012). dalam beberapa penelitian di indonesia yang menerapkan intervensi terapi penerimaan dan komitmen (act), mengatasi respon ketidakberdayaan sedang pada klien gagal ginjal kronik (widuri 2012), meningkatkan penerimaan penderita hiv/aids (widjijati, wahyuningsih 2014), meningkatkan insight dan efikasi diri pada pasein skizofrenia (jalil et al. 2013), dan dapat meningkatkan subjective well being pada dewasa muda pasca putusanya hubungan pacaran (kusumawardhani 2012). hingga kini, penelitian mengenai pengaruh penerapan acceptance and commitment therapy (act) terhadap kualias hidup penderita kanker belum dapat dijelaskan. menurut perkiraan badan internasional untuk penelitian kanker (iarc), terdapat 12,7 juta kasus kanker baru pada tahun 2008 di seluruh dunia, dimana 5,6 juta terjadi di negara-negara maju dan 7,1 juta di negaranegara berkembang (society 2011). berdasarkan riset kesehatan dasar (riskesdas) 2013, prevalensi kanker di indonesia sebesar 1,4 per 1000 penduduk. kanker merupakan penyebab kematian nomor tujuh di indonesia dengan presentasi 5,7% dari seluruh penyebab kematian (ditjen pp & pl kemenkes ri, 2014). data bappeda jawa timur (2011) melaporkan ada peningkatan penderita kanker dalam kurun waktu lima tahun antara 2005 hingga 2010. pada tahun 2005 terdapat 1.600 penderita, tahun 2008 meningkat menjadi 3.821 penderita, dan tahun 2010 mencapai 4.736 penderita (fitriawan 2013). berdasarkan penjajakan awal yang dilakukan peneliti di puskesmas pacar keling surabaya tanggal 23 september 2014, didapatkan informasi dari perawat penanggungjawab poli paliatif bahwa secara umum mereka tidak melakukan pengukuran kualitas hidup pasien kanker. namun, sebagai gambaran dijelaskan bahwa pasien sering mengeluh nyeri, mual, muntah, gangguan tidur, mudah lelah dalam melakukan aktivitas sehari-hari, dan tampak murung (tidak bersemangat). layanan pengobatan bagi pasien kanker dilaksanakan setiap hari sabtu. penelitian fitriawan (2013) yang dilakukan di puskesmas pacarkeling kota surabaya, ditemukan fakta beberapa pasien kanker mengalami penurunan kualitas hidup . berdasarkan survey awal peneliti pada penelitian tersebut, dari 30 orang pasien digambarkan kualitas hidup pasien yang rendah sebanyak 15%, sedang sebanyak 25%, dan tinggi sebanyak 60%. pada bagian saran, peneliti mengharapkan ada peneliti lain yang dapat memberikan intervensi untuk meningkatkan kulitas hidup pasien kanker. kualitas hidup adalah konsep yang mencakup karakteristik fisik, mental, sosial, emosional, yang mencakup komplikasi dan efek terapi suatu penyakit secara luas yang menggambarkan kemampuan individu untuk berperan dalam lingkungannya dan memperoleh kepuasan dari yang dilakukannya. kualitas hidup yang berhubungan dengan kesehatan menggambarkan tingkat kesehatan seseorang yang mengalami suatu penyakit dan mendapatkan pengelolaan sesuai dengan pedoman penyakit tertentu (suharto 2005). konsep kualitas hidup seseorang yang dipengaruhi olah kanker meliputi dimensi kesejahteraan fisik dan gejalanya, dimensi kesejahteraan psikologikal, dimensi kesejahteraan sosial dan dimensi kesejahteraan spiritual (potter & perry 2009). kesejahteraan fisik mencakup gejala dan efek samping seperti nyeri, kelelahan, dan kualitas tidur yang buruk, mempengaruhi kemampuan untuk melakukan aktivitas sehari-hari. kesejahteraan psikologis, mengacu pada kemampuan untuk mempertahankan kontrol atas kecemasan, depresi, takut kekambuhan kanker, dan masalah dengan memori dan konsentrasi. kesejahteraan sosial, terutama hubungan dengan anggota keluarga lain dan temanteman, termasuk keintiman dan seksualitas. kekhawatiran mengenai pekerjaan, asuransi, dan keuangan juga mempengaruhi kesejahteraan sosial. lalu, kesejahteraan spiritual berasal dari gambaran makna pengalaman kanker, baik dalam konteks agama atau melalui mempertahankan harapan dan ketahan dalam menghadapi ketidakpastian tentang kesehatan di masa depan (society 2011). acceptance and commitment therapy (saverinus suhardin, dkk.) 120 hidup yang berkualitas merupakan kondisi dimana pasien kendati mengalami penyakit yang diderinya, dapat tetap merasa nyaman secara fisik, psikologis, sosial, maupun spiritual serta secara optimal memanfaatkan hidupnya untuk kebahagiaan dirinya maupun orang lain (widuri 2012). setiap penderita kanker, mengalami suatu penderitaan yang dapat berkembang menjadi penderitaan total, mencakup derita fisik, mental, sosial, kultural dan spiritual. derita total tersebut terjadi karena proses kumulatif dari rasa nyeri dan keluhan fisik dan psikis lainnya, seperti mual, muntah, sesak, luka, tak nafsu makan, berbagai prosedur diagnostik, tindakan terapi, rasa takut, marah, sepi, khawatir, bosan, dan berbagai perasaan lain yang membuat penderita tidak merasa aman dan nyaman. apabila kualitas hidup pasien kanker tidak ditangani secara tepat, maka akan berdampak semakin buruknya kondisi kesehatan yang dialami sehingga mempengaruhi morbiditas dan mortalitas penderita kanker. kualitas hidup seseorang ditentukan oleh individu itu sendiri, karena sifatnya sangat spesifik, dan bersifat abstrak, sulit diukur. melakukan penilaian kualitas hidup pasien perlu diperhatikan beberapa hal, termasuk yang paling utama adalah beberapa domain/aspek yang mendasarinya. alat ukur kualitas hidup telah banyak dikembangkan oleh para ilmuan yang digunakan untuk mengukur kualitas hidup pasien-pasien yang menderita berbagai penyakit kronik, dan salah satunya adalah alat ukur yang dikembangkan oleh the european organization for research and treatment of cancer quality of life core questionnaire (eortc qlq-c30). kuesioner ini merupakan alat ukur yang spesifik mengukur kualitas hidup pasien kanker secara umum dan telah dinyatakan valid digunakan di indonesia oleh penelitian perwitasari (2011). act merupakan salah satu psikoterapi yang diyakini mampu memperbaiki kualitas hidup klien kanker. hal ini didasari bukti hasil penelitian act menunjukkan efektif dalam mengatasi beberapa gejala yang menjadi komponen pembentuk atau yang mempengaruhi kualitas hidup seseorang. act merupakan terapi yang mengajarkan pasien untuk menerima pikiran yang mengganggu dan dianggap tidak menyenangkan dengan menempatkan diri sesuai dengan nilai yang dianut sehingga ia akan menerima kondisi yang ada (widuri 2012). terapi act mengajarkan pasien untuk menerima pikiran yang mengganggu dan dianggap tidak menyenangkan seperti perasaan ketakutan, kecemasan, depresi, ketidakberdayaan dan berbagai respon fisik. selanjutnya pasien diarahkan untuk mampu menempatkan diri sesuai nilai yang dianut dan berkomitmen menjalankan berbagai terapi untuk mencegah bertambah parahnya gejala. tujuan akhir dari terapi act ini adalah, pasien akan mengalami fleksibilitas psikologis. kondisi psikologis yang fleksibel ini memberi persepsi dasar yang lebih positif akan meningkatkan kualitas hidup pasein kanker. bahan dan metode penelitian menggunakan metode praeksperimental dengan rancangan one group pre-post test design yang mengungkapkan hubungan sebab akibat dengan melibatkan satu kelompok subjek. populasinya adalah penderita kanker yang terdaftar dan bertempat tinggal di wilayah puskesmas pacar keling surabaya, berdasarkan pengambilan data awal pada tanggal 23 september 2014 sebanyak 30 penderita. pengambilan sampel dilakukan dengan teknik purposive sampling, yaitu suatu teknik penetapan sampel dengan cara memilih sampel diantara populasi sesuai dengan kehendak peneliti (tujuan atau masalah dalam penelitian), sehingga sampel tersebut dapat mewakili karakteristik populasi yang telah dikenal sebelumnya. pengambilan sampel dengan memenuhi kriteria inklusi sebagai berikut: 1) menderita kanker, 2) mengalami penurunan kualitas hidup, 3) sedang menjalani terapi pengobatan di puskesmas, 4) bisa membaca dan menulis. sedangkan kriteria eksklusi sebagai berikut: 1) penderita kanker yang mengalami penyakit komplikasi, yang mana menyulitkan dalam penerapan act (tidak kooperatif), 2) penderita kanker tidak didiagnosa gangguan jiwa. variabel independen dalam penelitian ini adalah acceptance and commitent therapy (act) sedangkan terapi dependen adalah kualitas hidup pada penderita kanker. alat ukur kualitas hidup penderita kanker menggunakan kuesioner eortc qlq-c30 (the european organization for research and treatment of cancer quality of life core questionnaire) karena dapat digunakan pada semua tipe kanker sesuai tujuan penelitian. instrumen lain yang digunakan dalam penelitian jurnal ners vol. 11 no. 1 april 2016: 118-127 121 ini adalah panduan atau strategi pelaksanaan kegiatan act, buku kerja, dan lembar observasi. data yang terkumpul kemudian dianalisis menggunakan uji statistik paired t-test dengan tingkat kemaknaan α = 0,05. hasil hasil penelitian ini akan dibagi menjadi tiga bagian mengikuti skala yang ada dalam pengukuran kualitas hidup berdasarkan eortc qlq-c30, meliputi: 1) hasil skala kesehatan umum/qol menunjukan tingkat signifikansi atau nilai p= 0,000 yang bermakna adanya pengaruh penerapan act, 2) hasil skala fungsional menunjukkan adanya pengaruh penerapan act terhadap hasil pengukurannya pasca-intervensi. terdapat sub bagian dari skala fungsional yang terdiri dari fungsi fisik, fungsi peran, fungsi emosional, fungsi kognitif, dan fungsi sosial dengan tingkat signifikansi atau nilai p secara berurutan sebagai berikut: p=0.005, p=0.001, p=0.001, p=0.042, dan p = 0.008. semua komponen skala fungsional tersebut memiliki signifikansi atau nilai p<0,05, yang berarti penerapan act memiliki pengaruh yang positif, 3) hasil skala gejala menunjukkan tidak semua komponen mempunyai tingkat signifikansi atau nila p<0,05. adapun komponen yang dipengaruhi oleh penerapan act diantaranya kelelahan (p=0,000), mual dan muntah (p=0.002), hilang nafsu makan (p=0,017), nyeri (p= 0,000) dan insomnia (p=0,007). sedangkan komponen yang tidak memiliki nilai signifikansi <0,05, meliputi: sesak nafas (p= 0,082), konstipasi (p= 0,339), diare (p= 0,166), dan kesulitan finansial (p=0,191). pembahasan hasil penelitian menunjukkan skala kesehatan umum / kualitas hidup (qol) memiliki tingkat signifikansi atau nilai p= 0,000. nilai tersebut menunjukkan adanya pengaruh penerapan act terhadap peningkatan kualitas hidup pasien kanker, dimana nilainya <0.05. pada kuesioner yang diisi responden, terdapat dua (2) pertanyaan yang mewakili untuk menggali skala kesehatan umum atau kualitas hidup. pertanyaan tersebut mengungkapkan penilaian masing-masing responden terhadap kondisi kesehatan secara keseluruhan dan kualitas hidup selama seminggu yang lalu. skor yang diperoleh responden sebelum dilakukan penerapan act (pre-test) diperoleh nilai rata-rata 48,6. pada post-test, terjadi peningkatan skor kesehatan umum/kualitas hidup dengan nilai rata-rata yang diperoleh 62,5. act merupakan terapi untuk meningkatkan fleksibilitas psikologis, yaitu kemampuan melakukan kontak dengan masa kini secara total dan mampu berperilaku sesuai dengan value hidup yang dianut (hayes 2013). penerapan act dapat meningkatkan kemampuan klien dalam menerima dan berdamai dengan kondisi kesehatannya, serta dapat membuat keputusan dalam memilih komitmen yang akan dilakukan untuk mencegah kekambuhan (jalil et al. 2013). penerimaan atau berdamai dengan kondisi sakitnya serta melakukan aksi untuk mencegah kekambuhan menunjukkan seseorang mempunyai persepsi yang positif akan kondisinya. persepsi yang baik tentang kesehatan seseorang memberi pengaruh pada kualitas hidup sesorang. hal ini berkaitan dengan teori yang pernah dikutip nofitri (2009) dalam laporan penelitiannya menerangkan bahwa lingkup dari konsep dan pengukuran kualitas hidup harus berpusat pada persepsi subjektif individu mengenai kualitas hidup dari kehidupannya sendiri. dikuatkan lagi dengan teori carr dan hingginson (2001) yang menegaskan bahwa kualitas hidup merupakan suatu konstruk yang bersifat individual. lalu kemudian disimpulkan bahwa, komponen objektif dari kualitas hidup tidak mempengaruhi kualitas hidup itu sendiri secara langsung, melainkan diperantarai oleh persepsi individu. kualitas hidup merupakan interaksi antara penghayatan subjektif (komponen subjektif) dan bobot kepentingan (komponen kepentingan) dalam / dari aspek-aspek kehidupan tertentu, dengan beberapa faktor kondisi kehidupan yang dapat berpengaruh ataupun tidak tergantung dari persepsi individu mengenai berbagai kondisi kehidupan (nofitri 2009). karena sangat subyektif, kualitas hidup sesorang dapat dikendalikan dengan membentuk persepsi yang sesuai. persepsi yang positif akan kondisi dirinya akan berpengaruh pada kualitas hidup. dalam penerapan act, terapis mengarahkan klien untuk mampu berdamai atau menerima kondisinya saat ini, sambil melakukan langkah konkrit untuk penyembuhan atau mencegah kekambuhan. jika klien mampu menerima kondisi sakitnya dan berkomitmen mengikuti terapi atau pengobatan penunjang, persepsi akan dirinya acceptance and commitment therapy (saverinus suhardin, dkk.) 122 sendiri menjadi lebih bermakna. persepsi inilah yang membentuk kualitas hidup sesorang. act mampu membentuk persepsi yang positif dijelaskan melalui penelitian kusumawardhani (2012). dalam penelitiannya, penerapan act dianggap efektif dalam meningkatkan subjective well being atau kebahagiaan seseorang. kondisi ini mendukung terciptanya kondisi atau persepsi yang positif terkait kondisi yang dialami. pernyataan ini dikuatkan oleh teori dari carr (2004) yang dikutip kusumawardhani (2012) bahwa subjective well being berkaitan erat dengan kondisi-kondisi positif yang membantu seseorang menjalankan fungsinya secara optimal. kondisi positif inilah yang akan membentuk persepsi yang positif pula, yang pada gilirannya mempengaruhi kualitas hidup seseorang. dari sejumlah responden yang terlibat dalam penelitian, diidentifikasi responden dengan nomor 06 memperoleh skor dimensi kesehatan umum/qol paling rendah, yaitu 33. berdasarkan data demografi dan wawancara peneliti, ada beberapa kondisi spesifik yang dialaminya. responden baru mengetahui sakit yang dideritanya merupakan kanker paru-paru sejak 2 bulan terakhir. saat memeriksa ke rumah sakit, pengobatan sementara yang dilakukan berupa pemberian obat penurun nyeri dan sesak nafas. dokter memberi kesempatan untuk berpikir atau berencana melakukan kemoterapi. kondisi fisiknya cukup lemah, mengeluh nyeri dada, sesak nafas, mual dan nafsu makan menurun. kondisi sakit yang cukup parah dan kemampuan adaptasi penderita dan keluarga belum optimal mengakibat kualitas hidup yang diukur menunjukkan skor terendah dari sejumlah responden lainnya. selain itu, keluarga dan penderita melakukan perundingan yang cukup lama sebelum memutuskan berobat ke rumah sakit. setelah beberapa kali menerapkan act oleh peneliti dan penjelasan bagi anggota keluarganya, barulah penderita dirawat ke rumah sakit. pada pengukuran kualitas hidup pascaintervensi, didapatkan skor lebih tinggi dari kondisi sebelumnya, meskipun tidak begitu signifikan. adapula responden yang memperoleh skor paling tinggi dari total keseluruhannya. responden nomor 3 dan 4 mendapat skor pling tinggi, yaitu 67. kondisi tersebut didukung oleh lamanya penyakit yang diderita, pengobatan yang cepat dan tepat, serta tetap melakukan pemeriksaan secara rutin di puskesmas . responden nomor 3 sudah mengalami kanker nasofaring semenjak satu tahun lalu, dan sudah dilakukan kemoterapi dan terapi sinar. penderita sering mendapatkan informasi serta motivasi dalam menghadapi penyakitnya selama masa pengobatan, sehingga lebih mampu menerima dan menjalani dengan ikhlas. begitupula dengan responden nomor 4, sudah menderita kanker serviks semenjak 2 tahun lalu. penderita sudah dilakukan operasi dan rutin melakukan kontrol di puskesmas maupun rumah sakit. adaptasi terhadap penyakitnya sudah dilakukan dengan baik sehingga kualitas hidup ikut membaik. semua komponen skala fungsional memiliki signifikansi atau nilai p <0,05, yang berarti penerapan act memiliki pengaruh yang positif. fungsi fisik mencakup kemampuan responden melakukan aktivitas sehari-hari, seperti membawa barang-barang yang berat, berjalan kaki dengan jarak yang jauh, berjalan kaki dengan jarak dekat (misalnya di sekitar rumah), apakah hanya berbaring di tempat tidur atau duduk di kursi saja, dan apakah memerlukan bantuan saat memenuhi kebutuhan dasar (mandi, makan, berpakaian, toileting). sesuai skor hasil pengisian kuesioner responden, terjadi perubahan nilai rata-rata setelah penerapan act, yaitu dari skor 72,9 menjadi 77,5. fungsi peran diidentifikasi melalui pertanyaan berkaitan dengan keterbatasan saat bekerja atau melaksanakan kegiatan sehari-hari dan melakukan kegiatan santai atau kegiatan yang merupakan hobi. skor hasil pengukuran kuesioner mengalami peningkatan setelah penerapan act, yaitu dari nilai 59,4 menjadi 69,4. fungsi emosional meliputi pertanyaan tentang perasaan tegang, khawatir, tersinggung, dan depresi. fungsi emosional juga mengalami perubahan nilai/skor setelah penerapan act, dari rata-rata 63 menjadi 69,4. fungsi kognitif meliputi kemampuan seseorang dalam berkonsentrasi pada suatu hal (mis. membaca koran atau menonton tv) dan kemampuan untuk mengingat sesuatu. pada fungsi kognitif ini, setelah penerapan act terjadi perubahan skor rata-rata dari 71,6 menjadi 75,5. komponen terakhir, fungsi sosial, dimana mengukur hubungan sosial responden selama menderita kanker. secara riil, fungsi sosial mengindentifikasi apakah keluarga merasa terganggu dan kesulitan yang jurnal ners vol. 11 no. 1 april 2016: 118-127 123 dihadapi responden sendiri dalam menjalankan aktivitas sosial akibat kondisi fisik atau terapi medis yang dijalani. secara umum, skor ratarata fungsi sosial berubah setelah penerapan act, yaitu dari 56,25 menjadi 64,08. hasil penelitian di atas didukung beberapa penelitian sebelumnya. penelitian mc cracken (2011) dalam widuri (2012) memberikan act dengan tindak lanjut follow up selama 3 bulan pada kelompok intervensi yang mengalami penyakit kronik menunjukan penurunan level depresi, kecemasan, intensitas nyri kronik yang dialami, peningkatan kemampuan fisik, dan menjadi lebih fleksibel secara psikologis dalam menghadapi stresor yang berkaitan dengan kondisinya. act dianggap sebagai terapi yang sesuai untuk menyelesaikan permasalahan depresi dan meningkatkan kesehatan mental karena act membuat seseorang mampu menerima setiap pengalaman dan peristiwa yang telah terjadi dan kembali berfungsi dengan normal dalam menjalani kehidupan sehari-hari sesuai dengan value dan tujuan hidupnya (kusumawardhani 2012). hasil penelitian pendukung terdahulu di atas menunjukan perubahan ke arah yang positif pada komponen gejala psikologis dari setiap masalah. komponen-komponen psikologis tersebut merupakan komponen yang sama sebagai penyusun skala fungsional dari pasien kanker. peningkatan kemampuan fisik, penurunan atau perubahan level depresi, kecemasan, stres dan menyadari dukungan sosial yang baik memberi peningkatan kemampuan bagi pasien kanker secara fungsional. jadi, bisa disimpulkan bahwa penerapan act memberi pengaruh yang signifikan terhadap perubahan positif skala fugsional pasien kanker. act melakukan perubahan pada skala fungsional pasien kanker melalui prinsipprinsip yang mendasarinya, meliputi: acceptance, cognitive defusion, mindfulness, observing self, value, dan commitment. kusumawardhani (2012) menjelaskan prinsip act tersebut seperti berikut ini. acceptance adalah proses untuk meingkatkan penerimaan secara menyeluruh terhadap pengalaman subjektif, meliputi pemikiran, kepercayaan, sensasi, dan perasaan yang menimbulkan distres, sebagai usaha untuk meningkatkan perubahan perilaku yang diinginkan sehingga mengarah pada meningkatnya kualitas hidup. prinsip cognitive defusion bermakna sebagai proses mengamati pemikiran, sehingga dampak dan pengaruhnya menjadi lebih sedikit dibanding ketika mengalami fusion dengan pemikiran kita. prinsip ketiga, mindfulness, diharapkan mampu memberikan fokus dan terlibat penuh terhadap apa yang ia lakukan di masa kini. kemudian, prinsip observing self memungkinkan individu untuk mengalami langsung bahwa dirinya bukan hanya sekedar pikirannya, emosinya, perannya, sensasi tubuhnya, dan dorongannya. prinsip kelima, value, bertujuan mengklarifikasi apa yang paling penting bagi seorang individu dalam hidupnya, ingin menjadi seperti apa, dan apa yang menjadi signifikan serta bermakna baginya. prinsip terakhir, commitment, diharapkan seseorang dapat menyusun tujuan hidup dipandu oleh value yang dianggapnya penting kemudian mengambil tindakan yang efektif untuk mencapainya. melalui teknik act ini, individu belajar untuk menghilangkan dampak dan pengaruh dari pikiran serta perasaan yang tidak diharapkan melalui penggunaan mindfulness secara efektif. jika sebelumnya mereka membuang waktu, energi, dan uang dengn sia-sia untuk mengontrol emosi, dengan teknik ini energi mereka disalurkan untuk proses pengambilan tindakan efektif agar hidup mereka menjadi lebih baik dan bermakna (harris 2011). ditemukan skor kualitas hidup dimensi fungsional terendah dilami oleh nomor 6. setelah dijumlahkan dari 5 item dimensi fungsional, didapatkan skor sebesar 238. kondisi tersebut sama atau berhubungan dengan dimensi kesehatan umum/qol yang telah dijelaskan sebelumnya. responden yang baru saja mengalami kanker paru-paru dan belum ditangani secara maksimal sangat berdampak pada dimensi fungsionalnya, yang terdiri dari fungsi fisik, fungsi peran, fungsi emosional, fungsi kognitif, dan fungsi sosial. kondisi fisik penderita makin melemah, keluhan nyeri, sesak nafas, mual dan tidak nafsu makan memperberat kemampuan fungsionalnya. sementara itu, responden nomor 5 memperoleh skor tertinggi pada dimensi fungsional, dimana setelah dijumlahkan dari 5 item fungsi menjadi 364. secara klinis, responden mengaku tidak merasakan lagi gejala akibat kanker maupun efek samping pengobatan. sudah 3 tahun melewati sakitnya, dan berhasil mengikuti pengobatan kemoterapi sebanyak 2 kali dan radiasi (sinar) sebanyak 35 kali, sehingga sudah mampu beradaptasi acceptance and commitment therapy (saverinus suhardin, dkk.) 124 dengan baik. responden bisa melakukan aktivitas atau fungsinya sehari-hari tanpa menimbulkan keluhan yang berarti. hasil penelitian skala gejala menunjukkan tidak semua komponen mempunyai tingkat signifikansi atau nila p < 0.05. adapun komponen yang dipengaruhi oleh penerapan act, diantanya: kelelahan, mual & muntah, hilang nafsu makan, nyeri, dan insomnia. sedangkan komponen yang tidak memiliki nilai signifikansi <0.05, meliputi: sesak nafas, konstipasi, diare, dan kesulitan finansial. pada responden, secara riil didapatkan gejala kelelahan bersumber dari kuesioner yang mencakup kebutuhan istirahat yang dirasakan, merasa badan lemah, dan merasa kelelahan. sebelum penerapan act, rata-rata responden memperoleh skor 47,4 dan setelanya mendapat skor rata-rata 36,4. khusus pada skala gejala, skor semakin rendah menunjukkan gejala yang dirasakan semakin berkurang. gejala mual dan muntah diidentifikasi dengan dengan pertanyaan tentang apakah merasa mual dan muntah. secara umum, responden mengalami sedikit gejala mual sebelum tindakan act tapi tidak sampai mengalami muntah. skor rata-rata yang diperoleh sebelum penerapan act adalah 16,9 dan setelahnya menjadi 7,08. gejala nyeri terdiri dari 2 unsur pertanyaan dalam pengindetifikasiannya, yaitu apakah merasa nyeri dan seberapa besar nyeri itu mengganggu aktivitas sehari-hari. skala gejala yang lainnya berupa item pertanyaan tunggal yang menanyakan tentang sesak nafas, kesulitan tidur, kehilangan nafsu makan, konstipasi, diare, dan kesulitan finansial. gejala kelelahan yang muncul pada pasien kanker bisa terjadi karena proses penyakit itu sendiri atau akibat gangguan tidur (potter & perry 2009). keletihan, sering terjadi akibat nutrisi yang buruk, malnutrisi protein, dan gangguan oksigenasi jaringan akibat anemia. sitokinin tertentu dihasilkan untuk menunjang respon imun terhadap kanker yang juga diketahui menyebabkan keletihan. tumor yang tumbuh menghambat suplai darah ke sel normal sambil merangsang suplai darah baginya. tumor tersebut mengambil alih nutrien dan suplai oksigen dari sel normal yang menyebabkan keletihan ekstrem (corwin 2009). sebagaimana penelitian terdahulu, penerapan act memberi hasil peningkatan kemampuan fisik (widuri 2012). selain itu, pada skala fungsional dalam penelitian ini juga mengalami peningkatan. skala fungsional, dimana salah satunya merupakan fungsi fisik yang optimal dapat meminimalkan gejala keletihan pasien kanker. didukung pula adanya perubahan positif pada skala gejala insomnia, dimana terjadi penurunan setelah intervensi act. hal ini memberi peluang bagi penderita kanker dapat melakukan istirahat yang cukup, sehingga keletihan ikut berkurang. secara umum terdapat dua efek fisiologis dari tidur: pertama, efek pada sistem saraf yang diperkirakan dapat memulihkan kepekaan normal dan keseimbangan diantara berbagai susunan saraf; dan kedua, efek pada struktur tubuh dengan pemulihan kesegaran dan fungsi dalam organ tubuh karena selama tidur terjadi penurunan (hidayat 2006). efek kedua inilah yang memberi manfaat positif bagi skala gejala kelelahan pada pasien kanker, sehingga mengalami penurunan setelah penerapan act. skala insomnia atau gangguan tidur juga mengalami perubahan ke arah yang baik pascaintervensi act. kebutuhan tidur yang terpenuhi dengan baik ini berhubungan dengan perubahanan pada skala fungsional setelah penerapan act juga. pada skala fungsional, khususnya fungsi emosional terjadi penurunan respon kondisi tegang, stres, depresi, yang dapat mengganggu tidur seseorang. selain itu, kebutuhan tidur juga saling berhubungan dengan kelelahan. pernyataan ini didukung teori kebutuhan tidur oleh hidayat (2006), yang menjelaskan bahwa keletihan akibat aktivitas yang tinggi dapat memerlukan lebih banyak tidur untuk menjaga keseimbangan energi yang telah dikeluarkan. hal tersebut terlihat pada seseorang yang telah melakukan aktivitas dan mencapai kelelahan, maka orang tersebut akan lebih cepat untuk dapat tidur karena tahap tidur gelombang lambatnya diperpendek. penderita kanker pada umumnya bisa mengalami gejala mual dan muntah akibat efek samping penyakit atau pengobatan yang diberikan. misalnya efek samping dari kemoterapi. pada penderita kanker yang menjalani kemoterapi, gangguan motiitas usus dapat disebabkan oleh neuropati otonomik akibat alkaloid vinca (vincristine, vinblastin) dan turut diperparah oleh antikanker lain, sehingga penderita mengalami mual-muntah (rasjidi 2013). namun, pada penelitian ini, responden tidak dalam sedang menjalankan kemoterapi karena telah melewatinya. jurnal ners vol. 11 no. 1 april 2016: 118-127 125 mual (nausea) adalah sensasi subjektif yang tidak menyenangkan dan sering mendahului muntah. mual disebabkan oleh distensi atau iritasi di bagian mana saja dari saluran gi, tetapi dapat juga distimulasi oleh pusat otak yang lebih tinggi. interpretasi mual terjadi di medula, berdekatan dengan bagian dari pusat muntah (corwin 2009). teori inilah yang mungkin terjadi pada responden, dimana kondisi stres, depresi akibat kanker mempengaruhi atau merangsang pusat mualmuntah di medula. karena penerapan act telah menurunkan stres, depresi, dan kondisi lainnya, maka gejala mual juga ikut menurun pascaintervensi. kondisi inilah yang menjelaskan bagaiman act menurunkan gejala mual-muntah pada penderita kanker. gejala hilang nafsu makan sangat berkaitan erat dengan dengan gejala mualmuntah di atas. saat gejala mual-muntah berkurang setelah penerapan act, gejala hilang nafsu makan juga ikut berkurang. sehingga dapat disimpulkan act dapat menurunkan gejala hilang nafsu makan pada pasien kanker. nyeri merupakan gejala yang sering muncul pada penderita kanker. terapi kanker sendiri sering menimbulkan rasa nyeri dan neuropati (potter & perry 2009). nyeri adalah sensasi subjektif rasa tidak nyaman yang biasanya berkaitan dengan kerusakan jaringan aktual atau potensial (corwin 2009). proliferasi kanker merupakan penyebab rusaknya jaringan falam konteks ini. beberapa penelitian tentang penerapan act menunjukan mampu mengurangi sensasi nyeri seseorang (harris 2011). widuri (2012) menyatakan bahwa act sangat berguna dalam mengatasi masalah penyakit kronik karena berfokus pada membangun perilaku yang baru dari pada melawan rasa sakitnya agar dapat menjalani kehidupan yang lebih dihargai. beberapa skala gejala yang dipengaruhi oleh penerapan act, secara umum, penjelasan proses kerjanya mengikuti hasil penelitian jalil et al. (2013) tentang efektivitas act dalam meningkat insight dan efikasi diri. jika hasil penelitian terbukti act meningkatkan insight dan efikasi diri, maka kedua kemampuan tersebut memungkinkan seseorang untuk mengenali gejala yang dialami dan mencari pertolongan yang tepat sehingga cepat teratasi. seperti itulah kinerja act dalam mengurangi beberapa gejala akibat penyakit kanker. komponen gejala sesak nafas, konstipasi, dan diare dari skala gejala tidak menunjukkan adanya pengaruh penerapan act. hal ini terjadi karena saat pre-test gejala-gejala ini hanya dialami sebagian kecil responden dengan intensitas yang rendah. sebagai gambaran, dari data hasil tabulasi menunjukkan gejala sesak nafas dialami oleh 4 orang responden, gejala konstipasi dialami 2 orang responden, dan gejala diare juga hanya dialami 2 orang responden. setelah dilakukan uji statistik, gejela-gejala tersebut tidak menunjukkan tingkat signifikansi pascaintervensi act. selain itu, gejala kesulitan finansial juga termasuk komponen yang tidak dipengaruhi act. hal ini didasari oleh pemahaman bahwa act merupakan terapi psikologis, yang merupakan bentuk pengembangan terapi kognitif perilaku, dimana keduanya melibatkan strategi tingkah laku dan kognitif (harris 2011). target dari act adalah membentuk fleksibilitas psikologis seseorang, yaitu kemampuan untuk melakukan kontak dengan masa kini secara totalitas dan sadar sebagai makhluk hidup dan mampu berperilaku sesuai dengan value yang dianut (kusumawardhani 2012). act tidak termasuk tindakan untuk mengatasi masalah kesulitan finansial seseorang. peneliti juga belum menemukan hasil penelitian sebelumnya yang berkaitan dengn kesulitan finansial dan act. sehingga, dapat disimpulkan bahwa penerapan act tidak berdampak pada kondisi finansial seseorang. berbeda dengan dimensi kesehatan umum dan fungsional, pada dimensi/skala gejala, nilai atau skor tertinggi menunjukkan beratnya gejala yang dialami responden. semakin rendah skor yang didapat, semakin baik gejala yang dialami penderita. hkeseluruhan responden, skor tertinggi (gejala memburuk) dialami responden nomor 6, dimana setelah ditotal dari beberapa item skala gejala didapatkan skor 467. kondisi tersebut bisa terjadi karena responden baru saja diketahui menderita kanker paru-paru dan belum mendapat penanganan khusus terhadap kanker. akibatnya, gejala yang timbul semakin memburuk. sebaliknya, skor terendah (gejala membaik) dialami oleh responden nomor 4 yakni sebesar 161 setelah dijumlahkan dari seluruh item gejala. kondisi tersebut didukung dengan riwayat sakit yang dialaminya. acceptance and commitment therapy (saverinus suhardin, dkk.) 126 menderita kanker serviks stadium ii sejak 2 tahun lalu dan langsung dilakukan operasi pada bulan ke-4 setelah didiagnosis. setelah itu, responden rutin melakukan kontrol atau pengobatan tambahan baik di puskesmas maupun rumah sakit. kini, secara klinis tidak menunjukkan gejala yang menganggu. itulah beberapa hal yang mendukung status kualitas hidup responden pada skala gejala. simpulan dan saran simpulan berdasarkan hasil penelitian yang telah dilakukan dapat disimpulkan bahwa: 1) penerapan act meningkatkan skala kesehatan umum / kualitas hidup (qol) pasien kanker. setelah penerapan act, responden lebih optimis menilai kondisi kesehatan yang dilaminya, 2) penerapan act meningkatkan skala fungsional pasien kanker, yang terbagi dalam beberapa fungsi fisik, fungsi peran, fungsi emosional, fungsi kognitif, dan fungsi sosial, 3) penerapan act dapat mengurangi beberapa item pada skala gejala pasien kanker dan adapula gejala yang tidak berubah. act dapat mengurangi beberapa item gejala, seperti: kelelahan, mual & muntah, hilang nafsu makan, nyeri, dan insomnia. sedangkan komponen/item skala yang tidak mengalami perubahan setelah penerapan act, meliputi: sesak nafas, konstipasi, diare, dan kesulitan finansial. saran berdasarkan kesimpulan yang telah diuraikan diatas maka saran yang dapat berikan oleh peneliti sebagai berikut: 1) bagi perawat puskesmas, khususnya bagian poli paliatif dapat menjadikan act sebagai modalitas keperawatan jiwa atau onkologi yang efektif untuk meningkatkan kualitas hidup pasien kanker, 2) bagi tenaga kesehatan, khususnya perawat perlu mempelajari atau terus memperdalam penerapan act ini sehingga mudah dilaksanakan pada tatanan nyata bagi pasien yang membutuhkan. perawat juga perlu mengembangkan riset dalam bidang penerapan act ataupun kanker, 3) bagi peneliti selanjutnya, diharapkan dapat mengembangkan penelitian dengan metode yang berbeda sehingga mendapat hasil yang lebih optimal dan dapat lebih aplikatif sehingga dijadikan acuan dalam memberikan pelayanan keperawatan onkologi atau jiwa. penelitian selanjutnya dapat menggunakan metode lain dengan sampel yang lebih banyak dan alat ukur yang akurat. kepustakaan corwin, e.j., 2009. buku saku patofisiologi, jakarta: egc. feist., l.b.& j., 2007. health psychology: an introduction to behavior and health sixth edit., united states of america: thomson. fitriawan, e., 2013. hubungan spiritualitas terhadap tingkat kualitas hidup pasien kanker di puskesmas pacarkeling, surabaya. surabaya: fakultas keperawatan universitas airlangga. harris, r., 2011. the happiness trap: hatihati dengan kebahagiaan anda !, yogyakarta: penerbit kanisius. hayes, et al., 2013. acceptance and commitment therapy and contextual behavioral science: examining the pogress of a distinctive model of behavioral and cognitif therapy. behavior therapi, pp.180–198. hidayat, a.a., 2006. pengantar kebutuhan dasar manusia: aplikasi konsep dan proses keperawatan, jakarta: salemba medika. jalil, keliat & pujasari, 2013. insight dan efikasi diri pada klien skizofrenia yang mendapatkan terapi penerimaan dan komitmen dan program edukasi pasien di rumah sakit jiwa. . ui. universitas indonesia. kusumawardhani, s.j., 2012. efektivitas acceptance and commitment therapy dalam meningkatkan subjective well being pada dewasa muda pasca putusnya hubungan pacaran, depok: universitas indonesia. nofitri, 2009. gambaran kualitas hidup penduduk dewasa pada lima wilayah di jakarata. universityas airlangga. perwitasari, et al, 2011. translation and validation of eortc qlq-c30 into indoensian version for cancer patients in indonesia. japanese journal of clinical oncology, pp.519–529. potter & perry, 2009. fundamental keperawatan edisi 7., jakarta: salemba medika. rasjidi, i., 2013. buku ajar onkologiklinik, jurnal ners vol. 11 no. 1 april 2016: 118-127 127 jakarta: egc. smeltzer, s.c., 2001. buku ajar keperawatan medikal-bedah brunner & suddarth edisi 8., jakarta: egc. society, a.c., 2011. breast cancer facts & figures 2011-2012, atlanta: american cancer society, inc. suharto, s., 2005. faktor-faktor yang berhubungan dengan kualitas hidup anak asma. tesis, universitas diponegoro, semarang. universitas diponegoro. widjijati, wahyuningsih, & f., 2014. aplikasi acceptance and commitment therapy (act) terhadap penerimaan dan komitmen diri dalam upaya pencegahan penularan hiv/aids, widuri, e., 2012. pengaruh acceptance and commitment therapy terhadap respon ketidakberdayaan klien gagal ginjal kronik di rsup fatmawati jakarta universitas indonesia. universitas indonesia. ners vol 10 no 1 april 2015.indd 20 paket dukungan terhadap breastfeeding self efficacy dan keberhasilan menyusui pada ibu postpartum (breastfeeding self effi cacy and effective breastfeeding on postpartum mother) retnayu pradanie* *fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya 60115 email: retnayu-p@unair.ac.id abstrak pendahuluan: air susu ibu (asi) merupakan sumber makanan terbaik bagi bayi. namun, masih banyak ibu yang tidak dapat menyusui bayinya secara ekslusif. salah satu faktor yang dapat dimodifi kasi untuk meningkatkan keberhasilan menyusui adalah breastfeeding self effi cacy dan tindakan menyusui efektif. penelitian ini bertujuan untuk menganalisis pengaruh paket dukungan menyusui untuk meningkatkan breastfeeding self effi cacy, sehingga berdampak pada tindakan menyusui yang efektif. metode: penelitian ini menggunakan desain quasy eksperiment pre-post test non equivalent dengan kelompok kontrol. sampel terdiri dari 20 ibu postpartum didapatkan dengan teknik sampling konsekutif di rsal dr. ramelan surabaya. instrumen yang digunakan adalah breastfeeding self effi cacy short form dan latch assessment tool. hasil: skor breastfeeding self effi cacy pada kelompok perlakuan meningkat lebih tinggi dibandingkan kelompok kontrol. namun, uji hipotesis menunjukkan bahwa tidak ada perbedaan antara kelompok perlakuan dan kontrol setelah diberikan intervensi paket dukungan menyusui (p = 0,104). tidak ada hubungan yang signifi kan antara breastfeeding self effi cacy dan tindakan menyusui efektif (p = 0,976). analisis dan diskusi: faktor yang mempengaruhi breastfeeding self effi cacy tidak hanya sumber informasi tapi juga pekerjaan dan tingkat pendidikan. breastfeeding self effi cacy bukan merupakan faktor pembentuk tindakan menyusui yang efektif. kata kunci: breastfeeding self effi cacy, keberhasilan menyusui, intervensi. abstract introduction: breastfeeding has been identifi ed as the optimal source of nutrition for infants. however, many mothers do not breastfeed their infants excusively. the possible modifi able factors to improve breastfeeding rates are breastfeeding self effi cacy and effective breastfeeding behavior. the aim of this study was to analyze the breastfeeding support package to improve breastfeeding self effi cacy and impact on effective breastfeeding behavior. method: this study was a quasy experiment pre-post test non equivalent control group design. samples were 20 respondents recruited using consecutive sampling in navy hospital dr. ramelan who met the inclusion criteria. instruments that used in this study were breastfeeding self effi cacy short form and latch assessment tool. results: the score of breastfeeding self effi cacy on experiment group was improve higher than control group. but, the hypothesis test showed that there were no difference score between experiment and control group after intervention (p = 0.104). the correlation between breastfeeding self effi cacy and effective breastfeeding behavior was not signifi cant (p = 0.976). analisis and discussion: the antecedent of breastfeeding self effi cacy were not only the information resources but also job and education level. breastfeeding self effi cacy was not an antecedent of effective breastfeeding behavior. keywords: breastfeeding self effi cacy, effective breastfeeding, intervention pendahuluan air susu ibu (asi) merupakan makanan terbaik untuk bayi sampai usia 6 bulan karena mengandung berbagai nutrien yang sangat dibutuhkan oleh bayi untuk tumbuh dan berkembang secara optimal (riordan, 2005). berbagai penelitian telah banyak menunjukkan manfaat pemberian asi bagi ibu maupun bayi, antara lain perlindungan terhadap risiko infeksi pada bayi, mengoptimalkan perkembangan kognitif anak serta mengurangi risiko kanker payudara dan kanker ovarium pada ibu (poon, 2011). berbagai hal tersebut mendorong world health organization (who) merekomendasikan untuk menyusui secara eksklusif bayi baru lahir sampai usia 6 bulan. berdasarkan data susenas tahun 20042009, cakupan nasional pemberian asi eksklusif pada bayi 0–6 bulan mengalami penur unan dari 62,2% pada tahun 2007 menjadi 56,2% pada tahun 2009 (minarto, 2011). survey yang dilaksanakan pada tahun 2002 oleh nutrition & health surveillance system (nss) kerja sama dengan balitbangkes 21 paket dukungan terhadap breastfeeding self effi cacy (retnayu pradanie) dan helen keller international di 4 perkotaan (jakarta, surabaya, semarang, makasar) dan 8 pedesaan (sumbar, lampung, banten, jabar, jateng, jatim, ntb, sulsel) menunjukkan bahwa cakupan asi eksklusif 4-5 bulan di perkotaan antara 4–12%, sedangkan di pedesaan 4–25%. pencapaian asi eksklusif 5– 6 bulan di perkotaan berkisar antara 1–13% sedangkan di pedesaan 2–13% (pusat kesehatan kerja depkes ri, 2005). keberhasilan dalam memberikan asi secara eksklusif har us ditunjang dengan tindakan menyusui yang efektif. tindakan menyusui efektif merupakan proses interaktif antara ibu dan bayi dalam rangka pemberian asi secara langsung dari payudara ibu ke bayi dengan cara yang benar dan kuantitas yang memadai untuk memenuhi kebutuhan ibu dan bayi (mulder, 2006). tindakan menyusui yang tidak efektif mengindikasikan posisi menyusui yang masih salah, perlekatan yang tidak benar, hisapan bayi yang kurang optimal dan milk transfer yang tidak adekuat. ketidakmampuan dalam menyusui secara efektif menimbulkan berbagai masalah selama menyusui seperti puting lecet, bayi terus menangis karena masih lapar dan pada akhirnya ibu akan tertarik untuk mencoba memberikan susu formula pada bayi. pemberian susu formula berdampak negatif pada bayi antara lain risiko pencemaran bakteri, imunitas yang tidak adekuat, sehingga meningkatkan risiko diare dan infeksi saluran pernapasan akut dan kemungkinan alergi protein susu sapi (siregar, 2004). faktor yang dapat mendukung tindakan menyusui efektif antara lain keyakinan diri bahwa mampu untuk menyusui secara efektif. self effi cacy merupakan rasa percaya diri yang dimiliki oleh seseorang terhadap suatu hal yang belum dilakukan yang dapat meningkatkan motivasi (bandura, 1994). breastfeeding self effi cacy merupakan rasa percaya diri yang dimiliki oleh ibu dalam hal menyusui yang dapat menjadi predictor apakah ibu akan memutuskan untuk menyusui, sebesar apa upaya yang akan dilakukan untuk menyusui, apakah mempunyai pola pikir membangun atau merusak dan bagaimana cara merespons berbagai masalah dan kesulitan selama menyusui (tores et al., 2003). hal tersebut berarti semakin tinggi breastfeeding self effi cacy, semakin keras usaha ibu agar dapat berhasil menyusui, begitu pun sebaliknya. breastfeeding self eff icacy ber pengar uh pada respons individu berupa pola pikir, reaksi emosional, usaha dan kegigihan serta keputusan yang akan diambil (denis, 2010). denis menjelaskan keputusan yang dimaksud adalah inisiasi menyusui, menyusui secara efektif dan keberlanjutan menyusui (asi eksklusif). self effi cacy yang rendah dalam hal menyusui dapat menyebabkan persepsi dan motivasi yang negatif (bandura, 1994; denis, 2010). berbagai penelitian menu nju k kan bahwa breastfeeding self effi cacy merupakan faktor penting yang berhubungan dengan inisiasi, durasi dan keeksklusifan menyusui (mcqueen, 2011). penelitian yang dilakukan oleh handayani et al (2010) membuktikan bahwa ada hubu ngan yang erat antara dukungan sosial, pengetahuan, sikap dan self eff icacy dengan perilaku menyusui. penelitian lain mendapatkan hasil bahwa ibu yang mempunyai breastfeeding self effi cacy yang tinggi cenderung untuk tetap menyusui selama 4 bulan (blyth et al., 2002). ibu dengan breastfeeding self effi cacy yang rendah terbukti cenderung menggunakan teknik alternatif untuk menyusui bayinya ketika menghadapi masalah selama menyusui (keemer, 2011). berbagai hasil penelitian tersebut membuka wacana baru bahwa breastfeeding self effi cacy diduga berhubungan erat dengan keberhasilan praktik menyusui. breastfeeding self effi cacy yang masih rendah dan tindakan menyusui yang belum efektif sering terjadi pada ibu yang belum pernah mempunyai pengalaman menyusui sebelumnya. ibu dengan pengalaman pertama menyusui seringkali sangat sensitif terhadap segala sesuatu yang menyangkut keadaan bayinya, sehingga mudah terprovokasi dengan berbagai anggapan yang negatif seperti, bayi tidak akan cukup kenyang bila hanya mendapat asi, apalagi di awal periode postpartum ibu hanya memproduksi kolostrum yang berjumlah sedikit atau bahkan belum mengeluarkan asi. ibu dengan harapan yang tinggi tentang perawatan bayi yang optimal, tetapi tidak 22 jurnal ners vol. 10 no. 1 april 2015: 20–29 ditunjang dengan pengetahuan dan dukungan yang adekuat dapat menyebabkan ibu jatuh pada kondisi stres selama periode postpartum (postpartum blues). ibu yang mengalami gejala postpartum blues di awal periode postpartum mempunyai kecenderungan berhenti menyusui lebih awal, mengalami berbagai kesulitan dalam hal menyusui dan breastfeeding self effi cacy yang rendah (dennis & mcqueen, 2009). berdasarkan data studi pendahuluan yang dilak u kan oleh peneliti pada ibu postpartum di ruang f1 dan e2 rumkital dr. ramelan surabaya didapatkan bahwa mayoritas ibu ingin meny usui bayinya, tetapi selama di rumah sakit ibu tersebut juga memberikan susu formula pada bayinya. berbagai alasan yang sering ditemui oleh peneliti antara lain asi belum keluar, puting rata atau tenggelam, sulit mencari posisi yang nyaman saat menyusui, puting terasa sakit saat dihisap oleh bayi dan takut bahwa bayinya belum kenyang kalau tidak ditambah dengan susu formula. u p a y a u n t u k m e n i n g k a t k a n breastfeeding self effi cacy pada ibu dengan p e nga la m a n p e r t a m a me ny u s u i p e rlu untuk dilakukan agar ibu dapat menyusui secara efektif dan pada akhirnya berhasil memberikan asi secara eksklusif. berbagai upaya yang selama ini telah dilakukan oleh petugas kesehatan di rumkital dr ramelan surabaya adalah dengan memberikan motivasi dan pendidikan kesehatan per individu ketika melakukan tindakan medis kepada pasien. rumkital dr. ramelan surabaya juga menganut 10 langkah menuju keberhasilan menyusui yang merupakan implementasi baby friendly hospital initiative dari who. beberapa isi dari protap tersebut yang telah berjalan di rumkital dr. ramelan surabaya hanya inisiasi menyusu dini dan rawat gabung. selain itu di rumkital dr. ramelan surabaya juga merupakan rumah sakit pendidikan yang dipakai praktik oleh mahasiswa kedokteran, keperawatan, gizi dan kebidanan yang pada suatu saat mendapat tugas untuk melakukan pendidikan kesehatan pada pasien seputar perawatan postpartum dan bayi termasuk dalam hal laktasi. berbagai upaya tersebut dipandang kurang karena hanya menyentuh aspek kognitif dari pasien dan belum sampai pada aspek afektif serta psikomotor, sehingga diperlukan upaya yang lebih komprehensif. paket dukungan menyusui merupakan sekumpulan intervensi keperawatan yang disusun berdasarkan 4 sumber breastfeeding self eff icacy yaitu pengalaman langsung, pengalaman tidak langsung, persuasi verbal dan keadaan emosional. intervensi yang pertama adalah demonstrasi teknik menyusui yang berfungsi untuk menciptakan pengalaman menyusui secara langsung, sehingga dapat membentuk pemahaman dalam diri ibu bahwa untuk berhasil menyusui diperlukan usaha dan kemauan untuk belajar. pengalaman tidak langsung diperoleh melalui pengamatan terhadap role model dalam video menyusui merupakan intervensi kedua yang diharapkan dapat memberikan pengetahuan dan mencontoh strategi agar dapat menyusui secara efektif. intervensi yang ketiga berupa persuasi verbal mengenai asi eksklusif diharapkan dapat memotivasi ibu untuk mencapai keberhasilan asi eksklusif. manajemen stres merupakan intervensi keempat yang diberikan untuk menciptakan strategi koping yang positif agar ibu mempunyai pandangan dan kepercayaan yang positif tentang kemampuan dirinya untuk berhasil menyusui. empat je n is i nt e r ve n si t e r sebut berdampak pada pembentukan breastfeeding self eff icacy yang kuat, sehingga dapat menga k tif kan proses kog n itif, afek tif, motivasi dan seleksi dalam diri ibu. berbagai proses tersebut mengakibatkan reaksi individu berupa pembentukan pola pikir yang positif tentang menyusui, reaksi emosional yang positif untuk mencegah stres, peningkatan motivasi yang ditunjukkan melalui usaha dan kegigihan dalam mengatasi berbagai masalah selama menyusui dan pada akhirnya ibu postpartum memutuskan untuk terus menyusui bayinya. keputusan ibu untuk menyusui tersebut berdampak pada perilaku menyusui ibu postpartum berupa: ibu mulai belajar untuk menyusui bayinya, berusaha untuk menyusui secara efektif dan pada akhir nya dapat mencapai asi eksklusif. namun, pengaruh paket dukungan menyusui terhadap peningkatan breastfeeding self 23 paket dukungan terhadap breastfeeding self effi cacy (retnayu pradanie) efficacy untuk tindakan menyusui efektif pada ibu postpartum primipara belum dapat dijelaskan. bahan dan metode peneletian ini adalah penelitian quasy experimental yang mengujicobakan suatu intervensi yaitu paket dukungan menyusui. desain yang digunakan adalah pre-post test nonequivalent control group design (dharma, 2011), di mana peneliti melibatkan 2 kelompok yaitu kelompok perlakuan dan kelompok kontrol tanpa ada randomisasi untuk menentukan subjek yang masuk pada kedua kelompok tersebut. tek nik sampling yang dig u nakan untuk mendapatkan sampel dalam penelitian i n i ad ala h nonprobabilit y consecutive sampling. sampel sebanyak 20 ibu postpartum didapatkan dengan memilih semua individu yang ditemui sesuai dengan kriteria penelitian dalam rentang 1 bulan. inst r umen yang dig unakan dalam penelitian ini ada 2 yaitu breastfeeding self efficacy scale short form (bses-sf) dan latch assessment tool. bses-sf merupakan kuesioner yang berisi 14 item pernyataan tentang keyakinan dan kepercayaan diri dalam hal menyusui. masing-masing item mempunyai 5 poin skala likert dan kemudian dijumlahkan untuk memperoleh total skor yang berkisar antara 14–70. bses-sf telah diter jemah kan ke dalam bahasa indonesia dan dilakukan uji validitas dan reliabilitas. hasil uji validitas menunjukkan bahwa dari 14 item pernyataan dalam bses-sf, 12 pernyataan dinyatakan valid dengan nilai r ≥ 0,3. berdasarkan hal tersebut, maka 2 item pernyataan yang tidak valid dihapus sehingga hanya terdapat 12 pernyataan. uji reliabilitas menunjukkan nilai cronbach alfa sebesar 0,921 (> 0,8) sehingga dikategorikan reliabel (dharma, 2011). latch assessment tool digunakan u nt u k me ng k aji ke efek t ifa n t i nd a k a n menyusui. instrumen ini terdiri dari 5 item yaitu latch (perlekatan), audible swallowing (bunyi menelan), type of nipple (tipe puting susu), comfort of nipple (kenyamanan puting susu) dan help to positioning (bantuan yang dibutuhkan ibu untuk memperoleh posisi yang nyaman ketika menyusui). masing-masing item mempunyai skor 0–2 sehingga total skor yang diperoleh antara 0–10. berdasarkan total skor tersebut, data dikategorikan menjadi menyusui tidak efektif (skor 0–3), kurang efektif (4–6) dan menyusui efektif (skor 7–10). uji paired t test digunakan untuk menganalisis perbedaan breastfeeding self eff icacy sebelum dan sesudah mendapat intervensi, sedangkan perbedaan breastfeeding self effi cacy antara kelompok perlakuan dan kontrol didapatkan dengan membandingkan selisih skor breastfeeding self effi cacy pretest dan posttest antara kelompok perlakuan dan kontrol menggunakan uji independent t test. hubungan antara breastfeeding self effi cacy dan tindakan menyusui efektif diketahui melalui uji korelasi spear man. tingkat kemaknaan yang digunakan untuk masingmasing uji adalah α ≤ 0,05. penelitian ini telah melalui uji etik di komisi etik rsal dr. ramelan surabaya. hasil seluruh responden dalam penelitian ini berada pada rentang usia yang produktif dan masuk pada kategori kehamilan risiko rendah menurut skor poedji rochjati yaitu 20-35 tahun. pada kelompok perlakuan (50%) berusia 20-25 tahun sedangkan pada kelompok kontrol (60%) berusia 26-30 tahun. seluruh responden dalam penelitian ini berstatus menikah dan tidak ada kehamilan di luar nikah (unwanted pregnancy). mayoritas responden pada kelompok perlakuan tidak bekerja atau ibu rumah tangga (irt), sedangkan mayoritas responden pada kelompok kontrol bekerja. seluruh responden dalam penelitian memiliki tingkat pendidikan minimal sekolah menengah atas (sma). ta b e l 1 m e n u n j u k k a n b a h w a terdapat peningkatan skala breastfeeding self effi cacy pada kelompok perlakuan dan kelompok kontrol. berdasarkan uji statistik dengan menghitung perbedaan selisih skala breastfeeding self effi cacy antara kelompok p e rla k u a n d a n kont rol me ng g u n a k a n 24 jurnal ners vol. 10 no. 1 april 2015: 20–29 didapatkan bahwa p = 0,130 (> nilai α yaitu 0,05) sehingga diartikan bahwa tidak ada perbedaan selisih skala breastfeeding self effi cacy. namun, selisih skala breastfeeding self eff icacy pada kelompok perlak uan lebih besar dan standar deviasi (sd) pada kelompok kontrol sangat besar yaitu 9,499 yang menunjukkan bahwa variasi data pada kelompok kontrol mempunyai rentang yang sangat lebar. hal tersebut yang menjadi penyebab hasil uji beda nilai selisih antara kedua kelompok menunjukkan tidak ada perbedaan. hasil identifi kasi tindakan menyusui melalui observasi menggunakan instrumen latch assessment tool didapatkan bahwa selur uh responden baik pada kelompok perlakuan dan kontrol telah dapat melakukan tindakan menyusui secara efektif, kecuali 1 responden pada kelompok perlakuan dengan tindakan menyusui yang cukup efektif. hasil uji korelasi spearman rho menunjukkan bahwa p = 0,976 (< 0,05), sehingga diinterpretasikan tidak ada hubungan antara breastfeeding self eff icacy dengan tindakan menyusui yang efektif. kendati demikian, jika dilihat dari distribusi data tampak bahwa rerata skala breastfeeding self effi cacy adalah 47,75 (cukup tinggi) dan skor rerata tindakan menyusui efektif 8,90 (efektif). penyebab dari hal tersebut adalah adanya responden dengan breastfeeding self eff icacy cukup tinggi memiliki skor tindakan menyusui yang belum optimal dan ada pula responden dengan breastfeeding self effi cacy yang kurang namun memiliki skor tindakan menyusui yang optimal. tabel 1. skala breastfeeding self effi cacy kelompok perlakuan dan kelompok kontrol di ruang f1 dan e2 rumkital dr. ramelan surabaya no. resp. kelompok perlakuan kelompok kontrol pre post selisih pre post selisih mean 44,40 49,50 5,10 43,50 46,00 2,50 sd 5,816 5,563 2,846 10,058 9,499 3,629 pre-post wilcoxon signed rank test p = 0,007 paired t test p = 0,057 pre test mann whitney u test p = 0,423 post test independent t test p = 0,104 selisih mann whitney u test p = 0,130 tabel 2. hubungan breastfeeding self effi cacy dengan tindakan menyusui efektif di ruang f1 dan e2 rumkital dr. ramelan surabaya no bses-sf latch mean 47,75 8,90 sd 7,786 1,447 spearman rho p = 0,976; r = 0,007; n = 20 pembahasan identifi kasi awal skala breastfeeding self effi cacy pada responden sebelum mendapatkan intervensi pada kelompok perlakuan dan kelompok kontrol menunjukkan rerata skor yang cukup tinggi. self effi cacy merupakan keyakinan yang dimiliki oleh individu terhadap suatu hal yang belum dilakukan sehingga dapat menjadi indikator seseorang dalam menentukan pilihan dan memotivasi diri sendiri agar berhasil dalam mencapai tujuan tindakan yang akan dilakukan (bandura, 1994). breastfeeding self effi cacy yang tinggi menunjukkan rasa keyakinan yang tinggi dalam diri seorang ibu dalam hal menyusui (dennis, 2010). faktor-faktor yang dapat mempengaruhi self effi cacy seseorang antara lain budaya, gender, sifat dari tugas yang dihadapi, insentif eksternal, status atau peran individu dalam lingkungan serta informasi tentang kemampuan diri (bandura, 1997). periode postpartum merupakan periode transisi untuk mencapai peran sebagai seorang ibu. periode tersebut sarat dengan berbagai 25 paket dukungan terhadap breastfeeding self effi cacy (retnayu pradanie) harapan tentang peran ibu yang ideal serta kesehatan bayi yang optimal. hal tersebut dapat menjadi pemicu bagi ibu untuk mencari tahu cara perawatan bayi yang baik termasuk dalam hal menyusui. seluruh responden adalah ibu postpartum yang belum pernah mempunyai pengalaman menyusui sebelumnya dan seluruh anak yang dilahirkan dapat diterima dengan baik oleh ibu dan keluarganya. hal tersebut mendorong ibu dan keluarga untuk selalu ingin memberikan yang terbaik bagi bayinya, termasuk dalam hal pemberian asi. seluruh responden juga memiliki tingkat pendidikan menengah ke atas, sehingga dapat mencari informasi mengenai cara perawatan bayi termasuk dalam hal pemberian nutrisi bayi. informasi tentang manfaat dan keunggulan asi bukan sesuatu hal yang baru, sehingga infor masi tersebut dapat dengan mudah diperoleh melalui tempat pelayanan kesehatan ser ta media massa. selu r u h responden juga berada pada kalangan dengan tingkat perekonomian menengah ke atas, sehingga mampu untuk melakukan perawatan kehamilan secara rutin. rumkital dr. ramelan sebagai rumah sakit sayang bayi yang menganut 10 langkah menuju keberhasilan menyusui dari who kemungkinan besar telah memberikan informasi tentang asi eksklusif sejak periode antenatal, sehingga dapat membantu kesiapan ibu dalam hal menyusui ketika memasuki periode postpartum. fakor-faktor tersebut diduga merupakan faktor yang membentuk breastfeeding self effi cacy yang tinggi dalam diri responden. responden yang terbagi dalam kelompok perlakuan dan kontrol dalam penelitian ini mendapatkan intervensi yang berbeda. intervensi untuk kelompok perlakuan adalah paket dukungan menyusui yang disusun oleh peneliti berdasarkan 4 sumber breastfeeding self efficacy yaitu edukasi asi eksklusif, demonstrasi cara menyusui yang benar, video teknik menyusui dan manajemen stress selama periode postpartum. intervensi untuk kelompok kontrol merupakan intervensi yang selama ini diterapkan di ruang f1 dan e2 rumkital dr. ramelan surabaya berupa pendidikan kesehatan dan motivasi dari petugas kesehatan serta mahasiswa yang sedang praktik dengan penyuluhan kesehatan seputar laktasi. kedua intervensi tersebut diberikan selama pasien rawat inap. lama rawat inap pasien di kedua ruang tersebut selama 2-3 hari. identifi kasi skala breastfeeding self effi cacy dilakukan kembali setelah responden mendapatkan intervensi (post test). skala breastfeeding self effi cacy yang didapatkan pada saat posttest (1 minggu setelah intervensi) menunjukkan peningkatan skala yang lebih besar pada kelompok perlakuan dari pada kelompok kontrol. hasil tersebut diperkuat dengan uji beda pretest – posttest pada masing kelompok yang menunjukkan bahwa terdapat perbedaan skala breastfeeding self effi cacy pretest dan posttest pada kelompok perlakuan, namun tidak pada kelompok kontrol. berdasarkan hasil tersebut dapat disimpulkan bahwa paket dukungan menyusui dapat meningkatkan breastfeeding self effi cacy pada kelompok perlakuan. dennis (2010) menerangkan bahwa terdapat 4 sumber yang mempengar uhi b re a st fe e d i n g se lf e f f i c a c y ya it u: 1) pengalaman menyusui bayi secara langsung; 2) pengalaman tidak langsung yang diperoleh melalui pengamatan atau cerita orang lain yang berhasil menyusui; 3) persuasi verbal dari teman, keluarga atau petugas kesehatan tentang laktasi; dan 4) respons fisiologis berupa ada tidaknya stress, keletihan atau kecemasan yang menyertai. intervensi dalam paket dukungan menyusui yang diberikan pada kelompok perlakuan disusun berdasarkan 4 sumber tersebut, sehingga peningkatan breastfeeding self effi cacy yang ditunjukkan oleh responden dalam kelompok perlakuan membuktikan bahwa teori yang dikemukakan oleh dennis adalah benar. ibu yang telah memiliki pengalaman menyusui secara langsung cenderung lebih percaya diri untuk terus menyusui, apalagi memang sejak awal mayoritas responden memiliki breastfeeding self efficacy yang cukup tinggi sehingga membuat ibu lebih gigih untuk dapat terus menyusui. pengalaman tidak langsung tentang menyusui diperoleh responden pada kelompok perlakuan melalui video menyusui yang diberikan oleh peneliti. hal ini dapat memberi pengetahuan dan 26 jurnal ners vol. 10 no. 1 april 2015: 20–29 pelajaran tentang strategi dalam menghadapi berbagai kend ala d an masalah selama menyusui. persuasi verbal yang diberikan oleh peneliti tentang asi eksklusif akan semakin membuat responden dalam kelompok perlak uan ingin memberikan asi pada bayinya karena telah mengetahui berbagai manfaat dan keunggulan asi. manajemen st ress post par t u m yang diajarkan oleh peneliti memberikan pengetahuan lebih dini pada responden tentang cara mengurangi stres dan merubah perasaan yang negatif, sehingga responden dapat membuat penilaian dan interpretasi yang lebih baik terhadap kemampuan yang dimiliki yang dapat menjadi cara untuk membentuk self effi cacy yang lebih tinggi (dennis, 2010). kelompok kontrol tidak mengalami peningkatan breastfeeding self effi cacy yang bermakna. peningkatan breastfeeding self effi cacy pada kelompok kontrol hanya terjadi pada beberapa responden saja. hal tersebut dikarenakan responden no 1 adalah seorang bidan sedangkan responden no 7 dan 8 adalah seorang perawat yang semuanya memiliki latar belakang pendidikan diploma/sarjana. pekerjaan responden yang merupakan petugas kesehatan berdampak pada pengetahuan dan tindakan responden seputar manajemen laktasi sehingga mendorong responden untuk selalu berusaha memberikan asi pada bayinya. sedangkan responden no. 10 walaupun bukan petugas kesehatan dan memiliki latar pendidikan sma, tetapi responden pernah mengikuti kegiatan penyuluhan yang diberikan oleh mahasiswa akademi gizi di ruang e2 tentang gizi yang baik bagi bayi. pada penyuluhan tersebut, mahasiswa memutarkan sebuah video tentang manajemen laktasi yang sama persis seperti video yang diberikan oleh peneliti pada kelompok perlakuan. hal tersebut memberikan tambahan pengetahuan bagi responden no 10 sehingga dapat menjadi faktor predisposisi pembentuk breastfeeding self effi cacy yang lebih tinggi. selain itu kelompok kontrol juga memiliki sumber breasfeeding self effi cacy. sumber tersebut yaitu intervensi yang diterima oleh kelompok kontrol berupa edukasi dan motivasi dari petugas dapat dikategorikan sebuah persuasi verbal tentang asi eksklusif dan pengalaman langsung menyusui selama 1 minggu sebelum posttest. faktor lain yang ikut berperan terhadap perbedaan posttest skala breastfeeding self eff icacy antara kelompok perlakuan dan kontrol adalah distribusi responden yang tidak homogen. pada kelompok perlakuan mayoritas (60%) responden tidak bekerja (ibu rumah tangga), sedangkan pada kelompok kontrol mayoritas adalah ibu yang bekerja (40% swasta dan 40% tni/pns). ibu yang tidak bekerja cenderung mempunyai skala breastfeeding self effi cacy yang tinggi karena terus dapat bersama dengan bayinya tanpa harus memikirkan cara bagaimana agar tetap bisa memberikan asi sewaktu ditinggal bekerja. hal tersebut dapat dilihat melalui rerata skor item pernyataan pada bsessf tentang keberlanjutan menyusui. rerata skor tersebut adalah: 1) pernyataan no. 3: “saya selalu dapat menyusui bayi saya tanpa menggunakan susu formula sebagai tambahan” rerata skor posttest pada kelompok perlakuan adalah 3,9 sedangkan pada kelompok kontrol 3,4; 2) pernyataan no. 12: “saya selalu bisa terus menyusui bayi saya” rerata skor posttest pada kelompok perlakuan adalah 4, sedangkan pada kelompok kontrol 3,6; 3) pernyataan no 13: “saya bisa selalu memenuhi kebutuhan bayi saya untuk menyusu” rerata skor posttest pada kelompok perlakuan adalah 4 dan pada kelompok kontrol 3,6. faktor lain yang juga mempengaruhi hasil penelitian ini adalah intervensi paket dukungan menyusui yang diberikan hanya satu kali pada fase taking in periode postpartum. hal tersebut menjadi kurang efektif karena pada fase taking in ibu masih fokus terhadap kebutuhan dirinya karena dampak proses persalinan ber upa nyer i dan keletihan, sehingga ibu kurang dapat menyerap informasi secara optimal. intervensi yang diberikan hanya satu kali dinilai kurang efektif untuk merubah perilaku seseorang, hal tersebut terbukti dengan adanya responden pada kelompok kontrol yang menerima intervensi dari ruangan dan edukasi dari mahasiswa cenderung mempunyai self effi cacy yang lebih tinggi. kendala teknis lain saat pemberian intervensi berupa bayi yang tiba-tiba menangis 27 paket dukungan terhadap breastfeeding self effi cacy (retnayu pradanie) atau adanya visite dokter juga diduga menjadi penyebab penyerapan informasi yang kuran optimal, sehingga sebaiknya intervensi untuk meningkatkan breastfeeding self eff icacy diberikan sejak periode antenatal. peneliti menduga breastfeeding self effi cacy merupakan salah satu faktor yang mempengaruhi keefektifan tindakan menyusui yang dilakukan oleh seorang ibu, oleh karena itu peneliti juga melakukan observasi terhadap tindakan menyusui yang dilakukan oleh responden. tindakan menyusui merupakan data yang berskala ordinal dengan kategori 0-3 tidak efektif, 4–6 kurang efektif dan 7–10 efektif. hasil observasi menunjukkan bahwa selur uh responden telah dapat menyusui secara efektif. hanya ada 1 responden dari kelompok perlakuan yang memiliki skor tindakan menyusui kurang efektif dikarenakan responden tersebut mempunyai bentuk puting yang tenggelam pada kedua payudara dan sulit untuk dikeluarkan walaupun telah distimulasi. observasi tindakan menyusui dilakukan sesaat setelah posttest breastfeeding self efficacy sehingga responden telah mendapatkan intervensi. tindakan menyusui dikatakan efektif jika terjadi perlekatan yang benar, bayi dapat menghisap dan menelan asi, serta posisi menyusui yang nyaman. beberapa faktor yang mempengaruhi tindakan menyusui antara lain kondisi bayi pada saat ingin menyusu, rooting, pengetahuan ibu tentang teknik laktasi, kondisi fi sik dan mental ibu, anatomi dan fi siologi payudara serta anatomi dan fisiologi bayi (mulder, 2006). mayoritas responden mempunyai faktor predisposisi tindakan menyusui yang baik. mayoritas ibu berusaha menyusui bayinya ketika menangis. responden pada kelompok perlakuan dan kontrol juga telah cukup mempunyai pengetahuan tentang tek nik menyusui, melalui edukasi yang diberikan oleh petugas kesehatan. pengalaman menyusui selama 1 minggu sebelum posttest juga ikut menambah pengetahuan dan pengalaman meny usui sehingga besar kemungkinan ibu sudah mulai terbiasa dengan kegiatan meny usui bayi nya. selu r u h responden juga berbahagia dengan kelahiran bayinya, sehingga kemungkinan ibu tidak mengalami postpartum blues. seluruh bayi yang dilahirkan oleh responden juga dalam usia gestasi yang aterm, sehingga tidak ada faktor kelainan anatomi dan fi siologi pada bayi. hanya saja beberapa responden ada yang mengalami kelainan anatomi payudara berupa puting yang tenggelam, sehingga dapat mempersulit tindakan menyusui. responden tersebut antara lain responden perlakuan no. 1, 9 dan 10 serta responden kelompok kontrol no. 12, 13 dan 18. hal tersebut yang menjadi alasan skor tindakan menyusui yang belum optimal pada beberapa responden tersebut. hasil uji korelasi antara breastfeeding self ef f ica c y d a n t i nd a k a n me ny u su i menunjukkan bahwa tidak ada hubungan yang signifi kan. alasan secara statistik dari hal tersebut adalah adanya beberapa responden dengan skala breastfeeding self effi cacy yang cukup tinggi namun memiliki skor tindakan menyusui yang belum optimal (responden no. 1, 12 dan 20). sebaliknya, ada beberapa responden dengan skala breastfeeding self effi cacy yang cukup rendah namun memiliki skor ti nd a kan meny usui yang optimal (responden no 5, 13 dan 18). hal tersebut diperkuat oleh standar deviasi (sd) yang besar pada skala breastfeeding self effi cacy (sd = 7,633) dan sd yang kecil pada tindakan menyusui efektif (sd = 1,447). secara teori, memang tidak ada yang menyebutkan bahwa breastfeeding self effi cacy merupakan salah satu faktor yang mempengaruhi tindakan menyusui. seperti yang telah disebutkan sebelumnya, self effi cacy merupakan keyakinan seseorang terhadap suatu hal yang belum dilakukan (bandura, 1997) sedangkan tindakan menyusui efektif merupakan proses interaktif antara ibu dan bayi dalam rangka pemberian asi secara langsung dari payudara ibu dengan cara yang benar dan kuantitas yang memadai untuk memenuhi kebutuhan ibu dan bayi (mulder, 2006). berdasarkan konsep, setiap tindakan seseorang selalu dipengaruhi oleh self effi cacy, namun self effi cacy yang tinggi belum tentu mengindikasikan keberhasilan tindakan meny usui yang efektif karena tindakan menyusui sangat dipengaruhi oleh perlekatan, 28 jurnal ners vol. 10 no. 1 april 2015: 20–29 posisi dan milk transfer, di mana hal tersebut sangat berkaitan erat dengan anatomi dan fi siologi payudara. a n at om i p ay u d a r a ya ng s a ng at mempengaruhi tindakan menyusui adalah bent uk puting susu sedangkan f isiologi pay ud a r a ya ng sa ngat mempe nga r u h i adalah laktogenesis (proses produksi asi) dan galaktopoiesis (pemeliharaan produksi dan pengeluaran asi). bentuk puting yang tidak sempurna (datar atau tenggelam) akan menjadi penyulit bagi bayi untuk melakukan perlekatan secara sempurna, sehingga bayi sulit untuk menghisap asi. gangguan pada proses laktogenesis dan galaktopoiesis aka menyebabkan produksi dan pengeluaran asi yang tidak lancar, sehingga dapat menganggu milk transfer (machfuddin, 2004 dan riordan, 2005). lebih lanjut dennis (2010) menyebutkan bahwa konsekuensi dari breastfeeding self eff icacy adalah apakah seorang ibu akan menyusui (choice of behavior), seberapa besar usaha yang akan dilakukan untuk menyusui (effort and persistence), apakah mempunyai pola pikir yang mambangun (thought patterns) dan bagaimana secara emosional merespon berbagai kesulitan yang ditemui selama menyusui (emotional reactions). berbagai konsekuensi tersebut akan berdampak pada tindakan menyusui seseorang yang meliputi brea st feeding initiation , per for mance, maintenance. pada penelitian ini, hasil uji statistik memang menunjuk kan bahwa tidak ada hubu nga n brea st fe e d ing self ef f ica c y dengan tindakan menyusui efektif. namun berdasarkan hasil wawancara peneliti terhadap responden tentang keberlanjutan pemberian asi pada bayi menunjukkan bahwa mayoritas responden pada kelompok perlakuan berusaha untuk memberikan asi secara eksklusif tanpa menggunakan susu formula (seluruh responden kecuali responden no. 5). responden no. 5 merupakan ibu rumah tangga yang berusia 34 tahun, mengatakan bahwa sebenarnya bayinya sudah pintar menyusui sejak awal. namun responden mengalami hambatan dalam produksi asi. responden merasa bahwa produksi asi sangat sedikit, sehingga bayi masih terus menangis jika tidak diberikan tambahan susu formula. berdasarkan uraian tersebut di atas dapat disimpulkan bahwa breastfeeding self efficacy secara teori berhubungan dengan tindakan menyusui efektif. namun secara statistik dan empiris lebih berhubungan dengan tindakan pemberian asi secara eksklusif tanpa memperhatikan efektif atau tidaknya tindakan menyusui yang dilakukan. implikasi dari temuan ini adalah perlu dilakukannya penelitian lebih lanjut tentang hubungan breastfeeding self effi cacy dengan perilaku pemberian asi secara eksklusif. simpulan dan saran simpulan ibu postpartum primipara di rumkital dr. ramelan su rabaya telah memili k i breastfeeding self effi cacy yang tinggi. paket dukungan menyusui dapat meningkatkan brea st fe e d ing self ef f ica c y walaupu n efektivitasnya tidak berbeda dengan intervensi standar berupa edukasi perorangan yang diberikan oleh petugas di ruangan. mayoritas responden telah dapat melakukan tindakan menyusui yang efektif. breastfeeding self efficacy bukan merupakan anteceden dari tindakan menyusui efektif sehingga kedua hal tersebut tidak saling berhubungan. saran bagi peneliti selanjutnya diharapkan meneliti variabel tingkat pendidikan dan pekerjaan serta pengalaman tidak langsung ya ng d i m i l i k i oleh r e s p onde n u nt u k mengetahui efek paket dukungan menyusui terhadap breastfeeding self effi cacy. responden dengan breastfeeding self effi cacy yang tinggi mempunyai kecenderungan untuk menyusui seca r a ek sk lu sif, seh i ngga d iperlu ka n penelitian lebih lanjut tentang hal tersebut. bagi institusi pelayanan, intervensi unt u k meningkatkan breastfeeding self effi cacy termasuk paket dukungan menyusui perlu diberikan sejak periode antenatal untuk membantu kesiapan ibu ketika memasuki periode postpartum. paket dukungan menyusui 29 paket dukungan terhadap breastfeeding self effi cacy (retnayu pradanie) sebagai salah sat u inter vensi yang bisa dilakukan oleh perawat hendaknya dikemas dalam bentuk yang lebih sederhana sehingga dapat diaplikasikan oleh petugas kesehatan di tatanan pelayanan tanpa harus menambah beban kerja petugas. kepustakaan bandura, a 1994, emory university, dilihat 21 februari 2012, http://www.des.emody. edu/mfp/bandura1994ehb.pdf bandura, a. 1997, ‘self-effi cacy: toward a univying theory of behavioral change’, psichologycal review, vol 84, no.2, hal. 191–215. blyth, r, creedy, dk, dennis, c-l, moyle, w, pratt, j & vries, smd 2002. ‘effect of maternal confi dence on breastfeeding duration: an application of breastfeeding self-effi cacy theory’, birth: issues in prenatal care, vol 29, no. 4, hal. 278– 284. dennis, cl & mcqueen, k 2009, ‘the relationship between infant-feeding outcomes and postpartum depression: a qu alit at ive systemat ic rev iew’, pediatrics, vol. 123, no. 4, pp. e736– e751. de n n is, cl 2010, brea st fee ding s elf effi cacy, dilihat 2 maret 2012, <http:// w w w.cindyleedennis.ca/research /1b r e a st fe e d i ng / b r e a s t fe e d i ngs el feffi cacy/>. dharma, kk 2011, metodologi penelitian keperawatan: panduan melaksanakan dan menerapkan hasil penelitian, cv trans info media, jakarta. handayani, l, kosnin, am, jiar yk 2010, ’social support, knowledge, attitude and self eff icacy as predictors on breastfeeding practice’, universiti teknologi malaysia, kuala lumpur dilihat 15 februari 2012, <http://eprints. utm.my/14945/1/social_support.pdf> keemer, f 2011, ‘breastfeeding self effi cacy and alternative techniques to overcome mater nal or i n fa nt breastfeed i ng chalengges: a retrospective descriptive study’, master of applied science (t hesis), school of nu rsi ng a nd midwiver y, queensland university of technology, id code 47144, qut digital repository, brisbane australia. m a c h f u d d i n , e 2 0 0 4. ‘pa t of i siolog i pembentukan asi’, refrat, bagian/ departemen obstetri dan ginekologi, fa k u lt as kedok tera n un iversit a s sriwijaya/rs dr. mohammad hoesin palembang, palembang. mcqueen, ka, dennis, cl, stremler, r, norman,cd 2011. ‘a pilot randomized controlled trial of a breastfeeding self effi cacy intervention with primiparous mothers’, jognn, vol 40, hal. 35–46. minarto, 2011. rencana aksi pembinaan gizi masyarakat (r apgm) tahun 2010–2014, dilihat 13 februari 2012, <ht t p://w w w.g i z i k ia.de pkes.go.id / archives/658>. mulder, pamela j 2006. ‘a concept analysis of effective breastfeeding’, jognn, vol. 35, hal. 332–339. poon , k ky, 2011. ‘doe s i n hospit al breastfeeding self ef iicacy predict breastfeeding duration?’, thesis of master of science, depar tment of community health and epidemiology, queen’s university, q space, kingston, ontario, canada. pusat kesehatan kerja depkes ri, 2005. ‘kebijakan depar temen kesehatan tentang peningkatan pemberian air susu ibu (asi) pekerja wanita’, depkes ri, jakarta riordan, j. 2005. breastfeeding and human lactation, 3rd edition, jones and barlett publishers, canada. siregar, dma, 2004. library.usu.ac.id, dilihat 13 februari 2012, <http://library.usu. ac.id/download/f km/f km-arifi n.pdf>. torres, mm, torres, rrd, rodríguez, amp & dennis, c-l 2003. ‘translation and validation of the breastfeeding selfeffi cacy scale into spanish: data from a puerto rican population’, journal of human lactation, vol. 19, no. 1, hal. 35–42. 242 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17111 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research influence of cognitive stimulation group activity memory game therapy on elderly cognitive function: quasi-experimental qolbi nur qoidah yahya, purwaningsih purwaningsih and makhfudli makhfudli faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: older adults experience a change in their nervous system that influences cognitive function, including the abilities of orientation, registration, attention-calculation, memory and language. these changes affect the independence of the elderly when carrying out their daily activities. the purpose of this research was to analyze the effect of cognitive stimulation group activity memory game therapy on elderly cognitive function. methods: this study used a quasi-experimental pre-post approach with a control group design. the population in this study was the elderly who were aged >60 in nursing home blitar, totaling 20 older patients. the data retrieval for this research was conducted between april and may 2012. the elderly in the treatment group were given flash card stimulus to practice their perceptual abilities 8 times (1 month). the measurement of elderly cognitive function used the mini mental state examination questionnaire. the data was analyzed using the wilcoxon sign rank test. results: the results showed that elderly cognitive function increased from 10,3 (pre test) to 14,65 (post test) with p=0,005 (p<0,05). this result shows that cognitive stimulation group activity memory games have a significance influence on elderly cognitive function. conclusion: practical nurses can use this therapy to improve elderly cognitive function not only in elderly social institutions but also in the community or through public health. article history received: december 26, 2019 accepted: december 31, 2019 keywords cognitive; stimulation group; activity memory; elderly contact qolbi nur qoidah yahya  qolbi.nur.qoidah2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: yahya, q. n. q., purwaningsih, p., & makhfudli, m. (2019). influence of cognitive stimulation group activity memory game therapy on elderly cognitive function: quasi-experimental. jurnal ners, 14(3si), 242-246 doi:http://dx.doi.org/10.20473/jn.v14i3(si).17111 introduction according to the republic of indonesia law no. 13 of 1998 concerning the welfare of the elderly, an elderly individual is someone who has reached 60 years and above. globally, the elderly population is predicted to continue to increase as shown in the figure below. the increasing number of elderly people can be a problem. problems that arise from the aging process cause the elderly to experience setbacks naturally in their lives, one of which is experiencing mental disorders.(kementerian kesehatan ri, 2013) according to the united nations 2015 data, the highest number of elderly people is in the asian continent, totaling 508 million people. the estimated number of elderly people in indonesia reached 85% in 2015.(kementerian kesehatan ri, 2017) based on the results of the 2016 susenas, the number of elderly people in indonesia reached 22.4 million or 8.69% of the total population. according to the 2015 bps projection, in 2018, the number of elderly people is estimated to reach 9.3% or 24.7 million. the elderly population in indonesia is predicted to increase more than the elderly population globally after 2100. the increase in the elderly population in indonesia can cause problems related to the medical, psychological, economic and social aspects of life, making it necessary to improve the health services for the elderly. some of these services can even begin to be given to the pre-elderly (aged 45 59 years). the mental disorders commonly experienced by the elderly are depression in 63.4% and cognitive decline in 88.7%. cognitive status disorders are a decrease in the brain’s cognitive abilities that include https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 243 attention, calculation, visual-spatial, language and memory. based on the data from the kementrian kesehatan ri 2013, the cognitive disorders that commonly attack the elderly are focused on language disorders (aphasia), disorientation and emotional disturbances.(kementerian kesehatan ri, 2013; kusumowardani & puspitorini, 2014; wreksoatmodjo & budi riyanto, 2012) a decline in cognitive function in the elderly usually begins with a setback of memory such as finding things easy to forget (forgetfulness) and mild cognitive impairment (mild cognitive impairment /mci) and through to dementia as a clinical form of cognitive function disorders, the hardest of which significantly disrupts the life activities of the elderly. this includes a loss of interest in caring for themselves such as eating, bathing, recreation and socialization, which can lead to dependence by the elderly on their family. one of the impacts of the decline in cognitive status is the shifting of the elderly individual’s role in social interaction activities in the community or within their families.(kusumowardani & puspitorini, 2014) based on the preliminary data collection conducted by researchers on march 30th, 2012 at nursing home blitar using the interview methods and the mini mental state examination (mmse) measuring devices, 55 elderly people were examined. the results were that 60% had decreased orientation functioning, 9% had decreased memory functioning, 12.7% had decreased memory functioning and 18.2% had decreased language functioning. the decline in cognitive function was mostly experienced by the elderly people aged 60 years and over with the education status of being elementary school graduates. the number of elderly people experiencing a decline in cognitive function has increased compared to 2011. however, the nursing home blitar has not applied therapy as an effort to prevent a decline in cognitive function in the elderly. social interaction is an interrelated relationship between an individual and an individual, an individual with a group and a group with another group. social interactions occur if there is communication and they can influence each other in terms of thoughts and actions.(laelasari. sari, s.p. dan rejeki, 2015) in a study conducted by kusumowardani and puspitosari (2014), the elderly who have good social interactions totaled 15%. the advantage of social interactions is that the abilities related to the memory and language skills of the elderly will always be used, so the cognitive status of the elderly is always honed. the loss of not carrying out social interactions means that the elderly individual can feel isolated. besides that, the cognitive status of the elderly such as language skills can be decreased.(laelasari. sari, s.p. dan rejeki, 2015) group activity therapy is one form of social interaction. sri lestari's research results in 2010 in the elderly social institution pare-kediri showed that group activity therapy through reality orientation can be used to maintain the memory ability. the researcher of this study intends to develop group activity therapy in the form of memory games as an effort to improve the cognitive function of the elderly. it is called cognitive stimulation group activity memory games therapy. materials and methods research design this study used a quasi experimental pre-post two group design with a control group. population and sample the population was 55 older people in a nursing home and the number of samples involved in this study was 20 older people. the respondents were taken using the purposive sampling technique with both inclusion and exclusion criteria. the inclusion criteria were the elderly aged over 60 years old, suspected cognitive impairment or impaired cognitive function (mmse score <26), living in the nursing home for at least 1 year, cooperative and they can read and write. the exclusion criteria were the elderly with physical weakness, hearing loss without aids, impaired vision without aids and severe mental disorders. variables the independent variable in this study was the cognitive function of elderly. the dependent variable was cognitive stimulation through the group activity of memory game therapy. instruments the study used the mini mental status examination (mmse) questionnaire, which consists of 10 questions about orientation, 1 question about regression, 1 question about attention and calculation, 1 question about recall and 6 questions about language. the mmse score was interpreted as normal with a score of 7 30, suspected cognitive function disorders with a score of 22 – 26 and definite cognitive function disorders with a score of 0 21. this study also used flash cards that contained material images, numbers and letters that adjusted to the mmse rating format. examples of the material on the flash cards includes calendar images, a clock picture, house drawings, numbers 1 – 100 and pictures of two intersecting pentagons. research procedure the procedure for retrieving the data was the filling out of a questionnaire by the respondents after they had given their informed consent. this study was conducted for one month (eight sessions). before conducting the study, the researcher divided the sample randomly into the control group and the experimental group. each group consisted of 10 samples. the control group and the experimental group received a pre-test. the experimental group was given the cognitive stimulation group activity of memory game therapy. for the control group, daily routine activities were provided in the elderly social institution. the post-tests for both two groups were given 1 day after the last session. q. n. q. yahyu, et al. 244 | pissn: 1858-3598  eissn: 2502-5791 the cognitive stimulation group activity memory game therapy was given twice a week (tuesday and thursday) for 1 month. the meeting took place at 10:00 – 11:00 o’clock. the researcher took 10 minutes to prepare the place and tools, 40 minutes for the therapy itself and 10 minutes for tidying up the place and the tools used. the activities were carried out in accordance with the guidelines for group activity therapy: cognitive stimulation, which consist of 5 stages, namely preparation, orientation, contract time, work and termination. the implementation of this therapy involved the researcher (leader) and the daily staff of the institution (2 people) as co-leader and facilitator respectively. the leader played the role of leading the course of activities while the co-leader played a role in observing the activities. the facilitator played a role in facilitating the respondents and preparing the infrastructure. the technical implementation of this therapy began with positioning the respondent to sit around the leader. the leader began the therapy by saying hello and asking how the respondent was, explaining the intent and purpose of each meeting and making a time contract. in the work stage, the leader asked the respondent to take one flash card prepared in front of each respondent and they then asked the respondent to tell them the contents of the flash card. this activity continued until all the cards in front of the respondent were used up. in the termination stage, the leader asked for help from the co-leader to evaluate and read out the values obtained where the respondent was able to explain the contents of the flash card correctly. before the activity was closed, the leader made a time contract for the next meeting. analysis of the research the collected data was analyzed using the wilcoxon sign rank test. results the number of elderly in the nursing home was 55 people. most (60%) of the elderly in blitar nursing home are suspected of having impaired cognitive function. for the elderly who live in the nursing home, 85% were a widow / widower whose partner had died and 85% of them had been at a/the nursing home for 1 5 years. the pre-test results on the 20 respondents showed that 70% were suspected of having cognitive impairment and 30% had impaired cognitive function. the pre-test results in the control group and the experimental group showed that 75% were suspected of impaired cognitive function. in the treatment group, 80% of the respondents experienced a disruption in orientation, 10% had a disorder of registration, 20% had an attentioncalculation disorder, 50% had a disturbance in remembering and 30% had a disorder in relation to language. the post-test results in the treatment group showed an increase in the mmse scores for 90% and as many as 70% (7 people) were stated as having normal cognitive function. in the control group, the post-test results showed that 70% had impaired cognitive function. table 1 is the demographic data of the respondents in the blitar nursing home. in the elderly with an age of 60 years, the nervous system starts to deteriorate which results in their cognitive function decreasing. the respondents involved in this study had an age range of 60 90 years old. the level of education is critical when related to the cognitive function of the elderly. the elderly who had a lower education level made up the majority (sinthania, 2015) the elderly had all lived in the or other nursing table 1. respondent’s demographic data in the blitar nursing home in may 2012 demographic data n % ages in year 60 – 74 years 14 70 75 – 90 years 6 30 level of education primary school 20 100 secondary school stay in nursing home 1 5 years 15 75 6 10 years 5 25 marriage status married not married 2 10 divorced widowed 18 90 table 2. respondent’s cognitive function in the blitar nursing home in may 2012 cognitive function n % normal suspected cognitive impairment 14 70 cognitive impairment 6 30 table 3. respondent’s cognitive function preand post-experiment in the blitar nursing home in may 2012 cognitive function pre test post test n % n % control group normal suspected cognitive impairment 8 80 6 60 cognitive impairment 2 20 4 40 experimental group normal 7 70 suspected cognitive impairment 8 80 2 20 cognitive impairment 2 20 1 10 table 4. comparison of the cognitive function impairment of the experimental group pre-posttest cognitive function impairment pre (%) post (%) orientation 80 80 registration 10 attention-calculation 20 memory 50 language 30 30 jurnal ners http://e-journal.unair.ac.id/jners | 245 homes for a long time. the respondents involved in the study had lived in nursing homes for between 1 10 years. marriage status also affects cognitive function. most of the respondents were widowed. based on table 2, it can be seen that most (70%) of the cognitive functions of the respondents had an mmse score between 22 26. most of the respondents began to see a change in their cognitive function. table 3 shows the changes in the cognitive function of the respondents preand postexperiment. after following along with the cognitive stimulation activity of group memory games, as many as 9 people (90%) in the treatment group experienced an increase in cognitive function and as many as 7 people (70%) were stated to have normal cognitive function. in the control group, as many as 6 people (60%) were still suspected of having impaired cognitive function and as many as 4 people (40%) had impaired cognitive function. based on table 4, we are able to describe the differences in the cognitive function of the elderly in the experimental group preand post-therapy. in the results of the pre-test, there were 5 types of cognitive function disorder in the elderly and most (80%) experienced orientation disorders. in the post-test results, there were only 2 types of cognitive function disorders that occurred in the elderly, namely orientation and language. orientation disorders are still mostly experienced by the elderly, for as many as 8 people (80%). discussion the results of the analysis in this study were based on the value of significance indicating that cognitive stimulation group activity memory games have a significance influence on the cognitive function of the elderly. changes in cognitive function begin to be experienced by someone aged over 60 years old. the changes in a person's cognitive function are influenced by age and education level. increasing age will change the brain, which triggers changes in a person's thinking process. the higher the level of education of a person, the more they tend to have better cognitive function despite being of the same age. impaired cognitive function that occurs in the elderly is closely related to brain function disorders in terms of orientation, attention, concentration, memory, language and intelligence. impaired cognitive function is a disorder similar to dementia which is shown by the presence of numerical disorders, semantic memory (words) and problem solving. impaired cognitive function that does not get immediate treatment for a long period of time will increase the likelihood of dementia. decreased cognitive status in the elderly is caused by several factors. the impact of the decline in the cognitive status of the elderly is the shift in the role of the elderly in their social interaction activities in both the community and in their family. someone who has decreased cognitive status will experience changes in the form of thinking, somatic sensation and activity and they become less productive in terms of developing the mind, talking and socializing (kusumowardani & puspitorini, 2014). cognitive damage occurs in the area of the cerebral cortex and limbic system. the cerebral cortex as a center for information from the brain, as it accepts, opposes and processes information which then becomes a reference for making decisions. memory (recall), visual-spatial functions and the ability to calculate and construct data and complexes becomes an understanding of coordination through the functions of the cerebral cortex. damage to the cortex causes damage to language. the function of the cortex regulates intelligence which consists of perception, thinking, understanding and hearing. the cerebral cortex is used for developing and interpreting data, making observations, solving problems and making conclusions. the limbic system regulates logic and memory and it is the basic driver for eating and sex aggression. intelligence, memory, ability to learn and a normal personality do not change in the elderly. in general, nerve cells cannot be repaired if there is damage. brain cell damage will result in permanent damage to some or all mental functions. (stuart, g.w., & sundeen, 2000) the results of this research were analyzed using the wilcoxon sign rank test for the pre-post tests on the experimental group, showing a significance value of p = 0.005 (p <0.05). this means that cognitive stimulation group activity memory games have a significant influence on the cognitive function of the elderly. in the experimental group, there were differences in the cognitive function status of the respondents before and after cognitive stimulation in the form of the group activity of the memory games therapy. as many as 70% showed mmse scores in the normal range between 27 30, while 20% were still suspected of impaired cognitive function and 10% were still experiencing impaired cognitive function. in the post-test results of the experimental group, it was explained that the respondents who were still experiencing interference in orientation amounted to 80% and that 20% still experienced interference in language. cognitive stimulation activity in the form of group memory games is a type of therapy that uses techniques to strengthen the stimuli by involving the participation or interaction of the group members guided by a nurse. during therapy, there will be interactions and dynamics that depend, need and can be used as a place for the group members to practice adaptive behavior and to practice perceiving a stimulus. the existence of other group members is able to stimulate its members to provide opinions and responses and to create a conducive atmosphere to train their members to socialize and communicate (keliat dan akemat, 2005). regular and pleasant stimuli in the form of group activities will facilitate the work of the brain in the acceptance process (apprehending phase) acquisition, (acquisition phase), storage (storage phase) and re-disclosure (retrieval phase) (simamora, 2008). a person with cognitive function disorders must be given activities q. n. q. yahyu, et al. 246 | pissn: 1858-3598  eissn: 2502-5791 in a structured manner and they need to be involved directly in each scheduled activity. the respondents who experience severe cognitive function impairment (mmse score <21) can be given cognitive stimulation therapy activity group memory games if there is an increase in the intensity of their activities. cognitive stimulation activity group memory games are not new as an intervention for patients who experience psychiatric disorders. however, this therapy has never been done to stimulate cognitive function in the elderly who experience decreased cognitive function. there is no previous research that proves that cognitive stimulation therapy in the form of memory activities in groups has a significant influence on elderly cognitive function. the results of this study are expected to be used as therapeutic modalities by the nurses in elderly social institutions or in public health care to stimulate the cognitive function abilities of the elderly who begin experiencing intellectual disability. conclusion there is an influence from the cognitive stimulation group activity memory game therapy on the elderly individual’s cognitive function. this therapy can be used to train the cognitive functions of the elderly that have begun to decline, both those in social care institutions and in public health services. references keliat dan akemat. (2005). keperawatan jiwa terapi aktivitas kelompok. jakarta: egc. kementerian kesehatan ri. (2013). buletin jendela data dan informasi kesehatan: gambaran kesehatan lanjut usia di indonesia. retrieved february 25, 2012, from www.depkes.go.id/download.php?file=download /pusdatin/buletin/buletin-lansia.pdf kementerian kesehatan ri. (2017). united nations 2015: world population aging, new york. jakarta: kementrian kesehatan ri. kusumowardani, a., & puspitorini, a. (2014). hubungan antara tingkat depresi lansia dengan interkasi sosial lansia di desa sobokerto kecamatan ngemplak boyolali. jurnal ilmu kesehatan. laelasari. sari, s.p. dan rejeki, y. f. (2015). faktorfaktor yang berhubungan dengan aktivitas fisik lansia di posbindu anggrek wilayah kerja puskesmas sindangjaya kota bandung. jurnal keperawatan. simamora, r. . (2008). buku pendidikan dalam keperawatan. jakarta: egc. sinthania, d. (2015). studi fenomena : pengalaman interaksi sosial lansia dengan sesama lansia dan pengasuh di panti sosial tresna werdha “sabai nan aluih” sicincin kabupaten padang pariaman. jurnal kesehatan stikes prima nusantara bukittinggi, 6(2). stuart, g.w., & sundeen, s. . (2000). principles and practice of psychiatric nursing (7th ed.). st. louis: mosby year book. wreksoatmodjo & budi riyanto. (2012). hubungan social engangement dengan fungsi kognitif (2nd ed.). jakarta: cdk-190 39. 16 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v13i1.12811 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the association of body mass index, physical activity and hypertension in indonesia hodimatum mahiroh, erni astutik and rochmad ardiansyah pratama faculty of public health universitas airlangga abstract introduction: hypertension can cause cardiovascular disease and it is still a serious global problem. the prevalence of hypertension has increased every year. some of the factors associated with hypertension are obesity and physical activity. the prevalence of obesity has increased every year and many people have lower levels of physical activity. this study aims to analyze the correlation between body mass index (bmi), physical activity and hypertension in indonesia. methods: this study used a cross-sectional study design using secondary data from the indonesia family life survey 5 (ifls5) conducted in 2014 2015. the sample consisted of individuals in the households interviewed and 26,472 respondents fulfilled the criteria. the data was analyzed using multivariate logistic regression. results: the results showed that most of the respondents were of productive age. more than half of the respondents were female (52.05%). the respondents who had hypertension totalled 22.63%. after being controlled by the covariate variables, the results showed that the obese respondents had 4.08 times higher odds of experiencing hypertension compared to the normal respondents (aor= 4.08, 95% ci = 3.68-4.53, p-value = 0.000) and that the respondents who were overweight were 2.49 times likely to get hypertension compared to the respondents who were normal (aor = 2.49, 95% ci = 2.32-2.67, p-value = 0.000). meanwhile, the respondents with an underweight bmi were 0.58 times more likely to have hypertension compared to the respondents who were normal (aor = 0.58, 95% ci = 0.52-0.65, p-value = 0.000). conclusion: individuals with a higher bmi will be more at risk of hypertension while physical activity is not related to hypertension. the government and health services need to increase the promotion of a healthy lifestyle, especially healthy diet programs, to encourage the population to maintain an ideal body weight and to reduce the rate of hypertension. article history received: april 16, 2019 accepted: july 13, 2019 keywords hypertension; ifls; bmi; physical activity contact erni astutik  erniastutik@fkm.unair.ac.id  faculty of public health universitas airlangga cite this as: mahiroh, h., astutik, e., & pratama, r. (2019). the association of body mass index, physical activity, and hypertension in indonesia. jurnal ners, 14(1), 16-22. doi:http://dx.doi.org/10.20473/jn.v13i1.12811 introduction hypertension is a silent killer disease that causes serious and dangerous diseases in the community (who, 2013). hypertension, or high blood pressure, is an increase of the systolic blood pressure of more than 140 mmhg and of the diastolic blood pressure by more than 90 mmhg taken via two measurements with an interval of five minutes when in a state of adequate rest or calm. hypertension in the long term can cause damage to the kidneys, heart and brain if it is not detected early and treated (kemenkes ri, 2013). globally, cardiovascular disease causes 17 million deaths every year. this is almost one-third of the total deaths, where 9.4 million deaths are due to complications from hypertension. hypertension contributed to 45% of deaths due to heart disease and 51% of deaths due to stroke (who, 2013). in indonesia, hypertension is a major challenge that often occurs in primary health care. the treatment for hypertension is often not sufficient even though there are many effective medicines available (kemenkes ri, 2013). indonesia has experienced an increase in the prevalence of hypertension based on the measurement results for people aged ≥18 years in 2013 through to 2018, which went from 25.8% up https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i1.12811 jurnal ners http://e-journal.unair.ac.id/jners | 17 to 34.1% (kemenkes ri, 2018). there are many risk factors for hypertension. some are modifiable and the rest are unmodifiable. the unmodifiable risk factors are age, gender, family history and genetics. meanwhile, the modifiable risk factors include smoking habits, saturated fat consumption, salt consumption, the use of used cooking oil, drinking habits, obesity, a lack of physical activity, stress and the use of estrogen (kemenkes ri, 2013). bmi is one of the risk factors of hypertension. bmi is related to determining nutritional status. nutritional status can be used to identify weight. weight problems at an early age can risk various degenerative diseases in adulthood (kemenkes ri, 2013). in addition to this, bmi is used as an adiposity index in terms of clinical research. central abdominal adiposity or obesity proves that there is a relation between obese and the risk of hypertension (mancini, et al., 2011). according to the results of a study conducted by kembuan, kandou & kaunang (2016) in southeast minahasa regency, it showed that respondents who were obese (bmi> 30 kg / m2) had a risk that was 3.4 times greater of developing hypertension than the respondents who were not obese. similar to hypertension, abdominal obesity is also associated with an increased risk of cardiovascular disease. diseases related to mechanical stress in the body are also associated with obesity due to the increase in weight (visscher and seidel in crawford and jeffery, 2006). another risk factor for hypertension is a lack of physical activity. a lack of physical activity and the availability of high-calorie foods can prompt the development of pathological conditions such as obesity and cardiovascular disease. physical activity would help to reduce excessive weight and to improve the efficiency of the cardiovascular system and overall psychological condition of well-being (d’isanto, tiziana, et.al, 2017). according to research conducted by sihombing marice (2017), a sufficient level of physical activity was significantly associated with hypertension. in addition, low-risk physical activity was 1.61 times to prompt the development hypertension than high physical activity. other studies have shown that low physical activity increases the risk by 3.5 times of obese hypertension in early adolescents (rabaity and sulchan, 2012). based on the previous studies, body mass index and physical activity were significantly correlated with hypertension. moreover, obese adults have a lower level of physical activity than those with a normal weight, so both factors possibly influence the incidence of hypertension (fernandes and zanesco, 2010). hypertension is now considered to be a major public health problem and its prevalence has increased in 2018 in indonesia. therefore, to overcome this problem, this study has sought to determine the factors related to hypertension, which are modifiable: body mass index and physical activity. materials and methods the method used in this study was a cross-sectional study design executed by analyzing the secondary data of the indonesia family life survey 5 (ifls5) conducted in 2014 2015. ifls5 had a response rate of 90.7%. the population of this study was individuals in households throughout indonesia. the sample totaled about 26,472 respondents after excluding the missing data of 6,209 respondents. the sampling technique used was multistage random sampling. ifls is a survey conducted longitudinally. a sampling of ifls1 was carried out by randomly selecting from the 13 provinces based on the sample in susenas 1993. from there, 321 areas were chosen including both urban and rural areas. after that, from each area, 20 urban and 30 rural households were chosen randomly. respondent in ifls5 were individuals interviewed in ifls1, ifls2, ifls3 and ifls4 (strauss, witoelar, and sikoki, 2016). the dependent variable of this study was hypertension status as obtained from the guideline books. hypertension status was based on the average blood pressure measurement of the respondent (us07a, us07b, us07c code) which was done three times. the respondents were claimed to have hypertension if their systolic blood pressure was ≥140 mmhg and diastolic blood pressure was ≥90 mmhg. blood pressure was measured using omron meter version hem-7203.the independent variables of this study were bmi and physical activity, as well as the characteristics of the respondents consisting of age, sex, education, marital status and smoking status. the bmi variable was divided into four categories: underweight (<18.5 kg/m2), normal (18.5-25 kg/m2), overweight (25.01-29.99 kg/m2) and obese (≥30 kg/m2). the physical activity variable was divided into three categories: low activity (<600 met (metabolic equivalents)), moderate activity (600-3000 met) and high activity (≥3000 met). the age of the respondents (age code) was categorized as productive age (15-64 years) and non-productive age (> 64 years). the sex variable (sex code) and marital status (marstat code) were selected as in the 3a book. the education variable (d06 code) was the length of the education period taken by the respondents categorized into three; low education (<8 years), moderate education (8-13 years) and high education (≥14 years). the smoking status variable was determined based on the smoking habits of the respondents (km04 code). the respondents were claimed to be a smoker if they had smoking habits and claimed as not being a smoker if they did not have smoking habits and if they had never consumed tobacco (km01a code). the data was analyzed using univariate, bivariate and multivariate techniques. univariate analysis was performed to determine the frequency and distribution of the variables. bivariate analysis was done used chi square. multivariate analysis was h. mahiroh et al. 18 | pissn: 1858-3598  eissn: 2502-5791 performed using multiple logistic regression tests to investigate the most dominant factors affecting the incidence rate of hypertension. the covariate variables that had a relationship with hypertension with a p-value <0,25 were included in the multivariate analysis. the backward method was used to select the variables. the confounding variables were assessed by issuing the covariate variables one by one. this part of the study started with the variable that had the largest p-value. after that, if there was a difference in the odds ratio of more than 10% before and after the covariate variable, the variable must be excluded from the model. results this study found that 22.63% of the respondents experienced hypertension and that 23.37% of them were overweight and 7.79% were obese. only 37.91% of the respondents had a high level of physical activity. meanwhile, 94.99% of the respondents were of a productive age and most of them were female, making up 52.05% of the respondents. the respondents who had achieved higher education made up 11.63%, 72.61% of them were married and 32.09% of the respondents smoked (table 1). based on table 2, bivariate analysis showed that obese respondents had a 3,12 times higher risk of hypertension compared to normal respondents (or=3.12, 95% ci = 2.83-3.43, p-value = 0.000). meanwhile, the respondents who were overweight were 2.11 times likely to have hypertension compared to the respondents who were of a normal weight (or=2.11, 95% ci = 1.97-2.25, p-value = 0.000). for respondents with underweight bmi had 0.58 times higher for experiencing hypertension compared with normal bmi (or=0.58, 95% ci = 0.52-0.65, p-value = 0.000). besides, there was no significant correlation between physical activity and the incidence of hypertension (p-value> 0.05). multivariate analysis after being controlled by the covariate variables, it was found that obese respondents had a 4.08 times higher risk of hypertension compared to normal respondents (aor= 4.08, 95% ci = 3.68-4.53, p-value = 0.000). meanwhile, the respondents who were overweight were 2.49 times likely to have hypertension compared to the respondents who were of a normal weight (aor = 2.49, 95% ci = 2.32-2.67, p-value = 0.000). for respondents with underweight bmi had 0.58 times higher for experiencing hypertension compared with normal bmi (aor = 0.58, 95% ci = 0.52-0.65, p-value = 0.000). moreover, there was no significant correlation between physical activity and the incidence of hypertension after being controlled by the covariate variables (p-value> 0.05). discussion in this study, the prevalence of hypertension was 22.63%. this number was lower than the riskesdas data from 2018, where the prevalence was 34.1%. the ifls5 survey was conducted in 2014 2015. the data illustrates that the prevalence of hypertension in indonesia has continued to increase. this increase table 1. characteristics of the respondents variable hypertension total (n) percentage (%) yes n=5,991 (22.63 %) no n=20,481 (77.37 %) (n) (%) (n) (%) body mass index underweight 381 11.64 2,892 88.36 3,273 100 normal 2,757 18.44 12,192 81.56 14,949 100 overweight 2,000 32.33 4,187 67.67 6,187 100 obese 853 41.35 1,210 58.65 2,063 100 physical activity high 2,269 22.61 7,767 77.39 5,682 100 moderate 2,490 23.15 8,264 76.85 10,754 100 low 1,232 21.68 4,450 78.32 10,036 100 age (year) 15-64 5,172 20.57 19,975 79.43 25,147 100 ≥65 819 61.81 506 38.19 1,325 100 sex male 2,877 22.66 9,817 77.34 12,694 100 female 3,114 22.60 10,664 77.40 13,778 100 education low 3,279 33.23 | 6,588 66.77 9,867 100 moderate 2,136 15.79 11,391 84.21 13,527 100 high 576 18.71 2,502 81.29 3,078 100 marital status yes 4,574 23.80 14,646 76.20 19,220 100 no 1,417 19.54 5,835 80.46 7,252 100 smoking status yes 1,865 21.95 6,630 78.05 8,495 100 no 4,126 22.95 13,851 77.05 17,977 100 jurnal ners http://e-journal.unair.ac.id/jners | 19 has been caused by changes in the lifestyle of indonesian people such as smoking, eating foods that are high in fat, stress, obesity and a lack of exercise (rsup dr. sardjito, 2018). the prevalence of hypertension in indonesia was also lower than that of india, which was 31.4%. india is a developing country just like indonesia (who, 2017). however, hypertension is still a health problem in indonesia. this study also found that 23.37% of respondents were overweight and that 7.79% were obese. this result was lower than the results of the research conducted by sari et. al (2018), in which 62.5% of respondents were overweight. meanwhile in the riskesdas data of 2018, 13.6% of respondents were overweight and 21.8% of respondents were obese. the results of the multivariate analysis showed that the respondents who were obese were 4.08 more likely to experience hypertension than the respondents with a normal weight. this result was higher than the research conducted in uzbekistan which consisted of the uzbekistan health screening survey. obese men were only 3.01 times more at risk of developing hypertension compared to the normal respondents. on the other hand, obese women were 2.82 times more at risk of developing hypertension compared to the normal respondents (mishra, arnold, semenov, hong, mukuria, 2006). research by mbolle, b.f.e, et. al (2014) showed obesity associated factor of prehypertension (pre-ht) and hypertension (ht) (p value = 0,004). research conducted by forman, j.p., stampfer, m.j., and curhan, g.c. (2009) also showed that obese women were 4.70 times more at risk of developing hypertension compared to women with a bmi <23.0. this was supported by the research conducted by sebayang (2017) which claimed that women were more likely to access health services than men. another study conducted by shuger, sui, church, meriwether, and blair (2008) showed that women who were overweight were 2.01 times more at risk of hypertension than women with a normal weight. as their bmi increased, so did their central obesity also increase (kasyani, sustyowati, and kandarina, b.j.i, 2017). research by amanda and martini (2017) also showed that the respondents with central obesity were 2.56 times more likely to have hypertension compared to respondents without central obesity. obesity is associated with hypertension because insulin has the ability to induce sodium retention. insulin resistance caused chronic sodium retention. based on the research that has been done, obese adolescents had selective insulin resistance so they were resistant to stimulate glucose absorption and still sensitive to the renal sodium-retaining effect of insulin (rocchini, 2002). meanwhile, someone who is obese needs more blood to supply oxygen and nutrition to their bodily tissues, so the volume of table 2. crude odds ratio and the adjusted odds ratio showing the correlation between the independent variables and hypertension in indonesia variable bivariate multivariate or(a) 95% ci p value aor(b) 95% ci p value lower upper lower upper bmi normal reff. reff. underweight 0.58 0.52 0.65 0.000 0.48 0.43 0.55 0.000 overweight 2.11 1.97 2.25 0.000 2.49 2.32 2.67 0.000 obese 3.12 2.83 3.43 0.000 4.08 3.68 4.53 0.000 physical activity high reff. reff. moderate 1.03 0.96 1.10 0.349 1.05 0.97 1.12 0.172 low 0.94 0.87 1.02 0.180 1.02 0.94 1.12 0.529 age (year) 15-64 reff. reff. ≥65 6.25 5.57 7.01 0.000 6.15 5.43 6.96 0.000 sex female reff. reff. male 1.00 0.95 1.06 0.903 1.48 1.36 1.61 0.000 education high reff. reff. moderate 0.81 0.74 0.90 0.000 0.97 0.87 1.08 0.600 low 2.16 1.96 2.39 0.000 2.35 2.11 2.61 0.000 marital status no reff. reff. yes 1.29 1.20 1.37 0.000 0.98 0.91 1.05 0.585 smoking status no reff. reff. yes 0.94 0.88 1.00 0.070 0.87 0.80 0.95 0.002 controlled by age, sex, education, marital status, and smoking status a = odds ratio b = adjusted odds ratio h. mahiroh et al. 20 | pissn: 1858-3598  eissn: 2502-5791 blood in the blood vessels increases. this means that the cardiac output increases and eventually, so too does the blood pressure (sheps sg. in sulastri, elmatris, ramadhani, 2012). being overweight also increases insulin levels, which causes sodium retention in the kidneys. this also causes the blood pressure to increase (morrison r. in sulastri, elmatris, ramadhani, 2012). the effect of excessive weight on blood pressure is related to fat deposits in the body. the heart of overweight people works harder to pump blood because of the fat in the body clamping the blood vessels. in addition, for overweight people, the body also works hard to burn calories as the process requires an adequate oxygen supply. the more calories are burned, the greater the supply of oxygen needed. this causes the heart to work harder and for the person to experience an increase in blood pressure (widharto in mardani, gustina, dewanto, and priwahyuni, 2011). in this study, physical activity factors were not significant with the p-value = 0.172 for moderate activity and the p-value = 0.529 for low activity. this result was not in accordance with the research conducted by chataut, adhikari and sinha (2011) in which the respondents with moderate physical activity showed significant results with the p-value = 0.00. in the study, the respondents with a moderate level of physical activity were 2.44 times at risk of developing hypertension than the respondents with a high level of physical activity. a study conducted by hasanudin, adiyani and perwiraningtyas, (2018) also stated that there was a significant correlation between physical activity and blood pressure in the society of kelurahan tlogomas, lowokwaru in malang city with the p-value = 0.005. however, research conducted by fernandes and zanesco (2010) showed that current physical activity was not significantly related to the incidence rate of hypertension after adjusting for the confounding factors where the p-value = 0.815. the measurement of physical activity should be conducted for at least nine months to avoid bias (fernandes and zanesco, 2010). in theory, individuals who were active in terms of physical activity had low levels of morbidity and mortality. this is because physical activity plays a role in reducing the pathological adverse effects including arterial hypertension, metabolic syndrome and type 2 diabetes mellitus (fernandes and zanesco, 2010). in addition, individuals with a low level of physical activity were at risk of developing hypertension due to a lack of energy expenditure (sugianti in sihombing marice, 2017). researchers in america explained that physical activity carried out for at least 15 minutes a day can reduce 14% of the risk of obesity hypertension (rabaity and sulchan, 2012). meanwhile, the physical activity factor in this study was not correlated significantly with hypertension because the researcher did not measure physical activity for at least nine months and they did not conduct a control history of the hypertension variable. bmi is a powerful confounder in the multivariate model. when it inserted into the analysis, current physical activity was not associated with hypertension (fernandes and zanesco, 2010). the strength of this study was in the large sample. it represents 83% of the population in indonesia. thus, the bias can be minimized because it used the secondary data from ifls5. in addition, the data was obtained through the measurement of the respondents' right and left arms repeated three times. this was to ensure that the data obtained was more valid. in this study, the researchers did not control for the history of hypertension variables which might influence changes in physical activity behavior before the measurements were made. for further research, it is suggested to examine the variables of hypertension history and other variables which are predicted to be related to hypertension, such as the respondent's diet. things that you can do to treat hypertension include modifying your lifestyle. individuals who commit to a healthy lifestyle are less likely to experience hypertension (forman, j.p., stampfer, m.j., and curhan, g.c., 2009). a healthy lifestyle includes having a healthy diet. a healthy diet is focused on maintaining weight by eating enough fruit, and salt and fat to a low degree. government and public health services need to increase the promotion of a healthy lifestyle in society to reduce the rate of hypertension. these efforts can be carried out through improving the management of noncommunicable disease control services comprehensively, especially promotive and preventive control services in particular. conclusion hypertension is a dangerous disease for the wider community. bmi factors are significantly associated with the incidence rate of hypertension. the higher the bmi, the greater the risk for hypertension. meanwhile, the factor of physical activity is not significantly related to the incidence of hypertension. government and health services need to increase the promotion of healthy lifestyles especially about healthy diet program to maintain an ideal body weight and to reduce the rate of hypertension. references amanda, d. & martini, s. (2018). hubungan karakteristik dan obesitas sentral dengan kejadian hipertensi. jurnal berkala epidemiologi, 6(1). [accesed 2019 march 22]. doi: 10.20473/jbe.v6i12018.43-50 chataut, adhikari, & sinha. (2011). prevalence and risk factors for hypertension in adults living in central development region of nepal. kathmandu univ med j, 9(1), 13-18. [accesed 2019 march 23]. available from https://doi.org/10.3126/kumj.v9i1.6255 jurnal ners http://e-journal.unair.ac.id/jners | 21 crawford, d. & jeffery, r.w. (2006). obesity prevention and public health. new york: oxford university press. doi: 10.1136/adc.2006.095372 d’isanto, tiziana, et al. (2017). health and physical activity. sport science, (10)1, 100-105. fernandes, r. a. & zanesco, a. (2010). early physical activity promotes lower prevalence of chronic diseases in adulthood. hypertension research. [accesed 2019 march 21]. available from https://doi.org/10.1038/hr.2010.106 forman, j.p., stampfer, m.j., & curhan, g.c. (2009). diet and lifestyle risk factors assosiated with incident hypertension in women. american medical association, 302(4), 401-411. [accesed 2019 march 27]. available from https://doi.org/10.1001/jama.2009.1060 hasanudin, ardiyani, v.m., & perwiraningtyas, p. (2018). hubungan aktivitas fisik dengan tekanan darah pada masyarakat penderita hipertensi di wilayah tlogosuryo kelurahan tlogomas kecamatan lowokwaru kota malang. nursing news, 3(1), 787-799 kasyani, sustyowati, & kandarina, b.j.i. (2017). lingkar pinggang dan hipertensi pada orang indonesia usia 40 tahun ke atas. seminar nasional kesehatan masyarakat sriwijaya. [accesed 2019 march 27]. kembuan, kandou, & kaunang. (2015). hubungan obesitas dengan penyakit hipertensi pada pasien poliklinik puskesmas touluaan kabupataen minahasa tenggara. fakultas kesehatan masyarakat universitas sam ratulangi, 16-35. http://dx.doi.org/10.20473/jbe.v6i12018.35-42 kemenkes ri. (2018). hasil riskesdas 2018. jakarta. [accesed 2019 march 25]. available from www.depkes.go.id. kemenkes ri. (2013). hasil riskesdas 2013. jakarta. [accesed 2019 march 26]. available from www.depkes.go.id kemenkes ri. (2013). infodatin hipertensi. jakarta. [accesed 2019 march 28]. available from www.depkes.go.id mancini, et al. (2011). nutritional and metabolic bases of cardiovascular disease. united kingdom: uk copyright, designs and patents act 1988. doi:10.1002/9781444318456 mardani, said, et al. (2011). hubungan antara indeks massa tubuh (imt) dan kebiasaan mengonsumsi lemak dengan tekanan darah. jurnal kesehatan komunitas, (1)3, 129-135. https://doi.org/10.25311/jkk.vol1.iss3.17 mbolla, b.f.e., et al. (2014). prehypertension and hypertension among schoolchildren in brazzaville, congo. international journal of hypertension. [accesed 2019 march 25]. available from http://dx.doi.org/10.1155/2014/803690 mishra, v, et al. (2006). epidemiology of obesity and hypertension an related risk factors in uzbekistan. european journal of clinical nutrition, (60), 1355-1366. [accesed 2019 march 26]. available from https://doi.org/10.1038/sj.ejcn.1602465 morrison, r. (2006). the zucker rat as a model of obesity-hypertension. thesis, university of marshall. huntington, usa, 20-7. [accesed 2019 march 23]. doi: 10.1161/01.hyp.13.6.896 rabaity, a. & sulchan, m. (2012). konsumsi gula sederhana dan aktivitas fisik sebagai faktor risiko kejadian hipertensi obesitik pada remaja awal. journal of nutrition college, 1(1), 185-191. [accesed 2019 march 24]. https://doi.org/10.14710/jnc.v1i1.674 rsup dr. sardjito. (2018). pencegahan penyakit hipertensi dengan gaya hidup sehat dan peningkatan pengetahuan tentang hipertensi. [accesed 2019 march 25]. rocchini. (2002). obesity hypertension. american journal of hypertension, 15, 50s-52s. [accesed 2019 march 26]. available from https://doi.org/10.1016/s0895-7061(01)022993 sari, nilam yusika, et al. (2018). demographical factors, not lifestyle factors, assosiated with the increase of random blood glucose in coastal areas. jurnal ners, (13)1. [accesed 2019 march 26]. available from http://dx.doi.org/10.20473/jn.v13i1.8148 sebayang, s. k., et al. (2017). health care-seeking behaviour of coastal communities in banyuwangi, indonesia: results of a crosssectional survey. jurnal ners, (12)1, 66-73. [accesed 2019 march 26]. available from http://dx.doi.org/10.20473/jn.v12i1.4439 sheps sg. (2005). mayo clinic hipertensi, mengatasi tekanan darah tinggi. intisari mediatama: jakarta. shuger, s.l., et al. (2008). body mass index as a predictor of hypertension incidence among initially healthy normotensive women. us national library of medicine national institutes of health. american journal of hypertension, (21)6, 613–619. [accesed 2019 march 27]. available from https://doi.org/10.1038/ajh.2008.169 sihombing, m. (2017). faktor yang berhubungan dengan hipertensi pada penduduk indonesia yang menderita diabetes mellitus (data riskesdas 2013). puslitbang sumber daya dan pelayanan kesehatan, 53-64. [accesed 2019 march 29]. available from http://dx.doi.org/10.22435/bpk.v45i1.5730. strauss j., witoelar f., & sikoki b. (2016). the fifth wave of the indonesia family life survey: overview and field report. [accesed 2019 march 30]. sulastri, elmatris, & ramadhani. (2012). hubungan obesitas dengan kejadian hipertensi pada masyarakat etnik minangkabau di kota padang. majalah kedokteran andalas, (2)36, 188-201. [accesed 2019 march 29]. available from https://doi.org/10.22338/mka.v36.i2.p188201.2012 https://doi.org/10.14710/jnc.v1i1.674 h. mahiroh et al. 22 | pissn: 1858-3598  eissn: 2502-5791 visscher, t.l.s & seidell, j.c. (2001). the public health impact of obesity. ann rev public health, 22, 75-355. [accesed 2019 march 23]. available from https://doi.org/10.1146/annurev.publhealth.22. 1.355 who. (2013). a global brief on hypertension. [accesed 2019 march 23]. available from https://www.who.int who. (2017). global health observatory data repository. [accesed 2019 march 23]. available from https://www.who.int widharto. (2007). bahaya hipertensi. jakarta: sunda kelapa pustaka. https://doi.org/10.1146/annurev.publhealth.22.1.355 https://doi.org/10.1146/annurev.publhealth.22.1.355 ners vol 10 no 2 okt 2015.indd 318 stres kerja dan kepuasan kerja perawat di rumah sakit daerah (rsd) mardi waluyo kota blitar (job stress and job satisfaction among nurses in mardi waluyo hospital blitar) ahsan*, adine yenie cahyaning pradyanti* jurusan ilmu keperawatan fakultas kedokteran universitas brawijaya malang jalan veteran malang 65145 email: ahsanfkub@yahoo.com abstrak pendahuluan: perawat sebagai tenaga profesional di rumah sakit rentan mengalami stres kerja yang menyebabkan gangguan fisiologis, psikologis, dan perilaku. suatu studi menunjukkan bahwa stres kerja yang tinggi akan menurunkan kepuasan kerja. tujuan penelitian ini adalah menganalisis hubungan stres kerja dengan kepuasan kerja perawat di ruang rawat inap rsd mardi waluyo kota blitar. metode: penelitian ini menggunakan metode penelitian cross-sectional dengan pengujian hubungan antar variabel menggunakan rank-spearman. sampel yang digunakan dalam penelitian ini adalah total sampling, yaitu seluruh perawat yang bekerja di ruang rawat inap rsd mardi waluyo kota blitar. seluruh responden mengisi kuesioner tentang stres kerja dan kepuasan kerja. jumlah responden adalah 61 orang. hasil: hasil uji rank-spearman menunjukkan nilai –0,674 menunjukkan hubungan antar dua variabel terbalik dengan tingkat hubungan kuat. selang kepercayaan dalam penelitian ini adalah 95% dengan p (0,000) < p-value. diskusi: semakin berat tingkat stres kerja perawat, maka tingkat kepuasan kerja perawat semakin rendah. kata kunci: stres kerja, kepuasan kerja, perawat abstract introduction: nurses as a professional worker in hospitals are often getting job stress that cause disturbance physiology, psychology, and behavior. a study had shown that job stress in a high level would decrease the job satisfaction. the objectived of this research was to analyze the relation of job stress with the nurse job satisfaction in mardi waluyo hospital in blitar city. methods: this research used cross-sectional as the method to conduct this research by examining the relation among variables using rank-spearman. sample of this research was the total sampling, which the total of all nurses that work in the hospital, mardi waluyo in blitar city. all of the respondents filled out the questionnaires about stress that occur while working and the job satisfaction. total of respondents were 61 nurses. results: the result of rank-spearman showed the value of -0,674; there was an inverted relation among variables with a strong relationship level, the significance in this research was 0,000 with a confidence interval of 95% (p-value). discussions: there was the more stress those nurses got, then there would be less job satisfaction. keywords: job stress, job satisfaction, nurse pendahuluan kepuasan kerja merupakan perasaan suka atau puas dan ketidakpuasan kerja merupakan perasaan tidak suka terhadap peker jaan yang dialami oleh individu. kepuasan kerja dapat menyokong untuk mendapatkan hasil kerja yang optimal (wasis, 2008). menurut hasil penelitian mukarommah (2007) kepuasan kerja perawat di rsud kabupaten pamekasan sebagian besar adalah kurang (53%). terdapat hasil penelitian lain oleh febrianny (2009) lebih dari separuh responden (62,5%) menyatakan ketidakpuasan kerja di ruang triage igd rs dr. m. djamil padang. rumah sakit daerah (rsd) mardi waluyo kota blitar merupakan rumah sakit milik pemerintah daerah tipe b non pendidikan yang ada di kecamatan sananwetan kota blitar. studi pendahuluan yang dilakukan peneliti pada tanggal 19 november 2013, para kepala ruang rawat inap mengungkapkan bahwa beker ja di r uang rawat inap di rsd mardi waluyo kota blitar memiliki stres kerja yang tinggi. sumber stres kerja yang dialami perawat, berkaitan dengan sumber daya perawat yang tidak seimbang dengan jumlah pasien, keberagaman diagnosa pasien, komplain dari pasien atau keluarga, alat-alat medis penunjang yang tidak tersedia dengan baik, keterbatasan r uangan, dan metode 319 stres kerja dan kepuasan kerja perawat (ahsan dan adine yenie cahyaning pradyanti) penugasan yang belum berjalan efektif. dari uraian diatas, ditemukan beberapa gambaran perawat mengalami stres kerja yang selanjutnya akan diteliti. berdasarkan penelitian mathew (2013), dikatakan bahwa ada hubungan terbalik antara stres dan kepuasan kerja, seperti stres meningkat, maka kepuasan kerja akan menur un. akibatnya, peningkatan stres umumnya bisa menyebabkan penur unan kepuasan kerja dan penur unan kualitas kehidupan. hal ini dapat berkontribusi untuk menimbulkan potensi bagi perawat untuk meninggalkan profesi dan sebagai konsekuensi akhir jumlah perawat akan berkurang. teori yang mendukung hasil penelitian di atas adalah teori oleh herzberg (as’ad, 2006) dikatakan bahwa ada dua faktor yang mempengaruhi kondisi pekerjaan seseorang, yaitu faktor motivasi motivation factor) yang disebut juga dengan satisfaction atau intrinsic motivation dan faktor kesehatan (hygienes) yang juga disebut dissatisfaction at au ekstrinsic motivation. berdasarkan fenomena dan masalah tersebut, peneliti tertarik untuk meneliti kekuatan “hubungan stres kerja dengan kepuasan kerja perawat di rsd mardi waluyo kota blitar”, bahan dan metode penelitian ini menggunakan rancangan deskriptif analitik korelatif dengan pendekatan cross sectional (nursalam, 2008). rancangan deskriptif korelasional ini menggambarkan hubungan stres kerja dengan kepuasan kerja perawat di rsd mardi waluyo kota blitar. populasi dalam penelitian ini adalah seluruh perawat yang bekerja di ruang rawat inap biasa di rsd mardi waluyo kota blitar. teknik sampling yang digunakan adalah total sampling, artinya seluruh perawat yang bekerja di ruang rawat inap biasa rsd mardi waluyo kota blitar dan bersedia menjadi responden. instrumen penelitian menggunakan kuesioner, yang terdiri dari tiga kuesioner. kuesioner satu berisi data umum responden. kuesioner dua berisi pertanyaan tentang stress kerja yang diukur menggunakan tiga indikator stres kerja, yaitu gangguan fisiologis, gangguan psikologis, dan perubahan perilaku. kuesioner tiga berisi pertanyaan tentang kepuasan kerja berdasarkan teori herzberg (as’ad, 2006). uji validitas dalam penelitian ini menggunakan pearson product momentdan hasil dari uji validitas dinyatakan valid untuk semua item pertanyaan. uji reliabilitas menggunakan alpha-cronbach dan dinyatakan reliabel dengan koefisien keandalan kuesioner stres kerja sebesar 0,74, kuesioner kepuasan kerja 0,73. analisis dalam penelitian ini dilakukan untuk mengidentifikasi hubungan stres kerja dengan kepuasan kerja perawat. jenis data dalam penelitian ini adalah ordinal dan ordinal, maka analisis bivariat non-parametrik pada penelitian ini menggunakan uji statistik uji korelasi spearman, yaitu untuk menguji tingkat atau eratnya hubungan antara dua variabel. pengolahan data ini dilakukan dengan program spss for windows. hasil penelitian hasil penelitian tentang karakteristik usia responden rsd mardi waluyo kota blitar menggambarkan bahwa dari 61 orang responden, usia terbanyak rentang antara 26 sampai 35 tahun sebanyak 41 orang. hal ini menunjukkan bahwa sebagian perawat rsd mardi waluyo kota blitar termasuk dalam usia dewasa muda atau dewasa awal. berdasarkan jenis kelamin dari 61 orang responden, sebanyak 43 orang (70,5%) berjenis kelamin perempuan dan 18 orang (29,5%) berjenis kelamin laki-laki. hal ini menunjukkan bahwa sebagian besar perawat rsd mardi waluyo kota blitar berjenis kelamin perempuan, berarti profesi perawat didominasi oleh perempuan. alasan individu menjadi perawat salah sat u nya adalah pekerjaan perawat identik dengan pekerjaan perempuan, yaitu merawat orang lain. karakteristik pendidikan responden menunjukkan bahwa perawat di rs mardi waluyo blit a r masi h d idom i nasi oleh p e nd id i k a n vok a sion a l. seba nya k 38 orang (62,3%) responden ber pendidikan 320 jurnal ners vol. 10 no. 2 oktober 2015: 318–323 d3 keperawatan dan 23 orang (37,7%) berpendidikan s1 keperawatan (ners). stres kerja perawat di rsd mardi waluyo kota blitar mayoritas tingkat sedang sebesar 62,3%, 34,4% mengalami stres kerja ringan dan sebagian kecil yaitu 3,3% perawat yang mengalami stres kerja berat. hal ini berarti perawat di rsd mardi waluyo kota blitar terdapat sebagian kecil perawat yang belum mampu memanajemen stres kerja sehingga berpotensi terjadi depresi terhadap pekerja. tingkat stres kerja berdasarkan jenis kelamin perawat didapatkan data 61 orang perawat di rsd mardi waluyo kota blitar, 21 orang mengalami stres kerja ringan, 17 orang diantaranya merupakan perempuan dan 4 lakilaki. sedangkan responden yang mengalami stres kerja sedang, dari 38 orang yang berjenis kelamin perempuan 24 orang dan laki-laki 14 orang. responden yang mengalami stres kerja berat adalah 2 orang perempuan. perawat yang berjenis kelamin perempuan lebih rentan terkena stres. b e r d a s a r k a n t i n g k a t k e p u a s a n kerja perawat menunjuk kan bahwa dari 61 responden, 2 orang (3,3%) memiliki kepuasan kerja rendah, 42 orang (68,9%) memiliki kepuasan kerja sedang, dan 17 orang (27,9%) memiliki kepuasan kerja tinggi. ti ng k at ke pu a sa n ke r ja pe r awat berdasarkan jenis kelamin, didapatkan data dari 61 responden, terdapat 2 orang perempuan dengan kepuasan kerja rendah. kepuasan kerja perawat sedang sebanyak 42 orang, terdiri dari 15 orang laki-laki dan 27 orang perempuan. kepuasan kerja perawat tinggi sebanyak 14 orang, terdiri dari 3 orang laki-laki dan 14 orang perempuan. sebagian besar perawat perempuan memiliki kepuasan kerja sedang. terdapat hubungan bermakna di antara kedua variabel. hasil uji korelasi spearman rank pada penelitian ini menunju k kan bahwa besar korelasi (r) antara variabel 1 dan 2 adalah 0,674 yang berarti korelasi tingkat stres kerja perawat dengan tingkat kepuasan kerja perawat adalah kuat. nilai tersebut masuk dalam rentang interval korelasi 0,60–0,799 yang berarti korelasi kuat. nilai korelasi bernilai negatif (-) berarti dua variabel memiliki hubungan terbalik, yaitu semakin tinggi stres kerja perawat, maka kepuasan kerja perawat semakin rendah. dengan demikian, h0 ditolak. pembahasan tingkat stres kerja perawat sebagian besar mengalami stres kerja sedang. tingkat stres kerja perawat di rsd mardi waluyo kota blitar sebagian besar mengalami stres kerja sedang diduga karena masa kerja pegawai yang tergolong cukup berpengalaman dalam mengelola dan mengikuti kebiasaan di rumah sakit maupun ruangan. masa kerja lebih dari dua tahun dapat memberikan gambaran bahwa pegawai telah mampu beradaptasi dengan lingkungan pekerjaan, sehingga tingkat stres kerja pun cenderung sedang. hasil penelitian ini menunju k kan adanya 2 perawat dengan stres kerja berat. menurut penelitian vita yustiya (2010), pada stres kerja tinggi, seseorang akan merasakan per ubahan f isiologis, psikologis, bahkan perubahan perilaku. pada stres kerja perawat sedang, seseorang akan merasakan terjadinya tabel 1. tabel tingkat stres kerja dan kepuasan kerja perawat tingkat stres perawat tingkat kepuasan kerja perawat total ringan sedang tinggi ringan 0 10 11 21 sedang 2 30 6 38 berat 0 2 0 2 total 2 42 17 61 uji korelasi rank-spearman (r) -0,674 signifi kansi (ρ) 0,000 321 stres kerja dan kepuasan kerja perawat (ahsan dan adine yenie cahyaning pradyanti) perubahan fisik dan psikologis dalam dirinya, namun ia masih mampu mengendalikan sehingga tidak sampai mengubah perilaku orang tersebut. sedangkan perawat yang mengalami stres kerja rendah akan tetap stabil dalam menjalani pekerjaannya. hal ini berarti bahwa ada perawat yang mengalami gangguan fisiologis, psikologis, dan perilaku di rsd mardi waluyo kota blitar. d it i njau d a r i seg i k a r a k t e r ist i k pekerjaan, pekerjaan perawat tergolong pekerjaan yang membutuhkan profesionalisme tinggi. menurut iwan sain, 2014, keperawatan adalah suatu bentuk perawatan profesional ya ng mer upa ka n bag ia n i nteg ral d a r i pelayanan kesehatan yang didasarkan pada ilmu dan kiat keperawatan. perawat selalu dituntut profesional dalam setiap tindakan. keprofesionalan akan mempengaruhi tingkat stres kerja individu dalam menjalankan tugas. hasil penelitian menunjukkan sebagian besar perawat kepuasan kerja sedang. kepuasan kerja perawat di rsd mardi waluyo yang sebagian besar adalah sedang menunjukkan bahwa sebagian besar perawat merasa cukup puas dengan pekerjaan yang dijalankan selama ini. ti ng k at ke pu a sa n ke r ja pe r awat menggambarkan kesukaan atau ketidaksukaan perawat terhadap pekerjaannya (mathew, 2013). bila terdapat sebagian kecil perawat yang memiliki kepuasan ker ja rendah, diduga perawat tersebut memiliki perasaan k e t i d a k s u k a a n t e r h a d a p p e k e r j a a n . ketidaksukaan individu terhadap pekerjaan berdampak adanya niat untuk meninggalkan pekerjaan (mutukrisnhan, 2011). meskipun hasil penelitian menunjukkan jumlah kecil perawat yang memiliki kepuasan kerja rendah, perawat tersebut harus mendapat motivasi eksternal yang baik agar tidak ada keinginan meninggalkan pekerjaan. hasil penelitian menunjukkan hampir separuh perawat memiliki kepuasan kerja tinggi. hal ini berkaitan dengan pemenuhan kebut uhan yang baik dan telah mampu membentuk aktualisasi diri sebagai perawat di rsd mardi waluyo kota blitar. seperti yang dipaparkan dalam teori maslow bahwa pemenuhan kebut uhan yang baik dapat memenuhi aktualisasi diri perawat. hanya sekitar sepertiga dari perawat dapat memenuhi aktualisasi diri terhadap pekerjaannya. ada hubungan stres kerja dengan kepuasan kerja perawat di rsd mardi waluyo kota blitar. hal tersebut dapat dikatakan bahwa antara stres kerja perawat mempunyai hubungan yang bermakna dengan kepuasan kerja perawat dengan arah korelasi negatif. korelasi negatif bermakna semakin tinggi stres kerja maka kepuasan kerja semakin rendah, begitu pula sebaliknya. berdasarkan kekuatan korelasi antar kedua variabel menunjukkan hubungan kuat dengan nilai korelasi sebesar 0,674. penelitian ini sesuai dengan penelitian oleh neenu, (2013) berjudul effect of stress on job satifaction among nurses in central kerala yang menyebutkan bahwa semakin tinggi stres kerja perawat maka kepuasan kerja perawat semakin rendah. penelitian lain yang mendukung hasil penelitian di atas adalah penelitian oleh simin bemana, et al, (2013) berjudul the relationship among job stress and job satisfaction in municipality personnel in iran dikatakan bahwa terdapat hubungan bermakna antara stres kerja dengan kepuasan kerja perawat. simpulan dan saran simpulan semakin tinggi tingkat stres kerja maka tingkat kepuasan kerja semakin rendah dengan tingkat korelasi hubungan kuat. saran pihak manajerial rumah sakit perlu mempertimbangkan dalam hal pengambilan keputusan dan penentuan kebijakan terkait stres kerja dan kepuasan kerja yang dialami perawat. ba g i p e nel it i s el a njut nya p e rlu mempertimbangkan dalam pemilihan desain penelitian yang dapat mengukur variabel stres kerja dan kepuasan kerja dalam minimal dua kali pengukuran agar terlihat perbedaan dalam waktu yang berbeda dan pemilihan instrumen 322 jurnal ners vol. 10 no. 2 oktober 2015: 318–323 penelitian untuk observasi secara langsung perubahan fisiologis, psikologis, dan perilaku perawat. hasil penelitian ini dapat dijadikan sebagai referensi bagi yang hendak meneliti lebih lanjut tentang stres kerja dan kepuasan kerja perawat. kepustakaan as’ad. 2006. seri ilmu sumber daya manusia: psikologi industri. cetakan kesebelas. yogyakarta: liberty. bemana, simin, et al. 2013. the relationship among job stress and job satisfaction in municipality personnel in iran. world applied science journal 22 (2): 233238. breuklin, selsbi rihulay. 2012. perbedaan tingkat stres kerja perawat di unit rawat inap dan perawat unit gawat darurat di rumah sakit panti wilasa citarum dan rumah sakit panti wilasa dr. cipto semarang. skripsi. salatiga: universitas kristen satya wacana. chanafi e, djuariah. 2005. hubungan presepsi perawat pelaksana tentang jenjang karir dengan kepuasan kerja di rsud budhi asih jakarta. tesis. jakarta: universitas indonesia. dwijayanti, w. 2010. stres kerja pada perawat pelaksana di ruang rawat inap rs krakatau medika tahun 2010. skripsi. jakarta: fakultas kesehatan masyarakat universitas indonesia. febriany, mimi. 2009. faktor-faktor yang berhubungan dengan kepuasan kerja perawat di ruang triase igd rs. dr. djamil padang tahun 2009. skripsi. padang: universitas andalas. greenberg, j.s. 2006. comprehensive stress management. edisi 7. new york: mcgraw-hill company, inc. hasibuan, h.h.s.p. 2009. manajemen sumber daya manusia. edisi ketiga. jakarta: bumi aksara. henny. 2007. hubungan stres kerja dengan kepuasan kerja karyawan bagian customer care pada pt telekomunikasi indonesia tbk bekasi. skripsi. bogor: institut pertanian bogor. indriyani, a. 2009. pengaruh konfl ik peran ganda dan stres kerja terhadap kinerja perawat wanita di rumah sakit. tesis. fakultas manajemen. universitas diponegoro. diakses pada 18 oktober 2013 dari http://eprints.undip.ac.id. mathew, m.n.a. 2013. effect of stress on job satisfaction among nurses in central kerala.journal of business and management, 7(2), 47. molouk dan ali khani. 2012. evalution of the nurses’ job satisfaction, and its association with their moral sensitivities and well-being. journal of clinical and diagnostic research. vol. 6(10): 1761–1764. mukarommah, nur., et al. 2007. hubungan pe ndidik an dan kine r ja de ngan kepuasan kerja perawat di ruang r a w a t i n a p r s u d k a b u p a t e n pamekasan. manuskrip. munandar, a.s. 2004. psikologi industri dan organisasi. jakarta: ui-press. munandar, a.s. 2008. psikologi industri dan organisasi. jakarta: ui-press. muthmainah s, iin. 2012. faktor-faktor penyebab stres kerja di ruangan icu pelayanan jantung terpadu dr. cipto mangunkusumo jakarta. skripsi. depok: ui lib. muthukrishnan, n, et al. 2011. factors driving occupational st ress of employees working in hospital in dehradun. international journal of research in it & management. 61:77. nakakis konstantinos, o.c. 2008. factors infl uencing stress and job satisfaction of nurses working in psychiatric units: a research review.health science journal, 2(4). notoadmodjo. 2005. metodologi penelitian kesehatan. jakarta: rineka cipta. nursalam. 2008. konsep dan penerapan m e t o d o l o g i p e n e l i t i a n i l m u keperawatan. edisi 2. jakarta: salemba medika. potter dan perry. 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktik. edisi 4. volume 2. alih bahasa: renata komalasar i, d k k. jakar ta: egc. price. 2003. professional turnover: the case for nurses. new york: medical and scientifi c books. 323 stres kerja dan kepuasan kerja perawat (ahsan dan adine yenie cahyaning pradyanti) robbins, stephen. 2003. perilaku organisasi. jakarta: gramedia. rosnawati, m.r., et al. 2010. the bahasa melayu version of the nursing stress scale among nurses: a reliability study in malaysia. asia-pasifi c journal of public health. 22(4), 501–504. s, timoteus. 2011. teori motivasi abraham h. maslow dan penerapannya dalam manajemen. skripsi. depok: ui lib. sain, iwan. 2014. keperawatan profesional. presentasi dalam seminar keperawatan januari 2014. sari, perdana. 2012. gambaran kepuasan kerja pada perawat di unit rawat inap rumah sakit jiwa daerah propinsi sumatera utara. sk r ipsi. medan: universitas sumatera utara. siagian, s.p. 2004. teori pengembangan organisasi. jakarta: bumi aksara. siagian, s.p. 2005. teori pengembangan organisasi. jakarta: bumi aksara. waluyo. 2009. psikologi teknik industri. jakarta: graha ilmu. wasis. 2008. pedoman riset praktis untuk profesi perawat. jakarta: egc. yustiya, vita. 2010. forgiveness dan stres kerja terhadap perawat. sk r ipsi. malang: umm press. 292 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17149 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review strategy intervention to prevent and reduce postpartum depression: a systematic review m. elyas arif budiman, supiah ningsih juita sari, winda kusumawardani and dhona sutopo faculty of nursing, universitas airlangga, surabaya, indonesia abstract background: postpartum depression is a non-psychotic depressive disorder with the criteria for diagnosis being that it can start early at four weeks postpartum. this can occur in the first year postpartum. postpartum depression can result in deep sorrow and even the risk of suicide. method: the sources of the articles used were from a search of the scopus, pubmed and proquest databases with the keywords “postpartum depression, nursing intervention, psychology and postpartum”. the search was restricted articles ranging from 2014 until 2018. after the articles were obtained, then the articles were reviewed until the stage of making a systematic review. result: the systematic review resulted in 15 of 19 choices of interventions that can be used to prevent and reduce the symptoms of postpartum depression. the results found that an internet cognitive behavior therapy intervention is very significant in terms of preventing and reducing the symptoms of postpartum depression. nursing interventions are packaged in a variety of programs proven to reduce the postpartum depression variables and actions needed to prevent and reduce the symptoms of postpartum depression significantly. conclusion: based on the results of the analysis of the 15 journals from the results of the study, internet cognitive behavior therapy intervention is recommended to prevent and reduce postpartum depression. this intervention can be developed practically and easily. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords post-partum depression; nursing intervention; psychology; postpartum contact m. elyas arif budiman  m.elyas.arif.budiman2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: budiman, m. e. a, sari, s. n. j, kusumawardani, w & sutopo, d. (2019). strategy intervention to prevent and reduce postpartum depression: a systematic review. jurnal ners, 14(3si), 292-297. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17149 introduction depression is a mental health disorder characterized by moods that are depressed or where they lose interest in their activities, causing a significant decrease in their quality of everyday life. depression can start from mild or moderate and range up to severe depression with or without psychotic features. depression conditions are very commonly found in primary care settings where the incidence of depression that is most commonly found is postpartum depression (w.stuart, 2013). post-partum depression is a non-psychotic depressive disorder with the criteria for diagnosis starting at four weeks post-partum. this can occur in the first year after giving birth (martha raile alligood, 2014). post-partum mood disorders such as postpartum depression are estimated to affect 10-20% of women and it is a serious health problem for both the mothers and their children (prevatt, lowder, & desmarais, 2018). an average of 50% of post-partum depression in women lasts for 6 months where the onset of the feeling of post-partum occurs in about 50% to 80% of women within 1 to 5 days after delivery. the onset of postpartum depression from 2 weeks up to 12 months after occurs around 10-15% in postpartum women(w.stuart, 2013). the impact of post-partum depression can be severe, one of which is suicide, which is a major cause of maternal death in the first year after childbirth. it is an indication that post-partum depression can have a negative impact on children's cognitive, socio-emotional and behavioral development. in addition, postpartum https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:m.elyas.arif.budiman-2018@fkp.unair.ac.id mailto:m.elyas.arif.budiman-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 293 depression can continue to have an impact on how the mothers care for their children after the post-partum period (perkins, yorke, & fancourt, 2018). depressive symptoms interfere with every aspect of a mother's functional and social interactions. depressed mothers may have difficulties related to being sensitive to their baby's cues and needs, and they feel less satisfied with their care. the assessment of maternal postpartum mental status and maternal adaptation are a part of the standard clinical care. post-partum depression screening tools, such as the edinburgh post-partum depression scale (epds), are now widely used in health clinics in many western countries. the symptoms of postpartum depression usually occur from birth through to six weeks postnatal. maternal age, the number of pregnancies, childbirth or the number of children born alive is not associated with the symptoms of postnatal depression. mothers with depressive symptoms, however, are less satisfied with their family life and their dynamics when compared to mothers without depressive symptoms (salonen, pridham, brown, & kaunonen, 2014). mental health and emotional well-being are important for complete health. soul welfare is very necessary to be maintained or improved, one of which is through the promotion and prevention of health. mental health promotion, when it is intended to improve the positive mental health in the community, can also support the achievement of goals and reduce the incidence of mental disorders. the prevention and promotion strategies are the same activities and they gave different but complementary results (w.stuart, 2013). there is strong research evidence that identifies depression (depression) as being overcome through several interventions. one of the results of the research is through the activities of peer groups, cognitive behavior therapy and social support. the purpose of this research was to find out preventive measures to overcome the problem of postpartum depression. materials and methods design a literature search was used to identify studies published in the last 5 years, from 2014 to 2018, in peer-reviewed journals for actions to reduce the incidence of postpartum depression. article selection criteria the inclusion criteria of the article were 1) all peerreviewed articles related to the action of reducing postpartum depression with a quasi-experimental approach and where the sampling method carried out was done via randomized controlled trials, 2) populations in the peer-reviewed articles were all postpartum mothers who experienced postpartum depression based on the criteria from the examination, 3) the measures taken in peer-reviewed articles were all non-pharmacological interventions that can reduce postpartum depression and 4) if the results measured in the peer-reviewed article saw a table 1. literature search summary decrease in postpartum depression after the intervention was measured using a depressive instrument. the exclusion criteria in this study were if the study did not report original data, if there were no non-pharmacological intervention measures, if there was no association with the handling of postpartum depression and if the journals were published before 2014. literature search strategy the approach used was a systematic review that began with the selection of topics, and then the keywords were determined in order to search for journals (primary research) using english and indonesian through several databases including scopus, pubmed and proquest. the search was limited to 2014 to 2018. the english keywords used were "depression postpartum", nursing, psychology, postpartum and "intervention". the next step was to identify the title of each article that was considered close to the research desired. the title identification identified postpartum depression and postpartum intervention respectively. there are 15 articles that are in accordance with the inclusion criteria. the articles that did not fit the inclusion criteria totaled 4 articles including 2 articles not in accordance with the type of study desired and 2 outcome articles are not as desired. then the 19th article was screened again according to the exclusion criteria. after screening, the results of the articles were in accordance with the exclusion criteria. quality study analysis articles or journals that fit the criteria underwent critical appraisal analysis in accordance with the rct research approach. the measuring instrument used was the critical appraisal skills program (csap). the data that was analyzed as then extracted and synthesized in accordance with the objectives. m. e. a. budiman et al. 294 | pissn: 1858-3598  eissn: 2502-5791 result characteristics the results of the review of the research articles that met the inclusion criteria showed there to be 15 different types of intervention used to reduce or prevent the occurrence of postpartum peer support depression, an internet-based intervention, mindfulness-based cognitive therapy groups, sausage support, telephone-based cognitive behavior, psychotherapy cantered on parenthood (pcp), adjuvant detached mindfulness and stress management, sexual counseling, internet cognitive behavior therapy, telephone-based peer support cognitive behavior intervention and focused counseling, lifestyle-based education, home visits, cognitive behavior and all of the above in combination with systemic family therapy and expressive writing. the interventions given in this study consisted of more than one intervention on average. the following are the results of the analysis of the existing journals in the review. the settings from the 15 research articles were either in the community (n = 10) and in the hospital (n = 5). the number of samples varied from 30 respondents to a total of 760 respondents. the interventions given in this study ranged from internet-based media through to support, cognitive, counseling, stress management and mind management. some in this study explained in detail the intervention procedures and how long the intervention was given for. the measuring instruments used in all of the articles consisted of the edinburgh postnatal depression scale, generalized anxiety disorder-7 (gad-7) questionnaire and the depression beck depression inventory. the parameters used were in accordance with the inclusion criteria to measure postpartum depression. from the review of the 15 research articles selected, there were four research articles using a quasi-experiment, where the intervention was given in the form of peer support, psychotherapy centered on parenthood, internet-based intervention, telephone-based peer support intervention and mindfulness-based intervention therapy group. ten studies used the rct approach with the choice of interventions being expressive writing, sexual counseling, internet cognitive behavior therapy, adjuvant detached mindfulness and stress management training, telephone-based cognitive behavior, cognitive behavioral and aids-focused counseling, lifestyle based education, home visit, cognitive behavior and combination with systemic family therapy, and social support. if viewed in terms of the method selection, then in accordance with the level of evidence, the research that uses the rct method approach can be more generalized than the research with the quasi-experimental design. effects of intervention in preventing and reducing postpartum depression. the prevention of mental disorders has the goal of reducing symptoms in people who have mental disorders. this prevention uses health intervention strategies as a way to reduce the symptoms of mental disorders. in addition, the prevention of mental disorders has the goal of reducing the incidence, prevalence and recurrence levels. in this study, several interventions that have a positive effect when it comes reducing the depressive symptoms, especially in postpartum depression, will be described(prevatt et al., 2018). as a prevention strategy, the social support system means strengthening the social support aimed at increasing the protective factors and developmental methods used to protect or safeguard against the effects of potential stressful events. social support can be used to design and implement actions in terms of primary prevention. one study explained that the social support felt by the mothers during pregnancy plays an important role as a protective factor against postpartum depression, both directly and indirectly, reducing the negative clinical aspects of birth experience (tani, castagna, tani, & castagna, 2016). in addition, individuals and groups can develop, maintain, expand and use their social networks. network therapy collects all important members of the family and it brings the networks of friendship together. the focus is then to strengthen the ties in the network and to break the dysfunctional features (w.stuart, 2013). one network that can be applied to break the dysfunctional pattern in the form of postpartum depression based on the results of the study is the implementation of peer group interventions. the results of this study indicate that peer group programs are very effective at reducing postpartum depression (prevatt et al., 2018). however, there are several telephone-based peer group developments that are considered to be more effective in the development of information and technology. one study showed that telephone-based peer support is effective against postpartum depression. another study utilizing groups in the used intervention was a lifestyle education-based training study on prenatal and postnatal depression and paternal anxiety. the study showed significant results in decreasing postpartum depression(mohammad, charandabi, & mirghafourvand, 2017). interventions by utilizing information and technology are very useful at reducing postpartum depletion. this is evidenced by a study that explains that internet cognitive behavioral therapy interventions can reduce postpartum depletion (milgrom et al., 2016). internet-based development cbt can also be applied through cbt that is phonebased which results in a reduction in depressive symptoms that is far greater than the standard care during the postpartum period. both internet-based and telephone-based studies show that prevention strategies can be developed practically and that they can be easily made accessible to all groups (ngai, wong, leung, & chau, 2015). jurnal ners http://e-journal.unair.ac.id/jners | 295 the development of cbt is not only limited to the internet. the cbt program can also be applied with a combination of other interventions such as when the results of the research that show that the integration of counseling programs focused on cognitivebehavioral in prenatal care can be effective at improving the mental health of pregnant women (ramezani, khosravi, motaghi, & hamidzadeh, 2016). another study applying cbt was focused on cbt combined with systemic family therapy. it improved depression and sleep quality in the patients with mild to moderate postpartum depression (hou et al., 2014). the development of interventions continues not only to develop cbt. one intervention that teaches clients to focus on their experiences also teaches them to be aware of the sensations, thoughts and feelings experienced that can also be developed into interesting interventions combined with others. one of the results of the research showed that both the mindfulness-based cognitive therapy group intervention and adjunctive treatment interventions had a clinically significant effect on the participants. in addition, the impact of the mindfulness-based cognitive therapy group intervention as well as the adjunctive treatment intervention is that it is beneficial in the acute phase and disease maintenance phase as evidenced by the symptom stability at three months, especially with depressive symptoms (shulman et al., 2017). other studies also explain that mindfulness can be combined with stress management training; this study shows that these results indicate that adjuvant detached mindfulness and stress management training are effective interventions to reduce postpartum depression (ahmadpanah et al., 2017). mental health education can be done in any order. it can have a formal or informal structure and it can be addressed to individuals or groups. health education can be done in various forms. an educational program is centered on the activities that can be done, one of which is counseling. health education in the form of counseling is urgently needed for a woman who experiences postpartum depression where research shows that sexual counseling can help reduce stress, anxiety, and depression in women who suffer from sexual problems during the postpartum period (zamani, roudsari, & moradi, 2017).this study explains that the counseling process has a positive impact on the decrease in depressions experienced by postpartum mothers. (ahmadpanah et al., 2017) in addition to several existing interventions, cooperation between the nurses and their families through home visits has also been shown to improve health, well-being and independence in the face of low income conditions. the first experience of becoming a parent, especially for a woman who has just given birth, is poignant (w.stuart, 2013).the opinion of the stratum was also in accordance with the results of the study which explained that giving postpartum home visits can affect postpartum depression in a way that is positive. this can improve maternal and infant health (shamshiri et al., 2017). although raising children is considered to be an important responsibility, relatively little attention is paid to believing that effective parenting is not a natural ability but that it needs to be studied. parent-centered psychotherapy is a promising intervention used to treat perinatal depression and to help the mothers to get involved in parenting. research clearly shows that involving new parents can increase the role of caregiving and it is also a process of preventing the occurrence of depression in postpartum mothers (nanzer et al., 2012). using an intervention to reduce postpartum depression does not only involve feelings and cognition but it can also be a training process as a form of diversion to prevent depression, one of which is writing. postpartum writing activities have also carried out research. this study shows that expressive writing can be an early universal intervention and its low cost is useful for preventing postpartum suffering in women (carla, caravita, ionio, milani, & valtolina, 2015). discussion this systematic review provides evidence of the effectiveness of health interventions in relation to preventing and reducing postpartum depression. the review results explain that there are 15 out of 19 intervention options that can be used to prevent and reduce postpartum depression. the results of this review are certainly useful for nurses, both clinical nurses and community mental health nurses. the nurse can apply one of the health interventions as a form of prevention of the incidence of postpartum depression. clinical nurses can conduct quality interventions and have the innovations tailored to the development of information and technology in an effort to prevent and reduce the symptoms of postpartum depression. the application of health interventions can prevent a better condition in the postpartum mothers who experience postpartum depression. mental health and emotional well-being are important for the health of postpartum mothers. some studies have explained that the emotional health of the post-research mothers greatly influenced the development of the children, the health of the mother physically and psychologically and their contribution to their welfare. however, these studies cannot be generalized. bias may occur. this can be caused by the non-homogeneous measurement parameters as well as the non-homogeneous research samples. developmental research is better and an easy and flexible intervention is needed. in addition, extraction needs to be considered during the process of assessing the inclusion and exclusion criteria. implication in nursing practice the results of the research reviewed critically in this systematic review indicate that there are viable m. e. a. budiman et al. 296 | pissn: 1858-3598  eissn: 2502-5791 strategies to prevent and reduce the symptoms of postpartum depression in the prevention / control of the occurrence of postpartum depression. although not all studies produce significant values in all of the measured parameters, this conclusion can be taken in the majority. mental nurses can optimize the health intervention programs by modifying the method of giving the intervention, including the media used, as well as the other parties involved in the intervention process. based on the results of an analysis of 15 journals, the results of the research on internet-based interventions, telephone-based cognitive behavior, internet cognitive behavior therapy and telephonebased peer support intervention are recommended to be applied by mental nurses as interventions to prevent and reduce postpartum depression. these interventions have several advantages, including 1) the method of providing the intervention is relayed and involves both information and technology media, 2) it involves groups and behaviors in managing interventions, 3) the media used are very varied and informative which are easily accessible to the people affected by technological developments and 4) there is a flexible application in accordance with the postpartum needs. conclusion the results of a systematic review of 15 research journals were related to the application of the latest nursing interventions to prevent and reduce the symptoms of postpartum depression. the implementation of nursing interventions should be facilitated by nurses who have a good understanding of the intervention and depression management. in preventing and reducing the symptoms of postpartum depression in the form of nursing interventions packaged into various programs, the interventions can be proven to significantly reduce the variables of postpartum depression. internet cognitive behavior therapy and telephone-based peer support interventions are the methods recommended. it should also be considered whether the results of this research are flexible or not. references ahmadpanah, m., nazaribadie, m., aghaei, e., ghaleiha, a., akhondi, a., bajoghli, h., … brand, s. (2017). influence of adjuvant detached mindfulness and stress management training compared to pharmacologic treatment in primiparae with postpartum depression. https://doi.org/10.1007/s00737-017-0753-6 carla, s., caravita, s., ionio, c., milani, l., & valtolina, g. g. (2015). the effects of expressive writing on postpartum depression and posttraumatic stress symptoms 1. 856–882. https://doi.org/10.2466/02.13.pr0.117c29z3 hou, y., hu, p., zhang, y., lu, q., wang, d., yin, l., & chen, y. (2014). cognitive behavioral therapy in combination with systemic family therapy improves mild to moderate postpartum depression. 47–52. https://doi.org/10.1590/1516-4446-2013-1170 martha raile alligood. (2014). pakar teori keperawatan. in pakar teori keperawatan (ke8, p. 224). singapura: elsevier. milgrom, j., danaher, b. g., gemmill, a. w., holt, c., holt, j., seeley, j. r., … ericksen, j. (2016). internet cognitive behavioral therapy for women with postnatal depression : a randomized controlled trial of mummoodbooster corresponding author : 18, 1–18. https://doi.org/10.2196/jmir.4993 mohammad, s., charandabi, a., & mirghafourvand, m. (2017). the effect of life style based education on the fathers ’ anxiety and depression during pregnancy and postpartum periods : a randomized controlled trial. community mental health journal, 53(4), 482–489. https://doi.org/10.1007/s10597-0170103-1 nanzer, n., rossignol, a. s., righetti-veltema, m., knauer, d., manzano, j., & espasa, f. p. (2012). effects of a brief psychoanalytic intervention for perinatal depression. 259–268. https://doi.org/10.1007/s00737-012-0285-z ngai, f., wong, p. w., leung, k., & chau, p. (2015). the effect of telephone-based cognitive-behavioral therapy on postnatal depression : a randomized controlled trial. 294–303. https://doi.org/10.1159/000430449 perkins, r., yorke, s., & fancourt, d. (2018). how group singing facilitates recovery from the symptoms of postnatal depression: a comparative qualitative study. bmc psychology, 6(1), 1–12. https://doi.org/10.1186/s40359-0180253-0 prevatt, b. s., lowder, e. m., & desmarais, s. l. (2018). peer-support intervention for postpartum depression: participant satisfaction and program effectiveness. midwifery, 64(may), 38–47. https://doi.org/10.1016/j.midw.2018.05.009 ramezani, s., khosravi, a., motaghi, z., & hamidzadeh, a. (2016). the effect of cognitivebehavioural and solutionfocused counselling on prevention of postpartum depression in nulliparous pregnant women. journal of reproductive and infant psychology, 6838(january 2017), 1–11. https://doi.org/10.1080/02646838.2016.126647 0 salonen, a. h., pridham, k. f., brown, r. l., & kaunonen, m. (2014). impact of an internetbased intervention on finnish mothers’ perceptions of parenting satisfaction, infant centrality and depressive symptoms during the jurnal ners http://e-journal.unair.ac.id/jners | 297 postpartum year. midwifery, 30(1), 112–122. https://doi.org/10.1016/j.midw.2013.02.009 shamshiri, h., milani, amiri, p., mohsey, m., davoudi, e., monfared1, … salmani4, f. (2017). effect of health care as the “ home visiting ” on postpartum depression : a controlled clinical trial. 1–6. https://doi.org/10.4103/2008-7802.204003 shulman, b., dueck, r., ryan, d., breau, g., sadowski, i., & misri, s. (2017). author ’ s accepted manuscript. journal of affective disorders. https://doi.org/10.1016/j.jad.2017.12.065 tani, f., castagna, v., tani, f., & castagna, v. (2016). maternal social support , quality of birth experience , and post-partum depression in primiparous women maternal social support , quality of birth experience , and post-partum. 7058(may). https://doi.org/10.1080/14767058.2016.118298 0 w.stuart, g. (2013). psychiatric (10, ed.). st.lois, missouri: elsevier. zamani, m., roudsari, r. l., & moradi, m. (2017). effect of sexual counseling on stress , anxiety , and depression in women during postpartum period. (098 51), 16–26. https://doi.org/10.22038/ebcj.2017.24244.1525 http://e-journal.unair.ac.id/jners | 7 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.17191 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research marital adjustment and prenatal breastfeeding efficacy of first time mothers in a low-income community in the philippines artemio morado gonzales jr occidental mindoro state college, philippines abstract introduction: all women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. this study aims to assess the level of marital satisfaction and its influence to prenatal breastfeeding self-efficacy in first time mothers during late pregnancy. methods: a descriptive correlational study was conducted among 128 systematically sampled primigravid women who agreed to participate and had prenatal care check-up in the health center at the time of data gathering. the instruments used were 15-item marital adjustment test (mat) to measure marital adjustment and 14-item breastfeeding self efficacy scale-short form (bses-sf) as a measure of breastfeeding self-efficacy. pearson’s correlation coefficient was utilized to test the relationships between the sample’s marital adjustment scores to correlate with bfse of the respondents. fisher’s t test was utilized to determine the significance of correlations. a p-value of equal to or less than .05 was considered statistically significant. results: the study revealed that the sampled mothers have a high level of marital adjustment score (112.05± 21.83). prenatal mothers responded in the study were highly confident and have high self-efficacy in breastfeeding first child currently bearing (4.55±.51). lastly, it was found that there is no significant correlation between marital adjustment and prenatal breastfeeding self-efficacy (β=-.052, p-value=.280). conclusion: it was found that there is a high level of marital adjustment and breastfeeding self-efficacy among sampled mothers. however, there is no significant correlation between marital adjustment and prenatal breastfeeding self-efficacy. the study suggests incorporating co-parenting intervention involving father’s involvement and assistance with breastfeeding when creating interventions in breastfeeding. article history received: january 11, 2020 accepted: february 13, 2020 keywords breastfeeding self-efficacy; marital adjustment; prenatal; primigravida contact artemio morado gonzales jr  jomergonzalesjr21@gmail.com  occidental mindoro state college, philippines cite this as: gonzales, a. m. (2020). marital adjustment and prenatal breastfeeding efficacy of first time mothers in a low-income community in the philippines. jurnal ners, 15(1). 7-13. doi:http://dx.doi.org/10.20473/jn.v15i1.17191 introduction in 2012, the world health assembly resolution 65.6 endorsed a comprehensive implementation plan on maternal, infant and young child nutrition, which specified six global nutrition targets for 2025 (world health organization, 2014). it urges developing or, where necessary, strengthening nutrition policies so that they comprehensively address the double burden of malnutrition and include nutrition actions in overall country health and development policy, and establishing effective intersectoral governance mechanisms in order to expand the implementation of nutrition actions with particular emphasis on the framework of the global strategy on infant and young child feeding (jones et al., 2014). all women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. support may be offered either by professional or lay/peer supporters, or a combination of both. strategies that rely mainly on face-to-face https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id mailto:mundakir.ners@fik.um-surabaya.ac.id a. m. gonzales 8 | pissn: 1858-3598  eissn: 2502-5791 support are more likely to succeed (renfrew, mccormick, wade, quinn, & dowswell, 2012). although health care professionals offer timely support to breastfeeding women (bäckström, wahn, & ekström, 2010; radzyminski & callister, 2015), the more constant presence and immediate support of the baby’s father, or mother’s partner offers an opportunity to influence the maintenance and duration of breastfeeding. in a study with primiparous mothers, it revealed that high level of breastfeeding self-efficacy during postpartum predicted positive emotional adjustment and fewer depressive symptoms at six weeks postpartum, as well as more exclusive breastfeeding. on the other hand, breastfeeding concerns were among the most commonly named reasons for stress, along with lack of sleep, lack of social support, and overwhelming learning demands involved with being a new parent (henshaw, fried, siskind, newhouse, & cooper, 2015). also, many studies measure breastfeeding self-efficacy during early postpartum period (chan, ip, & choi, 2016; mcqueen, dennis, stremler, & norman, 2011; noel-weiss, rupp, cragg, bassett, & woodend, 2006; wu, ho, han, & chen, 2018) and having less focus during prenatal period. there are studies focused on prenatal breastfeeding selfefficacy (mckinley et al., 2019), but evidence was limited to western countries and fewer studies conducted asian mothers especially in the philippine context. father or partner has been identified as an influencing factor in maternal decision-making (ghose et al., 2017). mothers reporting positive support from their partners had higher confidence in breast milk production and higher breastfeeding selfefficacy. if the mother feels that the father’s attitude toward breastfeeding is positive and supportive, there is a greater likelihood that she will continue breastfeeding (mannion, hobbs, mcdonald, & tough, 2013). this study aims to assess the level of marital adjustment and its influence to prenatal breastfeeding self-efficacy of the first-time mothers in late pregnancy period. materials and methods study design the research design of the study was descriptive correlational to determine the relationship between marital satisfaction and the level of prenatal breastfeeding self-efficacy of the primigravid mothers. the assumption in this study is that marital satisfaction has an influence to prenatal breastfeeding self-efficacy, but there was no causal relationship assumed. study site the study was conducted in the municipality of rizal, occidental mindoro, which is considered a low income and third-class municipality. this area is near and accessible from the site in which many primigravid mothers receive prenatal care checkup with the healthcare provider. sample a total of 128 primigravid women agreed to participate and had prenatal care check-up in the barangay health center at the time of data gathering. for each selected area, respondents were chosen using systematic sampling in the interval of 2. inclusion criteria in the study were: 1) primigravid women, 2) pregnant women without known complication that may be contraindicated with breastfeeding, 3) pregnant women who were willing to participate in the research. the study assumes a 95% confidence interval, 50% expected frequency, design effect of 1 and a margin of error of 5%. the study needed 168 samples, but has a 76% response rate. instrument the questionnaire was composed of three parts: socio-demographic section and the breastfeeding self-efficacy scale. the socio-demographic section includes age (ordinal); civil status (nominal); educational attainment (ordinal); income level (ordinal); number of prenatal visits (nominal). the second part is the marital adjustment test (locke & wallace, 1959), a 15-item scale that measures marital satisfaction. it was initially used to differentiate well-adjusted couples from distressed couples. the 15 items are answered on a variety of response scales and possible scores range from 0158, showing higher scores indicate greater satisfaction. the third part of the questionnaire was the 14item breastfeeding self efficacy scale-short form (bses-sf) by dennis (2003). the bses-sf is a selfsupport instrument containing two sub-scales: (1) the technique subscale, where items depict maternal skills and recognition of specific principles required for successful breastfeeding; and (2) the intrapersonal thoughts subscale, where 14 items are related to maternal attitudes and beliefs towards breastfeeding. items are preceded by the phrase “i can always” and anchored with a 5-point likert scale, where 1 means not at all confident and 5 means always confident. a study provided preliminary evidence that the bses-sf may be an internationally applicable, reliable and valid measure to assist health professionals in caring for breastfeeding women. cronbach’s alpha coefficient for internal consistency was 0.87. antenatal and postnatal bses-sf scores were significant predictors of breastfeeding duration and exclusivity at 12 weeks after the birth (aluş tokat, okumuş, & dennis, 2010). jurnal ners http://e-journal.unair.ac.id/jners | 9 data collection permission from the municipal health officer was secured to conduct the study. approved letter of request was presented to the rural health midwifes where the study was conducted. the coverage of the data collection started every thursday of the month of november 2018 during the scheduled prenatal care visit in the barangay centre. the data collection technique was through a survey interview using a questionnaire. the postpartum mothers were approached during visits in the barangay health center. informed consent was attained from the mothers before the researchers conducted the interview. ethical consideration this paper was technically reviewed and approved by the research council of the occidental mindoro state college under its research development and extension unit. participation in the study was voluntary and it was explained to the mothers that they have the option to answer the questionnaire or not. complete anonymity of the research participants was observed. the respondents were informed of the right to confidentiality and privacy. any clarifications were entertained by the researcher to facilitate easy understanding of the statement in the research instrument. the questionnaire was coded and listed in a separate sheet; the code from the list was later matched after data collection. specific information on the questionnaires could not be linked to specific individuals. access to the data was limited only to the researcher. data analysis data collected were entered in microsoft excel and were analyzed with spss for descriptive and inferential statistics. descriptive statistics used included percentages and frequencies for demographic profile and mean for bfse. pearson’s correlation coefficient was utilized to test the relationships between the samples’ marital adjustment scores to correlate with bfse of the respondents. fisher’s t-test was utilized to determine the significance of correlations. a p-value of equal to or less than .05 was considered statistically significant. results data presented in table 1 show that most of the young adults were aged 19-24 (45.8%). it also reveals that the respondents were unmarried (53.1%), reached high school graduate and high school and college graduate (both 25.8%), earning ≤ 7,890 and considered poor (66.4%) and most had met the national prenatal visit minimum requirement (42.2%). the results (table 2) show that the respondents have a high level of marital adjustment (mat scores; table 1. profile of the respondents (n=128) profile frequency percentages maternal age ≤ 18 13 9.9 19-24 60 45.8 25-29 38 29.0 30-34 14 10.7 ≥ 35 6 4.6 marital status unmarried 68 53.1 married 60 46.9 educational status never been to school 1 .8 elementary level 7 5.5 elementary graduate 6 4.7 high school level 31 24.2 high school graduate 33 25.8 vocational 5 3.9 college level 12 9.4 college graduate 33 25.8 income status poor 85 66.4 low income (but not poor) 38 29.7 low middle income 5 3.9 number of prenatal visits none 5 3.9 1 17 13.3 2 25 19.5 3 27 21.1 ≥ 4 54 42.2 a. m. gonzales 10 | pissn: 1858-3598  eissn: 2502-5791 112.05± 21.83). further, prenatal mothers who responded in the study were highly confident and had self-efficacy in breastfeeding their first child (4.55±.51). it was also revealed that the respondents were both highly confident in breastfeeding technique (4.47±.44) and intrapersonal thoughts on breastfeeding (4.59±.52) (table 3). the study revealed that there is no significant correlation in marital satisfaction and prenatal breastfeeding self-efficacy (β=-.052, p value=.280). on the other hand, it also showed that there is a significantly negative and weak downhill linear relationship (β=-.148, p value=.047) between marital satisfaction scores and intrapersonal thoughts on breastfeeding among prenatal mothers in their late post-partum period. discussion majority of these respondents were at their early adult age. in the philippines, fertility peaks at age 2024 and falls after 25-39 (bersales, 2014). the findings on the current study also suggest that the majority of them did not pursue at aiming for the highest level of formal education. studies have revealed that educated women are more likely to use maternal care services than women with no formal education period (adu, tenkorang, banchani, allison, & mulay, 2018; dutamo, assefa, & egata, 2015; hill et al., 2013; pulok, sabah, uddin, & enemark, 2016; simkhada, van teijlingen, porter, & simkhada, 2008). according to the philippine statistics authority, the national poverty threshold in 2015 is 10, 969 per month. poverty threshold includes basic non-food needs such as clothing, housing, transportation, health, and education expenses (psa, 2015). this indicates that the majority of the respondents were below poverty threshold. population who belong to low income family could hardly afford to subject themselves to adopt the recommendations required for health improvement due to economic status (bircher & hahn, 2017). one study of peer counseling support shows that breastfeeding duration was significantly associated with increased maternal age and personal breastfeeding experience (bolton, chow, benton, & olson, 2009). a pregnant woman has at least one visit for the first and second trimester and two visits for the third trimester. campbell and graham (2006) supported this and stated that quality prenatal care is an important indicator for maternal and infant health status. if a mother is equipped with adequate knowledge in prenatal care, she is most likely to comply with the prenatal check-up and habits to attain maximum health during pregnancy. the results show that the respondents have a high level of marital adjustment score. there was a statistically significant relationship between the perception of spouses toward their marriage or their table 2. marital satisfaction in late pregnancy marital adjustment mean standard deviation marital adjustment score 112.05 21.83 table 3. prenatal breastfeeding self-efficacy bfse sub-scale mean sd technique i can always determine that my baby is getting enough milk. 4.52 .64 i can always ensure that my baby is properly latched on for the whole feeding. 4.49 .60 i can always manage the breastfeeding situation to my satisfaction 4.48 .58 i can always manage to breastfeed even if my baby is crying. 4.16 .94 i can always comfortably breastfeed with my family members present 4.54 .65 i can always deal with the fact that breastfeeding can be time-consuming 4.50 .65 i can always finish feeding my baby on one breast before switching to the other breast 4.53 .56 i can always manage to keep up with my baby’s breastfeeding demands 4.51 .66 i can always tell when my baby is finished breastfeeding. 4.47 .60 weighted mean 4.47 .44 intrapersonal thoughts i can always successfully cope with breastfeeding like i have with other challenging tasks. 4.60 .55 i can always breastfeed my baby without using formula as a supplement. 4.48 .66 i can always keep wanting to breastfeed. 4.54 .61 i can always be satisfied with my breastfeeding experience. 4.63 .53 i can always continue to breastfeed my baby for every feeding. 4.69 .50 weighted mean 4.59 .52 overall bfe 4.55 .51 table 4. correlation between marital adjustment and prenatal breastfeeding self-efficacy bfse scores mat score beta coefficient p value technique -.078 .190 intrapersonal thoughts -.148 .047* prenatal bfse -.052 .280 *. correlation is significant at the 0.05 level (1-tailed) jurnal ners http://e-journal.unair.ac.id/jners | 11 level of satisfaction with their relationship and being sensitive parents. the consistency in the relationship between spouses is also important for the baby to understand relationship connections (mutlu, erkut, yildirim, & gündoğdu, 2018). further, it was also demonstrated that family functions, especially, problem solving, communications and family roles as well as marital adjustment, can explain more than half of the quality of life in women. therefore, it is suggested that any intervention in increasing women’s quality of life should take these aspects into consideration (basharpoor & sheykholeslami, 2015). lastly, in a couple expecting their first child, both women and partners' coping behaviors contributed to higher marital adjustment, suggesting that risks for marital dissatisfaction may exist for couples not able to implement adaptive strategies, or for those unsatisfied with the implemented coping behaviors (molgora, acquati, fenaroli, & saita, 2019). the results reveled that prenatal mothers who responded in the study were highly confident and had self-efficacy in breastfeeding their first unborn child. the results from the current study are consistent with the original bses-sf study of dennis (2003) and provide evidence that the bses-sf is reliable measure of breastfeeding self-efficacy among a representative sample in rizal, occidental mindoro. pollard and guill (2009) conclude that the score on bses-sf was a statistically significant predictor of breastfeeding length. the use of the bses-sf as the baseline assessment tool to identify women at high risk of weaning was also suggested. using the bses-sf as a screening tool, healthcare providers can target women at risk for early weaning and plan strategies that enhance mother’s knowledge and breastfeeding using dennis’s breastfeeding self-efficacy framework. the bfse-sf is also a useful tool in screening women who may need extra guidance and assistance once their children are born. if the individual leaves the class with a low self-efficacy score, the bse-sf can be an effective tool in communication with breastfeeding support staff and lactation consultants in the clinic and hospital when the at-risk mother delivers and needs support and guidance in breastfeeding. healthcare professionals can readily see the areas in which self-efficacy is low prenatally and help to empower the new mother to breastfeed successfully during the postpartum period. while previous research has found higher breastfeeding knowledge to positively impact both breastfeeding outcomes and breastfeeding intention (cottrell & detman, 2013; kornides & kitsantas, 2013), few studies have investigated the impact of breastfeeding knowledge on breastfeeding self-efficacy. lastly, the results revealed that there is no significant correlation in marital adjustment and prenatal breastfeeding self-efficacy. on the other hand, it also showed that there is a significantly negative and weak downhill linear relationship between marital satisfaction scores and intrapersonal thoughts on breastfeeding among prenatal mothers in their late post-partum period. on the contrary, in other studies, it was shown that women who reported active/positive support from their partners scored higher on the bses than those reporting ambivalent/negative partner support when we controlled for previous breastfeeding experience and age of infant (abbass-dick, stern, nelson, watson, & dennis, 2015; mannion et al., 2013). the studies suggested that a co-parenting intervention involving fathers warrants additional investigation to assess significant improvements in breastfeeding duration, paternal breastfeeding self-efficacy, and maternal perceptions of paternal involvement and assistance with breastfeeding. lastly, paternal involvement and paternal breastfeeding self-efficacy could increase the feeling of confidence to a breastfeeding mother (abbass-dick et al., 2015; dennis, brennenstuhl, & abbass-dick, 2018). this suggests conducting future studies to measure breastfeeding self-efficacy among fathers, especially in the prenatal period. a limitation of this study was the fact that the sample of the study was composed of women who presented to outpatient clinics and this does not include the pregnant women who do not seek consultation in the barangay health center. this research does not claim findings representative of all filipino women. it is difficult to state that the sample used fully represented the sociocultural groups who live in the province. it is important to conduct further studies to test the psychometric properties of the scale in samples representing different groups. also, this study was limited by its cross‐sectional nature, as a result of which the relationships between marital adjustment sociodemographic variables, and prenatal breastfeeding self-efficacy do not necessarily indicate causal relationships. conclusion the study shows that the respondents are young adult, unmarried, literate, considered poor, and receive minimum antenatal care. the results show that the respondents have a high level of marital adjustment. prenatal mothers who responded in the study were highly confident and had self-efficacy in breastfeeding their first unborn child. lastly, it was found that there is no significant correlation in marital satisfaction and prenatal breastfeeding selfefficacy. this study recommends to create intervention focused on maximizing these psychosocial resources, mother-to-infant attachment and social support intervention to breastfeeding selfefficacy. there is also need to incorporate coparenting intervention involving fathers, which warrants improvements in breastfeeding duration, paternal breastfeeding self-efficacy, and maternal perceptions of paternal involvement and assistance with breastfeeding. a. m. gonzales 12 | pissn: 1858-3598  eissn: 2502-5791 references abbass-dick, j., stern, s. b., nelson, l. e., watson, w., & dennis, c. l. (2015). coparenting breastfeeding support and exclusive breastfeeding: a randomized controlled trial. pediatrics, 135(1),102-10 . https://doi.org/10.1542/peds.2014-1416 adu, j., tenkorang, e., banchani, e., allison, j., & mulay, s. (2018). the effects of individual and community-level factors on maternal health outcomes in ghana. plos one, 13(11). https://doi.org/10.1371/journal.pone.0207942 aluş tokat, m., okumuş, h., & dennis, c. l. (2010). translation and psychometric assessment of the breast-feeding self-efficacy scale-short form among pregnant and postnatal women in turkey. midwifery, 26(1),101-108. https://doi.org/10.1016/j.midw.2008.04.002 bäckström, c. a., wahn, e. i. h., & ekström, a. c. (2010). two sides of breastfeeding support: experiences of women and midwives. international breastfeeding journal, 5(20). https://doi.org/10.1186/1746-4358-5-20 basharpoor, s., & sheykholeslami, a. (2015). the relation of marital adjustment and family functions with quality of life in women. europe’s journal of psychology, 11(3), 432–441. https://doi.org/10.5964/ejop.v11i3.859 bersales, l. g. s. (2014). philippines national demographic and health survey 2013. philippine statistics authority. bircher, j., & hahn, e. g. (2017). will the meikirch model, a new framework for health, induce a paradigm shift in healthcare? cureus, 9(3). https://doi.org/10.7759/cureus.1081 bolton, t. a., chow, t., benton, p. a., & olson, b. h. (2009). characteristics associated with longer breastfeeding duration: an analysis of a peer counseling support program. journal of human lactation, 25(1), 18-27. https://doi.org/10.1177/0890334408325985 campbell, o. m., & graham, w. j. (2006). strategies for reducing maternal mortality: getting on with what works. lancet, 368(9543(, 1284-1299. https://doi.org/10.1016/s0140-6736(06)693811 chan, m. y., ip, w. y., & choi, k. c. (2016). the effect of a self-efficacy-based educational programme on maternal breast feeding self-efficacy, breast feeding duration and exclusive breast feeding rates: a longitudinal study. midwifery, 36, 92-98. https://doi.org/10.1016/j.midw.2016.03.003 cottrell, b. h., & detman, l. a. (2013). breastfeeding concerns and experiences of african american mothers. mcn the american journal of maternal/child nursing, 38(5), 297-304. https://doi.org/10.1097/nmc.0b013e31829a56 06 dennis, c. (2003). the breastfeeding self‐efficacy scale: psychometric assessment of the short form. journal of obstetric, gynecologic & neonatal nursing, 32(6), 734-744. https://doi.org/10.1177/0884217503258459 dennis, c. l., brennenstuhl, s., & abbass-dick, j. (2018). measuring paternal breastfeeding selfefficacy: a psychometric evaluation of the breastfeeding self-efficacy scale–short form among fathers. midwifery, 64:17-22. https://doi.org/10.1016/j.midw.2018.05.005 dutamo, z., assefa, n., & egata, g. (2015). maternal health care use among married women in hossaina, ethiopia. bmc health services research,. 15(1),365, https://doi.org/10.1186/s12913-0151047-1 ghose, b., feng, d., tang, s., yaya, s., he, z., udenigwe, o., … feng, z. (2017). women’s decision-making autonomy and utilisation of maternal healthcare services: results from the bangladesh demographic and health survey. bmj open,7(9). https://doi.org/10.1136/bmjopen-2017-017142 henshaw, e. j., fried, r., siskind, e., newhouse, l., & cooper, m. (2015). breastfeeding self-efficacy, mood, and breastfeeding outcomes among primiparous women. journal of human lactation. https://doi.org/10.1177/0890334415579654 hill, j., hoyt, j., van eijk, a. m., d’mello-guyett, l., ter kuile, f. o., steketee, r., … webster, j. (2013). factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-saharan africa: a systematic review and meta-analysis. plos medicine, 10(7). https://doi.org/10.1371/journal.pmed.1001488 jones, a. d., ickes, s. b., smith, l. e., mbuya, m. n. n., chasekwa, b., heidkamp, r. a., … stoltzfus, r. j. (2014). world health organization infant and young child feeding indicators and their associations with child anthropometry: a synthesis of recent findings. maternal and child nutrition, 10(1), 1-17. https://doi.org/10.1111/mcn.12070 kornides, m., & kitsantas, p. (2013). evaluation of breastfeeding promotion, support, and knowledge of benefits on breastfeeding outcomes. journal of child health care, 17(3),264-273. https://doi.org/10.1177/1367493512461460 locke, h. j., & wallace, k. m. (1959). short maritaladjustment and prediction tests: their reliability and validity. marriage and family living, 21(3), 251-255. https://doi.org/10.2307/348022 mannion, c. a., hobbs, a. j., mcdonald, s. w., & tough, s. c. (2013). maternal perceptions of partner support during breastfeeding. international breastfeeding journal, 8(1),4. https://doi.org/10.1186/1746-4358-8-4 mckinley, e. m., knol, l. l., turner, l. w., burnham, j. j., graettinger, k. r., hernandez-reif, m., & leeper, j. d. (2019). the prenatal rating of efficacy in preparation to breastfeed scale: a new measurement instrument for prenatal breastfeeding self-efficacy. journal of human lactation, 25(1), 21-31. https://doi.org/10.1177/0890334418799047 mcqueen, k. a., dennis, c. l., stremler, r., & norman, jurnal ners http://e-journal.unair.ac.id/jners | 13 c. d. (2011). a pilot randomized controlled trial of a breastfeeding self-efficacy intervention with primiparous mothers. jognn journal of obstetric, gynecologic, and neonatal nursing, 40(1), 35-46. https://doi.org/10.1111/j.15526909.2010.01210.x molgora, s., acquati, c., fenaroli, v., & saita, e. (2019). dyadic coping and marital adjustment during pregnancy: a cross-sectional study of italian couples expecting their first child. international journal of psychology, 54(2),277-285. https://doi.org/10.1002/ijop.12476 mutlu, b. r., erkut, z., yildirim, z., & gündoğdu, n. (2018). a review on the relationship between marital adjustment and maternal attachment. revista da associacao medica brasileira, 64(3), 243-252. https://doi.org/10.1590/18069282.64.03.243 noel-weiss, j., rupp, a., cragg, b., bassett, v., & woodend, a. k. (2006). randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. jognn journal of obstetric, gynecologic, and neonatal nursing, 35(5), 616-624. https://doi.org/10.1111/j.15526909.2006.00077.x pollard, d., & guill, m. (2009). the relationship between baseline self-efficacy and breastfeeding duration. southern online journal of nursing research, 9(4). psa. (2015). poverty incidence among filipinos registered at 25.8%, as of first semester of 2014 — psa. poverty statistics press release. pulok, m. h., sabah, m. n. u., uddin, j., & enemark, u. (2016). progress in the utilization of antenatal and delivery care services in bangladesh: where does the equity gap lie? bmc pregnancy and childbirth, 16, 200. https://doi.org/10.1186/s12884-0160970-4 radzyminski, s., & callister, l. c. (2015). health professionals’ attitudes and beliefs about breastfeeding. the journal of perinatal education, 24(2), 102–109. https://doi.org/10.1891/10581243.24.2.102 renfrew, m. j., mccormick, f. m., wade, a., quinn, b., & dowswell, t. (2012). support for healthy breastfeeding mothers with healthy term babies. in cochrane database of systematic reviews, 16(5). https://doi.org/10.1002/14651858.cd001141.pu b4 simkhada, b., van teijlingen, e. r., porter, m., & simkhada, p. (2008). factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. journal of advanced nursing, 61(3),244-260. https://doi.org/10.1111/j.13652648.2007.04532.x world health organization. (2014). comprehensive implementation plan on maternal, infant and young child nutrition. world health organization. wu, y.-h., ho, y.-j., han, j.-p., & chen, s.-y. (2018). the influence of breastfeeding self-efficacy and breastfeeding intention on breastfeeding behavior in postpartum women. hu li za zhi the journal of nursing, 65(1), 42–50. https://doi.org/10.6224/jn.201802_65(1).07 issn 0000-0000 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. technical editor: gading ekapuja aurizki, s.kep., ns. lingga curnia dewi, s.kep., ns., m.kep. layouter: masunatul ubudiyah, s.kep., ns. dluha maf’ula, s.kep., ns. hidayat arifin, s.kep., ns. rifky octavia pradipta, s.kep., ns. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. p-issn: 1858-3598 e-issn: 2502-5791 acknowledgment to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 14 no. 2 oktober 2019. 1. dr. abu bakar., s.kep., ns., m.kep., sp.kep.mb universitas airlangga, indonesia 2. anna kurniati, s.km, ma, phd bppsdmk, ministry of health, indonesia 3. bayhakki bayhakki, phd university of riau, indonesia 4. dr. chong mei chan university of malaya, malaysia 5. erni astutik, s.km., m.epid universitas airlangga, indonesia 6. dr. ika yuni widyawati, s.kep., ns., m.kep., ns.sp.kep.mb universitas airlangga, indonesia 7. kumboyono, m.kep., sp. kom universitas brawijaya, indonesia 8. dr. kusnanto, s.kp., m.kes universitas airlangga, indonesia 9. dr. mira triharini, s.kp., m.kes universitas airlangga, indonesia 10. dr. muhammad miftahussurur., m.kes., sp.pd., phd universitas airlangga, indonesia 11. ni ketut alit armini, s.kp., m.kes universitas airlangga, indonesia 12. rista fauziningtyas, s.kep., ns., m.kep universitas airlangga, indonesia 13. rr. dian tristiana, s.kep., ns., m.kep universitas airlangga, indonesia 14. saldy yusuf, phd universitas hasanuddin, indonesia 15. dr. saryono, s.kp., m.kes universitas jendral soedirman, indonesia 16. susy katikana sebayang, m.sc., ph.d universitas airlangga, indonesia 17. dr. yulis setya dewi, s.kep., ns., m.ng universitas airlangga, indonesia 18. dr. yuni sufyanti arief, s.kp., m.kes universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 table of content editorial : improving resilience and nurse caring behavior yulis setya dewi 19. a qualitative inquiry into the adherence of adults type 2 diabetes mellitus with dietary programs kusnanto kusnanto, elfa lailatul izza, tri johan agus yuswanto, hidayat arifin 118 – 123 20. the affirmation – tapping on pain perception and serotonin serum level of post – caesarian section patients joko suwito, suhartono taat putra, agus sulistyono 124 – 128 21. analysis of risk factors occurrence of juvenile delinquency behavior tri anjaswarni, sri widati, ah yusuf 129 – 136 22. the effectiveness of prone and supine nesting positions on changes of oxygen saturation and weight in premature babies ayu prawesti, etika emaliyawati, ristina mirwanti, aan nuraeni 137 – 143 23. analysis of sociodemographic and information factors on family behaviour in early detection ff high-risk pregnancy ika mardiyanti, shrimarti rukmini devy, ernawati ernawati 144 – 150 24. the effect of combination therapy of a warm ginger stew compress and ki. 3 point acupressure on the pain level of gout arthritis patients in indonesia enji meilia era pertiwi, sidik awaludin, annas sumeru 151 – 154 25. ethnic foods diet program improve self-efficacy and diet compliance among type 2 diabetic patients eka mishbahatul mar'ah has, amira aulia, tiyas kusumaningrum, ferry efendi 155 – 160 26. differences in clinical simulation with audiovisual and practicum-based standard operating procedures in nursing student competencies hendri palupi, kusnanto kusnanto, slamet riyadi yuwono 161 – 164 27. developing family resilience models: indicators and dimensions in the families of pulmonary tb patients in surabaya 165 – 171 dhian satya rachmawati, nursalam nursalam, muhammad amin, rachmat hargono 28. factors influencing the success of the national nursing competency examination taken by the nursing diploma students in yogyakarta yulia wardani 172 – 180 29. the impact of self efficacy on the foot care behavior of type 2 diabetes mellitus patients in indonesia nuh huda, tintin sukartini, nadya wahyu pratiwi 181 – 186 30. content validity and the reliability of technological competency as caring in the nursing instrument_indonesian version (tccni_iv) ignata yuliati, ni luh agustini purnama, sri winarni 187 – 192 31. determinants of drug adherence on grade two and three patients with hypertension riza fikriana, shrimarti rukmini devy, ahsan ahsan, al afik 193 – 198 32. family support system as an effort to optimize coping mechanism of preschool children during hospitalization m. hasinuddin, ulva noviana, fitriah fitriah 199 – 204 33. correlation between emotional peer support and cyberbullying behaviour in senior high school students emi wuri wuryanningsih, enggal hadi kurniyawan, emila cahya aisyah 205 – 209 34. the relationship between partner support and interdialytic weight gain (idwg) hemodialysis patient mundakir mundakir, nur fadlilah, retno sumara, asri asri, yuanita wulandari 210 – 214 35. analysis of the sociodemographic and psychological factors of the family caregivers’ self-management capabilities for type 2 diabetes mellitus rondhianto rondhianto, nursalam nursalam, kusnanto kusnanto, soenarnatalina melaniani, ahsan ahsan 215 – 223 36. comparison between the qrma measurement with the anamnesis and the capillary blood glucose test muflih muflih, suwarsi suwarsi, fajarina lathu asmarani 224 – 230 editorials: improving resilience and nurse caring behavior nurses encounter many risk factors in their work life and have to provide professional care for and relieve the patients under unpleasant conditions in any case in the same time. a number of adverse events or antecedents can pose a significant threat to the wellbeing of nursing staff, such as workplace violence, fatigue, lack of resources, intimidation at work, and lack of capacity that can affect service to patients (cusack et al., 2016). these situation leads to abroad arrays of occupational stress which is happened in daily life. when stressors exceed nurse’s coping skills, their functional capacity becomes impaired. a study in a teaching hospital in surabaya in july 2017 found that nurses showed symptoms of stress characterized by frequent sleep disturbances (40%), loss of concentration and thinking small things were too detailed (40%), irritable and tension when interacting with other health workers (70%) (dewi, hargono, & rusdi, 2019). several methods were implemented to improve coping of nurses but not their resilience (icn, 2016). arguably, resilience skills are needed by nurses to provide a better care to patients and their family. resilience is a term that we are hearing a lot lately. there is no single definition of resilience approved by experts. however, a common theme in various definition of resilience is strength, ability to overcoming challenging obstacles and bounce back from adversities (çam, 2017). in this editorial, we discuss ways of engaging the nurses to resilience skill in order to improve their caring behaviour. resilience is the result of the accumulation of various factors and characteristics possessed by individuals, namely personality traits, protective factors, and experiences collected through life in the process and / or developing as a result. these internal and external factors can predispose to "protect" or put individuals "at risk" that cause resilience or maladaptation (garcia-dia, dinapoli, garcia-ona, jakubowski, & o’flaherty, 2013). subsequently, there are 2 concepts in the organization that can emerge simultaneously in building nurse resilience, namely support and development. support is defined as an intervention in the workplace that directs and provides opportunities for nurses to withstand the pressures at work. development is defined as an intervention in the workplace that empowers nurses to enhance their professional, practice and personal potential. furthermore, in each organizational concept there are three domains i.e personal, practice and professional. the personal domain covers the welfare of individual nurses. the practice domain consists of skills, abilities, and special competencies from the profession. the professional domain is about the service ideal which includes lifelong learning and adherence to ethical behavior patients (cusack et al., 2016; hsieh, hung, wang, ma, & chang, 2016). in addition, three conditions that affect caring namely matters relating to patients, nurses themselves and the organization (hospital) (tonges & ray, 2011). the organizational factors highlighted are leadership, compensation and reward and professional relations. this component will build a healthy work environment that supports the ability and commitment of nurses displaying caring behavior. as widely known that patients in the hospital need a care where nurse have to provide comprehensively in terms of bio-psycho-social-spiritual care. furthermore, caring is not only a set of attitudes that can be identified such as sympathy or support, nor does it consist of all activities undertaken by nurses (warelow & edward, 2007). professional nursing care is determined by the way a nurse can use knowledge and skills to value client uniqueness and be physically and emotionally and require resilience within the nurse (warelow & edward, 2007). resilient nurses are able to display professional nursing care, in this case is caring behavior. nurse resilience is a nurse's ability to positively adapt to adversity, and can be applied to build personal strengths of nurses through several strategies namely building positive professional relationships, maintaining positivity, developing emotional insight, achieving life balance and spirituality, and becoming more reflective (jackson, firtko, & edenborough, 2007). it can be concluded that resilient nurse will be able to help patients in any situation with nurse’s professional manner. several studies have been carried out to develop nurse resilience potential, namely through stress control workshops and resilience development interventions (pipe et al., 2012), a workbased educational intervention (mcdonald, jackson, wilkes, & vickers, 2012), mindfulness-based stress reduction intervention (mbsri ) (foureur, besley, burton, yu, & crisp, 2013) , multimodal resilience training program (mealer, conrad, evans, jooste, solyntjes, rothbaum, et al., 2014), mindful self-care and resilience intervention (mscr) (craigie et al., 2016), and stress management and resiliency training (smart) (chesak et al., 2015), a pilot integrative coping and resiliency program (tarantino, earley, audia, d’adamo, & berman, 2013), aware compassionate communication: an experiential provider training series (accepts) (gerhart et al., 2016). the latest model was developed by author using a model of resilience for caring enhancement (more care) and focused for icu nurses (dewi, nursalam, & hargono, 2019). however the result is still inconsistent and influenced by various factors. in general, strategies for building or developing resilience include a) building good relationships in teams; b) provide education and training to develop behaviors that help control or limit the intensity of stress, or help recovery; and c) help in processing emotions and learning from experience. although individuals must be responsible for developing personal strategies to help coping and resilience, organizational support is an integral part of equipping individuals to face work related challenges (adams, 2015). resilient nurses have greater potential to be able to provide professional (caring) nursing services. in accordance with the resilience process (lietz, julien-chinn, geiger, & hayes piel, 2016) individuals reach the stage of resilience fully when able to provide assistance to others (helping others). from the various explanations above, it can be highlighted that nurse resilience influences caring behavior in general. the concept of resilience is very important in the field of care because resilience plays an important role in nursing longevity and retention. nursing leaders should be knowing how resilience can be applied to nurses and how to improve and maintain this concept in other fields (turner, 2014). therefore, it is very important to build and strengthen resilience of nurses in a stressful work environment in daily basis. this editorial has touched briefly on the method of resilience capacity improvement and how this may mitigate the impact of work place stress on nurses by involving nurse as individual and organisation as where nurse have support. dr. yulis setya dewi, s.kp., m.ng faculty of nursing, universitas airlangga yulis.sd@fkp.unair.ac.id http://e-journal.unair.ac.id/jners | 47 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.15056 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research leader empowering behaviors and psychological empowerment as perceived by young hospital staff nurses: a pilot study ryan michael flores oducado west visayas state university, college of nursing, philippines abstract introduction: empowerment has become an important concept in nursing that has gained acknowledgment in theories and practice of leadership and management. a positive organization espouses empowerment to attract and retain employees. while it is not new to nursing, there is little published research on empowerment among nurses in the philippines. this study aimed to measure young staff nurses’ perception of leader empowering behaviors and psychological empowerment. methods: this study used a cross-sectional survey design participated by 44 conveniently chosen staff nurses in a private teaching and training hospital in iloilo city, philippines. the participants were asked to answer 5-point likert scale questions utilizing adopted instruments. descriptive and non-parametric statistical stools were used with mann-whitney u test to determine differences and spearman’s rank correlation to establish relationship between variables. results: overall, young staff nurses perceived their leaders’ behaviors to be highly empowering (m=3.89). staff nurses also had a high level of psychological empowerment (m=4.07). leader empowering behaviors was significantly related to staff nurses’ perception of psychological empowerment (p=.001). staff nurses’ level of psychological empowerment were significantly different in terms of employment status (p=.020) and years of work experience (p=.014). conclusion: this study highlights the positive influence of the empowering behaviors of leaders in enhancing staff nurses’ level of psychological empowerment. it is vital for nurse managers to continually demonstrate leadership behaviors that empower staff nurses at the unit level. article history received: august 29, 2019 accepted: october 09, 2019 keywords empowerment; leadership; psychological empowerment; leader empowering behaviors; nursing empowerment contact ryan michael flores oducado  rmoducado@wvsu.edu.ph  west visayas state university, college of nursing, philippines cite this as: oducado, r. m.f. (2019). leader empowering behaviors and psychological empowerment as perceived by young hospital staff nurses: a pilot study. jurnal ners, 14(1), 47-54. doi:http://dx.doi.org/10.20473/jn.v14i1.15056 introduction empowerment has become a focal concept in nursing. nursing empowerment is regarded as essential in ensuring professional success and in developing the professional image of nurses (lockhart, 2017). historically, nurses were viewed as submissive and dependent on the patriarchal medical hierarchy having little involvement in decisions affecting their practice standards (okuyama, wagner, & bijnen, 2014; lockhart, 2017). however, the nursing profession has changed over the past decades. today’s healthcare environment calls for a more empowered nursing profession. in a multidisciplinary healthcare setting, even staff nurses are now encouraged to get involved in clinical and organizational decision-making processes (van bogaert, peremans, de wit, van heusden, franck, timmermans, & havens, 2015). with the growing demands in the nurse manager’s role in today’s healthcare environment, the manager’s ability to engage in empowering leadership behavior becomes a challenge (greco, laschinger, & wong, 2006; lee & kim, 2013). the nursing literature flourishes with studies on empowerment indicating that nursing empowerment is associated with less burnout, higher workplace satisfaction, commitment, increased autonomy, positive work behaviors and environment, better performance and patient health outcomes (greco, laschinger, & wong, 2006; laschinger, gilbert, smith & leslie, 2010; leggat, bartram, casimir & stanton, 2010; jordan & davis 2013; oyeleye, hanson, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.150564 r. m. f. oducado et al. 48 | pissn: 1858-3598  eissn: 2502-5791 o’connor & dunn, 2013; asiri, rohrer, al-surimi, da’ar, & ahmed, 2016; goedhart, van oostveen, & vermeulen, 2017). empowered nurses are more likely to subscribe to more positive work practices resulting in positive patient outcomes (donahue, piazza, griffin, dykes & fitzpatrick, 2008). correspondingly, the empowerment of nurses appears essential in the delivery of high-quality patient care (goedhart, van oostveen, & vermeulen, 2017). on the other hand, disempowered or powerless nurses are ineffective, unproductive and dissatisfied nurses (manojlovich, 2007; lee & kim, 2013; mariano, javier, fauni, & de vera, 2014). in other words, powerless nurses are less likely to deliver the best possible care for their patients. despite the numerous positive benefits of empowerment, surveys reveal that nurses are still not sufficiently empowered. for instance, only a moderate level of empowerment was disclosed among staff nurses in the philippines (mariano, javier, fauni, & de vera, 2014) and canada (greco, laschinger, & wong, 2006). even among the nurse managers cohort in the united states, many were not fully empowered (regan & rodriguez, 2011; oliver, gallo, griffin, white, & fitzpatrick, 2014). this is critical because a leader must be empowered so that they can empower others (regan & rodriguez, 2011). the nurse leader's empowering behaviors can be pivotal on how nurses perceive and respond to their work environment (greco, laschinger, & wong, 2006). in this sense, nurse supervisors and managers have an essential role in empowering staff (regan & rodriguez, 2011). empowering staff is a vital nursing leadership function to cultivate a culture of productive work environment that encourages and sustains quality and safe patient care (kramer, schmalenberg & maguire, 2010; asiri, rohrer, alsurimi, da’ar, & ahmed, 2016). nevertheless, nurses may feel powerless relative to organizational administrators and medical staff (manojlovich, 2007). as empowerment of staff nurses can emerge from nursing leadership (wilson and laschinger, 1994), it is necessary to assess leadership behaviors that promote empowerment among staff. according to kanter’s (1993) theory of structural empowerment, opportunity, and power in organizations are essential to empowerment that contributes to getting the work done. kanter (1993) described access to information, resources, support, and having a chance for advancement or opportunity to be involved in activities beyond one’s job description as the main components of structural empowerment. although not explicitly mentioned, the essence of structural empowerment or behaviors that lead an individual to act in an empowered manner has also been linked with nursing leadership, participative management and staff involvement in decision making (kramer & schmalenberg, 1993; upenieks, 2003; linnen & rowley, 2014). this proposes that leadership behaviors can be sources of power in the work setting that enable staff to act or feel empowered. given the ability of managers to affect the job responsibilities of their workforce, managers are likely to influence the task perceptions of their staff (konczak, stelly, & trusty, 2000). konczak, stelly, & trusty (2000) identified six dimensions of leader empowering behaviors: delegation of authority, accountability, self-directed decision-making, information sharing, skills development, and coaching for innovative performance. the leader's ability to exhibit and showcase these empowering actions will have an impact on the way staff will perceive the tasks given to them by their leader (mendes & stander, 2011). meanwhile, empowerment also being both a process and an outcome must be facilitated (kettunen, poskiparta, & liimatainen (2001). with the call for a multidisciplinary approach in healthcare, nurse managers must acquire leadership competencies that can generate an empowered workplace (asiri, rohrer, al-surimi, da’ar, & ahmed, 2016). having the necessary structures that promote empowerment, such as empowering leader behaviors, may result in a psychologically empowering experience among staff. conger and kanungo (1988) and furthered by spreitzer (1995) viewed empowerment as an enabling process implying motivation through enhancing personal efficacy manifesting as a set of four cognitions: meaning, competence, self-determination, and impact, that are shaped by a work environment. conger and kanungo (1988) also characterized empowerment as a process that involves a manager sharing power with subordinates. while empowerment is not a new concept to nursing, limited published studies are available regarding the topic of nurses’ empowerment in the local setting. moreover, with the current nurse staffing challenges experienced by hospital organizations, fostering elements of a positive organization (mendes & stander, 2011), in this case an empowered workplace, is needed if hospitals want to attract and retain their staff nurses (bester, stander, & van zyl, 2015). the role of leadership is a dynamic one between the leader and followers (peachey, 2002). continuous assessment of nurses’ empowerment levels at every stage of their nursing career is henceforth essential (al-dweik, al-daken, abu-snieneh, & ahmad, 2016). this study is an attempt to investigate the young staff nurses’ perceptions of leader empowering behaviors and psychological empowerment within the philippine context and whether there is a significant relationship between the two major variables. materials and methods this study employed a descriptive, cross-sectional research survey design. the study was conducted in a private tertiary hospital categorized as training and teaching hospital in iloilo city, philippines. in coordination with the nursing service office of the hospital, administrative and ethical clearances were sought before the actual survey. data were gathered jurnal ners http://e-journal.unair.ac.id/jners | 49 during the monthly in-service training activity of the nursing service office. those who attended the activity, available, and willing to participate during the conduct of the survey were included in the study. forty-four (44) conveniently chosen young staff nurses, with age ranging from 21 to 38 years old with an average age of 27 (median = 28), consented and participated in the study. all staff nurses were with bachelor’s degree, with a mean year of work experience equal to 2.9 (median = 1.5) ranging from less than one year to 12 years. informed consent was secured prior to the administration of questionnaires. the participants were ensured of their voluntary participation, including their rights to anonymity and confidentiality. a sealed envelope containing the selfadministered questionnaires and a demographic and work-related profile sheet was distributed to the participants. participants were asked to return the sealed envelope without any identifiable information. data for this study were gathered using two adopted research instruments that have been found valid in healthcare: spreitzer’s (1995) psychological empowerment scale and konczak, stelly & trusty’s (2003) leader empowering behavior questionnaire. the psychological empowerment scale is a 12-item scale with four dimensions: meaning, competence, self-determination, and impact having three items measuring each dimension. according to spreitzer’s (1995), these subscales combined create psychological empowerment. the leader empowering behavior questionnaire is a 19-item scale, consisting of six subscales: delegation of authority, accountability, self-directed decision-making, information sharing, skill development, and coaching for innovative performance. each dimension has three items except for information sharing having four items. the original instrument consisted of 17 items, but two items on information sharing were added by bester, stander, & van zyl (2015). all items of both instruments were answerable using a 5-point likert-type scale (1=strongly disagree, 5=strongly agree). higher scores indicate a higher level of empowerment. moreover, authors of both scales disclosed an acceptable reliability level (α>.70). permission to adopt the scales were secured from authors prior to use. descriptive statistics (frequency, percentage, mean, median, mean rank, rank) were utilized in describing the demographic and work-related profile of the participants. means were employed to determine the level of empowerment. scale items were summed and averaged to yield scores ranging from 1 to 5 wherein 1.00 – 2.33 was considered low, 2.34 – 3.66 was moderate, and 3.67 – 5.00 was high level. mann-whitney u test was performed to test for differences while spearman rho tested for the correlation between leader empowering behaviors and psychological empowerment. the result was significant if alpha was less than .05. the data were computed with the aid of spss version 23. results table 1 shows that majority of nurses were female (68.2%), single (86.6%), with permanent status of employment (68.2%), with more than one year of work experience in the hospital setting (68.2%) and were assigned in medical and surgical units (68.2%). table 2 shows that overall, staff nurses perceive their leaders’ behaviors to be highly empowering (m=3.89; sd=.43). among the six (6) subscales, ensuring accountability (m=4.05, rank 1), skills development (m=4.03, rank 2), information sharing (m=3.95, rank 3) were the most used empowering leadership behaviors. these were followed by decision-making (m=3.80, rank 4) and delegation (m=3.77, rank 5) and coaching for innovative performance (m=3.69, rank 6). it can also be gleaned in table 2 that staff nurses generally had high perceptions of psychological empowerment (m=4.07; sd=.44). meaning (m=4.36, rank 1) had the highest mean score among the subscales followed by competence (m=4.07, rank 2), self-determination (m=4.01, rank 3) with impact (m=3.83, rank 4) having the lowest mean score. statistical analysis using spearman rho correlation revealed a significant positive relationship (r=.472; p=.001) between staff nurses’ perception of leader empowering behaviors and psychological empowerment. table 3 shows that leader empowering behaviors did not vary significantly according to sex (p=.350), employment status (p=.919), marital status (p=.394); years of work experience (.622), and area of work assignment (.061). likewise, there were no significant differences in the staff nurses’ perception of psychological empowerment classified as to sex (p=.899); marital status (p=.481); area of assignment (p=.098). there were, however significant differences in the psychological empowerment of staff nurses when grouped according to employment status (p =.020) and years of experience (p=.014). staff nurses with permanent employment status (mean rank = 25.57) had a significantly higher level of psychological empowerment over those with table 1. demographic and work-related profile of staff nurses variables n % sex male 14 31.8 female 30 68.2 marital status single 39 86.6 married 5 11.4 employment status permanent 30 68.2 contractual 14 31.8 years of work experience 1 year or less 14 31.8 more than 1 year 30 68.2 area of assignment medical-surgical units 30 68.2 specialty units (er, icu, dr) 14 31.8 r. m. f. oducado et al. 50 | pissn: 1858-3598  eissn: 2502-5791 contractual employment status (mean rank = 15.93). also, staff nurses with more than 1 year of work experience in the hospital (mean rank = 26.73) had a significantly higher level of psychological empowerment compared to those with at least one year or less work experience. discussion this study attempted to determine the level of leader empowering behaviors and psychological empowerment among young staff nurses in a private hospital in the philippines. nursing scholars view empowerment as either arising from the environment or developing from one’s psychological state (manojlovich, 2007). in this study, leadership behaviors exhibiting empowerment were considered a structure within the environment wherein these leader empowering behaviors serve as the basis of power or source of the sense of being empowered. on the other hand, psychological empowerment is the intrinsic or personal factor of one’s sense of empowerment. empowerment is viewed as a process by which a leader enables staff members to act (ibrahim, abo el-magd, & sayed, 2014). laschinger, gilbert, smith, and leslie (2010) emphasized the role of nurse managers in providing conditions or appropriate structures to enable staff nurses to perform effectively within their work environments, thereby contributing to the achievement of goals of the organization. this study supports kanter’s (1993) theoretical propositions that when leaders are effective in using empowering behaviors, staff nurses feel empowered to take on the tasks in their workplace. kanter (1993) argued that organizational structures within the workplace are a precursor in shaping the work experiences of staff members. consistent with prior studies, leader empowering behaviors was significantly related to staff nurses’ psychological empowerment. this means that the higher is the nurse leader’s empowering behaviors, the higher is the level of psychological empowerment experienced by staff nurses. in other words, staff nurses who believe that their nurse managers are providing them with the necessary information to get their work done, involving them in decision-making affecting their practice, sharing with them unit governance, developing their skills continually and making them accountable for their practice, are more likely than those who do not believe in their manager's abilities, to come together to as a high functioning team in the workplace. konczak, stelly & trusty’s (2003) disclosed that psychological empowerment was significantly related to leader empowering behaviors and was found to mediate between two outcome variables: job satisfaction and organizational commitment. similarly, peachey (2002) also found a significant correlation between leader empowering behaviors and psychological empowerment in a study conducted in canada. a similar result was obtained in an asian country where nurse managers’ leadership behaviors were directly related to psychological empowerment among nurses working in acute care hospitals in japan (kanai-pak, 2009). staff nurses’ perceptions of empowerment in their work setting are magnified by their leaders’ empowering behaviors. in this study, nurse managers’ leadership behaviors were essential for staff nurses to feel supported and empowered (greco, laschinger, & wong, 2006). this study also demonstrated a high level of leader empowering behaviors as perceived by young staff nurses. while all empowering behaviors of leaders in this study were rated high, the dimensions of decision-making, delegation, and coaching for table 2. level of leader empowering behaviors and psychological empowerment and relationship between variables variables mean sd interpretation rank leader empowering behaviors (overall) 3.89 0.43 high accountability 4.05 0.57 high 1 skills development 4.03 0.55 high 2 information sharing 3.95 0.53 high 3 decision-making 3.80 0.54 high 4 delegation 3.77 0.56 high 5 coaching for innovative performance 3.69 0.64 high 6 psychological empowerment (overall) 4.07 0.44 high meaning 4.36 0.61 high 1 competence 4.07 0.52 high 2 self-determination 4.01 0.51 high 3 impact 3.83 0.55 high 4 spearman r = .472 p-value = .001 table 3. differences in leader empowering behaviors and psychological empowerment variables leader empowering behaviors psychological empowerment p-value p-value sex 0.350 0.899 employment status 0.919 0.020 marital status 0.394 0.481 years of experience 0.622 0.014 area of assignment 0.061 0.098 jurnal ners http://e-journal.unair.ac.id/jners | 51 innovative performance fell below the composite mean. in contrast, researchers in canada revealed that staff nurses perceived their leaders' behaviors to be only somewhat empowering (greco, laschinger, & wong, 2006). nurses in the study of peachey (2002) also perceived their leaders were exhibiting low to moderate empowering behaviors. compared to the two studies conducted abroad, a higher level of leader empowering behaviors was demonstrated in this study. with the appreciation of the positive effects of empowerment in the nursing profession, nurse managers may have started to recognize and showcase empowering leadership behaviors. although asiri, rohrer, al-surimi, da’ar, & ahmed (2016) found that most nurses in their study believed that their immediate nursing managers were not displaying the ideal level of transformational leadership behaviors wherein empowerment is central, local studies provide support of the empowering leadership style or behaviors among filipino nurse managers. for example, lamasan & oducado (2018) found that filipino millennial nurse administrators consider their leadership to be empowering. correspondingly, filipino nurses in a tertiary hospital in the philippines agreed that their nurse managers utilized transformational leadership styles (lapeña, tuppal, loo, abe, 2017). even in a neighboring asian country, transformational leadership was said to enhance employee empowerment among nursing staff in malaysia (choi, goh, adam & tan, 2016). this study also found that young staff nurses have a high level of psychological empowerment. this is congruent with the findings of researchers in egypt (hashish, all, & mousa, 2018), revealing nurses with a high level of psychological empowerment. however, in contrast to what was demonstrated in this study, most of the literature suggests that registered nurses’ psychological empowerment is only at a moderate level. these studies include nurses in the philippines (mariano, javier, fauni, & de vera 2014), canada (peachey, 2002), new zealand (connolly, jacobs, & scott, 2018), iran (royan , alikhani, mohseni, alirezaei, khosravizadeh, & moosavi, 2017), china (ouyang, zhou, & qu, 2015), riyadh, saudi arabia (asiri, rohrer, al-surimi, da’ar, & ahmed, 2016) and even also in egypt (ibrahim, abo el-magd, & sayed, 2014). it is still noteworthy that nurses’ psychological empowerment was relatively moderate to high level. as to each subscale, the result of this study is similar to findings reported in prior studies conducted elsewhere, wherein meaning had the highest and impact had the lowest mean score among the four dimensions. the meaning dimension was reported to have the highest mean in earlier researches (peachey, 2002; lee, 2012; mariano, javier, fauni, & de vera, 2014; asiri, rohrer, alsurimi, da’ar, & ahmed, 2016). the meaning dimension is the value of a work goal or purpose, judged in relation to an individual's ideals or standards (thomas & velthouse, 1990). the result of the study indicates that leader empowering behaviors influence staff nurses’ perception of the value that they put in their job. moreover, the result may indicate that staff nurses form a satisfying connection with their job (mariano, javier, fauni, & de vera, 2014). on the other hand, the impact dimension was consistently noted to have the lowest mean score among the four aspects of psychological empowerment (peachey, 2002; lee, 2012; asiri, rohrer, al-surimi, da’ar, & ahmed, 2016, hashish, all, & mousa, 2018). the dimension of impact refers to the degree to which an individual can influence strategic, administrative, or operating outcomes at work (thomas & velthouse, 1990). while this was found to be high, staff nurses may still have hesitations over the degree of control or impact they have on certain strategic, administrative, and operating outcomes of their work attributed to their level in the organization. younger staff nurses have less degree of official power and influence within the hierarchal structure of the organization. for instance, staff nurses were not highly involved in decision making when unit managers made resolutions in the areas of professional practice governance and leadership, support staff practice, and recruitment (gatbonton, 2019). though there are varying mean scores in the four dimensions of psychological empowerment, sprietzer (1995) maintains that the interplay of these components produces an overall feeling of being psychologically empowered. it is also significant to note that in this study, variation in staff nurses’ perception of psychological empowerment was noted according to employment status. staff nurses with permanent status in their workplace may feel more psychologically empowered compared to those whose employment status is not permanent. insecurity in one’s job can exist when nurses experience uncertainty or danger of job loss (hashish, all, & mousa, 2018). employment status was found to be a good predictor of employment security among nurses in the philippines (egcas, 2017). having a permanent work employment status may give staff nurses a sense of security. it was earlier studied that psychological empowerment was negatively correlated with job insecurity (hashish, all, & mousa, 2018). also, this study discovered that years of work experience was significantly related to psychological empowerment. this suggests that staff nurses having longer years of working in the hospital may have better access to empowering structures within the hospital work setting. nurses may have learned to navigate themselves at assessing empowerment structures to accomplish their work goals over time (peachey, 2002). in china, nurses’ psychological empowerment was found to be significantly different in terms of age and length of service (ouyang, zhou, & qu, 2015). contrastingly, findings in egypt disclosed no relationship between years of experience and psychological empowerment (ibrahim, abo el-magd, & sayed, 2014). r. m. f. oducado et al. 52 | pissn: 1858-3598  eissn: 2502-5791 while there was a small sample size, this study provides additional evidence of nurses’ empowerment and addresses the dearth of scientific knowledge on empowerment in the philippine setting. also, this study contributes to the literature regarding the positive effects of empowerment among staff nurses by having empowering leaders. despite its input to the body of knowledge, this study has its limitations opening doors for future inquiry. the small sample size limited the generalization of findings hence, conclusions are considered preliminary. the use of self-administered questionnaires in data collection constrained findings to the danger of self-report bias. the researcher recommends the need for further study to address methodological issues experienced in this study. studies involving larger samples may be conducted in the future to validate the findings of the present investigation. conclusion empowerment has gained recognition and acceptance among nurses both in the nursing leader and staff role. in this study, leader empowering behaviors is significantly related to psychological empowerment. young staff nurses perceived the behaviors of their leaders as highly empowering, enabling them to feel highly empowered. nursing leaders play a substantial part in creating positive work environments influencing how staff nurses respond to their work. when nurse managers give staff nurses the opportunity to take more responsibility, provide access to relevant information to get their job done, delegate tasks, develop their skills to enhance staff performance, and when decision making is shared in the hands of those who practice at the bedside, positive outcome among staff is likely realized. the empowering actions of the leader build staff nurses’ confidence that permits them to act autonomously. likewise, these empowering practices increase staff nurses’ chance of finding meaning and impact in their work. nurse managers and leaders should continuously develop strategies that enhance staff nurses’ perceptions of feeling empowered. they should foster the elements of a positive organization to ensure empowering conditions at work. besides, cultivating empowerment in the nursing profession is vital and imperative. references al-dweik, g., al-daken, l.i., abu-snieneh, h., & ahmad, m.m. (2016). work-related empowerment among nurses: literature review. international journal of productivity and quality management, 19(2), 168-186. https://doi.org/10.1504/ijpqm.2016.078885 asiri, s.a., rohrer, w.w., al-surimi, k., da’ar, o.o., & ahmed, a. (2016). the association of leadership styles and empowerment with nurses’ organizational commitment in an acute health care setting: a cross-sectional study. bmc nursing, 15. https://doi.org/10.1186/s12912-016-0161-7 bester, j., stander, m.w., & van zyl, l.e. (2015). leadership empowering behaviour, psychological empowerment, organisational citizenship behaviours and turnover intention in a manufacturing division. sa journal of industrial psychology, 41(1). https://doi.org/10.4102/sajip.v41i1.1215 choi, s.l., goh, c.f., adam, m.b.h. & tan, o.k. (2016). transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment. human resources for health, 14(1), 73. https://doi.org/10.1186/s12960-0160171-2 conger, j.a., & kanungo, r.n. (1988). the empowerment process: integrating theory and practice. academy of management review, 13(3), 471-482. https://doi.org/10.5465/amr.1988.4306983 connolly, m., jacobs, s., & scott, k. (2018). clinical leadership, structural empowerment and psychological empowerment of registered nurses working in an emergency department. journal of nursing management, 28(6), 881-887. https://doi.org/10.1111/jonm.12619 donahue, m.o., piazza, i.m., griffin, m.q., dykes, p.c., & fitzpatrick, j.j. (2008). the relationship between nurses' perceptions of empowerment and patient satisfaction. applied nursing research, 21(1), 2-7. https://doi.org/10.1016/j.apnr.2007.11.001 egcas, r.a. (2017). employment security of nurses: baseline for a strategic human resource direction. asia pacific journal of multidisciplinary research, 5(4), 39-47. gatbonton, r.r.g. (2019). decisional involvement on work quality of nurses. nursing and palliative care international journal, 2(1), 21-27. doi:10.30881/npcij.00011 goedhart, n.s., van oostveen, c.j., & vermeulen, h. (2017). the effect of structural empowerment of nurses on quality outcomes in hospitals: a scoping review. journal of nursing management, 25(3), 194-206. https://doi.org/10.1111/jonm.12455 greco, p., laschinger, h.k., & wong, c. (2006). leader empowering behaviors, staff nurse empowerment and work engagement/burnout. nursing leadership, 19(4), 41-56. doi:10.12927/cjnl.2006.18599 hashish, e.a.a., all, n.h.a., & mousa, a.a. (2018). nurses’ perception of psychological empowerment and its relationship to work engagement and job insecurity. journal of nursing education and practice, 8(9), 36-44. https://doi.org/10.5430/jnep.v8n9p36 ibrahim, m., abo el-magd, m.h., & sayed, h.y. (2014). nurse’s psychological empowerment and perceived autonomy in university and teaching hospitals at menofia governorate/egypt. journal of nursing education and practice, 4(9), 59-68. https://doi.org/10.5430/jnep.v4n9p59 jurnal ners http://e-journal.unair.ac.id/jners | 53 jordan, r., & davis, c. (2013). are you empowered? nursing made incredibly easy, 11(2), 4. doi:10.1097/01.nme.0000426297.01571.5d kanai-pak, m. (2009). leadership behaviors that mitigate burnout and empower japanese nurses (doctoral dissertation). the university of arizona, tucson, arizona kanter, r.m. (1993). men and women of the corporation. new york, ny: basic books, inc. kettunen, t., poskiparta, m., & liimatainen, l. (2001). empowering counselling-a case study: nursepatient encounter in a hospital. health education research, 16(2), 227-238. https://doi.org/10.1093/her/16.2.227 konczak, l.j., stelly, d.j., & trusty, m.l. (2000). defining and measuring empowering leader behaviors: development of an upward feedback instrument. educational and psychological measurement, 60(2), 301-313. http://dx.doi.org/10.1177/00131640021970420 kramer, m., & schmalenberg, c. (1993). learning from success: autonomy and empowerment. nursing management, 24(5), 58-64. doi:10.1097/00006247-199305000-00012 kramer, m., schmalenberg, c., & maguire, p. (2010). nine structures and leadership practices essential for a magnetic (healthy) work environment. nursing administration quarterly, 34(1), 4-17. doi:10.1097/naq.0b013e3181c95ef4 lamasan, j.i.l. & oducado, r.m.f. (2018). a qualitative description of millennial nurse administrators’ perspectives on leadership and their practice environment. indonesian nursing journal of education and clinic, 2(3), 153-164. http://dx.doi.org/10.24990/injec.v3i2.226 lapeña, l.f.r., tuppal, c.p., loo, b.g.k., & abe, k.h.c. (2017). transformational and transactional leadership styles of nurse managers and job satisfaction among filipino nurses: a pilot study. nurse media journal of nursing, 7(2), 65-78. https://doi.org/10.14710/nmjn.v7i2.15171 laschinger, h.k.s., gilbert, s., smith, l., & leslie, k. (2010). towards a comprehensive theory of nurse/patient empowerment: applying kanter's empowerment theory to patient care. journal of nursing management, 18(1), 4-13. https://doi.org/10.1111/j.13652834.2009.01046.x lee, e.s. (2012). job satisfaction among staff nurses in relation to leader empowering behaviors, structural empowerment and psychological empowerment (master’s thesis). university of british columbia, vancouver, canada. doi: 10.14288/1.0166827 lee, j.w., & kim, d.w. (2013). mediating effects of psychological empowerment on the relationship between nurse’s self leadership and organizational commitment. health and social welfare review, 33(2), 366-400. doi:10.15709/hswr.2013.33.2.366 leggat, s.g., bartram, t., casimir, g., & stanton, p. (2010). nurse perceptions of the quality of patient care: confirming the importance of empowerment and job satisfaction. health care management review, 35(4), 355-364. doi:10.1097/hmr.0b013e3181e4ec55 linnen, d., & rowley, a. (2014). encouraging clinical nurse empowerment. nursing management, 45(2), 44-47. doi:10.1097/01.numa.0000442640.70829.d1. lockhart, l. (2017). let's hear it for empowerment. nursing made incredibly easy, 15(4), 55. doi:10.1097/01.nme.0000520146.46175.68 manojlovich, m. (2007). power and empowerment in nursing: looking backward to inform the future. ojin: the online journal of issues in nursing, 12(1), manuscript 1. doi:10.3912/ojin.vol12no01man01 mariano, s.m.n., javier, w.b., fauni, l.l., & de vera, l.a. (2014). level of empowerment of staff nurses in selected private hospitals in cavite. philippine journal of nursing, 84(2), 40-47. mendes, f., & stander, m.w. (2011). positive organisation: the role of leader behaviour in work engagement and retention. sa journal of industrial psychology, 37(1), 1-13. doi: https://doi.org/10.4102/sajip.v37i1.900 peachey, g.a. (2002). the effect of leader empowering behaviours on staff nurses workplace empowerment, psychological empowerment, organizational commitment, and absenteeism (doctoral dissertation). mcmaster university, hamilton, canada oliver, b., gallo, k., griffin, m.q., white, m., & fitzpatrick, j. (2014). structural empowerment of clinical nurse managers. jona: the journal of nursing administration: 44(4), 226–231. doi: 10.1097/nna.0000000000000059 okuyama, a., wagner, c., & bijnen, b. (2014). how we can enhance nurses’ assertiveness: a literature review. journal of nursing care, 3(5), 1-9. https://doi.org/10.4172/2167-1168.1000194 oyeleye, o., hanson, p., o’connor, n., & dunn, d. (2013). relationship of workplace incivility, stress, and burnout on nurses’ turnover intentions and psychological empowerment. the journal of nursing administration, 43(10), 536-542. doi:10.1097/nna.0b013e3182a3e8c9 ouyang, y.q., zhou, w.b. & qu, h. (2015). the impact of psychological empowerment and organisational commitment on chinese nurses’ job satisfaction. journal of contemporary nurse, 50(1), 80-91. https://doi.org/10.1080/10376178.2015.10102 53 regan, l.c., & rodriguez, l. (2011). nurse empowerment from a middle-management perspective: nurse managers' and assistant nurse managers' workplace empowerment views. the permanente journal, 15(1), e101–e107. royan, s., alikhani, m., mohseni, m., alirezaei, s., khosravizadeh, o., & moosavi, a. (2017) .nurses' psychological empowerment in iran: a systematic review and meta-analysis. annals of tropical https://doi.org/10.1097/00006247-199305000-00012 https://doi.org/10.1111/j.1365-2834.2009.01046.x https://doi.org/10.1111/j.1365-2834.2009.01046.x https://doi.org/10.4102/sajip.v37i1.900 r. m. f. oducado et al. 54 | pissn: 1858-3598  eissn: 2502-5791 medicine and public health,10(6),1558-1562. doi: 10.4103/atmph.atmph_509_17 spreitzer, g.m. (1995). psychological empowerment in the workplace: dimension, measurement, and validation. the academy of management journal, 38(5), 1442-1465. doi: 10.2307/256865 thomas, k.w., & velthouse, b.a. (1990). cognitive elements of empowerment: an “interpretive” model of intrinsic task motivation. academy of management review, 15, 666-681. doi: 10.2307/258687 upenieks, v.v. (2003). the interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. health care manager, 22(2), 83-98. doi: 10.1097/00126450-200304000-00002 van bogaert, p., peremans, l., de wit, m., van heusden, d., franck, e., timmermans, o., & havens, d. s. (2015). nurse managers' perceptions and experiences regarding staff nurse empowerment: a qualitative study. frontiers in psychology, 6, 1585. doi:10.3389/fpsyg.2015.01585 wilson, b., & laschinger, h.k.s. (1994). staff nurses' perception of job empowerment and organizational commitment: a test of kanter's theory of structural power in organizations. journal of nursing administration, 24(4s), 39–45. http://e-journal.unair.ac.id/jners | 393 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17176 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review factors that influence professional quality of life (pro-qol) on clinical nurses febrina secsaria handini, fitriyanti patarru', basilius yosepfus weu, heryyanoor and sena wahyu purwanza faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: nurses are professionals that work by involving cognitive and emotional aspects simultaneously when providing nursing care, which provides both positive and negative experiences. these experiences can affect nurses' professional quality of life (pro-qol). professional quality of life has three dimensions, namely burnout (bo), compassion satisfaction (cs) and secondary traumatic stress (sts). this paper presents a systematic review of the literature that examined factors that influence the professional quality of life on clinical nurses. methods: articles are obtained from the scopus, science direct and emerald databases using keywords compassion satisfaction, burnout, secondary traumatic stress, nurse. the search identified 69 articles and 15 relevant research articles published between 2014-2019. results: the results show that the inability of nurses to control the core of self-evaluation and the five-factor model (ffm) of personality traits, high workload, pressure in the work and imbalance between rewards and work, coping nurses and poor emotional support, rejection and giving up behavior can increase the number of those with compassion fatigue. conclusion: the results show that the inability of nurses to control the core of self-evaluation and the five-factor model (ffm) of personality traits, high workload, pressure in the work and imbalance between rewards and work, coping nurses and poor emotional support, rejection and giving up behavior can increase the number of those with compassion fatigue. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords self foot care; foot care behavior; diabetic foot; diabetes mellitus contact febrina secsaria handini  febrina.secsaria.handini2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: handini, f.s., patarru', f., weu, b.y., heryyanoor, h., & purwanza, s.w.. (2019). factors that influence professional quality of life (pro-qol) on clinical nurses. jurnal ners, 14(3si), 393-396. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17176 introduction clinical nurses often work in environments that are full of pressure and where the workload is quite high, because each day they face complex and different patient conditions. for example, professional care providers in cancer palliative care. nurses who provide professional care to patients with advanced cancer face challenges and stress because nurses must provide holistic care in the physical, psychological, spiritual, and environmental aspects (kaur, sharma, & chaturvedi, 2018). this can be a source of psychological stress for nurses and makes them vulnerable to burnout and/or compassion fatigue (kaur et al., 2018). burnout and compassion fatigue is an aspect of professional quality of life (proqol). the professional quality of life (pro-qol) is the quality perceived by a professional related to work as a service provider. there are two aspects in professional quality of life (pro-qol), namely compassion satisfaction (cs) as a positive aspect and compassion fatigue (cf) as a negative aspect (b.h. stamm, 2010). the nurse is able to feel satisfaction after helping others and is able to do a good job, so that satisfaction is called compassion satisfaction. this satisfaction is a positive perspective and can improve the ability of nurses to care for patient (stamm, 2016. bibliography et al., 2016). compassion fatigue (cf) is a negative consequence of taking care of patients (figley, 2018). compassion fatigue has two aspects, namely burnout (bo) and secondary traumatic stress (sts) (b.h. stamm, 2010). secondary traumatic stress refers to emotional https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). f. s. handini, et al. 394 | pissn: 1858-3598  eissn: 2502-5791 responses or behavior caused by exposure to other people's traumatic experiences. burnout is a negative emotional reaction to external stressors that are connected to the work environment. based on the description of the background, the purpose of the current study was to systematically review and synthesize the factors related to or which influence the professional quality of life (pro-qol). materials and methods search strategies the search strategy involved a review of three databases: scopus, science direct and emerald using keywords “burnout”, “satisfaction compassion”, “secondary traumatic stress”, and “nurse”. the search included english language articles published between 2014-2019. selection criteria article searches are conducted from november 2018 to march 2019. articles were selected and included if they met the following criteria 1) the study about professional quality of life in clinical nurses; 2) was original research; 3) were studies written in english; 4) the location of the study is a hospital or a health center; 5) research articles published between 20142019. an article was excluded if it was a thesis or part of conference proceedings. data extraction for articles that fulfill the inclusion and exclusion criteria for fifteen articles, we extracted the author, year, study design, sample, measurement, analysis, and whether the results of the study were significant or not significant. in addition, we extracted the results of articles that discuss factors related to or are influenced by professional quality of life (pro-qol). differences or disagreement in research results are resolved through discussion with all authors. results selection of studies the search resulted in a total of 244 studies: 69 from scopus, 13 from emerald, 162 from science direct. of these, 15 manuscripts were relevant to factors that are related to or are influenced by professional quality of life (pro-qol) and which were screened using inclusion criteria. fifteen studies were maintained after screening quality assessment. study methods from the results of the study selection, we found 15 study respondents. studies are limited to between 2014-2019. two studies were published in 2014, two studies were published in 2015, two studies were published in 2016, two studies were published in 2017, six studies were published in 2018, and one study was published in 2019. based on the study design, all respondents used a quantitative research approach with cross-sectional details of 7 respondents, a cross-sectional descriptive of 3 respondents, a cross-sectional survey of 4 respondents and a non-experimental longitudinal design of 1 respondent. regarding the research subjects, the following data were obtained: 12 respondents were nurses and/or nurse assistants who worked in hospitals or health care centers such as trauma centers, 2 health professionals and 1 respondent were pregnancy termination providers. for data sources, in addition to socio-demographic information, fifteen articles used questionnaires as instruments. thirteen of the fifteen articles used professional quality of life questionnaire version 5 (pro qol v) (amin, vankar, nimbalkar, & phatak, 2015; barr, n.d., 2018; foster, 2019; friedmann et al., 2014; hegney, desley g; craigie, mark; hemsworth, 2014; hegney, rees, eley, osseiran-moisson, & rees, 2015; jang, kim, & kim, 2016; kaur et al., 2018; c. f. rn & rn, 2017; s. j. rn, hons, rn, & rn, 2017; teffo, levin, & rispel, 2018; wu, singh-carlson, odell, reynolds, & su, 2016), one article used the copenhagen burnout inventory (cbi) (hämmig, 2018), and one article used the secondary traumatic stress scale (kellogg, knight, dowling, & crawford, 2018). in addition to a questionnaire to measure professional quality of life, there are several questionnaires that are used as measuring instruments to explore factors that are related to, or influence, professional quality of life, such as the core self-evaluation scale, big-five inventory (bfi), positive and negative affect schedule, copenhagen psychosocial questionnaire (copsoq), perceived stress scale (pss14), the chinese social support questionnaire, depression anxiety stress scale (dass 21-short form), a modified hall's professionalism inventory (hpi) scale, the brief cope, the marlowecrowne social desirability-short form, spielberger state-trait anxiety inventory form y2 (stai-y2), and the connor-davidson resilience scale (cd-risc25). figure 1: literature search flow jurnal ners http://e-journal.unair.ac.id/jners | 395 discussion professional quality of life is divided into two aspects, namely the positive aspect called compassion satisfaction (cs) and the negative aspect called compassion fatigue (cf), which consists of two things, burnout (bo) and secondary traumatic stress (sts). the results of the study by kaur et al. (2018) show that nurses are one of the professional health workers who have a higher level of burnout and secondary traumatic stress than the other professional health workers (kaur et al., 2018). from the results of the analysis of several literature studies above, it was found that several factors influence the positive and negative aspects in the professional quality of life in clinical nurses. increasing compassion satisfaction of a nurse can be influenced by several factors, including: nurses' ability to regulate core self-evaluation (self-esteem, self-efficacy, emotional stability, locus of control) and the five-factor model (ffm) of personality traits that includes neuroticism, agreeableness, extraversion, conscientiousness, and openness (barr, 2018), high professionalism at work (jang et al., 2016), and high educational qualifications (s. j. rn et al., 2017; wu et al., 2016). nurses who have the ability to build social relationships, especially with colleagues, have a positive relationship with colleagues or with the social environment (barr, n.d.; friedmann et al., 2014). nurses who have worked for more than 5 years will have more experience than nurses who work for less than 5 years (hegney, desley g; craigie, mark; hemsworth, 2014; kaur et al., 2018; s. j. rn et al., 2017). nurses who have attended training in accordance with their competencies (kaur et al., 2018). compassion satisfaction of nurses is a feeling of pleasure felt by a nurse when able to do a job for people who need care (beth hudnall stamm, 2010). however, compassion satisfaction can be a compassion fatigue which is a negative aspect of helping those who experience traumatic stress and suffering several factors are related to the increasing numbers of those with compassion fatigue, including the inability of nurses to control core of selfevaluation and five-factor models (ffm) of personality traits (barr, 2018), high workload, pressure in work and imbalance between rewards and work (hämmig, 2018), coping nurses and poor emotional support, rejection, and giving up behavior (kellogg et al., 2018). conclusion from the results of the study it can be concluded that to get a clinical nurse who has a good professional quality of life value, it is necessary to focus on the things that can influence it. an intervention is needed to reduce and prevent clinical nurses from fatigue and secondary traumatic stress and increase satisfaction compassion to improve high quality care in clinical settings. references amin, a. a., vankar, j. r., nimbalkar, s. m., & phatak, a. g. (2015). perceived stress and professional quality of life in neonatal intensive care unit nurses in gujarat , india. 82(november), 1001– 1005. https://doi.org/10.1007/s12098-0151794-3 barr, p. (n.d.). the five-factor model of personality, work stress, and professional quality of life in neonatal intensive care unit nurses. 0–2. https://doi.org/10.1111/jan.13543 barr, p. (2018). personality traits , state positive and negative affect , and professional quality of life in neonatal nurses. journal of obstetric, gynecologic, & neonatal nursing, (september). https://doi.org/10.1016/j.jogn.2018.08.003 figley, c. (2018). compassion fatigue : coping with secondary traumatic stress disorder in those who treat the traumatized . ny : brunner / routledge. (july). foster, c. (2019). investigating professional quality of life in nursing staff working in adolescent psychiatric intensive care units ( picus ). https://doi.org/10.1108/jmhtep-04-20180023 friedmann, e., mcquillan, k. a., gilmore, r., kramer, r. n. b., bm, b. s., & murray, m. (2014). trauma nurses. 21(4). https://doi.org/10.1097/jtn.0000000000000 055 hämmig, o. (2018). explaining burnout and the intention to leave the profession among health professionals – a cross-sectional study in a hospital setting in switzerland. 1–11. hegney, desley g; craigie, mark; hemsworth, d. et al. (2014). compassion satisfaction , compassion fatigue , anxiety , depression and stress in registered nurses in australia : study 1 results. (july 2013), 506–518. https://doi.org/10.1111/jonm.12160 hegney, d. g., rees, c. s., eley, r., osseiran-moisson, r., & rees, c. s. (2015). the contribution of individual psychological resilience in determining the professional quality of life of australian nurses. 6(october). https://doi.org/10.3389/fpsyg.2015.01613 jang, i., kim, y., & kim, k. (2016). professionalism and professional quality of life for oncology nurses. 1– 11. https://doi.org/10.1111/jocn.13330 kaur, a., sharma, m. p., & chaturvedi, s. k. (2018). professional quality of life among professional care providers at cancer palliative care centers in bengaluru , india. 167–172. https://doi.org/10.4103/ijpc.ijpc kellogg, m. b., knight, m., dowling, j. s., & crawford, s. l. (2018). journal of pediatric nursing secondary traumatic stress in pediatric nurses ☆. journal of pediatric nursing, 43, 97–103. https://doi.org/10.1016/j.pedn.2018.08.016 rn, c. f., & rn, m. y. (2017). associations of professional quality of life and social support f. s. handini, et al. 396 | pissn: 1858-3598  eissn: 2502-5791 with health in clinical nurses. (june), 1–8. https://doi.org/10.1111/jonm.12530 rn, s. j., hons, b., rn, l. p., & rn, j. l. (2017). australian intensive care nurses. australian critical care. https://doi.org/10.1016/j.aucc.2017.10.003 stamm, 2016. bibliography, p. m., reference, s., bibliography, c., using, d. s., measure, p., & style, a. p. a. (2016). a comprehensive bibliography of documents specifically using the proqol measure. (january). stamm, b.h. (2010). comprehensive bibliography of the effect of caring for those who have experienced extremely stressful events and suffering. stamm, beth hudnall. (2010). 2010 the concise proqol manual. teffo, m. e., levin, j., & rispel, l. c. (2018). compassion satisfaction , burnout and secondary traumatic stress among termination of pregnancy providers in two south african provinces. 1–9. https://doi.org/10.1111/jog.13665 wu, s., singh-carlson, s., odell, a., reynolds, g., & su, y. (2016). compassion fatigue, burnout, and compassion satisfaction among oncology nurses in the united states and canada. 43(4), 161–169. https://doi.org/10.1188/16.onf.e161-e169 374 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17217 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research relationship between the application of a full day school system and stress levels in junior high school maulidiyah junnatul azizah heru, atika jatimi, fakhrun nisa fiddaroini, dan achmad syamsudin faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: this research presents the relationship between the schools which implemented full day school and which did not apply the full day school to the level of stress students in junior high schools. this was influenced by the existence of regional autonomy as part of government policy and orientation toward quality education institutions. methods: this research used a quantitative correlational approach to obtain the significance of the relationship between the variables examined. the sampling technique used purposive sampling, with samples of 37 students for a group of cases and 37 students to control groups. data analysis was conducted using the kolmogorov smirnov test. results: the results showed that in the case group there were 83.78 experiencing mild stress and 16.22 experiencing moderate stress, while in the control group there were 89.19 experiencing mild stress, and 10.81 experiencing moderate stress with pvalue 0.000 (<0.05). conclusion: the conclusion of this study is that more moderate stress levels are found in students who apply the full day school system in junior high school. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords stress levels; quality education institutions; full day school contact maulidiyah junnatul azizah heru  maulidiyah.junnatul.azizah2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: heru, m. j. a., jatimi, a., fiddaroini, f.n.,& syamsudin, a. (2019). relationship between the application of a full day school system and stress levels in junior high school. jurnal ners, 14(3si), 374-377. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17217 introduction the full day school education system became popular in the 1980s in the united states and was followed by various other countries in europe (arifin, 2017). at present education in indonesia has undergone several policy changes from time to time (muali, islam, el, & bali, 2018). one policy that had become a conversation and interesting to study was the policy on fds (full day school) (hakim & parameswari, 2015). in general, the education system in indonesia is divided into two, namely the regular education system and the full day school education system, the fundamental difference between the two systems is the length of study time (saudatul & baharun, 2018). full day school can be interpreted as a school that applies a full day learning system or from morning to evening (indra & haris, 2017). in its implementation, a full day school based on a balancing program between cognitive, emotional, social, and spiritual abilities is considered an excellent program, because it makes student learning time effective and maximizes the full potential of students. others think that full day school can make students overly-stressed due to the burden of learning. it can even cause children to experience physical and mental fatigue (abai , m t m, huda, a. y s d, 2017). in educational activities, students often experience stress because of their inability to adapt to the program at school. the stress experienced by students in the school environment will accumulate against psychological disorders and physical illness (desmita, 2016). stress that is often experienced by students is academic stress (paulus w, t, & w, 2014). based on the results of the mufadhal barseli study, it shows that in general the academic stress conditions of junior high school students in padang are in the moderate category with a percentage of 41.1%. this shows that students can control the situation or condition that causes stress, which is https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 375 related to various academic demands. although in general the students' academic stress conditions are in the moderate category, but some students are in the high academic stress category with a percentage of 28.8%. this means that students do not escape the conditions of academic stress. high demands are placed on students both from parents, teachers and peers are one of the causes of the emergence of academic stress. besides these things, there are 30.2% of students in low academic stress conditions. this proves that academic stress is not entirely negative meaning that it can be positive in the sense of a challenge to overcome it (barseli, ifdil, & nikmarijal, 2017). the results of the interview with the head of the badridduja junior school found that the badridduja middle school which from its inception in 2013/2014 had 21 students and had not implemented the full day school system, but after the full day school system was implemented there were several students who stopped and moved to other institutions . this happened because of the intense activities, heavy lessons, and a very high level of discipline that made students bored and could not stand the application of the full day school system. materials and methods the design of this study was correlational with a case control approach. this study involved 74 respondents who were divided into two groups from two schools that were used as research sites. the schools published are badriduja junior high school and al mashduqiyah junior high school. the study was conducted using a purposive sampling technique. the validity of the values obtained 0,243. data collected was analyzed using kolmogorov smirnov. results table 1 shows that respondents from a group of cases consisted of 26 (70.27%) male students with 18 students in the control group (48.65%). the age of the respondents from the case group is 12-14 years old with 30 students or 81.08%. while the age of the control group 12-14 years of age accounted for 36 students or 97.3% table [2]. in this study the case group the majority of respondents from seventh grade numbered 29 students or 78.38%. while from the control the majority also consisted from seventh grade totaling 29 students or 78.38 tables [3]. based on the results of the kolmogorov smirnov test obtained a significant (p-value = 0,000) and that value (0,000 <0.05). this value indicates that there is a relationship between the application of a full day school system and stress levels in students junior high school at badridduja kraksaan-probolinggo table [5]. after being analyzed using kolmogorov smirnov then measuring the extent to which the strength of the two variables using the lambda test obtained p-value 0.756 and the value was greater than the approx. value. sig. 0.000 (0.756> 0.000) and it can be concluded that the strength of the relationship between the independent variable and the dependent variable is interpreted strongly so that the correlation direction is positive (+) table [6]. discussion according to astuti school with a full day school system was established to accommodate problems that exist in the community such as juvenile delinquency problems, parents of students expect their children to get a better religious education and avoid negative things, besides that full day school was established due to factors of work parents so they are table 1 distribution of respondents in full day school and non-full day school characteristic full day school (n=37) % non full day school (n=37) % sex male 26 70.27% 18 48.65% female 11 29.73% 19 51.35% age 12-14 30 81.08% 36 97.3% 15-17 7 18.92% 1 2.7% class vii 29 78.38% 29 78.38% viii 8 21.62% 8 21.62% table 2 distribution of stress levels instudents in two group stress level full day school (n=37) % non full day school (n=37) % low 31 83.78% 33 89.19% moderate 6 16.22% 4 10.81% high 0 0% 0 0% table 3. relationship distribution between of a full day school system with stress levels to students the group stress level full day school pvalue case control low moderate high low moderate high 31 6 0 33 4 0 0.000 table 4 overview of the lambda correlation test stress level full day school (n=37) non full day school (n=37) r p low 31 33 0.756 0.000 moderate 6 4 high 0 0 m. j. a. heru, et al. 376 | pissn: 1858-3598  eissn: 2502-5791 not able to monitor the behavior of children after school (astuti, 2013). full day school has a positive impact on student motivation in achievement so that it has a big influence on learning achievement (subiantoro, atmadja, & natajaya, 2013). students who have a full day school system have better religious values and are able to develop and manage learning supported by educator guidance (nurhayati, 2014). this contrasts with the results of research that has been conducted that the badridduja junior high school students who apply the full day school system are found to experience mild stress as many as 31 students and moderate stress 6 people. while the results of research conducted on al-masduqiah junior high school as a control group showed that 33 students had mild stress, moderate stress 4 students, and none of them experienced severe stress. while the results of research conducted on al-masduqiah junior high school as a control group showed that 33 students had mild stress, moderate stress 4 students, and none of them experienced severe stress. the level of stress on badriduja junior high school students above occurs because the students experience boredom on average when the teacher explains the subject matter, many students complain when there are subjects that are not liked, students are also often angry because things are trivial when in class it makes it difficult for students to concentrate in participating in teaching and learning activities. mild stress levels usually occur in each individual and last for several minutes or hours and do not cause disease or disorders unless they occur continuously (nurhayati, 2014). at this level of stress, individuals will feel calm when stress has ended. furthermore, at moderate academic stress levels, individuals tend to be easily emotional and unfocused. this can disrupt academic activities (australian psychology foundation, 2010). alvin stated that broadly academic stress is influenced by two factors namely internal factors and external factors. internal factors are pressures originating from within a person which include mindset, personality, and beliefs while external factors are pressure originating from outside the student such as solid learning, pressure for higher achievement, encouragement of social status, and the influence of parents' pressure in better academic achievement (sudarya.i.w, bagia. i.w, 2014). while those who oppose the application of fds believe that fds causes students to become stressed because of the many learning burdens (nurma fitria, 2017). this full day school program does tend to make students feel bored, and stressed. there needs to be new innovations that can make students excited about living it. these innovations really need the teacher's role so that their students feel at home in school. creating interesting and fun activities, so the fullday school program continues (n l l deck, 2017). conclusion the conclusion was that students were applying the fds system in junior high school. thereforenure s are expected to be used as an illustration for health services to prevent stress to students by providing health education / counseling on stressful factors and handling them and for educators are expended to avoid factors that can cause stress to students at school with new innovations at school. acknowledgment we would like to say thank you very much for the respondents that really the cooperative research and headmaster of badridduja junior high school and headmaster of al-masduqiyah junior high school that supports this research is very well. references abai , m t m, huda, a. y s d, i. n. (2017). strategy of principals in managing conflict responding to the negative impact of implementing a full day school. journal of education: 2017 theory, research and development, 2, 848–852. arifin, i. (2017). manajemen sistem long day school: studi etnografi pada sd anak saleh kota malang. 25–36. astuti, m. (2013). implementation of fullday school program as an effort to encourage social development of al-ya’lu superior kindergarten students in malang city. journal of educational policy and development, 1, 133–140. australian psychology foundation. (2010). anxiety depression scale. barseli, m., ifdil, i., & nikmarijal, n. (2017). konsep stres akademik siswa. 5(2005), 143–148. desmita. (2016). psychology of student development. bandung: rosda. hakim, s. n., & parameswari, a. (2015). comparative study of learning achievement of students in full-day elementary school class one program obtained from kindergarten full-day and regular programs. 363–367. indra, n. b., & haris, m. (2017). social sciences student learning outcomes between full day school and not full day school. progress in social sciences. humanities education and research, 118:74. muali, c., islam, s., el, m., & bali, i. (2018). free online learning based on rich internet applications ; the experimentation of critical thinking about student learning style free online learning based on rich internet applications ; the experimentation of critical thinking about student learning sty. n l l deck, i. u. r. (2017). activity innovation in instilling character values in elementary schools that implement fullday school programs. 2nd annual process, 188–194. nurhayati, i. (2014). application of “fun & full day school” learning system "to increase student jurnal ners http://e-journal.unair.ac.id/jners | 377 religiosity in sdit al islam kudus. journal of education and learning technology, 2, 231–244. nurma fitria, r. (2017). disiplin siswa dalam penerapan full day school. 61–75. paulus w, t, s., & w, c. k. (2014). maximizing your impact: impacting since young age. pt vision of grace indonesia. saudatul, a., & baharun, h. (2018). pendidikan full day school dalam perspektif epistemologi muhammad ‘abid al-jabiri. potensia j. kependidikan islam, 4(1), 1–22. subiantoro, r., atmadja, n. b., & natajaya, n. (2013). all day learning contribution, learning habits, achieving motivation against learning achievement of class ix students of albanna junior high school denpasar. indonesian education administration journal, 4. sudarya.i.w, bagia. i.w, s. i. w. (2014). analysis of factors affecting stress in students in compiling thesis. examination management bisma e-journal genesha university, 2. http://e-journal.unair.ac.id/jners | 101 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18974 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review of effectiveness of music therapy on depression in the elderly nur sayyid jalaluddin rummy, windarti rumaolat, trihartuty trihartuty faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: there are many non-pharmacological therapies in reducing symptoms of depression in older adult, one of which is music therapy. the aim of this article is to determine the effectiveness of the use of music therapy in reducing symptoms of depression in the elderly. methods: a systematic approach was performed in this review using the prisma approach and journal sources from several databases including scopus, sciencedirect, sage, ncbi, cinahl/ebsco in the last 6 years from 2014 to 2019. boolean operators were used within search process using and and or. the inclusion criteria are elderly aged ≥60 years with depression, either home or hospital treatment. exclusion criteria are additional physical illness such as diabetes mellitus, cva and other chronic diseases. literature review, editorial, critical synthesis, and the like also become an exclusion criteria in this review. results: overall, the review consists of 13 articles with seven articles using rct design, two quasi-experimental design, two preposttest design, and two exploratory design. in this review, several articles used an individual therapy and others a combination of music therapy with other activities such as singing, dancing and writing a lyric. average time spent for a music therapy in elderly with depression was given from two weeks to six months, which may have been effective in making an impact. every week had one or two sessions with a duration of30-60 minutes for every session. conclusion: music therapy is effective to reduce depression in the elderly. article history received: feb 27, 2020 accepted: april 1, 2020 keywords music therapy; depression; elderly contact nur sayyid jalaluddin rummy  nur.sayyid.jalaluddin-2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: rummy, n. s. j., rumaolat, w., & trihartity, t. (2020). a systematic review of effectiveness of music therapy on depression in the elderly. jurnal ners, special issues, 101-106. doi:http://dx.doi.org/10.20473/jn.v15i2.18974 introduction depression is a common psychiatric disorder with symptoms including low mood, low energy, poor concentration, loss of pleasure, poor self-care and low self-esteem (gold et al., 2019). depression and anxiety are disorders that often occur in older people. at age of 65 years old, the risk of getting depression increases three times if compared with the general population (aalbers et al., 2017). depression can also cause deterioration of cognitive function and may result in increased risk of dementia. depression is also a major cause of disability in the elderly and, if not treated immediately, will cause complex problems. long-term care providers will also aggravate this problem if this cannot be understood correctly (gold et al., 2019). depression is the most important problem in the elderly and often occurs in older people over 60 years of age (gök ugur, yaman aktaş, orak, saglambilen, & aydin avci, 2017). some reasons why the elderly often experience depression are disability, economic factors, loss of spouse, family and relatives (verrusio et al., 2014). the elderly who live in a care home have three times the risk of depression compared to the elderly who live at home (gök ugur et al., 2017). globally, based on the who figures, around 50 million people were living with dementia in 2017 and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. n. s. j. rummy et al. 102 | pissn: 1858-3598  eissn: 2502-5791 approximately 7% of the elderly (over 60 years) suffer from depression worldwide. this number is expected to reach 82 million by 2030 and 152 million in 2050(kemenkes ri, 2016). from 1990 to 2025, the elderly population in asia will increase from 50% of the world’s elderly to 58% (kalapala et al., 2017). geriatric citizens in indonesia reach 28.8 million or 11.34% in regard to the average life expectancy (uuh) of approximately 71 years. a health research association report of 2013 states that the prevalence of elderly aged 55-64 were depressed at 15.9%, the elderly aged 65-74 years at 23.2%, and the elderly aged over 75 years at 33.7%. this result shows an increase, especially in asia, america, and africa (foo et al., 2018), pharmacological treatment of depression in old age is often associated with adverse reactions and drug interactions due to polypharmacy and agerelated physiological changes (ibraheemsayied, ibrahim, ali abd el-fatah saraya, & rabea osman, 2019). therefore, a safer alternative for the treatment of depression in older adults should be sought. responding to the challenge posed by pharmacological treatment in old age, music intervention has been identified by researchers as an area of interest. music therapy is one of the complementary therapies that can have a variety of positive effects on users (gold et al., 2019). the use of music as a healing intervention is common in history (kendra d. ray & götell, 2018). this therapy has been used in particular specialisms such as psychiatry, neurology and cardiac care, as well as general surgery and geriatric care. music is a powerful stimulus that generates and modulates mood and emotion (petrovsky, cacchione, & george, 2015). the use of music therapy has changed over time and has gone through some innovations. the use of music therapy is also different or each region, such as in taiwan music therapy uses buddhist music (tai, wang, & yang, 2015) and in china it uses japanese music (wang, yu, & chang, 2017) it is also performed individually (ibraheemsayied et al., 2019) and also by groups (verrusio et al., 2014) and also combined with movement or singing (verrusio et al., 2014). music is often used to set the mood and emotions in daily life and also can affect the motivation, selfimage, and coping mechanisms around a difficult emotional state through some forms of music therapy. the therapist explicitly helps people processing feelings that have been generated by the total retrieved from databases = 1820 scopus = 132 articles sciencedirect = 345 articles ebsco/cinahl = 326 articles sage = 453 articles ncbi : 564 articles eligible for title review = 1325 articles eligible for abstract review = 73 records excluded as not related to the topic (n = 1252 articles) excluded due to inclusion criteria not met (n = 39 articles) eligible for full-text review =34 included = 13 articles excluded for lack of relevance based on title and abstract (n = 31 articles) duplicates removed = 365 articles figure 1. search strategy jurnal ners http://e-journal.unair.ac.id/jners | 103 music (aalbers et al., 2017). music affects the right hemisphere of the brain and, thus, leads to the secretion of dopamine, noradrenaline, encephalin and endorphin, which causes psycho-physiological responses through the limbic system, thereby reducing behavioral and psychological levels of depression (gök ugur et al., 2017). a study conducted by nadia in a nursing home in egypt with 42 patients suffering from moderate to severe depression showed that there is a decrease in the level of depression by session 12. this result is more effective than standard intervention of nursing home care (ibraheemsayied et al., 2019). in other study by sakamoto in india (mathew, sundar, subramaniam, & parmar, 2017), the merger between music therapy with other activities such as dancing and singing was also proven effective to decrease the level of depression in the elderly. several published studies have revealed the benefits of therapy in depression. one study revealed that six weeks of using music therapy can reduce agitation in the elderly (k. d. ray & mittelman, 2015). other studies also showed the same results, that the use of music for four weeks can reduce blood pressure in the elderly (tai et al., 2015). all of the studies showed positive results from the use of music therapy for the elderly, even with different times and ways. this systematic review is to identify research that used music therapy to reduce depression symptoms in the elderly. materials and methods the following review steps were performed in accordance with the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines for conducting a systematic review. a systematic search was first conducted using the following databases: scopus, science direct, sage, ncbi, cinahl/ebsco using search strategies described in figure 1. searches were conducted from december 10th, 2019. the search is restricted to publications from 2014 to 2019 in the scope of nursing, age, music therapy, and depression; the search is also be restricted to document type "article" in english. studies published in the english language from the past 6 years (from 2014 to 20019) were included. appropriate medical subject headings (mesh) were used along with text word searches and phrases. keywords with boolean operators that were searched in each database include (music therapy) or (music intervention) or (musical intervention) and (depression) or (depressive disorder) or (depressive symptoms) or (major depressive disorder) and (elderly) or (older adults) or (older people) or (aged). furthermore, where possible, in a given database, non-human studies were excluded. results results of systematic review of all 13 articles are attached to table 1. the most number of years of publication is 2019 with three articles and the most used design in this systematic review is rct. instrument to determine the level of depression in the elderly using mmse is five articles and the rest of the articles used csd, gds-sf instruments, and hamd. kind of music therapy there are various kinds of music therapy. the majority of researchers present music in accordance with participants’ wishes, on the other hand, some researchers also prepared a type of music to be the choice of the elderly, such as chinese music, buddhist spiritual music, active and passive music (tai et al., 2015) (cooke, moyle, shum, harrison, & murfield, 2010). some types of music therapy also use religious music as an intervention and also combine with some other interventions such as writing lyrics (kalapala et al., 2017), with therapists or independently (karmonik et al., 2016), listening passively and actively (clapping, singing, dancing) (liu, niu, feng, & liu, 2014; mathew et al., 2017; petrovsky et al., 2015; kendra d. ray & götell, 2018). duration of therapy average time spent on a music therapy in elderly with depression is as many as 20-32 sessions which have been effective in having an impact. the number of sessions each week 1-2x accounted for the majority of the sessions. duration of therapy gave an average of more than three weeks to one year (tai et al., 2015). effectiveness of music therapy on depression using music therapy in elderly with depression showed positive results when showing significant mental changes. thirteen articles showed change in table 1. general characteristics of selected studies (n=13) category n % year of publication 2014 2 15.38 2015 2 15.38 2016 2 15.38 2017 2 15.38 2018 2 15.38 2019 3 20.00 type of study rct 7 53.84 pretest and posttest study design 2 15.38 exploratory design 2 15.38 quasi-experiment 2 15.38 instrument mmse 5 38.46 gds-sf 3 23.07 hamd 1 7.69 csd 1 7.69 mmse and gds 3 23.07 duration of intervention < 6 months 10 76.92 ≥6 months 3 23.07 n. s. j. rummy et al. 104 | pissn: 1858-3598  eissn: 2502-5791 symptoms of depression in the elderly. the use of music therapy between short duration and long duration has a different change. this is proven in evidence in the use of music therapy with a long duration (> 1 year) having insignificant changes as opposed to the use of music therapy with short duration (3-5 weeks). discussion the purpose of this systematic review is to expose research that used music therapy to reduce depression symptoms in the elderly. music therapy uses music in a professional manner and the elements act as an intervention in a medical environment for individuals, groups, families, or people who strive to optimize their quality of life, improve their cognitive, social-welfare, communicative, emotional, intellectual and spiritual health (aalbers et al., 2017). in addition, music therapy also has a positive impact on improving mood, overcoming sleep disorders and can reduce blood pressure in the elderly. the method of using music therapy is different in each country, such as in taiwan religious music from buddhism is used, in egypt it uses murathal (tai et al., 2015) and several other methods combining with singing, writing song lyrics, improvising songs and dancing together (ibraheemsayied et al., 2019). the use of music therapy for both individuals and groups is also found in certain regions (verrusio et al., 2014). although using different methods, the use of music therapy had a positive impact on the elderly at the end of the studies, although some research results show results that are not very significant. the duration of music therapy varies greatly from the shortest ay two weeks and the longest of six months, giving 30-45minute sessions two or three times every week. the advantage of using music therapy is the low cost and it does not cause side effects. the longest research conducted by kendra lasted four weeks, giving music therapy for the first two weeks and then for the next two weeks giving music, singing and dancing activities led by practitioners. the use of music therapy for four weeks showed a reduction in signs of depression and an improvement in the quality of life in the elderly who lived in a nursing home (kendra d. ray & götell, 2018). hacer used a randomized controlled trial design study of a population of 64 men and women who were treated at home divided into two treatment groups and control. this rct study design, the endpoints of which were evaluated under stringent conditions, assessed the impact of music therapy on patients suffering from mild depression, moderate to severe. the results after giving an intervention showed significant differences between the two groups regarding depression. significant difference was observed between the two groups in change between the treatment group and the control group which showed progress in reducing levels of depression scores in the treatment group, while the average scores remained constant in the control group (gök ugur et al., 2017). one interesting study is that by moon fai chan, a randomized controlled trial with participants who listened to music of their choice as long as 30 minutes per week, for four weeks. this study was in elderly women aged 42 with depression and the therapy was for four weeks. the result of the experimental group shoed there was a statistically significant reduction in geriatric depression score and quality of sleep in week 4. in the control group, there was no statistically significant reduction in depression and sleep quality improvement for four weeks. however, for all outcome measures, no significant differences were found between groups for four weeks. the use of music therapy may stimulate and affect someone’s mood (verrusio et al., 2014). one theory that tries to explain how music can affect the human psychological response is the theory of music, mood and movement (mmm). this theory revealed that music produces a psychological response of the mood and then leads to better health outcomes (murrock & higgins, 2009 p. 2252). musical elements such as melody, tone and harmony can affect the emotional response for those who listen (murrock & higgins, 2009). when the elements pass through the auditory cortex of the brain, music processing occurs in the limbic system of the brain to obtain emotion (tramo, 2001). according to jourdain (1997), the music reminds us of the past experience of the emotions etched in them; this changes the emotional state of the listener. this shows that, when the right music is played. it has the potential to change the emotional state of the listener, thereby achieving therapeutic results such as reducing depressive symptoms. based on an analysis of 13 journals, the authors reported that music therapy has a beneficial effect on these symptoms. another study focused on the psychological and behavioral disorders and evaluated the effect of music therapy on behavior and depressive symptoms (petrovsky et al., 2015). the use of music therapy is effective and does not cause side effects in the elderly such as the use of sedatives (liu et al., 2014). using music therapy as prescribed can reduce some symptoms, such as depression, and can increase the life expectancy of the elderly (mathew et al., 2017). the use of music therapy should be recommended for health workers, especially nurses or healthcare workers with the elderly (karmonik et al., 2016). limitation limitation in this review is the lack of specific types of music therapy that have an impact on depression, cognitive, or social, or psychosocial. some studies also illustrate the types of respondents were less taken. design of this article also differs because lack of the number of the articles when searching. clinical implication jurnal ners http://e-journal.unair.ac.id/jners | 105 the scientific studies that have been done to showed that the use of intervention in the form of music therapy has an effect on the elderly with depression, behavioral, emotional, and cognitive. the results of this study are very useful in the field of nursing as this can help nurses to improve condition of elderly while providing a program either interpersonal, or making elderly and family independent. conclusion the use of music therapy can be applied practically and easily, especially because music can be combined with various activities, such as singing, clapping, dancing and others. nurses and caregivers may be able to use music interventions to prevent or eliminate depression. healthcare providers and nurses must remain knowledgeable about music and other alternative therapies because music therapy is more affordable and has little or no negative reaction compared by drugs. conflict of interest the author declares that there is no conflict of interest in this study. acknowledgement the author of this study would like to thank the faculty of nursing and all of my friends who contributed to present this study. references aalbers, s., re, f., spreen, m., jcf, k., ac, v., maratos, a., … xj, c. (2017). music therapy for depression ( review ) summary of findings for the main comparison. cochrane database of systematic reviews, (11). https://doi.org/10.1002/14651858.cd004517. pub3.www.cochranelibrary.com cooke, m., moyle, w., shum, d., harrison, s., & murfield, j. (2010). controlled trial exploring the effect of music on quality of life and depression in older people with. 765–776. https://doi.org/10.1177/1359105310368188 foo, s. q., tam, w. w., ho, c. s., tran, b. x., nguyen, l. h., mcintyre, r. s., & ho, r. c. (2018). prevalence of depression among migrants: a systematic review and meta-analysis. international journal of environmental research and public health, 15(9), 55–64. https://doi.org/10.3390/ijerph15091986 gök ugur, h., yaman aktaş, y., orak, o. s., saglambilen, o., & aydin avci, i̇. (2017). the effect of music therapy on depression and physiological parameters in elderly people living in a turkish nursing home: a randomized-controlled trial. aging and mental health, 21(12), 1280–1286. https://doi.org/10.1080/13607863.2016.12223 48 gold, c., eickholt, j., assmus, j., stige, b., wake, j. d., baker, f. a., … geretsegger, m. (2019). music interventions for dementia and depression in elderly care (middel): protocol and statistical analysis plan for a multinational clusterrandomised trial. bmj open, 9(3), 1–14. https://doi.org/10.1136/bmjopen-2018023436 ibraheemsayied, n., ibrahim, h., ali abd el-fatah saraya, o., & rabea osman, s. (2019). effectiveness of music therapy on the depression levels among elderly at assiut geriatric clubs. 8(2), 58–65. https://doi.org/10.9790/19590802055865 kalapala, g. r., zechariah, b. r., babu, p., thufail, ., sailu, ., & srujan, . (2017). a study on the effectiveness of music therapy on depression among elderly people at selected old age home: an epidemiological study on public health perspective in hyderabad. research in pharmacy and health sciences, 3(3), 344–349. https://doi.org/10.32463/rphs.2017.v03i03.17 karmonik, c., brandt, a., anderson, j. r., brooks, f., lytle, j., silverman, e., & frazier, j. t. (2016). music listening modulates functional connectivity and information flow in the human brain. brain connectivity, 6(8), 632–641. https://doi.org/10.1089/brain.2016.0428 kemenkes ri. (2016). lansia yang sehat, lansia yang jauh dari demensia. liu, x., niu, x., feng, q., & liu, y. (2014). effects of fiveelement music therapy on elderly people with seasonal affective disorder in a chinese nursing home. journal of traditional chinese medicine, 34(2), 159–161. https://doi.org/10.1016/s02546272(14)60071-6 mathew, d., sundar, s., subramaniam, e., & parmar, p. n. (2017). music therapy as group singing improves geriatric depression scale score and loneliness in institutionalized geriatric adults with mild depression: a randomized controlled study. international journal of educational and psychological researches, 3(1), 6. https://doi.org/10.4103/2395-2296.198415 petrovsky, d., cacchione, p. z., & george, m. (2015). review of the effect of music interventions on symptoms of anxiety and depression in older adults with mild dementia. international psychogeriatrics, 27(10), 1661–1670. https://doi.org/10.1017/s1041610215000393 ray, k. d., & mittelman, m. s. (2015). music therapy: a nonpharmacological approach to the care of agitation and depressive symptoms for nursing home residents with dementia. dementia. https://doi.org/10.1177/1471301215613779 ray, kendra d., & götell, e. (2018). the use of music and music therapy in ameliorating depression symptoms and improving well-being in nursing home residents with dementia. frontiers in medicine, 5(oct), 1–6. https://doi.org/10.3389/fmed.2018.00287 tai, s. y., wang, l. c., & yang, y. h. (2015). effect of music intervention on the cognitive and n. s. j. rummy et al. 106 | pissn: 1858-3598  eissn: 2502-5791 depression status of senior apartment residents in taiwan. neuropsychiatric disease and treatment, 11, 1449–1454. https://doi.org/10.2147/ndt.s82572 verrusio, w., andreozzi, p., marigliano, b., renzi, a., gianturco, v., pecci, m. t., … gueli, n. (2014). exercise training and music therapy in elderly with depressive syndrome: a pilot study. complementary therapies in medicine, 22(4), 614–620. https://doi.org/10.1016/j.ctim.2014.05.012 wang, s. c., yu, c. l., & chang, s. h. (2017). effect of music care on depression and behavioral problems in elderly people with dementia in taiwan: a quasi-experimental, longitudinal study. aging and mental health, 21(2), 156–162. https://doi.org/10.1080/13607863.2015.10936 02 ners vol 10 no 2 okt 2015.indd 195 pengembangan model perilaku ibu dalam pencegahan gizi buruk balita (development of mother’s behavior model in severe malnutrition prevention for children under five years old) ika nur fauziah*, lilik djuari**, yuni sufyanti arief* *fakultas keperawatan, universitas airlangga, kampus c mulyorejo surabaya telp/fax: (031) 5913257 **fakultas kedokteran, universitas airlangga, kampus a surabaya email:fauziahikaa@gmail.com abstrak pendahuluan: gizi buruk pada anak masih merupakan masalah kesehatan utama di dunia, termasuk di indonesia. menurut organisasi kesehatan dunia (who) afrika wilayah dan data wilayah asia tenggara, kekurangan gizi dialami kurang lebih 20 juta anak balita dan merupakan faktor utama penyebab kematian pada sepertiga anak di seluruh dunia. tujuan dari penelitian ini adalah untuk menganalisis dan mengembangkan perilaku model ibu dalam pencegahan gizi buruk bagi balita berbasis teori integrasi health belief model dan health promotion model. metode: jenis penelitian ini adalah observasional dengan desain cross sectional. populasi terjangkau yaitu balita dan kader yang mengunjungi posyandu di april 2015 sebanyak 136 dan 20 orang. penelitian ini menggunakan proporsional random sampling, dengan jumlah sampel 65 ibu; 10 anak di bawah lima ibu dan 10 kader posyandu balita untuk fgd. variabel dalam penelitian ini adalah faktor personal, behavioral specific cognitions and affect, persepsi individu, komitmen, isyarat untuk bertindak dan perilaku ibu dalam pencegahan gizi buruk. data dikumpulkan dengan menggunakan kuesioner dan food recall 24 jam, dianalisis dengan pls. hasil: model perilaku ibu dalam pencegahan gizi buruk bagi balita dapat dibentuk oleh komitmen ibu, perilaku kognisi tertentu dan faktor pribadi (pendapatan dan motivasi). diskusi: perawat sebagai penyedia layanan kesehatan masyarakat memiliki peran dalam meningkatkan derajat kesehatan masyarakat melalui promosi kesehatan. komitmen yang tinggi untuk berperilaku sesuai dengan rencana, meningkatkan kemampuan individu dalam memberikan promosi kesehatan. kata kunci: model, perilaku ibu, pencegahan gizi buruk, health belief model, health promotion model abstract introduction: child malnutrition still a major health problem in the world, including in indonesia. according to world health organization (who) african region and south-east asia region data, malnutrition affects nearly 20 million under five children and the main factors that affects about a third of child mortality worldwide. the aims of this study was to analyze and develop mother’s behavior model in severe malnutrition prevention for under five children based on integration health belief model and health promotion model. methods: type of this research was an explanatory observational with cross sectional design. affordable population namely children under five’s years and cadres who visited posyandu in april 2015 as many as 136 and 20 peoples. this study used proportional random sampling, with sample size 65 mothers; 10 children under five’s mothers and 10 posyandu balita’s cadres for fgd. variables were personal factors, behavioral specific cognitions and affect, individual perceptions, commitment, cues to action and mother’s behavior in severe malnutrition prevention. data were collected by using questionnaires and food recall 24 hours, analyzed by smart pls. results: mother’s behavior model in severe malnutrition prevention for under five children can be formed by mother’s commitment, behavioral specific cognition and affect and personal factors (income and motivation). discussions: nurse as a community health care providers have a role in improving community health status through health promotion. high commitment to behave in certain ways according to plan, improving the ability of individuals to maintain health promotion behavior all the time keywords: models, mother’s behavior, severe malnutrition prevention, health belief model, health promotion model pendahuluan malnutrisi pada anak masih menjadi masalah kesehatan utama di dunia, termasuk indonesia (rosari, rini, & masrul, 2013). menurut data world health organization (who) wilayah afrika dan kawasan asia tenggara, malnutrisi memengaruhi hampir 20 juta anak usia balita dan merupakan faktor utama yang memengaruhi sekitar sepertiga dari hampir 8 juta kematian anak di bawah usia 5 tahun di seluruh dunia. prevalensi balita gizi buruk merupakan salah satu indikator 196 jurnal ners vol. 10 no. 2 oktober 2015: 195–207 millenium development goals (mdgs) yang harus dicapai suatu kabupaten/kota pada tahun 2015, yaitu terjadinya penurunan prevalensi balita gizi buruk menjadi 3,6% atau gizi kurang pada balita menjadi 15,5% (bappenas, 2010). berdasarkan studi pendahuluan yang dilakukan di desa ngringin, salah satu desa di kecamatan lengkong kabupaten nganjuk, angka kejadian gizi buruk meningkat dalam kurun waktu tiga bulan terakhir, yaitu bulan februari 3,31%, bulan maret 3,70% dan bulan april 2015 sebesar 3,68%. kasus gizi kurang pada bulan februari 12,58%, bulan maret 8,15% dan bulan april 2015 sebesar 14,71%. sementara itu angka kunjungan posyandu pada bulan februari sebesar 75,50%; bulan maret 65,22% dan bulan april 2015 sebesar 68,69% (data puskesmas, 2015). menurut petugas gizi puskesmas (2015), salah satu faktor penyebab masalah gizi buruk tersebut adalah masih rendahnya pengetahuan ibu tentang gizi buruk. hasil wawancara yang dilakukan terhadap sepuluh orang ibu yang memiliki anak usia balita di desa ngringin kecamatan lengkong dengan menggunakan instrumen modifikasi dari angkat (2011), diperoleh data bahwa 50% ibu memiliki pengetahuan yang kurang baik mengenai gizi buruk, 30% ibu tidak memberikan asi eksklusif, dan 60% ibu tidak memberikan makanan yang beranekaragam kepada balita mereka. pemerintah kabupaten nganjuk melalui dinas kesehatan telah mencanangkan gerakan untuk mengatasi masalah gizi buruk melalui program pengentasan gizi buruk (gentasibu) seja k t a hu n 20 09. mesk ipu n prog ra m gentasibu telah berhasil menurunkan jumlah penderita gizi buruk, namun pengembangan perilaku ibu dalam upaya pencegahan gizi buruk belum pernah dilakukan. pencegahan penting dilakukan agar kasus gizi buruk tidak bertambah dan balita dengan kasus gizi kurang tidak berlanjut menjadi kasus gizi buruk. namun sampai saat ini model perilaku ibu dalam upaya pencegahan gizi buruk balita berbasis integrasi health belief model dan health promotion model belum dapat dijelaskan. banyak faktor yang memengar uhi terjadinya gizi buruk, diantaranya status sosial ekonomi, ketidaktahuan ibu tentang pemberian gizi yang baik untuk anak, dan berat badan lahir rendah (bblr) (kusriadi, 2010). sumber lain menyebutkan bahwa asupan makanan keluarga, faktor infeksi, dan pendidikan ibu menjadi penyebab kasus gizi buruk (razak, gunawan, & budiningsari, 2011). kasus gizi buruk apabila tidak dicegah d an segera diat asi a kan menyebabkan dampak yang buruk bagi balita. antara lain kelainan pada organ-organ tubuh, gangguan perkembangan dan kecerdasan, gangguan sistem endokrin hingga terjadinya kematian (pudjiadi, 2005 dalam sulistiyawati 2011). sebagai sala h sat u upaya u nt u k mengevaluasi perilaku ibu dalam melakukan pencegahan gizi bu r u k adalah dengan menggunakan teori health belief model dan health promotion model. health belief model memiliki empat konstruksi utama yaitu persepsi kerentanan yang dirasakan ( perceived susceptibility), keseriusan yang dirasakan ( perceived seriousness), manfaat yang didapatkan ( perceived benefits), dan hambatan yang dihadapi ( perceived barriers). sementara it u persepsi yang dirasakan individu dipengaruhi oleh modifying factors antara lain usia, jenis kelamin, ras/suku, motivasi, kepribadian, sosial ekonomi, dan tingkat pendidikan (jones & bartlett, 2010). perilaku/tindakan seseorang untuk mencegah atau mengobati penyakit juga dipengaruhi oleh petunjuk/pendorong untuk bertindak (cues to action) antara lain meliputi penyakit dari anggota keluarga (illness of a family member), laporan media (media reports) (graham, 2002), kampanye media massa, saran dari orang lain, dan nasehat dari petugas kesehatan (ali, 2002). s e d a n g k a n d a l a m t e o r i he a l t h promotion model, perilaku kesehatan individu dapat timbul dan diper tahankan karena adanya komitmen untuk berperilaku, bukan karena adanya rasa takut akan ancaman suatu penyakit. komitmen individu dipengaruhi oleh behavioral specific cognitions and affect yang antara lain meliputi perceived benefits, perceived barriers, perceived self-efficacy, 197 pengembangan model perilaku ibu (ika nur fauziah, dkk.) dan interpersonal inf luence. sementara itu behavioral specific cognitions and affect dipengaruhi oleh perilaku individu terdahulu dan faktor personal (pender, murdaugh & parsons, 2002). bahan dan metode metode penelitian yang digunakan adalah eksplanatif observasional dengan pendekat an cross sectional. penelitian dilaksanakan di desa ngringin kecamatan lengkong kabupaten nganjuk selama bulan juni 2015. populasi adalah ibu yang memiliki anak usia balita (1-5 tahun) yang berkunjung ke posyandu balita, desa ngringin, kecamatan lengkong pada bulan april 2015 sejumlah 136 orang serta seluruh kader posyandu balita sebanyak 20 orang. teknik pengambilan sampel menggunakan proportional random sampling, dengan besar sampel 65 orang ibu balita dan 10 kader berdasarkan kriteria inklusi. kriteria inklusi meliputi: 1) warga tetap di desa ngringin; 2) tinggal satu rumah dengan anak; 3) mengasuh anak secara mandiri; 4) bisa membaca dan menulis; serta 5) bersedia menjadi responden penelitian. sementara kriteria eksklusi yaitu ibu yang memiliki balita dengan penyakit penyulit. variabel penelitian meliputi faktor personal (usia, suku, pendidikan, penghasilan d a n m o t i v a s i ) , b e h a v i o r a l s p e c i f i c cognitions and affect ( perceived benefits, perceived barriers, perceived self-efficacy, dan interpersonal inf luence), individual perceptions ( perceived susceptibility dan perceived seriousness), komitmen, cues to action serta perilaku ibu dalam pencegahan gizi buruk balita. data dikumpulkan dengan kuesioner dan modif ikasi food recall 24 hours. kuesioner telah diuji validitas dan reliabilitasnya dengan uji cronbach alpha. data yang terkumpul kemudian dianalisis dengan smartpls. hasil b e r d a s a r k a n u j i m o d e l y a n g dilakukan, menunjukkan hasil penelitian ber upa rekomendasi model perilaku ibu dalam pencegahan gizi buruk pada balita. rekomendasi model tersebut tersusun atas faktor personal ibu (x1) yang terdiri dari dua indikator yaitu penghasilan dan motivasi ibu; faktor yang menyusun yaitu behavioral specific cognition and affect yang terdiri dari empat indikator perceived benef its, perceived barriers, perceived self-efficacy, tabel 1. nilai t-statistic analisis bootstrapping perilaku ibu dalam pencegahan gizi buruk balita di desa ngringin, kecamatan lengkong, juni 2015 indikator original sample t-statistic x1.4 (penghasilan) <x1 (personal) 0,833 8,425 x1.5 (motivasi) <x1 (personal) 0,659 3,484 x2.1 (p. benefi t) <x2 (behavioral specifi c cognition and affect) 0,649 5,608 x2.2 (p. barrier) <x2 (behavioral specifi c cognition and affect) 0,767 7,349 x2.3 (p. self effi cacy) <x2 (behavioral specifi c cognition and affect) 0,787 6,838 x2.4 (dukungan) <x2 (behavioral specifi c cognition and affect) 0,621 3,924 x3.1 (p. susceptibility) <x3 (individual perceptions) 0,892 22,042 x3.2 (p. seriousness) <x3 (individual perceptions) 0,885 20,353 x4 (komitmen) <x4 (komitmen) 1,000 x5 (cues to action) <x5 (cues to action) 1,000 y1 (asi) <y (perilaku) 0,909 31,669 y2 (mpasi) <y (perilaku) 0,830 12,497 y3 (aneka makanan) <y (perilaku) 0,796 10,778 198 jurnal ners vol. 10 no. 2 oktober 2015: 195–207 tabel 2. nilai path coeffi cients indikator original sample t-statistic keterangan x1 (personal) <x2 (behavioral spesifi c cognition and affect) 0,531 4,925 signifi kan x 1 ( p e r s o n a l ) < x 3 ( i n d i v i d u a l perceptions) 0,424 4,399 signifi kan x1 (personal) <y (perilaku) -0,092 0,597 tidak signifi kan x2 (behavioral specific cognition and affect) <x4 (komitmen) 0,443 4,222 signifi kan x2 (behavioral specific cognition and affect) <y (perilaku) -0,129 0,755 tidak signifi kan x 3 ( i n d i v i d u a l p e rc e p t i o n s ) < y (perilaku) 0,215 1,552 tidak signifi kan x4 (komitmen) <y (perilaku) 0,539 2,509 signifi kan x5 (cues to action) <y (perilaku) 0,119 0,516 tidak signifi kan gambar 1. hasil uji model. x4 (komitmen) x1 (personal) x1.4 (penghasilan) x1.5 (motivasi) y (perilaku) y1 (asi) y2 (mp-asi) y3 (aneka makanan) x2 (behavioral spesific cognition and affect) x2.1 (p. benefit) x2.2 (p. barrier) x2.3 (self-efficacy) x2.4 (dukungan) x3 (individual perceptions) x3.1 (p.susceptibility) x3.2 (p.seriousness) dan dukungan sosial keluarga; faktor ketiga yang menyusun perilaku ibu yaitu komitmen. sementara itu individual perception memiliki hubungan signifikan dengan faktor personal ibu tetapi tidak signifikan dalam menyusun perilaku ibu. berdasarkan gambar 1 tersebut di atas, dapat diketahui bahwa perilaku ibu dalam pencegahan gizi buruk dapat dibentuk oleh komitmen ibu, behavioral specific cognition and affect, dan faktor personal ibu. pembahasan hubungan antara faktor personal dengan behavioral specific cognitions and affect hasil uji statistik dengan menggunakan smartpls menunjukkan bahwa ada hubungan ya ng posit if sig n if i k a n a nt a r a fa k tor 199 pengembangan model perilaku ibu (ika nur fauziah, dkk.) personal (penghasilan dan motivasi) dengan behavioral specific cognitions and affect yang ditandai dengan path coeff. 0,531 dan nilai t-statistik 4,925. pada tabel 1, diketahui bahwa penghasilan dan motivasi merupakan indikator yang mampu menyusun faktor personal ibu dengan nilai loading factor 0,833 dan 0,659 (> 0,5) serta nilai t-statistik 8,425 dan 3,484 (> 1,96). sementara itu behavioral specific cognitions and affect dapat dibentuk dari empat indikator yaitu perceived benefit, perceived barrier, perceived self efficacy dan dukungan sosial keluarga dengan masingmasing nilai loading factor <0,5 (tabel 1). penghasilan responden didapatkan 69,2% responden memiliki penghasilan kurang dari sama dengan satu juta rupiah per bulan. sementara itu 35,4% diantaranya memiliki perceived benefit yang positif; 41,5% memiliki persepsi terhadap adanya hambatan (perceived barrier); 35,4% memiliki perceived self efficacy lemah dan 38,5% memiliki dukungan sosial keluarga yang kuat. who (1999) dalam cahyo (2004) mengungkapkan bahwa karakteristik penghasilan tidak memengaruhi seseorang dalam menerima suatu kepercayaan yang akan mengubah persepsi seseorang karena kepercayaan lebih ditentukan pada pengalaman hidup, observasi sehari-hari dan pengaruh orang sekitarnya. hal ini sesuai dengan hasil penelitian, di mana responden dengan penghasilan yang kurang sebagian besar memiliki perceived benefit yang positif, perceived barrier yang tinggi, perceived self efficacy lemah dan dukungan sosial keluarga yang kuat. hasil penelitian menunjukkan bahwa 60% responden memiliki perceived benefit positif. sementara itu 38,8% responden dengan perceived benefit positif memiliki motivasi yang kuat. motivasi merupakan keinginan kuat dalam diri individu untuk melakukan sesuatu dan mencapai tujuan tertentu. motivasi dipengaruhi oleh keinginan dan harapan dari individu (handoko, 2001). contento et al. (1993) dalam has (2012), menyatakan bahwa semakin tinggi motivasi ibu akan memunculkan perceived benefit yang semakin positif. hal ini sesuai dengan hasil penelitian, di mana responden dengan motivasi kuat paling banyak memiliki perceived benefit yang positif. sebaliknya, responden dengan motivasi lemah paling banyak memiliki perceived benefit yang negatif. hasil diskusi kelompok menunjukkan bahwa ibu sudah memiliki persepsi yang baik mengenai manfaat melakukan tindakan pencegahan gizi buruk pada balita. minimal ibu sud a h me m a ha m i ba hwa de nga n melakukan pencegahan gizi bur uk anak anak menjadi sehat, tidak mudah sakit, tumbuh kembang anak normal, anak menjadi cerdas dan perkembangan anak optimal. berdasarkan hal tersebut, diperlukan upaya untuk mempertahankan motivasi ibu dalam melakukan tindakan pencegahan gizi buruk pada balita, sehingga kemanfaatan yang dipersepsikan ibu semakin positif. salah satu upaya yang dapat dilakukan adalah memberikan reinforcement melalui pendidikan kesehatan, baik oleh kader posyandu balita maupun bidan desa. hasil penelitian menunjukkan bahwa 56,9% responden mempersepsikan adanya h a mbat a n ( p e r c e i ve d b a r r i e r) d a la m melakukan tindakan pencegahan gizi buruk pada balita. sedangkan 36,9% responden yang mempersepsikan adanya hambatan mempunyai motivasi yang lemah. menurut ajzen (1991), semakin kuat motivasi seseorang untuk melakukan sesuatu, maka persepsi terhadap adanya hambatan untuk melakukan hal tersebut akan semakin rendah. saat mempersepsikan adanya hambatan, responden dengan motivasi kuat akan melakukan berbagai cara untuk mengatasi hambatan-hambatan tersebut. hasil diskusi kelompok menunjukkan bahwa ibu berusaha untuk mencari informasi dari media elektronik dan memanfaatkan pengalaman ibu balita lain untuk mencari solusi dari hambatan yang mereka hadapi dalam melak u kan pencegahan gizi buruk balita. berdasarkan hasil penelitian, 52,3% responden memiliki perceived self efficacy yang kuat. sedangkan 38,5% responden dengan perceived self efficacy yang kuat memiliki motivasi yang kuat pula. menurut deci & ryan (2008), motivasi merupakan determinan penting bagi individu untuk dapat menjalankan perannya dengan baik. individu yang memiliki 200 jurnal ners vol. 10 no. 2 oktober 2015: 195–207 motivasi kuat cenderung memiliki self efficacy yang kuat, bertanggung jawab dalam perannya dan lebih aktif secara sosial. motivasi yang kuat membuat individu mengesampingkan hambatan dan berusaha menjalankan perannya secara optimal. dengan demikian, semakin kuat motivasi ibu untuk melakukan tindakan pencegahan gizi buruk pada balita maka akan berdampak pada perceived self efficacy yang semakin kuat pula. dukungan sosial keluarga diketahui 61,5% responden memiliki dukungan sosial keluarga yang k uat. sedangkan 41,5% responden dengan dukungan sosial yang kuat dari keluarga memiliki motivasi yang kuat pula. menurut friedman (2010), dukungan keluarga merupakan salah satu faktor yang memengar uhi perilaku seseorang dalam membuat keputusan dengan lebih tepat. dengan adanya dukungan keluarga mendorong kemauan dan kemampuan untuk berperilaku. hal ini sejalan dengan hasil penelitian bahwa dukungan keluarga yang baik memberikan dorongan /motivasi yang baik pula bagi responden d ala m mela k u ka n t i nd a ka n pencegahan gizi buruk pada balita. hubungan antara faktor personal dengan individual perceptions faktor personal ( penghasilan dan motivasi) dengan individual perceptions ( perceived susceptibilit y dan perceived ser iou sne ss) mem ili k i hubu nga n ya ng signifikan yang ditandai dengan nilai path coeff. = 0,424 dan nilai t-statistik 4,399 (tabel 10). hasil positif signifikan menunjukkan bahwa faktor personal (penghasilan dan motivasi) yang meningkat akan meningkatkan individual perceptions secara signifikan. berdasarkan data diketahui bahwa 69,2% responden memiliki penghasilan kurang dari satu juta rupiah dengan perceived susceptibility baik sebesar 36,9% dan perceived seriousness baik sebesar 33,8%. menurut wigati (2007), penghasilan yang kurang belum tentu dapat memperburuk persepsi kerentanan ( perceived susceptibility) karena seseorang yang telah merasa rentan terhadap sesuatu permasalahan penyakit akan berusaha untuk mengoptimalkan fasilitas yang ada untuk mendapatkan pengobatan. hal ini sejalan dengan hasil penelitian bahwa responden dengan penghasilan yang kurang sebagian besar memiliki individual perceptions yang baik. sedangkan untuk indikator motivasi, dapat diketahui bahwa responden terbanyak memili k i motivasi k uat dan perceived susceptibility dan perceived seriousness baik sebesar 36,9%. menurut becker dalam morton, et al. (1995) menyatakan bahwa persepsi merupakan proses pengamatan seseorang yang berasal dari komponen kognisi yang dipengaruhi oleh faktor pengalaman, proses belajar, wawasan, pengetahuan, pendidikan dan keadaan sosial budaya setempat. pada pr insipnya persepsi dan motivasi tidak bisa dipisahkan karena keduanya saling memengaruhi. persepsi membentuk pandangan seseorang terhadap orang lain, dunia dan segala isinya. pada gilirannya, pandangan personal ini memotivasi seseorang untuk berpendirian dan bertindak tertentu. perbedaan persepsi individu dengan yang lainnya antara lain ditentukan oleh pengalaman, motivasi, dan keadaan (azwar, 2000). hal ini sejalan dengan hasil penelitian bahwa responden dengan individual perceptions yang baik sebagian besar memiliki motivasi yang kuat. b e r d a s a r k a n h a s i l f g d y a n g dilakukan pada kader posyandu balita dapat diketahui bahwa kader posyandu balita sudah melakukan pendidikan kesehatan dan memberikan motivasi kepada ibu balita mengenai pemberian asi eksklusif dan mpasi. tentunya dengan pemberian motivasi dan pendidikan kesehatan pada ibu diharapkan dapat meningkatkan persepsi dan pemahaman ibu mengenai pencegahan gizi buruk pada balita. sehingga rekomendasi yang perlu dilakukan yaitu memberikan reinforcement bagi kader mengenai pencegahan gizi buruk melalui pendidikan kesehatan sebagai bekal dalam memberikan pendidikan kesehatan pada ibu balita. hubungan antara faktor personal dengan perilaku ibu penghasilan seseorang mer upakan salah satu hal yang berpengaruh terhadap 201 pengembangan model perilaku ibu (ika nur fauziah, dkk.) pembentukan perilaku (azwar, 2000). menurut pratiwi (2008) dalam sholihah (2014), tingkat penghasilan dapat memengaruhi seseorang d alam pemeli ha r a a n kesehat a n ka rena seseorang dengan pendapatan yang tinggi dapat melancarkan kegiatan pemeliharaan kesehat an. hal ini dit u nju k kan bahwa responden dengan pendapatan yang tinggi memiliki perilaku yang baik. sedangkan untuk indikator motivasi, dapat diketahui bahwa proporsi responden terbanyak memiliki motivasi kuat dengan perilaku baik sebesar 32,3%. menurut elder dalam notoatmodjo (2010), untuk berperilaku sehat diperlukan tiga hal yaitu pengetahuan yang tepat, motivasi dan keterampilan berperilaku sehat. faktor lingkungan pun dapat memengar uhi motivasi seseorang untuk berperilaku hidup sehat jika lingkungan keluarga tidak mendukung perilaku tersebut. ha sil penelit ia n pa d a ga mba r 1 menunjukkan bahwa faktor personal memiliki hubungan dengan perilaku ibu namun bukan hubungan secara langsung. faktor personal secara tidak langsung berhubungan dengan perilaku ibu akan tetapi melalui variabel moderator/ntervening yaitu behavioral specific cognition and affect ( perceived benef it, perceived barrier, perceived self efficacy dan dukungan sosial keluarga) dan komitmen ibu. health belief model menjelaskan dan memprediksikan kemungkinan terjadinya per ubahan per ilak u yang dihubu ngkan dengan pola keyakinan (belief ) atau perasaan ( perceived ) tertentu. perubahan perilaku terjadi apabila individu merasa kesehatannya terancam, adanya perasaan individu tentang kerentanannya dan keseriusan penyakit, adanya perasaan tentang manfaat dan hambatan dalam perubahan perilaku serta adanya petunjuk, edukasi, gejala atau media informasi yang dapat memengaruhi seseorang tentang bahaya penyakit sehingga merasa perlu mengambil tindakan (jones & bartlett, 2010). pe r i la k u ibu d ala m p e ncega h a n gizi buruk balita tidak dipengaruhi secara langsung oleh penghasilan dan motivasi ibu akan tetapi dipengaruhi melalui faktor lain seperti perasaan terancam akan kesehatan balita mereka, persepsi manfaat yang diperoleh dan hambatan yang dihadapi, persepsi akan kemampuan diri dan dukungan dari keluarga. berdasarkan hasil fgd ibu balita, ibu telah memiliki persepsi yang positif mengenai manfaat melakukan pencegahan gizi buruk akan tetapi ibu balita mempersepsikan adanya hambatan dalam melakukan pencegahan gizi buruk sehingga diperlukan adanya strategi u nt u k me m i n i m al k a n ha mbat a n ya ng dirasakan ibu, misalnya dengan membentuk kelompok diskusi atau konsultasi pada petugas gizi. hubungan antara behavioral specific cognition and affect dengan komitmen ibu te rd apat hubu nga n ya ng posit if signifikan antara behavioral specific cognition and affect (perceived benefit, perceived barrier, perceived self-efficacy, dan dukungan sosial) dengan komitmen ibu dalam pencegahan gizi buruk balita ( path coeff = 0,443; t = 4,222). hasil pengaruh positif signifikan menunjukkan bahwa behavioral specif ic cognition and affect ( perceived benefit, perceived barrier, perceived self-efficacy, dan dukungan sosial) yang meningkat akan meningkatkan komitmen ibu dalam pencegahan gizi buruk balita. hasil penelitian menunjukkan bahwa 60% responden memiliki perceived benefit positif. sementara itu 36,9% responden yang memiliki perceived benefit positif memiliki komitmen yang kuat. perceived benef it merupakan persepsi akan manfaat/ keuntungan yang menguatkan individu untuk melakukan perilaku kesehatan tertentu (pender, 2011). komitmen dalam health promotion model adalah intensi/niat untuk melakukan perilaku kesehatan tertentu, termasuk identifikasi strategi untuk dapat melakukannya dengan baik (pender, murdaugh & parsons, 2002). individu memiliki komitmen untuk melakukan perilaku di mana mereka telah memikirkan nilai personal yang menguntungkan (tomey & alligood, 2010). menurut walker, et al (2006), tingginya keuntungan yang dipersepsikan dari perilaku pemenuhan gizi sesuai kebutuhan berhubu nga n denga n kom it men u nt u k melakukan perilaku tersebut. sesuai dengan 202 jurnal ners vol. 10 no. 2 oktober 2015: 195–207 pendapat tersebut maka semakin positif persepsi ibu tentang kemanfaatan melakukan tindakan pencegahan gizi buruk, maka akan semakin kuat komitmennya terhadap perilaku tersebut. hasil penelitian menunjukkan bahwa 56,9% responden mempersepsikan adanya h a mbat a n ( p e r c e i ve d b a r r i e r) d a la m pencegahan gizi buruk pada balita. sementara itu 38,5% responden yang mempersepsikan adanya hambatan memiliki komitmen yang lemah. perceived barrier didefinisikan sebagai persepsi adanya hambatan yang dibutuhkan untuk melakukan perilaku kesehatan tertentu (pender, 2011). menurut tomey & alligood (2010) dalam pender’s health promotion model, perceived barrier diyakini dapat menurunkan komitmen untuk berperilaku kesehatan tertentu. sesuai dengan pendapat tersebut, hambatan yang semakin dipersepsikan ibu dalam melakukan pencegahan gizi buruk pada balita menurunkan komitmennya untuk memunculkan perilaku tersebut. h a s i l d i s k u s i k e l o m p o k d a p a t disimpulkan bahwa responden juga sudah berupaya untuk meminimalkan hambatan dalam pencegahan gizi buruk pada balita. akan tetapi responden masih mengeluhkan kurangnya kemampuan dalam pemilihan menu makanan yang sehat dan beranekaragam untuk anak. berdasarkan hal tersebut perlu upaya untuk meningkatkan kemampuan ibu dalam mengatasi hambatan dalam pencegahan gizi buruk pada balita, sehingga perceived barrier yang dirasakan ibu semakin rendah. sebagai salah satu upaya yang dapat dilakukan adalah dengan membentuk kelompok diskusi dengan ibu yang sebaya sebagai media untuk bertukar informasi dan pengalaman ibu dalam pencegahan gizi buruk pada balita atau dengan memberikan kesempatan bagi ibu untuk berkonsultasi pada petugas kesehatan ketika kegiatan posyandu berlangsung. hasil penelitian menunjukkan bahwa 52,3% responden memiliki perceived self efficacy yang kuat dalam pencegahan gizi bur uk pada balita. sementara itu 32,3% responden yang memiliki perceived self efficacy kuat memiliki komitmen yang kuat pula. perceived self efficacy didefinisikan sebagai penilaian kemampuan personal untuk mengatur dan melakukan perilaku kesehatan tertentu (pender, 2011). hpm menegaskan bahwa keyakinan diri yang kuat meningkatkan komitmen individu untuk memunculkan p e r i la k u ke seh at a n ya ng d i h a r apk a n. responden dengan keyakinan diri yang kuat merasa mampu melakukan pencegahan gizi buruk pada balita sehingga keinginannya untuk berperilaku juga menjadi lebih kuat. hasil penelitian menunjukkan bahwa 40 responden (61,5%) memiliki dukungan sosial keluarga yang kuat dalam pencegahan gizi buruk pada balita. dari 40 responden tersebut, 20 responden memiliki komitmen kuat dan 20 responden lainnya memiliki komitmen yang lemah. dalam teori hpm, komitmen dapat dipengaruhi oleh faktor interpersonal, manfaat tindakan, hambatan tindakan, selff efficacy serta sikap yang berhubungan dengan aktivitas (pender, 2011). sumber utama pengar uh interpersonal adalah keluarga, kelompok dan pemberi pengaruh pelayanan kesehatan. berdasarkan hasil diskusi kelompok dengan kader posyandu balita serta wawancara dengan petugas kesehatan, dapat diketahui bahwa dukungan sosial dari petugas kesehatan sudah cukup besar dalam upaya pencegahan gizi buruk pada balita. akan tetapi berdasarkan pengalaman petugas gizi ketika melakukan kunjungan rumah masih ada anggota keluarga yang belum mendukung upaya pencegahan gizi buruk pada balita diantaranya masih ada keluarga yang memberikan susu formula pada bayi di bawah usia 6 bulan dengan alasan asi ibu sedikit dan agar bayi menjadi lebih gemuk. salah satu upaya untuk meningkatkan dukungan keluarga tersebut adalah dengan melibatkan keluarga dalam pemberian edukasi mengenai pencegahan gizi buruk pada balita. hubungan antara behavioral specific cognition and affect dengan perilaku ibu hasil penelitian menunjukkan bahwa 60% responden memiliki perceived benefit yang positif dalam melakukan tindakan pencegahan gizi buruk pada balita. sementara itu 36,9% responden yang memiliki perceived benefit positif memiliki perilaku yang baik. perceived benefit adalah kepercayaan terhadap 203 pengembangan model perilaku ibu (ika nur fauziah, dkk.) keuntungan dari metode yang disarankan untuk mengurangi risiko penyakit. perceived benefit berarti persepsi keuntungan yang memiliki hubungan positif dengan perilaku sehat (subagiyo, 2014). hasil penelitian menunjukkan bahwa 56,9% responden mempersepsikan adanya h a mbat a n ( p e r c e i ve d b a r r i e r) d a la m pencegahan gizi buruk pada balita. sementara itu 33,8% responden yang mempersepsikan adanya hambatan memiliki perilaku yang tidak baik. perceived barrier didefinisikan sebagai persepsi adanya hambatan yang dibutuhkan untuk melakukan perilaku kesehatan tertentu (pender, 2011). hubungan antara perceived barrier dengan perilaku sehat adalah negatif. jika persepsi hambatan terhadap perilaku sehat tinggi maka perilaku sehat tidak akan dilakukan (subagiyo, 2014). hasil penelitian menunjukkan bahwa 52,3% responden memiliki perceived self efficacy yang kuat dalam melakukan tindakan pencegahan gizi buruk pada balita. perceived self efficacy didefinisikan sebagai penilaian kemampuan personal untuk mengatur dan melak u kan per ilak u kesehatan ter tent u (pender, 2011). sebagai seorang ibu, responden dituntut untuk mampu menyediakan kebutuhan gizi setiap anggota keluarga. hal ini membuat responden mempersepsikan kemampuan diri yang kuat dalam melakukan tindakan pencegahan gizi buruk balita. hasil penelitian menunjukkan bahwa 35,4% responden dengan perceived self efficacy kuat memiliki perilaku yang baik dalam pencegahan gizi buruk balita (35,4%) sedangkan 33,8% memiliki perceived self efficacy lemah dengan komitmen yang lemah pula. self eff icacy didef inisikan sebagai kepercayaan diri untuk dapat melakukan perilaku kesehatan dengan baik (bandura, 2004). responden dengan keyakinan diri yang kuat merasa mampu melakukan pencegahan gizi buruk pada balita sehingga keinginannya untuk berperilaku tersebut juga menjadi lebih kuat. hasil penelitian menunjukkan bahwa 61,5% responden memiliki dukungan sosial keluarga yang kuat dalam pencegahan gizi bur uk pada balita. sementara itu 35,4% responden yang memiliki dukungan sosial keluarga kuat memiliki perilaku yang baik. menurut friedman (2010), dukungan keluarga merupakan salah satu faktor yang sangat berpengaruh terhadap perilaku positif. hal ini sejalan dengan tabulasi silang hasil penelitian bahwa responden dengan dukungan sosial keluarga yang kuat sebagian besar memiliki perilaku pencegahan gizi buruk yang baik. ha sil penelit ia n pa d a ga mba r 1 menunjukkan bahwa behavioral specif ic cognition and affect ( perceived benef its, perceived barriers, perceived self-efficacy, dan dukungan sosial) memiliki hubungan dengan perilaku ibu namun bukan hubungan secara langsung. behavioral specific cognition and affect ( perceived benefits, perceived barriers, perceived self-efficacy, dan dukungan sosial) secara tidak langsung berhubungan dengan perilaku ibu akan tetapi melalui variabel moderator/intervening yaitu komitmen ibu. berd asa rka n proposisi d a r i teor i health promotion model bahwa rintangan yang dirasakan ( perceived barrier) dapat menurunkan komitmen untuk berperilaku, mediator perilaku seperti perilaku aktualnya. individu dapat memodif ikasi pengar uh kognitif, sikap, interpersonal, dan situasional (behavioral specific cognition and affect) supaya lebih mendukung perilaku promosi kesehatannya (tomey & alligood, 2010). berdasarkan hasil diskusi kelompok ibu balita diketahui bahwa ibu memiliki beberapa hambatan dalam melakukan tindakan pencegahan gizi buruk diantaranya adalah waktu yang terbatas untuk menyiapkan sendiri makanan yang bergizi untuk balita mereka, terbatasnya pilihan menu makanan bergizi untuk balita serta dukungan dari keluarga yang kurang. petugas kesehatan dalam indepth interview juga menyatakan bahwa hambatan dalam pencegahan gizi buruk dapat berasal dari keluarga ibu balita. sehingga upaya yang perlu dilakukan untuk meminimalkan ha mbat a n a d ala h denga n member i k a n informasi menu makanan bergizi yang cepat saji untuk balita ser ta perlu melibatkan keluarga dalam pemberian edukasi mengenai pencegahan gizi buruk pada balita. 204 jurnal ners vol. 10 no. 2 oktober 2015: 195–207 hubungan antara individual perceptions dengan perilaku ibu hasil pengujian dengan smartpls, diketahui bahwa tidak terdapat hubungan antara individual perceptions ( perceived susceptibility dan perceived seriousness) dengan perilaku ibu ditandai dengan nilai path coeff. yang dihasilkan sebesar 0,215 dengan nilai t-statistic sebesar 1,552 (< 1,96). hasil penelitian menunjukkan bahwa sebagian besar responden memiliki persepsi yang baik mengenai kerentanan yang dialami oleh balita akan penyakit gizi buruk ( perceived susceptibility) yaitu sebesar 58,5%. begitu pula dengan persepsi mengenai keseriusan penyakit gizi buruk, sebagian besar responden memiliki persepsi yang baik yaitu sebesar 60%. menurut subagiyo (2014), perceived susceptibility dan perceived seriousness memiliki hubungan positif dengan perilaku sehat. jika persepsi kerentanan terhadap penyakit tinggi maka perilaku sehat yang dilakukan seseorang juga tinggi, begitu pula jika persepsi keparahan individu tinggi maka ia akan berperilaku sehat. sebagian besar responden memiliki persepsi yang baik mengenai kerentanan yang dialami oleh balita akan penyakit gizi buruk ( perceived susceptibility) memiliki perilaku yang baik pula yaitu sebesar 30,8%. begitu pula dengan persepsi mengenai keseriusan penyakit gizi buruk ( perceived seriousness), sebagian besar responden memiliki persepsi dan perilaku yang baik yaitu 41,5%. hasil dari diskusi kelompok dengan ibu balita dan kader posyandu balita menunjukkan bahwa ibu dan kader belum mengetahui dampak terburuk dari penyakit gizi buruk yaitu kematian. sebagai salah satu upaya untuk meningkatkan persepsi ibu mengenai kerentanan dan keseriusan penyakit gizi buruk perlu diberikan informasi lebih lanjut mengenai penyakit gizi buruk sehingga apabila persepsi ibu menjadi lebih baik maka perilaku ibu dalam pencegahan gizi buruk balita menjadi lebih baik pula. hubungan antara komitmen dengan perilaku ibu hasil pengujian dengan smartpls, diketahui bahwa terdapat hubungan yang positif signifikan antara komitmen dengan per ila k u ibu ( path coef f. = 0,539; tstatistik=2,509). hasil pengar uh positif signifikan menunjukkan bahwa komitmen yang meningkat akan meningkatkan perilaku ibu secara signifikan. hasil penelitian menunjukkan bahwa 55,4% responden memiliki komitmen yang lemah dalam melakukan tindakan pencegahan gizi bur uk pada balita. menur ut pender (2011), komitmen mer upakan keinginan u nt u k mela k u k a n p e r i la k u ke sehat a n tertentu, termasuk identifikasi strategi untuk dapat melakukannya dengan baik. perilaku merupakan respons atau reaksi seseorang terhadap stimulus (rangsangan dari luar). respons individu terhadap stimulus dalam bent uk tindakan nyata disebut perilaku terbuka. perilaku inilah yang dapat diamati dan dinilai oleh orang lain (notoatmojo, 2010). perilaku ibu dalam pencegahan gizi buruk balita dinilai dari beberapa indikator yaitu pemberian asi eksklusif, mp-asi sesuai usia anak, makanan yang beranekaragam dan kunjungan ke posyandu. berdasarkan hasil penelitian diketahui bahwa 76,9% ibu memberikan asi eksklusif, 81,8% mp-asi diberikan saat bayi berusia >6 bulan, 81,5% kunjungan ke posyandu > 4×/6 bulan, akan tetapi jenis makanan yang diberikan kepada balita sebagian besar (60%) tidak beraneka ragam. berdasarkan hasil analisis dari kuesioner responden, diketahui bahwa komposisi menu makanan yang dikonsumsi anak sebagian besar adalah nasi, lauk dari sumber hewani/nabati dan susu. sementara itu bahan makanan yang jarang dikonsumsi anak adalah jenis sayur dan buah sehingga dari keempat indikator tersebut dapat disimpulkan bahwa 50,8% ibu memiliki perilaku yang tidak baik dalam pencegahan gizi buruk balita. responden dengan komitmen lemah paling banyak mempunyai perilaku yang tidak baik. begitu pula sebaliknya, responden yang memiliki komitmen kuat paling banyak memiliki perilaku yang baik pula. niat untuk berperilaku (komitmen) merupakan suatu keinginan atau rencana (pender, murdaugh, & parsons, 2002). berdasarkan pada proposisi 205 pengembangan model perilaku ibu (ika nur fauziah, dkk.) teori hpm, komitmen terhadap rencana aksi tidak berakhir pada perilaku yang diharapkan, jika individu mendapatkan kontrol yang lemah dan jika ada perilaku lain yang lebih atraktif dan disukai oleh individu. hasil dari diskusi kelompok ibu balita menunjukkan bahwa terdapat beberapa ibu yang lebih menyukai memberikan bubur instan kepada balita mereka karena lebih praktis serta membeli makanan kesukaan balita di warung daripada menyiapkan sendiri makanan untuk anak mereka. berdasarkan hal tersebut, ibu perlu diberikan infor masi mengenai pemilihan makanan sehat dan pentingnya makanan bergizi unt uk balita sehingga perilaku ibu dalam memberikan makanan yang beranekaragam dapat ditingkatkan. hubungan antara petunjuk/pendorong untuk bertindak (cues to action) dengan perilaku ibu berdasarkan hasil penelitian diketahui bahwa 52,3% responden memiliki cues to action yang negatif sedangkan 47,7% responden memiliki cues to action yang positif dalam melakukan tindakan pencegahan gizi buruk pada balita. cues to action adalah mempercepat t i nd a k a n ya ng membu at seseorang merasa butuh mengambil tindakan at au mela k u kan ti nd a kan nyat a u nt u k melakukan perilaku sehat. cues to action juga berarti dukungan atau dorongan dari lingkungan terhadap individu yang melakukan perilaku sehat (weinberger et al., 1981; stacy & llyod, 1990 dalam subagiyo, 2014). cues to action antara lain meliputi penyakit dari anggota keluarga (illness of a family member), laporan media (media reports) (graham, 2002), kampanye media massa, saran dari orang lain, dan nasehat dari petugas kesehatan (ali, 2002). berdasarkan hasil penelitian, diketahui bahwa proporsi terbanyak adalah responden dengan cues to action negatif memiliki perilaku yang tidak baik yaitu sebesar 46,2%. adanya petunjuk, edukasi, gejala atau media informasi (cues to action) dapat memengaruhi seseorang tentang bahaya penyakit sehingga merasa perlu mengambil tindakan (jones & bartlett, 2010). hasil pengujian dengan smartpls, menunjukkan bahwa tidak terdapat hubungan antara petunjuk/pendorong untuk bertindak (cues to action) dengan perilaku ibu, ditandai dengan nilai path coeff. sebesar 0,119 dengan nilai t-statistic sebesar 0,516 (< 1,96). tidak adanya hubungan antara cues to action dengan perilaku ibu dalam pencegahan gizi buruk dimungkinkan karena terdapat variabel lain yang tidak diteliti, yaitu perceived threat of disease. menurut teori hbm, perilaku kesehatan individu dapat terbentuk karena adanya rasa takut akan ancaman suatu penyakit ( perceived threat of disease). sehingga untuk mencari apakah ada hubungan tidak langsung antara cues to action dengan perilaku ibu perlu diteliti variabel lain yang mungkin memengaruhi sebagai variabel antara yaitu perceived threat of disease. simpulan dan saran simpulan perilaku ibu dalam pencegahan gizi buruk dapat dibentuk oleh komitmen ibu, behavioral specif ic cognition and affect dan faktor personal. faktor personal ibu memengaruhi persepsi mengenai keseriusan, kerentanan, keuntungan, hambatan, keyakinan diri, dukungan sosial dan perilaku ibu dalam pencegahan gizi buruk balita. saran k a d e r p o s y a n d u h e n d a k n y a mema n fa at k a n posya ndu balit a u nt u k memberikan pendidikan kesehatan tentang gizi buruk pada balita. ibu yang memiliki anak usia balita perlu meningkatkan pemahaman dan komitmen ibu mengenai pencegahan gizi buruk pada balita dengan aktif bertanya kepada petugas kesehatan (ahli gizi dan bidan desa) atau kader kesehatan setempat, mengikuti pendidikan kesehatan yang dilaksanakan dan secara mandiri mencari informasi melalui media cetak maupun elektronik. peneliti selanjutnya diharapkan meneliti hubungan variabel lain dalam hpm dan hbm dengan perilaku ibu dalam pencegahan gizi buruk pada balita. 206 jurnal ners vol. 10 no. 2 oktober 2015: 195–207 kepustakaan ajzen. 1991. the theory of planned behavior. organizational behavior and human decision process, 179–211. ali, n.s. 2002. prediction of coronary heart disease preventive behaviors in women: a test of the health belief model. women & health, 35(1), 83–96. angkat, yenita. 2011. pengaruh pengetahuan ibu dan sosial ekonomi keluarga terhadap pencegahan g izi bur uk pada balita di desa sikalondang kota subulussalam tahun 2011. diakses 20 januari 2015. website:http://repository. usu.ac.id/handle/123456789/29905 azwar, s. 2000. sikap manusia: teori dan pengukuran. yogyakarta: liberty. bandura. 2004. self efficacy. diakses dari http://treeppjkr.multiply.com/reviews/ item/22. bappenas. 2010. laporan pencapaian tujuan pembangunan milenium indonesia 2010. jakarta: kementerian perencanaan p e m b a n g u n a n n a s i o n a l / b a d a n perencanaan pembangunan nasional (bappenas). cahyo. 2004. kajian faktor-faktor perilaku dalam keluarga yang memengaruhi pencegahan penyakit demam berdarah dengue (dbd) di kelurahan meteseh semarang. media litbang kesehatan xvi, nomer 4. deci, e, & ryan, r. 2008. facilitating optimal motivation and psychological well being across life’s domain. can psychol, 14–23. friedman, marilyn m. 2010. buku ajar keperawatan keluarga: riset, teori dan praktek. jakarta: egc graham, m.e. 2002. health beliefs and self breast examination in black women. journal of cultural diversity, 9(2), 49–54. handoko, h. 2001. manajemen sumber daya manusia, edisi 2. yogyakarta: bpfe. has, e.m.m. 2012. perilaku ibu dalam pemenuhan gizi anak usia pra-sekolah berbasis integrasi health promotion model dan self regulation theory. tesis. surabaya: universitas airlangga (tidak dipublikasikan) jones & bartlett. 2010. chapter 4: health belief model. diakses 20 november 2014. web site http://www.jblearning. c o m / s a m p l e s / 0 76 3 743 8 3 6 /c h a p ter%204.pdf kusriadi. 2010. analisa faktor risiko yang memengaruhi kejadian kurang gizi pada anak balita di provinsi nusa tenggara barat (ntb) (karya ilmiah). bogor: institut pertanian bogor. morton, s., greene, w., & gottlieb, n. 1995. introduction to health education and healthpromotion, waveland, press inc, usa. notoatmodjo, s. 2010. prinsip-prinsip dasar ilmu kesehatan masyarakat. jakarta: rineka cipta. pender, n. 2011. the health promotion model, manual. retrieved february 4, 2014, from nursing.urnich.edu: http// nursing. urnich.edu/faculty-staff/nola-j-pender pender, n., murdaugh, c., & parsons, m. 2002. health promotion in nursingpractice. new jersey: prentice hall. razak aa, gunawan ima, budiningsari rd. 2011. pola asuh ibu sebagai faktor risiko kejadian kurang energi protein (kep) pada anak balita. jurnal gizi klinik indonesia. diakses 25 mei 2014. web site: http://www.ilib.ugm.ac.id/jurnal/ download.php?dataid=10761 rosari, a., rini, e.a., masrul. 2013. hubungan diare dengan status gizi balita di kelurahan lubuk buaya kecamatan koto tangah kota padang. jur nal kesehatan andalas. 2013; 2(3). diakses 28 februari 2014. web site: http://jurnal. f k.unand.ac.id/ sholihah, m. 2014. gambaran peluang perubahan perilaku perokok dengan health belief model pada pasien hipertensi di puskesmas ciputat tangerang selatan. sk ripsi: psik fkik uin syarif hidayatullah jakarta. diakses 4 agustus 2015. website: error! hyperlink reference not valid. subagiyo, a.a.a. 2014. health belief model sebagai pembentuk perilaku sehat. diakses 20 mei 2014. web site:http:// ar iqaay nif psi13.web.u nai r.ac.id /artikel_detail-112374-perilaku%20sehathealth%20belief %20mod el%20seb a g a i % 2 0 p e m b e n t u k % 2 0 perilaku%20sehat.html 207 pengembangan model perilaku ibu (ika nur fauziah, dkk.) sulistiyawati. 2011. pengaruh pemberian diet formula 75 dan 100 terhadap berat badan balita gizi buruk rawat jalan di wilayah kerja puskesmas pancoran mas kota depok. tesis fik ui. diakses 10 desember 2015. website: http://lib. ui.ac.id/file?file= digital/20282623t%20sulistiyawati. pdf tomey, a. & alligood, m. 2010. nursing theorist and their work. (6th ed.). st. louis: mosby elsevier, inc. wigati, a. 2007. sosiologi. jakarta: grasindo walker, s., pullen, c., hertzog, m., broekner, l., & hageman, p. 2006. determinants of older rural women’s activity and eating. western journal of nursing research, 449–474. ners vol 10 no 2 okt 2015.indd 360 senam disminorhea berbasis ar-rahman terhadap penurunan nyeri (ar rahman-based dysmenorrhea gymnastic to reduce pain) sri sumaryani*, praditiana indah puspita sari* *program studi ilmu keperawatan fakultas kedokteran dan ilmu kesehatan universitas muhammadiyah yogyakarta jl lingkar barat tamantirto kasihan bantul yogyakarta email: yanipsikumy@gmail.com abstrak pendahuluan: lebih dari 50% dismenorhea disebabkan oleh jumlah prostaglandin yang meningkat pada saat mensruasi. kombinasi senam dismenorhea dan teknik relaksasi dengan mendengarkan al qur’an surat ar rahman merupakan inovasi baru terapi non farmakologis untuk mengatasi dismenorhea. tujuan dari penelitian adalah untuk menjelaskan perubahan tingkat nyeri pada responden yang diberikan terapi senam dismenorhea, resitasi al quran surat ar rahman, dan kombinasi senam dismenorhea dengan resitasi al quran surat ar rahman. metode: penelitian dilakukan pada bulan maret sampai mei 2015 dengan desain quasi eksperimental pretest posttest menggunakan kelompok kontrol. sampel sebanyak 62 responden dibagi menjadi 3 kelompok: 18 responden dalam kelompok senam dismenorhea, 23 responden dalam kelompok resitasi al quran surat ar rahman, dan 21 responden dalam kelompok kombinasi senam dismenorhea dengan resitasi alquran surat ar rahman. uji statistik menggunakan wilcoxon dan kruskal wallis dengan level signifi kansi α < 0,05. hasil: senam dismenorhea berbasis ar rahman secara statistik terbukti lebih efektif dalam menurunkan nyeri menstruasi dibandingkan dengan intervensi yang lain: senam dismenorhea saja dan murrotal saja, dengan p= 0,01. rerata pre intervensi sebesar 31,31, sedangkan rerata post intervensi sebesar 19,50. diskusi: perawat dapat memberikan alternatif terapi non farmakologis untuk mengurangi dismenorhea dengan intervensi senam dismenorhea berbasis ar rahman. kata kunci: dismenorhea, ar rahman, senam dismenorhea abstract introduction: more than 50% dysmenorrhea are caused by excessive amounts of prostaglandin hormone during menstruation. the combination of dysmenorrhea gymnastics and qur’an surah ar-rahman relaxation techniques is a new innovation in non-pharmacological therapy to overcome dysmenorrhoea. the purpose of this study was to determine the level of pain differences on respondents who were given dysmenorrhea gymnastics treatment, al quran surah arrahman recitation, and dysmenorrhea gymnastics combined with al quran surah ar-rahman recitation. methods: the research was conducted from march to may 2015 with quasi-experimental pretest-posttest control group design. the samples were 62 respondents, divided into 3 groups: 18 respondents in group of dismenorrhea gymnastic, 23 respondents in group of al-qur an surah ar-rahman, and 21 respondents in group of dismenorrhea gymnastic combined with al quran surah ar-rahman recitation. statistical test used wilcoxon and kruskal wallis test with significance level α < 0.05. results: the results showed that the ar rahman-based dysmenorrhea gymnastics statistically proven can reduce menstrual pain more effectively compared with other interventions: menstrual gymnastics only and murrotal only, with p = 0.001 and the mean rank pre intervention is 31,31, and mean rank post intervention is 19,50. discussions: nurses may give non pharmacologic alternative therapies to reduce dysmenorrhea by providing intervention ar rahman-based dysmenorrhea gymnastic. keywords: dysmenorrhea, ar rahman, dysmenorrhea gymnastic pendahuluan disminore adalah nyeri menjelang atau selama menstruasi yang dapat bersifat primer atau sekunder akibat adanya peningkatan hormon prostaglandin yang mengakibatkan otot uterus berkontraksi. dismenore dapat diklasifikasikan menjadi dua, yaitu dismenore primer dan dismenore sekunder. dismenore primer yait u nyer i pada saat menst ruasi ya ng d iju mpa i t anpa ad a nya kela ina n pada alat kelamin yang nyata, sedangkan dismenore sekunder yait u nyer i pada saat menstruasi yang disebabkan oleh kelainan ginekolog i. disminore disebabkan karena ketidakseimbangan hormone progesterone dalam darah, prostaglandin dan vasopresin (bobak, 2010). 361 senam disminorhea berbasis ar-rahman (sri sumaryani dan praditiana indah puspita sari) prevalensi disminore primer di indonesia cukup tinggi yaitu 60-70% dan 15% diantaranya mengalami nyeri hebat yang umumnya terjadi pada usia remaja (calis, 2011). remaja yang mengalami disminore sering mengalami gejala nyeri yang terasa menusuk dan hebat di daerah suprapubis dan lumbo sakralis. nyeri tersebut berlangsung kurang lebih 12 jam pada hari pertama menstruasi. sebagian remaja yang mengalami disminore juga akan merasakan sensasi mulas, mual, muntah, nyeri kepala, cenderung mudah marah, sensitive bahkan pingsan (bobak, 2010). d i sm e no re me mb e r i k a n ba nya k dampak negatif pada remaja putri. dismenore menyebabkan 14% dari remaja put r i t idak mampu menjalani kegiatan sehari-hari dan tergangg u dalam mengik uti kegiatan di sekola h , ba h k a n tidak hadir d i sekolah. kualit as hidup seorang siswi pu n dapat menurun karena dismenore dapat menurunkan konsent rasi dan mot ivasi u nt uk belajar (ningsih, 2011; saguni, 2013). p e n a n g a n a n d i s m i n o r e d a p a t dilakukan dengan terapi farmakologi dan non-farmakologi. terapi farmakologi yang telah dilakukan sebagai upaya mengatasi disminore antara lain pemberian obat-obatan analgetik, terapi hormonal, obat nonsteroid prostaglandin, dan dilatasi kanalis sevikalis, sedangkan terapi non farmakologi yang biasa dilakukan adalah kompres hangat, terapi relaksasi dengan mendengarkan musik, akupuntur, akupresure, olah raga, dan terapi spiritual (anurogo, 2011). olahraga atau senam merupakan salah satu teknik relaksasi yang dapat digunakan untuk mengurangi nyeri, hal ini disebabkan saat melakukan olahraga atau senam tubuh akan menghasilkan endorfin yang dihasilkan diot a k d an su m-su m t ulang bela kang. hormon endorfin berfungsi sebagai obat penenang alami sehingga menimbulkan rasa nyaman.(anurogo, 2011). selain olahraga, terdapat pula terapi nonfarmakologi yang dijadikan sebagai upaya untuk mengurangi nyeri yaitu dengan terapi spiritual. salah satu terapi spiritual yang biasa dilakukan adalah dengan berdzikir maupun mendengarkan lantunan ayat-ayat suci al quran atau disebut dengan istilah murrotal. lantunan ayat suci al quran mampu memberikan efek relaksasi karena dapat mengaktifkan hormon endorfin, meningkatkan perasaan rileks, mengalihkan perhatian dari rasa takut, cemas, dan tegang, memperbaiki sistem kimia tubuh sehingga menurunkan tekanan darah, dan memperlambat pernapasan. surah ar rahman merupakan salah satu surah yang berulangkali menjelaskan tentang nikmat allah. pengaruh al quran surah ar-rahman terhadap tubuh adalah dapat memberikan relaksasi dan ketenangan jiwa. hal ini juga tersirat dalam al quran (qs) az-zumar (39): 23 yang berbunyi “allah telah menurunkan perkataan yang paling baik (yaitu) al quran surah ar-rahman yang serupa (ayat-ayatnya) lagi berulang-ulang, gemetar karenanya kulit orang-orang yang takut kepada tuhan-nya, kemudian menjadi tenang kulit dan hati mereka ketika mengingat allah, dengan kitab itu allah memberi petunjuk kepada siapa yang dia kehendaki. dan barangsiapa dibiarkan sesat oleh allah, maka tiada seorang pun yang memberi petunjuk”. bahan dan metode penelitian ini menggunakan desain quasy-experiment dengan rancangan “prepost test with control group”. populasi dalam penelitian ini adalah mahasiswi program studi ilmu keperawatan umy yang mengalami d ism i nore denga n k r iter ia d ism i norea primer, skala nyeri ringan, sedang, atau berat, usia 18–25 tahun, beragama islam, mampu mengungkapkan perasaan, dan siklus menstruasinya teratur. adapun mahasiswi yang memiliki gangguan ginekologis, sudah menikah, tidak menandatangani inform consent, dan menggunakan terapi penanganan lain, dikeluarkan dari sampel penelitian. jumlah sampel di awal penelitian adalah 69 responden yang terbagi dalam tiga kelompok, namun selama proses penelitian terdapat 7 sampel yang mengalami drop out, sehingga sampel dalam penelitian ini berjumlah 62 orang yang terbagi dalam 18 responden kelompok senam, 23 responden kelompok mur rotal ar-rahman, dan 21 responden 362 jurnal ners vol. 10 no. 2 oktober 2015: 360–365 kelompok senam disminorea berbasis ar rahman. teknik sampling yang digunakan untuk menentukan dalam tiga kelompok adalah simple random sampling. alat yang digunakan dalam penelitian ini adalah mp3 player, video senam disminore yang diambil dari website: http://duniaf itnes.com, dan senam relaksasi dengan mendengarkan ayat al quran surat ar rahman yang dilantunkan oleh mohammed taha al-junaid. penelitian dilakukan di program studi ilmu keperawatan universitas muhammadiyah yogyakarta pada bulan maret-mei 2015. prosedur penelitian meliputi pre test sebelum intervensi, pemberian intervensi pada ketiga kelompok dengan metode intervensi yang berbeda di mana masing-masing metode dilakukan selama 30 menit, dan setelah itu dilakukan post test untuk mengukur tingkat nyeri dengan menggunakan numeric rating scale (nrs). analisa data menggunakan uji statistik wilcoxon untuk mengetahui pengaruh pre dan post intervensi masing-masing kelompok, dilanjutkan dengan uji statistik kruskal wallis untuk mengetahui signifikansi perbedaan antara kelompok senam, murrotal ar rahman, dan senam berbasis murrotal ar rahman. hasil berdasarkan pengolahan data pada ketiga kelompok diperoleh hasil bahwa pre test kelompok senam sebagian besar atau 61,1% dalam kategori nyeri sedang, dan pada saat post test 50,0% dalam kategori nyeri ringan. untuk kelompok murrotal ar rahman diperoleh hasil pre test sebagian besar atau 56,5% dalam kategori sedang, dan pada saat post test sebagian besar atau 52,2% dalam kategori ringan, sedangkan untuk kelompok senam berbasis ar rahman, tingkat nyeri pre test sebagian besar atau 47,6% dalam kategori ringan, dan pada saat post test sebagian besar atau 81,1% dalam kategori ringan. hasil uji wilcoxon diperoleh data bahwa terdapat pengaruh antara tindakan pemberian senam disminore, murattal ar rahman, dan tabel 1. hasil uji wilcoxon pre-post test pada kelompok senam disminore, murrotal ar rahman, dan senam berbasis ar rahman kelompok tingkat nyeri pre-test post -test n % n % p-value senam ringan sedang berat 5 11 2 27.1 61.1 11.1 9 8 1 50.0 44.4 5.6 0.001 ar-rahman ringan sedang berat 6 13 4 26.1 56.5 17.4 12 10 1 52.2 43.5 4.3 0.000 senam berbasis arrahman ringan sedang berat 10 4 7 47.6 19.0 33.3 17 4 0 81.0 19.0 0 0.000 tabel 2. hasil uji kruskal wallis pada kelompok senam disminore, murrotal ar rahman, dan senam berbasis ar rahman kelompok pre-test post-test mean rank x2 p-value mean rank x2 p-value senam ar rahman senam berbasis ar-rahman 31,06 32,06 31,31 0,034 0,983 35,15 39,15 19,50 14,862 0,001 363 senam disminorhea berbasis ar-rahman (sri sumaryani dan praditiana indah puspita sari) senam disminore berbasis ar rahman dengan nilai signifikansi < 0,005 untuk masing-masing kelompok. hal tersebut menunjukkan bahwa senam disminore, murrotal ar rahman, maupun senam disminore berbasis ar rahman mampu menurunkan tingkat disminore. ad apu n hasil uji kr usk al wallis diperoleh data bahwa senam disminore berbasis ar-rahman lebih efektif menurunkan nyeri dibandingkan dengan intervensi yang hanya senam disminore saja dan murrotal al quran surah ar rahman saja, dengan nilai p = 0,001 dan mean rank pre test 31,31 dan mean rank post test 19,50, sehingga terdapat selisih mean rank sebesar 11,81 antara pre dan post intervensi sebagaimana tertera pada tabel 1 dan 2. pembahasan hasil uji wilcoxon pada pre test dan post test tingkat nyeri pada kelompok senam, menunjukkan nilai p = 0,001 atau < 0,005 yang artinya ada pengaruh pemberian senam dengan tingkat disminore. hasil penelitian ini didukung oleh penelitian yang dilakukan suparto (2011), tentang efektivitas senam disminore dalam mengurangi disminore pada remaja putri diperoleh hasil bahwa senam dismenore efektif untuk mengurangi disminore pada remaja. penelitian lain yang sejalan dengan hasil penelitian ini dilakukan oleh nurjanah (2014) yang berjudul pengaruh sena m aerobic low impact terha d ap penu r u nan dysmenor rhea pr imer pada mahasiswa diploma iii fisioterapi universitas muhammadiyah semarang diperoleh hasil bahwa responden mengalami penurunan nyeri yang signifikan dengan nilai p = 0,004 dan nilai mean sebesar 19,00, sedangkan pada kelompok kontrol didapatkan nilai p = 0,317 dengan mean penurunan tingkat nyeri sebesar 8,00. hasil penelitin ini juga sesuai dengan penelitian dehghanzadeh (2014) di iran yang menemukan bahwa latihan aerobik selama delapan minggu terbukti mampu menurunkan kejadian disminore primer. nyeri pada saat menstr uasi terjadi k a r e n a a d a n y a p e n a m b a h a n j u m l a h prostaglandin di dalam darah. peningkatan atau penambahan jumlah prostaglandin menga k ibatkan ter jadi nya peni ng kat a n aktivitas kontraksi miometrium. kontraksi miometrium yang meningkat menyebabkan aliran darah terganggu sehingga dinding uterus mengalami iskemia. kondisi iskemia akan merangsang serabut saraf nyeri pada uterus (bobak, 2010). olahraga atau senam merupakan salah satu teknik relaksasi yang dapat digunakan untuk mengurangi nyeri tersebut. senam yang dilakukan secara teratur dengan durasi 30-45 menit akan menyebabkan otototot pangg ul dan otototot uter us mengalami relaksasi, menstabilkan mood, meningkatkan aliran darah ke panggul, dan memperlancar pasokan oksigen ke pembuluh d a ra h ya ng mengala m i vasokonst r i k si sehingga disminore dapat berkurang. senam juga mampu meningkatkan kadar β endorfin empat sampai lima kali lipat di dalam darah. β endorfin terbukti mampu menurunkan rasa nyeri, meningkatkan daya ingat, memperbaiki nafsu makan, dan kemampuan seksual. hasil penelitian ini juga menunjukkan bahwa terjadi penurunan nyeri pada kelompok yang diberi perlakuan dengan mendengarkan murrotal al quran surah ar rahman yang dibuktikan dengan hasil uji statistik p = 0,000. hasil penelitian ini sejalan dengan pendapat anwar (2010) yang menyatakan bahwa mendengarkan bacaan al quran dapat memberikan efek ketenangan dalam tubuh disebabkan adanya unsur meditasi, autosugesti, dan relaksasi yang terkandung di dalamnya. rasa tenang atau rileks akan memberikan respons emosi yang positif dan sangat berpengaruh dalam mendatangkan persepsi yang positif. menurut mustamir (2009) menyatakan bahwa persepsi positif yang didapat dari ar rahman akan merangsang hipotalamus mengeluarkan hormon endorfin. berdasarkan teori menyebutkan bahwa mendengarkan bacaan ayat-ayat al-quran dengan tartil akan menyebabkan ketenangan jiwa. efek suara termasuk lantunan ayat-ayat al quran dalam hal ini murrotal al quran surah ar rahman dapat mempengar uhi keseluruhan fisiologi tubuh manusia dengan cara mengaktivasi neokorteks dan beruntun ke dalam sistem limbik, hipotalamus, dan 364 jurnal ners vol. 10 no. 2 oktober 2015: 360–365 sistem saraf otonom. perangsangan auditori mempunyai efek distraksi yang mampu meningkatkan pembentukan endorfin dan merelaksasikan otot. murrotal al quran surah ar-rahman yang diperdengarkan dengan menggunakan speaker box music atau earphone akan mengeluarkan vibrasi sehingga menghasilkan gelombang suara yang dapat didengar oleh telinga dan diter uskan ke ner v us viii, kemudian akan diubah menjadi impuls listrik. impuls tersebut dilanjutkan ke korteks serebri yang berhubungan dengan perasaan untuk dipersepsikan. jika suara atau bunyi tersebut dapat dipersepsikan dengan baik maka akan menimbulkan efek relaksasi. hasil uji wilcoxon juga menunjukkan bahwa senam disminore berbasis ar rahman mampu menurunkan dismenore, dibuktikan dengan nilai p = 0,000. hasil uji kruskal wallis juga menunjukkan bahwa senam disminore berbasis ar rahman terbukti secara statistik lebih efektif dalam menurunkan disminore dibandingkan intervensi senam disminore saja dan mendengarkan murrotal al quran surah ar rahman saja yang dibuktikan dengan nilai p = 0,001, dengan nilai mean rank pre 31,31 dan mean rank post sebesar 19,50. senam disminore berbasis ar rahman dapat mengurangi tingkat nyeri disminore. surah ar rahman menceritakan tentang luasnya rahmat allah. allah telah menciptakan manusia dalam bentuk yang sebaik-baiknya. a r rah man juga menceritakan tentang keseimbangan dan memuat unsur pendidikan. surah ar rahman dimaknai sebagai surah yang menjelaskan pentingnya bersyukur karena kar unia allah yang sangat luas tersebut, termasuk mensyukuri semua kondisi. sakit ataupun dismenore juga dimaknai sebagai karunia allah, sehingga orang yang memahami makna surah ar rahman akan mampu mencapai kesehatan jasmani, rohani, dan akal (zahro, 2011). terapi kombinasi antara senam dan mendengarkan murrotal al quran surah ar rahman mempunyai beberapa keunggulan dan mampu memberikan efek ganda dalam menurunkan nyeri. senam dapat memberikan efek relaksasi karena gerakan-gerakan senam dapat membantu melancarkan peredaran darah yang berada di sekitar rahim, mengurangi produksi prostaglandin dan mengurangi vasokontriksi pembuluh darah sehingga dapat meminimalkan kontraksi uterus, sedangkan terapi murrotal mempunyai efek yang sangat diperlukan dalam mengatasi kecemasan dan membentuk gaya koping yang positif karena murrotal al quran surah ar rahman mampu memberikan stimulan untuk memunculkan gelombang delta yang berfungsi membuat pikiran menjadi tenang dan nyaman sehingga menurunkan tingkat nyeri disminore. simpulan dan saran simpulan senam dismenore berbasis ar rahman lebih efektif menurunkan nyeri dibandingkan dengan intervensi yang hanya senam saja maupun murrotal saja. saran perawat dapat membuat alternatif terapi nonfarmakologi untuk menurunkan nyeri disminore dengan memberikan intervensi senam disminore berbasis ar rahman. kepustakaan anurogo, d., dan wulandari, a., 2011. cara jitu mengatasi nyeri haid. yogyakarta: andi offset. anwar, y.p., 2010. sembuh dengan al quran. jakarta: sabil bobak, lowdermilk, perry, cashion, 2010. maternity nursing. 8th. ed. st louis: mosby, inc. calis, karim, anton, 2011. dysmenorrhea. ( o n l i n e ) , ( h t t p : e m e d i c i n e . medscape,com, diakses tanggal 28 september 2015, jam 13.10 wib) dehghanzadeh, n., khoshnan, e., nikseresht, a., 2014. the effect of 8 weeks of aerobic training on primary dysmenorrhea. european jour nal of experimental biology, 4(1), 380–382. mustamir, p., 2009. metode super untuk menakhlukkan stres. jakarta: hikmah 365 senam disminorhea berbasis ar-rahman (sri sumaryani dan praditiana indah puspita sari) ningsih, r., setyowati, s., rahmah, h, 2011. efektivitas paket pereda pada remaja dengan disminore di sman kecamatan curup. (online), (http://www.jki.ui.ac. id, diakses tanggal 30 september 2015, jam 01.16 wib). nurjanah, a.a.a., 2014. pengaruh senam ae r o b i c l o w i m p a c t t e r h a d a p penurunan dysmenorrhea primer pada mahasiswa diploma iii fisioterapi universitas muhammadiyah surakarta, (online), (http://www.eprints.ums.ac.id., diakses tanggal 29 september 2015, jam 21.15 wib). saguni, f., madianung, a., masi, g., 2013. hubungan dismenore dengan aktivitas belajar remaja putri sma kristen i tomohon manado, (online), (http://ejournal unsrat.ac.id, diakses tanggal 30 september 2015, jam 01.08 wib). suparto, a., 2011. efektivitas senam dismenore dalam mengurangi dismenore pada remaja putri. phederal, 4(1), 7. zahro, f., 2011. aspek-aspek pendidikan dalam ar rahman 1-30, (online), (http://www. digilib.uin-suka.ac.id., diakses tanggal 28 september 2015, jam 13.30 wib). http://e-journal.unair.ac.id/jners | 25 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18905 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the influence of impedance and enhancement factors of discharge planning implementation at hospital: a systematic review hari soebagiyo1, nursalam nursalam1, ahsan ahsan2 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 nursing department, faculty of medicine, universitas brawijaya, malang, indonesia abstract introduction: discharge planning is one of various nursing duty agendas, starting from when patients are admitted to hospital up to being allowed to go home. the phenomenon of implementation discharge planning for patients today is not optimal whereby nurses just do limited implementation of routine activities in the form of information on recontrol. based on those facts, the author wishes to study the analysis of impedance and enhancement factors in discharge planning implementation at hospitals. methods: the researcher conducted investigation in february 2020 and involved exploration of some scientific papers journal from sciencedirect, proquest, scopus, and, pubmed as references with keywords nursing discharge planning, enhancement and impedance factors, implementation, and, hospital. this paper identified15 relevant research articles from 500 original full texts between 2010 and 2018 and analyzed inclusion criterion of enhancement and impedance factors in discharge planning implementation. it involves three rcts, eight descriptive, and four qualitative research papers results: as a result, there are found eight enhancement and five impedance factors influencing in discharge planning implementation. meanwhile, from 3250 research respondents, 2125 persons reports enhanced factors contrary 1.125 samples imply impedance factors. conclusion: the implementation discharge planning is influenced by some factors that should be given attention by nurses to do discharge planning properly. article history received: feb 27, 2020 accepted: april 1, 2020 keywords nursing discharge planning; enhancement and impedance factors; implementation; hospital contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: soebagiyo, h., nursalam, n., & ahsan, a. (2020). the influence of impedance and enhancement factors of discharge planning implementation at hospital: a systematic review. jurnal ners, special issues, 25-33 doi: http://dx.doi.org/10.20473/jn.v15i2.18905 introduction discharge planning is dynamic and systematic process starting when patients were admitted up to permitted to leave hospital related with activity evaluation, preparation , and coordination to provide health observation, and , social service preparation (nursalam, 2018). this process will give a professional healthcare team an opportunity to prepare patient to become more independent to their healthcare at home discharge planning must be focused on the patient's problem an includes; promotive, preventive, rehabilitative and nursing care aspects. nursing healthcare at hospital will have meaningful value when continued at home, principally by: focusing on patients’ health needs (yilmaz & ozsoy, 2010), identifying probably health problems at home (backer et al., 2007), integrating and collaborating team inter-professional healthcare (r. watts et al., 2005), adjusting implementation program with environment resources (yilmaz & ozsoy, 2010), applying discharge planning at every system / level of healthcare (gray, constance; christensen, martin; bakon, 2016). today, implementation discharge planning for patients is not optimal whereby nurses just do limited implementation of routine activities in the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nursalam@fkp.unair.ac.id h. soebagiyo et al. 26 | pissn: 1858-3598  eissn: 2502-5791 form of information on re-control (nursalam, 2018). other conditions related to implementation of discharge planning have been investigated by voie, tunby and strømsvik (2018) who explained how discharge plan implementation by nicu of premature patients at hospital are a result of: 1) different expectation and lack of communication between nicu nurses and public health nurses, 2) responsibility and interaction between two groups of nurses not clearly defined, 3) public health nurse’s competence not recognized by nicu nurses and patients (pauline voie , mona; tunby , jorunn; strømsvik, 2018). based on such facts, the author wishes to study an analysis of the influence of impedance and enhancement factors in discharge planning implementation at hospital. this analysis is aimed to give; 1) nurses’ awareness of enhancement and impedance in providing nursing discharge planning, purposely to make clients satisfied and to avoid organizations struggle to create an identity in the market and to help them contribute to the community they serve; 2) therefore, organizations must recognize the influence of impedance and enhancement factors of discharge planning implementation at hospital to improve the quality of nursing care. materials and methods search strategies we searched for articles published from 2010 to 2018 using pubmed, sciencedirect, scopus, and proquest as databases. we entered keywords by using the terms discharge planning, enhancement and impedance factors, and implementation as variables. using these terms, we also combined other keywords, such as nurse * or nursing *for nursing so as to retrieve all relevant articles. in addition, only studies written in english were used for the current study. search results in the form of titles and abstracts are the responsibility of the author to read and select articles that are relevant to the criteria set by the author selection criteria the inclusion criteria of the articles are: 1) including discharge planning implementation as part of nursing activity; 2) is original research; abstract and 3) the subjects of the study are nurses and patients; 4) the location of the study is a hospital. exclusion criteria from the articles sought are those focusing on location in the non-clinical area and the research is a thesis or part of a conference process. data extraction from the fifteen studies chosen, we extracted the types of research, research subjects, and research data sources. research subjects in fifteen of these studies could be nurses, nurse leaders, and patients. in addition, we extracted the results of articles that discussed the relationship between enhancement and impedance factors and discharge planning implementation at hospital. discussion of differences in research results requires consideration from the author. results selection of studies the initial search retrieved a total of 500 studies: 20 from pubmed, 30 from sciencedirect, 250 from proquest, and 200 from scopus. from this, 300 articles have been deleted. based on inclusion and exclusion criteria, the author reviewed each article and reached a consensus regarding its exceptions. the review process for selected articles was developed in three stages, including title review, abstract review, and full text review. we extracted 84 studies from abstract titles and reviews and 69 studies from full text review. finally fifteen articles in total were selected for this study. the retrieval and screening process is summarized in figure 1. based on the research subject, we found the number of respondents was 3250 respondents with details of nurses as many as 1551 respondents and patients as many as 1699. based on the location of the study, we found all of 15 studies were conducted at the hospital. based on the research design, we found eight quantitative studies with the type of descriptive 135 articles screened at title and abstract review 51 articles excluded 69 articles excluded: location not in hospital subject not nurse, or patients 15 articles included pubmed: 20 sciencedirect: 30 scopus: 200 proquest: 250 500 articles 300 articles removed 84 full-text articles assessed for eligibility figure 1. literature search flow jurnal ners http://e-journal.unair.ac.id/jners | 27 studies and three types of cross rcts, and, four qualitative studies. for data sources, the questionnaire is the instrument used from the fifteen articles. we identified several instruments, including r for hospital discharge scale, complete the selfdirected learning readiness scale, and delphi survey questionnaire methodology and a satisfaction questionnaire the enhancement and impedance questionnaire and discharge planning implementation questionnaire were tested for reliability with cronbach’ alpha and everything was stated as reliable, but some instruments were also utilized. from the fifteen journals, we found that the analysis tests used were pearson correlation coefficient, independent-samples t-test, sem, anova, t-test, independent t-test, mann–whitney, multiple logistic regression, and chi square. table 1 summary of studies’ methods. outcomes measure from the results of a review of fifteen articles it was found that the implementation of discharge planning at hospital can be influenced by enhancement and impedance factors. the enhancement factors that have been identified include: the level of knowledge of a nurse toward discharge planning implementation (roberts & moore, 2018); the ability of the discharge planning format to be implemented (durocher et al., 2016); patient readiness to do discharge planning and pro-active treatment rooms carry out discharge planning (yilmaz & ozsoy, 2010); effective communication (fitzgerald et al., 2011); and, a family role in implementing discharge planning (durocher et al., 2016). meanwhile, it is found that the factors that impede discharge planning implementation at hospital are : lack of planning of discharge programs and lack of coordination of health workers with different disciplines (yilmaz & ozsoy, 2010); lack of nurse communication in hospitals with nurses in community services and there no continuity of staff (fitzgerald et al., 2011). discussion this systematic review of enhancement and impedance factors in discharge planning implementation at hospital will try to explore some factors involved in these conditions. firstly, a correlation of those factors with each other has identified from the enhancement factors side; carrie et al (2012) state that the ability of the discharge planning format to be implemented is very influential for effective discharge planning implementation. in the discussion of the participants from their research it also stated that the lack of a number of human resources, skills and time also greatly affected the implementation of discharge planning effectively (yilmaz & ozsoy, 2010). it means there is also a relation to the level of knowledge of a nurse. elly (2011) explained that the effectiveness of discharge planning implementation for nurses who have been trained in the method and concept of discharge planning will be more effective in implementing discharge planning than nurses who have not trained (mohamed et al., 2014). also rudd and smith (2013) in found that treatment rooms that proactively carry out discharge planning will be able to reduce length of stay and decrease costs (rudd, caroline; smith, 2013). furthermore, there are also enhancement factors from the patients’ side. patient readiness to do discharge planning is also an important factor in achieving discharge planning implementation effectiveness at hospital, with its predictors being sex, age, education status, marital status, all of which will be very helpful in achieving table 1. general characteristics of subject study (n=15) category n % year of publishing 2010 1 6.67 2011 1 6.67 2012 1 6.67 2013 1 6.67 2014 2 13.3 2015 3 20 2016 1 6.67 2017 1 6.67 2018 3 20 participants nurses 11 73.3 patients 4 26.6 participants’ ages children 1 6.67 adults 14 93.3 type of study descriptive research 8 53.3 rct 3 20 qualitative research 4 26.7 rct: randomized control trial h. soebagiyo et al. 28 | pissn: 1858-3598  eissn: 2502-5791 table 2. summary of studies on enhancement and impedance factors in discharge planning implementation at hospital. study and author population / sample intervention comparison outcome time effectiveness of an instructional program on nurses knowledge and practice concerning patients discharge planning post cardiac surgery at cardiac centers and hospitals in baghdad city (abdulrdha & mansour, 2018) the study samples are composed of (58) nurses who have been working in the surgical wards of ibn al-bitar specialized center for cardiac surgery; iraqi center for heart disease and ibn al nafees hospital; those nurses are divided equally into the study group (29) and control group (29} those nurses are divided equally into the study group experiment (29) and control group (29). nurses as treatment group who participated in education program. level of knowledge at general information, follow-up, wounds care, exercise program and daily activity, common health problems, medication, nutrition and risk factor modification are tested by t-test. effectiveness of educational program regarding nurses’ practice toward planning patients’ discharge had a positive effect on nurses’ practice as compared with control group in relation to all discharge planning domains january , 2nd, 2017, to june 1st, 2018 patients’ readiness for discharge: predictors and effects on unplanned readmissions, emergency department visits and death (kaya & sainguven, 2018). this 1-year prospective cohort study included 1,601 respondents 1. the patient readiness for hospital discharge scale/short form is used. 2. data were analyzed using a chi-square test, mann–whitney u test, univariate logistic regression analysis and multiple logistic regression analysis. the determination of patients self assessment the results of multiple logistic regression analysis revealed that age, sex, marital status, educational status, presence of someone to help at home after discharge and length of stay were predictors of patients’ readiness for hospital discharge septemb er 2018 improving discharge planning using the reengineered discharge program (roberts & moore, 2018) sixty-nine participants complete the self directed learning readiness scale prior to the red education intervention. 1.provide thirtyminute education interventions addressing various learning preferences 1. nurses’ readiness to learn (rtl) before receiving education on the reengineered discharge (red) program 2. measured utilization of the red discharge process from patient chart reviews following an educational intervention. participants scored high m = 219.8 (sd 23.7) on the sdlr, indicating nurses’ high rtl prior to educational intervention chart. reviews found usage of the red 12 actionable item pre-intervention, (n = 60) m = 6.55 (sd 1.478) compared to post-intervention (n = 60) m = 10.08 (sd 1.544) indicated statistically significant improvement in pre-discharge patient education and planning (t = 17.730, p=0.000 [ci 3.13– 3.93]) 2018 framework and components. for a total of 24 nurses participated.in the delphi methodology was delphi approach 1. a total of 24 participants 24 augus jurnal ners http://e-journal.unair.ac.id/jners | 29 study and author population / sample intervention comparison outcome time effective discharge planning system (yam et al., 2012) an instructional program on nurse knowledge and practice concerning patients’ discharge planning post cardiac surgery at cardiac centers and hospitals in baghdad consensus-building process adopted to engage a group of experienced healthcare professionals to rate and discuss the framework and components of an effective discharge planning. the framework consisted of 36 statements under five major themes: initial screening, discharge planning process, coordination of discharge, implementation of discharge, and postdischarge follow-up. each statement was rated independently based on three aspects including clarity, validity and applicability on a 5point likert-scale and findings of the second stage on pretesting the framework developed so as to validate and at test to its applicability and practicabilit y in which consensus was sought on the key components of discharge planning. participated in the consensus-building process. in round one rating, consensus was achieved in 25 out of 36 statements. among those 11 statements not reaching consensus, the major concern was related to the “applicability” of the statements. 2.the participants expressed a lack of manpower, skills and time in particular during weekends and long holidays in carrying out assessment and care plans within 24h after admission t 2011 and re searc h text accept ed 2012 barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals (wong et al., 2011) a total of 41 healthcare professionals (9 physicians, 13 nurses, 6 occupational therapists, 5 physiotherapists, and 8 medical social workers) participated in the fgd. majority of the participants were female, and the age range was 30-59 years old. focus groups interviews were conducted with different healthcare professionals who were currently responsible for coordinating the discharge planning process in the public hospitals 1.current practice on hospita l discharge 2.barriers to effective hospital discharge 1. participants highlighted that there was no standardized hospital-wide discharge planning and policy-driven approach in the public health sector in hong kong. 2.potential barriers included lack of a standardized policydriven discharge planning program, and lack of communication and coordination among different health service providers and patients as the main issues julyaugust 2010. resea rch text is accepted in 2011 mediators of marginalization in discharge planning with older adults .qualitative study (durocher et al., 2016). 22 participant interviews including five older adults, seven family members and eight healthcare professionals critic bioethical approaches seeking to examine ethical issues in the provision of healthcare in relation to social and political structures, practices the themes of analysis included underlying beliefs, valued approaches and conventional practices 1. findings included the identification of coconstituting influences on participants’ perspectives and behaviors in the process of discharge planning, which intersected to affect older adults’ 2016 year h. soebagiyo et al. 30 | pissn: 1858-3598  eissn: 2502-5791 study and author population / sample intervention comparison outcome time and processes agency and participation in discharge planning. 2. resulting that discourses of ‘ageing-as-decline’ beliefs privileging healthcare professionals’ expertise; approaches that prioritized safety over all other values; and established conventions that guided the discharge planning family conference served to marginalize effectiveness of a discharge planning program and home visits for meeting the physical care needs of children with cancer (yilmaz & ozsoy, 2010). the research population was all children, and their caregivers, who were admitted to the pediatric oncology unit at the hospital in izmir, which.is located in western turkey. for the experimental group, 24 child discharge planning ,discharge teaching, home visits, and telephone consultation were provided and planned investigating effectivenes s o f a dischargeplanning program o n helping caregivers meeting the physical care needs of children with cancer between 0–18 years of age. a dischargeplanning program and a hospital-based home care model had a very significant effect on the care needs of children with cancer and their caregiver 2010 factors that enhance or impede critical care nurses’ discharge planning practices (r. watts et al., 2005). 502 critical care nurses, identified from the australian college of critical care nursing (acccn) a total of 218 eligible participants completed the survey. one-to-one semistructured interviews with 13 victorian critical care nurses were also conducted australian college of critical care nursing (acccn) (victoria) database were invited to participate in this study. a 31-item questionnaire was developed and distributed 1.participants reported that a lack of time was a barrier to discharge planning 2.communication, however, could enhance or impede the discharge planning process in critical care. 2015 discharge planning (rudd, caroline; smith, 2013) they were wellattended, with more than 50%, 42 of the 69 trained staff from the unit, attending. : two audits were conducted by a small team of nurses to measure the effectiveness of discharge management and planning in a fourward orthopedic and trauma unit lost bed days and reduce costs 1.the findings showed that some wards were proactive: planning started on admission and patients were given realistic planned discharge dates and a list of probable capabilities. 2013 jurnal ners http://e-journal.unair.ac.id/jners | 31 study and author population / sample intervention comparison outcome time 2.discharge planning varied from ward to ward, and there was no shared common practice a survey of malaysian critical intensive care unit nurses' awareness of patients' transition experiences (pe) and transitional care practice (tcp) (mohamed et al., 2014). the survey had a response rate of 65.2% (178 of 273 eligible nurses). the respondents' mean age was 29.6 years. most of the respondents were from public hospitals and the majority had one to five years' experience working as registered nurses, and in cicu 1.a descriptive questionnaire was used to survey registered nurses in seven cicus in four hospitals in malaysia. 2.data were analyzed using descriptive statistics and correlation analysis public teaching hospital nurses (tcp) transitional care practice there was a positive correlation between nurses' awareness of patients' transition experience and its impact, and their awareness of transitional care practice performance (rs=0.42; p<0.05). . 2014 collaboration challenges faced by nurses when premature infants are discharged (6). 1. qualitative individual interviews were undertaken with two nicu nurses and two public health nurses. 2. a qualitative content analysis was used to analyze the data. three main themes were identified: different expectations and lack of communication between nicu nurses and public health nurses; responsibilities and interactions between the two professional groups were not clearly defined; and the public health nurses’ competence was not recognized by the nicu nurses and .parents. 2018 year . the role of relatives in discharge planning from psychiatric hospital the perspective of patients and their relatives (backer et al., 2007). 98 psychiatric inpatients and 40 of their relatives with family involvement in discharge planning satisfaction questionnaires were completed most participants were satisfied if relatives were involved in discharge planning. however, up to 89% of patients, and 84% of relatives, reported no communication between clinical staff and relatives regarding discharge 2015 nurses’ discharge planning and risk assessment: behaviors, understanding and barriers (jane graham1, robyn gallagher2 31 nurse quantitative descriptive research nurse comprehension toward discharge plan nurse adherence to implement discharge planning nurse adherence toward implementation discharge planning is low 20 % impedance factors are is lack of time to implementation discharge planning 2015 h. soebagiyo et al. 32 | pissn: 1858-3598  eissn: 2502-5791 study and author population / sample intervention comparison outcome time and janine bothe3, 2015) how do critical care nurses define the discharge planning process (r. j. watts et al., 2005). 502 victorian critical care nurses were approached to take part in the study utilizing an exploratory descriptive approach, three common themes emerged. a significant number of participants did not believe that discharge planning occurred in critical care, and, therefore, thought that they could not provide a definition. there was uncertainty as to what the discharge planning process actually referred to in terms of discharge from critical care to the general ward or discharge from the hospital 2014 assessing the effectiveness of advanced nurse practitioners undertaking home visits in and out of hours urgent primary care service in england (collins, 2017). concerning patients discharge planning post cardiac surgery at cardiac centers and hospitals in baghdad city 34 advanced nurse practitioners at london observation and survey to measure the effectiveness of advanced nurse practitioner s (anps) against national quality requirement s for out of-hours advanced nurse practitioners are as effective as gps in undertaking urgent home visits. their documentation is more consistent and their refer-on rate to secondary care is less than that of gp colleagues., 2017 discharge planning, especially when at home (r. j. watts et al., 2005). in further discussion, it will affect also the readiness of their support system to provide back up to fulfill patient necessity at home. the role of the family cannot be denied as a very helpful support system, especially when the patient is at home. the patient will feel motivated to obey the treatment in order to speed up recovery. fitzgerald (2011) has revealed he role of the family as care giver, observer, and a reminder to always remember the importance of being obedient in the treatment corridor (durocher et al., 2016). from the other side, there are some impedance factors in discharge planning implementation, namely, lack of coordination between health workers with different disciplines also plays a role in discharge planning. wong et al. (2011) explains that the potential barriers include lack of standardized policy-driven discharge planning programs, and lack of communication and coordination among different health service providers and patients in both acute and sub-acute care settings, which were identified as mainly system issues. improving the quality of hospital discharge was suggested, including a multidisciplinary approach with clear identified roles among healthcare professionals and a communication of health professionals' enhancement of knowledge and patient psychology (r. watts et al., 2005). secondly, lack of nurse communication in hospital with nurses in community service (rudd, caroline; smith, 2013). based on those impedance factors, communication is the most crucial problem to properly afford jurnal ners http://e-journal.unair.ac.id/jners | 33 implementation discharge planning at hospital. finally, watts et al. (2015) implied that several factors influence the effectiveness of the implementation of the discharge, including inadequate effective communication (fitzgerald et al., 2011). conclusion the study results show discharge planning is a very important activity in nurse health care. unfortunately, it has still lack of implementation at hospital up to now. based on those conditions, this systematic review seeks to know what kind of factors influence discharge planning implementation at hospital. the results refer to two crucial factors, namely, enhancement and impedance factors. by knowing those factors the nurses, hopefully not only improve enhancement, but also impedance factors in their healthcare to provide high quality nursing care and patient safety optimally. conflict of interest no conflict of interest has been declared acknowledgement the researcher of this study wishes to thank the faculty of nursing and also the master’s in nursing study programme to provide support to present this study paper. references abdulrdha, & mansour. (2018). effectiveness of an instructional program on nurse’s knowledge and practice concerning patients discharge planning post cardiac surgery at cardiac centers and hospitals inbaghdad city. journal of nursing management, 26, 707–716. backer, t. e., howard, æ. e. a., & moran, æ. g. e. (2007). the role of effective discharge planning in preventing homelessness. journal primary prevent, 28, 229–243. https://doi.org/10.1007/s10935-007-0095-7 collins, d. (2017). assessing the effectiveness of advanced nurse practitioners undertaking home visits in an out of hours urgent primary care service in england. journal of nursing management, 25, 519–530. durocher, e., gibson, b. e., & rappolt, s. (2016). mediators of marginalisation in discharge planning with older adults. cambridge university press. fitzgerald, l. r., nurs, d. t., & lecturer, s. (2011). hospital discharge : recommendations for performance improvement for family carers of people with dementia. australian health review, 364–370. gray, constance; christensen, martin; bakon, s. (2016). nurse initiated and criteria led discharge from hospital for children and young people. nursing children and young people, 28(8). https://doi.org/10.7748/ncyp.2016.e714 kaya, s., & sainguven, g. (2018). patients’ readiness for discharge: predictors and effects on unplanned readmissions, emergency department visits and death. journal of nursing management. mohamed, s., parker, s., & arbon, p. (2014). a survey of malaysian critical intensive care unit nurses ’awareness of patients’ transition experiences (pe) and transitional care practice (tcp). intensive & critical care nursing, 30(4), 196–203. https://doi.org/10.1016/j.iccn.2013.12.006 nursalam. (2018). manajemen keperawatan aplikasi dalam praktik keperawatan profesional (5th ed.). salemba medika. pauline voie , mona; tunby , jorunn; strømsvik, n. (2018). collaboration challenges faced by nurses when premature infants are discharged. nursing children and young people, 3(2). https://doi.org/10.7748/ncyp.2018.e960 roberts, s., & moore, l. (2018). improving discharge planning using the re-engineered discharge programme. journal of nursing management. rudd, caroline; smith, j. (2013). discharge planning. nursing standard, 17. watts, r., gardner, h., & pierson, j. (2005). factors that enhance or impede critical care nurses ’ discharge planning practices. intensive and critical care nursing, 21, 302–313. https://doi.org/10.1016/j.iccn.2005.01.005 watts, r. j., pierson, j., & gardner, h. (2005). how do critical care nurses define the discharge planning process ? intensive and critical care nursing, 21, 39–46. https://doi.org/10.1016/j.iccn.2004.07.006 wong, e. l. y., yam, c. h. k., cheung, a. w. l., leung, m. c. m., chan, f. w. k., & wong, f. y. y. (2011). barriers to effective discharge planning : a qualitative study investigating the perspectives of frontline healthcare professionals. bmc health services research, 11(1), 242. https://doi.org/10.1186/1472-6963-11-242 yam, c. h. k., wong, e. l. y., cheung, a. w. l., chan, f. w. k., wong, f. y. y., & yeoh, e. (2012). framework and components for effective discharge planning system : a delphi methodology. bmc health services research, 12(1), 1. https://doi.org/10.1186/1472-696312-396 yilmaz, m. c., & ozsoy, s. a. (2010). effectiveness of a discharge-planning program and home visits for meeting the physical care needs of children with cancer. springer, 243–253. https://doi.org/10.1007/s00520-009-0650-2 http://e-journal.unair.ac.id/jners | jurnal ners vol. 15, no. 3, october 2020 http://dx.doi.org/10.20473/jn.v15i3. 17958 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research model theory of planned behavior to improve adherence to treatment and the quality of life in tuberculosis patients made mahaguna putra1, ni putu wulan purnama sari2 1 school of health sciences buleleng, bali, indonesia 2 widya mandala catholic university surabaya, indonesia abstract introduction: tuberculosis (tb) is a global public health problem and a leading cause of death from infectious diseases. the research objective was to determine the relationship between the theory of planned behavior, adherence and quality of life using the path model. methods: this study employed a cross-sectional design with 154 tuberculosis patients. the research was conducted in all community health centers in the buleleng, bali. data on subjective norms, attitudes, perceived behavior control, intention, physical and mental hrqol domains and medical adherence were collected. data were analyzed using a descriptive and structural equation model feature using structural equation model. results: most respondents have attitudes in the positive category and subjective norms in the good category. perceived behavior is control in the good category, intentions in the good category and physical health in the good category. almost all respondents have mental health in the good category and are married. all respondents in this study had adherence to treatment. the influence of subjective norms on intentions (p = <0.01), the influence of intentions on adherence (p = <0.01) and the effect of adherence on quality of life (p = <0.01) were found. conclusion: subjective norms are the most important part to influence intention. adequate tb treatment causes hrqol to improve. article history received: feb 18, 2020 accepted: august 25, 2020 keywords adherence; behavior; quality of life; tuberculosis contact made mahaguna putra md.mahagunaputra@gmail.com school of health sciences buleleng, bali, indonesia cite this as: putra, m. m., & sari, n. p. w. p. (2020). model theory of planned behavior to improve adherence to treatment and the quality of life in tuberculosis patients. jurnal ners, 15(3). x-x. doi:http://dx.doi.org/10.20473/jn.v15i1.17958 introduction tuberculosis (tb) remains a major cause of health problems. worldwide, around 10 million people are diagnosed with tb each year. there were 1.2 million (range 1.1-1.3 million) tb deaths among hivnegative people in 2018. tb is one of the 10 leading causes of death worldwide, and the main cause of tb is an infectious agent ( mycobacterium tuberculosis), ranking above hiv / aids (who, 2019). based on the results of the 2013-2014 tb indonesia prevalence survey, the estimated tb prevalence was 1,600,000 cases while the tb incidence was 1,000,000 and the tb mortality was 100,000 cases. in 2018, the second highest case finding was in the regency of buleleng at 114.6 per 100,000 population (dinas kesehatan provinsi bali, 2019). it was evaluated that, in terms of treatment, medication adherence is one of the main obstacles faced by patients due to adverse reactions, long-term therapy and initial perception of healing, which weakens adherence and contributes to treatment neglect; therefore, adherence to tb has become a challenge for patients, as well as for health services, and it is necessary to formulate strategies that minimize the difficulties encountered (carla et al., 2015). therefore, it is important to consider the social and clinical effects caused by this disease, especially those related to decreased quality of life. it should be understood that the quality of life in people with tb is a meeting of complex elements, such as disease, poverty, and stigma, which are negatively reflected in family life, work, and social activities. it is, therefore, considered important to create professional-patienthttps://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ayu.adnyadewi@gmail.com mailto:ayu.adnyadewi@gmail.com m. m. putra et al. | pissn: 1858-3598 eissn: 2502-5791 family relationships in care and follow-up, and it is necessary to implement health measures that seek to improve treatment adherence (farias, medeiros, paz, lobo, & ghelman, 2013). health-related quality of life (hrqol) is defined as "the extent to which a patient's subjective perception of physical, mental and social well-being by an illness and its treatment"(dion, tousignant, bourbeau, menzies, & schwartzman, 2004; leidy, revicki, & genesté, 1999). patients with chronic diseases value their mental and social wellbeing in addition to physical health (sherbourne, sturm, & wells, 1999). the need to measure hrqol is important because of the broader concept of measuring health status beyond conventional indicators, such as mortality and morbidity. hrqol is an indicator of the effects of disease and related morbidity on regular activities and functions. as a result, hrqol evaluations have become important health outcomes and areas of interest for policy makers, healthcare professionals and researchers. hrqol evaluation in patients with tb is very important to identify appropriate actions to improve their health status and quality of life (chamla, 2004). thus, one of the main goals in tb control is to reduce the rate of treatment neglect, because stopping treatment causes greater spread of bacilli, because patients remain as a source of transmission, contribute to preventative drugs and increase treatment time and care costs, jeopardizing the quality of life of patients (chirinos & meirelles, 2011). we employed the theory of planned behavior as the conceptual framework to guide this process. in a systematic review of guideline implementation studies, it was the most likely theory to predict guideline adherence (godin, bélanger-gravel, eccles, & grimshaw, 2008). this theory asserts that intention is the best predictor of behavior and that three factors mediate the strength of intention: (1) attitudes (expected value of behavioral performance); (2) subjective norms (what important others think about the behavior); and (3) self-efficacy (perception of ability to overcome barriers to behavioral performance) (ajzen, 1985). the lack of research on the application of theory planned behavior on the quality of life of tuberculosis patients made researchers interested in conducting this research. the research objective was to determine the relationship between the theory of planned behavior, adherence and quality of life using the path model. materials and methods this study employed a cross-sectional design with 154 tuberculosis patients who were selected using random sampling. data collection was conducted from may to september 2019. the research was conducted in all community health centers in the buleleng. the variables in this study are perceived behavior control, subjective norms, attitude, intention, adherence and quality of life. the instrument in this study consisted of six questionnaires. a) perceived behavior control assessment questionnaire: a closed questionnaire sheet containing questions about perceived behavioral control based on the development of the theory of planned behavior-based adherence approach model on type ii dm clients (lestarina, 2018) where researchers make modifications to the topic of questions in the questionnaire. the table 1. characteristic of respondent characteristic respondent n (%) age (mean ± sd) 50 years ± 13.79 gender male 92 (40.26) female 62 (59.74) education level no school 7 (4.55) elementary school 51 (33.12) middle school 70 (45.45) high school 19 (12.34) higher education 7 (4.55) employment labor 67 (43.51) government employees 6 (3.90) not working 40 (25.97) entrepreneur 41 (26.62) marital status single 12 (7.79) married 142 (92.21) family size member less than 3 members 52 (33.77) more than 3 members 102 (66.23) socioeconomic status < 1 million 57 (37.01) 1-2 million 54 (35.06) > 3 million 43 (27.92) attitude positive 87 (56.49) negative 67 (43.51) subjective norms good 93 (60.39) poor 61 (39.61) perceived behavior control good 80 (51.95) less 74 (48.05) intention good 101 (65.58) less 53 (34.42) physical health good 113 (73.38) less 41 (26.62) mental health good 142 (92.21) less 12 (7.79) adherence to treatment yes 154 (100) no 0 (0) jurnal ners http://e-journal.unair.ac.id/jners | determination of the questionnaire answers using a 4-point likert scale consists of eight questions, both if the score ≥ means data and less if the scores ≤ mean data. b) subjective norms assessment questionnaire:a closed questionnaire sheet containing questions about subjective norms based on the development of a theory of planned behavior-based adherence approach model on type ii dm clients (lestarina, 2018). the researcher modified the topic of questions in the questionnaire. the determination of the questionnaire answers uses the 4-point likert scale and consists of eight questions, both if the score ≥ means data and less if the scores ≤ mean data. c) attitude assessment questionnaire: a closed questionnaire sheet containing questions about attitudinal factors modified from knowledge and attitudes on ltbi treatments acceptance (biedenharn, 2015) and the development of a theory of planned behavior-based adherence approach model for type ii dm clients (lestarina, 2018). the researcher modified the topic of questions in the questionnaire. this questionnaire consists of 10 questions. d) intention assessment questionnaire: a closed questionnaire sheet containing questions about intentions / intentions based on the development of the theory of planned behavior-based adherence approach model on type ii dm clients (lestarina, 2018). the researcher modified the topic of questions in the questionnaire. determination of the questionnaire answers using the 4-point likert scale consists of six questions, both if the score ≥ mean data and less if the score ≤ mean data. e) adherence assessment questionnaire: the morinsky medication adherence scale (mmas) questionnaire was used in the study, which consisted of eight statements (de las cuevas & peñate, 2015) which had been translated into indonesian. questionnaire answers using the guttman scale, where respondents' answers are only limited to two answers, "yes" and "no". the higher the total value indicated the patient is compliant in treatment. f) quality of life assessment questionnaire: the sf-36v2 was used in the study. this questionnaire consisted of 36 question items consisting of eight scale items of health and welfare function profiles. the following are the detailed questions asked in this questionnaire, namely physical functioning (pf) in question number 3, rolephysical (rp) in question number 4, bodily pain (bp) in questions number 7 and 8, general health (gh ) in questions number 1 and 11, vitality (vt) questions number 9 (a, e, g, i), social functioning (sf) in questions number 6 and 10, role-emotional (re) question number 5, mental health ( mh) question number 9 (b, c, d, f, h) and self-evaluated transition (set) on question number 2. two main items assessed are: physical health summary: score 30-70, with an average of 50 and mental health summary: a score of 30-70, with an average of 50. for all scales and summary components, higher scores demonstrate better hrqol (zhou et al., 2013). data were analyzed using a descriptive and structural equation model feature using stata software. ethical approval for this study was obtained from the school of health sciences buleleng committee of ethic research no. 092/ec-kepksb/vii/2019. results table 1 shows the average age of the respondent is 50 years. nearly half the respondents have a middle school level of education, work as a laborer, have a socioeconomic status <1 million and most respondents have more than three family members. table 2 shows most respondent have attitudes in the positive category, subjective norms in the good category, perceived behavior control in the good category, intentions in the good category and physical health in the good category. almost all respondents have mental health in the good category and are married. all respondents in this study had adherence to treatment. table 2 shows the influence of subjective norms on intention, the effect of intention on adherence and the effect of adherence on quality of life. goodness of fit results: χ2: 93.02, rmsea: 0.220, cfi: 0.673, tli: 0.464, srmr: 0.158, aic: 5640.15. based on the results of the output goodness of fit statistics, the sem model developed in this study is not yet good table 2. characteristic variable variable n (%) attitude positive 87 (56.49) negative 67 (43.51) subjective norms good 93 (60.39) poor 61 (39.61) perceived behavior control good 80 (51.95) less 74 (48.05) intention good 101 (65.58) less 53 (34.42) physical health good 113 (73.38) less 41 (26.62) mental health good 142 (92.21) less 12 (7.79) adherence to treatment yes 154 (100) no 0 (0) table 2. summary of structural equation model variable z p attitude intention 1.39 0.16 subjective norms intention 6.34 <0.01 perceived behavior control intention -0,58 0.563 intention adherence 2.64 <0.01 adherence qol 14.35 <0.01 m. m. putra et al. | pissn: 1858-3598 eissn: 2502-5791 discussion this study found that all respondents who had medication adherence were influenced by intention. a pulmonary tb patient who has good intentions with high values will have a tendency to adhere to routine treatment. the new knowledge of this research is quality of life is influenced by medication adherence to tb patients. according to ajzen (2005) intention to perform behavior is a tendency for someone to choose to do / not do something work. this intention is determined by the extent to which the individual has a positive attitude to certain behaviors and the extent to which he chooses to do certain behaviors and he has the support of others who are influential in his life. intention is a factor that drives how someone has a strong desire to strive for a behavior, if they have the desire / interest to do it. intention is influenced by attitudes, subjective norms, and perceptions in controlling behavior. research (lestarina, 2018) shows that intention has an influence on adherence. intention / intention is the closest factor that can predict the emergence of behavior (alberta, proboningsih, & almahmudah, 2016). adherence in taking daily medication is the behavior to adherence the suggestions or procedures from doctors about the use of drugs, which was preceded by the consultation process between patients and doctors as health service providers. some aspects that are used to measure adherence in taking daily drugs are frequency, number of pills / other drugs, continuity, metabolism in the body, biological aspects in the blood, and physiological growth in the body. the determinants of the emergence of adherence in taking daily medication include: patient perception and behavior, interaction between patient and doctor, and medical communication between the two parties as well as intention to recover (lailatushifah, 2012). this study shows that respondents who have medication adherence have good quality of life. after treatment, tb still has an impact on the physical, emotional, psychological, social and economic dimensions of hrqol (kastien-hilka et al., 2016). significant side effects associated with prolonged pharmacological treatment affect tb patients in health-related quality of life (hrqol). thus, successful tb treatment is essential for public health (park, george, & choi, 2020). hrqol is important to consider at three critical points in treatment: at the beginning of tb treatment, during the intensive treatment phase (first two months), and at the completion of treatment (chirwa et al., 2013). in clinical research, quality of life related to health (hrql) has become an accepted measure of outcome (hansel, wu, chang, & diette, 2004) and has been described as an individual's perception of wellbeing in physical, psychological and social aspects (guo, marra, & marra, 2009). physical and mental stress are common in tb patients and as a result lead to poor disease outcomes or poor treatment outcomes (babikako, neuhauser, katamba, & mupere, 2010). physical function reflects the patient's capacity to perform basic daily activities, while psychological health takes into account several aspects of the mood and emotional wellbeing of the individual. this disease also affects nearly half of daily activities among patients with tuberculosis. most patients are worried, frustrated, or disappointed with the diagnosis, and nearly a quarter initially did not receive their diagnosis (rajeswari, muniyandi, balasubramanian, & narayanan, 2005). adequate tb treatment causes hrqol to improve (louw, mabaso, & peltzer, 2016). conclusion tb patients who have good intentions with high scores will have a tendency to adhere to routine treatment. quality of life is a complex concept which includes physical and mental health. patients who take adequate tb treatment affect their quality of life, figure 1. path model of relationships between variables attitude 14 25 subjective_norms 13 23 perceived_beahavior_control 9.9 19 intention 7.3 1 4.4 obey 7.7 2 5.2 qol 3 23 physical_health 46 4 31 mental_health 35 5 5.9 .082 .41 -.039 .23 .68 1 1 jurnal ners http://e-journal.unair.ac.id/jners | mentally and physically. in providing health promotion related to medication adherence, community service center nurses must increase the tb patient's intention to seek treatment so that quality of life is good. a limitation in the study was that adherence was observed only once. the study cannot be a reference adherence of tb patients in indonesia. references ajzen, i. (1985). from intention to action: a theory of palnned behavior. in j. kuhl & j. beckmann (eds.), springer series in social psychology (pp. 11–39). heidelberg: springer. ajzen, i. (2005). attitudes, personality and behavior : second edition. poland: mc graw hill. alberta, l. t., proboningsih, j., & almahmudah, m. (2016). the improvement of low salt diet behavior based on theory of planned behavior on elderly with hypertension. jurnal ners, 9(2), 297. https://doi.org/10.20473/jn.v9i22014.297304 babikako, h. m., neuhauser, d., katamba, a., & mupere, e. (2010). feasibility, reliability and validity of health-related quality of life questionnaire among adult pulmonary tuberculosis patients in urban uganda: crosssectional study. health and quality of life outcomes, 8, 93. https://doi.org/10.1186/1477-7525-8-93 biedenharn, a. m. (2015). assessment of knowledge and attitudes on latent tuberculosis treatment acceptance in a southwest ohio public health clinic. carla, l., oliveira, s., de almeida nogueira, j., duarte de sá, l., palha, p. f., alves da silva, c., … villa, s. (2015). the discourse of individuals on feelings associated with coping with tuberculosis* a discursividade do sujeito sobre sentimentos associados ao enfrentamento da tuberculose. revista eletrônica de enfermagem, 17(1). https://doi.org/10.5216/ree.v17i1.24523 chamla, d. (2004). the assessment of patients’ health-related quality of life during tuberculosis treatment in wuhan, china. international journal of tuberculosis and lung disease, 8(9), 1100–1106. chirinos, n. e. c., & meirelles, b. h. s. (2011). factors related to abandoning tuberculosis treatment: an integrative review. texto e contexto enfermagem, 20(3), 399–406. https://doi.org/10.1590/s010407072011000300023 chirwa, t., nyasulu, p., chirwa, e., ketlogetswe, a., bello, g., dambe, i., … joshua, m. (2013). levels of tuberculosis treatment adherence among sputum smear positive pulmonary tuberculosis patients attending care at zomba central hospital, southern malawi, 2007–2008. plos one, 8(5), e63050. https://doi.org/10.1371/journal.pone.006305 0 de las cuevas, c., & peñate, w. (2015). psychometric properties of the eight-item morisky medication adherence scale (mmas-8) in a psychiatric outpatient setting. international journal of clinical and health psychology, 15(2), 121–129. https://doi.org/10.1016/j.ijchp.2014.11.003 dinas kesehatan provinsi bali. (2019). profil kesehatan provinsi bali tahun 2018. denpasar: dinas kesehatan provinsi bali. dion, m. j., tousignant, p., bourbeau, j., menzies, d., & schwartzman, k. (2004). feasibility and reliability of health-related quality of life measurements among tuberculosis patients. quality of life research, 13(3), 653–665. https://doi.org/10.1023/b:qure.0000021320 .89524.64 farias, s. n. p. de, medeiros, c. r. da s., paz, e. p. a., lobo, a. de j. s., & ghelman, l. g. (2013). completeness in caring: study of quality of life in clients with tuberculosis. escola anna nery, 17(4), 749–754. https://doi.org/10.5935/14148145.20130020 godin, g., bélanger-gravel, a., eccles, m., & grimshaw, j. (2008). healthcare professionals’ intentions and behaviours: a systematic review of studies based on social cognitive theories. implementation science, vol. 3. https://doi.org/10.1186/1748-5908-3-36 guo, n., marra, f., & marra, c. a. (2009, february). measuring health-related quality of life in tuberculosis: a systematic review. health and quality of life outcomes, vol. 7, p. 14. https://doi.org/10.1186/1477-7525-7-14 hansel, n. n., wu, a. w., chang, b., & diette, g. b. (2004, april). quality of life in tuberculosis: patient and provider perspectives. quality of life research, vol. 13, pp. 639–652. https://doi.org/10.1023/b:qure.0000021317 .12945.f0 kastien-hilka, t., abulfathi, a., rosenkranz, b., bennett, b., schwenkglenks, m., & sinanovic, e. (2016). health-related quality of life and its association with medication adherence in active pulmonary tuberculosis– a systematic review of global literature with focus on south africa. health and quality of life outcomes, 14(1), 42. https://doi.org/10.1186/s12955-016-0442-6 lailatushifah, s. n. f. (2012). kepatuhan pasien yang menderita penyakit kronis dalam mengkonsumsi obat harian. fakultas psikologi universitas mercubuana. leidy, n. k., revicki, d. a., & genesté, b. (1999). recommendations for evaluating the validity of quality of life claims for labeling and promotion. value in health, 2(2), 113–127. https://doi.org/10.1046/j.15244733.1999.02210.x lestarina, n. n. w. (2018). theory of planned behavior sebagai upaya peningkatan m. m. putra et al. | pissn: 1858-3598 eissn: 2502-5791 kepatuhan pada klien diabetes melitus. media kesehatan masyarakat indonesia, 14(2), 201. https://doi.org/10.30597/mkmi.v14i2.3987 louw, j. s., mabaso, m., & peltzer, k. (2016). change in health-related quality of life among pulmonary tuberculosis patients at primary health care settings in south africa: a prospective cohort study. plos one, 11(5). https://doi.org/10.1371/journal.pone.015189 2 park, s., george, m., & choi, j. y. (2020). quality of life in korean tuberculosis patients: a longitudinal study. public health nursing, phn.12691. https://doi.org/10.1111/phn.12691 rajeswari, r., muniyandi, m., balasubramanian, r., & narayanan, p. r. (2005). perceptions of tuberculosis patients about their physical, mental and social well-being: a field report from south india. social science and medicine, 60(8), 1845–1853. https://doi.org/10.1016/j.socscimed.2004.08. 024 sherbourne, c. d., sturm, r., & wells, k. b. (1999). what outcomes matter to patients? journal of general internal medicine, 14(6), 357–363. https://doi.org/10.1046/j.15251497.1999.00354.x who. (2019). global tuberculosis report 2019. retrieved from http://apps.who.int/iris zhou, k., zhuang, g., zhang, h., liang, p., yin, j., kou, l., … you, l. (2013). psychometrics of the short form 36 health survey version 2 (sf-36v2) and the quality of life scale for drug addicts (qoldav2.0) in chinese mainland patients with methadone maintenance treatment. plos one, 8(11), e79828. https://doi.org/10.1371/journal.pone.007982 8 http://e-journal.unair.ac.id/jners | 71 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16986 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review obesity and stunting in childhood. do grandparents play a role? a systematic review rizki agustin purwaningtyas, ardila lailatul barik and dwi astuti faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: obesity and stunting in childhood has become one of the greatest global health challenges. the impact of this issue is serious and lasting for individuals, their families, communities and countries. most of the studies on child weight status have only focused on the mother as the primary caregiver, whereas the role and influence of the grandparents has received less attention. grandparent-provided child care has become a trend in many countries, with reported rates of approximately 40% to 58%. the objective of this systematic review was to analyze whether children become stunted or obese when they are cared for by their grandparents. methods: the methodological search of the literature was conducted using scopus, science direct, pubmed, pro quest and researchgate, and it was undertaken using prisma guidelines. the search identified 1803 papers and 135 full-text articles were screened for eligibility. finally, 15 met the inclusion criteria. the keyword chain was as follows: ("obesity" or "stunting") and (“children”) and (“grandparents”). results: as grandparents take on increasingly responsible roles in the lives of their grandchildren, there is an influence on the higher risk of child obesity rather than stunting. conclusion: in future, nurses should target not only the mother but also the grandparents to control their child’s health, especially when related to their weight status. article history received: dec 26, 2019 accepted: dec 31, 2019 keywords obesity; stunting; children; grandparents contact rizki agustin purwaningtyas  rizki.agustin.purwaningtyas2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: purwaningtyas, r. a., barik, a. l., & astuti, d. (2019). obesity and stunting in childhood. do grandparents play a role? a systematic review.jurnal ners, 14(3si), 71-75. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16986 introduction the increasing rate of overweight and obesity is faced in many developing countries, though undernutrition is still prevalent in these countries as well. this coexistence of overnutrition and undernutrition is often referred to as the double burden of malnutrition (sekiyama, jiang, gunawan, dewanti, & honda, 2015). if immediate action is not taken, then countless numbers of people will develop an array of serious, chronic and costly health disorders. unlike undernutrition, overnutrition has multifaceted, clustered effects that result in disability and disease, which creates a significant burden for both families and the healthcare system. because of their smaller stature, children who grow up with a state of malnutrition are at a greater risk of being overweight (weight related to height) as adults (walrod et al., 2018). most of the studies on child weight status have only focused on the mother as the primary caregiver. little rigorous research has been performed that focuses primarily on the influence of the grandparents on child dietary intake and weight status. the trend towards grandparent-provided child care applies internationally, with reported rates of grandparental caregiving being approximately from 40% (geurts, van tilburg, poortman, & dykstra, 2015) and up to 58% (bordone, arpino, & aassve, 2015). in 2010, 66.5% of mothers were engaged in some level of employment, and with this, there has been an increasing call on the grandparents to assist with ‘informal’ childcare (wellard, 2011). as the grandparents take on increasingly responsible roles in the lives of their grandchildren, it could reasonably https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:tria.anisa.firmanti-2018@fkp.unair.ac.id mailto:tria.anisa.firmanti-2018@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v14i3(si). r. a. purwaningtyas, et al. 72 | pissn: 1858-3598  eissn: 2502-5791 be assumed that their attitudes, beliefs and feeding practices may have a similarly significant influence on child dietary intake and weight status (young, duncanson, & burrows, 2018). the objective of this systematic review was to analyze whether children become stunted or obese when they are cared for by their grandparents. who is affected by the grandparent being the caregiver more – is it the boys or girls? how old is the child when their weight status is influenced by the grandparent’s provided care? who is the most common caregiver of the child; the grandparents only or the grandparents with others? materials and methods the study began with a systematic literature search. the next step was to determine the keyword chains, and two components were used as the search terms to identify studies on ‘obesity and stunting in childhood’ and ‘do the grandparents play a role?’: (1) grandparents and stunting, (2) grandparents and obesity. the results of this keyword formulation were used to find the relevant literature in 5 databases (scopus, science direct, pubmed, pro quest, and research gate). the keyword chain was as follows: ("stunting or obesity") and ("grandparents"). the first screening was based on the titles and abstracts. at this stage, the publication was considered to be potentially relevant if the title and abstract had a link to the review topic. articles that met the inclusion criteria were selected for all content. the selected articles totaled 15. this type of analysis requires themes that are relevant to the purpose of the review. the theme groups used for the review and for this form of analysis were: (1) grandparents only or with another caregiver, (2) age of children, (3) gender, and (4) body weight. the limitation regarding publication year was that it had to be between 2015 and now. the only type of document selected was articles. the search results concluded on february 20th, 2019 with a keyword chain and limitation criteria, and it obtained 1803 articles. various inclusion and exclusion criteria were applied; the publications must be in english, the number of qualitative research samples had to be >12 and quantitative >100 and the research sample must be children aged above or below the age of 5 who were cared for by their grandparents. articles that were only a trial and that did not contain written results were not included. results the search results used a predefined keyword chain that generated 1803 publications. the screening results have been presented in the figure below. in the first screening, 1352 publications were excluded after reading the titles based on the inclusion / exclusion criteria. in total, 135 publications were included in the second screening. for the second screening, the publication was downloaded. of the 135 articles, 120 publications were excluded after reading the full text. the reasons for exclusion were: (1) grandchild are not cared for by the grandparents; (2) the number of samples not meeting the minimum; (3) a combination of the reasons above. after the second screening, 15 publications were selected for the systematic review. a detailed description of the publications has been presented in the appendix. the results of the review illustrate that as many as 73.3% have excess weight or are obese when they are cared for by their grandparents. obese children who were cared for by their grandparents were under the age of 5 years making up a percentage of 40.0% while the children who were stunted made up only 26.7%. figure 1. results and selection procedure jurnal ners http://e-journal.unair.ac.id/jners | 73 however, the results of the reviewed journals did not specifically explain the sex of children who were potentially obese or stunted; 40.0% of children who were cared for by their grandparents were obese while the children who experienced stunting when cared for by their grandparents made up only 20.0%. the age of the caregivers that potentially influence their grandchildren to be obese was not specifically mentioned with a percentage of 66.7% while 13.3% of children potentially faced stunting when cared for by a caregiver aged more than 45 years old. by 53.3%, the sex of the caregiver in the articles that were reviewed was not mention specifically. discussion this systematic review discussed the relation between malnutrition (stunting and obesity) and being cared for by their grandparents. fifteen articles have been reviewed. the limitations of this study are that most of the studies didn’t mention the age and gender of the grandparents. so the researcher didn’t know how old the grandparents who cared for their children were and if they were a grandfather or grandmother. the results of this review show that the percentage of obesity is more often than the incidence of stunting in children who were cared for by their grandparents. obesity can occur because the energy intake from food exceeds the children's energy requirements. grandparents have inappropriate perceptions related to nutrition in children (they assume that obese children are healthier and well cared for). grandparents usually over-indulge their grandchildren including overfeeding them. children thus consume more unhealthy snack and sugar-added drinks (unicef; who; the world bank, 2015; (li, adab, & cheng, 2015). the classification of child age in this study showed that children who were more than five years old had the potential of facing obesity. this finding is the same as the research conducted by (lau, au, chao, elbaar, & tse, 2018) that showed that school-age (>5 years old) and adolescent children with grandparental care were more likely to be overweight and that there was no increased risk of being overweight or obese in the preschool group (<5 years old)(lau et al., 2018). the study found that most of the articles did not mention the gender of the child who had the potential to be obese or stunted. this finding is in line with the table 1. description of the relevant publications according to the analysis criteria classification sub category total (%) reference index (appendix 1)* publication year 2019 2018 2017 2016 2015 2 (13.3) 7 (46.7) 3 (20.0) 1 (6.7) 2 (13.3) 4, 15 1,2,3,7,8,11, 14 5,10, 13 6 9,12 body weight obesity stunting 11 (73.3) 4 (26.7) 1, 3, 4, 8, 9, 10, 11, 12, 13, 14, 15 2, 5, 6, 7 children’s age obesity stunting children aged <5 years children aged> 5 years children aged <5 years children aged> 5 years 5 (33.3) 6 (40.0) 4 (26.7) 0 8, 9, 11, 13, 14 1, 3, 4, 10, 12, 15 2, 5, 6, 7 0 children’s sex obesity stunting boy girls both boy and girl not mentioned boy girls both boy and girl not mentioned 1 (6.7) 0 (0) 3 (20.0) 7 (46.7) 1 (6.7) 1 (6.7) 0 (0) 2 (6.7) 3 0 1, 10, 15 4, 8, 9, 11, 12, 13, 14 2 6 0 5, 7 caregiver obesity stunting grandparents grandparents and others grandparents grandparents and others 6 (40.0) 5 (33.3) 1 (6.7) 3 (20.0) 1, 3, 4, 8, 10, 15 9, 11, 12, 13, 14 2 5, 6, 7 age of caregiver obesity stunting < 45 years old >45 years old not mentioned < 45 years old >45 years old not mentioned 0 (0) 1 (6.7) 10 (66.7) 0 (0) 2 (13.3) 2 (13.3) 0 3 1, 4, 8, 9, 10, 11, 12, 13, 14, 15 0 2, 7 5, 6 sex of caregiver obesity stunting male female not mentioned male female not mentioned 0 (0) 3 (20.0) 8 0 (0) 3 (20.0) 1 0 3, 11, 14 1, 4, 8. 9, 10, 12, 13, 15 0 2, 5, 7 6 *complete appendix available on supplementary file r. a. purwaningtyas, et al. 74 | pissn: 1858-3598  eissn: 2502-5791 research (maruf, aronu, chukwuegbu, & aronu, 2013) stating that there was no gender difference in the prevalence of obesity from childhood through to adolescence. in conclusion, bmi is larger in males in early childhood but larger in females during adolescence. another study(lau et al., 2018) also showed that there was no significant association between the sex of the child and having their grandparents as caretakers. review’s classification by the caregiver indicated that grandparent was the most caregiver who influence children become obesity. this is in accordance with a previous study (he, li, & wang, 2018) that showed that the coresidence of grandparents can affect childhood weight outcomes. first, grandparents, especially in rural areas, often consider overweight babies as being healthy and lean babies as malnourished, as they lack health-related (particularly nutrition-related) knowledge. therefore, they tend to overfeed their grandchildren. second, most chinese grandparents experienced low weight, malnutrition, food shortages, physical hardships and other deprivation in their early lives (li, adab, & cheng, 2015). most of the articles in this review did not mention the age of the caregiver. based on a previous study, this review suggests that the grandparents should not be too young. a possible explanation is that when the grandparents are very young and still reproductive themselves, they have to put their energy into running their own households and they have less possibility to take care of their grandchildren (schrijner & smits, 2018). this review foud that most of the articles that were reviewed did not mention the specific gender of the grandparents. but one study(schrijner & smits, 2018b) showed the result that grandfathers are less involved in household work and in helping their daughters(-in-law) with caring and feeding tasks. compared to the grandmothers, grandfathers are probably more focused on the future achievements of their grandchildren in society. this does not mean that the grandfathers are not important to their grandchildren but their role might differ from that of the grandmother (schrijner & smits, 2018). conclusion this systematic review found that co-residence of grandparents can affect children obesity. community health nursing must include the grandparents and other caregivers of the child when it comes to giving them information such as education about how to keep their children body weight in normal range. references ban, l., guo, s., scherpbier, r. w., wang, x., zhou, h., & tata, l. j. (2017). child feeding and stunting prevalence in left-behind children: a descriptive analysis of data from a central and western chinese population. international journal of public health, 62(1), 143–151. https://doi.org/10.1007/s00038-016-0844-6 bell, l. k., perry, r. a., & prichard, i. (2018). exploring grandparents’ roles in young children’s lifestyle behaviors and the prevention of childhood obesity: an australian perspective. journal of nutrition education and behavior, 50(5), 516–521. https://doi.org/10.1016/j.jneb.2017.12.007 bordone, v., arpino, b., & aassve, a. (2015). patterns of grandparental child care across europe: the role of the policy context and working mothers’ need. ageing and society, 37(4), 845–873. https://doi.org/10.1017/s0144686x1600009x finlay, j. e., fink, g., mccoy, d. c., tavárez, l. c., chai, j., danaei, g., … fawzi, m. c. s. (2016). stunting risk of orphans by caregiver and living arrangement in low-income and middle-income countries. journal of epidemiology and community health, 70(8), 784–790. https://doi.org/10.1136/jech-2015206346 geurts, t., van tilburg, t., poortman, a. r., & dykstra, p. a. (2015). child care by grandparents: changes between 1992 and 2006. ageing and society, 35(6), 1318–1334. https://doi.org/10.1017/s0144686x14000270 he, q., li, x., & wang, r. (2018). economics and human biology childhood obesity in china : does grandparents ’ coresidence matter ? economics and human biology, 29, 56–63. https://doi.org/10.1016/j.ehb.2018.02.001 ikeda, n., fuse, k., & nishi, n. (2017). changes in the effects of living with no siblings or living with grandparents on overweight and obesity in children: results from a national cohort study in japan. plos one, 12(4), 1–12. https://doi.org/10.1371/journal.pone.0175726 jongenelis, m. i., talati, z., morley, b., & pratt, i. s. (2019). the role of grandparents as providers of food to their grandchildren. appetite, 134, 78–85. https://doi.org/10.1016/j.appet.2018.12.022 lau, j. d., au, l. y., chao, e., elbaar, l., & tse, r. (2018). the association of grandparent care with childhood overweight and obesity in chinese american families. childhood obesity, 15(1), 14– 20. https://doi.org/10.1089/chi.2018.0113 li, b., adab, p., & cheng, k. k. (2015a). the role of grandparents in childhood obesity in china evidence from a mixed methods study. international journal of behavioral nutrition and physical activity, 12(1), 1–9. https://doi.org/10.1186/s12966-015-0251-z li, b., adab, p., & cheng, k. k. (2015b). the role of grandparents in childhood obesity in china evidence from a mixed methods study. international journal of behavioral nutrition and physical activity, 12(1). https://doi.org/10.1186/s12966-015-0251-z li, q., liang, f., liang, w., zhang, j., niu, m., & han, y. (2017). the influence of different caregivers on infant growth and development in china. frontiers in pediatrics, 5(november), 1–7. https://doi.org/10.3389/fped.2017.00243 jurnal ners http://e-journal.unair.ac.id/jners | 75 lidgate, e. d., li, b., & lindenmeyer, a. (2018). a qualitative insight into informal childcare and childhood obesity in children aged 0-5 years in the uk. bmc public health, 18(1), 1229. https://doi.org/10.1186/s12889-018-6131-0 lindberg, l., ek, a., nyman, j., marcus, c., ulijaszek, s., & nowicka, p. (2016). low grandparental social support combined with low parental socioeconomic status is closely associated with obesity in preschool-aged children: a pilot study. pediatric obesity, 11(4), 313–316. https://doi.org/10.1111/ijpo.12049 maruf, f. a., aronu, u., chukwuegbu, k., & aronu, a. e. (2013). influence of gender on prevalence of overweight and obesity in nigerian schoolchildren and adolescents. tanzania journal of health research, 15(4), 1–6. https://doi.org/10.4314/thrb.v15i4.6 metbulut, a. p., özmert, e. n., teksam, o., & yurdakök, k. (2018). a comparison between the feeding practices of parents and grandparents. european journal of pediatrics, 177(12), 1785–1794. https://doi.org/10.1007/s00431-018-3244-5 min, j., zhao, y., slivka, l., & wang, y. (2018). double burden of diseases worldwide : coexistence of undernutrition and overnutrition-related non communicable chronic diseases. (january), 49–61. https://doi.org/10.1111/obr.12605 schrijner, s., & smits, j. (2018a). grandmothers and children’s schooling in sub-saharan africa. human nature, 29(1), 65–89. https://doi.org/10.1007/s12110-017-9306-y schrijner, s., & smits, j. (2018b). grandparents and children’s stunting in sub-saharan africa. social science and medicine, 205, 90–98. https://doi.org/10.1016/j.socscimed.2018.03.03 7 sekiyama, m., jiang, h. w., gunawan, b., dewanti, l., & honda, r. (2015). double burden of malnutrition in rural west java : household-level analysis for father-child and mother-child pairs and the association with dietary intake. 8376–8391. https://doi.org/10.3390/nu7105399 unicef; who; the world bank. (2015). levels and trends in child malnutrition. unicef-who-world bank group joint child malnutrition estimates, 4. https://doi.org/10.1016/s0266-6138(96)900674 walrod, j., seccareccia, e., sarmiento, i., pimentel, j. p., misra, s., morales, j., … andersson, n. (2018). community factors associated with stunting , overweight and food insecurity : a communitybased mixedmethod study in four andean indigenous communities in ecuador. 1–11. https://doi.org/10.1136/bmjopen-2017-020760 wellard, s. (2011). doing it all?: grandparents, childcare and employment: an analysis of british social attitudes survey data from 1998 and 2009. (december). young, k. g., duncanson, k., & burrows, t. (2018). influence of grandparents on the dietary intake of their 2 – 12-year-old grandchildren : a systematic review. nutrition & dietics: the journal of the dietitian association of australia, 75(3), 291–306. https://doi.org/10.1111/1747-0080.12411 zhang, y., ji, m., zou, j., yuan, t., deng, j., yang, l., … lin, q. (2018). effect of a conditional cash transfer program on nutritional knowledge and food practices among caregivers of 3–5-year-old leftbehind children in the rural hunan province. international journal of environmental research and public health, 15(3), 1–13. https://doi.org/10.3390/ijerph15030525 418 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).17069 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review life experience of human immunodeficiency virus (hiv) sufferers: a qualitative systematic review rts netisa martawinarti, putri irwanti sari and vivi meiti berhimpong faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: hiv is a chronic disease that continues to increase from year to year, with many symptoms or obstacles encountered by hiv sufferers when going about their day. the experience of hiv sufferers is important to know in order to find out what they have experienced for as long as they have had the disease. the objective of this qualitative systematic review is to describe the experiences of people living with hiv. methods: the method used was searching for journals using the predetermined keywords of ‘experience’, ‘living with hiv’ and ‘coping’ through the databases of scopus, proquest, pubmed and sage between 2014 and 2019. results: the study results showed that there was still discrimination against people with hiv. they also experienced health problems due to the effects of the therapy, unpreparedness in accepting their conditions and the prevention of transmission to their family members. conclusion: understanding the role of uncertainty, stigma and resilience is important, since these factors may very well contribute to the patient’s mental health. article history received: december 26, 2019 accepted: december 31, 2019 keywords live experience; hiv; qualitative contact rts netisa martawinarti  netisamw@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: martawinarti, r. n., sari, p. i., & berhimpong, v. m. (2019). life experience of human immunodeficiency virus (hiv) sufferers: a qualitative systematic review. jurnal ners, 14(3si), 418-421. doi:http://dx.doi.org/10.20473/jn.v14i3(si).17069 introduction virtually no country is immune to the hiv pandemic that has impacted on global health for more than 30 years (alomepe, buseh, awasom & snethen, 2016). the human immunodeficiency virus is a major public health problem that has claimed the lives of more than 34 million people world-wide.1 in 2014 alone, .1.2 million people died from hiv-related causes globally. at the end of 2014, 36.9 million people were reported to be living with hiv and 2 million people are estimated to be newly infected each year. in mid2015, it was estimated that only 54% of all plwh knew that they were infected (norberg, nelson, holly, jewell & salmond, 2017). gaps in the health of the people who live with hiv based on racial, gender and social economic groups has survived for years. understanding the social and economic situation in which people live, collectively known as social health determinants, helps to uncover the processes that interact to produce significant and unavoidable injustices in health outcomes (caiola, barroso, docherty & univer, 2017) . since hiv was first identified more than 30 years ago, people living with the disease have experienced stigma from an array of people and institutions. this has continues to be a problem around the world. hiv stigma has a range of consequences, from emotional (e.g., verbal abuse, shunning) and through to physical (e.g., beatings, expulsion from the home) and financial (e.g., firing someone from a job). stigma can also have a direct impact on the health of people living with hiv (plwh) (yvette, alice, jennifer, alphoncina & carol, 2016) according to dewey (roth wm & jornet a, 2014) , experience is the term most often used in education and it is recognized as a learning process. experience shows transactions in a space and time that cannot be reduced. five peer-facilitated focus groups were conducted involving 33 aboriginal, latino, asian and african participants. the thematic analysis of their experiences revealed 4 dominant themes: the beginning of stigma, tensions related to disclosure, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:netisamw@gmail.com http://dx.doi.org/10.20473/jn.v14i3(si). jurnal ners http://e-journal.unair.ac.id/jners | 419 experience of service seeking and beyond the hiv stigma and discrimination. persons living with hiv from aboriginal and refugee communities continue to experience disproportionate rates of stigma and discrimination. fear remains a prime obstacle influencing the sufferer’s ability and willingness to access care in various settings (donnelly et al, 2016). materials and methods a systematic review was conducted by the researchers focused on qualitative methods. the researchers conducted semi-structured interviews, in-depth interviews and focus group discussions. the process was used to carry out systematic updates on several research articles published through electronic databases. the electronic databases used were scopus, sage journal, proquest and pubmed. the keywords used for searching for the journals in english were "experience", "hiv", "coping" and "qualitative research". the search results found in sage were 62 journals, while scopus had 99 journals, proquest had 143 journals and pubmed had 23 journals. the total number of journals found was 327. based on the inclusion criteria, namely 1) full text articles published in english, 2) research articles in the period 2014 2019, 3) qualitative research and 4) articles that use research content with hiv / aids sufferers, after the screening of the 327 articles, there were 15 articles that matched the expected criteria. the total number of respondents in this review was 450 people with hiv. the setting of this study was communities and clinics. for the 15 articles selected, the research was conducted in africa, america, canada, asia, the netherlands, spain and brazil. all of the articles analyzed based on the type of research were qualitative (n=15). the most widely used research design was descriptive research (n=6), followed by phenomenology (n=3), and the rest were cohort studies, meta-synthesis and a general approach. this was found to be in connection with the year of publication. all of the samples in this study were hiv positive. results a total of 15 studies were included in the systematic review. the sample used in the study varied with the minimum sample of 8 and the maximum of 114 participants. the places where the research was conducted included africa, america, canada, asia, the netherlands, spain and brazil. our search strategy was developed using a protocol guided by the prisma statement. the results of several research articles analyzed about the life experiences of hiv sufferers found there to be various life challenges experienced by plwh including stigma, socio-economic issues, psychological and emotional difficulties and decreased physical health (alomepe, buseh, awasom & snethen, 2016). according to research (caiola, barroso, docherty & univer, 2017), hiv sufferers tend to experience physical changes caused by the hiv disease and the effects of art, as well as loneliness problems. other researchers indicate that the experience of hiv sufferers, especially woman, is more sad and anxious because they are afraid of infecting their family members. there are wlph who are afraid to become pregnant because they can transmit t to their children but there are also wlwh who want to get pregnant (muze r & onsomu eo, 2017) (fletcher, ingram, kerr, buchberg, richter, 2016). experiencing unhappiness triggers feelings of despair, sadness and anger, which cause various effects such as low self-esteem, depression, anxiety, loneliness and sometimes the thought of suicide (donnelly et al, 2016).the experience of hiv sufferers to reduce or eliminate sadness, fear and depression is often by getting closer to god. for hiv sufferers, to surrender to god can bring them peace (tang k & chen w, 2018). discussion the 450 participants in this systematic review all had different life experiences since they were diagnosed with hiv. there were many changes that they had experienced while suffering from hiv and they had encountered various challenges while being plwh. unpleasant treatment starts includes discrimination, negative stigma, fear, difficulty getting access to health services, anger, uncertainty in life and anxiety when woman with hiv want to get pregnant. the feeling of fear of transmitting the disease to others is more likely to be experienced by women. women who want to have children must hold back that feeling of fear of transmitting their hiv to their children. however, there were also participants in this systematic review that did not care much about the disease and who continued to have unprotected sex. figure 1: flowchart of the study selection records identified through database searching (n = 327) records screened after removing duplicates (n = 238 ) full-text articles assessed for eligibility (n = 91) excluded due to methodological criteria (n = 147) full-text articles excluded, with reasons (n = 76 ) 1. not qualitative research 2. not english language 3. no relevant study design 4. no relevant outcome studies included in qualitative synthesis (n = 15 ) 15 studies included in systematic review id e n ti fi c a ti o n s c r e e n in g in c lu si o n e li g ib il it y r. n. martawinarti, et al. 420 | pissn: 1858-3598  eissn: 2502-5791 in theory, the experience of a disease will cause various feelings and stress reactions, including frustration, difficulties, recovery, denial, shame, grieving and a struggle towards disease adaption (nursalam, kurniawati & misutarno, 2018). the theoretical explanation of the results found in this article were almost the same; hiv sufferers often experience low self-esteem, which makes them aloof and removed away from others for fear of transmitting the disease. however in this article, it was found that there were sufferers who experienced unpleasant actions because they were discriminated against by the people around them. this is due to a lack of knowledge within people about the hiv disease. there is still an assumption that hiv is easily transmitted and dangerous, resulting in a negative stigma towards hiv sufferers. the sufferers feeling sad, disappointed and angry is a form of ineffective coping because of the unpreparedness of the hiv sufferers to accept their illness. the systematic review of the life experiences of hiv sufferers is needed to improve our understanding of the problems that are often faced by hiv sufferers, what factors can worsen the condition of hiv sufferers and what can affect the quality of life of people with hiv. this can help the medical personnel to find the right intervention or preventive measures to create the atmosphere needed by hiv sufferers so then their quality of life is better. this systematic review only addresses the experience of hiv sufferers in general, not specifically in terms of the experience of pregnant woman with hiv or the experiences of hiv sufferers in the face of negative stigma and discrimination. this systematic review discusses experience in general and it does not seek out experience that consistently has the same background problem, so the results of the experiences found vary. conclusion this systematic review shows the experience of hiv sufferers in living life as plwh, how they defend themselves and continue to live life like other healthy people, how the hiv sufferers look for health services that meet their expectations and how they find peace when they are feeling sad, angry and depression. not all hiv sufferers have good coping skills; many of the participants in this systematic review have ineffective coping mechanisms. a health worker or nurse ideally needs to systematically assess the aspects of suffering, coping, satisfaction and decision making of the hiv sufferers. references alomepe, j., buseh, a. g., awasom, c., & snethen, j. a. (2016). life with hiv : insights from hiv-infected women in cameroon , central africa. journal of the association of nurses in aids care, 1–13. https://doi.org/10.1016/j.jana.2016.04.010 brien, n. o., greene, s., carter, a., lewis, j., kaufman, e., nicholson, v., … kaida, a. (2017). envisioning women-centered hiv care : perspectives from women living with hiv in canada. 1–10. https://doi.org/10.1016/j.whi.2017.08.001 caiola, c., barroso, j., docherty, s. l., & univer-, d. (2017). an inquiry into how social determinants of health are framed. 209–221. https://doi.org/10.1097/nnr.00000000000002 13 donnelly, l., baily, l., jessani, a., postnikoff, j., kerston, p., & brondani, m. (2016). stigma experiences in marginalized people living with hiv seeking health services and resources in canada. journal of the association of nurses in aids care. https://doi.org/10.1016/j.jana.2016.07.003 fletcher, f., ingram, l. a., kerr, j., buchberg, m., & richter, d. l. (2016). ‘“ out of all of this mess , i got a blessing ”’: perceptions and experiences of reproduction and motherhood in african american women living with hiv. journal of the association of nurses in aids care, 1–11. https://doi.org/10.1016/j.jana.2015.12.003 furlotte, c., & schwartz, k. (2017). mental health experiences of older adults living with hiv : uncertainty , stigma , and approaches to resilience *. 16. https://doi.org/10.1017/s0714980817000022 imazu, y., ph, d., matsuyama, n., takebayashi, s., mori, m., ph, d., … ph, d. (2017). sc. international journal of nursing sciences. https://doi.org/10.1016/j.ijnss.2017.02.004 james-borga, j. c., & frederickson, k. (2018). sc. journal of the association of nurses in aids care. https://doi.org/10.1016/j.jana.2018.01.003 leyva-moral, j. m., mart, r. n. f., & v, b. m. (2019). the experience of growing old while living with hiv in spain : a phenomenological study. 30(1), 111–118. leyva-moral, j. m., piscoya-angeles, p. n., & edwards, j. e. (2017). the experience of pregnancy in women living with hiv : a meta-synthesis of qualitative evidence. journal of the association of nurses in aids care, 28(4), 587–602. https://doi.org/10.1016/j.jana.2017.04.002 muze, r., & onsomu, e. o. (2017). our children , our hope : voices of african american mothers living with hiv and rearing uninfected children our children , our hope : voices of african american mothers. journal of community health nursing, 34(3), 160–168. https://doi.org/10.1080/07370016.2017.13407 70 nation, a., waters, c. m., & dawson-rose, c. (2018). experiences and perceptions of black men who have sex with men about acquiring hiv: a qualitative narrative perspective. journal of the association of nurses in aids care, 29(5), 737–748. https://doi.org/10.1016/j.jana.2018.04.010 norberg, a., nelson, j., holly, c., jewell, s. t., & jurnal ners http://e-journal.unair.ac.id/jners | 421 salmond, s. (2017). systematic review protocol. 2645–2650. https://doi.org/10.11124/jbisrir2016-003278 nursalam, k, n. d., misutarno, & s, f. k. (2018). asuhan keperawatan pada pasien terinfeksi hiv/aids (2nd ed.; p. p. lestari & t. utami, eds.). jakarta: salemba medika. peltzer, j. n., ogawa, l., tusher, s., farnan, r., & gerkovich, m. m. (2016). ac. journal of the association of nurses in aids care. https://doi.org/10.1016/j.jana.2016.09.010 proudfoot, d. (2017). ac acknowledgements. journal of the association of nurses in aids care. https://doi.org/10.1016/j.jana.2017.10.003 roth, w. m., & jornet, a. (2014). toward a theory of experience. science education, 98(1), 106–126. https://doi.org/10.1002/sce.21085 stutterheim, s. e., brands, r., baas, i., lechner, l., kok, g., & bos, a. e. r. (2017). sc. journal of the association of nurses in aids care. https://doi.org/10.1016/j.jana.2017.06.014 tang, k., & chen, w. (2018). original article hiv and religion in hiv-infected asians and their families : a qualitative study. applied nursing research, 44(june), 18–24. https://doi.org/10.1016/j.apnr.2018.09.003 yvette p.cuca, alice asher, jennifer okonky, alphoncina kaihura, carol dawson, a. w. (2016). sc. journal of the association of nurses in aids care. https://doi.org/10.1016/j.jana.2016.09.001 118 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.16417 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research a qualitative inquiry into the adherence of adults type 2 diabetes mellitus with dietary programs kusnanto kusnanto1, elfa lailatul izza2, tri johan agus yuswanto3, hidayat arifin2 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 1 master of nursing study program, faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 poltekkes kemenkes malang, malang, east java, indonesia abstract introduction: diabetes mellitus (dm) is a chronic disease with the characteristic of treatment complexity. the toughest challenge for dm patients is dietary adherence. on the other hand, the socio-culture is one of the factors that influences dietary adherence. the aim of this study was to examine the dietary adherence of adults with type 2 diabetes mellitus (t2dm), particularly to dietary programs. methods: this study used a qualitative case study design with a positivist approach. the total participants consisted of 14 t2dm patients obtained through snowball sampling. the research phenomenon was the adherence of adults with type 2 diabetes mellitus to dietary programs. the data collection was conducted through in-depth interviews with question guidelines analyzed using qualitative thematic analysis. results: this study obtained five themes regarding the dietary adherence of t2dm patients such as activity, motivation, intention, behavior, and the benefits of dietary adherence. the focus points were activity, motivation, and the intention to comply with the dietary recommendations, including reducing the fatty and fried foods consumed. the patients who felt the benefits of complying with the dietary program found following the dietary adherence to be easier. conclusion: activity, motivation, intention, behavior and the benefits of the dietary adherence program all make it easier for the patient to comply with their diet. this result suggests that health workers should provide education to the patients on the importance, benefits and the way to comply with the t2dm dietary program. article history received: dec 04, 2019 accepted: dec 11, 2019 keywords adherence; behavior; diet; type 2 diabetes mellitus contact kusnanto  kusnanto@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: kusnanto, k., izza, e. l., yuswanto, t. j. a., & arifin, h. (2019). a qualitative inquiry into the adherence of adults type 2 diabetes mellitus with dietary programs. jurnal ners, 14(2), 118-123. doi:http://dx.doi.org/10.20473/jn.v14i2.16417 introduction diabetes mellitus (dm) is a health problem with the characteristic of hyperglycemia due to abnormal insulin secretion, insulin action or both. dm symptoms include polyuria, polydipsia, polyphagia, weight loss and blurred vision (ada, 2017).the most common problem in t2dm is dietary non-adherence. one of the causal factors of this is socio-cultural, which drives the t2dm patients to not comply with the dietary recommendations (basu & garg, 2017). whether the patients comply or not depends on the intention of the person (ajzen, 2005). the incidence of t2dm in indonesia has been rising every year. the data from the baseline health research of indonesia showed that t2dm patients aged ≥15 years in 2013 had an incident rate of 6.9%. this increased in 2018 to become 8.5%. the prevalence was higher in women at 12.7% than in men at 9%. the t2dm patients who did not take medicine made up 11% (national institute of health research and development indonesia, 2018). the data from the public health center in sidoarjo showed that the doctors had diagnosed 66,077 dm patients. from the 10 t2dm patients in porong and krembung public health center, 70% of patients feel that it is difficult to comply with the suggested diet and 50% feel bored with the dm treatment. the research conducted by (storz & iraci, 2019) showed that patients who adhere to a diet for a short time can reduce their blood sugar concentration and increase their insulin sensitivity. dietary adherence is https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 119 highly effective when it comes to achieving better glycemic control in patients with type 2 diabetes. adherence is supported by the environment and their family (hilliard, mcquaid, nabors, & hood, 2014). strengthening the resilience of dietary adherence in the t2dm patients will provide enthusiasm and a better ability to treat themselves. this is in addition to improved self-esteem and behavior (de souza ribeiro et al., 2017) the t2dm patients’ dietary adherence can reduce the incidence of hyperglycemic crisis (perkeni, 2015). the success of dietary adherence depends on the compliant behavior and intentions of the patients — compliance consists of close and open submissive behavior. close compliant behavior is a stimulus that has not been clearly seen that is still limited to the form that the knowledge, attitude, perceptions and feelings takes. open submissive behavior is a reaction to the stimulus in a way of practice that is visible (notoatmodjo, 2007). intention can be explained as motivational factors and they have a strong impact on behavior change. the firm intention of t2dm patients will increase their compliance in terms of carrying out dietary management properly (pinidiyapathirage, jayasuriya, cheung, & schwarzer, 2018). based on the description above, this study aims to examine the dietary adherence of adults with type 2 diabetes mellitus (t2dm) on dietary programs. materials and methods this study was a qualitative case study design used to inquire into the adherence of adults with type 2 diabetes mellitus to dietary programs with a positivist approach. the aim of a positivist approach is to explore a good story or experience from a participant related to their adherence to dietary programs. a case studies is a form of investigation and exploration that looks into a case in-depth and in detail. it allows the researchers to get a complete and detailed picture of the phenomenon that is to be studied. it involves the understanding of a person's events and activities (l mccaslin & scott, 2003). the following steps are a part of case studies in order to ensure the best possible outcome: 1) information organization, 2) reading all of the information and coding, 3) writing a detailed description of the case and its context, 4) interpreting and developing generalizations naturally from the cases and 5) presentation in narrative form (vanwynsberghe, 2007). the participants of this study were 14 t2dm patients obtained through the snowball sampling technique. the inclusion criteria were 1) t2dm patients from the public health center in sidoarjo, east java province, 2) good dietary adherence according to dietary adherence screening and 3) not a pregnant woman. the exclusion criteria were 1) resident citizens from the public health center in sidoarjo, east java province and 2) not communicating verbally well. the researchers themselves are the data collection tools and thus they cannot be represented or delegated. the data collection tools consisted of voice recorders, stationery, field notes and the indepth interview guidelines. the interview questions included behavioral attitude, subjective norm, perceived behavioral control, intention, and adherence behavior. the interview data was analyzed using qualitative thematic analysis by searching for any themes that emerge. this becomes important when looking into the description of a phenomenon or case. the stages of thematic analysis include: 1) developing manual code, 2) conducting reliability tests on the code, 3) summarizing the data and identifying the initial themes, 4) applying templates to the codes and supplementary codes, 5) linking the codes and identifying themes, and 6) strengthening and validating the theme (fereday & muir-cochrane, 2006). the study was conducted in three public health centers in sidoarjo, east java province for two months, january 2019 february 2019, with a high prevalence of good dietary adherence based on the successful achievement of the public health centerran programs. the participants determined the location of the interview at the time of the informed consent contract. this study was registered to research ethics board of the health research ethics commission of the faculty of nursing, universitas airlangga, letter-number: no.1194-kepk published on 3rd november 2018. results the participants in this study consisted of 14 people consisted of 1 male and 13 females aged between 45 85 years old. the most common education level of the participants was that of primary school. all of the participants were married. most of the participants did not work. one participant (p12) dropped out because he didn’t complete the interview stages. a total of five themes emerged from the results of the in-depth interviews concerning the dietary adherence of the t2dm patients such as activity, motivation, intention, behavior, and the benefits of doing dietary adherence. the characteristics of the participants have been summarized in table 1. theme 1: activity activities which increase dietary adherence include physical exercise (p10, p14), controlling their routine in the health care centre (p02, p15), reducing their sugar consumption (p01, p04) and praying to god (p06). “...if i want my body to feel good, i do exercises like jumping in the field after cooking...” (p10) “...i prefer walking around in the field while looking at green scenery. i feel better...” (p14) “...if i feel sick, i go to the health care centre to control it. yesterday i felt unwell. unfortunately, my uric acid was high...” (p02) k, kusnanto, et al. 120 | pissn: 1858-3598  eissn: 2502-5791 “...i want to feel healthy, so i routinely control it in the health care centre...” (p15) “... i used to drink less sugar milk. now i have a little sugar on my meal...” (p01) “... no, i do not eat sweet food. fatty food also. i reduce the amount of sugar...” (p04) “... i sincerely undergo this sickness. i prayed to god to give me a healthy and long life...” (p06) theme 2: motivation this theme explained that the participant get their motivation from social support, including from the health workers (p03), other t2dm sufferers (p05) and their family (p06). “...i get motivated to adhere to the diet from the doctor. the doctor said that i have to control my diet and he suggested for me to eat or take a meal once every three hours...” (p03) “... t2dm patients who i am acquainted with always remind me about dietary adherence and they invite me to the dm association so then i can get support and more information...” (p05) “...my wife reminds me about reducing my rice consumption, especially hot rice. if the rice is cold, then i can eat little more...” (p06) theme 3: intention this theme explained that the participants’ intention rises after getting education from the health care provider (p01). the participants maintain adherence through considering the amount, type and time of the food consumption (p05). “...after being educated by a health care provider, i have the intention to consider what i eat...” (p01) “...for example, if i have eaten and someone offers me food, i reject it wisely...” (p05) theme 4: behavior this theme explained the dietary adherence behavior done by the participants. the dietary adherence behavior considers the amount, type and time of the food (p03, p15), the reduction of their sugar consumption (p06) and reducing the amount of fried food (p13). “...i consider the amount of rice like 8 10 spoons. i only eat rice three times a day in the morning, noon, and evening. snacking is only at 3 pm...” (p03) “...i eat every 3 hours and start at 7 am. it consists of three-times eating eight spoons of rice and three times snacking. i avoid eating fried food ...” (p15) “...i reduce my sugar consumption. i do not eat sweet fruits like yam...” (p06) “...i avoid eating fried food and fatty chicken meat...” (p13) theme 5: benefit this theme explained the benefit of dietary adherence. the participant felt that dietary therapy could support their medical treatment (p01) and that accurate dietary therapy can reduce the signs and symptoms of sickness (p03, p05, p14). “...i only consume medicine, but i think that it does not heal my sickness well. i combine medication and diet and hope that it can help prevent wounds...” (p01) “...i do not comply with the diet. i feel sick like i have headache, plus tingling and pain. i comply with the diet only so then my glucose is stable and i do not feel sick anymore...” (p03) “...my vision is a blur when my glucose is high. my vision is brighter when my glucose level is stable. my glucose level is stable when i comply with the dietary adherence...” (p05) “...when i comply with dietary adherence, the pain and frequency of my urination decreases, my body is fit, and the tingling disappears...” (p14) table 1. characteristic of respondents code gender age (years old) marital status work education p01 female 53 married does not work junior high school p02 male 68 married does not work junior high school p03 female 70 married does not work primary school p04 female 69 married does not work primary school p05 female 73 married does not work junior high school p06 female 85 married seller primary school p07 female 45 married seller junior high school p08 female 60 married does not work junior high school p09 female 66 married does not work primary school p10 female 65 married does not work primary school p11 female 75 married does not work primary school p12 drop out p13 female 60 married does not work primary school p14 female 57 married does not work primary school p15 female 51 married does not work primary school *p=participants jurnal ners http://e-journal.unair.ac.id/jners | 121 discussion the first theme revealed that physical exercise, controlling their routine in the health care centre, reducing the sugar consumption and praying to god emerged as activities that influence dietary adherence. (ada, 2017) advises for people with dm to exercise at a medium to high intensity for at least 150 minutes per week. they should exercise for 15 minutes every two days and then the duration is increased slowly to at least 150 minutes per week according to the recommended amount (colberg et al., 2016). exercise not only reduces the blood sugar levels but it also lowers the blood pressure, reducing the levels of low-density lipids, increasing their energy, and reducing stress (restuning, 2015). dm patients have to routinely undergo control visits to the doctor or public health center every month. the time of control depends on the patient’s condition. the worse their condition, the more often they have a control visit to the doctor or the health care provider. the provider will assist in their dm management through education, dietary therapy, exercise, and pharmacology therapy (poretsky, 2017). dm patient need drugs and dm management to control their blood glucose level. belief in god and in the power of prayer, as well as in religious instructions, is obtained in conditions of difficulty. this is proven to decrease the incidence of depression (doolittle & farrell, 2004). the spiritual aspect has a significant influence on changes in patient behavior and motivation. the emotional stability resulting from good spiritual integrity not only affects the achievement of positive behavior but it also contributes to physical health (friedman, 2018). the second theme revealed that the participants get a variety of support which includes support from their family, from fellow dm sufferers, and from the health workers. the family factor has an important role in supporting diabetes management (delamater, 2006). for patients with chronic conditions such as diabetes, social support has been shown to provide positive outcomes in relation to glycemic control, adherence to care, and improvements in their emotional status. patients who have good family support will experience a comfortable feeling that can increase their motivation to comply with the dietary recommendations (ilmah & rochmah, 2015). social support from fellow dm sufferers has the same effect, or it was found to be better than support from their wives or friends who did not have diabetes (van dam et al., 2005). interactions between the health workers and patients will lead to an understanding of the importance of treatment. health workers give full attention to the patients, even though the consultation time is concise (niven, 2002). time is not a determinant of good quality interactions between the patients and health care workers. friendliness, attention and the empathy of officers will provide a feeling of security and inner security (moehyi, 1992). communication is very important in the context of providing nutrition education to the patients, in their willingness to provide explanations and in offering alternatives which will help them to fulfill their patient’s needs (wahyuningsih, 2009). the third theme revealed that participant’s intention in relation to dietary adherence is to comply with the amount, types and timing of the food recommendations. the various intentions possessed by the participants are a way to increase the persistence in dietary adherence. humans are unique individuals; the intention of each individual is varied. different desires called intentions represent the functions of two basic determinants, namely individual attitudes towards a behavior (a personal aspect) and the individual perceptions of the social environment (ajzen, 2005). practice or behavior according to the theory of planned behavior (tpb) is influenced by intention, while intention is influenced by subjective attitudes and norms (sommer, 2011). the fourth theme revealed that the participants were just trying to keep to the dietary adherence in the beginning and they whole-heartedly complied with the suggested guidelines. the results of this study also support the skinner theory in that behavior is a person's response to a stimulus or object. responding depends on the characteristics and other factors of the individual (gordan & amutan, 2014). the acceptance of new behavior must be based on knowledge so then the behavior is long-lasting. the change or adoption of new behavior follows the following stages through the process of change: knowledge (attitude), attitude (attitude) and action (practice) (notoatmodjo, 2003). individuals begin with trial and error until they really want to apply it forever. according to (green & kreuter, 1991), behavior is determined by three factors: predisposing factors (knowledge, attitudes, values and beliefs), enabling factors (facilities and infrastructure / facilities for the formation of healthy behavior) and reinforcing factors (family support/friend /figures/groups, health workers, health insurance and decision-makers). the fifth theme revealed that belief in the benefits of the diet in line with the results of the study shows that changing to a healthy diet can rearrange the normal insulin production process and improve the condition of type 2 diabetes (mann, allegrante, natarajan, halm, & charlson, 2007). the excess food intake is reduced significantly through a low-calorie diet. it shows that a decrease in body fat results in the stabilization of insulin sensitivity. t2dm patients only need to lose one-sixth of their body weight to be able to remove fat from the pancreas, thus allowing the organ to produce enough insulin to return to normal levels (sublett & bernstein, 2011). other findings from the interview were that the participants expressed some positive feelings towards the diet such as feeling healthy because of self-suggestion, used to being disciplined, being interested in the dietary advice, being satisfied with the present situation, and feeling happy and healthier. dm patients who can change their perspective of suffering will be able to see the meaning and wisdom k, kusnanto, et al. 122 | pissn: 1858-3598  eissn: 2502-5791 of their illness. the meaning of life can be found in the suffering condition that cannot be avoided (frankl, 2004). individuals who have a meaningful life experience show a vibrant lifestyle that is full of enthusiasm and passion for life. they become more directed, more disciplined, and adapt to the environment (bastaman, 2007). conclusion the findings of this study revealed the motivation, activity, intention and dietary adherence behavior. this includes complying with the amount, types and time of the diet recommendations and reducing their fat and sugar consumption as the themes. if the patient complies with the dietary advice, the easiness of meeting the dietary guidance will increase their dietary adherence too. easiness can be gained if the participant feels the benefit of the diet or the perceived benefit of the diet. health workers need to provide health education to every t2dm patient in order to increase the perceived benefits of dietary adherence. a good understanding of the importance of dietary adherence will improve the patients’ behavior in complying with the dietary recommendation. references ada. (2017). panduan terbaru ada 2017 berfokus pada pendekatan holistik. kalbemed, 44(9), 638– 639. ajzen, i. (2005). attitudes, personality, and behavior (2nd ed.). uk: mcgraw-hill. bastaman. (2007). logoterapi: psikologi untuk menemukan makna hidup dan meraih hidup bermakna. jakarta: pt rajagrafindo persada. basu, s., & garg, s. (2017). the barriers and challenges toward addressing the social and cultural factors influencing diabetes self-management in indian populations. journal of social health and diabetes, 05(02), 071–076. https://doi.org/10.1055/s0038-1676245 colberg, s. r., sigal, r. j., yardley, j. e., riddell, m. c., dunstan, d. w., dempsey, p. c., … tate, d. f. (2016). physical activity/exercise and diabetes: a position statement of the american diabetes association. diabetes care, 39(11), 2065–2079. https://doi.org/10.2337/dc16-1728 de souza ribeiro, m. de n., diniz, c. x., perdomo, s. b., de souza ribeiro, j. h., barbosa, o. g., de barros, k. m. s. c., … da costa oliveira, e. (2017). self-esteem and resilience in people with type 2 diabetes mellitus. mundo da saude, 41(2), 223–231. https://doi.org/10.15343/01047809.20174102223231 delamater, a. m. (2006). improving patient adherence. clinical diabetes, 24(2), 71–77. https://doi.org/https://doi.org/10.2337/diaclin. 24.2.71 doolittle, b. r., & farrell, m. (2004). the association between spirituality and depression in an urban clinic. the primary care companion to the journal of clinical psychiatry, 06(03), 114–118. https://doi.org/10.4088/pcc.v06n0302 fereday, j., & muir-cochrane, e. (2006). demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. international journal of qualitative methods, 5(1), 80–92. https://doi.org/10.1177/160940690600500107 frankl, v. e. (2004). man’s search for meaning. bandung: yayasan nuansa cendikia. friedman, p. h. (2018). life balance, emotional stability, well-being and spiritual awakening. the international journal of healing and caring, 18(1), 1–21. gordan, m., & amutan, k. i. (2014). a review of b. f. skinner’s ‘reinforcement theory of motivation. international journal of research in education methodology, 5(3), 680–688. green, l. w., & kreuter, m. w. (1991). health promotion planning : an educational and environmental approach. mountain view, ca: mayfield pub. co. hilliard, m. e., mcquaid, e. l., nabors, l., & hood, k. k. (2014). resilience in youth and families living with pediatric health and developmental conditions: introduction to the special issue on resilience. journal of pediatric psychology, 40(9), 835–839. https://doi.org/10.1093/jpepsy/jsv072 ilmah, f., & rochmah, t. n. (2015). kepatuhan pasien rawat inap diet diabetes mellitus berdasarkan teori kepatuhan niven. jurnal administrasi kesehetan indonesia, 3(1), 60–69. https://doi.org/http://dx.doi.org/10.20473/jaki. v3i1.2015.60-69 indonesia, i. n. i. of h. r. and d. (2018). main resulth of baseline health research 2018. jakarta: ministry of health of the republic of indonesia. l mccaslin, m., & scott, k. w. (2003). the fivequestion method for framing a qualitative research study. qual rep, 8(3), 447–461. mann, d. m., allegrante, j. p., natarajan, s., halm, e. a., & charlson, m. (2007). predictors of adherence to statins for primary prevention. cardiovascular drugs and therapy, 21(4), 311–316. https://doi.org/10.1007/s10557-007-6040-4 moehyi. (1992). pengaturan makanan dan diit untuk penyembuhan penyakit. cetakan keempat. jakarta: pt gramedia pustaka utama. niven, n. (2002). psikologi kesehatan keperawatan pengantar untuk perawat dan profesional kesehatan lain. jakarta: egc. jurnal ners http://e-journal.unair.ac.id/jners | 123 notoatmodjo. (2007). promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta. notoatmodjo, s. (2003). pendidikan dan perilaku kesehatan. jakarta: rineka cipta. perkeni. (2015). konsnsus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. jakarta: pengurus besar perkumpulan endokrinologi indonesia. pinidiyapathirage, j., jayasuriya, r., cheung, n. w., & schwarzer, r. (2018). self-efficacy and planning strategies can improve physical activity levels in women with a recent history of gestational diabetes mellitus. psychology & health, 0446, 1–16. https://doi.org/10.1080/08870446.2018.14589 83 poretsky, l. (2017). principles of diabetes mellitus. (springer, ed.) (3rd ed.). new york. restuning, d. (2015). efektifitas edukasi diabetes dalam meningkatkan kepatuhan pengaturan diet pada diabetes melitus tipe 2. mutiara medika, 15(1), 37–41. sommer, l. (2011). the theory of planned behaviour and the impact of past behaviour. international business & economics research journal, 10(1), 91– 110. https://doi.org/10.19030/iber.v10i1.930 storz, m. a., & iraci, f. (2019). short-term dietary oatmeal interventions in type 2 diabetes: a forgotten tool. canadian journal of diabetes. https://doi.org/10.1016/j.jcjd.2019.08.020 sublett, w., & bernstein, j. a. (2011). seminal plasma hypersensitivity reactions: an updated review. mount sinai journal of medicine: a journal of translational and personalized medicine, 78(5), 803–809. https://doi.org/doi:10.1002/msj.20283 van dam, h. a., van der horst, f. g., knoops, l., ryckman, r. m., crebolder, h. f. j. m., & van den borne, b. h. w. (2005). social support in diabetes: a systematic review of controlled intervention studies. patient education and counseling, 59(1), 1–12. https://doi.org/10.1016/j.pec.2004.11.001 vanwynsberghe, r. (2007). redefining case study vancouver , canada. international journal of qualitative methods, 6(2), 80–94. wahyuningsih. (2009). faktor yang mempengaruhi sisa makanan penderita diit diabetes mellitus di rumah sakit darmo surabaya. universitas airlangga. ners vol 10 no 1 april 2015.indd 74 gfr dan kadar timbal dalam darah pada pekerja pom bensin berdasarkan δ-alad gene polymorphisms (gfr and blood lead levels in gas station workers based on δ-alad gene polymorphisms) lantip rujito*, muhammad nur hanief*, paulus gozali*, joko mulyanto* *faculty of medicine and health sciences jenderal soedirman university jl gumbreg no 1, purwokerto 53146 email: l.rujito@unsoed.ac.id abstrak pendahuluan: timbal merupakan zat beracun yang dikenal dapat menimbulkan kerusakan pada organ tubuh. serum timbal sendiri dipengaruhi oleh δ-alad gene polymorphisms (amino levulinic acid dehydratase). gen δ-alad mengkode enzim alad yang digunakan untuk sintesis darah. karakteristik gen polymorphism mempengaruhi nilai gfr sebagai tanda kerusakan ginjal. tujuan dari penelitian ini adalah untuk menemukan hubungan antara kadar timbal dalam darah dengan gfr, berdasarkan δ-alad gene polymorphisms. metode: desain cross sectional digunakan dalam penelitian ini. sampel adalah pekerja 38 pom bensin yang ada di banyumas. δ-alad gene polymorphisms dikarakteristikan dengan metode pcr-rflp, di mana kadar serum timbal dikuantifi kasi dengan aas. serum kreatinin diukur dengan aas dan kadar gfr diformulasikan dengan metode schwartz. hasil: hasil penelitian menunjukkan bahwa proporsi genotipe alad untuk alad 1-1, 1-2, dan 2-2 adalah 94,7%, 5,3%, dan 0%. kadar serum dalam homozygous 1-1 adalah 15,94 ppb dan heterozygote 1-2 adalah 1,15 ppb. gfr responden berada pada rentang 71,11 ml/min sampai 185,20 ml/min dengan ratarata 117,34 ml/min. tidak ada hubungan antara serum pb dan gfr (p = 0,19). penelitian juga tidak bisa membuktikan hubungan antara gfr dan alad gene polymorphism. diskusi: dari hasil penelitian dapat disimpulkan bahwa tidak ada hubungan antara kadar timbal dalam darah dengan gfr pada setiap δ-alad gene polymorphisms. kata kunci: intoksikasi timbal, gfr, δ-alad, pekerja pom bensin abstract introduction: lead is a well-known toxic agent that makes an organ’s failure. lead serum itself is infl uenced by δ-alad gene polymorphisms (amino levulinic acid dehydratase). δ-alad gene encodes an alad enzyme used for heme synthesis. the characteristic of gene polymorphism may result in glomerulo filtration rate (gfr) value as mark of renal failure. the goal of this study was to fi nd correlations between blood lead levels with gfr in terms of δ alad gene polymorphisms. method: a cross-sectional design was used to perform this research. thirty-eight gas stations workers in banyumas were recruited in this study. δ-alad gene polymorphisms were characterized using pcr-rflp method, while lead serum levels were quantifi ed by atomic absorption spectrophotometer (aas). in addition, creatinin serum was done with a spectrophotometer and gfr value was formulated by means of the schwartz method. result: the study showed that the proportion of alad genotype for alad 1-1, 1-2 and 2-2 were 94.7%, 5.3%, and 0% respectively. the mean of serum levels in homozygous 1-1 was 15.94 ppb and heterozygote 1-2 was 1.15 ppb. gfr of participants ranged from 71.11 ml/min to 185.20 ml/min with a mean of 117.34ml/min. there was no correlation between serum pb and gfr (p = 0.19). study also could not determine the correlation between gfr and alad gene polymorphism. discussion: study then concluded that there was no correlation between blood lead levels in the gfr on each δ-alad genotypes. keywords: lead intoxication, gfr, δ-alad, gas station workers introduction he a v y m e t a l i n t ox i c a t i o n w a s associated with industrialization and use of fossil fuels (schwartz & hu, 2007). one of the most potentially heavy metal intoxication is plumbum (pb) aka lead. the data showed that housing in the united states contributed about 17% of lead contamination (jacobs, et al., 2002), while in china there was 53.7% of population passing the lead threshold (ye & wong, 2006). other study estimates that no less than 17,000 liters of fuel are burned every day in indonesia (santi, 2007). elevated levels of pb in the blood can cause such disorders including cardiovascular, gastrointestinal, hemolymphatic, urinar y system, immune system, reproductive system, cancer and also cognitive impairment (hirose, et al., 2004; atsdr, 2007). pb affects the enzyme of aminolevulinic acid dehydratase 75 gfr dan kadar timbal dalam darah pada pekerja pom bensin (lantip rujito, dkk) (alad) in the biosynthesis of heme (dongre, et al., 2011). it can bind sulf hydryl groups of cysteine, amino groups of lysine, and the hydroxyl group of tyrosine in the enzyme alad (kosnet, 2004). δ-alad gene is a functional genes that produce alad enzyme which have δalad three gene polymorphisms encoded with alad 1-1, alad 1-2 and alad 22 (schwartz & hu, 2007; kamel, et al., 2003). previous study showed that there was a relationship between δ-alad gene polymorphisms and blood pb intoxication rate. homozygous subjects of alad-2 gene tend to have higher rates of pb compare with alad1 allele (hopkins, et al., 2008). in addition, another study found that the increase of serum creatinin level in individuals of alad-2 gene was modifi ed by the enhancement of pb serum (weaver, et al., 2008). higher pb in blood can cause a decrease of renal function and trigger aminoaciduria. moreover, intranuclear inclusion bodies usually could be detected in the cells of human peritubuler (futrakul, et al., 2011). δ-alad genotypes were also reported could affect the k id neys per for mance. previous data in a meta-analysis study stated that its clearly declared that alad-2 allele had signif icantly association with serum creatinin levels (scinicariello, 2010). however, study using indonesian subjects has not been performed. this study was therefore aimed to determine the relationship between δ-alad gene polymorphism and renal function using glomerulo filtration rate (gfr) in indonesian people. materials and methods study was performed using a crosssectional design. subjects had the following criteria; working as fuel fi ller, has been worked at least 1 year, and having at least 8 hours working a day, were recruited as participants. those who suffered hypertension, diabetes, urinary tract obstruction, myopathy, athletes, alcohol consumer, and taking medications of anti-angiotensin ii and vasopressin were excluded from the study. the sampling method used in this study was consecutive sampling. every participant underwent informed consent, questionnaires, and blood sampling. interviews were conducted to obtain personal data and assess whether respondents meet the inclusion and exclusion criteria. gfr value was measured by creatinin levels in serum (csr) and calculated by the schwartz formula (mcpherson & pincus, 2006). lead level in the blood was examined using atomic absorption spectrophotometer method (aas). constitution of δ-alad gene allele polymorphism (g to c) base substitution at position 177 (g177) was carried out by means of pcr-rflp method. primers used in this research were agacagacatta gctc agta and ggcaaagaacaggtccattc generated 916 bp pcr products. enzyme msp1 was used to characterize the alad polymorphism. alad 1 allele had 582 bp and alad 2 allele had 511 bp. all the data collected then analyzed by using spearmen correlation test. results subjects underwent genotyping of dna and performed with various characteristics including age, smoking and, gfr, creatinin, pb serum and also gender. data in picture 1 and tables (1 & 2) showed that degree of pb picture 1. alad polymorphism pattern on pcr-rflp gel electrophoresis. alad1 allele was depicted by upper arrow and alad 2 allele was lower arrow. alad 1 allele had 582 bp and alad 2 allele had 511 bp. 76 jurnal ners vol. 10 no. 1 april 2015: 74–79 table 1. the characteristic of respondents variable n min max mean f p sd sex male 31 (81,6%) female 7 (18.4%) height 38 153.90 192.00 169.08 8.08 cr serum 38 0.51 1.27 0.84 0.18 pb serum 38 0.14 55.51 15.16 0.00 17.20 gfr 38 71.11 185.20 117.34 0.56 23.35 polymorphism 38 0.43 alad-1 36 (94.7%) alad-2 alad-1-2 2 (3.3%) smoking 38 yes 21 (55.3%) no 17 (44.7%) table 2. the characteristic of respondents by alad polymorphism variable n min max mean f p sd alad 1-1 age 36 18 54 34.28 10.91 height 36 153.90 192.00 169.02 8.25 cr serum 36 .51 1.27 .84 0.18 pb serum 36 .01 55.51 15.94 0.00 17.34 gfr 36 71.11 169.31 115.69 0.64 23.80 smoking 36 yes 52.8% no 47.2% alad 1-2 age 2 30 40 35 7.07 height 2 166.60 174.00 170.30 5.23 cr serum 2 0.78 0.99 0.89 0.15 pb serum 2 1.10 1.19 1.14 0.06 gfr 2 96.67 117.47 107.07 14.71 smoking 2 yes 100% no 0% and creatinin serum have wide value span from 0.14 to 55.51. genotyping data demonstrated alad 1-1 as dominant allele and most of the subjects have smoking habit in their daily living. the average level of gfr stated in 1.5 mg/dl. statistical analysis demonstrate the relationship between alad polymorphism and gfr showed a non-signifi cant value (p < 0.618; r = -0.084). discussion the study showed that the frequency of alad 1-1 had a proportion of 94.7%, while only 5.3% was recorded for alad 12. unfortunately, alad 2-2 allele was not found in this study. research carried out by weaver et al [15] reported that the proportion of alad 1-1 allele was more dominant than the alad 1-2, namely 90.1% versus 9.9%. 77 gfr dan kadar timbal dalam darah pada pekerja pom bensin (lantip rujito, dkk) his study also stated that only 4% of the population had alad-2 allele. this leads to the possibility of decrease in alad 1-2 allele due to the presence of cross-breeding between alad-1 and alad-2 allele. the mean of creatinin serum for all respondents amounted to 0.85 mg/dl. creatinin serum is affected by muscle mass and activity. the value among the respondents ranged from 0.51 to 1.27 mg/ dl. it’s comparable with the last study wu et al (2003), which examined the relationship between lead and renal function. they found the average serum creatinin of 1.2 mg/dl with a range of 0.6–2.5 mg/dl. the differences could be due to muscle mass and activity habit. american population is caucasian while indonesia is mongoloid race. they have larger body than the mongoloid so that muscle mass in caucasians is relatively larger than the mongoloid (weaver, et al., 2005) a mean serum creatinin in alad 1-1 is equal to 0.84 mg/dl, while in the alad 1-2 is 0.89 mg/dl. population with alad 1-2 in this study was only 2 subjects so that we could not draw statistical analysis. these fi ndings are consistent with previous research (wu et al., 2003). they found that the mean of serum creatinin in alad 1-2 is greater than alad-1. however, there is contradiction result compared with another team (weaver et al., 2003). workers exposed to lead in korea who had alad 1-1 allele had serum creatinin levels greater than alad 1-2. it could be explained that workers exposed to high lead exposure was in the battery factory and lead smelters in korea, whereas in the wu’s study lead exposure was quite low (wu et al., 2003). gfr value was calculated using scwahtrz formula. serum creatinin is inversely proportional to gfr, while gfr is linear with the body height, so the variation of serum creatinin and body height will affect the value of gfr (refaie, moocchhala, & kanagasundaram, 2007). the mean of gfr in alad 1-1 and alad-1-2 are 115.69ml/ min and 107.07ml/min respectively. the relationship between alad polymorphism and gfr showed a non-significant value (p < 0.618; r = -0.084). this may be due to variations of the respondents, there were 36 people who had alad 1-1 allele and only 2 subjects who have alad 1-2 allele. many studies support the fact that alad enzyme may modify different toxic effects in the organ. in addition, alad gene polymorphisms also related with several parameters of kidney function such as β2 micro-globulin, α1 microglobulin and α2 macroglobulin (chia, et al., 2006). the average level of pb in the blood is 1.5 mg/dl. according to who statement, the threshold values of pb in men is 40 mg/dl, while the female is 30 μg/dl. our fi ndings suggest that pb levels in this study were low. wu et al. (2003) found that the average level of pb in blood is of 6.2 mg/dl. there were some issues concerning about this result. subjects used in his study were elder people ranging from 43 to 93 years old. this wide difference in age may contribute the study result. low levels of pb in our study also can be caused by cessation of the use of lead in fuel oil process. indonesian government through pertamina has stopped production of fuel oil contain raising octane and anti-knocking agent since 2006 (dellyani & rb, 2010). all respondents worked at least for 1 year and they make low exposure to pb. gfr relationship and blood pb in this study was found not to be signifi cant (p < 0.195; r = 0.125). this fi nding could be due to the low quantity of pb so it did not cause damage to the nephrons. in line, previous study showed that there was no relationship between pb with gfr. low level of pb caused no signifi cant effect on gfr and intoxication (zhao, et al., 2007)). on the other hand, a fieldwork conducted in the united states population from 1988 to 1994, found that at higher pb levels > 4,21 mg/dl, subjects suffered hypertension while subjects with < 3,30 mg/dl did not affect hypertension. the study also depicted that gfr from those who suffered hypertension was higher than those who did not (muntner, et al., 2003). the effects of pb on the kidneys failure in each alad genotype showed that there were differences between the renal effects of pb on the alad 1-1 and alad 1-2 allele. there 78 jurnal ners vol. 10 no. 1 april 2015: 74–79 was a reduction in gfr and increased levels of unag (urinary n-acetyl-β-glucosaminidase) in the alad 1-2 [24]. in group of alad 1-2 there was an increase levels of unag urinary interpreted too many apoptosis in renal tubular cells. exsposure of pb led to damage the tubules and glomeruli in histopathological examination leading to a decline in kidney function (weaver, et al., 2008). our study showed a replication data that the alad 1-1 had lower degree in pb level compared with alad 1-2 allele. however, there was limitation study related to sample numbers, and study design. conclusion and suggestion conclusion in conclusion, there was no correlation between gfr and blood lead levels in the gas station employee concerning δ-alad gene alleles polymorphism. sugesstion further research could use more sample and prospective cohort design in order to assess the effects of pb exposure on the kidneys as well as more control over confounding variables exist. aknowledgment the authors would like to thank the health professional education quality program (hpeq) for funding, and research laboratory of jenderal sudirman university for research facilities. references schwartz, b.s. and h. hu, 2007. adult lead exposure: time for change. environ. hlth perspect., 3: 451–454. jacobs, d., r. clickner, j.y. zhou, s.e. viet, d. marker and j. rogers, 2002. the prevalence of lead-based paint hazards in u.s. housing. environ. hlth perspect., 10: 599–606. ye, x. and o. wong, 2006. lead exposure, lead poisoning, and lead regulatory standards in china, 1990–2005. regul. toxicol. pharmacol,, 2: 157–162. santi, d.n., 2007. pencemaran udara oleh timbal (pb) serta penanggulangannya. media fakultas kedokteran universitas sumatera utara, 1: 10–16. hirose, a., a. takagi, t. nishimura and j.e. kanno, 2004. review of reproduction and developmental toxicity induced by organization in aquatic organism and experimental animal. organohalogen compound, 66: 3042–3047. agency for toxic substances and disease registry (atsdr), 2007. case studies in environmental medicine (csem): lead toxicity, available at url:http://www. atsdr.cdc.gov/csem/lead/pbpatient_ evaluation2.. 2007 10/11/2011]. dongre, n.n., a.n. suryakar, a.j. patil, j.g. ambekar, and d.b. rathi, 2011. biochemical effects of lead exposure on systolic & diastolic blood pressure, heme biosynthesis and hematological parameters in automobile workers of north karnataka (india). ind. j. clin. biochem., 4: 400–406. kosnet, m., 2004. heavy metal intoxication and chelators, in basic and clinical pharmacology, ed. b. katzung. vol. 970-981., boston: mcgraw-hill. kamel f, umbach dm, lehman ta, park lp, munsat tl, shefner jm, sandler dp, hu h, taylor ja., 2003. amyotrophic lateral sclerosis, lead, and genetic susceptibility: polymorphisms in the delta-aminolevulinic acid dehydratase and vitamin d receptor genes. environ. hlth perspect., 10: 1335–1339. hopkins, m.r., ettinger, a.s., hernándezavila, m., schwartz, j., téllez-rojo, m.m., lamadrid-figueroa, h., bellinger, d., hu, h., wright, r.o, 2008. variants in iron metabolism genes predict higher blood lead levels in young children. environ. hlth perspect., 9: 1261–1266. weaver, v.m., m. griswold, a.c.todd, b.g.jaar, k.d. ahn, c.b. thompson, and b.k. lee, 2008. longitudinal associations between lead dose and renal function in lead workers. environ. res., 1: 101–107. 79 gfr dan kadar timbal dalam darah pada pekerja pom bensin (lantip rujito, dkk) futrakul, n., o. kulaputana, p. futrakul, a. chavanakul, and t. deekajorndech, 2011. enhanced peritubular capillary f low a nd renal f u nct ion ca n be accomplished in normoalbuminuric type 2 diabetic nephropathy. ren. fail., 3: 312–315. scinicariello, f., a. yesupriya, m.h. chang, and b.a. fowler, 2010. modifi cation by alad of the association between blood lead and blood pressure in the u.s. population: results f rom the third national health and nutrition examination survey. environ. hlth perspect., 2: 259–264. mcpherson and pincus, 2006. henr y’s clinical diagnosis and management by laboratory methods, 21st ed. w. b. saunders company weaver v.m, schwartz b.s, bernard g, kyudong ahn, todd a.c lee s.s, kelsey k.t, et al., 2005, associations of uric acid with polymorphisms in the δaminolevulinic acid dehydratase, vitamin d receptor, and nitric oxide sy nthase genes i n korean lead workers. environ. hlth perspect, 113: 1–7 wu m.t, k.k., j. schwartz, d. sparrow, s. weiss and h. hu, 2003. a deltaa m i nolev u l i n ic a cid dehyd r at a se (alad) polymorphism may modify the relationship of low-level lead exposure to uricemia and renal function: the normative aging study. environ. hlth perspect., 3: 335–341. hesselbacher, s., s. subramanian, j. allen, and s. surani, 2012. body mass index, gender, and ethnic variations alter the clinical implications of the epworth sleepi ness scale i n patients with suspected obstructive sleep apnea. open respir. med. j., 2: 20–27. weaver vm, schwartz bs, ahn kd, stewart wf, kelsey kt, todd ac, wen j, simon dj, lustberg me, parsons pj, silbergeld ek, lee bk., 2003. associations of renal function with polymorphisms i n t he delt a-a m i nolev u li n ic acid dehydratase, vitamin d receptor, and nitric oxide synthase genes in korean lead workers. environ. hlth perspect., 13: 1613–1619. r., s.h. moochhala, and n.s. kanagasundaram, 2007. how we estimate gfr--a pitfall of using a serum creatinine-based formula. clin. nephrol., 4: 235–237. chia, s.e., h.j. zhou, e. yap, m.t. tham, n.v. dong, n.t. hong tu, 2006. association of r e n a l f u n c i o n a n d a l a d polymorphism among viatnemesse and workers exposed to inorganic lead. occup. environ. med., 8: 180–186. dellyani, h.a.w. and r.b., pengaruh, 2010. timbal (pb) pada udara jalan tol terhadap gambaran mik roskopis ginjal dan kadar timbal (pb) dalam darah mencit balb/c jantan. laporan akhir hasil penelitian kti undip, 45–48. zhao, y., l. wang, h.b. shen, z.x. wang, q.y. wei, and f. chen, 2007.association between delta-aminolev ulinic acid dehydratase (alad) polymorphism and blood lead levels: a meta-regression analysis. j. toxicol. environ. hlth a., 23: 1986–94. muntner, p., j. he, s. vupputuri, j. coresh, and v. batuman, 2003. blood lead and chronic kidney disease in the general united states population: results from nhanes iii. kidney int., 3: 1044– 1050. udomah, f.p., u. ekpenyong ekrikpo, e. effa, b. salako, a. arije, and s. kadiri, 2012.association between urinary nacetyl-beta-d-glucosaminidase and microalbuminuria in diabetic black africans. int. j. nephrol., 5: 5–8. http://e-journal.unair.ac.id/jners | 155 jurnal ners vol. 14, no. 3, special issue 2019 http://dx.doi.org/10.20473/jn.v14i3(si).16954 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review home-based exercise training for heart failure patients roby aji permana, wikan purwihantoro sudarmaji, wahyu sukma samudera, agostinha soares and yanuar aga nugraha faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: exercise training is one of the recommendations for a cardiac rehabilitation program to increase exercise capacity and thus quality of life, decreasing both readmission and mortality in terms of heart failure. in spite of the evidence on the benefits and safety of cardiac rehabilitation, the uptake and participation of cardiac rehabilitation by patients with heart failure is currently poor. this study aimed to systematically review the effect of homebased exercise training on heart failure patients. methods: the studies were systematically identified by searching through the chosen electronic databases (scopus, science direct, proquest, pubmed, and cinahl) for articles from the 5 last years. the search algorithm identified a total 164 articles and 15 articles were selected based on the inclusion and exclusion criteria. for the 15 articles, 13 were rcts, 1 was quasi-experimental and 1 was a retrospective study results: the major result of this review shows that home-based exercise has an effect on functional and exercise capacity, quality of life and a decreased rate of readmission within 2-12 months follow up conclusion: home-based exercise has a long-term effect that is more effective than exercise that is hospital-based article history received: december 26, 2019 accepted: december 31, 2019 keywords home-based exercise; heart failure; blood pressure; hypertension contact roby aji permana  roby.aji.permana-2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: permana, r. a., sudarmaji, w. p., samudera, w. s., soares, a., & nugraha, y. a. (2019). home-based exercise training for heart failure patients. jurnal ners, 14(3si), 155-160. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16954 introduction heart failure (hf) is an increasingly common cardiovascular syndrome and it is the final pathway in several cardiac disorders. although mortality due to cardiovascular disease is decreasing, it remains one of the leading causes of death worldwide, placing a large social and economic burden on society. many hf patients experience dyspnea, fatigue, diminished exercise capacity and poor quality of life(kim et al., 2017; kraal, peek, van den akker-van marle, & kemps, 2014). advances in pharmacological therapies and devices have been shown to improve the physiological parameters and quality of life, to reduce symptoms and to decrease mortality and the readmission rate. however, hf continues to have a significant negative impact on the quality of life of patients and their families or caregivers(taylor et al., 2015). exercise training is one of the recommendations for a cardiac rehabilitation program to increase exercise capacity and quality of life and to decrease readmission and mortality in heart failure. cardiac rehabilitation (cr) is continuously needed for optimal management. in hf, the patients lack regular exercise training and self-imposed limitations related to exercise may play an important role. targeted physical activity is a vital element of comprehensive hf management (smolis-b et al., 2015). exercise training is a widely accepted intervention for hf leading to marked health benefits. in acquired heart failure, numerous studies have established unequivocally that regular exercise is related to better long-term prognosis and a reduced risk of cardiovascular death (dissel et al., 2018). research supports the importance of promoting exercise training to reduce mortality, hospitalization and the risk of other chronic diseases in patients with heart failure(evangelista & cacciata, 2017). despite the benefits of exercise training programs, many patients do not have access to hospitalbased https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i3(si). r. a. permana et al. 156 | pissn: 1858-3598  eissn: 2502-5791 training. the uptake and participation of cardiac rehabilitation by patients with heart failure is currently poor due to the knowledge of the program, distance, cost and poor health. one of the main reasons that people give for not accepting the invitation to attend cardiac rehabilitation are difficulties in regularly attending the sessions at their local hospital and a reluctance to take part in groupbased classes. furthermore, the patients have a lack of knowledge on how they can improve or maintain the functioning of their body after they had heart failure(peng et al., 2018). most studies on exercise in hf patients indicates the inability to access a formal rehabilitation program because they live in remote geographic locations, because they have difficulty with transportation or because do not have the financial resources to pay for a structured rehabilitation program. recently, homebased exercise training programs have been introduced to increase the access and thus to reach a broader range of patients. it is anticipated that homebased exercise programs enhance patient selfefficacy and facilitate the lifelong implementation of regular physical activity with increased adherence, since it takes into consideration the preference of the individual patient (dissel et al., 2018). two keys solutions to this poor provision and uptake include the development of a home-based self-help cr manual designed to meet the needs of those with hf and the close involvement of their caregivers(taylor et al., 2015). currently, limited data is available on exercise prescription regarding safety, feasibility, and efficacy. to address this problem, home-based exercise training may be an acceptable alternative method for patients. this systematic review will give an overview of the effect of home-based exercise in compliance with the primary outcome of functional capacity and quality of life. this systematic review sought to determine the effectiveness of home-based exercise programs compared with supervised centre-based exercise programs on exercise and/or the functional capacity, health-related quality of life, modifiable cardiac risk factors, mortality and morbidity of the patients with heart failure. materials and methods a three step strategy was used for the collection of the literature study materials. the initial phase was conducted by searching the literature using a systematic review format on chocrane, but a suitable theme was not found. the second step includes the keywords according to the selected topics in a selection of electronic databases: scopus, pubmed, cinahl, sciencedirect and proquest. the articles were identified by the use of search terms and keywords (“home-based exercise”, “heart failure”, “functional capacity”, “exercise capacity”, “quality of life”) published in the last 5 years (2015 2019) in english (figure 1). boolean logic was used for this searching strategy. the types of the studies that we selected were observational and experimental. the titles and abstracts of the studies that were identified were screened and any clearly irrelevant studies discarded. the full-text of all of the potentially relevant studies were obtained and assessed independently for eligibility, based on the defined inclusion criteria. in cases where insufficient data was reported (e.g. method of randomization, statistical methods), this was discussed by the author and the risk of bias in the eligible studies was assessed in terms of the randomization and description of dropout and withdrawal. the compilation of the review system followed the guidelines of the literature obtained from cochrane. the picot framework used to formulate the answerable questions for this study. population: the study population consisted of adult heart failure patients. intervention: the intervention was homebased exercise. comparison: usual care (center-based exercise). output: exercise or functional capacity, quality of life, mortality and morbidity and readmission. the study population included adults with heart failure that had undergone revascularization through devices or patients with heart failure who had taken part, or been invited to take part, in cardiac rehabilitation. home-based exercise is defined as a structured program with clear objectives for the participants, including monitoring, follow-up visits and letters or telephone calls from the staff. the comparison group consisted of centre-based cardiac rehabilitation in a variety of settings (e.g. the hospital physiotherapy department, university gymnasium, community sports centre). the primary outcome of this article is functional and exercise capacity and health-related quality of life. mortality, morbidity and the readmission rate were included as a secondary outcome. results literature search and study design a three-step strategy was used in the initial phase of the literature search in some databases with the specified keywords, which obtained 164 articles. the search found 14 articles from scopus, 9 articles from pubmed, 15 articles from cinahl, 79 articles from proquest and 47 articles from sciencedirect. the titles and authors of the studies were identified and duplicate studies were discarded. the second stage reviewed the abstracts retrieved according to the eligible criteria. we excluded the articles that did not match the inclusion criteria. the third step was reviewing the full articles. the full articles were reviewed using the picot framework. the relevant data regarding the inclusion criteria (participants, interventions and outcomes), the risk of bias and the results was extracted. data extraction was carried out by a single reviewer (rap) and this was checked by a second reviewer (wps). a total of jurnal ners http://e-journal.unair.ac.id/jners | 157 15 articles were selected based on the criteria. the 15 articles included 13 rcts, 1 quasi-experimental study and 1 retrospective study. the importance of the results of the study has been shown in table 1. although a number of studies reported dropout rates, the reasons for the drop out were often unclear so it was therefore not possible to consistently estimate the number of patients withdrawing from the cardiac rehabilitation program for each study. population the total number of respondents in this review was 5024. the population involved was between 16 to 3488 participants. the highest population was 3488 for the retrospective study and 360 from the randomized controlled trial. the participants involved were limited by several criteria such as age, clinical examination before action and their experience related to medical actions. all of the studies were conducted on adults (aged 18 70 years). the criteria of the respondents in several studies was based on the classification of the new york heart association (stages 1 4) (antonicelli et al., 2016; evangelista & cacciata, 2017; george et al., 2017; kim et al., 2017). other criteria in the study were the fraction ejection, any co-morbidities and the stability status of the heart failure patients(evangelista & cacciata, 2017; kim et al., 2017; nielsen, duncan, & pozehl, 2018). the articles in this review came from 3 continents, namely america, europe and asia.. intervention characteristic the intervention given to the respondents consisted of home-based physical activity/training. all of the studies used various models that were given to the patients. the home-based exercise interventions included walking exercises (babu, desai, maiya, guddattu, & padmakumar, 2016; hinrichs et al., 2016; nielsen et al., 2018; peng et al., 2018; ramadi et al., 2015; reeves, whellan, duncan, connor, & pastva, 2017; safiyari-hafizi, taunton, ignaszewski, & warburton, 2017; shoemaker et al., 2017; taylor et al., 2015), aerobic/strengthening exercises (evangelista & cacciata, 2017; hinrichs et al., 2016; reeves et al., 2017; shoemaker et al., 2017; smolis-b et al., 2015), treadmill (kim et al., 2017; shoemaker et al., 2017), cycling/riding (antonicelli et al., 2016; evangelista & cacciata, 2017; kim et al., 2017; shoemaker et al., 2017) and self-selected exercise training(dissel et al., 2018). furthermore, some studies showed the adherence strategies for the home-based exercise over the duration of the study. adherence strategies (logs, graphs, pedometers, phone follow-up, education, and a letter from cr staff) are intended to increase the rate of adherence(nielsen et al., 2018). some studies used telemonitoring/telehealth to follow-up as the strategy for better adherence.(peng et al., 2018; smolis-b et al., 2015). in addition, 1 study used the qq and wechat software to deliver the home-based telehealth exercise training(peng et al., 2018). the exercise period involved several duration differences; 2 months(babu et al., 2016; peng et al., 2018; smolis-b et al., 2015), 3 months (hinrichs et al., 2016; kim et al., 2017; nielsen et al., 2018; ramadi et al., 2015; reeves et al., 2017; safiyari-hafizi et al., 2017; shoemaker et al., 2017) and 6 months (antonicelli et al., 2016; dissel et al., 2018; evangelista & cacciata, 2017; george et al., 2017).the frequency of exercise that had been done by the patient ranged between 2 6 sessions every week for 20 60 minutes/session. all reported outcomes at the follow up which instead reported change in the outcomes at follow up (3 24 months) compared to the baseline (antonicelli et al., 2016; peng et al., 2018; ramadi et al., 2015). clinical outcome a number of studies give a specific primary outcome. the primary outcome in most of the studies was functional capacity/exercise capacity, quality of life, mortality and morbidity and the rate of readmission. functional capacity was measured by a 6-minute walking test. exercise capacity is measured as the maximal oxygen uptake (vo2max), referring to either the metabolic equivalents (mets) or milliliters per kilogram of body mass per minute (ml/kg/min) or milliliters (ml)(safiyari-hafizi et al., 2017; smolis-b et al., 2015). quality of life was measured by the minessotta living with heart failure questionnaire (mlhfq) and the medical outcome survey-short form 36sf36(babu et al., 2016). changes in the condition were associated with readmission rate, mortality and morbidity, which were also documented in the studies with the maximum follow up being up to 12 months (antonicelli et al., 2016; peng et al., 2018; ramadi et al., 2015). figure 1. prisma study flow diagram records identified through database searching (n = 164) cinahl : n = 15 , science direct : n = 47, pubmed : n = 9 , scopus : n = 14, proquest : n = 79 i n c l u d e d e l i g i b i l i t y i d e n t i f i c a t i o n records after duplicates removed (n = 67) abstracts assessed for eligibility (n = 15) articles excluded, with reasons (n = 52) ▪ age ▪ intervention ▪ outcomes full text downloaded (n = 15) studies included were assesed by picot(n = 15) record excluded based on title and author (n = 97) r. a. permana et al. 158 | pissn: 1858-3598  eissn: 2502-5791 discussion exercise training is a well-established adjunct therapy in acquired heart failure. substantial evidence shows that exercise markedly affects the prognosis and reduces mortality and hospitalization. it also improves functional capacity, exercise capacity and health-related quality of life (dissel et al., 2018). the chance of most patients with hf improving their exercise tolerance was limited due to an increased risk of related adverse events, frequently advanced age, poor adherence and comorbidities. in spite of that, attempts to promote regular physical activity such as diverse exercise training, are independent and effective options to improve the patients’ health status(smolis-b et al., 2015). increased functional capacity occurs due to the improved muscle pump function caused by many factors, including medical therapy, lifestyle education and exercise activity(mckelvie, 2008). smolis (2015) showed that after a period of home -based exercise, there were beneficial effects in terms of left ventricular remodeling and the parameters of exercise capacity in the cardiopulmonary exercise testing and 6mwt could be observed with a greater improvement seen in the patients participating in the regular exercise training program(smolis-b et al., 2015). exercise in heart failure facilitates the physiological adaptation of muscles that are trained to increase oxygen uptake, reduce oxidative stress, increase enzyme aerobics and increase the number of muscle type i(mckelvie, 2008). the findings of ramadi et al (2015) showed that every 1 ml·kg − 1 ·min − 1 (ie, 0.28 mets) increase in exercise capacity is associated with a 10% reduction in cardiovascular mortality. increases of 0.95 mets and 0.73 mets in exercise capacity (for the center-based and homebased groups, respectively) indicate the potential clinical significance of this study(ramadi et al., 2015). the significant improvement in aerobic power is important for improving the functional reserve of the patients with hf and reducing the risk for disability/functional dependence and premature mortality (safiyari-hafizi et al., 2017). physical exercise will stimulate the vasodilating factor of the vascular endothelium that improves remodeling in vascularization. this condition contributes to a decrease in peripheral vascular resistance, an increase n ejection fraction and improved stroke volume(mckelvie, 2008).the major new finding from safiyari-hafizi (2017) was that supervised home-based cardiac rehabilitation included a combination of high intensity interval and resistance training which resulted in a significant improvement in the vo2 peak in patients with hf. furthermore, the study showed a significant improvement in exercise capacity, quality of life, and the oxygen consumption at the ventilatory threshold (safiyari-hafizi et al., 2017). rehabilitation exercise can minimize the symptoms, increase exercise tolerance and quality of life and have a satisfying effect on patient recovery. home-based exercise was proven to increase exercise capacity and self efficacy and decrease the rate of readmission (mckelvie, 2008). exercise training has significant implications for the health status and overall quality of life of hf patients. given the important role that aerobic power and functional status plays in morbidity and mortality in hf, exercise training may also have potentially important implications for improving survival in hf and reducing the hospitalizations and the health care costs associated with treating hf. safiyari-hafizi (2017) revealed that their closely monitored homebased cardiac rehabilitation program (employing high intensity interval and resistance training) resulted in significant improvements in physiological well-being and overall quality of life. this is consistent with the other trials of hf management that support the use of home-based aerobic training programs that include close monitoring and interactions with the patients via a follow up. this speaks directly to the applicability and efficacy of home-based interval training in persons living with hf(safiyari-hafizi et al., 2017). prescribing physical exercise, adjusting the physical prescriptions and integrating exercises affect patient compliance when doing exercises. prescribing an adequate level of physical exercise in patients with heart failure should include the components of frequency, intensity, duration and the physical exercise mode. physical exercise adjustment prescriptions are needed to get optimal physical exercise results. an integrated training program should start when the patient is stable, followed by focused physical exercise in the hospital. after the patient returns home, they should continue independently with a home-based exercise. patients who start home-based rehabilitation programs must be convinced in terms of that their knowledge about physical training, their continuous access to the monitoring center and the telemonitoring guidance in that it guarantees their absolute safety. it is also important to motivate the patients to continue exercise training in all stages of rehabilitation and to offer them comprehensive care to maintain good exercise tolerance(smolis-b et al., 2015). in home-based programs, there is more emphasis on self-monitoring and independent exercise. selfmonitoring might in turn enhance the patient awareness of their behavior, which could ultimately lead to better adherence to long-term behavior changes. furthermore, developing an early adaptation of exercise behavior changes in the patient’s home environment may play a key role in exercise sustainability (ramadi et al., 2015). homebased exercise programs help to address these issues by enabling the elderly to exercise in the comfort of their own home using a program that was developed to be safe and suitable for elderly hf patients. additionally, giving the participants better access to an in home exercise program, as well as following up with regular phone calls from the study physician, jurnal ners http://e-journal.unair.ac.id/jners | 159 may have led to the increase in the positivity of their perceived physical and mental health, as indicated by the change in the sf-36 scores. this increase in positive health perception might have led to the perception of increased energy, reduced fatigue, increased health and a reduction in the limitations that their physical issues placed on their normal life activities in the intervention group (george et al., 2017). a structured home-based program must be prescribed clearly, including its objective, duration, intensity, adherence strategy and the monitoring or follow up visits. there are many confounding factors that will affect the program such as the magnitude of inactivity, the duration, environment and the customization of the exercise intervention. the most significant confounding factor is the readiness for behavioral change. in several studies, it is unknown the degree to which the subjects included in the study were ready for behavioral change (shoemaker et al., 2017). the initiation of behavioral change is needed to improve awareness and to increase the knowledge that will provide compliance in the patients included in the rehabilitation program. the various patients included in the rehabilitation program showed that home-based cardiac rehabilitation can be an alternative or additional program for patients with heart failure. conclusion the major result of review shows that home based exercise has an effect on functional and exercise capacity, quality of life, and decrease the rate of readmission within the 2 12 months of the follow up. home-based exercise has a long-term effect that is more effective than hospital based. furthermore, a structured home based exercise program must be considered according to the duration, environment, customization and the readiness for behavioral change in the patients with heart failure. references antonicelli, r., spazzafumo, l., scalvini, s., olivieri, f., mattasini, m. v., parati, g., … lattanzio, f. (2016). exercise: a “new drug” for elderly patients with chronic heart failure. aging, 8(5), 860–869. babu, a. s., desai, c. v., maiya, a. g., guddattu, v., & padmakumar, r. (2016). changes in derived measures from six-minute walk distance following home-based exercise training in congestive heart failure: a preliminary report. indian heart journal, 68, 527–528. https://doi.org/10.1016/j.ihj.2016.05.010 dissel, a. c. van, hooglugt, j. q., de, f. h., blok, i. m., jørstad, h. t., mulder, b. j. m., … winter, m. m. (2018). safety and effectiveness of home-based, self-selected exercise training in symptomatic adults with congenital heart disease: a prospective, randomised, controlled trial. international journal of cardiology. https://doi.org/10.1016/j.ijcard.2018.12.042 evangelista, l. s., & cacciata, m. (2017). doseresponse relationship between exercise intensity , mood states , and quality of life in patients with heart failure. journal of cardiovascular nursing, 1–8. https://doi.org/10.1097/jcn.000000000000040 7 george, m., azhar, g., pangle, a., peeler, e., dawson, a., coker, r., … wei, j. (2017). feasibility of conducting a 6-months long home-based exercise program with protein supplementation in elderly community-dwelling individuals with heart failure. journal of physiotherapy & physical rehabilitation, 2(2), 19–22. https://doi.org/10.4172/2573-0312.1000137 hinrichs, t., bucker, b., klaaßen-mielke, r., brach, m., dipl-stat, wilm, s., … mai, a. (2016). home-based exercise supported by general practitioner practices: ineffective in a sample of chronically ill, mobility-limited older adults (the homefit randomized controlled trial). the american geriatrics society, 1–10. https://doi.org/10.1111/jgs.14392 kim, m., kim, m. s., lim, s. j., ahn, j. m., kim, j. j., & park, s. j. (2017). comparison of supervised hospitalbased versus educated home-based exercise training in korean heart failure patients. korean circulation journal, 47, 742–751. https://doi.org/10.4070/kcj.2017.0061 kraal, j. j., peek, n., van den akker-van marle, m. e., & kemps, h. mc. (2014). effects of home-based training with telemonitoring guidance in low to moderate risk patients entering cardiac rehabilitation: short-term results of the fit@home study. european journal of preventive cardiology, 21, 26–31. https://doi.org/10.1177/2047487314552606 mckelvie, r. s. (2008). exercise training in patients with heart failure: clinical outcomes, safety, and indications. heart failure reviews, 13(1), 3–11. https://doi.org/10.1007/s10741-007-9052-z nielsen, j., duncan, k., & pozehl, b. (2018). patientselected strategies for post cardiac rehabilitation exercise adherence in heart failure. rehabilitation nursing journal, 1–5. https://doi.org/10.1097/rnj.000000000000012 7 peng, x., su, y., hu, z., sun, x., li, x., dolansky, m. a., … hu, x. (2018). home-based telehealth exercise training program in chinese patients with heart failure. medicine, 97(august), 1–9. ramadi, a., haennel, r. g., stone, j. a., arena, r., r. a. permana et al. 160 | pissn: 1858-3598  eissn: 2502-5791 threlfall, t. g., hitt, e., … martin, b. (2015). the sustainability of exercise capacity changes in home versus center-based cardiac rehabilitation. journal of cardiopulmonary rabilitation and prevention, 35, 21–28. https://doi.org/10.1097/hcr.00000000000000 84 reeves, g. r., whellan, d. j., duncan, p., connor, m. o., & pastva, a. m. (2017). rehabilitation therapy in older acute heart failure patients ( rehab-hf ) trial : design and rationale. american heart journal, 185, 130–139. https://doi.org/10.1016/j.ahj.2016.12.012 safiyari-hafizi, h., taunton, j., ignaszewski, a., & warburton, d. (2017). the health benefits of a 12 week home-based interval training cardiac rehabilitation program in patients with heart failure. canadian journal of cardiology, (2016). https://doi.org/10.1016/j.cjca.2016.01.031 shoemaker, m. j., oberholtzer, n. l., jongekrijg, l. e., bowen, t. e., cartwright, k., hanson, k., … kowalk, a. (2017). exerciseand psychosocial-based interventions to improve daily activity in heart failure : a pilot study. home health care management & practice, 1–10. https://doi.org/10.1177/1084822316683660 smolis-b, e., d, r., piotrowicz, e., chwyczko, t., dobraszkiewicz-wasilewska, b., kowalik, i., … szwed, h. (2015). hospital-based and telemonitoring guided home-based training programs : effects on exercise tolerance and quality of life in patients with heart failure ( nyha class iii ) and cardiac resynchronization therapy . a randomized , prospective observation . international journal of cardiology, 199, 442–447. https://doi.org/10.1016/j.ijcard.2015.07.041 taylor, r. s., hayward, c., eyre, v., austin, j., davies, r., doherty, p., … britten, n. (2015). clinical effectiveness and costeffectiveness of the rehabilitation enablement in chronic heart failure rehabilitation intervention in heart failure patients and caregivers : rationale and protocol for a multicentre randomised controlled trial. bmj journal, 5(12), 1–11. https://doi.org/10.1136/bmjopen-2015-009994 http://e-journal.unair.ac.id/jners | 213 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i1.10888 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research exclusive breastfeeding associated with the reduction of acute respiratory tract infections in toddlers with high-risk factors abu bakar1, elfira fitria rohma1, iqlima dwi kurnia1 and siti nur qomariah2 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 faculty of health science, universitas gresik, east java, indonesia abstract introduction: acute respiratory tract infections (ari) is a disease that is the primary cause of death, especially in children. toddlers can be prevented from developing ari with increased immunity. giving breast milk can increase children's immunity, but there are still children who experience ari. this study aimed to explain the differences in acute respiratory tract infections (ari) events in toddlers who are exclusively and non-exclusively breastfed. methods: the research design used was descriptive-comparative with a retrospective design. the population in this study were all children one to three years of age. a sample of 158 toddlers was recruited by a purposive sampling technique. data retrieval was done with the criteria that the child had visited a public health centre (puskesmas) or integrated health care service post (posyandu), and does not suffer from a disease such as asthma or have any allergies. the variables were measured using a questionnaire and observation sheet. data analysis was done by a chi-square test and binary logistic regression. results: the results showed that there were differences in ari incidence in toddlers (one to three years) who were exclusively and non-exclusively breastfed with a value of p = 0.003. the air pollution factor proved to be significant, dominantly affecting the incidence of ari. conclusion: differences in ari incidence in toddlers who are exclusively and nonexclusively breastfed is possible due to air pollution factors. key implications for nursing practice from this research are improving services, and prevent the occurrence of ari. article history received: december 26, 2018 accepted: february 18, 2019 keywords acute respiratory tract infections; breast milk; exclusive breastfeeding; toddler contact abu bakar  abu.bakar@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: bakar, a., rohma, e,f., kurnia, i,q., & qomariah, s,n. (2018). exclusive breastfeeding prevents the incidence of acute respiratory tract infections in toddlers who have high-risk factors. jurnal ners, 13(2), 213-218. doi:http://dx.doi.org/10.20473/jn.v13i1.10888 introduction acute respiratory tract infection (ari) is an infection that attacks the throat, nose, and lungs which occurs around fourteen days (kemenkes ri, 2012) and becomes the main cause of death, especially in children around the world (fillatre et al., 2018). around 18-33% of the death of children under five years is estimated to be caused by ari (khan & islam, 2017). in addition, 6.6 million children under five years old died in the world annually. as many as 95% occurred in developing countries, and one-third of which were caused by ari (tazinya et al., 2018). risk factors of ari include the provision of breastmilk, the nutritional status of infants, birth weight, air pollution, immunization status, and population density (kemenkes ri, 2012). incomplete exclusive breastfeeding is one of the risk factors for ari, especially in toddlers who are very susceptible to the infection. in other words, toddlers who are not exclusively breastfed have a high risk of ari (arifeen et al., 2001), while the risk can be reduced in those who are exclusively breastfed (hanieh et al., 2015). in addition, patients with mild ari (not pneumonia) can be worsened into severe if not treated properly (qazi et al., 2015). furthermore, ari can be experienced several times by children as many as three to six times per year on average (riskesdas, 2013). the existence of a stimulus, in this case, the provision of breastmilk, will lead to the emergence of coping mechanisms in individuals. the regulator subsystem is part of a coping mechanism that has https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:abu.bakar@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v13i1.10888 a. bakar et al. 214 | pissn: 1858-3598  eissn: 2502-5791 several adaptive modes. breast milk contains antibacterial factors including secretory ig a, igg, epithelial cell receptor analogues, casein, alphalactalbumin, lipids, and phosphorylated beta-casein (andreas, kampmann, & mehring le-doare, 2015) which will help the children to response viruses or bacteria inhaled. the presence of these substances will result in a high content of anti-bacterial factors and will prevent the entry of viruses or bacteria entering the body, and subsequently, prevent the occurrence of ari. previous research in indonesia indicated that there was a relationship between the history of exclusive breastfeeding and the incidence of ari in one-year-old children (anggraeni & warsiti, 2010). another study was that the incidence of ari was lower at the age of seven to twenty-four months who were given exclusive breastfeeding than those who were fed with formula milk (dewi, 2017). previous research conducted abroad showed that risk factors for age, sex, immunization status, breastfeeding, nutritional status, and population density were not significantly associated with ari events (tazinya et al., 2018). the results of previous studies in indonesia showed that there was no research subjects toddler. based on previous research that does not have a toddler's age, a study will be conducted on the differences in ari incidence in toddlers who are given exclusive and non-exclusive breastfeeding. the results of previous studies abroad showed that ari risk factors were not significantly associated with ari events. based on those results, re-research needs to be done, especially in indonesia due to differences in characteristics and culture. based on east java's 2016 health profile data, the number of babies in the east java region was 509,874 toddlers, 74.3% of these were exclusively breastfed. whereas in the lamongan area the number of toddlers was 18,542 with 73.3% of that number having been exclusively breastfed (riskesdas, 2013). the results of a preliminary study of ten mothers who had toddlers found five children were exclusively breastfed and five children were non-exclusively breastfed. from the five children who were exclusively breastfed, four children rarely experienced ari and one child often developed ari (rohma, 2018). meanwhile, three out of five children who were non-exclusively breastfed often experienced the incidence of ari and two children rarely experienced ari events. the frequency category of ari events in children is said to be rare if it occurs once in the last two months and often if it occurs twice or more than three times in the last two months (kemenkes ri, 2012). based on data obtained from the 2016 east java health profile, there were 102,712 cases of ari in infants were found and treated. preliminary study results at the health profile of lamongan regency 2016 recorded 5,372 toddlers of ari cases that were found and handled. lamongan was the highest of five regencies or cities that have ari cases in east java. according to the public health office of lamongan, in 2017, as many as 3,479 toddlers suffered from ari and 223 toddlers suffered from severe pneumonia. in a district community health centre in lamongan, from january to april 2018, there were 44 infants who suffered ari pneumonia and severe pneumonia. therefore, based on the description above, researchers are interested to conduct investigations that can determine the difference in the incidence of ari in toddlers who are exclusively and nonexclusively breastfed. knowing these differences will eventually encourage mothers to exclusively breastfeed children to reduce the incidence of ari. this research aimed to explain the differences in ari events in toddlers (one to three years) who are exclusively and non-exclusively breastfed. materials and methods the research design was descriptive-comparative with a retrospective approach looking at ari events that had occurred in the past, namely toddler age. the population of this study was all children one to three years old (toddlers) in lamongan, indonesia. the data was collected in a district which had a primary public health centre (puskesmas), and six health service posts (posyandu) as program implementers. the puskesmas noted that the number of children under five in april 2018 was 301 toddlers. a sample of 158 toddlers was recruited by purposive sampling technique. the technique was done by determining the sample based on predetermined criteria, namely toddlers who had visited a public health centre, and did not suffer from a disease such as asthma or have any allergies. the study was conducted from june 22 to july 9, 2018. the procedure for data collection was carried out for the first time at a puskesmas in one of lamongan’s districts by assessing medical records of the toddlers who met the inclusion criteria for some information such as address, demographical characteristics, and incidence of ari over the past two months. the ari incidence data were used to determine categories. toddlers who met the criteria were visited at their home in which the researchers asked for permission to the children’s parents to be involved as research subjects. the parents were explained with the purpose and procedure of the study and then asked for a signature as evidence of agreeing or disagreeing as for the subject of the study. respondents who agreed to be the subjects were accompanied to fill out questionnaires about selfidentity, exclusive breastfeeding, and air pollution. room occupancy density data was taken by measuring the respondent's room area directly. nutritional status data and immunization history were obtained from kartu menuju sehat (growth chart). the collected data were then analyzed and explained. research variables were breastfeeding, ari incidence in toddlers and ari risk factors. variables jurnal ners http://e-journal.unair.ac.id/jners | 215 of ari risk factors consisted of low birth weight (lbw), nutritional factors, air pollution, occupancy density, and complete immunization. the research instruments used were the ari and ari risk questionnaire which was modified from the research of agungnisa (2017) and simarmata (2017). in addition to questionnaires, there were variables measured by observation techniques, namely nutritional status by looking at the growth chart data, ari occurrences were determined by assessing the medical records, and the occupancy density of the room was measured using a meter. the category of ari events in children was divided into “rare”, less than once in the last two months; and “often”, more than twice in the last two months) (kemenkes ri, 2012). occupancy density categories were grouped into crowded, eight square meters for more than two people or less than four square meters for one person; and worthy, eight square meters for two people or more than four square meters for one person (agungnisa, 2019). this study used a chi-square test with a significance of α ≤ 0.05 for the analysis of the hypothesis of the relationship between the incidence of ari and breastfeeding. the relationship between ari and the risk factors were analyzed using a binary logistic regression test. the research procedure had been tested and declared ethical by the health research ethics committee of the faculty of nursing, universitas airlangga, on july 2nd, 2018 with an ethical approval number of 982-kepk. the ethical principles applied in this study included participants who were given information and provided informed consent before the data collection. they had the right to confidentiality of data by using initials. results out of 158 respondents, there were 76 toddlers who were not exclusively breastfed (table 1). the majority of toddlers who are non-exclusively breastfed, often experience ari (59.2%). in addition, the majority of toddlers who were exclusively breastfed rarely experienced ari (64.6%), which means that an incidence of rare ari was found. to identify the relationship between the variable risk factors for ari events and the main variable, namely the incidence of ari, a series of initial analyses were carried out (table 2). the proportion of underweight birth weight is in accordance with the standard, the majority of which was 135 (85.4%) of normal birth weight. also, most of the nutritional status and immunization status are good (96.2% and 79.1% respectively), which means that toddlers’ nutrition was fulfilled and the immunization was complete. moreover, air pollution around the homes of toddlers with poor or unhealthy air pollution was 35.4%, while moderate air pollution was 45.6% and only 19% were healthy. in accordance with the standards imposed by the indonesian government, more than half of toddlers (56.3%) experienced inadequate housing. lbw toddlers who are nonexclusively breastfed (47.8%) often experience ari. toddlers with good nutritional status and exclusive breastfeeding (32.9%) rarely experience ari. toddlers with complete immunization status and exclusive breastfeeding (32.8%) rarely experience ari. toddlers who lived in unhealthy air pollution areas and were non-exclusively breastfed (66.1%) often experience ari. toddlers who lived in homes with worthy room and obtained exclusive breastfeeding (37.7%) rarely experience ari. in particular, air pollution had the most dominant relationship to the incidence of ari in toddler children. this is indicated by p-value = 0.000. the results of this study indicate that there were differences in the incidence of ari in toddlers who were exclusively and non-exclusively breastfed. the results of the chi-square statistical test obtained a pvalue of 0.003 which means that the first hypothesis (h1) is accepted if p <0.05 (table 1). discussion ari events in the category are often lower for toddlers who are exclusively breastfed than for nonexclusive children. this is evidenced by the results of the data that most toddler who exclusively breastfed experienced ari in the rare category; whereas most toddlers who were non-exclusively breastfed experienced ari in the frequent category. the incidence of ari is said to be rare if it occurs once in the last two months and often if it occurs twice or more than three times in the last two months (kemenkes ri, 2012). the results of this study were in line with previous studies which stated that there was a significant difference in the incidence of ari between children who were exclusively breastfed and those who were given complimentary food for breast milk at the age of 7-24 months (dewi, 2017). the difference in ari incidence in children who were exclusively and non-exclusively breastfed is because breast milk contains anti-bacterial and anti-viral factors (andreas et al., 2015). breast milk also contains anti-inflammatory substances and antiinfective substances. the presence of these ingredients can prevent infectious diseases caused by bacteria, viruses, and parasites (riksani, 2012). some studies also prove that breast milk can reduce the incidence of infections in infancy and toddlers such as gastroenteritis, respiratory infections, otitis media, neonatal sepsis and urinary tract (aldy, krupnick, newell, parry, & pizer, 2009). most toddlers who were exclusively breastfed experienced ari in the rare category. it is evident that exclusive breastfeeding can reduce the risk of ari in infants (hanieh et al., 2015). as for toddlers who were given non-exclusive breastfeeding, most experienced ari in the frequent category. it proves that ari has a high risk in children who are not exclusively breastfed (arifeen et al., 2001). a. bakar et al. 216 | pissn: 1858-3598  eissn: 2502-5791 according to the results of previous studies, the lack of breastfeeding could increase the likelihood of ari and diarrhoea (khan & islam, 2017). these results were supported by previous findings, where children who have been formula milk-fed since babies had experienced severe respiratory diseases and required more than three hospitalizations compared to infants who were exclusively breastfed (bachrach, schwarz, & bachrach, 2003). morevover, mihrshahi et al. (2007) stated that the increase in exclusive breastfeeding can reduce child morbidity and mortality and is essential to increase the survival rate of children. these results are similar to other studies which also confirm that exclusive and prolonged breastfeeding has the large protective benefit of morbidity (quigley, kelly, & sacker, 2007). this study also analyzed five risk factors for the occurrence of other aris which according to the indonesian ministry of health was an essential element to control ari (kemenkes ri, 2012). the five risk factors include low birth weight, nutritional status, immunization status, air pollution, and occupancy density. the five factors had been tested using binary regression analysis and show that air pollution had a significantly associated with the incidence of ari. this result was in line with a study of kumar, roy, & suguna (2014) stating that there is a significant relationship between meeting clean air needs and the incidence of ari in infants. it indicates that children who live in a good environment of low air pollution have a lower chance of suffering ari compared to those who live with unhealthy air pollution. based on the ministry of health of the republic of indonesia, intensification carried out in the context of prevention and control of ari includes a family approach (kemenkes ri, 2012). the family approach that can be undertaken is through promotive and preventative methods. promotive efforts include exclusive breastfeeding, balanced nutrition, reducing air pollution, coughing behaviour, and early detection. preventive efforts include immunization table 1. the comparison of ari occurrence in toddlers who were given exclusive and non-exclusive breastfeeding (n=158) breastfeeding ari total n (%) chi-square test p-value often n (%) rare n (%) non-exclusive 45 (59.2) 31 (40.8) 76 (100) 0.003 exclusive 29 (35.4) 53 (64.6) 82 (100) table 2. risk factors of ari in non-exclusively and exclusively breastfed toddlers (n=158) risk factors ari frequency non-exclusive breastfeeding exclusive breastfeeding total p-value n % n % n % birth weight 0.829 low often 11 68.8 2 28.6 23 14.6 rarely 5 31.3 5 71.4 not low often 34 56.7 27 36.0 135 85.4 rarely 26 43.3 48 64.0 nutritional status 1.000 poor rarely 3 100.0 3 100.0 6 3.8 good often 45 61.6 29 36.7 152 96.2 rarely 28 38.4 50 63.3 immunization 0.619 less often 9 56.3 5 29.4 33 20.9 rarely 7 43.8 12 70.6 complete often 36 60.0 24 36.9 125 79.1 rarely 24 40.0 41 63.1 air condition 0.000 poor often 37 97.4 16 88.9 56 35.4 rarely 1 2.6 2 11.1 fair often 5 20.0 11 23.4 72 45.6 rarely 20 80.0 36 76.6 good often 3 23.1 2 11.8 30 19.0 rarely 10 76.9 15 88.2 occupancy 0.799 crowded often 30 68.2 18 40.0 89 56.3 rarely 14 31.8 27 60.0 worthy often 15 46.9 11 29.7 69 43.7 rarely 17 53.1 26 70.3 jurnal ners http://e-journal.unair.ac.id/jners | 217 which comprises diphtheria pertussis tetanus (dpt), measles, hepatitis, and tuberculosis (kemenkes ri, 2012). based on the results of previous studies, prevention of ari can be accomplished by improving maternal self-efficacy including educating mothers about the concept of ari, ari conventional treatment, environmental modification, the benefits of using masks, clean and healthy behavior, proper hand washing, nutrition, the provision of exclusive breast milk, stress management, making peer support groups for mothers of toddlers, and optimizing the role of health workers and family support (zatihulwani, sukartini, & krisnana, 2017). the air pollution observed in the study was due to the presence of family members smoking, the use of fuelwood stoves, burning garbage, the use of mosquito repellent, houses closed to animal pens and the type of floor of the house. the researcher found that most children lived with families who had smoking behaviour. in these environments, most ari events often occurred. these results were in line with a study which stated that secondhand smoke is a significant risk factor for ari (tazinya et al., 2018). cigarette smoke is also strongly associated with the incidence of ari in infants (kumar et al., 2014). exposure to cigarette smoke, especially at home and from family members, will increase the likelihood of ari cases. this result was consistent with the study of efni, machmud, & pertiwi (2016) explaining that the exposure to cigarette smoke in the home has a relationship with the incidence of pneumonia in infants. lbw, immunization status, nutritional status, and room occupancy density were factors that did not significantly influence the incidence of ari in toddlers who were exclusively and non-exclusively breastfed. this result was in line with previous research which stated that immunization status and nutritional status did not affect exclusive breastfeeding with the incidence of ari (prameswari, 2009). another study also stated that nutritional status was not significantly associated with ari events (tazinya et al., 2018). it can, therefore, be concluded that from some confounding factors, air pollution is an element that significantly influences the incidence of ari in an exclusive and non-exclusive toddler who were breastfed. conclusion there are differences in ari events in toddlers who are exclusively and non-exclusively breastfed. toddlers who are given exclusively breastfed rarely experience ari than toddlers who are nonexclusively breastfed. ari occurences in toddlers are also influenced by air pollution factor, especially in those who are not exclusively breasfed. the recommendation for further research is the relationship between the habits of parents of smokers and ari in infants who are exclusively and non-exclusively breastfed. references agungnisa, a. (2019). physical sanitation of the house that influence the incidence of ari in children under five in kalianget timur village. jurnal kesehatan lingkungan, 11(1), 1–9. https://doi.org/10.20473/jkl.v11i1.2019.1-9 aldy, j. e., krupnick, a., newell, r. g., parry, i. w. h., & pizer, w. a. (2009). designing climate mitigation policy. ssrn electronic journal. https://doi.org/10.2139/ssrn.1408695 andreas, n. j., kampmann, b., & mehring le-doare, k. (2015). human breast milk: a review on its composition and bioactivity. early human development, 91(11), 629–635. https://doi.org/10.1016/j.earlhumdev.2015.08.0 13 anggraeni, f. d., & warsiti. (2010). hubungan antara riwayat pemberian asi eksklusif dan kejadian ispa pada bayi umur 1 tahun di rsud panembahan senopati bantul. stikes ‘aisyiyah yogyakarta. arifeen, s., black, r. e., antelman, g., baqui, a., caulfield, l., & becker, s. (2001). exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in dhaka slums. pediatrics, 108(4), e67–e67. https://doi.org/10.1542/peds.108.4.e67 bachrach, v. r. g., schwarz, e., & bachrach, l. r. (2003). breastfeeding and the risk of hospitalization for respiratory disease in infancy. archives of pediatrics & adolescent medicine, 157(3), 237. https://doi.org/10.1001/archpedi.157.3.237 dewi, a. l. (2017). perbedaan angka kejadian infeksi saluran pernapasan akut (ispa) antara yang diberi asi eksklusif dengan yang diberi pengganti asi (pasi) pada usia 7-24 bulan. muhammadiyah surakarta. efni, y., machmud, r., & pertiwi, d. (2016). faktor risiko yang berhubungan dengan kejadian pneumonia pada balita di kelurahan air tawar barat padang. jurnal kesehatan andalas. fillatre, a., françois, c., segard, c., duverlie, g., hecquet, d., pannier, c., … castelain, s. (2018). epidemiology and seasonality of acute respiratory infections in hospitalized children over four consecutive years (2012–2016). journal of clinical virology, 102, 27–31. https://doi.org/https://doi.org/10.1016/j.jcv.20 18.02.010 hanieh, s., ha, t. t., simpson, j. a., thuy, t. t., khuong, n. c., thoang, d. d. biggs, b.-a. (2015). exclusive breast feeding in early infancy reduces the risk of inpatient admission for diarrhea and suspected pneumonia in rural vietnam: a prospective cohort study. bmc public health, 15(1), 1166. https://doi.org/10.1186/s12889015-2431-9 kemenkes ri. (2012). pedoman pengendalian infeksi saluran pernafasan akut. kementerian kesehatan ri. https://doi.org/616.24.ind p https://doi.org/10.20473/jkl.v11i1.2019.1-9 https://doi.org/10.2139/ssrn.1408695 https://doi.org/10.1016/j.earlhumdev.2015.08.013 https://doi.org/10.1016/j.earlhumdev.2015.08.013 https://doi.org/10.1542/peds.108.4.e67 https://doi.org/10.1001/archpedi.157.3.237 https://doi.org/https:/doi.org/10.1016/j.jcv.2018.02.010 https://doi.org/https:/doi.org/10.1016/j.jcv.2018.02.010 https://doi.org/10.1186/s12889-015-2431-9 https://doi.org/10.1186/s12889-015-2431-9 a. bakar et al. 218 | pissn: 1858-3598  eissn: 2502-5791 khan, m. n., & islam, m. m. (2017). effect of exclusive breastfeeding on selected adverse health and nutritional outcomes: a nationally representative study. bmc public health, 17(1), 889. https://doi.org/10.1186/s12889-017-4913-4 kumar, sg., roy, g., & suguna, e. (2014). prevalence and risk factors of acute respiratory infection among school children in coastal south india. journal of global infectious diseases, 6(3), 95. https://doi.org/10.4103/0974-777x.138498 mihrshahi, s., ichikawa, n., shuaib, m., oddy, w., ampon, r., dibley, m. j., … peat, j. k. (2007). prevalence of exclusive breastfeeding in bangladesh and its association with diarrhoea and acute respiratory infection: results of the multiple indicator cluster survey 2003. journal of health, population, and nutrition, 25(2), 195–204. retrieved from https://www.ncbi.nlm.nih.gov/pubmed/179858 21 prameswari, g. n. (2009). hubungan lama pemberian asi secara eksklusif dengan frekuensi kejadian ispa. jurnal kesehatan masyarakat. qazi, s., aboubaker, s., maclean, r., fontaine, o., mantel, c., goodman, t., … cherian, t. (2015). ending preventable child deaths from pneumonia and diarrhoea by 2025. development of the integrated global action plan for the prevention and control of pneumonia and diarrhoea. archives of disease in childhood, 100(suppl 1), s23–s28. https://doi.org/10.1136/archdischild2013-305429 quigley, m. a., kelly, y. j., & sacker, a. (2007). breastfeeding and hospitalization for diarrheal and respiratory infection in the united kingdom millennium cohort study. pediatrics, 119(4), e837--e842. https://doi.org/10.1542/peds.20062256 riksani, r. (2012). keajaiban asi (air susu ibu) (1st ed.). jakarta: dunia sehat. riskesdas. (2013). riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan kementeriaan kesehatan republik indonesia. rohma, e. f. (2018). perbedaan kejadian ispa pada anak toddler (1-3 tahun) yang diberi asi eksklusif dan non eksklusif. universitas airlangga, surabaya. tazinya, a. a., halle-ekane, g. e., mbuagbaw, l. t., abanda, m., atashili, j., & obama, m. t. (2018). risk factors for acute respiratory infections in children under five years attending the bamenda regional hospital in cameroon. bmc pulmonary medicine, 18(1), 7. https://doi.org/10.1186/s12890-018-0579-7 zatihulwani, e. z., sukartini, t., & krisnana, i. (2017). development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddlers. jurnal ners, 12(2), 171. https://doi.org/10.20473/jn.v12i2.4616 https://doi.org/10.1186/s12889-017-4913-4 https://doi.org/10.4103/0974-777x.138498 https://www.ncbi.nlm.nih.gov/pubmed/17985821 https://www.ncbi.nlm.nih.gov/pubmed/17985821 https://doi.org/10.1136/archdischild-2013-305429 https://doi.org/10.1136/archdischild-2013-305429 https://doi.org/10.1542/peds.2006-2256 https://doi.org/10.1542/peds.2006-2256 https://doi.org/10.1186/s12890-018-0579-7 https://doi.org/10.20473/jn.v12i2.4616 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 ners vol 10 no 1 april 2015.indd 118 cognitive support meningkatkan kadar cd4 pada pasien hiv di kota kediri (cognitive support increase cd4 level on patient with hiv at kota kediri) yuly peristiowati*, sandu siyoto*, ratna wardani* *stikes surya mitra husada kediri jl. manila, no. 37, sumberece, kediri, jawa timur, e-mail: yulystikes@gmail.com abstrak pendahuluan: hiv (human immunodefi ciency virus) merupakan masalah kesehatan yang mengancam indonesia dan banyak negara di seluruh dunia. ketika hiv masuk ke tubuh, maka virus mencari sel cd4 dan mulai menggandakan dirinya (replikasi virus). apabila telah bereplikasi virus dan meninggalkan cd4 yang telah mati, maka partikel virus baru akan mencari dan menginfeksi cd4 baru. penelitian ini bertujan untuk mengetahui pengaruh pemberian cogntive support kepada penderita hiv berupa informasi, support psikologis, dan spiritual terhadap peningkatan kadar cd4. metode: penelitian menggunakan metode quasy experiment dengan desain posttest group. populasi adalah semua pasien hiv di kota kediri. sejumlah 20 penderita hiv digunakan sebagai sampel, dibagi atas kelompok perlakuan dan kontrol. variabel independen adalah pemberian cognitive support. variabel dependennya adalah kadar cd4 pasien hiv. data sampel darah dikumpulkan untuk melihat kadar cd4. analisis dilakukan dengan uji statistik anova test dan t-test. hasil: hasil penelitian menunjukkan pemberian cognitive support secara signifi kan 0,003 berpengaruh terhadap peningkatan kadar cd4 absolut dan persen cd4 pada penderita hiv. namun, tidak ada perbedaan yang signifi kan antara kelompok kontrol yang mengkonsumsi arv secara rutin dan tidak rutin. diskusi: pemberian cognitive support dapat menstimulasi peningkatan sistem imun berupa limfosit t yang mempunyai molekul penanda cd4, sehingga dengan meningkatkan kadar cd4 diharapkan dapat meningkatkan kualitas hidup penderita hiv. kata kunci: cogntive support, hiv, cd4 abstract introduction: hiv still becomes health problem that threaten indonesia and many countries around the world. when hiv enters the body, it looks for cd4 cells and begins to replicate itself. once replicated and left the dead cd4, the new viral particles will be looking for and infecting new cd4. the purpose of this study was to determine the effects of cognitive supports on cd4 level people living with hiv. those cognitive supports consist of information, psychological, and spiritual support in order to increase the levels of cd4. method: this was quasy experiment research with posttest group design. population were all people living with hiv at kota kediri. samples were 20 respondents who meet the criteria, divided into two groups, intervention and control. the independent variable was cognitive support, while dependent variable was cd4 level of people living with hiv. blood samples were collected to examine cd4 level. data were then analyzed by using anova test and t-test. result: results indicated that the cognitive supports had an effect in increasing the levels of absolute cd4 and cd4 percentage of people living with hiv at a signifi cance value of 0.003. however, there was no signifi cant difference between the control groups taking arv regularly and irregularly. discussion: the provision of cognitive support was capable to stimulate the immune system by increasing t lymphocytes that have cd4 molecular markers. thus, an increase in the levels of cd4 is expected to improve the quality of life of people living with hiv. keywords: cognitive support, hiv, cd4 pendahuluan hiv merupakan masalah kesehatan yang mengancam indonesia dan banyak negara di seluruh dunia. saat ini tidak ada negara yang terbebas dari masalah hiv (djuanda, 2011). hiv adalah virus yang menyerang sistem kekebalan tubuh manusia lalu menimbulkan aids (zein, 2006). secara global diperkirakan terdapat 42 juta orang hidup dengan hiv/aids, yang terdiri dari 38,6 juta orang dewasa, 50% di antaranya adalah perempuan (19,2 juta) dan usia di bawah 15 tahun (3,2 juta) (who, 2007). menurut laporan kasus hiv-aids di indonesia dari april sampai dengan juni 2013, jumlah aids yang dilaporkan baru sebanyak 320 orang. persentase aids tertinggi pada kelompok umur 30–39 tahun (33,8%), diikuti kelompok umur 20–29 tahun (28,8%) dan kelompok umur 40–49 tahun (11,6%). rasio 119 cognitive support meningkatkan kadar cd4 pada pasien hiv (yuly peristiowati, dkk.) aids antara laki laki dan perempuan adalah 2:1. jumlah aids tertinggi dilaporkan dari sulawesi selatan (80), nusa tenggara timur (76), lampung (50), banten (31), dan sulawesi tenggara (25). persentase faktor risiko aids tertinggi adalah hubungan seks berisiko pada heteroseksual (78,4%), penggunaan jarum suntik tidak steril pada pengguna narkoba suntik (14,1%), dari ibu positif hiv ke anak (4,1%), dan lsl (lelaki seks lelaki) (2,5%) (ditjen pp & pl kemenkes ri, 2013). jumlah kasus hiv/aids di kota kediri tahun 2014 tercatat total 456 dengan perincian penderita hiv sebanyak 354 orang, penderita aids sebanyak 102 orang, penderita aids yang telah meninggal dunia sebanyak 36 orang, dan yang masih hidup sebanyak 420 orang. pada saat hi v masu k ke t ubu h, maka vir us mencari sel cd4 dan mulai menggandakan dirinya (replikasi vir us). cd4 merupakan target utama hiv untuk menghancurkan sistem imun tubuh. apabila telah bereplikasi virus dan meninggalkan cd4 yang telah mati, maka partikel virus baru akan mencari dan menginfeksi cd4 baru, sehingga kadar cd4 semakin rendah dalam tubuh. setelah melewati beberapa waktu, sel cd4 dihancurkan, sehingga sistem kekebalan tidak lagi dapat melindungi tubuh dari infeksi dan penyakit yang lain. oleh sebab itu, pemantauan cd4 pada seseorang yang terinfeksi hiv sangatlah penting untuk melihat perjalanan penyakit beserta prognosisnya (djuanda, 2011). meditasi untuk tujuan pengobatan adalah suatu praktek yang meliputi jiwa raga dan tergolong sebagai complementary dan alternative medicine (cam). meditasi dengan pendekatan agama dan spiritual dengan memfokuskan perhatian, perasaan dapat mengalihkan pikiran dan emosi (nccam, 2007). cognitive support melalui pendekatan visualisasi, psikologi, dan spiritual emotional merupakan salah satu meditasi yang dapat meningkatkan respons emosional dan spiritual pada penderita hiv/aids. pada penelitian yang dilakukan burack et al, 1993 menunjukkan dengan pemberian latihan pasrah diri (lpd) dengan mengatur pernafasan 16–20× per menit menjadi 4× per menit dapat menurunkan kadar lymphoscyte cluster of differentiation (cd4) pada penderita hiv. metode penelitian penelitian ini menggunakan metode quasy eksperiment dengan posttest group design. populasi adalah semua pasien hiv di kota kediri. sampel yang digunakan dalam penelitian ini adalah sebagian pasien hiv di kota kediri yang memenuhi kriteria sebagai berikut: 1) pasien hiv di kota kediri yang meliputi wilayah kota dan kabupaten yang tergabung dalam kelompok teman sebaya (kds) hiv/aids kota kediri; 2) bersedia megikuti terapi cognitive support selama 3 hari; dan 3) melakukan pengobatan rutin. sejumlah 20 responden diperoleh, dibagi menjadi kelompok perlakuan dan kontrol. kelompok perlakuan adalah responden penderita hiv yang menjalankan pengobatan arv secara rutin sebanyak 10 responden yang bersedia dilakukan cognitive support selama 3 hari dengan durasi waktu 3 jam per hari. sedangkan, kelompok kontrol adalah penderita hiv yang menjalani pengobatan arv rutin dan tidak rutin dan tidak diberikan cognitive support. selanjutnya dilakukan pengukuran kadar cd4 dari sampel darah responden pada hari terakhir perlakuan. data yang terkumpul dianalisis dengan uji statistik anova test dan t-test dengan tingkat kepercayaan α = 0,05. hasil berdasarkan diagram pie di atas, dapat diketahui bahwa sebagian responden adalah laki-laki, sejumlah 10 (50%) orang, sisanya perempuan. usia responden sebagian besar adalah 20-40 tahun, sebanyak 15 (75%) orang. pekerjaan responden sebagian besar adalah wiraswasta, sebanyak 11 (55%) orang. status perkawinan responden hampir setengah adalah menikah, sebanyak 9 (45%) orang. tingkat pendidikan responden lebih dari setengah adalah sma, sebanyak 11 (45%) orang. berdasarkan tabel 1 diketahui lama menderita hiv responden. rata-rata responden mengidap hiv 29,5 bulan. 120 jurnal ners vol. 10 no. 1 april 2015: 118–124 gambar 1. k a r a k t e r i s t i k r e s p o n d e n berdasarkan jenis kelamin gambar 2. k a r a k t e r i s t i k r e s p o n d e n berdasarkan usia gambar 3. k a r a k t e r i s t i k r e s p o n d e n berdasarkan pekerjaan gambar 4. k a r a k t e r i s t i k r e s p o n d e n berdasarkan status perkawinan gambar 5. k a r a k t e r i s t i k r e s p o n d e n berdasarkan tingkat pendidikan tabel 1. karakteristik responden berasarkan lama menderita hiv n minimum maximum mean std. deviation lama menderita 20 1,00 96,00 29,4500 26,76894 valid n (listwise) 20 hasil analisis diskriptif identifikasi peningkatan kadar cd4 absolut dan %cd4 pada penderita hiv yang diberikan cognitive support di kota kediri dapat diketahui bahwa nilai rata-rata cd4 absolut untuk kelompok arv + perlakuan sebesar 244,40. dan nilai rata-rata cd4% untuk kelompok arv + perlakuan sebesar 13,759. hasil nilai rata-rata cd4 absolut untuk kelompok kontrol yang tidak menggunakan arv sebesar 56,25, untuk kelompok arv non perlakuan sebesar 133,50. sedangkan hasil analisis deskriptif dapat diketahui bahwa 121 cognitive support meningkatkan kadar cd4 pada pasien hiv (yuly peristiowati, dkk.) nilai rata-rata cd4% untuk kelompok kontrol sebesar 2,7175 dan untuk kelompok arv non perlakuan sebesar 6,14. dari hasil analisa statistik uji one way anova pada kadar %cd4 didapatkan hasil nilai sig 0,003 < α = 0,05, sehingga hipotesis diterima yang berarti bahwa minimal ada satu perlakuan dari 3 perlakuan yang ada yang akan memberikan nilai cd4% yang sama. hasil analisis lanjut post hoc dari 3 perlakuan yang diberikan oleh peneliti ternyata membentuk 2 kelompok yaitu kelompok 1 yang terdiri dari perlakuan arv dan arv non perlakuan. dan kelompok 2 arv perlakuan. dari hasil tersebut dapat dikatakan bahwa pemberian arv + pemberian cognitive support berdampak secara signifi kan terhadap peningkatan kadar cd4 pada pasien hiv. pembahasan dari hasil analisa statistik uji one way anova pada kadar %cd4 didapatkan hasil nilai sig 0,003 < α = 0,05, sehingga hipotesis diterima yang berarti bahwa minimal ada satu perlakuan dari 3 perlakuan yang ada yang akan memberikan nilai cd4% yang sama. hasil analisis lanjut post hoc dari 3 perlakuan yang diberikan oleh peneliti ternyata membentuk 2 kelompok yaitu kelompok 1 yang terdiri dari perlakuan arv dan arv non perlakuan. dan kelompok 2 arv perlakuan. dari hasil tersebut dapat dikatakan bahwa pemberian arv + pemberian cognitive support berdampak secara signifi kan terhadap peningkatan kadar cd4 pada pasien hiv. pada analisis statistik kadar cd4 absolut dengan uji t-test independent didapatkan hasil antara kelompok kontrol (tanpa arv) dengan kelompok yang diberi arv non perlakuan didapatkan nilai sig 0,073 > α = 0,05. berarti hipotesis ditolak yang berarti tidak ada perbedaan kadar cd4 absolut pada kelompok yang tidak meminum arv dengan kelompok yang meminum arv tapi tidak diberi perlakuan. dari hasil uji t-independent di atas antara kelompok kontrol (tanpa arv) dengan kelompok yang diberi arv + perlakuan didapatkan nilai sig 0,02 < α = 0,05. berarti hipotesis diterima yang berarti ada perbedaan kadar cd4 absolut pada kelompok yang tidak meminum arv dengan kelompok yang meminum arv dan diberi perlakuan. dari hasil uji t-independent di atas antara kelompok yang diberi arv non perlakuan dengan kelompok yang diberi arv + perlakuan didapatkan nilai sig 0,01 < α = 0,05. berarti hipotesis diterima yang berarti ada perbedaan kadar cd4 absolut pada kelompok yang meminum arv non perlakuan dengan kelompok yang meminum arv dan diberi perlakuan. dari data-data hasil uji statistik di atas pemberian perlakuan cognitive support dapat mempengaruhi kadar cd4 absolut dan persen kadar cd4. cognitive support yang bisa diberikan pada penderita hiv pada penelitian ini adalah dukungan sosial dan psikoterapi. dukungan sosial diberikan dalam bentuk motivasi baik pada penderita dan pada keluarga penderita. dukungan ini dilakukan dengan didikannya kelompok dukungan teman sebaya (kds) friendship plus di kota kediri, di mana menjadi wadah untuk memberikan dukungan, motivasi, dan peningkatan pengetahuan penderita hiv. kegiatan yang dilakukan kds antara lain setiap bulan sekali dilakukan pertemuan rutin yang membahas tentang permasalahan-permasalahan yang terjadi pada sesama penderita hiv. permasalahan yang dibahas mulai dari kesehatan fisik, keteraturan minum arv, serta per masalah yang menyangkut kondisi psikologis penderita hiv. selain membahas permasalahan juga ada gerakan donatur dari mitra kerja terkait dalam bentuk bantuan materi, maupun dukungan moral dan peningkatan pengetahuan dengan pemberian penguluhan. kehadiran kds di kota kediri banyak memberikan manfaat bagi penderita hiv. mereka bisa bertemu dengan teman-teman yang mengalami penderitaan yang sama, sehingga mereka tidak merasa sendiri dan kesepian dalam berjuang melawan penyakitnya. pasien hiv mengalami masalah yang sangat kompleks diakibatkan infeksi virus hiv. pemberian terapi haart (highly active antiretroviral therapy) diharapkan dapat menurunkan angka kematian penderita 122 jurnal ners vol. 10 no. 1 april 2015: 118–124 hiv, tetapi kenyataannya angka kematian penderita aids masih tetap tinggi (hirschel, 2003; zavasky, gerberding & sande, 2001; dalam nasrodin, 2005). penderita hiv/aids memiliki masalah yang sangat kompleks, karena selain harus meng ha d api penya k it nya send i r i juga diskriminasi maupun stigma dari keluarga dan masyarakat. situasi tersebut berdampak pada kondisi penyakitnya. akan tetapi, dengan terapi antiretroviral saja tentu belum cukup untuk mengatasi per masalah tersebut, sehingga diperlukan terapi komprehensif unt uk meningkatkan kualitas hidupnya. terapi komprehensif (medikamentosa, nutrisi, dukungan sosial, dan psikoterapi) menjadi pilihan untuk mengurangi angka morbiditas dan mortalitas pada pasien hiv/aids. perlakuan pada responden dengan menggunakan cognitive support dalam bentuk pemberian terapi psikologis interpersonal dalam bentuk visual, meditasi, dan emosional spiritual dapat mengintegrasikan antar fi sik dan biologis mental, jiwa, dan spirit melalui transformasi kesadaran, sehingga terjadi keharmonisan atau keselarasan. pemberian c og ni t i ve s u p p o r t b e r up a p si kot e r api transpersonal dapat melalui opening-egoreduction akan meleburkan ego bersama jiwa dan jiwa melebur bersama spirit. psikoterapi t r a n spe r sonal i n i d apat me nyebabk a n seseorang memandang diri lebih ekspansi dalam perspektif yang lebih besar, sehingga orang tersebut akan melihat diri lebih utuh tidak sekedar badan. yang pada akhirnya dapat membawa kepada keselarasan manusia itu sendiri (hart, yang, l.j. nelson, robinson, olsen, d.a. nelson, et al., 2000). psikoterapi transpersonal memajukan transenden dari kesadaran, memungkinkan eksplorasi pra kesadaran dan membuka level yang lebih dalam pada diri manusia yaitu diri yang lebih tinggi, diri sejati, atau diri bagian dalam (strohl, 1998). selama 3 hari secara berturut-turut responden dikumpulkan di suatu ruangan khusus yang nyaman kurang lebih selama 2–3 jam mendapatkan materi-materi yang berupa visualisasi, meditasi, dan emosional spritual dengan fasilitator yang berpengalaman pada pengelola rumah motivasi. responden dibawa dalam suasana yang terbuka atau membuka pikiran, perasaan dan hatinya untuk dapat mengetahui kekuatan yang ada dalam diri mereka masing-masing. dengan menemukan kekuatan yang ada pada diri mereka, responden dibawa ke suasana penemuan masalah yang ada pada masing-masing individu, di mana selanjutnya dengan kekuatan yang dimiliki responden dibawa u nt u k mengg u nakan kekuatan dirinya dalam penyelesaian masalah tersebut dengan diberikan materi terkait tentang tujuan hidup, makna kehidupan, mak na kematian, dan persiapan ketika menghadapi kematian dan kehidupan setelah kematian. pikiran dan perasaan mereka dibawa ke alam di bawah sadar mereka untuk dapat menemukan arti hidup dan kehidupan. menemukan masalah dan memecahkan masalah dengan kekuatan yang dimiliki sendiri, memperkuat spiritual dan penyerahan diri pada yang maha kuasa, sehingga seakan jiwa dan raga mereka dibawa menghadap tuhan mereka untuk meminta petunjuk dan pengampunan atas segala kesalahan mohon diberikan kekuatan untuk menjalani hidup selanjutnya agar lebih baik. motivasi dan semangat unt uk melanjutkan kehidupan mereka melalui ditekankan supaya mereka mempunyai motivasi untuk sembuh dan meningkatkan semangat hidupnya. psikoterapi transpersonal diberikan d a l a m b e n t u k p e m b i m b i n g a n , p a d a responden agar mereka menemukan dirinya sendiri dengan teknik-teknik yang diberikan pembimbing. konselor dan terapis akan memfasilitasi untuk per tumbuhan klien, dan dilakukan pengembangan diri, sehingga mampu merasakan apa yang dialami klien. pada penelitian ini, cognitive support diberikan dalam bentuk pemberian psikoterapi transpersonal dengan pendekatan visualisasi, meditasi, dan emotional spiritual quotion (esq). dengan menggunakan teknik ini diharapkan sel sehat dan virus hiv akan terjadi proses fi ghting spirit terhadap penyakit hiv. semangat perlawanan menunjukkan bahwa dirinya menerima penuh diagnosis, kemudian membangun sikap optimis yang disertai dengan keyakinan sehingga membantunya 123 cognitive support meningkatkan kadar cd4 pada pasien hiv (yuly peristiowati, dkk.) melawan penyakit. semangat perlawanan akan memobilisasi sistem imun. sistem imun merespons otak dan pesan kimia pada sistem saraf, lebih 50 neuropeptide terstimulasi dan memobilisasi sistem imun (hafen, 1996). semangat perlawanan akan menstimulasi mediator kimia yang penting dalam proses ketahanan tubuh. m e d i t a s i d e n g a n p e n d e k a t a n e mot ion al spi r it u al a k a n me r a ngsa ng endorpin (endogeneus morphine), sehingga meng u rangi rasa nyer i, kelelahan, dan me n i ng k at k a n ke sega r a n . sela i n it u , meditasi dengan emosional spiritual dapat meningkatkan respons emosi yang positif karena peningkatan dopamin dan serotinin yang mempunyai implikasi pada kesenangan, afilasi, dan mengurangi nyeri. mekanisme penting lain dengan pemberian meditasi emosional spiritual dapat memperlambat metabolisme (hipomethabolic state), sehingga menurunkan tekanan darah, lebih lambat proses respirasi, detak jantung lebih rendah, gelombang otak menur un keaktifannya, secara fi siologis terjadi penurunan mediator kimia dalam tubuh, sehingga menurunkan jumlah adrenalin, noradrenalin dan hormon adenocorticotropine dan kortison yang dapat menyebabkan menurunnya kecemasan dan stres (brown & ryan, 2003). pemberian pujian dan motivasi penuh kepada penderita hiv akan menimbulkan optimisme di masa depan. hal ini menimbulkan harapan positif dan menstimulasi imunitas maupun sistem endokrin untuk memfasilitasi penyembuhan. pemberian pujian dan motivasi sebagai pengalihan konsentrasi terhadap bayangan masa lalu maupun masa depan membantu mencegah kekhawatiran perjalanan penyakit dan kemarahan akibat munculnya sakit disebabkan orang lain. ketahanan tubuh penderita hiv/aids sangat rentan jika mengalami gangguan psikis atau mental, sehingga perlu mendapatkan psikoterapi untuk meningkatkan kualitas hidupnya. dari hasil penelitian yang didapatkan jawaban hipotesa penelitian bahwa pemberian cognitf support dapat meningkatkan kadar cd4 absolut dan %cd4 pada penderita hiv, tetapi tidak memberikan kenaikan yang berarti pada kelompok yang tidak diberikan cognitive support baik pada kelompok pengguna arv dan kelompok yang tidak menggunakan arv. dengan pemberian cognitive support dapat menstimulasi beberapa mediator kimia dalam tubuh, berbagai hormon dan imunitas tubuh yang sangat berfungsi dalam meningkatkan kekebalan pada penderita hiv, sehingga dengan tersimulasinya sistem imun berupa limfosit t yang mempunyai molekul penanda cd4, maka dapat meningkat dengan pemberian perlakukan tersebut. meningkatnya kadar cd4 dalam tubuh yang merupakan penanda limfosit t dapat memberi gambaran peningkatan sistem imun, di mana sistem imun yang meningkat diharapkan dapat mengeleminasi antigen virus hiv dalam tubuh dalam bentuk penurunan viral load pada penderita hiv, sehingga kualitas hidupnya akan meningkat. simpulan dan saran simpulan pemberian cognitive support secara signifi kan berpengaruh terhadap peningkatan kadar cd4 absolut dan persen cd4 pada penderita hiv. namun, tidak ada perbedaan yang signifi kan antara kelompok kontrol yang mengonsumsi arv secara rutin dan tidak rutin. saran pemberian cognitive support dapat menstimulasi peningkatan sistem imun berupa limfosit t yang mempunyai molekul penanda cd4, sehingga dengan meningkatkan kadar cd4 diharapkan dapat meningkatkan kualitas hidup penderita hiv. kepustakaan a. aziz, alimul hidayat. 2010. metode penelitian keperawatan dan teknik a nalisis dat a. jakar t a: penerbit. salemba medika. brown, k.w. & ryan. r.m 2003. the benefi ts of being present: mindfulness and its role in physicological well-bwing. journal of personalit y and social psychology, 84(4). 822–848. 124 jurnal ners vol. 10 no. 1 april 2015: 118–124 depkes, ri. 2005. profi l kesehatan indonesia 2005. dibuka pada website: http.// www,depkes.co. id. pada tanggal 6 januari 2008). depkes, ri. 2010. riset kesehatan dasar. ja k a r t a : b a d a n p e n e li t i a n d a n pengembangan kesehatan kementrian kesehatan ri. 2010. ducan l, & weissenburger d. 2003. effect of a brief meditaton program on well being and loneliness.tca journal, 31 (1). 14–25. djuanda, adhi. 2011. ilmu penyakit kulit dan kelamin. jakarta: balai penerbit fkui. ditjen pp & pl kementerian kesehatan ri. 2013. laporan perkembangan situasi hiv & aids di indonesia triwulan 2 tahun 2013. jakarta. dinkes jawa timur, 2013. faisal idrus m., jayalangkara, t., syamsu., ilham. 2010. pengar uh psikoterapi spiritual terhadap hitung sel t-cd4 pada penderita hiv/aids. departement psychiatry, departement of internal medicine, departement of physiology, m e dical fa c ult y of ha sa n ud din university. halim, m.s & atmoko, w.d. 2005. hubungan antara kecemasan akan hiv/aids dan psychological well-being pada waria yang menjadi pekerja seks komersial. jurnal psikologi. 15: 17–31. kurniawati, 2006. coping stres pada orang dengan hiv/aids (sebuah studi kasus). skripsi. surabaya: fakultas psikologi universitas airlangga. lane, j.d. seskevich, j.e. & pieper, ce. 2007. brief meditation training can inprove preceived stress and negative moud. alternative therapies health and medicie. 13 (1), 38–44. lazarus, r.s & folkman, s. 1984. stress, appraisal and coping. new york: spranger. nihayati, a. 2012. dukungan sosial pada pe nya nd a ng h i v/a i ds dewa sa . skripsi. surakarta: fakultas psikologi u n i v e r s i t a s m u h a m m a d i y a h surakarta. nurlaila effendi, johana e, prawitasari, thomas dicky hastjarjo, nasronudin. 2008. pengaruh psikoterapi transpersonal terhadap kuaitas hidup pasien hiv dan aids. anima, indonesia psychological journal 2008. vol 24;1,1-16. phillips, k.d. 2007. social support, coping, and medication adherence among hivpositive women with depression living in rural areas of the southeastern united states. aids patiens care and stds. 21: 667–680. roberts,s. 2005. meditation help blood presure. diabetes forcast, 58(11), 24–26. stuart & sunden, 2002. principles and practice of psychiatric nursing sixth edition. st.louis missouri: west line industrial drive. tocan. a.m.mc comb. j. caldera, y & randolp. p. 2003. mindfulness meditation, anxiety reduction and heart deceases: a pilot study, medical care, 26(1), 25–34. umar zein, 2006. 100 pertanyaan seputar hiv/aids yang anda ketahui. usu press, medan. walton. k.g. cavanough.k.l & pugh, n.d. 2005). effect of group practice of the transcen-dental meditation program on biochemical indicators of stressnin nonmeditation: a.prospective time series study. journal of sosial beavior and personality. 17, 339–373. who, 2007. pencegahan aids melalui promosi kesehatan: masalah yang sensitif. bandung: penerbit itb. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 107 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18975 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review systematic review of family members in improving the quality of life of people with t2dm gabriel wanda sinawang , kusnanto kusnanto, ika nur pratiwi faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: many patients with type 2 diabetes (t2dm) experience psychological issues affecting their ability to cope and manage their disease. unfortunately, healthcare providers, including nurses, often report a lack of resources to provide sufficient support. during short and busy consultations, nurses and physicians often focus on etiology, diagnosis, pathophysiology, and treatment of the disease, while patients are more concerned with the consequences and impact on their daily life and family relations. the study aimed to find out forms of family support to improve the quality of live t2dm. methods: articles were framework using pocot searching science direct, scopus, google scholar databases, limited to the last 5 years and framework using pocot. the articles were from 2015 to 2020 and the language used was english. the study focused on family support and diabetic mellitus type 2 (t2dm). results: from 359 articles, 15 articles were included, most of the findings of the studies showed that family plays an important role in increasing selfefficacy so it contributes to blood sugar control which supports t2dm patients’ quality of life. the support that has been carried out by the family includes communication in the patient's treatment program, diet and blood sugar check, motivation in physical activity, support for medical expenses, accompanying them for controls. patients with higher perceived diabetes-specific family and friend support had healthier behaviors. conclusion: family support helps improve the quality of life and reduce physical and psychological complications in people with t2dm. article history received: feb 27, 2020 accepted: april 1, 2020 keywords family support; diabetic mellitus type 2; quality of life contact kusnanto kusnanto  kusnanto@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sinawang, g. w., kusnanto, k., & pratiwi, i. n. (2020). systematic review of family members in improving the quality of life of people with t2dm. jurnal ners, special issues, 107-112. doi:http://dx.doi.org/10.20473/jn.v15i2.18975 introduction diabetes is a chronic medical condition that requires people suffering from it to engage in a lifelong therapeutic self-management regimen in order to maintain glycemic control (uchendu & blake, 2016). social support has to be understood within its particular cultural context which should be part of the framework of any intervention that aims at using existing social support to improve diabetes management (pesantes et al., 2018). many patients with type 2 diabetes experience psychological issues affecting their ability to cope and manage their disease. unfortunately, healthcare providers, including nurses, often report lack of resources to provide sufficient support (bennich et al., 2017). family social support is a process that occurs over a lifetime, with the nature and type of social support varying in each stage of the family life cycle. family social support allows the family to function fully and can improve adaptation in family health (r, a, r, felicia, & preveena, 2018). full involvement of family members in health education helped patients with t2dm improve their quality of life compared to patients without family involvement (shi et al., 2016a). peer-support intervention, based on the social support theory, may result in improved diabetes care outcomes and subsequently improved quality of life in patients with t2dm (peimani, monjazebi, & https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:kusnanto@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. g. w. sinawang et al. 108 | pissn: 1858-3598  eissn: 2502-5791 ghodssi-ghassemabadi, 2018). high-quality relationships with and diabetes management support from intimate partners improve diabetes-specific and general quality of life, self-management behaviors, and metabolic outcomes (young-hyman, groot, hillbriggs, & gonzalez, 2016). dunbar et al. (2005) explained that family support correlates with promoting self-care behaviors, following medical diets, decreasing emotional stress, coping with changes in life, enhancing self-efficacy, reducing the frequency of hospitalization, achieving weight loss, better-controlled blood sugar levels, and ultimately, improving qol, particularly if the focus of family support is on treating and controlling the disease (ebrahimi, ashrafi, & rudsari, 2017). this study aims to describe the forms of family support for family members suffering from t2dm. materials and methods strategy for searching this study used a systematic review with the search “what the forms of family support improve the quality of life in t2dm?”. trials to be included in the review were identified through electronic database searching from the earliest available time to 2019 in the following databases: science direct, scopus, and google scholar by using keywords “family support”, “diabetes mellitus type 2 and “quality of life (qol)”. the inclusion criteria in this review were experimental study and non-experimental study, studies published from 2015 to 2019, english as the language used, focused on family support in type 2 diabetes mellitus and quality of life. the exclusion criteria were studies that did not involve adolescent patients. based on the literature research from three databases, science direct, scopus and google scholar, there were a total of 359 papers. the detailed identification process of the paper selection can be seen in figure 1. this study reviewed 15 chosen articles. study selection figure 1 article selection process. adapted from harris et al. (harris, harris, quatman, & manring, 2013) results general type of studies 15 articles were analyzed (table 1). all of the studies (100%) focused on studies type 2 diabetes mellitus (t2dm). the type of research design there were 8 (53,33%) cross-sectional articles. the measuring instrument used was the interview (experiences living with type 2 diabetes, changes and adherence to self-management behaviors, attitude and knowledge of obesity ant t2dm, attitudes toward intervention using monetary incentives) (pesantes et al., 2018), a family-support assessment questionnaire (r et al., 2018), persuasive social control strategies (yang, pang, & cheng, 2016), chronic illness resource survey (cirs)(soto, louie, cherrington, parada, & horton, 2015), kap questionnaire (shi et al., 2016b), diabetes care profile (dcp, self –perception of glycemic control) (shawon, hossain, adhikary, & gupta, 2016), diabetes knowledge questionnaire (dkq), diabetes health literacy , diabetes self-care activities questionnaire, diabetes distress scale, international physical activity questionnaire (ipaq) (mcewen, pasvogel, murdaugh, & hepworth, 2017), perceptions of collaboration questionnaire (pcq), other important climate questionnaires (iocq), perceived diabetes self-management scale (pdsms4) (lindsay s mayberry, berg, greevy, & wallston, 2019), partner care, summary of diabetes self-care activity (sdsca) (lindsay s mayberry & lee, 2018), diabetes family behavior checklist-ii (dfbc-ii, dawn ii (lindsay satterwhite mayberry, harper, & osborn, 2016), family apgar questionnaire, fra, life-orientation test (lot), diabetes knowledge test (dkt) (fain, 2016), depression scale, diabetes care profile (chiu & du, 2018), quality of life questionnaire (qol) (ebrahimi et al., 2017), dsme standard care (yeary et al., 2017), summary of diabetes self-care activities scale (sdsca) (ravi, kumar, & gopichandran, 2018). full-text screening (n=15) family support, diabetic mellitus type 2 and quality of life database scopus, science direct, google scholar title screening (n=359) papers are excluded because they do not fulfill the inclusive full-text screening (n=52) papers are excluded because they do not fulfill the inclusive table 1. general characteristics of the selected studies (n=15) category n % publication year 2015 1 6,67 2016 5 33,33 2017 3 20 2018 5 33,33 2019 1 6,67 type of dm t1dm t2dm 15 100 type of study cross-sectional 8 53,33 rct 3 20 descriptive 1 6,67 qualitative 1 6,67 mix method 2 13,33 jurnal ners http://e-journal.unair.ac.id/jners | 109 we will explain and answer the research question in the results section: what the study found about family support and quality of life. in this study, researchers found that family support is closely related to t2dm care management and its relationship and quality of life. dmt2 sufferers support providers include children, spouses, close family. the types of support include emotional author types of dm design sample variable result (pesantes et al., 2018) dmt2 qualitative 20 the role of family members in providing support to their relatives with t2dm support from family members mostly from their spouses and children. (r et al., 2018) dmt2 crosssectional 100 family support assessment, quality of life of patients with type 2 diabetes mellitus the family is the main source of support. the support provided is viewed from 4 dimensions, namely the emotional dimension, the dimensions of appreciation, the instrumental dimension, and the information dimension (yang et al., 2016) dmt2 cross-sectional 199 the differential associations between persuasion/pressure, psychological outcomes, and behavioral adherence at different levels of self-efficacy and to inform current familyoriented inter vention programs. patients with lower selfefficacy benefited from persuasion, but were adversely affected by pressure. in contrast, patients with higher selfefficacy were adversely affected by persuasion, but were less negatively affected by pressure (soto et al., 2015) dmt2 cross-sectional 317 self interpersonal and organization support in performing diabetes related self management behaviors and a1c levels higher levels of selfsupport were significantly associated with eating, self-support was also related to a1c. family/friend support was significantly associated with eating fruits and vegetables and engaging in physical activity most days/week (shi et al., 2016b) dmt2 cross-sectional 120 family involvement on health education for controlling the diabetes family involvement is beneficial to the control of t2dm (shawon et al., 2016) dmt2 cross-sectional 144 the attitude towards diabetes and social and family support positive attitude towards diabetes management and support from friends and family were associated with adequate diabetes management (ravi et al., 2018) dmt2 cross-sectional 200 diabetes family support improves diabetes self management and glycemic control family support was significantly associated with better self management activities, but better self-management did not reflect as better glycaemic control. (mcewen et al., 2017) dmt2 randomized controlled trial 157 effects of a familybased selfmanagement support intervention for adults with type 2 diabetes (t2dm). family-based interven tions to improve diabetes self-management and substantiate the need for intensive, longer, tailored interventions to achieve glycemic control. g. w. sinawang et al. 110 | pissn: 1858-3598  eissn: 2502-5791 support, appreciation, instruments, information, diet, activity, stress reduction. some research also shows that family control helps improve t2dm management so it affects the quality of life. discussion the family is the main source of support. individuals with chronic conditions receive help to manage such conditions from family members, mainly spouses and children (pesantes et al., 2018), interpersonal support (e.g., family and friends), health care professionals, the neighborhood, community organizations, the workplace, health insurance (soto et al., 2015). people with chronic diseases such as t2d stand to benefit from a family setting that provides care in terms of physical, emotional, and financial support for the management of their disease (ebrahimi et al., 2017). the support provided is viewed from 4 dimensions, namely the emotional dimension, the (lindsay s mayberry et al., 2019) dmt2 mixed-methods 904 develop and evaluate a measure assessing helpful and harmful family/friends’ involvement in adults’ type 2 diabetes (t2d) self-management. the family and friend involvement in adults’ diabetes (fiad) is a reliable and valid measure assessing family/friend involvement in adults’ t2dm. (lindsay s mayberry & lee, 2018) dmt2 cross-sectional 313 self-management, diabetes distress, and hba1c emotional closeness with a carepartner may be important for supporting t2dm self-management and reducing diabetes distress. carepartners may appropriately engage more frequently when patients with no in-home supporter have poorly controlled diabetes. (lindsay satterwhite mayberry et al., 2016) dmt2 mixed-methods study 68 family members in interventions to support diabetes selfcare. findings can inform the design and content of interventions targeting family involvement in adults’ type 2 diabetes, with implications for assessing family behaviors, intervention modalities, and who to engage. (fain, 2016) dmt2 nonexperimental 77 family functioning, family resilience, life orientation (measure of optimism), and diabetes knowledge previous evidence suggesting that a family member’s perspective of living and functioning with diabetes affects the entire family and its ability to deal with stress. (chiu & du, 2018) dmt2 cross-sectional 398 depressive symptom scores. family and friend support the level of family or friend support for diabetes management and depressive symptoms might be an important part of individualized diabetic care. (ebrahimi et al., 2017) dmt2 a randomized clinical trial 120 quality of life educating the families of patients was shown in this study to improve the qol of the patient. (yeary et al., 2017) dmt2 a randomized, controlled 240 family model of diabetes self management education (dsme) the utilization of a cbpr approach that involves the local stakeholders and the engagement of the family based social infrastructure of marshallese communities increase potential for the intervention's success and sustainability jurnal ners http://e-journal.unair.ac.id/jners | 111 dimension of appreciation, the instrumental dimension, and the information dimension. it was also conveyed that the support of the family is closely related to the patients’ compliance with treatment so it will affect their quality of life (r et al., 2018). emotional well-being is an important part of diabetes care and self-management. psychological and social problems can impair the individual’s or family’s ability to carry out diabetes care tasks and therefore potentially compromise health status (care & suppl, 2018). family members should consider the patient’s levels of self-efficacy in diabetes management (yang et al., 2016). supportive behaviors included the provision of emotional support, such as empathy and alleviation of diabetesrelated distress, and the provision of instrumental support such as paying for medications and helping participants inject their insulin. emotional support enabled patients to improve their diet, follow their treatment and increased their physical activity (pesantes et al., 2018). diabetes distress, the emotional burden experienced by adults with t2dm, has been shown to influence glycemic control (mcewen et al., 2017). families provide physical support to the patient and also emotional support in times of need (ravi et al., 2018). educational courses included psychological intervention, nutritional therapy, exercise intervention, medical care, blood glucose monitoring and oral care (shi et al., 2016b). family support correlates with promoting self-care behaviors, following medical diets (ebrahimi et al., 2017). individual/family factors are those characteristics of the individual and direct family (polly & kathleen, 2010). dietary changes have consistently been reported to be the most difficult, especially in low income persons with diabetes, as factors like culture, lifelong habits, family and socioeconomic resources influence dietary intake (mcewen et al., 2017). education about good glycemic management is crucial in order to achieve and maintain a better control over their diabetes status to stall further complications (shawon et al., 2016). helpful family and friend involvement were independently associated with greater diabetes self-efficacy, better dietary behaviors, more physical activity, more frequent blood glucose testing and better medication adherence (lindsay s mayberry et al., 2019). family support should be the focus of diabetes education for families living with diabetes (fain, 2016) the face-it intervention not only focuses on physical health but also addresses a broader perspective, including mental and social wellbeing. gilbert et al. argue in favor of the integration of psychosocial wellbeing (e.g., social support) (nielsen et al., 2020). close family members are associated with patient adherence (chiu & du, 2018). familybased, culturally-adapted diabetes interventions have positive effects on diabetes outcome (yeary et al., 2017). conclusion family support plays a large role in t2dm care. emotional, knowledge and financial support are forms of family support that help improve the quality of life in t2dm patients. nurses and the medical staff can collaborate with families to emphasize that there needs to be a balance between the emotional, physical and financial support for t2dm sufferers. the weak point of this literature review is that it has not explained in detail how to form a balance of support between emotional, physical and financial support. conflict of interest the authors declare there is no conflict of interest. acknowledgement the authors would like to acknowledge the faculty of nursing universitas airlangga surabaya for their unconditional support in this systematic review. references bennich, b. b., røder, m. e., overgaard, d., egerod, i., munch, l., knop, f. k., … konradsen, h. (2017). supportive and non ‑ supportive interactions in families with a type 2 diabetes patient : an integrative review. diabetology & metabolic syndrome, 1–9. https://doi.org/10.1186/s13098-017-0256-7 care, d., & suppl, s. s. (2018). lifestyle management : standards of medical care in diabetes d 2018. diabetes care, 41(january), 38–50. https://doi.org/10.2337/dc18-s004 chiu, c., & du, y. (2018). longitudinal investigation of the reciprocal relationship between depressive symptoms and glycemic control : the moderation effects of sex and perceived support. https://doi.org/10.1111/jdi.12969 ebrahimi, h., ashrafi, z., & rudsari, d. m. (2017). effect of family-based education on the quality of life of persons with type 2 diabetes : a randomized clinical trial. 00(0), 1–7. fain, j. a. (2016). factors affecting resilience in families of adults with diabetes. the diabetes educator. https://doi.org/10.1177/0145721716637124 harris, j. d., harris, j. d., quatman, c. e., & manring, m. m. (2013). how to write a systematic review how to write a systematic review. (may 2014). https://doi.org/10.1177/0363546513497567 mayberry, lindsay s, berg, c. a., greevy, r. a., & wallston, k. a. (2019). patient education and counseling assessing helpful and harmful family and friend involvement in adults ’ type 2 diabetes self-management. patient education and counseling, 102(7), 1380–1388. https://doi.org/10.1016/j.pec.2019.02.027 mayberry, lindsay s, & lee, a. a. (2018). out-of-home informal support important for medication adherence , diabetes distress , hemoglobin a1c among adults with type 2 diabetes. journal of g. w. sinawang et al. 112 | pissn: 1858-3598  eissn: 2502-5791 behavioral medicine. https://doi.org/10.1007/s10865-018-0002-0 mayberry, lindsay satterwhite, harper, k. j., & osborn, c. y. (2016). family behaviors and type 2 diabetes : what to target and how to address in interventions for adults with low socioeconomic status. https://doi.org/10.1177/1742395316644303 mcewen, m. m., pasvogel, a., murdaugh, c., & hepworth, j. (2017). effects of a family-based diabetes intervention on behavioral and biological outcomes for mexican american adults purpose. effects of a fmily based intervention, 1–14. https://doi.org/10.1177/0145721717706031 nielsen, k. k., dahl-petersen, i. k., jensen, d. m., ovesen, p., damm, p., jensen, n. h., … vinter, c. a. (2020). protocol for a randomised controlled trial of a co-produced , complex , health promotion intervention for women with prior gestational diabetes and their families : the face-it study. 1– 12. peimani, m., monjazebi, f., & ghodssi-ghassemabadi, r. (2018). patient education and counseling a peer support intervention in improving glycemic control in patients with type 2 diabetes. patient education and counseling, 101(3), 460–466. https://doi.org/10.1016/j.pec.2017.10.007 pesantes, m. a., valle, a. del, diez-canseco, f., bernabé-ortiz, a., portocarrero, j., trujillo, a., … miranda, j. j. (2018). family support and diabetes : patient ’ s experiences from a public hospital in peru. https://doi.org/10.1177/1049732318784906 polly, r., & kathleen, s. j. (2010). the individual and family self-management theory: background and perspectives on context, process, and outcomes. nih public access, 57(4), 217–225. https://doi.org/10.1016/j.outlook.2008.10.004. the r, a., a, s. w., r, a ariga, felicia, & preveena. (2018). relationship between family support with quality of life among type 2 diabetes mellitus patients at amplas primary health care in medan , indonesia relationship between family support with quality of life among type 2 diabetes mellitus patients at amplas. journal of physics: conference series, 1–6. https://doi.org/10.1088/17426596/1116/5/052004 ravi, s., kumar, s., & gopichandran, v. (2018). do supportive family behaviors promote diabetes selfmanagement in resource limited urban settings ? a cross sectional study. 1–9. shawon, s. r., hossain, f. b., adhikary, g., & gupta, r. das. (2016). attitude towards diabetes and social and family support among type 2 diabetes patients attending a tertiary ‑ care hospital in bangladesh : a cross ‑ sectional study. bmc research notes, 1–8. https://doi.org/10.1186/s13104-016-2081-8 shi, m., xu, m., liu, z., duan, x., zhu, y., & shi, h. (2016a). patient education and counseling effectiveness of family involvement in newly diagnosed type 2 diabetes patients : a follow-up study. patient education and counseling, 99(5), 776–782. https://doi.org/10.1016/j.pec.2015.12.018 shi, m., xu, m., liu, z., duan, x., zhu, y., & shi, h. (2016b). patient education and counseling effectiveness of family involvement in newly diagnosed type 2 diabetes patients : a follow-up study. patient education and counseling, (2015). https://doi.org/10.1016/j.pec.2015.12.018 soto, s. c., louie, s. y., cherrington, a. l., parada, h., & horton, l. a. (2015). an ecological perspective on diabetes self-care support, self-management behaviors, and hemoglobin a1c among latinos. the diabetes educator, 41(2), 214–223. https://doi.org/10.1177/0145721715569078 uchendu, c., & blake, h. (2016). systematic review or meta-analysis effectiveness of cognitive – behavioural therapy on glycaemic control and psychological outcomes in adults with diabetes mellitus : a systematic review and meta-analysis of randomized controlled trials. diabaaetic medicine, 328–339. https://doi.org/10.1111/dme.13195 yang, f., pang, j. s., & cheng, w. j. y. (2016). self-care adherence and psychological functioning of older patients with type 2 diabetes : effects of persuasion , social pressure , and self-efficacy. journal of clinical psychology in medical settings. https://doi.org/10.1007/s10880-016-9470-y yeary, k. h. k., associate, p. d., long, c. r., assistant, p. d., bursac, z., ph, d., … assistant, p. d. (2017). design of a randomized , controlled , comparativeeffectiveness trial testing a family model of diabetes self-management education ( dsme ) vs . standard dsme for marshallese in the united states. 6. https://doi.org/10.1016/j.conctc.2017.03.007 young-hyman, d., groot, m. de, hill-briggs, f., & gonzalez, j. s. (2016). psychosocial care for people with diabetes : a position statement of the american diabetes association. 39(december), 2126–2140. https://doi.org/10.2337/dc162053 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 142 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18999 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review supportive care needs of women with breast cancer: a systematic review irfan wabula, esti yunitasari, andri setiya wahyudi faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: an understanding of supportive care needs is essential to achieve good quality care for women with breast cancer. this concept defines the needs of cancer patients in relation to the physical, emotional, psychological, social, informational and spiritual domains since the start of their journey through diagnosis, treatment, survivorship, palliative care and the grief process. methods: this study was conducted to explore the unmet supportive care needs of women with breast cancer. databases were searched in the journals using pre-determined keywords such as ‘supportive care needs’, ‘breast cancer’ and ‘woman’. the databases used were scopus, pro quest, science direct and ebsco. the search was limited to journals published in the period 2014-2020. out of the 189 nursing journals initially found, 16 journals were selected that met all of the eligibility criteria. eight studies used a cross-sectional design. results: most of the breast cancer patients were in the post-diagnosis phase and had survived. more than 50% of the journals reported that the needs of breast cancer women were going unmet. the predictors of a higher level of need among the breast cancer patients are age, social support and information. the most prevalent unmet needs among the women with breast cancer were found to be in the health system and related to information. the women with breast cancer who had more unmet needs in the physical and psychological domains were more likely to have a poor quality of life.. conclusion: future research should focus on improving the education and psychological support programs available to provide for the unmet supportive care needs of patients newly-diagnosed with breast cancer. this can provide high quality care for them. article history received: feb 27, 2020 accepted: april 1, 2020 keywords supportive care needs; breast cancer; woman contact esti yunitasari  esti-y@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: wabula, i., yunitasari, e., & wahyudi, a. s. (2020). supportive care needs of women with breast cancer: a systematic review. jurnal ners, special issues, 142-148. doi:http://dx.doi.org/10.20473/jn.v15i2.18999 introduction breast cancer is the most common cancer and it is the leading cause of cancer death among women globally (lam et al., 2014). the incidence rate ranges from 21.6 per 100,000 women in china to 109.2 per 100,000 in belgium. it has been estimated that about 1.4 million cases are newly diagnosed globally each year (so et al., 2014). breast cancer survivors constitute 22% of the estimated 14.5 million cancer survivors. this is a population that is expected to grow to 18 million over the next decade (davis, nyamathi, abuatiq, fike, & wilson, 2018). the 5-year survival rate in the west is 70-90%, 57% in developing countries and globally 61%. in malaysia, the 5-year survival rate for breast cancer is 49% with a median interval of 68.1 months that is continuing to escalate every year (edib, kumarasamy, binti abdullah, rizal, & al-dubai, 2016). needs emerge when problems are perceived to exceed the person's capacity to deal with them, requiring external assistance or resources to achieve or maintain wellbeing (lam et al., 2014). this growing population represents the increased need for survivorship research that focuses on evidence-based, high-quality and patient centered supportive care (davis et al., 2018). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:esti-y@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 143 supportive care is defined as rendering essential services that satisfy the cancer patients’ physical, psychological, social, informational and spiritual needs over the entire illness trajectory. although it is acknowledged as an essential service, 1–93% of cancer patients’ supportive needs have been consistently unmet (edib et al., 2016). the goal of supportive care is to improve the qol of patients with a serious or life-threatening disease by treating the symptoms and side effects caused by the illness and its treatment (so et al., 2014). studies have reported that the prevalence of unmet scns among cancer survivors varies from 30-50%. however, most of them focus on the needs of cancer patients in the diagnosis and treatment phase. studies that have examined their needs immediately after treatment are lacking. to date, we do not have a precise or overall picture of what help women actually need or what they expect to manage the symptoms and problems that they face (han, kim, yoon, & kim, 2019). the symptom experience and supportive care needs of breast cancer survivors is heterogeneous across the survivorship journey (cheng, darshini devi, wong, & koh, 2014). unmet supportive needs related to physical and daily living, patient care and support and sexuality have also been reported but less frequently (abdollahzadeh et al., 2014). studies have been reported that breast cancer women who report the same symptoms may express a different level of need for help (torres, dixon, & richman, 2015). most cancer need assessment studies have examined the needs of mixed cancer populations including all stages at various times following diagnosis. the majority of these are cross-sectional in design, although there are a few descriptivecorrelational studies [9]; [7]; [13], retrospective studies [11], quasi-experimental designs (davis et al., 2018), and qualitative studies [8]. these studies also vary in their examination of other crucial factors such as qol and perceived symptoms. this discordance may be due to the disease factors, socio-demographic factors, faith, supportive structures, optimism and access to information (davis et al., 2018). identifying the patient-centered supportive care factors can facilitate a discussion among the patients, their family members and the oncology team members to determine what helps the patients best as they navigate the survivorship trajectory (davis et al., 2018). supportive care needs are a culture-dependent concept. therefore in order to develop an effective supportive care program, cultural issues must be considered (rahmani et al., 2014). in this review, we concentrated on the studies that examine the supportive care needs specific to women who have been diagnosed with breast cancer. this review attempts to answer the following question: ‘what are the domains and specific items of need most frequently reported as going unmet by breast cancer patients?’ the goal of this study was to summarize what the associations are, if any, between the unmet need factors of breast cancer patients. materials and methods strategy strategy a systematic search of the following databases was conducted: scopus, proquest, sciencedirect and ebsco. papers published in the period 2014-2020 assessing the supportive care needs of breast cancer patients were identified by entering key words in combination: supportive care needs, breast cancer and woman. they generally used the validated need assessment instrument, the supportive care needs survey (scns). the reference lists of the major articles on the subject were examined for any additional titles. the search returned a total of 189 nursing journals. inclusion and exclusion criteria all stages of breast cancer including advanced and recurring disease at any point along the cancer trajectory (post-diagnosis, in treatment and posttreatment) were included. the participants of the studies were adult breast cancer patients. quantitative studies employing validated needs assessment instruments focusing uniquely on supportive care needs of women with breast cancer were chosen for review. the papers were only considered if they were in english. we excluded studies reporting data on the participants who were pre-diagnosis and/or of a mixed cancer type except if they reported data for breast cancer separately. this was in addition to health care provider training studies and studies only looking at the needs of the bc patients’ partners. selection of the articles we extracted the prevalence of the needs in order to present the most commonly fulfilled and unmet needs both. the database search returned 189 hits. after records identified through database searching (n = 189) records screened after removing duplicates (n = 81 ) full-text articles assessed for eligibility (n = 41) records excluded based on title and abstract (n = 40) full-text articles excluded (n = 25) 16 studies included in the systematic review figure 1. diagram summarizing the literature search i. wabula et al. 144 | pissn: 1858-3598  eissn: 2502-5791 removing duplicates, 81 remained. the methods used table 2. summary of the selected studies author design sample supportive care need measure result (rahmani et al., 2014) descriptivecorrelational study 274 cancer patients supportive care needs survey (scns-59) more than 50% of the participants reported that their needs were unmet. most frequently, the unmet needs were related to the health system, information, physical and daily living domains. most of the met needs were related to the sexuality, patient care and support domains. (abdollahzadeh et al., 2014) descriptivecorrelational study 136 breast cancer patients. supportive care needs survey (scns-sf34) the patient’s perceived needs were the highest in the health systems and information (71%) and physical and daily living (68%) domains. the younger participants had more un-met needs in all domains and those with more children reported fewer un-met needs in the patient care and support domains. in addition, married women had more un-met supportive care needs related to sexuality. (edib et al., 2016) crosssectional study 117 breast cancer patients. scns-sf34 and eortc qlq-c30 the highest unmet supportive care needs were observed in the psychological domain, followed by the physical domain. the most prevalent unmet supportive care needs were uncertainty about the future, fear of the cancer spreading, feelings of sadness, feelings about death and dying, concerns about those close to the patient and feeling down or depressed. (faghani et al., 2015) descriptivecorrelational study 30 cancer survivors. scns-sf34 and mspss the participants demonstrated many unmet supportive care needs, especially in the health system and information and psychological domains. social support has a significant correlation with all of the domains of the supportive care needs. (davis et al., 2018) crosssectional study 155 africanamerican adult women diagnosed with breast cancer. open-ended questions four supportive care factors were identified: faith, supportive structures, optimism and access to information (mohammadzadeh nimekari et al., 2019) crosssectional study 150 breast cancer patients and 150 of their primary family caregivers. scns-sf34 and the caregiver quality of life index-cancer scale. the results of the study showed that physical needs were the most common supportive care needs of patients with breast cancer. such needs also significantly undermined the qol of the caregivers in terms of emotional burden and financial concerns. (dine, 2017) crosssectional study 236 breast, gynecological, colorectal, lung, head and neck cancer survivors. the cancer survivors’ unmet need measure (casun) and a single‑item measure from the global qol scale. cancer survivors generally perceived themselves as having a good qol, although there was a significantly low qol for the lung cancer survivors. this study mapped the unmet supportive care needs of thai cancer patients and the results showed that patients with head and neck cancer and lung cancer were strongly affected. jurnal ners http://e-journal.unair.ac.id/jners | 145 in the 81 studies were inspected, leading to the (so et al., 2014) crosssectional study 163 breast cancer survivors. chinese version of supportive care needs survey form (scns-sf34). the 5 most commonly reported unmet needs were all in the health system information domain. the majority reported at least 1 unmet need in relation to information on healthcare. the time spent travelling from home to the hospital, receiving hormonal therapy and physical and psychological unmet needs were independently associated with a poorer quality of life among the participants. (liao et al., 2014) quasiexperimental design 80 women newly diagnosed with breast cancer. chinese version of the supportive care needs survey form (scns-sf34). the education and psychological support components of our intervention program effectively improved the unmet supportive care needs of the patients newly diagnosed with breast cancer 3 months after surgery. (cheng et al., 2014) crosssectional study 150 breast cancer survivors. supportive care needs survey short form (scns-sf34). 88% of the survivors reported having at least 1 symptom while 51% reported at least 1 unmet need. lack of energy was the most prevalent symptom (47%), followed by numbness/tingling in the hands/feet (41%). most of the survivors had unmet needs in the health care system/information domain (37% reported at least 1 unmet need for help), followed by psychological needs (29%). (torres et al., 2015) qualitative study 32 africanamerican women with breast cancer. paper survey and in-depth focus group interviews. faith in god was an important coping mechanism essential to all women in the study and it was a critical facilitator of survivorship. their support networks consisted of their family, church family, friends and co-workers. the concept of fear included the discovery of breast cancer and their fear of death, the negative side effects of treatment and the social stigma of having breast cancer. (molassiotis et al., 2017) crosssectional study 1873 cancer survivors. cancer survivors unmet needs scale and a single-item measure of global qol perception. the most frequently reported symptoms were fatigue (66.6%), a loss of strength (61.8%), pain (61.6%), sleep disturbance (60.1%) and weight changes (57.7%). unmet needs to a moderate/strong level were high, particularly in the area of existential survivorship (psychosocial care) and receiving comprehensive cancer care. (lam et al., 2014) longitudinal study 228 chinese women with advanced breast cancer scns-34-ch, the hospital anxiety and depression scale, msas-ch and pseq-9. two distinct trajectories were identified for the hsips and sexuality need domains. there were 3 distinct trajectories for the psychological and physical daily living need domains. most women showed stable low levels of hsips (78.9 %), psychological (82.4 %), pdl (83.7 %) and sexuality (97.4 %) supportive care needs. one in 5 and 1 in 8 women showed high initial supportive care needs in the hsips, psychological and pdl domains, respectively. with the exception of sexuality needs, the trajectory patterns were predicted by the distress related to their physical symptoms. women in the high decline group reported greater physical symptom distress. i. wabula et al. 146 | pissn: 1858-3598  eissn: 2502-5791 exclusion of an additional 40. the remaining 41 were read in their entirety and an additional 25 were rejected. sixteen met all of the criteria and have been reviewed in this paper. all of the titles and abstracts were inspected for relevance. the categories used in the abstract tool included the demographics and populations studied and the supportive care needs (measured; not only fulfilled but also unmet). results the sample size regarding the breast cancer patients ranged from 51 to 1084. several different cultures and countries are represented. nearly half were asian including taiwan, singapore, china, malaysia, thailand and korea. others included iran, norway, australia and african-american. eight studies concentrated on the post-treatment phase and the 8 other studies concentrated on the treatment phase. one of the studies recruited patients diagnosed of different cancer types. the studies vary in terms of the elapsed time since diagnosis, ranging from the newly-diagnosed to those who were a survivor. the participant’s age in all of the studies was reported to be between 18 and 65 years old. the instruments of choice for these studies include the scns, either short form 34 or version 59 (rahmani et al., 2014), the cancer survivors’ unmet need measure (casun) (dine, 2017), the other version of scns-sf34 (lam et al., 2014);(so et al., 2014) and the unmet needs of patients with bc questionnaire paired with in-depth interviews (torres et al., 2015);(chou, chia-rong hsieh, chen, huang, & shieh, 2020);(davis et al., 2018); (aunan, wallgren, & sætre hansen, 2019). the most commonly used version, the scns-sf34, is comprised of 5 domains: psychological, health system and information, physical and daily living, patient care and support and sexuality. the scoring and reporting of supportive care needs varied between the studies. the other instruments employed were eortc qlqc30, mspss, the quality of life index-cancer scale, ch, the hospital anxiety and depression scale, msas-ch and pseq-9. more than 50% of the participants reported that their needs were unmet. according to these studies, the highest needs were in the health system and information domain, physical domain and psychological domain concerning uncertainty about the future, fear about the cancer spreading, feelings of sadness, feelings about death and dying, concerns about those close to the patient and feeling down or depressed. a significant proportion of women with breast cancer reported that 71% of their needs were unmet specifically in the health information domain. the physical and psychological domain unmet needs were independently associated with a poorer quality of life among the participants. there were studies that reported that supportive care factors were identified such as faith, supportive structures, optimism and access to information. these scores were used to compare the severity of the unmet needs across the different samples and among the same sample at different time points, in addition to examining the factors associated with the specified needs. discussion the purpose of this review is to summarize what is currently known about the unmet supportive care needs of breast cancer patients so then we are able to conduct the right interventions for the patients newly-diagnosed with breast cancer. the result showed that more than 50% of the breast cancer (aunan et al., 2019) qualitative, descriptive design 20 bc survivors after having participated in the bcs in-depth interviews and the coreq checklist. the study reveals the need for information tailored to each bc survivor’s unique needs. the bc survivors expressed both the need for and fear of information. bcs takes both a systematic and individual approach to provide expert information, dialog and the opportunity to meet with fellow patients. (han et al., 2019) crosssectional study 146 patients who had undergone surgery and treatment for breast cancer survey-short form questionnaire (scns-sf34). back-to-work breast cancer survivors show higher physical and mental health indices which reflect their quality of life where they have fewer physical supportive care needs. additionally, their physical and mental health indices based on the characteristics of the illness differed according to the cancer stage. (chou et al., 2020) retrospective study 1129 bc patients the unmet needs of patients with bc questionnaire that were divided into six domains, namely health information, patient care, treatment, nutrition, psychosocial and economic needs. the unmet needs of patients with cancer differ according to their age, cancer stage and treatment phase. appropriate and punctual tailored support provided by the medical care personnel to address the unmet needs of patients can reduce the unmet supportive care needs of such patients and improve the quality of the medical care services that they are provided with. ultimately, the overall quality of life of the patients can be improved. jurnal ners http://e-journal.unair.ac.id/jners | 147 patients reported that their needs were unmet concerning the health system and information, with these needs being the most prevalent and intense. most of the studies showed that the unmet needs of breast cancer patients were related to the health system and information domain, the physical and daily living domain and the psychological domain. the younger participants had higher unmet needs across all domains. married women had more un-met supportive care needs related to sexuality (abdollahzadeh et al., 2014). in the health system and information domain, 3 of the most common unmet needs were “to have one member of [the] hospital staff with whom you can talk about all aspects of your condition,” “to be informed about [your] cancer that is under control or diminishing” and “to be informed about things [that] you can do to help yourself get well” (rahmani et al., 2014). the studies reviewed here found there to be more common psychological needs. the most prevalent unmet supportive care needs in the psychological domain were uncertainty about the future (78.6%) followed by fears about the cancer spreading (76.1%), feelings of sadness (69.2%), feelings about death and dying (68.4%), concerns about the worries of those close to the patient (65%), worries that the results of the treatment were beyond [their] control (65%) and feeling down or depressed (65%) (edib et al., 2016). the studies reviewed here determined the more common psychological needs. the most prevalent unmet supportive care needs in the physical domain were feeling unwell a lot of the time (58.1 %) followed by a lack of energy/tiredness (57.3%) and pain (55.6%) (edib et al., 2016). the present review underscores the other factors that influence supportive care needs. the results of these studies show that spirituality, a positive attitude and support networks can potentially be effective and have a positive impact on the adjustments in life made by the breast cancer survivors. faith in god was an important coping mechanism essential to all of the women in the study and it was a critical facilitator of survivorship. support networks consisted of their family, church family, friends and co-workers. the concept of fear included the discovery of breast cancer and a fear of death, the negative side effects of treatment and the social stigma of having breast cancer (torres et al., 2015). social support is often recognized as a vital component of physical and psychological well-being. the majority of the participants indicated that their support came from their family, friends, spouses and health care providers. having a positive attitude helped the participants during their survivorship journey; a positive outlook was described as “living stress-free and not allowing people to stress me” (davis et al., 2018). a better understanding of the supportive care needs of breast cancer patients and survivors will help the service providers to develop optimal supportive care interventions. the main goal of supportive care is to improve the quality of life of breast cancer patients by helping them to manage their pain, fears and worries. we therefore have to know the factors highlighted in this review to understand these needs in a dynamic manner. conclusion the supportive care needs of breast cancer patients and survivors touch upon many domains. the most frequent of the unmet needs is related to the health system and information domain. the breast cancer patients feel fear about the [potential] metastatic process of their cancer, experience feelings of sadness and feelings about death and dying, show concern for those close to the patient and feel down or depressed. the younger participants have more un-met needs in all domains. in addition, married women had more un-met supportive care needs related to sexuality. faith, supportive structures, optimism and access to information are the factors that are able to affect the supportive care needs of breast cancer patients and survivors. the education and psychological support programs available should be improved to provide for the unmet supportive care needs of patients newlydiagnosed with breast cancer. conflict of interest no conflicts of interest have been declared. acknowledgement the authors of this study would like to say thank you to the faculty of nursing and the master’s students on the nursing study programs for providing us with the opportunity to present this systematic review. references abdollahzadeh, f., moradi, n., pakpour, v., rahmani, a., zamanzadeh, v., mohammadpoorasl, a., & howard, f. (2014). un-met supportive care needs of iranian breast cancer patients. asian pacific journal of cancer prevention, 15(9), 3933–3938. https://doi.org/10.7314/apjcp.2014.15.9.3933 aunan, s. t., wallgren, g. c., & sætre hansen, b. (2019). breast cancer survivors’ experiences of dealing with information during and after adjuvant treatment: a qualitative study. journal of clinical nursing, 28(15–16), 3012–3020. https://doi.org/10.1111/jocn.14700 cheng, k. k. f., darshini devi, r., wong, w. h., & koh, c. (2014). perceived symptoms and the supportive care needs of breast cancer survivors six months to five years post-treatment period. european journal of oncology nursing, 18(1), 3–9. https://doi.org/10.1016/j.ejon.2013.10.005 chou, y. h., chia-rong hsieh, v., chen, x. x., huang, t. y., & shieh, s. h. (2020). unmet supportive care needs of survival patients with breast cancer in different cancer stages and treatment phases. taiwanese journal of obstetrics and gynecology, i. wabula et al. 148 | pissn: 1858-3598  eissn: 2502-5791 59(2), 231–236. https://doi.org/10.1016/j.tjog.2020.01.010 davis, c. m., nyamathi, a. m., abuatiq, a., fike, g. c., & wilson, a. m. (2018). understanding supportive care factors among african american breast cancer survivors. journal of transcultural nursing, 29(1), 21–29. https://doi.org/10.1177/1043659616670713 dine, j. (2017). immune checkpoint inhibitors: an innovation in immunotherapy. asia pac j oncol nurs, 4(2), 95–97. https://doi.org/10.4103/apjon.apjon edib, z., kumarasamy, v., binti abdullah, n., rizal, a. m., & al-dubai, s. a. r. (2016). most prevalent unmet supportive care needs and quality of life of breast cancer patients in a tertiary hospital in malaysia. health and quality of life outcomes, 14(1), 1–10. https://doi.org/10.1186/s12955016-0428-4 faghani, s., mohammadian, r., rahmani, a., mohajjelaghdam, a. r., hassankhani, h., & azadi, a. (2015). supportive care needs of iranian cancer survivors and relationships with social support. asian pacific journal of cancer prevention, 16(15), 6339–6345. https://doi.org/10.7314/apjcp.2015.16.15.633 9 han, s. j., kim, h. w., yoon, d. s., & kim, m. r. (2019). quality of life and supportive care needs of backto-work breast cancer survivors. korean journal of adult nursing, 31(5), 552–561. https://doi.org/10.7475/kjan.2019.31.5.552 lam, w. w. t., tsang, j., yeo, w., suen, j., ho, w. m., yau, t. k., … fielding, r. (2014). the evolution of supportive care needs trajectories in women with advanced breast cancer during the 12 months following diagnosis. supportive care in cancer, 22(3), 635–644. https://doi.org/10.1007/s00520-013-2018-x liao, m. n., chen, s. c., lin, y. c., chen, m. f., wang, c. h., & jane, s. w. (2014). education and psychological support meet the supportive care needs of taiwanese women three months after surgery for newly diagnosed breast cancer: a non-randomised quasi-experimental study. international journal of nursing studies, 51(3), 390–399. https://doi.org/10.1016/j.ijnurstu.2013.07.007 mohammadzadeh nimekari, m., saei ghare naz, m., ashouri taziani, y., nasiri, m., evazi, m. r., shafizad, a., & ozgoli, g. (2019). correlation between supportive care needs of women with breast cancer and quality of life of their family caregivers. international journal of community based nursing and midwifery, 7(4), 300–308. https://doi.org/10.30476/ijcbnm.2019.73892. 0 molassiotis, a., yates, p., li, q., so, w. k. w., pongthavornkamol, k., pittayapan, p., … si, s. y. h. (2017). mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the asia-pacific region: results from the international step study. annals of oncology, 28(10), 2552–2558. https://doi.org/10.1093/annonc/mdx350 rahmani, a., ferguson, c., jabarzadeh, f., mohammadpoorasl, a., moradi, n., & pakpour, v. (2014). supportive care needs of iranian cancer patients. indian journal of palliative care, 20(3), 224–228. https://doi.org/10.4103/09731075.138400 so, w. k. w., chow, k. m., chan, h. y. l., choi, k. c., wan, r. w. m., mak, s. s. s., … chan, c. w. h. (2014). quality of life and most prevalent unmet needs of chinese breast cancer survivors at one year after cancer treatment. european journal of oncology nursing, 18(3), 323–328. https://doi.org/10.1016/j.ejon.2014.03.002 torres, e., dixon, c., & richman, a. r. (2015). understanding the breast cancer experience of survivors : a qualitative study of african american women in rural eastern north carolina. https://doi.org/10.1007/s13187-015-0833-0 ners vol 10 no 2 okt 2015.indd 217 penerapan tindakan keperawatan: terapi generalis terhadap ketidakberdayaan pada lansia (the application of nursing interventions: generalist therapy to against hopelessness on elderly) ike mardiati agustin*, budi anna keliat*, mustikasari* *fakultas ilmu keperawatan, universitas indonesia, depok kampus ui depok, jawa barat 16424 email: ikeagustin83@gmail.com abstrak pendahuluan: peningkatan jumlah lansia diikuti dengan meningkatnya masalah kesehatan jiwa. salah satu masalah kesehatan jiwa yang terus meningkat adalah ketidakberdayaan. tindakan keperawatan bagi lansia yang mengalami ketidakberdayaan di komunitas belum optimal. tujuan dari penelitian ini adalah untuk memberikan gambaran tentang penerapan intervensi keperawatan: terapi generalis terhadap ketidakberdayaan pada lansia. metode: penelitian ini berdesain deskriptif analitik. populasinya adalah lansia yang tinggal di rw 3 dan rw 4, kelurahan ciwaringin, kota bogor. sampel sejumlah 10 responden diambil dengan teknik purposive sampling. variabel independen dalam penelitian ini adalah terapi generalis, sementara variabel dependennya adalah tanda dan gejala ketidakberdayaan, serta kemampuan lansia dalam mengatasi ketidakberdayaannya. data dikumpulkan dengan menggunakan kuesioner, lalu dianalisis menggunakan distribusi frekuensinya. hasil: hasil penelitian menunjukkan bahwa terapi generalis dapat menurunkan tanda dan gejala ketidakberdayaan pada lansia (21%) dan meningkatkan kemampuan lansia dalam mengatasi ketidakberdayaannya (72%). diskusi: berdasarkan hasil kesimpulan dapat diketahui bahwa terapi generalis dapat digunakan sebagai salah satu pilihan intervensi keperawatan untuk mengatasi ketidakberdayaan pada lansia. kata kunci: ketidakberdayaan, lansia, terapi generalis abstract introduction: an increasing number of elderly people followed the emergence of mental health problems. one of mental health problem that arises is hopelesness. nursing action to hopelesness in elderly people in society is not to optimals. the aimed of this paper was gave an overview about the application of nursing intervention: generalist therapy to against hopelesness on elderly. methods: this research was used descriptive analytic design. population were elders who lived at rw 3 and rw 4, kelurahan ciwaringin, kota bogor. samples were 10 respondents, taken according to purposive sampling technique. independent variable was generalist therapy, while dependent variables were sign and symptoms of hopelessness and ability to cope with hopelessness. data were collected by using questionnaire, then analyzed by using frequency distribution. results: the results showed that generalist therapy can decrease elder’s sign and symptoms of hopelessness (21%) and increase their ability to cope with hopelessness (72%). discussions: it can be concluded that generalist therapy can be used as one of nursing intervention to against hopelesness in the elderly. keywords: hopelesness, elderly, generalist therapy pendahuluan pen i ng k at a n u sia ha r apa n h idup mengindikasikan bahwa jumlah penduduk lansia dari tahun ke tahun akan semakin meningkat. jumlah lansia di indonesia mengalami peningkatan sekitar 18.957.189 (8,42%) jiwa dari jumlah penduduk di indonesia (bps, 2013). berdasarkan kondisi tersebut dengan bertambahnya usia harapan hidup, maka jumlah lansia juga akan bertambah pada tahun 2020, yaitu sekitar 28.882.879 (11,34%) jiwa dari total penduduk indonesia (men kokesra, 2010; ronaw ulan, 2009; soeweno, 2009). peningkatan usia harapan hidup lansia berdampak pada permasalahan kesehatan. batasan lansia menurut who, adalah seseorang yang telah mencapai usia 60 tahun ke atas (kozier, 2012). batasan orang dengan usia lanjut yang ditetapkan pada penelitian ini dengan rentang usia 60–75 tahun. proses perubahan yang dapat terjadi pada lansia meliputi perubahan secara biologis, psikologi, sosial maupun spiritual. p rose s p e r uba h a n ya ng d iala m i lansia cenderung berpotensi menimbulkan 218 jurnal ners vol. 10 no. 2 oktober 2015: 217–221 masalah kesehatan jiwa secara khusus, seperti dimensia, ansietas, ketidakberdayaan, dan depresi (grandfa, 2007). prevalensi kejadian masalah kesehatan jiwa pada lansia di unit komunitas bervariasi antara 1-35% (frazer, christonson & griffith, 2005). kasus yang banyak ditemukan adalah ketidakberdayaan lansia dengan prevalensi kejadiannya berkisar 30-45% dari kasus kesehatan jiwa yang lain (dharmono, 2008). penanganan diagnosa ketidakberdayaan sendiri belum optimal bila dibandingkan dengan diagnosa pada lansia yang lain. tindakan keperawatan yang dilak u kan unt uk mengatasi diagnosa keperawatan ketidakberdayaan pada lansia ber t ujuan klien mampu meningkatkan harga diri dan meningkatkan sumber daya individu, memiliki mekanisme koping yang lebih efektif, mampu memulai hubungan atau interaksi dengan orang lain, ser ta dapat mengembangkan dan meningkatkan hubungan atau interaksi sosial dengan orang lain (stuart & laraia, 2009). pemberian tindakan keperawatan unt uk mengatasi diagnosa keperawatan ketidakberdayaan pada lansia dilakukan melalui tindakan keperawatan dengan terapi generalis. tindakan keperawatan generalis yang dilak ukan pada klien ketidakberdayaan memberikan dampak adanya penurunan tanda dan gejala ketidakberdayaan dan peningkatan k e m a m p u a n k l i e n d a l a m m e n g a t a s i ketidakberdayaannya. tindakan keperawatan melalui terapi generalis yang dilakukan adalah latihan afirmasi positif. asuhan keperawatan yang dilakukan pada klien lansia ini berada di tatanan komunitas atau masyarakat. oleh sebab itu, upaya kesehatan yang dilakukan salah satunya melalui cmhn (community mental heath nursing) yang merupakan bagian dari pelayanan kesehatan di masyarakat. melalui cmhn ini lansia yang berisiko diberikan tindakan-tindakan agar tidak mengarah pada gangguan jiwa (keliat, 2011). upaya pelayanan kesehatan jiwa di masyarakat yang dilakukan salah satunya dengan pemberdayaan kader kesehatan jiwa dalam melakukan asuhan keperawatan pada lansia. pener apa n t i nd a k a n ke perawat a n melalui terapi generalis ini dilakukan di rw 03 dan 04 kelurahan ciwaringan kota bogor, yang merupakan wilayah binaan dari program kelurahan siaga sehat jiwa praktik spesialis keperawatan jiwa tahun 2015. upaya pelayanan kesehatan pada lansia di wilayah rw 03 dan 04 kelurahan ciwaringin masih berfokus pada pelayan fisik melalui posyandu lansia, sedangkan pelayanan untuk kesehatan jiwa belum ada. berdasarkan hal tersebut tertarik untuk dilihat bagaimana upaya pelayanan kesehatan jiwa di masyarakat melalui tindakan keperawatan berupa penerapan terapi generalis khususnya di kota bogor. bahan dan metode metode ya ng d ig u na ka n melalu i deskriptif analitik. populasi orang lanjut usia di rw 03 dan 04 kelurahan ciwaringin kota bogor sebanyak 25 orang, proses pengambilan sampel dilakukan dengan purposive sampling dengan jumlah sampel sebanyak 10 orang lanjut usia dengan ketidakberdayaan yang telah melalui proses screening untuk orang lanjut usia dengan ketidakberdayaan. variabel independen dalam penelitian ini adalah penerapan tindakan keperawatan terapi generalis dan variabel dependennya adalah ketidakberdayaan pada orang lanjut usia. pengumpulan data dilakukan dengan menggunakan instrumen tanda dan gejala ketidakberdayaan dan kemampuan setelah terapi generalis. analisis data dilakukan dengan distribusi frekuensi untuk melihat penurunan tanda dan gejala serta peningkatan kemampuan. pengukuran tanda dan gejala dan kemampuan klien dilakukan setelah penerapan terapi generalis pad a k lien pengukuran kemampuan keluarga dalam merawat dilakukan setelah penerapan terapi generalis pada keluarga. kemampuan generalis klien yang diukur terdiri dari 10 kemampuan yaitu kemampuan untuk memahami penyebab dan perilaku akibat ketidakberdayaannya, mampu mengekspresikan perasaannya dan identifikasi area-area situasi kehidupannya yang tidak berada dalam kemampuannya 219 penerapan tindakan keperawatan: terapi generalis (ike mardiati agustin, dkk.) untuk mengontrol, mampu mengidentifikasi faktor-faktor yang ber pengaruh terhadap ketidakberdayaannya, mampu menyampaikan masala h ya ng d i had api k lien, ma mpu meningkatkan pemikiran positif, mampu melatih mengembangkan harapan positif (afirmasi positif ), dan mampu mengontrol perasaan ketidakberdayaan melalui latihan afirmasi positif. tanda dan gejala klien ketidakberdayaan ya ng d iu k u r mel iput i t a nd a kog n it i f ( kebi ng u nga n , su l it kon sent r a si, su l it me nga mbi l ke put u sa n , me r a sa gagal, pesimis). tanda dan gejala afektif (sedih, khawatir, takut, kesal, mudah tersinggung, merasa kesepian), tanda dan gejala fisiologis (kelelahan, kelemahan, nafsu makan menurun, perubahan tanda vital, gangguan pola tidur), tanda dan gejala perilaku (marah, menangis, tergantung pada orang lain), tanda dan gejala sosial (menghindari, jarang bersosialisasi, tidak dapat bekerja, partisipasi sosial kurang). hasil karakteristik responden yaitu, sebagian besar berusia ≥ 65 tahun, perempuan, janda/ duda, tidak bekerja, dengan tingkat pendidikan terakhir paling banyak smp, yaitu 40%. lihat tabel 1. kemampuan generalis responden dengan diagnosa ketidakberdayaan antara sebelum diberikan terapi (pre) dengan setelah diberikan terapi ( post), yaitu semua responden berhasil mencapai kemampuan generalis dengan ratarata peningkatan kemampuan terapi generalis untuk diagnosa ketidakberdayaan adalah 21%. penurunan tanda dan gejala yang signifikan terjadi pada aspek kognitif dan perilaku. secara lengkap dapat dilihat dalam (tabel 2 dan tabel 3). ada peningkatan kemampuan keluarga dalam merawat lansia dengan ketidakberdayaan sesudah diberikan terapi generalis. setelah diberikan terapi, semua keluarga lansia dengan diagnosa ketidakberdayaan mampu merawat anggota keluarganya tersebut. rata-rata peningkatan kemampuan tersebut adalah 72%, seperti dijelaskan pada tabel 4. pembahasan berdasarkan hasil asuhan keperawatan yang diberikan pada keluarga dalam merawat lansia yang mengalami ketidakberdayaan diperoleh peningkatan kemampuan keluarga sebesar (72%). keluarga sebagai sumber social support bagi klien sebagian besar tidak memiliki kemampuan dalam merawat klien ketidakberdayaan. dampak dari pemberian tabel 1. karakteristik responden no variabel item jumlah persen (%) 1 usia 60–65 tahun 3 30 ≥ 65 tahun 7 70 2 jenis kelamin laki-laki 3 30 perempuan 7 70 3 status perkawinan nikah 4 40 janda/duda 6 60 4 pekerjaan bekerja 2 20 tidak bekerja 8 80 5 pendidikan sd 2 20 smp 4 40 sma 2 20 pt 2 20 tidak sekolah 0 0 220 jurnal ners vol. 10 no. 2 oktober 2015: 217–221 tindakan ini adalah meningkatnya kemampuan care giver dan anggota keluarga lainnya dalam membentuk koping yang adaptif dalam merawat klien ketidakberdayaan karena terapi ini mengoptimalkan fungsi keluarga sebagai suatu sistem keseluruhan yang fungsional dalam memberi dukungan terhadap care giver dalam mengurangi beban keluarga (fisik, mental dan finansial) dalam merawat klien ketidakberdayaan. setiap keluarga (care giver) tabel 2. p e n g a r u h p e n e r a p a n t e r a p i g e n e r a l i s t e r h a d a p k e m a m p u a n l a n s i a d e n g a n ketidakberdayaan no kemampuan yang harus dicapai pre post peningkatan n % n % % 1 mampu memahami penyebab dan perilaku akibat ketidakberdayaan 2 20 4 40 20 2 mampu mengekspresikan perasaannya dan identifi kasi area-area situasi kehidupannya yang tidak berada dalam kemampuannya untuk mengontrol 2 20 5 50 30 3 mampu mengidentifi kasi faktor-faktor yang dapat berpengaruh terhadap ketidakberdayaannya 3 30 4 40 10 4 mampu menyampaikan masalah yang dihadapi klien 3 30 4 40 10 5 mampu menyampaikan pemikiran yang negatif 2 20 5 50 20 6 mampu meningkatkan pemikiran yang positif 1 10 4 40 30 7 mampu mengevaluasi ketepatan persepsi, logika, dan kesimpulan yang dibuat 1 10 3 30 40 8 mampu mengidentifi kasi persepsi klien yang tidak tepat, penyimpangan dan pendapatnya yang tidak rasional. 2 20 3 30 10 9 mampu melatih mengembangkan harapan positif (afi rmasi positif) 1 10 3 30 20 10 mampu latihan mengontrol perasaan ketidakberdayaan melalui peningkatan kemampuan mengendalikan situasi yang masih bisa dilakukan pasien (bantu klien mengidentifi kasi area-area situasi kehidupan yang dapat dikontrolnya) 1 10 3 30 20 rata-rata 21 tabel 3. pengaruh penerapan terapi generalis terhadap tanda dan gejala lansia dengan ketidakberdayaan no tanda dan gejala pre (%) post (%) penurunan (%) 1 kognitif (5) 6 4,2 1,8 2 afektif (6) 58,3 38,3 20 3 fisiologis (5) 66 38 28 4 perilaku (3) 53,33 30 50,33 rata-rata 58,84 37,84 21 selalu berupaya memberikan perawatan yang terbaik bagi lansia. k e t e r l i b a t a n k e l u a r g a m e l a l u i pendidikan kesehatan dan dukungan keluarga dalam perawatan klien dapat meningkatkan hasil perawatan (stuart & laraia, 2005). oleh sebab itu, perawat diharapkan selalu melibatkan peran serta anggota keluarga di setiap tindakan keperawatan yang dilakukan. dapat disimpulkan bahwa melalui pemberian 221 penerapan tindakan keperawatan: terapi generalis (ike mardiati agustin, dkk.) kepustakaan stuart & laraia. 2008. principles and practice of psychiatric nursing (8 ed.). missouri: mosby, inc. baranty, e.b.s, keliat, b.a & besral. 2011. pengaruh terapi reminiscence dan psikoedukasi keluarga terhadap kondisi depresi dan kualitas hidup lansia di katulampa bogor. depok: universitas indonesia, tesis tidak dipublikasi. cappeliez. 2004. cognitive-reminiscence therapy for depressed older adult. htt p://w w w.seniorsmentalhealth.ca. diakses tanggal 18 mei 2015. friedman. 2008. keperawatan keluarga: teori dan praktik (family nursing: theory and practice), alih bahasa: ina debora r.l. jakarta: egc. fontaine. 2009. mental health nursing. sixth editions. new jersey: pearson education inc. kapplan & saddock. 2007. sinopsis psikiatri: ilmu pengetahuan psikiatri klinis. jakarta: bina rupa aksara. hawari. 2001. pendekatan holistik pada gangguan jiwa skizoprenia. jakarta: fkui. youdha. 2012. konseling penyebab masalah k e j i w a a n . j a k a r t a : u n i ve r s i t a s gunadharma, 03 april http://c3i.sabda. org/30/jam/2012/konseling. tabel 4. pengaruh terapi generalis keluarga terhadap kemampuan keluarga dalam merawat lansia dengan ketidakberdayaan no kemampuan yang harus dicapai pre post peningkatan n % n % % 1 menyebutkan masalah yang dirasakan dalam merawat pasien ketidakberdayaan 10 100 10 100 100 2 menyebutkan pengertian ketidakberdayaan, tanda dan gejala dan proses terjadinya 1 10 10 100 90 3 mampu melatih klien berpikir positif, logis, rasional dan mengembangkan afi rmasi positif 3 30 7 70 70 4 mampu melatih klien mengembangkan pikiran dan harapan yang positif 5 50 5 50 50 5 mampu menyebutkan sumber-sumber pelayanan kesehatan yang tersedia (follow-up) 5 50 1 100 50 rata-rata (%) 72 terapi generalis dapat secara signif ikan menurunkan tanda dan gejala klien lansia dengan ketidakberdayaan dan meningkatkan kemampuan klien dalam menghadapi masalah ketidakberdayaannya. simpulan dan saran simpulan penerapan terapi generalis terhadap ketidakberdayaan orang lanjut usia sangat be r m a k n a d ibu k t i k a n de nga n a d a nya penurunan tanda dan gejala serta peningkatan k e m a m p u a n k l i e n d a l a m m e n g a t a s i ketidakberdayaan yang dialami. saran dinas kesehatan kota bogor diharapkan dapat terus memfasilitasi dan melakukan monitoring serta evaluasi secara rutin untuk keberlangsungan program cmhn, khususnya di wilayah kelu rahan ciwar i ngi n dan memberikan terobosan-terobosan baru khusus untuk pelayanan kesehatan pada lansia. bagi puskesmas, diharapkan mengadakan pelatihan khusus bagi perawat khususnya penanggung jawab program lansia dan jiwa tentang asuhan keperawatan jiwa, khususnya pada lansia yang mengalami masalah psikososial, sehingga perawat minimal mempunyai kemampuan ge n e r a l i s u nt u k m e mb e r i k a n a s u h a n keperawatan pada lansia. ners vol 10 no 1 april 2015.indd 30 efektivitas dzikrullah terhadap penurunan kecemasan dan nyeri persalinan kala i fase aktif ibu primigravida (the effectiveness of dhikr toward decreasing anxiety and labor pain during active phase of first stage among primigravida) irma nurbaeti* *departemen keperawatan maternitas, psik fkik uin syarif hidayatullah jakarta jl. ir h. juanda no. 95 ciputat 15412 email: nurbaeti.warcham@yahoo.co.id abstrak pendahuluan: melahirkan adalah peristiwa yang menyebabkan stres bagi ibu. cemas dan nyeri selama persalinan, jika tidak ditangani dengan baik akan mengganggu proses kelahiran. intervensi yang dapat dilakukan adalah dzikir kepada allah. tujuan dari penelitian ini adalah untuk mengetahui efektivitas dzikir untuk mengurangi kecemasan dan nyeri selama fase aktif persalinan. metode: penelitian menggunakan desain kuasi-eksperimen dengan melibatkan kelompok kontrol yang diukur pretest dan posttest. sampel adalah 40 primigravida muslim dengan usia kehamilan 3742 minggu dan dilatasi serviks > 3 cm yang diambil secara purposive sampling. data dikumpulkan dengan menggunakan kuesioner (taylor manifest anxiety scale) dan observasi nyeri persalinan (visual analog scale) per jam. analisis data dengan uji multivariat menggunakan anova pada α = 0,05. hasil: penelitian ini menunjukkan dzikir efektif (p = 0,001) efektif untuk mengurangi tingkat kecemasan selama persalinan pada primigravida (59,8%). skor rerata kecemasan ibu dan nyeri yang dirasakan saat melahirkan mengalami penurunan, dengan nilai p = 0,001. analisis dan diskusi: primigravida yang melakukan dzikir cenderung mengalami kecemasan ringan dalam menghadapi proses persalinan, sedangkan primigravida yang tidak melakukan dzikir kemungkinan besar akan mengalami kecemasan yang lebih berat. dzikir juga efektif untuk menurunkan nyeri persalinan selama fase aktif persalinan. kata kunci: persalinan, keperawatan, dzikir, kecemasan, nyeri. abstract introduction: childbirth is an event that causes stress to the mother. anxiety and pain during labor, if not handled properly will disrupt the process of birth. interventions to do is dhikr to god. the purpose of this study was to determine the effectiveness of dhikr to reduce anxiety and pain during the active phase of labor. method: the study used a quasiexperimental design involving control groups were measured pretest and posttest. the samples were 40 moeslem primigravida with 37–42 weeks gestation and cervical dilation > 3 cm were taken by purposive sampling. data was collected using a questionnaire (taylor manifest anxiety scale) and observation of labor pain (visual analog scale) per hour. multivariate data analysis using anova test at α = 0.05. results: this study showed that dhikr was effective to reduce the level of anxiety during labor in primigravida (59.8%). the average score of maternal anxiety and pain felt by mothers during childbirth have decreased, with a value of p = 0.001. analysis and discussion: primigravida who did dhikr tend to experience mild anxiety during delivery process, while primigravida who did not perform dhikr is likely to experience more severe anxiety. dhikr is also effective in reducing labor pain during the active phase of labor. keywords: birth, nursing, dhikr, anxiety, pain pendahuluan proses persalinan merupakan merupakan suatu peristiwa yang berat bagi seorang ibu, sebagaimana fi rman allah swt dalam surat al-ahqaaf ayat 15 yang artinya:“........ ibunya telah mengandungnya dengan susah payah pula”. pada saat melahirkan biasanya timbul reaksi alamiah yaitu perasaan cemas dan takut. bila tidak segera di atasi akan menimbulkan kejang pada bagian otot panggul, sehingga bisa mempersulit persalinan (bobak, 2009). stres, rasa takut dan kecemasan mempunyai efek yang dalam pada proses persalinan, sering memperlama fase pertama persalinan karena penggunaan cadangan glukosa menyebabkan peningkatan aktivitas miometrium dan kadar norepineprin yang dilepaskan cender ung meningkatkan aktivitas uterus. kecemasan juga memperberat persepsi nyeri sehingga mempengaruhi penggunaan teknik koping dan menstimuli pelepasan aldosteron yang dapat meningkatkan reabsorbsi natrium dan air yang 31 efektivitas dzikrullah terhadap penurunan kecemasan dan nyeri persalinan (irma nurbaeti) berakibat memperberat aktivitas miometrium (doengoes, 2010). nyeri persalinan seringkali menimbulkan stres yang merangsang pelepasan hormon katekolamin dan steroid, sehingga terjadi ketegangan otot polos dan vasokontriksi pembu lu h d a r a h ya ng menga k ibat k a n penurunan sirkulasi uteroplasenta (iskhemia uterus) dan impuls nyeri bertambah banyak sehingga menimbulkan siklus stres – tegang dan nyeri. hal tersebut sesuai dengan teori dick read (1959) menyatakan bahwa pada proses persalinan sering terjadi sindroma fear – tension – pain (bobak, 2009). i b u y a n g h a m i l p e r t a m a k a l i (primigravida) akan mengalami kecemasan yang lebih dibandingkan dengan multigravida seiring dengan semakin majunya pembukaan ser viks maka kontraksi uter us/his akan semakin kuat, panjang durasinya dan semakin sering. hal tersebut berdasar penelitian yonne, nurbaeti dan rosidati (2009) ditemukan hasil bahwa lebih dari separuh (52,5%) ibu hamil trimester iii mengalami kecemasan dalam menghadapi persalinan dan ibu primigravida secara bermakna tiga kali lipat mengalami ke c e m a s a n d iba nd i ng k a n de nga n ibu multigravida. salah satu inter vensi keperawatan adalah dengan pendekatan spiritual dengan melakukan dzikir selama proses persalinan, dengan mengucap doa-doa persalinan bagi pasien muslim. beberapa penelitian telah mengungkap pengaruh aspek spiritual (dzikir) terhadap tingkat kecemasan, seperti darwanti, handoyo dan ridwan (2007), dan maimunah dan retnowati (2011). tetapi penelitian tersebut meneliti pengaruh bimbingan spiritual terhadap aspek kecemasan pasien dengan desain kuasi eksperimen pre – post test, pengumpulan data dilakukan setelah perlakuan (post test) dilakukan satu kali. peneliti memandang perlunya penelitian tentang pengaruh dzikir dengan kecemasan dan nyeri persalinan dengan melakukan monitoring selama kala i fase aktif untuk menganalisi efektivitas intervensi dzikrullah. tujuan penelitian adalah menganalisis efektivitas dzikir terhadap penurunan kecemasan dan nyeri persalinan kala i fase aktif ibu primigravida. bahan dan metode j e n i s p e n e l i t i a n a d a l a h k u a s i eksperimen desain dua kelompok pre dan post test (two groups pre posttest design). kelompok pertama adalah kelompok intervensi dilakukan bimbingan dzikir dan kelompok dua adalah kelompok kontrol dilakukan prosedur penurunan nyeri sesuai standard operasional prosedur (sop) rumah sakit yaitu tarik nafas dalam. sebanyak empat puluh (40) orang responden beragama islam, primigravida dan usia kehamilan 37–42 minggu telah direkrut dalam penelitian ini secara purposive berdasar kriteria inklusi: ibu proses persalinan kala i fase aktif (pembukaan 4–9 cm), low risk, kondisi janin normal dan tidak ada tandagambar 1. kerangka teori untuk memutus sindroma fear – tension – pain dengan dzikir yang dikembangkan berdasarkan teori natural childbirth oleh dick-read (1959). 32 jurnal ners vol. 10 no. 1 april 2015: 30–37 tanda gawat janin. sampel penelitian terdiri dari dua kelompok yaitu kelompok kontrol 20 orang dan kelompok intervensi 20 orang. bimbingan dzikir pada ibu dilakukan selama 30 menit, dilakukan berulang-ulang hingga ibu hafal. bila ibu tidak hafal tetap dibimbing oleh enumerator. bimbingan dilakukan secara terus menerus setiap 30 menit dan/atau selama kontraksi dan di luar kontraksi. bimbingan dihentikan bila ibu telah memasuki pembukaan lengkap (pembukaan serviks 10 cm). instrumen penelitian terdiri dari tiga bagian. lembar kemajuan persalinan (meliputi tekanan darah, nadi, suhu, denyut jantung janin, pembukaan serviks, penurunan janin dan kontraksi uterus). kuesioner untuk menilai kecemasan menggunakan manifest anxiety scale dari taylor (t-mas) terdiri dari 21 pernyataan dengan skala likert. instrumen diterjemahkan dari bahasa inggeris ke bahasa indonesia. direview oleh ahli keperawatan maternitas. dan lembar observasi visual analogue pain scale. instrumen diadposi langsung dari kepustakaan yang telah banyak digunakan oleh beberapa peneliti lain. pengumpulan data dilakukan setelah mendapat persetujuan penelitian oleh pihak rsu daerah tangerang. pengumpulan data dibantu oleh 4 (empat) orang enumerator. enumerator adalah lulusan program sarjana keperawatan fkik yang memiliki praktik di kamar bersalin. sebelum pengumpulan data terlebih dahulu dilakukan pelatihan enumerator selama satu hari dengan tujuan memahami proses pengumpulan data dan mendapatkan kesamaan persepsi terhadap prosedur perlakuan pada kelompok intervensi dan kelompok kontrol serta metoda untuk monitoring. prosedur pengumpulan data pertama dilakukan pada kelompok kontrol terlebih dahulu dengan t ujuan tidak ter jadinya ko nt a m i n a si a t a u bi a s p e ng u m pu l a n data. responden kelompok kontrol tidak termanipulasi oleh intervensi dzikir. setelah pengumpulan data kelompok kontrol selesai 20 responden dilanjutkan pengumpulan data pada kelompok intervensi. a n a l i si s d at a d i l a k u k a n s e c a r a univariate (distribusi frekuensi), bivariat (dependent sampel t-test/paired t test pada α (0,05) dan uji eta (η) dan uji multivariat denga n mengg u na ka n general linear model repeated measure anova pada α 0,05 (tabachnick & fidell, 2007). analisis multivariat menggunakan general logistic measure untuk menganalisis efektivitas dzikir dengan menggunakan repeated measure anova design model 2 untuk menghindari type i error pada α 0.05 (tabachnick bg, fidell ls, 2007). asumsi glm adalah normalitas dan homogenitas data. etika penelitian pe rl i n d u n g a n s u bje k p e n el it i a n d i l a k u k a n d e n g a n m e n g h o r m a t i h a k responden dan memegang prinsip etik dalam penelitian. persetujuan penelitian dilakukan pada subjek sebelum penelitian dilaksanakan dengan menandatangani informed consent sebagai bukti bahwa telah menyetujui untuk berpartisipasi dalam penelitian. kerahasiaan dijamin dengan cara: anonimity pada kuesioner, kode diberikan untuk memberi tanda dan penyimpanan data dan pengolahan data hanya oleh peneliti utama. etika penelitian diberikan oleh komite etik penelitian fkik uin syarif hidayatullah jakarta. gambar 2. alur penelitian 33 efektivitas dzikrullah terhadap penurunan kecemasan dan nyeri persalinan (irma nurbaeti) hasil penelitian g a mb a r a n r e s p ond e n p e nel it ia n disajikan dalam tabel 2. secara umum, rerata berada pada kisaran antara 21 tahun hingga 30 tahun sebanyak 82,5% (33 orang). umur termuda responden adalah 17 tahun dan yang paling tua adalah 32 tahun. lebih dari separuh responden berpendidikan sma dan sederajat dan masih ada responden berpendidikan sd. hampir seluruh responden bersuku sunda, dan hanya sebagian kecil bersuku betawi dan jawa. tabel 1. distribusi frekuensi data demografi responden (n = 40) karakteristik n % umur (tahun) ≤ 20 tahun 21–30 tahun > 30 tahun 6 33 1 15 82,5 2,5 pendidikan terakhir sd smp sederajat sma sederajat 3 16 21 7,5 40 52,5 suku betawi sunda jawa 1 36 3 2,5 90 7,5 total 40 100 rerata tingkat kecemasan dan nyeri persalinan disajikan dalam tabel 2. tingkat kecemasan diukur berdasarkan 21 item k uesioner t-m as. nilai rerata tingkat kecemasan pada pengukuran awal adalah 35,63 dan menurun pada pengukuran berikutnya sebanyak 1 poin, sedangkan nilai maksimum adalah pada pengukuran awal, pengukuran berikutnya turun 2 poin. sedangkan rerata responden mengalami nyeri persalinan 7 atau lebih, baik pada kelompok intervensi maupun kelompok kontrol. nilai terendah intensitas nyeri adalah 3 (nyeri ringan) terjadi pada awal proses persalinan dan semakin majunya persalinan intensitas nyeri makin meningkat pada kelompok kontrol, sedang pada kelompok intervensi cenderung rata-rata intensitas nyeri menurun. pada tabel 2 terlihat rerata tingkat kecemasa n responden ya ng d ila k u ka n intervensi dzikir lebih rendah dibandingkan dengan reponden yang tidak dilak ukan intervensi dzikir (29,00 dan 37,45) pada pengukuran terakhir (akhir kala i). hasil uji t didapatkan pengaruh yang signifikan intervensi dzikir terhadap tingkat kecemasan ibu (t = 4,059; p value = 0,000). selain itu juga terdapat perbedaan rerata nyeri persalinan antara responden pada kelompok intervensi dan kelompok kontrol. responden pada kelompok intervensi memiliki rerata nyeri persalinan lebih rendah dibandingkan dengan kelompok kontrol. hasil uji t didapatkan hasil 7,165 dan nilai p = 0,000. artinya terdapat pengaruh yang signifi kan intervensi dzikir dengan tingkat nyeri persalinan pada proses persalinan kala i. tabel 2. rerata tingkat kecemasan dan nyeri persalinan kelompok mean (sd) min – maks pre post i post ii post iii pre post i post ii post iii kecemasan: intervensi 33,65 (8,106) 31,20 (7,164) 29,80 (6,437) 29,00 (5,938) 25–54 25–51 23–45 21–42 kontrol 37,60 (7,903) 37,50 (7,612) 36,95 (7,612) 37,45 (7,171) 25–60 26–58 26–58 29–58 nyeri persalinan: intervensi 9,15 (0,933) 8,30 (0,945) 7,60 (0,940) 7,55 (0,686) 7–10 7–10 6–9 6–9 kontrol 7,85 (1,725) 8,15 (1,424) 8,90 (1,021) 9,20 (0,768) 3–10 5–10 7–10 8–10 34 jurnal ners vol. 10 no. 1 april 2015: 30–37 tabel 3. rerata tingkat kecemasan dan nyeri persalinan pada akhir kala i (penilaian post iii) kategori n mean (sd) t p value tingkat kecemasan: intervensi 20 29,00 (5,938) 4,059 0,000 kontrol 20 37,45 (7,171) nyeri persalinan: intervensi 20 7,55 (0,686) kontrol 20 9,20 (0,768) 7,165 0,000 note: nilai p dalam italics mengindikasikan signifi kansi (p ≤ 0,05) tabel 4. skor tingkat kecemasan dan nyeri persalinan score n mean (sd) roy’s largest root pre post 1 post 2 post 3 grup difference over time tests of betweensubjects effects partial eta squared overall score kecemasan intervensi kontrol nyeri persalinan intervensi kontrol 20 20 20 20 33,65 (8,106) 37,60 (7,903) 9,15 (0,933) 7,85 (1,725) 31,20 (7,164) 37,50 (7,612) 8,30 (0,923) 8,35 (1,226) 29,80 (6,437) 36,95 (7,612) 7,60 (0,940) 8,32 (1,118) 29,00 (5,938) 37,45 (7,171) 7,55 (0,686) 9,25 (0,716) 34,144 (7,790) 8,315 (0,918) f = 17,818 p = 0,000 df = 5 f= 9,068 p = 0,000 df =27 f = 8,141 p = 0,007 df = 1 f = 4,998 p = 0,031 df = 1 0,598 0,665 note: nilai p dalam italics mengindikasikan signifi kansi (p ≤ 0,05) berdasar tabel 4 didapatkan hasil bahwa skor rerata kecemasan ibu adalah 34,144 dengan standar deviasi 7,790. kecemasan ibu primigravida secara signifikan mengalami perubahan selama proses persalinan kala i (f = 17,818; nilai p = 0,000). rerata awal kelompok intervensi adalah 33,65 dengan standar deviasi 8,106. setelah intervensi dzikir terdapat penurunan nilai rerata kecemasan ibu selama persalinan, baik post 1, post 2 dan post 3. sedangkan pada kelompok kontrol hampir tidak ada perubahan rerata kecemasan ibu selama proses persalinan. berdasar nilai eta didapat nilai 0,598, hal tersebut menerangkan bahwa intervensi dzikir secara efektif menurunkan kecemasan ibu selama proses persalinan sebanyak 59,8%. test of between-subjects effects merupakan uji yang dilakukan terhadap variabel dependent (skor kecemasan) berdasar variabel between (dalam hal ini kelompok inter vensi dan kelompok kontrol). didapatkan nilai f = 8,141 dengan signifi kansi 0, 007 derajat kebebasan (df) = 1. dapat disimpulkan bahwa intervensi dzikir selama proses persalinan berpengaruh secara signifi kan terhadap rata-rata tingkat kecemasan ibu selama proses persalinan. rerata nyeri persalinan kelompok intervensi dan kelompok kontrol adalah 8,315 (sd = 0,918). skor nyeri persalinan secara signifi kan bermakna mengalami perubahan overtime selama proses persalinan (f = 9,068; p = 0,000; df = 27). rerata awal skor nyeri kelompok intervensi adalah 9,15 dengan 35 efektivitas dzikrullah terhadap penurunan kecemasan dan nyeri persalinan (irma nurbaeti) standar deviasi 0,933. setelah intervensi dzikir terdapat penurunan rerata nilai nyeri persalinan selama proses persalinan kala i, baik post 1, post 2 dan post 3. sedangkan pada kelompok kontrol rerata nyeri persalinan mengalami peningkatan sebesar 1 poin pada kala i. berdasar nilai eta didapat nilai 0,665, hal tersebut menerangkan bahwa intervensi dzikir secara efektif menurunkan nyeri persalinan selama kala i persalinan sebesar 66,5%. test of between-subjects effects merupakan uji yang dilakukan terhadap variabel dependent (skore nyeri persalinan) berdasar variabel between (dalam hal ini kelompok inter vensi dan kelompok kontrol). didapatkan nilai f = 4,988 dengan signifi kansi 0, 031 derajat kebebasan (df) = 1. dapat disimpulkan bahwa intervensi dzikir selama proses persalinan secara efektif menur un kan nyer i persalinan pada ibu primigravida selama proses persalinan kala i. pembahasan kecemasan ibu selama persalinan dengan menggunakan kuesioner (t-mas) terdiri dari 21 pernyataan dengan observasi dan wawancara terpimpin, rata-rata kecemasan ibu sebelum intervensi adalah 33,65. menurut kategori cemas, maka pada awal proses persalinan rata-rata ibu mengalami kecemasan tingkat sedang. begitu halnya dengan kelompok kontrol pada awal pengukuran responden pun rata-rata mengalami tingkat kecemasan sedang (mean = 37,5). pada akhir kala i kelompok ibu yang dilakukan intervensi dzikir mengalami penurunan kecemasan menjadi cemas ringan (mean = 29,00), sedangkan pada kelompok responden yang tidak dilakukan intervensi dzikir tetap mengalami kecemasan sedang. kecemasan selama proses persalinan bisa disebabkan oleh semakin meningkatnya kontraksi uterus dan pembukaan serviks, sehingga dapat menyebabkan ibu primigravida mengalami ketegangan atas proses persalinan yang pertama kali dialaminya. pada waktu mengalami ketegangan dan kecemasan yang bekerja adalah sistem saraf simpatis, sedangkan pada waktu rileks yang bekerja adalah sistem saraf parasimpatis. relaksasi b e r u s a h a m e n g a k t i f k a n k e r j a s a r a f parasimpatetis. keadaan rileks menurunkan aktivitas amigdala, mengendurkan otot, dan melatih individu mengaktif kan kerja sistem saraf parasimpatis sebagai counter aktivitas sistem saraf simpatis (kalat, 2007). kecemasan ibu primigravida secara signifi kan mengalami perubahan selama proses persalinan kala i (f = 17,818; nilai p = 0,000). berdasar nilai eta didapat nilai 0,598, hal tersebut menerangkan bahwa intervensi dzikir secara efektif menurunkan kecemasan ibu selama proses persalinan sebanyak 59,8%. hal tersebut mendukung pernyataan bahwa dzikir membantu individu membentuk persepsi yang lain selain ketakutan yaitu keyakinan bahwa stresor apa pun akan dapat dihadapi dengan baik dengan bantuan allah. dzikir akan membuat seseorang merasa tenang sehingga kemudian menekan kerja sistem saraf simpatis dan mengaktif kan kerja sistem saraf parasimpatis (sholeh, 2010). penyebutan nama-nama allah secara berulangulang (dzikir) dapat menyembuhkan jiwa dan menyembuhkan berbagai penyakit (subandi, 2009). saat seorang muslim membiasakan dzikir akan membangkitkan percaya diri, kekuatan, perasaan aman, tenteram, dan bahagia (najati, 2005). hasil test of between-subjects effects didapatkan hasil f = 8,141 dengan signifi kansi 0,007 derajat kebebasan (df ) = 1. dapat disimpulkan bahwa intervensi dzikir selama proses persalinan berpengaruh secara signifi kan terhadap rata-rata tingkat kecemasan ibu selama proses persalinan. hasil penelitian ini menambah evident based penelitian-penelitian sebelumnya tentang pengaruh dan efektivitas dzikir terhadap penurunan kecemasan. seperti dengan penelitian maimunah dan retnowati (2011) bahwa pelatihan relaksasi dengan dzikir mengalami penurunan kecemasan yang signifi kan (p = 0,008). nyeri persalinan adalah nyeri kontraksi uterus yang dapat mengakibatkan peningkatan aktivitas sistem syaraf simpatis. selain itu peningkatan konsumsi glukosa tubuh pada ibu bersalin yang mengalami stres menyebabkan kelelahan dan sekresi katekolamin yang menghambat kontraksi uterus, hal tersebut menyebabkan persalinan lama yang akhirnya 36 jurnal ners vol. 10 no. 1 april 2015: 30–37 menyebabkan cemas pada ibu, peningkatan nyeri dan stres berkepanjangan (bobak, 2009). rasa takut menyebabkan pembuluhpembuluh arteri yang mengarah ke uterus berkont r a k si d a n menega ng, seh i ngga menimbulkan rasa sakit (nyeri). kalau tanpa adanya rasa takut, otot-otot melemas dan melentur, servik (leher rahim) dapat menipis serta membuka secara alami sewaktu tubuh berdenyut secara berirama dan mendorong bayi dengan mudah, sehingga membuat persalinan berlangsung secara lancar relatif lebih cepat dengan keluhan nyeri yang sangat minimal. dengan terbiasanya ibu melakukan relaksasi, jalan lahir untuk janin akan lebih mudah terbuka, sehingga ibu tidak akan terlalu kelelahan saat melahirkan. jadi dengan latihan relaksasi yang rutin, ibu akan terbiasa pada kondisi ini dan akan sangat terbantu dalam proses persalinannya (andriana, 2007). salah satu teknik relaksasi yang ditawarkan untuk umat islam adalah dengan berdzikir secara berulang-ulang selama proses persalinan. hasil penelitian menunjukkan hasil bahwa rata-rata nyeri persalinan kelompok inter vensi dan kelompok kontrol adalah 8,315. berdasarkan visual analogue scale (vas) nilai tersebut ter masuk kategori nyeri berat (skore 7–10). rata-rata awal skore nyeri kelompok intervensi adalah 9,15 sedangkan kelompok kontrol adalah 7,85. baik kelompok intervensi maupun kelompok kontrol keduanya mempersepsikan nyeri berat pada awal persalinan. hal tersebut mungkin dapat disebabkan oleh faktor primigravida (merupakan kehamilan pertama) yang tidak memiliki pengalaman melahirkan, waktu fase laten yang lebih lama dibandingkan dengan multigravida, dan kurangnya suport psikososial dan tidak tersedianya kelaskelas antenatal pada saat kehamilan. skor nyeri persalinan secara signifi kan bermakna mengalami perubahan overtime selama proses persalinan (f = 9,068; p = 0,000; df = 27). setelah intervensi dzikir terdapat penurunan rata-rata nilai nyeri persalinan selama proses persalinan kala i, baik post 1, post 2 dan post 3. sedangkan pada kelompok kontrol ratarata nyeri persalinan mengalami peningkatan sebesar 1 poin rata-rata nyeri persalinan pada kala i. hal tersebut mendukung pernyataan dari sholeh (2010) bahwa berdzikir akan membuat seseorang merasa tenang, sehingga kemudian menekan ker ja sistem sa raf simpatis dan mengaktif kan kerja sistem saraf parasimpatis. dengan demikian nyeri akan berkurang karena dengan dzikir dapat mensupresi aktivitas sistem saraf simpatis. relaksasi berusaha mengaktif kan kerja syaraf parasimpatetis. keadaan rileks menurunkan aktivitas amygdala, mengendurkan otot, dan melatih individu mengaktif kan kerja sistem saraf parasimpatis sebagai counter aktivitas sistem saraf simpatis (kalat, 2007). i nt e r ve n si d z i k i r se ca r a efek t i f menurunkan nyeri persalinan selama kala i persalinan sebesar 66,5%. test of betweensubjects effects didapatkan nilai f = 4,988 dengan signifi kansi 0,031 derajat kebebasan (df) = 1. dapat disimpulkan bahwa intervensi dzikir selama proses persalinan secara efektif menur un kan nyer i persalinan pada ibu primigravida selama proses persalinan kala i. hasil penelit ia n ya ng sig n if i ka n mendukung penelitian tentang intervensi keperawatan yang dapat menurunkan atau mengurangi nyeri pada proses persalinan. penelitian ini membuktikan bahwa relaksasi dengan dzikir juga dapat mengurangi nyeri persalinan pada kala i dengan memfokuskan pada keyakinan responden. simpulan dan saran simpulan dzikrullah efektif menurunkan tingkat kecemasan dan nyeri persalinan pada ibu primigravida selama proses persalinan. ibu primigravida yang dilakukan inter vensi dzikir mengalami kecenderungan mengalami kecemasan ringan dalam menghadapi proses kelahiran bayi, sedangkan ibu primigravida yang tidak dilakukan terapi dzikir cenderung mengalami kecemasan sedang. serta terjadi kecenderungan penurunan intensitas nyeri persalinan dalam menghadapi proses kelahiran bayi. 37 efektivitas dzikrullah terhadap penurunan kecemasan dan nyeri persalinan (irma nurbaeti) saran bimbingan rohani diperlukan bagi ibu sejak pada periode antenatal, dan diteruskan sampai pada saat persalinan dengan intervensi berdzikir bagi ibu dengan agama islam disertai dengan intervensi yang selama ini telah r utin dilakukan. inter vensi dzikir tersebut perlu dikembangkan dengan media lain menggunakan teknologi tepat guna untuk mempertahankan keberlanjutan intervensi. kepustakaan alqur’an terjemahan. kementrian agama ri. andriana, 2007. melahirkan tanpa rasa sakit. jakarta: pt buana ilmu populer batbual, b. 2010. hypnosis hypnobirthing nyeri persalinan dan berbagai metode penanganannya. yogyakarta: gosyen publishing. bijur pe, silver w, gallagher j. 2001. reliabilit y of the visual a nalog scale for measurement of acute pain. academic emergency medicine, 8: 1153–7. bobak, lowdermilk and perry, 2009. maternity and women’s health care. st. louis: mosby company. darwanti, handoyo, dan kamaludin, 2007. bimbingan rohani dan pengaruhnya terhadap penurunan tingkat kecemasan p a d a i b u p r i m ig r av id a d e n g a n persalinan kala i di rsu banyumas. jurnal keperawatan soedirman (the soedirman journal of nursing), volume 2, no. 1, 48–54. doengoes, m.e, 2010. rencana perawatan maternal/bayi. jakarta: egc. hacker & moore. 2001. esensial obstetri dan ginekologi. (edisi 2). jakarta: hipokratus. kalat, j.w. 2007. biological psycholog y. california: thomson learning, inc. kaplan & sadock. 1997. sinopsis psikiatri. (edisi ketujuh). jakarta: bina rupa aksara. manuaba, i.b.g. 1998. ilmu kebidanan, penyakit, kandungan dan keluarga berencana untuk pendidik bidan. jakarta: egc. maimunah, annisa dan retnowati, sofi a, 2011. pengaruh program pelatihan relaksasi denga n dzi k i r u nt u k mengat asi kecema sa n i bu ha m il pe r t a ma , psikoislamika, jurnal psikologi islam (jpi), 8(1). 2011 1-22 marpaung, lm, 2011. gambaran kecemasan d a n n ye r i p e r sa li n a n p a d a ib u primigravida di klinik bersalin sally medan tahun 2011. usu digital library. skripsi. tidak dipublikasikan. pot ter & pat r icia, a. 2005. buku ajar fundamental keperawatan: konsep, proses dan praktik. volume 1. (edisi 4). jakarta: egc. sa r wono. 20 01. buk u ac uan na sional pelayanan kesehatan maternal dan neonatal. ja ka r t a: yayasa n bi na pustaka. sholeh, m. 2010. terapi shalat tahajjud: menyembuhkan berbagai penyakit. jakarta: hikmah, pt. mizan publika. simkin, p dan bolding, a, 2010. update on nonpharmacologic approaches to relieve labor pain and prevent suffering. journal of midwifery and women’s health, 49 (6), 489–504. subandi, m.a. 2009. psikologi d zik ir. yogyakarta: pustaka pelajar. tabachnick, g. g., and fidell, l. s. 2007. experimental designs using anova. belmont, ca: duxbury. yonne a, nurbaeti i, dan rosidati c, 2009. hubungan karakteristik ibu hamil trimester iii dengan kecemasan dalam menghadapi persalinan di poliklinik dan kandungan, majalah keperawatan unpad, 10(19), 21–29. 7 peningkatkan kualitas hidup pasien kanker dengan implementasi perawatan kesehatan psikoseksual (improving quality of life on cancer patient by implementation of psychosexual health care) yati afiyanti*, budi ana keliat**, ida ruwaida***, imami nur rachmawati*, nur agustini**** * maternity & women’s health nursing, faculty of nursing, university of indonesia **psychiatric nursing, faculty of nursing, university of indonesia ***faculty of sociology, university of indonesia ****child nursing, faculty of nursing, university of indonesia, indonesia email: yatikris@ui.ac.id abstrak pendahuluan. kontribusi perawat dalam meningkatkan kualitas hidup pasien kanker menyebabkan perawat harus memiliki pengetahuan dan ketrampilan dalam memberikan asuhan keperawatan dalam aspek kesehatan psikoseksual. pelatihan perawatan kesehatan psikoseksual telah dikembangkan, diimplementasikan, dan diberikan kepada perawat onkologi di indonesia untuk memenuhi kebutuhan tersebut sehingga perawat dapat memberikan perawatan kesehatan psikoseksual terhadap penderita kanker dan pasangannya. metode. pelatihan menggunakan metode pre dan post test untuk mengidentifikasi hasil serta perubahan skor dalam mengevaluasi pengetahuan, keyakinan, tindakan, kepercayaan diri dari peserta sebelum dan setelah pelatihan. hasil. pelatihan diberikan pada 46 perawat onkologi di indonesia. setelah pelatihan dan pendampingan didapatkan perubahan yang signifikan pada pengetahuan, keyakinan, kepercayaan diri dalam memberika n perawatan kesehatan psikoseksual pada pasien kanker dan pasangannya, namun tidak terdapat perbedaan yang signifikan pada aspek tindakan. diskusi. pelatihan tersebut telah menjadi standar asuhan keperawatan di indonesia untuk perawatan pasien kanker dan telah menunjukkan bukti yang ilmiah bahwa perawat memang berkontribusi dalam meningkatkan kualitas hidup pasien kanker dengan memberikan asuhan keperawatan yang komprehensif melalui implementasi perawatan kesehatan psikoseksual pada pasien kanker dan pasangannya. kata kunci: perawatan kesehatan psikoseksual, pelatihan, keperawatan, kanker abstract introduction: the contribution of nurses in improving the quality of life of patients with cancer has caused them to have needs of getting knowledge and skills to provide services on psychosexual health care. training on psychosexual health care has been developed, implemented and given to oncology nurses in indonesia in order to fulfill the needs so that the nurses are able to provide psychosexual health care to cancer survivors and their spouse. method: the training utilized a method of preand post-test evaluation to identify outcomes including changes of evaluation scores of knowledge, belief, practice, and self-efficacy of trainees before and after receiving psychosexual health care training. result: the training has been implemented on 46 oncology nurses in indonesia so that they can have knowledge, practice, belief and self-efficacy in providing psychosexual health care to patients with cancer and their spouse. after training and mentorship had been provided, there were significant changes on knowledge, belief and self-efficacy in providing psychosexual health care services to patients with cancer and their spouse; however, there were no significant changes on practices. discussion: the training has become a standard nursing care for cancer in indonesia and has provided scientific evidences that nurses have contribution in improving quality of life of patients with cancer by providing a comprehensive nursing ca re through implementation of psychosexual health care in their daily nursing care for patients with cancer and their spouse. keywords: psychosexual health care, training, nursing, cancer introduction cancer may affect the quality of life of patients with cancer. various physical, psychological and sexual problems may be encountered by patients with cancer, either caused by the diagnosis of cancer itself or as a result of cancer therapy. psychosexual problems may give bad impacts of diminished social relationship of the patients with their family, spouse and community. for example, some studies on various experiences of cervical cancer survivors reported that the survivors had experienced various psychosexual problems, which caused bad impact on their quality of life (greenwald & mccorkle 2007; klee, m. et al. 2000; wenzel, l. 2005; burns et al. 2007). the patients’ social life including the intimacy with their spouse and playing the role as housewives, which is no longer perfect may bring risk of role dysfunction and may jeopardize family life. the problems are not easy to be solved by the patients themselves or by the mailto:yatikris@ui.ac.id jurnal ners vol. 11 no. 1 april 2016: 7-16 8 cancer survivors and their spouse. they need nurses and other health care personnel to manage psychosexual problems during and following cancer treatment (hughes 2009; p.t et al. 2003). survivors of cervical cancers and their spouse need help from health care personnel, especially nurses, to overcome the problems (gamel et al. 2000; afiyanti & milanti 2013; powell et al. 2008; de groot 2005). providing psychosexual health care is one of important roles for nurses who work at a cancer unit. nurses play active roles to provide assistance in managing psychosexual problems in patients with cancer. the role of nurses in providing psychosexual services including developing a professional trust to empower the patients so that they can discuss their sexual problems, performing sexual evaluation review, managing sexual counseling as well as providing information and emotional support (higgins et al. 2006; s & yoder 2009; risen 1995; moore & higgins 2009). nevertheless, there is only a small number of nurses who have contributed their assistance on psychosexual problems in patients with cancer (kautz et al. 1990; gamel et al. 1995; cort 1998; guthrie 1999; butler & banfield 2001; magnan et al. 2005), including the nurses for cancer patients in indonesia. most nurses have various obstacles to provide health care services associated with psychosexual problems. various studies reported that nurses have limitations on knowledge and communication skills to discuss psychosexual problems; moreover, they also have lack of knowledge on the sexuality concept. an interview with some nurses has identified that no nurse has optimally provided education and counseling in managing psychosexual health problem of patients following the cancer treatment. even if they did have given some explanation about it, the explanation was only a brief message to the patients. various problems such as lack of knowledge and skills about sexual education and counseling, reluctance on promoting sexual health, shyness to talk about sexuality and a taboo culture to have discussion about sex are obstacles for oncology nurses in indonesia to provide a holistic nursing care for patients with cancer. nurses need to be provided with knowledge and skills so that they can offer their assistance for cancer survivors and their spouse (personal communication with oncology nurses, october, 2013). similar problem has also been reported by previous studies, which reported that the nurses felt embarrassed and uncomfortable when discussing sexual issues with their patients and they did not have knowledge to provide counseling on sexual problems (gamel et al. 1995; cort 1998; guthrie 1999; magnan et al. 2005; tsai 2004). due to such limitations, many nurses have inappropriate perception on sexuality concept and assume that sexual problems are not important to be discussed and they do not feel comfortable to discuss sexual problems with the patients (kotronoulas, g et al. 2009; quinn 2003; stead et al. 2003; hughes 2009; hautamaki et al. 2007). nursing interventions have been developed overseas to provide assistance in managing psychosexual problems. the interventions include sexual counseling, providing information on sexual health, sexual education and rehabilitation for patients with heart diseases and standard sexual health care services to help overcoming sexual problems and promoting health sex for patients with cancer and those with heart diseases (gamel et al. 2000; maughan & clarke 2001; wilson & williams 1988; webb 1988; shuman & bohachuck 1987). a pilot study conducted by joint board of clinical nursing studies has also successfully hold a kind of training associated with principles of psychosexual counseling for nurses and midwives, which aimed to train nurses and midwives to identify and provide constructive responses on various psychosexual issues of their patients in their daily practices (irwin 2006). while in indonesia, no training was available to train nurses that enable them to perform an evaluation or intervention to manage psychosexual problems of their patients. such training is necessary for oncology nurses in indonesia so that they can have a contribution to provide assistance in managing psychosexual problems of their patients (personal communication with my, dw, an, yt, and m, oncology nurses, october, 2013). moreover, there is lack of knowledge and practice by oncology nurses in indonesia regarding psychosexual problems experienced by cancer survivors. it can restrain the development of researches and applied peningkatan kualitas hidup pasien kanker (yati afiyanti, dkk.) 9 clinical practice of psychosexual health care in indonesia. until now, nursing care in indonesia has no standard health care services to promote psychosexual health care services for patients; therefore, comprehensive nursing care conducted by nurses in indonesia has not been optimal. this article focuses on evaluation of psychosexual health care training, which has been developed, implemented and given to oncology nurses so that they are able to provide psychosexual health care service to help cancer survivors and their spouse to overcome their psychosexual problems. training materials, various activities during the training and the results of training are explained in this article, including discussion and various implication of nursing care associated with the results of training. materials and method approaches and development on psychosexual health care psychosexual aspect and its various problems has been identified as one of components in nursing care in the area of cancer nursing care. a holistic nursing care incorporates giving concern on psychosexual aspects for patients and their spouse. psychosexual health care services provided by a nurse may include performing evaluation on sexuality aspects, establishing diagnosis on sexuality problem, providing interventions on psychosexual problems and evaluating outcomes of interventions on sexuality problems. as health care personnel who provide a holistic / comprehensive care for the patients, nurses should have knowledge and understanding about psychological and sexual aspects of their patients who have cancer. they should identify information of various available sources, applying standard of practice and developing clinical skill to provide routine questions in association with psychosexual aspects of their clients when performing clinical assessment. providing intervention of psychosexual nursing care has been proven empirically to give improvement on psychosexual problems as complained by the cancer survivors. it has been reported by previous studies that providing intervention of sexual education and counseling following cancer treatment can reduce psychosexual problems and may improve harmonic relationship / the relationship of the patients or survivors with their spouse following cancer treatment. (afiyanti et al. 2011; jeffries. s.a. et al. 2006; powell et al. 2008). psychosexual health care provides supports for patients and their spouse through empowerment program so that they can discuss their psychosexual problem. the service also provides information for education, emotional supports, specific counseling to manage sexual dysfunction due to side effects of cancer treatment, helping patients and their spouse to adapt against physical and psychological changes and restoring the belief for women following cancer treatment (jun et al. 2011; moore & higgins 2009). information, education and counseling on improving sexual health have become something that needed by patients and their spouse following cancer treatment. it has been proven by a study conducted by (de groot 2005; jun et al. 2011) reported that patients and their spouse needed explanation about improved sexual relationship following cancer treatment. other studies have provided scientific evidences that intervention on counseling education may improve complaints of sexual dysfunction, reducing anxiety and depression, which finally may lead to increased quality of life in women following treatment of cervical cancer (brotto et al. 2008; powell et al. 2008). a cross-sectional study evaluating perception of nurses about their roles on promoting sexual health (butler & banfield 2001) reported that the majority of nurses suggested that sexuality is a part of practice in nursing care; although their knowledge, belief and responsibility have not fully reflected those issues. about 65% of them have played their role in discussing sexual health and only 15% have reported that they have never provided sexual health education to their patients. investigators the study has affirmed their limitation of study associated with unrepresentative sample problem. quinn (2003) in his study has found that the nurses admitted their lacking of experience, knowledge and skills in providing information and counselling for sexuality in patients with cancers. they indicated that they felt embarassed and fear to make mistakes in providing information on sexuality and cancer although the sexual review has already in jurnal ners vol. 11 no. 1 april 2016: 7-16 10 complete format. while a study by bruno (2003) demonstrated that about 61% nurses have never given any explanation about the effect of chemotherapy associated with the effect on reduced fertility. about 73% nurses did not explain the effect of chemotherapy on reduced sexual desire and early menopause symptoms as or following the effect of chemotherapy. various obstacles had been mentioned by nurses in the study including lack of knowledge of the nurses on chemotherapy effect and the patients had never talked about sexual issues to the nurses. psychosexual health care training for indonesian nurses psychosexual health care training is a trial and part of applied psychosexual health care services model that will be continuously developed in further studies. the final outcome of the training is to produce skilled nurses in providing psychosexual nursing care. the aim of this training was to provide education on knowledge, belief, clinical practice and skills to increase for the nurses in providing practices on psychosexual health care so that they can share their contribution in increasing the quality of life of patients with cancer in indonesia. furthermore, the objectives of the training were (1) to identify knowledge, belief, skills and self-efficacy of oncology nurse in managing psychosexual problems experienced by patients with cancer ; (2) to provide knowledge and to develop belief in order to establish psychosexual health care services ; (3) to practice clinical nursing skills and practice so that they can provide psychosexual health care services ; (4) t o increase self-efficacy of the nurses in providing psychosexual health care services. the method was competency-based training, i.e. the participants were expected to have competence for oncology nurses after completed the training including competence in providing psychosexual health care services. the process was performed by structured and group training thorugh interactive lectures, sharing nursing experiences, discussion, question and answer session, story-telling, training on communication skills, training on cases that had been proposed by the investigators, training on real cases (patients with cancer) and feed back bay trainers and facilitators. moreover, after the training had been completed, a mentorship process was performed by facilitator and it was reevaluated to assess the clinical skills of participants after 3 weeks of training. the material of training was presented in two modules developed by the investigators, i.e. a psychiatric nurse, a women’s health nurse and a sociologist who has expertise in gender and women sexuality studies. the first module contained study material about cancer, psychosexual problems and the role of nurses in providing psychosexual health care services to patients and their spouse. in addition, the second module contained material about standard nursing care on psychosexual problem. the training was provided by the investigators. training material was developed according to the need of nurses and it was referred to results of objective measurement on the first stage, which was enriched by additional material such as effective communication skills and techniques, the method of doing interview to discuss about sexuality topics, and the method of documenting services that had been given. plissit model, which is a conceptual framework, was given in the training to teach participants about providing nursing intervention for sexual dysfunction problem. utilization of plissit model needs a right and appropriate interpersonal communication skills performed by the nurses. the model was developed by annon (1974) which is more commonly known as the sexual counseling model. this model facilitates the discussion between nurses and their patients on sexual problems experienced by the patients. plissit model has been widely and systematically utilized by health care personnel including general and specialized nurses to help their patients to overcome or at least to minimize sexual dysfunction problem and psychosocial problems of patients with cancer. the trainings needed five days consisted of 6 class sessions or 3 lecture days and 4 sessions for practice, both in class through case simulation session or direct real cases; therefore, the total time needed for training was 35 hours. the trainings were performed in the class room, in the ward and outpatient clinic of each hospital where the participants were working. the media that have been used during training were module books containing training material and work books, which were used for training and evaluating the progress peningkatan kualitas hidup pasien kanker (yati afiyanti, dkk.) 11 of nursing practice. in addition to the books, other media used for trainings were power point slides which had been prepared by the trainers and other supporting materials such as lcd, laptop, white board, writing board and flipchart paper. the activity of each session was initiated by sharing previous experiences, which were associated with the material and it was followed by explaining and discussing material through discussion session or question and answer sessions. the participant of trainings were obliged to practice their clinical skills through direct practice (at the last day of training) for a patient with cancer after the lectures and case simulation practices had been completed. the results of trainings were reported in their log book. the facilitators monitored the training process in the ward or outpatient clinics. facilitators also helped participants when there was any problem during the training. method this study was conducted to evaluate a psychosexual health care training which had been given to nurses by transferring the learning process of knowledge, practices, belief and self-efficacy to the participants of the training. the nurses were expected to perform nursing intervention in helping cancer survivors and their spouse so that they can overcome psychosexual problem. the training used evaluation method of preand post-test to find final outcome which included changes on evaluation scores of knowledge, belief, practice, and self-efficacy of the participants before and after psychosexual health care training. the outcome for knowledge was measured by knowledge test in multiple choice questions. the outcomes for belief, self-efficacy and practice were measured by self-reported scale, which were done during the training and within 3 weeks after training. this study also had been granted ethical clearance from ethical commission at faculty of medicine, university of indonesia. data collection data collection was performed through trainings and mentorships between june and october 2013. trainings and mentorships were hold at the hospital where the participant nurses were working. participants of trainings were oncology nurses who provide nursing care for patients with cancer, either for those who were having treatment at the outpatient clinics or who were hospitalized in the wards. participants of training filled in questionnaires containing questions about knowledge, belief, practice and self-efficacy about providing psychosexual health care services before participating in the training (pre-test). furthermore, the questionnaires were filled in again after the trainings and mentorship (posttest). the training was conducted by three investigators; while mentorships were performed by facilitators that had been trained by the investigators team. measurement measurement of the nurses’ knowledge in this study was developed from module material. the knowledge test contained of 13 items of multiple choice questions. each item had 5 alternative answers and participants were asked to select the best answer for each question. the measurement of belief was developed from the sexual attitudes and beliefs survey (sabs), which had been translated into indonesian language. question items for measuring the belief of training participants developed from the sabs item were modified by the investigator team into 14 questions. training participants responded the belief items using a 5 point likert scale with answer options of: strongly disagree, disagree, neither agree nor disagree, agree, strongly agree. the cronbach’s alpha value of 0.70. (n=135). the measurement of self-efficacy was evaluated using 5 question items developed by the investigators. the items of self-efficacy measured confidence state of participants in providing psychosexual health care services. an example of item for measuring selfefficacy: ―i feel confident with my ability to discuss about patient’s sexuality problem.‖ training participants responded the selfefficacy items using a 5 point likert scale with answer options of: strongly disagree, disagree, neither agree nor disagree, agree, strongly agree. the measurement of nursing practice was evaluated using 11 question items developed by the investigators. the question items about the practice measured daily nursing practice in providing nursing care associated with the presence or absence of evaluation and intervention on the patient’s psychosexual jurnal ners vol. 11 no. 1 april 2016: 7-16 12 problem. an example of item for measuring practices: ―i provide opportunity for patients to talk about their sexuality problems,‖ training participants responded the practices items using a 5 point likert scale with answer options of: strongly disagree, disagree, neither agree nor disagree, agree, strongly agree. participants the inclusion criteria of participants who could take part in the training were those who had been working as oncology nurses for at least 2 years at an oncology unit and those who had education level of at least diploma in nursing. about 46 cancer / oncology nurses from 3 hospitals specialized in cancer services in jakarta had been participated in the training. the mean age of participants was at range of 31 – 50 years and most of them were female nurses (91.3%). about 54% of participants had education level of nursing diploma and 87% of participants had working experiences of approximately 4 years, either as a general nurse or oncology nurse. result table 1. characteristics of the participants (n=46) variables % age 20 30 17.4 31 40 50.0 41 50 30.4 51 – 55 2.2 sex male 8.7 female 91.3 levels of nursing education diploma in nursing 54.3 bachelor of nursing 8.7 master of science in nursing 37.0 working experiences as a nurse 1 4 year(s) 13.0 4 > years 87.0 working experiences as a nurse at a cancer unit < 1 year 8.7 1 4 year(s) 4.3 > 4 years 87.0 table 2 reports that there were significant statistical changes or increase of each measurement regarding knowledge, belief and self efficacy. however, no significant change had been found for the score of practices following the training. the mean score on the aspect of participants’ knowledge after training and mentorships was significantly higher (76.94 ± 8.25) compared to before training (51.78 ± 13.75). the p value of 0.000 indicated that there was a significant difference of score changes regarding the nurses’ knowledge before and after training on sexuality concept as well as on the method of doing evaluation and intervention for psychosexual health care services. the mean score on the aspect of participant’s belief in providing psychosexual health care services after training and mentorships was significantly higher (49.63 ± 4.73) compared to before training (49.28 ± 5.02). the p value of 0.008 indicated that there was significant difference on score changes of the nurses’ belief before and after training. the mean score on the aspect of participant’s selfefficacy after training and mentorship was significantly higher (14.76 ± 2.64) compared to before training (14.43 ± 2.79). the p value of 0.000 indicated significant difference on score changes of the nurses’ self-efficacy before and after training. the mean score on the aspect of participant’s practices after training and mentorship was significantly higher (26.89 ± 4.29) compared to before training (26.65 ± 4.26). the p value of 0.062 showed that there was no significant difference on score changes of the nurses’ practice before and after training. discussion the study results reported that the psychosexual health care training has successfully transferred knowledge and trained the participants to have ability in providing psychosexual health care services for patients with cancer and their spouse. the study material included topics on cancer, psychosexual problems and the role of nurses in providing psychosexual health problem for patients and their spouse. it has successfully provided knowledge and affirmed belief for participants that they have professional role as nurses to manage psychosexual problems experienced by the patients with cancer. moreover, the activity of practicing standard nursing care to overcome the patients’ psychosexual problems that had been given in the training has successfully increased self-efficacy and provided practice as well as experiences for the participants peningkatan kualitas hidup pasien kanker (yati afiyanti, dkk.) 13 table 2. mean value of differences on knowledge, practices, belief and self-efficacy before and after training (n=46) variables mean sd p value before training after training before training after training belief 49.28 49.63 5.02 4.73 0.008 practice 26.65 26.89 4.26 4.29 0.062 self-efficacy 14.43 14.76 2.79 2.64 0.017 nurses’ knowledge 51.78 76.94 13.75 8.25 0.000 when dealing with psychosexual problems of patients with cancer. following the training, there were changes on measurements of knowledge, belief, and practice. improved knowledge gives positive and significant effect to the participants to understand about the method of discussing and evaluating patients’ psychosexual problems and how to provide psychosexual health care services. psychosexual problem is a sensitive problem; therefore the nurses’ knowledge is necessary in evaluating and performing intervention against the patients’ psychosexual problems, which should keep the patient’s privacy; as well as earning the patient’s trust and managing the problem without judging the patients (mick et al. 2004; mick 2007; schain 1988). the participants had also learned communication skills or method of discussing sexuality problems with their patients such as how to practice empathy and provide motivation for their patients so that they can manage the psychosexual problem. difficulty in discussing sexual problem is one of obstacles for nurses in providing a comprehensive nursing care for patients with cancer (hautamaki et al. 2007; hordern & street 2007). therefore, in this training, the participants received knowledge and skills about how to discuss sexuality problems with their patients. moreover, they also have received knowledge about providing intervention using plissit model although to apply the model in daily practice, they still need to frequently use the mode in their daily practices with their other patients. the aspect of belief should be hold by the nurses in discussing sexuality with their patients. the training affirmed the participants to hold on belief that sexuality problem is not a taboo to be discussed with the patients and they should believe that patients with cancer have sexuality problems that need assistance from their nurses to manage the problem. moreover, the training participants of this study have also focused to hold a belief that evaluating and discussing the patients’ sexual problems is part of their professional role and responsible as nurses. as has been mentioned by many experts in nursing care, helping patients to discuss their sexual problems is part of the nurses’ role to provide a holistic nursing care, including recognizing other various psychosexual issues experienced by patients with cancer and their spouse (royal college of nursing 2000; higgins et al. 2006; s & yoder 2009; irwin 2006; haboubi & lincoln 2003). furthermore, on the aspect of selfefficacy, the participants have also shown improvement. after the training, the participants had good confidence to discuss about their patient’s sexuality problem and did not encounter any difficulty in discussing psychosexual problems with their patients. however, the participants have not shown significant results on score of clinical practice and skills after the training. this may occur since the participants had not been used to the techniques and they still need time to apply their various knowledge and skills from the training into their daily practice when providing nursing care for patients with cancer. in general, this training may fulfill the needs of participants to acquire knowledge, belief, self-efficacy and practice in providing psychosexual health care services, which have been regarded as a taboo and uncomfortable topic to be discussed with the patients. improved knowledge, practice and selfefficacy and improved belief of the nurses in providing psychosexual health care services after having training and mentorship may contribute to increase quality of life of the patients and their spouse by providing the necessary psychosexual health care services for the patients with cancer and their spouse. jurnal ners vol. 11 no. 1 april 2016: 7-16 14 the results of training in this study may become the means in giving knowledge, belief and skills for oncology nurses in indonesia as a contribution to provide psychosexual health care services for patients with cancer. evaluation of the training may become one of applied psychosexual health care services in clinical setting of oncology nursing care in indonesia. moreover, the results of the training may become a prototype model for applied nursing care in indonesia to achieve national standard in health care services in promoting psychosexual health care problems for cancer patients and survivors so that the nurses can provide a comprehensive nursing care to increase the quality of life of patients with cancer. by participating in the training, the participants acquire knowledge and skills to discuss sexual problems with their patients and hold on a belief that performing psychosexual evaluation and intervention is a part of professional roles of the nurses that should be implemented in daily nursing practice. conclusion and recommendation conclusion the results of this study have found effectiveness of training and mentorship for psychosexual health care services as had been participated by 46 nurses of three hospitals providing services for patients with cancer. oncology nurses have a special position to provide psychosexual education and counseling to increase the quality of life of cancer patients and survivors. recommendation something essential should be applied in daily nursing practice, i.e. the nurses need to evaluate and perform intervention on psychosexual problems of patients with cancer at the beginning of interaction by giving permission to every patient with cancer to have comfortable discussion on their psychosexual problems. the results of this training may be adapted as a standard of practice on providing psychosexual health care services in indonesia, particularly in the subject of cancer nursing care. references afiyanti, y., andrijono & d gayatri, 2011. perubahan keluhan seksual fisik dan psikologis pada perempuan pascaterapi kanker serviks setelah intervensi keperawatan. jurnal ners, 6(1), pp.68– 75. afiyanti, y. & milanti, a., 2013. physical sexual and intimate relationship concerns among indonesian cervical cancer survivors: a phenomenological study. nursing and health sciences, 15(2), pp.151–156. annon, j., 1974. the plissit model: a proposed conceptual scheme for the behavioral treatment of sexual problems. journal of sex education therapy, 2(1), pp.1–15. brotto, l.a. et al., 2008. a psychoeducational intervention for sexual dysfunction in women with gynecologic cancer 10th ed., burns, m. et al., 2007. assessing the impact of late treatment effects in cervical cancer: an exploratory study of women’s sexuality. european journal of cancer care, 16, pp.364–372. butler, l. & banfield, v., 2001. oncology nurses’s views on the provision of sexual health in cancer care. journal of reproductive medicine, 1(1), pp.35–39. cort, e., 1998. nurses’ attitudes to sexuality in caring for cancer patients. nursing times, 94, pp.54–56. gamel, c. et al., 1995. factors that influence the provision of sexual health care by dutch cancer nurses. international journal of nursing studies, 32(3), pp.301–314. gamel, c., hengeveld, m. & davis, b., 2000. informational needs about the effects of gynaecological cancer on sexuality: a review of the literature. journal of clinical nursing, 9, pp.678–688. greenwald, h.p. & mccorkle, r., 2007. remedies life change among invasive cervical cancer survivor. urology nursing, 27(1), p.47—53. de groot, et. al, 2005. the psychosocial impact of cervical cancer among affected women and their partners. international journal of gynecological cancer, 15(5), pp.918–925. guthrie, c., 1999. nurses’ perceptions of sexuality relating to patient care. journal of clinical nursing, 8(3), pp.313–321. haboubi, n.h. & lincoln, n., 2003. views of peningkatan kualitas hidup pasien kanker (yati afiyanti, dkk.) 15 health professionals on discussing sexual issues with patients. disability and rehabilitation, 25(6), pp.477–482. hautamaki, k. et al., 2007. opening communication with cancer patients about sexuality-related issues. cancer nursing, 30(5), pp.399–404. higgins, a., barker, p. & begley, c., 2006. sexuality: the challenge to espoused holistic care. international journal of nursing practice, 12(6), pp.345–51. hordern, a.j. & street, a.f., 2007. communication about patient sexuality and intimacy after cancer: mismatched expectations and unmet needs. medical journal of australia, 186(5), pp.224– 227. hughes, m.k., 2009. sexuality and cancer: the final frontier for nurses. oncology nursing forum, 36(5), pp.241–246. irwin, r., 2006. review paper: thirty years of psychosexual nursing. sexual and relationship therapy, 21(4), pp.445– 461. jeffries. s.a. et al., 2006. an effective group psychoeducational intervention for improving compliance with vaginal dilation: a randomised kelompok non intervensiled trial. international journal radiation oncology biology physics, 5, pp.404–411. jun, e.y. et al., 2011. the effect of a sexual life reframing program on marital intimacy, body image, and sexual function among breast cancer survivors. cancer nursing, 34(2), pp.142–149. kautz, d.d., dickey, c.a. & stevens, m.n., 1990. using research to identify why nurses do not meet established sexuality nursing care standards. journal of nursing quality assurance, 4(3), pp.67– 69. klee, m., thranov, i. & machin, d., 2000. life after radiotherapy: the psychological and social effects experienced by women treated for advanced stages of cervical cancer. gynecologic oncology, 76., pp.5–13. kotronoulas, g, papadopoulou, c. & patiraki, e., 2009. nurses’s knowledge, attitudes, and practices reganding provision of sexual health care in patients with cancer: critical review of the evidence. supportive care cancer, 17(5), pp.479– 501. magnan, m.a., reynolds, k.e. & galvin, e.a., 2005. barriers to addressing patient sexuality in nursing practice. medical-surgical nursing, 14(5), pp.282–290. maughan, k. & clarke, c., 2001. the effect of a clinical nurse specialist in gynaecology oncology on quality of life and sexuality. journal of clinical nursing, 10(2), pp.221–229. mick, j., hughes, m. & cohen, m.z., 2004. using better model to assess sexuality. clinical journal of oncology nursing, 8(1), pp.84–86. mick, j.m., 2007. sexuality assessment: 10 strategies for improvement. clinical journal of oncology nursing, 11(5), pp.671–675. moore, a.m. & higgins, a., 2009. testicular cancer: exploring the psychosexual issues. british journal of nursing, 18(19), pp.1182–1186. p.t, j. et al., 2003. early stage cervical carcinoma, radical hysterectomy and sexual function. cancer, 100(1), pp.97– 106. powell, c.b. et al., 2008. a randomized study of the effectiveness of a brief psychosocial intervention for women attending a gynecologic cancer clinic. gynecologic oncology, 111, pp.137– 143. quinn, b., 2003. sexual health in nursing care. nursing times, 99(4), pp.32–34. risen, c.b., 1995. a guide to taking a sexual history. psychiatric clinics of north america, 18(1), pp.39–53. royal college of nursing, 2000. sexuality and sexual health in nursing practice, london. s, b. & yoder, l., 2009. the medical-surgical nurse’s guide to testicular cancer. medical-surgical nursing, 18(2), pp.116–123. schain, w., 1988. a sexual interview is a sexual intervention. innovations in oncology nursing, 4(4), pp.2–3.15. shuman, n.a. & bohachuck, p., 1987. nurses’ attitudes towards sexual counseling. dimensions in critical care nursing, 6(2), pp.75–81. stead, m.l. et al., 2003. lack of communication between healthcare professionals and women with ovarian cancer about sexual issues. british jurnal ners vol. 11 no. 1 april 2016: 7-16 16 journal of cancer, 88(5), pp.666–671. available at: http://www.nature.com/doifinder/10.103 8/sj.bjc.6600799. tsai, y.g., 2004. nurses facilitators and barriers for taking a sexual history in taiwan. applied nursing research, 17(4), pp.257–64. webb, c., 1988. a study of nurses’s knowledge and attitudes about sexuality in health care. international journal of nursing studies, 16(6), pp.677–688. wenzel, l., et. al., 2005. quality of life in long-term cancer survivors. gynecologic oncology, 97, pp.310–317. wilson, m.e. & williams, h.a., 1988. oncology nurses’ attitudes and behaviours related to sexuality of patients with cancer. oncology nursing forum, 15, pp.49–53. ners vol 10 no 1 april 2015.indd 80 sistem diagnosa level asma menggunakan fuzzy inference system (the level of asthma diagnosing system by using fuzzy inference system) kholida hanum*, subiyanto* *teknik elektro, universitas negeri semarang, kampus sekaran gunungpati, semarang email: kholida.hanum@gmail.com abstrak pendahuluan: tulisan ini membahas tentang fuzzy inference system untuk proses diagnosa level asma. proses diagnosa dilakukan dari gejala-gejala yang timbul pada penderita asma. proses input, hasil, serta metodologi dalam pembuatan sistem dikerjakan dengan fokus dan teliti, sehingga sistem ini diharapkan valid dan layak digunakan untuk diagnosa medis. metode: metodologi dalam sistem meliputi knowledge base, fuzzyfi er, inference engine. dengan gejala yang digunakan pada diagnosa sistem antara lain sesak napas, mengi, tingkat kewaspadaan/gejala unik, tingkat pernapasan, tingkat bicara, denyut nadi/menit, serta pef setelah bronkodilator. dan hasil keluaran dari diagnosa yaitu level asma yang diderita pasien dari ringan, sedang, berat hingga rai/gagal napas. kinerja sistem telah diuji di rumah sakit pertamina cilacap dengan 20 pasien penderita asma. perbandingan antara hasil sistem dan ahli medis atau dokter yang telah menangani pasien asma. hasil: dari hasil uji sistem didapatkan 90% sesuai dengan diagnosa dokter. diskusi: sistem ini diharapkan dapat membantu ahli medis atau dokter dalam membantu diagnosa level asma pada pasien. kata kunci: fuzzy inference system, diagnosa, level asma abstract introduction: this paper discuss about fuzzy inference system for the diagnosis of asthma’s levels. the process of diagnosis was made from symptoms that occur in patients with asthma. input process, results, and methodology in making this system was done carefully, so this system is expected valid and fi t for medical diagnosis. method: methodology in the system including the knowledge base, fuzzyfi er, and inference engine. the symptoms used in diagnostic systems, including shortness of breath, wheezing, level of alertness/unique symptoms, respiratory rate, speech rate, pulse per minutes, and pef after bronchodilator. and the output of asthma’s level diagnosis was mild, moderate, severe, and rai/respiratory failure. the performance of system has been tested in cilacap pertamina hospital, 20 patients with asthma were involved. the results of system and doctor’s opinion who has been treating patients with asthma were compared. result: the result showed that the system obtained 90%, according to the doctor’s diagnosis. discussion: this system is expected to help the medical expert or doctor in diagnosing the level of asthma. keywords: fuzzy inference system, diagnosis, level of asthma pendahuluan asma dapat mempengaruhi kualitas hidup serta beban sosial ekonomi. asma mempunyai tingkat fatalitas yang rendah, tetapi kasusnya cukup banyak di negara dengan pendapatan menengah ke bawah. world health organization (2013) memperkirakan 235 juta penduduk dunia saat ini menderita asma dan jumlahnya diperkirakan akan terus bertambah. apabila tidak dicegah dan ditangani dengan baik, maka diperkirakan akan terjadi peningkatan prevalensi di masa yang akan datang (depkes ri, 2009). pengetahuan mengenai asma sangat penting dalam mencapai kontrol asma. pasien dan keluarga pasien yang memahami asma dengan baik secara sadar akan menghindari faktor-faktor pencetus serangan, menggunakan obat secara benar dan berkonsultasi kepada dokter secara tepat. selain memberikan mot iva si ke pa d a pa sie n , kebe rha sila n pengobatan juga ditentukan oleh pemberian obat-obatan yang tepat dan diikuti pemberian pengetahuan tentang penyakit asma dan penatalaksanaannya (eder, dkk., 2006). teknologi dan ilmu sangat memudahkan seorang ahli medis unt uk mendapatkan informasi, berdasarkan peneliti terdahulu bahwa sistem cerdas perawatan kesehatan telah berkembang dengan mempercepat laju untuk mengatasi masalah dalam pelayanan medis (stefanelli, 2001). 81 sistem diagnosa level asma (kholida hanum dan subiyanto) menurut naba (2009), logika fuzzy telah menjadi area riset yang mengagumkan karena kemampuannya dalam menjembatani bahasa mesin yang serba presisi dengan bahasa manusia yang cender u ng tidak presisi serta menekankan pada makna atau arti. bisa dibayangkan bahwa sistem fuzzy adalah sebuah mesin penerjemah bahasa manusia, sehingga bisa dimengerti oleh bahasa mesin dan juga sebaliknya. steimann dan adlassnig (2001), telah menyajikan kasus yang kuat untuk menggunakan fuzzy set untuk mendukung metode heuristik diagnosis berdasarkan menempatkan penekanan utama pada ketidakpastian informasi dalam proses. logika fuzzy telah diaplikasikan dalam bidang kedokteran, yang didalamnya terdapat ketidakpastian. bidang kedokteran merupakan contoh permasalahan untuk aplikasi logika fuzzy, karena terdapat ketidakpastian, ketidak tepatan pengukuran, keanekaragaman dan subjektivitas yang secara jelas hadir dalam melakukan diagnosa medis. logika fuzzy menyediakan metodelogi untuk model ketidakpastian pada pemikiran, situasi, alasan. dalam model klasik variabel memiliki nilai-nilai bilangan real, hubungan didefi nisikan dalam hal fungsi matematika dan output adalah nilai-nilai numerik yang disebut dengan crisp. logika fuzzy memiliki variabel yang mempengaruhi proses suatu dan hubungan antara variabel-variabel yang menggambarkan sistem. dalam logika fuzzy, nilai-nilai dalam variabel dinyatakan oleh istilah-istilah linguistik seperti besar, sedang dan kecil. hubungan didefinisikan dalam istilah jika-maka aturan dan output adalah subset fuzzy yang dapat dibuat crisp dengan menggunakan teknik defuzzifi cation. nilai-niai crisp pada variabel sistem fuzzifi kasi untuk mengekspresikan istilah linguistik. fuzzifi kasi adalah mengubah masukan-masukan yang nilai kebenarannya bersifat pasti (crisp input) ke dalam bentuk fuzzy input (alavi, 2013). zadeh (1965) memperkenalkan teori fuzzy, teori ini mengusulkan pembuatan fungsi operasi pada bilangan nyata. operasi baru untuk perhitungan fungsi keanggotaan logika yang diusulkan dan menunjukkan untuk menjadi alat yang wajar untuk generalisasi logika klasik. menggunakan variabel linguistik dan hubungan matematika dalam teknik ini dapat memberikan hasil yang cukup jelas. sistem fuzzy menyediakan sarana dalam mewakili pengetahuan pakar tentang proses dalam rule fuzzy ‘if-then’. rule fuzzy merupakan dasar untuk memahami pengetahuan tentang fuzzy. rule fuzzy itu seperti rule pada sistem cerdas, yang mempunyai dua komponen yaitu ‘if’ dan ‘then’. sugeno dan mamdani mer upakan dua jenis fuzzy inference system yang dapat diimplementasikan pada toolbox matlab (mathworks, 2004). ketika output fungsi keanggotaan fuzzy, mfis adalah metodelogi fuzzy yang sering digunakan (mazloumzadeh, et al., 2008). pada mfis merupakan salah satu jenis fuzzy inference system, selain pengetahuan basis dan fuzzy inference engine, serta fuzzyfier yang mengubah output ke crisp. bahan dan metode proses pengetahuan dapat dilakukan denga n berbagai ma ca m jala n , ya k n i penget a hu a n d a r i pa k a r, bu k u , ju r nal ilmiah, laporan dan sebagainya. sumber pengetahuan tersebut dik umpulkan dan kemudian direpresentasikan kedalam basis pengetahuan menggunakan kaidah jika–maka (if–then). metode logika fuzzy mencakup fuzzyfi er, dan inferensi. berikut mekanisme dasar aliran informasi logika fuzzy yang telah penulis modifi kasi dari pena-reyes & sipper (1999). yang akan diterapkan dengan diagnosa gejala dari zolnoori (2012) dan metode fuzzy mamdani dari kusumadewi dan purnomo (2010). komponen yang terdapat pada logika fuzzy, adalah sebagai berikut: 1) knowledge base; 2) fuzzifi er: dan 3) inference engine. knowlegde base 1. database: berisi tentang rekap medis data pasien. hal tersebut juga mencakup informasi tentang keluhan yang diderita pasien seperti yang ditangkap oleh ahli medis. 2. rule base: yang berisi aturan-aturan yang mendefi nisikan hubungan antara input dan output variabel fuzzy. 82 jurnal ners vol. 10 no. 1 april 2015: 80–86 gambar 1. arsitektur sistem inferensi fuzzy tabel 1. d i a g n o s a g e j a l a l e v e l a s m a zolnoori gejala/symptom values fuzzy interval sesak napas ringan 0-3 sedang 2-7 berat 5-10 mengi tanpa mengi 0-1 ringan 0-4 sedang 2-7 berat 6-10 kesadaran normal 0-3 gelisah 2-7 bingung 6-10 tingkat pernapasan ringan 0-3 sedang 2-6 berat 4-10 tingkat berbicara kalimat 0-3 frase 2-7 kata 5-9 tidak dapat bebicara 8-10 denyut jantung/ menit ringan 0-3 sedang 2-7 berat 5-8 pef setelah bronchodilator 80-100% 75-100 60-80% 55-85 rule pada level asma ada empat, dan salah satu contoh level asma sedang adalah: sesak is sedang, mengi is sedang, kesadaran is gelisah, tingkat pernapasan is sedang, tingkat bicara is frase, denyut nadi/menit is sedang, pef is 60–80%. dokter biasanya mengevaluasi tingkat keparahan asma didasar pada dua kelas data, kelas gejala dan kelas laboratorium data. berkenaan dengan masalah mengakses data laboratorium dalam pengaturan perawatan primer, atau bahkan rumah sakit, khususnya di negara-negara berkembang, fokus variabel dalam pengetahuan akan berada di kelas gejala. sejak beberapa pasien dapat mengakses dengan nilai-nilai pef, variabel ini dianggap sebagai masukan opsional (zolnoori, 2012). fuzzyfi er s e l a m a p r o s e s f u z z i f i e r, l a b e l l i ng u i st i k ya ng melek at p a d a geja la dan langkah-langkah diagnostik yang disertai dengan derajat terkait intensitas. gejala, values serta interval fuzzy dirujuk pada diagnosa gejala zol noor i (2012). setelah pasien menuturkan gejalanya kepada ahli medis, ahli medis memberikan nilai subjektif gejala dan 83 sistem diagnosa level asma (kholida hanum dan subiyanto) gambar 2. tampilan sistem diagnosa level asma mengimplementasikannya ke sistem (faithmichae dkk, 2011). diagnosa gejala, level asma, values, serta fuzzy interval disajikan pada tabel 1 dan 2: inference engine inti dari output pengambilan keputusan d iproses oleh i n feren si mengg u na k a n peraturan yang tertuang dalam rule base. proses inferensi mengevaluasi semua aturan dalam basis aturan dan menggabungkan hasil yang dipertimbangkan aturan ke dalam himpunan fuzzy tunggal dengan menggunakan mekanisme agregasi (faith-michael e, dkk., 2011). variabel-variabel yang telah dimasukkan dalam himpunan fuzzy, dibentuk aturan-aturan yang diperoleh dengan mengkombinasikan setiap variabel dengan variabel yang satu dengan atribut lingusitiknya masing-masing. at u ran-at u ran yang telah diperoleh kan dihitung nilai predik aturannya dengan proses implikasi. dalam metode mamdani proses implikasi dilakukan dengan operasi max. predikat aturan tersebut diperoleh dengan mengambil nilai maksimal dari derajat keanggotaan variabel yang satu dengan variabel yang lain, yang telah dikombinasikan dalam aturan yang telah ditentukan sebelumnya. inference engine sistem terdiri dari 3 meta rule: 1) petunjuk meta rule, yaitu jenis peraturan bertanggung jawab untuk memulai dan berhentinya program tersebut, juga memberikan panduan yang diperlukan untuk pasien dan mencegah kesalahan dalam entri data; 2) heuristic meta rule yang bertanggung jawab untuk mengelola kendala pada variabel. salah satu rule pada level asma dengan hasil level asma sedang misalnya, if sesak napas is sedang and tingkat bicara is frase and gejala unik is gelisah and tingkat pernapasan is sedang and mengi is sedang and denyut nadi is sedang and pef is percentmild then asma intensity is sedang at u ran st rategis: jenis perat u ran bertanggung jawab untuk mekanisme inferensi umum sistem ini. proses inferensi mamdani diterapkan untuk pemrosesan aturan paralel. operasi maksimum dan minimum digunakan untuk serikat dan persimpangan masingmasing (zolnoori, 2012). tabel 2. tabel hasil level asma dari zolnoori values interval ringan 0-3 sedang 2-6 berat 5-8 rai (respiratory arrest imminent)/gagal napas 7-10 84 jurnal ners vol. 10 no. 1 april 2015: 80–86 hasil hasil dari sistem diagnosa level asma adalah dengan cara memasukkan gejala yang diderita oleh pasien asma ke dalam sistem dari sesak nafas, tingkat bicara, tingkat kewaspadaan, tingkat pernapasan, tingkat bicara, mengi, denyut nadi jantung per menit, serta pef setelah bronkodilator. setelah itu sistem akan membantu untuk mengambil keputusan dari masukan gejala. kemudian sistem akan memproses dan mengeluarkan hasil diagnosa pasien di antara ringan, sedang, berat, serta rai (respiratory arrest imminent). berikut gambar tampilan input atau masukkan gejala disajikan pada gambar 2. pembahasan peng ujian ti ng kat a k u rasi sistem diagnosa medis dilakukan di rs pertamina cilacap. dengan manual memasukkan gejala langsung pada sistem didampingi oleh ahli medis. setelah itu membandingkan antara hasil diagnosa sistem dengan diagnosa yang dilakukan ahli medis. data pasien yang diambil untuk sampel yaitu 20 pasien penderita asma. dari 20 pasien hasil sistem dibandingkan dengan diagnosa dokter, 18 pasien asma gambar 3. membership function sistem diagnosa level asma tabel 3. hasil uji sistem no. pasien diagnosa sistem diagnosa dokter 1 ringan ringan 2 ringan ringan 3 ringan sedang 4 berat berat 5 ringan ringan 6 sedang sedang 7 ringan ringan 8 rai rai 9 sedang sedang 10 ringan ringan 11 berat berat 12 ringan ringan 13 ringan ringan 14 sedang sedang 15 ringan ringan 16 sedang sedang 17 ringan ringan 18 ringan ringan 19 sedang ringan 20 sedang ringan diagnosa sistem sama dengan diagnosa dokter. maka dari uji sistem menunjukkan persentase 90%. gambar 3 mer upakan membership function salah sat u dari hasil diagnosa 85 sistem diagnosa level asma (kholida hanum dan subiyanto) dengan hasil level asma “sedang (if 0,2 < × < 6,0)”, yang terlihat dari hasil asma intensity 3,91. penelitian selanjutnya diharapkan bisa mengembangkan dengan diagnosa penyakit lain dan metode lain. simpulan dan saran simpulan dari hasil uji sistem ( fuzzy inference system) didapatkan 90% sesuai dengan diagnosa dokter di rs pertamina cilacap. saran fuzzy inference system diharapkan dapat membantu dalam pengambilan hasil diagnosa asma. dengan menggunakan gejala yang diderita pasien sebagai diagnosa pada input sistem. uji sistem dilakukan di rekam medis dengan langsung memasukkan gejalagejala yang diderita pasien serta didampingi oleh ahli medis. kepustakaan abraham, a., & nath, b. 2000. hybrid intelligent systems: a review of a decade of research. school of computing and information technology, faculty of information technology, monash university, australia, technical report series, 5/2000, pp. 1–55. departemen kesehatan r.i. 2009. pedoman pengendalian penyakit asma. jakarta: depa r temen kesehat a n republi k indonesia. eder, waltroud, markus j. ege, erika m. 2006. the asthma epidemic. n engl j med 355; 21. f. steimann, fuzzy set theory in medicine, artifi cial intelligence in medicine 11 (1997) 1–7. f.steimann, k.-p. adlassnig, fuzzy medical diagnosis, 2000. f. steimann and k.p. adlassnig. fuzz y medical diagnosis, http://citeseer.nj.nec. com/160037.html, 2001. zolnoori maryam, m. h. fazel zarandi, mustofa moin. application of intelligent system in asthma disease: designing a fuzzy rule-based system for evaluating level of asthma exacerbation. 2012. gelley, ned and roger jang. 2000. fuzzy logic toolbox. usa: mathwork, inc. innocent, p.r, r.i. john, computer aided fu zz y medical diag nosis, 20 04. kumagai. 2013. medical surgical nursing. missouri. kusumadewi sri, hari purnomo. aplikasi log ik a fu z z y u n t u k pe n d u k u ng keputusan. 2010. mathworks, 2004. fuzzy logic toolbox user’s guide, for the use of matlab. the math works inc. <http://www.mathworks. com/>. mazloumzadeh, s.m., shamsi, m., nezamabadipour, h., 2008. evaluation of generalpurpose lifters for the date harvest industry based on a fuzzy inference system. computers and electronics in agriculture 60,60 – 66. http://dx.doi. org/10.1016/j.compag.2007.06.005. morell, f., genover, t., munoz, x., garciaaymerich, j., ferrer, j., and cruz, m.j., rate and characteristic of asthma exacerbation; the asmab i study. arch. bronconeumol. 44 (6):303–311, 2008. national education and prevention program (naepp). 2007. guidelines for the diagnosis and management of asthma. united states: national heart, lung and blood institute (nhlbi) of national institute of health (nhi) publication. n. alavi. 2013. quality determination of mozafati dates using mamdani fuzzy inference system. pena-reyes, c.a., & sipper, m. 1999. a fuzzy-genetic approach to breast cancer diagnosis.artif icial intelligence in medicine, 17 (2), 131–155. p.b. khanale and r.p. ambilwade. 2011. a fuzzy for diagnosis of hypothyroidism, journal of artifi cial intelligence, vol. 4, 1: 45–54. redman, barbara klung. 2003. measurement tools in patient education. new york: springer publishing company. pp. 160–163. s. k r ish na a na nd , r. k alpa na a nd s. vijayalaksh mi. 2013. desig n and 86 jurnal ners vol. 10 no. 1 april 2015: 80–86 implementation of a fuzzy expert system for detecting and estimating the level of asthma and chronic obstructive pulmonary disease. woolcock aj, konthen pg. lung function and asthma in balinese and australian children. joint international congress, 2n d asian pacif ic of respirolog y and 5th indonesia association of pulmonologists. bali july 1–4 1990. p. 72 (abstract) world health organization (who). 2013. asthma. http://www.who.int/respiratory/ a s t h m a /d ef i n it i /o n /e n /i n d ex . ht m l diakses pada 10 april 2013. zadeh, l.a., 1965. fuzzy sets. information and control 8, 338–353. 422 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).19647 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the comparison of self-esteem and premarital sexual behavior in teenagers between ex-localization areas and surrounding areas in surabaya retno indarwati, clauvega myrtha ranggun sunarya, elida ulfiana faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: adolescence is a vulnerable period involving behavior irregularities, especially premarital sexual behavior. premarital sexual behavior can be caused by personal and social factors. this study aimed to analyze self-esteem and premarital sexual behavior in teenagers between dolly ex-localization and the surrounding area in surabaya. methods: this study used a quantitative approach with a descriptive comparative method. the population was teenagers who were not married. the sample was 118 teenagers, consisting of 59 teenagers in exlocalization and 59 teenagers in the surrounding area. the variables were self-esteem and premarital sexual behavior in teenagers who live between ex-localization and the surrounding area. data were collected with a questionnaire and analyzed using mann-whitney u test with a level of significance α=0,05. results: results showed that there was no difference in self-esteem level between teenagers in ex-localization and the surrounding area (p = 0.568); there was a difference in premarital sexual behavior between teenagers in ex-localization and the surrounding area (p = 0.017). it can be concluded that both teenagers between ex-localization and surrounding area had high levels of self-esteem and were in a high risk category for premarital sexual behavior. teenagers in ex-localization areas have better levels of self-esteem than teenagers in the surrounding area but have a high risk in premarital sexual behavior. conclusion: further studies should include more variables such as the relationship between parents and their children, peer group, and social group. the next research should analyze the role of parents and peer group, and give interventions for health promotion to influence the knowledge level among teenagers about premarital sexual behavior. article history received: feb 27, 2020 accepted: april 1, 2020 keywords teenagers; premarital sexual behavior; self-esteem contact retno indarwati  retno-i@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: indarwati, r., sunaeya, c. m. r., & ulfiana, e. (2020). the comparison of self-esteem and premarital sexual behavior in teenagers between ex-localization areas and surrounding areas in surabaya. jurnal ners, special issues, 422-428. doi:http://dx.doi.org/10.20473/jn.v15i2(si).19647 introduction teenagers going through puberty often experience a vulnerable period of behavior irregularities, especially premarital sexual behavior. this relates to environmental situations that are classified as vulnerable and community stigma which can make teenagers existence unacceptable. ex-localization is an environment that is classified as vulnerable in the process of character development, social roles and mindset. increased deviation of sexual behavior from the 20th century until now has become a serious problem (chamie, 2018). indonesian demographic and health survey data showed that pregnancy, abortion, sexually transmitted diseases, and school dropouts can potentially negatively affect the health status and the future of teenagers (browning, 2015). dolly's localization is the largest prostitution in southeast asia since 1960. mid 2014, dolly's localization has become an area of localization. present condition, the area of localization was found veiled prostitution, and there are still bars and karaoke. results of preliminary studies in 16 teenagers aged 14-18 years showed that they had https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:retno-i@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2(si). jurnal ners http://e-journal.unair.ac.id/jners | 423 kissed hands and cheeks (0.9%), kissed on the forehead and lips (0.8%), kissed the mouth by playing the tongue (0.7%), petting ( 0.6%), and intercourse (0.7%). two teenagers said the intention to behave premarital sex is to show affection with a partner, desire to try and got experience. seventy percent of indonesian, chinese, indian and iran teenagers have do premarital sexual behavior (chamie, 2018). browning & malave research found that 30% of teenagers aged 15-16 years had sexual relations and at 17 had first sexual intercourse (browning, 2015). health research and development agency data showed that 6.17% of junior and senior high school students had premarital sex (litbangkes, 2015). the department of health & human services have shown that teenagers aged 1519 years had given birth to 230,000 babies (huda et al, 2018) . supported by surabaya city statistics showed an enhancement amount of sexually transmitted infections cases by 1,080 (bps, 2018). environmental situations that are unconsciously attached in teenagers become inconsistent with decision-making. this is supported by selfassessment that considers the surrounding environment does not accept or do not appreciate the actions taken (suhron, 2016). lawrence g's theory explained a person's behavior patterns are influenced by three factors: knowledge, attitudes, trust, family, table 1. characteristics of adolescent demographics between ex-localization areas and the surrounding areas in surabaya (june 2019) variable ex-localization the surrounding area total % n % n % age 16 years 29 49,2 19 32,2 48 41 17 years 13 22 27 45,8 40 34 18 years 17 28,8 13 22 30 25 gender male 40 67,8 29 49,2 70 59 female 19 32,2 30 50,8 48 41 religion islam 59 100 59 100 118 100 christian 0 0 0 0 0 0 hindu 0 0 0 0 0 0 buddha 0 0 0 0 0 0 first age dating not yet dating 15 25,4 9 15,3 24 20,3 10 years 0 0 1 1,7 1 0,8 11 years 0 0 0 0 0 0 12 years 3 5,1 4 6,8 7 5,9 13 years 1 1,7 6 10,2 7 5,9 14 years 7 11,9 6 10,2 13 11 15 years 17 28,9 20 33,9 37 31,4 16 years 9 15,3 9 15,3 18 15,3 17 years 5 8,5 4 6,8 9 7,6 18 years 2 3,4 0 0 2 1,7 table 2. distribution of frequency and differences of self esteem in teenagers between ex-localization areas and the surrounding areas in surabaya (june 2019) variable ex-localization the surrounding area total % n % n % self esteem high 39 66,1 36 61 75 63,6 low 20 33,9 23 39 43 36,4 mann whitney p = 0,568 meaningful high 57 96,6 56 94,9 113 95,8 low 2 3,4 3 5,1 5 4,2 mann whitney p = 0,195 strength high 49 83 48 81,3 97 82 low 10 17 11 18,7 21 17,8 mann whitney p = 0,397 competency high 57 96,6 56 94,9 113 95,8 low 2 3,4 3 5,1 5 4,2 mann whitney p = 0,47 r. indarwati et al. 424 | pissn: 1858-3598  eissn: 2502-5791 playmate and easier to find information. the environment has feedback on behavior (nursalam, 2014). this study aimed to explain the differences in self-esteem and premarital sexual behavior in teenagers between ex-localization and the surrounding area in surabaya. materials and methods this research used a quantitative design with a comparative descriptive study. the subjects of this study were teenagers in ex-localization and in the surrounding area with a total of 118 participants. inclusion criteria for ages 16-18 years and exclusion criteria for married teenagers. the determination of participants used purposive sampling. the variables measured in this study were selfesteem and premarital sexual behavior between exlocalization and the surrounding area. data collection was obtained by conducting a home visit using a questionnaire. two measurement instruments were used in this study, rses (rosenberg self esteem scale) questionnaire with a reliability value of 0.3 and a validity value of 0.2 for all items. (khumairoh & anriani, 2018), and a premarital sexual behavior questionnaire with a reliability value of 0.7 and a validity value of 0.361 (muflih & syafitri, 2018). data analysis using the mann-whitney u test with a significance level of α = 0.05 to determine differences in self-esteem and premarital sexual behavior in teenagers between ex-localization and the surrounding area. results demographic data demographic characteristics of participants included age, sex, religion and age of first date. the results showed that among 118 participants, 29 (49.2%) with a mean age of 16 years in the surrounding area and 27 (45,8%) with mean age 17 years in exlocalization area. table 1 showed that the mean sex of the teenagers in ex-localization area was majority male, about 41 participants (69.5%) and 30 participants (50.8%) were majority female in the surrounding area. the total distribution of participants based on religion among teenagers in two different areas is entirely islam. the data depicts that the age of first dating among teenagers in two differents areas was 15 years, about 17 participants (28,9%) in the exlocalization area and 20 participants (33,9%) in the surrounding area. self-esteem based on three parameters, meaningful, strength and competence, table 2. shows that the level of selfesteem in teenagers in the ex-localization area was higher than the surrounding area, which was 66.1% (39 participants). premarital sexual behavior based on three parameters, knowledge, attitudes and behavior, table 3 shows that premarital sexual behavior among teenagers of risk behavior category in the ex-localization was higher than the surrounding area, which was 66.1% (39 participants). the level of premarital sexual behavior among teenagers in two different areas had significant differences (p = 0.006). the two comparison areas are classified as an environment that is not conducive, but premarital sexual behavior among teenagers in the ex-localization area is higher than the surrounding area. teenagers are often involved in premarital sexual behavior including holding a partner's hand, hugging the partner's body, masturbating themselves and kissing the partner's cheek. factors affecting premarital sexual behavior including a low level of knowledge, negative attitudes, the role of parents, peers, and community norms in localization areas. self-esteem and premarital sexual behavior did not have a significant differences(p = 0.905). self-evaluation is assessed subjectively by various considerations of environmental norms and has a large role in behavior in teenagers. table 3. distribution of frequency premarital sexual behavior in teenagers between ex-localization areas and the surrounding areas in surabaya (june 2020) variable category ex-localization the surrounding area total % n % n % premarital sexual behavior risk 39 66,1 26 44,1 65 55,1 non risk 20 33,9 33 44,9 53 44,9 mann whitney p = 0,017 knowledge high 16 27,1 25 42,4 41 34,7 low 43 72,9 34 57,6 77 65,3 mann whitney p = 0,083 attitude positive 23 39 35 59,3 58 49,2 negative 36 61 24 40,7 60 50,8 mann whitney p = 0,028 behavior not safe 7 11,9 1 1,7 8 6,8 less safe 32 54,2 25 42,4 57 48,3 safe 20 33,9 33 55,9 53 44,9 mann whitney p = 0,006 jurnal ners http://e-journal.unair.ac.id/jners | 425 discussion teenagers can manage emotions and have a good relationship with people around them in the process of emotional and social development, so that teenagers are more understanding in assessing themselves subjectively. adolescent self-assessment is influenced by the mindset that is managed by teenagers when they start to ask questions and imagine things that have not been seen, so they have the opportunity to achieve self-satisfaction by liking what makes them accepted. social norms are formed in both comparison areas where teenagers assumed that parents, peers and local society accepted what they have done. in line with bongardt's study, good parents and child relationships can improve selfesteem and good behavior (bongardt, reitz, & deković, 2015). other studies explain that teenagers openness in communicating satisfaction or selfdissatisfaction with parents can increase the level of self-esteem and reduce risk behavior (mastro et al, 2015). the results of this study indicated that there are no differences in self-esteem in teenagers between ex-localization areas and the surrounding areas. the self-esteem of teenagers in both areas has found the ability and self-confidence in achieving an achievement by ignoring past events and having hope in the future. it has a relationship with the emotional and social development of teenagers after the closure of ex-localization. teenagers in the area of exlocalization area getting psychosocial support through children's forum activities, a place for children's learning to support their achievement and the reconstruction of ex-localization houses become umkm village residents of putat jaya. other studies mention perceptions that assumed women should be protected by men and the result was low levels of self-esteem (bleidorn et al, 2016). schmitt's study mentions that the male mindset considers of all people to be treated equally in religion, politics, economics, social and culture (schmitt et al., 2017). based on the frequency distribution of teenagers in the ex-localization, the level of self-esteem was higher than the surrounding area. most of the high levels of self-esteem are owned by adolescent boys, so it can be assumed that gender can influence the development of individual selfesteem. koentjoro (1989) mentions the role of parents, reception and appreciation from the social environment, influencing the formation of individual self esteem (zulfiana, 2017). coopersmith (1967) said that individuals who have high self esteem are easier to adjust themselves to their surrounding environment (suhron, 2016). permissive parenting can increase self-satisfaction, self-esteem, happiness, and good friendships (raboteg-saric & sakic, 2013). cellular and molecular processes of sex hormones in the brain changes the functioning of the nervous system and can influence the behavior (mcewen & milner, 2017). according to koeswara (1991) increasing self-esteem when the sense of love and a sense of belonging have been fulfilled (ifdil, 2014). other studies mention that the higher the level of selfesteem, the higher the sexual behavior (jempormasse, 2015). but, this study is not in line with zulfiana'sstudy that teenagers who have high self-esteem play a role in reducing premarital sexual behavior (zulfiana, 2017). other studies suggest that low self-esteem is associated with depression feel that increasing excessive sexual interest (doornwaard et al, 2015). this is due to the different characteristics of teenagers assessing themselves. according to santrock (2007) explains that teenagers self-esteem is formed from the subjective assessment of the feedback teenagers receive from people around and comparison with the value of the group (suhron, 2016). based on statistical tests the strength level of self-esteem relationships and premarital sexual behavior is low which means it does not have a significant level of relationship. reviewed from the process of forming self-esteem, the role of a character public in both regions in positive treatment such as the acceptance of roles and self-esteem from both regions raises self-awareness, identity and selfunderstanding. acceptance of the role of teenagers. subjective self-evaluation and differences in environmental norms around teenagers affect the unrelated self-esteem and premarital sexual behavior in two comparison areas. premarital sexual behavior, drug use and suicide intentions can be assumed that high self-esteem does not support to reduce risk behavior, and vice versa (jackman & macphee, 2015). premarital sexual behavior of teenagers is influenced by a permissive environment. norms that form in the environment affect the acceptance or rejection of adolescent sexual behavior and resulting risks such as pregnancy, abortion, and give birth ( amaliyasari & puspitasari, 2008; triningsih et al, 2015). the study of rojas, et al also mentioned that environments with higher crime rates have the opportunity to increase negative behaviors such as using illicit substances, consuming alcohol, and involve themselves in sexual behavior (rojas et al, 2016). based on the results of the study showed that there are differences between premarital sexual behavior in teenagers in the area of ex-localization and the surrounding area. the majority of premarital sexual behavior in adolescents in the ex-localization area is riskier than adolescents in the surrounding area, namely holding a partner's arms and hands, hugging the partner's body, masturbating to himself and partner. both regions both have an influence on adolescent behavior, so it is still invaluable in vulnerable areas. where dolly's ex localization areas still have prostitution in secret, there are still bars and karaoke, as well as the cessation of children's forums for 1 year, while the surrounding areas are close to dolly's ex localization. therefore, this study can be assumed that the environment is not conducive and has a negative potential for behavior. the lower health information about reproductive health among teenagers, the lower adolescent r. indarwati et al. 426 | pissn: 1858-3598  eissn: 2502-5791 behavior to promote positive sexual behavior (emilia et al, 2012). teenagers who are closed in discussing sexual experiences are far more at risk of sexual behavior (behulu et al, 2019). the perception of parents and the public who consider sexual behavior a taboo subject at the age of adolescents, so that teenagers are less active in looking and feeling indifferent about sexual knowledge. in line with haryani's research, the use of language and ways delivery of information that is difficult for children to accept, resulting in a higher vulnerability to premarital sexual behavior (haryani et al, 2015). other studies suggest that teenagers living with single parents or low religious levels affect adolescent behavior to vent their sexual desires as a form of escape (taye & asmare, 2016) the results of the study on parameters of knowledge showed that no differences in teenagers in the area of the surrounding and ex-localization. the majority of teenagers in both comparison areas had low levels of knowledge, its related to kissing is a prohibition in dating and intercourse using contraception does not guarantee to prevent pregnancy. however, based on the frequency distribution of teenagers in the area of the surrounding area shows a low level of knowledge. this can be related to the cessation of children's forums in the area of localization, so that they do not get facilities or access to get information related to sex education. on the other hand, most of the teenagers in the ex-localization area have experienced dropouts from their school. low knowledge is one of the risk factors for premarital sexual attitudes (rahman et al., 2012). other research also explains that social norms obtained from personal experience can influence the premarital sexual attitudes and behavior (motamedi et al., 2016). the parameters of teenagers attitudes in the area of ex-localization and the surrounding showed that the majority of teenagers in the area of ex-localization showed negative attitudes. teenagers consider dating style as holding hands and hugging a partner to be a normal thing to do as proof of love, as well as understanding of teenagers related to lack of sexual health education. this affects teenagers to behave according to the experience and information received. the parameters of adolescent actions indicate that there are differences in premarital sexual behavior in two comparison areas. in the area of ex-localization have higher levels of premarital sexual behavior than the surrounding area. teenagers in the ex-localization area often do dating styles such as hold on hand, and embracing the couple's body. this behavior is related to the vulnerable environment when feedback occurs after the closure of dolly's localization within 5 years. cultural feedback on the surrounding environment, and environmental situation that is unconsciously attached and parenting that have been applied to adolescent development who begins to find selfidentity, shape social roles and seek self-freedom that is formed from beginning to end. besides teenagers development factors, the results of these differences can be influenced by the level of knowledge and attitudes related to premarital sexual behavior in a low and negative level. lawrence green’s model explains that predisposing factors (knowledge and attitudes) can determine a person's behavior (nursalam, 2014). mc dougal's theory also explains that someone who has a high level of knowledge can increase their behavior (pratama et al, 2014). other studies have shown that teenagers perceptions related to normal premarital sexual behavior and the intensity of long discussions with peers about dating behavior can increase risky sexual behavior (putri et al, 2017). sexual behavior becomes an escape for teenagers in resolving harmonious relationships (noroozi et al, 2014). not in line with (behulu et al., 2019) study that teenagers who do not discuss with close friends are far more at risky sexual behavior, because it allows adolescents do not know the impact of sexual behavior. adolescence of puberty begins to play its role and seeks satisfaction from the role played, such as feelings of love between the opposite sex. this encourages behavior patterns of teenagers to strengthen the relationships or dating. long relationships result in the sexual desire of dating, so teenagers vent their desires by seeing their experiences. lawrence green's theory explains parenting style, playing time with peers and environmental situations which are factors that encourage person to determine the action to do (nursalam, 2014). gebreyesus's study explains that the active role of parents in monitoring the habits and behavior of their children outside and inside the home can reduce risky sexual behavior (gebreyesus et al, 2019). communication by parents (father) with boys about sex education through casual discussions, jokes, and warnings can increase knowledge and positive attitudes (lesch, 2019). other research states that love (physical pleasure) is the reason teenagers begin sexual relations and still vulnerable to receiving financial support from others (taye; & asmare, 2016). conclusion there are no differences in self-esteem in teenagers between ex-localization and the surrounding area. teenagers in both comparison areas had high levels of self esteem. however, based on the frequency of self-esteem in teenagers, the ex-localization is higher. high self-esteem is positive reception and selfappreciation. some factors that influence the level of selfesteem, that is psychosocial, mindset of men and women, social norms, parenting and good relationships with peers. the two comparison areas are classified as an environment that is not conducive, but premarital sexual behavior among teenagers in the ex-localization area is higher than the surrounding area. high self esteem cannot reduce risky sexual behavior. jurnal ners http://e-journal.unair.ac.id/jners | 427 conflict of interest no conflict of interest has been declared. acknowledgement the author of this study would like to thank the families who have agreed to be respondents in this study and also thanks the universitas airlangga for providing the opportunity to present this study. references behulu, g. k., anteneh, k. t., & aynalem, g. l. (2019). premarital sexual intercourse and associated factors among adolescent students in debre ‑ markos town secondary and preparatory schools , north west ethiopia ,. bmc research notes, 12(95), 4–9. https://doi.org/10.1186/s13104-019-41324 bleidorn, w., arslan, r. c., rentfrow, p. j., potter, j., & gosling, s. d. (2016). age and gender differences in self-esteem — a cross-cultural window. journal of personality and social psychology, 111(3), 396–410. bongardt, d. van de, reitz, e., & deković, m. (2015). indirect over-time relations between parenting and adolescents ’ sexual behaviors and emotions through global self-esteem indirect over-time relations between parenting and adolescents ’. the journal of sex research, 4499. https://doi.org/10.1080/00224499.2015.10461 55 bps. (2018). penduduk berumur 15 tahun ke atas menurut golongan umur dan jenis kelamin. browning, c. m. j. (2015). adolescent sexual risk. international encylopedia of the social & behavioural science, 1(2), 128–135. chamie, j. (2018). premarital sex: increasing worldwide. diambil 6 maret 2019, dari http://www.ipsnews.net/2018/04/premaritalsex-increasing-worldwide/ doornwaard, s. m., eijnden, r. j. j. m. van den, & baams, l. (2015). lower psychological well-being and excessive sexual interest predict symptoms of compulsive use of sexually explicit internet material among adolescent boys. journal of youth and adolescence. https://doi.org/10.1007/s10964-015-0326-9 emilia;, o., sukamdi;, & puspasari. (2012). paparan informasi kesehatan reproduksi melalui media pada perilaku seksual pranikah : analisis data survei demografi kesehatan indonesia 2012. bkm journal of community medicine and public health, 33(1), 31–36. gebreyesus, h., berhe, t., welegebriel, z., wubayehu, t., & hailemariam, g. (2019). premarital sexual practice and associated factors among adolescents in the refugee camps in tigray , northern ethiopia. bmc research notes, 12(415), 1–7. https://doi.org/10.1186/s13104-019-4459-x haryani;, d. s., wahyuningsih;, & haryani, k. (2015). peran orang tua berhubungan dengan perilaku seksual pra nikah remaja di smkn 1 sedayu of adolescent in smkn 1 sedayu. journal ners and midwifery indonesia, 3(3), 140–144. huda, p. n. s. u. n. (2018). pengaruh pendidikan kesehatan metode permainan redi (roda edukasi dan inspirasi terhadap pengetahuan remaja putri untuk mencegah seks pranikah). jom, 5(2), 563–571. ifdil, n. (2014). urgensi peranan keluarga bagi perkembangan self esteem remaja. jurnal konseling dan pendidikan, 2(2), 19–24. jackman, d. m., & macphee, d. (2015). self-esteem and future orientation predict adolescents ’ risk engagement. journal of early adolescence, 1–28. https://doi.org/10.1177/0272431615602756 jempormasse, e. a. (2015). hubungan antara harga diri dan asertifitas dengan perilaku seksual pada remaja putri sma negeri 9 lempake samarinda relationship between self-esteem and assertiveness with sexual behavior in adolescent senior high school state 9 lempake samarinda. ejournal psikologi, 3(3), 634–647. khumairoh, r., & anriani, f. (2018). pengaruh harga diri dan religiusitas terhadap kenakalan remaja laki-laki di pondok pesantren q. psikologi pendidikan dan perkembangan, 7, 29–39. lesch, e. (2019). man talk : exploring sexual communication between fathers and sons in a minority south african community. sex roles, 81, 173–191. litbangkes. (2015). perilaku berisiko kesehatan pada pelajar smp dan sma di indonesia. jakarta: badan litangkes kementrian kesehatan ri. mastro, s., zimmer-gembeck, m. j., mastro, s., & zimmer-gembeck, m. j. (2015). let ’ s talk openly about sex : sexual communication , self-esteem and efficacy as correlates of sexual well-being. european journal of developmental psychology, 12(5), 579–598. https://doi.org/10.1080/17405629.2015.10543 73 mcewen, b. s., & milner, t. a. (2017). review : understanding the broad influence of sex hormones and sex differences in the brain. journal of neurosciene research, 95, 24–39. https://doi.org/10.1002/jnr.23809 motamedi, m., merghati-khoei, e., shahbazi, m., rahimi-naghani, s., salehi, m., karimi, m., … khalajabadi-farahani, f. (2016). paradoxical attitudes toward premarital dating and sexual encounters in tehran , iran : a cross-sectional study. reproductive health, 13(102), 1–10. https://doi.org/10.1186/s12978-016-0210-4 muflih, m., & syafitri, e. n. (2018). perilaku seksual remaja dan pengukurannya dengan kuesioner. keperawatan respati yogyakarta, 5, 438–443. noroozi, m., taleghani, f., tavakoli, m., & gholami, a. (2014). premarital sexual relationships: explanation of the actions and functions of family. iranian journal of nursing and midwifery research, 19(4), 424–431. r. indarwati et al. 428 | pissn: 1858-3598  eissn: 2502-5791 nursalam. (2014). manajemen keperawatan : aplikasi dalam praktik keperawatan profesional. jakarta: salemba medika. pratama, e., hayati, s., & supriatin, e. (2014). hubungan pengetahuan remaja tentang pendidikan seks dengan perilaku seks pranikah pada remaja di sma z kota bandung. jurnal ilmu keperawatan, 2(2), 149–156. putri;, s., shaluhiyah;, z., & nugraha, p. (2017). faktor-faktor yang berhubungan dengan perilaku seksual remaja yang tinggal di lingkungan resosialisasi argorejo kota semarang. jurnal kesehatan masyrakat, 5(5), 1092–1101. raboteg-saric, z., & sakic, m. (2013). relations of parenting styles and friendship quality to selfesteem , life satisfaction and happiness in adolescents. springer. https://doi.org/10.1007/s11482-013-9268-0 rahman, a. a., rahman, r. a., ismail, s. b., ibrahim, m. i., hawa, s., salleh, h., … wan, m. (2012). factors associated with attitude toward premarital sexual activities among scholl-going adolescent in kelantan, malaysia. asia pacifis journal of public health, 20(10), 1–8. https://doi.org/10.1177/1010539512449856 rojas, p., huang, h., li, t., ravelo, g. j., & sanchez, m. (2016). sociocultural determinants of risky sexual behaviors among adult latinas : a longitudinal study of a community-based sample. international journal of enviromental research and public health, 13(1164), 1–21. https://doi.org/10.3390/ijerph13111164 schmitt, d. p., long, a. e., mcphearson, a., brien, k. o., remmert, b., & shah, s. h. (2017). personality and gender differences in global perspective. international journal of psychology, 52, 45–56. https://doi.org/10.1002/ijop.12265 suhron, m. (2016). asuhan keperawatan konsep diri self esteem. ponorogo: unmuh ponorogo press. taye;, a., & asmare, i. (2016). prevalence of premarital sexual practice and associated factors among. journal of nursing care, 5(2). https://doi.org/10.4172/2167-1168.1000332 triningsih, r. w; widjanarko, b; istiarti, t. (2015). faktor-faktor yang berpengaruh terhadap praktik seks pranikah pada remaja di sma dekat lokalisasi di wilayah kabupaten malang. promosi kesehatan indonesia, 10(2), 160–171. zulfiana, u. (2017). self esteem, social support, dan perilaku seksual pranikah pada remaja. jurnal psikologi, 4(2), 55–61. 178 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19006 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review contact investigation and preventive therapy as tuberculosis prevention in children with tuberculosis household contact: a systematic review apriana rahmawati1, budi utomo2, makhfudli makhfudli1 1faculty of nursing, universitas airlangga, surabaya, indonesia 2faculty of medicine, universitas airlangga, surabaya, indonesia abstract introduction: he increasing tuberculosis cases in children showed management of tuberculosis itself. there was a finding of tb case in children according to who tb report 2019 that not all childrens being well diagnosed, treated or reported each year. this systematic review aims to describes implementation of tb prevention often missed in children with adult tb household contacts. methods: is study uses based on pico, which contains participants are family who living household with adult tb, interventions are ci followed by pt, no comparison, outcomes are improving the implementation of ci and pt. searching for article is using the scopus, pubmed, and science direct and found 15 articles in final which limited to the last 3 years (20172020). keywords used in searching are” tuberculosis”, “transmission”, and “preventive therapy”. the population included were respondents identified as family having child aged ≤ 15 years with tb household contacts. the study design varied in rigorousness form of quantitative and mixed studies. results: household contact (hhc) contribute to tb cases in children. conclusion: contact investigation (ci) and preventive therapy (pt) could be succesfull strategies to prevent tb transmission to children provided not only by health care workers (hcws) but also public concerned to community-based approach in order to encouraged family members of tb affected. article history received: feb 27, 2020 accepted: april 1, 2020 keywords tuberculosis; transmission; preventive therapy contact makhfudli makhfudli  makhfudli@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: rahmawati, a., utomo, b., & makhfudli, m. (2020). contact investigation and preventive therapy as tuberculosis prevention in children with tuberculosis household contact: a systematic review. jurnal ners, special issues, 178-187. doi:http://dx.doi.org/10.20473/jn.v15i2.19006 introduction tuberculosis continues to be a major global health threat which less than two thirds of cases are reported. although the tb burden are infected in both adults and children, much of the attention on tb has been focused on adult tb. only 46% of the estimated number of cases are reported by national tb programs (ntps) around the world, leaving a gap of over 580 000 children who are not diagnosed, treated and/or reported each year. tb can affect everyone, but one of specific population groups have a higher risk of acquiring tb infection and progressing to disease once infected are others in settings with a high risk of transmission of m. tuberculosis (world health organization, 2018). the world health organization (who) recommendations for investigating contacts of person with those settings endorse household contact investigation as the active case finding (acf) strategy which enables early tb detection, including identification of latent tb infection, enabling preventive measures and prompt treatment initiation. although tb programmes worldwide have adopted acf, infrequent or inconsistent investigation of tb patient contacts remains a serious challenge . children represent about 10% of all tb cases. more than a million incident cases were estimated among children (aged <15 years) reflecting ongoing community transmission. the number of household contacts initiated on tb preventive treatment in 2018 was much smaller: 349 487 children aged under 5 years (a 20% increase from 292 182 in 2017), equivalent to 27% of the 1.3 million estimated to be https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:makhfudli@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 179 eligible, whereas household contact that untreated well can caused the increasing of tuberculosis cases in children (who, 2019).who said that the end tb strategy milestones for 2020 and 2025 can only be achieved if tb diagnosis, treatment and prevention services are provided within the context of progress towards universal health coverage (uhc). due to a combination of underreporting of detected cases and under diagnosis (including people with tb do not access health care or are not diagnosed when they do) (who, 2015). childhood tb represents mycobacterium tuberculosis (mt) recent transmission and the failure of disease control in community. in this age group pulmonary tb is the most frequent presentation. infants and young children are more likely to develop severe forms of tb (disseminated and meningitis) due to immature immunological response (carvalho et al., 2018) . the household contacts of tb patients (index case) are at the highest risk for tb infection. around a quarter (25%) of household contacts have been infected at the time the index case was diagnosed(wayan gede artawan eka putra et al., 2019). household contacts (hhc) are highly susceptible to acquire tb infection from the index cases because of their close proximity. the goal of contact tracing and their screening for tb could lead to the detection of additional cases of tb, maximizing the impact of case detection and effective treatment (begun, newall, marks, & wood, 2013). therefore, in high tb burden setting contact screening and preventive treatment in children less than 5 years of age need to be prioritized and implemented (assefa, klinkenberg, & yosef, 2015) . the risk of exposure to mtb is a combination of epidemiological, environmental, sociocultural, and behavioural factors that reflect how children, adolescents, and adults interact within societies. agerelated and culture-related factors such as sleeping practices, care-giving, play, religious practices, and school will influence how and where children interact with adults who might have tuberculosis and how much risk these interactions carry. similarly, population density, household composition, crowding, transport systems, and ventilation, both at home and in health-care facilities, all contribute to the risk of exposure. those are explaining that transmission of tb in children influenced by family role in household.. the aim of this review is to describe the implementation often missed and the obstacles of tb prevention in children with adult tb household contacts. materials and methods strategy for study selection arti to develop this review, a working group reviewed focuses on identification transmission factors of tuberculosis cases in children living with adult tuberculosis, including procedure of contact screening in children, how children to be diagnosed, and family factor of infectious individual. a literature search for this systematic review is carried out in database such as scopus, pubmed, and science direct with result limited to the last three years from 20172020. the keywords used in literature search are tuberculosis, transmission, and preventive therapy. type of study this systematic review was aimed to describes causing factors of tb transmission often missed in children with adult tb household contacts. methods used to this systematic review was quantitative approach which have numerical data such as crosssectional survey, either prospective or retrospective study. search of scopus, pubmed, and science direct. search terms: title-abs-key ( tuberculosis and prevention ) or (tuberculosis and prevention therapy) or (tuberculosis preventive therapy and children) or (tuberculosis transmission and children) screening of research result by reviewing titles, abstracts, and keywords. scopus (14 articles); pubmed (23 articles); science direct (20 articles) screening excluded due to articles lack of full-text availability and irrelevancy with topics(n= 177) full-text publication asessed for eligibility (n=32) full-text articles excluded due to irrelevancy with tuberculosis transmission and preventive therapy (n= 17) studies included in synthesis (n=15) figure 1 – flow of articles selection a. rahmawati et al. 180 | pissn: 1858-3598  eissn: 2502-5791 inclusion and exclusion criteria table 1. summary of selected studies author design sample variable results (bekken, g. k., ritz, c., selvam, s., jesuraj, n., hesseling, a. c., doherty, t. m., grewal, h.m. s., vaz, m., and jenum, s, 2020) crosssectional 525 household contacts tuberculin skin test, quantiferon test result, risk factors (age, gender, bcgscar, diabetes, smokin, indoor pollution, crowding) instrument : tuberculisis contact score (tcs) and relationship score analysis : chi-square test and anova of 525 household contacts, 29 were mtb-culture positive and 96.6% of these asymptomatic. (birungi et al., 2019) quantitative – qualitative 270 contacts variable: characteristic of child, index cases, households and health facilities, ipt adherence instrument: a quesionnare check list analysis: chi-square test of the 84 child contacts who started ipt, 74 (88%) had complete adherence and ten (12%) had incomplete adherence. there were no factors (individual characteristics of index cases, households and or health facility characteristics) found to be significantly associated with ipt adherence. (dorjee et al., 2019) crosssectional 617 participants clinical characteristics (age, sex, previous tb history, recent exposure, multiple tb exposure, exposure setting in school, cough-fever-night sweat, increased tiredness in last 2 weeks,weight loss in last 1 month) and risk of tb disease instrument: tuberculin skin testing analysis: descriptive, univariate, and multivariable logistic regression) forty-six tb cases, including 1 with multidrug resistance, were found in schoolchildren, for a prevalence of 853 per 100 000. extensively drugresistant tb was diagnosed in 1 staff member. the majority of cases (66%) were subclinical. tbi was detected in 930 of 5234 (18%) schoolchildren and 334 of 634 (53%) staff who completed testing. children in boarding schools had a higher prevalence of tbi than children in day schools (915/5020 [18%] vs 15/371 [4%]; p < .01). preventive therapy was provided to 799 of 888 (90%) schoolchildren and 101 of 332 (30%) staff with tbi; 857 (95%) people successfully completed therapy. (datiko et al., 2017) prospective cohort 6161 patient tb+ the number of children who completed 6-months ipt and the number who discontinued or were lost to followup, the number of children initiating ipt instruments: semiastructured questionnare analysis univariate of 6161 ptbþ cases identified by hews in the community, 5345 (87%) were visited, identifying 24 267 contacts, 7226 (29.8%) of whom were children aged ,15 years and 3102 (12.7%) were aged ,5 years; 2949 contacts had symptoms of tb and 1336 submitted sputum for examination. ninety-two (6.9%) were ptbþ and 169 had tb all forms. of 3027 asymptomatic children, only 1761 were offered (and accepted) ipt due to inh shortage. of these, 1615 (91.7%) completed the 6-month course. the most frequent reason for discontinuing ipt was inh shortage. jurnal ners http://e-journal.unair.ac.id/jners | 181 the inclusion criteria of articles are kind of author design sample variable results (c. emerson,1 b. ng’eno,1 b. ngowi,2 s. pals,1 w. kohi,3 m. godwin,4 a. date, 2019) quantitative – qualitative method 179 sputum smear-positive and 41 health care workers (hcws) tb screening, hiv testing, and receiving ipt instrument: a questionnare study, in-depth interview with hcws analysis: using an access database and analyzed a total of 141 adult smear-positive tb patients reported 396 children living in households; detailed in formation on 346 (87.4%) was available. only 37 (10.7%) children were clinically assessed for tb, 5 (13.5%) were diagnosed with tb, and 22 started on isoniazid preventive therapy (ipt) (59.0%). of the 320 children whose caregivers responded to whether their children had undergone human immunodeficiency virus (hiv) testing, 55 (17.2%) had been tested and one (1.8%) was hiv-positive. forty-one hcws described passive ccm without use of contact or ipt registers (van ginderdeuren et al., 2019) quasy – experimental three clinics serving the diepsloot community variables: average monthly number of new hiv diagnoses, ipt strategy, and tst placements instrument: survey questionnare analysis: chi-square two clinics implemented tst-guided ipt for all clients receiving hiv care, one clinic decided against use of tst. according to routine register data, the proportion of clients initiating ipt increased substantially at the clinic not opting for tst (6% vs 36%), but minimally (34% vs 37% and 0.7% vs 3%) in the two other clinics. (kigozi, g., heunis, j. c., engelbrecht, m. c, 2019) crosssectional 297 hhc variables: characteristic of contacts, the yield of shci analysis: binary logistic regression of 259 contacts screened, just under half (47.1%) underwent tb clinical investigation, during which 17 (6.6%) new tb cases were diagnosed, which represents a prevalence rate of 6564 per 100,000 population. fifteen contacts needed to be screened to detect one new tb case. (laghari et al., 2019) crosssectional 2397 household contacts characteristic of the hhc, environmental factors, active tb cases instrument:a questionnare consisting of patient characteristics analysis: logistic regression a total of 2397 family members at the median of 5 persons were recorded. of these, 223 (9.3%) were screened on symptoms basis and 35 (15.7%) of these contacts were diagnosed with tb. multivariate analysis revealed hhc with tb (or = 15.288, 95% ci: 5.378–43.457), hhc with smoking (or = 7.094, 95% ci: 2.128–23.648), and contact of > 18 h with tb individual (or = 4.681, 95% ci: 1.198–18.294) as statistically significant risk factors of tb among the hhc. (marquez et al., 2020) crosssectional 3154 hhc prevalent tb infection, proxies for household tb transmisson instrument: household survey in the search trial analysis: unadjusted and adjusted odds ratios with generalized estimating equations (gee) among children, having a household tb contact was strongly associated with tb infection (aor 5.5, 95% ci: 1.7–16.9), but the strength of this association declined among adolescents and did not meet significance (aor 2.3, 95% ci: 0.8– 7.0). a. rahmawati et al. 182 | pissn: 1858-3598  eissn: 2502-5791 prevention tb programs for children living with adult author design sample variable results the population attributable faction of tb infection due to a household tb contact was 8% for children and 4% among adolescents. mobile children and adolescents who travel outside of their community for school had a 1.7 (95% ci 1.0–2.9) fold higher odds of tb infection than those who attended school in the community. (okwara et al., 2017) cohort study 366 hhc variables: contacts and index case characteristic, ipt failure instrument:a structured questionnare analysis: chi-square at baseline, 428 contacts were screened, and 14(3.2%) had evidence of tb disease, hence excluded. of 414 contacts put on ipt, 368 (88.8%) completed the 1 year follow-up. operational challenges were reported by 258(70%) households, while 82(22%) reported side effects. good compliance was documented in 89% (ci:80.2–96.2). by endpoint, 6(1.6%) contacts developed evidence of new tb disease and required definitive anti-tuberculosis therapy. the main factor associated with ipt failure was under-nutrition of contacts (p = 0.023). (wayan gede artawan eka putra et al., 2019) crosssectional 498 contacts variables: household contacts’ sociodemographic characteristics, family relationship to index case, tb symptoms, participation in tb screening, evaluation (tb examination) instrument: a structured ques tionnaire 124 tb patients being visited and identified 498 contacts, thus the ratio of contacts to cases is 4:1. all tb contacts were invited to participate in tb screening and evaluation program. a total of 100 (20.1%) contacts have attended at least one examination session and 41 contacts have completed all sessions. ten tb cases were found among the contacts, of which four of them were adults (three bacteriologically confirmed and one clinically confirmed) and six were children (aged under 15 years). (mary r. reichler1, awal khan1, timothy r. sterling2, hui zhao1, joyce moran3,4, james mcauley5,6, patricia bessler1, bonita mangura7, and tuberculosis epidemiologic studies consortium task order 2 teammary r. reichler1, awal khan1, timothy r. sterling2, h, 2018) crosssectional 158 hhc variables: the timing of tb and tb rates instrument: a structured questionnare analysis: survival analysis (proc life test) tuberculosis was diagnosed in 158 of 4490 contacts (4%) of 718 index patients with tuberculosis. of tuberculosis cases among contacts, cumulative totals of 81 (51%), 119 (75%), 128 (81%), and 145 (92%) were diagnosed by 1, 3, 6, and 12 months, respectively, after the index patients’ diagnosis. tuberculosis rates among contacts were 2644, 115, 46, 69, and 25 cases per 100 000 persons, respectively, in the 5 consecutive years after the index patients’ diagnosis. of the tuberculosis cases among contacts, 121 (77%) were identified by contact investigation and 37 (23%) by tuberculosis registry cross-match jurnal ners http://e-journal.unair.ac.id/jners | 183 tb in their household mainly on contact investigation (ci) and preventive therapy (pt) implementation. all articles using english language were included. articles would be excluded if the study did not use survey based research. participants, interventions, comparators, and outcomes (pico) the feasibility of the study was assessed using the pico approach: participants are children under 15 years and their parents who living household with adult tb, interventions are ci followed by pt, no comparison, outcomes are improving the implementation of ci and pt in order to reducing tb cases in children. results total articles collected were 17 articles. after reviewing the results, there are types of prevention program influencing tb transmission to children, namely contact investigation (ci) and preventive therapy (ipt) implemented by health care workers (hcw) affected by family factors of children exposed. there are 7 articles that emphasized the implementation of preventive tb programs in children by hcws in this review. the research conducted by emerson et al (2019) in 10 health care facilities (hcf) explained from 346 child contacts in household tb adult, only 37 (10.7%) children were clinically assessed. five of them diagnosed with tb and received treatment, and 22 (59.5%) received ipt, and 10 (27.0%) of them received neither ipt nor tb treatment. the health care workers (hcws) interviewed was 41 hcws, 25 (61%) clinicians (clinical officers and medical officers) and 16 (39%) nurses. they are all had worked an average of 6 years in the current tb clinic and 7 years in the field of tb. all hcws reported they routinely ask adult tb patients about children with whom they are in author design sample variable results (martin-sanchez et al., 2019) retrospective cohort 3097 hhc variables: characteristic of contats, incident of tb (at 2 and 5 years) instrument: kaplan-meier curves analysis: the logrank and wilcoxon tests 953 contacts had ltbi, of which 14 developed tb. their risk of developing tb after two and five years was 0.7% (ci: 0.3–1.6) and 1.8% (ci: 1.1–3.1) respectively. contacts who had not been referred for ltbi treatment had a 1.0% (ci: 0.2– 4.0) risk at 5 years. (santos et al., 2020) retrospective study 72 patients variables: treatment, medical appointments, screening, and compliance analysis: fisher exact and mann-whitney test a total of 72 patients were enrolled, 33 (45.8%) on chemoprophylaxis and 39 (54.2%) on latent tuberculosis infection (ltbi) treatment. the majority of patients were compliant (63.9%, n = 46). (wang, 2019) prospectivecohort 700 tb patients and 3417 hhc variables: hhc factors: gender, age, previous tb history, hiv infection status, coexisting diabetes, socioeconomic status, employment status, and secondary education status tb patients factors: drug resistance status, alcohol and tobacco use,cough duration, hospitalization history, and side effect of treatment. instrument: lasso regression technique analysis: multivariate logistic regression the incidence of tb disease among the contacts of index cases was 4.4% (149/3417). ten variables (gender, age, tb history, diabetes, hiv, index patient’s drug resistance, socioeconomic status, spoligotypes, and the index-contact share sleeping room status). a. rahmawati et al. 184 | pissn: 1858-3598  eissn: 2502-5791 contact, yet none of those hcf applied a tb contact tracing or ipt register, they prefer to wait tb adult reported (c. emerson,1 b. ng’eno,1 b. ngowi,2 s. pals,1 w. kohi,3 m. godwin,4 a. date, 2019). the low result of contacts investigated also found on study held by kigozi et al (2019) that of 259 contacts screened, just less half (47.1%) underwent tb clinical investigation, during which 17 (6.6%) new tb cases were diagnosed. research conducted by laghari et al (2019) also found that from 2397 household contacts (hhc), only 223 (9.3%) were screened on symptoms basis, and 35 (15%) of these contacts were diagnosed with tb. research conducted by putra et al (2019) also explained from 498 contacts identified, 100 (20.1%) out who attended at least one tb examination session at a public health center (phc). twenty-two of them were children and 78 were adults. they who attended were completed anamnesis and physical examination. those 3 articles pointed that the leasted number of contacts who screened caused by lack of hcws so they were only provided a maximum five identified contacts to each hcws, repercussion of the passive programs because screening depend only clinical symptoms being experienced by the contacts (laghari et al., 2019). research conducted by sanchez et al (2019) detected 565 tb cases with 3097 contacts, of whom 81 (2.6%) were found have co-prevalent tb, and 977 (31.6%) had latent tb infection (ltbi). among the contacts with either co-prevalent tb or ltbi, the proportion of contacts that had co-prevalent tb in each age group was as follows: 60.7% in <5 years, 20.9% in 5–14 years; 6.9% in 15–39 years and 2.2% in >40 years. at the univariate level, tb risk was significantly higher in individuals who had not completed ltbi treatment. in the contacts who did not complete treatment, the risk of developing tuberculosis was 5% at 2 years, and 11.2% at 5 years. in contrast, the risk was close to 1% among contacts who had not been prescribed treatment and in those who had completed ltbi treatment. in addition to the cases that would have been prevented in the short term, secondary cases of these contacts would also have been prevented, as contact tracing makes it possible to break the infection. due to their vulnerability, tb cases in <5 years age group probably appear even before the diagnosis of the index case. in our study population, a 60.7% of the contacts with either active tb or ltbi at the baseline contact tracing were co-prevalent tb cases in <5 years old, as compared to the 2.2% in >40 years old (martinsanchez et al., 2019). children represent all contacts with tb cases also conceived by reichler et al (2018), 718 tb patients with 4490 close contacts were identified, 158 contacts were diagnosed. of the contacts with tb, 121 (77%) were identified during contact investigation (including 96 of 127 with a diagnosis after the index case), and 37 (23%) were identified by registry match; disease in 77 (49%) was confirmed by culture (67% of adults and 16% of children), and disease in 81 (51%) was diagnosed on the basis of clinical criteria. of the contacts with tuberculosis, disease in 27 (17%), 4 (3%), and 127 (80%) was diagnosed before, on the same day as, and after, respectively, the index cases’ diagnosis. of the contacts with tuberculosis, cumulative totals of 81 (51%), 119 (75%), 128 (81%), and 145 (92%) had tuberculosis diagnosed by 1 month, 3 months, 6 months, and 12 months, respectively, after the index cases’ diagnosis. they have shown that recently exposed close contacts have very high rates of tuberculosis, and that most cases occur soon after exposure and are already evident at the time of contact investigation (mary r. reichler1, awal khan1, timothy r. sterling2, hui zhao1, joyce moran3,4, james mcauley5,6, patricia bessler1, bonita mangura7, and tuberculosis epidemiologic studies consortium task order 2 teammary r. reichler1, awal khan1, timothy r. sterling2, h, 2018). these findings emphasized the importance of performing contact investigations immediately after identifying index cases, as a public health measure for detecting new cases of active tuberculosis and taking steps to interrupt transmission. research conducted by dorjee et al (2019) and bekken (2020) depicted that the window of hhc enrollment sooner following tb index cases identification could influence the number contacts tracing investigation, so the large case finding and implementation of preventive therapy by hcws could reducing the increasing number tb cases of children (dorjee et al., 2019). family of tb patients also hold important role for tb transmission regarding individual in contact with active tb patients are susceptible to tb, and household contacts are considered to be at higher risk due to their constant exposure to infected patients. research undertook by wang (2019) found that from 3417, 149 hhc developed tb disease. the median time for the first tb infection of hhc was 153 (52264) days. that study incorporates 10 predictors such as contact’s gender, age, previous tb history, diabetes, hiv infection status, index patient diabetes, index tb patient’s drug resistance status, socioeconomic status, spoligotypes, and the indexcontact share sleeping room status. from 10 predictors, researchers mentioned that main mode of tb transmission is contact with active tb due to their frequent exposure. as demonstrated from the previous study, the incidence of tb in hhc is higher in the case of drug-susceptible tb cases than in multi drug susceptible-tb index cases, and the independent risk factors for tb transmission was the fact that contacts and tb patients share the sleeping room (wang, 2019). research held in uganda and brazil also revealed that household with more crowded condition (more than three people per room) caused increasing individual-level risk factors of infection from tb transmission in children. prevalent tb infection was associated with other proxies of household transmission by having another child (5-15 years of age) in the house with tb infection (marquez et al., 2020). jurnal ners http://e-journal.unair.ac.id/jners | 185 delayed diagnosis due to unawareness of tb transmission in children from family is other factors that contribute to increasing tb cases in children. study from laghari et al (2019) that involved 2397 hhc were living with 443 index cases with a median number of 5 contacts, 1321 (55.1%) of those were adults and 1076 (44.9%) were children aged ≤5 years. the literacy in adult participants was very low as the researchers found that those participants having no formal education/ background. two-hundred twenty-three (9.3%) of 2397 were screened based on symptoms, 119 (53.4%) were females, 143 (64.1%) were children ≤ 14. of 223 screened, 15.7% of them were diagnosed with tb. the low rates of contacts screened is a possibly repercussion of the passive nature of the program, which mainly depend on distinctive clinical symptoms being experienced by the contacts. research conducted by putra et al (2019) identified 498 contacts, and all were invited in tb screening and program, yet only 100 contacts have attended at least one examination session and 41 contacts have completed all sessions. as those of tb evaluation, 10 new additional new tb cases consisted of six childhood tb, three bacteriologically confirmed tb, and one clinically confirmed tb. reported foremost reasons for this were unawareness in respect to the need for screening, illiteracy and fear stigma from society, also majority of caregivers did not know that contacts with prolonged cough be in need of screening(wayan gede artawan eka putra et al., 2019). various preventive strategies have been adopted in endemic settings. household contacts’ (hhc) tracing offers the best opportunity to identify children at risk and provide access to preventive therapy. world health organization (who) recommends 6 months isoniazid preventive therapy (ipt) for children under 5 years in close contact with infectious tb. birungi et al (2019) evaluated adherence of ipt given as prevention of tb cases in children. among 270 below 15 years-old child contacts, 84 (89%) started ipt and 74 (88%) of them completed six months of ipt, with ten (12%) of them who did not complete the treatment, whereas one (1.2%) of the 84 child contacts developed tb six months after completing the full 6-month of ipt. they were household-related factors affecting the incomplete adherence of parents/ caregivers. they were reported that poverty led to a lack of food, so they were prefer to gave priority to getting a job rather than going to phc to collect medication (birungi, graham, uwimana, musabimana, & van wyk, 2019; okwara, oyore, were, & gwer, 2017). barriers to ipt implementation also discussed in study conducted by santos et al (2020) and ginderdeuren et al (2019). santos et al (2020) enrolled 72 patients, 33 (45.8%) on chemoprophylax (cp) is in children under 6 years old tb exposure and 39 (54.2%) on ltbi stengthened with bcg vaccine according to standard in practice at that time. isoniazid was the main drug used on cp with a median duration of 9 weeks and in 35 cases of ltbi for 9 months. there was compliance to screening, visits, and treatment in 63.9% (n=46) and non-compliance in 36.1% (n=26). the reasons for non-compliance are included social problems/ family dysfunction and medication problems, and doings for noncomplliance are all parents/ caregivers were contacted by phone and encouraged to return to the appointmens and take medication, and resecheduling a new appoinments. by implementation of those strategies, a final compliance rate of 98.6% was achieved (n=71), and there were one case of loss of follow-up. ginderdeuren et al (2019) also stated that the main barriers reported by hcws were low family awareness of ipt, time needed counsel, burden to document ipt-related activities, and concerns regarding exclusion of active tb (santos, silva, rangel, barbosa, & carvalho, 2020; van ginderdeuren, bassett, hanrahan, mutunga, & van rie, 2019). though many study revealed about unawareness of infectious tb individual and the family, there are articles found in reverse. datiko (2019) involved 3503 participants, and 2483 (96%) of them reported high level of awareness about tb, the majority had heard about tb, those participants also knew that tb could be cured and would go to phc if they developed tb symptoms. study from rakhmawati (2019) revealed that 14 family caregivers participated as key informants, reflected their understanding of the risk of tb transmission from tb patients in the household to their children, and the importance of preventing tb transmission in the household (datiko, yassin, theobald, & cuevas, 2017; rakhmawati, nilmanat, & hatthakit, 2019). discussion this systematic review was aimed to identifying the articles around preventive strategies to tb transmission in children. as the point, an important role in tb child prevention is held by hcws and family affected. healthcare workers (hcws) at tb clinics play a critical role in implementing strategies. identifying children in contact with adults with tb is one of the first strategies for implementing ipt and preventing tb in children, thereby interrupting further transmission of tb within the community (c. emerson,1 b. ng’eno,1 b. ngowi,2 s. pals,1 w. kohi,3 m. godwin,4 a. date, 2019). despite knowing the strategies, we need to know about the obtascles so implementation could be improved for the further. several studies sound that hcws only involved infected contacts were the cases in which contact tracing was succesfull, they do not have information on tb risk of contacts that could not be traced or identified. on the other hand, delays in tb diagnosis commonly occur in clinical practice. atypical clinical presentations and clinician inexperience are partly responsible for delayed tb diagnosis [18]. less attention may be given to hiv-negative tb patients. the finding of high prevalence of tb among household contacts of hiv-negative index cases a. rahmawati et al. 186 | pissn: 1858-3598  eissn: 2502-5791 underscores the need for tb programmes to direct active case finding (acf) efforts, beyond children < 5 years and hiv-positive cases. community-based approach with collaboration of pediatricians with experience in tuberculosis, with closer contact with families and regular scheduled appointments was responsible for an increased awareness of the hcws to tb preventive therapy importance, reducing this non-compliance determinant reported in other studies, and could traines female health extension workers (hews) to identify individuals with symptoms of tb and hhc affected (datiko et al., 2017; santos et al., 2020; van ginderdeuren et al., 2019). the mycobacterium tuberculosis can also influence the level of transmission in household contacts and in the community. as expected, an independent risk factor for tb transmission is the fact that contacts and tb patients share the same sleeping room. therefore, accurate identification of active index tb cases and prediction of the risk of tb infection are essential to prevent transmission. exposure to someone with active tb in the previous 2 years at school environment, suggesting that over several years the majority of the school population would be contact, and finding that the living facilities, including their ventilation and time spent in them, play important roles in tb transmission and acquisition (dorjee et al., 2019; wang, 2019). in addition, the degree of exposure with tb contacts was assessed by recording the closeness of patients to the individual with tb within the household (in terms of time spend with tb contact). contact of > 18 h per day with tb individual was significantly connected with tb among hhc. beside, there could be possibility that not all the symptomatic contacts could attended at the treatment centres. there might be some asymptomatic contacts that could have tb infection. for that reason, the entire hhc of tb patient regardless of symptoms should be screened in order to have the early finding of additional cases of tb and to reduce tb transmission (laghari et al., 2019). in tb endemic areas, duration and intensity of exposure might be a critical factor affecting ipt effectiveness. factors were not independently associated with risk of ipt failure could suggest that they are surrogate indicators of the level of nutritional support from parents, indicated by closeness of the mother as the source of food or inability to get adequate nutrition on account of the numbers that need to be fed. parents/caregivers own experience concerning tb disease or their experience of taking care of a relative with tb has been identified as one of the main factors facilitating ipt adherence. the fear to see their offspring suffering from tb, a disabling and killer disease, has been a primary factor motivating them to make sure that their children had complete ipt adherence (birungi et al., 2019; okwara et al., 2017). limitation of study the following limitations are associated with the current study. first, the authors did not distinguished preventive therapy discussed in each study, even though preventive therapy has each of side effect influences adherence of the participants. second, studies included all countries, whether it is categorized as low, middle, or high burden of tb cases. third, authors did not discussed about other diseases could affecting the succes of the tb prevention program in children. conclusion household contact (hhc) contribute to tb cases in children. contact investigation (ci) and preventive therapy (pt) could be succesfull strategies to prevent tb transmission to children provided not only by health care workers (hcws) but also public concerned to community-based approach in order to encouraged family members of tb affected. conflict of interest no conflicts of interest have been declared. acknowledgement the author of this study would like to thank the master of the nursing study programme and the faculty of nursing universitas airlangga for providing the opportunity to present this study. references assefa, d., klinkenberg, e., & yosef, g. (2015). cross sectional study evaluating routine contact investigation in addis ababa, ethiopia: a missed opportunity to prevent tuberculosis in children. plos one, 10(6), 1–10. https://doi.org/10.1371/journal.pone.0129135 begun, m., newall, a. t., marks, g. b., & wood, j. g. (2013). contact tracing of tuberculosis: a systematic review of transmission modelling studies. plos one, 8(9). https://doi.org/10.1371/journal.pone.0072470 birungi, f. m., graham, s. m., uwimana, j., musabimana, a., & van wyk, b. (2019). adherence to isoniazid preventive therapy among child contacts in rwanda: a mixedmethods study. plos one, 14(2), 1–16. https://doi.org/10.1371/journal.pone.0211934 c. emerson,1 b. ng’eno,1 b. ngowi,2 s. pals,1 w. kohi,3 m. godwin,4 a. date, 1 s. modi. (2019). assessment of routine screening of pediatric contacts of adults with tuberculosis disease in tanzania. international union against tuberculosis and lung disease health, ix. https://doi.org//10.5588/pha.19.0034 setting: carvalho, i., goletti, d., manga, s., silva, d. r., manissero, d., & migliori, g. (2018). managing latent tuberculosis infection and tuberculosis in children. revista portuguesa de pneumologia jurnal ners http://e-journal.unair.ac.id/jners | 187 (english edition), 24(2), 106–114. https://doi.org/10.1016/j.rppnen.2017.10.007 datiko, d. g., yassin, m. a., theobald, s. j., & cuevas, l. e. (2017). a community-based isoniazid preventive therapy for the prevention of childhood tuberculosis in ethiopia. international journal of tuberculosis and lung disease, 21(9), 1002–1007. https://doi.org/10.5588/ijtld.16.0471 dorjee, k., topgyal, s., dorjee, c., tsundue, t., namdol, t., tsewang, t., … chaisson, r. e. (2019). high prevalence of active and latent tuberculosis in children and adolescents in tibetan schools in india: the zero tb kids initiative in tibetan refugee children. clinical infectious diseases, 69(5), 760–768. https://doi.org/10.1093/cid/ciy987 laghari, m., sulaiman, s. a. s., khan, a. h., talpur, b. a., bhatti, z., & memon, n. (2019). contact screening and risk factors for tb among the household contact of children with active tb: a way to find source case and new tb cases. bmc public health, 19(1), 1–10. https://doi.org/10.1186/s12889019-7597-0 marquez, c., atukunda, m., balzer, l. b., chamie, g., kironde, j., ssemmondo, e., … havlir, d. v. (2020). the age-specific burden and household and school-based predictors of child and adolescent tuberculosis infection in rural uganda. plos one, 15(1), 1–15. https://doi.org/10.1371/journal.pone.0228102 martin-sanchez, m., brugueras, s., de andrés, a., simon, p., gorrindo, p., ros, m., … orcau, à. (2019). tuberculosis incidence among infected contacts detected through contact tracing of smear-positive patients. plos one, 14(4), 1–16. https://doi.org/10.1371/journal.pone.0215322 mary r. reichler1, awal khan1, timothy r. sterling2, hui zhao1, joyce moran3,4, james mcauley5,6, patricia bessler1, bonita mangura7, and tuberculosis epidemiologic studies consortium task order 2 teammary r. reichler1, awal khan1, timothy r. sterling2, h, and t. e. s. c. t. o. 2 t. (2018). risk and timing of tuberculosis among close contacts of persons with infectious tuberculosis. physiology & behavior, 218(6). https://doi.org/10.1016/j.physbeh.2017.03.040 okwara, f. n., oyore, j. p., were, f. n., & gwer, s. (2017). correlates of isoniazid preventive therapy failure in child household contacts with infectious tuberculosis in high burden settings in nairobi, kenya a cohort study. bmc infectious diseases, 17(1), 1–11. https://doi.org/10.1186/s12879-017-2719-8 rakhmawati, w., nilmanat, k., & hatthakit, u. (2019). moving from fear to realization: family engagement in tuberculosis prevention in children living in tuberculosis sundanese households in indonesia. international journal of nursing sciences, 6(3), 272–277. https://doi.org/10.1016/j.ijnss.2019.06.002 santos, j. c., silva, j. b., rangel, m. a., barbosa, l., & carvalho, i. (2020). preventive therapy compliance in pediatric tuberculosis – a single center experience. pulmonology, 26(2), 78–83. https://doi.org/10.1016/j.pulmoe.2019.06.002 van ginderdeuren, e., bassett, j., hanrahan, c., mutunga, l., & van rie, a. (2019). health system barriers to implementation of tb preventive strategies in south african primary care facilities. plos one, 14(2), 1–12. https://doi.org/10.1371/journal.pone.0212035 wang, s. (2019). development of a predictive model of tuberculosis transmission among household contacts. canadian journal of infectious diseases and medical microbiology, 2019. https://doi.org/10.1155/2019/5214124 wayan gede artawan eka putra, i., kurniasari, n. m. d., dewi, n. p. e. p., ketut suarjana, i., made kerta duana, i., ketut hari mulyawan, i., … wahyuni, c. u. (2019). the implementation of early detection in tuberculosis contact investigation to improve case finding. journal of epidemiology and global health, 9(3), 191–197. https://doi.org/10.2991/jegh.k.190808.001 who. (2015). implementing the end tb strategy. antimicrobial agents and chemotherapy, 58(12), 7250–7257. https://doi.org/10.1128/aac.03728-14 who. (2019). global tuberculosis report 2019. retrieved from http://apps.who.int/iris world health organization. (2018). best practices in child and adolescent tuberculosis care. . 178 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.20395 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research analysis of factors related to nursing student self wareness in doing screening for psychosocial problems verantika setya putri, ah yusuf, and rr dian tristiana faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: mental health knowledge is a substantial part of mental health literacy. many psychosocial problems are transient and are often not noticed. this study aimed to analyze the factors related to student self-awareness in conducting psychosocial screening. methods: this study used a descriptive-analytic design with cross-sectional approach. the study was conducted at the faculty of nursing, universitas airlangga surabaya. a total of 160 respondents was chosen using simple random sampling techniques. the instrument used was a questionnaire. the dependent variable in this study was students’ awareness in conducting psychosocial problems screening. the independent variables in this study were knowledge, social interaction, family support, perceived vulnerability, perceived severity, perceived benefits, perceived barriers, and self-confidence. analysis used multiple linear regression statistical tests. results: the results showed there was a relationship between social interaction (p=0.00), perceived vulnerability (p=0.00), perceived benefits (p=0.001) and selfconfidence (p=0,000) with students’ self-awareness in conducting psychosocial screening. there was no relationship between knowledge (p=0.555), family support (p=0.720), perceived severity (p=0.070), perceived barriers (p=0.748) with students’ self-awareness in conducting psychosocial screening. conclusion: mental health awareness in nursing student should be enhanced and strengthened with health education. self-awareness of mental health is important for students. this can prevent mental disorders in the future article history received: july 1, 2020 accepted: september 2, 2020 keywords nursing students; psychosocial problems; screening; self-awareness contact ah yusuf  ah-yusuf@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: putri, v, s., yusuf, a., & tristiana, r, d. (2020). analysis of factors related to nursing student self wareness in doing screening for psychosocial problems. jurnal ners, 15(2). 178-184. doi:http://dx.doi.org/10.20473/jn.v15i2.20395 introduction anxiety is experienced by 75% of nursing students at airlangga university. anxiety is a symptom of psychosocial problems. based on preliminary study on december 13, 2019, problems above 56.4% were caused by poor coping and 49.1% were due to poor time management. other causes were too many assignments by 34.5%, rescheduling schedules, and heavy credit load with a small percentage that causes students to experience physical and psychological fatigue. the results of the preliminary study said that nursing students did not consider the anxiety problem caused by physical and psychological stress required to be addressed immediately, they considered the problem to be a normal thing to happen. according to ormel et al. (2020) this phenomenon illustrates that nursing students' awareness of psychosocial health is still low. the impacts felt by students due to the problems above include dizziness, diarrhea, increased stomach acid, and thrush (ashley & reiter-palmon, 2012). other impacts such as college assignments that were completed but not maximal in doing so were 92.3% and unfinished college assignments by 13.5%. the prevalence of severe mental disorders in indonesia is 1.7% and mental-emotional disorders reached around 6.1% in 2013 and increased to 9.8% in 2018 (riskedas, 2018). more than 19 million people aged over 15 years are affected by mentalemotional disorders. the world health organization ( who, 2010) mentions the suicide rate in indonesia reaches 1.6-1.8% per 100,000 people. the impact of extensive psychosocial problems covers all aspects of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:%20ah-yusuf@fkp.unair.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 179 human life, one of which is productivity; this is a concern that needs to be addressed through preventive efforts. secondary or preventive prevention is aimed at community members who experience psychosocial problems (risk of mental disorders). the purpose of this service is to reduce the incidence of mental disorders. service targets are student members who are at risk or show signs of psychosocial problems and mental disorders. screening is used as early detection of health problems. this is done through government programs that address mental health problems with health and screening counselors (prince & alexander, 2017). however, these efforts have not shown maximum results, due to low mental health concerns, including a screening process that is not in line with community conditions, lack of human resources, and available health facilities (andriyani & widigdo, 2017). self-awareness is influenced by demographic factors, including gender, education, age, and history of previous illnesses (manurung, 2018). psychological characteristic factors influence the courage to do screening as well as undertake treatment, while socio-cultural factors consisting of social interactions and family support affect awareness in screening; the more often a person interacts with other people the more experience and good socializing habits. this socio-cultural influence influences one's perception and belief in the problem of mental disorders. these factors are identified by the health belief model (hbm) theory, which is a model used to describe an individual's trust in healthy living behaviors so that individuals will engage in such behaviors. healthy behaviors can be preventive behavior or the use of health facilities. this health belief model is often used to predict preventive health behaviors. based on the description above, the researcher will further analyze the factors related to students' self-awareness in screening for psychosocial problems at the faculty of nursing, unair surabaya. materials and methods this research is a descriptive analysis type of research with a cross-sectional approach. the population of airlangga nursing faculty students is a regular program and has passed the mental nursing course. this research was conducted at the faculty of nursing unair surabaya in march-april 2020. the population of respondents was 267. the sample size in this study was determined using simple random sampling in a population of 267 people; with a confidence level of 95%, and an error rate of 5%, it obtained 160 samples. the dependent variable is awareness in screening, measurement used research questionnaires made by sabila okta unair psychology students (syarafina, 2019) and independent variables are knowledge, social interaction, family support, perceived vulnerability, perceived severity, perceived benefits, perceived obstacles, and trust in the perceived self. the validity test in this study used pearson product moment (r) at spss with a significance level of 5% and resulted in 20 respondents. the reliability test used the cronbach’s alpha formula. if r alpha> r table then the question is reliable, conversely if r alpha <r table then the question is not reliable. data were analyzed by multiple regression test. this research proposal has passed the ethical test by the health research ethics committee (kepk) with the number of ethical certificate no 1957 dated march 28, 2020. results respondents' contributions are based on demographic characteristics in 160 students. the data distribution of this study were respondents with the age of 21 years as many as 65 students (40.6%), the number of female respondents was 138 students (86.3%), collected by respondents obtained from semester 8 that were 104 students (65. 0%) and collect respondents to migrate or boarding houses in surabaya. respondents having a level of knowledge that is supported in the moderate category totaled 82 respondents (51.3%). the number of respondents who participated in the high category was 83 respondents (51.9%), students who received scholarships in the high category were 83 respondents (51.9%). a total of 87 respondents (54.4%) were accepted by students in the high category. the severity felt in the high category was 79 respondents (49.4%). the benefits received in the high category were 98 respondents (61.3%), the challenges received by respondents in the moderate category were 86 respondents (53.8%) and the confidence received by respondents increased in the moderate category by 106 respondents (66. 3%). respondents who had low self-awareness in screening psychosocial problems were 67 respondents (41.9%) and respondents who had high self-awareness in screening were 93 respondents (58.1%). statistical tests with multiple linear regression obtained the results of social interaction, the assessment received, the benefits received and the self-confidence received related to students' selfawareness in screening for psychosocial problems. based on the f test or simultaneous independent results obtained independent variables with the dependent variable with an f count of 24.057> f table 2.00 and a significance value of 0.00 <0.05. r square was 0.560, which means the independent variable related to the dependent variable by 56%. the dominant variable in this study is confidence obtained with a standard coefficient of 0.338. based on the table 2, it can be seen that the majority of the respondents' knowledge is in the medium category, namely as many as 82 respondents (51.3%). the majority of social interactions in the high category were 83 respondents (51.9%). the majority of respondents had family support in the high category, namely 83 respondents (51%). the v. s. putri et al. 180 | pissn: 1858-3598  eissn: 2502-5791 vulnerability felt by the majority of respondents was in the medium category as many as 72 respondents (45.0%). the majority felt the severity in the high category as many as 79 respondents (49.4%). the benefits felt by the majority in the high category were 98 respondents (61.3%). the obstacles felt by the majority were in the medium category as many as 86 respondents (53.8%). the majority who felt confidence in the medium category was as many as 106 respondents (66.3%) and the majority who felt confidence in the high category was as many as 93 respondents (58.1%). from the table above, it can be seen that the dominant variable in this study is the self-confidence variable with a standardized coefficient value of 0.338. discussion relationship of knowledge with selfawareness there is no partial relationship between knowledge and self-awareness of students in screening psychosocial problems, with a significance value of 0.55 > 0.05. the knowledge, which consists of six levels in this study, shows the level of respondents in the first level, namely tofu (top of funnel), and selfawareness indicators consisting of knowledge, understanding, attitudes, and patterns of behavior or action. the aspect of the respondent's self-awareness is still in the knowledge stage, in which is the first stage tofu). according to wawan and dewi (2017). knowing is defined as memorizing material that has been studied previously, people who already know table 1. respondents’ characteristics characteristics category n % age 18 years 1 0.6 19 years 1 0.6 20 years 32 20.0 21 years 65 40.6 22 years 59 36.9 23 years 2 1,3 gender male 22 13.8 girl 138 86.3 semester 8 104 65.0 6 56 35.0 address live with parents 43 26.9 dormitory 117 73.1 table 2. factors related to students’ self-awareness in conducting psychosocial problems screening variable category n % standardized coefficients (beta) t count p-value knowledge low 13 8.1 -.034 -.592 .555 medium 82 51.3 high 65 40.6 social interactions low 77 48.1 .235 3,945 .000 high 83 51.9 family support low 77 48.1 -,021 -359 .720 high 83 51.9 perceived vulnerability low 1 0.6 299 4,152 .000 medium 72 45.0 high 87 54.4 perceived severity low 12 7.5 -.124 -1,822 .070 medium 69 43.1 high 79 49.4 perceived benefits low 8 5,0 .242 3,344 .001 medium 54 33.8 high 98 61.3 perceived obstacles low 37 23.1 .019 322 .748 medium 86 53.8 high 37 23.1 perceived self-efficacy low 7 4,4 .338 4,924 .000 medium 106 66.3 high 47 29.4 self-awareness low 67 41.9 high 93 58.1 jurnal ners http://e-journal.unair.ac.id/jners | 181 must be able to understand the material or object. second is understanding (comprehension), the ability to explain an object that was known and interpret the material correctly; the interpretation phase consists of detection, observe an object and identify the characteristics of the objects based on hue, shapes and textures. analysis is processing and finding the characteristics of the object deeper so that it will produce accurate results, and deduction/classification, namely the conclusion or determination of the type of object (indarto, 2017). based on the results of data analysis, it is known that the aspects of signs and symptoms have the lowest value so that this is the background of the respondents' knowledge stage in the first stage (know) because they have not been able to interpret the material correctly. if the first stage of knowledge has been passed it will increase to the next and final stage, namely action. this explains why knowledge is not related to self-awareness because the stage through which self-awareness goes to cause action is still in the first stage so that, in this study, knowledge has no relationship with self-awareness. the relationship of social interaction with self-awareness there is a partial relationship between social interaction with student self-awareness in screening for psychosocial problems with a significance value of 0.000 < 0.05. social interaction is influenced by several things, one of which is motivation, here such as education, work, the desire to fulfill the necessities of life, the desire to add new insights, the desire to create harmony in the community and add experience (astuti et al., 2018). if someone is aware of the importance of a thing (motivation), it will increase the social interaction of individuals to meet their desires. according to ira dwi puspitasari and puji lestari (2015) self-awareness is needed if individuals interact so that they can place themselves in the community. self-awareness is the background of social interaction, where, with a conscious attitude toward what is inside the individual, both weaknesses and strengths, it will make it easy for someone to understand the potential that is within them, so that they do not experience difficulties to carry out social relations. according to astuti et al. (2018), social interaction begins with social contact, this is by supported by herimanto and winarno who stated that social contact is the beginning of social interaction. one form of social contact is lecture activities in the classroom (ira dwi puspitasari and puji lestari, 2015) wherein semester 8 and semester 6 students still often hold lectures in the classroom, so there are social contacts, makinge the majority of student social interactions in the high category. relationship of family support with selfawareness there is no relationship between family support and self-awareness with a significance value of 0.720 > 0.05. the lowest aspect of family support lies in the aspect of valuation support regarding assessment support. according to anwari (2018), lack of appraisal support due to lack of concern for family members about what is done by respondents, this is supported by the respondents who answered never on the question whether the family cares about the problem at hand. this will have an impact on feelings of disrespect for the actions taken and if this continues it will have an impact on depression. if an individual can understand well the source of stressors and has good coping strategies, the individual has high self-awareness, which means that the individual can understand themselves well, their weaknesses and strengths, so that they can deal with the situation appropriately. because of this, the third hypothesis is rejected, which means there is no partial relationship between family support and self-awareness. relationship of perceived vulnerability with self-awareness there is a partial relationship between perceived vulnerability if not screening with student selfawareness in conducting psychosocial screening with a significance value of 0.000 < 0.05. vulnerability perceptions represent an individual's beliefs about risk if they don't have a psychosocial screening. when an individual wants to screen for the first time, they will instinctively collect all the facts and stories, including the risk of screening. feelings of vulnerability in regard to psychosocial problems and their impact can trigger respondents' awareness of efforts to overcome these problems by screening. if not, they tend to experience the effects of psychosocial problems. therefore, awareness and subsequent experience have an important role to determine the success of screening (notoatmodjo, 2010). the more individuals feel their vulnerability regarding their health, the higher the level of individual awareness in conducting the psychosocial screening. the results of this study are consistent with the concept put forward that a person will act if they feel vulnerable to the disease. the positive relationship between perceived vulnerability and self-awareness in conducting psychosocial screening is influenced by patient experience. experience has an important role that will shape perceptions, such as cognitive, personality, and culture of the individual (notoatmodjo, 2010) so that the more the person feels vulnerable it will make the individual aware of screening for psychosocial problems. the quality of self-awareness is a clearer state of the individual conscious experience of the present conditions, which effectively realizes memories and anticipates the future (buglar et al., 2010). this explains how the respondents’ vulnerability to the occurrence of v. s. putri et al. 182 | pissn: 1858-3598  eissn: 2502-5791 psychosocial problems and their impact affects and relates to self-awareness; if an individual understands that they are vulnerable to a problem, they will instinctively predict what will happen to them, both now and in the future, so that they arise behavior to anticipate this. the main component of self-awareness is understanding of oneself and secondly the ability to anticipate how a person is valued by others. relationship of perceived severity with selfawareness with perceived severity if not having screening, there is no positive partial relationship with student selfawareness in conducting psychosocial screening, with a significance value of 0.720 > 0.05. perception of severity is an individual's belief in the severity of a disease. whereas perceptions of the severity of disease are often based on information or treatment knowledge, it may also come from belief in people who have difficulties with the illness suffered or the impact of the disease on their lives (buglar et al., 2010). based on the distribution of questions on this variable, the majority of respondents answered correctly on the question items in my opinion; if they do not do screening, it will have a bad impact on longterm health in addition to this, perception of severity can also be strengthened from information obtained from medical information and mass media, while psychosocial issues themselves have not been given special attention, so that minimal information is conveyed regarding psychosocial and screening issues. respondents only get this information from lectures in class because it is included in the subject in psychiatric nursing. relationship of perceived benefits with selfawareness there is a positive partial relationship between the perceived benefits of screening and self-awareness. evidenced by the significance value of 0.001 < 0.05. this means that someone who has self-awareness should be fully aware of their perceptions, feelings, dreams, or the world outside of themselves. humans can realize themselves, a unique and real ability that enables humans to be able to think and decide (widiatmoko & ardini, 2018). this is the background of how the benefits relate to self-awareness,. with someone considering the benefits to be gained after doing something, the individual will decide what they will do and with self-awareness owned by the individual they will determine the benefits that are good for them, so h6 is that the benefits felt after psychosocial screening are partially related to selfawareness. perceived benefits have an important role in determining behavior for secondary prevention (buglar et al., 2010). this shows that the perception of the benefits of disease prevention has a positive relationship with student self-awareness in conducting psychosocial screening. the more the patient knows the benefits of these health behaviors, the more aware the respondent is in screening. relationship of perceived obstacles with self-awareness there is no partial relationship between perceived obstacles and self-awareness of nursing students in conducting the psychosocial screening, as evidenced by the significance value of 0.748 > 0.05. stages of individual self-awareness are determined by the extent to which the individual is trying to enhance their self-awareness. based on the frequency distribution, the obstacle most felt by individuals is the lack of information, which is one of the efforts to increase self-awareness by conducting communication based on information so that, because of the limited source of information, about screening it is hampering the increase of individual selfawareness. according to yunti (2019), perceived barrier gets a low proportion of perception because it is the only factor that represents an individual's beliefs about obstacles to doing something. the smaller the obstacles, the higher the patient's compliance. perceived barriers have an important role in determining behavior change in individuals (buglar et al., 2010). this proves that respondents who are new to psychosocial screening are likely to face several obstacles that affect their awareness. students as respondents have obstacles in conducting psychosocial screening; these obstacles can be in the form of internal or external obstacles. internal barriers include feelings. relationship of self-confidence that is felt with self-awareness self-confidence has a significant relationship and has a positive influence on self-awareness in conducting psychosocial screening with a significance value of 0.000 < 0.05. self-confidence is a belief that is owned by individuals who can screen correctly. the belief in new behaviors derived from perceived benefits will increase respondents' self-awareness. someone's belief in healing a disease will motivate them to take action. this study is in line with research conducted (indah, 2016; prasetyowati, 2018) showing that there is a positive effect of confidence in preventive care in type 2 dm patients. patients with high self-confidence will improve self-care dm 2, where someone who has good self-confidence will be more obedient to preventive behavior to facilitate prevention. according to chaplin (2002), self-awareness is awareness of one's mental processes or existence as unique individuals. when someone understands and is aware of their emotions, it is easier for them to acknowledge and control emotions. they are also more confident because they do not let their emotions get out of their control. confidence is a belief in yourself the ability to do something. if someone believes a new behavior is beneficial, but does not jurnal ners http://e-journal.unair.ac.id/jners | 183 think they can do it (perceived barrier), chances are that will not be tried (buglar et al., 2010). simultaneous relationship between independent and dependent variables there is a simultaneous relationship between variables of knowledge, social interaction, family support, perceived vulnerability, perceived severity, perceived benefits, perceived obstacles, and selfconfidence with self-awareness on students in screening psychosocial problems, with a calculated f value of 24.057> f table 2.00 and a significance value of 0.000 < 0.05 so that it can be interpreted that there is a simultaneous influence of knowledge variables, social interaction, family support, perceived vulnerability, perceived severity, perceived benefits, perceived obstacles, and confidence in self-awareness variables. r square value of 0.560 means that the independent variable simultaneously influences the dependent variable by 56%, and other variables affect self-awareness by 44%, but in this study were not examined. based on the results of the regression coefficient (b) it is known that self-efficacy has the greatest value of 0.338 compared to other variables. so self-confidence has the most influence on student self-awareness in conducting psychosocial screening. where if someone has a high self-efficacy will increase preventive behavior to facilitate prevention (holm-hadulla & koutsoukou-argyraki, 2015) .psychosocial screening is an effort to prevent the worse effects due to existing psychosocial problems, so psychosocial screening is a preventive program for the prevention of disease. self-efficacy is an individual's belief in acting so that if the individual already has high confidence, it will be easy to carry out a health behavior. research (phillips & silvia, 2005) states that self-efficacy is the most powerful factor for determining compliance. ormel et al. (2020) say that humans are creatures that can be aware of and are, therefore, responsible for their existence. individuals with strong instincts of selfawareness can know when they feel less excited, easily upset, sad, or excited and realize how these various feelings can change their behavior, which causes others to feel uncomfortable. a person's ability to recognize their feelings and the way he responds, makes them able to control behavior that has the potential to harm them. knowledge, social interaction, family support, perceived vulnerability, perceived severity, perceived obstacles, perceived benefits, and self-confidence together influence selfawareness, wherewith the existence of broad insight and external support. conclusion there is a relationship in social interaction variables, perceived vulnerability, perceived benefits, and perceived confidence while the variables of knowledge, family support, perceived severity, and perceived obstacles do not have a positive relationship with self-awareness of students in screening for psychosocial problems. this dilator is due to many factors, both from the internal and external of the individual. the recommendation in this study is that there is a need for health education on mental emotional health that focuses on how to prevent psychosocial problems because these problems are most often experienced by students, and it is necessary to provide information about psychosocial problems as well as psychosocial screening that is easily accessible to students. references andriyani, a., & widigdo, j. (2017). model layanan screening dalam konseling kesehatan mental berbasis android (e-couns) untuk mendukung gerakan revolusi mental. seminar bimbingan dan konseling, 1(1), 96–103. anwari, misbakhul. (2018). hubungan dukungan keluarga dengan kualitas hidup lansia yang mengalami hipertensi di wilayah kerja puskesmas mandalle kabupaten pangkep. september, 160– 164. ashley, g., & reiter-palmon, r. (2012). selfawareness and the evolution of leaders: the need for a better measure of self-awareness. journal of behavioral applied management, 14(1), 2–17. astuti, p. d., hadiwinarto, h., & sholihah, a. (2018). studi deskriptif interaksi sosial mahasiswa s1 jurusan ilmu pendidikan berdasarkan keterlibatan organisasi kemahasiswaan di fakultas keguruan dan ilmu pendidikan universitas bengkulu. consilia : jurnal ilmiah bimbingan dan konseling, 1(2), 20–28. https://doi.org/10.33369/consilia.1.2.20-28 buglar, m. e., white, k. m., & robinson, n. g. (2010). the role of self-efficacy in dental patients’ brushing and flossing: testing an extended health belief model. patient education and counseling, 78(2), 269–272. https://doi.org/10.1016/j.pec.2009.06.014 farisa, i. i. (2016). hubungan pola asah pengasuh dengan perkembangan motorik anak usia prasekolah (3-5 tahun) di tpa taam ananda surabaya. universitas airlangga. holm-hadulla, r. m., & koutsoukou-argyraki, a. (2015). mental health of students in a globalized world: prevalence of complaints and disorders, methods and effectivity of counseling, structure of mental health services for students. mental health and prevention, 3(1–2), 1–4. https://doi.org/10.1016/j.mhp.2015.04.003 indarto. (2017). penginderaan jauh : metode analisis & interpretasi citra. ira dwi puspitasari dan puji lestari, m. h. (2015). the factors behind the social interaction between the public samin and the non-samin community ( community studies padukuhan karangpace klopoduwur village , banjarejo district , blora regency , central java ). manurung, lisma nurlina. (2018). asuhan v. s. putri et al. 184 | pissn: 1858-3598  eissn: 2502-5791 keperawatan keluarga. fakultas ilmu kesehatan ump, 2010, 8–42. notoatmodjo. (2010). pendidikan dan perilaku kesehatan. rineka cipta. ormel, j., cuijpers, p., jorm, a., & schoevers, r. a. (2020). what is needed to eradicate the depression epidemic, and why. mental health and prevention, 17(december), 200177. https://doi.org/10.1016/j.mhp.2019.200177 phillips, a. g., & silvia, p. j. (2005). self-awareness and the emotional consequences of self-discrepancies. personality and social psychology bulletin, 31(5), 703–713. https://doi.org/10.1177/0146167204271559 prince, h., & alexander, l. (2017). self-awareness: there is no cure and no improving of the world that does not begin with the individual himself . insights, 7, 1–11. riskesdas. (2018). hasil utama riskesdas 2018. jakarta: salemba medika: kementerian kesehatan ri badan penelitian dan pengembangan kesehatan. syarafina, s. o. (2019). pengaruh optimisme dan kesadaran diri terhadap adversity quotient pada mahasiswa universitas negeri malang yang menempuh skripsi sambil bekerja. wawan, a., & dewi, m. (2017). teori & pengukuran pengetahuan, sikap, dan perilaku manusia (kedua). yogyakarta: nuha medika. widiatmoko, m., & ardini, f. m. (2018). pendekatan konseling analisis transaksional untuk mengembangkan kesadaran diri remaja. jurnal kajian pendidikan dan pengajaran, 4(2), 99–108. https://doi.org/10.30653/003.201842.50 http://e-journal.unair.ac.id/jners | 473 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20514 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original article the effect of a cold compress on pain during the first stage of childbirth at bpm nur hidayatin, anita dwi a, erika prawitasari faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: childbirth is a physiological process that happens as part of a woman's development into becoming a mother. the process can be traumatic for some women because of the pain that they experience. cold compress therapy is one of the non-pharmacological approaches to reducing pain. the objective of this study is to determine the effect of a cold compress on pain in the first stage of childbirth. methods: this was an experimental study with a one group pretestposttest design. the population of this research consisted of women who had given birth, totaling 15 respondents. the samples were chosen using accidental sampling. the data was taken through observations and it was analyzed using the wilcoxon signed rank test with a significance level of 0,05. results: there were changes in pain level with a significance value of ρ = 0,008 with a testing rule ρ < 0,05. this shows that the cold pack affected the level of pain during the first stage of childbirth. conclusion: a cold compress is effective at reducing the pain felt during childbirth. the items used to make a cold compress are easy to find and a woman can make it herself. a cold compress can be given without causing harmful effects for either the babies or the mothers who are giving birth. article history received: feb 27, 2020 accepted: april 1, 2020 keywords a cold compress; childbirth pain; uterine contractions; first stage contact nur hidayatin  nur.hidayatin2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: hidayatin, n., a, a. d., prawitasari, e. (2020). the effect of a cold compress on pain during the first stage of childbirth at bpm. jurnal ners, special issues, 473-475. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20514 introduction childbirth is the process of the thinning and opening of the cervix followed by the descent of the fetus into the birth canal. this is followed by the birth of the fetus(deye, n., vincent, f., michel, p., ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.-f. (2016). the first stage of labor pain is often experienced by mothers who are about to give birth(srivastava, avan, rajbangshi, & bhattacharyya, 2015). this pain originates from the lower abdomen as a result of the cervix opening and thinning. the pain spreads to the lower back and down to the thighs. here it is caused by the fetal head pressure on the mother's spine(spector et al., 2013). as the volume and frequency of the uterine contractions increases, the pain will feel stronger. pain during childbirth is considered to be the single strongest physiological pain, so there is the opinion that it does not need to be reduced in intensity. this is paired with the belief that it can be relieved using non-pharmacological therapy(mesenburg et al., 2018). one form of nonpharmacological therapy is cold compress therapy. this is because cold compresses can have an analgesic effect. this can provide relaxation to tense muscles and joint stiffness(perez-brena, updegraff, umañataylor, jahromi, & guimond, 2015). according to the who, one report estimates that there are 210 million deliveries annually. out of this number, 20 million women experience pain as a result of childbirth. about 8 million experienced lifethreatening complications and more than 500,000 die (van der gucht & lewis, 2015). a total of 240,000 from this amount make up almost 50% from south and southeast asian countries, including indonesia. previous childbirth experiences can also affect a mother's response to pain(vowles, mccracken, sowden, & ashworth, 2014). primigravida mothers do not have the experience of childbirth compared to multigravida mothers. mothers who are giving birth for the first time will feel stressed or afraid in the face of childbirth (deye, n., vincent, f., michel, p., https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ n. hidayatin, et al. 474 | pissn: 1858-3598  eissn: 2502-5791 ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.f. (2016). stress or fear physiologically can cause the uterine contractions felt to be increasingly painful (deye, n., vincent, f., michel, p., ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.-f. (2016). mothers in the condition of giving birth are experiencing stress. the body stimulates the body to release stress hormones, namely catecholamine and adrenalin(deye, n., vincent, f., michel, p., ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.-f. (2016). catecholamine can be released in high concentrations during labor if the mother cannot eliminate her fear before giving birth(deye, n., vincent, f., michel, p., ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.f. (2016). as a result, the uterus becomes increasingly tense so the blood flow and oxygen sent to the uterine muscle decreases. this is because the arteries shrink and constrict. the result is an inevitable pain (deye, n., vincent, f., michel, p., ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.-f. (2016). multigravida mothers who have already given birth will be able to respond to the pain better. for the mothers who give birth in a relaxed state, all layers of muscle in the uterus will work together in harmony so then the labor will progress smoothly, easily and comfortably. materials and methods the research was experimental with a one group pretest post-test design. the study was conducted at bpm. the study population consisted of all mothers in the first stage of birth in bpm, totaling 15 respondents. the sample selection used was an accidental sampling technique. the research data was taken using an observation sheet. after tabulation, the data was analyzed using the wilcoxon sign rank test at a significance level of 0.05. this study was carried out beginning with the measurement of the pain scale when the mother’s uterus had begun contracting. a cold compress was given after measuring the pain scale. it was placed on the back of the waist at the top of the coccyx when the uterine contractions were apparent for 15 minutes. after the compress was applied, then we measured the pain scale again. results the results obtained showed that before getting cold compress therapy, the respondents experiencing mild pain totaling 0 (0) respondents. after getting therapy, this was felt by 4 respondents (27%). moderate pain before the cold compress was felt by 6 respondents (40%) and after, it was felt by 4 respondents (27%). severe pain before the cold compress was felt by 8 respondents (53%) and after, it was felt by 7 respondents (46%). the pain was very severe before the cold compress for 1 respondent (7%) and after being given the cold compress therapy, severe pain was felt by 0 respondents (0%). there was a change in the pain scale with a significant value of p = 0.008 with a testing principle p <0.05. this shows that the cold compresses affect first stage delivery pain at bpm. it can be seen that almost all of the respondents before undergoing cold compress therapy experienced severe pain. after the cold compress therapy was conducted, all respondents experienced a decrease in pain even if the decrease was not significant. this is because the pain is very subjective. after all, how the pain is felt varies in each individual in terms of scale in addition to the level, the mechanism of pain and their pain adaptations. from this, it can be seen that cold compresses greatly affect the decrease in labor pain in the first stage. discussion the first stage of labor is the result of the contraction of the uterine myometrium and the vasoconstriction of the blood vessels around the internal genitalia. this is in addition to the parasympathetic involvement of the efferent nerve fibers around the internal genitalia(mesenburg et al., 2018). because of these two nerve responses, rhythmic and intermittent uterine contractions occur. before a cold compress, the nerves that are around the uterus and cervix will experience tension. this can cause severe pain in the first stage of birth. after the cold compress, the nerves around the uterus and cervix begin to relax so then the labor pain at the first stage reduces(perez-brena et al., 2015). the effect of cold compresses on pain according to the gate control theory says that skin stimulation activates the greater and faster transmission of the sensory a-beta nerve fiber signals(van der gucht & lewis, 2015). this process decreases the pain transmission through the small diameter c and a-beta fibers. the syntax gate ends the pain implant transmission(deye, n., vincent, f., michel, p., ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.-f. (2016). cold compresses will have an analgesic effect by slowing down the speed of the nerve delivery so then the pain signal reaches the brain less often and more slowly. other mechanisms that might work are the cold perception becoming dominant, thus reducing the pain perception. cold compress therapy is useful as vasoconstriction reduces the blood flow to the injured body area, preventing the formation of edema and reducing inflammation. local anesthesia can be used to reduce the local pain. cellular metabolism decreases to reduce the oxygen demand of the tissue. increased blood viscosity increases blood coagulation at the site of the injury. decreased muscle tension is useful for pain relief. conclusion childbirth is a series of processes that ends with the release of the child from the womb of the mother. this process begins with labor contractions, marked by the opening of the cervix. it ends with the birth of the placenta. the labor process is identical to the pain that will be experienced. physiologically, pain occurs when the muscles of the uterus contract to open the cervix and push the baby's head towards the pelvis. to reduce the pain in the first stage of labor, nonjurnal ners http://e-journal.unair.ac.id/jners | 475 pharmacological methods can be applied including a cold compress. references deye, n., vincent, f., michel, p., ehrmann, s., da silva, d., piagnerelli, m., … laterre, p.-f. (2016). changes in cardiac arrest patientsâ€tm temperature management after the 2013 “ttm― trial: results from an international survey. annals of intensive, 6(1). http://doi.org/10.1186/s13613015-0104-6. al-hussaini, m., & mustafa, s. (2016). adolescentsâ€tm knowledge and awareness of diabetes mellitus in kuwait. alexandria journal of medicine, 52(1), 61–66. http://doi.org/10.1016/j.ajme.2015.04.001, pollach, g., brunkhorst, f., mipando, m., namboya, f., mndolo, s., & luiz, t. (2016). the “first digit law― – a hypothesis on its possible impact on medicine and development aid. medical hypotheses, 97, 102–106. http://doi.org/10.1016/j.mehy.2016.10.021, asiedu, k., kyei, s., ayobi, b., agyemang, f. o., & ablordeppey, r. k. (2016). survey of eye practitionersâ€tm preference of diagnostic tests and treatment modalities for dry eye in ghana. contact lens anterior eye, 39(6), 411–415. http://doi.org/10.1016/j.clae.2016.08.001, barakat, k. h., gajewski, m. m., & tuszynski, j. a. (2012). dna polymerase beta (pol β) inhibitors: a comprehensive overview. drug discovery today, 17(15–16), 913–920. http://doi.org/10.1016/j.drudis.2012.04.008, mocan, o., & dumitraşcu, d. l. (2016). the broad spectrum of celiac disease and gluten sensitive enteropathy. clujul medical, 89(3), 335–342. http://doi.org/10.15386/cjmed-698, … chinsembu, k. c. (2015). plants as antimalarial agents in sub-saharan africa. acta tropica, 152, 32–48. http://doi.org/10.1016/j.actatropica.2015.08.00 9. (2015b). cultural norms, knowledge and attitudes regarding abortion in rural ghana. annals of global health. mesenburg, m. a., victora, c. g., jacob serruya, s., ponce de león, r., damaso, a. h., domingues, m. r., & da silveira, m. f. (2018). disrespect and abuse of women during the process of childbirth in the 2015 pelotas birth cohort prof. suellen miller. reproductive health, 15(1). https://doi.org/10.1186/s12978-018-0495-6 perez-brena, n. j., updegraff, k. a., umaña-taylor, a. j., jahromi, l., & guimond, a. (2015). coparenting profiles in the context of mexican-origin teen pregnancy: links to mother-daughter relationship quality and adjustment. family process, 54(2), 263–279. https://doi.org/10.1111/famp.12115 spector, j. m., lashoher, a., agrawal, p., lemer, c., dziekan, g., bahl, r., … gawande, a. a. (2013). designing the who safe childbirth checklist program to improve quality of care at childbirth. international journal of gynecology and obstetrics, 122(2), 164–168. https://doi.org/10.1016/j.ijgo.2013.03.022 srivastava, a., avan, b. i., rajbangshi, p., & bhattacharyya, s. (2015). determinants of women’s satisfaction with maternal health care: a review of literature from developing countries. bmc pregnancy and childbirth, 15(1). https://doi.org/10.1186/s12884-015-0525-0 van der gucht, n., & lewis, k. (2015). women’s experiences of coping with pain during childbirth: a critical review of qualitative research. midwifery, vol. 31, pp. 349–358. https://doi.org/10.1016/j.midw.2014.12.005 vowles, k. e., mccracken, l. m., sowden, g., & ashworth, j. (2014). psychological flexibility in coping with chronic pain: further examination of the brief pain coping inventory-2. clinical journal of pain, 30(4), 324–330. https://doi.org/10.1097/ajp.0b013e31829ea18 7 513 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20520 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review of fatigue in type 2 diabetes bayu febriandhika hidayat, tintin sukartini , and tiyas kusumaningrum faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: fatigue is often found in people with type 2 diabetes and it is known as diabetes fatigue syndrome. fatigue is a widespread clinical complaint among people with type 2 diabetes (t2dm). it has been directly related to poor self-reported health and it is likely a key barrier to the successful self-management of diabetes. the aim of this study was to identify fatigue in type 2 diabetes. methods: the databases used to identify suitable articles were scopus, science direct and pubmed limited articles published between 2012 and 2019 in english with the full text available. the search utilized the keywords of “diabetes, fatigue, diabetes fatigue syndrome, and type 2 diabetes”. searching for the articles also used “and”. results: following the search, 7 articles met the inclusion criteria. the studies were classified into 3 groups based on the causes of fatigue. the causes of fatigue involve physiological factors, psychological factors and lifestyle factors. conclusion: diabetes fatigue syndrome is defined as a multifactor syndrome of fatigue or easy fatigability occurring in persons with diabetes caused by a variety of lifestyle, nutritional, medical, psychological, glycemia/diabetes-related, endocrine, and iatrogenic factors. article history received: feb 27, 2020 accepted: april 1, 2020 keywords diabetes fatigue syndrome; fatigue; type 2 diabetes contact tintin sukartini,  tintin-s@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: hidayat, b. f., sukartini, t., & kusumaningrum, t. (2020). a systematic review of fatigue in type 2 diabetes. jurnal ners, special issues, 513-517. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20520 introduction diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient selfmanagement, education, and support to prevent acute complications and to reduce the risk of longterm complications(american diabetes association, 2013). type 2 diabetes (t2dm) is associated with several long-term complications and symptoms, many of which are debilitating that compromise the physical and mental health of those affected (park, park, quinn, & fritschi, 2015). the most prevalent symptoms are acute and chronic pain, depression and fatigue (sudore et al., 2012). fatigue is a general, frequently seen complaint experienced by everyone in their daily life. fatigue is a word used very frequently in everyday conversations that has varied subjective meanings. words like fatigue, tiredness, lacking energy and exhaustion are commonly used interchangeably(singh, teel, sabus, mcginnis, & kluding, 2016). although it is a universal symptom that occurs in all physical and mental diseases to varying degrees, it is quite difficult to define and it has been defined differently by many healthcare disciplines. fatigue is used in the same sense as weakness, lassitude, a lack of energy, and debility. it can be defined as a state of physical and mental exhaustion to include, in a sense, all of the above (yönt, h., akin korhan, e. & çiray gündüzog˘ lu, 2012). fatigue is a widespread clinical complaint among patient with type 2 diabetes (t2dm) and it has been directly related to poor self-reported health. it is likely to be a key barrier to the successful selfmanagement of diabetes(c. fritschi & fink, 2012). the presence of shortand long-term complications of diabetes and their symptoms including the symptoms of hypo or hyperglycemia, cardiac disease, neuropathy, or retinopathy, has also been associated with increased fatigue (singh & kluding, 2013). fatigue has also been associated with decreased physical functioning and a decreased ability to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:tintin-s@fkp.unair.ac.id b. f. hidayat et al. 514 | pissn: 1858-3598  eissn: 2502-5791 manage routine daily activities (nijrolder, van der windt, & van der horst, 2008). fatigue is one of the most common somatic symptoms associated with depression. fatigue in diabetes may be associated with physiological phenomena such as hypoglycemia or hyperglycemia or wide swings between the two(cynthia fritschi & quinn, 2010). furthermore, in order to identify the features of the related variables, a comprehensive review of fatigue in diabetes should be performed. this study aims to contribute to the study of fatigue in relation to type 2 diabetes by performing a systematic review of the literature concerning fatigue in type 2 diabetes. materials and methods strategy for searching for studies articles published in english were searched for among the scopus, sciencedirect, and pubmed databases. the relevant literature was searched from january 18th to february 27th 2020. the publication time was limited to between 2012 and 2019. the search terms used were “diabetes”, “fatigue”, “diabetes fatigue syndrome” and “type 2 diabetes”. study selection all of the studies found related to the fatigue of patients with type 2 diabetes only. the search focused on the title, abstract and keywords. the inclusion criteria were as follows: (1) document type was an original article; (2) sourced from a journals; (3) article was in english and (4) article available in full text. the age of the subject in the items was not specified in order to fully capture fatigue related to type 2 diabetes mellitus (t2dm). the publication time limit was between 2012 and 2019 (figure 1). the researcher set the inclusion and exclusion criteria. the researcher consulted with experts in the field of nursing studies and their supervisor in order to determine the final results of the articles that were obtained for the final analysis. a meeting between the researchers and investigators was used to reduce and overcome any existing disagreements. the research process followed the cochrane guidelines. finally, 7 articles were found and included in the final analysis. the specific flow diagram used has been shown in fig 1 following identification, screening, eligibility, and inclusion. the table analysis can be seen in table 2. the ethical issues encountered when preparing the manuscript of the systematic reviews were as follows: 1) avoiding redundant articles or duplicates; 2) avoiding plagiarism; 3) the transparency of the screening of the article, process analysis, and evaluation; 4) ensuring accuracy, and 5) flagging suspected plagiarism or fraudulent research. results general features and type of studies based on the 7 articles that have been analyzed (table 1) and upon looking at the types of research design, there were 6 (85.7%) cross-sectional articles. general features and study types the results obtained by the researchers from the 7 articles that have been analyzed show that all of the articles show the final result that fatigue is common in patient with type 2 diabetes. this is likely affected table 1. general characteristics of the selected studies (n=7) category n % year of publishing 2012 2 28.6 2013 1 14.3 2014 1 14.3 2015 2 28.6 2016 1 14.3 type of study cross-sectional 6 85.7 descriptive 1 14.3 search of the scopus, science direct and pubmed databases. search terms: (fatigue and diabetes) or (fatigue and type 2 diabetes) or (diabetes and diabetes fatigue syndrome) or (diabetes fatigue syndrome and type 2 diabetes) records identified through database searching: scopus (12 articles); science direct (81 articles); pubmed (106 articles) screening of the research results by reviewing the titles, abstracts, keywords, and after duplicate articles were removed. scopus (2 articles); science direct (3 articles); pubmed (6 full-text publication assessed for eligibility (n=11) studies included in the synthesis (n=7) screening excluded due to articles lacking fulltext availability, nonenglish language, and irrelevancy with the topic (n=188) full-text articles excluded due to: irrelevancy with fatigue in type 2 diabetes and duplicate articles (n=4) figure 1 – articles selection process jurnal ners http://e-journal.unair.ac.id/jners | 515 by a combination of physiological, psychological and lifestyle-related phenomena, especially the presence and severity of the diabetes symptoms, depressive symptoms, and a high bmi. there were correlations between fatigue, a1c, depression, diabetes symptoms and diabetes distress in the articles (chyntia fritschi et al., 2012; park et al., 2015). although fatigue is a common complaint among patients with type 2 diabetes, few studies have directly tested the presence and severity of fatigue in people with type 2 diabetes (singh & kluding, 2013). fatigue was significantly higher among the female patients, the older patients and those with a longer expected disease duration (seo, hahm, kim, & choi, 2014). discussion patients with type 2 diabetes often experience fatigue. this impacts their self-care and quality of life (c. fritschi & fink, 2012). fatigue is defined as a decrease in the capacity to perform physical and/or mental tasks. uncontrolled blood glucose levels are indicated to be indirectly associated with fatigue in patients (zhao, suhonen, katajisto, & leino-kilpi, 2018). fatigue might be experienced as tiredness at rest, a lack of endurance or a loss of vigor (segerstedt, lundqvist, & eliasson, 2015). fatigue is defined as physical and/or mental exhaustion that can be triggered by stress, medication, overwork, or mental and physical illness or disease. fatigability is a term used to assess how fast someone gets exhausted. easy fatigability implies the occurrence of physical and/or mental exhaustion at a level of work or stress that should ordinarily not cause exhaustion. fatigue impairs physical as well as mental functioning, and it reduces quality of life. thus, a person presenting with complaints of fatigue deserves a focused endocrine and medical check-up (kalra & sahay, 2018). fatigue in type 2 diabetes can result from 3 factors. the physiological factors include it being due to acute or chronic hypoglycemia or hyperglycemia, the variability of the patient’s blood glucose and diabetes symptom distress. the psychological factors include depression or emotional distress related to the diagnosis or progress of diabetes, sleep disturbance, and restless legs syndrome. the lifestyle factors, for example, include sedentary behavior, weight control issues or obese sarcopenia. the severity of the fatigue symptoms is influenced by the variety of physical and pathological indicators. these etiologies contribute to the physical limitations present and functional independence. the decrease in muscle strength and quality leads to muscle fatigue and a consequent reduction in work capacity. long term and chronic fatigue will cause an inability for the diabetes to exercise self-care, resulting in physical disability, emotional distress and insomnia (c. fritschi & fink, 2012; kalra & sahay, 2018; lien, hwang, & jiang, 2018). etiology of fatigue in type 2 diabetes fatigue in type 2 diabetes can be caused by 2 factors, namely endocrine and non-endocrine factors. nonendocrine factors include decreased physical condition, poor sleep patterns, the consumption of alcohol and caffeine and the consumption of drugs (lifestyle). an unhealthy diet can cause macronutrient or micronutrient malnutrition or starvation ketosis, meaning that people with diabetes lack energy (nutrition) and have general medical conditions such as anemia, electrolysis, and multiple vitamin deficiencies. these conditions are characterized by fatigue (medical conditions) and psychological disorders can worsen fatigue in type 2 diabetes (psychological). the endocrine causes of fatigue in type 2 diabetes include poor glycemic control, diabetes complications, and concomitant endocrinopathy (diabetes). diseases such as hypothyroidism, addison's disease, cushing's syndrome and hypothyroidism, if left unrecognized and / or untreated, can exacerbate the fatigue of type 2 diabetes patients (endocrine). drugs such as corticosteroids, beta blockers, diuretics, and statins can also cause fatigue (iatrogenic)(kalra & sahay, 2018). therapy of fatigue type 2 diabetes therapy to overcome fatigue in diabetics can be classified as either pharmacological and behavioral therapy. pharmacological therapy aims to reduce the level of fatigue, depression and high levels of proinflammatory cytokines. antirheumatic drugs that modify the disease, including etanercept, the tnf-α receptor fusion protein, have been shown to reduce fatigue and improve the patient’s physical and psychological functioning. behavioral therapy to overcome fatigue in type 2 diabetes includes weight reduction, changes in diet and changes in sleep pattern (c. fritschi & fink, 2012). conclusion the systematic review of the research conducted by the researchers in the form 7 articles based on the inclusion criteria shows that people with type 2 diabetes appear to have greater levels of fatigue. a number of complications resulting from diabetes may be related to this fatigue. fatigue is caused by several factors including physiological, psychological or lifestyle factors. future researchers are expected to use this systematic review study as a reference related to fatigue in type 2 diabetes. references american diabetes association. (2013). standards of medical care in diabetes. diabetes care, 36(suppl.1). https://doi.org/10.2337/dc13s011 aylaz, r., karadağ, e., işik, k., & yildirim, m. (2015). relationship between social support and fatigue b. f. hidayat et al. 516 | pissn: 1858-3598  eissn: 2502-5791 in patients with type 2 diabetes mellitus in the east of turkey. japan journal of nursing science, 12(4), 367–376. https://doi.org/10.1111/jjns.12076 fritschi, c., & fink, a. m. (2012). fatigue in adults with type 2 diabetes—an overview of current understanding and management approaches. us endocrinology, 08(02), 84. https://doi.org/10.17925/use.2012.08.02.84 fritschi, chyntia, quinn, l., hacker, e. d., penckofer, s. m., wang, e., foreman, m., & ferrans, c. e. (2012). fatigue in women with type 2 diabetes. 38(5), 662–672. https://doi.org/10.1177/0145721712450925.f atigue fritschi, cynthia, & quinn, l. (2010). fatigue in patients with diabetes: a review. journal of psychosomatic research, 69(1), 33–41. https://doi.org/10.1016/j.jpsychores.2010.01.0 21 kalra, s., & sahay, r. (2018). diabetes fatigue syndrome. diabetes therapy, 9(4), 1421–1429. https://doi.org/10.1007/s13300-018-0453-x lasselin, j., layé, s., dexpert, s., aubert, a., gonzalez, c., gin, h., & capuron, l. (2012). fatigue symptoms relate to systemic inflammation in patients with type 2 diabetes. brain, behavior, and immunity, 26(8), 1211–1219. https://doi.org/10.1016/j.bbi.2012.03.003 lien, a. s.-y., hwang, j.-s., & jiang, y.-d. (2018). diabetes related fatigue sarcopenia, frailty. journal of diabetes investigation, 9(1), 3–4. https://doi.org/10.1111/jdi.12752 nijrolder, i., van der windt, d. a. w. m., & van der horst, h. e. (2008). prognosis of fatigue and functioning in primary care: a 1-year follow-up study. the annals of family medicine, 6(6), 519– 527. https://doi.org/10.1370/afm.908 park, h., park, c., quinn, l., & fritschi, c. (2015). glucose control and fatigue in type 2 diabetes: the mediating roles of diabetes symptoms and distress. journal of advanced nursing, 71(7), 1650–1660. https://doi.org/10.1111/jan.12632 segerstedt, j., lundqvist, r., & eliasson, m. (2015). patients with type 1 diabetes in sweden experience more fatigue than the general population. journal of clinical & translational endocrinology, 2(3), 105–109. https://doi.org/10.1016/j.jcte.2015.06.001 seo, y., hahm, j., kim, t., & choi, w. (2014). factors affecting fatigue in patients with type ii diabetes mellitus in korea. asian nursing research, 9(1), 60–64. https://doi.org/10.1016/j.anr.2014.09.004 singh, r., & kluding, p. m. (2013). fatigue and related factors in people with type 2 diabetes. the diabetes educator, 39(3), 320–326. https://doi.org/10.1177/0145721713479144 singh, r., teel, c., sabus, c., mcginnis, p., & kluding, p. (2016). fatigue in type 2 diabetes: impact on quality of life and predictors. plos one, 11(11), 1–13. https://doi.org/10.1371/journal.pone.0165652 sudore, r. l., karter, a. j., huang, e. s., moffet, h. h., laiteerapong, n., schenker, y., … schillinger, d. (2012). symptom burden of adults with type 2 diabetes across the disease course: diabetes & aging study. journal of general internal medicine, 27(12), 1674–1681. https://doi.org/10.1007/s11606-012-2132-3 yönt, h., akin korhan, e. & çiray gündüzog˘ lu, n. (2012). fatigue after stroke and quality of life. journal of health sciences firat university, 26, 115–120. zhao, f.-f., suhonen, r., katajisto, j., & leino-kilpi, h. (2018). the association of diabetes-related selfcare activities with perceived stress, anxiety, and fatigue: a cross-sectional study. patient preference and adherence, volume 12, 1677– 1686. https://doi.org/10.2147/ppa.s169826 jurnal ners http://e-journal.unair.ac.id/jners | 517 appendix table 2. summary of the selected studies title &author design sample variables results relationship between social support and fatigue in patients with type 2 diabetes mellitus in the east of turkey[aylaz, et al., 2015] descriptive 312 respondents social support, fatigue, type 2 diabetes. social support reduced the level of fatigue in a number of patients with type 2 diabetes. fatigue in women with type 2 diabetes [fritschi c. et al., 2012] crosssectional 83 respondents physiological, psychological, lifestyle, fatigue, type 2 diabetes. physiology, psychology and lifestyle are associated with fatigue in women with type 2 diabetes. fatigue and related factors in people with type 2 diabetes [singh & kluding, 2013] crosssectional 40 respondents fatigue symptoms, systemic inflammation, type 2 diabetes. this study findings indicate that systemic low-grade inflammation relates to fatigue symptoms in patients with type 2 diabetes. this suggests the involvement of inflammatory processes in the pathophysiology of diabetes-related fatigue. fatigue symptoms relate to systemic inflammation in patients with type 2 diabetes [lasselin, et al., 2012] crosssectional 155 respondents glucose control, fatigue, diabetes symptoms diabetes distress, type 2 diabetes. this study findings suggest that fatigue is indirectly related to glucose control. glucose control and fatigue in type 2 diabetes: the mediating roles of diabetes symptoms and distress[park, et al., 2015] crosssectional 180 respondents factors affecting diabetes, fatigue, type 2 diabetes. hypoglycemia symptoms were confirmed to be a predictor of fatigue. fatigue in type 2 diabetes: impact onquality oflife andpredictors[singh, et al., 2016] crosssectional 70 respondents fatigue, related factor of fatigue, type 2 diabetes. higher levels of fatigue were noted in people with type 2 diabetes compared to the healthy agematched control. factors affecting fatigue in patients with type ii diabetesmellitusin korea[seo, et al., 2014] crosssectional 48 respondents fatigue, quality of life (qol), type 2 diabetes. fatigue affects the quality of life (qol) of patient with type 2 diabetes. t2dm: type 2 diabetes mellitus; qol: quality of life; 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 199 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.19306 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research life experience of pregnant woman with gestational diabetes mellitus in maternal role attainment in special region of yogyakarta indah wulaningsih1, elsi dwi hapsari2, heny pangastuti2, and robert priharjo3 1 stikes karya husada semarang, indonesia 2 universitas gadjah mada, yogyakarta, indonesia 3 anglia ruskin university, cambridge, cambridgeshire, uk abstract introduction: gestational diabetes mellitus (gdm) is any abnormal carbohydrate intolerance that begins or is first recognized during pregnancy. the presence of gdm has important implications for both the baby and the mother. objective: this study explored life experience of pregnant woman with gdm in maternal role attainment. methods: this was a phenomenological approach qualitative research. participants were 12 mothers who gave birth to a maximum of 1 year with a history of gdm selected by purposive sampling technique with sampling criteria. data analysis used the colaizzi method (2011). results: there were eight categories, e.g. the experience of the mother in gdm diagnosis; the influence gdm of the pregnancy; mother's experience in trying hard to keep her pregnancy; a variation of life experience of mothers during pregnancy, childbirth, and post-delivery; the perception of mother of her role being a mother, the factors that support the development and achievement of the maternal role attainment; the mother's experience in integrating the identity of her role as mother; gap and the desire of the mother with gdm in receiving health services. life experience of gdm mothers in achieving maternal role attainment has a diversity. discussion: pregnant mothers with gdm experience various maternal role attainments. they cannot attain the role optimally. article history received: may 20, 2020 accepted: october 27, 2020 keywords gestational diabetes mellitus; life experience; maternal role attainment contact indah wulaningsih  ns.indah@gmail.com  stikes karya husada semarang, indonesia cite this as: wulaningsih, i., hapsari, e.d., pangastuti, h., & priharjo, r (2020). life experience of pregnant woman with gestational diabetes mellitus in maternal role attainment in special region of yogyakarta. jurnal ners, 15(2). 199-207. doi:http://dx.doi.org/10.20473/jn.v15i2.19306 introduction gdm is defined as glucose intolerance with onset or first recognition during pregnancy. the definition does not require any return to normal glucose levels following delivery. thus, gdm simply represents relatively high glucose levels at one point in the life of a young woman (buchanan et al., 2012). gdm is a form of hyperglycemia. in general, hyperglycemia results from an insulin supply that is inadequate to meet tissue demands for normal blood glucose regulation. studies conducted during late pregnancy, when, as discussed below, insulin requirements are high and differ only slightly between normal and gestational diabetic women, consistently reveal reduced insulin responses to nutrients in women with gdm. studies conducted before or after pregnancy, when women with prior gdm are usually more insulin resistant than normal women (also discussed below), often reveal insulin responses that are similar in the two groups or reduced only slightly in women with prior gdm. however, when insulin levels and responses are expressed relative to each individual’s degree of insulin resistance, a large defect in pancreatic ß cell function is a consistent finding in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ns.indah@gmail.com i. wulaningsih et al. 200 | pissn: 1858-3598  eissn: 2502-5791 women with prior gdm (buchanan et al., 2012; plows et al., 2018). the presence of gdm has important implications for both the baby and the mother. as regard baby complication, gdm is associated with a significantly increased risk of macrosomia, shoulder dystocia, birth injuries as well as neonatal hypoglycemia and hypobilurinemia. gdm also adds an intrauterine environmental risk factor to an increased genetic risk for the development of obesity, diabetes and/or metabolic syndrome in childhood. as regard mothers’ complications, gdm is a strong risk factor for the development of permanent diabetes later in life (40% in 10 subsequent. years) and gdm in successive pregnancies (35%), increasing with the age and weight of the mother. an important intervention on long-term metabolic benefits for both mother and offspring has been attributed to breastfeeding. in the offspring, a protective role was seen against excessive fat accumulation, protection against childhood infections, cardiovascular diseases and type 2 diabetes, while in women an association between lactation and low concentrations of glucose and insulin and a better tolerance to glucose was seen and a significant delay in the appearance of type 2 diabetes in women with gdm (alia et al., 2019). in indonesia, the prevalence of gdm is around 14% of all pregnant women, and 10-25% of the total cases handled are undiagnosed or diagnosed gdms (dewi et al., 2020). according to medical record department, sardjito hospital of yogyakarta, the prevalence of gdm in indonesia is approximately 1,93,6 on inpatient disease index of gdm in the last 10 years from 2012-2013. materials and methods this research was a phenomenological approach qualitative research. data collection was carried out through in-depth interviews with a voice recorder and field notes. participants were selected based on research needs with the principle of appropriateness and adequacy. participants in this research were mothers who delivered to a maximum of 1 year with a history of gdm. the data collection was finished in the twelve participant when the categorization of data was saturated. in addition, the availability of time and resources in research is also taken into consideration in ending data collection. this research instrument was the researchers themselves. purposive sampling technique with sampling criterion was used. the inclusion criteria in this study were 1). mothers who have given birth for a maximum of the last 1 year and were treated at dr. sardjito with a history of dmg. 2) living in the special region of yogyakarta province. 3). the maternal age of delivery was less than 18–45 years. 4). maternal gestational age was less than 32 weeks and more than 40 weeks. 5). willing to become a participant by agreeing the informed consent. the exclusion criterion was poor pregnancy outcome (stillbirth and severe defects). data analysis used the colaizzi method. the inclusion of additional steps were 1). transcribing all the subjects’ descriptions. 2). extracting significant statements (statements that directly relate to the phenomenon under investigation). 3). creating formulated meanings. 4). aggregating formulated meanings into theme clusters. 5). developing an exhaustive description (that is, a comprehensive description of the experience as articulated by participants). 6). additional step was researcher’s interpretative analysis of symbolic representations from the articulation of the symbolic representation (which occurred during participant interview). 7). identifying the fundamental structure of the phenomenon. 8). returning to participants for validation (edward & welch, 2011). data were collected between december 2013 and february 2014. nursing theory of maternal role attainment (shrestha et al., 2019) was used as a reference to analyse life experience of mother with gdm. the validity of the data in this research was tested and included the credibility, dependability, and conformability. the study was declared to have passed the ethical review by the research ethics committee, faculty of medicine, gadjah mada university. results based on the criteria for inclusion, participating gained as many as five mothers with gdm. in-depth interviews were conducted with participants, which showed mixed results about life experience of pregnant women with gdm in yogyakarta. this study obtained as many as eight themes of the subcategories that have been arranged. theme 1: experiences of mothers in the diagnosis of gdm mothers’ experiences when diagnosed of gdm determined the sustainability of the mother's condition during pregnancy. sub-categories of signs and symptoms, as well as the causes of diabetes mellitus in pregnancy, were expressed by the participants as follows: p5-12: "well heredity and lifestyle is wrong, wrong diet contains a lot of sugar." sub-category of mothers’ ignorance about the disease when pregnant was expressed by participants as follows: p2-18: "during pregnancy, i didn’t know jurnal ners http://e-journal.unair.ac.id/jners | 201 what diabetes mellitus is, so i didn’t take any treatment, just checked my pregnancy with midwives and district health centre. i’ve just known this after surgery process, so i didn’t realize and know before. i just knew when i had a treatment in sardjito hospital, and i was brought into a quiet room. after delivering, i was checked on sugar level, it reached 600 and i was placed in a different ward.” theme 2: influence of diabetes mellitus on pregnancy gestational diabetes mellitus influences maternal and fetal. from the results of interviews with participants it was found the data on the effect of the decrease in fetal condition. participant p1-5 said: “when i had doctor visits around 9 or 10 am, my baby’s heartbeat was supposed to 150 per minutes, but it declined 50 beats per minute, so the doctor advised me to have surgery in the afternoon. my baby was born after 8 months pregnancy, the weight was 1800 grams." the children's condition at birth showed varied circumstances, there were babies who in healthy condition and started to cry, some were born with sepsis and small infants and also experienced hypoglycemia and needed to be treated. there were not enough birth month and low birth weight data. theme 3: experiences of mothers’ effort to save their pregnancy maintaining pregnancy with diabetes mellitus make a mother desperate to retain the fetus and the mother to remain healthy. there are many ways for mothers to save their pregnancy, such as maintaining maternal and fetal maturity by checking their pregnancy into the hospital with a pregnancy condition of insufficient enough months, then the mothers continually do antenatal care. here are the expressions of participant: p2-27: "i do monthly check in kalasan hospital, i am not suitable to midwives. they said i had to check my pregnancy into the hospital. " theme 4: variation of life experience of the mother during pregnancy, childbirth, and postpartum participants have diverse life experiences during pregnancy, delivering, and postpartum. the experience of mothers with gdm during pregnancy is that pregnancy test was done at the health centre and hospital. there is also diversity when the mother checked the pregnancy, which is revealed by the participants as follows: p1-7: "examination of pregnancy is regularly done in health centre, but i never join maternal exercise." the experience of participants in facing the delivery process is very diverse; the delivery process was done by surgery. experiences of pregnant women suffering from gdm becomes a traumatic feeling. this is proved by the expression that, postpartum, the mothers decided to use iud. they were afraid they would get pregnant again and had complaints unwanted if they did not use contraception. theme 5: maternal perception of role during pregnancy mothers who have a good maternal role are able to find out the truth about something that is inherent in children (blind-ing-in) and have a comfortable sense of identity (maternal role identity). this means that a mother is able to integrate her role in the system itself with the suitability of herself and other roles. the situation makes mothers rate themselves on how they underwent her role is shown by the feeling of helplessness that indicated a sense of worry about whether their children have the degenerative disease of diabetes mellitus and the confusion of mothers in caring the baby because the baby is too small. here is the expression of participant : p1-15: "yes i am so happy. there is gladness and worry, i am worried whether my child has a degenerative disease. " theme 6: the factors that support the development and maternal role attainment husband's support, family support, and commitment of the mother are the support system for the mother to carry out her role as a mother. here are the expressions of participants: p4-14: "my husband supports me, he saves me, maintains my diet, delivers me to check my pregnancy..." p1-22: "my family has always suggested to check when my check-up time is due, encourage me that i will have a little girl and support me to have a treatment . they support me to do routine treatment, providing support, give support. my husband also supports me. " theme 7: experience in integrating maternal role as mother. the identity of the mother's role can be achieved when the mother is able to integrate herself into the role with her suitability and other roles. mothers will feel secure in their identity as a mother. data were obtained from participants in achieving that role identity, the mother can indicate how being parents makes them happy. participantsp1-46 expressed: "we’ll give our baby love too." i. wulaningsih et al. 202 | pissn: 1858-3598  eissn: 2502-5791 theme 8: gaps and desires of mothers with diabetes in receiving healthcare in providing health services to clients, health professionals are expected to provide care and other services because it influences the healing and prosperity of the client. clients’ hope of health workers is to give more attention to the patient, because pregnant women with diabetes mellitus are particularly vulnerable and cause complications of other diseases. participant p5-30 said: "well, basically if there is a patient, they hoped to be taken care of because dm is a disease that can cause fatal effect to fetal.” discussion theme 1: experiences of mothers in the diagnosis of gdm pregnancy is a normal physiological process. the majority of pregnancy is accepted by the mother as something that had to be lived with. but the experience of the mother diagnosed with diabetes during pregnancy is a special experience for the mother and a serious challenge to maintain and undergo pregnancy. therefore, it is very necessary to do prenatal care for the mother and fetus to align processes to avoid pregnancy complications and decrease the incidence of morbidity or perinatal and maternal mortality (schellinger et al., 2017). the antenatal care is the first step to establish a diagnosis. signs and symptoms of diabetes mellitus assessment need to be done when the mother's make their first visit to the antenatal care (muche et al., 2019). during pregnancy, increased levels of certain hormones made in the placenta (the organ that connects the baby by the umbilical cord to the uterus) help shift nutrients from mother to fetus. another hormone produced by the placenta helps prevent the mother from developing low blood sugar. during pregnancy, this hormone causes progressive disruption of glucose intolerance (blood sugar levels are higher) (soheilykhah et al., 2010). to try to lower blood sugar levels, the body makes more insulin so that the cells have glucose for producing energy sources. mother’s pancreas is able to produce more insulin (about three times the normal amount) to overcome the effects of pregnancy hormones on blood sugar levels. however, if the pancreas cannot produce enough insulin to overcome the effect of the increase hormones during pregnancy, blood sugar levels will rise, causing gdm (durnwald, 2015; shanthi et al., 2019). the result of this study shows that the cause of gdm is due to hereditary factors, immunological factors, and diabetes acquired during pregnancy. the etiologies of gdm are genetic, immunological factors, environmental factors, age, and obesity (bare & smeltzer, 2010). secondary data from this study revealed that, when mothers do first antenatal care, screening is not performed on blood sugar levels. it is similarly stated by participants when they did their first antenatal care. this is why gdm becomes unmanageable in trimester 1, trimester 2 and trimester 3, so mother and fetus experience pain, which, in turn, causes termination of pregnancy although at less than 38 weeks gestation. theme 2: the effect of gdm on pregnancy pregnant women need more insulin to maintain normal carbohydrate metabolism. if you are not able to produce insulin to meet these demands, it can cause diabetes, which results in changes in the metabolism of carbohydrates. gdm has a significant effect on pregnancy in the mother and baby. in the fetus, it is indicated by a decrease in the condition of the fetus with the fetal heart rate becoming weakened, children born with low birth weight and premature infants (plows et al., 2018). fetal heart rate (fhr) indicates a weakening of this increased parasympathetic response. fhr conditions can cause a bradycardia fetal wherein fhr is below 110 beats/min. this situation can be regarded as a sign of fetal hypoxia and is known to occur prior to the death of the fetus. some of the child's conditions at birth were born with healthy condition and immediately cry, low birth weight, sepsis infection, and hypoglycemia. infants with low birth weight and hypoglycemia are known to occur due to the disruption of placental insufficiency. because the glucose can diffuse through the placenta to the fetus, so the level in fetal blood is almost like the maternal blood levels. mother insulin cannot reach the fetus, so the mother's blood sugar levels affect fetal blood levels (alia et al., 2019; plows et al., 2018). these results are reinforced by compelling evidence that mild maternal hyperglycemia is a risk factor for fetal morbidity. failure to recognize and deal with these conditions will result in unwanted morbidity in multiple pregnancies, while overly aggressive management will result in the emergence of intervention is not required. infants of diabetic mothers have unique problems and require special handling (alia et al., 2019). one previous study showed that babies born to mothers with a history of dm revealed an increase in the sectio caesarean delivery and preterm births (joy & sivakumar, 2012). diabetes is a common complication of pregnancy. patients can be separated into two, namely those who had previously known about diabetes and those diagnosed with diabetes during pregnancy (gestational). maternal factors obtained in mothers with gdm are hypertension, preeclampsia, and increased risk of caesarean section (huang et al., 2020). maternal glucose levels are unstable and it can cause fetal death in utero, which is a typical occurrence in women with diabetes. the fetus exposed to hyperglycemia tends to asphyxia and jurnal ners http://e-journal.unair.ac.id/jners | 203 acidosis although the exact mechanism is unclear, but is thought ketoacidosis has close links with the death of the fetus. when maternal or blood glucose levels are within normal limits, the death of the fetus in the uterus is rare (alberico et al., 2017). hyperinsulinemia that occurs in the fetus will increase the metabolic rate and oxygen needs to deal with situations such as hyperglycemia, ketoacidosis, pre-eclampsia and vascular disease, which can reduce blood flow and oxygenation placenta-utero fetus. the frequency of fetal death in utero or stillbirth ranged from 15-20%. an attempt to avoid the sudden death of the fetus in the womb is to terminate the pregnancy a few weeks before term (alia et al., 2019). the risk factors occur in maternal age between 16-28 years old, women with multigravida, maternal history of diabetes mellitus and non-diabetic mothers (joy & sivakumar, 2012). family history of diabetes mellitus has a strong correlation with gdm. complications that arise are pih (pregnancy induced hypertension), hypothyroidism, and caesarean delivery. gdm causes significant complications, especially for mother and the fetus, including preeclampsia, eclampsia, polyhydramnios, fetal macrosomia, birth trauma, caesarean delivery, neonatal metabolic complications and perinatal mortality (soheilykhah et al., 2010). in this study, the opening of the cervix during delivering is not significant, because the action is performed by a medical team to spur the cervical dilatation. however, these measures do not give good results, so the operative action was done. caesarean delivery is one of the complications of gdm. this study is consistent with studies conducted by researchers in that the effect of gdm on the pregnancy occurred because of the same risk factors, namely maternal age in the range of 20-28 years, caesarean delivery, and recurrent miscarriage. theme 3: experiences of mothers in the extra effort to keep her pregnancy maintaining the pregnancy makes the mother desperate to retain the fetus and her own health. various efforts have been done for mother and the fetus to achieve good condition and wellbeing. the experience of mothers to keep a longer pregnancy is to maintain fetal maturity by way of check-ups to the hospital (alia et al., 2019). another effort made by mothers is doing movement exercises during pregnancy, doing routine blood sugar control and continuously making efforts for healthcare treatment (alia et al., 2019; dhingra & ahuja, 2016). when it was known that mother had diabetes during pregnancy, so the postpartum treatment efforts are also continued (ashraf et al., 2019). it is stated that monthly maternal health status and blood sugar checkup are performed. mother is still taking medication to maintain the condition of her dm. the results showed that after a mother is known to suffer from diabetes during pregnancy, there are many efforts to keep her pregnancy. maintaining pregnancy with routine antenatal care is one important factor to consistently ensure better fetal outcome despite suffering from diabetes mellitus. extra effort to maintain the pregnancy is part of the learning process. along with the process of pregnancy, the mother experiences such conditions as the presence of an increase in blood pressure, edema of the extremities, nausea and excessive vomiting, decreased fetal condition, and unreached gestational months. the mother’s condition is in a state required to maintain the pregnancy. therefore, they begin to adjust or adapt to the conditions of their pregnancy with diabetes. a condition that causes mothers to continue to strive to maintain the pregnancy and improve her health is by maintaining healthy adaptive behavior (ashraf et al., 2019; dhingra & ahuja, 2016). adaptation is the response of individuals to defend themselves in their environment. participants showed a response of adaptation to their pregnancy with the extra effort to keep their pregnancy. in a nursing care view, the holistic human being is an individual. in a holistic concept, the human figure is seen as a whole, which is able to adapt as a whole. adaptation is one of the nursing theories and explains how individuals or clients can improve their health by maintaining adaptive behavior and maladaptive behavioral change. the response that causes a decrease in the integrity of the body will lead to an individual's needs and causes or attempts to respond through certain behaviors and to adapt. everybody always tries to overcome changes in health status (ashraf et al., 2019). the relation of the nursing theory of adaptation with the results of this study are the experiences of mothers in the diagnosis of gdm; mothers have an adaptive response to maintain the pregnancy with the aim that there is harmony between the mother and fetus in the process of her pregnancy so that later there is a good pregnancy outcome. various behavioral adaptations are performed by mothers checking maturity of the fetus at the hospital, maternal movement exercises during pregnancy, blood sugar routine checks and also efforts on an ongoing basis to healthcare treatment (ashraf et al., 2019; dhingra & ahuja, 2016). doing exercise and movement is also an option to keep the mother's pregnancy. various ways of activities and exercises are performed by the mother. another exercise is walking. it is pointed out that it is a useful exercise to improve blood glucose levels. weight gain and number of pregnancy may increase the risk of diabetes mellitus; this suggests that insulin resistance may accelerate the decline in beta cell function, likely causing diabetes (durnwald, 2015). treatment for pregnant women includes efforts to reduce insulin resistance with exercise. proper exercise recommended by the american college of obstetricians and gynecologists (acog) is running, cycling in a special place, light aerobics, and swimming (dhingra & ahuja, 2016). each exercise i. wulaningsih et al. 204 | pissn: 1858-3598  eissn: 2502-5791 begins from 5-10 minutes to warm up including flexibility exercises to reduce the risk of musculoskeletal injury during exercise. after that, it is followed by recovery after exercise. there are three important things in the endocrine response to exercise, which lowers plasma insulin, increases sympathetic nerve activity due to changes in insulin counter regulatory hormones, and hormones increase sodium and water balance (mottola & artal, 2016). the indication to stop the practice and conduct medical evaluations is when there is vaginal bleeding, faintness, decreased fetal activity, generalized edema, and low back pain. theme 4: variation of life experiences of mothers during pregnancy, delivering, and postpartum baby life experience is a history that is very important for mothers to cope with life in a better future. moreover, for mothers with gdm have the experiences stored in memory and it cannot be forgotten because of their condition during pregnancy, delivering, and postpartum diabetes. the amount of experience is summarized in the diversity of life experience variations of the mother (shrestha et al., 2019). life experience of mothers with gdm during pregnancy, delivering, and the postpartum period are very important moments. there is a change of mindset in mothers to always maintain the health of themselves and their babies. due to the condition of the mother's own experience she is able to adopt a good lifestyle, the mother becomes aware of baby care, and there is always an attempt from the mother to maintain the blood sugar levels (ashraf et al., 2019; dhingra & ahuja, 2016). mothers experience in consuming food and beverages is a serious thing to be considered. the right and proper nutrition can control blood sugar levels. diet is an important initial step in the management of gdm aimed at achieving normoglycemia and to generate growth and optimal fetal development. however, it should be kept in mind that putting together a diet in mothers with gdm is necessary, not solely to achieve normoglycemia, but setting both the number of calories diet and food composition must be taken into account for the growth of the fetus in order to produce a healthy baby (moreno-castilla et al., 2016). the results of this study showed that mothers who consume herbal remedies can relieve numbness and the body becomes easily tired. mothers take herbs because there is the suggestion that taking an oral medication will earn ongoing insulin therapy to control blood sugar levels. however, other participants also believed that during pregnancy they would have to use insulin to control their blood sugar levels. if they do not take medication from a doctor, fear will happen and this influences the fetus. the variety of herbs, oral medications, and insulin usage makes mothers with gdm have a diversity of experience to control blood sugar levels to maintain good health (dhingra & ahuja, 2016; xu et al., 2019). the results of this study also showed for mothers undergoing operative delivery in patients with lumbar anesthesia that there are communications between patients and doctors in the surgery process. communication is what makes mothers have life experience so that delivery by way of operative delivery is not scary, but it is a labor that can be passed to either because the mother can see the baby's birth (sunny et al., 2020). life experience with gdm and birth process influence mothers to determine to use contraception. contraception has several different kinds of methods and is aimed to be tailored to the needs of the users. however, various methods are still not able to be an alternative option for some women (kiley & griffin, 2015). this is the reason for a mother with a history of gdm to use contraception. women with a history of dm should use effective contraception to reduce pregnancy which is accompanied by hyperglycemias. long-term management with low-dose combined oral contraceptives do not appear to increase the risk of diabetes after pregnancy. intra-uterine device (iud) is the most effective contraceptive, as it is metabolically neutral. conversely the use of progestin-containing contraceptives during lactation may increase the risk of diabetes (kiley & griffin, 2015). this study also indicates the presence of life experience for the mother means she continues to strive to maintain lifestyle and diet. this is done with the goal of staying healthy so mothers can provide care to the children. mothers’ experience of maintaining diet and lifestyle is one of the efforts to achieve normal glucose levels in order to generate growth and optimal fetal development. nutritional therapy is the mainstay of therapy in the management of diabetes in which the aim is to provide adequate nutrition for both mother and fetus, controlling blood glucose levels and prevent the occurrence of ketosis (increased levels of ketoses in the blood) (morenocastilla et al., 2016). theme 5: maternal perception of their role during their pregnancy in carrying out the role as a mother, there are a variety of perceptions that arise within the mother. feeling of helplessness that is followed by sadness will affect the condition of the child's birth, for example fetus born with a gestational age of 9 months with severe weight of 16 ounces. the role of the mother can be considered achieved when the mother feels there is harmony within herself with her roles and expectations (shrestha et al., 2019). the response of the expectations of their behavior is shown by a reflective and visible role in the concern and caring for the baby's ability, attitude and her love for the baby and taking on the responsibilities of the role. maternal role attainment leads us to consider jurnal ners http://e-journal.unair.ac.id/jners | 205 the many variables that have an impact on the identified identity of the mother role. environment variables are family and friends, which consist of mother, baby and father (the couple) (ashraf et al., 2019). the results of this study indicate a maternal perception of a sense of powerlessness in their role as mothers. this is evidenced by anxiety to the child if the child is born with the degenerative disease dm. sadness of the mother also affects their perception in their role as mothers, and, therefore, contributes to inadequate coping mechanisms. this study also obtains the result that pregnant women with gdm have not been able to reach their full potential role as a mother and are merely doing a part and doing their job as a housewife. although mothers had a history of dm pain, this does not affect the relationship between the mother and her husband and baby (shrestha et al., 2019). mothers are expected to have a sense of empathy, self-concept, be able to accept things when the baby is born, have a good attitude in the l role as mother, and the mother has a good role when there is a conflict in her life. related to the development of maternal role attainment is that the results of this study are not yet fully capable of achieving the maternal role as a mother. in the context of life experience in achieving the role of the mother, the baby is born and the husband is a partner in the achievement of the mother whereby the mother is able to interact with the baby and husband. this is evidenced by the support of the husband of the mother during pregnancy and postpartum diabetes mellitus in order to continue to provide regular support to control blood sugar levels and taking the baby to the pediatrician so that the baby’s sugar levels are well-controlled. mother-toinfant interaction is indicated by the mother in regard to the baby's care. feelings of helplessness and sadness are psychological triggers reduce the ability of the mother to perform her role as a mother. life experience is the cause of the mother's perception to play the role as a mother (shrestha et al., 2019). theme 6: the factors that support the development and maternal role attainment development and the role of the mother is reached if there is support from husband, family support, and commitment of the mother. support of her husband, family, and the mother's commitment is the support system that can sustain how the mother is able to achieve her role as a mother. the results of this study indicate the existence of a commitment that arises from the heart to perform the role as the mother, then the mother maintains her health, physical and spiritual needs for the child. it is also revealed that she should always be eager to live in order to remain able to care for the child. caring for children is indicated by providing healthy foods such as vegetables, small portions of rice, and fruit (shrestha et al., 2019). mother's spirit for life is offset by exercise. it reveals that the mother's commitment to families is to have a good family, as a family is needed to help each other and respect each other. the mother's husband is the commitment to give the best to way to educate children properly so that later the child will be useful. the results of this study indicate that the factors that support the development and achievement of the mother's role is the support system in the form of support provided by the mother's husband and family. the support given by the husband to the mother is to continue to remind about routine treatment, giving spirit, and urging to keep eating. the support of the family in the form of suggestions is doing routines check-up and treatment. and a commitment to themselves to play the role as a mother so she is able to achieve. this shows the seriousness of the commitment in achieving the maternal role (shrestha et al., 2019). a good support system is important for the mother to perform her role as a mother. husband and family support is very important because with a good rapport from her husband and family it contributes to the achievement of the role in a way that cannot be duplicated by others. the role of the mother and the achievement of relationship with her husband and family support is located at micro system components and mesosystem level. microsystems are the relationship between mother and their spouse and is a highly influential component of the maternal role attainment. in this study a good relationship with the husband and the mother was able to provide support to the mother when the mother underwent gdm and in the postnatal period to reach her role as a mother. family enters into mesosystem components that directly affect the microsystems’ components so that the mother is able to achieve her role. healthcare professionals, especially nurses, play a role in the overall maternal role identity recognition stage. prenatal education, teaching one of the classes, formal or informal, helps mothers during the preparation phase of an effort and commitment and the mother is able to achieve her role (shrestha et al., 2019). theme 7: experience in integrating maternal role as mother the identity of the mother's role can be achieved when the mother is able to integrate herself into the role with other roles and her suitability to these. the results of this study indicate a role in achieving identity is that the mother can show the parents’ happiness. it is a way of showing affection for her child. the mother's experience in integrating other roles is the simplicity of life and the mothers being able to socialize with the neighbors (shrestha et al., 2019). another mother's experience of integrating identity is the role of mothers' understanding of the task and role as a mother. the results of this study also showed that, in reaching her role as a mother, they thought that doing household chores, including caring for children of providing food, washing clothes, and educating i. wulaningsih et al. 206 | pissn: 1858-3598  eissn: 2502-5791 children is a core obligation which must be implemented. the role of a person's identity stage is achieved when the mother's role integrates herself with the suitability of the system itself and her other roles, she will be secure in her identity as a mother, emotionally committed to her baby and feel a sense of harmony, comfort, and ability in the role (shrestha et al., 2019). theme 8: gaps and desires of people with diabetes in mothers receiving healthcare healthy covers body and spirit so that one is able to perform any tasks and activities without any obstacles. in a state hospital, everyone hopes to get good healthcare from of the healthcare a team of. hope will bring enthusiasm from the mother to continue and defend herself from adversity because of dm, thus they still continue to run their daily life as well (shrestha et al., 2019). some of the factors that contribute to the provision of health services is the availability of competent health resources to provide complete healthcare and the availability of adequate infrastructure. hope and dissatisfaction are trigger factors of the gap and maternal desire with gdm in receiving healthcare. this expectation is for the other side dealing with diabetes during pregnancy, government, health personnel and other hospitals in providing health services. this expectation is basically very good and, if it is realized together, that would trigger better health service delivery in pregnant women with diabetes, the presence of trust among patients with stakeholders, and the incidence of gestational diabetes can be reduced (eeg-olofsson et al., 2020). the results of this study indicate the presence of maternal dissatisfaction against the government because the government was perceived as having lack of attention to the patient. on the other hand, health workers also provide services less well, and information about pregnant women with diabetes is not clearly communicated. it is said that, after the mother’s check-up, they do not get information from health workers. the expression of these participants is a negative image of the government and health workers in delivering health services (ashraf et al., 2019). dissatisfaction in pregnant women who suffer from diabetes is indicated by the data that the mothers feels government and health workers are lacking in providing health services, and there is lack of information from health personnel to provide education about infant care. the results of this study also show the triangulation of obstetricians and midwives, that the patient feeling satisfied and not satisfied is a relative thing and there are no specific indicators to measure satisfaction and dissatisfaction. it is emphasized that the team of healthcare providers, in carrying out its duties and obligations to patients, should be in accordance with sop or the standard operating procedure that is in the hospital (ashraf et al., 2019; sunny et al., 2020). and every hospital is believed to have sop and sop in providing healthcare to mothers with gdm. conclusion life experience of pregnant women with gdm in yogyakarta shows diversity. mothers’ experience in integrating her role identity as a mother with gdm can receive health services. mothers are able to internalize their role as a mother. mothers’ life experience in achieving her role as a mother with dmg is less than optimal. the achievement of the mother's role in the microsystem component has not been fully achieved because mothers only carry out routine tasks as housewives. life experience in achieving maternal role as a mother is less than optimal with gdm. maternal role attainment at microsystem component level has not been fully achieved because the mother only carries out routine duties as a housewife only. pregnant women with gdm are advised to routinely do antenatal care, do exercise and have a proper diet. the recommended contraception is iud (intra uterine device), which is a normal contraceptive after delivery and does not affect the hormones that cause an increase in blood sugar levels. gdm screening needs to be done at the beginning of the mother starting antenatal care. references alberico, s., erenbourg, a., hod, m., yogev, y., hadar, e., neri, f., ronfani, l., maso, g., & group, the g. (2017). immediate delivery or expectant management in gestational diabetes at term: the ginexmal randomised controlled trial. bjog: an international journal of obstetrics & gynaecology, 124(4), 669–677. https://doi.org/10.1111/14710528.14389 alia, s., pugnaloni, s., borroni, f., mazzanti, l., giannubilo, s. r., ciavattini, a., & vignini, a. (2019). impact of gestational diabetes mellitus in maternal and fetal health: an update. diabetes updates, 5(3), 1–6. https://doi.org/10.15761/du.1000129 ashraf, f., sultana, s., hasan, t., pervin, h., mustanzid, f., mallick, t. s., islam, j. a., khatun, m. h., tasmin, k. s., selim, s., & yusuf, m. a. (2019). patient empowerment: an effective strategy to improve management of gdm. journal of shaheed suhrawardy medical college, 10(2), 91–94. https://doi.org/10.3329/jssmc.v10i2.41167 bare, b., & smeltzer sc. (2010). buku ajar keperawatan medikal bedah. egc. buchanan, t. a., xiang, a. h., & page, k. a. (2012). gestational diabetes mellitus: risks and management during and after pregnancy. nature reviews. endocrinology, 8(11), 639–649. https://doi.org/10.1038/nrendo.2012.96 jurnal ners http://e-journal.unair.ac.id/jners | 207 dewi, e. r., prasetyo, b., laksana, m. a. c., joewono, h. t., & wittiartika, i. d. (2020). the early detection in gestational diabetes mellitus at indonesia primary health care. indian journal of forensic medicine and toxicology, 14(2), 1552–1556. dhingra, a., & ahuja, k. (2016). lifestyle modifications for gdm. jpma. the journal of the pakistan medical association, 66(9 suppl 1), s34-8. durnwald, c. (2015). gestational diabetes: linking epidemiology, excessive gestational weight gain, adverse pregnancy outcomes, and future metabolic syndrome. seminars in perinatology, 39(4), 254–258. https://doi.org/https://doi.org/10.1053/j.sempe ri.2015.05.002 edward, k. leigh, & welch, a. (2011). the extension of colaizzi’s method of phenomenological enquiry. contemporary nurse, 39(2), 163–171. https://doi.org/10.5172/conu.2011.163 eeg-olofsson, k., johansson, u.-b., linder, e., & leksell, j. (2020). patients’ and health care professionals’ perceptions of the potential of using the digital diabetes questionnaire to prepare for diabetes care meetings: qualitative focus group interview study. j med internet res, 22(8), e17504. https://doi.org/10.2196/17504 huang, y., zhang, w., go, k., tsuchiya, k. j., hu, j., skupski, d. w., sie, s. y., & nomura, y. (2020). altered growth trajectory in children born to mothers with gestational diabetes mellitus and preeclampsia. archives of gynecology and obstetrics, 301(1), 151–159. https://doi.org/10.1007/s00404-020-05436-2 joy, r., & sivakumar, v. (2012). a prospective study on the effect of gestational diabetes mellitus on maternal and fetal outcome. international journal of pharmecy teaching & practices, 3(3), 345–351. kiley, j. w., & griffin, l. r. (2015). contraceptive care after gestational diabetes: considerations for clinical practice. diabetes management, 5(6), 457– 472. https://doi.org/10.2217/dmt.15.37 moreno-castilla, c., mauricio, d., & hernandez, m. (2016). role of medical nutrition therapy in the management of gestational diabetes mellitus. current diabetes reports, 16(4), 22. https://doi.org/10.1007/s11892-016-0717-7 mottola, m. f., & artal, r. (2016). role of exercise in reducing gestational diabetes mellitus. clinical obstetrics and gynecology, 59(3). https://journals.lww.com/clinicalobgyn/fulltext /2016/09000/role_of_exercise_in_reducing_ges tational_diabetes.21.aspx muche, a. a., olayemi, o. o., & gete, y. k. (2019). prevalence of gestational diabetes mellitus and associated factors among women attending antenatal care at gondar town public health facilities, northwest ethiopia. bmc pregnancy and childbirth, 19(1), 334. https://doi.org/10.1186/s12884-019-2492-3 plows, j. f., stanley, j. l., baker, p. n., reynolds, c. m., & vickers, m. h. (2018). the pathophysiology of gestational diabetes mellitus. international journal of molecular sciences, 19(11), 1–21. https://doi.org/10.3390/ijms19113342 schellinger, m. m., abernathy, m. p., amerman, b., may, c., foxlow, l. a., carter, a. l., barbour, k., luebbehusen, e., ayo, k., bastawros, d., rose, r. s., & haas, d. m. (2017). improved outcomes for hispanic women with gestational diabetes using the centering pregnancy© group prenatal care model. maternal and child health journal, 21(2), 297–305. https://doi.org/10.1007/s10995-0162114-x shanthi, m., marimuthu, r., shivapriya, s. n., & navaneethakrishnan, r. (2019). diagnosis of diabetes using an extreme learning machine algorithm based model. 2019 ieee 10th international conference on awareness science and technology (icast), 1–5. https://doi.org/10.1109/icawst.2019.8923142 shrestha, s., adachi, k., & petrini, m. a. (2019). maternal role: a concept analysis. journal of midwifery and reproductive health, 7(3), 1732– 1741. https://doi.org/10.22038/jmrh.2019.31797.134 4 soheilykhah, s., mogibian, m., rahimi-saghand, s., rashidi, m., soheilykhah, s., & piroz, m. (2010). incidence of gestational diabetes mellitus in pregnant women. iranian journal of reproductive medicine, 8(1), 24–28. sunny, s. h., malhotra, r., ang, s. bin, lim, c. s. d., tan, y. s. a., soh, y. m. b., ho, x. y. c., gostelow, m., tsang, l. p. m., lock, s. h. s., kwek, s. y., lim, y. t. j., vijakumar, k., & tan, n. c. (2020). facilitators and barriers to post-partum diabetes screening among mothers with a history of gestational diabetes mellitus-a qualitative study from singapore. frontiers in endocrinology, 11, 602. https://doi.org/10.3389/fendo.2020.00602 xu, y. x. z., xi, s., & qian, x. (2019). evaluating traditional chinese medicine and herbal products for the treatment of gestational diabetes mellitus. journal of diabetes research, 2019, 9182595. https://doi.org/10.1155/2019/9182595 http://e-journal.unair.ac.id/jners | 81 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.26032 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research nurse manager competency model in a teaching hospital setiawan setiawan, dewi elizadiani suza and farida linda sari siregar faculty of nursing, universitas sumatera utara, indonesia abstract introduction: nurse managers in carrying out their duties must have a variety of competencies, one of which is managerial competencies. a model of competency for nurse managers will assist them in shaping their roles as managers in a teaching hospital. this study aims to develop the managerial competency model for nurse managers at the teaching hospital. methods: the research design used in this study was action research. this research was conducted with 20 nurse managers who work at inpatient wards of the teaching hospital. participants were selected by purposive sampling approach and have accepted to participate in the research. the data were obtained by using interview through focus groups discussions. the content analysis method was employed for analyzing the data. results: this study found six domains of managerial competencies of nurse managers: 1) provision of patient care (assignment methods, clinical excellence, collaborators, patient safety, evidence-based practice), 2) resource management (personnel management, information and technology management, equipment management, supplies management), 3) leadership (commitment, conflict resolution, negotiator, role model, professional mentor, initiator, motivator), 4) self and staff development (effective communication skills, interpersonal relationship skills, tridharma function of nurses), 5) customer and service orientation (team builder, customer service, quality improvement), and 6) function of preceptorships (basic teaching skills, clinical skills). these 24 fundamental competencies are rooted in caring foundation. conclusion: nurse managers in teaching hospitals should possess a set of managerial competencies to perform their optimal roles in order to achieve the unit goals. this model will provide comprehensive and solid ways for nurse managers to improve their performance. therefore, the set of nurse manager competencies needs to be standardized across the setting. article history received: march 22, 2021 accepted: april 26, 2021 keywords managerial competency; nurse manager; teaching hospital contact setiawan setiawan  setiawan@usu.ac.id  faculty of nursing, universitas sumatera utara, indonesia cite this as: setiawan, s., suza, d. e., & siregar, f. l. s. (2021). nurse manager competency model in a teaching hospital. jurnal ners, 16(1). 81-88. doi:http://dx.doi.org/10.20473/jn.v16i1.26032 introduction the nurse manager plays a very important role in the management of services in the hospital. these roles can be seen from the daily operational arrangements of the ward to the achievement of the goals of the ward in particular and the goals of the hospital as a larger unit. this is in line with the statement of furukawa and cunha (2011) that nurse managers play an important role in health services, especially in hospitals because their duties include administrative duties, providing care and also include education and research areas while remaining focused on the quality of care. the quality of care can be maintained and even improved by nurse managers by creating and enabling excellence in nursing as part of the vital role of the nurse manager (mcsherry et al., 20120). a study conducted by miri et al. (2014) found that first-line nurse managers have a multidimensional role. this includes three categories related to management principles: planning, organizing, and leadership, with derivatives of seventeen subcategories. in addition, miri et al. (2014) also stated that the role of other nurse managers is related to the nursing process and standards of care which consist of three categories: interpersonal contact, information processing and decision making. these https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ s. setiawan et al. 82 | pissn: 1858-3598  eissn: 2502-5791 complex roles present a challenge for nurse managers so that they can carry them out in an effective and efficient manner in real practice in the common hospital, there may be some nurse managers performing their roles poorly. this may be related to a lack of understanding of what a nurse manager's job is or a lack of direct experience leading a ward. research by feather and ebright (2013) conducted at a community-based hospital revealed the perception of staff nurses about the weaknesses of their nurse managers. staff nurses in feather and ebright's study perceived their nurse managers as being task-oriented, for example, attending meetings and scheduling staff, but did not perceive them as staff-oriented who focused on relationships, building teamwork, or identifying employees with the organization. therefore, it is necessary to have nurse managers who adopt an authentic sustainable leadership approach to facilitate and support frontline staff to make innovation and change (mcsherry et al., 2012) in indonesia, nurse managers in hospitals have a background with knowledge and practice in nursing management, but few have advanced educational background such as master of nursing administration. the weaknesses in carrying out the roles of nurse manager as found in feather and ebright's study may also be found in any hospitals. therefore, the hospital needs to have a standard about the role and function of nurse managers to become a common reference for both nurse managers, staff nurses, and hospitals in monitoring the implementation of the roles and functions of nurse managers. universitas sumatera utara hospital, which is located in medan city, serves as a teaching hospital. this hospital has been operating for five years and has received the title of full accreditation from the national hospital accreditation commission (kars). most of the nurses in this hospital are young nurse generation and still need more advanced experiences in managing nursing services on a ward as nurse managers. in addition, there is no managerial competency model in this hospital that can be used by the nurse managers. with the specific nurse manager competency model which fitted for this hospital, it is hoped that all nurse managers will quickly master this managerial competence and appropriately apply it in their daily work. this study aims to develop the managerial competence model of nurse managers at universitas sumatera utara hospital which serves as teaching hospital. materials and methods the study used an action research approach. kemmis, mctaggart, and nixon (2014) explained that, in conducting action research several steps of action are required: reconnaissance, planning, acting and observation, and reflection. data collection method used interview through focus group discussions (fgd). voice recording and field notes were used during fgd implementation. each fgd lasted around ninety minutes per session. a literature review was also carried out to complement the data obtained from participants. data analysis used content analysis approach (polit & beck, 2018). the content analysis was employed as a guideline to reveal significant statements which were identified later as domain and subdomain of managerial competencies of the nurse managers, as result of codings that were made. the process of developing the model lasts for two stages: reconnaissance stage and one action research cycle (planning, acting-observing, and reflecting phase). the reconnaissance stage was to obtain data about participant perspectives on existing nurse manager competencies. at this stage, the researchers conducted one session fgd for 90-minute. during the fgd, the head of the ward and the team head were asked about the competence of the nurse manager at the universitas sumatera utara hospital. the competencies are related to nursing management, preceptorship, and leadership. there was no standard of nurse manager competency in this hospital. therefore, it is necessary to develop a nurse manager competency model at the universitas sumatera utara hospital. the next stage was for developing a model for nurse manager competency, which consisted of planning, acting-observing, and reflecting phase. the things undertaken by researchers at the planning phase were 1) the socialization of the research program and the data collection results of the reconnaissance stage, 2) planning detailed research action plan, 3) planning the team that would participate in the formulation of the model and 4) formulating required competencies for nurse managers’ competencies. acting and observing phase was the phase of implementing model development. activities carried out at this phase were: 1) communication with the nursing committee related to the plan to develop the nurse manager's competency model, and 2) formulation of the nurse competency model. the researcher conducted discussions with various hospital nursing division parties, regarding 1) planning the development of the nurse manager competency model, 2) forming a team to formulate the nurse manager competency model and 3) determining participants during the research process. the first fgd was held on july 18, 2018, with all participants. the results of these discussions were: 1) all the drafting teams understood the research process, 2) the drafting team needed references as model development material, and 3) the drafting team set a meeting to formulate a model to be acceptable and applicable. the second fgd was conducted on august 8, 2018, attended by all participants. the results of the second meeting were the model draft (tentative model) which covers all input from participants and literature reviews and there were nine nurse manager competency domains. the third fgd was conducted on august 31, 2018, and the results of the discussion were: 1) all experts jurnal ners http://e-journal.unair.ac.id/jners | 83 validated the feasibility of the model, 2) the experts provided input to the model draft based on expertise and experience as a nurse manager in the other hospitals, and 3) there were six competencies domains of nurse manager competencies. the reflecting phase is the evaluation phase of the action research cycle. this phase was done by one fgd session held on october 2, 2018, attended by all participants. this last fgd was in the model finalization session and it was agreed that there were six domains with 24 managerial competencies for nurse manager competencies in the final model. the evaluation results found that, during the action research cycle, the model formulation process ran smoothly. models still in draft form were reconceptualized as intact models. credibility refers to confidence in the truth of data (lincoln & guba, 1985). credibility in this study was carried out with prolonged engagement, field notes, triangulation, and member checking. long involvement was carried out by the researchers with a two-year approach and regular meetings with the participants. field notes were made by noting situations that occurred during the study. triangulation was also carried out through data collection from the heads of hospital ward and head of team nurses. member checking was done by crosschecking the data findings in the form of a matrix of domain and subdomain of managerial competencies to be read by participants to obtain objectivity of the data. confirmability was carried out by expert checks who validated the model draft. this study was approved by the health research ethics commission of the faculty of nursing, universitas sumatera utara and the researcher also asked the participants’ approval with informed consent. results characteristic of the participants the participants in this study consisted of 20 nurses who work at the universitas sumatera utara hospital. all participants were in the managerial position with almost similar educational background. the majority participants’ age was 30 – 40 years old as much as 85%. all participants were female. all participants were married. most of the participants had graduated from bachelor nursing program (95%). the majority of participants’ length of work was 6–10 years (60%). the characteristic of the participants are illustrated in table 1. nurse manager competency model the results showed that there are six themes as main domains of nurse managerial competences with 24 subthemes as fundamental competencies). these competencies domains are (1) provision of patient care consisting of five competencies (assignment methods, clinical excellence, collaborators, patient safety, evidence-based practice); (2) resource management consisting of four competencies (personnel management, information and technology management, equipment management, supplies management); (3) leadership consisting of seven competencies (commitment, conflict resolution, negotiator, role model, professional mentor, initiator, motivator), (4) self and staff development consisting of three competencies (effective communication skills, interpersonal relationship skills, tridharma function of nurses), (5) customer and service orientation consisting of three competencies (team builder, customer service, quality improvement), and (6) function of preceptorships consisting of two competencies (basic teaching skills and clinical skills). these 24 fundamental competencies are rooted in a caring foundation. discussion the results showed that there were six domains of nurse managerial competence carried out by nurse managers at universitas sumatera utara hospital: provision of patient care consists of five competencies, resource management consists of four competencies, leadership consists of seven competencies, self and staff development consists of three competencies, customer and service orientation consists of three competencies), and preceptorship function consists of two competencies. overall, a nurse manager had 24 managerial competencies. provision of patient care the first competency domain that is mastered by nurse managers in this study is the provision of nursing care. this competency domain is a general competency for all front-line managers in the majority of hospitals throughout the world and is useful in managing daily nursing services in the ward. having this basic competency makes participants more confident in ensuring the completeness of nursing administrative tasks runs smoothly (mboineki et al., 2019). providing nursing care to patients is done by using nursing process with systematic stages and applying management concepts. table 1. characteristics of participants (n=20) characteristic n % age <30 years old 3 15 30 – 40 years old 17 85 gender female male 20 0 100 0 marital status married 20 100 graduated bachelor 19 95 master 1 5 length of work experience 1 – 5 years 7 35 6 – 10 years 12 60 >10 years 1 5 s. setiawan et al. 84 | pissn: 1858-3598  eissn: 2502-5791 the nurse manager is required to have detailed knowledge and experience of assignment methods. there are several methods of assignment that a nurse manager can perform on a ward. the selection and implementation of an assignment method that is appropriate to the situation and conditions in a particular ward will affect the effectiveness of providing nursing care in that ward. with the right assignment method, the nurse manager can ensure that the organization and implementation of the care that the nurse will perform can achieve the predetermined goals. clinical excellence is a competency that a nurse manager needs to have. this competency is certainly obtained by a nurse through clinical experience as a staff nurse as well as basic and advanced training in accordance with the field of work in their respective work units. by having clinical excellence, a nurse manager can perform management functions that are more primarily related to the leading or directing function. collaboration is carried out to improve the quality of nursing care performed to patients. the essence is generally collaboration done clinically. collaboration is carried out in accordance with scientific disciplines through professional communication effectively between other professions. collaboration starts from solving problems, making decisions, formulating and implementing nursing care action plans (elsous, radawan, & mohsen, 2017). this competency is very important in organizing all nursing services in each unit with other healthcare workers. with good collaboration skills, a nurse manager works closely with other parties and ensures the achievement of the goals of the organizational unit they lead. patient safety is carried out as a guarantee that the patient is safe while being treated in the hospital (motamedzadeh et al., 2019). nursing actions are carried out based on the existing evidence base, especially in the field of nursing. the knowledge and skills of a nurse manager regarding patient safety and its implementation in the hospital are very supportive of achieving indicators of success for patient safety. this competence is very important today and in the future because the issue of patient safety is a major issue in the field of health services and is an important domain in hospital accreditation in indonesia. nursing evidence-based practice is an active part of a nursing intervention based on valid evidence of nursing (chrisman et al., 2014). in providing nursing care , it cannot be separated from the management of nursing care provided. a nurse manager who has this competence will be able to ensure that the nursing care carried out under his/her responsibility is always of the best and following the latest scientific evidence. nurse compliance to evidence-based practice is the essential key to quality of professional health services. increased public awareness of the quality of health services provided by health workers to patients causes hospitals to be able to provide services and maintain service quality well so as not to cause other problems (akhu-zaheeya, al-maaitah, & bany, 2018). resource management all participants involved in this study believe that they must have competencies related to resource management. these competencies include personnel management, information technology management, equipment management, and supplies management. planning personnel resources in a hospital must carefully consider both quantity and quality aspects. the process of creating such human resources certainly requires a long process and time. highquality human resources certainly have high prices (gunawan & aungsuroch, 2016). by having personnel figure 1. proposed nurse manager competence model at universitas sumatera utara hospital c a r i n g f o u n d a t i o n 1. assignment methods 2. clinical excellence 3. collaborator 4. patient safety 5. evidencebased practice 1. personnel management 2. information & technology management 3. equipments 4. supplies 1. commitment 2. conflict resolution 3. negotiator 4. role model 5. professional mentor 6. initiator 7. motivator 1. effective communication skills 2. interpersonal relation skills 3. tridharma function of nurse 1. team builder 2. customer service 3. quality improvement 1. basic teaching skills 2. clinical skils usu hospital managerial competencies for nurse manager provision of patient care resources management leadership self and staff development customer and service orientation function of preceptorship jurnal ners http://e-journal.unair.ac.id/jners | 85 management competence, a nurse manager will be able to manage and empower each nurse to make the optimum contribution in providing nursing services. the nurse manager can also conduct an assessment of the adequacy and suitability of the qualifications of nursing personnel within the scope of their work. in addition, the nurse manager needs to have ability to carry out coaching and in-training program in order to improve the skills and career of each nurse. article 12 of the law of the republic of indonesia number 44 year 2009 concerning hospital states that a hospital must have permanent staff, including medical and medical supporting staff, nurses, pharmacists, management staff, and non-health personnel. it also mandates that the number and type of human resources must match the type and classification of the hospital. the need for highquality nurses is obtained by careful planning by the nurse manager. at one time, the knowledge and skills of staff can also be obsolete so that further education and training needs to be carried out on that person (who, 2009). information technology management is important in the assisting of nurses and nurse managers in performing their activities. the use of technology can replace the manual system in documenting nursing cares such as use of the leadership-endorsed electronic handoffs form (staggers et al., 2012). currently, a lot of hospitals have used a hospital information system (sirs), including nursing care and an integrated service system, in the wards. having the competence in managing information technology will certainly facilitate the role of nurse managers in monitoring and evaluating the implementation of nursing services in their work units. equipment management is also considered by participants as an important managerial competency needed by a nurse manager. in the nursing unit, there are various equipment and with a certain amount and sophistication for which they have responsibility of their use and maintenance. these various tools are indispensable to support the provision of nursing care and nursing services in the ward. consequently, the nurse manager's competence to manage this equipment becomes essential. just like equipment management, supplies management is also needed by nurse managers. routine equipment that is widely used in every ward needs to be properly organized to ensure effective and efficient utilization. with this competency, a nurse manager can ensure that nursing services can run well and ensure cost-effectiveness leadership nurse managers in this study assume that leadership is a very important competency that they must master. these leadership characteristics include commitment, conflict resolution, negotiators, role models, professional mentors, initiators, and motivators. commitment is a prerequisite that must be owned by nurse managers. a nurse manager needs a strong commitment to lead the nursing unit or division as his or her own driving force and this commitment can also be passed on to his or her subordinate staff. conflict resolution is a competence very much needed by a nurse manager because managing a care unit involves many parties: the nurses themselves, patients, administrative staff, and other health workers. the involvement of many parties in caring for patients will certainly create dynamics that can lead to conflict. this conflict must be resolved properly so that the provision of nursing services can take place in accordance with established standards. as a negotiator, nurse managers make efforts to bridge the obstacles that can be faced by nurses with other health workers. many collaborative activities require negotiation skills so that efforts to achieve patient care goals and care unit goals can run well and in balance. nurse managers may use their referent power to establish their important roles working in interprofessional collaborative team in healthcare (orchard et al., 2017). as a leader in the nursing unit or division, a nurse manager should serve as a role model. leading several nurses who are their subordinates, must entail knowledge, skills, and attitudes that can be emulated by such subordinates. performance as a role model can strengthen leadership style and allow a nurse manager to be more obeyed and carried out by all orders or agreements that have been made. nurse managers can be role models with charismatic power when they are capable of integrating their managerial and professional expert knowledge along with their power (orchard et al., 2017). professional mentor is a fundamental competency for a nurse manager in an effort to provide a form of continuing education for both novice and senior nurses. novice nurses or new nurses need to receive direct education from their leaders in the form of clinical guidance or direction related to managerial aspects. continuing education for nurses in the wards can be more effective with a direct mentoring process by the nurse manager, in addition to implementing formal education or training that nurses participate in outside the scope of nursing ward. other important competencies possessed by nurse managers are initiators and motivators. the development of the delivery of nursing services is very dependent on the initiative of the nurse managers. initiatives can be in the form of ideas or thoughts related to technical updates in the provision of nursing care and also to updating of service management techniques in the ward. as an initiator, the nurse manager will be more creative in producing solutions to the obstacles faced and also adaptive to changing circumstances and technological advances. as a motivator, a nurse manager is required to always be energetic and have a strong spirit. an energetic nurse manager will inspire other nurses to work. motivation that is conveyed directly to the nurses in daily practice will also have an impact on improving performance. providing consistent motivation combined with a good role model will s. setiawan et al. 86 | pissn: 1858-3598  eissn: 2502-5791 make nurses more motivated and more enthusiastic in carrying out activities to achieve patient care goals and the goals of the nursing as an organizational unit that have been set. these leadership characteristics are needed to ensure that all nursing duties in the ward will be effectively used by nursing staff. by having these characteristics, nurse managers will gain respect and trust from their nursing staff so that they lead the development of clinical practice in the ward (pullen, 2016). self and staff development nurse managers state that other competencies they need to master are related to personal and staff development. this includes effective communication, interpersonal relations, and tri dharma nurse functions. as a leader in their unit, the nurse manager has an important role in developing effective communication between themselves and staff so that they can carry out their duties of nursing care. effective communication is a process in which a message is conveyed to a person or group of people. effective communication is very necessary in nursing and minimizes errors in providing nursing services. therefore, a nurse manager really needs to have effective communication skills. in carrying out their role as a manager, the nurse always communicates and ensures that the communication which takes place is effective so that messages can be received and acted upon by the staff nurse. in addition, a nurse manager also needs to ensure that the communication with other health professionals is effective so that the nurse's collaboration function runs successfully to achieve patient outcomes. the quality of communication is a vital role in the success of nursing service and nursing care undertaken and nurses are very important in communicating the actions taken (kourkouta & papathanasiou, 2014). nurse managers are also responsible for enhancing interpersonal relationships skills both between themselves and also with other health workers. the ability to develop good relationships with staff nurses, patients and also other healthcare workers is very helpful in smoothing the efforts of nurse managers in coordinating the delivery of nursing services. good relations can facilitate overcoming non-technical constraints that occur in the field. the better the interpersonal relationships developed by the nursing team in the unit, the better the quality of services provided to patients (lee & doran, 2017). as part of the university, in this study nurse managers must also carry out the tri dharma function: providing services, conducting research, and carrying out community services. this tri dharma function is an additional role for nurse managers who work in the usu teaching hospital and characterizes them. the function of service provider is carried out by performing nursing care and nursing service for patients. research functions can also be carried out by nurse managers at usu hospital and research funding has been provided in the form of talenta grants supported by the university. nurse managers can compete for research grants each year. meanwhile, community service functions can also be carried out by nurse managers together with staff nurses. this community service activity can be in the form of activities that are internal in nature and can also be carried out outside the hospital. generally, these community service activities are in the form of activities that are directly and indirectly related to the services provided by nurses at the hospital. customer and service orientation there are three nurse manager competencies covered in the customer and service orientation domain: team builder, customer service, and quality improvement. as a team builder, nurse managers must have the ability to build a compact team in the effort to provide nursing services. this competence is important because building a team is very common in an organization. by establishing a compact team, nurse managers will have opportunity to achieve an excellent performance. they must establish a team that can work together in order to achieve the vision and mission of nursing division. the established team has to work effectively and efficiently. the resilience of a team can be seen from the coordination of the leadership and staff awareness that they are an important part of the team (davis, 2017). excellent team work will support the realization of good performance from nurses and also depends on the process of how individuals work together to achieve a goal (lockhart, 2015). managerial competence of nurse managers is also related to the ability to implement a customer service approach in nursing services. knowledge and skills of nurse managers in customer service aspects are expected to improve the quality of service to patients and families. the manager role plays a vital role in encouraging all nurse administrators to apply the principles of customer service in nursing services so that they can improve the quality of hospital services as a whole. another important managerial competence of nurse manager is the ability to carry out quality improvement. in addition to requiring the involvement of nurse managers in quality improvement efforts, they also have the ability and innovation in creating new work procedures and processes. included in this competence is the nurse manager's ability to provide encouragement for the staff nurse to be involved in quality improvement efforts. therefore, improved quality of services is highly dependent on the performance of nurses. nurses who display excellent performance will be able to provide the best nursing care and will enhance nursing care (bruyneel et al., 2015). function of preceptorship the usu hospital is a teaching hospital. accordingly, besides providing nursing services to their jurnal ners http://e-journal.unair.ac.id/jners | 87 customers, the nurse manager also functions as a preceptor for nursing students. the preceptorship function, which includes nurse managers, includes basic teaching skills and clinical skills. the involvement of nurse managers in the clinical learning process of nursing students has the consequence that they must be able to provide supervision to students in conducting nursing procedures using their basic teaching skills. they must also teach the practice of nursing services that they provide to patients and families. in addition, they must be role models both as nurses and as professional managers. clinical skills are obtained through the implementation of nursing care during their daily practice. these skills are acquired as a career path possessed by nurses. through preceptorship process, nursing students, along with the nurse manager as the preceptor, will gain knowledge, skills and others aspects of being a professional nurse. the preceptorship program for undergraduate nursing students aims to shape their roles and responsibilities to be a professional nurse, by taking advantage of opportunities for development of confidence and professional socialization as well as knowledge and skills that must be acquired (sedgwick & harris, 2012). the process of socialization of nursing professionalism may occur through observation and modeling the role of behavior in the learning environment (lai & lim, 2012). in the implementation of the preceptorship program, the role of a preceptor is very important. a preceptor has a complex role and it requires development of key skills in order to assist students with the reality in the workplace (ford, courtneypratt, & fitzgerald, 2013). implemented preceptorship by the nurse managers certainly has positive impacts. a study found that an effective preceptorship program reduced turnover by 46.5% and led medication error rate to drop 50-0% by new nurses (lee et al., 2009). it also influences on the nurse students as candidates for professional nurses so that to ensure competent health professionals, nurses must do so in authentic, unique and often complex situations with conflicting interests and values (theander et al., 2016). finally, to complete all these competencies, nurse managers must have a strong background in caring because this teaching hospital has made caring the basis for their nursing practice. a caring foundation will facilitate nurse managers in creating a caring culture and caring environment, and also in organizing caring activities in their organization (chen & liu, 2019). overall, the managerial model for nurse manager at usu hospital has 24 essential competencies. this competency model is expected to be carried out by all nurse managers at usu hospital. by mastering all the competencies contained in this model, the nurse manager can execute their functions appropriately in achieving their unit goals. implication this managerial model can be applied as a standard for all nurse managers in teaching hospitals, especially usu hospital by mastering 24 competencies so that all heads of wards as a nurse manager have the same competency and it is easy to lead change and innovate health services, especially nursing in the each ward. conclusion the result of this study is a model of managerial competency for nurse managers who work in a teaching hospital. the model consists of six domains with 24 competencies. the existence of this model is very helpful for nurse managers in performing their roles as professional nurse managers. it is recommended that this model could be tested further so that they can be applied more extensively in teaching hospitals in indonesia. references akhu-zaheya, l., al-maaitah, r. and bany hani, s. (2018) ‘quality of nursing documentation: paperbased health records versus electronic-based health records’, journal of clinical nursing, 27(3– 4), pp. e578–e589. doi: 10.1111/jocn.14097. bruyneel l, li b, ausserhofer d, et al. organization of hospital nursing, provision of nursing care, and patient experiences with care in europe. med care res rev. 2015;72(6):643-664. doi:10.1177/1077558715589188 chen, r & liu, y. (2019). constructing a caring training content for nurse managers: a delphi study. frontiers of nursing. 6,2. 161-168. doi: 10.2478/fon-2019-0024. chrisman, b. j. et al. (2014) ‘exploring evidence-based practice research’, (august), pp. 8–12. davis, c. (2017) ‘teamwork and the patient care experience’, nursing made incredibly easy, 15(5), p. 4. doi: 10.1097/01.nme.0000521812.07765.11. elsous, a., radwan, m. and mohsen, s. (2017) ‘nurses and physicians attitudes toward nurse-physician collaboration: a survey from gaza strip, palestine’, nursing research and practice, 2017, pp. 1–7. doi: 10.1155/2017/7406278. feather, r.a & ebright, p.r (2013). how staff rns perceive nurse manager roles. open journal of leadership. 2(3). 63-67. doi:10.4236/ojl.2013.23008 ford, k., courtney-pratt, h. and fitzgerald, m. (2013) ‘the development and evaluation of a preceptorship program using a practice development’, australian journal of advanced nursing, 30(3), pp. 5–13. furukawa, p, & cunha, i (2011). profiles and competencies of nurse managers at accredited hospitals. rev. latino-am emfermagem. 19(1).106-14. s. setiawan et al. 88 | pissn: 1858-3598  eissn: 2502-5791 gunawan, j., & aungsuroch, y. (2016) ‘managerial competence of first-line nurse managers: a concept analysis’, . international journal of nursing practice. 23. doi: 10.1111/ijn.12502. kemmis, s., mctaggart, r., & nixon, r. (2014). the action research planner: doing critical participatory action research. singapore: springer. doi: 10.1007/978-981-4560-67-2. kourkouta l, papathanasiou iv. communication in nursing practice. mater sociomed. 2014;26(1):65– 67. doi:10.5455/msm.2014.26.65-67 lai pk, lim ph. concept of professional socialization in nursing. iejsme 2012 : 6(1) 31-35 lee, c. t. s. and doran, d. m. (2017) ‘the role of interpersonal relations in healthcare team communication and patient safety: a proposed model of interpersonal process in teamwork’, the canadian journal of nursing research = revue canadienne de recherche en sciences infirmieres, 49(2), pp. 75–93. doi: 10.1177/0844562117699349. lee t-y, tzeng w-c, lin c-h & yeh m-l. effects of a preceptorship programme on turnover rate, cost, quality and professional development. j clin nurs. 2009 apr; 18(8): 1217– 1225. doi: 10.1111/j.1365-2702.2008.02662.x lincoln, y.s. & guba, e. g. (1985) naturalistic inquiry. ca: sage publications, newbury park. lockhart l. the art of team building. nursing made incredibly easy. 2015; 13(3): 51-52 doi: 10.1097/01.nme.0000462648.19515.8a mcsherry, r, pearce, p, grimwood, k & mcsherry, w (2012). the pivotal role of nurse managers, leaders, and educators in enabling excellence in nursing practice. journal of nursing management. 20. 7-19. doi: 10.1111/j.1365-2834.2011.01349.x https://journals.lww.com/nursingmadeincrediblyeasy/toc/2015/05000 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 213 faktor pencetus gejala dan perilaku pencegahan systemic lupus erythematosus (precipitating factors and preventive behavior towards the exposures of systemic lupus erythematosus) ni putu wulan purnama sari fakultas keperawatan, universitas katolik widya mandala surabaya telp. (031) 99005299 email: moonygalz@yahoo.com abstrak pendahuluan: systemic lupus erythematosus (lupus) dan kekambuhan gejalanya yang sulit diprediksi berpotensi menurunkan kualitas hidup penderita lupus secara signifikan. faktor pencetus gejala lupus perlu dikurangi paparannya melalui perilaku pencegahan untuk menurunkan frekuensi kekambuhan. penelitian ini bertujuan menganalisis hubungan antara faktor pencetus gejala lupus dan perilaku pencegahan paparannya. metode: penelitian korelasional ini menggunakan desain cross-sectional. populasi adalah semua penderita lupus yang rawat jalan di poli rheumatologi rsud dr. soetomo, surabaya. sampel adalah penderita lupus yang rawat jalan pada bulan oktober-desember 2014 dan memenuhi kriteria sampel. besar sampel 36 dipilih dengan teknik total sampling. variabel independen faktor pencetus gejala lupus; variabel dependen pengetahuan lupus, sikap (efikasi diri) dan tindakan pencegahan. instrumen penelitian meliputi kuesioner faktor pencetus gejala lupus dan odapus-hebi (bagian 1,2,3). analisis data dengan uji korelasi spearman rho dengan α < 0.05. hasil: mayoritas responden berusia dewasa akhir, sudah menikah, lulusan sma dan masih aktif bekerja. rentang lama sakit lupus mayoritas 1-2 tahun. faktor pencetus gejala lupus mayoritas adalah stres fisik (66,7%). gejala lupus yang paling sering kambuh adalah nyeri sendi. tingkat pengetahuan seluruhnya tinggi, sikap mayoritas tinggi dan tindakan pencegahan mayoritas optimal. tidak ada hubungan antara faktor pencetus gejala dengan pengetahuan lupus (p = 0,342) dan dengan sikap (p = 0,651). ada hubungan yang lemah namun signifikan antara faktor pencetus gejala dengan tindakan pencegahan (r = 0,360; p = 0,031). diskusi: faktor pencetus gejala lupus berbeda-beda di antara para penderita lupus sehingga tindakan pencegahan yang dilakukan juga menyesuaikan dengan jenis paparan faktor pencetus. tindakan pencegahan yang dilakukan secara optimal dapat meminimalisir kekambuhan gejala lupus. ada hubungan antara faktor pencetus gejala dengan tindakan pencegahan paparannya pada penderita lupus. kata kunci: systemic lupus erythematosus (sle), faktor pencetus gejala, perilaku pencegahan abstract introduction: systemic lupus erythematosus (lupus) and its unpredictable flares have lowering the patients’ quality of life significantly. precipitating factors’ exposures need to be reduced by doing preventive behaviors to reduce the frequency of lupus flare. this study aimed to analyze the correlation between precipitating factors and preventive behavior in lupus patients. method: this is a cros-sectional study. population was all lupus patients doing regular check-up in rheumatology unit of dr. soetomo public hospital, surabaya. sample was lupus patients who did regular check-up in the period of october-december 2014 and matched to sample’s criteria. sample size was 36 enrolled by means of total sampling. independent variabel: precipitating factors of lupus flare; dependent variable: knowledge of lupus, attitude (self-efficacy) and preventive action towards exposures. instruments used were questionnaire of lupus precipitating factors and odapushebi (part 1,2,3). data analysis used spearman rho correlation with α<0.05. result: most respondents are late adulthood, get married, high school graduates and actively working. the majority had lupus for 1-2 years. precipitating factors were mostly physical stres (66.7%). symptom of lupus that most often relapse was joint pain. knowledge of lupus in all respondents was high, as for attitude mostly were high and most respondents doing optimal preventive action. there was no correlation between the precipitating factors of lupus flare with lupus knowledge (p=0.342) and attitude (p=0.651). there was a weak but significant correlation between the precipitating factors with preventive action (r = 0.360; p=0.031). discussion: precipitating factors of lupus flare vary among patients so that preventive actions taken adjust to the type of exposure. the preventive action taken optimally could minimize the recurrence of lupus flare. there is a correlation between the precipitating factors of flare with preventive action in lupus patients. keywords: systemic lupus erythematosus (sle), precipitating factors of lupus flare, preventive behavior pendahuluan lupus adalah penyakit dimana sistem imun, yang normalnya memerangi infeksi, mulai menyerang sel sehat dalam tubuh. fenomena ini disebut autoimun dan apa yang diserang oleh sistem imun disebut autoantigen (laura k. delong, md 2012). para penderita lupus sering disebut dengan odapus (orang dengan lupus). kehidupan odapus bisa berubah drastis sejak sakit lupus dan mereka merasa sangat sulit untuk mengelola penyakit ini (de barros et al. 2012). dalam kehidupannya, odapus akan beberapa kali mengalami suatu periode kemunculan gejala lupus yang parah (lupus flares) dan periode lainnya dimana gejalanya lebih ringan. sebenarnya gejala lupus bisa diatasi secara efektif dengan terapi mailto:moonygalz@yahoo.com jurnal ners volume 11 no. 2: 213-219 214 yang sudah ada sekarang, namun untuk saat ini belum ditemukan obat apapun yang dapat menyembuhkan penyakit lupus (ferenkehkoroma 2012). lupus merupakan penyakit autoimun kronis yang tanda dan gejalanya dapat menetap selama lebih dari enam minggu dan seringnya hingga beberapa tahun (lupus foundation of america 2012). namun demikian, ada juga odapus yang berhasil mengendalikan gejala lupus dengan baik sehingga tampak seperti orang sehat (kategori quiescent). memang kemunculan gejala lupus tidak akan selalu sama antara odapus satu dengan yang lain, ada banyak faktor yang dapat mempengaruhi hal ini. peningkatan intensitas paparan faktor pencetus tentunya akan menyebabkan gejala lupus lebih sering muncul. untuk mengantisipasi hal ini maka odapus perlu memiliki pengetahuan sensoris yang memadai tentang penyakit lupus dan efikasi diri yang tinggi guna memfasilitasi tindakan pencegahan paparan faktor pencetus. namun demikian, hubungan antara faktor pencetus gejala dan perilaku pencegahan paparannya pada penderita lupus masih belum jelas. lupus telah diderita setidaknya oleh lima juta orang di seluruh dunia. lupus dapat menyerang pria dan wanita di semua usia, namun 90% dari orang yang terdiagnosis lupus adalah wanita, dan usia rentan lupus adalah 1544 tahun. 70% kasus lupus berupa sle (systemic lupus erythematosus), 10% berupa cle (cutaneous lupus erythematosus), 10% berupa drug-induced lupus, dan 5% lainnya berupa neonatal lupus (s.l.e. lupus foundation 2012). di indonesia, estimasi jumlah penderita lupus sekitar 200-300 ribu orang, perbandingan jumlah penderita lupus pria dan wanita adalah 1:6-10, sehingga lupus sering disebut penyakit kaum wanita. tren penyakit lupus di negara kita terus menunjukkan peningkatan setiap tahunnya (yayasan lupus indonesia 2012; utomo 2012). penyebab lupus masih belum sepenuhnya dimengerti, namun beberapa ahli berpendapat bahwa penyebab lupus berasal dari beberapa faktor, yaitu: genetik, lingkungan (sinar uv, obat-obatan, infeksi, trauma/kecelakaan), faktor internal (stres emosional, stres fisik, demam, dan hormon estrogen) (lupus foundation of america 2012; stichweh & pascual 2005). lupus dapat menyebabkan inflamasi dan merusak berbagai organ tubuh, seperti persendian, kulit, ginjal, jantung, paru-paru, pembuluh darah, dan otak (niams 2012; ferenkeh-koroma 2012; nery et al. n.d.). gejala lupus yang paling sering dilaporkan oleh odapus adalah demam, ruam kulit karena fotosensitif, sendi yang bengkak/nyeri, kelemahan/kelelahan, dan gangguan ginjal (gallop et al. 2012; ferenkehkoroma 2012; niams 2012; nery et al. n.d.). komplikasi renal, neurologikal, dan hematologikal adalah yang paling sering ditemukan pada odapus (kannangara et al. 2008). baik manifestasi klinis maupun komplikasi penyakit lupus keduanya berpotensi menurunkan derajat kesehatan odapus, dan dapat berakibat fatal hingga menyebabkan kematian. gejala lupus yang muncul sewaktu-waktu sangat berpotensi untuk mengganggu aktivitas sehari-hari dan menimbulkan banyak masalah lain. agar dapat mencapai status kesehatan yang optimal dan kualitas hidup yang tinggi maka odapus harus bersikap proaktif dalam pengelolaan penyakitnya. salah satu caranya adalah dengan berperilaku sehat dan mengelola penyakit lupus secara mandiri melalui tindakan pencegahan paparan faktor pencetus. untuk itu diperlukan pengetahuan yang memadai dan sikap yang positif (l.w. green & kreuter 1991). hubungan antara faktor pencetus gejala dan perilaku pencegahan paparannya pada penderita lupus perlu diteliti lebih lanjut. penelitian ini bertujuan menganalisis hubungan antara faktor pencetus gejala lupus dan perilaku pencegahan paparannya. bahan dan metode penelitian ini merupakan penelitian korelasional dengan pendekatan crosssectional. populasi adalah semua penderita lupus murni (tanpa komplikasi organ) yang rawat jalan di poli rheumatologi rsud dr. soetomo surabaya. populasi terjangkau adalah semua penderita lupus murni yang rawat jalan di poli rheumatologi rsud dr. soetomo surabaya pada bulan oktoberdesember 2014, sebanyak 54 orang. kriteria sampel: 1) kriteria inklusi: sakit lupus minimal 6 bulan, usia dewasa (19-44 tahun), minimal lulusan smp, pernah mengikuti pelatihan manajemen perawatan diri untuk penderita lupus yang dilaksanakan peneliti (sari, 2015); 2) kriteria eksklusi: hospitalisasi, mengalami faktor pencetus gejala dan perilaku pencegahan sle (ni putu wulan p.s.) 215 gangguan jiwa, bekerja sebagai tenaga kesehatan (khususnya dokter / perawat). dari 54 orang anggota populasi terjangkau diperoleh 36 orang yang memenuhi kriteria sampel. sampel dalam penelitian ini adalah total populasi (total sampling), sehingga 36 orang penderita lupus yang memenuhi kriteria sampel dijadikan responden penelitian seluruhnya. variabel independen dalam penelitian ini adalah faktor pencetus gejala lupus. variabel dependen terdiri dari tiga domain perilaku, yaitu: pengetahuan tentang lupus, sikap (efikasi diri) dan tindakan pencegahan paparan. peneliti mengembang-kan sendiri alat ukur untuk mengidentifikasi semua variabel penelitian. berdasarkan literatur, faktor pencetus gejala lupus terdiri dari sinar uv (dari matahari dan/atau bola lampu fluorosens), obat-obatan (golongan antibiotika: tetrasiklin, penicillin, anti-fungal, golongan sulfa; dan golongan non-antibiotika: anti-convulsan, antihipertensi, pil kontrasepsi), infeksi, demam, trauma/kecelakaan, stres emosional (perceraian, kematian anggota keluarga, kondisi sakit, atau masalah kehidupan lainnya), dan stres fisik (kelelahan, pembedahan, kekerasan, kehamilan, persalinan) (lupus foundation of america 2012; nadhiroh 2007; stichweh & pascual 2005). peneliti kemudian membuat pertanyaan sesuai dengan faktor pencetus di atas dalam bentuk kuesioner pertanyaan tertutup dengan pilihan jawaban ya (nilai 1) dan tidak (nilai 0). jumlah pertanyaan 26 item dan diperlukan waktu 30 menit untuk menjawab semuanya. setelah di-scoring maka data faktor pencetus dikategorikan berdasarkan intensitas paparannya: 1) paparan minimal (0-9) ; 2) paparan sedang (10-18) ; 3) paparan tinggi (19-26). peneliti mengembangkan sendiri alat ukur untuk menilai perilaku kesehatan pada odapus dan memberinya nama odapushebi (odapus health behaviour) (sari, 2015). instrumen ini pada awalnya terdiri dari empat bagian, yaitu: 1) 20 pertanyaan pilihan ganda untuk mengkaji pengetahuan lupus, 2) 20 pernyataan untuk mengkaji efikasi diri, 3) 25 pernyataan untuk mengkaji tindakan pencegahan paparan faktor pencetus dan 4) 25 pernyataan untuk mengkaji aktivitas perawatan diri. dalam penelitian ini, peneliti hanya menggunakan instrumen odapus-hebi bagian 1, 2 dan 3 disesuaikan dengan variabel penelitian. uji coba instrumen yang dilakukan terhadap 18 responden yang rawat jalan di poli rheumatologi rsud dr. soetomo pada bulan februari 2015 menunjukkan hasil sebagai berikut. tabel 1.hasil uji instrumen odapus-hebi instrumen odapus-hebi validitas (r) reliabilitas (α) bagian 1. pengetahuan 0,477 0,774 0,519 bagian 2. efikasi diri 0,503 – 0,903 0,927 bagian 3. tindakan pencegahan paparan 0,547 – 0,908 0,945 tabel di atas menunjukkan instrumen odapus-hebi valid dan reliabel. setelah data perilaku pencegahan paparan di-scoring maka masing-masing bagian dikategorikan berdasarkan domain: 1. pengetahuan: a. rendah (0-15). b. cukup (16-30). c. tinggi (31-47). 2. sikap (efikasi diri): a. rendah (20-60). b. cukup (61-90). c. tinggi (91-120). 3. tindakan pencegahan paparan: a. kurang (25-65). b. cukup (66-105). c. optimal (106-150). setelah semua data penelitian terkumpul maka dilakukan editing, scoring, tabulating dan uji hipotesis. uji korelasi spearman rho digunakan untuk menganalisis hubungan antara faktor pencetus gejala lupus dan perilaku pencegahan paparannya, yang terdiri dari domain pengetahuan, sikap dan tindakan. hipotesis penelitian diterima jika signifikansi data kurang dari nilai α (0,05). hasil jumlah responden penelitian sebanyak 36 orang. mayoritas responden berusia dewasa akhir (44,4%), sudah menikah dan tinggal bersama suaminya (77,8%), lulusan sma (83,3%), aktif bekerja sebagai wirausaha (33,3%) dan pegawai swasta (33,3%) dengan penghasilan mandiri lebih dari rp. 1,5 – 2 juta perbulan (33,3%). pada penelitian ini, lupus banyak diderita oleh wanita usia produktif dengan latar belakang pendidikan sma yang sudah menikah dan masih aktif bekerja. data demografi responden sebagai berikut. jurnal ners volume 11 no. 2: 213-219 216 tabel 2. data demografi responden karakteristik frekuensi persentase 1. usia a. 17-25 tahun (remaja akhir) 8 22,2 a. 26-35 tahun (dewasa awal) 12 33,3 b. 36-45 tahun (dewasa akhir) 2. status pernikahan a. menikah b. single 16 28 8 44,4 77,8 22,2 3. pendidikan a. sma 30 83,3 b. s1 6 16,7 4. pekerjaan a. ibu rumah tangga b. mahasiswa c. wirausaha d. pegawai swasta 8 4 12 12 22,2 11,1 33,3 33,3 5. penghasilan mandiri perbulan a. belum/tidak berpenghasilan b. 500 ribu – 1 juta c. >1 – 1,5 juta d. >1,5 – 2 juta e. > 2 juta 6. tinggal serumah dengan a. suami b. anak 12 2 6 12 4 28 20 33,3 5,6 16,7 33,3 11,1 77,8 55,6 c. orangtua 10 27,8 d. saudara 2 5,6 tabel 3. data primer penelitian karakteristik frekuensi persentase 1. lama sakit lupus a. < 1 tahun b. >1-2 tahun c. >2-3 tahun d. >4-5 tahun e. > 5 tahun 2. gejala lupus yang pernah dialami a. demam b. pusing c. kebingungan d. arthritis e. fatigue f. malar rash g. nyeri dada saat nafas dalam h. myalgia i. anemia 3. faktor pencetus gejala lupus yang disadari a. stres emosional b. stres fisik c. sinar matahari d. makan tidak teratur e. kurang tidur f. perubahan hormon 4 12 8 2 10 8 6 2 22 12 6 2 2 4 16 24 4 4 4 2 11,1 33,3 22,2 5,6 27,8 22,2 16,7 5,6 61,1 33,3 16,7 5,6 5,6 11,1 44,4 66,7 11,1 11,1 11,1 5,6 data primer mencerminkan aktivitas penyakit lupus pada diri responden selama ini, terhitung sejak awal diagnosis lupus hingga saat penelitian. data primer meliputi lama sakit lupus, gejala yang pernah dialami dan faktor pencetus gejala lupus yang disadari. data primer penting untuk dikaji karena kekambuhan lupus bisa diprediksi melalui paparannya atau dapat diperoleh gambarannya secara umum. berdasarkan data primer sebagian besar responden sakit lupus sejak 1-2 tahun yang lalu (33,3%). gejala lupus terbanyak adalah arthritis (61,1%). faktor pencetus mayoritas adalah stres fisik/kelelahan (66,7%). berdasarkan gejala yang dialami dan terapi yang didapatkan, seluruh responden penelitian ini masuk kategori stabil menurut ferenkeh-koroma (2012) dengan indikator: jarang mengalami lupus flare, gejala yang dialami dapat berupa ruam kulit dan/atau nyeri dada, terkadang menghubungi petugas kesehatan untuk meminta bantuan, terapi yang didapat berupa obat kortikosteroid kontinum (methylprednisolone) dan imuno-supresan (cyclosporine). berdasarkan standard perhimpunan rheumatologi indonesia (pri, 2011), seluruh responden masuk kategori lupus ringan dengan indikator: mengalami arthritis dan/atau ruam kulit, secara klinis tenang, tidak terdapat gejala lupus yang mengancam nyawa, fungsi organ normal/stabil. arthritis teridentifikasi sebagai gejala lupus mayoritas (61,1%), hal ini sesuai dengan pendapat dias & isenberg (2014) bahwa pada gejala lupus ringan, persendian adalah organ utama yang terkena dampak penyakit lupus. kelelahan fisik juga teridentifikasi sebagai faktor pencetus gejala lupus mayoritas (66,7%), hal ini sesuai dengan pendapat gordon (2013) bahwa kelelahan fisik adalah pencetus gejala lupus yang paling umum dimana kelelahan ini tidak selalu hilang dengan istirahat dan dapat berlangsung lama. data khusus penelitian terkait variabel yang diteliti yang meliputi paparan faktor pencetus gejala, pengetahuan tentang lupus, efikasi diri, dan tindakan pencegahan paparan faktorpencetus disajikan dalam tabel 4. mayoritas responden cukup terpapar oleh faktor pencetus gejala lupus dalam enam bulan terakhir (88,9%). semua responden memiliki pengetahuan yang tinggi tentang penyakitnya (100%). efikasi diri responden mayoritas juga tinggi (72,2%). tindakan pencegahan paparan faktor pencetus gejala lupus mayoritas optimal (77,8%). tabel 4. data khusus penelitian faktor pencetus gejala dan perilaku pencegahan sle (ni putu wulan p.s.) 217 variabel kategori frekuensi persentase paparan faktor pencetus gejala minimal 4 11,1 sedang 32 88,9 tinggi 0 0 pengetahuan tentang lupus rendah 0 0 cukup 0 0 tinggi 36 100 efikasi diri rendah 2 5,6 cukup 8 22,2 tinggi 26 72,2 tindakan pencegahan paparan faktor pencetus kurang 2 5,6 cukup 6 16,7 optimal 28 77,8 hasil uji korelasi spearman rho menunjukkan tidak ada hubungan antara faktor pencetus gejala dengan pengetahuan lupus (p=0,342) dan dengan sikap (efikasi diri) (p=0,651). ada hubungan yang lemah namun signifikan antara faktor pencetus gejala lupus dengan tindakan pencegahan paparannya (r=0,360; p=0,031). pembahasan di dalam penelitian ini, pengetahuan tentang lupus tidak berhubungan dengan faktor pencetus gejala lupus. dari 100% responden yang pengetahuannya tinggi, terdapat 88,9% responden yang mengalami paparan sedang. berdasarkan kerangka konseptual yang digunakan dalam penelitian ini, khususnya precede proceed model dari l.w. green & kreuter (1991), pengetahuan telah diidentifikasi secara spesifik dalam domain faktor predisposisi perilaku kesehatan yang dapat secara langsung mempengaruhi gaya hidup/ tindakan yang diambil individu. pengetahuan berhubungan dengan tindakan yang diambil seseorang untuk mempertahankan status kesehatannya. hal ini selaras dengan hasil penelitian yang menunjukkan tidak ada hubungan signifikan antara pengetahuan dan faktor pencetus gejala lupus, namun pengetahuan potensial berhubungan dengan tindakan pencegahan yang dilakukan odapus. pengetahuan merupakan suatu perwujudan dari faktor internal individu yang mempermudah individu untuk berperilaku. penerapan pengetahuan odapus dalam kehidupannya sehari-hari bisa ditunjukkan dalam tindakan pencegahan paparan faktor pencetus gejala lupus. hasil penelitian menunjukkan dari 100% responden yang pengetahuannya tinggi, hanya 77,8% responden yang melakukan tindakan pencegahan secara optimal. masih ada 22,8% responden yang tidak melaksanakan tindakan pencegahan secara optimal. hal ini potensial disebabkan karena para responden tersebut efikasi dirinya tidak tinggi (masih cukup/ rendah). ditemukan 27,8% responden yang efikasi dirinya cukup – rendah pada saat penelitian. bila seorang individu memiliki pengetahuan yang sudah memadai namun keyakinan dirinya kurang/rendah karena berbagai faktor, maka tindakan yang diambilpun menjadi kurang maksimal. hasil penelitian ini menunjukkan efikasi diri tidak berhubungan dengan faktor pencetus gejala lupus. efikasi diri merupakan cerminan rasa percaya diri seseorang terhadap kemampuan yang dimilikinya untuk dapat melakukan dan melaksanakan suatu tindakan untuk mencapai sebuah tujuan. mayoritas responden yang memiliki efikasi diri tinggi (72,2%) mengalami paparan sedang (88,9%) dan melakukan tindakan pencegahan paparan faktor pencetus gejala lupus secara optimal (77,8%). tinginya efikasi diri responden memfasilitasi optimalnya tindakan pencegahan yang diambil. berdasarkan precede proceed model dari green & kreuter (1991), efikasi diri termasuk sikap yang telah diidentifikasi secara spesifik dalam domain faktor predisposisi perilaku kesehatan yang dapat secara langsung mempengaruhi gaya hidup/tindakan yang diambil individu. jadi, efikasi diri potensial berhubungan dengan tindakan pencegahan yang dilakukan odapus, namun tidak berhubungan dengan faktor pencetus gejala lupus. hasil penelitian ini menunjukkan tindakan pencegahan paparan faktor pencetus berhubungan dengan faktor pencetus gejala lupus. mayoritas responden mengalami paparan sedang (88,9%) dan melakukan tindakan pencegahan paparan faktor pencetus gejala lupus secara optimal (77,8%). ada 11,1% responden yang mengalami paparan sedang namun belum melaksanakan tindakan pencegahan secara optimal. faktor pencetus gejala lupus yang teridentifikasi dalam penelitian ini meliputi stres fisik (mayoritas), stres emosional, sinar matahari, makan tidak teratur, kurang tidur dan perubahan hormon (terkait siklus menstruasi dan proses kehamilan). para responden penelitian menyatakan beberapa kesulitan dalam usahanya mencegah paparan faktor-faktor pencetus ini jurnal ners volume 11 no. 2: 213-219 218 karena tuntutan peran, keterbatasan diri maupun sumberdaya yang dimiliki. namun demikian, mayoritas responden bisa melakukan tindakan pencegahan secara optimal. faktor pencetus stress fisik relatif sulit dicegah karena responden merasa sulit menjaga tubuh dari rasa lelah akibat bekerja maupun menjalankan perannya sebagai ibu yang harus menyelesaikan pekerjaan rumah tangga. hal ini potensial terjadi akibat tingginya tuntutan peran dan kurangnya dukungan keluarga dalam hubungan sosialnya. hasil penelitian lain mendukung hasil penelitian dias et al. (2014) yang berpendapat bahwa tindakan yang ditujukan untuk meminimalisir paparan faktor pencetus gejala lupus dapat mengurangi kekambuhan lupus. tindakan pencegahan ini diperlukan untuk mengendalikan kekambuhan gejala lupus dan mempertahankan status kesehatan odapus tetap baik. green & kreuter (1991) berpendapat bahwa tindakan spesifik yang ditujukan untuk meningkatkan/mempertahankan status kesehatan dapat mempengaruhi kualitas hidup individu. tindakan pencegahan paparan faktor pencetus yang dilakukan oleh odapus dapat memberi perbaikan yang bermakna pada kekambuhan gejala lupus bila dilakukan dengan benar dan rutin. namun demikian, ada beberapa jenis faktor pencetus yang dirasa sulit dicegah, misalnya stres fisik (tergantung tuntutan peran), stres emosional (tergantung mekanisme koping), sinar matahari (tergantung aktivitas), dan lain-lain. simpulan dan saran simpulan faktor pencetus gejala lupus mayoritas adalah stres fisik / kelelahan. ada hubungan antara faktor pencetus gejala dengan tindakan pencegahan paparannya pada penderita lupus. tidak ada hubungan antara faktor pencetus gejala dengan pengetahuan dan efikasi diri (sikap) pada penderita lupus. saran pendekatan multi-center study dapat dilakukan untuk menjangkau jumlah responden yang lebih besar. paradigma penelitian mixed-methods dapat diterapkan untuk memperoleh hasil penelitian yang lebih akurat. instrumen baru yang dikembangkan dapat diuji dalam skala yang lebih besar sehingga bisa distandardisasi. kepustakaan america, l.f. of, 2012. understanding lupus. available at: www.lupus.org. de barros, b.p., de souza, c.b. & kirsztajn, g.m., 2012. the structure of the “livedexperience”: analysis of reports from women with systemic lupus erythematosus. journal of nursing education and practice, 2 (3), p.p 120. available at: http://www.sciedu.ca/journal/index.php/jnep/ article/view/594 [accessed october 28, 2016]. dias, s.s. et al., 2014. advances in systemic lupus erythematosus. medicine, 42(3), pp.126–133. available at: http://linkinghub.elsevier.com/retrieve/pii/ s1357303913003666 [accessed october 28, 2016]. ferenkeh-koroma, a., 2012. systemic lupus erythematosus: nurse and patient education. nursing standard, 26(39), pp.49–57. available at: http://rcnpublishing.com/doi/abs/10.7748/ ns2012.05.26.39.49.c9134 [accessed october 28, 2016]. foundation, s.l.e.l., 2012. about lupus. available at: www.lupusny.org. gallop, k. et al., 2012. development of a conceptual model of health-related quality of life for systemic lupus erythematosus from the patient’s perspective. lupus, 21(9), pp.934–43. available at: http://www.ncbi.nlm.nih.gov/pubmed/224 33917 [accessed october 28, 2016]. indonesia, y.l., 2012. info tentang lupus. available at: www.yayasanlupusindonesia.org. kannangara, l. et al., 2008. a study on aggravating factors for exacerbations, complications and hospital prevalence of systemic lupus erythematosus (sle). available at: http://pgimrepository.cmb.ac.lk:8180/han dle/123456789/2862 [accessed november 1, 2016]. l.w. green & kreuter, m.w., 1991. health promotion planning: an educational and environmental approach 2nd ed., mountain view: mayfield publishing company. laura k. delong, md, m., 2012. vitamin d status, disease specific and quality of life outcomes in patients with cutaneous lupus-full text view-clinicaltrials.gov, faktor pencetus gejala dan perilaku pencegahan sle (ni putu wulan p.s.) 219 atlanta, georgia, united states, 30322. available at: https://clinicaltrials.gov/ct2/show/nct01 498406. nadhiroh, f., 2007. lupus: penyakit seribu wajah dominan menyerang wanita. available at: http://surabaya.detik.com. nery, f.g. et al., major depressive disorder and disease activity in systemic lupus erythematosus. comprehensive psychiatry, 48(1), pp.14–9. available at: http://www.ncbi.nlm.nih.gov/pubmed/171 45276 [accessed october 28, 2016]. niams, n.i. of a. and m. and s.d., 2012. handout on health: systemic lupus erythematosus. available at: www.niams.nih.gov. stichweh, d. & pascual, v., 2005. systemic lupus erythematosus in children. an pediatr (barc), 63(4), pp.321–329. available at: www.analesdepediatria.org/en/pdf/13079 815/s300/. utomo, y.w., 2012. tingkatkan riset dasar tentang lupus. available at: www.health.kompas.com. microsoft word 27418-123721-1-le.docx http://e-journal.unair.ac.id/jners | 119 jurnal ners vol. 16, no. 2 october 2021 http://dx.doi.org/10.20473/jn.v16i2.27418 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research perspectives of pregnant women regarding iron deficiency anemia sirikanok klankhajhon1, kornkarn pansuwan1, kanokon klayjan1, somsak thojampa1 and nannaphat nensat2 1 faculty of nursing, naresuan university, phitsanulok, thailand 2 watbot hospital, phitsanulok, thailand abstract introduction: iron deficiency anemia (ida) is a global health problem. the prevalence of anemia in pregnancy worldwide is nearly half of pregnant women. it impacts on women and offspring outcomes during pregnancy, intrapartum and postpartum period associated with increasing rate of preterm labor, pregnancy induced hypertension, low birth weight, perinatal death including postpartum hemorrhage, postpartum infection, unsuccessful rate of exclusive breast feeding, and postpartum depression. inadequate iron intake, maternal physiological changes during pregnancy, and bleeding were indicated as common causes of ida in pregnancy. the objective was to explore the experiences of pregnant women regarding ida. methods: a total of eighteen women between 16-36 weeks’ gestation participated in the qualitative research. women were selected by purposive sampling according to inclusion criteria to in-depth interviewed at antenatal care clinic, watbot hospital, phitsanulok, thailand. results: thematic analysis of the qualitative interviews identified four main themes: iron-deficiency anemia in pregnant as a normal pregnancy; concern on food rather than hematocrit (hct) level; maternal instinct in healthy baby; and low socioeconomic as a main obstacle. conclusion: the findings illustrated to enhance better understanding the nature, attitude, knowledge, perception, and behavior of pregnant women on ida, facilitators to support women for healthy behavior, and barriers to ida in pregnancy based on thai context. article history received: june 06, 2021 accepted: september 09, 2021 keywords iron deficiency anemia; pregnant women contact sirikanok klankhajhon * sirikanok_k@hotmail.com + faculty of nursing, naresuan university, phitsanulok, thailand cite this as: klankhajhon, s., pansuwan, k., klayjan, k., thojampa, s., & nensat, n. (2021). perspectives of pregnant women regarding iron deficiency anemia. jurnal ners, 16(2). 119-127. doi:http://dx.doi.org/10.20473/jn.v16i2.27418 introduction iron deficiency anemia (ida) in pregnant women is a serious global health issue (who, 2011). anemia in pregnant women is defined as the hemoglobin (hb) level lower than 11 g/dl or hematocrit (hct) level lower than 33%, divided into three classifications of severity as follows: mild (hb10-10.9 g/dl), moderate (hb 7-9.9 g/dl) and severe (hb <7 g/dl) (center of disease control (cdc), 1989; who, 2011). the center of disease control defined the severity of anemia in each trimester as hb level lower than 11 g/dl or hct level lower than 33% in the first and third trimester of pregnancy and hb level lower than 10.5 g/dl or hct level lower than 32% in the second trimester of pregnancy due to the physiological changes during pregnancy (center of disease control, 1989). the global health observatory (gho) reports indicated that the prevalence of anemia worldwide is increasing with around 40% of pregnant women in 2016 (murray-kolb et al., 2012; who, 2011,, 2016). one of five cases of anemia in pregnant women is caused by iron deficiency anemia (ida) (department of health, 2017, 2018; who, 2011). ida in pregnant women has direct and indirect impacts on maternal health and offspring outcomes, including both medical and obstetrical complications during pregnancy, labor, and postpartum period. it is associated with increasing rate of preterm labor, pregnancy induced hypertension, low birth weight, perinatal death, postpartum hemorrhage, s. klankhajhon et al. 120 | pissn: 1858-3598 � eissn: 2502-5791 postpartum infection, unsuccessful rate of exclusive breast feeding, and postpartum depression (american college of obstetricians and gynecologists (acog), 2008; camaschella, 2015; maha et al., 2011; tandon et al., 2018). the evidence strongly supports that maternal physiological changes during pregnancy with inadequate iron intake are indicated as common causes of ida in pregnancy (camaschella, 2015; goonewardene et al., 2012; lowdermilk et al., 2016; pinchaleaw, 2017; reinold et al., 2012; tana, 2017; techakampholsarakit et al., 2018). in thailand, the policy promotes to decrease rate of ida in pregnant women by the department of health (doh), ministry of public health (moph) that provides iron supplement for all pregnant women. including nurses use in the nursing processes with group and individual health education about ida such as severity, consequences, prevention, treatment, dietary and iron supplement, and self-care during pregnancy (bureau of nutrition, department of health, 2011; center of disease control, 1989; department of health, 2018; food division, bureau of food, food and drug administration, 2016) and based on the recommendation from the world health organization (who, 2016) processes may support and decrease rate of ida in pregnant women. in addition, most of the studies focused on the risk factors, intervention, and program to prevent and improve the iron deficiency anemia in pregnant women (kaljarueg, 2017; sookdee & wanaratwichit, 2016; sukkai & khiewyoo, 2012). the national statistics reports that ida in thai pregnant women was around 20.43%, 21.05%, 20.39%, 18.55%, 17%, and 17%, respectively, from 2013 to 2018 (department of health, 2017; 2018). although, the prevalence of ida in pregnant women slightly decreased, it is quite steady around 17%. it is still more than kpi for anemia in pregnancy. the key performance indicator (kpi) must be less than 10% for anemia in pregnancy. the prevalence of anemia in thai pregnant women is still higher than the kpi of anemia in pregnant women. these data illustrated the current studies that focused on the intervention to prevent and improve the iron deficiency anemia in pregnant women. it might not fit with the women’s views, which affect the practical use for pregnant women with ida. therefore, the overall aim of the study was to explore the experiences and perspectives of pregnant women regarding ida to understand their attitude, knowledge, and behavior during pregnancy based on the thai context including their insight of barriers and facilitators to anemia in pregnant women. this identification of phenomena and experiences of pregnant women with ida will be used to design the program or intervention that might fit and be of practical use for them. materials and methods a phenomenology qualitative research was used to explore the experiences and understand the phenomena of pregnant women with ida through indepth interviews. their experiences provided better understanding of the attitude, knowledge, self-care and behavior of pregnant women and provided insights into their experiences of the barriers and facilitators based on the thai context. a target sample size was ten to fifteen pregnant women for interviews. the researcher believes the number of sample size around ten to fifteen women is sufficient to identify and understand the phenomena and their lived experiences of pregnant women with ida (creswell, 2014; holloway, 2010). the sampling grid is shown in table 1. women were selected by purposive sampling for in-depth interview at antenatal care clinic, watbot hospital, phitsanulok, thailand. women were initially invited by the nurse at anc. when a pregnant woman expressed willingness to participate in the interviews, they contacted the researcher by telephone (free call) or in person at the anc during office hours. then, women interested in participation were given full information by the researcher. the researcher took written consent. the participants were screened through inclusion and exclusion criteria. the inclusion criteria are woman able to read, speak and understand the thai language. pregnant women diagnosed as ida, who had hct level less than 33 percentages, and no complications would be eligible for recruitment. women with any complications and extremely high stress scores (st-5 score > 8 points) during pregnancy were excluded. women with extremely high stress scores were referred to nurse at anc. st-5 is a stress self-assessment tool within the thai version of the mother and child health handbook. stress score was collected from the women as part of their usual antenatal clinical assessments and these data were then extracted by the researcher. participants were offered a gift voucher of 200 baht for taking part in the interviews. the data were collected through individual indepth interviews from february to september 2020. the semi-structured questions were developed by the researcher based on the concepts of anemia in table 1. purposive sampling frame for pregnant women in the interviews variable details of variable number of pregnancy primigravida (first time) multigravida (second or more) maternal age age < 20 years old age > 20 years old history of ida during pregnancy yes no gestational age (ga) at the first visit > 12 weeks < 12 weeks antenatal care visit at clinic following the recommendation yes no severity of anaemia hb < 7 g/dl hb > 7 g/dl jurnal ners http://e-journal.unair.ac.id/jners | 121 pregnancy, research objective, and context. the items of questions were verified by the three experts in maternal and newborn nursing in terms of content, construct, and language. the question guide consisted of the participant’s experiences with the ida during pregnancy, caring during pregnancy, facilitators and barriers related the ida and healthcare service. for example, the key questions were guided to in-depth interview: “could you tell me about your experiences during pregnancy?”; “could you tell me about your current hct level?”; and “i would like to start with your usual care, please tell me about what do you do during pregnancy with ida.” steps in conducting the interviews were as follows: (1) the name, position and contact details of the researcher were introduced to the participants; (2) study information was briefed to the participants on the purposes, benefits and processes of the study, and ethical issues; (3) any questions from the participants were answered by the researcher before starting the interviews; and (4) the main findings from the interviews were summarized for checking accuracy and correction with the participants (creswell, 2014; holloway, 2010). the interviews ended with eliciting the participant’s demographic characteristics. all interviews took about 30 to 45 minutes per participant and were recorded with a digital voice recorder and field notes. thematic analysis was used to analyze data. the data were managed by the researcher as well as manually. the processes in conducting a thematic analysis were as follows (braun& clarke, 2006; creswell, 2014; holloway, 2010). firstly, the data were fully transcribed. the full transcripts were checked and cross-checked for accuracy. next, all transcripts were read and reread several times to understand each interview in depth. the data were compared for similarities and differences among participants based on a list of all topics from interviews. verbatim quotes were underlined and highlighted as key words. the data contents were coded. the codes were checked back with the transcripts for accuracy. the codes were grouped according to initial categories and progressed to subthemes and themes. the themes were examined in terms of relationships in two dimensions between data set and codes; and codes and themes. the themes were defined and named for presenting the overall data in each theme. lastly, the coding and the themes were examined for accuracy by the researcher, co-researcher and consultant. the process of thematic analysis was reported in relation to the research questions and literature. for instance, the data were transcribed as: “i feel nothing. i had morning sickness and fatigue in the early pregnancy. it is normal signs and symptoms of pregnancy.” (g1p0, age 34 years, ga 30 wk., hb 9 g/dl) “i have had an anemia before as same as this time. i feel nothing. it is a normal, just low level of hct. i never had signs of anemia.” (g3p2 l2, age 30 years, ga 32 wk., hb 8.5 g/dl) the verbatim quotes were underlined and highlighted as keywords as “never had signs of anemia” and “a normal signs and symptoms of pregnancy.” the data contents were coded and then were examined into the theme. the study rigor was obtained in terms of trustworthiness through credibility, confirmability, objectivity and transferability (anney, 2014). the process of qualitative interviews was checked by consolidated criteria for reporting qualitative studies (coreq) in three domains: research team and reflexivity; study design; and analysis and findings. the researcher summarized the findings from the interviews, which were re-examined by the researcher, co-researcher and consultant in each phase of the data analysis, including codes and themes as a peer-debriefing for credibility (anney, 2014). the protocols of data collection and data analysis were checked with the researcher, coresearcher and consultant to ensure that they were described well enough in terms of data collection process, raw data, process of data analysis and interpretation of the findings as an audit trial for dependability. the methods of data collection and data analysis process were reported in rich description of characteristics with the details of research setting, characteristics of participants, and the thai context. the decision-making of the researcher in each stage was demonstrated so that the research processes and context of the study can be applicable for justification to other contexts or situations in future research as a transferability (anney, 2014; baillie, 2015; creswell, 2014). the research process was recorded with a diary by the researcher including the feelings and contexts behind the decision-making for confirmability. the effect of the researcher on the research process was recognized because the researcher as an instrument might influence the process of the data collection and data analysis. the data analysis process was demonstrated in rich description to ensure that the findings were interpreted from the interviews (anney, 2014; baillie, 2015; creswell, 2014; shenton, 2004). ethical approval for this study was obtained from the naresuan university institution review board, naresuan university, thailand (irb no. 0596/62) dated on october 08, 2019. the decision to participate was made by individual women independently and without pressure. pregnant women could withdraw any time without giving any reason and their withdrawal from the research did not affect the standard of care. all data in this study were identified by individual codes, except for copies of the consent form which contained the names and contact details of all participants. no data could be accessed by anyone other than the researcher, co-researcher and consultant. the data were presented and reported without personal identification. during data collection s. klankhajhon et al. 122 | pissn: 1858-3598 � eissn: 2502-5791 and analysis, the researcher used a personal laptop with strong password protection. all files and documents were kept securely in locked storage at naresuan university, thailand. personal information will be kept for one year after the end of the study; all other anonymized data will be kept for a period of ten years after completion of the study in locked storage at naresuan university, thailand. results a total of twenty-five pregnant women had expressed an interest in participating in the in-depth interviews. five women withdrew from the study due to their duties: taking care of their children, transportation and their households. two women withdrew from the interviews due to their mother and husband having not allowed them to participate in the interviews. they also decided after the introduction to have explained again the aim of the study, the interview process, and checked consent for recording the interviews. one woman’s mother said, “it takes quite a time and there’s nothing for us to do that”; and the husband said, “it’s not significant to us. we just go back home to prepare our street food: thai sweets.” the participants were residents of the lower northern region of thailand such as sukhothai, pichit, phitsanulok, and tak in both the rural (village or countryside) and urban (town) areas. the demographic characteristics of pregnant women are summarized in table 2. the age of participants ranged from 16 to 40 years. the average income of participants was 10,000 baht a month. around half of participants had a healthy pre-pregnancy bmi (10, 55.6%), five women had an overweight (27.8%) and three women had an underweight (16.6%). most of the pregnant women had a mild severity of ida (hb 10-10.9 g/dl) (n = 13; 66.7%). they had no signs and symptoms of ida. topics of in-depth interviews covered a range of issues on pregnancy and ida. there were an initial twelve codes and initial nine sub-themes. these are shown in figure 1. four main themes emerged from the interviews: iron-deficiency anemia in pregnant women as a normal pregnancy; concern on food rather than hct level; maternal instinct in healthy baby; and low socioeconomics as a main obstacle. theme 1: iron-deficiency anemia in pregnant women as a normal pregnancy this theme illustrates the perception of pregnant women with ida. their point of views was still feeling it as a normal pregnancy even though they have had an anemia during pregnancy. they said: “i feel as the same as i am a normal pregnant woman. i know, i have a hematocrit level quite lower than usual pregnant women.” (g1p0, age 18 years, ga 32 wk., hb 6 g/dl) “when i was pregnant with the last child, this time, i feel the same as well.” (g3p2a0l2, age 32 years, ga 28 wk., hb 7 g/dl) pregnant women perceive the ida in the real word as quite different impacts from information from healthcare professionals. “i got information from the nurse and doctor at this hospital. they also said that my baby will have growth restriction. it means like a small baby but when the doctor checked my baby via ultrasound, she told me the size of baby is appropriate with my gestation. so, i feel ida for me as a normal.” (g2p1a0l1, age 27 years, ga 30 wk., hb 10 g/dl). sub-theme 1.1: nothing: not any signs and symptoms pregnant women expressed their experiences about ida during pregnancy. they indicated that they have not had any signs and symptoms and related complications of ida such as severe fatigue, abortion, infection, baby low birth weight, preterm labor, and others. “i’m ok. i don’t have any signs and symptoms about anemia that the nurses at the antenatal clinic told me about, such as infection, abortion, and intrauterine growth retardation. i am aware and take care myself and my baby the same as in the previous pregnancy. i just have an anemia in this pregnancy. last pregnancy, i am not sure, i have hct table 2. demographic characteristics of pregnant women in the in-depth interviews characteristics n % age < 20 years 20-34 years > 35 years 5 9 4 27.8 50.0 22.2 number of gravida primigravidarum multigravidarum 8 10 44.4 55.6 occupation employee self-employed agricultural housewife 4 3 5 6 22.2 16.6 27.8 33.4 education secondary school or equal high school or college degree bachelor degree or equal 9 6 3 50.0 33.4 16.6 pre-pregnancy body mass index (bmi) underweight (bmi < 18.5 kg/m2) healthy (bmi 18.5-22.9 kg/m2) overweight (bmi 23-29.9 kg/m2) 3 10 5 16.6 55.6 27.8 income < 200 us dollar 200-400 us dollar 400-800 us dollar >800 us dollar 3 6 6 3 16.6 33.4 33.4 16.6 gestational age at the first anc <12 weeks >12 weeks 11 7 61.1 38.9 hb level < 7 g/dl 7-9.9 g/dl 10-10.9 g/dl 2 4 12 11.1 22.2 66.7 jurnal ners http://e-journal.unair.ac.id/jners | 123 level around 35-37 vol%.” (g4p2a1l2, age 42 years, ga 34 wk., hb 8 g/dl) “i feel nothing. i had morning sickness and fatigue in the early pregnancy. it is normal signs and symptoms of pregnancy.” (g1p0, age 34 years, ga 30 wk., hb 9 g/dl) “i have had anemia before, same as this time. i feel nothing. it is normal, just low level of hct. i never had signs of anemia.” (g3p2l2, age 30 years, ga 32 wk., hb 8.5 g/dl) sub-theme 1.2: common way of life during pregnancy participants indicated their lifestyle during pregnancy with ida as similar as the common way of life during pregnancy. they expressed that they can run their job, take care of their children, household, and come to the hospital by themselves. “i feel as similar as other pregnant women because i can do my job at the convenience store and household including take care of my husband. i feel the nurse and doctor care for me the same as normal pregnancy.” (g1p0, age 34 years, ga 30 wk., hb 9 g/dl) “i have two children at 9 and 5 years old. i take care of this pregnancy the same as normal. now, i am a single mom. i think, i have a common way of life as a normal pregnancy although i have anemia during pregnancy. it’s just anemia, it’s the same as normal pregnancy. i do it as my usual life during pregnancy. i also got iron supplement the same as normal pregnancy.” (g4p2a1l2, age 42 years, ga 34 wk., hb 8 g/dl) they illustrated that they also work, live, and do other things during pregnancy with ida the same as pregnant women without ida, including getting iron supplement. theme 2: concern on food rather than hct level this theme illustrates the pregnant women’s concern on their food and diet as related to their gestational weight gain. they expressed that when they got information from the nurse about their complication: ida during pregnancy, they were concerned about their usual food, that they should take more food such as milk, vegetables, eggs, and meat. surprisingly, they did not concern to take iron-rich food such as pork liver, broccoli, green bean, and pork blood. “when i know, i am a pregnant. i take a lot of food such as milk, eggs, meat, and veggies. i think, it might help me to get high gestational weight gain. when i know that i have a low level of hct. i still take a lot of food and i don’t focus on iron-rich foods. i think, if i take more food (general foods), my weight will gain. it’s quite significant for me. frankly, i did not concern about my hct level. sometimes, i forgot to take an iron supplement.” (g1p0, age 24 years, ga 36 wk., hb 10.4 g/dl) pregnant women also expressed their experiences that iron-rich foods and iron supplements might not benefit to treat ida. they perceived iron supplements for all pregnancy, not specifically for ida during pregnancy. “i’m not sure about nutrients in the iron supplements that i got from hospital. i take it following the prescription but i didn’t see the outcomes. i still have low hct level both the previous figure 1. themes and sub-themes of pregnant women with ida •living expense is rising •impacts of covid-19 pandemic •social support based on believes and religion •goal on big baby •focus on maternal weight gain •doubt in nutrients during pregnancy •nothing: no any signs and symptoms •common way of life during pregnancy ida in pregnant as a normal pregnancy concern on food rather than hct level low socioeconomic as a main obstacle maternal instinct in healthy baby s. klankhajhon et al. 124 | pissn: 1858-3598 � eissn: 2502-5791 and this time. does it really help?” (g2p1a0l1, age 29 years, ga 31 wk., hb 8 g/dl) sub-theme 2.1: focus on maternal weight gain pregnant women focus on their gestational weight gain. “it’s my experience, the first pregnancy i had was normal hct level but my weight gain was only 9 kilograms in total. my first baby, it’s quite smallest just 2,600 grams. then, i have anemia in the second pregnancy. my total gestational weight gain is 1516 kilograms, baby birth weight is 3,200 grams. it’s quite a difference. if you have anemia and don’t have anemia during pregnancy, it may not impact on the different size of the baby.” (g3p2a0l2, age 35 years, ga 32 wk., hb 7.8 g/dl) they stated that they desired to take a lot of food. they believed that food benefits for them to gain their gestational weight. “i have anemia during this pregnancy. so, i try to take a lot of food, such as milk, eggs, and fruits. i believe that it’s good for me and my baby.” (g2p0a1l0, age 22 years, ga 29 wk., hb 7.8 g/dl) they pointed out that they did not concern about iron-rich foods and iron supplements. they assumed that it’s might not be an advantage for them during pregnancy. “i still believe you are what you eat in foods rather than iron-rich foods or iron supplements such as pork liver, pork blood, green beans, and vitamin supplements. if i take only pork liver, pork blood, green beans, etc., and obimin az and ferrous fumarate every day, my weight might not gain. it’s quite bad for me and baby. i think, all pregnant women should gain their total gestational weight around 10-15 kilograms even though you have anemia. hct level is less significant for me. it means iron-rich foods or iron supplements are less significant than my weight gains.” (g2p1a0l1, age 38 years, ga 33 wk., hb 8 g/dl) “when i have anemia, i must take more food for gaining my weight.” (g1p0, age 21 years, ga 31 wk., hb 8.5 g/dl) sub-theme 2.2: doubt in nutrients during pregnancy pregnant women indicated that iron-rich foods and iron supplements might benefit for increasing the hct/hb level but might not be of benefit for them. “i don’t know about the nutrients or iron in the ironrich foods and iron supplements. i got ferrous fumarate 200 mg. to treat anemia. i regularly take it three times a day: morning, noon, and evening from 12 weeks of gestation until now. the level of hct quite swings. i mean up and down and up and down between hct 28-31 vol%.” (g4p3a0l3, age 36 years, ga 32 wk., hb 10 g/dl) they showed that they did not know about the real benefits of iron nutrients in iron-rich foods and iron supplements. they also expressed that they hesitated about nutrients during pregnancy, especially iron. “i feel confused about nutrients during pregnancy. i have a question as to how much iron does a pregnant woman need daily? i got triferdine and ferrous fumarate. i take triferdine one tablet once a day and ferrous one tablet three times a day. i try to eat pork blood soup most of the week. when i checked up my hct level, it’s the same level. i don’t know what’s happened?” (g1p0, age 16 years, ga 27 wk., hb 6.5 g/dl) theme 3: maternal instinct in healthy baby pregnant women pointed out about their maternal instinct on a healthy baby. they claimed that the characteristics of a healthy baby consisted of good appearances, no complications and birth weight more than 3,000 grams. the most significant aspect of a healthy baby is big baby. “i try to do the best. if you have a big baby, it shows you have good food and self-care during pregnancy. you try to compare the big and small baby. the small baby might to get more frequently sick than the big baby.” (g3p2a0l2, age 35 years, ga 32 wk., hb 7.8 g/dl) pregnant women supposed that they get social support based on the thai context, belief and religion. “my husband finds a lot of information from his family, friends and internet and prays for my baby every day, when he knows i have anemia. i try to do everything, if i can for my baby.” (g1p0, age 34 years, ga 30 wk., hb 9 g/dl) sub-theme 3.1: social support based on beliefs and religion social support was illustrated by pregnant women that assisted them to be a healthy mom based on the thai context, including beliefs and religion. “he (my husband) extremely believes what his mother and grandmother give me about local food to decrease my anemia. it’s is a local vegetable; it’s called “pak good” (paco fern or small vegetable fern). he also prays before bedtime every day. maybe average five days a week.” (g1p0, age 34 years, ga 30 wk., hb 9 g/dl) informational support from healthcare professional indicated that pregnant women got an overview on ida such as diagnosis, causes, signs and symptoms, treatment, consequences, and follow up. “the nurse at the antenatal clinic told me in the first visit that i have anemia, hct 24 vol%, and gave me information about causes, signs, protocol for treatment and impacts on me and the baby. then, i met the doctor. she said i need to get blood transfusion and then take a blood test after that. i jurnal ners http://e-journal.unair.ac.id/jners | 125 have had iron supplements since after blood transfusion until now.” (g1p0, age 17 years, ga 32 wk., hb 9 g/dl) sub-theme 3.2: goal of a big baby pregnant women claimed their goal of pregnancy was that they wanted to get a big baby. they do the best to gain high gestational weight during pregnancy. based on their belief and thai context, pregnant women expressed their experiences that having a big baby came from their parents and grandparents. “my aim is to get a baby birth weight more than 3,500 grams. i’m not sure, is it quite high? but my mom and my grandmother told me you should take more foods to have a baby more than 3.5 kilograms. it’s a healthy baby.” (g1p0, age 21 years, ga 32 wk., hb 9.8 g/dl) “in thailand, if you have a big baby that means you are healthy during pregnancy and have a healthy boy too. most people don’t concern about what hct level do you have during pregnancy. they also ask you as a common question: how much weight did you gain during pregnancy and how does your baby weigh?” (g1p0, age 22 years, ga 33 wk., hb 8.2 g/dl) theme 4: low socioeconomics as a main obstacle the socioeconomic aspects showed that pregnant women concerned about their income and monthly stipend during pregnancy. pregnant women illustrated that they worried about cost of vitamin supplements and others during pregnancy with ida. it is a main barrier to pregnant women regarding ida. “i still keep money for my family rather than for myself although i have an ida during pregnancy. i think, the iron supplement that i got from the clinic is quite enough for me and my context. i have two children. i don’t want to pay more for iron-rich food. i ate a lot of rice noodles with curry no meat. it helps me to gain my weight.” (g4p2a1l2, age 42 years, ga 34 wk., hb 8 g/dl) “i cannot do my job. i work at the local restaurant. i have not enough money to pay for iron-rich food. i focus on living expenses in each month during the covid-19 pandemic.” (g1p0, age 19 years, ga 27 wk., hb 10 g/dl) sub-theme 4.1: living expenses rising pregnant women expressed the living expenses are constantly rising in thailand due to the impacts from the thai socioeconomics, political situations and covid-19 pandemic. they indicated that they got the same rate of salary, but the cost of living is rising, such as the price of pork meat, vegetables, milk, and gas for car or motorcycle. they have limited money to take care of their pregnancy with ida. “i concern on our living expenses (my husband, son and daughter and me). the price of pork meat, green beans, tomatoes and milk are rising. i think, it’s not good if i spend too much money for my pregnancy. i try to keep a balance. so, i take care of my pregnancy the same as previous pregnancy although this pregnancy has an ida. i choose sticky rice with fish sauce to eat rather than milk, salad, or noodle soup. i have no choice.” (g4p3a0l3, age 36 years, ga 32 wk., hb 10 g/dl) sub-theme 4.2: impacts of covid-19 pandemic participants indicated that the covid-19 pandemic impacts on the lifestyle and their work. some pregnant women changed their work outside to work from home. in addition, their income was decreased around 30-75%. they also expressed that they have adapted their lifestyle, including their expenses. they need to take care of their pregnancy and their life also. “i don’t know how to say. i think, i cannot think about me and my pregnancy. i have not enough money because i got only 50% of my salary from my boss due to the covid-19 pandemic. i cannot perfectly take care of my pregnancy with ida.” (g1p0, age 23 years, ga 30 wk., hb 8.6 g/dl) discussion the findings of this study reflect on their attitude, knowledge, and behavior including the selfawareness on ida during pregnancy. most of the pregnant women indicated that they did not have any signs and symptoms of anemia during pregnancy. they still have a common way of life as in a normal pregnancy. this experience reveals their attitudes that ida in pregnant women is the same as a normal pregnancy. in their point of view, pregnant women with ida and normal pregnancy got the information, treatment, and iron supplements the same as normal pregnancy. this is similar to findings of study conducted in mumbai, india where the participants expressed their experiences of anemia as “normal during pregnancy” because they perceived weakness or fatigue might not directly impact their offspring (chatterjee & fernandes, 2014). pregnant women indicated that they were more concerned on their food intake to gain higher gestational weight rather than the severity of anemia. based on their beliefs and thai context, most pregnant women focused on the maternal weight gain that benefited for them and their fetuses. they also pointed out that they concerned on their general foods rather than ironrich foods and iron supplement. they revealed that they hesitated over the benefits or advantages of iron supplement or nutrients of iron-rich foods during pregnancy. these findings reflected on their low level of attitude and knowledge including the behavior of pregnant women with ida about iron-rich foods and iron supplement. it is related to the study of factors affecting iron deficiency anemia in pregnant women that indicated the low level of knowledge and misunderstanding affecting their attitude and behavior during pregnancy, including iron s. klankhajhon et al. 126 | pissn: 1858-3598 � eissn: 2502-5791 supplements and iron-rich foods as a nutrition for pregnant women (kaljarueg, 2017; sookdee & wanaratwichit, 2016; sukkai & khiewyoo, 2012). the self-care during pregnancy with ida was expressed that they concerned on their food intake rather than iron-rich foods and iron supplements. it might impact on their hct or hb level. they also believed that if they take a lot of food it will be good so that they have high total gestational weight gain. participants indicated that the iron supplements and iron-rich foods were not significant to treat ida during pregnancy. they seemed to have less knowledge about the advantages of iron-rich foods and iron supplements on ida during pregnancy and self-awareness to enhance their behavior. a previous study aimed to determine factors affecting iron deficiency anemia among pregnant women and showed inappropriate attitude of taking iron tablets and self-care about iron deficiency anemia during pregnancy, including knowledge about iron-rich foods that were significantly associated with higher rate of ida (sookdee & wanaratwichit, 2016). these findings related to maternal instinct in a healthy baby. they believed that if they were healthy during pregnancy, they will have a big baby. it illustrated their social support from their families, friends, and significant persons, including healthcare professionals based on their beliefs and religion. it is quite important for pregnant women with ida regarding their informational and emotional supports as a facilitators during pregnancy (bilimale et al., 2010; chatterjee & fernandes, 2014; senanayake et al., 2010). in addition, the findings also illustrated the barriers to behavior of pregnant women regarding ida, that is socioeconomics and political situation. the increasing living expenses and impacts of the covid-19 pandemic, such as lockdown, should be a concern that impacts on their income and monthly stipend, especially ida during pregnancy. they expressed that they have enough money to support the iron-rich foods and iron supplement such as milk, meat, and offal. they still take local nutrients with high calories that they believe would afford a high maternal weight gain such as sticky rice with fish sauce and rice noodles with curry without meat. it affected their baby birth weight. it is similar to findings that the covid-19 pandemic affected income and household consumption due to income loss and unemployment (hawkins et al., 2010; martin et al., 2020). these issues will be improved by the prenatal educational program for pregnant women with ida that develops their iron supplements adherence and health behavior of pregnant women (bilimale et al., 2010; pipatkul et al., 2015; senanayake et al., 2010; sirisopa & pongchaidecha, 2015). the results of this study are significant for healthcare professionals, especially nursed, that should aware and take a role as a supporter during pregnancy based on informational, emotional, tangible, and appraisal supports to enhance attitude, knowledge, selfawareness, and behavior of pregnant women with ida (kaljarueg, 2017; sookdee & wanaratwichit, 2016; sukkai & khiewyoo, 2012). conclusion the results verified to enhance better understanding the nature and perception of pregnant women on ida, facilitators to support women for healthy behavior, and barriers to ida in pregnancy based on a thai context in beliefs, socioeconomics, and religion. the findings revealed the insight of attitude and knowledge that impacts on their experiences, behavior and self-care during pregnancy with ida. it is very useful for healthcare professionals to be aware and gain understanding of pregnant women with ida based on their backgrounds and context. this study will be applied in clinical practice of antenatal care clinic and health promoting hospital for reconsideration of the protocol for pregnant women with ida in terms of diagnosis, treatment, nursing care and transfer to community. for nursing administration, the collaboration between multidisciplinary such as pharmacist, doctor and nutritionist will be established for prenatal education about ida. in addition, the nursing clinical practice guideline (ncpg) for pregnant women with ida will be designed based on the findings from this study and will be tested in a future clinical trial. the limitation of this study should be considered. most of the pregnant women represented a low to medium level of education and family income, which cannot be generalized to the entire population. acknowledgment the authors would like to thank associate professor dr. chommanard wannapornsiri, dean of faculty of nursing, naresuan university, thailand for her kind support. i also would like to acknowledge my deepest thanks and gratitude to assistant professor dr. raweewan pilaikiet as a consultant for her kind support and useful advice and guidance. we also thank our colleagues for their kind support and helpful suggestions. references american college of obstetricians and gynecologists (acog). (2008). acog practice bulletin-clinical management guidelines for obstetriciangynecologists: anemia in pregnancy. obstetrics & gynecology, 112(1), 201–207. anney, v. n. (2014). ensuring the quality of the findings of qualitative research: looking at trustworthiness criteria. journal of emerging trends in educational research and policy studies (jeteraps), 5(2), 272–281. baillie, l. (2015). promoting and evaluating scientific rigour in qualitative research. nursing standard, 29(46), 36–42. bilimale, a., anjum, j., sangolli, h.n., & mallapur, m. (2010). improving adherence to oral iron jurnal ners http://e-journal.unair.ac.id/jners | 127 supplementation during pregnancy. aust med j, 3(5281–90). braun, v. & clarke, v. (2006). using thematic analysis in psychology. qualitative research in psychology. 3(2), 77–101. bureau of nutrition, department of health, m. of p. h. (2011). nutritive values of thai foods. department of health, ministry of public health. camaschella, c. (2015). iron-deficiency anemia. new england journal of medicine, 372(19), 1832–1843. center of disease control (cdc). (1989). cdc criteria for anemia in children and childbearing-aged women. mmwr morbidity and mortality weekly report, 138(22), 400–404. chatterjee, n., & fernandes, g. (2014). “this is normal during pregnancy”: a qualitative study of anaemia-related perceptions and practices among pregnant women in mumbai, india. midwifery, 30(1), e56–e63. creswell, j. w. (2014). research design: qualitative, quantitative and mixed methods approaches (4th ed.). sage publications. department of health, m. of p. h. (2017). health data centre for standard on maternal and child care service of department of health, ministry of public health. http://www.hpc.go.th/director/data/ standardupload/lr_profile_090217_105208.pdf department of health, m. of p. h. (2018). standard of care on maternal and child service of department of health, ministry of public health. http://www.hpc. go.th/director/data/standardupload/lr_profile_ 090217_105208.pdf. food division, bureau of food, food and drug administration, m. of p. h. (2016). knowledge of food and nutrition for all ages. food and drug administration. goonewardene, m., shehata, m., & hamad, a. (2012). anemia in pregnancy. best practice & research clinical obstetrics and gynaecology, 26(1), 3–24. hawkins, r.b., charles, e.j., & mehaffey, j. h. (2010). socioeconomic status and coronavirus disease 2019 (covid-19) related cases and fatalities. public health. https://doi.org/https://doi.org/ 10.1016/j.puhe.2020.09.016 holloway, i., wheeler, s., & holloway, i. (2010). qualitative research in nursing and healthcare: chichester (3rd ed.). blackwell. kaljarueg, p. (2017). anemia among pregnant women at u-thong community hospital, u-thong district, suphanburi province. nursing journal of the ministry of public health, 27(1), 22–32. lowdermilk, d.l., perry, s.e., cashion, k., & alden, k. . (2016). maternity & women’s health care (11th ed.). elsevier. maha, s.s., tondare, s.b., & tondare, m. . (2011). study of impact of anemia on pregnancy. international journal of reproduction, contraception. obstetrics and gynecology, 6(11), 4847–4850. martin, a., markhvida, m., hallegatte, s. & walsh, b. (2020). socio-economic impacts of covid-19 on household consumption and poverty. economics of disasters and climate change, 4, 453–479. https://doi.org/https://doi.org/10.1007/s41885 -020-00070-3 murray-kolb, l.e., chen, l., chen, p., shapiro, m., & caulfield, l. (2012). cherg iron report: maternal mortality, child mortality, perinatal mortality, child cognition, and estimates of prevalence of anemia due to iron deficiency. cherg. pinchaleaw, d. (2017). nurses and management of iron deficiency anemia in pregnant women. journal of the police nurses, 9(2), 195–201. pipatkul, w., sinsuksai, n., & phahuwatanakorn, w. (2015). effects of a nutrition and iron supplement promoting program on iron deficiency anemia in pregnant women. journal of nursing science, 33(1), 69–76. reinold, c., dalenius, k., brindley, p., smith, b., & grummer-strawn, l. (2012). pregnancy nutrition surveillance 2008 report. u.s.department of health and human service. senanayake, h.m., premaratne, s.p., palihawadana, t., & wijetrat, s. (2010). simple educational intervention will improve the efficacy of routine antenatal iron supplementation. j obstet gynaecol res, 36(3), 646–650. shenton, a. (2004). strategies for ensuring trustworthiness in qualitative research projects. education for information, 22(2), 66–67. sirisopa, n. & pongchaidecha, m. (2015). evaluation of a pharmaceutical care program with pregnant women with iron deficiency anemia. journal of science & technology, ubon ratchathani university, 17(2), 53–62. sookdee, j., wanaratwichit, c. (2016). factors affecting iron deficiency anemia among pregnant women receiving antenatal care at sub-districts health promoting hospital. journal of health science research, 10(1), 1–7. sukkai, c., khiewyoo, j. (2012). factors related to anemia among pregnant women in khaopanom district, krabi province. srinagarind med j, 27(2), 133–138. tana, c. (2017). anemia in pregnancy. http://www.med.cmu.ac.th tandon, r., jain, a., & malhorta, p. (2018). management of iron deficiency anemia in preganancy in india. indian journal of hematology blood transfusion, 34(2), 204–215. techakampholsarakit, l., kantaruksa, k., & sansiriphun, n. (2018). interventions to promote anemia prevention among pregnant women: a systemic review. nursing journal, 45(1), 62–74. who. (2011). haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. who. who. (2012). the global prevalence of anemia in 2011. who. who. (2016). who recommendations on antenatal care for a positive pregnancy experience. who. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 221 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19018 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review non-pharmacological therapy for the elderly to prevent dementia through cognitive stimulation therapy: a systematic review martha lowrani 1,3, retno indarwati1 and pudji lestari2 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 faculty of medicine, universitas airlangga, surabaya, indonesia 3 institute of health science (stikes) william booth, surabaya, indonesia abstract introduction: dementia is the most prevalent disease in older people and it has become the largest global public health priority. not only does it cause a progressive loss of independent functioning, a decline in the cognition of people with dementia and family restlessness but it also leads to an enormous social and economic burden. the aim of this study was to describe the non-pharmacological therapy that is commonly used and to show the significantly effect that it has in terms of preventing cognitive decline in the elderly with dementia. methods: the literature review approach was used with a cross-sectional framework. data was taken using a checklist and observations that were modified from the key words used to search scopus databases. the 20 final articles were published from 2010 to 2019. the data was analyzed through a comparative study results: there are several interventions based on cognitive stimulation therapy including clock-drawing, board games, story-telling, musical therapy, bright light therapy, aromatherapy, touch therapy, gardening, brain gym, modality therapy etc. from the study, it was found that cognitive stimulation therapy is suitable in all conditions, is easy to implemented and it significantly improved the cognitive and executive functioning of the elderly with dementia. conclusion: nowadays, most studies concern alternative approaches that are non-invasive, cost-effective, safe and easy to implement. cognitive stimulation therapy can be the best choice. it is expected that further research is needed to find other tools for scoring the intervention that is most suitable for all. article history received: feb 27, 2020 accepted: april 1, 2020 keywords cognitive stimulation therapy; prevent dementia; elderly; nonpharmacological therapy contact retno indarwati  retno-i@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: lowrani, m., indarwati, r., & lestari, p. (2020). non-pharmacological therapy for the elderly to prevent dementia through cognitive stimulation therapy: a systematic review. jurnal ners, special issues, 221-229. doi:http://dx.doi.org/10.20473/jn.v15i2.19018 introduction ageing populations represent a great challenge to the health and social care systems. dementia is one of the most common age-related disorders and with the number of cases expected to double every 20 years, governments worldwide are being urged to make dementia a clinical and research priority (milláncalenti et al., 2016). previous reviews have investigated the potential impact of cognitive stimulating leisure activities on cognitive decline and the risk of dementia (iizuka et al., 2019). however, this review seeks to a) pool data from studies on cognitively stimulating leisure activities in a series of meta-analyses, b) to assess the impact on cognition and risk of dementia in later life and c) to determine what are the treatments or non-pharmacological actions that people can do to prevent cognitive deterioration especially among the elderly with dementia. as limited effective treatment alternative for dementia are currently available, the identification of risk or protective factors, especially modifiable factors, could provide potential or prevent the disorder. however, evidence on the modifiable https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. m. lowrani et al. 222 | pissn: 1858-3598  eissn: 2502-5791 preventive factors of dementia is still limited. among the proposed protective factors, leisure activities are studied for non-pharmacological therapy (review, 2016). leisure activities can be defined as the voluntary use of free time for activities outside of the daily routine. it is the one of the major components of a healthy lifestyle. the use of board games as a cognitive stimulation activity has grown in recent years which has drawn the attention of researches in the field of geriatrics. however, studies on the application of board games as an intervention and for the assessment of older adults have been scarce. more evidence-based research is therefore required to verify if playing board games can be a valid non-pharmacological treatment in social work (ching-teng, 2019). this paper has 3 specific aims as follows: 1) to review the literature on the non-pharmacological therapies used to manage cognitive decline and social interactions in the elderly with dementia over the 10 years, 2) to assess the specific effectiveness of each non-pharmacological; therapy and 3) to provide evidence-based recommendations about the use of specific therapies and future research on this topic. materials and methods data source and search strategy a systematic review of the literature published over the past 10 years (january 2009 to june 2019) was performed. scopus electronic database was searched using the following keywords: cognitive stimulation therapy; prevent dementia; elderly and nonpharmacological therapy. several interventions that were noticed by the author were based on cognitive stimulation therapy inclusive of clock-drawing, board-games, story-telling, musical therapy, light therapy, aromatherapy, touch therapy, gardening, brain gym, modality therapy etc. inclusion and exclusion criteria some of the included original scientific articles in english met the following criteria.1) population: elderly with dementia (60 years of age or older). this was reported using a validated measurement via mmse or a medical diagnosis of dementia. 2) intervention: non-pharmacological interventions aimed at managing cognition. 3) type of experimental design: rct comparing cognition before and after the interventions. 4) outcome: only studies exploring non-pharmacological interventions for cognitive stimulation as a primary outcome (measured quantitatively and with a validated scale) or studies including sufficient information to determine the effect of non-pharmacological interventions on cognition were included. 5) type of study: only original articles were included. abstracts, reviews, descriptive studies, studies based on descriptive studies, studies based on the description of a protocol and studies based on the perspective of the authors, books, short surveys, observational studies, comments on an article and conference abstracts were excluded. data extraction the studies were synthesized according to the following characteristics: author and year, title, methods (design, sample, variables, instruments, analysis) and results. a narrative synthesis approach was performed to examine the results. more details have been given in the appendix in table 1, namely a summary of the non-pharmacological therapies given to the elderly to prevent dementia in the form of cognitive stimulation therapy. results the early literature search obtained 1015 articles. all came from a scopus database search engine. the 20 articles reviewed are relevant to the theme and they were adjusted for the inclusion and exclusion criteria and keywords needed. there following points were made: benefits of cognitive leisure activity there were 20 studies from a systematic review that came from 3 electronic databases: pubmed, psycinfo, and psycarticles. the articles said that some intervention are related to the activities done in leisure time including arts, writing, board games, reading, handicrafts, crossword puzzles and learning computer skills (iizuka et al., 2019). from the research findings, these activities can increase the cognition of the elderly because they trigger new learning and their intellectual and effective communication abilities. there was also a cohort study that explained that a higher level of education can be good for maintaining cognition and memory function. there are some positive relationships between the participation of the elderly in their leisure time and doing activities to prevent dementia as shown by their increased cognitive test performance (matyas et al., 2019). multidimensional stimulation therapy (mst) activity programs that work in groups are based on cognitive stimulation such as occupational, recreation and physical exercise / psychomotorics. these have been known to increase the cognition of persons with dementia as showed by the behavior aspect and some cognitive function (farina et al., 1949). cognitive stimulation therapy (cst) a randomized controlled trial as part of a quantitative scientific research reported that cst provides significant statistical data that shows that it can increase cognition and that it can decrease the on depression of dementia patients. it can also reduce the dependency of elderly people on the activities of daily living (adl) (filipa, cardoso, & rosa, 2014). another perspective held by a descriptive study said that there are practical guidelines that recommend that interventions are easy to adopt in any culture. jurnal ners http://e-journal.unair.ac.id/jners | 223 the cst structure means that it will be more effective and accepted by other cultures (aguirre, spector, & orrell, 2014). gaming activity or board game activity the cognition of the elderly could be increased through board game activities. conventional or modern gaming is still effective at improving cognitive function because there are words skills, language and attention skill involved in technology engagement, known as the visuo-perspective (programming, caring) (cecilia, giacomo, & vittorini, 2015). other satisfying results show a significantly increase in the cognitive function of the intervention table 1. summary of the non-pharmacological therapies for the elderly to prevent dementia through cognitive stimulation therapy no research title and author country metode (desain, sampel, variabel, instrumen, analisis) result 1 optimal nonpharmacological management of agitation in alzheimer’s disease: challenges and solutions (milláncalenti et al., 2016) ➢ spain ➢ d : descriptive review ➢ s : not mentioned ➢ v: i : challenges and solutions ➢ d : optimal nonpharmacological management of agitation in alzheimer’s disease ➢ i : systematic review of 754 studies ➢ a : randomized controlled trials (rcts) from 754 studies, 8 studies were found that matched the inclusion criteria. music therapy is optimal to use to provide therapy for agitated patients with moderate and severe dementia, both for an individual ad i groups. bright light therapy didn’t have a significant result in terms of reducing agitation but it did decline the need for baby-sitting to help with their daily needs. touch therapy was effective at reducing physical non-aggressive behavior but it is inappropriate to be given to those who are physically aggressive with verbally agitated behaviors. melissa oil aromatherapy and behavioral management techniques are not as good as a placebo/pharmacology to manage the agitation of dementia. 2 can cognitive leisure activity prevent cognitive decline in older adults? a systematic review of intervention studies (iizuka et al., 2019) japan ➢ d : descriptive ➢ s : 20 studies ➢ v : i : cognitive leisure activity ➢ d : cognitive decline ➢ i : search of 3 electronic databases: pubmed, psycinfo, and psycarticles ➢ a : prisma collection of the data some of the interventions related to the activities: arts, writing, board games, reading, handicrafts, a crossword puzzle and learning computer skills. the results found there to be a cognitive function increase and an increase in the elderly cognition through activities done in their leisure time. this was because there were new things learnt that triggered intellectual and effective communication between older people. 3 meaningful activities for improving the wellbeing of people with dementia: beyond mere pleasure to meeting their fundamental psychological needs (review, 2016) ➢ london, uk ➢ d : narrative peer review ➢ s : not mentioned ➢ v : i : meaningful activities for improving well-being and meeting their fundamental psychological needs ➢ d : people with dementia (pwd) ➢ i : database search using pubmed and psycinfo ➢ a : aforementioned theories the life review therapy and life story work was chosen as important to review including spiritual/religious activity, the need to prepare for the last minute of death, intergenerational activities, the need to be always looks good and putting on a creative performance activity during leisure time. 4 effect of board game activities on cognitive function improvement among older adults in adult day care centers (ching-teng, 2019) ➢ taiwan ➢ d : quasi-experimental study ➢ s : 82 subjects, 2 group ➢ v: i : effect of board games ➢ d : cognitive function ➢ i : questionnaire ➢ a: spss 22.0, a paired t-test good results seem to be more satisfied in the intervention groups than in the control groups in terms of increasing cognitive function. the board game activity that was frequently done in a nursing home was really effective. in the board game, the elderly learn to take the initiative, there is a recreation effect, planning and strategy is required and it is an adaptation where there is a winner and loser. m. lowrani et al. 224 | pissn: 1858-3598  eissn: 2502-5791 group related to the activity of board gaming in the elderly. this is because a lot of this type of recreation is a new experience that takes initiative, planning, organizing and adaptation when it comes to winning or losing (ching-teng, 2019). brain activity the reasons behind brain exercise were to prevent cognitive decline: in a high population of the elderly, as adults we need to maintain and increase our cognitive function to prevent the neuroplasticity brain process (reichman, fiocco, & rose, n.d.). no research title and author country metode (desain, sampel, variabel, instrumen, analisis) result 5 continuing education for the prevention of mild cognitive impairment and alzheimer’s-type dementia: a systematic review and overview of systematic reviews (matyas et al., 2019) ➢ austria ➢ d : systematic review, cohort study ➢ s : 459 participants ➢ v : i : continuing education prevention ➢ d : mild cognitive impairment and alzheimer’s-type dementia ➢ i : identified 4933 citations from 6 databases from january 1990 to april 2018 ➢ a : published studies and grey literature ➢ the prospective cohort study found matching inclusion criteria, where the level of education had a significant effect on language and memory ability. better executive memory function in a given period was reported. sr showed a consistency when it was reported that ther was a positive relation between a stimulating leisure activity able to prevent dementia and increasing cognitive test performance. 6 multi-dimensional stimulation therapy (mst): the practical protocol (farina et al., 1949) ➢ italy ➢ d : deskriptif ➢ s : not mentioned ➢ v : i : mst ➢ d : practical protocol ➢ i : intervention / stimulation ➢ a : the activity program driven in a group was much more effective at cognitive stimulation than when done individually. the activities were: occupational therapy, recreation, sports, physical or psychomotoric. these are known to bring increase the cognition of people with dementia people in the behavior aspect. 7 the effect of cognitive stimulation among nursing home elders: a randomized controlled trial (filipa et al., 2014) ➢ portugal d : quantitative s : 56 patients v : i :effect of cognitive stimulation d : i :two groups (intervention and control) a : cst had a significant impact on increasing cognition but it is still unknown if it was effective or not at healing depression. this is because there was not enough statistical data and there was no change in the selfdependency. 8 guidelines for adapting cognitive stimulation therapy to other cultures (aguirre et al., 2014) ➢ london, uk ➢ d : descriptive perspective ➢ s : not mentioned ➢ v : i : adapting cst ➢ d : other cultures ➢ i : formative method for adapting psychotherapy (fmap) ➢ a : guideline protocols that can be recommended in a practical culture because the included cst structure is both suitable and effective and easily accepted in other cultures. 9 influence of gaming activities on cognitive performance (cecilia et al., 2015) ➢ italy ➢ d : quantitative ➢ s : 67 elderly (60-85 yo) ➢ v : i : gaming activity ➢ d : cognitive performance ➢ i : questionnaire ➢ a : manova the performance of cognition in the elderly at a nursing home can be increased through board games or a technology instrument. board games are a classic method but still effective when used to increase cognition because there are word processing skills, language skills, an attention need that is close to a technology instrument and visuoperceptive ability (visual duty: programming, caring). jurnal ners http://e-journal.unair.ac.id/jners | 225 no research title and author country metode (desain, sampel, variabel, instrumen, analisis) result 10 exercise the brain to avoid cognitive decline: examining the evidence (reichman et al., n.d.) canada d : deskriptif s : 7010 healthy adults 283 with alzheimer’s disease v: i: exercise the brain d : avoid cognitive decline i : systematic review, search engine a : the rationale of brain exercises was to prevent the cognitive decline that comes from the greater population of the elderly. the aging process has always been linked with the deterioration of cognitive function in healthy older people and it can also be increasingly preventive regarding dementia in the elderly. hopefully adults have the ability to maintain and increase their cognitive function during the increase in age to prevent the neuroplasticity process. 11 the effects of an expanded cognitive stimulation therapy model on the improvement of cognitive ability among the elderly with mild stage dementia living in a community – a randomized waitlist controlled trial (young et al., 2018) ➢ hong kong ➢ d : quantitative research, rct ➢ s : 101 elderly individuals with mild stage dementia (ewmd) ➢ v: i : the effect of an expanded cognitive stimulation therapy model on the improvement of cognitive ability ➢ d : elderly with mild dementia ➢ i : questionnaire: the chinese mattis dementia rating scale (drs) and the chinese mini mental state examination (mmse) ➢ a: ancova demonstration this scientific research showed the effectiveness of the model-expanded cst on increasing cognitive ability in the ewmd community. in a group, the intervention showed more significant results than the control group, even though there were differences in age status, gender, education and the level of dementia. 12 application and interpretation of functional outcome measures for testing individuals with cognitive impairment (sj, wayne, 2018) ➢ las vegas, nevada ➢ d : descriptive study ➢ s : not mentioned ➢ v: i : application and interpretation of functional outcome measures ➢ d : cognitive impairment ➢ i : subjective examination; mmse; fast; bcrs; gds tools ➢ a : descriptive to identify the tools that can be used to screen for cognition level for use with functional clients with dementia. it is very important for practitioners that they can be able to teach and show their client some easy exercises that are interactive and involve communicating. 13 effectiveness of weekly cognitive stimulation therapy for people with dementia and the additional impact of enhancing cognitive stimulation therapy with a career training program (jacobi et al., 2014) london, uk d : descriptive study s : three communities v : i: effectiveness of weekly cst d: therapy for pwds i: measurement standard cognition, qol, quality of relationship with career a : rct there is no benchmark that showed in the 3 groups. when doing the follow up, there were no significant differences at all between the pwds. giving cst should be doing regularly, not only once a week (weekly cst) so then the results will be accurate data that can support evidencebased practice. 14 would older adults with mild cognitive impairment adhere to and benefit from a structured lifestyle activity intervention to enhance cognition? a cluster randomized controlled trial (lam et al., 2015) hong kong d : cluster randomized controlled trial s : 555 clients of which 250 are female v : i : benefit from a structured lifestyle activity intervention d: older adults with mci i : questionnaire a : descriptif structured lifestyle activity interventions were not associated with changes in everyday functioning. higher adherence was associated with a greater improvement in cognitive score. factors that enhance adherence should be specially considered in the design of psychosocial interventions for older adults with cognitive decline m. lowrani et al. 226 | pissn: 1858-3598  eissn: 2502-5791 no research title and author country metode (desain, sampel, variabel, instrumen, analisis) result 15 leisure activities, cognition and dementia (wang et al., 2012) stockholm, sweden ➢ d : systematic review ➢ s : not mentioned ➢ v : i : leisure activities, cognition ➢ d: dementia ➢ i : systematically summarized, articles published in english from 1991 to march 2011, with a total of 52 articles a : longitudinal studies, observational studies and interventional studies. the relationship between mental activity and dementia risk was found to be very strong in the observational study but there was inconsistency in the clinical trial. current evidence concerning the beneficial effect of other types of leisure activity on the risk of dementia is still limited and inconsistent. there should be standardized leisure activities in terms of frequency, intensity, duration and the type of activity in addition to the cognitive test batteries. the definition of cognitive decline needs to be harmonized/standardized. 16 development of 6 arts, a culturallyappropriate multimodal nonpharmacological intervention for dementia (wong et al., 2015) ➢ hong kong ➢ d : using 6 arts as a framework ➢ s : 263 people with dementia ➢ v: i: development of the 6 arts, a culturallyappropriate multimodal non-pharmacological intervention ➢ d : dementia ➢ i : intervention activity databases ➢ a : scoring system used to assess intensity level the 6 arts was operationalized through the development of an intervention activity database, a scoring system for intensity level and a service delivery model for application in a dementia day center. 17 playing board games, cognitive decline and dementia: a french population-based cohort study (dartigues et al., 2013) ➢ paris, france ➢ d : prospective population-based study ➢ s : 3675 participants ➢ v : i : playing board games ➢ d: cognitive decline, dementia ➢ i : mmse and gds ➢ a: cohort with a 20 year follow up from 3675 non-dementia participants at baseline, 32.2% reported regular board game playing. later on, 840 participants developed dementia during the 20 year follow up. the risk of dementia was 15% lower in the board game players than in the non-players after adjustment for age, gender, education and other confounding factors. a possible beneficial effect of board game playing on the risk of dementia could be mediated by less cognitive decline and less depression in the elderly board game players. 18 cerebral changes improved by physical activity during cognitive decline: a systematic review of mri studies (haeger et al., 2019) aachen, germany d : systematic review s : the highest sample size (n=100) via mris v: i : cerebral changes improved by physical activity d: cognitive decline i : search of pubmed database a: descriptive 19 psychosocial interventions for people with dementia: a synthesis of systematic reviews (mcdermott et al., 2018) london, uk ➢ d : systematic intervention with a psychosocial focus ➢ s : not mentioned ➢ v : i : psychosocial intervention ➢ d: people with dementia (pwd) ➢ i : database search from january 2010 february 2016 found 197 studies ➢ a : synthesis / systematic review cognitive stimulation that had been done in a group consistently showed an increase in the areas of cognitive function, social interaction and quality of life. this study highlights the importance of group activities to increase the social integration of people living with dementia. there was some authentic proof that multi-component exercises of a good intensity will be able to increase physical function, global cognition and daily activity skills. jurnal ners http://e-journal.unair.ac.id/jners | 227 non-pharmacological management of dementia a descriptive review of 754 studies found 8 that suitable according to the inclusion criteria. music therapy is known as the best optimal intervention used to calm agitated persons with dementia. musical therapy through listening is more effective on an individual basis than in groups. others interventions like bright light therapy and touching therapy are still not observed because of the need for them to be used in an appropriate time and situation (millán-calenti et al., 2016) discussion efficacy of board games at improving older adult cognitive function regarding health-related cognitive function, the results imply the board game activities may possibly improve their abilities related to cognitive function. playing board games could be a particularly relevant way to preserve cognition and to prevent cognitive decline or dementia. it could be recommended for older adults living in adult day care centers (young et al., 2018) delivering manual cst frequently or twice a week may be necessary to provide the required “dose” to combat the natural deterioration of dementia and to have a positive effect (sj, wayne, 2018). pursuit of new leisure activities opportunities to engage in new social and leisure activities not only provides pleasure in the moment but it is also an opportunity to maintain a good quality of life and sense of well-being (jacobi, donovan, orrell, stott, & spector, 2014). daily routine activities can’t be significant when it comes to changing the score of the cognitive status in daily activity. they should have a structured lifestyle activity intervention in the time set aside for leisure (lam, chan, leung, & fung, 2015). social activities may offer a stimulating social environment that involves not only dealing with complex and challenging social issues but also physical movement and information processing (wang, xu, & pei, 2012). there are some difference in the design and development of cognitive stimulation therapy based on the culturally-appropriate approaches to dementia intervention such as when adopting and maintaining a health behavior. this includes the utilization of nonpharmacological interventions that often require motivation in addition to an understanding of the associated benefits (wong et al., 2015). playing board games is a common stimulating leisure activity among elderly people globally because people of all ages, especially participants older than 60 in the general population, still like and enjoy playing board games and have reported regularly doing so. the rate of activity remained high even in an old age participant with cognitive deficit. cohort data with a 20 year follow up showed that board game players have a 15% lower risk of developing dementia than nonplayers (dartigues et al., 2013). for another explanation, there was a study that observed the results of magnetic resonance imaging (mri). a total of 23 mri studies focused on physical activity and cognitive decline met the inclusion criteria. in addition, 13 studies reported on participants with mci, 8 studies on participants with early ad and one study on participants with subjective memory loss. there were 12 intervention studies of different durations (range 3-6 months) and frequency (range 2-5 sessions per week). among the intervention studies, 9 studies applied aerobic exercise, 2 applied resistance training and 1 applied multi-component exercise (haeger, costa, schulz, & reetz, 2019). from this study, we also learnt about the benefit and importance of physical exercise in the decline and potential risk of dementia. conclusion knowing that every individual has different needs, interests and abilities, a person-centered approach will need to be adopted when working with people with dementia. facilitating people to continue to engage in their cherished hobbies and to carry out activities that are important to them will help people to adjust to their growing deterioration regarding their capabilities. for example, a person with a no research title and author country metode (desain, sampel, variabel, instrumen, analisis) result 20 cognitive therapy for dementia patients: a systematic review (article, 2018) barcelona, spain ➢ d : descriptive systematic review ➢ s : not mentioned ➢ v : i : cognitive therapy ➢ d : dementia patient ➢ i : review using several bibliographical databases (january 2009 to december 2017) a : pre-specified selection criteria, data extraction, and a methodological quality assessment. the results from reality orientation trials showed a minor effect in cognitive assessments while skills training trials and mixed trials showed contradicting effects on cognition. effects related to other outcomes (e.g. daily functioning, depression, language) were limited or not found. skills training trials and mixed trials seem to affect cognitive impairment in a positive way, although the results are inconclusive. m. lowrani et al. 228 | pissn: 1858-3598  eissn: 2502-5791 passion for sport or gaming strongly desires to continue with that activity not only for the pleasurable feeling but to help them keep in contact with their passion and therefore to maintain a sense of control/purpose and memory function (review, 2016). the implication of this systematic review was that exercise for people with dementia to improve their physical and cognitive functions, adl skills and behavioral and psychological symptoms will be the best non-pharmacological therapy that can be prevent dementia. it can also increase the psychosocial interaction between dementia patients through the provision of frequent stimulation-based cognitive therapy (mcdermott et al., 2018), (article, 2018). conflict of interest there is no conflict of interest between the authors. acknowledgement thank you goes to the faculty of nursing and universitas airlangga for this great opportunity to be a participant in this special event. references aguirre, e., spector, a., & orrell, m. (2014). guidelines for adapting cognitive stimulation therapy to other cultures. 1003–1008. article, r. (2018). cognitive therapy for dementia patients : a systematic review. 1–26. https://doi.org/10.1159/000490851 cecilia, m. r., giacomo, d. di, & vittorini, p. (2015). influence of gaming activities on cognitive performances. 67–72. https://doi.org/10.1007/978-3-319-19632-9 ching-teng, y. (2019). social work in health care effect of board game activities on cognitive function improvement among older adults in adult day care centers. social work in health care, 0(0), 1–14. https://doi.org/10.1080/00981389.2019.16561 43 dartigues, j. f., foubert-samier, a., goff, m. le, viltard, m., amieva, h., orgogozo, j. m., … helmer, c. (2013). playing board games , cognitive decline and dementia : a french population-based cohort study. 1–8. https://doi.org/10.1136/bmjopen-2013002998 farina, e., critelli, r., villanelli, f., fioravanti, r., mantovani, f., & sardini, l. (1949). m ultidimensional s timulation t herapy : t he p ractical p rotocol. 3(1). filipa, d., cardoso, b., & rosa, a. i. (2014). the effect of cognitive stimulation on nursing home elders : a randomized controlled trial. 157–166. https://doi.org/10.1111/jnu.12072 haeger, a., costa, a. s., schulz, j. b., & reetz, k. (2019). neuroimage : clinical cerebral changes improved by physical activity during cognitive decline : a systematic review on mri studies. neuroimage: clinical, 23(march), 101933. https://doi.org/10.1016/j.nicl.2019.101933 iizuka, a., suzuki, h., ogawa, s., kobayashi-cuya, k. e., kobayashi, m., takebayashi, t., & fujiwara, y. (2019). can cognitive leisure activity prevent cognitive decline in older adults ? a systematic review of intervention studies. 1–14. https://doi.org/10.1111/ggi.13671 jacobi, n., donovan, h., orrell, m., stott, j., & spector, a. (2014). effectiveness of weekly cognitive stimulation therapy for people with dementia and the additional impact of enhancing cognitive stimulation therapy with a carer training program. 2143–2151. lam, l. c., chan, w. c., leung, t., & fung, a. w. (2015). would older adults with mild cognitive impairment adhere to and benefit from a structured lifestyle activity intervention to enhance cognition ?: a cluster randomized controlled trial. 1–18. https://doi.org/10.1371/journal.pone.0118173 matyas, n., aschenberger, f. k., wagner, g., teufer, b., auer, s., gisinger, c., … klerings, i. (2019). continuing education for the prevention of mild cognitive impairment and alzheimer ’ s-type dementia : a systematic review and overview of systematic reviews. 1–10. https://doi.org/10.1136/bmjopen-2018-027719 mcdermott, o., charlesworth, g., hogervorst, e., stoner, c., moniz-cook, e., spector, a., … monizcook, e. (2018). psychosocial interventions for people with dementia : a synthesis of systematic reviews. 7863. https://doi.org/10.1080/13607863.2017.14230 31 millán-calenti, j. c., lorenzo-lópez, l., alonso-búa, b., labra, c. de, gonzález-abraldes, i., & maseda, a. (2016). optimal nonpharmacological management of agitation in alzheimer ’ s disease : challenges and solutions. post, m. (2014). definitions of quality of life: what has happened and how to move on. topics in spinal cord injury rehabilitation, 20(3), 167–180. reichman, w. e., fiocco, a. j., & rose, n. s. (n.d.). exercising the brain to avoid cognitive decline : examining the evidence. review, p. (2016). meaningful activities for improving the wellbeing of people with dementia : beyond mere pleasure to meeting fundamental psychological needs. 136(2), 99–108. https://doi.org/10.1177/1757913915626193 sj, wayne, romero rm baumgart. (2018). application and interpretation of functional outcome measures for testing individuals with cognitive impairment. 34(1), 13–35. https://doi.org/10.1097/tgr.00000000000001 71 wang, h., xu, w., & pei, j. (2012). biochimica et biophysica acta leisure activities , cognition and dementia ☆. bba molecular basis of disease, 1822(3), 482–491. https://doi.org/10.1016/j.bbadis.2011.09.002 jurnal ners http://e-journal.unair.ac.id/jners | 229 wong, g. h. y., ng, c. k. m., lai, c. k. y., lee, m. n. y., lum, t. y. s., jiang, n., … wu, j. y. m. (2015). development of six arts , a culturally appropriate multimodal nonpharmacological intervention in dementia. 55(5), 865–874. https://doi.org/10.1093/geront/gnu102 young, d. k., ng, p. y., kwok, t., ho, f., cheng, d., mak, v., … kwok, t. (2018). the effects of an expanded cognitive stimulation therapy model on the improvement of cognitive ability of elderly with mild stage dementia living in a community — a randomized waitlist controlled trial. 7863(may). https://doi.org/10.1080/13607863.2018.14715 86 yusra, a. (2011). hubungan antara dukungan keluarga dengan kualitas hidup pasien diabetes mellitus tipe 2 di poliklinik penyakit dalam rumah sakit umum pusat fatmawati jakarta. tesis. 157 pengembangan instrumen diagnosis & intervensi keperawatan berbasis standardized nursing language (nanda-i, noc, nic) (development of nursing diagnosis & intervention instrument based on standardized nursing language (nanda-i, noc,nic)) diana rachmania*, nursalam*, esti yunitasari* *magister keperawatan fakultas keperawatan universitas airlangga email: widiana1925@gmail.com abstrak pendahuluan: dokumentasi keperawatan yang sesuai standar bahasa keperawatan (standarized nursing language), masih merupakan masalah di dalam profesi perawat, khususnya keseragaman dalam penggunaan bahasa diagnosa dan intervensi keperawatan. dibutuhkan suatu instrumen untuk bisa menghasilkan dokumentasi diagnosis dan intervensi yang baik. tujuan dari penelitian adalah meyusun pengembangan instrument diagnosis dan intervensi keperawatan berbasis standardized nursing language (nanda-i, noc, nic). metode: desain penelitian ini adalah action reserach dilaksanakan dalam 2 tahap. populasi tahap 1 adalah 16 partisipan dan 9 sampel. partisipan dan sampel dipilih dengan tehnik purposive sampling dengan partisipan sebanyak 15 dan sampel 7. populasi tahap 2 adalah 13 partisipan dan 8 sampel. partisipan dan sampel dipilih dengan tehnik tehnik purposive sampling dengan partisipan sebanyak 13 dan sampel 8. analisa data menggunakan analisis deskriptif, analisis statistik product moment pearson correlation untuk uji validitas dan cronbach alpha untuk uji reliabilitas. hasil: pengembangan instrumen diagnosis dan intervensi keperawatan yang disusun berdasarkan hasil kegiatan fgd dinyatakan valid dan reliable. diskusi: setiap rumah sakit diharapkan selalu rutin dalam mengevaluasi instrumen diagnosis dan intervensi keperawatan yang sesuai standar dan kebijakan yang berlaku agar tercipta dokumentasi keperawatan yang berkualitas kata kunci: standarized nursing language, nanda-international, nursing outcomes classification, nursing interventions classification abstract introduction: nursing documentation appropriate standards of nursing language (standarized nursing language), was still a problem in the nursing profession, especially uniformity in using nursing diagnoses and interventions language. instrument were needed to produce a good quality of nursing diagnosis and intervention’s documentation. the purpose of the research was to develop nursing diagnosis and interventions instrument based on the standardized nursing language (nanda-i, noc, nic). methods: this study was action reserach carried out in 2 phases. the population of phase 1 were 16 participants and 9 samples. participants and samples selected by purposive sampling techniques with participants were 15 and samples were 7. the population of phase 2 was 13 participants and 8 samples. participants and samples selected by purposive sampling technique with participants were 13 and samples were 8. analyze data using descriptive analysis, statistical analysis using pearson product moment correlation for validity test and cronbach alpha for reliability test. results: development of nursing diagnostic and interventions instruments, that was formulated based on focus group discussion, declared valid and reliable. discussion: each hospital was expected to always routinly evaluate the nursing diagnosis and interventions instrument as a standard and policies in order to create a quality nursing documentation keywords: nursing diagnosis, nursing intervention, standardized nursing language, nanda-international, nursing outcomes classification, nursing interventions classification introduction documentation appropriate with standards nursing language was still a problem in the nursing profession, especially uniformity in using nursing diagnoses and nursing interventions language. in order to produce a good nursing documentation, need to be supported with good quality of nursing instrument . the phenomena that often occurs is nursing documentation instrument especially nursing diagnoses and nursing interventions instrument is still not in accordance with the rules of standardized nursing language (nanda-i, noc, nic) one of which occurred in amelia pare hospital. the use of the language contained in the nursing diagnosis instrument in rs amelia pare were less appropriate to the use of language in nanda-i (north america nursing diagnoses associationinternational), writing outcomes and action plans on nursing interventions instrument was already there, but it was still not fully describe all activities performed by nurses in planning actions. it was also necessary that an instrument need to be mailto:airlanggaemail:%20widiana1925@gmail.com mailto:airlanggaemail:%20widiana1925@gmail.com jurnal ners vol 11 no 2 oktober 2016: 157-163 158 standardized in common nursing language usage among nurses with nurse one another so as to create a good communication process which was reflected from the nursing documentation process contained in rs amelia pare. data collection on the nursing documentations in teratai room rs amelia pare conducted by researchers at the date of october 4, 2015 by interview and observation. the num of teratai room said that actualliy nurses knew that their task after implementation was documented, but only certain things such as ttv, injection drug delivery, and other routine activities that documented in nursing instrument. resut of interviews with four from the 13 nurses (30%), that the four nurses said that they had not much time to write in the instrument that has been provided for the number of actions that must be done to the patient instead of writing on the existing format/instrument. documentation that has not been completed by a nurse is a diagnosis and intervention, nursing implementation, and evaluation. the results of observations conducted by researchers of the diagnosis and intervention instruments that contained a check list format that facilitates nurses in selecting appropriate nursing diagnoses. but there are not appropriate with nanda-i nuring diagnoses. one sheet format consists of a variety of purposes and no nursing outcomes and the action plans mixed together with one another diagnosis that made care plan was less specific and less complete. nursing documentation seized almost 50% of his time nurse per shift (gugerty et al, 2007). most nurses in the clinical order, did not do a complete documentation. the reason why nurses did not do nursing documentation was most nurses prefer to spend their time to perform actions on the patient and not documenting it. factors of employment, training and workload according to siswanto, mh., hariyati, ts., (2013) was a factor that can affect the completeness of the documentation of nursing. work environment, high workload, and the difficulty of charging time format documentation contributes to lack of quality of nursing documentation (okaisu, e.m., kalikwani, f., wanyana, g. & coetzee 2014) the concept of the solutions developed in this research was to develop nursing diagnoses and interventions instruments based on the standardized nursing language (snl) in a format in the form of check list (√) in patients with cases diabletes mellitus in order to facilitated nurses in filling nursingdiagnoses and interventions instrument and efficiency time of nursing care. nursing diagnosis instrument was made according to the nanda-i (north america nursing diagnoses associationinternational), and for nursing interventions, nursing outcome according to the noc (nursing outcomes classification), and the selection of action plans according to the nic (nursing interventions classification). the benefits of the use of standardized languages was to improve communication between nurses and other health care providers and patients, increase the visibility of nursing interventions, and improving data collection to evaluate the results of nursing care (rutherford 2008) the strategy was increased knowledge and skills of nurses through socialization and training, as well as the practice of charging instrument nursing documentation in accordance stadardized nursing language. development of nursing diagnosis and intervention instrument based on standardized nursing language (nanda-i, noc, nic) was expected to improve the quality of nursing diagnosis and interventions. based on the description that had been described previously so it need to be develop nursing diagnosis and intervention instrument based on standardized nursing language (nanda-i, noc, nic). materials and methods design research was action research conducted in two phases. the first phase was the preparation of nursing diagnosis and intervention instrument so that the instrument developed valid and reliable, supported by statistical analysis using pearson product moment correlation test to determined the validity and cronbach alpha test to determined the reliability and descriptive analysis. phase two was the process of socialization and training in the used of instruments so that the nurses were able to use the nursing diagnosis and interventions instrument based on standardized nursing language (nanda-i, noc, nic). descriptive analysis was used to determined the frequency distribution of each sub-category variable. the population of the first phase of activities fgd consists of a field of nursing, nursing committee, num and the nurses. participants in the focus group were selected based on purposive sampling technique. participants in the fgd amounted to 15. the population of the first phase to test the validity and reliability is a nurse and the selection of development of nursing diagnosis & intervention instrument (diana rachmania,dkk) 159 the sample using purposive sampling technique gained 7 nurses. the population of the second phase that used to evaluate the capability of nurses in the charging nursing diagnoses and intervention instrument based on standardized nursing language (nanda-i, noc, nic) was a nurses at teratai room and the selection of the sample using purposive sampling technique gained 8 nurses. the population of the second phase for fgd activities consist of nursing, nursing committee, num and the nurse at teratai room. participants in the focus group were selected based on purposive sampling technique. participants in the fgd amounted to 13 participant. variables in this research was the development of nursing diagnosis and intervention instruments based on standardized nursing language (nanda-i, noc, nic). phase 1 consisted of standard nursing diagnostic evaluation and assessment of nursing interventions used in hospital amelia, drafting nursing diagnosis and intervention instrument through fgd (focus group discussion), to test the validity and reliability of the instrument diagnosis and nursing interventions. phase 2 consisted of filling training instruments based nursing diagnosis and intervention standardized nursing language (nanda-i, noc, nic), the evaluation of the ability of the nurse in charge of instruments and recommendations resulting from the study. data processing at one phase consists of a descriptive analysis of the results of the evaluation standards for diagnosis and assessment of nursing interventions used in hospital diagnosis amelia and drafting instruments and nursing interventions through fgd (focus group discussion). inferential analysis was carried out to test the validity with pearson product moment correlation test to determine the validity and cronbach alpha test to determine the reliability of the provisions of the table r 0.754 (by 7 respondents). the data processing phase 2 is done with descriptive analysis to determine the frequency distribution of each sub-category variable. results results & analysis research phase 1 characteristics of 15 participants fgd is almost part of the participants (33%) were aged> 40 years, the entire pastisipan (100%) were women, almost half of the participants (46%) working time> 15 years, most of the last education is d3 of nursing, and all participants (100%) is a permanent employee. this shows that the fgd participants is included in the category of productive age, with work experience long enough so that it can give an idea of the needs of the instrument nursing documentation in accordance with the conditions in each room. seven characteristics of the respondents, almost half of respondents (42%) aged > 31-35 years, all respondents (100%) were women, almost half of respondents (42%) work between 5-10 years old, most of the last education is d3 of nursing, and all respondents (100%) is a permanent employee. it showed that the respondents to the category of productive age, work experience long enough at more than 5 years can be used as a benchmark of the validity and reliability of the instrument. the evaluation results of observation nursing diagnosis and interventions instrument used in the teratai room amelia pare hospital were judged by the standards of nursing care was quite appropriate nursing diagnoses and nursing intervention instruments appropriate nursing interventions pretty standard. recommendations from fgd about the structure of the nursing diagnosis and nursing interventions instrument based on standardized nursing language that was be applied at teratai room that participants agree with the arrangement of the instruments presented by researchers was the formulation of nursing diagnoses according nanda international with selection check list according to the standard formulation of nursing diagnosis is composed of problem, etiology, symptomp for actual and problem diagnosis, etiology for the diagnosis of risk with check list format. nursing intervention instruments used in accordance with the noc (nursing outcomes classification) and nic (nursing intervention classification) with a check list format. results validity and reliability of the nursing diagnosis and interventions based standardized nursing language (nanda-i, noc, nic) as follows: jurnal ners vol 11 no 2 oktober 2016: 157-163 160 table 1. the validity of the nursing diagnoses instrument table 1 shows that the validity of the test results with spss to test pearson's product moment correlation by 7 respondents, with r table was 0.754. all the items about the nursing diagnosis instruments that tested by pearson's product moment correlation with r count> r table so that the item is declared tabel 2. the validity of nursing interventions instrument no intervensi keperawatan r hitung uji korelasi pearson’s product moment r tabel (n=7) kesimpulan 1 soal no 1 r : 0,959 0,754 valid 2 soal no 2 r : 0,767 0,754 valid 3 soal no 3 r : 0,959 0,754 valid 4 soal no 4 r : 0,959 0,754 valid rata-rata r hitung r : 0,911 0,754 valid tabel 3. the reliability of nursing diagnoses and interventions instrument no instrumen hasil uji cronbach alpha r tabel (n=7) kesimpulan 1 nursing diagnoses α : 0,862 0,754 reliabel 2 nursing interventions α : 0,875 0,754 reliabel results and analysis research phase 2 8 characteristics of the respondents, the majority of nurses (50%) were aged 26-30 years, mostly female (62%), the majority of nurses (50%) had a working time of 1-5 years, all respondents (100%) last education is d3 nursing, and all respondents are permanent employees (100%). it shows that age is still relatively young, with the last d3 nursing education is expected to receive a new science properly so as to apply the instrument developed by researchers well. characteristics of participants fgd stage 2 that almost half of the participants (33%) were aged> 40 years, the entire pastisipan (100%) were women, almost half of the participants (46%) working time> 15 years, most of the last education is d3 of nursing, and the whole participants (100%) is a permanent employee. this shows that the fgd participants is included in the category of productive age, with long work experience. socialization and training of the charging instrument-based nursing documentation standardized nursing language (nanda-i, noc, nic) in the rs teratai amelia pare held on 13 april 2016 in two phases with a total participant 47. broadly speaking, the participants were able to accept material submitted by researchers. training is conducted by nurses in hospitals lotus lounge amelia's practice of charging instruments based nursing diagnosis and intervention standardized nursing language (nanda-i, noc, nic). the instrument has been developed for patients with a medical diagnosis of diabetes mellitus, so the nurse assigned to document nursing care in patients with diabetes mellitus. one nurse in charge of documenting a patient with diabetes mellitus in which the documentation is completed in a single shift. this process takes place from the date of 14 april-29 april, 2016 the instrument has been developed for patients with a medical diagnosis of diabetes mellitus, so the nurse assigned to document nursing care no nursing diagnosis r hitung uji corellationpearson’s product moment r table (n=7) conclution 1 soal no 1 r : 0,767 0,754 valid 2 soal no 2 r : 0,910 0,754 valid 3 soal no 3 r : 0,910 0,754 valid rata-rata r hitung r : 0,862 0,754 valid development of nursing diagnosis & intervention instrument (diana rachmania,dkk) 161 in patients with diabetes mellitus. one nurse in charge of the results of the evaluation of the ability of nurses in the application of nursing diagnoses and interventions instruments based on standardized nursing language (nandai, noc, nic) show that the ability of respondents in filling nursing diagnosis instrument as a whole (100%) was good, the ability of respondents in filling nursing intervention instrument majority (75%) is good. the evaluation of the ability of nurses in the application of nursing diagnoses and interventions instruments based on standardized nursing language (nanda-i, noc, nic) at the teratai room shows that the ability of respondents in filling nursing intervention instrument majority (75%) is good. recommendations fgd phase 2, is necessary to record a list of nursing diagnoses in patients with diabetes mellitus to assist in a language that has been standardized, the formulation of nursing interventions in accordance with the noc and nic, where the target score outcome can be modified with lists the normal standard of the best conditions of the patient and also for the interventions activity need to be made in full either act independently or collaborative actions, should be evaluated on a regular basis regarding the use of language standards of nursing and nursing interventions in accordance with the standards applicable at any given moment. results of research findings to shape the development of the nursing diagnosis instrument based on the research that nursing diagnoses associated with causal factors for actual nursing diagnosis and risk factors for the nursing diagnosis risk in accordance languages nanda-international, nursing diagnoses were made in accordance with the authority of nurses. form of nursing interventions instrument that had been developed based on the research process, namely destinations care plan is only a target date for the achievement of goals and are the outcome of the desired target can be measured using a scale according to the noc, the action plan drawn up to resolve the issue based on nursing diagnoses of patients, the action plan in the form of a sentence instruction, concise, easily understandable language firm with appropriate nic. discussion evaluation of the implementation of documentation standards in nursing care in teratai room amelia hospital pare kediri the result evaluation of observation nursing diagnoses and interventions instrument that used in teratai room amelia hospital pare were judged by the standards of nursing care based on departement of health standard. the result show that nursing diagnosis is quite appropriate standard because nursing diagnosis is still not linked to the causes of the gap and meet the needs of patients. nursing diagnoses has been created by a nurse under the authority of nurses, nursing diagnosis actual still using one statement diagnoses, should have at least 2 statements diagnoses to actual nursing diagnosis that is labeled as a problem and explain the factors related to the etiology. nursing interventions instrument quite match the standard because there are goals that are specific and measurable, but no time limit is realistic in the goals, action plan already exists but mixed into one coloumn between the plan and purpose of some nursing diagnoses so it is unclear boundary between the action plan one with an action plan on the other nursing diagnosis, plan of action in the form of sentences instructions, quick, firm with the language easily understandable. development nursing diagnoses and interventions instrument based on standardized nursing language (nanda-i, noc, nic). recommendations from fgd about the structure of the nursing diagnosis and nursing interventions instrument based on standardized nursing language that will be applied at teratai room, that participants agree with the arrangement of the instruments presented by researchers is the formulation of nursing diagnoses according to the nanda international with selection check list according to the standard formulation of nursing diagnosis is composed of problem, etiology, symptomp for actual and problem diagnosis, etiology for the diagnosis of risk with check list format. nursing intervention instruments used in accordance with the noc (nursing outcomes classification) and nic (nursing intervention classification) with a check list format. the composition of the format used in the study of nursing diagnosis is composed of jurnal ners vol 11 no 2 oktober 2016: 157-163 162 "nursing diagnoses" relates to "causes /related factors" is marked with "symptoms / defining characteristics". in the medical record has been based electronics, sometimes do not include the component "related factors" and "symptoms". however should need also to be noted that component in order to support the nursing diagnoses. without such data it is impossible to verify the accuracy of the nursing diagnosis that affects the quality of nursing care (herdman & kamitsuru 2015). planning is part of the organizing phase of the nursing process as a guide to direct the actions of nursing in an effort to help, relieve, solve problems or to meet the needs of clients (setiadi 2012). researchers develop nursing diagnoses and interventions instrument based on standardized nursing language (nanda-i, noc, nic) based on the results of fgd and based on the theory described in the preceding paragraph. the instrument has been designed by researchers presented and offered to the participants. in accordance with the expectations of the nurses who want their diagnosis and nursing intervention instrument which is simple, easy to use, according to the theory and efficient. analysis of the validity and reliability table 1 shows the test results of pearson product moment correlation average value of r count validity of the instrument diagnosis 0, 862> 0.754, which means valid. table 2 shows the pearson product moment correlation average value of r count validity intervention instruments 0, 911> 0.754, which means valid. table 3 indicating the hasul iji cronbach alphadengan count r diagnosis and interevsni instruments are 0.862 and 0.875> 0.754 declared reliable. the principle of the preparation of the instrument according to nusalam, (2013) that the validity and reliability. the principle is the validity of measurements and observations imply reliability principle instrument in collecting data. the instrument must be able to measure what should be measured. good instrument instrument is tested for validity and reliability. therefore, in the drafting process is very important to pay attention to the content of the instrument is able to measure what should be measured, and the results of these measurements are able to provide accurate information. a total of 7 respondents employed researchers in measuring the validity and reliability of the instrument to deliver results that truly significant dissemination and training of the development of nursing diagnoses and interventions instruments based on standardized nursing language dissemination and training of the development of nursing diagnoses and interventions instruments based on standardized nursing language (nanda-i, noc, nic) in amelia hospital pare went smoothly and was held on 13 april 2016 attended by 47 participants in two stages. training is preparation to improve the competence and skills of staff, promotion to leadership performance improvement (danim 2008) indicators training methods can be viewed below (hasibuan 2005) interest or interest on the method used; 2) harmonization of training activities with the sustainability of activities on the ground; 3) facilities adequate practice space; 4) the timeliness with trainees. socialization activities carried out as many as two stages in order to facilitate nurses in teratai room, who was on duty in the morning shift. in ethics and responsibility, it is not possible to require all nurses to follow socialization teratai room at a time where the nurse had to leave the patient who is being treated in the room. the existence of such training is expected to increase the knowledge of nurses about the standard language and its application. evaluation of the ability and the opinion of nurses regarding application of nursing diagnoses and intervention based on standardized nursing language (nanda-i, noc, nic) the ability of respondents in filling nursing diagnosis instrument as a whole (100%) was good, the ability of respondents in filling nursing intervention instrument majority (75%) is good. evaluation should have clear objectives, in accordance with the objectives set in the program. (potter, p 2011). basically the development of nursing diagnoses and interventions instrument is not new for nurses. every day nurses are faced with the activity. therefore, it is possible in spite of the new information on how to fill out the instrument documentation with a new format, is not a difficult thing to be applied. in development of nursing diagnosis & intervention instrument (diana rachmania,dkk) 163 reality the respondents were able to fill up easily and smoothly instruments developed. recommendations recommendations fgd phase 2, to the amelia hospital is necessary to record a list of nursing diagnoses in patients with diabetes mellitus to assist in the preparation of stadar nursing with a language that has been standardized, the formulation of nursing interventions in accordance with the noc and nic, where the target score outcome can be modified with lists the normal standard of the best conditions of the patient and also for the manufacture activity interventions need to be made in full either act independently or collaborative actions, should be evaluated on a regular basis regarding the use of language standards of nursing and nursing interventions in accordance with the standards applicable at any given moment. conclusions & suggestions conclusions recommendations outcomes of the focus group discussion (fgd) in the development of instrument-based nursing documentation standardized nursing language (nanda-i, noc, nic) in the lotus room amelia pare hospital in the form of a check list that nursing diagnosis instrument based on nanda-international, intervention nursing by noc and nic. instruments of diagnosis and intervention, based nursing standardized nursing language (nanda-i, noc, nic) are valid and reliable. training charging instrument-based nursing documentation standardized nursing language (nanda-i, noc, nic) in rs amelia pare went smoothly and was held on 13 april 2016 attended by 47 participants in 2 stages. application of instrument-based nursing diagnosis and intervention standardized nursing language (nanda-i, noc, nic) in the lotus room amelia pare hospital showed that the ability of the nurse in charge of nursing diagnosis instrument either wholly (100%), and nursing interventions most ( 75%) either. recommendations outcomes of the focus group discussion (fgd) on the instrument nursing documentation that nursing documentation standard evaluation instruments need to be observed on a regular basis and can be developed according to the policies in force at any given moment. suggestion the nursing committee to begin record nursing diagnosis has ever appeared in any room so he could begin to formulate the nursing care based on the standardized nursing language (nanda-i, noc, nic) so as to produce formulation of nursing care in the form of check list and in accordance with the standards, as well as facilitate the nurse in the filling. for further research needs to be done research on the effectiveness of using the target score ourcome compared with normal data usage for the accuracy of data on nursing interventions made by the noc references danim, s., 2008. kinerja staf dan organisasi, bandung: pustaka setia. hasibuan, m.s.., 2005. manajemen sumber daya manusia revisi., jakarta: bumi aksara. herdman & kamitsuru, 2015. nursing diagnoses; definition and classification 2015-2017 tenth edit., uk: wiley blackwell. nusalam, 2013. metodologi penelitian ilmu keperawatan, jakarta: salemba medika. okaisu, e.m., kalikwani, f., wanyana, g. & coetzee, m., 2014. improving the quality of nursing documentation: an action research project’, curationis. available at: art. #1251, 11 pages. http://dx.doi. org/10.4102/curationis. v37i1.1251. [accessed october 6, 2015]. potter, p, & p., 2011. basic nursing ed. 7th., canada: mosby elsevier. rutherford, m.., 2008. standardized nursing language: what does it mean for nursing practice? available at: www.nursingworld.org/mainmenucateg ories /anamarket place/anaperiodicals/oji [accessed october 10, 2015]. setiadi, 2012. konsep & penulisan dokumentasi asuhan keperawatan, yogyakarta: graha ilmu. siswanto, mh., hariyati, ts., s., 2013. faktorfaktor yang berhubungan dengan kelengkapan pendokumentasian asuhan keperawatan. available at: http://jki.ui.ac.id/ index.php/jki/aticle/view/5 [accessed october 1, 2015]. jurnal ners vol 11 no 2 oktober 2016: 157-163 164 ners vol 10 no 1 april 2015.indd 165 model sistem manajemen mutu berdasarkan kriteria malcolm baldrige pada pendidikan keperawatan di kota surabaya (model of quality management system using malcolm baldrige criteria in nursing education in surabaya) a. aziz alimul hidayat*, stefanus supriyanto**, nursalam*** * faculty of health science, muhammadiyah university of surabaya ** faculty of public health, airlangga university *** faculty of nursing, airlangga university abstrak pendahuluan: sebagian besar pendidikan keperawatan di surabaya masih berada pada level rendah. beberapa faktor penyebab diantaranya adalah proses peningkatan mutu pada perguruan tinggi secara umum masih dilakukan secara parsial dan tidak terintegrasi dengan kebutuhan lulusan yang dirumuskan secara sistematik. penelitian ini bertujuan untuk mengembangkan model sistem manajemen mutu program studi keperawatan berdasarkan kriteria malcolm baldrige untuk kinerja excellence. metode: desain penelitian ini adalah cross sectional survey. penelitian ini dilakukan dengan sampel dari delapan lembaga, sejumlah dua puluh empat responden. pengumpulan data dilakukan dengan cara wawancara, kuesioner dan dokumentasi. analisis data yang digunakan adalah partial least square (pls). hasil: hasil penelitian menunjukkan bahwa: 1) kepemimpinan mempengaruhi profi l program studi, seperti halnya profi l organisasi mempengaruhi kinerja program studi; 2) kepemimpinan mempengaruhi perencanaan strategis, seperti halnya perencanaan strategis mempengaruhi fokus sumber daya manusia. selain itu, fokus sumber daya manusia mempengaruhi proses fokus dan akhirnya mempengaruhi hasil kinerja; 3) fokus pelanggan mempengaruhi kepemimpinan, seperti halnya kepemimpinan mempengaruhi perencanaan strategis. dampaknya, perencanaan strategis mempengaruhi fokus sumber daya manusia serta proses focus, sehingga pada akhirnya mempengaruhi hasil kinerja; 4) semua variabel, keculai perencanaan strategis, dipengaruhi oleh pengukuran, analisis dan manajemen pengetahuan. diskusi: berdasarkan hasil di atas, model sistem manajemen mutu dapat dikembangkan dengan menggunakan kriteria malcolm baldrige dengan tujuan untuk meningkatkan kualitas program studi keperawatan. di sisi lain, model ini dapat digunakan sebagai acuan organisasi pada level program studi keperawatan (unit bisnis strategis) untuk merestrukturisasi kinerja perguruan tinggi dalam persaingan global. kata kunci: model sistem manajemen mutu, program studi keperawatan, kriteria malcolm baldrige for performance excellence abstract introduction: most of the quality of nursing education in surabaya is still at the low level. it is due to the fact that the process and job performances which have not been integrated yet, systematic and fl exible which are in line with the capacity of the organization and the needs of graduates. this study aims to develop a model of quality management systems of nursing bachelor’s degree program based on the malcolm baldrige criteria for performance excellence. method: the method used is a cross sectional survey design. this research was conducted with a sample of eight institutions and twenty four of respondents. the data was collected by means of interviews, questionnaires and documentation. analysis of the data used partial least square (pls). result: the results showed that 1) leadership affects the study program as well as the profi le that affects job performances; 2) leadership affects the strategic planning as well as the strategic planning that affects focus of human resources. in addition, the focus of human resources affects the focus process and fi nally affects job performances as well; 3) customer focus affects leadership as well as leadership affects strategic planning. as the impact, strategic planning affects focus of human resources and it affects similarly on the focus process and fi nally affects job performances; 4) all variables are affected by measurements, analysis and knowledge management, except in strategic planning. discussion: based on the above results, the model of quality management system can be developed by using the malcolm baldrige criteria for the purpose of increasing the quality of nursing study program. on the other hands, this model can be used as a reference of the organization at the level of nursing study program (strategic business unit) to restructure the performance of the college in global competition. keywords: model of quality management system, nursing study program, malcolm baldrige criteria for performance excellence pendahuluan masalah umum yang sering dihadapi oleh pengelola perguruan tinggi khususnya keperawatan adalah masalah mutu, hal ini dapat dilihat masih banyak nya program pendidikan keperawatan yang memeroleh 166 jurnal ners vol. 10 no. 1 april 2015: 165–174 akreditasi dari ban-pt kategori c (rendah). berdasarkan hasil evaluasi badan akreditasi nasional perguruan tinggi (ban-pt) tahun 2011 menunjukkan sebagian besar (75,6%) program studi di bidang kesehatan di jawa timur memiliki mutu yang rendah (akreditasi c) (ban-pt, 2012). beberapa hal yang menjadi kemungkinan penyebab, diantaranya proses peningkatan mutu pada perguruan tinggi secara umum masih dilakukan secara parsial atau secara acak (random performance improvement) dan tidak terintegrasi dengan kebutuhan lulusan yang dirumuskan secara sistematik. berdasarkan hasil dari evaluasi implementasi sistem penjaminan mutu perguruan tinggi tahun 2008, menunjukkan dari 384 perguruan tinggi di indonesia hanya 68 perguruan tinggi (17,7%) dengan sistem penjaminan mutu internal dengan kategori baik. selanjutnya dari empat belas perguruan tinggi yang memiliki pendidikan keperawatan di kota surabaya hanya satu perguruan tinggi (7,14%) yang memiliki sistem penjaminan mutu yang baik (dirjen dikti, 2008; kuspijadi & sudarso, 2011; hidayat, 2013). salah sat u alter natif yang d apat dilakukan untuk peningkatan mutu program studi adalah menerapkan sistem manajemen mutu yang unggul, terintegrasi antara proses dan hasil. sistem tersebut terdapat pada kriteria malcolm baldrige. kriteri malcolm baldrige memiliki perbedaan dengan sistem mutu lainya salah satunya adalah iso, yang mana iso lebih menekankan pada proses di lingkungan manajerial organisasi. sedangkan malcolm baldrige tidak berarti menghilangkan proses, walaupun prosesnya baik namun hasilnya kurang, maka penilaian malcolm baldrige akan menghasilkan nilai atau poin yang rendah bagi organisasi. selain itu kriteria malcolm baldrige criteria for performance excellence pada pendidikan umumnya masih digunakan pada tingkat institusi (level strategis) dan masih ada beberapa kriteria yang perlu dikembangkan khususnya dalam tingkat program studi (level operasional) (hidayat; 2014). beberapa alasan lain, diantaranya: kerangka berf ikir nya f leksibel, di mana suatu organisasi diberi kebebasan untuk mengembangkan pendekatan dan metode yang sesuai dengan kebutuhan dan kemampuan organisasi, k riteria yang in klusi, yak ni pendekatan berfokus hanya pada aspek penilaian, seperti kepemimpinan, perencanaan strategis atau manajemen proses, kriteria berfokus pada persyaratan umum bukan prosedur atau teknik semata, kriteria yang adaptif, yakni dapat digunakan untuk menilai organisasi besar bahwa bagian dari organisasi, seperti jur usan atau program studi, dan kebaruan kriteria, bahwa malcolm baldrige setiap tahun kriteria dievaluasi dan disesuaikan dengan perkembangan dan tuntutan kebutuhan organisasi dan stakeholder (kuspijani dan sudarso, 2009; hidayat 2014). berdasarkan uraian tersebut, maka komponen model yang diteliti adalah: 1) kepemimpinan ber pengar u h sig n if ikan terhadap profi l program studi, perencanaan strategis, dan fokus proses; 2) profi l organisasi prog ram st udi ber pengar u h sig n if i kan terhadap hasil kinerja program studi; 3) fokus customer ber pengar uh signif ikan terhadap kepemimpinan program st udi, dan perencanaan strategis; 4) perencanaan strategis program studi berpengaruh signifi kan terhadap fokus sumber daya manusia, dan fokus proses; 5) fokus sumber daya manusia ber pengar uh sig nif ikan terhadap fok us proses, dan hasil kerja; 6) fokus pada proses berpengaruh signifi kan terhadap hasil kinerja; 7) pengukuran, analisis dan manajemen pengetahuan berpengaruh signifi kan terhadap kepemimpinan, fokus customer, perencanaan strategis, fokus sumber daya manusia, fokus proses, dan hasil kerja. bahan dan metode populasi dalam penelitian ini adalah seluruh perguruan tinggi di kota surabaya yang terdiri atas 9 institusi pendidikan yang memiliki program studi keperawatan pada tahun 2013. sampel dalam penelitian ini adalah unit program studi keperawatan pada perguruan tinggi di kota surabaya, dengan kriteria inklusi telah memiliki lulusan tiga tahun terakhir. dari kriteria inklusi yang memenuhi syarat adalah 8 institusi. 167 model sistem manajemen mutu berdasarkan kriteria malcolm baldrige (a. aziz alimul hidayat, dkk.) pengumpulan data dilakukan selama 5 bulan. sumber data diperoleh dari sumber primer dan sekunder. data primer didapat dari responden melalui pemberian kuesioner secara langsung dan data sekunder dapat diambil dari pusat data di program studi keperawatan universitas di kota surabaya. prosedur pengumpulan data dilakukan dengan menggunakan cara, kuesioner dan wawancara. kuesioner terdir i atas 350 pertanyaan dengan skala likert untuk tujuh variabel diantaranya profi l organisasi (visi, misi, tujuan, tenaga kerja, prasarana dan sarana, struktur organisasi, kerja sama dan situasi organisasi), variabel kepemimpinan (kepemimpinan senior dan tata kelola, tanggung jawab sosial), variabel perencanaan st rategis ( pengembangan st rategis dan implementasi st rategis), var iabel fok us pelanggan (suara pelanggan dan keterikatan mahasiswa dan stakeholder), variabel fokus sumber daya manusia (lingkungan tenaga kerja dan keterikatan tenaga kerja), variabel fokus proses/operasi (sistem kerja dan proses kerja), dan variabel hasil (hasil program pelayanan pendidikan, hasil fokus pelanggan, hasil fokus sumber daya manusia, hasil kepemimpinan dan tata kelola dan hasil keuangan dan pasar). penilaian kuesioner menggunakan modifi kasi m bcfpe 2011–2012, denga n kategor i 90–100% = sangat tinggi, 80–89% = tinggi, 60 –79% = sedang, 40 –59% = rendah, < 40% = sangat rendah. analisis data yang digunakan adalah: 1) analisis deskriptif untuk menganalisis data tentang variabel profi l, kepemimpinan, profi l organisasi kepemimpinan, perencanaan strategis, fokus customer, fokus sumber daya manusia, fokus proses/operasi, dan hasil kinerja dengan persentase distribusi frequensi; 2) analisis model persamaan struktural (sem) yang berbasis variance atau component based. model persamaan ini sering dikenal dengan partial least square (pls). evaluasi model dari pls ada dua bagian evaluasi, yakni evaluasi pengukuran dan evaluasi model struktural. (1) evaluasi model pengukuran atau outer model dengan indikator refl ektif dievaluasi berdasarkan hasil validity dan realibility dari indikator. pengujian outer model adalah convergent validity, yakni indikator dianggap valid jika memiliki outer loading lebih dari 0,5 dan nilai t > 1,96. dan realibility untuk menguji realibilit y indikator dari konstruk yang membentuknya. (2) pengujian hipotesis, pengujian ini dilakukan dengan uji statistik t (t test), jika t > 1,96 dengan α = 0,05 maka hasil pengujian signifi kan, demikian sebaliknya, apabila hasil pengujian hipotesis pada outer model signifi kan menunjukkan indikator dipandang dapat digunakan sebagai instrumen pengukur variabel laten, dan jika pada inner model adalah signifikan maka terdapat pengaruh variabel laten satu terhadap variabel laten lainnya. hasil hasil analisis model 1 (model awal) penelitian menggunakan analisis persamaan struktural (sem) yang berbasis variance atau component based yakni partial least square (pls) ditunjukkan dalam gambar 1. g a m b a r 2 m e n u n j u k k a n j a l u r pertama kepemimpinan berpengaruh pada profil program studi, profil program studi berpengaruh pada hasil kerja. jalur kedua kepemimpinan berpengaruh pada perencanaan strategis, perencanaan strategi berpengaruh pada fokus sumber daya manusia, fokus sumber daya manusia berpengaruh pada fokus proses, fokus proses berpengaruh pada hasil kinerja. temuan ini membuktikan bahwa kepemimpinan program studi merupakan determinan penting dalam meningkatkan mutu program studi melalui perencanaan strategis, fokus sumber daya manusia dan fokus proses. temuan ini pula menunjukkan bahwa kondisi organisasi (profi l organisasi) yang meliputi visi, misi, prasarana, sarana, struktur organisasi, tenaga kerja, kerja sama, dan situasi organisasi (kebijakan organisasi) menjadi faktor penentu pada peningkatan mutu program studi sarjana keperawatan. jalur ketiga gambar 2. menunjukkan fokus customer berpengaruh pada kepemimpinan, kepemimpinan berpengaruh pada perencanaan strategis, perencanaan strategis berpengaruh pada fokus sumber daya manusia, fokus sumber daya manusia ber pengar uh pada 168 jurnal ners vol. 10 no. 1 april 2015: 165–174 gambar 2. analisis persamaam struktural (sem) yang berbasis variance atau component based yakni partial least square (pls) model 2 (model akhir) gambar 1. analisis persamaam struktural (sem) yang berbasis variance atau component based yakni partial least square (pls) model 1. 169 model sistem manajemen mutu berdasarkan kriteria malcolm baldrige (a. aziz alimul hidayat, dkk.) tabel 1. hasil pengujian hipotesis pengaruh langsung antar variable pada penelitian model self assessment mutu berdasarkan kriteria malcolm baldrige pada pendidikan keperawatan di kota surabaya hubungan antar variabel sample mean t-statistik keterangan kepemimpinan terhadap profi l program studi 0.725 23.56 signifi kan profi l organisasi program studi terhadap hasil kinerja program studi 0.697 26.89 signifi kan fokus customer terhadap kepemimpinan program studi 0.188 3.48 signifi kan fokus customer terhadap perencanaan strategis 0.374 8.98 signifi kan kepemimpinan ketua program studi terhadap perencanaan strategis 0.732 15.83 signifi kan kepemimpinan ketua program studi terhadap fokus proses 0.106 0.56 tidak signifi kan perencanaan strategis program studi terhadap fokus sumber daya manusia 0.309 3.33 signifi kan perencanaan strategis terhadap fokus proses 0.262 3.94 signifi kan fokus sumber daya manusia terhadap fokus proses 0.059 1.98 signifi kan fokus sumber daya manusia terhadap hasil kinerja 0.047 1.13 tidak signifi kan fokus pada proses terhadap hasil kinerja 0.090 8.94 signifi kan pengukuran, analisis dan manajemen pengetahuan terhadap kepemimpinan 0.684 22.04 signifi kan pengukuran, analisis dan manajemen pengetahuan terhadap fokus customer 0.204 3.44 signifi kan pengukuran, analisis dan manajemen pengetahuan terhadap perencanaan strategis 0.012 0.71 tidak signifi kan pengukuran, analisis dan manajemen pengetahuan terhadap fokus sumber daya 0.409 4.42 signifi kan pengukuran, analisis dan manajemen pengetahuan terhadap fokus proses 0.537 7.70 signifi kan pengukuran, analisis dan manajemen pengetahuan terhadap hasil kinerja 0.208 13.99 signifi kan fokus proses, fokus proses berpengaruh pada hasil kinerja. temuan ini pula menunjukkan bahwa fokus customer dapat sebagai faktor penentu dalam peningkatan mutu melalui proses kepemimpinan berfokus pada customer. jalur keempat gambar 2. menunjukkan semua variabel dipengaruhi oleh pengukuran, analisis dan manajemen pengetahuan, kecuali pada perencanaan strategis. pembahasan pengaruh kepemimpinan terhadap profi l program studi, dan perencanaan strategis, dapat dibuktikan melalui hasil pengujian yang menunjukkan koefisien jalur positif sehingga dapat diartikan bahwa semakin baik kepemimpinan (kepemimpinan senior, tata kelola dan tanggung jawab sosial), maka secara langsung menjadikan semakin baik profi l organisasi dan perencanaan strategis di program studi keperawatan. ad a nya penga r u h kepem i mpi na n terhadap profi l program studi dan perencanaan strategi, karena kepemimpinan merupakan proses di mana seseorang atau tim dalam memainkan pengaruh atas orang lain atau tim lain dengan memberi inspirasi, motivasi dan mengarahkan aktivitas dalam mencapai sasaran dan tujuan (malcom baldrige, 2011; iqaf, 2011). kepemimpinan dalam kriteria malcol m bald r ige men ilai bagai ma na pemimpin senior bertindak sesuai dengan petunjuk organisasi dan dapat menopang 170 jurnal ners vol. 10 no. 1 april 2015: 165–174 keberlangsungan organisasi, dan juga menilai bagaimana sistem tata kelola serta bagaimana organisasi memenuhi aspek hukum etik dan tanggung jawab sosial, sehingga pada kategori kepemimpinan malcolm baldrige memberikan skor tertinggi di antara sistem atau kategori yang lain, hal ini menunjukkan kepemimpinan memiliki peran yang tinggi dalam menggerakkan organisasi (malcom baldrige, 2011; iqaf, 2011; hidayat, 2014). pengar uh kepemimpinan terhadap profi l dan perencanaan strategis juga sejalan dengan konsep sparkle, yang membagi peran pemimpin ada tiga, yakni sebagai pemimpin, sebagai fasilitator dan sebagai administrator. sebagai seorang pemimpin memiliki tugas dalam memotivasi anak buah, memberikan sugesti, menciptakan inspirasi, sebagai sumber inspirasi dan konseptor. sebagai fasilitator memiliki peran liason offi cer (interaksi antara individu dan unit), negoitator (pengalokasian sumber daya antar unit, menciptakan keadilan), dan mediator (penghubung manajemen dan pekerja). sebagai administrator memiliki f u ngsi sebagai k at al isator, penga mbil keputusan strategis, delegator (pendelegatian tugas dan tanggung jawab, pemberdayaan dan monitoring sdm, serta sebagai problem solver (supriyanto, 2011; hidayat, 2014). sedangkan profi l organisasi itu sendiri menurut malcolm baldrige adalah konteks bagaimana organisasi dijalankan, lingkungan, tata hubungan kerja, tantangan dan keunggulan strategis memiliki fungsi sebagai pemandu dalam sistem kinerja organisasi, yang meliputi kepemimpinan, perencanaan strategis, fokus customer, fokus sumber daya manusia, fokus proses dan result. dengan demikian profi l organisasi memiliki peranan atau pengaruh dalam sistem yang dijalankan yang sangat ditentukan oleh kepemimpinan (malcom baldrige, 2011; iqaf, 2011; hidayat, 2014). pe ng a r u h p e r e nc a n a a n st r at eg i s terhadap fokus sumber daya manusia dan fokus proses, dapat dibuktikan melalui hasil pengujian kedua variabel yang memiliki koefi sien jalur positif sehingga dapat diartikan bahwa semakin baik perencanaan strategis (pengembangan strategis dan implementasi strategis), maka secara langsung menjadikan semakin baik fokus sumber daya manusia dan fokus proses di pendidikan keperawatan. dari kedua pengaruh antara variabel, pengaruh p e re nca na a n st r at eg is t e rha d ap fok u s sumber daya manusia lebih tinggi (koefi sien jalur = 0,310) dibandingkan dengan pengaruh perencanaan strategi terhadap fokus proses (koefi sien jalur = 0,260). adanya pengaruh perencanaan strategis terhadap fokus sumber daya manusia dan fokus proses, karena perencanaan strategis m e r u p a k a n u p a y a o r g a n i s a s i d a l a m mengembangkan sasaran strategis dan rencana kerja. sasaran strategis dan rencana kerja yang telah ditetapkan, selanjutnya dijabarkan dan diubah bila situasi yang mengharuskan. dalam malcolm baldrige perencanaan strategis dapat dinilai dari pengembangan strategis dan implementasi strategis. pengembangan merupakan upaya organisasi dalam membangun strategi untuk menjawab tantangan yang dapat meningkatkan keunggulan dari strategisnya. s e d a n g k a n i m ple m e nt a si m e r u p a k a n bagaimana organisasi dalam menerjemahkan sasaran strategis ke rencana kerja selanjutnya dijabarkan dalam ukuran dan indikator kinerja dan proyeksi kerja. pada kategori perencanaan strategis malcolm baldrige menekankan pada implementasi strategis dengan memberikan skor yang tinggi dibandingkan dengan skor pengembangan strategis, sehingga perencanaan strategis sangat menentukan sumber daya manusia dan proses operasi (malcom baldrige, 2011; iqaf, 2011; hidayat, 2014). pe nga r u h p e r e nc a n a a n st r at eg i s terhadap fokus sumber daya manusia dan fokus proses juga sejalan dengan konsep manajemen sumber daya manusia yang menyatakan dalam pengembangan sumber daya manusia dapat dipengaruhi oleh dua faktor, yakni faktor internal organisasi dan faktor eksternal organisasi. faktor internal o r g a n i s a si m e r u p a k a n ke a d a a n y a ng bersumber dari dalam organisasi itu sendiri yang meliputi misi, kebijakan ter masuk didalamnya perencanaan strategi, budaya, organisasi pekerja dan memiliki organisasi. faktor eksternal merupakan keadaan eksternal yang mempengaruhi pengembangan sumber daya manusia diantaranya angkatan kerja, 171 model sistem manajemen mutu berdasarkan kriteria malcolm baldrige (a. aziz alimul hidayat, dkk.) legal consideration, persaingan, konsumen, teknologi, politik, ekonomi dan demografi (rachmawati, 2008). sedangkan beberapa faktor yang mempengar uhi fokus proses dalam pendidi kan adalah semua i nput dalam pendidikan, diantaranya perencanaan pembelajaran, sumber daya manusia, prasarana dan sarana (hidayat, 2014). pengaruh fokus pada customer terhadap kepemimpinan dan perencanaan strategis dapat dibuktikan dari hasil pengujian yang menunjukkan koefi sien jalur positif sehingga dapat diartikan bahwa semakin tinggi fokus customer (suara customer dan keterikatan customer), maka secara langsung menjadikan semakin baik kepemimpinan dan perencanaan strategis di program studi keperawatan. adanya pengar uh fok us customer terhadap kepemimpinan dan perencanaan strategis karena fokus customer merupakan upaya organisasi mengikat mahasiswa dan stakeholder untuk keberhasilan penguasaan pa sa r d a la m ja ng k a pa nja ng melalu i membangun hubungan budaya yang berfokus pada mahasiswa dan stakeholder. fokus customer dalam kriteria malcolm baldrige menilai bagaimana organisasi memahami kebutuhan, keinginan, dan harapan customer atau pihak lainnya, kesenangan customer dan membangun loyalitas, sehingga kategori ini menekankan pada hubungan sebagai bagian dari strategi. sehingga pada kategori fokus pada customer malcolm baldrige memberikan skor yang tinggi pada keterikatan customer dibandingkan dengan skor suara customer sehingga dalam manajemen modern organisasi selalu akan memenuhi kebutuhan pelanggan yang tentu akan memengaruhi kepemimpinan dan perencanaan strategis organisasi (malcom baldrige, 2011; iqaf, 2011; hidayat, 2014). pengar uh fokus customer terhadap kepemimpinan dan perencanaan strategis juga sejalan dengan konsep kepemimpinan, yang banyak dipengaruhi oleh berbagai faktor salah satunya adalah tujuan, sasaran atau hasil yang akan dicapai. sasaran yang dimaksud dapat berupa kebutuhan/keinginan customer, sehingga dapat merubah gaya kepemimpinan yang selalu berorientasi dalam pemenuhan kebutuhan customer (soekarso, dkk, 2010). demikian halnya pada perencanaan strategis yang menu r ut asmarani (2006) bahwa perencanaan strategis dapat dipengaruhi oleh tiga faktor, diantaranya faktor manajerial, faktor lingkungan dan kultur organisasi. fokus customer merupakan bagian dari faktor lingkungan yang tentunya memiliki pengaruh dalam perencanaan strategis (hidayat, 2014). pengaruh fokus sumber daya manusia terhadap fokus proses dan hasil kerja dapat dibuktikan hasil pengujian menunjukkan kedua variabel memiliki koefi sien jalur positif sehingga dapat diartikan bahwa semakin baik fokus sumber daya manusia (lingkungan tenaga kerja dan keterikatan tenaga kerja), maka secara langsung menjadikan semakin baik fokus pada proses di program studi keperawatan. dari kedua pengaruh antar variabel, pengaruh fokus sumber daya manusia terhadap fokus proses memiliki koefisien jalur = 0,091. adanya pengaruh fokus sumber daya manusia terhadap fokus proses dan hasil kerja karena fokus sumber daya manusia merupakan bagaimana kemampuan manajemen organisasi dalam menilai kapabilitas dan kebutuhan karyawan dalam membangun tenaga kerja yang kondusif agar mencapai kinerja yang tinggi melalui keterlibatan, pengelolaan, dan pengembangan karyawan dalam menggunakan kemampuan dalam menyelaraskan visi, misi, nilai dan rencana tindakan organisasi. dalam malcolm baldrige fokus sumber daya manusia dapat dinilai dari lingkungan tenaga kerja dan keterikatan tenaga kerja. lingkungan tenaga kerja merupakan upaya organisasi dalam membangun lingkungan tenaga kerja yang efektif. sedangkan keterikatan tenaga kerja merupakan upaya organisasi dalam melibatkan secara aktif, memberi kompensasi, penghargaan untuk mencapai kinerja yang tinggi (malcom baldrige, 2011; iqaf, 2011; hidayat, 2014). adanya pengaruh fokus sumber daya manusia terhadap fok us proses, karena program studi merupakan level operasional, yang lebih menekankan pada proses/aktivitas pembelajaran program, dalam hal ini fokus proses lebih diutamakan, selain itu proses hasil lebih dititikberatkan dari proses pembelajaran, 172 jurnal ners vol. 10 no. 1 april 2015: 165–174 demikian juga dalam pengembangan sumber daya manusia masih rendah dan mulai ada upaya peningkatan kapasitas dan kapabilitas dalam sumber daya manusia (hidayat, 2014). pengaruh fokus proses operasi terhadap hasil kinerja dapat dibuktikan dari hasil pengujian yang menunjukkan hasil memiliki koefi sien jalur positif sehingga dapat diartikan bahwa semakin baik fokus proses (sistem kerja dan proses kerja), maka secara langsung menjadikan semakin baik hasil kerja di program studi keperawatan. ad anya penga r u h proses operasi t e rh a d ap h a si l k i ne r ja , k a re n a fok u s proses mer upakan bagaimana organisasi merancang sistem kerjanya, mendesain, mengelola, memperbaiki proses utamanya untuk melaksanakan sistem kerja, untuk memberikan nilai kepada mahasiswa dan stakeholder, mencapai keberhasilan dan keberlanjutan organisasi. dalam malcolm baldrige fokus proses dapat dinilai dari disain sistem kerja dan proses kerja. disain sistem kerja merupakan upaya organisasi unt uk mendesain kerjanya, menent ukan proses-proses utamanya dalam memberikan nilai kepada customer, mempersiapkan diri dalam menghadapi potensi dar urat. sedangkan proses kerja merupakan upaya organisasi dalam mendesain, menerapkan, mengelola dan memperbaiki proses kerja utamanya dalam memberikan nilai kepada pelanggan dalam mencapai keberhasilan dan keberlangsungan organisasi. pada kategori fokus proses malcolm baldrige menekankan pada sistem kerja dengan memberikan skor yang tinggi dibandingkan dengan skor proses kerja (malcom baldrige, 2011; iqaf, 2011; hidayat, 2014). dalam penelitian ini proses kerja memiliki nilai yang tinggi dalam menentukan variabel fokus proses, hal tersebut dapat didasarkan karena pengelolaan program studi lebih menekankan pada proses/aktivitas pembelajaran program (hidayat, 2014). pe n g a r u h p e n g u k u r a n a n a l i si s , d a n ma najemen penget ahu a n terhad ap kepemimpinan, perencanaan strategis, fokus customer, fokus sumber daya manusia, fokus proses dan hasil kinerja, dapat dibuktikan dari hasil pengujian yang memiliki koefi sien jalur positif sehingga dapat diartikan bahwa semakin baik manajemen pengetahuan, maka secara langsung menjadikan semakin baik kepemimpinan, fokus customer, fokus sumber daya manusia, fokus proses dan hasil kinerja di program studi sarjana keperawatan. ad a nya p e ng a r u h a n a l i si s , d a n m a n a j e m e n p e n g e t a h u a n t e r h a d a p kepemimpinan, perencanaan strategis, fokus customer, fokus sumber daya manusia, fokus proses dan hasil kinerja, karena pengukuran, a n al isis d a n m a n aje me n p e nget a hu a n mer upakan bagaimana organisasi dalam menyeleksi, mengatur dan menggunakan data informasi dalam pengukuran kinerja, analisis dan mengkaji ulang kinerja serta bagaimana organ isasi menjam i n ketersedia an d an kualitas data, informasi yang dibutuhkan oleh karyawan dan stakeholder. dalam malcolm baldrige pengukuran, analisis dan manajemen pengetahuan dapat dinilai dari pengukuran, analisis dan perbaikan kinerja organisasi, pengelolaan informasi, teknologi informasi dan manajemen pengetahuan. pengukuran, analisis dan perbaikan organisasi merupakan indikator untuk mengukur, menganalisis dan meningkatkan kinerja organisasi. sedangkan pengelolaan informasi, teknologi informasi dan manejemen pengetahuan merupakan indikator yang menekankan bagaimana organisasi mengelola informasi, teknologi informasi dan manajemen pengetahuan melalui penyediaan informasi dan kemudahan akses (malcom baldrige, 2011; iqaf, 2011; hidayat, 2014). dalam penelitian ini pengelolaan informasi, teknologi informasi dan manajemen pengetahuan memiliki nilai yang tinggi dalam menentukan variabel pengukuran, analisis dan manajemen pengetahuan, hal tersebut dapat didasarkan karena unit program studi suatu organisasi yang bergerak dalam bidang pendidikan maka lebih menekankan pada proses/aktivitas pengelolaan pengetahuan (knowledge management) (hidayat, 2014). hasil penelitian ini ditunjang oleh beberapa hasil penelitian, diantaranya: pa nja it a n (2011) me nyat a k a n a d a nya pengar uh pengg unaan sistem tek nologi i n fo r m a si t e r h a d a p k u a l it a s l aya n a n akademik pada perguruan tinggi. piccoli 173 model sistem manajemen mutu berdasarkan kriteria malcolm baldrige (a. aziz alimul hidayat, dkk.) et al (2001) menyatakan model knowledge managament dapat diterapkan pada perguruan tinggi, dengan model tiga unit (engine) yang mengarahkan proses dan penyebaran pengetahuan, antara lain research engine, production engine dan learning engine. gold et al (2001); yu et al (2004); hariharan (2005), menyatakan teknologi informasi menjadi elemen penting dalam penciptaan dan transfer pengetahuan, dalam berbagai cara, seperti memfasilitasi, pengumpulan, penyimpanan dan pertukaran data dengan cepat (hidayat, 2014). berdasarkan hasil penelitian tersebut di atas, maka dapat ditemukan model sistem manajemen mutu berdasarkan kriteria malcom baldrige pada pendidikan keperawatan di kota surabaya, sebagai berikut: 1. model sistem manajemen mutu dengan menggunakan tujuh kriteria & profil organisasi dapat digunakan sebagai komponen model sistem manajemen mutu program studi. tujuh kriteria tersebut meliputi kepemimpinan, perencanaan strategis, fokus customer, fokus sumber daya manusia, fokus proses, pengukuran, analisis, manajemen pengetahuan dan hasil kerja; 2. hasil kerja program studi dalam komponen sistem manajemen mutu merupakan indikator outcome keberhasilan program studi yang ditentukan oleh katagori proses (kepemimpinan, perencanaan strategis, fokus customer, fokus sumber daya manusia, fokus proses, dan pengukuran, analisis dan manajemen pengetahuan); 3. hasil kerja sangat ditentukan langsung oleh fokus proses melalui fokus sumber daya manusia yang menurut malcom baldrige lebih ditentukan langsung oleh fokus sumber daya manusia dan fokus proses (hidayat, 2014). simpulan dan saran simpulan model sistem manajemen mutu sebagai temuan baru pada program studi keperawatan adalah sebagai berikut: (1) model sistem manajemen mutu dengan menggunakan tujuh kriteria malcolm (kepemimpinan, perencanaan strategis, fokus customer, fokus sumber daya manusia, fokus proses, pengukuran dan manajemen pengetahuan dan hasil kerja) dapat digunakan pada organisasi level operasional; (2) pengukuran malcom baldrige dapat digunakan sebagai sistem manajemen mutu mutu di level operasional dengan memiliki indikator yang sama pada level strategik.; (3) hasil kerja sangat ditentukan langsung oleh fokus proses melalui fokus sumber daya manusia yang menurut malcom baldrige lebih ditentukan langsung oleh fokus sumber daya manusia dan fokus proses. saran saran yang dapat diberikan adalah model sistem manajemen mutu berdasarkan kriteria kriteria malcolm baldrige dapat digunakan sebagai salah satu model sistem manajemen mutu pada level operasional (program studi), untuk menuju mutu yang unggul. kepustakaan asmarani, d.e. 2006. analisis pengaruh perencanaan strategi terhadap kinerja perusahaan dalam upaya menciptakan keungg ulan bersaing. semarang: universitas diponegoro. ba n-p t.2012. ha sil eva lu a si s ta t u s ak reditasi program studi bidang kesehatan di jawa timur, (http://www. ban-pt.kemendi k nas.go.id diakses tanggal 17 juni) d i r je n d i k t i. 2 0 0 8. ha s i l e v a l u a s i implementasi sistem penjaminan mutu internal perguruan tinggi. jakarta: depdiknas. gold, a.h., malhotra, a., & segars, a.h. 2001. knowledge management: an organizational capabilities perspective. journal of management information systems; 18 (1): 185–214. hariharan, a. 2005. implemeting seven k m enablers at bar ti. knowledge management review; 8 (3): 8–9. hidayat, a.a.a. 2013. model self assessmet mutu progam studi sarjana keperawatan berdasarkan kritera malcolm baldrige di kota surabaya. disertasi. surabaya: universitas airlangga. 174 jurnal ners vol. 10 no. 1 april 2015: 165–174 hidayat, a.a.a. 2014. model self assessmet mutu progam pendidikan keperawatan berdasarkan kritera malcolm baldrige. jakarta: salemba medika kuspijadi & sudarso. 2011. pengukuran kinerja fakultas teknik ubhara dengan m e ng g u n a k a n k r ite r ia m alcolm baldrige. http://www.digilib.its.ac.id diakses 18 maret panjaitan, h. 2011. sistem informasi, kualitas layanan, citra, dan respon konsumen perguruan tinggi. surabaya: revka petra media rachmawati, i.k. 2008. manajemen sumber daya manusia. yogyakarta: penerbit andi soekarso, sosro, a., pitong, i., hidayat, c. 2010. teori kepemimpinan. jakarta: mitra wacana medika supriyanto, s. 2011. how to become a succesful entrepreneur 113 red rosella tea and avocado as simvastatin therapy support reduce total cholesterol budi artini*, elyana asnar**, ika yuni widyawati*** *stikes william booth, cimanuk streat, no. 20, surabaya, east java, indonesia, 60241 **faculty of medicine, universitas airlangga ***faculty of nursing, universitas airlangga email: budiartini76@ymail.com abstract introduction: hypercholesterolemia is a condition characterized by high levels of total cholesterol in the blood. many studies have proven that steeping tea rosella and flesh of an avocado can reduce total cholesterol levels. this study was conducted to determine the effectiveness of therapy companion rosella tea and avocado in lowering total cholesterol levels in hypercholesterolemic clients. method: this type of research is a quasi-experimental study with pre-post test control group design. the population study was a client with hypercholesterolemia in the working area of menganti health centers. first sample group consisted of nine respondents received the drug simvastatin 10 mg and rosella tea consumed as much as 2 g 1x/day. the second group consisted of nine respondents received the drug simvastatin 10 mg and avocado meat weighing 330 grams were consumed 1x/day. the control group consisted of 11 respondents have a drug simvastatin 10 mg oral 1x daily at night before bed. all groups examined total cholesterol levels before treatment and after treatment on day 15. result: the results of one-way anova test showed a significant difference between before and after treatment in the first group (p=0,001) and the second group (p= 0,005), and there is no significant difference before and after treatment in the control group (p= 0,248). the difference between the three groups showed p= 0.025. conclusion: the conclusion of this study is giving rosella tea, and avocado has the same effectiveness in lowering total cholesterol levels so that health workers can suggest the use of rosella tea and avocado as a companion therapy to reduce total cholesterol level. keywords: hypercholesterolemia, rosella tea, avocado, simvastatin introduction progress in the field of health and technology utilized by the community at present. health is very expensive, so for those who are trying to maintain good healthy and for the sick seeking treatment are not harmful to him. one of them with an effort to make the treatment go back to nature. the wider community is now beginning to switch from modern medicine (medical) into complementary medicine, even though modern medicine is also very popular among the people discussed. non-conventional intervention is one of the alternatives or complementary medical interventions. intervention complementary (complementary therapies) are all interventions used as an adjunct to conventional interventions recommended by the implementation of individual health services. according to the health profile of indonesia in 2008, the national population morbidity rate is 33.24% of the total is 65.59% chose their treatment using modern and traditional medicine, the remaining 34.41% choose outpatient treatment to health centers, physician practices or to other medical facilities. this shows public interest in traditional medicine is quite high (kiki 2013). in connection with this traditional medicine governments to establish policies and laws that regulate complementary medicine among them is law no. 36 of 2009 on health article 1 para 16 healthcare is the traditional treatment or treatment in a manner and drugs that draws on the experience and skills of hereditary empirically accountable and applied in accordance with the norms prevailing in the community, regulation of the minister of health, no: 1076/menkes/sk/2003 on traditional medicine, and the regulation of the minister of health, no: 1109/menkes/per/ ix/2007 on the implementation of complementary-alternative medicine in health care facilities. at the policy and legislation, one health worker role is a nurse. nurses participate in the effort to develop complementary medicine through research. according to the health profile of indonesia in 2008, the national population morbidity rate is 33.24% of the total is 65.59% chose their treatment using modern and traditional medicine, the remaining 34.41% choose outpatient treatment to health centers, physician practices or to http://stikeswilliambooth.ac.id/ mailto:budiartini76@ymail.com rosella tea and avocado as simvastatine therapy support (budi artini et.l.) 114 other medical facilities. this shows public interest in traditional medicine is quite high (kiki, 2013). the use of complementary interventions is also used for clients who have problems with cholesterol levels in the blood. cholesterol is a fatty substance found in every cell of our bodies (bull, e.& morrell 2007). today many people are trying to use alternative treatments, such as with roselle tea consumption of plant hibiscus sabdariffa and consume the flesh of an avocado. both of these materials as an alternative option because both contain the active ingredient which has a benefit when consumed it regularly through the regulatory processes in the body can lower total blood cholesterol, triglycerides, ldl and hdl may increase. efforts to reduce cholesterol levels are necessary to remember the first hypercholesterolemia can occur at the age of 50 years and over. but now, research in 2004 by the national heart, lung and blood institute showed that 9.3% of hypercholesterolemia occurs at a young age i.e., 25-34. not surprisingly, the national heart, lung and blood institute in the united states advocated for routine check cholesterol levels sometime after the age of 20 years, the goal estimates the risk of heart disease. who reported in february 2012 and that the number of clients of heart disease in developing countries like indonesia will increase by 137% in 2020, whereas in developed countries is only 48%. research and development of the ministry of health stated that the percentage of deaths from cardiovascular disease increased from 5.9% (2004) to 9.1% (2007) and 19.0% (2011). hypercholesterolemia is also a risk factor for the cause of death at a young age, as reported by the world health organization (who) in 2002, there were 4.4 million deaths due to chd are due to hypercholesterolemia or 7.9% of the total number of deaths at a young age (yulinda 2015). based on these issues, the case needs to be handled hypercholesterolemia effectively. efforts to reduce hypercholesterolemia, in addition to the provision of treatment with cholesterol-lowering drugs may be accompanied by efforts to alternatives to the use of herbs. research on granting steeping red rosella flower petals already been done to lower blood cholesterol levels as well as the flesh of an avocado. it's just that until now has never been any studies to determine the effectiveness of the comparison between the tea rosella flower petals dried red and fresh avocados in a decrease in total cholesterol levels for clients hypercholesterolemia. therefore, researchers wanted to examine the comparative effectiveness of tea rosella with avocado fruit in a decrease in total cholesterol levels in hypercholesterolemic clients. method the design of this research is a quasiexperimental pre-posttest control group design. the treatment group consisted of group 1 who were given intervention of rosella tea and simvastatin, group 2 given the flesh of avocado and simvastatin, while the control group was group 3 which only given simvastatin. the population in this study were all clients of hypercholesterolemia in puskesmas menganti gresik. the sample in this study is part of hypercholesterolemia existing clients in puskesmas menganti gresik. sample inclusion criteria were aged 25-50 years, men and women with total cholesterol levels ≥ 200 mg/dl, can read and write. exclusion criteria samples are client hypercholesterolemia with concomitant diseases such as stroke or cardiovascular disease, liver disease, diabetes mellitus, thyroid, gastritis, client hypercholesterolemia who have low blood pressure (hypotension), clients who are allergic rosella tea or avocado. the tools used in this research are: questionnaire, observation sheets, food recall, scales for weighing cake dried rosella petals weighing 2 grams of avocado flesh and weighing 330 grams, the tool checks the blood cholesterol level is 100. biolizer research material is dried petal tea red rosella obtained from pt dita renowned, bacon avocado butter types derived from avocado farmers in lumajang, and venous blood specimen taken from the respondents. rosella flower petals dried red and the flesh of an avocado is ripe given to the treatment group. dried flower petals red rosella weighed weighing 2 grams are packed in small plastic wrap number 14 and a teaspoon of sugar are packaged in a small plastic wrap and some 14 drug simvastatin 10 mg was given to each of the respondents in the treatment group 1. meat avocado ripe weighed weighing 330 grams for one-time consumption given once daily for 14 days as well as drug jurnal ners vol. 12 no. 1 april 2017: 113-118 115 simvastatin 10 mg were given to each respondent in the treatment group 2. in the control group given the drug simvastatin 10 mg taken once daily consumed at night before bed. at the end of the study, after the intervention for 14 days in the treatment group 1, 2, and control groups were then carried back to the measurement of blood cholesterol levels at day 15. the respondents in the evening before the examination is recommended to fast for at least 8 hours. respondents to the clinic the next morning to do blood tests in the laboratory clinic. the results included in the observation sheet the collected data normality test. in the treatment group, 1 and 2 tested using the shapiro-wilk normality. in the treatment group 1 and 2 to analyze the decrease in total cholesterol levels using a paired t test. based on the analysis using spss, the research data in the control group are not normally distributed, then the appropriate test is wilcoxon. in the treatment group 1, 2 and control after the completion of the normality test are then performed statistical tests as follows: 1. univariate analysis univariate analysis performed to obtain descriptive characteristics of each of the variables studied included demographic data as well as confounding variables. all demographic data described by the value of the number and percentage of each group then presented using tables and interpreted. 2. analysisbivariat the bivariate analysis was performed on two variables to determine the relationship or not. among the independent variables with the dependent variable characteristics of respondents in total cholesterol levels by the statistical test. data in the form of nominal (gender, occupation, food recall, physical activity/exercise, and smoking was analyzed using contingency coefficient. data education, long-suffering, body mass index (bmi) were analyzed using a categorical form spearman`s correlation test. age pearson statistical test. the test that used to compare the two data before and after treatment for each group in the treatment group was paired t-test. anova test was used to compare the decline in total cholesterol levels between treatment groups 1, 2 and the control group. results the test results of normality with shapiro-wilk test showed the treatment group 1 and 2 normal distribution of data so as to compare data before and after treatment using paired t-test. in control group, data is not normally distributed so as to compare data before and after taking the drug using the wilcoxon test. the test results of a test of homogeny of variances, the three groups have the data shows the same variant as the value of p = 0,404 or p> 0.05. a further test is used bonferroni test. the results of paired t-test show that blood cholesterol levels of hypercholesterolemic client decreased significantly, this is evidenced by the value of significance p=0,001 or p<0,05 (table 1). show that in group 2, the results if the test statistic paired t-test many reduce cholesterol levels of the total significant to client hypercholesterolemia who gets avocado meat and simvastatin medicine. this is evidenced by the value of significance p=0,005 or p < 0,05 (table 2). table 1. average total blood cholesterol levels before and after treatment in group 1 group 1 number f % total cholesterol levels (mg/dl)± standart deviation pvalue pre-test 8 100 258,4 ± 31,464 0,001 post-test 8 100 193,9 ± 34,893 table 2. average total blood cholesterol levels before and after treatment in group 2 group 2 number f % total cholesterol levels (mg/dl)± standart deviation p-value pre-test 9 100 252 ± 31,941 0,005 post-test 9 100 179,3 ± 49,922 rosella tea and avocado as simvastatine therapy support (budi artini et.l.) 116 table 3. average total blood cholesterol levels before and after treatment in control group group 3 number f % total cholesterol levels (mg/dl)± standart deviation p-value pre-test 11 221,5 ±13,779 0,248 post-test 11 205,5 ± 46,025 table 4 effectiveness between treatment groups 1, 2, and control group mean ± standart deviation p-value p1 (n=8) 64,50 ± 34,978 0,025 p2 (n=9) 72,67 ± 55,996 k (n=11) 16,00 ± 46,052 information: p1 = group 1, rosella tea by steeping 2 gr/hr and drug simvastatin 10 mg p2 = group 2, given flesh of an avocado 330 gr/hr and drug simvastatin 10 mg k = the control group, given the drug simvastatin 10 mg the result of control group shows that giving only simvastatin medicine to a client with hypercholesterolemia reduce total blood cholesterol but not significant (p=0,248 or p>0,05) (table 3). table 4 showed anova test result in a significant difference between first group, two group and the control group with p=0,025. discussion results of research can be seen in the treatment group 1 and 2 found a significant decrease in total cholesterol levels between pre-test and post-test. this suggests that the companion therapy rosella tea and bacon avocado effective in lowering total cholesterol levels in clients with hypercholesterolemia. the results of the study in the control group there was no decrease in total cholesterol levels were significantly in hypercholesterolemic clients who received the drug simvastatin. the results showed that when seen from the difference between each group, the treatment group 2, has the greatest difference is 72.6 mg/dl, it is supported by the results of anova test showed no significant difference between treatment groups 1, 2 treatment and control groups. the role of rosella flower petals itself is as anti-cholesterol due to the effect of antioxidant compounds contained by rosella flower petals are flavonoids and polyphenols can reduce fat deposits (ldl) in the blood vessels (mardiyah; sarwani; ashadi; rahayu 2009). flavonoids are one of the antioxidants and can capture free radicals. flavonoids stabilize free radicals by lowering the energy activity and further inhibit the oxidation of ldl. inhibition of oxidation of ldl cholesterol levels decreased. substance anthocyanins can lower lipid profile, namely, cholesterol, triglycerides, and blood ldl cholesterol and raise hdl cholesterol levels. also, the content of niacin in rosella can degrade back triglycine (totong 1993) ride synthesis. niacin can also affect the activity of the enzyme lipoprotein lipase resulting in decreased production of ldl in the liver resulting in a decrease in total cholesterol, ldl, and triglycerides. niacin can increase hdl. rosella also contains vitamin c can reduce the absorption of triglycerides by acting as a laxative (sotyaningtyas 2007), vitamin c is in addition to reduce the absorption of triglycerides also plays an important role in the breakdown of cholesterol in the body. in the treatment group, 2 showed that administration of the drug simvastatin and flesh of an avocado could cause a decrease in total cholesterol levels. the results are consistent with results of previous studies (setiawan 2015) which states ethanol extract fruit avocados can lower total cholesterol levels in male wistar rats. other research supports is research anggraheny (2007) which states that the provision of avocado juice led to a decrease in total cholesterol levels were significant at all doses compared to the control group. the results of the study (usman 2013) shows that there are differences in the average decrease cholesterol levels in the intervention group and the control group. all three previous studies avocado flesh before being given processed first, there is presented in the form of juice or extracted. in this study conducted avocado meat supplied directly without being processed first. so that jurnal ners vol. 12 no. 1 april 2017: 113-118 117 the dose is given appropriate without an addition of other materials such as water when making juice. it also allows individuals to consume and retain the active ingredients contained therein to stay awake. according to (sediatama, a. 2000) flesh of an avocado contains 72.2% omega-9 oleic acid which is a phytochemical that demonstrate the ability to affect the availability of blood plasma cholesterol. meat avocado also contains 90% unsaturated fatty acids which have a complex function that is as bioregulator endogenous, structural function, namely water barrier on the skin, nerve tissue as nerve stimulation conducting material, the cell membrane as signal transduction. regulatory functions, including gene expression, growth factors, moisture membrane and the formation of eicosanoids. also, the fruit flesh avocado contains beta-sitosterol which phytochemical compounds that serve to normalize blood levels of ldl, triglycerides and total blood fats. according to budiana, n.s. (2013) of approximately 90% content of fat in avocados is that 80% in the form of oleic acid, a monounsaturated fat which beneficial for health. the advantages include lowering ldl, total cholesterol, and triglycerides and stabilize blood sugar levels. fiber and monounsaturated fatty acids along with vitamin c, e and glutathione, may protect arteries from damage due to deposition of ldl. the content of betasitosterol can reduce the absorption of cholesterol in the intestine. in the control group, there was no decrease in total cholesterol levels were significantly in hypercholesterolemic clients who received the drug simvastatin alone. simvastatin is a drug indicated for lowering cholesterol on clients who have hypercholesterolemia. simvastatin drugs are chemical modifications of the compounds produced by fungi. these drugs included in the hmg-coa reductase inhibitors that may inhibit the formation of cellular cholesterol and causes a decrease in serum cholesterol and serum ldl, with a slight increase or no change in the levels of ldl (karch 2010). performance simvastatin drugs are cholesterol-forming enzyme thus inhibiting cholesterol levels in the blood is reduced. the effectiveness of these drugs would be even better when accompanied by the application of a healthy lifestyle such as exercise regularly and stay away from greasy foods. conclusions based on the results of the study showed that there are a significants decreases in total cholesterol levels before and after receiving treatment both of the rosella tea with simvastatin medicine and avocado meat with simvastatin medicine on hypercholesterolemia clients. there was a significant difference between three groups in reduction of total cholesterol in hypercholesterolemia clients. in conclusion, if they are only consuming simvastatin medicine like in a group of controlled, without consuming rosella tea or avocado meat, the decreasing of total cholesterol in hypercholesterolemia patient is not too good or giving the non-significant result. reference anggraheny, h.d., 2007. influence of perseaamericana mill. the rat serum cholesterol levels total male wistar strain hyperlipidemia. diponegoro university of semarang. budiana, n.s., 2013. tumpas magical fruit diseases 1st ed, jakarta: sower selfreliance. bull, e. dan morrell, j., 2007. simple guides cholesterol, jakarta: erlangga. karch, a.., 2010. textbook of pharmacology nursing 2nd ed, jakarta: egc. kiki, z., 2013. herbal healthcare center, bandung: institute of technology bandung. mardiyah; sarwani; ashadi; rahayu, 2009. cultivation and processing rosella the red myriad benefits, jakarta: agromedia library. sediatama, a ., 2000. nutritional sciences for students and professionals 1st ed, jakarta: dian rakyat. setiawan, f.j., 2015. effects of ethanol extracts fruit avocado (perseaamericana mill) against total cholesterol levels decreased in male wistar rats. maranatha christian university. sotyaningtyas, c., 2007. healthy and fresh from nature, totong, m., 1993. pharmacology world anti hyperlipidemia mirror of medicine rosella tea and avocado as simvastatine therapy support (budi artini et.l.) 118 usman, m., 2013. influence of consumption of fruit avocado (perseaamericana mill) for total cholesterol levels in patients with hypercholesterolemia in puskesmas kota padang padang pasir year 2013. yulinda, p. h., 2015. effect of stepping rosella to decrease cholesterol hypercholesterolemia patients http://e-journal.unair.ac.id/jners | 1 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.22502 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research depression and the quality of life among filipino chemotherapy patients pearl irish v. de paz school of nursing and health sciences, biliran province state university, naval, filipina abstract introduction: undergoing chemotherapy has adverse effects to the physical, emotional and mental health of the chemotherapy patient that may cause depression and disturb the quality of the chemotherapy patient’s life. hence, the study aimed to determine the level of depression and the quality of the filipino chemotherapy patient’s life. methods: the study applied a quantitative descriptive-correlational research design. purposive sampling was done to identify the 102 respondents, who were filipino chemotherapy patients admitted in a tertiary hospital in eastern visayas from december 2018 to march 2019. the study used standardized questionnaires and these were distributed among the respondents. to analyze the data, descriptive statistics and total scores were used. likewise, pearsonproduct moment coefficient analysis was also used to determine the correlation between the two variables. results: 102 patients participated in the study. findings indicated that most of the respondents (52.38%) experienced mild depression and that their quality of life is good (97.05%). however, there were four respondents who experienced moderate depression. moreover, results also show that there is a strong relationship between the two variables (r=-0.053; p-value=0.000). conclusion: the study’s result highlights the crafting of a home-based care plan that will guide the chemotherapy patients and their families in the prevention of depression. likewise, it is also aimed in achieving a favorable quality of the chemotherapy patient’s life. article history received: october 08, 2020 accepted: december 28, 2020 keywords depression; quality of life; chemotherapy; cancer; mental health contact pearl irish v. de paz  pearlirishvdepaz@gmail.com  school of nursing and health sciences, biliran province state university, naval, filipina cite this as: paz, p. i. v. d. (2021). depression and the quality of life among filipino chemotherapy patients. jurnal ners, 16(1). 1-5. doi:http://dx.doi.org/10.20473/jn.v16i1.22502 introduction chemotherapy has been used by many cancer patients to eradicate cancer cells in their bodies, not only in the united states but also in asian countries like the philippines. according to chabner and roberts (2005), the treatment method has been utilized by cancer patients to achieve higher survival rate. during the treatment, it not only kills the cancer cells, but also destroys the normal and healthy cells. hence, the use of chemotherapy treatment has adverse effects which can cause changes not only to the body, but also to the emotional and mental state of the cancer patient undergoing chemotherapy (american cancer society, 2014). depression is one of the common health issues faced by cancer patients undergoing chemotherapy and which is characterized by a decrease or loss of interest in things, guilt, low self-confidence, sleeping and eating disorders, fatigue and inability to perform daily activities (smith, 2015). studies show that a range of 1.5 to 53% prevalence rate of depression occurs during chemotherapy treatment and 25% of the patients experience a severe level of depression, which implies that both depression and the quality of the cancer patient’s life are positively associated (craig & abeloff, 2004). the quality of a person’s life pertains to the insight of life, morals, interest and indicates one's general wellbeing (world health organization, 1998) . hence, one of the priorities in cancer management is achieving a favorable quality of life since it indicates one’s effectiveness of cancer treatment modality (ngelangel, 2012). several studies revealed that the majority had a good quality of life immediately after chemotherapy treatment. however, the occurrence of bodily and mental issues, such as pain and depression, were still evident, which can hamper the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id p. i. v. d. paz et al. 2 | pissn: 1858-3598  eissn: 2502-5791 quality of one’s life (bower et al., 2006). furthermore, studies also suggest that the quality of a cancer patient’s life who has had 3-5 chemotherapy cycles is good and also claimed that their sleep patterns were improved after chemotherapy. likewise, study also showed that the number of chemotherapy cycles is associated with the cancer patient’s quality of life (dehkordi, heydarnejad, & fatehi, 2009). with the above given premise, it is, therefore, necessary that healthcare providers such as nurses are able to recognize the signs and symptoms of depression so as to be able to render prompt management and treatment to avoid further complications. moreover, several studies were conducted that focused on measuring the level of depression and its association with the quality of the cancer patient’s life in foreign countries, but not in the philippines. few studies were documented about the depression level and the quality of filipino chemotherapy patients’ life. hence, this issue has been addressed by conducting this study among chemotherapy patients residing in eastern visayas which has aimed to determine the level of depression and the quality of life of filipino chemotherapy patients. materials and methods the study utilized a descriptivecorrelational design which used two standardized tools for data gathering. this study focused on the assessment of the level of depression and the quality of the chemotherapy patients’ life in a tertiary categorized hospital in eastern visayas. likewise, it also examined the association of the depression level toward the quality of the chemotherapy patients’ life. the study sample was a total of 102 cancer patients undergoing chemotherapy treatment in a tertiary hospital in eastern visayas. the purposive sampling method was used in the selection of the respondents. the inclusion criteria were the following (1) must be 18 years old and above; (2) must be a filipino; (3) lives in eastern visayas; (4) a cancer patient undergoing chemotherapy from december 2018-march 2019; (5) completed at least three chemotherapy sessions prior to data collection;(6) can understand the english language; (7) willing to be part of the study. those not mentioned in the inclusion criteria are the exclusion criteria. the study used two standardized tools. the first was beck’s depression inventory tool (bdi) tool, which is composed of 21 items and the second is the quality of life tool for those treated with anti-cancer drugs (qol-acd), which is composed of 22 items. bdi is answerable by the rating of 0-3 and the level of depression is determined by calculating the sum total of scores (beck, steer, & gabin, 1996). on the other hand, qol-acd is a tool which is answerable by the scale of 0-5 and the quality of life is determined by calculating the average score (kurihara et al., 1999). first, transmittal letters were sent to the tertiary hospitals where the cancer patients were undergoing chemotherapy treatment for their permission and approval to conduct the study. after the approval, the list of qualified respondents was obtained from the selected tertiary hospital. attendance during the fourth week of chemotherapy treatment was done by the researcher to find possible respondents. before the actual data gathering, the informed consents of the respondents were secured by asking them to sign the informed consent form, which indicated the respondent’s voluntary decision to be part of study after the researcher explaining carefully the study and the questionnaire. next, the selfadministered questionnaires were distributed among the participants and retrieved after a week. lastly, the accomplished questionnaires were then processed, analyzed, presented in tabular forms and interpreted. the data on the level of depression were derived from the beck depression inventory by summing up all scores in the 21-item test. the scores were interpreted using the following scale: 0-13 for depression at minimal level, 14-19 for depression at mild level, 20-28 depression at moderate level and 29-63 for depression at severe level. moreover, the quality of the chemotherapy patients’ life was determined by calculating the average score of the 22-item test. the average score of 1 would mean worst, 2 for bad, 3 for normal, 4 for better and 5 for best quality of life. furthermore, the relationship between the two variables was determined by using the pearson-product moment coefficient analysis. before the data collection, the respondents were given informed consents, which indicated the purpose of the study, the potential benefits and harm of the research, ensured their complete anonymity throughout the research and stated that they had the freedom to withdraw from the study anytime. after the distribution of the informed consents, the respondents were asked to sign the informed consent signifying the respondent’s voluntary decision to be part of the study. the researcher addressed issues such as confidentiality, anonymity and privacy. furthermore, the accomplished questionnaires were stored in a safe place and will be shredded or burned after two years. results a total of 102 chemotherapy patients in eastern visayas agreed to participate in the study and completed the questionnaire. table 1 shows the depression level while table ii shows the quality of the chemotherapy patient’s life and table 3 shows the test for significance between the two variables. discussion table 1 shows the level of depression of the respondents based on the results of beck depression inventory. the result reveals that the majority (52.38%) experienced a mild level of depression. however, there were four respondents with jurnal ners http://e-journal.unair.ac.id/jners | 3 moderate depression. mild depression means that symptoms such as the feelings of sadness, being discouraged about the future, lack of enjoyment in things, guilt, thoughts of committing suicide, worthless, crying, difficulty in concentrating, sleep and eating pattern changes, irritability, fatigue, loss of interest in sex were mildly felt by the respondents. the results of this present study supported the study of breitbart et al. (2014) which also revealed that breast cancer patients who underwent chemotherapy treatment reported an overall mild level of depression and individual participants ranged from mild to severe depression. the symptoms of sleeping problems, fatigue, weight loss, and appetite change were the most prevalent symptoms of depression in the study. likewise, a study conducted among 79 lung cancer patients who underwent chemotherapy treatment showed that the majority (34.2%) of the respondents experienced mild depression (sah, sapkota, adhikari, singh, & pokhrel, 2018). another study conducted among iranian cancer patients who underwent chemotherapy treatment revealed that the majority reported mild depression (mashadi, shakiba, & zakeri, 2013). however, there were some studies that did not support the result of this present study. a study by warmenhoven et al. (2011).showed that 10 out of the 46 post-chemotherapy patients with advanced cancer were diagnosed with severe depression further, derogatis et al. (2003)also reported that, among the 215 cancer patients admitted at various cancer centers and randomly assessed for the prevalence and severity, it was found that 44% of the respondents had severe depression hence, all postchemotherapy patients regardless of the sociodemographic profile and the cancer diagnosis and treatment must be screened for depression. quality of life table 2 presents the information on the quality of the chemotherapy patient’s life. the majority (97.06%) of the respondents perceived that their quality of life was good while the rest of the respondents have normal quality of life (2.94%). the following are the indicators of a good quality of life, even when experiencing the adverse effects of chemotherapy: still able to accomplish their daily activity; go out without help; take a half hour walk;felt no difficulties in walking even a short distance; able to walk up and down the stairs; bath by themselves; felt well; had good appetite; enjoyed their meals; often experienced vomiting; had lost weight; able to devote themselves to becoming enthusiastic about something; able to deal with stress; can concentrate on something; got encouragement from something or somebody they believed in; worry about their disease; had no problems dealing with people outside their family; thinks that their family was not troubled by their treatment; does not worry about their social life in the future; and does not worry much about financial problems caused by their treatment the results of the study are congruent to studies previously conducted among breast cancer patients who had chemotherapy treatment. the study revealed that the breast cancer patients undergoing chemotherapy treatment still reported a good quality of life. another study conducted among 200 patients receiving chemotherapy reported that 29% of the respondents had fear about their future and 26% of the respondents were thinking about the disease and its consequences, yet still reported a good quality of life (newel, 2009). another study conducted among cancer patients by singh and bala, (2014) revealed that their quality of life was enhanced progressively over six months after the completion of the chemotherapy sessions and they also reported to have good quality of life. however, there were also studies that deviated from the results of this present study. in a study conducted among breast cancer patients, the results revealed that the majority of the respondents had a bad quality of life, which may be caused by the disruption of daily activities as the result of the toxicity of the therapy (alzabaidey, 2012). likewise, a study of 103 young patients with breast carcinoma receiving adjuvant therapy revealed a bad quality of life, especially in the daily activities domain (arora, gustafson, hawkins, mctavish, & cella, 2001). hence, based on the studies presented, it can be concluded that the quality of the cancer patient’s life can be affected differently and should be assessed, especially after undergoing chemotherapy treatment. relationship between depression level and the quality of the chemotherapy patient’s life table 3 reflects that the quality of the chemotherapy patient’s life is positively associated with their depression level. in this study, the majority had a minimal level of depression and reported a ‘good’ table 1. level of depression level of depression f % minimal 43 42.16 mild 55 52.38 moderate 4 3.81 total 102 100 table 2. quality of life qol f % good 99 97.05 normal 3 2.94 total 102 100 table 3. test of relationship between level of depression and quality of life paired variables r p-value interpretation level of depression and quality of life -0.053 0.000 significant p. i. v. d. paz et al. 4 | pissn: 1858-3598  eissn: 2502-5791 qol while those who had depression at a mild level reported a ‘normal’ qol. the result indicates that those who claimed to have a normal quality of life have a greater tendency to declare ‘mild‘depression. depression is commonly experienced by chemotherapy patients. being diagnosed with cancer and undergoing chemotherapy treatment is a life changing event that may result in extensive emotional, physical and social suffering, which may lead to depression. after a series of chemotherapy treatments, there is a high probability of experiencing adverse effects, which may lead the person's quality of life to be at a reduced level (tierney et al., 1991). chemotherapy’s adverse effects have the possibility to influence the overall wellbeing of the person (humpel & iverson, 2007). studies in western countries have demonstrated a prevalence rate of 1%-56% of depression among cancer patients after undergoing chemotherapy treatment (zainal, nikjaafar, baharudin, sabki, & ng, 2013). moreover, depression significantly impairs functioning in different areas, such as in work functioning, social functioning and health (mendlowicz & stein, 2000). being depressed can reduce physical, emotional, mental and social functioning, which may hamper the person’s quality of life (brenes, 2007). a depressed person will manifest several symptoms, such as loss of pleasure or joy in life, difficulty in concentrating or focusing, feels hopeless, lack of self -esteem, sleeping problems, low energy level, loss of appetite, worthlessness and suicidal thoughts and wishes and, when left untreated, this could lead to altered physical, mental, social and psychological functioning (keith, harvey, & merika, 2007). moreover, several studies have reported that the quality of the cancer patient’s life depends on the depression level being experienced. a study shows that a ‘favorable’ quality of the breast cancer patient’s life was noted after undergoing chemotherapy for a year. however, they reported a deterioration in body image, sexual interest and functioning after two years. moreover, a study conducted among prostate cancer patients reported a low to moderate quality of life after treatment and experience of moderate fatigue (rondorf-klym & colling, 2003). likewise, results also reveal that the quality of life is worst among persons showing severe levels of depression (seeman et al., 2017). hence, the literature cited above are congruent with the results of this study. conclusion this study revealed that the majority of the chemotherapy patients had mild depression. moreover, a good level of quality of a chemotherapy patient’s life was also reported and showed strong association between the two variables. this implies that patients with cancer and who had undergone chemotherapy treatment in eastern visayas have successfully coped with the different adverse effects of chemotherapy treatment that could possibly lead them to depression. however, a few of the respondents were not able to cope with the adverse effects of chemotherapy treatment, particularly those who manifested moderate depression. therefore, prompt management and treatment are deemed necessary. the researcher recommends the development of a home-care plan for the chemotherapy patients and their families that will serve as a guide in dealing with the management of chemotherapy patients. therefore, prevalence of depression is prevented, and a favourable quality of life is expected among the chemotherapy patients. acknowledgment the author would like to express her sincerest gratitude to the biliran province state university administration and the commission on higher education for the financial support given in conducting the study. references alzabaidey, f. (2012). quality of life assessment for patients with breast cancer receiving adjuvant therapy. journal of cancer science and therapy, 5155. doi:https://www.researchgate.net/publication/2 88759296_quality_of_life_assessment_for_patien ts_with_breast_cancer_receiving_adjuvant_thera py american cancer society. (2014). a guide to chemotherapy. united states of america: american cancer society. doi:https://www.cancer.org/treatment/treatme nts-and-side-effects/treatmenttypes/chemotherapy.html arora, n., gustafson, d., hawkins, r., mctavish, f., & cella, d. (2001). impact of surgery and chemotherapy on the quality of lie of younger women with breat carcinoma. cancer, 1288-1298. doi:https://acsjournals.onlinelibrary.wiley.com/ doi/full/10.1002/10970142(20010901)92:5%3c1288::aidcncr1450%3e3.0.co;2-e beck, a., steer, r., & gabin, m. (1996). psychometric properties of beck depression inventory manual. san antonio: psychological corporation. doi:http://www.scielo.br/scielo.php?script=sci_a rttext&pid=s1516-44462013000400416 bower, j., ganz, p., desmond, k., bernaads, c., rowland, j., & meyerowtiz, b. (2006). cancer. fatigue in long term carcinoma survivor's: a longitudinal investigation, 751-758. doi:https://www.semel.ucla.edu/sites/default/fil es/publications/feb%202006%20%20fatigue%20in%20longterm%20breast%20carcinoma%20survivors.pd f breitbart, w., rosenfeld, b., tobias, k., pessin, h., ku, g., yuan, j., & wolchok, j. (2014). depression, cytokines, and pancreatic cancer. psychooncology. doi:https://pubmed.ncbi.nlm.nih.gov/24136882/ jurnal ners http://e-journal.unair.ac.id/jners | 5 brenes, g. (2007). anxiety, depression and quality of life in primary care patients. journal of clinical psychiatry, 437-443. doi:https://pubmed.ncbi.nlm.nih.gov/18185823/ chabner, b., & roberts, t. (2005). timeline chemotherapy and the war for cancer. nature reviews cancer, 65-72. doi:https://www.nature.com/articles/nrc1529 craig, t., & abeloff, m. (2004). psychiatric symptomalogy aamong hospitalized cancer patients. american journal of psychiatry, 131-137. doi:https://ajp.psychiatryonline.org/doi/abs/10. 1176/ajp.1974.131.12.1323 dehkordi, a., heydarnejad, s., & fatehi, a. (2009). quality of life in cancer patients undergoing chemotherapy. oman medical journal, 204-207. doi:https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc3251183/ derogatis, l., morrow, g., fetting, j., penman, d., piasetsky, s., schmale, a., . . . carnicke, c. (2003). the prevalence of psychiatric disorders among cancer patients. journal of american medical association, 751-757. doi:https://bpspsychub.onlinelibrary.wiley.com/ doi/abs/10.1348/1359107042304542 humpel, n., & iverson, d. (2007). depression and quality of life in cancer survivors: is there a relationship with physical ability? international journal of behaviorral nutrition and physical activity. doi:https://ijbnpa.biomedcentral.com/articles/1 0.1186/1479-5868-4-65 keith, g., harvey, m., & merika, g. (2007). depression and anxiety disorders in palliative cancer care. journal of pain symptom management, 118-129. doi:https://pubmed.ncbi.nlm.nih.gov/17280918/ kurihara, m., shimizu, h., shibuya, m., yamaji, y., eguchi, k., fukoks, m., & niitani, h. (1999). the development of a quality of life assessment for cancer patients receiving chemotherapy. psycho oncology. doi:https://onlinelibrary.wiley.com/doi/abs/10. 1002/%28sici%2910991611%28199907/08%298%3a4%3c355%3a% 3aaid-pon401%3e3.0.co%3b2-i mashadi, m., shakiba, m., & zakeri, z. (2013). evaluation of depression in patients with cancer in south iran (zahedan). iran journal of cancer prevention, 12-16. doi:https://www.researchgate.net/publication/2 66086929_evaluation_of_depression_in_patients_ with_cancer_in_south_of_iran_zahedan mendlowicz, m., & stein, m. (2000). quality of life in individuals with anxiety disorders. american journal of psychiatry, 669-682. doi:https://pubmed.ncbi.nlm.nih.gov/10784456/ newel, r. (2009). altered body image: a fear avoidance model of psycho-social difficulties following disfigurement. journal of advance nursing, 1230-1238. doi:https://onlinelibrary.wiley.com/doi/abs/10. 1046/j.1365-2648.1999.01185.x ngelangel, c. (2012). quality of life of filipino cancer patients. asia pacific oncology and hematology. doi:https://www.researchgate.net/publication/2 6241150_epidemiology_and_clinicopathology_of_ breast_cancer_in_metro_manila_and_rizal_provin ce_philippines rondorf-klym, l., & colling, j. (2003). quality of life after radical prostatetectomy. oncology nursing forum. doi:https://www.researchgate.net/publication/1 0806605_quality_of_life_after_radical_prostatec tomy sah, g., sapkota, a., adhikari, j., singh, j., & pokhrel, n. (2018). assessment of depression among advance cancer patients in developing countries. medical oncology, 15-25. doi:https://www.jto.org/article/s15560864(18)32857-0/pdf seeman, t., pozzobom, f., viera, m., boing, m., boing, l., & machado, z. (2017). influence of symptoms depression on the quality of life of men diagnosed with prostate cancer. scielo. doi:https://www.scielo.br/scielo.php?script=sci_ arttext&pid=s1809-98232018000100070 smith, h. (2015). depression in cancer patients: pathogenesis, implications and treatment. oncology letters, 1509-1514. doi:https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4356432/ tierney, a., leonard, r., taylor, j., closs, s., chetty, u., & rodger, a. (1991). side-effecrs expected and experieced by women receiving chemotherapy treatmet. britsish medical journal, 272-302. doi:https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc1668972/ warmenhoven, f., rijswijk, e., engels, y., kan, c., prins, j., weel, . . . vissers, k. (2011). the beck depression inventory and a single screening question as screening tools for depression disorder in dutch advanced cancer patients. support care cancer, 319-324. doi:https://pubmed.ncbi.nlm.nih.gov/21243377/ world health organization. (1998). the development of who quality of life assessment. psychology med. doi:https://www.who.int/mental_health/media/ 68.pdf zainal, n., nikjaafar, n., baharudin, a., sabki, z., & ng, c. (2013). prevalence of depression in breast cancer survivors: a systematic review of obsevational studies. asian pacific journal of cancer prevention, 2649-2656. doi:https://pubmed.ncbi.nlm.nih.gov/23725190/ 26 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.21443 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research a normative behavior of pre-travel health consultation and the associated factors among travelers i gede nova ariawan, kadek eka swedarma, ni putu emy darma yanti school of nursing faculty of medicine udayana university, bali, indonesia abstract introduction: travelers may transmit diseases due to their behavior of travel, consequently travelers should consider preventive measurement through pre-travel health consultation seeking behavior. pre-travel health consultation is a particular preparation ideally conducted by international travelers to obtain risk assessment and management to prevent the transmission of diseases. this study investigates the relationship of sociodemographic characteristics and itinerary on pre-travel health consultation behavior among international travelers in badung, bali. methods: a descriptive-correlative design using a cross-sectional approach employed 125 participants determined by a purposive sampling technique performed in the ten tourist destinations of badung regency. data collection was conducted on february 15th until march 5th, 2020. data demography, travel plan, and anonymous questionnaires regarding pre-travel health consultation behavior are used in this research. the gamma coefficient correlation and kruskal-wallis statistic tests were performed in the study for bivariate analysis. results: the results showed that age (p<0.001; r=-0.650) and past-travel history to bali (p=0.004; r=-0.475) were significantly correlated with pretravel health consultation behavior among international travelers in badung, bali. meanwhile sex, nationality, last education, travel duration, and types of the destination visited were not significantly associated with pre-travel health consultation behavior among international travelers in badung, bali (p>0.05). conclusion: the age and past-travel history to bali seem to be predictors for travelers to uptake pre-travel health consultation, thus nurses should be able to promote the implementation of pre-travel health consultation by utilizing the media promotion appropriately adjusted to the age of travelers and travel experience. article history received: august 17, 2020 accepted: january 23, 2021 keywords consultation; itinerary; nurse’s role; travelers; travel health contact i gede nova ariawan  novaariawan@student.unud.ac.id  school of nursing faculty of medicine udayana university, bali, indonesia cite this as: ariawan, i. g. n., swedarma, k. e., yanti, n. p. e. d. (2021). a normative behavior of pre-travel health consultation and the associated factors among travelers. jurnal ners, 16(1). 26-34 doi:http://dx.doi.org/10.20473/jn.v16i1.21443 introduction international tourism has been increasing in the last decade due to the dynamic of individual mobility. it urges all aspects of human life to follow the movement. it was proved by the fact that the number of international travelers in the world has been growing steadily to around 1.1 billion in 2015 (heywood et al., 2012). approximately, 6.54% growth of arrivals to bali in 2018 were made by international travelers (bali government tourism office, 2019), which indicates the escalation of traveling among international travelers. the high number of trip intensity can affect the health of travelers and the local population in the destination country. travelers play a significant role in transmitting travel-related infectious diseases due to the their travel pattern and behavior (heywood et al., 2012). masen, yohan, somia, myint, and sasmono (2018) noted 66.2% of 201 travelers were infected with dengue also 48.7% was caused by dengue virus type 2 (denv-2). diarrhea or gastroenteritis, systemic febrile disease, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 27 respiratory tract infection, and typhoid are other diseases susceptible for travelers (sohail et al., 2019; sumadewi et al., 2018). additionally, in the beginning of december 2019, a newly severe acute respiratory syndrome-coronavirus 2 (sars-cov 2) was discovered in china and rapidly spread around the globe (chinazzi et al., 2020). consequently, many governments, including indonesia’s, admitted they were unprepared to cope with the pandemic and one of the strategies was to issue travel restrictions from and to hubei, china (chinazzi et al., 2020; djalante et al., 2020). it shows travelers have health risks related to travel that require preventive behavior to alleviate travel-related illnesses and they should be prepared for all possibility, such as a pandemic. pre-travel health consultation (pthc) implementation with a health professional is one of the preventive measures conducted by travelers before departure. it aims to reduce health risk during the trip, by assessing health risk, itinerary, and individual characteristics, communicating the information regarding infectious diseases risk adjusted to travelers’ needs and providing risk management, such as relevant vaccination of the destination (heywood et al., 2012; paudel et al., 2017; zuckerman et al., 2015). the effectiveness of this program can diminish risk behavior and improve the preventive measures of infectious diseases (al-abri et al., 2016). tan, st. sauver, and sia (2018) also reported that travelers who had travelers’ diarrhea (td) and did not uptake pthc would be faced with prolonged hospitalization and lack of capability to comply with medication regimen while diagnosed with td. travelers that engage with health behavior have the probability to be affected by several factors. predisposition, enabling, and reinforcing factors can encourage healthy behavior (green, 1974). sociodemographic characteristics such as age, sex, nationality, and education level were mentioned as predisposition factors that influenced pthc seeking behavior (adou et al., 2019; el-ghitany et al., 2018; shady et al., 2015; zhang et al., 2016), yet shady et al. (2015) revealed that sex was not significantly correlated to visits to the travel health clinic (thc). moreover, travel plan characteristics, including travel duration, types of travel destination visited, and pasttravel history, were noted as factors that influenced pthc uptake behavior among travelers (gagneuxbrunon et al., 2016; pavli et al., 2014). although the pthc utilization can provide a positive impact on international travelers that influences by their sociodemographic and itinerary, previous studies found that most travelers did not seek pthc with a health professional (heywood et al., 2012a; larocque et al., 2010; paudel et al., 2017). those studies showed that travelers had not yet carried out this program well. nurses play a crucial role in practicing of health promotion in the community, thus conducting an assessment regarding knowledge, attitude, and practice (kap) regarding pthc is one of the initial nursing processes required to do in reaching and convincing travelers to implement the community-based program, otherwise the advice of nurses and other health professionals have to compete with non-medical information sources, such as the internet and friends (bauer et al., 2013). kap are behavior domains that influence travelrelated illness prevention (omer et al., 2015). al-abri, abdel-hady, and al-abaidani (2016) found that most travelers had good knowledge and positive attitude regarding travel-related infectious diseases; however, only 22.5% of 204 travelers conducted pthc. that condition describes that a good knowledge, and a positive attitude did not align with preventive behavior tangibly. most of the previous studies investigated knowledge, attitudes, and practice regarding infectious illnesses related to travel (adou et al., 2019; chow et al., 2018), travel health (al-abri et al., 2016), and vaccination (zhang et al., 2016). it shows that there has been no report that quantified a normative behavior of pthc and associated factors among international travelers. this study was aimed to identify the relationship of sociodemographic and itinerary characteristics on pthc behavior among international travelers in badung, bali. materials and methods a quantitative study with descriptive-correlative design by using a cross-sectional approach was performed in the ten tourist destinations of badung regency, namely sangeh monkey forest, seminyak beach, kayu aya beach, petitenget beach, canggu beach, batu bolong beach, batu belig beach, uluwatu temple, pandawa beach, and dreamland beach. data collection was conducted on february 15th until march 5th, 2020. this study examined several variables, including age, sex, nationality, last education, travel duration, types of the destination visited, and past-travel history to bali as independent variables, additionally pthc behavior was the dependent variable. the population of this study was the total number of international traveler arrivals in badung regency in 2018, which was 2,951,941 arrivals. a purposive sampling technique used in this research and a minimum sample was 100 participants calculated by slovin formula and the error tolerance level was 10% (0.1). international travelers aged ≥18 years, communication with english, the traveler willing signed the informed consent were eligible as a research participant, while international travelers who lived in bali over 12 months were excluded from this study. a total of 125 participants were enrolled in the present study. the primary data were collected by using selfadministered and anonymous questionnaire that composed demographic data (birth of date, sex, nationality, and last education), travel plan (travel duration, types of the destination visited, and pasttravel history to bali), and pthc behavior. the pthc i. g. n. ariawan et al. 28 | pissn: 1858-3598  eissn: 2502-5791 behavior questionnaire comprised 20 items of statements to measure pthc behavior normatively. the pthc behavior questionnaire was developed by the researchers based on the literature review regarding the pthc and encompassed: (1) the principles of pthc; (2) risk assessment related to the assessment of demography, itinerary, culture of travelers; (3) risk communication associated to provides the information of the travel-related illness prevention, destination country, and vaccination adjusted to the traveler’s requirement; and (4) risk management, including administered the vaccination. it included positive and negative statements related to three indicators (kap). the guttman scale (true/false) was used for knowledge indicator and the likert scale (strongly agree until strongly disagree) was used for attitude and practice indicators. the maximum score of pthc behavior attained 68, classified into two categories of behavior: good (cut-off point median >50) and poor (cut-off point median ≤50). the instrument was translated into english by the translator from the language center of the udayana university. the validity test of the questionnaire involved 30 travelers and the resulted cronbach’s alpha values were 0.454-0.608 for the knowledge indicator, 0.422-0.830 for the attitude indicator, and 0.478-0.751 for the practice indicator, while the reliability test of pthc behavior questionnaire found cronbach’s alpha value. 0.898 the researchers obtained data collection permission from the institutions. research explanation was delivered to travelers who volunteered and informed consent was administered after declaring willing to become a research participant in the current study. data collection was conducted by the researchers without a research assistant. our study was appraised by the ethical research commission of the faculty of medicine, udayana university and sanglah general hospital denpasar by the approval number: 404/un14.2.2.vii.14/lp/2020. the univariate analysis was conducted to describe the characteristics of sociodemography, itinerary, and pthc behavior of the participants by displaying the distribution frequency. our study performed a bivariate analysis by using the gamma coefficient correlation and kruskal-wallis statistic tests. the bivariate analysis determined the relationship between sociodemography and itinerary characteristics on pthc behavior. this study employed 95% confidence interval (α = 0.05) that was analyzed by using computer software. results table 1 describes the sociodemographic characteristics of travelers, including 68% of participants were an adult category, 54.4% were female, 78.4% were europeans, dominated by russian, british, dutch, german, and french. the domination of other nationalities was also reported from the united states (america), indian (asia), australian (oceania), and moroccan (africa). most of the travelers had tertiary education (72%). in addition, table 1 also reports travel plan characteristics. approximately 54.4% of travelers had short-travel (≤28 days), 76.8% of participants visited the nature-based tourism, and 51.2% had not traveled to bali. table 2 also shows that most of the travelers had a poor category of pthc behavior (54.4%) nonetheless 45.6% of travelers had good behavior. table 3 shows that there was significance with a strong and negative correlation between age with pthc behavior among international travelers in badung, bali (p <0.001; r = -0.650), moreover, pasttravel history to bali also had a moderate and negative association significantly (p = 0.004; r = 0.475). other sociodemography and itinerary characteristics such as sex, nationality, last education, travel duration, and types of the destination visited were not significantly associated with pthc behavior among international travelers in badung, bali (p > 0.05). further analysis reports that a higher proportion of the good behavior was found among adolescent travelers compared to adult and elderly travelers. female travelers also had a higher proportion of good behavior. asian travelers reported a higher number of good behaviors compared to other nationalities from four continents that more likely had poor behavior. a good behavior was predominantly found among travelers who had secondary education (46.9%); however, there was no significant difference with travelers who had tertiary education (45.6%). a higher percentage of the good behavior was noted among travelers with shorttravel, meanwhile, travelers with long-travel more likely had poor behavior. the proportional differences were not significantly reported among travelers that visited nature or wellness-based tourism, nevertheless, a higher proportion of the good behavior was found among travelers who visited the nature-based tourism. the first-time visitors were dominated by a good category of pthc behavior (57.8%). discussion our study evaluated pthc behavior normatively and associated factors among international travelers in badung, bali. this topic is strongly relevant with the current situation in bali because travel health is evolved by the policy makers in bali and some health facilities have been providing travel health service. in addition, the number of tourist arrivals in bali is growing steadily. the finding of this study also showed that majority of the participants had a poor category of pthc behavior. in contrast, previous studies found that travelers had a higher proportion of good knowledge (63.2%) and positive attitude (60.8%) toward travel health, nonetheless only 22.5% of 204 travelers received pthc (al-abri et al., 2016). it indicates that the travelers are not able to demonstrate the jurnal ners http://e-journal.unair.ac.id/jners | 29 knowledge and positive attitude in a tangible behavior of the preventive measures because they assume that to commit with the preventive behavior, they need guidance. notoatmodjo (2010) explained that a guided practice is an individual ability to require guidance in implementing a certain action, hence, in this stage, an individual cannot yet adopt or modify the preventive behavior in their life. our study also demonstrated that age had a significant and negative correlation with pthc behavior among international travelers in badung, bali. it implies that the younger travelers were more likely to have a good behavior of the pthc compared to the old group of travelers who had a poor behavior. previous studies noted a consistent result, namely age was significantly correlated with pthc seeking behavior (gagneux-brunon et al., 2016) and good knowledge regarding travel health (chow et al., 2018). likewise, zhang et al. (2016) also reported that older travelers had lack of awareness of vaccinations, which plays a role in preventing disease. it showed that a negative association was found in the previous study. conversely, shady et al. (2015) found a different result. the negative correlation between age and pthc behavior could be explained because the younger travelers are more likely to have better risk perception, and this can be the protection, thus it can increase the focus to the risk and force travelers to indicate a positive attitude about hazards in the destination (el-ghitany et al., 2018). kwon et al. (2019) also explained that lacking compliance to the vaccination and malaria prophylaxis among adults and elderly is because they have frightened fear toward adverse effect of the vaccination, cost, they did not intend to adopt risky behavior during traveling, and had a history of past immunization. a higher risk perception among older adolescent travelers was also reported in this study, they had the highest proportion of good category of the pthc behavior (83.3%). this condition revealed that younger travelers are able to apply good knowledge and positive attitude to the real practice compared to older travelers, thus it seems the difference of theory in this research, namely age-maturity, tends to encourage individuals to adopt healthy lifestyle behavior (potter & perry, 2005). age is well-known as a predisposition factor that affects behavior, the increasing age can describes the maturity in arguing and judgment (green, 1974). underestimating health risk, have traveling experience, and financial limitation among older travelers need to be considered; however, these are challenges for health professionals to provide the recommendation (del prete et al., 2019). nurse has significant role as an educator, importantly to emphasize the table 1. the sociodemography and itinerary characteristics of international travelers in badung, bali in 2020 (n=125) variables n % age (year) older adolescent (17-25) 24 19.2 adult (26-64) 85 68.0 elderly (≥65) 16 12.8 sex male 57 45.6 female 68 54.4 nationality european 98 78.4 american 11 8.8 oceania 9 7.2 asian 6 4.8 african 1 0.8 last education primary education 3 2.4 secondary education 32 25.6 tertiary education 90 72.0 travel duration (days)a short travel (≤28 days) 68 54.4 long travel (>28 days) 57 45.6 type of destination visited wellness-based tourism 29 23.2 nature-based tourism 96 76.8 past-travel history to bali (times)a first time 64 51.2 >1 times 61 48.8 a category based on cut off point median (not normal distributed) table 2. pthc behavior among international travelers in badung, bali in 2020 (n=125) variable n % pre-travel health consultation behavior poor behavior 68 54.4 good behavior 57 45.6 i. g. n. ariawan et al. 30 | pissn: 1858-3598  eissn: 2502-5791 communication process effectively in order to administer an optimal nursing care which is influenced by language proficiency and communication of nurses (swedarma et al., 2016). conversely, sex had no association significantly with pthc behavior among international travelers in badung, bali. this result was consistent with previous studies, namely sex was not significantly correlated with visits the thc to conduct pthc or seek health information (kwon et al., 2019; shady et al., 2015). in contrast, several studies reported that sex was significantly correlated to pthc implementation, especially among female travelers (chow et al., 2018; heywood et al., 2012). this condition shows that sex is still a polemic which affects individual behavior. our study found that sex was not significantly associated with pthc behavior because genderrelated stigma has been shifting which is often linked to healthy lifestyle behavior. stigma friction was caused by various programs from the world health organization, such as eradication of gender stereotypes, upholding gender equality, omitting gender barriers in accessing health, moreover implementation of gender-responsive and gendertransformative (world health organization, 2020). therefore, further analysis noted that good category of the pthc behavior is more likely found among female travelers. female travelers also mentioned that they had a better perception in controlling behavior, receive more vaccines, and had higher compliance of malaria prophylaxis (kwon et al., 2019; lammert et al., 2017). women were more motivated to conduct pthc because they have awareness and anxiousness toward their health, do not adopt risky behavior, and men are not willing to attach with health information, which frequently correlates to masculinity (chow et al., 2018; ek, 2015). it implies that men and women have an equal position and an entitlement in accessing health facility and applying healthy behavior in their daily activity. additionally, the globalization era has been leading the population to be interested in reading about health topics. moreover, nationality was not associated significantly with visits to the thc or seeking pthc (omer et al., 2015; paudel et al., 2017), which showed a consistent result with this study. in addition, nationality was not significantly related with good or poor knowledge and attitude regarding travel health (chow et al., 2018). yet, other studies found that nationality was a predictor for travelers to visit the thc (shady et al., 2015), lack of pthc implementation seems more likely among immigrant travelers (heywood et al., 2012). recently, every country has had an equal focus on addressing health problem-related communicable diseases, child and maternal health, and noncommunicable diseases (doubova & pérez-cuevas, 2018). this condition has pursued the availability and table 3. the relationship of sociodemography and itinerary characteristics among international travelers in badung. bali in 2020 (n=125) variables pre-travel health consultation behavior r p-value poor good n % n % age -0.650 <0.001* older adolescent 4 16.7 20 83.3 adult 52 61.2 33 38.8 elderly 12 75.0 4 25.0 sex 0.283** male 34 59.6 23 40.4 female 34 50.0 34 50.0 nationality 0.358** european 55 56.1 43 43.9 american 6 54.5 5 45.5 asian 1 16.7 5 83.3 oceania 5 55.6 4 44.4 african 1 100.0 0 0.0 last education 0.005 0.980* primary education 2 66.7 1 33.3 secondary education 17 53.1 15 46.9 tertiary education 49 54.4 41 45.6 travel duration -0.317 0.067* short travel 32 47.1 36 52.9 long travel 36 63.2 21 36.8 types of destination visited 0.924** wellness-based tourism 16 55.2 13 44.8 nature-based tourism 52 54.2 44 45.8 past-travel history to bali -0.475 0.004* first time 27 42.2 37 57.8 >1 times 41 67.2 20 32.8 total 68 54.4 57 45.6 *gamma correlation statistic test (α = 0.05); **kruskal-wallis statistic test (α = 0.05) jurnal ners http://e-journal.unair.ac.id/jners | 31 accessibility to reach a health facility, thus deliberating the number of health professionals is a requirement (doubova & pérez-cuevas, 2018). green (1974) explained that availability and accessibility of resources and services are reinforcing factors that can influence individuals in applying health behavior. health services such as promotion, preventive, curative, and rehabilitative will create a culture and belief in the community. furthermore, other analysis showed that most of the asian travelers had good category of the pthc behavior (83,3%). it could be caused by the asian travelers have already known infectious illnesses, including malaria, typhoid, hepatitis a and b, dengue, rabies, and japanese encephalitis; therefore, it cannot be risks for asian travelers who visit asia countries (piyaphanee et al., 2012). travel medicine practice was developed with focus on travelers from western countries (europe, north america, australia, and new zealand) that will be travel to the developing with tropical and sub-tropical climate countries (leder et al., 2017; piyaphanee et al., 2012). per capita income country, health program and service, and promotion program also affect pthc seeking behavior among travelers (heywood et al., 2012; shady et al., 2015). although our study noted inconsistency with several studies that reported level of education was significantly correlated with travel-related health risks and vaccine acquisition (el-ghitany et al., 2018; zhang et al., 2016), shady et al. (2015) supported our findings that education level was not significantly associated with pthc implementation, preventive measurement, and non-compliance with malaria prophylaxis regimen. it occurred due to various accessible resources of the information provided for travelers related to travel health or which described the destinations’ condition, such as website (heywood et al., 2012; zuckerman et al., 2015). the low numbers of pthc implementation was because travelers had lack of trust to the health providers, hence the health providers need to update their information based on the websites frequently visited by the travelers (zuckerman et al., 2015). however, pthc seeking needs to be conducted with the health provider to obtain suggestions that are adjusted with travelers’ needs and avoid misconception to the information which has already been accessed (heywood et al., 2012). further analysis showed that travelers with secondary and tertiary education had higher proportion of good category of the pthc behavior. travelers with higher education level have the capability to receive information easier and be able to utilize the information for disease prevention (notoatmodjo, 2010). el-ghitany et al. (2018) assumed that education provides better skills to deal with health risks. clinically, education is still a factor which influences individual behavior. a negative correlation not significantly associated between travel duration with pthc behavior among international travelers in badung, bali was also demonstrated in our study, which implies that travelers with long-travel duration are more likely to have a poor behavior as compared with travelers with short-travel duration. likewise, previous study had consistent findings with this study (gautret et al., 2011). this finding shows that there are other factors which affect pthc seeking behavior: travelers unwilling to seek health information through pthc implementation due to they have traveled before to the same areas and have elicited of pthc in previous travel (shady et al., 2015). lacking awareness among travelers toward health risk was noted in this study, even travelers with long-travel should seek pthc because they might acquire higher health risk exposure. it was inconsistent with further analysis, due to travelers with long-travel (>28 days) dominated with poor category of the pthc behavior (63.2%). our finding was also confirmed in previous study that reported travelers who lived more than four weeks in the destination country were rarely likely to seek health information to the thc (shady et al., 2015). it shows, clinically, travel duration affects traveler visits to the thc and against health problems (chow et al., 2018; shady et al., 2015; vilkman et al., 2016). the prolonged duration of trip is associated with the enhancement of health risk exposure and pthc seeking (pavli et al., 2014). for instance, among 15,180 travelers who visited to kenya with average length of stay was 13.2 days, it increased the incidence of td that attained 64 cases per 100 travelers (leder et al., 2015). although types of the destination were not significantly correlated with pthc behavior, a consistent finding was also found in our study, namely types of the destination was not associated with the acceptance of malaria chemoprophylaxis regimen (stoney et al., 2016). nevertheless, previous studies revealed that types of the destination correlated with the improvement of compliance to the anti-vector prevention (kain et al., 2019), and visits to the thc (shady et al., 2015). it shows that for the enhancement of travelers visiting to t naturebased destinations, they should seek pthc prior travel. most of the travelers have traveled to the naturebased destination (76.8%) and are dominated by a good category of the pthc behavior (55.2%), although a poor behavior was also found in large proportion (54.2%). the nature-based destination aims to provide a ‘back to nature’ concept with a wide range of travel experience. including adventure tourism, ecotourism, and rural tourism (roxana, 2012). travelers who visit to the nature-based destination received higher health hazards, such as travel-associated communicable diseases (gautret et al., 2011). most of the travelers from western countries that enrolled in this study spent their time on the beach to gain a tanned skin by doing sun bathing and surfing. rawlings (2006) explained that western countries travelers have type i and type ii skin pigmentation, i. g. n. ariawan et al. 32 | pissn: 1858-3598  eissn: 2502-5791 which implies both of those skin pigmentations are light pigmentation. the light pigmentation has fewer melanosomes, hence it could increase the sunburnt caused by uv light. the protection is vital to implement for travelers who visit to the tropical beach and sea by applying sun screen (villard et al., 2017). moreover, there was a significant correlation between past-travel history to bali with pthc behavior among international travelers in badung, bali. other studies also reported that travel history was associated with visits to the thc (pavli et al., 2014; shady et al., 2015), memory and knowledge after seeking pthc (mcguinness et al., 2015). in contrast, previous studies mentioned that travel history was not a predictor for visiting thc (liu et al., 2015), and knowledge regarding infectious diseases (adou et al., 2019). further analysis described that the higher proportion of good category of the pthc behavior was found among travelers without travel experience to bali. it was showed a consistency with negative correlation in our study. travelers who have traveled to bali already knew the condition in bali and had the confidence; in contrast, first-time travelers have alertness toward the health hazard related travel. those conditions can affect their risk perception and unwillingness to comply with health recommendation (shady et al., 2015). this research has several limitations, including we were not able to reach out to all the tourist destinations mapped due to weather and uncertainty of the traveler’s condition, thus we changed the target of the destination in badung area. in addition, we did not identify pthc implementation or seeking behavior and source of the information of pthc among travelers prior the departure. we did not determine the time limit of past-travel history to bali. moreover, we had difficulty to accommodate travelers who visit a high mobility tourist destination. conclusion to conclude this study, we found a significant and negative correlation between age and past-travel history to bali with pthc behavior among international travelers in badung, bali. other variables such as sex, nationality, last education, travel duration, and types of the destination visited were not significantly associated with pthc behavior. we recommend the travelers should uptake pthc around six to eight weeks before departure. nurses should be able to promote the implementation of pthc to the target by heeding the age and past-travel history characteristics of the traveler because it can influence the compliance of travelers in implementing pthc, thus nurses can develop an appropriate media promotion adjusted to the characteristics of travelers to persuade them to visit the thc. it also can be an opportunity for nurses to evolve their roles in the travel health sector as a care provider, educator, collaborator, case manager, and empower society to increase awareness toward health risk. furthermore, we expected the government to consider our study while regulating the policy regarding pthc implementation among international travelers as travel-related infectious disease prevention. a qualitative research needs to be conducted for exploring the factors related to travelers’ awareness in implementing pthc by addressing limitations and applying other health behavior theories. references adou, a.a., napolitano, f., vastola, a., angelillo, i.f., 2019. travelers’ knowledge, attitudes, and behavior related to infectious diseases in italy. plos one 14, e0215252. https://doi.org/10.1371/journal.pone.0215252 al-abri, s.s., abdel-hady, d.m., al-abaidani, i.s., 2016. knowledge, attitudes, and practices regarding travel health among muscat international airport travelers in oman: identifying the gaps and addressing the challenges. j. epidemiol. glob. health 6, 67–75. https://doi.org/10.1016/j.jegh.2016.02.003 bali government tourism office, 2019. bali tourism statistic 2018. bali government tourism office, denpasar. bauer, i., hall, s., sato, n., 2013. providing travel health care – the nurses’ role: an international comparison. travel med. infect. dis. 11, 214–224. https://doi.org/10.1016/j.tmaid.2013.04.004 chinazzi, m., davis, j.t., ajelli, m., gioannini, c., litvinova, m., merler, s., piontti, a.p. y, mu, k., rossi, l., sun, k., viboud, c., xiong, x., yu, h., halloran, m.e., longini, i.m., vespignani, a., 2020. the effect of travel restrictions on the spread of the 2019 novel coronavirus (covid-19) outbreak. science 368, 395–400. https://doi.org/10.1126/science.aba9757 chow, z.y., ching, s.m., ramachandran, v., hoo, f., sulaiman, w.a.w., foo, y.l., tey, y.y., liong, c.w., wen, l.h., han, t.c., 2018. travellers’ knowledge, attitudes and practices regarding prevention of infectious diseases: a cross sectional study from malaysian airports. southeast asian j trop med public health 49, 707–716. del prete, v., mateo-urdiales, a., bueno-cavanillas, a., ferrara, p., 2019. malaria prevention in the older traveller: a systematic review. j. travel med. 26. https://doi.org/10.1093/jtm/taz067 djalante, r., lassa, j., setiamarga, d., sudjatma, a., indrawan, m., haryanto, b., mahfud, c., sinapoy, m.s., djalante, s., rafliana, i., gunawan, l.a., surtiari, g.a.k., warsilah, h., 2020. review and analysis of current responses to covid-19 in indonesia: period of january to march 2020. prog. disaster sci. 6, 100091. https://doi.org/10.1016/j.pdisas.2020.100091 doubova, s.v., pérez-cuevas, r., 2018. going further to measure improvements in health-care access and quality. the lancet 391, 2190–2192. jurnal ners http://e-journal.unair.ac.id/jners | 33 https://doi.org/10.1016/s0140-6736(18)309875 ek, s., 2015. gender differences in health information behaviour: a finnish population-based survey. health promot. int. 30, 736–745. https://doi.org/10.1093/heapro/dat063 el-ghitany, e.m., abdelmohsen, m.a.m., farghaly, a.g., abd el-gawwad, e.s., abd el-wahab, e.w., 2018. travel health survey: risk perception, healthseeking behavior, and subjective evaluation of travel health services in egypt. int. j. travel med. glob. health 6, 16–24. https://doi.org/10.15171/ijtmgh.2018.04 gagneux-brunon, a., andrillat, c., fouilloux, p., daoud, f., defontaine, c., charles, r., lucht, f., botelhonevers, e., 2016. pre-travel advice seeking from gps by travellers with chronic illness seen at a travel clinic. j. travel med. 23, taw013. https://doi.org/10.1093/jtm/taw013 gautret, p., tantawichien, t., hai, v.v., piyaphanee, w., 2011. determinants of pre-exposure rabies vaccination among foreign backpackers in bangkok, thailand. vaccine 29, 3931–3934. https://doi.org/10.1016/j.vaccine.2011.03.096 green, l.w., 1974. toward cost-benefit evaluations of health education: some concepts, methods, and examples. health educ. monogr. 2, 34–64. https://doi.org/10.1177/10901981740020s106 heywood, a.e., watkins, r.e., iamsirithaworn, s., nilvarangkul, k., macintyre, c.r., 2012. a crosssectional study of pre-travel health-seeking practices among travelers departing sydney and bangkok airports. bmc public health 12, 321. https://doi.org/10.1186/1471-2458-12-321 kain, d., findlater, a., lightfoot, d., maxim, t., kraemer, m.u.g., brady, o.j., watts, a., khan, k., bogoch, i.i., 2019. factors affecting pre-travel health seeking behaviour and adherence to pretravel health advice: a systematic review. j. travel med. 26, 1–14. https://doi.org/10.1093/jtm/taz059 kwon, h.y., lee, h., im, j.h., park, s.-g., lee, y.j., baek, j.h., lee, j.-s., 2019. determinants of compliance of travelers with vaccination and malaria prophylaxis at a travel clinic. j. korean med. sci. 34, e217. https://doi.org/10.3346/jkms.2019.34.e217 lammert, s.m., rao, s.r., jentes, e.s., fairley, j.k., erskine, s., walker, a.t., hagmann, s.h., sotir, m.j., ryan, e.t., larocque, r.c., 2017. refusal of recommended travel-related vaccines among u.s. international travellers in global travepinet. j. travel med. 24. https://doi.org/10.1093/jtm/taw075 leder, k., borwein, s., chanthavanich, p., chatterjee, s., htun, k., marma, a.s.p., nakatani, i., ok, j.-j., pakasi, l., pandey, p., piyaphanee, w., rupali, p., schwartz, e., shinozuka, t., phu, p.t.h., watanabe, h., visser, j., wilder-smith, a., zhang, m., mcguinness, s.l., 2017. travel medicine perspectives of select travel medicine experts practicing in the asia-pacific region. j. travel med. 24. https://doi.org/10.1093/jtm/tax012 leder, k., steffen, r., cramer, j.p., greenaway, c., 2015. risk assessment in travel medicine: how to obtain, interpret, and use risk data for informing pretravel advice. j. travel med. 22, 13–20. https://doi.org/10.1111/jtm.12170 liu, s.j., sharapov, u., klevens, m., 2015. patient awareness of need for hepatitis a vaccination (prophylaxis) before international travel. j. travel med. 22, 174–178. https://doi.org/10.1111/jtm.12186 masyeni, s., yohan, b., somia, i.k.a., myint, k.s.a., sasmono, r.t., 2018. dengue infection in international travellers visiting bali, indonesia. j. travel med. 25, 1–7. https://doi.org/10.1093/jtm/tay061 mcguinness, s.l., spelman, t., johnson, d.f., leder, k., 2015. immediate recall of health issues discussed during a pre‐travel consultation. j. travel med. 22, 145–151. https://doi.org/10.1111/jtm.12183 notoatmodjo, s., 2010. ilmu perilaku kesehatan. rineka cipta, jakarta. omer, f., hassan, n., hussain, h., mana, s., awad, o., 2015. travel health, gaps in knowledge, attitudes, and practices among dubai travellers, dubai, uae. int. j. prev. med. res. 1, 126–131. paudel, p., raina, c., zwar, n., seale, h., worth, h., sheikh, m., heywood, a.e., 2017. risk activities and pre-travel health seeking practices of notified cases of imported infectious diseases in australia. j. travel med. 24. https://doi.org/10.1093/jtm/tax044 pavli, a., silvestros, c., patrinos, s., lymperi, i., maltezou, h.c., 2014. pre-travel preparation practices among business travellers to tropical and subtropical destinations: results from the athens international airport survey. travel med. infect. dis. 12, 364–369. https://doi.org/10.1016/j.tmaid.2013.12.004 piyaphanee, w., steffen, r., shlim, d.r., gherardin, t., chatterjee, s., 2012. travel medicine for asian travelers—do we need new approaches? j. travel med. 19, 335–337. https://doi.org/10.1111/j.17088305.2012.00661.x potter, p.a., perry, a.g., 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktik, 4th ed. egc, jakarta. rawlings, a.v., 2006. ethnic skin types: are there differences in skin structure and function?1. int. j. cosmet. sci. 28, 79–93. https://doi.org/10.1111/j.14672494.2006.00302.x roxana, d.m., 2012. considerations about ecotourism and nature-based tourism realities and perspectives. int. j. acad. res. econ. manag. sci. 1, 215–221. shady, i., gaafer, m., bassiony, l., 2015. travel risk behaviors as a determinants of receiving pretravel health consultation and prevention. trop. i. g. n. ariawan et al. 34 | pissn: 1858-3598  eissn: 2502-5791 dis. travel med. vaccines 1. https://doi.org/10.1186/s40794-015-0003-8 sohail, a., mcguinness, s.l., lightowler, r., leder, k., jomon, b., bain, c.a., peleg, a.y., 2019. spectrum of illness among returned australian travellers from bali, indonesia: a 5-year retrospective observational study. intern. med. j. 49, 34–40. https://doi.org/10.1111/imj.13993 stoney, r.j., chen, l.h., jentes, e.s., wilson, m.e., han, p.v., benoit, c.m., macleod, w.b., hamer, d.h., barnett, e.d., 2016. malaria prevention strategies: adherence among boston area travelers visiting malaria-endemic countries. am. j. trop. med. hyg. 94, 136–142. https://doi.org/10.4269/ajtmh.150565 sumadewi, k.t., eka, p.a., masyeni, s., rusni, n.w., witari, n.p.d., 2018. utilization review inpatient and outpatient of traveller related to thypoid in bali (study in two regencies: a case report), in: iop conference series: materials science and engineering. presented at the 3rd annual applied science and engineering conference (aasec 2018), iop publishing, bandung. https://doi.org/10.1088/1757899x/434/1/012335 swedarma, k.e., yanti, l.p.e., sulistiowati, n.m.d., 2016. nursing role in supporting the development of community based on health tourism in bali. j. injec 1, 15–18. https://doi.org/10.24990/injec.v1i1.101 tan, e.m., st. sauver, j.l., sia, i.g., 2018. impact of pretravel consultation on clinical management and outcomes of travelers’ diarrhea: a retrospective cohort study. trop. dis. travel med. vaccines 4, 16. https://doi.org/10.1186/s40794-018-0076-2 vilkman, k., pakkanen, s.h., lääveri, t., siikamäki, h., kantele, a., 2016. travelers’ health problems and behavior: prospective study with post-travel follow-up. bmc infect. dis. 16, 328. https://doi.org/10.1186/s12879-016-1682-0 villard, m., bonini, j., criquet-hayot, a., baubion, e., derancourt, c., 2017. kite-surfers’ sun risk in the tropics. j. travel med. 24. https://doi.org/10.1093/jtm/taw079 world health organization, 2020. gender [www document]. gender. url https://www.who.int/westernpacific/healthtopics/detail/gender (accessed 3.20.20). zhang, min, zhang, j., hao, y., fan, z., li, l., li, y., ju, w., zhang, h., liu, w., zhang, mengzhang, wu, d., he, h., 2016. vaccination knowledge, attitude and practice among chinese travelers who visit travel clinics in preparation for international travel. j. travel med. 23, taw051. https://doi.org/10.1093/jtm/taw051 zuckerman, j.n., brunette, g.w., leggat, p.a., 2015. essential travel medicine, 1st ed. wiley blackwell, west susex. 256 mekanisme koping pada odha dengan pendekatan teori adaptasi callista roy (coping mechanism on people living with hiv using theory of adaptation callista roy) sandu siyoto*, yuly peristiowati*, eva agustina* *stikes surya mitra husada kediri email : siyotos@gmail.com abstrak pendahuluan: dampak negatif yang ditimbulkan oleh individu yang hidup dengan hiv/aids adalah masalah fisik, psikososial dan emosional, sehingga odha perlu untuk meningkatkan mekanisme koping kearah adaptif. roy menjelaskan ada 3 stimulus yang dapat mempengaruhi mekanisme koping yaitu stimulus fokal, stimulus kontektual,stimulus residual. tujuan penelitian ini adalah untuk mengetahui faktor yang berhubungan dengan mekanisme koping berdasarkan teori adaptasi roy. metode: desain penelitian menggunakan analitik korelasional pendekatan cross sectional, 30 responden dipilih dengantehnik purposive sampling.instrumen penelitian menggunakan kuesioner. hasil: hasil penelitian menunjukan stimulus fokal, stimulus kontektual, adan stimulus residual berhubungan dengan mekanisme koping pada odha, sebagian besar responden memiliki mekanisme koping negatif sebanyak 18 responden (60.0%) dan mekanisme koping positif sebanyak 12 responden (40.0%). diskusi: berdasarkan hasil analisa menunjukan ada hubungan stimulus fokal p-value = 0.018 dan stimulus kontektual p-value = 0.004, sedangkan stimulus residual tidak ada hubungannya dengan mekanisme koping pada odha di kds friendship plus kota kediri.selama bergabung dalam kelompok dukungan sebaya odha mempunyai wadah untuk mencurahkan perasaan dan emosi serta dapat berkomunikasi sosial dengan baik, sehingga adanya stimulus fokal dan kontektual dari kds dapat menstimulasi respon kognator dan regulator yang dapat mempengaruhi fungsi fisiologis sehingga mampu beradaptasi secara adaptif. kata kunci: teori adaptasi roy, stimulus fokal, kontektual, residual, mekanisme koping, odha. abstract introduction: the negative impact caused by people living with hiv/aids is a matter of physical, psychosocial and emotional, so that people living with hiv need to improve towards adaptive coping mechanisms. roy explained that there are three stimulus that can influence the coping mechanisms, there are stimulus focal, contextual stimulus, stimulus residual. the purpose of this study was to determine the factors related with coping mechanisms based on the roy adaptation theory. methods: the study design using analytic correlational cross-sectional approach, 30 respondents were selected by purposive sampling technique. the research instrument used questionnaire. results: the results showed focal stimulus, stimulus contextual, adan residual stimulus associated with coping mechanisms in people living with hiv, the majority of respondents have a negative coping mechanisms as many as 18 respondents (60.0%) and positive coping mechanisms as much as 12 respondents (40.0%). discussion: based on the analysis showed there is relationship stimulus focal p-value = 0.018 and contextual stimulus p-value = 0.004, while the residual stimulus doesn’t have relation with the coping mechanisms of people living with hiv in kds friendship plus kediri. during join the peer support groups people with hiv has a place to share the feelings and emotions and be able to communicate social well, so that their focal and contextual stimuli can stimulate a response from kds cognator and regulators that can affect physiological functions so they can adapt adaptively. keywords: roy adaptation theory, stimulus focal, contextual, residual, coping mechanisms, people living with hiv. pendahuluan hiv/aids merupakan masalah kesehatan yang mengancam indonesia dan banyak negara di seluruh dunia. saat ini tidak ada negara yang terbebas dari masalah hiv/aids. hiv (human immunodeficiency virus) adalah virus yang menyerang system kekebalan tubuh manusia lalu menimbulkan aids. aids (acquired immuno deficiency sindrom) merupakan kumpulan gejala penyakit yang disebabkan oleh virus hiv yang merusak sistem kekebalan tubuh manusia (zein 2006) penderita hiv/aids mempunyai masalah terkait dengan mekanisme koping, karena masih banyaknya stigma negatif dari masyarakat tentang hiv/aids sehingga banyak penderita hiv/aids yang mengisolasi diri dari lingkungannya dan banyak penderita hiv/aids yang menganggap dirinya tidak berguna lagi. dengan adanya gangguan psikis pada pasien hiv/aids sehingga berakibat juga pada penurunan sistem kekebalan tubuh dan sistem imun (yayasan spiritia 2006). jurnal ners vol. 11 no. 2 oktober 2016: 256-260 257 berdasarkan studi pendahuluan yang dilakukan peneliti di kelompok dukungan sebaya friendship plus terdapat odha sebanyak 221 orang dan dari 10 penderita didapatkan 7 orang dengan mekanisme koping negatif seperti menutup diri, menganggap dirinya tidak berguna dan mengasingkan diri dari masyarakat, dan 3 orang dengan mekanisme koping positif terlihat dengan dirinya masih mempunyai rasa percaya diri yang tinggi,menggap dirinya patut menjadi tokoh dimasyarakat. dinas kesehatan kota kediri, mulai tahun 2003 – 2015 dengan kumulatif ditemukan 644 orang terinfeksi hiv/aids, dari jumlah tersebut ditemukan 49 orang meninggal dan 595 orang masih hidup. penderita hiv/aids sangat mudah merasa bersalah dan menerima penolakan dari sekitarnya, hal inidisebabkan karena anggapan bahwa tingkah laku mereka, terutama tingkah laku seksual, dapat membahayakan orang lain. penderita hiv/aids akan mengalami berbagai stresor atau stimulus yang dapat mempengaruhi mekanisme koping, stimulus atau input yang masuk diantaranya adalah stimulus fokal, stimulus konstektual dan stimulus residual sehingga odha membutuhkan mekanisme koping yang tepat untuk upaya yang diarahkan pada pengelolaan stressor (roy, sr 2009). individu yang utuh dan sehat, akan mampu berfungsi untuk memenuhi kebutuhan biopsikososial menggunakan koping yang positif maupun yang negatif. untuk mampu beradaptasi tiap individu akan berespon terhadap kebutuhan fisiologis, konsep diri yang positif, mampu memelihara integritas diri, selalu berada pada rentang sehat sakit untuk memelihara proses adaptasi. demikian besar dampak mekanisme koping adaptif untuk kualitas hidup pada pasien hiv reaktif maka diperlukan pertukaran informasi secara mendetail dan menyeluruh antar sesama pasien hiv. model adaptasi roy menjelaskan adanya pertahanan dan peningkatan kemampuan proses adaptasi pasien terhadap stimulus kearah koping yang lebih adaptif. berdasarkan uraian diatas, maka penulis tertarik untuk melakukan penelitian dengan judul analisis faktor yang berhubungan dengan mekanisme koping pada odha (orang dengan hiv/aids) berdasarkan pendekatan teori adaptasi callista roy di kota kediri. bahan dan metode desain penelitian ini menggunakan “analitik korelasional”dengan menggunakan model rancangan cross sectiona.lpopulasipenelitian ini semua odha yang ada di kelompok dukungan sebaya friendship plus di kota kediri yang berjumlah 221 orang. tehnik sampling purposivedenganjumlah sampel 30 responden. instrumen penelitian menggunakankuesioner. analisis data menggunakan uji statistik regresi logistik α = 0,05. hasil data umum data umum akan menyajikan karakteristik responden.berdasarkan karakteristik responden menunjukkan sebagian besar usia resonden berumur 25-35 tahun sebanyak 20 (67%), 18 responden (60%) berjenis kelamin laki-laki. sebagian besar sudah pernah mendapatkan informasi tentang hiv/aids sebanyak 22 responden (73%) dan sebanyak 13 responden (43%) telah terkena hiv/aids selama ≤1 tahun. data khusus tabel 1mekanisme koping pada odha di kds friendship plus kota kediri tabel 2.stimulus fokal pada odha di kds friendship plus kota no. kategori frekuensi presentas e 1. negatif 18 60% 2. positif 12 40% jumlah 30 100 no. kategori frekuensi prosentase 1. rendah 10 33.3% 2. sedang 8 26.7% 3. tinggi 12 40.0% 30 100% mekanisme koping odha dengan pendekatan teori adaptasi c. roy (sandu, dkk) 258 tabel 3. stimulus kontektual pada odha di kds friendship plus kota kediri no. kategori frekuensi presentasi 1. rendah 12 40.0% 2. sedang 10 33.3% 3. tinggi 8 26.7% 30 100% tabel 4. stimulus residual pada odha di kds friendship plus kota kediri no. kategori frekuensi presentasi 1. rendah 17 56.7% 2. sedang 7 23.3% 3. tinggi 6 20.0% 30 100% tabel 5. hasil analisa data : uji statistik regresi logistik faktor stimulus dengan mekanisme koping no. kategori nilai signifikan 1. stimulus fokal 0.018 2. stimulus kontektual 0.004 3. stimulus residual 0.111 berdasarkan uji statistik regresi logistik faktor yang paling dominan terhadap mekanisme koping adalah faktor stimulus kontektual dengan nilai uji wald stimulus kontektual adalah 8.244 dan nilai signifikan 0.004 < (0.05). pembahasan hasil penelitian di kds kota kediri di dapatkan bahwa sebagian besar odha memiliki mekanisme koping yang negatif yaitu sebanyak 18 responden dengan presentase (60.0%) . stimulus fokal dengan kategori tinggi sebanyak 12 responden yaitu (40.0%), stimulus fokal dengan kategori rendah sebanyak 10 responden yaitu sebesar (33.3%) stimulus fokal dengan kategori sedang sebanyak 8 responden yaitu sebesar (26.7%,) dan stimulus fokal dengan kategori tinggi sebanyak 12 responden (40.0%). stimulus kontektual dengan kategori rendah adalah sebanyak 12 responden yaitu sebesar (40.0%)responden dengan stimulus kontektual kategori sedang adalah sebanyak 10 responden (33.3%) dan stimulus kontektual dengan kategori tinggi adalah sebanyak 8 respoden (26.7%). stimulus residual dalam kategori rendah sebanyak 17 responden yaitu sebesar (56.7%) dan yang memiliki stimulus residual dalam kategori tinggi yaitu sebesar 6 responden (20.0%). hasil analisis dari uji statistik regresi logistik menunjukan bahwa ada hubungan antara stimulus fokal dengan mekanisme koping pada odha dengan pvalue = 0.018 < (0.05). stimulus kontektual dengan mekanisme koping menunjukan hasil p-value = 0.004 < (0.05). stimulus residual dengan mekanisme koping menunjukan hasil p-value = 0.111 > (0.05). mekanisme koping merupakan distorsi kognitif yang digunakan oleh seseorang untuk mempertahankan rasa kendali terhadap situasi,mengurangi rasa tidak aman, dan menghadapi situasi yang menimbulkan stress (videbeck, 2011). roy mengemukakan bahwa manusia sebagai sebuah sistim yang dapat menyesuaikan diri (adaptive system). sebagai sistim yang dapat menyesuaikan diri manusia dapat digambarkan secara holistik (bio, psicho, sosial) sebagai satu kesatuan yang mempunyai input (masukan), control dan feedback processes dan output (keluaran/hasil). proses kontrol adalah mekanisme koping yang dimanifestasikan dengan cara-cara penyesuaian diri. lebih spesifik manusia didefinisikan sebagai sebuah sistem yang dapat menyesuaikan diri dengan proses mekanisme kognator dan regulator untuk mempertahankan adaptasi dalam empat jurnal ners vol. 11 no. 2 oktober 2016: 256-260 259 cara-cara penyesuaian yaitu : fungsi fisiologis, konsep diri, fungsi peran, dan interdependensi (roy, sr 2009). stimulus fokalmerupakan stimulus yang secara langsung dapat mempengaruhi suatu individu untuk berperilaku menuju mekanisme koping yang adaptif. dalam penelitian ini stimulus fokal adalah adanya stigma negatif dari masyarakat atau lingkungan sekitar dan penolakan keluarga terhadap odha yang dapat mempengaruhi seorang individu dalam menghadapi stimulus yang masuk untuk menuju respon mekanisme koping yang positif . roy menjelaskan bahwa respon yang menyebabkan penurunan integritas tubuh akan menimbulkan suatu kebutuhan dan menyebabkan individu tersebut berespon melalui upaya atau perilaku tertentu. setiap manusia selalu berusaha menanggulangi perubahan status kesehatan dan perawat harus merespon untuk membantu manusia beradaptasi terhadap perubahan ini. 5 stimulus kontektual merupakan stimulus yang dapat menunjang terjadinya sakit (faktor presipitasi) seperti keadaan tidak sehat. keadaan ini tidak terlihat langsung pada saat ini, misalnya penurunan daya tahan tubuh,lingkungan yang tidak sehat dan isolasi sosial. banyak odha yang ketika mereka mengalami gangguan psikis dari luar dan menyebabkan terganggunya psikis atau beban pikiran sehingga mengakibatkan sistem imun odha yang rentan akan terjadi penurunan sehingga akan mempengaruhi cd4 pada odha. stimulus residual adalah karakteristik atau riwayat seseorang dan timbul secara relevan sesuai dengan situasi yang dihadapi tetapi sulit diukur secara objektif. stimulus residual merupakan sikap, keyakinan dan pemahaman individu yang dapat mempengaruhi terjadinya keadaan tidak sehat, atau disebut dengan faktor predisposisi, sehingga terjadi kondisi fokal, misalnya : persepsi pasien tentang penyakit, gaya hidup, dan fungsi peran.(wilkins n.d., 2006) hal ini menunjukan bahwa odha yang mendapatkan stimulus fokal akan mempengaruhi mekanisme koping kearah yang negatif, karena masih banyak odha yang mendapatkan stigma dari masyarakat dan juga penolakan dari keluarga, sehingga odha sering merasa hidupnya tidak berguna lagi merasa gagal dalam hidup dan berakibat ke mekanisme koping yang negatif. koping yang efektif atau mekanisme koping yang positif menepati tempat yang sentral terhadap ketahanan tubuh dan daya penolakan tubuh terhadap gangguan maupun serangan suatu penyakit baik bersifat fisik maupun psikis dan social (nursalam dan ninuk 2013). dalam penelitian ini stimulus residual pada odha adalah sejauh mana presepsi odha serta keyakinan terhadap penyakit hiv/aids. sebagian odha yang mempunyai persepsi bahwa hiv/aids adalah penyakit yang telah membuat hidup odha tidak ada gunanya lagi. sehingga dengan adanya persepsi odha yang membut hidupnya tidak berguna lagi akan mempengaruhi dampak dari mekanisme koping, namun sebagian odha juga tidak mau memikirkan hal tersebut mereka sudah mengetahui cara pengobatan tentang hiv/aids dan akan tetap meneruskan hidupnya walaupun sebagai odha. mereka percaya bahwa arv adalah terapi yang dapat meningkatkan kualitas hidupnya. persepsi adalah pengamatan tentang objek , peristiwa atau hubungan-hubungan yang diperoleh dengan menyimpulkan informasi dan menafsirkan pesan proses menginterpretasikan rangsangan (input) dengan penerimaan informasi, dengan kata lain persepsi dapat juga didefenisikan sebagai segala sesuatu yang dialami manusia (jalaludin rakhmat 2007). faktor stimulus kontektual merupakan faktor yang paling dominan,dengan nilai uji wald stimulus kontektual adalah 8.244 dan nilai signifikan p-value 0.004 < 0.05. stimulus kontektual dalam penelitian ini adalah adanya stimulus lain yang merangsang seseorang baik internal maupun eksternal serta mempengaruhi situasi dan dapat diobservasi, diukur, dan secara subjektif disampaikan oleh individu. rangsangan ini muncul secara bersamaan dimana dapat menimbulkan respon mekanisme yang negatif (roy, sr 2009). roy mendefinisikan lingkungan sebagai semua kondisi yang berasal dari internal dan eksternal,yang mempengaruhi dan berakibat terhadap perkembangan dari perilaku seseorang dan kelompok untuk menuju ke mekanisme koping yang adaptif. yang mempengaruhi suatu stimulus kontektual adalah adanya perubahan eksternal yaitu adanya gangguan fisik, kimiawi, psikologis. sedangkan adanya perubahan internal yaitu mekanisme koping odha dengan pendekatan teori adaptasi c. roy (sandu, dkk) 260 adanya gangguan proses mental (pengalaman, emosional dan kepribadian) dan proses stressor biologis (sel maupun molekuler) (nursalam, & kurniawati 2008). simpulan dan saran simpulan berdasarkan hasil uji statistik menggunakan regresi logistik kesalahan α < 0,05 didapatkan hasil signifikan nilai p = 0.018 < 0.05 untuk stimulus fokal,stimulus kontektual p = 0.004< 0.05yang berarti ada hubungan dengan mekanisme koping pada odha dan stimulus residual p = 0.111 > (0.05) yang berarti tidak ada hubungan dengan mekanisme koping pada odha, faktor yang paling dominan adalah faktor stimulus kontektual dengan nilai uji wald stimulus kontektual adalah 8.244 dengan nilai signifikan p-value 0.004 < 0.05. saran bagi responden diharapkan odha (orang dengan hiv/aids) lebih memiliki sikap percaya diri dalam melakukan aktifitas sehari-hari, dan juga odha bisa bertanya ketenaga kesehatan jika terjadi masalah fisik maupun psikis. daftar pustaka jalaludin rakhmat, 2007. persepsi dalam proses belajar mengajar, jakarta: rajawali pers. nursalam dan ninuk, 2013. asuhan keperawatan pada pasien terinfeksi hiv/aids, jakarta: salemba medika. nursalam, & kurniawati, n., 2008. asuhan keperawatan pada pasien terinfeksi hiv/aids., jakarta: salemba medika. roy, sr, c., 2009. the roy adaptation model (3rd ed.). upper saddle river, nj : person. tomey and alligood m.r. 2006. nursing theoriest, utilization and application, mosby: elsevier. wilkins, k.w.&, kluwer/lippincott williams & wilkins. yayasan spiritia, 2006. lembaran informasi tentang hiv dan aids untuk orang yang hidup dengan hiv dan aids (odha)., jakarta: yayasan spiritia. zein, u., 2006. seputar hiv/aids yang perlu anda ketahui, medan: usu press. . 209 respons bio-psiko-sosio-spiritual pada keluarga tenaga kerja indonesia yang terinfeksi hiv (bio-psycho-social-spiritual responses of family and relatives of hiv-infected indonesian migrant workers) nursalam*, ninuk d.k*, abu bakar*, purwaningsih*, candra p.a*, *fakultas keperawatan universitas airlangga, kampus c jl. mulyorejo surabaya e-mail: nursalam@fkp.unair.ac.id abstrak pendahuluan: angka kejadian human immunodeficiency virus (hiv) di kalangan pekerja tenaga kerja indonesia (tki) yang pulang dari negara tujuan kerjanya terutama di propinsi jawa timur cukup tinggi. stres yang dialami oleh penderita akan bertambah dengan perilaku anggota keluarga yang maladaptif, sehingga bisa mempengaruhi proses penyembuhan dan bahkan meningkatkan angka kematian. penelitian ini bertujuan untuk mengetahui respons bio-psiko-sosio-spiritual anggota keluarga tki yang terinfeksi hiv. tujuan dari penelitian ini adalah menganalisis respons bio-psiko-sosio-spiritual pada keluarga tenaga kerja indonesia yang terinfeksi hiv serta membandingkannya dengan respons keluarga non tki yang terinfeksi hiv. metode: desain penelitian yang digunakan adalah komparatif, yaitu untuk mengungkap respons bio-psiko-sosio-spiritual pada keluarga tki yang terinfeksi hiv dan membandingkan dengan keluarga tki yang tidak terinfeksi hiv. populasi dalam penelitian ini adalah keluarga pasien tki yang terinfeksi dan tidak terinfeksi di dua kabupaten di wilayah jawa timur. sampel sebanyak 17 orang diambil dengan teknik consecutive sampling. pengumpulan data dalam dilakukan di rumah keluarga tki yang terinfeksi virus hiv, meliputi respons biologis dengan pengambilan darah vena untuk pemeriksaan kortisol, dan pengukuran variabel psikologis sosial dan spiritual dengan menggunakan kuesioner dan wawancara. analisa data dilakukan dengan uji statistik t test dan mann-whitney dengan signifikansi 0,05. hasil: hasil penelitian menunjukkan ada perbedaan respons biologis keluarga pasien hiv tki dan non tki (p = 0,000) meskipun sebagian besar responden berada dalam rentang normal atau tidak stres. sebaliknya, pada respons psikologi, sosial dan spiritual tidak terdapat perbedaan yang signifikan secara statistik dengan nilai-nilai signifikasi psikologis p = 0,065, sosial p = 0,057, dan spiritual p = 0,243. diskusi: kesimpulan dari penelitian respons biologis (kortisol) pada kelompok responden keluarga pasien hiv tki lebih baik dibandingkan dengan non tki, tetapi tidak terdapat perbedaan secara statistik pada respons psikologis, sosial dan spiritual. kata kunci: hiv, tki, keluarga pasien, stres, psikologis, sosial, spiritual abstract introduction: incidence of human immunodeficiency virus (hiv) among indonesian migrant workers (tki) returning from his destination countries, especially in east java is quite high. stress experienced by the patient is affected bythe family member maladaptive behaviors; thus affect healing process and even increased mortality. the purpose of this study was to analyze the response of the bio-psycho-socio-spiritual family of indonesian workers who are infected with hiv and compared with the response of non-family workers who are infected with hiv. method: research design was comparative to reveal the response of the bio-psycho-socio-spiritual families of hiv-infected familyof migrant workers and non-migrant workers. the population was family of both migrant and non-migrant in two districts in east java in 2014. sample of 17 people were recruited by simple random sampling technique. data were performed at the family home, including biologic response (venous blood sampling for cortisol examination), and measurement of the psychological, social and responses by using questionnaires and interviews. data were analysed with statistical t test and mannwhitney test with a significance level of 0.05. result: the results showed no differences in the biological response of hiv patients’ families among migrant and non-migrant workers (p = 0.000) although the majority of respondents were in the normal range or not stress. in contrast, the psychology, social and spiritual responsesshowed no statistically significant difference with p = 0.065, p = 0.057, p = 0.243 for psychological, social, and spiritual responses respectively. discussion: there is a difference in the biological response (cortisol) in the group of family and relatives of patients with hiv among migrant workers compared with non-migrant workers, but there is no statistical difference in the psychological, social and spiritualresponses. keywords: hiv, migrant workers, their families, stress, psychological, social, spiritual pendahuluan human immunodeficiency virus (hiv) adalah sebuah retrovirus yang menginfeksi selsel sistem imun, menghancurkan atau merusak fungsi dari sel-sel sistem imun. sebagai progress dari infeksi, sistem imun menjadi lemah, dan manusia menjadi lebih rentan terkena infeksi. stadium yang paling lanjut 210 jurnal ners vol. 9 no. 2 oktober 2014: 209–216 dari infeksi hiv adalah acquired immune deficiency syndrome (aids) (who, 2013a). virus hiv ditemukan dalam cairan tubuh terutama pada darah, cairan sperma, cairan vagina, dan air susu ibu. virus tersebut merusak kekebalan tubuh manusia dan mengakibatkan turun dan hilangnya daya tahan tubuh sehingga mudah terjangkit penyakit infeksi lainnya (nursalam & kurniawati, 2007). penurunan imunitas dipengaruhi oleh beberapa faktor. faktor yang perlu diperhatikan oleh tenaga kesehatan adalah stresor psikososial. aspek psikososial menurut stewart (1997) dibedakan menjadi tiga hal, antara lain: (1) stigma sosial; (2) diskriminasi terhadap orang yang terinfeksi hiv; (3) terjadinya waktu yang lama terhadap respon psikologis mulai penolakan, marah, tawar-menawar, dan depresi berakibat pada keterlambatan upaya pencegahan dan pengobatan. lingkup terkecil dari lingkungan sosial pasien adalah keluarga. dukungan sosial terutama dari keluarga adalah penting, dan sangat menentukan perkembangan penyakit yang dapat menurunkan kondisi kesehatan pasien, mempercepat progresivitas penyakit hingga timbul kematian. namun, bagaimana gambaran respon bio-psiko-sosio-spiritual pada keluarga tenaga kerja indonesia (tki) yang terinfeksi virus hiv ini masih belum diteliti. data dari who tentang jumlah orang yang terinfeksi hiv di indonesia pada tahun 2011 berkisar 380.000 jiwa. data ini selalu meningkat tiap lima tahunnya, yakni pada tahun 2006 tercatat sebanyak 180.000 jiwa dan pada tahun 2001 berkisar 12.000 jiwa (who, 2013b). pada tahun 2013 ini, ditjen pp & pl kementerian kesehatan republik indonesia merilis data tentang penemuan kasus baru hiv pada tahun 2012 mencapai 21.511. data ini meningkat daripada tahun sebelumnya pada 2011 sejumlah 21.031. jumlah penderita hiv khusus propinsi jawa timur, seperti yang disampaikan oleh dinas kesehatan propinsi jawa timur pada tahun 2011 tercatat sebanyak 2646 jiwa, terjadi peningkatan dari tahun sebelumnya sejumlah 2233 jiwa. data hingga juni 2012 menunjukkan bahwa kabupaten a dan kabupaten tulung agung termasuk dalam zona merah distribusi kasus aids di propinsi jawa timur (dinkes provinsi jawa timur, 2012). data secara nasional mengenai tki yang positif terinfeksi hiv & aids belum terdokumentasi dengan baik. namun, terdapat sumber menyatakan bahwa terjadi kewaspadaan oleh pihak dinas tenaga kerja, transmigrasi, dan kependudukan (disnakertransduk) jawa timur mengenai penyebaran kasus hiv & aids di propinsi jawa timur adalah dari mantan tenaga kerjatenaga kerja indonesia (depkes, 2013). data jumlah pekerja di jawa timur yang terjangkit hiv & aids sebanyak 1700-an, dengan 10% diantaranya adalah mantan tenaga kerja indonesia (antara, 2011). individu dengan hiv & aids yang mendapat perawatan di rumah sakit akan mengalami kecemasan dan stres pada semua tingkat usia. penyebab kecemasan yang dialami pasien tersebut salah satu faktor yang mempengaruhi selain dari petugas kesehatan adalah keluarga yang menunggui selama perawatan. keluarga juga sering merasa cemas dengan perkembangan keadaan pasien, pengobatan, dan biaya perawatan. meskipun dampak tersebut tidak secara langsung kepada pasien, tetapi secara psikologis pasien akan merasakan perubahan perilaku dari keluarga yang menu ngg uinya selama perawat an (marks, 1998 dalam subowo, 1992). pasien menjadi semakin stres dan ber pengar uh terhadap proses penyembuhannya karena penurunan respon imun. ader (1885) dalam subowo (1992) telah membuktikan bahwa individu yang mengalami kegoncangan jiwa akan mudah terserang penyakit, karena pada kondisi stres akan terjadi penekanan sistem imun. ada keterkaitan antara lingkungan sosial (keluarga) pasien hiv & aids dengan progresifitas penyakit tersebut, membuat penulis ingin mengetahui bagaimana gambaran reaksi psikologis (respon stres) pada keluarga tenaga kerja indonesia (tki) yang terinfeksi virus hiv. dukungan dari lingkungan sosial (keluarga) sangat dibutuhkan pasien hiv & aids sehubungan dengan rasa putus asa yang dialami pasien sejak pasien tersebut dinyatakan terinfeksi virus hiv. harapannya, dengan 211 respons bio-psiko-sosio-spiritual pada keluarga (nursalam, dkk.) adanya respon emosi yang positif dari keluarga dapat mengurangi stres yang dialami pasien. tujuan penelitian ini adalah menganalisis respons bio-psiko-sosio-spiritual pada keluarga tenaga kerja indonesia yang terinfeksi hiv serta membandingkannya dengan respons keluarga non tki yang terinfeksi hiv. metode desain penelitian yang digunakan adalah komparatif, yaitu untuk mengungkap respons bio-psiko-sosio-spiritual pada keluarga tki yang terinfeksi hiv dan membandingkan dengan keluarga tki yang tidak terinfeksi hiv. hasil dari riset ini bertujuan untuk menjadi bahan penambah wawasan/khasanah keilmuan keperawatan keluarga khusus pada keluarga tki dengan penyakit hiv & aids, sehingga indikator pencapaian riset ini bisa merubah perilaku keluarga tki dengan hiv & aids dalam menyikapi dan memperlakukan anggota keluarga yang terinfeksi hiv ke arah yang positif. populasi dalam penelitian ini adalah keluarga pasien tki yang terinfeksi dan tidak terinfeksi di dua kabupaten di wilayah jawa timur. sampel sebanyak 17 orang direkrut dengan teknik consecutive sampling. pengambilan dat a dilak u kan selama 5 bulan. pengumpulan data dalam penelitian ini dilakukan di rumah keluarga tki yang terinfeksi vir us hiv, di mana per tama keluarga pasien diambil sampel darah dengan menggunakan peralatan dan prosedur sesuai standar t. waktu pengambilan dilakukan sewaktu-waktu pada saat peneliti bertemu dengan responden. darah diambil kurang lebih 3 ml dan dilakukan kontrifusi di tempat untuk pemeriksaan kortisol. variabel psikologis sosial dan spiritual diukur dengan menggunakan kuesioner dan wawancara. responden yang lansia atau pun kurang bisa lancar membaca maka pengisian kuesioner dengan dibantu peneliti dengan dibacakan kuesionernya. pengambilan darah dilakukan sebelum pengisian kuesioner. analisa data dilakukan dengan uji statistik t-test dan mann-whitney dengan signifikansi 0,05. ethical clearance penelitian ini sudah diuji dan dinyatakan laik etik oleh tim etik universitas airlangga pada tanggal 23 juli 2014, dengan nomor surat persetujuan no. 1245/un3.14/lt/2014. prinsip etik yang diterapkan dalam penelitian ini meliputi prinsip beneficence, prinsip justice dan prinsip menghargai martabat manusia. hasil hasil pengumpulan data menunjukkan bahwa dari 17 responden (8 responden terkena hiv, tetapi bukan sebagai tki sedang 9 responden terkena hiv dan pernah sebagai tki keluar negeri) didapatkan proporsi yang sama pada responden laki-laki dan perempuan. seluruh responden adalah keluarga dekat penderita hiv baik suami atau istri, adik, kakak, anak, orang tua, dan keponakan. tabel 1 menu nju k kan nilai hasil pemeriksaan kortisol pada kelompok keluarga tki lebih baik dibandingkan dengan non tki, tetapi hampir seluruh responden baik anggota keluarga tki maupun non-tki penderita hiv & aids mempunyai kadar kortisol berada dalam rentang normal. hanya masing-masing satu orang responden yang memiliki kadar kortisol tinggi pada kelompok keluarga tki, dan satu orang pada tingkat rendah yaitu pada keluarga non-tki. uji t-test menunjukkan angka p = 0,000 artinya terdapat perbedaan kadar kortisol antara keluarga pasien hiv tki dan non tki. tabel 2 menunjuk kan bahwa pada aspek psikologis, sebagian keluarga penderita hiv tki berada pada tahap bargaining, sedangkan keluarga penderita non tki pada tahap acceptance (menerima). respon sosial terbanyak adalah emosi dan sosial, sedangkan cemas berada pada minoritas responden. respons spiritual keluarga, baik tki maupun non tki adalah mayoritas tabah. hasil uji statistik dengan mann whitney menunjukkan tidak ada satu pun respons psikologis, sosial dan spiritual yang bermakna antara kelompok keluarga tki dan non-tki dengan nilai signifikasi psikologis p = 0,065, sosial p = 0,057, dan spiritual p = 0,243. 212 jurnal ners vol. 9 no. 2 oktober 2014: 209–216 tabel 1. tabulasi kadar kortisol responden keluarga penderita hiv tki dan non tki tki non tki kode resp kortisol nilai normal kode resp kortisol nilai normal 01 9.63 (4.322.4) 10 15.37 (3.0916.66) 02 10.52 (4.322.4) 11 12.49 (4.322.4) 03 20.29 (4.322.4) 12 8.63 (3.0916.66) 04 9.72 (4.322.4) 13 331.5 (p:171-536/ s:64327) 05 11.03 (4.322.4) 14 4.0 (p:171-536/ s:64327) 06 11.52 (4.322.4) 15 152.1 (p:171-536/ s:64327) 07 10.45 (4.322.4) 16 434.6 (p:171-536/ s:64327) 08 22.50 (4.322.4) 17 346.1 (p:171-536/ s:64327) 09 13.07 (3.0916.66) mean = 13, 19 mean = 163, 09 sd = 4,79 sd = 181,01 t-test = 0,000 keterangan: perbedaan rentang nilai normal berdasarkan waktu pengambilan darah tabel 2. tabulasi silang respons psikologis, sosial dan spiritual responden keluarga penderita hiv tki dan non tki respons sub respons non tki tki f % f % psikologis denial anger bargaining 1 12,5 6 66,7 depression 1 12,5 1 11,1 acceptance 6 75 2 22,2 mann whitney = 0,065 sosial emosi 3 37,5 6 66,7 cemas 1 12,5 2 22,2 sosial 4 50 1 11,1 mann whitney = 0,057 spiritual harapan 1 12,5 tabah 7 87,5 9 100 hikmah mann whitney = 0,243 pembahasan hampir seluruh responden baik anggota keluarga tki maupun non-tki penderita hiv & aids mempunyai kadar kortisol berada dalam rentang normal. hal ini disebabkan karena beberapa hal, di antaranya lama keluarga mengetahui status penyakit anggota keluarga dengan hiv. sebagian besar anggota keluarga yang tinggal dengan odha baik yang tertular saat tki atau pun non-tki telah mengetahui status penyakit yang dialami oleh anggota keluarganya yang tertular hiv selama lebih dari 3 tahun. sebagian besar keluarga jika dikaitkan dengan teori berduka menurut engels (1964) dalam suseno (2004) sudah mencapai fase reorganization/the outcome, sehingga keluarga telah mampu mengembangkan suatu 213 respons bio-psiko-sosio-spiritual pada keluarga (nursalam, dkk.) kesadaran baru bahwa mereka perlu merawat anggota keluarganya yang sakit. sebagai akibatnya, merawat anggota keluarga yang menderita hiv bukan lagi merupakan sumber stress bagi responden. teori adaptasi roy mengemukakan bahwa adaptasi dari jaringan atau sel imun yang memiliki hormon kortisol dapat terbentuk bila dalam waktu lain menderita stres atau yang biasa disebut dengan mekanisme regulator. faktor pemahaman tentang cara penularan hiv & aids oleh individu turut memengaruhi tingkat kecemasan. hal ini dibuktikan oleh penelitian yang dilakukan oleh anurmalasari, karyono, & dewi (2009) yang melakukan penelitian yang menghasilkan kesimpulan bahwa terdapat hubungan antara pemahaman hiv & aids dengan kecemasan tertular hiv & aids pada wanita tuna susila di cilacap. persepsi individu dapat dibentuk bersumber dari banyak faktor seperti faktor adanya peran kelompok dukungan sebaya. hal ini dibuktikan berdasar penelitian yang dilakukan kamila & siwiendrayanti (2010) yang menyatakan terdapat hubungan yang kuat dengan adanya peran dukungan sebaya dalam membentuk persepsi pada sesama orang dengan hiv & aids (odha) untuk patuh dalam mengonsumsi anti-retroviral virus (arv). walaupun sebagian kecil responden yang tidak tinggal serumah dengan odha, tetapi mereka tetap yang merawat anggota keluarga yang odha apabila terserang infeksi oportunistik di rumah sakit. pemahaman tentang cara penularan hiv dari responden sebagian besar diperoleh dari peran serta kelompok sebaya dalam hal ini odha yang bekerja sosial di bawah kendali dinas kesehatan kabupaten. dinas kabupaten a misalnya, mempunyai kader hiv & aids yang juga anggot a per wak ilan komisi penanggulangan aids nasional (kpan) cabang kabupaten a. mereka sangat mengenal betul para odha di kabupaten a dibuktikan dengan interaksi yang cukup bersahabat baik pada odha amupun ke keluarganya. peran serta yang baik ini turut mendukung pemahaman responden akan penyakit hiv & aids yang dialami anggota keluarga mereka. hampir tidak ada perbedaan kadar kortisol responden dengan anggota keluarga hiv & aids yang tertular saat tki maupun nontki, menunjukkan respons biologis (kortisol) dalam rentang normal. dapat dikatakan tidak ada kecemasan secara biologis pada responden baik dengan anggota keluarga hiv & aids yang tertular saat tki maupun non-tki. sebagian besar responden dengan anggota keluarga tki penderita hiv & aids respons psikologisnya berada dalam tahap bargaining. berbeda dengan responden dengan anggota keluarga hiv & aids non-tki yakni sebagian besar responden, respons psikologisnya berada dalam tahap acceptance. sebagian kecil responden dengan anggota keluarga hiv & aids yang tki dan non-tki respons psikologisnya berada dalam tahap depresi. respons psikologis dalam tahap menerima dialami oleh sebagian kecil responden dengan anggota keluarga hiv & aids yang tertular saat menjadi tki. sebagian kecil saja responden dengan anggota keluarga hiv & aids non-tki yang respons psikologisnya berada dalam tahap bargaining. respons adaptasi psikologis terhadap stresor menurut kubler ross (1974) dalam potter & perry (2005) menguraikan lima tahap reaksi emosi seseorang terhadap stresor yakni 1) pengingkaran; 2) marah; 3) tawar menawar; 4) depresi; dan 5) menerima. adanya anggota keluarga yang terinfeksi hiv & aids dipandang sebagai sumber stresor bagi responden, sehingga respons psikologis atau tingkat penerimaan responden terhadap anggota keluarga yang terinfeksi hiv & aids tidak hanya dilihat secara kualitatif dengan melihat kadar kortisol, tapi juga dibuktikan secara kuantitatif menggunakan kuesioner untuk melihat tahapan respons psikologis responden. menur ut peneliti, terdapat perbedaan tahapan psikologis yang dicapai secara kuantitatif. pada responden dengan anggota keluarga yang terinfeksi hiv & aids saat bekerja sebagai tki berada dalam tahap bargaining. tahap bargaining menurut kubler ross mempunyai ciri antara lain marah-marah telah berlalu, tidak ada manfaatnya menyesali yang terjadi, dan mulai 214 jurnal ners vol. 9 no. 2 oktober 2014: 209–216 berpikir dan mempunyai niat atau bersikap tenang. hal ini seperti yang dialami salah satu responden yang menyatakan sering kali masih takut dengan penyakit hiv & aids, namun jika melihat keadaan anggota keluarganya yang terinfeksi hiv & aids saat ini yang dalam keadaan sehat dan mampu mengurus keluarga dengan baik serta bisa bekerja dengan berdagang makanan membuat responden ingin berperan aktif merawat anggota keluarganya tersebut terbatas pada mengingatkan untuk minum obat dan menjaga stamina. pa d a responden denga n a nggot a keluarga yang terinfeksi hiv & aids nontki berada dalam tahap acceptance. menurut peneliti terdapat bukti yang sesuai antara yang dialami responden dengan ciri individu berada dalam tahap acceptance menurut kubler ross. ciri tersebut antara lain responden lebih sabar dalam menerima anggota keluarga yang terinfeksi hiv & aids dan berusaha melindungi anggota keluarga tersebut dengan stigma-stigma masyarakat terkait adanya tetangga yang mengerti penyakit apa yang dialami anggota keluarganya dan menyebarkan isu ke yang lain. respons sosial responden dengan anggota keluarga terinfeksi hiv & aids baik saat menjadi tki dan non-tki mengemukakan bahwa terdapat sebagian besar responden dengan anggota keluarga hiv & aids tki mempunyai respons sosial dalam tahap emosi, sebagian kecil yang berada dalam tahap cemas dan sosial yang baik. responden dengan anggota keluarga terinfeksi hiv & aids non-tki terdapat sebagian kecil responden respons sosialnya berada dalam tahap cemas, hampir setengahnya dalam tahap emosi, dan setengahnya berada dalam tahap sosial yang baik. respons adaptif sosial individu yang menghadapi stresor tertentu menurut stewart (1997) dibedakan dalam 3 aspek yang antara lain: 1) stigma sosial memperparah depresi dan pandangan yang negatif tentang harga diri individu; 2) diskriminasi terhadap orang yang terinfeksi hiv, misalnya penolakan bekerja dan hidup serumah juga akan berpengaruh terhadap kondisi kesehatan; dan 3) terjadinya waktu yang lama terhadap respons psikologis mulai penolakan, marah-marah, tawar menawar, dan depresi berakibat terhadap keterlambatan upaya pencegahan dan pengobatan. adanya dukungan sosial yang baik dari keluarga, teman, maupun tenaga kesehatan dapat meningkatkan kualitas hidup odha. hal ini sesuai dengan penelitian oleh payuk, arsin, & abdullah (2012) tentang hubungan antara dukungan sosial dengan kualitas hidup odha di daerah kerja pusat kesehatan masyarakat (puskesmas) jumpandang baru, makasar. bentuk dukungan sosial terutama kepada odha menurut nurbani & zulkaida (2012) antara lain emotional support, informational support, instrumental or tangible support, dan companionship support, dukungan tersebut berdampak positif pada kehidupan odha. unt uk kesehatan, odha menjadi lebih memperhatikan kesehatannya. jika dilihat dari dampak psikologis, odha menjadi memiliki motivasi, lebih percaya diri dalam menjalankan sesuatu dan menjadi lebih ringan dalam melakukannya. adapun dampak sosial, odha menjadi lebih banyak teman, merasa dirinya berarti, serta odha diikutsertakan dalam kegiatan kelompok. selain dampak tersebut, ada pula dampak perkerjaan yang dapat mengoptimalkan kemampuannya, menjadikan kemampuan odha bertambah, odha dapat mengevaluasi pekerjaannya serta mendapatkan informasi yang dibutuhkan, sehingga odha dapat membantu dalam memberikan informasi mengenai akses kesehatan kepada kelompok anggota dukungan. selama pengambilan data berlangsung, pada responden dengan anggota keluarga yang terinfeksi hiv & aids saat bekerja sebagai tki mempunyai respons sosial yang kurang sesuai dengan yang ditunjukkan atau dihasilkan dari kuesioner berdasar data secara kuantitatif. responden memiliki interaksi sosial dengan masyarakat sekitar yang baik. peneliti hampir tidak pernah, walaupun ada, melihat responden harus mengisolasi sosial dengan masyarakat sekitar, sehingga merasa emosi dan cemas ketika melakukan interaksi sosial dengan masyarakat sekitar terutama tetangga meskipun tetangga mengetahui penyakit yang diderita anggota keluarga responden. 215 respons bio-psiko-sosio-spiritual pada keluarga (nursalam, dkk.) responden mengetahui cara penularan vir us ini dengan cukup baik dari peran serta kelompok sebaya yang juga pemerhati odha yang bersama dinas kesehatan kota/ kabupaten melakukan pendampingan tidak hanya terhadap odha-nya sendiri tapi juga memberi pengetahuan kepada responden tentang penularan penyakit hiv & aids. hal ini memengaruhi respons penerimaan responden akan anggota keluarga mereka yang tertular hiv & aids saat bekerja sebagai tki sehingga responden tidak menjadi sumber stresor bagi odha melainkan menjadi faktor pendukung bagi odha dalam meningkatkan kualitas hidup odha. responden dengan anggota keluarga terinfeksi hiv & aids non-tki menunjukkan kegiatan interaksi sosial dengan masyarakat sekitar yang baik. beberapa responden terlibat dalam acara kemasyarakatan saat peneliti melakukan pengambilan data. walaupun juga terdapat responden yang merasa malu untuk berinteraksi sosial karena telah diketahuinya penya k it a nggot a kelu a rga mereka d i masyarakat. namun responden tidak terbatasi interaksi sosialnya dengan kelompok lainnya. seluruh responden dari anggota keluarga hiv & aids yang tertular saat bekerja sebagai tki yang respons spiritualnya berada dalam tahap tabah. sedangkan pada responden dengan anggota keluarga hiv & aids nontki terdapat sebagian kecil responden saja yang respons spiritualnya berada dalam fase harapan dan sebagian besarnya dalam fase tabah. responss adaptif spiritual dikembangkan dari konsep ronaldson (2000) dalam nursalam & ku r niawati (2007). respons adaptif spiritual, meliputi: 1) harapan yang realistis; 2) tabah dan sabar; dan 3) pandai mengambil hikmah. gambaran respons spiritual responden dari kedua populasi odha yang berbeda tersebut yang berada dalam fase tabah tergambar jelas saat peneliti melakukan pengambilan data. hampir seluruh responden menyatakan tabah dan menerima anggota keluarganya yang terinfeksi hiv & aids dan menjalani kehidupan seperti orang-orang biasa yang lain. bersikap seperti tidak ada yang terjadi, dalam artian dapat melupakan diagnosis penyakit yang diterima anggota keluarganya. simpulan dan saran simpulan respons biologis (kor t isol) pad a kelompok responden keluarga pasien hiv tki menunjukkan respons yang lebih baik dibandingkan dengan non tki. sebaliknya, psikologis, sosial dan spiritual kedua kelompok keluarga dirasakan sama dan tidak ada perbedaan. saran perlu dilakukan pendampingan terus menerus kepada pasien maupun keluarga pasien hiv oleh petugas dan pendamping odha. penelitian lebih lanjut perlu melakukan intervensi terhadap aspek pengelolaan koping untuk mengurangi stres anggota keluarga sebagai dampak dari merawat anggota keluarga yang menderita hiv. kepustakaan antar a news. 2011. jatim tertinggi kasus hiv/aids. (online) (http://www. antarajatim.com /lihat/ berita/77591/ jatim-tertinggi-kasus-hivaids. diakses tanggal 22 desember 2013 pu k ul 17.35) anurmalasari, r., karyono, & dewi, k.s. 2009. hubungan antara pemahaman tentang hiv/aids dengan kecemasan tertular hiv/aids pada wps (wanita penjaja seks) langsung di cilacap. (o n l i n e) ( h t t p : //e p r i n t s . u n d i p . ac.id/11101/. diakses tanggal 6 oktober 2014 pukul 10.00 wib) depkes. 2013. profil kesehatan indonesia 2012. (online) (http://www.depkes. go.id/downloads/profil%20kesehatan_ 2012%20%284%20sept%202013%29. pdf . diakses tanggal 19 desember 2013 pukul 18.16) dinkes provinsi jawa timur. 2012. program pengendalian penyakit menular di jawa timur. (online) (http://dinkes.jatimprov. go.id/userimage/p2.pdf. diakses tanggal 22 desember 2013 pukul 17.33) 216 jurnal ners vol. 9 no. 2 oktober 2014: 209–216 kamila, n & siwiendrayanti, a. 2010. persepsi orang dengan hiv dan aids terhadap peran kelompok dukungan sebaya. jurnal kesehatan masyarakat, 6 (1) 36 43. (online) (http://journal.unnes. ac.id /nju /i ndex.php/ kema s/a r t icle/ view/1750/1945. diakses tanggal 6 oktober 2014 pukul 10.00 wib) nurbani, f & zulkaida, a. 2012. dukungan sosial pada odha. (online) (http:// p u b l i c a t i o n . g u n a d a r m a . a c . i d / h a nd le /123456789/188 0. d ia k s e s tanggal 6 oktober 2014 pukul 10.00 wib) nursalam, & kurniawati, n.d. 2007. asuhan keperawatan pada pasien terinfeksi hiv. jakarta: salemba medika payuk, i., arsin, a.a., & abdullah, a.z. 2012. hubungan dukungan sosial dengan kualitas hidup orang dengan hiv/ aids di puskesmas jumpang baru makassar. (o n l i ne) ( ht t p://222.124.222.229/ h a nd le /123456789/3975. d ia k s e s tanggal 6 oktober 2014. pukul 10.00 wib) po t t e r & pe r r y. 2 0 0 5. fu n d a m e n t a l keperawatan volume 1. jakarta: egc stewart, g., 1997. managing hiv. sydney: mja publisher subowo, 1992. histologi umum. jakarta: bumi aksara suseno, t. 2004. pemenuhan kebutuhan dasar manusia: kehilangan, kematian dan berduka dan proses keperawatan. jakarta: sagung seto who, 2013a. hiv/aids. (online) (http://www. who.int/topics/hiv_aids/en/>. diakses tanggal 19 desember 2013 pu k ul 18.00) who. 2013b. data on the size of the hiv/aids epidemic: prevalence of hiv among adults aged 15 to 49 (%) by country. (online), (http://apps.who.int/gho/data/ node.main.562?lang=en. diakses tanggal 19 desember 2013 pukul 18.05) http://e-journal.unair.ac.id/jners | 155 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.21765 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the relationship between level of knowledge and behaviors of covid-19 prevention among indonesian population weni widya shari departmen of nursing, stikes raflesia depok, depok, indonesia abstract introduction: currently, there are no specific drugs to cure covid-19, so it is an important strategy to be implemented in the community to increase knowledge and preventive behavior in order to prevent transmission. the purpose of this study was to see the relationship between the level of knowledge and preventive behavior against covid-19 among indonesian population. methods: this study used an analytical method with a cross-sectional design. samples were taken from the people of depok city as many as 406 people. the independent variable was knowledge and the dependent variable was preventive behavior. the instruments used were questionnaires on the characteristics of the respondents and knowledge and behavior with online questionnaire via google forms. the sampling technique was non-probability sampling with a consecutive sampling method. data analysis used descriptive analysis test, chi-square and correlative hypothesis test. results: the results showed that respondents have good knowledge (56.9%) and good prevention behavior (75.9%). the largest source of information about covid-19 respondents was from television news (84.4%). there was a significant relationship between the level of knowledge and preventive behavior toward covid-19 (p=0.000). moreover, there is a significant relationship between age (p=0.000), gender (p=0.000), education level (p=0.000) and work status (p=0.016) with knowledge. conclusion: the findings suggest that the local government should initiate an innovative program of health education focusing on knowledge and preventive behavior toward covid-19 at a community level. the strategies to combat covid-19 will require community involvement to control and prevent the disease outbreak. article history received: september 8, 2020 accepted: oktober 29, 2021 keywords covid-19; knowledge; prevention behavior contact weni widya shari  when2_ners@ymail.com  departmen of nursing, stikes raflesia depok, depok, indonesia cite this as: shari, w., w. (2021). the relationship between level of knowledge and behaviors of covid-19 prevention among indonesian population. jurnal ners, 16(2). 155-161. doi: http://dx.doi.org/10.20473/jn.v16i2.21765 introduction corona virus disease 2019 (covid-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), which was first discovered in the city of wuhan, china at the end of december 2019 (who, 2020a). this virus causes disease from human to animals and has now been transmitted from human to human (kemenkes ri, 2020a; who, 2020b) in humans, this virus can infect the respiratory path with the main symptoms of fever, dry cough, shortage of breath (daryai et al., 2020; hoque et al., 2020; taghrir et al., 2020; who, 2020b) including other nonspecific symptoms such as headache, dyspnea, fatigue and muscle pain (mo et al., 2020). there are also those who report suffering from symptoms, digestion such as vomiting and diarrhea (huang et al., 2020). this virus spreads very quickly and has spread to almost all countries, including indonesia, in just a couple of months. at least more than 200 countries around the world have been infected so that this virus becomes a serious threat to public health in the world (ahmed et al., 2020; daryai et al., 2020; hoque et al., 2020). according to who (2020a) there were an additional 185,536 cases as of july 14, 2020, bringing the total cases in the world to 13,150,645 cases while developments in the case in indonesia has taken a significant increase amounting to 1,591 cases spread over 34 provinces and 461 cities with the total cases https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v16i2.21765 w. w. shari et al. 156 | pissn: 1858-3598  eissn: 2502-5791 of 78,572 patients. depok is a city in west java province, where it is the second province with the highest number of cases after dki jakarta with an increase of 74 cases, with the total number of positive cases being 5,160. meanwhile, depok city is the first city where the covid-19 cases appeared. as of july 14, 2020, there were also seven additional cases in depok, with the total number of confirmed positive patients 890 people, so it can be concluded that the transmission is still ongoing up to now (kemenkes ri, 2020b). the increasing number of cases has impacted on many fields in various aspects, either health, economy, politics, social, education, religion or even security. sukmana et al. (2020) stated that covid-19 has an impact on health, tourism, economy, social and other sectors. the biggest major impact is in the health sector where there are additional positive cases that threaten public health and even cause death. on the other hand, the economy is also very much impacted, where people find it difficult to find jobs, difficulty to meet their daily needs, and even lose their income. meanwhile, indonesia's economic figure continues to significantly decline by 5%. the minister of finance said that if the prevention strategies were not implemented correctly and properly, indonesia's economic growth could be depressed to a level of 2.5% or even lower (hanoatubun, 2020). that is why an effective and correct handling strategy is needed to maintain the stability of an economy that is being threatened. at the moment, there are no specific drugs and vaccines to fight covid-19; therefore, the most crucial strategy in the community is preventive behavior to reduce the number of cases. cvetković et al. (2020) and ouassou et al. (2020) stated that preventive behavior with a clean and healthy lifestyle is effective for controlling and breaking the chain of transmission of covid-19, when pharmacological interventions have not been found. preventive actions that can be taken are washing hands regularly, covering mouth and nose with a mask, avoiding touching the face, covering mouth when coughing and sneezing, isolating cases that are suspected of being positive at home, maintaining a minimum distance of one meter (cvetković et al., 2020; daryai et al., 2020; kemenkes ri, 2020a), implementing a clean and healthy lifestyle, controlling comorbid diseases and managing positive emotions (kemenkes ri, 2020a). the basis for change and prevention must start in society because it is a key element in the success of reducing the covid-19 numbers. this is confirmed by the research of qiu et al. (2020) on the public in china, that the involvement of the society in prevention factors significantly reduces the rate of virus transmission. the community must take responsibility for the health and safety of their family members by providing them continuous education. a preliminary study conducted by researchers in china resulted in the large number of people who gather at several points for such unnecessary activities, leaving the house without putting a mask on, wearing a mask but not in an appropriate way and other activities that do not apply health protocols. the increasing number of positive cases continues every day probably because of inappropriate community preventive behavior. this could be based on a lack of knowledge or biased behavior by disobeying government calls. health education is needed on knowledge of disease prevention and control behaviors to reduce the incidence of covid19 (ouassou et al., 2020). based on the above background, the researcher was interested in conducting research on the relationship between the level of knowledge and prevention behavior against covid-19 in depok city. materials and methods this research used a correlation analytic method with a cross-sectional design which aims to find the relationship between the level of knowledge and behavior of the people of depok city towards the prevention of covid 19. the data were obtained from questionnaires that were distributed to the researchers' social media accounts via google forms which were filled in online because of the covid-19 pandemic situation. in addition, the researcher also asked for the help of students and colleagues to distribute questionnaires through their social media accounts. in the questionnaire, the instructions for filling and a statement of the respondent's willingness to be used as research respondents were explained. respondents who gave consent to willingly participate in the survey would click the 'continue' button and would then be directed to complete the self-administered questionnaire. the research and community service unit of stikes raflesia (uppm) approved our study protocol, procedure, information sheet and consent statement (number: 247 b/stikes-raf/vii/2020). the ethical principles used during the research involve using the informed consent principles, anonymity, confidentiality and justice. after that, the researcher distributed the questionnaires. research data collection was carried out from july 20 to august 3, 2020, with a total population of all depok city people aged 15-69 years, as many as 884,540 people. the minimum sample size obtained is 399.8 people based on the slovin formula calculation (nursalam, 2017). the consecutive sampling method was used for sampling where respondents are willing to fill out the questionnaires if they meet the inclusion criteria. the inclusion criteria for this study were willing to become respondents, age range between 15-69 years, living in depok city, and able to read. the number of samples obtained was 406 people. knowledge was measured with 14 closed-ended questions and categorized into good (>75%), moderate (56-74%) and insufficient knowledge (<55%) (arikunto, 2016). meanwhile, preventive behavior was measured with 13 close-ended jurnal ners http://e-journal.unair.ac.id/jners | 157 questions on a 3-point likert scale which is categorized into good (75%), moderate (56-74%) and insufficient behavior (55%) (budiman & riyanto, 2013). meanwhile, the confounding variables were age, gender, education, occupation and sources of information. the survey instrument was an adapted from previous research (calano et al., 2019; sari et al., 2020; zhong et al., 2020) and guidelines for the prevention and control of coronavirus disease, revision iv (kemenkes ri, 2020a). the questionnaire was tested for its reliability and validity. cronbach's alpha value for the reliability of the knowledge questionnaire was 0.675. the result added credence where, according to griethuijsen et al. (2014), the range of cronbach’s alpha within 0.6 to 0.7 is considered adequate and reliable. data analysis was performed using ibm spss statistical software version 20. the researcher performed univariate and bivariate analysis (chi-square). results the characteristics of the respondents based on table 1, it is shown that the majority age of respondents are 12-25 years old (49.3%). based on gender, the majority of respondents were 68.5% women. in addition, based on the education level, the majority of respondents earned senior high school education (52.7%). based on employment status, the majority of patients were employed (86.5%). most of them obtained source of information about covid-19 from television news (8.4%) and at least 0.7% received information from family doctors. the respondents were allowed to answer more than one regarding the source of information. the relationship between knowledge level and preventive behaviors table 2 explains that the majority of respondents have good knowledge (56.9%). the distribution of respondents based on prevention behavior shows the majority of respondents with good preventive behavior was 75.9%. the relationship between respondents’ characteristics and knowledge level table 3 explains that the majority of respondents having a good level of knowledge are aged 12-25 years (31%). in the gender category, the majority who have a good level of knowledge are women (43.8%). the majority of respondents who have a good level of knowledge in the education level category graduated from senior high school or equivalent (28.3%). majority of respondents based on the employment status category who had a good level of knowledge were respondents who worked (47%). the chisquare test showed that age, gender, level of education, and employment status have a significant relationship with knowledge level. the relationship between knowledge level and preventive behavior table 4 shows that respondents who have good knowledge and have good preventive behavior are 54.9%. the results of statistical tests using the chisquare test obtained p = 0.000, which means that there is a relationship between the level of knowledge and covid-19 prevention behavior. it can also be seen that the correlation coefficient value is 0.642, which means that the close relationship between the level of knowledge and covid-19 prevention behavior is strong. a positive value means that if the level of knowledge increases, the better the preventive behavior will be. discussion this study found that there was a significant relationship between age and the level of knowledge about covid-19. the correlation coefficient value shows that the higher the age, the knowledge about covid-19 is minimum. this study aligns with research by scoy et al. (2020) but contrasts with some previous research (bates et al., 2021; kirac et al., 2021; wulandari et al., 2020). according to lerik and damayanti (2020), the relationship between age table 1. respondents’ characteristics characteristics n % age 12-25 years 36-45 years 46-65 years >65 years 200 162 41 3 49.3 39.9 10.1 7 gender male female 128 278 31.5 68.5 education elementary school junior high school senior high school higher education 14 32 214 146 3.4 7.9 52.7 36 employment status employed unemployed 351 55 86.5 13.5 source of information television news radio newspaper, magazine friends, relatives, colleagues online social media government/who official websites online news portal family doctors 343 216 156 91 45 14 5 3 84.4 53.2 38.4 22.4 11.08 3.4 1.2 0.7 table 2. respondents’ knowledge and preventive behavior variable n % knowledge level insufficient 41 10.1 moderate 134 33 sufficient 231 56.9 preventive behaviors insufficient 29 7.1 moderate 69 17.0 sufficient 308 75.9 w. w. shari et al. 158 | pissn: 1858-3598  eissn: 2502-5791 and level of knowledge about the myths and facts of covid-19 was nowhere to be found. different results to this research are conveyed in nurmala et al.'s (2018) study, that people of different ages were able to have the same exposure to information. wawan and m (2014) presented a different persepective which explains that the more people grew up, the level of maturity and strength of a person will be more in thinking and working. this study also found female participants with better knowledge and preventive behavior than male ones. these findings were consistent with some of previously conducted studies (bates et al., 2021; hosen et al., 2021; kirac et al., 2021; wulandari et al., 2020). their research shows a relationship between gender and physical distancing prevention behavior where the gender variable has a significant relationship with physical distancing behavior. the women tend to have good physical distancing behavior by 3.4 times better than men. in addition, in this study there is a relationship between work status and the level of knowledge about covid-19. this is following the theory presented by nursalam (2011) that work will affect a person's level of knowledge. while the correlation coefficient shows that the relationship is very weak and has a positive correlation, which means that if the respondents work, the level of knowledge is increased. it is the same with the results of research by scoy et al. (2020) and (bates et al., 2021) but contrary to the research conducted by wulandari et al. (2020). last, this study found that the respondents with higher education had higher knowledge. this result is the same compared with previous research (anhusadar & islamiyah, 2020; bates et al., 2021; hosen et al., 2021; kirac et al., 2021). this result is also supported by nursalam (2011), that a person's knowledge is also influenced by educational factors. however, the result of this research is contrary to some previously conducted studies (lerik & damayanti, 2020; wulandari et al., 2020). it has been assumed that information or knowledge is not only obtained in formal education but can be obtained from experience, environment, and non-formal education (ayurti et al., 2016; wawan & m., 2014). any information greatly affects a person's knowledge; even though someone has low education, when he/she is often exposed to information from various sources, the knowledge will be increased. the educational factor is not very influential because various information about covid-19 at this time is very easy to be accessed (wawan & m, 2014). there is a significant relationship between the level of knowledge and covid-19 prevention behavior in respondents. these results echo the research conducted by sari et al. (2020) which stated that there is a relationship between public knowledge and obedience in the use of masks as an effort to prevent covid-19 in ngronggah. research by syadidurrahmah et al. (2020) also showed that the variable of knowledge related to physical distancing has a significant relationship with physical distancing behavior. this research shows that respondents who have good knowledge of physical distancing have a 1.7 times chance of having good physical distancing behavior than those who have less knowledge. the correlation coefficient states that, if the level of knowledge increases, the prevention behavior will be better. this is supported by juwariyah and table 3. the relationship between respondents’ characteristics and knowledge level against covid-19 characteristics knowledge level total p-value correlation coefficient insufficient moderate sufficient n % n % n % n % age (years) 12-25 5 1.2 69 17 126 31 200 49.3 0.000 -0.166 26-45 27 6.7 49 12.1 86 21.2 162 39.9 46-68 9 2.2 16 3.9 19 4.7 44 10.8 gender males 22 5.4 53 13.1 53 13.1 128 31.5 0.000 0.218 females 19 14.7 81 20 178 43.8 278 68.5 education level elementary and junior high school† 25 6.2 17 4.2 4 1 46 11.3 0.000 0.397 senior high school 12 3 86 21.2 115 28.3 213 52.5 higher education 4 1 31 7.6 112 27.6 147 36.2 employment status unemployed 1 0.2 14 3.4 40 9.9 55 13.5 0.016 0.134 employed 40 9.9 120 29.6 191 47 351 86.5 †) elementary and junior high school levels were combined into one category because three cells (25%) had an expected value less than 5, which was exceding the maximum 20% standard for chi-square test. table 4. the relationship between knowledge level and preventive behavior against covid-19 knowledge preventive behaviors total p-value correlation coefficient insufficient moderate sufficient n % n % n % n % insufficient 24 5.9 15 3.7 2 0.5 41 10.1 0.000 0.642 moderate 5 1.2 46 11.3 83 20.4 134 33.0 sufficient 0 0 8 2 223 54.9 231 56.9 total 29 7.1 69 17 308 75.9 406 100 jurnal ners http://e-journal.unair.ac.id/jners | 159 priyanto (2018) and hosen et al. (2021) but contrasts with research by bates et al. (2021). knowledge and behavior factors play a role in forming healthy habits (shaw, 2016). most people have inadequate health behaviors due to a lack of knowledge of health (nurjanah & mubarokah, 2019). knowledge is a very important domain to creates one's actions (nurmala et al., 2018). behavior which is based on knowledge, awareness, and positive attitude will last longer rather than behavior that is not based on these three things (notoatmodjo, 2014). as previously discussed, many factors connect knowledge and behavior. knowledge is a predisposing factor before a person adopts a new behavior; people must understand first about the meaning or benefit of this behavior for one's self or family (notoatmodjo, 2014). a person will take preventive action for covid-19 if he/she knows what the benefits and goals of prevention are for (hamel et al., 2020). pratama and hidayat (2020) found that society is still maintaining social distancing because they recognize the importance of the safety of themselves and others. the results of the research show that there are still respondents who have good knowledge with adequate preventive behavior (2%). this is possible because of other factors from that person. as everyone knows, the covid-19 pandemic has had many impacts on the various sectors. economic sectors have a big impact on society. now people experience difficulties to find jobs, experience difficulties to fulfill their daily needs, and even lose their income (hanoatubun, 2020; pratama & hidayat, 2020) so even though people have good knowledge, they are constrained by the economy because they do not have money to buy masks, hand sanitizers or vitamins to prevent covid-19, and thus, preventive behavior cannot be done properly. the other influencing factor is the social relationship factor in the form of disruption of social relations. there is still a belief that social distancing will lead to distant social relationships (pratama & hidayat, 2020). the lack of preventive behavior can also arise due to the nonobedience factor, a condition when an individual or group wishes to comply but several factors stop them from being submissive to the advice given by health professionals (prihantana & wahyuningsih, 2016). this study has limitations by conducting research in one location, as in depok, indonesia. the study may be conducted in other areas to explore the same context with various variable. in addition, the data collection instruments, particularly the behavioural aspect, were self-administered by the respondents; thus, the researchers could not directly observe the actual behaviour demonstrated by the participants. conclusion the results showed that a good level of knowledge will lead to good behavior as well. variables of age, gender, education level, work status also have a relationship with a person's level of knowledge. innovative health education is still needed to increase public knowledge in order to increase knowledge and prevention behavior for reducing the risk transmission of covid-19. this study can provide input on level of knowledge and covid-19 behavior to the government in making the right policies and strategies regarding covid-19. references ahmed, n., shakoor, m., vohra, f., abduljabbar, t., mariam, q., & rehman, m. a. (2020). knowledge, awareness and practice of health care professionals amid sars-cov-2, corona virus disease outbreak. pakistan journal of medical sciences, 36(covid19-s4), s49–s56. https://doi.org/10.12669/pjms.36.covid19s4.2704 anhusadar, l., & islamiyah. (2020). penerapan perilaku hidup bersih dan sehat anak usia dini di tengah pandemi covid 19. jurnal obsesi: jurnal pendidikan anak usia dini, 5(1), 463–475. https://doi.org/10.31004/obsesi.v5i1.555 arikunto, s. (2016). prosedur penelitian: suatu pendekatan praktik. rineka cipta. ayurti, f., betan, y., & goa, m. (2016). hubungan pengetahuan dan sikap terhadap perilaku keluarga dalam pencegahan penularan penyakit tuberkulosis di wilayah kerja puskesmas oesapa. chm-k health journal, 11(2), 30–36. bates, b. r., tami, a., carvajal, a., & grijalva, m. j. (2021). knowledge, attitudes, and practices towards covid-19 among venezuelans during the 2020 epidemic: an online cross-sectional survey. plos one, 16(4), 1–16. https://doi.org/10.1371/journal.pone.0249022 budiman; riyanto, a. (2013). kapita selekta kuesioner: pengetahuan dan sikap dalam penelitian kesehatan. salemba medika. calano, b., cacal, m., cal, c. b., calletor, k. p., guce, f., bongar, m., & macindo, j. (2019). effectiveness of a community based health programme on the blood pressure control, adherence and knowledge of adults with hypertension: a precede-proceed model approach. journal of clinical nursing, 28(9–10), 1879–1888. https:// doi.org/10.1111/jocn.14787 cvetković, v. m., nikolić, n., nenadić, u. r., öcal, a., noji, e. k., & zečević, m. (2020). preparedness and preventive behaviors for a pandemic disaster caused by covid-19 in serbia. international journal of environmental research and public health, 17(11), 1–23. https://doi.org/10.3390/ijerph17114124 daryai, u. g., deore, k. g., deore, p. r., imran, m., bairagi, v. a., usman, m. r. m., & patil, p. v. (2020). corona virus (covid-19) pandemic: a systematic review. journal of pharmaceutical sciences and research, 12(4), 516–523. griethuijsen, r. a. l. f. van, eijck, m. w. van;, haste, h., brok, p. j. den;, skinner, n. c. ., mansour, n., gencer, a. s., & boujaoude, s. (2014). global patterns in students’ views of science and interest in science. w. w. shari et al. 160 | pissn: 1858-3598  eissn: 2502-5791 res sci educ, 45(4), 581–603. https://doi.org/10.1007/s11165-014-94386 hamel, l., lunna, l., muñana, c., kates, j., michaud, j., & brodie, m. (2020). kff health tracking poll – february 2020. february. hanoatubun, s. (2020). dampak covid-19 terhadap perekonomian indonesia. journal of education, psychology and counseling, 2(1), 146–153. hoque, m. n., chaudhury, a., akanda, m. a. m., hossain, m. a., & islam, m. t. (2020). genomic diversity and evolution, diagnosis, prevention, and therapeutics of the pandemic covid-19 disease. peerj, april, 1–47. https://doi.org/http://dx.doi.org/10.7717/peerj. 9689 hosen, i., pakpour, a. h. ., sakib, n., hussain, n., mamun, f. a., & mamun, m. a. (2021). knowledge and preventive behaviors regarding covid-19 in bangladesh: a nationwide distribution. plos one, 16(5), 1–17. https://doi.org/https://doi.org/10.1371/journal. pone.0251151 huang, c., wang, y., li, x., ren, l., zhao, j., hu, y., zhang, l., fan, g., xu, j., gu, x., cheng, z., yu, t., xia, j., wei, y., wu, w., xie, x., yin, w., li, h., liu, m., … cao, b. (2020). clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet, 395(10223), 497–506. https://doi.org/10.1016/s0140-6736(20)301835 juwariyah, t., & priyanto, a. (2018). hubungan tingkat pengetahuan dengan perilaku pencegahan kekambuhan luka diabetik. jurnal ners dan kebidanan (journal of ners and midwifery), 5(3), 233–240. https://doi.org/10.26699/jnk.v5i3.art.p233-240 kemenkes ri. (2020a). kmk no. hk.01.07-menkes413-2020 tentang pedoman pencegahan dan pengendalian covid-19 (pp. 106–109). kementrian kesehatan ri. kemenkes ri. (2020b). situasi terkini perkembangan coronavirus disease (covid-19) 15 juli 2020. kirac, r., soyler, s., & cavmak, d. (2021). knowledge and awareness level of the society about covid19 in turkey: a cross sectional research. malaysian journal of public health medicine, 21(1), 244–252. https://doi.org/https://doi.org/10.37268/mjph m/vol.21/no.1/art.751 lerik, m. d. c., & damayanti, y. (2020). mitos covid-19 di kalangan masyarakat kota kupang : survey cross-sectional. journal of health and behavioral science, 2(2), 130–137. https://doi.org/10.35508/jhbs.v2i2.2259 mo, p., xing, y., xiao2, y., deng, l., zhao, q., wang, h., xiong, y., cheng, z., gao, s., liang, k., luo, m., chen, t., song, s., ma, z., chen, x., zheng, r., cao, q., wang, f. w., & zhang, y. (2020). clinical characteristics of refractory covid-19 pneumonia in wuhan, china. oxford university press for the infectious diseases society of america. https://doi.org/10.1093/cid/ciaa270. notoatmodjo, s. (2014). promosi kesehatan dan perilaku kesehatan (edisi revi). rineka cipta. nurjanah, & mubarokah, k. (2019). health literacy and health behavior in the rural areas. kne life sciences, 4(10), 8. https://doi.org/10.18502/kls.v4i10.3702 nurmala, i., rahman, f., nugroho, a., erlyani, n., laily, n., & anhar, v. y. (2018). promosi kesehatan (cetakan pe). airlangga university press. nursalam. (2011). manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 3. in salemba medika. salemba medika. nursalam. (2017). metodologi penelitian ilmu keperawatan: pendekatan praktis. metodologi penelitian ilmu keperawatan: pendekatan praktis. ouassou, h., kharchoufa, l., bouhrim, m., daoudi, n. e., imtara, h., bencheikh, n., elbouzidi, a., & bnouham, m. (2020). the pathogenesis of coronavirus disease 2019 (covid-19): evaluation and prevention. journal of immunology research, 2020. https://doi.org/10.1155/2020/1357983 pratama, n. a., & hidayat, d. (2020). pengetahuan dan perilaku masyarakat memaknai social distancing. jurnal digital media & relationship, 2(1), 1–10. prihantana, a. s., & wahyuningsih, s. s. (2016). hubungan pengetahuan dengan tingkat kepatuhan pengobatan pada pada pasien tuberkulosis di rsud dr. soehadi prijonegoro sragen. farmasi sains dan praktis, ii(1), 47. qiu, y., chen, x., & shi, w. (2020). impacts of social and economic factors on the transmission of coronavirus disease 2019 (covid-19) in china. journal of population economics, 33(4), 1127– 1172. https://doi.org/10.1007/s00148-02000778-2 sari, d. p., sholihah, n., & atiqoh. (2020). hubungan antara pengetahuan masyarakat dengan kepatuhan penggunakan masker sebagai upaya pencegahan penyakit covid-19 di ngronggah. infokes journal, 10(1), 52–55. scoy, l. j. v., miller, e. l., snyder, b., wasserman, e., chinchili, v. m., zgierska, a. e., rabago, d., lennon, c. l., lipnick, d., toyobo, o., ruffin, m. t. i., & lennon, r. p. (2020). knowledge, perceptions and preferred information sourcet relate to covid-19 among central pennsylvania adults early in the pandemic: results of a mix methods cross sectional survey. shaw, k. (2016). exploring beliefs and attitudes of personal service practitioners towards infection control education, based on the health belief model. environmental health review, 59(1), 7–16. https://doi.org/10.5864/d2016-003 sukmana, m., aminuddin, m., & nopriyanto, d. (2020). indonesian government response in covid-19 disaster prevention. east afrian scholars journal of medical sciences, 3(3), 2617–7188. https://doi.org/10.36349/easms.2020.v03i03.0 25 syadidurrahmah, f., muntahaya, f., islamiyah, s. z., & fitriani, t. a. (2020). perilaku physical distancing jurnal ners http://e-journal.unair.ac.id/jners | 161 mahasiswa uin syarif hidayatullah jakarta pada masa pandemi covid-19. jurnal perilaku dan promosi kesehatan, 2(1), 29–37. taghrir, m. h., borazjani, r., & shiraly, r. (2020). covid-19 and iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception. archives of iranian medicine, 23(4), 249–254. https://doi.org/10.34172/aim.2020.06 wawan, a., & m, d. (2014). teori & pengukuran pengetahuan, sikap, dan perilaku manusia, dilengkapi contoh kuesioner (cetakan ii). nuha medika. who. (2020a). coronavirus disease 2019 situation report-177. july. who. (2020b). infection prevention and control guidance for long-term care facilities in the context of covid-19. interim guidance of world health organization, march, 1–5. wulandari, a., rahman, f., pujianti, n., sari, a. r., laily, n., anggraini, l., muddin, f. i., ridwan, a. m., anhar, v. y., azmiyannoor, m., & prasetio, d. b. (2020). hubungan karakteristik individu dengan pengetahuan tentang pencegahan coronavirus disease 2019 pada masyarakat di kalimantan selatan. jurnal kesehatan masyarakat indonesia, 15(1), 42. https://doi.org/10.26714/jkmi.15.1.2020.42-46 zhong, b.-l., luo, w., li, h.-m., zhang, q.-q., liu, x.-g. l., li, w.-t., & li, y. (2020). knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online crosssectional survey. international journal of biological sciences, 16(10), 1745–1752. https://doi.org/doi: 10.7150/ijbs.45221 issn 0000-0000 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. technical editor: gading ekapuja aurizki, s.kep., ns. lingga curnia dewi, s.kep., ns., m.kep. layouter: masunatul ubudiyah, s.kep., ns. dluha maf’ula, s.kep., ns. hidayat arifin, s.kep., ns. rifky octavia pradipta, s.kep., ns. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. p-issn: 1858-3598 e-issn: 2502-5791 acknowledgment to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 15 no. 1 april 2020. 1. dr. abu bakar., s.kep., ns., m.kep., sp.kep.mb universitas airlangga, indonesia 2. prof. dr. ah. yusuf, s.kp., m.kes universitas airlangga, indonesia 3. anna kurniati, s.km, ma, phd bppsdmk, ministry of health, indonesia 4. bayhakki bayhakki, phd university of riau, indonesia 5. erni astutik, s.km., m.epid universitas airlangga, indonesia 6. hilmi yumni, s.kep., ns., m.kep., sp. mat poltekkes kemenkes surabaya, indonesia 7. dr. ika yuni widyawati, s.kep., ns., m.kep., ns.sp.kep.mb universitas airlangga, indonesia 8. joko gunawan, phd poltekkes kemenkes pangkal pinang, indonesia 9. kumboyono, m.kep., sp. kom universitas brawijaya, indonesia 10. dr. kusnanto, s.kp., m.kes universitas airlangga, indonesia 11. linlin lindayani, phd sekolah tinggi ilmu keperawatan ppni jawa barat, indonesia 12. dr. mira triharini, s.kp., m.kes universitas airlangga, indones 13. rista fauziningtyas, s.kep., ns., m.kep universitas airlangga, indonesia 14. dr. rizki fitryasari p. k., s.kep., ns., m.kep universitas airlangga, indonesia 15. rosnani, s.kp., m.kep., sp. mat poltekkes kemenkes palembang, indonesia 16. rr. dian tristiana, s.kep., ns., m.kep universitas airlangga, indonesia 17. saldy yusuf, phd universitas hasanuddin, indonesia 18. dr. saryono, s.kp., m.kes universitas jendral soedirman, indonesia 19. shanti wardaningsih, phd universitas muhammadiyah yogyakarta, indonesia 20. dr. yulis setya dewi, s.kep., ns., m.ng universitas airlangga, indonesia 21. dr. yuni sufyanti arief, s.kp., m.kes universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 table of content editorial : improving resilience and nurse caring behavior yulis setya dewi 1. the psychological capital and anxiety felt by post-market fire disaster victims dian fitria, mustikasari mustikasari, ria utami panjaitan 1 – 6 2. marital adjustment and prenatal breastfeeding efficacy of first time mothers in a low-income community in the philippines artemio jr morado gonzales 7 – 13 3. self-efficacy and health status in coronary artery disease patients wantiyah wantiyah, mochamad riko saputra, fitrio deviantony 14 – 18 4. indicators and index of elderly well-being to support an age–friendly city pipit festi wiliyanarti, hari basuki notobroto, hamidah hamidah, erfan rofiqi 19 – 25 5. the relationship between fulfilment of basic needs with the incidence of stunting in toddlers endang surani, endang susilowati 26 – 30 6. modern and classic wound dressing comparison in wound healing, comfort and cost ferdiansyah mahyudin, mouli edward, m hardian basuki, yunus basrewan, ansari rahman 31 – 36 7. social care in improving self-concept of leprosy patients nur hamim, mariani mariani, sismulyanto sismulyanto 37 – 41 8. risk of mortality on patients with traffic accidents of emergency department at dr. soebandi hospital, jember regency baskoro setioputro, indah listiyawati, kholid rosyidi muhammad nur 42 – 48 9. family health tasks implementation and medication adherence of pulmonary tuberculosis patients: a correlational study tintin sukartini, nora dwi purwanti, herdina mariyanti 49 – 58 10. fear of falling among the elderly in a nursing home: strongest risk factors 59 – 65 anastasia putu martha anggarani, raditya kurniawan djoar 11. the effects of acceptance and commitment therapy (act) on depression in tbhiv co-infection patients avin maria, untung sujianto, niken safitri dyan kusumaningrum 66 – 71 12. the effect of nursing intervention-based levine conceptual model program on rehabilitation process among fracture patients henrianto karolus siregar, dudut tanjung, nunung febriany sitepu 72 – 78 13. hypnotherapy and yoga combination decrease the anxiety of patients in elective preoperative basir basir, sidik awaludin, arif imam hidayat 79 – 84 14. exploring the influencing factors on breast self-examination among myanmar women: a qualitative study nyein moh moh myint, nursalam nursalam, eka mishbahatul mar’ah has 85 – 90 15. the effectiveness chewing gum versus cryotherapy on salivary volume among patient with head and neck cancer undergoing radiotherapy dwi uswatun sholikhah, i ketut sudiana, ninuk dian kurniawati 91 – 97 16. cardiovascular risk estimation in patients with hypertension: a crosssectional study nyayu nina putri calisanie, santi susanti, linlin lindayani 98 – 104 17. self-efficacy of exercise in older adults with diabetes: a concept analysis somsak thojampa, chawapon sarnkhaowkhom, sirikanok khankhajhon, roongtiva boonpracom, amaraporn puraya, wuttichai sahattecho 105 – 112 editorials: nursing education during covid-19 pandemic while the covid-19 pandemic impacts on global changes, nursing education has been especially challenged by using online learning for nursing students. the adaptation of nursing instructors and nursing students take into account significant factors to overcome barriers during the changes. in our point of view, the biggest challenge faced during this faculty crisis is how to adopt a response and manage nursing education based on the standard of nursing education. an online learning program was considered as a first choice to solve the issue during this crisis. online learning would be appropriate due to flexibility, convenience, interactive learning experiences, and advancement opportunities for nursing education during the faculty of nursing closure, including serving the international and national policies that recommend to make a decision on social distancing and personalized protection. online learning resources were concerned that nursing instructors and students received support about online learning knowledge, e-learning platform, notebook and internet package from the national and university policy. nursing instructors provided home study exercises and followed up their students such as with feedback on their study exercises and study discussion as an active learner by chat application and/or an e-learning platform at least once a week. during the nursing education, nursing students were evaluated based on desired learning outcomes, such as online examination and study report, including teaching evaluation. however, the online learning program must be evaluated for reviewing outcomes using a swot analysis, strengths, weaknesses, opportunities, and threats, that helps to understand the outcomes and improve the quality of nursing education. as the new normal after covid-19, nursing education should be designed based on international and national policies, standard of nursing education, desired learning outcomes, nursing competency, and nursing educational resources. in addition, blended learning as an integrative online and traditional classroom should be considered based on the quality of nursing education, such as balancing between online and face-to-face learning hours, learning content, and nursing educational resources, including research and innovation experiences. assistant professor dr. somsak thojampa, phd, rn. dr.sirikanok klankhajhon, phd, rn. faculty of nursing, naresuan university, thailand. somsakth@outlook.com table of content kinerja bidan dalam deteksi dini penyimpangan tumbuh kembang anak (midwife’s performance on early detection of deviations in child’s growth and development) sri utami*, nursalam**, rachmat hargono***, rekawati susilaningrum* *poltekkes kemenkes surabaya, jl. pucang jajar tengah no. 56 surabaya, 60282 **fakultas keperawatan universitas airlangga *** fakultas kesehatan masyarakat universitas airlangga email: bu.sri.utami67@gmail.com abstrak introduction: anak merupakan generasi penerus bangsa, mereka harus dapat tumbuh dan berkembang secara optimal. salah satu upaya yang dapat dilakukan adalah melalui deteksi dini penyimpangan tumbuh kembang anak. tujuan penelitian ini adalah menyusun model peningkatan kinerja bidan melalui optimalisasi strategi self leadership. metode: jenis penelitian ini adalah obsrvasional dengan rancangan cross sectional, subyek yang diteliti adalah sebagian bidan di puskesmas wilayah kerja dinas kesehatan kota surabaya, dipilih secara propotional random sampling, sejumlah 222 responden. variabel eksogennya adalah job design, riwayat pelatihan ddtk, strategi self leadership, kemampuan bidan, aktivitas bidan dalam ddtk, varibel endogennya adalah hasil capaian bidan dalam ddtk. analisis data menggunakan metode partial least square (pls). hasil: dari hasil analisis inner model diperoleh nilai t-statistik pada pengaruh strategi self leadership terhadap peningkatan kemampuan bidan, pengaruh kemampuan terhadap peningkatan kinerja aktivitas, strategi self leadership terhadap peningkatan kinerja aktivitas dan terhadap peningkatan hasil capaian dalam deteksi dini penyimpangan tumbuh kembang didapatkan niali t-statistik lebih besar dari nilai t-tabel (1,96). sedangkan untuk training sdidtk tidak berpengaruh terhadap peningkatan kemampuan bidan, tidak berpengaruh terhadap peningkatan kinerja aktivitas bidan, begitu juga job design tidak terdapat pengaruh terhadap peningkatan kemampuan bidan dan terhadap peningkatan kinerja aktivitas bidan dalam deteksi dini penyimpangan tumbuh kembang anak karena diperoleh nilai t-statistik lebih kecil dari t-tabel (<1,96). diskusi: optimalisasi kemampuan self-leadership bidan merupakan faktor yang perlu diperhatikan sebagai upaya peningkatan kinerja bidan dalam deteksi dini pemyimpangan tumbuh kembang anak. kata kunci: tumbuh kembang anak, job desain, training , strategi self leadership, kinerja. abstract introduction: children are the future of a nation.they should be able to grow and develop optimally. one effort that can be done to help children grow and develop optimally is through an early detection of deviationsin child’s growth. the purpose of this study was to develop a model of midwife performance improvement through the optimization of self leadership strategy. method: this study was an observational study with cross sectional design. the subjects were 222 midwives working at the health center services in the area of surabaya health department taken by using proportional random sampling technique. exogenous variables were job design, history of training of early detection of deviationsin child’s growth, self leadership strategy, midwife skill, midwife activity in early detection of deviationsin child’s growth, andendogenous variable was midwife performance in early detection of deviationsin child’s growth. data were analyzed using partial least square (pls). result: the result of inner model analysis showed that the value of t-statistic of the influence of self leadership strategyon midwife performance improvement, the influence of midwife skill on activity performance improvement, the influence of self leadership strategyon activity performance improvement and on midwife performance improvement was higher than t-table (1.96). whereas, training of early detection of deviationsin child’s growth did not influence midwife skill improvement since the value of t-statistic was lower than t-table (<1.96). in addition, there was also no influence of job design on midwife skill improvement and on midwife activity performance improvement in early detection of deviationsin child’s growth. discussion: optimization of midwife self-leadership ability is a factor to be considered as an effort to improve the performance of midwives in early detection of deviationsin child’s growth. key words: child’s growth and develoment, job desain, training, self leadership strategy, performance. pendahuluan anak harus tumbuh dan berkembang secara optimal sampai dewasa agar dia dapat menjadi generasi penerus bangsa yang berkualitas. mengingat jumlah balita sangat besar, yaitu sekitar 10 persen dari seluruh populasi, maka tumbuh kembang balita di indonesia perlu mendapat perhatian serius (depkes. ri., 2007). deteksi dini penyimpangan tumbuh kembang anak merupakan upaya yang sangat penting untuk dilakukan mulai dari tingkat keluarga, masyarakat dan tingkat pelayanan dasar, hal ini bertujuan untuk mengenali sedini jurnal ners vol. 11 no.2 oktober 2016: 201-209 mungkin terjadinya gangguan pertumbuhan dan perkembangan anak (depkes. ri., 2007). target cakupan deteksi dini tumbuh kembang (ddtk) anak balita dan anak pra sekolah telah ditetapkan sebesar 90%. ketetapan tersebut sesuai dengan surat keputusan menteri kesehatan ri no. 1457/menkes/sk/x/2003 tentang standar pelayanan minimal (spm) bidang kesehatan di kabupaten/kota bab ii pasal 2 butir b. di surabaya belum semua puskesmas mencapai pelaksanaan deteksi tumbuh kembang anak sesuai target. tahun 2011 dari 60 puskesmas masih ada 46 (77%) puskesmas yang capaian ddtk pada balita dan 38 (63%) puskesmas pada anak pra sekolah yang masih dibawah target. pada tahun 2012 dari 62 puskesmas, masih ada 47 (76%) puskesmas yang capaian ddtk pada balita dan 36 (58%) puskesmas pada anak pra sekolah yang masih dibawah target. pada tahun 2013 dari 62 puskesmas, masih ada 31 (50%) puskesmas yang capaian ddtk pada balita dan 25 (40%) puskesmas pada anak pra sekolah yang masih dibawah target (dinas kesehatan kota surabaya 2013; dinkes propinsi jawa timur 2012; dinas kesehatan kota surabaya 2012; dinas kesehatan kota surabaya 2010)(dinas kesehatan kota surabaya, 2011, 2012, 2013) beberapa faktor yang mempengaruhi kinerja, meliputi faktor organisasi, faktor ini terdiri dari sistem perhargaan, penetapan tujuan termasuk di dalamnya adalah visi dan misi organisasi, sistem seleksi pegawai, adanya pelatihan dan pengembangan dari sumber daya yang ada. faktor berikutnya adalah faktor karakteristik pekerjaan, faktor ini meliputi desain pekerjaan, jadwal kerja, umpan balik tujuan hasil pekerjaan. salah satu upaya untuk meningkatkan kinerja bidan dapat dilaksanakan melalui pendekatan self-leadership. self-leadership merupakan faktor penting dalam mengoptimalkan kemampuan diri bidan, karena dengan kemampuan self-leadership akan meningkatkan kepercayaan diri bidan terhadap kemampuannya dalam melaksanakan tugastugasnya dan hal ini dapat meninkatkan berbagai faktor yang berpengaruh terhadap peningkatan kinerja. tujuan penelitian ini adalah menyusun model peningkatan kinerja bidan melalui optimalisasi strategi self leadership. bahan dan metode jenis penelitian ini adalah analitik observasional, dengan pendekatan crossectional, waktu penelitian mulai januari 2015-juni 2016. subyek dalam penelitian ini adalah sebagian bidan di puskesmas wilayah kerja dinas kesehatan kota surabaya, dengan kriteria inklusi: pendidikan minimal diploma iii kebidanan, pelaksana dalam kegiatan deteksi dini tumbuh kembang anak, bersedia menjadi responden. sebesar 222bidan yang tersebar di 43 puskesmas, tehnik pengambilan sampel menggunakan proposionalrandom sampling. variabel eksogennya adalah job design, riwayat pelatihan ddtk, strategi self leadership, kemampuan bidan, variabel endogennya adalah aktivitas dan hasil capaian bidan dalam ddtk. intrumen yang digunakan adalah kuesioner dan untuk kinerja menggunakan lembar pengumpul data. analisis data menggunakan structural equation modelling (sem) berbasis variance yang disering disebut dengan partial least square(pls). hasil hasil penelitian ini menyajikan data karakteristik responden dan deskripsi variabel sertahasil analisis inferensial. hasil penelitian selengkapnya dapat dilihat pada tabel berikut. berdasarkan tabel 1 dapat dijelaskan bahwa, beban kerja bidan mayoritas dalam kategori cukup. waktu yang dimiliki untuk melaksanakan pekerjaannya mayoritas dalam kategori cukup, beban kerja yang dirasakan bidan mayoritas dalam kategori berat, keterampilan yang dibutuhkan untuk menyelesaikan tugas mayoritas dalam kategori cukup. variasi dalam pekerjaan yang dilakukan mayoritas dalam kategori banyak variasi, dan mayoritas membutuhkan pemikiran yang cukup banyak. berdasarkan tabel 2 dapat dijelaskan bahwa mayoritas bidan belum pernah mengikuti pelatihan tentang ddtk, dan mayoritas terlibat dalam kegiatan ddtk antara 6-10 tahun. berdasarkan tabel 3 diketahui bahwa mayoritas bidan dengan strategi self-leadership dalam kategori cukup yang ditunjukkan oleh (>50%) bidan memiliki strategi berfokus perilaku, strategi imbalan alami, strategi pola berpikir konstruktif dalam kategori cukup kinerja bidan dalam deteksi dini (sri utami, dkk) 203 tabel 1. diskripsi karakteristik pekerjaan atau job desain no. indikator kategori frekuensi σ % 1. beban kerja sedikit 36 16,2 cukup 165 74,3 banyak 21 9,5 2. butuh waktu kurang 52 23,4 cukup 152 68,5 banyak 18 8,1 3. beban fisik ringan 8 3,6 sedang 64 28,8 berat 150 67,6 4. kebutuhan keterampilan sedikit 9 4,1 cukup 176 79,3 banyak 37 16,7 5. variasi pekerjaan kurang 4 1,8 cukup 41 18,5 banyak 177 79,7 6. butuh pemikiran sedikit 12 5,4 cukup 175 78,8 banyak 35 15,8 tabel 2. deskripsi riwayat training no. indikator kategori frekuensi σ % 1. riwayat training belum pernah 178 80.2 sudah pernah 44 19.8 2. lama ketrerlibatan dalam ddtk 3-5 tahun 101 45.5 6-10 tahun 107 48.2 11-15 tahun 10 4.5 16-20 tahun 4 1.8 tabel 3. deskripsi self leadership no. indikator kategori frekuensi σ % 1. behavior focused strategies kurang 23 10.4 cukup 121 54.5 baik 78 35.1 2. natural reward strategies kurang 16 7.2 cukup 125 56.3 baik 81 36.5 3. constuctive thought pattern strategies kurang 18 8.1 cukup 132 59.5 baik 72 32.4 tabel 4. deskripsi kemampuan bidan tentang deteksi tumbuh kembang anak no. indikator kategori frekuensi σ % 1 kemampuan deteksi pertumbuhan kurang 31 14,0 cukup 102 45,9 baik 89 40,1 2 kemampuan deteksi perkembangan kurang 32 14,4 cukup 98 44,1 baik 222 41,4 jurnal ners vol. 11 no.2 oktober 2016: 201-209 tabel 5. deskripsi aktivitas bidan dalam deteksi penyimpangan tumbuh kembang anak no. aktivitas bidan kategori frekuensi σ % 1. deteksi penyimpangan pertumbuhan bayi kadang-kadang 3 1.4 sering 14 6.3 selalu 205 92.3 2. deteksi pertumbuhan balita dan anak pra sekolah kadang-kadang 25 11.3 sering 99 44.6 selalu 98 44.1 3. deteksi penyimpangan perkembangan bayi tidak pernah 3 1.4 kadang-kadang 40 18.0 sering 101 45.5 selalu 78 35.1 4. deteksi penyimpangan perkembangan balita dan anak pra sekolah tidak pernah 2 .9 kadang-kadang 50 22.6 sering 104 46.8 selalu 66 29.7 5. tdl dan tdd tidak pernah 8 3.6 kadang-kadang 51 23.0 sering 98 44.1 selalu 65 29.3 6. deteksi mental emosional (mme, autis, gpph) tidak pernah 22 9.9 kadang-kadang 81 36.5 sering 79 35.6 selalu 40 18.0 tabel 6. deskripsi hasil capaian/hasil layanan bidan dalam deteksi penyimpangan tumbuh kembang anak no. hasil capaian bidan kategori frekuensi σ % 1. deteksi penyimpangan pertumbuhan bayi kurang 15 6.8 cukup 58 26.1 baik 149 67.1 2. deteksi penyimpangan pertumbuhan balita dan anak pra sekolah kurang 18 8.1 cukup 68 30.6 baik 136 61.3 3. deteksi penyimpangan perkembangan bayi kurang 22 9.9 cukup 60 27.0 baik 140 63.1 4. deteksi penyimpangan perkembangan balita dan anak pra sekolah kurang 29 13.1 cukup 64 28.8 baik 129 58.1 5. deteksi tdd dan tdl kurang 72 32.4 cukup 39 17.6 baik 111 50.0 6. deteksi mme, autis, gpph kurang 117 52.7 cukup 34 15.3 baik 71 32.0 berdasarkan tabel 5 diketahui bahwa aktivitas bidan dalam deteksi penyimpangan pertumbuhan pada bayi mayoritas (92,3%) bidan selalu melakukan setiap bulan sesuai dengan umur anak. sedangkan untuk aktivitas bidan dalam deteksi dini penyimpangan pertumbuhan pada balita dan anak pra sekolah, deteksi penyimpangan perkembangan, tes daya dengar, tes daya lihat, deteksi mme, autis, maupun gpph pada bayi, balita dan anak pra kinerja bidan dalam deteksi dini (sri utami, dkk) 205 sekolah sering dilakukan tetapi belum selalu sesuai jadwal yang dibutuhkan anak. berdasarkan tabel 6 diketahui bahwa mayoritas (sekitar 50%-67,1%) bidan telah melakukan deteksi dini penyimpangan pertumbuhan, penyimpangan perkembangan, tes daya dengar, tes daya lihat pada ≥ 90 % bayi, balita dan anak prasekolah dalam kategori baik. sedangkan pelayanan deteksi mme, autis, gpph mayoritas (52.7) bidan dalam kategori kurang, artinya mayoritas bidan dapat melakukan deteksi pada ≤ 45 % bayi, balita dan anak prasekolah yang ada di wilayah kerjanya. selanjutnya untuk data di analisis dengan menggunakan sem-pls. terdapat dua pengujian mendasar, yaitu pengujian model pengukuran (outer model), dan pengujian model struktural (inner model). tahap model pengukuran (outer model) hasil pengujian model pengukuran (outer model) pada pengujian validitas konvergen didapatkan 4 indikator dari faktor job design yaitu indikator beban kerja, kebutuhan waktu, beban fisik, dan variasi pekerjaan diperoleh nilai faktor loading kurang dari 0,5 sehingga indikator tersebut dinyatakan tidak valid mengukur konstraknya. sedangkan untuk indikator dari masing-masing indikator dari kontruks atau variabel yang lainnya memiliki nilai loading faktor lebih besar dari 0,5 yang berarti semua indikator tersebut dinyatakan valid dapat mengukur konstruknya. hasil pengujian menunjukkan bahwa reliabilitas konstruk (variabel) seluruh variabel memiliki nilai composite reliability lebih besar dari 0,7. sehingga reliabel dinyatakan semua variabel tersebut reliabel. tabel 7. analisis model pengukuran (outer model) variabel laten/kontruk dimensi/ indikator faktor loading tahap 1 faktor loading tahap2 keterangan job design beban kerja 0.45 tidak valid kebutuhan waktu 0.49 tidak valid beban fisik -0.73 tidak valid keterampilan 0.67 0.89 valid variasi -0.48 tidak valid butuh pemikiran 0.73 0.92 valid training sdidtk lama terlibat ddtk 0.94 1.00 valid pelatihan ddtk 0.58 tidak valid strategi self leadership behavior focused 0.92 0.92 valid constructive 0.91 0.92 valid natural reward 0.91 0.91 valid kemampuanbidan deteksi perkembangan 0.98 0.98 valid deteksi pertumbuhan 0.98 0.98 valid kinerjaaktivitas deteksi masalah emosi 0.77 0.77 valid deteksi perkembang 0.84 0.84 valid tdd dan tdl 0.81 0.82 valid deteksi pertumbuhan 0.74 0.74 valid strategi self leadership behavior focused 0.92 0.92 valid constructive 0.91 0.92 valid natural reward 0.91 0.91 valid hasilcapaian deteksi masalah emosi 0.69 0.69 valid deteksi perkembang 0.8427 0.84 valid tdd dan tdl 0.7841 0.78 valid deteksi pertumbuhan 0.8186 0.82 valid jurnal ners vol. 11 no.2 oktober 2016: 201-209 tahap structural model gambar 5. uji structural model 1. pengujian hipotesis berikut adalah nilai estimate dari masing – masing hubungan antar variabel penelitian : tabel 5. gambar 1. model peningkatan kinerja bidan melalui (model awal) tabel 8. nilai koefisien estimate antar variabel hubunganantarvariabel original sample (o) t statistics (|o/sterr|) penerimaanhipotesis training sdidtk -> kemampuan bidan 0.0124 0.2144 ho diterima job desain -> kemampuan bidan -0.0772 1.1732 ho diterima job desain -> kinerja aktivitas 0.0607 1.1027 ho diterima training sdidtk -> kinerja aktivitas 0.0687 1.2602 ho diterima kemampuan bidan -> kinerja aktivitas 0.2979 5.3766 ho ditolak strategi self leadership -> kemampuan bidan 0.5588 12.6447 ho ditolak strategi self leadership -> kinerja aktivitas 0.4503 7.7281 ho ditolak strategi self leadership -> hasil capaian 0.4330 6.3142 ho ditolak kinerja aktivitas -> hasil capaian 0.2525 3.3834 ho ditolak tahap structural model ini bertujuan untuk mengetahui ada tidaknya pengaruh antar variabel. variabel dikatakan memiliki pengaruh apabila t hitung lebih besar dari t standar. t standar pada penelitian ini sebesar 1,96. demikian juga apabila hubungan antara variabel negatif maka keputusannya adalah jika – t hitung lebih kecil dari – t ftabel. berdasarkan gambar 1 menunjukkan bahwa dari 9 hipotesis atau pengaruh antar variabel, terdapat 4 pengaruh antar variable yang terbukti tidak ada pengaruh karena memiliki nilai t-staatistik < 1,96, sedangkan 5 hipotesis lainnya diterima dengan nilai t-statistik > 1,96. hipotesis penelitian yang diterima atau ho ditolak, adalah ada pengaruh kemampuan bidan terhadap peningkatan kinerja aktivitas, ada pengaruh kinerja aktivitas terhadap peningkatan hasil capaian, ada pengaruh strategi self leadership terhadap peningkatan hasil capaian, ada pengaruh strategi self leadership terhadap peningkatan kemampuan bidan dan ada pengaruh strategi self leadership terhadap peningkatan kinerja aktivitas . sedangkan 4 hipotesis tidak diterima atau ho diterima yaitu tidak ada pengaruh signifikan job desain kinerja bidan dalam deteksi dini (sri utami, dkk) 207 gambar 2. model peningkatan kinerja bidan (modelakhir) terhadap peningkatan kemampuan bidan, tidak terdapat pengaruh job desain terhadap peningkatan kinerja kinerja aktivitas, tidak terdapat pengaruh riwayat training sdidtk terhadap peningkatan kemampuan bidan dan tidak terdapat pengaruh riwayat training sdidtk dengan kinerja aktivitas. sehingga dari hasil tersebut di atas diperoleh hasil model akhir seperti pada gambar berikut. nilai t statistik pada masing-masing pengaruh antar variabel dapat dilihat pada tabel 8. berdasarkan hasil pada tabel 8, maka diperoleh hasil model akhir seperti pada gambar berikut pengujian goodness of fit pengujian goodness of fit dari inner model/analisis struktural model dilakukan untuk memastikan bahwa model struktural yang dibangun termasuk robust dan akurat. evaluasi inner model dapat dilihat dari beberapa indikator yang meliputi: koefisien determinasi (r 2 ) nilai ini menjelaskan seberapa besar variabel eksogen (independen/bebas) pada model mampu menerangkan variabel endogen (dependen/terikat). hasil analisis rsquare diperoleh nilai r 2 kinerja hasil capaian = 0.3875, kemampuan bidan = 0.3063, kinerja aktivitas = 0.4569. dilanjutkan dengan menghitung nilai predictive relevance (q 2 ), nilai dari q-square dapat dihitung dengan perhitungan sebagai berikut : q 2 = 1 – (1 – 0.3875) (1 0.3063) (1 0.4569) = 0.7692. berdasarkan hasil dari perhitungan q-square dapat dilihat bahwa nilai q-square sebesar 0.7692. karena nilai q2 > 0, dapat disimpulkan bahwa model memiliki tingkat prediksi yang baik. selanjutnya dapat dihitung juga nilai goodness of fit index (gof) dengan menggunakan rumus tanenhaus (2004), dari hasil perhitungan tersebut dapat diperoleh nilai gof index sebesar 0,4977 yang berarti goodnes of fit dari model ini adalah bagus/besar. pembahasan self-leadership atau kepemimpinan diri merupakan serangkaian proses yang digunakan individu untuk mengendalikan perilaku mereka sendiri (robbins sp. 2006). strategi selfleadership merupakan kemampuan awal yang mempunyai pengaruh terhadap berbagai aspek yang dapat meningkatkan kinerja. hasil penelitian ini menunjukkan bahwa strategi self leadership berpengaruh langsung maupun tidak langsung terhadap kinerja aktivitas maupun terhadap kinerja hasil capaian layanan bidan dalam deteksi dini penyimpangan pertumbuhan dan perkembangan anak, pengaruh tidak langsung tersebut dimediasi oleh kemampuan dalam deteksi dini penyimpangan pertumbuhan dan perkembangan anak. kemampuan diri adalah kepercayaan individu bahwa ia dapat melakukan tugas tertentu dengan menerapkan kemampuannya secara benar (wirawan 2013). kemampuan tersebut tercermin dalam pengetahuan dan keterampilan bidak dalam melaksanakan kegiatan deteksi dini penyimpangan pertumbuhan dan perkembangan anak. pengaruh stategi self leadership baik langsung maupun melalui jaliur tidak langsung terhadap kinerja bidan karena berbagai strategi dari self-leadership mempunyai peranan masingmasing yang mempunyai pengaruh positif terhadap berbagai aspek yang dapat meningkatkan kinerja. strategi tersebut me l iputi : x3selfleaders hip y1 aktivitas y2 hasil capaian x4 kemampp jurnal ners vol. 11 no.2 oktober 2016: 201-209 strategi pola pikir konstruktif (constructive thought pattern strategies), strategi ini melibatkan kreasi dan proses berpikir yang konstruktif, dirancang untuk membantu formasi pola pikir yang konstruktif dan caracara yang positif mempengaruhi kinerja individu. membangun kebiasaan atau pola konstruktif dan efektif dalam pemikiran kita (misalnya, kecenderungan untuk mencari peluang daripada hambatan yang tertanam dalam tantangan) dengan mengelola: keyakinan dan asumsi (beliefs and assumptions) melalui proses. (jeffery, et al., 2012) melalui proses identifikasi dan pengubahan berbagai keyakinan yang keliru ini, individu dapat meminimalkan proses pemikiran yang disfungsional dan terlibat dalam proses kognisi yang lebih rasional dan efektif.strategi pola pemikiran konstruktif ini terdiri dari: a) self observation, b) self goal setting, c) self reward, d) self punishment, e) self cueing (manz and sims 1997). strategi imbalan alamiah (natural reward strategies), strategi ini adalah strategi yang dilakukan dengan menciptakan reward yang alami yang ditujukan untuk mendapatkan penghargaan terhadap aktivitas yang dilakukan. menurut (manz and sims, 1997) ada dua strategi yang dilakukan, yaitu dengan menciptakan features yang lebih menyenangkan pada aktivitas sehingga tugas-tugasnya sendiri menjadi reward yang bersifat alami. selain itu dapat dengan cara memfokuskan perhatian pada tugas-tugas yang tidak menyenangkan tetapi ada aspek penghargaan. kedua cara ini akan menciptakan perasaan kompeten dan meningkatkan motivasi instrinsik sehingga dapat meningkatkan kinerja. strategi ini lebih memfokuskan pada aspek positif yang diberikan oleh tugas atau aktivitas. reward yang alami akan diperoleh dari insentif yang dibangun dari tugas itu sendiri. strategi imbalan alami merupakan strategi yang dilakukan dengan menciptakan imbalan alami yang ditujukan untuk mendapatkan penghargaan terhadap aktivitas yang dilakukan. ada dua strategi yaitu self-redesign of tasks, merupakan self redesign dari apa yang dilakukan dan bagaimana melakukan pekerjaan untuk meningkatkan tingkat penghargaan alami dalam pekerjaan. natural reward merupakan bagian terpisah dari tugas itu sendiri (yaitu pekerjaan, seperti hobi hal ini menjadi imbalan) dari hasil kegiatan yang menyebababkan ada perasaan kompeten (a sense of competence),merasa self control (a sense of self-control), dan rasa tujuan (a sense of purpose). redesign dari konteks pekerjaan anda (redesign of the context of your work) merupakan kegiatan mendesain ulang lingkungan sekitar pekerjaan atau mengubah waktu dan tempat kerja untuk meningkatkan manfaat alami yang berasal dari lingkungan terdekat (yutthana, 2010). strategi berfokus perilaku (behavior focused strategies), strategi terfokus pada perilaku dilaksanakan untuk meningkatkan kesadaran diri dalam memfasilitasi manajemen perilaku, terutama manajemen perilaku yang terkait dengan tugas-tugas yang dibutuhkan tetapi tidak menyenangkan. strategi ini meliputi observasi diri, penentuan tujuan diri, memberikan imbalan diri sendiri, menghukum diri sendiri dan memberi petunjuk diri sendiri. mengobservasi diri sendiri meliputi meningkatkan kesadaran diri ketika dan mengapa seseorang melakukan perilaku tertentu. jenis kesadaran diri ini merupakan langkah pertama yang diperlukan untuk mengubah atau menghilangkan perilaku yang tidak efektif dan tidak produktif. dengan mempergunakan informasi yang akurat mengenai perilaku dewasa ini dan level kinerja, seseorang akan dapat lebih efektif menentukan perilaku mengubah tujuan untuk diri sendiri. perilaku yang terfokus pada strategi self-leadership dirancang untuk mendorong perilaku-perilaku positif sesuai harapan yang mengarah pada keluaran sukses, dan menekan perilaku-perilaku negatif yang tidak diharapkan yang mengarah pada kegagalan (manz, et. al. 1997). namun menghukum diri yang berlebihan, termasuk kritik diri yang keras dan realistis, dapat menyebabkan perasaan bersalah dan tidak mampu, hal ini harus dihindarkan (jeffery, et al.,2012). kesimpulan dan saran kesimpulan strategi self-leadership merupakan faktor penting yang dapat meningkatkan berbagai aspek yang dapat berpengaruh terhadap peningkatan kinerja bidan dalam deteksi dini penyimpangan tumbuh kembang anak. self-leadership yang tinggi seorang bidan akan memiliki persepsi yang baik terhadap kemampuan dirinya, sehingga mereka akan melaksanakan kegiatan/aktivitas dalam deteksi dini sesuai dengan jadwal dan kebutuhan anak. aktivitas deteksi yang sesuai kinerja bidan dalam deteksi dini (sri utami, dkk) 209 dengan jadwal dan kebutuhan anak anak dapat meningkatkan hasil capaian layanan bidan dalam deteksi dini penyimpangan tumbuh kembang anak. saran mengingat sebagian besar bidan masih memiliki kemampuan self-leadership dalam kategori cukup maka disarankan perlu adanya upaya peningkatan kemampuan self-leadership yang dapat dicapai melalui pelatihan maupun pembelajaran secara mandiri atau alamiah dengan pemberian motivasi, otonomi dan kesempatan pada bidan untuk dapat memimpin dirinya sendiri. referensi depkes, r.., 2007. pedoman pelaksanaan stimulasi, deteksi dan intervensi dini tumbuh kembang anak, jakarta: dirjen pembinaan kesehatan masyarakat. dinas kesehatan kota surabaya, 2013. profil dinas kesehatan kota surabaya, surabaya: dinkes kota surabaya. dinas kesehatan kota surabaya, 2012. profil dinas kesehatan kota surabaya, surabaya: dinkes kota surabaya. dinas kesehatan kota surabaya, 2010. profil dinas kesehatan kota surabaya, surabaya: dinkes kota surabaya. dinkes propinsi jawa timur, 2012. profil dinas kesehatan propinsi jawa timur surabaya, ed., dinkes propinsi jawa timur. jeffery d. houghton, david dawley, t.c.d., 2012. the abbreviated self-leadership questionnaire (aslq)o title. international journal of leadership studies, vol 7, pp.216–232. manz, charles c and sims, j., 1997. the new superleadershipleading others to lead themselves, san francisco: berretkoehler publishers, inc. robbins sp., 2006. perilaku organisasi kontroversi, aplikasi edisi baha., jakarta: pt. prehallindo. wirawan, 2013. kepemimpinan teori, psikologi, perilaku organisasi, aplikasi dan penelitian, jakarta,: pt raja grafindo persada. yutthana c, 2010. an examination of selfleadership performance mecahanism model in thai private organization,. the journal of behavioral science, 5(1), pp.15–32. model pemberdayaan masyarakat (miftahul munir, dkk) 288 model pemberdayaan masyarakat sadar kesehatan (community empowerment aware of health model) miftahul munir, suhartono school of nursing nahdlatul ulama institute of health science tuban indonesia jl. letda sucipto no. 211 tuban email: munir.stikesnu@gmail.com abstrak pendahuluan: derajat kesehatan dipengaruhi oleh beberapa faktor, yaitu keturunan, pelayanan kesehatan, perilaku dan lingkungan. faktor perilaku dan lingkungan mempunyai andil paling besar dalam meningkatkan derajat kesehatan masyarakat. tujuan dari penelitian ini untuk membuktikan dan menganalisis pengaruh karakteristik individu, self efficacy dan team work terhadap komitmen dan produktivitas kader kesehatan. metode: metode penelitian ini menggunakan penelitian analitik dengan pendekatan explanatory. sampel dalam penelitian ini berjumlah 200 responden. pengambilan data menggunakan simple random sampling. pengumpulan data dengan menggunakan kuesioner, wawancara dan observasi. analisis data dengan menggunakan uji statistik partial least square (pls). hasil: hasil penelitian menunjukkan pengaruh variabel produktivitas kader kesehatan terhadap investasi ekonomi kesehatan adalah sebesar 0,291 dengan nilai t-statistic sebesar 4,645, dimana nilai t-statistic tersebut lebih besar dari 1,96 yang berarti produktivitas kader kesehatan berpengaruh signifikan terhadap investasi ekonomi kesehatan, hal ini menunjukkan pengaruh produktivitas kader kesehatan terhadap investasi ekonomi kesehatan adalah positif, artinya apabila produktivitas kader kesehatan semakin tinggi maka investasi ekonomi kesehatan juga akan semakin baik. diskusi: penelitian ini dapat dijadikan acuan pemerintah kabupaten tuban dalam peningkatan derajat kesehatan masyarakat. peningkatan kesehatan masyarakat harus dilakukan lewat upaya promotif dan preventif, yaitu melalui program produktivitas kader kesehatan. produktivitas kader kesehatan memiliki peranan penting dalam upaya peningkatan kesehatan masyarakat, sehingga pemerintah dapat menghemat dana untuk kesehatan atau investasi ekonomi kesehatan. kata kunci: pemberdayaan masyarakat, kader kesehatan, self-efficasy, komitmen, produktivitas abstract introduction: health degree influenced by several factors and the offspring of the ministry of health and behavior and the environment. the behavior and environmental factors have contributed most in improving the degree of community health. the purpose of this research is to prove and analyzing the influence of the characteristics of the individual, self efficacy and team work against the commitment and productivity of health cadres. methods: this research method using analytically research with explanatory research approach. samples in this research totaled 200 respondents. the data was taken using simple random sampling. the collection of data use of the questionnaire, interview and observation. data analysis was used the statistical test partial least square (pls). result: research results show the influence of the productivity variable health cadres of economic investment health is of 0,291 with the value of t-statistic of 4,645, where the value of the t-statistic was greater than 1.96 which means the productivity of health cadres significant effect of economic investment health, this shows the influence of the productivity of health cadre of economic investment health was positive, it means that when the productivity of health cadres are higher then the economic investment will also increasingly good health. discussion: this research can serve as a reference for the district government of tuban in increasing the degree of community health. improving the health of the community must be done via promotif efforts and preventive measures through productivity program health cadres. the productivity of health cadres have an important role in efforts to improve the health of the community so that the government can save the funds for health or economic investment of health. key words: community empowerment, health cadres, self-efficasy, commitment, productivit. introduction the development of health indicators in indonesia showed a tendency to continue to improve, among others infant mortality, life expectancy, and labor by health professionals. but on the other hand, health development in indonesia is currently facing the problem still high morbidity, namely the outbreak of several types of diseases, for example polio, malnutrition cases, outbreaks of dengue fever, bird flu, diarrhea and hiv/aids. in addition to the main problem is the cost of increasing health. the cost of health care in indonesia tend to increase caused by various factors, among others the patterns of degenerative diseases, orientation on the financing of the curative, advanced technology, the development of a sub jurnal ners vol. 11 no. 2 oktober 2016: 288-292 289 specialization in medical science and not remove also from the inflation rate. the degree of health influenced several factors and the offspring of the ministry of health and behavior and the environment. the behavior and environmental factors have contributed most in improving the degree of community health. because, to improve the degree of health, then every person has two obligations, namely behaves is healthy and active in maintaining the cleanliness and health of the environment around. the behavior contributes large enough contribution to the degree of community health namely 40 percent, while the environment contribute 30 percent, genetic factors contribute 20 percent, and access to health contribute 10 percent (wijono 1999). according to the data from the central statistics agency indonesia (2012), indonesia consists of sub-district and village 79.075 6793. the village has started to realize the active standby village as much as 44.255 (55, 96%) from 79.075 existing village. based on the coordination meeting village of se east java 2013, in east java there are 7.968 village that serves as a standby village from 8.506 existing village. active standby village in east java province on 2011 reach 91,7 % and rose to 93,7% on 2012. the efforts that need to be done in order to improve the scope of the services of the behavior of clean and healthy active pratama to levels madya, full moon or mandiri is doing community self survey (css), community leaders are able to perform a survey analysis of self-with health workers, thereby expected to educate become aware of the health problems faced by didesanya, as well as the rise of intention and determination to find the solution, including building village health posts as an effort to draw the basic health services to the people of the village, therefore needs to be done the selection and entrepreneurship skills for health professionals. the characteristics of the individual is the characteristics of the individuals that consists of demographics such as gender, age and social status such as level of education, work, race and economic status etc. (suhartono, at al. 2016). self efficacy is the ability of a person to regulate and decide what action is needed to achieve the desired results, self efficacy is the largest mediator for human behavior and behavior change, trust individuals give impact on the behavior of the motivation, the success or failure (munir m, at al. 2016). the important keys from the team work is to invite the public to use his experience, articulate expectations, determine the main problems faced and formulate effective steps to optimize the potential together (cornwall a, & pratt g 2011). the development of the productivity of health workers is needed is to take advantage of the resources available in the village efficiently to produce a healthy life in the community (foster st 2004). a health workers is expected to have characteristics, self efficacy, team work and commitment in performing their duty as health workers. material and method the research design used was the study explanatory research. the population in this research is the tuban district nurse in accordance with the criteria for the inclusion of as many as 200, with large samples of research respondents determined by 200 using the technique of simple random sampling. exogenous variables are the characteristics of the individual, self efficacy and team work, endogenous variable is the commitment as cadres and productivity health cadres. the instrument used in the collection of data in the form of the questionnaire. research analysis using analysis techniques partial this square (pls) for projecting linier relationship between the variables observation. in addition to the number of samples is relatively small, pls has the advantage able to handle complex models with exogenous variables that have many indicators and can be used for the indicator with the nature of reflective or formative, and does not require the data berdistribusi normal. partial this square (pls) is a method of analysis of the powerful because it can be applied to all the scale data, not many need many assumptions and sample size does not have to be large. partial this square (pls) in addition can be used as a confirmation of the theory can also be used to build relationships that has no basis in theory or to test model pemberdayaan masyarakat (miftahul munir, dkk) 290 such a proposition. the conceptual framework used in this research will be described in figure 1 figure 1. the conceptual framework describes the influence between the variables examined: the individual characteristics (x1), the participatory rural appraisal (x2), self efficacy (x3), productivity cadres (y1), health investment (y2) and a clean and healthy life (y3). this research examines the influence of participatory rural appraisal and self efficay against the productivity of health cadres and also as a health investment on a clean and healthy life result the following is the value of the outer loading for each of the indicators on the participatory rural aparisal (pra), self efficay, productivity health cadres, health economic investment and the behavior of a clean and healthy active. results of the outer loading the first model for each of the indicators also can be seen in the figure 2. figure 1. conceptual framework work h 7 h 5 h 3 h 2 h 1 h 6 the characteristics of the individual (x 1 ) participatoy rural appraisal (x 2 ) self efficasy (x 3) productivity health cadres (y 1 ) health investment (y 2 ) clean and healthy life (y 3 ) h 1 h 4 figure 2. the results of the hypothesis test jurnal ners vol. 11 no. 2 oktober 2016: 288-292 289 the characteristics of the individual (x 1 ) participatoy rural appraisal (x 2 ) self efficasy (x 3 ) productivity health cadres (y 1 ) health investment (y 2 ) clean and healthy life (y 3 ) h 1 h 7 h 5 h 3 h 2 h 1 h 4 h 6 table 1 results of the inner weight and hypothesis test hip. the relationship between the variables the path coefficient t stat. description h 1a individual characteristics the participatory 0.039 0.142 not sig h 1b individual characteristics 0.352 2.132 significant h 2 the participatory rural appraisal cadres 0.256 3.461 mln significant h 3 self efficacy cadres 0.464 10.975 significant h 4a the participatory rural appraisal cadres 0.256 3.461 mln significant h 4b self efficacy cadres 0.464 10.975 significant h 5 health cadres productivity 0.291 4.645 significant h 6 health cadres productivity clean and healthy behavior 0.194 2.642 significant h 7 economic investment clean and healthy behavior 0.243 3.749 significant : figure 3. coefficient model pls model pemberdayaan masyarakat (miftahul munir, dkk) 288 the results of the hypothesis test can be seen through the path coefficient on the inner model by comparing the value of t-statistic with critical value 1.96. the test result inner model is also can be seen through the following in figure 3. from the figure 3 can be explained the results of the test the hypothesis as follows: hypothesis 1: individual characteristics significantly influential against the participatory rural appraisal and self efficay on health cadres in the behavior of a clean and healthy active in tuban regency. from the table variable known of the individual characteristics significantly influential against the participatory rural appraisal on health cadres was 0.039 with the value of tstatistic of 0,142 where value t-statistic is smaller than 1.96. the individual characteristics influence toward self efficay on health cadres was 0,352 with the value of t-statistic of 2,132 where value t-statistic is greater than 1.96. thus it can be concluded that the quality of individual characteristics influential significantly against the participatory rural appraisal and self efficay on health cadres, so that the first hypothesis proven. the individual characteristics influence of the toward participatory rural appraisal and self efficay on health cadres is positive, it means that when the variables individual characteristics getting better then the participatory rural appraisal and self efficay on health cadres will also be the better. hypothesis 2: the participatory rural appraisal affect the productivity of health cadres in the behavior of a clean and healthy active in tuban regency. from the table known to the influence of the variables participatory rural appraisal of productivity is 0,256 health cadres with the value of t-statistic of 3,461 with the value of t-statistic is greater than 1.96. thus it can be concluded that the participatory rural appraisal influence significant impact on productivity health cadres, so that the second hypothesis was proven. hypothesis 3: self efficacy affect the productivity of health cadres in the behavior of a clean and healthy active in tuban regency. from the table known to the influence of the variables self efficacy against the productivity of 0,464 health cadres is with the value of t-statistic of 10,975, where the value of the t-statistic is greater than 1.96. thus it can be concluded that self efficacy affect the significant impact on the productivity of health cadres, so that the third hypothesis proven. the influence of the self efficacy against the productivity of health cadres is positive, it means that when the self efficacy the better the quality of the productivity of health cadres will also be the better. hypothesis 4: the participatory rural appraisal and self efficacy affect the productivity of health cadres in the behavior of a clean and healthy active in tuban regency. from the table known to influence the participatory rural appraisal variable against the productivity of health cadres on health cadres was 0,256 with the value of t-statistic of 3,461 where value t-statistic is greater than 1.96. the influence self efficay variable against the productivity of health cadres on health cadres was 0,464 with the value of t-statistic of 10,975 where value t-statistic is greater than 1.96. thus it can be concluded that the participatory rural appraisal and self efficay influential significantly against the productivity of health cadres, until the fourth hypothesis proven. the influence of participatory rural appraisal and self efficay against on productivity is positive health cadres, means when the participatory rural appraisal and self efficay on the better health cadres and productivity health cadres will also be the better. hypothesis 5: the productivity of health cadres investment significantly influence on the health of the behavior of clean and healthy active in tuban regency. from the table known influence productivity variable health cadres of health investment is usd 0,291 with the value of tstatistic of 4,645, where the value of the tstatistic is greater than 1.96. thus it can be concluded that the productivity of health cadres significant effect of health investment so that the fifth hypothesis was proven. the influence of the productivity of health cadres of health investment is positive, it means that when the productivity of jurnal ners vol. 11 no. 2 oktober 2016: 288-292 289 health cadres are higher then the health investment will also be the better. hypothesis 6: health cadres productivity significantly influence the behavior of clean and healthy active in tuban district. from the table of known influence productivity variable health cadres against the behavior of clean and healthy active was 0,194 with the value of t-statistic of 2,642, where the value of the t-statistic is greater than 1.96. thus it can be concluded that the productivity of health cadres significant effect against the behavior of clean and healthy active, so that the sixth hypothesis proven. the influence of the productivity of health cadres of health investment is positive, it means that when the productivity of health cadres are higher then clean and healthy active will also increasingly good. hypothesis 7: health cadres productivity through participatory rural appraisal approach and self efficacy affect health investment, clean and healthy active in tuban district. this hypothesis will prove the influence does not directly from the productivity of health cadres against the behavior of clean and healthy active through investment health. proof of this hypothesis depending on the results of the two tests the path coefficient (1) from the productivity of health cadres of health investment and (2) from health investment against the behavior of clean and healthy active. from the table there are known significant influence productivity variable health cadres of health investment with a 0,291 coefficient with the value of t-statistic of 4,645 (t-statistic > 1.96). obtained a significant influence health investment variable against the behavior of clean and healthy active with a 0,243 coefficient with the value of t-statistic of 3,749 (t-statistic > 1.96). thus it can be concluded that the productivity of health cadres influential not directly against the behavior of clean and healthy active through investment health, until the seventh hypothesis proven. the higher the productivity of health cadres will raise the behavior of clean and healthy active after first successful in improving health investment. discussions the influence participatory rural appraisal against the productivity of health cadres in the behavior of a clean and healthy active the test result causation using methods of shem-pls with the help of software smart pls prove that participatory rural appraisal significant effect against the productivity of health cadres in a clean and healthy life is active in the area of tuban. descriptive results show that participatory rural appraisal belonging to a very high standard of 155. the results of confirmatory factor analysis (cfa) indicates that the participatory rural appraisal more determined by indicators that have the largest loading factor, namely academy. loading factor that is produced from the cfa also indicates that the participatory rural appraisal variable is determined by the relevance. from the descriptive statistics and the value of the factor loading can be explained that the participatory rural appraisal of the behavior of clean and healthy active in the area of tuban can be enhanced with how to improve the participatory rural appraisal that better. the participatory rural appraisal test results showed that the participatory rural appraisal variables affect the significant impact on the productivity of health cadres with tstatistic = 3,461≥ 1.96. the greatness of the influence of participatory rural appraisal against the productivity of health cadres was 0,256, this shows that the change in the participatory rural appraisal will cause changes in the productivity of health cadres that his nature clockwise (positive), which means when the participatory rural appraisal the better then productivity health cadres active standby village in the area of tuban will also be the better. with these results and research hypothesis which stated that the participatory rural appraisal influence significant impact on productivity health cadres in a clean and healthy life is active in the area of tuban then can be accepted. participatory rural appraisal approach is an approach to facilitate the understanding of the problem among the rural and recognition associated with the priority of some research studies become more sensitive to local conditions that sometimes have the sense that some model pemberdayaan masyarakat (miftahul munir, dkk) 290 approaches have been beyond the view of luck for the appropriate techniques (alam a 2012). the participatory rural appraisal is a research method used to identify problems faced by the community as well as to formulate a way of bringing together the community itself (uddin mn 2013). besides, participatory rural appraisal describes the growth of the family with the approach and methods to make the sharing, add, and analyze their knowledge of life and conditions to plan and act. in addition the principles of participatory rural appraisal more emphasize on the behavior and attitudes and awareness critical thinking (chambers 1994). so it can be concluded that the cadres productivity can be improved by performing activities share, add and analyze their knowledge and more stressed against the attitudes and behavior of critical thinking so that the cadres are able to develop their ability related to the development of himself. the influence self efficacy against the productivity of health cadres in the behavior of a clean and healthy active the test result self efficacy using the method of shem-pls with the help of software smart pls prove that self efficacy affect the significant impact on the productivity of health cadres in a clean and healthy life is active in the area of tuban. descriptive results show that self efficacy is classified on a very high rank (mean 2.50). the results of confirmatory factor analysis (cfa) shows that self efficacy is determined by indicators that have the largest loading factor, namely the orientation of the destination. loading factor that is produced from the cfa also shows that the variables self efficacy is determined by the relevance. from the descriptive statistics and the value of the factor loading can be explained that the self efficacy of the behavior of clean and healthy active in the area of tuban can be enhanced with how to increase self efficacy better. the test result self efficacy shows that the variables self efficacy affect the significant impact on the productivity of health cadres with t-statistic = 10,975≥ 1.96. the greatness of the influence of self efficacy against is by 0,464, this shows that the change self efficacy will cause changes in the productivity of health cadres that his nature clockwise (positive), which means when the self efficacy the better the quality of the productivity of health cadres active standby village in the area of tuban will also be the better. with these results and research hypothesis which stated that the self-efficacy affect the significant impact on the productivity of health cadres in a clean and healthy life is active in the area of tuban then can be accepted. the influence participatory rural appraisal and self efficacy against the productivity of health cadres in the behavior of a clean and healthy active the test result participatory rural appraisal and self efficacy using the method of shem-pls with the help of software smart pls prove that the participatory rural appraisal and self efficacy affect the significant impact on the productivity of health cadres in a clean and healthy life is active in the area of tuban. descriptive results showed that the participatory rural appraisal and self efficacy are classified as on a very high rank (mean 3.98). the results of confirmatory factor analysis (cfa) indicates that the participatory rural appraisal and self efficacy more determined by indicators that have the largest loading factor, namely usefullness. loading factor that is produced from the cfa also shows that the variables participatory rural appraisal and self efficacy is determined by the relevance. from the descriptive statistics and the value of the factor loading can be explained that the participatory rural appraisal and self efficacy of the behavior of clean and healthy active in the area of tuban can be enhanced with how to improve the participatory rural appraisal and self efficacy better. the test result participatory rural appraisal and self efficacy , indicates that the participatory rural appraisal variables affect the significant impact on the productivity of health cadres with t-statistic = 3,461 consecutive patients 1.96. the greatness of the influence of the influence of participatory rural appraisal against the productivity of health cadre was 0,256, the influence self efficay variable against the productivity of 0,464 health cadres is with the value of t-statistic of 10,975 where value tstatistic is greater than 1.96. thus it can be jurnal ners vol. 11 no. 2 oktober 2016: 288-292 291 concluded that the participatory rural appraisal and self efficay influential significantly against the productivity of health cadres, until the fourth hypothesis proven. with these results and research hypothesis which stated that the participatory rural appraisal and self efficacy affect the significant impact on the productivity of health cadres in a clean and healthy life is active in the area of tuban then can be accepted. the influence productivity health cadres of health investment in the behavior of a clean and healthy active the results of the test the productivity of health cadres using methods of shem-pls with the help of software smart pls prove that the productivity of health cadres significant effect of health investment on a clean and healthy life is active in the area of tuban. descriptive results show that the productivity of health cadres belonging to a very high rank (mean 3.98). the results of confirmatory factor analysis (cfa) shows that the productivity of health cadres more determined by indicators that have the largest loading factor, namely usefullness. loading factor that is produced from the cfa also shows that the productivity variable health cadres more determined by the relevance. from the descriptive statistics and the value of the factor loading can be explained that the investment of health behavior of clean and healthy active in the area of tuban can be enhanced with how to improve the productivity of better health cadres. the test results showed that health cadres productivity productivity variables affect significant health cadres of health investment with t-statistic = 4,645 consecutive patients 1.96. the greatness of the influence of the productivity of health cadres was 0,291, this shows that the change in the productivity of health cadres will cause the health investment changes his nature clockwise (positive), which means when the productivity of the better health cadres and the quality of health investment behavior of clean and healthy active in the area of tuban will also be the better. with these results and the research hypothesis that states that the productivity of health cadres significant effect of health investment on a clean and healthy life is active in the area of tuban then can be accepted. the influence productivity health cadres against the behavior of clean and healthy active the results of the test the productivity of health cadres using methods of shem-pls with the help of software smart pls prove that the productivity of health cadres significant effect against the behavior of a clean and healthy life is active in the area of tuban. descriptive results show that the productivity of health cadres belonging to a very high rank (mean 3.98). the results of confirmatory factor analysis (cfa) shows that the productivity of health cadres more determined by indicators that have the largest loading factor, namely usefullness. loading factor that is produced from the cfa also shows that the productivity variable health cadres more determined by the relevance. from the descriptive statistics and the value of the factor loading can be explained that the productivity of health cadres of the behavior of clean and healthy active in the area of tuban can be enhanced with how to improve the productivity of better health cadres. the test results showed that health cadres productivity productivity variable health cadres significant effect against the behavior of clean and healthy active with t-statistic= 2.642 consecutive patients 1.96. the greatness of the influence of the productivity of health cadres was 0,194, this shows that the change in the productivity of health cadres will cause changes to the behavior of clean and healthy active that his nature clockwise (positive), which means when the productivity of health cadre the better the quality of a clean and healthy life is active in the area of tuban will also be the better. with these results and the research hypothesis that states that the productivity of health cadres significant effect against the behavior of clean and healthy active on a clean and healthy life is active in the area of tuban then can be accepted. model pemberdayaan masyarakat (miftahul munir, dkk) 292 productivity health cadres through participatory rural appraisal approach and self efficacy affect health investment behavior of clean and healthy active in tuban regency. the results of the test the productivity of health cadres through participatory rural appraisal approach and self efficacy using the method of shem-pls with the help of software smart pls prove that the productivity of health cadres significant effect against the health investment behavior of clean and healthy active in the area of tuban. descriptive results show that the productivity of health cadres belonging to a very high rank (mean 3.98). the results of confirmatory factor analysis (cfa) shows that the productivity of health cadres more determined by indicators that have the largest loading factor, namely usefullness. loading factor that is produced from the cfa also shows that the productivity variable health cadres more determined by the relevance. from the descriptive statistics and the value of the factor loading can be explained that the productivity of health cadres of the behavior of clean and healthy active in the area of tuban can be enhanced with how to improve the productivity of better health cadres. the results of the test the productivity of health cadre shows that there is a significant influence productivity variable health cadres of health investment with a 0,291 coefficient with the value of t-statistic of 4,645 ( t-statistic > 1.96). obtained a significant influence health investment variable against the behavior of clean and healthy active with a 0,243 coefficient with the value of t-statistic of 3,749 ( t-statistic > 1.96). thus it can be concluded that the productivity of health cadres influential not directly against the behavior of clean and healthy active through investment health, until the seventh hypothesis proved or can be accepted. conclusions and recommendations conclusion this study provides support for the results of research that has been done previously involving research variable individual characteristics health cadres, participatory rural appraisal, self-efficasy, productivity health cadres, investment health and behavior of clean and healthy active. a review of the concepts are expected to enrich and fortifying the theory of the field of human resources and the behavior of the organization. it has been done by the study related to the commitment and productivity of health cadres, but to the object of research about health cadre especially in the village has not been done. expected from the results of this research can be an important aspect to manage the ability of human resources that need to be prepared to health cadres who independently. this research shows that there is the influence of the individual characteristics, self-efficacy, and team work against the commitment and productivity of cadres. some of the variables had an effect on the commitment and productivity of cadres, the results of the study showed that the competencies cadres have the most influence on the productivity of cadres. recommendation health workers have an important role in improving public health. so this research could be used by local governments tuban in an effort to improve public health, with preventive and promotive through the implementation of productivity improvement programs cadres. references alam a, 2012. role of participatory rural appraisal in community develompment (a case study of barani develompment area project in agricultural, live stock ad forestry develompment in kohat), international journal of academic research in business and social sciences, 2(8). 25-38. chambers r, 1994. the origins and practice of participatory rural appraisal. world development, 22(7): 953-969. doi:10.1016/0305-750x(94)90141-4 chambers r, 1994. participatory rural appraisal (pra): challenges, potentials and paradigm. world development, 22(10): 1437-1454. doi: 10.1016/0305-750x(94)90030-2 chambers r, 1994. participatory rural apparaisal (pra): analysis of experience. world development, jurnal ners vol. 11 no. 2 oktober 2016: 288-292 293 22(9):1253-1268. doi:10.1016/0305750x(94)90003-5 cornwall a, & pratt g, 2011. the use and abuse of participatory rural apparaisal: refleksions from practice, agriculture hum values, 28(2):263–272. doi:10.1007/s10460-010-9262-1 foster s.t, 2004. managing quality an integrative approach, new jersey: pearson prentice hall. indonesian departement health, 2006. the national guide hospital patient safety, jakarta: bhakti husada. ministry of the republic of indonesia, 2004. the health system national indonesia, jakarta: bhakti husada. munir m, triyoga, r. s, & nursalam, 2016. village health post (ponkesdes) development into community nursing center-based health promotion model, nursing center, and behavioral performance, int j med sci public health, 5 (2), 292-297.doi:10.5455/ijmsph.2016.07092015119 uddin m.n, & anjuman n, 2013. participatory rural appraisal approaches: an overview and an exemplary application of focus group discussion in climate change adaptation and mitigation strategies, int j agril res innov & tech, 3(2):72-78. doi: http://dx.doi.org/10.3329/ijarit.v3i2.17 848 kozier b, erb g, & blais k, 1997. professional nursing practice concept and prespective, california: addison wesley logman. nursalam, 2002. nursing management applications in professional nursing practice. jakarta: salemba dermatology suhartono, sulistiawati, & yunitasari e. 2016. performance model of nurse community approach to organizational culture in indonesia. international journal of public health science. 5(3). 62-72. doi: http://dx.doi.org/10.11591/.v5i3.4791 tomey am, & alligoog mr, 2006. nursing theorist and their work. 6rd. rev. ed. louis: mosby. wijono d. 1999. management of the quality of health services (theory, strategies and applications), 2rd. rev. ed. surabaya: airlangga university press http://dx.doi.org/10.5455/ijmsph.2016.07092015119 model pemberdayaan masyarakat (miftahul munir, dkk) 294 96 | pissn: 1858-3598 eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20596 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the correlation between stimulation, nutritional status and child development heri saputo, intan fazrin, eva agustina yalestyarini institut ilmu kesehatan strada indonesia, kediri, east java, indonesia abstract introduction: developmental disorder could be affected by many factors, such as stimulation and nutritional status. this study aimed to determine the correlation between stimulation, nutritional and development of children aged 3 to 6 years old. methods: the study design was an analytic survey with cross-sectional approach. population was parents having children aged 3 to 6, as many as 419 in sonorejo village, the work area of the uptd puskesmas grogol, kediri regency. sample used were 109 respondents taken by simple random sampling technique. independent variables were stimulation and nutritional status collected using questionnaire. dependent variable was development of children aged 3 to 6 years old, collected using observation. data were analyzed using ordinal regression test. results: results showed roughly half of respondents (52, 47.7%), with good stimulation, those with normal nutritional status 80 respondents (73.4%) and having appropriate development 88 respondents (80.7%). there was an effect caused by stimulation and nutritional status for development of children aged 3 to 6 years. results from the statistical test showed p value 0.000 for stimulation factor. this means that stimulation was a dominant factor for children's development. conclusion: stimulation and nutritional status are very important for development of children aged 3 to 6 years old. this study suggested that parents should be more active in joining with health service centers so they can give an appropriate stimulation and increasing nutritional status for their children, so they can have optimal growth and development. article history received: feb 27, 2020 accepted: april 1, 2020 keywords stimulation; nutritional status; development of children contact heri saputro intelsehat@gmail.com institut ilmu kesehatan strada indonesia, kediri, east java, indonesia cite this as: saputro, h., fazrin, i., & yalestyarini, e. a. (2020). the correlation between stimulation, nutritional status and child development. jurnal ners, special issues, 96-100. doi:http://dx.doi.org/10.20473/jn.v15i2(si).20596 introduction parents always want their children to grow and develop optimally according to their age stages. development concerns the development of language, social, fine motor or gross motor skills. in theory, it is mentioned that children can develop optimally requiring stimulation with the support of good growth, including normal nutrition. the problem is that there are still children who do not develop optimally according to their age (fatimah, 2012). nutritional status is the state of the body as a result of food consumption and use of nutrients (astuti, kapantow, & ratag, 2015), while stimulation is the stimulation of the child’s external environment in the form of exercise or play (nursalam, susilaningrum, & utama, 2013). data show that among 200 million children under the age of 5 in developing countries, more than one-third of them have not fulfilled their potential for development (kusuma, syamlan, & yoniko, 2013). according to unicef (2015), of 23.5 million children under five in indonesia, 5 million or 27.5% experience growth and development disorders (kementrian kesehatan ri, 2016). based on the records of the east java provincial health office, 2% or 1,700 children under five suffer from weight disorders that do not match age, intelligence or mental retardation. based on data from the kediri district health office in 2016, from 14,697 children under five, there were as many as 352 toddlers (2.4%) whose development was not appropriate (experiencing deviations). in east java, based on the results of the early detection of growth and development in 2016, out of 2,321,542 toddlers and preschoolers,63.48% of 3,657,353 children under five showed poor development (dinkes jatim, 2010). based on the 2016 monthly nutrition report of the uptd puskesmas grogol, it is known that the results of the early detection of growth and development of 3,397 toddlers showed 63 toddlers (1.8%) having inappropriate development. the results of the nutritional status assessment did not reveal any cases of malnutrition, but there were 5 toddlers (0.15%).with malnutrition status the results of a preliminary study in the sonorejo village, the work area of the uptd puskesmas grogol, kediri regency, found three children (20%) with developmental disorders three children (20%) not independent, four children (26.7%) with gross motor delay https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:intelsehat@gmail.com http://dx.doi.org/10.20473/jn.v15i2(si). jurnal ners http://e-journal.unair.ac.id/jners | 97 and five children (33.7%) with delayed development of fine motor skills. parents who provide daily stimulation to their children were as many as three people (20%), rarely giving stimulation as many as 9 people (60%) and never giving as many as 3 people (20%). there are four risk factors that affect child development, namely nutritional status (severe chronic malnutrition), inadequate early stimulation, iodine deficiency and iron deficiency anemia. one important risk factor related to the interaction of mother and child is the provision of early stimulation (ritayani, 2010). according to soetjiningsih, there are two factors that influence the growth and development of children, namely genetic (intrinsic) and environmental (extrinsic) factors. environmental factors concern the psychological and social environment, such as nutritional status, the role of parents, the active role of children and the education of parents (soetjiningsih, 2013). in order for a child's development to proceed normally, parental involvement is required through early care programs in the form of coordinated services and fostering partnerships between experts and families (soetjiningsih, 2013). parental assistance is needed in monitoring the child's growth through monitoring the growth and development of children in the posyandu every month (warisyah, 2015). for growth and development, adequate food substances are needed. as the age of the child grows, the variety of food provided must be nutritionally complete and balanced, so it is important to support the child's growth and development (pratiwi, masrul, & yerizel, 2016). this study aimed to determine the correlation between stimulation, nutritional and development of children aged 3 to 6 years old. materials and methods this study uses analytic survey research methods, namely research that tries to explore how and why health phenomena occur. in this analytic survey research, research is not conducted on all objects (population), but only a portion of the population (sample). the research design used was cross-sectional, namely analytic survey research in which the collection of independent and bound variable data was carried out in one measurement and at the same time (notoatmojo, 2018). the location in this study was in sonorejo village, grogol district, kediri regency. the study was carried out in july 2019. the independent variables were stimulation and nutritional status and the bound of children's development was collected by questionnaire and observation sheet (prescreening developmental questionnaire). statistical analysis was performed using statistical techniques using the spearman correlation test and multiple linear regression. this survey was approved by the ethics committee of institut ilmu kesehatan strada indonesia (number: 481/kepk/iv/2019). the participants were assured that their engagement was voluntary, and that anonymity, privacy, and confidentiality of the data were guaranteed. furthermore, they were informed about the purpose and the method of the study before signing a written informed consent. the questionnaires were distributed to eligible participants in sonorejo village, grogol district, kediri regency, and respondents were asked to complete and return them at the same time. results this study used a sample of 109 respondents. univariate analysis results found that out of a total of 109 respondents, almost half conducted early stimulation in the good category with 52 respondents (47.7%), 80 respondents (73.4%) had nutritional status in the normal category and almost all respondents (88, 80.7%) had a development in the normal category the results of bivariate analysis show the effect of early stimulation on child development (spearman p value 0.000<0.05, so h0 is rejected). the level of influence is low and positive (r = +0.392), meaning that the better the early stimulation, the more normal child development, and vice versa; there is the influence of nutritional status on child development in sonorejo village grogol district kediri regency 2019 (p value 0.002 <0.05, thus h0 is rejected). the level of influence is low and positive (r = +0.300), meaning that the more normal the nutritional status, the more normal the child's development, and vice versa. multivariate analysis results found that the most dominant factor between early stimulation and nutritional status on child development is the stimulation variable (p value 0.000 <0.05, thus h0 is rejected). table 1. ordinal regression test sig r sig simultan stimulation 0.000 0.202 0.000 nutritional status 0.254 discussion the out of a total of 109 respondents, nearly half (52, 47.7%) conducted early stimulation in the good category stimulation is stimulation from the child’s external environment in the form of exercise or play (nursalam et al., 2013). there are several factors that influence the success of stimulation, including individual basic abilities, health, family, environment, and socioeconomic conditions. it is also influenced by the time when the initial stimulation is given, for how long, and how to it is done. the ability of children's development has a distinctive characteristic, which is to have a fixed pattern and occur sequentially, so that early stimulation must be directed and emphasized first for the formation of basic abilities before developing cognitive-academic abilities and more complex behaviors (hati & lestari, 2016). if almost half of respondents do early stimulation in the good category, then this can be influenced by various factors. the environment (family, neighbors, friends and other people around them) has a string importance for children. this can happen because, at that age, children are already able to be invited to communicate and be funny, causing adult interest to randomize joking and other behaviors that consciously or unconsciously result in an excellent stimulation for development child (saputro & talan, 2017). mother’s age is one of the factors that influence stimulation. based on the analysis results, it was found that most respondents aged 20-35 years with early stimulation were good, namely 44 respondents (40.4%). this can happen because parents aged 20-35 years are at their best physical condition so that they physically have the ability to provide early stimulation to their children. psychologically, people aged 20-35 years are also in a period of maturity, and mentally also in their best condition so that they are also willing and able to provide early stimulation for their children's development. h. saputro et al. 98 | pissn: 1858-3598 eissn: 2502-5791 educational background of the mother is one of the factors that influence stimulation. based on the analysis results, it was found that the most respondents were junior high school graduates with early stimulation, including the sufficient category, namely 30 respondents (27.5%). this is because, despite the background of junior high school education, respondents still had limited knowledge and insight, including insights on early stimulation for the development of their children, resulting in providing early stimulation but only up to the good category. number of children in family is one of the factors that influence stimulation. based on the analysis results, it was found that the most respondents had or two siblings with early stimulation, which included both categories, respectively 26 respondents (23.9%). this is because, due to the relatively small number of children, parents are able to give maximum attention to their children. included in this case, efforts to provide early stimulation for the development of their children can also be done well because it does not take time to pay attention to other children if the condition of the family is as a large family. of the total 109 respondents, most respondents (80, 73.4%) have nutritional status in the normal category. nutritional status is an expression of balance in the form of certain variables, or the embodiment of nutrition in the form of certain variables. for example: endemic goiter is an imbalance of iodine intake and expenditure in the body. the point is that nutritional status is an expression of a state of balance in the form of certain variables (aramico, sudargo, & susilo, 2013). nutritional status is also expressed as a state of the body as a result of food consumption and use of nutrients, with four classifications, namely poor nutritional status, poor, good, and more (munawaroh, 2016). nutritional status is the state of the body as a result of food consumption and use of nutrients (astuti et al., 2015). nutritional status can be influenced by two kinds of factors, namely food consumption and health. food consumption includes nutritional factors in food, the presence or absence of feeding programs outside the family, family finance and eating habits. health factors include maintaining health and the physical and social environment (aramico et al., 2013). the majority of respondents have nutritional status in the normal category; this can be influenced by various factors, such as the presence of food outside the family, such as feeding when there are meals at birthdays, weddings, salvation, groups recitation, religion group and other activities. in addition, it is also related to the purchasing power of families who, at this time, generally have a very good ability to buy food for their children. this condition is very different compared to poor families, whose purchasing power for food supply is generally low so that they do not meet the requirements of quality and quantity. children's eating habits are one of the factors that influence normal nutritional status. in general, among families who are currently economically capable, then eating habits are not eating in a potluck manner, but rather thinking about the best nutritional elements for children, such as rice with tofu, soy sauce, crackers, meat, fish and various other dishes that are highly nutritious. if this habit proceeds continuously, it leads children to get the sufficient nutrients needed for their growth. as a result, in the long run, it will also affect the nutritional status, so that it includes normal nutrition (siwi, 2015). healthcare is another factor that also affects the nutritional status of children. currently, the awareness of parents to generally carry out preventive measures against diseases has been done well, such as immunizations. if clean living habits have also been done well with a pattern of bathing at least twice a day, and keeping the house clean and others is also good, then the child's immune system is also good, so the child is not susceptible to disease. environmental factors can also affect the nutritional status of children. the principle of influence is the same as the preventive measures mentioned above. social factors (certain traditional foods, especially sago, corn, cassava, or abstinence from certain foods, etc.) can also affect the nutritional status of children. this is related to the source of carbohydrates, proteins, fats and various vitamins that cannot be consumed, thereby reducing the nutritional status of children. in the community of sonorejo village, grogol subdistrict, kediri regency, in general, there are not many who practice abstinence from eating, so there are no food restrictions for their children. staple food is generally in the form of rice with side dishes, but there is also a lot of meat and fish, so that the nutritional status of children is normal. various efforts can be realized because it is supported by the characteristics of mothers, such as age, education and number of children. based on the results of the analysis, it was found that mothers aged 20-35 years with normal nutritional status were as many as 69 respondents (63.3%). this condition supports the mother's ability to work to earn an income, so that it can help her husband to increase family income. this will affect food consumption patterns, especially nutrient intake in children. thus the nutritional status of children will increase. of a total of 109 respondents, early all (88, 80.7%) had a normal category of development. development is the increased ability (skill) in the structure and function of the body that is more complex in an orderly and predictable pattern, as a result of the maturation process. this concerns the process of differentiation of body cells, body tissues, organs and organ systems that develop in such a way that they can fulfill their functions, including the development of emotions, intellect and behavior as a result of interaction with the environment (soetjiningsih, 2013). development is an increase in the ability of body structures and functions that are more complex. development involves the differentiation of cells, tissues, organs, and organ systems that develop in such a way that each can fulfill its function (chamidah, 2009). given the majority of respondents are found to have normal development, this can be caused by various factors that support the development of children under five. in theory, it has been explained that children's development can be influenced by various factors, both internal and external. external factors in this case are also influenced by environmental factors. the form of the environment in question can include the physical environment and social environment of children under five. the family environment also influences the development of children under five (fazrin, saputro, chusnatayaini, & ningrum, 2017). in accordance with the results of research successfully obtained by researchers, this development could be due to a relationship with hereditary factors. this means that children are able to develop properly because the average parent also has a pretty good intelligence. this can be assessed through communication between researchers and mothers of children under five. in the context of general knowledge, it looks quite good and, in the context of child development, generally, parents of toddlers already have a pretty good understanding base. generally, they already know that the child's development must be trained (given stimulation). without this effort, they have realized that children will be less optimal in their development. therefore, parents also always train their children to play, jurnal ners http://e-journal.unair.ac.id/jners | 99 they are always invited to talk, tell stories, sing, and write rudimentarily, all of which are efforts to stimulate early. based on the results of the study, it was found that almost all mothers were aged 20-35 years (95,87.2%). this age group is a productive age group so that mothers can easily monitor the development of their children and mothers will actively seek information related to the development of their children, coupled with the many social media that they can access. from other social media, mothers can easily get information about the development of toddlers. information about children's development can be practiced by the mother toward her child so that the child's development is in accordance with the stage of age. another factor which is in accordance with the theory and which also supports the development of children is the number of children. in accordance with the results of this study, it was found that out of a total of 109 respondents almost half (56, 42.2%) had one sibling. this means that, in the family there are two children, thus the mother already has experience with previous children so they can monitor the development of toddlers. based on experience with the first child, the mother already has the knowledge to monitor the development of toddlers, so that it grows normally according to the child's age. effects of early stimulation on development it is known that there is an influence of early stimulation on the development in sonorejo village grogol subdistrict, kediri regency in 2019 (p value 0.000 <0.05, thus h0 is rejected). the level of influence is low and positive (r = +0.392), meaning that the better the early stimulation, the more normal the child's development, and vice versa. the purpose of providing early stimulation to children is "to help the child so that he can achieve a good level of development, so that there is no developmental delay, train children to encourage mastering their developmental tasks according to their age level” (hidajaturrokhmah & saputro, 2016). stimulation that is given correctly will provide benefits for child development. this is explained that "the stimulation given correctly to children will be able to direct the child's development, prevent the occurrence of growth retardation, development and educate the child so that the child reaches an optimal level of development" (kementrian kesehatan ri, 2016). it is found that there early stimulation influences child development, so that the child gets stimulation from the external environment in the form of exercise or play. this is in accordance with existing theories that stimulation given correctly to children will be able to direct the child's development, prevent the occurrence of growth retardation, and assist in the development and education of the child so that the child reaches an optimal level of development. there are also those who say that children who receive targeted stimulation will develop more quickly than children who lack stimulation. this condition also occurs in the results of this study in that respondents with good early stimulation and normal development were as many as 49 (45.0%). this proves that early stimulation is indeed a predisposing factor for children's development. effect of nutritional status on development it is known that there is an influence of nutritional status on child development in sonorejo village, grogol district, kediri regency in 2019 (p value 0.002 <0.05, thus h0 is rejected). the level of influence is low and positive (r = +0.300), meaning that the more normal the nutritional status, the more normal the child's development, and vice versa. to grow and develop, children need adequate food substances. sulistijani revealed that, as a child ages, the variety of foods must be nutritionally complete and balanced to support their growth and development (pratiwi et al., 2016). food must contain energy and all nutrients (carbohydrates, protein, fat, vitamins and minerals) needed (kania, 2007). fulfillment of good nutrition plays an important role in achieving optimal growth, including the growth of the child's brain. lack of one of the nutrients can lead to impaired growth and development of children. associated with brain performance, malnutrition can reduce the level of work of certain neurotransmitters and affect children's development (chamidah, 2009). the influence of nutritional status on children's development is due to the development needed by brain performance. growth and development itself requires nutrition from food. if the food given to children is lacking, both in quality and quantity, then the nutrients to support brain growth and development are also lacking (briawan & herawati, 2008). as a result, the power of brain development is also reduced, so that the brain does not develop optimally and eventually also results in children's developmental disorders. conversely, when the intake of nutritious foods can be fulfilled, the growth and development of the brain can occur optimally, so that the child's mind is also developing well. this will support the child's development in accordance with the stages of his age and take place optimally. conclusion the most dominant factor between stimulation and nutritional status of a child's development is that stimulation due to the achievement of development is more prioritized by stimulation. through stimulation, the child will practice the pattern of thinking, so that more optimal growth is seen from the psychological aspects. on the other hand, nutritional status is not a factor that is directly related to psychological development. generally, the greater the nutritional status, the more the physical condition grows, i.e. the greater the physical condition, the more it indirectly also supports the intelligence of children. it can be interpreted that more stimulation is needed to support child development. conflict of interest the authors declare no conflicts of interest. acknowledgement the authors wish to appreciate all participant, whose contributions enabled the production of this article. references aramico, b., sudargo, t., & susilo, j. (2013). hubungan sosial ekonomi, pola asuh, pola makan dengan stunting pada siswa sekolah dasar di kecamatan lut tawar, kabupaten aceh tengah. jurnal gizi dan dietetik indonesia (indonesian journal of nutrition and dietetics), 1(3), 121–130. https://doi.org/http://dx.doi.org/10.21927/ijnd.2013. 1(3).121-130 astuti, v. c. p., kapantow, n. h., & ratag, b. t. (2015). hubungan antara pola asuh ibudengan status gizi anak usia1-3 tahun di wilayah kerja puskesmas walantakankabupaten minahasa. universitas sam ratulangi, manado. h. saputro et al. 100 | pissn: 1858-3598 eissn: 2502-5791 briawan, d., & herawati, t. (2008). peran stimulasi orangtua terhadap perkembangan anak balita keluarga miskin. jurnal ilmu keluarga & konsumen. jurnal ilmu keluarga dan konsumen, 1(1), 63–76. https://doi.org/https://doi.org/10.24156/jikk/2008.1 .1.63 chamidah, a. n. (2009). deteksi dini gangguan pertumbuhan dan perkembangan anak. jurnal pendidikan khusus, 5(3), 83–93. dinkes jatim. (2010). profil kesehatan jawa timur. surabaya: dinkes prov jatim. fatimah, l. (2012). hubungan pola asuh orang tua dengan perkembangan anak di r.a darussalam desa sumber mulyo, jogoroto, jombang. prosiding seminas competitive advantage, 1(2), 1–6. fazrin, i., saputro, h., chusnatayaini, a., & ningrum, n. a. (2017). mengembangkan intelegensi quotient (iq) pada anak prasekolah dengan stimulasi keluarga dan pendidikan anak usia dini. ponorogo: forum ilmiah kesehatan (forikes). hati, f. s., & lestari, p. (2016). pengaruh pemberian stimulasi pada perkembangan anak usia 12-36 bulan di kecamatan sedayu, bantul. jurnal ners dan kebidanan indonesia, 4(1), 44–48. https://doi.org/http://dx.doi.org/10.21927/jnki.2016. 4(1).44-48 hidajaturrokhmah, n. y., & saputro, h. (2016). pertumbuhan berat badan bayi usia 6 bulan ditinjau dari jenis nutrisi. strada jurnal ilmiah kesehatan, 5(1), 38–45. kania, n. (2007). stimulasi dini untuk mengembangkan kecerdasan dan kreativitas anak. kementrian kesehatan ri. (2016). pedoman pelaksanaan stimulasi, deteksi dan lntervensi dini tumbuh kembang anak stimulasi, deteksi dan lntervensi dini tumbuh kembang anak. jakarta: kementrian kesehatan ri. kusuma, i. f., syamlan, r., & yoniko, c. a. (2013). hubungan pengetahuan ibu tentang stimulasi dini dengan perkembangan motorik pada anak usia 6-24 bulan di kecamatan mayang kabupaten jember. ikesma: jurnal ilmu kesehatan masyarakat, 9(1), 27–38. munawaroh, s. (2016). pola asuh mempengaruhi status gizi balita relationship of parenting pattern and toddlers’ nutrititional status. jurnal keperawatan, 6(1). notoatmojo, s. (2018). metodologi penelitian kesehatan (revisi). jakarta: rineka cipta. nursalam, susilaningrum, s., & utama, s. (2013). asuhan keperawatan bayi dan anak : untuk perawat dan bidan. jakarta: salemba medika. pratiwi, t. d., masrul, & yerizel, e. (2016). hubungan pola asuh ibu dengan status gizi balita di wilayah kerja puskesmas belimbing kota padang. jurnal kesehatan andalas, 5(3), 661–665. https://doi.org/https://doi.org/10.25077/jka.v5i3.59 5 ritayani, l. (2010). hubungan pola asuh ibu dengan status gizi anak balita di wilayah kerja puskesmas pantai cermin kecamatan tanjung pura kabupaten langkat tahun 2008. university of sumatera utara. saputro, h., & talan, y. o. (2017). pengaruh lingkungan keluarga terhadap perkembangan psikososial pada anak prasekolah. journal of nursing practice, 1(1), 1–8. https://doi.org/https://doi.org/10.30994/jnp.v1i1.16 siwi, s. a. (2015). hubungan antara pola asuh dengan status gizi pada balita usia 2-5 tahun. universitas muhammadiyah surakarta. soetjiningsih. (2013). tumbuh kembang anak. jakarta: egc. warisyah, y. (2015). pentingnya “pendampingan dialogis” orang tua dalam penggunaan gadget pada anak usia dini. prosiding seminar nasional pendidikan, 130–138. 63 perilaku ibu dalam pemenuhan kebutuhan asah, asih dan asuh anak dengan leukemia (mother’s behaviour in meeting the needs of stimulation, emotion and physical children with leukemia) praba diyan rachmawati*, igm reza gunadi ranuh**, yuni sufyanti arief* * fakultas keperawatan universitas airlangga mulyorejo kampus c unair surabaya ** rsu dr. soetomo surabaya email: diyanatha@gmail.com abstrak pendahuluan: anak-anak dengan leukemia memiliki kualitas hidup yang kurang baik. perawatan dan pengobatan jangka panjang, efek samping dari pengobatan dan gejala dari penyakit leukemia akan berdampak pada kualitas hidup anak dengan leukemia. orang tua memiliki peran penting dalam memenuhi kebutuhan dasar anak akan asah, asih dan asuh. terpenuhinya kebutuhan dasar anak dengan baik, kualitas hidup anak dengan leukemia akan meningkat. metode: desain yang digunakan dalam penelitian ini adalah observasional analitik. populasi adalah ibu dari anak-anak leukemia di ruang hematologi anak, dilakukan pada selama 1 bulan tahun 2014. pengambilan sampel berturut-turut digunakan dalam penelitian ini. sampel sejumlah 20 ibu yang memenuhi kriteria inklusi, variabel independen adalah karakteristik ibu, sumber efikasi diri, perawatan berpusat keluarga, efikasi diri orang tua dan variabel dependen adalah perilaku ibu dan kualitas hidup anak. data dikumpulkan dengan menggunakan kuesioner dan dianalisis menggunakan pls (partial least square). hasil: hasil penelitian menunjukkan bahwa sumber efikasi diri berpengaruh terhadap efikasi diri, efikasi diri dan karakteristik ibu berpengaruh langsung pada perilaku ibu. perawatan berpusat keluarga tidak dapat secara langsung mempengaruhi perilaku ibu. diskusi: dapat disimpulkan bahwa model perilaku ibu dalam pemenuhan kebutuhan asah, asih dan anak dengan leukemia dapat dibentuk dari karakteristik ibu, sumber efikasi diri dan efikasi diri orang tua. efikasi diri orangtua dapat ditingkatkan terutama dengan meningkatkan mekanisme koping dan pengalaman orang lain. kata kunci: stimulasi, emosi, perilaku fisik ibu, anak-anak leukemia kualitas hidup abstract introduction: children with leukemia have a poor quality of live. a long term periode of care, treatment, side effect of treatment and the symptom of the leukemia disease will have an impact on leukemia children quality of life. parents have an important role in meeting the basic needs of the child by stimulation, emotion and physical. with the fulfillment of the basic needs of children, the quality of life of children with leukemia will increase. method: design used in this study was an observational analytic. the population was mother of leukemia children. conducted a month on 2014. consecutive sampling was used in this study. sample were 20 mother who met in inclusion criteria. independ ent variables were mother’s characteristics, self efficacy source, family centre care, parental self efficacy and dependent variables were mother’s behaviour and child quality of life. data was collected using quetionnaire and analyzed using pls (partial least square) regression. result: result showed that sources of self-efficacy influence on self-efficacy, self efficacy and mother’s characteristics directly affects the mother’s behaviour. family centered care can’t directly affect mother’s behaviour. discussion: it can be concluded that mother’s behaviour model in stimulating, loving and physical caring children with leukemia can be formed from mother’s characteristics, self efficacy source and parental self efficacy. parental self efficacy can be increased especially by improving coping mechanisms and vicarious experience. keyword: stimulation, emotion, physical, mother’s behaviour, leukemia children quality of life pendahuluan anak dengan leukemia yang menjalani masa perawatan dan pengobatan juga memiliki keinginan serta kebutuhan untuk beraktivitas, melakukan hal yang sama dengan anak normal pada umumnya sesuai dengan tumbuh kembangnya. pengobatan yang lama serta efek samping yang dirasakan oleh anak yang menjalani pengobatan leukemia dalam jangka waktu lama akan berdampak pada kualitas hidup anak baik dari segi fisik, emosional maupun sosial (umiati, m., rakhmawati, w., simangunsong, b., lukitowati, fauzi, e., setiawan, e. 2013; eiser, c. richard, e., stride, c. 2005). orang tua akan merasa bersalah, marah, lelah dan stres dalam menghadapi kondisi tersebut, oleh karena itu penyakit leukemia pada anak akan memberikan pengaruh dalam beberapa hal yang dialami orang tua yaitu dalam hal psikologis, emosi, ekonomi dan sosial (jones, b 2012; mussato 2006). berbagai situasi ini menyebabkan orang tua anak dengan penyakit leukemia merasakan kesedihan yang berulang, mendalam dan permanen (eakes 1995). hal ini akan berpengaruh terhadap perilaku orang tua. penelitian yang dilakukan di ruang bona 1 dan bona 2 rsud dr. soetomo menunjukkan jurnal ners vol. 11 no. 1 april 2016: 63-72 64 bahwa 64,3 % orang tua memberikan perawatan pada anak leukemia yang menjalani kemoterapi dengan kategori sedang dan 7,1 % menunjukkan perawatan yang kurang (quraniati 2013). hasil pengamatan tentang kualitas perawatan orang tua di ruang hematologi anak rsud dr. soetomo didapatkan 50% orang tua kurang dalam melakukan upaya stimulasi perkembangan anak, orang tua jarang bermain bersama anak serta memilih permainan yang tidak sesuai dengan kebutuhan perkembangan. selain itu beberapa orang tua anak dengan kanker di instalasi rawat inap (irna) anak rsud dr. soetomo kurang memperhatikan kondisi emosi anak akibat penyakit dan pengobatan jangka panjang yang dijalani. diperlukan upaya perawat dalam penerapan family centre care (fcc) sebagai filosofi keperawatan anak untuk melibatkan dan memampukan orang tua sebagai upaya meningkatkan kualitas perawatan orang tua melalui optimalisasi pemenuhan kebutuhan dasar anak asah, asih dan asuh (3a). hal ini sejalan dengan misi irna anak rsu dr. soetomo surabaya yaitu menerapkan asah, asih dan asuh dengan melibatkan orang tua (care with parent). namun sampai saat ini perilaku ibu dalam pemenuhan kebutuhan asah, asih dan asuh untuk meningkatkan kualitas hidup anak dengan leukemia belum dapat dijelaskan. kualitas hidup anak akan menurun karena nyeri yang dirasakan, kehilangan aktitivitas sehari-hari yang menyenangkan serta ketakutan akan masa depan, begitu pula pada orang tua, orang tua akan merasakan depresi dan kecemasan yang tinggi serta mengalami penurunan kualitas hidup yang signifikan bila dibandingkan dengan populasi orang tua anak normal (eiser, c. richard, e., stride, c. 2005). stres dan berbagai permasalahan psikologis yang dialami orang tua menurunkan parental self efficacy (pse) (guimond, a, b., wilcox, m, j., lamorey 2008; hastings, r. p., & brown 2002). self efficacy berpengaruh terhadap perilaku seseorang parental self efficacy (pse) (peterson, s, j., bredow, t 2004) sehingga akan berpengaruh pada kualitas orang tua dalam memberikan perawatan terhadap anak (jones, t. l., & prinz 2005).merupakan hal yang dapat digali dari orang tua dimana orang tua merasa berkompeten dan percaya diri akan kemampuan, ketrampilan serta pengetahuan dirinya untuk merawat anak dengan penyakit kronis ketika anak harus menjalani penyakit dan perawatan dalam jangka waktu yang lama (guimond, a, b., wilcox, m, j., lamorey 2008). self efficacy ini dapat merubah perilaku seseorang (bandura 1977; peterson, s, j., bredow, t 2004) dengan adanya kekuatan dan keyakinan akan sebuah harapan bahwa diri seseorang mampu menghadapi akan terwujud suatu perilaku yang postif. hal ini dapat diterapkan pada kondisi penyakit kronis yang dialami oleh anak, dimana menunjukkan bahwa efikasi diri orang tua merupakan mediator untuk meningkatkan kualitas perawatan orang tua secara optimal untuk menigkatkan kualitas hidup anak. irmawati, m., irwanto, cahyadi (2012) menyebutkan bahwa target pelaksanaan tenaga kesehatan dalam penanganan penyakit kronis tidak hanya diprioritaskan dari segi pengobatan saja, tetapi juga perawatan. salah satu tujuan perawatan dari anak dengan penyakit kronis adalah mengoptimalkan tumbuh kembang anak baik dalam perkembangan fisik, kognitif maupun psikososial. orang tua memiliki peranan penting dalam memenuhi kebutuhan dasar anak untuk dapat bertumbuh dan berkembang, yaitu dengan asah, asih dan asuh (3a). kebutuhan dasar anak akan asah merupakan pemenuhan kebutuhan stimulasi anak, asih adalah pemenuhan kebutuhan anak akan emosi atau kasih sayang sedangkan asuh adalah pemenuhan kebutuhan fisik anak (soetjiningsih 2005). terpenuhinya kebutuhan dasar anak maka kualiatas hidup anak terutama anak dengan leukemia akan meningkat. perawat dalam upaya meningkatkan kualitas hidup anak memiliki peranan juga untuk menggali kekuatan yang ada dalam orang tua, meningkatkan kepercayaan diri orang tua dan kemampuan untuk merawat anak dengan kondisi penyakit kronis (soetjiningsih 2005). perilaku merawat anak dengan prinsip asah, asih dan asuh orang tua terhadap anak dengan leukemia ditentukan oleh bagaimana self efficacy orang tua. berawal dari pemikiran dan fenomena tersebut diatas dirasa perlu adanya pengembangan suatu model perilaku ibu dalam pemenuhan kebutuhan asah, asih, asuh (3a) untuk meningkatkan kualitas hidup anak leukemia. kerangka penelitian yang akan digunakan dalam penelitian ini adalah dengan pendekatan teori keperawatan middle range self efficacy barbara (peterson, s, j., bredow, t 2004) melalui pemenuhan kebutuhan dasar perilaku ibu dalam pemenuhan kebutuhan asah, asih, dan asuh (praba diyan r., dkk.) 65 anak asah, asih, asuh (3a) (soetjiningsih 2005). bahan dan metode jenis penelitian yang digunakan dalam penelitian ini adalah eksplanatif observational dengan pendekatan cross sectional. populasi terjangkau seluruh ibu dengan anak terdiagnosa leukemia yang sedang di rawat di ruang hematologi anak rsud dr. soetomo, sampel penelitian adalah ibu dengan anak terdiagnosa leukemia yang memenuhi kriteria inklusi, yaitu ibu bisa membaca dan menulis, ibu yang sedang menunggu anak selama di rawat di rumah sakit, ibu dengan anak leukemia yang terdiagnosa ≥ 4 minggu dan ibu dengan anak leukemia yang berusia 6-12 tahun teknik pengambilan sampel yang digunakan non probability sampling, yaitu consecutive sampling dimana penetapan subyek yang memenuhi kriteria penelitian dimasukkan dalam penelitian sampai kurun waktu tertentu (nursalam 2013). kurun waktu yang ditetapkan dalam penelitian ini adalah 1 bulan. variabel independen dalam penelitian ini adalah sumber self efficacy (performance accomplisment, vicarious experience, verbal persuassion, mekanisme koping), karakteristik personal ibu (usia, tingkat pendidikan, lama merawat anak, kualitas hidup ibu, kesedihan kronis ibu, kecerdasan emosional ibu), dan parental self efficacy. penelitian dilaksanakan selama 1 bulan pada tahun 2014. analisis yang digunakan dalam penelitian ini adalah dengan analisis bivariate, dimana dilakukan terhadap dua variabel yang diduga berhubunagn atau berkorelasi dan dengan partial least square (pls), dimana digunakan untuk menguji model hipotesis yang diusulkan dalam penelitian ini. pengujian hipotesis dilakukan dengan uji statistic t (ttest). jika dalam pengujian ini diperoleh tvalue >1,96 (alpha 5%) berarti pengujian significant, dan jika nilai t value <1,96 (alpha 5%) berarti hasil tidak signifikan. hasil sebagian besar responden yang tidak memiliki performance accomplishments memiliki tingkat self efficacy yang rendah yaitu sebanyak 7 orang (35%). sebanyak 35% responden memiliki persuasi verbal yang baik dan berada pada tingkatan parental self efficacy yang rendah. lebih dari separuh responden (55%) memiliki mekanisme koping yang negatif dengan tingkat self efficacy yang rendah. hasil penelitian ini menunjukkan bahwa sebagian besar berada pada rentang usia 20-40 tahun sebanyak 70%, dari jumlah tersebut 50% responden memiliki self efficacy dalam kategori yang rendah. indikator pendidikan menunjukkan bahwa pendidikan responden sebagian besar adalah berpendidikan rendah memiliki self efficacy dalam kategori yang rendah yaitu sebanyak 8 ibu (40%). pada indikator lama orang tua merawat anak dengan leukemia diketahui bahwa sebagian besar orang tua merawat anak dengan leukemia selama 1-3 bulan, dari jumlah tersebut 30 % berada pada tingkat self efficacy yang rendah. indikator kesedihan kronis yang dirasakan orang tua menunjukkan bahwa 55% orang tua yang mengalami kesedihan kronis dalam tingkatan sedang memiliki tingkat self efficacy yang rendah. pada indikator kualitas hidup orang tua menunjukkan bahwa sebagian besar responden berada pada kategori kualitas hidup yang buruk berada pada rentang self efficacy pada kategori yang rendah yaitu sebanyak 8 orang (40%). asosiasi faktor personal ibu dengan perilaku ibu dalam pemenuhan kebutuhan asah, asih dan asuh pada anak dengan leukemia menujukkan bahwa indikator pendidikan menunjukkan bahwa sebagian besar ibu dengan pendidikan rendah memiliki perilaku asih maupun asuh dalam kategori baik, yaitu sebanyak 7 orang (35%), begitu pula dengan asah juga dalam kategori baik yaitu sebanyak 6 orang responden (30%). kualitas hidup ibu dalam kategori buruk memiliki perilaku perawatan asah yang kurang baik (40%), asih dalam kategori yang kurang baik (30%), asuh dalam kategori kurang baik (30%). responden yang memiliki self efficacy dalam kategori rendah memiliki perilaku asah dalam kategori yang kurang baik (55%), asih dalam kategori yang rendah (35%) dan asuh juga dalam kategori yang rendah (40%). fcc dalam kategori baik mempengaruhi 45% responden untuk berperilaku pemenuhan asah dalam kategori baik, separuh responden (50%) memiliki perilaku asih dalam kategori baik dan lebih dari separuh responden (55%) yang memiliki perilaku asuh dalam kategori baik. personal ibu qol ibu jurnal ners vol. 11 no. 1 april 2016: 63-72 66 gambar 1. hasil uji hipotesis faktor personal semula tersusun atas usia, tingkat pendidikan, kesedihan kronis, lama diagnosa anak dan kualitas hidup ibu. hasil uji statistik dengan menggunakan pls menunjukkan bahwa usia, dan kesedihan kronis yang dialami ibu tidak menunjukkan hasil yang signifikan sehingga indikator penyusun tersebut dihilangkan. begitu pula indikator penyusun sumber self efficacy dimana semula sumber self efficacy menurut teori dari (bandura a 1994) tersusun atas 4 komponen yaitu performance accomplishment, vicarious experience, verbal persuasion dan mekanisme koping, namun hasil penelitian ini menunjukkan performance accomplishment tidak signifikan dalam membentuk sumber self efficacy sehingga indikator tersebut dihilangkan. semua variabel dalam gambar diatas menunjukkan pengaruh yang siginifikan sesuai dengan kerangka yang direncankan, kecuali pada variabel lingkungan (fcc) tidak menunjukkan adanya pengaruh yang signifikan dengan perilaku ibu, sehingga variabel lingkungan (fcc) dihilangkan pembahasan hasil penelitian ini menunjukkan bahwa pengalaman langsung (performance accomplishment) tidak membentuk sumber self efficacy ibu. menurut bandura a (1994) performance accomplishment merupakan salah satu penyusun sumber self efficacy, namun dalam penelitian ini tidak sesuai dengan teori tersebut. performance accomplishment menurut (bandura a 1994) adalah pengalaman menguasai suatu prestasi atau keberhasilan yang pernah dicapai pada masa lalu, dan faktor ini merupakan faktor utama dalam membentuk keyakinan seseorang akan kemampuannya dibandingkan dengan sumber self efficacy yang lain. semua ibu yang menjadi responden dalam penelitian ini tidak mempunyai pengalaman sebelumnya mempunyai anak dengan kondisi penyakit kronis, dimana anak dengan penyakit kronis membutuhkan perawatan dalam jangka waktu pengobatan dan masuk rumah sakit lebih dari 3 bulan (wong, d.l., hokenberry-eaton, m., wilson, d., winkelstein, m. l., schwartz 2010). hal inilah yang menyebabkan performance accomplishment tidak dapat menjadi faktor yang membentuk sumber self efficacy dalam penelitian ini. performance accomplisment ibu dalam kategori baik disebabkan karena para ibu yang menjadi inklusi dalam penelitian ini telah melakukan perawatan pada anak minimal 1 bulan, dengan perawatan minimal 1 bulan ibu akan memiliki pengalaman. jumlah terbanyak responden tidak memiliki vicarious experience (pengalaman tidak langsung) dan memiliki tingkat self efficacy yang rendah, begitu pula terdapat responden yang memiliki vicarious experience juga memiliki self efficacy dalam kategori tinggi. penelitian ini menunjukkan hasil bahwa vicarious experience ini menduduki urutan kedua yang menjadi indikator pembentuk sumber self efficacy, serta mempunyai skor yang cukup tinggi. hasil analisis pada diskusi kelompok menunjukkan bahwa yang dapat menguatkan keyakinan ibu adalah pengalaman dari ibu lain yang memiliki masalah sama. vicarious experience merupakan pengalaman yang diperoleh dari orang lain yang memiliki karakteristik sama, dapat melewati atau melakukan dengan berhasil (bandura a 1994). menurut (peterson, s, j., bredow, t 2004) bahwa apabila seorang individu tidak memiliki pengalaman sendiri maka individu tersebut akan belajar dari pengalaman sukses orang lain. berdasarkan hasil dan pembahasan sebelumnya ibu yang menjadi responden dalam penelitian ini tidak memiliki pengalaman sendiri sebelumnya mempunyai anak dengan penyakit kronis, sehingga para ibu yang menjadi responden penelitian ini banyak mempelajari pengalaman mekanisme koping verbal pesuasion vicarious experience pse perilaku sumber pse tkt pendidikan asah asih asuh perilaku ibu dalam pemenuhan kebutuhan asah, asih, dan asuh (praba diyan r., dkk.) 67 berhasil dari orang lain, sehingga dapat membangkitkan keyakinan pada diri ibu bahwa juga akan bisa merawat anak dengan leukemia dengan baik. persuasi verbal dalam penelitian ini menujukkan hasil bahwa jumlah terbanyak adalah responden yang mempunyai persuasi vebal yang baik namun memiliki tingkat self efficacy yang rendah. hasil uji statistik juga menunjukkan bahwa persuasi verbal memiliki nilai yang kecil dalam membentuk sumber self efficacy, dengan persuasi verbal seseorang akan mendapat pengaruh atau sugesti bahwa akan mampu mengatasi masalah-masalah yang akan dihadapi. seseorang yang senantiasa diberikan keyakinan dan dorongan untuk sukses, maka akan menunjukkan perilaku untuk mencapai kesuksesan tersebut, begitupun sebaliknya dan keyakinan seseorang (bandura a 1994). persuasi verbal ini memberikan dorongan pada seseorang namun tidak menunjukkan pengalaman yang nyata yang dapat diamati. hal ini sesuai dengan hasil diskusi kelompok bahwa ibu dengan anak leukemia seringkali mendapat persuasi secara verbal oleh orang lain yang memilki pengalaman masa lalu yang tidak dapat diamati oleh ibu pada saat ini. hal ini menunjukkan bahwa tidak ada gambaran nyata yang dapat diamati oleh ibu untuk dapat dibentuk sebagai proses belajar untuk meningkatkan ketrampilan ibu dalam memberikan perawatan berbasis asah, asih dan asuh pada anak leukemia. menurut (bandura a 1994) seseorang akan meningkat keyakinannya dengan mengamati orang lain yang memilki karakteristik sama sukses melakukan sesuatu yang sama. pengamatan dari peneliti responden dalam penelitian ini berada pada ruang kelas 3 yang berada di bangsal, sehingga aktifitas seharihari yang dilakukan responden selama merawat anak mereka di rumah sakit sering diketahui dan diamati oleh satu sama lain secara nyata terutama dalam aspek asuh. sesuai dengan pernyataan responden ketika diskusi kelompok bahwa ketika berada dirumah sakit responden merasa tidak sendirian, banyak yang memiliki masalah sama dengan respoden dan dapat dengan sukses merawat anak mereka. hasil diskusi kelompok menunjukkan pula bahwa responden selain mendapatkan persuasi verbal dari orang yang memiliki pengalaman dimasa lalu, juga mendapat persuasi verbal dari orang tua pasien yang lain, sehingga dengan adanya persuasi verbal dan vicarious experience dapaat mendukung self efficacy yang baik, namun dalam penelitian vicarious experience lebih mendominasi dalam membentuk sumber self efficacy. responden terbanyak dalam penelitian ini memiliki mekanisme koping yang negatif juga memilki self efficacy dalam kategori rendah. menurut bandura a (1994) seseorang untuk dapat yakin akan kemampuannya yaitu salah satunya adalah koping sesorang tersebut terhadap stressor yang dihadapi. pengelolaan emosi dengan mengurangi stres dan perasaan positif akan merubah persepsi dan interpretasi seseorang akan kemampuan yang dimilikinya juga positif sehingga koping yang baik dapat menjadi cara untuk merubah self efficacy seseorang menjadi baik (bandura a 1994). koping dapat menjadi indikator dan cara untuk membentuk self efficacy. responden dalam penelitian ini adalah ibu dengan anak yang menderita penyakit kronis, dimana membutuhkan perawatan dan pengobatan dalam jangka waktu yang lama. stres yang dialami ibu diakibatkan karena keparahan penyakit anak (wong, d.l., hokenberry-eaton, m., wilson, d., winkelstein, m. l., schwartz 2010), orang tua dengan penyakit kanker diruang hematologi anak bona 1 sebagian besar mengalami stres (krisnana, i. 2012). stres atau kondisi psikologis yang dialami ibu dapat mempengaruhi self efficacy ibu (guimond, a, b., wilcox, m, j., lamorey 2008) untuk bangkit dan merawat anak leukemia dengan baik, dengan koping yang baik yang akan dapat menciptkan keyakinan akan kemampuan diri yang baik pula. terdapat pengaruh yang signifikan antara faktor personal ibu dengan parental self efficacy. faktor personal ibu dalam rancangan penelitian ini sebelumnya tersusun dari faktor usia, tingkat pendidikan, lama merawat anak, kualitas hidup dan tingkat kesedihan kronis yang dialami, dari kelima faktor yang menyusun faktor personal ibu tersebut, faktor usia dan kesedihan kronis ibu tidak terbukti dapat membentuk faktor personal ibu serta hasil penelitian ini menunjukkan bahwa pendidikan adalah indikator yang paling besar dalam menyusun faktor personal. tingkat pendidikan responden dalam penelitian ini sebagian besar berada pada tingkat pendidikan rendah (sd dan smp) dan memiliki self efficacy yang rendah. hasil analisis statistik menunjukkan bahwa pendidikan ibu ini menjadi indikator yang paling mendominasi jurnal ners vol. 11 no. 1 april 2016: 63-72 68 dalam membentuk faktor personal, hal ini disebabkan karena sebagian besar ibu tidak memiliki pendidikan yang tinggi. menurut bandura (1997) pendidikan merupakan salah satu faktor yang mempengaruhi self efficacy seseorang. tingkat pendidikan seseorang yang tinggi lebih banyak mendapatkan pendidikan formal dibandingkan dengan seseorang dengan tingkat pendidikan yang lebih rendah, hal ini disebabkan karena dengan pendidikan formal yang lebih tinggi seseorang akan lebih banyak memiliki kesempatan untuk menghadapi berbagai persoalan yang memerlukan aspek kognitif dalam pemecahannya. self efficacy merupakan suatu pembentukan yang melalui proses kognitif dalam diri seseorang. ibu yang menjadi responden dalam penelitian ini sebagian besar berpendidikan rendah, responden yang berpendidikan rendah ini memiliki tingkatan self efficacy yang rendah. lama ibu merawat anak dalam penelitian ini lebih dari separuhnya berada pada rentang 1-3 bulan. lama waktu ibu merawat anak dengan leukemia berkaitan dengan pengalaman ibu, menurut bandura a (1994) pengalaman merupakan salah satu faktor yang berpengaruh dalam pembentukan self efficacy. semakin lama ibu merawat anak dengan leukemia semakin banyak rintangan yang menjadikan suatu proses pembelajaran yang harus dilalui oleh ibu. namun dalam penelitian ini menunjukkan bahwa ibu yang memiliki pengalaman 4-12 bulan memiliki nilai self efficacy yang sama rendahnya dengan ibu yang memiliki pengalaman merawat anak 1-3 bulan. ibu atau orang tua selama merawat anak akan seringkali merasakan kekhawatiran akan kondisi kekambuhan anak yang tidak pasti, jadi meskipun ibu yang menjadi responden penelitian ini telah lama merawat anak dengan leukemia namun masih memiliki self efficacy yang rendah. sebagian besar ibu dengan kualitas hidup yang buruk ini memiliki pse yang rendah. menurut (bandura a 1994) salah satu pembentukan self efficacy adalah melalui proses afektif, yaitu suatu proses pengontrolan terhadap stressor yang terjadi. self efficacy yang rendah berkaitan dengan stres dan depresi yang dialami oleh seseorang (hastings, r. p., & brown 2002) oleh karena itu seseorang yang memiliki mekanisme pengontrolan terhadap stresor yang kurang baik akan memiliki self efficacy yang rendah. ibu dengan anak leukemia memiliki tingkat stres yang tinggi (masa’deh, r., collier, j., and hall 2012) dan berbagai permasalahan psikologis yang menyertai (mussato 2006). menurut eakes (1995) orang tua dengan anak penderita penyakit kronis memiliki berbagai permasalahan psikologis seperti shock, tidak percaya, berduka, marah, frustasi, sedih, bingung dan putus asa yang berlangsung mendalam, berulang, dan permanen. teori keperawatan chronic sorrow menyebutkan bahwa salah satu manajemen internal dalam diri seseorang yang mengalami kesedihan kronis adalah dengan proses kognif, sehingga dari pernyataan ini nampak bahwa dengan manajemen internal yang kurang baik, dilihat dari self efficacy yang rendah akan memunculkan kesedihan yang terus berulang. salah satu aspek penyusun kualitas hidup ibu adalah faktor mental emosional. beberapa hasil ini menunjukkan bahwa ibu yang menjadi responden dalam penelitian ini belum memiliki pengontrolan terhadap stressor yang baik sehingga memiliki self efficacy yang rendah. hasil penelitian ini menunjukkan hasil yang signifikan adanya pengaruh antara faktor personal ibu (tingkat pendidikan dan kualitas hidup) dengan perilaku ibu dalam asah, asih dan asuh. hasil penelitian ini juga menunjukkan bahwa indikator usia, lama merawat anak, kesedihan kronis tidak terbukti dapat membentuk faktor personal ibu. responden dalam penelitian ini sebagian besar adalah berpendidikan rendah. responden yang berpendidikan rendah ini dari hasil tabel asossiasi menunjukkan bahwa terdapat nilai yang mendominasi yaitu ibu dengan pendidikan rendah memiliki perilaku pemenuhan kebutuhan asah, asih maupun asuh yang baik. menurut soetjiningsih (2005) menyatakan bahwa pendidikan orang tua merupakan faktor yang penting dalam pertumbuhan dan perkembangan anak, dengan pendidikan yang tinggi orang tua dapat lebih mudah menyerap informasi. pernyataan ini kurang sesuai dengan hasil penelitian ini meskipun secara teori maupun penelitian yang menyatakan bahwa pendidikan yang tinggi akan berpegaruh terhadap perilaku yang baik, namun berbeda dengan situasi dimana tempat penelitian dilaksanakan. notoadmodjo (2013) mengatakan bahwa perilaku merupakan totalitas peghayatan dan aktivitas yang merupakan hasil akhir dari rangkaian proses dalam diri manusia seperti perhatian, pegamatan, pikiran, ingatan maupun fantasi seseorang. di tempat penelitian yaitu ruangan hematologi anak bona perilaku ibu dalam pemenuhan kebutuhan asah, asih, dan asuh (praba diyan r., dkk.) 69 1 rsud dr soetomo merupakan ruangan kelas 3 dimana sangat mudah bagi masing-masing ibu untuk saling bertukar informasi dan pengalaman baik melalui panca indra maupun secara verbal. family centre care merupakan suatu program dimana seorang perawat memampukan dan melibatkan keluarga dalam setiap asuhan keperawatan yang dilakukan terhadap anak, dengan family centre approach ini perawat dapat meningkatkan rasa percaya diri dan kemampuan orang tua dalam merawat anaknya (soetjiningsih 2005), sehingga meskipun tingkat pendidikan responden dalam penelitian ini cenderung rendah namun memiliki aspek pendukung yang memadai untuk dapat meningkatkan pengetahuan maupun kemampuan ibu dalam memenuhi kebutuhan anak akan asah, asih maupun asuh. lama ibu merawat anak dengan leukemia di nilai mulai dari anak terdiagnosa leukemia hingga waktu penelitian. hasil penelitian ini menunjukkan bahwa lama merawat anak dengan leukemia tidak signifikan dalam membentuk faktor personal ibu. lama merawat anak tidak selalu menjamin baik buruknya perilaku ibu dalam penelitian ini. terdapat faktor internal dan eksternal yang dapat mempengaruhi perilaku seseorang (notoadmodjo 2013). model dari resnick yang merupakan pengembangan dari teori self efficacy bandura yang mendasari penelitian ini menampilkan lingkungan sebagai faktor eksternal sedangkan faktor personal sebagai faktor internal. menurut notoadmodjo (2013) dari segi faktor eksternal lingkungan merupakan faktor yang mendominasi terbentuknya perilaku seseorang. lama merawat anak disini merupakan salah satu faktor internal dari ibu. faktor internal maupun eksternal saling terkait untuk membentuk perilaku seseorang. responden penelitian ini memiliki banyak dukungan dari lingkungan, hal ini dapat dilihat dari hasil penelitian bahwa responden memiliki vicarious experience atau pengalaman dari orang lain yang memiliki masalah sama, hasil diskusi kelompok juga menunjukkan bahwa dukungan berupa belajar dari pengalaman dari ibu lain yang memiliki masalah sama yang telah lebih dulu anaknya terdiagnosa leukemia. selain itu di ruangan perawatan anak rsud dr soetomo surabaya telah menerapkan family centered care yang dapat mempengaruhi personal ibu, dimana sesuai dengan model teori dari resnick yang menunjukkan bahwa selain lingkungan dapat berpengaruh langsung terhadap perilaku, faktor lingkungan juga sebelum dapat mempengaruhi perilaku, faktor ini merubah atau mempengaruhi faktor personal terlebih dahulu kemudian bisa merubah perilaku. hasil penelitian ini menunjukkan bahwa jumlah rerata terbanyak responden adalah responden yang memiliki kualitas hidup yang buruk dan memiliki perilaku pemenuhan kebutuhan asah, asih dan asuh dengan kualitas yang buruk pula. penelitian ini dapat diketahui bahwa kualitas hidup ibu yang menjadi responden dalam penelitian ini sebagian besar adalah memiliki kualitas hidup yang buruk. penelitian ini sesuai dengan hasil penelitian eiser, c. richard, e., stride, c. (2005) bahwa kualitas hidup ibu anak dengan penyakit kronis akan menurun. kualitas hidup ibu menurut ware, j, e., gandek (1998) terdiri dari fungsi kesehatan fisik, keterbatasan peran karena kesehatan fisik, nyeri, persepsi kesehatan secara umum, fungsi sosial, masalah emosional, psikis dan vitalitas. dimensi kualitas hidup memiliki aspek yang cukup luas, yaitu aspek masalah fisik maupun psikologis. menurut notoadmodjo (2013) mengatakan kondisi emosi seseorang dapat mempengaruhi perilaku, karena emosi akan mempengaruhi pikiran dan daya nalar seseorang. hasil pengambilan data menunjukkan bahwa sebagian besar ibu yang memiliki self efficacy rendah juga memiliki perilaku asah, asih dan asuh yang rendah juga. hasil uji statistik dalam penelitian ini menujukkan pula adanya pengaruh yang signifikan antara pse dengan perilaku ibu dalam asah, asih dan asuh. menurut (bandura a 1994) efficacy adalah keyakinan seseorang akan kemampuan dirinya dalam melakukan suatu aktivitas tertentu untuk mencapai suatu tujuan, menghadapi suatu tantangan atau bangkit dari masalah. parental self efficacy (pse) didefinisikan oleh guimond, a, b., wilcox, m, j., lamorey (2008) sebagai persepsi orang tua akan kemampuan dirinya dalam menjalankan tugasnya sebagai orang tua terhadap anaknya secara efektif. hal ini sejalan dengan peterson, s, j., bredow, t (2004) yang menyebutkan bahwa self efficacy akan berpengaruh terhadap perilaku seseorang. bandura (1994) mengatakan bahwa self efficacy akan melalui suatu proses dalam diri individu yaitu proses kognitif, motivasional, afektif dan seleksi. melalui proses kognitif yaitu self efficacy mempengaruhi bagaimana pola pikir sehingga dapat mendorong atau menghambat perilaku seseorang. proses ini sejalan dengan pendapat gist & mitchell jurnal ners vol. 11 no. 1 april 2016: 63-72 70 (1992) dalam peterson, s, j., bredow, t (2004) bahwa sebelum terbentuk suatu perilaku terjadi proses dalam diri seseorang yaitu analisis dari tugas yang akan dilalui, analisis dari pengalaman yang dimiliki dan mengkaji berbagai kebutuhan yang diperlukan sehingga akan muncul keyakinan atau kesiapan seseorang dalam menghadapi suatu tantangan, dari sinilah kemudian terbentuk perilaku yang tepat (resnick, 2004). ibu dengan anak leukemia yang memiliki self efficacy tinggi akan terbentuk pola pikir akan tercapainya suatu kesuksesan yaitu harapan kesembuhan anak atau kualitas hidup anak yang baik, sehingga dengan terbentuknya pola pikir yang positif ini akan terwujud suatu hal yang positif pula, perawatan ibu yang berdasar pada asah, asih dan asuh dengan kualitas baik sehingga terwujud kualitas hidup anak yang baik. self efficacy merupakan hal terpenting dalam diri seseorang untuk membentuk sebuah motivasi yang kuat, menurut teori expectancyvalue menyatakan bahwa motivasi terbentuk melalui harapan, usaha yang dilakukan seseorang berdasarkan dari seberapa besar harapan yang ingin diraih (bandura a 1994). adanya kepercayaan self efficacy yang tinggi pada seorang ibu dengan anak yang terdiagnosa leukemia dimana harus melaukan perawatan dalam jangka waktu yang panjang akan melewati berbagai tantangan selama perawatan, dengan motivasi yang kuat akan terbentuk suatu komitmen serta tingkatan pencapaian harapan yang tinggi yaitu terwujudnya kualitas hidup anak yang baik sehingga terbentuk perilaku pemenuhan kebutuhan anak asah, asih dan asuh dengan kualitas yang baik. parental self efficacy dalam penelitian ini memiliki pengaruh yang signifikan dalam membentuk perilaku asah, asih dan asuh ibu dengan anak leukemia. pengaruh yang signifikan ini salah satunya juga dibentuk oleh faktor personal yang mendasari self efficacy ibu, yaitu usia, pendidikan, lama merawat anak, tingkat kesedihan dan kualitas hidup ibu, yang telah dibahas pengaruhnya pada sub bab sebelumnya. hasil penelitian menunjukkan bahwa mayoritas perawat mengaplikasikan family centerd care (fcc) dengan baik. hasil uji statistik menunjukkan tidak adanya pengaruh antara fcc dengan perilaku ibu. teori middle range self efficacy dari barbara resnick (2004) dalam (peterson, s, j., bredow, t 2004) menunjukkan bahwa faktor lingkungan memberikan pengaruh pada perilaku, namun pada penelitian ini tidak dapat membuktikan model tersebut. penelitian untuk menyusun model tersebut dilaksanakan di negara asing yang berbeda budaya dan karakteristik personalnya dengan penelitian ini. teori middle range self efficacy oleh barbara resnick (2004) dalam peterson, s, j., bredow, t (2004) nampak bahwa lingkungan selain dapat langsung mempengaruhi perilaku juga dapat melalui jalur peningkatan karakteristik personal terlebih dahulu sebelum kemudian dapat meningkatkan self efficacy dan juga perilaku. menurut judge (1997) dalam guimond, a, b., wilcox, m, j., lamorey (2008) pemberdayaan orang tua terbukti secara signifikan dapat meningkatkan parental self efficacy ibu sehingga meningkatkan peran sebagai orang tua dengan baik. hal ini sejalan dengan dust (1999) bahwa perlunya dukungan pada faktor personal orang tua untuk dapat meningkatkan perilaku sehingga dapat tercipta output yang baik pada anak melalui program fcc. menurut soetjiningsih (2005) peran pelayanan kesehatan pada anak dengan penyakit kronis atau leukemia bukan hanya pada aspek peyembuhan tetapi juga perawatan, tujuannya adalah untuk mencegah dampak dari kondisi kesehatan kronis dan mengoptimalkan tumbuh kembang anak baik fisik, kognitif dan psikososial, untuk dapat mencapai tujuan ini diperlukan perawatan yang berorientasi kepada keluarga (family centered). perawatan dengan prinsip fcc ini memberikan dukungan dalam hal mengetahui kekuatan yang ada dalam keluarga, meningkatkan rasa percaya diri dan kemampuan dalam merawat anak. dua konsep dasar dalam asuhan berpusat keluarga adalah memampukan (empowerment) dan memberdayakan (enabling) (wong, d.l., hokenberry-eaton, m., wilson, d., winkelstein, m. l., schwartz 2010). fcc memberikan informasi mulai dari yang dasar sampai dengan perkembangannya secara berkelanjutan, dengan tujuan agar keluarga dan anak dapat lebih efektif dalam perawatan dan pengambilan keputusan, menyediakan fasilitas pendukung baik yang formal maupun informal. seperti contoh pendukung informal yaitu adanya support group, bekerja sama dengan pasien dan keluarga di semua tingkat pelayanan kesehatan (american academic of pediatric 2012). perawat telah mengaplikasikan filosofi keperawatan anak fcc dalam memberikan perilaku ibu dalam pemenuhan kebutuhan asah, asih, dan asuh (praba diyan r., dkk.) 71 perawatan pada pasien anak di ruang bona 1 rsud dr soetomo surabaya, dimana sejalan dengan misi irna anak yaitu memberikan pelayanan profesional berprinsip pada asuh, asih, asah dengan melibatkan orang tua (care with parents). fcc yang diaplikasikan oleh perawat tidak dapat langsung merubah perilaku ibu dalam asah, asih dan asuh, namun harus merubah karakteristik personal dari ibu terlebih dahulu. indikator pendidikan merupakan indikator pembentuk karakteristik personal ibu yang paling utama. responden dalam penelitian sebagian besar memiliki pendidikan dalam kategori yang rendah, sehingga diperlukannya peran perawat dalam memberdayakan dan memampukan ibu dalam perawatan anak untuk meningkatkan pengetahuan maupun ketrampilan ibu dalam perawatan anak, sehingga dengan pengetahuan dan ketrampilan yang baik akan dapat merubah perilaku ibu. simpulan dan saran simpulan model perilaku ibu dalam pemenuhan kebutuhan asah, asih dan asuh sebagai upaya peningkatkan kualitas hidup anak dapat disusun dari beberapa faktor yaitu sumber self efficacy, parental self efficacy dan faktor personal ibu dengan anak leukemia. kualitas personal ibu dapat ditingkatkan melalui program family centered care. parental self efficacy dapat ditingkatkan dengan cara memperbaiki sumber self efficacy terutama mekanisme koping dan dukungan berupa pengalaman orang lain. saran perlu adanya program diskusi kelompok secara terstruktur bagi orang tua dengan anak leukemia yang di fasilitasi secara kolaboratif oleh tenaga kesehatan, baik dokter, perawat, maupun tenaga kesehatan lain untuk saling bertukar pengalaman dan memecahkan permasalahan bersama berbasis pemenuhan kebutuhan dasar anak asah, asih dan asuh. perawat perlu meningkatkan pengetahuan orang tua tentang gejala fisik dan efek samping pengobatan anak dengan leukemia serta cara perawatan fisik anak leukemia dengan pendekatan dimensi fisik kualitas hidup anak yaitu memantau respons anak terhadap pengobatan kemoterapi, mencegah infeksi , mencegah cedera yang dapat menyebabkan perdarahan, pemberian nutrisi, mengatasi nyeri, istirahat dan tidur. perlunya peningkatan pengetahuan orang tua dengan pemberian edukasi tentang perkembangan anak usia sekolah dan stimulasi yang terarah dan aman untuk perkembangan anak usia sekolah dengan p e n y a k i t l e u k e m i a . p e r l u n y a p e r a w a t memberikan edukasi kepada orang tua dengan anak leukemia tentang kondisi emosional anak dengan leukemia dan pemenuhan kebutuhan emosional anak yang meliputi kasih sayang, rasa aman, harga diri, kebutuhan sukses, mandiri, dorongan, mendapatkan kesempatan dan pengalaman dan rasa memiliki kepustakaan bandura, 1977. self-efficacy: toward a unifying theory of behavioral change. psychological review, 84, pp.191–215. available at: www. sciencedirect.com. bandura a, 1994. self efficacy. in v. s. ramachaudran (ed.). encyclopedia of human behavior,, 4, pp.71–81. available at: http://www.uky.edu/~eushe2/bandura/ba ndura1994ehb.pdf. eakes, g., 1995. chronic sorrow: the lived experience of parents of chronically mentally ill individuals. archives of psychiatric nursing, 9(2). eiser, c. richard, e., stride, c., b., 2005. quality of life in children newly diagnosed with cancer and their mothers. health and quality of life outcomes, 29(3). guimond, a, b., wilcox, m, j., lamorey, j., 2008. the early intervention parenting self-efficacy scale (eipses) scale construction and initial psychometric evidence. journal of early intervention, 30(4), pp.295–320. hastings, r. p., & brown, t., 2002. behavior problems of children with autism, parental self-efficacy, and mental health. american journal on mental retardation,, 107, pp.222–232. irmawati, m., irwanto, cahyadi, a., 2012. penilaian kualitas hidup anak penderita kanker. jurnal ners, 7(2). jones, b, l., 2012. the challenge of quality care for family caregivers in pediatric cancer care. seminars in ocology nursing, 28(4), pp.213–1220. jones, t. l., & prinz, r.j., 2005. potential roles of parental self-efficacy in parent jurnal ners vol. 11 no. 1 april 2016: 63-72 72 and child adjustment: a review. clinical psychology review, 25, pp.341–363. krisnana, i., 2012. model asuhan keperawatan dengan pendekatan creating oportunity for parent empowerment (cope) sebagai upaya menurunkan stres hospitalisasi orang tua dengan anak leukemia. jurnal ners, 7(2). masa’deh, r., collier, j., and hall, c., 2012. parental stress when caring for a child withcancer in jordan: a cross-sectional survey. health and quality of life outcomes, pp.1–7. available at: http://www.hqlo.com/content/10/1/88. mussato, k., 2006. adaptation of child and family to life with a chronic illness. cambridge journal, 16. notoadmodjo, 2013. promosi kesehatan dan perilaku kesehatan, jakarta: rineka cipta. nursalam, 2013. metodologi peneliian ilmu keperawatan., jakarta: salemba medika.: salemba medika. pediatric, a.a.o., 2012. patientand familycentered care and the pediatrician’s role. pediatrics, 129(2), pp.394–404. available at: www.pediatrics.org. peterson, s, j., bredow, t, s., 2004. middle range theories application to nursing research, philadelpia: lippincot william & wilkins. quraniati, n., 2013. model empowerment sebagai upaya meningkatkan perilaku orang tua dalam perawatan anak leukemia dengan kemoterapi, surabaya. soetjiningsih, 2005. tumbuh kembang anak dan remaj 2nd ed., jakarta: sagung seto. umiati, m., rakhmawati, w., simangunsong, b., lukitowati, fauzi, e., setiawan, e., t., 2013. gambaran kualitas hidup anak usia 6-18 tahun yang menjalani kemoterapi. indonesian journal of cancer. available at: indonesianjournalofcancer.org. ware, j, e., gandek, b., 1998. overview of the sf-36 health survey and the international quality of life assessment (iqola) project for the iqola project. j clin epidemiol, 51(11), pp.903–912. available at: http://www.qualitymetric.com/whatwed o/generichealthsurveys/tabid/184/defau lt.aspx. wong, d.l., hokenberry-eaton, m., wilson, d., winkelstein, m. l., schwartz, p., 2010. buku ajar keperawatan pediatrik, jakarta: egc. issn 0000-0000 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. ilya krisnana, s.kep., ns., m.kep. dr. rizki fitryasari p. k, s.kep., ns., m.kep. technical editor: hidayat arifin, s.kep., ns., m.kep masunatul ubudiyah, s.kep., ns. layouter: masunatul ubudiyah, s.kep., ns. dluha maf’ula, s.kep., ns. hidayat arifin, s.kep., ns. rifky octavia pradipta, s.kep., ns. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. p-issn: 1858-3598 e-issn: 2502-5791 acknowledgment to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 15 no. 2 october 2020. 1. prof. dr. ah. yusuf, s.kp., m.kes universitas airlangga, indonesia 2. anna kurniati, s.km, ma, phd bppsdmk, ministry of health, indonesia 3. bayhakki bayhakki, phd university of riau, indonesia 4. budi santoso, s.kep,.m. kep, sp.kep.kom poltekkes kemenkes palembang, indonesia 5. erni astutik, s.km., m.epid universitas airlangga, indonesia 6. elsi dwi hapsari, s.kp., ms, ds universitas gajah mada, indonesia 7. hilmi yumni, s.kep., ns., m.kep., sp. mat poltekkes kemenkes surabaya, indonesia 8. dr. ika yuni widyawati, s.kep., ns., m.kep., ns.sp.kep.mb universitas airlangga, indonesia 9. prof. dr. khatijah l. abdullah sunway university, malaysia 10. linlin lindayani, phd sekolah tinggi ilmu keperawatan ppni jawa barat, indonesia 11. meidiana dwidiyanti, s.kp., m.sc. universitas diponegoro, indonesia 12. dr. mira triharini, s.kp., m.kes universitas airlangga, indonesia 13. muhammad miftahussurur dr., m.kes., sp.pd-kgeh., ph.d. universitas airlangga, indonesia 14. ni ketut alit armini, s.kp., m.kep universitas airlangga, indonesia 15. phat prapawichar, m.nurs assumption university, thailand 16. rr. dian tristiana, s.kep., ns., m.kep universitas airlangga, indonesia 17. shanti wardaningsih, ns., m.kep., sp.jiwa., ph. d universitas muhammadiyah yogyakarta, indonesia 18. dr. saryono, s.kp., m.kes universitas jendral soedirman, indonesia 19. profil sarni maniar berliana, m.si sekolah tinggi ilmu statistik, indonesia 20. dr. tri johan agus yuswanto, s.kp., m.kep. poltekkes kemenkes malang, indonesia 21. dr. yuni sufyanti arief, s.kp., m.kes universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by the ministry of science, research, technology and higher education of indonesia, republic of indonesia no: 21/e/kpt/2018 table of content editorial: research utilization and evidence-based practice in education and nursing practice yulis setya dewi, smriti kana mani 18. relationship between demographic characteristics and moral sensitivity among professional nursing students in bali ni putu emy darma yanti, komang menik sri krisnawati 113-117 19. the study of learning outcomes under thai qualifications frameworks for higher education (tqf: hed) in community health nursing practicum course of 4th year students, faculty of nursing, naresuan university amaraporn puraya, somsak thojampa, srisupha jaisopha 118-125 20. how do people living with hiv acquire hiv related information: a qualitative evaluation of jakarta setting mahathir mahathir, wiwin wiarsih, henny permatasari 126-134 21. domestic violence and postpartum depression winnellia fridina sandy, djaswadi dasuki, elli nur hayati, suhariyanto suhariyanto 135-141 22. summary guidance for daily practices on glycemic control and foot care behavior devi mediarti, rosnani rosnani, hidayat arifin 142-147 23. the differences of inpatients’ satisfaction level based on socio-demographic characteristics ni komang ayu adnya dewi, ni putu emy darma yanti, kadek saputra 148-156 24. what do our nurses know about managing patient with permanent pacemakers? muhamad al muizz ismail, nor marini ibrahim, muhammad kamil che hasan 157-161 25. reducing labor pain intensity within first stage active phase through hegu li 4 acupressure and quranic recital method nurul azizah, rafhani rosyidah, hanik mahfudloh 162-166 26. model theory of planned behavior to improve adherence to treatment and the quality of life in tuberculosis patients 167-172 made mahaguna putra, ni putu wulan purnama sari 27. empowerment for children aged less than 5 years with stunting: a quasiexperimental design eli amaliyah, mulyati mulyati 173-177 28. analysis of factors related to nursing student self wareness in doing screening for psychosocial problems verantika setya putri, ah yusuf, rr dian tristiana 178-184 29. the relationship between family harmony with stress, anxiety, and depression in adolescents heni dwi windarwati, amin aji budiman, renny nova, niken asih laras ati, mira wahyu kusumawati 185-193 30. effectiveness of an intervention based on peplau’s model on health literacy among nurses who smoke: a quasi-experimental study achmad djojo, suhariyanto suhariyanto, lily yuniar, arsad suni, efi riani, yogi ervandi, sepni walvri, anggie aprizal, rr tutik sri hariyati, hanny handiyani 194-198 31. life experience of pregnant woman with gestational diabetes mellitus in maternal role attainment in special region of yogyakarta indah wulaningsih, elsi dwi hapsari, heny suseani pangastuti, robert priharjo 199-207 32. knowledge, attitude, and culture influence visual inspection with acetic acid service use alifina izza, pungky mulawardhana, samsriyaningsih handayani 208-213 33. determinants of nutritional status among pregnant women: a transcultural nursing approach ni ketut alit armini, nurul hidayati, tiyas kusumaningrum 214-221 34. social support attainment of older adults living in a flood-prone community arlene supremo, sillmark bacason, alpha issa christianne abegonia, louverille bacason 222-227 35. determinant analysis of trigger risk of death of father because of noncommunicable diseases in the family miftahul munir 228-231 142 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.23921 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the influence of web-based spiritual problem solving on the prevention of suicidal risk among university students siti khadijah1, ah. yusuf2, hanik endang nihayati2, and esti yunitasari2 1politeknik kesehatan kemenkes surakarta, surakarta, indonesia 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: suicide is a health phenomenon that is currently increasing, especially in young adults aged 15-29 years. the spiritual aspect in the form of belief in god is one way to prevent suicide. this study was conducted to determine the effect of web-based spiritual problem solving on the prevention of suicide risk in college students. methods: the research design used a pre-experimental one-group pre-posttest. the sample was 59 respondents using the purposive sampling technique. the independent variable was web-based spiritual problem solving, and the dependent variable was suicide risk prevention. the intervention was delivered via the web using powerpoint media, inspirational videos, and counselling for approximately one month with four sessions. data were collected using a questionnaire and analysed using the wilcoxon sign rank test. results: web-based spiritual problem solving significantly decreases suicide risk with a p-value of 0.000 (p < 0.05). conclusion: web-based spiritual problem solving has been shown to be effective in reducing students’ suicide risk. this web intervention can be used for 24 hours and specifically for counselling and two-way communication on the web; privacy is maintained because of a hidden identity, which is seen in code when interacting with counsellors so as to minimize stigma. article history received: january 4, 2021 accepted: november 2, 2021 keywords spiritual problem solving webbased; suicide risk prevention; college students contact siti khadijah  s.khadijah3029@gmail.com  politeknik kesehatan kemenkes surakarta, surakarta, indonesia cite this as: khadijah, s., yusuf, ah., nihayati, h. e., yunitasari, e., & tristiana, r. d. (2021). the influence of web-based spiritual problem solving on the prevention of suicidal risk among university students. jurnal ners, 16(2). 142-147. doi: http://dx.doi.org/10.20473/jn.v16i2.23921 introduction suicide is a phenomenon of increasing health problems among young adults aged 15-29 years. suicide cases often appear in media coverage (kementerian kesehatan republik indonesia, 2019). suicide is the leading cause of morbidity and mortality worldwide (ballesteros & hilliard, 2016). that there is an increasing need for mental health in us colleges, as many as 35% of college students report “feeling so depressed and having difficulty learning and another 50% experiencing intense anxiety that makes it difficult to succeed academically, according to the center for collegiate mental health (ccmh) counselling., it was found that from 263 universities, 33% had serious mental health problems and were accompanied by suicidal ideation (tsong et al., 2018). a person's inability to control stress will lead to suicidal behaviour (keliat & pasaribu, 2016). the suicide death rate in indonesia was higher in 2016 by 100,000 population, men 4.8/100,000 higher than women by 2.0/100,000 population (kementrian kesehatan republik indonesia, 2019). students are a group of young adults entering their early adulthood who will experience a period of challenges, rewards, and crises (potter & perry, 2005). the life challenges and responsibilities that a person feels when approaching adulthood will be heavier, especially when entering the phase of being a student, the number of tasks and the perceived pressure will affect mental health. in 2019 a university student in surakarta committed suicide (ryantono, 2019). a preliminary study on students at surakarta health college in 2019 revealed that the idea of suicide occurred highly in 32% students, and was lower in 68% of students. the results of researcher interviews indicates there were problems https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v16i2.23921 jurnal ners http://e-journal.unair.ac.id/jners | 143 with consulting students as some did not want to meet directly but only wanted to go through whatsapp communication due to embarrassment, students blamed and were disappointed in god for the problems experienced. this needs to get serious attention so that preventative efforts can be made so that no suicide occurs. college students as the nation's next-generation must be aware of the potential risk of suicide that exists in themselves and it is increasingly important for universities to provide prevention and intervention programmes in the campus environment (tsong et al., 2018). a study by wolitzky-taylor et al. (2019) described a metaanalysis that revealed that suicide data programmes were effective in university suicides. spiritual factors are part of the internal protective factors that are easier to modify so that problemsolving efforts can be done by reinforcing aspects. spiritual (belief) is one way to prevent suicide. the online world can be used as a means to help lecturers provide guidance to counsellors to counsel. counselling is not only done face-to-face (ftf) in one closed space, but can be done through a remote format assisted by technology which is further known as e-counselling (hidayat, 2018). the use of the internet and social media is very high in college students as a repository to find solutions to solving mental health problems while maintaining privacy, reducing stigma, and efficiency of distance and time, so it is necessary to make facilities in the form of webbased spiritual problem-solving. this web-based spiritual problem solving is an effort to overcome obstacles with focused thought to find solutions by pouring out the spiritual aspect, namely belief by interpreting life problems and life goals through online networks. web-based spiritual problem solving with the watson approach that links healing roots, caring, and spirituality in nursing will be very important. belief systems can affect clients emotionally, physically, psychologically, and behaviourally (o’brien et al., 2013). mcauliffe, mcleavey, and fitzgerald (2014) explained that problem-solving skills training provided significant psychological and social improvements, showed a positive treatment effect in the self-harm group. based on the phenomenon of problems above, this study is needed to analyse the effect of web-based spiritual problem solving on the prevention of suicide risk in college students. materials and methods this study used a pre-experimental design of one group pre-post-test. before the research was carried out informed consent was gained from respondents. the study was conducted between march and june 2020. the population was 359 college students at the health college in surakarta. the total sample was 59 respondents obtained by purposive sampling with inclusion criteria: 1) regular students; 2) young adults aged 17-29 years; and 3) college students with positive screening results at high risk of suicide, screening using the suicide behavior questionnairerevision (sbq-r). the independent variable is webbased spiritual problem solving, and the dependent variable is the prevention of suicide risk. the risk of suicide was measured using the sbq-r, which has four total score items. the total score was obtained by accumulating the individual item scores with total score ranges from 3 to 18 points. a total score of ≥ 7 indicates a high risk of suicidal behaviour, while the <7 indicates a low risk of suicidal behaviour (osman et al., 2001). the instrument has been tested for validity and reliability using cronbach alpha with a value of 0.785. the validity test was conducted in november 2019 by first testing the questionnaire on a number of 30 respondents who were not study subjects and who had the same characteristics as the study subjects. the intervention was delivered via the web using powerpoints, inspirational videos, and counselling for approximately one month with four sessions. the web can be used for 24 hours and specifically for counselling, the contract is made in advance according to the agreement with the counsellor so that two-way communication can occur. this research was in collaboration with an it consultant from the institute of phicos group surakarta so that there was a letter of agreement to maintain the privacy and security of respondents’ data. during the counselling process, the data that appears on the consultation screen is only a student numeric code so that the counsellor will not know the identity of who was communicating with the counsellor. this was done to maintain the privacy of respondents. the investigators explained the research process to the respondents and provided guidance books on the use of spiritual problem-solving web to students, respondents fill out informed consent through the web by choosing willing or unwilling choice. the first step was session 1, pre-test by filling out assessment questionnaire links on the web. the second step was session 2, intervention with the web problem solving media using powerpoint system and inspirational video which tells an inspiring story in the face of problems. the third step was session 3, two-way counselling with a counsellor. the fourth step was session 4, an evaluation. a two-way solution was conducted with the counsellor and filling in the post-test by filling in from the web system. the evaluation was carried out 1 week after counselling. the time allotted for two-way counselling was 60-90 minutes. counselling was done online based on the web. respondents were not identified because they appeared on the web as a code to reduce stigma and students willing to seek mental health help through the web can get the problems solved. ethical clearance for this research was carried out at the ethics committee at the faculty of nursing, airlangga university on december 9, 2019, with certificate number 1854-kepk. before the data collection, the respondents were given informed consent which indicated the purpose of the study, the s. khadijah et al. 144 | pissn: 1858-3598  eissn: 2502-5791 potential benefits and harm of the research, and ensures their complete anonymity throughout the research profess, and that they have the freedom to withdraw from the study at any time. after the informed consent distribution, the respondents were asked to sign it signifying the respondent's voluntary decision to be part of the study. the researcher addressed issues such as confidentiality, anonymity, and privacy. further, the completed questionnaires are stored on the web and can only be accessed by it admins. results based on table 1, some college students at surakarta health college had a positive risk of suicide (n = 59, 16%). the response rate was 85%. for the positive risk group totaling 59 college students, the majority of respondents were women (93.2%), at the second semester (first-year students; 37.3%), aged 20 years old, (27.1%), having physical or sexual abuse experience (3.4%), and preferring to keep their problem alone (45.8%). based on table 2 and on the indicators of risk of suicide, there is a change for the better, the majority think that the desire to try suicide is a pre-test, the mind only passes it to be better during the post-test, that is, there is never any thoughts of suicide, for the frequency of suicidal thoughts in the pre-test year, the majority is rare (1 time) to change for the better during the post-test, namely never. based on table 3, the study found a high risk of suicide pre-test 98.3% to 40.7%. this shows that after being given a web-based problem-solving spiritual intervention the risk of suicide has decreased. the results of the study were carried out by the wilcoxon test because the data were not normally distributed, the wilcoxon test results were different or there was a significant effect between the risk of pre and post suicide carried out by web-based spiritual problemsolving interventions with a p-value of 0.000 (p < 0.05). the wilcoxon test results on the variable risk of suicide produced a z-value of -4,676 with p = 0.000. it shows the value of significance was lower than level of significance (a = 5% or 0.05). so, it can be concluded that there is a significant difference in the results of the risk of suicide at the pre-test and posttest. this means that there is an influence of webbased spiritual problem solving on the ability to prevent student suicide risk. discussion based on the results of the screening the risk of suicide was measured using the sbq-r, the positive prevalence of student suicide risk at the surakarta health college was 16% of the total respondents, with the highest demographic character in first-year students. they have a higher risk of suicide than those with second-year students or above because they are new students and are still in the transition period from late adolescence to early adulthood, learning methods that are different from high school education, greater responsibility, and the period of adaptation to lectures cause them to have higher stress levels. meanwhile, the students above are stronger because they have adapted and are psychologically mature. even though the positive number is only 16%, it is very important to note because it can have serious consequences for them. research results from lu, bian, and song (2015) explains that mental health problems such as anxiety, depression and suicidal thoughts often occur in new students (pieter & lubis, 2017). the psychological hazards in early adulthood, both personally and socially, stems from a failure in development that leaves them immature compared to other adults. some of the factors that hinder this development include physical health barriers, parents who are overprotective of their children, and the influence of associations or peers. the age range of college students who were positive for the risk of suicide was 17-23 years and most occurred at the age of 20 years. this contradicts the theory of yusuf, fitriyasari, r, and nihayati (2015), that the risk factors for suicide in adolescents and those aged up to 45 years have a higher risk than those aged 25-45 years and 12 years. today's young adult groups face greater challenges than the previous era, this is due to the very rapid development of science and technology, one of which is social media, which can influence their attitudes and behaviour, including suicidal behaviour. putri (2018), dr. nova riyanti yusuf, spkj from the table 1. respondents’ characteristics (n = 59) characteristics n % semester 2 22 37.3 4 9 15.3 6 21 35.6 8 7 11.9 age (years old) 17 1 1.7 18 12 20.3 19 13 22.0 20 16 27.1 21 13 22.0 22 3 5.1 23 1 1.7 gender male 4 6.8 women 55 93.2 response to problems talk to friends 21 35.6 keep it alone 27 45.8 talk to family 1 1.7 talk to friends & kept alone 2 3,4 talk to friends & family 2 3,4 keep alone, talk to friends & family 4 6.8 history of physical/sexual violence yes 2 3,4 not 57 96.6 jurnal ners http://e-journal.unair.ac.id/jners | 145 association of indonesian psychiatrists (pdskji) jakarta said that social media is one of the factors that trigger a person to commit suicide. ages 16-24 years have a higher risk of suicide. the suicide rate is directly proportional to the increase in age, and increases at a young age, namely 15-24 years (riyadi, 2004). it is strengthened by research from kementerian kesehatan republik indonesia, (2019), which states that suicide is currently the second leading cause of death in adolescents and young adults aged 15-29 years. the research findings reveal that the majority of students prefer to keep their problems to themselves, and some of them have a history of physical/sexual violence. student who prefers to keep their problems alone, tends to be introverted, and has physical/sexual abuse traumas, has a higher chance of mental health disorders, to the point that it can result in a person at risk of suicide because a history of physical/sexual violence will result in trauma and affect psychological resilience in dealing with problems. if someone has a problem and feels unable to face it and does not ask for advice, solutions, or motivation from other people, it will add to a heavier burden. if this condition is not addressed, it will cause suicidal thoughts. humans are created as social beings and need the attention and support of others when facing problems. alternative solutions and motivation are needed so that he does not feel alone but has attention and help from others in solving/facing life's problems. baertschi, costanza, and conuto (2018) described personality as a potential determinant of suicidal ideation and attempts. yusuf, fitriyasari, and nihayati (2015) explained that several factors cause suicide, one of which is behaviour and personality disorders. there are four aspects of a closed personality associated with an increased risk of suicide, namely hostility, impulsivity, depression, and hopelessness. the results of the study found that most of the students attempted suicide, namely passing thoughts with a rare frequency. suicide is an act that is prohibited by all religions so that the desire to try suicide that comes to students' minds will decrease when they remember god and will appear again when they feel unable to face the problem at hand. the factor of close people or loved ones also plays a role in reducing suicidal thoughts/desires. but what needs to be watched out for is that a history of suicidal thoughts can recur or come back if you do not have the knowledge and skills of problem-solving as well as good coping mechanisms. spirituality is a tendency to create meaning in life through intrapersonal and transpersonal relationships in overcoming life's table 2. the pre and post-test suicide risk scores indicator pre-test post-test n % n % thinking of trying to kill yourself never 0 0.0 17 28.8 only thoughts pass by 39 66.1 32 54.2 have a plan 18 30.5 8 13.6 has attempted suicide 2 3,4 2 3,4 frequency of suicidal thoughts in a year never 2 3,4 19 32.2 rarely (1x) 28 47.5 22 37.3 sometimes (2x) 19 32.2 13 22.0 often (3-4x) 4 6.8 3 5.1 very often (≥ 5x) 6 10.2 2 3,4 have told someone else that you wanted to kill yourself none 34 57.6 38 64.4 yes, at one time 21 35.6 20 33.9 yes, more than 1x 4 6.8 1 1.7 how big will it be to try to kill yourself one day never 5 8.5 31 52.5 no way at all 7 11.9 6 10.2 more than impossible 6 10.2 3 5.1 impossible 28 47.5 9 15.3 maybe 1 18.6 0 15.3 more than possible 1 1.7 1 0.0 very likely 1 1.7 1 1.7 table 3. wilcoxon test statistics for student suicide risk (n = 59) suicide risk pre-test post-test n % n % low 1 1.7 35 59.3 high 58 98.3 24 40.7 z-value -4,676 p-value 0.000 s. khadijah et al. 146 | pissn: 1858-3598  eissn: 2502-5791 problems (yusuf et al., 2017). shinde and wagani (2019) explained that thoughts or attempts to commit suicide that have occurred will be the most significant risk factor for the occurrence of repetition of actions in the future, so it is very important to screen students for suicide risk to identify quickly so that efforts can be made to prevent suicide risk as early as possible for students. the results of pre-test research is that the risk of suicide is high. this is because they do not have problem-solving skills. research mcauliffe, mcleavey, and fitzgerald (2014) explained that problem-solving skills training provided significant psychological and social improvements and showed a positive treatment effect in the self-harm group. problem solving training has a positive impact and is proven worthy of self-harm therapy, quality of life and depression (perry et al., 2019). social problemsolving therapy was found to provide an additional percent of the variance in non suicidal self injury (nssi) predictions (lucas et al., 2019). supported by the results of the lutz et al. (2020), the research study found that problem solving therapy as a psychotherapy intervention reduces the risk of suicide in adults and anxiety disorders. breitborde, wastler, pine, & moe's (2021) study showed that improved social problem-solving skills may facilitate suicide reduction. after conducting spiritual problem-solving interventions via the web, it is found that there is a decreased risk of suicide. screening found an increase in the number of respondents who said they "never thought about trying to kill themselves". the number of suicidal thoughts in the year saying "never" increased. the majority of students said that they "do not speak of suicidal thoughts to others," and will never attempt suicide again. spiritual problemsolving interventions via the web provide high motivation to make changes to themselves for the better and have a more adaptive coping mechanism and find ways to solve the problems faced appropriately according to the demands and desires of current students. motivation is an active impulse so that there is a change in energy in humans that moves to achieve goals or needs. motivation has a function as a driving force and driving behaviour (candra et al., 2017). motivation and learning are two inseparable things. learning something based on strong motivation will give good results, as it is known learning is the process of acquiring various skills, skills, and attitudes, and learning brings about behaviour change (muhammad, 2017). in addition to motivation problem-solving skills are also needed. research from sarkisian, van hulle, & goldsmith (2021) found that problem solving research in children was significantly meaningful with the risk of suicidal thoughts. such problem-solving therapies can improve the prediction and treatment of suicidal ideation in adolescents. in the results of the evaluation in the counselling session via the web, the respondents said that they prefer web-based interventions because their identity is unknown, they are more flexible in conveying problems, are not ashamed, and can facilitate students who have introverted personalities or have difficulty communicating directly. intervention conventionally has a weak side, namely the presence of stigma that reduces the interest of respondents to seek solutions to problems/solutions to professionals, so that an alternative solution to problems through web applications is needed. web applications have the advantage of being more efficient in time, place, and cost. the results of this study are consistent with other studies, namely research luca, lytle, and yan (2019), students prefer to seek mental health assistance online, this type of intervention could be beneficial for students who need services who are afraid to visit mental health centres on campus because of the stigma. an effective way to reduce student distress, and the presence of suicidal thoughts, with a combination of online and conventional services, can be provided. research from ballesteros and hilliard (2016) explained that online counselling has a significant relationship with self-stigma. problem-solving skills have resulted in systems that are now suitable for chronic mental disorder management, problem solving using technologies such as an application whose operation has more privacy and confidentiality of all information stored in the application, and users can anonymize their identity. troubleshooting using smartphone apps with self-harm prevention management (hatcher et al., 2020). conclusion web-based spiritual problem solving has been shown to be effective in reducing college students’ suicide risk. the interventions were delivered via the web using powerpoints, inspirational videos, and counselling. it can be used 24 hours and specifically for counselling, two-way communication on the web, and privacy is maintained because of a hidden identity. it is hoped that the researchers will further develop web-based interventions in the prevention of suicide risk in the campus environment. references baertschi, m., costanza, a., & conuto, a. (2018). the function of personality in suicidal ideation from the perspective of the interpersonal-psychological theory of suicide. international journal of environmental research and public health, 15, 1– 15. https://doi.org/10.3390/ijerph15040636 ballesteros, j. l., & hilliard, r. c. (2016). u.s.-based latina/o college students’ attitudes toward online counseling. international journal for the advancement of counselling, 38(4), 269–285. https://doi.org/10.1007/s10447-016-9271-x breitborde, n. j. k., wastler, h., pine, j. g., & moe, a. m. (2021). suicidality and social problem-solving skills among individuals with first-episode psychosis participating in coordinated specialty care. early intervention in psychiatry, 15(3), 497– jurnal ners http://e-journal.unair.ac.id/jners | 147 504. https://doi.org/10.1111/eip.12967 candra, i. ., harini, i. g. ., & sumirta, i. . (2017). psikologi landasan keilmuan praktek keperawatan jiwa. penerbit andi. hatcher, s., heisel, m., ayonrinde, o., campbell, j. k., colman, i., corsi, d. j., edgar, n. e., gillett, l., kennedy, s. h., hunt, s. l., links, p., maclean, s., mehta, v., mushquash, c., raimundo, a., rizvi, s. j., saskin, r., schaffer, a., sidahmed, a., … vaillancourt, c. (2020). the beacon study: protocol for a cohort study as part of an evaluation of the effectiveness of smartphone-assisted problem-solving therapy in men who present with intentional self-harm to emergency departments in ontario. trials, 21(1), 1–16. https://doi.org/10.1186/s13063-020-04424-w hidayat, d. r. (2018). konseling di sekolah : pendekatan-pendekatan kontemporer. pertama. prenadamedia group. keliat, b. ., & pasaribu. (2016). prinsip dan praktek keperawatan kesehatan jiwa stuart (indonesia). elsevier. kementerian kesehatan republik indonesia. (2019). situasi dan pencegahan bunuh diri. in pusat data dan informasi (pp. 1–10). lu, w., bian, q., & song, y. (2015). prevalence and related risk factors of anxiety and depression among chinese college freshmen. 35(6), 815–822. luca, s. m. de, lytle, m. c., & yan, y. (2019). helpseeking behaviors and attitudes of emerging adults : how college students reporting recent suicidal ideation utilize the internet compared to traditional resources. journal of american college health, 1–8. https://doi.org/10.1080/ 07448481.2018.1539397 lucas, a. g., chang, e. c., li, m., chang, o. d., & hirsch, j. k. (2019). perfectionism and social problem solving as predictors of nonsuicidal self-injury in ethnoracially diverse college students: findings controlling for concomitant suicide risk. social work (united states), 64(2), 165–174. https://doi.org/10.1093/sw/swz005 lutz, j., mashal, n., kramer, a., suresh, m., gould, c., jordan, j. t., wetherell, j. l., & beaudreau, s. a. (2020). a case report of problem solving therapy for reducing suicide risk in older adults with anxiety disorders. clinical gerontologist, 43(1), 110–117. https://doi.org/ 10.1080/07317115.2019.1617378 mcauliffe, c., mcleavey, b. c., & fitzgerald, t. (2014). group problem-solving skills training for selfharm : randomised controlled trial. 383–390. https://doi.org/10.1192/bjp.bp.111.101816 muhammad, m. (2017). pengaruh motivasi dalam pembelajaran. lantanida journal, 4(2), 87. https://doi.org/10.22373/lj.v4i2.1881 o’brien, p. ., kennedy, w., & ballard, k. . (2013). keperawatan kesehatan jiwa psikiatrik : teori & praktik (b. angelina (ed.); bahasa ind). egc. osman, bage, & guetierrez. (2001). the suicide behaviors questionnaire-revised (sbq-r) overview. 5, 4–6. perry, a., waterman, m. g., house, a., wright-hughes, a., greenhalgh, j., farrin, a., richardson, g., hopton, a. k., & wright, n. (2019). problemsolving training: assessing the feasibility and acceptability of delivering and evaluating a problem-solving training model for front-line prison staff and prisoners who self-harm. bmj open, 9(10), 1–9. https://doi.org/10.1136/bmjopen-2018-026095 pieter, h. ., & lubis, n. . (2017). pengantar psikologi dalam keperawatan (3rd ed.). pt kharisma putra utama. potter & perry. (2005). buku ajar fundamental keperawatan: konsep, proses & praktek (4th ed.). egc. putri, f. . (2018, september). dampak negatif media sosial bisa picu seseorang bunuh diri. detikhealth. riyadi, y. (2004). hubungan antara self esteem dengan kecenderungan bunuh diri pada remaja. skripsi (tidak diterbitkan). fakultas psikologi universitas widya mandala. surabaya. ryantono. (2019). “mahasiswa s2 uns solo tewas bunuh diri, selama lima bulan terakhir konsumsi obat depresi.” tribun solo. sarkisian, k., van hulle, c., & goldsmith, h. h. (2021). persistence during childhood problem-solving as a predictor of active suicidal ideation during adolescence. research on child and adolescent psychopathology, 49(4), 533–543. https://doi.org/10.1007/s10802-020-00726-4 shinde, f., & wagani, r. (2019). does spirituality work as a buffer in suicide : a systematic. 14(2), 249– 256. tsong, y., young, j. t., killer, j. d., & takemoto, m. a. (2018). suicide prevention program on a diverse college campus : examining the effectiveness of a peer-topeer model suicide prevention program on a diverse college campus : journal of college student psychotherapy, 00(00), 1–14. https://doi.org/10.1080/87568225.2018.14347 16 wolitzky-taylor, k., lebeau, r. t., perez, m., gong-, e., fong, t., lebeau, r. t., perez, m., & gong-, e. (2019). suicide prevention on college campuses : what works and what are the existing gaps ? a systematic review and meta-analysis. journal of american college health, 0(0), 1–11. https:// doi.org/10.1080/07448481.2019.1577861 yusuf, a., fitriyasari, r, &, & nihayati. (2015). buku ajar keperawatan kesehatan jiwa. salemba medika. yusuf, nihayati, & iswari, m. . (2017). kebutuhan spiritual: konsep dan aplikasi dalam asuhan keperawatan. (edisi pert). mitra wacana media. authors index volume 16 number 1 april 2021 adi, wien soelistyo 35 alfriani, delisa 35 amin, andi nurzakiah 74 anggarawati, tuti 35 ariawan, i gede nova 26 arifin, hidayat 54 astari, asti melani 17 astuti, yuni 35 boonpracom, roongtiva 89 collera, marian madelyn m. 41 darmawan, rendi editya 13 elviani, yeni 54 handayani, samsriyaningsih 49 indriati, indriati 35 iskandar, imelda 74 kasiati, kasiati 49 krisnana, ilya 96 kusumawaty, ira 54 mashudi, sugeng 67 musni, musni 74 nihayati, hanik endang 96 nurhanifah, laeli 96 nursalam, nursalam 6, 60 ohiman, jeremy b. 41 ortiningsih, rika 49 paz, pearl irish v. de 1 piyakong, duangporn 89 priyantini, diah 60 puraya, amaraporn 89 ramagos, john anthony d 41 riveral, willard n 41 rochana, nana 13 setiawan, setiawan 81 siregar, farida linda sari 81 sujianto, untung 13 sukartini, tintin 6, 60 suza, dewi elizadiani 81 swedarma, kadek eka 26 syam, azniah 74 ubudiyah, masunatul 6 utami, yulian wiji 17 wongwiggan, sugritta 89 yanti, ni putu emy darma 26 yektiningsih, erwin 17 yunike, yunike 54 yusuf, ah 67 subject index volume 16 number 1 april 2021 a accuracy of compression depth 13 adolescent 6 attitude 49 b breast cancer (ca mammae) 96 bullying 6 c cancer 1 cardiac arrest 13 chemotherapy 1 chest compression 13 consultation 26 covid-19 54, 60 covid-19 pandemic 35 crisis 60 culture shock 17 cyberbullying behavior 54 d depression 1 disasters 41 e economic lost 74 emerging adulthood 54 exclusive breastfeeding 74 f factors 60 family coping 67 family experience 35 family health 67 formula feeding 74 h health emergencies 41 health promoting school 6 hems 41 i itinerary 26 j job experience 17 k knowledge 49 m managerial competency 81 medical expenses 74 mental disorders 35 mental health 1, 60 n non-medical expenses 74 nurse 17 nurse manager 81 nurse’s role 26 p positive outcomes 67 premarital counseling 49 psychoeducation 96 psychological 96 psychological management 96 q quality of life 1 s schizophrenia 67 sexual and reproductive health 49 t teaching hospital 81 thailand 89 the elderly 89 the elderly care system 89 travel health 26 travelers 26 typhoons 41 w working environment 17 5 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of: ▪ a highly respected journal in the nursing field. ▪ it is indexed in major databases: science and technology index (sinta), indonesian publication index (ipi), google scholar, bielefeld academic search engine (base), (doaj), worldcat, indonesia onesearch, ebsco, pkp index, index copernicus, isjd, asean citation index ▪ rapid initial screening for suitability and editorial interest. jurnal ners has been accredited by the ministry of science, research, technology and higher education of indonesia since 2010. ii. focus and scope the scope of this journal includes studies that intend to examine and understand nursing health care interventions and health policies which utilize advanced nursing research. the journal also committed to improve the high-quality research by publishing analytic techniques, measures, and research methods not exception to systematic review papers. policy concerns of this journal are as follows: fundamentals of nursing, management in nursing, medical-surgical nursing, critical care nursing, emergency and trauma nursing, oncology nursing, community health nursing, occupational health nursing, mental health nursing, holistic nursing, geriatric nursing, family nursing, maternity nursing, women's health nursing, pediatric nursing, education in nursing, nursing policies, legal nursing, advanced practice nursing, and nursing informatics please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. author information pack update: march 5, 2020 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 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(hons), (scopus id: 56660628500; h-index: 4); faculty of nursing, universitas airlangga, indonesia international advisory board reviewers 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740; h-index: 13); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200; h-index: 10); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, (scopus id: 8293647300; h-index: 12); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172; h-index: 2); college of nursing, university of the philippines manila, philippines 5. dr. nicola cornally, (scopus id: 36982904800; h-index: 13); school of nursing and midwifery, university college cork, ireland 6. dr. david pickles, (scopus id: 57190150026; h-index: 5); college of nursing & health sciences, flinders university, south australia, australia 7. dr. farhan alshammari, (scopus id: 57192298773; h-index: 3); college of nursing, university of hail, saudi arabia 8. dr. patricia leahy-warren, (scopus id: 55954181800; h-index: 11); school of nursing and midwifery, university college cork, ireland 9. dr. wendy abigail, (scopus id: 24467540600; h-index: 3); school of nursing and midwifery, flinders university, australia 10. dr. chong mei chan, (scopus id: 57189591887; h-index: 2); dept. of nursing faculty of health science, university of malaya, malaysia 11. dr. sonia reisenhofer, (scopus id: 16310818100; h-index: 4); school of nursing and midwifery, la trobe university, australia, australia editor: 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100; h-index: 3); faculty of nursing, universitas airlangga, indonesia 2. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756; h-index: 1); faculty of nursing, universitas airlangga, indonesia, indonesia 3. retnayu pradanie, s.kep., ns., 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nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data 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............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who 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frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 14 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: 𝐇′ = −∑ (𝑃𝑖)(log2 𝑃𝑖)𝑠𝑖=1 ………............................................................................................... (1) remarks: .............................................................................................................................................. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old type of care age groups (years) <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 15 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: https://www.mendeley.com/guides/harvard-citation-guide 16 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author, • hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language. • have read the final version of the manuscript and responsible for what is said in it. • have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website. • hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below. • acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk 476 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20515 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original article the effect of health education on gastritis prevention behavior among high school students m taufan umasugi1, fathmy f soulissa1, inta susanti2, and grolya r latuperissa2 1college of health sciences (stikes) maluku husada, maluku, indonesia 2faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: gastritis is the inflammation of the gastric mucosa that is characterized by discomfort felt in the upper abdomen in addition to nausea, vomiting, a decreased appetite and headaches. gastritis is one type of discomfort that is generally suffered by adolescents caused by various factors including their level of knowledge related to being aware of the necessary behavior to prevent gastritis. the purpose of this study was to determine the effect of health education on the student’s behavior and on the prevention of gastritis. methods: the design used was pre-experimental with a pretest-posttest design approach. the sampling technique used in this study was a total sampling technique resulting in 57 respondents. before the intervention, the respondents filled in a questionnaire about the concept of gastritis. furthermore, the respondents were given health education intervention material about gastritis in the form of leaflets containing information on the understanding, causes, signs and symptoms, risk factors and prevention. the intervention was only conducted for one session for 2030 minutes per respondent. following this, 1 hour later, the intervention was evaluated by giving the same questionnaire to the respondent to fill in according to the questions. the data analysis used a paired sample t-test ρ = 0,000. results: the results showed an increase in behavior before and after the intervention related to preventing gastritis among the students. the results showed that 28 respondents (49.1%) with good behavior changed to 33 respondents (57.9%) who behaved well. conclusion: the conclusion is that there is a significant influence from counseling on the prevention of gastritis among high school students. article history received: feb 27, 2020 accepted: april 1, 2020 keywords gastritis; health counseling; behavior students contact fathmy f soulissa  fathmy.fitriany.soulissa2019@fkp.unair.ac.id  college of health sciences (stikes) maluku husada, maluku, indonesia cite this as: umasugi, m. t., soulissa, f. f., susanti, i., & latuperissa, g. r. (2020). the effect of health education on gastritis prevention behavior among high school students. jurnal ners, special issues, 476-479. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20515 introduction gastritis, often known as ulcer disease, is a disease that can be very disturbing. gastritis usually occurs in people who have irregular eating patterns and they eat foods that stimulate stomach acid production. some microorganism infections can also cause gastritis. gastritis pain symptoms, besides pain in the abdomen, include nausea, vomiting, weakness, bloating, tightness, a decreased appetite, pale face, rising body temperature, cold sweats, dizziness, always belching and in more severe conditions, the patient can vomit blood. (pratiwi, 2013) gastritis can affect all ages and genders. some of the surveys show that gastritis most often attacks those of a productive age. at a productive age, they are prone to gastritis symptoms because of the level of busyness and lifestyle that involves not paying attention to health. stress easily occurs due to the influence of the environmental factors (hartati, utomo, & jumaini, 2014) https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 477 according to the data from the world health organization (who) in 2012, a review of several countries in the world showed the percentage of gastritis events in the world: the uk had 22%, china 31%, japan 14.4%, canada 35% and france 29.5%. the incidence of world gastritis is around 1.8-2.1 million of the population every year. the incidence of gastritis in southeast asia is around 583,635 of the population every year. the prevalence of gastritis confirmed through coffee endos out of the population in shanghai made up around 17.2%. this is much higher than the western population which is around 4.1%, and some have no symptoms. (saroinsong, palandeng, & bidjuni, 2014) based on the data from the ministry of health of the republic of indonesia (2013), the incidence of gastritis in several regions in indonesia is quite high with a prevalence of 274,396 cases out of 238,452,952 residents. it was found that in the city of surabaya, gastritis totaled 31.2% while in denpasar, 46% of the population had it. in central java, the incidence of infection was quite high at 79.6% [5]. based on the data from the maluku provincial health office, the incidence of gastritis in 2014 totaled 32,275 cases. the incidence of gastritis in 2016 totaled 31,921 (5.2%) out of the 10 most common diseases. based on the data from the 10 biggest diseases obtained from the tehoru health center in 2018, there were as many as 688 gastritis sufferers. out of the patients with gastritis over the last 3 years, adolescents made up 218 sufferers. in 2016, there were 48 patients, in 2017 there were 94 patients and in 2018, there were 76 patients with gastritis who were adolescents. preliminary research was conducted at tehoru public middle school 4 using interviews. using leaflets was focused on 10 grade 3 students and this showed that prevention of gastritis behavior was good, amounting to 3 students. those that behaved reasonably totaled 2 students and those that behaved less well totaled 5 students. from these results, it can be concluded that the lack of student behavior regarding the prevention of gastritis is due to a lack of knowledge about gastritis. counseling is needed to add insight into the prevention of gastritis. materials and methods design the design used in this research was preexperimental with a one group pre-test and post-test design. the experimental design was implemented through a questionnaire (measurements) before and after treatment n (treatment). the research was conducted by providing a pretest (initial observation) first before the intervention was given and then after the intervention was given, which refers to the posttest (final observation). this study aims to determine the effect of counseling and the prevention behavior of gastritis by providing health education about gastritis and its prevention. the research was conducted with a focus on high school students from 1st august 2019 to 8th september 2019. sample the sample has a number of characteristics possessed by the wider population. the sample in this study totaled57 high school students. data collection techniques the data collection techniques used were questionnaires and direct interviews with the respondent. before the intervention, the respondents filled in a questionnaire about the concept of gastritis. furthermore, the respondents were given health education interventions about gastritis disease material in the form of leaflets containing information covering the understanding, causes, signs and symptoms, risk factors and prevention. the intervention was only conducted through one session for 20-30 minutes per respondent. following this, 1 hour later after the intervention, it was evaluated by giving the same questionnaire to the respondents to fill in. data processing after the data retrieval was done and the data was obtained, the data processing was then performed which includes several parts, namely editing, coding, processing, cleaning, and tabulating the data. data analysis was performed using the spss version 21 computer software. the analysis used univariate and bivariate analysis conducted using a paired sample t test. results the most common age group of respondents was aged 16 years, totaling 29 people (50.8%). the most common sex of the respondents was male, totaling as many as 30 people (52.6%). the knowledge of the respondents before (pre-test) and after (post-test) table 1. pretest and posttest results for behavioral prevention (n=57) behavioral prevention pre test post test n % n % good 28 49.1 33 57.9 not good 29 50.9 24 42.1 table 2. paired sample t-test before and after health education about gastritis (n=57) counseling the mean p value pre test t 21.44 0.000 post t-test 24.88 m. t. umasugi et al. 478 | pissn: 1858-3598  eissn: 2502-5791 counseling for gastritis prevention behavior was determined. the pretest value for most of the respondents showed that they behaved well (28 people: 49.1%) and those that had bad knowledge totaled 29 respondents (50.9%). after the intervention, there was an increase. most of the respondents behaved, totaling 33 respondents (57.9%). the behavior of 24 respondents was not good (24.1%) (table 1). bivariate analysis was used to find out the effect between the dependent and independent variables using the paired-samples t-test statistically to determine the effect of illumination on the prevention of gastritis behavior. the significance value (ρ) from the results of the paired sample t-test was 0,000. the hypothesis decision is that there is a significant influence from counseling on the prevention of gastritis in high school students (table discussion health education aims to change unhealthy behaviors into healthy ones. any new behaviors that are formed are usually only limited to understanding the target.(shalahuddin, 2018) there are several factors that influence the success of health education, including counseling factors, counseling target factors and health education process factors. from the results of the frequency distribution of the respondents, it can be seen that the effect of health education on preventive behavior carried out on the respondents indicates that out of the 57 respondents, most were aged 16 years old, totaling 29 people (50.8%). those aged 17 years old totaled as many as 15 people (26, 3%) and those who were 15 years old totaled as many as 13 people (26.3%). it can be said that age can also influence the behavior of the respondents because those of certain young and adult ages are also included in the productive age category. the age range of 15-17 years old is an age range with a busy schedule because of work, school work and other activities. the respondents are more likely to have behaviors that can increase their risk of developing gastritis such as irregular eating patterns, smoking habits, lazy eating and an unhealthy lifestyle. according to august (2013), it affects one's understanding and mindset. as you get older, you will also develop your perception and mindset so the knowledge that you get will be able to be used better. for gender, men totaled 30 people and women totaled 27 people. the discussion above shows that the number of male respondents is greater than the number of female respondents. this is because the total population of class 3 natural sciences and social sciences was 57 respondents. the number of male respondents in middle school 4 was higher than the number of female respondents who were high school students. regarding the effect of counseling on the prevention of gastritis behavior, it can be seen that the pretest value of the majority of respondents showed that they were behaving well. this totaled 28 respondents (49.1%). this also shows that the student’s behavior was quite good before counseling because some of the students already knew about and understand the behavior used to prevent gastritis. some of the students had adopted a healthy lifestyle in their daily lives. the respondents who behave badly totaling as many as possible 29 respondents (50.9%) indicated that the lack of gastritis prevention behavior is caused by the respondents never following and understanding the health education given on gastritis prevention. the behavior of the respondents is thus in accordance with the statement in the questionnaire on the prevention of gastritis behavior. this is also reinforced by the theory put forward by rahma et al (2013), in that the occurrence of gastritis can be caused by poor and irregular eating patterns, namely referring to eating frequency in addition to the type and amount of food. the stomach thus becomes sensitive when the level of stomach acid increases.(rahma, ansar, & rismayanti, 2012) in the posttest, there was found to be an increase in that most of the respondents behaved well, totaling as many as 33 respondents (57.9%). it can be seen that there is an influence from health education on gastritis prevention behavior among the students. this shows that they can change their mindset and behavior in order to change bad habits into good habits. it can be concluded that students who engage in gastritis prevention behavior in the good category have a good eating pattern. this involves eating small amounts of food but often, and multiplying the eating of foods that contain flour such as rice, corn, and bread. this will produce less gastric acid. reducing the consumption of foods that can irritate the stomach, for example foods that are spicy, sour, fried and fatty, according to (sumangkut, rompas, & karundeng, 2014), can prevent the recurrence of gastritis. this means that the disease will not occur even though a person cannot always eliminate helicobacter pylori. another action is maintaining a good and regular diet. health education can influence knowledge and behavior. according to wood, health education is a useful experience that can influence one's habits, attitude and knowledge (mawey, kaawoan, & bidjuni, 2014). according to nyswander, health education is a dynamic process of behavior change (mawey et al., 2014). there were 24 respondents (42.1%) who misbehaved. this is because after counseling, the respondent did not change their bad habits regarding having a healthy lifestyle. health education is an educational activity carried out by spreading the message and instilling confidence so then the students are not only aware and understand but so then they can also make suggestions related to their health (mawey et al., 2014). the statement is also in accordance with the theory put forward by bandura in 1977 [13]. the behavior or activity in individuals or in one posttest does not appear by itself. it is a result of the stimulus received by one of the posttests concerning both the external stimulus and internal stimulus. individual jurnal ners http://e-journal.unair.ac.id/jners | 479 behavior can affect the individual. this behavior also affects the environment. likewise, the environment can affect individuals and vice versa. the results of the analysis conducted using a paired sample t-test can be seen as the effect of health education on prevention behavior carried out by the respondents totaling 57 people. the average value obtained by the respondents is regarding gastritis prevention behavior before being given the health education. the value is (21.44), which shows that the behavior of students about the prevention of gastritis is still lacking because the students do not understand gastritis and how to prevent it. they are given very minimal health education about gastritis in high school. the average d value of the respondents after being given the health education about gastritis prevention behavior increased to (24.88). this shows that most students have understood and changed their life to gain a lifestyle that is healthy. there is a better effect after counseling that was compared with before doing the counseling related to the behavior used to engage in gastritis prevention among the students. health education can affect knowledge and behavior. according to wood, health education is a useful experience when it comes to influencing one's habits, attitudes and knowledge. according to nyswander, health education is a dynamic process of behavior change (jamil & tahun, 2019). based on table 5.4, from the analysis of the paired sample t-test, the value obtained from the prevention of gastritis before and after counseling was 0,000. the result of < ρ = 0.05 shows that the health effects influence the behavior of gastritis prevention. the decision-based hypothesis shows that there is no significant effect from counseling on the prevention of gastritis in terms of the student’s behavior in middle school. there is an increase before and after the given counseling related to the preventive health behaviors involved in gastritis. this study is in line with the research conducted by (jamil & tahun, 2019) in semarang city. the results of research using the wilcoxon match pair test has a p-value = 0,000. it can be concluded that there is an influence from health education on the adolescents concerning the efforts undertaken to prevent gastritis based on the level of knowledge and attitude of the adolescents when it comes to preventing gastritis. health education is an educational activity carried out by spreading the message and instilling confidence so then the community is more aware. the community must also be willing and able to carry out the given suggestions related to health (mawey et al., 2014). health education aims to change unhealthy behaviors into healthy ones. new behaviors that are formed are usually only limited to understanding the target. there are factors that influence the success of health education, including counseling factors, counseling target factors and health counseling process actors. the broader limits of counseling can be seen in terms of general health and the health education conducted in schools. the theory of counseling in one education site for the students in schools is related to the discussion of the theories of "guidance and counseling." some even refer to the term "guidance and counseling” . the research was carried out by the researchers with a focus on the high school students in class 3 natural sciences and social sciences totaling 57 respondents. the researcher determined that there was a significant difference between the pretest and 1 posttest with a p-value 0,000 <0.05. conclusion health education improves the behavioral prevention of gastritis in the students and a difference was found before and after the counseling was given. the results of this study can be useful information for the students, especially those suffering from gastritis. this can be used to provide an understanding of the gastritis prevention behavior among students. references hartati, s., utomo, w., & jumaini. (2014). hubungan pola makan dengan resiko gastritis pada mahasiswa yang menjalani sistem kbk. jom psik, 1(2), 1–8. https://doi.org/10.1017/cbo9781107415324.0 04 jamil, r. m., & tahun, p. (2019). menara ilmu vol. xiii no.4 april 2019. xiii(4), 105–112. mawey, b., kaawoan, a., & bidjuni, h. (2014). hubungan kebiasaan makan dengan pencegahan gastritis pada siswa kelas x di sma negeri 1 likupang. jurnal keperawatan unsrat, 2(2), 112502. pratiwi, w. (2013). hubungan pola makan dengan gastritis pada remaja di pondok pesantren daar el-qolam gintung, jayanti, tanggerang. jurnal kesehatan, 1. rahma, m., ansar, j., & rismayanti. (2012). faktor risiko kejadian gastritis di wilayah kerja puskesmas kampili kabupaten gowa. jurnal mkmi, 1–14. saroinsong, m., palandeng, h., & bidjuni, h. (2014). hubungan stres dengan kejadian gastritis pada remaja kelas xi ipa di sma negeri 9 manado. jurnal keperawatan unsrat, 2(2), 111663. shalahuddin, i. (2018). hubungan pola makan dengan gastritis pada remaja di sekolah menengah kejuruan ybkp3 garut. jurnal kesehatan bakti tunas husada: jurnal ilmu-ilmu keperawatan, analis kesehatan dan farmasi, 18(1), 33. https://doi.org/10.36465/jkbth.v18i1.303 sumangkut, m., rompas, s., & karundeng, m. (2014). pengaruh penyuluhan kesehatan tentang gastritis terhadap pengetahuan dan perilaku pe 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 518 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20521 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review effect of physical exercise on insulin sensitivity and the modifiable cardiovascular risk factors of patients with t2dm: a systematic review wahyu sukma samudera, ferry efendi, and retno indarwati faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: diabetes mellitus is one of the chronic diseases that have increased in prevalence in indonesia and the world. optimal glycemic control is important to prevent the complications of diabetes mellitus. several recommendations that are used in diabetes treatment involve regular exercise training. this study was undertaken to verify effect of regular exercise training on insulin sensitivity and the modifiable cardiovascular risk factors, and to determine if there was any effect from the different regular exercises. methods: a database search using prisma examined articles from scopus, sciencedirect and proquest. the inclusion criteria were that the article used a randomized controlled trial within the last 10 years, that the respondents were people with type 2 diabetes mellitus and that only physical exercise was the intervention involved. in total, 1,303 articles were screened and 16 articles were included that fit the criteria of inclusion in this systematic review. results: based on the review of the 15 articles, the findings show that regular exercise training has some benefits related to glycemic control. it can reduce insulin resistance, plasma insulin, fasting blood glucose, postpandrial blood glucose and hba1c. it also can increase insulin sensitivity and the disposition index of insulin as well. furthermore, regular exercise training has benefits concerning some of the cardiovascular risk factors. it can reduce the systolic and diastolic blood pressure, waist circumference, fat mass, visceral fat, total cholesterol, and improve the lipid profile and endothelial function by decreasing the carotid intima media thickness and left ventricle wall mass. conclusion: regular exercise training has benefits for people with type 2 diabetes mellitus and it can allow them to achieve of optimal glycemic control by improving insulin resistance and decreasing the cardiovascular risk factors. physical exercise such as combined exercises (aerobic and resistance exercise) or a single exercise such as aerobic exercise can be recommended to improve insulin sensitivity and the modifiable cardiovascular risk factors in patients with t2dm. article history received: feb 27, 2020 accepted: april 1, 2020 keywords regular physical training; insulin resistance; cardiovascular risk factors; type 2 diabetes mellitus contact ferry efendi  ferry-e@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: samudera,w. s., efendi, f., & indarwati, r. (2020). effect of physical exercise on insulin sensitivity and the modifiable cardiovascular risk factors of patients with t2dm: a systematic review. jurnal ners, special issues, 518-530. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20521 introduction type 2 diabetes mellitus (t2dm) is a chronic disease. it is one of the most common metabolic diseases. the hyperglycemic condition in t2dm is related to 3 main defects. this defects include increased hepatic glucose, decreased insulin secretion and impaired insulin action (teixeira-lemos, nunes, teixeira, & reis, 2011). the total prevalence of diabetes mellitus has increased in the last few years. based on the international diabetes federation data from 2017 about the prevalence of diabetes mellitus, it was https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 519 estimated around 425 million or 8.8% people aged 20-79 years old in the world have diabetes mellitus (international diabetes federation, 2017). there are many reasons for this, among which is the increase in a few of the risk factors that are related with t2dm. these risk factors include less activity, an increased life span and an increased prevalence of obesity as a key component (shaw, sicree, & zimmet, 2010). glycemic control in people with t2dm is an indicator that is used as outcome to evaluate the effect of any treatment that has been done. this requires a combination role between the health provider and patient. diabetes treatment needs to control for a few risk factors by maintaining a level of physical exercise necessary to remain active. physical inactivity has contributed significantly to the increased prevalence of t2dm worldwide by increasing the level of insulin resistance (cornell, 2015). moreover, glycemic control in t2dm is determined by insulin sensitivity and pancreatic endocrine function. improving insulin sensitivity is an important thing to achieve in relation to the goal of the optimum glycemic target (karstoft et al., 2014). previous studies have shown that during exercise there is decreased peripheral insulin resistance. this leads to an increase peripheral glucose uptake (aminilari et al., 2017). insulin resistance decreases the capability of insulin to stimulate absorption and to save glucose (aminilari et al., 2017). glycemia when uncontrolled leads to several complications such as cardiovascular disease (international diabetes federation, 2017). people with t2dm must be in control of their glycemic index. they need to reduce any cardiovascular risk factors that arise as soon as possible. both things are an important part of preventing cardiovascular disease as a complication of t2dm. previous studies have showed that moderate to high physical exercise has been related to a reduction in cardiovascular mortality (stefano et al., 2010). regular physical exercise as a nonpharmacological treatment for people with type 2 diabetes mellitus has an important role in the prevention of diabetes complication (international diabetes federation, 2017). this is recommended as a part of diabetes treatment according to the international diabetes federation (international diabetes federation, 2017). there were few studies that showed the benefits of physical exercise in terms of improving the outcome of the people with t2dm (comtec, 2012; ng et al., 2010; rodrigo et al., 2015). physical exercise is generally beneficial for preventing cardiovascular disease but there is little known about the impact of physical exercise on the cardiovascular risk factors of people with t2dm. the purpose of this study was to verify the effect of regular physical exercise on insulin sensitivity and the modifiable cardiovascular risk factors of people with t2dm. moreover, we intend to see if there are any different effects as a result of different regular physical exercises for people with t2dm. materials and methods design this study used a systematic review of randomized controlled trials to find out the effect of regular physical training on insulin sensitivity and cardiovascular risk factors in people with type 2 diabetes mellitus. electronic database searches were performed involving scopus, science direct and proquest. the search strategy of this systematic review used the following keywords: regular physical training; insulin resistance; cardiovascular risk factors and type 2 diabetes mellitus. the type of articles examined were randomized controlled trials as a result of screening for articles published in the last 10 years. non-randomized controlled trials were excluded from the review. database searches using scopus, science direct, and proquest. the search strategy in this systematic review used the following keywords: regular physical training; insulin resistance; cardiovascular risk factors and type 2 diabetes mellitus. title screening (n = 1,303) abstract and full text screening (n = 26) appropriate paper (n = 16) 11 articles were excluded because part of the intervention was outside of physical exercise 1.277 articles were excluded because they were not rcts, did not focus on t2dm and were more than 10 years old figure 1 – flowchart for the search and selection of the studies w. s. samudera et al. 520 | pissn: 1858-3598  eissn: 2502-5791 inclusion of articles criteria the inclusion criteria of this systematic review was as follows: 1) patients/people with type 2 diabetes mellitus (t2dm), 2) aged between 18 and 65 years old, 3) only physical exercise or combined more than one type of physical exercise used as the intervention, 4) the reporting of insulin sensitivity as an outcome and 4) the reporting of cardiovascular risk factors as an outcome. the exclusion criteria were: 1) a sample sizes less than 25, 2) any additional intervention or combined intervention outside of physical exercise, 3) patients with t2dm had complications and 4) women who were pregnant. the information and the results of the selected articles was organized into a systematic table containing the following information: first author, research design, sample size, the type of physical exercise(s), the outcome of articles that were measured and the results of the studies (figure 1). results a total of 1,303 articles were found and screened in this study. there were 1,277 articles excluded because they were not a randomized controlled trial, because they did not focus on type 2 diabetes mellitus and because they were more than 10 years old. a total of 26 articles were analyzed according to the abstract and full text. after this, 11 articles were excluded because they did not use physical exercise as an intervention or because there was an additional combined intervention outside of physical exercise. finally, 16 articles were analyzed and included in this study. insulin sensitivity the study by (motahari-tabari, shirvani, & shirzad-eahoodashty, 2015) performed 8 weeks of aerobic exercise focused on insulin resistance in type 2 diabetes mellitus patients. the sample consisted of women aged between 30 and 65 years old divided into 2 groups: 1) the group sample with 8 weeks of aerobic exercise as the intervention and 2) the control group without an intervention. this study showed that 8 weeks of aerobic exercise decreased insulin resistance, fasting blood glucose, and insulin plasma. the study by (brinkmann et al., 2019) performed a comparison between exercise in an overnight fasted state and exercise without being n an overnight fasted state over 4 months. the sample was divided into 2 groups: 1) the group sample for exercise in an overnight fasted state and 2) the group ample for exercise without being in an overnight fasted state. the entire sample completed an 8 week combined endurance and strength training program. this study showed that both exercise groups benefited in terms of improved physical fitness, body composition and glycemic regulation (hba1c values, insulin values, homa-ir index). the study by (aminilari et al., 2017) performed a comparison between aerobic exercise and resistance exercise carried out over 12 weeks. the sample was divided into 4 groups: 1) the group sample for aerobic exercise, 2) the group sample for resistance exercise, 3) the group sample for combined aerobic and resistance exercise and 4) the group sample as a control. all of the participants in the exercise groups finished after 12 weeks according to the group division. this study showed that aerobic exercise, resistance exercise and a combination of both were effective at decreasing fasting blood glucose. moreover, aerobic exercise and combined exercises (aerobic + resistance) were effective at decreasing insulin resistance. furthermore, combined exercise (aerobic + resistance) was effective at increasing the omentin-1 level. the study by (karstoft et al., 2014) performed a comparison between interval walking training and continuous walking training and how it relates to glycemic control and insulin sensitivity. the sample was divided into 3 groups: 1) the group sample for interval walking training, 2) the group sample for continuous walking training and 3) the group sample for the control without an intervention. all of the participants finished the exercises after 4 months according to the group division. in this study, only interval walking training had an effect in terms of improving glycemic control and increasing the insulin disposition. the study by (el-kader, 2011) performed a comparison between aerobic and resistance training and how it relates to insulin resistance, adipocytokines and inflammatory cytokines level. table 1. characteristics of the studies category n % year of publication 2010 3 18.75 2011 2 12.5 2012 3 18.75 2014 1 6.25 2015 3 18.75 2017 2 12.5 2019 2 12.5 type of dm t2dm 16 100 type of study rct 16 100 jurnal ners http://e-journal.unair.ac.id/jners | 521 the sample was divided into 2 groups: 1) the group sample for aerobic training and 2) the group sample for resistance training. all of the participants finished training after 3 months. this study showed that the aerobics group and resistance group had similar benefits in terms of reducing the insulin resistance, hba1c, tnf-α and il-6. the group for aerobic training had a greater impact on insulin resistance than the group for resistance training. the study by (luiza et al., 2011) performed a comparison between aerobics, resistance and a combination of both (aerobic + resistance) exercises on metabolic control, inflammatory markers, adipocytokines and muscle insulin signaling. the samples were divided into 4 groups: 1) the group sample for aerobics, 2) the group sample for resistance training, 3) the group sample for combined exercise (aerobic + resistance) and 4) the group sample as the control group. all of the participants finished the exercises after 12 weeks according to the group division. this study was showed that the 4 groups were effective at decreasing fasting blood glucose, postprandial blood glucose, blood pressure, lipid profile, and the high sensitivity of the c-reactive protein. furthermore, the group for resistance exercise and the group for combined exercises showed an increase in the insulin receptor substrate (irs)-1. the study by (stefano et al., 2010) performed an examination of intensive exercise (aerobic + resistance) and its impact on the modifiable cardiovascular risk factors. the sample was divided into 2 groups: 1) the group sample for intensive exercise and 2) the group sample as a control. all of the participants in the exercise group carried out the program for 12 months. this study showed that intensive exercise (aerobic + resistance) benefited the patient by decreasing insulin resistance and hba1c. modifiable cardiovascular risk factors the study by (stefano et al., 2010) performed an examination of the impact of intensive exercise (aerobic + resistance) on the modifiable cardiovascular risk factors. the sample was divided into 2 groups: 1) the group sample for intensive exercise and 2) the group sample as a control. all of the participants in the exercise group carried out the exercise for 12 months. in this study, intensive exercise (aerobic + resistance) improved physical fitness, blood pressure, ldl, cholesterol and body mass index. the study by (comtec, 2012) performed a comparison between interval walking training and continuous walking training and how it impacts on glycemic control, body composition and physical fitness. the sample was divided into 3 groups: 1) the group sample for interval walking training, 2) the group sample for continuous walking and 3) the group sample as a control. all of the participants in the 2 intervention groups carried out the stated exercise for 4 months. in this study, the group for interval walking training showed a decrease in body mass index, body mass fat, visceral fat and blood glucose level. the study by (bacchi et al., 2012) performed a comparison between aerobic exercise and resistance exercise and how it impacts metabolic effect, the v02 peak and fat. the sample was divided into 2 groups: 1) the group sample for aerobics and 2) the group sample for resistance exercise. all of the participants had finished each exercise according to the group division after 4 months. this study showed that the group for aerobic exercise and the group for resistance exercise both showed a decrease in total fat, visceral fat, subcutaneous fat, hba1c and an increased consumption rate 02 (v02 peak). the group sample for resistance exercise showed greater benefits than aerobic exercise. the study by (magalhães et al., 2019) performed a comparison between (continuous + resistance training) and (interval + resistance training) and how it impacts on vascular health. the samples were divided into 3 groups: 1) group sample for combined exercise (continuous + resistance training) and 2) group sample for combined exercise (interval + resistance training). all of the participants finished according to the group division after 12 months. in this study, (continuous + resistance training) and (interval + resistance training) both decreased the carotid intime media thickness. the study by (cassidy et al., 2015) performed a high intensity intermittent exercise in order to determine its effect on cardiac structure, function and liver fat. the sample was divided into 2 groups: 1) the group sample for high intensity intermittent exercise and 2) the group sample for the control. all of the participants finished according to the group division after 12 weeks. this study showed that high intensity intermittent exercise improved the cardiac structure (mass left ventricle wall), systolic function, early refill rate diastolic and decreased the fat in the liver and hba1c. the study by (rahbar, naimi, rezasoltani, & rahimi, 2017) performed for 8 weeks examined aerobic exercise and its relation to vascular structure. the sample was divided into 2 groups: 1) group sample of 8 weeks of aerobic exercise and 2) the group sample as a control. the participants finished according to the group division after 8 weeks. in this study, it showed that aerobic exercise indicated a decrease in carotid intima media thickness, a decrease in the intima-media/lumen thickness of the carotid bulb in addition to a decrease in the thickness of the common carotid, internal carotid and bulb wall. the study by (ng et al., 2010) performed a comparison between progressive resistance training and aerobic training on metabolic profile and fitness. the sample was divided into 2 groups: 1) the group sample doing progressive resistance training and 2) the group sample doing aerobic training. all of the participants finished each set of exercises according to the group division after 8 weeks. in this study, both w. s. samudera et al. 522 | pissn: 1858-3598  eissn: 2502-5791 exercises showed an improvement in hba1c and peak oxygen consumption. the group for aerobic exercise showed a greater improvement in peak oxygen consumption. moreover, only in the group for progressive resistance exercise was there a decrease in waist circumference. the study by (randomized & trial, 2012) examined moderate walking exercise related to the soluble receptors of advanced glycation products and cardiometabolic risk factors. the samples were divided into 2 groups: 1) group sample for moderate walking exercise and 2) group sample as a control. all of the participants in the group for moderate aerobic exercise finished exercising after 12 weeks. in this study, the results showed that moderate walking exercises decrease body weight, waist circumference, hba1c, apolyprotein b, body fat, visceral fat, free fatty acid level and high sensitivity c-reactive protein. moreover, moderate walking exercise increased the number of soluble receptors of advanced glycation product. the study by (rodrigo et al., 2015) performed a comparison between aquatic aerobic training and dry land aerobic training by examining glucose control, cholesterol, blood pressure and c-reactive protein. the samples were divided into 2 groups: 1) the group sample for aquatic aerobic training and 2) the group sample for dry land aerobic training. all of the participants had finished each exercise according to the group division after 12 weeks. in this study, it was shown that both exercises showed a decrease in hba1c, total cholesterol, high density lipoprotein (hdl), plasma renin activity, the concentration of angiotensin ii, c-reactive protein and systolic blood pressure. the study by (okada et al., n.d.) performed combined exercises (aerobic and resistance) and focused on endothelial function and the incidence of cardiovascular disease. the samples were divided into 2 groups: 1) combined exercise and 2) a control without an intervention. all of the participants in the group sample for combined exercise did so for 3 months. in this study, the results showed that combined exercise has shown to improve endothelial function by increasing the flow-mediated endothelium dependent vasodilation. all of the participants were followed for 24 months after randomization. in the control group, there were 3 patients who had developed a cerebral infarction and 1 developed angina pectoris. discussion the most common exercise used as an intervention in this systematic review was aerobic exercise with differences in terms of frequency, duration and intensity. there were 11 articles that used aerobics as the main intervention in at least in 1 group while 3 articles used aerobics as a combined exercise. motahari et al’s (motahari-tabari et al., 2015) study demonstrated that 8 weeks of aerobic exercise lasting for 50 minutes 3 times a week was able to decrease insulin resistance, fasting blood glucose and plasma insulin in patients with t2dm. in another randomized controlled trial (luiza et al., 2011), 12 weeks of aerobic exercise lasting for 60 minutes 3 times a week was able to decrease the fasting blood glucose. furthermore, combined exercise (aerobic and resistance) benefited insulin sensitivity by increasing the insulin receptor substrate (ir) -1. another study that was a randomized controlled trial (el-kader, 2011) referred to 12 weeks of aerobic exercise lasting for 40 minutes for 3 times a week. it was able to decrease the insulin resistance and hba1c. another study that was a randomized control trial (karstoft et al., 2014) showed that 4 months of interval walking training lasting 60 minutes 5 times a week was able to improve insulin sensitivity and glycemic control. the results in this systematic review are similar to those of the previous studies (way, hackett, baker, & johnson, 2016) which show that regular exercise can be used as a nonpharmacological treatment for improving the insulin sensitivity of patients with t2dm. based on the explanation above, it shows that most of the results of the studies showed that aerobic exercise can be used as a physical exercise to improve the insulin sensitivity of patients with t2dm. only 1 article used interval walking training as a physical intervention for improving insulin sensitivity. balducci et al’s (stefano et al., 2010) study demonstrated that 12 months of combined exercise (aerobic and resistance) for 150 minutes a week across 2 supervised sessions was able to improve the physical fitness, blood pressure, low density lipoprotein (ldl), waist circumference, cholesterol and body mass index (bmi) of the patients with t2dm. another study that consisted of a randomized controlled trial (randomized & trial, 2012) of 12 weeks of moderate aerobic exercise lasting for 60 minutes for 5 times a week was able to decrease body weight, waist circumference, hba1c, apolyprotein b, body fat, visceral fat, the free fatty acid level and high sensitivity c-reactive protein. another study that was a randomized controlled trial (rodrigo et al., 2015) showed that 12 weeks of aquatic aerobic and dry land aerobic exercise lasting for 45 minutes for each exercises 3 times a week was able to decrease hba1c, total cholesterol, high density lipoprotein (hdl), plasma renin activity, the concentration of angiotensin ii, c-reactive protein and systolic blood pressure. another study (magalhães et al., 2019) examined the results of 1 year of different combined exercise (continuous + resistance training and interval + resistance training) with a duration according to the results of the calculated weekly target of 10 kcal. this considered the peak individual oxygen uptake 3 times a week. this study showed that in the groups for the combined exercises (continuous + resistance training and interval + resistance training), each one decreased the carotid intime media thickness. another study (cassidy et al., 2015) involved 12 weeks of high intensity intermittent exercise consisting of 36 circular ergometry sessions jurnal ners http://e-journal.unair.ac.id/jners | 523 for 3 sessions a week. this study showed that high intensity intermittent exercise resulted n an improvement in the cardiac structure (mass left ventricle wall), systolic function, increased the early refill rate diastolic, decreased the fatty liver and hba1c. another study (rahbar et al., 2017) focused on 8 weeks of aerobic exercise on a treadmill lasting for 30 minutes per session over 3 sessions a week. the study found that it is able to decrease carotid intima media thickness, the intima-media/lumen thickness of the carotid bulb in addition to the thickness of the common carotid, internal carotid and bulb wall. the article results in the systematic review were similar to those in the previous studies (jansen, hoorweg, hoeks, & den, n.d.). this showed that physical exercise can be used as a non-pharmacological treatment for improving the modifiable cardiovascular risk factors, specifically blood pressure and cholesterol level. based on the explanation above, several types of physical exercise such as aerobic, resistance and high intensity intermittent exercise can be used to improve the modifiable cardiovascular risk factors. physical exercise can be used in the form of a single exercise or combined exercise to assist in the prevention of cardiovascular risk in patients with t2dm. conclusion the systematic review conducted by the researchers examined 15 articles that were selected based on the inclusion criteria in this study. the findings showed that physical exercise in a single exercise or combined format can be used as a non-pharmacological treatment for improving the insulin sensitivity of patients with t2dm. the most common exercise in this systematic review was aerobic exercise. furthermore, physical exercise such as aerobic exercise or combined exercise (aerobic and resistance) can be recommended for use in physical exercise programs. based on the review, there are benefits in the form of improving insulin sensitivity and the modifiable cardiovascular risk factors among the patients with t2dm. it can be in the form of a nonpharmacological intervention for preventing cardiovascular disease as a possible complication of t2dm. further studies need to be carried out regarding the influence of aerobic physical exercise concerning insulin sensitivity and the cardiovascular risk factors of patient with t2dm. references aminilari, z., fararouei, m., amanat, s., sinaei, e., dianatinasab, s., aminilari, m., … dianatinasab, m. (2017). the effect of 12 weeks aerobic, resistance, and combined exercises on omentin-1 levels and insulin resistance among type 2 diabetic middle-aged women. diabetes and metabolism journal, 41(3), 205–212. https://doi.org/10.4093/dmj.2017.41.3.205 bacchi, e., negri, c., zanolin, m. e., milanese, c., faccioli, n., trombetta, m., … moghetti, p. (2012). metabolic effects of aerobic training and resistance training in type 2 diabetic subjects: a randomized controlled trial (the raed2 study). diabetes care, 35(4), 676–682. https://doi.org/10.2337/dc11-1655 brinkmann, c., weh-gray, o., brixius, k., bloch, w., predel, h. g., & kreutz, t. (2019). effects of exercising before breakfast on the health of t2dm patients—a randomized controlled trial. scandinavian journal of medicine and science in sports, 29(12), 1930–1936. https://doi.org/10.1111/sms.13543 cassidy, s., thoma, c., hallsworth, k., parikh, j., hollingsworth, k. g., taylor, r., … trenell, m. i. (2015). high intensity intermittent exercise improves cardiac structure and function and reduces liver fat in patients with type 2 diabetes : a randomised controlled trial. https://doi.org/10.1007/s00125-015-3741-2 comtec, k. (2012). the effects of free-living interval walking training on glycemic control, body composition, and physical fitness in type 2 diabetes patients. (april). https://doi.org/10.2337/dc12-0658. cornell, s. (2015). continual evolution of type 2 diabetes: an update on pathophysiology and emerging treatment options. therapeutics and clinical risk management, 11, 621–632. https://doi.org/10.2147/tcrm.s67387 el-kader, s. m. a. (2011). aerobic versus resistance exercise training in modulation of insulin resistance , adipocytokines and inflammatory cytokine levels in obese type 2 diabetic patients. journal of advanced research, 2(2), 179–183. https://doi.org/10.1016/j.jare.2010.09.003 international diabetes federation. (2017). idf diabetes atlas (eighth edi; s. karuranga, r. joao da rocha fernandes, j, y. huang, & b. malanda, eds.). international diabetes federation. jansen, s. c. p., hoorweg, b. b. n., hoeks, s. e., & den, m. m. l. van. (n.d.). a systematic review and metaanalysis of the effects of supervised exercise therapy on modi fi able cardiovascular risk factors in intermittent claudication. journal of vascular surgery. https://doi.org/10.1016/j.jvs.2018.10.069 karstoft, k., winding, k., knudsen, s. h., james, n. g., scheel, m. m., olesen, j., … solomon, t. p. j. (2014). mechanisms behind the superior effects of interval vs continuous training on glycaemic control in individuals with type 2 diabetes : a randomised controlled trial. 2081–2093. https://doi.org/10.1007/s00125-014-3334-5 luiza, m., pereira, m., neves, v., oliveira, d., maria, n., ferreira, l., … geloneze, b. (2011). the effects of aerobic , resistance , and combined exercise on metabolic control , inflammatory markers , adipocytokines , and muscle insulin signaling in w. s. samudera et al. 524 | pissn: 1858-3598  eissn: 2502-5791 patients with type 2 diabetes mellitus. metabolism, 60(9), 1244–1252. https://doi.org/10.1016/j.metabol.2011.01.006 magalhães, j. p., melo, x., correia, i. r., ribeiro, r. t., raposo, j., dores, h., … sardinha, l. b. (2019). effects of combined training with different intensities on vascular health in patients with type 2 diabetes: a 1-year randomized controlled trial. cardiovascular diabetology, 18(1), 1–13. https://doi.org/10.1186/s12933-019-0840-2 motahari-tabari, n., shirvani, m. a., & shirzad-eahoodashty, m. (2015). the effect of 8 weeks aerobic exercise on insulin resistance in type 2 diabetes : a randomized clinical trial. 7(1), 115– 121. https://doi.org/10.5539/gjhs.v7n1p115 ng, c. l. w., goh, s., malhotra, r., østbye, t., tai, e. s., qspmmf, n., … usjbm, b. s. (2010). minimal difference between aerobic and progressive resistance exercise on metabolic profile and fitness in older adults with diabetes mellitus : a randomised trial. journal of physiotherapy, 56(3), 163–170. https://doi.org/10.1016/s18369553(10)70021-7 okada, s., hiuge, a., makino, h., nagumo, a., takaki, h., & konishi, h. (n.d.). effect of exercise intervention on endothelial function and incidence of cardiovascular disease in patients with type 2 diabetes. 828–833. rahbar, s., naimi, s. s., rezasoltani, a., & rahimi, a. (2017). changes in vascular structure in diabetic patients after 8 weeks aerobic physical exercise : a randomized controlled trial. https://doi.org/10.1007/s13410-017-0579-9 randomized, d. a., & trial, c. (2012). effects of exercise on srage levels and cardiometabolic risk factors in patients with type. 97(october), 1–8. https://doi.org/10.1210/jc.2012-1951 reid, r. d., tulloch, h. e., sigal, r. j., kenny, g. p., fortier, m., mcdonnell, l., … coyle, d. (2010). effects of aerobic exercise, resistance exercise or both, on patient-reported health status and wellbeing in type 2 diabetes mellitus: a randomised trial. diabetologia, 53(4), 632–640. https://doi.org/10.1007/s00125-009-1631-1 rodrigo, a., ana, s. d., kanitz, c., bertoldi, k., macedo, r. c. o., siqueira, i. r., … fernando, l. (2015). glucose control can be similarly improved after aquatic or dry-land aerobic training in patients with type 2 diabetes: a randomized clinical trial. journal of science and medicine in sport. https://doi.org/10.1016/j.jsams.2015.10.008 shaw, j. e., sicree, r. a., & zimmet, p. z. (2010). and clinical practice global estimates of the prevalence of diabetes for 2010 and 2030. 87, 4– 14. https://doi.org/10.1016/j.diabres.2009.10.007 stefano, b., silvano, z., antonio, n., pierpaolo, d. f., stefano, c., patrizia, c., … investigato, i. d. e. s. (ides). (2010). effect of an intensive exercise intervention strategy on modifiable cardiovascular risk factors in subjects with type 2 diabetes mellitus: a randomized controlled trial: the italian diabetes and exercise study (ides). archives of internal medicine, 170(20), 1794– 1803. teixeira-lemos, e., nunes, s., teixeira, f., & reis, f. (2011). regular physical exercise training assists in preventing type 2 diabetes development : focus on its antioxidant and anti-inflammatory properties. 1–15. way, k. l., hackett, d. a., baker, m. k., & johnson, n. a. (2016). the effect of regular exercise on insulin sensitivity in type 2 diabetes mellitus : a systematic review and. 253–271. jurnal ners http://e-journal.unair.ac.id/jners | 525 appendix table 2. summary of the intervention programs and results type of exercises frequency duration result aerobic (motaharitabari et al., 2015) 3 times/week for 50 mins 8 weeks aerobic exercise has been shown to be effective at decreasing plasma glucose (p = 0.05) and insulin resistance (p = 0.02). combined of endurance and strength exercises (brinkmann et al., 2019) 3 times a week on nonconsecutive days between 7am and 10am 8 weeks combined exercise program in the group in a fasted state (12 hours fasted before exercise) and the group in a fed state (eat breakfast at 1-2 hours before exercise) have been effective at improving physical exhaustion (p<0.001), hba1c (p=0.001), insulin resistance (p=0.029), fat free mass (p=0.015) and serum triglycerides (p=0.024). aerobic, resistance and combined of both exercises (aminilari et al., 2017) 3 times a week for each exercise 12 weeks for each exercise both exercises are effective at decreasing the fasting blood glucose. insulin resistance showed a decrease in the group for aerobics (p=0.004) and in the group for combined exercise (p=0.005). furthermore, the group for combined exercise (aerobic + resistance) was effective at increasing the omentin-1 level (p=0.001). interval walking training (iwt), contionus walking training (cwt) (karstoft et al., 2014) 5 times a week for 60 minutes for each exercise 4 months interval walking training (iwt) has been effective at improving glycemic control, insulin sensitivity index (p<0.001), peripheral glucose disposal (p<0.005), disposition index (p<0.001) and insulin signaling in skeletal muscle (p<0.05). aerobic exercise, resistance exercise (el-kader, 2011) 3 times a week for 40 minutes for each exercise 3 months both exercises were effective at decreasing insulin resistance (p=0.005 in aerobic) (p=0.037 in resistance), hba1c (p=0.008 in aerobic) (p=0.045 in resistance), tnf-α (p= 0.009 in aerobic) (p=0.016 in resistance) and il-6 (p=0.007 in aerobic) (p=0.023 in resistance). there was a significant difference between aerobic and resistance exercise. aerobic exercise is more appropriate for modulating insulin resistance and inflammatory cytokine levels than resistance exercise. aerobic, resistance and combined exercises (aerobic + resistance) (luiza et al., 2011) 3 times a week for 60 minutes for each exercise 12 weeks both exercises were effective at decreasing the fasting blood glucose (p<0.05 in all group exercises), postpandrial blood glucose (p<0.05 in all group exercises), blood pressure (p<0.05 in all group exercises) and lipid profile (p<0.05 in all group exercises). the groups for resistance exercise and combined exercise (aerobic + resistance) were effective at increasing the insulin receptor substrate (irs)-1. intensive exercise (aerobic + resistance) (stefano et al., 2010) 2 times a week for 75 minutes 12 months intensive exercise (aerobic + resistance) was effective at improving insulin resistance (p<0.001), physical fitness (p<0.001), hba1c (p<0.001), blood pressure (p<0.001), ldl (p<0.001), waist circumference (p<0.001), cholesterol (p<0.001) and body mass index (p<0.001). interval walking training, continuous walking training (comtec, 2012) 5 times a week for 60 minutes 4 months interval walking continuous was effective at decreasing fat body mass (p<0.001), visceral fat (p<0.001), blood glucose level (p<0.001) and increasing the v02 max (p<0.001). aerobic exercise, resistance exercise (reid et al., 2010) 3 times a week for 60 minutes for each exercise 4 months both exercises were effective at decreasing hba1c (p<0.0001), total fat (p<0.0001), visceral fat (p<0.0001) and subcutaneous fat (p=0.001). it also increased the v02 peak (0.001 < p < 0.01 in group aerobic) (p< 0.001 in group resistance). the group of resistance exercise was more effective at increasing the v02 peak than the aerobics group. combined exercises (moderate continuous training + resistance training), combined 3 times a week 1 year both groups of combined exercise were effective at decreasing the carotid intima media thickness (p< 0.01) w. s. samudera et al. 526 | pissn: 1858-3598  eissn: 2502-5791 type of exercises frequency duration result exercises (high intensity + resistance training) (magalhães et al., 2019) high intensity intermittent training (cassidy et al., 2015) 3 times a week 12 weeks high intensity intermittent training was effective at improving the left ventricle wall mass (p=0.03), systolic function (p<0.05) and early diastolic filling rate (p=0.02). aerobic exercise (ng et al., 2010) 3 times a week for 30 minutes 8 weeks aerobic exercise was effective at improving the carotid intima media thickness, the intimamedia/lumen in the carotid bulb, the common carotid and internal carotid and decreasing the bulb wall (p<0.05). aerobic exercise, progressive resistance exercise (el-kader, 2011) 18 sessions for 50 minutes 8 weeks both exercises were effective at decreasing hba1c and increasing the v02 peak. in the group for progressive resistance training, there was decreased waist circumference. moderate walking (randomized & trial, 2012) 5 times for 60 minutes 12 weeks moderate walking was effective at decreasing body weight (p<0.001), waist circumference (p<0.001), apolipoprotein b (p<0.032), hba1c (p=0.003), free fatty acid (p<0.001), systolic blood pressure (p=0.006) and diastolic blood pressure (p<0.001) while increasing the soluble receptor for advanced glycation end-products (p=0.003). aquatic aerobic training, dry land aerobic training (okada et al., n.d.) 3 times a week for 45 minutes 12 weeks both exercises decreased hba1c, low density lypoprotein, plasma renin activity, the concentration of angiotensin ii and systolic blood pressure (p<0.05). combined exercises (aerobic + resistance) (okada et al., n.d.) 3-5 times a week for 75 minutes 3 months combined exercises (aerobic + resistance) improved endothelium dysfunction by increasing the flowmediated endothelium dependent vasodilation (p<0.005). table 3. summary of the selected studies author design sample variable results (balducci, stefano, et al, 2010) rct 606 respondents with t2dm intensive exercise intervention strategy; modifiable cardiovascular risk factors; insulin resistance the results of the study showed that intensive exercise with supervision for 12 months was effective at improving physical fitness, hba1c, systolic and diastolic blood pressure, low density lipoprotein (ldl), waist circumference, cholesterol, body mass index and insulin resistance in patients with t2dm. (motahari-tabari, narges, et al, 2015) rct 54 respondents with t2dm aerobic exercise; insulin resistance the results of the study showed that aerobic exercise for 8 weeks was effective at decreasing the fasting blood glucose, plasma in the insulin and insulin resistance in patients with t2dm. (karstoft, kristian, et al, 2012) rct 32 respondents with t2dm continuous walking training (cwt); interval walking training (iwt); glycemic control; body composition; physical fitness the results of the study showed that only the iwt group that carried on for 4 months was effective at increasing the vo2 max and decreasing the body mass, fat jurnal ners http://e-journal.unair.ac.id/jners | 527 author design sample variable results mass, visceral fat and blood glucose level of the patients with t2dm. (choi, mook, kyung, et al, 2012) rct 75 respondents with t2dm exercise; soluble receptor of advanced glycation product level; cardiometabolic risk factors the results of the study showed that moderate walking exercise for 12 weeks was effective at decreasing body mass, waist circumference, hba1c, apolypoprotein b, body fat, visceral fat, free fatty level and the high sensitivity creactive protein level. furthermore, it can increase the soluble receptor of advanced glycation products. (bacchi, elisabetta, et al, 2012) rct 40 respondents with t2dm aerobic training; resistance training; metabolic effects the results of the study showed that regarding aerobic exercise and resistance exercise, each one showed an effective decrease in insulin resistance, hba1c, total fat, visceral fat and subcutaneous fat. furthermore, both exercises can increase the peak consumption 02 but in the group for resistance exercise, they benefited greater than the group for aerobic exercise in terms of improving the peak consumption of o2. (jorge, maria, et al, 2011) rct 48 respondents with t2dm aerobic exercise; resistance exercise; combined exercise (aerobic and resistance); metabolic control; inflammatory markers; adipocytokines; muscle insulin signaling the results of the study showed that the entirety of the group exercises (aerobic, resistance, and combined of aerobic and resistance) were carried for 12 weeks. all of the exercises resulted in effective decreases in blood pressure, blood glucose level, lipid profile and high sensitivity c-reactive protein in the patients with t2dm. (rodrigo, et al, 2015) rct 35 respondents with t2dm aquatic aerobic training; dry land aerobic training; glucose control; cholesterol; blood pressure; c-reactive protein the results of the study showed that both exercises (aquatic aerobic and dry land aerobic training) for 12 weeks showed a decrease in hba1c, total cholesterol, high density lipoprotein w. s. samudera et al. 528 | pissn: 1858-3598  eissn: 2502-5791 author design sample variable results (hdl), plasma renin activity, concentration of angiotensin ii, creactive protein and systolic blood pressure. (brinkmann, christian, et al, 2019) rct 30 respondents with t2dm exercise in a fasted state, exercise in a fed state; health of t2dm patients the results of the study showed that both exercise groups (exercise in a fasted state and exercise in a fed state) for 8 weeks benefited in terms of improved physical fitness, better body composition and improved glycemic regulation (hba1c values, insulin values, homa-ir index). magalhaes, joao, et al, 2019) rct 80 respondents with t2dm combined training at different intensities; vascular health the results of the study showed that in the group of combined exercises ( continuous + resistance training) and the group of combined exercises (interval + resistance training) for 12 months, each one showed decreased carotid intime media thickness (aminilari, zeinab, et al, 2017) rct 60 respondents with t2dm aerobic exercise; resistance exercise; combined exercises; omentin-1 levels; insulin resistance the results of the study showed that aerobic exercise, resistance exercise and a combination of both carried out for 12 weeks was effective at decreasing the fasting blood glucose. moreover, aerobic exercise and combined exercise (aerobic + resistance) were effective at decreasing insulin resistance. furthermore, combined exercise (aerobic + resistance) was effective at increasing the omentin-1 level. (cassidy, sophie, et al, 2015) rct 28 respondents with t2dm high intensityintermittent training; cardiac structure and function; liver fat the results of the study showed that high intensity intermittent exercise for 12 weeks was shown to improve cardiac structure (mass left ventricle wall), systolic function, increase the early refill rate diastolic and decreased liver fat and hba1c jurnal ners http://e-journal.unair.ac.id/jners | 529 author design sample variable results (karstoft, kristian, et al, 2014) rct 32 respondents with t2dm interval walking training (iwt); continuous walking training; glycemic control the results of the study showed that only interval walking training for 4 months had an effect in terms of improving glycemic control and increasing insulin disposition. (rahbar, soulmaz, et al, 2017) rct 28 respondents with t2dm aerobic physical exercise; vascular structure the results of the study showed that aerobic exercise for 8 weeks resulted in a decrease in the carotid intima media thickness, a decrease in the intimamedia/lumen in the carotid bulb and common carotid and a decrease in the internal carotid and bulb wall. (shehab, et al, 2011) rct 40 respondents with t2dm aerobic exercise training, resistance exercise training; insulin resistance; adipocytikens; inflammatory cytokine levels the results of the study showed that the group of aerobics and the group of resistance training for 3 months had similarly benefited from reduced insulin resistance, hba1c, tnf-α and il-6. in the group of aerobic training, there was a greater impact on insulin resistance than in the group of resistance training. (cindy, et al, 2010) rct 60 respondents with t2dm aerobic exercise; progressive resistance exercise; metabolic profile the results of the study showed that both exercises for 8 weeks improved hba1c and peak oxygen consumption. in the group that did aerobic exercise, there was a greater improvement in the peak oxygen consumption than in the group of progressive resistance exercise. moreover, only in the group of progressive resistance exercise was there a decrease in waist circumference. (okaada, et al, 2010) rct 38 respondents with t2dm exercise intervention; endothelial function; incident of cardiovascular disease in this study, the results show that combined exercises result in improved endothelial function by increasing the floww. s. samudera et al. 530 | pissn: 1858-3598  eissn: 2502-5791 author design sample variable results mediated endothelium dependent vasodilation. all of the participants were followed for 24 months after randomization. in the control group, 3 patients developed a cerebral infarction and 1 other developed angina pectoris. t2dm: type 2 diabetes mellitus; ldl: low density lipoprotein; rct: randomized controlled trial. vol 9 no 1 april 2014.indd 35 peranan kebersihan kulit kepala dan rambut dalam penanggulangan epidemiologi pediculus humanus capitis (the importance of hair and scalp hygiene for pediculus humanus capitis epidemic prevention) maria vonny rumampuk* *fakultas keperawatan universitas katolik de la salle manado kampus kombos, kairagi 1 manado sulawesi utara kode pos 95233 e-mail: mariarumampuk@yahoo.com abstrak pendahuluan: pediculus humanus capitis bersifat kosmopolit, merupakan masalah umum pada anak-anak usia sekolah. penelitian ini bertujuan untuk mengetahui jumlah masyarakat yang terinfestasi pediculus humanus capitis berdasarkan umur, jenis kelamin, pendidikan, sosial ekonomi, cara hidup, prevalensi kutu kepala, nimfa, dan telur kutu pada anakanak di sepuluh panti asuhan provinsi sulawesi utara, tahun 2012. metode: disain penelitian adalah pendekatan cross sectional dengan sampel 568 orang. hasil: sebanyak 106 anak (18,66%) yang memiliki pediculus humanus capitis. hasil uji statistik dengan chi-square diperoleh nilai p<0,05 yang berarti ada hubungan antara panjang rambut, jenis yang dipakai keramas, frekuensi keramas, penggunaan handuk, penggunaan sisir rambut, tidur bersama, rasa gatal di kepala, iritasi kulit kepala dengan prevalensi kutu pada rambut. hasil analisis multivariat dengan uji regresi logistik diperoleh nilai p<0,05 yang berhubungan dengan prevalensi kutu dewasa antara panjang rambut, frekuensi keramas, penggunaan sisir rambut dan kebiasaan tidur dan yang paling berhubungan dengan prevalensi kutu adalah frekuensi keramas dengan nilai wald 58 dan or 326. diskusi: pediculus humanus capitis ditemukan pada anak usia 7–12 tahun, jenis kelamin perempuan lebih banyak dari pada pria, pendidikan sd, status sosial ekonomi rendah, cara hidup yang kurang sehat, anak tinggal di panti asuhan yang berpenghuni padat. anak yang terinfestasi kutu kepala mengalami gatal-gatal di kepala dan iritasi. panti asuhan hendaknya mengupayakan pencegahan, pengendalian dan penanggulangan kutu kepala serta menanamkan kesadaran pengasuh dan anak panti asuhan tentang pentingnya kebersihan kulit kepala dan rambut. kata kunci: epidemiologi, pediculus humanus capitis, anak, panti asuhan. abstract introduction: pediculus humanus capitis have cosmopolite attributes, and normally affect school age children. this research aims at obtaining the number of people infested with pediculus humanus capitis and is categorized by the age, sex, education, social-economic status, way of life, and prevalence of lice, louse nymphs and eggs among children living in ten orphanages within the province of north sulawesi in 2012. method: the research is designed using crosssectional approach and is based on samples taken from 568 respondents. result: the fi ndings of this research indicate that 106 (18.66%) children are infested by pediculus humanus capitis. statistic test using chi-square approach results in a score of p<0.05 which indicates a correlation between hair length, type of cleansing agents used for hair wash, the frequency of hair wash, the use of towels, the use of combs, sleeping habit, scalp itchiness, and scalp irritation with lice prevalence in the hair. multivariate analysis using logistic regression test results in a score of p<0.05 attributable to the prevalence of adult lice among children with long hair, hairwash frequency, use of comb and sleeping habit. those that are mostly attributable to lice prevalence is hairwash frequency with a score of wald 58 and or 326. discussion: pediculus humanus capitis is found among children of 7 – 12 years, and dominated by girls, elementary school education, low social-economic status, unhealthy way of life, comprising children living in densely populated orphanages. children infested with head lice suffer from head itches and irritation. it is recommended that orphanages make efforts of head lice prevention, control and eradication as well as instilling the awareness in governesses and orphans of the importance of scalp and hair hygiene. key words: epidemiology, pediculus humanus capitis, child/children, orphanage/orphanages. pendahuluan pediculus humanus capitis/kutu kepala merupakan ektoparasit obligat yang ditemukan pada kulit kepala dan rambut dan ditularkan melalui kontak fisik (yousefi dkk, 2012; sembel, 2009; soedarto, 2011). diperkirakan anak indonesia mengalami masalah pediculus humanus capitis, serangga kecil tanpa sayap yang mengisap darah manusia lewat kulit kepala. meskipun pediculus humanus capitis tidak menimbulkan masalah kesehatan serius, keberadaannya bisa sangat mengganggu dan 36 jurnal ners vol. 9 no. 1 april 2014: 35–42 menjengkelkan karena menimbulkan rasa gatal terus-menerus di kepala. prestasi belajar anak pun dapat terancam karena sulit berkonsentrasi. sering menggaruk kepala adalah tanda utama seseorang memiliki pediculus humanus capitis (sembel, 2009; irianto, 2011; soedarto, 2011). pediculus humanus capitis dapat diketahui dengan mempelajari siklus hidup pediculus humanus capitis yang dimulai de nga n a d a nya p elet a k a n t elu r ya ng ditempelkan pada rambut kepala. sesudah 3-4 hari, telur menetas menjadi nimfa, nimfa mengalami tiga kali pengupasan kulit, dan menjadi kutu dewasa. dua puluh empat jam sesudah terjadi perkawinan kutu jantan dan betina, serangga betina akan meletakkan telur sebanyak 7–10 telur (nits) setiap hari. lama hidup pediculus humanus capitis dapat mencapai 30 hari dan hidup dengan mengisap darah manusia. pediculus humanus capitis tidak dapat hidup tanpa darah dalam waktu 15-20 jam. nimfa dan kutu dewasa mengisap darah dan dalam proses ini penderita akan merasa gatal sehingga menggaruk kepala. kaki pediculus humanus capitis didesain untuk mengcengkeram rambut dan dapat berjalan 2–3 cm permenit. pediculus humanus capitis biasanya hanya dapat hidup 1–2 hari diluar kepala sedangkan telurnya dapat bertahan hingga 10 hari (sembel, 2009; soedarto, 2011; natadisastra, d. dan agoes, r. 2009). hasil penelitian salih di desa al-alam, provinsi salahadin (2002) tentang incidence pediculus humanus capitis among children at al-alam menunjukkan bahwa dari 170 anak 36 (21,2%) yang memiliki pediculus humanus capitis. proporsi yang tinggi kutu kepala ditemukan di antara anak perempuan, ber usia 7–8 tahun memiliki kutu kepala dengan persentasi yang sangat tinggi (40,3%) dibandingkan dengan kelompok usia lainnya. juga, proporsi yang tinggi dari kutu kepala ditemukan di antara anak-anak yang tinggal di keluarga besar dan dengan tingkat pendidikan orang tua yang rendah (buta huruf). pediculus humanus capitis terdapat di antara anakanak muda yang berambut panjang dengan kebersihan kepala dan rambut yang buruk di daerah pedesaan. hasil penelitian yousefi dkk (2012) tentang epidemiological study of head louse (pediculus humanus capitis), infestation among primary school students in rural areas of sirjan country, south of iran menunjukkan sejumlah 20 dari 1772 (1,12%) siswa ditemukan kutu kepala. tingkat infestasi kutu kepala lebih tinggi pada anak perempuan dibandingkan dengan laki-laki, perbedaan tingkat infestasi kutu kepala berdasarkan jenis kelamin secara statistik tidak signifi kan (p>0,05). hubungan k ut u ke pala de nga n pe r ila k u me rek a mencuci rambut secara statistik signifikan (p<0,05). hubungan pendidikan orang tua adalah nyata berkaitan dengan kutu kepala (p<0,05). disimpulkan pedikulosis merupakan masalah kesehatan utama di banyak bagian dunia ter masuk negara maju dan belum berkembang. infestasi kutu kepala lebih tinggi pada keluarga dimana orang tua memiliki tingkat pendidikan rendah, di rumah keluarga tidak mempunyai kamar mandi. oleh karena itu, mempekerjakan petugas kesehatan untuk mendidik keluarga merupakan metode yang sesuai untuk mencegah pedikulosis. pe n el it i a n i n i b e r t uj u a n u nt u k me nget a hu i ju m la h m a sya r a k at ya ng ter infest asi pediculus humanus capitis berdasarkan umur, jenis kelamin, pendidikan, sosial ekonomi, cara hidup di sepuluh panti asuhan di provinsi sulawesi utara. bahan dan metode penelitian ini dilakukan di sepuluh panti asuhan di provinsi sulawesi utara. penelitian dilaksanakan pada tanggal 24 januari sampai dengan 25 agustus 2012. jenis penelitian yang digunakan adalah observational dengan desain cross sectional study. sampel pada penelitian ini berjumlah 568 orang. data diperoleh dengan menggunakan kuesioner untuk mendapatkan data karakteristik responden dan pemeriksaan kutu kepala dengan menggunakan sisir kutu untuk mendapatkan gambaran kutu kepala dewasa, nimfa dan telur kutu. analisis univariat digunakan untuk melihat distribusi frekuensi dari selur uh variabel yang terinfestasi dan tidak terinfestasi kutu kepala, umur, jenis kelamin, pendidikan, 37 peranan kebersihan kulit kepala dan rambut (maria vonny rumampuk) status sosial ekonomi, cara hidup. analisis bivariat chi – square digunakan untuk membu k tikan adanya hubu ngan antara karakteristik individu dengan prevalensi kutu dewasa. analisis multivariate menggunakan uji regresi logistik pada enam variabel digunakan untuk mengetahui variabel yang paling berhubungan dengan prevalensi kutu rambut. hasil usia responden menunjukkan bahwa, frekuensi usia responden paling banyak adalah 7–12 tahun sebanyak 247 orang (43,5%) dan paling sedikit pada kelompok usia 46 –54 tahun sebanyak 6 orang (1,1%). jenis kelamin responden umumnya perempuan sebanyak 296 orang (52,1%) sedangkan laki-laki sebanyak 272 orang (47,9%). pendidikan responden menunjuk kan paling banyak adalah sd sebanyak 229 orang (40,3%) dan paling sedikit tamat sma sebanyak 2 orang (0,4%). frekuensi stat us sosial ekonomi responden paling banyak yatim/piatu sebanyak 262 (46,1%) dan paling sedikit yatim piatu sebanyak 64 orang (11,3%). berdasarkan cara hidup, responden dengan rambut pendek 3 cm sebanyak 258 orang (45,4%) sedangkan rambut panjang 8 cm sebanyak 38 (6,7%), responden menggunakan sabun untuk keramas sebanyak 412 orang (72,5%) sedangkan yang mengg u nakan shampoo sebanyak 156 orang (27,5%). frekuensi keramas responden yang keramas tiap hari 412 orang (72,5%) lebih banyak dibandingkan yang keramas tiap 3 hari sekali sebanyak 156 orang (27,5%). penggunaan handuk, responden menggunakan handuk ber sa ma seba nya k 318 or a ng (56,0%) sedangkan yang pakai sendiri sebanyak 250 orang (44,0%). penggunaan sisir, responden menggunakan sisir bersama sebanyak 336 orang (59,2%) sedangkan yang pakai sendiri sebanyak 232 orang (40,8%). frekuensi potong rambut, paling banyak adalah 1-3 bulan sekali sebanyak 319 orang (56,2%) dan paling sedikit 7-12 bulan sekali sebanyak 3 orang (0,5%). responden tidur sendiri sebanyak 301 orang (53,0%) sedangkan yang tidur bersama sebanyak 267 orang (47,0%). pada umumnya pengasuh tidak berperan dalam mencari kutu anak asuhnya yaitu 192 orang (33,8%) sedangkan menyisir dan mencari kutu sebanyak 52 orang (9,2%). prevalensi responden yang mempunyai kutu dewasa pada rambut di panti asuhan sebanyak 106 orang (18,7%), rata-rata kutu dewasa (7,2%). prevalensi responden yang mempunyai nimfa pada rambut sebanyak 106 orang (18,7%), rata-rata nimfa (13,1%) . prevalensi responden yang mempunyai telur kutu pada rambut 106 orang (18,7), ratarata telur kutu (98,3%). responden yang mengalami rasa gatal di kepala sebanyak 106 orang (18,7%), iritasi di kepala sebanyak 5 orang (0,9%), papul warna merah di kepala sebanyak 2 orang (0,4%), pustula di kepala sebanyak 2 orang (0,4%), dan krusta di kepala sebanyak 1 orang (0,2%). usia responden yang mempunyai kutu paling banyak berumur 7–12 tahun sebanyak 69 orang (27,9%) dan paling sedikit yang berumur 20-45 tahun sebanyak 3 orang (6,3%). jenis kelamin responden yang mempunyai kutu paling banyak perempuan sebanyak 86 orang (29,1%) sedangkan laki-laki sebanyak 20 orang (7,4%). pendidikan responden yang mempunyai kutu paling banyak mempunyai pendidikan sd (28,8%) dan paling sedikit sma (3,8%). status sosial ekonomi responden yang mempunyai kutu paling banyak mempunyai status sosial ekonomi yatim/piatu (22,1%) dan paling sedikit dari keluarga miskin (14,5%). kajian epidem iologi berd asarkan lingkungan menunjukkan bahwa di panti asuhan a n-nur dan al-ik hwan k urang memadai karena jumlah penghuni masingmasing 65 anak, terdiri anak perempuan dan anak laki-laki. fasilitas yang disediakan juga kurang memadai, yaitu satu rumah yang hanya mempunyai dua ruangan yang terdiri dari satu ruang untuk kamar tidur perempuan dan satu ruang digunakan untuk tamu/kantor/tempat makan/kamar tidur anak laki-laki pada malam hari, kasur diletakkan dilantai untuk tidur dan pagi hari kasur diangkat kembali disimpan di kamar tidur perempuan. kondisi panti asuhan yang kurang memadai tersebut mempermudah penyebaran kutu kepala. 38 jurnal ners vol. 9 no. 1 april 2014: 35–42 berdasarkan tabel tersebut dapat dilihat bahwa kutu rambut banyak terdapat pada responden yang mempunyai rambut panjang 8 cm (57,9%), menggunakan sabun untuk keramas (24,8%), melakukan keramas setiap hari (24,8%), menggunakan handuk bersama (28,6%), menggunakan sisir bersama (28,6%), frekuensi potong rambut 4–6 bulan sekali (38,6%), dan tidur bersama teman (23,6%). dengan demikian analisis hubungan dengan tabel 1. hubungan antara rambut, jenis yang dipakai keramas, frekuensi keramas, penggunaan handuk, penggunaan sisir rambut, frekuensi potong rambut, tidur dengan prevalensi kutu dewasa variabel ada kutu dewasa tidak ada kutu total n % n % n % rambut pendek 3 cm 5 1.9 253 98.1 258 100.0 panjang 8 cm 22 57.9 16 42.1 38 100.0 panjang sebahu 78 42.9 104 57.1 182 100.0 panjang sampai punggung 1 1.1 89 98.9 90 100.0 total 106 18.7 462 81,3 568 100.0 p 0,000 jenis yang dipakai keramas shampoo 4 2.6 152 97.4 156 100.0 sabun 102 24.8 310 75.2 412 100.0 total 106 18.7 462 81,3 568 100.0 p 0,000 frekuensi keramas rambut tiap hari 102 24.8 310 75.2 412 100.0 3 hari sekali 4 2.6 152 97.4 156 100.0 total 106 18.7 462 81,3 568 100.0 p 0,000 penggunaan handuk bersama 91 28.6 227 71.4 318 100.0 sendiri 15 6.0 235 94.0 250 100.0 total 106 18.7 462 81,3 568 100.0 p 0,000 penggunaan sisir rambut bersama 96 28.6 240 71.4 336 100.0 sendiri 10 4.3 222 95.7 232 100.0 total 106 18.7 462 81,3 568 100.0 p 0,000 frekuensi potong rambut 1 3 bulan 40 12.5 279 87.5 319 100.0 4 6 bulan 56 38.6 89 61.4 145 100.0 7 -12 bulan 3 100.0 3 100.0 tidak pernah 10 9.9 91 90.1 101 100.0 total p 106 18.7 462 81,3 568 100.0 0,000 tidur bersama 63 23.6 204 76.4 267 100.0 sendiri 43 14.3 258 85.7 301 100.0 total 106 18.7 462 81,3 568 100.0 p 0,004 39 peranan kebersihan kulit kepala dan rambut (maria vonny rumampuk) chi square menunjukkan ada hubungan antara panjang rambut, jenis yang dipakai keramas, frekwensi keramas, penggunaan handuk, penggunaan sisir, frekwensi potong rambut, dan tidur bersama teman dengan prevalensi kutu pada rambut dengan nilai p<0,005. responden yang mempunyai k ut u semuanya merasakan gatal di kepala, lebih banyak yang mengalami iritasi (60%), dan pengasuhnya menyisir dan mencari kutu tiap minggu (25%). hasil uji statistik dengan chi square diperoleh nilai p<0,05 yang berarti ada hubungan antara kejadian gatal di kepala, iritasi di kepala, dan peran pengasuh dengan prevalensi kutu pada rambut. tabel 2. hubungan kejadian gatal di kepala, iritasi kulit kepala, peran pengasuh dengan prevalensi kutu dewasa variabel ada kutu dewasa tidak ada kutu total n % n % n % kejadian gatal gatal 106 100.0 106 100.0 tidak gatal 462 100.0 462 100.0 total 106 18.7 462 81,3 568 100.0 p 0,000 iritasi pada kepala iritasi 3 60.0 2 40.0 5 100.0 tidak iritasi 103 18.3 460 81.7 563 100.0 total 106 18.7 462 81,3 568 100.0 p 0,047 peran pengasuh di panti asuhan sisir kutu dan cari kutu tiap minggu 13 25.0 39 75.0 52 100.0 cari & sisir kutu setelah keramas 4 7.7 48 92.3 52 100.0 ajarkan manfaat keramas & sisir kutu 21 15.4 115 84.6 136 100.0 sisir kutu dan cari kutu 28 20.6 108 79.4 136 100.0 tidakberperan 40 20.8 152 79.2 192 100.0 total 106 18.7 462 81,3 568 100.0 p 0,118 tabel 3. faktor yang paling berhubungan dengan prevalensi kutu dewasa kutu b wald sig. or 95.0% c.i.for or panjang rambut -1,627 43,098 0,000 0,197 0,121-0,319 frekuensi keramas 5,787 58,026 0,000 325,905 73,532-1444,461 penggunaan handuk -0,620 0,404 0,525 0,538 0,080-3,634 penggunaan sisir 2,336 5,803 0,016 10,343 1,546-69,211 frekuensi potong rambut -0,249 0,659 0,417 0,779 0,427-1,423 kebiasaan tidur -0,886 5,664 0,017 0,412 0,199-0,855 constant -1,914 4,531 0,033 0,148 berdasarkan hasil uji regresi logistik pada enam variabel, maka diperoleh empat variabel yang berhubungan dengan prevalensi kutu pada panti asuhan adalah panjang rambut, frekuensi keramas, penggunaan sisir dan kebiasaan tidur (p<0,05). diantara keempat variabel tersebut yang paling berhubungan dengan prevalensi kutu adalah frekuensi keramas dengan nilai wald 58 dan or = 326. pembahasan hubungan interaksi antara satu variabel dengan lainnya akan menentukan proses dan arah dari proses infestasi kutu kepala pada 40 jurnal ners vol. 9 no. 1 april 2014: 35–42 penghuni panti asuhan. anak-anak terinfestasi kutu kepala tidak hanya ditentukan oleh unsur penyebab/agent dalam hal ini pediculus humanus capitis, tetapi yang utama adalah bagaimana rantai penyebab dan hubungan sebab akibat dipengaruhi oleh berbagai faktor maupun unsur lainnya. dalam epidemiologi, proses terinfestasi kutu kepala terutama diarahkan pada interaksi antara penyebab pediculus humanus capitis, pejamu/manusia dan lingkungan yang menyatu dalam satu kondisi, baik pada individu maupun pada masyarakat. kondisi ini menentukan proses kejadian terinfestasi kutu kepala (noor, n.n. 2008). unsur host/manusia meliputi usia, jenis kelamin, pendidikan, status sosial ekonomi, peran pengasuh, cara hidup (rambut, jenis yang dipakai keramas, frekuensi keramas, pengg u naan handu k, pengg u naan sisir, frekuensi potong rambut, kebiasaan tidur). usia anak yang terinfestasi kutu kepala di panti asuhan pada anak-anak usia muda 7 – 12 tahun 69 (27,9%). hal ini sesuai dengan teori yang menyatakan bahwa pediculus humanus capitis lebih banyak menginfestasi anak dan remaja. anak-anak kurang dapat menjaga kebersihan kulit kepala, karena kelompok ini adalah kelompok usia sekolah dimana aktifitasnya lebih banyak bersama dengan kelompok sebaya ( peer group), penularan lebih mudah terjadi dari interaksi mereka. aktifi tas anak di luar rumah/panti asuhan juga lebih lama sehingga perhatian terhadap kebersihan diri ( personal hygiene) terabaikan yang memungkinkan kutu kepala berkembang dengan baik di rambut kepala (brunner dan suddart, 2002). faktor jenis kelamin merupakan salah satu variabel deskriptif yang dapat memberikan perbedaan angka terinfestasi kutu kepala. wanita lebih banyak terinfestasi daripada lelaki. hal tersebut sesuai dengan teori karena anak perempuan mempunyai rambut yang lebih panjang dari pria. namun pada penelitian ini juga ditemukan lelaki terinfestasi kutu kepala, yang kemungkinan besar disebabkan tertular dari perempuan yang terinfestasi kutu kepala yang tinggal serumah. anak-anak sekolah dasar lebih banyak terinfestasi kutu kepala dibandingkan anak sekolah lanjutan. anak sekolah lanjutan sudah bisa menjaga kebersihan rambut mereka karena pada umumnya anak remaja sudah lebih mengerti daripada anak-anak sekolah dasar. tingkat pengetahuan seseorang mempengaruhi cara orang tersebut merawat diri. o r a ngor a ng ya ng h idup d isat u tempat dalam jumlah yang banyak akan mempermudah penyebaran kutu kepala. ratarata anak yang tinggal di panti asuhan adalah anak dari keluarga yatim/piatu, keluarga yatim piatu, keluarga miskin, keluarga retak, dan anak terlantar. dengan demikian jelas bahwa anak-anak panti asuhan dari keluarga miskin, sangat membutuhkan dana untuk kehidupan sehari-hari, lebih khusus dana untuk membeli shampoo. status sosial ekonomi mempengaruhi kemampuan penghuni panti asuhan untuk memenuhi sarana dan prasarana yang dibutuhkan untuk mempertahankan kebersihan diri. kondisi keuangan panti asuhan yang kurang mempengaruhi untuk membeli sabun mandi dan shampoo. panti asuhan yang dihuni anak-anak tersebut, merupakan suatu lembaga untuk mengasuh anak, menjaga dan memberikan bimbingan. panti asuhan selain sebagai unsur pengganti keluarga juga merupakan pelayanan kesejahteraan sosial yang bersifat sementara dan memungkin kan adanya pemenuhan kebut u han anak-anak u nt u k ter penu hi. dalam rangka pemenuhan kebutuhan seharihari dari anak tersebut panti asuhan sangat mengharapkan pemberian dari para donaturdonatur yang bersedia menyumbang. manusia terinfestasi kutu kepala dipanti asuhan mempunyai kebiasaan hidup, rambut panjang 8 cm, keramas setiap hari dengan sabun, menggunakan handuk dan sisir rambut bersama-sama, memotong rambut setiap 1 – 3 bulan, tidur bersama-sama. kutu kepala ini disebarkan dari orang ke orang melalui kontak fi sik atau melalui formit (sisir, handuk, seprei). keseluruhan unsur tersebut diatas merupakan sifat karakteristik individu sebagai manusia/pejamu yang memegang peranan dalam proses terinfestasi pediculus humanus capitis. 41 peranan kebersihan kulit kepala dan rambut (maria vonny rumampuk) unsur lingkungan memegang peranan yang cukup penting dalam menent ukan terjadinya proses interaksi antara manusia dan pediculus humanus capitis. berdasarkan teori pediculus humanus capitis cepat meluas dalam lingkungan yang padat, seperti panti asuhan, ditunjang dengan kondisi kebersihan rambut kepala yang buruk atau jarang membersihkan rambut pada wanita. lingkungan biologis sangat berpengaruh dan memegang peranan penting bagi pediculus humanus capitis dalam berinteraksi dengan manusia sebagai pejamu dengan unsur penyebab pediculus humanus capitis. pada aspek lingkungan fi sik, fasilitas pada delapan panti asuhan memadai sedangkan pada dua panti asuhan kurang memadai. anak-anak pada dua panti asuhan yang kurang memadai, mereka harus beradaptasi dengan kondisi yang ada, yang mana satu ruangan digunakan untuk tidur dil antai yang beralaskan kasur. jumlah penghuni panti yang banyak akan mempermudah penyebaran kutu kepala ini. lingkungan sosial juga berpengaruh besar. semua bentuk kehidupan sosial di panti asuhan, perlu hidup bersama sesama penghuni panti asuhan, saling menggunakan handuk dan sisir rambut. kepadatan penghuni panti asuhan saling bekerja sama untuk memenuhi kebutuhan dan tuntutan hidup. kutu kepala mer upakan gangguan yang hanya menyusahkan masyarakat kelas bawah atau orang yang higiene perorangannya buruk. kutu pengisap darah (ordo anoplura) lebih menyukai manusia, hidup pada rambut kepala dekat tengkuk dan telinga. siklus hidup kutu kepala dihabiskan pada manusia. ketiga tahapan kehidupan kutu kepala (telur, nimfa, dewasa) berlangsung sekitar 3 minggu. jika kutu kepala keluar atau tidak menetap lagi pada manusia, mereka akan mati dalam sehari atau dua hari. kutu kepala ini sangat kecil sekitar 2–3 mm dan mereka terlihat menggenggam batang rambut dekat kulit kepala dengan kukunya yang berbentuk khusus. kutu betina hidup sekitar sebulan dan menghasilkan 150 atau lebih telur (nit), kurang lebih 10 telur sehari, nit berwarna putih kekuningan, berbentuk oval melekat erat pada bagian bawah batang rambut dan membutuhkan waktu satu minggu untuk menetas. adapun faktor yang berhubungan erat dengan pediculus humanus capitis antara lain lingkungan tempat pediculus humanus capitis berada atau lingkungan tempat manusia dan pediculus humanus capitis berinteraksi yakni anak-anak panti asuhan (lingkungan yang padat), sifat pediculus humanus capitis mengisap darah manusia 3–5 kali perhari, dan manusia sebagai individu yang bervariasi d alam hubu nga n nya denga n pediculus humanus capitis, semua merasa gatal di kepala dengan menggar uk kepala untuk menghilangkan rasa gatal. rasa gatal tersebut timbul karena pengaruh liur dan ekskreta dari kutu kepala yang dimasukan kedalam kulit waktu mengisap darah. kemudian dengan garukan, terjadi iritasi kulit kepala, papul warna merah dan infeksi sekunder (pustula dan krusta) (handoko, 1987; natadisastra, d. dan agoes, r. 2009; soedarto, 2011, sembel, 2009). infestasi kutu kepala berhubungan erat dengan manusia antara lain sifat karakteristik ma nu sia seca r a pe ror a nga n d a n sifat karakteristik kelompok sosial di panti asuhan. faktor lain yang erat hubungannya dengan derajat terinfestasi, antara lain sifat terinfestasi yang prosesnya berlangsung terus menerus di panti asuhan, sifat lingkungan dimana proses terinfestasi terjadi, yakni keadaan lingkungan yang padat, kebersihan kepala dan rambut kurang diperhatikan di panti asuhan, menguntungkan pediculus humanus capitis berkembang biak, serta tempat dan keadaan panti asuhan, menimbulkan manusia terinfestasi pediculus humanus capitis. simpulan dan saran simpulan anak yang terinfestasi kutu kepala rerata berusia 7–12 tahun, berjenis kelamin perempuan, pendidikan sekolah dasar, sosial ekonomi rendah. cara hidup anak-anak di panti asuhan yang tinggi terinfestasi kutu kepala meliputi anak dengan panjang rambut 8 cm, frekuensi potong rambut 1–3 bulan sekali potong, keramas setiap hari dengan sabun, menggunakan handuk dan sisir rambut bersama-sama, dan tidur bersama. anak yang 42 jurnal ners vol. 9 no. 1 april 2014: 35–42 terinfestasi kutu kepala mengalami rasa gatal, iritasi kulit kepala, papul warna merah, pustula dan krusta. panti asuhan berpenghuni padat, penghuninya banyak yang terinfestasi kutu kepala. saran panti asuhan hendaknya mengupayakan pencegahan, pengendalian dan penanggulangan kutu kepala serta menanamkan kesadaran pengasuh dan anak panti asuhan tentang pentingnya kebersihan kepala yang dapat membebaskannya dari serangan kutu kepala. kepustakaan alzain, b. 2012. pediculosis capitis infestation in school children of a low socio economic area of the north gaza governorate. department of zoology, al-quds open university, beit lahia, gaza strip – palestine. (online) journal medicine science 2012; 42 (sup.1): 1286-1291. tubitak. (http://journals.tubitak.gov.tr/medical/issues/ sag-12-42-sup.1/sag-42-sup.1-21-110335.pdf, diakses 10 desember 2012) br un ner dan suddar t, 2002. buku ajar keperawatan medikal bedah. ed. 8 egc. jakarta. handoko. 1987. pedikulosis, ilmu penyakit kulit dan kelamin. ed. 4. fakultas kedokteran universitas indonesia. jakarta. irianto, k. 2011. parasitologi: berbagai p e n y a k i t y a n g m e m p e n g a r u h i kesehatan manusia. cetakan 2. cv yrama widya. bandung. nat adisast ra, d. d an agoes, r. 2009. parasitologi kedokteran ditinjau dari organ tubuh yang diserang. cetakan 1. egc. yakarta. noor, n.n. 2008. epidemiologi. ediisi revisi. rineka cipta. jakarta. salih, s. m. 2002. incidence pediculus humanus capitis among children at al-alam. journal of kirkuk university scientific studies, volume 1 no. 1. 2006. (online) sembel, d. t. 2009. entomologi kedokteran. ed. 1. percetakan andi. yogyakarta. soedar to. 2011. buku ajar parasitologi kedokteran. cv sagung seto. jakarta yousefi , s., shamsipoor, f., salim abadi y. 2012. epidemiological study of head louse (pediculus humanus capitis) infestation among primary school students in rural areas of sirjan, south of iran. 29 penambahan besar sudut inklinasi insole sepatu kerja menurunkan kadar glukosa darah puasa dan hba1c (insole inclination of work shoes decrease fasting blood glucose and hba1c level) herdianty kusuma * , ahmad abdullah * , bambang purwanto ** , suhartatik *** * program studi magister ilmu kesehatan olahraga fakultas kedokteran universitas airlangga ** departemen ilmu faal fakultas kedokteran universitas airlangga *** departemen biokimia fakultas kedokteran universitas airlangga jl. prof. dr. moestopo 47, surabaya, 60131 email: kusuma.herdianty@gmail.com abstrak pendahuluan: lari downhill dapat memperbaiki ekspresi glut-1 otot dan kadar glukosa darah puasa mencit. kontraksi eksentrik pada lari downhill juga ditemukan pada kegiatan keseharian seperti menuruni tangga dan berjalan jinjit. kegiatan menuruni tangga dan berjalan jinjit tidak mudah dilakukan berulang, tunggal, stabil dan universal, sehingga posisi jinjit pada kegiatan menuruni tangga digantikan dengan pemakaian insole pada sepatu yang digunakan untuk beraktivitas. tujuan penelitian ini adalah untuk mengetahui pengaruh penggunaan insole sepatu terhadap kadar glukosa darah puasa dan hba1c. metode: penelitian ini menggunakan experimental pre and post tes design dengan subyek wanita pekerja sebanyak 12 orang di lingkungan fakultas kedokteran universitas airlangga selama 2 minggu dan dilakukan tes sebanyak tiga kali. subjek diambil darah sebelum pemakaian insole sepatu dan setelah pemakaian insole sepatu. insole sepatu yang dipakai memiliki perbedaan inklinasi 5 0 dan 10 0 . setiap subjek menggunakan insole sepatu selama 1 minggu. hasil: data hasil penelitian menunjukkan kadar glukosa darah puasa (gdp) dan hba1c subjek yang memakai insole sepatu lebih rendah dibandingkan dengan kelompok kontrol. kadar glukosa darah puasa (gdp) dan hba1c subjek yang memakai insole 10 0 memiliki nilai p < 0,05. diskusi: pemakaian insole sepatu menyebabkan penurunan kadar glukosa darah puasa (gdp) dan hba1c. kata kunci: insole sepatu, glukosa darah puasa (gdp), hba1c, diabetes, eksentrik. abstract introduction: running downhill improved the expression of glucose transporter 1 (glut 1) and fasting blood glucose in mouse. eccentric contraction during running downhill found daily in activity such as down stairs and walking on tiptoe. descend the stairs and walking on tiptoe are not easy to repeated, single, stable and universal, so that we purposed to replace it with additional insole in shoes for daily activity. the aim of this research was to investigate the effect of the additional shoe insole on fasting blood glucose and hba1c. method: this research using experimental pre and post test design with 12 subject female staff at medical faculty of airlangga university for two weeks and the test was performed in three times. the blood was taken before and after using shoe insole. the shoe insole inclination designed into 5 0 and 10 0 . all subjects used the shoe insole for a week. result: the result research showed the fasting blood glucose and hba1c on subject that use shoe insole lower than control group. the fasting blood glucose and hba1c on subject that use shoe insole 10 0 has value p<0,05. discussion: application of shoe insole lead to reduce the fasting blood glucose and hba1c. keywords: shoe insole, fasting blood glucose, hba1c, diabetes, eccentric. ____________________________________________________________________________________________________ pendahuluan diabetes mellitus merupakan gangguan metabolisme karbohidrat, lemak dan protein yang disebabkan penurunan sekresi insulin atau penurunan sensitivitas jaringan terhadap insulin (hall 2015). perbandingan diabetes mellitus pada orang dewasa dengan usia 20 sampai 79 tahun di dunia mencapai 6,4% pada tahun 2010 dan akan meningkat menjadi 7,7% pada tahun 2030 (shaw dalam muktabhant et al. 2012). oleh karena itu diperlukan upaya untuk mengobati penderita diabetes mellitus, salah satunya dengan melakukan aktivitas fisik untuk meningkatkan sensitivitas terhadap insulin. salah satu aktivitas kontraksi eksentrik dapat terjadi saat lari menuruni bukit (lari downhill) yang diketahui dapat memperbaiki ekspresi glut-1 otot dan kadar glukosa darah puasa pada mencit. pada aktivitas keseharian kontraksi eksentrik ternyata juga terjadi saat berjalan menuruni tangga dan berjalan jinjit, tetapi aktivitas seperti ini tidak selalu dilakukan apalagi dalam waktu yang lama. untuk mengetahui pengaruh kontraksi eksentrik dalam aktivitas keseharian maka posisi jinjit sambil menuruni tangga digantikan dengan memakai insole sepatu. insole sepatu adalah bagian dalam dari sepatu yang terletak di bawah kaki yang mailto:kusuma.herdianty@gmail.com jurnal ners vol. 11 no.1 april 2016: 29-33 30 merupakan titik kontak antara kaki dengan tanah. pada kondisi diabetes, insole sepatu dapat digunakan untuk memberikan kenyamanan dan melindungi kaki dari mikro trauma (uccioli & giacomozzi 2009). pemakaian insole sepatu didesain untuk menghasilkan kontraksi eksentrik dalam waktu yang cukup lama yaitu saat aktivitas bekerja. insole sepatu ini memiliki ketinggian 5 0 dan 10 0 pada bagian belakang. ketinggian sudut menyebabkan unloading lebih cepat pada bagian belakang kaki saat berjalan dan memuat beban lebih besar pada ujung metatarsal. di sisi lain, peningkatan ketinggian insole sepatu dapat menyebabkan pemendekan pada tendon achilles yang dapat mengurangi daya ledak dari otot kaki. oleh karena itu ketinggian insole sepatu yang umum adalah sekitar 1,5-3cm dari tanah (rossi dalam uccioli & giacomozzi 2009). kontraksi eksentrik merupakan kontraksi yang terjadi ketika serabut otot mengalami perubahan panjang. kontraksi ini merupakan lawan dari kontraksi konsentrik sehingga disebut juga kontraksi negatif. pemakaian energi selama kontraksi eksentrik ini membutuhkan oksigen dan cadangan energi lebih sedikit dibanding kontraksi konsentrik, sehingga untuk aktivitas seperti berlari atau berjalan menuruni bukit mampu memperbaiki daya tahan otot lebih efektif karena kelelahan otot terjadi lebih lambat (kisner & colby 2007). penelitian ini bertujuan untuk mengetahui pengaruh pemakaian insole model aktivitas eksentrik terhadap kadar glukosa darah puasa dan hba1c. kadar glukosa darah puasa (gdp) dan hba1c merupakan pemeriksaan untuk mengetahui seseorang memiliki riwayat penyakit diabetes atau tidak. pemeriksaan ini dilakukan dengan cara mengambil sampel darah. berdasarkan kriteria dari american diabetes association (ada) kadar glukosa darah puasa (gdp) 126 mg/dl atau lebih didiagnosa sebagai diabetes mellitus tipe 2 (who dalam veghari et al. 2014). nilai hba1c pada orang non diabetes antara 20-42 mmol/mol atau setara dengan 4-6 %. sedangkan pada orang diabetes nilainya sedikit lebih tinggi dibanding nilai tersebut (diabetes federation of ireland 2010). bahan dan metode penelitian ini merupakan penelitian eksperimental dengan menggunakan pre and post test design yang akan membandingkan efek penggunaan insole 5 0 dan 10 0 terhadap kadar glukosa darah (gdp) dan hba1c. bahan yang dipakai dalam penelitian ini adalah insole sepatu dengan ketinggian 5 0 , sepatu standart dengan ketinggian insole 5 0 dan sampel darah subyek untuk mengetahui kadar glukosa darah puasa (gdp) dan hba1c. gambar 1. insole sepatu 5 derajat subyek penelitian adalah karyawan wanita di lingkungan fakultas kedokteran universitas airlangga non diabetes mellitus sebanyak 12 orang yang bersedia menandatangani inform consent. setelah dilakukan pengukuran berupa tinggi badan, berat badan, lingkar perut dan ukuran sepatu subyek dilakukan pre test dengan cara pengambilan darah melalui intra vena oleh analis yang berpengalaman setelah subyek berpuasa selama 10 jam. kemudian subyek dibagi menjadi 3 kelompok, yaitu kelompok kontrol, kelompok pemakaian insole 5 0 dan kelompok pemakaian insole 10 0 . kelompok kontrol merupakan kelompok sebelum diberikan perlakuan berupa pemakaian insole 5 0 maupun 10 0 . pemakaian insole 5 0 dan 10 0 ini pada masing-masing kelompok dilakukan selama 5 hari kerja. proses penelitian ini dilakukan pada bulan mei-juni 2015 di fakultas kedokteran universitas airlangga. setelah dilakukan pre test subyek menggunakan sepatu standar dengan ketinggian sudut insole sepatu 5 0 selama 5 hari kerja. kemudian pada hari ke tujuh dilakukan tes kedua. setelah itu subyek diberi tambahan insole sepatu 5 0 sehingga ketinggian insole menjadi 10 0 selama 5 hari kerja. kemudian pada hari ke empat belas dilakukan tes ketiga. setiap selesai melakukan tes, sampel darah dibawa ke laboratorium untuk diketahui kadar glukosa darah puasa (gdp) dan hba1c. penambahan besar sudut inklinasi insole (herdianty kusuma, dkk.) 31 gambar 2. aplikasi insole sepatu tambahan ke dalam sepatu kerja gambar 3. sepatu kerja dengan insole tambahan selama penelitian pola makan pada subyek dikendalikan dan dilakukan pemantauan kondisi subyek selama beraktivitas menggunakan insole sepatu. dari 12 subyek terdapat 4 subyek yang drop out karena tidak mampu melanjutkan penelitian. hasil setelah dilakukan analisis data diketahui hasil uji normalitas pada kadar glukosa darah puasa kelompok kontrol nilai p=0,05, kelompok pemakaian insole sepatu 5 derajat nilai p=0,96 dan kelompok pemakaian insole sepatu 10 derajat nilai p=0,266. sedangkan hasil uji normalitas pada kadar hba1c kelompok kontrol nilai p=0,59, kelompok pemakaian insole 5 derajat p=0,748 dan kelompok pemakaian insole sepatu 10 derajat p=0,60. dari semua hasil tersebut disimpulkan nilai p>0,05, maka semua data tersebut adalah normal. kemudian dilakukan analisis data uji beda menggunakan one way anova diketahui kadar glukosa darah puasa (gdp) memiki nilai p=0,005, sedangkan hba1c memiliki nilai p=0,022. hal tersebut menunjukkan terdapat penurunan kadar glukosa darah puasa (gdp) dan hba1c yang bermakna antara sebelum dan setelah pemakaian insole sepatu. penurunan kadar glukosa darah puasa (gdp) dan hba1c antara pemakaian insole sepatu 5 0 dan 10 0 menunjukkan hasil yang lebih bermakna pada pemakaian insole sepatu 10 0 . tabel 1. rerata dan standar deviasi kadar gdp pada kelompok kontrol, kelompok pemakaian insole 5 0 dan kelompok pemakaian insole 10 0 kelompok rerata ± sd kontrol 80,5 ± 14,313 a insole 5 0 76 ± 13,79 a insole 10 0 59,38 ± 6,52 b pada tabel tersebut superscript yang berbeda menunjukkan nilai p<0,05 yang berarti bahwa kelompok insole sepatu 10 0 lebih bermakna terhadap penurunan kadar glukosa darah puasa (gdp). tabel 2. uji beda kadar gdp antar kelompok berdasarkan data antara kelompok kontrol dengan kelompok insole 5 0 tidak memiliki perbedaan yang bermakna (p=0,464), tetapi antara kelompok kontrol dengan kelompok insole 10 0 terdapat perbedaan bermakna (p=0,002). sedangkan antara kelompok insole 5 0 dan 10 0 terdapat perbedaan yang bermakna (p=0,012). hal ini menunjukkan bahwa ada perbedaan yang bermakna pada kelompok pemakaian insole 10 0 tabel 3. rerata dan standar deviasi kadar hba1c pada kelompok kontrol, kelompok pemakaian insole 5 0 dan kelompok pemakaian insole 10 0 kelompok rerata ± sd kontrol 5, 337 ± 0,4926 a insole 5 0 4,862 ± 0,4719 a insole 10 0 4,650 ± 0,4209 b pada tabel tersebut superscript yang berbeda menunjukkan nilai p<0,05 yang kelompok pembanding nilai p kontrol insole 5 derajat 0,464 insole 10 derajat 0,002* insole 5 derajat insole 10 derajat 0,012* jurnal ners vol. 11 no.1 april 2016: 29-33 32 berarti bahwa kelompok insole sepatu 10 0 lebih bermakna terhadap penurunan kadar hba1c. tabel 4. uji beda kadar hba1c antar kelompok kelompok pembanding nilai p kontrol insole 5 derajat 0,053 insole 10 derajat 0,007* insole 5 derajat insole 10 derajat 0,369 *nilai p< 0,05 menunjukkan perbedaan yang bermakna berdasarkan data antara kelompok kontrol dengan kelompok insole 5 0 tidak memiliki perbedaan yang bermakna (p=0,053), tetapi antara kelompok kontrol dengan kelompok insole 10 0 terdapat perbedaan bermakna (p=0,007). sedangkan antara kelompok insole 5 0 dan 10 0 tidak terdapat perbedaan yang bermakna (p=0,369). hal ini menunjukkan bahwa ada perbedaan yang bermakna pada kelompok pemakaian insole 10 0 terhadap penurunan kadar hba1c. pembahasan pemakaian insole sepatu model aktivitas eksentrik terbukti dapat menurunkan kadar glukosa darah puasa (gdp) dan hba1c secara bermakna pada wanita pekerja di lingkungan fakultas kedokteran universitas airlangga. penggunaan insole sepatu yang tinggi dapat mengurangi daya dorong dari ibu jari kaki, sehingga gerakan kaki saat berjalan lebih efisien daripada berjalan tanpa alas kaki atau dengan sepatu datar (rossi dalam uccioli & giacomozzi 2009). hal inilah yang menjadi dasar untuk menerapkan aktivitas kontraksi eksentrik. kontraksi eksentrik merupakan kontraksi yang sering terjadi dalam aktivitas keseharian. pada pemakaian insole sepatu selama aktivitas kerja kontraksi eksentrik terjadi karena otot berkontraksi sedangkan gaya dari luar berusaha untuk memanjangkan otot, sehingga kontraksi ini juga dapat digunakan untuk latihan meningkatkan kekuatan (cluett 2014). kontraksi eksentrik memiliki peran dalam meningkatkan performa. saat terjadi kontraksi eksentrik tenaga maksimal yang dihasilkan tidak memberikan efek terhadap kecepatan pemanjangan otot, sedangkan pada kontraksi konsentrik meskipun otot memendek lebih cepat tetapi tenaga yang digunakan kurang maksimal. sehingga tenaga yang lebih besar dihasilkan dari kontraksi eksentrik. kontraksi eksentrik juga berperan dalam efisiensi mekanis dan penghematan energi. menurut penelitian yang dilakukan oleh komi, yang membandingkan penggunaan energi terhadap performa kerja, diketahui bahwa kerja akan lebih ekonomis jika diberikan gerakan yang meliputi siklus pemanjangan dan pemendekan (kontraksi eksentrik) dibandingkan hanya kontraksi konsentrik saja. selanjutnya kemampuan otot untuk menyerap energi selama kontraksi eksentrik dapat digunakan untuk menghentikan gerakan dan memungkinkan melindungi komponen penting seperti tulang, kartilago dan ligamen dari kerusakan (enoka 1996). penggunaan insole sepatu model aktivitas eksentrik yang digunakan dalam aktivitas kerja dapat berperan dalam meningkatkan performa, efisiensi dalam hal mekanis dan menghemat energi. selain itu dapat menstimulasi kontraksi eksentrik dinamik pada otot gastrocnemius. sehingga dapat membantu meningkatkan ekspresi dan kinerja glut-1 dalam membantu ambilan glukosa. gangguan metabolisme karbohidrat, lemak dan protein pada diabetes mellitus dapat membaik yang ditandai dengan penurunan kadar glukosa darah puasa (gdp) dan hba1c (price & wilson 2006). simpulan dan saran simpulan pemakaian insole sepatu 5 0 dan 10 0 memberikan pengaruh terhadap penurunan kadar glukosa darah puasa (gdp) dan hba1c. meskipun kedua model insole sepatu tersebut memberikan penurunan yang bermakna, tetapi model insole sepatu 10 0 diketahui memberikan hasil yang lebih baik. dengan demikian kontraksi eksentrik dengan memakai insole sepatu model aktivitas eksentrik terbukti dapat menurunkan kadar glukosa darah puasa (gdp) dan hba1c, sehingga model ini dapat diterapkan untuk penderita diabetes mellitus. saran pada penelitian selanjutnya disarankan pemakaian insole sepatu model aktivitas eksentrik dapat diterapkan pada penderita penambahan besar sudut inklinasi insole (herdianty kusuma, dkk.) 33 diabetes mellitus untuk mengetahui efek terhadap kadar glukosa darah puasa (gdp) dan hba1c. kepustakaan ’diabetes federation of ireland', 2010. diabetes federation of ireland annual report 2010, available at: https://www.diabetes.ie/wpcontent/uploads/2014/11/annual-report2010-with-lay-summary-appendix.pdf. cluett, j., 2014. eccentric contraction. available at: http://orthopedics.about.com/cs/sprainsstr ains/g/eccentric.htm. enoka, r.m., 1996. eccentric contractions require unique activation strategies by the nervous system. journal of applied physiology (bethesda, md. : 1985), 81(6), pp.2339–2346. hall, j.e., 2015. guyton and hall textbook of medical physiology, elsevier health sciences. available at: https://books.google.co.id/books?id=krl scqaaqbaj. kisner, c. & colby, l.a., 2007. therapeutic exercise: foundations and techniques, f.a. davis. available at: https://books.google.co.id/books?id=phtn qgaacaaj. muktabhant, b. et al., 2012. interventions for preventing excessive weight gain during pregnancy. the cochrane database of systematic reviews, 4, p.cd007145. price, s.a. & wilson, l.m., 2006. buku patofisiologi: konsep klinis prosesproses penyakit edisi 6 volume 2 6th ed., egc. uccioli, l. & giacomozzi, c., 2009. biomechanics and choosing footwear for the diabetic foot. the diabetic foot journal, 12(4), p.11. available at: http://www.diabeticfootjournal.co.uk/jour nal-content/view/biomechanics-andchoosing-footwear-for-the-diabeticfoot/?preview. veghari, g. et al., 2014. the association of fasting blood glucose (fbg) and waist circumference in northern adults in iran: a population based study. journal of diabetes and metabolic disorders, 13, p.2. available at: http://www.ncbi.nlm.nih.gov/pmc/articles /pmc3937214/. vol 9 no 1 april 2014.indd 49 pengetahuan, self efficacy dan stres pasien kusta melalui penerapan support group dengan pendekatan teori adaptasi (knowledge, self effi cacy and stress in patient with leprosy through implementation of support group using adaptation theory) margareta kewa lamak*, kusnanto**, yulis setya dewi** ** fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257 e-mail: kusnanto_ners@yahoo.com abstrak pendahuluan: pandangan bahwa kusta merupakan penyakit yang tidak dapat diobati, penyakit keturunan, kutukan, najis dan menyebabkan kecacatan membuat penderita merasa marah, kecewa bahkan cenderung menutup diri yang pada akhirnya tidak tekun berobat. tujuan penelitian adalah menjelaskan peningkatan pengetahuan, self effi cacy, dan penurunan stres pasien kusta melalui penerapan support group di rsk sumberglagah. metode: jenis penelitian adalah quasy eksperimen menggunakan desain pre test and post test nonequivalent control group. besar sampel adalah 28 pasien kusta di ruang rawat inap dan poli kusta. instrumen yang digunakan adalah kuesioner dan pemeriksaan kadar kortisol. analisis data dilakukan secara deskriptif dan uji wilcoxon, mann-whitney serta uji paired t test dan independent t test dengan α≤0,05. hasil: analisis deskriptif rerata usia responden adalah 40,92 tahun. sebagian besar responden berpendidikan dasar. pengetahuan responden pre test 57,14% baik dan post test 100% baik (p = 0,041). self effi cacy responden pre test 42,86% tinggi dan post test 28,57% tinggi (p = 0,307). tingkat stres responden pre test 35,71% tidak stres dan post test 50% tidak stres (p = 0,046). rerata kadar kortisol pre test 66,35 ± 28,72 dan post test 71,80 ± 23,84 (p = 0,598). diskusi : support group yang dilakukan pada pasien kusta di ruang melati rsk sumberglagah dapat meningkatkan pengetahuan dan menurunkan stres namun tidak terbukti dapat meningkatkan self effi cacy dan menurunkan kadar kortisol. kata kunci : support group, kista, pengetahuan, self effi cacy, stres, kortisol abstract introduction: assumption of leprosy that it is uncurable, hereditary, cursed, and impure disease causes the patients angry, disappointed even being introvert and leads them to a treatment adherence. the goal of this study was to explain the increasing of knowledge, self effi cacy and the decreasing of stress in patient with leprosy by support group in leprosy hospital of sumberglagah.method: this study was a quasy experiment study using pre test and post test nonequivalent control. total sample was 28 respondents in inpatient ward and outpatient. the instruments were questionnaire and cortisol level. data were then analyzed descriptively and statistically using wilcoxon test, mann-whitney test, paired t test and independent t test with α 0,05. results: results showed that mean of age was 40,92 years old. almost all of respondents were in primary education. knowledge pre and post was 57,14% good; 100% good (p = 0,041). self effi cacy pre and post was 42,86% high; 28,57% high (p = 0,307). stres level pre and post was 35,71% normal; 50% normal (p = 0,046). mean of cortisol level pre and post was 66,35 ± 28,72; 71,80 ± 23,84 (p = 0,598). discussion: it can be concluded that support group increases knowledge and decreases stress but doesn’t increase self effi cacy and decrease cortisol level in patient with leprosy in leprosy hospital of sumberglagah. keywords : support group, leprosy, knowledge, self effi cacy, stress, cortisol pendahuluan kusta merupakan penyakit menular dan menahun yang disebabkan oleh kuman m yc ob a c te r i u m l e p ra e, p e nya k it i n i menyerang kulit, saraf tepi dan dapat pula menyerang jaringan tubuh lainnya. penyakit kusta merupakan salah satu penyakit menular yang menimbulkan masalah yang sangat kompleks. masalah yang dimaksud bukan hanya dari segi medis tetapi meluas sampai masalah sosial, ekonomi, budaya, keamanan dan ketahanan nasional (depkes ri, 2007). penyakit ini berkembang perlahan-lahan (dari enam bulan sampai 40 tahun) dan dapat menyebabkan lesi pada kulit hingga menjadikan seseorang menjadi cacat. masalah fi sik seperti bentuk kulit dan wajah yang rusak, kecacatan membawa dampak pada pengucilan dari masyarakat sehingga menimbulkan gangguan kognitif pada panderita kusta (pikiran-pikiran negatif), masalah emosional seperti kecemasan, stres, dan depresi, serta kehilangan rasa percaya diri yang ditunjukkan dengan menyalahkan diri sendiri, berlaku 50 jurnal ners vol. 9 no. 1 april 2014: 49–58 negatif dan menarik diri dari masyarakat (fajar, 2010). penyakit kusta masih ditakuti oleh masyarakat, keluarga pasien, dan pasien kusta sendiri disebabkan karena masih kurangnya pengetahuan dan kepercayaan yang keliru terhadap kusta dan cacat yang ditimbulkannya. pandangan tersebut mendasari konsep perilaku penerimaan penderita terhadap penyakitnya, dimana untuk kondisi ini penderita masih saja menganggap bahwa penyakit kusta mer upakan penyakit tidak dapat diobati, penyakit keturunan, kutukan tuhan, najis dan menyebabkan kecacatan, sehingga penderita akan merasa sangat marah, kecewa atau bahkan cenderung menutup diri yang pada akhirnya mereka tidak tekun untuk berobat (depkes ri, 2002). jawa timur termasuk wilayah endemis penyakit kusta di indonesia. pada tahun 2010, sepertiga penderita lepra di indonesia ada di jawa timur atau setara dengan 4.653 penderita (14 persen diderita anak-anak dan cacat permanen). sedangkan hingga september 2011 ditemukan penderita baru sebanyak 4.142 penderita. angka itu menempatkan indonesia di urutan ketiga terbesar dunia untuk jumlah penderita setelah india dengan angka 126.800 penderita dan brazil di angka 34.894 penderita. jumlah itu merupakan 30% dari jumlah penderita kusta di indonesia yang jumlahnya mencapai 17.000 orang (shohibul, 2012). masyarakat memandang penyakit kusta termasuk penyakit yang diturunkan atau merupakan penyakit kutukan. ada beberapa kebudayaan yang menganggap penderita kusta sebagai orang buangan dan sedapat mungkin tidak bergaul dengan mereka dan sebaiknya pasien k usta diasingkan atau diisolasi. itulah sebabnya selama ini pasien kusta sangat sulit untuk mendapatkan dukungan sosial dari masyarakat sekitar. penolakan, stigma, dan diskriminasi yang dilakukan masyarakat terhadap pasien kusta dan kondisi penyakit kusta yang menimbulkan kecacatan menimbulkan rasa tidak percaya diri dan berpotensi menyebabkan stres bagi pasien kusta. stres yang dialami akan memodulasi sistem imun melalui jalur hpa (hipothalamicpituitary adrenocortical) axis dan sistem limbik (mengatur emosi dan learning process). kondisi stres tersebut akan menstimulasi hypothalamus untuk mensekresi neuropeptida yang nantinya akan mengaktivasi ans (autonomic nerve system) dan hypofi sis untuk melepaskan kortikosteroid dan katekolamin yang mer upakan hor mon-hor mon yang bereaksi terhadap kondisi stres. peningkatan kadar glukokortikoid akan mengganggu sistem imunitas. bila kondisi stres dapat dikendalikan maka modulasi sistem imun menjadi lebih baik. stres yang lama dan berkepanjangan akan berdampak pada penurunan sistem imun dan mempercepat progresivitas penyakit (gunawan & suwadiono, 2007 dalam henny 2011). stres merupakan sumber dari berbagai penyakit pada manusia. apabila stres tidak cepat ditanggulangi atau dikelola dengan baik, maka akan berdampak lebih lanjut seperti mudah terjadi gangguan atau terjadi penyakit bahkan mempercepat proses penyakit (hidayat, 2008). stres menjadi pemicu timbulnya depresi dan peningkatan kadar kortisol. penderita kusta yang mengalami stres emosional akan cender ung membut uh kan adaptasi yang berat pula. pada keadaan stres tubuh akan mengalami gangguan umum, yang dapat memicu terjadinya reaksi kusta (prawoto, 2008). menurut judith swarth (2000), stres bisa mengakibatkan penurunan kekebalan tubuh sebanyak 50%. penelitian shriya dave, et al. (2003), menyatakan bahwa stres mental berhubungan dengan terjadinya reaksi enl (eritema nodusum leprosum) pada pasien kusta. penelitian yang dilakukan oleh prawoto di wilayah kerja puskesmas kabupaten brebes terbukti pada tahun 2008 menunjukkan bahwa terdapat hubungan yang bermakna antara stres dengan terjadinya reaksi kusta. pada pasien kusta, bayangan cacat kusta menyebabkan penderita seringkali tidak dapat menerima kenyataan bahwa ia menderita kusta akibatnya akan ada perubahan mendasar pada kepribadian dan tingkah lakunya, selain itu masalah psikososial yang timbul pada penderita kusta lebih menonjol dibandingkan dengan masalah medis itu sendiri. hal ini disebabkan karena adanya stigma dan leprofobi 51 pengetahuan, self effi cacy dan stres pasien kusta (margareta kewa lamak, dkk) yang banyak dipengaruhi oleh berbagai paham keagamaan, ser ta infor masi yang kelir u tentang penyakit kusta (depkes ri, 2000). selain menimbulkan masalah bagi penderita, penyakit kusta juga menimbulkan masalah bagi keluarga dan masyarakat di sekitar penderita kusta, yaitu adanya perilaku keluarga dan masyarakat yang cenderung mengucilkan atau menyingkirkan penderita kusta sehingga menyebabkan stres (stresor) pada penderita kusta tersebut. dengan kondisi tersebut maka dapat menyebabkan faktor pencetus stres bagi penderita kusta sehingga akan memperlambat penyembuhan (depkes ri, 1997). peneliti memilih rumah sakit kusta ( r sk) su mb e rglaga h sebagai t e mpat penelitian karena rumah sakit ini merupakan upt dinas kesehatan propinsi jawa timur yang mempunyai tugas menjalankan sebagian tugas dinkes propinsi jawa timur di bidang promotif, preventif, kuratif, dan rehabilitatif bagi pasien kusta di jawa timur, merupakan rumah sakit milik pemerintahan propinsi jawa timur, menjadi unit pelayanan publik terbaik pada tahun 2006 yang dipilih oleh gubernur jawa timur, memiliki manajemen yang baik dalam merawat pasien kusta, serta terbuka terhadap penelitian-penelitian tentang penyakit kusta yang jumlahnya tidak sebanyak penelitian yang telah dilakukan di bidang lain. pendidikan kesehatan untuk pasien kusta rutin dilakukan oleh pihak rsk sumberglagah melalui kegiatan penyuluhan sebulan sekali, namun evaluasi mengenai tingkat pengetahuan pasien k ust a belu m per nah dilak u kan. berdasarkan studi pendahuluan yang telah dilakukan peneliti pada tanggal 5 januari 2013, dari 10 pasien yang diwawancara oleh peneliti kesepuluh pasien tersebut mengatakan bahwa jika dalam keadaan lelah dan stress karena banyak pikiran maka mereka akan mengalami reaksi. sehingga jika sudah mulai merasakan lelah secara fi sik dan psikologis maka mereka memilih untuk beristirahat dan tidak ada tindakan khusus untuk mengatasi masalah psikologis tersebut. masalah psikologis yang sering dirasakan pasien antara lain ketakutan terhadap kecacatan yang dapat ditimbulkan oleh kusta serta penolakan dan diskriminasi dari masyarakat sekitar dalam hal pekerjaan dan tempat tinggal. prokop (1991) dalam rohmah (2006) menyatakan bahwa salah satu faktor psikologis yang digunakan untuk meningkatkan daya tahan terhadap stres adalah melalui self eff icacy. bandura (1997) dalam rohmah (2006) menyatakan bahwa self effi cacy adalah kepercayaan individu yang dimiliki untuk menunjukkan suatu perilaku. sumber stres menjadi ancaman bagi mereka yang merasa dirinya tidak mampu melakukan t ugas. diharapkan dengan semakin tinggi kesadaran seseorang akan kemampuannya, semakin mudah mereka mengatasi persoalan yang dihadapi dengan cara konstruktif. kondisi emosi seperti cemas, stres, dan suasana hati yang negatif mempengaruhi kegagalan atau kesuksesan terhadap hasil (pajares, 2002). banyak cara yang dapat dilakukan untuk meningkatkan self effi cacy dan mengurangi stres antara lain dengan adanya dukungan dari sesama penderita atau support group. kotler (1996) dalam rohmawati (2012) menyatakan bahwa support group merupakan suatu bentuk kelompok dimana para anggotanya berkumpul untuk membangun kekuatan, minat umum, serta kompetensi dari masing-masing anggota. support group memanfaatkan kesamaan pengalaman peserta untuk membantu satu sama lain. di dalam support group setiap anggota mendapat dukungan penuh dari sesama anggota, dapat mengekspresikan semua perasaan negatifnya, dan merupakan tempat bagi para anggota untuk mencari informasi (under wood & gottlieb, 2000). namun bagaimana pengar uh penerapan support group terhadap peningkatan pengetahuan, self effi cacy, dan penurunan stres pada pasien kusta masih belum jelas. penelitian yang dilakukan oleh ussher, kirsten, butow & sandoval di denmark pada tahun 2005 tentang support group pada pasien kanker melaporkan bahwa penderita akan mengalami peningkatan rasa percaya diri, empati dan rasa persahabatan dalam kelompok tersebut. dukungan dalam support group menawarkan dukungan emosional, rasa saling memiliki juga sebagai fasilitas koping 52 jurnal ners vol. 9 no. 1 april 2014: 49–58 penderita dan pemahaman informasi tentang penyakit (ussher, kirsten, butow & sandoval, 2005). support group pada pasien kusta belum banyak diterapkan di indonesia dan belum ada intervensi khusus dari perawat dalam upaya pemenuhan kebutuhan psikososial pasien kusta. maka dari itu, pada penelitian ini, peneliti ingin menerapkan metode support group pada pasien kusta dan meneliti pengaruh metode support group terhadap kognitif, self effi cacy, dan stres pasien kusta di rsk sumberglagah. peneliti menerapkan metode support group dengan pendekatan teori adaptasi roy karena teori ini sangat sesuai menggambarkan proses adaptasi yang dialami oleh pasien kusta mulai dari stresor yang merupakan input, sampai pasien dapat mencapai output yang diharapkan yaitu tingkat stres yang menurun dan kualitas hidup yang baik. bahan dan metode jenis penelitian ini adalah quasy eksperimen dengan menggunakan pretest and posttest nonequivalent control group design. populasi target pada penelitian ini adalah pasien kusta di ruang melati dan poli kusta rsk sumberglagah mojokerto. sampel yang ditetapkan adalah 28 responden yang dipilih dengan menggunakan purposive sampling. sampel tersebut kemudian dibagi menjadi dua kelompok yaitu kelompok perlakuan dan kelompok pembanding. variabel dependen dalam penelitian ini adalah pengetahuan, self efficacy, dan stres pada pasien kusta, sedangkan variabel independennya adalah support group. instr umen yang digunakan dalam penelitian adalah kuesioner untuk pengetahuan, modifikasi chronic disease self efficacy scale, depression anxiet y stress scale (dass) dan pemeriksaan laboratorium untuk mengetahui kadar kortisol darah. pengetahuan, self effi cacy, dan stress menggunakan data ordinal, sedangkan kadar kortisol darah menggunakan data rasio. intervensi dilakukan terkait support group dengan menggunakan sak, meliputi check ing in, present asi masalah, klarifi kasi masalah, berbagi usulan, perencanaan tindakan, dan checking out. kegiatan dilakukan 3×/minggu masing-masing 60 menit untuk setiap kelompok dengan jarak antar pertemuan 2 hari, selama 3 minggu. data yang didapat kemudian diolah menggunakan analisis deskriptif, uji wilcoxon dan uji mann whitney dengan tingkat kemaknaan α ≤ 0,05. hasil penelitian ini dilakukan di ruang melati rumah sakit kusta sumberglagah. waktu penelitian dilaksanakan selama 4 minggu di rumah sakit kusta (rsk) sumberglagah yang merupakan upt dinas kesehatan propinsi jawa timur. melibatkan 28 responden yang terbagi menjadi 2 kelompok yaitu 14 responden kelompok pembanding dan 14 responden kelompok perlakuan. karakteristik responden dilihat dari nilai rerata u mu r responden kelompok pembanding adalah 42,57 dan rerata umur kelompok perlakuan adalah 40,92. hasil uji normalitas menggunakan kolmogorov-smirnov didapatkan p 0,795 (p > 0,05) yang berarti data berdistribusi normal. karakteristik responden dilihat dari jenis kelamin berdasarkan uji homogenitas antara kelompok pembanding dan perlakuan menggunakan chi-square test didapatkan nilai p 1,000 yang berarti bahwa tidak ada perbedaan karakteristik jenis kelamin responden didapatkan. karakteristik pendidikan responden kedua kelompok didapatkan data sebagian besar responden berpendidikan sd (71,43%) dan hasil uji homogenitas antara kelompok pembanding dan perlakuan menggunakan mann whitney didapatkan nilai p 0,816 (p > 0,05) berarti bahwa tidak ada perbedaan karakteristik pendidikan pada kedua kelompok. hasil uji wilcoxon terkait dengan pengetahuan pada kelompok pembanding didapatkan nilai p 0,267 (p > 0,05), artinya tidak terdapat peningkatan pengetahuan, sedangkan pada kelompok perlakuan setelah mengikuti kegiatan support group didapatkan nilai p 0,041 (p < 0,05), artinya terdapat peningkatan pengetahuan. hasil analisis data terkait dengan self effi cacy pada kelompok pembanding didapatkan nilai p 0,598 (p > 0,05) dan kelompok perlak uan p 0,307 53 pengetahuan, self effi cacy dan stres pasien kusta (margareta kewa lamak, dkk) (p > 0,05), artinya tidak terdapat peningkatan self eff icacy yang bermakna pada kedua kelompok. hasil uji wilcoxon terkait tingkat stress pada kelompok pembanding didapatkan nilai p 0,479 (p > 0,05), artinya tidak terdapat penurunan stress. sedangkan pada kelompok perlakuan didapatkan nilai p 0,046 (p < 0,05), artinya terdapat penurunan stres yang bermakna. nilai kadar kortisol darah pada kelompok perlakuan dari hasil uji normalitas saat pre didapatkan nilai p 0,630 dan saat post didapatkan nilai p 0,517. sedangkan pada kelompok pembanding saat pre didapatkan nilai p 0,959 dan saat post didapatkan nilai p 0,846. berdasarkan hasil uji statistik paired t test pada kelompok pembanding dan kelompok perlakuan didapatkan p 0,867 dan p 0,598 yang berarti tidak terdapat penurunan kadar kortisol pada kedua kelompok. hasil uji mann-whitney pengar uh support group terhadap pengetahuan, self effi cacy, stres, dan kadar kortisol pada pasien kusta dapat dilihat pada tabel 1. tabel 1. pengaruh support group terhadap pengetahuan, self effi cacy, dan stres di rsk sumberglagah 6 mei–6 juni 2013 variabel n uji mannwhitney pengetahuan pembanding 14 p = 0,025 perlakuan 14 self effi cacy pembanding 14 p = 0,854 perlakuan 14 stres pembanding 14 p = 0,549 perlakuan 14 dari tabel diatas menunjukkan bahwa terdapat perbedaan yang bermakna antara kedua kelompok untuk pengetahuan (nilai p 0,025), sedangkan untuk self effi cacy dan tingkat stres tidak terdapat perbedaan, masingmasing dengan nilai p = 0,854 dan p = 0,549. hasil analisis statistik menggunakan uji independet t test kadar kortisol antara kelompok pembanding dan kelompok perlakuan yang mengikuti kegiatan support group didapatkan p 0,709 (p > 0,05) artinya bahwa tidak terdapat perbedaan yang signifi kan. pembahasan penyakit kusta masih ditakuti oleh masyarakat, keluarga pasien, dan pasien kusta sendiri disebabkan karena masih kurangnya pengetahuan dan kepercayaan yang keliru terhadap kusta dan cacat yang ditimbulkannya. pandangan tersebut mendasari konsep perilaku penerimaan penderita terhadap penyakitnya, di mana untuk kondisi ini penderita masih saja menganggap bahwa penyakit kusta mer upakan penyakit tidak dapat diobati, penyakit keturunan, kutukan tuhan, najis dan menyebabkan kecacatan, sehingga penderita akan merasa sangat marah, kecewa atau bahkan cenderung menutup diri yang pada akhirnya mereka tidak tekun untuk berobat (depkes ri, 2002). pengetahuan yang adekuat tentang penyakit kusta dapat membantu seseorang melakukan deteksi dini sehingga kecacatan dapat dicegah. deteksi dini dan penanganan yang cepat merupakan kunci dari keberhasilan pengobatan penyakit kusta (mcdougall, 1996). keterlambatan penanganan pada pasien kusta dapat menyebabkan kecacatan. deteksi dini dapat dilakukan dengan cara waspada terhadap tanda atau ciri khas dari kusta yaitu bercak putih seperti panu, tidak gatal, semakin lebar, dan mati rasa. kegiatan support group merupakan salah satu bentuk individu mendapatkan pengetahuan, yaitu dari pengalaman baik dari diri sendiri maupun orang lain serta dari otoritas/kekuasaan dalam hal ini peneliti (notoadmodjo, 2010). pengetahuan individu dipengar uhi oleh usia, pendidikan, dan pengalaman (notoadmodjo, 2003). selain mendapatkan pengetahuan secara formal, seseorang dapat memperoleh pengetahuan secara informal yaitu dari pengalaman diri sendiri dan orang lain. dalam kegiatan support group responden saling berdiskusi tentang pemahaman penyakit kusta dan keterampilan atau upaya menjaga dan merawat diri sendiri misalnya cara mencegah reaksi kusta dan kecacatan. setiap responden menyampaikan 54 jurnal ners vol. 9 no. 1 april 2014: 49–58 informasi dan pengalaman yang didapat selama menderita kusta. fasilitator dalam kelompok ber t ugas melu r uskan pemahaman at au informasi yang kurang tepat terkait penyakit kusta. informasi yang diperoleh dari fasilitator dan sesama responden dalam kegiatan support group dapat meningkatkan pengetahuan responden yang memiliki tingkat pengetahuan sedang. hal ini sesuai dengan penelitian yang dilakukan oleh underwood dan gottlieb pada tahun 2000 yang menyatakan bahwa di dalam support group setiap anggota mendapat dukungan penuh dari sesama anggota, dapat mengekspresikan semua perasaan negatifnya, dan merupakan tempat bagi para anggota untuk mencari informasi. penelitian ussher tahun 2005 tentang support group menyebutkan bahwa support group menawarkan dukungan emosional, rasa saling memiliki juga sebagai fasilitas koping penderita dan pemahaman informasi tentang penyakit. d a l a m keg i a t a n s u p p o r t g r o u p responden mencer it a ka n perasa a n d a n hambatan selama menjalani pengobatan kusta. beberapa responden menyatakan ke su l it a n u nt u k me ncega h t i mbu l nya reaksi kusta. mereka telah berusaha untuk meminum obat dan menjaga kondisi tubuh agar tidak terlalu lelah namun masih tetap saja mengalami reaksi dan terdapat responden lain yang menyatakan pasrah bila memang harus mengalami penyakit kusta dan menjadi cacat. hanya sedikit responden yang merasa yakin dan optimis dapat menjaga kondisi kesehatan selain bergantung pada obat salah satunya dengan melakukan perawatan mata, tangan, dan kaki secara teratur. pada periode kegiatan pertama saat hari terakhir terdapat 2 responden yang mengalami penurunan kondisi sehari sebelum pertemuan. penurunan kondisi ini menyebabkan responden menjadi semakin pesimis dan merasa gagal untuk dapat menjaga kondisi kesehatannya serta mencegah terjadinya reaksi. sebagian besar responden menyatakan bahwa penyakit kusta yang diderita menjadi beban pikiran yang mengganggu kondisi psikologis mereka. hanya sedikit responden yang optimis bahwa penyakit kusta yang diderita tidak akan menggangu kondisi psikologis mereka. responden yang lain menyatakan bahwa mereka masih merasa khawatir bila dikucilkan oleh masyarakat di lingk ungan sekitar mereka sehingga harus merahasiakan penyakit yang mereka derita. responden yang masih bersekolah merahasiakan penyakitnya dari teman-teman sekolah nya. seorang responden bah kan merahasiakan penyakitnya dari keluarga. responden yang lain menyatakan bahwa selama dirawat di r umah sakit mereka merasa lebih diterima daripada saat berada di rumah. menur ut under wood dan gottlieb (2000) kegiatan support group memberikan kesempatan seseorang untuk perbandingan sosial. individu membandingkan dirinya dengan orang lain ketika sedang mengalami stres. hal ini dilakukan untuk mengevaluasi perasaan dan kemampuan mereka. dalam kegiatan support group responden belajar bahwa tidak hanya dirinya yang menderita, ada responden lain yang juga mengalami masalah yang sama dan mereka dapat berbagi dukungan, motivasi, harapan, ketakutan, serta kekhawatiran yang sama. responden dapat mengungkapkan perasaan negatif yang dialami sehingga dapat berbagi beban dengan responden yang lain. dalam kegiatan support group peneliti sebagai fasilitator dan sesama responden memberikan dukungan dan motivasi bagi responden yang merasa pesimis. dukungan diberikan agar responden menjadi optimis dapat menjaga kondisi kesehatan, mencegah timbulnya reaksi atau kecacatan kusta, dan siap untuk menghadapi stigma yang ada di masyarakat. adanya stigma yang muncul di masyarakat menyebabkan penderita kusta mengalami kehilangan kemampuan fisik, kehilangan rasa percaya diri dan kualitas hidup yang rendah serta rapuhnya ikatan sosial. hal ini yang menyebabkan responden lebih memilih untuk merahasiakan penyakitnya dari orang lain bahkan keluarga. s e o r a n g r e s p o n d e n m e n g a l a m i peningkatan self effi cacy dari sedang menjadi tinggi. peningkatan self effi cacy ini disebabkan oleh verbal persuasion yaitu keyakinan akan kemampuan diri yang diperoleh dari orang lain 55 pengetahuan, self effi cacy dan stres pasien kusta (margareta kewa lamak, dkk) yang disampaikan secara lisan dan vicarious experience yaitu penilaian mengenai keyakinan diri yang sebagian diperoleh melalui hasil yang dicapai oleh orang lain yang dijadikan sebagai model. pendidikan responden yang lebih tinggi dengan usia yang masih muda dan kondisi fi sik yang masih baik menyebabkan individu memiliki kemampuan dan kemauan yang besar untuk belajar dari pengalaman responden yang lain dalam menjaga kondisi kesehatan, mencegah reaksi dan kecacatan kusta, berani menghadapi stigma yang ada di masyarakat dan belajar untuk optimis bahwa penyakit kusta yang diderita tidak akan mengganggu kondisi psikologis. stresor merupakan variasi stimulus bai k ek ster nal maupu n i nter nal ya ng menimbulkan stres (atwater & duffy dalam mulyani, 2011). lahey (2007) dalam mulyani (2011) mengatakan sumber-sumber stres antara lain life events, frustrasion, confl ict, pressure, dan environmental conditions. salah satu faktor dari lingkungan yang menjadi stresor bagi penderita kusta adalah stigma. stigma menjadi masalah yang umum dialami oleh pender ita k usta di semua negara. penerimaan oleh masyarakat non kusta tergantung dari mind set masyarakat di lingkungan sekitar penderita kusta. reaksi negatif dari keluarga, teman, dan masyarakat membuat penderita kusta mengalami gangguan psikologis bahkan menjadi depresi. penderita kusta membutuhkan dukungan psikologis dan konseling segera setelah didiagnosis kusta (gopal, 2010). fajar (2010) menyatakan bahwa stigma membuat penderita kusta mengalami kesulitan mencari pekerjaan, mencari jodoh, dan bahkan sulit mendapatkan pelayanan kesehatan. dalam kondisi semacam ini penderita kusta biasanya menyadari bahwa dirinya telah kehilangan masa depan dan mereka merasa aman jika bergabung dengan penderita kusta lainnya. beberapa responden menyatakan bahwa jika sedang banyak pikiran atau stres maka timbul reaksi. penyebab timbulnya stres pada setiap responden berbeda satu dengan yang lain. terdapat responden yang mengalami stres berat. faktor pencetus stres pada salah satu responden tersebut disebabkan karena penyakit kusta yang diderita pada usia yang masih muda yaitu 17 tahun, sehingga responden merahasiakan penyakitnya dari lingkungan sekitar tempat tinggalnya dan teman-temannya. rasa sakit yang ditimbulkan oleh kusta juga menimbulkan stres pada responden tersebut sehingga setiap akan dilakukan perawatan luka pada pagi hari responden selalu merasa ketakutan dan menangis bahkan responden mengalami kesulitan tidur dan gelisah. sedangkan responden yang lain mengalami st res berat karena har us merahasiakan penyakit yang diderita dari keluarganya dan hal ini menjadi beban pikiran tersendiri karena tidak dapat jujur terhadap keluarga dan harus menghadapi penyakit kusta tanpa dukungan dari keluarga. beberapa responden menyatakan bahwa stres yang dialami disebabkan karena adanya masalah pribadi, sedangkan responden yang lain mengungkapkan penyebab stres yang dialami karena penyakit kusta yang tidak kunjung sembuh dan harus sering dirawat di rumah sakit. setiap responden memiliki upaya yang berbeda-beda untuk mengatasi stres yang dialami. beberapa responden mengatasi stres dengan cara menonton tv, bercengkerama dengan pasien kusta yang lain, bermain catur, dan bahkan ada responden yang menulis lirik lagu untuk mencurahkan perasaannya. sala h sat u penyebab st res ya ng dirasakan oleh hampir semua responden yaitu adanya stigma dari masyarakat sekitar. stigma tidak terlalu dirasakan oleh responden yang tinggal di panti karena penghuni panti juga merupakan penderita kusta. bagi responden yang tinggal di lingkungan normal dengan masyarakat non kusta, stigma sangat dirasakan dan menjadi stresor bagi responden. beberapa responden yang mengikuti kegiatan support group mengungkapkan bahwa selama di rumah sakit mereka sering merasa gelisah dan tidak tenang karena ingin segera pulang dan bertemu dengan keluarga. hal ini menjadi stresor bagi responden yang dirawat di rumah sakit. responden yang lain menyatakan bahwa mereka merasa lebih nyaman bila dirawat di rumah sakit daripada di rumah sendiri karena menurut mereka keadaan di lingkungan sekitar rumah dan masalah dalam keluarga menjadi 56 jurnal ners vol. 9 no. 1 april 2014: 49–58 stresor bagi mereka, sedangkan di rumah sakit mereka menjadi lebih tenang karena dapat melupakan permasalahan yang dialami selama di rumah. faktor pencetus stres yang dialami oleh sebagian besar responden pada kelompok pembanding adalah masalah hidup pada umumnya antara lain masalah ekonomi dan masalah dalam keluarga, hanya beberapa responden yang mengalami stres karena proses penyakit kusta dan penerimaan lingkungan sekitar terhadap penyakit yang dialami responden. karakter kepribadian dan motivasi individu mempengaruhi persepsi terhadap st resor. responden dengan kepr ibadian ya ng pem i k i r d a n ter t ut up cender u ng memiliki persepsi negatif terhadap stresor yang menyebabkan responden menganggap informasi yang didapat tentang penyakit merupakan suatu stresor negatif sehingga menjadi beban pikiran bagi individu tersebut. responden dengan kepribadian terbuka cenderung memiliki persepsi positif terhadap st re sor ya ng me nyebabk a n re sponde n menganggap informasi yang didapat tentang penyakit merupakan stresor positif sehingga responden tersebut berusaha untuk merawat dan menjaga kondisi kesehatan serta mencegah agar penyakit yang diderita tidak semakin parah. menur ut under wood dan gottlieb (2000) kegiatan support group memberikan kesempatan seseorang untuk perbandingan sosial. individu membandingkan dirinya dengan orang lain ketika sedang mengalami stres. hal ini dilakukan untuk mengevaluasi perasaan dan kemampuan mereka. dalam kegiatan support group responden belajar bahwa tidak hanya dirinya yang menderita, ada responden lain yang juga mengalami masalah yang sama dan mereka dapat berbagi dukungan, motivasi, harapan, ketakutan, serta kekhawatiran yang sama. responden dapat mengungkapkan perasaan negatif yang dialami sehingga dapat berbagi beban dengan responden yang lain. dalam teori adaptasi roy terkait dengan stres, input berupa stresor akan diproses oleh individu melalui respon biologis dan respon emosional kemudian dengan adanya kegiatan support group diharapkan output yang dihasilkan adalah penurunan tingkat stres. namun stres masing-masing individu berbeda dan dipengaruhi oleh banyak faktor. lazarus dan folkman dalam sarafi no (2006) mengungkapkan bahwa penilaian individu terhadap sesuatu yang dianggap sebagai sumber stres dipengaruhi oleh faktor individu, meliputi intelekt ual, motivasi, karakter kepribadian dan faktor situasi, meliputi besar kecilnya tuntutan keadaan yang dilihat sebagai stres. reaksi masing-masing individu terhadap stres berbeda-beda dipengaruhi oleh pengalaman stres ( prior experience with the stres), faktor perkembangan, predictability and control (peristiwa yang dapat diprediksi dan dipembanding), dan dukungan sosial. dukungan sosial dapat diperoleh salah satunya dari kegiatan support group. support group memanfaatkan kesamaan pengalaman peserta untuk membantu satu sama lain. di dalam support group setiap anggota mendapat dukungan penuh dari sesama anggota, selain itu support group menawarkan dukungan emosional, rasa saling memiliki juga sebagai fasilitas koping penderita dan pemahaman informasi tentang penyakit (ussher, kirsten, butow & sandoval, 2005). menurut kubler ross, terdapat 5 tahap respon psikologis yaitu pengingkaran, marah, tawar-menawar, depresi, dan penerimaan. seseorang yang sudah berada pada tahap penerimaan dapat kembali lagi pada tahaptahap sebelumnya sehingga memungkinkan seseorang dengan kondisi sudah tidak stres kemudian mengalami stres setelah mendapatkan st resor. responden dapat mengalami penurunan tingkat stres karena pencetus stres atau stresor sudah diatasi dan responden telah mengetahui dampak stres terhadap penyakit yang diderita sehingga responden berusaha mengelola stres dengan baik seperti yang telah didiskusikan bersama dengan responden yang lain dalam support group. kadar kortisol semua responden dalam penelitian ini berada dalam batas normal yaitu 50-250 μg/ml. meskipun responden menyatakan bahwa dirinya sedang dalam 57 pengetahuan, self effi cacy dan stres pasien kusta (margareta kewa lamak, dkk) keadaan stres namun belum tentu kadar kortisol dalam darah sangat tinggi atau di atas normal. dalam penelitian ini terdapat responden yang saat pre termasuk kategori tidak stres dan saat post termasuk kategori stres ringan. peningkatan stres ini tidak didukung dengan adanya peningkatan kadar kortisol. demikian juga pada responden yang mengalami penurunan tingkat stres namun tidak didukung dengan adanya penurunan kadar kortisol. ketidaksesuaian antara peningkatan atau penurunan tingkat stres dengan kadar kortisol dalam darah disebabkan karena ada banyak faktor yang turut mempengaruhi kadar kortisol salah satunya adalah obatobatan kortikosteroid. obat kortikosteroid yang umum dikonsumsi oleh penderita kusta adalah prednison. responden dalam penelitian ini tidak ada yang mendapatkan terapi prednison, namun terdapat faktor lain yang juga turut mempengaruhi kadar kortisol responden antara lain kelelahan fi sik, kurang tidur, dan kadar kafein yang tinggi dalam darah. kadar kafein yang tinggi menyebabkan seseorang mengalami kesulitan tidur dan hal ini dapat meningkatkan kadar kortisol. kondisi seseorang yang sering gelisah atau cemas tentang sesuatu menyebabkan seseorang tersebut sulit untuk istirahat atau tidur dan hal ini juga dapat meningkatkan kadar kortisol. beberapa responden menyatakan seringkali tidur larut malam karena bermain catur dengan pasien kusta yang lain. kondisi kurang tidur juga dapat menyebabkan peningkatan kadar kortisol pada responden. simpulan dan saran simpulan berdasarkan hasil penelitian, maka dapat diambil kesimpulan bahwa kegiatan support group yang dilakukan pada pasien kusta di ruang melati rsk sumberglagah d apat men i ng k at k a n penget a hu a n d a n menurunkan stres namun tidak terbukti dapat meningkatkan self effi cacy dan menurunkan kadar kortisol. saran metode support group dapat digunakan oleh perawat sebagai upaya pemenuhan kebutuhan informasi dan psikologis pasien kusta. perawat dapat menerapkan konsep support group untuk berdiskusi tentang m a s a l a h y a ng d ia l a m i p a sie n k u s t a , memberikan dukungan serta meningkatkan hubungan interpersonal antara perawat dengan pasien dan antar sesama pasien kusta. kegiatan support group dapat menjadi sistem dalam standar pemberian edukasi pada pasien rawat jalan dan rawat inap. daftar pustaka depkes ri 2000, materi pelatihan p2 kusta bagi medis dan paramedis puskesmas, jakarta. depkes ri 2002, penyakit kusta di indonesia, jakarta. de pkes r i 20 07, penge mba nga n d a n pe n y e l e n g g a r a a n po s k e s d e s , jakarta. fajar, na 2010, dampak psikososial penderita kusta dalam proses penyembuhannya, jurnal pembangunan manusia vol. 10, no.1. gopal, pk 2010, “psychosocial aspects”, dalam kumar hk (ed.), ial textbook of leprosy, jaypee brothers medical publishers, new delhi, hal. 559-564. hidayat, aa 2008, pengantar konsep dasar ke p e ra wa ta n, sa le mba me d i k a , jakarta. mcdougall, ac 1996, “impor tant facts about le prosy”, d ala m le pros y: basic information and management, novartis foundation for sustainable development, switzerland, hal. 35-36. mulyani 2011, hubungan antara dukungan s o s i a l d e n g a n s t r e s d a l a m menyelesaikan skripsi pada mahasiswa jurusan psikologi binus university, skripsi fakultas psikologi universitas bina nusantara, jakarta. notoatmodjo 2003, pendidikan dan perilaku kesehatan, rineka cipta, jakarta. notoadmodjo 2010, promosi kesehatan: teori & aplikasi, rineka cipta, jakarta. 58 jurnal ners vol. 9 no. 1 april 2014: 49–58 pajares, f 2002. overview of social cognitive theory and of self-efficacy, diakses tanggal 23 pebruari 2013, http:// www. emor y.edu / education/ mf p/eff. html. prawoto 2008, faktor faktor risiko yang berpengaruh terhadap terjadinya r e a k s i k u s t a , te s i s m a g i s t e r epidemiologi program pascasarjana universitas diponegoro semarang. rohmawati & siti 2012, kebutuhan akan support group pada penderita kanker ser viks yang mengalami depresi, skripsi fakultas psikologi universitas airlangga, surabaya. roh ma h, fa 20 06, pengar uh disk usi kelompok untuk menurunkan stres pada mahasiswa yang sedang skripsi, humanitas: indonesian psychological journal vol. 3, no. 1, hal. 50-62. saraf ino, ep 2006, health psycholog y : biopsychosocial interaction, 5th ed, john willey & sons, inc, new york. swarth, j 2000, stres dan nutrisi, bumi aksara, jakarta. underwood, lg, gotlieb, bh & cohen, s 2000, social support measurement and intervention: a guide for health and social scientists, oxford university press. ussher, j, kristen, l, butow, p & sandoval, m 2005, what do cancer support group provide which other supportive relationships do not? the experience of peer support group for people with cancer, journal of social science& medicine 62, hal. 25652576. 194 penggunaan sistem informasi berbasis website pada remaja (the use of web-based information system in adolescents) hery ernawati*, elsi dwi hapsari**, lely lusmilasari** *fakultas ilmu kesehatan, universitas muhammadiyah ponorogo, jl. budi utomo no 10 ponorogo **program studi ilmu keperawatan, fakultas kedokteran, universitas gadjah mada yogyakarta e-mail: heryernawati@gmail.com abstrak pendahuluan: pengetahuan tentang kesehatan reproduksi sangat penting bagi remaja. remaja dapat membuat keputusan terhadap kesehatan reproduksi mereka secara mandiri. salah satu media penting yang berfungsi sebagai sumber informasi tentang kesehatan reproduksi pada remaja adalah melalui website. tujuan dari penelitian ini adalah untuk mengetahui hubungan antara penggunaan informasi berbasis web dan pengetahuan tentang kesehatan reproduksi pada remaja. metode: penelitian ini menggunakan desain analitik dengan pendekatan cross sectional, yang melibatkan siswa kelas x dan xi sma, smk, ma di kabupaten ponorogo. penelitian ini dilakukan di sekolah-sekolah dengan fasilitas komputer dan koneksi internet, yang melibatkan 210 remaja, yang dipilih dengan menggunakan teknik simple random sampling. pengumpulan data dilakukan dengan kuesioner. analisis data dilakukan dengan univariat, bivariat dengan menggunakan uji statistik spearman rank, dan cara-cara multivariat menggunakan uji regresi logistik. hasil: hasil penelitian menunjukkan bahwa rata-rata frekuensi akses situs dan durasi untuk informasi tentang kesehatan reproduksi oleh remaja adalah 1.36 kali seminggu dan 1,65 jam; pengetahuan tentang kesehatan reproduksi adalah 58,1% dalam kategori rendah; dan tidak ada hubungan yang ditemukan antara penggunaan sistem informasi berbasis web dan pengetahuan tentang kesehatan reproduksi pada remaja, meskipun ada kecenderungan meningkat dalam frekuensi dan durasi kunjungan situs web untuk informasi yang berkaitan dengan kesehatan reproduksi pada remaja. diskusi: penggunaan sistem informasi berbasis web tidak memiliki hubungan yang signifikan dengan pengetahuan tentang kesehatan reproduksi pada remaja. penelitian lebih lanjut diperlukan untuk mengeksplorasi subjek yang sama dengan metode yang berbeda, yang tidak memilih responden di pertemuan pertama dan menggunakan kuesioner tertutup untuk memilih responden, sehingga para remaja akan merasa bebas dan terbuka untuk peneliti. kata kunci: sistem informasi berbasis web, pengetahuan, kesehatan reproduksi pada remaja abstract introduction: knowledge about reproductive health is very important for adolescents. they can make informed decision on their reproductive health. one of important media that serve as the source of information on reproductive health in adolescents is website. the objective of this study was to find out the relationship between the use of web-based information and knowledge about reproductive health in adolescents. method: a cross sectional was conducted from february 2013 to april 2014, involving the tenth and eleventh grade students of sma, smk, ma in ponorogo regency. the study was conducted in schools with computer facilities and internet connection, involving 210 adolescents, who were selected using simple random sampling technique. the data was collected by questionnaire. data analysis was conducted in univariate, bivariate with using spearman rank test, and multivariate ways using logistic regression test. results: the study showed that mean website access frequency and duration for information about reproductive health by adolescents were 1.36 times a week and 1.65 hours; knowledge about reproductive health was 58,1% in low category; and no relationship was found between the use of web-based information system and knowledge about reproductive health in adolescents, even though there was an increasing trend in the frequency and duration of website visits for information related to reproductive health in adolescents. discussion: the use of web-based information system does not have a significant relationship with knowledge about reproductive health in adolescents. further research is necessary to explore the same subject with a different method, which is not selecting the respondents in the first meeting and use a closed questionnaire to select the respondents. this way, the adolescents will feel free and open to the researcher. keywords: web-based information system, knowledge, reproductive health in adolescents pendahuluan kesehatan reproduksi remaja adalah suatu kondisi sehat yang menyangkut sistem, fungsi dan proses reproduksi yang dimiliki oleh remaja, yang tidak hanya bebas penyakit atau bebas dari kecacatan namun juga sehat secara mental serta sosial kultural (who, 2013). usia remaja dibedakan menjadi usia remaja awal (12–15 tahun) dan usia remaja akhir (15–18 tahun). perubahan yang terjadi 195 penggunaan sistem informasi berbasis website (hery ernawati, dkk.) pada usia remaja adalah perubahan secara fisik maupun perubahan non fisik. kematangan seksual dan terjadinya perubahan bentuk tubuh sangat berpengaruh pada kehidupan kejiwaan remaja (santrock, 2003). remaja membutuhkan informasi terkait dengan perubahan dalam dirinya, sebagai bagian dari masa transisi remaja menuju dewasa. baik secara fisik, mental maupun sosial yang tidak terlepas dari fungsi, proses dan sistem reproduksinya (respati, 2013). remaja yang hidup pada jaman sekarang masuk pada jaman platinum, mereka memiliki karakter yang ekspresif dan eksploratif terhadap perubahan yang terjadi pada dirinya, dengan berusaha mendapatkan informasi melalui beberapa media elektronik dan internet (atmaji, 2008). remaja perlu mengetahui kesehatan reproduksi agar memiliki pengetahuan, sikap dan tingkah laku yang bertanggung jawab mengenai proses reproduksi. dampak jika remaja tidak mengetahui tentang kesehatan reproduksi berupa praktik kesehatan yang buruk, kejadian kehamilan tidak diinginkan (ktd), anemia, aborsi, meningkatnya kejadian hiv/aids dan penyakit menular seksual lainya (cahyo, 2008; bkkbn, 2010; respati, 2013). data dari badan koordinasi keluarga berencana nasional (bkkbn) kabupaten ponorogo tahun 2012 bahwa permasalahan kesehatan reproduksi pada remaja di ponorogo meliputi belum mengetahui tentang menstruasi. selain itu sekitar 80% remaja perempuan di ponorogo pernah melakukan hubungan seksual. media website banyak digunakan oleh remaja sejak internet menjangkau rumah dan sekolah, sehingga waktu yang dipergunakan remaja untuk mengakses internetpun semakin meningkat karena mudah diakses, murah, dan bersifat pribadi. penelitian tentang kemanfaatan internet terhadap kehidupan manusia khususnya remaja selama ini masih menjadi perdebatan. berdasarkan beberapa penelitian sebelumnya, penggunaan website dikaitkan u nt u k pendidikan seks, atau memba nd i ng k a n pengg u na a n nya pa d a remaja sekolah dan putus sekolah. website sebagai salah satu sumber informasi kesehatan reproduksi remaja. namun motivasi membuka website untuk mencari informasi kesehatan reproduksi masih jarang dibandingan untuk komunikasi dan hiburan (goold, 2003; nwagwu, 2007; widyastari, 2010; bkkbn, 2012). hasil studi pendahuluan yang dilakukan pada 27 remaja di kabupaten ponorogo bahwa 90 persen remaja pernah mengenal dan menggunakan internet, baik dengan memanfaatkan warnet, melalui handphone maupun melalui komputer pribadi. alasan remaja mencari artikel tersebut karena ada penugasan dari sekolah (mata pelajaran biologi dengan bab reproduksi) (56%) dan menambah wawasan tentang kesehatan reproduksi remaja, sehingga bisa menjaga kesehatan reproduksi (19%). aspek kesehatan reproduksi remaja yang sering di akses adalah aspek menstruasi (74%), perubahan fisik dan psikologis pada remaja (35%), organ reproduksi laki-laki dan perempuan (56%), penyakit menular seksual termasuk hiv/aids (56%), serta nutrisi pada remaja (67%). berdasarkan fakta di atas, maka peneliti tertarik untuk melakukan penelitian tentang hubungan penggunaan sistem informasi berbasis website dengan pengetahuan kesehatan reproduksi remaja di kabupaten ponorogo. bahan dan metode jenis penelitian yang digunakan adalah penelitian analitik, dengan rancangan cross sectional. penelitian ini dilakukan di sma, ma, dan smk yang berada di wilayah kabupaten ponorogo. sebanyak 210 responden dari sekolah yang memiliki fasilitas komputer dan internet dan berasal dari kelas x dan xi. teknik sampling menggunakan simple random sampling. alat yang digunakan dalam penelitian ini ber upa k uesioner, peng u k u r tinggi badan dan berat badan. kuesioner yang dig u nakan u nt u k var iabel pengetahuan kesehatan reproduksi remaja dikembangkan dari kuesioner dari bkkbn (2007) dan arfan (2009). sedangkan untuk kuesioner penggunaan sistem informasi berbasis website 196 jurnal ners vol. 9 no. 2 oktober 2014: 194–202 dimodifikasi dari kuesioner goold (2003) dan xu (2012). alat untuk mengukur berat badan menggunakan timbangan digital merk camry model eb 9003 yang memiliki presisi 0,1 kg, sedangkan untuk mengukur tinggi badan menggunakan meteran siku yang ditempelkan di dinding. jala n nya penelit ia n d i mulai d a r i penetapan sekolah yang akan digunakan. dipilih sekolah yang berada di daerah perkotaan yang memungkinkan memiliki fasilitas komputer dan internet untuk siswanya, sehingga ditetapkan yang dijadikan populasi terjangkau adalah sekolah yang berada di wilayah kecamatan ponorogo, babadan dan siman. penentuan sekolah yang dijadikan tempat penelitian dengan menggunakan teknik lotere sehingga didapatkan 12 sekolah dengan rincian dari kecamatan ponorogo 2 sma, 3 smk, 2 ma; dari kecamatan babadan 1 sma, 1 smk, 1 ma; dan dari kecamatan siman 1 sma dan i ma. namun, hanya 7 sekolah yang bersedia dijadikan sampel penelitian. alasan sekolah tidak bersedia menjadi sampel penelitian karena sedang banyak kegiatan pembelajaran dan sekolah ma yang berbasis pondok pesantren fasilitas internet tidak boleh dipergunakan oleh siswa. masing-masing sekolah diambil sebanyak 30 responden. pe m i l i h a n r e s p ond e n d i la k u k a n dengan menentukan siswa yang sudah pernah membuka website yang berisi materi kesehatan reproduksi remaja. responden yang memenuhi syarat dan telah mendapatkan ijin dari orang tua dikumpulkan di satu ruangan dan diberi kuesioner untuk diisi dengan waktu 60 menit. selesai mengisi kuesioner dilanjutkan dengan mengukur tinggi badan dan berat badan untuk mendapatkan data status nutrisi responden. analis data meliputi analisi univariat, bivariat dan multivariat. analisis bivariat mengg unakan uji spearman rank , dan analisis multivariat menggunakan uji regresi logistik. hasil penggunaan sistem informasi berbasis website diukur melalui frekuensi dan lama akses website yang berisi kesehatan reproduksi remaja. hasil penelitian ini dapat diketahui bahwa rerata frekuensi akses website kesehatan reproduksi remaja 1,36 kali per minggu tabel 1. penggunaan sistem informasi berbasis website indikator n; mean±sd frekuensi akses (kali/minggu) 210; 1,36±0,80 lama akses (jam/minggu) 210; 1,65±1,73 tabel 2. pengetahuan kesehatan reproduksi remaja kriteria n; mean±sd n ( %) skor total 210; 33,83±3,40 pengetahuan rendah 122 (58,1) pengetahuan tinggi 88 (41,9) tabel 3. hubungan antara penggunaan sistem informasi berbasis website dengan pengetahuan kesehatan reproduksi remaja di kabupaten ponorogo penggunaan sistem informasi berbasis website pengetahuan kesehatan reproduksi remaja p-valuerendah n; mean±sd tinggi n; mean±sd frekuensi akses (kali/minggu) 122; 1,29±0,64 88; 1,45±0,98 0,163 lama akses (jam/minggu) 122; 1,46±1,17 88; 1,92±2,27 0,086 197 penggunaan sistem informasi berbasis website (hery ernawati, dkk.) dan rerata lama akses website kesehatan reproduksi remaja 1,65 jam per minggu yang mana ditunjukkan pada tabel 1. lebih dari setengahnya pengetahuan remaja tentang kesehatan reproduksi remaja berada pada kategori rendah, dengan rerata skor total pengetahuan yaitu 33,83 ditunjukkan pada tabel 2. te rd apat ke ce nde r u nga n a d a nya peningkatan penggunaan sistem informasi berbasis website (f rek uensi a kses d an lamanya akses per minggu) pada remaja yang memiliki pengetahuan tinggi. uji statistik yang digunakan adalah uji spearman rank dan didapatkan tidak ada hubungan antara penggunaan sistem informasi berbasis website dengan pengetahuan kesehatan reproduksi remaja hasil ini ditunjukkan pada tabel 3. analisis multivariat yang digunakan adalah regresi logistik dengan metode back ward lr didapatkan bahwa variabel asal jur usan memiliki hubungan dengan pengetahuan kesehatan reproduksi remaja dengan nilai p-value 0,018 dan or 2,344 (ci 1,154-4,763) (tabel 4). pembahasan media website banyak digunakan oleh remaja sejak internet menjangkau rumah dan sekolah, sehingga waktu yang dipergunakan remaja untuk mengakses internetpun semakin meningkat karena mudah diakses, murah, dan bersifat pribadi (goold, 2003; nwagwu, 2007; widyastari, 2010). penggunaan sistem informasi berbasis website bisa diketahui dengan menggunakan parameter frekuensi mengakses website dan lamanya mengakses website pad a k u r u n wa k t u sem i ngg u. penelitian ini merupakan penelitian pertama kali yang meneliti penggunaan inter net hanya untuk mengakses informasi tentang kesehatan reprodu ksi remaja, sehingga menjadikan penelitian ini sebagai hal baru yang bisa menambah dan melengkapi dari hasil penelitian sebelumnya. pada penelitian ini rerata frekuensi me nga k se s web site sebe sa r 1,36 k al i dalam seminggu. hal ini sesuai dengan penelitian yang dilakukan borzekowski (2006) menyebutkan bahwa pada remaja pada kelompok yang di sekolah lebih dari separuhnya frekuensi mengakses internet 1 kali atau lebih dalam seminggu tanpa dipengaruhi oleh jenis kelamin, usia dan etnis. rerata lama mengakses website sebesar 1,65 jam dalam seminggu dan lebih rendah dibandingkan dengan hasil penelitian widyastari (2010) disebutkan bahwa lebih dari setengah pelajar di semarang mengakses internet selama 9 jam per minggu. hal ini kemungkinan penyebabnya karena pada penelitian ini difokuskan pada akses informasi tentang kesehatan reproduksi remaja saja, sedangkan pada penelitian widyastari motif mengakses internet untuk pendidikan, komunikasi dan hiburan sehingga lamanya akses internet lebih lama. hal ini juga didukung oleh penelitian goold (2003) bahwa alasan mengakses internet pada remaja lebih banyak untuk e-mailing, dan sangat sedikit untuk alasan mencari informasi kesehatan. tabel 4. distribusi frekuensi hubungan variabel bebas dan variabel luar dengan pengetahuan kesehatan reproduksi remaja variabel bebas dan luar pengetahuan kesehatan reproduksi remaja p-valuerendah tinggi n; mean±sd n n; mean±sd n frekuensi akses website (kali/minggu) 122; 1,29±0,64 88; 1,45±0,98 0,163 lama akses website (jam/ minggu) 122; 1,46±1,17 88; 1,92±2,27 0,086 sumber informasi (jumlah) 122; 2,66±1,18 88; 2,98±1,09 0,046 pendidikan: ipa non ipa 16 106 23 65 0.017 198 jurnal ners vol. 9 no. 2 oktober 2014: 194–202 pembelajaran sekolah untuk setingkat sma, smk, ma di kabupaten ponorogo rata-rata dimulai dari pukul 07.00 sampai dengan pukul 15.00, dan sisa waktu lainnya dipergunakan oleh remaja untuk kegiatan ekstra sekolah, mengerjakan tugas sekolah, ber mai n / bersosialisasi. memu ng k i n kan sekali remaja sudah merasa lelah ketika pulang sekolah, sehingga membuat remaja kurang berminat untuk membuka website yang berisi dengan infor masi kesehatan remaja, dan lebih menyukai untuk membuka website yang berisi hiburan, atau membuka facebook dan twitter. selain itu sebetulnya buku panduan untuk pelajaran biologi sudah terintegrasi dengan internet, sehingga di setiap akhir bab selalu ada alamat website yang bisa diakses untuk menambah wawasan remaja, termasuk bab reproduksi manusia. tetapi responden membuka website kesehatan reproduksi seringkali hanya untuk kepentingan mengerjakan tugas sekolah, jika tidak ada tugas maka tidak akan membuka website kesehatan reprodu k si remaja. qoma r iya h (20 09) menyatakan bahwa perilaku penggunaan internet pada kalangan remaja diperkotaan di surabaya paling banyak dilakukan untuk mencari sumber atau bahan yang berkaitan dengan tugas pelajaran sekolah. remaja yang menyadari bahwa dirinya mengalami banyak perubahan pada fisik maupun psikologis ter utama yang berkaitan dengan sistem reproduksi, maka dengan kesadaran nya mereka akan berusaha mencari informasi dari berbagai sumber sehingga mereka akan memahami segala perubahan yang terjadi pada dirinya sebagai bentuk perwujudan adanya rasa tanggung jawab terhadap kesehatan reproduksinya. lokasi yang digunakan oleh responden untuk mengakses website yang berisi kesehatan reproduksi antara lain di warung internet (warnet), sekolah, rumah maupun melalui handphone. secara umum 3 urutan tersering yang digunakan remaja untuk mengakses website melalui handphone, warung internet, sekolah, dan hasil ini sesuai dengan penelitian sebelu m nya bahwa lokasi yang ser i ng digunakan untuk mengakses internet dari warung internet, diikuti oleh sekolah, rumah dan rumah teman, dan juga tidak dipengaruhi oleh perbedaan jenis kelamin, usia dan etnis (goold, 2003; borzekowski, 2006). di kabupaten ponorogo warnet merupakan jasa penyedia fasilitas internet yang belakangan ini dapat dengan mudah ditemukan bagi pengguna internet. tersedianya warnet dengan biaya yang sangat terjangkau yaitu rp3.000,00 sampai dengan rp5.000,00 untuk setiap jamnya telah memberi peluang kepada banyak orang termasuk remaja yang tidak memiliki komputer dan saluran internet sendiri untuk berkomunikasi dengan orang lain atau untuk kepentingan lainnya melalui internet. pada penelitian ini didapatkan hasil bahwa lebih dari setengahnya remaja memiliki pengetahuan kesehatan reproduksi remaja yang rendah. pengetahuan remaja laki-laki yang masih kurang mengenai penggunaan sabun pembersih khusus genitalia, saluran pengeluaran kencing dan sperma, dampak pemijatan pada kehamilan, kegunaan kb untuk remaja serta jumlah konsumsi protein unt uk remaja laki-laki dan perempuan. sedangkan pengetahuan remaja perempuan yang masih kurang yaitu menganggap sunat sebagai tanda pubertas dan mulai berfungsinya sistem reproduksi pada laki-laki, penggunaan sabun pembersih k husus genetalia pada perempuan, fungsi organ reproduksi laki-laki dan perempuan, kegunaan kb untuk remaja serta jumlah konsumsi protein untuk remaja laki-laki dan perempuan. kemungkinan penyebabnya adalah remaja masih memahami kesehatan reproduksi remaja secara dangkal, dan masih mengutamakan ciri puber tas dari segi f isik saja. sedangkan masalah kb hanya mengetahui jenisnya saja tetapi mengenai kapan penggunaannya, indikasi dan kontraindikasi masing-masing alat kontrasepsi masih belum tahu. pengetahuan remaja yang berasal dari sma dan ma serta berasal dari jurusan ipa memiliki pengetahuan tentang kesehatan reproduksi remaja yang lebih tinggi. hal ini berkaitan dengan adanya pemberian mata pelajaran biologi pada bab reproduksi manusia yang diberikan pada kelas xi semester ii jurusan ipa di sma atau ma. berdasarkan uji statistik mengg unakan 199 penggunaan sistem informasi berbasis website (hery ernawati, dkk.) chi square didapatkan terdapat hubungan antara asal jur usan dengan pengetahuan kesehatan reprodu ksi remaja walaupu n keeratan hubungannya lemah (kk=0,163). keingintahuan remaja tentang kesehatan reproduksi dapat diperoleh melalui berbagai sumber, diantaranya melalui pendidikan di sekolah. sekolah merupakan salah satu pendidikan yang dilakukan di luar keluarga yang pada dasarnya membantu keluarga dalam membimbing dan mengarahkan perkembangan anak, sehingga dapat mempersiapkan anak menjadi anggota masyarakat yang baik (kartika, 2013). penelitian oleh widyastar i (2011) yang dilakukan untuk melihat pengetahuan kesehatan reproduksi remaja di sma kelas xi kota semarang yang sudah mendapatkan pelajaran biologi, menunjukkan hasil bahwa pengetahuan remaja masih rendah mengenai kesehatan reproduksi remaja. disebutkan pula bahwa materi kesehatan reproduksi hanya 10% dari keseluruhan materi biologi, dan seringnya hanya membahas anatomi dan fisiologi organ reproduksi saja. di kabupaten ponorogo materi bab reproduksi manusia pada pelajaran biologi diberikan sebanyak 4–5 kali tatap muka dan ditambah dengan penugasan dari 50 kali tatap muka dalam satu semester. sehingga disarankan peran guru biologi tidak hanya menyampaikan materi anatomi dan fisiologi sistem reproduksi manusia, tetapi juga bisa menambahkan dengan materi kesehatan reproduksi remaja, dan ada pesan moral terhadap remaja agar lebih bisa menjaga diri dalam pergaulan. usia rerata responden pada penelitian ini 16,59 tahun dan merupakan pada kategori usia remaja akhir (15-18 tahun) mengalami masa formal-operasional sesuai dengan teori piaget, yang mengatakan bahwa remaja harus mampu mempertimbangkan semua kemungkinan untuk menyelesaikan masalah dan memper-tanggungjawabkannya, mampu berpikir kritis serta rasa ingin tahu yang kuat (kusmiran, 2012). namun, dalam penelitian ini pengetahuan remaja tentang kesehatan reprodu ksi masih rendah kemu ngkinan karena infor masi yang didapat remaja tentang kesehatan reproduksi belum begitu menyeluruh, mempelajari materi kesehatan reproduksi karena orientasi tugas sekolah ser ta k urangnya kesadaran dari remaja bahwa dirinya memerlukan informasi tentang kesehatan reproduksi. beberapa sumber informasi yang telah ada ternyata tidak selalu menjadi sumber informasi yang tepat untuk remaja dalam mendapatkan informasi tentang kesehatan reproduksi. hal tersebut diperkuat oleh pendapat devy (2001), yang menyatakan bahwa sumber yang tidak tepat dalam memperoleh informasi tentang kesehatan reprodu ksi dapat member i kan dampak yang buruk terhadap remaja. berdasarkan kondisi tersebut, bila pada masa remaja tidak diperkenalkan informasi tentang kesehatan reproduksi dari sumber yang tepat, remaja akan memiliki risiko perilaku yang tidak baik. remaja tanpa pengetahuan yang memadai mengenai risiko yang berhubungan dengan kesehatan reproduksi, mudah terjebak dalam penggunaan narkoba dan atau melakukan hubungan seks yang berisiko (moeliono, 2004). salah satu sumber informasi yang digunakan adalah website. be rd a sa rk a n ha sil uji spea r m a n ra nk denga n α= 0,05 d id apat ka n n ilai p>0,05 sehingga tidak ada hubungan antara penggunaan sistem informasi berbasis website dengan pengetahuan kesehatan reproduksi remaja , mesk ipu n a d a kecender u nga n peningkatan frekuensi dan lamanya akses website kesehatan reproduksi remaja pada remaja yang memiliki pengetahuan pada kategori pengetahuan tinggi. kemungkinan penyebabnya adalah bent uk per tanyaan dalam kuesioner berupa pilihan benar dan salah, sehingga memungkinkan remaja saat memilih jawaban tanpa melalui penalaran soal, responden malu menyatakan bahwa dirinya pernah mengakses materi kesehatan reprodu ksi remaja sehingga hanya ada beberapa saja yang menyatakan menggunakan website untuk mencari informasi kesehatan reproduksi remaja, ditunjang dengan fakta bahwa remaja mencari informasi kesehatan reproduksi remaja di website lebih banyak untuk memenuhi tugas sekolah, bukan karena adanya kesadaran bahwa dirinya memerlukan 200 jurnal ners vol. 9 no. 2 oktober 2014: 194–202 informasi kesehatan reproduksi remaja agar lebih bisa memahami perubahan yang terjadi pada dir inya, sehingga mengak ibatkan pengetahuannya rendah. kuesioner mer upa kan alat u nt u k mengumpulkan data pada sebuah penelitian. meskipun telah dilakukan uji validitas dan reliabilitas. akan tetapi bentuk pertanyaan dalam kuesioner bisa mempengaruhi terhadap jawaban responden. pada penelitian ini bentuk pertanyaan berupa pilihan benar dan salah dengan jumlah soal 44 untuk dikerjakan selama 60 menit. pada pertanyaan yang dianggap sulit maka responden akan memilih salah satu jawaban tanpa dilakukan telaah soal yang lebih mendalam, apalagi jika melihat ada temannya yang lebih dahulu selesai. proses pemilihan responden dilakukan pada pertemuan pertama dengan para calon responden dan dilakukan secara terbuka di kelas. bagi remaja bahasan kesehatan reproduksi remaja merupakan suatu hal yang pribadi, sehingga tidak semua orang bisa diajak berdiskusi. apalagi peneliti baru pertama kali bertemu, dan mungkin remaja merasa belum ada rasa percaya dengan peneliti, sehingga pada saat pemilihan responden merasa malu dan kurang terbuka untuk menyatakan bahwa dirinya pernah mengakses materi kesehatan reproduksi remaja melalui website, sehingga menimbulkan bias responden pada penelitian ini. pa d a s a at p e m i l i h a n r e s p onde n menyatakan bahwa dia mencar i mater i kesehatan reproduksi pada saat mencari tugas sekolah atau karena ada kaitan dengan pelajaran biologi, sehingga motivasi remaja mencari infor masi kesehatan reproduksi remaja lebih karena adanya suatu kewajiban, bukan karena adanya kesadaran bahwa dirinya memerlukan informasi tersebut karena ingin mengetahui terhadap perubahan dan kondisi fisik serta psikologis pada diri seorang remaja proses menyerap informasi menjadi kurang intens dan mengakibatkan pengetahuannya rendah walaupun sudah mengakses materi melalui website. berdasarkan hasil analisis bivariat antara jumlah sumber informasi dengan pengetahuan kesehatan reproduksi menunjukkan adanya hubungan di antara kedua variabel. semakin banyak jumlah sumber informasi yang bisa dipergunakan remaja untuk mendapatkan informasi tentang kesehatan reproduksi maka semakin tinggi pengetahuan remaja. sumber informasi yang digunakan oleh remaja untuk mendapatkan informasi kesehatan reproduksi lebih banyak yang berasal dar i media cetak dan elektronik, teman, serta petugas kesehatan. pada penelitian sebelum nya disebutkan bahwa media cetak, elektronik dan teman menjadi faktor prediktor pengetahuan kesehatan reproduksi remaja (kusmiran, 2006; widyastari, 2011; wahyuni, 2012; shiferaw, 2014). hal ini bisa dipahami bahwa sebagian besar remaja menghabiskan waktu bersama temannya dan mereka merasa nyaman untuk menanyakan atau mendiskusikan mengenai kesehatan reproduksinya dengan teman sebaya dibandingkan dengan orang tua atau guru. salah satu ciri perkembangan pada remaja adalah kuatnya pengar uh teman sebaya, sebagai perwujudan remaja untuk mulai melepaskan diri dari pengaruh orang tua dan ketergantungan secara emosional pada orang tua (kusmiran, 2012). orang tua ternyata bukanlah sumber informasi utama bagi remaja. hal ini mungkin dikarenakan remaja tidak dapat berbicara secara bebas dengan orang tua mereka mengenai kesehatan reproduksi karena mendiskusikan tentang seks dan seksualitas pada remaja yang belum menikah dianggap sebagai hal yang tabu di kalangan masyarakat (santrock, 2003; widyastari, 2011). be rd a s a rk a n d a r i h a si l a n a l isis multivariat bahwa variabel asal jur usan berhubungan dengan pengetahuan kesehatan reproduksi remaja dengan nilai or 2,344 sehingga berarti bahwa remaja yang berasal dari jurusan ipa memiliki kemungkinan 2,344 kali lebih besar dari remaja yang berasal dari jurusan non ipa untuk memiliki pengetahuan yang tinggi tentang kesehatan reproduksi remaja. pada jur usan ipa mendapatkan pelajaran biologi bab reproduksi manusia pada kelas xi semester ii, sedangkan pada jurusan non ipa tidak mendapatkan pelajaran biologi sama sekali, atau pada kelas x sma dan ma terdapat pelajaran biologi tetapi tidak ada materi reproduksi manusia. hasil 201 penggunaan sistem informasi berbasis website (hery ernawati, dkk.) penelitian bakti (2010) di sman i sukoharjo pada kelas xi ipa menunjukkan pengetahuan tentang kesehatan reproduksi sebagian besar dalam kategori baik, sedangkan dari penelitian widyastari (2011) yang dilakukan untuk melihat pengetahuan kesehatan reproduksi remaja di sma kelas xi kota semarang yang sudah mendapatkan pelajaran biologi, menunjukkan hasil bahwa pengetahuan remaja masih rendah mengenai kesehatan reproduksi remaja. simpulan dan saran simpulan simpulan pada penelitian ini adalah rerata frekuensi mengakses website dan lamanya mengakses website kesehat an reproduksi pada remaja dalam seminggu yaitu 1,36 kali dan 1,65 jam; pengetahuan kesehatan reproduksi remaja sebanyak 58,1% pada kategori rendah; tidak ada hubungan antara penggunaan sistem informasi berbasis website dengan pengetahuan kesehatan reproduksi remaja , mesk ipu n a d a kecender u nga n peningkatan frekuensi dan lamanya akses website kesehatan reproduksi remaja pada remaja yang memiliki pengetahuan pada kategori pengetahuan tinggi. saran pi ha k sekolah perlu mem i k i rka n adanya cara yang digunakan untuk pemberian informasi kesehatan reproduksi remaja pada kelompok siswa yang tidak mendapatkan materi biologi khususnya bab reproduksi manusia, sehingga remaja dari kelompok tersebut tetap mendapatkan materi kesehatan reproduksi remaja di sekolah, meningkatkan peran serta guru sebagai sumber informasi kesehatan reproduksi remaja agar informasi yang diterima remaja menjadi lebih jelas dan dari sumber yang bisa dipertanggung jawabkan. orang tua yang merupakan orang yang paling dekat dengan remaja diharapkan juga meningkatkan peran serta sebagai sumber informasi kesehatan reproduksi remaja agar informasi yang diterima remaja menjadi lebih jelas dan dari sumber yang bisa dipertanggung jawabkan. peneliti selanjutnya yang akan melanjutkan penelitian ini diharapkan untuk tidak langsung mengadakan pemilihan calon responden pada awal pertemuan dan menggunakan angket tertutup untuk pemilihan calon responden pada remaja sehingga remaja bisa terbuka dengan peneliti. kepustakaan atmaji, w., 2008. generasi platinum: karakter unik, lebih ekspresif, dan eksploratif. (online), (htttp://www. suara merdeka. com., diakses tanggal 5 agustus 2013). arfan, m., 2009. efektivitas pendidikan kesehatan melalui e-file multimedia materi krr dan tatap muka di kelas terhadap peningkatan pengetahuan k e sehata n re prod uk si re maja di kabupaten bantul yogyakarta. tesis tid ak dipubli kasi kan. universit as gadjah mada. bakti, martinda. 2010. hubungan antara t i n g k a t p e n ge t a h u a n k e s e h a t a n reproduksi dengan perilaku seksual remaja siswa-siswi sman i sukoharjo. (online), (http://www. dgilib.uns.ac.id, diakses tanggal 21 mei 2014). bkkbn. 2007. survei indikator kinerja r e n c a n a p e m b a n g u n a n j a n g k a m e n e n g a h n a s i o n a l p r o g r a m kependudukan dan kb nasional tahun 2007. jakarta: bkkbn. borzekowski, d. l., g., fobil, j.n., asante, k., o., 2006. online access by adolescents in acra: ghanaian teens' use of the i nter net for healt h i n for mat ion. developmental psycholog y, 42 (3), 450–458. cahyo, k., kurniawan, t., p., margawati, a ., 2 0 0 8 . fa k t o rfa k t o r ya n g mempengar uhi praktik kesehatan reproduksi remaja di sma negeri i purbalingga kabupaten purbalingga. jurnal promosi kesehatan indonesia, 3(2), 86–101. goold, p., c., ward, m., charlin, e.m. 2003. can the internet be used to improve sexual health awareness in webwise young people? journal of family 202 jurnal ners vol. 9 no. 2 oktober 2014: 194–202 planning and reproductive health care 2003, 29(1), 28–30. kartika, r., c., kamidah. 2013. hubungan pengetahuan remaja tentang kesehatan reproduk si dengan perilaku sek s pranikah pada siswa kelas xi di sman colomadu. gaster, 10(1). kusmiran, e., 2006. hubungan peran teman sebagai sumber informasi kesehatan reprod uk si dengan sik ap remaja mengenai hubungan seksual pranikah (analisis survey kesehatan reproduksi re m aja 20 02 –20 03). te sis t id a k dipublikasikan. universitas gadjah mada. moeliono, l., 2004. seksualitas dan kesehatan reproduksi remaja. apa yang masih bisa kita lakukan? majalah kesehatan perkotaan, 11(1), 30–35. nwagwu, w., e., 2007. the internet as a source of reproductive health infor mation among adolescent girls in an urban city in nigeria. bmc public health, 7, 354. qomariyah, a., n., 2009. perilaku penggunaan inter net pada kalangan remaja di perkotaan. palimpsest jurnal ilmu informasi dan perpustakaan. 1 (1). respati, w.s. 2013. problematika remaja akibat kurangnya informasi kesehatan reprodu ksi. jur nal ilmiah bunga rampai, 7 (1). sa nt ro ck , j., w., 20 03. ad ole sc e n c e perkembangan remaja, edisi ke-6, diterjemahkan oleh sb adelar dan s saragih. jakarta: erlangga. shiferaw, k., getahun, f., getahun, a. 2014. assessment of adolescents’ c o m m u n i c a t i o n o n s e x u a l a n d reproductive health matters with parents and associated factors among secondary and preparatory schools’ students in debrema rkos tow n, nor t h west ethiopia. reproductive health, 11(2). wa hy u n i, s., 2012. hubu nga n a nt a ra pengetahuan remaja tentang penyakit menular seksual (pms) dengan jenis kelamin dan sumber informasi di sman banda aceh. jurnal ilmiah stikes u’budiyah, 1(2). widyastari, d., a., shaluhiyah, z., widjanarko, b., 2010. adole sc e nt s i n pe r i l: internet and other factors inf luencing adolescents’ sexual attitudes. jurnal kesehatan reproduksi, 1(1), 1–13. xu, et al. 2012. personal characteristics related to the risk of adolescent internet addiction: survey in shanghai china. bmc public health, 12, 1106. 252 peningkatan penerimaan pada nyeri kronis, comfort dan kualitas hidup lansia melalui acceptance and commitment therapy (act) (the improvement of elderly acceptance in cronic pain, comfort, and quality of life through acceptance and commitment therapy (act)) dhina widayati*, ahmad yusuf*, rizki fitryasari p.k.* *program studi magister keperawatan fakultas keperawatan universitas airlangga jl. mulyorejo (kampus c unair) surabaya e-mail: dhinawida@yahoo.com abstrak pendahuluan: nyeri sendi kronis masih menjadi masalah utama pada lansia. faktor psikososial berdampak besar terhadap penderita nyeri kronis. penerimaan terhadap nyeri pada penderita nyeri kronis diduga dapat meningkatkan kemampuannya melakukan aktivitas sehari-hari, kenyamanan, dan kualitas hidup. acceptance and commitment therapy (act) merupakan bentuk psikoterapi yang cukup efektif dalam manajemen nyeri kronis. tujuan dari penelitian ini adalah untuk menganalisis pengaruh act terhadap peningkatan penerimaan nyeri, kenyamanan, dan kualitas hidup lansia dengan nyeri sendi kronis. metode: penelitian berdesain quasy experiment pre-post test control group. populasi adalah lansia yang tinggal di upt pslu jombang di pare-kediri. sampel meliputi 32 responden, diperoleh dengan teknik purposive sampling, dibagi menjadi kelompok perlakuan dan kontrol. data dikumpulkan dengan kuesioner cpaq (penerimaan nyeri), gcq (kenyamanan), dan who-qolbref (kualitas hidup), lalu dianalisis dengan wilcoxon signed ranks test, mann whitney u test, paired t test dan independent samples t test, dengan tingkat signifikansi 0,05. hasil: hasil menunjukkan bahwa ada pengaruh act terhadap peningkatan penerimaan nyeri (p=0,003), kenyamanan (p=0,008), dan kualitas hidup lansia dengan nyeri sendi kronis (p=0,002). diskusi: act meningkatkan penerimaan, kenyamanan, dan kualitas hidup lansia dengan nyeri sendi kronis. perawat geriatrik dapat menggunakan aktivitas psikososial dalam kegiatan sehari-hari lansia, sehingga dapat meningkatkan kualitas hidupnya. selain itu, kualitas pelayanan keperawatan kepada lansia juga dapat ditingkatkan. kata kunci: act, penerimaan nyeri, kenyamanan, kualitas hidup, lansia, nyeri sendi kronis abstract introduction: chronic joint pain is a problem for the majority of elderly. psychosocial factors have a great impact on people with chronic pain. the acceptance of pain in people with chronic pain can increase their activity daily living, comfort, and quality of life. acceptance and commitment therapy (act) is a form of psychotherapy which effective in the management of chronic pain. the objective of this study was to analyze the effect of act on improvement acceptance of chronic pain, comfort, and quality of life elderly with chronic joint pain. method: this study was used a quasy experiment pre-post test control group design. population were elderly who lived at upt pslu jombang di pare-kediri. sample were 32 respondents gotten by purposive sampling, divided into experiment and control group. independent variable was act, and dependent variables were pain acceptance, comfort, and quality of life elderly with chronic joint pain. data were collected by using questionnaire with cpaq (pain acceptance), gcq (comfort) and who-qolbref (quality of life). data then analyzed by using wilcoxon signed ranks test, mann whitney u test, paired t test and independent samples t test with significance value of 0.05. result: the results had showed that there was an influence act to improvement acceptance of chronic pain (p=0,003), comfort (p=0,008), and quality of life elderly with chronic joint pain (p=0,002). discussion: act improved pain acceptance, comfort, and quality of life of elderly with joint chronic pain. geriatric nurses should include psychosocial activities as a routine activities, as an effort to improve the quality of life. beside that, the quality of nursing care for elderly can be improved . keywords: act, pain acceptance, comfort, quality of life, elderly, chronic joint pain pendahuluan per ubahan karakteristik demograf i p opu la si du n ia ya ng me nga r a h pa d a peningkatan jumlah penduduk usia lebih dari 65 tahun menjadi tantangan bagi para praktisi kesehatan. hal serupa juga terjadi di indonesia, di mana pada 2010 jumlah penduduk lansia sebanyak 18,57 juta jiwa, meningkat 7,9% dari tahun 2000. pertambahan usia yang dialami lansia juga diikuti oleh berbagai penurunan fungsi tubuh yang meliputi fungsi penglihatan, pendenga ra n, pengecapa n, penciu ma n, kekuatan otot, serta kerentanan terhadap 253 peningkatan penerimaan pada nyeri kronis (dhina widayati, dkk.) penyakit tertentu. berbagai penurunan fungsi tubuh inilah yang menyebabkan lansia rentan menderita nyeri (pain) yang dapat menghambat rutinitas harian. menurut sebagian besar lansia, nyeri merupakan keadaan yang sangat mengganggu, suat u masalah yang akan mempengaruhi aktivitas harian dan kualitas hidup (papila 2009; sares 2008). hasil studi pendahuluan yang dilakukan di upt panti sosial lanjut usia (pslu) jombang di pare-kediri menyatakan keluhan nyeri kronis pada persendian menduduki peringkat pertama. sekitar 37,64% lansia mengalami nyeri kronis yang disebabkan oleh penyakit pada persendian. hasil wawancara yang dilakukan lebih lanjut menunjukkan bahwa lansia merasa terganggu dan tidak nyaman dengan nyer i yang dirasakan. sejumlah 56,25% lansia menyatakan nyeri tersebut sampai mengganggu aktivitas seharihari, merasa putus asa karena nyeri yang dirasakan tidak kunjung sembuh walaupun sudah meminum obat setiap hari. nyeri yang terus-menerus membuat lansia merasa hidupnya menjadi kurang berkualitas dan tergantung dengan bantuan orang lain. pener imaan lansia terhadap nyer i kronis yang dirasakan dapat meningkatkan keberfungsiaannya dalam kehidupan seharihari. kolcaba (2011) dalam teori comfort menyatakan terdapat tiga tipe intervensi comfort, yaitu: teknis pengukuran kenyamanan, coa ching (mengaja rk a n), d a n comfor t food (untuk jiwa, meliputi intervensi yang menjadikan penguatan jiwa dan merupakan terapi untuk kenyamanan psikologis, act termasuk di dalamnya). penerimaan (acceptance) bermakna menerima. individu har us terlebih dulu mengerti mengenai keadaannya, setelah itu baru individu tersebut mampu menerima kondisinya. komit men mempu nyai ar ti perjanjian (keterikatan) untuk melakukan sesuatu. melalui penerapan act diharapkan lansia dengan nyeri kronis akan menerima kondisinya dan dapat menentukan apa yang terbaik untuk dirinya dan berkomitmen untuk melakukan apa yang dipilihnya. pendekatan act yang dig u nakan dalam manajemen nyeri memiliki tiga tujuan. pertama, membantu penderita menemukan solusi dari masalah yang dimilikinya secara mandir i, sehingga dapat meningkatkan perasaan optimis di dalam dirinya. hal ini juga membuat penderita menyadari bahwa nyeri kronis yang dialaminya dapat diatasi dengan baik. kedua, penderita nyeri kronis khususnya lansia dapat menyadari hubungan antara pikiran, emosi, dan perilaku yang dimilikinya. hal ini penting untuk membantu penderita memahami bahwa pikiran dan emosi yang negatif dapat mempengaruhi persepsinya terhadap nyeri, emotional distress, dan hambatan psikososial yang dialami. terakhir, membantu penderita khususnya lansia menemukan strategi yang efektif untuk mengatasi rasa nyeri, emotional distress, dan hambatan psikososial yang dialami (hayes 2006; morrison & bennet 2009). berdasarkan latar belakang di atas, peneliti ingin membuktikan acceptance and commitment therapy (act) sebagai salah satu upaya untuk meningkatkan comfort dan kualitas hidup melalui peningkatan penerimaan terhadap nyeri kronis. tujuan penelitian ini adalah menganalisis pengaruh act dalam meningkatkan penerimaan terhadap nyeri kronis, comfort dan kualitas hidup lansia dengan nyeri kronis persendian. bahan dan metode desain penelitian yang digunakan adalah quasy experiment pre post test control group design. besar sampel diperoleh 32 responden (dibagi menjadi kelompok perlakuan dan kelompok kontrol). teknik sampling menggunakan purposive sampling dengan kriteria inklusi: 1) lansia dengan nyeri kronis pada persendian; 2) lansia dengan skor mmse=24-30; dan 3) lansia kooperatif. kriteria eksklusi dalam penelitian ini adalah: 1) lansia yang mengalami komplikasi dan membutuhkan perawatan penuh; 2) lansia denga n nyer i k ron is per send ia n ya ng mengalami ketergantungan dengan konsumsi analgesik; dan 3) lansia yang mengalami gangguan pendengaran. variabel independen pada penelitian ini adalah act. variabel dependennya meliputi 254 jurnal ners vol. 9 no. 2 oktober 2014: 252–261 penerimaan terhadap nyeri kronis, comfort, dan k ualitas hidup. peng u mpulan data dilakukan dengan menggunakan kuesioner: cpaq (penerimaan nyeri), gcq (comfort), dan who-qolbref (kualitas hidup). pre-test dilakukan pada kelompok kontrol terlebih dahulu dengan melakukan pengukuran penerimaan nyeri, comfort, dan kualitas hidup. dua minggu kemudian dilakukan post-test pada kelompok kontrol. pada minggu ketiga responden perlakuan d ibe r i k a n i nt e r ve n si act sela m a 60 menit 2×/minggu (selasa dan kamis) yang terbagi dalam 4 sesi dengan terlebih dahulu melakukan pre-test. setiap sesi dilaksanakan dalam 1x pertemuan, kecuali pada sesi ke-4 yang dilaksanakan selama 3 kali. latihan dilakukan pada pukul 09.00 –10.00 secara kelompok di ruang pertemuan. post-test kelompok perlakuan dilakukan 1 hari setelah perlakuan yang terakhir dengan mengukur tingkat penerimaan nyeri, tingkat comfort dan kualitas hidup lansia. d a t a y a ng d ip e r ole h d i a n a l i si s menggunakan wilcoxon signed ranks test dan mann whitney u test (penerimaan terhadap nyeri kronis dan comfort), paired t test dan independent samples t test (kualitas hidup) dengan nilai signifikansi 0,05. hasil sebagian besar responden kelompok perlakuan berumur 75–90 tahun, perempuan, riwayat pendidikan terakhir sd, beragama islam, riwayat pekerjaan sebagai petani, status pernikahan janda oleh karena pasangan meninggal, telah menderita nyeri kronis persendian dalam kurun waktu 1–3 tahun, telah tinggal di upt pslu jombang di parekediri selama 1–3 tahun, lokasi nyeri di area ekstremitas bawah, mempunyai penyakit dasar hipertensi dan persendian (arthritis/ gout), dan datang ke panti dengan diantar oleh keluarga. d a t a p a d a k e l o m p o k k o n t r o l m e nu nju k k a n b a hw a s e b a g i a n b e s a r responden berumur 75–90 tahun, laki-laki, riwayat pendidikan terakhir tidak bersekolah, beragama islam, riwayat pekerjaan sebagai petani, stat us per nikahan duda karena pasangan meninggal, telah menderita nyeri dalam kurun waktu 1–3 tahun, lama tinggal di upt pslu jombang di pare-kediri dalam kurun waktu 1–3 tahun, lokasi nyeri di area ekstremitas bawah, mempunyai penyakit dasar hipertensi dan persendian (arthritis/gout), dan diantar ke panti oleh keluarga. hasil analisis uji homogenitas pada data umum menggunakan independent sample t test (usia dan skor mmse), chi square (jenis kelamin) dan kruskall wallis (riwayat pendidikan, agama, riwayat pekerjaan, status pernikahan, lama nyeri, lama tinggal di panti, lokasi nyeri, penyakit dasar, dan pengantar lansia ke panti) menunjukkan hampir seluruh data umum homogen, kecuali pada data jenis kelamin. data tingkat penerimaan lansia terhadap nyeri kronis pada tabel.1 menunjukkan bahwa mayoritas responden kelompok perlakuan, ya it u 14 or a ng (87, 50%) me mpu nya i penerimaan terhadap nyeri kronis dalam kategori sedang pada pre test dan 10 orang tabel 1. tabulasi silang pre test dan post test tingkat penerimaan terhadap nyeri kronisingkat penerimaan terhadap nyeri kronist penerimaan terhadap nyeri kronis kroniskronis responden kelompok perlakuan dan kontrolkelompok perlakuan dan kontrol pengantar lansia ke panti) menunjukkan hampir seluruh data umum homogen, kecuali pada data jenis kelamin. tabel 1. tabulasi silang pre test dan post test tingkat penerimaan terhadap nyeri kronis responden kelompok perlakuan dan kontrol kelompok perlakuan kelompok kontrol post test ∑ post test ∑ r s t r s t pre test r 1 1 pre test r 2 1 3 s 6 8 14 s 12 12 t 1 1 t 1 1 ∑ 0 6 10 16 ∑ 2 13 1 16 wilco�on (p= 0,004) wilco�on (p= 0,317) mann whitney u test (p= 0,003) ket : r (ringan), s (sedang), t (tinggi) data tingkat penerimaan lansia terhadap nyeri kronis pada tabel.1 menunjukkan bahwa mayoritas responden kelompok perlakuan, yaitu 14 orang (87,50%) mempunyai penerimaan terhadap nyeri kronis dalam kategori sedang pada pre test dan 10 orang (62,50%) mempunyai penerimaan terhadap nyeri kronis dalam katagori tinggi pada post test. analisa data prepost menggunakan uji wilco�on signed rank test dengan nilai p=0,004 (p<0,05) menunjukkan terdapat perbedaan tingkat penerimaan lansia terhadap nyeri kronis pre dan post pemberian intervensi act pada kelompok perlakuan. hasil pengukuran tingkat penerimaan lansia terhadap nyeri kronis pada kelompok kontrol, menunjukkan bahwa mayoritas responden, 12 orang (75,00%) mempunyai penerimaan terhadap nyeri kronis dalam kategori sedang pada pre test dan 13 orang (81,25%) pada post test. analisa data pre-post menggunakan uji wilco�on signed rank test dengan nilai p=0,317 (p>0,05) menunjukkan tidak terdapat perbedaan tingkat penerimaan lanisa terhadap nyeri kronis pada kelompok kontrol. perbedaan antara dua kelompok dianalisis menggunakan uji mann whitney u test dengan nilai p=0,003 (p<0,05) menujukkan bahwa terdapat pengaruh act dalam meningkatkan penerimaan terhadap nyeri kronis pada lansia dengan nyeri kronis persendian. tabel 2 tabulasi silang pre test dan post test tingkat comfort responden kelompok perlakuan kelompok kontrol post test ∑ post test ∑ r s t r s t pre test r 1 1 2 pre test r 4 1 5 s 5 7 12 s 10 10 t 1 1 2 t 1 1 ∑ 1 7 8 16 ∑ 4 11 1 16 wilco�on (p= 0,002) wilco�on (p= 0,180) mann whitney u test (p= 0,008) ket : r (ringan), s (sedang), t (tinggi) hasil pengukuran tingkat comfort seperti yang tampak pada tabel.2 menunjukkan bahwa pada pre test kelompok perlakuan terdapat 2 orang (11,11 %) dengan tingkat comfort dalam kategori tinggi. sedangkan pada 255 peningkatan penerimaan pada nyeri kronis (dhina widayati, dkk.) tabel 2. tabulasi silang pre test dan post test tingkat comfort responden pengantar lansia ke panti) menunjukkan hampir seluruh data umum homogen, kecuali pada data jenis kelamin. tabel 1. tabulasi silang pre test dan post test tingkat penerimaan terhadap nyeri kronis responden kelompok perlakuan dan kontrol kelompok perlakuan kelompok kontrol post test ∑ post test ∑ r s t r s t pre test r 1 1 pre test r 2 1 3 s 6 8 14 s 12 12 t 1 1 t 1 1 ∑ 0 6 10 16 ∑ 2 13 1 16 wilco�on (p= 0,004) wilco�on (p= 0,317) mann whitney u test (p= 0,003) ket : r (ringan), s (sedang), t (tinggi) data tingkat penerimaan lansia terhadap nyeri kronis pada tabel.1 menunjukkan bahwa mayoritas responden kelompok perlakuan, yaitu 14 orang (87,50%) mempunyai penerimaan terhadap nyeri kronis dalam kategori sedang pada pre test dan 10 orang (62,50%) mempunyai penerimaan terhadap nyeri kronis dalam katagori tinggi pada post test. analisa data prepost menggunakan uji wilco�on signed rank test dengan nilai p=0,004 (p<0,05) menunjukkan terdapat perbedaan tingkat penerimaan lansia terhadap nyeri kronis pre dan post pemberian intervensi act pada kelompok perlakuan. hasil pengukuran tingkat penerimaan lansia terhadap nyeri kronis pada kelompok kontrol, menunjukkan bahwa mayoritas responden, 12 orang (75,00%) mempunyai penerimaan terhadap nyeri kronis dalam kategori sedang pada pre test dan 13 orang (81,25%) pada post test. analisa data pre-post menggunakan uji wilco�on signed rank test dengan nilai p=0,317 (p>0,05) menunjukkan tidak terdapat perbedaan tingkat penerimaan lanisa terhadap nyeri kronis pada kelompok kontrol. perbedaan antara dua kelompok dianalisis menggunakan uji mann whitney u test dengan nilai p=0,003 (p<0,05) menujukkan bahwa terdapat pengaruh act dalam meningkatkan penerimaan terhadap nyeri kronis pada lansia dengan nyeri kronis persendian. tabel 2 tabulasi silang pre test dan post test tingkat comfort responden kelompok perlakuan kelompok kontrol post test ∑ post test ∑ r s t r s t pre test r 1 1 2 pre test r 4 1 5 s 5 7 12 s 10 10 t 1 1 2 t 1 1 ∑ 1 7 8 16 ∑ 4 11 1 16 wilco�on (p= 0,002) wilco�on (p= 0,180) mann whitney u test (p= 0,008) ket : r (ringan), s (sedang), t (tinggi) hasil pengukuran tingkat comfort seperti yang tampak pada tabel.2 menunjukkan bahwa pada pre test kelompok perlakuan terdapat 2 orang (11,11 %) dengan tingkat comfort dalam kategori tinggi. sedangkan pada (62,50%) mempunyai penerimaan terhadap nyeri kronis dalam katagori tinggi pada post test. analisa data pre-post menggunakan uji wilcoxon signed rank test dengan nilai p=0,004 (p<0,05) menunjukkan terdapat perbedaan tingkat penerimaan lansia terhadap nyeri kronis pre dan post pemberian intervensi act pada kelompok perlakuan. hasil pengukuran tingkat penerimaan lansia terhadap nyeri kronis pada kelompok kontrol, menunjuk kan bahwa mayoritas responden, 12 orang (75,00%) mempunyai penerimaan terhadap nyeri kronis dalam kategori sedang pada pre test dan 13 orang (81,25%) pada post test. analisa data pre-post menggunakan uji wilcoxon signed rank test dengan nilai p=0,317 (p>0,05) menunjukkan tidak terdapat perbedaan tingkat penerimaan lansia terhadap nyeri kronis pada kelompok kontrol. perbed a a n a nt a r a du a kelompok dianalisis menggunakan uji mann whitney u test dengan nilai p= 0,003 (p<0,05) menunjukkan bahwa terdapat pengaruh act dalam meningkatkan penerimaan terhadap nyeri kronis pada lansia dengan nyeri kronis persendian. hasil pengukuran tingkat comfor t seperti yang tampak pada tabel 2 menunjukkan bahwa pada pre test kelompok perlakuan terdapat 2 orang (11,11 %) dengan tingkat comfort dalam kategori tinggi. sedangkan pada post test didapatkan hasil 8 orang (50,00%) dengan tingkat comfort dalam kategori tinggi. uji wilcoxon signed rank test dengan nilai p=0,020 (p<0,05) menunjukkan terdapat perbedaan tingkat comfort pre dan post pemberian intervensi act pada kelompok perlakuan. tingkat comfort pre test dan post test pada kelompok kontrol menunjukkan hasil pengukuran yang tidak jauh beda. sebagian besar responden mempunyai tingkat comfort dalam kategori sedang, 11 orang (68,75%) pada pre test dan 10 orang (62,50%) pada post test. analisa data pre-post menggunakan uji wilcoxon signed rank test dengan nilai p=0,180 (p>0,05) menunjukkan tidak terdapat perbedaan tingkat comfort pre dan post pada kelompok kontrol. perbandingan data tingkat comfort responden pada kelompok perlakuan dan kontrol sesudah pemberian intervensi act menunjukkan bahwa sebagian responden, 8 tabel 3. tabulasi silang rekapitulasi skor kualitas hidup responden pada kelompok perlakuan dan kontrol sesudah intervensi post test didapatkan hasil 8 orang (50,00%) dengan tingkat comfort dalam kategori tinggi. uji wilco�on signed rank test dengan nilai p=0,020 (p<0,05) menujukkan terdapat perbedaan tingkat comfort pre dan post pemberian intervensi act pada kelompok perlakuan. tingkat comfort pre test dan post test pada kelompok kontrol menunjukkan hasil pengukuran yang tidak jauh beda. sebagian besar responden mempunyai tingkat comfort dalam kategori sedang, 11 orang (68,75%) pada pre test dan 10 orang (62,50%) pada post test. analisa data pre-post menggunakan uji wilco�on signed rank test dengan nilai p=0,180 (p>0,05) menunjukkan tidak terdapat perbedaan tingkat comfort pre dan post pada kelompok kontrol. perbandingan data tingkat comfort responden pada kelompok perlakuan dan kontrol sesudah pemberian intervensi act menunjukkan bahwa sebagian responden, 8 orang (50,00%) pada kelompok perlakuan mempunyai tingkat comfort dalam kategori tinggi. sedangkan pada kelompok kontrol, terdapat 1 orang (6,25%) yang mempunyai tingkat comfort dalam kategori tinggi. uji mann whitney u test dengan nilai p=0,008 menunjukkan bahwa terdapat perbedaan tingkat comfort post intervensi act pada kelompok perlakuan dan kelompok kontrol. hasil kedua jenis uji statistik menunjukkan bahwa hipotesis diterima, yang artinya terdapat pengaruh act terhadap comfort pada lansia dengan nyeri kronis persendian. tabel 3. tabulasi silang rekapitulasi skor kualitas hidup responden pada kelompok perlakuan dan kontrol sesudah intervensi no klp test naik tetap turun total paired t test mean ± sd independent t test f % f % f % f % 1 p pre 0,003 8,94±9,69 0,002 post 12 75,00 1 6,25 3 18,75 16 100 2 k pre 0,366 1,00±4,28 post 3 18,75 10 62,50 3 18,75 16 100 ket : p (perlakuan), k (kontrol) data pengukuran kualitas hidup pada kelompok perlakuan pada tabel 3 menunjukkan bahwa mayoritas responden kelompok perlakuan, yaitu 12 orang (75,00%) mengalami peningkatan kualitas hidup setelah pemberian intervensi act. sedangkan pada kelompok kontrol yang tidak mendapatkan act, sebagian besar responden, yaitu 10 orang (62,50%) tidak mengalami perubahan. hasil uji paired t test menujukkan nilai p=0,003 (p<0,05) pada kelompok perlakuan dan p=0,366 pada kelompok kontrol. hal ini menunjukkan bahwa pada kelompok perlakuan terdapat perbedaan kualitas hidup pre dan post intervensi act, sedangkan pada kelompok kontrol tidak terdapat perbedaan. perbedaan efektifitas act terhadap kualitas hidup pada kelompok perlakuan dan kontrol di uji menggunakan independent t test dengan nilai p=0,002 (p<0,005) menujukkan bahwa terdapat perbedaan kualitas hidup post intervensi act pada kedua kelompok. hasil kedua jenis uji statistik menujukkan bahwa hipotesis diterima, yang artinya terdapat pengaruh act terhadap kualitas hidup. pengujian statistik yang dilakukan terhadap kedua kelompok (perlakuan dan kontrol) menunjukkan hasil bahwa terdapat pengaruh acceptance and commitment therapy (act) terhadap penerimaan nyeri kronis, comfort dan kualitas hidup lansia dengan nyeri kronis persendian. pembahasan 256 jurnal ners vol. 9 no. 2 oktober 2014: 252–261 orang (50,00%) pada kelompok perlakuan mempunyai tingkat comfort dalam kategori tinggi. sedangkan pada kelompok kontrol, terdapat 1 orang (6,25%) yang mempunyai tingkat comfort dalam kategori tinggi. uji mann whitney u test dengan nilai p=0,008 menunjukkan bahwa terdapat perbedaan tingkat comfort post intervensi act pada kelompok perlakuan dan kelompok kontrol. hasil kedua jenis uji statistik menunjukkan bahwa hipotesis diterima, yang artinya terdapat pengaruh act terhadap comfort pada lansia dengan nyeri kronis persendian. dat a peng u k u ra n k u alit as h idup pada kelompok perlakuan pada tabel 3 menunjukkan bahwa mayoritas responden kelompok perlakuan, yaitu 12 orang (75,00%) mengalami peningkatan kualitas hidup setelah pemberian intervensi act. sedangkan pada kelompok kontrol yang tidak mendapatkan act, sebagian besar responden, yaitu 10 orang (62,50%) tidak mengalami perubahan. hasil uji paired t test menunjukkan nilai p=0,003 (p<0,05) pada kelompok perlakuan dan p=0,366 pada kelompok kontrol. hal ini menunjukkan bahwa pada kelompok perlakuan terdapat perbedaan kualitas hidup pre dan post intervensi act, sedangkan pada kelompok kontrol tidak terdapat perbedaan. perbedaan efektivitas act terhadap kualitas hidup pada kelompok perlakuan dan kontrol di uji menggunakan independent t test dengan nilai p=0,002 (p<0,005) menunjukkan bahwa terdapat perbedaan kualitas hidup post intervensi act pada kedua kelompok. hasil kedua jenis uji statistik menunjukkan bahwa hipotesis diterima, yang artinya terdapat pengaruh act terhadap kualitas hidup.erhadap kualitas hidup. pengujian statistik yang dilakukan terhadap kedua kelompok (perlakuan dan kontrol) menunjukkan hasil bahwa terdapat pengar uh acceptance and commitment therapy (act) terhadap penerimaan nyeri kronis, comfort dan kualitas hidup lansia dengan nyeri kronis persendian. pembahasan mayoritas responden pada kelompok perlakuan mengalami peningkatan penerimaan terhadap nyeri kronis yang diderita. motivasi dan ant usiasme responden yang tinggi mempunyai pengaruh dalam peningkatan penerimaan terhadap nyeri kronis tersebut. peningkatan penerimaan terhadap nyeri kronis juga seiring dengan peningkatan kemampuan adaptasi terhadap nyeri. hal ini sejalan dengan penelitian esteve dkk. (2007) yang menemukan bahwa penerimaan yang tinggi terhadap nyeri kronis yang diderita membuat penderita semakin dapat beradaptasi dengan nyeri kronisnya tersebut dan mengoptimalkan keberfungsiannya sehari-hari. penerimaan terhadap nyeri kronis juga dapat menurunkan perhatian penderita terhadap nyeri dan meningkatkan keterlibatannya di dalam aktifitas harian. meskipun demikian, tidak semua responden mengalami peningkatan dalam masing-masing subskala penerimaan terhadap nyeri kronis. d a t a p a d a s u b s k a l a a c t i v i t y engganggement (tetap menjalani rutinitas sehari-hari dengan nor mal, bahkan saat nyeri yang dialami muncul) terdapat dua responden yang mengalami penurunan. hal ini berkaitan dengan penur unan jumlah aktivitas harian. terlalu banyak kegiatan yang dikerjakan oleh dua responden tersebut, sehingga meningkatkan intensitas nyeri yang dideritanya. lefort (2008) menyatakan bahwa terlalu banyak melakukan aktivitas di luar kapasitas tubuh dapat menyebabkan intensitas nyeri yang dirasakan penderita meningkat, sehingga ia perlu menyeimbangkan antara waktu aktivitas dan istirahat. oleh karena itu, dua orang responden tersebut menurunkan jumlah aktivitas hariannya dan meningkatkan waktu istirahatnya. hal ini mengindikasikan bahwa penerimaan terhadap nyeri kronis pada kedua responden tersebut mengalami penur unan. bila dikaitkan dengan data demografi yang mendukung yaitu keduanya berusia usia <75 tahun. menurut brunner dan suddarth (2001), semakin tinggi usia seseorang, dia akan cenderung mengabaikan nyeri dan menahan nyeri karena sudah terbiasa dengan nyeri yang dirasakannnya, sehingga lebih menerima nyeri yang dirasakan. sebaliknya pada kedua responden tersebut berada pada usia <75 tahun, sehingga penerimaan terhadap 257 peningkatan penerimaan pada nyeri kronis (dhina widayati, dkk.) nyeri kronis yang dirasakan menjadi lebih rendah. pa d a s ubsk a la p a i n willi n g n e s s ( k e t e r b u k a a n a t a u k e m a u a n u n t u k mengalami sensasi nyeri) terdapat sat u responden yang mengalami penurunan. hal ini menunjukkan bahwa responden tersebut cenderung menghindari nyeri kronis yang dideritanya. upayanya menghindari nyeri kronis ini ditunjukkan melalui jarangnya ia menggerakkan tangan kanannya pada latihan exercise ringan. ia hanya menggerakkan tangan kanannya saat benar-benar har us melakukannya. dengan sikapnya tersebut, responden tersebut terhindar dari nyeri bahu saat tangan kanan digerakkan. meskipun demikian, selama menjalani intervensi, ia melaporkan adanya penurunan dalam sikapnya tersebut. ia mulai mencoba menggerakkan tangan kanannya perlahan-lahan secara rutin, salah satunya dengan melakukan exercise ringan. bila dikaitkan dengan data demografi yang mendukung, responden tersebut berjenis kelamin laki-laki dan baru menderita nyeri sejak 1 tahun yang lalu. seorang wanita lebih dapat mengekspresikan nyeri yang dirasakan d a r i pad a seora ng la k i-la k i, seh i ngga penerimaan akan nyerinya lebih baik. kurun waktu menderita nyeri juga berkorelasi positif dengan tingkat adaptasi terhadap nyeri. semakin lama seseorang menderita nyeri, maka tingkat adaptasi terhadap nyerinya semakin tinggi. perbedaan hasil pengukuran pre dan post intervensi menunjukkan bahwa act efektif dalam meningkatkan penerimaan lansia terhadap nyeri kronis. hal ini dapat disebabkan oleh sifat-sifat pendekatan act yang digunakan dalam pemberian intervensi ini. menur ut hayes (2007), terapi act bertujuan untuk meningkatkan aspek psikologi yang lebih fleksibel atau kemampuan untuk menjalani perubahan yang terjadi saat ini dengan lebih baik. terapi act menggunakan konsep penerimaan, kesadaran, dan penggunaan nilai-nilai pribadi untuk menghadapi stresor internal jangka panjang, dalam hal ini nyeri kronis persendian, yang dapat menolong seseorang untuk dapat mengidentif ikasi pikiran dan perasaannya, kemudian menerima kondisi untuk melakukan perubahan yang terjadi tersebut dan berkomitmen terhadap diri sendiri. hal ini dapat diperoleh setelah seseorang melaksanakan sesi 1-3 dalam act. pada sesi 1: identifikasi kejadian, pikiran, dan perasaan yang muncul dan menghilangkan pikiran negatif (acceptance & cognitive defusion). penerimaan (acceptance) bermakna menerima, sehingga penekanannya adalah bahwa seseorang harus terlebih dulu mengerti mengenai keadaannya, setelah itu barulah ia mampu menerima kondisinya dengan menghilangkan pi k i ran-pi k i ran negatif (cognitife defusion). seseorang akan menerima kondisinya apabila mendapat pengetahuan cukup mengenai kondisi penyakitnya yang akan mengubah persepsinya menjadi positif sehingga koping juga positif. upaya ini dapat dilakukan melalui pemberian psikoedukasi tentang nyeri kronis yang dilakukan di awal sesi 1. selu r u h r e s p onde n me nga ng gap pemberian psikoedukasi nyeri kronis sebagai kegiatan yang bermanfaat untuk meningkatkan pemahaman mereka tentang nyeri kronis yang diderita, termasuk mengenai cara-cara efektif dalam menghadapinya. sifat nyeri kronis yang berkelanjutan sering kali membuat penderitanya membutuhkan pengobatan yang berkesinambungan unt uk mengatasinya. pemberian psikoedukasi juga dapat membuat penderita lebih mengenal nyeri kronis yang dialami. dengan pengetahuan tersebut, penderita dapat membuat rencana untuk mengatasi nyeri kronis yang diderita sesuai dengan kondisi tubuhnya saat ini sehingga lebih dapat menerimanya. penerimaan terhadap nyeri kronis juga diperkuat dengan pelaksanaan sesi dua dan tiga, di mana pada sesi 2: identifikasi nilai berdasarkan pengalaman untuk mendapatkan pengalaman yang lebih terarah ( present moment & values) dan sesi 3: berlatih menerima kejadian dengan nilai yang dipilih dan berfokus pada kemampuan diri (self as context). sesi kedua dan ketiga ini bermanfaat untuk meningkatkan kepercayaan diri klien bahwa mereka mempu nyai kemampuan untuk menerima kejadian dan menentukan 258 jurnal ners vol. 9 no. 2 oktober 2014: 252–261 nilai-nilai positif terkait manajemen nyeri melalu i ident if i kasi pengala ma n ya ng positif. hal ini membuat seseorang optimis dalam merencanakan kegiatan positif untuk mengatasi nyeri kronis yang diderita, sehingga mempunyai perasaan lebih dapat menerima. pada umumnya terjadi peningkatan comfort pada kelompok perlakuan setelah pemberian act. akan tetapi terdapat satu orang yang tidak mengalami per ubahan tingkat comfort (tetap rendah) dan satu orang yang mengalami penurunan tingkat comfort (tinggi ke sedang). responden yang tetap rendah tingkat comfort-nya adalah responden perempuan dengan usia 74 tahun, janda, mengalami nyeri sejak 3 tahun yang lalu dan tinggal di panti dalam kurun waktu 7 bulan yang lalu. sedangkan responden yang mengalami penurunan tingkat comfort adalah seorang perempuan, 74 tahun, janda, telah menderita nyeri dalam kurun waktu 5 tahun, dan baru 2 bulan tinggal di panti. hal ini menunjukkan bahwa seseorang yang telah mengalami nyeri kronis dalam waktu yang lama mempunyai kondisi emosi yang lebih stres dari pada seseorang yang baru mengalami nyeri kronis. selain itu, lama tinggal di panti juga menjadi salah satu faktor yang meningkatkan stres. lansia yang baru tinggal di panti masih mengalami proses adaptasi dengan lingkungan yang baru dan rentan mengalami stres. komponen komitmen (commited action) dalam act yang tergambar pada sesi ke4 menunjukkan kemauan dan kesanggupan seseorang dalam melakukan manajemen nyeri yang efektif yang telah dipilih dan disepakati, dalam hal ini terdapat aspek relaksasi (slow deep breath dan doa diiringi alunan musik) dan aspek exercise dengan gerakan ringan. teknik ini dapat memberikan dua manfaat sekaligus, yaitu: aspek relaksasi dengan timbulnya ketenangan dan perasaan r ileks, aspek exercise ditandai dengan timbulnya getaran ritmis pada otot yang dapat melancarkan peredaran darah ke seluruh tubuh serta dapat meningkatkan sekresi opiad endogen yang dapat menimbulkan perasaan gembira. secara akumulatif kedua aspek tersebut menghasilkan ketenangan, kebugaran, kesehatan serta daya tahan tubuh dalam menghadapi stres sehingga dapat menurunkan tingkat stres, di mana dalam hal ini nyeri sebagai suatu stressor. apabila kondisi stres berkurang, maka melalui sistem hpa axis akan mempengaruhi hipothalamus dalam menurunkan crf (corticotropin releasing factor), sehingga kadar acth (adrenocorticotropic hormone) yang diproduksi oleh kelenjar pituitary menjadi berkurang yang berdampak pada penurunan growth hormone dan kortisol dari korteks adrenal. apabila jumlah kortisol menurun, maka akan diikuti dengan pengolahan prekursor pro opio melano cortin (pomc) yang akan mensekresi β-endorphin sebagai indikator fisiologis tingkat kenyamanan. act d ala m bebe r apa se si ya ng pada akhirnya tercapai suatu commitment bersama dalam manajemen nyeri dengan multi komponen (beberapa cara: slow deepth breath, musik, berdoa, dan exercise ringan) dengan setting kelompok ini juga serupa dengan hasil penelitian rycarczyk, dkk. (2001) dalam hanum, l (2012) yang menemukan bahwa intervensi multi-komponen kelompok efektif dalam mengurangi nyeri yang diderita individu. inter vensi multi-komponen ini mengajarkan berbagai keterampilan kepada responden untuk membantu menghadapi rasa nyerinya, sehingga mereka dapat mengatasi nyeri yang dideritanya tersebut secara lebih menyeluruh. peng u k u ra n k u alit as h idup pad a kelompok perlakuan menunjukkan bahwa mayoritas responden, 12 orang (75,00%) mengalami peningkatan k ualitas hidup setelah pemberian intervensi act. who (1991) menyatakan terdapat empat domain pada kualitas hidup, yaitu domain kesehatan fisik, psikologis, relasi sosial dan lingkungan. data yang diperoleh menunjukkan bahwa nilai tertinggi terdapat pada domain psikologis. hal ini berkaitan dengan intervensi act ya ng berba sis psi kot er api. ter api i n i mengajarkan pasien untuk menerima pikiran yang menggangg u dan dianggap tidak menyenangkan dengan menempatkan diri sesuai dengan nilai yang dianut, sehingga ia akan menerima kondisi yang ada (hayes 2006; montgomery, kim & franklin 2011). 259 peningkatan penerimaan pada nyeri kronis (dhina widayati, dkk.) melalui penerapan act, lansia dengan nyeri kronis akan menerima kondisinya dan dapat menentukan apa yang terbaik untuk dirinya dan berkomitmen untuk melakukan apa yang dipilihnya. pemberian act terdiri dari beberapa rangkaian kegiatan dari latihan relaksasi dan psikoedukasi. latihan relaksasi dengan iringan musik yang mengawali setiap sesi pelaksanaan act diharapkan dapat mempengaruhi persepsi lansia terhadap nyeri yang dirasakan, sehingga akan menimbulkan kondisi comfort. lansia dengan nyeri kronis yang merasakan comfort akan mempunyai respons yang baik terhadap nyeri, sehingga i nt e n sit a s nye r i ya ng d i r a sa k a n juga akan berkurang. dengan demikian akan menurunkan respons ketidakberdayaan dan meningkatkan kualitas hidup seseorang dengan nyeri kronis. act yang dilakukan secara berkelompok juga bermanfaat dalam menurunkan stres yang dialami responden karena baik fasilitator maupun peserta dapat saling mengkonfrontasi berbagai stressor yang meningkatkan stres pada responden. di samping itu, format pertemuan yang terstruktur dapat mengurangi st res yang dialami. a k tivitas-ak tivitas menyenangkan dan santai di dalam kelompok juga menjadi salah satu faktor penurun stres yang dapat meningkatkan perasaan bahagia dan nyaman, sehingga membuat hidup lebih berkualitas. k u a l it a s h id u p s e s e o r a n g j u g a dipengaruhi oleh tujuh faktor, antara lain: faktor jenis kelamin, bain, dk k. (2003) dalam nof itri (2009) menemukan bahwa kualitas hidup perempuan cenderung lebih tinggi daripada laki-laki. hal ini sejalan dengan hasil pada penelitian ini, peningkatan kualitas hidup tertinggi terjadi pada responden perempuan. seorang perempuan lebih dapat mengekspresikan nyeri persendian yang dirasakan, sehingga merasa lebih lega dan nyaman. selain itu, mayoritas penghuni panti yang didominasi oleh perempuan juga menyebabkan peer group support yang lebih bagus berkaitan dengan perasaan senasib sepena ngg u nga n. hal i n i member i ka n penguatan pada masing-masing individu untuk melawan perasaan putus asa dan tidak berdaya dalam mengahadapi nyeri persendian yang diarasakan. faktor usia, perubahan nilai kualitas hidup yang pali ng besar dialami oleh responden usia 81 tahun, dalam konsep pembagian usia menurut hurlock, termasuk dalam advanced old age. pada tahapan ini, seseorang lebih menerima dan memberikan penilaian terhadap hidupnya dengan lebih positif karena mereka beranggapan bukan saatnya lagi untuk melakukan perubahanperubahan dalam hidupnya. faktor pendidikan, wahl, dkk (2004) dalam nof itri (2009) menemukan bahwa k ualitas hidup akan meningkat seir ing dengan lebih tingginya tingkat pendidikan yang didapatkan oleh individu. hal ini sesuai dengan hasil penelitian ini, bahwa perubahan nilai kualitas hidup yang paling besar dialami oleh responden dengan tingkat pendidikan terakhir pada jenjang sma. pada jenjang pendidikan yang lebih tinggi, seseorang dimungkinkan mendapatkan informasi yang lebih banyak terkait nyeri yang dirasakan dan mempunyai pemahaman yang lebih baik terhadap manajemen nyeri. faktor pekerjaan, per ubahan nilai kualitas hidup tertinggi didapatkan pada responden yang mempunyai riwayat pekerjaan sebagai petani. walaupun demikian, secara khusus riwayat pekerjaan ini tidak berkorelasi secara penuh terhadap kualitas hidup lansia, karena mereka saat ini sama-sama tidak bekerja. korelasi yang ada berkaitan dengan stressor yang timbul di masa lalu, seorang petani bekerja dengan waktu yang fleksibel dan tidak dikejar oleh target layaknya pedagang. hal ini yang menyebabkan nilai kualitas hidup yang paling tinggi didapatkan pada responden dengan riwayat pekerjaan sebagai petani. faktor status pernikahan, wahl (2004) menemukan bahwa baik pada pria maupun wanita, individu dengan status menikah memiliki kualitas hidup yang lebih tinggi. hal ini sejalan dengan hasil pada penelitian ini, perubahan nilai kualitas hidup tertinggi terdapat pada responden dengan stat us pernikahan sebagai istri dan tinggal bersama dengan suami dalam satu wisma di panti. kondisi ini memungkinkan responden tersebut 260 jurnal ners vol. 9 no. 2 oktober 2014: 252–261 mendapatkan du k ungan pasangan yang mempunyai pengaruh terhadap penerimaan terhadap nyeri kronis dan komitmen dalam manajemen nyeri. ia menjadi lebih termotivasi d a n mempu nyai pe r a sa a n ya ng lebi h tenteram. faktor penghasilan, baxter, dkk. (1998) dan dalkey (2002) dalam nof itri (2009) menemukan adanya pengaruh dari faktor demografi berupa penghasilan dengan kualitas hidup seseorang. pada penelitian ini, semua responden tidak mempunyai penghasilan dari hasil bekerja melainkan mendapatkan pendanaan biaya hidup dari pemerintah. faktor hubungan dengan orang lain, myers dalam kahneman, diener, & schwarz (1999) yang mengatakan bahwa pada saat kebutuhan akan hubungan dekat dengan orang lain terpenuhi, baik melalui hubungan pertemanan yang saling mendukung maupun melalui pernikahan, manusia akan memiliki kualitas hidup yang lebih baik secara fisik maupun emosional. pada penelitian ini responden yang mempu nyai per ubahan kualitas hidup paling besar adalah sesorang yang mempunyai hubungan pertemanan baik dengan semua lansia yang ada di panti, dia berperan sebagai ketua kelompok dari wisma yang dihuni. kondisi ini memungkinkan dia mendapatkan rasa percaya diri dan perasaan optimis yang lebih tinggi. simpulan & saran simpulan act me n i ng k at k a n p e ne r i m a a n nyeri pada lansia yang menderita nyeri k ronis persendian melalui peningkatan pengetahuan dari pemberian psikoedukasi dalam meningkatkan komponen acceptance dan cognitive defusion. act meningkatkan kenyamanan (comfort) pada lansia yang menderita nyeri kronis persendian melalui komponen committed action dan komitmen pada manajemen nyeri yang efektif (aspek relasasi dengan slow deep breath dan doa diiringi alunan musik, aspek exercise dengan gerakan ringan). act meningkatkan kualitas hidup pada lansia yang menderita nyeri kronis persendian melalui penerimaan nyeri dan kenyamanan (comfort) yang diperoleh dari komitmen dalam melakukan manajemen nyeri dengan cara yang efektif sesuai pilihan dan kesepakatan. saran kegiatan act dapat digunakan oleh perawat gerontik sebagai salah satu upaya meningkatkan penerimaan nyeri, comfort dan meningkatkan kualitas hidup lansia dengan nyeri k ronis persendian, sehingga mutu pelayanan keperawatan pada lansia dengan nyeri kronis persendian melalui pendekatan psikoterapi dapat ditingkatkan. penelitian selanjutnya tentang tingkat comfort diharapkan aga r d ila k u k a n peng u k u r a n i nd i k ator penilaian comfort terhadap nyer i tidak hanya menggunakan kuesioner, akan tetapi juga menggunakan uji laboratorium melalui pemeriksaan β-endorphin agar didapatkan hasil pengukuran yang komprehensif. kepustakaan badan pusat statistik. 2012. pendudu k lanjut usia menurut provinsi. buletin jendela data dan informasi kesehatan. kementerian kesehatan ri. diener dan suh. 2000. similarity of the relations between marital status and subjective well-being across cultures. journal of cross-cultural psychology, 31 (4), 419–436 hanum, l. 2012. manajemen nyeri untuk meningkatkan penerimaan nyeri kronis pada lansia dengan intervensi multikomponen kelompok cognitive behavior therapy (cbt). tesis. fakultas psikologi ui. tidak dipublikasikan. hayes, steven., jason, b.l., frank w.b., akihiko. m., jason, l. 2006. act: model, processes and outcomes. journal of behaviour research and therapy, 44, 1–25 kolcaba. 2011. comfort theory colcaba. http. currentnursing.com. diakses pada tanggal 26 september 2013 lefort, s. m. (ed.). 2008. chronic pain selfmanagement program workbook. st. john’s. nl: author. 261 peningkatan penerimaan pada nyeri kronis (dhina widayati, dkk.) nofitri. 2009. gambaran kualitas hidup. skripsi. fpsiui. tidak dipublikasikan papila, d. e., olds, s. w., & feldman, r. d. 2009. human development (11th edition). usa: mcgraw-hill. pochop, j. a. 2011. acceptance and commitment group therapy for older women with chronic pain. california: faculty of the kalmanovitz school of education saint mary’s college of california. sares, a. 2008. coping strategies of older ad ults living with chronic pain. fullerton: california state university. schwarz, n., & strack, f. 1999. reports of subjective well-being: the foundations of hedonic psychology (pp. 61–84). new york: russell sage foundation. the whoqol group. 1996. the world health organization quality of life assessment (w hoqol): position paper f rom the world health organization, social science and medicine, vol. 41, no. 10, pp. 1403–1409 210 media pornografi dan pengaruh teman sebaya dalam perilaku seks remaja (pornographic media and peer’s influence towards sexual behavior among teenagers) murdiningsih * , rosnani ** , hidayat arifin *** * lecturer; department of midwifery, polytechnic of health palembang ** lecturer; department of nursing polytechnic of health palembang *** bachelor student; faculty of nursing universitas airlangga email: murdiningsih@poltekkespalembang.ac.id abstrak pendahuluan: masalah yang terkait dengan perilaku seksual yang tidak aman pada remaja disebabkan oleh hubungan seksual pranikah dengan pasangan usia mereka sendiri. peningkatan kejadian seks pranikah disebabkan oleh perkembangan melalui penggambaran media adegan seks dalam bentuk televisi, majalah, klip video, media online, dan film. di musi banyuasin terdapat 7.754 siswa sma serta banyak siswa yang putus sekolah karena hamil diluar nikah. tujuan penelitian adalah untuk mengetahui hubungan media pornografi dan pengaruh teman sebaya terhadap perilaku seksual pada remaja di sekolah tinggi. metode: penelitian observasional dengan cross sectional dan pendekatan kuantitatif. populasi adalah siswa sma di kabupaten musi bayuasin. teknik pengambilan sampel adalah menggunakan multistage random sampling diperoleh 393 sampel. analisis bivariat, chi-square. hasil: menunjukkan adanya korelasi antara pengaruh teman sebaya dengan perilaku seksual remaja memiliki p-value (0,000). tidak ada hubungan antara media pornografi dengan perilaku seksual karena hasilnya lebih dari pvalue (0,05). diskusi: diperlukan untuk diberikan pengetahuan dan bantuan kepada remaja tentang positif dan kreatif hal dan pengawasan orang tua untuk anak-anak mereka untuk memiliki teman dan menghindari perilaku seksual yang tidak aman. kata kunci: pengaruh teman sebaya, media pornografi, perilaku seks tidak aman, remaja abstract introduction: the problems associated with unsafe sexual behavior in teenagers are caused by premarital sexual intercourse with a partner of their own age. increased incidence of premarital sex is caused by the development through media depictions of sex scenes in the form of television, magazines, video clips, online media, and films. in musi banyuasin there are 7754 high school students, many students have dropped out of school because they get pregnant before marriage. the aim study was to investigate the correlation between pornographic media and the influence of peers towards teenager’s sexual behavior in high school. method: observational research with cross sectional and quantitative approach. the population was high school students in musi banyuasin regency. sampling technique was using multistage random sampling obtained 393 samples. bivariate analysis, chi-square result: the result showed a correlation between the influence of peers with adolescent sexual behavior has p-value (0,000). there was no relationship between media pornography with sexual behavior because the result more than p-value (0,05). discussion: necessary to be given knowledge and assistance to teenagers about positively and creatively thing and supervision of parents to their children in order to have friends and avoid unsafe sexual behavior. key words: the influence of peers, pornographic media, unsafe sexual, adolescent _______________________________________________________________________________________________________ introduction various institutions in indonesia for the period of 1993-2002, found that five to tenth percent of teenagers aged 16-24 years have had sexual intercourse before marriage (hasmi 2011). one of the problems caused by premarital sex is an unwanted pregnancy. pregnancy at a young age, in terms of reproductive health, is a kind of high risk both in pregnancy and childbirth. psychologically, sex before marriage is also bringing the perpetrators experienced changes (kusmiran & eny 2012). the globalization of information through the media in the form of sexual exploitation on television, magazines, videos, online media and movies encourage teenagers assume that free sex activities may be done by anyone, anywhere regardless of the norms and ethics (annisa et al. 2013). another factor that led to premarital sexual behavior in teenagers according to (oktiva & yayuk, 2010) in (kencana & rida, 2011) is a peer influence. teenagers are very influenced by their peer groups, so they must follow all the pressures from their peers when they want to maintain their status in the group. this behavior is an attempt to meet the needs of teens in relationships with others, especially if those needs are not met within the family (notoadmodjo, 2010). reproductive health survey data of indonesian adolescent and the national family planning coordinating board (bkkbn) showed mailto:murdiningsih@poltekkespalembang.ac.id jurnal ners vol. 11 no. 2 oktober 2016: 210-212 211 as many as 5912 women aged 15-19 years at national level had sexual intercourse. while men in the same age totally 6578, or 3.7% have had sex. but surprisingly the case of pre-marital sex is actually happening in the countryside. urban 0.9%, while rural 1.7% (bkkbn 2012). child protection commission (kpa) in 2008 showed 62.7% of middle and high school teenagers have had sex before marriage, 93.7% of teenagers had done kissing, oral sex and genital stimulation. then 97% of teenagers had watched a porn movie, 25% of teenagers had an abortion because because of unwanted pregnancy (kumalasari & inthan 2013). method the study was used cross-sectional approach. the populations were teenagers aged 15-18 years who were students of high school in the musi banyuasin regency in 2014 amounted to 7754 students. the total samples obtained were 393 students. data were analyzed using chi square test and kolmogorov smirnov. result table 1. distribution of correlation between influence of peers with sexual behavior among teenagers influence of peers sexual behavior total % good bad n % n % influenced uninfluenced 39 89 21 43 147 118 79 57 186 207 100 100 p-value = 0,000 or =0,352 table 2. distribution of correlation between exposure of pornographic media with sexual behavior pornography exposure sexual behavior total % good bad n % n % ever never 200 65 65,8 73 104 24 34,2 27 304 89 100 100 p-value = 0,248 or =0,710 based on table 1 and 2, majority teenagers were had good sexual behavior (67.4%), influenced by their peer group (52.7%), and have been exposed to pornography (77.4%). using chi square test, the p-value for the correlation between peer influence and sexual behavior among teenagers was 0.000 with odds ratio (or) 0.352. it means students were included influence 0.35 times more likely to sexually behave well. the correlation between pornography exposure and sexual behavior had the p-value 0.248 that indicates no correlation between those variables. the or was 0.710 which means students were included ever seen pornographic media 0.71 times more likely to sexually behave well. disscussion based on table 1, there was correlation beetwen influenced of peers with unsafe sexual behaviour of teenagers. it was becaue teenagers were not stay with parents, so the have more time with their peers and have pottential to influence unsafe sexual behavior because less control of parents. the research had similar result with (maryatun & nur 2013) that teenagers at sma muhammadiah surakarta iii had correlation beetween peers with unsafe sexual behavior (p-value 0,001; or 19,723). based on (nugroho et al. 2015)’s research, the subjects were teeangers in courtship. even thought major teenagers in courtship have’nt risk in unsafe sexual behavior category, but there were teenagers in courtship had unsafe sexual behavior. peers, teacher, and parrents must support teenager by giving suggestion, advice, and good verbal communication. parrents have important roles in education and monitoring of teenagers sexual behavior. based on (eka 2012)’s research, showed teenagers with good education in family about sexual behavior that will caused good sexual behavior as many as 62,1%. table 2 showed that there was no correlation bettwen pornography media with saxual behavior. it was supported by many factors: the location of musi banyuasin is suburbs; limited internet access; limited media to operate internet; at school teenagers were banned use handphone. the research had similar result with (abadi & rizky 2015) that there was no correlation between pornography media access with sexual behavior, it was because the location at suburbs of malang. media pornografi dan pengaruh teman sebaya (murdiningsih, dkk.) 212 base on (ririn et al. 2011), this result was different and explained there was correlation between information resource (internet, tv, handphoe, vcd, porn video, poster, etc.) with sexual behavior (p-value 0,022). the similar result of (annisa et al. 2013), there was correlation between access of pornographic media with sexual behavior before married (pvalue 0,022). pratiwi & ayu (2014) had explained that need the government’s role to block sites or pornographic content in the internet and supported with (amelia & hafied 2011) that there were three things to help how pornography or pornographic sites can be removed include: self-controlling; the existence of the regulation or policy; and in cooperation with the satellite operator and provider in indonesia conclusion and recommendation conclusion more leisure time of teenagers with peers can give effect to do unsafe sexual behavior (masturbation, kiss, hug, hold or touch sensitive parts, petting, oral sex and intercourse). recommendation parents and families need to provide care and controlled to teenagers who don’t stay at home (lodging house) or stay at home, so teenagers are more selective in choosing friends to avoid unsafe sexual behavior. referencies abadi & rizky, a., 2015. hubungan mengakses pornografi melalui fasilitas handphone dengan perilaku seksual remaj usia 16 – 19 tahun di smk muhammadiyah 2 kota malang. amelia, c.r. & hafied, c., 2011. kebijakan pemerintah republik indonesia dalam mengatasi situs porno pada media maya. jurnal komunikasi kareba, 1(3). annisa, u., hikmah & endang, s.n., 2013. hubungan kases media pornografi internet dengan sikap seksual pranikah pada remaja kelas ix di sma negeri 1 bambanglipuro bantul yogyakarta. bkkbn, 2012. survei demografi dan kesehatan indonesia, jakarta. eka, s.d., 2012. hubungan pendidikan seks dalam keluarga dengan perilaku seksual remaja di sma n 3 bukittinggi. jurnal kesehatan masyarakat stikes prima nusantara bukittinggi, 3(2). hasmi, e., 2011. meeting reproductive health needs of adolescent in indonesia. journal of adolescent reproductive and sexual health unesco. available at: http://www.unescobkk.org/ips/arh. kumalasari & inthan, 2013. kesehatan reproduksi untuk mahasiswa kebidanan dan keperawatan, jakarta: salemba medika. kusmiran & eny, 2012. kesehatan reproduksi remaja dan wanita, jakarta: salemba medika. maryatun & nur, h., 2013. hubungan antara pengaruh teman sebaya dengan perilaku seksual pranikah pada remaja si smk batik 1 surakarta. gaster, 10(2). nugroho, dwi, r.a. & devy, s.r., 2015. dukungan sosial yang mendorong perilaku pacaran berisiko pada remaja sma di kota surabaya. jurnal promkes, 3(1). pratiwi & ayu, r., 2014. analisis kriminologis peredaran gambar pornografi yang dilakukan melalui media game online di kalangan siswa di bandar lampung. ririn, d., noor, s.a. & azzizah, g., 2011. kajian perilaku sex pranikah remaja sma di surakarta. jurnal kesehatan, 4(2), pp.111–119. 305 faktor sustainability yang berhubungan dengan implementasi community mental health nursing (cmhn) (sustainability factor related with the implementation of community mental health nursing (cmhn) in south and west jakarta) neng esti winahayu*, budi anna keliat*, ice yulia wardani* departemen keperawatan jiwa fakultas ilmu keperawatan universitas indonesia e-mail: estiwinahayu@yahoo.co.id abstrak pendahuluan: tujuan dari penelitian ini adalah untuk menentukan faktor keberlanjutan terkait dengan pelaksanaan community mental health nursing (cmhn) di jakarta selatan dan barat. metode: metode penelitian ini menggunakan metode cross sectional, instrumen yang digunakan dengan menggunakan kuesioner cmhn dan analisis data menggunakan korelasi pearson. wawancara dilakukan pada pemangku kepentingan untuk mendapatkan persepsi pemangku kepentingan tentang faktor keberlanjutan cmhn. kemampuan perawat dalam pelaksanaan cmhn adalah 45,86%. persepsi perawat terhadap faktor keberlanjutan cmhn adalah 67,49%. hasil: hasil penelitian menunjukkan hubungan yang signifikan antara faktor keberlanjutan dengan pelaksanaan cmhn. hasil wawancara dengan analisis stakeholder tentang 8 faktor keberlanjutan dibagi menjadi beberapa tema: opini positif dari pemangku kepentingan terhadap cmhn (adanya asuhan keperawatan kepada pasien, mendeteksi kasus baru, dan mengurangi stigma) dan usaha untuk keberlanjutan dari cmhn (meningkatkan persepsi, perencanaan anggaran, dan sosialisasi). diskusi: hasil penelitian ini direkomendasikan untuk meningkatkan pelayanan keperawatan komunitas kesehatan mental di daerah lain. kata kunci: perawat cmhn, stakeholder, keberlanjutan, pelaksanaan cmhn abstract the aim of this study was to determine the sustainability factor related with the implementation of cmhn in south and west jakarta. the method of the study was cross sectional, data of the nurses was collected by questionnaire of cmhn and pearson correlation was used to analyzed the data. interviews conducted on stakeholder to get stakeholder perceptions about the sustainability factor of cmhn. the ability of nurse in the implementation of cmhn is 45,86%. the nurse perception toward sustainability factor of cmhn is 67,49%. the result of study shows the significant relationship between the sustainability factor with the implementation of cmhn. the result of analysis interviews with stakeholder about 8 sustainability factors is obtained into several themes: the positive opinion of stakeholder toward the cmhn (the existence of nursing care to the patients, detecting of new case, and reducing stigma) and the effort for the sustainability of cmhn (increasing the perception, budget planning, and socialization). the result of the study is recomended to improve the community mental health nursing service in other region. keywords: cmhn nurses, stakeholder, sustainability, the implementation of cmhn pendahuluan pelayanan kesehatan jiwa komunitas sudah diimplementasikan di beberapa negara (asia australia mental health, 2008). indonesia merupakan salah satu negara yang sudah mengembangkan pelayanan kesehatan jiwa komunitas yang dikenal dengan community mental health nursing (cmhn). cmhn sudah dijalankan pada tahun 2005 setelah terjadinya bencana tsunami dan gempa bumi di aceh dan nias (prasetyawan, viora, maramis, & keliat, 2006). tingkatan cmhn terdiri dari basic course cmhn (bc-cmhn), intermediate course cmhn (ic cmhn) dan advance course cmhn (ac cmhn). cmhn (bc cmhn) sudah diterapkan di dki jakarta sejak tahun 2009, karena dki jakarta mempunyai prevalensi gangguan jiwa tertinggi yaitu 2,03%. jakarta selatan dan barat merupakan wilayah yang sudah melaksanakan cmhn (bc cmhn). prevalensi gangguan jiwa di jakarta selatan 3,36% dan jakarta barat 0,03% (depkes, 2008). bc cmhn merupakan serangkaian keg iat a n pembelaja r a n u nt u k per awat komunitas agar memiliki kompetensi untuk melaksanakan asuhan keperawatan kepada pasien gangguan jiwa yang ada di masyarakat (keliat, akemat, daulima, & nurhaeni, 2011). cmhn yang dilaksanakan di jakarta 306 jurnal ners vol. 9 no. 2 oktober 2014: 305–312 selatan dan barat adalah bc cmhn yang dimodifikasi dengan ic cmhn. kegiatan bc cmhn meliputi penggunaan konsep dasar keperawatan kesehatan jiwa komunitas, pelaksanaan asuhan keperawatan, pelaksanaan pencatatan pelaporan dan monitoring evaluasi. kegiatan ic cmhn yang diterapkan adalah pemberdayaan kader kesehatan jiwa. cmhn yang dilaksanakan di jakarta selatan dan barat sudah berjalan 4 tahun belum pernah diteliti hasil implementasinya. sehingga peneliti ingin mengetahui faktor sustainability terhadap implementasi cmhn di jakarta selatan dan barat. peneliti ingin melihat faktor sustainabilit y mulai dari dukungan politik, stabilitas pendanaan, kemitraan, kapasitas organisasi, evaluasi program, adaptasi program, komunikasi dan rencana strategi. bahan dan metode penelitian ini menggunakan metode cross sectional dan triangulasi sumber data. penelitian menggunakan kuesioner yang diberikan kepada perawat cmhn, berupa data demografi, kemampuan perawat dalam implementasi cmhn, dan persepsi perawat terhadap faktor sustainability. persepsi perawat ini akan divalidasi dengan data triangulasi dari stakeholder menggunakan wawancara. populasi adalah semua perawat cmhn dan stakeholder di jakarta selatan dan barat. populasi perawat cmhn berjumlah 138 orang. sampel adalah perawat cmhn yang memenuhi kriteria inklusi yaitu perawat yang telah mengikuti pelatihan cmhn, perawat yang masih aktif menjalankan cmhn, perawat yang bekerja di puskesmas wilayah jakarta selatan dan barat, bersedia menjadi responden dibuktikan dengan surat kesediaan menjadi responden. teknik penelitian menggunakan total sampling yaitu mengambil semua perawat yang memenuhi kriteria inklusi, berjumlah 85 orang. pengambilan partisipan untuk stakeholder dengan purposif the sampling yait u dipilih dengan per timbangan dan tujuan tertentu. jumlah stakeholder adalah 8 orang mulai dari dinas kesehatan propinsi dki jakarta, suku dinas kesehatan, dan puskesmas. pengumpulan data perawat cmhn menggunakan kuesioner untuk memperoleh karakteristik perawat cmhn, persepsi perawat tentang faktor sustainability dan kemampuan p e r awat d ala m i mple me nt a si cm h n. kemampuan perawat meliputi kemampuan menggunakan konsep dasar keperawatan kesehatan jiwa komunitas, melaksanakan a s u h a n k e p e r a w a t a n , m e l a k s a n a k a n pencatatan, pelaporan, dan monitor ing evaluasi, dan melaksanakan pemberdayaan kader kesehatan jiwa. persepsi stakeholder terhadap sustainability cmhn menggunakan pedoman wawancara. penelitian ini dilakukan di jakarta selatan dan barat. analisis data menggunakan univariat dan bivariat. analisis univariat dilakukan untuk melihat distribusi data pada semua variabel. analisis bivariat untuk mengetahui apakah ada hubungan yang signifikan antara persepsi perawat terhadap faktor sustainability d e n g a n k e m a m p u a n p e r a w a t d a l a m implementasi cmhn. sedangkan wawancara dengan stakeholder dilakukan dengan analisis collaizi. hasil hasil penelitian ini menunjukkan bahwa kemampuan perawat dalam menggunakan konsep dasar keperawatan adalah 46%, kemampuan perawat dalam melaksanakan asuhan keperawatan 46,25%, kemampuan perawat melaksanakan pencatatan, pelaporan dan monitoring evaluasi adalah 48,62, ratarata kemampuan perawat melaksanakan pemberdayaan kader kesehatan jiwa adalah 47,16%, dan kemampuan perawat dalam implementasi cmhn adalah 45,86% (tabel 1) rer at a per se psi per awat tent a ng dukungan politik adalah sebanyak 71 perawat, rerata persepsi perawat terhadap stabilitas pendanaan 66,8%, rerata persepsi perawat terhadap kemitraan 69,33%, rerata persepsi perawat terhadap kapasitas organisasi 69,47%, rerata persepsi perawat terhadap evaluasi program adalah 69,4, rerata persepsi perawat 307 faktor sustainability yang berhubungan dengan implementasi (neng esti winahayu, dkk.) terhadap adaptasi program 71,28% ,rata-rata persepsi perawat terhadap komunikasi adalah 66,6%, rerata persepsi perawat terhadap rencana strategi 65%, rerata persepsi perawat terhadap faktor sustainability 67,49%. terdapat hubungan yang bermakna antara persepsi perawat terhadap faktor sustainability (8 faktor) dengan kemampuan perawat dalam implementasi cmhn ( p value < 0,05), hubungan sedang dan arahnya positif (tabel 3). tabel 1. kemampuan perawat dalam implementasi cmhn (n=85) implementasi cmhn mean median standar deviasi min max 95% ci 1. konsep dasar keswa 2. askep 11 diagnos kep 3. pencatatan, pelaporan dan monev 4. pemberdayaan kkj 5. implementasi cmhn 33,38 159,20 17,21 9,66 219,45 32,00 168,00 18,00 9,00 225,00 11,677 40,963 5,059 2,750 60,364 14-56 69-264 7-28 4-16 97-364 30,86-35,90 149,83-168,57 16,12-18,30 9,66-10,25 206,44-126,50 tabel 2. persepsi perawat terhadap faktor sustainability cmhn (n=85) faktor sustainability mean median standar deviasi min max 95% ci 1. dukungan politik 2. stabilitas pendanaan 3. kemitraan 4. kapasitas organisasi 5. evaluasi program 6. adaptasi program 7. komunikasi 8. rencana strategi 9. faktor sustainability 15,65 15,02 15,40 15,42 15,41 14,98 14,99 14,99 122, 24 16,00 15,00 15,00 15,00 15,00 15,00 15,00 15,00 125,00 3,030 2,623 2,854 2,945 2,674 2,614 2,911 2,684 19,770 5–20 5–20 5–20 5–20 5–20 5–19 5–20 5–20 48–58 14,99–16,30 14,46–15,59 14,78–16,02 14,79–16,06 14,41–15,54 14,41–15,54 14,75–15,99 14,41–126,50 117,97–126,50 tabel 3. hubungan persepsi perawat terhadap faktor sustainability dengan kemampuan perawat dalam implementasi cmhn (n=85) variabel r p value r2 dukungan politik stabilitas pendanaan kemitraan kapasitas organisasi evaluasi program adaptasi program komunikasi rencana strategi faktor sustainability 0,345 0,291 0,358 0,441 0,309 0,328 0,385 0,340 0,397 0,001 0,007 0,001 0,000 0,004 0,002 0,000 0,001 0.000 11,90 8,46% 12,81% 19,44% 9,54% 10,75% 14,82% 11,56% 15,76% ada hubungan bermakna antara persepsi perawat terhadap faktor sustainability (8 faktor) dengan kemampuan perawat dalam melaksanakan konsep dasar keperawatan kesehatan jiwa komunitas ( p value < 0,05). hubungan sedang dan berpola positif (tabel 4). persepsi perawat terhadap fak tor sustainability (8 faktor) dengan kemampuan perawat melaksanakan asuhan keperawatan memiliki hubungan yang signifikan ( p value < 0,05). hubungan sedang dan berpola positif (tabel 5). 308 jurnal ners vol. 9 no. 2 oktober 2014: 305–312 ada hubungan bermakna antara faktor sustainability dengan kemampuan perawat dalam melaksanakan pencatatan, pelaporan, dan monitoring evaluasi (p value < 0,05) kecuali faktor kapasitas organisasi (p value = 0,066). semua faktor menunjukkan hubungan sedang kecuali faktor dukungan politik, stabilitas pendanaan, dan evaluasi program. semua berpola positif (tabel 6). terdapat hubungan bermakna antara persepsi perawat terhadap faktor sustainability d e n g a n k e m a m p u a n p e r a w a t d a l a m melaksanakan pemberdayaan kader kesehatan jiwa ( p value < 0,05). semua menunjukkan hubungan sedang, kecuali faktor stabilitas pendanaan. dan semua berpola positif (tabel 7). tabel 4. hubungan persepsi perawat terhadap faktor sustainability dengan kemampuan perawat dalam menggunakan konsep (n=85) variabel r p value r2 dukungan politik stabilitas pendanaan kemitraan kapasitas organisasi evaluasi program adaptasi program komunikasi rencana strategi faktor sustainability 0,277 0,265 0,330 0,392 0,291 0,322 0,376 0,343 0,368 0,010 0,014 0,002 0,000 0,007 0,003 0,000 0,001 0.001 7,67 % 6,94 % 10,89 % 39,20 % 8,46 % 10,36 % 14,13 % 11,76 % 13,54 % tabel 5. persepsi perawat terhadap faktor sustainability dengan kemampuan perawat melaksanakan asuhan keperawatan (n=85) variabel r p value r2 dukungan politik stabilitas pendanaan kemitraan kapasitas organisasi evaluasi program adaptasi program komunikasi rencana strategi faktor sustainability 0,357 0,291 0,358 0,444 0,309 0,320 0,373 0,327 0,395 0,001 0,007 0,001 0,000 0,004 0,003 0,000 0,002 0.000 12,14 % 8,46 % 12,81 % 19,71 % 9,54 % 10,24 % 13,91 % 10,69 % 15,60 % tabel 6. persepsi perawat terhadap faktor sustainability dengan kemampuan perawat melaksanakan pencatatan, pelaporan, dan monitoring evaluasi (n=85) variabel r p value r2 dukungan politik stabilitas pendanaan kemitraan kapasitas organisasi evaluasi program adaptasi program komunikasi rencana strategi faktor sustainability 0,239 0222 0,251 0,325 0,200 0,257 0,304 0,273 0,294 0,028 0,041 0,020 0,002 0,066 0,018 0,005 0,012 0.006 5,71 % 4,92 % 6,30 % 10,56 % 4,00 % 6,60 % 9,24 % 7,45 % 8,64 % 309 faktor sustainability yang berhubungan dengan implementasi (neng esti winahayu, dkk.) hasil wawancara dengan stakeholder d id apat k a n a d a nya pa nd a nga n posit if stakeholder terhadap cmhn dan upaya untuk keberlangsungan cmhn. pandangan positif stakeholder terhadap cmhn yaitu adanya asuhan keperawatan ke pasien, terdeteksinya kasus baru, dan mengurangi stigma. upaya untuk keberlangsungan cmhn yaitu dengan peningkatan wawasan, perencanaan anggaran, dan sosialisasi cmhn. pembahasan k e m a m p u a n p e r a w a t d a l a m implementasi cmhn adalah kemampuan dalam kegiatan bc cmhn dengan modifikasi ic cmh n. kemampuan tersebut adalah kemampuan menggunakan konsep dasar keperawatan kesehatan komunitas, asuhan keperawatan, pencatatan pelaporan dan monitoring evaluasi, dan pemberdayaan kader kesehatan jiwa. kemampuan perawat dalam implementasi cmhn masih rendah. hal ini berbeda dengan kemampuan perawat di aceh (junardi, 2014). kemampuan yang rendah ini disebabkan karena pelatihan hanya dalam waktu singkat, khususnya di jakarta barat dan tidak semua materi diberikan, juga tidak ada monitoring evaluasi terhadap pelaksanaan cmhn secara kontinue. sedangkan di aceh pelatihan sampai 10 hari, dan dilakukan pend a mpi nga n d ala m pela k sa na a n nya. sehingga diharapkan cmhn yang sudah berjalan di jakarta selatan dan barat lebih ditingkatkan terhadap monitoring evauasi pelaksanaan cmhn dan pelatihan lebih ditingkatkan. persepsi perawat terhadap fak tor sustainability sudah baik, namun perawat mempunyai persepsi bahwa faktor yang paling rendah adalah stabilitas pendanaan. hal ini sesuai dengan hasil wawancara dengan stakeholder bahwa untuk kegiatan cmhn, dana sudah dianggarkan dari anggaran pendapatan belanja daerah (apbd), tetapi dana tersebut tidak prioritas seperti kegiatankegiatan yang lain. hal ini juga disebabkan karena program kesehatan jiwa merupakan program pengembangan puskesmas. sehingga d i h a r apk a n walaupu n ke seh at a n jiwa merupakan program pengembangan, maka tetap memerlukan pendanaan yang stabil dan diperlukan adanya dukungan pendanaan dari stakeholder. persepsi perawat terhadap fak tor sustainability dengan kemampuan perawat dalam implementasi cmhn menunjukkan a d a n y a h u b u n g a n y a n g b e r m a k n a . fak tor du k u ngan politi k menu nju k kan adanya hubungan yang bermakna dengan implementasi cmhn. hal ini sesuai penelitian di bireun bahwa perawat yang merasakan ad anya du k u ngan d ar i pimpi nan akan menunjukkan kinerja yang baik (sulastri, keliat, & er yando, 2007). hal ini juga sesuai pernyataan yang menyatakan bahwa dukungan politik mempunyai dampak yang besar bagi pelaksanaan suatu program atau kegiatan (washington university, 2012). dukungan politik dapat berasal dari propinsi, kota, kabupaten, kecamatan, kelurahan, rw, rt, kader, dan tokoh masyarakat. dengan demikian suatu kegiatan supaya dapat berjalan tabel 7. persepsi perawat terhadap faktor sustainability dengan kemampuan perawat melaksanakan pemberdayaan kader kesehatan jiwa (n=85) variabel r p value r2 dukungan politik stabilitas pendanaan kemitraan kapasitas organisasi evaluasi program adaptasi program komunikasi rencana strategi faktor sustainability 0,304 0249 0,322 0,387 0,283 0,295 0,389 0,346 0,365 0,005 0,022 0,003 0,000 0,009 0,006 0,000 0,001 0.001 9,24 % 6,20 % 10,36 % 14,97 % 8,00 % 8,70 % 15,13 % 11,97 % 13,32 % 310 jurnal ners vol. 9 no. 2 oktober 2014: 305–312 dengan baik harus didukung penuh oleh pemangku kepentingan yang ada di wilayah tersebut. berdasarkan penelitian didapatkan bahwa ada hubungan bermakna antara faktor pendanaan dengan kemampuan perawat, tetapi faktor pendanaan merupakan faktor yang paling rendah. berdasarkan wawancara dengan stakeholder bahwa untuk kegiatan cmhn dana terbatas, namun diupayakan tetap berjalan seperti kegiatan home visit, asuhan keperawatan pada pasien dan keluarga. dana yang belum maksimal tidak mengurangi semangat untuk melakukan kegiatan. hal ini sesuai dengan penelitian di aceh bahwa pendanaan untuk kegiatan cmhn masih minimal (junardi, 2014). sedangkan stabilitas pendanaan merupakan faktor penting dalam program komunitas (nordqwist, timpka, & lindqwist, 2009). suatu kegiatan dapat berjalan baik perlu didukung dengan pendanaan yang stabil (washington university, 2012). keberlangsungan suatu program tergantung pada kelanjutan dan jaminan keuangan yang tersedia (kelleher, 2007). dengan demikian kegiatan cmhn membutuhkan pendanaan yang stabil, sehingga diharapkan stakeholder memberikan anggaran yang cukup untuk kegiatan cmhn. persepsi perawat terhadap fak tor kemitraan dengan kemampuan perawat dalam implementasi menunjukkan adanya hubungan bermakna. hal ini sesuai dengan pernyataan bahwa kemitraan dapat dimanfaatkan untuk melaksanakan suatu kegiatan yang sedang berlangsung (king, christo, fletcher, machlin, nicholas, & pirkis, 2013) dan dapat membantu pela k sa na a n kegiat a n u nt u k mencapai tujuan (plochg, delnoij, hoogedoor n, & klazinga, 2013; washington university, 2012). yang mendorong keberlangsungan program komunitas adalah faktor kemitraan (nordqwist, timpka, & lindqwist, 2009). sehingga kemitraan sangat penting sekali terhadap pelaksanaan cmhn, karena suatu kegiatan cmh n tidak dapat dilak ukan sendiri, tentunya harus bermitra dengan yang lainnya. persepsi perawat terhadap fak tor kapasitas organisasi dengan kemampuan perawat menunjukkan adanya hubungan yang bermakna. dan kapasitas organisasi paling tinggi pengaruhnya terhadap implementasi cmh n baik dalam penggunaan konsep kesehatan jiwa, asuhan keperawatan, pencatatan pelaporan dan monitoring eavaluasi, serta pemberdayaan kader. hal ini sesuai dengan pernyataan bahwa kapasitas organisasi sangat dibutuhkan untuk berjalannya suatu program seperti sumber daya manusianya, pemimpin yang memadai, dan fasilitas yang dibutuhkan untuk pelaksanaan kegiatan (washington university, 2012; leffers & mitchel, 2011). ha sil wawa nca r a de nga n sta k eh old e r didapatkan bahwa untuk pelaksanaan kegiatan membutuhkan sumber daya manusia yang cukup dan apabila tidak cukup tentunya harus dibuat seefektif mungkin, kemudian adanya pemimpin yang komit terhadap pelaksanaan cmhn, serta tersedianya fasilitas untuk kegiatan cmh n. sehingga peningkatan kapasitas organisasi harus dilakukan dengan meningkatkan kemampuan sdm khususnya perawat cmhn seperti kemampuan dalam membimbing dan melatih kader yang ada di wilayahnya, melakukan evaluasi terhadap kinerja kader, sumber-sumber lain yang dibut uh kan, kemampuan dalam asuhan keperawatan, dan perlu adanya evaluasi oleh stakeholder. persepsi perawat terhadap evaluasi prog r a m de nga n kema mpu a n pe r awat me nu nju k k a n a d a nya hubu nga n ya ng bermakna. hal ini sejalan dengan pernyataan bahwa evaluasi program sangat berpengaruh terhadap keberlangsungan suatu program (patrick, capetola, towsend, & hanna, 2011). penelitian di aceh juga didapatkan bahwa perawat yang mempunyai persepsi baik terhadap supervsi memiliki hubungan dengan kinerja perawat (sulastri, keliat, & eryando, 2007). namun persepsi perawat terhadap sustainability dengan kemampuan perawat dalam monitoring evaluasi menunjukkan hubungan yang tidak bermakna. hal ini disebabkan tidak adanya evaluasi secara kontinue terhadap pelaksanaan pencatatan, pelaporan, dan monitoring evaluasi. dengan adanya evaluasi program maka implementasi cmh n akan ber jalan secara continue, 311 faktor sustainability yang berhubungan dengan implementasi (neng esti winahayu, dkk.) sehingga untuk pelaksanaan cmhn perlu diadakan evaluasi secara continue untuk mengetahui keberhasilan dan hambatannya. persepsi perawat terhadap adaptasi prog r a m de nga n kema mpu a n pe r awat menunjukkan hubungan bermakna. hasil penelitian ini sama dengan hasil penelitian di aceh (junardi, 2014). hasil wawancara dengan stakeholder did apat kan bahwa adaptasi program sangat diperlukan, karena harus menyesuaikan dengan ilmu-ilmu baru. stakeholder juga menyatakan bahwa perlu adanya peningkatan wawasan kepada petugas yang baru maupun lama. dengan demikian sustainability implementasi cmhn perlu adanya penyesuaian terhadap kegiatan yang sedang berjalan, dan perlu dibuat keputusan kegiatan mana yang harus dilanjutkan dan kegiatan mana yang tidak harus dilakukan. persepsi perawat terhadap fak tor komunikasi dengan implementasi cmhn menunjukkan hubungan bermakna. hal ini sejalan dengan penelitian di aceh (junardi, 2014). komunikasi merupakan sarana untuk menginformasikan kegiatan kepada pemangku kepentingan dan masyarakat (washington university, 2012). komunikasi juga penting bagi kader karena kader merupakan perpanjangan tangan dari petugas kesehatan yang mampu memberikan informasi tentang perawatan kesehatan jiwa kepada individu, keluarga, dan kelompok (syukri, yani, & daulima, 2013). hal ini juga sejalan dengan hasil wawancara dengan stakeholder bahwa untuk pelaksanaan cmhn sangat membutuhkan komunikasi, sehingga kegiatan yang dilaksanakan diketahui oleh pemangku kepentingan dan masyarakat. oleh karena itu perlu adanya peningkatan terhadap komunikasi agar kegiatan cmhn semakin dikenal. persepsi perawat terhadap rencana st r at eg i de ng a n ke m a mpu a n p e r awat menunjukkan adanya hubungan bermakna. rencana strategi memegang peranan penting dalam melaksanakan suatu kegiatan (schell, luke, herbers, & elliot, 2012). rencana s t r at eg i s d ip e rlu k a n u nt u k me mbu at perencanaan ke depannya terkait penggunaan konsep dasar keperawatan kesehatan jiwa, asuhan keperawatan, pencatatan pelaporan dan monitoring evaluasi, dan pemberdayaan kader kesehatan jiwa. simpulan dan saran simpulan kesimpulan dari penelitian ini adalah karakteristik perawat cmhn berusia rata-rata 37,39 tahun, lama bekerja 12,08 tahun. lebih banyak: perempuan, pendidikan terakhir d3 keperawatan, menikah, peran pada program puskesmas sama atau lebih dari 3 program. karakteristik stakeholder adalah berumur 30–57 tahun, semua perempuan, menikah, pendidikan s1 kesehatan 6 orang, dan s2 kesehatan 2 orang. kemampuan perawat dalam implementasi cmhn masih rendah (konsep dasar keperawatan kesehatan jiwa; asu han keperawat an pada 11 diag nosa keperawatan; pencatatan, pelaporan, dan monitoring evaluasi; pemberdayaan kader kesehatan jiwa). persepsi perawat terhadap faktor sustainability cmhn yang berhubungan dengan implementasi cmhn antara 66,6 % dan 71,28 %. persepsi perawat terhadap faktor sustainability cmhn berhubungan bermakna (signifikan) dengan kemampuan perawat dalam implementasi cmhn. gambaran persepsi stakeholder ditemukan tema yaitu pandangan positif stakeholder terhadap cmhn dan upaya untuk keberlangsungan cmhn. saran p e r a w a t c m h n d i h a r a p k a n dapat meningkatkan kemampuan dalam menggunakan konsep dasar keperawatan kesehatan jiwa komunitas, melaksanakan asuhan keperawatan, pencatatan pelaporan dan monitoring evaluasi, dan pemberdayaan kader kesehatan jiwa dengan pendampingan, super visi dan reguler meeting sehingga ke m a m p u a n p e r aw a t d a p a t o p t i m a l . stakeholder mulai dari dinas kesehatan, suku dinas kesehatan, dan puskesmas perlu memberikan dukungan terhadap pelaksanaan cmhn dengan memberikan persetujuan terhadap kegiatan-kegiatan cmhn, membuat perencanaan keuangan (pendanaan yang stabil) untuk implementasi cmhn seperti home visit 312 jurnal ners vol. 9 no. 2 oktober 2014: 305–312 maupun penyuluhan, sehingga hasilnya lebih optimal, menjalin kemitraan yang baik untuk implementasi cmhn, menyiapkan sumbersumber untuk mengelola pelaksanaan cmhn, baik sdm-nya, pemimpin yang memadai, dan fasilitas yang tersedia untuk kegiatan cmhn, melakukan evaluasi terhadap cmhn yang sudah berjalan, sehingga akan terlihat kegiatan mana yang sudah berjalan dan tidak berjalan, melakukan adaptasi terhadap program dengan menyesuai kan dengan il mu-il mu bar u, sehingga cmhn tidak tertinggal dengan program yang lain, adanya komunikasi yang baik dengan berbagai lintas program maupun lintas sektor, dengan tokoh masyarakat, maupun kader kesehatan jiwa, adanya rencana strategi untuk membuat pelaksanaan cmhn berjalan lebih baik, sehingga dengan adanya faktor sustainability maka pelaksanaan cmhn dapat membudaya. bagi ilmu keperawatan diharapkan dengan adanya penelitian ini akan menambah wawasan keilmuan sehingga diharapkan faktor sustainability terhadap pelaksanaan cmh n dapat dimasukkan dalam proses pembelajaran bagi peneliti selanjutnya diharapkan kriteria inklusi untuk perawat cmhn lebih dipersempit, sehingga hasilnya lebih optimal. mengg u nakan metode k ualit atif u nt u k mendapatkan kedalaman suatu fenomena tentang persepsi perawat terhadap faktor sustainability dalam implementasi cmhn. kepustakaan keliat, b.a., akemat, daulima, n.h.c, dan nu rhaeni, h., 2011. keperawatan kesehatan jiwa komunitas: cmhn (basic course). jakarta: egc. kelleher, k., 2007. perawatan kesehatan jiwa komunitas: tinjauan dan evaluasi modul dasar. brisbane: jta international. king,k., christo,j., fletcher, j., machlin, a., nicholas., dan pirkis, j., 2013. the sustainability of an australian initiative designed to improve interdisciplinary collaboration in mental health care. international journal of mental health system. (online), (http://www.ijmhs. com., diakses tanggal 1 febr uar i 2014). leffers, j., dan mitchell, e., 2010. conceptual model for partnership and sustainability in global health. public health nursing, 28 (1), 91–102. patrick, r., capetola, t., towsend, m., dan hanna, l., 2011. incorporating sustainability into community based healthcare practice. ecohealth, 8, 277–289. plochg.,t., delnoij, d., m., j., hoogedoorn, n., p., c., dan klazinga, n.s., 2006. collaborating while competing? the sustainabilit y of communit y–based integrated care initiatives through a health partnership. (online), (http:// w w w.biomedcent ral.com., diakses tanggal 1 februari 2014). schell, s., luke, d., herbers, s., dan elliott, m., 2012. sustainability assestment. st louis: washington university. sulastri, keliat, b.a., dan eryando, t., 2008. faktor-faktor yang berhubungan dengan kinerja perawat cmhn di kabupaten pidie aceh. jur nal kepera watan indonesia, 12 (3). syukri, m., yani, a., daulima, n.h.c., 2013. studi fenomenologi: pengalaman kader kesehatan jiwa dalam menjalankan perannya untuk meningkatkan status kesehatan jiwa masyarakat di kota bogor. depok: fik ui. washington university, 2012. sustainability framework and assestment tool. st. louis: center for public health systems science, (online), (http://cphss.wusti. edu) http://e-journal.unair.ac.id/jners | 429 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19718 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the demonstration and audiovisual health education package (demavi) could affect the housewives’ knowledge of first-aid in burns nutrisia nu’im haiya, iwan ardian, siti marfu’ah faculty of nursing, sultan agung islamic university, semarang, indonesia abstract introduction: burns is a condition that is experienced by the community that can cause skin damage to the epidermis. this is often experienced by housewives due to their daily life in the kitchen. so that this does not cause serious problems, then housewives need sufficient knowledge. the use of demonstration and audiovisual (demavi) health education is packaged to increase one's knowledge. the study aims to recognize the impact of the demonstration health education package and audiovisual on the first aid knowledge of the burns on housewives in bangetayu wetan methods: this type of research is quantitative research. the design used a quasi-experiment with the control group pretest-posttest. the instrument used in this study was a questionnaire with 27 closed-ended questions with multiple choice answer. the number of respondents is 107 which are 54 in treatment group and 53 in control group using the simple random sampling. data obtained are statistically processed using chisquare test results: the result of the statistical test shows significant effects of demonstrations and audiovisual and health education packages on knowledge about first aid burns among housewives with p-value of 0.094. conclusion: the demonstration and audiovisual health education packages has an effect on housewives’ knowledge of first aid in burns. other package methods can be developed to make it easier for health workers to do health promotion, and other methods of health promotion package development should be adapted to the theme of the material and the existing audience characteristic. article history received: feb 27, 2020 accepted: april 1, 2020 keywords burn knowledge; health education package (demavi); housewife contact siti marfu’ah  sitimarfuah020698@gmail.com  faculty of nursing, sultan agung islamic university, semarang, indonesia cite this as: haiya, n, n., ardian, i., & marfu’ah, s. (2020). the demonstration and audiovisual health education package (demavi) could affect the housewives’ knowledge of first-aid in burns. jurnal ners, special issues, 429-432. doi:http://dx.doi.org/10.20473/jn.v15i2.19718 introduction burns are one of the most common conditions in society. a burn is an injury caused by intense heat, such as hot water, fire, radiation, and chemicals. burns are also caused by a mild frost bite. burns are one of the most common traumas, ranging from the shock stage to the advanced stage. burns can have devastating effects and risks resulting from exposure to any cooking fire. one of them is skin damage. besides skin, burns can also damage muscle tissue, blood vessels, and epidermal tissue. severe burns can cause the sufferer shock and psychological stress resulting from his or her physical disability (ahuja et al., 2016). one way to treat a burn is using first aid, which is the quickest step taken outside a hospital to save a life [2]. however, today, people are still using incorrect methods of applying first aid to burns, such as using toothpaste and oil to treat burns. besides containing potassium content that could increase skin infections, people also use ice cubes to relieve heat, but these actions could actually stop blood circulation. the successful first treatment of burns requires the public to have extensive knowledge, and, as such, this must reach the community. this is done by using health promotion techniques. health education in megacities uses effective learning methods and media. the method used for research is demonstration, while the media is audio-visual. this https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:sitimarfuah020698@gmail.com http://dx.doi.org/10.20473/jn.v15i2. n. n. haiya, et al. 430 | pissn: 1858-3598  eissn: 2502-5791 demonstration method reduces the rate of error and enhances the responder's clarity, as live demonstration methods are performed in front of learners, while audiovisual media is a health education media that uses audio and visual messages [3]. a study by savitri in the sidodadi village in the puring sub-district obtained that in a previously treated group there were seven respondents (35%) in the enough knowledge category and 13 respondents (65%) in inadequate category, then, after being given health education, this became 20 (100%) in adequate category with some 10,000, indicating that there is an increase [4]. a study by siwi conducted in the village of garen padean ngemplaque boiali found results prior to health education wherein most respondents had knowledge in the family pre-hospital in correct burn treatment of 50.7%. after medical training, most of those polled with knowledge of the family prehospital treatment were in the good category (62.7%) [5].the preliminary study was carried out on april 16, 2019 in bangetayu wetan. lurah's interview with the cadre mothers in bangetayu wetan obtained information that they had been burned while doing housework. their jobs, while cooking, often result in oil eruptions and then burns from the handle of the pan while lifting the cookware, as well as those taken while ironing. these are a few causes of burns in the home, and good, proper precautions are required. good precautions can be taken by replacing a pan handle with a stable grip, using a protective pan during cooking and checking the electrical connections before ironing, but most of the housewives in bangetayu wetan still use the wrong method to apply first aid to burns. the remedies that some housewives in bangetayu wetan have used in treating burns are toothpaste, cooking oil, margarine, and soy sauce. with improper burns and limited knowledge of first aid, promoting and preventive effort is required in the first aid of burns, and, hence, the author is interested in studying "the effect of demonstration and audiovisual education packages on first aid for burns among housewives in bangetayu wetan.” materials and methods this study was quantitative research, whereby this study reveals causal relationships in a way that involves control group instead of treatment group. the study used the design experiment with control group pretest-posttest. the respondents in this study were mothers – housewives in bangetayu wetan in the 25-59 year old or adult age category. this research was implemented around september to october 2019. the population is 4433 and this study took a sample of 107 by simple random sampling technique.. for the group treatment, 54 of the respondents in this group were treated initially with pretests and then treated with demavi treatment. demavi itself is a demonstration and an audiovisual, so the group responders for treatment by the researcher showed audiovisual media about first aid for burns, followed by a posttest. on the other hand, the control group, as many as 53 respondents, received a pretest and posttest, but they were not treated by demavi. the instrument used in this study was a questionnaire with 27 multiple choice closed-ended questions. the questionnaire used by researchers is valid as all 27 item questions obtained a coefficient more than the r table (0.444), as well as it reliability with a cronbach’s alpha value of 0.959. this research strongly implemented ethical principles of research, including respect for human dignity by ensuring informed consent and confidentiality of respondents’ data. results table 1 explains the results of analysis of differences in knowledge before and after being given the demavi healthcare package and obtained the posttest group for adequate category treatment while control was inadequate. the treatment group totaled 38 respondents, while control group was as many as 33 respondents. according to the results in table 1, there is an increase in the number of respondents with adequate knowledge compared to the control group, table 1. the differences of knowledge before and after the demavi (n=107) variable intervention control pre-test post-test pre-test post-test n % n % n % n % knowledge sufficient 34 63% 16 29.6% 25 47.2% 20 37.7% adequate 20 37% 38 70.4% 28 52.8% 33 62.3% total 54 100% 54 100% 53 100% 53 100% table 2. statistical result of demavi effect on housewives’ knowledge of first aid in burns (n=107) knowledge posttest pvalue odd ratio chi-square test intervention control sufficiently 16 20 0.094 0.309 2.801 adequate 38 33 total 54 53 jurnal ners http://e-journal.unair.ac.id/jners | 431 which are only 20 to 28 respondents at pretest becoming 33 to 38 respondents at posttest. according to analysis on table 2, the impact of the demavi on first aid knowledge, the results show in the treatment group, which covered a total of 38 respondents while those in the control group had 33 respondents in the adequate category. in addition, in the study, the result was that there was a p value is 0.094, the value of chi–square was 2.801 variability with odds ratio 0.309. the results of this test indicate that the health education package with demavi has an effect on the knowledge of first aid in burns among housewives. discussion there was a difference between treatment group and control group seen during research. the difference of results could be due to the possibility of deficiencies in human ability at the time of research. for the responders who were given demavi, the figure is high because this group was given both video imaging and demonstrations using visual aids. apart from this, the probability of this difference could result because of the environment, etc.this study, moreover, was supported by earlier studies by nurul aeni and sriyuhandini (aeni and yuhandini, 2018), where preintervention results of 65.17 appear to have risen to 76.50 after intervention. this study also matched up with a previous study by zakaria et al. [7], about the effect of health education with audiovisual media on the knowledge that 15.8 can produce. kapti (kapti, rustina and widyatuti, no date) said that audiovisual media is an effective medium for improving one's knowledge, and that it cannot only be used to stimulate an active emancipation of knowledge. audiovisual media is a healthcare medium which can encourage one's attraction and increase one's motivation for receiving messages, stimulate high curiosity and can improve future behavior and patterns of life [9]. based on previous research, the researchers assume that the health education package that combines media with methods in health education is different. this would be viewed in the category of respondent's knowledge. the study shows the effect of demavi on housewives’ knowledge of first aid in burns. the use of health education is one way to increase knowledge. one gains knowledge through several senses, including 83% vision, 11% hearing, 1% taste and 2% touch [3]. health education can be done using demonstration methods and audiovisual media. the demonstration method has the benefit that it can stimulate one's active understanding, whereas audiovisual media relies on hearing and sight [10]. previous research also proves there is an influence of various health education methods on knowledge in the treatment of burns, including audiovisual media, demonstration methods and leaflets (lestari, amelia and rahmalia, 2012; savitri, 2017; sari et al., 2018). based on existing studies, theories and previous studies, have assumed that a health education package consisting of demonstration methods and audiovisual media has benefits that can affect one's knowledge, because one's knowledge will increase through both hearing and sight. it can be achieved when using the media for media and health education methods. it is proven by the study that health education that combines the media with these methods can affect individual's knowledge. conclusion the demonstration and audiovisual health education package (demavi) has an effect on the housewives’ knowledge of first-aid in burns in bangetayu wetan district, semarang, central java province, indonesia. this demavi package can be taught to cadres because this health education package is simple, so that it can be easily learned and health cadres, as an extension of the government, can teach it to the wider community. other methods can be developed based on the topics and the audience characteristics for the delivery of a health education. thus, it could enhance the quality of health promotion in society. conflict of interest the author states that in this study there were no conflicts of interest. acknowledgement our gratitude goes to the rector of sultan agung islamic university and dean of the faculty of nursing who supported this research. we would also like to thank the head of the bangetayu wetan sub-district who gave us permission to conduct research in the area he leads. references aeni, n. and yuhandini, d. s. (2018) ‘pengaruh pendidikan kesehatan dengan media video dan metode demonstrasi terhadap pengetahuan sadari’, jurnal care, 6(2), pp. 162–174. ahuja, r. b. et al. (2016) ‘isbi practice guidelines for burn care’, burns, 42(5), pp. 953–1021. doi: 10.1016/j.burns.2016.05.013. kapti, r. e., rustina, y. and widyatuti (no date) ‘efektifitas audiovisual sebagai media penyuluhan kesehatan terhadap peningkatan pengetahuan dan sikap ibu dalam tatalaksana balita dengan diare’. lestari, w., amelia, n. r. and rahmalia, s. (2012) ‘efektifitas pendidikan kesehatan tentang asi terhadap tingkat pengetahuan, kemampuan dan motivasi menyusui primipara’, jurnal ners indonesia, 2(2), pp. 192–199. sari, s. i. et al. (2018) ‘pengaruh pendidikan kesehatan dengan metode demonstrasi terhadap pertolongan pertama luka bakar pada ibu rumah tangga’, jurmal kesmadaska, pp. 98–105. savitri, s. h. (2017) ‘pengaruh pendidikan kesehatan terhadap pengetahuan tentang pertolongan n. n. haiya, et al. 432 | pissn: 1858-3598  eissn: 2502-5791 pertama pre hospital keluarga dalam penanganan luka bakar’. ners vol 10 no 1 april 2015.indd 125 pengalaman keputusasaan stroke survivor di kota semarang (hopelessness experience among stroke survivor in semarang) sawab*, moch. bahrudin*, novy helena catharina daulima* *jurusan keperawatan politeknik kesehatan kementerian kesehatan semarang jl. tirto agung pedalangan, banyumanik, semarang e-mail: sawabfatih@yahoo.com abstrak pendahuluan: keputusasaan merupakan penilaian negatif terhadap hasil yang akan dicapai dan ketidakberdayaan terhadap suatu harapan. keputusasaan dapat terjadi pada stroke survivor karena adanya disabilitas akibat defi sit neurologisnya serta waktu yang lama dalam penyembuhannya. kondisi ini dapat berlanjut pada gangguan mental emosional maupun tindakan suicide. oleh karena itu gambaran pengalaman keputusasaan stroke survivor dibahas dalam penelitian ini. metode: penelitian ini merupakan penelitian kualitatif deskriptif fenomenologi terhadap 6 partisipan. hasil: hasil penelitian didapatkan tujuh tema utama yaitu (1) perubahan fi sik sebagai akibat respons keputusasaan, (2) respons kehilangan sebagai stressor keputusasaan, (3) disfungsi proses keluarga, (4) kehilangan makna hidup, (5) dukungan dan motivasi diri sebagai sumber koping menghadapi keputusasaan, (6) hikmah spiritual dibalik keputusasaan stroke survivor, dan (7) dapat menjalani kehidupan dengan lebih baik. diskusi: penelitian ini menyarankan dikembangkannya standar asuhan keperawatan keputusasaan dan pemberian dukungan keluarga serta psikoedukasi keluarga bagi stroke survivor. kata kunci: stroke survivor, pengalaman keputusasaan, kualitatif abstract introduction: hopelessness was a negative feelings about goal achievement and powerlessness feeling against an expectation. hopelessness in stroke survivors can occur due to prolonged disability and neurologic defi cit. this condition can lead to emotional and mental disorders even a suicide action. therefore, it was a need to explore hopelessness experience in stroke survivors. method: this study was a qualitative descriptive phenomenology with 6 participants. results: 7 themes were revealed in this study, (1) physical changes as a response on hopelessness, (2) loss response as a hopelessness stressor, (3) dysfunction of the family process, (4) loss of meaning of life, (5) self support and motivation as a coping resource against hopelessness, (6) the spiritual meaning behind hopelessness, (7) can go through a better life. discussion: this study suggests to develop a nursing care standards in hopelessness, encourage a family support and family psychoeducation for stroke survivors. keywords: stroke survivor, hopelessness experiences, qualitative pendahuluan disabilitas klien paska stroke sebagai akibat defi sit neurologis memerlukan waktu penyembuhan yang lama dan berdampak terhadap kondisi psikososial stroke survivor. terjadinya perubahan psikososial, seperti perasaan harga diri yang rendah, perasaan tidak beruntung, perasaan ingin mendapatkan kembali kemampuan yang menurun, berduka, takut dan putus asa merupakan manifestasi dari keputusasaan bahkan tanda dari depresi. menurut abramson, alloy dan metalsky (1989) keputusasaan pada hakekatnya merupakan precursor dalam perjalanan depresi. hasil riset di india 35,29% stroke survivor mengalami depresi. st roke sur vivor mengalami sa k it yang berlangsung lama, sehingga dapat mempengaruhi harga diri. harga diri yang rendah akan dapat berlanjut ke kondisi keputusasaan, depresi bahkan tindakan suicide. teasdale dan eingberg (2001) menjelaskan stroke survivor berisiko mengalami tindakan suicide pada 5 tahun pertama sakitnya. kondisi ini menyebabkan stroke survivor dengan keputusasaan sangat berisiko mengalami gangguan mental emosional. di sisi lain st roke su r vivor denga n ke put u sa sa a n membutuhkan penanganan jangka panjang untuk mengembangkan mekanisme koping yang adaptif dan mencegah berkembangnya s t r e s s o r d i s a bi l it a s m e nja d i ko n d i si maladaptif. 126 jurnal ners vol. 10 no. 1 april 2015: 125–132 upaya antisipasi menurunkan angka gangguan jiwa adalah dengan mengelola klien yang mempunyai risiko mengalami gangguan mental emosional supaya tidak mengalami masalah gangguan jiwa, salah satunya adalah klien stroke survivor dengan keputusasaan. berdasarkan fenomena tersebut penting untuk dilakukan kajian yang mendalam terhadap stroke survivor dengan masalah psikososial keputusasaan. oleh karena itu, penelitian ini ingin menjawab pertanyaan “bagaimanakah pengalaman keputusasaan stroke survivor di kota semarang?” bahan dan metode desain penelitian ini menggunakan penelitian kualitatif fenomenologi deskriptif. partisipan penelitian ini adalah stroke survivor dengan riwayat lebih dari tiga bulan, serangan lebih dari 1 kali, usia dewasa pertengahan (40-60 tahun), pernah mempunyai pengalaman keputusasaan kategori sedang yang diukur dengan skor beck hopelessness scale (bhs) dan gangguan kognitif ringan yang dilihat dengan skor mini mental state examination (mmse). jumlah sampel yang berpartisipasi pada penelitian ini enam orang. lokasi penelitian di kelurahan srondol kulon wilayah kerja puskesmas srondol kota semarang dan dilaksanakan pada bulan april sampai dengan juni 2013. pengumpulan data dilakukan dengan wawancara mendalam (indepth interview) dan catatan lapangan. analisis data menggunakan langkah colaizzi, dengan membuat transkripsi verbatim, membaca trankrip secara berulangulang, mengumpulkan pernyataan signifi kan, menentukan arti setiap per nyataan yang p e nt i ng, m e ng u m pu l k a n k a t a k u nc i , mengelompokkan ke dalam kategori, kemudian disusun dan dikelompokkan menjadi tema hasil penelitian. hasil partisipan dalam penelitian ini adalah stroke survivor, dengan 4 orang berjenis kelamin laki-laki dan 2 orang berjenis kelamin perempuan dengan usia antara 45 sampai 51 tahun dan berstatus menikah. tingkat pendidikan par tisipan terdiri atas smp, diploma iii dan sarjana. lama menderita menderita stroke mulai 1 sampai 3,5 tahun dengan 4 orang mengalami kelemahan pada ektremitas kanan dan 2 orang mengalami kelemahan pada ektremitas kiri. keseluruhan stroke survivor pernah mempunyai pengalaman keputusasaan sedang dan mempunyai kognitif baik. berdasarkan wawancara mendalam, diperoleh berbagai pengalaman stroke survivor dalam menghadapi keputusasaan dalam 7 tema utama, antara lain: p e r u b a h a n f i s i k a k i b a t r e s p o n s keputusasaan per ubahan f isik yang diungkapkan sebagai akibat dari keputusasaan adalah perasaan fatigue seperti lemas dan tidak ber tenaga seper ti u ng kapan par tisipan berikut: “rasanya saat saya down seperti tidak ada tenaga, tangan dan kaki yang lemes tambah lemes.....”(p1) akibat yang dirasakan partisipan lain adalah merasa letih dan penurunan kemampuan kerja fi sik dengan contoh ungkapan di bawah ini: “terus terang badan saya sepertinya loyo tenaganya kok hilang, tangan dan kaki kanan saya tambah lemas saat semangat dan kondisi saya menurun atau dwon”(p4) akibat keputusasaan juga dirasakan dalam gangguan pencernaan dan gangguan tidur sebagaimana ungkapan partisipan berikut ini: “biasanya kan saya kalau pagi itu rasanya lapar walaupun seadanya saya makan sama minum air putih, tapi waktu itu pas saya dwon saya setiap mau makan rasanya kenyang, nafsu makan tidak ada sampai sampai istri seperti marah.”(p4) gangguan tidur yang dialami oleh partisipan diungkapkan seperti: “.......terus terang saat saya serangan lagi, kemudian perasaan putus asa saya muncul semalam tidak tidur rasanya tidak kantuk, itu bisa sampai 2 hari, saat mau tidur kepikir terus kalau saya jadi merepotkan”(p5) 127 pengalaman keputusasaan stroke survivor di kota semarang (sawab, dkk) akibat keputusasaan mempengaruhi perfusi cerebral dengan rasa pusing seperti ungkapan berikut ini: “kondisi pas saya semangatnya hilang, sepertinya les-lesan (berkunangkunang seperti mau pingsan) sama pusing pak.”(p3) respons kehilangan sebagai stressor keputusasaan re spon keh ila nga n d iu ng k apk a n partisipan dengan ketidakpercayaan atau tawar menawar sebagaimana ungkapan berikut ini: “mengapa kok sudah 1 tahun kaki saya malah tambah berat”.(p4) respons kehilangan dalam dirinya berusaha di atasi dengan menekan (supresi) permasalahan yang dihadapi seperti yang diungkapkan partisipan: “saya gak mau ngomong sama istri kasihan nanti kalau malah kepikiran istri saya”(p1) s e l a i n i t u p a r t i s i p a n j u g a meng u ng k apk a n pe r a sa a n ma r a h at a s kondisinya “kadang-kadang tangan dan kaki kanan saya, saya pukul-pukulkan di dipan bagaimana sih kok saya seperti ini terus gitu lho, marah pada diri sendiri”(p5) perilaku depresi seperti kehilangan semangat,perasaan sedih, serta khawatir diungkapkan sebagai berikut: anak anak saya masih kecil, sementara saya tidak bisa bekerja, pokoknya sepertinya saya sudah menyerah”.(p4) “sepertinya kok seperti ini rasanya sedih, kuatir, pak saya jadi malas melakukan apa-apa, saya cuma menangis”.(p3) kehilangan makna hidup ketidakberdayaan dalam mencapai tujuan hidup dimaknai sebagai hilangnya mak na hidup bahkan muncul keinginan mengak hir i hidupnya seper ti ungkapan berikut: “ya saya kan perempuan, suami saya kerja kalau sebelumnya saya bisa membantu kerja di pabrik masak, bersih bersih rumah tetapi sekarang saya malah jadi merepotkan suami saya..........”.(p3) “dipikiran saya muncul kalau memang saya waktunya meninggal dunia atau diambil nyawa saya tidak apa-apa saya kasihan sama suami dan anak anak repot”. (p5) disfungsi proses keluarga pe n g a l a m a n d i sf u n g si kel u a r g a y a n g d i a l a m i p a r t i si p a n d i s e b a b k a n ke t id a k m a m pu a n d a l a m me nja l a n k a n fungsi peran dirinya dan ketidakmampuan anggota keluarga memberikan penghargaan bagi anggota keluarganya, sebagaimana diungkapkan sebagai berikut: “sempat waktu itu istri bilang tidak enak ke saya, saya bilang pada istri mau saya pukul tapi saya masih sadar, bahkan sempat ingin saya bunuh, terus terang..”(p1) s e d a n g k a n k e t i d a k m a m p u a n memberikan penghargaan antar anggota keluarga diungkapkan sebagai berikut: “kalau di rumah saya minta bantuan sama anak saya memasak air untuk mandi saya kadang-kadang anak saya itu tidak langsung mau, nunggu di suruh sampai beberapa kali, seperti tidak mengormati ibunya”(p3) dukungan dan motivasi diri sebagai sumber koping menghadapi keputusasaan su mb e r kopi ng st r oke s u r v i v o r berasal dari dukungan keluarga, lingkungan, keyakinan diri serta motivasi untuk aktivitas. sumber koping dari keluarga inti sebagaimana diungkapkan: “anak saya yang kuliah waktu itu kebetulan libur kalau pas saya diam di kamar menemani saya terus kemudian bilang ibu sabar tabah, terus suami ya ngasih semangat, nah kalau anak dan bilang suami memberi semangat saya rasanya semangat hidup muncul lagi”(p5) selain dukungan keluarga keyakinan atau semangat dari dalam diri stroke survivor diungkapkan seperti berikut: “tapi yang perlu ketahui pokoknya ya semangat dari dalam diri sendiri, pas waktu itu saya parkir mau terima uang jatuh, kan tangan kanan saya masih belum seperti sekarang saya diomelin pokoknya dikatakatain, saya tidak peduli sampai sekarang itu yang terus saya ingat”.(p2) 128 jurnal ners vol. 10 no. 1 april 2015: 125–132 hikmah spiritual dibalik keputusasaan stroke survivor stroke survivor mendapatkan hikmah atau makna hidup kembali melalui proses memaknai ulang akan nilai-nilai spiritual dalam kondisi ketidakberdayaannya dan makna terhadap dirinya seperti berikut ini: “saya bersyukur, sebetulnya saya mungkin ditunjukkan ke jalan yang lebih terang dan hikmah yang paling mendalam saya diberi kesempatan untuk beribadah memperbaiki hidup”.(p3) “sejak saya pernah down sampai sekarang saya bisa bekerja semampu saya menjadikan saya lebih sabar”(p4) dapat menjalani kehidupan dengan lebih baik ma k n a d ibal i k ke put u sa sa a n nya par tisipan mendorong par tisipan u nt u k berkeinginan mempunyai harapan hidup yaitu kembali sembuh dan sehat, dapat menjalankan fungsi perannya sebagaimana ungkapan berikut: “harapan saya sembuh, bisa cari rongsok n ya la n ca r, te r u s a n a k a n a k sehat”(p4) pembahasan karakteristik partisipan penelitian ini belum dapat menggambarkan pengalaman keput usasaan dar i individu yang tidak mempunyai sistem pendukung seperti suami, istri serta pengalaman di tinggalkan orang yang dicintai. keputusasaan dalam proses perjalanannya masih terdapat perdebatan, khususnya mengenai penyebab keputusasaan it u sendiri. penelitian ini menunjuk kan manifestasi keputusasaan terjadi pada stroke sur vivor dengan gangguan f isik ber upa hemiplegi dektra pada empat partisipan dan dua partisipan mengalami hemiplegi sinistra. penelitian yang dilakukan oleh robinson menyebutkan bahwa terdapat hubungan antara lesi area frontal, sub kortikal dan ganglia basalis dalam terjadinya depresi paska stroke dengan hipotesis sentralnya adalah lesi di hemisfer k ir i mer upakan fak tor utama timbulnya depresi paska stroke (dalam meifi & agus, 2009). hal ini menunjukkan bahwa keputusasaan tidak hanya disebabkan oleh faktor organik akan tetapi dapat disebabkan karena faktor reaksi psikologis sebagai konsekuensi klinis akibat stroke. penelitian yang dilakukan oleh chen (2011) menyebutkan kelemahan motorik yang terjadi pada klien paska stroke mer upakan faktor penting terjadinya depresi paska stroke. penelitiannya menyebutkan 61,3% responden yang memiliki fungsi motorik buruk mengalami depresi post stroke sedangkan 38,7% responden dengan fungsi motorik bagus mengalami depresi. perubahan fisik akibat keputusasaan antara lain fatigue, anoreksia serta insomnia. perasaan fatigue diungkapkan oleh partisipan berupa perasaan ekstremitas tambah lemas dan perasaan loyo serta tidak bertenaga. menurut naess, lunde dan brogger (2012) perasaan fatigue berhubungan dengan adanya nyeri dan depresi klien paska stroke. hasil penelitiannya menyebutkan terdapat tiga manifestasi yang sering muncul pada klien stroke yaitu depresi (19%), fatigue (46%) dan nyeri (48%). selain itu, dalam studi korelasi, depresi dan fatigue menunjukan hubungan yang kuat sedangkan antara nyeri dan depresi mempunyai hubungan yang sedang. pengalaman nyeri stroke survivor tidak didapatkan dalam penelitian ini. menurut peneliti hal ini dimungkinkan pengaruh dari faktor budaya. budaya jawa, khususnya di jawa tengah, rasa nyeri sulit diungkapkan ke orang lain/lawan bicara karena adanya perasaan khawatir dapat mengganggu lawan bicara. faktor lain yang dapat mempengaruhi adalah usia. menurut kozier, erb, berman dan snyder (2010) orang dewasa dapat mengabaikan rasa nyeri karena pengakuan rasa nyeri dapat dianggap sebagai tanda kelemahan atau kegagalan. k l ie n p a s k a s t r o ke m e r a s a k a n kehilangan kemampuan fungsional karena penyakit yang dapat mengubah citra tubuhnya. pada kondisi ini klien stroke mendapatkan stressor yang menyebabkan klien tersebut mempunyai harapan negatif dan muncul ketidakberdayaan terhadap harapan nya tersebut. hal ini sejalan dengan penelitian pada penyakit kronik seperti kanker payudara 129 pengalaman keputusasaan stroke survivor di kota semarang (sawab, dkk) yang menyebutkan 80% mempunyai perasaan khawatir akan masa depannya, 30% merasakan ketakutan (gumus, cam & malak, 2011). hasil penelitian ini mengungkap bahwa respons kehilangan stroke survivor tidak lagi berada pada tahap penolakan (denial), akan tetapi masuk pada tahap marah (angry). hal ini sebagai bentuk perasaan frustasi dengan kondisi ketidakberdayaan dalam menjalankan peran dirinya. rasa marah yang diungkapkan oleh stroke survivor ini sebenarnya merupakan salah satu bentuk koping. selain perasaan marah, mekanisme koping lain yang dilakukan oleh stroke survivor berupa supresi, yaitu keengganan menceritakan permasalahan yang ada pada dirinya pada orang lain. bertambahnya jumlah stressor dapat menyebabkan bertambahnya waktu yang dibutuhkan partisipan untuk sampai pada kondisi acceptance. pengalaman partisipan ini sejalan dengan hasil penelitian jones dan morris (2012) yang mengungkapkan salah satu tema yaitu perasaan tidak berguna dan perasaan kehilangan pada orang dewasa dengan pengalaman stroke. ketidakmampuan menjalankan peran memunculkan rasa ketidakberdayaan, yaitu persepsi bahwa situasi perubahan dirinya tidak mampu mempengaruhi hasil yang ingin dicapai sehingga stroke survivor merasa tidak memiliki makna hidup. hal ini sejalan dengan penelitian kariasa, sitorus dan afi yanti (2009) yang mengungkapkan bahwa perubahan makna hidup klien paska stroke terjadi karena adanya perasaan kurang dihargai, tidak diperhatikan dan tidak berguna. kondisi tersebut sebenarnya mer upakan ketidakberdayaan yang juga diungkap dalam penelitian ini. penelitian ini juga menunjukkan bahwa klien paska stroke mengalami perasaan tidak berguna sehingga muncul ide atau keinginan untuk mengakhiri hidupnya. hal ini sesuai penelitian yang dilakukan oleh towfi ghi (2013) bahwa stroke survivor di amerika sebanyak 7,8% memiliki niat bunuh diri. hasil penelitian ini mengungkapkan adanya konfl ik antar anggota keluarganya dan ketidakmampuan memberikan penghargaan terhadap anggota keluarganya. hal ini disebabkan oleh karena efek dari perubahan peran dan harga diri stroke survivor sehingga keluarga tidak mampu melakukan fungsi afektif keluarga. menurut friedman (2010) fungsi afektif keluarga yaitu fungsi internal keluarga sebagai dasar kekuatan keluarga. di dalamnya terkait rasa saling mengasihi, saling mendukung dan saling menghargai antar anggota keluarga. gambaran hasil penelitian ini juga didukung penelitian yang dilakukan oleh clark et al (2004, dalam gillespie & campbell, 2011) yang menyebutkan bahwa 32% disfungsi keluarga pada sembilan bulan pertama paska stroke disebabkan ketidakmampuan keluarga menjalankan fungsinya dan 66% terjadi karena adanya konfl ik dalam keluarga. sejalan dengan hasil penelitian jones dan moris (2012), sumber koping yang menjadi pilihan utama stroke survivor pada kondisi keput usasaan adalah du k u ngan keluarga, khususnya keluarga inti, yaitu istri, suami atau anak-anaknya. signifi cant other dinilai mempunyai makna dan arti penting dalam menumbuhkan stroke survivor dengan keputusasaan. usaha stroke survivor untuk tetap semangat dilakukan melalui usaha untuk menumbuhkan keyakinan internal diri, dan motivasi untuk beraktivitas agar terbebas dari keputusasaannya. keyakinan internal diri atau positive belief ini biasa disebut juga sebagai self effi cacy. menurut bandura (1997 dalam stuart & laraia 2006) self efficacy mer upakan kapabilitas dari kepercayaan diri individu. individu yang mempunyai self effi cacy yang tinggi akan memberikan efek terhadap pemikiran, motivasi, suasana hati serta kesehatan fi sik individu tersebut sehingga stressor dianggap sebagai tantangan. penelitian albal dan kultu (2010) menjelaskan terdapat hubungan antara koping self effi cacy dan sosial support pada klien depresi, di mana klien dengan depresi mempunyai skor self effi cacy yang rendah. peranan dukungan sosial mengatasi keputusasaan stroke survivor juga terungkap dalam penelitian ini. panzarella, alloy dan whitehouse (2006) menjelaskan dukungan sosial mer upakan bagian dari adaptive inferential feedback (aif) yang bekerja menurunkan sensitivitas kognitif depresi 130 jurnal ners vol. 10 no. 1 april 2015: 125–132 dengan menur unkan kesimpulan negatif individu, selain itu juga menurunkan perilaku maladaptive sebagai hasil dari kesimpulan negatif dari pengalaman yang menyebabkan keputusasaan. menurut bastaman (2007) makna hidup dapat ditemukan dalam setiap keadaan yang menyenangkan dan tidak menyenangkan, keadaan bahagia, dan penderitaan, ungkapan seperti “makna dalam penderitaan” (meaning in suffering) atau “hikmah dalam musibah” (blessing in disguise). makna hidup stroke survivor didapatkan melalui proses memaknai ulang terhadap nilai-nilai spiritual bagi dirinya. penelitian ini mengungkapkan perbedaan dengan penelitian terdahulu pada penyakit kronis yang dilakukan oleh sasmita, hamid dan daulima (2011) di mana makna spiritual pada penelitiannya didapat pada saat kondisi acceptance sedangkan stroke survivor dengan keputusasaan makna hidupnya diperoleh dalam kondisi ketidakberdayaan menuju ke kondisi acceptance. pengalaman partisipan i n i mer upa ka n ma n ifest asi per jala na n tahapan kehilangan sebagaimana dijelaskan sebelumnya bahwa setiap individu tidak sama dalam melalui suatu proses kehilangan. ada yang bisa langsung mencapai fase penerimaan ada yang sangat lama bahkan berbulan-bulan untuk akhir nya dapat menerima kondisi sakit nya (yosep, 2009). penelitian lain dilakukan oleh wachholtz dan pearce (2009 dalam lewis & peterson, 2013) menjelaskan bahwa peranan spiritualitas dalam penyakit konis dan kecacatan dapat mendorong klien menemukan perasaan positif pada dirinya. menur ut snyder (dalam cheavens, feldman, woodward & snyder, 2006) harapan merupakan motivasi positif untuk memenuhi t ujuan. terdapat empat kategori t ujuan harapan yaitu tujuan untuk menuju hasil yang diinginkan, tujuan untuk menghalangi atau menunda kejadian yang tidak diinginkan, tujuan pemeliharaan atau mempertahankan status quo, dan peningkatan tujuan untuk menambah hasil yang sudah positif. dalam kontek i n i, harapan d an keput usasa an adalah dua hal yang berbeda namun saling terkait dalam konstruksi psikoterapi. terapi kognitif untuk mengatasi keputusasaan dapat dilakukan dengan menggali pikiran-pikiran akan harapannya dalam hidupnya. studi yang dilakukan oleh curry, snyder, cook, ruby, dan rehm (1997 dalam cheavens, feldman, woodward & snyder, 2006) juga memaparkan bahwa harapan orang dewasa yang tinggi dapat meningkatkan harga dirinya. berdasarkan hal tersebut dapat disimpulkan bahwa stroke survivor dengan keputusasaan dan harapan yang tinggi merupakan suatu motivasi untuk menuju hasil yang diinginkan. hal ini bermanfaat bagi stroke survivor karena dapat meningkatkan harga dirinya. simpulan dan saran simpulan hasil penelitian menunjukkan bahwa pengalaman keputusasaan stroke survivor antara lain berupa adanya perubahan fi sik sebagai a k ibat respon s ke put u sa sa a n , terjadi respons kehilangan sebagai stressor keputusasaan, disfungsi proses keluarga, serta kehilangan makna hidup. hilangnya makna hidup stroke survivor justru menambah temuan pengalaman baru yaitu keinginan untuk mengakhiri hidup dan dapat menjadikan domain penting dalam menentukan kualitas hidup stroke survivor dalam hal psycological being khususnya dalam kontrol diri. munculnya berbagai dampak dari keput usasaan membuat st roke sur vivor melakukan pilihan dan strategi koping, antara lain mencari dukungan dari keluarga dan lingkungan. dukungan keluarga inti bagi stroke survivor merupakan signifi cant others dalam menghadapi keputusasaannya. sementara itu usaha untuk menumbuhkan keyakinan diri dan kemandirian stroke survivor juga merupakan sumber koping pilihan dalam menghadapi keputusasaan. dibalik keputusasaannya stroke survivor mendapatkan makna hidup akan nilai-nilai spiritual yang diperoleh dengan memaknai ulang kondisi ketidakberdayaannya. sebagai seorang individu, dibalik keputusasaannya stroke survivor mempunyai harapan terhadap penyakitnya, yaitu harapan sembuh kembali, harapan tidak terjadi serangan ulang serta mampu menjalankan peran dirinya kembali 131 pengalaman keputusasaan stroke survivor di kota semarang (sawab, dkk) dan menginginkan motivasi dan pelayanan kesehatan yang baik dari petugas kesehatan. hasil penelitian ini juga menggambarkan bahwa pengalaman keputusasaan klien stroke berhubungan erat dengan proses adaptasi klien saat mendapat stressor, baik stressor fisik maupun stressor psikologis. proses tersebut melibatkan beberapa f ungsi antara lain fungsi fi siologis, konsep diri, peran maupun interdependensi yang dapat dimaknai sebagai support sistem. saran perlu adanya terapi kog nitif bagi stroke survivor. terapi kognitif yang telah ada di keperawatan kesehatan jiwa dapat dikembangkan bagi stroke survivor melalui modifi kasi, yaitu dengan menambahkan sesi tentang membangun harapan positif. sesi ini akan dapat membangkitkan motivasi dan harga diri stroke survivor yang mengalami keputusasaan. perlu adanya penempatan perawat spesialis jiwa di poliklinik rawat jalan maupun di puskesmas untuk membantu memperbaiki respons koping keluarga dalam pengambilan keputusan untuk menyelesaikan masalah yang dirasakan oleh stroke survivor terkait disfungsi proses keluarga dengan melakukan terapi keluarga triangle. kepustakaan abramson, l.y., alloy, l.b. dan metalsky, g.i., 1989. hopelessness depression: a theory-based subtype of depression. psychological review, 96 (2), 358–372. albal, e., dan kultu y., 2010. the relationship bet ween t he depression copi ng self eff icacy level and perceived sosial support resources. journal of psychiatric nursing, 1(3), 115–120. bastaman, h.d., 2007. logoterapi; psikologi untuk menemukan makna dan meraih hid u p be r m a k n a. ja k a r t a: r aja grafi ndo persada. chen, y., 2011. investigation of prevalence and assosiated risk factor of depressive symptom following acute ischemic st roke (psd) in aged. scientif ic research, 2(5), 522–525. cheavens, j.s., feldman, d.b., woodward, j.t., dan snyder, c.r., 2006. hope in cog nitive psychotherapies: on work i ng wit h cl ient st reng t h s. journal of cognitive psychotherapy: an international quarterly, 20, 135–145. friedman, m.m., 2010. family nursing: re s e a r c h , t h e o r y & p r a c t i c e . connecticut: appleton & lange. gilespie, d., dan campbell, f., 2011. effect of stroke on family carers and family relationships. nursing standard, 26(2), 39–46. gumus, a.b., cam, o. dan malak a.t., 2011. relationships between psychososial adjust ment a nd hopelessness i n women with breast cancer. asian pasifi c journal of cancer prevention, 14(1), 571–578. jones, l., dan morris r., 2012. experiences of adult stroke survivors and their parent carer: qualitative study. clinical rehabilitation, 27(3), 272–280. kariasa, i.m., sitorus, r. dan afi yati, y., 2009. persepsi pasien paska serangan stroke terhadap kualitas hidupnya dalam perspektif asuhan keperawatan. tesis fakultas ilmu keperawatan, universitas indonesia. tidak dipublikasikan. kozier, erb, berman dan snyder, 2010. buku ajar fundamental keperawatan; konsep, proses dan praktek. (alih bahasa: wahyuningsih e et al. jakarta: egc. lewis, m.b., dan peterson, e.j., 2013. spirituality as coping mechanism for chronic illness. clinical scholars review, 6. meifi & agus, d., 2009. stroke dan depresi paska stroke. majalah kedokteran damianus, 8(1). naess, h., lunde, l., dan brogger, j., 2012. the triad of pain, fatigue and depression in ischemic stroke patient: the bergen stroke study. cerebrovascular disease, 33(5), 461–465. panzarella, c., alloy, l.b. dan whitehouse, w.g., 2006. expanded hopelessness t he or y of d e p r e s sio n : o n t he mechanisms by which social support protects against depression. cognitive therapy and research, 30(3), 307– 333. 132 jurnal ners vol. 10 no. 1 april 2015: 125–132 sasmita. h., hamid. a.y., dan daulima, h.c., 2011. makna kehidupan klien dengan diabetes mellitus kronik di kelurahan bandarjo semarang, sebuah studi fenomenologi. tesis fakultas ilmu keperawatan, universitas indonesia. tidak dipublikasikan. stuart g.w, laraia m.t., 2006. principles and practice of psychiatric nursing, 7th edition. philadelphia: mosby. teasdale, a.w., dan engberg, a.w., 2001. suicide af ter st roke. journal of epidemiolog y communit y health, 55(12), 863–866. towfighi, a., 2013. depression almost 8 percent of us stroke survivor may have suicide thought. news health & science. may 21, 2013. yosep, i. 2009. keperawatan jiwa. edisi revisi, bandung: refi ka aditama. 17 model family centered maternity care sebagai strategi optimalisasi competent mothering (family centered maternity care model as the strategy to optimize competent mothering) asmuji*, diyan indriyani* * faculty of health sciences muhammadiyah university jember, jl. karimata 49 jember email: asmuji@gmail.com abstrak pendahuluan: angka kematian ibu (aki) dan angka kematian bayi (akb) di indonesia masih cukup tinggi dibandingkan dengan negara asean lainnya.untuk persoalan tersebut perlu pemecahan dalam mengatasi masalah kesehatan ibu dan bayi, salah satunya dengan membangun model edukasi postnatal yang difokuskan pada ibu postpartum dengan melibatkan keluarga sebagai dukungan sosial. metode: penelitian ini dilakukan dengan pendekatan penelitian partisipatif (kualitatif) dan participatory action research (pra), dengan tujuan uji coba model edukasi postnatal secara komprehensif sekaligus evaluasi dalam menyempurnakan model sehingga diperoleh model yang tepat. tehnik pengumpulan data pada penelitian ini dilakukan dengan cara survei/observasi, wawancara, fgd, wawancara mendalam pada ibu postpartum dan keluarga sejumlah 100 responden, maupun petugas kesehatan. hasil: penelitian yang dilakukan telah berhasil merumuskan model edukasi postnatal melalui pendekatan fcmc sebagai strategi optimalisasi competent mothering dalam menurunkan angka kematian ibu dan bayi. model tersebut telah dilakukan ujicoba secara komprehensif baik terhadap ibu postpartum dan keluarga serta terhadap petugas kesehatan dengan media modul dan booklet tentang perawatan diri ibu nifas dan perawatan bayi baru lahir yang disesuaikan dengan tahapan masa postpartum. terdapat pengaruh model edukasi postnatal dengan pendekatan fcmc terhadap persepsi ibu nifas dan keluarga tentang perawatan diri pada masa immediately postpartum, perawatan diri dan bayi baru lahir pada fase early postpartum dan fase late postpartum dengan nilai p masing-masing adalah 0,00 (α≤0,05). selain itu juga didapatkan ada pengaruh sosialisasi model edukasi postnatal dengan pendekatan fcmc terhadap persepsi petugas kesehatan dengan nilai p 0,00. diskusi: rekomendasi penelitian ini adalah model edukasi postnatal melalui pendekatan fcmc sebagai strategi optimalisasi competent mothering dapat diterapkan sebagai salah satu upaya dalam menurunkan angka kematian ibu dan bayi. kata kunci: model edukasi postnatal, fcmc, competent mothering. abstract introduction: indonesia’s rate of mmr and imr remains high among other asean countries. this issue needs to be seriously addressed, particularly in dealing the mother-and-infant related problems, through developing the postnatal education model which focuses on postpartum mother by involving family as the social support. methods: this research employed participative approach (qualitative) and participatory action research (pra), with the intention of conducting the try-out to the postnatal education model comprehensively, as well as evaluating the perfection attempts to the model in order to generate the fittest model. the data collection technique used in this research were survey/observation, interview, fgd, in-depth interview for postpartum mothers and family (100 respondents), as well as healthcare extension agents. results: this research has successfully formulated the postnatal education model through fcmc approach as the optimization of competent mothering strategy in lowering the infant and maternal mortality rate. this model has undergone comprehensive trial to postpartum mothers and family as well as the healthcare extension agents by providing modules and booklet concerning the treatment of postpartum mother and newly born infants in accordance with the postpartum stages. the results also revealed that postnatal education model through the fcmc approach affected the perception of postpartum mothers and their family regarding the self-care treatment during the immediately post partum period, the infant and selfcare treatment at the early and late postpartum stages as shown by the p value of 0,00 (α≤0.05). furthermore, there was also an impact of the extension attempt of postnatal education model through the fcmc towards the perception of the healthcare extension agents with the p value of 0,00. discussion: this research recommended that the postnatal education model through family centered maternity care (fcmc) as the optimization of competent mothering is implemented as one of the attempts in lowering the maternal and infant mortality rates, respectively. keywords: postnatal education model, fcmc, competent mothering ____________________________________________________________________________________________________ pendahuluan periode masa nifas yang dijalani ibu postpartum masih memiliki berbagai kendala salah satunya persepsi yang belum sinergis dengan anjuran kesehatan. paradigma perawatan post partum yang baru menekankan bahwa ibu post patum adalah ibu sehat dan merupakan peristiwa yang fisiologis, sehingga prinsip keperawatannya berorentasi pada kemandirian ibu. peran sebagai orang tua tidak terlepas dari partisipasi atau kerja sama antara ibu dan keluarga (suami) serta anggota keluarga yang lain (sulistyawati 2009). hambatan yang masih ditemukan dalam perawatan ibu postpartum mailto:asmuji@gmail.com 18 adalah adanya anggapan masyarakat bahwa ibu post partum merupakan ibu yang sakit, mobilisasinya dihambat, jenis makanannya dibatasi, pemberian asi colostrum dihambat sehingga kebutuhan ibu post partum diprioritaskan untuk istirahat penuh. keterlibatan keluarga besar dalam perawatan bayi sejauh ini disalah artikan, dimana perawatan bayi diserahkan pada anggota keluarga yang lain. kondisi ini membuat ibu nifas cenderung merasa belum siap dalam melakukan perkembangan dan tugas-tugas perawatan bagi diri serta bayinya. oleh karena itu pentingnya adanya pembelajaran pada periode postnatal yang memiliki tujuan untuk mengadaptasikan ibu dan keluarga berpartisipasi dalam perawatan ibu nifas dan bayi baru lahir melalui pendidikan postnatal. salah satu jembatan untuk mengoptimalkan upaya edukasi postnatal adalah melalui keterlibatan keluarga. ibu dengan dukungan keluarga melalui pendekatan fcmc diharapkan memiliki kemampuan yang optimal dalam beradaptasi secara maternal pada masa nifas, juga kemampuan dalam mengasuh bayi. berbagai persepsi yang kurang tepat dalam dua kondisi ini akan sangat berisiko terhadap kesehatan baik ibu maupun bayi. pemerintah memerlukan upaya yang sinergis dan terpadu untuk mempercepat penurunan aki dan akb di indonesia khususnya dalam mencapai target millenium development goals (mdgs) pada tahun 2015. tentunya hal ini merupakan tantangan yang cukup berat bagi pemerintah indonesia (ri 2007) target rpjmn tahun 2010-2014 mengamanatkan agar aki dapat diturunkan menjadi 118 /100.000 kelahiran hidup pada tahun 2014. berbagai upaya pemerintah telah dilakukan untuk menurunkan aki dan akb ini. bila diidentifikasi terkait faktor-faktor yang berkontribusi terhadap aki dan akb sangatlah kompleks (saifuddin 2004) kondisi penyebab kematian ibu tersebut ternyata memang bisa ditemukan pada periode postnatal. untuk itu perlu perhatian dalam mengidentifikasi masalah kesehatan ibu selama periode perinatal yang salah satunya adalah masa nifas, termasuk bayi yang menjadi tanggungjawab ibu dalam berperan sebagai orangtua. berkaitan dengan permasalahan tersebut di atas telah dipecahkan, salah satunya dengan membangun model edukasi postnatal yang difokuskan pada ibu postpartum dengan melibatkan keluarga sebagai sosial support. model ini memiliki keunggulan bahwa dalam mengoptimalkan pemahaman ibu tentang peran dan fungsinya dalam beradaptasi secara maternal dan perawatan bayi baru lahir, keluarga ikut terlibat aktif dalam upaya tersebut. dampak dari peningkatan pemahaman ibu postpartum tersebut ibu akan memiliki kemampuan competent mothering secara optimal. hal ini tentunya berkontribusi terhadap optimalisasi status kesehatan ibu maupun bayi yang dilahirkan, sehingga dapat berdampak untuk menekan angka kematian ibu dan bayi. masalah yang diteliti ini berkaitan dengan 1) peran petugas kesehatan dan institusi kesehatan dalam optimalisasi competent mothering ibu postpartum dalam upaya menurunkan angka kematian ibu dan bayi; 2) peran keluarga dengan pendekatan fcmc dalam optimalisasi competent mothering ibu postpartum dalam upaya menurunkan angka kematian ibu dan bayi. bahan dan metode penelitian ini diawali dengan tahap penggalian data faktual persepsi tentang adaptasi maternal fisiologis dan psikologis, perawatan diri dan perawatan bayi baru lahir (bbl) masa nifas dan status kesehatan pada ibu nifas dan keluarga. selain itu juga penggalian data peran (dinas kesehatan, pelayanan kesehatan, dan petugas kesehatan). selanjutnya pada tahap 2 dilakukan penyusunan rancangan model dengan cara telaah hasil analisis data dan selanjutnya mengadakan diskusi untuk menetapkan model. pada tahap 3 dilakukan uji coba model secara komprehensif yang dilakukan dengan: a) melakukan pendidikan kesehatan tentang adaptasi maternal fisiologis dan psikologis, perawatan diri masa nifas, keluarga sebagai social support, perawatan bayi baru lahir, dan fgd tentang kesiapan penerimaan peran menjadi orangtua; b) melakukan koordinasi dengan institusi kesehatan terkait penyusunan kebijakan pelaksanaan edukasi postnatal bagi ibu nifas dan keluarga; dan c) melakukan pelatihan terhadap petugas kesehatan tentang strategi edukasi postnatal dengan pendekatan fcmc serta pelatihan tentang optimalisasi competent mothering ibu nifas. model family centered maternity care (asmuji, diyan indriyani) 19 model edukasi postnatal dengan pendekatan fcmc memiliki beberapa ketetapan seperti pada gambar 1. ketetapan tersebut antara lain: 1) pemberian edukasi postnatal dilakukan dengan menyediakan format discharge planning; 2) melibatkan keluarga terdekat bagi ibu nifas (misal: suami, ibu maupun mertua) sebagai social support; 3) memperhatikan tahapan masa nifas yang terdiri dari fase immediately postpartum (0-24 jam pertama), early postpartum (>24 jam-1 minggu pertama) dan late postpartum (> 1 minggu6/8 minggu); 4) memperhatikan karakterisktik ibu nifas dan keluarga, termasuk budaya yang digunakan oleh mereka; 5) topik edukasi disesuaikan dengan kebutuhan ibu terkait tahapan masa nifas. adapun topik pada fase immediately postpartum meliputi adaptasi nyeri dan mobilisasi dini. topik pada fase early postpartum meliputi perawatan payudara, pijat oksitosin, tehnik menyusui yang benar, nutrisi masa menyusui, perawatan perineum, personal hygiene, kebutuhan istirahat, senam nifas, asi ekslusif, perawatan bayi baru lahir (memandikan, perawatan tali pusat, dan mengganti popok). sedangkan topik pada fase late postpartum meliputi kontrasepsi, seksualitas, imunisasi bayi, mengenal perilaku bayi, tumbuh kembang bayi dan keamanan bayi. penelitian ini melibatkan ibu nifas dan keluarga di ruang dahlia rsd dr. soebandi jember dan wilayah kecamatan kaliwates kabupaten jember dengan pendekatan penelitian partisipatif (kualitatif) dan participatory action research (pra). tehnik pengumpulan data dilakukan dengan cara survei/observasi, wawancara, fgd, indept interview. penentuan sampel dilakukan dengan tehnik purposive sampling. jumlah sampel diambil 50 orang sampel di rsd dr. soebandi jember dan 50 sampel ibu postpartum di wilayah kecamatan kaliwates, sehingga jumlah keseluruhan adalah 100 responden. data yang telah dikumpulkan pada penelitian ini meliputi data 1) persepsi ibu nifas dan keluarga tentang adaptasi maternal fisiologis dan psikologis; 2) persepsi ibu nifas dan keluarga tentang perawatan diri masa nifas; 3) persepsi ibu nifas dan keluarga tentang perawatan bayi baru lahir; 4) persepsi petugas kesehatan tentang edukasi postnatal dengan pendekatan fcmc; 5) pengaruh edukasi postnatal terhadap persepsi ibu nifas dan keluarga tentang perawatan diri masa nifas dan bayi baru lahir. pengolahan data yang diperoleh baik secara teoritis maupun lapangan dianalisis secara kuantitatif baik secara deskriptif maupun menggunakan uji dependent t-tes. gambar 1. model edukasi postnatal dengan pendekatan family centered maternity care fcmc fcmc f c m c f c m c immediately postpartum (first 0-24 hours) early postpartum (>24 hours 1 week) late postpartum (week 2 – 6/8 weeks) education on postpartum period postpartum mothers family as social support topics: early mobilization, pain adaptation topics: breast care, oxytocin massage, breastfeeding technique, nutrition, perineum care, personal hygiene, the need of rest, gymnastic parturition, exclusive breastfeeding, neonatal care (bathing, umbilical cord care, changing diapers) topics: contraception, sexuality, baby immunization, infant’s behavior, infant’s savety postnatal education by health workers jurnal ners vol. 11 no. 1 april 2016: 17-28 20 hasil tabel 1 distribusi persepsi tentang perawatan diri pada masa immadiately postpartum dan early postpartum pada ibu nifas dan keluarga nilai immadiately postpartum early postpartum pretest (n=50) posttest (n=50) pretest (n=50) posttest (n=50) mean 44.20 70.00 47.80 71.20 median 45.00 70.00 50.00 70.00 mode 40 70 50 70 std. deviation 14.441 9.476 12.171 7.990 minimum 10 50 10 50 maximum 70 90 70 90 tabel 2 distribusi persepsi ibu nifas dan keluarga tentang perawatan bayi baru lahir pada masa early postpartum nilai early postpartum (n=50) pretest posttest mean 47.80 70.00 median 50.00 70.00 mode 50 70 std. deviation 11.301 7.559 minimum 20 50 maximum 70 90 tabel 3 distribusi persepsi petugas kesehatan tentang edukasi postnatal dengan pendekatan fcmc nilai persepsi tentang mep (n=17) pretest posttest mean 52.53 77.82 median 56.00 77.00 mode 56 70 std. deviation 11.495 7.376 minimum 28 70 maximum 70 91 tabel 4 pengaruh edukasi postnatal dengan pendekatan family fcmc terhadap persepsi perawatan diri pada ibu nifas dan keluarga variabel mean std. deviation std. error mean p value persepsi fase immadiately postpartum (n=50) pretest 44.20 14.441 2.042 0,00 posttest 70.00 9.476 1.340 persepsi fase early postpartum (n=50) pretest 47.80 12.171 1.721 0,00 posttest 71.20 7.990 1.130 tabel 5 pengaruh edukasi postnatal dengan pendekatan fcmc terhadap persepsi ibu nifas dan keluarga tentang perawatan bayi baru lahir pada 1 minggu pertama variabel mean std. deviation std. error mean p value persepsi perawatan bbl 1 minggu pertama (n=10) pretest 47.80 11.301 1.598 0,00 posttest 70.00 7.559 1.069 model family centered maternity care (asmuji, diyan indriyani) 21 tabel 6 pengaruh sosialisasi edukasi postnatal dengan pendekatan fcmc terhadap persepsi petugas kesehatan variabel mean std. deviation std. error mean p value persepsi petugas tentang mep dengan pendekatan fcmc (n=17) pretest 52.53 11.495 2.788 0,00 posttest 77.82 7.376 1.789 tabel 7 distribusi persepsi tentang perawatan diri pada ibu nifas dan keluarga tabel 8 distribusi persepsi ibu nifas dan keluarga tentang perawatan bayi baru lahir nilai early postpartum (n=50) late postpartum (n=50) pretest posttest pretest posttest mean 50.40 70.00 41.80 65.80 median 50.00 70.00 40.00 70.00 mode 50 70 40 70 std. deviation 6.987 6.999 12.728 11.445 minimum 40 60 10 10 maximum 60 80 60 90 tabel 9 distribusi persepsi petugas kesehatan tentang edukasi postnatal dengan pendekatan fcmc nilai persepsi tentang model edukasi postnatal (n=11) pretest posttest mean 52.91 77.00 median 49.00 77.00 mode 42 a 70 a std. deviation 10.454 7.000 minimum 42 70 maximum 70 91 tabel 10 pengaruh edukasi postnatal dengan pendekatan fcmc terhadap persepsi perawatan diri pada ibu nifas dan keluarga variabel mean std. deviation std. error mean p value persepsi fase immadiately postpartum pretest 49.00 9.530 1.348 0,00 posttest 69.20 6.652 .941 persepsi fase early postpartum pretest 47.40 13.219 1.869 0,00 posttest 66.60 12.715 1.798 persepsi fase late postpartum pretest 44.20 12.469 1.763 0,00 posttest 68.40 8.657 1.224 nilai immadiately postpartum (n=50) early postpartum (n=50) late postpartum (n=50) pretest posttest pretest posttest pretest posttest mean 49.00 69.20 47.40 66.60 50.40 70.00 median 50.00 70.00 50.00 70.00 50.00 70.00 mode 50 70 50 60 a 50 70 std. deviation 9.530 6.652 13.219 12.715 6.987 6.999 minimum 30 50 10 40 40 60 maximum 70 80 70 90 60 80 jurnal ners vol. 11 no. 1 april 2016: 17-28 22 tabel 11 pengaruh edukasi postnatal dengan pendekatan fcmc terhadap persepsi ibu nifas dan keluarga tentang perawatan bayi baru lahir variabel mean std. deviation std. error mean p value persepsi perawatan bbl 1 minggu pertama (n=50) pretest 50.40 6.987 .988 0,00 posttest 70.00 6.999 .990 persepsi perawatan bbl 2-6 minggu pertama (n=50) pretest 41.80 12.728 1.800 0,00 postest 65.80 11.445 1.619 tabel 12 pengaruh sosialisasi edukasi postnatal dengan pendekatan fcmc terhadap persepsi petugas kesehatan variabel mean std. deviation std. error mean p value persepsi petugas tentang mep dengan pendekatan fcmc (n=11) pretest 52.91 10.454 3.152 0,00 posttest 77.00 7.000 2.111 pembahasan berdasarkan uji coba model yang telah dilakukan di rsd dr. soebandi jember dan di puskesmas kaliwates jember didapatkan hasil bahwa edukasi postnatal dengan pendekatan fcmc efektif diterapkan untuk menguatkan persepsi bagi ibu nifas dan keluarga yang menjalani perawatan di rumah sakit maupun di rumah. peneliti berpendapat bahwa pemberian edukasi bagi ibu nifas akan optimal jika diberikan sesuai tahapan masa nifas yang meliputi tiga fase yaitu immediately postpartum, early postpartum, dan late postpartum. topik yang diberikan jika disesuaikan dengan fase yang sedang dijalani oleh ibu nifas akan lebih optimal karena sesuai dengan kebutuhan yang sedang dijalani. topik edukasi pada fase immediately postpartum (0-24 jam pertama) meliputi adaptasi nyeri dan mobilisasi dini. topik edukasi pada fase early postpartum (>24 jam1 minggu pertama) meliputi: perawatan payudara, pijat oksitosin, tehnik menyusui yang benar, kebutuhan istirahat, senam nifas, asi ekslusif, perawatan perineum, personal hygiene, dan perawatan bbl (memandikan, perawatan tali pusat, nutrisi masa menyusui, mengganti popok). sedangkan topik edukasi pada fase late postpartum (> 1 minggu6/8 minggu) meliputi: kontrasepsi, seksualitas, imunisasi bayi, mengenal perilaku bayi, tumbang bayi dan keamanan bayi. proses pemberian edukasi tersebut dengan melibatkan keluarga sebagai social support. keluarga merupakan sekumpulan individu yang menyatu dalam sebuah hubungan yang diikat denga norma-norma tertentu (friedman, m.m. 2003). keluarga ini adalah kumpulan masyarakat terkecil yang ada di dalam sebuah komunitas. adanya hubungan yang erat antar sesama anggota keluarga merupakan dasar bahwa keluarga merupakan individu yang saling mendukung satu sama lain. sama halnya pada ibu nifas, dimana tahap perkembangan keluarga yang dijalani yaitu keluarga dengan childbearing. keluarga dengan childbearing adalah tahap kedua dalam perkembangan keluarga yang dimulai sejak kelahiran anak pertama sampai bayi berusia 30 bulan (friedman, m.m. 2003) namun menurut calgary tahap ini merupakan tahap ketiga dimana terjadi transisi dari peran individu menjadi orang tua dan mulai membentuk sistem yang permanen. masa transisi dalam tahap ini menjadi faktor pencetus stres dan ketidakseimbangan dalam keluarga. setiap tahap dalam keluarga memiliki tugas yang harus dipenuhi, yang berkaitan dengan tanggung jawab yang harus dicapai oleh keluarga sehingga keluarga dapat memenuhi kebutuhan keluarga, yang disebut tugas perkembangan keluarga. tugas perawat pada fase nifas ini adalah memfasilitasi keluarga khususnya ibu agar mempunyai kompetensi yang maksimal untuk melakukan perawatan diri dan bayinya. melalui edukasi postnatal dengan pendekatan fcmc keluarga menjadi optimal dalam memenuhi tugas perkembangan keluarga dengan ibu nifas baik dalam melakukan perawatan diri maupun perawatan bayinya. melalui ujicoba pada ibu nifas dan keluarga yang dirawat di ruang dahlia rsd model family centered maternity care (asmuji, diyan indriyani) 23 dr. soebandi jember dan di wilayah puskesmas kaliwates jember pada kebutuhan informasi tentang perawatan diri pada masa immadiately postpartum diperoleh nilai p (p value 0,00). berdasarkan hasil tersebut dapat dinyatakan bahwa etopik dukasi pada fase tersebut efektif diberikan pada ibu nifas. topik edukasi pada fase immediately postpartum (024 jam pertama) meliputi adaptasi nyeri dan mobilisasi dini. topik tersebut penting disampaikan pada ibu dan keluarga karena adaptasi nyeri dan mobilisasi dini merupakan kebutuhan utama ibu pada 0-24 jam pertama pasca melahirkan. ketika melahirkan terdapat beberapa perubahan fisiologis pada anatomi reproduksi ibu sehingga menimbulkan nyeri. rasa nyeri yang dialami ibu karena perubahan serviks dan iskemia uterus pada persalinan kala i (wiknjosastro 2005). kala i fase laten lebih banyak penipisan di serviks sedangkan pembukaan serviks dan penurunan daerah terendah janin terjadi pada fase aktif dan transisi. rasa nyeri ini perlu diadaptasikan oleh perawat melalui edukasi yang tepat dengan memanfaatkan dukungan yang ada yaitu keluarga. hal ini sesuai dengan teori yang disampaikan pillitery (pillittery 2003) bahwa dukungan dari pasangan, keluarga maupun pendamping persalinan dapat membantu memenuhi kebutuhan ibu bersalin juga membantu mengatasi rasa nyeri. topik lain pada fase immadiately postpartum adalah mobilisasi dini. beberapa penelitian telah banyak membuktikan bahwa mobilisisasi dini memberikan manfaat yang besar bagi ibu nifas. penelitian mahdiyah (mahdiyah 2013) membuktikan bahwa terdapat hubungan yang signifikan antara mobilisasi dini dengan penurunan tinggi fundus uteri pada ibu postpartum. mobilisasi dini juga memberikan manfaat pada penyembuhan luka perineum bagi ibu yang melahirkan normal dan luka post operasi sectio caesarea. hal ini telah dibuktikan bahwa terdapat hubungan antara mobilisasi dini dengan penyembuhan luka perineum pada ibu postpartum (dewi, ratnawati 2011). penelitian dari mustakim telah membuktikan bahwa moblisasi dini dinyakatan efektif dalam mencegah terjadinya infeksi luka pada ibu postpartum dengan sectio caesarea (mustakim 2009). mobilisasi dini penting untuk disampaikan oleh petugas kesehatan disamping karena manfaatnya yang positif bagi ibu nifas, juga karena keberagaman budaya yang terjadi di indonesia. beberapa masyarakat terkadang masih menganut budaya tertentu dan berkembang dalam keluarga seperti keyakinan bahwa ibu nifas tidak diperbolehkan bergerak karena akan membuat luka penyembuhannya menjadi lama, akan menambah rasa sakit pada ibu, dan masih banyak lagi kepercayaan masyarakat yang salah terkait mobilisasi dini. perawat perlu meluruskan anggapan tersebut dengan pendekatan melalui keluarga sebagai sumber dukungan utama ibu nifas. edukasi yang diberikan akan efektif jika keluarga saling mendukung dan memahami pentingnya melakukan perawatan pada ibu nifas salah satunya mobilisasi dini khususnya pada fase 024 jam pertama melahirkan. fase selanjutnya yang dilalui ibu nifas adalah early postpartum. topik edukasi pada fase early postpartum (>24 jam-1 minggu pertama) meliputi: perawatan payudara, pijat oksitosin, tehnik menyusui yang benar, kebutuhan istirahat, senam nifas, asi ekslusif, perawatan perineum, personal hygiene, dan perawatan bbl (memandikan, perawatan tali pusat, nutrisi masa menyusui, mengganti popok). berdasarkan hasil uji coba pada ibu nifas dan keluarga di ruang dahlia rsd dr. soebandi jember dan di wilayah puskesmas kaliwates jember terkait perawatan diri pada fase early postpartum didapatkan p value 0,00. hasil tersebut menunjukkan bahwa topik edukasi yang diberika pada fase ini efektif dapat diberikan pada ibu nifas dan keluarga. pentingnya kompetensi ibu dalam merawat diri dan bayinya adalah salah satu faktor penting untuk menurunkan angka kematian ibu dan bayi. fase early postpartum adalah periode di mana ibu seharusnya telah mampu untuk merawat diri dan bayinya. melalui dukungan keluarga tentunya kompetensi ini akan lebih mudah dimiliki oleh ibu nifas. perawatan diri pada ibu nifas meliputi perawatan payudara, pijat oksitosin, tehnik menyusui yang benar, kebutuhan istirahat, senam nifas, asi ekslusif, perawatan perineum, dan personal hygiene. perawatan diri yang sedikit dilakukan adalah senam nifas, istirahat dan tidur, asupan energi dan protein, dan memiliki pantangan makan sehingga direkomendasikan untuk memberikan edukasi secara optimal bagi ibu nifas dan keluarga terkait topik edukasi tersebut. topik pertama yang perlu disampaikan oleh petugas kesehatan adalah jurnal ners vol. 11 no. 1 april 2016: 17-28 24 perawatan payudara pada ibu nifas. perawatan payudara adalah suatu kegiatan yang dilakukan secara sadar dan teratur untuk memelihara kesehatan payudara dengan tujuan untuk mempersiapkan laktasi pada waktu post partum (bobak, lm., lowdermilk, d.l., & jensen 2005). tindakan ini dilakukan dengan tujuan untuk 1) memelihara kebesihan payudara; 2) melenturkan dan menguatkan puting susu; 3) mengeluarkan puting susu yang masuk kedalam atau daftar; 4) mempersiapkan produksi asi; 5) mencengah pembendungan asi; 6) meningkatkn hygiene payudara; 7) meningkatkan produksi asi; 8) melenturkan dan menguatkan puting payudara. hal tersebut telah dilakukan penelitian oleh astari & djuminah (2008) yang membuktikan bahwa ada hubungan antara perawatan payudara masa antenatal dengan kecepatan sekresi asi (djuminah 2008). hasil uji korelasi menunjukkan perawatan payudara akan menyebabkan sekresi asi pada ibu postpartum cenderung lebih cepat atau kurang dari 24 jam dengan peluang 11 kali lebih cepat dibandingkan dengan ibu yang tidak melakukan perawatan payudara. hal ini juga didukung oleh penelitian masnila (masnila 2013) yang membuktikan bahwa ada hubungan perawatan payudara dengan produksi asi pada ibu postpartum. selain itu pentingnya perawatan payudara ini ternyata mampu meningkatkan kualitas kolostrum. hal tersebut telah dibuktikan bahwa terdapat perbedaan yang signifikan antara kandungan protein dalam kolostrum sebelum dan sesudah perawatan payudara (machmudah, khayati 2013). melalui dukungan keluarga, kegiatan perawatan payudara pada ibu nifas mampu dilakukan dengan baik karena edukasi yang diberikan akan langsung dipraktikkan oleh ibu dengan didukung oleh keluarga khususnya suami dalam pelaksanaannya sehingga ibu mampu melakukan perawatan payudara dengan benar dan rutin sehingga memberikan manfaat yang baik bagi produksi asi ibu nifas. pijat oksitosin merupakan topik edukasi selanjutnya yang perlu disampaikan pada ibu nifas dan keluarga. pijat oksitosin adalah pemijatan pada sepanjang tulang belakang (vertebrae) sampai tulang costae kelima-keenam dan merupakan usaha untuk merangsang hormon prolaktin dan oksitosin setelah melahirkan (bobak, lm., lowdermilk, d.l., & jensen 2005). kegagalan dalam proses menyusui sering disebabkan karena timbulnya masalah, baik pada ibu maupun pada bayinya, salah satunya yaitu produksi asi yang kurang. untuk memperlancar produksi asi dapat dilakukan dengan merangsang reflek oksitosin yaitu dengan pijat oksitosin. penelitian suryani & astuti (2013) membuktikan bahwa pijat oksitosin efektif meningkatkan produksi asi pada ibu nifas. hal ini sesuai dengan pedoman depkes (departemen kesehatan republik indonesia 2007) bahwa pijat stimulasi oksitosin untuk ibu menyusui berfungsi untuk merangsang hormon oksitosin agar dapat memperlancar asi dan meningkatan kenyamanan ibu, mengurangi bengkak (engorgement), mengurangi sumbatan asi, dan mempertahankan produksi asi ketika ibu dan bayi sakit. mengingat gerakan dalam melakukan pijat oksitosin ini adalah di vertebrae (tulang belakang) maka lebih optimal jika dibantu oleh orang lain. petugas kesehatan dapat melakukan pijat oksitosin pada ibu sambil mengajarkan pada ibu dan keluarga cara dan titik yang harus dilakukan pemijatan sehingga keluarga sebagai pendamping utama bagi ibu nifas dapat memberikan tindakan pemijatan baik ketika di rumah sakit maupun saat di rumah agar produksi asi lancar dan proses menyusui dapat berjalan dengan optimal. proses menyusui akan berjalan optimal jika kondisi fisik dan psikologis ibu dalam keadaan baik. selain itu produksi asi juga merupakan faktor penting keberhasilan proses menyusui. namun produksi asi yang banyak jika tidak dilakukan dengan teknik menyusui yang benar juga akan menghambat proses menyusui. teknik menyusui yang benar adalah cara memberikan asi kepada bayi dengan perlekatan sehingga proses menyusui optimal karena posisi ibu dan bayi ketika menyusui dapat memberikan rangsangan pengeluaran asi dan bayi dapat menghisap puting dengan benar. mengajari ibu bagaimana teknik menyusui yang benar adalah tugas dari petugas kesehatan dengan mengoptimalkan dukungan keluarga sebagai social support utama bagi ibu nifas. posisi menyusui yang salah dapat menimbulkan masalah pada ibu dan bayi seperti puting menjadi lecet karena perlekatan tidak sempurna sehingga membuat ibu enggan menyusui, produksi asi tidak lancar yang model family centered maternity care (asmuji, diyan indriyani) 25 menyebabkan proses menyusui terhambat, dan bayi sering menangis karena tidak merasa kenyang setelah disusui. hal tersebut dapat menjadi masalah ketidakberhasilan ibu dalam menyusui sehingga edukasi yang optimal diperlukan agar ibu mampu dan kompeten dalam menyusui bayi. dukungan keluarga sangat penting di sini karena petugas kesehatan tidak selalu berada di samping ibu untuk mengamati apakah posisi menyusui sudah benar. keluarga adalah individu yang selalu berada di samping ibu sehingga bisa diberdayakan untuk mengingatkan dan membantu ibu melakukan teknik menyusui yang benar. masa nifas adalah masa yang cukup melelahkan bagi ibu dan keluarga karena adanya anggota keluarga baru yaitu bayi. tahap perkembangan keluarga dengan anak kecil menurut calgary adalah tahap ketiga. pada tahap ini orang dewasa menjadi pengasuh untuk bayinya. pengalaman keluarga dapat mempengaruhi pembentukan keluarga baru. tahap ini merupakan tahap terjadinya transisi dari peran individu menjadi orang tua dan mulai membentuk sistem yang permanen. peran tersebut pada mulanya sulit karena perasaan ketidakadekuatan menjadi orangtua baru, kurangnya bantuan dari keluarga dan teman-teman, dan para profesional perawatan kesehatan yang bersifat membantu dan sering terbangun tengah malam oleh bayi yang berlangsung 3 hingga 4 minggu. ibu merasa letih secara psikologis dan fisiologis. ia sering merasakan beban tugas sebagai ibu rumah tangga dan mungkin juga bekerja selain merawat bayi. ketika periode tersebut ibu membutuhkan istirahat yang cukup agar terhindar dari stress fisik maupun psikologis. petugas kesehatan penting menyampaikan kebutuhan istirahat dan tidur selama fase early postpartum karena kebutuhan ini adalah kebutuhan utama bagi ibu. kegunaan atau fungsi dari tidur yang cukup bagi ibu nifas yaitu regenerasi sel-sel tubuh yang rusak menjadi baru, memperlancar produksi hormon pertumbuhan tubuh, mengistirahatkan tubuh yang letih akibat aktivitas seharian, meningkatkan kekebalan tubuh dari serangan penyakit, menambah konsentrasi dan kemampuan fisik. dengan kondisi fisik dan psikologis yang baik, asi akan diproduksi dengan baik sehingga proses menyusui akan berjalan dengan lancar. produksi asi dapat dipengaruhi oleh beberapa faktor selain pijat oksitosin, perawatan payudara, teknik menyusui yang benar, cukup istirahat. faktor lain yang juga mempengaruhi produksi asi yaitu nutrisi yang baik dan benar untuk ibu menyusui. hal ini penting disampaikan karena ternyata pengetahuan ibu terkait nutrisi masa menyusui masih tergolong kurang. berdasarkan penelitian didapatkan bahwa pengetahuan ibu menyusui tentang asupan nutrisi cukup, hal ini disebabkan masih kurangnya informasi dan penyuluhan dari tenaga kesehatan tentang asupan nutrisi yang baik (maisyarah 2011). disarankan kepada petugas kesehatan agar memberikan pemahaman tentang pentingnya memberikan informasi mengenai asupan nutrisi yang baik. hal tersebut juga disebabkan masih banyaknya budaya pantang makan bagi ibu nifas yang berkembang di masyarakat sehingga kebutuhan nutrisi kadang belum tercukupi. petugas kesehatan penting untuk menyampaikan nutrisi bagi ibu nifas karena menjadi salah satu faktor kelancaran produksi asi dan meningkatkan kesehatan ibu nifas serta bayinya. dukungan keluarga sangat dominan di sini karena keluarga yang biasanya menyiapkan makanan bagi ibu nifas yang tinggal di tengah-tengah keluarga. gizi pada ibu menyusui sangat erat kaitannya dengan produksi air susu, yang sangat dibutuhkan untuk tumbuh kembang bayi. bila pemberian asi berhasil baik, maka berat badan bayi akan meningkat, integritas kulit baik, tonus otot serta kebiasaan makan yang memuaskan. topik penting lainnya adalah asi eksklusif yang perlu disampikan pada ibu dan keluarga. keberhasilan asi eksklusif ini sangat bergantung pada sikap ibu dan dukungan keluarga. berdasarkan penelitian didapatkan bahwa ada hubungan antara sikap ibu dengan pemberian asi eksklusif (wenas. w, malonda, n.s, bolang. a, kapantow 2010). hasil penelitian menyatakan bahwa dukungan keluarga berhubungan dengan keberhasilan pemberian asi eksklusif (rahmawati, bahar, b, & salam 2013). asi eksklusif adalah air susu ibu yang diberikan untuk bayi sejak baru lahir sampai 6 bulan tanpa makanan pendamping dan minuman lainnya seperti air, air gula, teh, dan sebagainya. makanan terbaik bagi bayi adalah asi sampai usia 6 bulan. hal ini penting disampaikan oleh petugas kesehatan pada ibu dan keluarga. terkadang masih banyak kepercayaan di masyarakat jurnal ners vol. 11 no. 1 april 2016: 17-28 26 bahwa bayi harus diberikan makanan tambahan seperti pisang, minuman manis, dan makanan tambahan agar gizinya baik. padahal pencernaan bayi masih belum mampu bekerja optimal sehingga tidak jarang ditemukan kejadian penyakit pencernaan yang dialami bayi karena perilaku ibu dan keluarga yang salah dalam memberikan makanan pada bayi. pentingnya asi eksklusif bagi bayi adalah untuk meningkatkan status kesehatan bayi karena asi adalah makanan paling aman dan paling baik bagi bayi, memberikan banyak manfaat bagi bayi juga bagi ibu. perawatan diri bagi ibu yang juga penting disampaikan yaitu senam nifas. senam nifas merupakan latihan gerak yang dilakukan secepat mungkin setelah melahirkan supaya otot-otot yang mengalami peregangan selama kehamilan dan persalinan dapat kembali kepada kondisi normal seperti semula. senam nifas dapat di mulai 6 jam setelah melahirkan dan dalam pelaksanaanya harus dilakukan secara bertahap, sistematis dan kontinue. senam nifas ini telah terbukti memberikan banyak manfaat bagi ibu nifas. hasil penelitian menyatakan bahwa senam nifas efektif menurunkan involusi uterus pada ibu nifas (puspitaningrum 2012). penurunan involusi uterus yang berlangsung cepat akan mencegah risiko perdarahan akibat bendungan uterus pasca melahirkan. senam nifas membantu penyembuhan rahim, perut, dan otot pinggul yang mengalami trauma serta mempercepat kembalinya bagian-bagian tersebut kebentuk normal; membantu menormalkan sendi-sendi yang menjadi longgar diakibatkan kehamilan; menghasilkan manfaat psikologis, dan menambah kemampuan menghadapi stress dan bersantai sehingga mengurangi depresi pasca persalinan (bobak, lm., lowdermilk, d.l., & jensen 2005). selain senam nifas, perawatan diri ibu nifas yang lainnya yaitu perawatan perineum dan personal hygiene. luka di perineum pasti akan dialami oleh ibu pasca melahirkan. jika tidak dijaga dengan baik akan menimbulkan infeksi yang saat ini menjadi penyebab kematian nomer 1 di dunia. untuk mengatasi masalah infeksi pada masa nifas, ibu penting diajari bagaimana merawat perineum dan melakukan perawatan diri dengan benar. perawatan perineum adalah pemenuhan kebutuhan untuk menyehatkan daerah antara paha yang dibatasi vulva dan anus pada ibu yang dalam masa antara kelahiran placenta sampai dengan kembalinya organ genetik seperti pada waktu sebelum hamil. tujuan perawatan perineum adalah mencegah terjadinya infeksi sehubungan dengan penyembuhan jaringan (hamilton 2000). kebersihan diri ibu membantu mengurangi sumber infeksi dan meningkatkan perasaan nyaman pada ibu. anjurkan ibu untuk menjaga kebersihan diri dengan cara mandi yang teratur minimal 2 kali sehari, mengganti pakaian dan alas tempat tidur serta lingkungan dimana ibu tinggal, ibu harus tetap bersih, segar dan wangi. merawat perineum dengan baik dengan menggunakan antiseptik dan selalu diingat bahwa membersihkan perineum dari arah depan ke belakang. selain topik mengenai perawatan diri ibu nifas, topik edukasi mengenai perawatan bayi baru lahir juga penting disampaikan pada fase early postpartum. melalui uji coba model pada ibu nifas dan keluarga di ruang dahlia rsd dr. soebandi jember dan di wilayah puskesmas kaliwates jember terkait persepsi ibu nifas dan keluarga tentang perawatan bayi baru lahir pada fase early postpartum didapatkan p value 0,00. perawatan bbl terdiri dari memandikan, mengganti popok, dan perawatan tali pusat. peneliti berpendapat bahwa perawatan bayi adalah tanggungjawab dari seorang ibu. perawatan bayi yang dilakukan oleh ibu akan menimbulkan kedekatan antara ibu dan bayi baik secara fisik maupun psikologis. kompetensi ibu dalam melakukan perawatan bayi akan lebih optimal dengan adanya pendampingan keluarga sebagai pendukung. hasil penelitian menyatakan bahwa salah satu faktor yang mempengaruhi pengetahuan dan keterampilan ibu dalam perawatan bayi adalah dukungan keluarga (rohani 2013). menurut friedman (2003) keluarga merupakan social support utama bagi ibu ketika menjalani masa nifas khususnya dalam melakukan perawatan bayi baru lahir. keluarga yang saling mendukung akan mengurangi stressor ibu ketika belum terampil melakukan perawatan bayi sehingga ibu akan tetap termotivasi untuk belajar dan menjadi terampil dalam melakukan perawatan bayi. setelah melewati fase early postpartum maka tahap selanjutnya adalah late postpartum (> 1 minggu6/8 minggu). melalui ujicoba model tentang perawatan bayi pada fase early postpartum dan fase late postpartum model family centered maternity care (asmuji, diyan indriyani) 27 diperoleh p value 0,00. hal ini berarti topik edukasi pada fase ini bisa disampaikan pada ibu dan keluarga untuk mengoptimalkan kompetensi ibu dalam melakukan perawatan diri dan bayinya selama fase ini. topik edukasi meliputi kontrasepsi, seksualitas, imunisasi bayi, mengenal perilaku bayi, tumbang bayi dan keamanan bayi. proses pemberian edukasi tersebut dengan melibatkan keluarga sebagai social support. melalui pelibatan keluarga diharapkan ibu mempunyai kompetensi yang optimal dalam fase ini. berdasarkan penelitian didapatkan bahwa pengetahuan ibu berpengaruh terhadap perilaku ibu dalam perawatan bayi seperti imunisasi, tumbuh kembang bayi, dan mengenai kemanan bayi (nuraprilyanti & indah 2009) . pengetahuan ibu yang optimal melalui edukasi, akan semakin kuat jika didukung oleh keluarga. fase 1-8 minggu pasca melahirkan adalah tahapan dimana ibu dan keuarga telah siap untuk menjadi sebuah keluarga baru dengan kelahiran bayi. kesiapan secara fisik dan psikologis harus sudah dimiliki oleh ibu dan keluarga sehingga mampu dalam melakukan perawatan diri maupun bayi selama tahap ini. friedman (2003) menjelaskan bahwa keluarga yang kokoh dan saling mendukung satu sama lain akan menghasilkan sebuah hubungan yang harmonis dan timbul rasa kasih sayang antar anggota keluarga. melalui edukasi postnatal yang disesuaikan dengan tahapan masa nifas maka ibu dan keluarga akan mempunyai kompetensi yang baik dalam melakukan perawatan diri dan bayinya. adanya dukungan dari keluarga menjadikan komiten yang kuat dalam sebuah keluarga yang baru melewati masa melahirkan dan siap menyongsong tahapan baru yaitu mempunyai bayi sehingga tugas perkembangan keluarga akan terpenuhi diantaranya mempersiapkan menjadi orang tua, membentuk keluarga muda sebagai sebuah unit yang mantap (mengintegrasikan bayi baru ke dalam keluarga), memberikan asi sebagai kebutuhan dasar bayi, memberikan berbagai kebutuhan anak, pasangan kembali melakukan adaptasi karena kehadiran anggota keluarga baru dan menyesuaikan dengan kebutuhan anggota keluarga, mempertahankan hubungan perkawinan yang memuaskan, dan memperluas persahabatan dengan keluarga besar dengan menambahkan peran orang tua dan kakek nenek (l.m & maureen 2009). dengan demikian selain tugas perkembangan keluarga terpenuhi, keterampilan ibu dalam melakukan perawatan diri dan bayi akan berkontribusi besar dalam menurunkan angka kematian ibu dan bayi di masa mendatang. simpulan dan saran simpulan model edukasi postnatal dengan pendekatan family centered maternity care efektif digunakan sebagai strategi optimalisasi competent mothering bagi ibu nifas dengan melibatkan keluarga secara langsung. namun sampai dengan akhir penelitian masih perlu melakukan penyempurnaan modul dan booklet sebagai medianya. saran model edukasi postnatal dengan pendekatan fcmc dapat dipalikasikan oleh petugas kesehatan untuk meningkatkan persepsi ibu nifas dan keluarga dalam mengoptimalkan perannya dalam merawat diri dan merawat bayi yang dilahirkan. keluarga sebagai social support utama bagi ibu nifas disarankan untuk terlibat aktif dalam proses edukasi postnatal maupun dalam proses perawatan ibu dan bayinya selama periode postpartum. diperlukan kebijakan pada system pelayanan kesehatan untuk implementasi model ini terkait dengan jumlah sumber daya manusia, serta sarana dan prasarana untuk edukasi. kepustakaan bobak, lm., lowdermilk, d.l., & jensen, m.., 2005. alih bahasa * wijayarini, m.a). buku ajar keperawatn maternitas 4th ed., jakarta: egc. departemen kesehatan republik indonesia, 2007. pedoman pelayanan kebidanan dasar, jakarta: depkes. dewi, ratnawati, & b., 2011. hubungan mobilisasi dini dengan kecepatan kesembuhan luka perineum pada ibu post partum di seluruh wilayah kerja puskesmas singosari kabupaten malang. fk universitas brawijaya malang. djuminah, a.&, 2008. hubungan perawatan payudara masa antenatal dengan kecepatan sekresi asi post partum jurnal ners vol. 11 no. 1 april 2016: 17-28 28 primipara. fk brawijaya. friedman, m.m., b.& j., 2003. family nursing: research, theory, and practice 5th ed., connecticut: appleton & lange. hamilton, p.., 2000. dasar-dasar keperawatan maternitas 7. alih ba., jakarta: egc. l.m, w. & maureen, l., 2009. nurses and families : a guide to family assesment and intervention 5th ed., philadelphia: fa davis company. machmudah, khayati, & i., 2013. peningkatan kualitas kolostrum pada ibu postpartum yang dilakukan pijat payudara dengan metode oketani. universitas muhammadiyah semarang. mahdiyah, d., 2013. hubungan mobilisasi dini dengan penurunan tinggi fundus uteri pada ibu postpartum di blud rs h. moch. ansari saleh banjarmasin. jurnal akademi kebidanan sari mulia banjarmasin, 11(11). maisyarah, s., 2011. pengetahuan ibu menyusui tentang asupan nutrisi di klinik nurhasanah medan. fakultas keperawatan universitas sumatera utara. masnila, 2013. hubungan perawatan payudara terhadap produksi asi pada ibu post partum di rumah bersalin tutun sehati tanjung morawa 2013. jurnal ilmiah pannmed, 9(1). mustakim, 2009. pengaruh mobilisasi dini terhadap kejadian infeksi luka pada ibu post partum dengan sectio caesaria. universitas muhammadiyah jember. nuraprilyanti & indah, 2009. faktor-faktor yang berhubungan dengan perilaku ibu dalam pemberian imunisasi campak pada bayi di kec pancoran mas depok. fkm ui. pillittery, a., 2003. maternal and child health nursing, care of the childbearing and chieldbearing family fourth edi., philadelphia: lippincott williams & wilkins. puspitaningrum, n., 2012. hubungan antara tingkat pengetahuan dan pelaksanaan senam nifas dengan kecepatan proses involusi uterus. rahmawati, bahar, b, & salam, a., 2013. hubungan antara karakteristik ibu, peran petugas kesehatan dan dukungan keluarga dengan pemberian asi eksklusif di wilayah kerja puskesmas bonto cani kabupaten bone. fkm universitas hasanuddin makassa. ri, d., 2007. rencana strategis nasional making pregnancy safer (ms) di indonesia, jakarta: depkes. rohani, s., 2013. faktor-faktor yang mempengaruhi pengetahuan dan keterampilan ibu dalam perawatan bayi di ruang nifas rsud lanto dg pasewang kab. janeponto. jurnal stikes nani hasanuddin makassar., 3(5). saifuddin, a.., 2004. buku panduan praktis pelayanan komplikasi perinatal dan neonatal., jakarta: yayasan bina pustaka sarwono prawirohardjo. sulistyawati, a., 2009. asuhan kebidanan pada ibu nifas., jakarta: salemba medika. wenas. w, malonda, n.s, bolang. a, kapantow, n.., 2010. hubungan antara pengetahuan dan sikap ibu menyusui dengan pemberian air susu ibu eksklusif di wilayah kerja puskesmas tompaso kecamatan tompaso. fakultas kesehatan masyarakat universitas sam ratulangi. wiknjosastro, h., 2005. ilmu kebidanan, jakarta: yayasan bina pustaka sarwono prawirohardjo. 106 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i1.22785 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research parental interactions associated with adolescent health risk behavior: premarital sexual and aggressive behavior ilya krisnana, praba diyan rachmawati, iqlima dwi kurnia and nur sayyid j. rummy faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: interactions within the family will determine the behavior of adolescents. lack of interaction in adolescents is a risk factor for adolescent behaving deviant, among others, unmerried sexual and aggressive behaviors. the purpose of this study was to analyze the relationship between parental interaction and the premarital sexual and aggressive behavior among adolescents. methods: a cross-sectional approach was taken. the sample consisted of 744 adolescents from junior high school and senior high school in java island aged 13 19 years old who had completed a google form. the independent variable was parent interaction while the dependent variable was premarital sexual and aggressive behaviors. the pachiq-r questionnaire was used for measuring parent interaction. while the dependent variable was using checklist questionnaire. the data was analyzed using spearman rank correlation with a level of significance α=0.05. results: the results show that there is a correlation between the parent interactions and premarital sexual (p=0.007; r=0.100) and aggressive behavior among adolescents (p=<0.001;r=0.156). parental interaction has an association on the adolescent’s behavior, especially in terms of premarital sexual and aggressive behavior. conclusion: nurses need to provide education not only to parents, but also for adolescents to prevent premarital sexual and aggressive behaviors among adolescents in any media that available. article history received: october 24, 2020 accepted: june 03, 2021 keywords health risk; parent-child relation; sexual behavior; aggression; adolescent contact ilya krisnana  ilya-k@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: krisnana, i., rachmawati, p. d., kurnia, i., d., & rummy, n. s. j. (2021). parental interactions associated with adolescent health risk behavior: premarital sexual and aggressive behavior. jurnal ners, 16(2). 106-110. doi:http://dx.doi.org/10.20473/jn.v16i1.22785 introduction chemotherapy risky behaviors in adolescents greatly affect their health (achhab et al., 2016). the behaviors include fighting, drug use and extortion. one of the behaviors that is less often in the spotlight is sexual behavior when dating (catur, 2015). it is also supported that the factors that influence adolescent sexual behavior include the adolescent’s parental relationships, negative peer pressure, an understanding of religion (religiosity) and exposure to pornographic media (arista, 2015; murdiningsih, rosnani, & arifin, 2016; yusuf, bahiyah, nihayati, & wiyono, 2017). parental interactions have been shown to be associated with risky behavior in adolescents (kurnia et al., 2019)(krisnana, diyan, yuni, arief, & dwi, 2019). the impact of aggressive behavior can be seen from the impact on both the perpetrators and victims. the impact of the perpetrators is that they will be shunned and not liked by others. the impact of the victim includes physical and psychological pain and losses due to aggressive behavior (restu & yusri, 2013). based on a reproductive health survey conducted by the national family planning board (bkkbn) 2017, 67% of adolescents were dating, 18,6% boys had kissed each other and 5% of adolescent (male) teens who were dating had had sexual intercourse before marriage(bkkbn, 2017). based on the data from who (2018) stated that nearly one in three adolescent girls aged 15 – 19 years (84 million) has been a victim of emotional, physical and/or sexual violence perpetrated by their husband or partner (who, 2018). based on the data from the national https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 107 commission on child protection 2016, there were 41 brawls between students, while childhood violence (bullies) totaled 93 cases (komisi perlindungan anak, 2016). child relationship with family becomes an important factor in the prevention and management of juvenile delinquency (doly purba, 2014). the parent-child interactions are a mutually beneficial process because the parental behavior will affect the child and vice versa. the child will affect the parents so then both experience change(adah & arisna, 2015). various theories of nursing have been introduced by nursing experts, one of which is the theory of kathry e. barnard. this theory discusses the interaction between children and their parents. the reason for taking this theory into account is because it is in accordance with the problems that are to be explored, namely the interaction between the parents and the evidence of pre-marital sexual and aggressive behavior in adolescents. the focus of barnard's theory is to view the parents and children as an interactive system (alligood, 2014). the parent-child system is influenced by the individual characteristics of each member involved and the individual characteristics are modified to meet the needs of the interactive system in turn. the identification of the parent interactions as it relates to the premarital sexual behavior of adolescents is very important. this is because indonesia is a country that still adheres to norms of eastern behavior and customs. there is still only a small amount of research that explains the relationship between parental interactions, aggressive behavior and premarital sexual behavior in adolescents. the researchers are interested in conducting an analytical study of the relationship between parental interactions, aggressive behavior and premarital sexual behavior in adolescents. study on parental interaction with premarital sexual behavior and aggressive behavior in adolescents on the island of java has not been carried out. therefore, the purpose of this study is to analyze the relationship between parental interactions with pre-marital sexual behavior and aggressive behavior among adolescents on the java island. materials and methods the design in this study was cross-sectional. this research was conducted in one time data collection on the subject. the population of this study consisted of 13 19 year old adolescents attending junior and senior high school in indonesia, particularly in java island. the inclusion criteria in this study were 1) adolescents living in java, aged 13-19 years old, 2) adolescents who can access google forms. the determination of the sample size in this study was done using the gpower 3.1.9.2 application and statistical test correlations: two dependent pearson r's (common index). the results of the calculation using power analysis obtained 744 samples as the ideal size. sampling based on quota sampling according to the results of the sample size formula. the independent variable was parent interaction and the dependent variable was pre-marital sexual behavior and aggressive behavior. the researcher made an online questionnaire using google forms https://goo.gl/forms/49lv8trn2d3qzfcs1. the form contained the informed consent sheet, the respondent’s demographic data, the pachiq-r questionnaire, the premarital sexual behavior questionnaire and the aggressive behavior questionnaire. the questionnaires were distributed through social media such as line, whatsapp, facebook and instagram to be filled in by the respondents on 3 months period (septembernovember 2017). the respondents fill out the informed consent form first. after agreeing, the respondents filled in the biodata and pachiq-r questionnaire, in addition to the premarital sexual behavior questionnaire and the aggressive behavior questionnaire that was used in the google form. the pachiq-r questionnaire (the parent-child interaction questionnaire-revised) was made by lange (2002) and it was filled in by the adolescents(lange, evers, jensen, & dolan, 2002). the pachiq-r questionnaire was translated from english into indonesian and it was tested for validity and reliability (krisnana et al., 2019). all of the items in the questionnaire had good validity scores. the reliability testing had a cronbach’s alpha score = .854. the questionnaire was divided into 2 measurements, namely the measurement of the interactions of the parent and the measurement of the interactions of the adolescent. the adolescent version had 25 questions. the 2 subscales were conflict resolution (certain behaviors) and acceptance (certain feelings). there were both positive and negative questions in the pachiq-r questionnaire: (6, 8, 9, 11, 14, 16, 17, 18, 19, 20, 21, 23, 24, and 25) and (1, 2, 3, 4, 5, 7, 10, 12, 13, 15, and 22) respectively. pachiq-r used five response categories: “never”, “hardly ever”, “sometimes”, “almost always”, and “always”. the higher the score, the higher the level of interaction between the adolescents and their parents. the questionnaire was completed by those with the means who had understood the instructions for filling it in. meanwhile, the dependent variable data is in the form of descriptive data, namely the percentage of adolescents who did and did not engage in premarital sexual behavior and aggressive behavior. the researcher gave the participants a cellphone number that they could be contacted on if there were questions related to the questionnaire. the completion of the questionnaire took approximately 20 minutes. for the completed questionnaire, the researcher checked google forms directly to find out the number of questionnaires that had been filled in. once they met the target, the researcher turned off the link that allowed access to the google form. the data was analyzed using spearman rank correlation with a level of significance of α=0.05. this study has passed the review and certification of the ethical agreement with no. 566 kepk issued https://goo.gl/forms/49lv8trn2d3qzfcs1 i. krisnana et al. 108 | pissn: 1858-3598  eissn: 2502-5791 by the faculty of nursing university of airlangga. this study follow the princip of ethic are anonymity, justice, informed concent, confidentially, beneficience. results the results show that the majority of respondents were their mid adolescents, in the range of 15 17 years old (as many as 374 people; 50.2%). the majority of respondents (606) had a high school level of education (81.3%). the majority of the respondents' parent's education was high school for the father and mother, totaling 328 people (44.1%) and 314 people (42.2%) respectively. the majority of the respondents resided with their parents (672 people; 90.3%). most of the respondents used motorbikes as their medium of transportation to get to school (as many as 462 people; 62.1%). the majority of respondents were given pocket money by their parents, totaling as much as < 50,000 idr (as many as 626 people; 84.1%) (table 1). the parent interactions with the adolescents had a minimum score of 55. this score indicates that there were no adolescents who had never interacted with their parents. the maximum score was 121. this score shows that none of the adolescents had a perfect score. the mean value was 95 which means that the adolescent interactions were in the range of ‘sometimes’ and ‘almost always’ (table 2). most of the adolescents had never engaged in premarital sexual behavior (96.1%) and they had not engaged in aggressive behavior either (73.1%). the parent interactions with the adolescents consist of a very weak positive relationship. these results indicate that the higher the level of interactions, the higher the tendency of the adolescents to not engage in premarital sexual behavior (p = .007; r = .100) and aggressive behavior (p = <. 001; r = .156) (table 3). discussion table the results showed that there was a relationship between parental interactions with premarital sexual behavior and aggressive behavior in adolescents. interaction refers to contact and communication which is interpreted as the mutual influence on various aspects of a shared life(lange, evers, jansen, & dolan, 2002). there were 2 subscales used to measure the interaction between parents and adolescents, namely conflict resolution and acceptance. for the conflict resolution subscale, most adolescents call their parents directly by their names. for the acceptance subscale, the acceptance of a small proportion of teenagers is related to always being told by their parents to do everything. good family interactions will provide happiness in the family which can provide protection various problems and minimize the occurrence of negative things in the children(adah & arisna, 2015). adolescents, while developing, need love, attention and a sense of security from their parents(saputri, 2014). this is consistent with the research conducted by(rogi, 2015) where the results showed that juvenile delinquency occurred due to the lack of intense family communication where the power related t the control and guidance of the parents towards adolescent behavior was very limited. adolescence is a period of rapid physical, cognitive, emotional and social maturity in both males and females(wong, hockenberry, wilson, winkelstein, & schwartz, 2009). adolescents who actively communicate with their parents have risky sexual behavior that is in the mild category. the respondents who passively communicate with their parents have risky sexual behavior in the severe table 1. demographic characteristics of the adolescents (n=744) characteristics n % sex boys girls 391 353 52,6 47.4 ages early adolescent mid-adolescent late adolescent 105 374 265 14.1 50.3 35.6 education junior high school senior high school 138 606 18.5 81.5 father’s education bachelor diploma senior high school junior high school elementary school 141 37 328 109 129 19.0 5.0 44.1 14.7 17.3 mother’s education bachelor diploma senior high school junior high school elementary school uneducated 110 42 314 125 152 1 14.8 5.6 42.2 16.8 20.4 0.1 stay at home with parents grandparents other family boarding house 672 25 7 40 90.3 3.4 0.9 5.4 transportation motorcycle public transportation delivered bicycle 462 95 180 7 62.1 12.8 24.2 0.9 pocket money per day < 50,000 idr (3 usd) > 50,000 idr (3 usd) 626 118 84.1 15.9 table 2. correlation between premarital sexual and aggressive behaviors with parent interaction in adolescents (n=744) variables minmax mean sd p r parent interaction 55121 95.4 10.9 premarital sexual behavior 1-2 1.96 0.19 .007 .100 aggressive behavior 1-2 1.73 0.44 <.001 .156 jurnal ners http://e-journal.unair.ac.id/jners | 109 category (sekarrini, 2012). the research conducted by(gustina, 2017) showed the same result, that there is a relationship between parental communication and sexual risk behavior. poor communication between parents and adolescents results in the adolescents engaging in risky sexual behavior. interactions between the teenagers and their parents can delay and even reduce the level of sexual intercourse behavior in adolescents(hidayah & maryatun, 2013). the impact of free sexual behavior is that it puts the adolescents at risk of developing stds, human immunodeficiency virus (hiv) and acquired immune deficiency syndrome (aids). the risk of unplanned pregnancy can lead to the action of abortion which can result in death(arista, 2015). some of the factors that can cause the teenagers to behave freely include puberty, poor communication with their parents and friends, other social factors and media exposure(sekarrini, 2012). adolescent health risk behavior includes casual sex, brawling and alcoholism(hartono & gianawati, 2013). children from harmonious families have more of a stronghold when it comes to the prevention of aggressive behavior(gómez-ortiz, romera, & ortega-ruiz, 2016). the interactions in a harmonious family can have a positive influence on adolescents. . physical punishment and strict disciplinary practices on part of the parents will result in negative impacts, one of which is the emergence of aggressive behavior in the children(hidayah & maryatun, 2013). the level of parental interaction related to adolescent health risk behavior includes free sex and aggressive behavior. efforts to minimize the increase in adolescent health risk behavior can be applied by increasing the understanding of the parents about the importance of maintaining open communication and interactions with adolescents. based on the results of this study showed that parental interaction has a relationship with premarital sex behavior and violent behavior in adolescents. the school and the government need to provide education and empowerment for parents so that they can monitor adolescents in order to prevent health risk behaviors. the limitation of this study was that the researchers could not directly observe the process of the questionnaires being filled out by the adolescents via a google form. conclusion parental interaction has an impact on the adolescent’s behavior, especially in terms of premarital sexual and aggressive behavior. nurses need to provide education not only to parents, but also to teenagers to prevent premarital sexual and aggressive behaviors among adolescents in any media that available. for futher study need to explore the parents perspective of premarital sexual and aggressive behavior of adolescents. acknowledgment we would like to say thank you to the directorate of research and community service, deputy for strengthening research and development of the ministry of research and technology/ national agency for research and innovation for funding this study. references achhab, y. el, ammari, a. el, kazdouh, h. el, najdi, a., berraho, m., tachfouti, n., … nejjari, c. (2016). health risk behaviours amongst school adolescents : protocol for a mixed methods study. bmc public health, 16(1209), 4–9. https://doi.org/10.1186/s12889-016-3873-4 adah, l., & arisna, d. (2015). effects of parent-child interaction and family decision making on juvenile delinquency. institut pertanian bogor. alligood, m. r. (2014). nursing theorists and their work eight edition (eight). united states of america: elsevier inc. arista, d. (2015). factors associated with risk sexual behavior among adolescents in jambi senior high school state 1 in 2015. scientia journal, 4(3), 255– 264. bkkbn. (2017). survei kependudukan, keluarga berencana, kesehatan reproduksi remaja dan pembangunan keluarga di kalangan remaja indonesia. jakarta. catur, t. (2015). hubungan antara komunikasi orang tua-remaja tentang seksualitas dengan perilaku seksual remaja yang telah bekerja di pekalongan. universitas kristen stya wacana. doly purba, a. (2014). dampak kenakalan remaja dalam perspektif kriminologi di kota medan. jurnal mahupiki, 2(1). gómez-ortiz, o., romera, e. m., & ortega-ruiz, r. (2016). parenting styles and bullying. the mediating role of parental psychological aggression and physical punishment. child abuse & neglect, 51, 132–143. https://doi.org/10.1016/j.chiabu.2015.10.025 gustina, e. (2017). komunikasi orangtua-remaja dan pendidikan orangtua dengan perilaku seksual berisiko pada remaja. unnes journal of public health, 6(2). hartono, r., & gianawati, n. (2013). the factors that causes teenagers behave deviant ). artikel ilmiah hasil penelitian mahasiswa. hidayah, n., & maryatun. (2013). hubungan antara pola asuh orang tua dengan perilaku seksual pranikah pada remaja di smk batik 1 surakarta. gaster, 10(2), 53–61. komisi perlindungan anak. (2016). bank data. retrieved from http://www.kpai.go.id/ i. krisnana et al. 110 | pissn: 1858-3598  eissn: 2502-5791 krisnana, i., diyan, p., yuni, r., arief, s., & dwi, i. (2019). adolescent characteristics and parenting style as the determinant factors of bullying in indonesia : a cross-sectional study. international journal of adolesecent medicine and health, 1–9. https://doi.org/10.1515/ijamh-2019-0019 kurnia, i. d., krisnana, i., rachmawati, p. d., kristiawati, ., arief, y. s., budiarto, h., & j.r, m. s. (2019). the increased interaction of parents can prevent smoking behavior and alcohol consumption of adolescents in indonesia. in proceedings ofthe 9th international nursing conference (inc 2018) (pp. 274–279). scitepress – science and technology publications. https://doi.org/10.5220/0008323802740279 lange, a., evers, a., jansen, h., & dolan, c. (2002). the parent-child interaction questionnaire-revised. family process, 41(4), 709–722. retrieved from http://www.alfredlange.nl/site/publications/pdf /fp2002.pdf lange, a., evers, a., jensen, h., & dolan, c. (2002). pachiq-r (the parent-child interaction questionnaire-revised). family process, 41(4), 709–722. murdiningsih, m., rosnani, r., & arifin, h. (2016). corelation between pornographic media and influence of peers with unsafe sexual behavior in adolescent of south sumatera. jurnal ners, 11(2), 210. https://doi.org/10.20473/jn.v11i22016.210-212 restu, y., & yusri. (2013). studi tentang perilaku agresif siswa di sekolah. jurnal ilmiah konseling, 2(1), 243–249. rogi, b. a. (2015). peranan komunikasi keluarga dalam menanggulangi kenakalan remaja di kelurahan tataaran 1 kecamatan tondano selatan. jurnal acta diurna, iv(4). saputri, e. . (2014). the correlation between social interaction and family harmony with the aggressiveness of the tenth grade students of smk n 1. jurnal bk unesa, 4(2), 375–382. sekarrini. (2012). faktor-faktor yang berhubungan dengan perilaku reksual remaja di smk kesehatan di kabupaten bogor tahun 2011. skripsi. depok: fakultas kesehatan masyarakat ui. who. (2018). adolescents: health risks and solutions. retrieved march 21, 2020, from http://www.who.int/news-room/factsheets/detail/adolescents-health-risks-andsolutions wong, d. l., hockenberry, m., wilson, d., winkelstein, m. l., & schwartz, p. (2009). buku ajar keperawatan pediatrik (6 volume 2). jakarta: egc. yusuf, a., bahiyah, k., nihayati, h., & wiyono, a. (2017). hubungan pola asuh orang tua dan lingkungan sosial dengan perilaku seksual remaja usia 14–21 tahun di lingkungan lokalisasi. jurnal ners (surabaya), 2(1), 14–17. https://doi.org/10.20473/jn.v2i1.4951 peran asah (3a) pengasuh (ilya krisnana, dkk) 240 peran asah (3a) pengasuh dengan perkembangan bahasa anak usia toddler di taman penitipan anak (role of care giver stimulation on toddler’s language development in day care) ilya krisnana, praba diyan rachmawati, mar’atus sholihah fakultas keperawatan universitas airlangga kampus c unair jalan mulyorejo surabaya 60115 email: ilyakrisnana28@gmail.com abstrak pendahuluan: pengasuh di tpa memegang peranan penting dalam mengasah seluruh aspek perkembangan anak. penelitian ini bertujuan untuk menganalisis hubungan peran pengasuh dalam pemberian asah dengan perkembangan bahasa di 3 taman penitipan anak (tpa) di surabaya. metode: desain penelitian ini menggunakan deskriptif korelasi dengan pendekatan cross sectional. populasi dalam penelitian ini adalah pengasuh dan anak di tpa dengan teknik purposive sampling. 16 pengasuh dan 33 anak menjadi responden yang ditentukan berdasarkan kriteria inklusi dan eksklusi. variabel dependen yang diukur adalah pemberian asah pengasuh. variabel independen yang diukur adalah perkembangan bahasa anak. pengumpulan data dilakukan dengan menggunakan observasi responden pengasuh dan denver ii pada responden anak. data dianalisis dengan menggunakan analisis korelasi non parametrik (spearman rho) dengan nilai signifikansi α= 0,05. hasil: hasil penelitian menunjukkan bahwa pemberian asah pengasuh berhubungan dengan perkembangan bahasa anak, nilai p=0,002 dan r=0,0510. hal ini menunjukkan adanya hubungan yang cukup kuat dan signifikan antara pemberian asah pengasuh dengan perkembangan bahasa anak. diskusi: hubungan peran pengasuh dalam pemberian asah dengan perkembangan bahasa anak di tempat penitipan anak signifikan dan berhubungan cukup kuat. penilti selanjutnya diharapkan dapat mengidentifikasi faktor genetik, dan faktor lingkungan lainnya. kata kunci: perkembangan bahasa, asah, taman penitipan anak, pengasuh, toddler abstract introduction: role of caregiver in the day care is really important in every aspect of children development, especially language development. this study aimed to analyze the relationship between role of caregiver in giving stimulation and language development toddler in 3 day care in surabaya. methods: this study was using cross-sectional study. the population were children and caregivers in day care with purposive sampling. 16 caregivers and 33 children as respondents, taken according to inclusion and exclusion criteria. the dependent variable was role of cargiver in giving stimulation. the independent variable was the toddler language development. data collection for caregivers stimulation through observation sheets and for language development children through denver ii, and were analyzed by using non-parametric correlation analysis (spearman rho) with significance value α=0.05. result: the result showed that caregiver in giving stimulation has correlate with language development toddler (p-value = 0.002, r = 0.0510). discussion: it can be concluded that correlation between role of cargiver in giving stimulation with language development toddler was significant and has strong enough correlation. further research need to identify more factors such as genetic factor and the other aspects of environmental factor. keywords: language development, stimulation, children day care center, caregiver, toddler pendahuluan peningkatan prosentase ibu bekerja diikuti dengan peningkatan jumlah anak yang dititipkan di tpa (kusumastuti 2013). pengasuh di tpa memegang peranan penting dalam proses tumbuh kembang anak terutama perkembangan bahasa (kemendikbud 2015). keterlambatan perkembangan bahasa pada anak dapat menyebabkan learning disabilities yang akan membuat anak mengalami masalah perilaku dan penyesuaian psikososial (wijaya 2015). prevalensi keterlambatan kemampuan berbahasa dilihat pada anak usia dini menurut studi cochrane terakhir, pada usia 2-4,5 tahun adalah 5-8% mengalami keterlambatan bicara dan 2,3-19% mengalami keterlambatan verbal (soetjiningsih 2013). (hartanto 2011) menerangkan selama tahun 2007 di poliklinik tumbuh kembang anak rs dr. kariadi semarang didapatkan 22,9% dari 436 kunjungan baru, datang dengan keluhan terlambat bicara, 13 (2,98%) diantaranya didapatkan gangguan perkembngan bahasa. berdasarkan hasil survei dari 17 tpa di surabaya, terdapat 3 tpa yang belum mempunyai kurikulum pembelajaran dan belum rutin melakukan stimulasi dalam bentuk bermain sambil belajar. hasil pengukuran perkembangan bahasa menggunakan denver development screening test (ddst) menunjukkan 25% termasuk kategori suspek keterlambatan perkembangan bahasa dari 20 anak di ketiga tpa. mailto:ilyakrisnana28@gmail.com jurnal ners vol. 11 no.2 oktober 2016: 240-245 241 proses pembelajaran perkembangan bahasa menurut kaum behavioris diperoleh melalui rangsangan dari lingkungan. menurut salah satu tokoh behavioris (thorndike 1913) belajar merupakan peristiwa terbentuknya asosiasi antara peristiwa-peristiwa yang disebut stimulus (s) dengan respon (r) yang diberikan atas stimulus tersebut. stimulus yang didapatkan seorang anak di tempat penitipan anak dari pengasuh berupa asah yang kemudian anak memberikan respon berupa perkembangan anak. proses asosiasi yang terjadi antara stimulus dan respon menurut thorndike akan mengikuti law of readiness, law of excercise, dan law of effect. ketiga hukum tersebut membuat stimulasi rutin meningkatkan respon perkembangan anak termasuk perkembangan bahasa (thorndike 1913). berdasarkan data, teori, dan penelitian sebelumnya, peneliti memandang perlu untuk melakukan penelitian tentang hubungan peran pengasuh dalam pemberian asah dengan perkembangan bahasa anak usia todler di tpa. metode desain penelitian ini menggunakan deskriptif korelasi dengan pendekatan cross sectional. dilaksanakan di 3 tpa surabaya yakni tpa masha, cemerlang, dharma wanita. populasi dalam penelitian ini adalah pengasuh dan anak di tpa. 16 pengasuh dan 33 anak menjadi responden yang ditentukan berdasarkan kriteria inklusi dan eksklusi dengan teknik purposive sampling. variabel dependen yang diukur adalah pemberian asah pengasuh. variabel independen yang diukur adalah perkembangan bahasa anak. pengumpulan data dilakukan dengan menggunakan observasi responden pengasuh dan denver ii pada responden anak. data dianalisis dengan menggunakan analisis korelasi non parametrik (spearman rho) dengan nilai signifikansi α= 0,05. hasil tabel 1 menunjukkan bahwa sebagian besar (37,6%) responden pengasuh di tpa memenuhi kebutuhan asah dalam kategori kurang, dan mayoritas (63,6%) responden anak di tpa memiliki perkembangan bahasa dalam kategori normal. tabel 2 menunjukkan bahwa ada hubungan antara peran pengasuh dalam pemberian asah di tempat penitipan anak dengan perkembangan bahasa anak usia todler. dengan menggunakan uji statistik spearmen’s rho (r) dengan tingkat kemaknaan α < 0,05 didapatkan hasil korelasi r = 0,510 dan nilai p = 0,002. nilai p tersebut berarti h1 diterima dan h0 ditolak. hasil statistik tersebut menunjukan hubungan yang kuat antara pemberian asah pengasuh dengan perkembangan bahasa anak pada usia todler. tabel 1 pemberian asah pengasuh dan perkembangan bahasa anak di tpa surabaya, juni 2016 variabel yang diukur kategori f % pemberian asah baik 5 31,2 cukup 5 31,2 kurang 6 37,6 total 16 100 perkembangan bahasa normal 21 63,6 suspect 11 33,3 untestable 1 3,1 total 33 100 tabel 2 peran pengasuh dalam pemberian asah dengan perkembangan bahasa anak usia todler peran pengasuh dalam pemberian asah perkembangan bahasa total untestable suspect normal f % f % f % f % kurang 1 3 7 21,2 4 12,1 12 36,4 cukup 0 0 3 9,1 7 21,2 10 30,3 baik 0 0 1 3 10 30,3 11 33,3 total 1 3 11 33,3 21 63,6 33 100 p = 0,002 koefisien korelasi spearman’s rho = 0,510 peran asah (3a) pengasuh (ilya krisnana, dkk) 242 pembahasan berdasarkan hasil penelitian, responden pengasuh dalam memberikan asah yang termasuk kategori kurang memiliki proporsi paling besar, kemudian yang kategori baik dan cukup memiliki proporsi yang sama besar. pembarian asah pengasuh dalam kategori baik karena pengasuh memberikan asah dengan memberi contoh, pembiasaan, latihan, dan kompetisi secara rutin. menurut kemendikbud (2015) dalam juknis tpa, pengasuh dalam memberikan asah artinya pengasuh memberi dukungan kepada anak untuk dapat belajar melalui bermain yang bermakna, menarik, dan merangsang imajinasi, kreativitas anak untuk melakukan, mengekplorasi, memanipulasi, dan menemukan inovasi sesuai dengan minat dan gaya belajar anak. pengasuh yang memberikan asah dalam kategori baik, dapat menciptakan beberapa komunikasi ketika bermain menjadi bentuk asah untuk perkembangan bahasa. bentuk asah yang mayoritas dilakukan oleh semua pengasuh adalah mengasah dengan membiasakan menyebut nama anak ketika bermain dan menyebut nama permainan/ barang saat memberikan ke anak atau meminta anak mengambilnya. thorndike (1913) menyebutkan dalam law of excercise bahwa hubungan stimulus dan respon akan bertambah erat jika sering digunakan atau dilatih dan akan lenyap sama sekali jika jarang digunakan. bentuk pembiasaan pengasuh sebagai salah satu upaya pemberian asah agar respon perkembangan anak berjalan dengan normal. berdasarkan hasil observasi selama penelitian, pengasuh dalam memberikan asah termasuk kategori cukup, karena pengasuh memberikan asah dengan memberi contoh, pembiasaan, dan latihan, tetapi tidak memberikan asah dengan kompetisi. fakta ini sesuai dengan pernyataan dari afin (2014) yang menyatakan bahwa memberikan asah melalui kompetisi dilakukan setelah anak cukup mampu menguasai satu bidang yang bisa diandalkan maka bisa diikutkan dalam kompetisi yang ada di sekitar. penyebab pemberian asah pengasuh termasuk kategori cukup adalah beberapa pengasuh beranggapan bahwa anak usia todler belum siap untuk diajak berkompetisi antar terman. berdasarkan hasil peneilitian pemberian asah oleh pengasuh termasuk dalam kategori kurang karena pengasuh hanya memberikan asah dengan pembiasaan. mayoritas pengasuh yang memberikan asah dalam kategori kurang termasuk kategori usia dewasa muda. supartini (2014) menjelaskan bahwa rentang usia yang tidak terlalu tua atau terlalu muda adalah baik untuk menjalankan peran pengasuhan karena memiliki kekuatan fisik dan psikososial, sehingga dapat menjalankan peran pengasuhan secara optimal. usia pengasuh mempengaruhi kesiapan mereka untuk menjadi pengasuh dan menjalankan tugas sebagai pengganti orang tua sementara. berdasarkan data demografi yang diperoleh, mayoritas orang tua responden anak juga pada masa dewasa muda. pengasuh dan orang tua yang terlalu muda cenderung belum memiliki kesiapan untuk mendidik dan mengarahkan pendidikan anak, mereka beberapa kali tidak menghiraukan anak dan lebih memilih untuk bersenang-senang sendiri karena masih ingin menikmati masa muda seperti bermain hp saat sedang mengasuh anak. berdasarkan hasil penelitian menunjukan bahwa mayoritas responden anak memiliki perkembangan bahasa normal. anak yang mengalami suspect keterlambatan perkembangan bahasa dan untestable hanya sebagian kecil. mayoritas anak dengan perkembangan bahasa normal dapat melewati satu atau lebih komponen 25-75% menyentuh garis. (sulistyawati 2014) menjelaskan bahwa jika anak dapat melewati komponen 25-75% maka artinya anak dapat melakukan komponen yang baru bisa dilakukan oleh 25-75% anak. perkembangan bahasa anak yang termasuk kategori normal terlihat berbeda dari anak yang suspect keterlambatan perkembangan bahasa. perbedaan terlihat saat dilakukan tes pada setiap komponen, anak dapat menjawab lebih cepat dan tepat. anak dengan perkembangan bahasa normal juga tetap bisa melakukan komponen yang anak-anak lain sudah tidak bisa, bahkan terdapat anak dengan interpretasi skor advance karena anak dapat lulus pada komponen yang terletak di kanan garis. mayoritas anak dengan suspect keterlambatan perkembangan bahasa gagal melewati komponen di sebelah kiri garis. sulistyawati (2014) menjelaskan bahwa bila anak gagal atau menolak melakukan komponen tes yang terletak berada di sebelah kiri garis umur, maka termasuk mengalami delayed, karena 90 persen anak pada sampel standar telah dapat melewati komponen tersebut. anak yang mengalami suspect keterlambatan perkembangan bahasa selain mengalami delayed juga memiliki interpretasi skor caution, sehingga perlu dilakukan uji ulang dalam 1-2 pekan untuk menghilangkan faktor sesaat seperti rasa takut, jurnal ners vol. 11 no.2 oktober 2016: 240-245 243 keadaan sakit, dan kelelahan pada waktu skrining perkembangan. hasil penelitian menunjukkan bahwa terdapat anak dengan hasil penilaian perkembangan bahasa yang untestable. pada responden anak yang mendapatkan intrepretasi hasil untestable, terdapat satu komponen delay dan tiga caution karena anak menolak melakukan bukan karena anak gagal melakukan. (sulistyawati 2014) menyebutkan bahwa langkah penilaian perkembangan harus diawali dengan pemeriksa membangun hubungan yang baik dengan anak dan pengasuh karena saat telah terbina hubungan saling percaya maka akan meminimalisir terjadi penolakan saat dilakukan tes perkembangan. penyebab hasil penilaian perkembangan bahasa yang untestable menunjukkan kesesuian dengan penjelasan sulistywati. waktu penelitian yang terbatas membuat tidak semua anak dengan mudah menerima kehadiran peneliti. perilaku anak dalam beradaptasi dengan orang baru tidak dapat dianggap sama karena berdasarkan pengalaman saat proses penelitian meskipun peneliti telah berusaha membangun hubungan dengan semua anak sejak studi pendahuluan, terdapat satu responden anak yang hasil penilaian perkembangan bahasanya tetap untestable dari sejak studi pendahuluan sampai tes kembali saat penelitian. berdasarkan hasil penelitian, diketahui tingkat korelasi yang cukup artinya hubungan antara kedua variabel cukup kuat dan menunjukkan arah yang searah yaitu jika pemberian asah lebih baik maka perkembangan bahasa akan normal. nilai signifikansi yang cukup signifikan bermakna hubungan antara kedua variabel signifikan. pernyataan diatas menunjukkan bahwa hubungan pemberian asah pengasuh dengan perkembangan bahasa anak cukup kuat, signifikan dan searah. berdasarkan teori(thorndike 1913) bahwa perkembangan bahasa dikendalikan oleh rangsangan dari lingkungan, karena belajar merupakan peristiwa terbentuknya asosiasi antar stimulus dengan respon yang diberikan atas stimulus tersebut. maka dari itu, stimulus yang didapatkan seorang anak di tempat penitipan anak dari pengasuh berupa asah yang baik direspon oleh anak dengan perkembangan yang normal. hasil penelitian ini selaras dengan penelitian (maria 2009) yang menunjukkan terdapat hubungan antara asah dengan perkembangan karena responden anak yang terasah secara terarah dan penuh kasih sayang akan dapat mengendalikan dan mengkoordinasi otot-otot yang melibatkan perasaan emosi dan pikiran sehingga perkembangan bahasa anak berjalan dengan optimal. mayoritas responden anak yang memiliki perkembangan bahasa normal lebih sering diasuh oleh pengasuh dengan pemberian asah dalam kategori baik dan cukup. hasil penelitian bahwa perkembangan bahasa anak yang diasuh oleh pengasuh yang memberikan asah dengan baik termasuk kategori normal sesuai dengan pernyataan (soetjiningsih 2013) bahwa memenuhi kebutuhan asah merupakan cikal bakal dalam proses belajar (pendidikan dan pelatihan) pada anak termasuk belajar memaksimalkan perkembangan bahasa. perkembangan bahasa anak periode todler yang harus mencapai banyak kemampuan dibandingkan periode lain, membuat pemberian asah diperlukan, karena dengan pengasuh yang mempunyai durasi cukup lama berinteraksi dengan anak, mengasah kemampuan secara rutin maka perkembangan bahasa anak tidak akan mengalami keterlambatan. berdasarkan hasil peneilitian pemberian asah oleh pengasuh dalam kategori kurang menunjukkan hasil skrining perkembangan bahasa mayoritas suspect keterlambatan perkembangan bahasa. hasil penelitian ini selaras dengan penelitian zukhrifatin tahun 2006 bahwa anak yang mendapat stimulasi kurang, mayoritas anak mengalami gangguan perkembangan. hasil tersebut menunjukkan peningkatan kejadian penyimpangan perkembangan pada anak yang mendapat stimulasi kurang. disisi lain, fakta di ketiga tpa menunjukkan bahwa meskipun pengasuh pemberian asah dalam kategori kurang, tidak selalu hasil skrining perkembangan bahasa menunjukkan dicurigai keterlambatan tetapi juga ada yang normal. fakta ini menunjukkan ketidaksesuaian dengan penjelasan yang dikemukakan oleh (soetjiningsih 2013) bahwa anak yang mendapat stimulasi kurang dan tidak teratur akan mengalami keterlambatan perkembangan termasuk perkembangan bahasa. hal ini dipengaruhi oleh beberapa faktor lain seperti kesehatan anak, peran orang tua di rumah dalam berinteraksi dengan anak. berdasarkan data demografi yang didapatkan, mayoritas orang tua responden anak memiliki pendidikan terkahir s1 dan pekerjaan swasta/ pegawai negeri sipil. (kliegman 2012) menjelaskan orang tua dengan tingkat pendidikan tinggi akan memiliki pengetahuan yang lebih luas tentang perkembangan anak, seperti mengetahui cara bertanya dan memberi perintah pada anak yang tepat sehingga perkembangan bahasa anak sesuai tahap perkembangan. orang tua dengan peran asah (3a) pengasuh (ilya krisnana, dkk) 244 pengetahuan yang luas lebih terlibat aktif dalam setiap upaya pendidikan anak, mengamati segala sesuatu dengan berorientasi pada masalah anak, dan selalu menyediakan waktu untuk anak, karena mereka mengetahui kualitas interkasi orang tua dan anak sangat menentukan perkembangan anak. (kemenkes 2013) menyebutkan bahwa salah satu faktor yang mempengaruhi perkembangan anak adalah pekerjaan orang tua, karena menentukan tingkat sosio-ekonomi yang dimiliki. anak dari orang tua yang memiliki penghasilan diatas rata-rata akan memiliki lingkungan yang baik dan mendapatkan pemeriksaan perkembangan secara reguler sehingga jika ada gangguan perkembangan dapat dideteksi secara dini. mayoritas responden anak yang perkembangan bahasa normal menerima pemberian asah baik karena kegiatan pemberian asah dengan contoh, pembiasaan, latihan dan kompetisi diberikan secara rutin. mayoritas anak yang dicurigai mengalami keterlambatan perkembangan bahasa menerima pemberian asah yang kurang karena kegiatan mengasah dengan memberi contoh, kompetisi dan latihan tidak semua dilakukan. hasil penilitian ini selaras dengan teori (thorndike 1913) yang menyebutkan bahwa proses asosiasi dalam stimulus dan respon memenuhi ketiga hukum yakni law of readiness, law of excercise, dan law of effect, dengan “state of affairs” yang memuaskan, agar hubungan menjadi lebih kuat. pemberian asah yang baik akan menyebakan perkembangan bahasa normal karena ketiga hukum terpenuhi. law of readiness terpenuhi dari bentuk kegiatan mengasah dengan memberi contoh. pengasuh yang memberikan contoh dapat membuat anak memiliki “kecenderungan bertindak” menirukan pengasuh. law of excercise terpunuhi dari bentuk kegiatan mengasah dengan pembiasaan dan mengasah dengan latihan, karena hubungan antara asah dari pengasuh dan respon perkembangan bahasa akan semakin kuat jika sering dilatih dan digunakan. law of effect terpenuhi dari kegiatan mengasah dengan kompetisi karena dapat menimbulkan “state of affairs” berupa feedback yang menyenangkan atau menganggu. anak yang segera mengetahui hasil belajar dari pengasuh akan dapat meningkatkan motivasi anak dalam belajar. kedekatan hubungan antara variabel pemberian asah pengasuh dengan perkembangan bahasa termasuk cukup kuat karena nilai koofisien korelasi r=0,510. kedekatan yang cukup kuat menunjukkan pengasuh memang berperan terhadap terhadap perkembangan anak di tpa, tetapi orang tau maupun lingkungan keluarga juga sangat menentukan. fakta ini sesuai dengan pernyataan yusuf dalam (eka 2008) bahwa proses berinteraksi dan berkomunikasi dengan lingkungan keluarga terutama orang tua yang mengajar, melatih dan memberikan contoh berbahasa kepada anak menentukan perkembangan bahasa anak. hubungan yang sehat antara orang tua dan anak akan memfasilitasi perkembangan bahasa anak, sedangkan hubungan yang tidak sehat mengakibatkan anak mengalami kesulitan dalam perkembangan bahasa. simpulan dan saran simpulan penelitian ini menyimpulkan bahwa sebagian besar pemberian asah pengasuh dalam kategori kurang terutama pada kegiatan mengasah dengan kompetisi. mayoritas responden anak di tempat penitipan anak memiliki perkembangan bahasa dalam kategori normal. pemberian asah pengasuh mempengaruhi perkembangan bahasa anak di tempat penitipan anak. pemberian asah yang semakin baik akan menyebabkan hasil skrining perkembangan bahasa anak termasuk kategori normal. pemberian asah yang baik adalah pengasuh mengasah perkembangan bahasa dengan memberi contoh, pembiasaan, latihan dan kompetisi secara rutin dan optimal. saran perawat diharapkan dapat memberikan pengetahuan kepada pengasuh bahwa pemberian asah secara rutin dan optimal kepada anak dapat mencegah keterlambatan perkembangan bahasa anak. tempat penitipan anak sebaiknya membuat standar operasional prosedur pemberian asah kepada anak sesuai dengan tahap perkembangan bahasa. pengasuh diharapkan untuk lebih memperhatikan perkembangan anak dengan meningkatkan pemberian asah yang diberikan. peneliti selanjutnya diharapkan dapat melakukan p e n e l i t i a n me n ge n a i f a kt o r f a kt o r l a i n ya n g mempengaruhi perkembanan anak, misalnya factor genetik, lingkungan prenatal, dan faktor lingkungan postnatal yang lainnya. kepustakaan eka, w.h., 2008. hubungan pola asuh orang tua terhadap perkembangan bicara dan bahasa pada anak usia 2 tahun. jurnal kesehatan, 1(1). hartanto, f., 2011. pengaruh perkembangan bahasa terhadap perkembangan kognitif anak, semarang: sari pediatri. kemendikbud, 2015. nspk (norma, standar, prosedur, dan kriteria) petunjuk teknis penyelenggaraan taman penitipan anak, kemenkes, 2013. pedoman pelaksanaan: stimulasi, deteksi dan intervensi dini tumbu kembang jurnal ners vol. 11 no.2 oktober 2016: 240-245 245 anak ditingkat pelayanan kesehatan dasar, jakarta. kliegman, r.., 2012. ilmu kesehatan anak nelson 1st ed., jakarta: egc. kusumastuti, n.i., 2013. fenomena taman penitipan anak bagi perempuan yang bekerja. jurnal ilmiah pendidikan sosial antropologi, 3(2). maria, f.n., 2009. hubungan pola asah, asih, asuh dengan tumbuh kembang balita usia 1-3 tahun. universitas airlangga. soetjiningsih, 2013. tumbuh kembang anak, jakarta: egc. sulistyawati, a., 2014. deteksi tumbuh kembang anak, jakarta: salemba medika. thorndike, e.., 1913. the psychology of learning 2nd ed., new york: teachers college press. wijaya, s., 2015. efektivitas pelatihan identifikasi dini keterlambatan bicara pada anak usia pra sekolah untuk meningkatkan kompetensi pedagogik guru paud. in seminar nasional psikologi jilid i. surakarta: universitas muhammadiyah surakarta. 74 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.23285 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research potential loss among infant feeding options azniah syam1, musni musni2, andi nurzakiah amin3 and imelda iskandar4 1 college of health sciences general nani hasanuddin, indonesia 2 akademi kebidanan batari toja watampone, indonesia 3 universitas cendrawasih papua, indonesia 4akademi kebidanan yapma makassar, indonesia abstract introduction: the conceptual relationship between economics and breastfeeding is still mathematically invaluable, while the family's economic burden increases along with babies born. indicating potential loss when a family chooses other than breastmilk is a progressive way to manage campaign messages about exclusive breastmilk and prolonged breastfeeding. descriptive studies are needed to magnify all of these indicators and transform them into measuring instruments generalized to assess family expenditures related to infant feeding. methods: this study uses a quantitative descriptive design, questionnaire draft upon qualitative open questions containing all micro indicators impacted financially during the baby’s first year. data collection was carried out in makassar based on telephone surveys with 330 preliminary samples. after structural analysis and data reduction, the expenditure indicators were divided into medical and non-medical expenses. results: the study show there is a difference in the average amount of family expenses of those who provide formula milk compared to breastmilk. this outcome is 21.1 times higher in non-medical components and 2.5 times higher in the medical component. one of the highest contributions in medical expenses is the cost of a recurrent visit to a pediatrician due to a history of illness such as allergies, respiratory infections, and diarrhea. conclusion: this empirical fact stated the strong affirmation of how families should consider wisely to choose the best feeding pattern for babies aged 012 months. article history received: november 17, 2020 accepted: march 17, 2021 keywords economic loss; medical expenses; non-medical expenses; exclusive breastfeeding; formula feeding contact azniah syam  azniahsyam@gmail.com  college of health sciences general nani hasanuddin, indonesia cite this as: syam, a., musni, m., amin, a. n., & iskandar, i. (2021). potential loss among infant feeding options. jurnal ners, 16(1). 74-80. doi:http://dx.doi.org/10.20473/jn.v16i1.23285 introduction various factor influence the mother's decision to meet the nutritional needs of infants aged 0-12 month (brown et al., 2014a; ulak et al., 2012). despite the undeniable fact that breastmilk is the best choice (eidelman & schanler, 2012; kent, 2007) especially for ages 0-6 months (chowdhury et al., 2015), there are still many families who fail to fulfill this option (bascom & napolitano, 2016; cato et al., 2017; ogbo et al., 2017). termination of breastmilk encourages them to choose formula milk as a substitute. some of the factors that caused families to choose this option reported from various surveys were low milk production, breast milk did not come out on the first postpartum day, problems with nipples (pain, blisters, sores), breasts (swelling, mastitis), fatigue, work (brown et al., 2014b; dennis et al., 2014; olang et al., 2012; puapornpong et al., 2017). the reason for working is a trigger for the high use of formula milk (buccini et al., 2014; thomas-jackson et al., 2016). but many mothers who do not work choose formula milk due to several physiological problems in the nipples and breasts (puapornpong et al., 2017). this nipple problem and fatigue can be overcome with proper breastfeeding techniques by providing the best support system in the mother's environment, such as sharing the caregiver's duties in caring for children (aubel & alvarez, 2011; houghtaling et al., 2018), maintaining hormonal and mental balance to avoid https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 75 anxiety (akman et al., 2008; douglas & hiscock, 2010; nicklas et al., 2013; susiloretni et al., 2013; xu et al., 2014). sometimes there are reasons that the baby is not satisfied with breast milk, so that they cry too much and the mother becomes frustrated to calm them down (douglas & hiscock, 2010; richter & reck, 2013). again, this reason can be overcome by increasing the closeness of communication with the fetus during pregnancy through hypnobirthing and initiating early breastfeeding in the first hour of birth to stimulate suction and skin to skin contact (creedy et al., 2008; phillips-moore, 2012). although the campaign for milk is intense, especially in developing countries, formula milk companies are ever more creative in marketing their products (abrahams, 2012; who, 2011). they even target gaps in several national policies regulating breastfeeding for babies (better work indonesia, 2004; gupta et al., 2013). in indonesia, even though the policy on breastmilk already exists, the achievement rate of giving exclusive breastmilk is still far from the sdg 2030 target (national population and family planning board (bkkbn), statistics indonesia (bps), ministry of health (kemenkes), 2018). negative values seem to be normalized by formula milk producers through extraordinary advertisements, causing overestimation, such as completely nutritious food, smarter, stronger, happier babies and so on. although buying formula milk means more expense, parents think this choice is better quality. indications of over expenditure in milk purchasing not only have an impact on higher expenditure, but also have an economic impact in the medium and long term. world breastfeeding week 2018 reported that breastfeeding can prevent malnutrition in all forms, ensure food security even in times of crisis, and break the chain of poverty in the long term. despite the relatively high global initiation rate, only 40% of all infants under 6 months of age are exclusively breastfed and 45% continue to breastfeed until 24 months of age. in addition, there are large variations in state and country breastfeeding rates. increasing optimal breastfeeding can prevent more than 823,000 children and 20,000 maternal deaths each year. not breastfeeding is associated with lower intelligence and results in an estimated $ 302 billion in economic losses each year. however, this figure is just a number if there are no stressor indicators that provoke mothers and families being wiser in choosing formula feeding. therefore, it is necessary to explore what disadvantages are experienced by families based on their feeding choices for babies. materials and methods this research is a preliminary study, through a quantitative exploratory approach and aims to openly identify indicators related to all affected aspects of the choice of feeding patterns for infants aged 0-12 months. this research was carried out during the january-july 2019 period, in one of the primary healthcare areas in makassar city which has a moderate density level, various socio demography varieties, and the lowest achievement rate of exclusive breastfeeding in 2018. determination of research subjects using purposive sampling technique was as many as 330 mothers who were surveyed by telephone. all research subjects were selected based on criteria, having babies aged 0-12 months, willing to be contacted via mobile phone several times according to data collection needs, and willing to be visited at home as one aspect of verifying the validity of the data provided. the design of measuring instruments was in the form of a questionnaire with open questions from information about the mother's sociodemographic characteristics, the method of feeding the baby, the reasons for choosing this method, the daily consumption of formula milk products, the use of accompanying tools and materials such as bottled water, pacifiers, baby diapers to history of disease and hospitalization that the baby has had in the last three months. all semi-qualitative instruments will be coded and classified quantitatively so that they can be objectively calculated and analyzed. descriptive data analysis is entirely presented in the form of comparison tables between groups, and the final hypothesis of the study, namely infants fed formula milk has a much greater loss effect than exclusive breastfeeding, which was tested using the independent t test. results based on the survey data, after going through the data quantification, they were grouped into two major items, namely medical complaints and non-medical expenses related to the feeding patterns of infants. non-medical expenses are the accumulated increase in family spending including accessories for baby needs, and the financial needs of purchasing breastmilk replacement products. medical expenses in the form of health impacts arising from the choice of feeding include health problems experienced by the baby during the last three months. table 1 shows that, out of 330, mothers are generally in the reproductive age of 20-35 years, with almost a quarter of the percentage of married young people (<20 years). generally, mothers have primary to secondary education, the percentage of housewives is more than half of the subjects, with a small percentage of husbands who do not work. unemployment will aggravate the situation for families to meet the needs of newborns, with data on the percentage of income below 3 million more than half. most of them had more than two children, with babies under six months exceeding two thirds of the number of subjects; this means that the infants studied were still in the phase of exclusive breastfeeding. as much as 86.97% of families used disposable diapers, babies who had experienced illness and a. syam et al. 76 | pissn: 1858-3598  eissn: 2502-5791 outpatient care were 88.55%, hospitalization was 29.39% in the last one year. generally, families prefer service facilities from primary healthcare clinics, as many as 21.82% are participants of national insurance, 18.78% are beneficiaries, a small proportion (3.33%) have private insurance which is a facility from the workplace, and 9.67% of families do not have health insurance. this will be burdensome for the family's economic condition when there is an unpredictable risk of disease. table 2 shows the pattern of formula feeding with several related aspects. the use of formula milk with paper packaging was 84.8%. many of the reasons cited for choosing a particular brand of formula are because it is suitable for babies; most families who choose this diet prepare a special allocation budget. some of the accompanying accessories, such as the use of teat media, periodic pacifier changes and the use of bottled water, contribute to formula feeding. this means that choosing formula will add some additional expense items and maintenance of the drinking medium. also, the resulting effect in the form of waste adds to the environmental burden. based on the accumulated results of medical and non-medical expenditures, it can be concluded that the selection of formula milk clearly increases household routine expenditures, because formula milk requires media and materials for manufacture. this study also found empirically the increase in household spending from the medical aspect of formula milk groups. in other words, formula milk has a direct or indirect impact on the health status of the baby. statistical test in both groups showed significant results. based on table 4, it is shown that the frequency of occurrence of symptoms of allergies, asthma, and dengue fever is more experienced by infants who receive formula milk. meanwhile, influenza symptoms were equally experienced by the two groups. the frequency of healthy babies was also seen to be higher in the breastfeeding group. of the many cases of allergic symptoms, asthma, and flu symptoms, the percentage of babies who had to be hospitalized was higher in the formula milk group. meanwhile, all cases of dengue fever received inpatient treatment. the identification of health problems in this study was validated by re-verifying the data on patient visits to health facilities mentioned by the mother when experiencing illness events. the identified diagnosis is based on the medical record that is written on the patient’s visit report. discussion this study aims to determine and measure the adverse effects of feeding between infants who are exclusively breastfed and formula milk. several measures were collected regarding the primary needs of infants under one year of age. the gauge identified is the effect of expenditure on food-related needs. the data collected from periodic telephone surveys are then divided into non-health expenditures and health-related expenditures. in the breastfeeding group, the number of non-medical routine expenditures increased from the use of disposable diapers, while, in the formula milk group, nonmedical routine expenditures were added with milk, pacifiers, bottled water, and disposable diapers. a must have extra item to this expense formula is sure to cause the family to spend more money (stuebe et al., 2017). table 1. subject characteristic (n=330) characteristic f % mother’s age < 20 years 20-35 years > 35 years 47 239 44 14.24 72.42 13.34 mother’s marital age < 20 years  20 years 97 233 29.39 70.61 mother’s education basic middle high graduated 82 131 55 62 24.84 39.70 16.67 18.79 working profile working mothers housewife 159 171 48.18 51.82 working profile working husband unemployed husband 301 29 91.22 8.78 parity primipara multiparous 106 224 32.12 67.89 babies’ age < 6 month  6 month 227 103 68.79 31.21 amount of income < idr 3,000,000,  idr 3,000,000, 177 153 53.64 46.36 disposable diaper used yes no 287 43 86.97 13.03 outpatient period in last one year yes no 279 51 84.55 15.45 hospitalization period in last one year yes no 97 240 29.39 72.71 healthcare preference primary healthcare clinic pediatrician 208 122 63.03 36.97 health insurance belongings indonesian nationals health insurance (bpjs) indonesian health care beneficiary (bpjs-kis) private insurance none 72 62 11 32 21.82 18.78 3.33 9.67 feeding option exclusive breastfeeding formula feed 165 165 50.0 50.0 jurnal ners http://e-journal.unair.ac.id/jners | 77 for the most expenditure identified in this study, we emphasize on medical related expenses. in formula feeding, most babies experience at least one or two episodes of recurrent illness. the hospitalization is also higher in babies who experience an outpatient report. the occurrence of allergic symptoms and asthma was also found higher in formula feed. allergic related symptoms were reported high in formula (comberiati et al., 2019; mathias et al., 2019; woicka-kolejwa et al., 2016). allergic symptoms were preserved from the use of feeding equipment, such as pacifier, spoon, and bottled feed. almost all babies are bottle fed, yet 25% found irregular pacifier replacement. this compromised hygiene habit using bottle-feed contributes to a reported risk of food allergy. pacifier and bottle are normally replaced after two or three months' use to minimize the risk of bacteria exposure. performing disinfection protocol in all feeding equipment is highly recommend for those who have to choose formula milk. the role of midwife and other clinician related to baby and mother care in educating the proper ways of giving formula determines the outcome of healthy feeding behavior in nonbreastmilk baby, especially if the baby is in a condition unable to have breastmilk and direct breastfeeding. table 2. formula feeding pattern (n=165) formula feeding pattern n % formula milk packaging: cans paper box 25 140 15.2 84.8 reason for formula milk feeding choice: suitable for babies complete nutrition suggested by healthcare nurse/midwife 123 38 4 74.5 23.0 2.5 financial specific allocation for formula milk: prepared unprepared 106 50 67.9 32.1 formula feeding equipment: pacifier other 154 2 98.7 1.3 pacifier changed frequency: regular (every 3 months) irregular 117 37 75.6 24.4 water consumption: bottled water boiled water 66 90 42.3 57.7 table 3. comparison of average family losses based on accumulated non-medical economic impacts (in indonesian rupiah) family expenditure breastfeeding formula feeding *p non-medical expenditure 421,450.0  273,098.6 8,873,569.3  4,012,883.9 <0.001 medical expenditure 162,500.0  222,715.6 405,374.1  913,769.3 <0.001 total annual expenditure 578,540.9  245,977.8 9,675,706.4  4,449,391.8 <0.001 table 4. illness history diagnosis breastfeeding formula feeding total n % n % n % respiratory tract infection 87 48.6 92 51.4 179 100.0 asthma 1 0.1 8 99.9 0 100.0 allergic symptoms (including diarrhea and vomiting) 1 0.1 38 99.9 39 100.0 measles 0 0.0 3 100.0 3 100.0 dengue fever 1 0.1 7 99.9 8 100.0 never 75 81.6 17 18.4 92 100.0 table 5. hospitalization history (n=165) diagnosis breastfeeding formula feeding total n % n % n % allergic symptoms (including diarrhea and vomiting) 1 5.0 19 95.0 20 100.0 asthma 1 0.0 4 95.0 5 100.0 respiratory tract infection 0 0.0 5 100.0 5 100.0 dengue fever 1 0.0 7 95.0 8 100.0 measles 0 0.0 3 100.0 3 100.0 never 162 57.1 127 43.9 289 100.0 a. syam et al. 78 | pissn: 1858-3598  eissn: 2502-5791 substantially reported in developed countries, baby birth is a potential target market for formula milk. the formula industry market estimates that it will reach a sales target of $ 70.6 billion by 2019 (ezeh et al., 2019; hemmingway et al., 2020). the production process of consumption of formula milk has been confirmed to have a direct impact on global damage, especially climate change, global warming index, environmental degradation, and pollution (dadhich et al., 2015). waste generated from packaging and non-biodegradable plastics accumulates, and is burned in open flames or in incinerators, which results in toxic emissions. meanwhile, direct breastfeeding can eliminate all negative environmental impacts ( leissner & ryanfogarty, 2019). breastfeeding directly maintains environmental sustainability, is a lifestyle choice with zero waste and zero water footprint (hamilton, 2015; linnecar et al., 2014). this study emphasizes the same data, that almost 85% of families use canned formula milk, the rest use paper boxes. this pack will be added every week. non-recycled duplication by thousands of families using formula milk adds to the accumulation of solid waste. meanwhile, waste management technology in indonesia is still lagging behind, and public awareness of zero waste lifestyle is still low. milk industry from farming, packaging, storing, distribution, and preparation with a large amount of water aggravate the climate change and water scarcity. therefore, breastfeeding might the smartest decision in ensuring milk supply chain even in crisis situation (fao, 2019). in the economic burden, breastfeeding will save three point six billion, this figure is from preventing premature death of around three point one, and reducing the expenditure of traditional medicine by about 0.5 billion. traditional medical expenses include hospital visits, laboratory tests, and indirect losses on parental income among those who provide formula milk (weimer, 2001). in lowand middleincome countries, a lower risk of death in the first year was reported among infants who were breastfed, compared with those who were never breastfed (black & victora, 2002; kavle et al., 2017; straub et al., 2019). breastfeeding and obesity: study links the components of mother's milk to the growth of her baby (metzger & mcdade, 2010; papatesta & iacovidou, 2013) and shows the accumulative loss seen by families is a ratio of 16-17 times greater than direct breastfeeding. this new ratio is measurable and real, not taking into account long-term ratios such as the resulting productive generation. the wbw 2018 report shows that, by not giving baby milk, there is a loss of 2.6 iq grade (who, 2017). a lower iq means a lower potential in all possible productivity, including achieving a decent standard of living in the future. ensuring that the baby is exclusively breastfed for the full term means the assurance of a nutritional basis for growing evenly among others. this option prevents them from malnutrition in any form, including the incidence of expulsive stunting (child malnutrition). despite all the benefits of breastfeeding mentioned above, only 40% of babies each year receive exclusive breastfeeding for up to six months, and 45% persist for up to two years. typical failures still revolve around a lack of support from the workplace, community, and health system. therefore, it takes continuous efforts from all levels to upgrade the scale of the breastfeeding program (alianmoghaddam et al., 2018; behzadifar et al., 2019). conclusion this study is empirical evidence of the degree of loss experienced by families by giving formula milk. this tangible loss causes the family to experience economic disabilities in the future. this study has not been able to measure intangible losses, such as the impact of potential iq loss, and the impact of other non-communicable health disorders such as risk of metabolic syndrome, and obesity. thus, further researchers can devise strategies to fulfill this aspect, in a higher quality longitudinal study. references abrahams, s. w. (2012). milk and social media: online communities and the international code of marketing of breast-milk substitutes. journal of human lactation. https://doi.org/10.1177/0890334412447080 akman, i̇., kuscu, m. k., yurdakul, z., özdemir, n., solakoğlu, m., orhon, l., karabekiroğlu, a., & özek, e. (2008). breastfeeding duration and postpartum psychological adjustment: role of maternal attachment styles. journal of paediatrics and child health, 44(6), 369–373. https://doi.org/10.1111/j.14401754.2008.01336.x alianmoghaddam, n., phibbs, s., & benn, c. (2018). reasons for stopping exclusive breastfeeding between three and six months: a qualitative study. journal of pediatric nursing. https://doi.org/10.1016/j.pedn.2018.01.007 aubel, j., & alvarez, m. (2011). the roles and influence of grandmothers and men: evidence supporting a family-focused approach to optimal infant and young child nutrition: literature review. bascom, e. m. e., & napolitano, m. a. (2016). breastfeeding duration and primary reasons for breastfeeding cessation among women with postpartum depressive symptoms. journal of human lactation. https://doi.org/10.1177/0890334415619908 behzadifar, m., saki, m., behzadifar, m., mardani, m., yari, f., ebrahimzadeh, f., majidi mehr, h., abdi bastami, s., & bragazzi, n. l. (2019). prevalence of exclusive breastfeeding practice in the first six months of life and its determinants in iran: a systematic review and meta-analysis. in bmc pediatrics. https://doi.org/10.1186/s12887-0191776-0 jurnal ners http://e-journal.unair.ac.id/jners | 79 better work indonesia. (2004). law and regulations on breastfeeding. black, r. e., & victora, c. g. (2002). optimal duration of exclusive breast feeding in low income countries. in british medical journal. https://doi.org/10.1136/bmj.325.7375.1252 brown, c. r. l., dodds, l., legge, a., bryanton, j., & semenic, s. (2014a). factors influencing the reasons why mothers stop breastfeeding. canadian journal of public health. https://doi.org/10.17269/cjph.105.4244 brown, c. r. l., dodds, l., legge, a., bryanton, j., & semenic, s. (2014b). factors influencing the reasons why mothers stop breastfeeding. canadian journal of public health. https://doi.org/10.17269/cjph.105.4244 buccini, g. d. s., beni´cio, m. h. d. a., & venancio, s. i. (2014). determinants of using pacifier and bottle feeding. revista de saude publica. https://doi.org/10.1590/s00348910.2014048005128 cato, k., sylvén, s. m., lindbäck, j., skalkidou, a., & rubertsson, c. (2017). risk factors for exclusive breastfeeding lasting less than two months identifying women in need of targeted breastfeeding support. plos one. https://doi.org/10.1371/journal.pone.0179402 chowdhury, r., sinha, b., sankar, m. j., taneja, s., bhandari, n., rollins, n., bahl, r., & martines, j. (2015). breastfeeding and maternal health outcomes: a systematic review and metaanalysis. acta paediatrica. https://doi.org/10.1111/apa.13102 comberiati, p., costagliola, g., d’elios, s., & peroni, d. (2019). prevention of food allergy: the significance of early introduction. in medicina (lithuania). https://doi.org/10.3390/medicina55070323 creedy, d. k., cantrill, r. m., & cooke, m. (2008). assessing midwives’ breastfeeding knowledge: properties of the newborn feeding ability questionnaire and breastfeeding initiation practices scale. international breastfeeding journal. https://doi.org/10.1186/1746-4358-3-7 dadhich, j., smith, j., alessandro, i., & adlina, s. (2015). report on carbon footprint due to milk formula: a study from selected countries of the asia-pacific region (issue 10098). https://doi.org/10.13140/rg.2.1.3934.5049 dennis, c. l., jackson, k., & watson, j. (2014). interventions for treating painful nipples among breastfeeding women. in cochrane database of systematic reviews. https://doi.org/10.1002/14651858.cd007366.p ub2 douglas, p. s., & hiscock, h. (2010). the unsettled baby: crying out for an integrated, multidisciplinary primary care approach. in medical journal of australia. https://doi.org/10.5694/j.13265377.2010.tb04039.x eidelman, a. i., & schanler, r. j. (2012). breastfeeding and the use of human milk. pediatrics, 129(3), e827–e841. https://doi.org/10.1542/peds.20113552 ezeh, o. k., ogbo, f. a., stevens, g. j., tannous, w. k., uchechukwu, o. l., ghimire, p. r., & agho, k. e. (2019). factors associated with the early initiation of breastfeeding in economic community of west african states (ecowas). nutrients, 11(11), 1–16. https://doi.org/10.3390/nu11112765 fao. (2019). the state of food security and nutrition in the world 2019. in the state of food security and nutrition in the world 2019. https://doi.org/10.4060/ca5162en gupta, a., holla, r., dadhich, j. p., suri, s., trejos, m., & chanetsa, j. (2013). the status of policy and programmes on infant and young child feeding in 40 countries. health policy and planning. https://doi.org/10.1093/heapol/czs061 hamilton, a. e. (2015). development of environmentally friendly messages to promote longer durations of breastfeeding for already breastfeeding mothers. health communication. https://doi.org/10.1080/10410236.2013.84048 3 hemmingway, a., fisher, d., berkery, t., dempsey, e., murray, d. m., & kiely, m. e. (2020). a detailed exploration of early infant milk feeding in a prospective birth cohort study in ireland: combination feeding of breast milk and infant formula and early breast-feeding cessation. british journal of nutrition. https://doi.org/10.1017/s0007114520001324 houghtaling, b., byker shanks, c., ahmed, s., & rink, e. (2018). grandmother and health care professional breastfeeding perspectives provide opportunities for health promotion in an american indian community. social science and medicine. https://doi.org/10.1016/j.socscimed.2018.05.01 7 kavle, j. a., lacroix, e., dau, h., & engmann, c. (2017). addressing barriers to exclusive breast-feeding in lowand middle-income countries: a systematic review and programmatic implications. in public health nutrition. https://doi.org/10.1017/s1368980017002531 kent, j. c. (2007). how breastfeeding works. journal of midwifery and women’s health. https://doi.org/10.1016/j.jmwh.2007.04.007 leissner, s., & ryan-fogarty, y. (2019). challenges and opportunities for reduction of single use plastics in healthcare: a case study of single use infant formula bottles in two irish maternity hospitals. resources, conservation and recycling, 151(march), 104462. https://doi.org/10.1016/j.resconrec.2019.10446 2 linnecar, a., gupta, a., dadhich, j., & dahiya, a. (2014). formula feeding vs breastfeeding on environment. mathias, j. g., zhang, h., soto-ramirez, n., & karmaus, w. (2019). the association of infant feeding patterns with food allergy symptoms and food a. syam et al. 80 | pissn: 1858-3598  eissn: 2502-5791 allergy in early childhood. international breastfeeding journal. https://doi.org/10.1186/s13006-019-0241-x metzger, m. w., & mcdade, t. w. (2010). breastfeeding as obesity prevention in the united states: a sibling difference model. american journal of human biology. https://doi.org/10.1002/ajhb.20982 national population and family planning board (bkkbn), statistics indonesia (bps), ministry of health (kemenkes), and i. i. (2018). indonesia demographic health survey 2017. nicklas, j. m., miller, l. j., zera, c. a., davis, r. b., levkoff, s. e., & seely, e. w. (2013). factors associated with depressive symptoms in the early postpartum period among women with recent gestational diabetes mellitus. maternal and child health journal, 17(9), 1665–1672. https://doi.org/10.1007/s10995-012-1180-y ogbo, f. a., eastwood, j., page, a., arora, a., mckenzie, a., jalaludin, b., tennant, e., miller, e., kohlhoff, j., noble, j., chaves, k., jones, j. m., smoleniec, j., chay, p., smith, b., oei, j. l., short, k., collie, l., kemp, l., … kleiman, c. (2017). prevalence and determinants of cessation of exclusive breastfeeding in the early postnatal period in sydney, australia. international breastfeeding journal, 12(1), 1–10. https://doi.org/10.1186/s13006-017-0110-4 olang, b., heidarzadeh, a., strandvik, b., & yngve, a. (2012). reasons given by mothers for discontinuing breastfeeding in iran. international breastfeeding journal. https://doi.org/10.1186/1746-4358-7-7 papatesta, e.-m., & iacovidou, n. (2013). breastfeeding reduces the risk of obesity in childhood and adolescence. journal of pediatric and neonatal individualized medicine (jpnim). https://doi.org/10.7363/020206 phillips-moore, j. (2012). birthing outcomes from an australian hypnobirthing programme. british journal of midwifery, 20(8), 558–564. https://doi.org/10.12968/bjom.2012.20.8.558 puapornpong, p., paritakul, p., suksamarnwong, m., srisuwan, s., & ketsuwan, s. (2017). nipple pain incidence, the predisposing factors, the recovery period after care management, and the exclusive breastfeeding outcome. breastfeeding medicine. https://doi.org/10.1089/bfm.2016.0194 richter, n., & reck, c. (2013). positive maternal interaction behavior moderates the relation between maternal anxiety and infant regulatory problems. infant behavior and development. https://doi.org/10.1016/j.infbeh.2013.04.007 straub, n., grunert, p., northstone, k., & emmett, p. (2019). economic impact of breast-feedingassociated improvements of childhood cognitive development, based on data from the alspac. british journal of nutrition. https://doi.org/10.1017/s0007114515001233 stuebe, a. m., jegier, b. j., schwarz, e. b., green, b. d., reinhold, a. g., colaizy, t. t., bogen, d. l., schaefer, a. j., jegier, j. t., green, n. s., & bartick, m. c. (2017). an online calculator to estimate the impact of changes in breastfeeding rates on population health and costs. breastfeeding medicine. https://doi.org/10.1089/bfm.2017.0083 susiloretni, k. a., krisnamurni, s., sunarto, widiyanto, s. y. d., yazid, a., & wilopo, s. a. (2013). the effectiveness of multilevel promotion of exclusive breastfeeding in rural indonesia. american journal of health promotion, 28(2), 1–12. https://doi.org/10.4278/ajhp.120425-quan221 thomas-jackson, s. c., bentley, g. e., keyton, k., reifman, a., boylan, m., & hart, s. l. (2016). inhospital breastfeeding and intention to return to work influence mothers’ breastfeeding intentions. journal of human lactation. https://doi.org/10.1177/0890334415597636 ulak, m., chandyo, r. k., mellander, l., shrestha, p. s., & strand, t. a. (2012). infant feeding practices in bhaktapur, nepal: a cross-sectional, health facility based survey. international breastfeeding journal. https://doi.org/10.1186/1746-4358-7-1 weimer, j. (2001). the economic benefits of breastfeeding: a review and analysis. food assistance and nutrition research report. https://doi.org/food assistance and nutrition research report no. 13. who. (2011). country implementation of the international code of marketing of breastmilk substitutes. who status report, 1–62. who. (2017). nurturing the health and wealth of nations: the investment case for breastfeeding. unicef, 7. woicka-kolejwa, k., zaczeniuk, m., majak, p., pawłowska-iwanicka, k., kopka, m., stelmach, w., jerzynska, j., & stelmach, i. (2016). food allergy is associated with recurrent respiratory tract infections during childhood. postepy dermatologii i alergologii. https://doi.org/10.5114/ada.2016.59151 xu, f., li, z., binns, c., bonello, m., austin, m.-p., & sullivan, e. (2014). does infant feeding method impact on maternal mental health? breastfeeding medicine : the official journal of the academy of breastfeeding medicine. https://doi.org/10.1089/bfm.2013.0142 452 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.20354 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of paradoxical intension session 1 logotheraphy on prisoners anxiety in lapas kediri lingga kusuma wardani, byba melda, dhita kurnia, and nurul azizah institut ilmu kesehatan strada indonesia, kediri, indonesia abstract introduction: living in the prison can causing anxiety to the prisoner. the major factor of anxiety is feeling worry their society won’t accept them again a lot of people stay away from ex-prisoner. logotherapy paradoxical intention session 1 can effect anxiety prisoner in lapas kediri. the purpose of this study is to determine the effect of paradoxical intention session 1 on the anxiety in lapas kediri. methods: the design of this study was pre-experimental with a one-group pretest posttest design approach. the population studied were detainees who were in lapas kediri, totalling 109 people, with a random sampling technique obtained by a sample of 78 people. the independent variable paradoxical intention logotherapy session 1 with dependent variable anxiety. collected data using questionnaire. data analysis using the wilcoxon test at α = 0.05. results: the results of the study before logotherapy showed that the majority of respondents in a panic situation were 33 respondents (42.3%) and after logotherapy showed that the fraction in severe anxiety were 18 respondents (23.1%). the results of the analysis, p-value (0.000) < (0.05), it means there is an effect of paradoxical intention session 1 on the anxiety of prisoner in lapas kediri. conclusion: anxiety was not significant caused of age, education, length of detention, and logotherapi given as session 1, lenght of administration, and provider of logotherapy. article history received: feb 27, 2020 accepted: april 1, 2020 keywords anxiety; logotherapy paradoxical intention session 1 contact lingga kusuma wardani  linggakusumawardani@gmail.com  institut ilmu kesehatan strada indonesia, kediri, indonesia cite this as: wardani, l, k., melda, b., dhita, k., & azizah, n. (2020). the effect of paradoxical intension session 1 logotheraphy on prisoners anxiety in lapas kediri. jurnal ners, special issues, 452-456. doi: http://dx.doi.org/10.20473/jn.v15i2.20354 introduction penitentiary (lapas) is a technical implementing unit under the directorate general of corrections of the ministry of law and human rights (formerly the department of justice). the purpose of lapas is to care for and foster the occupants who are in it. lapas residents can be inmates (prisoners) or penitentiary prisoners (wbp) even prisoners whose status is still in the judicial process and have not been found guilty or not by the judge (katona cornelius &coper claudia, 2008). according to hadjam (2014), the problem experienced by many prisoners who are in prison is anxiety. data from the international center for prison studies (2015) shows that the total population of prisoners in the world is around 9 million. indonesia is ranked 9th for the country with the most prisoners in the world. the directorate general of corrections of the ministry of law & human rights (2015) reported that on 22 february 2015 there were 137,495 prisoners and prisoners spread across 33 regions of indonesia (asmadi, 2010) this number consists of 45,138 adult prisoners, 666 child prisoners, 89,659 adult prisoners, and 2,032 child prisoners. the incidence of mental emotional disorders based on the results of riskesdas 2013 shows the prevalence of mental emotional disorders in the population aged ≥ 15 years is 6.0% with a prevalence in east java of 6.5%. according to riskesdas mental emotional disorder is a condition that indicates an individual experiences an emotional change that can develop into a pathological state if it continues (widianti et al., 2011). the prevalence of prisoners' psychosocial problems, namely anxiety, is https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:linggakusumawardani@gmail.com http://dx.doi.org/10.20473/jn.v15i2.20354 jurnal ners http://e-journal.unair.ac.id/jners | 453 the finding of trencin (who, 2008) in the international journal of nursing studies (2010) which states that one in nine perpetrators suffers from severe mental health problems, some suffer from mild mental health problems such as mild anxiety and depression (asmadi, 2010) widianti (2011) mentioned that out of 33 prisoners, 16 of them experienced anxiety problems, 80% of which were severe anxiety, 15% were moderate anxiety and the rest were mild anxiety.(widianti et al., 2011) preliminarystudy conducted on 18 september 2018 at the penitentiary class ii a of the city of kediri based on interviews conducted with 20 detainees found that anxiety that occurred in detainees ie 1 person experienced mild anxiety with the client's symptoms having a bad feeling about his future, 10 people experienced moderate anxiety with rapid and hardened pulse symptoms, difficulty sleeping for several days, and thought of family health at home, and 9 people experienced severe anxiety with fast and hardened pulse symptoms, did not ask for activities carried out at the prison, wanted to get out immediately, and the client looked nervous and confused. to deal with the anxiety of detainees, there are currently no supporting facilities to deal with it, so that most detainees make diversions by praying, reciting, or going around the prison to feel tired. lapas kediri is a state institution that has the authority and obligation to be responsible in handling the life of prisoners to be able to foster, care for and humanize prisoners (widhiarso & hadjam, 2014). prison is occupied by several people who commit acts of guilty against the law, one of them a prisoner . detainee is a person who is in detention, a prisoner who is still in the process of investigation,prosecution and examination in a state court, a high court and a supreme court placed in a detention center (agoes, 2008) . life in prison has a different dynamic from the life of the community in general. limiting activities and communication with others are some things that must be experienced by inmates while in prison. not infrequently life in prison raises psychological effects in prisoners one of them anxiety (widhiarso & hadjam, 2014). anxiety is an unpleasant emotional state, involving subjective fear, body discomfort, and physical symptoms (katona cornelius &coper claudia, 2008) some of the problems that often become conflicts that cause anxiety to prisoners are fear of not being accepted by the environment, shame to get back into the community, self-esteem and community attitudes that tend to stay away from them, but also because of the atmosphere of detainees such as their relationship with prisoners others, and with officers (effendi dkk, 2009).anxiety can provide anxious response, easily surprised, confused, guilty, and ashamed. (gail w. stuart, 2013) towsend (2009) states that the use of anti-anxiety drugs continuously can cause physical and psychological dependence so it is not recommended for long-term use. in addition to the psychopharmaceutical approach, anxiety management can be done with a psychotherapy approach. one of the psychotherapies that can be applied as anxiety solutions is logotherapy paradoxical intention. paradoxical intention for short-distance treatment of phobia patients (irrational fear) and obsessive compulsive behavior, anxiety and social difficulties (suhita et al., 2020). the implementation of logotherapy on the client can be carried out in the form of group therapy, with group therapy providing an opportunity for participants to solve their problems in the presence of others, observing how other people react. in the logotherapy group therapy session paradoxical intention, each member directly searches for and reveals the meaning of life related to the experience they experience. it aims to find the meaning or wisdom of a life event even though it is considered very heavy or sad. from the background description above, the researcher is interested in conducting a study entitled "the effect of logotherapy paradoxical intention session 1” on prisoner anxiety in class ii a penitentiary in kediri city." materials and methods design pre-experimentalone group pretest posttest design. the study population was all prisoners who were in class ii a in kediri city. the sampling method used was random sampling and 78 samples were obtained. data collection was carried out using a questionnaire to obtain data on anxiety experienced by prisoners by giving a questionnaire pre tes then prisoners were treated in the form of logotherapy paradoxical intention session . i then given a questionnaire posttest anxiety, logotheraphy session 1 give twice treatment in one weeks. data processing using editing is the process of reexamining the data records obtained for the next process.coding is changing data in a more concise form by using codes. analysis of the data used is the statistical program for social science (spss) software with the "" statistical wilcoxon test . the degree of significance is determined α = 0.005 meaning that if the statistical test results show a p value ≤ 0.005 then there is a significant influence between the variables independent with the variable dependent. results the results of this study were elaborated on the characteristics of the respondents, cross tabulation anxiety before and after the first “logotherapy session of paradoxical intention.” based on table 1 it is known that of the 78 respondents mostly aged 21-30 years as many as 49 respondents (62.8%). based on table 2, it is known that from 78 respondents most of them had elementary school education of 30 respondents (38.5%). based on table 3 it is known that of the 78 respondents mostly detained for 1-2 months, 34 respondents (43.6%). based on table 4, crosstabulation of prisoners' anxiety before and after l. k. wardani et al. 454 | pissn: 1858-3598  eissn: 2502-5791 paradoxical intention session logotherapy, after logotherapy, it was found that a small proportion experienced severe anxiety as many as 18 respondents (23.1%). based on table 5, the results of outputrank the influence of logotherapy paradoxical intention session 1 on prisoners anxiety in class ii a penitentiary in kediri, obtained results, from a total of 78 data, there are 30 data with negative rank, nodata positive rank, and there are pairs of data with the same value. 48 data. based on table 6, the results of data output of the influence of logotherapy paradoxical intention session 1 on prisoners anxiety in class ii a penitentiary in kediri based on statistical tests using wilcoxon obtained p = 0,000, meaning p value 0.003 <0.05 then h0 is rejected and h1 is accepted which means influence of logotherapy paradoxical intention session 1 on prisoners' anxiety in class ii a penitentiary in kediri city. discussion however, the output rank shows that from a total of 78 data there are 30 data with negative rank, there is no positive rank data, and there are pairs of data that score as much as 48 data. from the output rank results, it can be interpreted as negative rank 30 data which shows that the resistance that has been given treatment is more than the exception of before the treatment was given. whereas for the value of positive rank with zero point which showed that anxiety was not found after more than logistical therapy before treatment was given. the evidence was found that the pair of data with the same value as much as 48 data that could be interpreted as anxiety after the logotherapy value was the same as anxiety before treatment was given.anxiety is a person's emotional turmoil related to something outside of himself and the self mechanism used in overcoming problems. uneasy feelings whose sources are unclear will be able to threaten a person's personality both physically and psychologically (asmadi, 2010). according to routledge (2010) states that an individual who loses meaning to events in his life will more easily experience anxiety(routledge & juhl, 2014). likewise, life in the prison which seems to be alienated from life and communication restrictions is one of the things that can make prisoners experience anxiety, other things that can cause anxiety to detainees are unacceptable to the environment, a sense of shame to be detached from the community, disruption of the price of the people who tend to stay away from them, in addition to being caused by nonacceptance of the environment, embarrassment to the detainees of the detention and detention in relation to other detainees (effendi dkk, 2009). anxiety experienced by prisoners after logotherapy did not change to the maximum that can be seen from the negative rank values, there are 30 data and 48 ties, this can be caused by several things, namely the results of the study found that age of most prisoners 21-30 years at this age are productive ages to continue their education or higher education, work or get married according to the ministry of health republic of indonesia (2009) at the end of adolescence is 17-25 years which is a mature personal development and adulthood at the age of 2645 years which is a period of responsibility towards others with imprisoned conditions making them forced to not continue these activities. in terms of education, it is found that most of the elementary school education according to kaplan and saddock (2010) the ability to think of a person is influenced by the higher level of education, the easier it is to think rationally and capture new information, formal education can be used to develop one's potential and can be used as an indicator of ability solve the problem.(kaplan h.i, 2010) the length of detention that is almost half detained 1-2 months which can be said of all categories selected by detention researchers detained less than 1 year detention period which can be related to the transition or adaptation that initially was in a free external environment because criminal acts require entry prisons which are certainly all restricted so that individuals or detainees have to adapt to this according to stuart (2010) individuals who are in a foreign environment are more prone to anxiety than if he was in the environment he used to table 1. distribution of respondents by age in class ii a in kediri city age frequency percent percent percent 21-30 year 49 62.8 62.8 75.6 31-40 year 13 16.7 16.7 92.3 41-50 year 6 7.7 7.7 100.0 total 78 100.0 100.0 table 2. distribution of respondents by education in class ii a in kediri city education frequency percent percent percent elementary 30 38.5 38.5 38.5 junior 23 29.5 29.5 67.9 senior 22 28.2 28.2 96.2 bachelor 3 3.8 3.8 100.0 total 78 100.0 100.0 table 3. distribution of respondents by length of detention in penitentiary class ii a kediri city length of detention frequency percent percent percent <20 day 11 14.1 14.1 14.1 1-2 month 34 43.6 43.6 57.7 >2-3 month 15 19.2 19.2 76.9 >3 month 18 23.1 23.1 100.0 total 78 100.0 100.0 jurnal ners http://e-journal.unair.ac.id/jners | 455 occupy. (gail w. stuart & michele t. laraia, 2005)apart from the length of time in detention that in the study found almost half were new prisoners anxiety prisoners can also be caused by factors of the type of crime committed, from observations found that most respondents committed crimes of theft, illtreatment, violence and even disappearance.(agoes, 2008) but there are also respondents who, if asked for their mistakes to go to prison, are unwilling to tell stories and change the subject because it is because the respondent is ashamed of his status as a detainee or his level of serious crime is so unwilling to tell researchers (gail w. stuart, 2013). the level of crime that is judged or felt to be high which will have an impact on the length of imprisonment can also cause anxiety in prisoners in line with the theory that anxiety in prison can also occur due to several causes, such as personality factors, severity of detention, and the type of crime committed. prisoners imprisoned for violent crimes have a higher level of anxiety than prisoners incarcerated who commit crimes without violence (indonesia et al., 2009). another thing that causes the administration of logotherapy is not maximal is in terms of logotherapy that is given by yourself, paradoxical intention logotherapy actually has 4 sessions namely session 1; identifying client events and problems, session 2; identifying reactions and how to overcome problems, session 3; paradoxical techniques intention, session 4; meaning of life after using the paradoxical intention technique. while the researchers carried out in this case only session 1 and conducted for 2 meetings so that the results obtained are not optimal, namely there is still anxious prisoners' anxiety, the frequency is the same between before and after logotherapy even though there are prisoners who have decreased anxiety after logotherapy.(indonesia et al., 2009) another thing that makes this logotherapy less optimal in reducing anxiety prisoners is in terms of therapy, it can be seen that paradoxical intention logotherapy itself is logotherapy in the logotherapy group for specialists which can be interpreted that in the administration of this logotherapy must be those who master or have this ability as well. with the problem of implementation time which is certainly table 4. cross tabulation of prisoners' anxiety before and after a paradoxical intention logotherapy session 1 at the penitentiary class ii a of the city of kediri anxiety pre and post logotheraphy intervention anxiety post logotheraphy intervention total mild moderate heavy panic anxiety pre and post logotheraphy moderate count 6 13 0 0 19 % of total 7.7% 16.7% .0% .0% 24.4% heavy count 0 8 18 0 26 % of total .0% 10.3% 23.1% .0% 33.3% panic count 0 0 16 17 33 % of total .0% .0% 20.5% 21.8% 42.3% total count 6 21 34 17 78 % of total 7.7% 26.9% 43.6% 21.8% 100.0% table 5. results of output rank effect of logotherapy paradoxical intention session 1 against anxiety prisoners in class ii a penitentiary in kediri city ranks n mean rank sum of ranks anxiety pre and post logotheraphy negative ranks 30a 15.50 465.00 positive ranks 0b .00 .00 ties 48c total 78 table 6. results of data output effects of paradoxical intention session 1 logotherapy on prisoners anxiety in class ii a penitentiary in kediri city test statisticsb anxiety pre and post logotheraphy z -5.477a asymp. sig. (2-tailed) .000 a. based on positive ranks. b. wilcoxon signed ranks test l. k. wardani et al. 456 | pissn: 1858-3598  eissn: 2502-5791 not enough with 2 meetings only prisoners anxiety can be directly reduced or not even become anxious, so for further researchers are expected to consider the time of research and therapy providers to obtain maximum results (suhita et al., 2020). conclusion anxiety before doing logotherapy paradoxical intention session 1 found that most were in a state of panic as many as 33 respondents (42.3%). anxiety after logotherapy paradoxical intention session 1 found that a small proportion experienced severe anxiety of 18 respondents (23.1%). after the wilcoxon test was obtained p = 0.000 which means p value 0.003 <0.05, then h0 was rejected and h1 was accepted, which means that the influence before and after logotherapy paradoxical intention intensification session 1 action against anxiety in the institution of social security in class ii a kediri city . in the output rank obtained from a total of 78 data, there are 30 data with negative rank, there is no positive rank data, and there are 48 pairs of data values. for nursing education, it is expected that this research can be used as input or reference about anxiety of prisoners who get logotherapy paradoxical intention .researcher is expected to be able to consider sessions in the implementation of paradoxical intensity logotherapy, the timing of administration of logotherapy, and the provider of logotherapy in order to obtain the expected results. expected to increase the role of nurses in providing services to prisoners. anxiety in inmates can be overcome with paradoxical therapy (bastaman, 2008; indonesia et al., 2009), however, this therapy requires special treatment by trained personnel, one of them is a nurse or physicologis. (hankin, 2009)for the future, prisons can work together gradually and continuously to provide this therapy for prisoners in prison by fulfilling applicable requirements such as prisoners' conditions who can participate in therapy and they will serve as prison services in maintaining mental health for prisoners.(towsend, 2009). references agoes, d. (2008). psikologi perkembangan. pt. reflikaaditama. asmadi. (2010). teknik prosedural keperawatan konsep dan aplikasi kebutuhan dasar klien. salemba medika. bastaman, h. . (2008). logoterapi: psikologi untuk menemukan makna hidup dan meraih hidup bermakna. rajawali pers. effendi dkk. (2009). keperawatan kesehatan komunitas: teori dan praktek keperawatan. salemba medika. gail w. stuart. (2013). prinsip dan praktik keperawatan kesehatan jiwa. elsevier. gail w. stuart, & michele t. laraia. (2005). principles & practice of psychiatric nursing 8th (8th ed.). elsevier mosby; 8th edition (2005). hankin, b. l. (2009). nih public access. 38(2), 219– 231. https://doi.org/10.1080/15374410802698396.i nsecure indonesia, u., keperawatan, f. i., & pascasarjana, p. (2009). pengaruh logoterapi..., sutejo, fik ui, 2009. kaplan h.i, s. b. . (2010). sinopsis psikiatri jilid 2. binarupa aksara. katona cornelius &coper claudia. (2008). psikiatri edisi keempat. erlangga. routledge, c., & juhl, j. (2014). when death thoughts lead to death fears : mortality salience increases death anxiety for individuals who lack meaning in life when death thoughts lead to death fears : mortality salience increases death anxiety for individuals who lack meaning in life. august 2010. https://doi.org/10.1080/02699930902847144 suhita, b. m., kusumawati, p. d., saputro, h., & yusuf, a. (2020). mechanism of family-coping in treating patient with schizophrenia viewed from factors that affected it at public health center of balowerti , kediri. 1230–1235. towsend, m. . (2009). mental health nursing concepts of care in evidence-based practice. (6th ed). saunders elseiver. widhiarso, w., & hadjam, m. n. r. (2014). exploring somatization types among patients in indonesia: latent class analysis using the adult symptom inventory. 2(1), 208–216. https://doi.org/10.5114/cipp.2014.47810 widianti, e., keperawatan, f. i., magister, p., & keperawatan, i. (2011). universitas indonesia pengaruh terapi logo dan terapi suportif. 170 role attainmetn ibu dalam pemberian mp – asi dengan peningkatan berat badan bayi usia 6-12 bulan (mother’s role attaintment in giving additional food for baby weight of age 6-12 months) ririn probowati * , heri wibowo * , septi fitrah ningtyas *, mamik ratnawati *, nursalam ** * sekolah tinggi ilmu kesehatan pemkab jombang ** fakultas keperawatan universitas airlangga email: ririn_probowati@yahoo.com abstrak pendahuluan: role attainment ibu dalam pemberian makanan pendamping asi (mpasi) akan mempengaruhi barat badan bayi. tujuan penelitian menganalisis role attainmet ibu dalam pemberian mp-asi dengan berat badan bayi usia 6 – 12 bulan diwilayah kerja puskesmas jogoloyo jombang. metode: desain penelitian retrospektif, populasi semua ibu yang memiliki bayi usia 6-12 bulan di wilayah kerja puskesmas jogoloyo sumobito jombang bulan juli 2016 sejumlah 327 orang dengan jumlah sampel 130 orang dengan tehnik simple random sampling. variabel independen role attainment ibu dalam kompetensi pemberian mp asi. variabel dependent bayi usia 6-12 bulan. pengumpulan data menggunakan kuesioner dan observasi buku kia. analisa data menggunakan chi square dengan taraf signifikan 0,05. hasil: hasil analisa menggunakan uji chi squaredidapatkan bahwa ρ = 0,005< 0,05 yang artinya ada hubungan role attainment dalam pemberian mp-asi dengan pertumbuhan bayi usia 6 – 12 bulan. diskusi: role attainment ibu dalam pemberian mp asi mempengaruhi berat badan bayi. setelah umur 6 bulan bayi harus mendapatkan mp asi karena asi sudah tidak mencukupi kandungan gizi untuk pertumbuhan bayi. kata kunci : role attainment, mp –asi, pertumbuhan bayi abstract introduction: mother’s role attainment in giving additional food will affect growth in infants. the study aims to analyze the role of mothers in the attainmet competency in giving additional food with infant growth age 6-12 months working area jogoloyo jombang health care centre. methods: design used in this study was retrospectives, the population was mother of babies aged 6-12 months in health care centre jombang jogoloyo sumobito on july 2016. simple random sampling technique was used in this study, with sample were 130 mother. the independent variables were maternal role attainment in the competence of giving complementary feeding. the dependent variable were growth of infants aged 6-12 months. data was collected using questionnaires and observation kia book and analyzed using chi square with a significance level of 0.05. results: results showed that ρ = 0.005 <0.05, which means that there is a relation role attainment in giving additional food to the growth of infants aged 6-12 months. discussion: mother role attainment in giving additional food affect the babies weight. after the age of 6 months babies should receive additional food because breast milk is not sufficient nutrients to the baby's growth. keywords: role attainment, mp -asi, baby's growth ____________________________________________________________________________________________________ pendahuluan masa bayi termasuk didalam masa periode emas yang terbagi dari umur 0-6 bulan hanya mendapatkan asi saja yang disebut asi eklusif dan umur 6-12 bulan mulai diperkenalkan dengan makanan pendamping asi (mp-asi) pada masa bayi terjadi pertumbuhan otak sangat pesat yang dapat mendukung proses pertumbuhananak dengan sempurna. kekurangan gisi dimasa bayi tidak dapat diperbaiki dimasa–masa kehidupan selanjutnya, pertumbuhan jasmanii menjadii pendek, pertumbuhan otak terhambat anak akan tidak cerdasdan perkembangan kemampuan terhambat, anak akan sulit mengikuti pelajaran saat bersekolah, anak akan mudah sakit setelah dewasa sulit mencari pekerjaan. pada akhirnya anak menjadi beban keluarga dan negara. kebutuhan nutrisi yang sebagian besar diperoleh dari asi karena kandungan zat gizi pada asi sangat kompleks dan sudah sangat memenuhi gisi bagi pertumbuhan bayi. mulai usia 6 bulan, secara fisiologis kandungan asi sudah tidak cukup untuk memenuhi kebutuhan nutrisi bayi, bayi mulai meningkat kebutuhan nutrisi untuk melakukan aktifitas yang lebih misalnya untuk miring kiri kanan, tertawa, duduk, merangkak, memegang, belajar berjalan dan pada saat ini lambung bayi telah siap menerima makanan tambahan dan pertumbuhan role attainment ibu dalam mp-asi (ririn, dkk) 171 gigi di mulai umur 6 bulan yang akan membantu memecahkan makanan dimulut sebelum masuk ke dalam lambung oleh karena itu pemberian makanan pendamping air susu ibu (mp-asi) sangat diperlukan (yogi 2014). pemberian mp-asi ini diberikan bersamaan dengan pemberian asi dahulu baru diberikan mp asi yang dimulai dari makanan bubur, sari buah dalam bentuk cair dan secara bertahap dalam bentuk setengah padat dan selanjutnya padat. mulai usia 6 bulan hingga 24 bulan. seiring bertambahnya usia bayi mulai usia 6 bulan diperkenalkan dengan makanan pendamping untuk memenuhi kebutuhan giziny (riksani 2012). hal ini sejalan dengan program world health organization (who) yakni global strategy on infant young child feeding yang secara khusus menyebutkan kebijakan pemberian asi bagi bayi sampai usia enam bulan dan mulai pemberian makanan pendamping mp-asi yang memadai pada usia 6 bulan dan diteruskan hingga anak berusia dua tahun atau lebih dapat membantu proses tumbuh kembang bayi (depkes ri 2013) berdasarkan riset kesehatan dasar (riskesdas) 2013 pemberian mp-asi pada bayi di indonesia masih sangat rendah dimana baru mencapai 48,6% bayi yang mendapat asi ekslusif hingga enam bulan dari target 75%. penelitian yang dilakukan di daerah pedesaan di jawa timur, ditemukan bahwa praktek pemberian makan pada bayi sebelum usia 6 bulan mencapai 32,4%, dan pada usia tersebut didapatkan 66,7% jenis makanan yang diberikan adalah pisang (dinkes jatim 2014) data kabupaten jombang pada tahun 2014 balita yang mengalami gizi kurang sebanyak 2.184 (6,14%) laki-laki dan 2.426 (6,93%) perempuan. balita dengan gizi sangat kurang sebanyak 148 (0,24%) laki-laki dan 224 (0,64%) perempuan. role attainment ibu dalam kompetensi pemberian mp asi akan berdampak pada pertumbuhan bayi nampak pada berat badan tidak sesuai dengan umur dan dampak terhadap perkembangan anak akan menjadi apatis, mengalami gangguan bicara dan gangguan perkembangan yang lain. sedangkan dampak jangka panjang adalah mengalami penurunan kepandaian, anak menjadi pendek, sering sakit, skor tes iq rendah,, penurunan perkembangan kognitif, penurunan integrasi sensori, dan gangguan pemusatan perhatian (soekirman 2010) kekurangan gizi merupakan faktor utama yang menyebabkan kematian bayi dan balita. masalah pertumbuh dan perkembang pada bayi dan anak < 2 tahun sebagian besar di pengaruhi oleh pemberian makanan tambahan yang tidak sesuai dengan kebutuhan bayi baik ditinjau dari jenis, jumlah, cara memasak mp asi. pemberian makanan adalah salah satu faktor yang mempengaruhi status gizi bayi. pemberian makanan yang kurang tepat dapat menyebabkan terjadinya kekurangan gizi dan bila berlebih akan terjadi kegemukan (septiana 2009). role attainment ibu dalam kompetensi pemberian mp asi dapat diperoleh ibu dengan mencari informasi kepada petugas kesehatan atau kader kesehatan yang dipandang berhasil melakukan pemberian mp asi. pemberian mp asi tentang jenis makanan, frekuensi pemberian, waktu pemberian, tahapan pemberian makanan, cara pemberian dan cara membuatnya. bahan dan metode desain penelitian yang digunakan adalah korelasi dengan retrospektif yaitu. rancangan penelitian dengan melakukan pengukuran atau pengamatan pada saat yang lalu (nusalam 2013) dengan mengobservasi grafik pertumbuhan di dalam buku kia untuk 2 bulan berturutturut. populasinya adalah semua ibu yang memiliki bayi usia 6-12 bulan diwilayah kerja puskesmas jogoloyo jombang sejumlah 327responden pada bulan juli 2016 dengan sampel penelitian sebanyak 130 respondent dengan kriteria mempunyai buku kia dengan grafik pertumbuhan minimal 3 bulan berturut –turut yang terisi dengan tehnik simple random sampling yaitu pengambilan sampel pada anggota populasi secara acak dengan lotrey (setiadi 2013). penelitian ini menggunakan uji statistik chi square dengan tingkat signifikan 0,05 untuk mengetahui hubungan antara variabel role attainment ibu kompetensi pemberian mp asi dengan pertumbuhan bayi 6 – 12 bulan. hasil table 1. role attainment ibu dalam kompetensi pemberian mp-asi no role attainment frek (f) prosentase 1 baik 20 15.4 2 cukup 70 54 3 kurang 40 30.6 total 130 100 tabel 2 berat badan bayi 6-12 bulan n o berat badan frekwen si (f) prosent ase (%) 1. naik 60 47.2 2. tidak naik 70 53.8 total 130 100 172 jurnal ners vol 11 no 2. oktober 2016:170-175 tabel 3. tabulasi silang role attainment ibu dengan pertumbuhan bayi role attainment pertumbuhan bayi naik tidak naik total f % f % f % baik 12 20 8 11.5 20 15. 4 cukup 32 53.3 38 54.2 70 53. 8 kurang 16 26.7 24 34.3 40 30. 6 jumlah 60 100 70 100 130 100 uji chi square= 0,005 nilai pearson correlation sebesar 0,644 sehingga dapat disimpulkan bahwa hubungan role attainment ibu dalam kompetensi pemberian mp-asi dengan pertumbuhan bayi usia 6 – 12 bulan adalah kuat dan arah hubungannya positif artinya semakin banyak ibu yang mempunyai role attainment dalam kompetensi pemberian mpasi cukup maka berat badan bayi akan mengalami kenaikan. pembahasan role attainment ibu dalam pemberian mp asi hasil penelitian menunjukkan bahwa sebagian besar (54%) role attainment ibu dalam pemberian mp-asi dalam katagori cukup sebanyak 70 orang. role attainment ibu merupakan suatu pencapaian peran yang dicapai oleh seorang wanita/ibu dalam melakukan pengasuhan dalam hal ini adalah pengasuhan dalam kemampuan memberikan mp asi kepada bayi umur 6-12 bulan. role attainment atau pencapaian peran sebagai ibu dipengaruhi oleh system pendukung social yang meliputi pasangan hidup, keluarga, teman dan masyarakat di sekitar tempat tinggal. sistem pendukung social dapat diberlikanan melalikan melalui interaksi social dan dukungan social (kim jihyaongungand k.a.s wickrama 2013). interaksi social dapat dilakukan oleh ayah/keluarga/masyarakat khususnya tenaga kesehatan yang mempunyai kemampuan dalam memberikan informasi cara pemberian mp asi yang tepat dan benar. dukungan social dapat diberikan oleh masyarakat disekitar tempat tinggal ibu dengan fasilitasi kegiatan berupa posyandu atau penyuluhan – penyuluhan yang dilakukan oleh petugas kesehatan melalui kegiatan ibu-ibu misalnya kegiatan pkk, pengajian. faktor umur, pendidikan ibu, sumber informasi juga memegang peran penting dalam pencapaian peran (m.r alligo 2006). sebagian besar (72.3%) ibu berumur 20-35 tahun sebanyak 94 ibu. sebagian besar(75.4%) pendidikan ibu menengah sebanyak 98 ibu. sebagian besar (85.6%) ibu pernah mendapatkan informasi tentang mp asi sebanyak 111 ibu sebagian besar(89.2%) sumber informasi petugas kesehatan sebanyak 116 ibu. umur, pendidikan, sumber informasi tentang pemberian mp asi mempengaruhi.. kelompok uisa produktif dan pendidikan menengah akan mempermudah seorang ibu menerima informasi baru yang diberikan oleh orang lain. sumber informasi yang berasal dari petugas kesehatan membuat seorang ibu percaya bahwa informasi yang diberikan adalah benar dan tepat karena yang memberikan adalah orang yang berkompetence. role attainment/ pencapaian peran ibu juga dipengaruhi oleh pengalaman sebelumnya. seorang ibu bila sudah pernah memberikan mp asi kepada bayi dan bayi tumbuh dengan baik akan memberikan pengalaman yang menyenangkan bagi seorang ibu dan akan menjadikan pembelajaran yang sanagat bearti. hal ini akan di lakukan lagi bagi seorang ibu untuk bayibayi selanjutnya. sebaliknya bila seorang ibu sebelumnya gagal memberikan mp asi karena pertumbuhan bayi tidak sesuai dengan grafik pertumbuhan di buku kia maka ibu akan takut/ tidak mau memberikan mp asi kepada bayi lagi takut terulang pengalaman yang tidak menyenangkan hal ini dapat dilihat dari jumlah anak, posisi anak saat ini, umur dan pendidikan dan ibu. sumberinformasi status pekerjaan seseorang menunjukkan tingkat penghasilan seseorang dan waktu luang yang dimiliki. ibu yang tidak bekerja atau ibu rumah tangga memiliki banyak waktu luang dalam mengurus keluarga. hasil penelitian kim jihyaongungand k.a.s wickrama 2013) status pekerjaan ibu mempengaruhi harga diri dan pola asuh pada bayi. harga diri tinggi akan membuat seorang ibu dapat melaksanakan pemberian mp asi dengan baik. pada ibu tidak bekerja mempunyai harga diri yang kurang karena merasa hidupnya hanya bergantung pada suami, hal ini diperlukan suatu dorongan untuk meningkatkan harga diri ibu bahwa ibu mampu untu memberiakn mp asi dengan baik. role attainment ibu dalam kompetensi pemberian mp asi adalah pemberian mprole attainment ibu dalam mp-asi (ririn, dkk) 173 asi yang sesuai dengan dengan tahapan usia bayi, jenis makanan yang diberikan dan jadwal pemberian makanan pendamping asi. role attainment ibu dalam kompetensi pemberian mp asi dapat dilihat dari jawaban responden pada kuesioner dimana ibu mulai memberikan makanan pendamping asi sejak usia 6 bulan dengan mengurangi frekwensi asi karena bayi sudah kenyang. dan di berikan mp asi dahulu baru asi. pemberian makanan pendamping seperti susu formula, bubur sari buah, sayuran dengan bentuk yang menarik dan sesuai dengan usia bayi. mp-asi ini diberikan bersamaan dengan asii mulai usia 6 bulan hingga 12 bulan. seiring bertambahnya usia bayi, setelah bayi berusia 6 bulan, mulai diperkenalkan dengan makanan pendamping untuk memenuhi kebutuhan gizinya.pada usia 6 9 bulan mulai diperkenanalkan dari yang cair yaitu sari buah, bubur susu nasi tim saring kemudian secara bertahap diperkenalkan dengan makanan yang bertekstur lebih kasar (semi padat), yaitu nasi tim tanpa disaring.jenis sayur dan buah yang disarankan: tomat, wortel, bayam, sawi,cambah, kacang polong, kentang, labu kuning, kacang merah, mangga, blewah, timun, apokat, apel, papaya, melon bisa juga ditambahkan ayam, daging sapi giling, hati ayam/sapi, ikan segar tampa duri (salmon, kakap, gurami, tuna, tonggkol, lele) tahu, tempe, dan telur ayam kampung. pemberian mpasi dilakukan di selasela pemberian asi dan dilakukan secara bertahap pula. misalnya untuk pertama 1 kali dalam sehari, kemudian meningkat menjadi 3 kali dalam sehari. ibu yang tidak bekerja atau ibu rumah tangga menyebabkan responden mempunyai banyak waktu luang dalam pemberian mp-asi, ibu lebih banyak perhatian terhadap anaknya seperti memperhatikan jenis makanan yang dikonsumsi dan sangat telaten dalam menyuapi anak, selain itu ibu yang tidak bekerja mempunyai banyak waktu luang untuk mencari informasi dari berbagai media seperti majalah, tayangan televisi yang berisikan menu atau resep masakan sehingga ibu mempunyai pengetahuan dan pemahaman yang baik tentang menu makanan yang sesuai dengan usia anak. semakin banyak informasi yang didapat maka pengetahuan dan pemahaman yang dimiliki oleh responden semakin meningkat (notoadmodjoo 2010). responden yang belum pernah mendapatkan informasi tentang pola pemberian mp-asi maka responden tidak dapat mengerti bagaimana pola pemberian mp-asi yang sesuai pada bayi usia 6 – 12 bulan. sedikitnya ibu memperoleh informasi tentang pola pemberian mp-asi menyebabkan ibu memberikan makanan pendamping asi yang salah yaitu tidak sesuai jenis, jumlah dan jadwal makan bayi, bahkan ibu cenderung memberikan makanan pendamping asi secara dini serta tidak sedikit ibu yang menghentikan pemberian asi pada bayi. berat badan bayi pertumbuhan adalah bertambahnya ukuran sel seluruh bagian tubuh yang bersifat kuantitatif dan dapat diukur. pertumbuhan yang naik dapat dilihat dari berat badan bayi yang mengalami kenaikan jika dibandingkan dengan berat badan bulan yang lalu (syamsu 2012). sebagian besar bayi yang mengalami kenaikan berat badan dapat dilihat dari peningkatan berat badan bayi dibandingkan dengan berat badan sebelumnya dengan kriteria pertumbuhan/ kenaikan berat badan sama dengan kenaikan berat badan minimal (kbm) atau lebih (kementerian kesehatan republik indonesia, 2012) sesuai dengan kartu menuju sehat (kms). bayi yang tidak naik dengan kriteria grafik berat badan mendatar atau menurun memotong garis pertumbuhan dibawahnya atau kenaikan berat badan kurang dari kbm. pada kelompok usia bayi serng mengalami sakit, hal ini disebabkan karena system kekebalan tubuh bayi sedang berkembang dan memerlukan immunisasi dalam upaya menimbulkan/meningkatkan kekebalan terhadap penyakit pada bayi yang sebagian dilakukan dengan route suntikan yang berdampak pada bayi akan merasakan tidak nyaman atau mengalamii peningkatan suhu tubuh. untuk melawan proses penyakit dibutuhkan nutrisi tambahan selain nutrisi yang pokok untuk pembentukan sel yang baru. pada bayi yang sakit biasanya terjadi penurunan nafsu makan yang pada saat itu akan mempengaruhi perubahan berat badan yang dratis, setelah bayi melewati masa tersebut bayi akan meningkat nafsu makannya. pada kelompok usia 6-12 bulan terjadi perkembangan yang pesat misalnya mulai melakukan aktifitas berupa miring kanan kiri, merangkat duduk, berdiri, berlatih berjalan, memegang, berceloteh, menangis membutuhkan nutria yang meningkat dan pada saat ini gigi 174 jurnal ners vol 11 no 2. oktober 2016:170-175 bayi tumbuh pertama kali yang kadang-kadang membuat bayi tidak nyaman, sering reweldan pengalaman pertama bagi bayi untuk perubahan jenis makan yang dimasukan lewat mulut membuat bayi harus beradaptasi. hal tersebut biasanya membuat bayi tidak bernafsu untuk makan dan akan berdampak pada perubahan berat badan. bila fase tersebut sudah dapat dilalui bayi akan meningkat nafsu makannya role attainment ibu dalam pemberian mpasi dengan pertumbuhan bayi usia 6-12 bulan sebagian besar( 54.2%) role attainment/ pencapaian peran ibu dalam kompetensi pemberian mp asi dalam katagori cukup dengan berat bada dalam katagori tidak naik sebesar 38 responden, tetapi juga sebagian besar ( 53.3%) role attainment/ pencapaian peran ibu dalam pemberian mp asi dalam katagori cukup dengan berat badan dalam katagori naik sebesar 32 responden. hasil analissis menggunakan uji statistik didapatkan bahwa ρ = 0,005< 0,05 yang artinya ada hubungan role attainment ibu dalam kompetensi pemberian mp-asi dengan pertumbuhan bayi usia 6-12 bulan. nilai pearson correlation sebesar 0,644 sehingga dapat disimpulkan bahwa hubungan role attainment ibu dalam kompetensi pemberian mp-asi dengan pertumbuhan bayi usia 6-12 bulan adalah kuat atau erat dan arah hubungannya positif artinya semakin banyak bayi dengan role attainment ibu pemberian mp-asi cukup maka pertumbuhan bayi akan mengalami kenaikan. role attainment/ pencapaian peran ibu dalam pemberian mp asi dalam katagori cukup dapat menyebabkan pertumbuhan bayi mengalami kenaikan berat badan. kompetensi diperlukan dalam role attainment/ pencapaian peran (mercer r 2006). kompetensi merupakan suatu kemampuan ibu dalam melaksanakan suatu kegiatan dalam hal ini adalah kompetensi pemberian mp asi. kompetensi dapat diperoleh melalui pengalaman sebelumnya, informasi yang benar dan dukungan sosial. pada ibu yang mempunyai bayi di masyarakat yang di fasilitasi oleh puskesmas dapat mengikuti kegiatan posyandu untuk pemantauan kesehatan bayi dan menambah informasi tentang pengasuhan pada bayi khususnya pemberian mp asi. ibu bila tidak mempunyai waktu untuk mengikuti kegiatan posyandu yang diadakan pagi hari karena ibu bekerja dapat datang ke bpm (bidan praktek mandiri) yang ada pada setiap desa untuk memantau kesehatan bayi dan memperoleh informasi tentang pengasuhan pada bayi khususnya pemberian mp asi. selain itu kegiatan yang digerakan oleh masyarakat ada kelompok pendukung asi (kp asi) yaitu sekelompok orang berkumpul untuk memberikan dukungan kepada ibu yang sedang memberikan asi pada bayinya . didalam kegiatan tersebut banyak dilakukan penyuluhan kesehatan tentang pengasuhan pada bayi termasuk didalamnya penyuluhan tentang pemberian mp asi. apabila ibu lebih rajin datang ke pusat pelayanan kesehatan dan mengikuti kegiatan di masyarakat yang berhubungan dengan pengasuhan pada bayi akan berdampak pada pengetahuan yang meningkat yang pada akhirnya akan mempengaruhi role attainment ibu menjadi baik. simpulan saran simpulan role attainment ibu dalam kompetensi pemberian mp asi pada bayi yang cukup mempengaruhi kenakan berat badan bayi perubahan berat badan bayi selain dipengaruhi oleh role attainment dipengaruhi oleh status kesehatan bayi semakin baik role attainment ibu dalam kompetensi pemberian mp asi akan semakin baik mempengaruhi kenaikan berat badan bayi saran diharapkan ibu meningkatan role attainment dengan memperdayakan dukungan social yang ada di masyarakat yaitu aktif mengikuti kegiatan posyandu, kp asi bagi petugas kesehatan diharapkan mempertahankan dan meningkatkan penyuluhan tentang pemberian mp-asi yang bervariasi sesuai dengan tahapan usia bayi. bagi peneliti selanjutnya, diharapkan dapat melakukan penelitian untuk bayi sampai umur 24 bulan kepustakaan jatim, d., 2014. data status gizi berdasarkan dinkes propinsi jwa timur 2014. available at: www.dinkes-jatim.go.id [accessed february 12, 2015]. role attainment ibu dalam mp-asi (ririn, dkk) 175 kim jihyaongungand k.a.s wickrama, 2013. mother’s working status and infant develoment: mediational procesess. journal of family issues, xx(x). m.r alligo, a.. t., 2006. nursing theoritis and their work edisi 7., mosby inc st louis missouri. mercer r, w. lo, 2006. a review of nursing intervention faster becoming a mother, departement of family health nursing in the univercity of california, usa: san fransisco, burlingame. notoadmodjoo, 2010. metodologi penelitian kesehatan., jakarta: rineka cipta. nusalam, 2013. konsep dan penerapan metodologi penelitian iimu keperawatan, jakarta: salemba medika. ri, d., 2013. no title, jakarta: depkes. riksani, 2012. gambaran pengetahun ibu yang memberikan mp-asi pada bayi kurang dari 6 bulan. available at: www.googlecendekia.com [accessed february 12, 2015]. septiana, 2009. hubungan antara pola pemberian makanan pendamping asi (mp-asi) dan status gizi balita usia 624 bulan di wilayah kerja puskesmas gedongtengen yogyakarta. available at: www.googlecendekia.com. setiadi, 2013. metodelogi penelitian kesehatan, jakarta: egc. soekirman, 2010. ilmu gizi dan aplikasinya untuk keluarga dan masyarakat, jakarta: departemen pendidikan nasional. syams, 2012. psikologi perkembangan., jakarta: egc. yogi, 2014. pengaruh pola pemberian asi dan pola makanan pendamping asi terhadap status gizi bayi usia 6-12 bulan. available at: www.googlecendekia.com [accessed february 12, 2015]. http://e-journal.unair.ac.id/jners | 41 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.22504 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research capacities and needs assessment on health emergency management in biliran province, philippines willard n riveral, john anthony d. ramagos, marian madelyn m. collera, and jeremy b. ohiman biliran province state university-main campus, naval, philippines abstract introduction: this study aimed to describe the level of preparedness of the healthcare facilities and the healthcare professionals concerning the four components (health, psychosocial and mental health, nutrition on emergencies, and water sanitation and hygiene) of the health emergency management system (hems) in the province of biliran. methods: the researchers used a sequential explanatory research design and utilized two sets of research instruments for the purpose of data gathering. the participants were healthcare workers from rural health units (rhus) and representatives from the local government units (lgus) in biliran province in the philippines. for the analysis of the quantitative data, a qualified statistician analyzed the raw data transcribed using the spss imb 21 tool. the qualitative data was analyzed and processed using mayring and miles-huberman’s technique. results: the study found that the respondents were suitable to provide reliable data and to credibly assess the condition of the rhus. they were also knowledgeable enough to determine the gaps confronting the rhus, including their corresponding solutions. the healthcare facilities of the province were only rated to be average. their capacity to provide posttraumatic counselling was poor, although their referral systems were rated excellent. conclusion: the study concludes that the healthcare workers of biliran province and the hems of the eight rhus in the province are not prepared to manage health emergencies during disasters. the low capacity of the hems is due to the low utilization of the budget, resulting in insufficient supplies and equipment which is necessary when addressing people’s immediate needs during disasters and health emergencies. the study recommends a thorough deliberation of the system to plug the gaps and provide rapid equitable health services during emergencies. article history received: october 08, 2020 accepted: january 19, 2021 keywords typhoons; disasters; health emergencies; hems contact willard n riveral  wriveral@yahoo.com  biliran province state university-main campus, naval, philippines cite this as: riveral, w. n., ramagos, j. a. d., collera, m. m. m., & ohiman, j. b. (2021). capacities and needs assessment on health emergency management in biliran province, philipines. jurnal ners, 16(1). 4148. doi:http://dx.doi.org/10.20473/jn.v16i1.22504 introduction the philippines is among the countries in southeast asia that is prone to natural disasters. annually, an average of 80 typhoons develop in tropical waters according to the joint typhon warning center (jtwc) (wingard & brändlin, 2013). about 20 of these typhoons enter the philippine area of responsibility (par) with 6 to 9 of them making landfall. an average of 5 of these typhoons is considered to be deadly. the strongest typhoon that ever had landfall, super typhoon haiyan, struck the country in 2013 with tacloban city and the entire region viii being the hardest hit areas (fischetti, 2013). typhoons in general can result in an outbreak of infectious diseases and in the case of super typhoon yolanda, communicable diseases had the highest consultation rates in community health centers, followed by a https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ w. n. riveral et al. 42 | pissn: 1858-3598  eissn: 2502-5791 consultation related to injuries and noncommunicable diseases (salazar et al., 2017). given the country’s disaster-risk profile, the government enacted republic act (ra) 10212 or the philippine disaster risk reduction and management act of 2010. this institutionalized the proactive disaster risk reduction and management or “drrm” approach. the approach is the “systematic process of using administrative directives, organizations, and operational skills and capacities to implement strategies, policies and improved coping capacities in order to lessen the adverse impacts of hazards and the possibility of disaster” (williams, 2010). with the passing and approval of ra 10212, the national disaster risk reduction and management council (ndrrmc) was established, which the department of health (doh) is a member of. the doh is mandated by law to work hand in hand with lgus, along with other different agencies, to provide aid and health assistance to the communities through its programs such as the health emergency management system (hems). hems is about securing the right to life with dignity as more than just a front line humanitarian response and relief during emergencies (world health organization, 2007) or beyond coping capacity that includes financing and human resources (heylin, 1986). in eastern visayas (region viii), biliran province is considered to be a geo-hazard area. it is ranked number 5 in the country’s top provinces due to the combined risks of climateand weather-related change threats. in addition, biliran’s main island is part of the curvilinear belt of the quaternary volcanic center that is active in the eastern trench (biliran volcano biliran island, n.d.). given the vulnerabilities of biliran province and the country as a whole, it is both critical and vital to evaluate the readiness and capacities of its health management systems during emergencies and crises. this study was undertaken to determine the effectiveness of hems in the province of biliran when handling emergency situations. this is in addition to assessing its readiness to deliver health services in the event of catastrophes. this study was also conducted to revisit the existing health-related programs and health facilities in the province, including their budget utilization, in order to assess their capacities in terms of prevention, mitigation and health service delivery in an emergency setting and in the recovery period after a disaster. this paper can help the province of biliran to determine the level of preparedness of its healthcare facilities, especially in terms of the prevention, mitigation and recovery aspects related to the 4 components of hems; health, psychosocial and mental health, nutrition and wash. by knowing the status of their healthcare facilities including its strengths and weaknesses, the province can easily craft programs that will enhance the health services and capacities. this will be considered on par with the standards set by the doh and other relevant agencies. the study can also add to the existing literature and to aid other studies in support of the local and international efforts of the governments and its agencies in relation to providing quality and immediate healthcare during disasters. to guide the study regarding its conduct, the researchers assessed the three pillars that comprise the hems of biliran province. the three pillars are profiles, the readiness capacity and financial capacity. these together make up the foundation of hems. once the three pillars have been assessed through data gathering and analysis, the level of the four components of hems will be determined. the researchers can then describe the current state of hems in the 8 rhus of biliran that have contributed, thus fulfilling the objectives of the study. materials and methods this study was primarily qualitative with a very minimal quantitative component. it only used the quantitative dimension during the gathering of the data that utilized checklists and a rating system to draw out the findings and conclusions. no extensive and elaborate quantitative tools were utilized for the computations. the study further utilized sequential explanations as its research design. the samples of this study were taken from the 8 rhus and lgus of biliran province. the purposive sampling method was used to select the 33 study participants. the samples were healthcare workers, such as municipal health officers, midwives and nurses and budget officers, from the lgus. the respondents of the fgds were representatives from the lgu which consisted of one planning coordinator, one budget and finance officer, and two rhu representatives. the inclusion criteria were employment in one of the 8 rhus and lgus of biliran province. the exclusion criteria were all those not mentioned in the inclusion criteria. the second phase of the data collection process involved collecting qualitative data from the key informant interviews and focus group discussions. the qualitative data gathered assisted the researchers in explaining and interpreting the quantitative side of the research. the interviews assisted the researchers in coming up with the preliminary analysis of the data. to ensure that the data was gathered properly, pre-field activities including the preparation, pre-testing and modifying of the questionnaire tool were conducted. the modified questionnaire went through pilot testing at five different sites utilizing cronbach’s alpha test. the tool had to attain a value of 86% in the five selected disaster-prone sites in order to validate its reliability and internal consistency. this also entailed training the field enumerators or fieldworkers based on the research instruments administered. focus group discussions were conducted among the rhu personnel in order to gather insights specifically related to determining the gaps or challenges in the 8 rhus of biliran. jurnal ners http://e-journal.unair.ac.id/jners | 43 the researchers used a modified version of the doh safe hospital in emergencies and disaster or shed (health emergency management bureau & who western pacific regional office, 2009) and the who hospital emergency response or her (commission, 2013) checklists and rating system as it consists of research instruments with question at the end of the checklist in such a way that the instrument will capture both the qualitative and quantitative data. the ratings were based on the healthcare facility’s structure, readiness, referral system, healthcare capacities, emergency preparedness, supplies, water and food capacity, sanitation and waste disposal capacity, and post-traumatic counseling capacity. all of the indicators were rated with 5 as the highest or excellent and 1 as the lowest or poor. to utilize the forms, the checklist was filled in by the local healthcare professionals in the 8 lgus in the province. to ensure the quality of the data collection, a series of activities were conducted prior to the actual gathering of the data. the activities included the preparation, pre-testing and modifying of the questionnaire tool. the modified questionnaire went through pilot testing at 5 different sites utilizing the cronbach’s alpha test. the tool had to attain a value of 86% in the 5 selected disaster-prone sites in order to validate its reliability or internal consistency. this also entailed training the field enumerators or fieldworkers based on the research instruments administered. post-field work activities were also conducted. the activities were not limited to the final drafting and processing of the report and data and it entailed other relevant activities such as a review of the data gathered to achieve the desired output. the collection of the data was conducted between january 2017 and october 2018 in all 8 rhus and lgus in the province of biliran in the philippines. the questionnaires were personally administered and collected by the lead researcher with the help of the research assistants. ample time was given for the respondents to accomplish the questionnaire and to answer the questions during the interviews and focus group discussions. some of the topics discussed included the current state of their rhu and other related information in relation to their health care facility’s capacity to respond to emergency situations. the respondents were also asked to describe their health care emergency budget and its utilization over the last 5 years. the retrieval of the questionnaires was also done by the researchers. the gathered data was analyzed based on its type. for the quantitative data, basic statistics were employed. all raw data was transcribed into spss imb 21 for analysis and evaluation by a qualified statistician. the qualitative data was analyzed and processed using mayring (mayring, 1969) and mileshuberman’s (dull & reinhardt, 2014) technique. mayring (mayring, 1969) utilized systematic and rule guided qualitative text analysis which attempts to contain some of the methodological strengths of the quantitative context analysis to arrive at a concept of the qualitative procedure. on the other hand, mileshuberman’s (dull & reinhardt, 2014) technique describes the major parts of the data analysis such as the data reduction, data display, conclusion drawing and verification. the thematic analyses extracted from the principles were validated by the respondents of the kiis and fgds. the instruments used in the study were found to be valid and reliable as they were developed by the world health organization and are utilized by the government’s lead agency to provide the public health services. this study adhered to ethical principles in the conducting of this research. before gathering the data from the target offices and individuals, the researchers communicated with the target respondents’ respective head of office. the researchers were also provided with approval by the ethics committee of their institution and relevant entities which allowed them to conduct the data collection for the benefit of the study. before the data gathering, the participants were oriented with the purpose of the study and assured confidentiality regarding the data collected from them. data protection was also observed throughout and after the conducting of the study. after the data gathering and interviews were completed, the researchers thanked the participants for their participation. the researcher stored the data for a year after the research was completed, after which the data will be completely deleted. results in reference to the 10 the data shows that the respondents were either middle aged or old-aged, and that the majority of them (81%) were female. the majority of the respondents (37%) were comprised of public health midwives, followed by municipal health officers (30%). another finding of the study is that the majority of respondents were degree holders of nursing, midwifery and other programs. furthermore, 97% of the respondents hold permanent positions while the remaining 3% hold contractual positions. regarding the structure of the rhus, the highest rating was 3 garnered by both naval and caibiran rhus with biliran having the lowest at 1. the rhu facilities were rated based on their capacity to accommodate patients during both normal and emergency situations and whether they have an ongoing physical plan for improvement. the rhu was also rated based on their accreditation given by the national disaster medical system. regarding the readiness capacity of the rhus, caibiran and naval both gathered a rating of 3. the rest of the rhus were at 2 and 1. it must be noted that 3 is an average score, which means that the rhus did not reach the optimum standard rating for an rhu to be considered prepared. the readiness capacity of the rhus was assessed based on the number of available health personnel who were on-call 24/7, the w. n. riveral et al. 44 | pissn: 1858-3598  eissn: 2502-5791 availability of ppes in the rhus and the trainings that the health workers have undergone. regarding the aspect of the referral system and its functionality, the study found that all 8 rhus were rated 5 or excellent. this means that the personnel are already trained and knowledgeable and have a full understanding of the process and what they are going to do when they need to refer a patient to the nearest recommended health facility for further medical assistance. in terms of the healthcare capacity, the results show that caibiran and naval are both rated 5 for this category while the lowest rated were biliran and maripipi at 3. emergency preparedness, which was the main point assessed in this study, refers to the rhu’s existing emergency disaster plan and its usability. the study found that 5 out of the 8 rhus only have average capacities while the remaining 3 rhus were rated below average. concerning the availability of supplies, water and food in the rhus during disasters, only caibiran obtained a score of 4 while the rest of the rhus were rated 3. a similar finding was noted for the sanitation and waste disposal capacity of the rhus. all rhus were rated above average. another salient finding of the study was the rhus’ poor capacity to provide post-traumatic counselling, which was poor across all rhus with only 2 or below average to 1 or poor as their rating. to satisfy the aim of the study, which was to identify the gaps and challenges in the rhus and to find tailored-fit solutions for the identified gaps, the data collected was categorized into three groups; prevention, mitigation and recovery. the following table 1, table 2 dan table 3 are presented on the supplementary materials (supplementary 1). discussion regarding the budget utilization trends, it was found that there is a budget allocation for health emergencies in all rhus in biliran. however, it is glaring and noticeable that the majority of the expenditure is way lower than the budget allocated. for instance, naval had a 6.2 million budget allocation for health emergencies in 2016. however, they were only able to spend 2 million of the funds allocated. in kawayan, they had a budget of 3 million but were only able to spend around 700 thousand in 2015. this trend is similar across all of the rhus in biliran province within the 5-year period. healthcare professionals’ profile the study primarily perused the demographic profile of the healthcare professionals who were interviewed as the key informants and participants of the focus group discussions. as can be noticed on the results, the majority of the participants were from the categories of old age and middle age. or 46 to 59 years old and 22 to 45 years old respectively. both age groups totaled 42% of the total number of respondents. this is not a far cry from the findings of abrigo and ortiz (abrigo & ortiz, 2019) stating that the median age for physicians and other health workers is 42. this goes to show that the respondents who participated in the study were in their prime (22 45 years old) who can thus effectively articulate and express their ideas in a straightforward manner. on the other hand, those belonging to the older group (46 59 years old) had been working in the health industry long enough to share their insights and experience that was necessary when creating the valuable analysis in this study. based on the data gathered from the survey forms, 27 (82%) were female while only 6 (18%) were males. this imbalance between the number of male and female health workers was also mentioned in the study by szabo et al. (szabo et al., 2020) in their research in nepal and finland. this finding also corroborates with the study by abrigo and ortiz (abrigo & ortiz, 2019) stating that the once maledominated industry has shifted towards being female-dominant. this is not only in the setting of the philippines but also in western countries such as in canada, where 4 out of every 5 health workers are women (galarneau, 2006). according to the world health organization, 70% of the world’s current health workers are women (ghebreyesus, 2019). the top position in the rhus, that of the municipal health officer (mho), is also handled mostly by women at 70% with only 30% being men. this contradicts the findings of ghebreyesus (ghebreyesus, 2019) stating that men are more likely to be physicians and specialists than women, and that they are more likely to hold a leadership position. while the global statistics and data show that the overall labor and working conditions for women is disadvantageous compared to men, having more women healthcare workers in the rhus or in the local settings makes the healthcare services more accessible and equitable for women, especially those with special needs. this includes pregnant or lactating mothers because women healthcare workers can more easily understand their special needs and are more likely to provide these services to women, especially during disasters when the healthcare services are highly needed. the results of the study indicate that the majority of the respondents are public health midwives (phm) (37%), followed by public health nurses (30%) and mhos (24%). this data further concretizes the findings of the different studies indicating a lack of mhos or doctors in the rural health units (rhu). the majority of the lgus in biliran have only one government medical doctor. this is inversely proportional to the population to be served, especially during disasters. the results of the kiis and fgds coincide with this data as the respondents shared that they need more health officers in the evacuation centers and medical doctors during disasters. the philippines health systems review written by dayrit (dayrit et al., 2018) and their colleagues stated that there are only 3.9 government https://docs.google.com/document/d/1pe3mbriiaoiucsmhncdfi2_k2akgh59h/edit?usp=sharing&ouid=108703314134198291339&rtpof=true&sd=true jurnal ners http://e-journal.unair.ac.id/jners | 45 physicians in the country for every 10,000 population. the study also revealed that 97% of the respondents hold permanent positions in the rhus while only 3% of the respondents have a contractual employment status. this reveals that while there is an insufficient number of healthcare workers in the rhus, the workers are predominantly holding permanent positions which somehow augments the labor conditions of the healthcare workers in the rural health units. however, this does not negate the need to hire additional doctors and healthcare workers to meet the healthcare demands of the people, especially during emergencies. healthcare facility profile the healthcare facilities of the 8 rhus in biliran province were gauged in terms of their preparedness to provide any of the necessary health services during disasters. the ratings were based on the healthcare facility’s structure, readiness, referral system, healthcare capacities, emergency preparedness, supplies, water and food capacity, sanitation and waste disposal capacity, and post-traumatic counseling capacity. all of the indicators were rated with 5 as the highest or excellent and 1 as the lowest or poor. for the structure of the rhus, the highest rating was 3 garnered by both naval and caibiran rhus with biliran having the lowest at 1. the rhu facilities were rated based on their capacity to accommodate patients during normal and emergency situations, and if they have an on-going physical plan for improvement. for the referral system of the rhus and their functionality, all 8 rhus were rated 5 or excellent. this means that the personnel are already trained and knowledgeable and have full understanding of the process and what they are going to do in case they need to refer a patient to the nearest recommended health facility for further medical assistance. healthcare capacities is used to refer to the rhus’ capacity to provide medical assistance such as burn care, wound/trauma care, neonatal care and maternal care, among others. the results show that caibiran and naval were both rated 5 for this category while the lowest ratings were given to biliran and maripipi at 3. although the latter rhus got the lowest rates, they are still considered to be average. thus, they can still dispense the necessary healthcare during normal days and during emergencies. emergency preparedness, the main point assessed in this study, refers to the rhu’s existing emergency disaster plan and its usability. the data revealed that 5 out of the 8 rhus only have average capacities while the remaining 3 rhus were rated below average. regarding the availability of supplies, water and food in the rhus during a disaster, only caibiran obtained a score of 4 while the rest of the rhus were rated 3. this is a similar finding to the data on sanitation and waste disposal capacity in the rhus. all rhus were rated above average. water and food supply are heavily related to sanitation and the waste disposal capacity because if there is no water and food supply, sanitation will be a major challenge, especially in an evacuation setting where the centers are normally crowded. if there are large number of families cramped into an evacuation center, the chances are that the sanitation and waste disposal will be poor, more so if there are only few personnel manning the area. it was revealed that the rhus are capacitated to provide the necessary services when needed, such as in the case of emergencies. based on the results of this study, the capacity of rhus to provide post-traumatic counselling was poor across all rhus with only 2 or below average to 1 or poor as the given rating. in developing countries such as the philippines, the provision of mental health and psychosocial services is often neglected during disasters and emergencies due to scant resources. whatever resources the lgus have would be allocated to immediate needs such as relief goods, retrieval operations and evacuation center maintenance. mental health is commonly not considered to be a priority, more so because its impact is not easily detectable unless a thorough examination is conducted by experts. readiness capacity of the 8 rhus in biliran province: gaps/challenges and identified tailored-fit solutions the data gathered from the respondents during the kiis and fgds were categorized into 3 groups: prevention, mitigation and recovery. as illustrated in table 1, the respondents cited insufficient funds as being behind the lack of training and capacity building in its front liners, particularly the bhws and responders at the barangay level. this knowledge gap was mentioned in khan’s (khan et al., 2018) study, in addition to the need to come up with a framework that understands the complexity of health systems in an emergency context. by having the right capacities and plans in place, the overwhelming of the health systems during disasters will be prevented (landesman & burke, 2017). the respondents also emphasized that in order to prevent disarray during disasters, supplies such as medicines, emergency kits and even food packs should be prepared at all times. there should also be a separate supply of medicines that are specifically allocated for emergency purposes. this way, the rhus are prepared at any given time if a disaster or emergency strikes. another gap identified by the respondents in terms of prevention is poor garbage collection since there is an insufficient number of garbage trucks. this is also aggravated by the fact that some of the houses do not have their own toilets. with systematized sanitation in the communities, an outbreak of diseases could be effectively prevented. regarding the aforementioned gaps, the respondents recommended the early procurement of supplies, medicines and food packs in order to prevent w. n. riveral et al. 46 | pissn: 1858-3598  eissn: 2502-5791 cramming and for the proper distribution of basic necessities to take place in the event of disasters. table 2 presents the gaps and challenges identified by the respondents in terms of mitigating the impact of disasters, including the tailored-fit solutions recommended. the respondents identified a lack of information and awareness in the surrounding communities as one of the major barriers to reducing or mitigating the effects of disasters. for instance, anthropogenic activities, such as throwing of garbage and human and animal waste into the sea, can result in health threats and emergencies. that said, they can be prevented with the right awareness of its effects. during disasters, a lack of understanding of how to behave, such as maintaining personal hygiene while staying at evacuation centers, can also increase the risk of contracting and spreading communicable diseases, especially among vulnerable groups. all of these can also be addressed with the right information disseminated to the public prior to disasters. however, it was also expressed by the respondents that one of the barriers to getting a full grasp on the impact of disasters is difficulty understanding the communication materials provided to the communities. thus, the respondents recommend that the authorities use the local dialect when spreading information to the communities. one glaring example was the use of the term “storm surge” by the authorities during super typhoon haiyan. had the people known what a storm surge was or had the authorities used the term tidal wave instead, more people would have evacuated and the impact of the super typhoon would have been mitigated (ocon & olaff, 2015). the lack of manpower and healthcare workers in the health facilities and evacuation centers was also pointed out by the respondents. having enough healthcare workers would also spread out the delivery of services among the evacuees and victims of the disaster, allowing the evacuation centers to be effectively managed. then again, this relates back to the need for a budget since hiring more rhu personnel requires an additional budget for their salaries and benefits. this reflects that there are several aspects and elements involved in effectively mitigating the impact of disasters and emergencies, and that it is important to take a comprehensive look at the different aspects in order to manage the situation and understand how the aspects interplay (pourhosseini et al., 2015). another challenge identified by the healthcare workers in the rhus is the lack of the necessary means to respond to emergencies, such as the lack of ambulances or vehicles for rescue operations, the lack of communication equipment, no back up or emergency power supply and the limited budget with which to operationalize rescue initiatives. the respondents believe that having all of these needs met/in place would dramatically reduce the impact of disasters. the respondents also mentioned that their rhu is located right in front of the sea. they see this as a potential risk to their safety and to that of the people who will seek medical assistance from the rhu during an emergency. simpson (simpson, 2001) in his study stated that the key to averting disaster or minimizing its effects is a solid data security plan where a facility identifies the existing risks and develops a plan to counteract them to ensure the patient’s health and their data. the findings of simpson’s study correlates with the cited solution of the respondents which is to review the hazardous areas in their locality and to implement the necessary steps to mitigating the risks and its impacts. table 3 reveals the identified gaps and challenges and the corresponding solutions that the respondents identified in terms of recovery after a disaster. knowing that biliran province is considered to be a geo-hazard area, the area is prone to natural calamities and other forms of health emergency. the lack of evacuation centers and facilities currently hampers its immediate recovery after a disaster strikes. a contingency plan for disaster recovery (disaster & recovery planning : a guide for, n.d.) that includes the construction of the necessary buildings and infrastructure is a sound solution to the identified gap. however, the data reveals that even if the rhus created exemplary plans to hasten the recovery of the health system, the plans would be rendered useless without the necessary budget and its speedy release. faster recovery after a disaster would also be easier to achieve if there was the necessary equipment made available, such as backhoes for road clearing operations. this statement was also mentioned in the study by dela cruz and ortega-dela cruz (cruz & cruz, 2019) where they found that a lack of equipment, technological innovations, insufficient knowledge, and skills and human resources hampered the speedy recovery of a disaster-stricken area. the purchasing of heavy equipment or linking to the right government agencies were seen of as two solutions to this particular recovery challenge. budget utilization trends of the 8 rhus in biliran province this study looked into the budget allocation of the 8 rhus of biliran vis-à-vis their actual utilized funds or expenditures. the data was collected over 5 years from 2013 to 2017 to determine the budget utilization trends of the rhus for health emergencies. it must be noted that there was no data for the total funds expended (tfe) in 2017 for all rhus because the figures were not yet made available as of the time of the data gathering. by looking at the figures, one can easily determine that there is budget allocation for health emergencies in all rhus in biliran. however, it is noticeable that the majority of the expenditure is way lower than the budget allocated. this goes to show that the lgus allocate funds for health emergences, although the amount varies depending on the budgetary and jurnal ners http://e-journal.unair.ac.id/jners | 47 financial conditions. nevertheless, there are funds for health emergencies. the only thing questionable is the low burn rate or expenditure of the rhus. the data gathered from the lgus contradicts with the data collected from the respondents stating that there are limited supplies for use in an emergency response due to insufficient funds. the figures coincide with the findings of katz, attal-juncqua and fischer (katz et al., 2017) stating that allocating a budget for health emergencies would not suffice without coordination and the speedy disbursement of funds. barasa et al. (barasa et al., 2017) also emphasized the importance of proper budgeting in their study. the researchers were able to find conclusive evidence to satisfy the aims of this study. however, this study is limited to the provinces of biliran with the samples derived from the rhus and lgus. the sample representatives from the lgus were low since most of them were not available during the time of the data collection. however, this limitation does not negate the quality and validity of the general findings of this study. conclusion all in all, based on the demographic data, the respondents were the key healthcare personnel from the rhus and lgus in biliran who were able to dispense reliable information and were knowledgeable on the subject matter. while the facilities and its personnel are capable of referring patients, due to the capacities given, the rhus and its healthcare workers fall short or are even rated poor in terms of providing post-traumatic counselling due to the fact that mental health is not a priority service during disasters. the study concludes that a gap lies in the process of requesting, disbursement and procurement which logically impacts on the service delivery throughout the prevention, mitigation and recovery phases during a disaster. the study also concludes that if and when a disaster strikes at any given time, the healthcare facilities may have difficulty delivering adequate services or providing immediate relief or rescue operations because the health emergency management system requires a thorough deliberation to stop the gaps and provide rapid equitable health services, especially to the underserviced and vulnerable groups. the gaps and challenges in the health emergency management systems are recognized and tailored-fit solutions have been accurately and reliably identified. the problem lies in the process and lack of the right capacities of the rhus to follow and understand this process for the right and timely utilization of the budget. furthermore, this study recommends providing capacities and involving healthcare professionals and workers in the budgeting and overall financial process in order for them to contribute to developing effective health emergency plans that address the recurring needs of the communities during disasters and emergencies. acknowledgment the authors would like to extend their sincerest gratitude to everyone who made this study possible. to biliran province state university president dr. victor c. canezo jr. for all of his support, to past nsu oic president dr. matias bentor jr. for the endorsement and to the evhrdc family for their trust and guidance. thanks also go to mr. jeremy b. ohiman for their support all the way, to dr. ophelia mendoza for the training and mentoring, and to ms kathreen macawili for polishing the final report. the authors also wish to thank the different government agencies that provided assistance during the data gathering in the lgus and communities, specifically the pdrrmo, dilg, bph, doh-pho and the 8 municipalities in the province of biliran, especially the respondents. the authors would also like to express their gratefulness to their parents for their patience, support and understanding, and above all, to god to whom everything is dedicated. references abrigo, m. & ortiz, d. (2019, december). re: who are the health workers and where are they? revealed preferences in location decision among health care professionals in the philippines. philippine institute for development studies. barasa, e., cleary, s., molyneux, s. & english, m. (2017). setting healthcare priorities: a description and evaluation of the budgeting and planning process in county hospitals in kenya. health policy and planning, 32(3):329– 337. https://doi.org/10.1093/heapol/czw132 biliran island. (n.d.). biliran volcano. retrieved from https://www.biliranisland.com/volcano/biliranvolcano/ brändlin, a.s. & wingard, j. (2013). philippines: a country prone to natural disasters. centers for disease control and prevention. (2018). public health emergency preparedness and response capabilities. dela cruz, r. & ortega-dela cruz, r. (2019). mangement of public healthcare facilities in the philippines: issues and concerns. british journal of healthcare management, 25(10). https://doi/abs/10.12968/bjhc.2019.0018 department of health. (2009). safe hospital in emergencies and disaster or shed checklist. fischetti, m. (2013). was typhoon haiyan a record storm? galarneau, d. (2003). health care professionals. perspectives on labour and income, 4(12). ghebreyesus, t. (2019). female health workers drive global health. hannah, k.j., ball, m.j., & edwards, m.j. (2006) disaster recovery planning. in: introduction to nursing informatics. health informatics (formerly computers in health care). springer, https://doi.org/10.1093/heapol/czw132 https://www.biliranisland.com/volcano/biliran-volcano/ https://www.biliranisland.com/volcano/biliran-volcano/ w. n. riveral et al. 48 | pissn: 1858-3598  eissn: 2502-5791 new york, ny. https://doi.org/10.1007/978-0387-32189-9_17 katz, r., attal-juncqua, a., & fischer, j. e. (2017). funding public health emergency preparedness in the united states. american journal of public health, 107(s2), s148–s152. https://doi.org/10.2105/ajph.2017.303956 khan, y., o’sullivan, t., brown, a. tracey, s., gibson, j., genereux, m., henry, b. & schwartz, b. (2018). public health emergency preparedness: a framework to promote resilience. bmc public health, 18 (1344). https://doi.org/10.1186/s12889-018-6250-7 mayring, p. (2000). qualitative content analysis [28 paragraphs]. forum qualitative sozialforschung / forum: qualitative social research, 1(2), art. 20, http://nbn-resolving.de/urn:nbn:de:0114fqs0002204 miles, m.b, and huberman, a.m. (1994). qualitative data analysis, 2nd ed., p. 10-12. newbury park, ca: sage. national disaster risk reduction and management council. (n.d.). national disaster response plan. retrieved from https://www.preventionweb.net/files/62898_na tionaldisasterresponseplanforeart.pdf ocon, g. & neussner, o. (2015). assessing early warning efforts for typhoon haiyan in leyte. retrieved from https://odihpn.org/magazine/assessing-earlywarning-efforts-for-typhoon-haiyan-in-leyte/ pourhosseini, s. s., ardalan, a., & mehrolhassani, m. h. (2015). key aspects of providing healthcare services in disaster response stage. iranian journal of public health, 44(1), 111–118. salazar, m. a., law, r., pesigan, a., & winkler, v. (2017). health consequences of typhoon haiyan in the eastern visayas region using a syndromic surveillance database. plos currents, 9, ecurrents.dis.4a3d3b4474847b2599aa5c5eefe3a 621. https://doi.org/10.1371/currents.dis.4a3d3b447 4847b2599aa5c5eefe3a621 simpson, r.(2001). what to do before disaster strikes. nursing management (springhouse), 32 (11): p 13-14. szabo, s., nove, a., matthees, z., bajracharya, a., dhillon, i., singh, d., saares, a. & campbell, j. (2020). health workforce demography: a framework to improve understanding of the health workforce and support achievement of the sustainable development goals. human resources for health, 18(7). https://doi.org/10.1186/s12960-020-0445-6 united nations. (2009). 2009 unisdr terminology on disaster risk reduction. retrieved from https://www.unisdr.org/files/7817_unisdrter minologyenglish.pdf world health organization. (2007). risk reduction and emergency preparedness. world health organization. (2011). hospital emergency response (her). https://doi.org/10.1007/978-0-387-32189-9_17 https://doi.org/10.1007/978-0-387-32189-9_17 https://doi.org/10.2105/ajph.2017.303956 https://doi.org/10.1186/s12889-018-6250-7 http://nbn-resolving.de/urn:nbn:de:0114-fqs0002204 http://nbn-resolving.de/urn:nbn:de:0114-fqs0002204 https://www.preventionweb.net/files/62898_nationaldisasterresponseplanforeart.pdf https://www.preventionweb.net/files/62898_nationaldisasterresponseplanforeart.pdf https://odihpn.org/magazine/assessing-early-warning-efforts-for-typhoon-haiyan-in-leyte/ https://odihpn.org/magazine/assessing-early-warning-efforts-for-typhoon-haiyan-in-leyte/ https://doi.org/10.1371/currents.dis.4a3d3b4474847b2599aa5c5eefe3a621 https://doi.org/10.1371/currents.dis.4a3d3b4474847b2599aa5c5eefe3a621 https://doi.org/10.1186/s12960-020-0445-6 https://www.unisdr.org/files/7817_unisdrterminologyenglish.pdf https://www.unisdr.org/files/7817_unisdrterminologyenglish.pdf 188 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.28037 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research challenges of online education among university students, saudi arabia lizy sonia benjamin1, b. joshua steve abishek2, yulis setiya dewi3, priya sivaram4, and yoyok bekti prasetyo5 1department of medical-surgical nursing, king khalid university, abha, kingdom of saudi arabia 2department of bioinformatics, sastra university, thanjavur, india 3faculty of nursing, universitas airlangga, surabaya, indonesia 4apollo college of nursing, chennai, india 5faculty of health sciences, university of muhammadiyah malang, indonesia abstract introduction: online education during covid 19 pandemic is witnessing significant growth, particularly in higher education. the aim of the study will explore the challenges that are being encountered related to online education for nursing students. methods: a correlational study using cross-sectional approach was adopted among 150 participants selected through convenient sampling technique. data was collected through electronic survey from undergraduate students participated voluntarily studying in college of nursing, king khalid university, abha, saudi arabia. the survey forms (rating scales on satisfaction and barriers of online education) were used to collect the data. descriptive and inferential statistics were used to analyze the data by using spss version 24.0. results: the results revealed nearly 92% of participants were highly satisfied with online education. the mean scores and sd related to satisfaction of online education was (37.50+ 8.50). the global perceived barriers mean scores and sd were (35.19+11.19) which indicates that they were able to quickly adopt new strategies by overcoming the limitations. conclusion: the researcher concludes with the fact that study findings support that, students had positive perception on benefits of online learning by overcoming the limitations. in conclusion, online teaching and learning can be effectively incorporated in future also using blended approach. article history received: july 05, 2021 accepted: november 16, 2021 keywords online education; e-learning; nursing; covid 19 pandemic; university students contact yulis setiya dewi  yulis.sd@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: benjamin, l., s., abishek, b., j., s., dewi, y., s., sivaram, p., & prasetyo, y., b. (2021). challenges of online education among university students, saudi arabia. jurnal ners, 16(2). 188-192. doi: http://dx.doi.org/10.20473/jn.v16i2.28037 introduction digital transformation is not a novel phenomenon, and it has been accompanying higher education institutions for some years now (leszczyński et al., 2018; kopp, gröblinger and adams, 2019). digital transformation of higher education institutions is a topical issue that involves several stakeholders of education must feel concerned about, abilities to apply ict in every spheres of life, thus universities must be up to the task of preparing potential professional to be able to face challenges and provide solutions (sandkuhl, k., & lehmann, 2017; bond et al., 2018), and this transformation has suggested the integration of sustainable management to be able to adjust to the modifications enforced as a result of novel technologies (abad-segura et al., 2020) and pandemic recently. digital transformation in the context of higher education institutions can be regarded as the summation of all digital processes required to accomplish transformation process that gives higher education institutions the opportunities to positively apply digital technologies optimally (kopp, gröblinger and adams, 2019). this process also consists of adequate strategic preparation, trust establishment, thinking in processes, amalgamation https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v16i2.28037 jurnal ners http://e-journal.unair.ac.id/jners | 189 and reinforcement of all parties involved, separate, collaborative and organizational knowledge (cameron and green, 2019). a study to assess the challenges of online education among undergraduate university students, king khalid university, saudi arabia. covid-19 pandemic has disrupted face-to-face teaching in university students globally. the global impact of the covid-19 pandemic on education systems across the world has led to major and rapid changes in the provision of higher and medical education, with increasing delivery of the curriculum by online approaches. a recent synthesis of the global responses by universities to the covid-19 pandemic noted that the majority of universities were using online learning, but with differences between countries in the rapidity and extent of the shift (gaur et al., 2020). this pandemic has forced global physical closure of businesses, sport activities and schools by pushing all institutions to migrate to online platforms. online learning is the use of internet and some other important technologies to develop materials for educational purposes, instructional delivery and management of program (fry, 2001). there are two types of online learning, namely asynchronous and synchronous online learning, are majorly compared but for online learning to be effective and efficient, instructors, organizations and institutions must have comprehensive understanding of the benefits and limitations (hrastinski, 2008). designing effective online learning requires careful consideration of many inter-related factors. the factors include the previous experience and preferences of students in using online learning, the experience of the educators in the use of online learning, the available technology, the learning content and the curriculum, the instructional approach to pro-vide activities that enhance learning and the local context, such as the culture and available infrastructure resources (zaharias and poylymenakou, 2009). all of these factors are unique to a specific local context and optimization of online learning requires a close alignment between the different factors within each context. the use of remote learning as an emergency measure has affected students, faculty, support staff, and administrators. the aim of this narrative review paper is to examine the challenges and opportunities faced by medical schools in implementing remote learning for basic science teaching in response to the covid-19 crisis. in a study conducted by (sean, block and judge, 2014) regarding certified adapted physical educators’ (capes) advantages and disadvantages of online education. one-hundred and six capes representing 29 states completed the survey in us. the age range was 22 to 67 years (m=42), 72% of respondents were female, and average years of experience ranged from 1 to 38 years (m= 12.9). nearly 86% reported to be satisfied with the experience. the perceived barriers of online education were studied among 211 undergraduate students enrolled in fundamental english course. results indicated that the levels of needs and barriers of online learners in general were moderate. there were no statistically significant differences at 0.05 level found in barriers and needs of online learners as classified by gender, computer ownership, and computer aptitude. there was a negative relationship between computer table 1. frequency & distribution of demographic variables of participants related to challenges of online education (n=150) baseline characteristics n % level 3 32 21.3 4 19 12.6 5 18 12 6 19 12.6 7 28 18.6 8 34 22.6 age in years 1720 113 75.3 21-30 19 12.6 above 30 18 12 gender female 100 100 marital status single 141 94 married 9 6 area of residence urban 108 72 rural 42 28 previous online education no online experience 101 74.3 taken online courses 49 25.7 most commonly used online tool blackboard collaborator 109 90.8 zoom 41 9.2 preference of lectures live 42 22.6 recorded 60 13 live and recorded 48 64.4 table 2. mean and sd of satisfaction scores of online courses among the students (n=150) score obtainable score mean sd level satisfaction score 10-50 37.60 8.50 highly satisfied table 3. mean and sd of perceived barriers of online courses among the students (n=150) barriers obtainable score mean sd teaching and learning 5-25 14.55 4.52 communication 1-5 2.27 1.14 use of technology 1-5 2.27 1.13 internet 2-10 5.36 2.16 physical 4-20 10.43 4.33 global score 13-65 35.19 11.19 l. s. benjamin et al. 190 | pissn: 1858-3598  eissn: 2502-5791 aptitude and barriers of online learners at 0.01 level (srichanyachon, 2014). the pandemic has posed several challenges to premedical education (e.g., suspension of face-to-face teaching, lack of cadaveric dissections, and practical/laboratory sessions) but has provided many opportunities as well, such as the incorporation of online learning in the curriculum and upskilling and reskilling in new technologies. to date, many medical schools have successfully transitioned their educational environment to emergency remote teaching and assessments. during covid-19 crisis, the preclinical phase of medical curricula has successfully introduced the novel culture of “online home learning” using technology-oriented innovations, which may extend to post-covid era to maintain teaching and learning in medical education. however, the lack of hands-on training in the preclinical years may have serious implications on the training of the current cohort of students, and they may struggle later in the clinical years. the use of emergent technology (e.g., artificial intelligence for adaptive learning, virtual simulation, and telehealth) for education is most likely to be indispensable components of the transformative change and postcovid medical education. the article includes an exploration of the satisfaction, methods of evaluation and perceived barriers related to online education among students studying in college of nursing, saudi arabia. materials and methods a correlational study using cross-sectional approach was used to fulfill the objectives of the study. the total population of the nursing students at king khalid university is 300. the study adopted convenient sampling technique conducted among 150 undergraduate students studying b.sc nursing in college of nursing, king khalid university, abha, saudi arabia. female students above 17 years of age, who showed willingness to participate were only selected for the study. data was collected using tools such as baseline profile of participants and rating scale to assess the challenges of online education. the following tools were used for data collection. 1)proforma to collect baseline variables of the students. it was used to collect information on background characteristics such as gender, age, experience, and characteristics related to computer skills and online teaching & learning. 2)rating scale on perceived benefits, of online education among students. there are 20-items, 5-point likert scale (5-strongly agree, 4-agree, 3not sure, 2-disagree, 1-strongly disagree). the obtainable score was 20-100. higher scores indicated positive perception and vice versa. 3)rating scale on perceived barriers, of online education among students. there are 20-items, 5-point likert scale (1 not a barrier, 2somewhat a barrier, 3-not sure, 4barrier, 5significant barrier) under five sub components such as teaching-learning barriers (5 items), physical barriers (5 items), internet barriers (3 items), technology barriers (3 items) and communication barriers (4 barriers). the obtainable score was 20-100. higher scores indicated more barriers and vice versa. the study was conducted after obtaining clearance from ethical committee, king khalid university, saudi arabia approval number ecm#2020-0807. consent was obtained from all the participants, before the data collection. confidentiality was maintained throughout the study. data was collected from participants through electronic google forms. descriptive and inferential statistics were used to analyze the data by using spss version 24.0. results a total of 150 students participated in the study. table 1 illustrates baseline profile of the participants from college of nursing, king khalid university, abha. the table 4. association between selected variables and satisfaction of online education (n=150) variables n mean sd test statistics (anovaf) p value gender 1.28 p>0.05 female 150 35.22 10.96 marital status single 141 35.21 11.0 0.199 p>0.05 married 9 34.76 14.38 area of residence urban 168 35.03 10.67 0.516 p>0.05 rural 82 35.61 12.56 previous online education no online experience 108 34.84 11.98 0.342 p>0.05 taken online courses 41 35.27 11.01 table 5. correlation between age and satisfaction & age and barriers of online courses students (n=150) variables r value p value age vs satisfaction 0.039 0.375 ns age vs barriers -0.008 0.856 ns jurnal ners http://e-journal.unair.ac.id/jners | 191 respondents’ opinions on whether online education was satisfactory or not and whether they would prefer online from traditional learning are vividly illustrated in the tables and figure 1. the present study revealed that more than half of the study participants were between the age group of 17-20 years (53.3%) female students (51.4%). majority of the participants were unmarried (95.6%) with their area of residence from city (73.4%) had no online education previously. majority of the participants utilized blackboard collaborator (90.8%) preferred live and recorded lectures (64.4%). table 2 denotes the satisfaction score of online education were highly satisfied with mean and sd (37.50+ 8.50) and 92% were satisfied with online education. the perceived barriers of online courses can be highlighted in table 3. the global perceived mean scores and sd were (35.19 + 11.19). majority of the participants expressed teaching learning mean and sd (4.55+4.52). physical barriers (43+4.33) internet barriers (5.36+2.16) technology barriers (2.27+1.14) and communication barriers (2.27+1.13). figure 1 highlights majority of the participants rated overall online education to be very good (36.90%) excellent (24.70%) good (25.30%) fair (1.60%) and poor (11.60%). in table 4 there were no significant association between selected demographic variables such as gender, marital status, area of residence, previous online experience, and satisfaction scores at p>0.05 level of significance. table 5 indicates there is a weak negative correlation between age and satisfaction (r=-0.03) which was not significant (p>0.05). also, there is a weak negative correlation between age and barriers (r=-0.008) which was not significant (p>0.05) discussion this this study reports the challenges of online education among undergraduate students studying in college of nursing, king khalid university, abha, kingdom of saudi arabia. the study provides valuable information for administrators and faculty to consider as they wrestle with online delivery issues such as satisfaction, barriers and needs of online learners. majority of the participants 92% were satisfied with online education. this research supported previous finding that the students are satisfied with the university staff and faculty members who agreed on specific online platforms to use, grading system, assessment options, training workshops, online technical support, and more (almusharraf and khahro, 2020). the study results can be compared to similar study conducted among undergraduate students enrolled in fundamental english course was moderately satisfied (srichanyachon, 2014). majority of the participants expressed barriers as teaching learning. some participants did voice concern about the lack of social interaction with teachers and students. there was also lack of personal relationship with teachers, lack of visibility with students. physical barriers such as too much of eye strain, neck problems and typing problems were expressed by few participants. another study also reveal similar finding that communication problem and physical barrier were another barrier for online learning (baticulon et al., 2021). communication barriers were expressed mean scores and sd (2.27+1.13). lack of communication skills were expressed by students in another study (gupta et al., 2016). similar findings are also reported in study conducted by (srichanyachon, 2014) who reported that students found the barriers of online learning general in terms of communication barriers. even though they are experiencing online education satisfaction, but they also encounter barriers with the new method of learning due to limited face to face direct communication. internet barriers such as frequent connectivity issues were expressed by students residing in remote areas, technology barriers such as navigation of portal, submitting assignments, increased load. this situation also similar to other study conducted by (baticulon et al., 2021; roslan and halim, 2021) that technological constraint also experience by medical students which pertain to hardware, software, and internet connectivity. another study also have similar finding that the use of technology as well as connectivity become detention in successfulness of online learning, along with the availability of internet devices (efriana, 2021) it is true that, to successfully accomplish the task related to technology one must be skillful and confident in working with computers, which is further facilitated by accessibility and availability of the lap tops/ desktops, practicing in day today life which is mandatory in the institutions of higher education. in the current study, moderate scores in perceived barriers may be due to the fact that, online education during covid-19 pandemic was first of its kind. therefore, the students may be more anxious even though it was realized that, it was the only option which is available and feasible to continue learning to achieve the best outcome among the students. many students were also more concerned about availability of the technology support for all especially those who are residing in villages and remote areas. at the same time, they also responded figure 1. percentage distribution of overall rating on online courses attended by the students 11.60% 1.60% 25.30% 36.9% 24.70% 0% 5% 10% 15% 20% 25% 30% 35% 40% l. s. benjamin et al. 192 | pissn: 1858-3598  eissn: 2502-5791 that, this in the only option which is available when traditional class room teaching method is not possible due to various circumstances, such as the current lockdown situation, facing major disaster, natural calamities etc. in this research there was negative correlation between age and satisfaction with online courses, between age and barriers of online courses. similar study also depicts there was a negative relationship between computer aptitude and barriers of online learners (srichanyachon, 2014). this finding was not supported previous study (baticulon et al., 2021) that students with older age found it difficult with self evaluation on online learning. another study (rabin et al., 2020) found that age provide contribution to barriers which leads to dissatisfaction in online learning. from this finding we can state that in some cases ages were not correlated with barriers and satisfaction where younger generation found excitement with new technology of learning where older generation may find it difficult to adapt with the new method. conclusion online technology education should take advantage of the perceived need to facilitate a wide variety of learner needs and capabilities. the coronavirus infection 2019 (covid-19) pandemic is profoundly affecting emotional wellness. in conclusion, online education has found highly satisfied among undergraduate students. faculty and institutions can take the results of this study into consideration for future development. references abad-segura, e. et al. (2020) ‘sustainable management of digital transformation in higher education: global research trends’, sustainability, 12(5), p. 2107. doi: 10.3390/su12052107. almusharraf, n. m. and khahro, s. h. (2020) ‘students’ satisfaction with online learning experiences during the covid-19 pandemic’, international journal of emerging technologies in learning, 15(21), pp. 246–267. doi: 10.3991/ijet.v15i21.15647. baticulon, r. e. et al. (2021) ‘barriers to online learning in the time of covid-19: a national survey of medical students in the philippines’, medical science educator. springer us, 31(2), pp. 615–626. doi: 10.1007/s40670-021-01231-z. bond, m. et al. (2018) ‘digital transformation in german higher education: student and teacher perceptions and usage of digital media’, international journal of educational technology in higher education, 15(1), p. 48. doi: 10.1186/s41239-018-0130-1. cameron, e. and green, m. (2019) making sense of change management: a complete guide to the models, tools and techniques of organizational change. kogan page publishers. efriana, l. (2021) ‘problems of online learning during covid-19 pandemic in efl classroom and the solution’, jelita: journal of english language teaching and literature, 2(1), pp. 2721–1916. fry, k. (2001) ‘e‐learning markets and providers: some issues and prospects’, education + training, 43(4/5), pp. 233–239. doi: 10.1108/eum0000000005484. gaur, u. et al. (2020) ‘challenges and opportunities of preclinical medical education: covid-19 crisis and beyond’, sn comprehensive clinical medicine. sn comprehensive clinical medicine, 2(11), pp. 1992–1997. doi: 10.1007/s42399-020-00528-1. gupta, a. k. et al. (2016) ‘an online survey of the problems being faced by students and teachers in higher education with special reference to jammu region’, mier journal of educational studies, 6(2), pp. 204–210. available at: www.miercollege.in. hrastinski, s. (2008) ‘asynchronous and synchronous e-learning’, educause quarterly, 31(4), pp. 51–55. kopp, m., gröblinger, o. and adams, s. (2019) ‘five common assumptions that prevent digital transformation at higher education institutions’, in inted2019, pp. 1448–1457. doi: 10.21125/inted.2019. leszczyński, p. et al. (2018) ‘multimedia and interactivity in distance learning of resuscitation guidelines: a randomised controlled trial’, interactive learning environments, 26(2), pp. 151–162. doi: 10.1080/10494820.2017.1337035. rabin, e. et al. (2020) ‘what are the barriers to learners’ satisfaction in moocs and what predicts them? the role of age, intention, self-regulation, self-efficacy and motivation’, australasian journal of educational technology, 36(3), pp. 119–131. doi: 10.14742/ajet.5919. roslan, n. s. and halim, a. s. (2021) ‘enablers and barriers to online learning among medical students during covid-19 pandemic: an explanatory mixed-method study’, sustainability (switzerland), 13(11). doi: 10.3390/su13116086. sandkuhl, k., & lehmann, h. (2017) ‘digital transformation in higher education – the role of enterprise architectures and portals’, digital enterprise computing. sean, h., block, m. e. and judge, j. p. (2014) ‘certified adapted physical educators’ perceptions of advantages and disadvantages of online teacher development’, palaestra, 28(4), pp. 14–16. srichanyachon, n. (2014) ‘the barriers and needs of online learners’, turkish online journal of distance education, 15(3), pp. 50–59. doi: 10.17718/tojde.08799. zaharias, p. and poylymenakou, a. (2009) ‘developing a usability evaluation method for e-learning applications: beyond functional usability’, international journal of human–computer interaction. taylor & francis, 25(1), pp. 75–98. doi: 10.1080/10447310802546716. 142 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.21127 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research summary guidance for daily practices on glycemic control and foot care behavior devi mediarti1, rosnani rosnani1, and hidayat arifin2 1poltekkes kemenkes palembang, south sumatera, indonesia 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the prevalence of diabetes foot ulcers (dfu) in indonesia is increasing every year. summary guidance for daily practice (sgfdp) is a media used to discuss and share knowledge to prevent foot ulcer in patients with type 2 diabetes mellitus (t2dm). the aim was to know the influence of applying sgfdp on glycemic control (fasting blood glucose levels) and foot care behavior. methods: the study was quasi-experimental utilizing a pretest-post-test with a control group design. the sample obtained was 232 respondents through consecutive sampling. the variables were sgfdp, glycemic control, and foot care behavior. the intervention was conducted for three weeks meeting. the data collected using observation sheets and the nottingham assessment of functional footcare (naff) questionnaire. the results were analyzed using the wilcoxon and mann-whitney tests. results: most of respondents were elderly aged 41-50 years old. respondents showed significant progressed of foot care behavior on before and after treatment. the results showed a significant influence from sgfdp on foot care behavior (p=0.001). conclusion: the application of sgfdp as an approach to prevent foot ulcers among adults t2dm was significantly affected. it was conducted by discussing and sharing knowledge and utilizing a foot ulcer prevention simulation with foot exercises. sharing information and the attention given by the nurses in the form of regular meetings can increase patient knowledge and induce behavior changes among adult t2dm. article history received: august 03, 2020 accepted: august 10, 2020 keywords diabetes foot care; diabetes mellitus; glycemic control; prevention contact devi mediarti  devi.mediarti@gmail.com  poltekkes kemenkes palembang, south sumatera, indonesia cite this as: mediarti, d., rosnani, r., & arifin, h. (2020). summary guidance for daily practices on glycemic control and foot care behavior. jurnal ners, 15(2). 142-147. doi:http://dx.doi.org/10.20473/jn.v15i2.21127 introduction diabetes mellitus (t2dm) is a metabolic disease characterized by an increase in blood sugar levels. this occurs due to abnormalities in insulin secretion, insulin action or both (kusnanto, 2017). t2dm is one of the most chronic diseases experienced by people in the world. t2dm patients are susceptible to nerve and vascular damage which can result in a loss of the protective sensation in the legs, poor circulation, biomechanical changes in leg and skin trauma (fan, 2012). if it is not treated well, it can occur because the development of ulcers is known in diabetic patients to be preceded by a history of trauma (neuropathy) or vasculopathy (schaper et al., 2017). t2dm-related complications are a major cause of morbidity and mortality, and they have a serious impact on the quality of life of the patients (hsieh et al., 2016). foot ulceration and subsequent lower limb amputation are common and serious chronic complications for t2dm patients (fan, 2012). it is estimated that in 2035, the global prevalence of t2dm will increase to nearly 600 million (shearman & rawashdeh, 2016). in indonesia, t2dm patients are known to have increased from 1.1% in 2007 to 2.1 percent in 2013. the province of east java, with the prevalence of t2dm based on a doctor's diagnosis and symptoms, is 1.2% and 1.6% respectively (badan penelitian dan pengembangan kesehatan, 2013).the four main objectives of service providers include health promotion, disease prevention, patient care and meeting the patient’s needs. the management of t2dm patients in the physical aspect with early education is about t2dm, the monitoring of routine blood sugar levels, diet, how to use the health facilities, physical exercise and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id mailto:mundakir.ners@fik.um-surabaya.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 143 the importance of foot care (perkeni, 2015). the role of the nurses is to prevent the risk of ulcers related to t2dm through education, demonstration and monitoring about foot care. sgfdp is a summary of suggested guidelines for daily practice summarizing the essence of the prevention and management of foot problems in t2dm patients. sgfdp as part of a more complete guide on foot care consisting of the identification of risky feet, the inspection and routine checking of feet at risk, health education for patients regarding foot care, routine footwear care and identification and the handling of pre-ulcer signs (schaper et al., 2017). sgfdp is provided more complete in health education and activity. due to the important of sgfdp among t2dm to manage dm, thus we encouraged to determine the influence of applying sgfdp on glycemic control and foot care behavior. materials and methods research design, population, sample, and variables the design was quasi-experimental with a pre-posttest control group design. the population in this research consisted of all outpatients with t2dm in three primary health services (hps). the researcher used two hps for treatment group and one hps for control group because the population is bigger, and the area coverage is wider. the samples obtained 232 respondents (116 in the treatment group and 116 in the control group) with consecutive sampling technique. this research was conducted at palembang in south sumatera from october 9 to december 20, 2018. the inclusion criteria in this research were 1) low risk t2dm patients, 2) t2dm history of more than 10 years, 3) can communicate verbally well, and they are able to read and write and 4) taking t2dm therapy in the form of oral subcutaneous therapy. the exclusion criteria were 1) patients with t2dm who experienced cognitive impairment and 2) t2dm patients with foot ulcers. the independent variable was the application of sgfdp and the dependent variables were glycemic control and foot care behavior. instruments sgfdp used the modules as form of media to give to the respondents. the module of sgfdp consists of information about t2dm, diet, the behavior of people with t2dm, foot care behavior with exercise and psychosocial education to reduce stress in t2dm patients. the instrument of glycemic control was an observation sheet. glycemic control used peripheral blood and measured by easy touch 3in1 glucose, uric acid and cholesterol. foot care behavior was measured using the nottingham assessment of functional footcare (naff) questionnaire by lincoln, et. al. (lincoln et al., 2008), which was modified by putri, at. al. (putri et al., 2013) and translated into the indonesian language. the number of questions totaled 27 using a likert scale with a score of 0-3. we obtained a range of scores from 0 to 81; the higher the score, the better the t2dm foot care behavior. this questionnaire was tested for validity and reliability with a cronbach’s alpha value of 0.720. research procedure and analysis this research was carried out in collaboration with the existing program activities in the primary health service in order to increase the knowledge of the t2dm patients through empowerment and health education. the research has passed the ethical review and obtained an ethical approval certificate no. 208/un2.f12.d/hkp.02.04/2018 issued by the health research ethics committee of faculty of nursing science, universitas indonesia. the research was conducted in the treatment group by providing sgfdp that formulated by researcher with select modules on three meetings over three weeks. the first week was to provide health education about t2dm and the screening of the respondents with the risk of foot ulcers. the second week was explained as the ideal diet and behavior of people with t2dm, and the third weeks was on teaching prevention of foot ulcers through a demonstration of foot exercises and monitoring. the control group was given information about t2dm through sgfdp modules. the data was analyzed using ibm spss statistic 25 (spss, 2019). the statistical analysis used a wilcoxon signed rank and mann-whitney u test. the confidence interval was 95% with alpha (α) = 0.05. results the characteristics of the respondents in (table 1) shows that the majority of the respondents in both groups were in the age group of the elderly and that the majority were female. the last level of education for both groups was high school and the majority of respondents in both groups did not work. the majority of the income in the control and treatment groups was >2.6 million. the majority of the respondents in the control group had had t2dm for 14-15 years and the treatment group had had t2dm for 10-13 years. the results of the analysis of fasting blood glucose in the control and treatment groups at the pre-test and post-test showed that all of the respondents had differences in the mean and std. deviation. the results of the data obtained using the wilcoxon signed ranks test on fasting blood glucose in the pre-test and posttest of the control group showed no change in the results between the pre-test and post-test of the respondents. the test results showed p>0.05 which was 0.11, which means that there was no significant difference. the treatment group showed p<0.05 which was equal to 0.013, which means that the pretest and post-test in the treatment group had significant differences. the results of the post-test carried out using the mann-whitney u test on fasting blood glucose data in the control and treatment groups was 0.836 which equals p>0.05. it can be d. mediarti et al. 144 | pissn: 1858-3598  eissn: 2502-5791 concluded that there were no significant differences in the results of the post-test data in the control and treatment groups (table 2). the results of the foot care behavior analysis in the control and treatment groups in the pre-test and posttest showed that all of the respondents had differences in the mean and std. deviation. the results of the data obtained using the wilcoxon signed ranks test on foot care behavior on pre-test and post-test of the control group showed no change in the results between the pre-test and post-test of the respondents. the test results showed p>0.05, which was 0.274 which means that there was no significant difference. the treatment group showed p<0.05, which was equal to 0.003, which means that the pretest and post-test in the treatment group had significant differences. the results of the post-test foot care behavior data using the mann-whitney u test in the control and treatment groups were 0.001 which means p<0.05. it can be concluded that there were significant differences in the results of the posttest data between the control and treatment groups (table 2). discussion the sgfdp approach explains the basic principles of the prevention of foot problems in t2dm patients (schaper et al., 2017) and it seeks to prevent ulcers in patients at risk with t2dm by providing integrated and adequate foot care (s.a bus, d.g. armstrong, r.w. van deursen, j.e.a.lewis, c.f caravaggi, 2016). prevention bases sgfdp include risky feet identification, risky inspection and routine foot checks, patient health education about foot care, appropriate footwear care and the identification of pre-ulcerative signs. table 1. characteristics of the respondents in the control and treatment groups of patients with t2dm (n=232) characteristic control group treatment group n % n % age adult (30-40 year) elderly (41-50 year) 16 100 13.8 86.2 27 89 23.3 76.7 sex male female 44 72 37.9 62.1 50 66 43.1 56.9 education elementary school junior high school senior high school university 19 26 54 17 16.4 22.4 46.6 14.7 23 39 46 8 19.8 33.6 39.7 6.9 work does not work private government employees 72 26 18 62.1 22.4 15.5 85 23 8 73.3 19.8 6.9 average income <1.5 million 1.5-2.5 million >2.6 million 43 28 45 37.1 24.1 38.8 39 32 45 33.6 27.6 38.8 long suffer from t2dm 10 – 13 years 14 – 15 years 49 67 42.2 57.8 83 33 71.6 28.4 table 2. distribution of blood glucose and foot care behavior in the control and treatment groups of patients t2dm (n=232) variables control group treatment group pretest posttest pretest posttest blood glucose mean ± sd 121.47 ± 29.153 122.72 ± 29.396 117.29 ± 8.344 115.9 ± 14.62 p-value 0.11a 0.013a p-value 0.836b foot care behavior mean ± sd 38 ± 7.489 36.28 ± 9.878 43.02 ± 7.889 45.42 ± 8.254 p-value 0.274a 0.003a p-value 0.001b a wilcoxon signed rank test b mann-whitney u test jurnal ners http://e-journal.unair.ac.id/jners | 145 one risk factor of t2dm was age, especially for those older than 40 years. this is because at that age, there is an increase in glucose intolerance (chai et al., 2018). in old age, bodily functions are physiologically decreasing because the aging process causes a decrease in insulin secretion or resistance. therefore, the body's ability to control high blood glucose is not optimal. the aging process causes a decrease in insulin secretion or resistance, resulting in a macroangiopathy, which can affect the decrease in blood circulation, one of which is in the large or medium blood vessels in the legs. gender is one of the factors associated with the occurrence of t2dm, where women who have experienced menopause tend to be more insensitive to insulin. diabetes in general, for men, comes faster than it does for women. women can be protected from diabetes until they reach menopause because of the influence of the female hormone estrogen, which is a reproductive hormone that helps to regulate blood sugar levels in the body. the results of a study conducted by martis, r et. al. (martis et al., 2018) showed a higher prevalence of the incidence rate of t2dm in women than in men. women are more at risk of developing diabetes because physically, women have a greater chance of increasing their body mass index. post-menopausal monthly cycle (premenstrual syndrome) syndrome makes the distribution of body fat more easily accumulated due to the hormonal processes, so therefore women are more at risk of developing t2dm (hsieh et al., 2016). education level has an important role in increasing the knowledge of t2dm. the majority of the residents did not know about t2dm. knowledge can have an important role in the prevention of t2dm in the community. education can influence a person, including a person's behavior and lifestyle, especially in reference to motivating people to participate in developments. in general, the higher the education level of someone, the easier it is for them to receive information (wawan & dewi, 2014). the respondents who suffered from t2dm needed to do more physical activities. in t2dm, exercise plays a major role in regulating blood glucose levels. muscle contractions have properties such as the production insulin and increasing the permeability of the membrane to glucose in the contracting muscle (bakar et al., 2017). at the time of exercise, insulin resistance is reduced, whereas insulin sensitivity increases when inactive. this is not a permanent effect. therefore, exercise must be carried out continuously. physical activity can be in the form of diabetic foot exercises. exercise is very beneficial for improving blood circulation, losing weight and improving insulin sensitivity as it will improve the glucose levels in the blood. hyperinsulinemia (10feu/ml) can cause atherosclerosis, which has an impact on vasculopathy which makes the legs prone to t2dm ulcers (rachmawati et al., 2015). in addition, it is often accompanied by an increase in triglyceride and plasma cholesterol levels which will result in poor blood circulation to the tissue, which appears in the decrease of the dorsalis pedis artery pulse (<60 x/m) and decreased ankle brachial index (<0.9), resulting in ulcers that usually start from the tip of the leg (waspadji, 2006). all of the respondents in this study had suffered from t2dm for more than 10 years. foot ulcers are especially common in t2dm patients who have suffered with the disease for 10 years or more. if their uncontrolled blood sugar levels are not seen to, then this will result in vasculopathy and neuropathy. physical activity is included in this research in the form of t2dm foot exercises. physical activity increased the sensitivity of the insulin receptors in the active muscles (albargawi et al., 2017). the main problem that occurs in t2dm is the occurrence of insulin resistance which causes glucose to not enter the cells. when a person engages in physical activity, there will be a muscle contraction which will eventually make it easier for glucose to enter the cell (jankowska-polaska et al., 2015). this means that when a person is engaged in physical activity, it will reduce the level of insulin resistance and this will eventually reduce their blood sugar levels. there are other factors that influence blood sugar levels. in addition to sgfdp implementation, there are several things that cause one’s blood sugar to rise, namely a lack of exercise, an increased amount of food consumed, increased stress and emotional factors, weight gain and age, and the impact of treatment from drugs, such as steroids (iljaž et al., 2017). the driving factor was the factor obtained from the closest person to the patient and the social support given to the individual, such as their family, friends and teachers, and especially in this case, the health workers who can strengthen the behavior of sgfdp management. with the support provided by the closest people to them, it is expected to encourage behavior change in the patients (nursalam, 2016). in terms of the prevention of injury in t2dm patients, foot care behavior is carried out in accordance with sgfdp, which consists of the identification of risky feet, the inspection and routine examination of risky feet, health education for patients about foot care, routine foot care and the identification of pre-ulcer signs in t2dm patients (yamin et al., 2018). the level of education of a person is very influential on any changes in attitude and behavior related to healthy living. higher levels of education will make it easier for a person or community to absorb information and to implement it in their daily behavior patterns and lifestyle, especially in terms of health. based on the information obtained by the researchers through questioning the respondents, the respondents said they always tried to maintain good foot care behavior in accordance with the principles of sgfdp so then further foot injuries can be prevented. this is because of the intervention given by the researchers in the form of sgfdp through daily practice guidance that explain the basic principles of the prevention of foot problems in t2dm patients to prevent ulcers in patients at risk who have t2dm. d. mediarti et al. 146 | pissn: 1858-3598  eissn: 2502-5791 foot problems in t2dm are one of the more serious complications. foot problems are the main source of suffering and costs for the patients and they also place a considerable financial burden on health care and on society in general. strategies include prevention, patient education and close foot monitoring (schaper et al., 2017). t2dm patients with peripheral neuropathy also have a history of foot ulceration or lower limb amputation, foot deformity, poor foot hygiene and inappropriate or inadequate footwear. furthermore, routine inspections and checks of at-risk feet should be conducted at least once a year to identify those at risk of foot ulceration. patients who have any of the risk factors must be examined more frequently. these include a history of ulcers, previous amputations, end-stage kidney disease, social isolation, access to poor health care, walking without using a pedestal and a regular foot examination concerning vascular status, skin, footwear and an assessment of neuropathy (s.a bus, d.g. armstrong, r.w. van deursen, j.e.a.lewis, c.f caravaggi, 2016). health education for patients about foot care is presented in a structured, organized and repeated manner, both verbally and through media channels. this plays an important role in preventing foot problems. patients with t2dm must learn how to recognize potential foot problems and they must be aware of the steps that they must take when problems arise. one of the sports recommended for people with t2dm is foot exercises (lincoln et al., 2008). gymnastic foot stretches aim to smooth the blood circulation that is disrupted. this is because leg exercises can strengthen the leg muscles. this is in accordance with mariana, et.al. (souza et al., 2017), who stated that t2dm foot exercises aim to improve blood circulation so then the nutrients can get to the tissues smoother. it can also strengthen the small muscles, calf muscles and thigh muscles, and overcome the limitations of joint motion that often experienced by t2dm patients. this is supported by theories involving endoneuria blood flow, increased nitric oxide synthesis and increased na + / k + atpase activity with given training efforts (brand & d, 2016). regular footwear, improper footwear and barefoot walking with insensitive feet are the main causes of foot ulceration. patients with a loss of sensation should be taught about protection and the appropriate use of footwear so then the use of footwear at any time, both inside and outside the room, is paired with the identification of pre-ulcer signs in t2dm patients characterized by redness or pain (schaper et al., 2017). the limitations in this study were that it was limited in terms of the time available and the intervention in the treatment group was for 3 weeks. patient changes and any developments will be more visible if the intervention is carried out over a longer time period. conclusion sgfdp explains the basic principles of preventing foot problems in patients in a manner that can be carried out in a session once a week and re-evaluated after 3 weeks by discussing, sharing knowledge and undergoing foot ulcer prevention simulation using foot exercise. sharing information and the attention given by the nurses with regular meetings can increase patient knowledge and behavior changes in the t2dm patients to encourage them to take positive actions. this was proven to prevent foot injury in patients with t2 t2dm. sgfdp can be done regularly to train the t2dm type 2 patients to maintain a good lifestyle including good food, a balanced diet, exercise and regular activities. the next researchers could improve the treatment of sgfdp based on culture and by evaluating the qualitative results. conflict of interest the authors have declared that they have no conflict of interest. acknowledgement this study was funded by politeknik kesehatan kementrian keseahatan palembang. we would like to thank to health primary care for permission and assistance and all respondents that cooperate to join the research. references albargawi, m., snethen, j., gannass, a. al, & kelber, s. (2017). relationship between person ’ s health beliefs and diabetes self-care management regimen. journal of vascular nursing, 1–6. https://doi.org/10.1016/j.jvn.2017.07.002 badan penelitian dan pengembangan kesehatan. (2013). riset kesehatan dasar (riskesdas) 2013. in laporan nasional 2013. bakar, a., nursalam, adriani, m., kusnanto, qomariah, s. n., hidayati, l., pratiwi, i., & ni’mah, l. (2017). spiritualitas perawat meningkatkan perilaku caring. international journal of evaluasi dan penelitian dalam pendidikan (ijere), 6(april), 23–30. brand, s. l., & d. (2016). evaluation of the effect of nurse education on patient-reported foot checks and foot care behaviour of people with diabetes receiving haemodialysis. diabetic medicine, 33(2), 204–207. https://doi.org/10.1111/dme.12831 chai, s., yao, b., xu, l., wang, d., sun, j., yuan, n., zhang, x., & ji, l. (2018). the effect of diabetes selfmanagement education on psychological status and blood glucose in newly diagnosed patients with diabetes type 2. patient education and counseling, 101(8), 1427–1432. https://doi.org/10.1016/j.pec.2018.03.020 fan, l. (2012). examining the feasibility , acceptability and effects of a foot self-care educational intervention in adult patients with diabetes at low risk for foot ulceration by. in jurnal ners http://e-journal.unair.ac.id/jners | 147 proquest. university of toronto. hsieh, y. l., lee, f. h., chen, c. l., chang, m. f., & han, p. h. (2016). factors influencing intention to receive examination of diabetes complications. asian nursing research, 10(4), 289–294. https://doi.org/10.1016/j.anr.2016.10.004 iljaž, r., brodnik, a., zrimec, t., & cukjati, i. (2017). ehealthcare for diabetes mellitus type 2 patients – a randomised controlled trial in slovenia ezdravstvena oskrba bolnikov s sladkorno boleznijo tipa ii – randomizirana kontrolirana raziskava v sloveniji. 56(3), 150–157. jankowska-polaska, b., fal, a. m., uchmanowicz, i., sen, m., polanski, j., & kurpas, d. (2015). influence of organized diabetic education on self-control and quality of life of patients with type 2 diabetes. international journal of diabetes in developing countries, 35, 79–87. https://doi.org/10.1007/s13410-014-0253-4 kusnanto. (2017). asuhan keperawatan pada klien dengan diabetes mellitus pendekatan holistic care. aup. lincoln, n. ., radford, k. ., game, f. ., & jeffcoate, w. . (2008). education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. diabetologia, 51, 1954–1961. martis, r., crowther, c. a., shepherd, e., alsweiler, j., downie, m. r., & brown, j. (2018). treatments for women with gestational diabetes mellitus: an overview of cochrane systematic reviews. cochrane database of systematic reviews. https://doi.org/10.1002/14651858.cd012327.p ub2 nursalam. (2016). metodologi penelitian ilmu keperawatan (4th ed.). salemba medika. perkeni. (2015). pengolahan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. https://doi.org/10.1017/cbo9781107415324.0 04 putri, d. s. r., yudianto, k., & kurniawan, t. (2013). perilaku self-management pasien diabetes melitus ( dm ). 1(april 2013), 30–38. https://doi.org/10.24198/jkp.v1n1.4 rachmawati, n., safitri, n., k, d., keperawatan, m. j., kedokteran, f., & diponegoro, u. (2015). gambaran kontrol dan kadar gula darah pada pasien diabetes melitus di poliklinik penyakit dalam rsj prof. dr. soerojo magelang. 01, 1–8. s.a bus, d.g. armstrong, r.w. van deursen, j.e.a.lewis, c.f caravaggi, p. r. c. (2016). iwgfd guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. diabetes/metabolism research and reviews, 32(30), 13–23. https://doi.org/10.1002/dmrr schaper, n. c., van netten, j. j., apelqvist, j., lipsky, b. a., & bakker, k. (2017). prevention and management of foot problems in diabetes: a summary guidance for daily practice 2015, based on the iwgdf guidance documents. diabetes research and clinical practice, 124, 84–92. https://doi.org/10.1016/j.diabres.2016.12.007 shearman, c. p., & rawashdeh, m. (2016). foot complications in patients with diabetes. surgery (oxford), 34(4), 192–197. https://doi.org/10.1016/j.mpsur.2010.02.002 souza, a. l. r., guimarães, r. a., de araújo vilela, d., de assis, r. m., de almeida cavalcante oliveira, l. m., souza, m. r., nogueira, d. j., & barbosa, m. a. (2017). factors associated with the burden of family caregivers of patients with mental disorders: a cross-sectional study. bmc psychiatry, 17(1), 1–10. https://doi.org/10.1186/s12888-017-1501-1 spss, i. (2019). ibm spss statistics vers 25. https://www.ibm.com/id-en/marketplace/spssstatistics/details waspadji, s. (2006). komplikasi kronik diabetes: mekanisme terjadinya diagnosis dan strategi pengelolaan. fk ui. wawan, a., & dewi, m. (2014). teori dan pengukuran pengetahuan. nuha medika. yamin, a., windani, c., & sari, m. (2018). relationship of family support towards self-management and quality of life of patients with type 2 diabetes mellitus. 6, 175–182. 148 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.20610 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the differences of inpatients’ satisfaction level based on socio-demographic characteristics ni komang ayu adnya dewi, ni putu emy darma yanti, and kadek saputra faculty of nursing, universitas udayana, bali, indonesia abstract introduction: assessing the quality of nursing care has become a global health issue. especially for caregivers and recipients of care in the inpatient department. patient satisfaction is one of the indicators to measure quality of nursing care. this study aimed to identify the differences of patient satisfaction level in inpatient ward based on socio-demographic characteristics at siloam hospitals bali. methods: this study was cross-sectional design with descriptive comparative and correlation methods. patient satisfaction data were collected using the patient satisfaction with nursing care quality questionnaire (psncqq) that was provided after the patient was discharged. purposive sampling technique was used to determine 107 samples. the analytical tests used in this study were the spearman correlation test, mann-whitney test and kruskal-wallis test. results: the results of this study showed that there was a significant weak and negative correlation between the level of satisfaction and age of the patient (p = 0.017; r = -0.231; α <0.05). there were significant differences of patient satisfaction based on marital status (p = 0.036; α <0.05) and nationality status (p = 0.001; α <0.05), but there were no differences in patient satisfaction based on sex (p = 0.276; α <0.05) and education level (p = 0.434; α <0.05). conclusion: this study concluded that social demographic characteristics of patients can influence the satisfaction, but only on age, marital and nationality status. this showed that inpatients provide good satisfaction evaluations of nursing care. the optimal nursing care needs to be maintained and improved, either routine evaluation or sustainable program development. article history received: july 09, 2020 accepted: august 11, 2020 keywords nursing service quality; patient satisfaction. contact ni komang ayu adnya dewi  ayu.adnyadewi@gmail.com  faculty of nursing, universitas udayana, bali, indonesia cite this as: dewi, n. k. a.a., yanti, n. p. e. d., & saputra, k. (2020). the differences of inpatients’ satisfaction level based on socio-demographic characteristics. jurnal ners, 15(2). 148-156. doi:http://dx.doi.org/10.20473/jn.v15i2.20610 introduction health has now become one of the main goals of the sustainable development goals (sdgs) for 2030, which states that everyone has the right to achieve universal health coverage, including affordable medicines, accessibility, safe and effective quality of services and access to quality essential health services (world health organization, 2015). high health needs demand facilities and health service providers to perform better quality services and comply with established standards. the health services quality was previously measured only by using professional standards and ignored the patient satisfaction value. nevertheless, some findings revealed that patient satisfaction as an indicator to measure the health services quality. patient satisfaction is defined by the happiness level by the patient during treatment or the patient's perception about the care received while treated in hospital (worku & loha, 2017). patient satisfaction surveys can directly evaluate whether the extent of the care provided is able to meet the patient's health needs (price et al., 2014). the ministry of health republic of indonesia act number 129 year 2008 established a minimum service standard for patient satisfaction of ≥ 90%. if health services are found with patient satisfaction levels lower than 90%, it could be assumed that the health services provided did not meet with the minimum standards or no quality. the patient satisfaction percentage in indonesia obtained from https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ayu.adnyadewi@gmail.com jurnal ners http://e-journal.unair.ac.id/jners | 149 one central hospital was 77.1% (novitasari et al., 2014), at regional hospitals was 83.3% (mustika & sari, 2019), and at private hospitals was 54.52% (oini et al., 2017). these show that the picture of patient satisfaction level in indonesia is still under the minimum standard established. variations in the patient satisfaction level with the service quality could be affected by several factors. chen et al. (2019) revealed that there are nonmodifiable factors that affect the patient satisfaction levels with variations such as age, sex, race and socioeconomic status. the patient satisfaction level also could be affected by several factors originating from the health services themselves, such as reliability, responsiveness, assurance, empathy and service quality (mumu et al., 2015sulistyo et al. (2019) stated that the funding sources, treatment duration and accreditation status could also affect patient satisfaction. patients who are satisfied with the treatment given will tend to adhere to the healthcare provider’s treatment plan (mohan & kumar, 2011). patient satisfaction also provides benefits to health services such as making patients loyal and increasing the visits percentages. loyal patients will visit the same health service if they need back-to-back treatment (nursalam, 2014), whereas for patients who are dissatisfied, services will lead to lower utilization of health services. other forms of negative attitudes due to dissatisfaction could show as verbally influencing others to not to seek healthcare (debono & travaglia cited in mukhtar et al., 2013). efforts made to improve the patient satisfaction with health services are achieved by improving facilities cleanliness, privacy settings and providing interpersonal services (adhikary et al., 2018). hospitals also need to pay attention about ongoing efforts to improve the collaboration and discipline between health professionals (de oliveira et al., 2017). nkwinda et al. (2019) also revealed that the hospital’s high concern through the presence and nurses professional abilities could make patients satisfied with the services provided. siloam hospitals bali is part of the siloam group hospital located in the province of bali. this hospital has become one of the private hospitals prepared to support medical tourism. therefore, siloam hospitals bali not only serves indonesian patients, but also serves patients with foreign nationality. this can be seen from the results of preliminary studies obtained by the researcher on the number of tourists who have been hospitalized at siloam hospitals bali from 2017 to 2019, respectively amounting to 1,269, 1,303 and 1,402 patients. the change in number of inpatients at siloam hospitals bali every year is a reflection of the patient satisfaction level with the care service received. these are certainly influenced by efforts to improve accreditation which demands a health service facility also to improve the treatment process provided (alkhenizan & shaw, 2011). however, the presence of patient-related factors, such as socio-demographic characteristics, could also affect the patients’ satisfaction level during hospitalization. therefore, patient satisfaction needs to be explored on an ongoing basis to identify variables that can influence patient responses during treatment and find out the changes needed to perform nursing care. this study aims to identify the differences of inpatients’ satisfaction level based on socio-demographic characteristics at siloam hospitals bali. materials and methods this study is a non-experimental research with descriptive comparative and correlation methods and a cross sectional research design. the variables examined in the study were patient satisfaction as the dependent variable and socio-demographic characteristics (age, sex, education, marital status, and nationality status) as independent variables. this study was conducted at inpatient installation of siloam hospitals bali with the selected room number as research locations, namely four inpatient rooms consisting of inpatient department (ipd) -1, 2, -3, and maternity ward. the population in the study were all inpatients at siloam hospitals bali. the inclusion criteria used in this study are: patients aged ≥12 years; inpatients at siloam hospitals bali who declared allowed going home, willing to be the subject by signing informed consent, able to understand indonesian or english. meanwhile the exclusion criteria from this study are: patients in decreased consciousness condition and patients with cognitive impairment. this study also used dropout criteria, such as patients who did not fill the instruments completely and lost patients. this study obtained a sample size of 107 patients selected using a non-probability sampling technique with purposive sampling. the research instrument used in this study was the patient satisfaction with nursing care quality questionnaire (psncqq). the psncqq was developed by laschinger et al. (2005) to measure patient satisfaction with the nursing services quality. the psncqq instrument validity and reliability test was carried out on 445 patients in canada and the results showed that the psncqq has excellent psychometric with 0.97 cronbach’s alpha reliability and correlation items ranging from 0.61 to 0.89 (laschinger et al., 2005). the psncqq instrument was also tested in several developing countries, such as serbia (n = 240) and poland (n = 85); the results showed that the psncqq instrument is valid and reliable (ksykiewicz-dorota et al., 2011; milutinović et al., 2012). the psncqq instrument consists of 19 questions summarized in nine dimensions, namely individual assessment, nurses’ attention, nurse abilities and skills, staff collaboration, comfort, nurse response, and information provided by nurses, return instructions and coordination after patients discharged. data were collected through instruments given to patients after patients were declared as discharge allowed. the researcher also obtained n. k. a. a. dewi et al. 150 | pissn: 1858-3598  eissn: 2502-5791 ethical clearance from the research ethics commission, prior to data collection. the analysis test used in this study is the spearman correlation test to determine the differences in satisfaction levels based on age, the mann-whitney test to determine the levels of satisfaction differences based on sex, marital status and nationality, as well as kruskal-wallis test to determine the differences in patient satisfaction levels based on education level. results social demographic characteristics description and patient satisfaction are seen in table 1. the patients’ age characteristics in this study indicate that the mean age of patients is 41 years with the youngest age being 12 years and the oldest age being 74 years. patient characteristics based on sex, education level, marital status and nationality showed that the majority of patients were male (51.4%), tertiary educated (46.7%), married (74.8%), and indonesian (80.4%) the patient satisfaction description to nursing services shows that of the 107 patients undergoing hospitalization, it was found that the median patient satisfaction score was 75 with the lowest satisfaction score being 50 and the highest satisfaction score 95. the analysis of inpatient satisfaction levels differences based on age, gender, education level, marital status and nationality are seen in table 2. the differences analysis of inpatient satisfaction levels by age shows that there is a weak significant relationship with the negative correlation direction between patient satisfaction levels and age. the analysis shows that age can influence the level of patient satisfaction with weak strength (p value = 0.017; r = -0.231; α <0.05). the differences analysis of inpatient satisfaction levels by sex shows that the median value of patient satisfaction is found higher in men (76) table 1. the differences analysis of inpatient satisfaction levels by age, sex, education level, marital status and nationality variable n (%) median (min-max) age (years) 41 (12-74) gender male 55 (51,4) female 52 (48,6) level of education primary education 8 (7,5) secondary education 49 (45,8) tertiary education 50 (46,7) marital status married 80 (74,8) unmarried 27 (25,2) nationality indonesian 86 (80,4) non-indonesian 21 (19,6) patients satisfaction 75 (50-95) tabel 2. the differences analysis of inpatient satisfaction levels by age, sex, education level, marital status and nationality variable patient satisfaction n median (min–max) mean rank p-value age 107 -0,231# 0,017* gender 0,276** male 55 76 (56–95) 57,17 female 52 74,5 (50–95) 50,64 education level 0,434*** primary education 8 79 (57–95) 65,38 secondary education 49 76 (55–95) 55,31 tertiary education 50 70,5 (50–95) 50.90 marital status 0,036** married 80 73 (50–95) 50,36 unmarried 27 79 (55–95) 64,78 nationality 0,001** indonesian 86 72,5 (50–95) 48,87 non-indonesian 21 85 (57–95) 75,02 # : coefficient correlation (r) * : spearman correlation test result ** : man-whitney test result *** : kruskal-wallis test result jurnal ners http://e-journal.unair.ac.id/jners | 151 than women (74.5). statistical test results showed that there was no significant difference between satisfaction scores in male and female patients at siloam hospitals bali (p value = 0.276; α <0.05). the differences analysis of inpatient satisfaction level based on the level of education obtained the result that the higher median value of patient satisfaction was found in primary educated patients (79), compared to secondary educated (76) and tertiary educated (70.5). statistical test results showed that there was no significant differences between satisfaction scores in primary, secondary and tertiary educated patients at siloam hospitals bali (p value = 0.434; α <0.05). the differences analysis of inpatients’ satisfaction level based on marital status obtained results that a higher median value was found in patients who were single (79) compared to those who were married (73). statistical test results show that there were significant differences between the patient satisfaction scores with married and unmarried status at siloam hospitals bali (p = 0.036; α <0.05). the differences analysis of inpatients’ satisfaction level based on nationality shows higher median score found in nonindonesian patients (85) compared to indonesian patients (72.5). statistical test results show that there is a significant difference between satisfaction scores in indonesian patients and non-indonesian patients in siloam hospitals bali (p value = 0.001; α <0.05). discussion inpatient satisfactions’ overview this study results indicated that all inpatients satisfaction scores were in range 50 to 95. based on the median values obtained, these findings indicated that the patient satisfaction score is close to the maximum, which is 95. according to thapa and joshi (2019), the patient satisfaction level value with the care quality measured using the psncqq instrument divided into two categories, which were good patient satisfaction (median ≥70) and poor patient satisfaction (median <70). based on these categories, the median patient satisfaction score found in this study is categorized as good. this proves that inpatients at siloam hospitals bali as a whole were satisfied with the nursing services received. this study result is in line with the thapa and joshi (2019) study at one hospital in chitwan city, nepal, which found that the majority of patients had good satisfaction (50.5%). research by konduru et al. (2015) which categorizes the patient satisfaction level as good, moderate and bad also supports this study result, namely the majority of patients hospitalized at a public hospital in india have good satisfaction (66%) of nursing care services. in the all items results of the statements given, the majority of inpatients gave a good evaluation value. this study shows that inpatients at siloam hospitals bali received good quality nursing services. this is because the service quality will positively influence patient satisfaction, i.e. the better service quality, the higher patients satisfaction (sulistyo et al., 2019). nursing services are professional services performed by nurses in accordance with service standards with the aim of delivering services that exceed patient expectations (nursalam, 2014). nursalam (2014) explains that the high and low level of patient expectations about the service quality can also be influenced by four interrelated factors, wordof-mouth communication, personal needs, past experiences and external communication (company's external communication). this shows that, in addition to factors in the nursing services quality, the gap between patient expectations and the care quality received can also affect patient satisfaction. the service quality could be defined to meet satisfying if the expected service is the same as perceived. similarly, a service is said to not meet expectations or is not qualified if the expected service is greater than the perceived service (nursalam, 2014). this study also shows that hospital care management has been able to understand patient expectations, and that the majority of patients have good satisfaction. this is explained in the grand theory developed by parasuraman (cited in nursalam, 2014) related to gaps in service quality, as patient dissatisfaction can occur when the management of healthcare institutions has not been able to correctly identify and understand the health service users’ expectations. differences in patient satisfaction levels by age based on this study’s results, shows that there are differences in the inpatient satisfaction level based on age. based on rank spearman test, there is a weak significant relationship with the negative correlation direction between the satisfaction level and patients’ age. these results indicated that the younger the patient, the satisfaction will increase, while the older the patient, the satisfaction level will be lower. this study results are supported by batbaatar et al. (2017) who revealed that age as a demographic characteristic factor could influence the patient satisfaction level. karaca and durna (2019) also found that patients aged >65 years or patients with an older age tend to give less satisfied quality of care ratings compared to other age groups. other research related to public satisfaction with the health system performance also found that the younger age group had higher satisfaction than the older age group (footman et al., 2013). other studies related to patient satisfaction with the nursing care quality found different results. chen et al. (2019) found that younger patients tended to show lower satisfaction compared to older patients. this is in line with research by dzomeku et al. (2013) who found that patients with age <40 years tend to feel less satisfied with care services than patients aged> 40 years. older patients tend to be more satisfied with care services because elderly people generally n. k. a. a. dewi et al. 152 | pissn: 1858-3598  eissn: 2502-5791 experienced chronic diseases. this condition causes them to be more receptive to their physical limitations than younger. this will encourage older patients to have lower demands and expectations. therefore, older patients are generally more satisfied with care services than younger (haj-ali et al., 2014). in addition, the existence of cultural values factors, such as parents must be more respected and given special privileges, affects satisfaction because nurses will pay more attention to older than younger patients (dzomeku et al., 2013). although the age factor can be said to be consistent, the relationship between age and satisfaction is still in a nonlinear pattern. this is proved by the findings, which stated that patient satisfaction increases until the age of 40 years, but can decrease sharply after 40 years (amro et al., 2018). the variation in differences in the patient satisfaction level due to age is caused by several things, such as differences in cultural values, less positive patient responses, tolerance levels in each individual patient and age-related maturity levels (karaca & durna, 2019). the differences results found in this study were caused by differences of patient needs that affect patient care services expectations. karaca and durna (2019) state that the low level of satisfaction in the patients group with older age is caused by the nurses' lack of attention in providing care to the elderly. this can lead to differences in patient needs, i.e. older patients have unique needs during treatment compared to younger. according to chumbler et al. (2016), the differences in needs is caused by the inherent heterogeneity in the elderly patient group, the complex health status experiences, health wrong perceptions, and an illness history due to age. these findings indicated that inpatient care providers need to pay special attention when providing care to older patients. one way is to improve and maintain communication between nurses and patients. chumbler et al. (2016) revealed that nurses’ communication was the second most influential factor on care satisfaction in a group of patients with older age (>70 years). in addition, salehi et al. (2018) argued that older patients will feel more satisfied with healthcare if they receive more respect and attention. therefore, inpatient care providers need to improve care services by ensuring good communication by nurses and maintaining the nursing staff's responsiveness to patient needs so that overall care can be patient-centered. differences in patient satisfaction levels based on gender this study results obtained statistical data that showed that there were no differences in the patient satisfaction level by sex. this study is supported by the research of karaca and durna (2019) who found that there were no significant differences in satisfaction levels between male and female patients. alsaqri (2016), in her research, also found the same, that there were no significant differences in satisfaction between men and women in providing nursing care evaluation. gender is a factor that still has strength and direction of the association that is not consistent with patient satisfaction (batbaatar et al., 2017). this is proved by chen et al. (2019) research which found that patients with female sex had higher levels of satisfaction compared to male patients. other studies have found different results, namely male patients tend to feel more satisfied with treatment compared with female patients (dzomeku et al., 2013). gender could affect patient satisfaction because they have different views of the hospital services provided. women tend to pay more attention to the appearance in details, whereas men generally do not attach importance to it (oroh et al., 2014). those female patients will be more careful and critical of the quality aspects when evaluating the performance of service provider staff (dzomeku et al., 2013). in addition, men also have different ways in managing relationships with women. men tend to be more ignorant about what is stated by women, and they are considered more flexible (gunarsa cited in oroh et al., 2014). this study found that gender did not affect inpatient satisfaction. aspects that came from care service providers, such as hospital accreditation status, caused this. this is because good accreditation status will require hospitals to improve the services quality provided. quality improvement could see from the hospitals efforts to improve cooperation and discipline among health workers in providing services (de oliveira et al., 2017). in addition, accreditation is a determinant of patient satisfaction because of the complete hospital facilities and infrastructure support (haj-ali et al., 2014). in addition to the factors originating from the care provider, the length of stay in the hospital can also affect patient satisfaction. according to sulistyo et al. (2019), patient's length of stay can significantly affect patient satisfaction positively. this is because patients treated for a long time feel that they have received more attention (salehi et al., 2018). longterm treatment will also increase the health workers’ attention and empathy to patients, then patients generally will more feel comfortable (sulistyo et al., 2019). differences in patient satisfaction levels based on education level based on this study, results showed that there were no differences in patient satisfaction levels based on primary, secondary and tertiary education levels. this is in line with konduru et al. (2015) and edmealem et al. (2019) who found that there were no significant differences in patient satisfaction with nursing care based on the level of patient education. this study results differ from those of amro et al. (2018) who found that patients with master's education had higher satisfaction compared to jurnal ners http://e-journal.unair.ac.id/jners | 153 bachelors, diploma and no education certificates. this is supported by chen et al. (2019) who found that the majority of low satisfaction was experienced by less education patients and who did not have an education degree. this can be caused by the influence of the patient's education level on communication skills. highly educated patients are better able to listen and integrate the opinion differences along with medical services (amro et al., 2018). bu-alayyan (cited in baltaci et al., 2013) also revealed that patients with high levels of education more easily communicate with medical personnel. other studies have also found different results, namely illiterate patients and only primary education patients tend to be satisfied with treatment (dzomeku et al., 2013). low-educated patients are more satisfied with the service because they do not have more information about the treatment they will receive, so they do not place high expectations on the service provider. salehi et al. (2018) also supported that the majority of patients with low education did not have sufficient access to know good health service standards. dzomeku et al. (2013) also argued that highly educated patients tend to be less satisfied because they are more able to access information about nurses' tasks. in addition, highly educated patients have obtained more information about the alternative treatments they will receive, so they will expect a higher care standard (karaca & durna, 2019). in addition to accessing information easily, service quality can also affect patient satisfaction, i.e. the better service quality, the higher the patients’ satisfaction. this is because good service quality will increase the speed of the service process provided, such as the easy registration administration process, nurses working systematically and effectively, and arrival on time, then patients will feel more satisfied and provide a positive assessment (fuad et al., 2019). differences in patient satisfaction levels based on marital status based on this research, the results show that there is a significant difference between the satisfaction of married and unmarried patients. this study analysis results indicated that unmarried patients have higher satisfaction than married patients. marital status is categorized as either unmarried patient who is unmarried, divorced and dead divorced, or as a married patient, who is married and having married status. this study finding are supported by karaca and durna (2019) who stated that marital status influences patient satisfaction. the study found that patients with divorced status had higher satisfaction with nursing services compared to patients who were married. this study results are also in line with the akbas (2019) study at obstetrics and gynecology clinics in several hospitals types. the study found that single-status patients were more satisfied with nursing care services than married patients. one study found different results, i.e. married patients were more satisfied with health services than single patients, divorced or patients living with partners (ayranci & atalay, 2019). edmealem et al. (2019) also found that married patients were more satisfied with nursing care than single patients were. although marital status is a contradictory factor in influencing patient satisfaction, other studies have found that there is no significant difference in satisfaction between married and single or unmarried patients (konduru et al., 2015; olomi et al., 2017). this study found that unmarried patients tended to be more satisfied with nursing services. this tendency is attributed to the satisfaction description results based on the age characteristics found in this study, namely patients with younger ages tend to be more satisfied with care services. this is because the majority of unmarried individuals are younger, i.e. 017 years (99.94%) (kementerian pemberdayaan perempuan and perlindungan anak ri, 2019). however, this relationship is used as a basis if the status category of unmarried patients is divorced or divorced. this is because the majority of divorced and dead divorced people is experienced by the age group of 45 years and over, which is 2.28% and 35.80%, respectively (badan pusat statistik, 2018), while the percentage of divorced life and death divorce experienced by the age group of 10 to 17 years is only 0.04% (kpppa ri, 2019). if the patient satisfaction tendency categorized as unmarried occurs in patients with divorce status, this can be related to their older age. according to chen et al. (2019), older patients will be more satisfied with the services received. this is because older patients are more receptive to their physical limitations, causing them to tend to have lower demands and expectations (haj-ali et al., 2014). in addition to the age influence, aspects that come from healthcare providers, such as the environment, can also cause the satisfaction tendency found in patients who are not married. quintana (cited in batbaatar et al., 2017) , supports this in stating that patients with single or divorced status tend to be more satisfied with health services, especially in the comfort and hygiene aspects. this is because a satisfying physical environment, such as clean clothing availability, clean bedding and clean food will be considered as a good care evidence (heidari et al., 2017). these findings indicated that to be able to know differences in satisfaction levels based on marital status more clearly, it is necessary to identify the satisfaction scores proportion based on the category of single, married, divorced and dead divorced. it aims to analyze deeply the effect of marital status on patient satisfaction. n. k. a. a. dewi et al. 154 | pissn: 1858-3598  eissn: 2502-5791 differences in patient satisfaction levels based on nationality based on the study result, obtained statistical data show that there are significant differences between the satisfaction of indonesian patients and nonindonesian patients. this study analysis results indicated that the patients with foreign nationality have higher satisfaction than indonesian nationality. this study results are different from research conducted by chaker and al-azzab (2011) related to the relationship between patient nationality and satisfaction scores at one of the specialized athlete hospitals in qatar and which found that participants with qatar nationality had higher satisfaction with hospital services compared to participants of european, asia, north africa, america and other countries. alnemer et al. (2015) also conducted a similar study at a primary healthcare clinic in riyadh, saudi arabia. this study results found no significant differences in patients’ satisfaction between those who were saudi arabian and patients who were not. the satisfaction tendency in non-indonesian patients found in this study can be caused by differences in the patient's work status. based on the survey, the number of foreigners who came to bali in 2018 with a health tourism aim reached 6,070,473(bali goverment tourism office, 2019). the data show that the majority of patients undergoing treatment at siloam hospitals bali are foreigners. this refers to their activities while living in bali, which is the majority of trips compared to work. sulistyo et al. (2019) revealed that patients who did not work had higher satisfaction than patients who worked. this is because individuals who work generally have a habit of always focusing on the services, they should get to suit their needs. therefore, individuals who work tend to be very dependent on health services, while individuals who do not work will tend to be more independent (lupiyoadi cited in sulistyo et al., 2019). in addition to the influence of differences in patient work status, the strategic location of the hospital and the tourism area can also affect the satisfaction of non-indonesian patients compared to indonesian patients. damghi et al. (2013) found that patients who lived within 10 kilometers of the hospital tended to be more satisfied than patients who lived more than 10 kilometers. based on the observations, siloam hospitals bali is located in the kuta district, which causes this hospital to be the main health service access for tourists. patients who are foreigners will be more satisfied because the location of a hospital that is easily accessible means patients get emergency care more quickly. this is also supported by amro et al. (2018) who stated that patients who live in cities are more satisfied than patients who live in villages, because most private and government hospitals are located in cities. conclusion based on the research, it can be concluded that age can influence inpatient satisfaction with weak strength and negative correlation direction. other socio-demographic characteristics factors that were found to influence inpatient satisfaction were marital status and nationality, while gender and education level were found to have no significant effect on patient satisfaction. overall, inpatients provide good satisfaction evaluations of nursing care. references adhikary, g., shajedur rahman shawon, m., wazed ali, m., shamsuzzaman, m., ahmed, s., shackelford, k. a., woldeab, a., alam, n., lim, s. s., levine, a., gakidou, e., & jasim uddin, m. (2018). factors influencing patients’ satisfaction at different levels of health facilities in bangladesh: results from patient exit interviews. plos one, 13(5), 1–13. https://doi.org/10.1371/journal.pone.0196643 akbas, m. (2019). patient satisfaction on nursing care: the case of gynecology and obstetrics clinics. acta bioethica, 25(1), 127–136. https://doi.org/10.4067/s1726569x2019000100127 alkhenizan, a., & shaw, c. (2011). impact of accreditation on the quality of healthcare services: a systematic review of the literature. annals of saudi medicine, 31(4), 407–416. https://doi.org/10.4103/0256-4947.83204 alnemer, k. a., al-homood, i. a., alnemer, a. a., alshaikh, o. m., alsaidan, m. a., & alzahrani, a. t. (2015). a multicenter study of factors affecting patient’s satisfaction visiting primary health care clinics in riyadh, saudi arabia. family medicine and medical science research, 4(2), 1–4. https://doi.org/10.4172/2327-4972.1000169 alsaqri, s. (2016). patient satisfaction with quality of nursing care at governmental hospitals, ha’il city, saudi arabia. journal of biology, agriculture and healthcare, 6(10), 128–142. https://www.iiste.org/journals/index.php/jbah /article/view/30595 amro, n., kamel, a. m. a., qtait, m., yagi, h., amro, b., amro, r., & amro, r. (2018). factors affect patients satisfaction in emergency departments in palestine. journal of health, medicine and nursing, 54(1), 3–8. https://www.researchgate.net/publication/3280 31303 ayranci, e., & atalay, n. (2019). demographic determinants of patient satisfaction: a study in a turkish context. international journal of academic research in business and social sciences, 9(6), 829– 839. https://doi.org/10.6007/ijarbss/v9i6/6041 badan pusat statistik. (2018). statistik penduduk lanjut usia tahun 2018. bps jakarta. bali goverment tourism office. (2019). direct foreign tourist arrivals to bali in 1971-2018. jurnal ners http://e-journal.unair.ac.id/jners | 155 https://disparda.baliprov.go.id/ baltaci, d., eroz, r., ankarali, h., erdem, o., celer, a., & korkut, y. (2013). association between patients’ sociodemographic characteristics and their satisfaction with primary health care services in turkey. kuwait medical journal, 45(4), 291–299. https://www.researchgate.net/publication/2872 73429 batbaatar, e., dorjdagva, j., luvsannyam, a., savino, m. m., & amenta, p. (2017). determinants of patient satisfaction: a systematic review. perspectives in public health, 137(2), 89–101. https://doi.org/10.1177/1757913916634136 chaker, m., & al-azzab, n. (2011). patient satisfaction in qatar orthopedic and sports medicine hospital (aspitar). international journal of business and social science, 2(7), 69–78. https://www.semanticscholar.org/ chen, q., beal, e. w., okunrintemi, v., cerier, e., paredes, a., sun, s., olsen, g., & pawlik, t. m. (2019). the association between patient satisfaction and patient-reported health outcomes. journal of patient experience, 6(3), 201– 209. https://doi.org/10.1177/2374373518795414 chumbler, n. r., otani, k., desai, s. p., herrmann, p. a., & kurz, r. s. (2016). hospitalized older adults ’ patient satisfaction : inpatient care experiences. 2016. https://doi.org/10.1177/2158244016645639 damghi, n., belayachi, j., armel, b., zekraoui, a., madani, n., abidi, k., benchekroun, a. b., zeggwagh, a. a., & abouqal, r. (2013). patient satisfaction in a moroccan emergency department. international archives of medicine, 6(20), 1–8. https://doi.org/10.1186/1755-76826-20 de oliveira, j. l. c., gabriel, c. s., fertonani, h. p., & matsuda, l. m. (2017). mudanças gerenciais resultantes da acreditação hospitalar. revista latino-americana de enfermagem, 25, 1–8. https://doi.org/10.1590/1518-8345.1394.2851 dzomeku, v. m., atinga, ba-etilayoo, perekuu, t., & mantey, r. e. (2013). in-patient satisfaction with nursing care: a case study at kwame nkrumah university of science and technology hospital. international journal of research in medical and health sciences, 2(1), 1–6. http://www.ijsk.org/ijrmhs.html edmealem, a., asfaw, y., & ademe, s. (2019). patients’ satisfaction and associated factors towards nursing care in dessie referral hospital, northeast ethiopia. clinical journal of nursing care and practice, 3, 53–58. https://www.heighpubs.org/hjncp footman, k., roberts, b., mills, a., richardson, e., & mckee, m. (2013). public satisfaction as a measure of health system performance: a study of nine countries in the former soviet union. health policy, 112(1–2), 62–69. https://doi.org/10.1016/j.healthpol.2013.03.004 fuad, l., tamtomo, d., & sulaeman, e. s. (2019). multilevel analysis on the effect of marketing mix strategy toward patient satisfaction in magelang, central java. journal of health policy and management, 4(1), 39–46. https://doi.org/10.26911/thejhpm.2019.04.01.0 5 haj-ali, w., karroum, l. b., natafgi, n., & kassak, k. (2014). exploring the relationship between accreditation and patient satisfaction-the case of selected lebanese hospitals. international journal of health policy and management, 3(6), 341–346. https://doi.org/10.15171/ijhpm.2014.116 heidari, m., pour, h., norouzzadeh, r., temel, e., & şahin, b. (2017). assessment patients’ satisfaction related on quality of care: a cross-sectional descriptive study. asian journal of medicine and health, 5(4), 1–8. https://doi.org/10.9734/ajmah/2017/34513 karaca, a., & durna, z. (2019). patient satisfaction with the quality of nursing care. nursing open, 6(2), 1–11. https://doi.org/10.1002/nop2.237 kementerian pemberdayaan perempuan dan perlindungan anak ri. (2019). profil anak indonesia tahun 2018. konduru, a., sujatha, t., & judie, a. (2015). a study to assess the level of patient satisfaction on quality of nursing care among patients in srm general hospital, kattankulathur. international journal of pharmaceutical and clinical research, 7(6), 458– 461. https://www.researchgate.net/publication/3030 89344 ksykiewicz-dorota, a., sierpińska, l., gorczyca, r., & rogala-pawelczyk, g. (2011). polish version of patient satisfaction with nursing care quality questionnaire (psncqq). progress in health sciences, 1(1), 51–56. laschinger, h. s., hall, l. m., pedersen, c., & almost, j. (2005). a psychometric analysis of the patient satisfaction with nursing care quality questionnaire. journal of nursing care quality, 20(3), 220–230. https://doi.org/10.1097/00001786-20050700000006 milutinović, d., simin, d., brkić, n., & brkić, s. (2012). the patient satisfaction with nursing care quality: the psychometric study of the serbian version of psncq questionnaire. scandinavian journal of caring sciences, 26(3), 598–606. https://doi.org/10.1111/j.14716712.2012.00969.x mohan, d. r., & kumar, k. s. (2011). a study on the satisfaction of paitnets with reference to hospital services. zenith international journal of business economics & management research, 1(3), 15–25. http://zenithresearch.org.in/ mukhtar, f., anjum, a., bajwa, m., shahzad, s., hamid, s., masood, z., & mustafa, r. (2013). patient satisfaction. professional med j, 20(6), 973–980. https://doi.org/10.3109/9780824706081.114 mumu, l. j., kandou, g. d., & doda, d. v. (2015). analisis faktor-faktor yang berhubungan dengan n. k. a. a. dewi et al. 156 | pissn: 1858-3598  eissn: 2502-5791 kepuasan pasien di poliklinik penyakit dalam rsup prof . dr . r . d . kandou manado. jurnal unsrat, 5(4). https://ejournal.unsrat.ac.id/index.php/jikmu/ar ticle/view/7460 mustika, d., & sari, k. (2019). kepuasan pasien terhadap layanan rawat inap rsud jagakarsa tahun 2017/2018. jurnal arsi, 5(3), 147–152. http://journal.fkm.ui.ac.id/arsi/article/view/295 0 nkwinda, b., jacobs, w., & downing, c. (2019). patient satisfaction with caring at a district hospital in malawi. global journal of health science, 11(1), 15–27. https://doi.org/10.5539/gjhs.v11n1p15 nursalam. (2014). manajemen keperawatan: aplikasi keperawatan profesional (4th ed.). selemba medika. novitasari, a., hidayat, m., & kaporina, a. (2014). kepuasan pasien rawat inap terhadap pelayanan keperawatan di rsup dr. kariadi semarang. jurnal kedokteran muhammadiyah, 3(1). https://jurnal.unimus.ac.id/index.php/kedoktera n/article/view/2553 oini, o., komalasari, r., & hasibuan, s. y. (2017). tingkat kepuasan pasien terhadap pelayanan keperawatan di unit rawat inap. nursing current, 5(2), 50–60. https://ojs.uph.edu/index.php/ncjk/article/vie w/1707 olomi, g., mboya, i., & manongi, r. (2017). patients’ level of satisfaction with the health care services received at outpatient departments in kilimanjaro region, tanzania. journal of patient care, 3(1). https://doi.org/10.4172/2573-4598.1000124 oroh, m. e., rompas, s., & pondaag, l. (2014). faktorfaktor yang berhubungan dengan tingkat kepuasan pasien rawat inap terhadap pelayanan keperawatan di ruang interna rsud noongan. jurnal keperawatan, 2(2). https://ejournal.unsrat.ac.id/index.php/jkp/artic le/view/5220 peraturan menteri kesehatan republik indonesia nomor 129 tahun 2008 tentang standar pelayanan minimal rumah sakit. price, r. a., elliott, m. n., zaslavsky, a. m., hays, r. d., lehrman, w. g., rybowski, l., edgman-levitan, s., & cleary, p. d. (2014). examining the role of patient experience surveys in measuring health care quality. medical care research and review, 71(5), 522–554. https://doi.org/10.1177/1077558714541480 salehi, a., jannati, a., nosratnjad, s., & heydari, l. (2018). factors influencing the inpatients satisfaction in public hospitals: a systematic review. bali medical journal, 7(1), 17. https://doi.org/10.15562/bmj.v7i1.533 sulistyo, s. a., tamtomo, d., & sulaeman, e. s. (2019). accreditation status and other factors affecting patient satisfaction in hospital. journal of health policy and management, 4(3), 139–149. https://doi.org/10.26911/thejhpm.2019.04.03.0 1 thapa, s., & joshi, a. (2019). patients’ satisfaction with quality nursing care at teaching hospital, chitwan. journal of nursing and health science (iosr-jnhs), 8(3), 71–75. https://doi.org/10.9790/19590803077175 world health organization. (2015). health in 2015 from mdgs to sdgs. https://www.who.int/gho/publications/mdgssdgs/en/ worku, m., & loha, e. (2017). assessment of client satisfaction on emergency department services in hawassa university referral hospital, hawassa, southern ethiopia. bmc emergency medicine, 17(1), 1–5. https://doi.org/10.1186/s12873-0170132-7 159 model integrated maternity management melalui penguatan promotif dan preventif sebagai upaya menurunkan angka kematian ibu dan bayi (the integrated maternity management model through promoting and preventive encouragement in the attempts of lowering the maternal and infant mortality rates) diyan indriyani*, asmuji* * fakultas ilmu kesehatan universitas muhammadiyah jember, jl. karimata 49 jember. e-mail: dieindri@yahoo.com abstrak pendahuluan: angka kematian ibu (aki) dan angka kematian bayi (akb) merupakan salah satu indikator penting dalam menilai tingkat derajat kesehatan masyarakat di suatu negara. aki dan akb di indonesia masih cukup tinggi dibandingkan dengan negara asean lainnya. untuk persoalan tersebut perlu segera dipecahkan dengan kerja sama yang sinergisme dari lintas sektor, salah satunya dengan membangun model integrated maternity management dengan penguatan promotif dan preventif terutama bagi masyarakat pedesaan yang relatif memiliki pengetahuan lebih rendah dibandingkan masyarakat perkotaan. metodologi: penelitian ini dilakukan di kecamatan mumbulsari dan sukorambi. teknik pengumpulan data pada penelitian ini dilakukan dengan cara survei/observasi, wawancara, fgd, indept interview dan pra baik pada masyarakat (tokoh masyarakat, masyarakat kelompok berisiko: remaja putri, ibu hamil dengan usia dini, dan ibu muda), pemerintah maupun institusi lokal. hasil: penelitian yang dilakukan telah berhasil merumuskan model integrated maternity management bagi masyarakat pedesaan sebagai upaya menurunkan aki dan akb.. model tersebut telah dilakukan uji coba, tetapi masih bersifat sederhana dengan media modul (1) tentang kesehatan reproduksi remaja, yang didapatkan hasil rata-rata persepsi remaja tentang kesehatan reproduksi sebelum intervensi sebesar 58,67 dengan nilai minimal 30 dan nilai maksimal 85 dan nilai setelah intervensi rata-rata 81,33 dengan nilai minimal 60 dan nilai maksimal adalah 95. selisih nilai pretest dan posttest yaitu 22,66, sehingga dapat dikatakan pemberian informasi tentang modul (1) yang membahas tentang topik kesehatan reproduksi berdampak terhadap pemahaman siswi menjadi lebih baik. diskusi: oleh karena itu perlu diaplikasikan model integrated maternity management dengan penguatan aspek promotif dan preventif, dengan langkah awal melakukan uji coba terlebih dahulu secara komprehensif untuk mendapatkan model secara sempurna. kata kunci: model integrated maternity management, promotif, preventif, aki dan akb, masyarakat pedesaan abstract introduction: maternal mortality rate (mmr) and infant mortality rate (imr) remain the major indicator in assessing the level of certain country’s health quality. both of indonesia’s mmr and imr levels are high enough compared to other asean countries. to address this problem, a synergic cooperation among the cross-linked authorities is of prime important. one possible alternate option is building the integrated maternity management model through promoting and preventive encouragement particularly designated for rural societies whose knowledge is relatively lower than the ones in urban areas. methods: this research is conducted in mumbulsari and sukorambi sub-districts. the data collection techniques used in this research are survey/observation, interview, fgd, in-depth interview and, pra conducted both to societies (local figures, people at risk, female teenagers, under-aged pregnant mother and young mothers) and local institutions and authorities. result: this research has been able to formulate the integrated maternity management model through promoting and preventive encouragement particularly designated for rural societies in the attempts of lowering the mmr and iimr. this model has undergone trial, although the trial is simple in nature, by using the module medias of (1) teenager’s reproductive health which generated the average perception of the teenagers shown by the figure of 58,67 regarding their reproductive health prior to the intervention with minimum score of 30 and maximum score of 85. meanwhile, upon applying the intervention, the average showed the figure of 81,33 with minimum score of 60 and maximum score of 95. the margin between the pre-test and post-test values reaches the figure of 22,36. this means that the supply of information regarding the module (1) which discusses the health reproductive issue generates better knowledge of those female teenagers concerning the respective issue. discussion: therefore, it is suggested that the implementation of the integrated maternity management model through promoting and preventive encouragement put into action by initiating a comprehensive trial in order to generate the most suitable model, respectively. keywords: integrated maternity management model, promotive and preventive, mmr and imr, rural societies 160 jurnal ners vol. 9 no. 2 oktober 2014: 159–172 pendahuluan kesehat an mer upakan hak setiap manusia, termasuk manusia pada kalangan masyarakat miskin atau kurang mampu. hal ini sesuai dengan deklarasi tentang hak asasi manusia. upaya meningkatkan kesehatan suatu bangsa menjadi tanggung jawab semua pihak baik pemerintah, maupun masyarakat (anando, 2010). pembangunan kesehatan saat ini telah berhasil meningkatkan status kesehatan masyarakat. namun demikian keberhasilan tersebut masih perlu ter us ditingkatkan, mengingat aki dan akb di indonesia masih cukup tinggi dibandingkan dengan negara asean lainnya. angka kematian ibu (aki) dan angka kematian bayi (akb) merupakan salah satu indikator penting dalam menilai tingkat derajat kesehatan masyarakat di suatu negara (depkes ri, 2009). oleh karena itu pemerintah memerlukan upaya yang sinergis dan ter padu untuk mempercepat penurunan aki dan akb di indonesia khususnya dalam mencapai target millenium development goals (mdgs) pada tahun 2015. tentunya hal ini merupakan tantangan yang cukup berat bagi pemerintah indonesia (depkes ri, 2007). target rpjmn tahu n 2010 -2014 mengamanatkan agar aki dapat diturunkan menjadi 118/100.000 kelahiran hidup pada tahun 2014. selain itu, kesepakatan mdgs menargetkan aki di indonesia dapat dit ur un kan menjadi 102/100.000 kelahiran hidup dan angka kematian bayi menjadi 23/1000 kelahiran hidup pada tahun 2015 (kemenkes, 2011). dalam mencapai tujuan pembangunan kesehatan nasional dan mdgs, kita memang me ng ha d api be rbagai hal ya ng mu lt i kompleks seperti masalah budaya, pendidikan masya ra kat, penget ahu a n, li ng k u nga n, kecukupan fasilitas kesehatan, sumberdaya manusia dan lain sebagainya (kemenkes, 2011). terkait dengan permasalahan tersebut salah satu faktor yang fenomenal di masyarakat pedesaan adalah adanya kondisi pernikahan dini yang dapat berkont ribusi terhadap kondisi aki dan akb. dalam penelitian indriyani (2011) didapatkan bahwa faktor yang berhubungan dengan kejadian pernikahan dini di masyarakat adalah faktor pendidikan, ekonomi, adat dan budaya. selain itu juga oleh indriyani (2011) dalam penelitiannya yang mengangkat pengetahuan remaja putri tentang dampak pernikahan dini pada sistem reproduksi didapat hasil bahwa 52,83% masih memiliki pengetahuan kurang dan sedang tentang masalah tersebut. padahal seorang ibu hamil yang umurnya masih dini akan berisiko memiliki kehamilan dan persalinan yang lebih berisiko, termasuk bayi yang dilahirkannya. upaya penurunan aki harus difokuskan pada penyebab langsung kematian ibu, yang terjadi 90% pada saat persalinan dan segera setelah persalinan, yaitu perdarahan (28%), eklamsia (24%), infeksi (11%), komplikasi pueperium 8%, partus macet 5%, abortus 5%, trauma obstetrik 5%, emboli 3%, dan lainlain 11% (skrt, 2001). kematian ibu juga masih banyak diakibatkan faktor risiko tidak langsung berupa keterlambatan (tiga terlambat), yaitu terlambat mengambil keputusan dan mengenali tanda bahaya, terlambat dirujuk, dan terlambat mendapat penanganan medis (wijaya, 2009). berbagai upaya pemer intah telah dilakukan unt uk menur un kan ak i dan akb ini. bila diidentifikasi terkait faktorfaktor yang berkontribusi terhadap aki dan akb sangatlah kompleks (saifuddin, 2002; chapman, 2003), sehingga hal tersebut memerlukan upaya kerja sama mulai dari pemerintah (kebijakan, petugas kesehatan, pelayanan kesehatan), masyarakat (tokoh masyarakat, masyarakat yang berisiko) dan pihak terkait sebagai transfasilitator (institusi lokal: perguruan tinggi, pihak sekolah, lembaga sosial masyarakat). khususnya bila digunakan pendekatan teori proses yang meliputi inputproses-output, maka salah satu akses input yang dimaksud adalah mengupayakan masyarakat yang berisiko terhadap kondisi kematian ibu dan bayi memiliki kesadaran yang lebih baik terhadap fungsi reproduksinya. hal ini bisa dilakukan dengan mengoptimalkan persepsi masyarakat yang berisiko dengan pendekatan kerja sama dari semua komponen baik pemerintah, institusi lokal dan masyarakat. 161 model integrated maternity management (diyan indriyani dan asmuji) untuk persoalan tersebut perlu segera dipecahkan, salah satunya dengan membangun model integrated maternity management terutama bagi masyarakat pedesaan yang relatif memiliki pengetahuan lebih rendah dibandingkan masyarakat perkotaan. model ini memiliki keunggulan yaitu adanya kerja sama yang sinergisme antara pemerintah, masya r a kat d a n i nst it u si lokal d ala m membangun persepsi yang positif masyarakat pedesaan dalam upaya menurunkan aki dan akb. dampak dari persepsi yang positif ini akan meningkatkan masyarakat pedesaan dalam berperilaku yang mengarah kepada upaya dalam menurunkan aki dan akb yang selaras dengan kondisi tersebut. masalah yang diteliti berkaitan dengan 1) peran institusi lokal seper ti lembaga penelitian, perguruan tinggi dan institusi sekolah terhadap masyarakat pedesaan dalam upaya menurunkan aki dan akb, 2) peran pemerintah (dinas kesehatan, pelayanan kesehatan dan petugas kesehatan) dibantu institusi lokal dan masyarakat (tokoh masyarakat, lembaga swadaya masyarakat/ lsm dan masyarakat yang berisiko) sebagai upaya menurunkan aki dan akb. bahan dan metode tahap 1 adalah penggalian data faktual persepsi tent ang kesehat an reprodu ksi kelompok berisiko (remaja putri di sekolah, remaja putri drop out sekolah, ibu muda dan ibu hamil pada usia muda). selain itu, juga dukungan yang diberikan oleh kelompok pendukung (orang tua, suami, guru, petugas kesehatan dan dinas kesehatan). tahap 2 adalah penyusunan rancangan model yang dilakukan dengan cara telaah hasil analisis data dan selanjutnya mengadakan diskusi untuk menetapkan model. tahap 3 adalah uji coba model secara sederhana yang dilakukan dengan: a) melakukan pelatihan pada guru tentang materi kesehatan reproduksi remaja, b) menyiapkan siswi untuk uji coba model, c) melakukan uji coba model sederhana (guru mentransfer informasi tentang topik modul kepada siswi. penelitian ini dilakukan di wilayah kecamatan mumbulsari dan sukorambi dengan asumsi wilayah tersebut memiliki angka pernikahan dini yang masih tinggi, ter masu k pendidi kan masyarakat yang masih rendah meskipun terdapat pelayanan pendidikan sampai sekolah menengah atas. variabel yang diukur dalam penelitian ini antara lain persepsi remaja putri di sekolah dan remaja putri drop out sekolah, persepsi ibu muda dan ibu hamil pada usia muda, persepsi keluarga dan dukungan yang diberikan, dukungan guru, dukungan petugas kesehatan dan program dari dinas kesehatan. model integrated maternity management adalah adanya suatu hubungan kerja sama yang terintegrasi dengan suatu permodelan manajemen dalam permasalahan kesehatan ibu dan bayi. model integrated maternity management ini mer upakan pendekatan sebagai upaya untuk menurunkan angka kematian ibu dan bayi secara partisipatif aktif dengan mengutamakan pemberdayaan m a sya r a k at melalu i p e ndek at a n pa d a penguatan aspek promotif dan aspek preventif. model integrated maternity management ini dilakukan dengan mengintegrasikan peran yang melibatkan masyarakat secara aktif, pihak pemerintah dan institusi lokal. bila digambarkan kaitan tersebut seprti gambar 1. adapun yang menjadi pertimbangan ut ama u nt u k di kemba ng ka n nya model integ rated mater nit y management i n i adalah masyarakat pedesaan sebagian besar menyumbangkan risiko terhadap kejadian masalah yang diteliti berkaitan dengan 1) peran institusi lokal seperti lembaga penelitian, perguruan tinggi dan institusi sekolah terhadap masyarakat pedesaan dalam upaya menurunkan angka kematian ibu dan angka kematian bayi, 2) peran pemerintah (dinas kesehatan, pelayanan kesehatan dan petugas kesehatan) dibantu institusi lokal dan masyarakat (tokoh masyarakat, lembaga swadaya masyarakat/lsm dan masyarakat yang berisiko) sebagai upaya menurunkan angka kematian ibu dan angka kematian bayi. bahan dan metode tahap 1 adalah penggalian data faktual persepsi tentang kesehatan reproduksi kelompok berisiko (remaja putri di sekolah, remaja putri drop out sekolah, ibu muda dan ibu hamil pada usia muda). selain itu juga dukungan yang diberikan oleh kelompok pendukung (orangtua, suami, guru, petugas kesehatan dan dinas kesehatan). tahap 2 adalah penyusunan rancangan model yang dilakukan dengan cara telaah hasil analisis data dan selanjutnya mengadakan diskusi untuk menetapkan model. tahap 3 adalah uji coba model secara sederhana yang dilakukan dengan: a) melakukan pelatihan pada guru tentang materi kesehatan reproduksi remaja, b) menyiapkan siswi untuk uji coba model, c) melakukan uji coba model sederhana (guru mentransfer informasi tentang topik modul kepada siswi. penelitian ini dilakukan di wilayah kecamatan mumbulsari dan sukorambi dengan asumsi wilayah tersebut memiliki angka pernikahan dini yang masih tinggi, termasuk pendidikan masyarakat yang masih rendah meskipun terdapat pelayanan pendidikan sampai sekolah menengah atas. penelitian dilakukan sejak maret-oktober 2013. variabel yang diukur dalam penelitian ini antara lain persepsi remaja putri di sekolah dan remaja putri drop out sekolah, persepsi ibu muda dan ibu hamil pada usia muda, persepsi keluarga dan dukungan yang diberikan, dukungan guru, dukungan petugas kesehatan dan program dari dinas kesehatan. model integrated maternity management adalah adanya suatu hubungan kerjasama yang terintegrasi dengan suatu pemodelan management dalam permasalahan kesehatan ibu dan bayi. model integrated maternity management ini merupakan pendekatan sebagai upaya untuk menurunkan angka kematian ibu dan bayi secara partisipatif aktif dengan mengutamakan pemberdayaan masyarakat melalui pendekatan pada penguatan aspek promotif dan aspek preventif. model integrated maternity management ini dilakukan dengan mengitegrasikan peran yang melibatkan masyarakat secara aktif, pihak pemerintah dan institusi lokal. bila digambarkan kaitan tersebut adalah sebagai berikut: gambar 1. model integrated maternity management dengan penguatan aspek promotif dan preventif model integrated maternity management pemerintah masyarakat pedesaan institusi lokal promotif preventif gambar 1. model integrated maternity management dengan penguatan aspek promotif dan preventif 162 jurnal ners vol. 9 no. 2 oktober 2014: 159–172 kematian ibu dan bayi lebih tinggi karena terkait erat dengan faktor budaya, pengetahuan, pendidikan, lingkungan dan lain sebagainya yang membangun persepsi masyarakat akan kesehatan, khususnya kesehatan reproduksi. selain itu faktor yang menyebabkan kematian ibu dan bayi adalah berupa faktor langsung maupun tidak langsung, di mana faktor tidak langsung ini mer upakan hal yang tidak kalah penting, karena sifatnya adalah penanganan masalah dengan arahan yang bersifat jangka panjang. pada aspek tidak langsung penyebab kematian ibu dan bayi ini lebih tepat untuk menggunakan pendekatan promotif dan preventif, karena diharapkan dapat membangun persepsi masyarakat yang kurang tepat tentang kesehatan reproduksi dan diperlukan kerja sama yang terintegrasi dari berbagai pihak untuk mempermudah dan mengoptimalkan upaya tersebut, yaitu dengan cara integrasi secara sinergisme antara masyarakat, pemerintah dan institusi lokal. adapun dalam pelaksanaan model integrated maternity management ini dapat dilakukan berdasarkan langkah-langkah strategis seperti pada gambar 2. langkah strategis pelaksanaan upaya promotif dan preventif dalam pendekatan model integrated maternity management sebagai upaya pendekatan dalam menurunkan aki dan akb pada masyarakat pedesaan dapat dilakukan dengan langkah sebagai berikut: 1) mengidentifikasi program yang telah dicanangkan oleh dinas kesehatan terkait program penurunan aki dan akb; 2) petugas kesehatan mengadakan pendekatan kepada kelompok pendukung yaitu guru, orang tua dan suami; 3) kelompok pendukung diberikan pendidikan kesehatan dan teknik melakukan pendampingan ser t a tek ni k du k u ngan; 4) menetapkan sasaran kelompok masyarakat berisiko yaitu remaja putri di sekolah, remaja putri drop out di masyarakat, ibu muda dan ibu hamil pada usia muda; 5) teknik penguatan yang ditekankan adalah pada aspek upaya promotif dan preventif dan dilaksanakan secara terintegrasi; (6) topik pendidikan kesehatan yang disampaikan kepada guru meliputi: kesehatan reproduksi remaja, risiko seks bebas/ seks pranikah, kehamilan usia dini, kehamilan yang tidak dikehendaki, bahaya aborsi, teknik pendampingan g ur u pada remaja put ri; 7) topik pendidikan kesehatan pada orang tua, meliputi: pernikahan dini, risiko seks bebas/ seks pranikah, kehamilan usia dini, teknik memberikan dukungan pada remaja putri yang drop out sekolah; 8) topik pendidikan kesehat an pad a orang t ua d an suami, meliputi: kehamilan usia dini, upaya preventif dalam mempertahankan kesejahteraan ibu dan adapun yang menjadi pertimbangan utama untuk dikembangkannya model integrated maternity management ini adalah masyarakat pedesaan sebagian besar menyumbangkan risiko terhadap kejadian kematian ibu dan bayi lebih tinggi karena terkait erat dengan faktor budaya, pengetahuan, pendidikan, lingkungan dan lain sebagainya yang membangun persepsi masyarakat akan kesehatan, khususnya kesehatan reproduksi. selain itu faktor yang menyebabkan kematian ibu dan bayi adalah berupa faktor langsung maupun tidak langsung, dimana faktor tidak langsung ini merupakan hal yang tidak kalah penting, karena sifatnya adalah penanganan masalah dengan arahan yang bersifat jangka panjang. pada aspek tidak langsung penyebab kematian ibu dan bayi ini lebih tepat untuk menggunakan pendekatan promotif dan preventif, karena diharapkan dapat membangun persepsi masyarakat yang kurang tepat tentang kesehatan reproduksi dan diperlukan kerjasama yang terintegrasi dari berbagai pihak untuk mempermudah dan mengoptimalkan upaya tersebut, yaitu dengan cara integrasi secara sinergisme antara masyarakat, pemerintah dan institusi lokal. adapun dalam pelaksanaan model integrated maternity management ini dapat dilakukan berdasarkan langkah-langkah startegis seperti pada gambar. gambar 2 strategi pelaksanaan upaya promotif dan preventif dalam pendekatan model integrated maternity management. langkah strategis pelaksanaan upaya promotif dan preventif dalam pendekatan model integrated maternity management sebagai upaya pendekatan dalam menurunkan aki dan akb pada masyarakat pedesaan dapat dilakukan dengan langkah sebagai berikut: 1) mengidentifikasi program yang telah dicanangkan oleh dinas kesehatan terkait program penurunan aki dan akb, 2) petugas kesehatan mengadakan pendekatan kepada kelompok pendukung yaitu guru, orang tua dan suami, 3) kelompok pendukung diberikan pendidikan kesehatan dan tehnik melakukan pendampingan serta tehnik dukungan, 4) menetapkan sasaran kelompok masyarakat berisiko yaitu remaja putri di sekolah, remaja putri drop out di masyarakat, ibu muda dan ibu hamil pada usia muda, 5) tehnik penguatan yang ditekankan adalah pada aspek upaya promotif dan preventif dan dilaksanakan secara terintegrasi, (6) topik pendidikan kesehatan yang disampaikan kepada guru meliputi: kesehatan reproduksi remaja, risiko seks bebas/seks pranikah, kehamilan usia dini, kehamilan yang tidak dikehendaki, bahaya aborsi, tehnik pendampingan guru pada remaja putri, 7) topik pendidikan kesehatan pada orangtua meliputi program dinas kesehatan program dinas kesehatan p r o g r a m d i n k e s petugas kesehatan guru remaja putri di sekolah kelompok masyarakat berisiko petugas kesehatan suami & orangtua ibu muda p e t u g a s k e s e h a t a n o r a n g t u a remaja putri drop out s u a m i & o r a n g t u a p r o g r a m d i n k e s ibu hamil usia muda p e t u g a s k e s e h a t a n gambar 2. strategi pelaksanaan upaya promotif dan preventif dalam pendekatan model integrated maternity management. 163 model integrated maternity management (diyan indriyani dan asmuji) janin, teknik memberikan dukungan pada ibu muda dan ibu hamil pada usia muda; dan 9) evaluasi pencapaian program kegiatan de nga n me ng u k u r pe r se psi kelompok pendukung dan persepsi kelompok masyarakat berisiko. penelitian ini melibatkan masyarakat pedesaan yang terdiri dari remaja, ibu hamil usia dini dan ibu muda yang ada di kecamatan mumbulsari dan sukorambi kabupaten jember. penentuan sampel dilakukan dengan teknik purposive sampling. jumlah sampel diambil 50 orang sampel tiap kecamatan, sehingga jumlah keseluruhan adalah 100 responden. data yang dikumpulkan pada penelitian ini meliputi data primer dan data sekunder. data primer diperoleh secara langsung melalui observasi/pengamatan dan wawancara langsung di lapangan. data primer yang diperoleh antara lain: 1) umur remaja saat ini; 2) persepsi remaja tentang kesehatan reproduksi; 3) persepsi keluarga tentang kesehatan reproduksi dan dukungan yang diberikan; dan 4) status kesehatan reproduksi remaja. d a t a s e k u n d e r d i p e r o l e h d a r i pemerintah, institusi lokal dan masyarakat p e n d u k u n g. d a t a t e r s e b u t m el i p u t i: 1) peran masyarakat (orang tua) dalam upaya menurunkan aki dan akb; 2) peran institusi lokal seperti lembaga penelitian, perguruan tinggi dan sekolah terhadap masyarakat pedesaan dalam upaya menurunkan aki dan akb; 3) peran pemerintah (dinas kesehatan, pelayanan kesehatan, dan petugas kesehatan) terhadap masyarakat pedesaan sebagai upaya menurunkan aki dan akb; dan 4) peran pemerintah dibantu masyarakat dan institusi lokal dalam upaya menurunkan aki dan akb pada masyarakat pedesaan. kegiatan penelitian yang digunakan adalah pendekatan partisipatif baik untuk tahun pertama maupun tahun kedua dalam memperoleh data kualitatif maupun kuantitatif untuk memberikan penjelasan yang lebih lengkap terhadap lingkup permasalahan yang sedang dikaji. ada 2 tahapan yang dilakukan pada penelitian ini yaitu: (1) pendekatan partisipatif (kualitatif ) maupun kuantitatif yang diarahkan untuk pendalaman kasus sebagai pendukung model integrated maternity management yang menjadi luaran peneliti, (2) dilakukan upaya untuk peningkatan penyadaran dengan metode participatory action research (pra). pengolahan data yang diperoleh baik secara teoritis maupun lapangan dianalisis secara kualitatif, sedangkan data yang berupa angka akan digunakan untuk melengkapi dan membantu dalam mendeskripsikan data kualitatif yang telah diperoleh. penyajian data kuantitatif juga dilakukan baik berupa distribusi frekuensi. analisa kualitatif yang dilakukan adalah menggunakan pendekatan fenomenologis, yang secara garis besar meliputi data yang diperoleh melalui fgd, wawancara, dan observasi langsung untuk menemukan permasalahan yang ada pada masyarakat pedesaan yang berkontribusi terhadap aki dan akb. data tersebut dirangkum dan direduksi untuk dikembangkan menjadi instr umen dasar dalam menyusun interview mendalam, sehingga mampu menggali informasi yang lebih akurat. sumber data dari pemerintah dan instansi terkait digunakan untuk melengkapi data tentang upaya penanganan yang telah dilakukan terhadap masyarakat pedesaan. data yang telah terkumpul dilakukan analisa data. analisa data tersebut dilakukan setelah data yang terkumpul memenuhi tujuan yang dicapai, dan dilakukan secara kontekstual dan diolah, sehingga dihasilkan gambaran dan pemaknaan sebagai mana yang diharapkan dalam tujuan. hasil sebagian besar usia remaja putri adalah 17–18 tahun yaitu sebanyak 50 responden (62,6%). distribusi usia ibu muda dari 10 responden yaitu 2 orang berusia 16 tahun (20%), 7 orang berusia 17 tahun (70%) dan sisanya 1 orang berusia 18 tahun (10%). dari 10 orang yang sedang hamil didapatkan data bahwa 3 responden berusia 17 tahun (30%), 6 responden (60%) berusia 18 tahun dan didapatkan juga 1 responden (10%) ibu hamil yang masih berusia 16 tahun. s e b a g i a n b e s a r u s i a m e n a r c h e responden adalah usia 12–13 tahun sebanyak 164 jurnal ners vol. 9 no. 2 oktober 2014: 159–172 67 responden (67%). sebagian besar siklus haid responden adalah normal yaitu 21–35 hari sekali sebanyak 79 responden (79%). adapun lama haid responden sebagian besar anatara 5–7 hari yaitu sebanyak 74 responden (74%). sebagian besar siklus haid responden adalah teratur yaitu sebanyak 79 responden (79%), dan juga sebagian responden yaitu sebnayak 73 responden (73%) tidak mengalami keluhan selama masa haid. selain itu juga diperoleh data distribusi riwayat t umor dan kan ker pada sistem reproduksi. dari 100 responden didapatkan 99 responden (99%) mengatakan tidak pernah memiliki riwayat terjadinya tumor maupun kanker sistem reproduksi, hanya ada 1 orang (1%) yang mengatakan pernah mengalami benjolan di sekitar daerah perineum. distribusi hasil pemeriksaan laboratorium didapatkan data bahwa dari 100 responden mayoritas memiliki kadar hb normal berkisar 11–12,54 tabel 1. distribusi frekuensi usia remaja putri di sekolah dan remaja putri drop out di wilayah mumbulsari dan sukorambi, kabupaten jember no umur (tahun) jumlah persentase (%) 1 13–14 8 10 2 15–16 22 27,5 3 17–18 50 62,6 total 80 100 tabel 2. distribusi frekuensi usia menarche pada responden di wilayah mumbulsari dan sukorambi, kabupaten jember no umur (tahun) jumlah persentase (%) 1 12–13 67 67 2 14–15 17 17 3 16–17 15 15 4 19 1 1 total 100 100 tabel 3. distribusi frekuensi siklus haid dan lama haid pada responden di wilayah mumbulsari dan sukorambi, kabupaten jember no siklus haid lama haid hari jumlah persentase (%) hari jumlah persentase (%) 1 < 21 9 9 < 5 21 21 2 21–35 79 79 5-7 74 74 3 >35 12 12 >7 5 5 total 100 100 100 100 tabel 4. distribusi frekuensi keteraturan siklus haid dan keluhan saat haid pada responden di wilayah mumbulsari dan sukorambi, kabupaten jember no keteraturan siklus haid keluhan saat haid keteraturan jumlah persentase (%) keluhan jumlah persentase (%) 1 teratur 79 79 tidak ada keluhan 73 73 2 tidak teratur 21 21 ada keluhan 27 27 total 100 100 100 100 165 model integrated maternity management (diyan indriyani dan asmuji) gr% yaitu sebanyak 97 responden (97%), dan hanya 3 responden (3%) yang memiliki kadar hb 10,4–10,6 gr%. selain itu juga didapatkan kadar leukosit dari keseluruhan responden 100 responden (100%) dinyatakan normal yaitu berada pada rentang 6300–7460. hasil distribusi pemeriksaan f isik didapatkan kondisi seluruh responden 100 responden (100%) dalam keadaan sehat dan tidak ada kelainan dan gangguan kesehatan. adapun distribusi usia kehamilan pada ibu hamil usia muda diperoleh data pada 10 responden ibu hamil yaitu 4 orang hamil 22–23 minggu, 1 orang hamil 13–14 minggu, 3 orang hamil 19–10 minggu dan 2 orang hamil usia 27–28 minggu. hasil distribusi keluhan selama hamil pada ibu hamil usia muda, 10 responden ibu hamil (totalitas) mengalami keluhan mual dan muntah di kehamilan 1–13 minggu, dan membaik di kehamilan 14 minggu ke atas. selain itu 3 ibu hamil mengeluh pernah terjadi flek-flek darah pervaginan namun kehamilan masih berlanjut, dan 2 ibu mengatakan kadang kepalanya terasa pening. data distribusi pemeriksaan antenatal care pada ibu hamil usia muda, dari 10 responden terdapat 8 responden (80%) mengatakan mulai melakukan pemeriksaan kehamilan saat sudah masuk usia 4 bulan (16 minggu), dan hanya 2 responden (20%) yang melakukan pemeriksaan kehamilan saat usia kehamilan 4–6 minggu, hal ini dilakukan karena mengalami keluhan muntah-muntah yang hebat dan ada yang mengalami f lek darah pervaginam. selain itu 7 responden (70%) mengatakan periksa rutin anc baik di posyandu maupun di bidan praktek swasta (bps), dan terdapat 3 responden (30%) mengatakan pemeriksaan anc-nya tidak rutin, meskipun tetap melakukan pemeriksaan kehamilan. hal ini dikarenakan kesibukan unt u k mencari naf kah g una membant u suami. pembahasan gambaran usia responden untuk 80 remaja putri jumlah terbanyaknya adalah pada usia dewasa akhir yaitu 17–18 tahun (62,6%), untuk 10 ibu muda usia terbanyak adalah 17 tahun (70%) dan pada 10 ibu hamil usia yang paling banyak yaitu 18 tahun (60%). usia secara tidak langsung bisa berpengaruh pada seseorang dalam pengambilan keputusan, karena mengandung makna kedewasaan. semakin dewasa usia seseorang diduga semakin baik proses dalam pengambilan suatu keputusan, termasuk keputusan dalam mend apat k a n ha k-ha k re produ k si d a n keputusan yang berkaitan dengan fungsi reproduksi. untuk itu usia aman dalam kehamilan sangatlah penting, baik untuk aspek fisiologis maupun psikologis. hal ini selaras dengan pendapat notoatmodjo (2012), yang mengatakan bahwa semakin dewasa umur seseorang akan semakin matang pula dalam pengambilan sikap dan keputusan. demikian juga yang dikatakan dalam skor poedji rochjati dalam indriyani (2013) bahwa usia berkaitan dengan keamanan dalam proses kehamilan, seseorang yang memiliki usia kurang dari 20 tahun dikategorikan dalam kriteria kehamilan yang berisiko. s el a i n u si a r e s p o n d e n p e n el it i mendapatkan gambaran riwayat kesehatan reprodu ksi seper ti usia saat menarche, siklus haid, lama waktu, keteraturan haid, dan gangguan haid secara umum dalam kondisi nor mal. gambaran menst r uasi ini dapat memberikan informasi terhadap keberadaan fungsi reproduksi. bagi wanita usia produktif, cara yang paling mudah dalam mengidentifikasi fungsi reproduksi salah satunya melalui gambaran menstruasi, karena biasanya penyimpangan awal dari fungsi reproduksi ini akan ditandai secara klinis antara lain dengan perubahan menstruasi. indriyani (2013) mengatakan bahwa haid merupakan perdarahan periodik pada uterus yang dimulai sekitar 14 hari setelah ovulasi. khusus responden ibu hamil sejumlah 10 orang peneliti mendapatkan kondisi yang berhubungan dengan pemeriksaan kehamilan (anc) masih terdapat 3 orang (30%) yang melakukan anc tidak teratur. alasan yang diuraikan adalah karena ikut membantu suami dalam mencari naf kah, sehingga kadang lupa untuk melakukan pemeriksaan kehamilan sesuai jadwal yang telah ditentukan. memang 166 jurnal ners vol. 9 no. 2 oktober 2014: 159–172 untuk rutinitas anc dipengaruhi oleh banyak faktor, antara lain misalnya pengetahuan dan sikap ibu hamil tentang pentingnya anc, dukungan petugas kesehatan dan dukungan dari keluarga terutama suami atau orang tua, karena suami atau keluarga merupakan social support yang paling utama selama ibu menjalani kehamilan. kondisi ini sesuai hasil penelitian oleh indriyani (2008) yang mendapatkan adanya hubungan pengetahuan d a n si k ap t e nt a ng keha m ila n de nga n kepatuhan pelaksanaan antenatal care pada ibu primigravida, demikian juga dalam hamzah (2013) yang mendapatkan hasil bahwa ada hubungan antara dukungan keluarga dengan keteraturan antenatal. juga menurut notoatmodjo (2003) yang mengatakan bahwa ketersediaan fasilitas, sikap dan perilaku para petugas kesehatan terhadap kesehatan juga akan mendukung dan memperkuat terbentuknya perilaku individu. menurut peneliti hal ini menguatkan asumsi bahwa dukungan petugas kesehatan juga sangat menentukan keberhasilan cakupan anc bagi ibu hamil, sehingga dapat menekan risiko kematian ibu dan bayi. makna kesehatan reproduksi masih dimaknai dengan sehat secara fisik saja dengan cara menjaga kebersihan organ reproduksi. padahal tentunya remaja putri memiliki pengetahuan yang baik tentang anatomi dan fisiologi sistem reproduksi termasuk makna dari kesehatan reproduksi. hal ini karena dengan persepsi yang baik akan membangun perilaku remaja menjadi lebih baik terkait hak-hak reproduksinya. selain itu persepsi remaja putri tentang hal-hal yang berkaitan dengan kesehatan reproduksi seperti perilaku seks bebas serta dampak dan risikonya, kehamilan yang tidak diinginkan, kehamilan pada usia dini dan bahaya perilaku aborsi didapatkan pendapat yang sangat bervariasi. variasinya persepsi remaja ini karena mereka mendapatkan sumber informasi yang berbeda, dan sekolah belum memiliki program khusus secara intensif tentang topik-topik tersebut. secara umum pendapat remaja sudah mengarah kepada konsep yang benar, hanya saja kualitas persepsinya masih beragam termasuk remaja putri yang drop out sekolah masih malu-malu menanggapi topik ini. seks bebas ditanggapi sebagai perilaku yang tidak tepat dan berisiko menimbulkan kehamilan dan terkena penyakit menular seksual. remaja sudah memaknai dengan tepat tentang seks bebas dan bahayanya, namun menurut remaja kadang sulit untuk menghindari hal tersebut bila sudah memiliki pacar yang sangat dipercaya. menu r ut peneliti, kondisi ini mungkin terjadi karena informasi yang diterima belum terlalu lekat dan teretensi dengan baik, sehingga persepsi remaja masih belum membentuk perilaku yang sesuai dengan makna persepsinya. sunaryo (2004) mema k nai persepsi mer upa ka n pengalaman tentang objek, peristiwa atau hubungan-hubungan yang diperoleh dengan menyimpulkan informasi dan meanggapi pesan. persepsi sendiri dipengaruhi oleh banyak faktor seperti karakteristik individu, sasaran persepsi dan faktor situasi. menurut peneliti supaya remaja memiliki persepsi yang selaras dengan perilakunya diperlukan pemaknaan yang sangat kuat terhadap suatu objek, sehingga akan membangun keyakinan yang tepat untuk pengambilan keputusan dalam perilaku tertentu seperti menghindari seks bebas. salah satu dampak perilaku seks bebas menurut remaja adalah bisa terjadi kehamilan, dan kehamilan yang terjadi adalah kehamilan yang tidak diinginkan. pada kondisi hamil pad a hal belu m ter jad i per n i ka ha n i n i menurut remaja bisa berdampak dikeluarkan dar i sekolah, malu ter masu k membuat malu keluarga, stres hingga berbuat untuk melakukan tindakan pengakhiran kehamilan yaitu aborsi. selain itu kehamilan yang terjadi merupakan kehamilan pada usia dini. persepsi remaja ini sudah tepat, meskipun pendapat remaja juga sangat bervariasi. menurut peneliti persepsi remaja ini merupakan hal positif dalam mengarahkan perilaku remaja untuk mencegah kehamilan yang tidak diinginkan dan hamil pada usia yang masih dini. kehamilan yang tidak diinginkan dan hamil di usia dini akan memiliki dampak pada beberapa aspek meliputi aspek fisik, psikologis, social, ekonomi dan spiritual. berkaitan dengan aspek fisik hal ini akan berkontribusi pada risiko kematian ibu dan bayi, sehingga mestinya 167 model integrated maternity management (diyan indriyani dan asmuji) diperlukan tindakan pencegahan perilaku supaya tidak terjadi kehamilan dengan cara mencegah seks bebas. remaja mayoritas mengungkapkan pendapat bahwa tindakan yang paling sering dilakukan saat remaja terjadi kehamilan di luar nikah adalah keinginan dan atau perilaku aborsi. berbagai alasan dikemukakan oleh remaja tentang alasan aborsi dan secara umum karena perasaan malu atau tidak mau mempermalukan orang tua, karena alasan ini remaja melakukan aborsi, meskipun dalam pendapat remaja mereka memahami bahwa aborsi adalah tindakan yang berbahaya dan dapat merenggut nyawa karena adanya perdarahan. namun biasanya aborsi tetap akan dilakukan karena remaja juga beralasan masih ingin sekolah dan belum siap secara mental dan ekonomi. asumsi peneliti bahwa keputusan remaja memilih tindakan aborsi karena pada masa remaja mereka merupakan kelompok usia yang masih belum matang dalam menanggapi suatu stimulus, sehingga keputusan yang diambil adalah keputusan yang masih didasarkan pada sikap agresivitas sesuai masa perkembangan remaja. remaja masih melihat dari satu aspek saja dan belum pada aspek secara menyeluruh. aborsi merupakan tindakan abortus provokatus kriminalis yang dapat berdampak pada ker usakan organ reproduksi dan juga menimbulkan risiko perdarahan. seperti yang dipaparkan di atas bahwa penyebab utama kematian ibu dan bayi di indonesia termasuk kabupaten jember adalah perdarahan, hipertensi dan infeksi. perdarahan merupakan penyebab kematian tertinggi. jatinangor (2013) mengatakan bahwa saat ini banyak sekali kasus aborsi yang dilakukan karena para remaja yang berpacaran tanpa kenal batas, sehingga berhubungan badan dan hamil. untuk menutupinya maka dilakukanlah aborsi. aborsi bisa berdampak pada kondisi perdarahan, risiko kanker, infeksi, risiko kehamilan prematur pada kehamilan selanjut nya, risiko kematian dan juga berdampak psikologis. adapun menurut bararah (2010) dikatakan bahwa mendapatkan kehamilan yang tidak terduga memang sering menimbulkan beban mental tersendiri. akibatnya banyak praktik aborsi yang dilakukan meski itu terbilang ilegal. menurut peneliti berdasarkan hal tersebut penting sekali mengenalkan pada remaja dengan lebih intensif dan terprogram tentang topik mengenali lebih baik anatomi dan fisiologi sistem reproduksi, perilaku seks bebas serta dampak dan risikonya, kehamilan yang tidak diinginkan, kehamilan pada usia dini dan bahaya perilaku aborsi. melalui program informasi yang intensif diharapkan akan membangun perilaku remaja menjadi lebi h opt i mal d ala m memper t a ha n ka n hak-hak reproduksinya. berdasarkan teori perilaku menurut notoatmodjo (2003) dalam setiawan (2010) dikatakan bahwa perilaku baru terjadi bila ada sesuatu yang diperlukan untuk menimbulkan suatu reaksi yang disebut rangsangan. dari pengalaman dan penelitian terbukti bahwa perilaku yang didasari oleh pengetahuan akan lebih langgeng daripada tidak didasari pengetahuan. seperti yang disampaikan juga dalam notoatmodjo (2010) yang membagi domain perilaku dalam 3 ranah yaitu pengetahuan, sikap dan praktik atau tindakan. hasil penelitian menunjukkan bahwa menurut guru di sekolah, sekolah belum memiliki program khusus yang berkaitan dengan optimalisasi persepsi tentang kesehatan reproduksi remaja dan segala permasalahannya. sekolah tidak memiliki mata pelajaran khusus tentang kesehatan reproduksi. selama ini guru telah melakukan upaya membangun persepsi siswi melalui mata pelajaran seperti biologi, agama, penjaskes, keputrian dan bk, dan penyampaiannya secara implisit saat mengajar. namun program khusus secara periodik dan continue belum ada. hal ini sesuai dengan pengakuan siswi bahwa mereka mengatakan tidak ada pelajaran khusus tentang kesehatan reproduksi dan segala permasalahan yang berhubungan dengan hal itu. menurut peneliti informasi yang lengkap dan detail tentang kesehatan reproduksi sangat penting untuk disampaikan ke siswi, mengingat siswi suatu saat akan memasuki usia produktif yang akan bertanggung jawab terhadap hak-hak reproduksinya. namun, untuk memberikan informasi secara continue termasuk melakukan pendampingan pada siswi tentang kesehatan 168 jurnal ners vol. 9 no. 2 oktober 2014: 159–172 reproduksi, diperlukan kompetensi yang baik dari seorang guru. hal ini agar guru mampu melakukan peran secara tepat saat melakukan pendampingan. selain guru, orang tua juga merupakan pendukung yang sangat penting dalam mendidik remaja putri. berdasarkan hasil penelitian orang tua mayoritas mengatakan bahwa menikah pada usia yang masih dini tidak menjadi masalah dan tidak berdampak pada risiko kesehatan. kekhawatiran orangtua lebih pada risiko permasalahan ekonomi yang masih belum stabil, karena usia anak dan menantu masih muda, sehingga orangtua masih ikut bertanggung jawab secara ekonomi meskipun anaknya sudah menikah. selain itu persepsi bahwa kehamilan pada usia muda juga tidak menjadi masalah, dan tidak berdampak pada risiko kesehatan. secara umum persepsi orang tua tentang dampak pernikahan dini dan kehamilan pada usia dini masih rendah. menurut peneliti hal ini dipengaruhi oleh banyak faktor antara lain pendidikan yang rata-rata adalah pendidikan rendah (sd), faktor budaya dan paparan informasi tentang kesehatan masih kurang. pada masyarakat pedesaan faktor budaya sangat kuat. budaya yang dimaksud seperti anak perempuan tidak perlu sekolah terlalu tinggi, karena nantinya akan menjadi istri yang tergantung pada suami, bila fisik sudah kelihatan besar bisa dinikahkan karena takut jadi perawan tua dan lain sebagainya. menurut pengakuan orangt ua bahwa du k ungan utama yang dilakukan pada remaja putri lebih pada aspek moralitas, seperti jangan hamil sebelum menikah. menurut peneliti dukungan orangtua mestinya tidak hanya pada aspek moralitas, namun juga harus menyentuh aspek-aspek yang lain. namun untuk memiliki kemampuan dalam memberikan dukungan yang optimal, orang tua juga harus memiliki pengetahuan yang baik tentang masalah tersebut. karena adanya dukungan yang baik dari orangtua akan menguatkan persepsi remaja putri dalam menyikapi masalah kesehatan reproduksi. katc dan kahn (2000) dalam mazbow (2009) berpendapat bahwa dukungan sosial adalah perasaan positif, menyukai, kepercayaan, dan perhatian dari orang lain yaitu orang yang berarti dalam kehidupan individu yang bersangkutan berupa pengakuan, kepercayaan dan bantuan langsung dalam bentuk tertentu. salah satu bentuk dukungan sosial ini adalah berupa dukungan informasi kelompok masyarakat berisiko selain remaja putri adalah ibu muda dan ibu hamil dengan usia muda. didapatkan hasil penelitian bahwa persepsi kelompok ini tentang risiko hamil di usia muda masih tergolong berpersepsi kurang. mereka secara umum mengatakan kalau tidak menjadi masalah hamil saat usianya masih muda, yang terpenting adalah bisa mengejan yang kuat saat melahirkan. mereka mengatakan penting untuk melakukan pemeriksaan kehamilan, meskipun keputusan untuk melahirkan di petugas kesehatan atau bersalin di rumah ditolong oleh dukun belum diputuskan. menurut partisipan melahirkan di bidan atau di dukun sama-sama tidak masalah. partisipan juga melakukan kebiasaan untuk pijat di dukun di samping melakukan pemeriksaan kehamilan (anc). partisipan sangat tergantung dengan orang tua dalam mengambil keputusan untuk menetapkan penolong persalinan. pendapat peneliti dengan kondisi tersebut bahwa persepsi ibu muda dan ibu hamil dengan usia muda ini masih kurang. hal ini kemungkinan didukung oleh banyak fak tor seper ti pendidikan rendah, pengetahuan tentang kehamilan dan persalinan masih kurang, pengambilan keputusan dalam keluarga juga faktor budaya. ibu hamil dalam usia risiko sehar usnya mendapatkan pemantauan lebih tinggi karena risiko-risiko yang mungkin terjadi. namun memang fenomenanya risiko tersebut tidak dirasakan oleh partisipan. dalam kondisi seperti ini sangat memerlukan bantuan berupa dukungan untuk mengoptimalkan persepsi ibu. melalui upaya penguatan dukungan dari keluarga diharapakan ibu muda dan ibu hamil dalam usia muda ini akan memiliki perilaku kesehatan yang lebih baik dalam mencegah kejadian kematian ibu dan bayi. indriyani (2013) mengatakan suatu kehamilan dapat memiliki kondisi yang disebut risiko, baik berisiko rendah maupun tinggi. dikatakan risiko adalah ukuran statistik dari peluang untuk terjadinya suatu keadaan yang tidak 169 model integrated maternity management (diyan indriyani dan asmuji) diinginkan di masa mendatang. adapun yang dimaksud faktor risiko yaitu suatu keadaan atau ciri seseorang atau kelompok yang mempunyai hubungan dengan peluang akan terjadinya kondisi seperti penyakit atau kematian. mengingat konsep ini maka menurut peneliti ibu hamil yang memiliki peluang risiko harus berbuat untuk melakukan pencegahan terhadap timbulnya risiko. untuk terjadinya perilaku pencegahan antara lain dengan membangun persepsi yang tepat dari ibu hamil guna melakukan upaya anc secara teratur. upaya menurunkan aki dan akb pada masyarakat pedesaan menjadi tanggungjawab bersama. berdasarkan informasi dari dinas kesehatan dan petugas kesehatan didapatkan data bahwa upaya promotif dan preventif untuk menur unkan aki dan akb telah dilakukan, namun hasil pencapaian masingmasing program bervariasi. banyak kendala yang dihadapi antara lain faktor sdm, factor eksternal dan faktor budaya masyarakat. sebagai sasaran program adalah remaja putri, pasangan usia subur, calon pengantin, pengantin baru dan ibu hamil baru. namun khusus untuk remaja putri drop out sekolah dan ibu muda masih belum tersentuh dalam program kegiatan. selain it u orang t ua dan suami sebagai social support dalam pemberdayaan masyarakat untuk mendukung remaja putri dan ibu muda serta ibu hamil juga masih belum tersentuh dalam program. sedangkan pendidikan kesehatan di sekolah tentang kesehatan reproduksi belum dilakukan secara terprogram dan kontinu, upaya yang dilakukan petugas kesehatan masih bersifat sporadis. kondisi ini menu r ut peneliti memerlukan upaya yang lebih koordinatif dalam melaksanakan upaya promotif dan preventif. u p a y a p r o m o t i f d a n p r e ve n t i f merupakan pintu masuk untuk memutus rantai aki dan akb, sehingga masyarakat menjadi mandiri dan memiliki perilaku kesehatan yang tepat. bila ditelaah kembali tentang daur siklus kehidupan, maka remaja putri merupakan kelompok yang sangat memerlukan informasi tepat tentang kesehatan reproduksi dan segala per masalahan nya. melalui peningkatan persepsi remaja putri, diharapkan mereka akan berperilaku lebih baik dalam mempertahankan ha k-ha k reprodu k si nya. hal i n i tent u akan sinergis dengan berkurangnya angka pernikahan dini yang masih cukup tinggi yaitu sekitar 30%. remaja putri ini nantinya akan menyongsong tahap perkawinan pada usia yang cukup dan sesuai dengan kriteria sehat di usia produktif. tugas berat yang diemban oleh petugas kesehatan ini tidak akan optimal tanpa partisipasi dari masyarakat. dengan mengoptimalkan peran guru dan orangtua serta suami, diharapkan hal ini akan mengefektif kan upaya promotif dan preventif yang telah diprogramkan dalam menekan aki dan akb. dukungan menurut gottlieb (1983) dalam zainudin (2002) dikatakan sebagai informasi verbal atau nonverbal, bantuan nyata atau tingkah laku yang diberikan oleh orang yang akrab dengan subyek dalam lingkungan sosialnya yang dapat memberikan keuntungan emosionalnya atau berpengaruh pada tingkah laku penerimanya. mazboy (2009) menguatkan bahwa keluarga sebagai pendukung memiliki makna yaitu keluarga merupakan sumber dukungan sosial karena dalam hubungan keluarga tercipta hubungan saling mempercayai. individu sebagai anggota keluarga akan menjadikan keluarga sebagai harapan, tempat mengeluarkan keluhankeluhan bila mengalami per masalahan. berdasarkan hal tersebut menurut peneliti dengan adanya dukungan keluarga yang optimal akan menguatkan persepsi dan perilaku remaja putri maupun ibu muda dan ibu hamil dengan usia muda. upaya memandirikan masyarakat agar dapat menolong dirinya sendiri dalam mengatasi masalah kesehatan d i kenal denga n ist ila h pembe rd aya a n masyarakat. wikipedia (2013) menjelaskan bahwa makna pemberdayaan masyarakat yaitu proses pembangunan di mana masyarakat berinisiatif untuk memulai proses kegiatan untuk memperbaiki situasi dan kondisi diri sendiri. pemberdayaan masyarakat hanya bisa terjadi apabila warganya ikut berpartisipasi. petugas kesehatan juga mengatakan bahwa cakupan deteksi dini kehamilan (k1 murni) masih rendah. salah satu faktor yang mempengaruhi hal ini karena adanya keyakinan 170 jurnal ners vol. 9 no. 2 oktober 2014: 159–172 masyarakat tentang budaya pamali (tidak baik) bila melakukan pemeriksaan kehamilan saat masih hamil muda. masyarakat meyakini akan terjadi risiko yang tidak diinginkan terhadap kelangsungan kehidupan janin. karena budaya ini, maka ibu hamil rata-rata melakukan pemeriksaan kehamilan yang pertama kali saat kehamilan sudah memasuki usia 4 bulan ke atas. hal ini tentu bertolak belakang dengan anjuran dalam program k4 yang menganjurkan ibu hamil minimal melakukan 1 kali pemeriksaan kehamilan saat trimester 1. keterlambatan deteksi dini kehamilan bisa ber pengar uh pada risiko kehamilan ibu. karena bila permasalahan kesehatan di usia kehamilan trimester 1, maka dapat menimbulkan kemungkinan keterlambatan penanganan. jadi rendahnya cakupan k1 murni juga dapat berkontribusi terhadap peningkatan aki dan akb. leininger (1984) dalam indriyani (2013) mengatakan bahwa budaya adalah nilai-nilai atau norma-norma yang diyakini oleh individu atau kelompok sehingga mereka melakukan tindakan. budaya dipandang juga sebagai rencana hidup. strategi yang dapat digunakan dalam menyikapi budaya masyarakat yang dikembangkan oleh leininger yaitu mempertahankan budaya (bila budaya masyarakat tidak bertentangan dengan kesehatan), negosiasi budaya (bila budaya tertentu lebih menguntungkan kesehatan) dan mengganti budaya (bila budaya masyarakat merugikan status kesehatan). pada akhirnya semua upaya untuk menurunkan aki dan akb akan kembali dan terkait erat serta tergantung dari partisipasi masyarakat. untuk itu masyarakat perlu diberi pemahaman menyeluruh tentang mengapa d a n bagai ma na mereka ber pa r t isipasi, sehingga aki dan akb dapat diturunkan (wiknjosastro, 2005). oleh sebab itu upaya promotif dan preventif dalam menurunkan aki dan akb sebenarnya justru menjadi pintu masuk yang sangat penting (herawani, 2000). berdasarkan hal tersebut diperlukan model kerjasama saling sinergisme antara masyarakat, petugas kesehatan dan institusi lokal dengan penguatan aspek promotif dan preventif dalam menurunkan aki dan akb. simpulan dan saran simpulan persepsi remaja putri di sekolah tentang masalah kesehatan reproduksi masih belum optimal. guru memiliki rasa tanggung jawab untuk meningkatkan pemahaman siswi terkait kesehatan reproduksi yang dilakukan dengan memberikan nasehat sesuai dengan peran dan tanggung jawab sesuai bidang ilmu dalam mata pelajaran karena secara umum kurikulum khusus tentang kesehatan reproduksi tidak ada. orang tua secara umum tidak merasa khawatir terhadap risiko status kesehatan pada anak perempuan yang menikah dini maupun hamil pada usia muda. kekhawatiran orang tua lebih kepada risiko ekonomi yang belum matang saat pernikahan anak pada usia yang masih dini. berkaitan dengan dukungan orangtua pada remaja putri secara umum masih sebatas dukungan yang bersifat moralitas, dan belum pada aspek fungsi kesehatan. program kegiatan bidang kesehatan t e rk ait upaya promot if d a n preve nt if dalam menurunkan aki dan akb sudah dilaksanakan. namun pencapaian masingmasing program masih bervariasi. khusus sasaran program pada kelompok remaja drop out dan ibu muda dan orangtua secara umum masih belum tersentuh, sedangkan pada remaja putri di sekolah pendidikan kesehatan terkait kesehatan reproduksi masih bersifat sporadic. adapun untuk sasaran program pada kelompok ibu hamil, bayi dan balita sudah dilaksanakan secara optimal. kendala yang dihadapi dalam pelaksanaan program meliputi faktor sdm, faktor eksternal, faktor budaya, dan faktor geografis. upaya pendekatan promotif dan preventif dalam menurunkan aki dan akb bagi masyarakat pedesaan dapat dilakukan secara terintegrasi dan mengoptimalkan pemberdayaan masyarakat dalam mendukung kelompok masyarakat berisiko, sehingga perubahan perilaku kesehatan menjadi lebih optimal. saran orang t ua dan suami disaran kan untuk mengoptimalkan pemahaman tentang 171 model integrated maternity management (diyan indriyani dan asmuji) kesehatan reproduksi dan per masalahan yang berkaitan, kehamilan dan persalinan. pemahaman yang meningkat akan membantu orangtua dan suami memiliki kemampuan memberikan dukungan yang lebih optimal pada kelompok berisiko yaitu remaja putri, ibu muda dan ibu hamil pada usia muda. selain itu hendaknya orangtua memfasilitasi remaja putri untuk mendapatkan hak-hak reproduksinya dengan cara berkontribusi dalam pendewasaan usia menikah pada putrinya. m e n a m b a h w a w a s a n t e n t a n g masalah seputar kesehatan reproduksi pada remaja sangat penting bagi gur u. selain itu memberikan dukungan pada siswi di sekolah dengan cara meningkatkan persepsi siswi tentang kesehatan reproduksi dan permasalahan yang berkaitan, dan dilakukan secara intensif dan terprogram. saran lain agar guru mengaktif kan layanan bimbingan dan konseling yang didalamnya termasuk berperan aktif membantu siswi mengatasi permasalahan kesehatan reproduksi yang dibutuhkan. mengoptimalkan program pelayanan kesehatan ter utama aspek promotif dan pr eve nt i f se c a r a t e r i nt eg r a si mela lu i perpanjangan tangan dengan mengoptimalkan pemberd aya a n ma sya r a k at pendu k u ng seperti guru, suami dan orangtua. integrasi dengan adanya kerjasama petugas kesehatan, institusi local dan masyarakat tersebut akan mengefektif kan upaya promotif dan preventif dalam menurunkan aki dan akb. dinas kesehatan sebaiknya membuat kebijakan dalam memperkuat sistem integrasi layanan pada aspek promotif dan preventif melalui kerjasama yang intensif antara dinas kesehatan, institusi lokal dan masyarakat. selain itu agar arah kebijakan program dapat dilakukan secara intensif dan terprogram dengan jelas. penelitian selanjutnya perlu untuk melakukan uji coba secara lebih komprehensif terhadap efektivitas model integrated maternity management dengan penguatan aspek promotif dan preventif dalam menurunkan aki dan akb pada masyarakat pedesaan. uji coba tersebut hendaknya dijadikan landasan untuk menyempurnakan model. kepustakaan anondo, d. 2010. pelayanan gratis melalui p r o g r a m j a m i n a n p e r s a l i n a n (jampersal).http://manajemen-rs.net. diakses 06 januari 2012. bararah, v.f. 2010. bahaya melakukan aborsi. health.detik.com bobak, lm., lowdermilk, d.l., & jensen, m.d., 2005. (alih bahasa * wijayarini, m . a). b u k u a j a r k e p e r a w a t n maternitas. edisi 4. jakarta: egc chapman, v. 2003. the midwifw’s labour & birth handbook. oxford: blackwell publishing company. depkes ri, 2001. rencana strategis nasional making pregnancy safer (ms) di indonesia 2001–2010. jakarta: depkes hamzah, f. 2013. hubungan antara dukungan keluarga dengan keteraturan antenatal ca re d i p u ske sma s uju ng l e ro kecamatan suppa kabupaten piring sulawesi selatan. (online) (w w w. poltekes-mks.ac.id. di akses 20 oktober 2013) herawani, dkk. 2000. pendidikan kesehatan dalam keperawatan. jakarta: egc. indriyani, d. (a) 2009. hubungan tingkat pe ngeta h ua n d a n sik a p re m aja terhadap pernikahan dini. jember: fakultas ilmu kesehatan universitas muhammadiyah jember. indriyani, d.(b) 2010. hubungan pengetahuan tentang kesehatan reproduksi dengan perilaku seksual pada remaja. jember: fakultas ilmu kesehatan universitas muhammadiyah jember. indyiyani, d.(c) dkk. 2011. studi pengetahuan re m a ja p u t r i t e n t a n g d a m p a k pernikahan dini pada kesehatan reproduksi. jember: fakultas ilmu kesehatan universitas muhammadiyah jember. indriyani, d. (d) dkk. 2011. identifikasi faktor yang berhubungan dengan kejadian pernikahan dini di masyarakat. jember: fakultas ilmu kesehatan universitas muhammadiyah jember. indriyani, d. (e) 2013. keperawatan maternitas pada area pera watan antenatal. yogyakarta: graha ilmu indriyani, d. (f ). 2013. penerapan konsep dan teori keperawatan: ibu postpartum 172 jurnal ners vol. 9 no. 2 oktober 2014: 159–172 dengan kematian janin. yogyakarta: arr-ruzz media. jati nangor. 2013. bahaya aborsi bagi kesehatan fisik dan mental. (online) (http://www.jatinangorku.com. diakses tanggal 20 oktober 2013) kemenkes ri. 2011. petunjuk tehnis jaminan persalinan. jakarta : kemenkes ri. ladewig, p.w., london, m.l., & olds, s.b. 2002. clinical handbook: contemporary maternal-neonatal nursing care. 5th ed. new jersey: prentice hall. listyani, a.s., 2010. angka kematian ibu dan angka kematian bayi di surabaya lampaui target minimal. (online) (http://kelanakota.suarasurabaya.net. diakses 04 januari 2012) mazboy. s. 2009. dukungan keluarga dalam perilaku kesehatan. (online) (http:// www.masbow.com. diakses tanggal 5 januari 2012) mochtar, r., 2001. sinopsis obstetri, obstetri fisiologi-obstetri patologi. jilid 1. edisi 3. jakarta: egc. notoat modjo, s. 2010. i l mu per ila k u kesehatan. jakarta: rhineka cipta pillitery, a. 2003. maternal and child health nursing. fourth edition. philadelphia: lippincott. saifuddin, a,b. 2002. buku acuan nasional pelayanan maternal dan neonatal. jakarta: jnpkkr-pogi bekerja sama dengan ybp-sarwono prawirohardjo. saifuddin, a.b. 2002. buku panduan praktis pelayanan komplikasi perinatal dan neonatal. ja kar t a: yayasan bi na pustaka sarwono prawirohardjo. wijaya, a.m., 2009. angka kematan ibu dan bayi target mdgs. (online), ( http:// www.infodokterku.com. diakses 06 januari 2012) wikipedia. 2013. pemberdayaan masyarakat. (o n li ne), ( ht t p://id.w i k iped ia.org. diakses tanggal 06 januari 2012) wiknjosastro, h. 2005. ilmu kebidanan. jakarta : yayasan bina pustaka sarwono prawirohardjo. yustina, i. 2010. upaya strategis menurunkan angka kematian ibu (aki) dan angka kematian bayi (akb). (online), (jurnal. pdii.lipi.go.id. diakses tanggal 18 oktober 2013) zainudin. (2002). psikologi kesehatan. (online), (http://www.e-psikologi.com. diakses tanggal 18 oktober 2013) http://e-journal.unair.ac.id/jners | 75 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19010 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family experience of caring for a diabetes mellitus patient: a qualitative study indah wulandari 1,3, kusnanto kusnanto1, sony wibisono2 and titin puspitasari3 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 faculty of medicine, universitas airlangga, surabaya, indonesia 3 nursing program, faculty of health science, universitas faletehan, banten, indonesia abstract introduction: diabetes mellitus is a chronic disease that requires lifelong care. the treatment of diabetes mellitus patients at home requires a family role so then the patients can optimize their care. the diabetes complications can be reduced as a result. the aim of this study was to explore the family experience of treating diabetes mellitus patients at home. methods: a semi-structured phenomenological approach including inductive thematic analysis was used in this research. thirteen family members of diabetes patients participated in the discussion. participant recruitment was focused on families that have treated diabetes patients for more than 1 year with no complications. data saturation occurred after 2-3 meetings per participant. results: the experiences of the family members while caring for diabetes mellitus patient can be used to determine the presence of 5 themes: family feelings that appear when caring for diabetes mellitus patients, patient adherence to taking medication, patient’s disobedience of their diet, patient’s disobedience of activity and the family expectations of the future conclusion: in every theme, family experience obstacles arise between the families’ wants and the patients’ needs. diet and activity became a major obstacle to diabetic care at home. some topics needed more attention, such as the information and support provided for the family. article history received: feb 27, 2020 accepted: april 1, 2020 keywords diabetes care; diabetes mellitus; family experiences; family support contact indah wulandari  indah.wulandari2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: wulandari, i., kusnanto, k., wibisono, s., & puspitasari, t. (2020). family experience of caring for a diabetes mellitus patient: a qualitative study. jurnal ners, special issues, 75-81. doi:http://dx.doi.org/10.20473/jn.v15i2.19010 introduction a person's experience becomes one of the sources of learning when treating disease, one of which is diabetes mellitus. experience teaches a person knowledge, prompts an attitude improvement, and results in behavior modification through the observation of the reaction to an action (dziegielewski, wodarski, lawrence, zittekpalamara, & dulmus, 2007; royer, 1998). diabetes mellitus is a chronic disease that must be suffered for a lifetime. diabetes mellitus patients and their families must have good knowledge and skills because the treatment is done continually (alpers, 2010; ansari, hosseinzadeh, harris, & zwar, 2018; macedo, cortez, santos, reis, & torres, 2017). experience can be a true source of information but it can also provide incorrect information if it is not balanced with formal information. patients and their families can assume that their experience is correct if the observations show there to be an improvement in their health status. they can assume that they are wrong if the observations show worsening symptoms (royer, 1998). the results of these observations were discussed with the health workers to validate whether or not the actions needed are what they are actually doing. however, if the patients and their families do not have access to validate their observations, then they may infer incorrectly (alpers, 2010; royer, 1998). the recent studies indicate that the family has a role in helping the diabetes patients to care for https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. i. wulandari et al. 76 | pissn: 1858-3598  eissn: 2502-5791 themselves at home (kristianingrum, wiarsih, & nursasi, 2018; shahab et al., 2019; yue et al., 2019). the support received by the diabetes mellitus patients from their family comes in the form of helping the patients in their daily activities, assistance when preparing food, accompanying them to the health center, helping financially, helping them to solve problems and giving them attention (kristianingrum et al., 2018). family behavior has a positive impact but sometimes the patients feel that the family attention is nagging and disturbing (mayberry, harper, & osborn, 2016). in addition, the differences in perception between the patients and their families are also obstacles in the treatment of the diabetes mellitus patients (shahab et al., 2019; yue et al., 2019). the family is the closest environment that provides assistance to the patients with diabetes mellitus in terms of their care. the family experience of treating patients with diabetes mellitus at home is influenced by several things such as knowledge, attitude, motivation, socioeconomic level and access to information sources (ansari et al., 2018; coser, sittner, walls, & handeland, 2018; gomes et al., 2017; mayberry et al., 2016). the family has an important role in supporting the patients with diabetes mellitus care at home (coser et al., 2018; gomes et al., 2017; king et al., 2010; mayberry et al., 2016; ramkisson, pillay, & sibanda, 2017; shawon et al., 2016). good support from their family member will help the patients with diabetes mellitus to undergo their treatment. the impact of good care for each patients is intended to enhance the patient’s motivation to carry out regular care, to reduce the risk of complications, to reduce patient anxiety and to improve the quality of life of patients with diabetes mellitus (ahola & groop, 2013; al-khawaldeh, alhassan, & froelicher, 2012; jannoo & mamode khan, 2019; mogre, abanga, tzelepis, johnson, & paul, 2017; pamungkas, chamroonsawasdi, & vatanasomboon, 2017). the support provided by the family members also helps the diabetes mellitus patients to achieve compliance in terms of self care (jannoo & mamode khan, 2019; mogre et al., 2017; simon-tuval, shmueli, & harman-boehm, 2016). a recent study showed that the patients had difficulty achieving adherence to their diet, recommended activities and medication when they did not get support from their family (ahola & groop, 2013; al-khawaldeh et al., 2012; baek, tanenbaum, & gonzalez, 2014; jannoo & mamode khan, 2019; mogre et al., 2017). the impact showed that the patients did not achieve a stable regulation of their blood glucose and so their quality of life decreased. in addition, the patients also experienced anxiety and emotional disturbances (a.a., j.d., m., & a.-m., 2018; pamungkas et al., 2017; sina, graffy, & simmons, 2018). therefore good family experience is needed in the care of diabetes mellitus patients at home. the aim of this study was to explore the family experiences when treating diabetes mellitus patients. materials and methods design this study used a phenomenological approach. inductive thematic analysis was used to get themes from the data collection. phenomenology was used to describe the phenomena that exists as an integral part of the world in which we are living (astalin, 2013; berg, 2001). in this study, this refers to the family experience of caring for the diabetes mellitus patient. we conducted the data collection using in-depth interviews that were recorded and documented in the form of field notes. a semi-structured interview was selected as a guide. the determination of the theme used the 7 steps of inductive thematic analysis from colaizzi: 1) transcribing all of the subjects’ descriptions, 2) extracting significant statements, 3) creating the formulated meanings, 4) aggregating the formulated meanings into theme clusters, 5) developing an exhaustive description, 6) identifying the fundamental structure of the phenomenon and 7) returning to the participants for validation (edward & welch, 2011; morrow, rodriguez, & king, 2015). sample and setting the families were recruited using purposive sampling in one of the sub-district level health centers. the selection criteria for the family members were that they were 18 years or older and that they had been living with and providing care for a diabetes patient for one year or more. a sub-district level health center officer was involved in the selection of the participants and they helped the researchers with their field notes. the families willing to become participants were given information on the research, on their involvement in the research, and if there were to be any rewards received. if the family was willing to become a participant, then they signed the prepared consent form. thirteen family members participated in this study (see table 1). the researcher explained to the participants that they could refuse to participate at any time. data collection the interviews were held at the sub-district level health center. thirteen semi-structured interviews were held based on the families’ experiences. the interviews were conducted from november 2019 to december 2019, and they lasted between 30 and 60 minutes. we were started the interview with an open question: ‘could you tell me about the care that provide for diabetes mellitus at patient at home?’ the semi-structured questions were based on the literature to ensure that the relevant topics were covered. data saturation occurred after 2 3 meetings per participant. data analysis the researcher used a type-recorder and transcribed verbatim. inductive thematic analysis was used to enhance the understanding of the families’ jurnal ners http://e-journal.unair.ac.id/jners | 77 knowledge and their competencies regarding the caring of the diabetes mellitus patients. some of the family members also talked about the disturbances or barriers when taking care of the diabetes mellitus patient. the inductive thematic analysis was conducted by the researcher and the transcripts were used to make up the content analysis. the transcripts were analyzed line by line and the codes were noted in the margin, creating a label for each sentence. the codes were grouped and labeled using broader categories and themes. ethical approval the data was collected after getting approval from the district level health office of serang in the form of a research permit. the researchers got a recommendation letter for the research permit from their institution and presented this to the district level health office. the district level health office examined the incoming letter, gave them permission and designated a place of research. the basis for the appointment of the research site is that it has the highest number of cases of diabetes mellitus in the table1. demographics of participant no family relationship age time of the patients cared for patients’ health status 1 wife 61 7 years no complications 2 wife 33 2 years diabetic ulcer 3 son 18 7 years hypercholesterolemia 4 daughter 18 5 years hypertension 5 daughter 20 2 years no complications 6 daughter 27 3 years hypertension 7 niece 42 2 years no complications 8 wife 56 5 years hypertension 9 wife 35 3 years hypertension 10 daughter 35 2,5 years hypertension 11 daughter 37 2 years hypertension 12 wife 44 4 years no complications 13 sister 30 8 years no complications figure 1. scheme of the themes that the family experiences related to diabetes patient care i. wulandari et al. 78 | pissn: 1858-3598  eissn: 2502-5791 city of serang, indonesia. this research was conducted with respect to the subject’s rights, justice, confidentiality and beneficence. results the study findings show that most family members had negative experiences when caring for the diet and activity of the diabetes mellitus patient. most of the patients struggled to keep their diet and activity consistent with the health worker’s suggestion. the experience of the family members when caring for the diabetes mellitus patient can be determined using 5 themes: 1) family feelings that appear when caring for diabetes mellitus patients, 2) patient adherence to taking medication, 3) patient disobedience of the diets,4) patient disobedience of physical activity and 5) the family expectations in the future. in every theme, family experience obstacles arise between the families’ wants and the patients’ needs. family feelings that appear when caring for the diabetes mellitus patients most of the families expressed fear, helplessness and worry while caring for the patients with diabetes mellitus. the fear that arises among the family members due to the possibility of complications related to diabetes mellitus that can lead to early patient death. ‘i was afraid that if my mother was sick …..i was afraid that her illness would cause death.’ (family member 4). ‘i am worried and scared, i am afraid of the danger of my husband's illness…’ (family member 2). the family was also worried about the boredom felt by the patients undergoing treatment because the family realized that diabetes mellitus is experienced for a lifetime. ‘i feel sad and scared… and afraid because my aunt was diagnosed [with] diabetes by a doctor. i was also desperate and worried that if there was a wound th[en it] would [not] heal for a long time.’ (family member 7). patient adherence to taking medicine most patients adhere when it comes to taking the recommended medication. according to the family, patient compliance arises because of the free program from the sub-district level health center that the patients can follow every month. in addition, the patients are more likely to trust the doctor's advice on medication, as well as there being the hope of recovery with routine treatment. ‘my husband still routinely takes the medicine .... and [not] just injecting insulin by himself.’ (family member 12). ‘my mom is still taking medication regularly…’ (family member 5). ‘my mother is taking routine medical treatment at the sub-district level health center every month…’ (family member 11). patient disobedience diet most of the patients do not adhere to their diet. the most common reasons were boredom, not holding to their diet plan and always feeling hungry. families have difficulty helping the patients as they prepare menus separately or the patients do not want to follow the dietary advice. patients who feel bored following a different diet have often been diagnosed with diabetes mellitus for more than 5 years. there were also patients who did not adhere to the diet because of the difficulty resisting their desire to eat or always feeling hungry. this was common in the patients diagnosed <5 years ago. only 2 families stated that the patient adhered to the diet. “’my father is difficult when abstaining from eating. drinking coffee is also still do[ne]... hard to stop…’ (family member 8). ‘my mother had difficulty being told to go on a diet. she just wanted [to eat] when looking at any food.’ (family member 10). ‘in the past, she liked to stick to the diet, but now she likes to be disobedient. she likes to secretly eat without me knowing.’ (family member 13). patient disobedience activity the families said that one of the obstacles when caring for patients is regular exercise. most patients do not want to exercise regularly because they are lazy. the other reason was that they had a complication that was a difficulty in the context of routine exercise. in addition, some of the patients were still actively working so it is reasonable for them not to have the opportunity to exercise. ‘my mom just do[es] exercise sometimes ... it's usually just a morning walk…’ (family member 6). ‘my sister never do[es] any exercise. she know[s] that she ha[s] to exercise but if i t[ell] her to do it, the answer[is that she is] just lazy ...’ (family member 13). ‘my father still works every day. he is returning late [in the] afternoon or evening. he often feels [that it is] difficult to adjust the time [taken] to do an exercise. sometimes he runs early on sundays.’ (family member 5). family expectations of the future most families hope that the patients can live their lives normally without complications while always in a good condition. most of the families said that if the patients were treated for complications or have unstable blood glucose, then they feel helpless and difficult during the recovery period. this is due to the fact that most patients fail to comply with the treatment because they feel hopeless, especially the patients who have the role of being the head of the family. they tend not to want to think about the disease and continue to work as though they were not sick. ‘……hopefully there are no complications that occur in my husband.’ (family member 1). ‘i hope [that] my husband is always healthy. he is the head of the family. if he is sick, no one will support my family.’ (family member 9). jurnal ners http://e-journal.unair.ac.id/jners | 79 discussion feelings of fear, anxiety or a loss of hope that appear when treating chronically-ill patients are often experienced by the family. the causes include family knowledge, the patient's physical and psychological condition, and socioeconomic status (abubakari et al., 2016; baek et al., 2014; mayberry et al., 2016; salom? et al., 2017). the ignorance of the family when it comes to how to provide care and the impact of care is caused by anxiety or fear in the family (jannoo & mamode khan, 2019; joo & lee, 2016; mayberry et al., 2016). there is also the fear of facing pain or the death of the family member diagnosed with diabetes mellitus. the physical condition of the patient, referring to the complications due to diabetes or the psychological state of the patient, is also a source of stress for the family. the socioeconomic condition of the family, such as the existence of health insurance, is another factor that causes anxiety in the family. the knowledge that diabetes mellitus is a lifelong disease that requires a lot of treatment and the associated costs is a major obstacle for the families with a lower socioeconomic status with a family member who is a patient with diabetes mellitus (abubakari et al., 2016; jannoo & mamode khan, 2019; joo & lee, 2016; mayberry et al., 2016; sina et al., 2018). the family members often cannot refute the patient's wishes when they are undergoing diabetes treatments, referring to their diet and exercise, due to their existing emotional attachment. culture and race as well as the close relationship also allegedly causes the family difficulty when it comes to rejecting the desire of the patients to not adhere to the recommended diet (ansari et al., 2018; gomes et al., 2017; mansyur, rustveld, nash, & jibaja-weiss, 2015). in this study, where the patient was the husband of the participant, there is the cultural factor where the husband's position is higher than that of their wife. the wife must obey her husband even though it is wrong. when a child is taking care of their parents, if they do not fulfill the parents' desire to eat what they want, there is a feeling of guilt. this feeling arises in the family so it is difficult to maintain consistency in terms of diet or exercise. apart from the cultural factors, the desire of the families to make the patients happy is one of the obstacles faced. in this study, if a patient with diabetes mellitus is given a diet menu that is recommended by their doctor, they often do not want to eat according to it. the patient does not eat and so the family will try to fulfill the patient's wishes. the study found that this is common where the patient is over the age of 50 years old. another case is where the patient has a good level of desire and motivation when it comes to adhering to the diet and exercise rules. the results will be better than before. the adherence of the patient showed better results, namely the achievement of blood glucose stability (abubakari et al., 2016; gamboa moreno et al., 2018; mansyur et al., 2015; simon-tuval et al., 2016; sina et al., 2018). the study results showed that the patients with diabetes who were supported by their family had better adherence than those without family support. the family support that is needed by the patients most is emotional support. this strengthens the patients when facing the disease, allowing them to carry out better care. the family experience of caring for patients provides additional family knowledge and skills in order to provide the best care for patients with diabetes mellitus. conclusion the treatment of diabetes mellitus patients at home requires an equality of perception between the patients and their family members. the patients, as the main character and the focus of the care, must be fully supported by their family in order to have the passion and desire to undergo treatment. conflict of interest this study does not have a conflict of interest. the research is independently funded and has no sponsor interests. each participant was free to choose to be a participant or not, and they could have stopped their participation in the research whenever it was deemed to be necessary without any negative consequences. acknowledgement acknowledgments are given to the leadership of the sub-district level health center and to the participants who provided their time in this study references a.a., l., j.d., p., m., h., & a.-m., r. (2018). diabetes distress and glycemic control: the buffering effect of autonomy support from important family members and friends. diabetes care, 41(6), 1157– 1163. https://doi.org/10.2337/dc17-2396 abubakari, a., cousins, r., thomas, c., sharma, d., naderali, e. k., park, h., & liverpool, l. (2016). sociodemographic and clinical predictors of selfmanagement among people with poorly controlled type 1 and type 2 diabetes : the role of illness perceptions and self-efficacy. journal of diabetes research, 2016. ahola, a. j., & groop, p. h. (2013). barriers to selfmanagement of diabetes. diabetic medicine, 30(4), 413–420. https://doi.org/10.1111/dme.12105 al-khawaldeh, o. a., al-hassan, m. a., & froelicher, e. s. (2012). self-efficacy, self-management, and glycemic control in adults with type 2 diabetes mellitus. journal of diabetes and its complications, 26(1), 10–16. https://doi.org/10.1016/j.jdiacomp.2011.11.002 alpers, r. r. (2010). a review of “nursing and family caregiving: social support and nonsupport.” in health care for women international (vol. 31). https://doi.org/10.1080/07399332.2010.50013 4 ansari, r. m., hosseinzadeh, h., harris, m., & zwar, n. i. wulandari et al. 80 | pissn: 1858-3598  eissn: 2502-5791 (2018). self-management experiences among middle-aged population of rural area of pakistan with type 2 diabetes: a qualitative analysis. clinical epidemiology and global health, (february), 0–1. https://doi.org/10.1016/j.cegh.2018.04.003 astalin, p. k. (2013). qualitative research designs: a conceptual framework. international journal of social science and interdisciplinary reasearch, 2(1), 118–124. https://doi.org/10.1063/1.2163485 baek, r. n., tanenbaum, m. l., & gonzalez, j. s. (2014). diabetes burden and diabetes distress: the buffering effect of social support. annals of behavioral medicine, 48(2), 145–155. https://doi.org/10.1007/s12160-013-9585-4 berg, b. l. (2001). qualitative research methods for the social sciences (fourth). boston: allyn and bacon. coser, a., sittner, k. j., walls, m. l., & handeland, t. (2018). caregiving stress among american indians with type 2 diabetes: the importance of awareness of connectedness and family support. journal of family nursing, 24(4), 621–639. https://doi.org/10.1177/1074840718810550 dziegielewski, s. f., wodarski, j. s., lawrence, s. a., zittek-palamara, ki., & dulmus, c. n. (2007). human behavior and the social environment. in j. s. wodarski & s. f. dziegielewski (eds.), new york. https://doi.org/10.1109/icde.2002.994737 edward, k. leigh, & welch, a. (2011). the extension of colaizzi’s method of phenomenological enquiry. contemporary nurse, 39(2), 163–171. https://doi.org/10.5172/conu.2011.39.2.163 gamboa moreno, e., mateo-abad, m., ochoa de retana garcía, l., vrotsou, k., del campo pena, e., sánchez perez, á., … rotaeche del campo, r. (2018). efficacy of a self-management education programme on patients with type 2 diabetes in primary care: a randomised controlled trial. primary care diabetes, 1–12. https://doi.org/10.1016/j.pcd.2018.10.001 gomes, l. c., coelho, a. c. m., gomides, d. dos s., fossfreitas, m. c., foss, m. c., & pace, a. e. (2017). contribution of family social support to the metabolic control of people with diabetes mellitus: a randomized controlled clinical trial. applied nursing research, 36, 68–76. https://doi.org/10.1016/j.apnr.2017.05.009 jannoo, z., & mamode khan, n. (2019). medication adherence and diabetes self-care activities among patients with type 2 diabetes mellitus. value in health regional issues, 18, 30–35. https://doi.org/10.1016/j.vhri.2018.06.003 joo, j. y., & lee, h. (2016). barriers to and facilitators of diabetes self-management with elderly koreanamerican immigrants. international council of nurses, 63, 277–284. king, d. k., glasgow, r. e., toobert, d. j., strycker, l. a., estabrooks, p. a., osuna, d., & faber, a. j. (2010). self-efficacy, problem solving, and socialenvironmental support are associated with diabetes self-management behaviors. diabetes care, 33(4), 751–753. https://doi.org/10.2337/dc09-1746 kristianingrum, n. d., wiarsih, w., & nursasi, a. y. (2018). perceived family support among older persons in diabetes mellitus self-management. bmc geriatrics, 18(suppl 1), 1–5. https://doi.org/10.1186/s12877-018-0981-2 macedo, m. m. l., cortez, d. n., santos, j. c. dos, reis, i. a., & torres, h. de c. (2017). adherence to selfcare practices and empowerment of people with diabetes mellitus: a randomized clinical trial. revista da escola de enfermagem, 51, 1–8. https://doi.org/10.1590/s1980220x2016050303278 mansyur, c. l., rustveld, l. o., nash, s. g., & jibajaweiss, m. l. (2015). social factors and barriers to self-care adherence in hispanic men and women with diabetes. patient education and counseling, 98(6), 805–810. https://doi.org/10.1016/j.pec.2015.03.001 mayberry, l. s., harper, k. j., & osborn, c. y. (2016). family behaviors and type 2 diabetes: what to target and how to address in interventions for adults with low socioeconomic status. chronic illness, 12(3), 199–215. https://doi.org/10.1177/1742395316644303 mogre, v., abanga, z. o., tzelepis, f., johnson, n. a., & paul, c. (2017). adherence to and factors associated with self-care behaviours in type 2 diabetes patients in ghana. bmc endocrine disorders, 17(1), 1–8. https://doi.org/10.1186/s12902-017-0169-3 morrow, r., rodriguez, a., & king, n. (2015). colaizzi’s descriptive phenomenological method. the psychologist, 28(8), 643–644. pamungkas, r. a., chamroonsawasdi, k., & vatanasomboon, p. (2017). a systematic review: family support integrated with diabetes selfmanagement among uncontrolled type ii diabetes mellitus patients. behavioral sciences, 7(3), 1–17. https://doi.org/10.3390/bs7030062 ramkisson, s., pillay, b. j., & sibanda, w. (2017). social support and coping in adults with type 2 diabetes. african journal of primary health care and family medicine, 9(1), 1–8. https://doi.org/10.4102/phcfm.v9i1.1405 royer, a. (1998). life with chronic illness: social and psychological dimensions. westport, connecticut: greenwood publishing group. salom?, g. m., de almeida, s. a., mendes, b., de carvalho, m. r. f., bueno, j. c., massahud, m. r., & ferreira, l. m. (2017). association of sociodemographic factors with spirituality and hope in patients with diabetic foot ulcers. advances in skin and wound care, 30(1), 35–39. https://doi.org/10.1097/01.asw.0000508446.5 8173.29 jurnal ners http://e-journal.unair.ac.id/jners | 81 shahab, y., alofivae-doorbinnia, o., reath, j., macmillan, f., simmons, d., mcbride, k., & abbott, p. (2019). samoan migrants’ perspectives on diabetes: a qualitative study. health promotion journal of australia, 30(3), 317–323. https://doi.org/10.1002/hpja.240 shawon, m. s. r., hossain, f. b., adhikary, g., das gupta, r., hashan, m. r., rabbi, m. f., & ahsan, g. u. (2016). attitude towards diabetes and social and family support among type 2 diabetes patients attending a tertiary-care hospital in bangladesh: a cross-sectional study. bmc research notes, 9(1), 1–8. https://doi.org/10.1186/s13104-016-20818 simon-tuval, t., shmueli, a., & harman-boehm, i. (2016). adherence to self-care behaviors among patients with type 2 diabetes—the role of risk preferences. value in health, 19(6), 844–851. https://doi.org/10.1016/j.jval.2016.04.003 sina, m., graffy, j., & simmons, d. (2018). associations between barriers to self-care and diabetes complications among patients with type 2 diabetes. diabetes research and clinical practice, 141, 126–131. https://doi.org/10.1016/j.diabres.2018.04.031 yue, p., lamb, k. v., chen, x., wang, y., xiao, s., feng, x., & wu, y. (2019). identification of family factors that affect self-management behaviors among patients with type 2 diabetes: a qualitative descriptive study in chinese communities. journal of transcultural nursing, 30(3), 250–259. https://doi.org/10.1177/1043659618793713 126 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.19432 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research how do people living with hiv acquire hiv related information: a qualitative evaluation of jakarta setting mahathir mahathir1, wiwin wiarsih2, and henny permatasari2 1faculty of nursing universitas andalas, west sumatra, indonesia 2faculty of nursing, universitas indonesia, west java, indonesia abstract introduction: people living with hiv are fully aware of their risk behavior and future threats that might arise. the rapid progress of hiv serves the population with many options of healthcare services and treatments. insufficient knowledge and information will only lower the outcomes of hiv eradication efforts. the ultimate goals to eradicate hiv are to upscale status notification and treat all with appropriate antiretroviral and viral suppression, but it needs sufficient information to administer. programs and interventions have already been proposed, but an inquiry is needed to ensure all the information is actually there. the study aimed to explore the experience of people living with hiv acquiring hiv-related information. methods: this study used phenomenological qualitative study and in-depth interviews were conducted to 12 people living with hiv. semi-structured questions were delivered to all participants which explored their tangible experience in terms of nurturing sufficient hiv-related information. results: the study found four consequential themes: non-government organizations play a major role in hiv education, peers are a comfortable platform to discuss, it is all over the media and healthcare personnel are a source of knowledge. conclusion: the distribution of hiv information and knowledge is now widespread. this situation marks part of the success in fighting hiv. remarkable attempts can be maintained by optimizing the viable option of information delivery. article history received: may 27, 2020 accepted: july 20, 2020 keywords hiv knowledge; people living with hiv; qualitative study contact mahathir mahathir  mahathirmahat@nrs.unand.ac.id  faculty of nursing universitas andalas, west sumatra, indonesia cite this as: mahathir, m., wiarsih, w., & permatasari, h. (2019). how do people living with hiv acquire hiv related information: a qualitative evaluation of jakarta setting. jurnal ners, 15(2). 126-134. doi:http://dx.doi.org/10.20473/jn.v15i2.19432 introduction as of today, at least 32 million people have died as devastating consequences of hiv and aids since the start of the epidemic (unaids, 2019). in order to achieve the 2030 target urgent pressing needs have to be fulfilled (unaids, 2020). various strategies will be provided with global solidarity, evidence-based action and multi stakeholders’ partnerships in order to attain hiv treatment for all (unaids, 2014). the progress toward sustainable development goals of health and wellbeing reported that there is strong and steady national and global financial commitment, the acceleration of evidence-based hiv prevention, testing and treatment programs availability among different countries. the total incidence rate of hiv incidence has declined by 22% since 2010 (un, 2019). mortality caused by aids-related disease is also declining globally, but both of those achievements are far away from the target. hiv prevention, testing and treatment needs to be accelerated and focus on analyzing the gap of implementation (world health organization, 2019). the hiv burden is still haunting most of countries worldwide, particularly for low and middle income countries (haakenstad et al., 2019). the hiv global statistic data show 37.9 million people are now living with hiv, 1.7 million people are newly infected with the virus and 770.000 of them died caused by hivrelated illness. it expected around 24.5 million people living with hiv are accessing antiretroviral therapy (unaids, 2019). there are 13 million numerical gaps https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:%20mahathirmahat@nrs.unand.ac.id mailto:%20mahathirmahat@nrs.unand.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 127 of people living with hiv not possessing antiretroviral treatment. indonesia has been known as the fourth largest number of hiv new infections per year. indonesia is the only country in the asia pacific region which has rapid increasing of hiv prevalence (januraga et al., 2018). in the hiv statistics, indonesia alone recorded 640,000 people affected by the virus, at least 46,000 people who are newly infected in the most recent year, and 38,000 of them have died of aids-related disease (unaids, 2018a). the 90-90-90 target demands to end hiv by achieving 90% population knowing their status, 90% hiv positive persons engaging in antiretroviral and 90% people living with hiv on antiretroviral treatment virally suppressed. it is not easy to achieve; the target needs to improve knowledge and reduce stigma by inserting sufficient knowledge (maddali, gupta, & shah, 2016). the programs focused specifically for key populations are aimed to provide evidence-based recommendation and increasing awareness of the hiv issues and needs (who, 2017). in most studies it was reported there was a wide variety of hiv-related intervention types (faust & yaya, 2018). health education of hiv-related information has been recognized to deliver remarkable outcomes in improving hiv knowledge, diagnosis and treatment (martínez sanz et al., 2019), also contributing in reducing stigma (nyblade et al., 2019). it has been noticed that the state of hiv knowledge improvement is growing, but the trend is still minimal. a study in sub-saharan africa found only close to half of the research population retained comprehensive hiv knowledge (chan & tsai, 2018). in accessing hiv-related information, key populations often face a complex challenge. the lack of guidance and follow-up of information, discriminatory acts among information providers, uncomfortable services and inadequacy of privacy insurance are the common reasons for key populations to ignore hivrelated information seeking (liu et al., 2016). in indonesia, hiv knowledge is considered low with only 11.37 per 1000 population among aged 15-24 (unaids, 2018b). it is crucial to assess the implementation gap in providing hiv-related information to boost the reach of key population in its acquisition. the evaluation of data is important to guide the hiv response in providing comprehensive and high quality performance of information providers (hakim et al., 2018). hiv-specific health literacy also contributes as important marking in the hiv behavior and decision of the key populations. interventions are improving the health literacy of people living with hiv with low health literacy and bringing up better health behavior and outcomes (wawrzyniak, ownby, mccoy, & waldrop-valverde, 2013). health literacy drives health cognition, decision and behavior; poor health literacy will lead to lack of access to healthcare services and appropriate treatments, deriving from poor health education (palumbo, 2015). the role of hiv health education is vital in terms of developing the health literacy of the people living with hiv. hiv health literacy is an important mediator between hiv-related information and the outcomes (tique et al., 2017). one of the notable hiv specific health literacy interventions is health education by using technology, known as e-health literacy. it is proven to promote hiv-related knowledge, medication adherence and individual self-management of the people living with hiv (perazzo, reyes, & webel, 2017). in the current time, there are various new and innovative ways to confront the hiv epidemic. these interventions have been developed and implemented with the focus to increase individual knowledge, risk perception and motivation to avoid risky behavior. hiv health education has been conducted by using various methods to contribute to antiretroviral adherence and viral suppression (wawrzyniak et al., 2013). evaluation is necessary to build better capacity of the healthcare system in providing information and care for the populations. evaluation also criticized the learning focus of the community development (phillips et al., 2019). evaluation of hiv health education interventions is crucial to drive better understanding in facing the challenges and to redesign more effective strategies in the future. evaluation also creates better capture of complex information (iskarpatyoti, lebov, hart, thomas, & mandal, 2018). the comprehensive tools to record hiv knowledge remain lacking and there is a need to design comprehensive assessment (hooshyar et al., 2017). evaluation of the interventions to boost hivrelated knowledge and literacy is an important measure to break through the obstacles. this study aimed to evaluate the experience of people living with hiv in acquiring hiv-related information. materials and methods the design of the study was using qualitative study with phenomenological approach. this type of research design provides thick description of the phenomenon experienced by the people living with hiv in acquiring hiv-related information. this study interpreted the narrative situation of the information access for people living with hiv. this design was used to fully understand the uniqueness and concreteness of the representation of the hiv information access situation in the healthcare system according to the subjects’ perspective. it will illustrate and individualize the genuine life experience of the people living with hiv in acquiring hiv related information. this study aimed to explore the complex and varied life experiences of people living with hiv in acquiring hiv-related information. it is expected to describe the particular form of interaction between people living with hiv and the healthcare system available regarding to hiv-related information. m. mahathir et al. 128 | pissn: 1858-3598  eissn: 2502-5791 the study was conducted in jakarta, indonesia, by involving a non-government organization in hiv activism. jakarta has 38 active non-government organizations and foundations, which entail to the hiv movement arrangement. two notable nongovernment organizations were enlisted as prospective participants for the study. this qualitative study used purposive sampling method to choose participants to contribute in the research. the participants were considered as commonly knowing the research situation and providing an overview of life experiences in acquiring hiv-related information. qualitative research does not require a rigid standard in terms of a minimum sample, but the number participants depends on the repetitive information presented. data saturation examines the maximum participants that could be used for the research. the participants’ criteria of the study were people living with hiv who have experienced healthcare service utilization, obtained hiv-related information, be willing to tell and consent to the research issue. the study used 12 participants whom provided narrative data of how people living with hiv acquire hivrelated information. the data collection in this study used in depth interviews with open-ended and semi-structured questions to all participants by the primary author. all data were recorded to tape recorder for verbal data and field notes for non-verbal expressions. the conversation took 30-45 minutes for each participant with a comfortable atmosphere in a dedicated room, open posture, private one-on-one interview and appropriate tone of speech. the questioning was triggered by asking how do people living with hiv acquire hiv-related information. the interview terminated when the data attained the information depth justified by the researcher as the instrument itself. the conversation ended by ensuring the physical and psychological condition of the participant. the data saturation marked by the repetition of information at 12 participants. the recorded data were then transferred into a soft computer file and saved in a specific and secured folder. afterwards, the data were listened to repeatedly and shifted into a verbatim transcript. the transcripts and field notes were combined to complement the suitability of the data collected. the transcripts were then sorted to find significant statements of the participants. these were then classified into categories, which were grouped into themes and subthemes. the themes were written in a thoughtful and representative narrative form, to make it easy to understand the experience. at the end, the research concluded four consequential themes. the analysis and the results were obliged to the qualitative data validities by ensure credibility, transferability, dependability, and conformability. this study was committed to the ethical guidelines and consideration in all research activities. ensuring that no one was harmed or obtained negative impacts was crucial. this research strictly provides autonomy, beneficence, non-maleficence, confidentiality and justice. this study also committed to protect the participants involved. this study was reviewed by the universitas indonesia ethical council committee and declared as ethically feasible to be conducted. the study concluded four consequential themes describing how people living with hiv acquire hiv-related information. results the participants in this study were 12 people living with hiv using healthcare services in jakarta, indonesia. the 12 participants participated voluntarily in in-depth interviews conducted during the research process. the 12 participants acknowledged their positive status and performed openness to be involved in the study and in table 1. participant characteristic participant code age (years old) education length of disease (in years) risk population gender p1 29 high school 10 idu male p2 30 elementary 9 idu male p3 31 junior high 7 heterosexual male p4 32 junior high 7 idu male p5 34 high school 7 prisoner male p6 34 high school 7 idu male p7 34 high school 5 prisoner male p8 34 bachelor 5 heterosexual female p9 39 high school 7 idu male p10 41 bachelor 2 idu male p11 22 high school 1 msm male p12 31 diploma 1 msm male *idu= injecting drug user *msm= men who have sex with men jurnal ners http://e-journal.unair.ac.id/jners | 129 cooperatively answering the questions during interview. participants did not express objections or unwillingness in providing information in semistructured questions. all quoted texts in the manuscript were originally in bahasa indonesia and translated into english to fulfill publication requirements. the characteristics of the participants are displayed in table 1 below (attached at the last page of the manuscript). the study found four consequential themes: nongovernment organizations play a major role in hiv education, peers are a comfortable platform to discuss, it is all over the media and healthcare personnel are a source of knowledge. the details of each theme are explained as follows: theme 1: non-government organizations play a major role in hiv education a bon-government organizations (ngo) was recognized as a platform which contributed in hivrelated information for the most participants. they realized their risky behavior and what would be the consequences for them. non-government organization provided them with essential information and knowledge related to hiv. the ngo interacted with participants through hiv seminars conducted by the organization. also, the organization actively came to participants to deliver the message and information. the organization activists offered strong advice to prevent disease transmission and pointed out the importance of hiv testing to get knowledge of the participants' serostatus. one participant admitted that he was persuaded to go for a voluntary counselling test after the organization member approached him and made him understand the potential threat of the disease. the statement of the participant is documented below: “at that time, as i remember there was a foundation, i guess, which i didn’t really know the details, but i was sure it was related to the hiv activism movement. they came to us and explained everything about the risks and the importance of ‘vct’ (voluntary counselling test). they said they also provided it and asked us to do the check. afterwards i was found to be positive.” (p1) another participant told that he was really aware of the situation because one member of the organization came to him and explained the details of hiv. then, with a gentle smile and rounded eyes, he recommended him to access the vct in the healthcare facility nearby, as, recalling his expression, the participant commented as follows: “so, this member of the organization was explaining it (hiv-related information) completely to me. it made me understand quite a bit though about the disease. he recommended me to check my status by accessing the vct in the nearby healthcare facility. he gave me the contact and i went for a status check.” (p2) another participant also shared the same experience. this participant said that he went to a hiv seminar held by the organization. of his own volition, he decided to gain more knowledge about the disease and got to know the risks that he might have. he explained: “i saw there was a free seminar about hiv disease in a flyer back then conducted by a hiv ngo. it had been my curiosity at that time, i guess i had the risk, but i was not sure. so, i went to the seminar and got a full understanding that my risks were real.” (p7) theme 2: peers are a comfortable platform to discuss four participants in this study stated that they acquired hiv related information from their peers. they affirmed that peers were an important circle in hiv-related information distribution. peers optimally constructed their understanding of the disease and acknowledged them as a person with a wide spectrum. they felt accepted in considering themselves as an alter ego of their peers. peer provided them with palpable experience and information so they felt connected to each other. peers are a platform that allows them to express what they feel freely and without boundaries. the participants may discuss the hidden situation and information that often make them shy to tell others in terms of the secrecy. peers also become an important role model for the participants to see the whole truth of the disease and the intricacy of hiv-related knowledge. below is the statement of a participant: “back then, i had a friend, a childhood friend. eventually he came with his secret story, which shocked me. he told me that he had hiv, after that i could not resist my own situation. i asked him so many things and he tried to make me understand by explaining all the information and then i realized i should have a check. he convinced and accompanied me to the public health center nearby.” (p1). another participant also told the same experience. he knew the information from his friend, who told him of a place to get a check. “…my friend told me don't be afraid, just go to ‘pro' (name of a notable private laboratory) they often not bother our lives that much…” (p5). another participant also said the same thing. he knew a friend that might have sufficient information about hiv. he felt free to speak about the situation and curiosity that he had. he admitted that he never got a negative judgment from his friend, which made him very relieved. through his friend’s experience, the information he provided was also easy and comprehensive to understand. passionately speaking, the participant said as follows: “i heard one of my friends had the same thing, and he must know many more things than. i approached him and he told me everything i needed to know. i hid nothing, then i went to the hospital that he also went to.” (p4). theme 3: it is all over the media all of the participants disclosed that the media also gives them information insight about hiv. even though it was not enough information to convince them, they acknowledged it was quite helpful in transmitting hiv-related information. the media m. mahathir et al. 130 | pissn: 1858-3598  eissn: 2502-5791 provided them brief and straightforward information that led them to access more hiv knowledge and information. printed media, such as posters, flyers, newspapers and magazines, were the resources to get the information. online media and website based made it easier for them to obtain such information. one participant states that he got the information from printed media such as poster and billboard. it briefly gave him the essential information about hiv. “when i walked around, sometimes i found a printed poster on the wall that told about hiv. i stopped for a while and read. i could feel the risks in me, i knew it. also, on the billboard they also put the information there, not much but enough for a basic understanding.” (p2) another participant affirmed that he got the information online from the electronic media on the internet. he tried to surf the information and there are very many resources if you want to seek hivrelated information. with a smirking smile, the participant told as follows: “there are so many of them (hirelated information) on the internet, you could just click and you will find it easily. there are websites that completely tell you about the disease and i guess it is also provided by the ngo.” (p3) theme 4: healthcare personnel as source of knowledge four of the participants also commented that they got the hiv-related information from the healthcare personnel. healthcare personnel actively came to them directly and distributed the knowledge by themselves. they approached the participants at their ‘hot spot’ group gathering places. they realized that it might be a regular program made by the healthcare providers to reach out to the key populations. the healthcare personnel convinced the participants because they had sufficient knowledge and knew everything about hiv. they felt that they were the experts. healthcare personnel also knew them appropriately because had been interacting with them for quite some time. one of the participants said: “the healthcare personnel came to us at that time. they explained about the risks and the disease. they seemed very expert about this. we got convinced, eventually and they also provided vct and then we tried. that time, i then knew my status was positive.” (p8) another participant told that ,after all the risks that they have been taking it was useful to have relevant information from other sources. they believed that the doctor and nurses convinced them to take a test and they obtained all the important and relevant information. “i went to the doctor and asked more about myself. he explained many things to me and i got convinced. he asked me to get tested, and i did.” (p11) “i met the nurse; he told me anything that he knew about hiv. i believed in him, he explained it in such detail. every information i’ve got from anywhere, i always cross-check on him. it feels relieving when i talk to him to justify any information i’ve got.” (p12). discussion the study tells us the access of hiv-related information is now broadened and well-provided. key populations may reach all necessary information by addressing various choices. the active or nonactive delivery ways used by the providers have equipped high-risk behavior population with basic essential knowledge. it is expected that, with certain knowledge, this will lead to better-desired outcomes of the disease prevention, treatment and care. finer understanding of a population’s perspective on hiv health education is important to get to know which are the best ways of delivery to improve hiv knowledge (stonbraker et al., 2018). the participants on the study acknowledge hiv non-government organizations contribute in a large scale. nongovernment organizations focusing on hiv are recognized as outstanding community lead groups to respond to health challenges and gaps (lo, 2018). non-government organizations have contributed in hiv progressive changes till the current time (wang et al., 2016). the struggles that have been proved by this institution are undoubted. study acknowledges that non-government organizations implement a holistic approach in all program activities, ensuring confidentiality, nurturing professionals and cultural competence, and strictly preserving equality and empathy. non-government organizations focus their work by maintaining preventive implementation through a progressive empowerment health education approach (berenguera et al., 2011). the participants in this study realizes that peers are a safe space to gain more information. peer-led hiv programs and activities are also a key step to improve access to information that leads to hiv eradication desired outcomes. a peer hiv knowledge delivery program significantly enriches key populations’ knowledge. a study in highly stigmatized male sex workers in africa proved a significant improvement of the knowledge of prevention behaviors. peers also improve hiv prevention initiative coverage among key populations (geibel, king’ola, temmerman, & luchters, 2012). the essential knowledge provided by peers will influence key populations’ decision and behavior. it also notably known that peer led programs increase significantly the degree of hiv testing among key populations. previous study highlighted the changing numbers of key population engaging in hiv testing (shangani et al., 2017). peer education assigns key population with sufficient increase in knowledge of risk reduction through condom use, sexual transmission of hiv and transmission through sharps (faust & yaya, 2018). peers also help in achieving treatment engagement and antiretroviral compliance (genberg et al., 2016). peers are considered as a platform that overcomes the stigma often felt by the key population (hall et al., 2017). peers also build jurnal ners http://e-journal.unair.ac.id/jners | 131 perpetuated social norms that justify hiv testing behavior of key populations’ inner circle (witzel, weatherburn, rodger, bourne, & burns, 2017). social network influences hiv testing behavior in key population, and peers persuade and provide assistance in all testing process activities (conserve, alemu, yamanis, maman, & kajula, 2018). in the indonesia context, a study also found a narrative finding that people living with hiv determined their hiv healthcare access seeking behavior and healthcare function depended on social support (setyoadi, 2013). peer support also boosts the autonomy and self-determination of people living with hiv among indonesian migrant workers (nursalam, yusuf, widyawati, & asmoro, 2015) the study found the media as an accessible platform to obtain hiv-related information. media certainly take a role in becoming an integral part of hiv-related information distribution in the community. accessing media strongly influences knowledge and the face of hiv education. media are positively associated with hiv knowledge and awareness about transmission and prevention (jung, arya, & viswanath, 2013). through technological improvement, the media can be accessed by anyone. technology increases exposure among certain population and is considered as a significant predictor of hiv knowledge (muhammad hamid, tamam, & nizam bin osman, 2020). media provides the key population with an interactive yet understandable interface in the urban settings and shape the variable as hiv knowledge predictors for urban population (bekalu & eggermont, 2014). media becomes a platform to boost creative and innovative information delivery. innovative digital improvisation in media delivery of hiv-related information has proved cost effectiveness in information distribution with large-scale coverage (daher et al., 2017). varies media options give the key populations freedom of choice to choose what is best for them. the individual approach of social media also marked a new trend of interventional strategies in hiv eradication activities (tso, tang, li, yan, & tucker, 2016). the media has also proved its contribution by showing positive impacts in changing prevention behavior (bertrand, o’reilly, denison, anhang, & sweat, 2006), hiv testing ( wang et al., 2019), and adherence monitoring (bychkov & young, 2018). the healthcare providers also play a substantial role in providing information among participants. the rapid progress of healthcare services is also changing hiv programs and activities overlook. healthcare providers are now accessible by the population to seek help and information. in a study, hiv risk populations admitted that healthcare personnel are moving forward to serve the hiv patients with equal treatments, more valued relationship, social support and confidentiality assurance (stutterheim et al., 2014). patient-centered care has also become a new focus trend in order to optimize hiv working progress. providing access, uses and education of key population are the main variables in developing and deploying hiv-related interventions. coordinated patient focus care is essential to build empowering situations among affected populations (dixon & kaneshiro, 2012). healthcare services delivery by healthcare personnel faces many factors for improvement. training, working experience, appropriate timetable plans are a necessity to be developed. a primary prevention practice is encouraged to push down new transmission disease in the population (davis et al., 2016). in forming an appropriate attitude in delivering services among kin, healthcare providers have now become important to attract more people to engage healthcare services for obtaining hivrelated information (abu moghli, al habeesh, & abu shikha, 2017). the limitation of the study found some participants found it difficult to express the qualitative narration of their experience. it required the communication competency of in-depth semistructured interviews of the interviewer. conclusion this study showed a changing progress of hiv-related information delivery. the underpinning qualitative evaluation assures optimistic strategies need to be implemented and optimized years ahead in order to achieve 2030 goals. maintaining the consequential pattern is crucial and developing better and strategic programs in hiv-related information delivery remains vital. acknowledgement we extend our gratitude to the faculty of nursing, universitas indonesia and universitas andalas for their technical and related support. references abu moghli, f., al habeesh, s., & abu shikha, l. (2017). perception of hiv/aids education at the community level in jordan. iranian journal of public health, 46(3), 301–307. retrieved from https://pubmed.ncbi.nlm.nih.gov/28435815 bekalu, m. a., & eggermont, s. (2014). media use and hiv/aids knowledge: a knowledge gap perspective. health promotion international, 29(4), 739–750. https://doi.org/10.1093/heapro/dat030 berenguera, a., pujol-ribera, e., violan, c., romaguera, a., mansilla, r., giménez, a., & almeda, j. (2011). experiences about hiv-aids preventivecontrol activities. discourses from nongovernmental organizations professionals and users. gaceta sanitaria, 25(3), 184–190. https://doi.org/10.1016/j.gaceta.2010.10.015 bertrand, j. t., o’reilly, k., denison, j., anhang, r., & sweat, m. (2006). systematic review of the effectiveness of mass communication programs to change hiv/aids-related behaviors in developing countries. health education research, 21(4), 567– m. mahathir et al. 132 | pissn: 1858-3598  eissn: 2502-5791 597. https://doi.org/10.1093/her/cyl036 bychkov, d., & young, s. (2018). social media as a tool to monitor adherence to hiv antiretroviral therapy. journal of clinical and translational research, 3(suppl 3), 407–410. retrieved from https://pubmed.ncbi.nlm.nih.gov/30873489 chan, b. t., & tsai, a. c. (2018). hiv knowledge trends during an era of rapid antiretroviral therapy scaleup: an analysis of 33 sub-saharan african countries. journal of the international aids society, 21(7), e25169–e25169. https://doi.org/10.1002/jia2.25169 conserve, d. f., alemu, d., yamanis, t., maman, s., & kajula, l. (2018). “he told me to check my health”: a qualitative exploration of social network influence on men’s hiv testing behavior and hiv self-testing willingness in tanzania. american journal of men’s health, 12(5), 1185– 1196. https://doi.org/10.1177/1557988318777674 daher, j., vijh, r., linthwaite, b., dave, s., kim, j., dheda, k., … pai, n. p. (2017). do digital innovations for hiv and sexually transmitted infections work? results from a systematic review (1996-2017). bmj open, 7(11), e017604– e017604. https://doi.org/10.1136/bmjopen2017-017604 davis, t., teaster, p. b., thornton, a., watkins, j. f., alexander, l., & zanjani, f. (2016). primary care providers’ hiv prevention practices among older adults. journal of applied gerontology : the official journal of the southern gerontological society, 35(12), 1325–1342. https://doi.org/10.1177/0733464815574093 dixon, b. e., & kaneshiro, k. (2012). improving access to hiv and aids information resources for patients, caregivers, and clinicians: results from the shine project. online journal of public health informatics, 4(1), ojphi.v4i1.3849. https://doi.org/10.5210/ojphi.v4i1.3849 faust, l., & yaya, s. (2018). the effect of hiv educational interventions on hiv-related knowledge, condom use, and hiv incidence in subsaharan africa: a systematic review and metaanalysis. bmc public health, 18(1), 1254. https://doi.org/10.1186/s12889-018-6178-y geibel, s., king’ola, n., temmerman, m., & luchters, s. (2012). the impact of peer outreach on hiv knowledge and prevention behaviours of male sex workers in mombasa, kenya. sexually transmitted infections, 88(5), 357–362. https://doi.org/10.1136/sextrans-2011-050224 genberg, b. l., shangani, s., sabatino, k., rachlis, b., wachira, j., braitstein, p., & operario, d. (2016). improving engagement in the hiv care cascade: a systematic review of interventions involving people living with hiv/aids as peers. aids and behavior, 20(10), 2452–2463. https://doi.org/10.1007/s10461-016-1307-z haakenstad, a., moses, m. w., tao, t., tsakalos, g., zlavog, b., kates, j., … dieleman, j. l. (2019). potential for additional government spending on hiv/aids in 137 low-income and middle-income countries: an economic modelling study. the lancet hiv, 6(6), e382–e395. https://doi.org/10.1016/s2352-3018(19)300384 hakim, a. j., macdonald, v., hladik, w., zhao, j., burnett, j., sabin, k., … garcia calleja, j. m. (2018). gaps and opportunities: measuring the key population cascade through surveys and services to guide the hiv response. journal of the international aids society, 21 suppl 5(suppl suppl 5), e25119–e25119. https://doi.org/10.1002/jia2.25119 hall, b. j., sou, k.-l., beanland, r., lacky, m., tso, l. s., ma, q., … tucker, j. d. (2017). barriers and facilitators to interventions improving retention in hiv care: a qualitative evidence metasynthesis. aids and behavior, 21(6), 1755–1767. https://doi.org/10.1007/s10461-016-1537-0 hooshyar, s. h., shahesmaeili, a., faramani, r. s., khajehkazemi, r., nasirian, m., sharifi, h., & kamali, k. (2017). 85: knowledge, attitude and practice of hiv/aids: a systematic review among key populations at risk for hiv infection in iran. bmj open, 7(suppl 1), bmjopen-2016-015415.85. https://doi.org/10.1136/bmjopen-2016015415.85 iskarpatyoti, b. s., lebov, j., hart, l., thomas, j., & mandal, m. (2018). evaluations of structural interventions for hiv prevention: a review of approaches and methods. aids and behavior, 22(4), 1253–1264. https://doi.org/10.1007/s10461-017-1997-x januraga, p. p., reekie, j., mulyani, t., lestari, b. w., iskandar, s., wisaksana, r., … kaldor, j. m. (2018). the cascade of hiv care among key populations in indonesia: a prospective cohort study. the lancet hiv, 5(10), e560–e568. https://doi.org/10.1016/s2352-3018(18)301486 jung, m., arya, m., & viswanath, k. (2013). effect of media use on hiv/aids-related knowledge and condom use in sub-saharan africa: a crosssectional study. plos one, 8(7), e68359–e68359. https://doi.org/10.1371/journal.pone.0068359 liu, y., osborn, c. y., qian, h.-z., yin, l., xiao, d., ruan, y., … amico, k. r. (2016). barriers and facilitators of linkage to and engagement in hiv care among hiv-positive men who have sex with men in china: a qualitative study. aids patient care and stds, 30(2), 70–77. https://doi.org/10.1089/apc.2015.0296 lo, c. y.-p. (2018). securitizing hiv/aids: a game changer in state-societal relations in china? globalization and health, 14(1), 50. https://doi.org/10.1186/s12992-018-0364-7 maddali, m. v., gupta, a., & shah, m. (2016). epidemiological impact of achieving unaids 9090-90 targets for hiv care in india: a modelling study. bmj open, 6(7), 1–6. https://doi.org/10.1136/bmjopen-2016-011914 jurnal ners http://e-journal.unair.ac.id/jners | 133 martínez sanz, j., pérez elías, m. j., muriel, a., gómez ayerbe, c., vivancos gallego, m. j., sánchez conde, m., … drive 03, opt. w. and f. s. g. (2019). outcome of an hiv education program for primary care providers: screening and late diagnosis rates. plos one, 14(7), e0218380–e0218380. https://doi.org/10.1371/journal.pone.0218380 muhammad hamid, a., tamam, e., & nizam bin osman, m. (2020). relationships between media exposure and knowledge, attitude, and practice on hiv/aids: a cross sectional survey of adolescent islamiyya girls in nigeria. health communication, 35(4), 419–429. https://doi.org/10.1080/10410236.2018.15649 60 nursalam, yusuf, a., widyawati, i. y., & asmoro, c. p. (2015). peningkatan kemandirian perawatan tenaga kerja indonesia (tki) yang terinfeksi hiv melalui pengembangan model pemberdayaan keluarga dan peer group support. jurnal ners, 10(march 2016), 265–271. nyblade, l., stockton, m. a., giger, k., bond, v., ekstrand, m. l., lean, r. m., … wouters, e. (2019). stigma in health facilities: why it matters and how we can change it. bmc medicine, 17(1), 25. https://doi.org/10.1186/s12916-019-1256-2 palumbo, r. (2015). discussing the effects of poor health literacy on patients facing hiv: a narrative literature review. international journal of health policy and management, 4(7), 417–430. https://doi.org/10.15171/ijhpm.2015.95 perazzo, j., reyes, d., & webel, a. (2017). a systematic review of health literacy interventions for people living with hiv. aids and behavior, 21(3), 812– 821. https://doi.org/10.1007/s10461-016-13296 phillips, g., lindeman, p., adames, c. n., bettin, e., bayston, c., stonehouse, p., … greene, g. j. (2019). empowerment evaluation: a case study of citywide implementation within an hiv prevention context. the american journal of evaluation, 40(3), 318–334. https://doi.org/10.1177/1098214018796991 setyoadi. (2013). pengalaman odha mendapatkan dukungan sosial dalam menjalani kehidupan sehari-hari di malang raya. jurnal ners, 8(2), 240– 252. shangani, s., escudero, d., kirwa, k., harrison, a., marshall, b., & operario, d. (2017). effectiveness of peer-led interventions to increase hiv testing among men who have sex with men: a systematic review and meta-analysis. aids care, 29(8), 1003–1013. https://doi.org/10.1080/09540121.2017.12821 05 stonbraker, s., smaldone, a., luft, h., cushman, l. f., lerebours nadal, l., halpern, m., & larson, e. (2018). associations between health literacy, hivrelated knowledge, and information behavior among persons living with hiv in the dominican republic. public health nursing (boston, mass.), 35(3), 166–175. https://doi.org/10.1111/phn.12382 stutterheim, s. e., sicking, l., brands, r., baas, i., roberts, h., van brakel, w. h., … bos, a. e. r. (2014). patient and provider perspectives on hiv and hiv-related stigma in dutch health care settings. aids patient care and stds, 28(12), 652– 665. https://doi.org/10.1089/apc.2014.0226 tique, j. a., howard, l. m., gaveta, s., sidat, m., rothman, r. l., vermund, s. h., & ciampa, p. j. (2017). measuring health literacy among adults with hiv infection in mozambique: development and validation of the hiv literacy test. aids and behavior, 21(3), 822–832. https://doi.org/10.1007/s10461-016-1348-3 tso, l. s., tang, w., li, h., yan, h. y., & tucker, j. d. (2016). social media interventions to prevent hiv: a review of interventions and methodological considerations. current opinion in psychology, 9, 6–10. https://doi.org/10.1016/j.copsyc.2015.09.019 un. (2019). special edition: progress towards the sustainable development goals. retrieved from https://undocs.org/e/2019/68 unaids. (2014). to help end the aids epidemic. united nations, 40. retrieved from http://www.unaids.org/sites/default/files/medi a_asset/90-90-90_en.pdf unaids. (2018a). country factsheets china | 2018 hiv and aids estimates| 2018 hiv people living with hiv coverage of adults and children. unaids, 1–6. retrieved from https://aidsinfo.unaids.org/%0d unaids. (2018b). country factsheets china | 2018 hiv and aids estimates| 2018 hiv people living with hiv coverage of adults and children. unaids. retrieved from https://aidsinfo.unaids.org/%0d unaids. (2019). global hiv and aids statistics 2019 fact sheet. global hiv and aids ststistics, world aids day 2019 fact sheet, 1(june), 1–6. unaids. (2020). summary of strategy development process and phase i : review of the current strategy ( unaids 2016-2021 on the fasttrack to end aids ), its implementation , and the results obtained scope of the review 20162021 strategy result areas. wang, d., mei, g., xu, x., zhao, r., ma, y., chen, r., … hu, z. (2016). chinese non-governmental organizations involved in hiv/aids prevention and control: intra-organizational social capital as a new analytical perspective. bioscience trends, 10(5), 418–423. https://doi.org/10.5582/bst.2016.01134 wang, l., podson, d., chen, z., lu, h., wang, v., shepard, c., … mi, g. (2019). using social media to increase hiv testing among men who have sex with men beijing, china, 2013-2017. mmwr. morbidity and mortality weekly report, 68(21), 478–482. https://doi.org/10.15585/mmwr.mm6821a3 wawrzyniak, a. j., ownby, r. l., mccoy, k., & waldropvalverde, d. (2013). health literacy: impact on the health of hiv-infected individuals. current m. mahathir et al. 134 | pissn: 1858-3598  eissn: 2502-5791 hiv/aids reports, 10(4), 295–304. https://doi.org/10.1007/s11904-013-0178-4 who. (2017). policy brief hiv prevention , diagnosis , treatment and care for key populations. geneva. retrieved from https://www.who.int/publicationsdetail/consolidated-guidelines-on-hivprevention-diagnosis-treatment-and-care-forkey-populations witzel, t. c., weatherburn, p., rodger, a. j., bourne, a. h., & burns, f. m. (2017). risk, reassurance and routine: a qualitative study of narrative understandings of the potential for hiv selftesting among men who have sex with men in england. bmc public health, 17(1), 491. https://doi.org/10.1186/s12889-017-4370-0 world health organization. (2019). progress report on hiv, viral hepatitis and sexually transmitted infections 2019. accountability for the global health sector strategies, 2016–2021. geneva: who/cds/hiv/19.7). licence: cc by-nc-sa 3.0 igo. microsoft word 1646 layout jners.docx http://e-journal.unair.ac.id/jners | 569 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.22127 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research correlation of family support with quality of life of patient chronic renal failure undergo hemodialysis rika isdiarti and iwan ardian faculty of nursing, universitas islam sultan agung semarang, semarang, indonesia abstract introduction: patients who experience the chronic renal failure with hemodialysis and undergo such therapy for a long time has an impact on patients life, like economic problem, financial, difficulty to work, decreasing sexual motivation, fear and depression facing death, also a big changes of life style, could influencing the spirit of someone life. quality of life of patient chronic renal failure which experience hemodialysis enough draw attention to health professional, because problem of the quality of life become of vital importance in treatment service which totally to patient, on the chance of patient can experience hemodialysis and can live on although constructively machine of dialisa. family support in patients with chronic renal failure undergoing hemodialysis consists of instrumental support, informational support, emotional support, hope support and self-esteem support. this support is provided throughout the patient's life. the purpose of this research to identify correlation between family support with quality of life of patient chronic renal failure with undergo hemodialysis. methods: this research was a correlational study. the population was all chronic renal failure patients at one of general hospital in demak, central java, indonesia, from october to november 2019 as many as 60 patients. this study used total sampling which mean all 60 respondents joined in the study. the instrument is a quality of life questionnaire according to whoqol. data was analyzed with bivariate analysis by using somer's test with level of significance <0.05. results: the results showed most of the respondent have family support enough counted 37 respondent (61.7%). most quality of life of respondent is enough counted 31 respondent (51.7%). statistical tests performed using somer’s test show the results of a p-value of 0,000 or significance value of 0,000 <0.05. conclusion: there is a correlation between family support with quality of life of patients chronic renal failure with hemodialysis. this research can be used as motivation for hd patients and families in improving the quality of life of patients by providing support to improve the patient's life spirit. article history received: feb 27, 2020 accepted: april 1, 2020 keywords family support; quality of life; chronic renal failure; hemodialysis contact iwan ardian * iwanardian@unissula.ac.id + faculty of nursing, universitas islam sultan agung semarang, semarang, indonesia. cite this as: isdiarti, r., & ardian, i. (2020). correlation of family support with quality of life of patient chronic renal failure undergo hemodialysis. jurnal ners, special issues, 569-573. doi:http://dx.doi.org/10.20473/jn.v15i2.22127 introduction chronic renal failure has been suffered by many people in several parts of the world, in the united states in 2010 an estimated 20 million people aged ≥ 20 years suffered from chronic renal failure. this condition is not much different from in the asian continent, chronic renal failure is recorded to continue to increase in the number of sufferers in several countries. in malaysia in 2000 it was estimated that 300 people per 1 million population suffered from chronic renal failure (0.03%). this r. isdiarti et al. 570 | pissn: 1858-3598 � eissn: 2502-5791 figure jumped in 2006 to 600 people per 1 million population (0.06%). like malaysia, in taiwan chronic renal failure occupies the highest number of sufferers in asia, where in 2000 the sufferers reached 1400 people per 1 million population (0.14%) and increased in 2016 to 2200 people per 1 million population (0.22 %) (cruz, 2013). who estimates that there will be an increase in chronic renal failure sufferers between 1995-2025 by 41.4%. in 2011 in indonesia there were 15,353 patients undergoing hemodialysis and in 2012 an increase of 4,268 people so that overall there were 19,621 patients newly undergoing hemodialysis until the end of 2016 in 244 hemodialysis units in indonesia (mulia et al., 2018). based on data from the ministry of health republic of indonesia, in 2015, the 10 most causes of death are non-communicable diseases as follows stroke (4.87%), intracranial hemorrhage (3.71%), septicemia (3.18%), chronic renal failure (3.16% ), heart (2.67%), diabetes mellitus (2.16%), intrauterine hypoxia (1.95%), inflammation of the nervous system (1.86%), heart failure (1.77%) and hypertension (1,62%) (malik & mazahir, 2015). data from the central java health office (2015) shows that the highest incidence of renal failure in central java is surakarta city with 1497 cases (25.22%) and the second is sukoharjo regency with 742 cases (12.50%). patients who undergo hemodialysis for a long period of time have to face various problems, such as financial problems, difficulty in working, decreased sexual drive, depression and fear of facing death, as well as lifestyle that must change, more or less affect one's zest for life. hemodialysis measures indirectly affect the quality of life of a patient which includes physical health, psychological, spiritual conditions, socioeconomic status and family dynamics (indonesia et al., 2010). the quality of life of patients undergoing hemodialysis attracts enough attention for health professionals, because the problem of quality of life becomes very important in the provision of comprehensive nursing services for patients, with the hope that patients can undergo hemodialysis and be able to survive even with the help of dialysis machines. according to supriyadi (2015), in his research stated that after undergoing hemodialysis there are changes in the psychological dimensions, social dimensions and environmental dimensions of a person that is having positive feelings, being able to think, remember and concentrate and feel more comfortable with interacting. research to determine the level of quality of life of patients with chronic diseases lately more and more conducted. one research on the quality of life of chronic renal failure patients undergoing hemodialysis in bandung showed that of 91 hemodialysis patients, 52 patients (57.2%) perceived quality of life at a low level and 39 other patients (42.9%) in high level (wijaya et al., 2005). family support is very influential on the quality of life of family members. family support for patients with chronic renal failure undergoing hemodialysis consists of instrumental support, informational support, emotional support, hope support and selfesteem support. family support can affect health (through healthy behaviors), psychological and physiological, where family support can be provided through emotional support, information or giving advice. family support is provided throughout the patient's life. if this kind of support is not available, then the success of healing (rehabilitation) is greatly reduced. family support obtained by patients with chronic renal failure undergoing hemodialysis therapy concerns support in financial matters, reducing the level of depression and fear of death and frequent limitation of fluid intake an initial study was done on 6 (six) patients in the hemodialysis unit of demak general hospital. the results of interviews and filling in the checklist of study aid sheets obtained data that from the six patients with chronic renal failure found, showed a decrease in quality of life related to changes in health, physical, psychological, economic and social status (rahayu et al., 2012). decreased quality of life in patients who are undergoing hemodialysis can be seen from various statements of the patient when interviewing and telling the life that has been lived. almost all of them experience physical weakness that is disturbance of daily activities, shortness of breath, dry skin, dizziness, pale, lack of sleep and restrictions on intake of nutrients and fluids that must be obeyed. it also creates psychological burdens such as sadness, fear of death, anxiety, despair, disappointment and even inferiority. the sufferer states that life is no longer useful, always troublesome for the family. based on interviews, there were 3 (three) patients who came alone on the grounds that there were busy family members, and lacked support from the family, so when the hemodialysis schedule had to be done they came alone. while others always get assistance from family members during hemodialysis. hemodialysis that must be lived for 4-5 hours is always monitored to anticipate the emergence of complications in patients during and after hemodialysis. thus, assistance by family members during hemodialysis is very important for patients and is also a tangible form of family support. while the availability of family support is not well known to families and patients to work on it, so patients are still feeling sad, inferior and anxious during therapy even though the family is there when the therapy is undertaken. materials and methods knowing the relationship of family support with the quality of life of renal failure patients at sunan kalijaga general hospital, demak regency, central java, indonesia. the population is the whole object under study (notoatmodjo, 2010). population is the entire source of data needed in a study. in this study jurnal ners http://e-journal.unair.ac.id/jners | 571 the population was all chronic renal failure patients at sunan kalijaga demak general hospital from october to november 2019 totaling 60 respondents. the sample is a portion of the population that represents a population. the samples in this study were all renal failure patients at sunan kalijaga demak general hospital as many as 60 respondents. results based on table 1 it can be seen that the mean age of respondents is 65.02 years, the youngest age is 51 years and the oldest is 74 years with a standard deviation of 4.7. in addition, most respondents are male as many as 40 respondents (46.7%), passed only elementary level of education (40.0%), and most respondents work as farmer (36.7%) as well. majority of respondents showed family support in moderate level (61.7%) and the quality of life as well (51.7%). based on table 2 it can be seen that respondents with less family support have less quality of life as many as 2 (40.0%) respondents, have enough quality of life as many as 1 (20.0%) respondents and have good quality of life as many as 2 (40.0%) respondents. respondents with sufficient family support have less quality of life as many as 3 (8.1%) respondents, have enough quality of life as many as 27 (73.0%) respondents and have good quality of life as many as 7 (18.9%) respondents. respondents with good family support have less quality of life as many as 3 (5.6%) respondents, have enough quality of life as many as 1 (16.7%) respondents and have good quality of life as many as 14 (77.8%) respondents. the results of statistical tests conducted using the chi square test show the results of the p-value of 0,000 that means there was a correlation between family support and the quality of life of patient chronic renal failure with hemodialysis. in addition, somer’s results show 0.410 which shows the close relationship between variables is in the moderate level of correlation. discussion family support is very important to improve the quality of life of patients undergoing hemodialysis therapy. family support is associated with the characteristics of age at most people at age 61-70 years as many as 54 respondents (90%). the existence of family support has an important role in one's life as motivation, including which can affect one's satisfaction in living everyday life, including satisfaction with their health status. the results showed that the majority of respondents had sufficient family support of 37 respondents (61.7%). the existence of low family support can add to the problem for patients and families, because sick patients really need moral and spiritual support to speed up the healing process. patients with chronic renal failure who undergo hemodialysis therapy which requires a long time and cost if there is no support from within themselves and their families can reduce the quality of life. the study also showed that most of the quality of life of respondents was sufficient as many as 31 respondents (51.7%). most of the quality of life in the category that is not good in patients with renal failure undergoing hemodialysis therapy causes decreased work productivity, decreased function of the organs experiencing negative mood changes, this can cause a decrease in quality of life research results show that there is a relationship between family support and the quality of life of hemodialysis patients at sunan kalijaga demak general hospital with a value of α = 0.05. family support is any form of positive behavior and attitude given by the family to one of the sick family members, namely a family member who is experiencing health problems (friedman, 2015). this can be seen in the number of family members who come to wait for patients who are undergoing hemodialysis. every patient undergoing hemodialysis must be delivered by the family. observations and interviews with the patient's family can be known to every patient who is undergoing hemodialysis is always delivered by at least 2 families. not infrequently until all family members come to wait outside the hemodialysis room. this shows that family support is very good in helping cure hemodialysis patients. the role of the family is very important in the stages of health care, starting from the stage of health improvement, prevention, treatment to rehabilitation. social support is needed by every individual in each life cycle. social support will be increasingly needed when someone is experiencing pain problems, this is where the role of family members to undergo difficult times quickly. in this case the form of family emotional support seems very dominant in helping to improve the quality of life of patients with hemodialysis. the family is a service unit because family health problems are interrelated and also affect each other in the surrounding families or the surrounding community or in a broad context affecting the country (yosephin, 2012). results of the study illustrate that most respondents have adequate family support of 48 respondents (80.0%). this shows that the family helps members in terms of providing facilities when patients need the need for hemodialysis therapy, plays an active role in each patient's therapy and care, finances hemodialysis therapy and treatment, finds the advice and equipment needed by the patient. the family pays good attention to hemodialysis patients who often worry about their unpredictable pain and disruption in their lives. the researcher's observations show that when a patient is undergoing hemodialysis there must be one of the family members who is beside the patient who accompanied by inviting conversation, giving what the patient asked for and helping the patient's needs while undergoing hemodialysis. r. isdiarti et al. 572 | pissn: 1858-3598 � eissn: 2502-5791 quality of life is an individual's perception of his position in life, in the cultural context and value system in which the individual lives, and the relationship to goals, expectations, standards and desires (indanah et al., 2018). this is a concept that is combined with various ways for a person to get physical health, psychological condition, independent level, social relations, and relationships with the surrounding environment. quality of life in this study is the perception of patients with hemodialysis about its position in everyday life. patients who undergo hemodialysis for a long period of time have to face various problems, such as financial problems, difficulty in working, decreased sexual drive, depression and fear of facing death, as well as lifestyle that must change, more or less affect one's zest for life. patients with hemodialysis have decreased enthusiasm for life because of changes that must be faced and will affect the quality of life of patients. hemodialysis measures indirectly affect the quality of life of a patient which includes physical health, psychological condition, spiritual condition, socioeconomic status and family dynamics (zurmeli et al., 2015). the results of interviews with the patient's watchdog family found that of the 60 respondents studied, 12 respondents had good support for hemodialysis patients. in this case the good support given by family members in meeting all patients' needs can be seen by providing funding, driving to the hospital, encouraging life, and meeting all the needs of patients during illness. while families with insufficient support are as many as 48 respondents, they say they are getting bored having to always come and queue for hemodialysis, in addition to the need for funds that are not small to come to do hemodialysis is also a problem in itself. the results of this study are in line with (warhamna & husna, 2016) research showing that there is a significant correlation between social support and the quality of life of patients in both the guaranteed and non-guaranteed groups. this shows the role of financing does not affect the quality of life of hemodialysis patients. this is understandable because according to the observations of researchers all respondents who did hemodialysis use a health bpjs for which all hemodialysis costs are fully borne by the health bpjs. table 1. distribution of variables (n=60) variables n % mean standard of deviation (sd) min-max age 60 100 65.02 4.7 51-74 sex male female 40 20 66.7 33.3 education no school elementary school middle school high school 23 24 2 11 38.3 40.0 3.3 18.3 occupation farmer private housewife civil servants no occupation 22 20 9 1 8 36.7 33.3 15.0 1.7 13.2 family support less moderate good 5 37 18 8.3 61.7 30.0 quality of life less moderate good 6 31 23 10.0 51.7 38.3 table 2. correlation of variables (n=60) variables quality of life chi square test somer’s test less % moderate % good % total family support less 2 40.0 1 20.0 2 40.0 5 p= 0.000 0.410 moderate 3 8.1 27 73.0 7 18.9 37 good 1 5.6 3 16.7 14 77.8 18 total 6 10.0 31 51.7 23 38.3 60 jurnal ners http://e-journal.unair.ac.id/jners | 573 conclusion most respondents have sufficient family support, while most of the quality of life of respondents is moderate. there is a correlation between family support with quality of life of patients chronic renal failure with hemodialysis. this research can be used as motivation for hd patients and families in improving the quality of life of patients by providing support to improve the patient's life spirit. conflict of interest in this study there were no conflicts of interest with the participants involved in the research activity process. acknowledgement this research can be carried out with the support of several parties, for that the researcher would like to thank the unissula rector, deans of the faculty of nursing and the entire academic community of the faculty of nursing at sultan agung islamic university in semarang. thank you for the support of both moral and material until this research can be completed. hopefully this article can provide benefits to the community. references cruz, a. p. s. (2013). 済無no title no title. journal of chemical information and modeling, 53(9), 1689– 1699. https://doi.org/10.1017/cbo9781107415324.0 04 indanah, sukarmin, & rusnoto. (2018). kualitas hidup pasien dengan gagal ginjal. the 7th university research colloqium 2018, 608–615. indonesia, u., ayu, i. g., astuti, p., keperawatan, f. i., studi, p., ilmu, p., keperawatan, k., & bedah, m. (2010). universitas indonesia hubungan antara quick of blood ( qb ) dengan adekuasi hemodialisis pada pasien yang brsu daerah tabanan bali. malik, a. m., & mazahir, s. (2015). trust, hope and quality of life in renal failure patients. 27(4), 3493– 3498. mulia, d. s., mulyani, e., pratomo, g. s., & chusna, n. (2018). kualitas hidup pasien gagal ginjal kronis yang menjalani hemodialisis di rsud dr. doris sylvanus palangka raya. borneo journal of pharmacy, 1(1), 19–21. https://doi.org/10.33084/bjop.v1i1.238 notoatmodjo, s. (2010). metodologi penelitian kesehatan. rineka cipta. rahayu, f., ramlis, r., & fernando, t. (2012). hubungan frekuensi hemodialisis dengan tingkat stres pada pasien gagal ginjal kronik yang menjalani hemodialisis. jurnal keperawatan silampari (jks), 6(1), the aim of this study was to determine whether the. warhamna, n., & husna, c. (2016). chronic kidney diseases based on the length in undergoing haemodialysis in dr . zainoel abidin general hospital zainoel abidin banda aceh pada februari umum daerah dr zainoel abidin banda. 000, 1–8. wijaya, a., mudjaddid, e., siregar, p., & manurung, d. (2005). kualitas hidup pasien penyakit ginjal kronik yang menjalani hemodialisis dan mengalami depresi. universitas indonesia. yosephin. (2012). universitas indonesia universitas indonesia jakarta. fmipa ui, 1–95. zurmeli, bayhakki, & utami, g. t. (2015). hubungan dukungan keluarga dengan kualitas hidup pasien gagal ginjal kronik yang menjalani terapi hemodialisis di rsud arifin achmad pekanbaru. jurnal online mahasiswa, 2(1), 670–681. 230 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19019 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the factors associated with successful aging in elderly: a systematic review inta susanti 1,2, glorya riana latuperissa1, fathmy fitriany soulissa1, anis fauziah1, tintin sukartini1, retno indarwati1, arifal aris1,2 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 universitas muhammadiyah lamongan, lamongan, indonesia abstract introduction: successful aging (sa) is defined as adding life to years and as feeling satisfied with past and present life. criteria for successful aging: free of disease and disability; high levels of physical and cognitive functioning; and social engagement. the aim of this study was to describe factors associated with successful aging among older people methods: the literature search strategy identified 1.914 articles. the prisma strategy was used to identify articles that met inclusion criteria. initially 255 duplicated studies were excluded; resulting in 1659 articles screened for inclusion in this review. a further 1567 articles were removed based on the title and abstract. the remaining 32 articles were assessed for inclusion this review. nineteen articles were excluded. in total 13 studies met inclusion criteria for this review. these 13 studies were assessed for quality, data extraction and synthesis. results: the factors associated with successful aging are age, gender, few physical morbidities, absence of depression, body weight or bmi in the overweight range, carrying out more than six aadl and high levels of physical activity, education, smoking, alcohol consumption, marital status, proactive engagement, wellness resources, positive spirit, and valued relationships, sleep quality, leisure activity, economic status, religious activity, and high perceived meaningfulness. conclusion: the factors that influence successful aging are sociodemographic factor, physiological, psychological, and lifestyle behavioral factors. this study shed light on the key factors that healthcare providers or researchers should consider in intervention studies and programs to promote healthy aging. article history received: feb 27, 2020 accepted: april 1, 2020 keywords successful aging; elderly contact inta susanti  inta.susanti-2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: susanti, i., latuperissa, g.r., soulissa, f.f., fauziah, a., sukartini, t., indarwati, r., & aris, a. (2020). the factors associated with successful aging in elderly: a systematic review. jurnal ners, special issues, 230-237. doi:http://dx.doi.org/10.20473/jn.v15i2.19019 introduction increasing life expectancy results in a growing number of older people, so that maintaining a good health and function in older people is an important target in aging societies. the universal outcome is for successful aging or healthy aging. this has been a main subject of investigation in recent decades. successful aging (sa) is defined as adding life to years and as feeling satisfied with past and present life (eun & kahana, 2017). identifying factors that may positively influence successful aging (sa) is of great interest both for individuals and society, as the proportion of the world’s population over 60 years is expected to almost double between 2015 and 2050 (eun & kahana, 2017). successful aging has been recently investigated, but it is a concept that remains without a consensus definition, even though different factors have been examined, such as avoiding disease and disability, having high cognitive, mental or physical function, being actively engaged in life and psychologically well adapted (boero, francesco, vizzuso, & dessì, 2017). the domains of physical and functional health, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 231 psychological wellbeing and cognition, social engagement and family support, economic resources and financial security have been included in the definition of successful aging.(boero et al., 2017) successful aging shows a low level of disease and/or disease-related disability, relatively high physical and cognitive functioning and active and productive engagement in life activities (boero et al., 2017). there are several theoretical models to explain the phenomenon of aging successfully. for example, rowe and kahn (1997) interpreted successful aging as “avoidance of disease and disability, maintenance of high physical and cognitive function, and sustained commitment to social and productive activities.” the model is in line with the definition of health from the world health organization as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (bosnes et al., 2016). from a psychosocial perspective, baltes and baltes (1990) proposed the model of selection, optimization and compensation (soc) that considers the aging process as a dynamic process, that is to say, a number of adjustments made by individuals throughout their life course. another more recent model is the one by lee, lan, and yen (2011) that includes four successful aging factors: a physical factor, a psychological factor, a social factor and a factor of leisure time. on the other hand, troutman, nies, small, and bates (2011) have measured successful aging through functional performance, intrapsychic factors, gerotranscendence and spirituality, considering the four dimensions being related to each other. following troutman et al. (2011, p. 223), functional performance may be defined as the use of conscious awareness and choice as an adaptive response to cumulative physiological and physical losses related to the aging process. intrapsychic factors are enduring character features that promote adaptation to change and problem solving. spirituality could be defined as personal views and behaviors a person has that express his/her relatedness to something greater than oneself. and finally, gerotranscendence, following the conceptualization by tornstam, is defined as a shift in perspective in the adult and old age from a materialistic and rationalistic perspective to a more mature and existential one. therefore, we follow here the theoretical framework of flood (2002; 2005), who measures successful aging based on a theoretical definition that includes multiple dimensions of successful aging, and does not exclude individuals from being considered successful agers based on physical limitations alone (gutiérrez, tomás, & calatayud, 2018). healthy aging depends on genetic, environmental and behavioral factors, as well as socioeconomic determinants. very important is the point of view of older respondents (pac et al., 2019). in one review, sa was related to younger age, not smoking, absence of disability, arthritis and diabetes, better self-rated health, absence of depression and cognitive impairment, fewer medical conditions, and more physical activity and social networks. (hsu, tsai, chen, & wang, 2017). few relationships to sa were found for demographic factors. studies using a multidimensional concept of sa have suggested that younger age, a higher level of education, marriage, greater satisfaction with life, higher socioeconomic status, and higher income are related to sa. regarding gender differences, the results are inconclusive, as both male gender and female gender have been found to be associated with sa. based on previous research, it is hypothesized that the prevalence of sa, the relative importance of components of sa, and the correlates of sa will change with increasing age (bosnes et al., 2016). one of the protective factors for successful aging in older age is resilience; it includes self-efficacy, access to social support network, optimism, perceived economic and social resources, spirituality and religiosity, relational accord, emotional expression and communication, and emotional regulation (boero et al., 2017). in older people, greater ability to savor positive experiences and higher resilience may predict greater happiness, lower depression, and greater satisfaction with life (greater psychological wellbeing) (boero et al., 2017). physical resilience has been recently defined as a characteristic which determines one’s ability to resist or recover from functional decline following health stressors and it is highly relevant in successful aging (boero et al., 2017). the aim of this systematic review was to assess the risk factors that are associated with successful aging in older people. the goal was not to summarize the whole of the prevalence on risk factors in adult life. rather, we aimed to identify associations specifically derived from people in life to inform the development of well-targeted interventions that will minimize the impact of ill health in later life. materials and methods search strategy the following review steps were performed in accordance with the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines for conducting a systematic review. a systematic search was first conducted using the following databases: scopus, pubmed, cinahl/ebsco, sciencedirect, springer link, and cambridge using search strategies described in figure 1. studies published in the english language from the past five years (january 2015 to january 2020) were included. the search was conducted in december 2019, to ensure that any articles published after the initial search were included. appropriate medical subject headings (mesh) were used along with text word searches and phrases. keywords with boolean operators that were searched in each database include (risk factors) or (precipitating factors) or (protective factors) and (successful aging) or (healthy aging) or (positive aging) or i. susanti et al. 232 | pissn: 1858-3598  eissn: 2502-5791 (robust aging) or (optimal aging) or (productive aging) or (effective aging) or (aging well) and (elderly) or (older adults) or (older people) or (aged). these phrases were used with both “aging” and “ageing” spelling conventions, put in quotations, and linked via the boolean operator “or.” where possible, a wildcat operator, i.e. “∗” was inserted as a suffix to capture all permutations of the phrase. furthermore, where possible, in a given database, non-human studies were excluded. an example of the search input for the phrase “successful aging” in pubmed is as follows: “successful∗ aging” or “successful∗ ageing.” this search is processed by pubmed as: successful∗ aging (all fields) or “successful∗ ageing” (all fields) and “humans” (mesh terms). inclusion and exclusion criteria we included all english language studies that regarded risk factors associated with successful aging in older people published between january 2015 and january 2020. this review includes original research (experimental, non-experimental, observational, and qualitative studies). systematic review and literature review were excluded. studies were deemed eligible if they were explicitly targeted at the population aged 60 years and over or those papers specifically targeting the older persons (i.e. explicated in their title or in the aim of their abstract). research needed to report as outcome measures factors associated with successful aging in older people. quality assessment figure 1. article selection process table 1. overview of included study articles (authors, year) country n age baseline length of follow up quality canêdo et al., 2018 brazil 845 ≥ 65 years 1 years ++ arroyo-quiroz, brunauer, & alavez, 2020 mexico 1.845 63-77 years 14 years ++ bosnes et al., 2016 norwegian 5.773 70 – 89 years 2 years ++ eun & kahana, 2017 usa 550 ≥ 65 years 9 months + shi et al., 2016 china 2.296 ≥ 65 years 3 years ++ foscolou et al., 2018 mediterranean islands 3.131 ≥ 65 years 12 years + hsu, tsai, chen, & wang, 2017 taiwan 1.977 62 – 69 years 14-18 years ++ kollia et al., 2018 england 10.906 61-75 years 10 years ++ liu & su, 2016 taiwan 11.145 ≥ 60 years 14 years ++ manasatchakun, et al., 2016 thailand 453 ≥ 60 years 5 period + pac et al., 2019 poland 4.653 ≥ 65 years 1 years ++ cohen, talamas, & sabik, 2019 usa 165.259 ≥ 65 years 1 years + tarraf, 2017 usa 7.335 65-101 years 2 years ++ jurnal ners http://e-journal.unair.ac.id/jners | 233 quality appraisal of studies was done using a validated quality appraisal checklist from the centre for evidence based medicine (cebm). each full paper was assessed by one reviewer and checked for accuracy by another. the studies were assessed twice and discrepancies resolved by discussion. no studies were excluded on the basis of quality. data collection and extraction data from the eligible studies were extracted using structured sheets containing information on authors/years, type of study, participants/sample, table 2 summary of selected study (design, measure, outcome) authors, year design instruments outcomes canêdo et al., 2018 cross-sectional the minnesota leisure physical activity instrument, selfreported depression, advanced adl the prevalence of sa was 25%. the factors associated with sa were age, few physical morbidities, absence of depression, bmi in the overweight range, carrying out more than six aadl and high levels of physical activity. arroyo-quiroz, brunauer, & alavez, 2020 cohort questionnaire, physical examination modifiable life style factors, including physical activity, depression and body weight, are associated with healthy aging. maternal longevity is related to healthy aging at age 77 which might suggest a genetic determinant. in accordance with studies carried out in caucasian and asian populations, our findings suggest that not only genetic, but also behavioral factors have an important influence on healthy aging and longevity. bosnes et al., 2016 cross-sectional hunt3 survey the prevalence of sa is 14.5. the significant correlates of sa were younger age, female gender, higher education, weekly exercise, more satisfaction with life, non-smoking, and alcohol consumption, whereas marital status was not related to. eun & kahana, 2017 survey sai (successful aging inventory modified version of the positive and negative affective schedule (panas) the ces-d (centers for epidemiologic studies – depression scale) iadl rating scale measure the 4-factor solution provided a satisfactory fit to the data: proactive engagement, wellness resources, positive spirit, and valued relationships. shi et al., 2016 survey questionnaire, physical examination the prevalence of sa was 38.81% in the clhls in 2012. there were significant differences between age groups, with sa compromising 56.85% among ≥65 years group and 20.31% among ≥100 years group. the prevalence of sa among females was 33.59%, males (45.58%). in the regression analysis, having anemia (or=0.744, 95% ci: 0.609-0.910), poor lifestyle (or=0.697, 95% ci: 0.5680.854), poor sleep quality (or=0.558, 95% ci: 0.456-0.682), and central obesity (or=0.684, 95% ci: 0.556-0.841) were the main factors associated with sa. the promoting sa rate decreased as age increased, and the group of 65-79 years had higher odds than the other age group. foscolou et al., 2018 cohort international physical activity questionnaire (ipaq), food frequency questionnaire (ffq), physical examination a decrease in the prevalence of current smoking (p < 0.001), engagement in physical activities (p=0.001) and participation in social events (p=0.001) for every year increase in age was found. moderate alcohol drinking increased through aging (p=0.008), whereas adherence to mediterranean diet remained stable, but adequate (p=0.90). hsu, tsai, chen, & wang, 2017 cohort row and khan with modification higher educational level, conjugal living, absence of smoking or betel quid chewing, moderate alcohol drinking, routine physical activity, more leisure activities, no hypertension, no diabetes, sleeping well and satisfied with economic condition were the positive predictors for becoming a healthy octogenarian. kollia et al., 2018 cohort elsa study protocol both education and household wealth over time were positively associated with the health metric (p<0.001). lifestyle behaviors (i.e., physical activity, smoking habits and alcohol consumption) mediated the effect of education and household wealth on the health metric and the latter mediated their effect on overall mortality. liu & su, 2016 cohort tlsa questionnaire age and sex disparities, educational and economic status, health behaviors, and social participation at the individual level were found to be the robust factors in predicting healthy aging. i. susanti et al. 234 | pissn: 1858-3598  eissn: 2502-5791 follow-up periods/time, quality of the studies, outcomes measured and main findings. the first author performed data extraction and the second author checked data were extracted. data synthesis based on various results, such a different methodological approaches, different findings and a limited number studies for the risk factors of successful aging outcome, it was impossible to conduct meta-analysis of these outcomes. therefore, the results were presented in narrative form, including tables to clarify. figure 1 show articles selection process from prisma strategy. total articles retrieved from databases were 1,914 articles, potentially selected for study. there were 255 authors, year design instruments outcomes manasatchakun, et al., 2016 cross-sectional healthy aging instrument (hai) older persons in north eastern thailand have 24.30 % of the variance in hai scores living outside central city, religious activities may be the source of good emotional support, being married, income level, high perceived meaningfulness were major factor associated with perceived health and healthy aging. pac et al., 2019 cross--sectional row khan model of successful aging the prevalence of ha appeared as high as 17.6% if none or 1 chronic disease was present and 42.8% if no information about chronic diseases was taken into account. the association between known health predictors (age, marital status, education, income) and ha was observed. moreover, ha appeared in relation with indicators of physical functioning and lifestyle. there was a strong concordance between ha and the fair self-rated health (or = 1.87; 1.99, and 2.74 for the 1st, 2nd and 3rd definitions, respectively) and opposite relation with self-reported need for help (or = 0.15; 0.15. cohen, talamas, & sabik, 2019 survey behavioral risk factor surveillance system (brfss) alaska natives/american indians were more likely than respondents of other races to be smokers (or 1.62, 95%ci 1.60–1.63), while in alaska, the association between race and smoking was not significant (or 1.00, 95%ci 0.94–1.06). tarraf, 2017 survey rand hrs survey module we find that favorable childhood conditions significantly improve healthy aging scores, both directly and indirectly, mediated through education, income, and wealth. we also find that good health habits have positive effects on healthy aging that are larger in magnitude than the effects of childhood factors. our findings suggest that exercising, maintaining proper weight, and not smoking are likely to translate into healthier aging. table 3. overview of included study (factors related with successful aging) articles (authors, year) factors related with successful aging canêdo et al., 2018 age, few physical morbidities, absence of depression, bmi in the overweight range, carrying out more than six aadl and physical activity arroyo-quiroz, brunauer, & alavez, 2020 physical activity, depression and body weight bosnes et al., 2016 age, gender, education, exercise, satisfaction with life, non-smoking, and alcohol consumption, eun & kahana, 2017 proactive engagement, wellness resources, positive spirit, and valued relationships. shi et al., 2016 ages, gender, anemia, poor sleep quality and obesity foscolou et al., 2018 smoking, physical activities and participation in social events, alcohol drinking hsu, tsai, chen, & wang, 2017 higher educational level, conjugal living, absence of smoking or betel quid chewing, moderate alcohol drinking, routine physical activity, more leisure activities, no hypertension, no diabetes, sleeping well and satisfied with economic condition kollia et al., 2018 education and household wealth, lifestyle behaviors (i.e., physical activity, smoking habits and alcohol consumption) liu & su, 2016 age and sex disparities, educational and economic status, health behaviors, and social participation manasatchakun, et al., 2016 religious activity, being married, income level, high perceived meaningfulness pac et al., 2019 age, marital status, education, income and lifestyle cohen, talamas, & sabik, 2019 smokers tarraf, 2017 childhood conditions, education, income, and wealth. exercising, maintaining proper weight, not smoking jurnal ners http://e-journal.unair.ac.id/jners | 235 duplicated articles, thereby resulting in 1,659 articles. these were screened for inclusion with this review. a further 1,533 articles were removed because they were not related with the topic of studies, resulting in 126. the next step selected the 126 articles based on title, resulting in 66 articles and removing 34 articles because the title was not related with the studies. then, 66 articles were screened with the abstract. resulting in 32 articles and 34 articles removed because the abstract was not related with the studies. the last were selected by reading the full text from 32 articles, which resulted in13 articles and 19 articles excluded for these reasons: participants aged below 60 years, published in others language than english, outcome not about prevalence and risk factors of successful aging. . in total, 13 studies met inclusion criteria for this review and were then assessed for quality, data extraction and synthesis. results this systematic review obtained 13 selected articles originated from brazil, mexico, norwegian, china, thailand, french, germany, usa, taiwan, england, poland, spanish and mediterranean islands. the results of the systematic review and scoring of articles from all 13 articles are attached to the existing matrix, table 1. it was found nine journals having good quality, and the four journals having moderate quality. the number of samples varies between 453 165,259 respondents. length of follow-up also varies between nine months and 18 years. from the results of the review, it showed the factors associated with successful and healthy aging in elderly, as in the following table. based on table 2, we know that the design of studies was crosssectional, cohort and survey. measuring instruments used in all the studies are observation sheets, questionnaires and assessment sheets. there was found prevalence and the factors associated with successful aging (sa). the prevalence in several countries are 25% in brazil, 14.5% in norwegian, 38.81% in china, 24.30% in thailand, 17.6% and 42.8% in poland. the factors associated with successful aging are age, gender, few physical morbidities, absence of depression, body weight or bmi in the overweight range, carrying out more than six aadl and high levels of physical activity, education, smoking, alcohol consumption, marital status, proactive engagement, wellness resources, positive spirit, and valued relationships, sleep quality, leisure activity, economic status, religious activity, high perceived meaningfulness. discussion the aim of this systematic review is to explore multiple factors associated with successful aging (sa) among older people. this review analyzed the roles of socio-demographic factors, physiological factors, psychological factors and lifestyle behavior factors (canêdo et al., 2018). socio-demographic characteristics have a strong influence on healthy aging over time. age, sex, and socioeconomic, education, marital status, religion are significantly and highly associated with individuals’ odds of successful aging, with successful aging being defined strictly as “having no major disease, no activity of daily living (adl) disability, no more than one difficulty with seven measures of physical functioning, good cognitive functioning, and being actively engaged” (as defined by mclaughlin et al. cited in liu, 2016). the relationship between age and sa has been widely documented: a significantly higher proportion of younger individuals achieve sa versus older individuals. research showed that, for each additional five years of age, the probability of sa would be lowered by 64%, while another study showed that longevity was the third element of successful aging (shi et al., 2016). successful aging was more prevalent among males, because they had more social resources and relatively higher income. in addition, men tend to live fewer years than women. our study finds this same gender difference, with men having an advantage in sa (shi et al., 2016). another socio-demographic factor associated with perceived health and healthy aging was being married. one might argue that married persons’ support from their spouse or children is connected to positive effects on individual health (manasatchakun, chotiga, hochwälder, & roxberg, 2016). being married might confer health advantages that influence perceived health. these could be, e.g., emotional support, instrumental support, and social exchange with the partner (manasatchakun et al., 2016). however, we also found that older people who were divorced or widowed reported higher hai scores than those who were unmarried, possibly because they receive emotional support from their children (manasatchakun et al., 2016). the children are expected to be the primary sources of support for older persons. they can help older people with personal management, physical care, economic, and emotional support. based on the present findings, one suggestion is that healthcare providers or policy makers should target unmarried and childless older people to promote healthy aging. another suggestion is, therefore, that neighbors or friends of older people should be involved in promoting healthy aging among older people who are single and among those who live alone (manasatchakun et al., 2016). from physiological variables, we found a directly proportional association with the number of physical morbidities. those who reported the absence of or less than two morbidities showed a higher probability of sa. evidence suggests that the functional consequences of chronic diseases are not inevitable, and can be significantly and positively influenced by several potentially modifiable factors, such as physical activity, social support, self-efficacy and psychological profile (canêdo et al., 2018). regarding bmi, overweight was positively associated with sa in relation to obesity. there are few studies evaluating the relationship between bmi and successful aging in elderly, despite the association of overweight with a i. susanti et al. 236 | pissn: 1858-3598  eissn: 2502-5791 discrete increase in incapacities among older adults when compared with the normal weight group (canêdo et al., 2018). income and education have positive relationship with sa. higher income and education have high impact on sa. education and financial status over time were both proved as strong and independent predictors of healthy aging (kollia et al., 2018). older people with a source of income might, in turn, feel financially independent and have access to quality resources and health services. a few participants continued to work after retirement, and a few continued to receive minimal salaries after retirement. therefore, it was difficult for them to access the services that they wanted on a limited income (manasatchakun et al., 2016). high level of education makes older people have more knowledge about health and how to maintain healthy aging. lifestyle behavioral factors were smoking, alcohol consumption, and physical activity. respondents who had never smoked were also more likely to be sa compared to current smokers, a finding in accordance with previous studies. less than weekly consumption of alcohol was also positively related to sa, compared to no consumption last year and weekly consumption (bosnes et al., 2016). smoking has been widely reported to be harmful and responsible for several chronic diseases. people who had smoked >20 packs/year were observed to be more likely to be frail than those who had never smoked. whether drinking contributes to good health is somewhat controversial (hsu et al., 2017); however, no alcohol consumption has good significance with sa achievement. physical activity has been suggested to have a long-term effect on people’s perception of health and be an essential element of successful aging. the level of physical activity at age 65 years was reported to predict successful aging seven years later in the proof (prognostic indicator of cardiovascular and cerebrovascular events). physically active people are more likely to have a healthier lifestyle, avoiding smoking or excessive drinking. furthermore, sedentary behavior and physical activity have both been identified as independent predictors of healthy aging. higher level of leisure activity was associated with a lower risk of cognitive decline, whereas cognitive decline was associated with inactive leisure activity, but not with physical activity or social activity. recent studies also support the findings of li et al. who reported that sleeping 7–8h daily was a predictor of good health in older chinese (hsu et al., 2017). because poor sleep quality can cause psychological stress, illness or neuropsychological problems, difficulty in initiating or maintaining sleep could be associated with depression. between psychosocial variables, being engaged in multiple social or productive activities was positively associated with sa. several studies have shown that a high level of participation in productive and social activities has both subjective impacts related to life satisfaction and objective effects on functional and cognitive status, physical health, and mortality. in addition, we found a positive association between sa and the absence of depression. evidence has shown that even mild and sub-syndromic depression is associated with declining overall functioning and disability. regular social participation was found in this research to be a robust factor in terms of protecting a person from deteriorations in health. that means that the healthy behaviors and social relationships appear to be influential factors of health status, which might compensate for personal factors, such as marital status. we identified the factors of healthy aging based on a multidimensional definition. the present findings have added evidence to the associations of those frequently identified factors and some specific factors with the probability of healthy aging. these findings should be useful for designing health promotion strategies to increase the likelihood of achieving aging with good health for older adults (hsu et al., 2017). healthy lifestyle promotion could focus on changes earlier in the life of an elderly individual. the old people should not only use the existing healthcare services to maintain their health, but also try their best to maintain a balanced diet, participate in sufficient physical activity, adequate sleep and eliminate bad habits, so as to increase the positive factors in sa. conclusion the promotion of health and maintenance of a sense of wellbeing among older adults are vitally important aims for policy makers and healthcare providers because the older population is increasing dramatically. the factors that influence successful aging are socio-demographic, physiological, psychological, and lifestyle behavioral factors. this study shed light on the key factors that healthcare providers or researchers should consider in intervention studies and programs to promote healthy aging. conflict of interest the authors declare that there is no conflict of interest. acknowledgement authors of the study would like to thank the faculty of nursing and also the master of nursing study program for providing the opportunity to present this study references arroyo-quiroz, c., brunauer, r., & alavez, s. (2020). maturitas factors associated with healthy aging in septuagenarian and nonagenarian mexican adults. maturitas, 131(august 2019), 21–27. https://doi.org/10.1016/j.maturitas.2019.10.008 boero, m. e., francesco, a. de, vizzuso, p., & dessì, s. (2017). an observational study on the factors of successful aging in a sample of nonagenarian patients in a rehabilitation hospital complex. jurnal ners http://e-journal.unair.ac.id/jners | 237 https://doi.org/10.1007/s12062-017-9175-5 bosnes, i., almkvist, o., bosnes, o., stordal, e., romild, u., & nordahl, h. m. (2016). prevalence and correlates of successful aging in a population-based sample of older adults : the hunt study. 1–10. https://doi.org/10.1017/s1041610216001861 canêdo, a. c., canêdo, a. c., francisco, s., st, x., bloco, f., & joão, p. (2018). prevalence of and factors associated with successful aging in brazilian older adults : frailty in brazilian older people study ( fibra rj ). 1–6. https://doi.org/10.1111/ggi.13334 eun, j., & kahana, b. (2017). successful aging from the viewpoint of older adults : development of a brief successful aging inventory ( sai ). 44242, 359–371. https://doi.org/10.1159/000455252 gutiérrez, m., tomás, j. m., & calatayud, p. (2018). contributions of psychosocial factors and physical activity to successful aging. 1–9. https://doi.org/10.1017/sjp.2018.27 hsu, w., tsai, a. c., chen, y., & wang, j. (2017). predicted factors for older taiwanese to be healthy octogenarians : results of an 18-year national cohort study. 1–7. https://doi.org/10.1111/ggi.13112 kollia, n., caballero, f. f., sánchez-niubó, a., tyrovolas, s., ayuso-mateos, j. l., haro, j. m., … panagiotakos, d. b. (2018). social determinants , health status and 10-year mortality among 10 , 906 older adults from the english longitudinal study of aging : the athlos project. 1–9. manasatchakun, p., chotiga, p., hochwälder, j., & roxberg, å. (2016). factors associated with healthy aging among older persons in northeastern thailand. journal of cross-cultural gerontology, 369–384. https://doi.org/10.1007/s10823-016-9296-y pac, a., skalska, a., szybalska, a., zdrojewski, t., chudek, j., & grodzicki, t. (2019). influence of sociodemographic , behavioral and other health-related factors on healthy ageing based on three operative definitions. 23(9), 862–869. shi, w. h., zhang, h. y., zhang, j., lyu, y. bin, brasher, m. s., yin, z. x., … shi, x. m. (2016). the status and associated factors of successful aging among older adults residing in longevity areas in china *. biomedical and environmental sciences, 29(5), 347–355. https://doi.org/10.3967/bes2016.045 http://e-journal.unair.ac.id/jners | 35 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.24130 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research familial experiences of caring for schizophrenia patients during the covid-19 pandemic: a qualitative study indriati indriati1, wien soelistyo adi1, tuti anggarawati2, yuni astuti2 and delisa alfriani1 1 nursing department of health polytechnic semarang, central java, indonesia 2 nursing academy of kesdam, indonesia abstract introduction: due to the covid-19 pandemic, families are facing problems caring for and implementing covid-19 health protocols when caring for schizophrenia patients. a lack of knowledge and behavior changes make it difficult for the families to care for the schizophrenia patients. this study aims to explore the familial experiences of caring schizophrenia patients during the covid-19 pandemic. methods: a phenomenological qualitative design was undertaken as of november 2020. a total of 10 participants via the purposive sampling technique were recruited. the study was conducted in semarang, indonesia. we used semi-structured interviews to obtain the data and we used thematic content analysis to examine it. results: from the 10 participants, we got three themes, namely family fears, financial problems, and health treatment access. the themes were obtained from the families of the patients who care for them on a daily basis. during the covid-19 pandemic, caring for schizophrenia patients has become more difficult and the cause of a lot of worry. conclusion: the families experienced several problems when caring for schizophrenia patients. the families experienced fear of the schizophrenia patients being infected by covid-19, the families worried about whether or not the schizophrenia patients would experience a relapse and they felt stressed due to the news circulating. the families also had to spend more money to cover the cost of the patient’s care and transportation, and the schizophrenia patients were rarely controlled because of the family’s fears. this problem can be an issue for nurses who should strive to provide proper education and plan interventions for schizophrenia patients at the family level. article history received: december 28, 2020 accepted: february 22, 2021 keywords family; experience; schizophrenia; covid-19; pandemic contact delisa alfriani  alfrianidelisa@gmail.com  nursing department of health polytechnic semarang, central java, indonesia cite this as: indriati, i., adi, w, s., anggarawati, t., astuti, y., & alfriani, d. (2021). familial experiences of caring for schizophrenia patients during the covid-19 pandemic: a qualitative study. jurnal ners, 16(1). 35-40. doi:http://dx.doi.org/10.20473/jn.v16i1.24130 introduction the latest novel coronavirus disease (covid-19) has become a problem around the world (yang et al., 2020). tens of thousands of people have died from this disease so far (chakraborty & maity, 2020). the transmission of covid-19 from one person to another can be through droplets in the air, contaminated surfaces, fecal-oral or through contact with human waste. the prevention of covid-19 transmission can be done by implementing strict health protocols (kementrian kesehatan republik indonesia, 2020). not only that, covid-19 also affects the families caring for schizophrenia patients. various fears and worries arise from both the families and patients themselves. schizophrenia patients are vulnerable people who have increasingly experienced mental and psychosocial health impacts due to the covid-19 pandemic (kementrian kesehatan republik indonesia, 2020). this vulnerable group needs special attention. the news of death and illness due to covidhttps://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ i. indriati et al. 36 | pissn: 1858-3598  eissn: 2502-5791 19 could be a stressor for schizophrenia patients that may cause emotional problems. according to the who, (2020), a pandemic causes stress to various layers of society. previous studies related to previous pandemics such as severe acute respiratory syndrome (sars) have shown there to be a negative impact on the mental health of sufferers. research among sars survivors showed that in the medium and long-term (41-65%), the survivors experienced various kinds of psychological disorder (maunder, 2009). in addition, a study conducted in hong kong showed that the psychological problems of sars survivors did not diminish within one year of the incident and that 64% of survivors had the potential to experience psychiatric disorders (lee, 2007). the covid-19 pandemic has caused stressors to arise. families must improve their ability to adapt to the covid-19 pandemic so then they are able to treat the schizophrenia patients optimally (brailovskaia & margraf, 2020). due to the covid-19 pandemic, caring for patients should reflect their health and security needs. their relatedness needs consist mainly of their interpersonal needs, humanistic concern needs, and family needs. furthermore, their growth needs are mainly reflected as a strong need for knowledge. existence needs are the main needs during an epidemic, with the health and security needs influencing each other. humanistic concern needs are the most important of the relatedness needs (yin & zeng, 2020). the government's efforts to overcome the mental and psychosocial health impacts due to the covid-19 pandemic have been summarized by the composition of a guidebook for mental and psychosocial support and how to engage in mental and psychosocial support for the volunteers (kemenkes, 2020). a previous study showed that the family description of caring for schizophrenia patients includes the family knowledge of the disease, any treatment efforts, the family functions, social support (attepe özden & tuncay, 2018), the family acceptance regarding readiness to care (diorarta & pasaribu, 2018), any emotional and physical burdens (reknoningsih et al., 2015), support needs and changed perspectives (attepe özden & tuncay, 2018; ntsayagae et al., 2019). the experience of the families when caring for schizophrenia patients feels different in the covid-19 pandemic. families must care for the patients while adjusting to the health protocols on covid-19. it is not easy for the families to do this. thus, the researchers conducted this research with the aim of exploring the family experience of caring for schizophrenia patients during the covid-19 pandemic. materials and methods this research used a qualitative study with a phenomenological approach. in this study, the sampling technique used was purposive sampling. to get the participants, the researcher collected data on the number of schizophrenia patients in the study location and found 16 schizophrenic patients in total. the door-to-door technique to get participants according to the inclusion criteria was carried out. one of the family members who was responsible for the patient was selected as the participant. the participants were selected on the condition that they were able to read and write, that they live with the schizophrenia patients, that they had cared for the schizophrenia patients for approximately two years, that they were aged 16 70 years old, and that they were able to communicate in either indonesian or javanese. we got 10 participants in total who matched the study inclusion criteria. the identity of each participant was protected using a code known only to the researcher. in addition, the research data in the form of recordings, field notes, and other notes were kept confidential by the researchers and have only been used for research purposes. the study was conducted in november 2020 in the public health center (phc) in semarang, indonesia. we used semi-structured interviews to obtain the data. the interview guidelines were developed by the researchers. the interview guideline component consisted of the problems that arise while caring for schizophrenic patients during the covid-19 pandemic such as family anxiety, how the family copes with problems, and the support system that the family needs. each question set began with an open-ended question. the interview process was conducted in the homes of the participants and was only attended by the participants and researchers. this was done in order to get a detailed description of the information. as this took place during the covid-19 pandemic, the researchers adhered to the health protocols by wearing masks, by not touching participants, and by maintaining a distance from the participants during the interviews. the interviews were conducted for 30 until 45 minutes. the interview process was carried out twice in order to get as complete of a set of information as possible. data triangulation was applied to the interview design. the researchers used the methodological triangulation approach and researcher triangulation. the triangulation method involves using more than one data collection technique to obtain the same data, such as using audio recorders and observation techniques tied into the field notes. the transcription process was carried out after completing the interview. when saturation was reached and no new information was obtained, the data retrieval process was stopped. the data transcripts and analyzes were returned to the participants for cross-checking. the researchers also engaged in consultations with experts in qualitative research and mental disorders to obtain the most accurate data. the researchers kept the raw study data non-anonymous for two months until the analysis and research processes were complete. the researcher submitted an application to the health commission ethics services for permission to delete the raw research data and it was approved. jurnal ners http://e-journal.unair.ac.id/jners | 37 the analysis process was carried out using a thematic analysis approach (braun et al., 2006). the researchers were assisted by nvivo software version 12 regarding the coding, data management and quotations gained from the participants. the ethical principles, referring to the national guidelines for health research ethics in 2004, consist of three principles, namely respect for persons, beneficence, and justice. this study received approval from the health research ethics committee of the health polytechnic of the ministry of health in semarang on 4 november 2020, number 276/ea/kepk/2020. results in reference to the 10 participants in this study, the majority of the respondents were aged 30 45 years old with the majority of them having an education level of senior high school completion. the gender proportion of the participants in this study was equal between male and female, and the majority were housewives. the majority of the participants had treated the schizophrenia patients for 1 10 years. in our study, we determined there to be three themes, namely family fears, financial problems, and health treatment access. the details for each theme have been described as follows. theme 1: family fears we found that as many as 7 participants (p1, p3, p4, p5, p7, p8 and p9) in this study were addressing the fears of the family as a whole and the schizophrenia patients in particular being infected by covid-19. this theme was identified through 4 sub-themes, namely death, non-compliance, and infectiousness. the participants expressed a fear of death caused by covid-19. the participants saw a lot of news about deaths caused by covid-19, so the participants felt afraid if their families and patients died from covid19. this is expressed in the following sentence: “on television, there is a lot of news about the huge number of deaths due to covid-19. i'm afraid… i'm afraid if my family and this patient will also infected by covid-19. can die from the disease. covid-19 is not visible, so you don't know, and anyone can get out of covid-19…” (p1) furthermore, the non-compliance of the patients concerning using masks and washing their hands made families afraid of the patients being more easily infected by covid-19. this is expressed in the following sentence: "you must know that schizophrenia patients have to be told, sometimes obey, sometimes not... sometimes they want to wear a mask, sometimes they take it off because they can't breathe. so it's hard to be told to use a mask. wash hands before eating. this patient is very difficult to be told to comply with health protocols ..." (p7) the participants mentioned that the covid-19 disease is very infectious. ‘so i have to be careful. i, my family, and patients do not get infected.’ the participants also said that in order to reduce their fear, they listened to less news on covid-19, limited the patients from interacting with other people, and advised the patients to wash their hands regularly. this is expressed in the following sentence: “i'm also afraid if i catch covid-19. very dangerous. i usually tell patients to wash their hands frequently using running water in the bathroom. i also rarely watch news about covid-19, so i'm not too scared." (p9) theme 2: financial problems in this study, 6 participants (p1, p2, p3, p5, p9 and p10) revealed that caring for schizophrenia patients during covid-19 had resulted in additional costs such as the cost of purchasing masks, hand sanitizer and safe transportation. while treating the schizophrenia patient, the family had to spend extra money while their income decreased. this is because several family members were fired from work. this theme was identified through the sub-themes of health protocol costs and daily living costs. the participants complained about the additional costs of purchasing masks and hand sanitizer on a regular basis. at the start of the pandemic, masks and hand sanitizer were very expensive. however, the participants still bought these items to prevent themselves from being infected with covid-19. this is expressed in the following sentence: “the price of masks is very expensive. but we still have to buy that. so that i, my family, and the patient are not infected with covid-19. it's okay for me to pay extra, as long as my family is not infected with covid-19. but… if this continues, i can't. because income has decreased…” (p1) in addition, the participants also complained about the increase in the cost of basic necessities such as vegetables, rice, and transportation costs used to bring the patients to the hospital. the participants choose to save money by reducing any excess expenditure. apart from that, the assistance from the local government was also very helpful. this is expressed in the following sentence: “…what can we do? all the prices of basic necessities also go up. vegetables, large, and others also went up. the transportation costs for treating my child to the hospital also went up. all prices have gone up. but i have to be frugal, not be wasteful, i have to be smart in managing expenses. the local government also provided assistance. just lighten up ...” (p9) theme 3: health treatment access there were 7 participants (p1, p2, p4, p5, p6, p7 and p10) who said that while caring for schizophrenia patients during the covid-19 period, they felt that the procedures they had to go through to get health treatment or control had to go through many procedures, such as checking their temperature, screening, and rapid testing. in addition, during a pandemic, it is rare for the patients to go to the hospital. the theme was obtained through 3 subthemes, namely examination procedures, rarely in i. indriati et al. 38 | pissn: 1858-3598  eissn: 2502-5791 control, and persuading the patients to control themselves. the participants said that in order to be able to establish control at the hospital, the participants and patients must go through strict health examination procedures such as screening, temperature checks and proving that they are free of covid-19 through rapid tests. the participants felt that this made ensuring control in the hospital take longer and be more difficult. this is expressed in the following sentence: "to be honest, sir ... during the covid-19 pandemic, there were more procedures for examination. my brother (patient) must wear a mask. it is very difficult for my sister to be asked to wear a mask. my brother also had to be examined before he was admitted to the hospital, using a thermometer like that shot. my brother got scared. not to mention, first if you want to check you have to bring a rapidtest result. have to spend more money. yes, i find it more difficult during this pandemic…” (p2) we found that during a pandemic, the patients are rarely under control and were often admitted to the hospital. this is because the procedure is long, and the participants were afraid that the patient can become infected in the hospital. the family themselves came to the hospital to get the medicine. this is expressed in the following sentence: “i rarely took my son (patient) during this pandemic for treatment sir… i am afraid that my son will be infected by covid-19. so, i myself came to the hospital to get the medicine. my son stays at home.” (p5) during the covid-19 pandemic, the participants said that getting the patients to the hospital had become more difficult. one patient said that he was afraid that he would catch covid-19 in the hospital. “my brother is very difficult to control to the hospital. especially during the covid-19 pandemic. he (patient) is afraid of being infected with covid19. i'm scared too. then, i usually chat with the doctor via whatsapp for the consul regarding my brother's condition." (p7) discussion covid-19 places an emotional burden on the families caring for schizophrenia patients. the emotional problems experienced by the families include an increased fear of death due to covid-19, patient noncompliance with the health protocols, and the risk of transmission of covid-19. previous research has shown that covid-19 induces fear in everyone (fitzpatrick et al., 2020; mertens et al., 2020). the previous research is in accordance with this research. we learned that the participants experienced a fear of being infected with covid-19 which could result in the death of their family members. providing appropriate information can reduce participant fear excessively. patients with schizophrenia have the potential to not comply with the covid-19 prevention health protocols because of their impaired cognition and consideration. according to (stuart, 2013) schizophrenia is characterized by changes in tension, cognition, sensation, personality, lifestyle, attention, willpower, emotions, thought processes, psychomotor, memory, association, and the consideration of others. patients with schizophrenia are less aware of the external environment that is currently being hit by the covid-19 pandemic and they are less able to make choices about wearing masks, maintaining distance, and washing their hands frequently to prevent covid-19 transmission (london, 2020; szczesniak et al., 2020). this situation causes the focus of the family on the patients with schizophrenia to increase, including accompanying them and ensuring that the patients do not contract and transmit covid-19 by repeatedly advising the patients to comply with the health protocols. in this study, we also found that during covid-19, the participating families were very vulnerable to experiencing financial problems. during covid-19, families need extra expenses to purchase masks, transportation, and daily necessities. previous research has shown that covid-19 causes financial problems that have an impact on meeting their needs (adekoya & oliyide, 2020; wolfe & patel, 2021). not only that, to protect themselves from covid-19, the families must buy masks at a higher price (garber, 2020). financial disruption greatly impacts the care of schizophrenia patients. the treatment required includes providing their basic necessities such as food and drink, using personal protective equipment, and the need for a consultation at the hospital. the largescale social restrictions regulation ultimately limits human activities in terms of working hours, the use of public transportation and the enforcement of trade restriction regulations. collectively, these have a major impact on the business sector. people do not leave their homes due to the fear of contracting covid19, so the demand for offline products has decreased dramatically. in contrast, the online demand has increased sharply. according to kiril mankovski, in times like these, the majority of people tend to choose cashless transactions to maintain their health (mihaela rus, mihaela luminița sandu, 2020). during covid-19, the participants faced difficulty getting access to and seen by the health services including more complicated health care procedures. this has an impact on the patients seeking control and treatment in the hospital. previous research has shown that covid-19 reduces the number of visits by schizophrenia patients for control at the hospital (gonçalves-pinho et al., 2020; moreno et al., 2020). for this reason, persuasion techniques can be used by the families to make bringing the schizophrenia patients to the hospital easier (rus-calafell et al., 2015). furthermore, during the covid-19 pandemic, the participants came to the hospital to get the patient's medicine. this is done to keep the patient's condition stable during the covid-19 pandemic. this study provides an overview of the experiences of the families treating schizophrenia patients. however, this study is still limited in terms jurnal ners http://e-journal.unair.ac.id/jners | 39 of the number of participants. in the future, studies with a larger number of participants can provide a more detailed picture of the family experiences when treating schizophrenia patients. conclusion the covid-19 pandemic puts an emotional burden on the families in caring for schizophrenia patients. fear of being infected with covid-19, which can result in death, becomes an emotional burden for the participants. not only that, the covid-19 pandemic can result in financial problems that in turn can have an impact on patient care. this causes the basic needs and care of the schizophrenia patients to be disrupted. furthermore, due to the limitations in terms of access to the health services, the patients still have to receive good care and their medication regularly. for this reason, families must look for other alternatives to treat the schizophrenia patients by making savings, taking drugs on behalf of the family and online consultation with doctors. providing the correct information can reduce the level of participant fear regarding covid-19. furthermore, the results of this study can be used as basic information when making policies at the level of the local government. it can also allow nurses to determine the appropriate nursing interventions to use through education. further research with different approaches and designs is needed for the development of the information. references adekoya, o. b., & oliyide, j. a. (2020). how covid-19 drives connectedness among commodity and financial markets: evidence from tvp-var and causality-in-quantiles techniques. resources policy, 101898. https://doi.org/10.1016/j.resourpol.2020.10189 8 attepe özden, s., & tuncay, t. (2018). the experiences of turkish families caring for individuals with schizophrenia: a qualitative inquiry. international journal of social psychiatry, 64(5), 497–505. https://doi.org/10.1177/0020764018779090 brailovskaia, j., & margraf, j. (2020). predicting adaptive and maladaptive responses to the coronavirus (covid-19) outbreak: a prospective longitudinal study. international journal of clinical and health psychology, 20(3), 183–191. https://doi.org/10.1016/j.ijchp.2020.06.002 braun, v., clarke, v., braun, v., & clarke, v. (2006). applied qualitative research in psychology. applied qualitative research in psychology, 3(2), 77–101. https://doi.org/10.1057/978-1-13735913-1 chakraborty, i., & maity, p. (2020). covid-19 outbreak: migration, effects on society, global environment and prevention. science of the total environment, 728, 138882. https://doi.org/10.1016/j.scitotenv.2020.13888 2 diorarta, r., & pasaribu, j. (2018). the experiences of family in caring schizophrenic patients with violent behavior. jurnal keperawatan, 10(2), 106– 113. fitzpatrick, k. m., drawve, g., & harris, c. (2020). facing new fears during the covid-19 pandemic: the state of america’s mental health. journal of anxiety disorders, 75, 102291. https://doi.org/10.1016/j.janxdis.2020.102291 garber, a. (2020). analysis: coronavirus spike most surgical mask, sanitizer proces at least 505 on amazon. gonçalves-pinho, m., mota, p., ribeiro, j., macedo, s., & freitas, a. (2020). the impact of covid-19 pandemic on psychiatric emergency department visits – a descriptive study. psychiatric quarterly. https://doi.org/10.1007/s11126-020-09837-z kemenkes. (2020). direktorat jenderal pencegahan dan pengendalian penyakit kementerian kesehatan ri tahun 2020. germas, 1–64. kementrian kesehatan republik indonesia. (2020). corona virus disease 2019 pedoman pembatasan sosial berskala besar dalam rangka percepatan penanganan corona virus disease 2019 (covid19). in menteri kesehatan republik indonesia: vol. nomor 9. london, s. (2020). covid-19, autonomy, and the inpatient psychiatric unit. academic psychiatry, 44(6), 671–672. https://doi.org/10.1007/s40596-020-01314-w maunder, r. g. (2009). was sars a mental health catastrophe? general hospital psychiatry, 31(4), 316–317. https://doi.org/10.1016/j.genhosppsych.2009.0 4.004 mertens, g., gerritsen, l., duijndam, s., salemink, e., & engelhard, i. m. (2020). fear of the coronavirus (covid-19): predictors in an online study conducted in march 2020. journal of anxiety disorders, 74, 102258. https://doi.org/10.1016/j.janxdis.2020.102258 mihaela rus, mihaela luminița sandu, t. t. (2020). a new decade for social changes. technium:social science journal, 6(6), 69–87. moreno, c., wykes, t., galderisi, s., nordentoft, m., crossley, n., jones, n., cannon, m., correll, c. u., byrne, l., carr, s., chen, e. y. h., gorwood, p., johnson, s., kärkkäinen, h., krystal, j. h., lee, j., lieberman, j., lópez-jaramillo, c., männikkö, m., … arango, c. (2020). how mental health care should change as a consequence of the covid-19 pandemic. the lancet psychiatry, 7(9), 813–824. https://doi.org/10.1016/s2215-0366(20)303072 ntsayagae, e. i., poggenpoel, m., & myburgh, c. (2019). experiences of family caregivers of persons living with mental illness: a meta-synthesis. curationis, 42(1), 1900. https://doi.org/10.4102/curationis.v42i1.1900 i. indriati et al. 40 | pissn: 1858-3598  eissn: 2502-5791 reknoningsih, w., daulima, n. h. c., & putri, y. s. e. (2015). pengalaman keluarga dalam merawat pasien pascapasung. jurnal keperawatan indonesia, 18(3), 171–180. https://doi.org/10.7454/jki.v18i3.421 rus-calafell, m., caqueo-urízar, a., urzúa, a., escudero, j., & gutiérrez-maldonado, j. (2015). the role of family therapy in the management of&amp;nbsp;schizophrenia: challenges and solutions. neuropsychiatric disease and treatment, 145. https://doi.org/10.2147/ndt.s51331 sang min lee, crystal r. baker, seong ho cho, danette e. heckathorn, michael w. holland, rebecca a. newgent, nick t. ogle, michael l. powell, james j. quinn, s. l. w. & k. y. (2007). development and initial psychometrics of the counselor burnout inventory, measurement and evaluation in counseling and development. https://doi.org/10.1080/07481756.2007.11909 811 stuart, g. (2013). principles and practice of psychiatric nursing. mosby, inc. szczesniak, d., ciulkowicz, m., maciaszek, j., misiak, b., luc, d., wieczorek, t., witecka, k.-f., & rymaszewska, j. (2020). psychopathological responses and face mask restrictions during the covid-19 outbreak: results from a nationwide survey. brain, behavior, and immunity, 87, 161– 162. https://doi.org/10.1016/j.bbi.2020.05.027 who. (2020). physical health and psychosocial considerations during the coronavirus disease 2019 outbreak. psychosomatics, 61(6), 851–852. https://doi.org/10.1016/j.psym.2020.07.005 wolfe, m. t., & patel, p. c. (2021). everybody hurts: self-employment, financial concerns, mental distress, and well-being during covid-19. journal of business venturing insights, 15, e00231. https://doi.org/10.1016/j.jbvi.2021.e00231 yang, j., zheng, y., gou, x., pu, k., chen, z., guo, q., ji, r., wang, h., wang, y., & zhou, y. (2020). prevalence of comorbidities and its effects in coronavirus disease 2019 patients: a systematic review and meta-analysis. international journal of infectious diseases, 94, 91–95. https://doi.org/10.1016/j.ijid.2020.03.017 yin, x., & zeng, l. (2020). a study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory. international journal of nursing sciences, 7(2), 157–160. https://doi.org/10.1016/j.ijnss.2020.04.002 194 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.21444 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effectiveness of an intervention based on peplau’s model on health literacy among nurses who smoke: a quasi-experimental study achmad djojo1, suhariyanto suhariyanto1, lily yuniar1, arsad suni2, efi riani1, yogi ervandi1, sepni walvri1, angie aprizal1, rr tutik sri hariyati3 and hanny handiyani3 1jurusan keperawatan singkawang, poltekkes kemenkes pontianak, pontianak, indonesia 2 poltekkes kemenkes ternate, indonesia 3 faculty of nursing science, universitas indonesia, depok, indonesia abstract introduction: : lack of health literacy for smoking nurses has worsened image of nursing services. the role of leader can be a support in increasing behavior change of nurses who smoke. the aimed to find out health literacy of smokers in nursing staff through interpersonal role of the head of the room by intervention based on peplau’s model. methods: a quasi-experimental research with a pre-and post-control group design, using modification questionnaire of knowledge and behavior. the target population was nurses living in singkawang who smoke in a hospital. sample was 35 respondents for each group (controlling group and intervention group) using purposive sampling. dependent variable is health literacy among nurses who smoke and independent variable is intervention based on peplau’s model. intervention is in the form of a guide module consisting of strengthening health literacy (health awareness, self-reflection, cognitive competence and behavioral interpersonal relationships in the head of the room) and will be implemented to nurses who smoke. analysis data for bivariate used paired t – test and for multivariate used the mcnemar test. results: the research showed that the difference before and after intervention was 2.23 (p = 0.001) and control group was 8.00 with a default value of 0.870 deviation. the results showed a significant increase in health literacy in nurse smokers through the role of interpersonal head nurse (p=0.001). conclusion: role of head of room in interpersonal relationship with peplau’s model affects the health literacy of nursing staff who smoke. article history received: august 17, 2020 accepted: october 20, 2020 keywords head of nurse; peplau’s model; health literacy; smoking; guide module contact suhariyanto suhariyanto  suhariyantoputra1986@gm ail.com  poltekkes kemenkes pontianak, pontianak, indonesia cite this as: djojo, a., suhariyanto, s., yuniar, l., suni, a., riani, e., ervandi, y., et al. (2020). the relationship between family harmony with stress, anxiety, and depression in adolescents. jurnal ners, 15(2). 194-198. doi:http://dx.doi.org/10.20473/jn.v15i2.21444 introduction nurses are role model who provide education for patients or community to change for better behavior (morsiani, bagnasco and sasso, 2017). nurses who don’t have good health awareness are given interventions to change these behaviors (morsiani, bagnasco and sasso, 2017; kirkman et al., 2018). nurses' health literacy can be formed through interpersonal relationships that can change the way they think about health behavior. the findings indicate that healthcare professionals need support from leaders and coworkers, who play an important role in promoting behavior change (blackstone and pressman, 2016; morsiani, bagnasco and sasso, 2017). other studies suggest that positive support, training, motivating, and disciplined healthcare personnel promote increased adherence that changes behavior (renner et al., 2012). the ability to understand individual behavior requires a nursing theory approach, which is a theory developed by peplau regarding interpersonal relationships that help carry out their duties through cooperative relationships (canadian interprofessional health https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:suhariyantoputra1986@gmail.com mailto:suhariyantoputra1986@gmail.com jurnal ners http://e-journal.unair.ac.id/jners | 195 collaborative, 2010). the interpersonal relationships that are built can influence changes in affective, cognitive, and multidimensional behavior by using several positive social and interpersonal interventions (choi et al., 2016). the approach through health professionals, especially nurses, has a role in maintaining patient safety by providing patient and family education (scully, 2015). in addition, one of the competencies of nurses is being able to apply interpersonal relationships to provide education and examples for patients in changing behavior. health literacy rate of nurses in implementing health has not yet reached the standard level, more than 50% of nurses in developing countries still need higher education and support (niederdeppe et al., 2008; seymour, 2018). the results of a preliminary study and encroachment carried out in five hospitals in kalimantan in may 2019 showed that the level of knowledge and health literacy was still low (45%) and moderate (55%). the results of interviews with the head of nursing and medical services for health workers stated that most male nurses had smoking behavior, even though information on smoking bans in the hospital already existed. the results of observations also show that health workers still smoke around the hospital, both in the surrounding area and in the canteen. bad health literacy carried out by nurses can make patients and their families to not believe in the education provided by nurses, because of the behavior they see (choi et al., 2016). the phenomenon of nurse behavior not having high health literacy needs to be changed, so that the quality of nursing and hospital services improves. in addition, patient and family satisfaction is important for maintaining the existence of the hospital and accreditation. good services can improve the health status of patients, thereby supporting the sdgs 2030 program of healthy living and promoting welfare for all communities. this study aim was to find out health awareness of smokers in nursing staff through the interpersonal role of the head of the room by intervention based on peplau’s model. materials and methods this research is a quasi-experimental study with pre and post-control group design, which was held for six months at hospital in kalimantan with criteria of hospitals that have a large number of smoking nurses. the target population was nurses who smoke in a hospital and lives in singkawang. researchers selected research respondents using purposive sampling technique with the inclusion criteria being male nurses, productive age and active smokers, while the exclusion criteria were nurses who had quit smoking and were unwilling to be observed. there are 70 respondents that contain 35 respondents for control group and 35 respondents for intervention group. dependent variable is health literacy among nurses who smoke and independent variable is intervention based on peplau’s model. intervention is in the form of a guide module consisting of strengthening health literacy and implemented to nurses who smoke. instruments of this study consist of guide module (strengthening health awareness, self-reflection, cognitive competence and behavioral interpersonal relationships in the head of the room) and health awareness questionnaire with 49 items using likert scale. after dividing into two groups, we did pretest then gave intervention with guide module (strengthening health awareness, selfreflection, cognitive competence and behavioral interpersonal relationships in the head of the room). analysis data for bivariate used paired t – test and for multivariate used mcnemar test. this study was accepted for ethical clearance from poltekkes kemenkes pontianak no. 191/kepk-pk.pkp/v/ 2019. results the research conducted in 35 respondents in each group showed that all respondents were male. the highest educational background of the nurses was diploma (intervention vs. control; 88.6% vs. 85.7%) and the average of age of each group was 26 – 30 years. the majority respondents were permanent employee with working period average 3-4 years (table 1). there are differences between intervention group before and after giving intervention; before intervention the intervention group mean was 7.76 and increased after intervention to 10.00 with p value 0.001, while in the control group with 35 respondents the average health literacy obtained a value of 8.00 with a default value of 0.870 deviation (table 2). based on the results of the calculation of the statistical test, it was obtained p = 0.001. this means that the p value <α = 0.05), which states that the interpersonal role of the head of the room strengthens the interpersonal role with the peplau’s model affecting the health literacy of nursing staff. for head of the room, there are guide modules that can increase the knowledge about interpersonal role with peplau’s model and which consist of role of teaching and resource persons, leadership role, role of guardian, advisory role and role of the stranger. it will be implemented to nursing staff who smoke using peplau’s model, so health literacy among nurses who smoke will increase. discussion health literacy is defined as a person's ability to obtain, process, and understand health information and healthcare that is necessary so as to make appropriate decisions for individual health conditions. the health literacy of respondents who are smoking nurses is to be aware of the knowledge and motivation to change (dewalt et al., 2011; sheridan et al., 2011). in this study, before the respondents were given intervention, the head of the room was given a guide module containing interpersonal roles with peplau’s model. after that, a. djojo et al. 196 | pissn: 1858-3598  eissn: 2502-5791 the head of the room implemented it to nursing staff. the result of this study shows that afterwards the intervention group increased health literacy; before intervention the mean was 7.76 and after intervention it was 10.00 with p value 0.001, which means p value <α = 0.05) indicating the interpersonal role of the head of the room strengthens the interpersonal role with the peplau’s model affecting the health literacy of nursing staff. sorensen stated that the causes of low health literacy include increasing age, latest education level, motivation, and individual behavior. it has been researched by sorensen et al. (2012) that motivation also affects a person's ability to seek information about health and try to understand what is obtained from that information (kim, 2009; protheroe, wolf and lee, 2010; berkman et al., 2011). the result of this research supports the theory found by other researchers. persons with low health literacy have low knowledge of health, while a person with high health literacy has good knowledge of health (lee, lee and moon, 2016). in this study, there was no difference in the control group results because it wasn’t given treatment. in this case, it is necessary to have a continuous mentoring from the field of nursing to perform competence as head nurse in conducting interpersonal peplau. it cannot be done only one or twice, but must be continuous (mosley and taylor, 2017). the motivation also affects a person's ability to seek information about health and seek to understand what the information provides. the motivation is gained from interpersonal head of room with peplau’s model. this is supported by the head of room providing support and commitment to the goal that raises productivity and can motivate the work behavior of nurses. the competency of head nurses in implementing leadership functions is the most dominant factor affecting the health literacy in nurses (laschinger et al., 2014; marquis and huston, 2017). leadership roles and managerial head of room are important in applying interpersonal peplau’s model. this role can’t be given only once, but needs to be continuous in the form of continuous supervision of the head of nurse to the staff who are smoking in order to create health literacy. a briefing function that is included in the interpersonal role of the head nurse is one of the forms of leadership management to increase effectiveness and efficiency in working further to create a healthy work environment because the head of room is capable to direct to nursing staff (scully, 2015; marquis and huston, 2017). it is influenced by the ability and responsibility of the head of room and the cooperation of nurses in the room. interpersonal relationships are one of the measures to change viewpoints related to health behavior. findings suggest that healthcare professionals need the support of leaders and peers, who play an important role in raising behavioral changes (barrantes et al., 2017; ogoncho, sanga and halake, 2017). the ability to understand behavior requires an approach to nursing theory. the hildegard peplau theory (1952) focuses on individuals, nurses, and the interactive process; the results show the relationship between nurses and clients. based on this theory, the client is an individual with a feeling of need, and nursing is an interpersonal and therapeutic process. the goal of nursing is to educate clients and families and to help clients achieve personality development maturity. therefore, nurses seek to develop a relationship between nurses and clients, where nurses serve as table 1. distribution of respondent characteristics parameter intervention control total n % n % n % gender male 35 100 35 100 70 100 age 20-25 year 26-30 year 31-35 year 15 10 10 42.8 38.5 28.7 12 17 6 34.3 48.6 17.1 27 27 16 38.5 38.5 23 education bachelor diploma 4 31 11.4 88.6 5 30 14.3 85.7 9 61 12.8 87.2 employment status permanent employee contract employee 21 14 60.0 40.0 19 16 54.3 45.7 40 30 57 43 working duration < 1 year 1-5 year > 5 year 5 17 13 14.3 48.6 37.1 6 13 16 17.1 37.1 45.8 11 30 29 15.7 42.8 41.5 table 2. the difference of health literacy of the respondents no health literacy n mean mean differences sd p 1 intervention group before 35 7.76 2.23 1.550 0.001 after 35 10.00 0.870 2 control group before after 35 8.00 0.870 0.037 jurnal ners http://e-journal.unair.ac.id/jners | 197 speakers, counselors, and guardians. when the client seeks help, the nurse first discusses the problem and explains the type of service available. with the growing relationship between nurses and clients, nurses and clients together define problems and possibly resolve the problem. from this relationship, the client benefits by utilizing the available services to meet his needs and nurses assist the client in terms of lowering the anxiety associated with his health problems. conclusion based on this study regarding the health literacy of smokers in nursing staff through the interpersonal role of the head of the room with the strengthening of the peplau’s model, it can be concluded that there is an influence of the interpersonal role of the head of the room with peplau’s model on the health literacy of nursing staff. the role of head of room in interpersonal relationships using peplau’s model affects the health literacy of nursing staff who smoke. this role cannot be assigned once, but needs to be continuous in the form of continuous supervision from the head of the room to the smoking staff so as to create health literacy. references barrantes, r. j. et al. (2017) ‘the role of minority stressors in lesbian relationship commitment and persistence over time’, psychology of sexual orientation and gender diversity. doi: 10.1037/sgd0000221. berkman, n. d. et al. (2011) ‘low health literacy and health outcomes: an updated systematic review’, annals of internal medicine. doi: 10.7326/00034819-155-2-201107190-00005. blackstone, s. w. and pressman, h. (2016) ‘patient communication in health care settings: new opportunities for augmentative and alternative communication’, aac: augmentative and alternative communication. doi: 10.3109/07434618.2015.1125947. canadian interprofessional health collaborative (2010) a national interprofessional competency framework, health san francisco. choi, s. l. et al. (2016) ‘transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment’, human resources for health. doi: 10.1186/s12960-016-0171-2. dewalt, d. a. et al. (2011) ‘developing and testing the health literacy universal precautions toolkit’, nursing outlook. doi: 10.1016/j.outlook.2010.12.002. kim, s. h. (2009) ‘health literacy and functional health status in korean older adults’, journal of clinical nursing. doi: 10.1111/j.13652702.2008.02739.x. kirkman, t. et al. (2018) ‘strategies for implementing a multiple patient simulation scenario’, nurse education today. doi: 10.1016/j.nedt.2018.01.032. laschinger, h. k. s. et al. (2014) ‘resonant leadership and workplace empowerment: the value of positive organizational cultures in reducing workplace incivility.’, nursing economic$. lee, e. h., lee, y. w. and moon, s. h. (2016) ‘a structural equation model linking health literacy to self-efficacy, self-care activities, and healthrelated quality of life in patients with type 2 diabetes’, asian nursing research. doi: 10.1016/j.anr.2016.01.005. marquis, b. l. and huston, c. j. (2017) leadership roles and management functions in nursing: theory and application, leadership roles and management functions in nursing: theory and application. doi: 10.1097/00006216-200407000-00013. morsiani, g., bagnasco, a. and sasso, l. (2017) ‘how staff nurses perceive the impact of nurse managers’ leadership style in terms of job satisfaction: a mixed method study’, journal of nursing management. doi: 10.1111/jonm.12448. mosley, c. m. and taylor, b. j. (2017) ‘integration of health literacy content into nursing curriculum utilizing the health literacy expanded model’, teaching and learning in nursing. doi: 10.1016/j.teln.2016.12.005. niederdeppe, j. et al. (2008) ‘message design strategies to raise public awareness of social determinants of health and population health disparities’, milbank quarterly. doi: 10.1111/j.1468-0009.2008.00530.x. ogoncho, i. m., sanga, p. and halake, d. g. (2017) ‘case management of substance induced psychosis using peplau ’ s theory of interpersonal relations’, clinical practice. doi: 10.5923/j.cp.20170602.03. protheroe, j., wolf, m. s. and lee, a. (2010) ‘health literacy and health outcomes’, in health literacy in context: international perspectives. renner, b. et al. (2012) ‘dynamic psychological and behavioral changes in the adoption and maintenance of exercise’, health psychology. doi: 10.1037/a0025302. scully, n. j. (2015) ‘leadership in nursing: the importance of recognising inherent values and attributes to secure a positive future for the profession’, collegian. doi: 10.1016/j.colegn.2014.09.004. seymour, j. (2018) ‘the impact of public health awareness campaigns on the awareness and quality of palliative care’, journal of palliative medicine. doi: 10.1089/jpm.2017.0391. a. djojo et al. 198 | pissn: 1858-3598  eissn: 2502-5791 sheridan, s. l. et al. (2011) ‘interventions for individuals with low health literacy: a systematic review’, in journal of health communication. doi: 10.1080/10810730.2011.604391. 480 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20516 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original article identification of nursing problems in hospitalized patients with diabetes mellitus wikan purwihantoro sudarmaji, nursalam nursalam, and sartika wulandari faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: one of the duties of nurses when managing patients with diabetes mellitus is establishing a nursing diagnosis. this study aimed to identify the nursing problems that arise in hospitalized patients with diabetes mellitus. methods: a descriptive analytical study involving 100 medical records of inpatients with diabetes mellitus from june, july and august 2019 was conducted. the data collection was done through an observation sheet according to the indonesian nursing diagnosis standards (sdki). results: there were 30 types of nursing problems identified with the total number of nursing problems found being 332. the most frequent nursing problems were d.0142 risiko infeksi (risk of infection) 30.12%, d.0027 ketidakstabilan kadar glukosa darah (instability of blood glucose levels) 14.16%, d.0011 risiko penurunan curah jantung (risk of decreased cardiac output) 12.65%, d.0017 risiko perfusi serebral tidak efektif (risk of cerebral perfusion not effective) 8.73%, d.0037 and risiko ketidakseimbangan elektrolit (risk of electrolyte imbalance) 4.52%. conclusion: this research found there to be 30 variations of nursing problems among the hospitalized patients with diabetes mellitus with the most frequent nursing problems in the physiological category and nutrition and fluid sub-categories. article history received: feb 27, 2020 accepted: april 1, 2020 keywords nursing diagnosis; nursing problem; diabetes mellitus contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: sudarmaji, w.p., nursalam, n., & wulandari,s. (2020). identification of nursing problems in hospitalized patients with diabetes mellitus. jurnal ners, special issues, 480-485. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20516 introduction type 2 diabetes mellitus involves a complex diagnosis and requires complex care (sutoto, 2019). type 2 diabetes constitutes 90% of all diabetes (kemenkes, 2014). diabetes puts a burden on both the patient and society in the form of medical expenses, lost income, premature death and non-material burden in the form of decreased quality of life. diabetes and its complications bring in huge economic losses for diabetic patients and their families, the health system and the national economy through direct medical costs, job loss and income (kementerian kesehatan ri, 2019). the american diabetes association stated that the total costs incurred for the handling of diabetes mellitus in 2017 was $327 billion, which consists of $237 billion in direct medical costs and $90 billion due to a reduction of productivity (american diabetes association, 2018). another impact of diabetes mellitus is long hospital stays. patients with diabetes mellitus over the age of 45 years old are admitted to hospital for an average f 8.2 days (american diabetes association, 2018). in patients with diabetes mellitus with complications of peripheral arterial disease (pad), the average length of treatment is 15 + 18.2 days (malone, 2014). the who estimates that globally, 422 million adults aged over 18 years were living with diabetes in 2014 (who, 2016b). the largest number of people with diabetes is estimated to come from southeast asia and the western pacific, accounting for about half of the cases of diabetes in the world (kementerian kesehatan ri, 2019). the prevalence of diabetes mellitus in indonesia based on the diagnosis of doctors in a population of all ages in 2018 was 1.5% of the total population of indonesia (kementerian kesehatan ri, 2018). in 2030, the estimated number of people with diabetes mellitus in indonesia is set to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 481 be 21.3 million people (kementerian kesehatan ri, 2019). the role of nurses as professionals when handling diabetes mellitus cases involves the provision of comprehensive, effective and quality nursing care. nurses can carry out nursing interventions based on identifying the patient's response that arises due to his illness, which is expressed through nursing diagnoses. it is important to describe and identify precisely the nursing problems that arise in the patients. identifying the patient's problems appropriately can improve the quality of the nursing assistance. however, sometimes the nurses do not describe the nursing problems present using standard terminology (carmona, lima, & araujo, 2013). nursing problems are one of the main components of nursing diagnoses and it describes the core of the client's response to his health condition or life processes (ppni, 2017). the indonesian nursing diagnosis standards (sdki) is a standardized terminology used for the enforcement of nursing diagnoses in indonesia to allow it to be uniform, accurate and unambiguous to avoid inaccurate decision making and a mismatch in the nursing care provided to the clients (ppni, 2017). the identification of nursing problems in patients with diabetes mellitus using the terminology of the indonesian nursing diagnostic standards (sdki) is needed to assist the nurses in identifying the nursing problems that arise in patients with diabetes mellitus. the purpose of this research is to find out the nursing problems according to the indonesian nursing diagnosis standards (sdki) that appear in patients with type 2 diabetes mellitus. materials and methods this study used a descriptive analytic approach. the study was conducted at a teaching hospital in the city of surabaya, east java province, indonesia. we used 100 medical records from the patients with diabetes mellitus with the following inclusion criteria: aged over 30 years, diabetes mellitus with complications, diabetes mellitus without complications and hospitalized in june, july or august 2019. the exclusion criteria were that they had either diabetes insipidus or gestational diabetes. the sampling method chosen was a random sampling technique. the researcher identified the major signs and symptoms in the medical record and then grouped them according to the criteria of the nursing problems according to the sdki. the research instrument used was an observation sheet compiled based on the indonesian nursing diagnosis standards (sdki) published by the indonesian national nurses association (ppni). the observation sheet contained data on their medical record number, age, sex, marital status, education level, occupation, religion, financial status, medical diagnoses, subjective major signs and symptoms, objective major signs and symptoms, risk factors and any nursing diagnoses that can be established. this study passed the ethical test conducted by the health research ethics commission with ethical code number 194/keh/2019. results using the 100 patient medical records, it was determined that 55% of the patients female. the age range was from 32 to 84 years old with an average age of 59.03. most were married at 83%, muslim at 97%, had a high school education or equivalent at 43% and took care of the household at 46%. table 2 shows the 10 most found nursing problems from a total of 30 types of nursing problem. most diabetes mellitus patients are at risk of experiencing or contracting an infection. table 3 shows the categories and subcategories of the nursing problems. most nursing problems were found to be in the physiological category (55%) with a distribution across the sub-categories of circulation (25%), nutrition and fluids (23%), activity and rest (4%), respiration (2%) and elimination (1%). discussion diabetes mellitus refers to an absolute or relative insulin deficiency and impaired insulin function. diabetes mellitus is classified into type 1 dm, type 2 dm, other type dm and dm in pregnancy. diabetes mellitus type 2 (dmt2) is a group of metabolic diseases characterized by hyperglycemia occurring table 1. characteristics of the study characteristics n % gender male 45 45 female 55 55 age (years) 30 40 3 3 41 50 15 15 51 60 40 40 61 70 29 29 71 80 12 12 marital status married 83 83 not married 17 17 religion islam 87 87 protestant 11 11 katolik 1 1 budha 1 1 education status elementary school 29 29 high school 52 52 diploma 1 1 1 diploma 3 7 7 bachelor’s 15 15 employment status not working 3 3 took care of the household 46 46 retired 9 9 government employee 3 3 general employee 24 24 fisherman 9 9 farmer 1 1 driver 1 1 entrepreneur 12 12 w. p. sudarmaji et al. 482 | pissn: 1858-3598  eissn: 2502-5791 due to abnormal insulin secretion, insulin action or both (decroli, 2019). type 2 diabetes accounts for 90% of all diabetes (kemenkes, 2014). dmt2 is characterized by impaired insulin sensitivity and/or impaired insulin secretion. dmt2 clinically arises when the body is no longer able to produce enough insulin to compensate for the increase in resistant insulin. the signs and symptoms of diabetes mellitus are hyperglycemia accompanied by polyuria, polydipsia and polyphagia. hyperglycemia accompanied by ketoacidosis or hyperosmolar nonketotic syndrome is the most common lifethreatening complication in patients with uncontrolled diabetes mellitus. patients with diabetes mellitus may also suffer from high blood pressure and anomalies in lipoprotein metabolism. in the long term, the symptoms of retinopathy appear with the possibility of a loss of vision. nephropathy can cause kidney failure. neuropathy is associated with the appearance of lesions in the legs, amputations, and joint charcot. autonomic neuropathy produces signs of gastrointestinal, genitourinary, and cardiovascular disorders. sexual dysfunction may occur in patients with diabetes mellitus. eventually, patients with diabetes mellitus usually develop atherosclerotic cardiovascular disease, peripheral artery disease and cerebrovascular disease (okur, karantas, hospital, & siafaka, 2017). dm complications include acute complications and chronic complications (perkeni, 2015). the crisis of hyperglycemia and hypoglycemia is an acute complication while macroangiopathy and microangiopathy are chronic complications. diabetic ketoacidosis (kad) is an acute complication of diabetes that is characterized by an increase in high blood glucose levels (300-600 mg/dl) accompanied by the signs and symptoms of acidosis and strong (+) ketone plasma. osmolarity increases the anion gap. hyperglycemic status hyperosmolar (shh) is a condition where an increase in blood glucose is very high (600-1200 mg/dl), without the signs and symptoms of acidosis. plasma osmolarity is greatly increased (330-380 mos / ml), plasma ketone (+/) and the anion gap is normal or slightly increased. hypoglycemia is characterized by a decrease in blood glucose levels <70 mg/dl. hypoglycemia is a decrease in serum glucose concentration with or without the symptoms of the autonomic system, such as the presence of whipple's triad. this is where there are symptoms of hypoglycemia, namely low blood glucose levels, where the symptoms can be reduced with treatment. macroangiopathy will cause disorders of the heart arteries including coronary heart disease, and disorders of the brain blood vessels, resulting in ischemic stroke or hemorrhagic stroke. the effect on the peripheral blood vessels includes peripheral artery disease that often occurs in people with dm. the typical symptoms that usually appear first is pain during activity that is diminished at rest (claudication intermittent) but often it can also be present without symptoms. ischemic ulceration of the foot is a disorder that can be found in diabetic patients. microangiopathy can cause diabetic retinopathy, diabetic nephropathy and diabetic neuropathy. good glucose and blood pressure control will reduce the risk or slow the progress of retinopathy, nephropathy and neuropathy. in peripheral neuropathy, a loss of distal sensation is an important risk factor for foot ulcers which increases the risk of amputation. symptoms that are often felt include that the feet feel like they are burning and vibrating on their own, and there is more pain felt at night. table 2. the nursing problems (sdki) that arise in patients with type 2 diabetes mellitus nursing problem n % risk of infection 100 30,12 instability of the blood glucose level 47 14,16 risk of decreased cardiac output 42 12,65 risk of cerebral perfusion 29 8,73 risk of electrolyte imbalance 15 4,52 impaired physical mobility 12 3,61 impaired tissue integrity 11 3,31 nausea 10 3,01 acute pain 10 3,01 fall risk 10 3,01 table 3. the categories and subcategories of nursing diagnoses (sdki) in patients with type 2 diabetes mellitus category n % subcategory n % physiological 184 55% safety and protection 126 38% environmental 126 38% circulation 83 25% behavioral 1 0% nutrition and fluid 78 23% psychological 20 6% pain and comfort 20 6% relational 1 0% activity and rest 14 4% respiration 7 2% elimination 2 1% social interaction 1 0% personal hygiene 1 0% jurnal ners http://e-journal.unair.ac.id/jners | 483 diabetes is a leading cause of blindness, kidney failure, the amputation of the lower limbs and other long-term effects (who, 2016a). in this study, all of the patients with diabetes mellitus have a nursing-assessed risk of infection. the definition of risk of infection according to the indonesian nursing diagnosis standard is the risk of experiencing an increase in pathogenic organisms. one risk factor for nursing problems concerning the risk of infection is that it is a chronic disease (e.g. diabetes mellitus) (ppni, 2017). hyperglycemia and diabetes provide a higher risk of serious complications such as infection, diabetic ketoacidosis, hyperosmolar hyperglycemic states, dehydration, electrolyte balance, a greater use of antibiotics and increased hospitalization (crawford, 2013). the condition of hyperglycemia in patients with diabetes mellitus is thought to impair neutrophil function and the response of the t lymphocytes to infection (critchley et al., 2018). this is consistent with the complications of the disease found in the study, namely that 7.43% had hyperglycemia. another study states that diabetes mellitus patients are estimated to cause 6% of cases of infection associated with hospitalization and 12% of cases of infection-related deaths. they have a high susceptibility to all infections, especially bone and joint infections, sepsis and cellulitis (dewilde, harris, hosking, & cook, 2018). patients with diabetes mellitus are at risk of developing hypoglycemia or hyperglycemia. according to the indonesian nursing diagnosis standards, the definition of instability in blood glucose levels is the variation in blood glucose levels up / down from the normal range. in this study, the complications of hyperglycemia were found to total 7.43% while hypoglycemia totaled 3.72%. age, being of african-american ethnicity, having had diabetes for longer, insulin therapy, therapy with oral antidiabetic agents, macroalbuminuria, inadequate physical activity, and genetic factors are the risk factors of hypoglycemia. elderly patients have a higher risk of hypoglycemia due to factors such as the side effects of treatment, poor nutrition, cognitive impairment, kidney failure, autonomic dysfunction, and long-term dm (teixeira & cassia, 2017). the research sample obtained data stating that those aged 50 to 90 years old made up 82% of the sample. the complications of chronic kidney failure were found to total 4.46%, diabetic nephropathy totaled 4.09% and acute kidney injuries totaled 1.49%. the intermediate risk factors for hyperglycemia include being aged 45 years old over, having a body weight above normal, genetic heredity, doing physical activity less than 3 times a week, having gestational diabetes, giving birth to a baby more than 9 lb, and having polycystic ovary syndrome (piccinini, 2020). the indonesian nursing diagnosis standard defines the risk of a decrease in cardiac output as the risk of experiencing inadequate heart pumping compared to the body's metabolic needs with the risk factors for afterload changes, changes in heart frequency, changes in heart rhythm, changes in contractility or changes in preload involved (ppni, 2017). cardiac output, which is the volume of blood pumped by the heart per minute, is the result of heart rate and stroke volume which is affected by preload, afterload and contractility (ribeiro et al., 2016). the heart rate/rhythm is controlled by the depolarization rate of the sinoatrial node which can be modified by hormones (epinephrine, thyroxine), the electrolyte concentration in the plasma, body temperature, the autonomic nervous system and atrial wall stretching. preload is associated with ventricular filling pressure at maximum stretching and it is influenced by the end-diastolic volume of the ventricles and the frank-starling mechanism. afterload refers to blood pressure or resistance at the time of ventricular ejection (melo et al., 2011). the result obtained in this study shows that 10.41% of the sample had complications from hypertension, 3.72% had complications from acute decompensated heart failure, 1.49% had complications from hypertensive heart disease, 0.37% had complications from an acute myocardial infarction, 0, 37% had ischemic cardiomyopathy and 0.37% had complications from multiple premature atrial contractions. the risk of cerebral perfusion is not effectively defined as a risk of decreased blood circulation to the brain (ppni, 2017). type 2 diabetes mellitus affects the circulation of glucose and insulin across the blood-brain barrier. this results in changes in the regional metabolism and microcirculation (jansen et al., 2016). increased insulin resistance is an important risk factor for decreased cerebral blood flow and the pattern of cerebral hypoperfusion in patients with type 2 diabetes mellitus is similar to the pattern in the early stages of dementia (cui et al., 2016). the condition of hyperglycemia persisting for a long time can reduce the regional blood flow and increase membrane permeability which results in permanent damage to brain cells (jansen et al., 2016). in line with this study, the data indicated that 7.43% of the study sample had stroke complications. the risk of electrolyte imbalance is defined as the risk of experiencing changes in serum electrolyte levels with one of the risk factors being an interference with the regulatory mechanisms (e.g. diabetes) (ppni, 2018). electrolyte disturbances can occur in patients with decompensated diabetes mellitus including as a result of complex regimen therapy, being elderly and having a kidney disorder (liamis et al., 2014). diuretic therapy in patients with diabetes mellitus can cause hyponatremia (woyesa, gebisa, & anshebo, 2019) and hypokalemia, whereas hyperkalemia can result from a shift in potassium due to hypertonicity, insulin deficiency, cell lysis (rhabdomyolysis), acidosis, drugs (e.g. beta-blockers) and excretion disorders related to kidney potassium (woyesa et al., 2019). other studies have suggested that abnormal potassium values are caused by insulin treatment (woyesa et al., 2019). this study found the number of patients with hypokalemia made up 2.97%, while hyperkalemia made up 1.49% and hyponatremia made up 0.74%. w. p. sudarmaji et al. 484 | pissn: 1858-3598  eissn: 2502-5791 conclusion referring to the nursing problems among the inpatients with diabetes mellitus, the most commonly found problems following the terminology of the sdki include the risk of infection, the instability of the patient’s blood glucose levels and the risk of decreased cardiac output. nursing problems were found to adequately describe the human response to the diabetes mellitus as indicated by the study sample. the use of standard terminology when writing up the nursing problems is necessary for uniformity, to improve accuracy and to avoid ambiguity. the limitation of this research is that the data retrieval was done retrospectively, as the researchers did not have the opportunity to validate the data on the major signs and symptoms of the nursing problems with the patients. the implication of this research is the necessity of assisting the nurses in terms of identifying the nursing problems that arise in patients with diabetes mellitus. references american diabetes association. (2018). economic costs of diabetes in the u.s. in 2017. care diabetes journals, 1–12. https://doi.org/10.2337/dci18-0007 carmona, e. v., lima, m. h., & araujo, e. p. (2013). nursing diagnoses of diabetic patient medical charts : a descriptive study nursing diagnoses patient medical descriptive study of diabetic charts : a. online brazilian journal of nursing, (january). https://doi.org/10.5935/1676-4285.20133894 crawford, k. (2013). guidelines for care of the hospitalized patient with hyperglycemia and diabetes diabetes hyperglycemia diabetes medications insulin hypoglycemia. critical care nursing clinics of na, 25(1), 1–6. https://doi.org/10.1016/j.ccell.2012.11.001 critchley, j. a., carey, i. m., harris, t., dewilde, s., hosking, f. j., & cook, d. g. (2018). glycemic control and risk of infections among people with type 1 or type 2 diabetes in a large primary care cohort study. 41(october), 2127–2135. https://doi.org/10.2337/dc18-0287 cui, y., liang, x., gu, h., hu, y., zhao, z., & yang, x. (2016). cerebral perfusion alterations in type 2 diabetes and its relation to insulin resistance and cognitive dysfunction. brain imaging and behavior. https://doi.org/10.1007/s11682-016-9583-9 decroli, e. (2019). diabetes melitus tipe 2 (1st ed.). padang: pusat penerbitan bagian ilmu penyakit dalam fakultas kedokteran universitas andalas. dewilde, s., harris, t., hosking, f. j., & cook, d. g. (2018). risk of infection in type 1 and type 2 diabetes compared with the general population : a matched cohort study. diabetes care, 2045(1), 1–9. https://doi.org/10.2337/dc17-2131/-/dc1. jansen, j. f. a., buss, f. c. g. van, haar, h. j. van de, matthias, j. p., hofman, p. a. m., boxtel, m. p. j. van, … backes, w. h. (2016). cerebral blood flow , blood supply , and cognition in type 2 diabetes mellitus. scientific reports, (february), 1–9. https://doi.org/10.1038/s41598-016-0003-6 kemenkes. (2014). situasi dan analisis diabetes. jakarta selatan: pusat data dan informasi kementerian kesehatan ri. kementerian kesehatan ri. (2018). hasil utama riskesdas 2018. badan penelitian dan pengembangan kesehatan. kementerian kesehatan ri. (2019). infodatin hari diabetes sedunia tahun 2018. pusat data dan informasi kementerian kesehatan ri. liamis, g., liberopoulos, e., barkas, f., elisaf, m., liamis, g., liberopoulos, e., & barkas, f. (2014). diabetes mellitus and electrolyte disorders. world journal of clinical cases, 2(10), 488–497. https://doi.org/10.12998/wjcc.v2.i10.488 malone, m. (2014). the effect of diabetes mellitus on costs and length of stay in patients with peripheral arterial disease undergoing vascular surgery. european journal of vascular & endovascular surgery, 48(4), 447–451. https://doi.org/10.1016/j.ejvs.2014.07.001 melo, r. p. de, ven, m., oliveira, d., araujo, t. l. de, de, l., silva, f., … moorhead, s. (2011). risk for decreased cardiac output : validation of a proposal for nursing diagnosis. british association of critical care nurses, 16(6). https://doi.org/10.1111/j.14785153.2011.00453.x okur, m. e., karantas, i. d., hospital, h. g., & siafaka, p. (2017). diabetes mellitus : a review on pathophysiology , current status of oral diabetes mellitus : a review on pathophysiology , current status of oral medications and future perspectives. acta pharmaceutica sciencia, (april). https://doi.org/10.23893/1307-2080.aps.0555 perkeni. (2015). konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. in pengurus besar perkumpulan endokrinologi indonesia (pb perkeni) (vol. 1). https://doi.org/10.1017/cbo9781107415324.004 piccinini, c. j. (2020). development of type 2 diabetes mellitus in people with intermediate hyperglycemia. (april), 48–49. https://doi.org/10.1097/nur.0000000000000504 ppni. (2017). standar diagnosis keperawatan indonesia : definisi dan indikator diagnostik (edisi 1). jakarta selatan: dpp ppni. ppni. (2018). standar intervensi keperawatan indonesia : definisi dan tindakan keperawatan (1, ed.). jakarta selatan: dpp ppni. ribeiro, e., lopes, c. t., lucia, v., maria, r., lucia, a., & leite, b. (2016). risk factors for decreased cardiac output after coronary artery bypass grafting : a prospective cohort study. https://doi.org/10.1177/1474515116681373 sutoto. (2019). standar nasional akreditasi rumah sakit (1.1). jakarta selatan: komisi akreditasi rumah sakit (kars). teixeira, a. m., & cassia, r. de. (2017). risk factors for unstable blood glucose level : integrative review of the risk factors related to the nursing diagnosis. rev. jurnal ners http://e-journal.unair.ac.id/jners | 485 latino-am. enfermagem, 25(e2893). https://doi.org/10.1590/1518-8345.1688.2893 who. (2016a). diabetes fact sheet. diabetes fact sheet, (april), 17–19. who. (2016b). global report on diabetes. who library cataloguing-in-publication data global. woyesa, s. b., gebisa, w. c., & anshebo, d. l. (2019). assessment of selected serum electrolyte and associated risk factors in diabetic patients. dove press journal, 12, 2811–2817. 217 penurunan perilaku berisiko tertular hiv pada kuli bangunan dengan pendekatan behaviour change communication (bcc) (decrease risk behavior hiv infected on construction laborers with behavior change communication (bcc) approach) purwaningsih*, nasronudin**, nuzul qur’aniati*, ferry efendi* *fakultas keperawatan universitas airlangga, kampus c unair. jl mulyorejo surabaya, **lembaga penyakit tropis universitas airlangga, surabaya e-mail : purwaningsih1@gmail.com abstrak pendahuluan: persentase jumlah kasus hiv-aids berdasarkan jenis pekerjaan di jawa timur pada tahun 2011 menunjukkan bahwa kuli bangunan menduduki kelompok peringkat lima besar dengan jumlah 249 orang (31%) setelah kelompok pekerja seks komersil (psk). tujuan dari penelitian ini adalah mengetahui efektivitas pendekatan bcc terhadap penurunan perilaku berisiko tertular hiv pada para kuli bangunan. metode: penelitian ini merupakan penelitian riset operasional disertai penilaian sebelum dan sesudah pemberian intervensi. pada penelitian ini dilakukan pengukuran efektivitas perubahan perilaku para kuli bangunan terhadap pencegahan penularan hiv, yaitu dengan membandingkan perilaku dari para kuli bangunan sebelum dan sesudah diberikan intervensi. subjek dari penelitian ini adalah 150 orang kelompok risiko para kuli bangunan yang bekerja dan tersebar di wilayah kota surabaya. penelitian ini dilakukan 3 tahap yaitu, tahap penelitian preintervensi, tahap penelitian intervensi dan tahap penelitian post intervensi, yang dilaksanakan selama 2 tahun. pada tahun pertama dilaksanakan tahap praintervensi dan tahun kedua dilaksanakan tahap intervensi dan post intervensi. hasil penelitian ini menunjukkan sebanyak 72% kuli bangunan pada usia produktif, yaitu 18–35 tahun dan terdapat 38% lebih dari satu bulan sekali mengunjungi keluarganya. hasil: terdapat 20% kuli bangunan yang pernah melakukan hubungan seks dengan pekerja seks komersial dan tidak ada yang menggunakan narkoba. sebesar 50% kuli bangunan tidak pernah mendapatkan informasi hiv/aids dan sebanyak 48% tidak pernah memanfaatkan layanan hiv/aids. diskusi: motivasi eksternal kuli bangunan berhubungan dengan perilaku pemanfaatan layanan hiv/aids dengan korelasi cukup. motivasi eksternal kuat dipengaruhi oleh perilaku berisiko hiv/aids yang dilakukan dan keinginan mendapatkan bantuan. motivasi eksternal lemah dipengaruhi oleh kurangnya paparan informasi terkait layanan hiv/aids. hasil fgd dari stakeholder adalah mempunyai persepsi yang sama jika kuli bangunan adalah kelompok risiko tinggi tertular hiv. sebagian besar kuli bangunan belum mempunyai pengetahuan yang cukup terkait pencegahan penularan hiv karena tidak mempunyai akses pada pelayanan hiv dan terdapat perilaku berisiko tertular hiv pada kuli bangunan. kata kunci: pekerja bangunan, behavior change communication, perilaku abstract introduction: percentage of hiv-aids cases based on the types of work in east java in 2011 shows that construction workers occupied ranks the top five ranked groups with 249 people (31%) after a group of commercial sex workers (csws) group. the purpose of this study was to determine the effectiveness of bcc approach to the reduction of contracting hiv risk behavior in the construction laborers. method: this study used operational research design. in this study measures the effectiveness of behavior change of construction workers on the prevention of hiv transmission by comparing the behavior of the construction workers before and after the intervention. the subjects of this study were 150 people risk group of construction workers who work and are spread throughout the city of surabaya. this research was carried out into three phases, namely, phase preintervention research, intervention research, and post-intervention phase of the study. implemented in the first year and second year praintervensi stage implemented intervention and post-intervention phases. result: the results of this study showed that 72% of construction workers is productive (18–35 years) and visit his family more than once a month (38%). there is 20% of construction workers had sex with commercial sex workers and no one was using drugs. by 50% of construction workers never get information about hiv/aids and as many as 48% never use the services of hiv/aids. discussion: external motivation construction workers associated with the utilization of behavioral hiv/aids services with sufficient correlation. strong external motivation is influenced by risk behaviors of hiv/aids were conducted and the desire to get help. weak external motivation is influenced by a lack of exposure to information related to hiv/aids services. the results of the fgd stakeholders have the perception is the same if a construction worker is a high risk group of contracting hiv. most of the construction workers not have enough knowledge for the prevention of hiv transmission because they do not have access to hiv care and behavior are at risk of contracting hiv by construction workers. keywords: construction workers, behavior change communication, behavior 218 jurnal ners vol. 9 no. 2 oktober 2014: 217–225 pendahuluan berdasarkan data dari dinas kesehatan jawa timur 2011 jumlah orang yang terinfeksi hiv di jawa timur hingga september 2011 adalah mencapai 11.069 (40%) untuk hiv + dan 5.091 (18,8%) untuk aids (ditjen pp & pl kemenkes ri, 2012) 15 agustus 2012. berdasarkan jumlah aids tersebut menjadikan jawa timur menduduki peringkat ke empat setelah dki jaya, jawa barat, dan papua. persentase jumlah kasus hiv/aids berdasarkan jenis pekerjaan di jawa timur pada tahun 2011 menunjukkan bahwa kuli bangunan menduduki kelompok peringkat lima besar dengan jumlah 249 orang (31%) setelah kelompok pekerja seks komersil (psk). melihat data di atas, ke depan propinsi jawa timur akan benar-benar booming kasus hiv dan aids karena hiv sudah masuk ranah publik yaitu lingkungan rumah tangga. survei awal yang telah kami lakukan pada desember 2011 terhadap 50 orang kuli bangunan di surabaya (yang kami ambil secara acak) menunjukkan bahwa 12% berasal dari surabaya, 62% berasal dari luar kota surabaya masih dalam area jawa timur dan 26% berasal dari jawa tengah. frekuensi para kuli bangunan bertemu keluarga setiap 2 minggu sekali sebanyak 36% orang kuli bangunan, bertemu keluarga 1 bulan sekali sebanyak 26% , dan bertemu keluarga lebih satu bulan sebanyak 16%. sebanyak 44% kuli bangunan menyatakan belum pernah mendapatkan informasi mengenai hiv dan mereka juga tidak dapat mengakses informasi dari media masa karena tidak tersedia di tempat kerjanya. tiga orang dari para kuli bangunan tersebut mengatakan jika ada temannya yang meninggal karena terkena aids. berdasarkan pengamat an kami, d ar i 7 tempat k uli bangunan bekerja terdapat 2 warung yang berlokasi di sekitar tempat kerja kuli bangunan yang menyediakan wanita pekerja seksual (wps) untuk menjajakan diri pada para kuli bangunan. pada data tersebut menunjukkan bahwa para kuli bangunan juga rentan terpapar hiv karena situasi dan kondisi di lingkungan tempat kerjanya. para kuli bangunan tersebut tidak ha membutuhkan informasi mengenai hiv tetapi juga membutuhkan pendampingan agar mampu mengubah perilakunya sehingga tidak terpapar hiv atau mengakses layan hiv jika melalukan perilaku berisiko. salah satu upaya yang sudah dilakukan dalam menurunkan angka kesakitan dan kematian dari program penanggulangan hiv/aids adalah melakukan pencegahan dan pendidikan terhadap kelompok berisiko. unt u k mendu k ung program yang telah dilakukan baik oleh pemerintah maupun swasta, salah satunya yang harus dilakukan adalah dengan menggunakan pendekatan behaviour change communication (bcc). da la m kont ek s e pide m i a i ds, bcc merupakan bagian penting dari program yang komprehensif yang mencakup layanan (medis, sosial, psikologis, dan spiritual) dan komoditas (misalnya: kondom, jarum suntik). sebelum individu dan komunitas dapat mengurangi tingkat risiko atau mengubah perilaku mereka, mereka harus terlebih dahulu memahami fakta dasar tentang hiv dan aids, mengadopsi sikap kunci, belajar satu set keterampilan dan diberikan akses ke produk dan layanan yang sesuai. mereka juga harus melihat lingkungan mereka sebagai pendu k u ng per ubahan perilaku dan pemeliharaan perilaku yang aman, serta mendukung mencari pengobatan yang tepat untuk pencegahan, perawatan dan dukungan. bcc yang efektif sangat penting untuk pengaturan irama untuk intervensi sesuai dan bertanggung jawab. hal ini juga dapat menghasilkan wawasan yang lebih luas terhadap dampak sosial ekonomi dari epidemi dan memobilisasi pada politik, sosial dan ekonomi yang diperlukan untuk meningkatkan program yang lebih efektif. bcc yang diterapkan dalam upaya penurunan kuli bangunan diharapkan dapat meningkatkan pengetahuan tentang hiv dan meningkatkan kesadaran perilaku kuli bangunan dalam mencari akses tentang pelayanan kesehatan dan informasi terkait dengan screening hiv dengan tujuan akhir dapat menurunkan risiko tertularnya hiv pada pekerja kuli bangunan yang merupakan kelompok risiko. 219 penurunan perilaku berisiko tertular hiv (purwaningsih, dkk.) bahan dan metode penelitian ini merupakan penelitian riset operasional disertai penilaian sebelum dan sesudah pemberian intervensi. pada penelit ia n i n i dila k u ka n peng u k u r u a n efektivitas per ubahan perilaku para kuli bangunan terhadap pencegahan penularan hiv, yaitu dengan membandingkan perilaku dar i para k uli bang u nan sebelu m dan sesudah diberikan intervensi. penelitian ini dilaksanakan 2 tahun, yang mencakup tahun pertama dilakukan identifikasi faktor-faktor yang berhubungan dengan perilaku tertular hiv. setelah dilakukan uji coba program, dilakukan penerapan program bcc terhadap para kuli bangunan yang sebelumnya diukur tentang perilakunya terhadap pencegahan penularan hiv. pada akhirnya penelitian ini dapat menghitung efektivitas perubahan perilaku yang terjadi pada para kuli bangunan setelah dilakukan intervensi bcc dengan cara membandingkan sebelum dan sesudah intervensi. penelitian ini akhirnya mempunyai dampak terhadap strategi penurunan penularan hiv pada para kuli bangunan, pada penelitian tahun kedua. penelitian ini dilaksanakan dengan tiga tahap penelitian yaitu, tahap praintervensi, intervensi dan post intervensi. penelitian ini dilaksanakan mulai tahun 2013 sampai dengan 2014. subyek dari penelitian ini adalah 150 orang kelompok risiko para kuli bangunan yang bekerja dan tersebar di wilayah kota surabaya. rekrutmen dilakukan pada beberapa tempat yang sedang melakukan pembangunan skala besar dengan jumlah kuli bangunan lebih dari 50 orang dan besar sampel ditentukan dengan metode purposive sampling. data dikumpulkan menggunakan kuesioner dan wawancara oleh peneliti setelah responden menandatangani informed consent, kemudian dilakukan focus group discussion (fgd) yang membahas tentang perbaikan program pencegahan hiv-aids pada kelompok kuli bangunan dengan stakeholder. analisis data yang digunakan adalah analisis kuantitatif dan kualitatif. hasil pertemuan pertama dengan agenda melakukan pelaksanaan behavior change communication mulai dari tahap i sampai tahap ii. tahap i yaitu menentukan tujuan. tujuan umum yang disepakati dalam upaya menu r u n ka n per ila k u ber isi ko a d ala h memberikan pemahaman pada para kuli bang unan agar tidak ter t ular hiv dan bersedia menggunakan layanan hiv-aids jika sudah melakukan perilaku berisiko. pelaksanaan penentuan tujuan ini dilakukan bersama dengan kepala divisi keselamatan dan kesehatan kerja (k3) officer proyek pembangunan, dan perwakilan dari kuli bangunan. pelaksanaan kegiatan disepakati dilakukan seminggu sekali pada saat kegiatan safety talk. ta hap ke du a a d ala h mel ibat k a n stake holders. pelaksanaan bcc di proyek pembangunan melibatkan pihak kementerian pekerjaan umum provinsi jawa timur, tim vct (voluntary, counseling, and testing) dan konselor dari upipi rsu dr. soetomo surabaya, kontraktor pp-gng-bli, tim keselamatan dan kesehatan, super visor atau mandor dari pekerja bangunan. hasil pertemuan ini adalah mempunyai persepsi yang sama jika para pekerja bang unan mempunyai faktor risiko tertular hiv. tahap ketiga adalah mengidentifikasi sit uasi dan kondisi para kuli bangunan terhadap risiko penularan hiv. hasil fgd yang dilakukan populasi yang diusulkan adalah pekerja bangunan dan beberapa staf dari pihak manajemen kontraktor. namun kemudian keputusan akhir yang disepakati adalah target populasi utama pelaksanaan bcc adalah pekerja karena termasuk kelompok yang memiliki risiko terinfeksi hiv-aids. agenda utama pada pertemuan kedua adalah melakukan bcc tahap iv sampai tahap vi. tahap keempat adalah mengidentifikasi faktor-faktor yang terkait dengan program bcc. identifikasi secara kualitatif dilakukan melalui fgd denga n sta k eholder d a n identifikasi faktor berisiko meliputi faktor 220 jurnal ners vol. 9 no. 2 oktober 2014: 217–225 demog raf i, per masalahan terk i ni yang dihadapi pekerja bangunan terkait dengan hiv-aids, yang mencakup: situasi yang berisiko, persepsi dan perilaku yang berisiko, stigma dan pelayanan kesehatan. tahap kelima adalah menentukan kuli bangunan yang berisiko tertular hiv. segmen target populasi dilakukan pada seluruh kuli bangunan dengan jumlah sampel 150 orang. penentuan kuli bangunan yang berisiko tertular hiv adalah para kuli bangunan yang telah melakukan perilaku berisiko tertular hiv. tahap keenam adalah menentukan indikator pencapaian perubahan perilaku gambar 1: distribusi responden berdasarkan sumber informasi hiv-aids yang pernah diterima kuli bangunan di proyek pembangunan di wilayah surabaya. gambar 2: distribusi responden berdasarkan pernah atau tidak melakukan seks bebas oleh kuli bangunan di proyek pembangunan di wilayah surabaya tabel 1: hubungan antara motivasi eksternal dengan pemanfaatan layanan hiv-aids pada kuli bangunan di proyek pembangunan di wilayah surabaya motivasi eksternal indikator pemanfaatan layanan hiv/aids totalya akan tidak akan n % n % n % kuat 19 38 6 12 25 50 lemah 7 14 18 36 25 50 total 26 52 24 48 50 100 spearman rho p = 0,000 r = 0,480 para kuli bangunan. indikator pencapaian perubahan yang diharapkan antara lain a) tidak melakukan hubungan seks bagi mereka yang belum menikah, b) tidak menggunakan jasa pekerja seks komersial, c) peningkatan praktik safer sex dengan menggunakan kondom dan d) mengurangi stigma terkait dengan hivaids. berdasarkan gambar 1 dan 2 ditemukan bahwa 50% kuli bangunan tidak pernah mendapatkan informasi terkait penularan hiv dan 20% mengatakan pernah melakukan hubungan seks bebas. berdasarkan tabel 1 dapat diketahui bahwa hasil uji statistik 221 penurunan perilaku berisiko tertular hiv (purwaningsih, dkk.) tabel 2: hubungan antara motivasi internal dengan pemanfaatan layanan hiv-aids pada pekerja bangunan di proyek pembangunan di wilayah surabaya. motivasi internal indikator pemanfaatan layanan hiv-aids totalya akan tidak akan n % n % n % kuat 19 38 9 18 28 56 lemah 7 14 15 30 22 44 total 26 52 24 48 50 100 spearman rho p = 0,011 r = 0,358 menggunakan spearman rho dengan nilai signifikansi p = 0,000 dan lebih kecil dari p yang ditetapkan yaitu < 0,05 (h1 diterima) dan nilai korelasi 0,480 didapatkan kategori cukup. hal ini menunjukkan bahwa terdapat hubungan antara motivasi eksternal dengan pemanfaatan layanan hiv/aids pada kuli bangunan dengan korelasi positif, yaitu semakin tinggi motivasi eksternal responden maka semakin kuat pula keinginan mereka untuk memanfaatkan layanan hiv/aids. motivasi eksternal kuat menyebabkan 19 responden (38%) menyatakan bersedia s e d a ng k a n mot iva si ek s t e r n a l le m a h menyebabkan 18 responden (36%) menyatakan tidak bersedia memanfaatkan layanan hiv/ aids. berdasarkan data di atas diperlukan sosialisasi kepada para kuli bangunan tentang jenis layanan yang ada dan tujuannya mengapa harus memanfaatkan layanan hiv-aids. berdasarkan tabel 2 dapat diketahui bahwa dari hasil uji statistik menggunakan spearman rho dengan nilai signifikansi p = 0,011 lebih kecil dari p yang ditetapkan yaitu < 0,05 (h1 diterima) dan nilai korelasi 0,358 didapatkan kategori kekuatan korelasi rendah. hal ini menunjukkan bahwa ada hubungan antara motivasi internal dengan pemanfaatan layanan hiv-aids pada kuli bangunan dengan korelasi positif, yait u semakin tinggi motivasi internal responden maka semakin kuat pula keinginan mereka untuk memanfaatkan layanan hiv-aids. motivasi internal kuat menyebabkan 19 kuli bangunan (38%) menyatakan bersedia, sedangkan motivasi internal lemah menyebabkan 15 kuli bangunan (30%) menyatakan tidak bersedia memanfaatkan layanan hiv-aids. hal tersebut menunjukkan bahwa motivasi yang sudah ada dalam diri responden sangat mempengar uhi keinginan mereka untuk memanfaatkan layanan hiv-aids. pembahasan jika para k uli bang u nan tersebut melakukan perilaku berisiko tertular hiv pada tidak hanya berdampak pada dirinya tetapi juga pada keluarganya dan juga masyarakat. menurut social learning/social cognitive theory, perubahan perilaku ditentukan oleh lingkungan, personal dan elemen-elemen perilaku (bandura, 1977 dalam hurst, 2012 ). masing-masing faktor saling mempengaruhi satu dengan lainnya. faktor lingkungan dalam hal ini apakah tempat bekerja kuli bangunan dekat dengan wilayah lokalisasi atau di sekitar tempat kerjanya ada tempat mangkal para pekerja seks komersial. pada penelitian ini juga ditemukan warung yang menyediakan pekerja seks komersial sehingga para kuli bangunan juga terpapar oleh perilaku berisiko tertular hiv. faktor usia juga merupakan hal penting dalam menentukan sikap seseorang, dalam penelitian ini juga menunjukkan semakin tinggi usia responden maka mempunyai sikap yang positif terhadap perilaku berisiko tertular hiv dan bersedia untuk menggunakan layanan hiv-aids jika melakukan faktor berisiko (international labour organization 2008). tetapi masih ada, meskipun dalam jumlah kecil, para responden yang berusia dewasa tua tetapi mempunyai sikap negatif terhadap perilaku berisiko penularan hiv dan tidak bersedia menggunakan layanan hivaids jika sudah melakukan perilaku berisiko tertular hiv. 222 jurnal ners vol. 9 no. 2 oktober 2014: 217–225 bagi responden yang telah berstatus menikah, sebagian besar memiliki motivasi internal yang kuat dalam berperilaku dan mengg unakan layanan hiv-aids yang tersedia. menu r ut theor y of reasoned ac t i o n i n d i v i d u m e ny a t a k a n b a h w a mempertimbangkan konsekuensi dari perilaku yang diterapkan sebelum melakukan perilaku yang bar u (bandura, 1977 dalam hurst, 2012 ). hasil penelitian ini sesuai dengan teori tersebut sehingga para responden yang berstatus menikah akan berpikir panjeng jika akan melakukan perilaku berisiko tertular hiv. pada penelitian ini pula masih sedikit terdapat responden yang sudah menikah tetapi memiliki motivasi internal yang lemah, sehingga masih juga melakukan perilaku berisiko tertular hiv. kondisi ini merupakan salah satu penyebab penularan hiv terus meningkat pada ranah keluarga. faktor yang juga sangat mempengaruhi perilaku tersebut karena pendidikan yang rendah serta kurangnya mendapat informasi terkait masalah hiv-aids. sebagian besar responden berasal dari luar kota surabaya dan dapat menemui keluarganya satu bulan sekali. para responden melakukan hal ini karena sebagai tanggung jawab kepala keluarga untuk memenuhi kebutuhan keluarga sehingga harus bekerja di luar kota. sedangkan faktor ekonomi merupakan alasan mengapa baru bisa menemui keluarganya satu bulan sekali. mobilitas tinggi berarti jangka waktu lama jauh dari pasangan dan keluarga, isolasi, kesepian, akses ke alkohol (dan obat lain) dan akses ke pekerja seks merupakan faktor pendukung perilaku seksual berisiko yang membahayakan pekerja, pasangan dan keluarganya (hdn, iom, and phamsa, 2006). kuli ba ng u na n mer upa ka n sala h satu sektor pekerjaan yang masuk ke dalam kategori mobile migrant population, sering ber pindah-pindah dan menetap di suatu tempat, jauh dari pasangan atau keluarga, serta pada umumnya kurang informasi mengenai hiv-aids (mutia, 2008). peningkatan risiko untuk infeksi hiv pada populasi migrasi telah dikaitkan dengan meningkatnya risiko terkait dengan seks. hasil penelitian menunjukkan bahwa responden yang frekuensinya pulang ke rumahnya satu bulan sekali bisa memiliki motivasi internal dan eksternal yang lemah sehingga melakukan perilaku berisiko tertular hiv. perubahan perilaku para kuli bangunan pada situasi tersebut, kita bisa menggunakan pendekatan social learning/social cognitive theory yaitu perubahan perilaku ditentukan oleh lingk ungan, personal dan elemenelemen perilaku. masing-masing faktor saling mempengaruhi satu dengan lainnya. para kuli bangunan harus diberikan informasi terkait masalah jika tertular hiv serta dibantu untuk dapat mengakses layanan hiv-aids yang sudah tersedia. distribusi motivasi eksternal pekerja bangunan dengan indikator kuat dan lemah memiliki jumlah yang sama. motivasi adalah keadaan dalam pribadi seseorang yang mendorong keinginan individu melakukan kegiatan ter tentu untuk mencapai suatu tujuan. motivasi pada diri seseorang akan mewujudkan perilaku yang diarahkan untuk mencapai kepuasan (ariani, 2011). purba (2009) menyatakan bahwa motivasi adalah psikologis dalam diri seseorang yang muncul oleh karena adanya dorongan untuk memenuhi kebut u han ter tent u. motivasi ekster nal merupakan aktivitas yang dilakukan untuk memperoleh suatu hasil ter tentu namun terpisah dari aktivitas itu sendiri, misalnya u nt u k mend apat k a n peng ha rga a n d a n menghindari hukuman, serta meningkatkan penghargaan diri (zycinska et al., 2012). responden akan memanfaatkan layanan hiv-aids terkait dengan seberapa tinggi motivasi eksternal mereka untuk mencari bantuan dari perilaku berisiko hiv-aids yang telah dilakukan. responden dengan motivasi eksternal kuat dipengaruhi oleh beberapa faktor dari luar antara lain karena mereka ingin mendapatkan bantuan dalam penyelesaian masalah, dapat berbagi pengalaman, dapat melakukan konsultasi, dan keinginan mereka untuk mendapatkan dukungan jika terdiagnosa hiv positif. selain itu juga dipengaruhi oleh perilaku teman sebaya atau sesama pekerja bangunan. mot iva si ek st e r n al le m a h d apat dipengaruhi oleh kondisi kurangnya paparan 223 penurunan perilaku berisiko tertular hiv (purwaningsih, dkk.) informasi tentang layanan hiv-aids dari pihak k3 dan pimpinan proyek. responden juga belum pernah mendapatkan informasi baik dari media masa, tenaga kesehatan, maupun penyuluhan tentang hiv-aids. selain itu, motivasi eksternal lemah dalam penelitian ini dapat terlihat dari persepsi mereka bahwa kondisi mereka akan baik-baik saja meskipun tidak menggunakan layanan hiv-aids. mereka merasa perilaku seks bebas yang telah dilakukan tidak akan dapat dihentikan, sehingga mereka tidak harus mengambil keputusan untuk memanfaatkan layanan ini. oleh karena itu diharapkan pihak proyek pembangunan memberikan pendidikan kesehatan terkait hiv-aids dan bagaimana cara untuk memanfaatkan fasilitas dalam layanannya. terdapat hubungan dengan korelasi cu k up a nt a r a mot iva si ek st e r nal d a n pema n fa at a n laya na n h i v-a i ds pad a pekerja bangunan. menurut notoatmodjo (2010), motivasi merupakan keinginan yang terdapat pada diri seseorang untuk melakukan perbuatan, tindakan, tingkah lak u atau perilaku. sedangkan menurut zhou et al. (2009), salah satu motivasi seseorang untuk datang ke layanan hiv-aids adalah persepsi perilaku berisiko tinggi yang telah dilakukan. menurut jereni dan muula (2008), salah satu alasan utama individu mencari layanan hivaids adalah persepsi pada risiko terinfeksi hiv. semakin tinggi persepsi seseorang terkait perilaku berisiko hiv-aids yang telah dilakukan, maka semakin kuat pula motivasi eksternal mereka untuk memanfaatkan layanan hiv-aids. motivasi internal dengan indikator kuat dimiliki oleh sebagian besar responden. motivasi internal kuat responden terlihat dari keyakinan mereka bahwa layanan hiv-aids ini akan memberikan hasil dan manfaat bagi mereka. selain itu menurut teori king et al. (2009) bahwa dorongan dalam diri untuk memanfaatkan layanan hiv-aids sebagai bentuk tanggung jawab terhadap anak dan pasangan seksual (istri) terkait perilaku berisiko yang dilakukan. responden yang memanfaatkan layanan hiv-aids dengan mot iva si i nter nal k u at denga n ala sa n sudah pernah melakukan seks tidak aman. pemeriksaan hiv-aids dilakukan dengan alasan agar responden yakin bahwa dirinya, istri, dan keluarga dalam keadaan sehat atau terbebas dari hiv-aids karena hal tersebut merupakan hal yang sangat penting bagi responden. individu yang berperilaku berdasarkan motivasi internal akan lebih bertahan dan terus termotivasi daripada individu yang berperilaku karena motivasi eksternal. motivasi internal paling dimungkinkan membuat efek dalam perubahan perilaku dibandingkan dengan motivasi eksternal (zycinska et al., 2012). namun, hasil penelitian ini menunjukkan bahwa motivasi eksternal memiliki hubungan dengan korelasi yang lebih kuat dibandingkan motivasi internal, yakni motivasi eksternal dengan signifikansi p = 0,480 dan motivasi internal dengan signifikansi p = 0,358, sehingga dapat disimpulkan bahwa motivasi eksternal lebih berpengaruh terhadap pemanfaatan layanan hiv-aids. hal ini disebabkan karena beberapa faktor dari luar seperti pengaruh teman sebaya, ketersediaan dan kemudahan mencapai sarana serta estimasi biaya yang akan dikeluarkan yang dapat mempengaruhi motivasi seseorang untuk melakukan suatu perilaku. pema n fa at a n laya na n h i v-a i ds tergantung pada bagaimana orang berisiko tinggi berpikir tentang manfaat yang diperoleh untuk mengatasi masalah kesehatan, terutama masalah yang berkaitan dengan hiv-aids. individu mungkin lebih mengutamakan keyakinan terhadap efektivitas suatu tindakan, bukan melihat secara obyektif terhadap efektivitas suatu tindakan yang diambil (purwaningsih et al., 2011). hasil penelitian menunjukkan terdapat separuh dari jumlah total responden yang menolak memanfaatkan layanan hiv-aids dengan alasan pemeriksaan ini memerlukan biaya yang mahal, sehingga menjadi hambatan dalam pemanfaatannya. faktor lain yang dapat memotivasi seseorang untuk datang ke layanan hiv-aids antara lain saat individu tersebut merasakan gejala h i v-a i ds, tela h mela k u k a n per ila k u berisiko hiv-aids, dan pengetahuan terkait hiv-aids dan layanannya yang baru saja 224 jurnal ners vol. 9 no. 2 oktober 2014: 217–225 didapatkan. beberapa hambatan antara lain individu takut dengan hasil tes yang positif, takut kehilangan pekerjaan atau keluarga, tak ut dengan prosedu r pemer iksaan di rumah sakit, khawatir seseorang mengetahui hasil tes dan tidak tersedianya waktu akibat kesibukan lain (zhou et al., 2009). sedangkan menurut sarwono (2007), ketersediaan sarana kesehatan, kemudahan mencapai sarana, tersedianya biaya dan kemampuan untuk mengatasi stigma dan jarak sosial juga menjadi pertimbangan seseorang untuk mencari upaya pengobatan. dari data dan tersebut dapat disimpulkan bahwa tingkat pendidikan tinggi tidak selalu disertai dengan motivasi yang kuat pula. namun banyak faktor lain juga yang memberikan pengaruh kuat terhadap seseorang. sa at d ila k sa na k a n nya pe nel it ia n didapatkan bahwa lebih dar i setengah responden memiliki motivasi eksternal dan internal kuat untuk memanfaatkan layanan hiv-aids. hal ini dikarenakan persepsi kuat mereka tentang perilaku berisiko hiv-aids yang telah dilakukan dan manfaat yang akan diperoleh dari layanan hiv-aids, sehingga meskipun mereka memiliki pengetahuan yang kurang terkait layanan hiv-aids ini, mereka akan tetap datang untuk mendapatkan bantuan. simpulan dan saran simpulan hasil penelitian ini dapat disimpulkan bahwa: 1) motivasi eksternal pekerja bangunan berhubungan dengan perilaku pemanfaatan layanan hiv-aids dengan korelasi cukup; 2) motivasi inter nal peker ja bang u nan berhubungan dengan perilaku pemanfaatan layanan hiv-aids dengan korelasi rendah; 3) sebag ia n b e s a r p eke r ja ba ng u n a n memiliki pengetahuan kurang terkait dengan pengetahuan risiko penularan hiv-aids; 4) sebagian besar pekerja bangunan memiliki sikap positif terkait dengan perilaku berisiko penularan hiv-aids; 5) sebagian besar pekerja bangunan memiliki perilaku yang baik tentang perilaku berisiko penularan hiv-aids dan ada yang melakukan perilaku berisiko tertular hiv; dan 6) perilaku pekerja bangunan dalam menggunakan layanan hivaids di surabaya sebagai sarana pencegahan hiv-aids mayoritas memiliki nilai kurang dan perilaku baik memiliki nilai minoritas. saran berdasar hasil penelitian ini saran yang diajukan adalah 1) bagian k3 proyek p e mba ng u n a n d i h a r apk a n lebi h r ut i n melaksanakan safety talks setiap sabtu sesuai jadwal sebelumnya dengan menambahkan mater i h i v-a i ds; 2) i nst it usi proyek pembangunan hendaknya dapat melakukan kerja sama dengan rumah sakit atau puskesmas setempat terkait penyediaan fasilitas pendukung safety talks sebagai salah satu bentuk kegiatan peningkatan motivasi pemanfaatan layanan hiv; 3) pekerja bangunan yang berada di proyek bangunan diharapkan mengikuti kegiatan sosialisasi tentang pengetahuan pencegahan risiko penularan hiv-aids di tempat kerja yang diadakan oleh petugas k3 dengan sukarela, sehingga dapat mencegah penyebaran risiko penularan hiv/aids; dan 4) bagian p2pl dinas kesehatan melakukan monitoring evaluasi program hiv-aids pada kuli bangunan melalui kerja sama lintas sektor dengan perusahaan konstruksi kepustakaan alebachew frehiwot. 2006. behavior change communication and the young responds. sale. ethiopia braun, v& clarke, v. 2006. using thematic analysis in psychology. qualitative research in psychology, p. 77-101. cullen trevor. 2009. health communication theories: implication for hiv reporting in asia and the pacific. usa. asia pacific media educator ditjen pp & pl kemenkes ri. 2012. angka kejadian hiv/aids di indonesia. kemenkes ri. tidak dipublikasikan. jakarta family health international institute for hiv/aids, 2004. behaviour change communication (bcc) for hiv/aids a strategy framework, arlington, usa. 225 penurunan perilaku berisiko tertular hiv (purwaningsih, dkk.) family health international. 2004. monitoring and evaluating beha vior change com m unication prog ra m s. usa: impact. international labour organization/family health international. 2008. hiv/aids behavior change communication. genewa. ilo knott, d. 2008. achieving culture change: a policy framework. prime minister’s strateg y unit, uk cabinet off ice, (online), (http://www.cabinetoffice. g o v. u k /s t r a t e g y/ ~ / m e d i a /a s s e t s / www.cabinetoff ice.gov.uk /strategy/ achieving _cult u re_change%20pdf. ashx. diakses tanggal 11june 2008) melissa hurst. 2012. social-cognitive learning theor y: def inition and examples. (o n li ne), ( ht t p://educat ion-por t al. com/academy/lesson/social-cognitivel e a r n i n g t h e o r y d e f i n i t i o n a n d examples.html#lesson . diakses pada tanggal 27 juni 2012) nih guide. 2003. maintenance of long term behavioral change, (online), (http:// grants.nih.gov/grants/guide/rfa-files/ rfa-ob-03-003.html. diakses tanggal 31october 2007) usaid, 2005. a guide to participator y m onitor ing of beh a vior ch a nge communication for hiv/aids. (online), (http://www.path.org. diakses tanggal, 14 september 2011) usaids. 2006. theories inform behavior c h a n g e c o m m u n i c a t i o n . u s a : usaids. http://e-journal.unair.ac.id/jners | 113 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18991 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review of the factors associated with cervical cancer screening uptake among women in low and middle-income countries elok faradisa, husna ardiana, diah priyantini, anis fauziah, inta susanti faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the high prevalence of cervical cancer is a global health problem. approximately 90% of deaths from cervical cancer occur in low and middle-income countries. this can be because of the awareness and uptake of cervical cancer screening services having remained poor in these countries. this review aims to explore the factors influencing cervical screening uptake among women in low and middle-income countries. methods: the studies were systematically identified by searching electronic databases with the keywords “cervical cancer and screening and low of income countries and middle of income countries.” the results consisted of 94 articles from scopus, 100 articles from science direct, 74 articles from ebsco, and 32 articles from pubmed. following this, 16 studies were included in this systematic review with the inclusion criteria being quantitative or qualitative studies exploring the factors influencing woman’s cervical cancer screening uptake covering women in lowand middleincome countries, a clear study outcome and details on the associated factors, barriers to, and facilitators of screening uptake. results: knowledge about the disease and its prevention, knowing someone with cervical cancer and someone who has ever been screened, attitude and perception, husband approval, advice from the health care providers, and the distance to health care service were all important factors related to cervical cancer screening uptake in low and middleincome countries. the uptake of cervical cancer screening services was poor in low and middle-income countries. there is a need to strengthen the knowledge and awareness of woman related to cervical cancer screening services. conclusion: the available evidence shows that intrapersonal and organizational factors are the most important factors that influence woman to undergo cervical cancer screening. article history received: feb 27, 2020 accepted: april 1, 2020 keywords cervical cancer; screening; low income countries; middle income countries contact elok faradisa  elok.faradisa-2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: faradisa, e., ardiana, h., priyantini, d., fauziah, a., & susanti, i. (2020). a systematic review of the factors associated with cervical cancer screening uptake among women in low and middle-income countries. jurnal ners, special issues, 113-119. doi:http://dx.doi.org/10.20473/jn.v15i2.18991 introduction the high prevalence of cervical cancer is a global health problem. it causes hundreds of thousands of deaths among women annually worldwide. with an estimated 570,000 cases and 311,000 deaths in 2018 worldwide, this disease ranks as the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women (bray et al., 2018). approximately 90% of deaths from cervical cancer occur in lowand middle-income countries (idowu, olowookere, fagbemi, & ogunlaja, 2016). cervical cancer is a malignant proliferation of the cells of the uterine cervix and it occurs when abnormal cells in the lining of the cervix grow in an uncontrolled way (donatus et al., 2019). this disease is potentially preventable and some effective screening programs can lead to reduced morbidity and mortality (schliemann et al., 2019). early detection and education to promote early diagnosis and the screening of cervical cancer greatly increase the chances of successful treatment and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. e. faradisa et al. 114 | pissn: 1858-3598  eissn: 2502-5791 survival (islam, billah, hossain, & oldroyd, 2017). one of the screening methods is a cytology-based approach. the beneficial effects of this program are that it has hastened the decline in cervical cancer rates upon its implementation in high-income countries (bray et al., 2018). this success has been attributed to greater access to healthcare, an increased uptake of cervical screening, and the increased awareness of screening practices among the women in these countries (ncube, bey, knight, bessler, & jolly, 2015). in contrast, in low and middleincome countries, this program can’t achieve a major impact in most settings because of the low screening uptake (liebermann, vandevanter, hammer, & fu, 2018). prior research in lowand middleincome countries has shown there to be several factors that are thought to affect the uptake of cervical cancer screening. based on the “ecological models” by mc leroy et al about the factors that affect health behavior, they can be divided into 5 levels. these levels are interpersonal and intrapersonal factors, community, organizational and policy-related (owen, heart, & fisher, 2008). the intrapersonal level describes an individual’s characteristics such as knowledge and attitude which influences behavior. the interpersonal level describes their interactions with the primary groups of family and friends. this provides social support related to their health behavior. the organizational level includes the rules or regulations (and the physician’s recommendations) that may constrain or modify their health behavior. the community level concerns the influence of social networks or the standards that exist either formally or informally among groups and organizations (e.g. acculturation). the policy-related level describes the existence of policies that support disease prevention and detection, control and management (e.g. health insurance) (chan & so, 2017). the objective of this systematic review was to explore the factors associated with the uptake of screening among women in lowand middleincome countries. these findings could be used to inform public policy and to develop and implement strategies to increase screening activities, thereby reducing the incidence, morbidity, and mortality of the disease. understanding the factors and facilitators with cervical cancer screening encountered by the women in low and middle-income countries can guide the government in conducting health sector efforts to increase the screening rate among the population. materials and methods literature search the literature review was employed according to the prisma guidelines. the database search was performed in january 2020 for articles dated in the last 10 years. the databases included scopus, ebsco, pubmed, and science direct. the following keywords were used alone or in combination: factors, cervical cancer, screening, low-income countries, middleincome countries. the limitations of the literature search were that they had been published in the last 10 years and english-only articles. once all of the articles were found, duplicate articles were removed. inclusion/exclusion criteria the criteria for inclusion in this review were as follows: (1) quantitative or qualitative studies exploring the factors influencing woman’s cervical cancer screening uptake; (2) studies covering women in lowand middleincome countries and (3) studies with the outcome related to the associated factors, barriers to, and facilitators of screening uptake. the criteria for exclusion included the following: (1) unpublished studies; (2) language used was not english and (3) outside of the limitation on publication, between 2011 2020. study selection figure 1. flowchart of the articles selected for the systematic review and the selection process using prisma (preferred reporting items for systematic reviews and meta-analyzes) data extraction the following information was extracted from the 16 articles: information on the demographics, study design, outcome measures, sample size, associated factors, barriers to and facilitators of the screening uptake, country and year of publication. results general features and types of study all 16 studies were published between 2012 and 2020 and they were conducted in low and middleincome countries. among these, 14 (88%) adopted quantitative and 2 (12%) adopted qualitative approaches. the target participants were women in the countries where the studies took place. they were grouped into 2 major categories: low-income jurnal ners http://e-journal.unair.ac.id/jners | 115 countries consisting of ethiopia (n=2), tanzania (n=2) and uganda (n=2) and middle-income countries consisting of cambodia (n=1), cameroon (n=1), indonesia (n=1), iran (n=1), jamaica (n=1), kenya (n=2) and nigeria (n=3). the sample size of the studies ranged from 82 to 9016, and the participants’ ages ranged from 15 to 69 years old. all of the studies (100%) that were included in this review reported that intrapersonal factors are associated with the uptake of cervical cancer screening. good knowledge about the disease and its prevention were found to be the most important factors in 8 (50%) articles. having good knowledge was a facilitator to get cervical cancer screening because it can make the women more aware and thus encourage them to undergo the screening intensively. four studies (25%) mentioned that attitude and perception about the screening are associated factors that influenced the women to undergo cervical cancer screening. having known somebody with cervical cancer or somebody who had undergone cervical cancer screening was a motivating factor for women to access screening in 5 (31.25%) studies. the interpersonal factor mentioned in 1 (6%) study in this review was husband approval. the support from the husband is a way of providing social support for the women to undergo cervical cancer screening. to increase the awareness and knowledge about cervical cancer screening, 1study (6%) mentioned that the community factors can be altered through the management and health promotion conducted using public events, media, religious communities and other civic society channels. the uptake of cervical cancer screening is associated with the organizational factors mentioned in 5 (31.25%) of the included studies. women found it difficult to present for screening when the health facilities were not nearby. being recommended to attend screening by the health care workers was a significant facilitator that was mentioned in 3 (18.75%) studies. women who had been recommended by a health-care-worker were more likely to have been screened for cervical cancer compared with women who had not advised. discussion intrapersonal factors the intrapersonal level describes an individual’s characteristics, such as knowledge and attitude, which influence their behavior. it was noticed that some of the factors were common among women in low and middle-income countries. these factors include knowledge about the disease and its prevention (ndikom & ofi, 2012; nigussie, admassu, & nigussie, 2019; orang’o et al., 2016; touch & oh, 2018), knowing someone with cervical cancer and knowing someone who has ever been screened (ncube et al., 2015; ndikom & ofi, 2012; nigussie et al., 2019), attitude and perception, level of education (anwar et al., 2018; weng, jiang, haji, nondo, & zhou, 2020), literacy and media exposure (tiruneh, chuang, ntenda, & chuang, 2017), fear about the result of the screening, awareness, belief, self-efficacy, and having a history of gynecological examination (donatus et al., 2019; idowu et al., 2016). knowledge about the disease and its prevention is the most important factor at the intrapersonal level. if women have information concerning cervical cancer severity, they may utilize the screening services. this may be due to their knowledge about cervical cancer clearing up any rumors about cervical cancer and increasing their awareness about the advantages of undergoing screening (nigussie et al., 2019). level of education was consistently associated with higher odds of having an awareness about the cervical cancer screening uptake (anwar et al., 2018). education level was found to be positively associated with level of knowledge which means that a lack of knowledge could be due to the low education level and the low coverage of cancer awareness initiatives in the country (weng et al., 2020). some evidence shows that knowing someone who has ever been screened for cervical cancer is associated with cervical cancer screening service utilization. women who know someone who has ever screened been were more likely to undergo cervical cancer screening themselves when compared with women who do not know someone who has been screened for cervical cancer (nigussie et al., 2019). this result is consistent with the study done in uganda. this might be due to the screened women discussing it with unscreened women, focusing on the screening service-procedure and the time that it takes. this will decrease the fear of the women towards undergoing screening (ndejjo, mukama, kiguli, & musoke, 2017). table 1. general characteristics of the selected studies (n=16) category n % year of publishing 2012 1 6 2015 3 19 2016 3 19 2017 3 19 2018 3 19 2019 1 6 2020 2 12 type of country middle-income countries 10 63 low-income countries 6 37 factors associated with cervical cancer screening uptake intrapersonal factors 16 100 interpersonal factors 1 6 community 1 6 organizational factors 5 31,25 type of study cross-sectional 12 80 case control 1 7 qualitative 2 13 e. faradisa et al. 116 | pissn: 1858-3598  eissn: 2502-5791 belief and self-efficacy should be a concern of women in cervical cancer screening. farzaneh et al showed that the perceptions of a specific health behavior play an important role in reducing the cervical cancer risk and engaging in the health behavior of focus (farzaneh, heydari, shekarchi, & kamran, 2017). interpersonal factors the interpersonal level describes the interactions with the primary group, their family, and friends. this provides social support to a given health behavior. in this review, we found that husband approval is the only interpersonal factor that influences a woman to get cervical cancer screening. the first family member closest to the wife is the husband, so the husbands’ approval of cervical cancer screening is therefore strongly associated with the participants’ cervical cancer screening status (lyimo & beran, 2012). this was confirmed by rahmawati et al’s (rahmawati & dewanti, 2018) study, which showed that the negative attitude of men towards the screening or the treatment of cervical cancer is to be a considered a table 2. summary of the selected studies author type of country design sample variables results (nigussie et al., 2019) lowincome country crosssectional 737 respondents cervical cancer screening service utilization and the associated factors having a history of gynecological examinations, good knowledge of cervical cancer screening, perceived susceptibility to cervical cancer, government employee, knowing someone who has ever been screened and getting advice from the health care providers. (teame et al., 2019) lowincome country case control 624 respondents factors affecting the utilization of cervical cancer screening services age, employee status, having ever given birth and a history of multiple sexual partners. (anwar et al., 2018) middleincome country crosssectional 5397 respondents determinants of cancer screening awareness and participation. level of education, social participation, health insurance and a shorter distance to the health services were the determinant factors of cervical cancer screening participation. (tiruneh et al., 2017) middleincome country crosssectional 9016 respondents individualand community-level factors related to cervical cancer screening. media exposure, a higher household wealth index, employed, insured, and had visit a health facility in the last 12 months in addition to sexual autonomy. (steinhardt et al., 2015) middleincome country crosssectional 2505 respondents factors associated with the limited uptake of the screening services. a high percentage of women knew that it is appropriate for all women to getcervical cancer screening, but only a small proportion of women actually got screening. the associated factors were knowledge, fear and beliefs. (weng et al., 2020) lowincome country crosssectional 1483 respondents attitudes toward the acceptability of and barriers to cervical cancer screening (ccs). educational level, family income, personal and family history, paritas, fear of screening and the inconvenience of screening. (ndejjo et al., 2017) lowincome country qualitative 119 participants community knowledge, facilitators and barriers to cervical cancer screening the perceptions of cervical cancer and screening were majorly positive with many of the participants stating that they were at risk of getting cervical cancer. the facilitators to accessing cervical cancer screening were experiencing signs and symptoms of cervical cancer, a family history of the disease and awareness of the disease/screening service. jurnal ners http://e-journal.unair.ac.id/jners | 117 key factor contributing to the poor uptake of the (pyatak et al., 2018) middleincome country crosssectional 440 respondents knowledge, attitude, and the practices related to cervical cancer prevention the intrapersonal factors related to cervical cancer prevention are knowledge about the disease and prevention, and personal choice. (donatus et al., 2019) middleincome country crosssectional 253 respondents cervical cancer knowledge and associated factors for uptake in cervical cancer screening. the majority of the participants had heard of cervical cancer and had undergone cervical cancer screening. following this, 24.51% and 29.25% of the participants respectively could not identify any of the risk factors and symptoms of cervical cancer. (farzaneh, heydari, shekarchi, & kamran, 2017) middleincome country crosssectional 1,134 respondents screening behaviours for breast and cervical cancer, selfefficacy, beliefs, and the barriers to breast and cervical cancer screening. females who had high belief scores were more likely to undertake a mammogram, bse, and pap smears. females who had high self-efficacy scores were more likely to perform regular screening for breast and cervical cancer. (ncube, bey, knight, bessler, & jolly, 2015) middleincome country crosssectional 403 respondents women’s cervical cancer screening history, knowledge, attitudes and the practices regarding the disease and screening interpersonal: being married, age, parity, perception of the consequences of not having a pap smear ad knowing a person with cervical cancer. health care system: discussing cancer with the health provider. (ndikom & ofi, 2012) middleincome country qualitative 82 participants awareness, perception of the utilization of the cervical cancer screening service intrapersonal factors: ignorance, illiteracy, belief in not being at risk, having many contending issues, nonchalant attitude to their health, financial constraints and a fear of having a positive result. (idowu, olowookere, fagbemi, ogunlaja, 2016) middleincome country crosssectional 338 respondents determinants of cervical cancer screening uptake knowledge and self awareness were the determinant factors of cervical cancer screening uptake. (okunowo et al., 2018) middleincome country crosssectional 225 respondents knowledge of cervical cancer and an uptake of pap smear screening the knowledge of the women in this study regarding the symptoms and risk factors of cervical cancer was very poor. fear of a positive result, and the recommendation to be screened given by doctors/nurses were the important factors. (lyimo & beran, 2012) lowincome country crosssectional 354 respondents demographic, knowledge, attitude, and accessibility factors are associated with the uptake ofcervical cancer screening women’s level of education, and their knowledge of cervical cancer and its prevention, embarrassment and pain concerning the screening, preference for the health provider female, awareness, husband’s approval of the cervical cancer screening and the distance to the cervical cancer screening services. (ndejjo, mukama, musabyimana, & musoke, 2016) lowincome country crosssectional 900 respondents uptake of cervical cancer screening and the associated factors knowing where the screening services are offered, knowing someone who had ever been screened and being recommended to do so by a health worker e. faradisa et al. 118 | pissn: 1858-3598  eissn: 2502-5791 screening services. community according to the who recommendations on the management of cervical cancer, health promotion should be conducted through public events, media, religious communities and other civic society channels. preventive measures include mass screening, mainly for cervical cancer using a visual inspection with acetic acid, which should be organized as a public event. social participation may help to enhance the presence of cancer screening in low-resource settings (anwar et al., 2018). organizational factors the organizational level includes the rules or regulations (and physician’s recommendations) that may constrain or modify health behavior. consultation/advice from the health professions was associated with cervical cancer screening service utilization. women who had advice from their health care providers were more likely to be screened when compared to women who had not had such advice. this may be due to the information from the health care providers increasing their awareness of the disease and the advantages of the screening services (nigussie et al., 2019). it has been shown that the non – recommendation of a pap smear test is a major reason for not doing the test. several studies have identified physician recommendation as a major determinant and predictor of the uptake of cancer screening tests. the regular health education of women and the recommendation to undergo a pap smear screening by clinicians and other health care providers will go a long way to improving the uptake and ultimately reducing the incidence and burden of the disease (okunowo et al., 2018). accessibility has also been identified as an organizational factor related to the screening uptake. the long distance to the cervical cancer screening service reduces the likelihood of women accessing screening. women who know the location of the nearest cancer screening facility are more likely to have been screened for cervical cancer compared to those who do not (lyimo & beran, 2012). conclusion the uptake of cervical cancer screening services is poor in low and middle-income countries. there is a need to strengthen the knowledge and awareness of the woman towards the cervical cancer screening services. the available evidence shows that the intrapersonal factors of knowledge about the disease and its prevention and organizational factors are the most important factors that influence the woman in lowand middle-income countries when it comes to undertaking cervical cancer screening. conflict of interest no conflicts of interest have been declared. acknowledgement the authors of this study would like to thank the faculty of nursing and the master’s of nursing study programme for providing us with the opportunity to present this study. references anwar, s. l., tampubolon, g., van hemelrijck, m., hutajulu, s. h., watkins, j., & wulaningsih, w. (2018). determinants of cancer screening awareness and participation among indonesian women. bmc cancer, 18(1), 1–11. https://doi.org/10.1186/s12885-018-4125-z bray, f., ferlay, j., soerjomataram, i., siegel, r. l., torre, l. a., & jemal, a. (2018). global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: a cancer journal for clinicians, 68(6), 394–424. https://doi.org/10.3322/caac.21492 chan, d. n. s., & so, w. k. w. (2017). a systematic review of the factors influencing ethnic minority women’s cervical cancer screening behavior: from intrapersonal to policy level. cancer nursing, 40(6), e1–e30. https://doi.org/10.1097/ncc.00000000000004 36 donatus, l., nina, f. k., sama, d. j., nkfusai, c. n., bede, f., shirinde, j., & cumber, s. n. (2019). assessing the uptake of cervical cancer screening among women aged 25-65 years in kumbo west health district, cameroon. pan african medical journal, 33, 1–11. https://doi.org/10.11604/pamj.2019.33.106.16 975 farzaneh, e., heydari, h., shekarchi, a. a., & kamran, a. (2017). breast and cervical cancer-screening uptake among females in ardabil, northwest iran: a community-based study. oncotargets and therapy, 10, 985–992. https://doi.org/10.2147/ott.s125344 idowu, a., olowookere, s. a., fagbemi, a. t., & ogunlaja, o. a. (2016). determinants of cervical cancer screening uptake among women in ilorin, north central nigeria: a community-based study. journal of cancer epidemiology, 2016(vili). https://doi.org/10.1155/2016/6469240 islam, r. m., billah, b., hossain, m. n., & oldroyd, j. (2017). barriers to cervical cancer and breast cancer screening uptake in low-income and middle-income countries: a systematic review. asian pacific journal of cancer prevention, 18(7), 1751–1763. https://doi.org/10.22034/apjcp.2017.18.7.175 1 liebermann, e. j., vandevanter, n., hammer, m. j., & fu, m. r. (2018). social and cultural barriers to women’s participation in pap smear screening programs in lowand middle-income latin american and caribbean countries: an integrative review. journal of transcultural jurnal ners http://e-journal.unair.ac.id/jners | 119 nursing, 29(6), 591–602. https://doi.org/10.1177/1043659618755424 lyimo, f. s., & beran, t. n. (2012). demographic, knowledge, attitudinal, and accessibility factors associated with uptake of cervical cancer screening among women in a rural district of tanzania: three public policy implications. bmc public health, 12(1), 1–8. https://doi.org/10.1186/1471-2458-12-22 ncube, b., bey, a., knight, j., bessler, p., & jolly, p. e. (2015). factors associated with the uptake of cervical cancer screening among women in portland, jamaica. north american journal of medical sciences, 7(3), 104–113. https://doi.org/10.4103/1947-2714.153922 ndejjo, r., mukama, t., kiguli, j., & musoke, d. (2017). knowledge, facilitators and barriers to cervical cancer screening among women in uganda: a qualitative study. bmj open, 7(6), 1–8. https://doi.org/10.1136/bmjopen-2017016282 ndejjo, r., mukama, t., musabyimana, a., & musoke, d. (2016). uptake of cervical cancer screening and associated factors among women in rural uganda: a cross sectional study. plos one, 11(2), 1–13. https://doi.org/10.1371/journal.pone.0149696 ndikom, c. m., & ofi, b. a. (2012). awareness, perception and factors affecting utilization of cervical cancer screening services among women in ibadan, nigeria: a qualitative study. reproductive health, 9(1), 1–8. https://doi.org/10.1186/1742-4755-9-11 nigussie, t., admassu, b., & nigussie, a. (2019). cervical cancer screening service utilization and associated factors among age-eligible women in jimma town using health belief model, south west ethiopia. bmc women’s health, 19(1), 1–10. https://doi.org/10.1186/s12905-019-0826-y okunowo, a. a., daramola, e. s., soibi-harry, a. p., ezenwankwo, f. c., kuku, j. o., okunade, k. s., & anorlu, r. i. (2018). women’s knowledge of cervical cancer and uptake of pap smear testing and the factors influencing it in a nigerian tertiary hospital. journal of cancer research and practice, 5(3), 105–111. https://doi.org/10.1016/j.jcrpr.2018.02.001 orang’o, e. o., wachira, j., asirwa, f. c., busakhala, n., naanyu, v., kisuya, j., … inui, t. (2016). factors associated with uptake of visual inspection with acetic acid (via) for cervical cancer screening in western kenya. plos one, 11(6), 1–12. https://doi.org/10.1371/journal.pone.0157217 owen, n., heart, b., & fisher, e. b. (2008). and health. pyatak, e. a., carandang, k., vigen, c. l. p., blanchard, j., diaz, j., concha-chavez, a., … peters, a. l. (2018). occupational therapy intervention improves glycemic control and quality of life among young adults with diabetes: the resilient, empowered, active living with diabetes (real diabetes) randomized controlled trial. diabetes care, 41(4), 696–704. https://doi.org/10.2337/dc17-1634 rahmawati, n. a., & dewanti, l. (2018). direct experience with cervical cancer patient, husband support, and self-perception as determinant factors of women’s desire to take via screening test. kesmas, 13(1), 36–42. https://doi.org/10.21109/kesmas.v13i1.1617 rohan, j. m., huang, b., pendley, j. s., delamater, a., dolan, l., reeves, g., & drotar, d. (2015). predicting health resilience in pediatric type 1 diabetes: a test of the resilience model framework. journal of pediatric psychology, 40(9), 956–967. https://doi.org/10.1093/jpepsy/jsv061 schliemann, d., su, t. t., paramasivam, d., treanor, c., dahlui, m., loh, s. y., & donnelly, m. (2019). effectiveness of mass and small media campaigns to improve cancer awareness and screening rates in asia: a systematic review. journal of global oncology, (5), 1–20. https://doi.org/10.1200/jgo.19.00011 steinhardt, m. a., brown, s. a., dubois, s. k., harrison, l., matthew lehrer, h., & jaggars, s. s. (2015). a resilience intervention in african-american adults with type 2 diabetes. american journal of health behavior, 39(4), 507–518. https://doi.org/10.5993/ajhb.39.4.7 teame, h., gebremariam, l., kahsay, t., berhe, k., gebreheat, g., & gebremariam, g. (2019). factors affecting utilization of cervical cancer screening services among women attending public hospitals in tigray region, ethiopia, 2018; case control study. plos one, 14(3), 1–11. https://doi.org/10.1371/journal.pone.0213546 tiruneh, f. n., chuang, k. y., ntenda, p. a. m., & chuang, y. c. (2017). individual-level and community-level determinants of cervical cancer screening among kenyan women: a multilevel analysis of a nationwide survey. bmc women’s health, 17(1), 1–14. https://doi.org/10.1186/s12905-017-0469-9 touch, s., & oh, j. k. (2018). knowledge, attitudes, and practices toward cervical cancer prevention among women in kampong speu province, cambodia. bmc cancer, 18(1), 1–8. https://doi.org/10.1186/s12885-018-4198-8 weng, q., jiang, j., haji, f. m., nondo, l. h., & zhou, h. (2020). women’s knowledge of and attitudes toward cervical cancer and cervical cancer screening in zanzibar, tanzania: a crosssectional study. bmc cancer, 20(1), 1–12. https://doi.org/10.1186/s12885-020-6528-x http://e-journal.unair.ac.id/jners | 149 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19001 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review psychosocial interventions to promote recovery for patient with schizophrenia: a systematic review iskandar iskandar, devis yulia rohmana, ah yusuf, rizki fitryasari p.k faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: managing cancer and living meaningfully (calm) is a supportive-expressive psychotherapy designed to address such barriers and to facilitate communication of mortality-related concerns in patients facing advanced disease and their primary caregivers. the study was meant to review the benefits of the calm psychotherapy on patients with advanced or metastatic cancer and caregivers. methods: this study was done through a systematic review with the preferred reporting items for systematic reviews and meta-analysis (prisma) approach. it broadly used scopus, science direct, and proquest database. the search utilized the boolean phrases “cancer”, “living meaningfully”, and “psychotherapy” throughout the title, abstract, or keywords. the consideration criteria in the literature study were: an original article, the source from journals, article in english, and available in full text. we obtained 97 articles, and 11 were considered relevant for this systematic review. results: the findings from the results of this study are that calm has several psychological benefits for patients with advanced cancer, including: can reduce anxiety and depression, relieve distress, promote psychological growth and well-being, and improve quality of life. based on these findings, it can be concluded that the calm psychotherapy has many benefits for patients with advanced cancer and their caregivers and can be used as additional therapy to improve the quality of life to face the end-oflife. conclusion: calm may be a feasible intervention to benefit patients with advanced cancer. it may help them overcome obstacles in communication and alleviate death-related distress. article history received: feb 27, 2020 accepted: april 1, 2020 keywords psychosocial interventions; schizophrenia; recovery contact rizki fitryasari p.k  rizki-f-p-k@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: iskandar, i., rohmana, d. y., yusuf, ah., & fitryasari, r. (2020). psychosocial interventions to promote recovery for patient with schizophrenia: a systematic review. jurnal ners, special issues, 149-156. doi:http://dx.doi.org/10.20473/jn.v15i2.19001 introduction breaking the word down, we see that 'psycho' refers to psychology the study of human nature or the mind, its functions, and behavior and 'social' refers to society groups of people living together with shared laws and organizations. if we put these two ideas together, we can see that psychosocial means how humans interact with and relate to others around them. it focuses on relationships and how humans work in society. when a person is not interacting with society well, psychosocial intervention may be used to help guide the person back into a healthy state of being. that is the use of non-medicinal means to alter a person's behaviors and relationships with society in order to reduce the impact of the person's disorder or condition. the key to psychosocial intervention is that it does not use pharmaceutical assistance in the endeavor to change a person's behaviors toward a more healthy interaction with society. recovery is a multidimensional concept and some research findings suggest that relevant indicators must consider at least two areas, namely clinical remission and social function. recovery of patients with schizophrenia is defined as recovery as a meaningful https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:rizki-f-p-k@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. i. iskandar et al. 150 | pissn: 1858-3598  eissn: 2502-5791 and valued life achievement and a return to normal function, that is with no symptoms based on objective criteria. this shows that functional outcomes should be a priority target for therapeutic interventions. a large amount of literature has studied the factors that can influence this functional outcome. neurocognition is one of the first factors described. other variables such as intrinsic motivation and metacognition have also been mentioned in several studies and can function as mediators between neurocognition and functional outcomes. to better explain the causal pathway, researchers have built sophisticated models with parameters such as functional capacity, social cognition, and symptoms to take into account the complexity of functions. functional capacity is defined as the ability to perform tasks that are relevant to daily life in a structured environment that is guided by the examiner. this includes the ability to perform in the areas of housing, employment and social skills. several works have shown that functional capacity is at least strongly correlated with real-world functional results as cognitive performance. recent studies have revealed that the effects of cognitive impairment can be mediated by functional capacity. social cognition is a multidimensional construct consisting of emotional processes, social perceptions and knowledge, thought theories and attribution biases (lysaker, keane, poirier, & lundin, 2020). according to most studies, social cognition might also mediate the effects of neurocognitive disorders on real life functions. symptoms have been associated with functional outcomes from the beginning with negative symptoms appearing to interfere more than positive ones. both direct and indirect relationships between negative symptoms and real life functions have been reported. they seem to mediate the impact of variables such as neurocognition or functional capacity on real-world functioning. it seems that symptoms such as lack of motivation have the biggest impact. most recent work confirms this finding and also refers to additional variables that are more connected to the patient's environment. studies show that resilience, stigma, and involvement with mental health services mediate the relationship between symptoms, cognition, and real-world functioning. other recent work shows that negative symptoms predict social deficits, but not with a decrease in daily activities and vocational outcomes that conflict with cognition and functional capacity. some researchers suggest that various factors need to be assessed to establish an individual's "functional diagnosis". some factors are inherent to patients (cognition, involvement with services, functional capacity, symptoms, resilience, and recovery processes), while others are related to their social context (internal stigma, social support, resources). such assessments will help to determine individualized intervention plans and to determine life goals in collaboration with patients (kuo, lin, & king, 2010). then appropriate treatment targets neurocognition, social cognition, negative symptoms and functional capacity, and integrative interventions combining different therapies need to be institutionalized taking into account the specific needs of each patient. rehabilitation or psychosocial interventions have been developed to complement psychotherapy and psychopharmacological treatments. basically, drug treatment and supportive therapy do not have specific effects on cognitive impairment, insight, social skills, and interaction disorders, whereas rehabilitation tools primarily target this dimension. psychosocial interventions also share common values with the recovery model by promoting an active position against disturbances, which encourages self-determination and empowerment. many interventions can be used in the field of rehabilitation: case management, supported work (se), cognitive remediation, psychoeducation, and cognitive behavioral therapy(bowie et al., 2020). in this review, we focus on rehabilitation interventions that specifically target the dimensions cited above. thus, we studied the following three interventions: (1) cognitive improvement, (2) psychoeducation, and (3) cognitive-behavioral therapy. the purpose of compiling this review systematic is to explain interventions that can be used as a basis for providing interventions aimed at the recovery of patients with schizophrenia. materials and methods literature search strategy searching for articles in the compilation of the systematic review is done using the scopus, sciencedirect, pubmed, proquest, and sage databases. the specified time span is between 2016 studies identified through keywords database searching (n=431) scopus = 102 sciencedirect = 170 pubmed = 76 sage = 59 proquest = 24 studies excluded due to duplication n= 400 records excluded based on title and abstract n= 201 full text assessed article for eligibility n=199 full text article exclude with reasons n=179 not intervention (117) not english (50) not >17 years old (12) figure 1. flow diagram studies randomised trial included in systematic review n=20 jurnal ners http://e-journal.unair.ac.id/jners | 151 and 2020 and only articles in english are selected. keywords used in literature search are "recovery" and "intervention" and "schizophrenia" and "psychosocial". a total of 431 articles were found in this search, but only 20 articles were used in the writing. the selected article is an article in english, published in the last five years, and refers to the recovery of patients with schizophrenia. study design the study design inclusion criterion in this systematic review is a random controlled trial (rct) design that is published using english. the population in this systematic review are all studies that describe patients who get recovery interventions with or without a control group, men and women > 17 years old with schizophrenia and seeing the effect of recovery intervention. various types of recovery interventions affect cognitive remediation, psychoeducation, and cognitive-behavioral therapies (cbt). the main outcome of this systematic review is to look at the influence of recovery interventions in psychological, cognitive and social terms. data extraction and analysis data are extracted from each study that meets the requirements. the extracted data include the characteristics of the study, characteristics of recovery intervention, characteristics of the results and summary of results. studies are grouped according to the effects of recovery intervention in psychological, cognitive and social terms. figure 1 summarizes the search results and the selection of studies following the prisma guidelines. the selection of journals based on the keywords used produces 431 articles; 400 articles were found after duplication screening and 201 eliminated due to irrelevant studies based on titles and abstracts. a total of 199 articles with full text was taken with 20 studies excluded because they did not meet the inclusion criteria as follows: not an intervention study (n = 117), not using english (n = 50), subject <17 years (n = 12). thus, the 20 studies selected will form the systematic review results population the sample size of the 20 studies used is that the least systematic review is 23 people divided into two groups, namely the control and intervention groups, with the age range 18-51 years, and the sex of patient is female. characteristics of intervention there are several types of recovery interventions, including cognitive remediation, psychoeducation, and cbt size of clinical outcomes research reports the outcome measures used to measure recovery are attention reaction conditioner (arc), personal and social performance scale (psp), the measure of insight into cognition-self report (mic-sr), the nimh matrics consensus cognitive battery (mccb), scale for the assessment of negative symptoms (sans), scale for the assessment of positive symptoms (saps), dynamic social cognition battery (dscb), pittsburgh sleep quality index (psqi), psychotic symptoms rating scale (psyrats), anxiety sensitivity index (asi), beck depression inventory (bdi), and positive and negative syndrome scale (panss). intervention efficacy analysis for each rct intervention, it was explained they evaluated the effect of recovery intervention on treatment separately. some journals continue to follow-up for up to 12 months after the intervention so that they can assess the long-term influence of the intervention that has been done. effectiveness of cognitive remeditation the main criteria used to assess the efficacy of psychoeducation are the level of recurrence, symptom reduction, medication adherence, knowledge about the disease, and function in the community. most large-scale work on psychoeducation does not distinguish between information provided to families from that given to patients. effects of cognitive remediation were significant interaction between the effect of psi and performance on the different cognitive exercises (pb0.05). more precisely, when patients performed the session with psi, they demonstrated better cognitive performances than with n-psi in the orm exercise that provides training in processing speed, alertness, and reaction time (the standard attention reaction conditioner, or arc) (pb0.01, corrected). psi did not significantly affect other cognitive domains, such as target detection and spatial attention (sandoval et al., 2019). significant cognitive benefits for functioning were observed (personal and social performance scale, psp). moreover, improvement of the mccb total score mediated a positive effect on functional capacity (ucsd performance-based skills assessment, upsa), and mediated decreases in negative symptoms across both groups. ccrt improved social functioning and general cognitive functioning among communitydwelling patients with schizophrenia. these improvements persisted for six months after treatment. ccrt also led to improvements in functioning and symptom severity by modulating cognitive functioning (pre-proof et al., 2020).greater perceived competency was associated with shorter time to treatment completion (p= .0025). intrinsic motivation measured at end-point t was associated i. iskandar et al. 152 | pissn: 1858-3598  eissn: 2502-5791 with cognitive change (p=.02)(bowie et al., 2020). conduct cognitive remediation program with the help of caregivers in patients’ home settings and homebased cognitive remediation is as effective as the clinic-based cognitive remediation (kumar et al., 2019). the combined intervention, crt + mrige, showed greater improvements in the mccb indices of visual learning, working memory, reasoning and problem solving, and the neurocognitive composite score compared to crt alone (bonferroni adjusted p=0.004,p=0.005,p= 0.01, respectively), as did social cognition measures (bonferroni adjusted p=0.006,p= 0.005, respectively) (lindenmayer et al., 2018). post hoc testing showed that, compared to the control group, the cbt-i group showed significant reductions in isi and psqi at both week 4 and week 8. for the psyrats, asi, and bdi scores, the cbt-i and control groups showed significant time-group interactions, but post hoc testing revealed no significant group differences at either week 4 or week 8. therefore, cbt-i was effective for reducing insomnia symptoms in patients with schizophrenia and the effect lasted for four weeks after the intervention (hwang, nam, & lee, 2019) cognitive-behaviour therapy (cbt) effectiveness the results of the cbt intervention show that patients with schizophrenia can learn various skills. it indicates that participants in the cbt + cr condition worked significantly more hours and had a more positive trajectory of improving global work performance and work quality across the study compared with the cbt alone and vocational support condition. compared to the other conditions, cbt + cr also had a significant increase in overall neurocognition that continued to the 12-month follow-up, particularly in the domains of verbal learning and social cognition. in conclusion, cbt + cr may be an effective intervention to improve work functioning and neurocognition in persons with schizophrenia (kukla, bell, & lysaker, 2018). at 21month follow-up, cbt did not have a lasting effect on total symptoms of schizophrenia compared with treatment as usual; however, cbt produced statistically, though not clinically, significant improvements on total symptoms by the end of treatment. there was no indication that the addition of cbt to treatment as usual caused adverse effects. the results of this trial do not support a recommendation to routinely offer cbt to all people who meet the criteria for clozapine-resistant schizophrenia; however, a pragmatic individual trial might be indicated for some (morrison et al., 2018). therapy is important for those that receive cbt in the absence of antipsychotic medication. secondly, using principal stratification, we examined the process variables that modified treatment effects. findings revealed that those who received a longitudinal formulation in the first four sessions of cbt had poorer treatment effects than those who did not; however, this finding was not statistically significant (95% ci−37.244, 6.677, p = 0.173) (spencer et al., 2018). the results revealed identical one-factor structures for both participant groups. for both groups, the biq total score was positively associated with performance on social cognitive and everyday functioning assessments. further, control participants were rated more positively on all biq items and received higher biq total scores. in the schizophrenia sample, biq scores predicted performance on social functioning assessments while controlling for symptom severity (lanser et al., 2018); the complete training plus preand posttreatment assessment data were available from sixteen participants. clinical ratings of symptom severity were obtained at preand post-training. retention rates were very high and training was rated as extremely satisfactory for the majority of participants. participants exhibited a significant reduction in overall clinical symptoms, especially negative symptoms following 10 sessions of masi-vr (adery, ichinose, torregrossa, wade, & nichols, 2018). clinical features, cognition and functioning were assessed at baseline, post-treatment and six months after finishing the intervention. a significant progressive improvement in neurocognition and functioning was globally shown with no differences observed between the experimental and control group at post-training or follow-up. all cognitive domains but social cognition improved between 0.5 and 1 s.d. through the study period (garcía-fernández et al., 2019). following crt + sst, participants demonstrated statistically significant improvement for mccb reasoning and problem solving, mccb verbal learning, and masc total correct score. improvements on upsa total score approached significance (p= .07) (mcclure et al., 2019). psychoeducation effectiveness a large significant improvement of knowledge was observed (p< 0.001; d= 0.77). by contrast, the analysis reported no significant effect of psychoeducation on insight (p= 0.86; d= 0.07). panss total scores were significantly decreased after treatment (p= 0.001; d= 0.66) (dondé, senn, eche, kallel, & saoud, 2019). there was a significant group×time interaction effect on knowledge (f = 8.71; p<0.01; ηp2= 0.14) and self-stigma scores (f = 14.47; p<0.001; ηp2= 0.21), wherein the brief psychoeducation group showed a significant increase in knowledge and reduction in self-stigma with medium effect size through baseline to the third month follow-up as compared to the treatment as usual group. we also observed a significant main effect of time; irrespective of the group allocation, there was a significant increase in the knowledge through baseline to third month follow-up (f = 5.69; p = 0.02; p2= 0.09). no main or interaction effects of group and time were observed on burden (amaresha, vasu, joseph, mahavir, & subbakrishna, 2018). one hundred and sixty (89%) patients completed at least jurnal ners http://e-journal.unair.ac.id/jners | 153 two post-tests. their mean age and duration of illness were 25e28 years (sd=6.1e7.8) and 2.1e2.5 years (sd=1.3e2.0; range 4-54 months), respectively. compared with the two other groups, the mindfulness-based group exhibited a significantly greater improvement with moderate to large effect sizes (cohen's d=.49e0.98) in functioning (p¼0.005), duration of psychiatric re-hospitalizations (p=0.007), psychotic symptoms (p¼0.008) and illness insight (p¼0.001) over the 18-month follow-up. supplementary mri findings indicated that the mindfulness-based intervention resulted in significant changes in gray matter volume and density in brain regions concerning attention and emotional regulation(tong, yu, mcmaster, yip, & wong, 2019). the mean post-test score of the beck cognitive insight scale was 4.89 ± 6.05 in the experimental group, 1.68 ± 5.67 in the control group and the difference between the mean scores was statistically significant (p < 0.05). the mean post-test score of medication adherence ratıng scale was 1.76 ± 0.42 in the experimental group, 1.50 ± 0.50 in the control group and the difference between the mean scores was statistically significant (p < 0.05)(çetin & aylaz, 2018). the efficacy of medication subscale score, and the total dai-10 score exhibited significant group × time interactions(matsuda & kohno, 2016). the findings from the results of this study suggest that calm has several psychological benefits for patients with advanced cancer, including: reducing anxiety and depression, relieving distress, promoting psychological growth and well-being, it may help patients with advanced cancer overcome obstacles in communication and alleviate death-related distress (table 1). discussion a number of results show that cognitive improvement, psychoeducation, and cbt are efficient rehabilitation tools. data in the literature on cognitive remediation are homogeneous and show that it is efficient in cognitive function and psychosocial function, specifically the ability to work. according to most studies, the impact of cognitive remediation on social functioning is more important, both when combined with other rehabilitation techniques and when therapy is based on learning strategies. data on the effect of cognitive remediation on symptomatology are more heterogeneous. this may not have an effect on positive symptoms, and, in fact, severe positive symptoms can be obstacles to improvement during cognitive remediation sessions (sandoval et al., 2019). data on negative symptoms are more complex because they are influenced by cognitive remediation. the effectiveness of negative symptoms may be indirect, hypothetically caused by a reduction in defeated beliefs, avoidance behavior, and poor motivation, and, consequently, an increase in self-esteem (pre-proof et al., 2020). further studies should try to determine the effects of cognitive remediation, the active elements of the intervention, the factors that lead to positive responses and permanent benefits over time. it seems, however, that factors such as motivation, social cognition, and metacognition can play a key role in the success of this remediation technique (saperstein, lynch, qian, & medalia, 2020). psychoeducation for families and patients has proven to be effective in preventing relapses, readmissions, and also in increasing drug compliance. interventions with the highest level of evidence appear to be those that involve relatives. actually, psychoeducation for patients shows its effectiveness, but with a lower level of evidence compared to patient and family psychoeducation. it is important for patient and family psychoeducation not only to send information, but also to provide practical skills such as real problem solving techniques (dondé et al., 2019). although methodological reduction limits the psychosocial rehabilitation to a single intervention, it appears that interventions that combine psychoeducation, cognitive and behavioral techniques, and homework strategies are more effective in increasing medication adherence than unidimensional approaches. future research should focus on developing new types of programs, such as psychoeducation led by peers. it seems important for participants to receive information from and exchange with peers. conversely, giving too much information about a disease can cause a defensive reaction (uncertainty still remains about the efficiency of psychoeducation in areas such as global functioning, awareness of disorders, need for care, and quality of life, especially in the long term (2 years). other parameters need to be clarified by better designed studies, such as the minimum effective "dose" of psychoeducation and the specificity of the psychoeducation format according to patient status social skills training produces conflicting results with lack of consistency caused by methodological problems in several studies including small samples, sampling bias, and lack of flushing for treatment allocation; however, there are some methodological problems with the cochrane review, and many other studies have come to the same conclusion that social skills training has proven to be efficient in social skills, psychosocial functions and negative symptoms(amaresha et al., 2018). with further results, existing reviews and meta-analyses do not consistently support the positive effects of social skills training on outcomes such as relapse rates, psychotic symptoms, and quality of life. it also seems important to note that transferring the skills learned during therapy sessions to daily life is not always easy, which is why generalization techniques (home-based training) are very important. they give patients the opportunity to practice skills in natural situations. social skills training has proven to be very efficient when linked to cognitive remediation or se, which is why the three rehabilitation interventions are often combined. i. iskandar et al. 154 | pissn: 1858-3598  eissn: 2502-5791 in addition to allowing patients to practice newly acquired skills in daily life, it gives them appropriate feedback and provides social reinforcement. data in the literature on ct are quite homogeneous, showing that ct is efficient in reducing positive symptoms (spencer et al., 2018). cognitive therapy can be used as an adjunct to chemotherapy in patients in remission or in patients with active symptoms and may also be effective in reducing negative symptoms. however, further controlled trials with negative symptoms as a primary outcome measure are needed. the quality and effectiveness of cognitive therapy is partly determined by the training and supervision of the therapist. additional studies on ct and minimal doses are still needed. some work seems to indicate the effectiveness of low intensity cbt, but low and high intensity cbt must be compared in future studies. it also seems important to consider for future research that patients do not always need their symptoms to be eradicated, and such observations are common in the literature about recovery from psychosis or schizophrenia. recovery means being able to live with symptoms, that is, being able to overcome the "sound". thus, although ct analysis only focuses on reducing important psychotic symptoms, further research should focus on secondary outcomes such as pressure reduction or self-determined recovery (morrison et al., 2018). we must also concentrate on changing the way people relate to their thoughts and feelings, as did the third wave. in this review, we are primarily interested in the effects of technique on psychosocial functioning. the techniques that lead to the most powerful improvements in psychosocial functioning are cognitive improvement and social skills training. with both techniques, improvement in social functioning is highly dependent on general characteristics, which consist in supporting practice with rehabilitation activities or opportunities to reflect on how to apply skills in daily life. these programs also often require personal contact with a therapist. it is likely that, by providing these elements, the program facilitates the consolidation of learning by making new cognitive or social skills accessible in everyday life. programs that use supported practices and other methods to maximize the transfer of skills learned by therapy to everyday life and those involving therapists may be more likely to have an impact on functioning(adery et al., 2018). regarding patient or family psychoeducation, the effect on psychosocial functioning seems limited, but that does not mean that the interventions have no effect on functioning, but rather that functioning assessments are rarely reported in works about psychoeducation intervention and, when they are, functioning is not a priority outcome. further research should investigate the effect of psychoeducation on functioning as a primary outcome measure. since psychoeducation seems to be effective on variables influencing real-world functioning (engagement in service and internalized stigma), interpreting results on functioning were rather difficult because psychosocial functioning assessment is very heterogeneous in the literature. most of the works reviewed here included studies using different scales. it seems that future research on psychosocial interventions could focus more on functional outcomes. another important issue is how to assess realworld functioning: it would be useful to find a common set of criteria that would enable its assessment. all these interventions are always delivered within the framework of rehabilitation and are not intended to be standalone treatments. several programs combining interventions proved to be efficient, such as cbt and skills training, se and skills training, cognitive remediation and social skills training, or social cognitive training and cbt and skills training. the impact of psychosocial interventions on functional outcomes seems to be improved by combining elements from each therapeutic approach. clinical experience has shown the relevance of combining techniques based on patient issues and the stage of the disease. these techniques seem to be complementary: on the one hand, psychoeducation and cbt allow patients to gain knowledge about their illness and play an active role in the recovery process, while, on the other, social skills training and cognitive remediation may enhance adaptive skills. nevertheless, further research is needed to identify the synergistic effects of combined interventions and the active ingredients of successful therapeutic modalities. conclusion the interventions used in recovery in patients with schizophrenia have different effects on each type. in this case, the resulting output can affect the needs of each patient. cognitive remediation has an impact on social functioning and decreased symptoms, cbt has an impact on psychological conditions and social abilities while psychoeducation can have an impact on medication adherence and daily skills training. conflict of interest the authors declare that they have no conflict of interest. acknowledgement the authors would like to acknowledge the lecturer and reviewer team at the international nursing conference in airlangga university surabaya, for the suggestions and support. references adery, l. h., ichinose, m., torregrossa, l. j., wade, j., & nichols, h. (2018). the acceptability and feasibility of a novel virtual reality based social skills training game for schizophrenia : preliminary findings. psychiatry research, 270(march), 496–502. https://doi.org/10.1016/j.psychres.2018.10.014 jurnal ners http://e-journal.unair.ac.id/jners | 155 amaresha, a. c., vasu, s., joseph, b., mahavir, s., & subbakrishna, d. k. (2018). short term e ff ects of brief need based psychoeducation on knowledge , selfstigma , and burden among siblings of persons with schizophrenia : a prospective controlled trial. asian journal of psychiatry, 32(october 2017), 59–66. https://doi.org/10.1016/j.ajp.2017.11.030 bowie, c. r., bell, m. d., fiszdon, j. m., johannesen, j. k., lindenmayer, j., mcgurk, s. r., … wykes, t. (2020). cognitive remediation for schizophrenia : an expert working group white paper on core techniques. 215, 49–53. https://doi.org/10.1016/j.schres.2019.10.047 çetin, n., & aylaz, r. (2018). archives of psychiatric nursing the e ff ect of mindfulness-based psychoeducation on insight and medication adherence of schizophrenia patients. archives of psychiatric nursing, 32(5), 737–744. https://doi.org/10.1016/j.apnu.2018.04.011 dondé, c., senn, m., eche, j., kallel, l., & saoud, m. (2019). well-informed but not aware : the p . a . c . t . ® psychoeducation program for schizophrenia improves knowledge about , but not insight into , the illness. asian journal of psychiatry, 46(august), 15–18. https://doi.org/10.1016/j.ajp.2019.09.034 garcía-fernández, l., cabot-ivorra, n., rodríguezgarcía, v., medicine, c., hernández, u. m., alshafra, e. m., … juan, s. (2019). computerized cognitive remediation therapy , rehacom , in first episode of schizophrenia : a randomized controlled trial. psychiatry research, 281(april), 112563. https://doi.org/10.1016/j.psychres.2019.11256 3 hwang, d., nam, m., & lee, y. g. (2019). the e ff ect of cognitive behavioral therapy for insomnia in schizophrenia patients with sleep disturbance : a non-randomized , assessor-blind trial. psychiatry research, 274(june 2018), 182–188. https://doi.org/10.1016/j.psychres.2019.02.002 kukla, m., bell, m. d., & lysaker, p. h. (2018). a randomized controlled trial examining a cognitive behavioral therapy intervention enhanced with cognitive remediation to improve work and neurocognition outcomes among persons with schizophrenia spectrum disorders. schizophrenia research, 197, 400–406. https://doi.org/10.1016/j.schres.2018.01.012 kumar, d., ashwini, k., hegde, s., prasanna, l., joseph, b., bose, a., … varambally, s. (2019). caregiver assisted home-based cognitive remediation for individuals diagnosed with schizophrenia : a pilot study. asian journal of psychiatry, 42(304), 87–93. https://doi.org/10.1016/j.ajp.2019.03.010 kuo, j., lin, s., & king, l. (2010). functional recovery in schizophrenia. 24(2), 87–98. lanser, i., browne, j., pinkham, a. e., harvey, p. d., jarskog, l. f., & penn, d. l. (2018). evaluating social skill in individuals with schizophrenia with the brief impression questionnaire ( biq ). psychiatry research, 269(february), 38–44. https://doi.org/10.1016/j.psychres.2018.08.047 lindenmayer, j., khan, a., mcgurk, s. r., kirstie, m., kulsa, c., ljuri, i., … parker, b. (2018). does social cognition training augment response to computer-assisted cognitive remediation for schizophrenia ? schizophrenia research, 201, 180–186. https://doi.org/10.1016/j.schres.2018.06.012 lysaker, p. h., keane, j. e., poirier, s., & lundin, n. b. (2020). schizophrenia research : cognition schizophrenia , recovery and the self : an introduction to the special issue on metacognition. schizophrenia research: cognition, 19(november 2019), 100167. https://doi.org/10.1016/j.scog.2019.100167 matsuda, m., & kohno, a. (2016). archives of psychiatric nursing effects of the nursing psychoeducation program on the acceptance of medication and condition-speci fi c knowledge of patients with schizophrenia. archives of psychiatric nursing, 30(5), 581–586. https://doi.org/10.1016/j.apnu.2016.03.008 mcclure, m. m., gra, f. s., triebwasser, j., perezrodriguez, m. m., rosell, d. r., szeszko, p. r., … hazlett, e. a. (2019). psychiatry research : neuroimaging neuroimaging predictors of response to cognitive remediation and social skills training : a pilot study in veterans with schizophrenia. 293(april 2018), 2018–2020. https://doi.org/10.1016/j.pscychresns.2019.11 0988 morrison, a. p., pyle, m., gumley, a., schwannauer, m., turkington, d., maclennan, g., … barnes, t. r. e. (2018). cognitive behavioural therapy in clozapine-resistant schizophrenia ( focus ): an assessor-blinded , randomised controlled trial. 633–643. https://doi.org/10.1016/s22150366(18)30184-6 pre-proof, j., tan, y., yang, f., wang, z., xue, f., & xiao, c. (2020). improving social functioning in community-dwelling patients with schizophrenia: a randomized controlled computer cognitive remediation therapy trial with six months follow-up. psychiatry research, 112913. https://doi.org/10.1016/j.psychres.2020.11291 3 sandoval, l. r., lópez, b., stone, w. s., guimond, s., torres, c., sheynberg, d., … keshavan, m. s. (2019). effects of peer social interaction on performance during computerized cognitive remediation therapy in patients with early course schizophrenia : a pilot study. 203, 17–23. https://doi.org/10.1016/j.schres.2017.08.049 saperstein, a. m., lynch, d. a., qian, m., & medalia, a. (2020). how does awareness of cognitive impairment impact motivation and treatment outcomes during cognitive remediation for schizophrenia ? schizophrenia research, (xxxx), i. iskandar et al. 156 | pissn: 1858-3598  eissn: 2502-5791 10–15. https://doi.org/10.1016/j.schres.2020.02.014 spencer, h. m., mcmenamin, m., emsley, r., turkington, d., dunn, g., morrison, a. p., … dudley, r. (2018). cognitive behavioral therapy for antipsychotic-free schizophrenia spectrum disorders : does therapy dose in fl uence outcome ? schizophrenia research, 202, 385–386. https://doi.org/10.1016/j.schres.2018.07.016 tong, w., yu, h., mcmaster, t. w., yip, a. l. k., & wong, j. c. l. (2019). effectiveness of a mindfulnessbased psychoeducation group programme for early-stage schizophrenia : an 18-month randomised controlled trial. schizophrenia research, 212, 140–149. https://doi.org/10.1016/j.schres.2019.07.053 peran ayah dalam keberhasilan program inisiasi menyusui dini (imd) pada bayi yang lahir secara sectio cesaria (the role of father in successfulness of early breastfeeding initiation program to the newborn with sectio cesarea) sestu retno d.a*, nursalam**, budi santoso***, rachmat h**** *stikes pemkab jombang, jl. dr. soetomo no. 75-77 jombang jawa timur 61411 indonesia **fakultas keperawatan universitas airlangga ***fakultas kedokteran universitas airlangga ****fakultas kesehatan masyarakat universitas airlangga email: sestu.retno@yahoo.com abstrak pendahuluan: persalinan secara sectio cesaria(sc)merupakan salah satu kendala untuk melakukaninisiasi menyusui dini(imd). kesiapan ibu yang baru melahirkan untuk memberikan asinya pada bayi yang baru dilahirkan memerlukan adanya persiapan karena ibu mengalami perubahan peran.pencapaian peran ibu bisa berhasil bila ibu menjadi dekat dengan bayinya dan mendapatkan dukungan dari ayah.peran ayah dalam pelaksanaan imd adalah sangat penting.keterlibatan ayahi dalam pelaksanaan imd ini meliputi pemberian dukungan dan interaksi. ayah merupakan orang terdekat bagi ibu menyusui yang diharapkan selalu ada di sisi ibu dan selalu siap memberi bantuan. jika ibu mendapatkan kepercayaan diri dan mendapat dukungan penuh dari ayah, motivasi ibu untuk menyusui akan meningkat.penelitian ini bertujuan untuk mengetahui peran ayah dalam pelaksanaan imd.metode: penelitian ini menggunakan jenis penelitian eksplanatif observasional dengan rancangan cross sectional, bertujuan menggumpulkan data responden untuk menjawab issu strategis yang sedang terjadi, yang menyebabkan ibu postsc tidak melaksanakan imd. responden sejumlah 282 ibu post sc yang memenuhi kriteria inklusi dan eksklusi. tempat penelitian ini dilakukan di ruang operasi (ok) kebidanan rumah sakit tipe b, yaitu rsud jombang dan rsud sogaten madiun. hasil: hasil pengujian secara bersama terdapat pengaruh dari variabel dukungan ayah dan interaksi ayah terhadap pelaksanaan imd.hasil pengujian secara individu terhadap variabel dukungan ayah terdapat pengaruh terhadap pelaksanaan imd, sedangkan pada variabel interaksi ayah tidak terdapat pengaruh terhadap pelaksanaan imd.pelaksanaan imd dipengaruhi oleh dukungan ayah sebesar 3,7%. diskusi: ibu yang didukung ayahi lebih termotivasi untuk melaksanakan imd kepada bayinya. kata kunci: persalinan sectio cesaria, inisiasi menyusui dini (imd) abstract introduction: delivery through sectio caesaria (sc) is one of the obstacles to doing initiation of breast feeding. the readiness of new mothers to give her milk to the newborns in need of psychological preparation, because the mother has a role change. the achievement of the role of the mother can be successful if the mother close to the baby and get the support from the spouse (husband). husband's role in the implementation of imd is very important. husband's involvement in the implementation of imd include the provision of support and interaction. the husband is the closest person for breastfeeding mothers who are expected to always be on the maternal side, and are always ready to provide assistance. if mothers gain confidence and full support of her husband, the motivation for breastfeeding mothers will increase.the objective of this study was to know the role of husband in accompanied the mother with section caesarean in implementing of imd.methods: this study used observational eksplanatif, with cross-sectional design, the aims were collecting the respondent data to answer the strategic issues which were going on, which caused the post sc women do not implemented the imd. respondent: as many 282 post sc mothers who covered the inclusion and exclusion criteria. the study was conducted in the operating room (ok) type b obstetrics hospitals, namely rsud jombang and rsud sogaten madiun.result: the test results together showed there was an effect from spouse support variable and spouse’s interaction to the implementation of imd. individual test result of spouse support to the effect of implementation of imd, however variable of spouse’s interaction, there was no effect to the implementation of imd. the implementation of imd was effected by spouse support as many as 3,7%.discussion:the mother that had the support from spouse had a higher motivation in implementation of imd to the baby key words: caesarian delivery, initiation of breast feeding pendahuluan pelaksaanaan inisiasi menyusu dini (imd) s a n ga t di pe n ga r uhi oleh metode persalinan.persalinan secara sectio caesaria (sc)merupakan salah satu kendala untuk melakukan imd. hal ini berhubungan dengan rasa nyeri akibat luka operasi, pengaruh anastesi, ketidaknyamanan ibu, dan belum keluarnya asi setelah operasi (prior, e., santhakumaran, s., gale, c., philipps, l. h., modi, n., & hyde 2012). meskipun telah dilakukan pemberian anestesi tetapi rasa nyeri masih dirasakan oleh ibu. seperti yang jurnal ners vol. 11 no. 2 oktober 2016: 224 229 225 dikemukakan oleh (padmavathi, p., jayadeepa, t., &babu 2014) ,dalam penelitiannya menunjukkan bahwa alasan ibu tidak melaksanakan imd adalah akibat nyeri luka operasi (92%), ketidaknyamanan (78%), efek anestesi (74%). nyeri postsc apabila tidak segera diatasi dapat menurunkan kemampuan ibu dalam melaksanakan imd (storm, 2007). penelitian sebelumnya menunjukkan bahwa sc merupakan salah satu kendala untuk melakukan imd. hasil penelitian prior, e., santhakumaran, s., gale, c., philipps, l. h., modi, n., & hyde (2012)menunjukkan adanya hubungan yang negatif antara persalianan secara sc dengan pelaksanaan imd. hal ini berhubungan dengan rasa nyeri akibat luka operasi, pengaruh anastesi, ketidaknyamanan ibu, dan belum keluarnya asi setelah operasi. seperti yang dikemukakan oleh padmavathi, p., jayadeepa, t., &babu (2014) dalam penelitiannya menunj ukkan bahwa alasan ibu tidak melaksanakan imd adalah akibat nyeri luka operasi (92%), ketidaknyamanan (78%), dan efek anestesi (74%). ibu yang baru melahirkan perlu mempersiapkan diri untuk memberikan asinya pada bayi yang baru dilahirkan, persiapan secara psikologis diperlukan karena ibu mengalami perubahan peran. berdasarkan teori keperawatan maternal role attainmentbecoming a mather yang dikembangkan oleh ramona t. mecer, yang mengemukakan bahwa focus utamadari teori ini adalah gambaran proses pencapaian peran ibu dan proses menjadi seorang ibu. pencapaian peran ibu bisa berhasil bila ibu menjadi dekat dengan bayinya dan mendapatkan dukungan dari pasangan (suami) termasuk mengekspresikan kepuasan dan penghargaan peran selanjutnya setelah melahirkan (alligood 2002). peran suami dalam pelaksanaan imd adalah sangat penting, karena suami akan turut menentukan kelancaran refleks pengeluaran asi yang sangat dipengaruhi oleh keadaan emosi atau perasaan ibu. suami dapat berperan aktif dalam membantu ibu dalam memberikan asi dengan memberikan dukungan emosional dan bantuan-bantuan praktis lainnya (roesli 2001). kebutuhan kenyamanan fisik termasuk defisit dalam mekanisme fisiologis yang terganggu atau beresiko karena sakit atau prosedur invasif.kebutuhan fisik yang terlihat seperti nyeri mudah tangani dengan maupun tanpa obat. standar kenyamanan intervensi diarahkan untuk mendapatkan kembali dan mempertahankan homeostasis (kolcaba, k., &dimarco 2005;wong, j. y., & earl 2009) kebutuhan kenyamanan psikospiritual termasuk kebutuhan untuk kepercayaan diri, motivasi dan kepercayaan agar klien lebih tenang ketika menjalani prosedur invasif yang menyakitkan atau trauma yang tidak dapat segera sembuh.kebutuhan ini sering dipenuhi dengan tindakan keperawatan yang menenangkan bagi jiwa klien serta ditargetkan untuk trasedensi seperti relaksasi dan distraksi, sentuhan dan kepedulian.fasilitasi diri untuk strategi menghibur dan kata-kata motivasi. tindakan ini termasuk intervensi khusus karena perawat sering sulit meluangkan waktu untuk melaksanakannya tetapi apabila perawat menyempatkan diri maka tindakannya akan sangat bermakna. tindakan ini dapat me mf a sil itas i kl ien da n keluar ga mencapai transendence(kolcaba, k., &dimarco 2005;wong, j. y., & earl 2009) kebutuhan kenyamanan sosiokultural adalah kebutuhan untuk jaminan budaya, dukungan, bahasa tubuh yang positif, dan caring.kebutuhan ini terpenuhi melalui pembinaan yang mencakup sikap optimisme, pesan-pesan kesehatan dan dorongan semangat, penghar gaa n ter ha da p penca paia n klien, persahabatan perawat selama bertugas , perkembangan informasi yang tepat tentang setiap aspek yang berhubungan dengan prosedur, dan pemulihan kesadaran setelah anastesi. kebutuhan sosial ini juga termasuk kebutuhan keluarga untuk menghormati tradisi budaya (kolcaba, k., &dimarco 2005;wong, j. y., & earl 2009) kebutuhan kenyamanan lingkungan meliputi ketertiban, ketenangan, perabotan yang nyaman, bau yang minimal, dan keamanan.ketika perawat tidak mampu untuk menyediakan lingkungan benar-benar tenang, perawat dapat membantu klien dan keluarga untuk mampu menerima kekurangan dari pengaturan yang ideal. namun perawat harus mampu untuk melakukan upaya mengurangi kebisingan, cahaya lampu, dan pengaturan suhu ruangan dalam rangka memfasilitasi lingkungan yang meningkatkan kesehatan klien (kolcaba, k., &dimarco 2005;wong, j. y., & earl 2009) secara psikologis, seorang ibu yang didukung suami atau keluarga akan lebih termotivasi untuk memberikan asi kepada bayinya (sari, 2011). februhartanty (2008) peran ayah dalam imd (sestu retno, dkk) 226 mengemukakan bahwa untuk memenuhi asi diperlukan adanya keharmonisan hubungan pola menyusui tripartit, yaitu antara ayah, ibu, dan bayi. keberhasilan menyusui sangat ditentukan oleh peran ayah karena ayah akanturut menentukan kelancaran refleks pengeluaran asi yang sangat dipengaruhi oleh keadaan emosi atau perasaan ibu. ayah dapat berperan aktif dalam membantu ibu dalam memberikan asi dengan memberikan dukungan-dukungan emosional dan bantuanbantuan praktis lainnya. pengertian tentang perannya yang penting ini merupakan langkah pertama bagi seorang ayah untuk dapat mendukung ibu agar berhasil menyusui dini (roesli 2001). seorang ayah punya peran penting dalam keberhasilan ibu menyusui.perasaan dan semangat ibu untuk menyusui dan untuk terus memberikan yang terbaik bagi anaknya sangat bergantung pada peran ayah untuk terus menjaga suasana kondusif. proses menyusui menjadi terhambat bila kondisi ayah dan ibu tidak harmonis, ibu tidak mendapat dukungan dari suami, tidak bisa berkomunikasi dengan baik, dan perasaan ibu yang tidak aman dan nyaman (sari, 2011).dukungan suami yang merupakan faktor pendukung dalam keberhasilan asi eksklusif merupakan suatu kegiatan yang bersifat emosional maupun psikologis yang diberikan kepada ibu menyusui dalam memberikan asi. hal ini berkaitan dengan pikiran, perasaan, dan sensasi yang dapat memperlancar produksi asi (roesli 2001).suami merupakan orang terdekat bagi ibu menyusui yang diharapkan selalu ada di sisi ibu dan selalu siap memberi bantuan.keberhasilan ibu dalam menyusui tidak terlepas dari dukungan yang terusmenerus dari suami. jika ibu mendapatkan kepercayaan diri dan mendapat dukungan penuh dari suami, motivasi ibu untuk menyusui akan meningkat (sari, 2011). bahan dan metode penelitian ini menggunakan jenis penelitian eksplanatif observasional. jenis penelitian eksplanatif observasional bertujuan mengumpulkan data responden untuk menjawab isu strategis yang sedang terjadi, yang menyebabkan ibu postsc tidak melaksanakan imd.rancangan yang digunakan adalah cross sectional, dimana variabel sebab dan akibat diukur dalam waktu yang bersamaan(supriyanto dan djohan 2011).respondent: 282 ibu post sc yang memenuhi kriteria inklusi dan eksklusi. sampel dalam penelitian ini ibu post sc yang memenuhi kriteria inklusi dan eksklusi. kriteria inklusi usia kehamilan > 37 minggu, ibu dengan anastesi sab, ibu bersedia menjadi responden, puting susu menonjol, indikasisc bukan karenapeb/eklamsi, kelainan jantung dan asma. kriteria eksklusi dalam penelitian ini adalah bayi dengan kelainan kongenital, bayi lahir dengan keadaan tidak bugar, ibu dengan komplikasi sc. penelitian ini dilakukan di ruang operasi (ok) kebidanan rumah sakit tipe b, yaitu rsud jombang dan rsud sogaten madiun. results peran ayah dalam keberhasilan program imd pada bayi yang lahir secara sc terdiri dari 2 indikator, yaitu dukungan ayah dan interaksi ayah.hampir semua ayah mendukung ibu dalam melaksanakan imd meskipun persalinannya secara sc. tetapi pelaksanaan imd masih tetap rendah. tabel 1. tabel distribusi frekuensi dukungan ayah pada ibu sc dalam melaksanakan imd. no indikator imd tidak imd total 1. 2. dukungan ayah: kurang cukup (f) (%) (f) (%) (f) (%) 0 10 0 3,6 3 268 100 96,4 3 278 100 100 3. baik 1 100 0 0 1 100 tabel 2: tabel distribusi frekuensi interaksi ayah pada ibu sc dalam melaksanakan imd no indikator imd tidak imd total (f) (%) (f) (%) (f) (%) 1. interaksi ayah: kurang 0 0 0 0 0 0 2. 3. cukup baik 0 11 0 4 1 270 100 96 1 281 100 100 jurnal ners vol. 11 no. 2 oktober 2016: 224 229 227 seluruh ibu yang kurang mendapatkan dukungan ayah dalam melaksanakan imd, tidak melaksanakan imd.ibu yang mendapatkan dukungan ayah dalam pelaksanaan imd, melaksanakan imd.hampir semua ibu memiliki interaksi yang baik dengan ayah, tetapi mayoritas ibu tidak melaksanakan imd, yakni sebesar 96%. metode analisa statistik yang digunakan adalah analisa regresi linier berganda. analisa regresi linier berganda adalah analisa statistik yang digunakan untuk menguji pengaruh variabel independen terhadap variabel dependen, dimana jumlah variabel independen lebih dari satu, dan variabel dependen berjumlah satu. berdasarkan deskripsi variabel diatas, maka diketahui variabel dukungan suami (x1) dan interaksi suami (x2) merupakan variabel mempengaruhi (independent variable), sedangkan pelaksanaan imd (y) yang merupakan variabel dipengaruhi (dependent variable). hasil pengujian uji-t terhadap variabel dukungan suami (x1) didapatkan t-hitung 3,270 dimana nilai sig. 0,001 dengan tingkat signifikansi (α)= 5%. berdasarkan kriteria pengujian jika nilai sig. < α maka disimpulkan terdapat pengaruh signifikan variabel dukungan suami terhadap pelaksanaan imd. hasil pengujian uji-t terhadap variabel interaksi suami (x2) didapatkan t-hitung 1,465 dimana nilai sig. 0,144 dengan tingkat signifikansi (α)= 5%. berdasarkan kriteria pengujian jika nilai sig. > α maka disimpulkan tidak terdapat pengaruh signifikan variabel interaksi suami (x2) terhadap pelaksanaan imd (y). hasil pengujian uji-t terhadap konstanta didapatkan t-hitung 2,901 dimana nilai sig. 0,004 dengan tingkat signifikansi (α) = 5%. berdasarkan kriteria pengujian jika nilai sig.< α maka disimpulkan terdapat pengaruh signifikan konstanta terhadap pelaksanaan imd (y). berdasarkan hasil pengujian individu terhadap masing-masing variabel dukungan ayah (x1), interaksi ayah (x2), dan konstantan, maka disimpulkan hanya interaksi ayah (x2) yang tidak signifikan berpengaruh terhadap pelaksanaan imd (y). variabel yang signifikan berpengaruh yakni konstanta dan dukungan ayah (x1) yang memiliki nilai koefisien yakni sebesar 0,809 yang merupakan koefisien konstanta regresi, dan nilai 0,346 yang merupakan koefisien variabel dukungan suami (x1). sehingga selanjutnya didapatkan persamaan regresi y = 0,809 + 0,346 x1 konstantan sebesar 0,809 menyatakan bahwa jika tidak ada dukungan ayah ( jika x1 bernilai nol), maka pelaksanaan imd memiliki nilai sebesar 0,809. koefisien regresi x1 sebesar 0,346 menyatakan bahwa setiap peningkatan dukungan ayah sebesar satu satuan, maka akan meningkatkan pelaksanaan imd sebesar 0,346 satu satuan. berdasarkan hasil pengolahan didapatkan nilai r-square sebesar 0,037. hal ini berarti sekitar 3,7% pelaksanaan imd (y) dapat dijelaskan oleh dukungan ayah (x1). sedang sisanya 96,3% dijelaskan oleh variabel-variabel lainnya. pembahasan faktor ayah dijelaskan oleh dua indikator yaitu dukungan ayah dan interaksi ayah-ibu. hasil penelitian menunjukan mayoritas ayah memberikan dukungan cukup terhadap ibu yang melahirkan secara sc. hampir semua ayah-ibu memiliki interaksi yang baik. faktor dukungan ayah membuktikan mampu meningkatkan pelaksanaan imd pada ibu bersalin secara sc. suami atau pasangan intim (father or intimate partnert), berdasarkan teori keperawatan mercer berkontribusi pada proses pencapaian peran ibu yang pada pelaksanaannya tidak bisa digantikan oleh orang lain. interaksi ayah membantu mengurangi tekanan dan memfasilitasi pencapaian peran ibu (nursalam 2013). mercer, r. t., & ferkehch (1990) mengidentifikasi bahwa dukungan emosional dan penghargaan yang dimaksud adalah perasaan mencintai, penuh perhatian, percaya dan mengerti, tentang peran pelaksanaan, dan bagaimana ia menampilkan perannya. dukungan instrumental sebagai pertolongan yang langsung seperti membantu merawat bayi serta dukungan informasional untuk membantu individu menolong dirinya sendiri dengan memberikan informasi yang berguna dan berhubungan dengan masalah dan atau situasi. secara psikologis, seorang ibu yang didukung ayah atau keluarga akan lebih termotivasi untuk memberikan asi kepada bayinya (sari, 2011). februhartanty (2008) mengemukakan bahwa untuk memenuhi asi diperlukan adanya keharmonisan hubungan pola menyusui tripartit, yaitu antara ayah, ibu, dan bayi. keberhasilan menyusui sangat ditentukan oleh peran ayah karena ayah akan t urut me nent ukan kela nc ara n ref le ks pengeluaran asi yang sangat dipengaruhi olehkeadaan emosi atau perasaan ibu. ayah dapat berperan aktif dalam membantu ibu peran ayah dalam imd (sestu retno, dkk) 228 dalam memberikan asi dengan memberikan dukungan-dukungan emosional dan bantuanbantuan praktis lainnya. pengertian tentang perannya yang penting ini merupakan langkah pertama bagi seorang ayah untuk dapat mendukung ibu agar berhasil menyusui dini (roesli 2001). seorang ayah punya peran penting dalam keberhasilan ibu menyusui. perasaan dan semangat ibu untuk menyusui dan untuk terus memberikan yang terbaik bagi anaknya sangat bergantung pada peran ayah untuk terus menjaga suasana kondusif. proses menyusui menjadi terhambat bila kondisi ayah dan ibu tidak harmonis, ibu tidak mendapat dukungan dari ayah, tidak bisa berkomunikasi dengan baik, dan perasaan ibu yang tidak aman dan nyaman (sari, 2011). dukungan ayah yang merupakan faktor pendukung dalam keberhasilan asi eksklusif merupakan suatu kegiatan yang bersifat emosional maupun psikologis yang diberikan kepada ibu menyusui dalam memberikan asi.hal ini berkaitan dengan pikiran, perasaan, dan sensasi yang dapat memperlancar produksi asi (roesli 2001).ayah merupakan orang terdekat bagi ibu menyusui yang diharapkan selalu ada di sisi ibu dan selalu siap memberi bantuan.keberhasilan ibu dalam menyusui tidak terlepas dari dukungan yang terusmenerus dari suami. jika ibu mendapatkan kepercayaan diri dan mendapat dukungan penuh dari suami, motivasi ibu untuk menyusui akan meningkat (sari, 2011). keterlibatan seorang ayah dalam pelaksanaan imd akan memberi motivasi ibu dan menentukan kestabilan emosi ibu. kondisi emosi yang stabil menentukan sikap positif ibu. kestabilan tersebut bisa diraih bila sang ayah atau keluarga memberikan dukungan atau motivasinya secara maksimal. dukungan memberikan suatu kesan bahwa ia dicintai dan diperhatikan, memiliki harga diri dan dihargai sehingga dengan sendirinya akan berpengaruh terhadap emosional ibu dimana ia lebih tenang, nyaman (lumula, et. al, 2012). selain itu, ayah didukung untuk mengenali perilaku bayi sebelum menyusu.hal ini dapat berlangsung beberapa menit atau satu jam. dukungan ayah akan meningkatkan rasa percaya diri ibu (roesli 2001). pada kenyataannya, hal ini sesuai karena aya tidak diperbolehkan mendampingi istrinya di kamar operasi terutama saat di ruang operasi, sehingga dukungan yang diberikan ayah tidak maksimal. padahal dukungan ayah selama di kamar operasi diperlukan untuk meningkatkan percaya diri ibu dalam melaksanakan imd. sehingga dapat disimpulkan bahwa meskipun ibu mendapatkan dukungan ayah, tetapi ayah tidak berada disisi ibu saat operasi menyebabkan ibu tidak mampu melaksanakan imd. simpulan dan saran simpulan variabel dukungan ayah berpengaruh signifikan terhadap pelaksanaan imd. semakin baik dukungan ayah tentang pelaksanaan imd pada ibu, semakin meningkatkan pelaksanaan imd, sedangkan variabel interaksi ayah tidak berpengaruh signifikan terhadap pelaksanaan imd.interaksi ayah dan ibu tidak mempengaruhi pelaksanaan imd. saran dukungan ayah saat ibu sc sangat diperlukan untuk meningkatkan pelaksanaan imd. perlu dilakukan penelitian lagi untuk mengetahui faktor lain yang mampu meningkatkan pelaksanaan imd. kepustakaan alligood, m.r., 2002. a theory of the art of nursing discovered in rogers’ science of unitary human beings. international journal for human caring, 6, pp.55–60. kolcaba, k., &dimarco, m.a., 2005. comfort theory and its application to pediatric nursing. pediatric nursing, 31(3), pp.187–194. mercer, r. t., &ferkehch, s.l., 1990. predictors of parental attachment during early parenthood. journal of advanced nursing, 15(3), pp.268–280. nursalam, 2013. metodologi penelitian ilmu keperawatan: pendekatan praktis 3rd ed., jakarta: salemba medika. padmavathi, p., jayadeepa, t., &babu, a.a., 2014. initiation of breast feeding after caesarian deliver. asian journal of nursing education and research, 4(1), p.114. prior, e., santhakumaran, s., gale, c., philipps, l. h., modi, n., & hyde, m.j., 2012. breastfeeding after cesarean delivery: a systematic review and metaanalysis of world literature. american jurnal ners vol. 11 no. 2 oktober 2016: 224 229 229 journal of clinical nutrition, 95(5), pp.1113–1135. roesli, 2001. bayi sehat berkat asi eksklusif, jakarta: pt elexkomputindo. sari, reni, (2011). hubungan karakteristik, sikap, dan dukungan ayah terhadap pemberian asi eksklusif di puskesmas takang kabupaten solok tahun 2014. supriyanto dan djohan, 2011. metodologi riset bisnis dan kesehatan, kalimantan: pt grafika wangi. wong, j. y., & earl, j.k., 2009. towards an integrated model of individual, psychosocial, and organizational predictors of retirement adjustment. journal of vocational behavior, 75(1), pp.1–13. vol 9 no 1 april 2014.indd 1 efek teh hijau terhadap peningkatan fluiditas darah dan penurunan berat badan (the impact of green tea on blood fluidity improvement and weight loss) djoko agus purwanto,* asri darmawati*, purwaningsih** *department of pharmaceutical chemistry, faculty of pharmacy, airlangga university, campus b, jl. dharmawangsa dalam, surabaya 60286, indonesia **department of fundamental nursing, faculty of nursing, airlangga university, surabaya, indonesia e-mail: djokoagus@ff.unair.ac.id abstrak pendahuluan: berbagai penelitian telah menunjukkan efek menguntungkan dari teh hijau, tidak hanya pada penyakit jantung tetapi juga pada diabetes tipe 2. metode: dalam penelitian ini, penyusunan ekstrak air teh hijau sudah terstandarisasi untuk (-)-epigalocatechin gallate (egcg), komponen utama teh hijau. efek ekstrak air teh hijau terhadap fl uiditas darah dan diabetes dipelajari dalam 13 fruktosa fed rat (ffr). tikus diberi diet tinggi fruktosa ad libitum selama satu minggu dan kemudian kombinasi dengan ekstrak air teh hijau setiap hari selama 6 hari. hasil: hasil penelitian menunjukkan, air ekstrak teh hijau dapat mengurangi 100 ul darah dari wistar tikus secara signifi kan (p<0,01) dengan alat micro-channel array arus analyzer (mc-fan). ekstrak air teh hijau juga memiliki efek yang kuat dalam mengurangi lemak perut (p<0,05), kadar glukosa darah (p<0,01) dan berat badan (p<0,01). diskusi: hasil ini menunjukkan bahwa ekstrak air teh hijau memiliki potensi menguntungkan untuk pengobatan diabetes dan mengurangi kekentalan darah. kata kunci: teh hijau , (-)-epigallocatechin gallate, hplc, fl uiditas darah , fruktosa-fed rat abstract introduction: various studies have shown the benefi cial effects of green tea, not only on cardiovascular diseases but also on type 2 diabetes. method: in this study, the preparation of green tea water extract has been standardized to (-)epigalocatechin gallate (egcg), the major component of green tea. the role of green tea water extract on blood fl uidity and diabetes diseases has been studied in 13 fructose-fed rat (ffr). the rats were given high fructose diet ad libitum for one week and then combination with green tea water extract every day for 6 days. results: the results show, green tea water extract can reduces 100 μl blood passage times of wistar rat signifi cantly (p<0.01) by micro-channel array flow analyzer (mc-fan) instrument. green tea water extract also had strong effect in reducing abdominal fat (p<0.05), blood glucose level (p<0.01) and body weight (p<0.01). discussion: these results suggest that green tea water extract may has benefi cial effects for the treatment of diabetes and reduce blood viscosity. keywords: green tea, (-)-epigallocatechin gallate, hplc, blood fl uidity, fructose-fed rat introduction tea has been consumed by many people in the world since ancient times. in various countries, green tea has been processed into a variety of foods and beverages such as cakes, ice cream and candy. beside water, tea product also consumed in varous type. at least there are four basic form of tea product: green tea, oolong tea, pu’erh tea and black tea. these forms are different in process of production. black tea was made from fermentation of tea leaf. the main componen of green tea is (-)-epigalocatechin gallate (egcg). during production process, oxidation of egcg and another substance are promoted, so that most of these substances are oxidized. because of that reason, level of egcg and total catechin in tea were depend on type of tea. in old leaf of green tea, egcg contain is higher than young leaf, and higher than oolong tea, and also higher than black tea and pu’erh tea (lyn, et al, 2003). t here is good evidence f rom i n vitro studies that green tea catechins have an impor tant role in protection against degenerative diseases. egcg from green tea extract has many activities such as anticarcinogenic (beltz et al, 2006, spinela, et al, 2006), antioxidant (luximon et al, 2006), anti-microbial activities (paul, et al., 2006, watson, et al., 2005) as well as anti-diabetic activity (kim et al., 2013). feeding of tea 2 jurnal ners vol. 9 no. 1 april 2014: 1–5 catechins has benefi cial effect for the reduction of high fat diet induced obesity by increasing lipid metabolism. egcg may modulate the distribution of rstn protein, an adipocytespecific secretory hormone that can cause insulin resistance (liu. et al, 2006). in the present study, the effect of standardized of green tea extract on egcg as the active compounds, on blood fl uidity, body weight and diabetes impact of fructose-fed wistar rat were investigated. in addition, further investigations of the effect of this extract on some organs were also examined. materials and methods g r e e n t e a w a s o b t a i n e d f r o m commersial product of ptpn 12, indonesia. heparin is included on venoject tube 5 ml sterile from kruuse. fructose, casein, vitamins and minerals were purchase from wako pure chemical industry. male wist ar rats were obt ai ned from clea inc. japan at 7 weeks of age. the fructose-fed diet mixed in laboratory of nutrition physiology kobe women’s university. the components of the fructose fed (100 g) were follows: 66% fructose, 22% casein, 12% lard plus essential vitamins and minerals. samples experiment were given green tea extract 300 mg/kg body weight in water solution the control was made by given the same volume of distilled water. wistar rat were kept in an animal room maintained at constant temperature (22 + 2oc). the rat consumed a fructose fed ad libitum and had free access to distilled water for 2 weeks. body weight was measured every day. all procedures were performed in accordance with standards related to the care and management of experimental animals (including ethics) of the kobe women’s university. wistar rat (8-10 weeks old) were fasted 12 h before the starting point of experiments. the rats were per orally administered with either a suspension of green tea powder on hot water at 9:20 a.m. ten minute after the administration (at 9:30 a.m.), the rats were perorally administered with 1.0 ml of glucose solution containing 350 mg glucose. blood glucose levels were measured before and 30, 60, and 120 min after the administration with glucose solution. mix 2.0 ml of fresh blood with 100 μl heparin. blood passage time was measured for 100 μl of blood through an artifi cial capillary using mc-fa n (micro chan nel a r ray flow analyzer). the micro-channel array consisting of 8,736 capillaries with 4.5 μm in diameter and 30 μm in length. the time needed was determined and expressed against 100 μl saline solution adjusted to 12 seconds. for statistical evaluation of the data in rat, repeated measures student’s t test were used. difference of p < 0.05 were considered signifi cant. spss 14.0 for windows software was used for all statistical analysis. values in the text are means + sd. results in the chromatograms of the egcg standard solution analyzed by hplc, the peak of standard egcg was identifi ed as the single peak and separated completely from other compound in sample of green tea extract. standard egcg concentration has linier correlation (r =0.9994, p<0.01) with hplc peak area. concentration of egcg in sample extract green tea was found 4.53 + 0.03 % and calculated from dry weight. this standardized sample was used for further examination in blood fl uidity and diabetic impact of fructose fed rat. effect of green tea extract on blood parameter, fat and organs can be seen in table 1. abdominal fat decreases signifi cantly after drinking green tea. the average abdominal fat for the control group being 70% greater than in the animals with green tea. all of the blood parameter did not change signifi cantly between two groups. organs weight also has no signifi cantly different except pancreas and kidney. effect of green tea water ext ract treatment on glucose metabolism in ffr was observed by oral glucose tolerance test (ogtt) at 2 week. figure 2 shows that no signifi cant differences of ogtt were observed between control and green tea extract groups. 3 efek teh hijau terhadap peningkatan fluiditas darah (djoko agus purwanto, dkk.) figure 1. structure of (-)-epigallocatechin gallate (egcg) from green tea. figure 2. oral glucose tolerance test of green tea extract (gte) and control on fructose-fed rats. tabel 1. effect of green tea extract on blood parameters, fats and organs weight of fructose-fed rat (ffr) control (n = 5) green tea (n = 8) p** blood parameter white blood cell (x102 /μl) 51.07 + 14.25 54.04 + 11.48 ns red blood cell (x104 /μl) 773.40 + 15.75 792.42 + 33.36 ns hemoglobin (g/dl) 15.21 + 0.28 15.63 + 0.46 ns hematocrite (%) 48.35 + 0.85 49.35 + 1.48 ns mcv (fl ) 62.53 + 0.84 62.31 + 0.96 ns mch (pg) 19.66 + 0.24 19.73 + 0.34 ns mchc (g/dl) 31.47 + 0.20 31.69 + 0.20 ns platelet (x104 /μl) 111.86 + 8.64 113.28 + 15.80 ns fat abdominal fat (g) 3.58 + 0.68 2.03 + 0.46 s abdominal fat (g/100 g b.w) 1.48 + 0.23 0.87 + 0.20 s organs spleen (g/100 g b.w) 0.21 + 0.02 0.20 + 0.04 ns pancreas (g/100 g b.w) 0.20 + 0.09 0.27 + 0.05 s kidney (g/100 g b.w) 0.42 + 0.02 0.35 + 0.05 s adrenal (g/100 g b.w) 0.0073 + 0.0034 0.0644 + 0.1390 ns genital (g/100 g b.w) 0.63 + 0.07 0.69 + 0.05 ns lung (g/100 g b.w) 0.45 + 0.04 0.48 + 0.04 ns thymus (g/100 g b.w) 0.12 + 0.08 0.10 + 0.02 ns liver (g/100 g b.w) 3.88 + 0.17 3.58 + 0.31 ns heart (g/100 g b.w) 0.33 + 0.01 0.35 + 0.03 ns *results are expressed as means + sd. **signifi cance of difference between control and green tea (p<0.05); s=signifi cantly; ns=not signifi cantly (p>0.05) 4 jurnal ners vol. 9 no. 1 april 2014: 1–5 discussion the oral glucose tolerance test (ogtt) measures the body’s ability to use glucose, as an energy source for the body. an ogtt can be used to diagnose prediabetes and diabetes. but, there is no signifi cant differences were observed between control and green tea extract groups, although some researcher expects that high-fructose feeding could induce insulin resistance (nakagawa et al., 2002). this fact may be due to the treatment is too short so insulin tolerance has not happened. green tea extract has been known as chemo preventive agent in various diseases, and egcg as its major component has important role for this activity. egcg contain in some green tea leaf and products are different. many in vitro studies on green tea report mechanisms consistent with protection against degenerative diseases (huang et al., 1999, nakagawa et al., 2002). nevertheless, many of these studies used various concentrations of catechin and thus do not ref lect certain catechin concentrations found in herbal extract. it is diffi cult to decide these results to egcg concentration. however, because of the lack information of active compounds role and also biological effects of the conjugates, thus, animal studies are more relevant for investigating the physiological effects of catechins. this research studies the most interesting in vivo animal of the biological effects of standardized green tea extract on egcg before used as herbal medicine to get suffi cient effects. the results showed that consumption of green tea extract for 6 days caused a suppressive effect on weight gain and visceral fat accumulation in ffr. green tea extract contains caffeine and egcg as the principal constituents, and these constituents showed a tendency to suppress body weight gain and visceral fat accumulation. studies conducted with human subjects report reduced body weight and body fat, as well as increased fat oxidation and thermogenesis (wolfram et al., 2006). thus, these constituents (egcg and coffein) are suggested to be partially involved in the suppressive effect on body weight gain and visceral fat accumulation. blood rheolog y is now receiving increasing attention as an important potential contributory factor to diabetic angiopathy (le dévéhat et al., 2004). therefore, monitoring of the blood fl uidity becomes very important in handling of diabetics impact. the use of green tea extract may increase blood fl uidity, thereby reducing the impact of diabetic angiopathy. conclusions and recomendation conclusions it can be concluded that the water extract of green tea can decrease blood passage time of ffr, suppress body weight and visceral fat accumulation, but have no effect on blood parameter, insulin tolerance and organs weight except kidney and pancreas. figure 3. green tea extract can reduces ffr body weight signifi cantly for 6 days of treatment (p < 0.01). figure 4. effect of green tea extract on ffr blood fl uidity measured by microchannel array fl ow analyzer (mcfan). green tea extract lowers blood passage time signifi cantly (p < 0.01). 0 50 100 150 200 250 300 350 400 control green tea extract b lo od p as sa ge ti m e (s ec ) 5 efek teh hijau terhadap peningkatan fluiditas darah (djoko agus purwanto, dkk.) recommendation according to the result, it is suggest that green tea water extract may has benefi cial effects for the treatment of diabetes and reduce blood viscosity. references lin ys, tsai yj, tsay js, lin jk. factors affecting the levels of tea polyphenols and caffeine in tea leaves. j agric food chem, 2003;51(7):1864-73. beltz la, bayer dk, moss al, simet im. mechanisms of cancer prevention by green tea and black tea polyphenols. a n t i c a n c e r a g e n t me d c h e m , 2006;6(5):389-406. spinella f, rosano l, dicastro v, decandia s, albini a, nicotra mr, natali pg, bagnato a. green tea poly phenol epigallocateci n 3-gallate i n h ibits the endothelin axis and downstream signaling pathways in ovarian carcinoma. mol cancer ther, 2006;5(6):1483-92. luximon-ramma a, neergheen vs, bahorun t, crozier a, zbarsky v, datla kp, dexter dt, aruoma oi. assessment of the phenolic composition of the organic extracs of mauritian black teas: a potential contributor to their antioxidant functions. biofactors, 2006;27(1-4):7991. paul ds, saroj s, yukihiko h, peter wt. potentiation of catechin gallate-mediated sensitization of staphylococcus aureus to oxacillin by nongalloylated catechin. a nt i m ic r ob age nt s c h e m ot h e r, 2006;50(2):752-755. watson jl, vicario m, wang a, moreto m, mckay dm. immune cell activation and subsequent epithelial dysfunction by staphylococcus enterotoxin b is attenuate by green tea polyphenol (-)epigallocatechin gallate. cell immunol, 2005;237(1):7-16. kim hm, and kim j. the effects of green tea on obesity and type 2 diabetes. diabetes metab j, 2013;37:173-175. liu hs, chen yh, hung pf, kao yh. inhibitor y effect of green tea (–)epigallocatechin gallate on resistin gene expression in 3t3-l1 adipocytes depends on the erk pathway. am j physiol endocrinol metab, 2006;290: e273-e281. huang y, chan nw, lau cw, yao xq, chan fl, chen zy. involvement of endothelium/ nitric oxide in vasorelaxation induced by purifi ed green tea (–)epicatechin. biochim biophys acta, 1999;1427:322328. nakagawa t, yokozawa t, terasawa k, shu s, juneja lr. protective activity of green tea against free radicaland glucosemediated protein damage. j agric food chem, 2002;50:2418-2422. król e, krejpcio z, michalak s, wójciak rw, b o g d ańs k i p. e f f e c t s of combined dietar y ch romium(iii) propionate complex and thiamine supplementation on insulin sensitivity, blood biochemical indices, and mineral levels in high-fructose-fed rats. biol trace elem res, 2012;150:350–359. wolfram s, wang y, thielecke f. antiobesity effects of green tea: from bedside to bench. mol nutr food res, 2006;50(2):176-87. le dévéhat c, vimeux m, khodabandehlou t. blood rheology in patients with diabetes mellitus. clin hemorheol microcirc. 2004;30(3-4):297-300. microsoft word 27479-120618-2-le.docx 128 | pissn: 1858-3598 � eissn: 2502-5791 jurnal ners vol. 16, no. 2 october 2021 http://dx.doi.org/10.20473/jn.v16i2.27479 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the older adults experience caring for grandchildren with special needs sylvia dwi wahyuni, retno indarwati, and aditya budi nugroho faculty of nursing, universitas airlangga, east java, indonesia abstract introduction: nowadays, grandparents are still involved in the care of grandchildren. the previous research showed that the grandparent involvement in the care of grandchildren has a bad and good impact for older adults. this study aims to gain a deep understanding of the experience of older adults while caring for their grandchildren with special needs. methods: researchers use a phenomenological approach to explore the experience based on awareness that occurs in some individuals. the participants involved in this study were six older adults. data were collected by in-depth interview and analyzed by colaizzi’s method. results: all participants have grandchildren who attended school for special needs children in surabaya city. this study showed all participants responded positively and related involvement in taking care of grandchildren. in addition, the decision to being a part of caring for the grandchildren came from themselves and the discussions with both parents. most of the activities with grandchildren were spending time together. however, all participants complained of being tired and this condition can be solved by seeing grandchildren’s happiness. they believed that grandchildren care is better with grandmothers or grandfathers than with servants. conclusion: it can be concluded that the experiences of the older adult taking care of grandchildren are very varied and positive for the older adults. further researchers are advised to continue to explore more detail about the psychological influence of grandparents taking care of their grandchildren with special needs. article history received: june 13, 2021 accepted: october 11, 2021 keywords older adults; experience; caring; grandchildren with special needs contact sylvia dwi wahyuni *sylvia.dwiwahyuni@fkp.unair.ac.id + faculty of nursing, universitas airlangga, east java, indonesia cite this as: wahyuni, s. d., indarwati, r., & nugroho, a. b. (2021). the older adults experience caring for grandchildren with special needs. jurnal ners, 16(2). 128-134. doi:http://dx.doi.org/10.20473/jn.v16i2.27479 introduction in general, there are challenges for families raising children with special needs (franklin, 2020). children who have physical, mental, and social behavioral characteristics (such as: communication disorder, social interaction difficulties, emotional disturbances and others) need special strategies and approaches in treatment (tigere & makhubele, 2019). on the one hand, there is a change in the pattern of the role of mothers as career women and housewives so that other family members in the family (extended family) such as grandmothers will become substitute figures for parents while caring for their grandchildren (wahyuni & abidin, 2015). preliminary studies conducted by researchers at several sekolah luar biasa (extraordinary schools, a school for children with special needs) in surabaya city showed that children with special needs are more cared for by their grandparents than their parents. based on the initial data survey through interviews with the principal, information was obtained that the number of older adults with grandchildren was approximately 20 people. various experiences make parents more comfortable if the care of grandchildren is carried out by the older adults than others, such as a babysitter. however, the description of the experience of the older adults in the care of their grandchildren is still not clearly illustrated. the purpose of this study was jurnal ners http://e-journal.unair.ac.id/jners | 129 to explore the older adults who are involved in the care of grandchildren with special needs. on the other hand, the care of grandchildren has positive and negative impacts to the older adults (fauziningtyas et al., 2018). the care of grandchildren for older adults has a positive impact on physical, psychological, social, and environmental aspects (putu et al., 2020). based on the other research, grandmothers and grandfathers who are involved in caring their grandchildren reported higher rate of life satisfaction and quality of life than non-grandparents. the result also show that grandmothers reported fewer depressive symptoms than women without grandchildren (tanskanen et al., 2019).in addition, the older adults who were interviewed accepted gracefully if they were given responsibility for caring for their grandchildren. however, there are also negative effects such as fatigue and family conflict (fauziah, 2020). the major factor that affected grandparents’ health self-management who involved in taking care of grandchildren was caregiving burden (jing & guo, 2019). meanwhile, many older adults in indonesia live with their families. the older adults who live with their families in three generations are as much as 40.64% (statistik, 2019). moreover, indonesia is among the top five countries with 8.9% older adults in 2013 and will increase to 21.4% in 2050 (bps & jawa timur, 2012). the number of adults aged >60 years in east java province is 3.6 million people (bps & jawa timur, 2012). the number of older adults aged >60 years in surabaya in 2019 is 256,007 people (surabaya, 2019). in addition, the central statistics agency (bps) in 2017 stated that the number of children with special needs in indonesia was 1.6 million people. however, there is no definite data regarding the number of older adults who care for grandchildren (fauziningtyas et al., 2018). based on the background above, the experience of the older adults in the care of grandchildren with special needs to be explored. the description of this experience can be explored by qualitative research through in-depth interviews. therefore, the researchers are interested in seeing a picture of that specific experience. materials and methods this research is a qualitative method with a phenomenological approach. the population were the older adults with grandchildren who attend an extraordinary school in surabaya. sampling method used purposive sampling with the following criteria: 1) older adult aged 60-74 years, 2) take care of grandchildren for 1-12 hours per day, 3) live with grandchildren, and 4) grandchildren who attend extraordinary schools. the number of participants in the study was six older people. data collection tools consisted of interview guidelines, voice recorder, and field notes. the interview used open questions and consisted of fourteen questions that aim to explore the experience of grandparents in caring for grandchildren with special needs. the question framework was based on the theory of family centered nursing. researchers conducted interviews with participants in a facing position with a fairly close distance (approximately 50-100 cm), with the consideration that the voice recorder could record the conversation clearly. the voice recorder was placed in the open with a distance of approximately 30-50 cm from the participants. the interview process in the study lasted for 6090 minutes for each participant, ending when the required information had been obtained according to the research objectives through saturation. in addition, field notes were used to document the atmosphere, facial expressions, behavior and nonverbal responses of participants during the interview process. after all the interviews were completed, the researcher then made a contract again with the participants for the next meeting, namely for data validation. furthermore, the researcher ignores all personal assumptions related to the phenomenon under study when digging research data, puts aside his personal knowledge and understanding, and tries fully to position himself as a participant and see things from the participant's perspective. this concept is called epoche or bracketing. the data were analyzed by the colaizzi method. the data analysis was through nine stages as follows: describe the phenomenon under study, collecting descriptions of phenomena through participant opinions; read the entire description of the participants about the phenomenon being studied, separating significant statements by giving a code to participant statements that have significant meaning listed verbatim; formulate the meaning of each significant statement; categorize each unit of meaning into one theme/cluster of meaning; integrate each theme into a complete description, validating the results of the analysis to participants, and improving the results of the analysis with the data obtained during the validation process. this study has passed the ethical test by the ethics committee of the faculty of nursing, universitas airlangga. results participants in this study were six older adults consisting of one male and five female older adults. this study resulted in nine themes that were elaborated according to the research objectives to obtain a deep understanding of the experiences of the older adults and grandchildren with children with special needs. the data on the characteristics of grandparents and grandchildren are presented in the table below. theme 1: caring engagement participants in this study expressed a meaningful response based on their involvement with the mother s. d. wahyuni et al. 130 | pissn: 1858-3598 � eissn: 2502-5791 and grandchildren. all participants responded positively, namely accepting anything related to involvement with the mother of the grandchildren and one sub-theme was obtained, namely that the older adults were involved in caring for their grandchildren for one full day. statements about involvement in the mother and grandchildren were expressed by the following participants: custodian “currently, this child's parents are already working, so 100% of the care is with me and my wife. actually they have a house but it is not inhabited because we chose to raise this child here.” (p2) "as a grandmother, i take care of all day, starting to drop off school in the morning, take care when at home and outside the house because this child with special needs requires full attention. eating, drinking, and resting time should also be a priority.” (p4) theme 2: the feeling of caring for grandchildren with special needs gratitude "yes, he feels grateful to be able to teach him all the time, to keep talking, if not invited to talk, his child will continue to be silent like this. so ... oh no ... just be grateful if i just give thanks for the gift of allah swt. yes, if asked to sing, taught to recite the koran, that's how it used to be if now i rarely want to talk about it like that….” (p1) happy “yes, i am happy, bro, i have never had grandchildren, that only grandchildren, but yes, god gave it, yes, we accept it as it is, bro. maybe there are people who are ashamed, but i'm not ashamed, bro, entrusted it like that, inshaallah, bro, because it was a deposit from god, bro, my mandate, bro, i will feel guilty. actually, i'm sorry to see a child like that, for example learning, the obstacle is lazy, bro, if you can actually learn, bro, it's just that there is less interest in learning, bro, so it's hard there, so you have to be patient....” (p6) sad "as a human, sometimes there is sadness, sometimes there is anger. it's sad if someone wants their grandchildren, since i was little i took care of them so there were signs ‘this body is not feeling well or something,’ that's sad...." (p2) annoyed “sometimes i get annoyed because i can't say if i want to pee so i still use a pamper, so i don't to the point of littering the house. so he can't be independent yet....” (p6) angry "sometimes i get angry because he doesn't obey, but i really love him. angry at my grandchildren can't really be angry. he's just a matter of taking a shower is hard. he didn't even want to enter the bathroom, so we had to seduce him with a gold toy so that his grandson would go to the bathroom and take a shower...." (p3) attention "yes, it's normal, it's normal, children with special needs need affection, so if their parents can't take care of it, i take care of it...." (p5) fatigue "that's the complaint, my legs get tired sometimes because i have gout...." (p1) theme 3: parenting decisions self-decision "they (parents and grandchildren) all work so i take a stand to take care of him. if a helper is handed over, it is not certain that it will be done. there is also no coercion in the care of grandchildren....” (p5) joint decision "his parents work, yes, we want to happily accept them together with his siblings as well, we are very supportive, so this is a mutual agreement, while people wanted to take it in the past, but we are table 1. grandparent characteristics participant gender education level profession religion marital status age (year) 1 female junior high school housewife islam married 67 2 male senior high school retired islam married 72 3 female junior high school housewife islam married 66 4 female diploma iii housewife islam married 65 5 female diploma iii retired islam widow 68 6 female junior high school housewife islam widow 72 table 2. grandchildren characteristics participant gender age (year) special condition 1 male 12 down syndrome 2 male 16 down syndrome 3 female 10 down syndrome 4 female 10 down syndrome 5 male 11 down syndrome 6 female 14 down syndrome jurnal ners http://e-journal.unair.ac.id/jners | 131 afraid because we are not in the same heart as we are afraid that something will happen to my grandchild. i used to have a student like this but he was not active, still like that, he continued to drink, he was given medicine, he continued to sleep and was left behind, how about that? well, i'm very scared, and i will think if there is something wrong with our grandchildren, so now we are just worried...." (p3) theme 4: activities during parenting learning "sometimes he studies, if he's in the mood we guide him, but if he is forced, he doesn't want to...." (p3) worship "i thank allah swt for the first time, he often saw me praying five times at that time, now he is the one who tells me the time for prayer and keeps saying he wants to go to the mosque or mosque, so he wants to ask to move to the prayer room, evening prayer at the prayer room for evening prayer ' the mosque is close to me, so i follow the problem according to my wishes....” (p2) taking a walk "where have you been if you want to walk like that, if i get it, go for a walk with his brother, younger brother, his father, his mother. yes, i sometimes walk to tp, yes, but sometimes if i want to go to malang, like yesterday, i didn't go along, i was tired so i couldn't join....” (p5) playing "yes, i usually bathe, yes i am invited to play. come on, don't worry, yes that's usual, i want to ask for my pan to give me a bribe..." (p4) watching tv "grandma watching tv together, sometimes you listen to radio, listen to me..." (p6) doing homework “in the morning, cook, cook, there are employees, right? yes, i did cook. this is when it's still early morning with the mother, so i'll cook later if i want to go to a new school with me, right, there is a mother in the morning too. brother, when night sleeps with his mother, this is the little one who sleeps with me, this is the second grandchild of my child..." (p1) selling snacks in front of the house "i help my son sell snacks in front of the house, i also help wholesale the ingredients when they run out. it's good to be able to fill time and increase income.” (p2) community activities "yes, at home, there are rw activities, mas, if there is a recitation and at home, the mother will take care of the mother. if the recitation in the mosque is wednesday and friday then the routine recitation is every wednesday, sometimes wednesday, sometimes it's wednesday, sometimes someone asks for saturday or sunday, but if there are no parents, i don't dare to die, if the parents haven't come home, i don't have the courage. died mas still a little pity...." (p4) theme 5: fulfillment of daily needs meeting the needs of children from parents “grandchildren’s daily needs are met by their parents, we (grandfathers) only buy snacks when our grandchildren ask for it.” (p2) “all the needs of grandchildren are met by his father because his mother does not work.” (p4) compliance with the grandchildren needs by grandparent “i also help meet the needs of my grandchildren because i have a pension every month.” (p4) “i fulfill all the needs of my grandchildren because their parents need a lot of other expenses including therapy.” (p6) theme 6: addressing complaints break "yes, sleep, rest and take medicine so that we don't get tired the next day we can do what we do again, so take care of the man...." (p3) pray “i always pray for my grandson. i recited a verse about illness so that my grandson's illness would be removed. in addition, the doctor also said that before taking medication, read a prayer first. i believe god will help us if we pray.” (p2) get treatment "yes, you anticipate if the medicine is routine every day, you have to drink it, sometimes you get hit with food, which may be too salty, so sometimes you are alert, sometimes you fight, bro. cholesterol is indeed from a lot of fried foods, but if you boil tempeh, it's not delicious if it's not fried. the doctor's advice is not too strict on a diet, you just have to reduce it, but sometimes chronic disease conditions change to become uncomfortable, right, the mind can also catch a cold too. yes, if he sleeps sometimes i can definitely rest if i don't sleep, i can't....” (p5) theme 7: attitudes and perceptions informational support "yes, you already know that the neighbors often ask ‘where are you being treated?’ yes, i said therapy. so you usually just ask" ‘mom, mom?’ yes, you can do it yourself, if you don't bring up your own children, you can run away, but you can do it, mom. s. d. wahyuni et al. 132 | pissn: 1858-3598 � eissn: 2502-5791 receive "ohhh nothing, if in my neighborhood where there is a grandmother it is commonplace to take care of the grandchild because it seems like there is a grandmother, so if you want to join her grandmother, it doesn't matter because there is a tradition here...." (p4) disregard "it's not important to the neighbors, although there are assumptions that there are those who tend to talk like that, but my grandson, how come i don't receive payment, not forced to, if he thinks it's good, please if not yes please...." (p5) ordinary "just normal, you don't say the one who takes care of me is only the parents saying thank you. yes, if i asked for this, it was bought because it was spoiled education. if i did that, i taught dewe. i should just have to rest because it is still needed so i have to help. i myself am a maid in mongol, so don't have the heart for people to be the same, how come sometimes there are people who clam up, there is something like that, because they are still able to move unless there is no strength....” (p5) gossip "yes, it is common for villagers to talk about their son-in-law, but i don't care about it ..." (p6) theme 8: family interaction harmonious "there is no problem, our relationship is all good...." (p4) lack of communication "yes, the interaction with my son number 5 is not good, like a disobedient child because he never calls. my son-in-law often wanders around rarely at home...." (p6) theme 9: hope independent "yes, he can continue to be independent on his own. if god gives him health, independence can be useful for the mother and father, just like that. independent in any way and must be supervised by parents. we support you together, you take care of each other. grandchildren and children are stickier to grandchildren….” (p3) healthy "yes, there is a limit, it's impossible for him to be faced with becoming an engineer. no need to be grandiose the important thing is healthy....” (p5) discussion the involvement of the older adults caring for grandchildren in this study is the role of the grandparents in meeting the educational and physical needs of the grandchildren. the role of the older adults is needed in the growth and development of grandchildren. raising grandchildren is a shared responsibility of grandparents and parents. this is in line with the previous research (fauziningtyas et al., 2018). moreover, about 80% of grandparents say they are happy with their grandchildren (santrock, 2002). the fundamental value in the family structure in asia is to place parents as parties to be held and respected (pujiatni & kirana, 2013). the family maintains relationships between generations, where the early generations will always leave an influence on the next generation (santrock, 2002). in addition, participants had feelings of joy during their time with their grandchildren and some older adults experienced or had complaints when caring for their grandchildren, but these complaints disappeared when the older adults saw their grandchildren happy. this is in line with research conducted by rista et al. which states that “grandparenting” in java provides positive experiences and feelings of happiness for grandparents (fauziningtyas et al., 2018). the experience gained by the older adults can make them the right figure to provide a benchmark for family values that should be applied (pujiatni & kirana, 2013). moreover, the existence of a family can achieve individual needs such as support, love, and emotions like happiness (wahyuni & abidin, 2015). furthermore, participants said that they tend to make decisions for themselves because the older adults think that their grandchildren are everything and are the successor of the family. this is in line with previous research (wahyuni & abidin, 2015) which states that the experience gained by the older adults makes them a figure appropriate to provide a benchmark for family values that should be applied. decisions that are taken collectively are due to the busy careers of the parents of the child. furthermore, a family can be decisive in making decisions on other family members (kertamuda, 2009). likewise, grandchildren will learn ways to achieve social roles for themselves. additionally, participants often spent their time doing activities with their grandchildren. the older adults also do other activities when they do not care for their grandchildren, such as participating in community activities and doing household chores. this condition is similar to papalia and olds (2008) who found that the grandparents’ activities are often having dinner together, watching television, shopping, and practicing or playing sports with their grandchildren. according to duvall, the developmental task at old age is to adjust the stage of retirement by changing ways of life; the older adults accept the death of a partner, friends and prepare for death, the older adults maintain the intimacy of their partner and care for each other, and carry out past life jurnal ners http://e-journal.unair.ac.id/jners | 133 reviews (setiadi, 2008). santrock (2002) said that successful aging indicates the success of the older adults in facing the changes that occur in their life. this success is characterized by the ability to perform daily activities such as homework (peterson, 2017). almost all of the fulfillment of the needs of the grandchildren came from both parents and grandparent. however, some grandparents meet almost all the needs of grandchildren because their mothers are not working and the older adults have pension funds. according to papalia and olds (2008), more than half of grandparents spend money on the needs of their grandchildren. grandparents take care of their grandchildren while their parents work and prepare school supplies for their grandchildren, wait for their grandchildren's school, until they come home from school and at home. the fulfillment of formal and informal support for the older adults in raising grandchildren is in the form of fulfilling financial needs in the form of money (choi, sprang, & eslinger, 2016). participants think that there are no damning complaints, everything can be resolved. it turns out that every time a complaint comes, the older adults feel paid off when they see their cute and healthy grandchild. psychologically, physical fatigue can be relieved by praying in overcoming the disease. this is in line with research which states that grandparents only raise grandchildren when their children work; when parents have returned from work, the grandchildren are handed back to their parents. in addition, they said that they did not only talk to their grandchildren, they could be involved in other activities. for rest hours, the older adults feel very adequate because, when their grandchildren take a nap, the older adults also take a nap so they don't feel disturbed for resting (suyanta & ekowarni, 2012). the attitudes and perceptions of the participants obtained different results, that the responses from neighbors about their grandchildren were different, some were normal, some supported helping remind, and some did not care. older adults also sometimes hear words that are not wearing from people around them but the older adults choose to ignore it and stay focused on taking care of their grandchild. parent figures in the extended family have a meaning in regard to parenting the children (yulion, 2013). parents trust more when their children are taken care of by grandparents than when they have to leave with someone else. this is in accordance with research which states that various experiences make a child believe that the care of grandchildren is carried out by the older adults rather than others outside the family, such as babysitters (pujiatni & kirana, 2013). each family member must support each other because of an absolute obligation; momong and grandchildren are natural (bulanda & jendrek, 2014). good relationships and support from family can help minimize discontinuity in the older adults (papalia & olds, 2008). a warm relationship with children is the highest support for the older adults. therefore, a good relationship between children, sonin-law, grandchildren and family is very good for the older adults psychologically. older adults are happy in continuing to care for their grandchildren because the older adults want their grandchildren to learn ways to achieve social roles for themselves. there is also a developmental task for the older adults, which is called a life review, and allows the older adults to see the past that is in their grandchildren so that the older adults are very happy if they continue to care for their grandchild because they see their old identity in their grandchild (wahyuni & abidin, 2015). conclusion overall, this study shows that all participants felt positive experiences during grandparenting. participants expressed the same response regarding the meaning of a grandchild. they believed that grandchildren are everything, beyond their own children, a diamond, a gift and a pride. in addition, they had feelings of joy at the birth of grandchildren and the decisions of grandparenting were from themselves. most of the activities that are often done with grandchildren are playing. the other activities were participating in community activities, taking care of the household, watching tv, and selling snacks in front of their house. on the other hand, the feeling of tiredness and negative experiences will disappear when they see their grandchildren happy and cheerful. all participants think that the care of grandchildren is better with grandparents than with helpers. references bps & jawa timur. (2012). profil penduduk lanjut usia provinsi jawa timur. bulanda, j. r., & jendrek, m. p. (2014). grandparenting roles and volunteer activity. the journals of gerontology, series b 71(1) january 2016 1–11. https://doi.org/10.1093/geronb/gbu033 choi, m., sprang, g., & eslinger, j. g. (2016). grandparents raising grandchildren: a synthetic review and theoretical model for interventions. family & community health, 39(2), 120–128. https://doi.org/10.1097/fch.00000000000000 97 fauziah, n. (2020). the role of grandmother ’ s grandparenting on family harmony : a phenomenological analysis. journal of educational, health, and community psychology, 9(4), 574–590. fauziningtyas, r., indarwati, r., alfriani, d., haryanto, j., & ulfiana, e. (2018). the experiences of grandparents raising grandchildren in indonesia working with older people, 23(1), 17-26 https://doi.org/10.1108/wwop-10-2018-0019 franklin, p. a. (2020). impact of disability on the family structure. social security bulletin, 17(6), 14711–14729. jing, x. w., & guo, c. c. (2019). the implications of childcare on grandparents ’ health selfs. d. wahyuni et al. 134 | pissn: 1858-3598 � eissn: 2502-5791 management in a chinese elderly population. int j health plann mgmt, september, 1–10. https://doi.org/10.1002/hpm.2904 kertamuda. (2009). konseling pernikahan dalam keluarga. papalia diane. e, old sally wendkos, f. r. d. (2008). human development (psikologi perkembangan) (9th ed.). kencana. peterson, t. l. (2017). social work in public health changes in health perceptions among older grandparents raising adolescent grandchildren adolescent grandchildren. social work in public health, 32(6), 394–406. https://doi.org/10.1080/19371918.2017.13273 89 pujiatni, k., & kirana, a. (2013). penjaga nilai-nilai dalam keluarga : peran kakek dan nenek dalam pengasuhan cucu. 302–309. putu, n., narayani, r., menik, k., & krisnawati, s. (2020). hubungan intensitas pengasuhan cucu dengan kualitas hidup lansia. 8(april), 25–32. santrock, j. w. (2002). life-span development, perkembangan masa hidup (5th ed.) (5th ed.). erlangga. suyanta, s., & ekowarni, e. (2012). pengalaman emosi dan mekanisme koping lansia yang mengalami penyakit kronis. jurnal psikologi, 39(2), 208–221. setiadi. (2008). konsep dan proses keperawatan keluarga. graha ilmu. statistik, b. p. (2019). katalog: 4104001. badan pusat statistik. surabaya, b. (2019). penduduk lanjut usia kota surabaya. tanskanen, a. o., danielsbacka, m., coall, d. a., & jokela, m. (2019). transition to grandparenthood and subjective well-being in older europeans : a within-person investigation using longitudinal data. evolutionary psychology, september, 1–12. https://doi.org/10.1177/1474704919875948 tigere, b., & makhubele, j. c. (2019). the experiences of parents of children living with disabilities at lehlaba protective workshop in sekhukhune district of limpopo province. african journal of disability, 8, 1–9. https://doi.org/10.4102/ajod.v8i0.528 wahyuni, y. t., & abidin, z. (2015). pengalaman hidup lansia yang mengasuh cucu : studi kualitatif fenomenologis dengan interpretative phenomenological analysis. jurnal empati, 4(4), 8–14. yulion, m. m. (2013). memahami pengalaman komunikasi pengasuhan anak dalam extended family. perception of indonesian nursing students (madiha mukhtar, dkk) 186 persepsi mahasiswa keperawatan indonesia tentang perilaku caring dan karakteristik pengajaran pembimbing akademik (perception of indonesian nursing students regarding caring behavior and teaching characteristics of their clinical nursing instructors) madiha mukhtar*, nursalam**, ninuk dian kurniawati** *bhawalpur college of nursing, punjab. pakistan **faculty of nursing, universitas airlangga email: mukhtar_maha@yahoo.com abstrak pendahuluan: pembelajaran dan kinerja mahasiswa mencerminkan sikap profesional, perilaku, etika dan standar pembimbing mereka. tujuan dari penelitian ini adalah untuk menganalisis persepsi mahasiswa keperawatan indonesia mengenai perilaku caring dan karakteristik pengajaran pembimbing akademik mereka. metode: studi cross-sectional eksplorasi ini menggunakana partisipan sebanyak 149 mahasiswa profesi keperawatan dari program regular dan alih jenis serta 15 pembimbing akademik fakultas keperawatan dari universitas negeri yang terletak di surabaya indonesia. data dikumpulkan melalui kuesioner dan focus group discussion (fgd) yang dilakukan untuk menggali informasi secara rinci. hasil: analisis deskriptif didapatkan 6% mahasiswa merasakan perilaku caring instruktur klinik mereka rendah, 52,3% merespon sebagai cukup dan 41,6% dianggap baik. karakteristik pengajaran pembimbing akademik 2,7% rendah, 26,8% cukup dan 70,5% baik dirasakan oleh siswa mereka. data yang dikumpulkan dari siswa dianalisis dengan menggunakan uji regresi logistik. komitmen profesional dengan (p-value 0,038), motivasi (p-value 0,010) dan lingkungan klinik (p-value 0,002) dalam kategori utama (nilai signifikansi adalah <0,05) menunjukkan pengaruh pada persepsi mahasiswa keperawatan indonesia mengenai perilaku caring dan karakteristik pengajaran pembimbing akademik mereka. pada focus group discussion siswa menyarankan agar pembimbing akademik meningkatkan jumlah kunjungan di lingkungan klinik dan menekankan pada demonstrasi di samping tempat tidur. diskusi: kesimpulan yang didapat bahwa karakteristik siswa memiliki pengaruh pada persepsi mereka mengenai perilaku caring dan lingkungan klinik mempengaruhi persepsi mereka mengenai karakteristik pengajaran pembimbing akademik mereka. kata kunci: perilaku caring, persepsi mahasiswa keperawatan, karakteristik pengajaran, instruktur keperawatan akademik abstract introduction: student’s learning and performance reflects the professional attitude, behavior, ethics and standards of their instructors. the aim of this study is to analyze the perception of indonesian nursing students regarding caring behavior and teaching characteristics of their clinical nursing instructors (cni). method: in this exploratory cross-sectional study, 149 professional nursing students from regular program (baccalaureate) and post diploma bsn and 15 cni were recruited from nursing faculty of goverment university located in surabaya indonesia. data were collected by questionnaire and focus group discussion (fgd) which conducted to explore detailed information. result: in descriptive analysis 6% students perceived the caring behavior of their clinical instructors as low, 52.3% respondents it as enough and 41.6 % considered it good. teaching characteristics of cni 2.7% low, 26.8 as enough and 70.5 % good as perceived by their students. data collected from students was analysed by using logistic regression test. professional commitment with (p-value .038), motivation (p-value .010) and clinical placement environment (p-value .002) in main category (significance value is < 0.05) shows influence on perception of indonesian nursing students regarding caring behaviour and teaching characteristics of their cnis. in fgd students’ recommended to increase the number of visits in clinical area and emphasises on bed side clinical demonstration. discussion: it can be concluded that students’ characteristics does have influence on their perception regarding caring behavior and clinical setting environment influence their perception regarding teaching characteristics of their cnis. key words: caring behavior, perception of nursing students, teaching characteristics, clinical nursing instructor introduction clinical nursing instructor have crucial role in development of professional progression of nursing students. clinical training is far more important in nursing education to become a professional nurse. nursing students learn about professional attitude, ethics and standards from their instructors. student’s learning and performance reflects the ability of instructors to create an environment where the students can learn (hanson & stenvig, 2008). clinical instructors must possess effective teaching characteristics such as professional knowledge, role modelling and clinical competence with communication skills to facilitate optimal clinical learning (madhavanprabhakaran, shukri, hayudini, & narayanan, 2013). based on observation, author finds that clinical nursing instructor doesn’t pay visit on daily basis (upon their visit cnis stay for 1 up to two hours in clinical area) who can guide students step by step and instruct them mailto:mukhtar_maha@yahoo.com jurnal ners vol. 11 no. 2 oktober 2016: 186-194 187 bedside while performing procedures in clinical placement area. in an interview with pns “our cnis (pembimbing akademik) assigned for supervision of professional year nursing students according to their speciality visits in clinical area for a short time period”. additionally the author realises that the number of contact hours of cnis and pnss are quite fewer to develop clinical skills and competencies expected to be a professional nurses. in an interview with a nurse member of education and training committee in universitas airlangga hospital, she stated that “professional nursing students are mostly guided by the nurse educator from hospital in each floor in inpatient units, only in the morning shift”. furthermore, she mentioned that there is a lack of student-faculty ratio in clinical area. in an initial data collected by questionnaire, total 18 professional nursing students from program a and b were responded including both genders. the questionnaire comprises 31 statements and developed from 10 carative factors of jean watson theory. the higher percentage is 80% and the lowest percentage is 45 %. total calculated mean of all 18 respondents is 67% of the perception of nursing students regarding caring behavior and teaching characteristics of their clinical nursing instructors. salimi & azimpour (2013) believed that determinants of caring behaviour are universal but cultural diversity, organizational issues, rules and regulations and laws may affect the universality of some items. political issues also affect the nurses in delivering care to patients and clients. mccance, slater, & mccormack (2009) mentioned in their study, in developing countries, it doesn’t matter whether a nurse listen to a patient or not, because in those countries there is no demand for this care either by the system or by the patients, where as in western countries this is an important caring behavior as quoted by salimi & azimpour (2013). faculty members and clinical instructors must act as role models and facilitate learning by providing an environment that promotes holistic care, inquiry, critical thinking, accountability, and more autonomous and professional behavior. nursing students should seek educational opportunities to acquire knowledge for role preparation, to participate in knowledge generation, and for personal and professional development khouri (2011). method an exploratory cross-sectional quantitative research design is used to conduct this research study. students and clinical nursing instructors were asked to fill the questionnaire after giving explanation and their agreement to express their perception based on internal and external factors regarding their clinical nursing instructor. total six questionnaire comprises on students’ characteristics as an internal factors (professional commitment, students’ attitude, motivation, experience (program type) and gender), clinical placement environment and job responsibilities of cnis as external factor and questionnaire related to perception of students regarding caring behavior (based on 10 carative factors of jean watson) and teaching characteristics (professional competence, relationship with students and personal attributes) of their cnis. based on questionnaire results, issue strategy is made. following focused group discussion (fgd) was conducted with two groups (one with pnss and second one with cnis from faculty of nursing universitas airlangga) to verify the data with professional year nursing students were followed for verification of data collected by questionnaire and to propose recommendations. population in this research study is all undergraduate professional nursing students (program a and b) of universitas airlangga faculty of nursing, those are completing their internship in universitas airlangga hospital, haji general hospital, dr. soetomo hospital, menur psychiatric general hospital and community are included in the study. on the other hand faculty members are selected from each department were selected randomly, those which are supervising the professional nursing students in clinical area. the independent variable in this research is internal factors (professional commitment, attitude, motivation, gender and (program type) experience) and external factor includes (clinical placement environment and job responsibilities of cnis). research were conducted (january 2016 – april 2016 ) in the premises of faculty of nursing universitas airlangga surabaya indonesia. professional nursing students were gathered from different clinical placements. data were gathered by questionnaire through retrospective (recalling) of their recent previous interaction with their clinical nursing instructors in clinical setting. data collection is carried out for the perception of professional year undergraduate nursing students based on individual (commitment, attitude, motivation and gender) and environmental characteristics (clinical placement environment, clinical instructor's behavior and teaching characteristics) regarding caring behavior and teaching characteristics of their clinical nursing instructor. early before joining the respondents in the study, respondents first get an explanation from the researcher about the intent and purpose of the study, after an explanation of the research respondents, respondents were asked for their willingness to join in the study. respondent was given informed consent after the respondents expressed willingness to participate in research. respondents were given an explanation of the questionnaire to be filled along with how to fill. at the perception of indonesian nursing students (madiha mukhtar, dkk) 188 time of filling the questionnaire respondents conducted mentoring of researchers to assist in filling out the questionnaire respondents. the focused group discussion was conducted in university campus in a feasible area. fgd was scheduled on date and time which was convenient for all participant. the goal of settings that allow participants to feel relaxed, comfortable, and free to share their perceptions, thoughts ,ideas and feelings openly. prior to collection of data for this research study, an ethical approval is obtained from (irb) institutional review board from ethical clearance committee of faculty of nursing and an official permission from dean of the faculty of nursing, universitas airlangga. informed consent from each participant before being a part of this research study. researcher maintained the anonymity of the respondents through not to publish the name of the respondent and does not use the results to mean beyond the interests of research. the confidentiality of information provided by respondents is guaranteed because the only certain groups of data that will be reported as a result of research and no personal information will be disclosed. results faculty of nursing is overall responsible of managing the pns, their clinical allocation, handling issue, marking. clinical supervision is divided into two domains; one is (pembimbing akademik) academic supervisor/cni (clinical nursing instructor) which is faculty member from the faculty of nursing and another one is clinical educator (ce) from the clinical setting. cni covers classroom teaching, laboratory teaching & demonstration and clinical area directions, guidelines and supervision while the ce is responsible for clinical procedure demonstration. characteristics of professional nursing students who became the respondent of this research study for first step were total 149 students from program a (regular) and b (alih jenis). total number of sample were calculated by using scientific formula. respondents were recruited through purposive sampling technique to respond the questionnaire program a 84 students were taken from total population of 109 students while 65 students from program b were taken as the total population are 87 students. total 15 faculty members who supervise/instruct the professional nursing students in clinical/community placement area. total number of sample were calculated by using scientific formula. respondents were recruited through purposive sampling technique to respond the questionnaire of their job responsibilities. out of 149 respondents only 60 (40.3%) have good professional commitment, total positive attitude 68 respondents (45.6%). 87 respondent (58.4 %) possess good motivation and the most frequency of gender is female with total number of 101 respondents (67.8 %). program a was on top with total 84 respondents with (56.4 %) as it becomes a basic nursing degree in the nursing profession. in responding to external factors, from 149 respondents 96 (64.4 %) answers in the good category. fair number professional nursing students considered their clinical learning environment as supportive and positive. on the other hand 13 cni (86.7%) reflected that their job related responsibilities are fair enough in accordance to their position. logistic regression was carried out using these all (6) independent variable (gender, experience (program type), professional commitment, attitude, motivation and clinical placement environment) included and only caring behavior was used as dependent variable. in this stage, stepwise removal probability is <0.1. as we can see in the category of main variables, gender has the highest value (.508), so it was excluded in the proceeding step. similar analysis was performed repetitively till the variables valued less than <0.1 is remained. there is an influence of internal factors (professional commitment, attitude, motivation, experience (program type) and gender) on their perception regarding caring behavior and teaching characteristics of their cnis. from six independent variables (gender, program type (experience), professional commitment, attitude, motivation, and clinical placement environment) two internal factors; commitment p-value .038 in main category (significance value is < 0.05) and motivation p-value .010 (significance value is < 0.05) of students have influence on their perception regarding caring behavior of their clinical nursing instructors. conversely, internal factors does not show any influence on the perception of professional nursing students regarding teaching characteristics of their cni. second hypothesis of this research study is: there is an influence of external factors (clinical placement environment and job responsibilities of cnis) on their perception regarding caring behavior and teaching characteristics of their cnis. from six independent variables (gender, program type (experience), professional commitment, attitude, motivation, and clinical placement environment) only one external factor; clinical placement environment pvalue .002 in main category (significance value is < 0.05) have influence on their perception regarding teaching characteristics of their clinical nursing instructors. internal factors which does not have influence on perception of pns was exclude gradually one by one. analysis proves that clinical learning environment does have effect on the perception of pns reading teaching characteristics of their clinical nursing instructors. in contrast clinical environment does not effect on their perception regarding caring behavior of their cni. clinical learning jurnal ners vol. 11 no. 2 oktober 2016: 186-194 189 environment (situations and circumstances) can be an obstacle in learning of professional nursing students. result of logistic regression analysis shows that there is no difference between perception of professional nursing students from program a and b. significance is .540, which is more than >0.05. students from both programs have same perception regarding their clinical nursing instructors. additionally it confirms that there is no difference between perceptions the professional nursing students from program a and b. fgd explored out their thoughts and concerns of professional nursing students. student counselling and awareness session to bring awareness regarding core of nursing profession in order to promote professional commitment. moreover, help the professional nursing students to find out their interests/passion within the nursing profession which will be their continuous motivation to move forward vigorously throughout their career. cnis must increase the number of their visits in clinical area to make sure their availability and build trustworthy relation with pns, which will develop their clinical skills, promote critical thinking, clinical decision making and research capabilities. clinical nursing instructors should expose to new technology and implement while supervising and teaching the professional nursing students in clinical practice area. clinical nursing instructors needs to conduct on-going evaluation and should conduct the discussion session after each semester to get feedback of the students. faculty of nursing must conduct cnes (continue nursing education) sessions to enhance the competencies, introduce cnis to new practice methods and skills. discussion obtained result indicates that professional commitment is a 46.3 % with highest number in the average category, measuring results statistics based on latent variable indicator significance commitment effect on latent variable. in the present study students statistical analysis showed that professional commitment with pvalue .038 in main category (significance value is < 0.05) does have influence on the perception of professional nursing students. munir sanihu, et al (2013) is emphasized in their study, that indonesian nursing curriculum needs improvement in term of developing analytical and critical thinking skills, leadership and managerial capabilities among the students and impress upon them that nurses re independent professionals who collaborate with physicians and other members of the health team in patient care regimen. “respondents expressed their disappointment on discovering that patients were not always as grateful as they had anticipated; that nursing involves so much administration; and that services are not always patient-focused” one of the leading reason of low professional commitment was mentioned by gould & fontenla, (2006) in their study. nursing is a humanistic profession; it has some particular characteristics due to the profession’s nature. loyalty and tendency to remain in the profession and responsibility to the professional issues were extracted in theoretical phase. commitment to promote caring abilities, satisfying of being a nurse, and belonging to the nursing profession were obtained in fieldwork phase. finally, two main themes including “commitment to offering the best nursing care” and “commitment to promotion of the nursing profession” were extracted (jafaragaee. et al, 2012). nurses exhibited a mediumhigh degree of professional commitment--the average score was 2.99 before graduation and 2.85 after graduation; the scores of overall commitment and four factors of professional commitment decreased from nursing students to registered nurses significantly; (4) personality traits were positively correlated with professional commitment for nursing students and registered nurses; and (5) there was no significant relationship between nurses' work backgrounds and the changes of professional commitment from nursing students to registered nurses (lu, chiou & chang, 2000). in this study students highlighted that worthy difference between theory and in real practice develops the low level of commitment with profession. moreover, lack of research application and innovations contributes in lacking the interest. cni needs to pay attention on applicable knowledge rather than only emphasizing on procedural or conceptual / bookish knowledge. results obtained from data showed motivation is mainly fall in good category with (58.4 %). low in terms of its goals, measuring results by applying statistics based on latent variable indicator significance motivational effect on latent variable. in the present study students statistical analysis showed that motivation of pnss with p-value .010 i the main category (significance value is < 0.05) does have influence on the perception of professional nursing students regarding caring behavior and teaching of their characteristics cnis. motivation is a human psychological characteristics contribute to a person's level of commitment. this includes factors cause, distribute and maintain human behavior toward a specific determination (nursalam, 2008). application of caring behavior by nurses cannot be separated from the aspect motivation (nursalam 2011). while the (suarli 2009) mengemuk that motivation is one of the last measure on a person to produce a behavior led to an increase in productivity because it is supported by good motivation of nurses including the motivation to apply caring behavior. students (234/315) with motivation score >6 reported positive opinions to becoming a nurse (125/234), perception of indonesian nursing students (madiha mukhtar, dkk) 190 organization of the programme and attitude to the studies. the mean score value for the motivation ranking differed significantly between male (5.8) and female (6.8) students. nursing students mainly grade their motivation positive distributed different throughout their entire education. the main motivation factor was becoming a nurse. this study result highlights the need of understanding the students' situation and their need of tutorial support (nilsson & warrén, 2008). most of the students, 73%, rated their motivation as ≥6 on a 0-10 likert scale; and 16% gave a rating of ≤4. having a negative attitude towards the studies was an explanation of decreased motivation. there was a significant decrease (p=0.001) in the motivation score with respect to number of semesters, and motivation increased with the student’s age (p=0.0119). suggestions for increasing motivation given by those who rated their motivation as ≤4 mainly focused on improvements in didactics and study organisation. motivation is vital to do anything, it leads to one’s encouragement to do something. frequent feedback will be helpful to optimize the motivation of professional nursing students towards achieving their objectives and goals. the desire to become a registered nurse (rn) and having a positive attitude towards the studies can be the main factors influencing high motivation. creating the curricula that promote student motivation, and of meeting the students individually during the study programme to discuss their study situation and possible misgivings about their future profession, which might improve their self-motivation. calculated data results presents that (64.4 %) professional nursing students perceived their clinical environment as supportive/conducive in their learning in clinical area. clinical placement environment p-value .002 in main category (significance value is < 0.05) shows influence on their perception regarding teaching characteristics of their clinical nursing instructors. in this study students mentioned that if there is some issue arise in clinical placement area, cni must play a role of an advocate. cni (clinical nursing instructor) from the faculty of nursing and ce (clinical educator) from clinical area must improve their communication and coordination in order to eliminate and minimize the obstacle and to optimize the learning of professional nursing students. hayajneh (2011) found in her study that the participants thought that the clinical instructor should be always available and accessible to offer help and guidance, make clinical work intrusting, and encourage active and cooperative learning. it prepares the students for their professional role, provides them with opportunity to apply knowledge and skills (o’connor, 2001). results from this study negate the negative views on clinical placements outside the hospital setting, especially those related to placements in nursing homes and mental healthcare settings (bjørk, et al, 2014). four themes emerged from the focus group data. from the students' point of view," initial clinical anxiety", "theorypractice gap"," clinical supervision", professional role", were considered as important factors in clinical experience. study showed that nursing students were not satisfied with the clinical component of their education. they experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting (sharif & masoumi, 2005). environment of the clinical placement plays a significant role in learning of nursing students. as it can enhance and decrease their level of learning through obstacles and unconducive circumstances. intense and constant coordination is needed to establish between faculty of nursing and clinical setting area for professional nursing students. calculated data results (86.7 %) indicates that the clinical nursing instructors are fairly contented with their job responsibilities as part of their job according to their position in the faculty of nursing. 15 full time cnis from faculty of nursing responds to questionnaire leading to focused group discussion. almost all of them confused while answering that “supervision of professional nursing students in clinical area is not my primary job” during focused group discussion. cnis felt that there is a need to recruit clinical instructors. “as a supervisor we have to maintain good relationship with clinical educator (from clinical area) and upgrade our knowledge, skills and attitude as a prominent need”, respond of one of the cni. another respondent stated that “pembimbing harus mengajarkan dan mencontohkan perilaku caring kepada mahasiswa” (supervisor must teach and give examples of caring behavior to the students). the cnis identified the need for assistance in assessing student competencies, in addition to needing general support and debriefing to reduce the feelings of isolation they often felt. they also felt their role was not well defined, leaving them with a lack of clarity on how to act (sherry et al, 2012). cnis needs to maintain their role and duties wisely and efficiently to deal with their responsibilities in faculty area (classroom & laboratory teaching) and clinical area. relationship with professional nursing students and clinical educator needs to improve to enhance learning of nursing students. job description for clinical nursing instructors need to develop in a clear and written form. nursing students wanted the clinical instructors to be knowledgeable and competent in their own field and agree that knowledge and experience competence is the most important and essential component for effective teaching. this may because of the nursing students wanted to spend their clinical training with specialized jurnal ners vol. 11 no. 2 oktober 2016: 186-194 191 educators and more experienced instructors and this may make them feel more secure in the clinical environment (ali, 2012). nursing students learn caring from their instructors through their words and caring actions. so that cni have enormous responsibility and must act like a role model for their students. wade (2006) found that when clinical instructors are perceived as caring, nursing students develop caring abilities. ali (2012) revealed in her study findings that clinical teaching ability of clinical instructors is the third important effective clinical teaching characteristic as perceived by the nursing students. also the study revealed that the nursing students considered the personality traits as the fourth factors that effect on their behavior in the clinical settings. a clinical instructor should be able to communicate expectations to students in a clear way, be well prepared, check student understanding, ensure that basic familiarization is well organized, and demonstrate that the ward can be regarded as a good learning environment (hayajneh, 2011). comparison of their opinion shows the clear contradiction between the views of professional nursing students and clinical nursing instructors. cni has responsibility of class room teaching, laboratory facilitation along with clinical supervision. work load is the possible difficulty to lack of clinical visitation. cni can make a small groups in clinical area rather than large groups, so they can better evaluate that which student was more active or passive and can also facilitate them to recognize the strengths and weaknesses of individuals while teaching in clinical area. students should understand the real meaning to be in nursing profession and find out the genuine interest and the reason of existence in the profession of nursing which will eventually motivate them and will boost up their commitment towards profession. cni needs to realize the demand of this technical era and find out some exciting clinical teaching methods which can maximize professional commitment and motivate students towards optimal learning. additionally, students have to polish their own abilities (as professional nursing students already graduated from 4 year of basic nursing degree) and realize the responsibilities of an adult learner as a professional university level student. faculty of nursing must evaluate on ongoing basis and express keen concern in training of cni and improve coordination with clinical placements of professional nursing students. research findings based on the all hypothesis testing, so that it clears out the significant path. the results shows that three internal factors (student characteristics) professional commitment, motivation and attitude are moderately low. professional commitment and motivation of students influence their perception regarding caring behavior of their cni while type of the program (experience) and gender does not show influence on perception of professional nursing students. from two internal factors (education and environment); clinical learning environment does showed the relationship between perception of professional nursing students and teaching characteristics of their clinical nursing instructors. results of this study provides the strength and areas which needs improvement. it provides an insight evaluation of concerns of professional nursing students. clinical teaching strategies can be modified and find out the ways to improve motivation and commitment in pns. it is necessary to integrate clinical teaching along with caring behavior. this study findings will provide the base for further research or development of new clinical supervision model. study findings are guide for cni to know the weaknesses of professional nursing students and students’s perception regarding cni for improvement to reach optimum level. faculty of nursing needs to develop formal job discriptions for clinical nursing instructors and modify the clinical teaching learning methods. conclusions and suggestions conclusion internal factors (student characteristicsprofessional commitment and motivation) show and influence on perception of pns regarding caring behavior of their cnis but does not have influence on the perception of pns regarding teaching characteristics of their cni. external factors (education & environment) does not influence on the perception of pns regarding caring behavior of their cnis however environment shows influence on perception of pns regarding teaching characteristics of their cnis. in general, professional nursing students from program a (regular) & b (post basic diploma) have same perception regarding caring behavior and teaching characteristics of their cnis. suggestions its mandatory for professional nursing students to advance their adult learning sense, instructors must pay close attention to applicative knowledge while supervising nursing students in clinical area, cni needs exclusive training based on clinical guidance, direction, demonstration and compassionately dealing with professional nursing students in clinical area. clinical faculty can be educated and provided with useful educational tools to assist them in providing effective clinical instructions and it is necessary to develop job perception of indonesian nursing students (madiha mukhtar, dkk) 192 description/guide book by nursing faculty for cni to clarify their role and tasks in clinical area. acknowledgement researcher thank to all the professional nursing students and instructors who participated in this study. researcher also express her gratitude to the dean (1 st supervisor) of nursing faculty for his great favor and 2 nd supervisor for keen support & guidance throughout this research project. references alasmari, a. m. (2014). respiratory therapy students' perceptions of effective teaching characteristics of clinical instructors at an urban university. ali, w. g. (2012). caring behavior and effective teaching characteristics of clinical nursing instructors as pereived by their students,3(7), 15-27, retrive on sep.2015 from http://www.iiste.org/journals/ index.php/jep/ article/view/1845/29915. american nurses association (ana, 2001). code of ethics for nurses with interpretive statements. washington, dc: american nurses association. american psychological association (apa, 2010). ethical principles of psychologists and code of conduct. washington, dc: retrived january, 2016, from http://www.apa.org/ethics/ anderson, jennifer. anne. (2014). understanding male nursing student perceptions of the influence of gender: a qualitative case study approach of students, faculty, and administration in a pacific northwest nursing program. http://pdxscholar.library.pdx.edu/cgi /viewcontent.cgi?article=2935& context=open_access_etds arthur, d & randle, j. (2007). the professional selfconcept of nurses: a review of a literature from 92-06. australian journal of advance nursing, 24 (60-64). article, o. (2015). academic training and clinical placement problems to achieve nursing competency, 3(1), 15–20. bagraim, j. j. (2003). the dimensionality of professional commitment, 29(2), 6–9., retrive on 15 th oct, 2015. beitz. j.m. and wieland.d. (2005). analyzing the teaching effectiveness of nursing faculty of full and part –time generic bsn, and rnbs nursing students, jour. of professional nursing, 21(1); 32_45, http://www.ejmanager.com/ mnstemps / 93/93-1428640720.pdf?t=1461429982. bjørk, t. ida., karin, berntsen., grethe, brynildsen., and margrete, hestetun. (2014). nursing students' perceptions of their clinical learning environment in placements outside traditional hospital settings. journal of clinical nurse. 2014 oct; 23(19-20):2958–2967. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4 263152/ cook. (2005). inviting teaching behaviors of clinical faculty and nursing students’ anxiety. journal of nursing education, 44(4), 156–162. retrivedjanuary,2015 https://www.researchgate.net/publication /78 76311_inviting_teaching_behaviors_of_clinic al_faculty_and_nursing_students'_anxiety core, t., practices, p., from, e., & watson, c. (2010). core concepts of jean watson ’ s theory of human caring / caring science dahlke sherry, jennifer baumbusch, frances affleck, jae-young kwon, (2012). the clinical instructor role in nursing education: a structured literature review (pdf download from:https://www.researchgate.net/publication/ 232646883_the_clinical_instructor_role_in_ nursing_education_a_structured_literature_r eview [accessed may 7, 2016]. edy siswantoro. (2015). pengembangan model perilaku caring mahasiswa berbasis kecerdasan emosional terhadap peningkatan kompetensi keperawatan. faculty of nursing, universitas airlangga. fry, s. t.,veatch, r. m. & taylor, c. (2011). case studies in nursing ethics (4 th edi.). sudbury, ma: jones & bartlett learning gibson, james. i., (1987) organisasi perilaku , strukture, proses, jakarta: erlangga gould, d., and fontenla, m., (2006). commitment to nursing: results of a qualitative interview study, journal of nursing management, 14, 213–221, http://www.fatih.edu.tr/~hugur/fri hanson, k., & stenvig, t., (2008). the good clinical nursing educator and the baccalaureate nursing clinical experience: journal of nursing education, 47(1), 38-42. retrieved on march 5, 2015, from google scholar hayajneh, f. (2011). role model clinical instructor as perceived by jordanian nursing students. journal of research in nursing. 16: 23. the online version of this article can be found at: http://jrn.sagepub.com/ content/16/1/23 hofler, l. (2008). nursing education and transition to the work environment: a synthesis of national reports. journal of nursing education, 47 (5). hsiang-chu pai. (2013). effect of caring behavior on disposition toward critical thinking of nursing students. journal of professional nursing, 29(6), p. 423-429 http://www.ncbi.nlm.nih.gov/pubmed/?term=bj%26%23x000f8%3brk%20it%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=berntsen%20k%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=brynildsen%20g%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=hestetun%20m%5bauth%5d jurnal ners vol. 11 no. 2 oktober 2016: 186-194 193 jafaragaee, fateme., soroor, parvizy., neda, mehrdad., and forough, rafii. (2012). concept analysis of professional commitment in iranian nurses. iran journal of nursing and midwifery res. nov-dec :17(7):472-479. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc 3730449/ jaros, s. (2007). meyer and allen model of organizational commitment : measurement issues, 7–26, http://stevejaros.com/wpcontent/uploads/ 2009/08/jaros-icfai-2007meyer-and-allen1.pdf. khouri, r. (2011). impact of an educational program on nursing students ’ caring and self-perception in intensive clinical training in jordan, 173–185, retrive on nov, 2015 from https://www.dovepress.com/impact-of-aneducational-program-on-nursing-studentsrsquocaring-andnb-peer-reviewed-article-amep. kube, m. l. (2010). the relationship of nursing faculty clinical teaching behaviors to student learning. proquest dissertations & theses: http://eric.ed.gov/ ?id=ed515024 full text database. (umi no. 3398533). krueger, r. a., (1994). focus groups: a practical guide for applied research (2nd ed). thousand oaks, ca: sage. lu, ky., chiou, sl., chang, yy. (2000). a study of the professional commitment changes from nursing students to registered nurses. kaohsiung journal of medical science. jan 16(1):39-46. http://www.ncbi.nlm.nih.gov/ pubmed/10741015 ma, f., li, j., liang, h., bai, y., & song, j. (2014). baccalaureate nursing students ’ perspectives on learning about caring in china : a qualitative descriptive study. bmc medical education, 14(1), 1–9. http://doi.org/10.1186/1472-6920-1442, retrive on 20 th sep,2015, http:// bmcmededuc.biomedcentral.com/articles/10.118 6/1472-6920-14-42. madhavanprabhakaran, g. k., shukri, r. k., hayudini, j., & narayanan, s. k. (2013). undergraduate nursing students ’perception of effective clinical instructor : oman, 3(2), 38–44. http://doi.org/10.5923/j.nursing. 20130302.02 meimanat, hosseini., tahereh, ashk torab., mohammad,hossein taghdisi., and safar, ali. esmaeili. vardanjani. (2013). study on situational influences perceived in nursing discipline on health promotion: a qualitative study.http://www.hindawi.com/journals/isrn/201 3/218034/ morgan. (1997). focus groups as qualitative research (2nd ed.). thousand oaks. morse. (2007). strategies of intraproject samling . nursing research:a qualitative perspective (4th ed.). munir, s., ramos, c. t., & hudtohan, e. t. (2013). benchmarking nursing education in indonesia for social development and global competitiveness, 10(1), 51–65. retrived january, 2016, from http://www.iosrjournals.org/iosrjdms/papers/vol10-issue1/l01015165. pdf?id=7241 nilsson, el. kerstin., and warrén, stomberg. i. margareta. (2008). nursing students motivation toward their studies – a survey study. bio med central nursing, 7:6. http://bmcnurs.biomedcentral.com/arti cles/ 10.1186/1472-6955-7-6 nursalam. (2007). mangemen keperawatan: aplikasi dalam praktik keperawatan professional (edisi kedua). jakarta: salemba madika nursalam. (2011). managemen keperawatan; aplikasi dalam praktik keperawatan professional, ed 3. jakarta:salemba medika nursalam. (2013). metodologi penelitian ilmu keperawatan,pendekatan praktis (3 rd ed), p.128. o'connor, ab.( 2001). clinical instructions and evaluation, london; tones and bartelt, pp.14_26. okoronkwo, i. l., agbo, m. e., okpala, p. u., & ndu, a. c. (2013). students ’ perception of effective clinical teaching and teacher behaviour, 63–70. polit & beck, c. t. (2001). caring with nursing education: a meta synthesis, journal of nursing education, 40 (3), p.101-109. rivai, v., mulyadi, d. (2010). kepemimpinan dan perilaku organisasi. jakarta: pt raja grafindo persada sabog, r. f. v, caranto, l. c., & david, j. j. t. (2015). effective characteristics of a clinical instructor as perceived by bsu student nurses, 5(1), 5–19. http://doi.org/10.5923/j.nursing.20150501.02, retrive on 2 nd nov, 2015, http://article.sapub.org/10.5923.j.nursing.201505 01.02.html. salimi, s., & azimpour, a. (2013). determinants of nurses ’caring behaviors (dncb): preliminary validation of a scale, 2(4), 269–278. retrived january,2016,from,http://www.ncbi.nlm.nih.gov/ pmc/ articles/ pmc 4134150/ sarmiento, t. p., laschinger, h. k. s., iwasiw, c., & laschinger, h. s. (2004). nurse educators ’ workplace empowerment , burnout , and job satisfaction : testing kanter ’ s theory. sharif, farkhondeh., and masoumi, sara. (2005). a qualitative study of nursing student experiences of clinical practice. bio med central nursing. http://www.ncbi.nlm.nih.gov/pubmed/?term=jafaragaee%20f%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=parvizy%20s%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=mehrdad%20n%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=rafii%20f%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=lu%20ky%5bauthor%5d&cauthor=true&cauthor_uid=10741015 http://www.ncbi.nlm.nih.gov/pubmed/?term=chiou%20sl%5bauthor%5d&cauthor=true&cauthor_uid=10741015 http://www.ncbi.nlm.nih.gov/pubmed/?term=chang%20yy%5bauthor%5d&cauthor=true&cauthor_uid=10741015 http://www.ncbi.nlm.nih.gov/pubmed/10741015 http://www.ncbi.nlm.nih.gov/pubmed/10741015 http://www.hindawi.com/journals/isrn/2013/218034/ http://www.hindawi.com/journals/isrn/2013/218034/ http://www.ncbi.nlm.nih.gov/pubmed/?term=sharif%20f%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=masoumi%20s%5bauth%5d perception of indonesian nursing students (madiha mukhtar, dkk) 194 2005;4:6.http://www.ncbi.nlm.nih.gov/pmc/articl es/pmc1298307/ susan k.groove, nancy burns, j. r. g. (2013). the practice of nuursing research; appraisal , synthesis, and generation of evidence (7th ed.). swansburg, kristen. (1993). basics of psycholoy (2nd ed.) p.65. swanson, k,m. (1991).empirical dvelopment of a middle range theory of caring. nursing research, vol 40, number 3. swanson, k,m. (1993). nursing as informed caring for the well-being of others. journal of nursing sholarship, 25(4), 352–357, vol 5,number 4. thomas. (2003). handling anger in the teacher-student relationship. nursing education perspectives, 24(1), 17–24. wade, g. h., & kasper, n. (1996). nursing students ’ perceptions of instructor caring : an instrument based on watson’s theory of transpersonal caring. retrived january, 2016, from http://www.ncbi.nlm.nih.gov /pubmed/16722498 warrén, stomberg. margareta., and nilsson, kerstin. (2010). nursing students’ self-graded motivation to complete their programme of study. open nursing journal. volume 4: 42–47. http://www.ncbi.nlm.nih.gov/pmc/ articles/ pmc3043268/ wilkinson, s., (2004). focus group research. in d. silverman, qualitative research: theory, method, and practice (p. 177-199). thousand oaks. zamanzadeh, v., valizadeh, l., azimzadeh, r., aminaie, n., & yousefzadeh, s. (2014). first and fourthyear student ’ s perceptions about importance of nursing care behaviors : socialization toward caring, 3(2), 93–101. http://doi.org/10.5681/jcs.2014.010 retrived january,2016,from,http://www.ncbi.nlm.ni h.gov/pmc/articles/pmc4134170/ http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1298307/ http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1298307/ http://www.ncbi.nlm.nih.gov/pubmed/?term=stomberg%20mw%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=nilsson%20k%5bauth%5d http://e-journal.unair.ac.id/jners | 557 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.20479 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the bullying phenomenon and handling efforts in reducing cases of bullying: a systematic review devis yulia rohmana, kartini estelina and iskandar iskandar faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: bullying is behavior that deliberately wants to dominate, hurt, or get rid of its victims, both directly (physical) or indirectly (verbal). the impact of bullying can cause psychological distress and if left untreated will worsen the victim to the point of committing suicide. this study aims to find out the most appropriate types of interventions that can be implemented to reduce intimidation and prevent the risk of suicide by using systematic reviews based on prisma guidelines. methods: the studies were searched in five databases: scopus, sciencedirect, proquest, pubmed and cinhl and had to be published from 2014-2019. the articles were identified using the keywords “bullying” and “intervention”, “anti-bullying program”. results: 14 articles found were used using this systematic review. the article reviewed mentions that an antibullying program that involves several parties has the benefit of reducing bullying. conclusion: several intervention efforts can be used in preventing recurring breaches and can also be used as promotive and preventive efforts in cases of bullying in schools and communities. article history received: feb 27, 2020 accepted: april 1, 2020 keywords bullying; intimidation; intervention; prevention contact devis yulia rohamana  devis.yulia.rohmana2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: rohmana, d. y., estelina, k & iskandar, i. (2020). the bullying phenomenon and handling efforts in reducing cases of bullying: a systematic review. jurnal ners, special issues, 557-562. doi:http://dx.doi.org/10.20473/jn.v15i2.20479 introduction bullying is a behavior that is carried out directly (physical bullying) and indirectly (verbal bullying). risk factors for cyberbullying and traditional bullying might be similar. for instance, lack of empathy has been shown among cyberbullies (chaux, velásquez, schultze-krumbholz, & scheithauer, 2016). direct bullying includes pushing, hitting, kicking. indirect bullying (verbal bullying) includes teasing, mocking, threatening, spreading false rumors or news that seeks either to cause fear, discomfort, or injury to others (vassallo, edwards, renda, & olsson, 2014). three-quarters of students in the usa reported being bullied at school or bullied online at some point in their lives (hinduja & patchin, 2017). bullying is a type of proactive aggressive behavior, which contains the intentional aspect to dominate, hurt, or get rid of someone. imbalance of strength whether physical, age, cognitive abilities, skills, and social status, which is done repeatedly by one or several children against other children is a characteristic of bullying behavior (garmy, vilhjálmsson, & kristjánsdóttir, 2018). according to plan international and the international center for research on women, one of the cases of bullying experienced by teens at school in 2013 reached 84%. this figure is higher compared to the asian region, where it is 70%. the research was carried out in five asian countries including vietnam, nepal, pakistan, and indonesia, involving 9000 students aged 12-17, teachers, principals, parents, and representatives. adolescence can be interpreted as a period of looking for one’s self-identity, as during this period there is rapid development and growth both physically, mentally or psychologically, and socially. adolescence is divided into three parts, namely early adolescence (11-14), middle adolescence (15-17) and late adolescence (18-20). in this period the problems often faced by adolescents. if adolescents fail to carry out their developmental tasks, then it will have an impact on the crisis of selfidentity, self-esteem, and belief, that can lead to juvenile delinquency and violent behavior and one of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2.1355 d. y. rohmana et al. 558 | pissn: 1858-3598  eissn: 2502-5791 them is to be a bullying perpetrator (fisher et al., 2012). bullying behavior needs to be dealt with early on because it will turn into juvenile delinquency which is difficult to handle so there needs to be an action to reduce intimidation and prevent the risk of suicide (damayanti, 2019). materials and methods this systematic review uses guidelines based on preferred reporting items for systematic review and meta-analysis (prisma) (liberati et al., 2009). the studies were searched in five databases: scopus, sciencedirect, proquest, pubmed and cinhl and had to be published from 2014-2019. the articles were identified using the keywords “bullying” and “intervention”, “anti-bullying program”; the criteria of inclusion was the use of interventions in preventing bullying. focusing on bullying and casecontrol studies, the data were assessed and compared before and after the intervention to ensure that changes verified in the experimental group were associated with the intervention rather than with any other conditions or variables not included in the investigation. no restrictions were imposed on the year of publication and only the language (english). results bullying has been defined as unwanted aggressive behavior that involves a real or perceived power imbalance (olweus & limber, 2010). bullying includes physical, verbal, relational and cyberbullying. according to the international research network health behaviour in school-aged children (hbsc), 11% of children aged 11–15 claimed to have been bullied at least two or three times per month within the last couple of months(cosma, whitehead, neville, currie, & inchley, 2017). the total respondents in this review were 16,847 participants. bullying is a type of proactive aggressive behavior, which contains the intentional aspect to dominate, hurt, or get rid of someone. this research area belongs to the community. in total, the review consisted of 14 articles. in this review, adolescence can be interpreted as a period of looking for one’s self-identity, as during this period there is rapid development and growth both physically, mentally or psychologically, and socially. several studies have been carried out by providing different interventions according to the criteria of researchers to adolescents who experienced bullying, for example, interventions carried out in stressed patients were measured using the strengths and difficulties questionnaire (sdq) for psychological distress (bhui, silva, harding, & stansfeld, 2017), which is used to assess emotional symptoms, attention in dealing with and seeing problems experienced in both relationships; prosocial behavior. other measures “bullying tendency scale”, “coping with bullying scale,” and “personal information form” were used in this section too (yuksel-sahin, 2015). also used, according to the journal discussion, to see depression in adolescents, were the mood and feel questionnaire (mfq) and youth self-report (ysr) carried out in schools with the effectiveness of approaches to reduce bullying. many implementations of anti-bullying, which is effective classroom management in a small class setting with a well-trained teacher(chan & wong, 2015), in line with research, that the program significantly stimulated can decrease bullying and cyberbullying (garaigordobil & martínez-valderrey, 2015), the functions of peer support and active coping (yin et al., 2017). furthermore, the interventions reported by the studies can be assigned into four categories: multi-component (whole-school), social skills training, bullying prevention integrated into the curriculum, and computer-based interventions (silva et al., 2017). bullying is quite prevalent and when considering its detrimental effects, it may well be said that there is a need for anti-bullying programs that will reduce this type of behavior (albayrak, yildiz, & erol, 2016). the effectiveness of policy interventions for school bullying gets policy results that can be done to guide organizational practices, such as establishing antibullying procedures and reporting incidents that occur in schools. but bullying policies can be table 1. type of bullying article physical bullying verbal bullying cyberbullying hinduja et al. (2017)    garaigordobil & martinezvalderrey (2015)    gaffney et al. (2019)    vassallo et al. (2014)   yin et al. (2017)   chan et al. (2015)    chaux et al. (2016)  albayrak et al. (2016)  bhui et al. (2017)   hall et al. (2017)   silva et al. (2017)   zhou et al. (2017)   garmy et al. (2017)    yuksel-sahin (2015)   jurnal ners http://e-journal.unair.ac.id/jners | 559 influenced by individual or organizational behavior (hall, 2017). another advantage of bullying policies is that they are upstream interventions that provide the basis for downstream interventions, in other words, more targeted intervention programs, practices, and services at the organization, group, and individual table 2. handling bullying article handling bullying chaux et al. (2016) schools randomly assigned classrooms to one of three conditions: control; long version; or short-version. self-report measures of bullying perpetration and bullying victimization were administered before and after the intervention. vassallo et al. (2014) interpersonal skills and parent and peer relationships garaigordobil & martinezvalderrey (2015) cyber program 2.0; cyberbullying intervention program, traditional bullying also included; 19 lessons aimed to raise awareness, outline the consequences of, and develop coping strategies relating to bullying and cyberbullying. participants are also taught to develop positive social and emotional skills. yin et al. (2017) enhancement of active control and peer support as a prevention strategy to reduce adverse mental health outcomes in adolescents due to bullying victims hinduja et al. (2017) resilience is a good protective factor in preventing bullying and reducing its effects. implications for school and community-based interventions. albayrak et al. (2016) the post-test results showed that the pvs and pbbs bullying scale were significantly lower than in the control group gaffney et al. (2019) confident kids program and whole-school program chan et al. (2015) the effectiveness of the whole school approach was proven in terms of preventing and reducing school bullying among chinese children and adolescents. bhui et al. (2017) family social support is independently associated with less psychological pressure hall et al. (2017) anti-bullying policies might be effective at reducing bullying if their content is based on evidence and sound theory and if they are implemented with a high level of fidelity. more research is needed to improve on limitations among extant studies silva et al. (2017) intervention models for the prevention and reduction of bullying cases have practical implications for reducing bullying and a positive impact on students' psychosocial wellbeing zhou et al. (2017) symptoms that can be mediated by the effects of endurance and mindfulness are stronger for children with low attention garmy et al. (2017) victims of bullying are at least 2-3 times each month at 5.5%, covering a younger age, not living with their parents, and living in rural areas. related parties and school health administrators must first consider sociodemographics when planning interventions to reduce bullying in schools yuksel-sahin (2015) bullying scores, bullying tendencies, and handling of bullying have differences with gender, participation in social activities, being submissive, and the presence of school counselors about bullying prevention table 3 review article sample measures findings chaux et al. (2016) 1,075 students aged 11 – 17 (mean = 13.36) from five schools in germany. self-report measures of bullying perpetration and bullying victimization schools randomly assigned classrooms to one of three conditions: control; long version; or short-version. self-report measures of bullying perpetration and bullying victimization were administered before and after the intervention. vassallo et al. (2014) n=1359 young adults a broader measure of oppositional behavior, self-report delinquency scale plus a single item asserting illicit substance preventive interventions that target interpersonal skills and parent and peer relationships are effective in reducing the adverse effects of bullying garaigordobil & martinez-valderrey (2015) n=352 classrooms from 3 different schools were randomly assigned to either the control or intervention condition and participants from both conditions completed self-report bullying measures preand postimplementation. cyber program 2.0; cyberbullying intervention program, traditional bullying also included; 19 lessons aim to raise awareness, outline the consequences of, and develop coping strategies relating to bullying and cyberbullying. participants are also taught to develop positive social and emotional skills. yin et al. (2017) sample: n=755 adolescents social supports scale enhancement of active control and peer support as a prevention strategy to reduce adverse mental health outcomes in adolescents due to bullying victims chan et al. (2015) sample: n=545 high school students the olweus bullying prevention program (obpp) the effectiveness of the whole school approach was proven in terms of preventing and reducing school bullying among chinese children and adolescents. d. y. rohmana et al. 560 | pissn: 1858-3598  eissn: 2502-5791 level. for example, bullying policies can be adopted in the state or district; the policy then applies to all schools in the country or district. discussion physical bullying is the first discussion of bullying in the journals we have analyzed, then there is verbal bullying, and also cyberbullying. the handling of bullying that was discussed throughout the journals that we analyzed said that it could not only provide intervention to the perpetrators or victims of bullying but also needed to involve many related parties who supported the implementation of a comprehensive bullying intervention. the greater impact of the risk of bullying on psychological pressure s in adolescents shows a greater increase in boys compared to girls in adolescents. overall this increase was influenced by difficulties, such as poverty and unemployment. also, most studies do not present the effectiveness of different interventions to prevent or fight bullying according to the type of intervention, age, and socioculture in the context of students. in terms of age, interventions are more efficient among older students. most studies include a sample consisting of participants older than 10 years, which limits the interpretation of the results. that means the results may be biased because of the large number of studies addressing older children. despite these limitations, one possible explanation for this result is that older student colleagues have further developed cognitive skills. they better understand the nature of bullying or the possibility of making more rational decisions, thus making themselves skilled in handling aggression in defending themselves. conclusion bullying behavior is one of the many problems of behavior and discipline among school students today. gaffney et al. (2019) n=474 prevention programs anti-bullying programs (the confident kids program and whole-school program to reduce bullying) were proven to reduce bullying in schools by more than 20%. hinduja et al. (2017) sample: 1204 adolescents between age 1217 years old the connor-davidson resilience 25-item self-report scale (cdrisc) resilience is a good protective factor in preventing bullying and reducing its effect. implications for school and community-based interventions. albayrak et al. (2016) n=367 adolescents peer bullying behaviour scale (pbbs) peer victimization scale (pvs) the post-test results showed that the pvs and pbbs bullying scale were significantly lower than the control group bhui et al. (2017) n=3322 students the strengths and difficulties questionnaire (sdq) total difficulties score (tds) for psychological distress family social support is independently associated with less psychological pressure hall et al. (2017) n= 489 anti-bullying policies anti-bullying policies might be effective at reducing bullying if their content is based on evidence and sound theory and if they are implemented with a high level of fidelity. more research is needed to improve on limitations among extant studies silva et al. (2017) n= 449 anti-bullying intervention intervention models for the prevention and reduction of bullying cases have practical implications for reducing bullying and a positive impact on students' psychosocial well-being zhou et al. (2017) n= 448 children in china the children and adolescent mindfulness measure, center of epidemiologic studies depression scale (ces-dc) symptoms that can be mediated by the effects of endurance and mindfulness and are stronger for children with low attention garmy et al. (2017) n=5.018 students family affluence scale (fas), the icelandic version of the survey included 12 questions regarding bullying victims of bullying are at least 2-3 times each month at 5.5%, covering a younger age, not living with their parents, and living in rural areas. related parties and school health administrators must first consider sociodemographics when planning interventions to reduce bullying in schools yuksel-sahin (2015) 402 senior high school students bullying tendency scale, coping with bullying scale bullying scores, bullying tendencies, and handling of bullying have differences with gender, participation in social activities, being submissive, and the presence of school counselors about bullying prevention jurnal ners http://e-journal.unair.ac.id/jners | 561 direct or indirect bullying behavior is part of the behavior of aggression. several factors encourage bullying behavior among school students, namely individual, family, peer group, school, media. bullying behavior needs to be prevented at school. therefore schools need to have a good intervention prevention program, a recovery program which involves all the components in the teaching and learning process in schools. this research shows, on the one hand, that by reducing bullying the effects of emotional coping are reduced at the level of depressive symptoms. on the other hand, by reducing emotional-oriented coping, it is better to replace it with more adaptive coping, the impact of risk factors such as being bullied in the development of depressive symptoms can be reduced. therefore it is important to prevent maladaptive coping strategies. more adaptive handling strategies must be incorporated as early as possible. interventions with elements of cognitivebehavioral therapy for distressed adolescents, including recognition, challenging negative thoughts, stopping self-blame, and increasing self-esteem, can help. conflict of interest no conflicts of interest have been declared. acknowledgement the authors of this study would like to thank the faculty of nursing and also masters in nursing study program, for providing the opportunity to present this study. references albayrak, s., yildiz, a., & erol, s. (2016). assessing the effect of school bullying prevention programs on reducing bullying. children and youth services review, 63, 1–9. https://doi.org/10.1016/j.childyouth.2016.02.00 5 bhui, k., silva, m. j., harding, s., & stansfeld, s. (2017). bullying, social support, and psychological distress: findings from relachs cohorts of east london’s white british and bangladeshi adolescents. journal of adolescent health, 61(3), 317–328. https://doi.org/10.1016/j.jadohealth.2017.03.00 9 chan, h. c. (oliver), & wong, d. s. w. (2015). traditional school bullying and cyberbullying in chinese societies: prevalence and a review of the whole-school intervention approach. aggression and violent behavior, 23, 98–108. https://doi.org/10.1016/j.avb.2015.05.010 chaux, e., velásquez, a. m., schultze-krumbholz, a., & scheithauer, h. (2016). effects of the cyberbullying prevention program media heroes (medienhelden) on traditional bullying. aggressive behavior, 42(2), 157–165. https://doi.org/10.1002/ab.21637 cosma, a., whitehead, r., neville, f., currie, d., & inchley, j. (2017). trends in bullying victimization in scottish adolescents 1994–2014: changing associations with mental well-being. international journal of public health, 62(6), 639–646. https://doi.org/10.1007/s00038-017-0965-6 damayanti, n. (2019). pengaruh penerapan teknik. 20, 59–67. fisher, h. l., moffitt, t. e., houts, r. m., belsky, d. w., arseneault, l., & caspi, a. (2012). bullying victimisation and risk of self harm in early adolescence: longitudinal cohort study. bmj (online), 344(7855), 1–9. https://doi.org/10.1136/bmj.e2683 garaigordobil, m., & martínez-valderrey, v. (2015). effects of cyberprogram 2 . 0 on “ face-to-face ” bullying , cyberbullying , and empathy. 27(1), 45– 51. https://doi.org/10.7334/psicothema2014.78 garmy, p., vilhjálmsson, r., & kristjánsdóttir, g. (2018). bullying in school-aged children in iceland: a cross-sectional study. journal of pediatric nursing, 38, e30–e34. https://doi.org/10.1016/j.pedn.2017.05.009 hall, w. (2017). the effectiveness of policy interventions for school bullying: a systematic review. journal of the society for social work and research, 8(1), 45–69. https://doi.org/10.1086/690565 hinduja, s., & patchin, j. w. (2017). cultivating youth resilience to prevent bullying and cyberbullying victimization. child abuse and neglect, 73(september), 51–62. https://doi.org/10.1016/j.chiabu.2017.09.010 liberati, a., altman, d. g., tetzlaff, j., mulrow, c., gøtzsche, p. c., ioannidis, j. p. a., … moher, d. (2009). the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. journal of clinical epidemiology, 62(10), e1–e34. https://doi.org/10.1016/j.jclinepi.2009.06.006 olweus, d., & limber, s. p. (2010). bullying in school: evaluation and dissemination of the olweus bullying prevention program. american journal of orthopsychiatry, 80(1), 124–134. https://doi.org/10.1111/j.19390025.2010.01015.x silva, j. l. da, oliveira, w. a. de, mello, f. c. m. de, andrade, l. s. de, bazon, m. r., & silva, m. a. i. (2017). anti-bullying interventions in schools: a systematic literature review. ciencia e saude coletiva, 22(7), 2329–2340. https://doi.org/10.1590/141381232017227.16242015 vassallo, s., edwards, b., renda, j., & olsson, c. a. (2014). bullying in early adolescence and antisocial behavior and depression six years later: what are the protective factors? journal of school violence, 13(1), 100–124. https://doi.org/10.1080/15388220.2013.84064 d. y. rohmana et al. 562 | pissn: 1858-3598  eissn: 2502-5791 3 yin, x., wang, l., zhang, g., liang, x., li, j., zimmerman, m. a., & wang, j. (2017). the promotive e ff ects of peer support and active coping on the relationship between bullying victimization and depression among chinese boarding students. psychiatry research, 256(2), 59–65. https://doi.org/10.1016/j.psychres.2017.06.037 yuksel-sahin, f. (2015). an examination of bullying tendencies and bullying coping behaviors among an examination of bullying tendencies and bullying coping behaviors among adolescents. (june). https://doi.org/10.1016/j.sbspro.2015.04.415 531 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20522 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research knowledge and skill in relation to the speed and accuracy of the nurses when assessing using an early warning system (ews) qolbi nur q.y.1 ,3, nursalam nursalam1, and ahsan ahsan2 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 faculty of medicine, universitas brawijaya, malang, indonesia 3 rsud dr. saiful anwar, malang, indonesia abstract introduction: errors when filling in or interpreting the results of the ews assessment causes delays and inaccuracies for the nurses when providing a clinical response. the aim of this study was to explain the relationship between the nurse’s knowledge and skill with the speed and accuracy of the nurse when assessing via ews. methods: this study used a correlation design with a cross-sectional approach. the sample consisted of 104 nurses working in the inpatient ward of internal medicine according to the inclusion criteria. the sample was obtained through purposive sampling. the independent variable was the nurses’ knowledge and skill while the dependent variable was the nurse’s speed and accuracy when assessing using the ews. the instruments used were questionnaires and observation sheets. the data was analyzed using spearman rho. results: the results of the study showed that there was a very strong correlation between the knowledge-accuracy of the nurses when assessing using the ews (r = 0.805; p = 0.000) and the nurse's skill-accuracy when assessing using the ews (r = 0.823; p = 0.000). there was a strong correlation between the knowledge-speed of nurses assessing using the ews (r = 0.269; p = 0.006) and the nurse's skill and speed when assessing using the ews (r = 0.262; p = 0.007). conclusion: the nurse’s knowledge and skill has a stronger relationship with accuracy when assessing using the ews when compared to the nurses' speed. the nurse’s knowledge about the ews and the nurse’s skill needs to be improved in order to support the increased speed and accuracy needed by the nurses when assessing patients using the ews. the development of an appropriate method needs to be done to improve the nurses' knowledge and skill related to the ews. article history received: feb 27, 2020 accepted: april 1, 2020 keywords early warning system;, nurses; accuracy; speed; skill; knowledge contact nursalamnursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: y.q. n. q., nursalam, n, & ahsan, a. (2020). knowledge and skill in relation to the speed and accuracy of the nurses when assessing using an early warning system (ews). jurnal ners, special issues, 531-537. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20522 introduction the early warning system (ews) is a detection system used to spot changes in a patient's worsening condition(peate, 2014). the ews has proven to be a very effective system for detecting patients who are at risk of deterioration in a clinical conditions up to the point of death(peate, 2014). this system is expected to provide better quality care for the patients and it is able to reduce mortality(alam et al., 2014). this system aims to assist the clinical staff when identifying the early danger signs of critical patients while in the inpatient room before there is a decline in the widespread clinical conditions(stafseth, grønbeck, lien, randen, & lerdal, 2016)(keene, kong, clarke, & brysiewicz, 2017). this is done to prevent unwanted events(komisi akreditasai rumah sakit;, 2017). it https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nursalam@fkp.unair.ac.id q. nur q.y et al. 532 | pissn: 1858-3598  eissn: 2502-5791 will also encourage the provision of action as early as possible with the aim of improving patient outcomes(peate, 2014). errors when filling in or interpreting the results of the ews assessment causes a delay and inaccuracy in the clinical response. this will worsen the patient's condition which can increase the mortality rate of the patients in the inpatient room(alam et al., 2014). preliminary data from 20 nurses about the implementation of the ews in an internal medicine inpatient installation hospital in malang explained that 75% (15 people) had difficulty applying the ews, 50% (10 people) made errors when completing the ews instruments, 50% (10 people) made errors when interpreting the ews instruments, 100% (20 people) had never received the necessary ews training but they had received information about the ews. in addition, 80% (16 people) said that the observation sheets were not practical because they had to read their interpretations on different sheets. several previous studies have attempted to uncover the nurses' knowledge of the ews assessments such as those conducted by dyah restuning prihati and maulidta karunianingtyas wirawati (2019), and desi ratnasari manurung (2018) and augustinus solagratia situmorang (2018) who examined the nurses' attitudes toward the ews assessments(restuning & karunianingtyas, 2019)(manurung, 2018)(situmorang, 2019). errors when conducting the ews assessment can be prevented by requiring every health worker to attend education, training and demonstrations on the implementation of an ews in the hospital(physicians;, 2012). timeliness and competence when conducting ews assessments can improve patient safety(royal colloge of physicians, 2017). delay and inaccuracy in an assessment using the ews will result in a worsening of the patient’s condition which pairs with an increase in the mortality risk in the inpatient room(tesalonike, 2019)(widiastuti, 2017). the ews has been widely applied by several hospitals in indonesia, especially since the hospital accreditation commission in indonesia (kars) established the ews in the national accreditation standard known as the snars edition 1 in 2017(komisi akreditasai rumah sakit;, 2017). an explanation of the ews is listed in the patient focused service standards: chapter 4 patient services and care (pap) 3.1 about detection (recognizing) changes in patient condition(komisi akreditasai rumah sakit;, 2017). the ews system allocates points in a weighted manner based on the derangement of a predetermined set of vital signs from an arbitrarily agreed “normal” range. the early warning scoring system (ewss) was introduced by morgan, et al in 1997 as a simple tool that can be applied by the ward staff to identify patients developing a critical illness(jarvis et al., 2015). in 2012, the royal college of physicians conducted an ewss evaluation and standardization. it came to be known as the national early warning score (news). news is a systematic approach that uses scoring to identify changes in someone's condition while determining the next step that must be done(physicians;, 2012). a standardized news has been introduced for use in the national health service (nhs) in the uk(physicians;, 2012). the rcp recommended that an ews assessment should be performed on adult patients (16 years or older) to assess an acute disease, to detect clinical decline and to initiate timely and appropriate clinical responses. it is used as an aid for clinical judgment and not as a substitute for competent clinical judgment. it is also used for the initial assessment of acute illness and for the ongoing monitoring of a patient's condition during their stay in the hospital, for prehospital assessments where there is an acute patient conditions conducted first responders such as the ambulance services, primary health services and the public health center to optimize the communication of the patient condition before they are received by the destination hospital (physicians;, 2012). the determination of news is based on 6 physiological parameters namely respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate and the level of consciousness(physicians;, 2012). ews scoring is allocated to each parameter measured. the magnitude of the score reflects how extreme the parameters differ from normal conditions(physicians;, 2012). each important mark is allocated a numerical value from 0 to 3 with an observation color code chart (a score of 0 is the most desired and a score of 3 is the most undesirable(a.; & p., 2020). the total score indicates whether someone needs oxygen or not(physicians;, 2012). knowledge is influenced by several factors, including age, education, occupation, environment and culture(soekijo notoadmodjo, 2014). the nurse's knowledge of the ews involves the level of the nurses' understanding of the ews instruments and how to apply them in terms of scoring, interpretation, and determining the most appropriate clinical response. the nurse's skill of assessing using the ews refers to the nurse's capacity to use the ews instrument. this includes the skill when scoring and interpreting the results, and determining the nurse's response. nurses play a central role in implementing an news and it is important to capture their ‘voice’ when evaluating the effectiveness of the tool. timeliness contributes to the review mechanism that will inform development(fox & elliott, 2015). the speed of the nurses when conducting the ews assessments refers to the time required by the nurses to score, interpret the results and determine the clinical responses that are best for the patients. the sum of the allocated points is used to indicate a patient’s severity in terms of their illness and to inform if there is a need to increase the patient’s physiological monitoring or to deliver expert help to their bedside(jarvis et al., 2015). the speed of the nurses when assessing using the ews is the time required by the nurses to conduct the scoring, the interpretation of the results, and the jurnal ners http://e-journal.unair.ac.id/jners | 533 determination of the clinical responses that will be given to patients. the accuracy of the ews assessment is a match between the results of the scoring, their interpretation, and the clinical response determined by the nurse. the aim of this study is to explain the relationship between the level of knowledge and skill of the nurses with the speed and accuracy of the nurses when assessing using the ews. materials and methods this study used a correlational design with a crosssectional approach that explains the relationship between the nurse’s knowledge and skill when conducting an assessment using the ews compared against the nurse’s speed and accuracy when assessing using the ews. the study was conducted between december 2019 and february 2020 in malang, east java. the researchers involved a population of nurses from an internal hospital with 143 people. a total of 104 samples were obtained based on purposive sampling, population size estimates formulas, and several inclusion criteria. the inclusion criteria used included: nurses who had served in the inpatient ward conducting inpatient care for internal medicine, who had a minimum education level of a diploma, and who had worked for a minimum of 3 years in the hospital. the independent variable was the nurses' knowledge and skill while the dependent variable was the speed and accuracy of the nurse when assessing using the ews. the initial stage of this research was to provide informed consent to the respondents. the informed consent explained the purpose, benefits and procedures of the research that were to be carried out. the nurses who agreed to be respondents were given the research questionnaire. the demographic data was assessed using gender, age, last education, length of working and position. collecting the data on the level of the nurse’s knowledge was done using a questionnaire that had previously been tested for validity and reliability. the results of the calculation of the validity test found that of the 15 questions, all items were declared to be valid. the questionnaire consisted of 15 question items which included the definition of the news, the purpose of writing the news, the parameters of the news, the requirements for news, news documentation, the news score, the interpretation of news and the clinical response of the nurses to the results of the scoring. a correct answer score was given 1 and a wrong answer score was given 0. the maximum score that a nurse can get if she answered correctly is 15 while the minimum score for a nurse’s skill possible is 0. the assessment of the nurses' skill in terms of the scoring, interpretation, and determination of the clinical responses showed that the researchers were helped with the observation sheets. a score of 1 was given for a correct answer while a score of 0 was given for an incorrect answer. the maximum score that a nurse could get if they answered correctly was 10 while the minimum score was 0. descriptive analysis was used to analyze the characteristics of the respondents. the analysis of the relationship of the dependent variables independently was done using spearman rho with the statistical significance level set at p <0.05. the ethical clearance was provided by dr. saiful anwar’s hospital-malang number 400/261 / k.3 / 302/2019 on november 22th 2019. results table 1 explains that the majority of respondents in the research totaled 63 women (60.58%). most had an age range of 30-34 years totaling 49 people (47.11%). most had a diploma as their last level education totaling as many as 73 people (70.20%). most had had more than 10 years of service (41.35%) and most of the respondents were a nurse associate (83.65%). table 2 explains that from the 104 nurse respondents who filled in the questionnaire about their ews knowledge, the majority of the nurses table 1. characteristics of the respondent nurses in the internal medicine inpatient room (n=104) characteristics of the respondents parameter σ (n=104) % gender male 41 39.42 female 63 60.58 total 104 100 age 25-29 years 26 25.00 30-34 years 49 47.11 >35 years 29 27.89 total 104 100 last education diploma 73 70.20 bachelor’s 31 29.80 total 104 100 length of working 1-5 years 35 33.65 6-10 years 26 25.00 >10 years 43 41.35 total 104 100 position nurse associate 87 83.65 nurse primer 17 16.35 total 104 100 q. nur q.y et al. 534 | pissn: 1858-3598  eissn: 2502-5791 totaling 74 people (71.15%) had good basic knowledge of the ews. however, as many as 80 people (76.93%) had less knowledge about the interpretation of the ews results. in general, most of the nurses (60%) have less knowledge. table 3 explains that most of the nurse respondents have good skill when it comes to documenting the results of the ews examination, especially regarding the ews scoring of 98 nurses (94.23%) followed by the skill needed to interpret the ews and the clinical response of the ews. table 4 explains that only a few nurses (19.23%) have ews training certificates, thus only 20 nurses have attended ews training. based on table 5, it was found that the majority of nurses (63.00%) need time in the range of 61 to 120 seconds to assess using the ews. from this data, it can be seen that the average time needed by the nurses to assess using the ews is 123 seconds. table 6 explains that the majority (69.00%) of nurses were able to carry out an ews assessment appropriately, namely the appropriateness of the results of the scoring, interpretation, and clinical response determined. based on the data in table 7, it can be determined that there are still many (80%) rooms that have not implemented the ews optimally. table 8 explains that only 10.00% of the internal medicine treatment rooms have ews implementation guidelines. table 9 shows the spearman-rho analysis. these results show that there is a very strong correlation between the knowledge and accuracy of nurses when assessing using the ews (r = 0.805; p = 0.000). there was a strong correlation between knowledge and the speed of nurses when assessing using the ews (r = 0.269; p = 0.006). there is a very strong correlation between the nurse's skill and accuracy when assessing using the ews (r = 0.823; p = 0.000). there is a strong correlation between the nurse's skill and speed when assessing using the ews (r = 0.262; p = 0.007). discussion ews, which is applied in the internal medicine wards in one hospital in malang city, was adopted from news 2012 with some adjustments according to the condition of the hospital. the parameters used include respiration, pulse, systolic blood pressure, body temperature, critical values, level of consciousness and additional oxygen, but only the parameters of respiration, pulse, systolic blood pressure and body temperature are scored. the clinical interpretations and responses used include green (score 0-1) ttv monitoring per 6 hours; yellow table 2. evaluation results of the nurse’s knowledge levels about ews in the inpatients rooms in internal medicine (n=104) knowledge parameter score σ(n=104) % basic ews well > 76 74 71.15 enough 56 – 75 23 22.11 less < 55 7 6.74 total 104 100 scoring well > 76 35 33.65 enough 56 – 75 64 61.54 less < 55 5 4.81 total 104 100 interpretation well > 76 3 2.88 enough 56 – 75 21 20.19 less < 55 80 76.93 total 104 100 clinical response well > 76 28 26.92 enough 56 – 75 55 52.89 less < 55 21 20.19 total 104 100 table 3. evaluation results of the nurses' capabilities in irna 1 when assessing using the ews (n=104) nurse’s skill parameter score σ(n=104) % ews scoring well > 76 98 94.23 enough 56 – 75 6 5.77 less < 55 0 0.00 total 104 100 ews interpretation well > 76 56 53.85 enough 56 – 75 48 46.15 less < 55 0 0.00 total 104 100 ews clinical response well > 76 72 69.23 enough 56 – 75 32 30.77 less < 55 0 0.00 total 104 100 jurnal ners http://e-journal.unair.ac.id/jners | 535 (score 2-3): ttv monitoring per 2 hours, reporting to the attending doctor; orange (score 4-5): ttv monitoring per 1 hour, nurse reporting to the on-duty doctor and the doctor reporting to the dpjp doctor and red (score> 6): monitoring ttv per half hour, nurse reporting to the on-duty doctor and the doctor reporting to the dpjp. the nurse's knowledge of the ews is the basis for conducting ews assessments. every nurse needs to receive socialization related to the basic knowledge of ews including definition, scoring, interpretation, the clinical response, requirements, goals and the benefits of the ews assessment. the results of the research conducted by suwaryo, putra, sutopo, rahmat, utoyo and bambang explain that the socialization of an ews is expected to increase the nurses' knowledge(suwaryo, sutopo;rahmat, & utoyo, 2019). based on the data obtained by the researchers, nurses who have less knowledge have lower levels of speed and accuracy compared to the nurses who have good levels of knowledge. based on the research data obtained, the level of the nurse’s knowledge related to the ews is influenced by the level of education and information that they have on the ews(bylow et al., 2019). most of the nurses (70.20%) involved in this study were educated to diploma level. only a small proportion (19.23%) had attended ews training since the ews observation sheet was socialized in 2017 at the internal medicine inpatient facility. each nurse must complete a training program before conducting an ews assessment(fox & elliott, 2015). in general, the level of knowledge of the nurses about the ews mostly (60.00%) indicates less knowledge. the results of the research by dyah restuning prihati and maulidta karunianingtyas wirawati (2019) and desi ratnasari manurung (2018) revealed that more nurses have implemented an ews (51.4%) who have enough knowledge than those who had good knowledge(restuning & karunianingtyas, 2019)(manurung, 2018). the results of the field study have shown that the nurse's skill when assessing using the ews is measured in terms of speed and accuracy when scoring, in addition to the interpretation of results and the determination of the clinical responses. most of the nurses (63.00%) were able to determine the clinical response in 61-120 seconds with an average of 123 seconds. the time needed to score is longer than when interpreting the results and determining the clinical response. furthermore, 69.00% of the nurses were able to perform correctly at the time of scoring, in the interpretation of the results and when determining the clinical response. the three abilities within the scoring skill play an important role when assessing using ews. accuracy in scoring at 100.00% indicates good accuracy in relation to the interpretation of results and the determination of the clinical response. the level of knowledge and skill was also influenced by the nurses' experience of conducting ews assessments. based on the results of the survey conducted in the internal medicine ward, out of 10 rooms, the implementation of the ews has not been running optimally. only 20.00% of the rooms have been proven to be active at implementing ews in relation to recognizing hereditary clinical conditions. this data is supported by the results of the study of augustinus solagratia situmorang (2018) showing that the nurses' lack of knowledge about the ews is the cause of the ews not running optimally(situmorang, 2019). nurses who often carry out ews assessments have higher levels of speed and accuracy when compared to the rooms that have not been optimal when implementing the ews. the nurse's level of knowledge about the ews and the skill of the nurses when conducting an ews assessment has an influence on the speed and accuracy of the nurses when assessing. a good understanding of the nurses about the ews can help the nurses to identify physiological changes in the patients so then the patients receive quality care safely [19]. this study shows that there is a very strong correlation between knowledge and accuracy and a strong correlation between the knowledge and speed of the nurses when assessing using the ews. the table 4. data on the nurses attending ews training in the internal medicine inpatient installation ews training certificate σ(n=104) % have 20 19.23 did not have 84 80.77 total 104 100 table 5. speed of the nurses when performing the ews assessment time (seconds) σ(n=104) % >60 6 6.00 61 – 120 66 63.00 > 120 32 31.00 total 104 100 table 6. accuracy of the nurses when assessing using the ews accuracy σ(n=104) % correct 72 69.00 incorrect 32 31.00 total 104 100 q. nur q.y et al. 536 | pissn: 1858-3598  eissn: 2502-5791 nurses with good knowledge will have a higher value for speed and accuracy compared to the medical personnel with sufficient or less knowledge. there is a very strong correlation between the nurse's skillaccuracy when assessing using the ews and there is also a strong correlation between the nurse's skillspeed when assessing using ews. nurses with the skill to conduct ews assessments better will have an improved level of speed and accuracy when compared to the nurses who have either sufficient or less skill. the result of this study can be used as a reference for the hospital in order to develop an appropriate method to improve the nurses' knowledge and skill when assessing using ews, thereby enhancing the rapid response system, decreasing the mortality rate and improving the patient clinical outcomes. conclusion the nurse's level of knowledge about the ews and the skills of the nurses when conducting an ews assessment has an influence on the speed and accuracy of the nurses when assessing using ews. the nurse’s knowledge and skills related to ews has a stronger relationship with accuracy compared to the nurses' speed when assessing using ews. the nurse’s knowledge and skill related to assessing using ews concerning the internal medicine inpatients needs to be improved, to support the increased speed and accuracy of the nurses when conducting assessments using the ews. a rapid and appropriate ews assessment will improve the prevention of a worsening patient condition in the inpatient room. the development of an appropriate method needs to be done to improve the nurses' knowledge and skills when assessing patients using the ews. references a.;, a. d., & p., d. d. (2020). persepsi perawat t erhadap p enerapan e arly w arning. 11(1), 120–125. alam, n., hobbelink, e. l., van tienhoven, a. j., van de ven, p. m., jansma, e. p., & nanayakkara, p. w. b. (2014). the impact of the use of the early warning score (ews) on patient outcomes: a systematic review. resuscitation, 85(5), 587– 594. https://doi.org/10.1016/j.resuscitation.2014.01 .013 bylow, h., karlsson, t., claesson, a., lepp, m., lindqvist, j., & herlitz, j. (2019). self-learning training versus instructor-led training for basic life support: a cluster randomised trial. resuscitation, 139, 122–132. https://doi.org/10.1016/j.resuscitation.2019.03 .026 fox, a., & elliott, n. (2015). early warning scores: a sign of deterioration in patients and systems. nursing management, 22(1), 26–31. https://doi.org/10.7748/nm.22.1.26.e1337 jarvis, s., kovacs, c., briggs, j., meredith, p., schmidt, p. e., featherstone, p. i., … smith, g. b. (2015). aggregate national early warning score (news) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. resuscitation, 87, 75–80. https://doi.org/10.1016/j.resuscitation.2014.11 .014 keene, c. m., kong, v. y., clarke, d. l., & brysiewicz, p. (2017). the effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward. chinese journal of traumatology english edition, 20(5), 283– 287. https://doi.org/10.1016/j.cjtee.2016.11.008 komisi akreditasai rumah sakit; (2017). standar nasional rumah sakit edisi 1. jakarta: komisi akreditasi rumah sakit. manurung, d. r. (2018). gambaran tingkat pengetahuan perawat dalam penerapan early warning score di ruang perawatan lantai 2,5 dan 6 rumah sakit siloam dhirga surya. universitas pelita harapan, tangerang. peate, i. (2014). fundamental of assessing and care planing for nurse. river street: wiley black well. physicians;, r. c. of. (2012). national early warning score (news): standarising the assessment of acute-illness severity in the nhs. london. restuning, p., & karunianingtyas, w. (2019). pengetahuan perawat tentang early warning score dalam penilaian dini kegawatan pasien kritis. jurnal keperawatan lppm sekolah tinggi ilmu kesehatan kendal, 22(4), 237–242. royal colloge of physicians. (2017). national early warning score (news) 2: standarising the assessment of acute-illness severity in the nhs. london. situmorang, a. s. (2019). hubungan pengetahuan dan sikap perawat terhadap kepatuhan skoring early warning score di ruang bethesda rumah sakit umum siloam kupang. journal of chemical information and modeling, 53(9), 1689–1699. https://doi.org/10.1017/cbo9781107415324.0 04 soekijo notoadmodjo. (2014). ilmu perilaku kesehatan. jakarta: rineka cipta. stafseth, s. k., grønbeck, s., lien, t., randen, i., & lerdal, a. (2016). the experiences of nurses implementing the modified early warning score and a 24-hour on-call mobile intensive care nurse: an exploratory study. intensive and critical care nursing, 34, 33–41. https://doi.org/10.1016/j.iccn.2015.07.008 suwaryo, p. a. w., sutopo;rahmat, & utoyo, b. (2019). pengetahuan perawat dalam menerapkan early warning score system ( ewss ) di ruang perawatan. htpp://ejournal.stikesmuhgombong.ac.id, 15(2), 64–73. jurnal ners http://e-journal.unair.ac.id/jners | 537 tesalonike, e. c. (2019). gambaran kelengkapan dokumentasi early warning score (ews) pada pasien code blue di paviliun umum rumah sakit siloam. journal of chemical information and modeling, 53(9), 1689–1699. https://doi.org/10.1017/cbo9781107415324.0 04 widiastuti, l. (2017). efektifitas early warning score dalam deteksi kegawatdaruratan di trauma center rumkital dr. midiyato s tanjungpinang. jurnal keperawatan, 7(2), 775–781. 1686. https://doi.org/10.2147/ppa.s169826 http://e-journal.unair.ac.id/jners | 177 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.26674 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research empowering health cadres on nutrition education for pregnant women in industrial areas during the pandemic lasiyati yuswo yani, raras merbawani, and asef wildan munfadlila stikes bina sehat ppni mojokerto, mojokerto, indonesia abstract introduction: pregnant women living in industrial areas are exposed to higher levels of toxic substances, pollutants, and other chemicals; this is exacerbated by the pandemic conditions. improving the nutritional status of pregnant women can be pursued through nutritional education for pregnant women. this study aimed to determine the differences in nutrition fulfilment patterns of pregnant women, before and after nutrition education. methods: this study used quasi-experimental research with a one group pre post-test design. the samples were 51 pregnant women in industrial areas. treatment in this study was nutrition education by empowering health cadres. the instrument of this research is an observation sheet that has been tested for validity and reliability. data analysis used a statistical paired t-test. results: knowledge of pregnant women increased by 5.21% after treatment, and behaviour increased by 5.2%. the t-test showed that the the nutrition education model for pregnant women in industrial areas could significantly increase the knowledge (p-value = 0.000) and improve the behaviour (p-value = 0.000) of pregnant women. conclusion: nutrition education for pregnant women provided by health cadres is proven to increase knowledge of pregnant women about nutrition and behaviour of fulfilling nutrition during pregnancy in a pandemic situation. during the pandemic, pregnant women can increase knowledge related to nutrition fulfilment through the assistance of health cadres without worrying about being exposed to viruses from care providers. article history received: july 14, 2021 accepted: november 16, 2021 keywords nutrition education; knowledge; behaviour contact lasiyati yuswo yani  yuswoyani@gmail.com  stikes bina sehat ppni mojokerto, mojokerto, indonesia cite this as: yani, l. y., merbawani, r., & munfadlila, a. w. (2021). empowering health cadres on nutrition education for pregnant women in industrial areas during the pandemic. jurnal ners, 16(2). 177-182. doi: http://dx.doi.org/10.20473/jn.v16i2.26674 introduction a healthy and balanced diet is important in the lifecycle and during pregnancy. the mother's diet must provide sufficient energy and nutrition to meet the usual needs of the mother, as well as the needs of the growing foetus and allow the mother to maintain her own stores of nutrients necessary for the health of the foetus and infant and for the practice of breastfeeding during the puerperium (fallah et al., 2013). pregnant women are among the vulnerable population groups with a need to take additional protection against the covid-19 outbreak (h. liu et al., 2020). the nutritional status of pregnant women is a concern of many countries in the world, this is related to the immunity of pregnant women in pandemic conditions (amini et al., 2021; whitaker et al., 2021). in indonesia, the problem of fulfilling nutrition for pregnant women during the pandemic is also a major concern for the government in protecting pregnancy (abadi & putri, 2020; soewondo et al., 2021). in addition, the fulfilment of the nutritional needs of pregnant women during this pandemic is also influenced by the knowledge of pregnant women about nutrition (darnton-hill & mkparu, 2015; prado et al., 2012) pregnant women who have good knowledge about nutrition will try their best to meet their nutritional needs during pregnancy (anwar et al., n.d.), (shah et al., 2017). one of the efforts that can increase the knowledge of pregnant women about the fulfilment of their nutrition is through nutrition https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v16i2.26674 l. y. yani et al. 178 | pissn: 1858-3598  eissn: 2502-5791 education (hakim et al., 2014; nimbalkar et al., 2017; otoo & adam, 2016). during this pandemic, nutrition education for pregnant women cannot be carried out intensively by care providers because of restrictions to reduce the transmission rate of the coronavirus disease (amini et al., 2021; n. liu et al., 2009; whitaker et al., 2021). this study aims to increase the knowledge of pregnant women in industrial areas with an outreach approach by health cadres. it is hoped that even though this nutrition education is not provided directly by the care provider, pregnant women can still optimize the fulfilment of nutrition during pregnancy through nutrition education provided by health cadres in the village. pregnant women living in industrial areas are exposed to higher levels of toxic substances, pollutants, and other chemicals, this has been exacerbated by the pandemic conditions (balabaeva et al., 1993). exposure to industrial chemicals is associated with pregnancy outcomes, such as low birth weight (lin et al., 2001; phatrabuddha et al., 2013). this is exacerbated because during this pandemic there are regulations limiting physical contact, especially with care providers. this contact restriction causes pregnant women to be limited in receiving knowledge related to pregnancy, including the problem of fulfilling nutrition during pregnancy. research conducted on working pregnant women showed that 76.5% had anaemia and 23.5% were not anaemic. in contrast to pregnant women who do not work, this is because pregnant women who work, especially in factories, have less free time that can be used to participate in health education (purbadewi & ulvie, 2013). the knowledge that pregnant women do not work has an effect on the lower incidence of anaemia in pregnant women compared to working mothers. in the midst of a still threatening pandemic, the fulfilment of balanced nutrition is needed to maintain the immunity of pregnant women as well as the growth of the foetus. the problems encountered today are not a few pregnant women who are worried about contact with health workers; this is because they are worried about being exposed to the coronavirus. this phenomenon makes nutrition education during pregnant women also less well received by pregnant women. this study applies a nutrition education model for pregnant women by optimizing the role of health cadres in order to minimize the contact between pregnant women and health workers. it is expected that there will be changes in the fulfilment of nutrition patterns before and after the provision of education. materials and methods this study was conducted in a quasi-experimental one-group pre-post design. the population was 90 pregnant women in industrial areas. purposive sampling was used to recruit the participants. the explanation of the terms and conditions of the study was given and informed consent for study participation was obtained. all respondents were assured of the voluntary and confidential nature of the study. a total of 51 pregnant women participated as respondents in this study. the criteria for respondents in this study were 1st trimester pregnant women who lived in industrial areas and also work as factory workers or factory office administrators and were willing to be observed during the study. there were two kinds of instruments used in this study. to assess the nutritional status of pregnant women using analysis of anthropometric measurements of bmi, measurements of upper arm circumference and haemoglobin levels. meanwhile, to assess the mother's knowledge about the fulfilment of maternal nutrition during pregnancy, a questionnaire instrument was used that has been tested for validity and reliability with cronbach’s alpha of 0.760, with a sensitivity ranging from 0.450 to 0.829. the questionnaire consists of 25 statements on a likert scale that explores the mother's knowledge about the basic concepts of nutrition: what are the views of table 1. characteristics of pregnant women in industrialized areas variable n % age (year) < 21 8 16 21-35 >35 41 2 80 4 education elementary school 6 12 junior high school senior high school higher education 5 31 9 10 60 18 parity primi para 20 40 multi para 29 56 grande multi 2 4 salary below usd 314 24 47 above usd 314 27 53 table 2. the level of knowledge of pregnant women before and after treatment knowledge before after n % n % poor 18 35 0 0 satisfactory 26 51 14 27 good 7 14 37 73 p-value = 0.000 table 3. the behaviour of nutritional consumption in pregnant women before and after treatment behaviour before after n % n % poor 16 31 0 0 satisfactory 20 39 11 22 good 15 30 40 78 p-value = 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 179 pregnant women about nutrition and pregnancy, food sources of nutrients, and how pregnant women improve nutrition during pregnancy. the treatment in this study was the provision of nutrition education by health cadres. health cadres, also known as village health promoters, are volunteers selected by the community and tasked with developing the community, usually dealing with health in the community. the health cadres that have been selected are given training beforehand on the fulfilment of nutrition for pregnant women by nutritionists and care providers at the community health centre. cadres are provided with a guidebook for the fulfilment of nutrition for pregnant women, this includes food sources containing iron and how to process them. the guide is equipped with leaflets and nutrition booklets as media used by cadres for nutritional assistance. assistance is carried out by cadres visiting pregnant women's homes once a week until the gestational age of pregnant women at the end of 2nd trimester. after being given this treatment, pregnant women are assessed post-test. the data scale of this study is the ratio interval, so the statistical test used is a parametric test. based on the normality test, the data is declared to be normally distributed, then data processing is carried out with a paired t-test. the ethical permit approval number 141/ec/kepk-hw/07/2020 was requested from the health office of the research ethics commission hafsyawati zainul hasan genggong. the ethical requirements and rights of respondents have been fulfilled during the research process to collect data and not cause damage or interference. results characteristics of pregnant women in industrialized areas can be seen in table 1. most of the respondents are of reproductive age, namely 21-35 years of age (80%), with the educational background of most of the high school seniors (60%), parity status is more than half of 56%, age of pregnancy in the first trimester is 30%, the second trimester 35%, and the third trimester 35%. meanwhile, 47% of economic status earn less than the standard minimum fee of industry employees and 53% earn more than the regional minimal wage (±usd 314). the results of the analysis in table 2 show that after being given treatment there was an increase in good knowledge by 73% and no respondent had a lack of knowledge. the analysis showed that 42 people experienced an increase in their level of knowledge and 9 people had no change in their level of knowledge. from the results of the spss output, the p = 0.000, which means that the h0 is rejected, meaning that there is an effect of nutrition education on the knowledge of pregnant women on nutritional consumption during pregnancy. the results of the analysis in table 3 show that after being given the nutrition education model, there was an increase in the consumption of appropriate nutrition by 78% and there were no respondents who behaved inappropriately. the analysis showed that 36 people experienced an increase in their nutritional consumption behaviour during pregnancy and 15 people had no change in their nutritional consumption behaviour during pregnancy. the pvalue is 0.000, which means that h0 is rejected, meaning that there is an effect of the nutritional education model on the nutrition consumption behaviour during pregnancy. discussion this study shows that the nutrition education model during pregnancy provided by health cadres during the pandemic has been proven to increase knowledge of nutrition consumption behaviour. similar results were reported by a randomized study conducted at the university of ghana showing that nutrition education that emphasizes consumption of iron-rich foods is positively associated with increased haemoglobin levels (otoo & adam, 2016). a quasiexperimental study conducted by el-guindi et al, (2010) showed a significant positive relationship between dietary practices and increased haemoglobin levels of pregnant women (el-guindi et al., 2010). similarly, in a pre-test post-test study on pregnancy conducted by garg & kashyap (2006), individual counselling significantly increased mean haemoglobin levels in pregnant women (0.97 vs 1.58, p <0.001) (garg & kashyap, 2006). likewise, in a randomized control trial among pregnant nepalese women, the educational programme saw only significantly higher haemoglobin changes (0.23 gm / dl) compared to the control group (p <0.01) (adhikari et al., 2012). while a randomized control trial conducted in greece did not show a significant effect of nutrition education and counselling on haemoglobin levels in the intervention group compared to the control group (kafatos et al., 1989). a review of previous randomized control trials and quasi-experimental studies reported substantial and significant effects when nutritional education and counselling was provided with nutritional supplements, mostly via micronutrients, compared to nutrition education alone (girard & olude, 2012). the nepal demographic and health survey report shows that only 42% of women used the recommended dose of iron during pregnancy and 41% of women between the ages of 15 and 49 are anaemic (ministry of health, 2016). thus, adherence to iron supplementation is still low in pregnant women in nepal. according to the multi-sectoral nutrition plan ii, nepal has a target to reduce the prevalence of anaemia among women of reproductive age by up to 50% in line with the sustainable development goals (ministry of health, 2016). counselling on nutrition education and a diet plan based on iron-rich foods for pregnant women can be effective strategies to reduce anaemia among pregnant women. the nutrition education intervention and diet plan based on iron-rich foods were significantly associated l. y. yani et al. 180 | pissn: 1858-3598  eissn: 2502-5791 with improved maternal nutritional knowledge scores of anaemia and intake of iron-rich foods in the intervention group compared to the control group (66% vs 24.1%). a randomized study conducted at a ghanaian university reported that a significant increase in knowledge was demonstrated by the intervention group at the end of the intervention period (otoo & adam, 2016). studies conducted in ethiopia revealed that the knowledge of pregnant women about nutrition during pregnancy increased significantly after the provision of nutrition education and special dietary practices (mwangi et al., 2017; robertson & ladlow, 2017). the intervention study design was conducted in kalyobia governorate (moshtoher, kafrshoukr, and kaha) (n = 200). the results showed 78% of pregnant women had achieved a good nutritional knowledge score after the intervention (el hameed et al., 2012). however, most of the counselling performed during antenatal visits tends to be general in nature in the nepalese context. our findings suggest that pregnant women who have good nutritional knowledge can increase haemoglobin levels. thus, nutrition education and counselling during antenatal visits can increase the nutritional knowledge of mothers about iron-rich foods. similar results were reported by another study conducted, an intervention study that after a nutrition education session, there was a significant increase in the nutritional knowledge score that could help prevent anaemia (nimbalkar et al., 2017). another study conducted by kafatos ag et al. indicated that nutritional counselling during pregnancy can increase food intake and increase maternal weight (kafatos et al., 1989). the results of this study indicated that pregnant women who received nutrition education and an iron-based diet experienced a significant increase in the consumption levels of red meat, fish liver, fruits rich in vitamin c, dairy products, eggs and dark green vegetables compared to controls. group. the study conducted by liu et al. (2009) also showed that fruit consumption increased by more in the intervention group than in the control group (n. liu et al., 2009). pregnant women in the intervention group reflected a change in behaviour by practicing a minimum dietary consumption of 3 or more (daniel et al., 2016; mclean et al., 2009). nutrition education and counselling have been found in other studies to improve maternal diet including dietary practices and consumption of macro and micro nutrients (adhikari et al., 2012; essén et al., 2005). micronutrient deficiencies can lead to poor maternal health outcomes and pregnancy-related complications. previous research showed that increasing the consumption of micronutrients in pregnancy can improve the nutritional status of pregnant women. research conducted by emilia (2009) also revealed the need to implement nutrition education as an effort to change behaviour to improve nutrition (emilia, 2009). health education with the information motivation behaviour skill (imb) approach plays a role in increasing knowledge and patterns of vegetable and fruit consumption in pregnant women (farhati et al., 2019). our study has several limitations. our study sample size is insufficient because the findings cannot be generalized to a wider population. adherence to nutritional education and diet plans based on ironrich foods was not assessed in this study. only haemoglobin levels were measured so we could not assess the differentiation of anaemia, such as iron deficiency, nutrition, genetics, and infectious anaemia in this study. there is a possibility of bias because there was no control group in this study. conclusion nutrition education for pregnant women during the pandemic by village health cadres is proven to increase knowledge of pregnant women in meeting nutritional needs. this increased nutritional knowledge resulted in changes in the pattern of nutritional fulfillment of pregnant women for the better. it is recommended for pregnant women to increase their knowledge related to nutritional fulfillment intensively in assisting health cadres without worrying about being exposed to the virus from service providers. for community health centres it is recommended to increase the capacity of health cadres by more intensively providing training as a provision in assisting pregnant women in the community. references abadi, e., & putri, l. a. r. (2020). konsumsi makronutrien pada ibu hamil kekurangan energi kronik (kek) di masa pandemi covid-19. jurnal kesehatan manarang, 6(2), 85–90. adhikari, b., koirala, u., lama, s., & dahal, p. (2012). situation of iron deficiency and its management prioritizing dietary intervention in nepal. nepal j epidemiol, 2(2), 182–90. https://doi.org/https://doi.org/10.3126/nje.v2i 2.6573 amini, s., mohseni, h., kalantar, m., & amani., r. (2021). nutrition in caring for pregnant women during the covid-19 pandemic in low-income countries. nutrition today, 56(2), 80–84. anwar, a., bashir, m. k., adil, s. a., hassan, s., & ali, a. (n.d.). food and nutritional security of pregnant women in rural areas: the case of district lahore, pakistan. balabaeva, tabacova, s., & liudmila. (1993). environmental pollutants in relation to complications of pregnancy. environmental health perspectives supplements, 2(2), 27–31. daniel, s., pu, g., gnanaraj, s., & sharmine, e. (2016). effect of nutrition education among pregnant women with low body mass index: a community based intervention. int j community med public heal, 3(11), 3135–3139. https://doi.org/doi:10.18203/23946040.ijcmph20163924 jurnal ners http://e-journal.unair.ac.id/jners | 181 darnton-hill, i., & mkparu, u. c. (2015). micronutrients in pregnancy in lowand middleincome countries. nutrients, 7(3), 1744–1768. https://doi.org/10.3390/nu7031744 el-guindi, f., soliman, n., & el-nana, h. (2010). effect of nutritional interventions on anemic pregnant womens health promotion model. med j cairo univ. el hameed, h. s. a., mohammed, a. i., & el hameed, l. t. a. (2012). effect of nutritional educational guideline among pregnant women with iron deficiency anemia at rural areas in kalyobia governorate. life science journal, 9(2), 1212– 1217. emilia, e. (2009). pendidikan gizi sebagai salah satu sarana perubahan perilaku gizi pada. jurnal tabularasa, 6(2), 161–174. essén, b., sjöberg, n.-o., gudmundsson, s., östergren, p.-o., & lindqvist, p. g. (2005). no association between female circumcision and prolonged labour: a case control study of immigrant women giving birth in sweden. european journal of obstetrics & gynecology and reproductive biology, 121(2), 182–185. https://doi.org/10.1016/j.ejogrb.2004.12.010 fallah, f., pourabbas, a., delpisheh, a., veisani, y., & shadnoush, m. (2013). effects of nutrition education on levels of nutritional awareness of pregnant women in western iran. international journal of endocrinology and metabolism, 11(3), 175–178. https://doi.org/10.5812/ijem.912 farhati, f., resmana, r., & nurhadianti, d. (2019). pendidikan kesehatan dengan pendekatan model information motivation behavior skill (imb) terhadap peningkatan pengetahuan dan pola konsumsi sayur dan buah pada ibu hamil. jurnal kesehatan, 10(3), 320–328. garg, a., & kashyap, s. (2006). effect of counselling on nutritional status during pregnancy. indian jpediatr, 73(8), 687–692. girard, a., & olude, o. (2012). nutrition education and counselling provided during pregnancy: effects on maternal, neonatal and child health outcomes. paediatr perinat epidemiol, 26(1), 191–205. hakim, e. w., moffat, m., becker, e., bell, k. a., manal, t. j., schmitt, l. a., & ciolek, c. (2014). application of educational theory and evidence in support of an integrated model of clinical education. journal of physical therapy education, 28, 13–21. kafatos, a. g., vlachonikolis, i. g., & codrington, c. a. (1989). nutrition during pregnancy: the effects of an educational intervention program in greece. the american journal of clinical nutrition, 50(5), 970–979. https://doi.org/10.1093/ajcn/50.5.970 lin, m., yu, h., tsai, s., cheng, b., hsu, t., wu, t., & yang, c. (2001). adverse pregnancy outcome in a petrochemical polluted area in taiwan. journal of toxicology and environmental health part a, 63, 8. liu, h., wang, l., zhao, s., kwak-kim, j., mor, g., & liao, a. (2020). since january 2020 elsevier has created a covid-19 resource centre with free information in english and mandarin on the novel coronavirus covid19 . the covid-19 resource centre is hosted on elsevier connect , the company ’ s public news and information. 139(january), 2–4. https://doi.org/https://doi.org/10.1016/j.jri.202 0.103122 liu, n., mao, l., sun, x., liu, l., yao, & chen, b. (2009). the effect of health and nutrition education intervention on women’s postpartum beliefs and practices: a randomized controlled trial. bmc public health, 9(45), 1–9. https://doi.org/doi:10.1186/1471-2458-9-45 mclean, e., cogswell, m., egli, i., wojdyla, d., & de benoist, b. (2009). worldwide prevalence of anaemia, who vitamin and mineral nutrition information system, 1993–2005. public health nutrition, 12(04), 444. https://doi.org/10.1017/s1368980008002401 ministry of health. (2016). new era, the dhs program icf. nepal demographic and health survey. mwangi, m. n., prentice, a. m., & verhoef, h. (2017). safety and benefits of antenatal oral iron supplementation in low‐income countries: a review. british journal of haematology, 177(6), 884–895. https://doi.org/10.1111/bjh.14584 nimbalkar, p., patel, j., thakor, n., & patni, m. (2017). impact of educational intervention regarding anaemia and its preventive measures among pregnant women: an interventional study. int j reprod contraception, obstet gynecol, 6(12), 5317–5321. otoo, g., & adam, y. (2016). effect of nutrition education with an emphasis on consumption of iron-rich foods on hemoglobin levels of pregnant women in ghana. faseb j, 30(1). phatrabuddha, n., maharatchpong, n., keadtongtawee, s., & saowakhontha, s. (2013). comparison of personal btex exposure and pregnancy outcomes among pregnant women residing in and near petrochemical industrial area. environmentasia, 6(2). prado, e. l., ullman, m. t., muadz, h., alcock, k. j., & shankar, a. h. (2012). the effect of maternal multiple micronutrient supplementation on cognition and mood during pregnancy and postpartum in indonesia: a randomized trial. plos one, 7(3). https://doi.org/10.1371/journal.pone.0032519 purbadewi, l., & ulvie, y. n. s. (2013). hubungan tingkat pengetahuan tentang anemia dengan kejadian anemia pada ibu hamil. jurnal gizi, 2(1). robertson, n., & ladlow, b. (2017). effect of individual dietetic intervention on gestational weight gain and associated complications in obese pregnant women. aust n z j obstet gynaecol. shah, s., sharma, g., shris, l., shah, s. k., sharma, m., & sapkota, n. k. (2017). knowledge on dietary patterns among pregnant women attending antenatal care check-up in narayani hospital, nepal. international journal of community medicine and public health, 4(5), 1466–1472. soewondo, m., prastuti, sakti, koemara, g. m., irawati, l. y. yani et al. 182 | pissn: 1858-3598  eissn: 2502-5791 oktiana, d., pujisubekti, retno, rahmayanti, maretia, n., sumartono, indrawan, a. h., & nurfitriyani. (2021). potret adaptasi dan inovasi layanan gizi di masa pandemi covid-19: studi kasus di 8 kabupaten/kota di indonesia. in prosiding forum ilmiah tahunan (fit) iakmi. whitaker, k. m., hung, p., alberg, a. j., hair, n. l., & liu, j. (2021). variations in health behaviors among pregnant women during the covid-19 pandemic. midwifery, 95, 102929. 1 factors affecting the compliance of myanmar nurses in performing standard precautions sa sa aung*,**, nursalam**, yulis setiya dewi** *department of adult health nursing, university of nursing mandalay, myanmar **faculty of nursing, universitas airlangga surabaya email: sasanaing@gmail.com abstract introduction: exposure to pathogens is a serious issue for nurses. the literature explains that standard precautions have not been taken consistently in nursing. the purpose of this study was to analyse the factors affecting the compliance of nurses in myanmar in taking standard precautions. methods: this study used a cross-sectional design. samples included 34 nurses in waibagi specialist hospital (shw), myanmar. the independent variables were the characteristics of nurses, knowledge of standard precaution, and exposure to blood/body fluids and needle puncture wounds. the dependent variable was the performance of standard prevention. data were analysed using descriptive analysis and logistic regression. results: the results showed that almost respondents (91.18%) had a good knowledge of prevention standards and 73.5% of respondents had good adherence in taking standard precautions. however, in practice, nurses have not been consistent in closing the needles that have been used correctly. the results showed that nurse characteristics did not significantly affect adherence to standard precautions with statistical test results as follows: age (p = 0.97), gender (p = 1.00), religion (p = 0.72), education (p = 0.85), work experience at shw (p = 0. 84), education training program (p = 0.71), knowledge (p = 0.76), and needle stick injury (p = 0,17). but, there was a significant influence between adherence to standard precautions and the incidence of injury due to needle puncture with p-value = 0.01. discussion: the barriers to applying standard precautions by myanmar nurses can be reduced by providing basic training, supervision, and improvement of standard operational procedures. keywords: standard precautions, knowledge, obedience introduction health care worker (hcw) exposures and potential exposures to pathogens are widespread (karmon, mehta, brehm & dzurenko, 2013; henderson, 2012). globally, in 35 million hcws, about 3 million receive percutaneous exposures to bloodborne pathogens each year, and about 40% of hbv and 40% of hcv infections and 4.4% of hiv infections in health care workers are attributable to occupational sharps exposure among health care workers (who, 2002). almost all health care workers are at risk of exposure to these pathogens, but among those, nurses are the group that is most affected (yang et al., 2013). it has been estimated that > 50% of nurses will experience at least one needle stick injury in their careers (rhode & dupler, 2013). compliance with standard precautions has been shown to reduce the risk of exposure to blood and body fluids (parkin, 2012). however, some studies show that compliance with standard precautions among nurses is still sub-optimal and inconsistent (efstathiou, papastavrou, raftopoulos & merkouris, 2011a; gebresilassie, kumei & yemane, 2014; punia, nair & shetty, 2014; eljedi & dalo, 2014; jackson, lowton & griffiths, 2014; takimani, 2015; abu bakar, haruna, teryila, hamina & ahmadu, 2015). in myanmar, some studies show that most hcws in myanmar have high knowledge and a positive attitude, but compliance with universal precautions/standard precautions is inconsistent (shwe, 2007). this is a similar finding to that of thu (2012) who stated that knowledge of universal precautions already high, only (37.4%) of hcws (including nurses) had a high compliance score at yangon orthopedic hospital and khine (2007). thu also found that most nurses had good knowledge levels but only 49.2% of nurses had good adherence to universal precautions in 300 beds teaching hospital, mandalay, myanmar. in specialist hospital waibagi (shw), the results of an initial collection of data (preliminary study) on 7 to 8 december 2016, showed that around half of the nurses exposed to the blood and body fluids of hiv infectious patients (40%) and needle stick injury during recapping needle within one year was 12.5% among nurses. through telephone interview with one of the nurses in shw regarding compliance with standard precautions, it was shown that her experience of nurses’ compliance with standard precautions was inconsistent and the major reasons were that they had forgotten to wear gloves and wash hands, available resource storage is a little far from where nursing care is provided, there are time constraints and emergency situations. mailto:sasanaing@gmail.com jurnal ners vol. 12 no. 1 april 2017: 1-8 2 there is a very limited previous study analysing the factors affecting compliance with standard precautions among nurses in myanmar. the results of this study will be applicable in determining a strategy for improving health behaviours and the development of an infection control program to prevent occupational exposure to pathogens. therefore, the researcher aims to examine nurses’ compliance with standard precautions and analyse factors affecting compliance with standard precautions. methods in this study, an explanatory research design was used to explain and explore the affecting factors of compliance with standard precautions. there were two phases with a cross-sectional study to formulate the strategic issues in the first phase of study. the sample size was 34 nurses who are working in shw and, except for a nursing officer (matron), they were recruited and this research was conducted during march 2016 to april 2016. the dependent variable was compliance with standard precautions, while the independent variables were characteristics of nurses, knowledge of standard precautions, experienced exposure to blood/body fluids and needle stick injury. the instruments used to measure the level of basic knowledge, and compliance with standard precautions was structured questionnaires. the data were collected and analysed using descriptive and logistic regression with a significance level of α≤0.05. ethical clearance the study was approved for protection of human rights and welfare in medical research by the ethical committee of the faculty of nursing universitas airlangga, surabaya, indonesia no 120-kepk and the department of health professional resource development and management, department of health, ministry of health and sports nay pyi taw, myanmar. as this project was part of a masters thesis, the protocol was reviewed, evaluated and approved by a supervisory committee. the completion of questionnaires was considered as informed consent for participation. the participants were free to participate in or withdraw from the study; anonymity and confidentiality of the participants’ information was strictly maintained. data analysis the statistical package for the social sciences (spss) version 23.0 was used to analyse the data. in descriptive statistics, the scoring of knowledge involves 10 questions, with each question rated as giving 1 mark for the correct response and zero scores for incorrect and no response, and for the score of compliance with standard precautions, it was rated on a likert scale (1=never, 2=seldom, 3=sometimes, 4=often and 5=always), while for negative statemeng were the conversely. the categories for knowledge for compliance with standard precautions were: low: ≤ 5.5, enough: 5.5-7.5, good: >7.5. for compliance with standard precautions they were: poor: ≤90, good: >90. in inferential statistics, logistic regression was used with a significance level of α≤0.05. result the content validity index (cvi) was determined and all items were ≥ 0.98, evidence that a cvi of at least 0.80 is considered to be a good criterion for accepting an item as valid (davis, 1992). moreover, the cronbach’s alpha was also determined by the response to all questionnaires by using the likert-type response format. it was found to be > 0.70, evidence that the questionnaires had an acceptable level of internal consistency (bowling, 2009). demographic characteristics of nurses demographic characteristics of 34 participants were age, gender, religion, nursing education, working experiences at shw, education and training. the mean age of participants ranged from 22 to 57 years and the majority of participants (50%) were in the 26– 35 year age group. in terms of gender, almost all (97.1%) participants were females and only one was male. most of the participants (85.3%) were buddhist and the remaining participants (14.7%) were christian. more than two thirds (67.6%) of them were bachelor degree holder and one third had a diploma degree. total service of participants ranged from less than one year to 19 years and two thirds of participants had 5 to 10 years of service in shw and only factors affecting the compliance of myanmar nurses ( sasa, et. al) 3 20.6% attended educational training for infection control locally or internationally. compliance with standard precautions for overall compliance with standard precautions, analysis data showed that 73.5% of participants had good compliance and 26.5% participants had poor compliance with standard precautions practice in this study. specifically, all participants had good practice for hand washing and gloving as 100% of participants reported good compliance in each. on the other hand, practice of safety glases was very poor since 100% participants described poor practice and no participant always used an eye shield. in wearing a mask and following safety measures for sharp handling practice, only 8.8% and 17.6% responded positively indicating poor compliance (table 3). major reasons for non-compliance with standard precautions most reasons for non-compliance with standard precautions in this study were emergency situations, workload, recapping needles, that it is unusual to wear eye shields, that nurses forgot to wear gloves and wash hands, that it is uncomfortable to use personal protective equipment (ppe) and a poor fit, availability of resources storage is a little far from where nursing care is provided, and time constraints. therefore, factors affecting compliance with standard precautions should be explored to improve nursing staff’s compliance with standard precautions. the effects of characteristics of nurses, exposure to blood/bodyfluid, needlestick injury and knowledge of compliance with standard precautions statistical test results using logistic regression showed a significant value in exposure to blood/body fluids p=0.01, characteristics of nurses such as age p=0.97, gender p=1.0, religion p=0.72, nursing education p=0.60, working experience p=0.84, and educational training program p=0.71, knowledge of standard precautions p=0.76, and needlestick injury p=0.17, did not show a significant effect on compliance with standard precautions (table 4). table 1. level of knowledge of standard precautions no knowledge total frequency percentage (%) 1 high 32 94.11 2 average 2 5.89 3 low total 34 100 table 2. experienced exposure to blood/body fluids and needlestick injury among nurses in shw no structural variables category total f(%) yes f(%) no f(%) 1 exposure to blood or body fluids 15 (44.12) 19 (55.88) 34 (100) 2 experienced needlestick injury 5 (14.71) 29 (85.29) 34 (100) table 3. overall compliance and specific compliance with hand washing, gloving, wearing mask, eye wearing, safe sharp handling no compliance with sp good f (%) poor f (%) total f (%) 1 overall compliance 25 (73.5) 9 (26.5) 34 (100) 2. hand washing 34 (100) 0 (0) 34 (100) 3. gloving 34 (100) 0 (0) 34 (100) 4 wearing mask 31 (91.2) 3 (8.8) 34 (100) 5 eye wearing 0 (0) 34 (100) 34 (100) 6 safety sharp handling 28 (82.4) 6 (17.6) 34 (100) jurnal ners vol. 12 no. 1 april 2017: 1-8 4 table 4 the effects of variables on compliance with standard precautions variables b s.e wald df sig. 95% ci for odds ratio age 1.10 1.723 .000 1 0.97 1.01 gender (male/female) 0 -19.91 40192.99 .000 1 1.00 .000 religion 0.530 1.453 .133 1 0.72 1.70 education 3.625 1.202 .271 1 0.60 .535 service at shw 4 .816 3 0.84 training (yes/no) 0-626 1.698 .136 1 0.71 .535 exposure (yes/no) 2.559 .993 6.642 1 .010 12.929 needle stick injury (yes/no) -1.747 1.299 1.808 1 .179 .174 knowledge (good/average) -474 1.557 .093 1 .761 .622 discussion in this study, regarding overall compliance with standard precautions, almost three-quarters (73.5%) of participants showed good compliance among myanmar nurses in shw. in myanmar, this result compared favorably with other studies that reported 62.6% of nurses had good compliance among 92 participants in yangon orthopedic hospital (thu, 2012) and 49.2% of myanmar nurses were found to have good compliance in mandalay, 300 beds teaching hospital (khine, 2007). international studies reported that 59.4% of nurses presented a high mean score of adherence to standard precautions in a university hospital in brazil (toffan et al., 2011), hcws (including nurses) had good compliance in ethiopia (42.9%) (gebresilassie et al., 2014) in contrast, it is still lower than the rate of compliance reported by 32 hospital nurses in cyprus (100%) (efstathiou et al., 2011b), 120 nurses in iran whose copmpliance was 97.5% and among 1444 clinical nurses from 18 hospitals in hunan, china (95%) (luo, he & zhou, 2010). specifically, with regard to hand washing, all participants (100%) self-reported as having good compliance with hand washing, and only 5.88% participants self-reported that they seldom wash their hands before and after giving care to the patient. these findings strongly approve the statement that hand washing should always be carried out before and after the provision of care as it reduces the count of microorganisms on one’s hands, protecting both healthcare professionals and patients from the spread of infection (apostolopoulou, raftopoulos, terzis, pissaki & pagoni, 2010). regarding gloving in practice, there was also good compliance with gloving (100%) in this study. while drawing patient’s blood participants (81.2%) always and only (8.8% of the time) sometimes wear gloves. these are not similar findings as one-third of participants reported that they did not always wear gloves when exposure was likely to happen (e.g. during the drawing of blood) among cypriot nurses (efstathiou et al., 2011a). however, it was consistent that gloves were used while drawing the blood (81.0%) and during instances when coming into contact with mucous membranes or non-intact skin of the patients (88.3%) (punia et al., 2014) in contrast, the practice of wearing safety glasses was very poor since all participants described compliance with safety glasses as there was poor compliance and no participant always used an eye shield during nursing caring procedures that may lead to the splashing of blood and body fluids. similarly, takimani (2015) found that only 5.6% of participants used eye protection and the most neglected personal protective equipment in a high-risk procedure is eyewear among nurses in nairobi. punia et al. (2014) also mentioned that only 22.2% of participants always wear eye protection in an emergency and trauma triage centre from south india. this does not comply with the infection control manual, 2014 that protective eyewear must be worn while performing any procedure where there is a likelihood of splashing or splattering of blood or other body substances (infection control manual, 2014). this practice leads to the greatest hazard in terms of the possibility of splash or splatter to nurses’ eyes that can increase occupational exposure. factors affecting the compliance of myanmar nurses ( sasa, et. al) 5 with regard to wearing a mask, most participants reported satisfactory good practice (91.2%). they may believe that a face mask can prevent the inhalation of air-transmitted microorganisms and they are highly recommended when the exposure to such microorganisms is anticipated (siegel & rhinehart, 2007). safety sharp handling practice also showed good compliance (82.4%) among nurses in this study. when at work nurses always disposed of all potentially contaminated materials in a red (and/or labeled) bag for disposal as biomedical waste and they always discarded the sharp objects in puncture resistant sharps containers (73.5%). similarly, the majority (95.7%) of participants answered that nurses always discarded used sharp objects into a sharps container among cypriot nurses (efstathiou et al., 2011a) this behaviour is in accordance with the requirements of standard precautions, which require such action to prevent the risk of danger of injury for the safety of all healthcare workers. however, punia et al. (2014) reported improper disposal of sharps among the healthcare workforce in a trauma care setting in south india. a used needle poses a serious danger from needlestick injury (schmid, schwager & drexler, 2007). used needles should never be recapped, as this could lead to a needlestick inury. statistical test results using logistic regression showed significant value in exposure to blood/body fluids p = 0.01, (p ≤ 0.05). unfortunately, two thirds of participants selfreported that nurses always recapped needles before discarding them in this study.this finding agreed with other studies in myanmar; it was surprising to find that a significantly large proportion of respondents (94.9%) recapped the needle after use (shwe, 2007) and 89% recapped and more than half of the respondents had experience of needlestick injury (thu, 2012). some studies from other countries, punia et al. (2014) reported inadequate needle safety precautions among the healthcare workforce in a trauma care setting in south india. before they discarded needles, 43.7% of the respondents did not always avoid recapping a used needle according to the study of cypriot nurses (efstathiou et al., 2011a) and reda et al. (2010) also demonstrated needle recapping (46.9%) by healthcare workers (including nurses) in ethiopia. in contrast, the practice of recapping used needles was uncommon, (94.4%) amongst participants disposing of the syringe and needle immediately into puncture resistant containers without recapping among nurses in nairobi (takimani, 2015). abubakar et al. (2015) also found that among nurses working at the federal medical centre gumbo, nigeria, the majority (76.25%) of the respondents did not recap the needle after use and most respondents (80%) disposed of used syringes and needles in the safety box. in this study, the practice of recapping needles was not satisfactory. it causes a very dangerous situation for hcws. used needles should never be recapped, as this could lead to a needlestick injury. consequently, it is apparent that recapping a used needle poses a high risk of needlestick injury among nurses in shw. the effects of characteristics of nurses on compliance with standard precautions this current study reported that there was no significant effect between compliance with standard precautions and characteristics of nurses in terms of age, gender, religion, years of experience, nursing education and education training. osborne (2003) in australia, demir (2009) and hosoglu et al., (2011) in turkey found that there was a relationship between the low compliance rate and the participant’s demographic characteristics in terms of age, gender and religion. this is consistent with ayed, equait, fashafsheh and ali's (2015) study in palestine and fashafaheh et al.’s study in egypt (2015) according to age, gender, years of experience, nursing education, education training but is inconsistent with ayed et al. (2015), efstathiou et al.’s, study (2011a) and mortada & zalat's (2013), in terms of gender. moreover, inconsistently, abubakar et al.’s (2015) study in nigeria and efstathiou et al.’s (2011a) study in cyprus showed that the longer years of experience nurses had working, the more frequently they would follow standard precautions. in addition, efstathiou et al. (2011a) showed that educational programs can influence nurses’ compliance levels and persuade them to use standard precautions more frequently. according to luo et al., (2010), the education and health promotion needed to make nurses comply with standard precautions are constant jurnal ners vol. 12 no. 1 april 2017: 1-8 6 training and provision of continuous seminars especially if these training sessions become a compulsory requirement for nursing staff in hospitals. cdc (2013) also asserted that education on the basic principles and practices for preventing the spread of infections should be provided to all heath care professionals. furthermore, the cdc (2014) stressed that education and training should be conducted on a regular basis (e.g., annually) to maintain competency. in this study, only less than onefifth of participants received educational training about infection control workshops. this is a very small amount of education programs for nurses in shw who are caring for patients with hiv and aids, with opportunistic infections such as tuberculosis, hepatitis b, hepatitis c and other contagious diseases. concerning effect of knowledge, exposure and needlestick injury almost all (91.18%) of the participants were found to have a high level of knowledge, and this satisfactory knowledge was found to be higher than the similar report before. a study by thu (2012) in myanmar revealed that 68% of participants were reported to have high knowledge of standard precautions. ayed et al. (2015) in palestine found about three quarters (76%) of the respondents had good and fair knowledge of standard precautions. and abu bakar et al. (2015) in nigeria reported that 28.75% of the participants had good knowledge of the components of standard precautions. this study also demonstrated that knowledge of compliance with standard precautions and needle stick injury were not statistically significant on compliance with standard precautions. in contrast, different studies have indicated that a high level of knowledge of standard precautions was a significant predictor of better compliance with standard precaution practices (hinkin & cutter, 2014; mitchell, say, wells wilson, cloete and matheson, 2014). the influence of knowledge and training were the predictors for nursing students’ compliance with standard precautions among nursing students in china (cheung et al., 2015). moreover, it should be the nurse who has experienced needlestick injuries, the fear of lethal infection who is more frequently willing to follow the precautions and more careful to protect their life from hospital infections. it is urgently necessary to improve nurses’ behaviour that is at high risk of getting exposed to blood-borne infections (hiv, hbv and hcv). the results of parameter estimations indicated that there is a statistically significant effect of exposure to blood/body fluids on compliance with standard precautions (p = 0.01, p ≤ 0.1). inconsistently, efstathiou et al. (2011) and mortada & zalat (2014) also stated that their study detected a high level of self-reported exposure to blood and body fluids that was significantly different among noncompliant compared with compliant participants. in agreement with another study among hcws in ethiopia (reda et al., 2010) the regression model indicated that hcws who regularly apply standard precautions reduced their exposure to incidents by 20%. in this study, almost half of the nurses in shw had exposure to blood/body fluids. even though nurses were exposed to infected blood/body fluids, nurses still attributed risk perceptions. nurses did not always use ppe and focused on work accomplishment rather than their own safety. however, there are some limitations that dictate caution in the interpretation of the results of this outcome data. even though the samples size is strongly and completely representative for all nurses in specialist hospital waibagi, it cannot be generalised to all hospital settings. while collecting the data, there were some nurses leaving for vacation and going back home, causing separate data collection which leads to a possibility of data collection bias. conclusion the results of this study showed that nearly all respondents had a good knowledge of the standards for prevention and the majority of respondents had good adherence to standard precautions, but the prevention of injuries from needle puncture still low among myanmar nurses in shw. the characteristics of nurses such as age, gender, religion, nursing education, working experience and educational training programs, knowledge of standard precautions and needlestick injury did not significantly affect compliance with standard precautions. nurses who have experience of being exposed to a needle prick when performing nursing actions provide significant results in terms of compliance. factors affecting the compliance of myanmar nurses ( sasa, et. al) 7 nurses should always be alert for infections, prohibited from recapping used needles, anticipate all personal protective equipment and need to take part in continuous education and advance knowledge. nurse managers and senior nursing officers need to continuously remind hcws to follow compliance with standard precautions and update information on cne (continuing medical/nursing education) about infection control and get feedback from all nurses every month. health authorities should provide adequate human and material resources, mandatory seminars/workshops and internal and external motivations for quality health care, a safe occupational environment and reducing identified standard precaution barriers. assessment of exposure, and checkup for all hcws needs to be introduced at shw. references abubakar s.m., haruna h., teryila k.r., hamina d., ahmadu i., b.m. & b.u., 2015. assessment of knowledge and practice of standard precautions among nurses working at federal medical centre gombe, nigeria. direct research journal of health and pharmacology, pp. 3(1):1– 11. available at: http//:direct researchpublisher.org/drjhp>. apostolopoulou e., raftopoulos v., terzis k., pissaki k., pagoni m., d.s., 2010. infection probability score, apache ii and karnofsky scoring systems as predictors of infection onset in haematology–oncology patients. journal clinical nursing patients., 19, p. 1560– 1568. ayed a., eqtait m., f.i. and a.g., 2015. knowledge & compliance of nursing staff towards standard precautions in the palestinian hospitals 36th ed., bowling a., 2009. research methods in health. investigating health and health services. 3rd. edition. berkshire: open university press. cdc, 2014. guide to infection prevention for outpatient settings: minimum expectations for safe care. available at: <http://www.cdc.gov/hai/pdfs/guideline s/outpatient-care-guide withchecklist.pdf.> [accessed december 17, 2015]. demir f., 2009. a survey on prevention of surgical infections in operating theatres, worldviews evidence based nursing, pp.102–113. available at: http://www.ncbi.nlm.nih.gov/pubmed/19 422673> [accessed december 8, 2015]. efstathiou g., papastavrou e., r.v.& m.a., compliance of cypriot nurses with standard precautions to avoid exposure to pathogens. nursing and health sciences,, 13(1), pp.53–59. efstathiou g., papastavrou e., r.v.& m.a., no titlefactors influencing nurses’ compliance with standard precautions in order to avoid occupational exposure to microorganisms : a focus group study. bio medical center nursing, 10(1). available at: http://www.biomedcentral.com/1472 6955/10/1> [accessed april 10, 2015b]. gebresilassie a., kumei a., & y.d., 2014. standard precautions practice among health care workers in public health facilities of mekelle special zone, northern ethiopia. community medicine & health education, 4(3), p.1000226. henderson d.k., 2012. management of needlestick injuries. a house officer who has a needlestick. journal of the american medical association, 37(1). hinkin j. & cutter j., how do university education and clinical experience influence pre-registration nursing students’ infection control practice? a descriptive, cross-sectional survey. nurse education today, 34(2), pp.196–201. jackson, c., lowton, k. & griffiths p., 2014. international journal of nursing studies infection prevention as 'a show': a qualitative study of nurses’ infection prevention behaviours. international journal of nursing studies, 51(3), pp.400–408. karmon s.l., mehta s.a., brehm a., dzurenko j., p.m., 2013. evaluation of bloodborne pathogen exposures at an urban hospital. american journal of infection control, 41(2), pp.185–186. khine m.m., 2007. adherence of nurses to universal precautions of blood products in 300 bedded teaching hospital, mandalay, myanmar. luo y., he g.p., z.j.& l.y., 2010. nursing and care factors impacting compliance with standard precautions in nursing, china. jurnal ners vol. 12 no. 1 april 2017: 1-8 8 international journal of infectious diseases, 3(6). mortada e.m. & zalat m.m., 2013. assessment of compliance to standard precautions among surgeons in zagazig university hospitals, egypt, using the health belief model. j arab social medical research. parkin v., 2012. infection prevention policy standard precautions policy punia s., nair s. & s.r., 2014. health care workers and standard precautions : perceptions and determinants of compliance in the emergency and trauma triage of a tertiary care hospital in south india. international scholarly research notices. punia, s., nair, s. & shetty, r.s., 2014. health care workers and standard precautions : perceptions and determinants of compliance in the emergency and trauma triage of a tertiary care hospital in south india, 2014. reda, a.a. et al., 2010. standard precautions : occupational exposure and behavior of health care workers in ethiopia. , 5(12), pp.1–6. rhode k.a., dupler a.e, p.j.& s.a., 2013. minimizing nurses’ risks for needlestick injuries in the hospital setting. schmid k., schwager c., d.h., 2007. needlestick injuries and other occupational exposures to body fluids amongst employees and medical students of a german university: incidence and follow-up. journal of hospital infection 2007, 65, pp.124–130. shwe w.w., 2007. compliance of universal precautions among house officers of north okkalapa genaeral hospital (nogh)’, university of medicine (2), and yangon. siegel j.d., rhinehart e., j.& c.l., 2007. guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, healthcare infection control practices advisory committee. available at: <http://www.cdc.gov/hicpac/pdf/isolation /isolation2007.pdf> [accessed december 1, 2015]. takimani, 2015. factors influencing compliance with infection prevention standard precautions among nurses working at mbagathi district hospital nairobi. available at: http://nursing.uonbi.ac.ke/node/449 [accessed december 17, 2015]. thu k.h., 2012. knowledge and compliance of universal precautions among medical doctors and nurses at yangon orthopaedic hospital, public health. who, 2002. world health report 2002: reducing risks, promoting healthy life. ners vol 10 no 1 april 2015.indd 133 teknik perawatan luka modern dan konvensional terhadap kadar interleukin 1 dan interleukin 6 pada pasien luka diabetik (modern and convensional wound dressing to interleukin 1 and interleukin 6 in diabetic wound) werna nontji*, suni hariati*, rosyidah arafat* program studi ilmu keperawatan fakultas kedokteran universitas hasanuddin jalan perintis kemerdekaan km. 10, kampus unhas tamalanrea makassar e-mail:shekawai@yahoo.co.id abstrak pendahuluan: perawatan luka secara holistik merupakan salah satu cara untuk mencegah gangren dan amputasi, teknik rawat luka modern lebih efektif daripada konvensional dengan cara meningkatkan perubahan faktor pertumbuhan dan sitokin, terutama interleukin. penelitian ini bertujuan untuk mengidentifi kasi efektivitas teknik rawat luka modern dan luka konvensional dressing terhadap kadar interleukin 1 (il-1) dan interleukin 6 (il-6) pada pasien luka diabetik. metode: sebuah kuasi eksperimental pre-post dengan desain kelompok kontrol yang digunakan. intervensi yang diberikan adalah pembalut luka modern dan kelompok kontrol dengan pembalut luka konvensional, penelitian ini dilakukan di makassar dengan 32 sampel (16 di kelompok intervensi dan 16 kelompok kontrol). hasil: hasil uji pooled t menunjukkan bahwa p = 0,00 (p < 0,05), berarti ada signifi kansi korelasi antara teknik rawat luka modern terhadap kadar interleukin 1 (il-1) dan interleukin 6 (il-6) dari pada teknik rawat luka konvensional. diskusi: proses penyembuhan luka dipengaruhi faktor pertumbuhan dan sitokin (il-1 dan il-6), hai ini akan dirangsang oleh pembalutan luka, teknik pembalutan luka modern (kalsium alginat) dapat menyerap luka drainase, non oklusive, non adhesif, dan debridement autolitik. kata kunci: pembalutan luka modern, interleukin 1 (il-1), interleukin 6 (il-6) abstract introduction:holistic wound care is one of the ways to prevent gangrene and amputation, modern wound dressing is more effective than convensional with increasing transforming growth factor and cytokine, especially interleukin. this study aims to identify the effectiveness of modern and convensional wound dressing to interleukin 1 (il-1) and interleukin 6 (il-6) in diabetic wound. method:a quasi eksperimental pre-post with control group design was used. the intervention given was modern wound dressing and control group by convensional wound dressing, this study was conducted in makassar with 32 samples (16 in intervention group and 16 in control group). result: the result of pooled ttest showed that p = 0.00 (p < 0.05), it means that there was signifi cant correlation between modern wound dressing to il-6 and il-1 than convensional wound dressing. discussion: process of wound healing was produced growth factor and cytokine (il-1 and il-6), it will stimulated by wound dressing, modern wound dressing (calcium alginat) can absorb wound drainage, non oklusive, non adhesif, and autolytic debridement. keywords: modern wound dressing, interleukin 1 (il-1), interleukin 6 (il-6) pendahuluan masalah gizi di indonesia merupakan beban ganda bagi kebijakan pembangunan kesehatan nasional. di bidang kesehatan bangsa indonesia masih berjuang memerangi berbagai macam penyakit infeksi dan kurang gizi yang saling berinteraksi satu sama lain. namun, di beberapa daerah atau kelompok masyarakat lain terutama di kota-kota besar, masalah kesehatan utama justru dipicu oleh perubahan hidup akibat urbanisasi dan modernisasi. yaitu obesitas. masih tingginya angka kurang gizi di beberapa daerah dan meningkatnya prevalensi obesitas di daerah lain merupakan beban yang kompleks dan harus dibayar mahal oleh bangsa indonesia dalam upaya pembangunan bidang kesehatan, sumber daya manusia dan ekonomi. meningkatnya masalah kelebihan gizi atau obesitas diikuti oleh peningkatan prevalensi diabetes mellitus tipe 2 yang sangat tajam dan peningkatan ini diperkirakan akan terus berlanjut. badan kesehatan dunia (who) memprediksi penderita diabetes mellitus tipetipe di indonesia meningkat pesat dalam 10 tahun terakhir karena pada tahun 2000 ada 8,4 juta penderita dan meningkat jadi 21,3 juta orang tahun 2010. who tahun 2000 juga menunjukkan bahwa indonesia merupakan 134 jurnal ners vol. 10 no. 1 april 2015: 133–137 negara dengan penderita diabetes terbanyak keempat di dunia setelah india (31,7 juta), china (20,8 juta) dan amerika serikat (17,7 juta) (medan bisnis daily, 2011). secara epidemiologi, diperkirakan bahwa pada tahun 2030 prevalensi diabetes melitus (dm) di indonesia mencapai 21,3 juta orang (diabetes care, 2004). sedangkan hasil riset kesehatan dasar (riskesdas) tahun 2007, diperoleh bahwa proporsi penyebab kematian akibat dm pada kelompok usia 45-54 tahun di daerah perkotaan menduduki ranking ke-2 yaitu 14,7%. dan daerah pedesaan, dm menduduki ranking ke-6 yaitu 5,8%. prevalensi dm di perkotaan sulawesi selatan adalah berkisar 4.6%. diabetes mellitus merupakan suatu kelompok penyakit metabolik dengan karakteristik hiperglikemia yang terjadi karena kelainan sekresi insulin (ada, 2003 dikutip dari soegondo, 2007). penyakit ini belakangan terjadi karena perubahan pola hidup atau gizi salah, namun ternyata penyakit ini juga bisa terjadi karena konsumsi makanan yang banyak mengandung racun misal: singkong yang banyak terdapat pada daerah tropis (tropical diabetes). komplikasi yang paling sering terjadi pada penderita diabetik adalah terjadinya per ubahan patologis pada anggota gerak (irwanashari, 2008). salah satu perubahan patologis yang terjadi pada anggota gerak ialah timbulnya luka. luka yang timbul ini dapat berakibat fatal hingga amputasi pada daerah luka. penanganan luka secara komprehensif diperlukan agar tidak menimbulkan gangren dan amputasi. salah satu penanganan luka yang dewasa ini digunakan adalah perawatan luka teknik modern dengan menggunakan hidrokoloid. perawatan luka modern dipercaya lebih efektif dari perawatan luka konvensional (menggunakan kassa steril) yang banyak digunakan di rumah sakit. penelitian yang dilakukan oleh kristianto menyimpulkan perawatan lu ka moder n mempengar u hi ekspresi transforming growth factor beta 1 (tgf pi). proses penyembuhan luka diabetik dipengar uhi oleh ekspresi transforming growth factor beta 1 (tgf pi), interleukin 1 dan 6. oleh karena itu kami ingin meneliti pengaruh teknik perawatan luka terhadap kadar interleukin 1 dan interleukin 6. bahan dan metode penelitian ini merupakan penelitian kuantitatif dengan menggunakan quasiexperimental design dengan prepost testcontrol g ro u p de sig n u nt u k me mba nd i ng k a n tindakan yang dilak u kan sebelu m dan sesudah eksperimen. pada penelitian ini subjek dibagi menjadi dua kelompok yaitu kelompok yang menggunakan perawatan luka teknik modern dan kelompok kontrol yang menggunakan perawatan luka konvensional. tek nik perawatan lu ka moder n adalah teknik perawatan luka yang menggunakan calsium alginat untuk menutup luka diabetik. perawatan ini merupakan perawatan yang digunakan dan dipilih oleh responden (bukan atas inter vensi peneliti). perawatan ini dilakukan selama 7 hari. teknik perawatan luka konvensional adalah teknik perawatan luka yang menggunakan kasa untuk menutup ulkus diabetik. perawatan ini merupakan perawatan yang digunakan dan dipilih oleh responden (bukan atas intervensi peneliti). perawatan ini dilakukan selama 7 hari. pengamatan interleukin 1 dan interleukin 6 pad a prete st d a n d ia nalisis denga n menggunakan metode human interleukin immunoassay (r & dsystem) atau dengan teknik elisa dan memiliki satuan pg/ml. hasil rata rata kadar interleukin 1 sebelum obser vasi penelitian berkisar 3,293 pg/ mldan rata rata kadar interleukin setelah 7 hari penelitian adalah 2.012 pg/ml. rata rata kadar interleukin 6 sebelum observasi penelitian berkisar 16.6581 pg/ml dan ratarata kadar interleukin setelah 7 hari penelitian adalah 27.8644 pg/ml. terdapat perbedaan ekspresi interleukin 1 antara kelompok perawatan luka konvensional dan perawatan luka modern pada penderita ulkus diabetik di makasar. hal ini dibuktikan dengan melihat p value < a (0,05) yaitu 0,00. berdasarkan p value tersebut, maka dapat disimpulkan bahwa pada tingkat kepercayaan 95% terdapat perbed a an ekspresi kad ar i nterleu k i n1 yang ber mak na antara responden yang menggunakan perawatan luka modern dan 135 teknik perawatan luka modern dan konvensional (werna nontji, dkk.) responden yang menggunakan perawatan luka konvensional te r d a p a t p e r b e d a a n e k s p r e s i interleukin 6 antara kelompok perawatan luka konvensional dan perawatan luka modern pada penderita ulkus diabetik di makasar. hal ini dibuktikan dengan melihat p value < a (0,05) yaitu 0,00. berdasarkan p value tersebut, maka dapat disimpulkan bahwa pada tingkat kepercayaan 95% terdapat perbedaan ekspresi kadar interleukin 6 yang bermakna antara responden yang menggunakan perawatan luka modern dan responden yang menggunakan perawatan luka konvensional. pembahasan penyembuhan luka adalah proses yang komplek dan dinamis dengan per ubahan lingkungan luka dan status kesehatan individu. fisiologi dari penyembuhan luka yang normal adalah melalui fase hemostasis, inf lamasi, granulasi (proliferatif) dan maturasi. proses perbaikan terjadi segera setelah adanya luka dengan mengeluarkan berbagai growth factor, cytokine dan molekul dari serum pembuluh darah yang cedera dan degranulasi platelet. respons infl amasi menyebabkan pembuluh darah menjadi bocor mengeluarkan plasma dan pmn’s ke sekitar jaringan. neutropil memfagositosis sisa-sisa mikroorganisme dan merupakan pertahanan awal terhadap infeksi. mereka dibantu sel-sel mast lokal. fibrin kemudian pecah sebagai bagian dari pembersihan ini. untuk membangun kembali kompleksitas yang membutuhkan kontraktor. sel yang berperan sebagai kontraktor pada penyembuhan luka ini adalah makrofag. ma k rofag ma mpu mem fagosit ba k ter i dan mer upakan garis pertahanan kedua. makrofag juga mensekresi komotaktik yang bervariasi dan faktor pertumbuhan seperti faktor pertumbuhan fi brobalas (fgf), faktor per t u mbu han epider mal (egf), fa k tor per t umbu han betat rasfor masi (tgf ) dan interleukin-1 (il-1) dan interleukin-6 (il-6). proses perbaikan terjadi segera setelah adanya luka dengan mengeluarkan berbagai growth factor, cytokine dan molekul dari ser um pembuluh darah yang cedera dan degranulasi platelet. cytokine pada fase inf lamasi terdiri dari interleukin 1 (il-1), interleukin 6 (il-6) dan tnf a, leukosit polymorfo nukleus dan makrofag merupakan sumber utama dari cytokines tersebut. jika terjadi luka, makrofag langsung ke tempat peradangan, sel makrofag yang teraktivasi pada jaringan yang meradang dan sel yang meradang memproduksi interleukin1 (il1) yang memproduksi granulosit-monosit p e m i l i h a n d a n p e ng g u n a a n d r e s si n g ya ng tepat a ka n mem fasilit asi proses penyembuhan. beberapa faktor yang perlu dipertimbangkan dalam pemilihan dressing antara lain (whitney, et al., 2006): faktor luka (infeksi, nekrosis), luas, kedalaman dan keberadaan undermining atau tunneling, lokasi, jenis jaringan dasar luka, eksudat tabel 1. distribusi rata-rata interleukin 1 dan interleukin 6 pada penderita luka diabetik variabel dependen n mean sd minimum maximum interleukin 1 (pg/ml) a. pre b. post 32 3.293 2.012 2.07842 1.75167 0.29 7.13 0.01 5.93 interleukin 6 a. pre b. post 32 16.6581 27.8644 9.02486 11.52267 90 37.90 5.39 52.17 tabel 2. perbedaan ekspresi interleukin 1 dan interleukin 6 antara kelompok perawatan luka konvensional dan perawatan luka modern pada penderita ulkus diabetik variabel mean lower upper p va/t/e interleukin 1 .692 .13844 1.5238 .00 interleukin 6 8.995 4.58025 13.4097 .00 136 jurnal ners vol. 10 no. 1 april 2015: 133–137 dan drainaseluka, kondisi tepi luka, tujuan perawatan, kebutuhan pasien (kontrol nyeri, kontrol bau), biaya, ketersediaan, kemudahan dalam penggunaan. kondisi luka harus dimonitor setiap penggantian dressing dan dikaji secara berkala untuk menentukan apakah jenis dressing diganti atau dipertahankan. pada perawatan lu ka konvensional masih mengg unakan balutan kasa nacl sedangkan pada perawatan luka modern lebih banyak menggunakan hydrocoloid. hydrocoloid terbukti jauh lebih efektif dibandingkan kasa dalam hal penurunan luas luka dan mempercepat laju penyembuhan bila dibandingkan dengan kasa nacl (werneret al, 2003). payne, et al (2009) menemukan bahwa penggunaan foam dressing lebih murah cost efektif dan frekuensi penggantian balutan menjadi berkurang bila dibandingkan dengan kasa nacl. dibutuhkan keterampilan perawat dalam mengambil keputusan klinis dalam memilih balutan untuk perawatan luka. salah satu faktor yang mempengaruhi penyembuhan luka adalah teknik perawatan luka yang diberikan. teknik perawatan luka dm telah berkembang pesat, yaitu teknik konvensional dan modern. teknik konvensional menggunakan kasa, antibiotik, dan antiseptik, sedangkan teknik modern menggunakan balutan sintetik seperti balutan alginat, balutan foam, balutan hidropolimer, balutan hidrofi ber, balutan hidrokoloid, balutan hidrogel, balutan transparan fi lm, dan balutan absorben. dampak teknik perawatan luka akan mempengaruhi proses regenerasi jaringan sebagai akibat dari prosedur membuka balutan, membersihkan luka, tindakan debridemen, dan jenis balutan yang diberikan sehingga m e m b e r i k a n r e s p o n s nye r i. h a l i n i didasarkan pada mekanisme pengangkatan sisa-sisa jaringan pada dasar luka sehingga menstimulasi produksi mediator peradangan. salah sat u aspek yang pent i ng d alam perawatan lu ka adalah pemilihan jenis balutan yang digunakan. pada penelitian ini, kelompok modern digunakan jenis balutan calcium alginat yang memiliki sifat absorben, nonoklusif, nonadhesif, bersifat autolitik debridemen. sedangkan pada kelompok konvensional digunakan metronidazole, iodin, h2o2 dan kompres kasa nacl. berdasarkan h a si l p e n g a m a t a n s el a m a p e n el it i a n menunjukkan bahwa tingkat kelembaban luka lebih dapat dipertahankan dan balutan jarang dibuka pada kelompok modern dibandingkan pada kelompok konvensional. pada balutan konvensional cenderung memberikan dampak yang buruk karena pemakaian kompres kasa sebagai upaya mempertahankan kelembaban kurang dapat diper tahan kan lebih lama sehingga luka lebih sering diganti balutannya. fenomena ini akan membawa dampak timbulnya cidera ulang pada dasar luka yang akan menstimulasi terjadinya infl amasi ulang pada dasar luka. penggunaan antiseptik, seperti iodine 1% dan h2o2 pada kelompok konvensional dapat memicu rusaknya caloncalon kapiler darah. berdasarkan pengamatan di klinik menunjukkan bahwa penggantian balutan pada kelompok konvensional lebih sering dilakukan dibandingkan kelompok modern. hal ini akan berpengaruh terhadap kondisi stress jaringan yang sedang regenerasi sehingga secara psikologis. pasien akan lebih sering mengeluh kesakitan sebagai dampak terjadinya cidera ulang pada dasar luka. adanya respons tersebut maka tubuh akan mengaktif kan hipotalamus-pituitary-adrenal (hpa-aksis) unt uk melepaskan hor mon acth, crf dan kortisol. secara lokal akan terjadi pengaktifan mediator pro infl amasi, seperti il-1, il-8 and tumour necrosis factor (tnf) sehingga dapat terjadi proses infl amasi yang memanjang berakibat meningkatnya keparahan luka. kadar interleukin 1 pada penelitian ini cender ung menur un pada kelompok yang diberikan perawatan luka moder n d iba nd i ng k a n kelompok ya ng memakai perawatan luka konvensional. hal ini membuktikan bahwa pada kelompok yang memakai perawat an lu ka konvensional memiliki kadar interleukin 1 yang tinggi sehingga proses infl amasi yang terjadi akan memanjang dan berakibat pada peningkatan keparahan luka. 137 teknik perawatan luka modern dan konvensional (werna nontji, dkk.) simpulan dan saran simpulan perawatan luka modern lebih efektif dari perawatan luka konvensional (menggunakan kasa steril), hal tersebut tampak dari ekskresi sitokin interleukin 1 dan interleukin 6, pada perawatan luka konvensional interleukin 1 mengalami peningkatan yang menunjukkan bahwa proses fase inf lamasi memanjang sehingga penyembuhan luka lambat. saran perawat diharapkan mampu memberikan perawatan luka diabetik yang terbaik bagi pasien dengan memper timbangkan jenis perawatan luka yang diberikan dan disesuaikan dengan kondisi luka pasien. peneliti selanjutnya diharapkan melakukan penelitian terkait dengan berbagai jenis balutan modern dan efeknya terhadap sitokin dan growth factor. kepustakaan ebihara, n., matsuda, a., nakamura, s., matsuda, h., & murakami, a. 2011. role of the il-6 classicand transsig n a l i ng pat hway s i n c or ne a l st e r i lei n f la m m at ion a nd wou nd healing. (online) (http://www.iovs.org/ content/52/12/8549.long. diakses tanggal 12 februari 2012, jam 13.00 wib) japan guy ton & hall. 2006. fisiologi kedokteran. kovazs & dipietro. 1994. fibrogeniccytokines and connective tissue p roduct ion. usa: loyola niversity. jakarta: egc. kristianto, h. 2010. perbandingan perawatan luka teknik moderen dan konvensional t e r h a d a p tr a n s f o r m i n g g r o w t h factorbeta (tgf 8) dan respons nyeri pada luka diabetes mellitus. depok: makara ui. lin, kondo, ishida. 2003. essential involvement of il-6 in the skin wound-healing process as evidenced by elayedv wound healing in il-6-defi cient mice. (online) (http://citeseerx.ist.psu.edu/viewdoc/do wnload?doi=10.1.1.328.8785&rep=rep1 &type=pdf. diakses tanggal 10 maret 2012, jam 10.30 wib) naidu, k.a. 2003. vitamin c in human health and disease is still a mystery. nutritional journal; 2: 7; 1475-2891. (online) (http://www.nutritionj.com/ content/2/1/7. diakses tanggal 10 maret 2012, jam 10.49 wib) rolfe, k.j., richardson, j., vigor., c., rvine, l.m., grobbelaar, a.o., & linge, c. 2007. a role for tgf-pi-inducedcellular responses during wound healingof the non-scarring early human fetus.journal investigative dermatology; 127; 2656– 2667. (online) (http://www.nature.com/ jid/journal/v127/n11/full/5700951a.html. diakses tanggal 10 maret 2012, jam 10.45 wib) sri gitarja. 2008. perawatan luka diabetik. bogor: wocare publishing. werner, s & grose, r. 2003. regulation of wound healing by growth factors and cytokines. physiol rev. 83: 835–870. (online) (http://physrev.physiology.org/ content/83/3/835.long. diakses tanggal 12 februari 2012, jam 13.20 wib) yajing hu et al. 2007. the role of interleukin1 in wound biology. part i: murine in silicoand in vitro experimental analysis. inter national anesthesia researchsociet y. (online). (htt p:// pt.wk health.com /pt/re/lwwgateway/ landingpage.htm;jsessionid=vs1j8t2b m3vptfpq1ysytjfgrvll7lvjy5yqv7 4jnj1hljg5j2n8!-1552477860!18119562 8!8091!-1?issn=00032999&volume=111 &issue=6&spage=1525. 15 maret 2012, jam 09.55 wib) 60 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.23321 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research analysis of factors affecting the mental health crisis of coronavirus disease infection in java island diah priyantini, nursalam nursalam and tintin sukartin faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: corona virus disease 2019 (covid-19) is a health problem that remains a health emergency in the world and causes mental health crisis. the purpose of this study was to analyze the factors that influence the mental health crisis of covid-19 infection on the island of java. methods: a cross sectional study between june-july 2020 in java island, indonesia with 1.218 respondents selected using convenience sampling. the independent variables were demographic, individual internal, psychological factors and the dependent was mental health crisis. data were measured by demographic information, knowledge and attitude questionnaires, depression anxiety stress score, the brief 28-item cope inventory, questionnaire on problem faces and mental health crisis. analysis of data is conducted by chi square and multivariate logistic regression. results: the relation of demographic, individual internal and psychological factors were significant to mental health crisis and p <0.05. after adjusted with logistic regression, psychological factors have more significant relation and the highest relation was found in stress level with p = 0.000 and ci 95% was 1.064 – 2.131. conclusion: the contributing factor that has the strongest relationship with a mental health crisis is the level of stress that people experience. the biggest contribution that causes disruption of psychological conditions and mental health is psychological factors, which include levels of anxiety, stress, coping mechanisms and problems faced. article history received: january 18, 2021 accepted: march 28, 2021 keywords crisis; covid-19; factors; mental health contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: priyantini, d., nursalam, n., & sukartini, t. (2021). analysis of factors affecting the mental health crisis of coronavirus disease infection in java island. jurnal ners, 16(1). 60-66. doi:http://dx.doi.org/10.20473/jn.v16i1.23321 introduction corona virus disease 2019 (covid-19) is a health problem that remains a health emergency in the world (who, 2020). treatment due to covid-19 has not been found and is still in the research stage, it makes covid-19 still a concern (hotez, corry and bottazzi, 2020; huang et al., 2020), and affects to the increase in covid-19 cases (wang et al., 2020; w.wu et al., 2020). the very rapid transmission increase in the number of cases has made people around the world worried about the existence of covid-19 (huang et al., 2020). this condition happens because of the ease by which the virus is transmitted so that individuals easily fall ill, and some are in critical condition and die (covaci, 2020). covid-19, which causes many people to fall ill and also has a high number of cases of death, makes people afraid (fofana, 2020) and begin to overprotect themselves so that the virus does not spread (covaci, 2020). many people show excessive responses such as frequent hand washing, avoiding interactions, suspicious of each other because they are afraid of carrying the virus and discriminating against individuals and families of covid-19 patients and cases of close contact (carroll et al., 2020; dymecka, gerymski and machnik-czerwik, 2020; nursalam et al., 2020). the positive incidence of covid-19 in the world is increasing day by day (staden, 2020), since december 2019, which was the first-time cases were found in the city of wuhan, china, and shows an increasing number of cases (stoecklin et al., 2020). from december 2019 to february 2020, there were around 30 thousand cases of covid-19, but by july 2020 the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 61 number of covid-19 cases in the world had reached 16.39 million and in indonesia it had reached 86,521 (staden, 2020; who, 2020). the total number of deaths has reached 651 thousand cases and 65 thousand patients are hospitalized with critical conditions (jung et al., 2020). the highest number of cases of covid-19 is in java with a proportion of 80% of the total cases in indonesia (nursalam et al., 2020). the high number of cases makes people show varied psychological responses, ranging from mild to severe responses (barzilay et al., 2020; carroll et al., 2020). based on research conducted in china on 7,143 students, it showed that as many as 75.1% did not experience symptoms of anxiety, while the proportion of students with mild, moderate, and severe anxiety was 21.3%, 2.7%, and 9%, respectively (cao et al., 2020; ying wang et al., 2020). meanwhile, based on the research results, people in italy showed that 31.38% experienced general psychopathological symptoms, 37.19% experienced anxiety and 27.72% showed symptoms of posttraumatic stress disorder (maugeri et al., 2020; pakenham et al., 2020). in indonesia, the cases of physical problem showed that 60% have mild and asymptomatic symptoms, but in psychological responses showed that 75% people felt anxiety and were afraid during first wave of covid-19 crisis. this shows that the psychological response faced by a person is also a serious problem that needs to be intervened by all sectors of the response to covid-19 (cao et al., 2020; pakenham et al., 2020). the psychological impact shown by society is very diverse (barzilay et al., 2020; dymecka, gerymski and machnik-czerwik, 2020), many people are really afraid of covid-19 and many also think that this virus is just a conspiracy and does not exist in the world (georgiou, delfabbro and balzan, 2020). this incorrect assumption makes virus transmission more difficult to control (fofana, 2020), because people do not want to participate in taking prevention. during the year that covid-19 became a pandemic, public vigilance was still not 100% (16), such as washing hands (92.7%), maintaining social distancing (92.3%), using face masks (86.5%) ), avoiding travel to infected areas or countries (86.9%) and seeking correct information behavior (42.4%). in addition, people who think that covid-19 is a dangerous and easily transmitted virus at any time will show an exaggerated psychological response (carroll et al., 2020; dymecka, gerymski and machnik-czerwik, 2020). the community will show excessive psychosomatic symptoms, resulting in behaviors that are repeated in implementing health protocols (barzilay et al., 2020; carroll et al., 2020; dymecka, gerymski and machnik-czerwik, 2020). the national health emergency that has occurred in indonesia since march 2020 has made covid-19 a frightening infection for the community (fofana et al.,2020). the large number of confirmed cases and deaths due to covid-19 have created a negative stigma to stay away from anyone who is at risk of transmitting it, health workers who are caring for it (nursalam et al., 2020). patients, families of positive patients and patients who have recovered from covid-19, including the community also rejects the patient's body because they think it can still be contagious (hotez, corry and bottazzi, 2020). inaccurate information obtained from various media makes people more anxious and excessively anxious, as a result a mental health crisis, psychological impact and community stigma also occur (covaci, 2020; dymecka, gerymski and machnik-czerwik, 2020). psychological problems found in indonesian society, including mental health crisis and stigma, must be immediately given further intervention so as not to cause more severe problems (nursalam et al., 2020). so far, there are still many research that have been implemented in indonesia that are physical, but psychological factors have not been given much attention, so there are still many who experience anxiety because the information obtained is also inaccurate (dymecka, gerymski and machnikczerwik, 2020). based on previous research about covid-19, the psychological response that causes crisis condition has not yet been greatly identified, because the pandemic condition makes people need to first adapt to the crisis. the psychological problem has certainly initiated mental health crisis, a condition that causes severe psychological problems and risk factors to mental disorder. based on the above problems, psychological impacts need to be explored more deeply so that they can produce the most appropriate psychological interventions in dealing with psychological impacts, mental health crisis and social stigma that exist in society. the purpose of this study was to analyze the factors that influence the mental health crisis of covid-19 infection on the island of java. materials and methods this research is a cross-sectional study conducted in june-july 2020 in java island, indonesia. the affordable population of this study are people in the community aged 20-54 years who live in java island. the selection of research samples used convenience sampling techniques through online and offline media. assessment of demographic factors, individual internal factors, psychological factors and community mental health crisis was done using a structured questionnaire. charging is confidential to ensure confidentiality and reliability of data. the research sample was 1218 respondents spread across five provinces in java island, namely jakarta, west java, yogyakarta, central java and east java. this study uses independent variables, namely demographic factors, individual internal factors and psychological factors. demographic factors consist of location of residence, ethnicity, marital status, income, religion and health status. individual internal factors consist of age, gender, level of education, knowledge and attitudes. meanwhile, psychological factors consist of the level of stress, anxiety, coping mechanisms and the problems faced. the dependent d. priyantini et al. 62 | pissn: 1858-3598  eissn: 2502-5791 variable of this study is mental health crisis. the research instrument is in the form of a structured questionnaire package which includes asking for demographic information, knowledge and attitude questionnaires from mohammed dauda goni (2018), and depression anxiety stress score (lovibond and lovibond, 1995), the brief 28-item cope inventory (carver, 1997), questionnaire on problem faced (gilhooly et al., 2007) and mental health crisis emergencies questionnaire (talevi et al., 2020). the entire questionnaire consisted of 5-21 questions using a likert rating scale of 4 items ranging from 1 (strongly disagree) to 4 (strongly agree), so that the total score ranges from 0 to 84. the instrument has conducted initial trials which are well-validated, and has shown a reliability value that is cronbach's ɑ between 0.875 to 0.995. data collection started in june 2020 and online and offline questionnaire were conducted by the researchers. research beforehand was used to conduct licensing to institutions and to take care of ethical due diligence. offline data collection was carried out by giving questionnaires to respondents directly. respondents filled out questionnaires by first giving informed consent without coercion. online data collection was done via google forms and it was ensured that all respondents filled in voluntarily and without coercion. respondents filled in the questions that have been written; if there were respondents who did not fill in completely, the respondent was considered to be in the drop out criteria and not counted as research respondents. the researcher then collected questionnaires that had been filled in and conducted data recapitulation for further data analysis. data analysis was performed using spss version 22.0 software to test inferential statistics, namely the chi square test and logistic regression. descriptive statistical analysis was conducted to describe the demographic characteristics of the respondents. bivariate analysis (nonparametric test) with chi square was used to explore the significant relationship between sample characteristics, individual internal factors, psychological factors and mental health crisis. statistically significant variables were screened and included in the multivariate logistic regression analysis to identify the most dominant factor of all variables. estimates of association strength are indicated by odds ratio (or) with 95% confidence interval (ci), p value is considered significant with value 0.05. this research has received ethical approval from the ethics committee of the faculty of nursing, airlangga university, indonesia and has received a certificate of ethical acceptance with the number 2038-kepk. after being given an explanation and instructions regarding the research procedure, all respondents voluntarily gave their consent and participated in the research. this research procedure was in accordance with the provisions of the declaration of helsinki on human participant research. results based on the results of research conducted in junejuly 2020, it was found that the highest demographic characteristics of respondents were domiciled in east java, as many as 569 respondents (46.7%), with the majority ethnicity being javanese, with 895 respondents (73.5%). the majority religion was islam as many as 1139 respondents (93.5%). respondents who were not married were 813 respondents (66.7%), as many as 376 respondents (30.9%) as students and working as nurses were 240 respondents (19.7%). the majority of the income level is still below the regional minimum wage (umr), which is as many as 652 respondents (53.5%). in health status, 1122 (92.1%) respondents were healthy and those who were confirmed positive for covid-19 were 59 (4.8%) respondents (table 1). table 1 describes the variables of individual internal factors, which consist of age, gender, education level, knowledge and attitudes and psychological factor variables consisting of stress levels, anxiety levels, coping mechanisms and problems faced by respondents. based on the results of the study, it showed that the most respondents were women, as many as 841 (69.0%) respondents, with the most dominant age range late adolescence (17-25 years) as many as 544 (44.7%) respondents and 698 (57, 3%) respondents have a bachelor's level education. the level of knowledge possessed by the respondents showed that the results were mostly good at 867 (71.2%) of respondents, while 869 (71.3) respondents had attitudes in the good category as well. the stress level of the research respondents showed that the highest result was in the normal category, although there were 143 (11.7%) respondents who indicated that the stress category was very heavy. the level of anxiety also shows the results of 538 (44.2%) respondents are in the normal category and the condition of a very high level of anxiety is found quite extensively, namely 288 (23.6%) of respondents. for the coping mechanism shown by respondents, 906 (74.4%) of respondents showed a high ability of the mechanism, while the problems faced by respondents were mostly in the category of moderate problems as many as 874 (71.8%) of respondents. in the mental health crisis, 23.4% of the community showed a response to the crisis, namely the need for counseling services, mental health resolution and experiencing a mental health crisis. demographic characteristics of respondents have a significant relationship with the incidence of mental health crisis with all p values <0.005. based on the location of the respondents who experienced the most mental health crisis in west java (2.6%), according to the request for counseling needs of the sundanese ethnic group, this was 19.2%. 11.9% of individuals who are still single also need counseling, while 24.1% of people with a confucian religion experience a mental health crisis. the occupations that need counseling the most are students (17.3%) https://docs.google.com/document/d/1rysryeu7ntwcikdup9w4v0soas_wfb7v/edit jurnal ners http://e-journal.unair.ac.id/jners | 63 and entrepreneurs (21.1%). workers who have a source of income below the minimum regional income are also prone to mental health crisis, including people who are often exposed to covid-19 or at high risk (16.7%) (table 2). the internal factors of the individual indicate that age, level of education, knowledge and attitudes have a significant relationship with mental health crisis (all p <0.05). the highest incidence rate of mental health problems was indicated by late adolescence, namely 15.4% needed mental health services, 11.0% needed counseling and 1.8% experienced a mental health crisis. women are the respondents who experience the most mental problems, at the level of education the higher the risk of mental health crisis. low public knowledge and attitudes also have the potential for mental health problems (table 2). psychological factors are the highest predisposition for causing mental health problems, based on the x table of individuals with stress levels, anxiety levels, low coping mechanism abilities and facing severe problems shows a greater mental health crisis. the proportion of mental health crisis was mostly experienced by individuals with very severe stress levels (7.7%) and low coping mechanisms (6.3%). in the multivariate analysis test (table 3) the factors that had a significant relationship with p <0.05 were age, location, marital status, occupation, educational background, income, knowledge, anxiety levels, stress levels and coping mechanisms. after being adjusted, multivariate analysis was performed using logistic regression with a 95% ci showing that the factor that had the highest association with mental health crisis was stress level (p = 0.000) with ci between 1.064 and 2.131, it shows that stress level influenced mental health crisis more than other factors. discussion psychological factors are closely related to the causes of mental health crisis, especially the level of stress experienced by individuals (wu et al., 2020). the important finding of this research was stress level has highest relation with mental health crisis, and some variables, like age, location, marital status, occupation, educational background, income, knowledge, anxiety levels, stress levels and coping mechanisms, too. significant relation of the results finding indicated that crisis condition has many contributing factors. based on the research results, data show the level of stress from the community due to the covid-19 pandemic, which shows the severe and very severe categories are still very high. this is in accordance with research conducted in the u.s., israel and several other countries showing that the level of stress due to the covid-19 pandemic is very high in all countries in the world. the results showed that the stress experienced by the community was due to: 1) fear of being infected; 2) many cases of people who died from covid-19 infection; 3) the situation in the environment is not conducive and the whole community uses masks, suspect each other and always keep their distance; 4) the presence of an infected family member and close contact; 5) asymptomatic positive cases that unknowingly infected others; and 6) the resulting economic impact, causing financial distress (barzilay et al., 2020; carroll et al., 2020). the cause which is the main triggering factor is that the information and knowledge received by the community is not quite right. this is also in line with research (georgiou, delfabbro and balzan, 2020) which states that the public believes more in conspiracy theories, so that they think that covid-19 is just a lie. the behavior of the people who think that covid-19 does not exist has ultimately made the spike in cases increase (qiu et al., 2020). as a result, 60% of health workers showed moderate and severe stress responses in one study in china. what makes them stressed is that health workers are ready to be at the forefront, but people do not want to participate positively in joint prevention, so health workers are exhausted because they have to use personal protective equipment every day (who, 2020). demographic factors also have an impact on the incidence of mental health crisis. the older or younger people have higher response to crisis than optimal age. females also have higher risk factors for crisis because they always feel very sad whenever they have some problems. the level of education indicated that higher education makes coping mechanism to stress better than less education, likewise those with higher knowledge also have table 3. multivariate analysis in mental health crisis contributing factors variable p value odds ratio (or) ci 95% lower upper age 0.004* 0.912 0.764 1.089 gender 0.177 1.162 0.784 1.721 location 0.000* 0.819 0.710 0.944 marital status 0.000* 0.788 0.509 1.219 ethnics 0.933 1.064 0.918 1.232 religion 0.255 0.878 0.680 1.135 occupation 0.008* 1.041 0.978 1.108 educational background 0.000* 1.082 0.895 1.307 income 0.005* 0.825 0.559 1.217 covid-19 status 0.974 0.939 0.753 1.170 knowledge 0.001* 0.578 0.396 0.843 attitude 0.238 0.494 0.347 0.702 anxiety level 0.000* 0.756 0.540 1.058 stress level 0.000* 1.506 1.064 2.131 coping mechanism 0.000* 0.297 0.177 0.498 problem faced 0.869 1.131 0.755 1.693 * significant relation p < 0.05 https://docs.google.com/document/d/1rysryeu7ntwcikdup9w4v0soas_wfb7v/edit https://docs.google.com/document/d/1rysryeu7ntwcikdup9w4v0soas_wfb7v/edit d. priyantini et al. 64 | pissn: 1858-3598  eissn: 2502-5791 better response to crisis (giallonardo et al., 2020), the effects of self-quarantine and social restrictions also cause fear (dymecka, gerymski and machnikczerwik, 2020). the results show that mental health crises are prevalent in locations with the most cases of covid-19 and large-scale social distancing, such as jakarta (59.7%). jakarta is the highest location with mental health crisis because of the highest cases and small size of area, so the covid-19 transmission is fast. a pandemic also hampers various sectors of the economy and education, thus making students and entrepreneurs vulnerable to stress levels and some need counseling (bonaccorsi et al., 2020; könig, jägerbiela and glutsch, 2020). this is in line with research conducted in china, where many students experience delays in graduation due to digital adaptation and cannot immediately get a job after graduating (fernandes, 2020; könig, jäger-biela and glutsch, 2020). meanwhile, entrepreneurs experience a financial crisis due to their business being quiet and then closed, unlike entrepreneurs who sell products needed during a pandemic (ashraf, 2020; bonaccorsi et al., 2020). community income tends to decline due to covid-19 because many are dismissed and work from home, employees then experience burnout and eventually fall into a state of mental health crisis (zar et al., 2020). internal factors of the individual show that age, level of education, knowledge and attitudes are also the cause of the emergence of a mental health crisis (nursalam et al., 2020). mental health crises are more likely to occur in vulnerable groups, such as young people, the elderly and women. some groups with low levels of education and knowledge also have a higher risk. this high risk is caused by insufficient information that can be explored properly, resulting in confusion and fear. based on research conducted in several countries, it shows that negative responses occur in many groups of people who are too young and too old, because they are not ready for the changes that occur (boulle et al., no date; nepomuceno et al., 2020). the level of education also has an effect, people with higher education tend to be easier to provide health education than people who think that conspiracy is the cause of covid-19 (georgiou, delfabbro and balzan, 2020; nepomuceno et al., 2020). however, difficulties are experienced by people who are very ignorant of the situation, they do not want to contribute to breaking the chain of transmission (nursalam et al., 2020). the knowledge and attitudes of the community also show much variation, there are people who are very obedient and obedient to health protocols, there are others who only do so sometimes and some do not care at all. i is very important for health workers to take a promotive and preventive approach (williamson et al., 2020; wu et al., 2020; yenan wang et al., 2020). psychology from society also plays an important role in controlling mental health problems, the level of public anxiety due to the information that is widely circulating raises anxiety and fear, a lot of information is invalid and only makes the situation worse (boulle et al., no date; dymecka, gerymski and machnikczerwik, 2020). as a result, the community stigmatizes individuals who are positive for covid19, including their families, and refuses health workers to return home (bagcchi, 2020; ramaci et al., 2020). the coping mechanisms shown by health workers are still adaptive; however, many people are saddened to overdo it because family members died of covid-19 and were buried using strict procedures (benussi et al., 2020). in addition, many exhibit psychosomatic symptoms and fear of their own psychological problems, which are the main cause of mental health crisis, and which need attention so that they do not get worse. the limitation of this study is the need to pay attention to several other factors that may have the effect of causing a mental health emergency crisis, including external or environmental factors. the study was conducted by using convenience sampling, so that the sample needed to represent the national level is multicenter. this research was conducted at a time when the crisis conditions due to covid-19 were very high, so that in the last months of the year it started to return to normal, so that psychological and mental health problems began to adapt to the pandemic. however, this research is strong enough to detect significant impacts, using validated instruments with validity and reliability values according to standards. conclusion the contributing factor that has the strongest relationship with a mental health crisis is the level of stress that people experience. the biggest contribution that causes disruption of psychological conditions and mental health is psychological factors, which include levels of anxiety, stress, coping mechanisms and problems faced; these four factors can become precipitative in the covid-19 pandemic, so it is necessary to give psychological treatment as a form of preparedness. acknowledgment we would like to thank all participants who were willing to fill in the research data. this research is a study that has received grant support from the institute for research and innovation, universitas airlangga in the form of covid-19 mandate research. organizations that provide funding contribute to monitoring the implementation of research and researchers carry out research in accordance with the research method that has been conceptualized, so that research publications will be produced as outputs to be reported. references ashraf, b. n. (2020). journal of behavioral and experimental finance economic impact of government interventions during the covid-19 pandemic : international evidence from financial jurnal ners http://e-journal.unair.ac.id/jners | 65 markets. journal of behavioral and experimental finance, 27, 100371. https://doi.org/10.1016/j.jbef.2020.100371 bagcchi, s. (2020). stigma during the covid-19 pandemic. the lancet. infectious diseases. https://doi.org/10.1016/s1473-3099(20)304989 barzilay, r., moore, t. m., greenberg, d. m., didomenico, g. e., brown, l. a., white, l. k., gur, r. c., & gur, r. e. (2020). resilience, covid-19related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers. translational psychiatry, 10(1). https://doi.org/10.1038/s41398-02000982-4 benussi, a., pilotto, a., premi, e., libri, i., giunta, m., agosti, c., alberici, a., baldelli, e., benini, m., bonacina, s., brambilla, l., caratozzolo, s., cortinovis, m., costa, a., cotti piccinelli, s., cottini, e., cristillo, v., delrio, i., filosto, m., … padovani, a. (2020). clinical characteristics and outcomes of inpatients with neurologic disease and covid-19 in brescia, lombardy, italy. neurology. https://doi.org/10.1212/wnl.00000000000098 48 bonaccorsi, g., pierri, f., cinelli, m., flori, a., galeazzi, a., porcelli, f., schmidt, a. l., valensise, c. m., scala, a., quattrociocchi, w., & pammolli, f. (2020). economic and social consequences of human mobility restrictions under covid-19. proceedings of the national academy of sciences of the united states of america, 117(27), 15530–15535. https://doi.org/10.1073/pnas.2007658117 boulle, a. a., davies, m., hussey, h., morden, e., vundle, z., zweigenthal, v., mahomed, h., paleker, m., pienaar, d., tembo, y., lawrence, c., mathema, h., allen, d., allie, t., bam, j., dane, p., heekes, a., matlapeng, b., muzarabani, l., … pienaar, r. (n.d.). risk factors for covid-19 death in a population cohort study from the western cape province , south africa. 1–31. cao, w., fang, z., hou, g., han, m., xu, x., & dong, j. (2020). the psychological impact of the covid-19 epidemic on college students in china. psychiatry research, 287(march), 112934. https://doi.org/10.1016/j.psychres.2020.112934 carroll, n., sadowski, a., laila, a., hruska, v., nixon, m., ma, d. w. l., & haines, j. (2020). the impact of covid-19 on health behavior, stress, financial and food security among middle to high income canadian families with young children. nutrients, 12(8), 1–14. https://doi.org/10.3390/nu12082352 carver, c. s. (1997). brief cope inventory. international journal of behavioral medicine. covaci, a. (2020). how can airborne transmission of covid-19 indoors be minimised? environment international, 142(may), 1–7. https://doi.org/10.1016/j.envint.2020.105832 dymecka, j., gerymski, r., & machnik-czerwik, a. (2020). how does stress affect our life satisfaction during covid-19 pandemic? moderated mediation analysis of sense of coherence and fear of coronavirus. https://doi.org/10.31234/osf.io/3zjrx fernandes, n. (2020). economic effects of coronavirus outbreak ( covid-19 ) on the world economy nuno fernandes full professor of finance iese business school spain. ssrn electronic journal, issn 1556-5068, elsevier bv, 0– 29. fofana, nina-kandiatou, latif, faiza, sarfraz, summaira, bilal, bilal, bashir, muhammad farhan, komal, b. (2020). fear and agony of the pandemic leading to stress and mental illness: an emerging crisis in the novel coronavirus (covid-19) outbreak. psychiatry research, 291(april), 9–11. https://doi.org/10.1016/j.psychres.2020.113230 georgiou, n., delfabbro, p., & balzan, r. (2020). personality and individual di ff erences covid-19related conspiracy beliefs and their relationship with perceived stress and pre-existing conspiracy beliefs. personality and individual differences, 166(april), 110201. https://doi.org/10.1016/j.paid.2020.110201 giallonardo, v., sampogna, g., vecchio, v. del, luciano, m., albert, u., carmassi, c., carrà, g., cirulli, f., osso, b. d., nanni, m. g., pompili, m., & sani, g. (2020). the impact of quarantine and physical distancing following covid-19 on mental health : study protocol of a multicentric italian population trial. 11(june), 1–10. https://doi.org/10.3389/fpsyt.2020.00533 gilhooly, m. l., gilhooly, k. j., phillips, l. h., harvey, d., brady, a., & hanlon, p. (2007). real-world problem solving and quality of life in older people. british journal of health psychology. https://doi.org/10.1348/135910706x154477 hotez, p. j., corry, d. b., & bottazzi, m. e. (2020). covid-19 vaccine design : the janus face of immune enhancement. nature reviews immunology, 20(june), 347–348. https://doi.org/10.1038/s41577-020-0323-4 huang, l., rong, y., pan, q., yi, k., & tang, x. (2020). sars-cov-2 vaccine research and development : conventional corresponding author . clinical trial center of zhongnan hospital , wuhan. asian journal of pharmaceutical sciences. https://doi.org/10.1016/j.ajps.2020.08.001 jung, s., akhmetzhanov, a. r., hayashi, k., linton, n. m., yang, y., yuan, b., kobayashi, t., kinoshita, r., & nishiura, h. (2020). real-time estimation of the risk of death from novel coronavirus (covid-19) infection: inference using exported cases. journal of clinical medicine, 9(2), 523. https://doi.org/10.3390/jcm9020523 könig, j., jäger-biela, d. j., & glutsch, n. (2020). adapting to online teaching during covid-19 school closure : teacher education and teacher competence effects among early career teachers in germany. european journal of teacher education, 43(4), 608–622. https://doi.org/10.1080/02619768.2020.18096 50 d. priyantini et al. 66 | pissn: 1858-3598  eissn: 2502-5791 lovibond, s. h., & lovibond, p. f. (1995). manual for the depression anxiety stress scales. in psychology foundation of australia. maugeri, g., castrogiovanni, p., battaglia, g., pippi, r., agata, v. d., palma, a., di, m., & musumeci, g. (2020). heliyon the impact of physical activity on psychological health during covid-19 pandemic in italy. heliyon, 6(may), e04315. https://doi.org/10.1016/j.heliyon.2020.e04315 nepomuceno, m. r., acosta, e., alburez-gutierrez, d., aburtod, j. m., aburtod, j. m., gagnon, a., gagnon, a., & turra, c. m. (2020). besides population age structure, health and other demographic factors can contribute to understanding the covid-19 burden. proceedings of the national academy of sciences of the united states of america, 117(25), 13881–13883. https://doi.org/10.1073/pnas.2008760117 nursalam, n., sukartini, t., priyantini, d., mafula, d., efendi, f., & airlangga, u. (2020). risk factors for psychological impact and social stigma among people facing covid-19 : a. systematic reviews in pharmacy, 11(6), 1022– 1028. pakenham, k. i., landi, g., boccolini, g., furlani, a., grandi, s., & tossani, e. (2020). journal of contextual behavioral science the moderating roles of psychological flexibility and inflexibility on the mental health impacts of covid-19 pandemic and lockdown in italy. journal of contextual behavioral science, 17(july), 109–118. https://doi.org/10.1016/j.jcbs.2020.07.003 qiu, j., shen, b., zhao, m., wang, z., xie, b., & xu, y. (2020). a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations. in general psychiatry. https://doi.org/10.1136/gpsych-2020-100213 ramaci, t., barattucci, m., ledda, c., & rapisarda, v. (2020). social stigma during covid-19 and its impact on hcws outcomes. sustainability (switzerland). https://doi.org/10.3390/su12093834 staden, c. van. (2020). covid-19 and the crisis of national development. nature human behaviour, 4(may), 443–444. https://doi.org/10.1038/s41562-020-0852-7 stoecklin, s. b., rolland, p., silue, y., mailles, a., campese, c., simondon, a., mechain, m., meurice, l., nguyen, m., bassi, c., yamani, e., behillil, s., & ismael, s. (2020). first cases of coronavirus disease 2019 ( covid-19 ) in france : surveillance , investigations and control measures , january 2020. eurosurveillance, 25(6). https://doi.org/10.2807/15607917.es.2020.25.6.2000094 talevi, d., socci, v., carai, m., carnaghi, g., faleri, s., trebbi, e., bernardo, a. d. i., capelli, f., & pacitti, f. (2020). mental health outcomes of the covid-19 pandemic. rivista di psichiatria. https://doi.org/10.1708/3382.33569 wang, h., liu, y., hu, k., zhang, m., & du, m. (2020). healthcare workers ’ stress when caring for covid19 patients : an altruistic perspective. 27(1095), 1490–1500. https://doi.org/10.1177/0969733020934146 wang, yenan, di, y., ye, j., & wei, w. (2020). study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (covid-19) in some regions of china. psychology, health and medicine, 8506. https://doi.org/10.1080/13548506.2020.17468 17 wang, ying, ma, s., yang, c., cai, z., hu, s., zhang, b., tang, s., bai, h., guo, x., wu, j., du, h., kang, l., tan, h., li, r., yao, l., & wang, g. (2020). acute psychological effects of coronavirus disease 2019 outbreak among healthcare workers in china : a cross-sectional study. translational psychiatry. https://doi.org/10.1038/s41398-020-01031-w who. (2020). novel coronavirus 2020 (3) (issue january, pp. 1–7). https://www.pio.gov.cy/coronavirus/pdf/8_1_od hgies_plhroma_asthenophoron.pdf williamson, e. j., walker, a. j., bhaskaran, k., bacon, s., bates, c., morton, c. e., curtis, h. j., mehrkar, a., evans, d., inglesby, p., cockburn, j., mcdonald, h. i., mackenna, b., tomlinson, l., douglas, i. j., rentsch, c. t., mathur, r., wong, a. y. s., grieve, r., … goldacre, b. (2020). factors associated with covid-19-related death using opensafely. nature, 584(7821), 430–436. https://doi.org/10.1038/s41586-020-2521-4 wu, c., chen, x., cai, y., xia, j., zhou, x., xu, s., huang, h., zhang, l., zhou, x., du, c., zhang, y., song, j., wang, s., chao, y., yang, z., xu, j., zhou, x., chen, d., xiong, w., … song, y. (2020). risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in wuhan, china. jama internal medicine, 180(7), 934–943. https://doi.org/10.1001/jamainternmed.2020.0 994 wu, w., zhang, y., wang, p., zhang, l., wang, g., lei, g., xiao, q., cao, x., bian, y., xie, s., huang, f., luo, n., zhang, j., & luo, m. (2020). psychological stress of medical staffs during outbreak of covid-19 and adjustment strategy. journal of medical virology. https://doi.org/10.1002/jmv.25914 zar, h. j., dawa, j., bueno, g., & castro-rodriguez, j. a. (2020). challenges of covid-19 in children in low and middle-income countries. paediatric respiratory reviews, 35, 70–74. https://doi.org/10.1016/j.prrv.2020.06.016 http://e-journal.unair.ac.id/jners | 457 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.20361 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family support is the key to compliance with the treatment of relapsing schizophrenia patients betie febriana, wigyo susanto, dwi heppy rochmawati, and wahyu endang setiawati faculty of nursing, sultan agung islamic university, semarang, indonesia abstract introduction: one problem in treating schizophrenia patients is relapse. the previous study results state that the biggest factor causing relapse is non-compliance with taking medication. this non-compliance with taking medication is influenced by several factors, including patient sociodemography, drug side effects, and family support. the purpose of this study was to determine the factors associated with medication adherence in schizophrenia patients who were undergoing rehospitalization in an inpatient installation at rsjd in one city in central java, indonesia. methods: this study is a descriptive correlational analytic study with a cross-sectional approach. the population in this study were schizophrenia patients who were undergoing re-hospital in the inpatient installation. thirty-six samples were taken with the consecutive sampling method. the research instruments used were a socio-demographic questionnaire, family support questionnaire, medication adherence rating scale (mars), and glasgow antipsychotic side-effect scale (gass). data analysis using descriptive analysis and chi-square test. results: there is a relationship between family support for relapse in schizophrenia patients (p = 0.023). conclusion: researchers suggest that the hospital improves the treatment of family motivation to provide good support to patients to reduce the rate of re-hospitalization. article history received: feb 27, 2020 accepted: april 1, 2020 keywords medication adherence; rehospitalization; schizophrenia contact wigyo susanto  orangjiwa@gmail.com  faculty of nursing, sultan agung islamic university, semarang, indonesia cite this as: febriana, b., susanto, w., rochmawati, d, h., & setiawati, w, e. (2020). family support is the key to compliance with the treatment of relapsing schizophrenia patients. jurnal ners, special issues, 457-461. doi: http://dx.doi.org/10.20473/jn.v15i2.20361 introduction schizophrenia disorder is a type of mental disorder that results in psychotic behavior, concrete thinking, and difficulties in processing information, interpersonal relationships, and problem-solving (stuart, 2014). nearly 1% of the world's population suffers from schizophrenia, which persists throughout their lives (riba et al., 2005). according to the american psychiatric association (apa), schizophrenia can affect anyone by showing that about 75% of people with schizophrenia aged 16 to 25 years have been diagnosed as a schizophrenic disorder (riba et al., 2005). schizophrenia affects more than 21 million people in the world (who, 2016)and affects 1.7 million people in indonesia (kementrian kesehatan ri, 2018). relapse of people with schizophrenia is a reemergence of symptoms of mental disorders that were previously and improved; usually, people with schizophrenia will have difficulty in learning, difficulty meeting the needs of life, and will experience a loss of productivity (who, n.d.). in patients with schizophrenia, non-compliance with treatment is considered a major factor of relapse and is a common event-driven by various factors (jeong & lee, 2013). based on a study, the prevalence of relapse in people with schizophrenia disorders is in the range of 50-92% globally (who, 2016). in korea, the number of patients diagnosed with first-episode schizophrenia over 2 years was 4567, of which 1265 (27.7%) (lee et al., 2018). through naturalistic studies found a cumulative relapse rate in five years ranging from 70-80%. studies in hong https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:orangjiwa@gmail.com http://dx.doi.org/10.20473/jn.v15i2.203 b. febriana et al. 458 | pissn: 1858-3598  eissn: 2502-5791 kong found that out of 93 psychosis patients, relapse rates were 21%, 33%, and 40% in the first, second, and third years (christy, 2011). in indonesia, the average relapse of people with schizophrenia in two years is 1.48 times (fadli & mitra, n.d.). jalil revealed, based on the results of his research at dr. sardjito yogyakarta in 2003, the relapse rate of people with mental disorders reached 25% in the first year, 70% in the second year, even 100% in the third year (jalil, 2006). from various literature found that the factors that influence patient relapse are disobedience to treatment (hui et al., 2015; kazadi et al., 2008; porcelli et al., 2016; sariah et al., 2014); poor family support (sariah et al., 2014); life stress (rohan et al., 2015) (sariah et al., 2014), occupation (chabungbam et al., 2007), and religion (sariah et al., 2014) (hui et al., 2015); duration of illness and the presence of chronic illness (alphs et al., 2016); psychiatric disorders comorbid additives (kazadi et al., 2008); patient and family psychoeducation (chabungbam et al., 2007; porcelli et al., 2016). a survey from the world federation of mental health, which stated that of 982 families with mental disorders, 51% of people with mental disorders had a relapse due to stop taking medication and 49% of patients had a relapse due to changing their own medication dose (world federation of mental health, 2008). predictors of relapse in schizophrenia patients in indonesia are caused by: (1). lack of family knowledge in treating schizophrenia patients (pratama et al., 2015; ryandini et al., 2011). (2). expression of family emotions / excessive/unfavorable attitude (ryandini et al., 2011) (3). lack of patients undergoing treatment / taking antipsychotic drugs (pratama et al., 2015; ryandini et al., 2011) . (5). lack of family support (christiawati, 2012; pratama et al., 2015) 8). lack of patient religious activity (pratama et al., 2015) (9). financial factors(christiawati, 2012). identification of factors that influence relapse is important for developing preventive modalities. this study limits itself to socio demographic factors, and family support to find out what factors are associated with relapse in schizophrenia patients. materials and methods this research used a correlational descriptiveanalytic study with a cross-sectional approach. the population in this study was schizophrenia patients who were undergoing re-hospital in the inpatient installation of central java province rsjd, indonesia. sampling using consecutive sampling techniques, to get a total sample of 36 samples, each of which was given 5 packages of research questionnaires. the research instruments used were a sociodemographic questionnaire, family support questionnaire, medication adherence rating scale (mars), and glasgow antipsychotic side-effect scale (gass). data analysis using descriptive analysis and chi-square test. results based on table 1, there are two genders of the respondents, 19 respondents were male (52.8%), and 17 respondents were female (47.2%). most respondents were aged 41-60 years (middle adulthood), as many as 17 respondents (47.2%), and respondents who were at least aged> 60 years (elderly) as much as one respondent (2.8%). most respondents have secondary education, which is 20 respondents (54.1%), and one respondent (2.8%) who do not go to school. respondents who have income above the regional minimum wage are three respondents (8.3%), and respondents who have income below the regional minimum wage are 33 respondents (91.7%). respondents who have twice medical treatment were 16 respondents (44.4%), and respondents who have more than two times medical treatment were 20 respondents (55.6%). respondents who paid using insurance were 35 respondents (97.2%), and respondents who paid without using insurance/general were one respondent (2.8%). most antipsychotics used by respondents were risperidone, which is 21 users (56.8%). the least antipsychotics used by respondents were haloperidol, only one user (8.1%). discussion there are two factors related to adherence, namely family support and gender, in terms of demographics. it is understandable if family support becomes a determining factor for medication adherence; this finding is in line with several previous studies that family support is important to prevent relapse (christiawati, 2012; sariah et al., 2014) (pratama et al., 2015) (chabungbam et al., 2007; porcelli et al., 2016). family attitudes can affect patient comfort both physically and mentally (habibi et al., 2015) and this support can improve the quality of life of patients (eack m, 2007). family support seems to be a circle that, if good, will be good for the patient, but if it is bad, it will be bad for the patient (nadeem, 2013; sharif et al., 2012). this happens because the family burden is also heavy in treating patients. family knowledge, emotions, economic level, determine family support provided. the lower family knowledge causes the frequency of relapse of schizophrenic patients to increase after being controlled by variables of attitude, support, family emotional expression (habibi et al., 2015; zahnia & sumekar, n.d.). the knowledge that needs to be possessed by the family includes an understanding of mental disorders suffered by the client/schizophrenia, causes, medication administration, medication dosage, and side effects of treatment, symptoms of relapse, and attitudes that need to be demonstrated and avoided while caring for clients at home. educational needs related to patient care are a major factor in family support as a source of longterm care for schizophrenic patients (khankeh et al., jurnal ners http://e-journal.unair.ac.id/jners | 459 2011; yildirim, 2014), (chakrabarti, 2011; panayiotopoulos et al., 2013).another study by simanullang, stated that significant family support consisted of instrumental, informational support, emotional support and appraisal (simanullang, 2018). schizophrenic patients who live in a family environment with highly expressed emotion or negative affective style significantly experience relapse more often than those who live in a family environment with low emotional expression (low expressed emotion) or normal affective style (sadock & sadock, 2010). if the family shows emotions that are overexpressed, for example, the client is often restrained by excessive rules, the possibility of relapse will increase (goddess). family support also influences the meaning of life in schizophrenia (stuart, 2014). after being hospitalized, they can make sense of their present life and are very dependent on their responsibilities according to the status of the sufferer. although in conditions that have not fully recovered from the symptoms of schizophrenia, when remembering the responsibilities according to the status carried, the patient still has the desire to make himself more meaningful than before. therefore, the family has a big role in directing to the meaning of life that is more meaningful. if this fails, then the chances of relapse become large. a family caring for a schizophrenic must be someone who is physically, mentally and economically capable. a study conducted dewi,the needs of schizophrenics are very high compared to table 1. the distribution of frequency sociodemography of patient (n=36) variable amount n % gender male 19 52.8 female 17 47.2 age 15-21 years old (adolescent) 2 5.6 22-40 years old (early adulthood) 16 44.4 41-60 years old (middle adulthood) 17 47.2 > 60 years old (elderly) 1 2.8 edcuation no school 1 2.8 elementary 12 33.3 secondary 21 58.3 higher education 2 5.6 income per-month > regional minimum wage 3 8.3 < regional minimum wage 33 91.7 hospitalization frequency 2 times 16 44.4 3 times 16 44.4 4 times 1 2.8 5 times 1 2.8 6 times 1 2.8 7 times 1 2.8 payment method using health insurance 35 97.2 non-insurance/public 1 2.8 antipsychotics risperidon (atypical) 20 54.1 chlorpromazine (typical) 10 27.0 haloperidol (typical) 1 2.8 olanzapine (atypical) 2 5.6 klozapine (atypical) 3 8.3 table 2. family support related to medication adherence for schizophrenia patients (n = 36) variable medication adherence p value adhere non-adhere n % n % family support support 7 19.4 24 66.7 0.023 no-support 4 11.1 1 2.8 b. febriana et al. 460 | pissn: 1858-3598  eissn: 2502-5791 normal non-sufferers (dewi et al., 2013). finance, information about conditions and treatment, physical health is the need for sufferers. found a similarity in the assessment of high physical needs for both schizophrenics and family members who care. some things related to the need for proper family support are educational needs related to interpersonal and family relationships, adaptive and problem-solving skills (khankeh et al., 2011; sharif et al., 2012), [37] establish therapeutic relationships and interact with patients (khankeh et al., 2011; sharif et al., 2012), (chakrabarti, 2011; panayiotopoulos et al., 2013) social support and family education programs (koujalgi & shobhadevi, 2013). conclusion family support is an important factor influencing the relapse of schizofreania patients. special training for caring families schizophrenia patients are needed to improve the quality of care to reduce the patient's relapse rate. the family will be an effective therapy team if they have significant knowledge and skills. conflict of interest no conflicts of interest have been declared acknowledgment the author would like to thank the dean of the faculty of nursing, the director of the hospital, who has given permission to conduct this research. references alphs, l., nasrallah, h. a., bossie, c. a., fu, d.-j., gopal, s., hough, d., & turkoz, i. (2016). factors associated with relapse in schizophrenia despite adherence to long-acting injectable antipsychotic therapy. international clinical psychopharmacology, 31(4). https://journals.lww.com/intclinpsychopharm/f ulltext/2016/07000/factors_associated_with_rel apse_in_schizophrenia.4.aspx chabungbam, g., avasthi, a., & sharan, p. (2007). sociodemographic and clinical factors associated with relapse in schizophrenia: factors affecting schizophrenic relapse. psychiatry and clinical neurosciences, 61(6), 587–593. https://doi.org/10.1111/j.14401819.2007.01722.x chakrabarti, s. (2011). s. family interventions in schizophrenia: issues of relevance for asian countries. world journal of psychiatry, 1(1), 4. christiawati. (2012). hubungan cara bayar, jarak tempat tinggal, dan dukungan keluarga dengan kepatuhan berobat rawat jalan pasien skizofrenia di rsjd surakarta. universitas muhammadiyah surakarta. christy, c. (2011, may). relapse in schizophrenia. the hongkong medical gallery, 16(5), 9. dewi, s., elvira, s., & budiman, r. (2013). gambaran kebutuhan hidup penyandang skizofrenia. jurnal indonesi medical associacion, 63(3), 84–90. eack m. (2007). quality of life for persons living with schizophrenia: more than just symptoms. psychiatric rehabilitation journal, 30(3), 219. fadli, & mitra. (n.d.). pengetahuan dan ekspresi emosi keluarga serta frekuensi kekambuhan penderita skizofrenia. kesmas: national public health journal, 7(10), 466. https://doi.org/10.21109/kesmas.v7i10.6 habibi, r., nayer, m., & zadeh, m. (2015). educational needs of families of patients with schizophrenia: a literature review. international journal of medical reviews, 2(2), 250–255. hui, c., chiu, c., li, y.-k., law, c., chang, w. c., chan, s., lee, e., sham, p., & chen, e. (2015). the effect of paternal age on relapse in first-episode schizophrenia. canadian journal of psychiatry. revue canadienne de psychiatrie, 60, 346–353. https://doi.org/10.1177/070674371506000803 jalil, m. (2006). faktor-faktor yang mempengaruhi kekambuhan penderita skizofrenia di rsj prof dr. soeroyo magelang. jeong, h.-g., & lee, m.-s. (2013). long-acting injectable antipsychotics in first-episode schizophrenia. clinical psychopharmacology and neuroscience, 11. https://doi.org/10.9758/cpn.2013.11.1.1 kazadi, n., moosa, m., & jeenah, f. (2008). factors associated with relapse in schizophrenia. s afr j psychiatry, 14. https://doi.org/10.4102/sajpsychiatry.v14i2.158 kementrian kesehatan ri. (2018). riset kesehatan dasar 2018. kementrian kesehatan. https://www.kemkes.go.id/resources/download /info-terkini/hasil-riskesdas-2018.pdf khankeh, h., rahgozar, m., & ranjbar, m. (2011). the effects of nursing discharge plan (post-discharge education and follow-up) on self-care ability in patients with chronic schizophrenia hospitalized in razi psychiatric center. iranian journal of nursing and midwifery research., 16(2), 162. koujalgi, s., & shobhadevi, r. (2013). family burden in patient with schizophrenia and depressive disorder: a comparative study. indian journal of psychological medicine., 35(3), 251. lee, s.-u., soh, m., ryu, v., kim, c.-e., park, s., roh, s., oh, i.-h., lee, h.-y., & choi, s. (2018). risk factors for relapse in patients with first-episode schizophrenia: analysis of the health insurance review and assessment service data from 2011 to 2015. international journal of mental health systems, 12(1), 9. https://doi.org/10.1186/s13033-018-0187-1 nadeem, b. m. (2013). attitude of schizophrenic patients’ care givers about their method of patient caring at home. holistic nursing and midwifery journal, 23(1), 54–62. panayiotopoulos, c., pavlakis, a., & apostolou, m. (2013). family burden of schizophrenic patients and the welfare system; the case of cyprus. int j jurnal ners http://e-journal.unair.ac.id/jners | 461 ment health syst., 7(1), 13. porcelli, s., bianchini, o., de girolamo, g., aguglia, e., crea, l., & serretti, a. (2016). clinical factors related to schizophrenia relapse. international journal of psychiatry in clinical practice, 20(2), 54– 69. https://doi.org/10.3109/13651501.2016.11491 95 pratama, syahrial, & ishak. (2015). hubungan keluarga pasien terhadap kekambuhan skizofrenia di blud rsj aceh. jurnal kedokteran syiah kuala, 15(2). riba, m., sharfstein, s., & tasman, a. (2005). the american psychiatric association. international psychiatry, 2, 18–20. https://doi.org/10.1192/s1749367600007360 rohan, j. m., huang, b., pendley, j. s., delamater, a., dolan, l., reeves, g., & drotar, d. (2015). predicting health resilience in pediatric type 1 diabetes: a test of the resilience model framework. journal of pediatric psychology, 40(9), 956–967. https://doi.org/10.1093/jpepsy/jsv061 ryandini, saraswati, & meikawati. (2011). faktorfaktor yang berhubungan dengan kekambuhan pada pasien skizofrenia di rumah sakit jiwa daerah dr. amino gondohutomo semarang. jurnal keperawatan dan kebidanan. stikkes telogorejo semarang, 1(4), 211–215. sadock, b., & sadock, v. (2010). kaplan & sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. (10th ed.). lippincott williams & wilkins. sariah, a. e., outwater, a. h., & malima, k. i. y. (2014). risk and protective factors for relapse among individuals with schizophrenia: a qualitative study in dar es salaam, tanzania. bmc psychiatry, 14, 240–240. pubmed. https://doi.org/10.1186/s12888-014-0240-9 sharif, f., shaygan, m., & mani, a. (2012). effect of a psycho-educational intervention for family members on caregiver burdens and psychiatric symptoms in patients with schizophrenia in shiraz, iran. bmc psychiatry, 12(1), 48. simanullang, r. h. (2018). the correlation between family support and relapse in schizophrenia at the psychiatric hospital. belitung nursing journal; vol 4, no 6 (2018): november-december 2018do 10.33546/bnj.389. https://belitungraya.org/brp/index.php/bnj/art icle/view/389 stuart, g. w. (2014). principles and practice of psychiatric nursing—e-book. elsevier health sciences. https://books.google.co.id/books?id=ivalbaaaq baj who. (2016). schizophrenia. http://www.who.int/mental health schizophrenia/en/2016 world federation of mental health. (2008). learning about schizophrenia: an international mental health awareness packet. http://www. wfmh.org. yildirim, a. (2014). the effect of family-to-family support programs provided for families of schizophrenic patients on information about illness, family burden and self-efficacy. turkish journal of psychiatry., 25(1). zahnia, s., & sumekar, d. w. (n.d.). kajian epidemiologis skizofrenia. 7. 313 pengembangan model intensi untuk tinggal pada tenaga keperawatan honorer di rumah sakit universitas airlangga (development of intention to stay model for temporary nursing staff in rs unair) ike nesdia rahmawati*, nursalam*, ninuk dian kurniawati* *fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya telp/fax: (031) 5913257 e-mail: nesdia@ymail.com abstrak pendahuluan: intensi untuk tinggal perawat merupakan hal yang penting untuk mengurangi tingkat turnover dan meningkatkan stabilitas rumah sakit. kualitas kehidupan kerja perawat (qnwl) telah diketahui memiliki pengaruh terhadap intensi untuk tinggal, namun informasi yang ada masih terbatas. tujuan dari penelitian ini adalah untuk mengembangkan model intensi untuk tinggal pada tenaga keperawatan honorer di rumah sakit universitas airlangga. metode: penelitian ini menggunakan desain penelitian survey eksplanatif dengan pendekatan cross-sectional. data diperoleh melalui kuesioner yang diberikan kepada 32 perawat yang bekerja di unit yang berbeda di rumah sakit ini dengan teknik simple random sampling. analisis data menggunakan partial least square (pls). hasil: qnwl mempengaruhi kepuasan kerja tetapi tidak mempengaruhi komitmen. komitmen secara signifikan dipengaruhi oleh kepuasan kerja. tidak ada pengaruh kepuasan kerja terhadap intensi untuk tinggal. komitmen secara signifikan mempengaruhi intensi untuk tinggal. pembahasan: qnwl secara tidak langsung mempengaruhi intensi untuk tinggal melalui kepuasan kerja dan komitmen. rekomendasi untuk meningkatkan intensi untuk tinggal adalah dengan mengembangkan kualitas kehidupan kerja, kepuasan kerja, dan komitmen perawat. rumah sakit perlu merekrut tenaga non-keperawatan untuk melaksanakan billing dan tugas administratif. saran untuk penelitian lebih lanjut adalah menganalisis pengaruh empowerment, remunerasi, dan jenjang karir terhadap intensi untuk tinggal perawat. kata kunci: intensi untuk tinggal, kualitas kehidupan kerja perawat, kepuasan kerja, komitmen. abstract introduction: intention to stay of nurses is important to reduce turnover rate and to improve the stability of hospital. quality of nursing work life (qnwl) has been found to influence intention to stay. however, reliable information of this effect is limited. the purpose of this study was to develop the model of intention to stay for temporary nursing staff in rs unair. method: anexplanative cross-sectional survey design was used in this study. data were collected by using questionnaire among 32 nurses working at different units in this hospital through simple random sampling and analyzed by partial least square (pls). result: qnwl affected job satisfaction but did not affect commitment. commitment was significantly affected by job satisfaction. there was effect of job satisfaction on intention to stay. commitment also significantly affected intention to stay discussion: qnwl is a predictor of intention to stay trough job satisfaction and commitment. it is recommended that more focused interventions on qnwl, job satisfaction, and commitment developments may improve intention to stay. recruitment of non-nursing staff to carry out billing and administrative tasks is urgently needed. suggestions for further research is to analyze the effect of empowerment, remuneration, and career ladder on nurses’ intention to stay. keywords: intention to stay, quality of nursing work life, job satisfaction, commitment. pendahuluan intensi perawat untuk tinggal yang rendah telah lama diperbincangkan dan menjadi isu global di dunia (currie & hill, 2012). intensi untuk tinggal dipengaruhi oleh k ualit as kehidupan ker ja perawat (quality of nursing work life/qnwl) yang rendah (almalki, fitz gerald, & clark, 2012), ketidakpuasan kerja (sourdif, 2004), dan komitmen yang kurang (tourangeau & cranley 2006). dampak intensi untuk tinggal yang rendah dapat meningkatkan turnover perawat yang menyebabkan ketidakstabilan kondisi tenaga ker ja d an pen i ng kat an biaya sumber daya manusia, seperti biaya pelatihan yang telah diinvestasikan, biaya perekrutan, dan pelatihan kembali (waldman, kelly, arora, & smith, 2004). fokus utama strategi peningkatan intensi perawat untuk tinggal adalah dengan meningkatkan qnwl, 314 jurnal ners vol. 9 no. 2 oktober 2014: 313–320 kepuasan kerja, dan komitmen perawat. riset keperawatan masih berfokus pada pengaruh faktor lingkungan kerja dan karakteristik perawat terhadap intensi perawat untuk tinggal tanpa kerangka teori yang mendasari (cowden & cummings, 2012). penelitian untuk mengembangkan model yang secara utuh menjelaskan pengaruh qnwl, kepuasan kerja, dan komitmen terhadap intensi perawat untuk tinggal belum dilakukan. kejadian turnover perawat merupakan akibat dari intensi perawat untuk tinggal yang rendah. prevalensi kejadian turnover perawat di dunia berkisar dalam rentang 10–21% per tahun (el-jardali, dimassi, dumit, jamal, & mouro, 2009). negara maju seperti amerika dan australia melaporkan rata-rata turnoverpada perawat lebih dari 20% per tahun (hayhurst, saylor, & stuenkel, 2005). perawat honorer di rs unair yang pindah atau keluar dari pekerjaannya adalah sebanyak 11,4% pada tahun 2012. laporan rs unair pada tahun 2013 menunjukkan sebanyak 25,4% dari perawat rsua memiliki kualitas kehidupan kerja dalam kategori kurang dan 25,4% sedang. intensi perawat untuk tinggal yang rendah telah menjadi masalah serius bagi rumah sakit, di mana ketika proses perekrutan yang telah berhasil menjaring staf perawat yang berkualitas pada akhirnya menjadi sia-sia karena perawat yang direkrut tersebut telah memilih bekerja di tempat lain (toly, 2001). prediktor yang secara konsisten mempengaruhi intensi untuk tinggal adalah kepuasan kerja dan komitmen (hayes et al., 2006). perawat yang tidak puas dengan pekerjaannya atau perawat yang memiliki komitmen kurang kuat terhadap organisasi tempat dia bekerja akan memilih untuk keluar dari organisasi. kepuasan kerja dan komitmen dibangun oleh qnwl (sirgy, reilly, wu, & efraty, 2008). qnwl juga memiliki peran penting dalam intensi untuk tinggal (mosadeghrad, ferlie, & rosenberg, 2011). solusi untuk meningkatkan intensi perawat u nt u k t i nggal ad ala h denga n peningkatan qnwl (brooks& anderson, 2005), kepuasan kerja dan komitmen organisasi (wang, tao, ellenbecker & liu, 2011) yang terintegrasi, sistematis, dan fleksibel. literatur keperawatan yang menjelaskan kerangka konseptual atau model yang komprehensif, yang secara teoritis menghubungkan masingmasing faktor yang berpengaruh terhadap intensi perawat untuk tinggal masih sangat k u rang (cowden & cu m mi ngs, 2012). berdasarkan masalah tersebut, penelitian ini diperlukan untuk mengembangkan model yang menjelaskan pengaruh kualitas kehidupan kerja perawat, kepuasan kerja, dan komitmen organisasi terhadap intensi perawat untuk tinggal secara sistematis dan terintegrasi. bahan dan metode desain penelitian yang digunakan adalah survei eksplanatif dengan pendekatan cross sectional yaitu penelitian yang dilakukan u nt u k menemu ka n penjelasa n tent a ng hubungan antara variabel independen dan dependen yang dikumpulkan pada waktu yang sama (nursalam, 2013). penelitian ini dilakukan di rs unair surabaya pada bulan februari sampai april 2014. populasi penelitian ini adalah tenaga keperawatan honorer di rs unair. sampel pada penelitian ini sebanyak 32 orang yang dipilih dengan menggunakan teknik simple random sampling sesuai dengan kriteria inklusi yaitu perawat dengan status pegawai honorer, perawat tersebut sehat secara fisik dan mental. kriteria eksklusi adalah perawat yang menolak menjadi responden dan perawat yang sedang cuti. variabel penelitian ini adalah qnwl, kepuasan kerja, komit men, dan intensi untuk tinggal. data dikumpulkan dengan memberikan kuesioner kepada perawat di tempat kerja. analisis data yang digunakan dalam penelitian ini adalah partial least square (pls). hasil karakteristik demografi dari responden penelitian menunjukkan bahwa usia responden yang paling banyak adalah pada rentang usia 21–25 tahun sebanyak 68,8%. jenis kelamin responden mayoritas adalah perempuan yaitu 84,4%. sebagian besar responden belum 315 pengembangan model intensi untuk tinggal (ike nesdia rahmawati, dkk.) menikah yaitu sejumlah 65,6%. ditinjau dari pengalaman kerja jumlah terbanyak adalah responden yang tidak pernah bekerja sebelumnya baik sebagai perawat maupun dosen keperawatan yaitu sebesar 56,3%. hasil qn w l jika ditinjau secara keseluruhan setelah dikomposisikan lebih dari separuh tenaga keperawatan honorer di rs unair memiliki qnwl pada kategori cukup yaitu 56,3%. hasil pengumpulan data tentang qnwl pada tabel di atas dapat dijabarkan bahwa nilai tertinggi pada ketiga dimensi worklife-homelife, work design, dan work world adalah pada kategori cukup dengan besar persentasi secara berurutan adalah 65,5%, 81,3%, dan 62,5%. hanya pada dimensi work context yang memiliki nilai tertinggi pada kategori baik (tabel 1). kepuasan kerja menunjukkan bahwa sebagian besar responden menyatakan puas yaitu sebanyak 81,3% dan yang tidak puas sebesar 15,6%. responden menyatakan tidak puas paling banyak adalah pada indikator rewards yaitu sebesar 37,5%. kemudian disusul indikator scheduling dan professional opportunities dengan jumlah yang sama pada responden yang tidak puas yaitu 12,5% (tabel 2). h a s i l d a r i v a r i a b e l k o m i t m e n me nu nju k k a n ba hwa seba nya k 68.8% responden memiliki komitmen afektif tinggi, tetapi masih terdapat 31,3% yang memiliki komitmen afektif pada kategori sedang. komitmen kontinuan dan komitmen normatif yang dimilik i responden menu nju k kan nilai cukup yaitu sebesar 71,9% dan 78,1% (tabel 3). tingkat intensi untuk tinggal yang dimiliki oleh sebagian besar responden adalah pada kategori sedang yaitu sebesar 68,8%. sebanyak 21,9% responden memiliki intensi untuk tinggal tinggi dan 9,4% adalah rendah (tabel 4). uji model menggunakan pls dilakukan melalui dua tahap. tahap awal uji model dengan pls dilakukan analisis terhadap tabel 1. kualitas kehidupan kerja tenaga keperawatan honorer rs unair variabel qnwl kurang sedang baik total f % f % f % f % worklife-homelife 2 6.3 21 65.6 9 28.1 32 100.0 work design 2 6.3 26 81.3 4 12.5 32 100.0 work context 0 0 12 37.5 20 62.5 32 100.0 work world 4 12.5 21 65.6 7 21.9 32 100.0 qnwl 0 0 18 56.3 14 43.8 32 100.0 tabel 2. kepuasan kerja tenaga keperawatan honorer rs unair variabel kepuasan kerja tidak puas netral puas total f % f % f % f % rewards 12 37.5 4 12.5 16 50.0 32 100.0 scheduling 4 12.5 3 9.4 25 78.1 32 100.0 coworkers 1 3.1 0 0 31 96.9 32 100.0 interaction opportunities 0 0 0 0 32 100.0 32 100.0 professional opportunities 4 12.5 2 6.3 26 81.2 32 100.0 work control & responsibility 1 3.1 1 3.1 30 93.8 32 100.0 recognition 0 0 0 0 32 100.0 32 100.0 kepuasan kerja 5 15.6 1 3.1 26 81.3 32 100.0 316 jurnal ners vol. 9 no. 2 oktober 2014: 313–320 item reliability (validitas tiap indikator) yang ditentukan dari nilai loading factor. semua indikator pada variabel qnwl, kepuasan kerja, dan komitmen memiliki nilai loading factor > 0.5 dan nilai t-statistik > 1.96 sehingga dinyatakan valid. beberapa indikator pada variabel intensi untuk tinggal yaitu item 7, 9, dan 10 memiliki nilai loading factor< 0.5, tetapi nilai t-statistiknya > 1.96, sehingga tetap dinyatakan valid. tahap selanjut nya dar i uji model menggunakan pls adalah menilai reliabilitas variabel dengan melihat nilai cronbach’s alpha dan nilai composite reliability (reliabilitas konstruk). nilai cronbach’s alpha dan nilai composite reliability pada variabel qnwl, kepuasan kerja, komitmen, dan intensi untuk tinggal adalah > 0.07 (0,862, 0,889, 0,809, 0,724) sehingga dinyatakan memiliki reliabilitas tinggi. hasil analisis uji model menunjukkan ada pengaruh yang signifikan dari qnwl terhadap kepuasan kerja dengan koefisien jalur adalah 0,77 dan t-statistik adalah 20,22. qnwl tidak berpengaruh terhadap komitmen dengan koefisien jalur adalah 0,30 dan t-statistik adalah 1,82. komitmen secara signifikan dipengaruhi oleh kepuasan kerja dengan koefisien jalur adalah 0,65 dan t-statistik adalah 8,01. tidak ada pengaruh kepuasan kerja terhadap intensi untuk tinggal dengan koefisien jalur adalah 0,162 dan tstatistik adalah 2,07. intensi untuk tinggal secara signifikan dipengaruhi oleh komitmen dengan koefisien jalur adalah 0,67 dan tstatistik adalah 10,61 (tabel 5). h a s i l a k h i r uji h i p o t e s i s d a r i p e n g e m b a n g a n m o d el i n t e n si u n t u k tinggal pada tenaga keperawatan honorer di rs unair surabaya dapat dilihat pada gambar 1. tabel 3. komitmen tenaga keperawatan honorer rs unair variabel komitmen rendah sedang tinggi totalf % f % f % f % afektif 0 0 10 31.3 22 68.8 32 100.0 kontinuan 1 3.1 23 71.9 8 25.0 32 100.0 normatif 4 12.5 25 78.1 3 9.4 32 100.0 tabel 4. intensi untuk tinggal tenaga keperawatan honorer rs unair variabel rendah sedang tinggi total f % f % f % f % intensi untuk tinggal 3 9.4 22 68.8 7 21.9 32 100.0 tabel 5. rekapitulasi hasil analisis model intensi untuk tinggal pada tenaga keperawatan honorer di rs unair surabaya no hipotesis path coefficient t-statistik keterangan 1. pengaruh qnwl terhadap kepuasan kerja 0.7708 20.2244 signifikan 2. pengaruh qnwl terhadap komitmen -0.3036 1.8214 tidak signifikan 3. pengaruh kepuasan kerja terhadap komitmen 0.6465 8.0199 signifikan 4. pengaruh kepuasan kerja terhadap intensi untuk tinggal 0.162 2.0737 signifikan 5. pengaruh komitmen terhadap intensi untuk tinggal 0.6748 10.6161 signifikan 317 pengembangan model intensi untuk tinggal (ike nesdia rahmawati, dkk.) pembahasan kualitas kehidupan kerja (qnwl) memiliki pengaruh yang signifikan terhadap kepuasan kerja. tingkat qnwl yang dimiliki oleh sebagian besar tenaga keperawatan di rs unair dalam kategori sedang. subvariabel qnwl yang paling tinggi kualitasnya bagi tenaga keperawatan honorer di rs unair adalah work context dan yang terendah adalah work design. hasil analisis menggunakan pls, work context adalah yang paling memberikan pengaruh dalam membentuk qnwl. subvariabel work world adalah yang paling kecil pengaruhnya dalam membentuk qnwl. h a si l p e n el it i a n s e s u a i d e ng a n penelitian yang dilakukan oleh gayathiri & ramakrishnan (2013) yang menyatakan bahwa ada pengaruh yang signifikan antara kualitas kehidupan kerja terhadap kepuasan kerja. penelitian lain yang mendukung adalah penelitian oleh manojlovich & laschinger (2007) yang menyatakan bahwa kualitas kehidupan kerja perawat berpengaruh terhadap kepuasan kerja. penambahan tenaga seperti tenaga administrasi dan pekarya atau asisten perawat diharapkan dapat meningkatkan qnwl karena perawat dapat fokus pada asuhan keperawatan sedangkan masalah administrasi, billing, dan transportasi dapat dilakukan oleh tenaga lain. upaya untuk mengatasi ketidaksesuaian pemikiran antara pimpinan dan perawat dapat dilakukan dengan cara pimpinan lebih terbuka terhadap kriteria dan hasil penilaian prestasi perawat sehingga dapat diketahui dan diterima oleh seluruh perawat serta tidak menimbulkan kecurigaan dan pertanyaan bagi perawat. qnwl yang dimiliki oleh perawat di rs unair tidak berpengaruh terhadap komitmen.hasil penelitian ber tentangan dengan penelitian oleh ahmadi, salavati, & rajabzadeh (2012) pada kar yawan di organisasi publik yang menyatakan kualitas keh idupa n ker ja berhubu nga n denga n komitmen. penelitian dari birjandi, birjandi,& ataei (2013) juga menyatakan bahwa terdapat hubungan yang positif secara signifikan antara kualitas kehidupan kerja dan komitmen. ketidaksesuaian disebabkan karena penelitian tersebut dilakukan pada responden non keperawatan di mana karakteristiknya mungkin berbeda dengan perawat. sebagian besar responden belum memiliki pengalama kerja sehingga perawat belum memiliki pembanding terhadap kualitas kehidupan kerja yang dirasakan saat ini. qnwl mempengaruhi komitmen secara tidak langsung melalui jalur variabel kepuasan kerja perawat. kepuasan kerja menunjuk kan ada pengaruh terhadap komitmen pada tenaga keperawat a n honorer d i ru ma h sa k it gambar 1. pengembangan model intensi untuk tinggal pada tenaga keperawatan honorer di rs unair surabaya 318 jurnal ners vol. 9 no. 2 oktober 2014: 313–320 universitas airlangga surabaya. sebagian besar perawat puas terhadap pekerjaan yang dijalaninya. ketidakpuasan paling banyak pada indikator imbalan (rewards). menurut wang et al. (2011) kepuasan kerja memiliki hubungan yang kuat dengan komitmen. perawat yang memiliki komitmen yang kuat merasa bahwa tujuan dari pekerjaan mereka telah sesuai dengan tujuan pribadi dan harapan yang ditandai dengan tingkat kepuasan kerja yang tinggi. penelitian oleh mosadeghrad et al. (2008) juga menyatakan ada hubungan yang positif antara kepuasan kerja dengan komitmen. temuan tersebut menunjukkan bahwa perawat yang memiliki kepuasan kerja tinggi juga memiliki tingkat komitmen yang tinggi pada instansi kesehatan tempat perawat bekerja. upaya untuk meningkatkan komitmen perawat adalah dengan meningkatkan kepuasan kerja perawat terutama pada pembenahan sistem imbalan di rumah sakit (konsistensi waktu pemberian gaji perawat, pemberian informasi tentang rincian gaji), transparansi penilaian kinerja perawat, serta perbaikan atau penambahan alat kesehatan yang rusak. analisis pengar uh kepuasan kerja terhadap intensi untuk tinggal menunjukkan hasil yang signif ikan, namun kontribusi kepuasan kerja dalam mempengaruhi intensi untuk tinggal relatif kecil, dilihat dari nilai path coeffisien yang rendah. mosadeghrad, et al., (2008) menyatakan bahwa kepuasan kerja dan komitmen memiliki hubungan terhadap turnover sehingga sangat penting untuk menguatkan keduanya dan menerapkannya pada kebijakan bagian sumber daya manusia pada institusi kerja. berdasarkan hasil analisis pengaruh komitmen terhadap intensi untuk pindah lebih besar daripada pengaruh kepuasan kerja terhadap intensi untuk pindah. wang, et al., (2011) menyatakan bahwa hubungan antara kepuasan kerja terhadap intensi untuk tinggal dinyatakan positif secara signifikan demikian juga hubungan antara komitmen terhadap intensi untuk pindah. namun jika dilihat dari besarnya kontribusi dalam mempengaruhi intensi untuk tinggal, komitmen memiliki nilai yang lebih besar dibandingkan dengan kepuasan kerja. ja lu r ko ef i sie n ke pu a s a n ke r ja menunjukkan kontribusi yang kecil terhadap intensi untuk tinggal meskipun secara statistik signifikan. kepuasan kerja berpengaruh langsung terhadap intensi untuk tinggal, namun hasil yang lebih besar akan didapat jika kepuasan kerja yang dimiliki perawat dikembangkan menjadi suatu komitmen dalam diri perawat untuk tetap tinggal di institusi tempat perawat bekerja. komitmen memiliki pengaruh terhadap intensi untuk tinggal pada tenaga keperawatan honorer di rs unair. sebagian perawat memiliki komitmen pada kategori sedang. model konsep dari cowden & cummings (2011) menunjukkan bahwa intensi untuk tinggal dipengaruhi oleh respon kognitif kerja di mana salah satu faktor yang paling utama adalah komitmen terhadap organisasi. liou (2009) dalam penelitiannya menyatakan bahwa komitmen merupakan prediktor dari intensi untuk tinggal, sehingga manajer keperawatan harus berupaya memperkuat komitmen tenaga keperawatan untuk meningkatkan intensi untuk tinggal. mayoritas perawat di rs u nair merupakan lulusan dari universitas airlangga sehingga mereka memiliki keterikatan emosi yang kuat saat bekerja di rumah sakit dari universitas tempat mereka memperoleh pendidikan. bangunan rs u nair yang baru menambah kenyamanan perawat dalam bekerja. terdapat beberapa faktor yang menur unkan tingkat komitmen perawat. faktor tersebut antara lain adalah pengakuan dari pimpinan atas kinerja perawat, status kepegawaian, penilaian yang dirasa perawat subyektif, dan imbalan. simpulan dan saran simpulan model intensi untuk tinggal pada tenaga keperawatan honorer dapat dikembangkan melalui peningkatan kualitas kehidupan kerja (qnwl), kepuasan kerja, dan komitmen. kualitas kehidupan kerja perawat terbukti berpengaruh terhadap intensi untuk tinggal melalui jalur kepuasan kerja dan komitmen. 319 pengembangan model intensi untuk tinggal (ike nesdia rahmawati, dkk.) rekomendasi untuk meningkatkan intensi untuk tinggal adalah dengan mengembangkan kualitas kehidupan kerja, kepuasan kerja, dan komitmen perawat. rumah sakit perlu merekrut tenaga non-keperawatan untuk melaksanakan billing dan tugas administratif. saran peningkatan intensi unt uk tinggal perawat dapat dilakukan melalui peningkatan qnwl, kepuasan kerja, dan komitmen. model intensi untuk tinggal perawat dapat digunakan oleh rs u na ir sebagai upaya u nt u k mempertahankan perawat agar tidak pindah atau keluar dari rumah sakit. penelitian lebih lanjut perlu dilakukan untuk menganalisis pengaruh empowerment, remunerasi, dan jenjang karir terhadap intensi untuk tinggal perawat. kepustakaan ahmadi, f., salavati, a.& rajabzadeh, e. 2012. sur vey relationship between quality of work lifeand organizational commitment in public organization in kurdistan province. interdisciplinary journal of contemporary research in business, 4(1), pp. 235–246. almalki, m. j., fitz gerald, g. & clark, m. 2012. the relationship between quality of work life and turnover intention of primary health care nurses in saudi arabia. bmc health services research, 12, pp. 314. birjandi, m., birjandi, h.& ataei, m. 2013. the relationship between the quality of work l ife a nd orga n i zat ional commitment of the employees of darab cement company: case study in iran. international journal of economics, business and finance,1(7), pp. 154– 164. brooks, b. a.& anderson, m. a. 2005. defining quality of nursing work life. nursing economics,23(6), pp. 319–326. currie, e. j.& hill, r. a. 2012. what are the reasons for high turnover in nursing? a discussion of presumed causal factors and remedies. international journal of nursing studies, 49(9), pp. 1180–1189. c owd e n , t. l .& c u m m i n g s , g. g. 2012. nursing theor y and concept development: a theoretical model of clinical nurses’ intentions to stay in their current positions. journal of advanced nursing, 68(7) pp. 1646–1657. el-jardali, f., dimassi, h., dumit, n., jamal, d.& mouro, g. 2009. a national crosssectional study on nurses’ intent to leave and job satisfaction in lebanon: implications for policy and practice. bmc nursing, 8(3), pp. 1–13. gayathiri, r.& ramak rishnan, l. 2013. quality of work life linkage with job satisfaction and perfor mance. international journal of business and management invention, 2(1), pp. 1–8. hayes, l. j., o’brien-pallas, l., duffield, c., shamian, j., buchan, j., hughes, f., laschinger, h. k. s., north, n. & stone, p. w. 2006. nursing turnover: a literature review. international journal of nursing studies. 43, pp. 237–263. hayhurst, a., saylor, c. & stuenkel, d. 2005. work environ mental factors and retention of nurses. journal of nursing care quality, 20(3), pp. 283–288. liou, s. r. 2009. nurses’ intention to leave: critically analyse the theory of reasoned action and organizational commitment model. journal of nursing management, 17, pp. 92–99. manojlovich, m.& laschinger, h. 2007. the nursing worklife model: extending and refining a new theory. journal of nursing management, 15, pp. 256 – 263. mosadeghrad, a. m., ferlie, e. & rosenberg, d. 2011. a st udy of relationship between job stress, quality of working life and tur nover intention among hospital employees. health services management research, 24(4), pp. 170– 181. nursalam, 2013. metodologi penelitian ilmu kepera watan pendek atan prak tis. jakarta: salemba medika sirgy, m., reilly, n. p., wu, j.& efraty, d. 2008. a work-life identity model of well-being: towards a research agenda linking quality-of-work-life (qwl) programs with quality of life (qol). 320 jurnal ners vol. 9 no. 2 oktober 2014: 313–320 applied research in quality of life, 3(3), pp. 181–202. sourdif, j. 2004. predictors of nurses’ intent to stay at work in a university health center. nursing health science, 6(1), pp. 59–68. toly, a. a. 2001. analisis faktor-faktor yang mempengaruhi turnover intention pada staf kantor akuntan publik. jurnal akuntansi dan keuangan, 3(2), pp. 102–125. tourangeau, a. e. & cranley, l. a. 2006. nurse intention to remain employed: understanding and st reng thening determinants. journal of advanced nursing, 55(4), pp. 497–509. waldman, j. d., kelly, f., arora, s. & smith, h. l. 2004. the shocking cost of t ur nover in health care.heath care management review, 29(1), pp. 2–7. wang, l., tao, h., ellenbecker, c. h. & liu, x. 2012. job satisfaction, occupational commitment and intent to stay among chinese nu rses: a cross-sectional que st ion n a i re s u r vey. jo u r n a l of advanced nursing, 68(3), pp. 539–549. 147 kesejahteraan psikologis pada pasien diabetes mellitus tipe 2 di puskesmas mulyorejo surabaya (psychological well being in type 2 diabetes mellitus patients in mulyorejo public health center surabaya) rr dian tristiana*, kusnanto*, ika yuni widyawati*, ah yusuf*, rizki fitryasari* fakultas keperawatan universitas airlangga, surabaya, indonesia email: diantristiana@fkp.unair.ac.id abstrak pendahuluan: hidup dengan penyakit kronis seperti diabetes mellitus tipe 2 akan membuat pasien mengalami perubahan atau ketidakseimbangan antara biologis, psikologis, sosial dan spiritual. salah satu aspek psikologi pada pasien dengan diabetes mellitus tipe 2 adalah kesejahteraan psikologis (pwb). tujuan dari penelitian ini adalah untuk mengeksplorasi deskripsi pwb pada pasien tipe 2 diabetes mellitus dalam enam aspek pwb dan pwb memfasilitasi dan faktor penghambat pada pasien dm tipe 2. metode: penelitian ini menggunakan desain penelitian kualitatif pendekatan studi kasus. subjek penelitian adalah 7 peserta yang memenuhi kriteria inklusi. pengumpulan data dilakukan dengan wawancara terstruktur dan observasi. analisis data dilakukan dengan analisis tematik. hasil dan analisis penelitian ini dihasilkan 14 tema. hasil: hasil penelitian menunjukkan bahwa proses pasien dm tipe 2 mengalami proses transisi dari kondisi sehat dalam kondisi sakit. proses transisi dimulai dengan respon kehilangan siklik yang mempengaruhi tipe 2 dm pasien untuk kontrol diri dan membuat hak pengambilan keputusan untuk perawatan diri. pengendalian diri akan membuat tipe 2 pasien dm mampu beradaptasi dan terlibat dengan pengalaman baru yang menjadi kebiasaan baru untuk tipe 2 pasien dm dan akan memfasilitasi tipe 2 pasien dm dalam beradaptasi dengan lingkungan internal dan eksternal dan membuat pasien dm tipe 2 memiliki harapan positif dalam hidup mereka. diskusi: penelitian ini diharapkan bermanfaat bagi staf kesehatan profesional untuk membuat penilaian tentang pwb di dm tipe 2 pasien, perawat diharapkan dapat membantu pasien dalam transisi dengan kondisi dm tipe 2. kata kunci: psikologis kesejahteraan, tipe 2 diabetes mellitus, kualitatif abstract introduction: living with chronic diseases such as diabetes mellitus type 2 will make patients experience change or imbalance include biological, psychological, social and spiritual. one of psychology aspects in patients with diabetes mellitus type 2 is psychological well being (pwb). the purpose of this research was to explore the description of pwb in patients of type 2 diabetes mellitus in six aspects of pwb and pwb facilitate and inhibitor factors in type 2 dm patients. methods: this research used qualitative design research with case studies approach. the subject of research was seven participants who met the inclusion criteria. data collection was done by structured interview and observation. data analysis was done by thematic analysis. results: this study generated 14 themes. the result showed that the process of type 2 dm patients subjected to the process of transition from a healthy condition into ill condition. the transition process started with cyclic lose response which influence type 2 dm patient to self control and make a right decision-making to self care. selfcontrol would make type 2 dm patients able to adapt and engage with new experiences that become a new habit for type 2 dm patients and will facilitate type 2 dm patients in adapting to the internal and external environment and make type 2 dm patients have a positive hope in their life. discussio: finding in this study would hopefully be beneficial for professional health staff to make assessment about pwb in type 2 dm patients, nurse hopefully can assist patients in transition with the condition of type 2 dm. key words: psychological well being, type 2 diabetes mellitus, qualitative _______________________________________________________________________________ pendahuluan diabetes mellitus (dm) merupakan salah satu penyakit kronis dengan angka kejadian tinggi dimana who memperkirakan penyakit dm akan menjadi epidemi global pada abad 21 dan 70% kasus dm ada di negara-negara berkembang (tol et al., 2013) termasuk diantaranya adalah negara indonesia. diagnosa dm tipe 2 serta banyaknya perawatan yang dilakukan akan menimbulkan perubahan atau ketidakseimbangan yang meliputi biologi, psikologi, sosial dan spiritual pasien serta memberikan dampak pada kehidupan keluarga pasien (who, 2014). variabel psikologis merupakan hal yang penting karena kepercayaan akan kesehatan, pengetahuan dan perilaku pada pasien dm akan mempengaruhi pasien dm dalam mengontrol penyakitnya (miley, 1999). hasil wawancara yang dilakukan pada 18 april 2014 di puskesmas mulyorejo, didapatkan bahwa 3 dari jurnal ners vol. 11 no. 2 oktober 2016: 147-156 148 4 pasien menyatakan bahwa pasien jenuh dengan rutinitas yang mereka lakukan sehingga menyebabkan pasien tidak patuh dengan pola diet dan aktivitas fisik yang dilakukan. dua orang pasien mengatakan putus asa dengan penyakit dm yang diderita, terkadang tidak mau makan karena takut dengan komplikasi yang akan terjadi. seorang pasien mengatakan mengurangi aktivitas berkumpul dengan temantemannya. seorang pasien masih belum mau menerima jika dirinya terkena dm. perawatan jangka panjang yang harus dijalani pasien dm sangat sulit dikontrol secara efektif, sehingga sangat penting memperhatikan aspek psikologis selain aspek fisik pasien dm tipe 2. psychological well being (pwb) merupakan salah satu bagian dari area psikologi positif umum yang disebut sebagai subjective well being (swb) yang merupakan suatu ukuran berfungsi secara positif dalam tingkat individu. pasien dm tipe 2 yang memiliki pwb yang rendah akan berakibat pada rendahnya tingkat perawatan diri (self care) (peyrot et al., 2005). tingkat perawatan diri yang rendah akan mengakibatkan peningkatan terjadinya komplikasi (davis, 2010; kusnanto, 2013). menurut who, psychological well being adalah sebuah appraisal subyektif fungsi seorang individu dalam realisasidiri (keyes, 2013). psychological well being (pwb) merupakan salah satu bagian dari area psikologi positif umum yang disebut sebagai subjective well being (swb) yang mana merupakan suatu ukuran berfungsi secara positif dalam tingkat individu. pengukuran pwb akan memberikan petunjuk mengenai apa yang sedang terjadi pada pasien dalam mengelola penyakitnya dan memberikan gambaran pada petugas kesehatan tentang cara pendekatan kepada pasien dalam meningkatkan kontrol (miley, 1999). konsep transisi memiliki kaitan yang erat dengan kesehatan dan well being karena mencakup adaptasi proses psikologis yang harus dilakukan oleh pasien (meleis, sawyer, im, messias, & schumacher, 2000). transisi dari kondisi sehat ke kondisi sakit pada pasien dm tipe 2 diperlukan untuk keberhasilan manajemen diri pasien dm tipe 2 (mcewen, baird, pasvogel, & gallegos, 2007). proses transisi tersebut telah dijelaskan oleh kralik et al (2004) dalam (jutterstrom, 2013) sebagai sebuah proses yang harus dialami individu untuk mencapai keseimbangan dalam memaknai kehidupan dan pada waktu yang sama mengalami dampak dari penyakit dan penanganannya. hidup dengan dm berarti beradaptasi dengan kondisi dm, mengembangkan pola dan beradaptasi dengan perubahan. psychological well being yang positif tidak muncul dengan sendirinya pada pasien dm tipe 2. banyak faktor yang mempengaruhi kondisi pwb pasien dm tipe 2. respon psikologis pasien dm tipe 2 merupakan hal yang subyektif dan unik sesuai pengalaman individu. proses transisi tiap individu juga merupakan hal yang subyektif, oleh sebab itu peneliti perlu untuk menggunakan penelitian kualitatif untuk menggali pwb pada pasien dm tipe 2 serta faktor apa saja yang mempengaruhi pwb pada pasien dm tipe 2. bahan dan metode peneliti ingin mengeksplorasi kondisi pwb pada pasien dm tipe 2 dari subyektivitas partisipan yang menderita dm tipe 2. pengalaman partisipan bersifat unik sesuai dengan karakteristik partisipan sehingga tidak dapat digambarkan secara kuantitatif. penelitian ini menggunakan metode kualitatif dengan pendekatan case study. alat bantu pangambilan data penelitian pada penelitian kualitatif dengan pendekatan studi kasus ini sebagai berikut: pedoman wawancara, catatan lapangan/field note (mencatat data yang didapatkan ketika wawancara): seperti ekspresi partisipan dan lainnya dan recorder/perekam berupa voice recorder. panduan wawancara pada penelitian ini dikembangkan dari teori psychological well being dari ryff dan berpedoman pada teori transisi meleis. pengambilan data dengan metode triangulasi yaitu wawancara dan observasi. subyek penelitian yang menjadi partisipan sesuai dengan kriteria inklusi penelitian dan diambil secara snowball sampling. tahapan analisis data pada penelitian ini menggunakan metode colaizzi (1978) dalam (streubert & carpenter, 2003). hasil penelitian ini menghasilkan 14 (empat belas) tema yang dijabarkan sesuai tujuan penelitian. gambaran kesejahteraan psikologis pasien diabetes meliitus tipe 2 dapat digambarkan dari tema respons kehilangan, kontrol/kendali diri, pengambilan keputusan, penyesuaian diri, keterlibatan, adaptasi lingkungan, kemampuan berhubungan dengan orang lain dan kesembuhan. faktor yang kesejahteraan psikologis pasien dm tipe 2 (rr. dian, dkk) 149 mempengaruhi kondisi kesejahteraan psikologi pasien diabetes mellitus tipe 2 dapat digambarkan melalui tema dukungan sosial, sumber informasi, pengetahuan, sikap, persepsi dan kepercayaan/keyakinan, ketersediaan sumber daya pribadi, dan layanan kesehatan. penerimaan diri tema 1: respon kehilangan “…..kadang menerima kadang kalo waktu pas rodok rodok galau yo gitu cik enakee orang yang nggak berpenyakit….” (p7) “….dijalani saja mbak…hidup mati kan takdir allah…” (p4) otonomi (autonomy) tema 2: kendali/kontrol pribadi “iya saya ngatur sendiri (diet)….” (p1) “…….daripada ngobatin mending saya nggak makan (makanan yang dilarang dokter) wis….” (p3) “…….kalo bisa saya menjaga sampai akhir hayat saya kalo bisa dijaga….” (p4) tema 3: pengambilan keputusan “…….saya sendiri sebagai pelakunya saya kan yang tahu diri saya yang lebih saya sendiri… (berkaitan dengan perawatan)…” (p1) “….… daripada saya mengobati itu lebih lebih baik saya taat…” (p3) pertumbuhan pribadi (personal growth) tema 4: penyesuaian diri “…trus sekarang saya pegang pokoknya saya kalo makan gini tu gitu jadi saya trus tak buat kunci gitu lho mbak, heheh...kunci tak buat kunci oo berarti aku sekarang sudah lain mungkin…” (p1) “….makan gorengan orang yang jual itu tapi yo tetep aja nyamilnya itu saya nggak bisa dok saya lebih baik ndak makan pokoknya lebih baik meninggalkan makan daripada meninggalkan nyamilnya itu aku bilang gitu…” (p7) tema 5: keterlibatan “….diibaratkan kayak ikut kb aja kalo saya ikut kb kan setiap hari (minum obat), oo gitu,…” (p4) “…..dari dulu saya tetap gak bisa merubah pola makan….” (p7) penguasaan lingkungan (environment mastery) tema 6: adaptasi lingkungan “…saya makan pokoknya saya kalo di mantenan gitu saya nggak pernah ngambil mbak…” (p2) “…. suami saya tak kasih tahu kamu kalo pengen njajan gak popo titipo aku tak nganu aku tak gak, punya panganan sego jagung tak urap kelopo saya gitu gak pa pa daripada saya sakit mbak jadi saya legowo….” (p1) hubungan positif dengan orang lain (positive relation with other) tema 7: hubungan dengan orang lain “…… sekarang tambah semangat (kegiatan di luar rumah)……” (p2) “….kadang gitu heem menyesuaikan heem kalau pas endak gitu (hubungan seks) ya gulanya bagus gitu ya anu santai gitu, pokoknya kudu nyadar…..” (p1) tujuan hidup (purpose of life) tema 8: harapan “….… aku tak diet supoyo engko sampe iso jalan-jalan maneh karo cucu ambek anak gitu…” (p1) faktor pendorong dan penghambat tema 9: dukungan social “….tambah anak anak ini tambah buk ati ati lho yo iyo hehehe…malah makan ati ati buk biar sehat iya anak anak begitu,…” (p1) “…dokter nah saya itu dah semangat semangat hidup harus terus saya itu wis ak…saya kalo terasa itu tho ibu ndak boleh (mengibaskan tangan) kepikiran begitu, orang hidup harus semangat ininya…” (p3) “…cuma mengingatkan bu ati-ati..” (p2) “…… setiap bulan tu ada yang mbantu susu ituuu diabetes yang satu bantu anlene….” (p4) sumber informasi tema 10: sumber informasi “…dokter, heem, dokter,… (informasi yang diperoleh)” (p1) “….ahli gizi di puskesmas itu suruh makan ini lho apa sego jaguung sego jaguung sudah ya….” (p2) pengetahuan tema 11: pengetahuan “…makannya itu kalo peraturannya tujuh sendok , jadi kalo pagi ya pagi jam umpamanya jurnal ners vol. 11 no. 2 oktober 2016: 147-156 150 saya sarapan jam tujuh ya lima jam jadi delapan sembilan sepuluh (menghitung menggunakan tangan) sepuluh ini snak, heemm jadi nggak boleh makan snek snek lain, jadi nek kalo sudah sarapan ya jam tujuh ya jam sepuluh itu makan roti apa makan apa gitu kalo buah mungkin habis makan nasi nggak pa pa heem tapi sneknya tiga jam sesudah itu tiga jam ya jadi jam tujuh ya lapan sembilan sepuluh sebelas dua belas lima jam ini makan lagi tapi minum obat dulu heem gitu…” (p1) sikap, persepsi dan kepercayaan komitmen pada sub tema komitmen, partisipan menyampaikan komitmennya dalam melakukan perawatan yang diungkapkan melaui transkrip wawancara di bawah ini: “…jadi apapun pokoknya saya jalankan perintahnya dokter saya diet gitu aja…” (p1) “…jangan sampe sakit lagi jangan sampe makan makanan yang menimbulkan sakit....” (p3) hal yang sulit dipatuhi “…….orang diabetes itu ya emang gejalanya tidak bisa untuk mengendalikan diri dalam hal makan itu ya iya kalo makan makan yang biasa tu utuh nggak tak jamah aku yo ngombe es teh halah es teh apa malah malah penyakit tapi kalo enak enak es teller apa…makan akuu yaa percuma ngombe gak enak nggarai penyakit lah sing enak sisan gitu aku…” (p5) strategi meningkatkan kesehatan “…diminumi atau kadang itu minum itu lho mahkota dewa itu bisa, bisa turun…” (p6) ketersediaan sumber daya pribadi “…saya sakit itu langsung beli alatnya saya cek sendiri…” (p6) “…didukung kalo misalnya saya minta cek up gitu ya dikasih uang sembilan ratus tujuh ratus tapi gak mau mengantar…” (p4) layanan kesehatan “…dokter umum…” (p2) “…dokter spesialis…” (p3) “….ke puskesmas…” (p7) “….apotek…” (p1) “…rumah sakit…” (p4) pembahasan respons kehilangan penelitian ini menemukan bahwa tahapan pada respons kehilangan mulai terjadi saat pasien mendengar diagnosa penyakit dm tipe 2. tahapan atau fase dari kehilangan ini teridentifikasi terdiri dari lima tahap yaitu menyangkal, marah, menawar, depresi dan menerima. tahapan ini sama dengan tahapan proses kehilangan yang dikembangkan oleh (kubbler-ross, 2005) yang terdiri dari lima tahap. partisipan tujuh telah berada dalam fase penerimaan, namun belum mengakhiri respon kehilangan pada tahap menerima namun perasaan tersebut kembali dirasakan oleh partisipan kembali yaitu pada tahap tawar menawar. partisipan tujuh mengalami masalah yang berkaitan dengan kondisi penyakitnya. temuan penelitian ini sejalan dengan penelitian blaska (1998) dalam (fitryasari, 2009) tentang “model siklus berduka”, yaitu suatu model dimana mengalami perasaan berduka sesaat namun terus berulang. mallow dan betchel (1999) dalam collins (2008) juga menyatakan hal yang sama yaitu merupakan bentuk berduka kronis, yaitu perasaan berduka yang dialami secara pervasif, permanen, berulang dan terus dialami sepanjang masa. hal ini sejalan dengan penelitian (nash, 2014) yang menunjukkan bahwa proses kehilangan berlangsung seumur hidup, pasien yang didiagnosa dm tipe 2 dapat kembali lagi pada tahapan sebelumnya, terjebak pada tahapan menyangkal maupun tahapan lainnya. partisipan yang masih belum ke tahapan penerimaan masih memiliki tingkat perawatan diri yang rendah. hal ini sejalan dengan penelitian (schmitt et al., 2014) yang menyatakan bahwa semakin tinggi tingkat penolakan diagnosa diabetes mellitus tipe 2 berkaitan erat dengan koping yang rendah, penurunan tingkat perawatan diri, peningkatan distres dm tipe 2 dan penurunan kontrol glikemik. kontrol pribadi martin dan pear (1999) menjelaskan bahwa kontrol diri adalah ketika individu melakukan upaya tertentu yang dapat mengatur lingkungan sekitarnya untuk mengarahkan konsekuensi perilakunya sendiri. kendali diri diartikan sebagai pengaturan diri kesejahteraan psikologis pasien dm tipe 2 (rr. dian, dkk) 151 dalam berperilaku (ningrum & hasanat, 2010). hasil penelitian menunjukkan bahwa kontrol diri yang rendah berhubungan dengan penurunan tingkat kepatuhan terhadap aktivitas dan diet (hagger, panetta, leung, & g.wang, 2013). hasil penelitian (basyiroh, 2011) menunjukkan bahwa pasien dengan kontrol diri yang baik cenderung lebih mampu mematuhi pengobatan. empat partisipan mampu mengontrol dirinya dalam hal diet sedangkan ketiga partisipan cenderung tidak mampu mengontrol dirinya sehingga tidak mampu mengatur diet yang dianjurkan. hal ini sejalan dengan hasil penelitian yang telah dilakukan hagger et al (2013) dan basyiroh (2011). pengambilan keputusan pasien dm tipe 2 yang memiliki kontrol diri maka pengambilan keputusannya juga positif hal ini sesuai dengan penelitian sebelumnya dimana kontrol diri mempengaruhi tingkat usaha dalam pengambilan keputusan dalam melakukan suatu perilaku (evans, dillon, goldin, & krueger, 2011). tahapan pengambilan keputusan menurut simon (1980) dalam kadarsah (2002) terdiri dari empat tahap yaitu: (1) intelligence, tahap ini merupakan proses penelusuran dan pendeteksian dari lingkup problematika serta proses pengenalan masalah; (2) design, tahap ini adalah proses menemukan, mengembangkan, dan menganalisis alternatif tindakan yang bisa dilakukan. tahap ini meliputi proses untuk mengerti masalah, menurunkan solusi, dan menguji kelayakan solusi, (3) choice, tahap ini dilakukan proses pemilihan diantara berbagai alternatif tindakan yang mungkin akan dijalankan. tahap ini meliputi pencarian, evaluasi, dan rekomendasi solusi yang sesuai untuk model yang telah dibuat; (4) implementation, tahap ini adalah tahap pelaksanaan dari keputusan yang telah diambil. pada tahap ini diperlukan untuk menyusun serangkaian tindakan yang terencana, sehingga hasil keputusan dapat dipantau dan disesuaikan apabila diperlukan perbaikan. hasil penelitian menunjukkan bahwa dua partisipan sudah dalam tahap implementasi yaitu dengan menerapkan perawatan diabetes. pasien dm tipe 2 yang memiliki kontrol diri yang baik maka pengambilan keputusannya juga positif hal ini sesuai dengan penelitian sebelumnya dimana kontrol diri mempengaruhi tingkat usaha dalam pengambilan keputusan dalam melakukan suatu perilaku (evans et al., 2011). penyesuaian diri menurut white dalam (bharatasari, 2008), penyesuaian diri atau disebut juga adaptasi adalah proses penyesuaian terhadap suatu perubahan. penyesuaian diri pasien dm tipe 2 yang efektif terukur dari seberapa baik seseorang mengatasi perubahan yang terjadi dalam hidupnya. menurut haber dan runyon dalam (hasibuan, 2010), penyesuaian diri yang efektif adalah dengan menerima keterbatasan yang tidak bisa berubah dan secara aktif memodifikasi keterbatasan yang masih bisa diubah. keterbatasan yang tidak bisa diubah pada pasien dm tipe 2 adalah kondisi penyakit dm tipe 2 yang diderita. pasien dm tipe 2 harus melakukan penyesuaian diri yang bisa diubah seperti melakukan perubahan pola makan, aktivitas, obat, kontrol serta perawatan lain sesuai dengan yang dianjurkan dalam perawatan diri pasien dm tipe 2. keterlibatan perubahan dalam identitas, peran, hubungan, kemampuan dan pola perilaku diharapkan membawa ke dalam perubahan proses internal sama halnya dengan proses eksternal (tomey & alligood, 2010). partisipan yang sudah terlibat dengan perubahan perilaku yang baru menganggap perubahan tersebut sebagai suatu kebiasaan baru. hal ini sejalan dengan hasil penelitian (graffigna, barello, libreri, & bosio, 2014) yang menyatakan bahwa keterlibatan (engagement) memainkan peran penting dalam meningkatkan perilaku kesehatan dan keluaran klinis. penyesuaian diri pasien dm tipe 2 yang efektif terukur dari seberapa baik seseorang mengatasi perubahan yang terjadi dalam hidupnya. menurut haber dan runyon dalam hasibuan (2010), penyesuaian diri yang efektif adalah dengan menerima keterbatasan yang tidak bisa berubah dan secara aktif memodifikasi keterbatasan yang masih bisa diubah. keterbatasan yang tidak bisa diubah pada pasien dm tipe 2 adalah kondisi penyakit dm tipe 2 yang diderita. pasien dm tipe 2 harus melakukan penyesuaian diri yang bisa diubah seperti melakukan perubahan pola makan, aktivitas, obat, kontrol serta perawatan jurnal ners vol. 11 no. 2 oktober 2016: 147-156 152 lain sesuai dengan yang dianjurkan dalam perawatan diri pasien dm tipe 2. adaptasi lingkungan seseorang yang sehat dapat mengenali kebutuhan personalnya dan juga merasa mampu untuk berperan aktif dalam mendapatkan apa yang diinginkan dari lingkungannya (keyes, 2005). partisipan dengan penguasaan lingkungan yang negatif cenderung tidak mampu berperan aktif dalam mendapatkan apa yang diinginkan, partisipan cenderung mengikuti lingkungannya. pasien dm tipe 2 harus mampu mengatur lingkungan internal dan eksternal agar dapat mendukung perawatan diri terkait penyakit dm tipe 2 yang diderita. hubungan dengan orang lain (ryff, 1989) menggambarkan individu yang memiliki hubungan yang positif dengan orang lain sebagai individu yang memiliki hubungan yang hangat, memuaskan, dan saling percaya satu sama lain, memperhatian kesejahteraan orang sekitarnya, mampu berempati dan mengasihi serta terlibat dalam hubungan timbal balik. relasi yang positif dengan orang lain juga menyatakan adanya kepuasan terhadap kontak sosial dan relasi (keyes, 2005). kemampuan berhubungan dengan orang lain tidak berkaitan dengan diagnosa dm tipe 2. partisipan tetap mampu berhubungan dengan orang lain walaupun terjadi perubahan emosi yang dirasakan seperti yang diungkapkan oleh partisipan dua dan tujuh. rasa cepat marah dan tidak mampu mengendalikan diri setelah didiagnosa dm tipe 2 diungkapkan oleh partisipan tujuh, namun partisipan masih bisa berhubungan baik dengan orang lain. kondisi hubungan dengan orang lain, adanya konflik dan masalah antara pasien dm tipe 2 dengan orang lain yang mempengaruhi pasien dm tipe 2 dalam melakukan perawatan diri. harapan seligman (2005) dalam (maghfirah, 2013) menyatakan bahwa optimisme dan harapan memberikan daya tahan yang lebih baik dalam menghadapi depresi ketika musibah terjadi di masa depan. individu dikatakan memiliki tujuan dalam hidup dan perasaan terarah, merasakan makna dan tujuan dari kehidupan yang sedang dan telah dilaluinya serta mempunyai tujuan hidup. kondisi transisi adalah keadaan yang mempengaruhi cara seseorang melalui sebuah proses transisi. kondisi transisi ini diartikan sebagai faktor pendorong dan penghambat proses transisi. kondisi transisi ini mencakup faktor personal, faktor komunitas, atau faktor sosial yang mungkin memfasilitasi atau menghambat proses transisi dan hasil yang sehat. dalam penelitian ini didapatkan faktor internal dan eksternal seperti dukungan sosial, sumber informasi, pengetahuan, sikap, nilai dan keyakinan, ketersedian sumber daya pribadi, dan layanan kesehatan. indikator hasil yang akan dicapai berupa kondisi pwb yang baik yang diartikan sebagai pencapaian suatu keterampilan peran dan kenyamanan dengan perilaku yang diperlukan dengan situasi yang baru . keperawatan terapeutik yang diharapkan dalam penelitian ini yaitu kemampuan perawat dalam pengkajian kesiapan dan persiapan proses transisi pasien dm tipe 2. dukungan sosial merupakan bentuk interaksi antar individu yang memberikan kenyamanan fisik dan psikologis melalui terpenuhinya kebutuhan akan afeksi serta keamanan. hasil penelitian yuan et al (2009) dalam (antari, rasdini, & triyani, n.d.) dukungan sosial dapat berperan meningkatkan kualitas hidup pada penderita diabetes mellitus tipe 2 dengan meregulasi proses psikologis dan memfasilitasi perubahan perilaku. bentukbentuk dukungan sosial menurut sarafino (2002) dalam (pudner, 2005) yaitu: 1) dukungan emosional yang mencakup ungkapan empati, kepedulian dan perhatian terhadap orang yang bersangkutan. dukungan emosional merupakan ekspresi dari afeksi, kepercayaan, perhatian, dan perasaan didengarkan. kesediaan untuk mendengar keluhan seseorang akan memberikan dampak positif sebagai sarana pelepasan emosi, mengurangi kecemasan, membuat individu merasa nyaman, tenteram, diperhatikan, serta dicintai saat menghadapi berbagai tekanan dalam hidup mereka; 2)dukungan instrumental mencakup bantuan langsung, dapat berupa jasa, waktu, atau uang. misalnya pinjaman uang bagi individu atau menghibur saat individu mengalami stres. dukungan ini membantu individu dalam melaksanakan aktivitasnya; 3) dukungan informatif mencakup pemberian nasehat, petunjuk-petunjuk, saran-saran, informasi atau umpan balik. dukungan ini membantu individu mengatasi masalah dengan cara memperluas wawasan dan pemahaman individu terhadap kesejahteraan psikologis pasien dm tipe 2 (rr. dian, dkk) 153 masalah yang dihadapi. informasi tersebut diperlukan untuk mengambil keputusan dan memecahkan masalah secara praktis. dukungan informatif ini juga membantu individu mengambil keputusan karena mencakup mekanisme penyediaan informasi, pemberian nasihat, dan petunjuk; 4) ukungan persahabatan mencakup kesediaan waktu orang lain untuk menghabiskan waktu atau bersama dengan individu, dengan demikian akan memberikan rasa keanggotaan dari suatu kelompok yang saling berbagi minat dan melakukan aktivitas sosial bersama. sumber informasi peran sumber informasi adalah meningkatkan pengetahuan pasien. pengetahuan dan informasi dapat memotivasi pasien untuk mencari perawatan yang tepat dan menginspirasi pasien melakukan sesutau yang berkaitan dengan penyakitnya (kiberenge, ndegwa, & muchemi, 2010). sikap, persepsi dan kepercayaan green dalam nursalam (2013) menjelaskan faktor-faktor predisposisi merupakan faktor internal yang ada pada diri individu, keluarga, kelompok atau masyarakat yang mempermudah individu untuk berperilaku yang terwujud dalam pengetahuan, sikap, kepercayaan, keyakinan, nilai-nilai dan norma. kegagalan untuk mematuhi seharusnya tidak semata mata disalahkan pada pasien, karena kepatuhan adalah produk dari perilaku dalam kaitannya dengan pengobatan, perilaku penyedia perawatan kesehatan, serta kondisi lingkungan dimana pasien dan penyedia bekerja secara individual dan bersama sama. kepatuhan harus dilihat sebagai akhir produk dari hubungan yang dibangun atas hormat, partisipasi aktif dan kemitraan antara pasien dan perawatan kesehatan professional, yang tidak melibatkan paksaan atau manipulasi dari salah satu pihak (melastuti, 2013). kamaluddin (2009) juga menjelaskan ada beberapa faktor yang bisa mempengaruhi kepatuhan pasien diantaranya faktor pendidikan, konsep diri, pengetahuan pasien, keterlibatan tenaga kesehatan dan keterlibatan keluarga. diperlukan kerja sama antara pasien, keluarga dan tenaga kesehatan untuk tetap memberikan dukungan kepada pasien agar pasien mempunyai motivasi dalam meningkatkan kepatuhan. ketersediaan sumber daya pribadi (cumming & mays, 2011) mengungkapkan bahwa kemampuan individu membayar biaya pelayanan dan pemeliharaan kesehatan akan mempengaruhi bagaimana mereka menggunakan pelayanan kesehatan. penelitian serupa juga sejalan dengan (clark & utz, 2014) yang menyatakan bahwa biaya berkaitan dengan manajemen diabetes yang dilakukan oleh pasien dm tipe 2. layanan kesehatan beberapa alasan memilih layanan kesehatan adalah dari faktor biaya, kelengkapan sarana pemeriksaan dan jarak tempuh serta keramahan petugas kesehatan. komunikasi antara pasien dengan petugas kesehatan juga mempengaruhi pemilihan sarana kesehatan oleh pasien dm tipe 2. integrasi hasil penelitian pada model teori transisi meleis transisi dari kondisi sehat ke kondisi sakit akan mempengaruhi pasien diabetes mellitus tipe 2. suatu proses transisi dipengaruhi oleh faktor pendorong dan faktor penghambat dalam transisi itu sendiri. suatu proses transisi diawali dengan tipe dan pola transisi, dimana dalam penelitian ini diartikan sebagai perubahan dari kondisi sehat dan sakit yaitu diagnosa penyakit dm tipe 2. perubahan tersebut menyebabkan suatu respons terhadap kondisi transisi yaitu suatu respons kehilangan kondisi sehat dimana setiap orang memiliki respons yang berbeda. kondisi transisi adalah keadaan yang mempengaruhi cara seseorang melalui sebuah proses transisi. kondisi transisi ini diartikan sebagai faktor pendorong dan penghambat proses transisi. kondisi transisi ini mencakup faktor personal, faktor komunitas, atau faktor sosial yang mungkin memfasilitasi atau menghambat proses transisi dan hasil yang sehat. dalam penelitian ini didapatkan faktor internal dan eksternal seperti dukungan sosial, sumber informasi, pengetahuan, sikap, nilai dan keyakinan, ketersedian sumber daya pribadi, dan layanan kesehatan. indikator hasil yang akan dicapai berupa kondisi pwb yang baik yang diartikan sebagai pencapaian suatu keterampilan peran dan kenyamanan dengan perilaku yang diperlukan dengan situasi yang baru . keperawatan terapeutik yang diharapkan dalam penelitian ini yaitu kemampuan perawat jurnal ners vol. 11 no. 2 oktober 2016: 147-156 154 dalam pengkajian kesiapan dan persiapan proses transisi pasien dm tipe 2. simpulan dan saran pasien dengan dm tipe 2 akan mengalami proses transisi dari kondisi sehat ke kondisi sakit yang akan mempengaruhi kesejahteraan psikologisnya. sejak awal mengetahui diagnosa terkena dm tipe 2, pasien dm tipe 2 akan mengalami respons kehilangan melalui lima tahapan yaitu menyangkal, marah, menawar, depresi dan menerima. perasaan kehilangan ini kembali terjadi secara fluktuatif dan berulang meskipun pasien dm tipe 2 telah mencapai tahapan menerima yaitu pada saat pasien dm tipe 2 menemui suatu keadaan yang menyebabkan kembali perasaan kehilangan tersebut. pasien dengan dm tipe 2 dalam mencapai kondisi pwb yang positif dipengaruhi oleh faktor internal dan faktor eksternal. faktor internal berupa pengetahuan, sikap, nilai dan kepercayaan, ketersediaan sumber daya pribadi. faktor internal ini berasal dari diri pasien dm tipe 2 sendiri serta dari keluarga. faktor eksternal berupa dukungan sosial, sumber informasi, dan layanan kesehatan. secara umum dapat disimpulkan, bahwa seluruh tema yang didapat dari penelitian ini dapat dijelaskan dalam teori transisi meleis. seseorang yang didiagnosa penyakit dm tipe 2 memerlukan suatu proses transisi agar mencapai suatu keterampilan peran dan kenyamanan dengan perilaku yang diperlukan dengan situasi yang baru. proses transisi ini diawali oleh adanya dasar transisi yaitu tipe transisi yang berupa diagnosa penyakit dm tipe 2, kondisi transisi yang berupa faktor pendorong dan penghambat proses transisi, pola respons pasien dm tipe 2 yang merupakan cara pasien memanajemen diri dalam melakukan perubahan serta indikator hasil yang berupa kesejahteraan psikologis (pwb) yang positif. pihak puskesmas sebagai tempat pasien dm tipe 2 melakukan pemeriksaan terutama perawat hendaknya menyediakan waktu untuk melakukan pengkajian terkait perubahan yang akan dilakukan oleh pasien dm tipe 2 sejak awal dilakukan diagnosis hingga mencapai tahap pencapaian yang ingin dicapai. peran petugas kesehatan cukup penting dalam proses penyesuaian diri pasien dm tipe 2 yaitu dengan membantu pasien dm tipe 2 dengan memberikan edukasi tentang kondisi penyakit kronis yaitu dm tipe 2 dan menjelaskan bahwa perawatan diri merupakan suatu proses penyesuaian diri dimana pasien secara bertahap akan terlibat. petugas kesehatan juga sebaiknya mengkaji prioritas seseorang dan menemukan cara agar prioritas itu dapat sejalan dengan perawatan diri yang akan dilakukan oleh pasien dm tipe 2. pendidikan ilmu keperawatan diharapkan mampu memanfaatkan hasil penelitian ini sebagai topik bahasan dalam kelas maupun praktik di masyarakat secara langsung. proses transisi diperlukan oleh pasien dengan penyakit kronis yaitu dm tipe 2 untuk mencapai kondisi pencapaian penuh dan keterampilan yang optimal. perawat dapat mengembangkan pendekatan psikologis pada pasien yang baru didiagnosa dm tipe 2 serta mendampingi proses transisi hingga pasien dm tipe 2 dapat mandiri melakukan perawatan diri. peneliti disarankan juga menggali lebih jauh lagi hubungan antara penerimaan diri pasien dm tipe 2 dengan kontrol diri, proses aktivasi pasien dm tipe 2 hingga terjadi engagement perawatan diri, dimensi-dimensi engagement pada pasien dm tipe 2, waktu yang diperlukan pasien dm tipe 2 untuk melalui tahapan kehilangan, melakukan adaptasi dengan perilaku baru, waktu yang diperlukan pasien dm tipe 2 dalam proses engagement, perceived support yang dirasakan oleh pasien dm tipe 2 terhadap kondisi pwb dan kepatuhan mengikuti perawatan diri. metodologi penelitian yang telah digunakan dalam penelitian ini disarankan untuk lebih ditingkatkan untuk menambah variasi data penelitian yang diperoleh. terutama dalam hal penetapan sampel seperti keluarga pasien, lingkungan sekitar pasien serta paetugas kesehatan. ethical clearance penelitian ini telah menerima ethical approval oleh komisi etik penelitian kesehatan fakultas kesehatan masyarakat universitas airlangga surabaya no 421-kepk kepustakaan antari, g. a. a., rasdini, i. g. a., & triyani, g. a. p. (n.d.). besar pengaruh dukungan sosial terhadap kualitas hidup pada penderita dm tipe 2 di poliklinik interna rsup sanglah. program studi ilmu keperawatan fakultas kedokteran universitas udayana. kesejahteraan psikologis pasien dm tipe 2 (rr. dian, dkk) 155 retrieved from portalgaruda.org basyiroh, a. n. (2011). hubungan antara kontrol diri dengan kepatuhanterhadap pengobatan pada pasien diabetes melitus tipe 2di rsud dr. moewardi surakarta. bharatasari, t. a. (2008). strategi koping pengidap diabetes mellitus. clark, m. l., & utz, s. w. (2014). social determinants of type 2 diabetes and health in the united states. world j diabetes, 5(3), 296–304. cumming, j., & mays, n. (2011). new zealand‟s primary health care strategy: early effects of the new financing and payment system for general practice and future challenges. health economics, policy, and law, 6(1), 1–21. http://doi.org/http://dx.doi.org/10.1017/s1 744133109990260 davis, m. (2010). psychological aspects of diabetes management. uk: elsevier. evans, a. m., dillon, k. d., goldin, g., & krueger, j. i. (2011). trust and selfcontrol: the moderating role of the default. judgement and decision making journal, 6(7), 697–705. fitryasari, r. (2009). pengalaman keluarga dalam merawat anak dengan autisme di sekolah kebutuhan khusus bangun bangsa surabaya. universitas indonesia. graffigna, g., barello, s., libreri, c., & bosio, c. a. (2014). how to engage type-2 diabetic patients in their own health management: implications for clinical practice. bmc public health, 14, 648. hagger, m., panetta, g., leung, c.-m., & g.wang, g. (2013). chronic inhibition, self-control and eating behavior: test of a „resource depletion model. ploss one. hasibuan, c. (2010). penyesuaian diri penderita komplikasi diabetes. jutterstrom, l. (2013). illness integration, selfmanagement and patient-centred support in type 2 diabetes. sweden: umea university. dissertation. keyes, c. l. (2005). gender and subjective well being in the united states: from subjective well being to complete mental health. in k. v. oxington (ed.), psychology of stress (pp. 1–15). new york: nova science publishers. keyes, c. l. (2013). gender and subjective well being in the united states: from subjective well being to complete mental health. in kimberly v. oxington (ed.), psychology of stress (pp. 1–15). new york: nova science publisher. kiberenge, m. w., ndegwa, z. m., & muchemi, e. w. (2010). knowledge, attitude and practices related to diabetes among community members in four provinces in kenya: a cross-sectional study. the pan african medical journal. kubbler-ross, e. (2005). on grief and grieving: finding the meaning of grief through the five stages of loss. retrieved august 20, 2014, from www.proquest.umi.com kusnanto. (2013). pengembangan model self care management-holistic psychospiritual care terhadap respon holistik penderita diabetes mellitus tipe 2. dissertation. universitas airlangga. maghfirah, s. (2013). optimisme dan stres pada pasien diabetes mellitus. jurnal florence. mcewen, m., baird, m., pasvogel, a., & gallegos, g. (2007). health-illness transition experiences among mexican immigrant women with diabetes. fam community health, 30(3), 201–12. meleis, a. i., sawyer, l. m., im, e.-o., messias, d. k., & schumacher, k. (2000). experiencing transitions: an emerging middle-range theory. adv nurs sci, 23(1), 12–28. miley, w. (1999). the psychology of well being. british: praeger publisher. nash, j. (2014). understanding the psychological impact of diabetes and the role of clinical psychology. journal of diabetes nursing, 18(4), 137–142. ningrum, r. p., & hasanat, n. (2010). dinamika regulasi diri pada penderita diabetes mellitus tipe 2. in first national conference on biopsychology (pp. 235– 246). peyrot, m., rubin, r. r., lauritzen, t., snoeks, f. j., matthews, d. r., & skovlund, s. e. jurnal ners vol. 11 no. 2 oktober 2016: 147-156 156 (2005). psychosocial problems and barriers to improved diabetes management: results of the cross-national diabetes attitudes, wishes and needs (dawn) study. diabetic medicine, 1379–1385. pudner, r. (2005). nursing the surgical patients (2nd ed.). elsevier. ryff, c. (1989). happiness is everything, or is it? explorations on the meaning of psychological well-being. journal of personality and social psychology, 1069– 1081. schmitt, a., reimer, a., kulzer, b., haak, t., gahr, a., & hermans, n. (2014). assessment of diabetes acceptance can help identify patients with ineffective diabetes self-care and poor diabetes control. diabetic medicine. streubert, h., & carpenter, d. (2003). qualitative research in nursing: advancing the humanistic imperative. philadelphia: lippincott williams & wilkins. tol, a., baghbanian, a., mohebbi, b., shojaeizadeh, d., azam, k., & esmaeeli, s. (2013). empowerment assessment and influential factors among patients with type 2 diabetes. j diabetes metab disord . tomey, a., & alligood, m. (2010). nursing theorists and their work (7th ed.). missouri: mosby elsevier. who. (2014). diabetes: the cost of diabetes. retrieved march 28, 2014, from http://www.who.int/mediacentre/factsheet s/fs236/en/ http://e-journal.unair.ac.id/jners | 553 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20536 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the relationship between parenting style and sexual behavior before marriage in teenagers zubaidah zubaidah, insana maria, and rusdiana rusdiana stikes intan martapura, south borneo, indonesia abstract introduction: the purpose of this study was to learn about the relationship between parent style and sexual behavior before marriage among the teenagers in smkn 3 banjarbaru. methods: the design of this study was analytical with a cross-sectional approach. the population consisted of 810 teen classes x, xi, xii with the sample totaling as many as 226 teen classes x and xii in smkn 3 banjarbaru. the sample was determined using a stratified random sampling technique. the independent variable was parenting style and the dependent variable was sexual behavior before marriage. the data was collected using a questionnaire. the analysis was done using spearman rho. results: sex before marriage is a bad behavior. conclusion: there is a significant relationship between the parenting style used and sex before marriage in terms of the behavior of teenagers in smkn 3 banjarbaru. article history received: feb 27, 2020 accepted: april 1, 2020 keywords premarital sex; parenting; teens contact insana maria  maria.insana82@gmail.com  stikes intan martapura, south borneo, indonesia cite this as: zubaidah, z., maria,i., & rusdiana, r. (2020). the relationship between parenting style and sexual behavior before marriage in teenagers. jurnal ners, special issues, 553-556. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20536 introduction modernization has brought in shifts in the social norms, especially those of adolescents, including their sexual behavior (nurmala, ahiyanasari, wulandari, & pertiwi, 2019). premarital sexual behavior is a common behavior in adolescence (pradanie, armini, & untari, 2020). the high curiosity of adolescents about human sexual life makes them look for information about sex, whether it is through books, films or pictures that are done clandestinely. this is done by adolescents due to a lack of dialogic communication between adolescents and adults, both parents and teachers, about sexual problems. most people still consider it taboo to discuss sexual problems in daily life (kusmiran, 2011). sexual behavior among teenagers tends to have a negative connotation, even though it naturally has many different meanings. sexual behavior is a behavior that aims to attract the attention of the opposite sex. examples include dressing up, rolling the eyes, seducing, teasing and whistling. sexual activity is an activity that is carried out in an effort to fulfill a sexual urge or it is an activity to get pleasure or sexual activity. examples of sexual behavior include fantasizing, menstruating, kissing on the cheeks, kissing on the lips, petting and having sex. the parents often complain because there is no sense of responsibility. it is difficult to expect that the parents are responsible for their children's sexual behavior. parenting style refers to certain parenting patterns. the use of parenting contributes to the development of the social behavior of children. parenting is influenced by two factors, namely the internal and external factors (adawiyyah, 2016). according to the data from the world health organization (who), 41% of the 208 pregnancies worldwide are unplanned. as many as 11% of this number were births to women aged 15-19 years old. this shows that in a year there were 16 million pregnancies to adolescent girls. in indonesia, a survey conducted by the indonesian child protection committee (kpai) and the ministry of health, (ministry of health) in october 2013 explained that around 62.7% of adolescents in indonesia have had sex outside of marriage. in addition, 20% of 94,270 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ zubaidah et al. 554 | pissn: 1858-3598  eissn: 2502-5791 women who become pregnant out of wedlock were adolescents and 21% have had an abortion. for the cases of hiv infection within a span of 3 months, as many as 10,203 cases, 30%, were teenagers. the head of the national population and family planning agency (bkkbn), surya chandra surapaty, on april 5th 2015 revealed that the pregnancy rate among indonesian teenagers was quite high at 48 out of 1000 teenagers. early marriage was equal to 38 per 1000 teenagers. in semarang, central java, nearly 50% of teenagers have engaged in premarital sexual intercourse between the ages of 10-15 years old (handayani, wiranti, & raharjo, 2019). based on the research by (darmasih, 2009), the forms of premarital sexual behavior of high school adolescents in surakarta involved kissing on the lips for as many as 93 people (81.6%), masturbating for as many as 23 people (20.2%), watching porn videos for as many as 101 people (88.6%) and sexual relations for 5.2%. a strong relationship between the children’s school achievements and parenting style was associated with a higher level of [x]. (kiran, 2017). the parenting style impacts on the family life cycle and the development processes of the family members. masoumeh fallah (2018) provided evidence for there being a positive relationship between parental religiosity and adaptive parenting qualities. this is because limited parenting measures are often focused on a narrow aspect of parenting, such as spanking, hugging or corporal punishment (duriez, soenens, neyrinck, & vansteenkiste, 2009). materials and methods this research was analytical and it used a crosssectional approach. the research sample was taken using the stratified random sampling technique. the data collected consisted of both primary and secondary data. this was carried out by directly surveying the respondents using a questionnaire. the questionnaire was used to provide answers about the premarital sexual behavior of adolescents in smkn 3 banjarbaru. in this study, the subjects of the study were 226 x and xii students in smkn 3 banjarbaru. the research variables consisted of the dependent variable of premarital sex behavior and the independent variable of parenting style. the research was conducted at smkn 3 banjarbaru. results the results of the study are based on the responses of the 226 teens in classes x and xii. the results of the questionnaire include the respondent characteristic data, univariate data and bivariate data. the data on the characteristics of gender showed that the respondents were predominantly female at 51%. the last education held by the teenager’s parents was that of senior high school for 52,2%. the data obtained from the adolescents about premarital sex showed that they learnt through the internet for 60.2%, from their friends for 46.4%, through health worker-based information obtained from their girlfriends for 8.8% .46.4%, through television for 44.8%, through their teachers for 41.4%, from their parents for 30.4%, through newspapers or magazines for 16%, through their siblings for 13.8% and through the radio for 9.9%. the least effective parenting style applied by the parents of the adolescents of class x and xii in smkn 3 banjarbaru was authoritarian parenting for as many as 188 respondents (83.2%). democratic parenting was experienced by as many as 25 respondents (11%) and permissive parenting was experienced by as many as 13 respondents (5.8%). the relationship between parenting style and premarital sexual behavior among the adolescents in table 1. characteristics of the respondents at smkn 3 banjarbaru characteristics n % gender female 114 51 male 112 49 total 226 100 education non-educated 1 0,4 elementary school 45 19,9 junior high school 32 14,2 senior high school 118 52,2 diploma i/ii/iii 6 2,7 bachelor’s 24 10,6 total 226 100 education level of the parents no school 1 0,4 elementary school 45 19,9 junior high school 32 14,2 senior high school 118 52,2 diploma i/ii/iii 6 2,7 bachelor’s 24 10,6 total 226 100 information sources never 181 80,1 ever 45 19,9 total 226 100 jurnal ners http://e-journal.unair.ac.id/jners | 555 smkn 3 banjarbaru shows that authoritarian parenting was used by 188 people (83.2%). good behavior was found in 152 respondents (67.3%) and 36 people behaved badly (15.9%). the least used parenting style was permissive parenting for as many as 13 people (5.85). good behavior was observed in 4 respondents (1.8%) while those who behaved badly totaled 9 respondents (4.0%). the spearman statistical test results showed there to be a significant relationship with a p-value = 0.001. because the value of p <0.05 (0.001 <0.05), it can be concluded that ho is rejected. this means that there is a significant relationship between parenting style and the premarital sexual behavior of adolescents at smkn 3 banjarbaru. in this study, the results of the spearman statistical test showed a significant relationship of p = 0.001. because the value of p <0.05 (0.001 <0.05), it can be concluded that ho is rejected. this means that there is a significant relationship between parenting style and the premarital sexual behavior of adolescents at smkn 3 banjarbaru. discussion the results for the 226 respondents showed that 178 respondents (78.8%) had good behavior while 48 (21.2%) had bad behavior. from the research, it was found that the forms of premarital sexual behavior engaged in by the respondents include dating by 79.6%, watching porn videos by 67.3%, holding hands with the opposite sex by 89.8%, embracing by 41.2%, masturbation by 21.2%, kissing on the cheeks by 39.8%, kissing on the lips by 23.5%, holding the sensitive areas of the opposite sex by 8.8%, petting by 3.5%, oral sex by 2.7% and intercourse by (premarital sex). the results of this study are in line with the research by fathul azmi (2015) which shows that the forms of sexual behavior carried out include going on table 2. distribution of the respondents based on the information sources obtained by the adolescents information frequency ever % never % parent 55 30,4 126 69,6 teacher 75 41,4 106 58,6 brother 25 13,8 156 86,2 friend 84 46,4 97 53,6 girlfriend 16 8,8 165 91,2 internet 109 60,2 72 39,8 television 81 44,8 100 55,2 radio 18 9,9 163 90,1 newspapers 29 16 152 84 health workers 84 46,4 97 53,6 table 3. frequency distribution of the respondents based on the parenting style of the adolescents at smkn 3 banjarbaru parental parents frekuensi persen (%) demokratis 25 11 otoriter 188 83,2 permisif 13 5,8 total 226 100 table 4. frequency distribution of the respondents according to the form of premarital sexual behavior p r e m a r it a l s e x u a l b e h a v io r g ir lf r ie n d w a tc h in g v id o e p r o n o h o ld in g h a n d s h u g g in g o n a n im a s tu rb a ti o n k is s o n c h e e k k is s o n l ip s h o ld s e n s it if a r e a p e tt in g o r a l s e k s s e x u a l r e la ti o n s h ip never 46 74 23 133 178 136 173 206 218 220 220 ever 180 152 203 93 48 90 53 20 8 6 6 jumlah 226 226 226 226 226 226 226 226 226 226 226 table 5: relationship test results between parenting style and adolescent premarital sex behavior variable parenting style premarital sexual behavior s p e a r m a n 's r h o parenting correlation coefficient 1.000 .223** sig. (2-tailed) . .001 n 226 226 premarital sexual behavior correlation coefficient .223** 1.000 sig. (2-tailed) .001 . n 226 226 zubaidah et al. 556 | pissn: 1858-3598  eissn: 2502-5791 a date, holding hands and cuddling. there are also risky sexual behaviors involved namely kissing on the lips, kissing the neck, touching each other’s intimate parts and having oral sex. sexual behavior consists of a variety of behaviors that are determined by an interaction of complex factors. sexual behavior is influenced by one's relationships with others, inclusive of both the environment and the culture that is brought or passed down from the parents where a person lives. this relates to parenting style which is the interaction between the parents and children or adolescents in the internal environment. a child or teenager gets their first form of education from their parents and the formation of their personality traits comes from the family environment(kusmiran, 2011). there is a significant relationship between the parenting style of the parents with premarital sexual behavior in adolescents at smkn 3 banjarbaru. in line with the research of raja pieba (adawiyyah, 2016), this proves that there is a significant relationship between parenting style and adolescent sexual behavior. this is evidenced by the results of the statistical tests that had a p-value = 0.001, which means that p <0.05. it can be concluded that there is a relationship between parenting style and adolescent sexual behavior. one of the causes of sexual behavior in adolescents is the influence of the parenting style experienced. the lack of open communication between the parents and adolescents on sexual issues can lead to deviations in sexual behavior. passive sex education (without two-way communication) can influence attitudes and behavior. this is because in child sex education, it is not enough to only see and hear the information once or twice. it must be done gradually and continuously. the parents are obliged to correct any incorrect information accompanied by an explanation of the risk of wrong sexual behavior (darmasih, 2009). during adolescence, the influence of their peers also serves as an important socialization agent. despite this new understanding of parenting during adolescence, it continues to affect behavior well into adulthood (hoskins, 2014). parenting is important in relation to public health. the parenting concept includes parenthood, childcare and the parental role and function (virasiri, yunibhand, & chaiyawat, 2011). conclusion from the results of the research conducted on 226 teenagers in smkn 3 banjarbaru, the study was concluded as follows. the parenting that is most often used is authoritarian. poor or worst pre-marital sexual behavior by the respondents is in the form of holding sensitive areas, petting (holding the genitals), oral sex and claiming to have had intercourse (premarital sex). there is a significant relationship between parenting style and the premarital sexual behavior of the adolescents at smkn 3 banjarbaru. references adawiyyah, r. (2016). relationship between parenting parent types and premarital sexual behavior in adolescents in samarinda islamic high school. jurnal kesehatan, 4 no.1. darmasih, r. (2009). factors affecting premarital sex behavior in surakarta adolescents. duriez, b., soenens, b., neyrinck, b., & vansteenkiste, m. (2009). is religiosity related to better parenting?: disentangling religiosity from religious cognitive style. journal of family issues, 30(9), 1287–1307. https://doi.org/10.1177/0192513x09334168 handayani, o. w. k., wiranti, i., & raharjo, b. b. (2019). the reproduction health behavior of high school teenagers in semarang, indonesia. open public health journal, 12(1). hoskins, d. (2014). consequences of parenting on adolescent outcomes. societies, 4(3), 506–531. https://doi.org/10.3390/soc4030506 kiran, k. m. v. d. k. (2017). parenting styles as perceived by parents and children. international journal of science and research (ijsr), 6(8), 978– 982. kusmiran, e. (2011). kesehatan reproduksi remaja dan wanita. bandung: salemba medika. nurmala, i., ahiyanasari, c. e., wulandari, a., & pertiwi, e. d. (2019). premarital sex behavior among adolescent: the influence of subjective norms and perceived behavioral control toward attitudes of high school student. mmalaysian journal of medecine and health science, 15(3). pradanie, r., armini, n. k. a., & untari, a. d. (2020). factors associated with premarital sexual behaviour of adolescents who lived in a former prostitution area. international journal of adolescent medicine and health, (20190203). https://doi.org/https://doi.org/10.1515/ijamh2019-0203 virasiri, s., yunibhand, j., & chaiyawat, w. (2011). parenting: what are the critical attributes? journal of the medical association of thailand, 94(9), 1109–1116. 14 quality improvement model of nursing education in muhammadiyah universities toward competitive advantage abdul aziz alimul hidayat, musrifatul uliyah, sukadiono sukadiono department of nursing, faculty of health science, muhammadiyah university of surabaya jl. sutorejo no. 59 surabaya email: azizhidayat@um-surabaya.ac.id abstract introduction: most (90.6%) nursing education quality in east java is still low. that is because the quality improvement process in nursing education generally has been conducted partially (random performance improvement). a solution which might be help would be to identify a proper quality improvement model in nursing education toward competitive advantage. method: this research used a survey to gain the data. the research sample was 16 muhammadiyah universities chosen using simple random sampling. the data were collected with questionnaires of 174 questions and a documentation study. data analysis used was partial least square (pls) analysis technique. result: the nursing education profile in muhammadiyah universities in indonesia showed of 10 years establishment, accredited b and the competition level in one city/regency was averagely more than three universities becoming the competitors. the quality improvement model analysis of nursing education towards competitive advantage in muhammadiyah universities was directly affected by the focus of learning and operational process through human resources management improvement; on the other hand information systems also directly affected quality improvement and quality process components: leadership, human resources, focus of learning and operational process. improving human resources would directly influence proper strategic planning. strategy planning was directly influenced by leadership. thus, in improving the quality of nursing education, the leadership role of the department, proper information systems, and the human resources management improvement must be implemented. discussion: a quality improvement model in nursing education was directly determined with learning and operational process through human resources management along with information systems, strategy planning factors, and leadership. the research findings could be developed in the quality analysis application program. keywords: quality, nursing education, competitive advantage ____________________________________________________________________________________________________ introduction education for health care professionals, especially nurses, has to be improved to prepare the professional to face the rapid challenge of the healthcare services worldwide (frenk et al., 2010). an appropriate education must be capable preparing competent alumni who can compete whether nationally or internationally (altuntaş and baykal, 2017). in facing these challenges, most nursing education institutions are failing to provide a high-quality standard in responding to the demand from patients and society (horton et al., 2010). based on the indonesian national accreditation agency for higher education (ban-pt), 90.6% of nursing schools in indonesia got a c grade (fair) in accreditation, some of which were nursing schools under muhammadiyah universities (ban-pt, 2012). several things that caused the problem include that most nursing education institutions have not comprehensively conducted a quality improvement model and are still conducting it partially (pepin et al., 2017). according to the evaluation of the quality assurance systems of the universities, from 384 universities in indonesia, only 68 universities (17.7%) had a good internal quality assurance system (dikti, 2008). moreover, the rate was lower in the nursing schools with only 7.14% with a qualified internal quality assurance system (dikti, 2008). based on the background, the nursing schools need a proper quality improvement model that is heading towards competitive advantage (kuspijadi and sudarso, 2009; hidayat, supriyanto and nursalam, 2015). moreover, based on the prior study, the quality improvement model of nursing education for competitive advantage has not been studied. methods the method used in this study was crosssectional. the samples of the study were the muhammadiyah universities in indonesia – as many as sixteen universities chosen by simple random sampling. the data were collected by collecting questionnaires, which included 174 questions and performing a documentation study over three months. the data sources quality improvement model of nursing education (abdul aziz alimul hidayat, et. al) 15 were obtained from primary and secondary sources. primary sources were obtained from the respondents through questionnaires and direct interview, while the secondary data was taken from the accreditation results of banpt. the data analysis technique applied in this study was partial least square (pls). results this study found that there were several characteristics of nursing schools selected as the samples. as many as 62.5% (n = 10) of the schools were established more than ten years ago. the accreditation status of the nursing schools based on ban-pt in health education showed that 87.5% (n = 14) of the nursing schools had a b grade (good) in accreditation, while 12.5% (n = 2) obtained an a grade (excellent). for the competitiveness, every nursing school had more than three competitor universities within the city (table 1). regarding the components of the quality process in each nursing school, the results of the analysis showed that the nursing education in muhammadiyah universities possessed a level of competitive advantage as follows: 25.0% in leadership (n = 4), 75.0% in strategy planning (n = 12), 50.0% in customer focus (n = 8), 25.0% in human resource focus (n = 4), 50.0% in both learning process focus and information system (n = 8) (table 2). turning these into the components of the quality results, the results of analysis showed that nursing education in muhammadiyah universities had an average of competitive advantage as follows: 50.0% (n = 8) in leadership, strategy planning achievement, and customer focus; 100% (n = 16) in the learning process and financial; while 75.0% (n = 12) in facilities and infrastructure. on the other hand, 87.5% (n = 14) of the samples had not shown competitive advantage in the human resource component (table 3). the results indicated as significant if the t-statistic was higher than the outer value loading t-statistic more than 1.96 (table 4), and the quality development model of nursing education is visualised in figure 1. table 1. profile of nursing schools under muhammadiyah universities in 2016 study department profile n % period of existence < 5 years 5-9 years > 10 years 0 6 10 0 37,5 62,5 accreditation status a (excellent) b (good) c (fair) not accredited (poor) 2 14 0 0 12,5 87,5 0 0 the number of similar programs in a city 0-3 > 3 0 16 0 100 table 2. the components of the quality process in nursing schools under muhammadiyah universities towards competitive advantage no process component competitive advantage yes no n % n % 1 leadership 4 25,0 12 75,0 2 strategy planning 12 75,0 4 25,0 3 focus on customer 8 50,0 8 50,0 4 human resource focus 4 25,0 12 75,0 5 learning process focus 8 50,0 8 50,0 6 information system 8 50,0 8 50,0 jurnal ners vol. 12 no. 1 april 2017: 14-18 16 table 3. the components of the quality results in nursing schools under muhammadiyah universities towards competitive advantage no result component competitive advantage yes no n % n % 1 leadership result 8 50,0 8 50,0 2 strategy planning achievement 8 50,0 8 50,0 3 the result of focusing on customer 8 50,0 8 50,0 4 management of human resource result 2 12,5 14 87,5 5 the result of student process and learning 16 100 0 0 6 finance 16 100 0 0 7 facilities and infrastructure 12 75,0 4 25,0 table 4. the test of the influence of variables with partial least square (pls) test no the influence of variables sample mean t-statistik complement 1 leadership to strategy planning 0.7423 15.8450 significant 2 strategy planning to human resource 0.3199 3.3465 significant 3 strategy planning to the learning process 0.2725 3.9500 significant 4 human resource to the learning process 0.0693 1.9940 significant 5 human resource to quality improvement with a competitive advantage 0.0570 1.1403 not significant 6 learning process to quality improvement with a competitive advantage 0.0900 8.9493 significant 7 information system to leadership 0,6947 22.0510 significant 8 information system to human resource 0.4193 4.4300 significant 9 information system to the learning process 0.5477 7.7140 significant 10 information system to quality improvement with competitive advantage 0.2186 13.9950 significant figure 1. quality development model of nursing education in the university of muhammadiyah towards competitive advantage discussion the output of this study was the quality development model of nursing education towards competitive advantage. the model emphasised the component process and result of leading indicators, strategy planning, and information systems. it was in line with the study conducted by teoman and ulengin (2016) which stated that leadership was the key to success in quality management. in addition, based on the study of gunasekaran, subramanian and papadopoulos (2017), the information technology also became a key role towards competitive advantage. in this model, the process components which directly influenced quality development the quality improvement of nursing education with competitive advantage human resource strategy planning leadership learning process information system quality improvement model of nursing education (abdul aziz alimul hidayat, et. al) 17 were the component of the learning process and operational management as well as an information system. the process components were significantly influenced by human resources, while human resources were influenced by strategy planning which was influenced by leadership. in addition, all of the process components were influenced by the information system. thus, the information system played a role in boosting quality development for every quality indicator (semuel, siagian and octavia, 2017). based on the findings of the model developed according to the higher education long term strategy (helps) 2003–2010 (dikti, 2004), to improve the quality of higher education and strengthen the nation's competitiveness required human resource management integrated with institutional management, and human resource management based on competence and performance (istanto, 2012). furthermore, the development of a model is directed to making the organisation into a customer-driven model based on a customer's needs and expectations towards competitive advantage, and the implementation of knowledge management through a knowledge sharing culture (abduljalal, toulson and tweed, 2013). it is consistent with the model strategies developed by kenichi ohmae with a model of a strategic triangle, known as model 3c (corporation, customer, and competitive), which states that in achieving competitive advantage an organisation must develop a strategic business-focused corporation, customer, and competitive base (ohmae, 1991). an organisation that wants to succeed and survive has to market what is required by the customer and remain in the competition; it needs to be superior to its competitors, and be able to create competitiveness by implementing a value creation strategy (hitt et al., 1999). kenichi ohmae states that strengthening the position of the strategy can be through the utilisation of human resources allocation, by using a relative advantage by finding the difference with competitors, using an aggressive strategic initiative to build an edge compared to other organisations, and using the strategy to innovate (ohmae, 1991). in winning the competition, the organisation also takes control of the management of intellectual assets; this is based on a model that can be developed in this research for the implementation of knowledge management through a knowledge sharing culture. the model is supported by ikujiro nonaka’s seci model that describes the life of the knowledge which undergoes a process described in a spiral shape, consisting of socialisation, externalisation, combination, and internalisation. the externalisation process is the change to explicit knowledge. the process of combination, utilising existing explicit knowledge that is implemented in another area. this process is very useful for developing skills and self-productivity. the internalisation process is changing the coming of inspiration of explicit knowledge as tacit knowledge. the socialisation process changes tacit knowledge into other tacit knowledge (sangkala, 2007; mulyanto, 2008). conclusion the profile of nursing education at the university of muhammadiyah in indonesia showed on average that it was established more than 10 years ago, with a b accreditation status and a level of competition in the program study in a city being from an average of more than three universities that are the main contenders. the model of quality improvement in the university of muhammadiyah towards competitive advantage is to emphasise the components process and outcome from indicators of leadership, strategy planning, focus on customer, human resource focus, the focus of the learning process, and information systems. the model components which directly affect quality improvement are the component of the learning process and operational management and information systems. process components are strongly influenced by human resources, and human resources are influenced by strategy planning, and strategic planning is influenced by leadership. quality improvement models can be used in courses that have the same indicator if you want to make universities have a competitive advantage, besides the results of research which can be developed to compile the application program to analyse the quality improvement of nursing education based electronics, to accelerate identification of the findings of the weak components of quality to be improved. jurnal ners vol. 12 no. 1 april 2017: 14-18 18 acknowledgements this research is funded by the ministry of research, technology, and higher education with leading universities research grant no. 010/sp2h/p/k7/km/2016. thanks to the kopertis vii east java for such funding and the leadership of the chairman of muhammadiyah universities in indonesia for research permits. refferences abdul-jalal, h., toulson, p. and tweed, d. (2013) ‘knowledge sharing success for sustaining organizational competitive advantage’, procedia economics and finance. elsevier b.v., 7(icebr), pp. 150–157. doi: 10.1016/s2212-5671(13)00229-3. altuntaş, s. and baykal, ü. (2017) ‘an analysis of alumni performance: a study of the quality of nursing education’. doi: 10.1016/j.nedt.2016.11.022. ban-pt (2012) hasil evaluasi status akreditasi program studi bidang kesehatan di jawa timur. dikti (2008) hasil evaluasi implementasi sistem penjaminan mutu internal perguruan tinggi 2008, strategy. jakarta. dikti, d. (2004) strategi jangka panjang pendidikan tinggi (helts 20032010) menuju sinergi kebijakan nasional. jakarta: departemen pendidikan nasional. frenk, j. et al. (2010) ‘health professionals for a new century: transforming education to strengthen health systems in an interdependent world’, lancet (london, england). jossey bass, san francisco, 376(9756), pp. 1923–58. doi: 10.1016/s0140-6736(10)61854-5. gunasekaran, a., subramanian, n. and papadopoulos, t. (2017) ‘information technology for competitive advantage within logistics and supply chains: a review’, transportation research part e: logistics and transportation review, 99, pp. 14–33. doi: 10.1016/j.tre.2016.12.008. hidayat, a.a.a., supriyanto, s. and nursalam, n. (2015) ‘model of quality management system using malcolm baldrige criteria in nursing education in surabaya’, jurnal ners, 10(1), p. 165. doi: 10.20473/jn.v10i12015.165174. hitt, m.a. et al. (1999) dynamic strategic resources: development, diffusion & integration. chichester, uk: john wiley & sons, inc. horton, r. et al. (2010) ‘a new epoch for health professionals’ education’, lancet (london, england). princeton university press, 376(9756), pp. 1875–7. doi: 10.1016/s01406736(10)62008-9. istanto, y. (2012) ‘pengaruh strategi keunggulan bersaing dan positioning terhadap kinerja’, buletin ekonomi, 8(2), pp. 124–135. kuspijadi and sudarso (2009) pengukuran kinerja fakultas teknik ubhara dengan menggunakan kriteria malcolm baldrige. mulyanto, a. (2008) implementasi knowledge management untuk meningkatkan kinerja perguruan tinggi. ist akprind, yogyakarta. ohmae, k. (1991) the mind of the strategist: the art of japanese business, mcgraw-hill. pepin, j. et al. (2017) ‘a nursing education research framework for transformative learning and interdependence of academia and practice ☆’, nurse education today, 52, pp. 50–52. doi: 10.1016/j.nedt.2017.02.001. sangkala (2007) knowladge managament; suatu pengantar memahami bagaimana organisasi mengelola pengetahuan sehingga menjadi organisasi yang unggul. jakarta: pt raja grafindo persada. semuel, h., siagian, h. and octavia, s. (2017) ‘the effect of leadership and innovation on differentiation strategy and company performance’, procedia – social and behavioral sciences, 237, pp. 1152–1159. doi: 10.1016/j.sbspro.2017.02.171. teoman, s. and ulengin, f. (2016) ‘the impact of management leadership on quality performance throughout a supply chain: an empirical study’, total quality management and business excellence. doi: 10.1080/14783363.2016.1266244. http://e-journal.unair.ac.id/jners | 185 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.21495 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the relationship between family harmony with stress, anxiety, and depression in adolescents heni dwi windarwati, amin aji budiman, renny nova, niken asih laras ati, and mira wahyu kusumawati school of nursing, faculty of medicine, universitas brawijaya abstract introduction: adolescents are a group vulnerable to mental health problems, including stress, anxiety, and depression. this study aimed to examine the interlink of a harmonious family with stress, anxiety, and depression in adolescents. methods: this study employed descriptive correlational design with crosssectional approach and examined 851 high school adolescents aged between 16-18 years who were recruited using a total sampling method from five high school in malang city. stress, anxiety and depression in adolescents was assessed employing the depression anxiety stress scale (dass 21), while, to assess family harmony, a questionnaire developed by the researcher was used. data were analyzed through descriptive statistics and bivariate tests using spearman rank correlation. results: it was revealed that 428 adolescents (50.3%) were male, 321 adolescents (37.7%) came from parents who worked privately, and 482 adolescents (56.6%) had their parents' social status above the minimum wage standard. eight hundred and two adolescents (94.2%) had harmonious families, while the remaining 49 adolescents (5.8%) had non-harmonious families. our study concluded that family harmony had a significant relationship with adolescent stress levels (p-value 0.013). on the other hand, the analysis showed that family harmony was not related to adolescents' anxiety (p-value 0.071) and depression level (p-value 0.13). a harmonious family makes children mentally healthy, able to adapt to the environment while a family that is not harmonious can trigger stress because conditions are not as expected, coupled with the burden of schoolwork, stressors from teachers and peers. conclusion: the results of the research showed that harmony in the family had a significant effect on stress in adolescents. therefore, it is necessary to provide education and counseling to the family to prevent fights in the family so that it can reduce the emergence of stress in adolescents. article history received: july 1, 2020 accepted: september 2, 2020 keywords adolescent; anxiety; depression; family harmony; stress contact heni dwi windarwati  henipsik.fk@ub.ac.id  school of nursing, faculty of medicine, universitas brawijaya cite this as: windarwati, h, d., budiman, a, a., nova, r., ati, n, a, l., kusumawati, m, w. (2020). the relationship between family harmony with stress, anxiety, and depression in adolescents. jurnal ners, 15(2). 185-193. doi:http://dx.doi.org/10.20473/jn.v15i2.21495 introduction mental health is a complex problem in society that requires synergistic and sustainable management (wuryaningsih, windarwati, dewi, deviantony, & hadi, 2018). mental health problems are also encountered in adolescents, in the forms of bullying, game or internet addiction, eating disorders (anorexia, bulimia), psychosis, drugs, suicide-self harm, and emotional disorders (e.g., anger, frustration, anxiety, depression) (who, 2019). teenagers also often experience stress due to bullying from peers at schools (rana et al., 2018). stress, anxiety, and depression in adolescents are caused by internal factors from within, cognitive, academic achievement, and external factors such as family or peer function (chi et al., 2020). gender is a major factor in causing depression in adolescents (liu et al., 2019). women have higher levels of depression than men because they have different hormones and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:henipsik.fk@ub.ac.id h. d. windarwati et al. 186 | pissn: 1858-3598  eissn: 2502-5791 quickly respond to stressors from family (sun et al., 2017). adolescents tend to experience anxiety due to the formation of self-identity, sensitivity to aspects of self-assessment, and self-compassion (gill et al., 2018). late teens are depressed because they are about to face graduation exams and go to college (liu et al., 2019). research has portrayed that the prevalence of mental health disorders among children and adolescents around the world has reached 13.4%, anxiety 6.5%, depression 2,6%, attention deficit hyperactivity disorder 3.4%, and other disorders 5.7% of 87.742 individuals in 27 countries (polanczyk et al., 2015). meanwhile, in turkey, as much as 13.9% of adolescents experienced anxiety (ercan et al., 2016). most of the psychiatric morbidity among adolescents in nigeria is caused by depression (oderinde et al., 2018). the results of a study conducted on school students with a mean age of 16 years found that the prevalence of depression, anxiety and stress was 65.53%, 80.85% and 47.02% respectively (sandal et al., 2017). based on data from the national institute of mental health (2017) in the united states, 13.3% of 3.2 million adolescents aged 12-17 have major depression (mental health information statistics, 2017). in indonesia, depression is more common in adolescents than adults as much as 50% and mostly occurs in women as much as 32% (brooks et al., 2019). socioeconomic factors of family, environment, peers, and family dysfunction are external factors related to stress, anxiety, and depression, where socioeconomic status is related to overall health conditions, including life satisfaction and happiness (guo et al., 2018; kezer & cemalcilar, 2020; leavey et al., 2020). also, gadget addiction and bullying are external factors of stress, anxiety, and depression because bullying causes psychological distress, aggressive behavior, hostility, and psychosomatic symptoms (hill et al., 2017; liu et al., 2020; zhao et al., 2020). bullying occurs due to experiences of bullying and a lack of parental affection during childhood, and it is more common among teenagers with stepfamilies (erika et al., 2017; fujikawa et al., 2018). every teenager faces stressors from family, school environment, peers, teachers, and lessons, but not all of them have good coping with adapting (zheng et al., 2016). parents who are not harmonious, family dysfunction, and conflict in the relationship between children and parents are significant stressors in the psychological development of adolescents (guo et al., 2018). family is a comfortable place to grow and develop for teenagers apart from school and peer groups (thariq, 2018). unhappy psychological experiences in the family during childhood lead to depression, low self-concept, and maladaptive coping in adolescents (hayward et al., 2020; wong et al., 2019). good coping and family support can increase self-esteem, a more optimistic view, and reduce stress, anxiety, and depression in adolescents (han et al., 2018; nursalam et al., 2017). based on the above factors, the family or parents have an attachment to the psychological resilience of children (liu et al., 2020). parents have the responsibility to monitor children's behavior and activities, especially in their teens, so as not to commit social deviations and be able to deal with stressors (ibnu et al., 2020). poor family parenting causes adolescents to experience internal conflicts, irritability, obsessiveness, frustration, and behavioral deviations (okaviani., 2018). adolescents who grow up in disharmonious families are more at risk of mental, anti-social, and emotional disorders (sas, nurdin, & bakar, 2018). several previous studies have discussed family harmony related to mental health problems in adolescents, such as depression, selfesteem and emotional maturity (artasari, 2017; budianti, 2015; rahmawati et al., 2015; witantri, 2018). however, the current research not only discusses the relationship between family harmony with depression but also stress and anxiety, especially in high school adolescents in indonesia. while theoretical research has found a possible relationship between family and adolescents' mental health problems, little attention has been geared to examining the interlink of a harmonious family with stress, anxiety, and depression in adolescents. therefore, the present study aimed to examine the association between family harmony with stress, anxiety, and depression in adolescents. materials and methods this study employed descriptive correlational design with cross-sectional approach. the population was 851 adolescents aged between 16-18 years in five high schools in malang city. the total sampling was used to recruit the participants. data were gathered using a pre-tested semi-structured questionnaire to determine the demographic details and family harmony of the participants during the period august 2019 to january 2020. harmony in the family was measured using a questionnaire developed by the researcher and filled out by adolescents. the self-reported questionnaire consisted of questions that ask whether adolescents feel that their families are harmonious, with a choice of harmonious and disharmonious answers. the harmony in the family questionnaire has passed the validity and reliability test (cronbach's alpha > 0.7). furthermore, the stress anxiety stress scale (dass-21), which was validated and translated into participants' national language (indonesian language), was used to determine the level of depression, anxiety, and stress in adolescents aged between 16-18 years. dass-21 was used to screen patients suffering from depression, anxiety, and stress in the community. the original 42-item dass of lovibond was changed to a shorter 21-item version. dass-21 is a well-established instrument for measuring depression, anxiety, and stress symptoms in clinical and non-clinical samples (antony et al., 1998; lovibond & lovibond, 1995). the dass-21 jurnal ners http://e-journal.unair.ac.id/jners | 187 questionnaire has passed the validity and reliability test (cronbach's alpha > 0.7). data were analyzed through descriptive statistics and bivariate tests using spearman rank correlation analysis. in this study, p-value <0.05 was considered statistically significant. this study has been approved by the research ethics committee of politeknik kesehatan malang (reg.no.335/kepkpolkesma/2019), and written consent was obtained from all participants. results it was revealed that almost 50% of the adolescents who took part in the study were female (49.7%). the majority of their parents' backgrounds work as private employees (37.7%) with the social and economic status mostly above the minimum wage standard (56.6%). most of the participants come from harmonious families (94.2%), with stress levels of table 1. adolescents’ demography information (n=851) characteristics n % gender female 423 49.7 male 428 50.3 parents' occupation not any 9 1.1 private employee 321 37.7 farmer 88 10.3 civil servant 157 18.4 merchant 182 21.4 others 94 11.0 socioeconomic status below minimum wage standard 369 43.4 above minimum wage standard 482 56.6 family harmony harmonious 802 94.2 not harmonious 49 5.8 stress very high 64 7.5 high 92 10.8 medium 129 15.2 light 89 10.5 normal 477 56.1 anxiety level very high 307 36.1 high 99 11.6 medium 117 13.7 light 97 11.4 normal 231 27.1 depression level very high 187 22 high 107 12.6 medium 198 23.3 light 115 13.5 normal 244 28.7 table 2. the relationship between stress, anxiety, and depression levels with family harmony family harmony very high high medium low normal total p r n % n % n % n % n % n % stress not harmonious 5 0.6 6 0.7 15 1.8 4 0.5 19 2.2 49 5.8 0.013* 0.086 harmonious 59 6.9 86 10.1 114 13.4 85 10 458 53.8 802 94.2 anxiety not harmonious 20 2.4 5 0.6 12 1.4 8 0.9 4 0.5 49 5.8 0.071 0.062 harmonious 287 33.7 94 11 105 12.3 89 10.5 227 26.7 802 94.2 depression not harmonious 13 1.5 5 0.6 16 1.9 7 0.8 8 0.9 49 5.8 0.13 0.052 harmonious 174 20.4 102 12 182 21.4 108 12.7 236 27.7 802 94.2 h. d. windarwati et al. 188 | pissn: 1858-3598  eissn: 2502-5791 most adolescents at normal levels (56.1%), anxiety levels mostly very high (36.1%), and depression levels of 28.7% of adolescents at normal levels [table 1]. association between harmony in the family with stress, anxiety, and depression table 2 shows a significant relationship between harmony in the family and stress levels in adolescents, as indicated by a p-value of 0.013 (pvalue <α). the correlation coefficient of 0.086 indicated a positive direction with a feeble relationship strength between variables. this showed that the more harmonious the relationship in the family was, the lower the stress level in adolescents. the results of further analysis related to stress levels and harmony in the family showed that most adolescents who had stress levels in the normal category had harmonious families (53.8%). meanwhile, only 1.3% of adolescents had unharmonious families and had high to very highstress levels. there was no significant relationship between harmony in the family and the level of anxiety in adolescents, as indicated by a p-value of 0.071 (pvalue > α). the correlation coefficient of 0.062 indicated a positive direction with a very weak relationship strength between variables. this showed that the more harmonious the relationship in the family was, the lower the level of anxiety in adolescents even though the decrease was not significant. the results of cross-tabulation between anxiety and harmony in the family indicated that the level of anxiety in adolescents with harmonious families and families who were not harmonious was 33.7% and 2.4%, respectively, and mostly in the anxiety category very high when compared to other classes. there was no significant relationship between harmony in the family and the level of depression in adolescents, as indicated by a p-value of 0.13 (p-value > α). the correlation coefficient of 0.052 indicates a positive direction with a very weak relationship strength between variables. this showed that the more harmonious the relationship in the family was, the lower the level of depression in adolescents, even though the decrease was not significant. the level of adolescent depression in the cross-tabulation showed that most of the adolescents having normal level of depression had a harmonious family (27.7%), while the adolescents with a non-harmonious family had a most moderate depression level (1.9%). discussion this study documented that most of the adolescents who participated in the study were female. this may be the reason for the high levels of anxiety and depression in this study. female adolescents respond faster to psychological changes and are more sensitive to self-assessment. theoretically, women experience hormonal changes, exposure to stressors, coping abilities, and cognitive abilities that are different from men (liu et al., 2019). men are better able to manage stressors, although they may not obtain much social support in dealing with the problem (sun et al., 2017; tyas, 2014). in addition, female adolescents also show a stronger interpersonal orientation and are more responsive to relationships than male adolescents (shi et al., 2017). our study also portrayed parents’ occupation as a large private employee with a socioeconomic status of above the minimum wage standard. in this study, the stress level of adolescents was mostly normal; this can be related to the socioeconomic status of the family. families with good socioeconomic conditions reduce symptoms of depression and stress in adolescents (bae, 2020). this is influenced by the mother's caring behavior (xu et al., 2019). lowincome parents do not care and behave rudely so that their children experience internal problems (bøe et al., 2017). in addition, physical health problems, selfconfidence, and motivation to go to school are lacking (zhou et al., 2018). family harmony affects adolescent mental health development, self-esteem formation, social behavior, and facing stigma from society. previous research carried out by wang et al. (2020) declared that family is an essential factor for mental development and higher academic expectations. family harmony is described by the creation of religious life, understanding, openness, compassion, and mutual trust between children and parents (sas, nurdin, & bakar, 2018). an uncomfortable, unpleasant family atmosphere and unfavorable family relationships can have a psychological impact on children in adolescence (mulyadi, 2017). psychological problems of adolescents with single parents (e.g., broken home) tend to occur due to lack of attention and affection. other factors, such as busy parents, low socioeconomic status, abusive behavior, and negative stigma from the environment, may contribute to adolescents' psychological problems (ghani et al., 2014). thus, it takes positive support from parents to reduce the psychological pressure of adolescents (joyce & liamputtong, 2017). the psychological wellbeing of adolescents is created when there are harmonious relationships and excellent communication within the family (tillman & miller, 2017). harmony in the family may be related to the high socioeconomic status of adolescents in this study as well as to the stress level of adolescents. stress is an emotional problem that often occurs in adolescents due to interpersonal stressors from relationships with family, social environment, and problems at school. according to widayati et al. (2019), stress is a form of vulnerable emotional disorder, which tends to occur in high school students. female teenagers experience stress since they worry too much when facing problems, while males tend to be aggressive (masdar et al., 2016). this behavior is related to adolescent coping abilities. problem focus coping is one of the strategies that teenagers can do to reduce stressors (nurlaila, 2019). jurnal ners http://e-journal.unair.ac.id/jners | 189 anxiety is a psychopathology that occurs in adolescents with physical and psychological responses to internal and external pressure (inchley et al., 2011; wang et al., 2020). internal pressure that often occurs in adolescents is low self-esteem, negative self-assessment, followed by seeking negative feedback from the environment, which triggers anxiety (sowislo & orth, 2013). in this study, most adolescents had normal stress levels related to economic status and harmony in the family. however, the unique thing is that teenagers have a very high category of anxiety. this may be due to other factors not examined in this study. depression is related to gender and anxiety. previous research has reported that women are more at risk of experiencing depression because they tend to be sensitive to stressors, vulnerable to selfcompassion, and self-criticism (bluth & blanton, 2015; sun et al., 2017). teenagers face multiple demands for final exams and their future, which can lead to depression (liu et al., 2019). meanwhile, excellent self-evaluation skills and accepting social criticism can minimize anxiety and reduce depression (gill et al., 2018). however, when the adolescents' self-concept is not good because the psychological experiences of childhood are less enjoyable, it can lead to depression (wong et al., 2019). stressors that cause depression also arise from the school environment and associations in the form of learning loads, social demands, hostility, rejection between friends, disappointment, and intimidating actions (anyan et al., 2018; zhao et al., 2020). stress in adolescents occurs due to puberty; there is a peak of growth and development, both physically and mentally (miller & prinstein, 2019). stress triggers aggressive actions and social behavior deviations, so it is essential to provide support to adolescents. lack of support from family and friends when dealing with stressors can trigger stress. every teenager has different coping strategies in responding to the stressors that arise. stress management using proper coping can help reduce the level of stress experienced (ramadhani & hendarti, 2017). stress management skills are also influenced by the psychological wellbeing of children in the family (dewi & soekandar, 2019). the results in this study indicated that most adolescents having stress in the normal category had harmonious families. a harmonious family makes children mentally healthy, able to adapt to the environment, and show filial piety to parents (filial piety) (bourassa et al., 2015; chen, 2014; meggiolaro & ongaro, 2014). a family that is not harmonious can trigger stress because conditions are not as expected, coupled with the burden of school work, stressors from teachers and peers (duarte et al., 2019). this suppresses the mind of adolescents and is often not expressed so that the stressor they feel is not reduced (kim, bassett, so, & voisin, 2019). it was found that harmony in the family is not related to the level of anxiety and depression in adolescents. although adolescents are found to freely choose their career pathways and future trajectories, parental support still holds a firm factor for such options. feeling worried about the future, hopes, and ambiguous desires can cause anxiety. anxiety per se is experienced by many individuals, especially women, which affects their survival, weakness, and helplessness (craske et al., 2017). adolescents with families who are not harmonious, but who are not anxious can be caused by good social support and coping skills. a recent study by wang et al. (2020) revealed that parents who are not harmonious can still reduce feelings of loneliness, provide affection by accompanying children's activities, pay attention, and fulfill their needs so that children do not feel anxious. adolescents who experience anxiety or depression tend to face academic difficulties, dropping out of school, maladaptive social relationships, drug abuse, and suicide (ingul & nordahl, 2013). therefore, if the conditions of the family are not harmonious, single parents still have to try to meet the physical and psychological needs of their children, and the environment must reduce the negative stigma of children with broken homes (ghani et al., 2014). adolescence is a transitional period that experiences many new challenges (guo et al., 2018). higher education levels and academic stress can play an important role in determining adolescent mental health (chellamuthu & kadhiravan, 2017). depression is a mental health problem in adolescents that is a response to the loss of parents, siblings, friends, or the end of a relationship with a lover (townsend, 2017). in this regard, adolescents with an unharmonious family are less able to communicate their emotions and thoughts effectively, and they also lack family support, which leads to anxiety and depression (kleiboer et al., 2015). a family that is not harmonious causes adolescents to lack communication skills, often feel blamed, and tend to experience loneliness (shi et al., 2017; wang et al., 2020). however, when adolescents can communicate and have good relationships, and their parents are willing to facilitate it, depression will not occur. this is because an adolescent has a basic need to give and receive a positive response to relationships with others (beata et al., 2018). the results of the correlation between anxiety and depression with family harmony in this study showed insignificant value. the insignificant results in this study may be related to the large differences in the distribution of adolescents with harmonious and disharmonious families. the advantage of this research is that it was carried out on a population of adolescents with almost the same age, in addition to which this research was also carried out in a large number of samples. however, this study has limitations; the family harmony questionnaire used in this study is a self-reported questionnaire that reveals youth perspectives on family harmony so that it may not reflect the condition of the family as a whole. however, the results showed that stress in adolescents was significantly related to family harmony. stress in everyday life is often ignored, even h. d. windarwati et al. 190 | pissn: 1858-3598  eissn: 2502-5791 though stress can develop into anxiety and depression and can be very detrimental to mental health (khan & khan, 2017). therefore, to prevent stressful conditions in adolescents, it is necessary to promote mental health by involving teenagers’ families. conclusion our study has attempted to uncover the relationship between family and mental health problems in adolescents, such as stress, anxiety, and depression. the results of the analysis showed that harmony in the family had a significant effect on stress. meanwhile, anxiety and depression in adolescents did not have a significant relationship with family harmony. although it is not significant, it does not mean that family harmony is not a neglected thing in the handling of anxiety and depression problems in adolescents. stress in adolescents should be addressed through early detection and promotion of mental health. mental health promotion activities need to be carried out to prevent increasing stress, anxiety, and depression in adolescents. therefore, it is necessary to provide education and counseling to the family to prevent fights in the family so that it can reduce the emergence of stress in adolescents. families also need to improve the relationship between parents and adolescents so that they know better the mental health conditions of adolescents. it is also recommended to explore more deeply about family harmony from the point of view of all family members and broaden the identification of factors contributing to mental health problems through more extensive studies to explore various aspects of mental health in adolescents. references antony, m. m., cox, b. j., enns, m. w., bieling, p. j., & swinson, r. p. (1998). psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample. psychological assessment, 10(2), 176–181. https://doi.org/10.1037/1040-3590.10.2.176 anyan, f., bizumic, b., & hjemdal, o. (2018). specificity in mediated pathways by anxiety symptoms linking adolescent stress profiles to depressive symptoms: results of a moderated mediation approach. journal of affective disorders, 228(december 2017), 109–117. https://doi.org/10.1016/j.jad.2017.12.011 artasari, d. n. (2017). hubungan antara keharmonisan keluarga dengan kematangan emosi pada siswa sma diponegoro tumpang [universitas malik ibrahim malang]. https://doi.org/10.1016/j.sbspro.2015.04.758 bae, s. m. (2020). the relationship between social capital, acculturative stress and depressive symptoms in multicultural adolescents: verification using multivariate latent growth modeling. international journal of intercultural relations, 74(february 2019), 127–135. https://doi.org/10.1016/j.ijintrel.2019.11.007 beata, m. d. r., rhodes, s., vasilopoulou, e., & hutton, p. (2018). loneliness in psychosis: a metaanalytical review. schizophrenia bulletin, 44(1), 114–125. https://doi.org/10.1093/schbul/sbx036 bluth, k., & blanton, p. w. (2015). the influence of self-compassion on emotional well-being among early and older adolescent males and females. journal of positive psychology, 10(3), 219–230. https://doi.org/10.1080/17439760.2014.9369 67 bøe, t., skogen, j. c., sivertsen, b., hysing, m., petrie, k. j., dearing, e., & zachrisson, h. d. (2017). economic volatility in childhood and subsequent adolescent mental health problems: a longitudinal population-based study of adolescents. bmj open, 7(9). https://doi.org/10.1136/bmjopen-2017017030 bourassa, k. j., sbarra, d. a., & whisman, m. a. (2015). women in very low quality marriages gain life satisfaction following divorce. journal of family psychology, 29(3), 490–499. https://doi.org/10.1037/fam0000075 brooks, h., irmansyah, i., lovell, k., savitri, i., utomo, b., prawira, b., iskandar, l., renwick, l., pedley, r., kusumayati, a., & bee, p. (2019). improving mental health literacy among young people aged 11-15 years in java, indonesia: codevelopment and feasibility testing of a culturally-appropriate, user-centred resource (impetus) a study protocol. bmc health services research, 19(1), 1–9. https://doi.org/10.1186/s12913-019-4328-2 budianti, a. k. (2015). hubungan antara keharmonisan keluarga dengan harga diri pada remaja. universitas muhammadiyah surakarta. surakarta. chellamuthu, s., & kadhiravan, d. (2017). academic stress and mental health among high school students. indian journal of applied research, 7(5), 404–406. chen, w. w. (2014). the relationship between perceived parenting style, filial piety, and life satisfaction in hong kong. journal of family psychology, 28(3), 308–314. https://doi.org/10.1037/a0036819 chi, x., liu, x., huang, q., huang, l., zhang, p., & chen, x. (2020). depressive symptoms among junior high school students in southern china: prevalence, changes, and psychosocial correlates. journal of affective disorders, 274(october 2019), 1191–1200. https://doi.org/10.1016/j.jad.2020.05.034 craske, m. g., stein, m. b., eley, t. c., milad, m. r., holmes, a., rapee, r. m., & wittchen, h. u. (2017). anxiety disorders. nature reviews disease primers, 3. https://doi.org/10.1038/nrdp.2017.24 jurnal ners http://e-journal.unair.ac.id/jners | 191 dewi, kartika sari; soekandar, a. (2019). kesejahteraan anak dan remaja pada keluarga bercerai di indonesia : review naratif. https://jurnalwacana.psikologi.fk.uns.ac.id/, vol 11, no. https://doi.org/https://doi.org/10.13057/wac ana.v11i1.135 duarte, t. a., paulino, s., almeida, c., gomes, h. s., santos, n., & gouveia-pereira, m. (2019). selfharm as a predisposition for suicide attempts: a study of adolescents’ deliberate self-harm, suicidal ideation, and suicide attempts. psychiatry research, 287. https://doi.org/10.1016/j.psychres.2019.1125 53 ercan, e. s., bilaç, ö., uysal özaslan, t., & akyol ardic, u. (2016). prevalence of psychiatric disorders among turkish children: the effects of impairment and sociodemographic correlates. child psychiatry and human development, 47(1), 35–42. https://doi.org/10.1007/s10578-0150541-3 erika, k. a., pertiwi, d. a., & seniwati, t. (2017). bullying behaviour of adolescents based on gender, gang and family. jurnal ners, vol 12, no, p.126-132. fujikawa, s., ando, s., nishida, a., usami, s., koike, s., yamasaki, s., morimoto, y., toriyama, r., kanata, s., sugimoto, n., sasaki, t., furukawa, t. a., hiraiwa-hasegawa, m., & kasai, k. (2018). disciplinary slapping is associated with bullying involvement regardless of warm parenting in early adolescence. journal of adolescence, 68(december 2017), 207–216. https://doi.org/10.1016/j.adolescence.2018.0 7.018 ghani, f. b. a., roeswardi, s. i. bt, & aziz, a. bt a. (2014). parenting styles and their relation to teenagers’ personality profile in single mother families: a case study. procedia social and behavioral sciences, 114, 766–770. https://doi.org/10.1016/j.sbspro.2013.12.782 gill, c., watson, l., williams, c., & chan, s. w. y. (2018). social anxiety and self-compassion in adolescents. journal of adolescence, 69(october), 163–174. https://doi.org/10.1016/j.adolescence.2018.1 0.004 guo, l., tian, l., & scott huebner, e. (2018). family dysfunction and anxiety in adolescents: a moderated mediation model of self-esteem and perceived school stress. journal of school psychology, 69(january), 16–27. https://doi.org/10.1016/j.jsp.2018.04.002 han, l., zhao, s. y., pan, x. y., & liao, c. j. (2018). the impact of students with left-behind experiences on childhood: the relationship between negative life events and depression among college students in china. international journal of social psychiatry, 64(1), 56–62. https://doi.org/10.1177/0020764017739332 hayward, l. e., vartanian, l. r., kwok, c., & newby, j. m. (2020). how might childhood adversity predict adult psychological distress? applying the identity disruption model to understanding depression and anxiety disorders. journal of affective disorders, 265(november 2019), 112– 119. https://doi.org/10.1016/j.jad.2020.01.036 hill, r. m., mellick, w., temple, j. r., & sharp, c. (2017). the role of bullying in depressive symptoms from adolescence to emerging adulthood: a growth mixture model. journal of affective disorders, 207, 1–8. https://doi.org/10.1016/j.jad.2016.09.007 ibnu, i. f., wahjuni, c. u., & devy, s. r. (2020). narrative stories of high risk sexual behaviors among adolescents in makassar city. journal of public health research, 9(2), 156–159. https://doi.org/10.4081/jphr.2020.1830 inchley, j., kirby, j., & currie, c. (2011). longitudinal changes in physical self-perceptions and associations withphysical activity during adolescence. pediatric exercise science, 23(2), 237–249. https://doi.org/10.1123/pes.23.2.237 ingul, j. m., & nordahl, h. m. (2013). anxiety as a risk factor for school absenteeism: what differentiates anxious school attenders from non-attenders? annals of general psychiatry, 12(1), 1–9. https://doi.org/10.1186/1744859x-12-25 joyce, l., & liamputtong, p. (2017). acculturation stress and social support for young refugees in regional areas. children and youth services review, 77(march), 18–26. https://doi.org/10.1016/j.childyouth.2017.03. 016 kezer, m., & cemalcilar, z. (2020). a comprehensive investigation of associations of objective and subjective socioeconomic status with perceived health and subjective well-being. international review of social psychology, 33(1), 10. https://doi.org/10.5334/irsp.364 khan, s., & khan, r. a. (2017). chronic stress leads to anxiety and depression. annals of psychiatry and mental health, 5(1), 1091–1095. kim, d. h., bassett, s. m., so, s., & voisin, d. r. (2019). family stress and youth mental health problems: self-efficacy and future orientation mediation. american journal of orthopsychiatry, 89(2), 125. https://doi.org/https://doi.org/10.1037/ort0 000371. kleiboer, a., donker, t., seekles, w., van straten, a., riper, h., & cuijpers, p. (2015). a randomized controlled trial on the role of support in internet-based problem solving therapy for depression and anxiety. behaviour research and therapy, 72, 63–71. https://doi.org/10.1016/j.brat.2015.06.013 leavey, g., rosato, m., harding, s., corry, d., divin, n., & breslin, g. (2020). adolescent mental health problems, suicidality and seeking help from h. d. windarwati et al. 192 | pissn: 1858-3598  eissn: 2502-5791 general practice: a cross-sectional study (northern ireland schools and wellbeing study). journal of affective disorders, 274(april), 535–544. https://doi.org/10.1016/j.jad.2020.05.083 liu, h., liu, l., & jin, x. (2020). the impact of parental remote migration and parent-child relation types on the psychological resilience of rural left-behind children in china. liu, q. q., yang, x. j., hu, y. t., zhang, c. y., & nie, y. g. (2020). how and when is family dysfunction associated with adolescent mobile phone addiction? testing a moderated mediation model. children and youth services review, 111(october 2019), 104827. https://doi.org/10.1016/j.childyouth.2020.10 4827 liu, w. j., zhou, l., wang, x. q., yang, b. x., wang, y., & jiang, j. f. (2019). mediating role of resilience in relationship between negative life events and depression among chinese adolescents. archives of psychiatric nursing, 33(6), 116–122. https://doi.org/10.1016/j.apnu.2019.10.004 lovibond, p., & lovibond, s. (1995). manual for the depression anxiety stress scales (2nd ed.). psychology foundation. masdar, h., saputri, p. a., rosdiana, d., chandra, f., & darmawi, d. (2016). depresi, ansietas dan stres serta hubungannya dengan obesitas pada remaja. jurnal gizi klinik indonesia, 12(4), 138. https://doi.org/10.22146/ijcn.23021 meggiolaro, s., & ongaro, f. (2014). family contexts and adolescents’ emotional status. journal of youth studies, 17(10), 1306–1329. https://doi.org/10.1080/13676261.2014.9182 46 menthal health information statistics. (2017). national institute of mental health. major depression. miller, a. b., & prinstein, m. j. (2019). adolescent suicide as a failure of acute stress-response systems. annual review of clinical psychology, 15(1), 425–450. https://doi.org/10.1146/annurev-clinpsy050718-095625 mulyadi, y. b. (2017). hubungan persepsi keharmonisan keluarga dan self esteem dengan kenakalan remaja. 2(1), 22–32. nurlaila, n. (2019). management stres, coping stres pada remaja dan dampak pada pembangunan ekonomi daerah kota ternate. cakrawala management business journal, 2(1), 185. https://doi.org/10.30862/cm-bj.v2i1.13 nursalam, n., armini, n. k. a., & fauziningtyas, r. (2017). family social support reduces post judegemental stress in teenagers. jurnal ners, 4(2), 182–189. oderinde, k. o., dada, m. u., ogun, o. c., awunor, n. s., awunor, n. s., ahmed, h. k., tsuung, a. b., tanko, s. t., & yusuff, a. a. (2018). prevalence and predictors of depression among adolescents in ido ekiti, south west nigeria. international journal of clinical medicine, 09(03), 187–202. https://doi.org/10.4236/ijcm.2018.93017 okaviani., d., l. (2018). keharmonisan keluarga dan kenakalan remajapada siswa kelas 9 mts negeri 2 palembang. psikis: jurnal psikologi islami, vol. 4no. https://doi.org/https://doi.org/10.19109/psi kis.v4i1.2027 polanczyk, g. v., salum, g. a., sugaya, l. s., caye, a., & rohde, l. a. (2015). annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. journal of child psychology and psychiatry and allied disciplines, 56(3), 345–365. https://doi.org/10.1111/jcpp.12381 rahmawati, l., arneliwati, & elita, v. (2015). hubungan dukungan keluarga dengan harga diri remaja di lembaga pemasyarakatan. jom, 2(2), 1221–1230. ramadhani, ah., hendarti, l. (2017). hubungan jenis kelamin dengan tingkat stres pada remaja siswa sma di kota kediri tahun 2017. jurnal keperawatan muhammadiyah. rana, m., gupta, m., malhi, p., grover, s., & kaur, m. (2018). effectiveness of a multicomponent school based intervention to reduce bullying among adolescents in chandigarh, north india: a quasi-experimental study protocol. journal of public health research, 7(1), 50–55. https://doi.org/10.4081/jphr.2018.1304 sandal, r. k., goel, n. k., sharma, m. k., bakshi, r. k., singh, n., & kumar, d. (2017). prevalence of depression, anxiety and stress among school going adolescent in chandigarh. journal of family medicine and primary care, 6(2), 405– 410. https://doi.org/10.4103/22494863.219988 sas, i., said, n., & bakar, a. (2018). hubungan antara keharmonisan keluarga dengan kestabilan emosi remaja. jurnal ilmiah mahasiswa bimbingan dan konseling, volume 3 n, hal 6875. shi, x., wang, j., & zou, h. (2017). family functioning and internet addiction among chinese adolescents: the mediating roles of self-esteem and loneliness. computers in human behavior, 76, 201–210. https://doi.org/10.1016/j.chb.2017.07.028 sowislo, j. f., & orth, u. (2013). does low self-esteem predict depression and anxiety? a metaanalysis of longitudinal studies. psychological bulletin, 139(1), 213–240. https://doi.org/10.1037/a0028931 sun, x. jun, niu, g. feng, you, z. qi, zhou, z. kui, & tang, y. (2017). gender, negative life events and coping on different stages of depression severity: a cross-sectional study among chinese university students. journal of affective disorders, 209(september 2016), 177–181. https://doi.org/10.1016/j.jad.2016.11.025 thariq, m. (2018). interpersonal communication role for self-concept of children and families. jurnal ners http://e-journal.unair.ac.id/jners | 193 budapest international research and critics institute (birci-journal) : humanities and social sciences, 1(2), 181–194. https://doi.org/10.33258/birci.v1i2.21 tillman, k. h., & miller, b. (2017). the role of family relationships in the psychological wellbeing of interracially dating adolescents. social science research, 65(2016), 240–252. https://doi.org/10.1016/j.ssresearch.2016.11. 001 townsend, m. c. a. m., k. i. (2017). psychiatric mental health nursing: concepts of care in evidencebased practice,philadelphia, f.a. davis company. f.a. davis company. tyas, h. a. (2014). perbedaan kebutuhan dukungan sosialantara laki-laki dan perempuan pada pasien penderitagagal ginjal di rsud dr. moewardi. universitas muhammadiyah surakarta. surakarta. wang, j.-l., rost, d. h., qiao, r.-j., & monk, r. (2020). academic stress and smartphone dependence among chinese adolescents: a moderated mediation model. children and youth services review, 105029. https://doi.org/10.1016/j.childyouth.2020.10 5029 who. (2019). adolescent menthal health. newsroom, fact sheet, detail. retrieved from: widayati, r. w., syafitri, e. n., & wiyani, c. (2019). managemen stress sebagai upaya meminimalkan resiko bencana sosial pada siswa di smp negeri 2 stress management as an effort to minimize social disaster risk in students at middle school ngemplak. 205–210. witantri, a. (2018). hubungan antara persepsi keharmonisan keluarga, penerimaan diri dengan depresi remaja perempuan. universitas muhammadiyah surakarta. surakarta. wong, a. e., dirghangi, s. r., & hart, s. r. (2019). selfconcept clarity mediates the effects of adverse childhood experiences on adult suicide behavior, depression, loneliness, perceived stress, and life distress. self and identity, 18(3), 247–266. https://doi.org/10.1080/15298868.2018.1439 096 wuryaningsih, e w., windarwati, hd., dewi, ei., deviantony, f., hadi, e. (2018). keperawatan kesehatan jiwa. percetakaan & penerbitan universitas jember. xu, f., cui, w., xing, t., & parkinson, m. (2019). family socioeconomic status and adolescent depressive symptoms in a chinese lowand middleincome sample: the indirect effects of maternal care and adolescent sense of coherence. frontiers in psychology, 10(apr), 1– 9. https://doi.org/10.3389/fpsyg.2019.00819 zhao, y., zhao, y., lee, y. t., & chen, l. (2020). cumulative interpersonal relationship risk and resilience models for bullying victimization and depression in adolescents. personality and individual differences, 155(november). https://doi.org/10.1016/j.paid.2019.109706 zheng, y., rijsdijk, f., pingault, j. b., mcmahon, r. j., & unger, j. b. (2016). developmental changes in genetic and environmental influences on chinese child and adolescent anxiety and depression. psychological medicine, 46(9), 1829–1838. https://doi.org/10.1017/s003329171600031 3 zhou, q., fan, l., & yin, z. (2018). association between family socioeconomic status and depressive symptoms among chinese adolescents: evidence from a national household survey. psychiatry research, 259(121), 81–88. https://doi.org/10.1016/j.psychres.2017.09.0 72 authors index volume 15 nomor 2 october 2020 abegonia, alpha issa christianne, 222 mahathir, mahathir, 126 amaliyah, eli, 173 mahfudloh, hanik, 162 aprizal, angie, 194 mediarti, devi, 142 arifin, hidayat, 142 mulawardhana, pungky, 208 armini, ni ketut alit, 214 mulyati, mulyati, 173 ati, niken asih laras, 185 munir, miftahul, 228 azizah, nurul, 162 nova, renny, 185 bacason, louverille, 222 pangastuti, heny, 199 bacason, sillmark, 222 permatasari, henny, 126 budiman, amin aji, 185 priharjo, robert, 199 dasuki, djaswadi, 135 puraya, amaraporn, 118 dewi, ni komang ayu adnya, 148 putra, made mahaguna, 167 djojo, achmad, 194 putri, verantika setya, 178 ervandi, yogi, 194 riani, efi, 194 handayani, samsriyaningsih, 208 rosnani, rosnani, 142 handiyani, hanny, 194 rosyidah, rafhani, 162 hapsari, elsi dwi, 199 sandy, winnellia fridina, 135 hariyati, rr tutik sri, 194 saputra, kadek, 148 hasan, muhammad kamil che, 157 sari, ni putu wulan purnama, 167 hayati, elli nur, 135 suhariyanto, suhariyanto, 135, 194 hidayati, nurul, 214 suni, arsad, 194 ibrahim, nor marini, 157 supremo, arlene, 222 ismail, muhamad al muizz, 157 thojampa, somsak, 118 izza, alifina, 208 tristiana, rr dian, 178 jaisopha, srisupha, 118 walvri, sepni, 194 krisnawati, komang menik sri, 113 wiarsih, wiwin, 126 kusumawati, mira wahyu, 185 windarwati, heni dwi, 185 kusumaningrum, tiyas, 214 wulaningsih, indah, 199 yanti, ni putu emy darma, 113, 148 yuniar, lily, 194 yusuf, ah, 178 subject index volume 15 nomor 2 october 2020 a active phase, 162 adherence, 167 adolescent,185 aged, 222 anxiety, 185 b behavior, 167 c cervical cancer, 208 community empowerment, 173 community health nursing, 118 d depression, 185 demographic characteristics, 113 diabetes foot care, 142 diabetes mellitus, 142 disaster, 222 domestic violence, 135 f family care, 222 family harmony, 185 g gestational diabetes mellitus, 199 glycemic control, 142 guide module, 194 h health, 214 health education, 173 health literacy, 194 head of nurse, 194 hegu li, 4 acupressure, 162 hiv knowledge, 126 k knowledge, 10, 28, 87 l labor pain intensity, 162 learning outcomes, 118 life experience, 199 m management, 157 maternal role attainment, 199 moral sensitivity, 113 n natural calamity, 222 non communicable diseases, 228 nurse, 113 nurses, 157 nursing service quality, 148 nursing students, 113, 178 nutritional, 214 nutrition rehabilitation, 173 p pacemaker, 157 patient satisfaction, 148 people living with hiv, 126 peplau’s model, 194 postpartum depression, 135 practicum, 118 pregnant, 214 prevention, 142 psychosocial problems, 178 q qualitative study, 126 quality of life, 167 quranic recital, 162 r risk factors for death, 228 s screening, 178 self-awareness, 178 smoking, 194 social relations, 222 stress, 185 stunting, 173 t thai qualifications frameworks for higher education (tqf: hed), 118 tuberculosis, 167 transcultural, 214 v visual inspection with acetic acid, 208 w women, 135, 214 women of childbearing age, 208 5 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of: ▪ a highly respected journal in the nursing field. ▪ it is indexed in major databases: science and technology index (sinta), indonesian publication index (ipi), google scholar, bielefeld academic search engine (base), (doaj), worldcat, indonesia onesearch, ebsco, pkp index, index copernicus, isjd, asean citation index ▪ rapid initial screening for suitability and editorial interest. jurnal ners has been accredited by the ministry of science, research, technology and higher education of indonesia since 2010. ii. focus and scope the scope of this journal includes studies that intend to examine and understand nursing health care interventions and health policies which utilize advanced nursing research. the journal also committed to improve the high-quality research by publishing analytic techniques, measures, and research methods not exception to systematic review papers. policy concerns of this journal are as follows: fundamentals of nursing, management in nursing, medical-surgical nursing, critical care nursing, emergency and trauma nursing, oncology nursing, community health nursing, occupational health nursing, mental health nursing, holistic nursing, geriatric nursing, family nursing, maternity nursing, women's health nursing, pediatric nursing, education in nursing, nursing policies, legal nursing, advanced practice nursing, and nursing informatics please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. author information pack update: march 5, 2020 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing https://drive.google.com/file/d/0b5ormcrmctnwq0dix2dictffdlk/view?usp=sharing 6 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam m.nurs. (hons), (scopus id: 56660628500; h-index: 4); faculty of nursing, universitas airlangga, indonesia international advisory board reviewers 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740; h-index: 13); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200; h-index: 10); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, (scopus id: 8293647300; h-index: 12); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172; h-index: 2); college of nursing, university of the philippines manila, philippines 5. dr. nicola cornally, (scopus id: 36982904800; h-index: 13); school of nursing and midwifery, university college cork, ireland 6. dr. david pickles, (scopus id: 57190150026; h-index: 5); college of nursing & health sciences, flinders university, south australia, australia 7. dr. farhan alshammari, (scopus id: 57192298773; h-index: 3); college of nursing, university of hail, saudi arabia 8. dr. patricia leahy-warren, (scopus id: 55954181800; h-index: 11); school of nursing and midwifery, university college cork, ireland 9. dr. wendy abigail, (scopus id: 24467540600; h-index: 3); school of nursing and midwifery, flinders university, australia 10. dr. chong mei chan, (scopus id: 57189591887; h-index: 2); dept. of nursing faculty of health science, university of malaya, malaysia 11. dr. sonia reisenhofer, (scopus id: 16310818100; h-index: 4); school of nursing and midwifery, la trobe university, australia, australia editor: 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100; h-index: 3); faculty of nursing, universitas airlangga, indonesia 2. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756; h-index: 1); faculty of nursing, universitas airlangga, indonesia, indonesia 3. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 4. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); faculty of nursing, universitas airlangga, indonesia javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/454') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3472') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3469') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3098') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3458') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3784') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3783') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3708') 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faculty of nursing, universitas airlangga, indonesia 2. masunatul ubudiyah, faculty of nursing, universitas airlangga, indonesia 3. dluha maf'ula, faculty of nursing,. universitas airlangga, indonesia 4. rifky octavia pradipta, s.kep., ns, faculty of nursing, universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., (scopus id: 57201187775); faculty of nursing, universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/542') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/1605') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10192') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10193') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/10603') 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refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. 11 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. title page example vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga 12 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 13 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 14 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: 𝐇′ = −∑ (𝑃𝑖)(log2 𝑃𝑖) 𝑠 𝑖=1 ………............................................................................................... (1) remarks: .............................................................................................................................................. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old type of care age groups (years) <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 15 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: https://www.mendeley.com/guides/harvard-citation-guide 16 | a u t h o r i n f o r m a t i o n p a c k f e b r u a r y 1 5 , 2 0 2 1 nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author, • hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language. • have read the final version of the manuscript and responsible for what is said in it. • have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website. • hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below. • acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk ners vol 10 no 1 april 2015.indd 175 efektivitas implementasi asuhan keperawatan isolasi sosial dalam mpkp jiwa terhadap kemampuan klien (the effectiveness of nursing care: social isolation implementation in mental pmhnpm to patient’s capability) retty octi syafrini*, budi anna keliat*, yossie susanti eka putri* *fakultas ilmu keperawatan universitas indonesia, depok email: rettyoctimakhfuz@yahoo.co.id abstrak pendahuluan: asuhan keperawatan isolasi sosial adalah salah satu poin penting dalam mpkp (metode praktik keperawatan profesional) jiwa. penelitian ini bertujuan untuk menjelaskan hubungan implementasi asuhan keperawatan isolasi sosial dalam mpkp jiwa dengan kemampuan klien dan keluarga. metode: penelitian ini berdesain korelasional dengan pendekatan cross sectional. sampel adalah pp yang telah mendapatkan pelatihan mpkp jiwa 58 orang, klien isolasi sosial yang dirawat di ruang rawat inap rsjd prov. jambi 32 orang, dan keluarga klien isolasi sosial yang sedang berkunjung 12 orang. variabel independen adalah pelaksanaan program mpkp jiwa oleh perawat pelaksana dan variabel dependennya adalah hasil asuhan keperawatan pada klien isolasi sosial dan keluarganya. pengumpulan data dilakukan dengan menggunakan instrumen kuisioner. analisis data dilakukan dengan distribusi frekuensi untuk melihat data kategorik, central tendency untuk melihat data numerik, dan korelasi pearson. hasil: hasil penelitian menunjukkan bahwa ada hubungan kemampuan pp dengan kemampuan klien dan keluarga (p < 0,05). kemampuan klien dalam memberikan asuhan keperawatan isolasi sosial berhubungan dengan penurunan tanda dan gejala klien (p < 0,05). diskusi: kemampuan pp dalam memberikan asuhan keperawatan dan implementasi mpkp jiwa dapat menurunkan tanda dan gejala, meningkatkan kemampuan klien dan keluarga dalam perawatan isolasi sosial. kata kunci: mpkp jiwa, asuhan keperawatan isolasi sosial, perawat pelaksana abstract introduction: nursing care: social isolation is one of the pillars in professional mental health nursing practice model (pmhnpm). this study was aimed to determine the relationship between the implementation of nursing care in pmhnpm with the ability of clients and families client’s. method: this study was used a correlational design with cross-sectional approach. samples were associate nurse who already follow pmhnpm training 58 respondents, client with social isolation problem who hospitalized at rsjd prov. jambi 32 respondents, and client’s family 12 respondents. independent variable was pmhnpm implementation by associate nurse, while dependent variables were the result of nursing care to client with social isolation problem and family. data were collected by using questionnaire. data were then analyzed by using frequency distribution for categoric data, central tendency for numeric data, and pearson correlation. result: the results showen that nursing management capabilities signifi cantly associated (p < 0.05) with the client’s ability and the ability of the family. the ability of nurses in providing nursing care social isolation were signifi cantly associated (p < 0.05) with a decrease in signs and symptoms of client upgrades. discussion: associate nurses ability on nursing care and pmhnpm implementation could reduce a signs and symptoms, improve an ability of the client and families client’s social isolation. keywords: pmhnpm, nursing care: social isolation, associate nurse pendahuluan isolasi sosial adalah suatu pengalaman menyendiri dari seseorang dan perasaan segan terhadap orang lain (nanda, 2012). perilaku yang diperlihatkan oleh pasien dengan isolasi sosial disebabkan karena seseorang menilai dirinya rendah, sehingga muncul perasaan malu u nt u k ber interaksi dengan orang lain, di mana jika tidak diberikan tindakan keperawatan yang berkelanjutan akan dapat menyebabkan terjadinya perubahan persepsi sensori dan berisiko untuk menciderai diri sendiri, orang lain, bahkan lingkungan (fitria, 2009). untuk itu, penting bagi perawat untuk membantu mengatasi masalah isolasi sosial pada pasien dengan memberikan asuhan keperawatan yang profesional dan tepat yang tersedia di pelayanan keperawatan. model praktik keperawatan profesional (mpkp) merupakan salah satu upaya yang 176 jurnal ners vol. 10 no. 1 april 2015: 175–182 dilakukan oleh bagian keperawatan untuk meningkatkan kualitas pelayanan ataupun kualitas asuhan keperawatan. mpkp adalah suat u sistem yang mendu k ung perawat untuk memberikan asuhan keperawatan di lingkungan di mana perawatan itu diberikan (hoffart & woods, 1996), yang bermanfaat untuk meningkatkan dan menstandarkan kualitas asuhan keperawatan, meningkatkan kepuasan baik secara inter nal maupu n eksternal, dan meningkatkan keefektifan kinerja, serta ef isiensi keuangan (davis, heath & reddick, 2002). m pk p jiwa ya ng d it e r apk a n d i rumah sakit jiwa (rsj) merupakan suatu upaya yang dilakukan untuk meningkatkan kualitas pelayanan dan asuhan keperawatan ya ng me m i l i k i n i lai-n i lai profe sion al yang terdiri dari 4 pilar yaitu pendekatan ma najemen, kompensa si peng ha rga a n, hubungan profesional, dan pemberian asuhan keperawatan. hasil penerapan mpkp jiwa di rsj menunjukkan hasil bor meningkat, alos menur un, dan angka lari pasien menur un, sehingga hasil penerapan ini menunjukkan bahwa dengan mpkp pelayanan kesehatan jiwa yang diberikan bermutu baik (keliat & akemat, 2012). isolasi sosial merupakan salah satu diagnosa keperawatan yang termasuk dalam pilar patient care delivery system di mpkp jiwa. dengan pemberian metode asuhan keperawatan yang digunakan dalam mpkp, diharapkan dapat meningkatkan kemampuan fungsi sosial klien. r sj d p r ov. ja mbi m e mb e r i k a n pelayanan dan asuhan keperawatan dengan pendekatan program mpkp jiwa yang telah dilakukan dari tahun 2009 sampai dengan sekarang di semua ruang rawat inap. namun belum pernah dilakukan evaluasi terkait dengan pemberian asuhan keperawatan pada pasien isolasi sosial. berdasarkan data pada awal maret 2014, isolasi sosial merupakan diagnosa keperawatan yang ada di ruang rawat inap rsjd provinsi jambi adalah terbanyak nomor dua setelah diagnosa keperawatan halusinasi yaitu 17,69%. berdasarkan pemaparan di atas, maka diperlukan penilaian pelaksanaan program mpkp jiwa dengan hasil asuhan keperawatan yang diberikan kepada pasien isolasi sosial. bahan dan metode desain dalam penelitian ini adalah korelasional dengan menggunakan pendekatan cross sectional. sampel adalah perawat pelaksana yang telah mendapatkan pelatihan mpkp jiwa 58 orang, klien isolasi sosial yang dirawat di ruang rawat inap rsjd prov. jambi 32 orang, dan keluarga klien isolasi sosial yang sedang berkunjung 12 orang. variabel independen dalam penelitian ini adalah pelaksanaan program mpkp jiwa oleh perawat pelaksana dan variabel dependen dalam penelitian ini adalah hasil asuhan keperawatan pada klien isolasi sosial dan keluarganya. pengumpulan data dilakukan dengan menggunakan instrumen kuesioner untuk mendapatkan data mengenai kemampuan perawat pelaksana dalam melaksanakan asuhan keperawatan isolasi sosial dan mpkp jiwa, tanda gejala dan kemampuan klien isolasi sosial, serta kemampuan keluarga dalam merawat klien isolasi sosial. analisis data dilakukan dengan distribusi frekuensi untuk melihat data kategori, central tendency untuk melihat data numerik, dan korelasi pearson untuk melihat data hubungan pada variabel independen dan variabel dependen. hasil karakteristik perawat pelaksana yang bekerja di ruang rawat inap mpkp jiwa ratarata berusia 30,84 tahun; 82,8% perempuan; 62,1% berpendidikan diii keperawatan; dan rata-rata telah bekerja selama 7,17 tahun. pencapaian kemampuan pp dalam m a adalah 107,86 (81,71%); cr 9,76 (61%); pr 18,28 (76,17%); dan pcd isolasi sosial 96,34 (77,69%). karakteristik klien isolasi sosial yang dirawat di ruang mpk p jiwa rata-rata berusia 34,78 tahun; 81,3% laki-laki; 59,4% berpendidikan sd; 56,3% tidak bekerja; 56,3% belum menikah; dan dengan lama rawat ratarata 39,78 hari. perkembangan tanda gejala klien dilihat dari perbandingan antara sebelum 177 efektivitas implementasi asuhan keperawatan isolasi sosial (retty octi syafrini, dkk.) tabel 1. kemampuan perawat pelaksana menerapkan mpkp jiwa variabel (standar skor) mean median sd ma (33–132) 107,86 110,00 15,463 cr (4–16) 9,76 10,00 2,892 pr (6–24) 18,28 19,00 3,116 pcd isolasi sosial (31–124) 96,34 93,00 15,854 tabel 2. karakteristik tanda gejala sebelum diberikan asuhan keperawatan isolasi sosial dan tanda gejala setelah diberikan asuhan keperawatan isolasi sosial tanda dan gejala mean pre tanda gejala mean post tanda gejala mean dif. p value kognitif afektif fisiologis perilaku sosial 6.06 3,84 3,41 5,31 7,13 3,59 1,34 1,16 2,66 3,13 2,469 2,500 2,250 2,656 4,000 0,000 0,000 0,000 0,000 0,000 komposit 25,75 11,88 13,87 0.000 tabel 3. karakteristik kemampuan klien isolasi sosial dan kemampuan keluarga klien variabel (standar skor) mean median sd kemampuan klien (0–14) 6,94 7,00 4,016 kemampuan keluarga (4–64) 42,75 35,06 12,107 tabel 4. hubungan kemampuan pp dalam implementasi mpkp jiwa dengan tanda gejala klien (n = 32) variabel r r² p value ma 0,169 0,029 0,354 cr 0,071 0,005 0,698 pr 0,008 0,000 0,967 pcd isolasi sosial -0,361 0,131 0,042** tabel 5. hubungan kemampuan pp dalam implementasi mpkp jiwa dengan kemampuan klien (n = 32) variabel r r² p value ma cr pr pcd isolasi sosial 0,481 0,160 0,277 0,524 0,231 0,026 0,077 0,275 0,005** 0,381 0,125 0,002** tabel 6. hubungan kemampuan pp dalam implementasi mpkp jiwa dengan kemampuan keluarga merawat klien (n = 12) variabel r r² p value ma 0,619 0,383 0,032** cr 0,013 0,000 0,967 pr -0,117 0,014 0,717 pcd isolasi sosial 0,369 0,136 0,237 dan setelah diberikan asuhan keperawatan dengan melihat sisa gejala yang terdapat pada kognitif, afektif, fi siologis, perilaku, dan sosial klien. karakteristik keluarga klien isolasi sosial yang berkunjung ke rsj adalah ratarata berusia 42,08 tahun; 58,3% laki-laki; 33,3% berpendidikan sma; 66,7% bekerja; dan 41,7% adalah saudara kandung klien. kemampuan klien dan kemampuan keluarga setelah diberikan asuhan keperawatan adalah 6,94 (49,57%) dan 42,75 (66,79%). tabel 3, 4, dan 5 menunjukkan ada hubungan yang bermakna antara kemampuan perawat pelaksana dalam implementasi pcd isolasi sosial dengan tanda gejala klien. ada hubungan yang bermakna antara kemampuan 178 jurnal ners vol. 10 no. 1 april 2015: 175–182 pp dalam implement asi m a dan pcd isolasi sosial dengan kemampuan klien. ada hubungan kemampuan pp dalam implementasi ma dengan kemampuan keluarga. pembahasan hasil penelitian menunjukkan ratarata perawat pelaksana memiliki kemampuan p e n d e k a t a n m a n aje m e n , ko m p e n s a s i penghargaan, hubungan profesional, dan asuhan keperawatan isolasi sosial di atas ratarata standar skor. kemampuan yang dimiliki perawat pelaksana dalam kegiatan pendekatan manajemen 81,71% termasuk tinggi mengingat kema mpu a n per awat pela k sa na ha nya mengerjakan rencana harian. rencana harian dan kegiatan pengarahan yang dilakukan di ruangan membantu perawat pelaksana dalam melaksanakan asuhan keperawatan kepada klien. kegiatan pengarahan yang d ii mplement asi ka n d alam m pk p jiwa terdiri dari kegiatan operan, preconference, postconference, iklim motivasi, supervisi dan delegasi (keliat & akemat, 2012). di ruang mpkp jiwa, perawat pelaksana terlibat dalam keseluruhan kegiatan yang ada di pendekatan manajemen kecuali kegiatan perencanaan untuk membuat rencana bulanan dan rencana tahunan, serta kegiatan pengendalian. rutinitas yang dilakukan perawat pelaksana untuk mengerjakan rencana harian dan mengikuti kegiatan pengarahan, membuat perawat pelaksana terbiasa dan memiliki kemampuan u nt u k melak u kan kegiat an pendekat an manajemen. pencapaian kemampuan yang dimiliki perawat pelaksana dalam kegiatan kompensasi penghargaan adalah 61%. hal ini menunjukkan bahwa kemampuan atau keterlibatan perawat dalam kegiatan kompensasi penghargaan masih rendah, yang dapat disebabkan karena belum adanya sistem kompensasi penghargaan yang belum disusun dengan baik. proses seleksi dan rekruitmen, orientasi, penilaian kinerja, dan pengembangan staf merupakan sistem kompensasi penghargaan yang terdapat dalam kegiatan mpkp jiwa (keliat & akemat, 2012). penelitian yang dilakukan oleh mark, salyer, dan wan (2003) didapatkan bahwa dengan kompensasi dan penghargaan, terjadi penurunan yang sangat signifikan dalam kepindahan/berhentinya perawat dari unit atau bagiannya bekerja. kegiatan-kegiatan yang dilaksanakan dalam kompensasi penghargaan belum dilaksanakan secara terstruktur dan rutin, sehingga perawat pelaksana belum merasakan terlibat dalam kegiatan ini. pe ncapaia n ke m a mpu a n p e r awat pelaksana untuk menjalin hubungan profesional adalah sekitar 76,17%. penerapan kegiatan hubungan profesional yang dilakukan oleh kepala ruang dan ketua tim di ruang mpkp jiwa membuat pp terbiasa dengan kegiatankegiatan yang terdapat di dalam pilar ketiga mpkp jiwa. hubungan profesional adalah hubungan kerja sama yang dilakukan pihak tertentu, di mana kedua belah pihak saling memiliki rasa kebersamaan, berbagi tugas, kerja sama, kesetaraan, memiliki tanggung jawab dan tanggung gugat dalam bekerja. penelitian yang dilakukan harwood et al (2007) menunjukkan bahwa penerapan mpkp di ruangan dapat membuat perawat merasa lebih saling memiliki dalam menjalankan peran nya dan meningkatkan koordinasi sesama perawat dalam memberikan asuhan keperawatan. pe ncapaia n ke m a mpu a n p e r awat pela k sa na d ala m membe r i k a n a su ha n keperawatan isolasi sosial adalah 77,695. kemampuan dan kinerja yang telah diberikan perawat pelaksana dalam merawat klien telah cukup baik. kemampuan yang dimiliki pp dalam menerapkan asuhan keperawatan isolasi sosial dan mpkp jiwa dapat dipengaruhi oleh lingkungan kerja yang ada di ruangan, seper t i li ng k u ngan f isi k, ketersedia an sarana, kejelasan kebijakan, dan supervisi. kemampuan dan keterampilan merupakan salah satu variabel individu yang dapat mempengaruhi perilaku dan kinerja seseorang (gibson, 1987). karakteristik individu yang dapat mempengaruhi kemampuan perawat ialah umur, pendidikan, lama kerja, dan jenis kelamin. hasil penelitian menunjukkan bahwa tanda gejala klien isolasi sosial dapat berkurang setelah diberikan asuhan keperawatan isolasi 179 efektivitas implementasi asuhan keperawatan isolasi sosial (retty octi syafrini, dkk.) sosial secara berkesinambungan, namun meskipun klien telah diberikan asuhan keperawat a n seca ra komprehensif d a n berkesinambungan, tetapi masih ditemukan tanda gejala sisa yang ada pada klien baik pada kognitif, afektif, fi siologi, perilaku dan sosial. hal ini bisa dipengaruhi oleh beberapa faktor baik faktor internal maupun faktor eksternal. faktor internal yang dapat mempengaruhi tanda dan gejala klien isolasi sosial adalah bahwa klien dengan isolasi sosial memiliki penilaian negatif terhadap diri sendiri, orang lain dan lingkungan yang menyebabkan perilaku negatif yaitu menarik diri atau isolasi sosial. menurut stuart dan laraia (2005), ada tiga tipe utama penilaian terhadap stressor yang bersifat kognitif, yaitu: 1) stressor dinilai sebagai bahaya yang akan terjadi; 2) stressor dinilai sebagai ancaman, sehingga perlu antisipasi; dan 3) stressor dinilai sebagai peluang/tantangan untuk tumbuh menjadi lebih baik. klien isolasi sosial biasanya akan menilai bahwa proses pemberian asuhan keperawatan dianggap sebagai suatu stressor yang akan menimbulkan bahaya bagi klien, sehingga klien akan menolak interaksi tersebut. faktor lain yang dapat mempengaruhi kemampuan klien isolasi sosial adalah usia, jenis kelamin, pendidikan, pekerjaan, status pernikahan, dan lama rawat. hal ini sesuai dengan hasil penelitian yang dilakukan oleh jumaini (2010), di mana pendidikan dapat mempengaruhi kognitif dan psikomotor klien isolasi sosial dalam menilai diri, orang lain, dan lingkungan. hasil pada penelitian ini menunjukkan bahwa terdapat hubungan yang signifikan antara kemampuan perawat pelaksana dalam implementasi asuhan keperawatan dengan tanda gejala klien isolasi sosial. perawat pelaksana yang memiliki kemampuan dalam implementasi asuhan keperawatan isolasi sosial yang tinggi dapat membantu menurunkan tanda gejala pada klien isolasi sosial. tujuan asuhan keperawatan pada klien isolasi sosial adalah untuk melatih keterampilan klien isolasi sosial, sehingga merasa nyaman dalam situasi sosial dan melakukan interaksi sosial (frisch & frisch, 2006). harwood et al (2007), menyatakan bahwa pemberian asuhan kepada klien dapat meningkatkan hubungan perawat dan klien, hubungan yang terbina lebih alami, klien lebih nyaman dan percaya dalam menerima perawat. dengan terciptanya hubungan saling percaya ini, perawat dapat mengkaji lebih dalam masalah yang sedang dihadapi klien dan dapat membantu mengurangi tanda dan gejala pada klien. hasil penelitian ini menunju k kan ba hwa kema mpu a n perawat pela k sa na dalam implementasi mpkp jiwa di atas nilai rata-rata standar skor. namun, tidak ada hubungan yang signifi kan antara pendekatan manajemen, kompensasi penghargaan, dan hubungan profesional dengan tanda gejala klien isolasi sosial. hal ini bisa dipengaruhi oleh jumlah tenaga keperawatan yang ada di ruang rawat inap. wawancara yang dilakukan dalam penelitian ini juga menguatkan hasil penelitian ini, di mana satu orang partisipan mengungkapkan bahwa masih dirasakan kurangnya jumlah tenaga perawat yang ada di ruangan dengan jumlah klien yang ada, sehingga perawat tidak dapat memberikan asuhan keperawatan dengan optimal dan perkembangan klien tidak terlihat secara jelas. hal ini sesuai dengan teori yang menyatakan bahwa penghitungan standar tenaga keperawatan dihitung berdasarkan pada jumlah klien dan tingkat ketergantungan klien terhadap perawatan (douglas, 1984 dalam swansburg, 2000). jumlah perawat dalam satu ruangan yang tidak sesuai dengan jumlah klien dapat menyebabkan pemberian asuhan keperawatan kepada klien tidak optimal, sehingga masalah yang dialami klien tidak terselesaikan. penelitian lain dilakukan dilakukan oleh rohmiyati (2009) di rsud gondohutomo semarang, di mana diungkapkan bahwa salah satu hambatanhambatan yang dirasakan perawat dalam menerapkan mpkp adalah karena adanya jumlah tenaga yang kurang. untuk mendapatkan keberhasilan yang dicapai dalam pemberian asuhan keperawatan, diperlukan kemampuan dan keterampilan k husus d ala m menyelesai kan masala h 180 jurnal ners vol. 10 no. 1 april 2015: 175–182 keperawatan yang dihadapi klien. standar asuhan keperawatan yang diberikan kepada klien isolasi sosial memerlukan intensitas waktu yang sering dan rutin, sehingga perawat memerlukan banyak waktu untuk pemberian asuhan keperawatan. kurangnya tenaga yang dibutuhkan, menyebabkan perawat tidak dapat memberikan asuhan keperawatan kepada klien dengan tidak optimal dan mengganggu stabilitas kinerja di ruangan, sehingga perawat tidak memiliki waktu untuk melakukan tindakan keperawatan yang sehar usnya dilakukan sesuai dengan rencana yang telah dibuat. hal lain yang dapat menyebabkan tidak ada hubungan yang signifi kan antara p e n d e k a t a n m a n aje m e n , ko m p e n s a s i penghargaan, dan hubungan profesional dengan tanda gejala klien isolasi sosial adalah terapi psikofarmaka yang didapatkan klien isolasi sosial. pada klien isolasi sosial, terdapat gangg uan pada f ungsi t ransmisi sinyal penghantar saraf (neurotransmitter) sel-sel susunan saraf pusat (otak) yaitu menurunnya pelepasan zat dopamine dan serotonin yang mengakibatkan gangguan pada alam pikir, alam perasaan, dan perilaku. terapi psikofarmaka terbagi dalam dua golongan yaitu golongan generasi pertama (typical) dan golongan generasi kedua (atypical). dalam penelitian ini sebagian besar responden (klien isolasi sosial) mendapatkan terapi psikofarmaka golongan generasi pertama sehingga tidak terlihat jelas penurunan tanda dan gejala negatif yang ada pada klien. hal ini sesuai dengan teori yang menyatakan bahwa psikofarmaka golongan obat generasi pertama sendiri kurang memberikan respons pada klien isolasi sosial dan tidak memberikan efek yang baik pada pemulihan fungsi kognitif klien (sadock & sadock, 2007). selain terapi psikofarmaka dan jumlah tenaga keperawatan yang mempengaruhi belum dapatnya penurunan tanda gejala klien, waktu awal terjadinya gejala gangguan jiwa sampai klien mendapatkan perawatan dan pengobatan sangat mempengar u hi hasil perawat an dan pengobatan itu sendiri. brady (2004) mengatakan bahwa jarak antara munculnya gejala dengan perawatan/pengobatan pertama berhubungan dengan kecepatan dan kualitas respons pengobatan dan gejala negatif yang muncul, semakin cepat klien mendapat pengobatan setelah terdiagnosis maka semakin cepat dan bermakna responnya. hasil pada penelitian ini menunjukkan bahwa terdapat hubungan yang signifikan antara kemampuan perawat pelaksana dalam implementasi pendekatan manajemen dengan kemampuan klien isolasi sosial. perawat pela k sa na ya ng mem ili k i kema mpu a n dalam implementasi pendekatan manajemen yang tinggi dapat membantu meningkatkan kemampuan klien isolasi sosial. harwood et al (2007), menyatakan bahwa pendekatan m a n aje m e n d a p a t m e m f a si l it a si d a n mendukung komunikasi yang pada akhirnya mempengaruhi konsistensi dan kesinambungan dalam melakukan perawatan, sehingga dapat memberikan manfaat kepada pasien. pada penelitian ini juga didapatkan bahwa ada hubungan yang signifi kan antara implementasi asuhan keperawatan isolasi sosial dengan kemampuan yang dimiliki oleh klien isolasi sosial. manajemen asuhan keperawatan yang baik sangat dibutuhkan dalam memberikan asuhan keperawatan kepada klien secara sistematis dan terorganisasi. hubungan antara implementasi mpkp dan kemampuan klien isolasi sosial menunjukkan bahwa perawat pelaksana yang memiliki kemampuan dalam implementasi asuhan keperawatan yang tinggi dapat membantu meningkatkan kemampuan klien isolasi sosial untuk mengatasi masalah menarik dirinya. langkah yang dapat dilakukan perawat pela k sa na d ala m membe r i k a n a su ha n keperawatan kepada klien isolasi sosial secara komprehensif meliputi terapi individu, terapi kelompok, dan terapi keluarga maupun komunitas. pemberian asuhan keperawatan dengan menerapkan terapi aktivitas kelompok sosialisasi juga perlu diterapkan pada klien isolasi sosial untuk meningkatkan kemampuan klien dalam melakukan interaksi sosial dalam kelompok karena dengan pendekatan secara berkelompok memungkinkan klien untuk saling mendukung, belajar menjalin hubungan inter personal, merasa kan kebersamaan dan dapat memberikan masukan terhadap 181 efektivitas implementasi asuhan keperawatan isolasi sosial (retty octi syafrini, dkk.) pengalaman masing-masing klien, sehingga de nga n a d a nya lat i h a n b e r sosia l is a si secara kelompok terjadi peningkatan pada kemampuan klien dalam bersosialisasi dengan orang lain. kemampuan klien dalam mengatasi isolasi sosial dipengaruhi oleh berbagai faktor baik eksternal maupun internal. salah satu faktor eksternal yang dapat mempengaruhi kemampuan klien adalah lama hari rawat. lama hari rawat merupakan salah satu unsur atau aspek asuhan dan pelayanan di rumah sakit yang dapat dinilai atau diukur. lama hari rawat dapat digunakan untuk melihat seberapa efektif dan efi siennya pelayanan kesehatan jiwa yang telah diberikan. pengukuran dilakukan dengan mengukur berapa lama hari perawatan dan kemampuan pasien setelah mendapatkan terapi perawatan dan pengobatan di rumah sakit tersebut. pada penelitian ini didapatkan bahwa kemampuan keluarga dalam merawat klien masih di bawah nilai 75%. hal ini dipengaruhi oleh frekuensi pemberian asuhan keperawatan ke pa d a kelu a rga ma si h sa ngat ja r a ng disebabkan karena keluarga jarang datang ke pelayanan kesehatan, sehingga keluarga belum mengetahui bagaimana cara merawat klien isolasi sosial. kemampuan keluarga dalam merawat klien isolasi sosial dipengaruhi oleh fungsi, peran, dan tugas keluarga. stressor yang muncul akibat penyakit klien, dapat mempengaruhi tugas keluarga untuk mempertahankan status kesehatan anggota keluarga yang lain. keluarga belum memahami keadaan dan kondisi klien, sehingga mempengaruhi kemampuan keluarga untuk memutuskan tindakan apa yang bisa dilakukan kepada pasien. hal ini dikuatkan dengan data wawancara yang didapatkan di mana empat orang perawat pelaksana mengungkapkan bahwa sebelumnya keluarga tidak mengetahui mengenai penyakit klien dan bagaimana cara mengatasinya, sehingga mempengaruhi tugas-tugas yang lain. hasil penelitian menunjukkan bahwa ada hubungan yang signifi kan antara kemampuan perawat pelaksana dalam implementasi pendekatan manajemen dengan kemampuan keluarga dalam merawat klien isolasi sosial. perawat pelaksana yang memiliki kemampuan dalam implementasi pendekatan manajemen yang tinggi dapat membantu meningkatkan kemampuan keluarga untuk merawat klien isolasi sosial. keluarga merupakan faktor yang sangat penting dalam proses kesembuhan klien yang mengalami masalah isolasi sosial. kondisi keluarga yang terapeutik dan mendukung klien sangat membantu kesembuhan klien dan memperpanjang kekambuhan. asuhan keperawatan yang diberikan oleh perawat, tidak hanya terfokus kepada klien, tetapi juga diberikan kepada keluarga klien isolasi sosial untuk meningkatkan pengetahuan dan keterampilan keluarga dalam merawat klien. keterlibatan keluarga dalam setiap perawatan klien isolasi sosial sangat penting. a s u h a n ke p e r awat a n ya ng d ib e r i k a n kepada keluarga, ter masuk dalam tugas dan kemampuan yang harus dimiliki oleh perawat. bekerja sama dengan anggota keluarga mer upakan bagian penting dari proses keperawatan klien gangguan jiwa (stuart & laraia, 2005). secara umum, asuhan keperawatan yang diberikan kepada keluarga adalah untuk meningkatkan fungsi kesehatan keluarga yaitu dengan: 1) membantu keluarga untuk mengenali masalah yang terjadi pada klien; 2) memutuskan untuk membawa klien ke pelayanan kesehatan; 3) melatih keluarga u nt u k merawat klien; 4) memodif ikasi lingkungan yang nyaman untuk klien; dan 5) melakukan follow up kepada keadaan klien isolasi sosial. tu j u a n d i b e r i k a n n y a a s u h a n keperawatan kepada keluarga adalah agar keluarga dapat merawat klien di rumah dan menjadi sistem pendukung yang efektif untuk pasien. pemberian asuhan keperawatan kepada keluarga dapat meningkatkan pengetahuan karena dalam asuhan tersebut mengandung unsur untuk meningkatkan pengetahuan keluarga mengenai penyakit yang di derita klien, mengajarkan atau melatih keluarga mengenai cara merawat klien dengan isolasi sosial, d a n memba nt u kelu a rga u nt u k mengetahui dan mengenali gejala-gejala penyimpangan perilaku menarik diri yang harus segera di rujuk kembali oleh keluarga ke 182 jurnal ners vol. 10 no. 1 april 2015: 175–182 pelayanan kesehatan (stuart & laraia, 2005). pemberian asuhan keperawatan kepada keluarga klien berfokus pada memberikan infor masi mengenai gangguan jiwa dan sistem kesehatan jiwa untuk meningkatkan pengetahuan anggota keluarga melalui metode pengajaran psikoedukasi (marsh, 2000 dalam stuart & laraia, 2005) yang dalam penelitian ini berfokus pada klien isolasi sosial. simpulan dan saran simpulan ke m a m pu a n p e r awa t p el a k s a n a dalam implementasi kegiatan pendekatan manajemen berhubungan secara bermakna dengan peningkatan kemampuan klien dan kemampuan keluarga. kemampuan perawat pelaksana dalam implementasi pemberian asuhan keperawatan isolasi sosial berhubungan secara bermakna dengan penurunan tanda gejala dan peningkatan kemampuan klien. saran bidang keperawatan dapat melakukan pengembangan staf dengan memberikan pelatihan mpkp jiwa untuk penyegaran p e nget a hu a n d a n p e nd id i k a n p e r awat pelaksana terkait dengan mpkp jiwa dan asuhan keperawatan isolasi sosial. kepala ruang maupun bidang keperawatan dapat memberikan supervisi secara rutin untuk menciptakan rutinitas budaya kerja dalam mengimplementasikan kegiatan-kegiatan mpkp jiwa di ruangan. kepustakaan davis, b., heath, o., & reddick, p. 2002. a multi-disciplinar y proffesional practice model: supporting autonomy and accountability in program-based structure. canadian journal of nursing leadership, 15(4), 21–25. fitria, nita. 200). buku ajar keperawatan jiwa. jakarta: salemba medika. frisch, n.c., & frisch, l.e. 2006. psychiatric mental health nursing. 3th ed. canada: thomson delmar learning. harwood, l, et al. 2007. nurses’ perceptions of the impact of a renal nursing professional practice model on nursng outcomes, characteristics of a practice environments and empowerment-part 1. cannt journal, 17, 1, proquest pg. 22. hoffart, n. & woods, c.q. 1996. elements of a nursing professional practice models. journal of professional nursing, vol. 12: 6, 354–364. keliat, b.a., & akemat. 2012. model praktik keperawatan profesional jiwa. jakarta: egc. gillies, d.a. 1994. nursing management a system approach. philadelphia: w.b saunders. jumaini., keliat, b.a., & hastono, s.p. 2010. pengaruh cognitive behavioral social skills training (cbsst) terhadap kemampuan bersosialisasi klien isolasi sosial di blu rs dr. h. marzoeki mahdi. tesis. depok: universitas ui. tidak dipublikasikan. mark, b.a., salyer, j., & wan, t.t.h. 2003. professional nursing practice: impact on organizational and patient outcomes. journal of nursing administration, vol. 33, no. 4, 224–234. na n da . 2 012 . n u r s i n g d i a g n o s i s: defi nitions & classifi cation 2012–2014 . philadelphia: nanda international. rohmiyati, ana. 2009. studi fenomenologi: p e n g a l a m a n p e r a w a t d a l a m menerapkan mpkp di rsjd dr. amino gondhohutomo semarang. http://eprints. undip.ac.id /14822/4/ar tikel mpk p. diunduh tanggal 14 januari 2014. sadock, b.j., & sadock, v.a. 2007. kaplan and sadock’s synopsis of psychiatry b e h a v i o r a l s c i e n c e s? c l i n i c a l psychiatry. 10th ed. lippincott williams & wilkins. stuart, g.w., & laraia, m.t. 2005. principles and practice of psychiatric nursing. 8th ed. missouri: mosby inc. swa nbu rg rc & swa nbu rg r j. 2000. i n t r o d u c t o r y m a n a g e m e n t a n d leadership for nurse. 2nd edition. toronto: jonash and burtlet publisher. vol 9 no 1 april 2014.indd 6 koherensi remaja pecandu miras dalam konteks salutogenesis (sense of coherence on liquor abuse among teenagers in salutogenesis context) oedojo soedirham*, verdian nendra dimas pratama* *fakultas kesehatan masyarakat, universitas airlangga kampus c mulyorejo surabaya 60115 e-mail: oedojo@yahoo.com abstrak pendahuluan: pecandu miras di indonesia, terutama kalangan remaja merupakan masalah kesehatan masyarakat yang sangat mencemaskan bahkan harus dihentikan. hal tersebut berdampak pada peningkatan perilaku yang menyimpang pada remaja seperti kejahatan, tawuran, geng remaja, tindakan amoral, dan perilaku kriminal yang merajalela di kalangan remaja. metode: tipe penelitian ini adalah descriptive cross sectional dengan teknik purposive sampling. kriteria inklusi digunakan untuk mendapatkan responden yang homogen. hasil: remaja pecandu miras tidak mempunyai tujuan hidup yang positif yang ditunjukkan dengan sebagian besar dari mereka tidak ingin berubah dan tidak tahu akan berubah atau tidak. perilaku tersebut mungkin disebabkan oleh pengaruh yang sangat besar dari teman kelompoknya. diskusi: berdasarkan pada 29 pertanyaan dalam soc dapat disimpulkan bahwa rerata responden tidak mau berubah menjadi lebih baik yang disebabkan oleh stress. sense of coherence merupakan formulasi yang berisi penjelasan teoritis tentang peran utama stres di dalam fungsi kehidupan manusia. tekanan hidup yang besar dapat menyebabkan distress karena mengurangi kepercayaan bahwa kehidupan sebetulnya dapat dimengerti, bermakna, dan dapat dikelola. oleh karena itu, sense of coherence juga merupakan mediator dari dampak stres terhadap gangguan jiwa. kata kunci : pecandu miras, remaja, rasa koherensi abstract introduction: liquor abuse in indonesia, especially among teenagers is now a public health problem that is quite alarming even been able to say ‘red lights.’ impact of follow such behavior is increasing deviation forms such as delinquency, fi ghts, the emergence of juvenile gangs, acts immoral, and rampant thuggery in teenagers. method: type in this study was a descriptive cross-sectional with a purposive sample collection methods. nonetheless applied inclusion criteria to be getting more specifi c respondents. results: the results showed that the teens did not have a positive life orientation evidenced by the majority of them do not want to change and do not know whether to change or not. the attitude may be due to the infl uence of a very strong group. discussion: based on the 29 soc questions concluded that on average the respondents did not want to turn in because of stress. “sense of coherence” is a formulation provides a theoretical explanation for the central role of stress in human functioning. the pressures of life signifi cantly reduces the belief that the world is understandable, meaning ful, and manageable, and can lead to psychological distress. thus, a sense of coherence is also a mediator of the effects of life stress on mental health. key words: liquor abuse, teenagers, sense of coherence pendahuluan penyalahgunaan minuman keras di indonesia terutama di kalangan remaja saat ini mer upakan per masalahan kesehatan masyarakat yang cukup mengkhawatirkan bahkan sudah dapat dibilang ‘lampu merah.’ dampak ikutan dari perilaku tersebut adalah meningkatnya bentuk-bentuk penyimpangan seperti kenakalan, perkelahian, munculnya geng-geng remaja, perbuatan asusila, dan maraknya premanisme pada kalangan remaja. beberapa peristiwa yang direkam oleh media baik cetak maupun elektronik menunjukkan hal yang mengkhawatirkan terutama bagi kehidupan para remaja. hubungan antara supply dan demand untuk minuman keras ini kelihatan sekali terjadi begiru intens. laporan yang berikut hanyalah sedikit dari begitu banyak yang sempat diliput ataupun yang tidak sempat terekam oleh media masa. tempo interaktif, kamis, 23 juni 2011 | 23:05 wib melaporkan bahwa kepolisian resor purbalingga memusnahkan 5.050 botol minuman keras berbagai merek, senin (3/5). ribuan minuman keras tersebut merupakan hasil razia yang digelar kepolisian selama maret menjelang pemilihan bupati purbalingga. selanjutnya dalam media yang sama juga dimuat berita bahwa di bogor dua 7 koherensi remaja pecandu miras (oedojo soedirham, dkk.) siswa sekolah menengah kejuruan (smk) dihukum menghormat bendera merah putih di kantor dinas pendidikan kota bogor saat panas matahari sedang terik, kamis 22 september 2011. keduanya kedapatan sedang teler karena menenggak minuman keras dan mengoleksi video porno. lebih lanjut juga dilaporkan oleh tempo.co, bahwa kepolisian sektor bogor utara menyita lima drum tuak ukuran 30 liter ditambah lima ember tuak yang baru setengah jadi dalam razia yang digelarnya, kamis 23 juni 2011. polisi menyisir sejumlah warung dan gudang di kawasan perumahan di tegallega setelah mendapat keluhan soal peredaran minuman keras yang meresahkan warga. sementara itu karena dampak minuman keras maka kejadian di blitar di laporkan oleh tempo.co (sabtu, 11 juni 2011 | 16:17 wib) di mana dua warga tewas usai tenggak arak oplosan yaitu ramuan arak dan buah gadung. racikan tradisional ini cukup terkenal di kalangan pemabuk sebagai obat penghilang stress. temuan di atas ini sama dengan temuan yang ada di desa jatigono kecamatan kunir kabupaten lumajang, di mana perkembangan remaja saat ini dalam menyikapi berbagai masalah, pada umumnya dengan meminum minuman keras. hal ini berarti bahwa kondisi penyalahgunaan minuman keras sudah berada pada taraf yang sangat mengkhawatirkan. sesuai dengan st udi pendahuluan yang dilak u kan pada t anggal 22 september 2012 peneliti mandapatkan jumlah seluruh penduduk di desa jatigono kecamatan kunir kabupaten lumajang berjumlah 4.510 jiwa dan remaja berjumlah 642 berdasarkan klasifi kasi u mu r 11-24 t ahu n. setelah melak u kan pendekatan dengan 48 orang remaja yang biasa minum minuman keras didapatkan hasil, bahwa mereka mengenal minuman keras akibat pergaulan juga karena ikutikutan hanya karena ingin dikatakan hebat. mereka mengatakan dengan minum minuman keras mereka mendapatkan banyak teman dimana mereka mudah bergaul setelah minum minuman keras, kepercayaan diri mereka timbul setelah minum minuman keras, masalah akan teratasi saat minum minuman keras, mereka mengatakan peminum akan sangat disegani oleh orang, untuk menghilangkan stres (merasa enjoy), salah seorang dari mereka mengatakan ” kalau gak minum bukan lakilaki ”, saat ini minum minuman keras telah menjadi hobby bagi mereka. mereka biasanya mium minuman keras dalam seminggu + 3-4 kali, mereka minum minuman keras dengan berkelompok yang terdiri dari 4–10 orang dan minuman yang sering diminum bermerek arak tuban, topi miring, vodka, bir bintang, bir hitam, cap tikus dan sekali-kali anggur merah bila kepepet, biasanya minuman keras itu dicampur dengan minuman lainnya seperti: m 150, pepsi blue, bintang zero, sprite, cocacola agar terasa nikmat kata mereka. mereka membeli minuman keras tersebut dari hasil patungan atau biasa dikenal dengan istilah sumbangan. saat ditanyakan tentang pengetahuan mereka tentang minuman keras mereka mengatakan minuman keras it u adalah minuman yang mengandung alkohol dengan beberapa golongan sesuai dengan kadar alkohol yang ada dalam minuman keras, minuman keras dapat mengurangi tingkat kesadaran, dalam agama minuman keras itu haram, dalam hukum negara minuman keras itu dilarang, dalam kesehatan minuman keras itu dapat merusak kesehatan. tapi mereka tetap minum minuman keras karena alasan yang telah diungkapkan mereka diatas. jadi penelitian ini lebih menitikbertkan pada orientasi hidup para remaja tersebut dengan mengg u nakan k uesioner sense of coherence (soc) d ar i a ntonovsk y (eriksson and lindström, 2005) yang sudah diterjemahkan ke dalam bahasa indonesia. bahan dan metode jenis dalam penelitian ini adalah deskriptif dengan potong lintang dengan metode pengambilan sampel secara purposive. meskipun demikian diberlakukan kriteria i n k lusi u nt u k mend apat ka n responden yang lebih spesifi k. kriteria inklusi adalah karakteristik umum subyek penelitian dari suatu populasi target dan terjangkau yang akan diteliti. adapun syarat yang diambil dalam penelitian ini adalah: 1) remaja berumur 11–24 8 jurnal ners vol. 9 no. 1 april 2014: 6–10 tahun dan belum menikah yang berdomisili di desa jatigono kecamatan kunir kabupaten lumajang, 2) remaja berumur 11-24 tahun dan belum menikah yang mengkonsumsi minuman keras yang berdomisili di desa jatigono kecamatan kunir kabupaten lumajang, 3) remaja yang bersedia menjadi responden, dan 4) remaja pengguna miras tidak dalam pengaruh miras ketika pengambilan data dilakukan. dalam meng uk ur aspek sense of coheren ada 3 (tiga) jenis variabel yaitu ingin ber ubah, tidak tahu ingin ber ubah atau tidak dan tidak ingin berubah. menurut monica eriksson memberikan gambaran untuk mengklasifi kasikan dengan perhitungan sebagai berikut: 1) tidak ingin berubah jika total skor ≤ 72,5, 2) tidak tahu ingin berubah atau tidak ingin berubah jika total skor > 72,5 ≤159,5 dan 3) ingin berubah jika total skor > 159,5. penelit ia n d ila k u ka n pad a bula n juli 2012 terhadap 43 remaja desa jatigono kecamatan kunir kabupaten lumajang. data diperoleh berdasarkan hasil jawaban kuesioner. kemudian diolah sesuai dengan t ujuan penelitian untuk mengetahui perilaku remaja pengguna minuman keras di desa jatigono kecamatan kunir kabupaten lumajang. hasil k a r a k t e r i s t i k r e s p o n d e n d a l a m penelit ian di kelompok kan berd asa rkan tingkat pendidikan, umur, dan jenis kelamin. mayoritas responden mempunyai tingkat pendidikan slta (67,4%), ber usia 19-24 tahun (65,1%), dan berjenis kelamin laki-laki (95,3%). tingkat pengetahuan remaja tentang minuman keras di desa jatigono kecamatan kunir kabupaten lumajang sebanyak 46,5% tabel 1. analisis butir pertanyaan kuesioner soc soal hasil analisis 1 rata-rata responden memiliki perasaan tidak percaya diri yang mengakibatkan timbulnya stress sehingga mereka mengekspresikan rasa itu dengan melakukan meminum minuman keras. 2 rata-rata responden memiliki perasaan tidak bisa melakukan pekerjaan yang dilakukan bersama dengan orang lain disebabkan kurangnya rasa percaya pada orang lain dan cenderung menarik diri dari lingkungan. 3 rata-rata responden mengenal orang-orang terdekatnya dengan baik hanya pada komunitasnya (para peminum-minuman keras) saja, itu disebabkan karena sering berinteraksi dan memiliki perasaan enak apabila berkumpul dengan mereka. 4 rata-rata responden memiliki kepedulian apa yang terjadi disekitar mereka tapi ada hambatan untuk berkomunikasi atau berkerjasama dengan orang lain. 5 rata-rata responden selalu dikejutkkan oleh orang yang mereka kenal betul, sehingga mereka merasa tidak enak dengan keadaan seperti itu dan mencoba melakukannya dengan meminum minuman keras. 6 rata-rata responden sering merasakan di kecewakan oleh orang yang di andalkan (pacar), sehingga itu memicu mereka untuk melampiaskan dengan hal-hal yang kurang baik dengan melakukan minum minuman keras. 7 rata-rata responden merasa hidup mereka membosankan. 8 rata-rata responden mengatakan hidup mereka tidak jelas tujuannya atau tidak ada tujuan sama sekali, itu dapat dipengaruhi karena mereka tidak memiliki cita-cita. 9 rata-rata responden sangat sering merasa di perlakukan tidak adil oleh lingkungan di sekitarnya, sehingga mereka melampiaskan kekecewaan itu hanya dengan komunitasnya (peminum minuman keras) saja. 10 rata-rata responden mengatakan bahwa dalam sepuluh tahun terakhir hidup mereka konsisten dan jelas. karena sebagian dari mereka memiliki pekerjaan. 11 rata-rata responden mengatakan apa yang mereka kerjakan kemungkinan dimasa depan sangat membosankan dan mematikan. 9 koherensi remaja pecandu miras (oedojo soedirham, dkk.) soal hasil analisis 12 rata-rata responden sangat sering mempunyai perasaan ada dalam situasi yang tidak biasanya dan tidak tahu harus melakukan apa. 13 rata-rata responden mengatakan bahwa kehidupan itu menyakitkan. 14 rata-rata responden mengatakan hidup mnurut meraka yang penting senang dan seenaknya saja. 15 rata-rata responden mengatakan bahwa mereka mempunyai solusi yang jelas dalam menghadapi situasi yang sulit, maksud dari solusi yang jelas itu adalah dengan berlari ke minuman keras. 16 rata-rata responden mengatakan aktivitas setiap hari mereka sebagai sumber rasa sakit dan kebosanan. 17 rata-rata responden mengatakan masa depan mereka penuh perubahan tanpa mengetahui apa yang terjadi selanjutnya. 18 rata-rata responden mengatakan ketika sesuatu yang tidak menyenangkan di masa depan mereka cenderung marah pada diri sendiri tentang hal itu. 19 rata-rata responden mengatakan tidak pernah atau sangat jarang mempunyai gagasan dalam hidup. 20 rata-rata responden mengatakan mereka melakukan sesuatu dengan kenyakinan bahwa meminum minuman keras akan membuat mereka terus akan merasa baik. 21 rata-rata responden mengatakan bahwa mereka sangat sering tidak mempunyai perasaan peduli terhadap orang lain. 22 rata-rata responden mengatakan bahwa kehidupan pribadi mereka dimasa mendatang akan benar-benar tanpa makna dan tujuan. dan mereka terkadang merasa bingung dengan kehidupan mereka. 23 rata-rata responden berfi kir meragukan akan ada atau tidak ada seseorang yang dapat di andalkannya di mmasa mendatang. 24 rata-rata responden merasa sangan jarang atau tidak pernah tahu persis apa yang akan terjadi selanjutnya pada kehidupannya. 25 rata-rata responden mengatakan bahwa mereka sangat sering menjadi pecundang dalam beberapa situasi tertentu di masa lalunya. 26 rata-rata responden mengatakan mereka bersikap berlebihan atau diremehkan saat sesuatu menimpa mereka. 27 rata-rata responden berfi kiran tidak akan berhasil mengatasi kesulitannya dalam menghadapi hal yang sulit dalam hidup. 28 rata-rata responden merasa mereka sangat jarang atau tidak pernah melakukan hal-hal yang berguna di kehidupannya. 29 rata-rata responden merasa sangat sering tidak yakin mengontrol emosi pada dirinya. (20 orang) pada kategori baik, pengetahuan sedang sebanyak 16 0rang (37,2%), dan pengetahuan kurang baik sebanyak 7 orang (16,3%). sedangkan rasa koherensi remaja pengguna minuman keras menunjuk kan perilaku tidak tahu sebesar 7 orang (16,3%), ingin berubah 15 orang (34, 9%), dan paling banyak mempunyai perilaku tidak ingin berubah sebesar 21 orang (48,8%). pembahasan berdasarkan 29 pertanyaan soc dapat di simpulkan bahwa rata-rata responden tidak ingin berubah di karenakan stress. adanya sikap tersebut dapat dikarenakan pengaruh kelompok yang sangat kuat. hal yang memperburuk keadaan adalah banyak diantara mereka yang ditinggal bekerja ke luar negeri oleh orang tua mereka sehingga mereka tidak punya panutan dalam hidup mereka. rasa koherensi merupakan formulasi teoritis yang memberikan penjelasan tentang peran stres dalam fungsi manusia. antonovsky juga menyatakan bahwa tekanan hidup yang signifi kan mengurangi kepercayaan bahwa dunia ini dipahami, bermakna, dan dikelola, dan dapat mengakibatkan tekanan psikologis. 10 jurnal ners vol. 9 no. 1 april 2014: 6–10 dengan demikian, rasa koherensi juga merupakan mediator dari efek kehidupan stres pada kesehatan mental (antonovsky, 1979). rasa koherensi sebagai orientasi global yang mengungkapkan sejauh mana seseorang memiliki perasaan, meresap dinamis dan abadi meskipun keyakinan bahwa rangsangan yang berasal dari lingkungan seseorang internal dan eksternal dalam perjalanan hidup yang terstruktur, dapat diprediksi dan dijelaskan, sumber daya yang tersedia untuk memenuhi tuntutan yang ditimbulkan oleh rangsangan, dan tuntutan adalah tantangan, layak investasi dan keterlibat an. dalam for mulasinya, rasa koherensi memiliki tiga komponen. comprehensibility mer upakan keyakinan bahwa hal-hal terjadi secara teratur dan dapat diprediksi dan perasaan bahwa anda dapat memahami peristiwa dalam hidup anda dan cukup memprediksi apa yang akan terjadi di masa depan. manageability adalah keyakinan bahwa anda memiliki keterampilan atau kemampuan, dukungan, bantuan, atau sumber daya yang diperlukan untuk mengurus halhal, dan bahwa hal-hal yang dikelola dan dalam kendali anda. kebermaknaan yang merupakan keyakinan bahwa hal-hal dalam hidup yang menarik dan merupakan sumber kepuasan, bahwa hal-hal yang benar-benar layak dan bahwa ada alasan yang baik atau tujuan untuk peduli tentang apa yang terjadi. menurut antonovsky, (1979) ketiga elemen tersebut adalah yang paling penting. jika seseorang percaya tidak ada alasan untuk bertahan dan bertahan dan menghadapi tantangan, jika mereka tidak memiliki rasa makna, maka mereka tidak akan memiliki motivasi untuk memahami dan mengelola acara. sedangkan rata-rata responden tidak memiliki ke tiga formulasi tersebut. hal tersebut di atas menunjukkan bahwa apabila seseorang ingin ada perubahan perilaku yang lebih baik di kehidupannya harus melakukan ke tiga criteria yang telah di jelaskan oleh antonovsky. (antonovsky, 1979) simpulan dan saran simpulan hasil penelitian menunjukkan bahwa para remaja tersebut tidak mempunyai orientasi kehidupan yang positif dibuktikan dengan mayoritas dari mereka tidak ingin berubah dan tidak tahu apakah ingin berubah atau tidak. saran pertanyaan soc sebanyak 29 butir dapat dipakai dalam penelitian di bidang lainnya misalnya keperawatan terutama untuk kasus-kasus kronis sehingga dapat membantu memberikan pelayanan yang lebih tepat. daftar pustaka antonovsky, aaron, 1978. health, stress and coping. san francisco, jossey-bass. antonovsky, aaron, 1996. the salutogenic model as a theor y to guide health p r o m o t i o n . h e a l t h p r o m o t i o n international. vol. 11, no. 1 pp 11-18. lindst röm, b. and m. er iksson, 2006. c o n t e x t u a l i z i n g s a l u t o g e n e s i s and a ntonovsk y in public health developme nt. he a lth p ro m ot i o n international, vol. 21 no. 3. becker, craig m, et al., 2010. salutogenesis 30 years later: where do we go from here? international electronic journal of health education, 2010; 13: 25-32. eriksson, m and b. lindström, 2008. a salutogen ic i nter pret at ion of t he ottawa charter. health promotion international, vol. 23 no. 2. (2008). lindst röm, b. and m. er iksson, 2005. salutogenesis. j epidemiol community health 59:440–442. eriksson, monica and b. lindström, 2005. validity of antonovsky’s sense of coherence scale: a systematic review. j epidemiol community health ; 59:460– 466. langeland, eva et al., 2007. promoting coping: salutogenesis among people with mental health problems. issues in mental health nursing, 28:275–295, 2007. 251 meningkatkan respon psikologis tenaga kerja indonesia yang terinfeksi hiv melalui dukungan keluarga dan peer group support (improving psychological response on indonesian’s migrant worker (tki) infected by hiv through family and peer group support) *tintin sukartini, *nursalam, *eka mishbahatul m.has, *candra panji asmoro, **misutarno *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya **rsud dr. soetomo surabaya email: dopaminsirup@gmail.com abstrak pendahuluan: human immunodeficiency virus (hiv) adalah sebuah retrovirus yang menginfeksi sel-sel sistem imun, menghancurkan atau merusak fungsi dari sel-sel sistem imun. isu yang beredar telah banyak penderita hiv baru yang terdeteksi sumber penularannya berasal dari mantan tki yang bekerja di luar negeri. tantangannya adalah bagaimana memperbaiki respon psikologis odha agar mampu percaya diri bersosialisasi dan tidak khawatir dengan stigma. tujuan dari penelitian ini adalah melaksanakan model dukungan keluarga tenaga kerja indonesia yang terinfeksi hiv dan peer group support melalui modul yang dilaksanakan oleh keluarga dan kelompok sebaya. metode: penelitian ini menggunakan desain pre-experiment. populasinya adalah odha yang tertular semasa kerja di luar negeri sebagai tki di wilayah jawa timur. sampel dipilih dengan menggunakan teknik simple random sampling. variabel independennya adalah peer group support dan keluarga, variabel dependennya adalah respon psikologis responden. data dikumpulkan dengan menggunakan kuesioner yang telah diuji validitas dan reliabilitas didukung dengan pelaksanaan focus group discussion responden sebagai penguat hasil secara kualitatif. hasil kuantitatif diuji menggunakan wilcoxon signed rank test dengan α ≤ 0,05. hasil: hasil menunjukkan bahwa metode ini dapat meningkatkan respon psikologis klien yang terinfeksi hiv semasa kerja sebagai tki di luar negeri dengan nilai signifikansi p=0,040. hasil kualitatif menyatakan bahwa sebagian besar responden menemukan makna hidup yakni berserah diri kepada tuhan yang maha esa. diskusi: dukungan keluarga dan peer group support dapat digunakan untuk meningkatkan respon psikologis penderita hiv yang terinfeksi semasa kerja di luar negeri menjadi tki. penelitian selanjutnya diharapkan dapat menggunakan sampel yang lebih besar sehingga mempunyai kelompok kontrol. kata kunci: dukungan keluarga, peer group support, respon psikologis, tki (tenaga kerja indonesia), human immunodeficiency virus (hiv) abstract introduction: human immunodeficiency virus (hiv) is a retrovirus that infects cells of the immune system, destroying or damaging the function of cells of the immune system. a lot of new detected hiv transmission source comes from former workers who work abroad. the challenge is how to improve the psychological response of people living with hiv (plwha) to be able to socialize confident and not worry about the stigma. the purpose of this study is to implement the model of family support indonesian workers who are infected with hiv and peer support group through modules implemented by families and peer groups. methods: this study was used a quasy-experimental. population in this study were the plwha who contracted during work abroad as migrant workers in east java. samples were selected using simple random sampling technique. the independent variable were the family and peer group support, the dependent variable was the psychological response of respondents. data were collected using a questionnaire that has been tested for validity and reliability and results were tested using the wilcoxon signed rank test with alpha ≤0.05 and supported by the implementation of the focus group respondents as a reinforcement of the qualitative results. results: the results showed that this method can improve psychological response of the plwha during labor as migrant workers abroad with a significance value of p=0.040. qualitative results stated that the majority of respondents found the meaning of life that is surrendered to god almighty. discussion: family and peer group support can be used to increase the psychological response of the plwha during work abroad as migrant workers. future studies are expected to use a larger sample so as to have a control group. keywords: family support, peer group support, psychological response, tki (indonesian labor), human immunodeficiency virus (hiv) pendahuluan human immunodeficiency virus (hiv) adalah sebuah retrovirus yang menginfeksi selsel sistem imun, menghancurkan atau merusak fungsi dari sel-sel sistem imun. sebagai progress dari infeksi, sistem imun menjadi lemah, dan manusia menjadi lebih rentan terkena infeksi. stadium yang paling lanjut dari infeksi hiv adalah acquired immune mailto:dopaminsirup@gmail.com jurnal ners vol. 11 no. 2 oktober 2016: 251-255 252 deficiency syndrome (aids) (who 2013). virus tersebut merusak kekebalan tubuh manusia dan mengakibatkan turun dan hilangnya daya tahan tubuh sehingga mudah terjangkit penyakit infeksi lainnya (nursalam, & kurniawati 2007) penurunan imunitas dipengaruhi oleh beberapa faktor. faktor yang perlu diperhatikan oleh tenaga kesehatan adalah stresor psikososial. lingkup terkecil dari lingkungan sosial pasien adalah keluarga. dukungan sosial terutama dari keluarga adalah penting, dan sangat menentukan perkembangan penyakit yang dapat menurunkan kondisi kesehatan pasien, mempercepat progresivitas penyakit hingga timbul kematian. pada penelitian lainnya oleh tim diperoleh hasil bahwa pengembangan model dukungan keluarga dan dukungan sebaya mampu meningkatkan kemandirian keluarga dalam tindakan perawatan anggota keluarga yang terinfeksi hiv ketika bekerja sebagai tki di luar negeri. berdasarkan hasil tersebut peneliti merasa perlu mengimplementasikan suatu modul hasil penelitian sebelumnya untuk melihat pengaruhnya terhadap respon psikologis responden. respon psikologis ini yang perlu diketahui terlebih dahulu karena merupakan manifestasi awal dari keyakinan responden sebelum muncul adanya interaksi sosial dengan yang lain dan juga kekhawatiran dari adanya stigma oleh masyarakat. pada tahun 2013 ini, ditjen pp & pl kementerian kesehatan republik indonesia merilis data tentang penemuan kasus baru hiv pada tahun 2012 mencapai 21.511. data ini meningkat daripada tahun sebelumnya pada 2011 sejumlah 21.031. jumlah penderita hiv khusus propinsi jawa timur, seperti yang disampaikan oleh dinas kesehatan propinsi jawa timur pada tahun 2011 tercatat sebanyak 2646 jiwa, terjadi peningkatan dari tahun sebelumnya sejumlah 2233 jiwa. data hingga juni 2012 menunjukkan bahwa kabupaten kediri dan kabupaten tulungagung termasuk dalam zona merah distribusi kasus aids di propinsi jawa timur. data secara nasional mengenai tki yang positif terinfeksi hiv&aids belum terdokumentasi dengan baik. namun, terdapat sumber menyatakan bahwa terjadi kewaspadaan oleh pihak dinas tenaga kerja, transmigrasi, dan kependudukan (disnakertransduk) jawa timur mengenai penyebaran kasus hiv&aids di propinsi jawa timur adalah dari mantan tenaga kerjatenaga kerja indonesia. data jumlah pekerja di jawa timur yang terjangkit hiv&aids sebanyak 1700-an, dengan 10% diantaranya adalah mantan tenaga kerja indonesia (news 2011) individu dengan hiv&aids yang mendapat perawatan di rumah sakit akan mengalami kecemasan dan stres pada semua tingkat usia. penyebab kecemasan yang dialami pasien tersebut salah satu faktor yang mempengaruhi selain dari petugas kesehatan adalah keluarga. keluarga juga sering merasa cemas dengan perkembangan keadaan pasien, pengobatan, dan biaya perawatan. meskipun dampak tersebut tidak secara langsung kepada pasien, tetapi secara psikologis pasien akan merasakan perubahan perilaku dari keluarga yang menungguinya selama perawatan (marks, 1998). pasien menjadi semakin stres dan berpengaruh terhadap proses penyembuhannnya karena penurunan respon imun. robert ader (1885) telah membuktikan bahwa individu yang mengalami kegoncangan jiwa akan mudah terserang penyakit, karena pada kondisi stres akan terjadi penekanan sistem imun (subowo 1992). penelitian ini merupakan lanjutan dari penelitian sebelumnya yang mencari pengembangan model dari kerangka konsep yang dibuat terhadap dampaknya bagi kemandirian perawatan anggota keluarga odha terhadap odha. penelitian tahun berikutnya ini mengambil fenomena yang ditemukan selama penelitian tahun sebelumnya, yakni melihat pengaruh intervensi yang dikembangkan terhadap respon psikologis responden. ada keterkaitan antara lingkungan sosial (keluarga dan teman sebaya) pasien hiv&aids dengan progresifitas penyakit tersebut, membuat penulis ingin mengetahui bagaimana gambaran reaksi psikologis (respon stres) pada tenaga kerja indonesia (tki) yang terinfeksi virus hiv. dukungan dari lingkungan sosial (keluarga) sangat dibutuhkan pasien hiv&aids sehubungan dengan rasa putus asa yang dialami pasien sejak pasien tersebut dinyatakan terinfeksi virus hiv. harapannya, dengan adanya respons emosi yang positif dari keluarga dapat mengurangi stres yang dialami pasien. bahan dan metode penelitian ini merupakan jenis penelitian preexperiment dengan pre-post test design. populasi terjangkau adalah tki yang terinfeksi hiv di kabupaten tulungagung. pengambilan sampel meningkatkan respon psikologis tki yang terinfeksi hiv (nursalam, dkk) 253 dilakukan dengan teknik simple random sampling dan diperoleh sampel sebanyak 11 responden. penelitian ini menggunakan dua variabel, yaitu variabel independen dukungan keluarga dan peer group support, serta variabel dependen berupa respon psikologis responden yang terinfeksi hiv dari semasa kerja sebagai tki di luar negeri. instrumen yang digunakan adalah instrumen respon psikologis yang evaluasinya diperkuat dengan focus group discussion (fgd) dengan pertanyaan terstruktur pada pasien yang terinfeksi hiv dari semasa kerja sebagai tki di luar negeri. kuesioner telah diuji validitas dan reliabilitasnya. hasil penelitian penelitian sampai jurnal ini diterbitkan telah menyelesaikan intervensi dan pengambilan data post-test di tulungagung. jumlah responden selama penelitian berlangsung sebanyak 11 responden. responden lainnya gugur karena keluarga tidak mengikuti koordinasi bentuk intervensi. tingkat respon psikologis responden yang terinfeksi hiv dari semasa kerja menjadi tki di luar negeri ditunjukkan dalam tabel di bawah. respon psikologis tki penderita hiv sebelum intervensi juni -september 2016 di kabupaten tulungagung lebih dari separoh memiliki respon psikologis bargaining sebesar 62,5%. tabel 1 tabel respon psikologis penderita hiv tertular saat tki setelah intervensi juni -september 2016 di kabupaten tulungagung res respon psikologis tot den ang barg depr acc % % % % % % tki 12,5 25 62,5 100 tabel 2 tingkat respon psikologis responden sebelum dan setelah intervensi di kabupaten tulungagung pada bulan juniseptember 2016 tingkat respon psikologis pre post % % kurang 62,5 12,5 cukup 12,5 25 baik 25 62,5 total 100 100 wilcoxon signed rank test p=0,040 data di atas menunjukkan bahwa sebagian besar responden penderita hiv sebelum intervensi respon psikologisnya berada dalam tahap bargaining. sebagian kecil responden sebelum intervensi respon psikologisnya berada dalam tahap depresi. respon psikologis dalam tahap menerima dialami oleh sebagian kecil responden. setelah mulai dilakukan intervensi, sebagian kecil saja responden yang respon psikologisnya berada dalam tahap bargaining dan tingkat psikologis depresi. respon psikologis acceptance dialami oleh sebagian besar responden. pengaruh intervensi dapat dilihat dari signifikansi perubahan respon psikologis sebelum dan sesudah intervensi. hasil analisis statistik menunjukkan terdapat pengaruh intervensi dukungan keluarga dan teman sebaya terhadap respon psikologis odha. pembahasan respon adaptasi psikologis terhadap stresor menurut kubler ross (1974) menguraikan lima tahap reaksi emosi seseorang terhadap stresor yakni 1) pengingkaran; 2) marah; 3) tawar menawar; 4) depresi; dan 5) menerima. tidak ada cara yang paling tepat dan cepat untuk menjalani proses berduka. konsep dan teori berduka hanyalah alat yang hanya dapat digunakan untuk mengantisipasi kebutuhan emosional klien dan juga rencana intervensi untuk membantu mereka memahami kesedihan mereka dan mengatasinya. dukungan keluarga merupakan sebuah proses yang terjadi sepanjang masa kehidupan, sifat dan jenis dukungan berbeda dalam setiap tahap siklus kehidupan. dukungan keluarga dapat berfungsi dengan kepandaian akal. sebagai akibatnya, hal ini meningkatkan kesehatan dan adaptasi keluarga. keberadaan dukungan keluarga yang adekuat terbukti berhubungan dengan menurunnya angka mortalitas (friedman, 2010). satu penelitian tentang dukungan kelompok sebaya yang dilakukan untuk mengetahui bagaimana perubahan kepatuhan pengelolaan/perawatan pada pasien dengan diabetes mellitus didapatkan hasil bahwa dengan peer group support mampu meningkatkan kepatuhan responden dalam menjalankan latihan fisik dan konsumsi obat pada penderita diabetes mellitus, namun tidak mampu meningkatkan kepatuhan akan diit penderita. saran yang jurnal ners vol. 11 no. 2 oktober 2016: 251-255 254 diberikan yakni membuat sebuah peer group support antar penderita dan keluarga sebagai wadah interaksi dan saling memberi dukungan baik berupa pengetahuan maupun emosional (diantiningsih , y, kusnanto, & bakar 2012) pemberian materi berupa dukungan keluarga selain aspek intensitas dalam pemberiannya, namun juga perlu diperhatikan aspek kedalaman dalam penanaman pentingnya peran keluarga secara bersamasama. peneliti dalam memberikan materi pentingnya dukungan keluarga memperhatikan tingkat pendidikan dan pengetahuan yang dimiliki oleh keluarga yang merawat. penerimaan keluarga akan sakit yang diderita anggota keluarga yang terinfeksi hiv juga diperhatikan. hal ini menjadi perhatian peneliti karena dibutuhkan komitmen sebelum membentuk intensi yang kuat dari anggota keluarga untuk mau dan mampu merawat anggota keluarga yang terinfeksi hiv, dimana penyakit ini akan selamanya diidap oleh anggota keluarga yang terifeksi hiv tersebut. aspek kemampuan keluarga dalam memenuhi peran sebagai perawat dilakukan pengidentifikasian terlebih dahulu oleh peneliti. sebagian besar responden tahu apa yang harus diperbuat atau perannya selama anggota keluarga yang terinfeksi hiv sedang sehat maupun ketika sakit. hal ini menjadi potensi yang perlu ditingkatkan oleh peneliti dengan menggunakan modul yang dibuat oleh tim peneliti. peneliti memberikan materi berupa manfaat-manfaat yang bisa diperoleh penderita hiv jika dirawat dengan kasih sayang oleh keluarga. adanya dukungan seperti hal tersebut dengan tidak disadari oleh keluarga maupun penderita memberi stimulus yang positif bagi penderita sehingga penderita tidak stres. tim peneliti mempunyai pendapat bahwa materi yang telah diberikan kepada anggota keluarga odha mampu diterapkan dengan baik oleh keluarga, sehingga tingkat respons psikologis responden juga meningkat dibuktikan dengan signifikasi analisis data yang telah dikerjakan. kombinasi intervensi dukungan keluarga oleh keluarga mereka sendiri bersama dengan peer group support membawa tim peneliti beropini bahwa intervensi tersebut juga berperan besar dalam hasil respon psikologis responden yang didapat. kegiatan pertemuan rutin yang diadakan pihak terkait yang menangani odha di wilayah tempat penelitian sering kali diadakan, namun peserta pertemuan yang merupakan penderita maupun keluarganya masing-masing mulai merasa malas untuk datang dengan berbagai alasan. tim peneliti memberi arahan dalam intervensi peer group support yakni merubah strategi menjadi jemput bola dan tidak perlu menunggu adanya kegiatan formal. kelompok sebaya juga diberi materi tentang peran mereka dalam memperbaiki respon psikologis responden oleh tim peneliti menggunakan modul. pertemuanpertemuan informal seperti misal saat keluarga penderita maupun penderita bertemu di rumah sakit untuk mengambil obat arv seringkali menjadi ajang bertukar informasi dan memberikan dukungan, serta memberikan pengetahuan terkini mengenai hiv oleh tim peneliti. peneliti melihat fungsi dari dilakukan peer group support pada responden sudah terlaksana setelah diberikan materi dan strategi pendampingan melalui observasi. dukungan keluarga dan dukungan kelompok sebaya yang terus menerus tentu menjadi tantangan bagi tim peneliti untuk menjaga konsistensi intervensinya terhadap responden. oleh karena itu, tim peneliti lebih sering memantau dengan berkomunikasi melalui telepon. kunjungan langsung kepada keluarga dan kelompok sebaya dilakukan untuk pemberian materi kepada mereka. antusias responden juga menjadi bahan evaluasi kami. melalui wawancara, dukungan antar kelompok sebaya diakui oleh beberapa responden mampu memberikan solusi dari setiap permasalahan psikologis yang muncul. kekhawatirankekhawatiran dalam kegiatan bersosialisasi di masyarakat baik pada saat di rumah maupun di tempat kerja mereka mampu ditemukan solusi yang mana solusi tersebut muncul dari keluarga responden lain yang pernah mengalami dan anggota keluarga penderita lain menguatkan solusi tersebut sehingga timbul dukungan antar kelompok sebaya untuk kemudian dipraktikkan kepada responden yakni odha tki. simpulan dan saran simpulan dukungan keluarga dan peer group support mampu meningkatkan tingkat respon psikologis tki yang terinfeksi hiv dari semasa kerja di luar negeri di wilayah kabupaten tulungagung. dukungan keluarga dan peer group support dalam hal ini mencakup peran keluarga dan teman sebaya dalam perawatan secara biologis (ketika meningkatkan respon psikologis tki yang terinfeksi hiv (nursalam, dkk) 255 penderita mengalami atau tidak penyakit penyerta hiv), psikososial, dan spiritual. saran peningkatan respon psikologis hanya mencakup pada pada odha yang menjadi kriteria penetapan responden penelitian. penambahan cakupan jumlah responden dengan penentuan kriteria diharapkan dapat menambah jumlah responden dan diharapkan desain penelitian yang diambil adalah quasyexperiment. pihak terkait juga melakukan kunjungan rumah penderita tanpa menggunakan identitas dari instansi mana untuk melakukan pengawasan atau pengkajian bagaimana respon psikologis berubah setiap saat karena manusia sangat unik. kepustakaan diantiningsih , y, kusnanto, & bakar, a., 2012. peer group support terhadap perubahan kepatuhan pengelolaan penyakit diabetes mellitus tipe 2. news, a., 2011. jatim tertinggi kasus hiv/aids. available at: <http://www.antarajatim.com/lihat/berita/ 77591/jatim-tertinggi-kasus-hivaids >. nursalam, & kurniawati, n., 2007. asuhan keperawatan pada pasien terinfeksi hiv, jakarta: salemba medika. subowo, 1992. histologi umum, jakarta: bumi aksara. who, 2013. hiv/aids. diakses tanggal 19 desember 2013 pukul 18.00. <http://www.who.int/topics/hiv_aids/en/ > dinkes provinsi jawa timur. 2012. program pengendalian penyakit menular di jawa timur. diakses tanggal 22 desember 2013 pukul 17.33 <http://dinkes.jatimprov.go.id/userimage /p2.pdf> depkes. 2013. profil kesehatan indonesia 2012. diakses tanggal 19 desember 2013 pukul 18.16. <http://www.depkes.go.id/downloads/pr ofil%20kesehatan_2012%20%284%20s ept%202013%29.pdf> depkes, 2003. pedoman nasional perawatan, dukungan dan pengobatan bagi odha: buku pedoman untuk petugas kesehatan dan petugas lainnya. jakarta: ditjen ppm dan pl depkes nursalam, yusuf, ah, widyawati y i, & asmoro , c p, 2015. pengembangan model pemberdayaan keluarga tenaga kerja indonesia (tki) yang terinfeksi hiv dan peer group support dalam kemandirian perawatan tenaga kerja indonesia (tki) yang terinfeksi hiv. jurnal ners, vol. 2 2015 stewart, g., 1997. managing hiv. sydney: mja publisher 134 peningkatan parenting self efficacy pada ibu pasca seksio sesaria melalui konseling (improving parenting self efficacy after caesarean section through counselling) diah astutiningrum*, elsi dwi hapsari**, purwanta** *stikes muhammadiyah gombong **magister keperawatan fakultas kedokteran universitas gadjah mada email: diahashari@gmail.com abstrak pendahuluan: parenting self efficacy (pse) merupakan keyakinan orang tua terhadap kemampuannya dalam mengatur dan melakukan tugas yang berhubungan dengan mengasuh anak. rasa sakit setelah persalinan sc dapat mengurangi kemampuan dan menurunkan keyakinan ibu dalam merawat bayi. konseling pada ibu postpartum merupakan upaya meningkatkan keyakinan diri dalam mengasuh bayi. tujuan: menguji pengaruh konseling yang diberikan pada ibu postpartum dengan sc terhadap peningkatan pse. metode: penelitian menggunakan quasi eksperimen dengan pre-test and post-test with control group. jumlah subjek penelitian sebanyak 66 subjek terbagi menjadi kelompok eksperimen 33 dan kontrol 33. subjek yang sesuai kriteria inklusi, diberikan kuesioner dan dilakukan pre-test dengan parenting self efficacy scale (pses), melakukan konseling dan memberi booklet pada kelompok eksperimen dan memberi booklet saja pada kelompok kontrol. pengukuran dilakukan dengan instrumen parenting self efficacy scale (pses). uji statistik yang digunakan adalah paired t-test dan independent sample t-test. hasil: peningkatan skor pse yang bermakna setelah dilakukan intervensi pada kelompok eksperimen dan kelompok kontrol (6,19±0,93 vs 7,54±0,71, p=0,001; 5,56±0,85 vs 5,87±0,68, p=0,001). perubahan skor setelah intervensi secara bermakna lebih tinggi pada kelompok eksperimen dibanding kelompok kontrol (1,35±0,58 vs 0,31±0,26, p= 0,000) . kesimpulan: konseling dengan menggunakan booklet berpengaruh terhadap parenting self efficacy pada ibu postpartum dengan sc. kata kunci : parenting self efficacy, konseling, postpartum, section caesarea abstract introduction: parenting self efficacy (pse) is the conviction of parents for their ability to manage and perform tasks related to parenting. pain after caesarean childbirth can reduce the ability and lower confidence in caring for the babies. counseling on postpartum mother is an effort to increase confidence in caring for the baby. this study was aimed to test the effect of counseling given to mothers after caesarean section to increase pse. methods: the study used a quasi experimental with pre-test and post-test with control group. number of research subjects were 66 divided into an experimental group and control group. subject who pass the inclusion criteria, given the questionnaire and conducted pre-test with parenting selfefficacy scale (pses), given counseling and provide booklets in the experimental group, while the control group only given booklets. measurements were made with instruments of parenting self-efficacy scale (pses). the statistical test used was paired t-test and independent sample t-test. results: increased pse significant score after the intervention in the experimental group and the control group (6.19 ± 0.93 vs 7.54 ± 0.71, p = 0.001; 5.56 ± 0.85 vs 5.87 ± 0 , 68, p = 0.001). changes in scores after the intervention were significantly higher in the experimental group than the control group (1.35 ± 0.58 vs 0.31 ± 0.26, p = 0.000). discussion: counseling by using booklets effect on parenting self-efficacy in women after caesarean section. keywords: parenting self-efficacy, counseling, postpartum, section caesarea ____________________________________________________________________________________________________ pendahuluan periode postpartum merupakan krisis bagi seorang ibu, pasangan, dan keluarga akibat berbagai perubahan yang terjadi baik secara fisik, psikologis, maupun struktur keluarga yang memerlukan proses adaptasi atau penyesuaian. adaptasi secara fisik dimulai sejak bayi dilahirkan sampai kembalinya kondisi tubuh ibu pada kondisi seperti sebelum hamil, yaitu dalam kurun waktu 6 sampai 8 minggu (piliteri, 2003: murray & mckinney, 2007). persalinan melalui pembedahan atau seksio sesarea (sc) juga memerlukan proses adaptasi yang tidak mudah bagi ibu postpartum. rasa sakit setelah persalinan dan keterbatasan fisik untuk bergerak dapat juga mengurangi kemampuan dalam merawat bayi karena ibu postpartum dengan sc biasanya akan merasa takut dan cemas terhadap kondisi kesehatannya sendiri. hal ini juga dapat menurunkan keyakinan ibu dalam merawat bayi baru lahir. parenting self efficacy merupakan keyakinan orang tua terhadap kemampuannya dalam mengatur dan melakukan tugas yang berhubungan dengan mengasuh anak dalam kondisi tertentu (bandura, 1997). dalam sebuah penelitian yang dilakukan oleh potter dan hui-chin pada tahun jurnal ners vol. 11 no. 1 april 2016: 134-141 135 2003 membuktikan bahwa ibu yang memiliki pse yang tinggi mempunyai kemampuan yang lebih baik dalam melakukan tugas sebagai orang tua, lebih tanggap dalam merespon setiap isyarat dan kebutuhan bayi serta memiliki hubungan interaksi yang lebih baik dengan anak. pendidikan kesehatan merupakan interaksi antara pendidik dan peserta didik yang mendorong terjadinya pembelajaran sebagai upaya menambah pengetahuan baru, sikap, dan ketrampilan untuk menghasilkan perubahan perilaku (notoatmodjo, 2007; potter & perry, 2009). pendidikan kesehatan memiliki berbagai macam metode yang dapat diterapkan sesuai dengan situasi dan kondisi dari penerima edukasi. pengetahuan dan sikap yang baik akan meningkatkan kepercayaan diri, yang selanjutnya membantu ibu beradaptasi terhadap perubahan-perubahan fisik, emosional, fungsi dan sosial setelah melahirkan (wess, fawcett, & aber, 2009). pemilihan metode pendidikan kesehatan yang diberikan secara individual yang disebut dengan konseling didasarkan pada keyakinan bahwa setiap individu itu unik serta memiliki minat dan kebutuhan yang berbeda, sehingga konseling menjadi pilihan yang tepat dalam metode pendidikan yang bersifat individual dan terstruktur. hasil penelitian yang dilakukan runiarti et al., (2005) menunjukkan bahwa metode pendidikan kesehatan yang efektif dan menjadi pilihan kebanyakan ibu postpartum adalah pendidikan kesehatan perorangan. selain karena masalah yang dialami oleh setiap ibu berbeda metode perorangan juga lebih bersifat privasi. konseling merupakan salah satu cara pendekatan dalam penyampaian informasi untuk menolong individu. konseling adalah bentuk komunikasi interpersonal yang khusus, yaitu pemberian bantuan yang dilakukan pada orang lain dalam membuat suatu keputusan atau m e m e c a h k a n s u a t u m a s a l a h m e l a l u i pemahaman terhadap klien meliputi faktafakta, harapan, kebutuhan dan perasaan klien m e n u r u t b a d a n k o o r d i n a s i k e l u a r g a berencana nasional (bkkbn, 2011). bahan dan metode penelitian ini menggunakan desain quasi eksperimen dengan pendekatan pre dan post test with control group design pemilihan sampel digunakan tehnik non probability sampling dengan pendekatan purposive sampling. subjek penelitian berjumlah 66 subjek dan dibagi m e n j a d i d u a k e l o m p o k y a i t u k e l o m p o k eksperimen dan kelompok kontrol. intervensi yang diberikan pada kelompok eksperimen berupa konseling dan pemberian booklet sedangkan pada kelompok kontrol berupa pemberian booklet saja. pada kedua kelompok dilakukan pre test dan post test. pengumpulan data menggunakan instrumen pse scale dan istrumen dukungan keluarga. penelitian dilakukan pada bulan agustus oktober 2014 diruang rahma rsu pku muhammadiyah gombong kabupaten kebumen. teknik analisis data dengan menggunakan independen sample t-test dan paired t-test. hasil tabel 1. analisis skor pse pada aspek kognitif, afektif, ketrampilan dan pse pada kelompok eksperimen dan kelompok kontrol eksperimen kontrol mean±sd p (pre-pos) ci 95%  (n=33) mean±sd p (pre-pos) ci 95%  (n=33) p  kognitif pre 6,18±0,99 0,001 1,18-1,62 1,41±0,61 5,50±0,85 0,001 0,21-0,41 0,31±0,29 0,0 kognitif pos 7,59±0,79 5,82±0,69 afektif pre 6,03±0,92 0,001 1,13-1,61 1,37±0,67 5,57±0,89 0,001 0,21-0,42 0,32±0,29 0,0 afektif pos 7,40±0,72 5,88±0,76 ketrampilan pre 6,37±0,94 0,001 0,98-1,52 1,25±0,76 5,65±0,91 0,001 0,17-0,41 0,29±0,34 0,0 ketrampilan pos 7,62±0,78 5,94±0,69 pse pre 6,19±0,93 0,001 1,15-1,56 1,35±0,58 5,56±0,85 0,001 0,22-0,40 0,31±0,26 0,0 pse pos 7,54±0,71 5,87±0,68  = selisih rerata peningkatan parenting self efficacy (diah astutiningrum, dkk.) 136 tabel 2. perbedaan tingkat pse sebelum dan setelah intervensi pada kelompok eksperimen dan kelompok kontrol sebelum setelah p eksperimen rendah 2 (6,1%) 0 (0,0%) 0,500 cukup 28 (84,8%) 20 (60,6%) 0,312 tinggi 3 (9,1%) 13 (39,4%) 0,021 kontrol rendah 4 (12,1%) 0 (0,0%) 0,125 cukup 29 (87,9%) 33 (100,0%) 0,704 tinggi 0 (0,0%) 0 (0,0%) 1,000 karakteristik subjek penelitian antara kelompok eksperimen dan kelompok kontrol adalah sama. sehingga kedua kelompok bisa dikatakan homogen. namun, setelah dilakukan konseling didapatkan peningkatan skor pse yang bermakna pada kelompok eksperimen, dibanding kelompok kontrol. aspek tersebut dibedakan menjadi aspek kognitif, aspek afektif, aspek ketrampilan, dan parenting self efficacy (tabel 1). perbedaan pse antara kelompok eksperimen dan kelompok kontrol disjikan dalam tabel 2. pada kelompok eksperimen tidak terdapat perbedaan proporsi pse kategori rendah dan cukup antara sebelum dan setelah intervensi (p>0,05) sedangkan pada kategori tinggi terdapat perbedaan bermakna proporsi pse antara sebelum dan setelah intervensi (p<0,05). pada kelompok kontrol tidak terdapat perbedaan proporsi pse kategori rendah, cukup, maupun tinggi antara sebelum dengan setelah intervensi (p>0,05). pembahasan perubahan pse pada aspek kognitif dalam penelitian ini tindakan konseling dengan menggunakan demonstrasi dan booklet yang dilakukan pada kelompok eksperimen berpengaruh signifikan terhadap peningkatan skor pse pada aspek kognitif. dengan menggunakan metode demonstrasi dan pemberian booklet pada kelompok eksperimen menjadi faktor yang dapat mempengaruhi peningkatan tersebut. selama proses konseling ibu mendapat kesempatan untuk mendengarkan informasi yang diberikan oleh petugas, bertanya secara langsung, terlibat dalam diskusi maupun melakukan praktek secara langsung dengan menggunakan alat peraga sehingga semakin banyak indera yang digunakan dalam menangkap materi akan semakin baik penyerapanya. berdasarkan the learning pyramid oleh edgar dale bahwa penyerapan materi pada metode melihat demonstrasi sebesar 30%, terlibat dalam diskusi 50% dan mempraktekkan kembali cara merawat bayi sebesar 75%. fokus perawatan postpartum menempatkan ibu sebagai individu yang sehat dan memiliki kemampuan, namun memerlukan dukungan baik dari keluarga maupun tenaga kesehatan untuk dapat melakukan aktivitas secara mandiri. dukungan dan nasehat dari orang yang tepat dan dapat dipercaya akan meningkatkan kepercayaan diri ibu dalam melakukan tugas dan tanggung jawabnya. perawat dapat membantu pasien membentuk suatu riwayat perilaku yang positif bagi masa depan dengan memfokuskan pada manfaat perilaku tersebut dan membantu pasien dalam mengatasi rintangan dalam melaksanakan perilaku tersebut, meningkatkan level efficacy dan pengaruh positif melalui pengalaman yang sukses dan feedback yang positif (pender, 2002). melalui konseling secara individual, perawat dapat menjadi system pendukung bagi ibu karena informasi yang disampaikan oleh perawat dirasa tepat dan jelas serta sesuai dengan kebutuhan ibu. artinya bahwa metode konseling secara individu terbukti dapat meningkatkan kemampuan ibu dalam menerima dan mengolah informasi yang disampaikan sehingga mempengaruhi pengetahuan ibu. sesuai dengan temuan runiarti et al.,(2005) bahwa ibu dan keluarga lebih memilih metode edukasi perorangan karena metode ini bersifat privacy dan memberikan kemudahan bagi ibu memahami informasi yang disampaikan. dalam teori the learning pyramid edgar dale hasil belajar seseorang diperoleh melalui pengalaman langsung (konkrit), kenyataan yang ada di lingkungan kehidupan seseorang kemudian melalui benda tiruan, sampai kepada lambang verbal (abstrak). semakin keatas puncak kerucut semakin abstrak media penyampai pesan itu. pembelajaran yang dikembangkan dengan merujuk pada piramida edgar dale, penguatannya pada bagian piramida terbawah yaitu benda tiruan dan pengalaman langsung, melalui praktek jurnal ners vol. 11 no. 1 april 2016: 134-141 137 pengalaman langsung akan memberikan informasi dan gagasan yang terkandung dalam pengalaman itu, karena melibatkan indera penglihatan, pendengaran, perasaan, penciuman, dan peraba. studi yang dilakukan oleh bloomfield dan kendall (2007) yang mengembangkan intervensi dengan metode diskusi kelompok dan pemberian booklet, intervensi ini terbukti dapat meningkatkan pse pada orang tua. perawat dapat menjadi fasilitator dalam sebuah diskusi kelompok dimana setiap individu dapat berbagi pengalaman menjadi orang tua. pemberian boo klet p ad a kelompo k ko ntro l juga m emp engaruhi p eningkatan p se, boo klet merupakan sumber informasi yang menarik dan dapat digunakan sewaktu-waktu sehingga dapat memenuhi kebutuhan belajar ibu dalam perawatan bayi baru lahir. perubahan pse pada aspek afektif perubahan rata-rata skor pse juga terlihat pada aspek afektif. perbedaan skor sebelum dan sesudah intervensi menunjukkan perbedaan yang bermakna. hasil penelitian ini membuktikan bahwa pemberian informasi dalam bentuk konseling dan pemberian booklet serta dukungan sesuai dengan prioritas kebutuhan ibu dapat meningkatkan reaksi emosional. secara umum bahwa faktor yang dapat mempengaruhi reaksi emosional adalah jenis persalinan yaitu ibu yang menjalani persalinan secara sc. kurangnya persiapan terhadap proses persalinan menjadi trauma psikologis bagi ibu terutama primipara. proses penyembuhan luka dan pemulihan fungsi tubuh yang lebih lama menyebabkan ketidaknyamanan secara fisik dan psikologis sesuai dengan pernyataan dari bandura (1977) bahwa kondisi psikologis dan emosional yang tidak stabil misalnya stress dan kecemasan akan mengancam kemampuan diri seseorang. hal ini juga didukung oleh penelitian yang dilakukan oleh salonen et al., (2008) bahwa salah satu faktor yang mempengaruhi penggunaan internet sebagai media belajar adalah jenis persalinan dengan sc, ketidaknyamanan fisik dan psikologis membuat ibu tidak mau untuk beraktifitas. pemberian dukungan dan informasi melalui konseling postpartum terbukti dapat meningkatkan penilaian positif ibu terhadap dirinya dalam melakukan pengasuhan bayi baru lahir. kesiapan belajar dan kondisi emosional ibu yang stabil menjadi faktor penentu dari keberhasilan konseling. pendampingan selama proses penelitian merupakan kesempatan bagi perawat untuk menilai kebutuhan dan kemampuan belajar setiap ibu, baik secara fisik maupun secara psikologis. mercer dan walker (2006) menegaskan bahwa kualitas interaksi dan dukungan sosial perawat secara langsung mempengaruhi kepercayaan diri ibu. interaksi positif yang telah terbina menjadi hal yang penting bagi ibu untuk bersedia mendengar dan mengikuti apa yang disampaikan oleh perawat, karena bagi pasien tenaga kesehatan adalah sebagai role model yang layak untuk ditiru. sesuai dengan pernyataan bandura (2005) bahwa seseorang akan cenderung mengikuti dan meniru orang yang dianggap sebagai model. dalam penelitian sebelumnya (salonen et al., 2011) juga ditemukan perubahan aspek afektif yang signifikan. perubahan ini terjadi karena adanya penambahan topik yang dibutuhkan oleh ibu postpartum dan tersedianya media interakif dalam bentuk website sehingga ibu mendapatkan dukungan yang cukup setelah melahirkan bayinya. perubahan pse pada aspek ketrampilan. ketrampilan merupakan aspek nyata dari perubahan perilaku menurut bloom dalam maulana (2009) kemampuan seseorang dalam melakukan tindakan tertentu biasanya terbentuk dari pengetahuan dan sikap sebelumnya. peningkatan skor pada kelompok eksperimen dan kelompok kontrol menunjukkan bahwa intervensi yang diberikan sangat berpengaruh terhadap peningkatan ketrampilan dalam merawat bayi baru lahir. hal ini disebabkan selama proses konseling pada kelompok eksperimen, subjek dapat lebih leluasa dalam berdiskusi dengan petugas kesehatan dan melakukan demonstrasi untuk melatih tindakan perawatan bayi baru lahir dengan pengawasan sehingga apabila terdapat kesalahan dalam tindakan akan lebih cepat untuk dikoreksi oleh petugas. kegiatan ini merupakan aktifitas yang membutuhkan keberanian dan pengalaman karena bayi baru lahir memiliki kondisi yang lemah. kurangnya pengalaman dalam merawat bayi sebelumnya menjadi salah satu faktor penyebab karena ketrampilan ini dapat ditingkatkan dengan latihan dan mencoba melakukan tindakan tersebut secara berulang-ulang. aktifitas perawatan dasar terhadap bayi baru lahir merupakan suatu ketrampilan sehingga ibu perlu latihan dan pendampingan agar ibu memiliki pengalaman melakukan tindakan tersebut, pendidikan kesehatan secara individual dengan metode konseling dan demonstrasi merupakan interaksi antara pendidik dan peningkatan parenting self efficacy (diah astutiningrum, dkk.) 138 peserta didik. metode ini sangat tepat digunakan dan terbukti dapat lebih meningkatkan keyakinan dalam melakukan tindakan perawatan dasar pada bayi baru lahir. demonstrasi dilakukan untuk memperagakan tindakan yang membutuhkan ketrampilan dan kecakapan. alat bantu peraga dibutuhkan sebagai perumpamaan objek yang dicontohkan. sesuai dengan pernyataan setiawati dan dermawan (2008) bahwa metode demonstrasi melibatkan lebih banyak indera yaitu indera pengelihatan, pendengaran, penciuman dan peraba sehingga mempermudah penerimaan informasi. metode redemonstrasi juga dilakukan sebagai upaya melatih ibu melakukan tindakan dengan pangawasan dan pendampingan perawat. penilaian dan koreksi dapat diberikan saat ibu menunjukkan tindakan yang kurang tepat. metode ini dapat bermanfaat untuk menurunkan kecemasan dan kekhawatiran ibu terhadap kesalahan yang mungkin terjadi. redemonstrasi juga terbukti efektif untuk melihat dan menilai ketrampilan ibu dalam melakukan tindakan tertentu. selain itu konseling dan demonstrasi selama di rumah sakit dan follow up setelah lebih dari tujuh hari setelah ibu dipulangkan dapat meningkatkan kepercayaan diri ibu dalam perawatan bayi baru lahir. peningkatan pada kelompok kontrol relative lebih rendah dibandingkan pada kelompok eksperimen karena pada kelompok kontrol hanya diberikan booklet saja dan tidak ada interaksi antara petugas kesehatan dengan ibu. metode demonstrasi dan redemonstrasi tidak dapat dilakukan pada intervensi berbasis internet karena intervensi ini dibatasi ruang dan waktu seperti hasil temuan salonen et al., (2011) menunjukkan peningkatan 0,11 poin. hal ini disebabkan tidak adanya kontak secara langsung antara penyedia informasi dengan ibu postpartum sehingga interaksi dan latihan tidak dapat dilakukan. rekaman video yang disediakan tentang tindakan perawatan bayi baru lahir dianggap kurang efektif karena seringkali ibu merasa takut dan khawatir melakukan kesalahan karena tidak ada yang mengawasi. konseling yang dilakukan terhadap ibu postpartum mempengaruhi peningkatan pse, dengan faktor yang menjadi penentu adalah waktu, materi, metode dan media pendidikan kesehatan yang sesuai. semua komponen tersebut menentukan kualitas konseling yang diberikan dan mempengaruhi kepuasan ibu terhadap perawatan yang diterimanya. sesuai dengan temuan davidson (2011) bahwa ibu yang mendapatkan edukasi yang berkualitas memiliki kepuasan yang lebih besar terhadap perawatan yang diterimanya. beberapa penelitian lain membuktikan pendidikan kesehatan postpartum dapat meningkatkan pengetahuan, sikap dan kemampuan ibu dalam melakukan perawatan bayi baru lahir (mutmaina et al., 2006). pengetahuan, sikap dan kemampuan ibu akan berpengaruh terhadap kesiapan, kepercayaan diri dan kemampuan ibu dalam menjalankan peran sebagai orang tua (weiss & lokken, 2009). hasil penelitian ini memberikan informasi bahwa konseling yang dilakukan pada ibu postpartum merupakan salah satu upaya yang baik untuk mempersiapkan ibu menjadi orang tua, yaitu masa transisi yang sangat penting bagi kehidupan seorang wanita (mercer, 2006). pengalaman pada periode ini bersifat permanen yang akan mempengaruhi kesehatan dan perkembangan anak. proses transisi menjadi orang tua dikatakan sehat dan berhasil apabila ibu mampu beradaptasi dan melaksanakan peran baru, mempertahankan hubungan dengan pasangan dan mampu membentuk kepuasan hubungan dengan anak (elek, hudson & flek, 2002). persiapan fisik dan psikologis menjadi hal yang penting dalam mencapai keberhasilan transisi peran sebagai seorang ibu, terutama yang baru pertama kali melahirkan dan mengalami operasi sc. fokus asuhan perawatan pada ibu postpartum yaitu tidak hanya pemulihan secara fisik tetapi juga menyiapkan ibu secara psikologis dan emosional agar mampu menjalankan tugas dan tanggung jawabnya dengan baik. beberapa penelitian telah membuktikan bahwa pse berpengaruh terhadap pertumbuhan dan perkembangan fisik, psikologis dan sosial anak yang optimal. ibu yang memiliki pse yang tinggi memiliki kemampuan yang lebih baik dalam melakukan tugas sebagai orang tua. semua hasil penelitian memberikan dukungan tentang pentingnya pendidikan kesehatan dengan berbagai metode dalam meningkatkan pse. pengaruh konseling terhadap pse pada ibu postpartum dengan sc peningkatan skor pada aspek kognitif, afektif dan ketrampilan antara kelompok eksperimen dan kelompok kontrol setelah mendapat intervensi, menggambarkan bahwa tindakan yang diberikan pada ibu berpengaruh jurnal ners vol. 11 no. 1 april 2016: 134-141 139 terhadap pse. perbedaan skor pada kelompok eksperimen dibanding kelompok kontrol sebelum perlakuan dipengaruhi oleh adanya kegiatan antenatal care yang diikuti oleh ibu selama masa kehamilan baik di rumah sakit, puskesmas maupun bidan setempat. pada saat dilakukan penelitian terjadi peningkatan hasil pengukuran sesudah intervensi baik pada kelompok eksperimen dan kelompok kontrol bermakna secara statistik. temuan ini membuktikan bahwa pse ibu postpartum mengalami perubahan positif. konseling yang diberikan kepada ibu postpartum pada kelompok eksperimen meningkatkan skor pse. hasil ini lebih tinggi signifikan dibandingkan dengan kelompok kontrol baik dari aspek kognitif, afektif, maupun ketrampilan. pendidikan kesehatan yang diberikan kepada orang yang memiliki kemampuan kognitif, afektif dan ketrampilan yang baik akan lebih muda diserap dan diaplikasikan dibanding pendidikan kesehatan yang diberikan pada orang kemampuan kognitif , afektif dan ketrampilan yang lebih rendah. perubahan pse pada ibu postpartum berdasarkan kategori yang terjadi kelompok eksperimen sebelum dan setelah dilakukan intervensi terlihat signifikan pada kategori tinggi. sedangkan pada kelompok kontrol tidak signifikan disemua kategori . perlakuan yang menekankan pada hubungan dan interaksi yang baik antara perawat dan klien menjadi pilihan yang tepat. kontak yang rutin dan keberlanjutan selama perawatan di rumah sakit memberikan kesempatan bagi perawat untuk mengamati serta menilai kebutuhan fisik dan psikologis setiap ibu. pelayanan yang sesuai dengan kebutuhan ibu merupakan usaha meningkatkan motivasi dan minat belajar ibu. berdasarkan teori keperawatan yang dikemukakan reva rubin bahwa perawatan menekankan pada pencapaian peran sebagai ibu. untuk mencapai peran ini seorang wanita memerlukan proses belajar melalui serangkaian aktivitas atau latihan. dengan demikian, seorang wanita terutama calon ibu dapat mempelajari peran yang akan di alaminya kelak sehingga ia mampu beradaptasi dengan perubahan-perubahan yang terjadi khususnya perubahan psikologis dalam kehamilan dan setelah persalinan. pendampingan dan rasa empati yang ditunjukkan oleh perawat sebagai bentuk persuasi untuk mempengaruhi orang lain dalam merubah perilaku positif (bandura, 2005). sesuai dengan hasil temuan schmied et al., (2008) bahwa usaha meningkatkan perawatan postpartum dapat dilakukan dengan membina hubungan baik dengan klien serta memenuhi kebutuhan setiap ibu secara individual. studi yang dilakukan oleh salonen (2008) mengembangkan sebuah intervensi berbasis internet untuk memberikan dukungan dan informasi bagi ibu postpartum. hasil penelitian ini menunjukkan bahwa perubahan rerata skor pse ibu sebelum dan sesudah perlakuan tidak bermakna secara statistik p>0.005 namun perlakuan tersebut terbukti meningkatkan pse ibu sebesar 0.30 poin. intervensi yang sama juga dikembangkan oleh hudson et al., (2003) sebagai bentuk penyediaan dukungan sosial dan informasi bagi pria yang baru pertama kali menjadi ayah. temuan pada penelitian tersebut menunjukkan pse ayah kelompok perlakuan meningkat signifikan p<0.001 pada dua kali pengukuran, yaitu 2.79 (sd 0.73) ketika bayi berusia 4 minggu, dan 3.66 (sd 0.53) ketika bayi berusia 8 minggu. perbedaan hasil penelitian ini dengan temuan sebelumnya dapat disebabkan bentuk perlakuan yang disediakan. dukungan dan informasi berbasis internet efektif dan tepat digunakan pada masyarakat yang memiliki kesadaran tinggi terhadap kebutuhan informasi. keterbatasan fisik selama masa pemulihan setelah melahirkan dan tugas perawatan bayi tidak menjadi penghalang bagi ibu dalam menggunakan internet karena akses internet tersedia kapan saja dan dimana saja. pengembangan informasi berbasis internet sangat efektif digunakan pada populasi di negara maju dengan tingkat pendidikan yang lebih tinggi, memiliki kemampuan menggunakan komputer dan internet, serta dukungan sarana dan prasarana yang memadai. konseling pada ibu postpartum merupakan salah satu upaya menyediakan dukungan dan informasi bagi ibu untuk meningkatkan kepercayaan diri dan kemampuan ibu dalam melakukan tugas dan tanggungjawab sebagai seorang ibu. sesuai dengan penelitian terdahulu, perlakuan konseling pada ibu postpartum dalam penelitian ini dikembangkan mengacu pada teori belajar sosial kognitif oleh bandura. edukasi dikemas dalam satu paket yang meliputi empat sumber informasi yang dapat meningkatkan pse (bandura, 2005) yaitu enactive mastery experience (pengalaman penguasaan tindakan), vicarious experience (pengalaman pemodelan), persuasi verbal serta pemulihan kondisi fisik dan psikologis. menurut bandura bahwa teori sosial kognitif sangat tepat digunakan pada intervensi-intervensi yang bertujuan untuk merubah perilaku dan promosi kesehatan, misalnya edukasi kesehatan. menurut teori self peningkatan parenting self efficacy (diah astutiningrum, dkk.) 140 efficacy oleh bandura (1997), pengalaman merawat anak sebelumnya merupakan sumber informasi utama yang mempengaruhi pse. hasil studi ini menunjukkan bahwa pemberian konseling dengan demonstrasi dan pemberian booklet meningkatkan pengetahuan dan keyakinan ibu terhadap kemampuannya dalam melakukan tugas mengasuh anak seperti: menyusui, mengganti popok, memandikan, menidurkan dan menenangkan bayi. semua tugastugas dalam merawat bayi baru lahir membutuhkan pemahaman, penguasaan dan keberanian ibu dalam tiga aspek yaitu kognitif, afektif dan ketrampilan. simpulan dan saran simpulan konseling dengan menggunakan booklet berpengaruh terhadap peningkatan pse pada ibu post partum dengan sc saran p ihak r um ah sakit agar dap at meningkatkan mutu pelayanan kepada ibu postpartum dengan melatih petugas kesehatan perawat dan bidan untuk dapat melakukan konseling secara individu sebelum pasien pulang agar dapat meningkatkan keyakinan diri dalam merawat bayi baru lahir, melakukan d isch a rg e p lan in g d engan p eng ka jia n menggunakan instrumen parenting self efficacy scale untuk mengetahui keyakinan ibu dalam merawat bayi sebelum ibu pulang, melakukan pengkajian kebutuhan belajar pasien dan menyediakan media informasi bagi pasien tentang perawatan bayi dalam bentuk booklet atau leaflet yang dapat dipelajari selama ibu merawat bayi baru lahir. pihak institusi pendidikan kesehatan agar dapat mengembangkan metode pembelajaran yang menekankan pada family centre nursing dan mengembangkan metode pendidikan kesehatan agar dapat meningkatkan self efficacy. kepustakaan ansara, d., cohen, m. m., gallop, r., kung, r., & schei, b. (2005). predictors of women’s physical health problems after childbirth. journal of psychosomatic obstetrics & gynecology aisyah., setyowati., & rekawati, e. (2010). pengaruh pemberian paket pendidikan kesehatan perwatan ibu nifas (pk-pin) yang dimodifikasi terhadap pengetahuan, sikap, dan perilaku ibu postpartum primipara dalam merawat diri di palembang. program pascasarjana fik ui. tesis ardinasari, e. (2013). panduan lengkap bayi 1 tahun pertama, klikbayi.com. all right reserved bandura, a. (1997). social learning theory. new jersey : prentice hall, englewood billek-sawhney, b., & reicherter, a. (2004). social cognitive theory use by physical therapist in education of the older adult clien. topic in geriatric rehabilitation, bkkbn. (2007). survey demografi kesehatan indonesia, jakarta bloomfield, l., & kendall, s. (2007). testing a parenting programme evaluation tool as a pre and post course measure of pse. journal of advanced nursing corwin, e. j., et al (2005). the impact of fatique on the development of postpartum depression. journal of obstetric, gynecology and neonatal nursing. dahlan, s., (2008). statistik untuk kedokteran dan kesehatan, salemba medika. jakarta dharma, k., (2011). metodologi penelitian keperawatan. trans info media. elek, s. m., hudson, d. b., & fleck, m. (2002). couple’s experiences with fatique during the transision to parenthood. journal of family nursing. elek, s.m., hudson, d.b., & boufard, c. (2003). marital and parenting satisfaction and infant care self efficacy during the transition to parenhood: the effect of infant sex. issues in comprehensive pediatric nursing. emmanuel, e., creedy, d.k., john, w. st., gamble, j., & brown, c. (2008) maternal role development following childbirth among australian women. journal of advanced nursing. handy, f. (2011). panduan cerdas perawatan bayi. jakarta : pustaka bunda. hudson, d.b et al., (2003). effects of the new fathers network on first time fathers pse and parenting satisfaction during the transition to parenthood: issue in comprehensive pediatric nursing. hurlock, e.b. (1994). psikologi perkembangan: suatu pendekatan sepanjang rentang kehidupan. jakarta: erlangga jones, t., & prinz, r., (2005). potential roles of parental self efficacy in parent and jurnal ners vol. 11 no. 1 april 2016: 134-141 141 child adjustment: a review. clinical physichology review leahy-warren, p.,(2005). first time mothers : social support and confidence in infant care. journal of advanced nursing leveno et al.,(2009). obstetri williams: panduan ringkas. edisi 21. jakarta: egc logsdon, m.c., wisner, k.l.,& pinto-foltz. m.d (2006), the impact of postpartum depression on mothering. jognn maulana heri, d.j. (2009). promosi ksehatan. jakarta: egc mcqueen, k.a., dennis, c.l.,stremler, r., & norman, c.d. (2011). a pilot randomized controlled trial of a breastfeeding self efficacy intervention with primiparous mothers. jognn, 40: 35-46. mercer, r., t. (2006). nursing support of the proses of bicoming a mother. jognn murray, s. s & mc kinney, e.s. (2007). foundations of maternal-newborn nursing. vol 1. 4ᵗ ed. philipines:elsevier mutmainah, m. rustinah, y. & besral. (2006). efektifitas pendidikan kesehatan pada periode awal postpartum dengan metode cpdl terhadap kemampuan ibu primipara merawat bayi di propinsi jambi. program pascasarjana ui. tesis notoatmojo, s. (2002). metodologi penelitian kesehatan. edisi revisi. jakarta : rineka cipta. perry, s. e., hockenberry, m. j., lowdermilk, d.l. & wilson, d. (2002). maternal and child nursing care. vol 1. 4 ed. missoury: mosby elsivier. pillitteri, a. (2003). maternal and child health nursing. philadelphia: lippincot williams and wilkins porter, c. h., & hui-chin. (2003). first-time mothers perceptions of efficacy during the transition to motherhood: links to infant temperament. journal of family psychology. potter, p.a., & perry, a.g., (2009). fundamental keperawatan. edisi 7 buku 1&2. jakarta: salemba medika. rahmawati., allenidekania., & wijarini. (2001). identifikasi kebutuhan perawatan mandiri ibu nifas. journal keperawatan indonesia. fakultas ilmu keperawatan ui. redman, b.k., (2007). the practice patient education. 10 th ed. st. louis: mosby reeder, s.j. martin, l. l. & koniak-griffin, d. (2011). keperawatan maternitas : kesehatan wanita, bayi dan keluarga ( terjemahan) edisi 18, jakarta. egc. runiarti, n., hamid, a.y.s., & sabri, l. (2005). persepsi perawat, ibu postpartum dan keluarga tentang matri yang prioritas dan metode pemberian edukasi ibu postpartum di rsup fatmawati tahun 2005. program pascasarjana fik ui. tesis. tidak dipublikasikan salonen, a., kaunonen, m., astedt-kurki, p., jarvenpaa, a-l., isoaho, h., &tarkka, m. (2008). development of an internetbased interventian for parents infants. journal of advanced nursing, 64, 1:6072 sastroasmoro, s., & ismael, s. (2010). dasardasar metodologi penelitian klinis. edisi 3. jakarta: sagung seto. setiawati, s. & dermawan, a.c.,(2008). proses pembelajaran dalam pendidikan kesehatan. jakarta: trans info media silalahi, y. f. (2012). efektivitas intervensi edukasi postpartum terhadap perubahan pse pada periode awal postpartum. program pascasarjana fik ui. tesis sugiyono, .prof., dr. (2012). metode penelitian kuantitatif dn kualitatif dan r & d. edisi 15. bandung. alfabet. sulihah, (2001). metode pendidikan kesehatan, jakarta: egc tomey a. m., alligood m. r., (2006). nursing theorists and their work, 6 th edition, st. louis, misouri, cv. mosby company. wagner, d.l., bear, m., & davidson, n.s. (2011). measuring patient satisfaction with postpartum teaching methods use by nurses within the interaction model of client health behavior. research and theory for nursing practice: an international journal, 25, no. 3 wong et al. (2009). buku keperawatan pediatrik. edisi 6, alih bahasa. jakarta : egc 486 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20517 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the effects from physical exercise on the blood glucose levels, hba1c and quality of life of type 2 diabetes mellitus patients: a systematic review novita fajriyah1, i ketut sudiana2, erna dwi wahyuni1 1faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2faculty of medicine, universitas airlangga, surabaya, east java, indonesia abstract introduction: physical inactivity affects the physical and mental health status of t2dm patients. physical training is recommended in several studies and guidelines for the control of t2dm. the present study aimed to analyze the effects of aerobic exercise, resistance and a combination of both on blood glucose levels, hba1c and quality of life for patients with t2dm. methods: this systematic review used prisma (preferred reporting items for systematic reviews and meta-analysis). scopus, science direct and pubmed online databases were extensively searched, focusing on the last five years. the search utilized the phrases "diabetes," "physical exercise,” "glucose" and "quality of life." the inclusion criteria in the study regarding the literature was that it had to be an original article, that the source was a journal, that the article was in english and that it was available in full text. results: we identified 1017 articles where 17 were considered to be relevant for this systematic review. the combination of resistance and aerobic physical exercise seems to have a greater impact on glucose, hba1c and quality of life. aerobic exercise, resistance exercise and a combination of both have benefits when it comes to reducing blood glucose levels and hba1c, as well as improving the quality of life of patients with t2dm. conclusion: the type and intensity of the exercise chosen for the management of t2dm must be adjusted to the clinical condition and the patient’s individual physical fitness. further research is needed to assess the combined effects of aerobic exercise and resistance on glucose, hba1c and the quality of life of t2dm adjusted for different age categories. article history received: feb 27, 2020 accepted: april 1, 2020 keywords diabetes mellitus; physical exercise; glucose;, hba1c; quality of life contact erna dwi wahyuni  erna-d-w@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: fajriyah, n., sudiana,i. k., wahyuni, e. d. (2020). the effects from physical exercise on the blood glucose levels, hba1c and quality of life of type 2 diabetes mellitus patients: a systematic review. jurnal ners, special issues, 486-496. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20517 introduction type 2 diabetes mellitus (t2dm) includes individuals who have insulin resistance (ir) and usually a relative (not absolute) level of insulin deficiency (american diabetes association (ada), 2016). diabetes and complications are related to long-term complications and the failure of various organ systems (chawla, chawla, & jaggi, 2016). t2dm has become an observable global public health problem. the world health organization reports that the number of people with diabetes has increased from 108 million in 1980 to 422 million in 2014. according to this increase, diabetes will be the seventh leading cause of death by 2030 (who). it has been predicted that by 2025, the world burden of diabetes will be 5.4% of the adult population (rasekaba et al., 2012). current research shows that insulin resistance and β cell dysfunction are major factors in the pathogenesis of t2dm (kahn, cooper, & prato, 2014). however, the disease process is heterogeneous including genetic and environmental determinants such as a lack of physical activity and poor nutrition (hu, 2011)(adamska et al., 2012). physical inactivity https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 487 has a negative impact on the quality of life of diabetic patients (çolak et al., 2016). psychological problems are relatively common among individuals suffering from t2dm (van der heijden, van dooren, pop, & pouwer, 2013). the rate of mental illness among people with diabetes is almost twice that of people without diabetes. individuals with type 2 diabetes have a worse quality of life so managing their emotional health is no less important than keeping their blood sugar under control. this condition requires constant attention which can trigger feelings of stress and anxiety (bril & perkins, 2013). among the treatment strategies, exercise has been considered to be a 'gold standard' in treatment and it has a very important role in controlling diabetes(rydén et al., 2013). regular exercise effectively improves blood glucose control, increases insulin sensitivity, reduces the cardiovascular risk factors, improves psychological well-being and decreases diabetes-related mortality(naci & ioannidis, 2015)(gillett et al., 2012). in addition, exercise also uses the extra calories to release endorphins. these are agents that create a sense of well-being for both the individual and their social life (gilani & feizabad, 2019). the american diabetes association considers the important role of planned efforts as a form of prevention and treatment for diabetes, especially type 2 diabetes mellitus (american college of sports medicine, pescatello, arena, riebe, & d., 2014). this is especially so for the individuals who are at a high risk of complications so as to minimize the occurrence of complications. over the last few years, more research has used a continuous glucose monitoring system and provided self-management education. this provides unprecedented access to controlling the blood glucose levels and the psychological conditions of patients. however, there is still a lack of research that shows what type of exercise should be recommended for t2dm. scientific organizations (the international diabetes federation, the european association for diabetes studies, the american college of sports medicine, the american diabetes association, the american heart association (mancini et al., 2015), the canadian diabetes association (bril & perkins, 2013), sports and sports science australia, the francophone diabetes society and the sweden national institute of public health(american college of sports medicine et al., 2014)) recommend physical exercise as a pillar of diabetes treatment, namely aerobic activity, resistance training and a combination of aerobic training and resistance (mendes et al., 2016). therefore the type of exercise and the volume of exercise (frequency, intensity, and duration of exercise) must be carefully analyzed and adjusted based on the patient's medical history and medical profile which may be the main determinants of the appropriate blood glucose levels. the aim of our study was to review the effects of aerobic exercise, resistance and a combination of both on blood glucose level, hba1c and the quality of life of patients with t2dm. materials and methods strategy used for searching for the studies the articles published in english were searched for on scopus, science direct and pubmed. the relevant literature was searched from september 5 to december 28, 2019. the publication time was limited to between 2015 and 2019. the search terms were "diabetes", "physical exercise", "glucose" and "quality of life." studies selection and extraction the selection process of the papers was made using four steps: identification, selection, eligibility and id e n ti fi c a ti o n s e le c ti o n e li g ib il it y in c lu d e d report found in database (n = 1017) then, excluding duplicates (n = 965) screened reports (n = 965) publications not considered scientific reports (n = 681) excluded reports per title and abstract (n = 184) full-text papers assessed for eligibility (n = 50) publications not considered scientific reports (n = 50) papers included in the systematic review (n = 17) figure 1 – article selection process. adaptation from físico et al., 2020(físico et al., 2020) n. fajriyah et al. 488 | pissn: 1858-3598  eissn: 2502-5791 inclusion. in total, 1017 articles were found. of these, 52 duplicates and 681 were excluded because they were book chapters, conference summaries or other types of publication that are not considered to be articles, or because they were systematic review articles. there were 184 articles analyzed using their title and abstract; 50 were excluded due to the fact that they did not use physical exercise as an intervention, that did not indicate blood glucose level, hba1c and quality of life as a marker or because did not have humans as samples. of the 50 papers remaining for full-text evaluation, 33 did not meet the inclusion criteria because they didn't use randomized control trials, quasi-experiments, or observational studies, and because they didn't have one main marker. the inclusion criteria were as follows: type 2 diabetes mellitus as the searched disease, an intervention in the form of exercise/aerobic activity, resistance training, a combination of both (aerobic and resistance), all durations of exercise, repetition training, quality of life, the age of patients with type 2 diabetes mellitus as well as a combination of both exercises that affect the blood glucose levels, hba1c, quality of life, randomized and controlled trials with humans, the document type being an original article, journal articles, articles in english and the article being available in terms of its full text. the article was excluded if the article was a systematic review and if the subjects in the study included t2dm patients accompanied by the complications of other diseases. the researcher set the inclusion and exclusion criteria. the researcher consulted with experts in the field of nursing study and their supervisors to determine the final results of the articles that were obtained for the final analysis. finally, 17 articles were found following diabetes mellitus, thus they were included in the final analysis. the specific flow diagram has been shown in fig 1 following the identification, selection, eligibility and included details. the table analysis can be seen in table 2. ethical issues when preparing the manuscript of the systematic reviews were as follows: 1) avoiding plagiarism, 2) avoiding redundant or duplicates among the publication, 3) the transparency when screening the articles, the process analysis and the evaluation and 4) ensuring accuracy(wager & wiffen, 2011). results general factors and types of studies several factors and types of articles have been analyzed in table 1. seventeen studies (100%) all refer to type 2 diabetes mellitus research. the most common type of research designs was a randomized controlled trial, totaling 9 studies (52.94%). the details of the intervention programs in the studies have been given in table 2. aerobic exercise the results obtained by the researchers from the 17 articles that have been analyzed all show that the articles indicate the final results of the decrease in blood glucose level, hb a1c, and the improvement in the quality of life of patients with t2dm. improved glycemic control and quality of life is not only demonstrated in adolescents or adults. it is also found among the older people with t2dm. the analysis also found that patients who routinely carry out aerobic exercise a minimum of 3 times a week with an average duration of 30-40 minutes per session, conducted for a minimum of 4 weeks (benkar & kanase, 2017) and a maximum of 25 weeks where the average study used a 12-week training protocol and an intensity of 50% -70% maximum heart rate, have a good quality of life, increased glycemic control and decreased hba1c. the quality of life of t2dm patients can improve significantly, especially in terms of selfesteem, mental health, better perceived physical condition, decreased anxiety and insomnia (gilani & feizabad, 2019)(lin et al., 2017). decreased blood glucose levels include fasting blood glucose(benkar & kanase, 2017; lin et al., 2017; rahbar et al., 2017; shakil-ur-rehman, karimi, & gillani, 2017), oral glucose tolerance levels (lin et al., 2017) and post-prandial blood glucose (nygaard, rønnestad, hammarström, holmboe-ottesen, & høstmark, 2017)(benkar & kanase, 2017). in addition, the level of hba1c decreased significantly (p <0.05) after carrying out aerobic exercise (rahbar et al., 2017)(jhingan & jhingan, 2017). the results of the study reported that aerobic exercise for 12 weeks (3 days / week) with the duration of each session being 30 minutes at 60% vo2 max can significantly improve the patient's respiratory cardiorespiratory fitness (lin et al., 2017). the study results report that after 24 sessions (8 weeks) of aerobic exercise on a treadmill for 3 days per week for 30 minutes per session at an intensity of 50% -70% maximum heart rate, there was a reduction in glycosylation hemoglobin (hba1c) to a significant level in the exercise group (p <0.05) (rahbar et al., 2017). the long-term exercise training program results from the study (najafipour et al., 2017) can significantly reduce the hba1c levels (f = 11.08, p <0.05) in the table 1. general characteristics of the selected studies (n=17) category n % year of publication 2015 1 5,88 2016 1 5,88 2017 11 64,7 2018 1 5,88 2019 3 17,64 type of dm t2dm 17 100 type of study rct 9 52,94 quasi-experiment 7 41,17 retrospective observational study 1 5,88 jurnal ners http://e-journal.unair.ac.id/jners | 489 intervention group compared to the control group (jhingan & jhingan, 2017). resistance exercise the results of this study revealed that there was a significant reduction in postprandial sugar levels (p <0,000) (gurudut & rajan, 2017). russel et al’s (2017) research shows that resistance training improves glycemic control (fasting blood glucose, hba1c, and glucose areas below the curve) (russell et al., 2017). there were significant differences between the resistance training group and the control group when it came to reducing glucose levels (p <0.05) (aminilari et al., 2017). in addition, benkar & kanase’s study (2017) resulted in a decrease in fasting blood glucose levels p≤0,0001(benkar & kanase, 2017). the results of russel et al’s (2017) research report showed that while undergoing an oral glucose challenge (ogc), blood glucose levels during ogc were significantly lower at each point in time after resistance training, i.e. fasting blood glucose decreased by 0.95 mmol / l ( p = 0.003). as a result, the area under the glucose-time curve was also lower after resistance training (p, 0.005) (russell et al., 2017). resistance training for 12 weeks can improve glucose homeostasis by increasing insulin sensitivity, i.e. the oral glucose tolerance test (ogtt) result increases after 15, 30, 45 and 90 minutes compared to resting at baseline after 12 weeks of training (p <0.05). hba1c, in the post hoc tests, showed the same result before and after reductions in both groups (short: 213%; p = 0.01; length: 218%; p = 0.001) (park et al., 2016). russel et al’s (2017) research shows that resistance training decreases hba1c by 0.16% (1.76 mmol / mol) (p = 0.025) (russell et al., 2017). resistance training with a thera-band could enhance muscular strength and improve the quality of life of the elderly (pourtaghi, moghadam, ramazani, vashani, & mohajer, 2017). combined aerobic and resistance exercise kang et al’s (2016) study confirms that an aerobic training program and a 12-week combination of resistance reduces the fasting blood glucose concentration significantly(liu et al., 2015). in addition, 3 weekly sessions for 60 minutes for 12 weeks is effective at improving glucose control (18% in hba1) (carus et al., 2015). in addition, the hba1c level was reduced by 0.67% to an average sample value below 7.0% after 12 weeks of utt (conners, caputo, coons, fuller, & morgan, 2019). the results of the study of carus et al in 2015 showed a significant increase in hrqol. this was accompanied by much larger relative improvements in the hrqol scores of physical function (53%), vitality (21%) and overall mental health (40%) (carus et al., 2015). discussion this review has systematically assessed the effectiveness of aerobic exercise, resistance training and joint training on blood glucose levels, hba1c and the quality of life of patients with type 2 diabetes mellitus. the most widely used intervention in at least one group was aerobic training 3 times a week for 12 weeks. aerobic exercise is a form of physical exercise that uses the aerobic energy-producing systems that involve large muscle groups. this can increase the capacity and efficiency of this system and it is effective at increasing cardiorespiratory endurance (colberg et al., 2016)(knapen, vancampfort, moriën, & marchal, 2015). types of aerobic exercise include running, walking, cycling, swimming and rowing(thent, das, & henry, 2013). the american diabetes association recommends that adults with regular t2dm engage in aerobic activity that lasts for at least 10 minutes with a goal of 30 minutes / day or more almost every day of the week (colberg et al., 2016). the international diabetes societies recommends 150 minutes of aerobic exercise spread over a minimum of 3 days per week at a moderate intensity (40% -59% of the heart rate reserves, 64% 76% of the maximum heart rate) with no more than 2 consecutive days without sports (mendes et al., 2016). moderate exercise training increases glucose utilization and tolerance, cardiorespiratory fitness, blood pressure and the quality of life and depression status of patients with t2dm over a 12 week exercise training program (lin et al., 2017). exercise training can stimulate the metabolism and blood glucose utilization of t2dm patients. the results of gilani et al. in 2019 show that regular aerobic exercise is an effective strategy and it plays an important role in improving self-esteem and mental health as well as improving the quality of life of patients with type 2 diabetes mellitus (gilani & feizabad, 2019). regular aerobic exercise training is an effective strategy to improve personal health and self-esteem. this improves the quality of life of diabetic patients and is highly recommended (gilani & feizabad, 2019). aerobic exercise increases the action of insulin and it is effective at managing blood glucose, blood lipids, blood pressure, the risk of cardiovascular death, and general quality of life. in addition to physical and psychological benefits, physical exercise and sports have other benefits including mental, emotional, and social benefits[30][38]. resistance training is a type of anaerobic exercise that is used to increase muscle strength, overall strength, and endurance by varying the intensity range of resistance between 50% -75% of the maximum 1-repetition [36][39]. according to the position statement from the american diabetes association, resistance training at any intensity is recommended for adults with diabetes. they should do resistance training at a frequency of 2-3 sessions / week on non-consecutive days (colberg et al., 2016)(colberg, 2017). in addition, resistance exercise can reduce the restrictions on motor function in the elderly. this is a positive impact that can encourage older people to continue with sports and training, especially when the sports are interesting such as training using the elastic band thera-band. therefore n. fajriyah et al. 490 | pissn: 1858-3598  eissn: 2502-5791 a cycle is established which can have many positive effects on muscle strength as well as the physical and mental health of this age group (burrows, 2002). it should be noted that increased muscular strength is considered to be the basis for improved physical and motor functioning. physical activity can also decrease the disabilities among the elderly and improve their independence and quality of life (leinonen et al., 2007). however, the combination of the two types of exercise seems to have a greater impact on blood glucose level, hba1c and the quality of life of patients compared to only one of the two types of exercise. a combination of aerobic and resistance training may be more effective for blood glucose management than either type of exercise alone. exercise simulates the glut4 protein translocation in the muscle cells leading to an improved intake of glucose in the muscle (sano, peck, kettenbach, gerber, & lienhard, 2011). the progressive and continued stimuli of this mechanism may lead to a relatively stable metabolic adaptation (carus et al., 2015). this common complication of diabetes usually leads to muscle weakness and atrophy in the legs and feet. accordingly, motor disturbances such as the inability to walk on the heels are outcomes that are often present. these can be used to identify highly-affected diabetic patients. similarly, muscle fatigue is a common characteristic among diabetic patients. despite the molecular mechanisms remaining unidentified, evidence suggests that several metabolic pathways may be involved such as reduced mitochondrial function or the inability to mobilize glycogen and phosphocreatine at the start of exercise(halvatsiotis, short, bigelow, & sreekumaran nair, 2002). interestingly, a combination of aerobic and resistance exercise also results in significant improvements in mental health and related interventions. this has important implications for several aspects of a patient's daily life (carus et al., 2015). this study by carus et al (2015) showed that combined aerobic-resistance exercise therapy was very effective at reducing muscle fatigue and improving muscle strength, glycemic control and the physical and mental aspects of hrqol in moderatelyaffected t2dm patients (carus et al., 2015). the psychological mechanisms of the beneficial effects of exercise on quality of life including increased selfesteem, increased self-satisfaction, increased selfconfidence and increased disorder and physiological mechanisms including increased central norepinephrine, changes in the adrenocortical system of the hypothalamus and changes in the synthesis and metabolism of serotonin and endorphins. thus the patients' perception of their own health seems to be improved by exercising. physical exercise is an extraordinary opportunity in the care of patients who have physical and mental health problems (knapen et al., 2015). physical activity can reduce geriatric pain if it is based on humor and laughter. because pain is considered an important component of quality of life in the elderly (behrouz et al., 2017), it can be concluded that pleasant physical activity along with laughter has a positive effect on the quality of life among this population. there are several limitations to our study that have been included. first, only one study assessed the effects of a combination of aerobic exercise and resistance and how it relates to quality of life(carus et al., 2015). because of the small number of studies conducted, the effect of a combination of exercises requires more evidence. second, some of the studies did not include supervised exercise. we could not determine whether the participants completed the training program or whether they achieved the moving targets, which might affect the quality of life outcomes. in addition, in some of the studies without a follow-up, we could not observe the long-term effects. physical exercise must be categorized by age (young adult, adults, elderly) because age affects the body's metabolism and degenerative processes, thus preventing biased results. conclusion aerobic exercise, resistance training and combination training have benefits when it comes to reducing the blood glucose level and hba1c, in addition to improving the quality of life of patients with type 2 diabetes mellitus. the type and intensity of the exercise chosen for the management of t2dm must be adjusted to the clinical condition and to the patient’s physical fitness. further research is needed to assess the combined effect of aerobic exercise and resistance to glucose, hba1c and quality of life adjusted for the different age categories. the implications for nursing are that it can be used as a form of therapeutic modality in the promotion and prevention of the complications of type 2 diabetes mellitus. this is tailored to the clinical profile of the patient. references adamska, a., przegaliński, m., rutkowska, i., nikolajuk, a., karczewska-kupczewska, m., górska, m., & stra̧czkowski, m. (2012). relationship between regular aerobic physical exerciseand glucose andlipidoxidationinobesesubjects-apreliminary report. polish annals of medicine, 19(2), 117– 121. https://doi.org/10.1016/j.poamed.2012.05.001 american college of sports medicine, pescatello, l. s., arena, r., riebe, d., & d., t. p. (2014). acsm’s guidelines for exercise testing and prescription. in medicine & science in sports & exercise (ninth edit, vol. 34). https://doi.org/10.1097/00005768200209000-00024 american diabetes association (ada). (2016). standards of medical care in diabetes—2016 : summary of revisions. diabetes care, 39(supplement 1), s4–s5. https://doi.org/10.2337/dc16-s003 jurnal ners http://e-journal.unair.ac.id/jners | 491 aminilari, z., fararouei, m., amanat, s., sinaei, e., dianatinasab, s., aminilari, m., … dianatinasab, m. (2017). the effect of 12 weeks aerobic, resistance, and combined exercises on omentin-1 levels and insulin resistance among type 2 diabetic middle-aged women. diabetes and metabolism journal, 41(3), 205–212. https://doi.org/10.4093/dmj.2017.41.3.205 balducci, stefano, sacchetti, massimo, haxhi, jonida, orlando, giorgio, d’errico, valeria, fallucca, sara, menini, stefano, pugliese, g. (2014). physical exercise as therapy for type ii diabetes. diabetes/metabolism research and reviews, 32(30), 13–23. https://doi.org/10.1002/dmrr behrouz, s., mazloom, s. r., kooshiar, h., aghebati, n., asgharipour, n., & vashani, h. r. b. (2017). investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in mashhad, iran. evidence based care journal, 7(2), 27–36. https://doi.org/10.22038/ebcj.2017.24247.152 9 benkar, a. p., & kanase, s. b. (2017). effect of aerobic exercises and resistance training on glucose levels in type 2 diabetic subjects. asian journal of pharmaceutical and clinical research, 10(7), 360–363. https://doi.org/10.22159/ajpcr.2017.v10i7.185 32 bril, v., & perkins, b. a. (2013). canadian diabetes association clinical practice guidelines expert committee. can j diabetes, 37 (suppl, s168-183. https://doi.org/10.1016/j.jcjd.2013.01.039 burrows, m. (2002). exercise, nutrition, and the older woman; wellness for women over fifty. british journal of nutrition, 88(3), 333–334. https://doi.org/10.1079/bjn2002592 carus, p. t., ortega, a., h.p, k., santos, v., g, h., ramos, j., & armando raimundo. (2015). a randomized controlled trial on the effects of combined aerobic-resistance exercise on muscle strength and fatigue, glycemic control and health-related quality of life of type 2 diabetes patients. the journal of sports medicine and physical fitness, (july). chawla, a., chawla, r., & jaggi, s. (2016). microvasular and macrovascular complications in diabetes mellitus: distinct or continuum? indian journal of endocrinology and metabolism, 20(4), 546–553. https://doi.org/10.4103/2230-8210.183480 chiang, s. l., heitkemper, m. m. l., hung, y. j., tzeng, w. c., lee, m. s., & lin, c. h. (2019). effects of a 12week moderate-intensity exercise training on blood glucose response in patients with type 2 diabetes: a prospective longitudinal study. medicine (united states), 98(36). https://doi.org/10.1097/md.00000000000168 60 çolak, t. k., acar, g., elçin dereli, e., özgül, b., demirbüken, i̇., alkaç, ç., & polat, m. g. (2016). association between the physical activity level and the quality of life of patients with type 2 diabetes mellitus. journal of physical therapy science, 28(1), 142–147. https://doi.org/10.1589/jpts.28.142 colberg, s. r. (2017). key points from the updated guidelines on exercise and diabetes. frontiers in endocrinology, 8(feb), 1–7. https://doi.org/10.3389/fendo.2017.00033 colberg, s. r., sigal, r. j., yardley, j. e., riddell, m. c., dunstan, d. w., dempsey, p. c., … tate, d. f. (2016). physical activity/exercise and diabetes: a position statement of the american diabetes association. diabetes care, 39(11), 2065–2079. https://doi.org/10.2337/dc16-1728 conners, r. t., caputo, j. l., coons, j. m., fuller, d. k., & morgan, d. w. (2019). impact of underwater treadmill training on glycemic control, blood lipids, and health-related fitness in adults with type 2 diabetes. clinical diabetes, 37(1), 36–43. https://doi.org/10.2337/cd17-0066 físico, t., glicemia, n. a., oxidativo, e. e., diabetes, e. m., revisão, t., sistemática, s., & a, r. (2020). physical training on glycemia and oxidative stress in type 2 diabetes : a systematic review. 26, 70–76. gilani, s. r. m., & feizabad, a. k. (2019). the effects of aerobic exercise training on mental health and self-esteem of type 2 diabetes mellitus patients. health psychology research, 7(65786), 10–14. https://doi.org/10.4081/hpr.2019.6576 gillett, m., royle, p., snaith, a., scotland, g., poobalan, a., imamura, m., … waugh, n. (2012). nonpharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation: a systematic review and economic evaluation. health technology assessment, 16(33), 1–235. https://doi.org/10.3310/hta16330 gurudut, p., & rajan, a. p. (2017). immediate effect of passive static stretching versus resistance exercises on postprandial blood sugar levels in type 2 diabetes mellitus: a randomized clinical trial. journal of exercise rehabilitation, 13(5), 581–587. https://doi.org/10.12965/jer.1735032.516 halvatsiotis, p., short, k. r., bigelow, m., & sreekumaran nair, k. (2002). synthesis rate of muscle proteins, muscle functions, and amino acid kinetics in type 2 diabetes. diabetes, 51(8), 2395–2404. https://doi.org/10.2337/diabetes.51.8.2395 hu, f. b. (2011). globalization of diabetes: the role of diet, lifestyle, and genes. diabetes care, 34(6), 1249–1257. https://doi.org/10.2337/dc110442 jhingan, a., & jhingan, r. m. (2017). effect of cycling on glycaemia, blood pressure, and weight in young individuals with type 2 diabetes. journal of clinical and diagnostic research, 11(7), oc09oc11. https://doi.org/10.7860/jcdr/2017/28111.10 162 n. fajriyah et al. 492 | pissn: 1858-3598  eissn: 2502-5791 kahn, s. e., cooper, m. e., & prato, s. del. (2014). pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future. the lancet, 383(9922), 136–137. https://doi.org/10.1016/s01406736(13)62154-6 knapen, j., vancampfort, d., moriën, y., & marchal, y. (2015). exercise therapy improves both mental and physical health in patients with major depression. disability and rehabilitation, 37(16), 1490–1495. https://doi.org/10.3109/09638288.2014.97257 9 leinonen, r., heikkinen, e., hirvensalo, m., lintunen, t., rasinaho, m., kallinen, m., & koski, j. (2007). customer-oriented counseling for physical activity in older people : study protocol and selected baseline results of a randomized controlled trial ( isrctn 07330512 ). scandinavian journal of medicine and science in sports, 156–164. https://doi.org/10.1111/j.16000838.2006.00536.x lin, c. h., ho, c. w., chen, l. c., chang, c. c., wang, y. w., chiou, c. p., & chiang, s. l. (2017). effects of a 12-week exercise training on insulin sensitivity, quality of life, and depression status in patients with type 2 diabetes. journal of medical sciences (taiwan), 37(6), 227–236. https://doi.org/10.4103/jmedsci.jmedsci_68_17 liu, y., liu, s.-x., cai, y., xie, k.-l., zhang, w.-l., & zheng, f. (2015). effects of combined aerobic and resistance training on the glycolipid metabolism and inflammation levels in type 2 diabetes mellitus. mancini, m. e., diekema, d. s., hoadley, t. a., kadlec, k. d., leveille, m. h., mcgowan, j. e., … sinz, e. h. (2015). part 3: ethical issues: 2015 american heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. in circulation (vol. 132). https://doi.org/10.1161/cir.00000000000002 54 mckay, h. g., king, d., eakin, e. g., seeley, j. r., & glasgow, r. e. (2001). the diabetes network internet-based physical activity intervention. diabetes care, 24, 1328–1334. mendes, r., sousa, n., almeida, a., subtil, p., guedesmarques, f., reis, v. m., & themudo-barata, j. l. (2016). exercise prescription for patients with type 2 diabetes a synthesis of international recommendations: narrative review. british journal of sports medicine, 50(22), 1379–1381. https://doi.org/10.1136/bjsports-2015-094895 naci, h., & ioannidis, j. p. a. (2015). comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. british journal of sports medicine, 49(21), 1414–1422. https://doi.org/10.1136/bjsports2015-f5577rep najafipour, f., mobasseri, m., yavari, a., nadrian, h., aliasgarzadeh, a., abbasi, n. m., … sadra, v. (2017). effect of regular exercise training on changes in hba1c, bmi and vo 2 max among patients with type 2 diabetes mellitus: an 8-year trial. bmj open diabetes research and care, 5(1), 1–7. https://doi.org/10.1136/bmjdrc-2017000414 nygaard, h., rønnestad, b. r., hammarström, d., holmboe-ottesen, g., & høstmark, a. t. (2017). effects of exercise in the fasted and postprandial state on interstitial glucose in hyperglycemic individuals. journal of sports science and medicine, 16(2), 254–263. park, b. s., khamoul, a. v, brown, l. e., kim, d. y., han, k. a., min, k. w., & an, g. h. (2016). effects of elastic band resistance training on glucose control,body composition, and physical function in women with shortvs. long-duration type-2 diabetes. journal of strength and conditioning research, 30(6), 1688–1699. https://doi.org/10.1519/jsc.000000000000125 6 pourtaghi, f., moghadam, z. e., ramazani, m., vashani, h. b., & mohajer, s. (2017). effect of resistance training using thera-band on muscular strength and quality of life among the elderly. evidence based care journal, 7(3), 7–16. https://doi.org/10.22038/ebcj.2017.25876.158 4 rahbar, s., naimi, s. s., soltani, a. r., rahimi, a., akbarzadeh baghban, a., rashedi, v., & tavakkoli, h. m. (2017). improvement in biochemical parameters in patients with type 2 diabetes after twenty-four sessions of aerobic exercise: a randomized controlled trial. iranian red crescent medical journal, 19(7). https://doi.org/10.5812/ircmj.13931 rasekaba, t. m., graco, m., risteski, c., jasper, a., berlowitz, d. j., hawthorne, g., & hutchinson, a. (2012). impact of a diabetes disease management program on diabetes control and patient quality of life. population health management, 15(1), 12– 19. https://doi.org/10.1089/pop.2011.0002 russell, r. d., hu, d., greenaway, t., blackwood, s. j., dwyer, r. m., sharman, j. e., … rattigan, s. (2017). skeletal muscle microvascularlinked improvements in glycemic control from resistance training in individuals with type 2 diabetes. 40(september), 1256–1263. https://doi.org/10.2337/dc16-2750 rydén, l., grant, p. j., anker, s. d., berne, c., cosentino, f., danchin, n., … xuereb, r. g. (2013). esc guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the easd. european heart journal, 34(39), 3035–3087. https://doi.org/10.1093/eurheartj/eht108 sano, h., peck, g. r., kettenbach, a. n., gerber, s. a., & lienhard, g. e. (2011). insulin-stimulated glut4 protein translocation in adipocytes requires the rab10 guanine nucleotide exchange factor dennd4c*. 286(19), 16541–16545. https://doi.org/10.1074/jbc.c111.228908 jurnal ners http://e-journal.unair.ac.id/jners | 493 shakil-ur-rehman, s., karimi, h., & gillani, s. a. (2017). effects of supervised structured aerobic exercise training program on fasting blood glucose level, plasma insulin level, glycemic control, and insulin resistance in type 2 diabetes mellitus. pakistan journal of medical sciences, 33(3), 576–580. https://doi.org/10.12669/pjms.333.12023 thent, z. c., das, s., & henry, l. j. (2013). role of exercise in the management of diabetes mellitus: the global scenario. plos one, 8(11), 1–8. https://doi.org/10.1371/journal.pone.0080436 van der heijden, m. m. p., van dooren, f. e. p., pop, v. j. m., & pouwer, f. (2013). effects of exercise training on quality of life, symptoms of depression, symptoms of anxiety and emotional well-being in type 2 diabetes mellitus: a systematic review. diabetologia, 56(6), 1210– 1225. https://doi.org/10.1007/s00125-0132871-7 wager, e., & wiffen, p. j. (2011). ethical issues in preparing and publishing systematic reviews. chinese journal of evidence-based medicine, 11(7), 721–725. https://doi.org/10.1111/j.17565391.2011.01122.x zhang, x. c., & kim, c. h. (2018). experimental study on the effect of aerobic exercise on body fat reduction in patients with type 2 diabetes. biomedical research (india), 2018(special issue artificialintelligenttechniquesforbiomedicalsign alprocessingedition-ii), s219–s221. https://doi.org/10.4066/biomedicalresearch.29 -17-622 n. fajriyah et al. 494 | pissn: 1858-3598  eissn: 2502-5791 appendix table 2. detailed intervention programs in the studies author modality local/ year method duration, frequency protocol measuring instruments and result park et al., (park et al., 2016) elastic band resistance training korea/ 2016 design: quasiexperimental sample: 26 age: 46 – 65 years the frequency (5 day/week) over 12 weeks involved training twice a day (morning and afternoon) over 15–20 repetitions maximum (rm). patients used the lowest resistance available (i.e., yellow band) and they were instructed on the proper exercise technique under the supervision of a clinical exercise physiologist. patients with a long history of diabetes responded positively to resistance training and in a manner comparable to their recently diagnosed counterparts. pourtagh i et al.,(pour taghi et al., 2017) resistance training using theraband iran/ 2017 design: rct sample: 70 age: ≥ 65 years the intervention was implemented through 2 30-minute sessions a week, lasting for 6 weeks. prior to each session, the elderly individuals performed stretching exercises for 10 mins to warm up and then they went jogging for 10 mins to cool down. the resistance training used a thera-band to perform 9 movements. resistance training with thera-band could enhance muscular strength and improve the quality of life of the elderly. rahbar et al., (rahbar et al., 2017) aerobic exercise iran/ 2017 design: rct sample: 30 age: 40-60 years 24 sessions (3 days per week) for 30 minutes over an 8 week duration. aerobic exercise on a treadmill (motorized treadmill®, omegagt, usa) with no slope. max heart rate estimated from the bruce protocol test. the training protocol was 50% to 70% of the max heart rate. a safe exercise regimen is advised in order to maintain a healthy cardiovascular function and to reduce the complications in patients with diabetes. jhingan & jhingan (jhingan & jhingan, 2017) cycling india/ 2017 design: retrospectiv e observationa l study sample: 20 age: 18 to <40 years distance of 25 km per day for at least 5 days a week. the study was conducted in accordance with ethical principles of the declaration of helsinki and it was approved by the institutional ethics committee. regular aerobic exercise in the form of cycling results in a significant reduction in hba1c, bp and weight. chiang et al., (chiang et al., 2019) treadmill taiwa n/ 2019 design: prospective longitudinal sample: 66 age: 40-60 years 3 sessions/ week, 3x/days, 30 minutes/ session for 12 weeks (total of 36 sessions). the training protocol followed the “fitt” principle according to acsm’s guidelines including frequency, intensity, time and type. 12 week duration. 70% heart rate over 150 minutes of moderate-intensity aerobic activity per week for 30 minutes. 12-week moderate intensity exercise training appears to be safe for patients with t2dm. lin et al., (lin et al., 2017) treadmill taiwa n/ 2017 design: quasiexperiment sample: 17 age: 20 – 60 years 3x/week. 12 weeks. 30 minutes moderate exercise. the intensity of the exercise training was set at 60% vo2max (72% hrmax) obtained from the participant’s gxt. moderate exercise training improves glucose utilization, glucose tolerance, cardiorespiratory fitness, blood pressure, and qol as well as the depression status of patients with t2dm. zhang & kim, (zhang & kim, 2018) aerobic exercise (taiji, dance & jogging) korea/ 2018 design: experimenta l study sample: 37 age: 37 – 68 years single aerobic exercise lasting for about 60 minutes, 3 times a week aerobic exercises like taiji and square dance can be adopted by elderly patients. aerobics and jogging can be adopted by younger patients. the heart rate was controlled at about 60%. the aerobic exercise intervention can improve the blood fat and blood glucose indicators of the patients with type 2 diabetes and reduce their body fat and weight. it can improve their treatment effect and life quality. jurnal ners http://e-journal.unair.ac.id/jners | 495 table 2. (continued) author modalit y local/ year methods duration, frequenc y protocol measuring instruments and result gilani & feizabad, (gilani & feizabad, 2019) aerobic exercise iran/ 2019 design: clinical trial study sample: 60 age: 45-55 years exercised in 3 45 to 60minutesessions a week for 12 weeks the intensity of the training, obtained by measuring pulses on the left wrist radial within one minute, was considered equal to be to 60% of the maximum consumed oxygen. maximum oxygen consumption was controlled using the heart reserve rate (hrr). regular aerobic exercise training as an effective strategy plays an important role in improving selfesteem and mental health while also promoting better life quality among diabetic patients. najafipour et al., (najafipou r et al., 2017) aerobic regular exercise training iran/ 2017 design: quasiexperimental trial sample: 65 age: 33-69 years 3 sessions per week with a duration of 15–40 min. the activities of the sessions included warm-up movements and aerobic exercise at a moderate intensity. 50% -80% vo2max. long-term regular physical activity training was found to be helpful for improving glycemic control, body composition and cardiovascular fitness among the patients with t2dm. shakil-urrehman, karimi, & gillani(sha kil-urrehman et al., 2017) supervis ed structure d aerobic exercise training (ssaet). medicall y-graded treadmill pakist an/ 2017 design: randomized controlled trial sample: 102 age: 40-70 years 25 week ssaet program divided into 5 phases of 5 weeks each. in phase 1, the duration of a single session was 10 minutes and the total duration per week was 30 minutes. a thirty minute increase per week was followed in the subsequent 4 phases. ssaet program along with routine medical management is a more effective treatment in the management of fasting blood glucose level, glycemic control, plasma insulin level and insulin resistance compared to the routine medical management and dietary plan in the management of t2dm. benkar & kanase (benkar & kanase, 2017) aerobic exercise, resistan ce training india/ 2017 design: comparative study sample: 30 age: 30 – 65 years 5 days/wee k for 4 weeks. aerobic exercise on a static bicycle. resistance training using dumbbells and weight cuffs. aerobic exercises and resistance training is proven to be beneficial at controlling the blood glucose levels of t2dm subjects. aminilari et al.,(aminil ari et al., 2017) aerobic, resistan ce, and combine d exercise s iran/ 2017 design: randomized controlled trial sample: 60 age: 45-60 years 3 times per week sessions for a total of 12 weeks ae: 50% 55% heart max re: intensity : 50% to 55% of onerepetition maximum (rm) or 1 rm. ae, re, ce: 3 sessions per week in 3 phases: warm-up, the main section and cooling-down. the warm-up involved 20 minutes of stretching exercises and jogging on the spot. the cooling-down phase involved running, exercising & stretching. ae: the main phase consisted of 25 minutes of exercise. re: the main phase consisted of 3 sets x 8 repetitions of weight training including leg extensions, prone leg curls, abdominal crunches, biceps, triceps, and seated calf movements. ce: the main phase consisted of aerobic training integrated with re. compared to aerobic and resistance exercises, 12 weeks of combined exercise was more efficient at improving homa-ir and increasing serum omentin1 among women with t2dm. nygaard, rønnestad, hammarst röm, holmboeottesen, & høstmar (nygaard et al., 2017) moderat e exercise europ ean/ 2017 design: randomized cross-over design sample: 8 age: 30 minutes/d ay. 60 min of treadmill walking 3 test days in a randomized cross-over design encompassing one test day without exercise, one test day with 60 min of treadmill walking prior to breakfast and one test day with an identical bout of exercise 30 min after the start of breakfast. moderate exercise in the postprandial state performing moderate exercise was done in the postprandial state but not fasted state. this decreased the glucose excursions during a subsequent 22 hours period in hyperglycemic individuals not using antidiabetic medications. n. fajriyah et al. 496 | pissn: 1858-3598  eissn: 2502-5791 table 2. (continued) 1st author modalit y local/ year methods duration, frequenc y protocol measuring instruments and result carus et al.(carus et al., 2015) combine d aerobicresistanc e exercise portug al/ 2015 design: randomized controlled trial sample: 43 age: 3 weekly sessions of 60 minutes for 12weeks 1) 10 minutes of warming up with slow walks. 2) 25 minutes of aerobic exercises at 60–65% of the maximal heart rate. 3) 15 minutes of strength exercises targeting specific muscle groups. 12 weeks of combined aerobic-resistance exercise was highly effective at improving muscle strength and fatigue, glycemic control and several aspects of hrqol in t2dm patients. benkar & kanase (benkar & kanase, 2017) aerobic exercise. resistan ce training india/ 2017 design: comparative study sample: 30 age: 30 – 65 years 5 days/wee k for 4 weeks. aerobic exercise on a static bicycle. resistance training using dumbbells and weight cuffs aerobic exercises and resistance training are proven to be beneficial for controlling the blood glucose level of t2dm subjects. conners, caputo, coons, fuller, & morgan(co nners et al., 2019) underwa ter treadmill training (utt) huntsv ill e/ 2019 design: randomized treatmentcontrol research sample: 26 age: middleaged adults 36 utt sessions (12 weeks × 3 sessions per week) the study participants completed 3 utt sessions per week on alternate days for a total of 12 weeks. each training session consisted of 3 walking sessions separated by at least 5 minutes of rest on a flotation device. the water temperature was kept in a neutral range (29–31ºc). utt is a safe and effective multimodal training approach that can improve glycemic control, blood lipid profile, cardiovascular function, body composition, and leg strength in middleaged adults with type 2 diabetes. russell et al., (russell et al., 2017) resistan ce training (rt) austra lia/20 17 design: quasiexperiment sample: 17 age: 18-60 years 3 days/ week. 6 weeks all of the exercises were fully supervised by trained sports physiologists and the weights were adjusted according to the individual abilities. minerals follow the training trail, length and development. rt improves the ogcstimulated muscle mbf and glycemic control concomitantly, suggesting that mbf plays a role in improved glycemic control due to rt. *t2dm: type 2 diabetes mellitus; rct: randomized controlled trial; hrqol: health related quality of life; ae: aerobic exercise; re: resistance exercise; ce: combined exercises; ocg: oral glucose challenge; mbf: microvascular blood flow efek zat aktif ekstrak daun jambu biji merah (ervi husni, dkk) 269 efek zat aktif ekstrak daun jambu biji merah (psidium guajava.l) terhadap spermatogenesis pada tikus putih jantan (rattus norvegicus) (effects of red guajava leaf extract (psidium guajava. l) active substance on fsh level and spermatogenesis in male white rats (rattus norvegicus)) ervi husni, sukesi poltekkes kemenkes surabaya, jl. pucang jajar tengah no. 56 surabaya, 60282 email: ervie.dh@gmail.com abstrak pendahuluan: jumlah penduduk indonesia sensus tahun 2010 sebanyak 237,6 juta jiwa dengan laju pertumbuhan penduduk 1,49 % per tahun. target rpjpmn 2010-2014 sebesar1,14 %, laju pertumbuhan penduduk saat ini 0,53 % masih lebih tinggi. pengendalian penduduk diperlukan antara lain dengan pemakaian kontrasepsi pada wanita maupun pria. keterlibatan pria dalam kb masih rendah hanya 6,26 %. tujuan penelitian untuk membuktikan zat aktif daun jambu biji merah dapat menurunkan kadar fsh dan spermatogenesis pada tikus putih jantan (rattus norvegikus). metode: penelitian ini merupakan penelitian eksperimen dengan rancangan post test only control group design. besar sampel menggunakan rumus federer dengan jumlah sampel 30 ekor tikus putih, terbagi tiga kelompok yaitu kelompok 1 (k1) kelompok kontrol diberikan larutan cmc 0,5 % 1 ml/ hari, kelompok perlakuan 1 (p1) diberikan ekstrak daun jambu biji merah dosis 40 mg/ml/hari dan kelompok perlakuan 2 (p2) diberikan ekstrak daun jambu biji merah dosis 80 mg/ml/hari dan diberikan selama 30 hari. variabel penelitian jumlah sel spermatogenik ( spermatogonium, spermatosit primer dan spermatid). data dianalisis menggunakan uji anova. hasil: hasil analisis data dengan uji anova jumlah sel spermatogonium nilai p 0,801 (p < 0,05): tidak ada perbedaan signifikan diantara ketiga kelompok, uji lsd tidak dilakukan. hasil uji anova untuk jumlah sel spermatosit primer didapatkan nilai p 0,102 ( p < 0,05 ), berarti tidak ada perbedaan signifikan diantara ketiga kelompok, uji lsd tidak dilakukan. hasil uji anova untuk jumlah sel spermatid nilai p 0,001 (p < 0,05) berarti terdapat perbedaan signifikan diantara ketiga kelompok. hasil uji lsd kontrol dengan p1 (p 0,036 ): berbeda, kontrol dengan p2 (p <0,000): berbeda, p1 dengan p2 (p <0,033) : berbeda. diskusi: kesimpulan penelitian ini adalah pemberian ekstrak daun jambu biji merah tidak menurunkan jumlah sel spermatogonium dan sel spermatosit primer tetapi menurunkan jumlah spermatid pada tikus putih jantan. kata kunci: ekstrak daun jambu biji merah (psidium guajava.l, sel spermatogenik (spermatogoniun, spermatosit primer dan spermatid). abstract introduction: the census in 2010 showed that the population of indonesia was as many as 237.6 million with a population growth rate of 1.49% per year. rpjpmn target in 2010-2014 was 1.14%, so the current population growth rate, which is 0.53%, is still high. it is necessary to control population growth. one method to control population is the use of contraception by using contraceptive both in males and females. male involvement in family planning remains low, only 6.26%. the purpose of this study was to proved that the active substance of red guava leaves can reduce spermatogenesis in male rats (rattus norvegicus). methods: this was an experimental study using post-test only control group design. sample size from federer's formula obtained 30 white rats. samples were divided into three groups: group 1 (k1), the control group, was given with 0.5% cmc na solution of 1 ml/day. treatment group 1 (p1) was given red guajava leaf extract in a dose of 40 mg/ml/day, and the treatment group 2 (p2) was given with red guajava leaf extract in a dose of 80 mg/ml/day for 30 days. the variables in this study were spermatogenic cell count. data were analyzed using anova test. result: results of anova data analysis, number of spermatogonial cells had p value 0.801 (p <0.05), it means there was no significant difference among the three groups, lsd test was not conducted. anova test results for a number of primary spermatocytes cells showed p value 0.102 (p< 0.05), there were no significant differences among the three groups, lsd test was not conducted. anova test results for a number of spermatid cells p value of 0.001 (p <0.05) means that there were significant differences among the three groups. lsd test results with p1 control (p 0.036): different, with p2 controls (p <0.000): different, p1 to p2 (p <0.033): different. discussion: the conclusion of this study was that the administration of guajava leaf extract does not reduce spermatogonium and spermatosit primer but reduce spermatid count in male rats. key words: red guava (psidium guajava. l) leaf extract, spermatogenic cells pendahuluan pengendalian jumlah penduduk yang telah dilaksanakan oleh pemerintah antara lain melalui pengendalian angka kelahiran berupa program keluarga berencana (moeloek 1994). usaha yang telah dilaksanakan dalam program kb adalah penyediaan sarana kontrasepsi. kontrasepsi prinsipnya mencegah terjadinya peleburan antara sel sperma pria dengan sel telur wanita. saat ini lebih banyak ditujukan pada kaum wanita, pada pria masih terbatas, sehingga perkembangan kontrasepsi pria jauh tertinggal (prajogo. b 2003). sensus penduduk tahun 2000, penduduk indonesia 205,8 juta jiwa. laju pertumbuhan jurnal ners vol. 11 no. 2 oktober 2016: 269276 270 penduduk periode 2000-2010 sekitar 1,45 % per tahun. penduduk indonesia hasil sensus tahun 2010 menjadi 237,6 juta jiwa dengan laju pertumbuhan penduduk 1,49 % per tahun. dibandingkan rencana pembangunan jangka menengah nasional (rpjmn) 2010-2014 sebesar 1,14 %, maka laju pertumbuhan penduduk saat ini 0,53 % masih lebih tinggi (bkkbn, 2014). jumlah penduduk yang tinggi tidak diikuti peningkatan kualitas hidup, terlihat dari belum terpenuhinya hak warga negara seperti kecukupan pangan, kualitas pendidikan yang bermutu, lingkungan, dan gaya hidup sehat, serta keamanan fisik dan sosial. diperlukan pengendalian jumlah penduduk. (shihab, 2005). laporan hasil pelayanan kontrasepsi oktober 2013 jumlah peserta baru menurut jenis kontrasepsi yaitu : peserta iud 7,78 %, mow 1,54 %, implan 9,29 %, suntik 48,78 %, pil 26,34 % dan mop 0,26 %, kondom 6,00 % . keikutsertaan pria dalam program kb masih sangat rendah yaitu hanya sebesar 6,26 % (bkkbn, 2014). proses spermatogenesis dikendalikan oleh poros hipotalamus hipofisis dan testis. gonadotropin realeasing hormon (gnrh) dilepaskan oleh hipotalamus sampai pada sasaran hipofise anterior. gnrh merangsang kelenjar hipofisa mengeluarkan homon gonadotropin fsh dan lh yang akan mempengaruhi testis untuk berfungsi. fsh menstimulasi pertumbuhan sel-sel germinatif dari tubulus seminiferus dan mendorong terjadinya proses spematogenesis secara sempurna. lh menstimulasi aktivitas dan pertumbuhan sel leydig dalam jaringan interstitial untuk menghasilkan hormon testosteron. spermatogenesis dikendalikan oleh interaksi hormon fsh, lh dan testosteron, gangguan interaksi ini dapat menyebabkan proses spematogenesis terganggu (speroff l & fritz 2005; ganong. wf 2003). hilangnya hormon gonadotropin akan mempunyai dampak pada berhentinya proses spermatogenesis, atropi testis dan tenunan testis menjadi lunak (harjopranjoto. s 1995). penggunaan kontrasepsi asal tanaman perlu diperhatikan sifat merusak atau pengaruhnya terhadap sistim reproduksi baik pada pria maupun wanita. sebaiknya digunakan tanaman yang sifatnya sementara (reversibel), bila tidak digunakan lagi sistem reproduksi kembali normal sehingga tidak terjadi kemandulan dan diharapkan dapat menurunkan fertilitas 100 % (winarno, dalam susetyarini. rr. e 2009). bahan obat-obatan dari tanaman mempunyai keuntungan antara lain toksisitasnya rendah, mudah diperoleh, murah harganya dan kurang menimbulkan efek samping (arsyad, 1986). tanaman yang diharapkan dapat menjadi antifertilitas adalah daun jambu biji merah (psidium guajava l). daun jambu biji merah mengandung zat aktif seperti alkaloid, flavonoid, tanin, minyak atsiri, avicullarin, oleanolic acid dan beta-sitosterol yang diduga bersifat antifertilitas. alkaloid dapat mempengaruhi sekresi hormon reproduksi yang diperlukan untuk berlangsungnya proses spermatogenesis, minyak atsiri bekerja tidak pada proses spermatogenesis tetapi pada transportasi sperma, tanin dapat menggumpalkan sperma sehingga menurunkan motilitas dan daya hidup sperma (wien dan dian, 2007). alkaloid yang bekerja menekan sekresi fsh dan lh sehingga akan mengganggu proses spermatogenesis dan akibatnya juga akan berpengaruh terhadap kualitas dan kuantitas spermatozoa (toelihere dalam hartini 2011). menurut indriani (2006) ekstrak etanol daun jambu biji mengandung senyawa tanin dan steroid yang tinggi serta sedikit senyawa hidrokuinon, flavonoid dan saponin. variabel yang di ukur adalah kadar fsh dan jumlah sel spermatogenik (spermatogonium, spermatosit primer dan spermatid) bahan dan metode penelitian ini merupakan penelitian eksperimen, dengan rancangan penelitian post test only control group design. subjek penelitian terdiri dari tiga kelompok yang dipilih secara acak dan telah diadaptasikan. masing-masing kelompok sebanyak 10 ekor dan dibagi dalam tiga kelompok. satu kelompok sebagai kontrol hanya mendapatkan cmc na 0,5 % saja per oral. sedangkan dua kelompok lainnya mendapat perlakuan 1 dan perlakuan 2 diberikan suspensi ekstrak daun jambu biji merah dengan dosis 40 mg/ml/hari dan 80 mg/ml/hari selama 30 hari. penelitian ini menggunakan tikus putih jantan (rattus norvegicus) strain wistar di fakultas kedokteran hewan unair, karena secara etik tidak memberikan perlakuan secara langsung kepada manusia. uji kelaikan etik (ethical clearance) dilaksanakan sebelum penelitian eksperimental laboratoris yang sesungguhnya fakultas kedokteran hewan universitas airlangga. bahan yang digunakan untuk penelitian ini adalah tumbuhan daun jambu biji merah diperoleh dari balai penelitian tanaman obat dan herbal departemen pertanian jalan tentara efek zat aktif ekstrak daun jambu biji merah (ervi husni, dkk) 271 pelajar no 3 bogor jawa barat. kemudian daun jambu biji merah dibuat simplisia (serbuk) lalu di ekstraksi. dari 2 kg daun jambu biji merah didapatkan 1300 g serbuk kering daun jambu biji. minuman yang diberikan adalah air pdam ad libitum dan makanan yang diberikan adalah makanan tikus putih pada umumnya. alat untuk perlakuan yaitu botol kecil, sonde, gelas ukur, corong gelas kecil. alat untuk pengambilan preparat histologi testis yaitu alat bedah, cawan petri. alat untuk menghitung sel spermatogonium, spermatosit primer dan spermatid yaitu mikroskop cahaya, counter pipet, gelas objek cekung dan stop wacth . alat untuk ekstraksi yaitu shaker, tabung erlenmeyer, rotary evaporator, penghitungan menggunakan hemositometer tahap persiapan meliputi: 1. tikus putih jantan dewasa yang memenuhi kriteria baik umur maupun berat badan disiapkan sebanyak 30 ekor. 2. melakukan adaptasi lingkungan selama 1 minggu untuk penyesuaian terhadap lingkungan dengan memberi makan dan minum tikus seperti biasa. 3. pengelompokan tikus yaitu satu kelompok kontrol dan 2 dua kelompok perlakuan yang masingmasing kelompok sebanyak 10 ekor. 4. tikus ditempatkan dalam kandang yang terbuat dari bahan plastik tertutup kawat sebanyak 10 buah dilengkapi tempat makan dan botol minuman. kandang berukuran 40 x 50 cm, sekam sebagai alas kandang di bersihkan setiap dua hari. lingkungan kandang tikus putih dengan suhu kandang dibiarkan dalam kisaran alamiah (27 – 27,5 o c). cahaya ruangan 12 jam terang dan 12 jam gelap. timbangan sartorius untuk menimbang berat badan tikus putih. makan adalah makanan tikus biasa (pelet) dan air minun pdam disuplai setiap hari. 5. pembuatan suspensi cmc na 0,5 %. ditimbang 0,5 gram serbuk cmc na 0,5 %, air panas sebanyak 40 ml ditaburkan di mortal, dibiarkan terendam dan mengembang beberapa menit. kemudian ditambahkan air mineral sampai volume 100 ml dan dikocok kemudian dipindahkan ke gelas. 6. membuat suspensi ekstrak daun jambu biji merah. daun jambu biji diiris-iris lalu dikeringkan, setelah kering lalu ditumbuk halus menjadi serbuk. tiap 2 kg daun jambu biji (basah) dapat menghasilkan 500 g serbuk. serbuk daun jambu biji sebanyak 500 gram dimaserasi dalam pelarut etanol sebanyak 1 liter sehari semalam (diulang 3 kali). filtrat diuapkan dalam rotary evaporator pada suhu 40 0 c sampai terbentuk ekstrak etanol. evaporasi dihentikan jika sudah terbentuk uap lagi. maserasi diulang hingga filtrat jernih seperti etanol. ekstrak cair yang diperoleh lalu dipekatkan dengan rotavapor. kemudian dilakukan skrining fitokimia yang bertujuan untuk mengetahui golongan senyawa yang terkandung dalam suatu bahan tanaman.. suspensi ekstrak daun jambu biji merah dibuat untuk kebutuhan 1 minggu dan pembuatan dilebihkan untuk mengantisipasi bila ada suspensi yang tumpah saat pengambilan. cara pembuatan suspensi dosis 40 mg / ml/ hari yaitu : 40 mg × 7 hari × 15 = 4200 mg ( 4,2 g ), kemudian di campurkan dengan 105 ml cmc na 0,5 %. cara penghitungan yang sama juga dilakukan untuk pembuatan suspensi dosis 80 mg/ ml/hari. tahap pelaksanaan: 1. memberikan perlakuan dengan cara memberikan larutan cmc 0,5 % 1 ml/hari pada kelompok kontrol dan memberikan ekstrak daun jambu biji merah dosis 40 mg/ml/hari pada kelompok perlakuan 1 serta 80 mg/ml/hari pada kelompok perlakuan 2 setiap hari pada jan 12.00 wib setiap hari selama 30 hari. 2. setelah hari ke 30 tikus disiapkan untuk pengambilan sampel jumlah sel spermatogenik. dilakukan setelah perlakuan terhadap hewan coba berakhir. tikus dikorbankan dengan menggunakan eter, setelah mati kemudian testisnya di ambil untuk pembuatan histologi testis. epididimis yang diambil adalah bagian kauda.dan diletakkan di cawan petri yang berisi larutan saline/pbs 1 ml, kemudian dipotong-potong halus hingga terbentuk suspensi. 3. untuk pemeriksaan sel spermatogeniknya organ testis dimasukkan kedalam larutan buoin, kemudian dibuat sediaan histologi dengan pewarnaan hematoksilin eoisin. pengamatan dilakukan dilakukan dengan mikroskop cahaya dengan pembesaran 400 kali, sampel diambil sebanyak lima lapangan pandang dan diambil rata-rata jumlah sel permatogenik. jurnal ners vol. 11 no. 2 oktober 2016: 269276 272 data yang diperoleh adalah nilai rerata dari jumlah sel spermatogenik meliputi spermatogonium, spermatosit primer dan spermatid tiap kelompok. data hasil penelitian disajikan dalam bentuk tabel. distribusi data normal atau tidak dilakukan uji kolmogorov smirnov z dan untuk mengetahui varian homogen atau tidak dilakukan uji homogenitas varian. hasil uji homogenitas varian apabila varian homogen dilanjutkan dengan uji anova satu arah pada taraf signifikansi p< 0,05 dan untuk mengetahui bermakna atau tidaknya beda antar pasangan perlakuan dilakukan uji lsd (least significantly difference) (bnt = beda nyata terkecil) (steel dan torrie, 1991). hasil penelitian jumlah sel spermatogenik jumlah spermatogonium jumlah spermatogonium adalah jumlah yang dihitung dengan menggunakan mikroskop nikon eclipse ci dengan pembesaran 400 kali pada preparat histologi testis dari sayatan tubulus seminiferus dengan pewarnaan hematoksilin eosin yang dilakukan pada lima lapang pandang dan dinyatakan dalam bentuk jumlah sel (sel per lapang pandang). hasil perhitungan jumlah rerata spermatogonium pada tikus putih jantan tidak terdapat perbedaan yang bermakna antara kelompok kontrol dengan kelompok p 1 dan kelompok p2. hasil uji normalitas kolmogorovsmirnov pada kelompok kontrol menunjukkan nilai p 0,710, kelompok p 1 nilai p 0,989 dan pada kelompok p 2 nilai p 0,859 ( p > 0,05 ), berarti ketiga data berdistribusi normal. dilanjutkan uji statistik dengan menggunakan uji anova satu arah, didapatkan nilai p 0,801 (p < 0,05), berarti tidak ada perbedaan yang signifikan diantara ketiga kelompok. nilai significant of level nya ˃0,05, maka disimpulkan tidak ada perbedaan yang bermakna pada ketiga kelompok, untuk itu uji lsd (least square difference) tidak bisa dilakukan. jumlah spermatogonium tikus putih jantan pada ketiga perlakuan secara statistik dianggap tidak berbeda signifikan (tabel 1). jumlah spermatosit primer jumlah spermatosit primer adalah jumlah yang dihitung dengan menggunakan mikroskop nikon eclipse ci dengan pembesaran 400 kali pada preparat histologi testis dari sayatan tubulus seminiferus dengan pewarnaan hematoksilin eosin yang dilakukan pada lima lapang pandang dan dinyatakan dalam bentuk jumlah sel (sel per lapang pandang). hasil perhitungan jumlah rerata spermatosit primer pada tikus putih jantan didapatkan penurunan antara kontrol dengan kelompok p 1 dan kelompok p2. hasil uji normalitas kolmogorov-smirnov pada kelompok kontrol menunjukkan nilai p 0,124, kelompok perlakuan 1 nilai p 0,799 dan pada kelompok perlakuan 2 nilai p 0,937 (p > 0,05) yang berarti bahwa ketiga data tersebut berdistribusi normal. kemudian dilanjutkan dengan uji statistik dengan menggunakan uji anova satu arah, didapatkan nilai p 0,102 ( p < 0,05). tidak ada perbedaan yang signifikan diantara ketiga kelompok. nilai significant of level nya ˃ 0,05 maka disimpulkan tidak ada perbedaan pada ketiga kelompok perlakuan, uji lsd ( least square difference ) tidak bisa dilakukan. jumlah spermatosit primer tikus putih jantan pada ketiga perlakuan secara statistik terbukti tidak berbeda signifikan (tabel 2). tabel 1 rata-rata ( ̅) dan simpangan baku (sd) jumlah spermatogonium pada tikus putih jantan kelompok replikasi ᾱ ± sd k (kontrol) p1 (40 mg/ml/hari) p2 (80 mg/ml/hari) 10 10 10 57,780 ± 5,46 a 58,400 ± 11,64 a 55,580 ± 6,69 a p: 0.801 keterangan : superskrip huruf yang sama menunjukkan tidak berbeda nyata tabel 2 rata-rata ( ̅) dan simpangan baku (sd) jumlah spermatosit primer pada tikus putih jantan kelompok replikasi ᾱ ± sd k (kontrol) p1 (40 mg/ml/hari) p2 (80 mg/ml/hari) 10 10 10 81,570 ± 8,86 a 70,710 ± 10,63 a 56,850 ± 10,60 a ρ : 0.102 keterangan : superskrip huruf yang sama menunjukkan tidak berbeda nyata efek zat aktif ekstrak daun jambu biji merah (ervi husni, dkk) 273 kelompok kontrol: terlihat gambaran sel spermatogenik masih padat dan tersusun rapat dari tepi ke tengah . kelompok perlakuan 1 : terlihat gambaran sel spermatogenik mulai renggang dari tepi ke tengah. kelompok perlakuan 2 : terlihat gambaran sel spermatogenik bertambah renggang mulai dari tepi sampai ke tengah. tabel 3 rata-rata ( ̅) dan simpangan baku (sd) jumlah spermatid pada tikus putih jantan kelompok replikasi ᾱ ± sd k (kontrol) p1 (40 mg/ml/hari) p2 (80 mg/ml/hari) 10 10 10 149,540 ± 31,46 a 120,830 ± 17,39 b 91,600 ± 35,12 c ρ : 0.001 keterangan : superskrip huruf yang berbeda menunjukkan berbeda nyata. jumlah spermatid jumlah spermatid adalah sel yang dihitung dengan menggunakan mikroskop nikon eclipse ci dengan pembesaran 400 kali pada preparat histologi testis dari sayatan tubulus seminiferus dengan pewarnaan hematoksilin eosin yang dilakukan pada lima lapang pandang dan dinyatakan dalam bentuk jumlah sel (sel per lapang pandang). hasil perhitungan jumlah rerata spermatid pada tikus putih jantan didapatkan penurunan antara kontrol dengan kelompok perlakuan 1 dan perlakuan 2. hasil uji normalitas kolmogorov-smirnov pada kelompok kontrol menunjukkan nilai p 0,888 kelompok perlakuan 1nilai p 0,890 dan pada kelompok perlakuan 2 nilai p 0,620 ( p > 0,05 ) yang berarti bahwa ketiga data tersebut berdistribusi normal. kemudian dilanjutkan dengan uji statistik dengan menggunakan uji anova satu arah, didapatkan nilai p 0,001 ( p < 0,05). ada perbedaan yang signifikan diantara ketiga kelompok. untuk mengetahui kelompok mana yang berbeda maka dilanjutkan dengan uji least significant difference (lsd). gambar 1 histologi testis sampel pembahasan jumlah sel spermatogenik hasil perhitungan jumlah rerata spermatogonium pada tikus putih jantan tidak terdapat perbedaan yang bermakna antara kelompok kontrol dengan kelompok perlakuan 1 dan perlakuan 2. dari hasil uji anova satu arah, didapatkan nilai p = 0,140 ( p < 0,05). berarti tidak ada perbedaan yang signifikan diantara ketiga kelompok. tabel 2 menunjukkan hasil perhitungan jumlah rerata spermatosit primer pada tikus putih jantan didapatkan penurunan antara kontrol dengan kelompok perlakuan 1 dan perlakuan 2. dari hasil uji anova satu arah, didapatkan nilai p 0,102 ( p < 0,05). berarti tidak ada perbedaan yang signifikan diantara ketiga kelompok. jumlah spermatogonium dan spermatosit primer tikus putih jantan pada ketiga perlakuan secara statistik dianggap tidak berbeda signifikan. artinya ekstrak daun jambu biji merah dengan dosis 40 mg/ml/hari dan 80 mg/ml/hari selama 30 hari belum memberikan efek terhadap penurunan jumlah spermatogonium dan spermatosit primer pada tikus putih jantan. pada tabel 3 menunjukkan hasil perhitungan jumlah rerata spermatid pada tikus putih jantan didapatkan penurunan pada kelompok perlakuan 1 dan perlakuan 2 dibanding kelompok kontrol. hasil uji anova satu arah, didapatkan nilai p 0,001 (p< 0,05). berarti ada perbedaan yang signifikan diantara ketiga kelompok. hasil uji lsd menunjukkan bahwa ada perbedaan yang bermakna antara kelompok kontrol dengan kelompok p 1 dengan nilai p 0,036 sedangkan kelompok kontrol dengan p 2 juga terdapat perbedaan yang bermakna dengan nilai p 0,000. untuk kelompok p1 dengan p2 juga terdapat perbedaan yang bermakna dengan nilai p 0,033. hasil gambaran histologi testis pada kelompok kontrol (gambar 1) terlihat potongan tubulus seminiferus testis terlihat sel-sel spermatogenik yang tersusun secara lengkap dan berurutan ke arah lumen menurut tingkat perkembanganya, sedangkan jurnal ners vol. 11 no. 2 oktober 2016: 269276 274 pada kelompok perlakuan 1 dan perlakuan 2 terlihat susunan sel longgar tidak beraturan dan kerapatannya berkurang. sel spermatogenik tersusun secara lengkap dengan sel yang berasosiasi secara berurutan kearah lumen menurut tingkat perkembangannya yaitu spermatogonium selapis, spermatosit primer, spermatid beberapa lapis dan lumen berisi spermatozoa (astuti ny dan soeradi o 2002). sel spermatozoa yang dihasilkan di tubulus seminiferus testis oleh sel-sel yang berasal dari germinal epitelium disebut spermatogonium yang bersifat spermatogenik. pembentukan sel spermatogonium dalam tubulus seminiferus berturut-turut dari tepi ke arah lumen adalah yang dimulai dari spermatogonium yang sudah terbentuk semenjak sebelum pubertas. spermatogonium akan berubah menjadi spermatosit primer, spermatosit sekunder dan kemudian berkembang menjadi spermatid. spermatid akan melewati proses maturasi untuk berkembang menjadi sel spermatozoa (poernomo, 2011). menurut fritz (1978) perkembangan dan jumlah sel spermatogonia serta sel sertoli lebih dipengaruhi oleh regulasi hormonal. fsh berperan sejak terjadinya proliferasi spermatogonia sehingga terbentuknya spermatosit primer dan terhadap perkembangan tahap akhir spermatid menjadi spermatozoa. fsh dan androgen (testosteron) mempertahankan fungsi gametogenik testis. fsh bekerja pada sel sertoli untuk memperlanjar stadium akhir pematangan (ganong. wf 2003). sel endotelial dari epididimis membutuhkan andogen dalam level tinggi untuk berfungsi secara normal. meski banyak testosteron yang disekresikan ke dalan tabung tubulus seminiferus diubah kedalam bentuk dht oleh enzim 5a-steroidereduktase, beberapa testosteron diubah ke estrogen oleh enzim aromatase. jumlah tertosteron yang cukup banyak dibutuhkan untuk pendewasaan spermatid (hafez. 2000). sel spermatogenik sangat peka terhadap senyawa toksik pada saat mitosis i, meiosis i dan spermatogenesis (arsyad dalam astuti ny dan soeradi o 2002). pada penelitian ini di duga bertambahnya jumlah lapisan spermatosit primer pada perlakuan mungkin disebabkan oleh adanya gangguan pada pembelahan meiosis. zat aktif daun jambu biji merah diduga menghambat perubahan spermatosit primer menjadi spermatid sehingga terlihat lebih banyak sementara jumlah lapisan sel spermatid berkurang. penurunnya jumlah spermatid dalam penelitian ini di duga dipengaruhi oleh kadar hormon testosteron yang masih rendah padahal hormon testosteron sangat diperlukan untuk pendewasaan spermatid. berkurangnya jumlah lapisan sel spermatozoa pada lumen terjadi karena jumlah spermatid berkurang dan ditambah dengan adanya gangguan spermatogenesis sehingga spermatid terhambat untuk berdiferensiasi menjadi spermatozoa. kerusakan di duga karena adanya vakuolisasi dan eksfoliasi sehingga metabolisme sel juga terganggu. kelainan tersebut merupakan indikator adanya gangguan spermatogenesis. dari satu spermatogonium setelah mengalami fase mitosis dan meiosis akan tebentuk dua spermatosit primer kemudian menhasilkan empat spermatid dan empat spermatozoa (poernomo bs, widjiati, mafruchati, m lugman 2011). penurunan jumlah spermatosit dan spermatid juga didukung oleh pernyataan everrit and johnson.m (1990) bahwa sel spermatogenik sangat peka terhadap pengaruh luar dan cenderung mengalami kerusakan setelah profase meiosis pertama yaitu pada saat terjadinya pindah silang antara kromosom yang homolog. pada tahap ini, inti serta sitoplasma tumbuh menjadi sel terbesar diantara lapisan sel spermatogenik, namun jika adanya bahan oksidan dalam proses spermatogenesis maka akan berpengaruh terhadap jumlah sel spermatogenik. flavonoid yang dihasilkan oleh hampir sebagian besar dunia tumbuhan dapat menghambat banyak reaksi oksidasi, baik enzim maupun non enzim (robinson, dalam nurliani a, rusmiati 2005). kellis dan vickery (1984) berpendapat bahwa flavonoid yang disintesis hampir seluruh dunia tumbuhan dapat menghambat enzim aromatase. dengan dihambatnya enzim tersebut yang berfungsi mengkatalis konversi androgen menjadi estrogen, maka jumlah testosteron (androgen) akan meningkat (hartini 2011). selain itu flavonoid diduga sebagai inhibitor dalam penurunan laju reaksi. ikatan inhibitor dapat merubah daya katalisator nya, karena adanya perubahan struktur enzim ketika suatu inhibitor maupun katalisator berinteraksi dengan enzim tersebut (boyer dalam basha h.s , lalithamma a, lakshman j 2013). hal ini dikarenakan beberapa senyawa bioaktif asal tumbuhan ketika ditambahkan ke dalam sistem reaksi enzimatik dapat berperan sebagai aktifator dan beberapa justru sebagai inhibitor. dengan bertambahnya jumlah reaksi enzimatik di efek zat aktif ekstrak daun jambu biji merah (ervi husni, dkk) 275 dalam tubuh seperti enzim primer sod (superoksida dismutase), maka akan menghambat sejumlah proses perkembangan sel didalam tubuh termasuk spermatogenesis. gaytan dan aguilar (1987) menyatakan bahwa jumlah sel sertoli dalam testis tikus lebih dikontrol oleh hormon fsh sedangkan menurut fritz (1978) perkembangan dan jumlah sel spermatogonia serta sel sertoli lebih dipengaruhi oleh regulasi hormonal. apabila kadar hormon (fsh dan lh) mencukupi kebutuhan sel dan jaringan pada organ reproduksi maka testis juga akan berfungsi dengan baik. namun untuk mengetahui mekanisme kerja secara jelas dari efek sitotoksik dan sitostatik tersebut masih perlu dilakukan penelitian lebih lanjut. simpulan dan saran simpulan pemberian ekstrak daun jambu biji merah dosis 40 mg/ ml/hari dan 80 mg/ ml/hari tidak menurunkan jumlah sel spermatogonium pada tikus putih jantan. pemberian ekstrak daun jambu biji merah 40 mg/ml/hari dan 80 mg/ml/hari tidak menurunkan jumlah spermatosit primer pada model tikus putih jantan. pemberian ekstrak daun jambu biji merah 40 mg/ml/hari dan 80 mg/ml/hari menurunkan jumlah spermatid pada model tikus putih jantan. saran. perlu dilakukan penelitian lebih lanjut apakah ekstrak daun jambu biji merah berpengaruh terhadap jumlah sel sertoli dan kadar inhibin pada tikus putih jantan, perlu dilakukan penelitian lebih lanjut apakah ekstrak daun jambu biji merah berpengaruh terhadap testis ( ukuran dan berat testis), perlu dilakukan penelitian lebih lanjut apakah ekstrak daun jambu biji merah berpengaruh terhadap kadar hormon fsh, lh dan testosteron pada tikus putih jantan, perlu penelitian lebih lanjut efek toksik ekstrak daun jambu biji merah terhadap organ reproduksi, perlu dilakukan penelitian lebih lanjut dengan dosis yang lebih tinggi, waktu pemberian yang lebih lama dan sampel yang lebih banyak. kepustakaan astuti ny dan soeradi o, 2002. toksisitas akut dan efek pemberian ekstrak etanol kayu secang (caesalpinia sappan l) terhadap struktur anatomi tubulus seminiferus testis tikus putih. jurnal bahan alam indonesia, 1(1). basha h.s , lalithamma a, lakshman j, c.c., 2013. antifertility effect of carica papaya linn.seed extract on hormones in male albino rats. international journal of biological & pharmaceutical research, 4(12), pp.859–861. everrit and johnson.m, 1990. essensial reproduction 3 nd editi., london: blackwell sci.pub. fritz, i.b., 1978. site of actions of androgen and follicle stimulating hormone on cell of the seminiferous tubule, new york: litwack (ed) academic press. ganong. wf, 2003. buku ajar fisiologi kedokteran ed. 20., jakarta: egc. harjopranjoto. s, 1995. ilmu kemajiran pada ternak. surabaya, surabaya: airlangga university press. hartini, 2011. pengaruh dekok daun jambu biji merah (psidium guajava. l) terhadap jumlah , kecepatan dan morfologi spermatozoa tikus putih jantan (rattus norvegicus). universitas andalas. moeloek. n, 1994. sistem reproduksi jantan/pria. reproduksi dan embriologi : dari satu sel menjadi organisme, jakarta: fkui. nurliani a, rusmiati, s.h.., 2005. perkembangan sel spermatogenik mencit (mus musculus l) setelah pemberian ekstrak kulit kayu durian (durio ziberthinus murr.). jurnal berk. penel. hayati, 11, pp.77–79. poernomo bs, widjiati, mafruchati, m lugman, e., 2011. buku ajar embriologi, surabaya: pusat penerbitan dan percetakan universitas airlangga. prajogo. b, 2003. dikembangkan kontrasepsi jurnal ners vol. 11 no. 2 oktober 2016: 269276 276 hormonal pria. available at: http://www.kontrasepsihormonalpria.co m/kes. speroff l & fritz, m., 2005. clinical gynecology endocrinology and infertility, philadelphia: lippincot william & wilkins. susetyarini. rr. e, 2009. efek senyawa aktif daun beluntas terhadap kadar testosteron tikuspputih (rattus norvegikus) jantan. jurnal gamma, v(1), pp.21–27. 34 ekspresi hsp 70 dan ekspresi reseptor opioid mu pada penurunan nyeri terapi bekam basah (expression of hsp 70 and mu opioid receptors decrease pain on wet cupping therapy) imam subadi * , hening laswati * , harjanto jm ** *departemen ilmu kedokteran fisik dan rehabilitasi fakultas kedokteran universitas airlangga **departemen ilmu faal fakultas kedokteran universitas airlangga email: isubadi_roesdam@yahoo.co.id abstrak pendahuluan: terapi bekam basah banyak digunakan untuk mengurangi nyeri, namun mekanisme penurunan nyeri terapi bekam basah belum jelas. peregangan dan tusukan pada terapi bekam basah menimbulkan stres pada sel. sel yang mengalami stres mengekspresikan hsp 70 dan reseptor opioid mu. penelitian ini bertujuan membuktikan korelasi peningkatan ekspresi hsp 70 dan peningkatan reseptor opioid mu pasca terapi bekam basah. metode: jenis penelitian ini adalah penelitian eksperimental dengan rancangan randomized control group post test only design. dua puluh empat tikus jenis wistar (rattus norvegicus) secara random dibagi menjadi tiga kelompok yang masing-masing terdiri dari 8 ekor tikus yaitu kelompok kontrol negatif (tikus normal), kelompok induksi nyeri dengan complete freund’s adjuvant (cfa) saja (kontrol positif) dan kelompok yang diberi induksi nyeri dan terapi bekam basah (10 tusukan dan tekanan negatif: 200 mmhg, 5 menit). sampel diambil dari kulit dan dilakukan pemeriksaan imunohistokimia dengan antibodi monoklonal anti reseptor opioid mu. waktu reaksi ambang nyeri diukur memakai hot-plate. data dianalisa dengan anova oneway dan pearson correlation dengan menggunakan spss versi 17. hasil: penelitian ini menunjukkan bahwa terdapat peningkatan ekspresi hsp 70 (20,25 ± 3,53; p< 0.05) dibandingkan kelompok kontrol positif (10,50 ± 2,44; p< 0,05) dan peningkatan ekspresi reseptor opioid mu (21,00 ± 6,34; p< 0.05) dibandingkan kelompok kontrol positif ( 4,25 ± 3,58; p< 0.05). terdapat peningkatan waktu reaksi ambang nyeri (22,81 ± 6,34; p< 0,05) dibandingkan kontrol positif (11,78 ± 3,56). terdapat korelasi antara peningkatan ekspresi hsp 70 dan peningkatan reseptor opioid mu (β= 0.893; p= 0.000) dan ada korelasi antara peningkatan reseptor opioid mu dengan waktu reaksi ambang nyeri (β= 0.713; p= 0.002). diskusi: terapi bekam basah meningkatkan ekspresi hsp 70, reseptor opioid mu dan waktu reaksi ambang nyeri. kata kunci: ekspresi hsp 70, ekspresi opioid, penurunan nyeri, bekam basah abstract introduction: wet cupping therapy widely used to reduce the pain, but the mechanisms of pain reduction on wet cuppig therapy is unclear. stretching and punctures on wet cupping therapy cause stress on the cell. cells that are stressed express hsp 70 and mu opioid receptors. this study aims to prove the correlation increased expression of hsp 70 and an increase in post-mu opioid receptor wet cupping therapy. methods: the study is an experimental research design with randomized control group post-test only design. twenty-four rats type wistar (rattus norvegicus) were randomly divided into three groups, each consisting of eight mice are negative control group (normal mice), group induction of pain with complete freund's adjuvant (cfa) alone (positive control) and group by induction of pain and bekam basah therapy (10 puncture and negative pressure: 200 mmhg, 5 minutes). samples were taken from the skin and immunohistochemical examination with the monoclonal antibody anti mu opioid receptors. the reaction time pain threshold measured using a hot -plate. data were analyzed by oneway anova and pearson correlation using spss version 17. results: this study shows that there is an increased expression of hsp 70 (p <0.05) compared to the positive control group (p <0.05) and increased expression of mu opioid receptors ( p <0.05) compared to the positive control group (p <0.05). there is an increased pain threshold reaction time (p <0.05) compared to the positive controls (11.78 ± 3.56). there is a correlation between an increased expression of hsp 70 and an increase in mu opioid receptor (β = 0893; p = 0.000) and there was a correlation between the increase in mu opioid receptor with a reaction time of pain threshold (β = 0713; p = 0.002). discussion: wet cupping therapy increase hsp 70 expression, opioid mu receptor, and decrease pain level. keywords: hsp 70, mu opioid receptors, wet cupping therapy __________________________________________________________________________________ pendahuluan bangsa indonesia mempunyai berbagai terapi alternatif, salah satu dari terapi alternatif tersebut adalah terapi bekam. masyarakat menggunakan terapi bekam untuk menyembuhkan sakit kepala, pegal linu, nyeri sendi, rematik, masuk angin (kasmui 2012). terapi bekam dikenal dua macam metode yaitu terapi bekam kering dan terapi bekam basah. terapi bekam kering adalah metode terapi dimana kulit dilakukan pengekopan atau pemberian tekanan negatif tanpa tusukan, sedangkan terapi bekam basah adalah metoda terapi dimana darah dikeluarkan dari tubuh melalui permukaan kulit dengan cara penusukan pada kulit kemudian dilakukan pengekopan. masyarakat menggunakan terapi bekam kering untuk nyeri yang ringan, sedangkan terapi bekam basah digunakan bila nyeri berat. jurnal ners vol. 11 no. 1 april 2016: 34-39 35 meskipun telah dikenal manusia sejak ribuan tahun yang lalu, sampai saat ini penelitian terapi bekam sangat terbatas (dk 2010) pada dekade terakhir dilaporkan terapi bekam basah efektif untuk menurunkan nyeri kepala (ahmadi et al. 2008), brachialgia parasthetica nocturna (lutdke, et al. 2006), carpal tunnel syndrome ( michalsen et al. 2009) nyeri punggung bawah (farhadi et al, 2009). mekanisme penurunan nyeri inflamasi terapi bekam basah sampai saat ini belum jelas. nyeri merupakan keluhan utama yang paling sering dijumpai dalam praktek dokter sehari-hari (smith bh 1999) penelitian tentang nyeri di 15 negara di eropa dilaporkan bahwa prevalensi nyeri kronis adalah sebesar 19% ( breivik et al. 2006) prevalensi nyeri kronis di amerika serikat sebesar 30,7% ( johanes et al. 2010) , sedangkan di hong kong sebesar 34,9% (wong dan feilding 2011). menurut world health organization (who), prevalensi nyeri kronis di negara sedang berkembang 41 % (croft et al. 2010). survei pada 4683 orang desa dan 1071 orang kota di jawa tengah, didapatkan angka kejadian nyeri 23,6% di desa dan 31,3% di kota (darmawan et al., 1992). dampak nyeri kronis mengganggu kehidupan sehari-hari. nyeri kronis berdampak pada gangguan tidur, aktifitas olah raga, berjalan, melakukan pekerjaan rumah tangga, menghadiri kegiatan sosial, kehidupan seksual dan kemandirian pola hidup ( breivik et al., 2006), kualitas hidup (katz 2002) dan pekerjaan (smith et al. 2001). di amerika serikat, dampak ekonomi nyeri kronis diperkirakan senilai 61, 2 milyard dollar amerika setiap tahun yang disebabkan waktu produktif yang hilang (reyes-gibby c 2008). saat ini penanganan nyeri kronis meliputi terapi farmakologi, non farmakologi dan terapi intervensi. pemberian nsaids berkepanjangan menimbulkan komplikasi (brattwall et al., 2010). gejala yang muncul akibat komplikasi nsaids antara lain dispepsia, tukak lambung, dan perdarahan lambung ( fujimori et al. 2010). analgesik opioid adalah obat yang paling efektif dan sering digunakan untuk mengurangi nyeri sedang sampai berat. salah satu opioid endogen adalah β-endorfin yang paling utama dikode oleh proopiomelanocortin (pomc) (koneru. a et al. 2009). opioid menghambat produksi l-glutamat di terminal sentral aferen primer pada kornu dorsal medula spinalis dan juga menghambat timbulnya potensial aksi pada terminal perifer aferen primer sehingga transmisi saraf tidak terjadi yang berakibat nyeri menurun. hipotesa penelitian ini adalah penurunan nyeri inflamasi disebabkan ekspresi reseptor opioid mu, mengingat sel yang mengalami stres merangsang hipofise mengekspresikan proopiomelanocortin yang memicu β-endorfin. reseptor utama β-endorfin adalah reseptor opioid mu. metode jenis penelitian yang digunakan adalah penelitian eksperimental dengan rancangan penelitian post test only control group design. kelaikan etik diperoleh dari fakultas kedokteran hewan universitas airlangga. dua puluh empat tikus putih jenis wistar (rattus norvegicus) secara random dibagi menjadi tiga kelompok yang masing-masing kelompok terdiri dari 8 ekor tikus putih. kelompok pertama adalah kelompok kontrol negatif yaitu tikus yang tidak mendapat apa-apa. kelompok kedua adalah kelompok kontrol positif yaitu tikus yang hanya mendapat induksi nyeri complete freund’s adjuvant (cfa), sedangkan kelompok ketiga adalah kelompok perlakuan yaitu selain diinduksi nyeri juga dilakukan terapi bekam basah. penelitian dilakukan di beberapa laboratorium yang berbeda. pembuatan jaringan model dilakukan di laboratorium departemen farmakognisi dan sitokimia fakultas farmasi universitas airlangga. pembuatan preparat dan foto dilakukan di laboratorium patologi anatomi fakultas kedokteran universitas airlangga. pewarnaan teknik imunohistokimia dan penghitungan dilakukan di laboratorium biomolekuler dan biokimia fakultas kedokteran universitas brawija ya. model hewan nyeri inflamasi yaitu tikus putih diinjeksi 100 μl cfa pada permukaan plantar kaki ipsilateral. empat puluh delapan jam setelah induksi nyeri, model hewan nyeri inflamasi yang terjadi dilakuan terapi bekam kering pada kelompok perlakuan. terapi bekam basah adalah pemberian tusukan dengan lancet kemudian diberi tekanan negatif sebesar – 200 mmhg pada kulit punggung bilateral selama 5 menit. dua puluh empat jam setelah terapi bekam basah, hewan coba dikorbankan dan diambil jaringan medula spinalis. ekspresi reseptor opioid mu adalah penilaian positif dengan teknik imunohistokimia menggunakan ekspresi hsp 70 dan opioid mu (imam subadi, dkk.) 36 antibodi monoklonal anti reseptor opioid mu. penilaian dilakukan secara kuantitatif visual dengan mikroskop cahaya dengan pembesaran 1000 kali terhadap sel saraf di medula spinalis yang mengekspresikan reseptor opioid mu. penghitungan dilakukan terhadap sel saraf yang imunoreaktif tercat coklat pada sitoplasma sel saraf pada dua puluh lapangan pandang yang berbeda. hasil setiap perhitungan ditulis pada lembar kerja dan diambil nilai rata-rata per lapang pandang. parameter nyeri diukur memakai alat hot plate (ugo basile) dengan suhu 51 0 c berdasarkan waktu reaksi ambang nyeri yaitu waktu mulai kaki tikus menginjak hot plate sampai tikus menjilat kaki atau melompat. data dianalisa dengan menggunakan anova oneway, brownforsythe, gomes-howell dan pearson correlation. hasil ekspresi hsp 70 hasil pemeriksaan preparat dengan teknik imunohistokimia menunjukkan peningkatan jumlah sel keratinosit yang mengekspresi hsp 70, ditandai dengan reaksi warna coklat terhadap antibodi anti hsp 70 pada kelompok terapi bekam basah dibandingkan kelompok kontrol (gambar 1). (a) (b) (c) gambar 1. sayatan jaringan kulit tikus putih dengan menggunakan antibodi monoklonal anti hsp 70 pada kelompok kontrol negatif (a), kelompok kontrol positif (b) dan kelompok terapi bekam basah(c). pembesaran 400 x dengan mikroskop cahaya dan kamera merk olympic. negatif : sel keratinosit tidak memberikan reaksi warna coklat. positif : sel keratinosit memberi reaksi warna coklat terhadap antibodi monoklonal anti β-endorfin. : negatif : positif hasil penghitungan sel keratinosit yang mengekspresikan hsp 70 pada kelompok kontrol negatif, kelompok kontrol positif, kelompok terapi bekam kering dan kelompok terapi bekam basah ditunjukkan pada tabel 1. tabel 1. rerata dan simpang baku ekspresi hsp 70 pada sel keratinosit masing-masing kelompok. kelompok hsp 70 (jml. sel/ lap. pandang/ pemb.1000x) anova oneway (p) x sd min maks kontrol negatif 5,62 a 1,84 3 8 p < 0,001 kontrol positif 10,50 b 2,44 6 14 terapi bekam basah 20,25 c 3,53 13 24 keterangan : signifikan pada α = 0,05. superscript yang berbeda menunjukkan ada perbedaan antar kelompok (berdasarkan lsd). uji normalitas dengan kolmogorovsmirnov ekspresi hsp 70 pada semua kelompok menunjukkan data berdistribusi normal (p> 0,05). uji homogenitas dengan levene’s test menunjukkan ekspresi hsp 70 antar kelompok mempunyai variansi yang homogen (p > 0,05). pengujian dengan anova oneway antar kelompok perlakuan jurnal ners vol. 11 no. 1 april 2016: 34-39 37 menunjukkan perbedaan yang signifikan (p < 0,05). berdasarkan analisis data diatas dapat disimpulkan terapi bekam basah meningkatkan ekspresi hsp 70 dibandingkan kontrol. ekspresi reseptor opioid mu hasil pemeriksaan preparat dengan teknik imunohistokimia menunjukkan peningkatan jumlah sel saraf di medula spinalis yang mengekspresi reseptor opioid mu yang memberi reaksi warna coklat terhadap antibodi anti resept or opioid mu pada kelompok terapi bekam basah dibandingkan kelompok kontrol (gambar 2). gambar 2. sayatan jaringan medula spinalis tikus putih dengan menggunakan antibodi monoklonal anti reseptor opioid mu pada kelompok kontrol negatif (a), kelompok kontrol positif (b) dan kelompok terapi bekam basah (c). pembesaran 400 x dengan mikroskop cahaya dan kamera merk olympic. negatif : sel keratinosit tidak memberikan reaksi warna coklat. positif : sel keratinosit memberi reaksi warna coklat terhadap antibodi monoklonal anti β-endorfin. negatif positif uji normalitas dengan dengan kolmogorov-smirnov ekspresi reseptor opioid mu pada semua kelompok menunjukkan data berdistribusi normal (p> 0,05). uji homogenitas dengan levene’s test menunjukkan ekspresi reseptor opioid mu antar kelompok mempunyai varians yang homogen (p > 0,05). pengujian dengan anova oneway antar kelompok perlakuan menunjukkan perbedaan yang signifikan (p < 0,05). hasil uji lsd menunjukkan bahwa ada perbedaan antara kelompok kontrol negatif dan kelompok kontrol positif. antara kelompok terapi bekam basah terdapat perbedaan yang bermakna dengan kelompok kontrol positif. tabel 2. rerata dan simpang baku ekspresi reseptor opioid mu pada sel saraf masing-masing kelompok. kelompok reseptor opioid mu (jml. sel/ lap. pandang/ pemb.1000x) anova oneway (p) x sd min maks kontrol negatif 10,62 a 3,92 3 16 p < 0,001 kontrol positif 4,25 b 3,58 7,5 18 terapi bekam basah 21,00 c 6,34 14,30 30 waktu reaksi ambang nyeri uji normalitas dengan dengan kolmogorovsmirnov waktu reaksi ambang nyeri pada semua kelompok menunjukkan data berdistribusi normal (p> 0,05). uji homogenitas dengan levene’s test menunjukkan waktu reaksi ambang nyeri antar kelompok mempunyai variansi yang tidak homogen (p < 0,05). karena levene’s test menunjukkan hasil yang tidak homogen maka dilakukan uji brownforsythe. uji brown-forsythe menunjukkan hasil yang signifikan (p<0,05) sehingga perhitungan antar kelompok digunakan uji games-howell. hasil uji games-howell menunjukkan tidak ada perbedaan antara kelompok kontrol negatif dan kontrol positif (p= 0,764). terdapat perbedaan antara kelompok kontrol negatif dan terapi bekam basah (0,002). terdapat perbedaan antara kelompok kontrol positif dan terapi bekam basah (0,003). berdasarkan analisis data di atas terapi bekam basah meningkatkan waktu reaksi ambang nyeri. korelasi ekspresi hsp 70, reseptor opioid mu dan waktu reaksi ambang nyeri uji korelasi pearson menunjukkan terdapat korelasi antara ekspresi hsp 70 dan b a c c ekspresi hsp 70 dan opioid mu (imam subadi, dkk.) 38 ekspresi reseptor opioid mu (β= 0,687; p= 0,000). terdapat korelasi antara ekspresi reseptor opioid mu dengan waktu reaksi ambang nyeri ((β= 0,617; p= 0,001). pembahasan penelitian ini menunjukkan terapi bekam basah meningkatkan ekspresi hsp 70, reseptor opioid mu dan waktu reaksi ambang nyeri. pada penelitian ini terapi bekam basah meningkatkan waktu reaksi ambang nyeri yang artinya bahwa hewan coba lebih tahan terhadap paparan panas. penelitian efek terapi bekam basah pada hewan coba belum pernah ada. penelitian pada manusia menunjukkan bahwa terapi bekam basah efektif untuk menurunkan nyeri kepala (ahmadi et al. 2008), brachialgia parasthetica nocturna (ludtke et al. 2006), carpal tunnel syndrome (michalsen. a et al. 2009), nyeri punggung bawah (farhadi et al. 2009). peningkatan ekspresi hsp 70 berhubungan dengan peningkatan ekspresi β-endorfin . tusukan pada kulit menyebabkan membran sel keratinosit rusak. kerusakan jaringan akibat tusukan menimbulkan reaksi inflamasi yaitu pengeluaran mediator-mediator inflamasi antara lain bradikinin, prostaglandin, leukotrien, serotonin, histamin, substansi p, tromboksan, platelet-activating factor (paf), adenosin dan adenosine triphosphat (atp), proton dan radikal bebas (dougherly dan raja, 2011). shah dan kawan-kawan menunjukkan bahwa prostaglandin e2 memicu ekspresi hsp 70. pada mamalia, aktivasi hypothalamic-pituitaryadrenal (hpa) axis merupakan respon endokrin utama terhadap stres dan ditandai peningkatan corticotopin releasing hormon (crh). pada sel corticotrophs hipofise, crh berikatan dengan reseptor crhr1 menstimulasi transkripsi gen proopiomelanocortin (pomc). proopiomelanocortin merupakan progenitor adrenocotropic hormone (acth) dan β-endorfin (slominski et al., 2000). meer dan kawan-kawan (1996) melakukan penelitian pada tikus yang diinduksi il-1β, tnf-α dan il-6 dan dilaporkan bahwa il-1β, il-6 dan tnf-α memicu ekspresi crh, dimana il-1β lebih kuat memicu ekspresi crh dibandingkan il-6 dan tnf-α. hasil penelitian melaporkan bahwa induksi nfkb pada sel corticotrophs hipofise memicu gen pomc melalui crh (karalis et al. 2004). hasil penelitian didapatkan bahwa bahwa nfkb secara langsung mengikat gen pomc untuk menstimulasi transkripsi pomc (jang pg, namkoong c, kang gm, hur mw, kim sw, kim gh, kang y, jeon mj, kim eh, lee ms, karin m, baik jh, park jy, lee ku 2010). hasil penelitian didapatkan bahwa induksi il-1β pada sel hipofise menstimulasi ekspresi β-endorfin namun tergantung dosis dan waktu (fagarasan, et al. 1989). pada 12 jam pasca induksi il-1β tidak terjadi sekresi β-endorfin, baru setelah 24 jam β-endorfin tersekresi. pada dosis 1pm il1β tidak terjadi sekresi β-endorfin, sedangkan dosis 1nm il-1β terjadi sekresi β-endorfin (fagarasan et al. 1989). hasil penelitian dilaporkan bahwa β-endorfin mengaktifkan reseptor opioid mu (gharagozlou p et al. 2006). pada uji korelasi pearson menunjukkan adanya korelasi antara peningkatan ekspresi hsp 70 dengan peningkatan reseptor opioid mu. peneliti menduga regangan dan tusukan menyebabkan hsp 70 terekspresi sehingga memicu ekspresi reseptor opioid mu. pada uji korelasi juga ditunjukkan adanya korelasi antara peningkatan ekspresi reseptor opioid mu dengan waktu reaksi ambang nyeri. simpulan dan saran simpulan terjadi peningkatan ekspresi hsp 70 dan reseptor opioid mu pada terapi bekam basah. terdapat korelasi antara peningkatan ekspresi hsp 70 dan peningkatan ekspresi reseptor opioid mu. terdapat korelasi antara peningkatan reseptor opioid mu dengan peningkatan waktu reaksi ambang nyeri. saran terapi bekam basah dapat digunakan sebagai alternatif terapi untuk menurunkan tingkat nyeri, namun uji coba pada manusia masih perlu diteliti lebih lanjut. kepustakaan a, a., dc, s. & m, r., 2008. the efficacy of wet-cupping in the treatment of tension and migraine headache. the american journal of chinese medicine, pp.37–44. a, k., s, s. & s, r., 2009. endogenous opioids: their physiological role and receptors. global journal of pharmacology, p.3( 3): 149–153. a, m. et al., 2009. effects of traditional cupping therapy in patients with carpal tunnel syndrome. the journal of pain, jurnal ners vol. 11 no. 1 april 2016: 34-39 39 p.10: 1–8. bh, s. et al., 2001. the impact of chronic pain in the community. family practice, cb, j. et al., 2010. the prevalence of chronic pain in united states adult: result of internet=based survey. the journal of pain, p.11: 1230–1239. dk, o., 2010. hijama, or cupping. greek medicine.net. available at: http://www.greekmedicine.net/therapies/ hijam_or_cupping.html [accessed november 10, 2013]. gharagozlou p et al., 2006. characterization of endogenous peptides at mu, delta and kappa opioid receptors. in proceedings of the western pharmacology society. p. 49: 109–113. h, b. et al., survey of chronic pain in europe: prevalence, impact on daily life, and treatment. european journal of pain, pp.287–333. j, d. et al., epidemiology of rheumatic disease in rural and urban populations in indonesia : a world health organization league against rheumatism copcord study, stage 1, phase 2. annals of the rheumatism diseases, jang pg, namkoong c, kang gm, hur mw, kim sw, kim gh, kang y, jeon mj, kim eh, lee ms, karin m, baik jh, park jy, lee ku, k.y. and k.m., 2010. nf-kb activation in hypothalamic proopiomelanocortin neurons is essential in illnessand leptin-induced anorexia. the journal of biological chemistry, p.285(13): 9706–97115. k, f. et al., 2009. the effectiveness of wetcupping for nonspecific low back pain in iran. complementary therapies in medicine. , p.17: 9–15. kasmui, 2012. bekam pengobatan menurut sunnah nabi. available at: http://www.archive.org/details/bekam_ pengobatan_menurut_sunnah_nabi. kp, k. et al., 2004. nf-kb participates in the corticotropin-releasing, hormoneinduced regulation of the pituitary proopiomelanocortin gene. the journal of biological chemistry, p.279(12): 10837–10840. mo, f., r, e. & j, a., 1989. interleukin-1 potentiates the secretion of β-endorphin induced by secretagogues in amouse pituitary cell line (att-20). in proceedings of the national academy of science. p. 86: 2070–2073. n, k., 2002. the impact of pain management on quality of life. journal of pain and symptom management, p.24: s38–s47. p, c., fm, b. & d, w., 2010. the global occurence of chronic pain. in: croft p, blyth fm and windt d eds, chronic pain epidemiology, oxford university press. r, l. et al., 2006. brachialgia paraesthetica nocturna can be relieved by wet cupping. complementary therapies in medicine, reyes-gibby c, t.-v.i. and c.r., 2008. epidemiology of chronic pain: classical to molecular approaches to understanding the epidemiology of pain. in (wilson pr, watson pj, haythornthwaite ja and jensen ts, eds). chronic pa., london: hodder arnold, pp. s, f., k, g. & c, s., 2010. a review of antiinflammatory drug-induces gastrointestinal injury. pharmaceuticals, smith bh, h.j. and c.w., 1999. chronic pain in primary care. famiy practice, ws, w. & r, f., 2011. prevalence and characteristics of chronic pain in the general population of hong kong. the journal of pain, p.12: 236–245. http://e-journal.unair.ac.id/jners | 67 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.24527 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family coping strategies to improve the health of family members living with schizophrenia sugeng mashudi1 and ah yusuf2 1 universitas muhammadiyah ponorogo, east java, indonesia 2 faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: schizophrenia is a serious mental illness that affects the thinking, emotions, relationships, and decision-making. one of the positive effects of treating schizophrenia in patients is family health. the family welfare management strategies provide help for coping, care preparation, organizing meetings, and mentoring. this study focuses on family coping strategies for improving the health of members living with schizophrenia. methods: a cross-sectional design was used by choosing 160 respondents randomly. the inclusion criteria were family members accompanying control schizophrenia patients to the public health center, with a minimum age of 18. the independent variable was family coping, which consist of two subvariables (problem-focused coping mechanism and emotion-focused coping mechanism), while the dependent variable was family health, which consists of three sub-variables (efficient, satisfaction, and happiness). the smart pls (2.0 version) was used to prove the impact of the variables. results: the results indicated that family coping had a significant impact on the health of the family. the hypothesis was taken from the value of the t-test on the structural model analysis, which shows tstatistics (13.966) > tcritical (1.96). the impact of family coping on the health is equal to 0.682 (or). this means that if family coping is given one-unit value, it will increase the family health by 0.682 times. conclusion: the implementation of the family coping strategy will improve the capacity of the family to clarify health issues encountered, resolve family behaviors effectively and minimize risk factors. furthermore, the coping mechanisms chosen by families in facing stress will have an impact on the reduction of illness symptoms in the members with schizophrenia. article history received: january 12, 2021 accepted: april 13, 2021 keywords family coping; family health; positive outcomes; schizophrenia contact sugeng mashudi  sugengmashudi@umpo.ac.id  universitas muhammadiyah ponorogo, east java, indonesia cite this as: mashudi, s., & yusuf, a. (2021). family coping strategies to improve the health of family members living with schizophrenia. jurnal ners, 16(1). 67-73. doi:http://dx.doi.org/10.20473/jn.v16i1.24527 introduction family caregivers are an important aspect of caring for people with serious mental illnesses, but the needs of those who do it are often not met (yesufuudechuku et al., 2015). furthermore, the family caregivers who support patients with psychosis frequently have poorer health (sin et al., 2021). treating a schizophrenic patient is a source of stress for the family, and there may be external or internal criticism before it affects the family (byba melda suhita, prima dewi kusumawati, & heri saputro, 2020). caring for a patient with mental illness creates a wide range of issues that place a significant burden on family caregivers (ebrahimi et al., 2018). the data obtained from the institute for health metrics and evaluation (ihme) show that schizophrenic disorders affect about 1.5 million individuals (0.3%) (oecd/european union, 2018); 1% of the population in the united kingdom are also experiencing mental disorders (smith, 2015). the 2018 riskesdas (basic health research) data in indonesia show an escalation of proportion in the number of households with mental disorders by 7 per mil from 1.7 per mil. specifically, the east java province shows that only 2.2 per mil households experienced mental disorders in 2013 but increased to 5 per mil in 2018 (riskesdas, 2018). generally, similar incident rate also occurred https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ s. mashudi et al. 68 | pissn: 1858-3598  eissn: 2502-5791 in ponorogo, with about 1,321 out of 600m336 residents in productive ages experiencing mental disorders (nasriati, 2017). however, a higher prevalence rate was found in paringan village and dukuh mirah, where the prevalence rate of mental disorders in paringan village was at 11.2 per mil (mashudi & widiyahseno, 2016). decreased family health has effects on patients and relatives. various causes of decreased family health of people with schizophrenia include those from within and outside the family. the complexity of the health service system (gear et al., 2018). and the complexity of the treatment program (murugappan et al., 2020), are factors that cause poor family health that comes from factors outside the family. decision-making conflicts (hamann & heres, 2019), economic difficulties (marazziti et al., 2020), and family conflicts (plessis, golay, wilquin, favrod, & rexhaj, 2018), are external factors in decreasing family health. various ways are used to improve family health, including family coping support (rayes et al., 2021). care planning support (nyman et al., 2020), coordinated family discussions (storm et al., 2020), and family mentoring (andersen et al., 2020). based on the family health theory, family coping support is very effective in improving family health (doornbos, 2002). furthermore, coping is described as the method of balancing external or internal demands that are perceived to be taxing or exceeding the person's resources, it may be problem-focused or emotion-focused (grover, pradyumna, & chakrabarti, 2015). choosing the best coping strategy increases mental health (o’hara et al., 2019). increases in problem-focused coping were associated with higher levels of wellbeing (de vibe et al., 2018). there is little research examining family coping in the context of family health. if an unhealthy caregiver is not treated immediately, it can affect people with schizophrenia. emotions of family caregivers that often increase will have an impact on increasing the recurrence of schizophrenics (pardede, sirait, riandi, emanuel, & ruslan, 2016). therefore, the optimal caregiver health will support the rehabilitation of people with schizophrenia. schizophrenics receiving occupational therapy are more appreciated by their families (sugeng mashudi et al., 2020). studies on the positive outcomes of treating schizophrenia in indonesia are still rare and one of the positive outcomes of schizophrenia in patients is family health, which is influenced by coping mechanisms (doornbos, 2007). study conducted by çuhadar, savaş, ünal, and gökpınar (2015) strengthens the previous studies, which reported that coping mechanism affects family health. the studies regarding stress and coping mechanisms in family with schizophrenic members show that there is an effect of stress on coping mechanisms (geriani et al., 2015). family coping consists of problem-focused coping and emotion-focused coping. furthermore, it is a cognitive assessment and behavior to manage internal and external needs that exceed ability (lazarus & folkman, 1984). the study carried out by crowe and lyness (2014) shows that family coping affects family health. a better family coping will increase the level of family health. this study focuses on family coping strategies to improve the family health people living with schizophrenia. materials and methods this study was conducted in ponorogo regency, east java, indonesia, with a sample of 160 respondents and a cross-sectional design. the data were collected through questionnaires, and the validity and reliability was tested. the respondents were selected by using a random sampling technique from five primary healthcare centers in the north and west ponorogo. the inclusion criteria included: 1) family members accompanying control schizophrenia patients to the public health center, 2) at least 18 years old. the exclusion criteria included: 1) caregiver suffering from psychiatric or physical disorders that may interfere with patient care and cooperation during data collection, 2) there is more than one schizophrenic patient in the family. families with schizophrenia that visit the health center according to the inclusion and exclusion criteria that have an odd number are targeted as research respondents. after completing the informed consent of the schizophrenic family of people that filled out the questionnaire prepared by the researcher, after the questionnaire was filled in and submitted to the researcher, the completeness of the answers was checked, if the answers were complete, then as a sign of anchovies, the researcher gave a gift to respondents. gender, age, marital status, education, number of family members, occupation, and income are all demographic variables. family coping variables were compiled based on the family coping questionnaire (fcq). fcq is a questionnaire to measure family coping based on plessis et al. (2018), which has been modified into indonesian. there are two components, namely the problem of focus coping and emotional focus coping with seven questions. i speak in a harsh or dirty tone to the patient; i will take care of the patient carefully; i share problems about the sufferer's condition with friends/relatives; i get help from people around me; i leave the house temporarily when the patient gets angry; i think of letting the patient suffer a relapse; i think to pray more in such a way that the patient’s condition is better. in positive questions, always scores 4, often 3, rarely 2, and never 1, while in negative questions always scores 1, often 2, rarely 3, and never 4. a higher score reflects better family coping. the cronbach's alpha coefficient for the scale was 0.534. family health variables were created based on the indicators of useful, satisfaction, and happiness. the useful questionnaires are arranged based on family assignments (susanto, arisandi, kumakura, oda, koike, tsuda, & sugama, 2018). there are five jurnal ners http://e-journal.unair.ac.id/jners | 69 questions: 1) the family is able to know the patient's health problem; 2) the family is able to decide the best course of action for the patient; 3) the family is able to care for the patient well; 4) the family is able to maintain a conducive environment; 5) the family is able to use health facilities for the patient. each positive item is scored using a 4-point scale (4= always, 3= often, 2= rarely, 1= ever), while for negative questions always scores 1, often 2, rarely 3, and never 4. satisfaction is measured based on the apgar family (takenaka & ban, 2016). there are four questions, namely: 1) i feel satisfied because my family can adjust to the patient; 2) i feel satisfied because my family is discussing the best solution to solve the problems that befell the patient; 3) i am satisfied because my family shows compassion and responds to patient emotions, such as feelings of anger, suffering, and compassion; 4) i feel satisfied with my family's way of spending time together by involving patient in overcoming problems. the respondents’ answers are scored always 4, often 3, rarely 2, and never 1. the happy indicator is measured based on the happy questionnaire (spears, 2017), with three questions, namely: 1) overall my family feels happy; 2) compared to the family of fellow caregivers with schizophrenia, my family feels happier; 3) the caregiver family with schizophrenia feels happy. they enjoy whatever is going on and get the most out of nurturing. the respondents’ answers are scored always 4, often 3, rarely 2, and never 1. a higher score reflects better family health. the cronbach's alpha coefficient for the scale was 0.883. before the statistical analysis, the data were selected based on three standard deviations above or below the average score. missing values are excluded from the analysis. descriptive statistics for demographic variables were performed with the spss program (version 22.0, ibm corp, armonk, ny, usa). family coping and family health variables were performed with structural equation models and tested with mplus (version 7.4, muthen & muthen, los angeles, ca, usa). the study of the structural model with a corrected level of confidence (ci) of 95% used 5000 bootstrap samples. results the data used in this study were taken from 160 families of schizophrenia patients who seek treatments in primary healthcare centers located in the north and west ponorogo. selected respondents were those who met the criteria of random sampling. the observation of the study was done in the selected primary healthcare centers. the complete characteristics of caregivers who handle schizophrenia patients can be seen in table 1. table 1 shows that the majority of caregivers are 81 men (50.6%) and 79 women (49.4%). their average age was 49 (sd = 14.2). furthermore, 139 respondents are married (86.6%) and 10 single respondents (6.3%). regarding education level, 102 respondents have completed basic education (24.4%), 39 respondents have achieved secondary education (48.68%), and three respondents have completed tertiary education (1.9%). they worked as farmers (56.2%) with >3 family members (54.4%) and salary less than idr 1,500,000 (82.5%). table 2 explains that the majority of schizophrenia patients are men (59.6%) in the age of 17-45 (81.9%), and siblings of the caregivers (51.8%). the majority of schizophrenics in productive age tend to behave in smoking, even though the effects of nicotine contained in cigarettes affect oocyte maturity (dwirahayu & mashudi, 2016). table 3 illustrates those coping mechanisms done by the family are dominantly problem-focused coping (λ = 0.915), whereas family health is determined by the satisfaction level in treating schizophrenia patients (λ = 0.914). coping mechanisms have an effect on family health (α = 0.05; t-statistics = 14.393). table 1. characteristics of family members living with schizophrenia in ponorogo, east java, indonesia. characteristics n % gender men women 81 79 50.6 49.4 age (based on central bureau of statistics republic of indonesia): productive (18-54) not productive (55-80) 102 58 63.8 36.2 status: married single widower/widow 139 10 11 86.8 6.3 6.9 education high (senior high school) low (elementary school, junior high school) 76 84 74.5 52.5 job private farmer others 47 90 23 29.4 56.2 14.4 family members (number) ≤ 3 >3 73 87 45.6 54.4 salary (regional minimum wage in ponorogo, indonesia) < idr 1,500,000, ≥idr 1,500,000 132 28 82.5 17.5 table 2: characteristics of schizophrenia patients characteristics n % gender men women 95 65 59.6 40.4 age productive (17-45) not productive (46-71) 131 29 81.9 18.1 relationship with caregiver: son/daughter parent others (siblings) 63 14 83 39.4 8.8 51.8 s. mashudi et al. 70 | pissn: 1858-3598  eissn: 2502-5791 discussion family coping significantly impacts family health. this is based on the t-test in the structural model analysis, where t-statistics (13.966) is greater than tcritical (1.96). the effect value of coping mechanisms on family health is 0.682. this means that if family coping is given one-unit value, it will increase family health by 0.682 times. family health is measured from the aspects of useful, satisfaction, and happiness. useful shown by the family may include knowing health problems experienced by patients, choosing the best action to treat patients, maintaining a conducive environment, and utilizing health facilities for patients. useful indicator (0.912) has the second-highest value in determining family health. useful throughout the treatment process can be seen when a family could identify patients’ health problems, decide the best decision for them, take care of them well, keep a conducive environment, and take advantages of health facilities for the family. as many as 64.4% of families are satisfied in caring for family members who have schizophrenia. satisfaction is shown as the family stated that family satisfaction with schizophrenia patient care may be obtained by adapting with patients, discussing the best solution to overcome problems that befall patients, showing affections and responses, such as anger, suffering, and love, and spending time together with patients. the satisfaction indicator (0.914) possesses the highest value in determining family health. satisfaction throughout the treatment process can be found when a family can adapt, choose the best solution for problems, show affection, respond positively to patients, and spend some time together with patients. family satisfaction in treating schizophrenia patients cannot be separated from the impact of coping mechanisms (problem-focused coping and emotion-focused coping) done by the family. happiness is shown as the family could enjoy the moment of treating patients with schizophrenia compared to other caregivers with schizophrenia patients. also, they could enjoy everything and obtain optimal treatment for schizophrenia patients. the happiness indicator (0.873) shows the smallest value in determining family health. the decline of happiness in treating schizophrenia patients can be seen when family feels less happy compared to other families with schizophrenia patients and cannot enjoy everything and obtain optimal caregiving. it is related to stress factors, such as the economy, abusive behavior, and stigma that befalls the family. despite the fact that parents reported being depressed as a result of prejudice, the effects of discrimination have no relationship to their depressive symptoms (cecilia ayo´n & bermudez-parsai, 2010). authors should explore the family health of the respondents, how the culture or finding explain efficiency, satisfaction and happiness, before comparing it with other research; authors could define the real condition in the study setting and finding being healthy is defined as an ability to adapt physically, mentally, and socially as a single unit free from illness and disability (who, 1948). the characteristics of being healthy according to who involve the ability to reflect an individual as a person in internal and external contexts and to involve creativity and productivity. king (1981) stated that being healthy is a form of efficiency, satisfaction, productivity, and happiness (alligood, 2017). in this study, family health refers to a healthy family (king, 1981). however, the productivity indicator in this study is invalid and unreliable because the submitted questions only focus on attendance, while the respondents of the study are farmers who were unable to attend regularly. the essential finding of this study is that family coping affects family health. family health theory by doornbos (2002) shows that coping mechanisms affect family health, whereas this study, in addition to the existing theory, finds family health indicator was measured not only based on family satisfaction, but also family efficiency and happiness. coping mechanisms chosen by families in facing stress will impact family health (martínez-montilla et al., 2017). caregiver burden had positive correlation with age of caregiver, employment of caregiver and level of education (s mashudi et al., 2019). family coping was related to increased family health in those with impaired attentional function (morimoto, furuta, & kono, 2019). coping was linked to increased psychological pressure in people who had poor attention management (tada, 2017). family coping and family health benefit from compassionate counseling (buckley, maayan, & soares-weiser, 2017). antonovsky's sense of coherence influences coping, resulting in increased family happiness (gassmann et al., 2013). stress may come from table 3: loading factors and t-statistical value. variables loading (λ) t-statistics t-table coping mechanisms problem-focused coping emotion-focused coping 0.915 0.710 14.393 1.96 family health useful satisfaction happiness 0.912 0.914 0.873 jurnal ners http://e-journal.unair.ac.id/jners | 71 chronic diseases, such as mental disorders (schizophrenia), addictions, accidents, disabilities, and economic problems. on the other hand, family coping used by families in treating schizophrenia patients are problem-focused coping and emotionfocused coping. stress in a family with schizophrenia patients can transform the family’s life balance. that is why every family needs to have good coping strategies. caregivers with patients who have mental disorders also need to identify the main stress factor in their family. the best coping strategy is also needed so that family health can improve. based on the theoretical and empirical studies, it can be inferred that family coping affects family health. family coping strategies include observation, counseling, education and cooperation. (ppni, 2017). an emotional reaction needs to be defined by the nurse (caqueo-urízar et al., 2017), prognosis strain (fusar-poli et al., 2020), decision-making (mandarelli et al., 2018) and expectations of family and family (knight et al., 2018). applying the family coping strategy may improve the capacity of the family to clarify experienced health issues, family practices to better resolve health problems, and minimize risk factors. the implementation of family coping can have an impact on reducing the symptoms of disease in family members. conclusion this research strengthens the family health theory, and the coping mechanisms carried out by families (problem-focused coping and emotion-focused coping) affect family health. in addition to family satisfaction, the family health can also be measured in terms of useful and happiness. additional research in needed to find out if patients and treatment factors contribute to family health. references alligood, m. r. (2017). imogene m.king: sistem konseptual dan teori middle-range pencapaian tujuan (model konseptual keperawatan). in pakar teori keperawatan dan karya mereka (edisi bahasa indonesia) (pp. 30–51). elsevier ltd. andersen, i., poudyal, b., abeypala, a., uriarte, c., & rossi, r. (2020). mental health and psychosocial support for families of missing persons in sri lanka: a retrospective cohort study. conflict and health, 14(1), 1–15. https://doi.org/10.1186/s13031-020-00266-0 buckley la, maayan n, soares-weiser k, a. c. (2017). supportive therapy for schizophrenia (review). cochrane database of systematic reviews, 4. https://doi.org/10.1002/14651858.cd004716.p ub4.www.cochranelibrary.com byba melda suhita, prima dewi kusumawati, heri saputro, a. y. (2020). mechanism of family-coping in treating patient with schizophrenia viewed from factors that affected it at public health center of balowerti, kediri. medico legal update, 20(1). caqueo-urízar, a., rus-calafell, m., craig, t. k. j., irarrazaval, m., urzúa, a., boyer, l., williams, d. r., & rus-calafell, m. (2017). schizophrenia : impact on family dynamics. current psychiatry reports, 19(2). https://doi.org/10.1007/s11920-0170756-z cecilia ayo´ n, f. f. m., & bermudez-parsai, and m. (2010). latino family mental health: exploring the role of discrimination and familismo. journal of community psychology, 38(6), 742–756. de vibe, m., solhaug, i., rosenvinge, j. h., tyssen, r., hanley, a., & garland, e. (2018). six-year positive effects of a mindfulness-based intervention on mindfulness, coping and well-being in medical and psychology students; results from a randomized controlled trial. plos one, 13(4), 1–17. https://doi.org/10.1371/journal.pone.0196053 doornbos. (2007). family health theory. in c. l. sieloff & m. a.frey (eds.), middle range theory development using king’s conceptual systemy (pp. 31–49). springer publishing company, inc. doornbos mm. (2002). predicting family health in families of young adults with severe mental illness. journal of family nursing, 8(3), 241–263. ebrahimi, h., seyedfatemi, n., namdar areshtanab, h., ranjbar, f., thornicroft, g., whitehead, b., & rahmani, f. (2018). barriers to family caregivers’ coping with patients with severe mental illness in iran. qualitative health research, 28(6), 987– 1001. https://doi.org/10.1177/1049732318758644 fusar-poli, p., de pablo, g. s., correll, c. u., meyerlindenberg, a., millan, m. j., borgwardt, s., galderisi, s., bechdolf, a., pfennig, a., & kessing, l. v. (2020). prevention of psychosis: advances in detection, prognosis, and intervention. jama psychiatry. gassmann, w., christ, o., lampert, j., & berger, h. (2013). the influence of antonovsky’s sense of coherence (soc) and psychoeducational family intervention (pefi) on schizophrenic outpatients’ perceived quality of life: a longitudinal field study. bmc psychiatry, 13, 2–7. https://doi.org/10.1186/1471-244x-13-10 gear, c., eppel, e., & koziol-mclain, j. (2018). exploring the complex pathway of the primary health care response to intimate partner violence in new zealand. health research policy and systems, 16(1), 1–13. https://doi.org/10.1186/s12961-018-0373-2 geriani, d., savithry, k. s. b., shivakumar, s., & kanchan, t. (2015). burden of care on caregivers of schizophrenia patients: a correlation to personality and coping. journal of clinical and diagnostic research, 9(3), vc01–vc04. https://doi.org/10.7860/jcdr/2015/11342.565 4 grover, s., pradyumna, & chakrabarti, s. (2015). coping among the caregivers of patients with schizophrenia. industrial psychiatry journal, 24(1), 5–11. s. mashudi et al. 72 | pissn: 1858-3598  eissn: 2502-5791 https://doi.org/https://doi.org/10.4103/09726748.160907 hamann, j., & heres, s. (2019). why and how family caregivers should participate in shared decision making in mental health. psychiatric services, 70(5), 418–421. https://doi.org/10.1176/appi.ps.201800362 king, i. m. (1981). a theory for nursing: system, concepts, pocess. delmar. knight, f., kokanović, r., ridge, d., brophy, l., hill, n., johnston-ataata, k., & herrman, h. (2018). supported decision-making: the expectations held by people with experience of mental illness. qualitative health research, 28(6), 1002–1015. lea plessis , philippe golay , h ´ el ´ ene wilquin , j ` er´ ome favrod, ̂ , & rexhaj, s. (2018). internal validity of the french version of the family coping questionnaire (fcq): a confirmatory factor analysis. psychiatry research. https://doi.org/https://doi.org/10.1016/j.psych res.2018.08.021 mandarelli, g., carabellese, f., parmigiani, g., bernardini, f., pauselli, l., quartesan, r., catanesi, r., & ferracuti, s. (2018). treatment decisionmaking capacity in non-consensual psychiatric treatment: a multicentre study. epidemiology and psychiatric sciences, 27(5), 492–499. marazziti, d., avella, m. t., mucci, n., della vecchia, a., ivaldi, t., palermo, s., & mucci, f. (2020). impact of economic crisis on mental health: a 10-year challenge. cns spectrums, 1–7. https://doi.org/10.1017/s1092852920000140 martínez-montilla, j. m., amador-marín, b., & guerramartín, m. d. (2017). estrategias de afrontamiento familiar y repercusiones en la salud familiar : una revisión de la literatura family coping strategies and impacts on family health : a literature review abstract : revista trimestral de enfermeria, 47, 576–591. https://doi.org/10.6018/eglobal.16.3.255721 mashudi, widiyahseno, p. (2016). grand design mad village ponorogo (sugeng mas). um ponorogo press. mashudi, s, yusuf, a., triyoga, r. s., kusnanto, & suhron, m. (2019). the burden in providing caregiving service to mentally illed patients in ponorogo. indian journal of public health research and development, 10(10), 1070–1074. https://doi.org/10.5958/09765506.2019.02967.x mashudi, sugeng, nasriati, r., & octaviani, e. (2020). terapi okupasi sebagai sarana peningkatan kesehatan jiwa penderita skizofrenia. jurnal abdidas, 1(5), 313–317. https://doi.org/10.31004/abdidas.v1i5.62 morimoto h, furuta n, kono m, k. m. (2019). stressbuffering effect of coping strategies on interrole conflict among family caregivers of people with dementia. clin gerontol, 42(1), 34–46. https://doi.org/10.1080/07317115.2017.13687 64. epub 2017 oct 9. pmid: 28990875 murugappan, m. n., seifert, r. d., & farley, j. f. (2020). examining medicare part d medication therapy management program in the context of mental health. journal of the american pharmacists association, 60(4), 571-579.e1. https://doi.org/10.1016/j.japh.2019.12.008 nasriati, r. (2017). stigma and family support in caring for people with mental disorders (odgj). jurnal ilmiah ilmu ilmu kesehatan, xv(1), 56–65. nyman, m., hofvander, b., nilsson, t., & wijk, h. (2020). mental health nurses’ experiences of risk assessments for care planning in forensic psychiatry. international journal of forensic mental health, 19(2), 103–113. https://doi.org/10.1080/14999013.2019.16463 56 o’hara, k. l., sandler, i. n., wolchik, s. a., & tein, j. y. (2019). coping in context: the effects of long-term relations between interparental conflict and coping on the development of child psychopathology following parental divorce. development and psychopathology, 31(5), 1695– 1713. https://doi.org/10.1017/s0954579419000981 oecd/european union. (2018). “promoting mental health in europe: why and how?”, in health at a glance: europe 2018: state of health in the eu cycle,. in health at a glance: europe 2018 state of health in the eu cycle (pp. 19–43). oecd publishing. https://doi.org/10.1787/health_glance_eur2018-4-en pardede, j. k., sirait, d., riandi, r., emanuel, p., ruslan, l. (2016). ekspresi emosi keluarga dengan frekuensi kekambuhan pasien skizofrenia emotional expression family with the frequency of recurrence of patients with schizophrenia. idea nursing journal, vii(3), 53– 61. plessis, l., golay, p., wilquin, h., favrod, j., & rexhaj, s. (2018). internal validity of the french version of the family coping questionnaire (fcq): a confirmatory factor analysis. psychiatry research, 269, 337–344. https://doi.org/10.1016/j.psychres.2018.08.021 ppni. (2017). standart diagnosis keperawatan indonesia: definisi dan indikator diagnostik (i (cetakan). dpp ppni. rayes, d., karnouk, c., churbaji, d., walther, l., & bajbouj, m. (2021). faith-based coping among arabic-speaking refugees seeking mental health services in berlin, germany: an exploratory qualitative study. frontiers in psychiatry, 12(february), 1–10. https://doi.org/10.3389/fpsyt.2021.595979 riskesdas. (2018). healthy portrait of indonesia from riskesdas 2018. ministry of health of the republic of indonesia. s.lazarus, r., & folkman, s. (1984). stress, appraisal and coping. springer publishing company, inc. sin, j., elkes, j., batchelor, r., henderson, c., gillard, s., woodham, l. a., chen, t., aden, a., & cornelius, v. jurnal ners http://e-journal.unair.ac.id/jners | 73 (2021). mental health and caregiving experiences of family carers supporting people with psychosis. epidemiology and psychiatric sciences, 30. https://doi.org/10.1017/s2045796020001067 smith, g. (2015). skizophrenia. in i. peate (ed.), mental health nursing at a glance (first edit, p. 34). john wiley&sons, ltd. spears, d. (2017). making people happy or making happy people? questionnaire-experimental studies of population ethics and policy. social choice and welfare, 49(1), 145–169. https://doi.org/10.1007/s00355-017-1055-7 storm, m., fortuna, k. l., brooks, j. m., & bartels, s. j. (2020). peer support in coordination of physical health and mental health services for people with lived experience of a serious mental illness. frontiers in psychiatry, 11(may), 1–7. https://doi.org/10.3389/fpsyt.2020.00365 susanto, t., arisandi, d., kumakura, r., oda, a., koike, m., tsuda, a., sugama, j. (2018). development and testing of the family structure and family functions scale for parents providing adolescent reproductive health based on the friedman family assessment model. journal of nursing measurement, 26(2), 217-236. https://doi.org/10.1891/1061-3749.26.2.217 tada, a. (2017). the associations among psychological distress, coping style, and health habits in japanese nursing students: a crosssectional study. international journal of environmental research and public health, 14(11). https://doi.org/10.3390/ijerph14111434 takenaka, h., & ban, n. (2016). the most important question in family approach: the potential of the resolve item of the family apgar in family medicine. asia pacific family medicine, 15(1), 3. https://doi.org/10.1186/s12930-016-0028-9 who. (1948). no title. definition of health. yesufu-udechuku, a., harrison, b., mayo-wilson, e., young, n., woodhams, p., shiers, d., kuipers, e., & kendall, t. (2015). interventions to improve the experience of caring for people with severe mental illness: systematic review and meta-analysis. british journal of psychiatry, 206(4), 268–274. https://doi.org/10.1192/bjp.bp.114.147561 microsoft word 1648 layout jners.docx 574 | pissn: 1858-3598 � eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.22128 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of storytelling on ability to control violence behavior in early childhood rana skharninda and wahyu endang setyowati faculty of nursing, universitas islam sultan agung semarang, semarang, indonesia abstract introduction: storytelling is a narrative activity that is close to children. this activity can convey the contents of stories, feelings or ideas without making the children feel like being patronized. narrators can also convey or teach about the behavior that children should do. early children often do aggressive or violent actions. based on the condition, storytelling becomes a way to teach children about good behavior. the purpose of the study was to determine the effect of storytelling on the ability to control violent behavior in early childhood at one of kindergarten in semarang. methods: this research is a quantitative research. sampling technique used total sampling with 24 students as respondents. the data obtained were processed statistically using the marginal homogeneity test. using marginal homogeneity test, it was obtained p value of 0,000 (<0.05). results: it can be concluded that there is a storytelling effect on the ability to control violent behavior in early childhood. conclusion: there is an effect of storytelling on the ability to control violent behavior in early childhood among students of one of islamic kindergarten in semarang. for institutions, the storytelling method can be used as daily learning because learning is not only about academics but also attitudes. article history received: feb 27, 2020 accepted: april 1, 2020 keywords storytelling; aggressive behavior contact wahyu endang setyowati * wahyu.endang@unissula.ac.id + faculty of nursing, universitas islam sultan agung semarang, semarang, indonesia. cite this as: skharninda, r., & setyowati, w, e. (2020). the effect of storytelling on ability to control violence behavior in early childhood. jurnal ners, special issues, 574-577. doi:http://dx.doi.org/10.20473/jn.v15i2.22128 introduction data from official journal of the american academy of pediatrics stated that an average of 50% or calculated around 1 billion children aged 2-17 years are vulnerable, suffering physical, sexual, and emotional violence; and neglected in africa, asia and north america region in the past year (mardina, 2018). in indonesia, the incidence of violence against children continues to increase. until mid-march 2018, the ministry of women empowerment and child protection (pppa) had received approximately 1,900 information for cases of violence against children and the most dominant was from sexual violence. in 2018, the indonesian child protection commission (kpai) wrote that there were 4,885 cases of violence against children 306 more than in 2017 which amounted to 4,579 cases (komisi perlindungan anak indonesia (kpai), 2019). in addition, the rate of violence against children in semarang also tends to increase from year to year and the case is dominated by sexual harassment. the family planning and women's empowerment agency (bkbpp) of semarang regency noted that in 2014 there had been at least 41 cases of violence against children, this figure had almost doubled in 2015 to 72 cases and it was dominated by sexual harassment (zuraya, 2015). the aarly age of child is also said to be a critical part of progress or golden age. it is said that most of the network of brain cells works to regulate every human activity and character. the first two years of human life is very influential for the growth of children. children then begins to build sensory, visual and auditory motor power which is then distributed and simulated through the surrounding environment. the fairy tales is close to the world of children. when listening to fairy tales, children will also enjoy and know the meaning contained in the story. therefore, in storing-telling activities, the way to tell the story becomes meaningful because the process and the impression through fairy tales can be conveyed to all. when the process is ongoing, an assimilation of jurnal ners http://e-journal.unair.ac.id/jners | 575 knowledge from the narrator to the listener is formed. storytelling describes one technique that is efficient in developing cognitive, social, and conative factors of children (wardiah, 2017). in indonesia, the art of storytelling is a tradition that has existed for centuries. along with the times, this oral tradition began to fade, displaced by the rise of technological development. however, this situation did not last long. in some regions of the developing world, storytelling activities start to rise again. moreover, it has been computerized and in every library, talks related to the act of storytelling are also held. storytelling or narration is getting famous again in class and being able to reach cyberspace, through a web or site that contains fairy tales. (wardiah, 2017). several previous research showed some positive progress on child behavior, such as emotional control. one researchers use storytelling method to reduce aggressive behavior is because it can attract children attention through characters in the story. these characters play a variety of behaviors that are right or wrong. moreover, storytelling is one of the effective tools in providing direction for changing children's behaviour (asl et al., 2015; musavi & hejazi, 2016). thus, the purpose of this study was to determine the effect of storytelling on the ability to control violent behavior in early childhood at one of kindergarten in semarang. materials and methods this research is a pre-experimental design research with one group pre and posttest design. this research aims to determine whether there is an effect between variables, the independent and dependent variable. respondents in this study were students of a kindergarten in semarang. this research was conducted in september-november 2019 with totally 24 respondents. instrument in this study was a questionnaire of violent behavior in early childhood with a number of 42 questions. this questionnaire determine the ability to control violent behavior in early childhood. questions in this instrument consists of 42 items with a kind of favourable and unfavorable statement. results table 1 below shows that the most respondent in this study was males, amounting to 13 children with a percentage of 54.2% and the rest was female. of 24 respondents, 54.2% was in 5 years old age and the rest 6 years old. table 2 shows the results that the most number of violent behaviors before the intervention of storytelling in this study were mostly violent behavior in the moderate category with 15 respondents (83.3%), while in the low category there were only 5 respondents (20.8%) and the rest in high category (16.7%). after the intervention, the result shows that the greatest number of violent behavior were in the low category with 15 respondents (62.5%). after being tested using marginal homogeneity, the significance results obtained 0.000 (p value 0.05). it means that there is a storytelling effect on the ability to control violent behavior in early childhood. discussion this study shows that there is an effect of storytelling on the ability to control violent behavior in early childhood, especially in age of 5 and 6 years old. several previous researches showed similar fact. in research conducted by (susanti, 2013), the results showed that there is a significant effect in the activities of storytelling using islamic story books on children's behavior at the age of 5-6 years. the research conducted by (musavi & hejazi, 2016) which says that storytelling is very helpful in the development of psychological or personality problems in pre-school children. it help parents, teachers or responsible adults to better understand table 1. distribution of respondents by variables (n = 24) variables n % sex male female 13 11 54.2 45.8 age 5 y.o. 6 y.o. 13 11 54.2 45.8 table 2. distribution of violent behavior before and after intervention and the statistical result violent behavior n % statistical test result* pre-test low moderate high 5 15 4 20.8 83.3 16.7 p= 0.000 post-test low moderate high 15 8 1 62.5 33.3 4.2 *marginal homogeneity test r. skharninda et al. 576 | pissn: 1858-3598 � eissn: 2502-5791 the importance of this story which will later be given to children. the other study by (indonesia, 2016) in the journal about differences in aggressive behavior of male and female students also showed that 38% male students with the aggressive behavior in the moderate level, while only 36% female students are in the same level. the results of research by (dewi, 2014) through listening to stories in one of kindergarten in sleman, central java, indonesia, obtained the results that applying storytelling is very capable of reducing or controlling aggressive behavior in children. this is also supported by research by (kelas et al., 2015) using the classroom action research method. the results showed that there is a more positive change in behavior that can be seen from how children begin to apologize when the they did something wrong and started showing good behavior. moreover, the children tend to repay bad behavior he got from his friends, they began to understand how it would affect if they did good or bad behavior, and also began to decrease for actions that could physically hurt. it was stated that there is an effect of giving prosocial-themed story to decrease aggressive behavior. this is marked by changes in the frequency graphs of aggressive behavior which decreases during 10 times giving prosocial-themed story. in addition, in the process of giving a pro-themed fairy tale, it was found that the aggressive behavior of the subject in the form of hitting his friend only appeared when the subject was provoked by his friend (dongeng & prososial, 2009). in a research article by (mashar & sulistiyowati, 2017) entitled story in reducing childhood aggression behavior, the researchers used 12 kinds of metaphorical stories consisting of 3 action cycles, showing the results if storytelling is effective in reducing aggressive behavior. the subject of violent behavior even decreased by 70% within 6 weeks of treatment. this research is in line with (gonçalves et al., 2017) which said that the effect of storytelling on aggressive behavior in children has a beneficial effect or an effect that leads to positive thing in reducing the amount of violent or aggressive behavior in children. moreover, it also showed that storytelling reduces anxiety and provides excitement, self-confidence, and relaxation. storytelling stimulates creativity, language, and memory, promotes healthy development and coping processes in social disorganization situations. these results are in line with research by (asl et al., 2015) that storytelling has a significant impact on reducing behavior and aggression in children. or in other words storytelling becomes an activity / intervention that can help children to control their aggression behavior. by showing aggressive behavior and its consequences, through stories and characters or character personality patterns for children, they can improve or reduce their behavior patterns. it can also be done by discussing the contents of the story and also remind them to need to avoid selfishness, gain the necessary knowledge, feel the behavior and achieve balance. the function of storytelling becomes more prominent, for children, because they cannot easily identify and express their thoughts and feelings. this is why telling stories is one of the excellent methods for children's emotional development. these results are in line with research conducted by (musavi & hejazi, 2016) that there are significant differences before and after the story is given, and the story is one effective way to prevent aggressive behavior in children. the main reason the researchers used the method story that aims to reduce aggression behavior is to attract the attention of children through the characters in the story where the character plays a variety of right or wrong behaviors and also story telling is one of the effective tools in providing direction to change children's behavior. conclusion it can be concluded that there is a storytelling effect on the ability to control violent behavior in early childhood. there is an effect of storytelling on the ability to control violent behavior in early childhood among students of one of islamic kindergarten in semarang. it can be recommend for institutions, the storytelling method can be used as daily learning because learning is not only about academics but also attitudes. conflict of interest in this study, there were no conflicts of interest among the researchers and participants involved in the research activity process. acknowledgement this research can be carried out with the support of several parties, for that the researcher would like to thank the rector of sultan agung islamic university, semarang, indonesia, deans of the faculty of nursing and all academic and supporting staff, and also the respondents for the contribution. references asl, n. s., naderi, f., & makvandi, b. (2015). the effect of storytelling on behavioral problems ( aggressionwithdrawal ) of preschoolers ’ in ahvaz. 5, 353–357. dewi, e. t. r. (2014). upaya mengatasi munculnya tingkah laku agresif anak melalui mendengarkan cerita di kelompok b tk aba tegal doman tempel sleman. dongeng, p., & prososial, b. (2009). pengaruh pemberian dongeng bertema prososialterhadap penurunan perilaku agresif anak. gonçalves, l. l., voos, m. c., de almeida, m. h. m., & caromano, f. a. (2017). massage and storytelling reduce aggression and improve academic performance in children attending elementary school. occupational therapy international, 2017. jurnal ners http://e-journal.unair.ac.id/jners | 577 https://doi.org/10.1155/2017/5087145 indonesia, j. p. (2016). perbedaan perilaku agresif siswa laki-laki dan siswa perempuan. jurnal educatio: jurnal pendidikan indonesia. kelas, p. t., br, p., & tahun, b. (2015). upaya mengurangi perilaku agresif anak melalui metode bercerita dengan media wayang (. 1104763, 2014– 2016. komisi perlindungan anak indonesia (kpai). (2019). kpai sebut pelanggaran hak anak terus meningkat | komisi perlindungan anak indonesia (kpai). mardina, r. (2018). kekerasan terhadap anak dan remaja. 1–11. mashar, r., & sulistiyowati. (2017). story in reducing childhood aggression behavior. international conference piaud, 1–9. musavi, z., & hejazi, m. (2016). effectiveness of narrative therapy in reducing aggression and stubborn preschoolers. 12(2), 173–179. susanti, m. d. (2013). pengaruh kegiatan bercerita dengan buku cerita islami terhadap perilaku moral anak. jiv, 8(1), 38–45. https://doi.org/10.21009/jiv.0801.6 wardiah, d. (2017). peran storytelling dalam meningkatkan kemampuan menulis, minat membaca dan kecerdasan emosional siswa. 46. zuraya, n. (2015, november). kasus kekerasan anak meningkat pesat di kabupaten semarang. republika online. 262 pendekatan transcultural nursing, child healthcare model dan transtheoretical model terhadap pengetahuan dan budaya keluarga (the effect of transcultural nursing, child healthcare model and transtheoretical model approaches to knowledge and culture of family) kadek ayu erika* *departemen anak program studi ilmu keperawatan fakultas kedokteran universitas hasanuddin jl.perintis kemerdekaaan km.10 tamalanrea makassar e-mail: kadek20_uh@yahoo.com abstrak pendahuluan: gaya hidup perkotaan dipicu oleh asupan makanan yang berlebih pada anak overweight dan obesitas. keluarga berpendapat bahwa anak gemuk adalah sehat dan tidak memiliki masalah kesehatan. strategi untuk meningkatkan pengetahuan dan budaya keluarga adalah dengan pendekatan transcultural nursing, child health care model dan transtheoretical model dalam mengendalikan gaya hidup anak overweight dan obesitas. penelitian ini bertujuan untuk membuktikan pengaruh pendekatan tcn, chm dan ttm terhadap asupan makan anak overweight dan obesitas. metode: penelitian ini dilaksanakan di wilayah kecamatan biringkanaya dan tamalanrea, makassar. desain yang digunakan adalah quasy eksperiment yaitu pre-test and post-test with control group design. subyek penelitian adalah orang tua yang memiliki anak overweight dan obesitas kelas 4 – 6 sekolah dasar. sampel terdiri dari 31 anak kelompok perlakuan dan 33 anak kelompok kontrol. sampel dipilih secara purposive. intervensi penelitian dilakukan selama 6 bulan dengan pemberian buku panduan gaya hidup sehat dan kunjungan rumah keluarga setiap bulan dengan menggunakan kuesioner. pengukuran imt anak menggunakan who anthro plus software, 2007. data dianalisis dengan univariat, bivariat dengan independent t-test, mann-whitney test and paired t-test. hasil: hasil penelitian menunjukkan bahwa ada perbedaan perubahan mean sebelum dan setelah intervensi yaitu pengetahuan keluarga dengan nilai p = 0.00 dan budaya keluarga dengan nilai p = 0.00. diskusi: penelitian ini menyimpulkan bahwa ada pengaruh pendekatan tcn, chm, dan ttm dalam meningkatkan pengetahuan dan budaya keluarga dalam mengendalikan gaya hidup anak overweight dan obesitas. pentingnya pendidikan kesehatan dengan memberikan buku pedoman gaya hidup sehat dan dampak pada anak obesitas. kata kunci: transcultural nursing theory, child health care, transtheoretical model, pengetahuan, budaya keluarga abstract introduction: urban lifestyle fueled by excessive food intake in overweight and obese children. famili esassumethatobese children are healthy and have no health problems. strategies to improve the knowledge and culture of the family is the approaches of tcn, chm dan ttm. this study aims to prove the influence of tcn, chm and ttm to knowledge and culture’s familyin controlling lifestyle of over weight and obese children. method: this research was conducted in the areas of biring kanaya and tamalanrea subdistricts, makassar from august 2013 to march 2014. it used the quasy experiment design namely pre-test and post-test with control group design. research subjects were parents of overweight or obese children in the 4th, 5th, and 6th grade of elementary school. there were 31 samples in the treatment group; and 33 samples in the control group. there were selected by using purposive sampling technique. the intervention was given for six months by providing guide books on healthy lifestyle, and visiting the families every month to give questionnaires. the measurements of children’s bmi was conducted by use who’s antrho plus software, 2007. the data were analyzed by using univariate, bivariate with independent t-test, mann-whitney test and paired t-test. result: the results showed that there were differences in mean changes before and after the intervention, namely knowledge of the family with p=0:00 and cultural family with p=0:00. discussion: it was concluded that the effect of tcn, chm, and ttm could improve the knowledge and cultural family in controlling lifestyle of overweight and obese children. the importance of health education is given to families with guide books about healthy lifestyles and the impact of child obesity. keywords: transcultural nursing theory, child health care, transtheoretical model, knowledge, cultural, family pendahuluan overweight dan obesitas disebabkan oleh interaksi faktor genetik dan faktor lingkungan misalnya aktivitas, gaya hidup, sosial ekonomi dan nutrisional yaitu perilaku makan dan pember ian makanan padat terlalu dini pada bayi (heird, 2002; wong et al., 2009). overweight dan obesitas saat 263 pendekatan transcultural nursing (kadek ayu erika) ini menduduki peringkat kelima sebagai risiko global terjadinya kematian. terdapat 44% kasus diabetes mellitus, 23% penyakit jantung iskemik dan 7–41% kanker disebabkan oleh kelebihan berat badan/overweight dan obesitas. prevalensi overweight dan obesitas pada anak diperkirakan 35 juta terdapat di negara berkembang dibandingkan dengan 8 juta yang ada di negara maju (who, 2010). berdasarkan the national youth r isk behaviour survey (yrbs) tahun 1999-2011 pada anak sekolah umur 9–12 tahun, prevalensi obesitas mengalami peningkatan dari 10,6% menjadi 13% sedangkan overweight juga meningkat dari 14,2% menjadi 15,2 (cdc, 2011). berdasarkan penelitian hudson (2009), prevalensi obesitas (15,6%) lebih tinggi dibandingkan rerata nasional (10,4%), namun sebagian besar orang tua (86,5%) dari anakanak obesitas tidak menganggap anak-anak mereka obesitas. per ubahan gaya hidup yang cepat termasuk pola makan dan aktivitas telah menyebabkan peningkatan prevalensi anak obesitas (5–19 thn) di negara berkembang. prevalensi obesitas pada anak usia 5–19 tahun mengalami peningkatan dari tahun 1999– 2004 di indonesia yaitu pada obesitas dari 5,3% menjadi 8,6% sedangkan overweight, dari 2,7% menjadi 3,7% (gupta et al., 2012). penelitian sartika (2011) menemukan bahwa prevalensi obesitas (persentil > 95) pada anak rentang usia 5–15 tahun di indonesia sebesar 8,3%.berdasarkan riskesdas (2010) prevalensi status gizi (imt/u) anak gemuk umur 6–12 tahun adalah 9,2% di indonesia lebih tinggi dibandingkan anak sangat kurus 4,6% dan kurus 7,6%. di samping itu, anak gemuk berdasarkan jenis kelamin laki-laki berjumlah 10,7% dan perempuan 7,7%. jumlah anak gemuk di kota (10,4%), dan di desa (8,1%). anak gemuk di sulawesi selatan berjumlah 3,9%. berdasarkan hasil riskesdas (2010) terjadi peningkatan berat badan lebih pada anak usia sekolah menurut jenis kelamin dan terdapat di perkotaan. menurut riskesdas (2013), prevalensi status gizi (imt/u) anak umur 5–12 tahun sebesar 18,8% yang terdiri dari 10,8% overweight dan 8% obesitas. menurut hassapidou et al., (2009) sosial budaya dan kepercayaan tradisional yang berhubungan dengan gizi, dan kebanyakan diturunkan selama berabad-abad dari ibu dan nenek yang tinggal di negara berkembang. kepercayaan ini antara lain anak overweight maupun obesitas sering dikatakan memiliki lemak bayi yang orang tua percayaakan hilang ketika usia mereka bertambah. namun mayoritas dari merekaakan tetap mengalami overweight atau obesitas selama hidupnya. berdasarkan wawancara dari ibu bahwa mereka menganggap anak gemuk adalah sehat dan selama anak tidak memiliki keluhan sakit maka ibu tidak membawa anak ke pelayanan kesehatan. ibu tidak mengetahui perbedaan overweight dan obes, serta dampak kesehatan pada anak. ad a nya d a mpa k over weight d a n obesitas yang merugikan bagi anak menuntut d it i ng kat ka n nya pera n perawat d ala m pendidikan nutrisi bekerja sama dengan gur u sekolah, orangtua dan anak untuk merencanakan dan mengimplementasikan pedoman nutrisi dan aktivitas fisik. metode ya ng d apat d ig u na ka n ad ala h denga n pendekatan transcultural nursing theory yang berkaitan dengan budaya keluarga merawat anak (leininger, 2002), pendekatan child health care model yaitu dengan promosi kesehatan dan pemeliharaan kesehatandalam semua aspek perawatan pada anak (ball & bindler, 2007), dan melalui pendekatan t ranstheoretical model yait u per ubahan perilaku yang membantu anak dan orang tua dalam menerapkan gaya hidup sehat anak (prochaska, 2008). penelitian ini menggunakan pendekatan tcn, chm, dan ttm melalui pendidikan kesehatan untuk meningkatkan pengetahuan dan budaya keluarga dalam mengendalikan gaya hidup anak overweight dan obesitas. bahan dan metode rancangan penelitian ini menggunakan quasy exsperiment, yaitu pre-test and posttest with control group design. penelitian d i l a k s a n a k a n d i w i l aya h ke c a m at a n 264 jurnal ners vol. 9 no. 2 oktober 2014: 262–269 biringkanaya dan tamalanrea makassar. kelompok perlakuan diberikan intervensi pendidikan kesehatan selama 6 bulan melalui pendekatan tcn, chm, dan ttm dengan memberikan buku panduan gaya hidup sehat dan leaf let pada anak dengan berat badan berlebih, sedangkan kontrol tidak diberikan intervensi, hanya berupa leaf let. sebelum inter vensi dilakukan screening awal di sekolah untuk mendapatkan anak overweight atau obesitas di sd inpres tamalanrea 1–5. setelah itu dilakukan kunjungan rumah untuk memperoleh data tentang pengetahuan dan budaya keluarga. kunjungan rumah dilakukan setiap bulan dengan memberikan pendidikan ke seh at a n pa d a kelomp ok p e rla k u a n , sedangkan kelompok kontrol tidak diberikan pendidikan kesehatan. subjek penelitian adalah keluarga yang memiliki anak overweight atau obesitas sekolah dasar kelas 4,5 dan 6 yang dipilih dengan metode purposive sampling (sastroasmoro & ismael, 2011) yaitu memilih sampel yang memenuhi kriteria inklusi dengan jumlah sampel sebanyak 64 orang yaitu terdapat 31 kelompok perlakuan dan 33 kelompok kontrol. subyek bersedia dan mengisi informed consent, berjenis kelamin laki-laki dan perempuan, suku bugis atau makassar yang beragama islam dan berada pada tahap action. variabel independen adalah pendekatan tcn, chm, dan ttm sedangkan variabel dependen adalah pengetahuan dan budaya keluarga. penelitian ini telah mendapatkan persetujuan dar i komite etik fak ultas kedok teran universitas hasanuddin dengan nomor surat 1197/h4.8.4.5.31/pp36-kometik/2013. pengisian kuesioner dengan wawancara langsung, dilakukan oleh tim yang sudah dilatih.semua sampel yang terpilih, dilakukan pengukuran oleh tim terlatih sebanyak 4 orang meliputi pengukuran bb dan tb, kemudian untuk menentukan imt anak menggunakan who antrhoplus software berdasarkan who, 2007 untuk anak usia 5–18 tahun. kuesioner pengetahuan dan budaya keluarga telah dilakukan uji validitas dan reliabilitasnya. kuesioner diberikan sebelum intervensi dan setiap kunjungan rumah. data yang diperoleh menggunakan uji mann whitney u test. hasil h a s i l p e n e l i t i a n m e n u n j u k k a n bahwa antara kelompok perlak uan dan kelompok kontrol telah memiliki kesetaraan/ homogenitas. hasil uji homogenitas antara kelompok perlakuan dan kelompok kontrol pada jenis kelamin anak didapat nilai p=0,313, pendidikan ayah didapat nilai p= 0,856, pendidi kan ibu did apat n ilai p= 0,453, pendapatan keluarga didapat nilai p=0,329, riwayat kegemukan orang tua didapat nilai p=0,694, riwayat kesehatan keluarga didapat nilai p=0,306, dan status keluarga didapat nilai p=0,112. hasil penelitian ini menunju k kan bahwa tidak terdapat perbedaan untuk jenis kelamin anak, pendidikan ayah, pendidikan ibu, pendapatan keluarga, riwayat kegemukan orang tua, riwayat kesehatan keluarga, dan status keluarga antara kelompok perlakuan dan kelompok kontrol (tabel 1). gambar 1 menunjukkan perubahan jumlah keluarga yang memiliki pengetahuan dalam persentase pada kelompok perlakuan dan kontrol setiap bulan selama 6 bulan. grafik menunjukkan terjadi peningkatan pengetahuan pada kelompok perlakuan yang mencapai 100% (31 keluarga) pada bulan keenam setelah intervensi, sedangkan kelompok kontrol mengalami fluktuasi dan hanya 36,4% keluarga yang memiliki pengetahuan baik di akhir bulan keenam. gambar 2 menunjukkan perubahan jumlah keluarga yang memiliki budaya mendukung dalam persentase pada kelompok perlakuan dan kontrol setiap bulan selama 6 bu la n. g r af i k menu nju k ka n ter ja d i peningkatan budaya keluarga pada kelompok perlakuan yang mencapai 100% (31 keluarga) pada bulan keenam, sedangkan kelompok kontrol cenderung statis dan hanya 15,2% keluarga yang memiliki budaya mendukung di akhir bulan keenam. hasil penelitian tabel 2 menunjukkan nilai mean pengetahuan keluarga pada kelompok perlakuan sebelum inter vensi yaitu 3.65 dan setelah intervensi yaitu 10.26, sedangkan nilai mean perubahan yaitu 6.61; sedangkan pada kelompok kontrol didapatkan nilai mean perubahan yaitu 0.54. hal ini 265 pendekatan transcultural nursing (kadek ayu erika) tabel 1. analisis karakteristik responden pada kelompok perlakuan dan kelompok kontrol karakteristik responden kelompok pperlakuan kontrol n (31) % n (33) % jenis kelamin laki-laki perempuan 18 13 58.1 41.9 15 18 45.5 54.5 0.313 pendidikan ayah tinggi rendah 20 11 64.5 35.5 22 11 66.7 33.3 0.856 pendidikan ibu tinggi rendah 14 17 45.2 54.8 18 15 54.5 45.5 0.453 pendapatan keluarga tinggi rendah 31 0 100 0 32 1 97 3 0.329 riwayat kegemukan orang tua ada riwayat tidak ada riwayat 29 2 93.5 6.5 30 3 90.9 9.1 0.694 riwayat kesehatan keluarga berisiko keluarga tidak berisiko 22 9 71 29 27 6 81.8 18.2 0.306 struktur keluarga keluarga inti keluarga besar 26 5 83.9 16.1 22 11 66.7 33.3 0.112 riwayat kesehatan keluarga berisiko keluarga tidak berisiko 22 9 71 29 27 6 81.8 18.2 0.306 struktur keluarga keluarga inti keluarga besar 26 5 83.9 16.1 22 11 66.7 33.3 0.112 gambar 1.perubahan pengetahuan keluarga gambar 2. perubahan budaya keluarga gambar 1. perubahan pengetahuan keluarga gambar 2. perubahan budaya keluarga 266 jurnal ners vol. 9 no. 2 oktober 2014: 262–269 tabel 2. perbedaan rerata pengetahuan keluarga sebelum dan setelah intervensi antara kelompok perlakuan dengan kelompok kontrol waktu pengamatan kelompok skor pengetahuan keluarga nilai p* mean min maks med sd pret test perlakuan 3.65 1.00 8.00 3.00 1.58 0.34kontrol 3.94 2.00 7.00 4.00 1.34 post test perlakuan 10.26 8.00 12.00 10.00 1.32 0.00kontrol 4.48 2.00 9.00 4.00 1.54 perubahan (post-pre) perlakuan 6.61 1.00 11.00 6.00 2.08 0.00 kontrol 0.54 -4.00 5.00 0.00 2.09 *uji mann whitney tabel 3. perbedaan rerata budaya keluarga sebelum dan setelah intervensi antara kelompok perlakuan dengan kelompok kontrol waktu pengamatan kelompok skor budaya keluarga nilai p* mean min maks med sd pret test perlakuan 2.10 1.00 4.00 2.00 0.94 0.38 kontrol 1.88 1.00 4.00 2.00 0.78 post test perlakuan 4.68 2.00 6.00 5.00 1.17 0.00 kontrol 2.03 1.00 5.00 2.00 1.02 perubahan (post-pre) perlakuan 2.58 -1.00 5.00 3.00 1.54 0.00 kontrol 0.15 -2.00 3.00 0.00 1.12 *uji mann whitney menunjukkan mean perubahan pengetahuan keluarga lebih besar pada kelompok perlakuan. hasil uji mann whitney kedua kelompok didapatkan nilai p=0.00, artinya terdapat perbedaan pengetahuan keluarga antara kedua kelompok pada bulan keenam. h a s i l p e n el i t i a n p a d a t a b el 3 menunjukkan nilai mean budaya keluarga pada kelompok perlakuan sebelum intervensi yaitu 2.10 dan setelah intervensi yaitu 4.68, sedangkan nilai mean per ubahan yait u 2.58; sedangkan pada kelompok kontrol didapatkan nilai mean perubahan yaitu 0.15. hal ini menunjukkan mean perubahan budaya keluarga lebih besar pada kelompok perlakuan. hasil uji mann whitney setelah intervensi pada kedua kelompok didapatkan nilai p=0.00, artinya terdapat perbedaan budaya keluarga antara kedua kelompok pada bulan keenam. pembahasan kel u a r g a h a r u s t e r l i b a t d a l a m perawatan kesehatan anak, karena keluarga dan masyarakat sangat mempengaruhi status kesehatan anak (ball & bindler, 2007). perawatan diri menurut orem dalam alligood (2010) bahwa praktek kesehatan atas kesadaran diri sendiri adalah untuk mempertahankan hidup, sehat, dan keadaan sejahtera. menurut virginia henderson, 1966 dalam potter dan perry (2005) bahwa peran perawat adalah untuk meningkatkan tingkat pemahaman klien terhadap kesehatan. pengambilan keputusan merupakan bagian integral dari model trans the oretical dalam perubahan perilaku yang membantu anak dan orang tua dengan membuat keputusan yang lebih efektif untuk mengurangi perilaku risiko kesehatan dari overweight, obesitas dan meningkatkan perilaku sehat (prochaska, et al., 2008). penting nya pengetahuan keluarga dalam mengubah perilaku anak, dapat dilihat pada grafik perubahan pengetahuan pada kelompok perlakuan meningkat dari bulan ke bulan mencapai 100% pengetahuan keluarga tentang gaya hidup pada bulan keenam. hal ini disebabkan karena di awal kunjungan, 267 pendekatan transcultural nursing (kadek ayu erika) keluarga telah diberikan buku panduan gaya hidup sehat kemudian diberikan 5 kali intervensi pendidikan kesehatan setiap kunjungan keluarga meliputi pendidikan kesehatan tentang gaya hidup sehat, asupan makan, aktivitas fisik, perilaku hidup sehat dan dampak kesehatan sehingga semua keluarga memiliki pengetahuan yang baik dalam mengendalikan gaya hidup pada anak overweight dan obesitas. buku panduan gaya hidup sehat ini menjamin bahwa keluarga dan anak menerima informasi yang diperlukan untuk mempertahankan kesehatan optimal anak. pola hidup sehat menurut notoatmodjo (2007) adalah segala upaya untuk menerapkan kebiasaan yang baik dalam kehidupan seharihari. hal ini sejalan dengan penelitian gupta (2005) bahwa melalui pendidikan kesehatan dalam perawatan anak menggunakan handout, orang tua percaya dan sangat berguna untuk menerima infor masi kesehatan sehingga dapat meningkatkan pengetahuan orang tua. pendekatan dengan mengubah kognitif orang tua dapat menumbuhkan perilaku hidup sehat pada anak overweight dan obes. hal ini sesuai dengan notoatmodjo (2003) bahwa pendidikan kesehatan adalah suatu kegiatan atau usaha menyampaikan pesan kesehatan kepada masyarakat, kelompok, dan individu. hal ini sejalan dengan standar pendidikan klien/keluarga menurut the joint commission on accreditation of health care organization (jcaho), 1995 dalam potter & perry (2005) adalah klien/keluarga diberikan pendidikan yang dapat meningkatkan pengetahuan, keterampilan dan perilaku yang diperlukan u nt u k member i ka n keu nt u nga n penu h dan intervensi kesehatan yang dilakukan oleh institusi. hal ini menunjukkan bahwa pendekatan tcn, chm, dan ttm sangat efektif dalam meningkatkan pengetahuan keluarga dalam mengendalikan gaya hidup sehat anak obes. budaya keluarga yang mendukung menunjukkan ada perbedaan sebelum dan setelah intervensi. dapat dilihat juga pada grafik perubahan budaya terjadi peningkatan budaya yang mendukung dari bulan pertama sampai keenam mencapai 100%. keluarga menyatakan bahwa anak yang gemuk belum tentu sehat, camilan makanan manis, minuman bersoda tidak baik untuk anak, makanan siap saji juga tidak baik bagi anak, setelah intervensi keluarga menyadari pentingnya aktivitas fisik teratur dan asupan makan yang bergizi seimbang bagi anaknya yang gemuk. b u d ay a m e m p e n g a r u h i p r a k t i k pemberian makan anak dalam hal keyakinan, nilai, dan perilaku yang berkaitan dengan makanan yang berbeda (brus, et al., 2005). fitzgibbon dan beech (2009) melaporkan bahwa orang tua dari anak overweight dan obesitas mengalami kesalahan persepsi yaitu tidak melihat anak mereka sebagai overweight, sehingga orang tua dieksplorasi dalam aspek budaya tentang ukuran tubuh dan bentuk, serta program intervensi untuk mengubah pola makan dan pola aktivitas anak. peran perawat dalam pendekat an tcn, chm, dan ttm adalah peran sebagai culture care preservation, accommodation d a n r e p a t t e r n i n g a d a l a h m e m b a n t u menciptakan, memodifikasi budaya keluarga yang sehat dengan perilaku hidup sehat dalam mengendalikan gaya hidup anak obes itu dengan aktivitas fisik teratur dan asupan makan yang sehat dan seimbang. hal ini sesuai leininger, 2002 daam alligood (2010) bahwa perawat mengembangkan perencanaan perawatan berdasarkan data karakteristik dimensi budaya, menyampaikan kepada keluarga dan dapat dimodifikasi bila diperlukan kemudian perawat melaksanakan dan mengobser vasi outcome perawatan budaya. simpulan dan saran simpulan pendekatan ketiga model yaitu trans cultural nursing, child health care model, dan transtheoretical model memberikan pengaruh ya ng sig n if i k a n d ala m men i ng k at k a n pengetahuan dan budaya keluarga dalam mengendalikan gaya hidup anak overweight dan obesitas melalui buku panduan gaya hidup anak sehat. 268 jurnal ners vol. 9 no. 2 oktober 2014: 262–269 saran pentingnya penyuluhan dan perlunya sosialisasi buku panduan gaya hidup sehat pad a a na k usia sekola h d asa r kepad a pemerintah, sekolah-sekolah, dan keluarga dalam upaya meningkatkan pengetahuan dan mengubah budaya masyarakat tentang anak gemuk, sehingga dampak risiko penyakit dapat dicegah, meningkatkan kesehatan dan kualitas hidup anak. perlu sosialisasi pendekatan trans cultural nursing, child health care model, dan transtheoretical model sebagai referensi bagi tenaga pengajar dan peserta didik dalam proses pembelajaran. kepustakaan alligood, m.r. 2010. nursing theor y: utilization & applicaton. fou r th edition. missouri: mosby elsevier. ball, j., & bindler, r. 2007. the bindler-ball healthcare model: a new paradigm for health promotion. pediatric nusing, 33(2): 121–126. brus, m.b., morris, j.r., dannison, l.l., orbe, m.p., quitugua, j.a., & palacios r.t. 2005. food, culture, and family: exploring the coordinated management of meaning regarding childhood obesity. health commun, 18: 155–175. centers for disease control and prevention (cdc). 2011. trends in the prevalence of obesity, dietary behaviours, and weight control practices national yrbs: 1991–2011. (online). (www.cdc. gov/yrbss, diakses 7 april 2013). fitzgibbon m.l., & beech, b.m. 2009. the role of culture in the context of schoolbased bmi screening. pediatrics, 124: s50–s62. gupta, n., goel k., shah p., & misra, a. 2012. childhood obesity in developing countries: epidemiology, determinants, and prevention. endocrine reviews (endojournals), 33(1), pp. 48–70. gupta, r.s., shuman, s., taveras, e.m., kulldorff, m., & jonathan, a. 2005. opportunities for health promotion education in child care.pediatrics,116(4): 499-505. hassapidou, m., papadopoulou, s.,k., frossinis, a., kaklamanos, i., & tzotzas, t. 2009. sociodemographic, ethnic and dietary factors associated with childhood obesity in thessaloniki, northern greece. hormones (athens), 8: 53–59. hudson, c.e., cherry, d.j., ratcliffe, s,j., & mcclellan, l.c. 2009. head start children’s lifestyle behaviors, parental perceptions of weight, and body mass index. journal of pediatric nursing, elsevier, 24(4), pp. 292–301. heird, w.c. 2002. parental feeding behavior and children’s fat mass. american jo u r n a l cli n i c a l nu t r i t i o n , 75: 451– 452. leininger, m. 2002. culture care theory: a major cont r ibution to advance transcultural nursing knowledge and practices. journal of transcultural nursing, 13(3), pp. 189–192. notoatmodjo, s. 2003. pendidikan & perilaku kesehatan. jakarta: rineka cipta. notoatmodjo, s. 2007. promosi kesehatan & ilmu perilaku. edisi 2. jakarta: rineka cipta. potter, p.,a., & perry a.,g. 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktik. vol. 1. e/4. jakarta: egc. prochaska, j.o., butterworth, s., redding, c.a., burden, v., perrin, n., leo, m., flaherty, r.m., prochaska, j.m. 2008. initial efficacy of bmi, ttm tailoring and hri’s with multiple behaviors for employee health promotion. prev med, 46(3), pp. 226–231. riset kesehatan dasar. 2010. badan penelitian dan pengembangan kesehatan. jakarta: kementerian kesehatan ri. riset kesehatan dasar. 2013. badan penelitian dan pengembangan kesehatan. jakarta: kementerian kesehatan ri. sartika, r.a.d. 2011. faktor risiko obesitas pada anak 5–15 tahun di indonesia. sistem informasi jurnal ilmiah makara kesehatan universitas indonesia. seri kesehatan, 15(1): 37–43. sastroasmoro, s., & ismael. 2011. dasar-dasar metodologi penelitian klinis, edisi 4. jakarta: sagung seto. 269 pendekatan transcultural nursing (kadek ayu erika) wong, d.l., eaton, m.h.. wilson, d., winkelstein, m.l., & schwartz, p. 2009. wong’s essentials of pediatric nursing, 6th edition.vol.1.missouri: mosby inc. world health organization (who). 2010. population-based prevention strategies for childhood obesity: report of a who forum and technical meeting. geneva: department of child and adolescent health and development. 120 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18995 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review: the experience of patient with diabetic foot ulcers mohamad roni alfaqih1, kusnanto kusnanto1, padoli padoli2 1faculty of nursing, universitas airlangga, surabaya, indonesia 2nursing program of politeknik kesehatan kemenkes, surabaya, indonesia abstract introduction: diabetic foot ulcers can have an impact on the individual responses related to the disease process and healing. the response depends on the perception of the disease, its severity, the environmental factors and the level of family support. the response that often occurs is the existence of fear and anxiety which is due to the stress experienced by the individual. the purpose of this study was to explore the experience of patients with diabetic foot ulcers. methods: this study used the preferred reporting items for systematic reviews and meta-analysis (prisma) approach. the methods used to arrange this systematic review included (1) the identification of the variables in the literature, (2) the identification of the relevant literature based on the topic and title, (3) obtaining the literature in full-text form and (4) conducting an analysis of the results from the literature. the databases used to identify suitable articles were scopus, google scholar, pubmed, proquest and ebscohost. results: based on the 15 articles reviewed, the results explains that the majority of patients who experience dm with the complication of diabetic ulcers experience stress, depression and anxiety. they also have a financial burden, feel helplessness, blame themselves and feel that there is uncertainty their life. they need support from their family and wider social support. conclusion: however, from the experience of the patients with diabetic foot ulcers, they must be able to adapt to a limited life. they must also have a good coping style and an adaptive response in order to survive and heal their diabetic ulcers. article history received: feb 27, 2020 accepted: april 1, 2020 keywords experience; stress; anxiety; diabetic foot ulcer contact kusnanto kusnanto  kusnanto@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: alfaqih, m. r., kusnanto, k., & padoli, p. (2020). a systematic review: the experience of patient with diabetic foot ulcers. jurnal ners, special issues, 120-128. doi:http://dx.doi.org/10.20473/jn.v15i2.18995 introduction diabetic foot ulcers can have an impact on the individual responses related to the disease process and healing. the response depends on the perception of the disease, the disease severity and the environmental factors and family support. the response that often occurs is the existence of fear and anxiety which is due to the stress experienced by the individual (vedhara et al., 2010). the slow process of wound healing in diabetes mellitus patients can increase the risk of wound complications which will have an impact on the duration of wound healing. complications in the form of diabetic ulcers can have an impact on the individual responses related to the disease process and healing. all of these aspects make the patient feel frustrated, dissatisfied, insecure, fearful, helpless and uncontrolled. individuals with injuries feel unable to carry out their daily activities, and they often consider themselves unable to play their role in society (de almeida, salomé, dutra, & ferreira, 2014). diabetic ulcer patients require several weeks or even months to heal. diabetic foot ulcers that cannot be cured are able to become infected, gangrenous, and even lead to amputations. poor healing in patients with diabetic ulcers will create a burden for the patients including morbidity, distress and the disruption of their functional abilities which will ultimately increase the costs involved due to the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:kusnanto@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 121 prolonged care and treatment. this can trigger increased stress levels in the patients with diabetic ulcers (vedhara et al., 2010). each patient builds his experience of the disease which includes both emotional aspects and cognitive aspects, which in turn will determine the coping strategies used. the right coping strategy plays a very important role in the physical and psychological health of the patient(siersma et al., 2017). diabetic ulcer injuries often affect quality of life, including marked limitations in the activities of daily living (adl) due to the pain, edema, fatigue and large dressing that makes simple activities such as changing clothes and bathing frustrating and unable to be done easily. diabetic ulcers can interfere with an individual’s social life, household chores, leisure activities and mobility(siersma et al., 2017). a research study conducted by meriç et al. in 2019 about the experience of patients with diabetic foot ulcers explained that most of the patients were afraid of losing their feet and that they had difficulty coping with the situation. the patients expected the health professionals to understand the difficulties that they were experiencing. another research conducted by delea et al., 2015 about the management of diabetic foot disease and amputation in the irish health system explained that they need supportive interactions with the health professionals according to their differing levels of education and information. there was also the financial cost of the foot complications, the geographical disparities in terms of access to services and supplies, their medical card being a lifeline, the responsibilities of the health care system, the wider social circumstances complicating and competing with the illness process, the importance of emotional support during treatment and the necessity for early education and information to consider. diabetic foot ulcers are a frequent complication of diabetes mellitus with subsequent disturbances in the daily life of the patients. the co-existence of depression and anxiety among diabetic foot patients is a common phenomenon and the role of each of them in perpetuating the other is highlighted in the literature. our study aimed to determine the prevalence of anxiety and depression and to examine the associated risk factors among diabetic foot patients. depression and anxiety are more common in dm patients with diabetic ulcer complications compared with dm patients without complications. this shows that they experience ineffective psychosocial adaptation(ahmad, abujbara, jaddou, younes, & ajlouni, 2018). this is due to the effect of the duration of illness experienced or due to the treatment not healing dm and causing complications. the longer the healing that the diabetes mellitus disease takes and in addition to the duration of the treatment of the ulcer wounds, the more that it will further increase the cost of care, the disruption of the body image, impaired function, the role of the family and depression. the aim of this systematic review was to explore the experience of patients with diabetic foot ulcers(delea et al., 2015). materials and methods strategy for searching studies articles published in english were searched for on scopus (medical and nursing subject category), google scholar, pubmed, proquest and ebscohost. the relevant articles were searched for from december 20th 2019 to february 28th 2020. the article search used the keywords “diabetic foot ulcers, experience, stress, anxiety”. when searching for the articles, “and” was also used. the methods used in arranging this systematic review were (1) the identification of the variable in the literature, (2) the identification of the relevant literature based on the records identified through database searching in scopus (n= 58) records screened (n=1378) records after duplicates removed (n=1378) records excluded (n= 1270) records identified through database searching in pubmed (n= 123), ebschost (n= 314) and proquest (n= 462) and google scholar (n=421) studies included in the quantitave synthesis (n= 15) full-text articles assessed for eligibility (n= 124) full-text articles excluded (n=109) with reasons: 1.not dfu complication (n=68) 2.not primary prophylaxis (n=20 ) 3.incomplete report (n= 5) 4.less duration of complication (n=12) 5.wrong study design (n= 4) in cl u d e d s cr e e n in g id e n ti fi ca ti o n e li g ib il it y figure 1. article selection process m. r. alfaqih et al. 122 | pissn: 1858-3598  eissn: 2502-5791 topic and title, (3) obtaining the literature in a fulltext form, and (4) the analysis of the results from the experience of the literature. study selection a systematic review research design resulting from the latest articles over the last 10 years was used. this study used the preferred reporting items for systematic reviews and meta-analyses (prisma) approach. all of the studies found related to the experience of patients with diabetic foot ulcers only. the search was focused on the titles, abstracts and keywords. the inclusion criteria in the study were 1) adult humans ≥ 30 years of age diagnosed with diabetic foot ulcers; 2) the duration of ulcers was for more than 3 years and 3) the study design was qualitative research. studies were excluded if the studies involved diabetes mellitus with the retinopathy complication, which does not have enough strength to use to detect a significant relationship. the publications were limited to between 2009-2020 (figure.1 article selection process). ethical issues considered when preparing the manuscript of the systematic reviews were following 1) avoiding redundant or duplicated articles among the publications; 2) avoiding plagiarism; 3) the transparency of the screening of the articles, the process of analysis and the evaluation; 4) ensuring accuracy and 5) flagging suspected plagiarism or fraudulent research. results strategy for searching studies diabetic ulcer complications can have an impact on the individual responses related to the disease process and healing. the response depends on the perception of the disease, the severity of the disease and the environmental and support factors. the response that often occurs is the existence of fear and anxiety due to the stress experienced by the no title, authors, & time variable design instrument main result 1 it is not [a] diabetic foot: it is my foot ((meriç et al., 2019)) diabetic foot ulcers, experience qualitative research patient interviews most of the patients were afraid of losing their feet and they had difficulty coping with the situation. the patients expected the health professionals to understand the difficulties they were experiencing. the need to better understand the needs and experiences of the patients. 2 the psychosocial responses and coping strategies of diabetes mellitus type 2 patients of the ambon culture(rayanti et al., 2016) psychosocial responses and coping strategies qualitative and descriptive using the case study approach observation and in-depth interviews. the participants’ psychosocial responses included resilience, optimism and social support from their family and close relatives, low self-esteem, and anxiety. to adapt to their condition, the male participants tended to use problem-focused coping while the female participants used emotion-focused coping. the factors that influenced the coping strategies were diabetes severity, the participant’s individual characteristics and the environment (culture and social support). they believe in traditional medicine such as the africa leaf, noni fruit, the kalabasa leaf and the alifuru leaf, and that the aforementioned traditional cures are able to reduce their blood glucose. jurnal ners http://e-journal.unair.ac.id/jners | 123 individual (siersma et al., 2017). physiological stress 3 exploring the factors that contribute to the delay in seeking help with diabetes-related foot problems: a preliminary qualitative study using interpretative phenomenological analysis(chithambo & forbes, 2015) factors that contribute to a delay in seeking help and diabetesrelated foot problems qualitative: interpretative phenomenological analysis in-depth interviews the level of prior foot care information, awareness of the foot problem, the ability to perform footcare behaviors, ulcer presentation and risk perception, competing priorities, the use of selfmanagement strategies for the foot problem, the presence of specific helpseeking triggers, comorbid conditions and concurrent illness and delayed secondary referral 4 management of diabetic foot disease and amputation in the irish health system: a qualitative study of patients’ attitudes and experiences with health services(delea et al., 2015) management, diabetic foot disease, amputation/ qualitative in-depth interviews need for supportive interaction with health professionals, different levels of education and information, financial cost of foot complications, geographical disparities in terms of access to services and supplies, medical card as a lifeline, 5 responsibilities of the health care system, wider social circumstances complicating and competing with the illness process, the importance of emotional support during treatment and the necessity of early education and information 5 premorbid risk perception, lifestyle, adherence and coping strategies of people with diabetes mellitus: a phenomenological study in the brong ahafo region of ghana ((tabong et al., 2018)) premorbid risk perception, lifestyle, and the coping strategies of people with diabetes mellitus: a phenomenological study qualitative in-depth interviews and nvivo 11 the respondents believed that diabetes was a condition for the aged and rich. this served as a premorbid risk attenuator. the majority of them engaged in diabetes-related high risk behaviors such as a lack of exercise, a sedentary lifestyle and unhealthy eating despite their foreknowledge about the role of lifestyle in diabetes pathogenesis. we also found that the patients used moringa, noni, prekese and garlic concurrently with orthodox medications 6 conditions for success in introducing telemedicine in diabetes foot care: a qualitative inquiry(kolltveit et al., 2017) conditions, telemedicine, diabetes foot care qualitative in-depth interviews user-friendly technology and training, a telemedicine champion, committed and responsible leaders, effective communication channels at the organizational level m. r. alfaqih et al. 124 | pissn: 1858-3598  eissn: 2502-5791 is a systematic response to the stressors that facilitate 7 patients’ experience of therapeutic footwear whilst living at risk of neuropathic diabetic foot ulceration: an interpretative phenomenological analysis (ipa) (paton et al., 2014) patients’ experience, therapeutic footwear, neuropathic diabetic foot ulceration qualitative: an interpretative phenomenological analysis (ipa) in-depth interviews the self-perception dilemma, adherence response, reflective adaption, reality appraisal 8 does physiological stress slowdown wound healing in patients with diabetes?(razjouyan et al., 2017) physiological stress, wound healing, diabetes qualitative in-depth interviews this study confirms an association between stress/vagal tone and wound healing in patients with dfus. in particular, it highlights the importance of vagal tone (relaxation) when expediting wound healing. it also demonstrates the feasibility of assessing physiological stress responses using wearable technology in an outpatient clinic during routine clinic visits. 9 burden of illness of diabetic peripheral neuropathic pain: a qualitative study(brod, pohlman, blum, ramasamy, & carson, 2015) burden of illness, diabetic peripheral neuropathic pain qualitative in-depth interviews, observation physical functioning, daily life, social/psychological 10 the experiences of people with diabetesrelated lower limb amputation at the komfo anokye teaching hospital (kath) in ghana(amoah et al., 2018) experiences, diabetes, lower limb amputation, hospital qualitative in-depth interviews physical experiences, changes in lifestyle, coping strategies, psychological/emotional experiences, economic experiences 11 patients’ perception of using telehealth for type 2 diabetes management: a phenomenological study(lee, greenfield, & pappas, 2018) patients’ perception, telehealth, type 2 diabetes, management qualitative in-depth interviews technology considerations, service perceptions, empowerment 12 coping style and depression influence the healing of diabetic foot ulcers(vedhara et al., 2010) coping style, depression influence, healing, diabetic foot ulcers observational and mechanistic evidence in-depth interviews for this prospective observational study, we recruited 93 (68 men; mean age 60 years) patients with neuropathic or neuroischaemic diabetic foot ulcers from specialist podiatry clinics in secondary care. the clinical and demographic determinants of healing, psychological distress, coping, salivary cortisol, mmp2 and mmp9 were assessed at baseline. jurnal ners http://e-journal.unair.ac.id/jners | 125 adaptation when meeting challenges. autonomic responses involved in the modulation of physiological stress include the activation of the sympathetic and parasympathetic nervous system which work together to keep the body in a state of homeostasis(de almeida et al., 2014). during tense events, the sympathetic nervous system dominates, producing fight-or-flight responses. however, the body cannot maintain this state for a long time. the parasympathetic system returns the physiological condition of the body to a rested and normal state. although sympathetic physiological responses are very important to protect the body and adapt to stressors, prolonged exposure to stress, which is referred to as episodic acute stress, can have adverse effects on psychological and physiological health and it can also affect the wound healing process(razjouyan et al., 2017). wound healing is a complex and fragile process. stress can interfere or lead to the formation of chronic wounds that do not heal in dfu patients. stress interferes with the healing process of wounds, mainly by mediating the hypothalamic-pituitary-adrenal and sympathetic-adrenal medullary axis and psychological responses, encouraging unhealthy behaviors such as a sedentary lifestyle, smoking and so on. several studies have confirmed the relationship between delayed wound healing and stress by measuring the physiological stress conditions(razjouyan et al., 2017). the participants’ psychosocial responses included resilience, optimism and social support from their the ulcers were assessed at baseline and at 6, 12 and 24 weeks post-baseline. the primary outcome was ulcer status at 24 weeks, i.e. healed vs not healed. results: after controlling for the clinical and demographic determinants of healing, ulcer healing at 24 weeks was predicted by confrontation coping but not by depression or anxiety. the patients with unhealed ulcers exhibited greater confrontational coping. 13 patients’ experiences of support for learning to live with diabetes to promote health and well-being: a lifeworld phenomenological study(johansson, österberg, leksell, & berglund, 2016) patients’ experiences, support for learning, diabetes, promotion, health, well-being qualitative in-depth interviews responsibility creating curiosity and willpower, openness enabling support, technology verifying their bodily feelings, a permissive climate providing for participation and exchanging experiences with others 14 when a diabetic foot ulcer results in amputation: a qualitative study of the lived experience of 15 patients(foster & lauver, 2014) financial burden, powerlessness, social support, placing blame, and uncertainty. 15 an exploratory phenomenological study exploring the experiences of people with systemic disease who have undergone lower limb amputation and its impact on their psychological wellbeing(washington & williams, 2016) qualitative: an explanatory model in-depth interviews being pre-conditioned, adapting to a restricted life, ability to adapt, need for support versus independence and relationships with others m. r. alfaqih et al. 126 | pissn: 1858-3598  eissn: 2502-5791 family and close relatives, low self-esteem and anxiety. to adapt to their condition, the male participants tended to use problem-focused coping while the female participants used emotion-focused coping. the factors that influenced coping strategies the most was the diabetes severity, the participant’s individual characteristics and the environment (cultural and social support). they believe in traditional medicine such as the africa leaf, noni fruit, kalabasa leaf and alifuru leaf and that the aforementioned traditional cures are able to reduce their blood glucose(rayanti, wariunsora, soegijono, kristen, & wacana, 2016). from this study, it is illustrated that the individual response when experiencing diabetic foot ulcers are also influenced by gender, culture and their beliefs. patient perception diabetes mellitus patients vary in their perception of their quality of life and in the coping styles used when dealing with daily stress. coping in dm patients is a continuous process and it is a major factor influencing a patient's assessment of the disease, the ability to perform adaptive tasks and the ability to learn and use skills to overcome the problems of the disease. cognitive evaluation or an evaluation of the meaning / significance of chronic illness is important and it is an influential part of the patient's adjustment to the disease(vedhara et al., 2010). the self-perception dilemma is about resolving the balance of risk experienced by people with diabetes and neuropathy day to day, such as between choosing to wear footwear to look and feel normal and choosing footwear to protect their feet from foot ulceration(paton, roberts, bruce, & marsden, 2014). reflective adaptive refers to the modification and individualization of a set of values about footwear usage created in the minds of people with diabetes and neuropathy. adherence response; this refers to the realignment of footwear choice with personal values to reinforce the decision not to change behavior or to bring about increased footwear adherence with or without appearance management. reality appraisal refers to a here and now appraisal of the personal benefits of footwear choice on their emotional and physical wellbeing with additional considerations related to the preservation of therapeutic footwear. the conclusion is that for some people living at risk of diabetic neuropathic foot ulceration, the decision whether or not to wear therapeutic footwear is driven by the individual ‘here and now’ risks and benefits, of footwear choice on their emotional and physical well-being in a given social context(paton et al., 2014). from the 15 studies as the evidence base, the majority of the research designs were qualitative with 14 of them using a phenomenological approach. this explains the description of the coping mechanisms, anxiety and the psychological responses of the diabetic ulcer patients. from the results of the several studies analyzed, the majority of the patients who have dm with the complication of diabetic ulcers experience stress, depression, and anxiety. however, one of the 15 studies on coping styles and depression affecting the healing of diabetic ulcers stated that the healing of diabetic ulcers is determined by the coping mechanisms involved and not because of anxiety and depression. this proves that the individual coping mechanism also determines the compliance process concerning the treatment of diabetic ulcers. discussion most of the patients were afraid of losing their feet and they had difficulty in coping with the situation. the patients expected the health professionals to understand the difficulties that they were experiencing. they should better understand the needs and experiences of the patients they are treating. the review of the literature shows that the literature itself has mostly focused on medical issues such as the causes and management of dfus rather than the patient experience of having a dfu. however, as having a dfu directly affects a patient’s qol and their psychosocial condition, treatment should be tailored to the patient, based on their level of acceptance of the disease and adherence to the treatment. a research study conducted by tabong et al.in2018 explained that the respondents believed that diabetes was a condition for the aged and rich. this served as a premorbid risk attenuator. the majority of them engaged in diabetes-related high risk behaviors such as a lack of exercise, a sedentary lifestyle and unhealthy eating despite their foreknowledge about the role of lifestyle in diabetes pathogenesis. we also found that the patients used moringa, noni, prekese, and garlic concurrently with orthodox medications. diabetic patients had a low premorbid perception of the risk and they engaged in diabetes-related risky behaviors. diabetic patients face challenges adhering to lifestyle changes and they use both biomedical and local remedies in the management of their condition. psychosocial support is necessary to enhance their level of coping with this condition. another research conducted by paton et al. in2014 spoke about the patients’ experience of therapeutic footwear whilst living at risk of neuropathic diabetic foot ulceration. they explained that there are several perceptions such as the self-perception dilemma, adherence response, reflective adaption and reality appraisal (paton et al., 2014). besides that, another study conducted by chithambo in 2015 about exploring the factors that contribute to a delay in seeking help with diabetes-related foot problems said that the level of prior foot care information, the ability to perform foot care behaviors, ulcer presentation and risk perception competing for priority, the use of self-management strategies for the foot problem, the presence of specific help-seeking triggering comorbid conditions and concurrent illness and delayed secondary referrals all played a part(chithambo & forbes, 2015). jurnal ners http://e-journal.unair.ac.id/jners | 127 limitation of the study this study is subject to some limitations. because the systematic review process integrates the interpretations of the findings of different researchers, it relies heavily on the quality of the researchers’ interpretations. thus the limitations of the systematic review are affected by the characteristics of the original studies. similarly, common speech is used to describe the experience connected to the diabetic foot ulcers. without a standard language to articulate the experience of diabetic foot ulcers, the contrasts between the similar experiences in and throughout the study lack accuracy. conclusion from the results of the studies analyzed, the majority of patients who have dm with the complication of diabetic ulcers experience stress, depression and anxiety. they need support from their family and social support. they also have a financial burden and feel helplessness, blame, and uncertainty in their life however, one of the 15 studies on coping styles and depression affecting the healing of diabetic ulcers stated that the healing of diabetic ulcers is determined by coping confrontation or coping mechanisms, not anxiety and/or depression. this proves that the individual coping mechanism also determines the compliance process regarding the treatment of diabetic ulcers. the patients with diabetic foot ulcers must be able to adapt to a limited life. they must also have a good coping style and adaptive response to survive and heal their diabetic ulcers. by knowing some of the experiences of patients with diabetic foot ulcers, it is expected that all health workers and nurses should provide comprehensive nursing care not only from the biological aspect but also from the physiological, social, cultural and spiritual aspects as well. providing comprehensive services to the patients with diabetic foot ulcers not only can improve their quality of life, but it can also improve their coping style and adaptive response. future researchers are expected to make this systematic review study a reference when examining the prevention of depression and anxiety in dm patients with complications. conflict of interest no conflicts of interest have been declared. acknowledgement the authors of this study would like to thank the faculty of nursing and the master’s of nursing study program, for providing the opportunity to present this study. references ahmad, a., abujbara, m., jaddou, h., younes, n. a., & ajlouni, k. (2018). anxiety and depression among adult patients with diabetic foot: prevalence and associated factors. journal of clinical medicine research, 10(5), 411–418. https://doi.org/10.14740/jocmr3352w amoah, v. m. k., anokye, r., acheampong, e., dadson, h. r., osei, m., & nadutey, a. (2018). the experiences of people with diabetes-related lower limb amputation at the komfo anokye teaching hospital (kath) in ghana. bmc research notes, 11(1), 1–5. https://doi.org/10.1186/s13104-018-3176-1 brod, m., pohlman, b., blum, s. i., ramasamy, a., & carson, r. (2015). burden of illness of diabetic peripheral neuropathic pain: a qualitative study. patient, 8(4), 339–348. https://doi.org/10.1007/s40271-014-0093-9 chithambo, t., & forbes, a. (2015). exploring factors that contribute to delay in seeking help with diabetes related foot problems: a preliminary qualitative study using interpretative phenomenological analysis. international diabetes nursing, 12(1), 20–26. https://doi.org/10.1179/2057331615z.000000 0006 de almeida, s. a., salomé, g. m., dutra, r. a. a., & ferreira, l. m. (2014). feelings of powerlessness in individuals with either venous or diabetic foot ulcers. journal of tissue viability, 23(3), 109–114. https://doi.org/10.1016/j.jtv.2014.04.005 delea, s., buckley, c., hanrahan, a., mcgreal, g., desmond, d., & mchugh, s. (2015). management of diabetic foot disease and amputation in the irish health system: a qualitative study of patients’ attitudes and experiences with health services. bmc health services research, 15(1), 1– 10. https://doi.org/10.1186/s12913-015-09269 foster, d., & lauver, l. s. (2014). when a diabetic foot ulcer results in amputation: a qualitative study of the lived experience of 15 patients. ostomy wound management, 60(11), 16–22. johansson, k., österberg, s. a., leksell, j., & berglund, m. (2016). patients’ experiences of support for learning to live with diabetes to promote health and well-being: a lifeworld phenomenological study. international journal of qualitative studies on health and well-being, 11(june 2017). https://doi.org/10.3402/qhw.v11.31330 kolltveit, b. c. h., gjengedal, e., graue, m., iversen, m. m., thorne, s., & kirkevold, m. (2017). conditions for success in introducing telemedicine in diabetes foot care: a qualitative inquiry. bmc nursing, 16(1), 1–10. https://doi.org/10.1186/s12912-017-0201-y lee, p. a., greenfield, g., & pappas, y. (2018). patients’ perception of using telehealth for type 2 diabetes management: a phenomenological study. bmc health services research, 18(1), 1–9. https://doi.org/10.1186/s12913-018-3353-x meriç, m., ergün, g., meriç, c., demirci, i̇., & azal, ö. (2019). it is not diabetic foot: it is my foot. journal m. r. alfaqih et al. 128 | pissn: 1858-3598  eissn: 2502-5791 of wound care, 28(1), 30–37. https://doi.org/10.12968/jowc.2019.28.1.30 paton, j. s., roberts, a., bruce, g. k., & marsden, j. (2014). patients’ experience of therapeutic footwear whilst living at risk of neuropathic diabetic foot ulceration: an interpretative phenomenological analysis (ipa). journal of foot and ankle research, 7(1), 1–9. https://doi.org/10.1186/1757-1146-7-16 rayanti, r. e., wariunsora, n. s., soegijono, s. p., kristen, u., & wacana, s. (2016). the psychosocial responses and coping strategies of diabetes mellitus type 2 patients of the ambon culture dengan budaya ambon. 389–399. razjouyan, j., grewal, g. s., talal, t. k., armstrong, d. g., mills, j. l., & najafi, b. (2017). does physiological stress slow down wound healing in patients with diabetes? journal of diabetes science and technology, 11(4), 685–692. https://doi.org/10.1177/1932296817705397 siersma, v., thorsen, h., holstein, p. e., kars, m., apelqvist, j., jude, e. b., … schaper, n. c. (2017). diabetic complications do not hamper improvement of health-related quality of life over the course of treatment of diabetic foot ulcers – the eurodiale study. journal of diabetes and its complications, 31(7), 1145–1151. https://doi.org/10.1016/j.jdiacomp.2017.04.00 8 tabong, p. t. n., bawontuo, v., dumah, d. n., kyilleh, j. m., & yempabe, t. (2018). premorbid risk perception, lifestyle, adherence and coping strategies of people with diabetes mellitus: a phenomenological study in the brong ahafo region of ghana. plos one, 13(6), 1–19. https://doi.org/10.1371/journal.pone.0198915 vedhara, k., miles, j. n. v., wetherell, m. a., dawe, k., searle, a., tallon, d., … campbell, r. (2010). coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence. diabetologia, 53(8), 1590– 1598. https://doi.org/10.1007/s00125-0101743-7 washington, e. d., & williams, a. e. (2016). an exploratory phenomenological study exploring the experiences of people with systemic disease who have undergone lower limb amputation and its impact on their psychological well-being. prosthetics and orthotics international, 40(1), 44– 50. https://doi.org/10.1177/0309364614556838 figure 1. article selection process 72 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19011 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research improving the fine motor skills with embroidery among children with an intellectual disability syiddatul budury 1, khamida khamida1, siti nurjanah1 and triana jamaliah jalaluddin2 1 nursing and midwifery faculty, nahdlatululama university surabaya, east java, indonesia 2 student of bachelor nursing, nursing and midwifery faculty, nahdlatululama university, indonesia abstract introduction: children with intelletual disability experience delays infine motor skills compared to normal children, if the child's fine motor skills are not trained and developed, it will affect to the child's growth and development. one of occupational therapies to improve their finemotor skills is through embroidery. the purpose of this study was to analyze the effect of embroidery to the fine motor development of children with moderate mental retardation at the special school, bangkalan indonesia. methods: the design was pre experimental research with one pre testpost test design group, population of all children with moderate mental retardationas many as 13 children. the research instrument use dwasobservation sheet. results: data analysisby wilcoxon signed ranks test.the embroidery therapy using cross stitch technique. it was held every monday and thursday for eight week, took an hour each session conclusion: the results of the study showed that most children after had embroidery had enough finemotor skills (84.6%) and the statistical test value was obtained p<α (0.002<0.05). the students improved their fine motor ability such as how they coloring, scissoring, grasping, and holding up a paper. the conclusion of this study is that there was an effect of embroidery therapy on fine motor skills in children with intellectual disability. article history received: feb 27, 2020 accepted: april 1, 2020 keywords intellectual disability; fine motor skills; embroidery contact syiddatul budury  syiddatbr@unusa.ac.id  nursing and midwifery faculty, nahdlatululama university surabaya, east java, indonesia cite this as: budury, s., khamida, k., nurjanah, s., & jalaluddin, t. j. (2020). improving the fine motor skills with embroidery among children with an intellectual disability. jurnal ners, special issues, 72-74. doi:http://dx.doi.org/10.20473/jn.v15i2.19011 introduction children are the next generation and the important potential of any nation. they need a good and healthy environment for optimal growth and development. the values that we impart to children will have a great effect on society. this does not only refer to normal children but also to children with an intellectual disability. the united nations development program estimates that globally over 200 million children have an intellectual disability (apa american psychiatric association, 2015) and that 80% of all people with disabilities live in a low income country. intellectually disabled children or children with mental retardation are ways to refer to children who experience a physical, mental-intellectual, social and emotional delay with a significant effect on their growth and development processes (kpppa, 2015). children who have an intellectual disability experience delays and limitations concerning their adaptive behavior and intellectual functioning (armatas, 2009). according to dsm-5, their intelligence range is 20 – 70 (shogren & turnbull, 2010). in reference to their adaptive behaviors, they have problems in terms of their gross motor and fine motor development, in addition to their speech and social skills. the fine motor abilities of children have an important role, namely to train the small muscles such as the hand and finger movements. the coordination of the fingers, hands and arms plays a vital role in activities such as eating, dressing, grasping and the use of utensils and tools (suchiporn https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 73 lersilp, supawadee putthinoi, 2016). the development of the small muscles facilitates the proper coordination needed to perform daily activities. a mentally retarded child needs moderate training in accordance with their physical, psychological and intelligence condition. children with mental retardation encounter barriers to their development and growth in the sensory and motor areas, including both gross motor and fine motor skills. the fine motor skills of intellectually disabled children are developing and so there needs to be training to develop the proper coordination (training, the, & retarded, 2001). the national institute for mentally handicapped has developed activities to improve the fine motor skills of intellectual disabled children such as turning a door knob, stacking objects, pasting paper, assembling objects, separating rolls of material, wrapping objects, cutting with scissors, drawing, painting and sewing (handicap, 2001). embroidery is occupational therapy that contains of cutting scissors, drawing, and sewing. embroidery is similar to the plastilinography technique used for promoting fine motor skills (maria lapshina, 2019). it can train children with mild and moderate intellectual disability to concentrate, enhancing the strength of their muscles when pulling threads. it enhances their fingers when forming patterns through embroidery. indirectly, embroidery can make the stiff muscles supple. embroidery can not only improve the fine motor skills but it can also improve their intellectual functioning including imaginative thinking, logic, accuracy and perseverance (sadovnika, 2019). materials and methods the research design that was used in this study was pre-experimental with a one group pretest-posttest design. the population consisted of intellectually disabled children at a special school in bangkalan with 24 students. the sample totaled 13children who were 12 – 14 years old with a moderate intellectual disability taken through simple random sampling. the criteria in this study were that they were boys and girls with a moderate intellectual disability who are able to follow instructions and who went to school regularly. the informed consent form was signed by their parents who accompanied them while the children were at school. the design was pre-experimental with one prepost group. the data collection used an observation sheet based on the madras developmental programming system modified and developed by purna (purna, 2015). the observation sheet consisted of 5 aspects: drawing, folding, gripping, cutting, squeezing and sticking. the embroidery took place at the school and it was held twice a week for 2 months. each session took 60 minutes. the embroidery method used the cross-stitch technique. what they sewed was three letters from the alphabet. the data was analyzed using the wilcoxon signed rank test. this research passed the ethical clearance held by unusa ethical board results table 1 showed that most of the respondents were girls and that most of them were 14 years old. from table 2, it can be seen that before being given the embroidery intervention, most of the children had moderate fine motor skills (8 children: 61.5%). a small number of children had good fine motor development (3 children: 23.1%). after being given the embroidery intervention, the level of fine motor development overall was good (11children: 84.6). before the intervention, more than half of the respondents had fine motor skills in the moderate category of 8 (61.5%) but there was a decrease after the intervention to 2 (15.4%). there was an increase in the number of respondents with fine motoric skills in the good category by 11 people (84.6%). there was a significant difference in the fine motor skills before and after the intervention with a value of p = 0.002. discussion when the embroidery is in process, the children with an intellectual disability are learning how to use their hands and fingers to sew, install a thread, strike and catch the yarn. they are then using the cross-stitch technique to do the embroidery itself. it helps their fine motor skills to improve, especially the 5 aspects of drawing, folding, gripping, cutting, squeezing and sticking. the results show that embroidery has a significant effect when it comes to improving the fine motor skills of children with an intellectual disability. this result relates to what boopathi and umarani found in that facilitating a fine motor activities program can promote fine motor skills (k ramesh boopathi, 2019). the playing activity enables the children with a mild and moderate intellectual disability to develop their self-help skills such as dressing, eating and playing. these skills are coordinated by the maturation of the central nervous system and specific motor experiences (vidoni, mccarley, edwards, & boyd, 2009). embroidery is a table 1. distribution of the frequency of the variables variable n % gender boys 6 46.2 girls 7 53.8 age 12 years old 3 23.1 13 years old 4 30.7 14 years old 6 46.2 table 2. distribution of the fine motor skill level before and after embroidery fine motor skill level pre % post % pvalue less 2 15.4 0 0 0.02 moderate 8 61.5 2 15.4 good 3 23.1 11 84.6 s. budury et al. 74 | pissn: 1858-3598  eissn: 2502-5791 form of occupational therapy using hand muscle strength activity sets. it requires coordination between visual attention on the object and hand-eye coordination. embroidery not only improved the intellectually disabled children’s activities such as grasping and wearing clothes but it also improved their concentration ability and writing and coloring skills.(islamiyah & widyana, 2017) fine motor skills, learning ability, and communication skills all have a relationship to the functioning of the cerebellum that is closely related to learning and social behavior (chen yu, 2013). as we can see, fine motor skills are needed as much by intellectually disabled children as they are needed by normal children. if they do not gain any strength in terms of their fine motor skills, the children’s activities and independency will be lacking. they will depend on us to do some of their daily task because their inability. that is why we do need to improve their fine motor skills. in addition, this study had the limitation of generalizing to a large population. future research should involve a larger number of subjects. conclusion the objective of this study was to improve the children’s fine motor skills using embroidery. it has been found that there is an effect from embroidery on the improvement of the fine motor skills of intellectually disabled children. children gradually respond to the stimulus and learn to develop their fine motor skills. the intervention condition can also apply in the contexts of coloring, scissoring, grasping and writing conflict of interest the authors declare that there are no conflicts of interest. acknowledgement thank you to all of the students with an intellectual disability who participated in this research. references apa american psychiatric association. (2015). what is intellectual disability? https://doi.org/10.1176/appi.pn.2018.4a22 armatas, v. (2009). mental retardation: definitions, etiology, epidemiology and diagnosis. journal of sport and health research, 1(2), 112–122. chen yu, li. b. s. (2013). joint attention without gaze following: human infants and their parents coordinate visual attention to objects through eye-hand coordination. plos one, 8(11). handicap, n. i. for the m. (2001). fine motor skills. unicef. islamiyah, d., & widyana, r. (2017). terapi okupasi menyulam untuk meningkatkan kemampuan motorik halus pada siswa tunagrahita ringan di slb yapenas yogyakarta. insight: jurnal ilmiah psikologi, 17(1), 56. https://doi.org/10.26486/psikologi.v17i1.685 k ramesh boopathi, s. u. (2019). effectiveness of play activity on fine motor skills among mentally retarded children. international journal of scientific study, 7(1). kpppa. (2015). panduan penanganan anak berkebutuhan khusus bagi pendamping (orang tua, keluarga dan masyarakat). in kementerian pemberdayaan perempuan dan perlindungan anak republik indonesia. maria lapshina, n. s. (2019). using plastilinografii on manual labor lessons in a special school. inovace a technologie ve vzdelavani, 1. purna, d. d. tri. (2015). pengaruh latihan menggambar dengan teknik mozaik terhadap kemampuan motorik halus anak tunagrahita di slb-c tpa jember. universitas jember. sadovnika, m. (2019). use of art embroidery at extra classic activities at school. shogren, k. a., & turnbull, h. r. (2010). public policy and outcomes for persons with intellectual disability: extending and expanding the public policy framework of aaidd’s 11th edition of intellectual disability: definition, classification, and systems of support. intellectual and developmental disabilities, 48(5), 375–386. https://doi.org/10.1352/1934-9556-48.5.375 suchiporn lersilp, supawadee putthinoi, k. p. (2016). fine motor activities program to promote fine motor skills in a case of down’s syndrome. global journal of health science, 8(12). training, s., the, i. n., & retarded, m. (2001). skill training in the mentally retarded persons. vidoni, e. d., mccarley, j. s., edwards, j. d., & boyd, l. a. (2009). manual and oculomotor performance develop contemporaneously but independently during continuous tracking. experimental brain research, 195(4), 611–620. https://doi.org/10.1007/s00221-009-1833-2 222 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.22524 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research social support attainment of older adults living in a flood-prone community arlene supremo1, sillmark bacason1, alpha issa christianne abegonia2, and louverille bacason2 1 faculty of biliran province state university 2 school nurse of department of education biliran abstract introduction: a flood, a catastrophic phenomenon often experienced by many, brings destruction to property and livelihood. this kind of event renders access to basic services difficult. during times of floods, older adults need additional social support, from family, friends, relatives, or significant others. the aim of this study was to investigate the level of attainment of social support of older adults during periods of floods and periods without floods. methods: a descriptive quantitative research design was used. purposive sampling was utilized to reach the population sample of 126 elderly respondents. they were interviewed face-to-face in their homes using a modified questionnaire. to analyze the data, descriptive statistics and mean scores were used. results: 126 older adults participated in the research study. most older adults strongly agreed that they received social support during periods of floods (with a mean score of 4.40) and without floods (with a mean score of 4.39). discussion: social support was extended to older adults both during times of floods and without floods. the support they received from people who were special to them maintained their health and well-being. article history received: october 9, 2020 accepted: november 11, 2020 keywords aged; disaster; family care; natural calamity; social relations contact arlene supremo  arlene.supremo1986@gmail.com  faculty of biliran province state university cite this as: supremo, a., bacason, s., abegonia, a, i, c., bacason, l. (2020). social support attainment of older adults living in a flood-prone community. jurnal ners, 15(2). 222-227. doi:http://dx.doi.org/10.20473/jn.v15i2.22524 introduction social support is a fundamental and substantial need for every person. with the attainment of this need, people can live well. at the community level, for instance, older adults are one of the groups of people who need social support because they have a higher prevalence of chronic diseases, physical disabilities, and other co-morbidities (benson, 2013). due to the predicted physical changes related to aging, they are a vulnerable age group (orimo et al., 2006). wu et al. (2015) concluded that the emergence of natural catastrophic calamities such as floods further hampers the attainment of social support among older adults. globally, older adults in both developed and underdeveloped countries have been affected by the effects of natural catastrophes with regard to attaining social support (who, 2008). abraham (2016) reported that older adults were seriously affected by the 2013 and 2014 severe flooding in northern england and northwest europe. similarly, older adults were significantly affected by the severe flooding in the southeastern united states due to hurricane katrina (dyer, 2006). moreover, wu et al., (2006) indicated that flooding is considered one of the most severe forms of natural disasters affecting various age populations, including older adults. the philippines has recorded debilitating effects of natural catastrophes due to various tropical storms https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:k%20arlene.supremo1986@gmail.com%20d jurnal ners http://e-journal.unair.ac.id/jners | 223 affecting the country (cadag et al., 2017). the tropical storms haiyan (yolanda), bopha (pablo), nesat (pedring), washi (sendong), ketsana (ondoy), and parma (pepeng) caused severe flooding in the lower regions of the urban and rural areas of the country in 2013, 2012, 2011, and 2010 (gilbuena, kawamura, medina, amaguchi, & nakagawa, 2013). in 2014, the intergovernmental panel on climate change (ipcc) forecasted that coastal regions and disaster-prone areas were likely to experience intense flooding due to typhoons and tropical storms. fernandez, stoeckl, and weltres (2019) emphasized that the possible severe impact of these events could be devastating to the lives of the filipinos residing in those areas. the social support that people may receive during these debilitating times has been hampered by some destruction in the national and provincial roads. the biliran province, an island community situated in the philippines, is considered a very highrisk place for climate and weather-related threats (santos, 2016). empirical study results showed that the four typhoons, namely urduja in 2017, yolanda in 2013, pablo in 2012, and ruby in 2004, hit the province and caused serious flooding in some areas and municipalities. local reports indicated that injuries occurred, but there were undocumented cases of injuries for elders. among the areas of biliran, barangay poblacion in the municipality of almeria was identified as one of the flood-prone places. it has been noted in the historical accounts of flooding in the poblacion, which started in the year 1961 when typhoon bebing caused heavy flooding in the area. however, the effects of the naturally-occurring phenomenon on older adults in biliran province, specifically in almeria, remained uninvestigated. there has been a dearth of research studies elucidating the extent of older adults’ attainment of social support, both in periods of floods and periods without floods, especially considering that older adults are a vulnerable population. meeting their social support needs will foster their increased health, enabling them to live longer. the aim of the study was to investigate the level of the attainment of the social support of older adults living in the floodprone community of the biliran province during a flood and when no flooding was present. materials and methods study design a descriptive quantitative study design was conducted through a cross-sectional approach. respondents the respondents of the study were 126 older adults age 65 years old and above. the inclusion criteria included elders who were willing to participate in the study, who were ambulatory and able to talk, communicate, and express their thoughts. the exclusion criteria included those elders who could not talk, were bed-ridden, stuporous, or comatose. a purposive sampling design was utilized in the study. the senior citizen organization located in one of the district in philippines, provided a list of 186 senior residents in the locality, and out of that number, 126 seniors consented to participate. instruments the instrument utilized in the study was derived from the studies of zimet, dahlem, zimet, and farley (1988). the modified questionnaire was composed of two parts. part i included the determination of the respondents' demographic profile in terms of age, gender, marital status, common illnesses, presence of chronic disease, and living style. part ii included data on the scoring of how the participant felt about five (5) statements of social support. these items were categorized according to the following sources of social support: acquaintances, relatives, and other important persons related to the care of the elderly. this part covers two periods: when there is no flood and when there is a flood. each period has a scale to assess the social support acquired by the older adult. responses were scaled with a five-point likert-scale. numbers 5, 4, 3, 2, and 1 represented strongly agree, agree, neutral, disagree, and strongly disagree. the scoring and quantification were designated as follows: 4.21–5.00 indicated strongly agree, 3.41– 4.20 indicated agree, 2.61– 3.40 indicated neutral, 1.81–2.60 indicated disagree, and 1.00–1.80 indicated strongly disagree. the semi-structured questionnaire was scrutinized by an external panel to improve certain items in order to ensure reliability and validity. data collection the researchers interviewed the respondents using the modified questionnaire. before the actual interview, informed consent was secured. an explanation of the study's intent was conducted, and the study's duration was explained. those who could not read and write were assisted by their caregivers or the researchers to complete the questionnaire. data analysis the data gathered was tallied using microsoft excel. in analyzing the data, the study utilized the following statistical techniques: descriptive statistics were used to describe the population studied. simple frequency and percentage were utilized to determine sample characteristics in terms of age, gender, marital status, common illness, presence of chronic disease, and living style. mean scores were used to determine a. supremo et al. 224 | pissn: 1858-3598  eissn: 2502-5791 the level of attainment of social support of the older adults. ethical consideration before embarking on the study, the researchers sought ethics approval from the internal review panel. once the study was approved, the older adults t a b le 1 . s o ci a l s u p p o rt d u ri n g p e ri o d o f n o f lo o d a n d w it h f lo o d s o c ia l s u p p o r t n o f lo o d w it h f lo o d 5 4 3 2 1 mean description 5 4 3 2 1 mean description f % f % f % f % f % f % f % f % f % f % t h e re i s a sp e ci a l p e rs o n w h o is a ro u n d w h e n i a m i n n e e d . 7 6 6 0 3 6 2 9 1 2 1 0 2 2 0 0 4 .4 6 s tr o n g ly a g re e 7 2 5 7 3 9 3 1 1 4 1 1 1 1 0 0 4 .4 4 s tr o n g ly a g re e t h e re i s a sp e ci a l p e rs o n w it h w h o m i c a n sh a re m y jo y s a n d so rr o w s. 7 3 5 8 4 2 3 3 9 7 2 2 0 0 4 .4 8 s tr o n g ly a g re e 7 0 5 6 4 5 3 6 1 0 8 1 1 0 0 4 .4 6 s tr o n g ly a g re e i h a v e a sp e ci a l p e rs o n w h o is a r e a l so u rc e o f co m fo rt t o m e . 7 2 5 7 3 9 3 1 1 4 1 1 1 1 0 0 4 .4 4 s tr o n g ly a g re e 7 2 5 7 4 2 3 3 1 1 9 1 1 0 0 4 .4 7 s tr o n g ly a g re e t h e re i s a sp e ci a l p e rs o n i n m y li fe w h o ca re s a b o u t m y f e e li n g s. 6 5 5 2 4 3 3 4 1 8 1 4 0 0 0 0 4 .3 7 s tr o n g ly a g re e 6 4 5 1 4 7 3 7 1 5 1 2 0 0 0 0 4 .3 9 s tr o n g ly a g re e i ca n t a lk a b o u t m y p ro b le m s w it h m y fr ie n d s. 5 6 4 4 4 4 3 5 2 4 1 9 2 2 0 0 4 .2 2 s tr o n g ly a g re e 5 9 4 7 4 5 3 6 1 8 1 4 4 3 0 0 4 .2 6 s tr o n g ly a g re e o v e ra ll m e a n 4 .3 9 s tr o n g ly a g re e o v e ra ll m e a n 4 .4 0 s tr o n g ly a g re e jurnal ners http://e-journal.unair.ac.id/jners | 225 were given informed consent forms to read and sign. then, a thorough explanation of the purpose of the study took place prior to the actual interview. signing the informed consent form indicated that the participant wanted to join the study. however, the participants were reminded that they could withdraw at any time. the consent process was also used to determine willingness for continued participation in the research endeavor. issues of anonymity and confidentiality of data were also addressed throughout the study using the following measures: (1) replacement of names with pseudonyms and other identifying information to conceal the identity of the interviewee; (2) data was stored in a locked cabinet inside a secure room; (3) data in computers were secured with a password that only the researchers could access; and (4) files will be destroyed five years after the study. results the findings of the study revealed that during floods, most older adults had people who provided them with comfort, with a mean score of 4.47. similarly, the older adults answered that these people were the ones with whom they shared their joys and sorrows, garnering a score of 4.46, and were around them especially in times of need (with a mean score of 4.44). also, findings showed that there were special people in the older adults’ lives who cared about their feelings, with a mean score of 4.39. last, older adults responded very strongly that their friends were the ones they could talk to when they had problems, with 4.26 as the mean score. the answers of the older adults referring to times when there is no flood showed a slim variance with their answers when there is a flood. first, older adults responded that there were special people with whom they shared their joys and sorrows (mean score of 4.48). second, older adults considered these special people as the group of people who were around with them whenever they needed help (mean score of 4.46). third, older adults answered that they had special people who provided them with the comfort they needed (mean score of 4.44), and the same people were recognized by them as the ones who truly cared about their feelings (mean score of 4.37). last, older adults shared that they had friends to whom they could talk whenever they need good conversation (mean score of 4.22). generally, the overall findings of the study revealed a slight difference of the results on the level of attainment of social support for older adults both during floods (mean score of 4.40) and without floods (mean score of 4.39). generally, the findings of the study revealed a slight difference in the results on the level of attainment of the social support for older adults both during a flood (mean score of 4.40) and when there was no flood (mean score of 4.39). the above findings are presented in table 1. discussion 126 older adults participated in the research study. most of them were 65–74 years old, female (61.9%), widowed (47.62%), had chronic diseases (60.32%) such as hypertension and diabetes mellitus, and had common issues such as coughs and colds (63.49%). also, they tended to live with their spouses and offspring (41.27%). older adults in the study were surrounded by significant people who journeyed with them during the flooding in barangay poblacion, almeria, biliran. these people were their children, partners, family, and significant others who had been with them through ups and downs. the older adults considered these people as special people who were readily available for them (with a mean score of 4.44 with flood and 4.46 without flood). these individuals were those to whom the elderly could turn in times of flooding. according to hays (2015), filipinos deeply value their family and culture. they are very sociable and love to have good conversations with family and friends. the older adults genuinely felt they had someone who could share their joys and sorrows (with a mean score of 4.46 with flood and 4.48 without flood). this someone was a loved one, friend, relative, or significant other. they shared their happiness and sadness. filipinos are people who enjoy fun and still maintain good attitudes in the face of adversity. according to global affairs canada (2019), filipinos are sociable, friendly, good-natured, and hospitable. these traits are shown whenever they are at home or in their work environment. therefore, sharing joys and sorrows with friends is very common. they live in the present moment, rather than dwell on the past, and think of what might be in the future (hays, 2015). in addition, the majority of older adults strongly agreed that they had a special someone to give them comfort and ease (with a mean score of 4.47 with flood and 4.44 without flood). this same person tried to help them in times of need, especially during flooding. when facing the ultimate unknown, older adults also had another source of solace: religion and spirituality. according to llaneta (2018), there is a clear correlation between religion, spirituality, and health in the elderly. the anxiety faced by the elderly dissipates when they have faith to hold on to, to give them a sense of fulfillment and positive well-being. spirituality and religious involvement have been strongly associated with healthy productive aging, nutrition, fitness, mental stimulation, selfeffectiveness, and communal interaction. older adults also mentioned that these special persons truly cared about their emotions and feelings (with a mean score of 4.39 and with flood and 4.37). this finding shows an obvious increase in support received by older adults during flooding periods. this support will lessen the possible apprehension and depression that would be felt by elders who are more susceptible to the dangers caused by isolation. a. supremo et al. 226 | pissn: 1858-3598  eissn: 2502-5791 depression and suicidal tendencies are common among older adults (pejner et al., 2012). knowing that someone cares about their feelings relieves some of their emotional baggage. spouses, children, or friends are significant persons that help the elderly feel cared for and loved. that is why it is not uncommon to find older adults living with their children and families. last, older adults had trustworthy friends with whom they shared their problems (with a mean score of 4.26 with flood and 4.22). it was noticeably apparent that there was an increase of support received by the older adults whenever they needed someone to support them. their friends always lent a helping hand when things went wrong. they valued friendships and being useful. this means that in times of trouble or calamity, older adults can rely on their friends. according to global affairs canada (2019), filipinos are sociable in nature, which allows them to befriend almost anyone they meet. they are able to form groups that will back them up when faced with uncertainties. interim healthcare (2015) presents an important link between social interaction and senior individuals' health. filipinos believe that to feeling loved and needed or to have someone to speak to each day are crucial elements in living a healthy life. conclusion there is a noticeable slight increase in social support extended to older adults during a flood compared to when there is no flood. the special persons were untiring in providing physical, emotional, psychological, and spiritual support to older adults during this time. these forms of support were beneficial to maintaining the health and well-being of the older adults whether or not there was flooding. the policymakers should craft a plan of action to maintain social support for older adults, especially during flooding. references abraham, c. (2016). older people and power loss, floods, and storms: reducing risk, building resilience. 1–40. retrieved march 7, 2019, from https://www.ageuk.org.uk/globalassets/ageuk/documents/reports-andpublications/reports-and-briefings/activecommunities/rb_feb16_older_people_and_power_ loss_floods_and_storms.pdf benson, w. f. (2013). disaster planning tips for older adults and their families. cdc healthy aging program health benefits abcs, 00221-5. retrieved march 7, 2019, from https://disasterplaybook.org/wpcontent/uploads/2015/12/cdcs-disasterplanning-tips-for-older-adults.pdf cadag, j. r. d., petal, m., luna, e., gaillard, j. c., pambid, l., & santos, g. v. (2017). hidden disasters: recurrent flooding impacts on educational continuity in the philippines. international journal of disaster risk reduction, 25, 72–81. doi:10.1016/j.ijdrr.2017.07.016 dyer, c. (2006). recommendations for best practices in the management of elderly disaster victims. baylor college of medicine. retrieved march 7, 2019, from https://assets.aarp.org/www.aarp.org_/articles/ aboutaarp/baylor_best_practices_guide.pdf fernandez, c. j., stoeckl, n., & welters, r. (2019). the cost of doing nothing in the face of climate change: a case study, using the life satisfaction approach to value the tangible and intangible costs of flooding in the philippines. climate and development, 11(9), 825–838. doi:10.1080/17565529.2019.1579697 gilbuena jr. r., a. kawamura, r. medina, h. amaguchi, & n. nakagawa. gap analysis of the flood management system in metro manila, philippines: a case study of the aftermath of typhoon ondoy, in proceedings of the 5th international conference on flood management – floods: from risk to opportunity, international association of hydrological science publication no. 357, pp. 32– 40. retrieved from https://www.researchgate.net/profile/akira_ka wamura/publication/283820205_gap_analysis_o f_the_flood_management_system_in_metro_manil a_philippines_a_case_study_of_the_aftermath_of_ typhoon_ondoy/links/577c5ad508aec3b743367 202/gap-analysis-of-the-flood-managementsystem-in-metro-manila-philippines-a-casestudy-of-the-aftermath-of-typhoon-ondoy.pdf global affairs canada. (2019, january 17). philippines: cultural information. retrieved march 7, 2019, from www.international.gc.ca: https://www.international.gc.ca/cilcai/country_insights-apercus_pays/ciic_ph.aspx?lang=eng hays, j. (2015, june). filipino character and personality: hiya, amor propio, emotions and the influences of catholicism, asia and spain. retrieved march 7, 2019 from http://factsanddetails.com/southeastasia/philippines/sub5_6c/entry-3867.html intergovernmental panel on climate change (2014). climate change 2014: synthesis report. contribution of working groups i, ii and iii to the fifth assessment report of the intergovernmental panel on climate change. core writing team, r.k. pachauri and l.a. meyer (eds.). geneva, switzerland: intergovernmental panel on climate change. interim healthcare. (2015, january 19). social seniors the importance of friendship. retrieved march 7, 2019, from interimhealthcare.com: https://www.interimhealthcare.com/lincoln/blo jurnal ners http://e-journal.unair.ac.id/jners | 227 g/january-2015/social-seniors-the-importanceof-friendship/ llaneta, c. a. (2018, january 8). from final endings to new beginnings. retrieved march 7, 2019, from university of the philippines: https://www.up.edu.ph/index.php/from-finalendings-to-new-beginnings/ orimo, h., ito, h., suzuki, t., araki, a., hosoi, t., & sawabe, m. (2006). reviewing the definition of elderly. geriatrics and gerontology international, 6, 149–158. doi:10.1111/j.14470594.2006.00341.x pejner, m. n., ziegert, k., & kihlgren, a. (2012). trying to cope with everyday life—emotional support in municipal elderly care setting. international journal of qualitative studies on health and wellbeing, 7(1), 19613. doi: 10.3402/qhw.v7i0.19613 santos, e. p. (2016). philippines among world's most disaster-prone countries. retrieved june 18, 2018, from http://cnnphilippines.com/news/2015/11/25/p hilippines-fourth-most-disaster-pronecountry.html world health organization (2008). older persons in emergencies: an active ageing perspective. 1–49. retrieved march 7, 2019, from https://www.who.int/ageing/publications/emer genciesenglish13august.pdf?ua=1 wu, j., xiao, j., li, t., li, x., sun, h., chow, e. p., ... & zhuang, x. (2015). a cross-sectional survey on the health status and the health-related quality of life of the elderly after flood disaster in bazhong city, sichuan, china. bmc public health, 15(1), 163. doi: 10.1186/s12889-015-1402-5. zimet, g., dahlem, n. w., zimet, s. g., & farley, g. k. (1988). the multidimensional scale of perceived social support. journal of personality assessment, 52(1), 30–41. doi:10.1207/s15327752jpa5201_2 http://e-journal.unair.ac.id/jners | 149 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).1419 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research lived experience of people living with hiv/aids undergoing antiretroviral therapy: a qualitative study rts netisa martawinarti, nursalam nursalam, andri setiya wahyudi faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: antiretroviral therapy is an important factor in improving the quality of life of hiv sufferers, but a complex problem in hiv sufferers is a trigger factor for non-compliance in undergoing arv therapy. the purpose of this study was to explore the experience of people living with hiv/aids (plwha) undergoing antiretroviral treatment. methods: this study was a qualitative phenomenological study, with a sample of 13 hiv patients (10 men and 3 women) who were taking antiretroviral therapy for more than one year; they were recruited using purposive sampling techniques, and data were collected through in-depth semi-structured interviews, field notes and document reviews. data were analyzed using the colaizzi method which consists of nine stages. results: there were six themes that emerged from the experience of plwha undergoing antiretroviral therapy and these became the subject of this study, namely knowledge of hiv disease and antiretroviral drugs, self-motivation, social support, and skills in undergoing treatment (selfmanagement), adherence, and quality of life. conclusion: of the six themes that emerged, poor knowledge (understanding of the disease and its treatment), social support and selfmanagement were the main factors that were obstacles to and causes of treatment failure; this was due to the unpreparedness for receiving information at the beginning of treatment, lack of motivation, and ignorance in behavior when people had problems with medication. article history received: feb 27, 2020 accepted: april 1, 2020 keywords adherence; plwha; experience; antiretroviral contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: martawinarti, r. n., nursalam, n., & wahyudi, i, d. (2020). lived experience of people living with hiv/aids undergoing antiretroviral therapy: a qualitative study. jurnal ners, special issues, 149-155. doi:http://dx.doi.org/10.20473/jn.v15i2(si).1419 introduction hiv patients' adherence to antiretroviral therapy (arv) is an important mechanism for preventing hiv transmission (zulliger, barrington, donastorg, perez, & kerrigan, 2015),but people living with hiv/aids (plwha) often disappear during the course of hiv treatment. various precipitating factors cause nonadherence to antiretroviral therapy, but the main factors of non-compliance until now have not yet been known with certainty. indonesia has been conducting free treatment for plwha since 2004, and various counseling has been conducted to improve hiv patient adherence to arvs, but non-compliance with arvs is still a problem in indonesia. this is evidenced by the lost follow up (lfu) rates for arv care and therapy which are quite high at 21.87% (kementerian kesehatan ri, 2018). non-compliance with treatment is a major factor in treatment failure in plwha. the effect of non-compliance can affect the quality of life of people with hiv because it will cause resistance and disease progression to death (capetti & rizzardini, 2019). decreased quality of life that occurs in hiv patients is not only caused by compliance but also due to illness and depression (mwesiga et al., 2015). plwha are increasing every year; currently more than 36.9 million people worldwide suffer from hiv and indonesia is one of the asian countries with a rapidly growing rate of human immuno-deficiency virus (hiv) infection (unaids, 2018). east java occupies the first position in indonesia with the highest incidence of hiv in 2017 followed by jakarta https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nursalam@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2(si). r. n. martawinarti et al. 150 | pissn: 1858-3598  eissn: 2502-5791 and central java (kementerian kesehatan ri, 2018). according to a report on hiv care and antiretroviral therapy in 2017, there were around 214,819 people who were eligible for arvs, but only 180,843 people had received arvs. out of 180,843 people who had received arv therapy 39,542 people (21.87%) had been lost to follow-up (21.87%) lfu) and 3,501 (1.93%) stopped taking arv. antiretroviral therapy (art) is a very important factor for improving the quality of life of plwha; complex problems that occur in plwha are a trigger for non-compliance in undergoing arv therapy (lindayani, chen, wang, & ko, 2018). quality of life is a multi-dimensional and dynamic concept, which reflects the non-biomedical perspective of hiv treatment, combining important subjective assessments on various aspects of individual wellbeing, including physical, functional, social, emotional and even spiritual well-being (tomita et al., 2014). the experience of plwha during art treatment changes over time. plwha stated that support from health workers or others greatly affected their adherence to art (hendrickson et al., 2019). social care, the home environment, finances, freedom, and opportunities to obtain information related to arv treatment get the lowest score that adversely affects the quality of life of plwha (ndubuka, lim, ehlers, & van der wal, 2017). subjective support and the use of social support and knowledge are very influential in improving the quality of life of plwha (liu, qu, zhu, & hu, 2015), research (lan et al., 2015)states that low social support has reduced the quality of life of plwha. counseling is also one way to improve adherence to arvs and the quality of life of plwha. the information has an important role in plwha in undergoing lifelong hiv care, but information alone is not enough to make plwha have good compliance and good quality of life. according to (nelson et al., 2018)adherence in undergoing art treatment is determined by three factors namely: information, motivation and behavioral skills. if there are obstacles in one of these components, it can reduce the possibility of behavior that is compliant or consistent with treatment. the information in question is an understanding of the disease, the use of drugs and drug reactions; motivation includes self motivation and social support. motivation is needed in art treatment adherence; without motivation art treatment cannot be continued (nursalam, k, misutarno, & s, 2018). behavioral skills in creating good adherence are seen from the ability to obtain drugs, take medication regularly and the ability to cope with or minimize the side effects of drugs that are uncomfortable in the body. previous research has discussed the experience of hiv sufferers in undergoing treatment extensively, but a specifically discussion of behavioral skills based on the information theory of motivational behavioral skills (imb) has never been undertaken before, so in this study more discussed about behavioral skills to still be able to maintain adherence and improve quality of life for the better. this study aims to describe what experiences hiv sufferers face during their art treatment using a qualitative research method with a phenomenological approach. identified factors are expected to be input and learning for health workers in providing appropriate nursing care materials and methods research design this research was qualitative based on an interpretive phenomenological approach. the design was used to answer the research objectives in obtaining the meaning of the experience of the research subjects while undergoing antiretroviral therapy. participants and recuitment the population is plwha at sidoarjo hospital, indonesia. this study involved 13 plwha as participants obtained using a purposive sampling technique. the inclusion criteria were plwha who had taken art for more than one year, were over 20 years old, were cooperative, and were not pregnant women. participants were recruited based on ethical principles. participants involved in previous studies have received written explanations regarding the research objectives, procedures, rights and obligations, benefits and losses during the study. only participants who have given informed consent are involved in this research. this research obtained ethical approval from the ethical committee of sidoarjo hospital, approval number 893.3 / 0059 / 438.6.7/2020 data collection and analysis before starting the data collection, the researchers framed interview guidelines and tried out three participants to validate questions. data were collected through in-depth interviews using semistructured interview guides and completed with field notes formal interviews were conducted with participants and took 20-40 min for each participant. the interview started with these questions: "how was your experience while on antiretroviral treatment?", "try to tell me your health condition in the past year?", "what is your attitude when given an explanation by health workers regarding lifelong hiv treatment?", and covered "treatment-related information", "personal motivation barriers", "social motivation barriers", and "behavioral skills barriers". questions were open-ended and interviews were recorded by a voice recorder. the interview process was carried out until no new data were found. interview results were written up as verbatim transcripts and this was done after each interview was completed with one participant. regular discussion between the three researchers was conducted to integrate the research findings. jurnal ners http://e-journal.unair.ac.id/jners | 151 risk factors for family resilience were analyzed and interpreted using analytic analysis according to collaizi consisting of nine steps. the analysis included: 1) describing phenomena to be studied; 2) collecting descriptions of phenomena through participants' opinions; 3) reading the entire description of phenomena submitted by participants; 4) re-reading interview transcripts and citing meaningful statements; 5) making outlines of meaningful statements; 6) organizing collections of meanings formulated into groups of themes; 7) writing complete descriptions; 8) meeting participants to validate the compiled descriptions; and 9) incorporating validation results data into full descriptions. data collection was conducted simultaneously with the data analysis process until data saturation occurred. demographic data were described and presented in the table of participants’ characteristics. results demographic data descriptive statistics of the characteristics of participants are shown in table 1. this study included 13 plwha who were taking art (3 females and 10 males), aged within the range of 22-51 years. the educational level of participants varied from elementary school to university. the majority of participants (11 people) were working, as civil servants, self-employed, traders, security, and a driver, while two people were not working. most of the participants tok the fixed dose combination (fdc) of antiretroviral drugs (9 people), 2 people were duviral-neviral and 1 person was tle. the average duration of drug consumption was between two and five years, and one person had been taking them for 13 years. overview of undergoing art treatment process six themes are extraced from the experience of plwha regarding the process of undergoing art treatment. the themes were knowledge, selfmotivation, social support, behavioral skills, adherence, and quality of life (table 2). the details of each theme are described. knowledge the theme of knowledge in this study includes the understanding of plwha related to the disease and its treatment. this knowledge theme was identified through sub-themes : 1) health education, 2) information providers, and patient experience. participants were given information related to how to take medicine, that it must be taken on time and routinely for a lifetime. sometimes participants were still often too late to take medicine, and there were those who already felt healthy who stopped taking medicine. there were participants who stated that they did not really understand the drugs and their effects if they stopped, those who did not understand the reasons when given information related to the disease and the medicine who were not in a mental condition of readiness, so they could not understand the explanation given very well. initially uncomfortable drug reactions in the body sometimes become an inhibiting factor for taking medication on time. the following is a participant quote : “i was first informed when i started taking art, but i didn't really understand at the time because i still didn't accept my condition at that time”(p13) self-motivation self-motivation is the support of yourself to be able to do the best thing. this theme was identified through the sub-themes: 1) perceived effects, 2) loved ones. the first effects felt by the participants when taking medication were mostly dizziness, nauseous, and weakness, but these were only temporary; the effect disappeared by itself. the participants who felt healthier after taking medicine regularly became convinced that the medicine they took had good benefits for them. children, wives or parents also were a separate motivation for plwha, in terms of wanting to be happy and wanting to see children grow up well; this was one of the reasons for plwha routinely taking medicine regularly. table 1 characteristics of participants no n gender age(year) antiretroviral(year) occupation education 1 p1 male 42 4 self-employment senior high 2 p2 male 41 13 self-employment senior high 3 p3 male 34 5 civil-government senior high 4 p4 male 30 5 self-employment university 5 p5 female 29 2 no work senior high 6 p6 male 31 5 security senior high 7 p7 male 47 2 trader junior high 8 p8 male 30 5 driver senior high 9 p9 male 50 5 self-employment senior high 10 p10 male 30 5 self-employment senior high 11 p11 male 27 2 self-employment senior high 12 p12 female 51 4 no work senior high 13 p13 female 49 5 self-employment elementary r. n. martawinarti et al. 152 | pissn: 1858-3598  eissn: 2502-5791 social support social support is the support obtained by participants in undergoing treatment. this theme was identified through sub-themes, namely: 1) family, and 2) peers. participants get support from the family in the form of instrumental support, which is accompanied by assistance in taking drugs every month; if the participants cannot take them themselves, the family helps monitor participants in terms of taking medicine and whether they have taken their medicine according to the dose and time. in terms of informational support, the family reminds them when to take the medicine. another form of social support is the support of peers; their fellow plwha have an organization where they remember each other when taking drugs from each other. table 2. identification of the description of the process of undergoing art for plwha theme sub-theme significant statement knowledge health education how to take medicine drug reaction information provider health workers media plwha companion ‘don't be late ... and at the same time …if the medicine comes out then i have to take more medicine until the medicine comes in ...’ (p2) (p5) (p10) ‘i am dizzy when i woke up .... i felt i lost concentration’ (p7) (p8) ‘first i was given an arv drug i was given an explanation by the nurse ... doctor ...’ (p5) (p9) (p13) ‘i got that information only verbally ...’ (p8) (p9) (p13) ‘from companion odha’ (p7) (p10) self-motivation effects that are felt people who loved ‘after taking medicine regularly i never drop ... i want to be healthy ... i used to be very weak ...’ (p1) (p9) ‘i have 1 cd4 left ... and i have been hospitalized for a long time ... after my cd4 art consumption has increased ...’ (p2) ‘my child is still small…need money ... i want to see my child grow up ...’ (p7) (p2) ‘i want to be healthy so i can help my parents ... i want to get married ...’ (p10) (p6) social support family instrumental support information support fellow hiv patients ‘if i don't have time to take medicine ... i am assisted by my family to get the medicine ... i was taken by my husband or driver ...’ (p9) (p2) ‘i have in a pillbox so that it's easy to remember taking medication’ (p5) ‘my child always reminds me, don't forget to take medicine when you have a little ...’ (p2) (p9) ' i get a solution from a fellow hiv friend to help solve my problem … i am reminded by my friend to take medicine’ (p10) (p2). disease management skills efforts to minimize side effects efforts to obtain drugs efforts to take medicine according to rules ‘‘i always eat before taking medicine so i don't feel sick, i also eat dry bread to avoid nausea when taking medicine ... if i get dizzy, i immediately go to sleep’ (p5) (p13) ‘i was always dizzy when i woke up ... and it bothers me to work ... i used to drink at 9 p.m.’(p7) ‘i always ask once for permission to take medicine ... replace with my fellow plwha to take medicine ...’ (p10) (p9) ‘i always take medicine when i get a day off’ (p6). ‘use a mobile alarm... carry medicine wherever i go ...’ (p3) (p8) ‘i take it every night when i go to sleep’ (p10) adherence motivation personal health officer information social (family and peers) behavior ‘i have seen people who often drop because they are not compliant to take art ... and i don't want to be like that’ (p9) ‘i must be healthy and live longer for my children and family’ (p2) ‘the nurse said that she should take the medication routinely and regularly, if not later the medicine will be resistant ...’ (p4) ‘if you don't obey, you will easily get the disease ... later you will get oi, so ... i just obey, i don't want to add disease’ (p11) ‘my mother always calls the phone every time she has taken medicine or not’ (p4) ‘i joined an odha organization ... there i got a lot of knowledge about my illness ... and many gave me motivation to stay motivated’ (p10) ‘i was nauseous and wanted to vomit after a while taking medicine ... then i tried eating before taking medicine ... and eating dry bread after taking medicine’ (p5) ‘wherever i go, i always carry my medicines ..., i put my medicine in a small place’ (p11) (p12) quality of life physical health aspects psychological aspects ‘before going to bed i take art medicine ... but every morning when i take art medicine at night i feel weak and have difficulty waking up’ (p3) ‘after a while i take art medication i feel dizzy ... when i get dizzy i can only lie down, can't go anywhere’ (p13) ‘for a year ... i have experienced loss of concentration after taking art medicine’ (p8) ‘in the beginning i took medicine ... i experienced nausea, vomiting, i once thought ... why after taking medicine my appetite was reduced’ (p5) jurnal ners http://e-journal.unair.ac.id/jners | 153 disease management skill disease management skills are the ability of individuals to be able to maintain a routine in order to remain well-implemented. in this study some participants already had good skills to manage medication times and to be on time, but there were also participants who had not been able to perform good skills, leading to carelessness in the consumption of art. the identified sub-theme was the management of taking art drugs. this covered t way or process of taking medication or obtaining medication carried out by participants. this subtheme consisted of three categories: 1) efforts to minimize side effects, 2) efforts to obtain drugs, and 3) efforts to take medication according to the rules. one good effort made by hiv sufferers in minimizing side effects and timely taking of medication is shown below: ‘i used to get dizzy when i woke up and it disturbed me to work, i used to drink at 9 pm but i advanced so at 7 pm so i didn't get dizzy when i woke up, now i rarely experience dizziness when i wake up’ (p7) ‘i always use an alarm to help remind me to take medicine and carry medicine wherever i go’ (p3)(p8) adherence this theme explains the participants' adherence to regular and timely medication and doses. two subthemes were identified namely: motivation and behavior. motivation for adherence were obtained from personal, information provided by health workers, and motivation from family or friends with plwha. from personal obedience for fear of seeing the condition of other plwha who are not compliant experiencing opportunistic infections, and because of a loved family. information from health workers also influences the adherence of hiv sufferers to take art drugs; explanations from health workers related to the benefits and impacts of being compliant and not compliant in undergoing art treatment are one of the reasons for participants' compliance in taking art medication. ‘health workers said… that taking medicine regularly and must be on time. if they are not obedient, they will easily get the disease, then they will get opportunistic infections, so i will only obey, i don't want to add disease’ (p4), (p11) quality of life quality of life in plwh is usually associated with adherence with taking art. this theme explains the perceptions of participants in terms of living their life. the sub-themes identified were in two categories, namely: 1) physical health aspects, and 2) psychological aspects. aspects of physical health were in the form of physical activity. plwha usually already know the limits of their ability to carry out activities, and what are the impacts that will affect their activities. there was a psychological health affect from the aspect of physical health. the following statement came from the participants: the authors in this study found six themes that emerged, namely: knowledge, self-motivation, social support, disease management, compliance and quality of life. the results of the assessment of researchers in the six themes show that there are themes that are interconnected and influence each other. the themes that were considered to be mutually influencing were: compliance and quality of life. the themes considered influencing him are self motivation, social support and disease management. based on the experience of plwha, the theme affects the compliance and quality of life of plwha. this study has also supported academic faculties and other researchers to continue to make appropriate and effective interventions to improve adherence and quality of life for plwha, as well as to identify the factors that influence them. this study is just a first step into studying and observing phenomena that occur and are experienced by plwha during antiretroviral therapy. discussion this study involved plwha with various backgrounds, ranging from contracting hiv/aids through needles to sexual relations (homosexual, heterosexual, bisexual) and from different economic backgrounds from middle to lower. the results of this study indicate that various experiences are experienced by plwha during their hiv care or when undergoing art therapy. in several studies that have been carried out it has been stated that the reasons for non-compliance with arvs are due to forgetfulness, careless use of arvs and due to side effects (sianturi, perwitasari, islam, & taxis, 2019). in this study, besides being careless, forgetting and drug side effects, a reason for participants' non-compliance with art was because they felt they were healthy, and they didn’t feel any symptoms. transportation was also a reason participants were not compliant in undergoing treatment. the unwillingness of participants to disclose their illnesses to families can also be a barrier in undergoing art therapy, in plwha who have not revealed the status of the disease to family or friends; this can be an obstacle when they want to take medication, and they choose to delay taking medication. provision of misinformation about how to take arv drugs and wrong perceptions of improving health can affect patients’ compliance with arv consumption (mckinney, modeste, lee, gleason, & maynard-tucker, 2014).in this study, the reasons for non-compliance were found because of lack of clear information from health workers, or the fact that were not ready to receive information. participants said they got a lot of hiv-related information from plwha companions. alarms were considered an effective tool to remind them to take medicine on time. previous research suggests that clocks and r. n. martawinarti et al. 154 | pissn: 1858-3598  eissn: 2502-5791 cellphones are seen as a contributing factor to help plwha remember to take medication on time (neupane, dhungana, & ghimire, 2019). plwha who have good behavior skills have relevant information and sufficient motivation to make them compliant in taking arv drugs (horvath, smolenski, & amico, 2014). it needs to be clearly and repeatedly stated to people with hiv / aids (plwh), that art must be consumed for life and must be taken whether they are well or healthy, especially in those newly diagnosed with hiv. social support is very influential for improving quality of life especially for older and married people (liu et al., 2015). barriers to the quality of life of plwha lead to helplessness, where individuals are socially / emotionally hampered and lack support related to more severe symptoms due to hiv (jesus1 et al., 2017). in participants who had their partners’ support and reminded one another to take medication and in patients whose parents knew that they had hiv, they had the support to always take medication on time by being reminded when they have to take medication and scheduling for control. while those whose family did not know they had hiv received full support from their companions. participants stated that the support they received from their family and companions was very meaningful to them and became their own motivation to remain adherent to art therapy. research was conducted from november 2019 to january 2020 and found much non-compliance due to lack of knowledge, lack of disease management skills while undergoing art therapy and impact on quality of life. there are studies that indicate that behavioral skills directly influence the adherence to taking art drugs in plhiv (horvath et al., 2014).. it was also found that the problem most often experienced by plwha after taking art was insomnia; participants complained of difficulty sleeping after they took the drug. hiv sufferers (lindayani et al., 2018). selfmotivation and social support greatly influence the adherence to art therapy and quality of life in plwha. more research needs to be done to increase knowledge, self-motivation or social and disease management behavior skills to be able to improve adherence and quality of life in plwha. conclusion knowledge or understanding of the disease and its treatment are considered to be very influential for patient adherence to art treatment. providing clear information and at the right time affects the receipt of information positively. self motivation in the form of effects or benefits that are felt after consuming drugs and loved ones become the driving force for plwha to be routine and adhere to treatment. social support for plwha is only obtained from those closest to them and their peers, because the patient's unpreparedness to disclose their status means only a few people know about the disease. behavioral skills are needed to be able to maintain compliance and improve quality of life for the better. compliance and quality of life are interrelated; if adherence to drugs is good, quality of life will be good too, but the most important factor of adherence or a good quality of life depends on behavioral skills in undergoing treatment. there is a need for a good understanding of behavioral skills to support compliance and a better quality of life. conflict of interest no conflict of interest has been declared. acknowledgement the authors of this study would like to thank the faculty of nursing and also the master’s in nursing study program for providing the opportunity to present this study, to study participants who have been willing to give their time, and hospitals that provided a place for the researchers to complete this research. references capetti, a., & rizzardini, g. (2019). expert opinion on pharmacotherapy choosing appropriate pharmacotherapy for drugresistant hiv. expert opinion on pharmacotherapy, 00(00), 1–12. https://doi.org/10.1080/14656566.2019.15701 31 hendrickson, c., moolla, a., maskew, m., long, l., fox, m. p., sanne, i., … pascoe, s. (2019). “ even if you ’ re hiv-positive there ’ s life after if you take your medication ”: experiences of people on long-term art in south africa : a short report. aids care, 0(0), 1–6. https://doi.org/10.1080/09540121.2019.15979 60 horvath, k. j., smolenski, d., & amico, k. r. (2014). aids care : psychological and socio-medical aspects of aids / hiv an empirical test of the information-motivationbehavioral skills model of art adherence in a sample of hiv-positive persons primarily in out-of-hiv-care settings. (march 2015), 37–41. https://doi.org/10.1080/09540121.2013.80228 3 jesus1, g. j. de, oliveira1, l. b. de, caliari1, j. de s., queiroz1, a. a. f. l., gir1, e., & reis1, r. k. (2017). dificuldades do viver com hiv / aids : entraves na qualidade de vida difficulties of living with hiv / aids : obstacles to quality of life. 30(3), 301–307. kementerian kesehatan ri. (2018). perkembangan hiv/aids dan infeksi menular (ims) triwulan iv tahun 2017. jakarta: kementerian kesehatan ri. lan, g., yuan, z., cook, a., xu, q., jiang, h., zheng, h., & wang, l. (2015). the relationships among social support and quality of life in persons living with hiv / aids in jiangxi and zhejiang provinces , china. 27(8), 946–953. lindayani, l., chen, y. c., wang, j. der, & ko, n. y. (2018). complex problems, care demands, and jurnal ners http://e-journal.unair.ac.id/jners | 155 quality of life among people living with hiv in the antiretroviral era in indonesia. journal of the association of nurses in aids care, 29(2), 300– 309. https://doi.org/10.1016/j.jana.2017.10.002 liu, j., qu, b., zhu, y., & hu, b. (2015). the influence of social support on quality of life of men who have sex with men in china : a preliminary study. 1–10. https://doi.org/10.1371/journal.pone.0127644 mckinney, o., modeste, n. n., lee, j. w., gleason, p. c., & maynard-tucker, g. (2014). determinants of antiretroviral therapy adherence among women in southern malawi : healthcare providers ’ perspectives. 2014. mwesiga, e. k., mugenyi, l., nakasujja, n., moore, s., kaddumukasa, m., & sajatovic, m. (2015). depression with pain co morbidity effect on quality of life among hiv positive patients in uganda : a cross sectional study. health and quality of life outcomes, 1–9. https://doi.org/10.1186/s12955-015-0403-5 ndubuka, n. o., lim, h. j., ehlers, v. j., & van der wal, d. m. (2017). health-related quality of life of patients on antiretroviral treatment in botswana: a cross-sectional study. palliative and supportive care, 15(2), 214–222. https://doi.org/10.1017/s1478951516000638 nelson, l. a., wallston, k. a., kripalani, s., lestourgeon, l. m., williamson, s. e., & mayberry, l. s. (2018). assessing barriers to diabetes medication adherence using the informationmotivationbehavioral skills model. diabetes research and clinical practice, 142, 374–384. https://doi.org/10.1016/j.diabres.2018.05.046 neupane, s., dhungana, g. p., & ghimire, h. c. (2019). adherence to antiretroviral treatment and associated factors among people living with hiv and aids in chitwan , nepal. 1–9. nursalam, k, n. d., misutarno, & s, f. k. (2018). asuhan keperawatan pada pasien terinfeksi hiv/aids (2nd ed.; p. p. lestari & t. utami, eds.). jakarta: salemba medika. sianturi, e. i., perwitasari, d. a., islam, a., & taxis, k. (2019). the association between ethnicity , stigma , beliefs about medicines and adherence in people living with hiv in a rural area in indonesia. 1–8. tomita, a., garrett, n., werner, l., burns, j. k., mpanza, l., mlisana, k., … karim, s. s. a. (2014). healthrelated quality of life dynamics of hiv-positive south african women up to art initiation: evidence from the caprisa 002 acute infection cohort study. aids and behavior, 18(6), 1114– 1123. https://doi.org/10.1007/s10461-0130682-y unaids. (2018). statistik hiv/aids. zulliger, r., barrington, c., donastorg, y., perez, m., & kerrigan, d. (2015). high drop-off along the hiv care continuum and art interruption among female sex workers in the dominican republic. 69(2), 216–222. http://e-journal.unair.ac.id/jners | 91 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.19444 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effectiveness of chewing gum versus cryotherapy on salivary volume among patient with head and neck cancer undergoing radiotherapy dwi uswatun sholikhah, i ketut sudiana, and ninuk dian kurniawati faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: hyposalivation is a common problem experienced by head and neck (h&n) cancer patients undergoing radiotherapy. hyposalivation can cause negative effects on the physical aspects of making oral mucositis, pain during eating and talking as well as psychological effects that cause feeling of discomfort sadness and, ultimately, depression. many nonpharmacological interventions can be done for hyposalivation that occur in patients, among which are chewing gum and cryotherapy because they are easy to do, easy to access, inexpensive and have minimal side effects. however, the effectiveness of these interventions is not yet clear. hence, this study is aimed to determine the effectiveness of chewing gum versus cryotherapy to increase salivary volume in h&n cancer patients undergoing radiotherapy. methods: a quasi-experimental time series group design to determine the most effective time to influence the increase in salivary volume. this research was conducted on 36 respondents h&n cancer undergoing radiotherapy with four times measurement are pretest-posttest on the 3rd, 5th, and 7th day of intervention between february and march 2020. subjects were chosen using consecutive sampling. chewing gum group will chew gum six (6) pieces/day and cryotherapy group will suck on ice cubes five (5) minutes before and after radiotherapy. the spitting method was used to collect saliva and the data were analyzed using general linear model-repeated measure (glmrm). results: chewing gum is more effective to increase salivary volume than cryotherapy. the glmrm within subjects at four (4) times measurement showed a significant difference between chewing gum and cryotherapy group with p value <0.05 on the 7th day. subjects in the chewing gum group had better salivary volume increment than cryotherapy group. conclusion: this study showed that chewing gum is more effective to increase salivary volume on patient h&n cancer undergoing radiotherapy because chewing gum has higher salivary volume increment than cryotherapy groups. article history received: may 27, 2020 accepted: june 15, 2020 keywords chewing gum; cryotherapy; salivary volume; radiotherapy contact ninuk dian kurniawati  ninuk.dk@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sholikhah, d, u., sudiana, i, k., & kurniawati, n, d. (2020). the effectiveness of chewing gum versus cryotherapy on salivary volume among patient with head and neck cancer undergoing radiotherapy. jurnal ners, 15(1). doi:http://dx.doi.org/10.20473/jn.v15i1.19444 introduction head and neck cancer is a tumor that arises in the nasal cavity, mouth. oropharynx, nasopharynx, salivary glands, paranasal sinuses, hypopharynx, and larynx (nih. 2019). radiotherapy is one of the three most common treatments for head and neck cancer and requires discipline and a long time (laursen et al., 2018). radiotherapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep cancer cells from growing (nih, 2019). the safe dose of the parotid gland is 26gy, the safe dose of the submandibular gland is 39gy and a 30gy dose for minor salivary glands remains safe (siddiqui & movsas, 2017). radiotherapy doses of 60-70gy can cause prolonged and severe problems in the mouth (villa & sonis, 2015). radiotherapy can shrink and kill tumor cells (santoso,surarso, & kentjono, 2009). but it has the most frequent side effects experienced by patients, namely hyposalivation, thickened saliva, mucosal infections, pain and taste sensory dysfunction (epstein et al., 2017). epstein et al. (2017) state radiation can cause problems in the mouth. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ninuk.dk@fkp.unair.ac.id d. u. sholikhah, et al 92 | pissn: 1858-3598  eissn: 2502-5791 hyposalivation is a common problem experienced by head and neck cancer patients undergoing radiotherapy (siddiqui & movsas, 2017). the incidence of hyposalivation due to radiation was 87.5% -100% experienced by patients undergoing radiotherapy of the head neck area (marinna & harijanti, 2017;(surjadi & amtha, 2012). continuous exposure to radiation and cytotoxic agents have several direct effects on the oral epithelium that can cause damage to the salivary gland duct cells and cause hyposalivation (eghbali, aziz, taherkhanch, & bagheri, 2017). hyposalivation is defined if salivary flow without stimulation is ≤0.2ml / min (kaae, stenfeldt, & eriksen, 2016). the volume of saliva produced per day ranges between 0.5 and 1.0l in normal physiological conditions, and the physiological ph range for saliva is 6.5–7.4 (simões, campos, arana-chavez, & nicolau, 2015). resting saliva flow rate (volume of saliva/collection time) is of 0.1ml/min or less and/or a stimulated whole saliva flow rate of 0.7ml/min or less (ra’abung, sudiana, & hidayati,2019). saliva has decreased production in patients undergoing radiotherapy compared to normal people (irna & subita, 2008; surjadi & amtha, 2012). hyposalivation could cause negative effects on the physical aspects of making oral mucositis, pain during eating and talking, papilla loss on chapped tongue and lips (plemons et al., 2014) as well as psychological effects causing feelings of discomfort, sadness, and, eventually, depression (traktama & sufiawati, 2018). hyposaliva management in saiful anwar malang hospital advises to drink sufficient water and clean the mouth, but hyposalivation is still often experienced to become oral mucositis. based on observations and interviews with head and neck cancer patients undergoing radiotherapy, there are patients who drink only a little because of pain when swallowing, so that intervention is needed that can stimulate the salivary gland without swallowing. several methods can be done to reduce the severity of hyposaliva, one of which is by stimulating the salivary glands to keep producing saliva. some methods used to reduce hyposaliva are chewing gum, sucking ice cubes, increasing the consumption of mineral water and cleaning the mouth (marinna & harijanti, 2017). research (kaae et al., 2016) shows that chewing gum can stimulate saliva output that is seen at the beginning and at the end of an intervention. findings by epstein et al. (2017) show that cryotherapy can stimulated saliva. previous research have carried out many studies of chewing gum or cryotherapy in patients undergoing chemotherapy (didem, ayfer, & ferda, 2014; utami & hayati, 2018). given the importance of the role of saliva and the consequences arising from hyposalivation, it is necessary for nurses to help increasing salivary volume in head and neck cancer patients undergoing radiotherapy. chewing gum and cryotherapy are easy, inexpensive, safe interventions done by patients to increase the volume of saliva and oral mucositis (utami & hayati, 2018). the use of cold therapy can make patients feel cold and toothache so that it requires criteria. teeth in a healthy condition (no history of sensitive teeth) (katranc et al., 2012) and strong flavors, such as peppermint or lemon, are not favored in the early phase of recovery; effects can be minimized by choosing flavors of xylitol gum such as blueberries and strawberries, but its effectiveness is unclear. nurses play an important role in helping patients protect and maintain their oral health. this study aimed was to determine the effectiveness of chewing gum versus cryotherapy to increase the volume of saliva in head and neck cancer patients undergoing radiotherapy. materials and methods this research was a quasi-experimental time series group design to determine the most effective time to influence the increase in salivary volume. this study involved 36 respondents who were divided into chewing gum groups and cryotherapy groups (18/18) obtained by consecutive sampling. respondents were taken based on inclusion criteria to reduce the effects of bias. the inclusion criteria in this study were: 1) patients having mucositis oral undergoing radiotherapy head and neck cancer; 2) type squamous cell carcinoma because it is the most common type of cancer; 3) patients can chew gum or suck ice cubes, confirmed with interviews. meanwhile, the exclusion criteria in this study are: 1) patients having sensitive tooth to minimize pain when sucking ice cubes; 2) patients having diabetes mellitus. the drop out criteria in this study include the patient dies and the patient not completing the therapy process. data collection was carried out at radiotherapy installation saiful anwar hospital malang between february 2020 and march 2020. the dependent variable was salivary volume and the independent variable was chewing gum and cryotherapy. researchers prepared equipment such as xylitol gum, ice cube, measuring cup, mask, gloves, stationery, 3cc syringe, cellphone stopwatch, observation sheet and informed consent. prior to the intervention, the respondent obtained an explanation of the purpose of the study and signed an informed consent as a sign of willingness to become a respondent. the researchers measured the patient's saliva volume as pre-intervention data. the researchers divided the respondents into the chewing gum group and the cryotherapy group according to the patient's condition at the beginning of the study meeting and continued for up to seven (7) days of radiotherapy. the researcher also involved the respondent’s family to be willing to help in the research, especially as the supervisor of the respondent in intervening correctly and routinely. researchers explained the interventions to be provided and educated them to keep doing the hospital standard in the form of adequate drinking and cleaning the mouth. jurnal ners http://e-journal.unair.ac.id/jners | 93 subjects in the chewing gum group were asked to chew six pieces of sugar-free gum xylitol a day (two pieces in the morning. afternoon and evening) each about 10 minutes respectively for a week after radiotherapy session. the ingredients contained in xylitol gum are natural ingredients and artificial flavors (sorbitol, maltitol, syrup, xylitol, aspartame. acesulfame k), rubber-based ingredients, binding agents (e903) and antioxidants (e321) (jerniga, chiung, chen, & sewell, 2014;leede, leersum, kroon,weel, & sijp, 2018) so they are safe for consumption. xylitol is anticaries because it is able to suppress the number of streptococcus mutans colonies, inhibits the growth of plaque, suppresses saliva acidity and inhibits inflammation in the mouth because xylitol cannot be metabolized by oral bacteria, including streptococcus mutans. and is a substance that plays a role in the process of glycolysis inhibition (rodian et al., 2011). to reduce the drop out of this research involved the family and filling out the intervention check list. the family were willing to help be a reminder of respondents in conducting chewing gum interventions, namely chewing xylitol gum three (3) times a day in the table 1. characteristics of participants characteristics of participants chewing gum group (n=24) cryotherapy group (n=18) total n % n % n % gender male 15 83.3 16 88.9 31 86.1 female 3 16.7 2 11.1 5 13.9 age (year) 17-25 1 5.6 0 0 1 2.8 26-35 1 5.6 0 0 1 2.8 36-45 4 22.2 3 16.7 7 19.4 46-55 5 27.8 7 38.9 12 33.4 56-65 2 11.1 4 22.2 6 16.7 >65 5 22.2 4 22.2 9 25 diagnosis of disease nasopharyngeal cancer 7 38.9 13 72.2 20 59.5 oropharyngeal cancer 1 5.6 0 0 1 2.8 larynx cancer 5 27.8 2 11.1 7 19.4 non-hodgkin's lymphoma 1 5.6 0 0 1 2.8 tongue cancer 3 16.7 0 0 3 8.3 lymphoma cancer 1 5.6 0 0 1 2.8 mandibula cancer 0 0 3 16.7 3 8.3 stage stage 1 0 0 1 5.6 1 2.8 stage 2 10 55.6 9 50 19 52.8 stage 3 6 33.3 4 22.2 10 27.8 stage 4 2 11.1 4 22.2 6 16.7 education status no school 1 5.6 2 11.1 3 8.3 elementary school 7 38.9 4 22.2 11 30.6 middle school 2 11.1 5 27.8 7 19.4 high school 6 33.3 6 33.3 12 33.3 bachelor 2 11.1 1 5.6 3 8.3 employment status farmers 4 22.2 5 27.8 9 25 private job 6 33.3 6 33.3 12 33.3 trader 3 8.3 5 27.8 8 22.2 civil servants 3 16.7 1 5.6 4 11.1 housewife 2 11.1 1 5.6 3 8.3 marital status married 16 88.9 16 88.9 32 88.9 not married 2 11.1 1 5.6 3 8.3 divorced 0 0 1 5.6 1 2.8 smoking habit not smoking 3 16.7 3 16.7 6 16.7 1 pack/day 12 66.7 10 55.6 22 61.1 2 pack/day 2 11.1 4 22.2 6 16.7 3 pack or more/day 1 5.6 1 5.6 2 5.6 length of smoking not smoking 3 16.7 3 16.7 6 16.7 1-10 years 9 50 4 22.2 13 36.1 11-20 years 5 27.8 7 38.9 12 33.3 21-30 years 1 5.6 4 22.2 5 13.9 d. u. sholikhah, et al 94 | pissn: 1858-3598  eissn: 2502-5791 morning, afternoon and evening for about 10 minutes on the radiotherapy schedule. subjects in the cryotherapy group were asked to suck an ice cube before and after radiotherapy session for five (5) minutes for a week. the patients suck the ice cubes evenly in the mouth area. ice cubes were provided by researchers to facilitate patients. posttest was held on third, fifth and seventh day of intervention. saliva volume measurements were carried out by the researchers themselves using the spitting method. the patient bowed his head deeply and the subject allowed the saliva to collect and flow through the lower lip into the tube and spit out the remaining saliva that did not flow. measurements were taken five (5) times in five (5) minutes. ethical approval was obtained from komisi etik penelitian kesehatan (kepk) saiful anwar hospital malang with the number 400/017/k.3/302/2020 on january 17, 2020. demographic data include gender, age, education, employment status and marital status, diagnosis of disease, stage of cancer and smoking habit. statistical tests using the general linear model-repeated measured anova within subjects to determine the difference in salivary volume values pretest and posttest in each group. general linear model repeated measured anova between subjects was used for showing effect of the chewing gum and cryotherapy on salivary volume between two groups. results descriptive statistical analysis of the respondent's characteristics is shown in table 1. this study was followed by 36 patients with head and neck cancer undergoing radiotherapy divided into chewing gum intervention and cryotherapy intervention. table 2 describes the statistical test glmrm anova within subjects of the effects of treatment on each group. table 3 describes the statistical test glmrm anova between subjects and the effect of treatment. table 1. shows that, in the chewing gum group and cryotherapy group, 31 people in this study were male and five were female and had the highest age range distribution of 46-55 years by 12 people. nasopharyngeal cancer was the majority diagnosis with 20 people. the highest stage was stage 2 with 19 people. the education level of as many as 12 people is educated high school with 12 respondents having private job. the marital status majority are 32 married people. smoking habit as many as 22 respondents smoking 1 pack/day and the majority over 1-10 years, 13 people. table 2 explains that the results of the glm-rm anova test showed that there were significant differences in salivary volume before and after the intervention of chewing gum and cryotherapy at the 4th time of measurement with p = <0.05. in the chewing gum and cryotherapy, the biggest delta group was on the 7th day of the intervention compared to the pretest3rd day and 5th day. delta value of the chewing gum intervention on the 7th day is 0.4278 and delta value on 7th day cryotherapy is 0.3167. table 3 explains that the glmrm test results between subjects showed no significant differences in salivary volume before and after the intervention of chewing gum and cryotherapy. but the chewing gum group had better results than the mean chewing gum, which was higher by 1.0722 ± 0.18087, than the smaller cryotherapy, 0.9611 ± 0.15770, although the statistical results were p values 0.058 (p> 0.05). results of the glm-rm (general linear modelrepeated measure) anova between subjects between the chewing gum group and the cryotherapy group showed that the effect of chewing gum intervention and cryotherapy on salivary volume is clearly visible after seven days of treatment. table 2. salivary volume in the chewing gum and cryotherapy groups in glmrm anova within subject test group time mean ± sd delta p-value chewing gum 3rd day vs pre-test 0.6444±0.17564 0.1223 0.000 day 5 vs pre-test 0.8944±0.14337 0.25 0.000 7th day vs pre-test 1.0722±0.18087 0.4278 0.000 7th day vs 3rd day 0.7667±0.16088 0.3055 0.000 7th day vs day 5 0.8944±0.14337 0.1778 0.000 cryotherapy 3rd day vs pre-test 0.6444±0.22287 0.1112 0.000 day 5 vs pre-test 0.8611±0.16852 0.2167 0.000 7th day vs pre-test 0.9611±0.15770 0.3167 0.000 7th day vs 3rd day 0.7556±0.15038 0.2055 0.000 7th day vs day 5 0.8611±0.16852 0.1 0.001 table 3. salivary volume in the chewing gum and cryotherapy groups in glmrm anova between subject test saliva (ml/minute) chewing gum mean ± sd cryotherapy mean ± sd delta (confidence interval 95 %) p-value pretest 0.6444±0.17564 0.6444±0.2228 0 (-0.109-0.145) 1.000 3rd day 0.7667±0.16088 0.7556±0.15038 0.0111 (-0.72-0.111) 0.832 5th day 0.8944±0.14337 0.8611±0.16852 0.0333 (0.060-0.138) 0.527 7th day 1.0722±0.18087 0.9611±0.15770 0.1111 (0.16-0.237) 0.058 jurnal ners http://e-journal.unair.ac.id/jners | 95 discussion result of this study is chewing gum is more effective to increase salivary volume than cryotherapy. according to research (pereira et al., 2016) chewing gum can increase the rate of salivary flow compared to the control group. chewing muscles that are affected by radiation can be stimulated (kaae et al., 2016). the main stimulus for increased salivary secretion is through mechanical stimulation (subramaniam & muthukrishnan, 2019). chewing gum is a form of mechanical stimulation that is useful for increasing saliva and ph (costa, fernandes, quinder,de souza, & pinto, 2003; llop, jimeno, acien, & dalmau, 2010). chewing movements can make changes in the permeability of the plasma membrane, so that calcium can enter the cell. influx cells occur and activate several enzymes, one of which is calcinurin, which affects the process of protein production transipsi, one of which is saliva (ambudkar, 2014) thus increasing saliva production (eghbali et al., 2017). factors that can affect the achievement of saliva are the patient's hydration status (samuels, 2017). drugs consumed, sleep, fasting, nutrition and imagining food and psychological factors are sadness and depression (plemons et al., 2014). previous studies do not yet know the effectiveness of chewing gum versus cryotherapy to increase saliva volume which reduces because radiation rays. saliva is a liquid produced from several glands, namely the parotid gland, which is the largest gland, then the submandibular gland which produces serus (thin saliva, low viscosity), and the smallest gland is the sublingual gland, which produces mucus (thick saliva, viscosity is higher) (yunus, 2008). saliva is very important because it contains antimicrobials such as lysozyme and secretes immunoglobulin a (subramaniam & muthukrishnan, 2019). this research was conducted using time series to obtain the most effective time effect. in line with previous opinions (plemons et al., 2014), measuring saliva periodically is an effective way to monitor changes in the volume and composition of saliva. chewing or sucking sugar-free gum to stimulate saliva flow is an intervention to minimize dry mouth (dental & ada, 2015). this study used xylitol gum because it contains lower sugar and is easy to find on the market. the results of this study support rodian et al. (2011) that xylitol chewing gum showed the highest increase in salivary volume compared to sucrose chewing gum and probiotic gums, but the statistical tests showed no significant difference. cryotherapy is applied because it has many advantages in that is practical to be applied, economical, easy and has minimal side effects (utami, 2017). the goals of cold therapy include reducing inflammation, inhibiting pain receptors, reducing edema and controlling bleeding (rosdahl & kowalski, 2014). symptoms of a dry mouth due to reduced saliva can make a patient feel uncomfortable. disturb the appetite and quality of life (plemons et al., 2014). study (dental & ada, 2015) states sucking ice cubes, drinking water while eating to help chew and swallow food, using mouthwash-free mouthwash, avoiding carbonated drinks (such as soda), caffeine, tobacco, and alcohol, and using lanolin-based lip balm to comfort cracked or dry lips can reduce dryness in the mouth and stimulate saliva discharge. increased salivary secretion leads to increased volume and thinning of saliva needed for ingestion and lubrication. in this study, not all of the patients' salivary volumes increased. this is influenced by several factors. according to samuels (2017) drugs, smoking, and alcohol consumption will reduce the flow rate of saliva. most respondents were aged in the range 46-65 years. old age will make the function of the salivary glands decrease, because the acinar element turns into fat and fibrous tissue (baird, donehower, stalsbroten, & ades,1991). the results of this study prove that the chewing gum and cryotherapy affect the stimulus production of saliva. hopefully, this study can increase information about nursing care in head and neck cancer, so that the symptoms caused by radiotherapy of the head and neck area can be reduced or avoided. the limitation of this study was the researcher cannot fully control the respondent’s intervention because it is done at home or boarding so this can have an impact on the result of the study. the strength of this study was there is an effective nonpharmacological action nurses can take to increase the volume of saliva in head and neck cancer patients by chewing gum. figure 1. graphs of salivary volume interactions (ml/min) between measurement times and between groups d. u. sholikhah, et al 96 | pissn: 1858-3598  eissn: 2502-5791 conclusion this study showed chewing gum is more effective to increase salivary volume than cryotherapy among patient head and neck cancer undergoing radiotherapy in saiful anwar hospital malang on 7th day intervention. the results from this recent study hope to be useful in future health therapies to increase the volume of saliva in radiotherapy patients in the head and neck area so that it can reduce side effects and make therapy successful. what must be considered when discussing clinical application is the suitability of the gum variant. future research is expected to control the factors that influence saliva production and conduct research by taking patients from the beginning of radiotherapy until radiotherapy is completed. acknowledgment the author would like to express gratitude to the supervisors for the guidance and the precious suggestions, radiotherapy patients in saiful anwar hospital malang for participation in this study and the relevant authorities for their permissions to conduct this research. references ambudkar, i. s. (2014). ca2+ signaling and regulation of fluid secretion in salivary gland acinar cells. cell calcium, 1–9. https://doi.org/10.1016/j.ceca.2014.02.009 baird, s. b., donehower, m. g., stalsbroten, v. l., & ades, t. b. (1991). a cancer source book for nurses (6th ed.). american cancer society. costa, e. m., fernandes, m. z., quinder, l. b., de souza, l. b., & pinto, l. p. (2003). evaluation of an oral preventive protocol in children with acute lymphoblastic leukemia. pesquisa odontologica brasileira, 17(2), 147–150. dental, a., & ada, a. (2015). managing dry mouth. the journal of the american dental association, 146(2), a40. https://doi.org/10.1016/j.adaj.2014.11.019 didem, a., ayfer, e., & ferda, o. a. (2014). the effect of chewing gum on oral mucositis in children receiving chemotherapy. health science journal, 8(3), 373–382. eghbali, aziz., taherkhanch., bagheri b., s. s. (2017). effect of chewing gum on oral mucositis in children undergoing chemotherapy : a randomized controlled study original article effect of chewing gum on oral mucositis in children undergoing chemotherapy : a randomized controlled study. march 2016. epstein, j. b., bensadoun, r., saunders, d. p., & rajesh, v. (2017). common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. cancer medicine, 1–14. https://doi.org/10.1002/cam4.1221 irna, & subita, g. p. s. (2008). identifikasi dan pengendalian faktor risiko mukositis oral selama radioterapi kanker nasofaring laporan kasus. indonesian journal of dentistry, 15(4), 155–162. jernigan, a. m., chiung, c., chen, g., & sewell, c. (2014). international journal of gynecology and obstetrics clinical article a randomized trial of chewing gum to prevent postoperative ileus after laparotomy for benign gynecologic surgery ☆. international journal of gynecology and obstetrics, 8–11. https://doi.org/10.1016/j.ijgo.2014.06.008 kaae, j. k., stenfeldt, l., & eriksen, j. g. (2016). xerostomia after radiotherapy fo r oral and oropharyngeal cancer: increasing salivary flow with tasteless sugar-free chewing gum. frontiers in oncology, 6(may), 1–6. https://doi.org/10.3389/fonc.2016.00111 katranc, n., ovayolu, n., ovayolu, o., & sevinc, a. (2012). european journal of oncology nursing evaluation of the effect of cryotherapy in preventing oral mucositis associated with chemotherapy e a randomized controlled trial. 16, 339–344. https://doi.org/10.1016/j.ejon.2011.07.008 laursen, m., specht, l., kristensen, c. a., & gothelf, a. (2018). an extended hypofractionated palliative radiotherapy regimen for head and neck carcinomas. 8(june), 1–8. https://doi.org/10.3389/fonc.2018.00206 llop, m. r., jimeno, f. g., acien, r, m., & dalmau, l. j. b. (2010). effect of xylitol chewing gum on salivary flow rate, ph, buffering capacity and presence of streptococcus mutans in saliva. european journal of paediatric dentistry, 11(1), 9–14. marinna, a., & harijanti, k. (2017). management of xerostomia post radiotherapy nasopharingeal carcinoma: case report (y. septorini, wimardhani, h. ruslijanto, h. djuaeni, i. sufiyawati, t. setiani, & a. f. irawan (eds.)). nih. (2019). salivary gland cancer treatment (adult). national cancer institute. pereira, j. v, maciel, r. p., jorge, m., & monteiro, f. (2016). effect of chewing gum containing cppacp on salivary flow and buffer capacity : an in vivo study. 16((1)), 425–431. plemons, j. m., al-hashimi, i., & marek, c. l. (2014). managing xerostomia and salivary gland hypofunction executive. the journal of the american dental association, 145(8), 867–873. https://doi.org/10.14219/jada.2014.44 ra’abung, a. s., sudiana, i. k., & hidayati, l. (2019). pengaruh mouthwash disertai mengunyah permen karet xylitol terhadap xerostomia, laju aliran saliva, dan ph saliva pada pasien yang menjalani hemodialisis. universitas airlangga. rodian, m., satari, m. h., & rolleta, e. (2011). efek mengunyah permen karet yang mengandung sukrosa, xylitol, probiotik terhadap volume, jurnal ners http://e-journal.unair.ac.id/jners | 97 kecepatan aliran, viskositas, ph, dan jumlah koloni streptococcuc mutans saliva. rosdahl, c. b., & kowalski, m. t. (2014). text book of basic nursing edisi 10 (e. a. mardella (ed.); 10th ed., p. 871). lippincott williams & wilkins/wolter kluwer health. samuels, m. a. (2017). radiation-induced oral mucositis. 7(may). https://doi.org/10.3389/fonc.2017.00089 santoso, b. s., surarso, b., & kentjono, w. a. (2009). radioterapi pada karsinoma nasofaring. tht kl, 2(3), 134–141. siddiqui, f., & movsas, b. (2017). management of radiation toxicity in head and neck cancer. seminars in radiation oncology, 27(4), 340– 349. https://doi.org/10.1016/j.semradonc.2017.04. 008 simões, a., campos, l. de, arana-chavez, v. e., & nicolau, j. (2015). low level laser therapy for hyposalivation and xerostomia. 335–339. subramaniam, n., & muthukrishnan, a. (2019). oral mucositis and microbial colonization in oral cancer patients undergoing radiotherapy and chemotherapy : a prospective analysis in a tertiary care dental hospital. july, 1–6. https://doi.org/10.1111/jicd.12454 surjadi, n., & amtha, r. (2012). radiotherapy reduced salivary flow rate and might induced c . albicans infection. 19(1), 1–6. traktama, d. o., & sufiawati, i. (2018). keparahan mukositis oral pada pasien kanker kepala leher akibat kemoterapi dan / atau radioterapi. 4(1). utami, k. c. (2017). mukositis oral sebagai dampak kemoterapi pada anak kanker yang mendapat kemoterapi. utami, k. c., & hayati, h. (2018). chewing gum is more effective than saline-solution gargling for reducing oral mucositis. enfermería clínica, 28, 5–8. https://doi.org/10.1016/s11308621(18)30026-3 villa, a., & sonis, s. t. (2015). mucositis : pathobiology and management. 159–164. https://doi.org/10.1097/cco.0000000000000 180 yunus, b. (2008). efek samping terapi radiasi penderita kanker kepala dan leher pada kelenjar saliva. 7(1), 57–62. 226 kesiapan mahasiswa untuk belajar kerjasama interprofesi dalam perawatan antenatal (the readiness of students to learn interprofessional teamwork in antenatal care) dina zakiyyatul fuadah*, sunartini hapsara**, mariyono sedyowinarso*** *program studi ilmu keperawatan stikes karya husada pare-kediri jalan soekarno-hatta no 01, kediri **fakultas kedokteran universitas gadjah mada, yogyakarta ***program studi magister keperawatan fakultas kedokteran universitas gadjah mada, yogyakarta e-mail: dinazakiyya_ichsan@yahoo.co.id abstrak pendahuluan: indonesia sebagai negara berkembang mempunyai rerata angka kematian ibu yang tinggi. usaha yang dilakukan adalah dengan mengembangkan praktik kolaborasi interprofesional pada tingkat pelayanan kesehatan. sikap kolaborasi dalam kerja tim harus dibentuk sejak pada tingkat pendidikan melalui latihan dan simulasi pembelajaran interprofesional bagi siswa. tujuan penelitian ini adalah untuk menganalisis pengaruh pembelajaran interprofesional terhadap kesiapan siswa untuk bekerja sama interprofesional dalam melakukan antenatal care. metode: desain yang digunakan adalah quasi eksperimen (pretest-posttest tanpa kelompok kontrol) dengan time series. responden pada penelitian ini adalah mahasiswa semester 5 di stikes karya husada kediri pada tahun 2011/2012 yang berjumlah 60 orang. teknik sampling yang digunakan adalah simple random. data didapatkan menggunakan kuesioner readiness interprofessional learning scale (ripls) dan teamwork score (tws) observations checklist. analisis statistic menggunakan anova, friedman, dan kruskal walllis. hasil: kesiapan siswa dalam belajar bekerja sama interprofesional menunjukkan angka p = 0,001 yang berarti terdapat perbedaan yang signifikan antara kesiapan sebelum dan sesudah pelatihan ipe. delta test menunjukkan nilai p > 0,05 sehingga tidak ada perbedaan antara 3 kelompok mahasiswa dalam hal kesiapan belajar bekerja sama interprofesional dalam melakukan antenatal care. diskusi: pelatihan pembelajaran interprofesional menggunakan metode simulasi berpengaruh terhadap kesiapan mahasiswa keperawatan, kebidanan, dan gizi untuk belajar bekerja sama interprofesional dalam melakukan antenatal care. kata kunci: pembelajaran interprofesional, kesiapan, pelatihan dan simulasi, mahasiswa pra klinik, antenatal care abstract introduction: indonesia as a developing country have a higher maternal mortality rate (mmr). the prevention efforts is developing interprofessional collaborative practice (ipcp) in the level of health care. collaboration attitudes should start from education level through interprofessional education training and simulation for student. the objective of this study was to analyze the effect of interprofessional education training toward the readiness of students to learn interprofessional teamwork in antenatal care. methods: quasi-experimental design (pre test and post test without control) with timeseries design. participants used in this study were students of five semester in stikes karya husada kediri year of 2011/2012 and the number of samples are 60 students. technique sampling using simple random. the data collected by used questionnaires readiness interprofessional learning scale (ripls) and checklist observations using teamwork score (tws). anova, friedman test, and kruskal wallis was used to statistically analyzed the data. results: readiness to learn interprofessional teamwork indicates the value of p = 0.001 thats means there are significant differences between the readiness before and after training ipe. delta test showed that p value > 0.05 so there is no difference between the three programs study on readiness to learn interprofessional teamwork in antenatal care. discussion: interprofessional education training using simulation methods can affect the readiness of nursing, midwifery and nutritionist students for learning interprofessional teamwork in antenatal care. keywords: interprofessional education, readiness, training and simulations, pre clinics students, antenatal care. pendahuluan world health organization (who) menyatakan setiap menit seorang wanita meninggal selama persalinan atau melahirkan. jurnal review in obstetric and gynecology tahun 2010 juga menyatakan bahwa sekitar 529.000 perempuan meninggal akibat kondisi yang berhubungan dengan kehamilan setiap tahunnya dan hampir semua yaitu 99% dari kematian ibu, terjadi di negara berkembang. indonesia sebagai negara berkembang masih memiliki angka kematian ibu (aki) yang 227 kesiapan mahasiswa untuk belajar (dina zakiyyatul fuadah, dkk.) cukup tinggi (sukmawati, 2012). penyebab tersering kematian ibu adalah perdarahan postpartum, eklampsia, persalinan macet, dan sepsis. kematian ibu masih disebabkan karena masalah terkait keterlambatan mengambil ke put u s a n , ke t e rla mb at a n me ng a k s e s pelayanan kesehatan dan keterlambatan dalam melakukan tindakan di sarana pelayanan kesehatan (armiatin, 2013). upaya menurunkan angka kematian ibu salah satunya melalui peningkatan pelayanan kesehatan neonatal dan ibu melalui program pelayanan kesehatan ibu dan anak (kia). perawatan selama kehamilan atau perawatan antenatal sebagai salah satu bentuk pelayanan kia yang aman dan bermutu bagi ibu hamil dan janin/bayi dapat terwujud bila sistem mikro pelayanan kia yang diberikan oleh klinis berjalan dengan baik (depkes, 2008). pelayanan dikatakan baik apabila tata kelola pelayanan dalam memberikan perawatan tidak terjadi fragmentasi atau tumpang tindihnya peran dan fungsi sebagai pemberi pelayanan dengan latar belakang profesi yang berbeda (susilaningsih, 2011). pelayanan yang tumpang tindih antar profesi terjadi karena kurangnya komunikasi antar tenaga kesehatan dalam kerja sama tim. saat ini, pada pelayanan antenatal masih sering terjadi overlapping kompetensi, di mana tidak ada pembagian atau batasan peran yang jelas dalam memberikan pelayanan perawatan antara profesi dokter, perawat dan bidan di mana hal tersebut dapat memicu ketegangan antar profesi yang menghambat terjadinya bentuk kerja sama yang efektif. dampak dari kurangnya kerjasama antar tenaga kesehatan yang baik menjadikan pemanfaatan fasilitas pelayanan yang harus diterima masyarakat tidak efektif dan efisien. melalui kerja sama yang baik antar profesi kesehatan dalam pelayanan, maka pasien akan ditangani secara holistik sehingga outcome perawatan dan kepuasan pasien akan meningkat (remington, 2006). kerja sama antara dokter dan perawat adalah hal yang sangat penting dalam mengoptimalkan pelayanan kepada pasien (liaw, 2013; way et al., 2000). kemampuan bekerja sama secara interprofesi (interprofessional teamwork) tidak muncul begitu saja, melainkan harus ditemukan dan dilatih sejak dini mulai dari tahap perkuliahan agar mahasiswa mempunyai bekal pengetahuan dan pengalaman mengenai cara bekerja sama secara tim yang baik dengan profesi lain sebelum mereka terjun ke dunia kerja (wagner, 2011). model pembelajaran pendidikan interprofesi atau interprofessional education yang selanjutnya disebut ipe dapat dijadikan suatu media pembelajaran bagi mahasiswa untuk belajar dan melatih kemampuan bekerja sama dengan profesi lain. ipe merupakan proses di mana sekelompok peserta didik atau tenaga kesehatan dengan latar belakang berbeda belajar bersama dalam jangka waktu tertentu pada masa pendidikan, dengan interaksi sebagai tujuan utamanya, u nt u k kolabor a si d ala m menyed ia k a n pelayanan preventif, promotif, rehabilitatif, dan pelayanan kesehatan lainnya (who, 2010). ipe memberikan kesempatan kepada mahasiswa yang mempunyai latar belakang profesi yang berbeda dengan tujuan yang sama bekerja bersama secara aktif dalam meningkatkan kualitas perawatan kepada pasien. saat ini pengembangan kurikulum ipe belum dikembangkan secara merata di instansi pendidikan. who (2010) mengeluarkan data tentang penerapan ipe di beberapa negara, yaitu pada tatanan institusi sebanyak 10,2% dokter, 16% perawat atau bidan, 5,7% ahli gizi, serta tenaga kesehatan lainnya telah menerima pembelajaran berbasis ipe. pada tatanan universitas hasil dari survei dari 42 negara menyatakan bahwa sebanyak 24,6% sudah mendapatkan kurikulum ipe pada tahap akademik. sementara di indonesia belum termasuk didalamnya, untuk itu perlu adanya sosialisasi tentang metode pembelajaran ipe ini secara menyeluruh di seluruh instansi pendidikan mengingat sekolah tinggi ilmu kesehatan merupakan penyedia utama calon tenaga kesehatan yang nantinya diharapkan mempunyai kompetensi yang baik terutama kemampuan untuk bekerja sama dengan tenaga kesehatan lainnya. pembelajaran ini ber potensi untuk menyiapkan mahasiswa dalam menghadapi praktik klinik, membantu meningkatkan hubungan profesional yang kuat dengan me ng ha rgai pe r a n nya ma si ng-ma si ng. 228 jurnal ners vol. 9 no. 2 oktober 2014: 226–235 pengenalan pembelajaran ipe salah satunya dapat melalui suatu pelatihan yang dilengkapi dengan simulasi di mana cara ini merupakan cara yang cukup efektif untuk meningkatkan kemampuan kognitif, afektif dan psikomotor mahasiswa dalam pembelajaran ipe. melalui pelatihan memungkin kan peser ta unt uk mengeksplorasi cara-cara kolaboratif untuk meningkatkan aspek komunikatif perawatan klinis. banyak penelitian menunjuk kan bahwa melalui simulasi akan meningkatkan kemampuan mahasiswa dalam berkolaborasi atau bekerja sama secara tim. penelitian liaw, s.y., et al (2011) menjelaskan bahwa pelatihan inter profesional berbasis simulasi dalam program sarjana telah memberikan kesempatan mahasiswa kedokteran dan keperawatan sebagai pengembangan awal keterampilan komunikasi dan kerja sama interprofesi. stikes karya husada kediri sebagai institusi pendidikan tinggi swasta yang menyelenggarakan pendidikan formal untuk sarjana dan diploma yang terdiri dari program studi s1 ilmu keperawatan dan diploma keperawatan, kebidanan dan gizi belum terpapar dengan metode pembelajaran ipe. melihat permasalahan tersebut maka perlu dipikirkan suatu program sosialisasi terkait tentang pembelajaran ipe pada institusi ini karena mempunyai kesempatan untuk dikembangkan nya metode pembelajaran secara inter profesi yait u salah sat u nya melalui pelatihan pendidikan interprofesi yang dilakukan pada mahasiswa keperawatan, kebidanan dan gizi di stikes karya husada pare kediri. bahan dan metode penelitian ini dilakukan di stikes kar ya husada kedir i. jenis penelitian merupakan quasy-experiment (pre test dan post test tanpa kontrol) dengan time series design di mana post test dilakukan sebanyak dua kali pengambilan data. populasi dalam penelitian ini adalah mahasiswa diploma (d3) stikes kar ya husada kediri angkatan 2011/2012 semester v (lima) jurusan keperawatan, kebidanan, dan gizi yang berjumlah 280 mahasiswa. pemilihan tersebut dilakukan dikarenakan mahasiswa pada tahap pre klinik dan sudah mendapatkan materi tentang perawatan antenatal. sampel yang masuk kriteria inklusi adalah mahasiswa reguler stikes kar ya husada angkatan 2011/2012 semester v (lima) yang bersedia menjadi responden. besar sampel dalam penelitian ini didasarkan pada studi literatur menggunakan rumus besar sampel penelitian analitik numerik berpasangan (shrader et al,.2012; dahlan, s. 2012). besar sampel adalah 60 responden, kemudian dibagi menjadi 10 kelompok kecil, masing-masing kelompok terdiri dari 6 mahasiswa meliputi mahasiswa keperawatan, kebidanan dan gizi kesehatan. pengambilan sampel dilakukan secara simple random sampling. j e n i s d a t a y a n g d i g u n a k a n dalam penelitian ini adalah data primer diperoleh melalui kuesioner readiness for interprofessional learning scale (ripls) (parsell dan blihg, 1999) untuk mengukur sikap yang langsu ng diber ikan kepada responden dan checklist teamwork score (tws) (shrader, et al.,2012) untuk mengukur keterampilan kerja sama mahasiswa melalui observasi pada saat simulasi. pada penelitian ini responden diberikan intervensi berupa pelatihan interprofessional education (ipe) yang dilengkapi dengan metode simulasi perawatan antenatal pada ibu hamil. pengambilan data dilakukan sebanyak tiga kali yaitu pre test, post test 1 dan post test 2, di mana jeda waktu pengambilan data adalah satu minggu. a n a l is a d at a u nt u k me nget a hu i perbedaan sikap dan perilaku responden sebelum dan sesudah intervensi menggunakan uji repeated anova untuk data berdistribusi nor mal d a n uji fried man u nt u k d at a berdistribusi tidak normal. uji delta beda menggunakan kruskal wallis hasil responden pada penelitian ini berjumlah 60 mahasiswa yang menyelesaikan proses penelitian mulai dari pre test sampai dengan post test pertama dan kedua. responden terdiri atas mahasiswa program studi keperawatan, 229 kesiapan mahasiswa untuk belajar (dina zakiyyatul fuadah, dkk.) program studi kebidanan, program studi gizi kesehatan. adapun karakteristik responden pada penelitian ini mayoritas responden memiliki karakteristik usia 20 tahun (56,7%), responden perempuan (85,0%) lebih banyak dari laki-laki, asal program studi responden memiliki persentase jumlah yang sama dari ketiga program studi (33,3%) untuk program studi keperawatan, kebidanan dan gizi, sebagian besar responden menyatakan belum pernah memiliki pengalaman pembelajaran interprofesi (90,0%). hasil pengambilan dan pengolahan data secara statistik menggunakan uji friedman (tabel 1) menjelaskan bahwa ada pengaruh yang signifikan antara pemberian pelatihan ipe dengan perubahan sikap mahasiswa untuk belajar kerja sama interprofesi dalam perawatan antenatal dengan nilai p = 0,001 (α < 0,05). hasil pada sub variabel menunjukkan sub variabel kerja sama dan kolaborasi, identitas profesi mengalami peningkatan kesiapan yang signifikan, namun sub variabel peran dan tanggung jawab tidak mengalami peningkatan. nilai mean berdasarkan rentang skala ripls antara 19-95 pada penelitian ini menunjukkan bahwa mahasiswa mempunyai sikap yang positif terhadap kesiapan untuk belajar kerja sama interprofesi dalam perawatan antenatal. hasil pengambilan dan pengolahan data secara statistik uji friedman (tabel 2) menjelaskan bahwa ada pengaruh yang signifikan antara pemberian pelatihan dengan keterampilan kerja sama mahasiswa dalam melakukan perawatan antenatal pada saat simulasi dengan nilai p = 0,001 (α < 0,05). nilai mean berdasarkan rentang skala tws antara 22–110 pada penelitian ini yang semakin meningkat menunjukkan perilaku yang positif terhadap kesiapan mahasiswa untuk belajar kerja sama interprofesi dalam perawatan antenatal. uji beda dilakukan untuk mengetahui perbedaan kesiapan antar program studi keperawatan, kebidanan dan gizi kesehatan dengan menggunakan uji kruskall wallis, didapatkan hasil nilai p > 0,05 baik dari kompetensi sikap dan keterampilan, maka hal ini menunjukkan tidak ada perbedaan kesiapan antara program studi keperawatan, kebidanan dan gizi kesehatan dalam perawatan antenatal. (tabel 3 dan 4) tabel 1. uji komparatif variabel dan sub variabel kesiapan untuk belajar kerja sama interprofesi dalam perawatan antenatal pada mahasiswa di stikes karya husada kediri variabel pre post 1 post 2 p mean (min-maks) sd mean (min-maks) sd mean (min-maks) sd kesiapan terhadap ipe (n= 60) 82,83 (70,0090,00) 5,57 87,22 (73,00-95,00) 5,62 84,77 (65,0095,00) 7,06 0,001* k e r j a s a m a d a n kolaborasi 40,15 (34,0045,00) 2,63 42,32 (35,00-45,00) 2,30 41,23 (31,0045,00) 3,40 0,001* identitas profesi 29,97 (19,0035,00) 2,82 31,92 (26,00-35,00) 3,05 31,05 (26,0035,00) 3,01 0,003* peran dan tanggung jawab 12,72 (10,0015,00) 1,40 12,98 (8,00-15,00) 1,46 12,48 (7,00-15,00) 1,84 0,210 sumber: data primer instrumen: ripls range scale 19-95, nilai 95 mengindikasikan sikap positif *p < 0,05 230 jurnal ners vol. 9 no. 2 oktober 2014: 226–235 tabel 2. uji beda kesiapan untuk belajar kerja sama interprofesi dalam perawatan antenatal antar prodi di stikes karya husada kediri responden ilmu keperawatan (n=20) kebidanan (n=20) gizi kesehatan (n=20) p mean st. dev mean st. dev mean st. dev pre-post 1 3,25 7,58 4,60 7,96 5,30 7,08 0,685 post 1-post 2 -0,45 9,32 -1,50 8,83 -5,40 9,14 0,396 pre-post 2 2,80 6,91 3,10 8,71 -0,10 8,68 0,203 sumber: data primer instrumen: ripls range scale 19–95, nilai 95 mengindikasikan sikap positif tabel 4. uji beda kesiapan untuk belajar kerja sama interprofesi dalam perawatan antenatal antar prodi di stikes karya husada kediri tahun 2014 responden ilmu keperawatan (n=20) kebidanan (n=20) gizi kesehatan (n=20) p mean st. dev mean st. dev mean st. dev pre-post 1 41,40 8,76 41,40 8,76 41,40 8,76 1,000 post 1-post 2 47,40 5,29 47,40 5,29 47,40 5,29 1,000 pre-post 2 6,00 7,38 6,00 7,38 6,00 7,38 1,000 sumber: data primer instrument: teamwork score (tws) range scale 22-110, nilai 110 mengindikasikan perilaku positif tabel 3. uji komparatif variabel kesiapan mahasiswa secara berkelompok untuk belajar kerja sama interprofesi dalam perawatan antenatal di stikes karya husada kediri variabel pre post 1 post 2 pmean (min-maks) sd mean (min-maks) sd mean (min-maks) sd keseluruhan (n= 60) 47,30 (41,00-54,00) 4,67 88,70 (78,00-101,00) 6,90 94,70 (82,00-102,00) 6,39 0,001* ilmu keperawatan 47,30 (41,00-54,00) 4,74 88,70 (78,00-101,00) 7,02 94,70 (82,00-102,00) 6,50 0,001* kebidanan 47,30 (41,00-54,00) 4,74 88,70 (78,00-101,00) 7,02 94,70 (82,00-102,00) 6,50 0,001* gizi kesehatan 47,30 (41,00-54,00) 4,74 88,70 (78,00-101,00) 7,02 94,70 (82,00-102,00) 6,50 0,001* sumber: data primer (observasi pada kelompok interprofesi) instrument: teamwork score (tws) range scale 22–110, nilai 110 mengindikasikan perilaku positif *p<0,05 pembahasan k e s i a p a n m a h a s i s w a s a n g a t mempengaruhi pelaksanaan pembelajaran secara interprofesional (parsell et al., 1999). seseorang dikatakan mempunyai kesiapan jika sudah memenuhi kriteria kompetensi yang ditentukan. kompetensi yang diharapkan dalam pembelajaran ipe meliputi pengetahuan, keterampilan, sikap dan kemampuan dalam tim yang akan dijalaninya dalam melakukan praktik bersama (a mer ican college of clinical pharmacy, 2009). pada penelitian ini 231 kesiapan mahasiswa untuk belajar (dina zakiyyatul fuadah, dkk.) pengukuran kesiapan mahasiswa dilihat dari dua kompetensi yaitu kompetensi sikap dan kompetensi keterampilan dalam ipe. hasil uji statistik menunjukkan bahwa terdapat perbedaan signif ikan kesiapan mahasiswa antara sebelum dan sesudah d iber i ka n i nter vensi ber upa pelat i ha n interprofessional education (ipe) pada keseluruhan mahasiswa dengan nilai p = 0,001 (α = 0,05). nilai mean yang semakin meningkat mengindikasikan sikap mahasiswa semakin positif terhadap pembelajaran ipe. coster et al., (2008), hind (2003) menyatakan bahwa mahasiswa keperawatan, kebidanan, kedokteran gigi, fisioterapi, farmasi, gizi kesehatan dan okupasi menunjukkan ratarata skor yang tinggi dalam kesiapan terhadap pembelajaran ipe, hal ini berarti mahasiswa mempunyai sikap yang positif terhadap kesiapan ipe, didukung dengan penelitian morison et al., (2004) yang menyatakan bahwa mahasiswa kedokteran dan keperawatan mempunyai kesiapan yang positif setelah mengikuti program ipe, mereka memperoleh pengalaman ter utama kaitannya dengan pengembangan keterampilan dalam kerja sama tim. hal senada juga disampaikan dalam penelitian cullen (2003) dengan menggunakan metode interprofessional team objective structured cinical examination (itosce) dengan skenario perawatan intrapartum, menyatakan bahwa mahasiswa kebidanan dan kedokteran menyatakan kesiapannya terhadap pembelajaran interprofesional. semua pendapat semakin menguatkan bahwa sebagian besar mahasiswa tenaga kesehatan dengan latar belakang profesi yang berbeda menunjukkan sikap yang positif terhadap keinginan untuk bekerja sama setelah mendapatkan program pelatihan atau training tentang pembelajaran ipe. sub variabel kerja sama dan kolaborasi diketahui nilai p signifikan pada semua waktu pengambilan data (lihat tabel 1). hal ini menunjukkan bahwa mahasiswa mengalami peningkatan yang signifikan terkait kerja sama dan kolaborasi setelah intervensi baik pada saat pengambilan data pertama maupun pengambilan data kedua setelah intervensi, seperti yang diungkapkan oleh barr (1998), bahwa salah satu outcome yang diharapkan dalam penerapan ipe adalah terjadinya kerja sama dan kolaborasi yang kuat antar professional kesehatan terutama dari disiplin il mu yang berbed a. responden d alam penelitian ini sebagian besar menunjukkan sikap positif bahwa pembelajaran interdisiplin di dalam kelas akan membantu mereka menjadi anggota tim pelayanan kesehatan yang lebih baik. sub variabel identitas profesi mengalami peningkatan pada pengambilan data pre-post 1 (p = 0,001). identitas profesi merefleksikan pentingnya identitas professional profesi untuk mendef inisikan kehidupan dan kekuatan budaya profesi masing-masing individu. morison et al., (2004) menyatakan bahwa mahasiswa kedokteran, keperawatan dan gizi kesehatan menjadi lebih memiliki rasa yang kuat berkaitan dengan peran profesi mereka sendiri setelah mendapatkan training ipe. begitu pula yang disampaikan coster et al., (2008) bahwa mahasiswa yang memiliki identitas profesi yang positif terhadap ipe saat berada pada tahap akademik akan lebih tertarik untuk berkolaborasi dengan mahasiswa profesi lain, karena mereka membawa persepsi yang lebih positif tersebut saat memasuki pendidikan klinik. sub var iabel peran profesi tidak mengalami perubahan yang signifikan (p = 0,210) setelah mengikuti pelatihan ipe. tidak adanya perubahan pada sub variabel peran dan tanggung jawab profesi bisa dipengaruhi oleh waktu pelatihan ipe yang singkat, sehingga mahasiswa belu m mengalami proses internalisasi peran yang maksimal. pada penelitian ini, pelatihan hanya dilakukan selama dua hari dan dievaluasi sebanyak dua kali dengan jeda waktu satu minggu. di universitas auckland, implementasi ipe dengan responden mahasiswa tahun pertama akademik pendidikan dokter, keperawatan dan farmasi berlangsung satu bulan (horsburgh et al, 2001). penelitian coster, (2008) membutuhkan waktu empat tahun melakukan program ipe dengan metode longitudinal survey untuk mengetahui perubahan kesiapan mahasiswa kesehatan dalam pembelajaran interprofesi yang dimulai dari mahasiswa 232 jurnal ners vol. 9 no. 2 oktober 2014: 226–235 masuk sampai studinya berakhir, waktu yang cukup lama ini mendukung terciptanya interaksi antara mahasiswa satu dengan yang lainnya. perubahan peran sangat berkaitan dengan pengamalan seseorang saat berada di lingkungan kerja, perubahan peran akan dirasakan mahasiswa setelah nantinya terpapar dengan dunia kerja di mana dia akan dituntut untuk bekerja bersama dengan profesi lain. uji statistik menunjukkan terdapat perbedaan kesiapan pada kelompok mahasiswa antara sebelu m dan sesudah diber ikan intervensi berupa pelatihan interprofessional education (ipe) pada mahasiswa keperawatan, kebidanan dan gizi dengan nilai p = 0,001 di semua pengambilan data pada saat simulasi perawatan antenatal kepada ibu hamil. pengukuran dilakukan dengan menggunakan ceklist teamwork score (shrader, d. 2013) di mana dalam ceeklist tersebut dapat mengevaluasi perilaku mahasiswa dalam aspek pembentukan struktur tim dari anggota kelompok, kepemimpinan, monitoring situasi pada saat melakukan perawatan, kemampuan memberikan dukungan kepada sesama anggota dan melakukan komunikasi yang efektif baik dengan anggota maupun dengan pasien dan keluarga pasien. melalui pembelajaran ipe yang disertai simulasi mengharuskan mahasiswa profesi kesehatan belajar dan meniadakan perbedaan di antara mereka dengan menjadikan tim yang solid diantara mereka sehingga mahasiswa dapat saling menghargai satu sama lain dan hanya berfokus pada peningkatan kesejahteraan pasien. ker et al., (2003) menyatakan bahwa pengenalan lebih dini tentang pembelajaran interprofesi kepada mahasiswa akan sangat bermanfaat bagi mereka ketika menjalankan profe si me rek a . pe mbelaja r a n be r upa pemberian pengetahuan tentang profesi mereka dan profesi kesehatan lain. serta adanya pelatihan simulasi ketika berada di bangsal rumah sakit dapat menambah pengalaman dan wawasan mahasiswa akan pentingnya kolaborasi saat melakukan tindakan bagi pasien. di samping itu, pembelajaran ini juga dapat meningkatkan kepercayaan diri bahwasanya mereka memiliki keterampilan yang baik. melalui model pendekatan tersebut maka diharapkan para mahasiswa mempelajari dan memahami hubungan antara berbagai subdisiplin yang berbeda dan keterkaitannya dengan kenyataan yang ada di dunia ini. model pendekatan ini memadukan keterampilan, pengetahuan, atau bahkan sikap dan perilaku, sehingga dengan pelatihan dan simulasi diharapkan mahasiswa dapat belajar untuk menyelesaikan permasalahan yang muncul dengan berkolaborasi bersama sesuai dengan kompetensi masing-masing profesi. pada hasil uji statistik mengenai kesiapan masing-masing prog ram st udi baik dari komponen sikap dan keterampilan menunjukkan nilai p > 0,05 hal ini berarti menunjukkan tidak adanya perbedaan kesiapan antara program studi keperawatan, kebidanan dan gizi. karakteristik responden dalam penelitian ini relatif homogen (lihat tabel 6), sebagian besar (85 %) berjenis kelamin perempuan, rentang usia tidak terlalu jauh yaitu antara 20-21 tahun, hampir seluruhnya (90%) belum mempunyai pengalaman pembelajaran interprofesi, dan jumlah mahasiswa mempunyai proporsi yang sama untuk masing-masing program studi yaitu 20 mahasiswa. pada penelitian ini peneliti memberikan intervensi yang sama untuk semua responden yaitu pre test dan post test, pemberian materi dengan topik yang sama yang dilakukan fasilitator yang sama untuk semua responden. hal tersebut mungkin menjadi salah satu faktor yang mendukung hasil analisis bahwa tidak ada perbedaan kesiapan untuk masing-masing program studi. keseimbangan kelompok, tahapan pembelajaran, serta subjek dari pelatihan merupakan hal yang esensial dari pelaksanaan ipe (morison et al, 2004). hal tersebut sesuai dengan pendapat oandasan & reeves, (2005); pirrie, (1999); lockhart wood, (2000) bahwa interaksi interprofesional yang efektif diperlukan keseimbangan dalam jumlah atau populasi, keseimbangan kelompok dalam pembelajaran merupakan hal yang dibutuhkan dalam kesuksesan ipe karena kelompok profesi yang lebih besar bisa menjadi penghalang yang membuat dominasi salah satu pihak. hal tersebut tercermin dalam penelitian ini, di mana masing-masing kelompok interprofesi 233 kesiapan mahasiswa untuk belajar (dina zakiyyatul fuadah, dkk.) mempunyai komposisi yang sama baik dari jumlah dana latar belakang profesi. tunstall pedoe et al, (2003) yang menyatakan bahwa mahasiswa yang sudah mendapatkan pengalaman dan pengetahuan mempunyai kesiapan yang lebih tinggi dalam bekerja maupun kolaborasi daripada mahasiswa yang belum memperoleh informasi sebelum nya mengenai interprofessional education. hal tersebut bertentangan dengan hasil penelitian ini, sebagian besar yaitu 90% dari responden belum mempunyai pengalaman tentang pembelajaran interprofesi, namun hasil pengukuran kesiapan relatif sama dan tidak ada perbedaan dari ketiga program studi. fungsi pelatihan dalam meningkatkan pengetahuan dan pengalaman belajar kerja sama interprofesi nampaknya cukup efektif untuk meningkatkan kesiapan mahasiswa, walaupu n ma ha siswa belu m mem ili k i pengalaman tentang pembelajaran interprofesi namun mereka menunjuk kan sikap dan perilaku yang positif untuk belajar kerja sama interprofesi. m e m i l i h t o p i k p e m b e l a j a r a n merupakan salah satu hal yang krusial dalam interprofessional education (buring, 2009). banyak topik pembelajaran yang dapat diaplikasikan dalam pembelajaran ipe, seperti halnya saini et al., (2011) yang berpendapat bahwa topik tentang health promotion pada anak-anak dengan kasus gangguan pernapasan efektif untuk dipelajari dengan pendekatan i pe. pend apat lai n d a r i vya s (2012) menyatakan bahwa modul tentang patient safety dapat meningkatkan pengetahuan dan keterampilan kerja sama mahasiswa profesi kesehatan dalam menangani pasien. cullen (2003); furber (2004) menggunakan skenario kasus perawatan intrapartum dalam program pembelajaran ipe. dalam hal ini peneliti ber usaha menggali beberapa topik yang sesuai dengan kondisi sumber daya manusia di institusi kami yaitu bidang maternitas dengan topik mengenai perawatan antenatal, karena mahasiswa pada tahap ini sudah mendapatkan mata kuliah tersebut sehingga lebih mudah untuk memahami, selain itu topik tersebut mampu mencakup berbagai disiplin ilmu yaitu keperawatan, kebidanan dan gizi dan sangat representatif untuk dilaksanakan di laboratorium skill. peran fasilitator dalam pembelajaran ipe juga sangat mempengaruhi kesiapan mahasiswa. barr (1994) menambahkan seorang fasilitator dalam ipe diharuskan telah terbiasa dengan dinamika pembelajaran interprofesi, memiliki kemampuan untuk mengoptimalkan kesempatan belajar, menghargai perbedaan dan keahlian dari profesi yang berparisipasi dalam grup pembelajaran ipe. bahwa dosen yang ideal dalam penyelenggaraan ipe selain dapat berkomunikasi dengan baik, sebagai inovator, dosen tersebut juga harus dapat menghargai profesi lain. temuan ini juga didukung barr et al., (2005), menyebutkan seorang dosen juga harus dapat bertindak sebagai inovator dalam penyelenggaraan pembelajaran ipe simpulan dan saran simpulan pelatihan interprofessional education (ipe) dengan menggunakan metode simulasi dapat mempengaruhi kesiapan mahasiswa program studi keperawatan, kebidanan dan gizi kesehatan untuk belajar kerja sama interprofesi d ala m per awat a n a ntenatal. kesiapa n mahasiswa dilihat melalui dua kompetensi yaitu sikap dan keterampilan. perubahan sikap mahasiswa semakin positif setelah dilakukan pelatihan terutama pada komponen kerja sama & kolaborasi dan identitas profesi. perubahan kemampuan keterampilan bekerja sama menunjukkan perilaku yang positif pada saat simulasi. saran perlu adanya kontinuitas kegiatan yang serupa dimulai dari institusi pendidikan dengan lebih banyak mengadakan kegiatan akademik yang melibatkan beberapa profesi. jadwal kegiatan simulasi interprofesi dengan muatan kasus yang berbeda perlu dimasukkan dalam kurikulum akademik. peningkatan sumber daya tenaga pengajar untuk menjadi role model masing-masing profesi melalui kegiatan bimbingan di klinik dengan menunjuk dosen yang bersertifikasi pelatihan ipe. peneliti selanjutnya sebaiknya melakukan evaluasi 234 jurnal ners vol. 9 no. 2 oktober 2014: 226–235 retensi memori pada mahasiswa yang dapat mempengaruhi perubahan sikap untuk bekerja sama interprofesi. kepustakaan american college of clinical pharmacy, 2009. interprofessional education: principles and application, a framework for clinical pharmacy. pharmacotherapy, 29(3), 145–164. barr, h. 1998. competent to collaborate: towards a competency-based model for interprofessional education. journal of interprofessional care, 12: 181–187. barr, h. 2005. effective interprofessional education: argument, assumption and evidence. 1st ed. oxford: blackwell publishing buring, s.m., bhushan, a., broeseker, a., conway, s., d u nca n-hewit t, w., hansen, l. & westberg, s. 2009. interprofessional education supplement: interprofessional education: edinitions, student competencies, and guidelines for impementation. american journal of pharmaceutical education, 73 (4) article 59. coster, s., 2008. interprofessional attitudes amongst undergraduate students in the health professions: a longitudinal questionnaire survey. international journal of nursing studies 45 1667– 1681. (online), (http://www.elsevier. com/ijns diakses tanggal 20 maret 2013) c u l le n , l ., sy mond s, i., fr a se r, d., 20 03. evalu at ion of a for mat ive i nt e r profe ssion al t e a m obje ct ive s t r u c t u r e d cl i n ic a l ex a m i n at ion (itosce): a method of shared learning in maternity education. medical teacher 25 (1). 3841. dahlan, s. 2012. statistik untuk kedokteran dan kesehatan. seri evidence based medicine 1. edisi 5. jakarta: salemba medika. departemen kesehatan republik indonesia. 2008. pedoman operasional: pelayanan ter padu kesehat a n reprodu k si d i puskesmas. jakarta: depkes ri. hind m., norman i., cooper s., gill e., 2003. inter professional perception of health ser vice student. journal interprofessional care. (online), (http:// www.ncbi.nlm.gov/pubmed/12772467., diakses tanggal 20 maret 2011). horsburg, m., lamdin, r., wiliamson, e. 2001. multiprofesional learning: the at tit udes of medical, nursing and pharmacy student to shared learning. medical education, 35: 876–883 ker, j. mole, l. bradley, p., 2003. early i nt roduct ion to i nter professional learning: a simulated ward environment. medical education, 37: 248–255. liaw, zhou, lau, siau, chan., 2013. an i nt e r profe ssion al com mu n icat ion training using simulation to enhance safe care for a deteriorating patient, nurse education today, (online), (http:// dx.doi.org/10.1016/j.nedt.2013.02.019., diakses tanggal 2 april 2013). mariano c., 1999. the case for interdisciplinary collaboration. nurse outlook, 37 (6): 285–258. morison, s., boohan, m., moutray, m & jenkins, j., 2004. developing prequalification interprofessional education for nursing and medical studenrs: sampling student attitudes to guide development. nurse education in practice (4), 20–29. nou r, n.m., 2008. a n int roduction to maternal mortality. review in obstetric gynecology 1 (2): 77: 81. oandasan i, reeves s (b)., 2005. key elements of interprofessional education. part 2: factors, processes and outcomes. journal of interprofessional care, 19(suppl 1): 39–48. parsell, g., bligh, j., 1999. the development of a questionnaire to assess the readiness of health care students for interprofessional learning (ripls). medical education journal, 33(1), 95–100. pirrie, a., 1999. reflection on multidisciplinary education in the health profession. british education research journal. 25 (1): 113–126. remington, t.l., foulk, m. a & williams, b.c., 2006. evaluation of evidence for interprofessional education. american journal of pharmaceutical education, 70(3), p. 66. 235 kesiapan mahasiswa untuk belajar (dina zakiyyatul fuadah, dkk.) shrader. s., kern, zoller, blue., 2012. interprofessional teamwork skills as predictors of clinical outcomes in a simulate health care setting. association of schools of allied health profession, wash., dc. saini. b., shah, kearey, basme, grootjans, armour., 2011. an interprofessional lear ning module on ast ma health promot ion. american jour nal of pharmaceutical skill 75 (2) article 30. sukmawati, f., purnami dan nugroho., 2012. sistem informasi geografis jejaring rujukan ibu dirujuk dan karakteristiknya di kota semarang tahun 2011. jurnal kesehatan masyarakat, 1(2) 163–176. susilaningsih, f,. mukhlas., sunartini dan ut a r i n i., 2011. nu r s e phy sic i a n collaborative practice in interdisciplinary model of patient care. jurnal manajemen pelayanan kesehatan. 14 (2) 92–98. tunstall pedoe, s., rink, e., hilton, s., 2003. st udent attit ude to undergraduate interprofessional education. journal of interprofessional care 17, 161–172. vyas. d., mc. culloh., dyer., gregory and higbee., 2012. an interprofessional course using human simulation patient simulation to teach patient safety and teamwork skill. american journal of pharmaceutical skill 76 (4) 71 wagner, j., liston, b. & miller, j., 2011. d e v e l o p i n g i n t e r p r o f e s s i o n a l communication skills. teaching and learning in nursing, 6(3), pp. 97–101. (online) (http://linkinghub.elsevier. com/retrieve/pii., diakses tanggal 25 februari 2013) world health organization. 2010. world health report 2006: working together for health. (online), (http://www.who. int/hrh/professional. diakses tanggal 4 desember 2012) world health organization. 2010 framework fo r a c t i o n o n i n te r p rofe s si o n a l education and collaborative practice. geneva, switzerland: who. 88 prolanis implementation effective to control fasting blood sugar, hba1c and total cholesterol levels in patients with type 2 diabetes musfirah ahmad*, rini rachmawaty**, elly l. sjattar,** saldy yusuf** * school of nursing, indonesian muslim university ** school of nursing, faculty of medicine, hasanuddin university email: musfirahmad@gmail.com abstract introduction: diabetes mellitus (dm) is a global disease endemic and cause of 4.6 million deaths in the world. the indonesian government and health insurance [bpjs kesehatan] formulate a chronic disease care program [program pengelolaan penyakit kronis (prolanis)] for type 2 diabetes that aims to control the glycemic status and the risk factors of macro and microvascular complications. the purpose of this study was to analyse the correlation between the implementation of prolanis and fasting blood sugar, hba1c, and total cholesterol levels in patients diagnosed with type 2 diabetes at antang and pampang community health centres, makassar, indonesia. methods: this study used a descriptive correlation design with a cross-sectional study approach. subjects were 40 patients diagnosed with type 2 diabetes who joined prolanis at puskesmas antang and pampang, makassar, and the sampling technique used was total sampling. the data were analysed using a correlation test to assess the significance (p), the direction (+/-), and the strength of the correlation (r). the implementation of prolanis was measured by using the observation sheets developed based on bpjs kesehatan criteria, while the laboratory checked the fasting blood sugar, hba1c, and total cholesterol levels. results: the mean of the implementation of prolanis was 15.05 (sd ± 5.62), while the mean levels of fasting blood sugar, hba1c, and total cholesterol were as follow: 191.80 mg/dl (sd ± 85.15); 8.4% (sd ± 2.08); and 192.87 mg/dl (sd ± 45.07). using the spearman's rho test, the study result showed that there was a significant and negative correlation between the implementation of prolanis and the levels of fasting blood sugar (p= 0.001; r= -0.724), hba1c (p= 0.001; r= -0.870), and total cholesterol (p= 0.029; r= -0.35) in patients diagnosed with type 2 diabetes at puskemas antang and pampang, makassar. conclusions: the optimal implementation of prolanis is very effective for controlling the levels of fasting blood sugar, hba1c, and total cholesterol in patients with type 2 diabetes. keywords: fasting blood sugar, hba1c, prolanis, primary health centre, type 2 diabetes. introduction diabetes mellitus (dm) can be defined as a group of metabolic diseases characterised by hyperglycemia resulting from defects in insulin secretion, insulin action or both. chronic hyperglycemia in diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels (abdel-rahman 2011). besides being a metabolic disease, diabetes is also a global disease endemic. the incidence of diabetes globally, it is estimated, will increase from 366 million to 552 million in 2030 and will present itself as a major health challenge that can be shown by the data of global dm (shaw, sicre & zimmet 2010). if no action is taken, it is estimated the number will rise to 552 million in 2030 and will be the cause of 4.6 million deaths (federation 2011). in indonesia, the number of people with diabetes is as many as 292,715 people, or about 1.8% of the total participants in social health insurance (bpjs kesehatan 2015). the number of cases of diabetes in the province of south sulawesi in 2014 (282 patients) consisted of reported dm (207 patients), unreported dm (160 patients) and dependent dm on insulin (72 patients) (sul-sel 2014). increasing cases of diabetes occurred in makassar. in 2012, dm was ranked the fifth leading cause of death with 191 deaths (dinkes kota makassar 2012), while in 2013 it rose to fourth with 217 (dinkes kota makassar 2013). data for dm patients at puskesmas antang makassar, from january to december 2015 showed 725 patients so that the average number of patients with type 2 diabetes per month was estimated at 61 people, while in january and february 2016 there were at least 136 people and the average number of patients per month was 68 people (rekam medik puskesmas antang kota makassar 2016). prevention of chronic complications is not only through controlling blood glucose levels itself but needs good diabetic control. control of diabetes should be done thoroughly, including mailto:musfirahmad@gmail.com prolanis implementation to control fasting blood sugar (musrifah ahmad et.al.) 89 blood glucose, hba1c, lipid (cholesterol lowdensity lipoprotein (ldl), high-density lipoprotein (hdl), and triglycerides (semiardji, 2003). therefore, the development of new strategies to improve diabetes control and its complications would be very helpful (bianchi, miccoli, daniele, penno & del prato 2009). in indonesia, one of the new strategies developed is the management program of chronic diseases (prolanis). prolanis was developed by bpjs. the main objective of prolanis is to reduce the risk of complications and achieve a better quality of life with the use of costeffective and rational measures. the prolanis program is a system of governance of health services and health education for social health insurance participants who suffer from hypertension and type 2 diabetes mellitus to achieve the optimal quality of life independently (idris 2014). the implementation of prolanis in indonesia took place in 2010. this program helps chronic disease management with an integrated promotive and preventive action format. one of the chronic diseases handled at this time is type 2 diabetes mellitus (idris 2014). the activities of prolanis itself consist of a medical consultation for prolanis participants: consultation schedules agreed between participants with health facility managers, high-risk educational clubs (prolanis club) which are an activity to improve health knowledge in an effort to restore the disease and prevent a resurgence of the disease and improve the health status of prolanis attendees, reminders or activities to motivate participants to make regular visits to health facilities through a consultation schedule reminding them to go to the health facilities manager, and home visits such as service activities of home visits of prolanis participants for the provision of information /self health education and the environment for prolanis participants and their families (bpjs kesehatan 2015). previous research (alexander 2012) has confirmed the effectiveness of the prolanis program. nonetheless, a prolanis effectiveness evaluation in health centers is still limited. therefore, this study aimed to analyse the correlation between the implementation of prolanis with fasting blood sugar, hba1c and total cholesterol in patients with type 2 diabetes mellitus in puskesmas antang and pampang makassar. it can be concluded that prolanis is very effective in controlling health status and improving the quality of life of patients with type 2 diabetes mellitus. based on the explanation, researchers were interested in analysing the correlation of prolanis implementation with fasting blood sugar, hba1c, and total cholesterol in type 2 diabetes mellitus at antang and pampang community health centres makassar. methods this study was a quantitative study with a descriptive correlational design, using a crosssectional study approach for the collection of data. the study was conducted during one month at antang and pampang community health centres makassar. the population in this study was made up entirely of patients with type 2 diabetes mellitus, male and female who were prolanis participants in makassar, as many as 66 (37 patients in antang community health centres and 29 patients in pampang community health centres). calculation of the number of samples shows 64 people, but the samples obtained in this study were 40 people. 24 patients dropped out due to the complications of coronary heart disease (chd) and as many as 12 persons were referred to the hospital, five people refused to respond and seven people were never present during the study. the samples in this study were patients with type 2 diabetes, prolanis participants at antang and pampang community health centres makassar who met the inclusion criteria: male or female ≥ 35 years old, suffered no injuries from diabetes and were willing to participate in this study and signed the informed consent. the exclusion criteria: patients with concomitant diseases such as acute renal failure or chronic renal failure, heart failure/cardiac arrhythmia, chronic liver disease/acute lung tumours or other malignancies, gastrointestinal disease, and patients who were not willing to participate in the study. data were analysed using univariate and bivariate analysis. for numerical data in the form of respondent characteristics such as age, jurnal ners vol. 12 no. 1 april 2017: 88-98 90 diagnosed with type 2 diabetes, the duration of being a participant in prolanis, and the research variables, namely, the implementation prolanis, fasting blood sugar, hba1c and total cholesterol levels using the mean and standard deviation (± sd), whereas categorical data such as gender, occupation and education are presented in the form of n (%). data normality test was done using the shapiro-wilk test. bivariate analysis used the correlative method. if the types of data are numerical data and normally distributed, the pearson correlation test was used, whereas when the data type is not normally distributed the spearman's test was used (dahlan 2015). this study has received ethical approval from the ethical comission of the faculty of medicine universitas hassanuddin with number 1048/h4.8.4.5.31/pp36-kometik/2016, in september 20th, 2016. results out of 40 respondents, most respondents were women (67.5%), did not work or were house wives (65%), had a level of education of junior high school (27.5%), senior high school (25.0 %) and university (27.5%). the average age of respondents was 55.83 years (± sd 8:04), old diagnosed with type 2 diabetes mellitus is 10.85 years (sd ± 4.63), and the duration average following prolanis program that is 17.55 months (sd ± 11.64) (table 1). the average score of prolanis implementation was 15.05 (sd ± 5.62), fasting blood sugar 191.80 mg/dl (sd ± 85.15), hba1c was 8.36% (± sd 2:08), and total cholesterol 192.87 mg/dl (sd ± 45.07). this distribution was based on the implementation of prolanis, fasting blood sugar, hba1c and total cholesterol as can be seen in table 2. table 1 distribution of individual characteristics variable frequency (n = 40) percentage (100%) age (years) mean (± sd) 55.82 8.04 gender male 13 32.5 female 27 67.5 employment farmers/ labour 1 2.5 enterpreanurer 6 15.0 civil servant / tni-police / retired 7 17.5 unemployed/ house wife 26 65.0 education no school / not completed primary school 1 2.5 elementary school 7 17.5 junior high school 11 27.5 senior high school 10 25.0 university 11 27.5 old diagnosed with type 2 diabetes (years) mean (± sd) 10.85 4.63 duration following prolanis (months) mean (± sd) 17.55 11.64 table 2. distribution of respondents by the implementation of prolanis, fasting blood sugar, hba1c, and total cholesterol in patient with type 2 diabetes mellitus (n = 40) variable mean ± sd prolanis implementation 15.055 62 fasting blood sugar 191.80 85.15 hba1c 8.37 2.08 total cholesterol 192.87 45.07 prolanis implementation to control fasting blood sugar (musrifah ahmad et.al.) 91 table 3. relationship of prolanis implementation and fasting blood sugar, hba1c and total cholesterol in patients with type 2 diabetes mellitus variable fasting blood sugar hba1c cholesterol r p r p r p prolanis implementation -0.72 0,001 -0.87 0.001 -0.35 0,029 medical consultation -0.66 0,001 -0.77 0,001 -0.34 0,031 activity group -0.68 0,001 -0.82 0,001 -0.33 0,037 sms gateway -0.7 0,001 -0.81 0,001 -0.37 0,021 home visit -0.39 0.047 -0:49 0:01 -0:36 0062 based on the spearman rho test in table 3, the data showed that there is a relationship between prolanis implementation with fasting blood sugar in patients with type 2 diabetes mellitus at antang and pampang community health centres makassar, with a significance value of (p) 0.001 with a negative correlation direction (r = -0724) and the strength of a strong correlation (r2 = 0.52). the correlation between the activity of prolanis, namely in terms of medical consultation, group activities, sms gateway, and home visit with fasting blood sugar also showed a correlation (p = 0.001; 0.001; 0.001; and 0.047) with the negative correlation direction and the strength of strong and moderate correlation (r = 0.66; 0.68; -0.70; and -0.39). this means that with the maximum implementation of prolanis the lower the levels of gdp with diabetes mellitus type 2. this relationship can be seen in figure 1. based on the spearman rho test in table 3, the data showed that there is a relationship between the implementation of prolanis with hba1c with a significance value of (p) 0.001 with a negative correlation direction (-0.87) and the strength of strong correlation (r2 = 0.76). the correlation between the activity of prolanis was namely in terms of medical consultation, group activities, sms gateway, and home visits with hba1c also showing a correlation (p = 0.001; 0.001; 0.001; and 0:01) with a negative correlation direction and a strength of strong and moderate correlation (r = 0.77; -0.82; -0.81; and -0.49). this means that with the maximum implementation of prolanis the lower the levels of hba1c with type 2 diabetes mellitus. this correlation can be seen in figure 2. figure1. correlationof prolanis implementation and fasting blood sugar figure 2. correlation of prolanis implementation and hba1c levels jurnal ners vol. 12 no. 1 april 2017: 88-98 92 based on table 3, the spearman's rho test data showed that there is a relationship between the implementation of prolanis with total cholesterol levels with a significance value of (p) 0.029 with a negative correlation direction (r = -0.35) and the strength of a weak correlation (r2 = 0:11). the correlation between the activity of prolanis was namely in terms of medical consultation, group activities, and sms gateway with total cholesterol also showing a correlation (p = 0.031; 0.037; and 0.021) with a negative correlation direction and the strength of moderate correlation (r = -0.34; -0.33; and 0.37). however, there is no correlation between a home visit with total cholesterol levels with p = 0.062. this means that with the maximum implementation of prolanis the lower the total cholesterol with type 2 diabetes mellitus. this correlation can be seen in figure 3. discussion prolanis implementation is one of the government programs cooperating with bpjs to encourage participants with chronic illness to achieve optimal quality of life so as to prevent complications of the disease (bpjs kesehatan 2015). prolanis activities are carried out at antang and pampang community health centres makassar, held every week on saturday mornings. according to researcher observations, prolanis activity is ongoing and offers routine activities and is strongly supported by the clinic by providing the facilities needed for these activities and often making activities to strengthen kinship between participants and the public health centres such as holiday activities together. the clinic crew was there as a participant in prolanis so that it became an example or model for other participants. according to green, & kreuter (1999) the habit, model, and the support of the environment, in this case the health care facilities, forms a positive attitude for an individual. the positive behaviour of patients with type 2 diabetes mellitus leads to an awareness of the importance of maintaining a diet, control treatment and regular physical activity, medical consultations and all of that could be obtained if the participants are active in following prolanis activities. in addition, according to the theoretical concepts of precede proceeds say that the individual behaviour is influenced by several predisposing factors, enabling and reinforcing. predisposing factors reflected in the characteristics of respondents, supporting factors described by the infrastructure support in implementing prolanis and reinforcing factors reflected in the attitudes and behaviour of health centre officers who became a model for the implementation of prolanis. good behaviour or lifestyle will both improve an individual's health status (green & kreuter, 1999). health status refers to the control of blood sugar levels and risk factors for complications. this study shows that there is a strong negative correlation between the implementation of prolanis and fasting blood sugar in patients with type 2 diabetes mellitus which means that with the maximum implementation of prolanis the lower the fasting blood sugar levels of type 2 diabetic patients. activity in the implementation of prolanis activities includes medical consultations/education, home visits, reminders, club activities and monitoring of health status. medical consultation exercises undertaken by participants along with health facility managers began with a contract time with medical personnel. consultation includes a prognosis of disease, complaints about the health problems of participants and drugs control (bpjs kesehatan 2015). this study shows there is a strong negative correlation between medical figure 3. correlation implementation prolanis and total cholesterol prolanis implementation to control fasting blood sugar (musrifah ahmad et.al.) 93 consultation with fasting blood sugar levels of respondents with a value of p<0.05 which means that with the maximum value of the medical consultation exercise the lower the fasting blood sugar in type 2 diabetic patients by salistyaningsih. previously salistyaningsih, puspitawati & nugroho (2011) showed a link between adherence in consuming the oral hyperglycemia drug (obat hiperglikemi oral (oho)) with blood glucose levels in patients with type 2 diabetes mellitus in puskesmasumbulharjo ii yogyakarta where patients were wayward in drinking oho 86 times at a risk od increasing blood sugar levels compared with patients who obeyed. hapsari (2014) also examined the treatment of type 2 diabetes mellitus. research results indicate a negative and weak correlation with p <0.05d and r = -0064, r 2 = 0.004 between compliance in taking the drug with blood sugar levels. this means that the higher value of compliance in taking the drug, the lower the blood sugar level which indicates the success of the therapy. besides mona, bintanah & astuti (2012) also examined the association of frequency of nutritional consultation with compliance diet and blood sugar levels in people with diabetes mellitus type 2 at the outpatient hospital tugerejo semarang which showed a significant correlation between the frequency of nutritional counseling and compliance with diet, and there is a correlation between diet compliance with the patient's blood sugar levels. club activity is an activity to improve health knowledge to restore the disease and prevent the return of disease and improve the health status of prolanis participants with physical activity (bpjs kesehatan 2015). physical activity is held every week on saturday mornings and health education on diet and type 2 diabetes treatment is carried out two times a month. based on the results of research conducted there is a strong negative correlation between the activity and the group with a blood sugar value of p = 0.001 and r = -0.68, which means that the higher the value of the implementation of prolanis the lower the fasting blood glucose of type 2 diabetic patients. other studies conducted by putri & isfandiari (2013) which aim to determine whether there is a correlation between the application of the 4 pillars controlling diabetes with the average of blood glucose levels indicate that there is a relationship between absorption education (p = 0.031), diet control (p = 0.002), sport (p = 0.017) and medication adherence (p = 0.003) with the average of blood sugar levels. reminders or sms gateway is an activity to motivate participants to make regular visits to the health facility through a recall schedule (bpjs kesehatan, 2015). sms gateway activity at puskesmas antang and pampang makassar includes recording mobile numbers of participants, enabling a communication network (jarkom) between participants and health centres, and evaluation of the activity of participants in a communication network and enabling the participants to understand the content given. hopefully, by the communication network formed, prolanis participants with type 2 diabetes are able to access information about the prolanis activities to be carried out whether medical consultations, drug taking schedules or group activities that are held every week. based on the results of the research conducted there is a strong negative correlation between the sms gateway with fasting blood sugar for type 2 dm patients at antang and pampang community health centres makassar with p = 0.001 and r = -0.68, which means that the higher the value of the implementation of prolanis the lower the fasting blood sugar of people with type 2dm. a home visit is a service activity visitation to the home of prolanis participants for the provision of information/self-health education and the environment for prolanis participants and their families. terms of these activities include home visits for patients newly enrolled, patients who were not present at prolanis activities for three months in a row, and those who have recently completed in hospitalisation. the results of the home visit are recorded in the book of health monitoring and reported to the clinic and bpjs (bpjs kesehatan 2015). from the data obtained during the study, the implementation of the home visits conducted at puskesmas antanghas have largely been carry out from the 24 patients with type 2 diabetes: 22 participants had received home visits and only two people never got home visits. of the 22 jurnal ners vol. 12 no. 1 april 2017: 88-98 94 participants, only three people who get a home visit of new participants registered and been hospitalised because of the deteriorating health and the 19 other participant visitations were to enroll a new patient in prolanis. but the problem is that for every home visit, there was no record of activity or actions taken by health officers; information was only presented in the report form such as ever or never visited and dates of visits for the evaluation report. in contrast to the puskesmas antang, prolanis participants with type 2 diabetes at puskesmas pampang only occasionally get a home visit. out of 16 patients with type 2 diabetes only five people ever got a home visit and that too was for newly registered participants. the rest (11 participants) never got home visits, and no record of the activities carried out at home visits are available in the patient health monitoring book. this is what underlies the fact that despite the results obtained there is a negative correlation between home visits with fasting blood glucose levels of type 2 diabetes patients in antang and pampang community health centres makassar with p = 0.047, but very weak correlation obtained, namely r = -0.39 and r 2 = 0:15. this means, only 15% of the variation in home visits affects fasting blood glucose levels of type 2 diabetes patients at antang and pampang community health centres makassar. hemoglobin hba1c test results are a highly accurate single examination to assess long-term glycemic status and are useful for all types of dm. this examination is beneficial for patients who need glycemic control. increased levels of hba1c> 8% indicate uncontrolled diabetes and risk of long-term complications such as nephropathy, retinopathy, or cardiopathy (soewondo, 2005). the research data showed that average a1c type 2 dm patients at puskesmas antang and pampang antang uncontrolled makassar city are 8.37%. a 1% decrease in hba1c will reduce complications by 35% (soewondo, 2005). this research was also supported by research conducted by alexander (2012), which aims to analyse the effectiveness of the prolanis in order to control the health status of patients with type 2 diabetes mellitus, who found that there are differences in cholesterol reduction, blood pressure systole and diastole, hba1c, and improved quality of life significantly in the intervention group compared with the control group (p <0.05), but there is no significant difference in bmi reduction between the intervention and control groups, with p> 0.05. syuadzah (2015) aimed to examine the association between adherence to following the activities of prolanis with hba1c levels in patients with type 2 diabetes mellitus in surakarta and showed a significant association (p = 0:04). it can be concluded that prolanis is very effective in controlling health status and improving the quality of life of patients with diabetes mellitus type 2 (burns& grove 2011). behaviour that is promoted is awareness of the importance of keeping your diet, medication control and regular physical activity, medical consultations and all that could be obtained if a participant is active in all the activities prolanis follows. the research done showed that type 2 diabetes patients at antang and pampang community health centres makassar actively carry prolanis with an average value of 15.05 or over half of the total value of a maximum observation sheet which is 25. the activity in prolanis implementation includes activities in the medical consultation/education, home visits, reminders, club activities and monitoring of health status. the partners in the medical consultation exercise that led to the consultation activities undertaken by participants along with health facility managers in this case are antang and pampang community health centres which began with a contract time with medical personnel. these activities include consultation regarding the prognosis of the disease, consultation regarding other complaints about the health problems of participants and the most important is control of drugs (bpjs health, 2015) based on research done there is strong and negative correlation between medical consultation with hba1c levels in diabetic patients with type 2 in antang and pampang community health centres in makassar with p<0.05 which means that with the maximum value of the implementation of a medical consultation, the lower the hba1c levels in type 2 diabetic patients. the research was also supported by research conducted by mona, prolanis implementation to control fasting blood sugar (musrifah ahmad et.al.) 95 bintanah and astuti (2012), which aims to examine the relationship between frequency of nutritional consultation with compliance diet and blood sugar levels in people with diabetes mellitus type 2 at an outpatient hospital tugerejo semarang, which showed a significant relationship between frequency nutrition consultation with diet adherence and a relationship between diet compliance with patient's blood sugar levels. another study about the treatment of diabetes type 2 was also performed by yoga, julianti & pramono (2011), aimed at assessing the relationship between the application of the 4 pillars of control of dm with the successful management of patients with diabetes type 2, where the success of the measure of hba1c levels of patients indicates that medication adherence regularly provided statistically significant results with p = 0.05. group activity is an activity of physical activity and health education to improve patients’ knowledge to restore the disease and prevent the return of disease and improve the health status of participants prolanis (bpjs health, 2015). research by testing using spearmen's rho shows that there is a negative and strong relationship between the activities of the group with blood sugar levels in diabetic patients with type 2 at antang and pampang community health centres makassar with p = 0.001 and r -0.68, which means that the higher the value of the implementation of prolanis the lower the hba1c in type 2 dm patients. physical activity is held every week on saturday morning at antang and pampang community health centres makassar implemented in the form of gymnastic fitness for the elderly. the results of research conducted by yoga, julianti & pramod (2011) aimed to assess the correlation between the implementation of the 4 pillars of control of dm with the successful management of patients with diabetes type 2, where the success of the measure of hba1c levels of patients showed that the regularity of exercise has a significant influence on the success of management of type 2 diabetes with a significant value of p = 0.00; and research by ramadhanisa, larasati, & mayasari (2013) aimed to determine the relationship of physical activity with the hba1c of people with type 2 diabetes mellitus in dr. h. abdul moeloek bandar lampung; this showed a significant association between physical activity levels of hba1c, with p = 0.001. it can be concluded that physical activity is very good for controlling blood sugar levels which can be viewed through an hba1c. in addition to physical activity in group activities education about diet and treatment of patients with diabetes type 2 were also included which, according to the results of research conducted by harum, larasati, & zuraida (2013) aimed to show the relationship between high dietary fibre with levels of hba1c in patients with dm type 2 in a hospital clinical pathology laboratory dr.hi.abdulmoeloek lampung province using the chi-square method; it showed a significant relationship between a high fibre diet with hba1c levels (p-value 0.001). total cholesterol level is the amount of cholesterol found in the blood which includes ldl, hdl, and tgl. cholesterol levels are closely linked to fatty deposits in the human body. if in the inside of the body a person has a lot of fat it is likely to cause various diseases such as heart disease and diabetes. for patients with dm, the amount of fat in the body of excess will aggravate the situation and accelerate the onset of complications due to fat being very easily broken down into glucose in the blood due to insulin resistance. based on the results of research conducted by ekawati (2012) there is a significant correlation between fasting blood sugar and cholesterol levels of triglycerides in the blood in patients with dm which is not well controlled in clinical hospital jombang. as is already known, cholesterol is strongly influenced by physical activity and the food intake of a person. according to research conducted by anam (2010) regular dietary interventions and physical activity or sports as often as 3 times a week for 8 consecutive weeks can lower ldl cholesterol levels in the blood to 13.5 mg/dl and boost levels of hdl to 7.5 mg/dl. research conducted by sari (2014) with pre-post design for 6 weeks showed a difference in total cholesterol before and after aerobic exercise (p= 0.009). according to the analysis of the researchers, the underlying average total jurnal ners vol. 12 no. 1 april 2017: 88-98 96 cholesterol levels of prolanis participants with type 2 diabetes patients at puskesmas antang and pampang makassar is within the normal range of 192.87 mg/dl because the average length for which these participants have followed prolanis activities is less over 18 months or for 72 weeks. physical activity and dietary interventions are one of the activities of prolanis. prolanis group activity is an activity to improve health knowledge to restore the disease and prevent the return of disease and improve the health status of participants of prolanis with physical activity (bpjs health 2015). physical activity is held every week on saturday mornings and health education on diet and type 2 diabetes treatment is carried out twice a month. based on the results of research conducted, there is a negative and weak relationship between activity with total cholesterol levels of type 2 diabetes patients at antang and pampang community health centres makassar with p = 0.037 and r -0.33, which means that the higher the value of the implementation of prolanis the lower the total cholesterol levels in patients with type 2 diabetes. in addition to group activities, other activities included in the prolanis implementation are medical consultations, reminder or sms gateway and home visits. the medical consultation exercise where the consultation activities are undertaken by participants along with health facility managers in this case are held at the health centres and pampang antang which began with a contract time with medical personnel. these activities include consultation regarding the prognosis of the disease, consultation regarding other complaints about the health problems of participants and most importantly the control of drugs (bpjs health 2015). physical activity is held every week on saturday mornings and health education on diet and type 2 diabetes treatment is carried out twice a month. based on the results of the research conducted there is a negative relationship between activity and weak group with total cholesterol levels of type 2 diabetes patients in primary health centres and pampang antang makassar city with p = 0.037 and r -0.33, which means that the higher the value of the implementation of prolanis the lower the total cholesterol levels in patients with type 2 diabetes. reminders or sms gateway are activities to motivate participants to regularly visit the health facility through a recall schedule (bpjs kesehatan, 2015). sms gateway activity at puskesmas antang and pampang includes recording mobile numbers of participants, enabling a communication network (jarkom) between participants and health centres, and evaluation of the activity of participants in jarkom and enabling participants to understand the content of the communication network used. hopefully, through the communication network formed, prolanis participants with type 2 diabetes are able to access information about the activities to be carried out either through prolanis in terms of medical consultation, drug taking schedules and group activities that are held every week. based on the results of research conducted there is a negative correlation between the weak and sms gateway with total cholesterol levels of type 2 diabetes patients at antang and pampang community health centres makassar with a value of p = 0.021 and r = -0.37, which means that the higher the value of prolanis implementation the lower the total cholesterol levels in patients with type 2 diabetes. home visits at puskesmas antang and pampang, based on the previous explanation, have not run optimally. according to the researchers, this is why the assumption based on the spearman's rho test found that there is no correlation between home visits with total cholesterol levels in patients with type 2 diabetes mellitus at puskesmas antang and pampang makassar with p = 0.062. the fourth prolanis activity shows that this event is a program that is highly complex and integrated as it includes activities associated with cholesterol levels in patients with type 2 diabetes. this is what underlies the fact that the spearman's rho test showed that, although weak, there is still a negative relationship between prolanis implementation with total cholesterol levels. the higher the value for implementation of prolanis the lower total cholesterol levels in prolanis implementation to control fasting blood sugar (musrifah ahmad et.al.) 97 patients with type 2 diabetes mellitus and at puskesmas antang and pampang makassar. conclusions maximum prolanis implementation is very effective in controlling fasting blood sugar levels, hba1c and total cholesterol in patients with type 2 dm thus indirectly preventing complications. therefore, it is suggested that prolanis should be implemented in each community health centre and primary health centre and comply with the standards set by government health insurance. the evaluation process of prolanis focused on the quality of implementation; the results can be seen from the impact and benefits to the target group in terms of the glycemic status of patients with type 2 diabetes in the form of measurable data. references abdel-rahman, z., 2011. the effects of antioxidants supplementation on haemostatic parameters and lipid profiles in diabetic rats. journal of american science, 7(3). bianchi, c., miccoli, r., daniele, g., penno, g., & del prato, s., 2009. is there evidence that oral hypoglycemic agents reduce cardiovascular morbidity/mortality? yes. diabetes care, 32(2), pp.342–348. bpjs kesehatan, 2015. panduan praktis prolanis (program pengelolaan penyakit kronis), jakarta: badan penyelenggara jaminan sosial kesehatan. burns, n., & grove, s., 2011. understanding nursing research, building and evidencebased practice 5th ed., usa: elsevier. dahlan, m., 2015. statistik untuk kedokteran dan kesehatan, deskriptif, bivariat, dan multivariat dilengkapi aplikasi menggunakan spss 6th ed., jakarta: epidemologi indonesia. dinkes kota makassar, 2013. profil kesehatan kota makassar, makassar: dinas kesehatan kota makassar. dinkes kota makassar, 2012. profilkesehatan kota makassar, makasar: dinkes kota makasar. federation, i.d., 2011. diabetes evidence demands real action from the un summit on non-communicable diseases. available at: www.idf.org: www.idf.org/diabetes-evidence-demandsreal action-un-summit-non-communicablediseases [accessed january 16, 2016]. green, l.w., & kreuter, m., 1999. health promotion planning: an educational and ecological approach 3, ed., mountain view, ca: mayfield publishing co. hapsari, p., 2014. hubungan antara kepatuhan penggunaan obat dengan keberhasilan terapi pada pasien diabetes mellitus di rs x surakarta, surakarta: fakultas farmasi universitas muhammadiyah surakarta. harum, a., larasati, & zuraida, r., 2013. hubungan diet serat tinggi dengan kadar hba1c pasien diabetes mellitus tipe 2. medical journal of lampung university, 2(4). idris, f., 2014. pengintegrasian program preventifpenyakit diabetes mellitus tipe 2 pt askes (persero) ke bpjs kesehatan. j indon med assoc, 64(3), pp.115–121. mona, e., bintanah, s., & astuti, r., 2012. hubungan frekuensi pemberian konsultasi gizi dengan kepatuhan diit. jurnal gizi universitas muhammadiyah semarang, 1(1). putri, n.h., & isfandiari, m., 2013. hubunganaktivitasfisikdengankadar hba1c pasien. medical journal of lampung university, 1(2), pp.234–243. ramadhanisa, a., larasati, & mayasari, d., 2013. hubungan aktivitas fisik dengan kadar hba1c pasien. medical journal of lampung university, 2(4). rekam medik puskesmas antang kota makassar., 2016. laporan rekam medik puskesmas antang kota makassar, makasar: puskesmas antang. salistyaningsih, w., puspitawati, t., & nugroho, d., 2011. hubungan tingkat kepatuhan minum obat hipoglikemik oral dengan kadar glukosa darah pada pasien diabetes mellitus tipe 2. berita kedokteran masyarakat, 27(4), pp.215– 221. sari, a., 2014. efektivitas pelaksanaan program pengelolaan penyakit kronis (prolanis) dalam penanganan diabetes mellitus (dm) jurnal ners vol. 12 no. 1 april 2017: 88-98 98 tipe 2 oleh dokter keluarga di kecamatan turi kabupaten sleman diy. universitas gadjah mada. shaw, j.e., sicre, r.a., & zimmet, p., 2010. diabetes research and clinical practice global estimates of the prevalence of diabetes for 2010 and 2030. diabetes research and clinical practice, 87, pp.4– 14. sul-sel., d.p., 2014. profil kesehatan pemerintah provinsi sul-sel, sulawesi selatan: dinkes pemprov sul-sel. yoga, a., julianti, h.p., & pramono, d., 2011. hubungan antara 4 pengelolaan diabetes mellitusdengankeberhasilanpengelolaan dm tipe 2, semarang: program pendidikan sarjana kedokteran umum. 462 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20509 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original article the analysis of the roasting tradition (se’i/nu), maternal hemoglobin level and the uterine involution process among puerperal women korbaffo anita restu, novita ana anggraini, and nur yeny hidajaturrokmah faculty of nursing, health sciences institute strada, kediri, east java, indonesia abstract introduction: se'i/nu is one of the traditions of the local community on the island of timor. the mother and the baby always breathe polluted air because the fuel commonly used is biomass fuel. this can lead to health problems for both the baby and the mother. the research objective was to prove the relationship between the roasting tradition (se'i/nu) with the hemoglobin level and the process of uterine involution in postpartum women. methods: the research design was analytical with an observational approach. the sample consisted of 42 respondents obtained through total sampling. the independent variable was the roasting tradition (se’i/nu) and the dependent variables were hemoglobin level and maternal uterine involution. the method used to measure the roasting tradition (se’i/nu) was an observation sheet. to measure the hemoglobin level, we used a laboratory check and to measure uterine involution, we conducted a physical examination and used an observation sheet. results: the results showed that the largest percentage of hemoglobin levels in postpartum mothers was among those that did the roasting tradition (se'i/nu) with an abnormal hemoglobin level of 66.66% (22 people). the puerperal women who did the tradition of roasting (se'i/nu) obtained high uterine fundus and the abnormal mothers made up the largest percentage of 69.70% (23 people). there was a correlation between the roasting tradition (se'i/nu) and maternal hemoglobin level (p=0.025) and there was also a correlation between the roasting tradition (se'i/ nu) with the process of maternal uterine involution (0.00). conclusion: the conclusion is that there is a prolonged uterine involution process and that the low hemoglobin levels in the puerperium may be due to exposure to chemical susceptibility as a result of inhaling polluted air due to the se'i/nu process. article history received: feb 27, 2020 accepted: april 1, 2020 keywords roast tradition (se’i/nu); maternal hemoglobin level; uterine involution process contact korbaffo anita restu  korbaffo@gmail.com  faculty of nursing, health sciences institute strada, kediri, east java, indonesia cite this as: restu, k. a., anggraini, n. a., & hidajaturrokmah, n.y. (2020). the analysis of the roasting tradition (se’i/nu), maternal hemoglobin level and the uterine involution process among puerperal women. jurnal ners, special issues, 462-465. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20509 introduction among the 240 million people in indonesia, there are many community groups who still hold to the local customs. these groups are spread out over 33 provinces and they are derived from 370 ethnicities/sub-ethnicities. one of community who still holds to the local culture is the local community in the middle of timor island, especially in north central timor district (timor tengah utara). the local community still implements the roasting tradition (se’i/nu) based on the observation conducted by interviewing the puerperal women initialed mn and the officer of subdistrict initialed jl, the roasting tradition is the heating of the woman’s vital area with smoke inside a traditional house (ume kbubu) within 40 days postpartum by an experienced shaman. this ritual obligates every woman who has just given birth to lie down next to a coal fire. the roasting tradition https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 463 is done in the morning and late in the afternoon whilst drinking a traditional concoction. this is a trusted way for the body to recover and to clean the body of “dirty blood” e.g. menstrual blood, blood clots or poisons. puerperal women are forbidden from eating certain kinds of food. because this activity has been banned, it is very rare to find a society where atoni meto is done nowadays(christina r, 2014). during the heating process, the puerperal women and her child will always suck in polluted air because they use biomass fuel (firewood). this incineration usually releases contaminants and pollutants such as dust particles (suspended particulate matter/spm), carbon dioxide (co2), sulfur oxide (so2), formaldehyde (hcho), nitrogen oxide (nox), carcinogenic compounds such as polycyclic aromatic hydrocarbons, carbon monoxide (co), nitrogen oxide (no) and other free radicals. the inhalation of these substances can cause health problems ranging from respiratory irritation to lung disorders (soerachman rachmalina and wiryawan yuana., 2013). in addition to carbon monoxide, exposure to carcinogenic substances such as benzene through inhalation over a certain range also has an effect on the blood hemoglobin levels. this can cause damage to human blood cells. this happens because benzene exposure can reduce the ability of the bone marrow to produce red blood cells and thus reduce the ability of the red blood cells to live, causing a decrease in blood hemoglobin levels. this can cause aplastic anemia, acute bleeding and immune cell damage(a athena and soerachman rachmalina, 2014). anemia in puerperal women is caused by factors such as childbirth hemorrhage, pregnant women with anemia, less nutrition and viral disease. anemia effect on the expectant phase is in the form of less breastfeeding and more easily getting a mammae infection. anemia in the expectant phase can cause the subinvolution of the uterus. this can cause hemorrhage postpartum and a pueperal infection. this happens because the uterus has difficulty contracting in the expectant phase. this is because the oxygen level in the blood is decreased so the blood is not enough to provide the oxygen to the uterus. the result can be seen from the high level of fundus in the uterus which does not going back to normal in expectant women. there is also a greater risk of hemorrhage after giving birth(prawirohardjo and sarwono, 2005). the purpose of this study was to analyze the relationship between the roasting tradition (se'i/nu), the hemoglobin level and the process of uterine involution in puerperal women. materials and methods this research was analytical. the design used was observational and analytical with a cross-sectional approach. the population in this study was mothers who had given birth who were still in the postpartum period. the sample in this research was the women who were still in the postpartum period from july to september 2017. the determination of the sample was doe using a total population equal to 42 respondents. some of the sample criteria were postpartum mothers in the 10th to 40th days following with babies who were willing to be examined with parental consent. the independent variable in this study was the roasting tradition (se’i / nu) and the dependent variable was the mother’s hemoglobin level and the uterine involution process of puerperal women. the process of collecting the data involved using a laboratory test to determine the maternal hemoglobin level. an observation sheet was used to check the uterine involution process and the roasting (se’i/nu) tradition. the data was analyzed using chi square (fisher’s exact) with a level of significant α = 0.05 in to determine the relationship between the roasting tradition (se’i/nu) and the hemoglobin level and uterine involution process. ethical clearance was sought before conducting the research. ethical clearance in this study was conducted by the faculty of public health of airlangga of university. results based on the research, it was found that of the puerperal women who over 30 years old and who practice the roasting tradition (se'i / nu) totaled 54.54% (18 people). most of the puerperal women who practice the roasting tradition (se'i / nu) have a low education level, totaling 84.85% (28 people). most of the puerperal women are housewives and they practice the roasting tradition (se'i / nu), totaling 90.90% (30 people). most of the puerperal women have a low incomes and practice se'i / nu, totaling 78.78% (26 families). based on the statistical test results, some of the variables that have a connection with the roasting tradition (se’i/nu) include the high level of the mother’s uterine fundus (p value = 0.000) and the mother’s hemoglobin level (p value = 0,025). this variable connection can be seen from the p value < ɑ. this means that there is a connection between the roasting tradition (se’i/nu) and the high level of the mother’s uterine fundus. there is also a connection between the roasting tradition (se’i/nu) with the mother’s hemoglobin level. the or (odd ratio) of the puerperal women’s hemoglobin levels is 7.00. this means that the roasting tradition (se’i/nu) is the risk factor that causes the hemoglobin level of puerperal women to become abnormal. discussion the results showed that almost all of the respondents (78.6%) still maintain childbirth in a traditional way by warming up in the form of roasting. this is done in the form of a charcoal fire being placed under the bed of the respondent. the respondents acknowledged that there were benefits after se'i/nu including the mother and baby becoming healthier and stronger, in addition to warmth, the removal of dirty blood after childbirth being smooth and restoring the mother's condition to normal as it was before giving birth. k. a. restu, et al. 464 | pissn: 1858-3598  eissn: 2502-5791 there were 9 respondents who did not carry out this tradition after giving birth. the 9 respondents, after further questioning, were found to be nonnative residents of the eban region. some came from families with a higher level of formal education and some acknowledged that they had received education from health workers stating that this tradition had been banned. this is because the se'i /nu tradition has a bad impact on both the mother and baby. the hemoglobin level of the postpartum mothers who practiced the roasting tradition (se'i/nu) showed as abnormal for 66.66%. most of the mothers who did not practice the roasting tradition (se'i/nu) had a normal hemoglobin level with a percentage of 77.77%. a study was conducted to see the contribution of smoke from firewood (biomass fuel) and the impact that it has on anemia among pregnant women in nagpur, india. the results of the study showed that the level of anemia was medium to high among the women who live in the house and use biomass fuel for their cooking activity compared to the women who live in a house that does not use biomass fuel. this research proves that using biomass fuel in a household as a part of the cooking activity can increase the anemia risk of pregnant women, despite the other factors involved. this result can be accepted logically because biomass smoke potentially evokes systemic infection. systemic inflammation is a causal factor of anemia which is mediated by cytokine inflammation due to the factors of a necrotic tumor alfa (tnf-ɑ), interleukin-1 (il-1), interleukin-6 (il-6) and interferon-γ (ifn-γ). the cytokine mechanism that causes anemia includes the dysregulation of iron homeostatis, the erytropoietin response being hampered due to the low level of hemoglobin and the response of the backbone to erythropoietin being changed(charlotte m. page, archana patel, 2015). another study (hashim, kadhim k. ghdha, 2015) found, that there is effect from firewood smoke on the hemoglobin levels of people who are in proximity to it. the results showed that the hemoglobin level tend to be lower in the group in proximity to the smoke than in the control group. this may have a connection with oxidative stress. oxidative stress will react with oxygen. the excess of reactive oxygen relative to glutathione peroksidase can cause red blood cell membrane damage and this can cause the lowering of the hemoglobin level. there are 22.22% (2) respondents of puerperal women who do not practice se'i/nu tradition and have abnormal hemoglobin levels. apart from exposure to biomass fuel as a trigger for the low or abnormal hemoglobin in postpartum mothers, hemoglobin level is influenced by many factors including chronic bleeding, vitamin b 12 deficiency or vitamin c, heredity, comorbidities and diet, especially in postpartum mothers. another research(k.a. radoff, lisa m. thompson, kc bly, 2012), stated that there is a tradition after giving birth in guatemala where a lukewarm bath takes place. it is believed to normalize, cure, and to heat the uterine. the “heating uterine” concept is based on the ethnic cultural knowledge where they believe in the concept of a “hot-cold balance”. the loss of blood during the postpartum period is believed to cause a cold condition and there are many practices for restoring and defending the warmth, thus repairing the condition of the mother during the expectant period. this cultural practice is believed to increase uterine involution and decrease blood loss after giving birth. one study dealt with tradisi badapu in aceh. there are some rituals in the badapu tradition such as heating the woman’s body in the morning and late in the afternoon with the flame of a coal fire. this table 1. respondent’s characteristics variable roasting tradition (se’i/nu) heated not heated mother’s age 20-30 years 15 (45.45%) 5 (55.55%) over 30 years old 18 (54.54%) 4 (44.44%) mother’s education low (elementary – junior high school) 28 (84.85%) 1 (11.11%) high (senior high school college) 5(15.15%) 8 (88.88%) mother’s work housewife 30 (90.90%) 3 (33.33%) private sector 2 (6.06%) 2 (22.22%) civil servant 1 (3.03%) 4 (44.44%) family income below the regional minimum wage ( umr*) (<850.000 idr,-) 26 (78.78%) 1 (11.11%) above the regional minimum wage (umr*) (>850.000 idr,-) 7 (21.21%) 8 (88.88%) table 2. statistical test results variable statistical test results ci (p value) or lower upper maternal hemoglobin level 0.025 7.000 1.416 45.772 uterine involution process 0.000 1.240 2.911 jurnal ners http://e-journal.unair.ac.id/jners | 465 restores the condition of the mother’s stomach after giving birth using bricks or coconut that have been heated in fireplace and then wrapped in cloth and morinda. it is put on the mother’s stomach and heated again after getting cold. it is believed that this will speed up the process of the stomach becoming wrinkled, bringing back the muscle tone of the stomach, making the body slender, making the mother’s genital organs tighter, cleaning the dirty blood (inong sri rahayu, mudatsir, 2017). another research (cindy-lee dennis, kenneth fung, sophie grigoriadis, gail erlick robinson, 2007) showed that the traditional treatments performed on postpartum mothers by heating or occupying something hot can make their maternal better, such as sitting on hot coals or warming the mother up. while this can cause dehydration, it also results in vasodilation and decreased blood pressure. it can even stimulate bleeding which results in anemia. most of the postpartum mothers who practice the roasting tradition (se'i/nu), have an abnormally high fundus of the uterus, amounting to 69.70%. for the mothers who did not practice se'i/nu, all of the respondents had a normal uterine fundus height. from the results of the statistical tests, it was found that there is a relationship between the tradition of roasting (se'i/nu) and the process of uterine involution among the postpartum mothers who practice the roasting tradition. the research shows that the low hemoglobin in puerperal women can cause anemia. during the postpartum period, anemia can make the uterus difficult to contract. this is because the oxygen that is bound in the blood decreases so then the blood is not oxygenated enough to provide oxygen to the uterine. the manifestations that are seen are from the height of the fundus of the uterus does not return to normal in the puerperal mothers and there is excessive postpartum/lochea blood expenditure after childbirth (richard e, 2005). the results of the study reveal that puerperal women who practice the se'i/nu tradition and who have a normal uterine involution process totaled 30.30% (10 people). the factors that influence the uterine involution process in postpartum mothers include the initiation of early breastfeeding (im), lactation, early mobilization and nutrition. breastfeeding immediately after the baby is born has a contracting effect on the uterine lining which helps to decrease the height of the uterine fundus. conclusion there is connection between the roasting tradition (se’i/nu) with the hemoglobin level of puerperal women. there is a connection between the roasting tradition and the uterine involution process among puerperal women. references a athena and soerachman rachmalina. (2014). kesehatan ibu dan bayi yang melakukan tradisi se’i dan gambaran kesehatan lingkungan rumah bulat (ume ‘kbubu) di kabupaten timor tengah selatan propinsi nusa tenggara timur. jurnal kesehatan reproduksi, 5(1). charlotte m. page, archana patel, p. l. h. (2015). . does smoke from biomass fuel contribute to anemia in pregnant women in nagpur, india? a cross-sectional study. plos onel doi:10.137, 137(journal.pone. 0127890). christina r, n. (2014). tradisi se’i (pantangan makanan ) suku timor dan dampaknya pada ibu nifas (status gizi dan kadar hemoglobin). tesis. program pascasarjana fakultas kesehatan masyarakat universitas airlangga. airlangga. cindy-lee dennis, kenneth fung, sophie grigoriadis, gail erlick robinson, s. r. & l. r. (2007). traditional postpartum practices and rituals a qualitative systematic review. women’s health, 4. hashim, kadhim k. ghdha, h. f. a. and k. m. t. (2015). effect of woodsmoke on lipid peroxidation, some antioxidants, vitamins a, c, e and some trace element levels in serum of iraqi workers. . . iosr journal of nursing and health science (iosrjnhs)e-issn : 2320-1959.p-issn:2320-1940, volume 4(5), 70–74. inong sri rahayu, mudatsir, k. h. (2017). faktor budaya dalam perawatan ibu nifas. jurnal ilmu keperawatan vol 5, no.1., 5(issn: 2338-6371). k.a. radoff, lisa m. thompson, kc bly, c. r. (2012). . practice related to postpartum uterine involution in the western highlands of guatemala. pmc journals. pmc : pmc3799972, 56. prawirohardjo and sarwono. (2005). . ilmu kebidanan. jakarta: bina pustaka. richard e, b. (2005). ilmu kesehatan anak edisi 15: nelson text book of pediatric. jakarta: egc. soerachman rachmalina and wiryawan yuana. (2013). persepsi dan sikap masyarakat desa di kabupaten timor tengah selatan tentang melahirkan. jurnal kesehatan repdroduksi, 4(1). jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.26676 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license editorial social capital in community nursing profession: rural vs. urban communities najla a barnawi assistant professor, college of nursing-riyadh, ksau-hs *corresponding author: najla a barnawi assistant professor, college of nursing-riyadh, ksau-hs email: barnawin@ksau-hs.edu.sa social capital is a complex, socially constructed phenomenon and essential in community nursing, basically considering the rurality variations versus urbanity discourse. applying sociological theory in rurality and urbanity discourse provides a deeper insight into the microscopic and macroscopic factors that concern social capital. sometimes social capital is used as a core concept of micro-sociological theory to illustrate the social network where the human interactions are the major components. therefore, networking in social capital aims to enhance trust and civism. in such a view, the nurse community interpersonal ties and skills are essential to sustain social capital. it distinguishes the civism characteristics between rural versus urban population. a network and trust relationship, for instance, maintains the social capital of rural communities more than urban ones because of the vital kinship status, which constructs the civism of urban communities. this indicates that interpersonal relationships, which construct rural communities' networks, create a powerful societal supportive system. however, the out-migration of younger communities negatively impacts the interpersonal and kinship status, threatening rural social capital sustainability. accordingly, it is logical to assume that social capital is more substantial in rural communities, though it is only sustained within the older generation. indeed, aging and a higher morbidity rate leads the older population to be more isolated from younger, especially the middle -age generations. in contrast, network and interpersonal relationships in urban communities seem to be more casual than in rural communities. based on that view, urbanization changes the pattern of networking and interpersonal relationships. this leads the younger population to seek alternatives to sustain interpersonal relationships, such as social media networking. however, these alternatives may not support the real meaning of civism and trust relationships. therefore, and from a microscopic view, some controversies impact social capital sustainability in urban communities. alternatively, social capital is a significant concept of a macro-sociological theory wherein that lens, societal and cultural construct, and collective human actions within a society are major social capital components. several scholars emphasize the importance of social ties and shared norms to societal wellbeing and economic efficiency. such a concept illustrates the social inequality and hierarchical social structures among rural and urban communities. therefore, it is logical to classify social capital sustainability at a mesoscopic level into economic sustainability and ethnic/cultural sustainability. these factors are overlapped with each other, though all of them are influenced by geographical and non-geographical factors. the low and unstable economic status in rural communities negatively impacts the sustainability of social capital finical status. the industrialization of agriculture increases the low -rate wages jobs among the rural population and evidence asserts that manufactured and industrialized agriculture shifts social capital financial status from rural areas to urban and suburban areas. indeed, the degree of unstained social capital varies between rural communities based on geographical location as well. for example, residents in rural areas, especially those with low income, are more isolated from taking the benefits of the minimal types of social services. furthermore, considering the state exchange of the affordable care act (aca), it is vital to address the potential disparities among rural communities in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:barnawin@ksau-hs.edu.sa n. a. barnawi | pissn: 1858-3598  eissn: 2502-5791 states that follow this legislation versus those which do not. this leads to inequalities in accessing and utilizing the most needed social services, such as healthcare. there are various assumptions about the role of ethnic diversity in social capital. some argue that it harms social capital at the community level, where ethnically diverse neighborhoods in urban communities decrease the social capital acculturation in urban and suburban communities more than rural communities. in contrast, some evidence highlights the association between ethnic diversity and trust, explaining an insignificant one percent of neighborhood-level fluctuation. the differential effect of diversity on neighborhood norms is less apparent once other factors, such as neighborhood poverty, are considered. however, there has also been found to be a slightly negative impact of diversity on social norms. therefore, it is logical to consider ethnic diversity as a factor that has other contextual variables. 173 upaya peningkatan keterampilan konseling kesehatan reproduksi mahasiswa melalui pelatihan konselor sebaya (improving counselling skills about reproductive health among students by using peer counselor training) ririn harini*, ibrahim rahmat**, wenny artanty nisman** * program studi ilmu keperawatan fakultas kesehatan universitas muhammadiyah malang, jl. bendungan sutami no 188a malang **program studi magister keperawatan fakultas kedokteran universitas gadjah mada, yogyakarta e-mail: ri2nharini@gmail.com abstrak pendahuluan: saat ini, tujuan millennium development goals (mdgs) untuk meningkatkan kesehatan maternal masih menjadi prioritas utama di banyak negara. pemerintah indonesia, melalui badan koordinasi keluarga berencana nasional (bkkbn) telah ditindaklanjuti dengan monitoring dan evaluasi program-program yang diwujudkan dengan memberikan pembinaan pada remaja melalui program generasi berencana dan pik-krm. untuk meningkatkan peran konselor sebaya, pelatihan harus dilakukan untuk meningkatkan pengetahuan, sikap, dan keterampilannya. tujuan dari penelitian ini adalah untuk mengetahui pengaruh pelatihan konselor sebaya terhadap pengetahuan, sikap dan keterampilan mahasiswa pengurus pik-krm. metode: penelitian ini berdesain quasy-eksperiment dengan metode pretest and posttest nonequivalent control group. populasi adalah pengurus pik-krm, di fakultas ilmu kesehatan, universitas muhammadiyah malang. sampel berjumlah 80 orang. variabel independennya adalah pelatihan, sementara variabel dependennya meliputi pengetahuan, sikap, dan keterampilan konselor sebaya. data dikumpulkan dengan kuesioner dan lembar observasi. data kemudian dianalisis dengan paired t–test, independent t-test, dan simple linear regression. hasil: hasil analisis linier regression menunjukkan bahwa ada pengaruh yang signifikan dari pelatihan terhadap pengetahuan (p=0,000; r square=0,254), sikap (p=0,000; r square=0,432), dan keterampilan (p=0,000; r square=0,191) konselor sebaya. diskusi: pelatihan dapat meningkatkan pengetahuan, sikap, dan keterampilan konselor sebaya di pik-krm dalam memberikan informasi dan konseling tentang kesehatan reproduksi (seksualitas, hiv/aids, dan penyalahgunaan obat terlarang). perawat diharapkan memberikan pelatihan berkelanjutan secara rutin, sehingga kemampuan konselor sebaya menjadi lebih baik. kata kunci: pelatihan, konselor sebaya, pengetahuan, sikap, keterampilan, pik-krm, kesehatan reproduksi mahasiswa abstract introduction: nowadays, the goal of mdgs to improve maternal health is one of the priorities of many countries. indonesian government, by the national family planning board (bkkbn), has followed up by monitoring and evaluating programs which is realized by providing technical guidance resilience in young people through generation planning program and developing information and consultation center for students reproductive health (pik-krm). in order to improve the role of peer counselors, a training should be done to increase their knowledge, attitudes, and skills. the objective of this research was to determine the effects of training on peer counselor’s knowledge, attitudes, and skills at pik-krm. methods: the study was used quasy experiment pre-test and post-test nonequivalent control group design. population were the committee of pik-krm at faculty of health, university of muhammadiyah malang, 80 students were included. independent variable was training, while dependent variables were peer counselor’s knowledge, attitude, and skills. data were collected by using questionnaire and observation form. data were then analyzed by using paired t–test, independent sample t-test, simple linear regression. results: the results of linear regression had showed that training have significant effect on peer counselor’s knowledge (p=0.000; r square=0.254), attitude (p=0.000; r square=0.432), and skills (p=0.000; r square=0.191). discussion: training can improve peer counselor’s knowledge, attitude, and skills at pik-krm board in giving information and counseling about reproductive health (sexuality, hiv/aids, and drugs). nurses should provide continous training regularly, so their ability can be more better. keywords: training, peer counselors, knowledge, attitudes, skills, pik-krm board, students reproductive health pendahuluan bkkbn (2010), menyatakan bahwa salah sat u program pembangunan yang berkaitan dengan kependudukan adalah keluarga berencana (kb), yang bertujuan m e n ge n d a l i k a n ju m l a h p e n d u d u k d i antaranya melalui program pendewasaan usia perkawinan (pup) yang di dalam 174 jurnal ners vol. 9 no. 2 oktober 2014: 173–182 pelaksanaannya telah diintegrasikan dengan penyiapan kehidupan berkeluarga bagi remaja (pkbr). pkbr merupakan salah satu program pokok pembangunan nasional yang tercantum d ala m renca na pemba ng u na n ja ng k a menengah (rpjm 2010–2014). arah kebijakan program penyiapan kehidupan berkeluarga bagi remaja adalah mewujudkan tegar remaja dalam rangka tegar keluarga untuk mencapai keluarga kecil bahagia sejahtera. tegar remaja adalah membangun setiap remaja indonesia menjadi tegar yaitu remaja yang menunda usia perkawinan, berperilaku sehat, menghindari risiko triad krr (seksualitas, hiv/aids dan napza), menginternalisasi norma keluarga kecil bahagia sejahtera dan menjadi contoh, idola, teladan dan model bagi remaja sebaya. kerangka tegar remaja merujuk dari hasil evaluasi program kesehatan reproduksi remaja (krr) tahun 1990 –2000, yang dilakukan oleh school of public health, university of michigan, usa, 2005 dan evaluasi kesehatan reproduksi remaja asia, afrika dan amerika latin (world bank report, 2007). ke ny a t a a n ny a s a a t i n i , r e m aja mempu nyai per masalahan yang sangat kompleks seiring dengan masa transisi yang dialami. masalah yang menonjol di kalangan remaja yaitu permasalahan seputar triad krr (seksualitas, hiv/aids dan napza), rendah nya pengetahuan remaja tentang kesehatan reproduksi, dan median usia pertama perempuan relatif masih rendah yaitu 19,8 tahun (sdki, 2007). dengan demikian, remaja masih membutuhkan pendampingan, bimbingan, dan penanganan serius dalam mengatasi masalah yang akan dan sudah dihadapinya. menurut policy brief-pusdu (2012), pengetahuan remaja tentang pup yang diperoleh melalui majalah, surat kabar, radio cukup tinggi. sementara informasi yang diperoleh dari pik-krm masih rendah. merujuk dari mdgs tentang pentingnya meningkatkan status kesehatan reproduksi remaja yang merupakan salah satu prioritas penanganan saat ini, maka pik adalah salah sat u wadah yang dikembangkan dalam prog ram gen re (generasi berencana), yang dikelola dari, oleh, dan untuk remaja/ mahasiswa guna memberikan pelayanan informasi dan konsultasi tentang pendewasaan usia perkawinan, delapan fungsi keluarga, triad krr (seksualitas, hiv dan aids, ser ta napza), keterampilan hidup (life skills), gender dan keterampilan advokasi, serta komunikasi, informasi dan edukasi. keberadaan dan peranan pik-k r m di lingkungan remaja/mahasiswa sangat penting dalam membantu untuk memperoleh informasi dan pelayanan konsultasi yang cukup dan benar tentang penyiapan kehidupan berkeluarga bagi remaja/mahasiswa (bkkbn, 2012). dalam menjalankan kegiatan konsultasi, infor masi dan edu kasi pada pik-k r m diharapkan dapat menjadikan remaja yang sehat, kreatif, mandiri, dan berakhlaqul k a r i m a h d a l a m r a n g k a t e r w uj u d ny a keluarga yang berkualitas. selain itu, juga menyelenggarakan kegiatan penyuluhan, penelitian dan pelayanan kesehatan reproduksi remaja tentang triad krr (seksualitas, napza dan hiv/aids), mewujudkan keluarga yang berkualitas dengan pendewasaan usia perkawinan, serta bercita-cita mewujudkan keluarga kecil bahagia sejahtera (jaringan epidemiologi nasional, 2009). dalam upaya meningkatkan pemahaman remaja tentang kesehatan reproduksi, menjadikan remaja tegar dalam menghadapi masalah, dan mampu mengambil keputusan terbaik bagi dirinya, maka pelayanan konsultasi sangat diperlukan bagi remaja dengan melakukan konsultasi pada teman sebayanya, yang disebut sebagai konselor sebaya (bkkbn, 2008). berdasarkan hasil wawancara diketahui bahwa pelaksanaan pelatihan konselor sebaya dilaksanakan satu kali dalam setahun oleh bkkbn pusat dengan jumlah peserta dalam kegiatan tersebut hanya 2 perwakilan dari setiap pik, sehingga jumlah konselor sebaya masih sedikit yang mendapatkan pelatihan. jumlah pik di kota malang saat ini berjumlah 36 dengan kondisi status yang baru tumbuh ada 22 orang, tegak 4 orang, dan tegar 10 orang. masing-masing pik diharapkan mempunyai inisiatif dan dukungan dari institusi untuk melaksanakan pelatihan bagi pengurus pik dalam meningkatkan sdm para pengurus pik, sehingga bisa menjadi konselor sebaya yang profesional secara mandiri. studi pendahuluan 175 upaya peningkatan keterampilan konseling kesehatan (ririn harini, dkk.) yang dilaksanakan oleh peneliti pada pik mahasiswa di kota malang dari 10 mahasiswa pengur us pik yang diberikan kuesioner mengatakan 5 orang (50%) mengatakan kurang percaya diri dalam memberikan konsultasi pada temannya, 3 orang (30%) mengatakan k u rang mendapatkan penget ahuan dan informasi tentang kesehatan reproduksi dan sisanya 2 orang (20%) mengatakan bahwa media untuk melakukan konsultasi masih sangat terbatas misalnya leaflet, lembar balik, modul, lembar balik dan masih banyak lagi yang lainnya. padahal seorang konselor itu diharapkan dapat memberikan informasi tentang kesehatan reproduksi dan membantu memberikan alternatif penyelesaian masalah yang sering dihadapi oleh teman sebayanya. menurut aryani (2010) pengetahuan remaja sebelum mengikuti pik-krr sebagian besar rendah (60%) dan setelah mengikuti pik-krr baik (96,7%). hal ini menunjukkan bahwa dengan masuk dalam pusat informasi dan konsultasi dapat mempengaruhi remaja dalam mencari informasi dengan saling berbagi menjadi pengurus pik agar terjadi peningkatan pengetahuan dan kemampuan dirinya dalam memberikan konsultasi pada teman sebaya. menurut widiantoro (2004), upaya pendekatan yang berpusat pada keluarga telah dilakukan pada sebuah proyek percontohan yang dilaksanakan di jawa tengah dan jawa timur untuk melatih rekan pendidik, dikoordinasikan oleh bkkbn. sebanyak 80 pendidik sebaya yang merasakan bahwa kegiatan seperti ini penting dilaksanakan secara berkala. namun pemerintah belum dapat memenuhi secara menyeluruh di berbagai daerah. pik-krm fakultas ilmu kesehatan, umm adalah salah satu pik-krm yang berada di kota malang, di bawah naungan bkbpm (badan keluarga berencana dan pemberdayaan masyarakat) kota malang, di mana saat ini masih menjalankan dan mengembangkan program kerja dan pelayanan secara aktif dengan tujuan agar tetap menjadi pik mahasiswa pada tahapan tegar. dalam menjalankan perannya sebagai pusat layanan kesehatan, maka konselor sebaya setempat diharapkan mampu membantu mengatasi masalah kesehatan reproduksi pada mahasiswa atau remaja. jika remaja tidak mengetahui tentang kesehatan reproduksi, maka dapat ter jadi prak ti k kesehat an yang bu r u k, kehamilan yang tidak diinginkan, kejadian hiv/aids dan penyakit menular seksual (sdkir, 2007). pemberian infor masi dan edu kasi me r upa k a n ca r a u nt u k me n i ng k at k a n penget ahuan remaja tent ang kesehat an reproduksi sehingga diakhir tahun 2015 minimal 90 persen remaja sudah mendapatkan infor masi (icpd dan mdgs). kegiatan seperti ini sudah dilakukan oleh pik-krm, fakultas ilmu kesehatan, umm. namun, ada beberapa kendala yang dialami seperti kurangnya pembekalan yang diberikan pada para konselor di kampus membuat pengurus pi k-k r m k u ra ng percaya d i r i d ala m memberikan pendidikan kesehatan pada teman sebaya. kegiatan koordinasi seperti frekuensi kunjungan belum rutin dilaksanakan, kegiatan promosi kesehatan belum sesuai program kerja, kesibukan akademik yang tinggi sehingga peran konselor belum bisa maksimal. berdasarkan permasalahan di atas, dapat diketahui bahwa pengetahuan, sikap, dan keterampilan harus dimiliki oleh remaja yang masuk dalam pik-krm masih perlu ditingkatkan. sedangkan, cara peningkatannya melalui berbagai kegiatan positif yang salah satunya melalui pelatihan konselor sebaya agar dapat diketahui kemampuannya saat melaksanakan peran nya di lingk u ngan sekolah/kampus, maupun di masyarakat pada umumnya. oleh karena itu, perlu diketahui pengaruh pelatihan konselor sebaya terhadap penget a hu a n , si k ap d a n ket e r a mpila n mahasiswa pengurus pik-krm di fakultas ilmu kesehatan, universitas muhammadiyah malang. bahan dan metode pe nel it ia n i n i b e rde s a i n qu a s y eksperiment dengan metode pretest and post test nonequivalent control group. quasy di mana kelompok kontrol maupun kelompok yang diberikan intervensi tidak dipilih secara random. kelompok intervensi merupakan kelompok yang diberikan pelatihan dengan 176 jurnal ners vol. 9 no. 2 oktober 2014: 173–182 metode ceramah, diskusi, simulasi/role play, dan pemberian modul. kelompok kontrol merupakan kelompok yang hanya diberikan modul saja. populasi dalam penelitian ini adalah mahasiswa pik-k r m di fak ultas ilmu kesehatan, universitas muham madiyah malang. sampel ditetapkan dengan beberapa kriteria inklusi, yaitu: 1) mahasiswa anggota pik-krm yang belum pernah mengikuti pelatihan; 2) mahasiswa yang aktif dalam kegiatan pik-krm; 3) minimal 3 bulan menjadi anggota; dan 4) bersedia menjadi responden. berdasarkan kriteria tersebut diperoleh 40 orang masing-masing kelompok. pengumpulan data pada penelitian ini meliputi pengisian identitas responden berupa usia, jenis kelamin, dan asal jurusan program studi. pengukuran data dalam penelitian ini menggunakan kuesioner pengetahuan dan sikap, serta checklist keterampilan dalam bent uk per tanyaan yang mengacu pada pedoman modul pelatihan bkkbn (2008) tentang kesehatan reproduksi dan triad krr (seksualitas, hiv/aids, dan napza). observer melakukan observasi sebelum dan sesudah dilaksanakan pelatihan konselor sebaya dengan alat ukur khusus observer. pengambilan data dilakukan sebanyak dua kali yaitu pretest dan post test di mana jeda pengambilan data adalah sat u mingg u. kemudian, data dianalisis menggunakan paired test, independent t-test, dan logistic regresi linear. hasil berdasarkan hasil penelitian yang telah dilakukan terhadap 80 orang mahasiswa pe ng u r u s pi k-k r m d i ket a hu i ba hwa karak ter isti k jenis kelamin mahasiswa pengurus pik-krm yang menjadi responden, pada kelompok perlakuan dari 40 orang terdapat 30 orang (75%) mahasiswa perempuan, dan pada kelompok kontrol dari 40 orang terdapat 26 orang (65%) mahasiswa perempuan. hal ini menunjukkan bahwa perempuan lebih banyak yang berminat sebagai pengurus pikkrm dengan alasan banyaknya teman sebaya perempuan yang curhat atau sharing tentang masalah pribadinya dibandingkan laki-laki. mahasiswa pengurus pik-krm yang menjadi responden, pada kelompok perlakuan yang paling banyak dari jurusan keperawatan, sebanyak 18 orang (45%), sedangkan sisanya berasal dari jurusan lain dengan persentase yang lebih kecil, 8 orang (20%) dari farmasi, 4 orang (10%) dari teknik, 7 orang (17.5%) dari psikologi, dan 3 orang (7,5%) dari fisip. sedangkan pada kelompok kontrol, seluruh responden (100%) berasal dari jur usan keperawatan. karakteristik usia responden pada kelompok perlakuan rata-rata berusia 19 tahun 6 bulan dan rata-rata usia sampel pada kelompok kontrol adalah 18 tahun 3 bulan. hal ini mengindikasikan bahwa responden dalam penelitian ini lebih banyak pada kisaran antara usia 18–19 tahun, di mana responden dengan usia 20 tahun dan 21 tahun mempunyai frekuensi yang lebih kecil. pada kelompok kont rol diketahui terdapat hubungan yang signifikan antara skor pengetahuan, sikap, dan keterampilan mahasiswa peng u r us pi k-k r m ant ara nilai pretest dan post test (tabel 1). terdapat peningkatan rerata pengetahuan pada kelompok kontrol sebesar 1,22 poin, peningkatan rerata sikap sebesar 4.23, dan rerata keterampilan 0.42. hasil uji paired t-test untuk perbandingan rata-rata skor pengetahuan, sikap, dan keterampilan kelompok kontrol antara pretest dan post test menunjukkan perbedaan yang signifikan pada rata-rata skor pengetahuan, sikap, dan keterampilan responden di kelompok kontrol antara pretest dan post test (tabel 2). pada kelompok perlakuan berdasarkan p e ng ujia n , d apat d isi mpu l k a n ba hwa terdapat hubungan yang signifikan antara skor pengetahuan, sikap, dan keterampilan kelompok perlakuan antara pretest dan post test, di mana saat post test menunjukkan skor yang relatif lebih tinggi (ditandai dengan nilai koefisien korelasi yang bernilai positif) pada skor pengetahuan, sikap, dan keterampilan dibandingkan saat pretest (tabel 3). rerata peningkatan pengetahuan pada kelompok perlakuan sebesar 1.83, peningkatan sikap sebesar 14.68, dan keterampilan sebesar 1.82. perbandingan rata-rata skor pengetahuan, sikap, dan keterampilan kelompok perlakuan antara 177 upaya peningkatan keterampilan konseling kesehatan (ririn harini, dkk.) pretest dan post test tersebut menunjukkan perbedaan yang signifikan (tabel 4). tab el 5 me nu nju k k a n h a si l uji independent t-test menunjukkan tidak ada perbedaan yang bermakna antara skor rerata pretest kelompok perlakuan dan kontrol. namun, perbedaan yang signifikan terlihat pada hasil uji perbandingan hasil skor rerata post test dan selisih skor antara pretest-postest pada variabel pengetahuan antara kelompok perlakuan dan kontrol, di mana kelompok perlakuan mempunyai rerata skor yang lebih tinggi. tabel 6 menu nju k kan skor sikap mahasiswa pengurus pik-krm saat pretest adalah sama, baik pada kelompok kontrol maupun kelompok perlakuan, dengan ratarata 50.7. skor sikap pada saat post test pada kelompok kontrol rata-rata sebesar 54.93 dan kelompok perlakuan rata-rata sebesar 65.38. sedangkan, untuk selisih skor sikap pada kelompok kontrol rata-rata sebesar 4.23 dan pada kelompok perlakuan rata-rata sebesar 14.68. hasil independent t-test menunjukkan nilai signifikansi untuk skor sikap pada saat post test dan selisih skor antara kelompok kont rol dan kelompok perlak uan yang berarti ada perbedaan yang bermakna antara kelompok perlakuan dan kontrol. skor keterampilan pada saat pretest pada kelompok perlakuan dan kelompok kontrol adalah sama sebesar 4.63. hasil independent t-test menunjukkan tidak ada perbedaan yang bermakna. skor keterampilan pada saat post test pada kelompok kontrol rerata sebesar 5.05 dan pada kelompok perlakuan rerata sebesar 6.45. selisih skor keterampilan pada kelompok kontrol rata-rata sebesar 0.43 dan pada kelompok perlakuan rata-rata sebesar 1.83. hasil independent t-test menunjukkan ada perbedaan yang bermakna (tabel 7). hasil regresi linier menunjukkan nilai signifikansi sebesar 0.000 (p<0.05), sehingga dapat disimpulkan bahwa pemberian pelatihan konselor sebaya memberikan pengaruh yang signifikan (bermakna) terhadap pengetahuan, sikap, dan keterampilan ( post test) mahasiswa p e ng u r u s pi k-k r m. be sa r p e nga r u h pemberian pelatihan konselor sebaya dapat diketahui dari nilai r square, di mana pengaruh terbesar dari pemberian pelatihan konselor sebaya tersebut adalah pengaruh pemberian pelatihan konselor sebaya terhadap skor sikap ( post test) yaitu sebesar 0,432 (43,2%), sedangkan 56,8% sisanya dipengaruhi oleh faktor lain selain pemberian pelatihan konselor sebaya. persamaan model untuk pengetahuan, sikap dan keterampilan ( post) terhadap pelatihan didapatkan hasil yaitu pengetahuan ( post) =12,650+1.85 pelatihan, sikap ( post) = 44.475+10.45 pelatihan, dan keterampilan ( post) = 3.65+1.40 pelatihan, dapat diartikan tabel 1. hubungan antara pretest dan post test kelompok kontrol variabel koefisien korelasi p pengetahuan 0.611 0.000 sikap 0.900 0.000 keterampilan 0.557 0.000 tabel 2. hasil perbandingan pengetahuan, sikap, dan keterampilan antara rerata pretest dan post test kelompok kontrol variabel kelompok kontrol nilai p dari paired t-testpre test post test mean ± sd mean ± sd pengetahuan 13.28 ±1.84 14.50 ±1.59 0.000 sikap 50.70 ±6.64 54.93 ±7.80 0.000 keterampilan 4.63 ±1.66 5.05 ±1.77 0.000 keterangan : sd = standard deviasi p = p value 178 jurnal ners vol. 9 no. 2 oktober 2014: 173–182 tabel 5. hasil perbandingan skor pengetahuan antara kelompok kontrol dan perlakuan variabel evaluasi nilai p dari independent t-test kontrol perlakuan mean ± sd mean ± sd pre test 13.28 ± 1.84 13.68 ± 1.82 0.331 post test 14.50 ± 1.59 16.35 ± 1.63 0.000 selisih skor 1.23 ± 1.53 2.68 ± 1.25 0.000 tabel 6. hasil perbandingan skor sikap antara kelompok kontrol dan perlakuan variabel evaluasi nilai p dari independent t-test kontrol perlakuan mean ± sd mean ± sd pre test 50.70 ±6.64 50.70 ±6.64 1.0 post test 54.93 ±7.80 65.38 ±3.57 0.000 selisih skor 4.23 ±3.42 14.68 ±6.04 0.000 tabel 7. hasil perbandingan skor keterampilan antara kelompok kontrol dan perlakuan variabel evaluasi nilai p dari independent t-test kontrol perlakuan mean ± sd mean ± sd pre test 4.63 ±1.66 4.63 ±1.66 1.0 post test 5.05 ±1.77 6.45 ±1.06 0.000 selisih skor 0.43 ±1.62 1.83 ±1.53 0.000 tabel 3. hubungan antara pretest dan post test kelompok perlakuan variabel koefisien korelasi p pengetahuan 0.742 0.000 sikap 0.431 0.006 keterampilan 0.433 0.005 tabel 4. hasil perbandingan pengetahuan, sikap dan keterampilan antara rata-rata pretest dan posttest kelompok perlakuan variabel evaluasi kelompok perlakuan nilai p dari paired t-test pre test post test mean ± sd mean ± sd pengetahuan 13.68 ± 1.82 16.35 ± 1.63 0.000 sikap 50.70 ± 6.64 65.38 ± 3.57 0.000 keterampilan 4.63 ± 1.66 6.45 ± 1.06 0.000 179 upaya peningkatan keterampilan konseling kesehatan (ririn harini, dkk.) bahwa tanpa mempertimbangkan pengaruh dari pemberian pelatihan konselor sebaya, maka skor pengetahuan, sikap dan keterampilan ( post) akan tetap meningkat secara konstan (karena koefisien konstanta bernilai positif). namun, apabila mempertimbangkan pengaruh dari pemberian pelatihan konselor sebaya, maka hal itu akan dapat meningkatkan skor pengetahuan, sikap, dan keterampilan ( post) secara signifikan karena koefisien bernilai positif. pembahasan pe n i n g k a t a n p e n g e t a h u a n p a d a kelompok perlakuan diakibatkan karena adanya inter vensi pelatihan yang telah diberikan selain itu juga adanya pengetahuan yang telah dimiliki oleh responden sebelumnya baik didapat dari pengalaman membaca literatur, media elektronik maupun pengalaman pribadi dan sharing dengan teman sebaya, sehingga mampu mengingat kembali materi pelatihan yang telah dipelajari sebelumnya. hal tersebut sesuai dengan pendapat morton et al. (1995), bahwa pengetahuan merupakan hasil stimulasi informasi yang diperhatikan dan diingat. sarwono (2004), juga berpendapat bahwa informasi yang telah diberikan dengan pendekat a n komu n i kasi i nter per sonal / konseling mengenai kesehatan reproduksi akan meningkatkan pengetahuan seseorang. hasil penelitian dari mevsim et al. (2008) menyebutkan bahwa pelatih teman sebaya dan metode pelatihan yang digunakan mampu merubah pengetahuan selama sesi pelatihan dengan baik pada teman sebaya tentang reproduksi kesehatan. si k a p t el a h d i m i l i k i s e s e o r a ng sebelu m nya ya ng diperoleh d a r i hasil belajar mandiri, pengalaman bersosialisasi, b a h k a n h a si l sh a r i n g d e ng a n t e m a n sebaya. pentingnya peran teman sebaya, pengembangan lingkungan teman sebaya yang positif merupakan cara efektif yang dapat ditempuh untuk mendukung perkembangan remaja. dalam kaitannya dengan keuntungan remaja memiliki kelompok teman sebaya yang positif, laursen (2005) dalam santrock (2012) menyatakan bahwa kelompok teman sebaya yang positif memungkinkan remaja merasa diterima serta memungkinkan remaja menguji nilai-nilai baru dan pandangan-pandangan baru. kelompok teman sebaya yang positif memberikan kesempatan kepada remaja untuk membantu orang lain, dan mendorong remaja untuk mengembangkan jaringan kerja untuk saling memberikan dorongan positif. interaksi di antara teman sebaya dapat digunakan untuk membentuk makna dan persepsi serta solusisolusi baru. budaya teman sebaya yang positif memberikan kesempatan kepada remaja untuk menguji keefektifan komunikasi, tingkah laku, persepsi, dan nilai-nilai yang dimiliki. budaya teman sebaya yang positif sangat membantu remaja untuk memahami bahwa dia tidak sendirian dalam menghadapi berbagai tantangan. budaya teman sebaya yang positif dapat digunakan untuk membantu mengubah tingkah laku dan nilai-nilai remaja (laursen, 2005). salah satu upaya yang dapat dilakukan untuk membangun budaya teman sebaya yang positif adalah dengan mengembangkan konseling teman sebaya dalam komunitas remaja. berdasarkan pendapat dari beberapa pakar tersebut dapat disimpulkan bahwa tabel 8. hasil uji liner regression pengaruh pemberian pelatihan konselor sebaya terhadap pengetahuan, sikap, dan keterampilan mahasiswa pengurus pik-krm regresi antara model persamaan p r square pelatihan dengan pengetahuan (post) pengetahuan (post) =12.650+1.85 pelatihan 0.000 0.254 pelatihan dengan sikap (post) sikap (post) = 44.475+10.45 pelatihan 0.000 0.432 pelatihan dengan keterampilan (post) ketrampilan (post) =3.65+1.40 pelatihan 0.000 0.191 180 jurnal ners vol. 9 no. 2 oktober 2014: 173–182 peningkatan skor sikap yang lebih besar pada kelompok perlakuan dapat dipengaruhi oleh penggunaan metode yang tepat dalam pelatihan. kirkpatrick (1994) mengatakan bahwa untuk keberhasilan pelatihan perlu diperhitungkan metode yang tepat sesuai dengan kebutuhan dari para peserta, metode tersebut dikatakan tepat apabila terjadi perubahan yang positif terhadap para peserta pelatihan. peningkatan skor baik pada pengetahuan, sikap, dan keterampilan pada kelompok intervensi mengindikasikan bahwa metode yang dipergunakan dalam pelatihan ini dapat meningkatkan pengetahuan, sikap, dan keterampilan tentang kesehatan reproduksi dan triad krr (seksualitas, hiv/aids, dan napza) dalam melakukan konseling pada teman sebaya. hal ini juga membuktikan bahwa responden mampu menyerap materi yang telah diberikan pada saat dilakukan intervensi. selain itu remaja perlu menguasai teknik komunikasi yang baik, sehingga materi komunikasi perlu diberikan sebelum materi pelatihan yang lain. hal ini sesuai dengan suwarjo (2008), bahwa calon konselor sebaya harus dibekali kemampuan untuk membangun komunikasi interpersonal secara baik. sikap dan keterampilan dasar konseling yang meliputi kemampuan berempati, kemampuan melakukan attending, keterampilan bertanya, keterampilan merangk um pembicaraan, asertivitas, genuineness, konfrontasi, dan keterampilan pemecahan masalah, merupakan kemampuan-kemampuan yang dibekalkan dalam pelatihan konselor sebaya. menurut azwar (1995) dalam gordon (1935) bahwa sikap merupakan semacam kesiapan untuk bereaksi terhadap suatu objek dengan cara-cara tertentu. dapat dikatakan bahwa kesiapan yang dimaksudkan merupakan kecenderungan potensial untuk bereaksi dengan cara tertentu apabila individu dihadapkan pada suatu stimulus yang menghendaki adanya respons. berdasarkan hasil penelitian di atas bahwa terjadinya peningkatan yang kecil pada kelompok kontrol bisa terjadi karena sebelumnya responden sudah mempunyai pengalaman dalam memberikan konseling pada teman sebaya secara alamiah. namun, karena responden tidak mendapatkan pelatihan yang lebih tepat bagaimana aplikasi yang benar sebagai seorang konselor sebaya, sehingga nilai skor sikap tidak dapat meningkat secara signifikan. keterampilan seseorang tidak mudah untuk diubah secepat mungkin tanpa melalui proses yang panjang dan ter us-mener us. pernyataan tersebut sesuai dengan pendapat winkel (2004) bahwa per ubahan akibat belajar itu akan bertahan lama, bahkan sampai taraf tertentu tidak akan menghilang lagi. kemampuan yang diperoleh akan menjadi milik pribadi dan tidak akan terhapus begitu saja. hasil belajar secara relatif bersifat konstan dan berbekas. pada keterampilan motor i k , set iap keg iat a n belaja r a ka n menghasilkan suatu perubahan yang positif. semakin sering orang tersebut melakukan dan mengulang keterampilan, maka akan semakin terampil. hasil belajar di bidang psikomotorik dan sikap juga tidak mudah terlupakan karena keterampilan dan sikap sekali dibentuk cenderung bertahan terus, bahkan menjadi semakin kuat dan mulai merupakan setumpuk kegiatan yang tidak lagi disertai kadar kesadaran yang tinggi. berdasarkan penelitian yang dilakukan oleh lestari (2010) dapat diperoleh kesimpulan bahwa pelatihan ddtk (deteksi dini tumbuh kembang) yang dilakukan selam tiga hari efektif meningkatkan pengetahuan, sikap, dan keterampilan pada bidan yang mendapatkan intervensi dalam melakukan deteksi dini tumbuh kembang pada anak. hal tersebut menunjukkan bahwa semakin lama seseorang mendapatkan pelatihan dan pembelajaran dengan metode yang tepat, maka hasil yang didapatkan semakin maksimal sesuai harapan. pe nel it ia n i n i me nc oba mel i h at pengar uh perlak uan pelatihan terhadap per ubahan skor pengetahuan, sikap, dan keterampilan. pengukuran yang dilakukan adalah dengan melihat hasil setelah intervensi ( post test). pengukuran dengan cara ini ditujukan untuk melihat seberapa besar pengaruh dari intervensi pelatihan konselor sebaya terhadap peningkatan pengetahuan, sikap, dan keterampilan mahasiswa pengurus 181 upaya peningkatan keterampilan konseling kesehatan (ririn harini, dkk.) pik-krm. nilai skor post test dipergunakan untuk melihat seberapa besar responden dapat menyerap materi pelatihan yang diberikan selama intervensi. hasil uji regresi linier menunjuk kan pelatihan konselor sebaya member i kan pengar u h yang ber mak na pada pengetahuan, sikap, dan keterampilan mahasiswa pengurus pik-krm. k i r k p a t r ick (19 9 4) m e n g a t a k a n bahwa untuk keberhasilan pelatihan perlu diperhitungkan metode yang tepat sesuai dengan kebutuhan dari para peserta. metode dikatakan tepat apabila terjadi perubahan yang positif terhadap para peserta pelatihan. peningkatan skor baik pada pengetahuan, sikap, dan keterampilan pada kelompok intervensi mengindikasikan bahwa metode yang dipergunakan dalam pelatihan ini dapat meningkatkan pengetahuan, sikap dan keterampilan tentang kesehatan reproduksi dan triad krr (seksualitas, hiv/aids, dan napza) dalam melakukan konseling pada teman sebaya. hal ini juga membuktikan bahwa responden mampu menyerap materi yang telah diberikan pada saat dilakukan intervensi. pada kelompok kontrol, peningkatan terjadi baik pada skor pengetahuan, sikap, dan keterampilan meskipun dengan nilai yang kecil. hal ini menunjukkan bahwa meskipun t id a k me nd apat k a n p elat i h a n t e nt a ng menjadi seorang konselor sebaya. namun, berbekal pengetahuan dan pengalaman sebelumnya seperti pembinaan awal masuk sebagai pengur us pik-k r m, buku dari bkkbn, sharing dengan teman, televisi, dan masih banyak lagi yang lain ternyata masih mampu meningkatkan skor dalam domain pengetahuan, sikap, dan ketrampilan pa d a ma ha siswa peng u r u s pi k-k r m. kemungkinan peningkatan yang terjadi pada kelompok kontrol terjadi karena pada kelompok ini mendapatkan stimulus dari kuesioner dan pernyataan-pernyataan yang diberikan oleh peneliti, selain modul pelatihan yang pada akhirnya menjadi proses belajar dalam diri. faktor lain yang mempengaruhi peningkatan pengetahuan dan keterampilan pada kelompok kontrol adalah pengalaman kerja maupun media massa. menurut who dalam notoatmodjo (2007), pengetahuan seseorang terhadap suatu objek dapat berubah dan berkembang sesuai dengan kemampuan, kebutuhan dan pengalaman tentang objek itu di lingkungannya. selain itu, kelompok kontrol kemungkinan besar telah mempunyai pengalaman tentang kesehatan reproduksi dan konseling sebelumnya meskipun tidak diberikan intervensi pelatihan pengetahuan dan keterampilannya masih tetap baik. pe l a t i h a n d a p a t m e n i n g k a t k a n pengetahuan, sikap dan keterampilan seseorang dalam bidang tertentu. hasil penelitian yang dilakukan oleh willets (2003) menunjukkan bahwa program pelatihan efektif meningkatkan pengetahuan dan keterampilan para karyawan. penelitian serupa juga dilakukan oleh sheffer et al. (2009), yang hasilnya menunjukkan bahwa pelatihan yang dilakukan kepada 1.286 tenaga kesehatan yang diberi intervensi selama 1 jam efektif meningkatkan pengetahuan dan mengubah sikap pesertanya menjadi lebih positif. hal yang sama juga didapatkan pada penelitian law et al. (2007), di mana hasilnya menunjukkan bahwa terjadi peningkatan sig nif ikan pada skor pengetahuan dan keterampilan antara sebelum dan sesudah mendapatkan pelatihan pada bidan yang mengikuti pelatihan . peningkatan skor pengetahuan, sikap, dan keterampilan pada kelompok perlakuan lebih tinggi dibandingkan dengan kelompok kontrol. hal ini dikarenakan pada kelompok perlakuan peserta dilibatkan secara aktif dalam pelatihan. metode pembelajaran yang digunakan dalam pelatihan adalah ceramah, tanya jawab, simulasi/role play, studi kasus, dan praktek langsung dengan teman sebaya. hal itu menyebabkan peserta pelatihan tertarik dan tidak jenuh, sehingga dapat memahami materi dengan baik. selain itu, penggunaan narasumber dari bkkbn yang sudah kompeten di bidang nya, mempu nyai pengalaman yang banyak, dan dapat mengemas acara pelatihan semenarik mungkin juga menjadi faktor pendukung. hal ini juga sesuai dengan pendapat sullivan dan gaffikin (1997), bahwa efektivitas pelatihan klinik penekanannya pada aplikasi pengetahuan dalam penampilan keterampilan. 182 jurnal ners vol. 9 no. 2 oktober 2014: 173–182 simpulan dan saran simpulan pelat i ha n kon selor sebaya d apat meningkatkan pengetahuan, sikap, dan keterampilan pada mahasiswa pengurus pikkrm dalam melakukan konseling pada teman sebaya tentang triad krr (seksualitas, hiv/aids, dan napza). saran pelatihan hendaknya dilakukan secara rutin dan berkelanjutan, sehingga bisa terus meningkatkan pengetahuan, sikap, dan keterampilan pada peng ur us pik-k r m sehingga dapat memberikan layanan konseling yang lebih baik. kepustakaan bkkbn. 2006. modul workshop konseling kesehatan reproduksi remaja bagi calon konselor sebaya. jakarta: direktorat remaja dan perlindungan hak-hak reproduksi. bkkbn. 2008. modul pelatihan konseling kesehatan reproduksi remaja bagi calon konselor sebaya. jakarta: direktorat remaja dan perlindungan hak-hak reproduksi, bkkbn. lestari. 2010. pengaruh pelatihan deteksi dini tumbuh kembang terhadap peningkatan pengetahuan, sikap dan keterampilan bidan di kabupaten banjar. tesis pasca sarjana, universitas gadjah mada. mevsim, v., guldal, d., ozcakar, n., saygin, o., 2008. what was retained? the assessment of the training for the peer trainers’ course on short and long term basis. bmc public health 8,24. aryani. 2010. efektifitas pik-krr terhadap peningkatan pengetahuan kesehatan reproduksi remaja di smu swasta alwasliyah i medan. ilmu kesehat. masy. univ. gadjah mada. santrock, j.w., 2012. psikologi pendidikan. jakarta: salemba humanika. morton. 2008. introduction to health education and health promotion. waveland press, inc, illinois. suwarjo. 2008. konseling teman sebaya (peer counseling) untuk mengembangkan resiliensi remaja. jurusan psikologi pendidikan dan bimbingan fakultas ilmu pendidikan. universitas indonesia, jakarta. ners vol 10 no 1 april 2015.indd 138 intervensi vap bundle dalam pencegahan ventilator associated pneumonia (vap) pada pasien dengan ventilasi mekanis (the incidence of vap after vap bundle intervention among patients with mechanical ventilation) diah susmiarti*, harmayetty**, yulis setiya dewi** *program studi pendidikan ners fakultas keperawatan universitas airlangga **staf pengajar fakultas keperawatan universitas airlangga email: diahsusmiarti@gmail.com abstrak pendahuluan: ventilator associated pneumonia (vap) merupakan infeksi nosokomial yang terjadi pada pasien dengan pemakaian ventilator > 48 jam. pasien kritis yang dirawat di icu berisiko tinggi terjadi infeksi nosokomial pneumonia sehingga mengakibatkan peningkatan angka kesakitan, kematian dan biaya perawatan. tujuan penelitian ini untuk mengetahui kejadian vap setelah diberikan penerapan vap bundle. metode: penelitian ini menggunakan metode one shot case study post test only dengan sampel sebanyak 6 orang mulai 31 desember 2013 sampai dengan 31 januari 2014. hasil hasil menunjukkan bahwa penerapan vap bundle berpengaruh dalam mencegah terjadinya vap. hasil dari penilaian total cpis didapatkan 4 dari 6 orang tidak terdiagnosa vap dan 2 orang terdiagnosa vap. diskusi: hasil penelitian yang ada perlu didukung dengan jumlah sampel yang lebih besar dan perlu penilaian cpis secara berkelanjutan untuk mengidentifi kasi vap yang disebabkan oleh bakteri onset lambat khususnya pada pasien yang terpasang ventilasi mekanis dalam waku lama. kata kunci: ventilator associated pneumonia (vap) bundle, kejadian ventilator associated pneumonia (vap) abstract introduction: ventilator associated pneumonia (vap) is a nosocomial infection in patients who use ventilator for more than 48 hours. the aimed of the study was to determine vap incidence after vap bundle application. methods: this study used one-shot case study posttest only designed with samples of 6 individuals beginning on december 31, 2013 up to january 31, 2014. the totally score of cpis assessment revealed that 4 of 6 patients was not diagnosed with vap and 2 were diagnosed with vap. result: the results showed that the application of vap bundle has infl uence in preventing vap incidence. the totally score of cpis assessment revealed that 4 of 6 patients was not diagnosed with vap and 2 were diagnosed with vap. discussion: this study need to be backed up furthermore with a larger sample size and continuous cpis assessment is needed to identify vap caused by bacteria, especially the late-onset bacteria, in patients using mechanical ventilation in longer a time. keywords: ventilator associated pneumonia (vap) bundle, vap incidence pendahuluan ventilator associated pneumonia (vap) merupakan penyebab umum kedua pada kasus health care associated infection (hai) di amerika serikat dan bertanggung jawab 25% dari kasus infeksi yang terjadi di intensive care unit. pasien kritis yang dirawat di icu berada pada risiko tinggi untuk terjadi infeksi nosokomial pneumonia sehingga mengakibatkan peningkatan angka kesakitan, kematian dan biaya perawatan. penggunaan ventilator meningkatkan risiko infeksi nosokomial 6 –21 kali dan tingkat kematian akibat vap adalah 24–70% sehingga menyebabkan peningkatan rata-rata waktu yang dihabiskan di icu menjadi 9,6 hari, dan juga menambah biaya pengobatan. tambahan biaya yang harus dikeluarkan untuk pengobatan setiap pasien dengan vap yaitu us $ 40.000. (ban, 2011). menu r ut mc car thy et al (2008) program pencegahan vap dengan melakukan pemberian vap bundle telah dilakukan di mercy hospital us mulai juni 2003 sampai dengan mei 2004 terhadap 205 sampel dan mendokumentasikan dalam sebuah format vap bundle. hasil yang ditemukan setelah pelaksanaan program secara konsisten tersebut terdapat penurunan vap yaitu dari 6,1 menjadi 2,7 kasus per 1000 hari pemakaian ventilator. menurut crunden et al (2005), pemberian vap bundle yang telah dilakukan pada 286 139 intervensi vap bundle dalam pencegahan vap (diah susmiarti, dkk) pasien di surrey hospital united kingdom, memberikan hasil tentang kebutuhan pasien dalam pemakaian ventilator menurun dari 10,8 menjadi 6,1 hari dan length of stay menurun dari 13,75 menjadi 8,36 hari. be rd a sa rk a n h a si l rek a m me d is rumkital dr. ramelan pada tahun 2011 jumlah pasien icu yang menggunakan ventilator 74 orang, meninggal 62 orang, jumlah hari pemakaian ventilator dalam 1 tahun yaitu 505 hari dan 8 kasus dengan vap. pada tahun 2012 jumlah pasien yang menggunakan ventilator 109 orang, meninggal 86 orang, jumlah hari pemakaian ventilator dalam 1 tahun yaitu 694 hari, dan 10 kasus dengan vap. pada tahun 2013 jumlah pasien icu yang menggunakan ventilator sebanyak 148 orang, jumlah pasien yang meninggal 100 orang, jumlah hari pemakaian ventilator yaitu 670 hari, dan data untuk kasus dengan vap didapatkan 7 kasus vap dengan hasil kultur yaitu a. baumanii, streptococcus, acinetobacter dan e. coli. hasil diagnosis vap di ruang icu rumkital dr. ramelan didapatkan berdasarkan hasil kultur yang didokumentasikan pada satu buku catatan vap berisi hasil kultur pasien. tindakan pencegahan ventilator associated penumonia seper ti elevasi kepala sudah dilakukan, tetapi masih terdapat kejadian vap dan setiap tahun hari pemakaian ventilator semakin meningkat. berdasarkan pengamatan yang dilakukan oleh peneliti, pada lembar observasi icu tidak didapatkan dokumentasi tentang pemberian vap bundle sedangkan menurut hasil wawancara pada perawat icu menjelaskan bahwa seluruh pasien sudah diberikan tindakan pencegahan seperti elevasi kepala kecuali ada kontraindikasi namun untuk pendokumentasian memang belum optimal dan untuk format vap bundle belum ada. menurut burns et al (2011) pasien yang terpasang ventilasi mekanik dan endotracheal tube (ett) menghambat mekanisme batuk alami yang merupakan mekanisme pertahanan alami tubuh terhadap perlawanan infeksi per napasan, menghindari aspirasi sekret saluran napas bagian atas yang normalnya dapat melindungi saluran pernapasan dari invasif patogen. adanya ett akan mencegah mu kosilia r d ala m pember si ha n sek ret kemudian sekret menumpuk di atas manset ett dan ak hir nya dapat menyebabkan microaspiration dan pneumonia. endotracheal tube juga menekan refl eks epiglotic sehingga memudahkan masuk nya bakteri vir ulen (karena sekresi yang berlebihan ataupun aspirasi dari lambung). obat-obat sedasi dalam jangka waktu yang lama pada pasien di icu dapat menekan kemampuan menelan pasien secara efektif yang dapat membantu membersihkan saliva dari rongga mulut. pasien dengan intubasi akan menghambat pertahanan alami tubuh terhadap perlawanan infeksi pernapasan. adanya endotracheal tube juga akan menghilangkan refl eks batuk efektif (mc carthy et al., 2008). pemberian sedasi, adanya ett berkontribusi pada kejadian vap yang terjadi akibat respons infl amasi terhadap mikroorganisme parenkim paru. respons yang terjadi tergantung pada jumlah dan jenis mikroorganisme, virulensi serta daya tahan tubuh. sebagian besar kasus vap disebabkan oleh aspirasi sekresi infeksi dari orofarings dan sebagian kecil berasal dari infeksi sistemik. berbagai bentuk mekanisme pertahanan yang terdapat di jalan napas, seperti saliva, refl eks batuk, mucociliary clearance dan sistem imun humoral melindungi paru dari infeksi. pada orang normal sekresi orofaringeal yang berkala dikeluarkan oleh karena ada mekanisme pertahanan sedangkan pada pasien kritis terjadi gangguan imun, pemakaian sedasi serta ett dapat mengganggu mekanisme pertahanan. ketika mikroorganisme masuk kedalam paru, mekanisme pertahanan tidak mampu membunuh organisme tersebut. makrofag alveolar, netrofi l dan elemen sistem imun humoral berinteraksi menimbulkan respons inf lamasi. jika sistem pertahanan tubuh terganggu maka pneumonia dapat terjadi (prasenohadi, 2008). untuk mencegah terjadinya kolonisasi orofaring dan kolonisasi l a m b u n g m a k a d i p e r l u k a n t i n d a k a n pencegahan diantaranya head elevation of bed dengan tujuan mengurangi terjadinya aspirasi aerodigestif (oroparingeal dan gastrointestinal), meningkatkan volume paru dan ventilasi paru pasien serta memberikan keamanan pada saat pemberian makanan melalui ngt. 140 jurnal ners vol. 10 no. 1 april 2015: 138–146 bahan dan metode pada penelitian ini mempergunakan rancangan penelitian “pra eksperimental” dengan one shot case study. populasi penelitian ini adalah pasien yang terpasang ventilator mekanis pada 31 desember 2013–31 januari 2014 sebanyak 16 orang. pengambilan sampel dilakukan dengan teknik purposive sampling, yaitu suatu teknik penetapan sampel dengan cara memilih sampel di antara populasi sesuai dengan kehendak peneliti (tujuan atau masalah dalam penelitian), sehingga sampel tersebut dapat mewakili karakteristik populasi yang telah dikenal sebelumnya. pengambilan sampel dengan beberapa kriteria inklusi, yaitu: 1) pasien dengan ett yang menggunakan ventilator mekanik mulai hari ke 0; 2) pasien adalah berusia dewasa > 18th; 3) pasien yang tidak terdiagnosa pneumonia saat masuk icu; 4) pasien mendapatkan antibiotika. kriteria ekslusi dalam penelitian ini yaitu: 1) pasien meninggal dalam pemasangan ventilator; 2) di tengah waktu penelitian pasien/keluarga pasien menolak/mundur dari penelitian variabel independen dalam penelitian ini adalah penerapan vap bundle pada pasien dengan ventilasi mekanis sedangkan terapi dependen adalah kejadian ventilator associated pneumonia (vap) pada pasien dengan ventilasi mekanis. alat ukur untuk penerapan va p bundle ber upa lembar observasi sedangkan untuk kejadian vap diukur melalui lembar monitoring clinical pulmonary infection score (cpis). pemberian vap bundle pada penelitian ini dimulai setelah responden terpasang ventilasi mekanis yaitu pada hari ke 0 sampai dengan hari ke 3. setiap pelaksanaan pemberian vap bundle dicatat pada checklist monitoring vap bundle. setelah penerapan vap bundle kemudian pada hari ke 3 dilakukan penilaian kejadian vap melalui monitoring clinical pulmonary infection score (cpis) dengan mengumpulkan data hasil pemeriksaan suhu, leukosit, sputum, pao2/ fio2, foto toraks, dan kultur sputum responden dan memasukkan data-data tersebut ke dalam lembar monitoring cpis. keseluruhan datadata tersebut di jumlah berdasarkan kriteria yang telah ditetapkan terhadap masing-masing karakteristik cpis. responden dengan nilai total cpis ≤ 6 dikategorikan tidak terdiagnosa vap dan responden dengan nilai total cpis > 6 dikategorikan vap. hasil hasil penelitian menunjukkan bahwa 6 responden sebagian besar memiliki skor apache ii dengan nilai skor apache 25–29 (83,3%) dengan interpretasi perkiraan mortalitas 55% dalam 24 jam pertama ventilator. data diagnosa, pemakaian sedasi dan jenis peptic ulcer diseases (pud) responden didapatkan sebagian besar responden (50%) masuk icu dengan diagnosa post operasi, sebagian besar responden (50%) dengan jenis sedasi morphin: dormicum selama 48 jam, dan sebagian besar (33,33%) dengan jenis peptic ulcer diseases yaitu ranitidin. hasil observasi nilai clinica pulmonary infection score (cpis) pada hari ke 3 pemakaian ventilator didapatkan hasil 2 dari 6 responden terdapat kejadian vap dengan skor vap > 6 (33,33%) dan 4 responden tidak terdiagnosa vap dengan skor vap ≤ 6 (66,67%). nilai suhu dari clinical pulmonary infection score (cpis) 6 responden didapatkan nilai suhu pada hari ke 3 sebanyak 5 responden mendapatkan skor 0, sedangkan 1 reponden mendapatkan nilai 2. nilai cpis untuk leukosit pada hari 3 yaitu sebanyak 2 responden tabel 1. usia responden di icu rumkital dr. ramelan surabaya umur jumlah prosentase 36–45 45–59 60–74 1 1 4 16,7% 16,7% 66,6% total 6 100,0% tabel 2. jenis kelamin responden di icu rumkital dr. ramelan jenis kelamin jumlah prosentase laki-laki perempuan 5 1 83,3% 16,7% total 6 100,0% 6 28 55% 141 intervensi vap bundle dalam pencegahan vap (diah susmiarti, dkk) mendapat skor 0 sedangkan 4 responden lain mendapat skor 1. skor sputum pada hari ke 3 yaitu sebanyak 5 responden mendapatkan skor 1 dan 1 responden mendapatkan skor 2. skor untuk pao2/fio2 pada hari ke 3 didapatkan 4 responden mendapatkan skor 0 dan 2 responden mendapatkan skor 2. nilai cpis untuk hasil foto thoraks pada hari ke 3 sebanyak 2 responden mendapatkan skor 0 dan 4 responden mendapatkan skor 2. berdasarkan hasil kultur sputum pada hari ke 3 didapatkan 6 responden mendapatkan skor 2. pembahasan berdasarkan tabel 5 penilaian cpis dari 6 responden yang diteliti setelah diberikan penerapan vap bundle yang meliputi elevasi kepala, profi laksis peptic ulcer diseases, oral hygiene dengan clorhexidine 0,1% dan hand hygiene menunjukkan sebanyak 4 orang (66,67%) dengan nilai cpis ≤ 6 yang berarti tidak vap yaitu responden 2, 4, 5 dan 6 tidak terdiagnosa vap. 2 orang (33,33%) dengan nilai cpis > 6 berarti terjadi vap yaitu pada responden 1 dan 3. jumlah responden sebagian besar masih didapatkan kejadian va p mesk ipu n penerapan vap bundle sudah dilaksanakan 100%. responden yang terdiagnosa vap dalam penelitian ini adalah responden 1 dan 3. responden 1 usia 48 tahun dengan diagnosa masuk cob + fr. costae 1, 2 dan 3 + hematothoraks + fr. zigoma. tingkat keparahan penyakit atau diagnosa awal pada responden 1, adanya penurunan kesadaran, dan serum albumin < 2,2 merupakan faktor risiko yang berasal dari pejamu (host) terhadap terjadinya infeksi nosokomial. pemasangan ventilasi mekanik diindikasikan karena ketidakmampuan paru untuk mensuplai oksigen pada darah secara adekuat untuk memenuhi kebutuhan metabolik tubuh. pada responden ini terjadi hipoventilasi alveolar diakibatkan terjadinya gangguan pada sistem saraf pusat atau sistem neuromuskuler, yang menyebabkan k u ra ng nya ok sigen ya ng d isuplai d a n kurangnya karbondioksida yang dikeluarkan. hematothoraks yang terjadi diakibatkan oleh trauma tumpul dada yang mengakibatkan tulang rusuk merusak jaringan paru-paru dan arteri. pemasangan wsd dilakukan untuk mengeluarkan darah dari rongga pleura sehingga mengurangi risiko terbentuknya bekuan darah di dalam rongga pleura, dan dapat dipakai dalam memonitor kehilangan darah selanjutnya. kondisi trauma tersebut merupakan stres fi siologik yang dialami oleh responden 1. menurut smeltzer and bare (2013) stressor fi siologik dan psikologik yang disertai karena cedera akan menstimulasi pelepasan kortisol dari korteks adrenal dan peningkatan kortisol serum juga turut mengakibatkan supresi respons imun yang abnormal. sistem imun terdiri atas komponen nonspesifi k dan spesifik. fungsi masing-masing komponen atau keduanya dapat terganggu baik oleh sebab kongenital maupun sebab yang didapat. keadaan imunokompromais yang sering ditemukan di dalam klinik dapat terjadi oleh infeksi, tindakan pengobatan, neoplasma dan penyakit hematologik, penyakit metabolik, t rau ma d a n t i nd a ka n bed a h. berbagai mikroorganisme (bakteri, vir us, parasit, jamur) yang ada di lingkungan maupun yang sudah ada dalam badan penderita, yang dalam keadaan normal tidak patogenik atau memiliki patogenesitas rendah, dalam keadaan imunokompromais dapat menjadi invasif dan menimbulkan berbagai penyakit. oleh karena itu penderita yang imunokompromais mempunyai risiko yang lebih tinggi terhadap infeksi yang berasal dari badan sendiri maupun nosokomial dibanding dengan yang tidak imunokompromais. tingkat kesadaran pada responden 1 yaitu koma berpengaruh terhadap kejadian vap. meskipun pemberian sedasi sudah dihentikan pada hari pertama namun tidak ada peningkatan kesadaran pada responden 1. menurut mc carthy et al (2008) adanya ett dan penurunan kesadaran akan menekan kemampuan menelan pasien secara efektif dan menghilangkan refl eks batuk efektif yang mer upakan mekanisme per tahanan alami tubuh terhadap perlawanan infeksi pernapasan sehingga ketika mikroorganisme masuk ke dalam paru, mekanisme pertahanan tidak mampu membunuh organisme tersebut. makrofag alveolar, netrofi l dan elemen sistem imun humoral berinteraksi menimbulkan 142 jurnal ners vol. 10 no. 1 april 2015: 138–146 respons infl amasi. menurut ihi (2012) pada pasien dengan ventilator mekanis selain adanya ett, penurunan kesadaran, serta hilangnya refl ek batuk, mikroorganisme dapat berkembang oleh karena adanya biofi lm plak gigi yang diakibatkan kurang atau hilangnya f u ngsi mekan i k yait u meng u nyah d an berkurangnya bahkan tidak adanya air liur yang dapat meminimalkan perkembangan biofi lm pada gigi. plak gigi dapat menjadi reservoir terhadap potensi patogen pernapasan yang menyebabkan vap. adanya hipoalbumin pada responden 1 yaitu < 2,2 merupakan faktor risiko untuk terjadinya infeksi nosokomial. protein dalam darah berbentuk albumin merupakan profi l dalam tubuh yang berfungsi sebagai sistem enzimatik dan bertanggung jawab terhadap kekebalan alamiah. indikator paling sensitif untuk mengukur ketersediaan protein dalam tubuh adalah dengan melihat kadar albumin darah. protein dapat digunakan untuk mempertahankan sistem kekebalan dan ukuran otot, mengatur keasaman darah serta memproduksi jutaan substansi yang dibutuhkan untuk mengatur proses tubuh. menu r ut stepanu k (2000) ji ka protei n digunakan sebagai sumber energi maka akan terjadi defi siensi protein yang sering menyebabkan depresi sistem kekebalan, sehingga kerentanan terhadap infeksi makin meningkat (stepanuk 2000). faktor-faktor lain yang juga berpengaruh terhadap kejadian vap pada responden 1 yaitu faktor intervensi seperti: pemakaian ventilator > 2 hari, ngt, antagonis h2 dan faktor personel dari petugas kesehatan mengenai kepatuhan cuci tangan. berdasarkan fakta yang ada terhadap penerapan vap bundle tentang profi laksis peptic ulcer diseases (pud), peneliti tidak menginklusikan jenis pud yang diberikan oleh medis sehingga terdapat beberapa jenis profi laksis pud yang terdapat pada 6 responden. pada responden 1 pemberian profi laksis pud diberikan sejak awal pasien masuk ruang icu mulai hari ke 0. pada awal masuk sampai dengan hari ke 1, responden 1 mendapatkan profi laksis ranitidin, namun pada hari ke 2 ranitidin diganti dengan sucralfat. berdasarkan penelitian yang dilakukan oleh huang (2010) mengenai efek h2 reseptor antagonis dan sucralfat melalui metode randomized controlled trial didapatkan hasil bahwa h2 reseptor antagonis (ranitidin) dan sucralfat tidak memiliki perbedaan yang signifi kan dalam timbulnya perdarahan lambung, akan tetapi golongan h2 reseptor anatagonis memiliki rata-rata yang lebih tinggi dalam kejadian munculnya kolonisasi lambung dan ventilator associated pneumonia. menurut ihi (2012), profi laksis ulkus peptikum jenis h2 antagonis yang diberikan pada pasien mempunyai efek yang negatif terhadap risiko terjadinya pneumonia nosokomial. obat-obatan profi laksis ini akan membuat ph lambung menjadi kondisi basa yang dapat meningkatkan per t umbuhan bakteri dalam perut, terutama kuman gram negatif yang berasal dari duodenum. kondisi tersebut diperberat bila terjadi refl uks dan sekresi pada pasien kritis yang terintubasi. hal tersebut dikarenakan pasien dengan ett tidak memiliki kemampuan untuk mempertahankan saluran pernapasan mereka. refl uks esofagus dan aspirasi isi lambung pada pasien ett dapat menyebabkan kolonisasi endobronkhial dan pneumonia. tindakan personel petugas kesehatan terhadap kepatuhan cuci tangan yang merupakan hal dasar dalam mencegah terjadinya infeksi nosokomial didapatkan bahwa complience cuci tangan perawat (81, 2%), sedangkan complience cuci tangan dokter (66,7%). hasil penilaian mengenai complience indi kasi didapatkan 43,4% perawat tidak mencuci tangan sebelum menyentuh pasien dan 42,86% dokter tidak mencuci tangan sebelum menyentuh pasien. berdasarkan hasil penelitian yang dilakukan oleh zuhriyah (2004) mengenai gambaran bakteriologis tangan perawat didapatkan hasil bahwa masih didapatkan adanya bakteri pada 20% tangan perawat meskipun petugas sudah mencuci tangan dengan sabun antimikroba. masih ditemukannya bakteri dari hasil swab setelah cuci tangan yaitu bakteri non patogen staphilococcus epidermis dan enterobacter aerogenes memberi dugaan bahwa cuci tangan yang dilakukan kurang efektif, selang waktu antara cuci tangan dengan pemeriksaan swab tangan terlalu lama, durasi cuci tangan yang terlalu cepat atau penggunaan sabun mikroba yang terlalu sedikit. 143 intervensi vap bundle dalam pencegahan vap (diah susmiarti, dkk) pe n i l a i a n t e r h a d a p r i si ko va p dilak u kan pada har i ke 3 pemasangan ventilator dengan menggunakan clinical pulmonary infection score. pada responden 1 terdapat peningkatan suhu pada hari ke 3 yaitu ≥ 39° c disertai adanya sputum namun tidak purulent dan tidak ada peningkatan leukosit. nilai pao2 = 93 dan fio2 = 40% didapatkan pao2/fio2 = 232,5. penilaian foto thorak hari ke 3 terhadap responden 1 tidak dapat dilaksanakan oleh karena mesin thoraks cito bed sedang dalam perbaikan, sedangkan foto thoraks hari ke 1 adanya infi ltrat sulit terbaca dikarenakan adanya hemotoraks pada rongga pleura. hasil kultur sputum terdapat adanya bakteri klebsiella ozaenae. menurut porzecanski (2006) berdasarkan pada kriteria klinik national nosocomial infection surveillance system (nnis) bahwa adanya tanda klinis demam > 38° c (> 100,4°f) yang bukan disebabkan gangguan lain merupakan salah satu tanda klinik adanya infeksi nosokomial pneumonia. menur ut kowalak (2012) demam terjadi ketika agen penyebab infeksi memasuki tubuh. kenaikan suhu akan membantu tubuh melawan infeksi karena banyak mikroorganisme tidak bisa hidup dalam lingkungan yang panas. apabila suhu tubuh naik terlalu tinggi, sel-sel tubuh dapat mengalami kerusakan, khususnya selsel pada sistem saraf sedangkan leukositosis yang terjadi merupakan tanda reaksi tubuh terhadap masuknya mikroorganisme patogen dengan meningkatkan jumlah dan jenis sel-sel darah putih yang beredar di mana leukosit atau sel darah putih berperan dalam melindungi tubuh terhadap infeksi dan bakteri berbahaya. menurut augustyn (2007) penurunan terhadap kemampuan tubuh dalam menyaring dan melembabkan udara pada saluran nafas bagian, hilang atau berkurangnya refl ek batuk akibat adanya endotracheal tube serta terganggunya mechanisms clearanse dari silia dalam pembersihan karena cedera mukosa selama intubasi. adanya endotracheal tube akan menyediakan tempat bagi bakteri untuk masuk ke dalam trakea, keadaan selanjutnya dari halhal tersebut akan meningkatkan produksi dan sekresi lendir. mekanisme pertahanan alami pasien yang menurun akan meningkatkan ke mu ng k i n a n kolon isa si ba k t e r i d a r i mikrorganisme. menurut brisse (2006) hasil kultur sputum yang terdapat pada responden 1 yaitu klebsiella ozenae merupakan bagian genus klebsiella yang normalnya terdapat dalam saluran pencernaan. koloni dapat ditemukan di kulit ataupun kerongkongan. bakteri fl ora normal pada organ tubuh tertentu bisa menjadi patogen apabila terjadi perubahan substrat dan berpindahnya bakteri ke organ lain. adapun pergerakan bakteri ini ke organ lain dikaitkan dengan lemahnya daya tahan tubuh penderita. berdasarkan fakta dan teori yang ada, peneliti berpendapat bahwa meskipun penerapan vap bundle telah diterapkan 100% pada responden dan penghentian sedasi dihentikan sejak dini, kemungkinan terjadinya vap masih dapat terjadi. hal tersebut diakibatkan masih adanya faktorfaktor lain yang berkontribusi besar dalam terjadinya proses infeksi. faktor pada pejamu (host) merupakan faktor yang berkontribusi besar pada kejadian infeksi nosokomial pada responden 1 yaitu adanya penurunan daya tahan tubuh oleh karena adanya trauma dan rendahnya kadar albumin < 2,2. adanya penu r u nan daya t ahan t ubu h ini akan berakibat perubahan substrat fl ora normal dan berpindahnya bakteri ke organ lain. meskipun pada penelitian ini tidak menilai mengenai bagaimana teknik petugas kesehatan dalam mencuci tangan akan tetapi masih didapatkan tingginya kebiasaan tidak mencuci tangan sebelum menyentuh pasien. hal ini merupakan salah satu yang dapat menyebabkan transmisi mikroorganisme dari petugas ke responden. faktor lain yang kemungkinan menyebabkan vap adalah masih digunakannya model open suction pada responden, meskipun cateter suction yang digunakan sekali pakai akan tetapi kemungkinan terkontaminasi akan sangat mungkin terjadi. responden 3 yang juga terdiagnosa vap melalui penilaian clinical pulmonary infection score mempunyai faktor-faktor risiko yang berbeda dengan responden 1. responden 3 usia 69th masuk dari ruang bedah ke icu dengan diagnosa post op laparatomi (cholelitiasis) dan sudah dirawat inap selama 14 hari di ruangan 144 jurnal ners vol. 10 no. 1 april 2015: 138–146 bedah. faktor-faktor risiko pada pejamu (host) yang memungkinkan terjadinya vap pada responden 3 yaitu: usia > 60 tahun (69th), albumin serum > 2,2. menurut smeltzer and bare (2013) usia merupakan salah satu faktor yang akan mempengaruhi sistem imun seseorang. frekuensi dan intensitas infeksi akan meningkat pada orang yang berusia lanjut dan peningkatan ini mungkin disebabkan oleh penurunan kemampuan untuk bereaksi secara memadai terhadap mikroorganisme yang menginvasinya. produksi maupun fungsi limfosit t dan b dapat terganggu. insidensi penyakit autoimun juga meningkat bersamaan dengan pertambahan usia, hal ini mungkin terjadi akibat penurunan kemampuan antibodi untuk membedakan antara diri sendiri dan bukan diri sendiri. menurut augustyn (2007) mekanisme pertahanan alami pasien yang menurun akan meningkatkan kemungkinan kolonisasi bak ter i dar i mik rorganisme. riwayat diabetes mellitus pada responden 3 sejak 4 tahun lalu juga merupakan faktor yang meningkatkan insidensi infeksi di mana berkaitan dengan insufi siensi vaskuler, neuropati dan pengendalian kadar gula darah yang buruk. menurut smeltzer and bare (2013) gangguan integritas kulit yang salah satuya diakibatkan oleh pressure ulcer merupakan faktor predisposisi yang memudahkan pasien lanjut usia untuk mengalami infeksi oleh mikroorganisme yang merupakan bagian dari f lora kulit yang normal. risiko terjadinya infeksi nosokomial pada responden 3 sangat besar, hal ini dikarenakan responden 3 sudah masuk r uang rawat inap selama 15 hari setelah post operasi laparatomi dan sudah mendapatkan pengobatan antibiotika sebelum masuk ruang icu. salah satu dampak yang diakibatkan dari pemakaian antibiotika adalah terjadinya resistensi obat dalam populasi mikroba serta perubahan fl ora normal tubuh yang menyebabkan ket id a ksei mbangan sehingga terjadi infeksi. penegakan diagnosa vap dilakukan pada har i ke 3 mengg u nakan clinical pulmonary infection score. pada responden 3 tidak mengalami peningkatan suhu seperti yang terjadi pada responden 1, akan tetapi terdapat leu kositosis (13.200/μl) ser t a per ubahan karakteristik sputum menjadi purulent. perburukan pertukaran gas terjadi pada responden 3 dan dapat dilihat dari rasio pao2/fio2 (pao2 = 75, fio2 = 0,35) didapatkan 214,3. hasil foto thoraks yang menggambarkan adanya infi ltrat dan terdapatnya bakteri c. freundii pada kultur sputum responden 3 menambah skor pada penilaian cpis. menurut porzecanski (2006) berdasarkan pada kriteria klinik national nosocomial infection surveillance system (nnis) untuk diagnosis pneumonia tidak hanya ditentukan berdasarkan satu gejala klinis saja yaitu peningkatan suhu seperti yang terjadi pada responden 1 akan tetapi penegakan diagnosis pneumonia dapat ditegakkan dengan kriteria klinis lain yaitu leukositosis. menur ut isselbacher (1999) per ubahan war na dan konsistensi pada seseorang menunjukkan adanya infeksi oleh bakteri atau kuman penyebab. dahak atau sputum yang dikeluarkan terdiri dari air, elektrolit dan glukosa, lendir glikoprotein, transudat, dan lipid sehingga diperlukan pemeriksaan sputum yang teliti yang akan memper jelas keadaan pasien dar i pada pemeriksaan sputum secara kasat mata. nilai pao2/fio2 pada responden 3 yaitu < 240 seperti yang terjadi pada responden 1. menurut morton (2012) tekanan parsial oksigen dalam darah arteri (pao2) menggambarkan tingkat kelarutan oksigen di dalam plasma, sedangkan fraksi oksigen inspirasi (fio2) merupakan jumlah kandungan oksigen inspirasi yang diberikan oleh ventilator ke pasien dengan konsentrasi 21–100%. nilai normal pao2/ fio2 yaitu 300 –500. adanya penur unan pao2/fio2 menggambarkan perburukan pada sistem respirasi pasien. bakteri c. freundii yang ditemukan pada hasil kultur sputum responden 3 merupakan enterobacter spesies, gram negatif, berbentuk batang, anaerob dan merupakan f lora normal pada saluran pencernaan. adapun pergerakan bakteri ini ke organ lain dikaitkan dengan lemahnya daya tahan tubuh penderita. berdasarkan data-data yang terdapat pada responden 3, peneliti ber pendapat bahwa kejadian vap pada responden 3 terjadi diakibatkan faktor-faktor risiko seperti pada responden 1 yang berasal dari pejamu (host) 145 intervensi vap bundle dalam pencegahan vap (diah susmiarti, dkk) seperti tingkat keparahan penyakit, adanya penurunan kesadaran, penurunan daya tahan tubuh, serum albumin < 2,2. faktor risiko lain yang didapat pada responden 3 yaitu usia lanjut (69 th) yang juga akan berpengaruh terhadap imun responden. diagnosa vap terhadap responden 3 oleh peneliti dianggap kurang akurat oleh karena beberapa pertimbangan yaitu pada hari ke 1 sudah terdapat gambaran infiltrat pada hasil foto thoraks, terdapat leukositosis (19.600/μl) dan adanya perburukan pada hasil pao2/fio2 (235). bila berdasarkan klinis tersebut maka dapat dikatakan bahwa responden 3 sudah mengalami pneumonia sejak awal masuk icu. lamanya rawat inap di ruangan sebelumnya, kurangnya mobilisasi (berdasarkan keterangan keluarga) menambah risiko pneumonia nosokomial yang terjadi pada responden. dalam hal ini penilaian secara klinis pada awal masuk sangat penting bagi perawat sehingga penilaian tidak hanya berfokus setelah > 48 jam saja. meskipun pada penelitian ini tidak menilai mengenai bagaimana teknik petugas kesehatan dalam mencuci tangan akan tetapi masih didapatkan tingginya kebiasaan tidak mencuci tangan sebelum menyentuh pasien. hal ini merupakan salah satu yang dapat menyebabkan transmisi mikroorganisme dari petugas ke responden. faktor lain yang kemungkinan menyebabkan vap adalah masih digunakannya model open suction pada responden, meskipun cateter suction yang digunakan sekali pakai akan tetapi kemungkinan terkontaminasi akan sangat mungkin terjadi. berdasarkan keterangan – keterangan yang telah dijelaskan dapat disimpulkan bahwa gambaran suhu, lekositosis, sputum purulent dan perubahan pada foto thoraks untuk mendiagnostik pneumonia tidak selalu tepat pada pasien yang menggunakan ventilasi mekanik. salah satu contoh yaitu demam, kondisi demam dapat ditemukan pada berbagai penyakit yang disebabkan respons infl amasi sedangkan sputum purulen dapat disebabkan oleh trakeobronkitis dan tidak selalu disertai kelainan parenkim. adanya infiltrat pada foto thoraks dapat disebabkan oleh berbagai kelainan noninfeksi seperti edema par u, perdarahan dan kont usio. berdasarkan protocol cdc (2013) mengenai protokol surveilans ventilator associated event (vae) untuk mempermudah surveilans terhadap kejadian vap maka data yang terdapat pada tabel 5.3 yang menerangkan mode dan setting ventilator responden selama 3 hari tidaklah memungkinkan. berdasarkan protocol cdc, kejadian atau kemungkinan va p dapat dideteksi awal dengan melihat perburukan oksigen responden melalui peingkatan fi o2 minimal harian ≥ 0,20 (20 point) di atas kebutuhan minimum 2 hari sebelumnya atau adanya peningkatan peep ≥ 3 cmh2o di atas kebutuhan minimum peep 2 hari sebelumnya d i ma na n ilai m i n i mu m peep ha r ia n 0 –5 c m h 2o. be rd a sa rk a n ket e r a nga n cdc tersebut peneliti berpendapat bahwa pengumpulan data terhadap kejadian atau kemu ng k i na n pasien terd iag nosa va p membutuhkan data penggunaan ventilator pasien minimal 6 hari sehingga dapat diketahui secara pasti. bila mengacu pada hal tersebut maka kemungkinan mortalitas yang terjadi pada pasien bukan diakibatkan oleh terjadinya vap akan tetapi besar kemungkinannya diakibatkan oleh kondisi penyakit primernya. perburukan oksigen memang terjadi pada responden 1 dan responden 3 yang terdiagnosa vap dengan melihat hasil bga melalui perbandingan pao2/fio2 di mana kedua responden < 240. responden lain yang tidak terdiagnosa vap yaitu responden 2, 4, 5, dan 6. meskipun pada hari ke 3 tidak terdiagnosa vap, responden-responden tersebut memiliki risiko untuk timbulnya vap pada hari selanjutnya oleh karena faktor risiko yang ada pada responden 2, 4, 5 dan 6 ini tidak jauh berbeda dengan responden 1 dan 3. faktor risiko pada pejamu (host) tersebut antara lain keparahan penyakit, penurunan kesadaran dan lanjut usia. oleh karena itu observasi cpis secara berkesinambungan perlu ditindaklanjuti sehingga dapat diketahui penyebab vap karena bakteri onset lambat. dan khususnya bagi pasien yang rawat inap lama diperlukan data lebih mengenai ada atau tidaknya perburukan oksigen yang terjadi dengan melihat peep dan fio2 selama rawat inap sehingga akan mudah memastikan apakah responden posible atau probable vap. 146 jurnal ners vol. 10 no. 1 april 2015: 138–146 simpulan dan saran simpulan berdasarkan hasil penelitian yang telah dilakukan dapat disimpulkan bahwa hasil yang didapatkan terhadap kejadian vap setelah penerapan vap bundle yang telah dilakukan terhadap 6 responden didapatkan 2 responden terdiagnosa vap dan 4 responden tidak terdiagnosa vap. hal tersebut diakibatkan f a k t o r-f a k t o r a nt a r a l a i n p e nu r u n a n kesadaran, usia lanjut, albumin serum < 2,2, dan penurunan sistem imun responden oleh karena trauma dan usia lanjut. faktor dari petugas kesehatan sendiri yaitu kepatuhan dalam mencuci tangan masih didapatkan kebiasaan tidak mencuci tangan sebelum menyentuh pasien. pada penelitian ini sulit untuk ditelusuri tingkat mortalitas yang terjadi pada responden apakah diakibatkan oleh vap atau akibat dari diagnosa primernya. saran rumkital dr. ramelan perlu membuat sop mengenai vap bundle pada pasien yang terpasang ventilator untuk mencegah terjadinya vap. p e r a w a t i c u h a r u s d a p a t mengidentifikasi faktor-aktor risiko pada pasien yang dirawat sehingga pencegahan secara dini terhadap kejadian vap dapat dilakukan dengan baik dan penilaian clinical pulmonary infection score (cpis) tidak saja dilakukan pada hari ke 3 namun dilakukan secara berkesinambungan untuk mengetahui kejadian vap yang diakibatkan oleh bakteri yang resisten. peneliti selanjutnya diharapkan dapat mengaplikasikan vap bundle dengan jumlah responden yang lebih besar, homogen serta di lakukan penilaian cpis secara berkelanjutan selama pasien di rawat. kepustakaan augustyn, beth, 2007. ventilator associated pneumonia: r isk and prevention. cr it ical ca re nu rse, a me r ic a n association of critical care nurses. columbia. ban, keum ok, 2011. the effectiveness of an evidence– based nursing care program to reduce ventilator – associated pneumonia in korean icu. intensive and critical care nursing 27. elsevier, 226 – 232. burns, karen, et al, 2011. guidelines for the prevention of ventilator associated pneumonia in adults in ireland, a srategy for the control of antimikrobial resistance in ireland (sari) working group. crunden, edi et al, 2005. an evaluation of the impact of the ventilator care bundle. nursing critical care. 242 – 46. huang, jiahao et al, 2010. effect of histamine-2 receptor antagonists versus sucralfate on stress ulcer prophylaxis in mechanically ventilated patients: a meta-analysis of 10 randomized controlled trials’, critical care. institute for healthcare improvement, 2006. getting started kit: prevent ventilator associated pneumonia: how to guide, hal. 7. isselbacher, 1999. pr insip-pr insip ilmu penyakit dalam. jakarta: egc. kowalak, jennifer, p, et al, 2011. buku ajar patofi siologi. jakarta: egc mccar thy, s.o, et al., 2008. ventilator a s s o ciat e d p ne u mon ia bu nd le d strategies; an evidence-based practice. worldview on evidence-based nursing fourth quarter. 193–204. porzecanski and bowton, 2006. diagnosis and treatment of ventilator associated pneumonia. american college of chest physicians. prasenohadi, 2008. ventilator associated pneumonia (vap) patogenesis dan d i a g n o si s . j u r n a l tu b e r k u lo si s indonesia vol. 5. 14–16. smeltzer, suzanne c and bare, brenda. g, 2013. buku ajar keperawatan medikal bedah brunner & suddarth. ed.8. vol. 3. jakarta: egc. hal. 1698 – 1700. stepanuk, 2000. biochemical and physiological aspecs of human nutrition, w b. sau nders company, philadelphia, pensylvania. zuhriyah, lilik, 2004. gambaran bakteriologis tangan perawat. jurnal kedokteran brawijaya, vol. xx no. 1, hal. 52. 133 preventing medication error based on knowledge management against adverse event apriyani puji hastuti*, nursalam**, mira triharini** *nursing study programpoltekkes rs dr soepraoen malang **nursing faculty universitas airlangga surabaya email: ns.apriyani@gmail.com abstract introductions: medication error is one of many types of errors that could decrease the quality and safety of healthcare. increasing number of adverse events (ae) reflects the number of medication errors. this study aimed to develop a model of medication error prevention based on knowledge management. this model is expected to improve knowledge and skill of nurses to prevent medication error which is characterized by the decrease of adverse events (ae). methods: this study consisted of two stages. the first stage of research was an explanative survey using cross-sectional approach involving 15 respondents selected by purposive sampling. the second stage was a pre-test experiment involving 29 respondents selected with cluster sampling. partial leas square (pls) was used to examine the factors affecting medication error prevention model while the wilcoxon signed rank test was used to test the effect of medication error prevention model against adverse events (ae). results: individual factors (path coefficient 12:56, t = 4,761) play an important role in nurse behavioral changes about medication error prevention based in knowledge management, organizational factor (path coefficient = 0276, t = 2.504) play an important role in nurse behavioral changes about medication error prevention based on knowledge management. work characteristic factor (path coefficient = 0309, t = 1.98) play an important role in nurse behavioral changes about medication error prevention based on knowledge management. the medication error prevention model based on knowledge management was also significantly decreased adverse event (p = 0.000, α <0.05). discussion: factors of individuals, organizations and work characteristics were important in the development of medication error prevention models based on knowledge management. keywords: medication error, knowledge management, adverse events (ae) introduction medication error is one type of error that gets the most attention effort to improve the quality and safety of healthcare because it can increase the cost of health care in large numbers. some of the most common medication errors are misconduct, incorrect dosages, and incorrect intervals (fm hurtsey, 2007). nurses and other health professionals involved in the management and use of drugs (medication management and use/mmu) have a responsibility to create an environment and working practices that prioritize the patient safety. medication error is deemed to occur if drug chart of patients showed any of the following: illegible handwriting, medication name and dosage error, medication admission, and access, discharge medication (wei, shrestha, williamson, & morgan, 2011). efforts should be made to improve safety in drug delivery include national efforts, education, and training for nurses and system changing (roterman, 2014). studies related to the causes of medication errors have been done and the result shows that lack of knowledge dissemination, especially 22% of the doctors who constitute the cause of error, insufficient information about the patient as well as laboratory data test and possibly the cause of dosing error is 10% does not obey the standard operational procedure and forgot 9% as the cause of medication errors. another causes related to misreading the prescription, wrong interpretation and abbreviations commands of prescription, misunderstanding verbal commands, confusing the nomenclature of labeling and packaging, wrong storage of medicine, standard and distribution problem, error delivery when purchasing and using drug for example chemotherapy drug infusion, disruption of tension and work environment; unknowledgeable patients (roterman, 2014). based on the report of hospital safety committee in 2010, incidences of medication errors during january-april 2010 reached 16.67%. nationally, 36% of medication errors occur in the administration phase (paparella, 2011). in the period of may until august 2010, there was 11.1% incidence of medication errors or third ranks incident after incident errors in clinical procedure and patient falls. the high incidence of medication errors due to patient safety needs serious attention from health professionals, especially nurses who play a role in the administration of drugs mailto:ns.apriyani@gmail.com jurnal ners vol. 12 no. 1 april 2017: 133-141 134 (medical administration). medication errors can cause serious adverse effect and potentially to evoke the fatal risk of the disease (perwitasari, abror, & wahyuningsih, 2010). a preliminary study conducted on april 16, 2016, at rsui malang found that the number of patients with uncontrollable drug reactions and the medication error in january december 2015 were 30 cases with the majority of patients are allergic to analgesic, antipyretic and antibiotic drugs. quality improvement of patient safety team of rsui malang has conducted risk grading including medium risk, simple investigation to the incident at the longest two weeks and the leadership commitment to manage the risk in preventing medication error. from the observation, it is found that there were still errors in drug injection and delivery medication schedule. while on the documentation aspect, the nurse only wrote down the activity of medication that has been done without a report or wrote the patient's response to the medication that has been given. medications are classified based on potential risk for medication errors/adverse drug events: high risk, moderate risk and low risk (swinkey & manthey, 2001; zafar, 2007). adverse event occurs due to the negligence of the nurse and medication errors. this fault happens because of high workload and a high number of inpatient. knowledge management in the institution to organize knowledge and facilitate employee to access information so that employees are informed and can apply it and affect employee performance. most knowledge can be obtained from some factors that include education, experience themselves or other people, the mass media and the environment. domain knowledge is very important for the formation of a person's behavior (w. maalej, 2013). to prevent adverse event cause of medication error, the supportive strategies for improving perception for the use of it-based systems would add to system construction, and positive error management climate would be more easily promoted (kim, 2012) knowledge management approach will be used in the prevention of medication errors (gasik, 2011). knowledge management according to gasik (2011) is a development of the concept of knowledge management by nonaka and takeuchi (1995). knowledge management has 7 stage, there are identification; knowledge acquisition, knowledge creation, knowledge application, knowledge transfer, knowledge sharing, knowledge documentation. the advantages of this model are on the data processed through collecting, classifying and grouping, so that it changes the shape and nature of their intended use, interpret the data, data storage, data delivery to the user, and its usefulness in supporting the interests of the organization. this model is based on the traditional model of quality and excellence so that there is a very strong relationship between knowledge management processes and organization with the expected results. the role of knowledge management as a whole is positioned as a tool that helps organizations to achieve the goal. knowledge management approach is the concept of managing knowledge that has been established to be applied to practice by the knowledge that has been gained and reflected in the performance of a nurse so that unexpected events related to the administration of drugs can be minimized. methods the first stage was explanative survey using cross-sectional and second stage was pre-experiment, the purpose was to prepare a model of medication error prevention-based on knowledge management model including to raise strategic issues of nurses. respondents in the first stage are 31 nurses in the icu, firdaus and mina rooms which selected by purposive sampling. the purpose of the second stage was a trial of medication error prevention-based model of knowledge management against unexpected events. data were collected using questionnaires, observation and analyzed by using partial least square (pls). pls results and strategic issues then lifted into the focus group discussion (fgd) with the aim to develop a medication error prevention modulebased knowledge management. participants of fgd were 15 respondents consists of team patient safety, nurse unit manager (num), the nursing committee selected by purposive sampling. nurses implemented a module that resulted by fgd in the second stage of research. respondents of the second stage are 29 in room safa marwah, mumtazah and arofah which collected by using cluster sampling. respondents of the second phase were observed in implementing the module of preventing medication error based on knowledge management (apriyani puji h. et.al) 135 medication error prevention based on knowledge management to the adverse event and the data were analyzed using the wilcoxon signed rank test results the results of the first stage described the causes of medication error (individual factors, organizational factors, job characteristic) and prevention of medication error based on knowledge management (assessment, planning, implementation, evaluation). the distribution of respondents’ answers can be seen in table 1 and table 2. table 1 shows the cause of medication error including individual factors, organizational factors, and respondent’s work characteristic. table 1. distribution causes of medication error no indicator good f (%) moderate f (%) low f (%) total f (%) individual factors 1 knowledge 0 24 (77%) 7 (23%) 31 (100%) 2 ability and skill 0 31 (100%) 0 31 (100%) 3 psychological 0 30 (97%) 1 (3%) 31 (100%) organizational factors 1 organizational comitment 1 (3) 30 (97) 0 31 100%) 2 structur & organizational culture 0 27 (87%) 4 (13%) 31(100%) respondent’s work characteristics 1 objective performance 0 31 (100%) 0 31 (100%) 2 feedback 7 (23%) 24 (77%) 0 31 (100%) tabel 2. prevention of medication error based on knowledge management indicator category total good f (%) moderate f (%) low f (%) assessment knowledge identification 23 (74%) 8 (26%) 31 (100%) knowledge application 1 (3%) 26 (84%) 4 (13%) 31 (100%) knowledge sharing and transfer 2 (6%) 17 (55%) 12 (39%) 31 (100%) knowledge repository 0 27 (87%) 4 (13%) 31 (100%) intervention knowledge identification 25 (81%) 6 (19%) 31 (100%) knowledge application 29 (94%) 2 (6%) 31 (100%) knowledge sharing and transfer 5 (16%) 21 (68%) 5 (16%) 31 (100%) knowledge repository 1 (3%) 22 (71%) 8 (26%) 31 (100%) implementation knowledge identification 30 (97%) 1 (3%) 31 (100%) knowledge application 31 (100%) 31 (100%) knowledge sharing and transfer 2 (6%) 26 (84%) 3 (10%) 31 (100%) knowledge repository 2 (6%) 21 (68%) 8 (26%) 31 (100%) evaluation knowledge identification 2 (6%) 21 (68%) 8 (26%) 31 (100%) knowledge application 25 (81%) 6 (19%) 31 (100%) knowledge sharing and transfer 2 (6%) 20 (65%) 9 (29%) 31 (100%) knowledge repository 4 (13%) 22 (71%) 5 (16%) 31 (100%) jurnal ners vol. 12 no. 1 april 2017: 133-141 136 for individual factors, mostly the knowledge of respondents in preventing medication error is in the moderate category (77%). all respondents (100%) have the ability and skill in the moderate category, and most respondents have psychological factor in the moderate category (97%) for organizational factors, organizational commitment in preventing medication error mostly in sufficient category (97%) and organizational structure and culture mostly in enough category (87%). for respondent’s work characteristics, the objective performance of all respondents in sufficient category are (100%), and feedback from the leadership in the sufficient category are 24 people (77%). as seen in table 2, in the assessment phase, 23 people (74%) has moderate knowledge identification, 26 people (84%) has moderate knowledge application, 17 people (55%) has moderate knowledge sharing, and transfer and 27 people (87%) has moderate knowledge repository. in the planning stage, the majority of respondents has moderate knowledge identification (25 people), moderate knowledge application (29 people), moderate knowledge sharing and transfer (21 people) and moderate knowledge repository (22 people). in the implementation phase the majority of respondents to the knowledge identification quite as many as 30 people (97%), knowledge application as many as 31 people (100%), knowledge sharing and transfer as many as 26 people (84%) and knowledge repository as many as 21 people (68%). in the evaluation phase the majority of respondents to the knowledge identification as many as 21 people (68%), knowledge application as many as 25 people (81%), knowledge sharing and transfer as many as 20 people (65%) and knowledge repository as many as 22 people (71%). observation result of 31 nurses from three rooms icu, mina, and vip eden who implement drug administration to patients through a variety of routes showed that adverse event is still happening as much as 1.5% model development of prevention medication error based on knowledge management the results of the evaluation outer convergent value model validity can be seen in the following figures and tables. based on picture 1, it can be seen that all the indicators declared invalid where the value of outer loading by the expected criteria is above 0.5. this shows that the whole indicator in the structural are valid. results composite reliability to test the value of reliability indicators in this study can be seen in table 3. picture 1 outer loading value on prevention medication error model based on knowledge management preventing medication error based on knowledge management (apriyani puji h. et.al) 137 table 3. results of convergent validity of the prevention medication error model based on knowledge management no variable concronbach alpha composite reliability note 1 individual factor 0.733 0.834 valid 2 organizational factor 0.769 0.867 valid 3 work characteristic 0.668 0.858 valid 4 prevention medication error based on knowledge management 0.777 0.857 valid table 4. statistical result of several variables that potentially prevent medication errors no variable result note 1 individual factor path coefficient = 0.560 standard deviation = 0,120 t statistic = 4,671 significant 2 organizational factor path coefficient = 0,276 standard deviation = 0,110 t statistic = 2,504 significant 3 work characteristic factor path coefficient = 0,309 standard deviation = 0,155 t statistic = 1,988 significant 4 prevention medication error based on knowledge management path coefficient = -0,486 standard deviation = 0,063 t statistic = 7,704 significant the value of each variable composite reliability study showed a value of > 0.7. cronbach alpha value of each variable also showed a value of > 0.6. it can be concluded that each variable has met reliability test. these results indicate that there is a significant relationship between the variables individual, organization, and work towards the prevention of medication errors characteristicbased on knowledge management. there is a significant relationship between medication error prevention based on knowledge management against the adverse event. the negative sign of the coefficient indicates the inversely proportional relationship means that the higher prevention medication error factorbased on knowledge management will decrease the incidence rate of an adverse event. recommendation of focus group discussion (fgd) for module development in the prevention of medication error based on knowledge management against adverse event 1. socialize about the adverse event and near missed to the nurses and allowed nurses to report to the nurse unit manager and documented in patient safety report. 2. patient safety report should regularly be reported to the patient safety team every week so that the risks can be found and prevention can be done immediately. 3. socialize related to principles of correct drug administration and completeness of drug delivery instrument documentation sheet 4. change the time of drug administration if the set time is still not applicable; give the autonomy to the each room related the drug administration so that the effectiveness of the drug is also noteworthy. time of drug administration implemented 10.00-18.00 02:00 hours 5. documenting drug administration should be relevant to what is done by each nurse. 6. there is a reward for the room which carries out regular reporting of patient safety incidents and for the room with the most minimally incident related patient safety. 7. sustainability and innovation in the prevention of medication errors should be jurnal ners vol. 12 no. 1 april 2017: 133-141 138 considered to be applied continuously and improve patient safety. phase 2 the trial of the model conducted from may 8, 2016. the pre-test conducted in 10-day by observation of nurses behavior in preventing medication errors and unexpected events. firstly, the module is given to nurses in arofah safa and marwah and researcher explain about the module. researcher accompanied the nurse in administering the drug for two weeks in the morning shift. after two weeks nurses perform independently until ten days and researcher observe it as a posttest. the results of pre-test and post-test of implementation of the application of medication error prevention module-based on knowledge management can be seen in table 5. table 5. results of implementation of medication error prevention-based on knowledge management against adverse event prevention medication error based on knowledge management pre post good enough less good enough less assessment knowledge identification 29 (100%) 4 (14%) 25 (86%) 0 knowledge application 5 (17%) 22 (76%) 2 (7%) 14 (48%) 15 (52%) 0 knowledge sharing and transfer 2 (7%) 24 (83%) 3 (10%) 9 (31%) 20 (69%) 0 knowledge repository 5 (17%) 22 (76%) 2 (7%) 13 (45%) 16 (55%) 0 intervention knowledge identification 0 20 (69%) 9 (31%) 5 (17%) 24 (83%) 0 knowledge application 7 (24%) 22 (76%) 0 14 (48%) 15 (52%) 0 knowledge sharing and transfer 6 (21%) 21 (72%) 2 (7%) 7 (24%) 22 (76%) 0 knowledge repository 5 (17%) 18 (62%) 6 (21%) 7 (24%) 22 (76%) 0 implementation knowledge identification 17 (59%) 12 (41%) 0 18 (62%) 11 (38%) 0 knowledge application 6 (21%) 23 (79%) 2 (7%) 28 (97%) 1 (3%) 0 knowledge sharing and transfer 5 (17%) 22 (76%) 2 (7%) 6 (21%) 23 (79%) 0 knowledge repository 12 (41%) 17 (59%) 0 14 (48%) 15 (52%) 0 evaluation knowledge identification 0 0 29 (100%) 5 (17%) 24 (83%) 0 knowledge application 0 0 29 (100%) 8 (28%) 21 (72%) 0 knowledge sharing and transfer 0 1 (3%) 28 (97%) 10 (34%) 19 (66%) 0 knowledge repository 0 0 29 (100%) 10 (34%) 19 (66%) 0 table 6. statistical analysis of pre and post intervention between adverse event and near missed ∆ – sd z asymp. sig (2-tailed) advers event 0.15 ± 0 2.023 0.043 near missed 89.08 ± 3.78 4.703 0.000 results of statistical analysis of the near missed by using wilcoxon signed rank test showed a significance value (p) = 0.000, less than the standard value of α = 0.05 which indicates that there is an influence of medication error prevention knowledge preventing medication error based on knowledge management (apriyani puji h. et.al) 139 management based on the nearly missed incident. while the results of the statistical analysis of the adverse event by using wilcoxon signed rank test showed significance value (p) = 0.043, less than the standard value of α = 0.05 which indicates that there is the influence of medication error prevention-based on knowledge management against the adverse event. discussion individual factors against the prevention of medication error based on knowledge management the results of pls analysis obtained that the coefficient value of 0.56 lines and 4,671 t statistic (t> 1.96). it can be concluded that individual factors contribute to the adoption of knowledge management-based medication error and indirectly an attempt to reduce the adverse event. components of the individual factors include knowledge, abilities, skills of nurses, and psychological. mc. closhey & mc. cain (1988) research results which cited in gillies (2004) stated that nurses who have higher education also have the ability to work better. efforts to increase knowledge is an important thing especially in the context of patient safety. human resource-limited knowledge was health services problem to unable manage service-oriented based on patient safety which is a required key for the sake of security created by the care given by health workers, including nurses. in this case, the ability and skills of nurses related to the implementation of the drugs correct administration principles conducted by nurses include right patient, right drug, right indication, right dose, right route of administration, the correct time and the correct documentation. psychological factors include perception, motivation, attitude and willingness to learn. perception in this case related to the satisfaction of nurses to the salary given by the health services. the motivation of nurse to maintain patient safety efforts and motivation of the leadership that made more development in work. the attitude and willingness to learn make nurses more responsible for their actions. their high willingness to study of rsui nurses thus requiring hospital organization active role as a media to conduct information and knowledge for nurses. organization factors against the prevention of medication error based on knowledge management the study results, the analysis of pls obtained coefficient t statistic lines 0276 and 2504 (t> 1.96), these results suggest that there is significant influence between the variables of organizational factors on medication error prevention-based knowledge management. organization factors have sub-variables included organizational commitment, leadership, structure, and culture of the organization. the organization structure shows how a group designed, lines of communication and relationships of authority and decision-making (marquis & huston, 2000). organization commitment stated here include hospitals vision and mission suitability, reward and punishment, training and development. rsui’s vision and the mission were appropriate, particularly related to quality improvement and patient safety. reward and punishment imposed by the hospitals, especially in a room with a patient safety incident reporting implemented by regularly documented every week and every month. currently, nurses in the hospitals are still got no reward and punishment in particular, but every month there is a favorite nurse election based on a poll of the patient. training and development at rsui were based on their regular schedule in the improvement of knowledge especially nurses with information in the form of inhouse training with the involvement of the expert of experts according to the field or socialization by peers who have been carrying out training of ex-house training. instruction model leadership is indicated by the high task and low relationship. rsui leadership has contributed greatly to the compliance of nurses in implementing guidelines for prevention of medication errors. this is consistent with the theory that nurse manager has a very important role in implementing patient safety, especially the prevention of medication errors. in other research, any correlation between nurse’s knowledge levels with right principle implementation of medication on injection action (gede, pratama, prabowo, & rahil, n.d.) the organization system in rsui was well structured so that the chain of command and jurnal ners vol. 12 no. 1 april 2017: 133-141 140 coordination lines between each field can be implemented quite well. given the structure of a good organization can support nurse adherence in doing medication error prevention. work characteristic against the prevention of medication error based on knowledge management the results of pls analysis obtained coefficient lines 0309 and t statistic is 1.98 (t> 1.96). this showed that there is significant influence between variable factors, work characteristic against the prevention of medication errors based knowledge management. further found also showed that the objective performance is a domain factor related to nursing compliance in applying the prevention of medication errors. robbin (2008) stated that a work characteristic is an approach to work that is specified in 5 dimensions of the core characteristics: skill variety, task identity, task significance, autonomy, and feedback. in rsui malang district, job design delivered at the beginning of nurse orientation after they accepted as a nurse. nurses are oriented about their responsibilities, rights, and duties as a nurse at the hospital. this activity is closely related to job performance, and supervision carried out by hospitals, but this activity still does not yet implemented optimally. therefore, the hospital should perform evaluation and amelioration of performance and supervision. implementation of medication error prevention based on knowledge management against adverse event the trial model of knowledge-based prevention of medication errors management as an effort to decrease the adverse event of 4 modules that have been tested to decrease the adverse event. the significant difference is the inaccuracy of time and documentation, where nurses do not realize the impact that may arise in the administration of drugs that do not correspond with the timing so that the next shift could be faster or slower administer the drugs so it can influence the effectiveness of drug delivery. based on the overall hypothesis testing, it can be seen significant lines, models describing these results is the variable of individuals ability, organizations and work characteristic variable against the prevention of medication errors based knowledge management and indirectly to decrease the adverse event. conclusions individual factors (demographics data, level of knowledge, abilities, and skills, and psychological) significantly influence on the prevention of medication errors based on knowledge management. while organizational factors (organizational commitment, leadership, structure, and organizational culture) significantly affect the prevention of medication errors based on knowledge management. job characteristic factors (objective performance and feedback) significantly influence the medication error prevention-based knowledge management. model of medication error preventionbased on knowledge management is influenced by individual factors, organization and work characteristic. medication error preventionbased knowledge management can significantly reduce the unexpected incidence. learning with knowledge management methods are used so that the nurse can learn about discussion, formulate, and decide on knowledge gained so can be easily applied to the ability of nurses in drug delivery. to enhance the prevention of medication error, it needs to make a list of the order of nursing personnel who will participate in continuing education, training or seminars as a form of nursing staff’s knowledge increase. application of medication error prevention module-based on knowledge management can be performed on orientation activities at the first time of nurse work. create pre-conference and post-conference activities routine at every turn shift as a medium to add information and knowledge for nurses. create continue evaluation and supervision for nurses to conduct the safe administration of drugs and as an effort to improve the behavior of the nurses. enable the nursing committee specifically to credentialing about the nurse actions. initiate pmkp program proactively that spurred the realization of a work culture toward patient safety oriented. hold a gradual guidance and training for nurses who still have less working period regarding its implementation about the hospital's patient safety. preventing medication error based on knowledge management (apriyani puji h. et.al) 141 references fm hurtsey, w.n, 2007, inappropriate prescribing in older ed population. am j emerg med, 22-32 gasik, s, 2011, a model of project knowledge management, project management journal, 42(3), 23-44. gede, i. d., pratama, m., prabowo, t., & rahil, n. h. (n.d.). the relation between nurse ’ s knowledge levels with right principle implementation of medication on injection action at rsud wates. gillies, 2004, manajemen keperawatan: suatu pendekatan sistem, edisi kedua, philadelphia, wb saunders kim, m. s. (2012). medication error management climate and perception for system use according to construction of medication error prevention system. journal of korean academy of nursing, 42(4), 568. https://doi.org/10.4040/jkan.2012.42.4.56 8 marquis & huston, 2010, kepemimpinan dan manajemen keperawatan. jakarta: egc paparella, s. (2011). is a back to basics approach to medication error reduction enough? journal of emergency nursing. https://doi.org/10.1016/j.jen.2011.05.003 perwitasari, d. a., abror, j., & wahyuningsih, i. (2010). medication errors in outpatients of a government hospital in yogyakarta indonesia, 1(1), 8–10. robbins, 2008, perilaku organisasi edisi ke 12, jakarta, salemba empat roterman, i, 2014, simulation in medicine, walter de gruyter gmbh & co kg. kualitatif, kuantotatif dan r&d. bandung, alfabeta. swinkey, n. j., & manthey, c. w. (2001). medication error/adverse drug event (meade) classification. ashp midyear clinical meeting, 36, p–737d. w. maalej, a. t, 2013, managing requirements knowledge. springerverlag berlin heidelber. wei, s., shrestha, r., williamson, j., & morgan, c. (2011). medication error prevention programme. internal medicine journal.conference: royal australasian college of physicians congress 2011 darwin, nt australia.conference start: 20110522 conference end: 20110525.conference publication: (var.pagings).41 ()(pp 45), 2011.date of publication: may 20. retrieved from do http://dx.doi.org/10.1111/j.14455994.2011.02494.x zafar, a. (2007). meaders: medication errors and adverse drug event reporting system. amia ... annual symposium proceedings / amia symposium. amia symposium, 1167. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18 694263 https://doi.org/10.1016/j.jen.2011.05.003 vol 9 no 1 april 2014.indd 59 posisi lateral kiri elevasi kepala 30 derajat terhadap nilai tekanan parsial oksigen (po2) pada pasien dengan ventilasi mekanik (left lateral positioning with head elevation increase the partial pressure of oxygen on patients with mechanical ventilation) karmiza*, muharriza*, emil huriani**, * rsup dr. m djamil. jl perintis kemerdekaan padang ** fakultas keperawatan universitas andalas. kampus universitas andalas limau manis padang e-mail : mizakarmiza@yahoo.co.id abstrak pendahuluan: pernapasan secara harfi ah berarti pergerakan oksigen dari atmosfer menuju ke sel dan pengeluaran karbondioksida ke udara bebas. tekanan parsial oksigen (po2) merupakan salah satu komponen yang penting pada proses pernafasan terutama pada pasien terpasang ventilasi mekanik. ada beberapa tindakan yang dapat dilakukan dalam upaya meningkatkan ventilasi yaitu perubahan posisi, salah satunya adalah posisi lateral kiri dengan elevasi kepala 30 derajat. penelitian ini bertujuan untuk mengetahui pengaruh posisi lateral kiri dengan elevasi kepala 30 derajat terhadap nilai tekanan parsial oksigen (po2) pada pasien dengan ventilasi mekanik di ruang intensif rsup dr. m. djamil padang. metodologi: jenis penelitian adalah pra eksperimen dengan one group pretes posttest design. sampel sejumlah 15 orang yang diambil dengan metode purposive sampling. nilai tekanan parsial oksigen (po2) diperoleh melalui pemeriksaan analisa gas darah. pengumpulan data dilakukan di ruang intensif rsup dr. m. djamil padang pada tanggal tanggal 8 mei sampai 5 juni 2013. data univariat disajikan dalam tabel distribusi frekuensi, sedangkan data bivariat menggunakan uji t berpasangan. hasil: analisis univariat menunjukkan nilai tekanan parsial oksigen (po2) sebelum intervensi antara 119–228 mmhg, sedangkan nilai tekanan parsial oksigen (po2) setelah intervensi antara 132–269 mmhg. hasil uji t berpasangan menunjukkan adanya perbedaan bermakna antara nilai po2 sebelum dan sesudah pemberian posisi lateral kiri dengan elevasi kepala 30 derajat di mana p= 0,040 ( p < 0,05). diskusi: posisi lateral kiri dengan elevasi kepala 30 derajat dapat meningkatkan tekanan parsial oksigen (po2) pada pasien yang terpasang ventilasi mekanik. hasil penelitian ini dapat dijadikan masukan untuk peningkatan kualitas pelayanan pasien yang dirawat di ruang intensif dengan pemasangan ventilasi mekanik sehingga dapat mengurangi hari rawatan pasien. penelitian lanjutan tentang intervensi ini dapat dikembangkan untuk pasien yang dirawat dengan masalah pernapasan atau penyakit primer paru untuk meningkatkan nilai tekanan parsial oksigen (po2). kata kunci: posisi lateral kiri, tekanan parsial oksigen (po2), ventilasi mekanik. abstract introduction: breathing literally means the movement of oxygen from the atmosphere and reach the cells and carbon dioxide into the atmosphere. partial pressure of oxygen (po2) is one of the important components in the process of respiration, especially in patients with mechanical ventilation. there are several interventions that can be performed in an effort to improve the ventilation, one of them is patients positioning: left lateral position with 30 degrees head elevation. this study aimed to determine the effect of left lateral position with 30 degrees head elevation to the value of partial pressure of oxygen in patients with mechanical ventilation in intensive care unit rsup dr. m. djamil padang. method: this study was pra experiments with one group pretest posttest design. 15 samples taken by purposive sampling method. data obtained by blood gasses analysis and it was conducted since may 8th untill june 5th, 2013. univariate data presented in frequency distribution table, while the bivariate data using the paired t test. result: univariate analysis showed the value of the partial pressure of oxygen ( po2 ) before intervention between 119-228 mmhg , while the value of the partial pressure of oxygen ( po2 ) after intervention between 132-269 mmhg . paired t test results showed a signifi cant difference between the value of the partial pressure of oxygen ( po2 ) before and after intervention (p = 0.040, p < 0.05 ). discussion: the left lateral position with 30 degrees head elevation could increase the partial pressure of oxygen (po2) in patients with mechanical ventilation. the results of this study can be used for increasing the nursingcare quality of patients with mechanical ventilation in order to reduce the time of hospitalization. further research on these positioning interventions can be developed for patients with primary respiratory problems or lung disease. keywords: left lateral position, partial pressure of oxygen (po2), mechanical ventilation 60 jurnal ners vol. 9 no. 1 april 2014: 59–65 pendahuluan per napasan secara harf iah berar ti pergerakan oksigen dari atmosfer menuju ke sel untuk proses metabolisme dalam rangka menghasilkan energi dan keluarnya karbon dioksida sebagai zat sisa metabolisme dari seluler ke udara secara bebas. pernapasan dilakukan organ pertukaran gas yaitu paru dengan pompa ventilasi yang terdiri atas dinding dada, otot diafragma, isi dan dinding abdomen serta pusat pernapasan di otak (guyton dan hall, 2006). kerja inspirasi dibagi menjadi 3 yaitu kerja compliance/elastisitas, kerja resistensi jaringan dan kerja resitensi jalan nafas. mekanisme pernapasan terdiri dari inspirasi dan ekspirasi melalui peranan compliance paru dan resistensi jalan nafas. selama inspirasi normal, hampir semua otot-otot pernapasan berkontraksi, sedangkan selama ekspirasi hampir selur uh nya pasif akibat adanya elastisitas paru dan struktur rangka dada. sebagian besar kerja napas dilakukan oleh otot-otot pernapasan untuk mengembangkan paru (guyton dan hall, 2006). te k a n a n p a r si a l ok sige n ( p o 2) merupakan indikator klinis untuk mengetahui status oksigenisasi. disamping itu terdapat beberapa faktor yang mempengaruhi tekanan parsial oksigen (po2), yaitu hemoglobin, jenis kelamin, umur, berat badan, tidal volume dan kondisi patalogis seperti penyakit paru (gravenstein dan paulus, 2004). stat us perbaikan ventilasi pada pasien dengan ventilasi mekanik ditunjukkan dengan adanya perbaikan bunyi nafas dan nilai analisa gas darah (peningkatan tekanan parsial oksigen (po2) pada konsentrasi oksigen yang sama) (horne dan swearingen, 2001). o k sige n m e r u p a k a n s a l a h s a t u komponen gas dan unsur vital dalam proses met ab ol isme, u nt u k me mp e r t a h a n k a n kelangsungan hidup seluruh sel tubuh. secara normal elemen ini diperoleh dengan cara menghirup udara ruangan dalam setiap kali bernafas. penyampaian oksigen ke jaringan tubuh ditentukan oleh interaksi sistem respirasi, kardiovaskuler dan keadaan hematologi. adanya kekurangan oksigen ditandai dengan keadaan hipoksia, yang dalam proses lanjut dapat menyebabkan kematian jaringan bahkan dapat mengancam kehidupan (brunner dan suddarth, 2002). kebutuhan oksigen tidak lepas dari gangguan yang terjadi pada sistem pernafasan. untuk menilai adanya gangguan pernafasan dapat dilakukan melalui pemeriksaan fi sik (untuk gangguan pernapasan berupa sesak nafas, sianosis, dan lain-lain), dan melalui pemeriksaan diagnostik, yaitu pemeriksaan analisa gas darah yang dapat dilakukan untuk menilai tekanan parsial oksigen (po2). analisa gas darah memberikan determinasi objektif tentang oksigenasi darah arteri, pertukaran gas alveoli dan keseimbangan asam basa. analisa gas darah dapat menilai terjadinya ganguan pernafasan atau permasalahan ventilasi dan difusi (asmadi, 2008). gangguan pernafasan yang sering terjadi salah satunya kegagalan pernafasan. menurut ignatavicius dan workman (2006), kegagalan pernapasan lebih lanjut dapat didefi nisikan sebagai kegagalan ventilasi dan atau kegagalan oksigenasi yang disebabkan karena gangguan pusat pernapasan, penyakit/ gangguan otot dinding dada, peradangan akut jaringan paru dan beberapa sebab lain seperti trauma yang merusak jaringan paru-paru maupun organ lain seperti jantung dan otak. dir uang intensif, untuk mengatasi kegagalan pernafasan digunakan bantuan pernafasan. pemberian bantuan pernapasan dengan pemasangan ventilasi mekanik dalam mengendalikan ventilasi paru ditujukan untuk meningkatkan oksigenasi dan mencegah kerusakan paru. ventilasi mekanik adalah alat bant u nafas yang dig u nakan pada penderita dengan gagal nafas dan penyakit lainnya. ventilasi mekanik diberikan dengan ketidakmampuan fungsi pernapasan untuk melakukan ventilasi alveolar secara optimal (sellares, 2009). smeltzer et al. (2008) menyatakan bant uan ventilasi mekanik dig u nakan u nt u k memenu hi kebut u han oksigen tubuh, mengurangi kerja pernapasan, meningkatkan oksigenasi ke jaringan atau mengoreksi asidosis per napasa n. pad a penggunaan ventilasi mekanik dapat timbul komplikasi-komplikasi jika tidak dilakukan perawatan dengan baik. 61 posisi lateral kiri elevasi kepala 30 derajat (karmiza, dkk.) me n u r u t h a w k i n s , st o n e , d a n plummer (1999), pengaturan posisi pasien adalah tindakan keperawatan dasar. pada posisi ini perawat mempunyai peran yang penting karena yang ada disamping pasien selama 24 jam ialah perawat. peran perawat menggunakan posisi terapi untuk mencegah komplikasi dan immobilitas, memonitor hemodinamik, kenyamanan serta perubahan patologis selama reposisi. diruang intensif perawat menyadari adanya komplikasi karena perawatan yang lama pada pasien kritis, oleh karena itu perubahan posisi sangat penting guna memperoleh hasil terbaik untuk pasien (mahvar et al., 2012). posisi yang digunakan diruang intensif pada pasien yang terpasang ventilasi mekanik cenderung tidur dengan posisi terlentang dimana semua pasien seharusnya posisi dengan elevasi kepala 30 derajat (raoof, 2009). perubahan posisi pasien rutin digunakan selama di unit perawatan intensif untuk prof ilaksis, mengutamakan kenyamanan, mencegah pembentukan ulkus, mengurangi kejadian deep vein thrombosis, emboli paru, atelektasis dan pneumonia (banasik, 2001). namun untuk beberapa diutamakan untuk membantu meningkatkan fungsi fisiologis dan bantuan pemulihan (evans, 1994). horne dan swearingen (2001) menganjurkan untuk merubah posisi pasien sedikitnya 2 jam untuk meminimalkan tekanan pada jaringan, seperti tumit dan area lain diatas tonjolan tulang. lamanya waktu dalam posisi terapi yang dipilih dapat melampaui standar dua jam atau dapat dipersingkat (30 menit), didasarkan pada efektivitas posisi yang dipilih dalam meningkatkan fungsi pernafasan. namun posisi lateral yang dilakukan secara rutin mugkin tidak cocok untuk semua pasien di ruang intensif, beberapa kontraindikasi, seperti pasien spondilitis, fraktur cervikal dan harus digunakan hati-hati pada pasien yang rentan terhadap disfungsi cardiopulmonary dan peredaran darah (banasik, 2001). penelitian oleh glanville dan hewitt (2009) menyimpulkan bahwa meskipun posisi lateral memberikan efek peningkatan perfusi untuk peningkatan tekanan parsial oksigen (po2) pada pasien dewasa yang sakit kritis dan terpasang ventilasi mekanik di ruang intensif. penelitian sebelumnya menemukan bahwa beberapa pasien sakit kritis mengalami perubahan yang signifikan dalam variabel transportasi oksigen selama reposisi. studi menggunakan isotop ventilasi-perfusi scan pasien dengan kardiomegali dan kelainan paru telah menunjukkan penurunan ventilasi 40% sampai 50% di lobus kiri bawah akibat posisi terlentang yang berkepanjangan (jonson, 2009). posisi lateral kiri dapat meningkatkan ventilasi dimana anatomi jantung berada pada sebelah kiri di antara bagian atas dan bawah paru membuat tekanan paru meningkat, tekanan arteri di apex lebih rendah dari pada bagian basal paru. tekanan arteri yang rendah menyebabkan penurunan aliran darah pada kapiler di bagian apex, sementara kapiler di bagian basal mengalami distensi dan aliran darahnya bertambah. efek gravitasi mempengaruhi ventilasi dan aliran darah dimana aliran darah dan udara meningkat pada bagian basal par u (rodney, 2001). pada posisi ini aliran darah ke paru bagian bawah menerima 60-65 % dari total aliran darah ke paru (gullo, 2008). pada pasien yang menggunakan ventilator mekanik, efek gravitasi terhadap kapiler darah menyebabkan peningkatan tekanan alveolar sehingga meningkatkan ventilasi (rodney, 2001). penelitian mahvar et al. (2012) tentang efektif itas 3 jenis posisi dengan selang waktu perubahan posisi 30 menit terhadap peningkatan nilai tekanan parsial oksigen (po2) pada pasien bypass arteri koroner menunjukkan hasil tekanan parsial oksigen (po2) dan saturasi oksigen pada posisi lateral kiri dan lateral kanan lebih tinggi secara sig nif ikan dibandingkan dengan posisi telentang dan posisi semi fowler, dimana posisi lateral kiri memperoleh peningkatan tekanan parsial oksigen (po2) yang lebih tinggi dibanding posisi lainnya. pasien dengan ventilasi mekanik membutuhkan oksigen untuk ventilasi (potter dan perry, 2005). penerapan posisi pasien di ruang intensif sebaiknya dilakukan untuk meningkatkan drainase sekresi pernafasan, m e n c e g a h g a s t r o e s o p h a g e a l r ef l u k , 62 jurnal ners vol. 9 no. 1 april 2014: 59–65 pneumonia nosokomial dan ulkus tekanan dan memberikan kenyamanan pasien (mahvar et al., 2012). posisi lateral kiri dan kanan pada pasien dengan ventilasi mekanik menyebabkan peningkatan nilai tekanan parsial oksigen (po2) yang lebih tinggi pada dari pada posisi telentang (glanville dan hewitt, 2009; reid dan chung, 2004). berdasarkan observasi selama 3 minggu di ruang intensif rsup dr. m. djamil padang diperoleh data bahwa dari total 10 pasien yang dirawat tidak ada yang memperoleh tindakan perubahan posisi secara rutin dengan berbagai sebab, yaitu belum adanya sop khusus terkait pengaturan posisi, dan motivasi perawat terkait tindakan perubahan posisi lebih ditujukan untuk pencegahan ulkus dekubitus dan vap. tindakan perubahan posisi yang dilakukan oleh perawat belum rutin dan tidak terjadwal. selain itu, tindakan perubahan posisi hanya dilakukan pada pasien yang memiliki resiko ulkus dekubitus atau bahkan yang telah mengalami ulkus dekubitus. tercatat dari 2 pasien yang dilakukan perubahan posisi, pasien tampak nyaman, hemodinamik stabil, saturasi oksigen sebelumnya dari 96–97% menjadi 99–100%, dan hasil analisa gas darah menunjukkan adanya peningkatan tekanan parsial oksigen (po2). bahan dan metode jenis penelitian yang digunakan adalah pra experiment dengan desain one group pretes posttest. populasi dalam penelitian ini adalah seluruh pasien yang terpasang ventilasi mekanik di ruang intensif rsup dr. m djamil padang pada tahun 2013. jumlah sampel yang digunakan dalam penelitian sejumlah 15 orang. unt u k menent u kan sampel peneliti menggunakan kriteria inklusi, yang meliputi: (1) usia 17– 60 tahun; (2) hemodinamik stabil, ditandai dengan tekanan darah sistole 100–130 mmhg, tekanan darah diastole 70–90 mmhg, dan frekuensi nadi 70– 90 kali/menit; (3) saturasi oksigen 96–100%, frekuensi pernapasan 10-24 kali/menit; (4) pasien terpasang ventilasi mekanik dengan setting ventilator bipap/cpap, fio2 50%, pasien terintubasi dan ramsay score 2–3; (5) hemoglobin lebih kurang 10 gr %. kriteria eksklusi meliputi: (1) adanya komplikasi paru: ppok, ards, asma, tuberculosis; (2) adanya cedera medula spinalis; (3) post craniotomy dengan peningkatan tekanan intrakranial; dan (4) penyakit komplikasi lain. penelitian ini telah mendapat rekomendasi dari komite etika penelitian fakultas kedokteran universitas andalas. p r o s e d u r p e n e l i t i a n m e l i p u t i pemeriksaan analisa gas darah, yaitu tekanan parsial oksigen (po2) sebelum (pretest) posisi lateral kiri dan elevasi kepala 30 derajat. selanjutnya peneliti melakukan perubahan posisi lateral kiri dan elevasi kepala 30 derajat selama 30 menit. posttest dilakukan (mahvar et al., 2012). analisa univariat menggambarkan nilai tekanan parsial oksigen (po2): minimum, maksimum dan nilai mean. analisa bivariat dilakukan menggunakan uji t berpasangan. hasil penelitian ini dilak ukan di r uang intensif rsup dr. m. djamil padang tanggal 8 mei 2013 hingga 5 juni 2013. dari jumlah sampel yang ditetapkan, terdapat 9 orang yang tidak memenuhi kriteria inklusi, sehingga jumlah responden dalam penelitian ini menjadi 15 orang responden. karakteristik responden menunjuk kan bahwa dari 15 responden yang terbanyak berjenis kelamin perempuan (53,3%) yait u seba nya k 8 responden , sedangkan proporsi responden berdasarkan umur terbanyak pada rentang 41-65 tahun sebanyak 6 orang (40%). hasil penelitian menunjukkan rerata tekanan parsial oksigen (po2) pretest (sebelum intervensi) sebesar 177 mmhg (sd ± 30,848), dimana nilai tertinggi po2 sebesar 228 mmhg dan nilai terendah po2 adalah 119 mmhg. hasil ini diperoleh melalui pemeriksaan analisa gas darah yang diambil pada posisi pasien terlentang (supine) dengan elevasi kepala 30 derajat, yang ditujukan untuk mencegah aspirasi dan pneumonia. dat a posttest menu nju k ka n n ilai teka na n pa rsial ok sigen ( po2) setela h dilakukan intervensi berada pada rentang 132–269 mmhg, dengan sd ± 33,909. hasil 63 posisi lateral kiri elevasi kepala 30 derajat (karmiza, dkk.) uji t berpasangan diperoleh nilai p=0,040 ( p<0,05), ar t i nya ad a perbed a an yang bermakna antara nilai po2 sebelum dan sesudah dilakukan posisi lateral kiri dengan elevasi kepala 30 derajat pada pasien dengan ventilasi mekanik. berdasarkan hasil observasi, posisi supine pada pasien yang terpasang ventilasi mekanik dapat menyebabkan penumpukan sekret di mulut dan ett. kondisi ini dapat merangsang ref lek batuk, sehingga pasien merasa tidak nyaman dan dapat meningkatkan usaha nafas (work of breathing) yang mengganggu proses ventilasi (sundana, 2008). pembahasan hasil penelitian pretest (sebelu m intervensi) diperoleh melalui pemeriksaan analisa gas darah yang diambil pada posisi pasien terlentang (supine) dengan elevasi kepala 30 derajat, yang ditujukan untuk mencegah aspirasi dan pneumonia. menurut raoof (2009) posisi pasien yang terpasang ventilasi mekanik di ruang intensif adalah posisi supine dengan elevasi kepala sebesar 30 derajat. elevasi kepala 30 derajat dapat memperbaiki ventilasi dan menurunkan resiko aspirasi pada pasien dengan ventilasi mekanik. namun, menurut price dan wilson (2006) adekuat tidaknya ventilasi paru ditentukan oleh volume paru, resistensi jalan nafas, compliance paru dan kondisi dinding dada. penurunan compliance paru dapat terjadi pada pasien dengan posisi telentang yang berdampak terhadap penur unan lingkar dinding thorak dan peningkatan frekuensi pernafasan sehingga dapat menimbulkan atelektasis (kolaps alveolus) pada pasien dengan ventilasi mekanik (charlebois dan wilmoth, 2004). berdasarkan hasil penelitian yang telah dilakukan sebagian besar responden mengalami peningkatan tekanan parsial oksigen (po2) setelah diberikan intervensi. perubahan posisi lateral kiri dan elevasi kepala 30 derajat dilakukan oleh peneliti dan dibantu petugas ruang intensif. berdasarkan hasil observasi yang dilakukan peneliti, selama posisi lateral kiri elevasi kepala 30 derajat pasien terlihat lebih nyaman, tidak gelisah, hemodinamik stabil, saturasi meningkat mencapai 100%, dan sekret mudah disuction. kondisi seperti ini menyebabkan bersihan jalan nafas efektif dan pasien dapat bernafas dengan baik sehingga oksigenasi adekuat. menurut osborn dan adam (2009) posisi lateral kiri dapat memfasilitasi pergerakan sekret dibantu oleh gaya grafi tasi dari paruparu ke saluran nafas bagian atas, sehingga sekret dapat dengan mudah dikeluarkan dengan tindakan suction. tekanan parsial oksigen (po2) jaringan ditentukan oleh keseimbangan antara (a) kecepatan transpor oksigen dalam darah ke jaringan dan (b) kecepatan pemakaian oksigen oleh jaringan (ober, garrison, dan silverthorn, 2001). menurut gravenstein dan paulus (2004), tekanan parsial oksigen (po2) dipengaruhi oleh beberapa faktor, antara lain hemoglobin, jenis kelamin, umur, berat badan, tidal volume dan kondisi patalogis seperti penyakit paru. diantara 15 responden terdapat 3 responden yang mengalami penurunan nilai tekanan parsial oksigen (po2), yaitu 2 responden dengan tumor otak, post craniotomy, serta usia > 55 tahun, dan 1 responden dengan post laparatomy eksplorasi luka, sepsis, serta terjadi perdarahan masif. price dan wilson (2006) menyatakan tumor otak dapat menyebabkan penekanan pada saraf pernafasan sehingga refl ek batuk lemah dan terjadi retensi jalan nafas yang disebabkan adanya penumpukan sekret di jalan nafas. selain itu, seiring dengan penambahan usia akan terjadi penurunan fungsi ventilasi paru. pada kondisi normal, sekitar usia 50 tahun, alveoli mulai kehilangan elastisitas dan perlahan terjadi kemunduran fungsi organ tubuh ter masuk par u-par u (smeltze et al., 2008; guyton dan hall, 2006). martin et al. (2002) juga mengatakan bahwa klien dengan usia lebih muda membutuhkan perawatan lebih singkat dan memiliki survival lebih tinggi, sedangkan usia lebih tua memiliki ketergantungan terhadap ventilator lebih tinggi. menurut guyton dan hall (2006) usia dan riwayat penyakit akan berdampak pada gangguan organ dan berpengaruh terhadap penurunan kemampuan fungsional paru. 64 jurnal ners vol. 9 no. 1 april 2014: 59–65 ad anya proses perd arahan dapat mempengaruhi kadar hemoglobin sehingga dapat menyebabkan terganggunya proses transportasi oksigen dalam darah. hampir 97 % transpor oksigen dalam darah dibawa oleh hemoglobi n seh i ngga penu r u na n konsentrasi hemoglobin mempunyai efek yang sama terhadap tekanan parsial oksigen (po2). penurunan konsentrasi hemoglobin menjadi seperempat dari normal dimana aliran darah normal dapat mengurangi po2 cairan interstisial menjadi kira-kira 13 mmhg. berdasarkan uraian diatas, 3 responden yang mengalami penur unan po2 kemungkinan terjadi karena faktor usia, resistensi jalan nafas, penurunan compliance paru dan kondisi penyulit atau penyakit seperti penekanan pusat pernafasan. keadaan ini memperberat kerja pernafasan yang berpengaruh pada ventilasi yang tidak adekuat. simpulan dan saran simpulan posisi lateral kiri dengan elevasi kepala 30 derajat dapat meningkatkan tekanan parsial oksigen (po2) pada pasien yang terpasang ventilasi mekanik. namun, kondisi penyulit seperti tumor otak dan perdarahan dapat menurunkan tekanan parsial oksigen (po2) meskipun telah diberi posisi lateral kiri dan elevasi kepala 30 derajat. saran hasil penelitian ini dapat dijadikan sebagai pertimbangan dalam penyusunan sop (standard operating procedure) perawatan pasien dengan ventilasi mekanik sehingga outcome pasien dapat lebih baik dan proses penyapihan ventilator menjadi lebih singkat. selain itu, hasil penelitian ini dapat dijadikan referensi atau masukan untuk peningkatan kualitas pelayanan pasien yang dirawat di ruang intensif dengan pemasangan ventilasi mekanik sehingga mengurangi hari rawatan pasien dan meningkatkan pendapatan rumah sakit. perlu adanya penelitian lanjutan tentang intervensi ini yang dikembangkan untuk pasien yang dirawat dengan masalah pernafasan atau penyakit primer paru untuk meningkatkan nilai tekanan parsial oksigen (po2). kepustakaan asmadi, 2008. teknik prosedur konsep dan aplikasi kebutuhan dasar klien jakarta: salemba medika. banasik, j.l. 2001. effect of lateral position on tissue oxygenation in the critically ill. heart lung, ncbi, 30 (4), 269–276. brunner dan suddarth. 2002. keperawatan medikal bedah. edisi 8. volume 2. jakarta: egc. charlebois dan wilmoth. 2004. critical care of patients with obesity, aacn advanced. crit care nurse; 24: 19–27. evans, d., 1994. the use of position during critical illness: current practice and review of the literature, australian critical care, 7 (3), 16–21. glanville, d dan hewitt, n. 2009. lateral position for critically patient adult (protocol). deakin research online, 3, 1–13. gravenstein, j.s. dan paulus, a.d., 2004. capnography:carbon dioxide over time and volume. cape town: canbrige university press. gullo, a. 2008. anaestesi pain intensive care intesive and emergency medicine. italy: springer. guyton, a.c. dan hall, j.e., 2006. textbook of medical physiology. 11th edition. philadelphia: wb. saunders company, misissipi. horne, m.m. dan swearingen, l.p., 2001. kesimbangan cairan elektrolit dan asam basa edisi 2. jakarta: egc. hawkins, s.k, stone, l, dan plummer. 1999. a holistic approach to turning patients. nursing standard. 14 (3), 51–2,54–6. ignatavicius, d. d. dan workman, m. l. 2006. medical surgical nursing: critical thinking for collaborative care. st. louis missouri: elsevier saunders. jonson, l.k. 2009. physiological rational and current evidence for therapeutic positioning of critically ill patients. aacn advanced critical care, 20 (3), 228-240. 65 posisi lateral kiri elevasi kepala 30 derajat (karmiza, dkk.) mahvar, t., et al., 2012. the effect of positioning after coronary artery bypass graff. life science journal, 9 (3). martin, a.d., davenport, p.d., franceschi, a.c., dan harman, e., 2002. use of inspiratory muscle strength training to fa cil it at e ve nt ilator wea n i ng. chest jour nal, 122 (1). (on li ne). (htt p://chestjour nal.chest pubs.org / content/122/1/192. full.html. diakses tanggal 2 pebruari 2010) osborn, s., dan adam, k.s., 2009. oxford hand book of critical care nursing. united state: oxford university press. ober w.c, garrison, c.w., dan silverthorn, a. 2001. the interactive oxyhaemoglobin dissociation cur ve. pennsylvania: department of medicine. pr ice, s.a., d a n wilson, l.m., 20 06. pathophysiology: clinical concepts of disease proces. ed. 6. usa: elsevier science. potter dan perry, 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktek. vol. 2. jakarta: egc. reid, w.d., dan chung, f., 2004. clinical management notes and case histories in cardiopulmonary physical theraphy. united state of america: slack. rodney, r.a., 2001. ventilasi perfusi apakah dipengaruhi posisi dan gravitasi, (online), http://dokterzarra. wordpress. com/.../ventilasi-perfusi-apa, diakses pada 03 februari 2013 raoof, s. 2009. manual critical care. united state of america. sundana, k., 2008. pendekatan praktis di unit perawatan kritis. bandung: cicu rshs. sellares, j., 2009. respiratory impedance during weaning from mechanical ventilation in a mixed population of critically ill patients, ncbi, 103 (6), 32–828. smeltzer, s.c, bare, b.g, hincle, j.i, dan cheever, k.h. 2008. textbook of medical surgical nursing; brunner & suddart. usa: lipincott williams & wilkins. http://e-journal.unair.ac.id/jners | 433 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19783 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors contributing to tb at primary health center in sidoarjo indonesia totok indarto, tintin sukartini, makhfudli makhfudli faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: tuberculosis (tb) is caused by mycobacterium tuberculosis, and remains a burden in indonesia. many factors contribute to the tb prevalence, including age, sex, body mass index, sputum smear conversion, hiv infection, and diabetes mellitus. the objective of this study is to identify factors contributing to tb prevalency at the primary health center. methods: this research used as a cross-sectional study and was conducted in march 2020. the population of this study was tb patients at porong primary health center in sidoarjo, east java province, indonesia. samples were all tb patients who registered in porong primary health center and were taken by total sampling. the sample size was 51 tb patients. there were no inclusion and exclusion samples criteria implemented. data were collected that used the secondary data of tb patients registration, between 1st – 31st march april 2020. data were analyzed using frequency distribution with spss version 21. results: result shows there were 30 (58.80%) male tb patients, 34(66.70%) tb patients were adults, 48 (94.10%) tb patients had sputum smear conversion from positive to negative after two months dots therapy, there were 48 (94,10%) tb patients not infected by hiv virus, and there were 36 (70,60%) tb patients had a history of diabetes mellitus. conclusion: factors contributing to tb prevalence are many, including age, sex, body mass index, sputum smear conversion, hiv infected, and diabetes mellitus. to improve care of tb patients requires integration and comprehension of care at the primary health center. article history received: feb 27, 2020 accepted: april 1, 2020 keywords tuberculosis; prevalence; primary health center contact tintin sukartini  tintin-s@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: indarto, t., sukartini, t., & makhfudli, m. (2020). factors contributing to tb at primary health center in sidoarjo indonesia. jurnal ners, special issues, 433-435. doi:http://dx.doi.org/10.20473/jn.v15i2.19783 introduction indonesia is the third country with the highest tb prevalence after india and china. the high prevalence of tb is partly because the case finding and complete treatment requires a long time while the spread of tb is very fast (world health organization, 2019). it is estimated that the incidence of new tb in indonesia is 399 per 100,000 population (total tb cases 1,000,000). sidoarjo is the third-largest contributor to lung tb sufferers in east java province after surabaya city and jember regency (dinkes, 2016). the total number of cases of pulmonary tb in sidoarjo in 2018 was 2153 patients. among these patients, there were 50 patients or 5% who were grouped out of the dots treatment program (sidoarjo, 2018). a large number of cases are caused by the transmission of mycobacterium tuberculosis from tb patient to the new host. many people do not understand the transmission of mycobacterium tuberculosis. many factors affect the prevalence of tb, such as age, hiv infection, the natural history of tb, hygiene, and socioeconomic condition (pai et al., 2016). prevalence of tb infection in the u.s. is related to various factors: age, sex, race/ethnicity, poverty, educational level, birthplace, diabetes, body mass index, cigarette smoking status, and hiv status (miramontes et al., 2015). the benefit that is taken by this research result is the provider will use different strategies to solve tb patients’ problems according to the factors so that tb patients complete the dots program successfully. thus, it is needed to identify https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:tintin-s@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. t. indarto, et al. 434 | pissn: 1858-3598  eissn: 2502-5791 factors contributing prevalence to tb in kabupaten sidoarjo, east java, indonesia. materials and methods this research was conducted on a cross-sectional study. the population and sample are all tb patients who registered as tb patients at porong primary health center between january to september 2019. sampling this research was total sampling, with sample size are 51 tb patients. the variables in this research are sex, age, sputum smear conversion, hiv infected, and diabetes mellitus. data were collected using secondary data of tb patients registration at the porong primary health center. data were presented and statistically analyzed using frequency distribution by spss version 21. this research has been ethically tested at the ethical board of faculty of nursing, universitas airlangga by number 1970-kep. results most respondents (58.80%) were male and 66.70% were adults. age of tb patient between a minimum of 7 years old and a maximum of 68 years old as well as the average age of tb patients was 42.82 years old. in addition, 94.10% respondents have sputum smear conversion from positive to negative after two months of dots therapy, 70.60% respondents suffering diabetes mellitus and only three respondents (5.90%) were infected by hiv as well (see table 1). discussion the results showed that the number of men with tb patients was more than women at porong primary health center by the year 2019. most patients were male (61.2%), according to data collected from four endemics-countries: indonesia, peru, romania, and south africa (ugarte-gil et al., 2019). the incidence of tb is approximately twofold higher in men than in women, and approximately 10% of all new cases are children (pai et al., 2016). these phenomena may relate to behavior. the behaviors related to tb patient are less exercise, smoke, bad diets, and low adherence to tb therapy. the highest rate prevalence of tb was significantly associated with an adult (21-60 years old). latent tuberculosis infection prevalence increased with age, with a prevalence of 29.4% among singapore-born aged 70–79 years (yap et al., 2018). the point of prevalence of tb infection probably rose with age group, with the elderly group more sensitive than the young men group, related to the ability of the body to protect against the agents, especially against mycobacterium tuberculosis. there were 6% percent of tb patients still showing a positive result of sputum smear after two months period of time treatment with dots. the proportion of pulmonary tuberculosis afb positive patients was sputum smear conversion 33.3% and no sputum smear conversion 66.7% in labuang baji hospital and lung health center, makasar (supardi, sudaryo and thaha, 2019). sputum smear conversion indicates that tb patients are responsive to the dots treatment. health education is the most needed for tb patients, so that they understand tuberculosis and prevent airborne transmission to other men and women. there were six (3%) tb patients with presence of hiv in their body. it can be concluded that effort toward the detection of tb-hiv within the optimal range yields both epidemic and economic gains (supardi, sudaryo and thaha, 2019). the strongest factors among the tb patients were hiv infection: 12% of all new active tb cases and 25% of tb-related deaths with hiv infection individuals (pai et al., 2016). tb patients with hiv infection need special treatment to prevent them from developing an active tb; they need tuberculosis preventive therapy (i.e., treatment for asymptomatic latent tuberculosis infection) (saunders and evans, 2019). tb is a contagious disease that results from being infected with a bacteria called mycobacterium tuberculosis. unfortunately, people with hiv have a low level of immunity, as a result, they will be easier infected by microorganisms, especially mycobacterium tuberculosis. one-third of tb patients at porong primary health center suffer diabetes mellitus, which raises the patient’s risk factor to active tb and worsens tb outcomes (ugarte-gil et al., 2019). in diabetes mellitus it is primarily known that many patients are unable to control blood glucose level diabetes mellitus attacks all human organs especially lung, and it worsens tb outcomes. it is important to improve the management of tb and diabetes mellitus therapy (ugarte-gil et al., 2019). improving support for patients with tuberculosis is a major priority for governments especially based on digital platforms to raise tb patients’ adherence to treatment(yoeli et al., 2019). tb patients need to maintain their blood glucose level every month, promote a balanced diet, maintain physical examination, and maintain table 1. characteristics of respondents (n=51) characteristics n % sex male female 30 21 58.8 41.2 age group child adult elderly 8 34 9 15.7 66.7 17.6 sputum smear conversion negative positive 48 3 94.1 5.9 hiv infection negative positive 48 3 94.1 5.9 diabetes mellitus not presence presence 36 15 70.6 29.4 jurnal ners http://e-journal.unair.ac.id/jners | 435 adherence to taking all medicine every day on schedule. conclusion factors contributing to tb prevalence are many, including age, sex, body mass index, sputum smear conversion, hiv infection, and diabetes mellitus. to improve care of tb patients requires integration and comprehension of care including, improved healthrelated behavior, health education, immunization, and social support of care for tb patients. furthermore, this can be used to improve health promotion and prevention of tb, especially at primary health centers. conflict of interest all authors declare no competing interests. acknowledgement we would like to thank the faculty of nursing, universitas airlangga, surabaya, indonesia. we would like to thank the doctor and nurses of the porong primary health center who took time to participate in this study. references dinkes (2016) ‘profil kesehatan provinsi jawa timur tahun 2016 [east java health profile 2016]’, provinsi jawa timur, dinkes. miramontes, r. et al. (2015) ‘tuberculosis infection in the united states: prevalence estimates from the national health and nutrition examination survey, 2011-2012’, plos one, 10(11), pp. 2011– 2012. doi: 10.1371/journal.pone.0140881. pai, m. et al. (2016) ‘tuberculosis’, nature reviews disease primers, 2. doi: 10.1038/nrdp.2016.76. saunders, m. j. and evans, c. a. (2019) ‘ending tuberculosis through prevention’, new england journal of medicine, 380(11), pp. 1073–1074. doi: 10.1056/nejme1901656. sidoarjo, d. k. k. (2018) profil kesehatan kabupaten sidoarjo. sidoarjo. supardi, u. k., sudaryo, m. k. and thaha, i. l. m. (2019) ‘analysis of risk factors for changing conversion of pulmonary tuberculosis afb positive patients in the intensive phase, makassar city, indonesia’, indian journal of public health research and development, 10(2), pp. 531–536. doi: 10.5958/0976-5506.2019.00346.2. ugarte-gil, c. et al. (2019) ‘diabetes mellitus among pulmonary tuberculosis patients from 4 tuberculosis-endemic countries: the tandem study’, clinical infectious diseases, 70(5). doi: 10.1093/cid/ciz284. world health organization (2019) ‘global tuberculosis report country profile 2019’, publication, 63(10), p. 476. doi: 10.1177/2165079915607875. yap, p. et al. (2018) ‘prevalence of and risk factors associated with latent tuberculosis in singapore: a cross-sectional survey’, international journal of infectious diseases. international society for infectious diseases, 72, pp. 55–62. doi: 10.1016/j.ijid.2018.05.004. yoeli, e. et al. (2019) ‘digital health support in treatment for tuberculosis’, new england journal of medicine, 381(10), pp. 986–987. doi: 10.1056/nejmc1806550. 14 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 14-18 http://dx.doi.org/10.20473/jn.v17i1.28707 original article open access indonesians’ readiness in facing long-term covid-19 pandemic yuyun setyorini 1, yopi harwinanda ardesa 2 , rendi editya darmawan 1.* 1 department of nursing, health polytechnics of surakarta, indonesia 2 department of orthotics-prosthetics, health polytechnics of surakarta, indonesia *correspondence: rendi editya darmawan. address: letjen sutoyo street, mojosongo, surakarta, central of java, indonesia, email: rendiedityad@gmail.com responsible editor: yulis setiya dewi received: 29 july 2021 ○ revised: 22 february 2022 ○ accepted: 1 march 2022 abstract introduction: long-term covid-19 pandemic which has existed in indonesia since 2020 not only poses a risk to public health but also to their social conditions. indonesia, as a country with strong social fabric within its people, has a high sense of social responsibilities in facing the pandemic. the aim of this study is to describe indonesians’ readiness in facing long-term covid-19 pandemic. methods: this descriptive study used a cross-sectional design with a sample of 305 residents of five cities in indonesia. they were chosen not randomized by distributing a survey invitation via whatsapp group with the background of the general public, and health cadres. we waited until the response received reached t he targeted number of respondents. the data were collected using google forms, and were analyzed by using a descriptive method (percentage, p -value, and odds ratio) by spss statistical software version 25. results: the readiness in facing the pandemic fell into two categories: the high readiness level (77.1%) and the low readiness level (22.9%). gender and age do not affect the level of readiness, while the level of education and employment status influenced the level of readiness. conclusions: the majority of indonesians have high readiness level. public participation can decrease covid-19 transmission rate. keywords: covid-19; indonesian; pandemic; readiness introduction coronavirus disease 2019 (covid-19) is a new strain that has never been identified before in humans (tarantola, 2020). based on the scientific facts available during the formulation of the research, covid-19 can be transmitted human-to-human through droplets of cough or sneeze and is not airborne. persons with the most risk of contracting this disease are those coming into close contact with covid-19 patients, including those treating them (heymann, 2020; song and lu, 2020). standard recommendations in preventing the transmission of the virus include washing hands regularly with soap and running clear water, applying coughing and sneezing etiquette, avoiding direct contact with livestock and wild animals, and avoiding close contact with anyone exhibiting respiratory disease symptoms such as coughing and sneezing (who, 2020a; 2020c). the public needs to be ready with the new habits like maintaining distance, washing hands, wearing masks, and not gathering. on the other hand, indonesians have a habit of gathering and socializing with family, and friends, and this has the potential for transmission of covid-19. another problem is not meeting with family, and friends (pasteruk, 2020). not socializing in a short time doesn’t cause problems, but not being able to meet for a long time will cause boredom (hwang et al., 2020). a long-lasting pandemic can make people tired of wearing masks because it’s uncomfortable and costs money (claresta, christian and sa’id, 2021). we need to see indonesian readiness to solve the problem, and carry out health protocols for a long time. readiness is defined as a point of maturity to accept and practice the health protocol behavior that has been set in life. the case of covid-19 has spread throughout the world, numbering 237 countries based on who data in https://creativecommons.org/licenses/by/4.0/ mailto:rendiedityad@gmail.com https://orcid.org/0000-0002-5242-0803 https://orcid.org/0000-0002-0720-2436 jurnal ners http://e-journal.unair.ac.id/jners 15 march 2022. the incidence of covid-19 based on who data on march 17, 2022 showed 462,758,117 confirmed cases with a mortality rate of 6,056,725 deaths. the who also reported data on confirmed cases of covid-19 in south-east asia of 56,626,996 (who, 2022). data from the indonesian ministry of health reported that, as of march 17, 2022, there were 5,939,082 indonesians confirmed covid-19 with 153,212 deaths. based on who data in february 2022, indonesia was placed 27 of 237 countries with the most covid-19 cases (kementerian kesehatan republik indonesia, 2022). jansen et al. (2021) stated that there is a faster transmission in the omicron variant, making the potential for covid transmission increase when public awareness is low. indonesia’s position was included in countries with a high number of covid-19 cases, in line with data monitoring health protocol compliance in july 2021. task force covid-19 reported that 27.03% people did not obey wearing masks, and disobedience to keep a distance was 28.38%. it is not only the responsibility of the government, but also community contribution to increase public participation of the importance for obeying health protocols (satgas, 2021). indonesians have a successful history in solving problems by involving the community, such as a successful program to prevent dengue fever by establishing larva monitoring (widyawati, 2019). the country also succeeded in controlling drug dropout in tuberculosis patients using drug monitoring, where support from the supervisor significantly influences the patients' obedience of taking tb drugs (widani and sianturi, 2020). these problems were solved by the community. history shows that the role of the community is very important in controlling covid-19 in indonesia. based on community roles win line with public health condition, community readiness in carrying out, inviting, and monitoring health protocols becomes important. community readiness depends on individual commitment to change, facilitating change, and implementing change (edwards et al., 2000; castañeda et al., 2012). indonesians are accustomed to the same behavior as their values. for instance, the residents of sukoharjo, province central java decided to isolate the village as a form of war against the coronavirus, and no one is allowed in or out until the situation return to normal, and each individual follows the rules (pasteruk, 2020). seeing the long-term likelihood of covid-19 pandemic, as well as compliance with fluctuating health protocols, a study was needed to determine the readiness of indonesians in dealing with a lengthy covid-19 pandemic. there was no research that discusses indonesians’ readiness in deal with a long-term covid19 pandemic, hence the objective of this research was to investigate indonesians’ readiness in facing a long-term covid-19 pandemic. materials and methods study design this research used a descriptive study with a crosssectional design and was carried out in indonesia between march and june 2021. respondent all participants (n=305) were indonesians living in five cities: surakarta, surabaya, jayapura, denpasar, and sukoharjo. the data of the research were collected through questionnaire via google forms including demographic information (age, sex, level of education, and employment status), and measures of readiness in coping with covid-19 undertaken. instrument the measures of readiness were assessed by using the 5-point likert scale to measure responses for 14 questions. the instrument made by the research team in consultation with linguists, and public health expert was then tested for validity and reliability. validity and reliability tests were carried out on 20 respondents outside the research sample. validity test was using pearson product moment and reliability test using cronbach’s alpha. the results of the r table with 20 respondents and the level of significance is 5%, namely 0.444. a statement is declared valid if r count > r table. the questions 1 through 14 have r count more than r table and it can be concluded that all statements are valid. the results of cronbach’s alpha show a value of 0.786 and are more than the r table (0.444), so it can be concluded that all statements are reliable (appendix 1). table 1 demographic characteristics and readiness level of the respondents (n = 305) variables frequency percentage gender female male 266 39 87.2% 12.8% age (years) 17-35 36-50 >50 69 157 79 22.6% 51.5% 25.9% education level elementary school junior high school senior high school diploma degree bachelor’s degree master’s degree 20 45 139 35 42 24 6.6% 14.8 45.6 11.5 13.8 7.7 occupation unemployed civil servants traders laborers students others 175 35 19 16 21 39 57.4% 11.5 6.2 5.2 6.9 12.8 readiness level high readiness level low readiness level 235 70 77.2% 22.8% setyorini, ardesa, and darmawan (2022) 16 p-issn: 1858-3598  e-issn: 2502-5791 data collection we distributed survey invitations via whatsapp to whatsapp groups with the background of the general public, and health cadres, and waited until the response received reached the targeted number of respondents. data analysis the results show that indonesians’ readiness in facing the pandemic fell into two categories, namely the high readiness level and the low readiness level. readiness level was determined by identifying 14 statements (appendix 2). the statement consists of readiness in identifying guests after the trip, quarantine for people with a high risk of covid-19, checking the health of residents, reducing the frequency of mobility, providing supporting facilities for health protocols, disinfection of public places, health education, participation in surveillance of suspected covid-19, and sharing food. each statement will get a value of 1-5. the maximum value for each respondent is 70. the result of the calculation of mean is 53. we measured group readiness levels with a formula, readiness value more than or equal to 53 was referred to as high readiness level, and readiness value less than 53 as low readiness level. the readiness measures collected were then grouped into those that carried the most (high readiness level) and those carried the least (low readiness level). data analysis was performed by using the spss statistical software version 25 by showing percentage, odds ratio (or), and pvalue. the data were presented or summarized as mean, frequency, or, and percentage. ethical consideration the study was approved by the research ethics committee of the indonesian ministry of health. the ethical approval was obtained from health research ethics committee of poltekkes kemenkes surakarta, number lb.02.02/1.1/2424.4/2021 dated on january 31 st, 2021. permission to conduct the study was proposed to the regional research and development design agency of central java province. the researchers applied research ethics principles of anonymity, beneficence and nonmaleficence, autonomy, and justice. an explanation of the background and aim of the study, as well as informed consent were contained in the google form, together with the instrument. participants were reminded at the beginning of the survey that proceeding and completing the survey indicated voluntary consent to participate in the study. anonymity and confidentiality were maintained throughout the study. results a total of 305 people was sampled with 95% response rate of 321 respondents who were recruited. the respondents ranged from 17-63 years of age sd of 34±6.3 years. table 1 shows demographic data of the respondents. the majority of participants were female (87.2%). a large number of respondents were within the age range of 36-50. most of respondents (45.6%) graduated from senior secondary school, and a large number of respondents (57.4%) were unemployed. the majority of respondents had a high readiness level (77.1%). based on the research, it is reported that women (68%) had higher level of readiness in facing covid-19. respondents falling into productive age of 17–50 were readier in dealing with the impacts of the pandemic. it is also reported that respondents with higher levels of education were 1.739 times readier than those with lower levels of education, and those who were employed were 2.164 times readier than those who were not (table 2). discussions the research results show that the majority of indonesians (77.1%) were of high readiness level in facing covid-19. the factors influencing readiness in facing the pandemic were education level (p =0.000) and employment status (p =0,000), while gender (p=0.591) and age (p=0.150) were not found to be correlated with public readiness level. this result is influenced by several determinants of readiness. the respondents with higher levels of education had 1.739 times higher readiness level than those with lower levels of education. education and skills have a strong influence on individual well-being. education creates many opportunities for individuals and is essential for high economic growth, and strong social cohesion table 2 relationship between characteristics of the respondents and readiness level variable readiness level or (95% ci) p value* high (%) low(%) gender female male 208 (68%) 29 (10%) 58 (19%) 10 (3%) 1.237 0.591 age 17-50 years old 171 (56%) 55 (18%) >50 years old 66 (22%) 13 (4%) 0.612 0.150 level of education high 78 (26%) 32 (10%) low 157 (51%) 38 (12%) 1.739 0.000 employment status employed unemployed 71 (23%) 166 (54%) 26 (9%) 42 (14%) 2.164 0.000 jurnal ners http://e-journal.unair.ac.id/jners 17 (mojtahedi et al., 2021). education guarantees income, social benefits, healthy neighbors, and healthy behaviors, so that those with higher levels of education are readier to face new diseases. this is in line with findings from yanti et al. (2020) that show indonesians have good knowledge, positive attitudes, and good behavior toward social distancing to prevent the transmission of the covid-19 pandemic in indonesia. it can be concluded that level of knowledge influences public readiness in facing covid-19. the respondents who were employed were 2.164 times readier than those who were unemployed. this is consistent with the findings of weil (2017), stating that employment influences one’s level of readiness in facing problems. employed people will have better economic state, which enables them to make ends meet. mojtahedi et al. (2021) said that people who lost their jobs during the pandemic felt depression, anxiety, and stress, so they had difficulty facing covid-19. as a consequence of the covid-19 pandemic, many companies terminated their staff’s employments. the rules of social distancing have forced coffee shops to lay off their employees. the implementation of the lockdown has also prevented the tourism, hotel and transportation sectors from allowing employees to work (al-fadly, 2020; bottan, hoffmann and vera-cossio, 2020). if this global health crisis is not resolved immediately, the economy will not do well, thereby causing an increase in vulnerability of transmission and rate of death (viezzer and biondi, 2021). the results of the study show that most of the men and women have high readiness. level of exposure risk, comorbidity, socioeconomic level, and individual experiences influence readiness in facing the pandemic. the who recommends that, in making decisions, governments should also consider gender factors in order to ensure public participation and readiness (who, 2020b). age correlates with level of experience and vulnerability to disease. in this research it was found that those aged 17-50 years, as well as those more than 50 years old, were in high readiness to face covid-19, although indonesians had no experience in dealing with diseases similar to covid-19. experience in facing diseases similar to covid-19 provides more readiness. as an example, taiwanese, as reported by chiu ( 2020) were ready to face covid-19 since they had experience in facing sars in 2003. the researchers stated that covid19 prevention efforts have been conducted earlier in taiwan, including countering false news spreading fear (chiu, 2020). vulnerability to covid-19 should cause people to be more vigilant, in which the elderly are more vulnerable to the disease (niu et al., 2020). however, since indonesians have no prior experience, age did not significantly influence readiness. indonesians voluntarily raised funds to make washbasins, distribute face masks, disinfect places of worship, and help others economically since they have a culture of mutual assistance (gotong royong), which has long taken root in the country (bowen, 1986). the history of three centuries of colonization enables indonesians to achieve high levels of solidarity. cooperation, mutual assistance, collective decision-making, and mutual respect are important parts in the national culture (dewantara, 2017). the limitation of this research is that the sample coverage is not comprehensive as it does not cover all 34 provinces in indonesia. conclusions research findings show that the majority of indonesians sampled have high readiness level in facing the covid-19 pandemic. most males and females in indonesia, both aged 17-50 years or more than 50 years, who are highly educated and have low education, as well as those who are working or not working have high readiness to face the pandemic. there is, however, a need of improvement in health education in order to improve readiness. we suggest that a wider survey is needed by adding a variable about covid-19 vaccination. health protocol compliance must also always be surveyed as a basis for determining government policies. references al-fadly, a. (2020) ‘impact of covid-19 on smes and employment’, entrepreneurship and sustainability issues, 8(2), pp. 629–648. doi: 10.9770/jesi.2020.8.2(38). bottan, n., hoffmann, b. and vera-cossio, d. (2020) ‘the unequal impact of the coronavirus pandemic: evidence from seventeen developing countries’, plos one, 15(10), pp. 1–10. doi: 10.1371/journal.pone.0239797. bowen, j. r. (1986) ‘on the political construction of tradition: gotong royong in indonesia’, the journal of asian studies. [cambridge university press, association for asian studies], 45(3), pp. 545– 561. doi: 10.2307/2056530. castañeda, s. f. et al. (2012) ‘dimensions of community and organizational readiness for change’, progress in community health partnerships: research, education, and action, 6(2), pp. 219– 226. doi: 10.1353/cpr.2012.0016. chiu, w. t. (2020) ‘determinants of taiwan ’ s early containment of covid-19 incidence’, ajph, 110(7), pp. 943–945. doi: 10.2105/ajph.2020.305720. claresta, a., christian, s. and sa’id, m. (2021) ‘public obedience to health protocols during covid-19 pandemic in indonesia: a perspective from health belief model theory’, journal of social sciences and humanities, 11(2), pp. 1–11. dewantara, a. (2017) ‘“gotong-royong” (mutual assistance of indonesia) according to soekarno in max scheler’s axiology perspective’, international journal of humanities and social science, 4, pp. 41–50. doi: 10.14445/23942703/ijhss-v4i5p106. edwards, r. w. et al. (2000) ‘the community readiness model: research to practice ruth’, journal of community psychology, 28(3), pp. 291–307. doi: 10.1002/(sici)1520-6629(200005)28. heymann, d. l. (2020) ‘a novel coronavirus outbreak of global health concern’, thelancet, 395, pp. 15–18. doi: 10.1016/s01406736(20)30185-9. hwang, t. j. et al. (2020) ‘loneliness and social isolation during the covid-19 pandemic’, international psychogeriatrics, 32(10), pp. 1217–1220. doi: 10.1017/s1041610220000988. jansen, l. et al. (2021) ‘investigation of a sars-cov-2 b.1.1.529 (omicron) variant cluster — nebraska, november–december 2021’, mmwr. morbidity and mortality weekly report, 70(5152), pp. 1782–1784. doi: 10.15585/mmwr.mm705152e3. kementerian kesehatan republik indonesia (2022) situasi covid-19 nasional. mojtahedi, d. et al. (2021) ‘the relationship between mental toughness, job loss, and mental health issues during the setyorini, ardesa, and darmawan (2022) 18 p-issn: 1858-3598  e-issn: 2502-5791 covid-19 pandemic’, frontiers in psychiatry, 11(february), pp. 1– 16. doi: 10.3389/fpsyt.2020.607246. niu, s. et al. (2020) ‘clinical characteristics of older patients infected with covid-19: a descriptive study.’, archives of gerontology & geriatrics. beijing emergency medical center, beijing, china: elsevier b.v., 89, p. n.pag-n.pag. doi: 10.1016/j.archger.2020.104058. pasteruk, i. (2020) ‘community development in indonesia: contemporary aspects of culture’, proceedings of the international conference on community development, 477(iccd), pp. 338–342. doi: 10.2991/assehr.k.201017.075. satgascovid-19 (2021) monitoring pemantauan protokol kesehatan di wilayah indonesia, satuan tugas penanganan covid-19. song, f. and lu, h. (2020) ‘emerging 2019 novel coronavirus (2019ncov) pneumonia’, radiology, 295(1), pp. 210–217. tarantola, d. (2020) ‘a public health perspective in the times of covid-19’, ajph, 110(7), pp. 925–927. doi: 10.2105/ajph.2020.305742. viezzer, j. and biondi, d. (2021) ‘the influence of urban, socio-economic, and eco-environmental aspects on covid-19 cases, deaths and mortality: a multi-city case in the atlantic forest, brazil’, sustainable cities and society, 69(june), pp. 1–15. doi: https://doi.org/10.1016/j.scs.2021.102859. weil, a. r. (2017) ‘the work/health relationship’, health affair, p. 199. doi: 10.1377/hlthaff.2017.0059. who (2020a) advice on the use of masks the community , during home care and in health care settings in the context of the novel coronavirus ( 2019-ncov ) outbreak interim guidance. who (2020b) gender and covid-19. who (2020c) novel corona virus, who. who (2022) who coronavirus (covid-19) dashboard, who. widani, n. l. and sianturi, s. r. (2020) ‘relationship between drug consumption, supervisors’ knowledge and support, and patients’ obedience to take tuberculosis drugs’, ijnp (indonesian journal of nursing practices), 4(1), pp. 46–52. doi: 10.18196/ijnp.41107. widyawati, w. (2019) satu rumah satu jumantik efektif cegah dbd, kementerian kesehatan. yanti, b. et al. (2020) ‘community knowledge, attitudes, and behavior towards social distancing policy as prevention transmission of covid-19 in indonesia’, jurnal administrasi kesehatan indonesia, 8(2), pp. 4–14. doi: 10.20473/jaki.v8i2.2020.4-14. how to cite this article: setyorini, y., ardesa, y. h., and darmawan, r. e. (2022) ‘indonesians’ readiness in facing longterm covid-19 pandemic’, jurnal ners, 17(1), pp. 14–18. doi: http://dx.doi.org/10.20473/jn.v17i1.28707 appendices appendix 1 validity and reliability readiness level assessment statements pearson r count cronbach’s alpha statement 1 0.715 0.786 statement 2 0.617 statement 3 0.694 statement 4 0.568 statement 5 0.782 statement 6 0.600 statement 7 0.785 statement 8 0.671 statement 9 0.598 statement 10 0.638 statement 11 0.641 statement 12 0.723 statement 13 0.652 statement 14 0.568 appendix 2 readiness level assessment statements totally agree (5) agree (4) partially agree (3) disagree (2) totally disagree (1) 1) do you carry out identity checks and ask the city of origin where the migrants come from? 2) do you ask visitors to check with the nearest health facility after the trip? 3) do you ask visitors to apply self-quarantine measures for 14 days inside their homes after the trip? 4) do you ask the arriving person to self-quarantine at the quarantine facility provided by the city government? 5) do you check the body temperature and health status of the people who come? 6) do you do road closures to reduce the frequency of mobility? 7) do you build a sink and provide soap? 8) do you distribute masks to the public? 9) do you disinfect places of worship and public places? 10) do you make health education posters or banners? 11) do you suspend meetings and rallies? 12) do you raise funds to ease the economic burden of the population? 13) do you participate in surveillance activities against suspected covid-19? 14) do you donate food to members of the community affected by covid-19 who are in need **scoring: total score: ___________ table2 table1 alfadly2020 bottan2020 bowen1986 castañeda2012 chiu2020 claresta2021 dewantara2017 edwards2000 heymann2020 hwang2020 jansen2021 kementeriankesehatanrepublik2022 mojtahedi2021 niu2020 pasteruk2020 satgascovid2021 song2020 tarantola2020 viezzer2021 weil2017 who2020a who2020b who2020c who2020 widani2020 widyawati2019 yanti2020 appendix1 appendix2 editorials: nursing education during covid-19 pandemic while the covid-19 pandemic impacts on global changes, nursing education has been especially challenged by using online learning for nursing students. the adaptation of nursing instructors and nursing students take into account significant factors to overcome barriers during the changes. in our point of view, the biggest challenge faced during this faculty crisis is how to adopt a response and manage nursing education based on the standard of nursing education. an online learning program was considered as a first choice to solve the issue during this crisis. online learning would be appropriate due to flexibility, convenience, interactive learning experiences, and advancement opportunities for nursing education during the faculty of nursing closure, including serving the international and national policies that recommend to make a decision on social distancing and personalized protection. online learning resources were concerned that nursing instructors and students received support about online learning knowledge, e-learning platform, notebook and internet package from the national and university policy. nursing instructors provided home study exercises and followed up their students such as with feedback on their study exercises and study discussion as an active learner by chat application and/or an e-learning platform at least once a week. during the nursing education, nursing students were evaluated based on desired learning outcomes, such as online examination and study report, including teaching evaluation. however, the online learning program must be evaluated for reviewing outcomes using a swot analysis, strengths, weaknesses, opportunities, and threats, that helps to understand the outcomes and improve the quality of nursing education. as the new normal after covid-19, nursing education should be designed based on international and national policies, standard of nursing education, desired learning outcomes, nursing competency, and nursing educational resources. in addition, blended learning as an integrative online and traditional classroom should be considered based on the quality of nursing education, such as balancing between online and face-to-face learning hours, learning content, and nursing educational resources, including research and innovation experiences. assistant professor dr. somsak thojampa, phd, rn. & dr.sirikanok klankhajhon, phd, rn. faculty of nursing, naresuan university, thailand. somsakth@outlook.com http://e-journal.unair.ac.id/jners | 193 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19012 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research perceived behavioral control and intention related to the smoking behavior of early adolescents in north surabaya lisa setyowati, ika yuni widyawati and sylvia dwi wahyuni faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: smoking behavior in adolescents is a phenomenon that should be considered and can be easily found nowadays. the prevalence of teenage smokers aged 10-18 years in indonesia increases every year. smoking behavior can have various negative impacts both in terms of health, but also economic, social and psychological. the purpose of this research was to analyze factors related to smoking behavior in adolescents. methods: a descriptive analysis with a cross-sectional approach was used in this research. 96 early adolescents participated in this research who were selected using a purposive sampling technique. the data was obtained from belief-based tobacco smoking scale questionnaires then analyzed using regression statistical tests (α<0.05). results: the results showed that perceived behavioral control and intention are significantly related to the smoking behavior of early adolescents in north surabaya. the most influencing factor is perceived behavioral control. weak perceived behavioral control by parents and strong intentions in adolescents to smoke the following month affect the behavior of early adolescents in north surabaya to smoke. conclusion: this finding can be used as one of the topics that need to be considered in improving community nursing services in the prevention of smoking phenomena in adolescents by providing adequate information through counseling about smoking cessation and treatment efforts that can be done. article history received: feb 27, 2020 accepted: april 1, 2020 keywords smoking behavior; perceived behavioral control; intention; early adolescents contact ika yuni widyawati  ika-y-w@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: setyowati, l., widyawati, i. y., & wahyuni, s. d. (2020). perceived behavioral control and intention related to the smoking behavior of early adolescents in north surabaya. jurnal ners, special issues, 193-196. doi:http://dx.doi.org/10.20473/jn.v15i2.19012 introduction the prevalence of adolescent smokers aged 10-18 years old in indonesia is increasing annually (ministry of health, 2018). the global youth tobacco survey in 2014 reported that indonesia has the largest number of teenage smokers in the world (who, 2015). based on a preliminary study, 113 students out of 3076 students or 3.6% of students in 3 junior high schools located in north surabaya have been found smoking by the counseling teachers. they found their students smoking in school areas and the cafeteria around the school, and the teacher said that they come from smoker families. adolescence is called a period of change. it includes the changes in emotions, body performance, interests and behavior patterns (hurlock, 2011). adolescents begin to abandon childish attitudes and behavior, strive to achieve the ability to behave in an adult manner (widayatun, 2009). many studies already focus on smoking behavior of late adolescents, which leads this study to ask the contribution of the early adolescents in the age category 12-15, because we find that early adolescents have shown smoking behavior at such a young age (based on a preliminary study). according to the theory of planned behavior, a person can act on intentions only if he has control of his behavior (ajzen, 2005). intention plays a unique https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. l. setyowati et al. 194 | pissn: 1858-3598  eissn: 2502-5791 role in directing behavior, namely connecting between profound behavior that is believed and chilled by a person with certain behaviors (ajzen, 2005). this intention is influenced by attitudes toward behavior, social pressure to perform behaviors known as subjective norms, and control over behavior that is referred to as behavioral control (ajzen, 2005). smoking behavior can have a variety of negative effects both in terms of health, but also economic, social and psychological. viewed from the negative impact on health, the effects of chemicals contained in cigarettes such as nicotine, co (carbon monoxide) and tar will stimulate the central nervous system and cause the heart rate to accelerate, stimulate cancer and various other diseases (aula, 2010). the negative impact of the economic aspect is smoking behavior basically burns teenagers’ money who do not have their own income. another impact is social, the smoke from cigarettes can inconvenience those around them. the psychological impact is that smoking can cause dependence if individuals feel anxious because they cannot smoke (komasari & helmi, 2000). this research is expected to provide benefits for students who are early teens to be able to control the factors that can cause them to smoke. the benefit for schools is that this research becomes basic information in developing and rearranging more effective ways in the school program especially about healthy behavior programs, forbidding smoking in schools. the purpose of this study was to explain the influence of perceived behavioral control and intention on the smoking behavior of early adolescents in north surabaya. materials and methods the design of this study was cross-sectional. a sample of 96 early adolescent smokers in three of surabaya state junior high schools was selected using a purposive sampling technique. the variables in this research are perceived behavioral control, intentions and smoking behavior. the data were obtained using belief-based tobacco smoking scale questionnaires, which evaluate the psychometric properties of the constructs of the theory of planned behavior (barati, allahverdipour, hidarnia, niknami, & bashirian, 2015). the data were collected after obtaining permission from the head principal of junior high school. the data were collected in a classroom containing a maximum of 20 respondents with 1 table for 1 respondent, and the study was conducted after students finished the school hours. this research has been reviewed and stated as ethically approved by the health research ethics committee, faculty of nursing, airlangga university, surabaya with number 1890-kepk in january 2020. the data were analyzed using regression statistical tests (α<0.05). results most of the respondents were 15 years (33.3%). most teenagers have a history of smoking since elementary school, with 71 students (74%) and most of them come from smoker families, as many as 75 students (78%). the results showed there was a significant relationship between knowledge, perceived behavioral control, and intention related to the smoking behavior of early adolescents in north surabaya. the most influencing factor is perceived behavioral control. factors that had no effect in this study were general attitude, values, media exposure, attitude toward behavior, subjective norms. discussion the effect of perceived behavioral control on smoking behavior this study showed there is an effect of perceived behavioral control on smoking behavior of early adolescents in north surabaya. the influence of the value of motivation to comply (desire/motivation to follow) with high smoking behavior that affects smoking behavior in early adolescents in north surabaya. respondents believe that many people around will approve of them smoking and the motivation to smoke, the respondent will approve him to become a smoker. this finding is supported by the results of respondents' demographic data which shows that majority of early adolescent smokers come from families of smokers' families. this research is consistent with a previous study by sari hidayatullah (2017) that teen smokers’ junior table 1. characteristics of respondents in early adolescent smokers in north surabaya, january 2020 respondents’ characteristics frequency percentage (%) age 12 y.o 8 8.3 13 y.o 37 38.5 14 y.o 19 19.7 15 y.o 32 33.3 start smoking from elementary school 71 74 from the beginning of middle school 25 26 family smoking history yes 75 78 no 21 22 table 2. analysis result on perceived behavioral control and intention towards smoking behavior of early adolescents in north surabaya. variable coefficient signification or ratio perceived behavioral control -1,754 0,000 0,172 intention 1,386 0,004 0,250 jurnal ners http://e-journal.unair.ac.id/jners | 195 activity started from the habit of smoking they have observed and felt in their environment, both within the family and their social environment. subjective norms are factors outside the individual that contain one's perceptions about whether others will approve or disapprove of a behavior (ajzen, 2005). a teenager would think that smoking behavior is something normal, fun, and profitable, they tend to have the urge to try because they feel like they could, thus making the intention to smoke stronger and forming the smoking behavior in the teenager (hamdan, 2015) behavioral conditions last for so long as to form a habit or habitus that is difficult to quit. the smoking habit that is generally only practiced by adult men is now mostly practiced by junior high school students because it is the social environment that makes them behave that way. things that are actually improper and considered deviant turn out to be normal and understandable behavior. the community is no longer surprised and considers the smoking behavior of junior high school adolescents, especially in big cities normal. the effect of intention on smoking behavior this study showed there is an effect of intentions on the smoking behavior of early adolescents in north surabaya. previous research carried out by pandayu and murti (2017)also states there is a relationship between intentions and teenage smoking behavior in adolescents. the theory of planned behavior states that a person can act on his intentions only if he has control of his behavior (ajzen, 2005). intention is a term associated with behavior and an important part of the range of actions that can or cannot be performed and directed to conduct current or future behavior. intention plays a distinctive role in directing behavior, i.e. connecting profound behavior that is believed and chilled by someone and certain behavior. this study found that almost half (46.8%) of early adolescents in north surabaya smoked more than 15 cigarettes a day and they were categorized as early teen smokers in north surabaya and heavy smokers. most (52%) cigarettes consumed by early teens in surabaya are clove cigarettes, with a high nicotine and tar content. most (51%) the early teens said they would smoke every 1 to 2 hours and almost all (80%) teenagers would smoke when gathering with friends. this study is supported by the theory behavior planning (tpb) stated by azjen that the intention was formed by attitudes toward behavior, subjective norms, and perceived behavioral control that each individual has. all three will interact and determine whether the intentions will be carried out or not (azwar, 2013). conclusion in this study, perceived behavioral control weakened by parents as well as a strong intention on teen smoking in the next month fatherly influence behavior of early adolescents in north surabaya to smoke. based on it, parents have a great influence on early adolescent smoking behavior, as early adolescents view smoking behavior as normal because parents become role models and increase smoking intention in adolescents. this leads to developing smoking behavior at an early age. conflict of interest the authors declare there are no conflicts of interest or financial interest in this study or in the preparation of this article. acknowledgement the author of this study would like to thank all the respondents in three of surabaya state junior high schools, indonesia for their highly valuable contribution. finally, the author would like to thank universitas airlangga for providing the opportunity to present and publish the valuable findings of this study. references ajzen, i. (2005). attitude, personality, and behaviour. new york: open university press. aula, l. e. (2010). stop merokok! (sekarang atau tidak sama sekali). yogyakarta: garai ilmu. azwar, s. (2013). sikap manusia (teori dan pengukurannya). yogyakarta: pustaka pelajar. barati, m., allahverdipour, h., hidarnia, a., niknami, s., & bashirian, s. (2015). belief-based tobacco smoking scale: evaluating the psychometricproperties of the theory of planned behavior’s constructs. health promotion perspectives, 5(1), 59–71. https://doi.org/https://doi.org/10.15171/hpp.2 015.008 hamdan, s. r. (2015). pengaruh peringatan bahaya rokok bergambar pada intensi berhenti merokok. mimbar, jurnal sosial dan pembangunan, 31(1), 241. https://doi.org/10.29313/mimbar.v31i1.1323 hurlock, e. b. (2011). psikologi perkembangan : suatu pendekatan sepanjang rentang kehidupan. jakarta: erlangga. komasari, d., & helmi, a. f. (2000). faktor-faktor penyebab merokok. jurnal psikologi, (1), 37–47. ministry of health. (2018). hasil utama riskesdas. https://doi.org/1 desember 2013 pandayu, a., & murti, b. (2017). effect of personal factors, family support, pocket money, and peer group, on smoking behavior in adolescents in surakarta, central java. journal of health promotion and behavior, 02(02), 98–111. https://doi.org/10.26911/thejhpb.2017.02.02.01 sari hidayatullah, d. (2017). praktik sosial merokok anak smp di kota surabaya. paradigma: jurnal online mahasiswa s1 sosiologi unesa, 6(1), 1–7. who. (2015). global youth tobacco survey (gyts): l. setyowati et al. 196 | pissn: 1858-3598  eissn: 2502-5791 indonesia report 2014. in who-searo. https://doi.org/http://www.searo.who.int/tobac co/documents/ino_gyts_report_2014.pdf widayatun. (2009). ilmu perilaku. jakarta: info medika. http://e-journal.unair.ac.id/jners | 563 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.20544 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research health promotion strategies in integrated healthcare program park of public health center kurniawan edi priyanto, sutrisno sutrisno, and mohammad as'ad effendy institut ilmu kesehatan strada indonesia, kediri, east java, indonesia. abstract introduction: one form of community empowerment effort in the field of health is to develop an integrated healthcare program. integrated healthcare program park in east java quantitatively until the year 2014 has exceeded as many as 12,227 or an increase of 22.27% from the declaration of movement activities of 10,000 starting from 2012. however, qualitatively in that year there were only 23% in the optimal category. to optimize function of integrated healthcare program park it is necessary to have a companion officer in the monitoring and assisting cadres. this study is to know the implementation of health promotion strategy in integrated healthcare program park at public health center methods: data were collected by in-depth interviews. implementation of empowerment activities found the training of companion officers and cadres are uneven. results: activity of developing the social support found the existence of problems because of the absence of early child development cadres and insufficient means of educational game tools. advocacy activities conducted policy proposals on the establishment of early child development cadres. conclusion: partnership activities have created a good coordination between companion officers with the stakeholders, but there are problems in the mechanism of distributing incentives for companion officers and cadres. article history received: feb 27, 2020 accepted: april 1, 2020 keywords companion officer; health promotion strategies; integrated healthcare program park contact kurniawan edi priyanto  kedipriyanto@gmail.com  institut ilmu kesehatan strada indonesia, kediri, east java, indonesia. cite this as: priyanto, k. e., sutrisno, s., & effendy, m. a. (2020). health promotion strategies in integrated healthcare program park of public health center. jurnal ners, special issues, 563-568. doi:http://dx.doi.org/10.20473/jn.v15i2.20544 introduction health is a human right as well as an investment, so it needs to be strived for and enhanced by every individual and by all components of the nation, so that people can enjoy healthy life and, ultimately, can realize the optimal health status of society. integrated healthcare program is a strategic step in the development of the human resources quality of the nation of indonesia in order to build and help itself; therefore, it needs to be enhanced coaching (ismawati, 2008). in march 2012, east java provincial government launched 10,000 integrated healthcare program parks in each village. quantitatively, integrated healthcare program parks in east java had, up to 2014, exceeded as many as 12,227 or an increase of 22.27% from the declaration of movement activities in 10,000 integrated healthcare program parks starting from 2012. however, qualitatively in that year only 23% were in the optimal category, while, in 2015, this reached 40% where the programs and policies implemented were more focused on improving the quality of services in integrated healthcare program park (faiq, 2017). to optimize the function of integrated healthcare program park, it is necessary to assist the cadres to evaluate and develop the park. through this facilitation officer, it is expected that integrated healthcare program park will provide better integrated services. the purpose of this research was to know implementation of health promotion strategy in integrated healthcare program park at public health center. the focus of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. k. e. priyanto et al. 564 | pissn: 1858-3598  eissn: 2502-5791 this research was to know the implementation of empowerment activities, the activity of developing the atmosphere, the advocacy activities and the partnership activities in integrated healthcare program park at public health center. materials and methods the type of this research is phenomenological study with qualitative approach with the focus of research directed to know the implementation or implementation of health promotion strategy in integrated healthcare program park at public health center. the research location is one of the working areas of a public health center and research was conducted in september 2017. sampling technique in this study used purposive sampling. the inclusion criteria of this research were companion officers of an integrated healthcare program park at a public health center who were willing to be an informant. the informants in this research are integrated healthcare program park companion officers at a public health center who have been willing to undertake an in-depth interview, totaling four people. results from the results of research conducted with purposive sampling techniques four informants were obtained. informants aged 21-40 years were as many as two informants and aged 41-60 years as many as two informants. all informants are female. most informants have a high school education, as many as three informants and educated junior high school is one informant. all informants’ job status is nongovernment employees. based on the results of the research, it is known that the implementation of health promotion strategy in integrated healthcare program park at public health center as related to the empowerment activity still running maximally because of the giving of education or training to the integrated service post park facilitation officer and uneven cadre and absence of special means for promotion or socialization of integrated healthcare program park to the community. based on the result of the research, it is known that the implementation of health promotion strategy in integrated healthcare program park at public health center is related to developing the atmosphere and there are obstacles in the process of integrated healthcare program park activity due to the absence of early childhood education program cadres in every integrated service post park so that the role is replaced by early childhood education program teachers or integrated service post park escort officers, and there is inadequate means of educational game tools used in the activities of integrated healthcare program park. there were some minor conflicts between of integrated healthcare program park officers and the cadres, namely the problem of delay in the presence of cadres or early childhood education programtutors and the problems of usage or monitoring of educational game tools among the cadres. based on the result of the research, it is known that in the implementation of health promotion strategy in integrated healthcare program park at public health center related to advocacy activities and there is potential support and direction toward ideas or suggestions from integrated healthcare program companion officers to the program holder of integrated healthcare program park in public health center and local government. there is a need for policies to add infrastructure facilities for integrated healthcare program park activities such as educational game tools and integrated healthcare program equipment, the establishment of early childhood education program cadres and the need for policies for the addition of cadres so that no double job or duplicate tasks are carried out by the companion officers . based on the result of the research, it is known that in the implementation of health promotion strategy in integrated healthcare program park at public health center is related to the partnership activity in that the implementation of coordination goes well between integrated healthcare program park companion officers with integrated healthcare program park holders at public health center, city health office, local technical implementation unit of national education and family planning counseling. direct communication methods are conducted with community leaders, involving important figures in the community to establish good cooperation, but there is no communicating or involving of ngos or mass media in the activities of integrated healthcare program park. there are problems related to the distribution mechanism of incentives for the companion officers of integrated healthcare program park and cadres. discussion in this research, the researcher obtained a description related to the implementation of health promotion strategy in integrated healthcare program park by the companion officers at public health center. from this research, there are four themes: 1) implementation of empowerment activities, 2) implementation of social support activities, 3) implementation of advocacy activities, and 4) implementation of partnership activities. implementation of empowerment activities in integrated healthcare program park at public health center the concept of empowerment emphasizes that people acquire the skills, knowledge and sufficient power to influence their lives and the lives of others concerned (putra, 2016). the results of research on empowerment activities found that there was already implemented education or training to the companion officers of integrated healthcare programs, integrated healthcare program cadres, early childhood education programcadre and family and toddler coaching cadres, but not evenly given all the jurnal ners http://e-journal.unair.ac.id/jners | 565 opportunities. education or training is very important for integrated healthcare program park companion officers and integrated healthcare program cadres, early childhood education programp cadres and family and toddler coaching cadres to improve their knowledge and skills in providing services in accordance with their duties and to increase the knowledge and ability to mobilize and empower the community. the results of research on empowerment activities on the implementation of monitoring of integrated healthcare program park companion officers on the performance of integrated healthcare program, early childhood education program and family and toddler coaching cadres found that the implementation of the monitoring went well, including attendance observation, recording and documentation and evaluation discussion. monitoring the performance of cadres is part of the evaluation process to monitor their shortcomings or inability in the implementation of their duties so that they can be followed up as soon as possible with efforts to provide knowledge and increased empowerment to the cadres. effective communication will lead to the active participation of community members in community development(unicef, 2015). the results of research on the implementation of activities to mobilize the community to increase the motivation and the active role of the community in following the activities of integrated healthcare program park shows that the community mobilization activities conducted by integrated healthcare program companion officers include the delivery of integrated healthcare program activities schedule, socializing in community activities and communicating directly about integrated healthcare program park activities of. effective communication with delivery methods that are easily accepted and understood by the community will help increase the motivation of the community to take an active role in supporting the activities of integrated healthcare program park. the findings of research on the implementation of empowerment activities indicate promotion activities or socialization of integrated healthcare program park to the community do not use media or facilities. various means or media need to be used in promoting activities and socialization of integrated healthcare program park to facilitate the delivery of the purpose and objectives to the community(sulistyani, 2004). implementation of social support activities in integrated healthcare program park at public health center factors that influence social support should meet physical, social and psychological needs. establishing an atmosphere in service activities is an effort to create good coordination and effective communication in order to achieve success according to mutually desired goals (alamsyah & muliawati, 2013). the findings of the research on the implementation of the activity of developing the atmosphere show that the coordination includes making a schedule of activities, the division of tasks among cadres, recording activities, and that there are constraints in the early childhood education program because of the lack of designated cadres. in addition to performing the task of being integrated healthcare program companion officers they also double as integrated healthcare program cadres and family and toddler coaching cadres. the availability of sufficient cadre personnel in accordance with the duties and roles of each cadre will greatly support the smoothness in coordination and service delivery in integrated healthcare program park activities. social support is support or assistance that comes from others, such as neighbors, co-workers and others (julita, 2013). the findings of research on the implementation of community development activities indicate that the communication approach to the community is done directly when there is activity of an integrated healthcare program park and also there meeting activity in the community in the form of regular social gatherings and neighborhood association or citizens association meetings. support and active role of the community is an important element that can determine the success rate of the objectives of a sustainable integrated healthcare program park activity to provide services to the community. cultivating an atmosphere is creating a conducive situation to promote the behavior of a clean and healthy life. clean and healthy life behavior can be created and developed if the environment supports (efendi & makhfudli, 2009). the findings of the research on the implementation of the activity of building the atmosphere found that the facilities or methods used in the activities of an integrated healthcare program park to create a comfortable and conducive environment for the cadres and the community are educational game tools, posters, flipcharts, stage puppets and good sanitation. educational game tool facilities are insufficient or insufficient in integrated healthcare program park activities. the method used is to communicate directly with the community at the time of integrated healthcare program park activities. such activities will run smoothly and create a comfortable and conducive environment if supported by adequate infrastructure facilities. social support is an emotional, informational or advisory source provided by people around the individual to deal with everyday problems and crises in life (hse, 2011). the findings of the research on the implementation of the activity of building an atmosphere found that there is no conflict or major problem either between cadres or with society. small problems arise when there are cadres who are late in the meeting and the problem of returning educational game tool loans between cadres in the integrated healthcare program service activities. alternative problem solving is done by communication between cadres and reminding each other. conflicts or k. e. priyanto et al. 566 | pissn: 1858-3598  eissn: 2502-5791 problems potentially happen in every relationship or interaction between individuals and groups. resolving conflicts early and in the right way will be able to minimize conflict that was previously small or light so that it does not become a major conflict. selfawareness and discipline need to be applied to individual escort personnel and cadres so as not to disrupt the process of task and performance in service activities and so as not to trigger conflict (iskandar, 2016). implementation of advocacy (advocacy) activities in integrated healthcare program park at public health centre advocacy is an attempt to influence public policy, through various forms of persuasive communication. in other words, advocacy is an effort or process to gain commitment, conducted persuasively by using accurate and precise information (notoatmodjo, 2010). the findings of the research indicated that, in the advocacy work, it was found that the policies of both the integrated healthcare program park holders in the public health center and the local government supported the performance of the companion officers and cadres of integrated healthcare program, but needed to be re-examined about the policy for the addition of infrastructure for the integrated healthcare program activities and the establishment of early childhood educational programs cadres. strategic policies of stakeholders are needed to improve the shortcomings or constraints in operational activities of integrated healthcare program park in order to improve the quality of their service to the community. the findings of research on advocacy activities obtained information that there are no policies that hamper or reduce the performance of companion officers of integrated healthcare program park and cadres, either from the integrated healthcare program park holders in a public health center and local government. advocacy is a leadership approach with the aim to develop sound public policy (efendi & makhfudli, 2009). the findings of the research on the advocacy activities of the feedback from the integrated healthcare program park holders in a public health center and local government, on opinions in the form of criticism or suggestions from the companion officers of integrated healthcare program park and the cadres as well as from the community regarding the established policies found that there is good response from the integrated healthcare program park holders in public health center and local government to suggestions or suggestions from companion officers of integrated healthcare program park and cadres. advocacy is a strategic or planned effort or process to get commitment and support from stakeholders (dewi & kiranasari, 2013). advocacy is directed toward generating support that is a policy (e.g. in the form of legislation), funds, means and others like. stakeholders in question can be formal community leaders who generally play a role as government policy makers and government funders. it can also be informal community leaders such as religious leaders, traditional leaders and others who can generally act as policy makers (not written) in their field (kholid, 2015). the findings of the research on advocacy activities showed that there was potential support and direction when there were ideas or suggestions from integrated healthcare program park companion officers to the integrated healthcare program park holders in public health center and local government. the policies of the program makers are the key to the implementation of an activity. there is need for reviews by organizers and implementers in the field to conduct monitoring and evaluation to find the inequality that occurs in an activity that raises the potential to provide a proposed policy revision or create a new policy better to improve the positive outcomes which are the main objective of the activity (machfoedz & suryani, 2009). implementation of partnership activities in integrated healthcare program park at public health center a partnership viewed from an etymological perspective is adapted and rooted from the word partner. partners can be translated as spouse, soul mate, ally, companion, while partnership is translated as fellowship. partnership in essence is known as cooperation from various parties, either individually or in groups. partnership is really a necessity for parties with a common orientation who want to save energy and generate multiple benefits(yusuf, syafar, & bahar, 2010). the result of the research shows that the partnership activity in coordinating with integrated healthcare program cadres, early childhood educational program cadres and family and toddler coaching cadres in terms of activities and follow up activities of integrated healthcare program park is found to be done during integrated healthcare program park activities, by conducting a meeting or discussion to evaluate the program activities and make planning for the next activity. beyond the park activities, coordination is done by using the communication to create a group on whatsapp social media among the cadres. coordination is one of the vital parts in an effort to create a solid partnership relationship. coordination is important to know the achievements and evaluate the constraints to each other so that it can make improvements to realize success in the direction and common goals. the results showed that the partnership activities in coordination with the program holders of integrated healthcare program park in public health center, city health office, local technical implementation unit of national education and family planning counseling in terms of activities and follow up activities of integrated healthcare program park all went well. coordination is done at the time of reporting integrated healthcare program park activity to city jurnal ners http://e-journal.unair.ac.id/jners | 567 health office once every three months and for reporting to public health center once a year and reporting to family planning counseling once a month while scheduling childhood educational programs cadres in integrated healthcare program park activity coordinates with local technical implementation unit of national education. to build a partnership, it must be based on the following things: common interest or interests, mutual trust and mutual respect, clear and measurable goals and willingness to sacrifice both time, energy and other resources (putra, 2016). partnership is a process of interaction of two or more parties that is realized in the form of cooperation. participating parties include various sectors, such as community groups, government agencies and non-governmental organizations. some of these parties work together to achieve common goals based on their agreement, principles, and roles . the findings of research on the partnership activities related to the means or methods used by the companion officers of integrated healthcare program park to maintain good cooperation with the community, community leaders, religious leaders, ngos, mass media and others found that, to establish good cooperation, direct communication methods with community leaders and involving important figures in the community in the activities of integrated healthcare program park is necessary. during this time, there was no communication or involvement of ngos or mass media in the integrated healthcare program activities. partnership is a formal cooperation between individuals, groups or organizations to achieve a certain task or goal (rezeki, mulyadi, & nopriadi, 2013). meanwhile, the promotion of online health suggests that partnership is a relationship (cooperation) between two or more parties, based on equality, openness and mutual benefit (dewi & kiranasari, 2013). the findings of research on partnership activities related to facilities, facilities or awards given to the companion officers of integrated healthcare program park and cadres by the integrated healthcare program park holders in public health center and local government in order to develop and improve the integrated healthcare program park services found that the facilities obtained are monthly incentives as escort officers and cadres, uniform facilities special activities, and incidental transport money when there is an invitation meeting. the obstacles are incentives that are not routinely received every once a month, but given every six months. partnership principles, which refer to partnerships based on equality, openness and mutual benefit, should be applied in a goal-oriented relationship. the awarding or reward that is in accordance with the achievement of the duty and the mechanism of granting the rights that must be obtained according to the rules and mutual agreement will support the smoothness in the process of activities carried out by each other. conclusion based on the results of the research, it is known that the implementation of health promotion strategy in integrated healthcare program at public health center, which is related to the empowerment activity still running, is not maximal because the giving of education or training to the integrated healthcare program companion officers and cadres is uneven and there is an absence of special means for promotion or socialization of integrated healthcare program park to the community. in the activity of developing the atmosphere there are constraints because there are no early child development services cadres in every integrated healthcare program park so that the role is replaced by early childhood educational program teachers or integrated healthcare program companion officers and inadequate educational game tool facilities are used in the activities of integrated healthcare program park. there were some minor conflicts between the integrated healthcare program park companion officers and the cadres, namely the problem of delay in the presence of cadres or early childhood educational program tutors and the problems of usage or monitoring of educational game tools among the cadres. in the implementation of advocacy activities, there is potential for support and direction to the ideas or suggestions from the officers of integrated healthcare program park holders in public health center and local government. there is a need for policies to add infrastructure facilities for integrated healthcare program park activities, such as educational game tools and integrated healthcare program equipment, the establishment of early childhood educational program cadres and the need for policies for the addition of cadres so that no double job or duplicate tasks are carried out by companion officers of integrated healthcare program park. however, the partnership activity of coordination implementation went well between integrated healthcare program companion officers and integrated healthcare program park holder in public health center, city health office, local technical implementation unit of national education and family planning counseling. it was found that direct communication methods with community leaders and involving important figures in the community to establish good cooperation were conducted but never communicating or involving ngos or mass media in activities of integrated healthcare program park. there are problems related to the distribution mechanism of incentives for the integrated healthcare program park companion officers and cadres. conflict of interest the authors declare that there is no conflict of interest. k. e. priyanto et al. 568 | pissn: 1858-3598  eissn: 2502-5791 references alamsyah, d., & muliawati, r. (2013). pilar dasar ilmu kesehatan masyarakat. yogyakarta: nuha medika. dewi, p., & kiranasari, n. h. (2013). buku saku tugas pendamping di taman posyandu. jakarta: salemba medika. efendi, f., & makhfudli. (2009). keperawatan kesehatan komunitas. teori dan praktik dalam keperawatan. jakarta: salemba medika. faiq, n. (2017). gerakan 10.000 taman posyandu melebihi target. hse. (2011). the health promotion strategic frame work. ireland: health service executive national health promotion office. iskandar, m. n. (2016). pelaksanaan strategi promosi kesehatan dalam program perilaku hidup bersih dan sehat (phbs) tatanan rumah tangga di puskesmas puuwatu kota kendari tahun 2015. universitas halu oleo. ismawati, c. (2008). posyandu dan desa siaga. panduan untuk bidan dan kader. yogyakarta: nuha medika. julita, d. (2013). “taman posyandu jatim, gerakan paud berpihak masyarakat miskin,” direktorat jenderal pendidikan anak usia dini dan pendidikan masyarakat,. kholid, a. (2015). promosi kesehatan. dengan pendekatan teori perilaku, media, dan aplikasinya. untuk mahasiswa dan praktisi kesehatan. jakarta: raja grafindo persada. machfoedz, & suryani. (2009). pendidikan kesehatan bagian dari promosi kesehatan. yogyakarta: fitramaya. notoatmodjo, s. (2010). promosi kesehatan. teori dan aplikasinya. jakarta: rineka cipta. putra, f. y. (2016). strategi promosi kesehatan dinas kesehatan kabupaten kutai kartanegara tentang pemahaman perilaku hidup bersih dan sehat (phbs) di puskesmas mangkurawang. ejurnal ilmu komun., 4(1), 74–87. rezeki, s., mulyadi, a., & nopriadi. (2013). strategi promosi kesehatan terhadap peningkatan perilaku hidup bersih dan sehat individu pada masyarakat perkebunan di wilayah puskesmas seikijang kab. pelalawan. jurnal imu lingkung, 7(1). sulistyani, a. t. (2004). kemitraan dan model-model pemberdayaan. yogyakarta: gaya medika. unicef. (2015). unicef’s strategy for health (20162030). unicef programme division. yusuf, y., syafar, m., & bahar, b. (2010). analisis strategi promosi kesehatan di puskesmas bambalamotu dalam pembinaan masysrakat suku da’a di desa kasolong kab. mamuju utara. j. mkmi, 6(3), 141–145. 9 the effectiveness of mangosteen peels extract against the total of t lymphocytes in hiv patients maria dyah kurniasari, edi dharmana, hussein gasem department of fundamental nursing, faculty of medicine and health science, universitas kristen satya wacana, jalan kartini no 11 a 50711, salatiga, indonesia email: mariadyah15@gmail.com abstract introduction: the province of west java is one of the highest hiv sufferers in indonesia that has increased accumulatively in 2013 to 2014. this condition was proven that in 2014 west java ranked 4th among the provinces with the highest hiv sufferers in indonesia. hiv has main target to infect a cell that contains of receptor, cd4. cd4 examination routinely is very important to decide hiv replication process. meanwhile, cd4 test in the laboratory is quite expensive and not always available in every health facilities. mangosteen peels extract contains of xanthones as an antioxidant, which is needed for body as a prooxidant that can inhibit the replication of hiv and the activity was seen from the total number of lymphocyte. method: the human experimental research has been done by randomized control group pretest-post test design. there were 20 patients sample for each group. in group 1, hiv patients with arv therapy were given mangosteen peels extract and in group 2, they were given placebo capsule. wilcoxon smith test and mann-whitney u test were used to determine the difference between group 1 and group 2. result: there is no significant difference between lymphocytes (p: 0.102) to hiv patients with arv in each group examination. discussion: the ineffectiveness is caused by the phagocytosis and cytoxity of tnf through the increasing of free radicals in hiv patients. keywords: mangosteen peels extract, lymphocytes ____________________________________________________________________________________________________ introduction nowadays, one of the major public health problems for the world is an epidemic of human immunodeficiency virus /hiv infection (swity et al. 2016). in indonesia, the number of hiv sufferers is increasing every year. west java got 4th rank with the highest hiv sufferers among the provinces in indonesia with the cumulative number of hiv cases: 9340 people, while the number of aids patients were reported until 2013 amounted to 4131 people (spritia y & kpa central java, 2014). then, an increasing number of hiv/aids people were reported till september 2014 are 13.507 and people with hiv: 4.191. this retrovirus changes ribonucleic acid (rna) into deoxyribonucleate acid (dna) after enter to the host cell. viral genetic material inserted to the infected dna cell. the main target is cd4, the cells that have receptors (nakatani et al. 2002). therefore, the arv therapy and cd4 examination routinely in patients are very important to detect hiv viral replication process. health services such as bjps has helped people with hiv to get a free cd4 examination, but not all of them get these services (swity et al. 2016). the cd4 examination is classified into expensive laboratory tests, especially if the examination is required as a routine examination. moreover, it is not always available at each health facilities. the previous study by swity (2016) reported that there was a significant correlation between the total numbers of t cell lymphocytes in patients with hiv in hasan sadikin hospital, bandung. it shows that the examination f immune cells (t cell lymphocytes) is also important when health facilities are limited (swity et al. 2016). the reports from previous researchers informed that the elevation of t lymphocytes total count depicts the level of the immune system (ghate et al. 2011). it has reported that the total number of t lymphocytes associated with the level of human body immunity, but the total number of t lymphocytes in immune relate to hiv patients are still rare. the number of t lymphocytes can replace in monitoring the treatment for hiv patients is not clear enough, but logically the total count of t lymphocytes had a scientific base in hiv patients immune monitor. mangosteen fruit is one of the diversity floras from indonesia that has a potential to be a medical plant. the skin of mangosteen fruit contains of xanthones as an antioxidant that is needed in human body as a prooxidant balance (reducing radicals, oxidizing radicals, carbon entered, uv light, metal, etc.) that can inhibit the replication of hiv and the activity t lymphocyte as immune mailto:mariadyah15@gmail.com jurnal ners vol. 12 no. 1 april 2017: 9-13 10 cells play a role in balancing prooxidant (chen et al. 1996). the medicinal plants can be adjuvant treatment. researchers hope mangosteen peel extract as an antioxidant can be used as a complementary medicine jointly with the provision of antiretroviral drugs/arv. the expectation from this study, there is an effectiveness of mangosteen peel extract to the total number of t lymphocytes in hiv with arv therapy, to improve cd4 cell and also improve health services, especially to decrease the risk of co-infection in people with hiv. methods experimental research in human used double blind randomized pretest-post test control group design (hiv patients with antiretroviral therapy in rsud gunung jati, cirebon, west java). the total number of respondents were 40 patients, chosen by inclusion and exclusion criteria. 40 patients were divided into 2 groups, treatment group and placebo group. treatment group was 20 patients who got 90 capsules of mangosteen peel extract for each patient and placebo group was 20 patients who got 90 placebo capsules for each patient. grouping was done by simple randomized sampling technique. all respondent consumed the capsule 3 times a day (in the morning, in the afternoon, and at night). researchers also did the blood test twice for both groups. it was before and after getting the treatment for 30 days. the blood test was used to know the total number of lymphocyte differences between treatment group and placebo group. the results of a descriptive analysis will be presented in tabular form.for identifying the differences between treatment and placebo group, the researcher used mannwhitney test and for pre and post test used wilcoxon smith test. data is considered as a significant difference when the value (p <0.05) with 95% confidence level. the study was conducted after obtained approval from health research ethics committee of medicine faculty, university of diponegoro and dr. kariadi, semarang. results the basic characteristics of research subjects as shown in table 1 describes the same starting point in each group (treatment and placebo). after determining the data equality and got the result of pre-post test examination, the changes of median value were presented from each group. the data was presented in median value because the data distribution was not normal. table 2 showed that there was a decline median value in treatment group and placebo. changes of this data will be the basis for comparative tests between pre and post-test in each group, as well as a comparison between the treatment and placebo group in pre-test and post-test. table 1. characteristics of basic research subjects characteristics the total number of research subjects (n=40) treatment (n=20) placebo (n=20) difference test (p) age (+sd) 34,10+5,93 33,25+5,17 34,95+6,63 0,464 sex (%) 0,744 male 62,5 60 65 female 37,5 40 35 the average of cd4 (mm3) ( +sd) 406+148 373 + 28 438 + 36 0,172 time using arv (tahun) (+sd) 3,55+2,3 3,1+2,31 4,0+2,27 0,135 weight (kg) 58,23+11,11 58,3+10,6 58,15+11,87 0,828 the number of t lymphocite (cells/mm3) 2066+728 1958+591 2175+844 the effectiveness of mangosteen peels extract (maria dyah k, et. al) 11 table 02. median total lymphocyte total groups pretest post test treatment 1879.50 1721 placebo 2035 2025 the comparative test conducted using wilcoxon smith test because the data were not normally distributed and it was tested in pairs. the result after comparative test between pre test and post test in treatment and placebo group confirmed that there was not a significant difference. table 3. wilcoxon smith test (the pre testpost test of treatment and placebo group) groups n p treatment pre test 20 0.370 post test 20 placebo pre test 20 0.794 post test 20 after comparative test using wilcoxon smith in pre test and post test examination was done, the researcher did comparative test using mann-whitney to identify the difference between treatment and placebo group as shown in table 4. table 04. different mann-whitney test (treatment group and placebo) groups n p pretest treatment 20 0.478 placebo 20 posttest treatment 20 0.102 placebo 20 it was also necessary to describe the partial distribution of the data from each sample in the following graph. graph 1 showed that the total lymphocytes count variation changed in each sample. as a result, the fluctuations of each individual in both group changed. it happened because the sample or individual had different multifactor, so the effect of total lymphocytes changing was different from each other. graph 1. the total of lymphocytes individual graph in treatment and placebo group discussion the process of hiv infection is t lymphocytes express cd4 as a surface marker and immune regulation system. cd4 monitoring is commonly done in clinical because it will help to begin giving the arv and or change different types of antiretroviral jurnal ners vol. 12 no. 1 april 2017: 9-13 12 drugs for patients with hiv. consuming the arv correctly will help patients to improve their health status. moreover, health status will be monitored by immune cells indicators and it will be checked routinely. delaying on consuming arv can cause decreasing of cd4 lymphocyte number and it may increase the risk of opportunistic infection (kaufmann et al. 2003). besides arv therapy, the subjects from this study were given mangosteen peel extract as an antioxidant and the researcher hoped that mangosteen peel extract could be as an adjuvant therapy jointly with the provision of antiretroviral drugs. after being given to hiv patients for 30 days, the total lymphocyte examination of pre-test and post-test was not significantly different in the treatment group, by non-parametric wilcoxon smith test: p = 0370 (p> 0.05). in addition, there was no significant difference in the post-test examination after 30 days consumed mangosteen peel extract between two groups: the treatment and placebo group. this result was shown in mann-whitney analysis table: p= 0478 (p>0.05). thus, in this case the mangosteen peel extract was not effective against the total lymphocytes in hiv patients with antiretroviral therapy. the antioxidant in body should be able to contribute or protect against tnf cytokine. this ineffectiveness was possible due to the increasing of free radical production that occurs in people with hiv (jaruga et al. 2002). the production of free radical increases in hiv patients because phagocytosis process that is done by phagocytic cells and tnf was mediated by target cell. then, when free radical induced tnf toxicity, it could increase hiv viral replication and destroy cd4 t cells (kameoka et al. 1993). unbalancing redox happens because superfluous amount of pro-oxidants or antioxidant reduction that affect normal physiological (kameoka et al. 1993). in previous study, there was a positive correlation between total lymphocytes with t cd4 cells in hiv patients: r= 0.68 (swity, 2013).however, in this study, there was no positive association for the results of cd4 t cells increased significantly: p = 0.001 (p <0.005). the result of this study showed that many factors could affect the total of lymphocytes count and complete blood test was needed to know the factor that affect of lymphocytes cell. in this study, the subject sampling was human where we know that people have a lot of factor that affect the total of lymphocytes. although the subject of this study had equal basic characteristic or same starting point based on the statics, but many factors such as daily meal that they consumed, the different daily activities from the research subject were different, the difference of environment, rna. these factors will have an effect on the general state of the patient. in contrast, if this study was conducted in confounding experimental animals, the factors can be controlled and minimized. as a result, further research is needed with intensity control in general so there are fewer factors that influence the assessment results of research variables. the result of this study could be much better with longer period of treatment and also more research subjects, as well as to minimize other factors that affect the total of lymphocytes. from hiv form that was provided the researchers also got subjective responses from respondents. some positive responses that the respondents felt were their appetite increased and they also felt their body healthier. motivation, support, and attention from others about their feelings and actions can be considered to next study. conclusion mangosteen peel extract (garciana mangostana) is not effective against the total lymphocyte count in hiv patient group treated with arv therapy. further research is needed to learn about the development of mangosteen peel extract (garcinia mangostana) and it is important to study about all of immune cells that contribute to hiv replication, like cytokines, immunoglobulin, cd4 and etc. references chen, s.-x., wan, m. & loh, b.-n., 1996. active constituents against hiv-1 protease from garcinia mangostana. planta medica, 62(4), pp.381–382. available at: http://www.ncbi.nlm.nih.gov/pubmed/879 2678 [accessed may 2, 2017]. ghate, m. et al., 2011. mortality in hiv infected individuals in pune, india. the the effectiveness of mangosteen peels extract (maria dyah k, et. al) 13 indian journal of medical research, 133(4), pp.414–20. available at: http://www.ncbi.nlm.nih.gov/pubmed/21 537095 [accessed may 2, 2017]. jaruga, p. et al., 2002. supplementation with antioxidant vitamins prevents oxidative modification of dna in lymphocytes of hiv-infected patients. free radical biology & medicine, 32(5), pp.414–20. available at: http://www.ncbi.nlm.nih.gov/pubmed/118 64781 [accessed may 2, 2017]. kameoka, m., kimura, t. & ikuta, k., 1993. superoxide enhances the spread of hiv1 infection by cell-to-cell transmission. febs letters, 331(1–2), pp.182–186. available at: http://doi.wiley.com/10.1016/00145793%2893%2980322-l [accessed may 2, 2017]. kaufmann, g.r. et al., 2003. cd4 tlymphocyte recovery in individuals with advanced hiv-1 infection receiving potent antiretroviral therapy for 4 years&lt;subtitle&gt;the swiss hiv cohort study&lt;/subtitle&gt; archives of internal medicine, 163(18), p.2187. available at: http://www.ncbi.nlm.nih.gov/pubmed/145 57216 [accessed may 2, 2017]. nakatani, k. et al., 2002. inhibitions of histamine release and prostaglandin e2 synthesis by mangosteen, a thai medicinal plant. biological & pharmaceutical bulletin, 25(9), pp.1137– 41. available at: http://www.ncbi.nlm.nih.gov/pubmed/122 30104 [accessed may 2, 2017]. swity, a.f., setiabudi, d. & garna, h., 2016. korelasi total lymphocyte count terhadap cd4 pada anak dengan infeksi human immunodeficiency virus. sari pediatri, 15(2), p.81. available at: https://saripediatri.org/index.php/saripediatri/article/view/275 [accessed may 2, 2017]. vol 9 no 1 april 2014.indd 11 pengetahuan, sikap, dan praktik kewaspadaan universal perawat terhadap penularan hiv/aids (nurses’ knowledge, attitudes, and practices of universal precaution toward hiv/aids transmission) kusman ibrahim*, wiwi mardiah*, ayu prawesti priambodo* *fakultas keperawatan universitas padjadjaaran jl. bandung sumedang km. 21, jatinangor, sumedang, jawa barat 45363 e-mail: kusman_ibrahim@yahoo.com abstrak pendahuluan: perkembangan kasus aids maupun hiv (+) di indonesia cederung meningkat setiap tahun. pekerjaan sebagai perawat sangat beresiko untuk tertular penyakit, termasuk hiv/aids. penelitian ini bertujuan untuk mengidentifi kasi pengetahuan, sikap, dan paktik kewaspdaan universal perawat serta menguji hubungan antara pengetahuan, sikap dengan praktik kewaspdaan universal perawat dalam pencegahan penularan hiv/aids. metode: penelitian ini menggunakan rancangan korelasi deskriptif. sembilan puluh sample dari perawat yang bekerja di rumah sakit daerah di jawa barat direkrut secara proposionate stratifi ed random sampling. instrumen dalam penelitian ini terdiri dari data demografi , pengetahuan dan sikap tentang hiv/aids, dan laporan diri pelaksanaan teknik pencegahan umum penyebaran hiv/aids. data yang terkumpul dianalisis dengan statistik deskriptif dan pearson product moment correlation. hasil: sebagian besar responden melaporkan pernah mengalami kecelakaan kerja cedera benda tajam. lebih dari setengah responden memiliki pengetahuan yang baik tentang pencegahan umum terhadap penularan hiv/aids. lebih dari setengah responden menunjukan sikap mendukung terhadap perawatan pasien hiv/aids. hasil uji korelasi menunjukan bahwa ada hubungan yang positif bermakna antara skor pengetahuan dengan skor praktik (r = 0,271 p = < 0,01), namun tidak ada hubungan antara pengetahuan dengan sikap, dan sikap dengan praktik. diskusi: perlu dilakukan langkah-langkah untuk mencegah atau meminimalkan kejadian cedera benda tajam sebagai akibat resiko kerja dan untuk menghindari ancaman terhadap produktifi tas pelayanan keperawatan di rumah sakit. peningkatan pengetahuan yang muthakhir, pembinaan sikap yang positif, serta evaluasi secara berkesinambungan perlu dilakukan untuk meningkatkan kemampuan perawat dalam mencegah penularan penyakit akibat resiko kerja. kata kunci: pengetahuan, sikap, praktik, kewaspadaan universal, hiv/aids abstract introduction: the incidence of hiv/aids is continuing increase in indonesia. nurses are the most risky occupations of gaining transmitted infection. this study aimed to identify the nurses’ knowledge, attitudes, and practices of universal precaution toward hiv/aids transmission in a hospital. method: descriptive correlation study was a design of this study. ninety nurses were recruited using proposionate stratifi ed random sampling. the instrument was kap (knowledge attitudes practices) questionnaire consisted of demographic data form, knowledge, attitude, and self-reported practices regarding universal precaution. the collected data, then were analyzed both descriptively and inferentially by using pearson product moment correlation. results: the majority of respondents reported experience of sharp injuries. more than a half of respondents had a good knowledge level about universal precaution and hiv/aids transmission, and showed favorable attitude toward caring for hiv/aids patients. there was signifi cant correlation between knowledge and practice (r=0,271 p=< 0, 01), whereas no correlation between knowledge and attitude score, and attitude and practice score. discussion: it is need to be taken immediately to prevent and minimize the occurrence of sharp injuries among nurses in order to assure safety working condition to improve the productivity of nursing service. updating knowledge, developing positive attitude, and continuing evaluation should be done simultaneously to improve the nurses’ competence in preventing the occupational related-disease. key words: knowledge, attitude, practices, universal precautions, hiv/aids pendahuluan aids (acquired immune deficiency syndrome) mer upakan penyakit menular dengan angka kematian yang tinggi dan dapat menjangkiti seluruh lapisan masyarakat dari mulai bayi sampai dewasa baik laki-laki maupun perempuan (swanson, 2010). di indonesia, sejak tahun 1987 perkembangan jumlah kasus aids maupun hiv (+) cenderung meningkat pada setiap tahunnya. menurut laporan kementrian kesehatan ri diketahui 12 jurnal ners vol. 9 no. 1 april 2014: 11–18 jumlah penderita hiv (+) di indonesia sampai juni 2013 diperkirakan 108.600 kasus hiv dan 43.667 kasus aids (kemenkes ri, 2013). sedangkan unaids memperkirakan jumlah orang hidup dengan hiv/aids di indonesia sampai 2012 diperkirakan 380.000 orang pada (unaids, 2012). di jawa barat, berdasarkan data dari kementrian kesehatan ri, sampai september 2012 dilaporkan bahwa penderita hiv (+) mencapai 8.161 orang, penderita aids sebanyak 4.131 orang (kemenkes ri, 2013). penderita hiv telah tersebar di 26 kabupaten dan kota di jawa barat, terutama daerah-daerah yang menjadi tujuan wisata dan penyangga ibu kota. dengan berkembangnya suatu daerah sebagai salah satu tujuan wisata di jawa barat, tidak menutup kemungkinan munculnya d a mpa k negat if ber upa ber t a mba h nya kelompok resiko tertular hiv, yang pada gilirannya bisa menyebar pada penduduk lokal yang notabene mereka adalah para pengguna sarana pelayanan kesehatan utama termasuk rumah sakit yang ada di daerahnya. tenaga keperawatan merupakan tenaga kesehatan terbanyak di r umah sakit dan memiliki kontak yang paling lama dengan pasien. pekerjaan perawat merupakan jenis pekerjaan yang beresiko kontak dengan darah, cairan tubuh pasien, tertusuk jarum suntik bekas pasien, dan bahaya-bahaya lain yang dapat menjadi media penularan penyakit. di amerika serikat pada tahun 2001 terdapat 57 kasus tenaga kesehatan yang terinfeksi hiv akibat resiko pekerjaan, dari 57 kasus tersebut 24 kasus diantaranya (terbanyak) dialami oleh perawat (icn, 2006). di indonesia, walaupun belum ada data yang pasti, namun jika melihat pengendalian infeksi di rumah sakit yang masih lemah, maka resiko penularan infeksi termasuk hiv terhadap perawat bisa dikatakan cukup tinggi. di suatu rumah sakit, tenaga perawat umum nya mer upakan tenaga terbanyak diantara tenaga kesehatan lainnya. dengan semakin meluasnya kejadian kasus hiv ke berbagai daerah, pencegahan penularan ke tenaga keperawatan melalui penerapan standar pencegahan umum sangatlah penting. sebelum dapat melaksanakan pencegahan umum secara baik tentunya perawat harus memahami terlebih dahulu tentang hiv/aids berikut berbagai kompleksitas masalahnya. pemahaman akan mempengaruhi sikap, dan dari sikap akan menentukan perilaku nyata yang akan dimunculkan (notoatmodjo, 2003). dalam konteks ini, perilakunya adalah berupa pelaksanaan pencegahan umum penularan hiv oleh perawat, yang tentunya terkait dengan pengetahuan dan sikap yang diyakininya. oleh karenanya penelitian ini bertujuan untuk mengungkap bagaimana pengetahuan, sikap, dan praktik kewaspadaan universal perawat terhadap penularan hiv/aids. masalah-masalah yang ingin digali dalam penelitian ini adalah (1) bagaimana pengetahuan perawat tentang hiv/aids? (2) bagaimana sikap perawat terhadap hiv/aids? (3) bagaimana pelaksanaan teknik pencegahan umum perawat dalam pencegahan penularan hiv/aids?, dan (4) adakah hubungan yang bermakna antara pengetahuan, sikap dan pelaksanaan teknik pencegahan umum perawat dalam pencegahan penularan hiv/aids? adapun manfaat dari peneltian ini adalah menyediakan informasi atau faktafakta (evidences) yang sangat berguna untuk meningkatkan kemampuan perawat dalam perawatan pasien hiv/aids, sebagai bahan masukan bagi pengembangan pembelajaran asuhan keperawatan pada klien hiv/aids, dan sebagai data dasar atau rujukan bagi penelitian lanjut yang berhubungan dengan perawatan pasien hiv/aids. metode penelitian penelitian ini menggunakan rancangan “descriptive correlation”. peneliti menguji data pada satu titik waktu, data dikumpulkan hanya pada satu kesempatan dengan subjek yang sama. peneliti juga berusaha untuk memaparkan variabel penelitian dan menguji hubungan antar variable yang diminati untuk mendapatkan pemahaman yang mendalam tentang fenomena yang diteliti. perawat yang tercatat dan aktif bekerja di sebuah rumah sakit daerah di jawa barat merupakan populasi dalam penelitian ini. sedangkan sampel dalam penelitian ini adalah representasi perawat yang memiliki 13 pengetahuan, sikap, dan praktik kewaspadaan universal perawat (kusman ibrahim, dkk.) k a r a k t e r i s t i k s a m a d e ng a n p o pu l a si. pemilihan sampel akan dilakukan dengan cara “proposionate stratifi ed random sampling” (yamane,1964) yaitu sampel dipilih secara acak dalam jumlah yang seimbang untuk tiap unit kerja yang terdiri dari unit gawat darurat, rawat intensif, dan rawat bedah, perawatan dalam, perawatan anak, perawatan kebidanan, perawatan saraf, perawatan umum dan sementara, kamar operasi, dan paviliun. dalam penelitian ini peneliti mengambil sampel sebesar 90 responden untuk mengantisipasi kemungkinan drop out, namun sampai akhir proses pengumpulan data, angket terkumpul 90 buah sehingga tidak ada drop out atau dengan kata lain respon rate mencapai 100%. d a l a m p e n e l i t i a n i n i p e n e l i t i m e n g g u n a k a n k a p-i n s t r u m e n t y a n g dikembangkan oleh peneliti sendiri berdasar pada kajian kepustakaan yang relevan. instrumen ini terdiri dari empat bagian yaitu bagian (1) data demografi , (2) pengetahuan tentang hiv/aids, (3) sikap terhadap hiv/ aids, dan (4) laporan diri (self-report) pelaksanaan tek ni k pencegahan u mu m penyebaran hiv/aids . data dianalisis dengan menggunakan program microsoft excel dan spss (statistical package for social science) untuk window versi 12. analisis data meliputi statistik deskriptif dan statistik inferensial. statistik deskriptif digunakan untuk menampilkan data demografi, pengetahuan, sikap, dan pelaksanaan teknik pencegahan umum dalam pencegahan infeksi. selain itu, mean, standar deviasi (sd), frekuensi dan range juga akan ditampilkan untuk data sikap. “pearson product moment correlation” dihitung untuk menguji hubungan skor pengetahuan, sikap dengan teknik pelaksanaan pencegahan umum penyebaran hiv/aids (polit & beck, 2010). hasil karakteristik responden pada penelitian ini rata-rata ber usia 29 tahun, sebagian besar perempuan (67,8%), berlatar belakang pendidikan d.iii keperawatan (93,3%), lama bekerja kurang dari 5 tahun (70%). diagram 1 menunjukkkan bahwa sebagian besar responden (74%) melaporkan pernah mengalami kecelakaan kerja cedera benda tajam. sedangkan untuk jenis kecelakaan cedera tersebut dan aktivitas yamg sedang dilakukan ketika cedara tersebut terjadi seperti termuat dalam tabel 1 dan tabel 2. tabel 1. jumlah dan jenis kecelakaan kerja berdasarkan shif kerja selama setahun terakhir jenis kecelakaan shif kerja jumlah (%)pagi (%) sore (%) malam(%) tertusuk jarum suntik 41 (13,6) 32 (10,6) 26 (8,6) 99 (32,8) teriris pisau 2 (0,7) 7 (2,3) 1 (0,33) 10 (3,3) tergores pecahan ampul/vial obat 28 (9,3) 25 (8,3) 21 (6,9) 74 (24,5) terkena cipratan darah/cairan tubuh pasien 59 (19,5) 31 (10,3) 29 (9,6) 119(39,4) jumlah (%) 130 (43) 95 (31,4) 77 (25,6) 302 (100) tabel 2. jenis aktivitas pekerjaan yang sedang dilakukan ketika kecelakaan kerja cedera benda tajam terjadi menutup kembali jarum suntik frekuensi prosentase 45 36,0 menusukan jarum suntik ke botol obat 14 11,2 membuka obat ampul 40 32,0 merawat luka 21 16,8 lainnya ; infus 5 4,0 jumlah 125 100 14 jurnal ners vol. 9 no. 1 april 2014: 11–18 tabel 3 me n a mpi l k a n f rek ue n si kecela k a a n ker ja ceder a bend a t aja m berdasarkan unit kerja. dari data tersebut tampak bahwa unit perawatan penyakit dalam merupakan ruangan dengan tingkat kecelakaan kerja tertinggi (14,4%) diikuti unit perawatan anak (10%) dan perawatan bedah (8,9%). sebagian besar responden (88%) menjawab “tidak atau belum pernah” mengikuti pelatihan pengendalian infeksi atau prosedur kewaspadaan universal. tabel 4 menunjuk kan jumlah skor m i n i mu m, ma k si mu m, mean, d a n sd dari nilai pengetahuan, sikap, dan praktik pencegahan umum terhadap penularan hiv/ aids. lebih dari setengah (52%) responden memiliki pengetahuan tentang pencegahan umum penularan hiv/aids dalam kategori baik, dengan rerata skor 24,06 (jumlah skor maksimal 31). responden dengan tingkat pengetahuan cu k up sebanyak 41% dan kurang sebesar 7%. lebih dari setengah (51%) responden menunjukan sikap mendukung tabel 3. responden yang pernah mengalami kecelakaan kerja cedera benda tajam berdasarkan unit kerja (n = 90) unit kerja pernah mengalami kecelakaan kerja cedera benda tajam total (%) ya (%) tidak (%) ugd 6 (6,7) 0 (0,0) 6(6,7) perawatan bedah 8 (8,9) 3 (3,3) 11 (12,2) perawatan dalam 13 (14,4) 4 (4,4) 17 (18,9) perawatan anak 9 (10) 9 (10) 18 (20) perawatan kebidanan 6 (6,7) 3 (3,3) 9 (10) kamar bedah (ok) 2 (2,2) 2 (2,2) 4 (4,4) icu 4 (4,4) 1 (1,1) 5 (5,6) neurologi 7 (7,8) 0 (0,0) 7 (7,8) umum/sementara 6 (6,7) 1 (1,1) 7 (7,8) vip 6 (6,7) 0 (0,0) 6 (6,7) total (%) 67 (74,4) 23 (25,6) 90 (100) tabel 4. jumlah skor dan konversi nilai pengetahuan responden tentang pencegahan umum terhadap penularan hiv/aids (n = 90) aspek minimum maksimum mean std. deviation pengetahuan 11 30 24,06 3,36 sikap 60 88 72,58 3,36 praktik 54 91 75,74 8,96 (favorable) terhadap perawatan pasien hiv/ aids dengan rerata skor sikap 72,58 (dari skor maksimal 100). responden dengan sikap unfavorable sebanyak 49%. praktik pencegahan umum terhadap pe nu la r a n h i v/a i ds ya ng d ila k u k a n responden mempunyai nilai mean tertinggi (m e n d e k a t i 4) m e n u nj u k a n s e m a k i n banyak responden yang melaporkan selalu melaksanakan praktik tersebut, sebaliknya semakin kecil nilai mean (mendekati 1) menunjukan responden banyak yang memilih ”tidak pernah” melakukan praktik sesuai yang ditanyakan (tabel 5). hasil uji statistik korelasi dengan menggunakan ”pearson product moment cor relat ion” menu nju k a n ba hwa skor pengetahuan berhubungan positif secara bermakna dengan skor praktik responden, sedangkan pengetahuan dengan sikap, dan sikap dengan praktik tidak berhubungan secara bermakna. 15 pengetahuan, sikap, dan praktik kewaspadaan universal perawat (kusman ibrahim, dkk.) pembahasan dari data karakteristik responden d i ket a hu i ba hwa mayor it as responden (70%) berusia antara 20 sampai 30 tahun, sebagian besar (67,8%) adalah perempuan, seluruhnya bergama islam, sebagian besar bekerja di unit perawatan anak, dalam, dan bedah, dengan lama bekerja sebagian besar (70%) kurang dari lima tahun. ketiga unit perawatan tersebut biasanya merupakan unit yang tingkat kapasitas hunian pasiennya lebih tabel 5. urutan mean dan sd praktik responden tentang pencegahan umum terhadap penularan hiv/aids (n = 90) jenis praktik mean sd mencuci tangan dengan menngunakan antiseptik setelah melakukan prosedur yang berhubungan dengan darah atau cairan tubuh pasien 3.91 .286 mencuci tangan setelah menyentuh ekresi tubuh pasien 3.82 .646 mencuci tangan setelah menyentuh cairan tubuh pasien 3.81 .652 mencuci tangan setelah merawat pasien 3.80 .524 mencuci tangan setelah menyentuh darah 3.79 .727 saya menutup jarum bekas suntik sebelum dibuang ke tempat sampah 3.78 .683 memakai sarung tangan ketika melaksanakan tindakan operasi 3.76 .739 memakai masker ketika merawat pasien dengan penyakit infeksi yang berpotensi menular melalui udara 3.70 .626 mencuci tangan setelah memakai sarung tangan 3.66 .823 mencuci tangan dengan menggunakan cairan antiseptik sebelum melakukan prosedur tindakan yang asepsis 3.54 .767 membuang jarum dan benda-benda tajam lainya ke tempat khusus (safety box) 3.52 .864 melakukan dekontaminasi alat/instrumen bekas tindakan ke pasien sebelum dicuci dan disterilisasi 3.40 .934 memakai sarung tangan ketika melaksanakan tindakan merawat luka 3.34 .926 mencuci tangan sebelum merawat pasien 3.32 .946 memakai sarung tangan ketika melaksanakan tindakan pasang ngt 3.31 1.098 jika luka atau radang di tangan, saya menutup dengan plester sebelum memakai sarung tangan 3.30 1.075 memakai sarung tangan ketika melaksanakan tindakan membersihkan insrumen bekas pakai 2.88 1.100 memakai sarung tangan ketika melaksanakan tindakan tindakan suction 2.87 1.192 mencuci tangan sebelum memakai sarung tangan 2.66 1.062 untuk tindakan yang beresiko tinggi terpajan darah atau cairan tubuh pasien, saya mengenakan masker, kacamata, dan pelindung wajah 2.36 1.266 memakai sarung tangan ketika melaksanakan tindakan memasang infus 2.03 1.126 memakai sarung tangan ketika melaksanakan tindakan menyuntik (iv, im, ic) 1.88 1.069 membuang jarum bekas suntik tanpa ditutup ke tempat khusus jarum suntik 1.81 1.121 membuang sampah medis ke tempat sampah umum 1.34 .621 tinggi dibanding unit-unit perawatan lainnya, sehingga jumlah tenaga perawat pun biasanya lebih banyak dibanding di unit-unit lainnya. walaupun tingkat huniannya yang tinggi, namun pasien-pasien yang dirawat di unitunit tersebut umumnya mempuyai tingkat kompleksitas ringan sampai moderat, karena untuk pasien-pasien yang tingkat kompleksitas tinggi umumnya dirawat di ruang perawatan intensif. hal ini berhubungan dengan pola ketenagaan perawat yang ditempatkan di unit16 jurnal ners vol. 9 no. 1 april 2014: 11–18 unit tersebut umumnya perawat yang masih junior atau belum banyak pengalaman dalam menangani pasien namun disisi lain mereka harus berhadapah dengan beban kerja yang tinggi. sebagiaan besar responden (74%) melaporkan pernah mengalami kecelakaan kerja cedera benda tajam, dengan jenis kecelakaan terbanyak adalah tertusuk jarum suntik (32,8%) diikuti oleh tergores pecahan ampul (24,5%) dan teriris pisau (3,3%). kecelakaan tertusuk jarum suntik dialami responden terutama ketika menutup kembali jarum suntik (36%). temuan penelitian ini memperkuat hasil temuan terdahulu bahwa seluruh tenaga kesehatan di dunia diperkirakan mengalami 2 juta kecelakaan kerja cedera benda tajam yang menjadi perantara penularan hepatitis b, c, dan hiv (wilburn & eijkemans, 2004). angka kejadian tersebut pun masih perkiraan kasar, angka sebenarnya bisa lebih besar lagi karena beberapa kasus banyak yang tidak tercatat dan tidak dilaporkan. data dari survei keselamatan injeksi yang dilakukan oleh who mengungkap bahwa di asia, afrika, dan mediteran timur, seorang tenaga kesehatan rata-rata mengalami cedera benda tajam sebanyak 4 kali per tahun (who, 2003). dua penyebab yang paling umum dari cedera benda tajam ini yaitu penutupan kembali jarum suntik dengan dua tangan dan pengumpulan dan pembuangan limbah benda tajam yang tidak aman (who, 2003). dari data tabel 3 unit perawatan dalam, anak, dan bedah mer upakan unit kerja yang angka cedera benda tajamnya paling tinggi dibanding unit-unit lainnya. seperti telah diungkapkan di atas bahwa ketiga unit tersebut umumnya kapasitas hunian pasiennya tinggi, beban kerja perawat terutama tindakan injeksi pun tinggi, dan perawat yang bekerja sebagian besar masih relatif baru ( junior) sehingga potensi resiko kecelakaan kerja cedera benda tajam pun tinggi. hal ini bisa menjadi bahan perhatian bagi pengelola tenaga atau sdm keperawatan dalam merancang pola ketenagaan di ruangan hendaknya ada komposisi seimbang antara senior dan junior serta pelunya pembinaan atau pelatihan yang berkelanjutan tentang pengendalian resiko kecelakaan kerja ter utama cedera benda tajam yang berpotensi menularkan beberapa penyakit berbahaya termasuk hiv/aids. hal ini diperkuat oleh temuan yang tergambarkan pada diagram 2 bahwa hanya sebagian kecil (12%) saja responden yang pernah mengikuti pelatihan pengendalian infeksi termasuk prosedur kewaspadaan umum. dari data pengetahuan responden tentang penecegahan umum terhadap penularan hiv/ aids diketahui bahwa lebih dari setengahnya responden termasuk berpengetahuan baik dengan rata-rata jumlah skor 24,06 (dari jumlah skor tertinggi 31). hal ini menunjukan bahwa meskipun responden banyak yang belum mengikuti pelatihan khusus tentang pengendalian infeksi, namun secara umum responden mengenal pengetahuan tersebut mungkin ketika dalam proses pendidikan keperawatan dan dengan pengalaman kerja yang relatif belum lama, pengetahuan tersebut masih mudah untuk diingat kembali. namun demikian seiring dengan perkembangan ilmu dan pengetahuan, maka mengikuti perkembangan ilmu pengetahuanterkini maer upakan kehar usan agar tetap bisa menjalani profesi secara baik. hal ini terlihat dari kebanyakan responden (57,8%) masih menjawab benar untuk pertanyaan ”jarum bekas su ntik sebaik nya dit ut up dahulu sebelum dibuang ketempat sampah”, padahal hal tersebut tidak direkomendasikan lagi oleh who (2003) yang menganjurkan tidak perlu lagi ditutup dulu karena saat penutupan ulang itulah yang banyak menimbulkan kecelakaan tertusuk. lebih dari setengahnya responden menujukan sikap mendukung ( favorable) terhadap perawatan pasien hiv/aids. hal ini menunjukan secara mental responden menunjukan kesiapan atau kemauan untuk merawat pasien hiv/aids. namun demikian, hampir setengahnya responden yang lainnya me nu nju k a n si k a p t id a k me nd u k u ng (unfavorable). idealnya, semua perawat harus menunjukan kemauan untuk merawat pasien hiv/aids karena perawat terikat sumpah profesi yang menyatakan akan tetap berusaha memberikan pelayanan keperawatan yang berk ualitas kepada semua pasien tanpa 17 pengetahuan, sikap, dan praktik kewaspadaan universal perawat (kusman ibrahim, dkk.) membeda-bedakan suku bangsa, agama, sosial, politik, termasuk jenis penyakit yang diderita. namun disisi lain, perawat juga berhak mendapat perlindungan dari berbagai dampak negatif sebagai resiko pekerjaan seperti kecelakaan kerja, tertular penyakit, dan sebagainya. oleh karenanya selama institusi tempat perawat bekerja dapat melindungi dari kemungkinan dampak negatif akibat kerja, misalnya dengan memberikan fasilitas yang cukup dan memenuhi standar keselamatan kerja serta peningkatan kompetensi secara berkesinambungan, maka perawat pun harus selalu siap untuk memberikan pelayanan keperawatan pada berbagai pasien dengan berbagai kasus penyakit. dilihat dari mean jumlah skor praktik sebesar 75,74 (dari jumlah skor tertinggi 96) menunjukan bahwa kebanyakan responden melaporkan sering dan selalu melakukan hal-hal yang ditanyakan diangket. jika dilihat dari urutan item yang paling sering atau selalu dilakukan oleh responden (tabel 7), ”mencuci tangan dengan menngunakan antiseptik setelah melakukan prosedur yang berhubungan dengan darah atau cairan tubuh pasien” merupakan item yang paling sering dilakukan oleh responden dalam penelitian ini. pada urutan selanjutnya tampak bahwa kebanyakan responden mempraktikan mencuci tangan sesuai indikasi yang diperlukan, kecuali sebagian kecil responden yang mencuci tangan sebelum memakai sarung tangan. responden masih banyak yang mempraktikan menutup jar um bekas suntik sebelum dibuang ke tempat sampah (mean = 3,78) dan sedikit responden yang memakai sarung tangan ketika melakukan tindakan suntik (mean = 1,88). hal ini konsisten dengan data pengetahuan yang menunjukan sebagian besar responden masih menganggap benar menutup kembali jarum suntik terlebih dulu sebelum dibuang ke tempat sampah, juga ditunjukan dengan sedikitnya responden yang membuang jarum bekas suntik tanpa ditutup ke tempat khusus jarum suntik (mean = 1,81). hasil uji statistik korelasi dengan menggunakan ”pearson product moment cor relat ion” menu nju k a n ba hwa skor pengetahuan berhubungan positif secara bermakna dengan skor praktik responden (r = 0,271 p = < 0,01), sedangkan pengetahuan dengan sikap, dan sikap dengan praktik tidak berhubungan secara bermakna. hal ini menunjukan bahwa semakin tinggi skor pengetahuan semakin tinggi pula skor praktik. penemuan ini memperkuat teori ”social cognitive theory” yang menyatakan bahwa perilaku seseorang (dalam konteks ini praktik pencegahan umum terhadap penularan hiv/ aids) dipengaruhi oleh aspek kognitif yang dibentuk dari pengetahuan tentang sesuatu yang berkaitan dengan perilaku yang akan dimunculkan. namun disisi lain, dalam penelitian ini tidak terbukti adanya hubungan yang bermakna antar pengetahuan dengan sikap, dan sikap dengan praktik, padahal baik secara teoritis maupun empiris keterkaitan antara pengetahuan, sikap, dan perilaku sudah banyak diketahui keterkaitannya. hal ini bisa dijelaskan bahwa, sikap merupakan kecenderungan perilaku yang belum nyata (overt behavior) dan sikap bukan satu-satunya penentu namun masih banyak faktor lain yang berpengaruh terhadap munculnya perilaku (azwar, 2003). oleh karenanya pada penelitian selanjutnya masih perlu diteliti faktor-faktor lain apa saja yang berkontribusi pada perilaku sekaligus menguji seberapa besar prediksinya terhadap munculnya perilaku. simpulan dan saran simpulan lebih dari setengah responden memiliki pengetahuan termasuk kategori baik, namun masih banyak responden yang masih salah dalam menjawab aspek-aspek pengetahuan yang berkaitan dengan resiko cedera benda tajam. hampir setengah responden masih menunjukan sikap negatif terhadap perawatan pasien hiv/aids. saran langkah-langkah unt uk mencegah atau meminimalkan kejadian cedera benda tajam sebagai akibat resiko kerja, perlu segera diambil oleh para pengelola tenaga keperawatan dan pihak terkait lain karena 18 jurnal ners vol. 9 no. 1 april 2014: 11–18 pada akhirnya akan menjadi ancaman bagi produktifi tas pelayanan keperawatan di rumah sakit. langkah-langkah yang bisa diambil diantaranya meningkatkan kompetensi para perawat dengan pendidikan dan pelatihan terkait, penyediaan fasititas pendukung, pengawasan, pengendalian serta penanganan dini kasus-kasus kecelakaan kerja terutama tertusuk benda tajam. pembinan sikap yang positif terhadap perawatan pasien hiv/aids perlu terus dilakukan. pembinaan ini bisa ditempuh dengan cara mensosialisasikan kemajuan yang positif dalam pengelolaan pasien hiv/aids, dukungan moril, fasilitas, dan kebijakan dari intitusi r umah sakit. mengingat masih banyak faktor lain yang belum terungkap yang turut berpengaruh terhadap munculnya perilaku, penelitian lanjutan masih diperlukan untuk mengeksplor faktor-faktor terkait serta menguji faktor mana yang paling kuat prediksinya sehingga bisa dilakukan kontrol terhadap faktor tersebut. daftar pustaka azwar, s., 2003. sikap manusia: teori dan pengukurannya. yogyakarta: pustaka pelajar bartholomew, l.k., parcel, g.s., kok, g., and gottlieb, n.h., 2001. intervention m a pping de sig ning t he or y a n d evidence-based health promotion promotion prog rams. new york: mcgraw-hill inter national council of nurses., 2006. reducing the impact of hiv/aids on nursing and midwifer y personnel. i m p r i m e r i e fo r n a r a : g e n e v a , switzerland kemen kes r i., 2013. lapor a n sit u a si perkembangan hiv/aids di indonesia s.d 30 juni 2013. notoatmodjo, s., 2003. pendidikan dan perilaku kesehatan. jakarta: rineka cipta polit, d.f., and beck, c.t., 2010. essentials of nursing research: appraisal evidence for nursing practice. philadelphia: lippincott williams & wilkins swanson, b., 2010. anac’s core curriculum h i v/a i d s nu r si n g, 3r d e d it io n . massachusetts: jones and bar tlett publishers unaids., 2012. report on the global aids epidemic, 2012: http://www.unaids. org/en/ resources/campaigns/20121120_ globalreport2012/globalreport/ wilbu r n, s.q., a nd eijkema ns., 20 04. preventing needlestick injuries among healthcare workers: a w ho-icn collaboration. international journal of occupational environmental health. 10: 451–456. world health organization., 2000. fact sheets on hiv/aids for nurses and midwives. geneva, switzerland world health organization., 2003. aidememorie for a strateg y to protect health care workers from infection with bloodborne viruses. geneva, switzerland: who yamane, t., 1964. statistics, an introductory analysis. new york: harper & row publishers 238 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19022 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review effectiveness of mobile-based health interventions for the management of hypertensive patients: a systematic review superzeki zaidatul fadilah, ika adelia susanti, dwi yoga setyorini and rifky octavia pradipta faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: cardiovascular disease is one of the biggest causes of death in the world. hypertension is known as a major risk factor for morbidity and mortality in cardiovascular disease. adherence to treatment is very important to overcome the problem, prevent complications, and prevent prolonged hospitalization in hypertensive patients. with the ever increasing technological development and the popularity of the use of internet-connected cellphones among the public, mobile-based and internet-based health interventions can be the right choice for the management of hypertensive patients. this study aimed to conduct a systematic review of the effectiveness of health interventions based on mobile health interventions for the management of hypertensive patients. methods: this systematic review used the related elements to content chosen by the prisma statement and using specific keywords in the database; ebscho, sciencedirect, elsevier, sage journals, scopus, and proquest, limited to the last five years, 2016 to 2020, obtained 13 articles. results: there were 13 articles that matched the inclusion criteria. there are various forms of intervention: from short message services (sms), smartphone applications, wechat, and a combination of sms with smartphone applications. conclusion: most studies report the value of customer satisfaction and high acceptance of each of the interventions provided. mobile-based health interventions are effective in controlling blood pressure and can improve adherence to treatment in hypertensive patients. article history received: feb 27, 2020 accepted: april 1, 2020 keywords hypertension; mobile health; randomized controlled trials contact superzeki zaidatul fadilah  superzeki21@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: fadilah, s. z., susanti, i, a., setyorini, d. y., & pradipta, r. o. (2020). effectiveness of mobile-based health interventions for the management of hypertensive patients: a systematic review. jurnal ners, special issues, 238-245. doi:http://dx.doi.org/10.20473/jn.v15i2.19022 introduction cardiovascular disease is the leading cause of death due to non-communicable diseases (who, 2017). hypertension is one of the main risk factors for cardiovascular disease (who, 2017). at present, it is estimated that >1.5 billion people worldwide suffer from hypertension (ma et al., 2015). hypertension is defined as systolic blood pressure greater than 140mmhg and diastolic blood pressure greater than 90mmhg. the prevalence of hypertension in indonesia in 2018 reached 34.1%, based on measurements of the adult population (≥18 years). furthermore, 45.6% of these patients do not take their medication regularly. most of them (59.8%) do not feel any symptoms while some others often forget (kemenkes ri, 2018). adherence to therapy by providing antihypertensive agents is very important to control symptoms, prevent complications of hypertension, and prevent prolonged hospitalization. however, non-compliance with long-term therapy is a barrier to the effectiveness of therapy and is still a global problem today. it is known that up to 50% of patients with cardiovascular disease have poor therapeutic compliance (omboni, 2019). reducing the patient's blood pressure level can reduce the incidence of stroke and cardiovascular events, significantly improve the quality of life of patients, and effectively reduce the burden of disease (andre, wibawanti, & siswanto, 2019). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 239 complex interventions often take a lot of time and require a lot of effort and high costs. therefore, it is necessary to develop interventions that are easy, and can be applied in daily practice. one example of an easy and simple intervention is to improve patient response to therapy by remote monitoring. telenursing / telehealth as part of telemonitoring is a way to provide nursing care using telecommunications and mobile-based information technology. with the increasing technological development, the popularity of the use of internetbased cellular phones has spread widely among the people; therefore, new models of health approaches through cellphones and information technology are increasingly being used in blood pressure management and become the right choice for overcoming non-compliance with drug use by providing medication reminder applications, providing healthy lifestyle education, measuring vital signs, consulting nutrition and keeping records of biometric measurements. continuing health interventions for patients returning from mobile cell-based hospitals and using internet networks solve the problem of long space distances in big cities and uncomfortable transportation between urban and rural areas and the community, which causes difficulties for patients seeking medical care, and this method of education is more flexible and diverse. therefore, the aim of this study is to conduct a systematic review of the effectiveness of health interventions based on mobile health interventions for the management of hypertensive patients. materials and methods a systematic review consists offive steps: (1) identification of instruments in the literature (database search); (2) identification of relevant literature based on title and abstract; (3) inclusion and exclusion criteria; (4) get the full text of the literature; (5) the assessment is based on the literature component and analysis of the chosen instrument. this systematic review used the related elements to content chosen by the prisma statement in the database ebscho, sciencedirect, elseiver, sage journals, scopus,and proquest and is limited to the last five years, 2016 to 2020, obtaining 13 articles. next, the search results are narrowed down through the selection process illustrated by figure 1. two main research areas are considered to design the search strategy as follows: (1) diseases and conditions; like hypertension and blood pressure, (2) mobile-based health intervention areas; such as applications, cellular programs, car applications, and mhealth. based on the determination of keywords according to the topics contained in the prisma statement, and complemented by the boolean logic method (sciencedirect, sage journal, scopus, proquest, pubmed) then the english keywords used are "hypertension", "pressure blood, "and" mobile applications, "and" mobile health,, "and" randomized controlled trials "and" cellular health ". the inclusion criteria for this study were randomized controlled trials using telephone-based health interventions and reminders with cellphones (sms, telephone), e-mail, android applications for remote health interventions for blood pressure management in hypertensive patients; all research subjects met the criteria diagnostic for hypertension, that is, systolic blood pressure ≥ 140 and / or diastolic blood pressure ≥90mmhg (1mmhg = 0.133 kpa); the study was a randomized controlled trial, clear outcome indicators were included; and the patient's age, sex, source of cases, course of disease, and types of hypertension are unlimited. type of experimental group intervention (distance health intervention); control group (traditional nursing intervention). main outcomes measured in the study: systolic blood pressure (mmhg) and diastolic blood pressure (mmhg), secondary outcome: medication adherence; and regular blood pressure measurement; reasonable diet; smoking cessation and restriction alcohol, heavy control, adhering to proper exercise, knowledge about prevention and treatment of hypertension and its dangers. exclusion criteria are articles about providing interventions other than telephone-based figure 1 – flow chart of the study identification process (liberati, 2009) (a. liberati et al, 2009) s. z. fadilah et al. 240 | pissn: 1858-3598  eissn: 2502-5791 table 1. summarize of selected studies author (year) design sample size intervention group control group outcome meurer, w. j. et al., (2019) rct 104 type: sms frequency : 1 day / week duration : 3 months the control group was instructed to follow up with their primary care doctor for treatment. the intervention group had significant bp reduction over time with a mean drop of 9.1mm hg (95% confidence interval = 1.1 to 17.6) chandler, et al., (2019) rct 54 type: smartphone applications (smash ) combined with sms frequency : every 3 days in the morning and evening. duration : 9 months the enhanced standard care (esc) participants received text messages, including links to pdfs and brief video clips containing healthy lifestyle tips for attention control. the smash group reported significantly greater increases in medication adherence at each evaluation. rehman, et al., (2019) rct 120 type: sms frequency : during their clinical checkup visits duration : 3 months the control group relied only on medication therapy to control hypertension the intervention group showed better hypertension control, with systolic blood pressure (sbp) declining by 8mmhg to 141.15 ± 5.73mmhg, and diastolic blood pressure (dbp) declining by 6mmhg to 88 ± 3.97mmhg. the control group showed a 2mmhg and 3mmhg decline in sbp and dbp, respectively. marquez contreas, et al., (2019) rct 154 type: smartphone applications (alerhta) frequency : duration : 12 months control group with usual intervention (control every 6 months of blood pressure, annual control of therapeutic adherence, annual analysis and biannual electrocardiogram) 1. the intervention group had a higher level of adherence to take daily dose intake. (p<0,001) 2. the intervention group had a higher control of high blood pressure at 12 months (p<0.05). tobe, s. et al., (2019) rct 243 type: active text messaging frequency : duration : 2 months passive text messaging (described healthy lifestyle and behavior changes ) blood pressure results overall showed a fall throughout the study in both groups, but there was no difference between the groups. the main study hypothesis that active text messages would lead to more bp lowering than the passive messages alone was not proven. li, t., ding, et al., (2019) rct 492 type: wechat frequency : duration : 6 months usual care the intervention group had a higher control blood pressure bobrow, et al., (2016) rct 1372 type: sms textmessages frequency : duration : 12 months usual care there was no significant differences in blood pressure control between all groups there was no evidence that an interactive intervention increased this effect varleta, p. et al., (2017) rct 314 type: sms frequency : duration : 6 months usual care adherence to hypertensive drugs improved significantly in the intervention group from 49% to 62.3% (p= 0.01) bp reduction was higher in the intervention group monroe, v. d. (2018) rct 67 type: mobile applications combine with sms ontimerx® application frequency : duration : 3 months only used mobile applications 1. the use of software applications that have a reminder service could significantly and positively impact medication adherence jurnal ners http://e-journal.unair.ac.id/jners | 241 health interventions, non-randomized controlled trial literature (rct); inconsistent baseline data; no specific intervention time; treatment measures do not meet the selection criteria. results in this review, we examine the effectiveness of mobile-based interventions in controlling blood pressure in hypertensive patients and treatment compliance for hypertensive patients. we analyzed 13 articles from various publicly publicized countries that fit the inclusion criteria that we had set. overall, 10 of the 13 studies showed that using telephonebased health interventions was effective in controlling blood pressure in hypertensive patients. this systematic review includes research with a randomized control trial design. some interventions used in this research study include sms, wechat, smartphone applications and sms combined with author (year) design sample size intervention group control group outcome zha, p. et al., (2020) rct 30 type: smartphone applications frequency : duration : 6 months standard care 1. there was no statistically significant difference in systolic and diastolic bp between the two groups at baseline, 3 months, and 6 months. 2. the mhealth group demonstrated higher bp monitoring adherence across the study period compared with the standard group. 3. mhealth group was more likely to have greater adherence in taking prescribed antihypertensive medications and consequently experienced better hypertension control. movahedi, et al., (2019) rct 188 type: sms frequency : 1 time/day duration : 2 months usual care 1. bp reduction was higher in the intervention group 2. sms training would be an effective method to control hypertension. morawski, k. et al., (2017) rct 413 type: smartphone applications medisafe frequency : duration : 3 months usual care 1. after 12 weeks, those in the intervention arm decreased their blood pressure by 10mmhg more than the control group. 2. statistically significant increase in self-reported medication adherence after 4 weeks li, x. et al., (2019) rct 253 type: wechat frequency : duration : 6 months usual care 1. individuals who participated in the intervention program had better bp monitoring, improved their hypertension selfmanagement as well as parts of their disease knowledge and selfefficacy. 2. the wechat-based selfmanagement intervention may be a feasible and efficient program to help chinese community middle-aged and elderly hypertensive patients lower bp and improve selfmanagement. s. z. fadilah et al. 242 | pissn: 1858-3598  eissn: 2502-5791 smartphone applications. the majority of studies (6 of 13) used sms as interventions (meurer et al., 2019), (rehman, naeem, abbas, ashfaq, & hassali, 2019) ,(tobe et al., 2019), (bobrow et al., 2016), (movahedi, khadivi, rouzbahani, & tavakoli-fard, 2019), (varleta et al., 2017), three studies used smartphone applications (márquez contreras et al., 2019), (zha et al., 2020), (morawski et al., 2018), two studies used chat applications namely wechat (t. li, ding, li, & lin, 2019),(x. li et al., 2019) and two studies used sms combined with smartphone applications (chandler et al., 2019),(monroe, 2018). the interventions given in each article mentioned the average intervention for two to 12 months. overall, 10 of the 13 studies showed that the use of telephonebased health interventions was effective in controlling blood pressure and increasing adherence to treatment therapy. most studies report the value of customer satisfaction and high acceptance of each of the interventions provided. the advantages that can be observed in the intervention by using smartphone related applications are interesting features, easily accessed anytime and anywhere because smartphones are always carried everywhere. sms most studies (6 of 13) used sms as an intervention. interventions were by sending text messages explaining health education about hypertension (definitions, signs and symptoms, complications, control methods), reminders to measure blood pressure, discuss healthy lifestyle to reduce blood pressure such as reducing salt consumption, increasing fruit and vegetable intake, smoking rehabilitation, anxiety reduction, selection of the right oil, appropriate body weight and regular physical activity. in addition, short messages also discussed the importance of compliance in using drugs. text messages are sent routinely according to a schedule determined by the researcher. in studies using text messaging interventions, almost all have shown significant results in increasing adherence to antihypertensive drugs and improving blood pressure control. text messaging offers attractive choices for behavioral interventions, given its popularity in underserved populations, low costs, ease of adoption, scalability, and the ability to reach people in real time while remaining flexible and comfortable (meurer et al., 2019) smartphone applications there are three studies using smartphone applications as interventions. several studies using smartphone application interventions use a blood pressure measuring device whose results are sent to a smartphone via bluetooth that is connected directly to the server, which can be accessed by health workers, so they can provide feedback related to health conditions or the results of blood pressure measurements of patients. other features provided through the smartphone application are health education about hypertension, reminders to measure blood pressure regularly and reminders to take medication. the average results from all studies using the smartphone application as an intervention show effective results in lowering blood pressure and increasing adherence in the treatment of hypertension. research conducted by (márquez contreras et al., 2019)with a total sample of 144 patients undergoing antihypertensive treatment showed the results that the intervention group had a higher level of adherence to taking hypertension medication every day compared to the control group. wechat wechat-based research interventions containing health education, health promotion, group chat, and blood pressure monitoring (bp) are used as a combination of modalities. research conducted by (t. li et al., 2019) consists of four types, namely health education about hypertension, health promotion about healthy lifestyles, how to avoid hypertension, how to control weight, group chat about the third two weeks containing individual experiences in disease management, and reporting on their physical condition and current life status, most recent active tracking of participants’ blood pressure about patients reporting blood pressure measured by patients at home and researchers providing feedback on patients' monthly blood pressure reports. the difference between the wechat intervention and the others is that there is a chat feature that can be used as a sharing between members of the intervention group. smartphone applications combined with sms the research intervention by combining sending sms and smartphone applications was used by two studies in this systematic review. one in this study is that participants measure blood pressure every three days in the morning and evening using a bluetooth monitor that is paired with a smartphone application (smash), while sms messages were sent to remind participants to measure blood pressure and remind them to take hypertension medication regularly discussion adherence to medication and blood pressure control is very important to control symptoms, delay development, and prevent the recurrence of hypertension (alessa, abdi, hawley, & witte, 2018). in this industrial era 4.0, the use of mobile-based health interventions will optimize the provision of nursing care which is not limited by distance and time (wu et al., 2019). in addition, the use of smartphone applications offers new strategies for patients and their families to be more actively involved in the care of hypertensive patients (márquez contreras et al., 2019). overall results show increased treatment adherence in hypertensive patients and increased blood pressure control. although the types of jurnal ners http://e-journal.unair.ac.id/jners | 243 interventions differed in each study, the results in line with all of them had a positive effect. health interventions for hypertension patients based on cell phones obtained from the results of a literature review study of 13 articles can be divided into four types: text messaging, wechat chat application, smartphone application and sms combination with smartphone application. all have the role of giving reminders of drug intake, reminders of independent blood pressure monitoring, or reminders of routine clinic visits. this is very important considering that it is not uncommon to encounter hypertension patients who use drugs and only visit the clinic when there are complaints, making the antihypertensive prevention role inefficient. noting blood pressure fluctuations is also very important for hypertensive patients and healthy patients, to prevent recurrent hypertension. mobile-based health interventions using smartphone applications as interventions have been proven effective in controlling blood pressure in hypertensive patients (andre et al., 2019), (alessa et al., 2018). as in the study conducted by (zha et al., 2020), which conducted a 6-month mhealth application trial of underserved urban communities with high numbers of hypertensive patients, and showed a significant increase in adherence to blood pressure monitoring controls themselves. the use of mhealth to motivate and facilitate adherence to treatment regimens can be significant for self-management of chronic hypertension and preventing complications (andre et al., 2019), (lakshminarayan et al., 2018). text messaging interventions offer attractive options for behavioral interventions, given their popularity in underserved populations, low costs, ease of adoption, scalability, and the ability to reach people in real time while remaining flexible and comfortable (movahedi et al., 2019)(chandler et al., 2019). text messages contain health education about hypertension, motivation to take medication regularly, and reminders when there are schedules for clinic visits (movahedi et al., 2019), (varleta et al., 2017). research conducted in pakistan (rehman et al., 2019) for three months showed good results in increasing adherence to nonpharmacological treatment of hypertension. interventions with sms generally contain personal data about the indications and motivations of patients and the appropriate barriers and information relating to health education / related diseases. based on the results of research, the use of sms can support monitoring of adherence to specific intervention treatments in patients with hypertension (kim, wineinger, & steinhubl, 2016). the third intervention of the wechat application is not much different from the cellular and sms applications, the difference in wechat being that there is a group chat room for hypertension sufferers to discuss with each other related to the disease. group chats create a positive group environment for patients by sharing personal self-management experiences, and personal chats provide personalized advice for patients, which will increase their confidence in disease control (t. li et al., 2019). participants in the intervention group did indeed receive social support from other patients in the same chat group and from health workers during the six-month intervention(x. li et al., 2019). the overall results of this study indicate an increase in the level of adherence in the treatment of hypertension and an increase in blood pressure control. in addition to increasing compliance with hypertension treatment, health interventions using mobile phones also improve healthy lifestyle habits for hypertensive patients (morawski et al., 2018), (sarfo et al., 2019). the mechanism of health interventions can influence blood pressure control and improve medication adherence, namely measuring blood pressure itself and reporting the results regularly, will increase patient awareness about the condition of their illness so that it leads to positive behavior to support their condition. providing health education will increase knowledge related to illness and understanding and confidence to conduct self-management so that it will change the lifestyle that is less good (andre et al., 2019), (sarfo et al., 2019), (midlöv et al., 2019) conclusion mobile-based health interventions are easy to apply to hypertensive patients and are not limited by distance and time so that they can improve adherence to treatment, and improve blood pressure control well. technological advances make smartphones a promising alternative, but more evidence-based research is needed for related learning outcomes to be obtained. conflict of interest no conflicts of interest have been declared. acknowledgement the authors of this study would like to thank the faculty of nursing and also master of nursing study program, for providing the opportunity to present this study. references a. liberati et al. (2009). the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. bmj, 339. alessa, t., abdi, s., hawley, m. s., & witte, l. de. (2018). mobile apps to support the self-management of hypertension: systematic review of effectiveness, usability, and user satisfaction. journal of medical internet research, 20(7). https://doi.org/10.2196/10723 andre, n., wibawanti, r., & siswanto, b. b. (2019). mobile phone-based intervention in hypertension management. international journal of hypertension, 2019. s. z. fadilah et al. 244 | pissn: 1858-3598  eissn: 2502-5791 https://doi.org/10.1155/2019/9021017 bobrow, k., farmer, a. j., springer, d., shanyinde, m., yu, l. m., brennan, t., … levitt, n. (2016). mobile phone text messages to support treatment adherence in adults with high blood pressure (sms-text adherence support [star]): a singleblind, randomized trial. circulation, 133(6), 592– 600. https://doi.org/10.1161/circulationaha.115. 017530 chandler, j., sox, l., kellam, k., feder, l., nemeth, l., & treiber, f. (2019). impact of a culturally tailored mhealth medication regimen self-management program upon blood pressure among hypertensive hispanic adults. international journal of environmental research and public health, 16(7), 1–13. https://doi.org/10.3390/ijerph16071226 kemenkes ri. (2018). laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2018. riset kesehatan dasar 2018, 182–183. kim, j. y., wineinger, n. e., & steinhubl, s. r. (2016). the influence of wireless self-monitoring program on the relationship between patient activation and health behaviors, medication adherence, and blood pressure levels in hypertensive patients:a substudy of a randomized controlled trial. journal of medical internet research, 18(6), 1–14. https://doi.org/10.2196/jmir.5429 lakshminarayan, k., westberg, s., northuis, c., fuller, c. c., ikramuddin, f., ezzeddine, m., … speedie, s. (2018). a mhealth-based care model for improving hypertension control in stroke survivors: pilot rct. contemporary clinical trials, 70, 24–34. https://doi.org/10.1016/j.cct.2018.05.005 li, t., ding, w., li, x., & lin, a. (2019). mobile health technology (wechat) for the hierarchical management of community hypertension: protocol for a cluster randomized controlled trial. patient preference and adherence, 13, 1339–1352. https://doi.org/10.2147/ppa.s215719 li, x., li, t., chen, j., xie, y., an, x., lv, y., & lin, a. (2019). a wechat-based self-management intervention for community middle-aged and elderly adults with hypertension in guangzhou, china: a cluster-randomized controlled trial. international journal of environmental research and public health, 16(21), 1–13. https://doi.org/10.3390/ijerph16214058 ma, l., zhao, x., tang, z., li, y., sun, f., diao, l., … wang, j. (2015). epidemiological characteristics of hypertension in the elderly in beijing, china. plos one, 10(8), 1–8. https://doi.org/10.1371/journal.pone.0135480 márquez contreras, e., márquez rivero, s., rodríguez garcía, e., lópez-garcía-ramos, l., carlos pastoriza vilas, j., baldonedo suárez, a., … martell claros, n. (2019). specific hypertension smartphone application to improve medication adherence in hypertension: a cluster-randomized trial. current medical research and opinion, 35(1), 167–173. https://doi.org/10.1080/03007995.2018.15490 26 meurer, w. j., dome, m., brown, d., delemos, d., oska, s., gorom, v., & skolarus, l. (2019). feasibility of emergency department–initiated, mobile health blood pressure intervention: an exploratory, randomized clinical trial. academic emergency medicine, 26(5), 517–527. https://doi.org/10.1111/acem.13691 midlöv, p., nilsson, p. m., bengtsson, u., hoffmann, m., wennersten, a., andersson, u., … kjellgren, k. (2019). person-centredness in hypertension management using information technology (perhit): a protocol for a randomised controlled trial in primary health care. blood pressure, 0(0), 1–8. https://doi.org/10.1080/08037051.2019.16971 77 monroe, v. d. (2018). testing a smartphone application intervention to improve medication adherence in african american female clinic patients with unstable high blood pressure : a two-group randomized control trial a dissertation submitted in partial fulfillment of the requir. (may). morawski, k., ghazinouri, r., krumme, a., lauffenburger, j. c., lu, z., durfee, e., … choudhry, n. k. (2018). association of a smartphone application with medication adherence and blood pressure control: the medisafe-bp randomized clinical trial. jama internal medicine, 178(6), 802– 809. https://doi.org/10.1001/jamainternmed.2018.0 447 movahedi, m., khadivi, r., rouzbahani, r., & tavakolifard, n. (2019). effect of training through short message service on compliance and mean blood pressure of hypertensive patients. international journal of preventive medicine, 10(1), 200. https://doi.org/10.4103/ijpvm.ijpvm_507_17 omboni, s. (2019). connected health in hypertension management. frontiers in cardiovascular medicine, 6(june), 1–17. https://doi.org/10.3389/fcvm.2019.00076 rehman, a. ur, naeem, f., abbas, s., ashfaq, f., & hassali, m. a. a. (2019). utilization of short message service (sms) in non-pharmacological management of hypertension. a pilot study in an urban public hospital of multan, pakistan. journal of public health (germany), 27(5), 561– 567. https://doi.org/10.1007/s10389-018-09829 sarfo, f. s., treiber, f., gebregziabher, m., adamu, s., nichols, m., singh, a., … ovbiagele, b. (2019). phone-based intervention for blood pressure control among ghanaian stroke survivors: a pilot randomized controlled trial. international journal of stroke, 14(6), 630–638. https://doi.org/10.1177/1747493018816423 jurnal ners http://e-journal.unair.ac.id/jners | 245 tobe, s. w., yeates, k., campbell, n. r. c., maar, m. a., perkins, n., liu, p. p., … bernick, j. (2019). diagnosing hypertension in indigenous canadians (dream-global): a randomized controlled trial to compare the effectiveness of short message service messaging for management of hypertension: main results. journal of clinical hypertension, 21(1), 29–36. https://doi.org/10.1111/jch.13434 varleta, p., acevedo, m., akel, c., salinas, c., navarrete, c., garcía, a., … romero, k. (2017). mobile phone text messaging improves antihypertensive drug adherence in the community. journal of clinical hypertension, 19(12), 1276–1284. https://doi.org/10.1111/jch.13098 who. (2017). the top 10 causes of death. wu, y., zhao, p., li, w., cao, m. q., du, l., & chen, j. c. (2019). the effect of remote health intervention based on internet or mobile communication network on hypertension patients: protocol for a systematic review and meta-analysis of randomized controlled trials. medicine, 98(9), e14707. https://doi.org/10.1097/md.000000000001470 7 zha, p., qureshi, r., porter, s., chao, y. y., pacquiao, d., chase, s., & o’brien-richardson, p. (2020). utilizing a mobile health intervention to manage hypertension in an underserved community. western journal of nursing research, 42(3), 201– 209. https://doi.org/10.1177/0193945919847937 208 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, oktober 2020 http://dx.doi.org/10.20473/jn.v15i2.21250 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research knowledge, attitude, and culture influence visual inspection with acetic acid service use alifina izza1, pungky mulawardhana2, samsriyaningsih handayani3 1 midwifery program, faculty of medicine universitas airlangga 2 department of obstetrics and gynaecology, faculty of medicine universitas airlangga 3 department of public health and preventive medicine, faculty of medicine universitas airlangga abstract introduction: the service use of visual inspection of cervix with acetic acid (via) has been low. this technique designed to detect cervical cancer at its earliest stage to prevent the unnecessary burden of its later stages. this study was aimed at showing the influence of knowledge, attitude and culture on the use of via service. methods: this research was a paired case-control study, conducted in 2019 in in the working area of kalijudan and mulyorejo community health centers, surabaya. ninety eight female respondents of childbearing age were grouped into control and case groups with 49 respondents respectively. samples were chosen consecutively. cases were obtained from the health centres’ records, while controls were chosen from cases’ close neighbours. interviews were conducted in the respondents’ house using closed questionnaires. results: the multivariate analysis showed that knowledge (p<0.001), attitudes (p=0.012) and culture (p=0.045) affected the use of via early detection services. conclusion: this study pointed out that knowledge, attitude and cultural factors were influential factors in the use of via early detection services. health workers may improve women’s knowledge and attitude through health promotion, and take into account supportive local cultural factors in the program to enhance the use of via. . article history received: august 07, 2020 accepted: october 23, 2020 keywords visual inspection with acetic acid; women of childbearing age; cervical cancer contact samsriyaningsih handayani  samsri.handayani@gmail.comm  department of public health and preventive medicine faculty of medicine universitas airlangga cite this as: izza, a., mulawardhana p., & handayani, s.. (2020). knowledge, attitude, and culture influence visual inspection with acetic acid service use. jurnal ners, 15(2). 208 213. doi: http://dx.doi.org/10.20473/jn.v15i2.21250 introduction visual inspection with acetic acid (via) is an examination performed by medical personnel to a cervix on which 3% 5% acetic acid/vinegar acid has been applied to detect cervical cancer. via examination is one of the joint programs between the government and the regional office of the ministry of health which is regulated in the minister of health regulation no. 34 of 2015 as an effort to prevent noncommunicable disease of cervical cancer which is carried out nationally, including in all districts/cities in east java. the via program is regarded as successful if its implementation can reach 80% of total women of childbearing age (wca). in 2016, because wca who underwent via examinations were still far from the target, the number of wca undergoing via examinations was regarded as adequate if it reached 50% of total wca. in 2017, because the number of wcs who underwent via examinations was still very low, the number of wca undergoing via examinations was regarded as adequate if it reaches 10% of total wca (ministry of health, 2016). the high incidence of cervical cancer in indonesia is due to low awareness (less than 5%) of married women or those who had engaged sexual relations for undergoing early detection. the indonesian ministry of health (2018) data showed that since 2014 via examination had not reached the target. from 6,012,729 women of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id http://dx.doi.org/10.20473/jn.v15i2.21250 http://dx.doi.org/10.20473/jn.v15i2.21250 jurnal ners http://e-journal.unair.ac.id/jners | 209 childbearing age (wca) in east java in 2017, only 3.81% of wca took the test (the department of health of east java provience, 2016). in the city of surabaya in 2014 through 2016, wca taking via tests were 0.94%, 2.25% and 1.23% respectively. in 2018 the average via coverage in surabaya was 6.03%. in the working area of the mulyorejo public health center, mulyorejo subdistrict, 2.13% were examined, whereas in the working area of the kalijudan public health center in the same subdistrict (3.80%) were tested. these were the lowest figures in surabaya ( the city of surabaya department of health, 2016) given the high incidence of cervical cancer, early detection of cervical cancer with via method should be carried out seriously. however, the success of the examination scope using via method is inseparable from the influence of various factors. the aim of the study was to analyze factors influencing the use of via services among women of childbearing age. materials and methods this study was a paired case control study, aiming to determine factors influencing the use of early detection services of via by wca in the areas of mulyorejo and kalijudan community health centers. population in this study were all wca in the working area of kalijudan and mulyorejo community health centers. cases were wca undergone via within the past one year, married and lived at the study site, identified through the health centres’ records. controls were wca had not taken via test in the past one year and lived in the same neighborhood with cases and chosen consecutively. the sample size was 49 respondents each for the control and case groups. data collection was carried out in the working area of kalijudan and mulyorejo community health centers, surabaya, from february to april 2019. interviews were conducted at respondents’ houses. seven questions to assess knowledge, 9 questions for attitude, and 2 questions for culture were tested for reliability and validity. cronbach's alphas were 0.412 for knowledge and 0.599 for attitude. pearson's product moment correlation for validity yielded pvalues between 0.008 to 0.750 for knowledge and 0.005 to 0.008 for attitude. results the study findings are presented as follows. the age of the respondents in this study ranged from 21 to 66 years old, with its mean of 13.50 ± 11.359 years old. the length of marriage ranged from 1 53 years, with the average of 16.18 ± 11.359 while the average number of lifetime sexual partners was 1.05 ± 0.333. the number of children of the respondents ranged from 0 to 7 children, with the average of 2.27 ± 1.117 the first time the respondents had sexual intercourse ranged from the age of 13 to 34 years with mean of 21.72 ± 3.618. continuous data were further dichotomized using mean as cut off value (table 1) responding to question on knowledge, the question most frequently incorrectly answered was at what age via is needed, while regarding the attitude that most people answer incorrectly was the assumption that doing via is enough only once in a lifetime. regarding culture, many respondents thought that their environment would suggest that via needs to be taken when they get symptoms of cervical cancer. knowledge was considered good if the total correct answers were 65% or more and poor if the total correct answers were less than 65% of the total correct answers expected. attitudes of respondents were divided into 2 categories namely favorable and unfavorable with the mean as cut off. for culture, it is divided into 2 categories, namely supporting and not supporting. it is said supportive if the total favorable answers were more than 50% and said to be unsupportive if the total favorable answers were less than 50% of the expected favorable answers. bivariate analyses were performed using x2 test to assess the difference of via takers and nontakers in the past one year by knowledge, attitude and culture (table 2) . multiple logistic regressions was performed to detect the influence of knowledge, attitude and culture simultaneously on the use of via services (table 3). table 3 shows that the most influential factor of via service use is knowledge, although attitude and culture also have significant impact on the use. those with good knowledge 7.284 times more likely to use via service. subjects with favorable attitude toward via 3.864 times more likely to use the service. those who perceived their culture as supportive toward via use were 2.13 more likely to use the service. discussion relationship between knowledge and the use of via services analysis showed that there was a relationship between knowledge and the use of via services. knowledge itself is the main part that is the basis for a person to do via or not, but the sources or media used to increase knowledge about via and all things about cervical cancer are currently very easy for us to reach so it is very possible to influence the increase in via use. this is related to the theory that the increase in respondent's knowledge is obtained from increased awareness (self-awareness) and interest in disease prevention (rogers 1974 in notoatmodjo 2012). this is in accordance with the results of research on mothers who conducted examinations at the hamparan perak public health center, deli serdang, explaining that there was a significant relationship between knowledge and iva examination and with good knowledge, the mother would pay attention to her reproductive health so that she would better recognize the signs of symptoms of cervical cancer and are motivated to a. izza et al. 210 | pissn: 1858-3598  eissn: 2502-5791 table 1. participants’ characteristics characteristics no via took via total p n % n % age ≤ 30 years 20 40.8 12 24.5 32 0.131 > 30 years 29 59.2 37 75.5 66 education completed elementary school 13 26.5 5 10.2 18 junior high school 5 10.2 11 22.4 16 0.109 senior high school 23 46.9 26 53.1 49 college/university 8 16.3 7 14.3 15 employment unemployed 42 85.7 38 77.6 80 0.708 self-employed 1 2.0 7 14.3 8 employee 6 12.2 4 8.2 10 marriage age ≤ 25 years 40 81.6 39 79.6 79 1.000 > 25 years 9 18.4 10 20.4 19 lifetime sexual partner 1 person 47 95.9 48 98.0 95 0.603 2 persons 1 2.0 1 2.0 2 ≥ 3 persons 1 2.0 0 1 child alive ≤ 3 children 46 93.9 42 85.7 88 0.317 > 3 children 3 6.1 7 14.3 10 smoking history passive and active smokers 30 61.2 32 65.3 62 0.834 not both 19 38.8 17 34.7 36 age of first time having sex ≤ 20 years 24 49 22 44.9 46 0.840 > 20 years 25 51 27 55.1 52 relevant symptom of cervical cancer risk factor 0 29 59.2 24 49 53 0.618 1 10 20.4 12 24.5 22 2 8 16.3 12 24.5 20 3 2 4.1 1 2 3 table 2. frequency distribution of knowledge, attitude and culture in via takers and non-takers in the past one year dependent variables no via took via total p n % n % knowledge poor 38 77.6 27 55.1 65 0.032 good 11 22.4 22 44.9 33 attitude unfavorable 24 49.0 7 14.3 31 0.000 favorable 25 51.0 42 85.7 67 culture not supportive 33 67.3 16 32.7 49 0.001 supportive 16 32.7 33 67.3 49 jurnal ners http://e-journal.unair.ac.id/jners | 211 carry out early detection, and perform early treatment if they are diagnosed with cervical cancer (sibero and hanum, 2018). this study is also in accordance with previous research which states that there is a significant relationship between knowledge and iva examination (gustiana et al., 2013; achmad, 2016; rahayu, 2017; fauza, aprianti and azrimaidaliza, 2019). this is because in the previous 4 studies the characteristics of respondents who became the majority of the sample were the same, namely in women of childbearing age with the majority of housewife and high school education. the theory presented states that the knowledge factor is one of the factors that influence health behavior in society, so that if someone has good knowledge, that person tends to carry out health behavior well, but knowledge is not the only factor that can change behavior a person, but knowledge can also be one of the determinants of changing one's behavior (notoatmodjo, 2012). most of a person's knowledge is obtained through the sense of hearing (ears) and the sense of sight (eyes). a person's knowledge of objects also has different intensity or level, so that counseling or information can be done in the mass media as an effort to increase public knowledge about early detection of iva detection (notoatmodjo, 2012). however, someone's knowledge of the object also has different levels of intensity, so that counseling or information can be carried out in the mass media as an effort to increase public knowledge about early detection of via. the relationship between attitude and use of via services the results of this study indicated relationship between attitude and the use of via services. this was in line with previous studies that found a significant relationship between attitude and willingness of women of childbearing age to conduct via examinations (achmad, 2016; pontoh, kairupan and sondakh, 2017; rahayu, 2017; silfia and muliati, 2017; indrayani, naziyah and rahmawati, 2018). the similarity of the finding in this study with that of previous studies was due to the same characteristics of respondents, who mostly were women aged 30 years and not working. attitude is a reaction or response that is still closed from a person against a stimulus or object. manifestations of an indirect attitude can be seen, but can be interpreted in advance of the closed behavior (notoatmodjo, 2012). rogers (1974) reveals that before people adopt new behaviours, inside them there occurs sequential stages (rogers in notoatmodjo, 2012). the first stage is awareness where the person is aware in the direction of the stimulus (object) or idea. the second stage is interest, that is people start to be attracted to the idea. the third stage is evaluation, where people ponder the benefit and the disadvantage of an idea being offered and whether the idea suits their needs. the fourth stage is trial in which people begin to practice the new idea. the last stage is adoption or rejection, where people adopt or reject the idea. nevertheless from subsequent research rogers conveyed that behavioral changes do not necessarily pass through the above stages. when the acceptance of new behaviour or adoption of behavior through such a process is based on knowledge, awareness and positive attitude, the behaviour will be lasting (long lasting). preferably if that behavior is not based on knowledge and consciousness then it does not quite last long was similar with it is not enough for the wca to only have a good level of knowledge about the willingness to conduct a via examination, but it must also be reflected in attitude. wca with a positive attitude will affect its desire to do early detection of cervical cancer with via method (fauza, aprianti and azrimaidaliza, 2019). previous via examination can be one of the factors that influence attitudes towards via because someone who has already done a via examination will do another via examination at a later time or can even tell their relatives that the via examination is not as scary as imagined (indrayani, naziyah and rahmawati, 2018). this contradicts the statement that there is no significant relationship between attitude and via early detection behavior (situmorang, winarni and mawarni, 2016). this can be motivated by behavior that refers to the experience of others or is based on one's own experience. the previous study had different characteristics of respondents, where the level of knowledge and attitudes among the groups studied were significantly different. in addition, a wca that is positive about something may not necessarily have positive behavior, because a positive attitude will be followed by behavior that refers to the experience of others or is based on the amount of experience a person has. wca who have negative attitude toward table 3. results of multiple logistic regressions of knowledge, attitude and culture on the use of via services dependent variables b sig. adjusted or 95% c.i for adjusted or lower upper knowledge 1.986 <0.001 7.284 2.417 21.951 attitude 1.352 0.012 3.864 1.354 11.030 culture 0.756 0.045 2.130 1.017 4.462 a. izza et al. 212 | pissn: 1858-3598  eissn: 2502-5791 early detection of cervical cancer can be related to their ignorance of this information and or do not yet know the purpose and benefits of via examination (rikandi and rita, 2009). someone with a good attitude is always expected to have good behavior. however, this is not always the case, so it is expected that the role of local people, including health workers, to continue to encourage wca who have a good attitude or not to conduct early detection of via examination. this study found that the impact of attitude was lower than knowledge but greater than. attitude tends to require a relatively shorter time than culture, but funding is one component that is quite dominant in influencing the level of willingness of the wca to carry out via, considering that until now there is still a treatment fee rate and can only be done at a health center which is relatively low. requires road fare. the relationship between culture and the use of via services this study showed relationship between culture and wca's willingness to conduct via examinations. this can be due to the fact that in the process of forming a supportive culture towards via use takes a very long time considering that community leaders, religious leaders and respected figures in the area are generally men where there is still a tendency to be indifferent to problems regarding female organs so that it is more difficult to increase the willingness to do via on wca. the relationship was consistent with a study conducted on women of childbearing age at the jatikalen community health center, nganjuk regency, which found that cultural value was a dominant factor for women of childbearing age to undergo an early detection of via (ummiyati, 2017). this was because the research site was still in a province with almost the same customs and habits in its community, especially in terms of health. the results of this study contradicted another previous study which found that there was no significant relationship between culture and wca's willingness to conduct via examinations (novalina, 2018). culture is “the set of distinctive spiritual, material, intellectual and emotional features of society or a social group … [which] encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs” (unesco, 2001). health and wellbeing have been found to be fundamentally influenced by the cultural context (napier, 2017). in this study, respondents who did not undergo via stated that the main reason for not undergoing the examination was because of shame. via examination procedures, which require that the pubic part be seen by health workers, are the main reason people do not want to do via. the respondents tended to have a culture that does not support via examination. they refused to do a via examination if there were no external factors that compel those respondents to do so, such as the policy of the health center that all members of family welfare development (pkk) and women are required to undergo via examination (novalina, 2018). cultural diversity or someone's interaction with many people who have cultural differences will affect one's beliefs that are reflected in their health behavior (napier, 2017). thus it can be concluded that culture is one of the most important components in determining a person's behavior, especially in health behaviors such as via early detection examination with via. to stimulate community interest in conducting early detection examination, via early detection program providers and/or planners should listen, learn from, partner with, and respond to communities that include women of childbearing age, both those who play an active or inactive role in the community (lee, 2015). culture in the communities that likely underestimate a disease also relates to low via examination rates. a previous study revealed that, in the case of early detection of cervical cancer, the wca assumed that if they were healthy or as long as there were no complaints they would not go to a healthcare provider because they thought via examination was useless. therefore, a more active role in every level of society and including in the officials, is needed to more seriously educating public about the importance of undergoing via examinations (nordianti and wahyono, 2018) conclusion factors related to the use of via services were knowledge about, attitude towards and culture of supporting via. health workers should emphasize the improvement of women's knowledge and attitudes in their work, and take into account local cultural in the program to increase the use of via. references achmad, n. (2016) ‘perubahan pengetahuan sikap wanita usia subur deteksi kanker serviks dengan pemeriksaan metode iva di wilayah kerja puskesmas pembangunan kecamatan tarogong kidul kota garut tahun 2016’, (november), pp. 1– 12. available at: urnal.umj.ac.id/index.php/semnastek. indrayani, t., naziyah and rahmawati (2018) ‘hubungan pengetahuan dan sikap wanita usia subur terhadap minat melakukan iva test di puskesmas kecamatan jatinegara’, jakhkj, 4(2). lee, s. (2015) ‘cultural factors associated with breast and cervical cancer screening in korean american women in the us : an integrative literature review’, asian nursing research. elsevier, 9(2), pp. 81–90. doi: 10.1016/j.anr.2015.05.003. napier, a. d. (2017) ‘culture matters: using a cultural contexts of health approach to enhance policymaking’, who regional office for europe, (1). nordianti, m. e. and wahyono, b. (2018) ‘determinan kunjungan inspeksi visual asam asetat di puskesmas kota semarang’, higeia journal of jurnal ners http://e-journal.unair.ac.id/jners | 213 public health, 2(1), pp. 33–44. available at: http://journal.unnes.ac.id/sju/index.php/higeia. novalina, a. (2018) faktor yang berhubungan dengan kesediaan wanita usia subur (wus) melakukan pemeriksaan inspeksi visual asam asetat (iva) di dua wilayah kerja puskesmas kota surabaya. universitas airlangga. pontoh, f., kairupan, b. h. r. and sondakh, j. (2017) ‘hubungan antara pengetahuan, sikap serta dukungan keluarga dengan tindakan pemeriksaan payudara sendiri (sadari) pada mahasiswi semester ii akbid makariwo halmahera’, (april). rahayu, s. (2017) ‘hubungan tingkat pengetahuan, sikap dengan perilaku deteksi dini kanker leher rahim metode iva pada wanita usia subur di dusun tempuran’, 000, pp. 74–84. rikandi, m. and rita, n. (2009) ‘faktor yang berhubungan dengan pemeriksaan dini kanker serviks pada wanita usia subur’. silfia, niluh nita and muliati, t. (2017) ‘hubungan karakteristik, pengetahuan dan sikap dengan pemeriksaan inspeksi visual asam asetat (iva) pada ibu pasangan usia subur di puskesmas talise’, caring, 1(2), pp. 69–83. situmorang, m. j., winarni, s. and mawarni, a. (2016) ‘hubungan pengetahuan dan sikap dengan perilaku deteksi dini pada penderita kanker serviks di rsup dr. kariadi semarang tahun 2015’, jurnal kesehatan masyarakat, 4(1), pp. 76–82. available at: http://ejournals1.undip.ac.id/index.php/jkm. the city health office of surabaya (2016) profil kesehatan kota surabaya. surabaya. the department of health of east java provience (2016) ‘profil kesehatan jawa timur’. ummiyati, m. (2017) determinan perilaku deteksi dini kanker serviks dengan metode iva (inspeksi visual asam asetat) pada wanita usia subur di puskesmas jatikalen kab. nganjuk. universitas airlangga. available at: http://repository.unair.ac.id/id/eprint/61766. unesco (2001) universal declaration on cultural diversity, paris: united nations educational, scientific and cultural organization. . http://e-journal.unair.ac.id/jners | 105 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.19814 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research self-efficacy of exercise in older adults with diabetes: a concept analysis somsak thojampa1, chawapon sarnkhaowkhom2, sirikanok klankhajhon1, roongtiva boonpracom1, amaraporn puraya1, and wuttichai sahattecho3 1 faculty of nursing, naresuan university, phitsanulok, thailand 2 faculty of nursing, saint louis college, thailand 3 faculty of management science, pibulsongkram rajabhat university, thailand abstract introduction: self-efficacy is defined as a person’s own judgment of their capabilities to perform a specific activity to attain a particular outcome. the concept of self-efficacy of exercise in older adults with diabetes may still be unclear, so it is essential to elucidate its meaning for better understanding in this concept. this paper aims to explore the meaning of self-efficacy with regard to exercise in older adults with diabetes. methods: using the walker and avant concept analysis, it discusses cases showing diabetic thai people and how they manage their health behavior changes, such as with exercise. results: analysis of the concept of self-efficacy in terms of its defining attributes, antecedents, consequences, and empirical referents provides information related to clinical usefulness. it helps healthcare professionals communicate the same notion when discussing self-efficacy and can distinguish this concept from other related concepts. conclusion: analysis of the concept of self-efficacy provides information related to exercise in older adults and can assist healthcare professionals in communicating the same notion when discussing the concept. article history received: may 15, 2020 accepted: june 22, 2020 keywords concept analysis; selfefficacy; diabetes; exercise contact somsak thojampa  somsakth@outlook.com  faculty of nursing, naresuan university, phitsanulok, thailand cite this as: thojampa, s., sarnkhaowkhom, c., khunkhajhon, s., boonpracom r., puraya a., & sahattecho, w. (2020). self-efficacy of exercise in older adults with diabetes: a concept analysis. jurnal ners, 15(1). 105-112. doi:http://dx.doi.org/10.20473/jn.v15i1.19814 introduction diabetes is a chronic disease that is becoming more common, especially among the elderly (chentli, azzoug, & mahgoun, 2015). the number of diabetics aged 65 years or older was projected to increase from 6.3 million in 2005 to 26.7 million by 2050 and the percentage of diabetic older persons was projected to increase from 39% to 55% (caspersen et al., 2012). the global health predicts that, in 2030, diabetic patients will be 450 million globally (who, 2014). the number of persons living with dm in asia was about 113 million in 2010, and this number is expected to increase to 180 million by 2030 (chan et al., 2009). in thailand, according to the department of disease control (2012), the rate of diabetes in the elderly is 2,128.04 per 100,000 population (aekplakorn et al., 2011). the world health organization (who) also claims that dm is an especially serious concern and becoming increasingly common in developing countries and among disadvantaged minorities (who, 2014). the international diabetes foundation (idf) reported that middleand low-income countries have more people under the age of 60 with dm compared to the world average (idf, 2014). thailand was ranked among the top ten countries in asia with a high prevalence rate of dm (aekplakorn et al., 2011). chronic hyperglycemia is a significant concern since it will lead to the progression of complications for an individual with dm. the complications of dm are the most significant contributing factor to the cost, since complications often require more intensive care in the hospital, or even may require surgery (riewpaiboon et al., 2007). self-efficacy is one of the central concepts of bandura’s theory. the author believed that a fundamental requirement to organize and execute a series of actions is required to attain expected outcomes is by exploring and utilizing one’s own capabilities, it is called “self-efficacy” (bandura, 1997). it is an important concept because it predicts human behavior. the self-efficacy concept has been https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:somsakth@outlook.com s. thojampa et al 106 | pissn: 1858-3598  eissn: 2502-5791 of considerable interest in several disciplines related to human behavior, such as nursing, sociology, and psychology. there are many authors that have misused this concept (williams & rhodes, 2016). bandura (1997) mentioned that some people used the terms ‘self-efficacy’ and ‘self-esteem’ interchangeably. however, they are different concepts and have various meanings. although the concept of self-efficacy of exercise in older adults with diabetes may still be unclear, it is essential to elucidate its meaning for better understanding in this concept. the term ‘perceived self-efficacy’ has been substituted in the literature to represent self-efficacy (bandura, 1997). the definition of the word perceive is to attain awareness or understanding of or to become aware of through senses. self-efficacy is defined as a person’s own judgment of their capabilities to perform a specific activity in order to attain a particular outcome. the term perceives is implied in the definition of self-efficacy and does not change the meaning. in most dictionaries, the term ‘self-efficacy’ is presented as two words ‘self’ and ‘efficacy’. the term ‘self’ is quite easily understood, it is a person as the object of his or her own reflective consciousness (kristen, 2009) while the term ‘efficacy’ is defined as the ability or power to produce desired things (liu, 2012). this paper aims to conduct a concept analysis of self-efficacy with regard to exercise in older adults with diabetes. materials and methods this concept analysis incorporated literature reviews from several healthcare disciplines, including nursing and medicine. the search for relevant articles was conducted utilizing databases including cinahl, pubmed, cochrane database, and the medical database in thailand (thailis and thai digital collection (tdc)). the search criteria was set to include only articles in the past 14 years and available in english or in thai languages. in addition, the search used the keywords ‘self-efficacy’, ‘older adult’, and ‘exercise’. the search results were reduced to 1758 articles. furthermore, after geographical restriction to asia was applied, the results reduced to 64 articles. finally, when the restriction to use self-efficacy as physical activity was applied, the results were reduced to 14 articles, which formed the basis of this review. the walker and avant methodology (walker & avant, 2010) was used for this concept analysis. there are eight steps in this method: selecting a concept; determining the aims or purpose of analysis; identifying all uses of the concept; determining the defining attributes; constructing a model case; constructing contrary, related and borderline cases; identifying antecedents, consequences; and defining empirical referents. step 1: select a concept concept analysis is a process to explore the meaning, the definition and the attributes of a particular concept. the first step of the process is to select a concept. the concept of self-efficacy of exercise in people with diabetes was chosen for this paper. step 2: determine the aims or purpose of analysis the purpose of analyzing a self-efficacy concept is to provide a clear understanding and description of this concept. this can be accomplished by utilizing various analytical methodologies. this paper would like to clarify the meaning of self-efficacy in order to use the concept appropriately in further theoretical developments, particularly in exercise of diabetes people. step 3: identify all uses of the concept exploring for meanings should start by searching from various sources because it helps in achieving the result from a significant amount of valuable information. the considering of all uses of the term, not only one aspect of the concept, is done by searching from various sources. thus, dictionaries, thesauri, and available literature from a variety of disciplines, such as psychology, sociology, nursing, medicine, and epidemiology, etc., were all employed to identify uses of the concept (walker & avant, 1995). self-efficacy is defined as a person’s belief about their competence to complete tasks and reach goals (bandura, 1997). bandura (1997) mentions that selfefficacy can be achieved by learning through personal experiences, observing others’ behavior and performance, following verbal persuasion, and controlling physiological arousals. there are many authors who have provided definitions of self-efficacy. kristen (2009), for example, defined self-efficacy as “a person’s own judgment of capabilities to perform a certain activity in order to attain a certain outcome.” edberg (2007) defined self-efficacy as “a person’s confidence that he or she can perform a behavior.” glanz, rimer, and viswanath (2008) stated “self-efficacy is a person’s beliefs about his or her capacity to influence the quality of functioning and the events that affect their lives”, while lowenstein, foord-may, and romano (2009) defined it as “the degree of confidence a person has that he or she can perform a certain behavior and overcome any barriers that may impede progress.” from reviewing available literature, it was found that most studies measure self-efficacy through respondent’s confidence in their capabilities. in summary, self-efficacy is commonly defined as the belief in one's capabilities to achieve a goal or an outcome and the word ‘efficacy’ can be applied to both human beings and objects. both cases are quite similar. they refer to the inherent attributes, which jurnal ners http://e-journal.unair.ac.id/jners | 107 is the meanings of ‘efficacy’. most dictionaries have a similar definition for the term ‘self-efficacy’ as a person’s own judgment of their capabilities to perform a particular activity in order to attain a certain outcome. the ability to recognize, which includes the affirmation and the strength, to produce effects in a particular task is a sense of self-efficacy. furthermore, the definitions as described in this paper help provide useful insights about selfefficacy. step 4: determine the defining attributes there were five defining attributes of self-efficacy that have been extracted from the literature: resources, knowledge, active participation, adherence to a self-efficacy plan as well as informed decision-making. these attributes compose a defined structure which represents the concept of selfefficacy. resources resources and knowledge form the foundation of self-efficacy. without proper resources and updated knowledge, it is impossible to carry out the selfefficacy tasks. the hcp should offer medical advice, support, and guidance to the individual living with chronic disease as part of the resource pool (huffman, 2005). in thailand, resources for selfefficacy intervention programs for persons with chronic diseases include local community health centers and local healthcare volunteers (srichairattanakull et al., 2014). there are local healthcare volunteers for every local community, such as in a village (wanitkun et al., 2011). support from family members, healthcare providers, and friends enhances adherence to self-care behaviors in thai people with cardiovascular disease (cad) (khuwatsamrit et al., 2006). knowledge knowledge can be obtained through education or through personal experience as well as from development of expertise (cameron et al., 2010). without proper knowledge, individuals with chronic diseases are unable to effectively participate in their self-efficacy (tanner, 2004). in thailand, knowledge of the disease and how to treat and prevent it are obtained mainly through health education and health promotion programs by the hospitals (deesiang & preechawong, 2008). patients are usually assigned to a focus group wherein health promotion and health education is conducted in a hospital (suwankruhasn et al., 2013). active participation active participation refers to achieving a balance between adherence and a person’s need to be responsible for his or her own care (cohen, 2009). this active participation is demonstrated by the patient’s lifelong behavioral changes which are required for an individual with chronic disease (tanner, 2004). activities such as exercise, dietary control, keeping appointments and following instructed self-care represent the patients’ commitment and their own desire to be active and responsible participants in the self-efficacy of their own disease (brody et al., 2005). in thailand, family support is most important for the patient. with solid family support, a patient can carry out any challenging medical treatment processes, including self-efficacy programs (srichairattanakull et al., 2014). adherence to a plan adherence to a plan requires that the patient follows a prescribed medical regimen prescribed by his or her hcp (funnell & anderson, 2004). taking prescribed medications appropriately and correctly is the most common measured outcome of adherence in the reviewed literature (gould & mitty, 2010). in thailand, nurses and local healthcare volunteers will prompt patients to adhere to a plan by either making a phone call or paying a home visit (srichairattanakull et al., 2014). several times, the local health volunteers will remind patients to follow instructions from their doctors. informed decision-making informed decision-making is the outcome of having adequate resources, proper knowledge, active participation and adherence to a plan. informed decision-making enables an individual with a chronic disease to make the best possible choices and deploy self-efficacy strategies on a daily basis (lorig & holman, 2003). informed decision-making puts the individual with chronic disease in control (funnell & anderson, 2004). this is less frequent in asia where most patients still rely on their hcp, mainly their doctors, to make decisions for them. moreover, thai patients trust and respect their doctors the most (wanitkun et al., 2011). step 5: construct a model case a model case is an example of the use of the concept that demonstrates all its defining attributes. that is, the model case should be a pure case of the concept, a paradigmatic example, or a pure exemplar (dugger, 2010; walker & avant, 2005). to clarify the concept, a model case of self-efficacy is illustrated as follows: mr. mo is a 76-year-old man, who exercises every day. he began exercising since he was 70 years old or six years ago. he had diabetes diseases and also had a right leg limp and was hospitalized once at the age of 71. he was hospitalized for three days. after he came back home, a community nurse visited him and gave some advice and discussed with him about the benefits of exercise and gave him examples of how exercise helped to improve the health of other patients. despite his old age and his illness, he s. thojampa et al 108 | pissn: 1858-3598  eissn: 2502-5791 believes that exercise is the best way for recovering from his disease. mr. mo also intends to learn about good exercising experiences from his friends. finally, he has strong beliefs in his ability and the advantages of exercise, so he decided to participate in an exercise program. he began doing exercise by walking slowly, but limited his walking to 50 feet. although sometimes he gets hurt from doing exercise, he continues to do exercise every day. every morning when he wakes up, he tells himself, "i have to walk soon, i can do it", and he intends to exercise every morning. after one month, he said, "before i began exercising, i was worried about my old age because i think that i cannot exercise and i have pains in nearly every joint, but now i am feeling better." and now, he has become more active in his local senior citizen's group because he has a positive feeling towards exercise. in addition, he believed that if he intended to exercise, he would succeed in walking one mile like others in his age bracket. his commitment was to go out for a walk every morning and gradually increase the distance that he walked. eventually, he was able to walk one mile like others in his age bracket. after two years of doing exercise, he walks one mile every morning, and he does not need medication to relieve pains. mr. mo demonstrated all of the defining attributes of self-efficacy. he had clear goals and an obvious confidence in his capabilities. these characteristics were illustrated in his decision to participate in the exercise program. the strength, affirmation of his confidence, perseverance, and mastery of experience were seen through his exercise goal and practice. he was persistent in his efforts. although he was in pain, he overcame the difficulty in walking at the beginning of his exercise program. in addition, he did the task with a strong sense of commitment to himself. step 6: constructing the contrary, related and borderline cases construct a contrary case walker and avant (2005) stated that contrary cases are clear examples of ‘not the concept’, but they are accommodating to understand the concept easily by excluding all its defining attributes. the following case is undoubtedly an example of a person with very poor self-efficacy expectations, devoid of all critical attributes of self-efficacy (dugger, 2010). mrs. kik is a 74-year-old woman who was diagnosed as having diabetes with arthritis in both knees. she was hospitalized for three days. after she came home, a community nurse visited her and gave her some advice and discussed with her about the benefits of exercise and examples of how exercise helped improve the health of other patients. although a community nurse gave some suggestions about the exercise programs, mrs. kik ignored the recommendations. she said, "at my age, i want to rest, i cannot do anything much, i had pains in both of my knees, and i cannot walk and run like a young woman." this case does not explain and exhibit defining attributes of self-efficacy. because she lacks confidence in her own abilities and she thought that her age was a barrier to doing exercise, she did not persist in her efforts to participate in exercise activities or even show a first attempt to exercise. construct a related case the related cases are similar to the concept of selfefficacy, but do not explain all of the defining attributes. those terms, which appear to be used often and are related to self-efficacy, are as follows: self-esteem, self-concept, self-control, selfactualization, self-confidence, health locus of control, perceived competence and perceived self-care agency. the related case of self-confidence described below is distinguishable from self-efficacy. mr. pongsit is a 72-year-old man. he has diabetes with an arthritic limp and was hospitalized for a week. after coming back home, a community nurse visited him and talked to him about exercising benefits. she gave suggestions about an exercise program, and she tried to explain that an exercise program will help reduce the severity of his symptoms. after that, he decided to participate in an exercise program with confidence in his abilities. when he began to exercise by strolling, he limited his walking to 50 feet. he complained to his nurse that he was hurting more. he thought that it was caused by doing exercise and he did not want to attempt it anymore. he wanted to quit exercising. although a community nurse has explained the process of the pain is caused by the disease and convinced him to continue exercising, he still wants to quit exercising. this case does not contain all of the defining attributes of self-efficacy. mr. pongsit has confidence in his ability; however, he does not demonstrate an affirmation of confidence in his belief in his ability to overcome the difficulties in order to achieve the goal. construct a borderline case mrs. susan, who is 72 years old, fell from her bed. she has diagnosed diabetes with having fractured her hip and was hospitalized for a month. after being discharged from the hospital, the nurse suggested that she rehabilitated herself in a nursing home since her husband may not be able to take care of her due to his deteriorating health. however, although her husband is 75, he insists that he will be able to handle it. although the nurse has explained the complexity of care that will be necessary, he believes that he is able to provide care for his wife. he helps his wife to do passive exercise every day, but it is less effective. his ongoing attempt to learn how to rehabilitate her correctly causes further harm to her healing process. jurnal ners http://e-journal.unair.ac.id/jners | 109 this case demonstrates some of the defining attributes of the concept of self-efficacy. the strength of her husband’s confidence in his ability to care for his wife is shown by his insistence that he would be able to perform the required tasks. he also illustrated his confirmation of confidence as he tried to master the passive exercise. however, he lacks the capability to learn how to successfully heal his wife through passive exercise. step 7: identifying antecedents and consequences identify antecedents walker and avant (2005) suggested that antecedents are those events that must occur prior to the occurrence of the concept. the antecedents of selfefficacy (nyi nyi htay, 2010) that arise from the literatures are: 1) performing self-efficacy appraisal through self-reflections on personal performance; 2) presence of strong self-efficacy expectations (performance accomplishments, vicarious experience, verbal persuasion and physiological cues); 3) a desire to acquire new challenging tasks or behaviors; 4) having reinforcement to adopt, change, or eliminate the behavior; 5) ability to make judgments and decisions; 6) proactive thinking; 7) having a supportive environment; and 8) ability and readiness to learn a difficult task or behavior. identify consequences walker and avant (2005) stated that consequences are those events or incidents that occur as a result of the occurrence of the concept. according to the result of literature analysis, the consequences of a robust self-efficacy encompass the following: views challenging problems as tasks to be mastered, increased confidence in one’s capacity to execute a task or behavior; increased self-determinism and self-responsibility; increased reasoning ability; stronger sense of commitment to one’s interests and activities; develop deeper interest and involvement in the targeted activities; recover quickly from setbacks and disappointments; harmonious in a social milieu; increased tolerance of difficulties and struggles; increased satisfaction and motivation; and increased ability to control emotional arousals (nyi nyi htay, 2010). step 8: define empirical referents determining the empirical referents is extremely useful in instrument development because these are categories of phenomena whose presence demonstrate the occurrence of the concept (dugger, 2010; walker & avant, 2005). in a standard way to measure the performance of beliefs, individuals are presented with items of progressively more difficult performance requirements within a particular behavioral domain (bandura, 1997). people’s beliefs and commitment are difficult to measure. the items are phrased in terms of whether they can or cannot perform the specific behavior. the strength and affirmation of an individual's confidence to overcome difficulties are rated on a 100-point scale, ranging in 10-unit intervals from 0 to 100. recently, several scales have been developed for health behaviors, such as physical activity, and have shown to have good reliability and validity (sallis, 1988). nyi nyi htay (2010) shows that various quantitative and qualitative studies are necessary to clarify and validate the empirical referents of selfefficacy, using structured questionnaires, table 1. the summary of the concept analysis of self-efficacy of exercise in older adults with diabetes: attributes, antecedents, and consequences attributes antecedents consequences a. knowledge b. active participation c. adherence to a plan d. informed decision-making a. performing self-efficacy appraisal through self-reflections on personal performance b. presence of strong self-efficacy expectations (performance accomplishments, vicarious experience, verbal persuasion and physiological cues) c. a desire to acquire new challenging tasks or behaviors d. having reinforcement to adopt, change, or eliminate the behavior e. ability to make judgments and decisions f. proactive thinking g. having a supportive environment h. ability and readiness to learn a difficult task or behavior. impacts on: a. views challenging problems as tasks to be mastered b. increased confidence in one’s capacity to execute a task or behavior c. increased self-determinism and self-responsibility d. increased reasoning ability stronger sense of commitment to one’s interests and activities e. develop deeper interest and involvement in the targeted activities f. recover quickly from setbacks and disappointments harmonious in a social milieu g. increased tolerance of difficulties and struggles increased satisfaction and motivation h. increased ability to control emotional arousals s. thojampa et al 110 | pissn: 1858-3598  eissn: 2502-5791 observations, interviews, focus group discussions and review of the method that it is appropriate to define the concept of self-efficacy. the study and analysis of literary evidence are needed to confirm the reliability and accuracy of these referents. analysis of the concept of self-efficacy in terms of its defining attributes, antecedents, consequences, and empirical referents provides information related to clinical usefulness. it helps healthcare professionals communicate the same notion when discussing self-efficacy and can distinguish this concept from other related concepts. results the concept of self-efficacy was analyzed in terms of its defining attributes, antecedents and consequences, and empirical referents provide information related to clinical usefulness following the steps of concept analysis. the meaning of selfefficacy in order to use the concept appropriately in further theoretical developments, particularly in exercise of diabetics was explored. data were extracted from the literature: resources, knowledge, active participation, adherence to a self-efficacy plan and informed decision-making. the related cases are similar to the concept of self-efficacy, but do not explain all of the defining attributes. those terms, which appear to be used often and are related to selfefficacy, are as follows: self-esteem, self-concept, self-control, self-actualization, and self-confidence, health locus of control, perceived competence and perceived self-care agency. the related case of selfconfidence described below is distinguishable from self-efficacy. it helps healthcare professionals communicate the same notion when discussing selfefficacy and can distinguish this concept from other related concepts. see table 1. discussion self-efficacy is a basic idea to develop a healthy and productive society. it is one of the best strategies for a challenging task or behavior with the ability to recognize the people and to learn through observation. self-efficacy refers to an individual’s perception of his or her ability to conduct certain acts without other people’s help. strong desire, motivation, and ability are a few aspects of selfefficacy. patients’ confidence in their ability to modify their behavior and perform self-management and self-monitoring will impact the outcome of the self-management, including maintaining those changed behaviors (urmimala et al., 2009). while self-efficacy is more emphasized in the west, family support is more common in the east (wanitkun et al., 2011). in asia, including thailand, patients will rely on their family members to ‘take care’ of them when they are ill or getting old. parents expect their adult children to take care of them when they are in need (wattanakul, 2012). even though more individuals with dm participated in or started ‘regular exercise’ (definition varied in different studies) after being diagnosed with having dm (kongsap & methakanjanasak, 2012, mosnier-pudar et al., 2009), not every individual with dm realizes the importance of physical activity (pa) for their selfmanagement of the disease. it is reported by houle et al. (2015) that completely stopping any exercise or pa after being physically active in their base study was associated with a rise in their hba1c level at 6month follow-up (houle et al.,2015). people must have a sense of efficacy in the maintenance of the perseverant effort needed to succeed. this paper is an attempt to explain the concept of self-efficacy, by examining its meanings, antecedent, consequences, usages and empirical referents, including an illustration of the model case and the contrary case. based on the results of the analysis, operation of self-efficacy was developed. symptoms of a dry mouth due to reduced saliva can make a patient feel uncomfortable. disturb the appetite and quality of life (plemons et al., 2014). study (dental & ada, 2015) states sucking ice cubes, drinking water while eating to help chew and swallow food, using mouthwash-free mouthwash, avoiding carbonated drinks (such as soda), caffeine, tobacco, and alcohol, and using lanolin-based lip balm to comfort cracked or dry lips can reduce dryness in the mouth and stimulate saliva discharge. increased salivary secretion leads to increased volume and thinning of saliva needed for ingestion and lubrication. in this study, not all of the patients' salivary volumes increased. this is influenced by several factors. according to samuels (2017) drugs, smoking, and alcohol consumption will reduce the flow rate of saliva. most respondents were aged in the range 46-65 years. old age will make the function of the salivary glands decrease, because the acinar element turns into fat and fibrous tissue (baird, donehower, stalsbroten, & ades,1991). the results of this study prove that the chewing gum and cryotherapy affect the stimulus production of saliva. hopefully, this study can increase information about nursing care in head and neck cancer, so that the symptoms caused by radiotherapy of the head and neck area can be reduced or avoided. the limitation of this study was the researcher cannot fully control the respondent’s intervention because it is done at home or boarding so this can have an impact on the result of the study. the strength of this study was there is an effective nonpharmacological action nurses can take to increase the volume of saliva in head and neck cancer patients by chewing gum. conclusion there is a noticeable variation of applying the concept of self-efficacy for the study of exercise in older adults with diabetes, particularly in thailand (wanitkun et al, 2011). more research is needed to jurnal ners http://e-journal.unair.ac.id/jners | 111 explore all aspects of self-efficacy, particularly from asian or thai culture and religious perspectives (wattanakul, 2012). this paper suggested a revised definition of the concept from a thai cultural point of view. this revised concept of self-efficacy can be used accurately for the evaluation of the effectiveness of a self-efficacy intervention program in thailand, with the aim for positive improved behavioral change, reduced healthcare expenditures as well as for improved quality of life. references aekplakorn, w., chariyalertsak, s., kessomboon, p., sangthong, r., inthawong, r.,putwatana, p., & taneepanichskul, s. (2011). prevalence and management of diabetes and metabolic risk factors in thai adults: the thai national health examination survey iv, 2009. diabetes care, 34(9), 1980-1985. https://doi.org/10.2337/dc110099 bandura a.(1997). self-efficacy: the exercise of control. new york: freeman. cameron, j., worrall-carter, l., page, k., & stewart, s. (2010). self-care behaviors and heart failure: does experience with symptoms really make a difference? european journal of cardiovascular nursing: journal of the working group on cardiovascular nursing of the european society of cardiology, 9(2), 92-100. https://doi.org/10.1016/j.ejcnurse.2009.10.004 chan, j. c. n., malik, v., jia, w., kadowaki, t., yajnik, c. s., yoon, k., & hu, f. b. (2009). diabetes in asia: epidemiology, risk factors, and pathophysiology. jama, 301(20), 2129-2140. https://doi.org/10.1001/jama.2009.726 caspersen, c. j., thomas, g. d., boseman, l. a., beckles, g. l., & albright, a. l. (2012). aging, diabetes, and the public health system in the united states. american journal of public health, 102(8), 1482–1497. https://doi.org/10.2105/ajph.2011.300616 chentli, f., azzoug, s., & mahgoun, s. (2015). diabetes mellitus in elderly. indian journal of endocrinology and metabolism, 19(6), 744–752. https://doi.org/10.4103/2230-8210.167553 deesiang, w. & preechawong, s. (2008). effectiveness of selfmanagement program on ldl cholesterol level of type 2 diabetic patients. journal of nursing science chulalongkorn university,20(2), 27-39. dugger b.(2010). concept analysis of health related quality of life in nursing home residents with urinary incontinence. journal of urologic nursing, 30,112-118. edberg, m. (2007). essentials of health behavior: social and behavioral theory in public health, jones and bartlett publishers, boston,52-55. glanz, k., rimer, b.k., & viswanath, k. (2008). health behavior and health education: theory, research, and practice (4th ed.). john wiley & sons, inc., san francisco, 97-121. huffman, m. h. (2005). compliance, health outcomes, and partnering in pps: acknowledging the patient's agenda. home healthcare nurse, 23(1), 23-28. international diabetes federation (idf).(2014). diabetes in thailand. retrieved september 14,2015: http://www.idf.org/membership/wp/thailand kristen, z. (2009). self-efficacy: a concept analysis. nursing forum, 44 (2): 93-102. khuwatsamrit, k., hanucharurnkul, s., chyun, d., panpakdee, o., tanomsup, s., & viwatwongkasem, c. (2006). social support, self-efficacy, and adherence to self-care requirements in patients with coronary artery disease. administrative advisory board, 156, 155-164. lowenstein, a.j., foord-may, l., & romano, j.c. (2009). teaching strategies for health education and health promotion: working with patients, families, and communities. jones and bartlett publishers, boston, pp. 310-313. nyi nyi htay. (2010). self-efficacy and concept analysis. retrieved september 14, 2015: http://nyinyiuonmdymyanmar.blogspot.com/201 1/09/self-efficacy-concept-analysis.html. riewpaiboon, a., pornlertwadee, p., & pongsawat, k. (2007). diabetes cost model of a hospital in thailand. value in health (wiley-blackwell), 10(4), 223-230. https://doi.org/10.1111/j.15244733.2007.00172 .x sallis jf, pinski rb, grossman rm, patterson tl, nader pr(1988). the development of self-efficacy scales for health-related diet and exercise behaviors. health education research,3,283-292. srichairattanakull, j., kaewpan, w., powattana, a., & pichayapinyo, p. (2014). self management improvement program combined with community involvement in thai hypertensive population: an action research. journal of the medical association of thailand = chotmaihet thangphaet, 97(4), 456-466. tanner, ek. (2004). home health care. chronic illness demands for self-management in older adults. geriatric nursing, 25, 313–317 walker lo, avant kc (1995). strategies for theory construction in nursing.3rd ed. ct: appleton & lange. wannipa asawachaisuwikrom (2002). concept analysis. thai journal nursing, 6,242-247. wanitkun, n., batterham, r., vichathai, c., leetongin, g., & osborne, r. h. (2011). building equity in chronic disease management in thailand: a whole-system provincial trial of systematic, pro-active chronic illness care. chronic illness, 7(1), 31-44. https://doi.org/10.1177/1742395310389495 williams, d. m., & rhodes, r. e. (2016). the confounded self-efficacy construct: conceptual http://www.socialresearchmethods.net/kb/order.php s. thojampa et al 112 | pissn: 1858-3598  eissn: 2502-5791 analysis and recommendations for future research. health psychology review, 10(2), 113–128. https://doi.org/10.1080/17437199.2014.941998 world health organization (who) (2015). diabetes mellitus. retrieved september 14,2015: http://www.who.int/mediacentre/factsheets/fs13 8/en/ 164 pernikahan dini berbasis transkultural nursing di desa kara kecamatan torjun sampang madura (early marriage based on transcultural nursing theory in kara village sampang) esti yunitasari*, retnayu pradanie*, ayu susilawati* *fakultas keperawatan universitas airlangga kampus c jl mulyorejo surabaya, telp. 031 5913754 email: esti-y@fkp.unair.ac.id abstrak pendahuluan: kasus pernikahan usia dini banyak terjadi di berbagai penjuru dunia dengan berbagai latarbelakang. pernikahan pada usia dini cenderung berdampak negatif dari segi pendidikan, sosial, ekonomi, psikologis, fisik, dan terutama bagi kesehatan reproduksi perempuan. penelitian ini bertujuan untuk menganalisis faktor yang berhubungan dengan pernikahan dini berbasis teori transcultural nursing di desa kara kecamatan torjun sampang. metode: penelitian ini menggunakan desain diskriptif analitik dengan jenis cross sectional. sampel penelitian ini adalah wanita yang menikah pada januari 2015-februari 2016 di desa kara kecamatan torjun sampang sebanyak 39 orang. pemilihan sampel dilakukan dengan cara purposive sampling. variabel bebas penelitian ini adalah pengetahuan, budaya, dukungan keluarga, ekonomi, teknologi dan variabel terikat adalah pernikahan dini data diperoleh dengan menggunakan kuisioner. analisis data menggunakan uji chi square dengan tingkat signifikasi α < 0,05. hasil: hasil penelitian ini menunjukkan hubungan yang signifikan antara faktor budaya (p=0,013), faktor dukungan keluarga (p=0,001), faktor ekonomi (p=0,040), dan faktor teknologi (p=0,002) dengan pernikahan dini sedangkan faktor pengetahuan tidak berhubungan dengan pernikahan dini yang terjadi di desa kara. pembahasan: sehubungan dengan hasil penelitian ini, diharapkan upaya dari pihak-pihak terkait untuk memberikan pendidikan kesehatan yang diikuti oleh remaja yang belum menikah untuk mencegah pernikahan dini. kata kunci: pernikahan dini, pengetahuan, budaya, dukungan keluarga, ekonomi, dan teknologi abstract introduction: the early-age marriage is still happened in the world with many reasons. early marriage has many negative impacts on education, social, economic, psychological, and reproductive health. the purpose of this study is to analyze the factors of early marriage based on transcultural nursing theory. methods: design used in this research was cross-sectional approach. the sampel was women who got married between january 2015 and february 2016. the 39 sample respondents were chosen by purposive sampling technique. the independent variables in this study were knowledge, culture, family suport, economic, technology and the dependent variable was early marriage. the data were collected by using questionnaire and analyzed by using chi square test. results: the results showed significant correlation between cultural factor (p=0.013), family support factor (=0,001), economic factor (p=0,040), and technology factor (p=0,002) with early marriage, while knowledge factor have not significant correlation with early marriage. discussion: by the result of this study, it was expected there will be some actions together with relevant parties to give health education for adolescent who has married yet to prevent early marriage. keywords: early marriage, knowledge, culture, support family, economic, and technology. _______________________________________________________________________________________________ introduction the age of married for women is one of the factors that affect the health status of mothers and children. according to the national family planning agency (bkkbn) determine the ideal age for girls to get marry considering the medical and psychological condition is after the age of 20 years while for male is 25 years old above, because at this age the reproductive system can function properly. initial data collection from the religious affairs office in the village of torjun in january to february 2016 showed data that there were 41% of women married before the age of 21 years. sixty nine of 218 women in kara, 69 were married and 34 of them were married before the age of 20 years. it means that the early marriages presentation in kara is still very high. thus, it is important to investigate the factors associated with early marriage based on transcultural nursing theory in torjun village sub district kara, sampang madura. data from bps (2013) showed that the number of women aged 10 years and under 17 years in east java on 2011-2013 was 26.33%. the number of early marriage is still high in bondowoso (53.26%), situbondo (51.54%), probolinggo (48.09%), sumenep (45.08%), and sampang (43.33%). those caused by various factors such as cultural factors, economics, technology and knowledge. desiyanti (2015) said that other factors that influenced early marriage is parents support. parents have jurnal ners vol. 11 no. 2 oktober 2016:164-169 165 authority to delay the marriage of their children. reproductive health problems began with sexual activity. early marriage could be a matter of reproductive health because the earlier age, the longer time span for reproduction (riskesdas 2013). early marriage has many consequences on education, health, economic, and family harmony. girls who married before 20 have increased risk of school drop out. early marriage of young females have a risk in reproductive health and also counts for the consequences of early pregnancy and increasing maternal mortality (noviyanti, w. & trihandini 2013). this is in line with research conducted by sarwono in lestari 2013 said that of women who married before the ideal age tend to have health problems: the reproductive organs are immature causes uterine contractions, the reproductive period is longer trigger the risk of cervical cancer, anemia in pregnancy causes low birth weight, and complication during pregnancy. according to bkkbn (2012) cultural factors are still the main reason that caused early marriage among girls in east java. the cultural dimension in madura is still very strong makes analysis of the problem with the transcultural approach is needed. effort to identify factors associated with early marriage in the madurese community can use the transcultural theory because of early marriage in the madurese community is a culture or habit that carried on from generation to generation. material & methods design used in this research was crosssectional approach. the samples were 39 women who got married from january 2015 until february 2016. the samples were chosen by purposive sampling technique. the independent variables in this study were knowledge, culture, family suport, economic, technology and the dependent variable was early marriage. the data were collected by using questionnaire and analyzed by using chi square test. this research was conducted for 4 days, on 25-26 june 2016 and 2-3 july 2016. instruments used in the form of a questionnaire drawn from research instruments by priyanti (2013), kharimaswatii (2014) and arika (2013). the questionnaire consist of 10 questions about knowledge (the definition of early marriage, the ideal age to get married, the impact of early marriage), culture (values and norms of early marriage, social interaction communities, tradition early marriage in the community), family support (emotional, cognitive, and material), economic (family income), technology (access to information technology, acces media massa and the press, and access to electronic tools and environment). the data were then analyzed using statistical test chi square α≤0,05 level of significance. result socio-demographic characteristics of the samples shown that almost (51.3%) of respondents were 20-35 years, and majority they were married on aged under 20 years old (66.7%). early marriage has the risk of complications during pregnancy because of the immature reproductive organs. most respondents had junior high school education bacground (64.1%), only 1 respondents finished higher education and 33.3% respondents classified as having a low education level. background of education is one of the internal factors that can affect a person's decision making. education is one of the main factors that determine the quality of life, the higher education level, the smaller intention to get married at an early age. on job categories, majority of respondents were housewifes (69.2%) and and the others were farmers and private sector worker. table 1 the correlation between knowledge and early marriage evidence in kara, madura knowle dege early marriage total no yes f % f % ∑ % lack 2 5.1 6 15.4 8 20.5 enough 3 7.7 7 17.9 10 25.6 good 8 20.5 13 33.3 21 53.8 total 13 33.3 26 66.7 39 100.0 uji chi square p = 0.773 coefficient contingency = 0.114 table 2. correlation between culture belief with early marriage evidence kara culture early marriage total no yes f % f % ∑ % embarace 3 7.7 17 43.6 20 51.3 not embarace 10 25.6 9 23.1 19 48.7 total 13 33.3 26 66.7 39 100.0 uji chi square p = 0.013 coefficient contingency = 0.371 pernikahan dini berbasis transkultural nursing (esti yunitasari, dkk) 166 tabel 3 assosiations family support with early marriage based on transcultural nursing in kara, sampang family support early marriage total no yes f % f % ∑ % support 3 7.7 20 51.3 23 59.0 not support 10 25.6 6 15.4 16 41.0 total 13 33.3 26 66.7 39 100.0 uji chi square p = 0.001 coefficient contingency = 0.459 table 4 assosiations of economics and early marriage based on transcultural nursing in kara, sampang ekonom ics early marriage total no yes f % f % ∑ % less 11 28.2 26 66.7 37 94.9 more 2 5.1 0 0 2 5.1 total 13 33.3 26 66.7 39 100.0 uji chi square p = 0.040 coefficient contingency = 0.312 majority respondents have low economic level (94.9%), and those who married at early age were 26 people (66.7%), while no respondents with upper middle income who married at early age. assosiations of technology and early marriage based on transcultural nursing showed that 16 respondents (41%) in the less categories of use of technology and 15 respondents (38,5%) were married at early age. discussion the number of women who married at early age is greater than women who married in ideal age. that is because there are several factors that support women to choosed to married earlier. these factors include knowledge, culture, family support, economic, and technology. knowledge influenced by education, mass media or information, sociocultural, family support, environment, experience, and age (rahmawati, 2010) . basd on the results of this study, knowledge is not related to early marriage because there were other factors that more influence early marriage decision. according to leininger (2002) educational background have an impact on the absorption of information. someone who has a higher education will also have a good knowledge. knowledge without a good education would enable women choose the wrong decision. different educational levels will affect different behavior in the decision to marry or not. some people who do not continue their education to higher levels tend to be productive so that a woman will decide to get married early (qibtiyah, 2014). but women who have a good knowledge will not necessarily be married at the ideal age, because there are several other factors such as social support and support for families who have a strong influence on the decision of a woman to get married early. this is also reinforced by the theory of leininger (1991) say that family support is very influential on a person's knowledge. high family support will affect a person's knowledge to be good because there is family support elements in the cognitive support which many families on these elements provide guidance, advice, and counsel. a good knowledge alone is not enough if the family support to get early marriage. cultural aspect in the community has a strong influence on early marriage. the result showed the relationship between culture with early marriage. individuals as social beings can not be separated from the environment in which they live by the norms and customs that are always binding, for example is weddings (syairwan, 2015). cultural factors that influence most in this study lies in the values and norms of early marriage developed in the community. this is evident from the respondents' answers when completing the questionnaire almost respondent agree with the prevailing belief is better to early get married than dating. there isi paradigm miss understanding the religion that is speeding up the wedding to avoid promiscuity and adultery reinforces early marriage. the results also supported by research conducted by rusiani 2013 obtained the fact that people do because it follows the tradition of early marriage, it is because the tradition is still strong. community interest did early marriage is influenced by the environment around the dwelling and desires of the individuals themselves. according to the theory of leininger's transcultural nursing stated that the behavior, values, beliefs and groups based on their individual needs must be taken to ensure that the nursing care provided effective and satisfactory. culture early marriage in kara village community if it continues will be harm in health status, so that health providers as jurnal ners vol. 11 no. 2 oktober 2016:164-169 167 nurses as care giver should seek common cultural restructuring their culture. family support have an important role in early marriage. according desiyanti (2015) mentions the factors that influenced early marriage is the role of parents in this regard have contributed greatly to the decision of child marriage. parents have the authority to delay the age of marriage. family support related to early marriage because of family support will influence a child's decision to get married at an early age. according daryanto (1998) in firanika (2010) prevailing belief in the family as well as the role of parents in decision-making in the family contributed to the women's age at first marriage. in undang undang pernikahan chapter ii article 6 confirms that to enter into marriage of a child who has not attained the age of 21 years must obtain permission from both parents. although it has been allowed to get married, the role of parents are needed to guide, help, and gave permission to all its responsibilities. results of research conducted by rahmawati (2010) showed that the decision to marry can not be separated from the influence of parents or family, within tribe osing decision making girls to marry much share the parents in it even still exist that all the decisions on the parents so that the child must follow their parents in terms of marriage. in this study economics associated with early marriage. a person with poor economic conditions were more likely to marry at an early age due to marry soon expected to raise the degree of economic family (faaulina, 2014). economic motive behind parents decided to marry off their children in the hope of reducing the financial burden of families because, when his son married the life of the child borne by the husband. the level of the poor economy will encourage early marriage. the results of the study by the center for research on population bkkbn in 2011 which stated that the economic factor is the most dominant factor for age at first marriage, especially in rural areas with married then there is help parents to work in the fields in order to harvest more abundant existing technology in society also influence early marriage. technology is one of the cultural dimension that can affect a person's health in this case relates to one's perception of the use and utilization of technology to manage health problems (leininger, 1978). utilization hp with various features to provide ease in finding information but besides that it also had a negative impact and positive impact. technological factors associated with early marriage, namely access to the mass media and the press. data analysis can show that of the respondents at the time of filling the questionnaire majority of respondents answered never get counseling about early marriage and most respondents answered that widespread exposure to sex in the media led to increasingly attract attention to prefer to get married. the mass media is also a factor that affects a person to behave. access to information obtained indirectly can make them behave over the information acquired . according qibtiyah (2014) received information capable of affecting the public mindset. almost every day the public was treated to the spectacle television that tells the story of early marriage, dating, violence etc. many spectacle educate but also there needs to be filtered. according astuty (2013) phenomenon of young age marriages are a phenomenon today is not only influenced by the lack of awareness and knowledge but indirectly influenced by a "role model" from the world of entertainment to watch. conclusion and recommendation conclusion from the result we conclude that factors associated with early marriage is a cultural, family support, economic level, and technology. knowledge was not significantly assosiated with early marriage. recommendation in relation to the factors related to the early marriage, it is recommended to involve religious leaders and community leaders in an effort to socialize maturation age of marriage. enhancing the role of health workers in health information and education about early marriage and its impact on the health of unmarried young people in order to prevent early marriage. references arika, n.h.n., 2013. analisis faktor yang berhubungan dengan pengetahuan ibu dalam pemenuhan status gizi anak usia 6-24 bulan berdasarkan teori pernikahan dini berbasis transkultural nursing (esti yunitasari, dkk) 168 transkultural nursing di posyandu dusun klagen peterongan jombang. universtas airlangga. astuty, s.., 2013. faktor penyebab terjadinya perkawinan usia muda di kalangan remaja di desa tembung deli serdang. universitas sumatra utara. bkkbn, 2012. kajian pernikahan dini pada beberapa provinsi di indonesia., jakarta. desiyanti, 2015. faktor-faktor yang berhubungan terhadap pernikahan dini pada pasangan usia subur di kecamatan mapanget kota manado. jurnal stikes muhammadiyah manado, 5, pp.pp.270–280. firanika, r., 2010. aspek budaya dalam pemberian asi esklusif di kelurahan bubulak kota bogor tahun 2010. uin syarif hidayatullah. kharimaswatii, e., 2014. analisis faktor pemberian asi esklusif pada bayi berdasarkan teori perilaku who di wilayah puskesmas mulyorejo surabaya. universitas airlangga, surabaya. leinngeer, 2002. cultural care theory: a major contribution to advance transcultural nursing and knowledge. journal of transcultural nursing,, 13, p.p.189. lestari, p., 2013. tingkat pengetahuan remaja putri tentang resiko pernikahan dini di desa jekawal tangen sragen tahun 2013, srakarta. noviyanti, w. & trihandini, i., 2013. analisa data sekunder survei demografi kesehatan indonesia 2007: tren dan dampak pernikahan dini. jurnal fakultas kesehatan masyarakat: universitas indonesia,, pp.1–18. priyanti, 2013. faktor-faktor yang berhubungan dengan perkawinan usia muda di deli serdang, sumatera utara. qibtiyah, m., 2014. pengaruh faktor sosial, ekonomi, budaya, terhadap usia kawin pertama muda perempuan wilayah urban dan rural di kabupaten tuban. universitas airlangga, surabaya. riskesdas, 2013. pokok pokok hasil riskesdas jawa timur 2013, jakarta. syairwan, i., 2015. ngka pernikahan dini di jawa timur lebih tinggi dari rata rata nasional. available. available at: http://www.tribunnews.com/regional/20 15/08/10/angka-pernikahan-dini-dijawa-timur-lebih-tinggi-dari-rata-ratanasional?page=1.. astuty 2013; bkkbn 2012; desiyanti 2015; firanika 2010; kharimaswatii 2014; leinngeer 2002; lestari 2013; noviyanti, w. & trihandini 2013; priyanti 2013; qibtiyah 2014; riskesdas 2013; syairwan 2015)arika, n.h.n., 2013. analisis faktor yang berhubungan dengan pengetahuan ibu dalam pemenuhan status gizi anak usia 6-24 bulan berdasarkan teori transkultural nursing di posyandu dusun klagen peterongan jombang. universtas airlangga. astuty, s.., 2013. faktor penyebab terjadinya perkawinan usia muda di kalangan remaja di desa tembung deli serdang. universitas sumatra utara. bkkbn, 2012. kajian pernikahan dini pada beberapa provinsi di indonesia., jakarta. desiyanti, 2015. faktor-faktor yang berhubungan terhadap pernikahan dini pada pasangan usia subur di kecamatan mapanget kota manado. jurnal stikes muhammadiyah manado, 5, pp.pp.270– 280. firanika, r., 2010. aspek budaya dalam pemberian asi esklusif di kelurahan bubulak kota bogor tahun 2010. uin syarif hidayatullah. kharimaswatii, e., 2014. analisis faktor pemberian asi esklusif pada bayi berdasarkan teori perilaku who di wilayah puskesmas mulyorejo surabaya. universitas airlangga, surabaya. leinngeer, 2002. cultural care theory: a major contribution to advance transcultural nursing and knowledge. journal of transcultural nursing,, 13, p.p.189. lestari, p., 2013. tingkat pengetahuan remaja putri tentang resiko pernikahan dini di desa jekawal tangen sragen tahun 2013, srakarta. noviyanti, w. & trihandini, i., 2013. analisa data sekunder survei demografi kesehatan indonesia 2007: tren dan dampak pernikahan dini. jurnal fakultas kesehatan masyarakat: universitas indonesia,, pp.1–18. priyanti, 2013. faktor-faktor yang berhubungan dengan perkawinan usia jurnal ners vol. 11 no. 2 oktober 2016:164-169 169 muda di deli serdang, sumatera utara. qibtiyah, m., 2014. pengaruh faktor sosial, ekonomi, budaya, terhadap usia kawin pertama muda perempuan wilayah urban dan rural di kabupaten tuban. universitas airlangga, surabaya. riskesdas, 2013. pokok pokok hasil riskesdas jawa timur 2013, jakarta. syairwan, i., 2015. ngka pernikahan dini di jawa timur lebih tinggi dari rata rata nasional. available. available at: http://www.tribunnews.com/regional/20 15/08/10/angka-pernikahan-dini-dijawa-timur-lebih-tinggi-dari-rata-ratanasional?page=1.. 538 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20523 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review the effectiveness of occupational therapy on patients with schizophrenia or another mental illness: a systematic review yuli anggraini, ahmad wahyudi, dutya intan larasati, and ah yusuf faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: a growing body of literature has shed light on occupational therapy (ot) interventions and outcomes in relation to mental illness. the purpose of this article is to provide an overview of the ot interventions used with patients with schizophrenia or mental illness and their documented outcomes in relation to functional level, well-being and quality of life.. methods: the databases searched were scopus, proquest, sage, and pubmed and the time of publication was in the last ten years. this was limited by the journal source type. the search terms, truncated when relevant, were "schizophrenia," "mental illness," “work training,” “occupational therapy” and “vocational therapy”. thirteen peer-reviewed intervention studies targeting adults with mental illness or schizophrenia were reviewed and analyzed. results: there are 6 categories related to the occupational interventions that emerged: skill training, cognitive-based occupational treatment, psychosocial-based occupational therapy, cognitive behavior therapybased occupational therapy, creative occupational therapy, and peer group support-based occupational intervention. conclusion: most of the previous literature states that there were significant effects from the occupational therapies on the level of functioning, well-being or quality of life of the patients with schizophrenia or mental illness. article history received: feb 27, 2020 accepted: april 1, 2020 keywords schizophrenia; mental illness; occupational therapy; level of functioning contact yulianggraini  yuli.anggraini2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: anggraini, y., wahyudi, a., larasati, d. i., & yusuf, a. (2020). the effectiveness of occupational therapy on patients with schizophrenia or another mental illness: a systematic review jurnal ners, special issues, 538-547. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20523 introduction schizophrenia has long been considered to be a chronic and debilitating illness with an almost inevitably deteriorating course. despite the demonstrated efficacy of antipsychotic medication in the short term, previous treatment goals were frequently modest with clinicians settling for outcomes such as ‘the control of behavior’ or ‘stability’(emsley, chiliza, asmal, & lehloenya, 2011). it has been emphasized that it is necessary to consider changes in the functionality of patients in the application of experimental treatments and their responses to said treatments. for this reason, importance has recently been given to therapeutic approaches and applications used to increase the functionality of patients during their treatment. in clinics providing treatment services to both inpatients and outpatients, occupational therapies with this aim and similar ways of increasing functionality are increasingly presented as an integral part of treatment. cochrane’s review addressing occupational therapy (ot) interventions pointed out the paucity of evidence in the field (steultjens, dekker, bouter, leemrijse, & van den ende, 2005). since then, a few systematic reviews have been explicitly focused on ot in the field of mental health. arbesman and logsdon (2011) reviewed the ot interventions aimed at facilitating education and work. seven categories of intervention emerged: employment/education, psychoeducation, creative occupations/activity, time https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 539 use/occupational balance, skills/habit development, group/family approaches and animal-assisted therapy. this was based on a review of 50 peerreviewed intervention studies targeting adults with mental illness(kirsh et al., 2019). d’amico and colleagues (2018) updated the evidence on this topic using a systematic review presenting evidence on the interventions and how they improve and maintain their performance and participation in adls, iadls, social participation, leisure, rest and sleep for people with smi. five themes in these areas were identified: occupation-based interventions, psychoeducation, skills training, cognitive-based interventions, and technology-supported interventions (spencer et al., 2017). according to the explanation above, there were no reviews focused on the theme referring to the outcomes of the occupational interventions on mental illness, especially regarding the level of functioning, well-being and quality of life. this is why the writer conducted this review in order to provide alternative references about what a suitable occupational intervention is for schizophrenia and other mental illness. materials and methods strategy for searching the databases searched included scopus, proquest, sage and pubmed. the publication period was over the last 10 years limited by journal source type. the figure 1 – article selection process search terms, truncated when relevant, were "schizophrenia" or "mental illness" and “work training” or “occupational therapy” or “vocational therapy.” study selection following the selection, 497 articles were obtained that met the inclusion criteria, that used the keywords above, journal source type, article type and the review specifications in which the subjects were medicine, psychology, nursing, and healthcare articles published in 2010-2020 as seen on (figure 1). the excluded articles that didn’t provide a full text totaled 164. after undergoing an abstract review, there were only 13 articles found to be suitable according to the variables needed. the independent variable was work therapy, occupational therapy, vocational therapy or a rehabilitation program. the dependent variables chosen were the level of functioning, wellbeing and the quality of life of the patients with schizophrenia or another mental illness. results general statistics of the studies referring to the 13 studies synthesized, most were conducted in the last 5 years and randomized control trials were the most common type of study conducted. general findings of the studies the 13 studies about occupational interventions were divided by writer into 6 categories, namely skills training, cognitive therapy-based occupational treatment, cognitive behavior therapy-based occupational therapy, psychosocial occupational therapy, creative-based therapy and a peer group support-based occupational intervention. the skills training-based occupational therapies were examined in 3 articles in which the interventions were balancing everyday life (bel), a grocery shopping program and an occupational goal intervention. the bel program has a strong focus on table 1. general characteristics of the selected studies (n=13) category n % year of publishing 2010 1 7.69% 2013 1 7.69% 2016 6 46.15% 2017 2 15.38% 2018 1 7.69% 2019 2 15.38% type of study rct 7 53.85% quasi experiment 4 30.77% cross-sectional 1 7.69% longitudinal 1 7.69% 167 articles obtained for abstract review 330 excluded that did not provide the full text, that were not in english or that were not a research article 13 studies after the full article review that met the inclusion criteria for a systematic review search of scopus, proquest, sage, and pubmed databases. search terms: "schizophrenia" or "mental illness" and “work training” or “occupational therapy” or “vocational therapy”. research found through the database search: scopus (164) and proquest (333) y. anggraini et al. 540 | pissn: 1858-3598  eissn: 2502-5791 accomplishing an activity balance for the participants. this is defined as having a satisfying amount of and a variation between activities. this is in addition to other aspects such as activity engagement and valued and satisfying activities. the bel group improved more than the cau group from the baseline after looking at the primary outcomes in terms of activity engagement, activity level, and activity balancing. the bel group also improved more in terms of symptom severity and the level of functioning from baseline (eklund, tjörnstrand, sandlund, & argentzell, 2017). a program based on the grocery-shopping process components(kim, park, kim, & park, 2019) aimed to improve the shopping skills of the patients with chronic schizophrenia living in communities. this intervention is a form of skill training occupational therapy. this program was in addition to the conventional rehabilitation programs which consisted of physical exercise, social skill training and social-adaptation training. the grocery shopping skill program was implemented in grocery shops in the local community for 50 minutes a session. after 8 sessions, the evaluation showed that the grocery shopping skill program in a real life situation could be useful for improving executive function and the instrumental activity related to the daily living of patients with schizophrenia. the ogi method has been shown to be reliable and effective for patients with treatment-resistant schizophrenia. in addition, the method appeared to improve their social and functional aspects. the study protocol of adjuvant occupational therapy was used to evaluate the effectiveness of an occupational intervention for depressed employees measured according to their level of work-participation and work-functioning including quality of life and neurocognitive functioning(vizzotto et al., 2016). psychosocial-based occupational therapies were included in 3 articles. two of them studied individualized occupational therapy and one used ot and psychosocial treatment. the iot program(shimada, nishi, yoshida, tanaka, & kobayashi, 2016) was aimed at facilitating a level of proactive participation in terms of the treatment and improving the patient’s functional outcomes. this consisted of a combination of effective psychosocial treatment programs: motivational interviewing, selfmonitoring, individualized visits, handicraft activities, individualized psychoeducation and discharge planning. the intervention was performed on hospitalized patients. the findings show that preliminary support for the feasibility of the iot and the efficacy of providing iot in addition to got improves the cognitive functioning and symptoms of patients with schizophrenia or schizoaffective disorder. patients who participated in the got+ iot demonstrated significant improvements in several areas of cognitive functioning, intrinsic motivation and social functioning. there were no statistically significant differences in the symptoms. in a multicenter randomized control trial, the patients who participated in the got+ iot demonstrated significant improvements in several areas of cognitive functioning, intrinsic motivation, and social functioning. there were no statistically significant differences in their symptoms(shimada, ohori, inagaki, & shimooka, 2018). occupational therapy in the form of a psychosocial intervention was conducted with mental illness groups. the results demonstrated significantly positive repercussions, specifically in the treatment of non-psychotic patients. both groups benefit from occupational activities as shown by the improvements in all of the psychiatric inpatients’ personal and social performance scores in comparison with the scores of the control group. psychosocial approaches can thus be said to enhance the personal and social performance in the patient group, thereby leading to additional clinical benefits. adjuvant occupational therapy conducted with the employees with depression was done in the form of cognitive-based occupational therapy. the study protocol showed that no results were reported in the study protocol. the results would have been used to evaluate the effectiveness of an occupational intervention among depressed employees measured by the level of work-participation and workfunctioning including quality of life and neurocognitive functioning(hees, koeter, vries, ooteman, & schene, 2010). the articles about ivip describe a cognitive behavior therapy-based occupational therapy. ivip (mervis et al., 2016) was more efficacious than sg when it came to improving work performance during the 4 month work therapy placements. this is associated with higher rates of participation at the time of the follow-up. ivip was also associated with a reduction in defeatist beliefs and an improvement in motivation for community employment. the sample as a whole, for their pre-post treatment changes in defeatist beliefs, correlated with pre-post treatment changes concerning social and occupational functioning. the creative activity-based ot shown in the articles (gunnarsson & bj, 2013)(gunnarsson, wagman, hedin, & håkansson, 2018) revealed that after 3 years in a follow-up study, the participants’ self-rating regarding their sense of coherence, occupational performance and satisfaction with their occupational performance showed significant positive changes after they had taken part in the ttm intervention. the participants’ ratings regarding psychological symptoms, self-mastery, activity level and the extent of satisfaction from their performed occupation were found to be stable even though there were no statistically significant positive changes. the peer ot can be seen on the article on the occupational therapy workshop, community support centers, job buddies training program and the otw and vocational development center (vdc) (bro, saw, row, & ja, 2017)(kei et al., 2016)(cic, aleksandra, & piotr, 2019). occupational therapy is performed based on expanded environmental support models (bro et al., 2017). these include the activities within jurnal ners http://e-journal.unair.ac.id/jners | 541 day structure modeling, social network compensation, social ability training, individual and group psychological support and help in the course of engaging with employment that were observed in the occupational therapy workshops (otw) and community-based support center (csc). the otw users had more numerous social networks that were statistically significant in the following categories: “cohabitants,” “service acquaintances” and “other acquaintances.” the level of obtained support in general shows there to be no differences between the groups on a statistically significant basis. the otw users obtained more support functions from outside the service. there were no significant differences between the scales of interpersonal behaviors/relations, pro-social activities and employment/occupation. in both scales, the otw users obtained higher scores than the csc users. there were no significant differences between the means for the scales of social engagement, recreation, independent performance and independent competence. discussion there are 6 categories presented concerning occupational therapy that involves positive outcomes for the functional level, well-being and quality of life of the patients with schizophrenia or another mental illness. these categories include skills training, cognitive therapy-based occupational treatment, cognitive behavior therapy-based occupational therapy, psychosocial occupational therapy, creativebased ot and peer group support-based occupational intervention. the results described in the articles show that occupational therapy in the experimental and cross-sectional designs have improved the patient’s level of functioning, well-being and quality of life. there is also some support to suggest that other ot interventions in the form of psychosocial approaches may provide more significant benefits than traditional ot. research into creative occupations and activity-based interventions shows good results. ot interventions that facilitate skills, habits, and motivation can significantly impact on the patient’s level of functioning. conclusion this review of occupational therapy is based on 13 original articles published in variety of journals in the areas of medicine, psychology, nursing, and healthcare. most of the articles were published in the last 5 years, leading to the conclusion that there is an increasing momentum to evaluate and report on occupational therapy concerning the level of functioning, well-being and quality of life. contrarily, very limited occupational intervention articles have been found in the last 10 years. only a few matched the criteria, showing that the research into occupational therapy has decreased in quantity. six categories of occupational therapy within the 13 articles reviewed have a positive effect on the level of patient functioning, well-being and quality of life. references bro, p., saw, m., row, m., & ja, m. (2017). social networks and social functioning level among occupational therapy workshops and community-based support centers users. 51(1), 139–152. cic, ł., aleksandra, a., & piotr, b. (2019). differences in subjective quality of life of people with a schizophrenia diagnosis between participants in occupational therapy workshops and those working in a sheltered employment establishment. 53(1), 81–92. eklund, m., tjörnstrand, c., sandlund, m., & argentzell, e. (2017). effectiveness of balancing everyday life (bel) versus standard occupational therapy for activity engagement and functioning among people with mental illness a cluster rct study. bmc psychiatry, 17(1), 1–12. https://doi.org/10.1186/s12888017-1524-7 emsley, r., chiliza, b., asmal, l., & lehloenya, k. (2011). the concepts of remission and recovery in schizophrenia. https://doi.org/10.1097/yco.0b013e3283436e a3 gunnarsson, a. b., & bj, a. (2013). sustainable enhancement in clients who perceive the tree theme method ® as a positive intervention in psychosocial occupational therapy. 154–160. https://doi.org/10.1111/1440-1630.12034 gunnarsson, a. b., wagman, p., hedin, k., & håkansson, c. (2018). treatment of depression and / or anxiety – outcomes of a randomised controlled trial of the tree theme method ® versus regular occupational therapy. 1–10. hees, h. l., koeter, m. w. j., vries, g. de, ooteman, w., & schene, a. h. (2010). effectiveness of adjuvant occupational therapy in employees with depression : design of a randomized controlled trial. kei, k., yam, n., tak, w., lo, l., lai, r., chiu, p., … man, s. (2016). asian pearls a pilot training program for people in recovery of mental illness as vocational peer support workers in hong kong – job buddies training program ( jbtp ): a preliminary fi nding. asian journal of psychiatry. https://doi.org/10.1016/j.ajp.2016.10.002 kim, y., park, j., kim, y., & park, j. (2019). l p re of. asian journal of psychiatry, 101896. https://doi.org/10.1016/j.ajp.2019.101896 kirsh, b., martin, l., hultqvist, j., eklund, m., kirsh, b., martin, l., … occupational, m. e. (2019). occupational therapy in mental health occupational therapy interventions in mental health : a literature review in search of evidence occupational therapy interventions in mental health : a literature review in search of y. anggraini et al. 542 | pissn: 1858-3598  eissn: 2502-5791 evidence. occupational therapy in mental health, 0(0), 1–48. https://doi.org/10.1080/0164212x.2019.15888 32 mervis, j. e., fiszdon, j. m., lysaker, p. h., nienow, t. m., mathews, l., wardwell, p., … choi, j. (2016). effects of the indianapolis vocational intervention program ( ivip ) on defeatist beliefs , work motivation , and work outcomes in serious mental illness. schizophrenia research. https://doi.org/10.1016/j.schres.2016.10.036 shimada, t., nishi, a., yoshida, t., tanaka, s., & kobayashi, m. (2016). development of an individualized occupational therapy programme and its effects on the neurocognition , symptoms and social functioning of patients with schizophrenia. 425–435. https://doi.org/10.1002/oti.1445 shimada, t., ohori, m., inagaki, y., & shimooka, y. (2018). a multicenter , randomized controlled trial of individualized occupational therapy for patients with schizophrenia in japan. 1–18. spencer, b., sherman, l., nielsen, s., thormodson, k., spencer, b., sherman, l., … thormodson, k. (2017). effectiveness of occupational therapy interventions for students with mental illness transitioning to higher education : a systematic review. occupational therapy in mental health, 0(0), 1–14. https://doi.org/10.1080/0164212x.2017.13805 59 vizzotto, a. d. b., celestino, d. l., buchain, p. c., oliveira, a. m., oliveira, g. m. r., di sarno, e. s., … elkis, h. (2016). a pilot randomized controlled trial of the occupational goal intervention method for the improvement of executive functioning in patients with treatment-resistant schizophrenia. psychiatry research, 245, 148– 156. https://doi.org/10.1016/j.psychres.2016.05.011 jurnal ners http://e-journal.unair.ac.id/jners | 543 appendix table 2. summary of the studies author design sample variables results (eklund et al., 2017) rct 133 participants in the bel group and 93 in the cau group with a broad spectrum of disorders such as psychoses, mood disorders and neuropsychiatric disorders. independent variable: 16 weeks bel (balancing everyday life). dependent variables: subjectively evaluated everyday activities in terms of engagement, satisfaction, balance, and activity level. this is in addition to well-being and functioning. the bel group improved more than the cau group from the baseline in terms of the primary outcomes f activity engagement, activity level and activity balancing. the bel group also improved more in relation to symptom severity and the level of functioning from the baseline. (kim et al., 2019) nonequivalent control group with a pretestposttest design 20 participants with schizophrenia independent variable: grocery shopping skill program. dependent variable: executive function and the instrumental activities of daily living. the grocery shopping skill program in a real life situation could be useful at improving executive function and the instrumental activity of daily living among patients with schizophrenia. (bro et al., 2017) crosssectional 119 participants with schizophrenia at a community based support centre (csc) and 79 participants with schizophrenia engaged in an occupational therapy workshop (otw). independent variables: communitybased support centre and occupational therapy workshop. dependent variables: network and social support, social functioning. otw users have statistically significantly social networks in the following categories: “cohabitants,” “service acquaintances” and “other acquaintances.” the level of obtained support in general shows there to be no differences between the groups on a statistically significant basis. the otw users obtained more support functions from outside the service. there were no significant differences between the scales of interpersonal behaviors/relations, pro social activities, and employment/occupation. in both scales, the otw users obtained higher scores than the csc users. there were no significant differences between the means of the scales: social engagement, recreation, independent y. anggraini et al. 544 | pissn: 1858-3598  eissn: 2502-5791 author design sample variables results performance and independent competence. (shimada et al., 2016) quasiexperimental control trial 30 participants with schizophrenia or schizoaffective disorder in group occupational therapy (got) and individualized occupational therapy (iot). 21 participants engaging in got only. independent variables: got + iot. dependent variables: neurocognition, symptoms and social functioning. the present study provides preliminary support for the feasibility of the iot and the efficacy of providing iot in addition to got to improve the cognitive functioning and symptoms of patients with schizophrenia or schizoaffective disorder. (vizzotto et al., 2016) pilot randomized control trial 16 patients with schizophrenia doing the occupational goal intervention (ogi). 14 patients with schizophrenia engaging in craft activities. independent variable: ogi. dependent variable: executive functioning. the ogi method has been shown to be reliable and effective for patients with treatment-resistant schizophrenia. in addition, the method appeared to improve their social and functional aspects. (calmak, sut, ozturk, tamam, & bal 2016) quasiexperimental 48 patients with mental illness in the study group. 43 patients with mental illness in the control group. independent variables: occupational therapy and a psychosocial intervention. dependent variable: interpersonal functioning and social performance levels. the results demonstrated significantly positive repercussions, specifically in relation to the treatment of non-psychotic patients. both groups benefited from occupational activities as shown by the improvements in all of the psychiatric inpatients’ personal and social performance scores in comparison with the scores of the control groups. the psychosocial approaches enhanced the personal and social performance in the patient group, leading to additional clinical benefits. (mervis et al., 2016) rct 29 participants with schizophrenia and schizoaffective disorder (ivip). 35 participants with schizophrenia and schizoaffective disorder in a support group (sg). independent variable: indianapolis vocational intervention program (ivip). dependent variables: primary variable: defeatist beliefs, motivation and ivip was more efficacious than sg at improving work performance during the 4-month work therapy placements. it was associated with higher rates of participation at the time of the follow-up. the ivip was also associated with a reduction in defeatist beliefs and an improvement in the motivation for community employment. the sample as a whole, in terms of their pre-post treatment changes in relation to defeatist beliefs, jurnal ners http://e-journal.unair.ac.id/jners | 545 author design sample variables results supported employment. secondary variables: symptoms of schizophrenia, quality of their social and occupational functioning, value of the work, productivity and work-related behavior. correlated with pre-post treatment changes in social and occupational functioning. (shimada et al., 2018) rct 66 patients with schizophrenia in the got and iot group. 63 patients in the got alone group aged 22-65 years. independent variable: individualized occupational therapy (iot). dependent variable: cognitive functioning, social functioning, intrinsic motivation and symptoms. the patients who participated in the got+ iot demonstrated significant improvements in several areas of cognitive functioning, intrinsic motivation and social functioning. there were no statistically significant differences in the symptoms. (kei et al., 2016) quasiexperiment 6 participants with mental illness independent variable: job buddies training program. dependent variable: mental health recovery from a customer perspective, perceived stigma and self stigma, occupational competence and problem-solving skills. there was an increase in the perceived level of their own recovery progress (overcoming stuckness, self-empowerment, learning and self-redefinition, basic functioning, overall well-being, new potentials, advocacy/enrichment, and spirituality), more confidence in their mastery over their job and decreased self-stigma. (hees et al., 2010) rct study protocol 117 participants who were employees with depression independent variable: care as usual with the addition of occupational therapy. dependent variable: the primary outcome was work participation and the time until no results were reported in this study protocol. this was used to evaluate the effectiveness of the occupational intervention on depressed employees which was measured by the level of workparticipation and work-functioning including quality of life, and neurocognitive functioning. y. anggraini et al. 546 | pissn: 1858-3598  eissn: 2502-5791 author design sample variables results work resumption. the secondary outcomes were work functioning, symptomatology, health-related quality of life, and neurocognitive functioning (gunnarsson & bj, 2013) longitudinal quantitative design 35 clients with affective syndromes, anxiety/obsession syndromes, eating disorders or personality disorders independent variables: tree theme method. dependent variables: perceived wellbeing, perceived everyday occupation. after 3 years follow-up, the study showed that the participants’ selfrating regarding their sense of coherence, occupational performance and satisfaction with their occupational performance showed significant positive changes 3 years after they had taken part in the ttm intervention. the participants’ ratings regarding psychological symptoms, self mastery, activity level and the extent of satisfaction from their performed occupations were found to be stable, even though there were no statistically significant positive changes. (gunnarsson et al., 2018) rct 118 people with depression and/or anxiety independent variable; ttm— five sessions with painting ot as usual. follow-ups at three and 12 months. dependent variables; primary and secondary healthrelated aspects involved a sense of coherence, the experience of control, quality of life, therapeutic alliance and patient satisfaction. no significant differences between the groups for the primary outcomes of activities in everyday life and psychological symptoms were identified in the follow-up. both groups reported significantly higher ratings for all outcomes, except for the satisfaction with activities in everyday life. this did not show significant changes in the ttm intervention group. for the secondary outcomes, i.e. various health-related and interventionrelated aspects, no differences between the groups were found. however, the analysis showed positive significant outcomes in both groups except for the experience of control. (cic et al., 2019) crosssectional 57 participants with schizophrenia independent variable: vocational rehabilitation at an occupational therapy accepting and retaining work in a vocational development center by a schizophrenia sufferer translates into better outcomes in the significant domains related to quality of life: family relationships, jurnal ners http://e-journal.unair.ac.id/jners | 547 author design sample variables results workshop (otw) and a vocational development center (vdc). dependent variables: quality of life, general functioning, social and vocational functioning. overall health and sense of selfworth 203 rational-emotive behavior therapy terhadap penurunan stres ibu dengan anak leukemia (the application of rational-emotive behavior therapy to reduce stress among mother with leukemia children) yuni sufyanti arief*, ilya krisnana* *fakultas keperawatan universitas airlangga, kampus c jl. mulyorejo surabaya e-mail: yuni_sa@fkp.unair.ac.id abstrak pendahuluan: seorang anak yang terdiagnosis leukemia akan menjalani beberapa prosedur tindakan yang lama dan menyakitkan. selama proses hospitalisasi akibat leukemia anak dan orang tua dapat mengalami berbagai kejadian atau tindakan penanganan yang menurut berbagai penelitian ditunjukkan dengan pengalaman yang sangat traumatik dan penuh dengan stress (supartini, 2004 dalam arif, s.y., 2007). beberapa metode yang digunakan menghadapi kecemasan adalah psikoprofilaksis, relaksasi dan imajinasi (reeder dkk., 2011). terapi rational-emotive behaviour oleh albert ellis tahun 1990 menjelaskan manusia pada dasarnya adalah unik yang memiliki kecenderungan untuk berpikir rasional dan irasional. metode: tujuan penelitian ini adalah menjelaskan efek rational emotive behavior therapy (rebt) terhadap tingkat stres ibu dengan anak menderita leukemia. desain penelitian yang digunakan adalah quasy-experiment pre-post control group design. sampel penelitian ini adalah 10 orang ibu dari anak yang terdiagnosis leukemia yang dirawat di ruang hematologi anak bona 2 rsud dr. soetomo surabaya. variabel dalam penelitian ini adalah tingkat depresi dan kecemasan ibu dengan anak menderita leukemia. hasil: berdasarkan uji statistik wilcoxon didapatkan p = 0,025 pada kelompok perlakuan dan p = 0,32 pada kelompok kontrol. hasil uji mann whitney didapatkan p = 0,012. hal ini menunjukkan bahwa terapi rationalemotive behaviour dapat menurunkan tingkat depresi dan kecemasan (stres) ibu dengan anak menderita leukemia. diskusi: diharapkan penerapan terapi rational-emotive behaviour dapat dilakukan untuk menurunkan depresi dan kecemasan ibu dengan pada kasus penyakit kronis dengan tetap mempertahankan keefektifan daripada tujuan rebt. kata kunci: stres, kecemasan, depresi, rational-emotive behaviour. abstract introduction: a child who is diagnosed with leukemia will undergo several procedures are long and painful action. during the process of hospitalization due to leukemia children and parents can experience a variety of events or actions handling according to various studies shown by the experience very traumatic and stressful (supartini 2004 in arif, sy, 2007). some of the methods used to deal with anxiety is psikoprofilaksis, relaxation and imagination (reeder et al., 2011). rational-emotive behavior therapy by albert ellis in 1990 describes a unique man who is basically have a tendency to think rational and irrational. methods: aim of this study is to explain the effect of rational emotive behavior therapy (rebt) for stress levels of mothers with children suffering from leukemia. the study design used was a pre-experiment quasy-post control group design. the sample was 10 mothers of children diagnosed with leukemia are treated in a child hematology ward soetomo hospital. variable in this study is the level of depression and anxiety mothers with children suffering from leukemia. result: based on the results obtained wilcoxon statistical test p = 0.025 in the treatment group and p = 0.32 in the control group. mann whitney test results obtained p = 0.012. conclution: rational-emotive behavior therapy can reduce levels of depression and anxiety (stress) mothers with children suffering from leukemia. it is expected that the application of rational -emotive behavior therapy can be done to reduce depression and anxiety in women with chronic disease cases while maintaining the effectiveness the goal of rebt. keywords: stress, anxiety, depression, rational-emotive behavior pendahuluan leukemia adalah suatu keganasan organ pembuat darah sehingga sumsum tulang didominasi oleh klon maligna limfositik dan terjadi penyebaran sel-sel ganas tersebut ke darah dan semua organ tubuh (permono, b., dkk., 2006). leukemia menempati 40% dari semua keganasan pada anak (permono, b., dkk., 2006). seorang anak yang terdiagnosis leukemia akan menjalani beberapa prosedur tindakan yang lama dan menyakitkan. selama proses hospitalisasi akibat leukemia anak dan orang tua dapat mengalami berbagai kejadian atau tindakan penanganan yang menurut berbagai penelitian dit unjuk kan dengan pengalaman yang sangat traumatik dan penuh dengan stress (supartini, 2004 dalam arif, s.y., 2007). permasalahan psikologis yang 204 jurnal ners vol. 9 no. 2 oktober 2014: 203–208 dialami oleh anak yaitu shock, stres, ketakutan, marah dan depresi (simon, h., 2005). anak yang mengalami stres selama dalam masa perawatan, dapat membuat orang tua menjadi stres dan stres orang tua akan membuat tingkat stres anak semakin meningkat (supartini, 2004). hasil penelitian menunjukkan orangtua pada anak leukemia mengalami depresi 85,6% dengan tingkatan sedang ke berat (rao, et al., 1992), gejala stress paska trauma mulai dari 12–80% (yalug, i., et al., 2011) dan 51% orang tua mengalami kecemasan tinggi pada 6–18 bulan post diagnosis leukemia (sloper, 2000 dalam hus, m.a., 2009). beberapa metode yang digunakan menghadapi kecemasan adalah psi koprof ilaksis, relaksasi, dan imajinasi (reeder dkk., 2011). terapi rationalemotive behaviour oleh albert ellis tahun 1990 menjelaskan manusia pada dasarnya adalah unik yang memiliki kecenderungan untuk berpikir rasional dan irasional. terapi ini menekankan bahwa manusia berpikir, beremosi, dan bertindak secara stimultan yaitu ketika mereka berpikir, mereka juga beremosi dan bertindak (hariadi, 2008). namun, sampai saat ini pengaruh terapi rational-emotive behaviour terhadap penurunan kecemasan ibu dengan anak menderita leukemia belum dapat dijelaskan. angka kejadian leukemia pada anak semakin meningkat. data dari rsud dr. soetomo pada tahun 2003–2005 terdapat 237 penderita baru leukemia (ratwita, m., dkk., 2006). berdasarkan sumber data dari yayasan onkologi anak indonesia tahun 2012 angka kejadian kanker di dunia pada anak umumnya adalah 140 penderita baru per satu juta per tahun anak di bawah umur 18 tahun. sedangkan di seluruh indonesia, dengan jumlah penduduk 220 juta jiwa diperkirakan terdapat kurang lebih 11.000 kasus baru per tahun. penyakit akut limfoblastik leukemia (all) di rsud dr. soetomo menempati urutan pertama dari penyakit neoplasma pada anak, yaitu sejumlah 209 pasien anak menderita leukemia pada tahun 2011. berdasarkan survey di ruang perawatan hematologi anak rsud dr. soetomo surabaya menunjukkan bahwa 80% anak mengalami stres hospitalisasi yaitu menangis dan berusaha menarik tangan saat dilakukan injeksi. oleh karena anak menangis orang tua menjadi cemas dan berusaha mengatakan kepada perawat untuk melakukan tindakan secara pelan. berdasar wawancara kepada orang tua, 100% orang tua mengatakan sedih, cemas dan bingung dengan kondisi anak. orang tua juga mengatakan belum paham sepenuhnya tentang leukemia dan penyebabnya. distres psikologis pada orang tua sangat terkait dengan timbulnya stress pada anak (robinson, et al., 2007 dalam hus, m.a., 2009). gejala distres pada anak merupakan keadaan yang wajar akibat tindakan pengobatan dan penatalaksanaan di r umah sakit (kazak, simms & rourke, 2002; mulhern, fairclough, smith, & douglas, 1992 dalam kazak, e.a., 2005). orang tua menunjukkan gejala stres yang sama dengan anak akibat hospitalisasi (hoekst ra-weebers, jaspers, kamps, & klip, 2001 dalam kazak, e.a., 2005). saat stres akan terjadi peningkatan kortisol yang dapat menghambat pembentukan antibodi dan menurunkan pembentukan sel darah putih (niven, 2002). penurunan antibodi akan menurunkan imunitas tubuh. jika stres dibiarkan maka akan berakibat pada anak yaitu proses penyembuhan penyakit menjadi terhambat, waktu perawatan lebih lama dan meningkatkan risiko terjadinya komplikasi selama perawatan (nursalam & susilaningrum, 2005). sedangkan stres pada orang tua dapat menurunkan imunitas, sehingga risiko terkena penyakit sangat mudah (subowo, 1992 dalam nursalam & susilaningrum, 2005). terapi rational-emotive behaviour adalah aliran yang berlandaskan asumsi bahwa manusia dilahirkan dengan potensi berpikir rasional dan jujur maupun berpikir irasional. sebagian besar reaksi emosional seseorang disebabkan oleh evaluasi dan interpretasi yang disadari maupun tidak disadari oleh individu. hambatan emosional adalah akibat dari cara berpikir yang tidak logis dan penuh prasangka (reeder dkk., 2011). fokus terapi rational-emotive behaviour yaitu pikiran irasional mendorong ke arah emosi negatif yang tidak sehat diganti dengan pikiran-pikiran alternatif yang rasional (elizabeth, 2008). terapis menerapkan model abcde dengan memberikan pikiran rasional 205 rational-emotive behavior therapy (yuni sufyanti arief dan ilya krisnana) (disputing) sehingga menghasilkan efek baru yang sesuai (effect) (wayne, 2005). terapi rational-emotive behaviour diharapkan dapat menurunkan kecemasan ibu dengan anak menderita leukemia. metode rancangan penelitian yang digunakan a d a l a h r a nc a ng a n p e n el it i a n q u a s y experiment. sampel dalam penelitian ini adalah ibu dari anak yang terdiagnosis leukemia yang dirawat di ruang hematologi anak bona 2 rsud dr. soetomo surabaya dengan kriteria inklusi ibu meliputi: 1) ibu kandung dari anak; dan 2) dapat membaca dan menulis. sedangkan kriteria inklusi anak meliputi: 1) anak terdiagnosis leukemia usia toddler dan prasekolah; 2) mrs pertama kali di ruang bona 2; dan 3) tidak dalam kondisi kritis. sampel dipilih dengan teknik purposive sampling yang dibagi menjadi kelompok kontrol dan kelompok perlakuan. alat pengumpul data penelitian menggunakan instrumen kuesioner untuk mengukur derajat kecemasan dengan menggunakan alat ukur dari depression anxiety and stress scale 42 yang telah dimodifikasi oleh peneliti. prosedur pengumpulan data dengan memilih calon responden yang sesuai dengan kriteria sampel. pada minggu ke-1, peneliti mencari responden dengan mengacu pada kriteria in klusi di ruang bona lantai 2 rsds surabaya. responden diberi informed consent sebagai persetujuan menjadi sampel penelitian dan diberi pre-test menggunakan kuesioner depresi dan kecemasan berdasarkan dass 42 dengan didampingi peneliti, sehingga diperoleh skor awal sebelum inter vensi. hasil skor pada pre-test tersebut dijadikan sebagai data awal dan matching sampel untuk menentukan kelompok sampel. pada minggu ke-2, kelompok kontrol hanya diberi leaf let mengenai konsep penyakit leukemia di rsds surabaya. kelompok perlakuan diberikan terapi rational-emotive behaviour selama 12 sesi dalam 3 minggu secara kontinyu dengan durasi tiap pertemuan ± 30 menit, dilakukan secara personal. 1 sesi terdiri dari 5 tahap. 1 minggu dilakukan 4 sesi dalam 4 hari berturutturut dengan 1 sesi/ hari. sesi berikutnya dilakukan setelah jeda istirahat 3 hari dan berakhir pada sesi ke-12. peneliti membuat kontrak waktu pertemuan dengan ibu dengan anak menderita leukemia yaitu 1 hari sebelum dilaksanakan terapi. terapi yang diberikan dalam 3 minggu, mengacu pada keyakinan irasional yang masih dialami ibu berhubungan dengan kecemasan melakukan perawatan pada anak yang menderita leukemia hingga ibu mengadopsi gaya baru dalam berpikir dengan menggunakan filosofi rebt yaitu keyakinan irasional diubah menjadi keyakinan rasional mengenai perawatan anak dengan leukemia. pada minggu ke-5, peneliti memberikan posttest kepada kelompok perlakuan dan kelompok kontrol untuk mengetahui hasil akhir dari terapi rational-emotive behaviour. post-test diberikan dengan menggunakan instrumen yang sama pada pre-test sehingga dapat diketahui progresivitas dari intervensi yang diberikan. data yang dikumpulkan, dianalisis secara sistematik dan dengan menggunakan uji statistik wilcoxon signed rank test. selain itu digunakan pula uji statistik mann whitney test. hasil usia r e s p onde n p a d a kelomp ok perlak uan ber usia 26 –35 tahu n, hanya 1 responden (20%) yang ber usia 20 –25, sedangkan responden pada kelompok kontrol sebagian besar berusia 20–25 tahun. tingkat pendidikan menunjukkan, 3 responden pada kelompok perlakuan (60%) memiliki tingkat pendidikan smp, 2 responden (40%) memiliki pendidikan sma sedangkan responden pada kelompok kontrol sebagian besar memiliki pendidi kan sm a (60%). kara k ter isti k peker ja a n responden, menu nju k ka n, 4 responden pada kelompok perlakuan (80%) sebagai ibu rumah tangga, 1 responden (20%) memiliki pekerjaan wiraswasta sedangkan responden pada kelompok kontrol sebagian besar sebagai ibu rumah tangga (60%), dan yang lainnya mempunyai pekerjaan wiraswasta (20%) dan pns (20%). tabel 1 menunjukkan bahwa sebanyak 4 orang responden (80%) mengalami stres ringan 206 jurnal ners vol. 9 no. 2 oktober 2014: 203–208 dan 1 orang responden (20%) mengalami stres sedang sebelum diberikan terapi reb. setelah diberikan terapi didapatkan sebanyak 4 orang responden memiliki skor stres normal dan 1 orang responden (20%) memiliki skor stres ringan. hal ini menunjukkan bahwa rebt dapat menurunkan stres hospitalisasi pada orang tua yang anaknya dirawat di rs. sedangkan untuk responden kelompok kontrol didapatkan hasil adalah sebagai berikut sebanyak 3 responden (60%) mengalami stres sedang, sisanya (40%) mengalami stres ringan. berdasarkan test kolmogorov smirnov didapatkan data p = 0,759 untuk kelompok perlakuan dan p = 0,903 untuk kelompok kontrol, hal ini berarti bahwa distribusi data pre test pada kedua kelompok adalah normal. dari uji statistik wilcoxon sign rank test pada kelompok perlakuan didapatkan nilai signifikansi (p) = 0,025, sehingga (α) < 0,05 berarti h0 ditolak h1 diterima. ada pengaruh pemberian rebt terhadap penurunan tingkat stres hospitalisasi orang tua yang anaknya dirawat di rumah sakit. sedangkan untuk responden kelompok kontrol didapatkan nilai signifikansi (p) = 0,32. berdasarkan uji statistik mann whitney didapatkan nilai signifikansi (p) = 0,012, sehingga (α) < 0,05 berarti h0 ditolak h1 diterima. ada perbedaan tingkat depresi dan kecemasan orang tua dengan anak leukemia yang diberikan rebt dan tidak. pembahasan berdasarkan tabel 1 menunjuk kan bahwa ada pengar uh pember ian r ebt terhadap penurunan tingkat stres hospitalisasi orang tua yang anaknya dirawat di rs. hal ini dapat dilihat dari skor stres responden sebelum dan sesudah diber ikan terapi. sebelum diberikan terapi sebagian besar responden memiliki skor stres ringan yaitu sebanyak 4 responden (80%) dan hanya ada 1 responden (20%) yang memiliki skor stres sedang. setelah diberikan rebt tingkat stres responden 100% mengalami penurunan. sebanyak 4 responden (80%) tidak mengalami stres (skor stres normal) dan hanya ada 1 responden (20%) yang mengalami stres ringan. hal ini sesuai dengan teori yang d ip a p a r k a n ole h c or e y (20 07 ) ya ng menjelaskan bahwa salah satu tujuan rebt adalah menghilangkan gangguan-gangguan emosional yang merusak diri seperti rasa takut, rasa bersalah, rasa berdosa, rasa cemas, merasa was-was, dan rasa marah, di mana gangguan emosional tersebut digolongkan dalam kategori stres. dari 28 orang yang dilakukan skrining stres dengan menggunakan dass-21 hanya ditemukan 10 orang yang mengalami stres. sedangkan skor stres yang didapatkan adalah stres ringan dan sedang saja, tidak ada yang menunjukkan stres berat maupun sangat berat. hal ini dipengaruhi oleh adanya beberapa faktor yaitu: 1) adanya peer group support dalam ruangan hematologi, sehingga orang tua dapat beradaptasi dengan kondisi yang dihadapi saat itu; 2) stres yang dialami orang tua tergantung pada kondisi anak saat dilakukan skrening stres (saat orang tua mengisi kuesioner stres). pada saat kondisi anak membaik atau stabil, stres orang tua berkurang tabel 1. tingkat stres responden ruang hematologi bona ii rsud dr. soetomo surabaya klasifikasi stres perlakuan kontrol pre post pre post jumlah % jumlah % jumlah % jumlah % normal 0 0 4 80 0 0 0 0 ringan 4 80 1 20 2 40 3 60 sedang 1 20 0 0 3 60 2 40 total 5 100 5 100 5 100 5 100 kolmogorov smirnov p=0,759 p=0,903 wilcoxon p = 0.025 p =0.32 mann whitney p = 0.012 207 rational-emotive behavior therapy (yuni sufyanti arief dan ilya krisnana) atau bahkan tidak muncul (normal), sedangkan ketika kondisi anak memburuk, stres orang tua dapat terlihat atau meningkat. hal ini sesuai dengan pernyataan nursalam, dkk (2005) yang menjelaskan bahwa ketidakpercayaan dan rasa penolakan orang tua terjadi apabila anaknya sakit. apalagi kalau dirasa anaknya yang sakit terjadi secara tiba-tiba. setelah diberikan rebt selama ratarata 5 kali tatap muka, responden mengalami per ubahan pemikiran yait u pemikiranpem i k i r a n i r a sion al be r uba h me nja d i pemikiran yang rasional. selain itu, responden lebih bisa mener ima berbagai prog ram pengobatan dan tindakan selama di rs. hal ini sesuai dengan konsep dasar rebt yang dijelaskan oleh wayne (2005) bahwa terapi rebt merupakan terapi yang diterapkan pada perilaku manusia secara komprehensif. terapi ini menjelaskan penyebab masalah berdasarkan biopsychosocial yaitu kombinasi biologi, psikologi, dan sosial yang digunakan dalam perasaan dan perilaku manusia. sedangkan corey (2007) menjelaskan bahwa tujuan utama rebt antara lain adalah memperbaiki dan mengubah sikap, persepsi, cara berpikir, keyakinan serta pandangan-pandangan klien yang irasional dan tidak logis menjadi rasional dan logis agar klien dapat mengembangkan diri, meningkatkan self actualization seoptimal mungkin melalui perilaku kognitif dan afektif yang positif. rebt memberikan pengaruh terhadap pemikiran irasional seseorang melalui biopsychosocial agar berubah menjadi pemikiran yang rasional. pada pelaksanaan terapi tahap activating event semua responden (100%) menyatakan dirinya mengalami stres karena memikirkan kondisi anak yang dipengaruhi oleh berbagai faktor penyebab internal maupun eksternal seperti ketidakpercayaan akan penyakit anak, bingung memikirkan dari mana penyakit itu didapatkan (terutama penyakit kanker) sedangkan keluarga maupun sanak saudara tidak ada yang memiliki penyakit serupa, serta tidak mendapatkan dukungan dari suami maupun keluarga. pada tahap beliefs about event sebagian besar responden menyatakan bahwa penyakit yang diderita anaknya merupakan ujian dari tuhan yme dan sebagian besar mereka percaya anaknya dapat disembuhkan. pikiran irasional yang dialami responden seperti keinginan agar anaknya segera dioperasi, tidak bersemangat untuk menjalani perawatan anak, dan tidak bisa yakin sepenuhnya kalau anaknya dapat disembuhkan. sedangkan pada tahap consequent sebagian besar responden (80%) memiliki pemikiran yang irasional yaitu berkeinginan yang tidak sesuai dengan prosedur pengobatan seperti meminta agar anaknya segera dioperasi sedangkan kondisi anak tidak memungkinkan untuk dioperasi dan tidak bersemangat untuk melanjutkan perawatan anak di rs. p a d a t a h a p d i s p u t i n g t e r a p i s mengarahkan klien pada hal-hal yang rasional, menjelaskan efek positif serta menanamkan pemikiran rasional tersebut. pada tahap new effect didapatkan responden mau menerima dan berjanji untuk menerapkan pemikiranpemikiran rasional baru yang sudah diberikan oleh terapis sebelumnya. hal ini sesuai dengan penjelasan elizabeth (2008) bahwa fokus terapi rationalemotive behaviour yaitu pikiran irasional yang mendorong ke arah emosi negatif yang tidak sehat diganti dengan pikiran-pikiran alternatif yang rasional. hasil evaluasi rebt menunjukkan, semua responden memiliki pemikiran baru yang rasional, sehingga hal ini berpengaruh pada skor stres responden. hasil skoring stres pada saat evaluasi akhir dengan menggunakan kuosioner dass 21, didapatkan 4 responden (80%) tidak mengalami stres (skor stres normal) dan 1 responden (20%) mengalami stres ringan. dengan demikian program inovasi rebt memiliki pengaruh terhadap pemikiran irasional yang berdampak pada penurunan stres hospitalisasi pada orang tua yang anaknya dirawat di rs dengan penyakit hemato-onkologi. simpulan dan saran simpulan pemberian rebt dapat menurunkan tingkat stres orang tua yang memiliki anak yang dirawat di rs. tingkat depresi stres orang tua yang memiliki anak yang dirawat di 208 jurnal ners vol. 9 no. 2 oktober 2014: 203–208 rs yang mendapat rebt dan tidak mendapat perlakuan menunjukkan adanya perbedaan penurunan. saran kepada perawat yang bertugas di ruang anak dapat menerapkan rebt pada orang tua pasien. kegiatan rebt dapat dilakukan pada kasus penyakit kronis yang lainnya dengan tetap mempertahankan keefektifan daripada tujuan rebt yaitu dilakukan di samping bed pasien. hal ini dilakukan karena keterbatasan sumber daya manusia yang ada. untuk penelitian selanjutnya pengaruh rebt dikembangkan dengan menggunakan variabelvariabel penelitian yang lainnya seper ti variabel stres hospitalisasi pada anak yang orang tuanya diberikan terapi tersebut. kepustakaan arif, s.y. 2007. efektivitas penurunan stres hospitalisasi anak dengan terapi bermain dan terapi musik. jurnal ners, 2(2), hal. 72–78. arikunto, 2007. prosedur penelitian suatu pendekatan praktik. jakarta: rineka cipta. brooks. 2011. rational emotive behaviour therapy (rebt). (online), (http://www. palmbeachstate.edu. diakses tanggal 10 april 2012) dharma, k.k. 2011. metodologi penelitian keperawatan. jakarta: cv. trans info media. damanik, e. d. 2010. pengujian validitas dan reliabilitas analisis item dan pembuat norma dass: penelitian pada kelompok sampel yogyakarta dan bantul yang mengalami gempa bumi 2010. (online), (http://www.digilib.ui.ac.id/ opac/themes/libri2/detail.jsp?id=94859. diakses tanggal 21 februari 2012) dryden, windy & michael neenan. 2004. the rational emotive behaviour therapy. california: sage publication. (online) (http://www.scribd.com. diakses tanggal 27 desember 2011) froggatt, wayne. 2005. a brief introduction to rational emotive behaviour therapy. edisi 3. new zealand: stortford lodge. (online), (http://www.rational.org.nz. diakses tanggal 27 desember 2011) hus, m.a. 2009. parents and children coping with pediatric cancer: associations between parent and child anxiety, and parent-child communication. thesis, na shv i l le te n ne sse e: va nde rbi lt university. k a z a k , e . a . 2 0 0 5. ev i d e n c e b a s e d interventions for survivors of childhood cancer and their families. journal of pediatric psychology, 30 (1), (online) ( ht t p://jp e p s y.ox for djou r n a l s.org. diakses tanggal, 8 desember 2011) lovibond, s.h. & lovibond, p.f. 1995. manual for the depression an xiet y stress scales. (2nd ed.). sydney: psychology foundation. nursalam, rekha & utami. 2005. asuhan keperawatan bayi dan anak. jakarta: salemba medika. niven, n. 2002. psikologi kesehatan pengantar u n t u k p e ra wa t d a n p r ofe si o n a l kesehatan lain. jakarta: egc. permono, b., ugrasena, ratwita, m. 2006. pedoman diagnosis dan terapi bagian ilmu kesehatan anak. edisi 3. surabaya: rsud dr.soetomo. ratwita, m., ugrasena, i.d.g.& permono, b. 2006. pengeloaan medik anak denga lelukemia dan kemungkinan pengelolaanya di rs kabupaten. naskah lengkap ilmu kesehatan anak xxxvi. surabaya: divisi hematologi-onkologi bagian ilmu kesehatan anak rsud dr. soetomo. simon, h. 2005. leukemia. (online) (http:// healthguide.howstuffworks.com/acutelymphocytic-leukemia-in-depth.htm/ printable. diakses tanggal 12 oktober, 2010) supartini. 2004. buku ajar konsep dasar keperawatan anak. jakarta: egc. wong, et al. 2009. buku ajar keperawatan pediatrik. volume 1. jakarta : egc. yalug, i. et al. 2011. post-traumatic stress disorder and post-traumatic stress symptoms in parents of children with cancer: a review. neurology, psychiatry and brain research, 17, pp. 27–31. http://e-journal.unair.ac.id/jners | 129 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18996 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review of foot exercises with group support to improve the foot health of diabetes mellitus patients rohmatul faizah1 , ferry efendi1, suprajitno suprajitno2 1faculty of nursing, universitas airlangga, surabaya, indonesia 2department of nursing, poltekkes kemenkes, malang, east java, indonesia abstract introduction: foot problems are a process and complication in patients with diabetes mellitus (dm). foot complications can be prevented by routine foot exercises. group support is needed to increase the routine of foot exercise. the effects of foot exercise can be seen by measuring the ankle brachial pressure index and foot sensation. the objective of this systematic review was to identify the prevention of dm foot complications in an easy way so then he patient can do it independently. methods: the method used in this study was a systematic review focused on 2015 – 2019 using the prisma method. the literature was obtained from scopus, science direct and proquest. the results found 25 items of literature on foot exercise which was reduced to 4 studies on preventing damage to the feet of dm patients through routine foot exercise. the literature of this study is supported by 3 other studies that state that foot health can also be used to examine the foot’s blood circulation status and sensation. results: these results have been presented concerning 7 studies regarding special group support in the form of exercise therapy for patients with dm. this study explains the prevention of foot complications through foot exercise. group support is needed provide motivation to conduct routine foot exercise. conclusion: foot exercise can accelerate the blood circulation as can be seen by the ankle brachial pressure index score and the increase in the neurological system of the foot through foot sensation status. article history received: feb 27, 2020 accepted: april 1, 2020 keywords foot exercise; group support; diabetes mellitus contact ferry efendi  ferry-e@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: faizah, r., efendi, f., & suprajitno, s. (2020). a systematic review of foot exercises with group support to improve the foot health of diabetes mellitus patients. jurnal ners, special issues, 129-134. doi:http://dx.doi.org/10.20473/jn.v15i2.18996 introduction a group of problems that is often found in patients with diabetes mellitus (dm) is foot problems. this problem is a form of microvascular complication.(shaw & cummings, 2012) the foot status points to consider include circulatory status and neurological status.(ji, bai, sun, ming, & chen, 2015) upon observing the world data, the number of dm patients in the world totals 123 million people and it is estimated that the number will increase by 40% in 2045. dm patients recorded with foot complications make up 60% and 20% of them also experience complications in the form of foot infections.(idf, 2017) in indonesia, dm patients have increased by a percentage of 2.4%, while in 2011, it was 8.5%. in 2015, it was 10.9%.(riskesdas, 2018) the basis of the management of dm therapy is divided into 2, namely pharmacological and nonpharmacological therapy. in this discussion, the patient can be directed to the therapies that can be done independently at home. exercise therapy is an option. the exercise therapy that can have a direct impact on foot problems as it in the form of foot exercise.(sheehan & ulchaker, 2011; taddei et al., 2018) foot exercises are a series of movements that are arranged systematically that can provide support to improve the diabetic’s foot problems.(taddei et al., 2018) the benefits of routine foot exercise include improving blood circulation, increasing muscle https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ferry-e@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. r. faizah et al. 130 | pissn: 1858-3598  eissn: 2502-5791 strength, improving neurological status, and preventing diabetic foot complications.(ji et al., 2015) these benefits can be seen by measuring the ankle brachial index to determine the status of the blood circulation, while the neurological status can be seen by assessing the foot sensation.(shaw & cummings, 2012; watkins, 2016) the techniques used for providing foot exercise education also need attention. recommendations from a variety of literature are used to mobilize support from the fellow sufferers of dm. this technique is called group support. group support has been proven to increase understanding and participation when carrying out several activities including foot exercises.(due-christensen, hommel, & ridderstråle, 2016; shomaker et al., 2017) therefore in this article, the review discusses foot exercises and group support based on the results of the previous studies. the objective of the systematic review was to identify techniques used to prevent dm foot complications in an easy manner in a way that the patient can do independently. materials and methods making this article review used the prisma method. strategy for searching studies the data was obtained using electronic media to access international journals. the data search was conducted from august 2019 to february 2020. the journal databases used in this article review were scopus, science direct and proquest. keywords used to obtain the journals included foot exercise, diabetes foot complications, diabetes foot prevention, health education delivery techniques, and group support therapy. study selection when selecting the journal articles, the title and abstracts of the articles found were used. the design of the article used referred to the actual research if it was not in the form of a systematic review or article review. the prisma method recommends using inclusion and exclusion criteria. the inclusion criteria compiled included the following. 1. a journal with actual research results. 2. a journal published in the last 5 years (2015-2019). 3. the population or study sample consists of dm patients. 4. the interventions described in the journal are preventive therapies for diabetic foot complications. the exclusion criteria included 1. journals in the form of a systematic review or article review and 2. interventions using either tools and/or health workers. data extraction and appropriate quality assessment data extraction was done by discussing the compilers of the article. the journals were obtained and collected and then their information was then extracted including the type of research carried out, the intervention, the duration of the intervention, the description of the intervention, the doses of the intervention, and explaining about the involved groups in the study. a proper quality assessment of the articles or journals was done by giving a score based on the inclusion criteria that had search the literature for journals from science direct, proquest and scopus. keywords used to obtain the journals include foot exercise, diabetes foot complications, diabetes foot prevention, health education delivery techniques, and group support therapy. selecting the journal articles using the title, abstract, study design and inclusion and exclusion criteria inclusion criteria: 1. journal of actual research results 2. journal published in the last 5 years (2015-2019) 3. the population or study sample consists of dm patients 4. the interventions described in the journal are preventive therapies to treat diabetic foot complications. exclusion criteria: 1. journal in the form of a systematic review or article review 2. interventions using tools and health workers the journals obtained and collected were then extracted from including: the type of research carried out, the intervention, the duration of the intervention, the description of the intervention, the doses of the intervention, and explained about the groups in the study. the journals taken had to meet the inclusion criteria by at least 50%. diagram 1. method of the systematic review jurnal ners http://e-journal.unair.ac.id/jners | 131 been prepared. if it met the criteria then it was given a value of one (1). if it did not meet the criteria then it was given a value of zero (0). results the results obtained from the search for research journals in scopus, science direct and proquest using the keywords ‘foot exercises, diabetic foot complications, diabetes foot prevention, health education delivery techniques, and group support therapy’ resulted in hundreds of journals. this was narrowed down by adding the criteria of being published in the last 5 years (2015-2019). after being selected, there were only 15 journals. an explanation of each journal is displayed in table 1. discussion prevention of diabetes mellitus complication the complications of diabetes mellitus are divided into 2 major groups, namely acute complications and chronic complications.(shaw & cummings, 2012) chronic complications occur over a long period of time (> 6 months) and they are not treated appropriately. chronic complications come in 2 types, microvascular and macrovascular. microvascular table 1. journal search results on the topic foot exercise and group support for diabetes mellitus patients title, author and year of the journal types of research explanation of the research results (ji et al., 2015) eksperimental foot exercise combined with music can significantly (p> 0.05) improve the adherence to foot exercise behavior. this increase can improve blood circulation in the body. (taddei et al., 2018) randomized control trial the results obtained from the evaluation after 8 weeks of a foot exercise intervention include the incidence of foot injury lessened by 28% and the functions of the feet increased by 97%. biomedical details also showed an improvement. (henni et al., 2018) restrospective analysis walking exercises done by dm patients can improve the value of their ankle brachial index (abi) score by an average of >0.9 and it can also reduce the risk of pad (peripheral arterial disease). (alqahtani et al., 2018) cross-sectional study exercise can increase the value of abi according to the results of the analysis (p = 0.04). (takahara, fujiwara, katakami, & sakamoto, 2014) restrospective analysis the risk factors that can affect the reduction in abi and tbi include age, the duration of dm and bmi as proven by the results of significance being p <0.05. (shomaker et al., 2017) randomized control trial interventions given in the form of group therapy can increase attendance, reduce depression and stress, and stabilize blood sugar. (due-christensen et al., 2016) pilot study group interventions can significantly improve hba1c (p = 0.0001), and fellow dm patients can exchange their experiences. (dadgostar, firouzinezhad, ansari, & younespour, 2016) randomized clinical trial exercise interventions in groups carried out for 6 weeks can reduce body fat, improve the physical health of dm patients, and for 12 weeks, it can significantly reduce hba1c (p <0.05). (vangeepuram, carmona, arniella, horowitz, & burnet, 2015) pilot study focus group discussions can increase the patient’s understanding when providing education, especially concerning the prevention of diabetes and other health problems. (hasneli & amir, 2019) quasyeksperimental the giving of an apiyu massage intervention can improve the sensitivity of both the right and left legs (p = 0.011). it can also significantly reduce the blood sugar level (p = 0.001). (alonso-domínguez, recio-rodríguez, & patino-alonso, 2019) randomized control trial exercise interventions in dm patients can reduce stiffness in the foot (p> 0.05) according to multiple parameters (cavi / cardio ankle vascular index and lower extremity pulse pressure). men get more influence than women. (mohammad ali morowatisharifabad, abdolkarimi, asadpour, & fathollahi, 2019) deskriptive study group support can increase the dm patient’s compliance with exercise and physical activity by 1.17 times. (juul, rowlands, & maindal, 2018) cross-sectional study social motivation can be an important form of support when dieting, and in physical activity adherence, especially for dm patients. (mouslech et al., 2018) quasyeksperimental group-based education programs can significantly influence the reduction of hba1c, decreasing the incidence rate of hyperglycemia, increasing adherence, and changing habits for the better. (rebecca et al., 2018) quasyeksperimental the provision of diabetes mellitus care services significantly increases awareness in relation to the care and exercise connected to physical activity. r. faizah et al. 132 | pissn: 1858-3598  eissn: 2502-5791 complications are the cause of new disorders such as neuropathy, retinopathy, nephropathy and diabetic foot ulcers. diabetic foot ulcers are often found and are clearly visible where the dm patients have disturbances on their foot. although not always shaped like wounds, these patients are at a high risk of suffering from injuries to the feet. an injury to the feet of dm patients, if not treated properly, can lead to amputation being performed.(scobie & samaras, 2014; shaw & cummings, 2012) an explanation of the complications of dm is necessary to better undertake effective measures to prevent these complications. a limitation of the found literature was that no-one discussed the complications of diabetes. rather, they combine the various complications that can arise. from the journals obtained and examined according to the theme, the articles previously used were screened according to the inclusion and exclusion criteria. psychological therapy such as cancer and living meaningfully (calm) intervention can decrease depression, anxiety, and death-related distress, which can improve the quality of life. foot exercise handling dm can be done through physical exercise. physical exercise can balance food intake and body energy production. glucose buildup in the body, which is related to the blood circulation, can worsen the condition of dm patients. therefore it is necessary to schedule regular exercise for dm patients. an easy and lightweight exercise for dm patients is foot exercise. foot exercise refers to a series of movements arranged systematically focused on the foot for dm patients.(taddei et al., 2018) foot exercises can be done routinely 3-4 times a week for 30 minutes.(perkeni, 2012) foot exercises have benefits that include increasing the blood circulation, increasing the leg muscle strength, improving foot sensitivity, and preventing complications from diabetic foot ulcers.(ji et al., 2015) the research that has been done on dm foot exercises explains that foot exercises are an alternative to prevent complications, especially diabetic foot ulcers. increased blood circulation is assessed by measuring the ankle brachial index parameters and the improved foot sensitivity by assessed by measuring the level of foot sensation or foot response.(ji et al., 2015; taddei et al., 2018) the limitation of the literature was that many discussed diabetes exercises instead of foot exercises specifically. group exercise group support can be interpreted as information given either verbally or nonverbally from the closest person to the patient.(rockville, 2015) group support can also provide motivation shared among people with the same conditions.(dadgostar et al., 2016) support comes in 4 forms: emotional, appreciation, instrumental and informative.(corcoran & roberts, 2015) optimal support can be provided by fulfilling all 4 forms of support. however, only 1 form of support can be given and it can still be interpreted as providing support.(rockville, 2015) health interventions with the group support method, especially among dm patients, have been shown to have a positive impact. the most dominant positive impact is improving the adherence to therapy, especially concerning foot exercises. it also can reduce anxiety and control their blood glucose levels. (dadgostar et al., 2016; due-christensen et al., 2016; m. a morowatisharifabad, abdolkarimi, asadpour, fathollahi, & balaee, 2019; shomaker et al., 2017) the limitation is that the found literature did not explained the form of group support in detail. conclusion diabetes mellitus is a condition that is a chronic disorder in the body of the sufferer. dm has the potential for complications. a complication that is often seen is foot problems. foot complications can be prevented by doing proper and easy foot exercises. foot exercises can have an optimal affect if done routinely 3-4 times a week. the foot exercise needs to be understood correctly by the dm patients. to improve patient understanding, the method of delivering the material must be appropriate. the method that has proven to be effective in terms of increasing understanding is group support or a group approach to therapy. group interventions can be carried out with the closest people to the patient and fellow dm patients to allow them to share their experiences and information. from the above description, dm patients need to do foot exercises regularly and they need to be given an understanding of the exercise by applying the group intervention / group support method. group support can be increase their adherence to therapy especially foot exercise. conflict of interest no conflicts of interest have been declared. acknowledgement the authors would like to thank the faculty of nursing and also the master’s students on the nursing study programme. the authors would further like to thank all those responsible for supporting us getting the systematic review completed and the appropriate original research from all articles used to share the final information. the authors also would like to thank those who have provided direction so then this article was completed and can convey the complication prevention information relevant to dm patients. references alonso-domínguez, r., recio-rodríguez, j. i., & patinoalonso, m. c. (2019). acute effect of healthy walking on arterial stiffness in patients with type 2 jurnal ners http://e-journal.unair.ac.id/jners | 133 diabetes and differences by age and sex : a pre-post intervention study. 1–9. alqahtani, k. m., bhangoo, m., vaida, f., denenberg, j. o., allison, m. a., & criqui, m. h. (2018). predictors of change in the ankle brachial index with exercise. european journal of vascular & endovascular surgery, 55(3), 399–404. https://doi.org/10.1016/j.ejvs.2017.12.004 corcoran, k., & roberts, a. r. (2015). social workers’ desk referenceq (3rd ed.). oxford university press. dadgostar, h., firouzinezhad, s., ansari, m., & younespour, s. (2016). supervised groupexercise therapy versus home-based exercise therapy : their effects on quality of life and cardiovascular risk factors in women with type 2 diabetes. diabetes & metabolic syndrome: clinical research & reviews, 1–7. https://doi.org/10.1016/j.dsx.2016.01.016 due-christensen, m., hommel, e., & ridderstråle, m. (2016). potential positive impact of group-based diabetes dialogue meetings on diabetes distress and glucose control in people with type 1 diabetes. patient education and counseling, 6–11. https://doi.org/10.1016/j.pec.2016.07.023 hasneli, y., & amir, y. (2019). identification and analysis of foot sensitivity and blood glucose levels post apiyu massage ଝ. enfermería clínica, (xx), 9–12. https://doi.org/10.1016/j.enfcli.2018.11.009 henni, s., ammi, m., gourdier, a., signolet, i., colasribas, c., picquet, j., & abraham, p. (2018). ankle brachial index is equally predictive of exerciseinduced limb ischemia in diabetec and nondiabetic patients with walking limitation. #pagerange#. https://doi.org/10.1016/j.jdiacomp.2018.03.01 1 idf. (2017). diabetes atlas. south-east asia: international diabetes federation. ji, l., bai, j. j., sun, j., ming, y., & chen, l. r. (2015). effect of combining music media therapy with lower extremity exercise on elderly patients with diabetes mellitus. international journal of nursing sciences, 2(3), 243–247. https://doi.org/10.1016/j.ijnss.2015.07.008 juul, l., rowlands, g., & maindal, h. t. (2018). relationships between health literacy, motivation and diet and physical activity in people with type 2 diabetes participating in peerled support groups. primary care diabetes, 12(4), 331–337. https://doi.org/10.1016/j.pcd.2018.02.005 morowatisharifabad, m. a, abdolkarimi, m., asadpour, m., fathollahi, m. s., & balaee, p. (2019). study on social support for exercise and its impact on the level of physical activity of patients with type 2 diabetes. journal of medical sciences, 1(7), 143–147. morowatisharifabad, mohammad ali, abdolkarimi, m., asadpour, m., & fathollahi, m. s. (2019). study on social support for exercise and its impact on the level of physical activity of patients with type 2 diabetes. 7(1), 143–147. mouslech, z., somali, m., sarantis, l., christos, d., alexandra, c., maria, p., … hatzitolios, a. i. (2018). significant effect of group education in patients with diabetes type 1. perkeni. (2012). konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia. jakarta: perkeni. rebecca, a., dyck, a., kleinman, n. j., funk, d. r., yeung, r. o., senior, p., & yardley, j. e. (2018). we can work (it) out together: boot camp for type 1 diabetes patients and providers improves exercise self-efficacy. canadian journal of diabetes. https://doi.org/10.1016/j.jcjd.2018.02.006 riskesdas. (2018). riset kesehatan dasar riskesdas 2018. jakarta: balitbang kemenkes ri. rockville. (2015). substance abuse treatment: group therapy. substance abuse and mental health services administration. scobie, i. n., & samaras, k. (2014). fast facts: diabetes mellitus (5th ed.). health press limited. shaw, k. m., & cummings, m. h. (2012). diabetes chronic complications. john wiley & sons, incorporated. sheehan, j. p., & ulchaker, m. m. (2011). obesity and type 2 diabetes mellitus : obesity and type 2 diabetes mellitus. oxford university press usa oso. shomaker, a. l. b., bruggink, s., pivarunas, b., skoranski, a., foss, j., dalager, s., … bell, c. (2017). pilot randomized controlled trial of a mindfulness-based group intervention in adolescent girls at risk for type 2 diabetes with depressive symptoms. complementary therapies in medicine. https://doi.org/10.1016/j.ctim.2017.04.003 taddei, u. t., matias, a. b., ribeiro, f. i. a., inoue, r. s., bus, s. a., & sacco, i. c. n. (2018). effects of a therapeutic foot exercise program on injury incidence, foot functionality and biomechanics in long-distance runners: feasibility study for a randomized controlled trial. physical therapy in sport. https://doi.org/10.1016/j.ptsp.2018.10.015 takahara, m., fujiwara, y., katakami, n., & sakamoto, f. (2014). shared and additional risk factors for decrease of toe-brachial index compared to ankle-brachial index in japanese patients with diabetes mellitus. atherosclerosis, 235(1), 76–80. https://doi.org/10.1016/j.atherosclerosis.2014. 04.014 vangeepuram, n., carmona, j., arniella, g., horowitz, c. r., & burnet, d. (2015). use of focus groups to inform a youth diabetes prevention model. journal of nutrition education and behavior, 47(6), 532-539.e1. https://doi.org/10.1016/j.jneb.2015.08.006 r. faizah et al. 134 | pissn: 1858-3598  eissn: 2502-5791 watkins, l. (2016). watkins’ manual of foot and ankle medicine and surgery (4th ed.). wolters kluwer health. 108 development of performance assessment instrument for nurses based on web in inpatient unit aprilia nuryanti, nursalam, mira triharini master program of nursing, faculty of nursing, universitas airlangga email: aprilnuryanti@gmail.com abstract introduction: performance assessment instrument will be problematic when it is not representative in describing the competency because it is not obvious indicators and inappropriate performance standard to nursing’s task. the purpose of this study is to develop nurses’ performance assessment instrument based on the web from multi sources assessment inpatient unit at smc hospital. methods: this study had two phases. the first phase was an explanatory overview of the performance assessment system using questionnaires completed by 53 respondents of nurses, selected by purposive sampling. instrument development based on fgd with six decision makers in the hospital. validity was tested by pearson product moment correlation and reliability of instrument’s was tested by alpha cronbach. the second phase was socialization and instrument test to observe the quality of instrument using a questionnaire by 47 respondents and recommendations made by 8 participants of fgd. the samples were selected by purposive sampling technique. performance assessment system was moderate at 58.49%. all questions which aimed to measure the performance of nurses were valid and reliable. the quality of nurses’ performance assessment instruments based on the web was a good category, which was functionality: 81.60; reliability: 78.16; efficiency: 80.85; usability: 81.70 and portability: 81.70. results: the result was a web-based assessment format, scoring with likert scale, resource assessment by the direct supervisor which was a multisource evaluator, the development of performance graph, and confidentiality of data on the database server. discussion: recommendations for hospital is to make policy based on the final value of the performance assessment by the supervisor which was multisource feedback and it needs a global writing on a form of performance assessment result. keywords: assessment instrument, nurses’ performance, web ____________________________________________________________________________________________________ introduction performance measurement is an important thing for the development of the health care system (beyan & baykal 2012). performance assessment instrument will be a problem if it does not describe competencies (kalb et al. 2006) and inappropriate performance standard to the nurses’ task (nikpeyma et al. 2014). satisfaction of the performance assessment which is done by managers influences positive things to build and improve performance, if the employees are not satisfied and feel the unfair process, they are unlikely to receive and utilize the assessment (keeping & levy 2000; giles & mossholder 1990 cit. dusterhoff et al. 2013). basic competency assessments for nurses at samarinda medika citra hospital had the same characteristics with the assessment for the whole employees. the nurse's performance assessment was conducted by self-assessment – supervisor evaluation (sapa). indicator assessment was in accordance with nursing profession, and the development of assessor resources have been expected to increase the satisfaction of the assessment process and the results of the assessment utilized. the purpose of this study is to develop nurses’ performance assessment instrument with web-based in the inpatient unit of samarinda medika citra hospital. the performance assessment will not increase productivity if there are biased, inaccurate and not accepted by users due to errors in the content evaluation, which are bias in the evaluation process, incompatibility between the needs of employees and the purpose of the assessment or there is not clear performance dimensions (giangreco, et al. 2012 cit. nikpeyma et al. 2014). less objective assessment leads to a subjective value. assessment which is not objective, unfair or unreliable (called bias such as hallo effect, leniency or strictness, central tendencies, matthew effect and the supervisor 's bias) causes distortion of the assessment process and will also be a source of frustration for employees who are discriminated (nikpeyma et al. 2014). multisource assessment is proven as an alternative to conventional valuation methods to increase employee’s satisfaction ratings (manoharan et al. 2012). development of information technology and communication may cause nurses to have a computer-based management information system to support decision-making. data processing with computer assessment is easier, faster, more reliable and more organized to avoid human mailto:aprilnuryanti@gmail.com jurnal ners vol. 12 no. 1 april 2017: 108-112 109 error manually. people nowadays use the internet to obtain information, it is supported by the development of mobile devices such as tablets and smartphones which make people easier to perform web-based activities (richwandi 2015). the concept of nurse performance assessment instrument using an approach is carried out by several sources. the assessment using the web aims to protect confidentiality and accessed restrictions reports. graph of performance assessment is expected to map out the nurse work performance. the performance indicators in this research are developed with basic competencies (behaviors work and personal character) stated in government regulation number 46 of 2011, and professional performance standard of nurses in the patient satisfaction views according to nursalam (2014). instrument’s quality will be assessed by software standards of iso 9126. validity and reliability of the instrument are tested before it was put in the web application. materials and methods this research design was an explanative survey to describe nurses’ performance assessment and construct a development of performance instrument used with focus group discussion (fgd). validity was tested by pearson product moment correlation and reliability was tested by alpha cronbach. the second round was socialization, mentoring, and testing of the instrument by the user from the administrator, head of nurses, nurses, and patients. the final result of the instrument testing was evaluation instrument quality and recommendation based on the evaluation. sample and participant were selected by purposive sampling technique. the first round of this study was selected 53 samples and 6 respondents for discussion. the second round was 47 samples and six respondents for discussion. results evaluation of the nurse performance assessment system was conducted by using a questionnaire to 53 sample of nurses in child care unit, maternal care unit, icu, nicu/ picu, a maternity room, surgery room and newborn nursery unit. thirty-one nurses (58.49%) found had moderate performance, 20 nurses (37.74%) had good performance and 2 nurses (3.77%) still had poor performance in doing an assessment to patients. the component of the assessment performance described in table 1. table 1. evaluation of the nurses’ performance assessment component in inpatient unit at samarinda medika citra hospital (n=53) no component categories good f (%) moderate f (%) poor f (%) total f (%) 1 evaluation criteria 37 (69,81) 6 (11,32) 10 (18,87) 53 (100) 2 value of performance measurement 44 (83,02) 7 (13,21) 2 (3,77) 53 (100) 3 performance assessment system 35 (66,04) 12 (22,64) 6 (11,32) 53 (100) 4 assessment feedback 36 (67,92) 11 (20,75) 6 (11,32) 53 (100) 5 performance report 30 (56,60) 22 (41,51) 1 (1,89) 53 (100) 6 performance achievement determination 25 (47,17) 17 (32,08) 11 (20,75) 53 (100) 7 assessor objectivity 34 (64,15) 19 (35,85) 0 (0) 53 (100) 8 satisfaction of performance assessment system 46 (86,79) 6 (11,32) 1 (1,89) 53 (100) 9 satisfaction of supervisor’s evaluation 37 (69,81) 15 (28,30) 1 (1,89) 53 (100) 10 supervisor’s knowledge for true performance 31 (58,49) 20 (37,74) 2 (3,77) 53 (100) 11 satisfaction of feedback 27 (50,95) 15(28,30) 11(20,75) 53 (100) development of performance assessment instrument (aprilia nuryanti et.al) 110 table 2. quality value of nurses performance assessment instrument based on the web (n=47) no component categories total f (%) good f (%) moderate f (%) poor f (%) 1 functionality 38 (80,85) 9 (19,15) 0 47 (100) 2 realiability 30 (63,83) 17 (36,17) 0 47 (100) 3 usability 35 (74,47) 12 (25,53) 0 47 (100) 4 efficiency 33 (70,21) 14 (29,79) 0 47 (100) 5 portability 34 (72,34) 13 (27,66) 0 47 (100) focus group discussion was conducted by the policy makers to discuss the issue and make recommendations for the development of the instrument. validity and reliability’s instrument content tested, either the institution evaluation or the patient assessment, showed valid and reliable for all questions. in the second round, socialization and mentoring during instrument testing in the adult patient unit 1, 2 and 3, conducted by the researcher to help user system, provide manual book user for the instrument based on the web, provide contact number which can be reached anytime if facing obstacles. during the trial, if an error occurred, the researcher would communicate to the web developer for instrument recovering. the instrument was applied to 47 users (1 administrator, 3 nurse unit managers, 29 nurses and 14 patients). the result for all quality indicators was good with the functionality (81.60); reliability (78.16); efficiency (80.85); usability (81.70), and portability (81.70). fgd conducted by users did observe the evaluation during the instrument trial and made recommendations for its further development. the development of nurses performance assessment instrument was basic competencies assessment indicator. the scoring system was originally used 1a, 1b, 2a, 2b, 3a, 3b, 4a and 4b (score 1-8) with a maximum value of the acquisition of 8, while the development of instrument using a likert scale with scoring (1-5) according to the indicator denominator. sa-pa assessor source was developed with peer and patient assessment rating. the database was provided safely on the server. the web-based instrument could be modified according to hospital needs. discussion the majority of evaluation of the performance assessment system was a moderate category. the most contributing proportion of satisfaction with the system was good. the source of the assessment methods was self-assessment supervisor (sa-pa). performance evaluation practices have a positive influence on employee performance (gyensare & asare 2012). development of instruments in this study was the structure of the instrument and the content of the assessment criteria. one of the main parts of the implementation was performance measurement. it was influenced by factors such as perspective assessment of decision makers, data source, the focus of measurement, the achievement of development targets, types of indicator, data and investigation types. performance assessment using this web allows structures to start measurement and qualitative types of indicator that provide a view of the professional behavior performance of nurses, the development of each work behavior assessment indicator can be used as a material for the supervisor to supervise its nurse subordinates. the data type uses a likert scale (1-5), which allows comparing the measurement values with the numerator and denominator defined. three of the eight stages performance assessment according to olabode et al. (2013) can be provided by a web-based performance assessment instruments: 1) ratings. this stage involves documenting the performance by observing, reminding, evaluating, communicating, assessment and analysis of data. this stage is putting together a record of votes. the information technologybased applications usage enables the acceleration of the conventional paper-based assessment and mathematical calculation performance score manually; 2) feedback. after the stage of formal assessment, feedback sessions is done as willingness. this session should involve verbal communication, listening, problem-solving, negotiation, jurnal ners vol. 12 no. 1 april 2017: 108-112 111 compromising, conflict resolution, and agreement; 3) decision-making. results of the assessment and feedback will lead many decisions made for example of the award (promotions, incentives, etc.) and penalties (e.g., demotion). web quality assessment instruments indicators are functionality, reliability, efficiency, usability, and portability. good was the highest percentages of functionality (web capability assessment of performance in meeting user needs in its function to measure the performance of nurses). the concept of the instrument characteristics was in accordance with the characteristics of software quality by iso 9126 (international organization for standardization), in this study are based assessment from the point of view (user's view). functionality is the ability to provide the satisfaction of user needs. reliability is the ability of the software to treat level of performance. usability is the ability associated with the use of the software. efficiency is the ability associated with physical resources that are used when the software is run. portability is the ability associated with software capabilities that are sent to different environments. an instrument is a tool or a means by which to measure the level of scientific work, official documents and legal form, can be used for research tools and results of data collection used as an ingredient in achieving objectives or specific policy. conclusions the conclusion of this study 1) nurses performance assessment system in smc hospital was in enough category, poor category was the most dominating proportion for job awarding and satisfaction determination of the assessment; 2) fgd recommendation is to develop assessor source with peer and patient assessment, and also assessment type consists of checklist, recording, and note assessment, time assessment, specific indicator assessment for nurse task and questionnaire for assessment. nurse achievement started from getting scores in 80 for final score of performance, needing essay column to complete the assessment, legalization for the recording assessment and security assessment process in the instrument based on the web which is the regulation needed; 3) all of the question for assessor from head, peer and patients were valid and reliable; 4) socialization and mentoring to users of instrument was based on the web during trial and there was manual book for application users; 5) nurse performance assessment instrument was based on web assessed by all user levels (admin, head of the nurse, nurses, and patients), they showed good category for all indicators (functionality, reliability, efficiency, usability dan portability) 6) fgd with users made recommendations that needed socialization and training performance assessment instrument user who was specifically set by hospital, the registration should be done independently by entering nurse’s email which managed by administrator. in developing the content of assessment indicators, they did similar additional indicators with technical competence assessment. recommendations of this study for the hospital is to invest in it engineering, and also it should involve another profession (doctor, physiotherapist, nutritionist, etc.) as an assessor, makes policies about the final score of nurse assessment from multi-sources and increase internet network bandwidth in the hospital. for managers and nursing committee, they should formulate a fair scoring in the assessment of the nurse's performance. for the head nurse, they should continue motivating nurses in using the web to provide its assessment evaluation instrument for the next development. for further research should develop the web with quantitative indicators for nurses assessment. references beyan, o.d. & baykal, n., 2012. a knowledge based search tool for performance measures in health care systems. journal of medical systems, 36(1), pp.201–21. dusterhoff, c., cunningham, j.b. & macgregor, j.n., 2013. the effects of performance rating, leader-member exchange, perceived utility, and organizational justice on performance appraisal satisfaction: applying a moral judgment perspective. journal of business ethics, pp.1–9. gyensare, m.a. & asare, j., 2012. relationship between human resource ( hr ) practices and perceived development of performance assessment instrument (aprilia nuryanti et.al) 112 performance of psychiatry nurses in ghana. african journal of business management, 6(6), pp.2137–2142. kalb, k.b. et al., 2006. a competency-based approach to public health nursing performance appraisal. public health nursing, 23(2), pp.115–138. manoharan, t.r., muralidharan, c. & deshmukdh, s.g., 2012. a composite model for employees’ performance appraisal and improvement. european journal of training and development, 36(4), pp.448–480. nikpeyma, n. et al., 2014. problems of clinical nurse performance appraisal system : a qualitative study. asian nursing research, 8(1), pp.15–22. olabode, t., abayomi, a. & abayomi, a., 2013. appraisal system : a tool for performance in selected organizations in nigeria. international journal of sociology and anthropology, 5(7), pp.249–261. richwandi, p.p., 2015. penggunaan html5 dalam perkembangan web 2 . 0 yang dirancang dengan responsive web design. jurnal teknik informatika, juni, pp.1–10. 42 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 42-46 http://dx.doi.org/10.20473/jn.v17i1.24539 original article open access the correlation between parental communication pattern, self-esteem, and moral disengagement with cyberbullying behavior in early adolescents: a cross-sectional study dian octavia 1,* , rian maylina sari 1 , diah merdekawati 1 , rara marisdayana 1 , rian yuliyana 2 1 institute of health science harapan ibu jambi, indonesia 2 health polytechnic tanjung pinang, indonesia *correspondence: dian octavia. address: kol. tarmizi kodir street no.71, pakuan baru, jambi city, 36122, indonesia. email: octaviadian04@gmail.com responsible editor: ilya krisnana received: 12 january 2021 ○ revised: 9 october 2021 ○ accepted: 13 october 2021 abstract introduction: cyberbullying has become a new case in young millennials that can lead to being a serious problem if it is not faced properly. many cases cannot be resolved because the victims did not tell the truth clearly to their parents and teachers. it may cause a lack of self-esteem among the students and also make the perpetrator become morally disengaged. the purpose of this study was to identify the correlation between parental communication patterns, moral disengagement, and self-esteem with cyberbullying behavior in junior high school. methods: a cross-sectional study was performed with 362 junior high school students in indonesia using purposive sampling. variables in this study were moral disengagement, self-esteem and parental communication patterns with cyberbullying behavior. the data were collected with the rosenberg self-esteem scale, the cyberbullying behavior scale, the moral disengagement scale and the family communication pattern scale. bivariate analysis with chi-square was used to analyze the data. results: this study found out that there were 223 students, 61.6% were female, and 43.6% were aged 14 years. there were 187 students (51.7%) who had mild cyberbullying behavior. the study revealed that there were significant correlations among cyberbullying behavior with moral disengagement (p = 0.005, self-esteem (p = 0.008), and parental communication pattern (p = 0.019). conclusions: parental communication, moral disengagement and self-esteem have a correlation with cyberbullying behavior. it was expected that the schools need to implement a training to improve social skills in junior high school students. keywords: cyberbullying; moral disengagement; parental communication pattern; self-esteem introduction the development of communication and information technology also has great impact on the development of today’s generation, which we know as millennials society (society 5.0 era). convenience in almost all daily activities can now be accessed very easily everywhere and any time. but, besides those great impacts, we cannot be blind to one of the negative impacts which be experienced by our young generation, that is cyberbullying. cyberbullying is a type of bullying which uses digital technologies and take place on social media, messaging platforms, gaming platforms or websites (febriana and fajrianthi, 2019). practically, it has many negative impacts on victims such as depression low self-esteem, difficulty concentrating in class, anxiety and suicide (talaei and ardani, 2009; patchin and hinduja, 2012; rahayu, 2012). other studies have found that bullying causes stress, emotional, social anxiety, and risk of drug use (sartana and afriyeni, 2017). another study revealed that students who experienced bullying in cyberspace were twice as likely to experience adverse health effects, such as headaches and stomachache, than those who did https://creativecommons.org/licenses/by/4.0/ http://orcid.org/0000-0002-6736-1375 http://orcid.org/0000-0003-0613-0677 http://orcid.org/0000-0003-3194-2474 http://orcid.org/0000-0003-4196-4060 http://orcid.org/0000-0002-9561-0797 jurnal ners http://e-journal.unair.ac.id/jners 43 not experience bullying (nursalam et al., 2019). in addition, another study stated that only one out of three adolescents who had been victims of cyberbullying shared their experiences with their parents, teachers and friends (mendez-baldwin et al., 2015). it shown that many cases are still undercovered and victims did not receive proper intervention to recover from the situation. the indonesian child protection commission (kpai) stated child victims of cybercrime in indonesia reached 679 cases and are growing very rapidly (kpai, 2019). the prevalence among junior high schoo students was around 48.2% (safaria, 2016). one factor that makes a child becomes of cyberbullying perpetrator is a grudge against the victim (pandie and weismann, 2016). there are several factors influencing the motives of cyberbullying behavior, namely family factors, failure to control oneself, and environmental factors. the poor quality of communication between parents and adolescents can cause adolescent behavior deviations (nursalam et al., 2019). other research also stated that through positive communication and interaction within the family, parents and adolescents can strengthen interpersonal relationships, so that adolescents would not be easily influenced by negative invitations, including becoming bullies, by their friends (firdanianty, lubis, et al., 2016). based on the preliminary survey in four junior high schools in four different districts of jambi city, indonesia, it was found that junior high school students tend not to open up with their parents if they become victims of bullying in social media. students are also reluctant to report the incident to their teachers and tell their close friends about problems instead. when it comes to asking about committing cyberbullying, they seemed to be reluctant to tell the truth. they said that they tend to be victims of bullying in social media. considering the lack of research related to cyberbullying in indonesia, this study aimed to identify the correlation among parental communication patterns, moral disengagement, and self-esteem with cyberbullying behavior in junior high schools in jambi city. materials and methods study design this was a quantitative study with a cross sectional design which aimed at determining the tendency of the early adolescents with cyberbullying behavior in junior high schools. the study sample was selected by purposive sampling technique. the study location was chosen by multistage random sampling. the study was carried out in two months between october and november, 2020. the independent variables were parental communication patterns, moral disengagement, and self-esteem, while the dependent variable was cyberbullying behavior. respondents the population of this study was all students from four selected junior high schools in jambi city, with 6,541 students in total. the sample size was 362 students selected by purposive sampling methods and calculated using lemeshow formula (sopiyudi dahlan, 2016). the samples were divided into four junior high schools using proportional sampling technique. the inclusion criteria were students registered as first, second and third year in selected public junior high schools in four districts (kota baru district, represented by public junior high school 14; telanaipura district, public junior high school 17; east jambi district, public junior high school 9, and paal merah district, public junior high school 4). the students must be able to communicate and willing to participate. the students will be excluded if they did not attend school during the data collection process. instrument cyberbullying behavior questionnaire the data were collected using cyberbullying behavior questionnaire (cbq), which consists of 20 items covering a wide range of work-related cyberbullying behaviors (jonsson, muhonen and backstrom, 2017). the participants scored the items on a four-point scale, 1 = never, 2 = monthly, 3 = weekly, 4 = daily. the scale has an internal consistency with a coefficient alpha of 0.638 to 0.879 (husna, tentama and purwadi, 2020). table 1 demographic characteristics of the respondents (n = 362) variables n % genders male 139 38.4 female 223 61.6 age (years) 11 8 2.2 12 77 21.3 13 101 27.9 14 158 43.6 15 17 4.7 16 1 3 cyberbullying information social media 252 69.6 friends 60 16.57 teacher 15 4.1 parents 10 2.76 not know 25 6.9 parents’ education levels primary school 29 8.0 junior high school 86 23.75 senior high school 197 54.1 bachelor high school 50 13.8 family income ≥ rp 1.750.000,150 41.4 ≤ rp 1.750.000,212 58.5 octavia, sari, merdekawati, marisdayana, and yuliyana (2022) 44 p-issn: 1858-3598  e-issn: 2502-5791 rosenberg self-esteem scale rosenberg self-esteem scale (rses) was developed by rosenberg in 1965. it consists of 10 items that refer to self-respect and self-acceptance rated on a four-point likert-scale, from 1 (totally disagree) to 4 (totally agree). five items were worded positively (i.e., 1, 3, 4, 7, and 10) and five items negatively (i.e., 2, 5, 6, 8, and 9) (martinalbo, nunez and navarro, 2007). the scale has an internal consistency with a coefficient alpha of 0.40 to 0.97 (tinakon and nahathai, 2012). moral disengagement scale moral disengagement constructs include vilifying victims through attribution of blame, reinterpreting conduct or moral justification, hiding personal causal responsibility, and misrepresenting the consequences of individual action (bussey, fitzpatrick and raman, 2015). the participants in this study were asked how much they agreed, starting from 1 = strongly disagree, 2 = disagree, 3= agree, 4 =strongly agree). the scale of internal consistency found a coefficient alpha of 0.80 to 0.87 (whang and yang, 2010). family communication pattern the family communication pattern consisted of 28item likert scale (gupta, 2019). this study used the fourpoint scale, namely 1 = strongly disagree; 2 = disagree; 3= agree; 4 = strongly agree. the scale of internal consistency had a cronbach’s alpha of 0.869. the validity and reliability of the test were carried out at a public junior high school in jambi city on august 8, 2020, with the total of 67 question items. the validity value with the rses was 0.87. the cbq was on a scale of 0.98, the moral disengagement scale was at 0.87, and the parental communication pattern scale was at 0.85. the reliability test of the overall instruments, cyberbullying behavior, self-esteem, moral disengagements and family communication pattern, were 0.88, 0.86, 0.83, and 0.81, respectively. data analysis the data were anslysed using univariate analysis to describe the demographic characteristics, cyberbullying behavior and all independent variables (i.e., self-esteem, moral disengagement and parental communication pattern). the normality data was tested by kolmogorov smirnov test for large sample. it was found that the pvalue were under 0.05 for all variables, which means the data were not normal (sopiyudi dahlan, 2016). the data used median to categorize all variables. the bivariate correlation used chi-square test to analyze independent and dependent variables. the correlation coefficients varied from -1 to +1. this study indicates a perfectly positive linear relationship. for a positive coefficient, as one variable increases, the other also increases. the analysis found strong relationship between independent and dependent variables in which α = 0.05 was used for analysis. the data analysis was processed in statistical package for the social sciences (spps file version 1.0.051). the data analysis included data screening and assumption of primary data analysis. table 2 relationship between parental communication pattern, self-esteem, and moral disengagement with cyberbullying behavior (n = 362) variable cyberbullying behavior total p-value mild strong n % n % n % parental communication 0.019 bad 86 46 103 58.9 189 52.2 good 101 54 72 41.1 173 47.8 self-esteem low 86 46 101 57.7 187 51.7 0.008 high 101 54 74 42.3 175 48.3 moral disengagement mild 110 58.8 76 43.4 186 51.4 0.005 strong 77 41.2 59 56.6 176 48.6 total 187 100 175 100 362 100 table 3 the types of cyberbullying behaviors in early adolescence (n = 362) type of cyberbullying n % flaming low (6-9) 194 53.6 high (10-24) 168 46.4 harassment low (2) 215 59.4 high (3-8) 147 40.6 denigration (put downs) low (3-4) 245 67.7 high (5-12) 117 32.3 cyber-stalking low (2) 302 83.4 high (3-8) 60 16.6 impersonation low (1) 312 86.2 high (2-5) 50 13.8 outing low (2) 198 54.7 high(3-10) 164 45.3 exclusion low (1) 239 66.0 high (2-5) 123 34.0 cyber-threat low (3) 291 80.6 high (4-15) 71 19.4 anonymity low (3) 290 80.1 high (4-15) 72 19.9 jurnal ners http://e-journal.unair.ac.id/jners 45 ethical consideration this research has got ethical approval with number: lb.02.06/2/123/2020. the ethical review was tested for all aspects in this research, including scope of study, methodology and the questionnaire. the researchers applied ethics principles of anonymity / confidentiality, beneficence and non-maleficence, autonomy, and justice. an explanation of the background and aim of the study, as well as informed consent, were contained together with the instrument. results the total of 362 early adolescents registered in four junior high schools in jambi city based on several subdistricts were recruited. the characteristics of early adolescents showed that the majority 223 (61.60%) were female, and almost a half, 158, were aged 14 years old (43.60%; see table 1). table 2 shows that parental communication pattern, self-esteem, and moral disengagement have significant correlation with cyberbullying behavior of students at the four public junior high schools. all p-value were below 0.05; parental communication (p = 0.019); self-esteem (p = 0.008); and moral disengagement (p = 0.005). table 3 shows that all cyberbullying types were in low categories, but high categories in few variables nearly reached a half, namely flaming (n = 168; 46.4%), outing (n = 164; 45.3%), and harassment (n = 147; 40.6%). discussions the majority of respondents were female and almost a half of 158 were at the age of 14 years old. boys and girls both participate in cyberbullying, although for different reasons. they also use different methods. girls tend to use a more passive approach, such as spreading rumors and reputation and relationship damage. boys tend to use direct and cyber-threats intended to revenge. in addition, another view says that, in carrying out their actions, women are more often the target of cyberbullying, while men tend to be the main perpretators of violence in cyberspace (pandie and weismann, 2016). this study found there were associations between self-esteem, parental communication pattern, and moral disengagement with cyberbullying behavior. several factors that could influence the variables were friends, parents and school environment, parents’ educational levels, and parents’ salary (aini, 2018). self-esteem was a component of self-concept factors that can influence self-concept such as pressure from outside from good peers (yuliayana and wichaikull, 2014). a peer group was a group of friends who had strong emotional ties and students who could be accepted, socialized, exchanged ideas, and experiences in providing the change and the development of social life. the experience of being a victim can lower person’s selfesteem, or people with low self-esteem are more likely to be targeted as victims. the quality of communication between parents and adolescents should be improved so the adolescents could get guidance and education to avoid cyberbullying. the poor quality of communications between parents and adolescents can cause adolescent behavior deviations (gunawan, 2013). other research stated communication between parents and adolescents that is less than optimal will cause adolescents to be easily influenced by deviant behavior (luk et al.2010). positive communication and interaction within family, parents and adolescents can strengthen interpersonal relationships, so adolescents will not be easily influenced by invitations to do negative activities from their friends (firdanianty, djuara et al., 2016). reframing behavior is accomplished through moral justifications, euphemistic labelling, and advantageous comparisons, which enable the individual to view their immoral behavior as ultimately moral or benign. individuals could also morally disengage by changing their perceptions of their own personal responsibility for the behavior by displacing or diffusing responsibilities to others. moral disengagement mechanisms blame the target for their suffering, or dehumanize the target, act to reframe the individual’s perceptions about the target’s role for the behavior. finally, the harmful outcomes of the immoral behavior can be minimized or viewed as providing benefits for the victim (bandura, 2002). cybercommunication may promote hostile attributions of intent, and triggering attributions of blame (runions, 2013). ambiguous communications, that are common on social media, may provoke self-justifications of cyberaggression as retaliatory responses, with responsibility for the perceived provocation attributed to the other person; one’s own behavior is perceived as merely a reaction. these processes may be particularly pertinent to aggressive-victims (i.e., bully-victims),whose responses to perceived provocation fuel cycles of bullying (salmivalli and nieminen, 2001). this study also found most adolescents have mild moral disengagement, self-esteem and cyberbullying behavior. this study was in line with jiang et al. (2021), that stated adolescents whose information was on the topic of self-acceptance and competence, or having good self-esteem, could judge themselves better than most people. according to other research, the sources related to bullying and self-esteem have consistently found that victims of bullying tend to have lower self-esteem than non-victims (patchin and hinduja, 2012). among people with different levels of self-esteem, victims of bullying tend to have lower self-esteem than non-victims. this study has several limitations. it only identified the correlation between independent and dependent variables with cross-sectional approach that cannot show causality. this study also did not examine any intervention to increase self-esteem, improve family octavia, sari, merdekawati, marisdayana, and yuliyana (2022) 46 p-issn: 1858-3598  e-issn: 2502-5791 communication, address moral disengagement, or prevent cyberbullying behavior. therefore, further study is needed to address these aspects. conclusions there is a correlation between self-esteem, moral disengagement, parental communication pattern and cyberbullying behavior in early adolescence in junior high school. further research need to address factors related to moral disengagement between genders, improvement by social group about self-esteem, and disengagement in cyberbullying behavior. references aini, d. f. n. (2018) ‘self in elementary school age children for prevention of bullying cases’, elementary school of thought and development, 6(1), pp. 36–46. doi: https://doi.org/10.22219/jp2sd.v6i1.5901. bandura, a. (2002) ‘selective moral disengagement in the excercise of moral agency’, journal of moral education, 31, pp. 101–119. bussey, k., fitzpatrick, s. and raman, a. (2015) ‘the role of moral disengagement and self-efficacy in cyberbullying.’, journal of school violence, 14(1), pp. 30–46. doi: 1080/15388220.2014.954045. febriana, s. k. t. and fajrianthi (2019) ‘cyber incivility perpetrator: the influenced of dissociative anonimity, invisibility, asychronicity, and dissociative imagination’, in 1st international conference on advance and scientific innovation, icasi 2018. universitas lambung mangkurat, banjarmasin, indonesia: institute of physics publishing. doi: 10.1088/1742-6596/1175/1/012238. firdanianty, djuara, l. p., et al. (2016) ‘adolescent communication patterns and influence on emotional intelligence of high school students in bogor city’, coomunication journal of indonesian association of communication of scholars, 01, pp. 37–47. gunawan, h. (2013) ‘jenis pola komunikasi orang tua dengan anak perokok aktif di desa jembayan kecaatan loa kulu kabupaten kutai kartanegara’, ejournal ilmu komunikasi, 1(3), pp. 1–5. husna, m., tentama, f. and purwadi (2020) ‘validity and reliability analysis of the cyberbullying scale’, american scientific research journal for engineering, technology, and sciences (asrjets), 71(1), pp. 20–33. jiang, s. et al. (2021) ‘cyber victimization and psychological well-being among chinese adolescents: mediating role of basic psychological needs satisfaction and moderating role of positive parenting’, children and youth services review. elsevier, 130, p. 106248. jonsson, s., muhonen, t. and backstrom, r. c. f. m. (2017) ‘assessing exposure to bullying through digital devices in working life: two versions of a cyberbullying questionnaire (cbq)’, psychology, 8(3), pp. 477–494. doi: 10.4236/psych.2017.83030. jose martin-albo, juan l. nunez, jose g. navarro, and f. g. (2007) ‘the rosenberg self-esteem scale: translation and validation in university students’, the spanish journal of psychology, 10(2), pp. 458–467. doi: 10.1017/s1138741600006727. kpai (2019) ‘catatan kpai di hardiknas_ kasus anak bully guru meningkat drastis _ komisi perlindungan anak indonesia (kpai)’, 24 july. available at: https://www.kpai.go.id/publikasi/kpai-sebutanak-korban-kejahatan-dunia-maya-capai-679-kasus. luk, j.w., farhat, t., iannotti, r.j., & morton, b. g. (2010) ‘parent-child communication and substance use among adolescents: do father and mother communication play a different role for sons and daughters?’, addictive behaviors, 35:426-431., 35, pp. 426–431. mendez-baldwin, m. et al. (2015) ‘cyberbullying among teens’, journal of bullying and social aggression, 1(1). nursalam, n. et al. (2019) ‘association between insomnia and social network site use in indonesian adolescents’, nursing forum. department of mental health, gerontology and community nursing, faculty of nursing, universitas airlangga, surabaya, indonesia: john wiley and sons inc., 54(2), pp. 149–156. doi: 10.1111/nuf.12308. pandie, m. m. and weismann, i. t. j. (2016) ‘the effect of cyberbullying on social media on reactive behavior as perpetrators and victims of cyberbullying in christian middle school students in makassar’, jurnal jaffray, 14(1), pp. 42–62. patchin, j. w., & hinduja, s. (2012) ‘cyberbullying prevention and respons’, in cyberbullying prevention and respons. new york: routledge. rahayu, flourensia sapty (2012) ‘cyberbullying as a negative impact of information technology users. journal of information systems’, journal of informations systems, 8(1). doi: https://doi.org/10.21609/jsi.v8i1.321. runions, k. c. (2013) ‘toward a conceptual model of motive and selfcontrol in cyber-aggression: rage, revenge, reward, and recreation’, journal of & youth adolescence, 42, 751–771, 42(5), pp. 751–771. doi: 10.1007/s10964-013-9936-2. safaria, t. (2016) ‘prevalence and impact of cyberbullying in a sample of indonesian junior high school students.’, turkish online journal of educational technology-tojet. eric, 15(1), pp. 82–91. salmivalli, c. and nieminen, e. (2001) ‘proactive and reactive aggression among school bullies, victims, and bully-victims’, agrressive behavior, 28(1), pp. 30–44. doi: https://doi.org/10.1002/ab.90004. sartana and afriyeni, n. (2017) ‘cyber bullying in early adolescence. journal of psychology insight’, jurnal psikologi isight, 1(1), pp. 25–39. savita gupta, g. (2019) ‘family communication patterns questionnaire: development and validation’, international journal of recent technology and engineering (ijrte), 8(ic2), pp. 542–550. sopiyudi dahlan, m. (2016) sample size in medical and health research, series 2 edition 4. 2nd edn. jakarta: epidemiolog indonesia. sopiyudi dahlan, m. (2021) statistics for medicine and health. indonesia: salemba medika. talaei, a., b, m. r. f. and ardani, a. r. (2009) ‘gender, self-esteem, social support and depression among seventh grade students in junior high schools’, iranian journal of psikiatry, 4, pp. 17–22. tinakon, w. and nahathai, w. (2012) ‘a comparison of reliability and construct validity between the original and revised versions of the rosenberg self-esteem scale’, psychiatric symptomatology, 9(1), pp. 54–58. doi: https://doi.org/10.4306/pi.2012.9.1.54. whang, xhing-chao and yang, j. (2010) ‘reliability and validity of moral disengagement scale in chinese students’, chinese journal of clinical psychology, 18(2), pp. 177–179. yuliayana, r. and wichaikull, s. (2014) ‘gender, self-esteem, social support and depression among seventh grade students in junior high schools’, international proceedings of social and behavioral sciences, 2(1), pp. 142–148. how to cite this article: octavia d., sari r. m., merdekawati d., marisdayana r., yuliyana r. (2022) ‘the correlation between parental communication pattern, selfesteem, moral disengagement with cyberbullying behavior in early adolescents’, jurnal ners, 17(1), pp. 42-46. doi: http://dx.doi.org/10.20473/jn.v17i1.24539 table1 table2 table3 aini2018 bandura2002 bussey2015 febriana2019 firdanianty2016 gunawan2013 husna2020 jiang2021 jonsson2017 jose2007 kpai2019 luk2010 mendez2015 nursalam2019 pandie2016 patchin2012 rahayu2012 runions2013 safaria2016 salmivalli2001 sartana2017 savita2019 sopiyudi2016 talaei2009 tinakon2012 whang2010 yuliayana2014 321 kualitas layanan keperawatan (studi tentang ruang rawat inap rumah sakit di mojokerto) (a study about the quality of nursing services a hospitals’ ward, mojokerto) abdul muhith*, nurwidji* *stikes majapahit mojokerto, jl. raya jabon gayaman km.02, mojokerto email: cua_muhith@yahoo.co.id abstrak pendahuluan: saat ini, tren kunjungan rumah sakit yang ada di mojokerto menunjukkan kecenderungan menurun. penyebab tren yang menurun diduga berasal dari unsur man (perawat), yaitu kualitas layanan keperawatan yang belum maksimal. tujuan penelitian ini adalah menganalisis kualitas layanan keperawatan pada ruang rawat inap rumah sakit di mojokerto. metode: penelitian merupakan explanatory menggunakan metode survey dengan pendekatan cross-sectional. populasi adalah perawat dan pasien yang menjalani rawat inap minimal tiga hari di rsu dr. wahidin sudiro husodo dan rs rekso waluyo di mojokerto. data dikumpulkan dengan lembar kuesioner dan dianalisis dengan uji statistik regresi. hasil: 1) ada pengaruh yang signifikan positif langsung antara kemampuan kerja, etika rumah sakit, dan perilaku kepemimpinan terhadap komitmen perawat; 2) ada pengaruh yang signifikan antara faktor kemampuan kerja (identifikasi kerja, signifikansi kerja, otonomi, dan umpan balik) terhadap peningkatan kualitas layanan keperawatan; 3) ada pengaruh yang signifikan antara faktor etika rumah sakit (pengkomunikasian, berkaitan dengan industri, keharusan, dan spesifik) terhadap peningkatan kualitas layanan; 4) ada pengaruh yang signifikan antara faktor kepemimpinan rumah sakit (penantang risiko, memasyarakatkan atau mensosialisasikan visi misi, penggerak, penuntun, dan pendukung) terhadap peningkatan kualitas layanan keperawatan; 5) ada pengaruh yang signifikan antara komitmen perawat (rasa kepemilikan, keterkaitan, percaya pada pimpinan, dan kesesuaian nilai) terhadap peningkatan kualitas layanan keperawatan. diskusi: berdasarkan hasil penelitian diketahui untuk meningkatkan kualitas layanan keperawatan, maka manajemen rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto harus meningkatkan kemampuan perawat, pemberlakuan etika rumah sakit kepada seluruh perawat tanpa terkecuali, menyusun etika rumah sakit yang dapat mewakili berbagai kepentingan stakeholder, serta menjaga dan meningkatkan perilaku kepemimpinan di rumah sakit. kata kunci: keperawatan, kualitas, layanan (tangibility, reliability, responsiveness, assurance, empathy) abstract introduction: nowadays, the trend of hospital visits in mojokerto is declining. it can caused by man (nurses), such as the quality of nursing services hasn’t been conducted optimally. this study was aimed to analyze the quality of nursing services at hospitals’ ward at mojokerto. method: this was explanatory research with survey method and cross sectional approach. the population were nurses and patients who undergo hospitalization minimally in three days at rsu. dr. wahidin sudiro husodo and rs reksa waluyo mojokerto. the data were collected by using questionnaire, and then will be analyzed by using regression statistical test. result: 1) there was positive significance influence of nurses capability, hospital’s ethic, and leadership to the commitment of nurses; 2) there was significant influence of capability work (identification, significance, autonomy, and feedback) to the improvement of nursing services quality; 3) there was significant influence of hospital’s ethics (communication, relatedness with industry, compulsion, and specification) to the improvement of nursing services quality; 4) there was significant influence of leadership (challenger risk, socialization in vision and mission, supporter, guiding, and supporting) to the improvement of nursing services quality; 5) there was significant influence of nurses’ commitment (sense of belonging, sense of linking, believable leader, and suitability of value) to the improvement of nursing services quality. discussion: it can be concluded that in order to improve the quality of nursing service, management of rsu dr. wahidin sudiro husodo and rs rekso waluyo mojokerto should improve the ability of nurses, the enforcement of hospital ethics to all employees without exception, and develop hospital ethics that can represent various stakeholder interests, as well as maintain and improve leadership issue. keywords: nurses, quality, services (tangibility, reliability, responsiveness, assurance, empathy) pendahuluan rumah sakit merupakan salah satu bentuk industri jasa, di mana eksis dan tidaknya sebuah r umah sakit tergantung pada tingkat kepercayaan masyarakat dalam menggunakan jasa r umah sakit tersebut. kualitas pelayanan r umah sakit menjadi harapan bagi masyarakat. kualitas pelayanan keperawatan biasanya dikaitkan dengan proses penyembuhan, berkurangnya rasa sakit, kecepatan dalam pelayanan, keramahtamahan, dan tarif pelayanan yang murah (wiyono, jurnal ners vol. 9 no. 2 oktober 2014: 321–328 322 1999). menur ut wiyono (1999), kualitas layanan mer upakan gambaran total sifat dari suatu produk atau jasa pelayanan yang berhubungan dengan kemampuannya untuk memenuhi kepuasan. untuk memenangkan sebuah persaingan global dalam merebut pangsa pasar dan makin dipercaya oleh masyarakat, maka rumah sakit harus bisa member ikan jaminan kepuasan kepada pasien. peningkatan kualitas pelayanan yang komprehensif dan menyeluruh terutama pada pelayanan keperawatan bisa menjadi modal utamanya. pelayanan keperawatan merupakan garis terdepan ( frontliners) dalam pemberian pelayanan jasa rumah sakit, di mana perawat selalu berada bersama pasien selama pasien rawat inap di rumah sakit. ke p e r awat a n sebaga i p elaya n a n profesional bersifat humanistik, menggunakan pendekatan holistik, dilakukan berdasarkan ilmu dan kiat keperawatan, berorientasi kepada kebutuhan pasien, mengacu pada standar profesional keperawatan, dan menggunakan etika keperawatan sebagai tuntutan utama. pelayanan keperawatan yang berkualitas merupakan salah satu kebutuhan dasar yang diperlukan setiap orang. sampai saat ini, para ahli keperawatan dan kesehatan senantiasa berusaha meningkatkan mutu diri, profesi, maupun peralatan keperawatan, demikian pula kemampuan manajerial keperawatan, khususnya manajemen kualitas pelayanan keperawatan juga ditingkatkan (nursalam, 2003). sebagai contoh apabila peralatan keperawatan sebagai salah satu sarana di dalam melayani pasien tidak tersedia dalam jumlah yang mencukupi (misalnya, jumlah tensimeter untuk mengukur tekanan darah pasien secara rutin setiap pagi jumlahnya tidak mencukupi). apabila peralatan tersebut tidak dapat berfungsi sebagaimana mestinya, hal ini mencer minkan bahwa pelayanan yang diberikan oleh rumah sakit kepada para perawat (pelayanan internal) tidak berkualitas. apabila kualitas pelayanan internal rendah maka akan berpengaruh terhadap kinerja perawat dalam melayani pasien. kualitas pelaya na n i nter nal ya ng rend a h a ka n mengakibatkan perawat tidak dapat melayani pasien secara optimal. perawat yang tidak puas terhadap kinerja perawat akan menunjukkan perilaku tidak loyal terhadap rumah sakit, seperti misalnya rentan untuk pindah kerja ke rumah sakit lain yang memiliki peralatan jauh lebih lengkap dan berkualitas yang dapat menunjang kelancaran pekerjaannya. selain itu, akibat dari ketidakpuasan kerja perawat juga berpengaruh terhadap kualitas pelayanan yang diberikan oleh perawat kepada pasien (pelayanan eksternal). apabila pelayanan yang diberikan kepada pasien berkualitas rendah, hal ini akan membawa pengaruh pada ketidakpuasan pasien terhadap pelayanan keperawatan yang mereka terima, khususnya kepuasan pasien pada aspek interpersonal akan rendah. akibat dari ketidakpuasan terhadap pelayanan keperawatan yang diterimanya tersebut, pasien akan berperilaku negatif seperti misalnya menceritakan hal buruk sehubungan dengan pelayanan keperawatan di rumah sakit yang bersangkutan. era globalisasi dan era infor masi telah menyebabkan berkembangnya tuntutan baru di segala sektor, tidak terkecuali dalam sektor pelayanan kesehatan. hal tersebut telah membuat dunia keperawatan di indonesia u nt u k ter u s mengemba ng k a n k u alit a s pelayanan keperawatan. namun, masih ada hambatan yang dihadapi oleh keperawatan di indonesia, di antaranya adalah keterbatasan sumber daya manusia bidang keperawatan dan ketersediaan teknologi informasi secara terpadu (rini, 2009). berkurangnya kepercayaan masyarakat pada industri rumah sakit berdampak pada menurunnya jumlah pengguna jasa rumah sakit. calon pengguna jadi tidak percaya akan pelayanan yang diberikan dan akan berpaling ke rumah sakit lain yang lebih menjanjikan dan lebih representatif. saat ini tren kualitas layanan rumah sakit yang ada di mojokerto menunjukkan masih belum optimal. penyebab tren yang menurun di ruangan rawat inap rumah sakit diduga karena unsur manusia (perawat) yaitu kualitas pelayanan keperawatan yang belum maksimal dalam memberikan pelayanan keperawatan. perawat merupakan salah sat u bagi dar i sistem pelayanan kesehatan di rumah sakit. menurut aditama (2003), keperawatan adalah salah satu profesi kualitas layanan keperawatan (abdul muhith dan nurwidji) 323 di rumah sakit yang berperan penting dalam menjalankan pekerjaannya, seorang perawat menggunakan standar praktik keperawatan. bahan dan metode penelitian mer upakan explanator y me ng g u n a k a n met ode su r vey de nga n pendekatan cross-sectional. populasi adalah perawat dan pasien yang menjalani rawat inap minimal tiga hari di rsu dr. wahidin sudiro husodo dan rs rekso waluyo di mojokerto. kriteria sampel untuk pasien, adalah 1) pasien atau keluarga berusia di atas 17 tahun; dan 2) mampu menjawab per t anya an yang diberikan. sedangkan kriteria sampel untuk perawat, adalah perawat yang bertugas di unit instalasi rawat inap di rsu dr. wahidin sudiro husodo dan rs rekso waluyo, diambil dengan stratified random sampling berdasarkan strata perawat. variabel terdiri atas 3 kelompok, yakni: 1) variabel eksogen (yaitu, kemampuan kerja, etika rumah sakit, dan perilaku kepemimpinan d i r u ma h sa k it); 2) va r iabel endogen intervening, yaitu komitmen perawat; dan 3) variabel endogen, yaitu kualitas layanan. variabel kemampuan kerja diukur dengan kuesioner job characteristics hackman dan oldman (luthans, 1998), etika rumah sakit diukur dengan kuesioner corporate ethics (murphy, 1995) dan program ethics control orientation (weaver et al., 1999), perilaku kepemimpinan rumah sakit diukur dengan leadership practice inventory (lpi-others) (kouzes dan posner, 1990; smith, 1996), komit men perawat diu k u r dengan the origanizatiorial commitment questionaire (mowday et al., 1979; luthans, 1998), serta kualitas layanan diukur dengan menggunakan kuesioner servqual (parasuraman et al, 1988) dan imrie (2002) yang telah disesuaikan dengan karakteristik jasa layanan keperawatan rumah sakit. pengujian keberlakukan hipotesis yang telah dirumuskan dalam penelitian ini menggunakan teknik analisis uji regresi yaitu untuk mengetahui ada tidaknya pengaruh variabel yang diteliti. hasil tabel 1. hasil analisis terhadap aspek tampilan fisik (tangibility) perawat no aspek tampilan fisik (tangibility) frekuensi % 1 sangat tidak baik 1 2,0 2 tidak baik 3 6,0 3 kurang baik 10 20,0 4 baik 33 66,0 5 sangat baik 3 6,0 total 50 100,0 tabel 2. h a s i l a n a l i s i s t e r h a d a p a s p e k kehandalan (reliability) no aspek kehandalan (reliability) frekuensi % 1 sangat tidak baik 1 2,0 2 tidak baik 3 6,0 3 kurang baik 14 28,0 4 baik 29 58,0 5 sangat baik 3 6,0 total 50 100,0 tabel 3. hasil analisis terhadap aspek daya tanggap (responsiveness) perawat no aspek daya tanggap (responsiveness) petugas frekuensi % 1 sangat tidak baik 2 4,0 2 tidak baik 4 8,0 3 kurang baik 13 26,0 4 baik 28 56,0 5 sangat baik 3 6,0 total 50 100,0 tabel 4. hasil analisis terhadap aspek jaminan rasa aman (assurance) no aspek jaminana rasa aman (assurance) frekuensi % 1 sangat tidak baik 1 2,0 2 tidak baik 5 10,0 3 kurang baik 12 24,0 4 baik 29 58,0 5 sangat baik 3 6,0 total 50 100,0 jurnal ners vol. 9 no. 2 oktober 2014: 321–328 324 berdasarkan tabel 6 diperoleh informasi bahwa nilai signif ikansi (p) pada faktor kemampuan kerja perawat adalah p=0,753 lebih dari 0,05 yang terdiri dari identifikasi kerja ( p=0,360), signifikansi kerja ( p=0,520), otonomi ( p=0,984), dan umpan balik ( p= 0,743) lebih dari α 0,05. hal ini menunjukkan bahwa ada pengaruh yang signifikan antara faktor kemampuan kerja (identifikasi kerja, signifikansi kerja, otonomi dan umpan balik) terhadap peningkatan kualitas layanan di ruang rawat inap rumah sakit mojokerto. tabel 7 menginfor masikan bahwa nilai signifikansi (p) dari faktor etika rumah sakit adalah p=0,979 lebih dari 0,05. hal ini menunjukkan bahwa ada pengaruh yang signifikan antara faktor etika rumah sakit (pengkomunikasian, berkaitan dengan industri, keharusan, dan spesifik) terhadap peningkatan kualitas layanan di ruang rawat inap rumah sakit mojokerto. b e r d a s a r k a n t a b el 8 d i p e r ole h informasi bahwa nilai signifikansi pada faktor kepemimpinan perawat p=0,321 lebih dari 0,05. hal ini berarti bahwa ada pengaruh yang signifikan antara faktor kepemimpinan tabel 5. hasil analisis terhadap aspek empati (empathy) perawat no aspek empati (empathy) petugas frekuensi % 1 sangat tidak baik 1 2,0 2 tidak baik 6 12,0 3 kurang baik 10 20,0 4 baik 30 60,0 5 sangat baik 3 6,0 total 50 100,0 tabel 6 hasil uji pengaruh faktor kemampuan kerja (identifikasi kerja, signifikansi kerja, otonomi dan umpan balik) terhadap meningkatkan kualitas layanan no variabel signifikansi faktor kemampuan kerja 0,753 1 identifikasi kerja 0,360 2 signifikansi kerja 0,520 3 otonomi 0,984 4 umpan balik 0,743 tabel 7 hasil uji pengaruh faktor etika rumah sakit (pengkomunikasian, berkaitan dengan industri, keharusan, dan spesifik) terhadap meningkatkan kualitas layanan no variabel signifikansi faktor etika rumah sakit 0,979 1 pengkomunikasian 0,723 2 berkaitan dengan industri 0,885 3 keharusan 0,575 4 spesifik 0,953 tabel 8 hasil uji pengaruh faktor kepemimpinan keperawatan rumah sakit (penantang risiko, memasyarakatkan atau mensosialisasikan visi misi, penggerak, penuntun, dan pendukung) terhadap meningkatkan kualitas layanan no variabel signifikansi faktor kepemimpinan perawat 0,321 1 penantang risiko 0,505 2 memasyarakatkan/ mensosialisasikan visi misi 0,759 3 penggerak 0,849 4 penuntun 0,309 5 pendukung 0,714 tabel 9. h a s i l u j i p e n g a r u h k o m i t m e n perawat (rasa kepemilikan, rasa keterkaitan, percaya pada pimpinan, dan kesesuaian nilai) terhadap meningkatkan kualitas layanan no variabel signifikansi faktor komitmen perawat 0,001 1 rasa kepemilikan 0,705 2 rasa keterkaitan 0,217 3 percaya pada pimpinan 0,191 4 kesesuaian nilai 0,000 keperawatan rumah sakit (penantang risiko, memasyarakatkan/mensosialisasikan visi misi, penggerak, penuntun, dan pendukung) terhadap peningkatan kualitas layanan di ruang rawat inap rumah sakit mojokerto. tabel 9 menginfor masikan bahwa terdapat pengaruh yang signifikan antara kualitas layanan keperawatan (abdul muhith dan nurwidji) 325 komitmen perawat (rasa kepemilikan, rasa keterkaitan, percaya pada pimpinan, dan kesesuaian nilai) terhadap kinerja perawat dalam meningkatkan kualitas layanan di ruang rawat inap rumah sakit mojokerto. pembahasan kemampuan kerja perawat di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto memiliki pengaruh yang signifikan terhadap kualitas layanan, telah dibuktikan keabsahannya melalui pengujian hipotesis. hasil dari pengujian tersebut menyatakan bahwa kemampuan kerja perawat di rsu dr. wahidin sudiro husodo dan rumah sakit rekso waluyo mojokerto berpengaruh secara signifikan positif langsung terhadap kualitas layanan keperawatan, dengan koef isien jalur sebesar 0,35. hasil ini diperkuat oleh perolehan nilai p= 0,000 (< 0, 05) yang menunjuk kan bahwa hubungan terbukti secara signifikan antara kemampuan kerja perawat dengan kualitas layanan keperawatan. ini mengindikasikan bahwa semakin tinggi kemampuan kerja perawat di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto (berdasarkan dimensi atau indikator identifikasi kerja, signifikansi kerja, otonomi, dan umpan balik), maka tingkat kualitas layanan rawat inap di rumah sakit berdasarkan penilaian perawat semakin baik pula. hasil penelitian ini konsisten dengan teori interaktif pemasaran gronroos (kotler, 2000), yang menekankan pentingnya proses penyampaian layanan kepada pelanggan. secara implisit (tidak langsung) kompetensi karyawan memberikan pengaruh terhadap kualitas layanan melalui terciptanya iklim layanan yang dapat memuaskan pelanggan. kualitas iklim penyajian layanan oleh para penyaji layanan ini dikenal dengan istilah internal service quality, yang pada prinsipnya dipengaruhi oleh berbagai faktor, antara lain kemampuan karyawan, sistem kerja, dan karakteristik dari organisasi. selain penemuan terhadap pengaruh positif langsu ng dan sig nif ikan antara kemampuan kerja perawat dengan kualitas l ay a n a n ke p e r aw a t a n , p e n el it i a n i n i membuktikan pula bahwa dalam hubungannya dengan k ualitas layanan, terdapat pula pengaruh positif dan tidak langsung antara kemampuan kerja perawat dengan kualitas layanan. ini disebabkan oleh keberadaan variabel komitmen perawat sebagai variabel yang mengantarai kemampuan kerja dengan kualitas layanan. temuan ini mengindikasikan bahwa kemampuan kerja perawat di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto tidak semata-mata berpengaruh langsung terhadap kualitas layanan, tetapi juga berpengaruh tidak langsung melalui variabel komitmen perawat. temuan ini mempertegas pendapat luthans (1998:200) yang menyatakan bahwa variabel komitmen karyawan dapat diperlakukan sebagai variabel antara yang mengantarai hubungan kausal antar dua variabel lain. pendugaan terhadap hubungan yang signifikan antara etika yang berlaku di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto dengan kualitas layanan keperawat a n tela h d ibu k t i ka n melalu i pengujian hipotesis. hasil yang diperoleh dari pengujian terhadap hipotesis ini adalah bahwa etika rumah sakit berpengaruh langsung dan signifikan terhadap kualitas layanan keperawatan, dengan koefisien jalur sebesar 0, 94. sedangkan signifikansi hasil ini dibuktikan dengan perolehan nilai cr>2 (uji t), dengan p<0.05. temuan ini mengindikasikan bahwa semakin baik pemberlakuan etika rumah sakit di lingkungan rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto, serta semakin baik penilaian perawat pada apa yang terkandung dalam etika rumah sakit, akan menyebabkan kualitas layanan menjadi semakin tinggi. temuan empiris ini sejalan dengan beberapa temuan robbins (murphy, 1995), di mana pada kode etik perusahaan-perusahaan besar di dunia, salah satunya adalah bersikap baiklah pada pelanggan anda. pernyataan ini memiliki makna yang sangat luas, yang artinya bahwa perlakukan pelanggan dengan sebaik-baiknya dengan memberikan layanan yang berkualitas kepada para pelanggan. d i a nt a r a ket iga va r iab el ya ng diprediksikan sebagai pembangun kualitas jurnal ners vol. 9 no. 2 oktober 2014: 321–328 326 layanan keperawatan, variabel etika rumah sakit ini yang memiliki pengaruh terbesar, yakni sebesar 0,94. selain penemuan terhadap pengaruh positif langsung antara etika rumah sakit dengan kualitas layanan keperawatan, ditemukan pula pengaruh positif tidak langsung antara etika rumah sakit dengan kualitas layanan keperawatan. hasil ini menunjukkan bahwa dalam hubungan etika rumah sakit dengan kualitas layanan keperawatan, terdapat variabel yang mengantarai hubungan antara kedua variabel tersebut, yak ni variabel komitmen perawat. dengan demikian dapat dinyatakan bahwa dalam rangka meningkatkan kualitas layanan keperawatan rsu dr. wahidin sudiro husodo dan waluyo mojoker to, pihak manajemen rumah sakit harus lebih mengutamakan pemberlakuan etika rumah sakit, serta lebih memperhatikan penilaian perawat pada apa yang terkandung pada etika rumah sakit tersebut. selain etika rumah sakit, dalam hubungannya dengan kualitas layanan keperawatan manajemen rumah sakit juga harus memberikan perhatian secara khusus pada komitmen perawat pada rumah sakit. per ila k u kepem i mpi nan rsu d r. wahidin sudiro husodo dan rs rekso waluyo mojokerto memiliki pengaruh yang signifikan terhadap kualitas layanan keperawatan melalui hasil pengujian hipotesis, telah terbukti keabsahannya. hasil pengujian terhadap dugaan ini menemukan bahwa perilaku kepemimpinan rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto berpengaruh positif langsung secara signifikan terhadap kualitas layanan keperawatan dengan koef isien jalur sebesar 0,71. sedangkan, signif ikansi hasil ini dibuktikan dengan perolehan nilai cr>2 (uji t), dengan p<0.05. hasil st udi ini mengindikasikan bahwa apabila para bawahan menilai baik perilaku kepemimpinan, maka tingkat kualitas layanan keperawatan rawat inap akan semakin baik pula. pada dasar nya studi ini konsisten dengan temuan para ahli sebelumnya yang menyatakan bahwa terdapat hubungan antara kepemimpinan dengan motivasi dan kinerja para bawahan. smith (1996) menyatakan ba hwa per ila k u kepem i mpi na n sa ngat mempengaruhi keberhasilan suatu organisasi. pernyataan ini menyiratkan bahwa perilaku kepemimpinan seorang pimpinan tercermin pada perilaku para karyawannya. oleh karena itu, perilaku kepemimpinan yang dapat menjadi contoh positif bagi karyawannya, mampu menga rah ka n ka r yawa n u nt u k mengoptimalkan kinerjanya. selain pengar u h langsu ng ant ara perilaku kepemimpinan dengan kualitas layanan keperawatan, yang telah terbukti secara empiris. terdapat pula pengaruh tidak langsung antara perilaku kepemimpinan dengan kualitas layanan keperawatan. keadaan ini menunjukkan bahwa dalam menelaah hubungan antara perilaku kepemimpinan dengan kualitas layanan keperawatan, terdapat satu variabel yang mengantarai hubungan tersebut, yakni variabel komitmen perawat. dengan demikian temuan terapan dar i hasil studi ini adalah bahwa dalam rangka meningkatkan kualitas layanan rawat inap pasien di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto, membutuhkan seorang pimpinan yang memiliki perilaku kepemimpinan sebagai penantang risiko, memasyarakatkan visi rumah sakit, penggerak, penuntun, dan pendukung perawat. perilaku pimpinan inilah yang menciptakan iklim layanan keperawatan rumah sakit berkualitas berdasarkan penilaian pasien sebagai pengguna layanan keperawatan rumah sakit. oleh karena itu, perilaku kepemimpinan pimpinan di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojoker to, (khususnya perilaku sebagai penantang risiko, memasyarakatkan visi rumah sakit, penggerak, penuntun dan pendukung) harus lebih ditingkatkan lagi. komitmen perawat di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto memiliki pengaruh yang signifikan terhadap kualitas layanan keperawatan. berdasarkan pengujian hipotesis, maka hasil pengujian menunjukkan diterimanya dugaan yang menyatakan bahwa terdapat pengaruh langsung yang signifikan antara komitmen perawat dengan kualitas layanan keperawatan, mesk ipu n koef isien penga r u h tersebut memiliki nilai cr>2,0 serta p< 0,05. hasil ini mengindikasikan bahwa terdapat pengaruh kualitas layanan keperawatan (abdul muhith dan nurwidji) 327 yang saling bertolak belakang antara komitmen perawat dengan kualitas layanan keperawatan. ini berarti bahwa dalam konteks komitmen perawat di rsu dr. wahidin sudiro husodo dan rs rekso waluyo mojokerto (berdasarkan indikator kepemilikan, ketertarikan, percaya dan kesamaan nilai), memiliki pengaruh yang saling ber tolak belakang terhadap kualitas layanan keperawatan (berdasarkan indikator tangibility, reliability, empathy, responsiveness, assurance). pada dasarnya kualitas layanan rumah sakit yang diukur oleh pasien merupakan salah satu pengukuran terhadap kinerja layanan yang disajikan oleh rumah sakit. berdasarkan pendapat para ahli terdapat tiga sudut pandang atau kelompok variabel yang dapat ditelaah dalam menjelaskan hubungan antara komitmen dengan kinerja karyawan (komitmen karyawan dan outcomes dari komitmen karyawan), antara lain: 1) kelompok variabel yang menggambarkan karakteristik pekerjaan yang harus dihasilkan karyawan; 2) kelompok variabel yang menggambarkan karakteristik perusahaan; serta 3) kelompok variabel yang menggambarkan karakteristik dari para karyawan dalam bekerja. ketiga kelompok variabel ini menjelaskan adanya hubungan antara variabel komitmen karyawan dengan variabel outcomes dari komitmen tersebut. nampak nya temuan atau hasil analisis terhadap hubungan antara komitmen kar yawan dengan k ualit as layanan ini mendukung temuan steers (1977). penjelasan terhadap fenomena ini telah disinggung oleh luthans (1998:150) dengan menyatakan bahwa pendefinisian dari variabel komitmen karyawan dan indikator yang membangun komitmen karyawan tersebut (antecedents dari komitmen karyawan) memiliki kemungkinan menjadi penyebab tidak adanya hubungan signifikan antara komitmen karyawan dengan outcomes komitmen tersebut. simpulan dan saran simpulan s e c a r a k e s e l u r u h a n p e n g a r u h kemampuan kerja, etika rumah sakit, dan perilaku kepemimpinan pimpinan rumah sakit, serta komitmen perawat terhadap kualitas layanan keperawatan dapat dibuktikan secara empiris dan teoritis. temuan ini memberikan gambaran bahwa dalam rangka meningkatkan kualitas layanan keperawatan, manajemen rsu dr. wahidin sudiro husodo dan rekso waluyo mojokerto harus meningkatkan kemampuan perawat, meningkatkan pemberlakuan etika rumah sakit kepada seluruh karyawan rumah sakit tanpa terkecuali, menyusun suatu etika rumah sakit yang dapat mewakili berbagai kepent i nga n sta k eholder r u ma h sa k it, serta menjaga dan meningkatkan perilaku kepemimpinan pimpinan rumah sakit. saran manajemen rumah sakit diharapkan membenahi lagi job spesifications perawat di rumah sakit untuk menghilangkan kesan bahwa para perawat cenderung melakukan pekerjaan apa saja (serabutan). selain itu, untuk mencegah timbulnya perasaan terbebani oleh rutinitas pekerjaan sehari-hari, manajemen rumah sakit sebaiknya mencanangkan program meningkatkan kemampuan, dengan berbasis open space course secara berkala (yaitu suatu program pelatihan yang diadakan di alam terbuka), yang dimaksudkan untuk mengupgrade kemampuan sekaligus secara tidak langsung relaksasi dari rutinitas dan beban pekerjaan sehari-hari. p i h a k m a n aje m e n r u m a h s a k it diharapkan juga memberikan ekstra perhatian kepada para karyawan rumah sakit (tanpa terkecuali), berkenaan dengan prestasi yang dicapai oleh mereka melalui pengevaluasian k i ne r ja p e r awat p e r t r iw u la n sek a l i. penghargaan tersebut tidak harus berupa benda yang mahal, akan tetapi substansi dari itu adalah pengakuan dari pihak manajemen rumah sakit pada keberadaan perawat, serta menunjukkan kepedulian rumah sakit pada kinerja perawat. keadaan ini akan mempertebal sense of belonging perawat pada rumah sakit, serta menumbuhkan iklim kompetisi di antara perawat sehingga semangat kerja mereka menjadi lebih tinggi lagi. pihak manajemen rumah sakit juga dapat menerapkan good hospital governance, yakni pengelolaan terhadap kualitas layanan keperawatan yang jurnal ners vol. 9 no. 2 oktober 2014: 321–328 328 baik. konsep ini memfokuskan pada prinsipprinsip akuntabilitas, profesionalisme, dan tranparansi. bo a r d of d i re c to r r u m a h s a k it diharapkan berperilaku sebagai penantang risiko, memasyarakatkan misi rumah sakit di antara para perawat rumah sakit, bertindak sebagai motivator, penuntun, dan pendukung bagi para perawat r umah sakit. dengan demikian pimpinan akan menjadi figur bagi para bawahan, sehingga tidak menimbulkan salah persepsi dan akan menimbul kan confidence in management leadership rumah sakit. kepustakaan aditama. 2006. manajemen administrasi rumah sakit, universitas indonesia press, jakarta gronroos. 1995. relationship marketing the strategy continum, journal of academy of marketing science, vol. 23, no. 4, pp. 252–254. kotler .1997. mark eting management, analysis, planning, implementation and control, nine edition, new jersey: prentice hall international, inc. kotler. 2000. marketing management, 10th ed, united states: prentice hall, englewood cliffs. kotler and amstrong. 2001. principles of marketing, ninth edition, usa: prentice hall inc. luthans. 1998. organizational behavior, eight edition, new jersey, usa: irwin mcgraw-hill. murphy. 1995. corporate ethics statement: current status and future prospect, journal of business ethics, vol. 99, p. 575–587. nursalam. 2003. proses dan dokumentasi k e p e r a w a t a n . ja k a r t a : sa le mb a medika. parasuraman, berry, and zeithaml. 1998. servqual: a multiple-item scale for measuring consumer perceptions for service quality, journal of retailing, 64, p. 12–40. rini. 2009. perkembangan ti dalam rumah sakit. jakarta: ecg. robbins. 1996. organizational behavior, concepts, controversies, aplications, 7 th-ed, new jersey, usa: prentice hall inc. smith. 1996. total quality service: principles, practices & implementation. singapore: ssmb publishing division. steers. 1977. antecedent and outcomes of o r g a n i z a t io n a l c o m m it m e n t , administrative science qartely, vol. 22, p. 46–56. wiyono. 2000. manajemen mutu paripurna pelayanan kesehatan. jakarta: salemba medika. vol 9 no 1 april 2014.indd 43 deteksi keparahan fungsi ginjal melalui perubahan kritis laju filtrasi glomerulus pasien hemodialisa (severity renal function detection through critical changes glomerular filtration rate in hemodialysis patients) martono*, satino* *jurusan keperawatan politeknik kesehatan surakarta, jl. letjend sutoyo mojosongo surakarta 0271-856929. fax. 0271-855388 e-mail: must_ton@ymail.com abstrak pendahuluan: hemodialisa (cuci darah ) sering diartikan salah. orang beranggapan bahwa tindakan tersebut merupakan tindakan yang akan menyembuhkan pengobatan pasien hemodialisa dengan gagal ginjal setelah hemodialisa. tujuan dari penelitian ini adalah untuk mengetahui kemampuan dari perubahan penting dalam laju fi ltrasi glomerulus ginjal pada pasien dengan hemodialisa asuhan keperawatan. metode: desain studi kuasi-eksperimental dilakukan 2 kali pengamatan bahwa pre-test dan post-test dengan pendekatan retrospektif. populasi penelitian adalah semua pasien yang menjalani hemodialisa dengan ukuran sampel 33 responden. analisis data penelitian menggunakan uji paired t berpasangan. hasil: hasil penelitian ini menunjukkan bahwa hemodialisa memperbaiki terhadap laju fi ltrasi glomerulus dan lebih mampu mendeteksi dan mencegah keparahan fungsi ginjal untuk perubahan yang dibuktikan dengan nilai p = 0,031. diskusi: laju fi ltrasi glomerulus hemodialisa fi x terhadap lebih mampu mendeteksi dan mencegah keparahan fungsi ginjal dengan kemampuan untuk memperhitungkan stabilitas usia dan jenis kelamin dan berat. semua pasien dengan gagal ginjal kronis dalam tahap terminal diharapkan untuk mengikuti dan mematuhi program hemodialisa reguler dengan berat hal stabilisasi, usia, dan jenis kelamin untuk menghindari keparahan fungsi ginjal buruk. kata kunci: laju filtrasi glomerulus, hemodialisa, keparahan fungsi ginjal abstract introductions: hemodialysis is often interpreted incorrectly. people assume that the action is an action that will cure the treatment of hemodialysis patients with renal failure after hemodialysis. the purpose of this study was to determine the ability of critical changes in renal glomerular fi ltration rate in patients with hemodialysis nursing care. method: the design is quasi-experimental study carried out 2 times the observation that pre-test and post-test with a retrospective approach. the study population was all patients who underwent hemodialysis with a sample size of 33 respondents. analysis of the research data using the paired t test. result: the results of this study indicate that the glomerular fi ltration rate fi xing hemodialysis towards better able to detect and prevent the severity of renal function as evidenced by the value of p = 0.031 for change 9.18. discussion: hemodialysis fi x glomerular fi ltration rate towards better able to detect and prevent the severity of renal function with the ability to take into account the age and sex and weight stability. all the patients with chronic renal failure in the terminal stage are expected to follow and adhere to regular hemodialysis program with regard stabilization weight, age, and sex in order to avoid the severity of kidney function worse. keyword: glomerular filtration rate, hemodialysis, severity of kidney function pendahuluan indonesia merupakan jumlah penduduk kelima terbesar di dunia. bergesernya pola kependudukan bergeser pula pola di dalam masyarakat dan penyakit tidak menular yang salah satunya adalah penyakit gagal ginjal. pasien dengan penyakit gagal ginjal yang berada pada tahap yang berat ditunjukkan denga n ket id a k ma mpu a n g i njal u nt u k membuang sisa-sisa zat metabolisme dari dalam tubuh. hal ini sesuai penjelasan perhimpunan nefrologi indonesia (pernefri, 2003) yang menjelaskan bahwa di indonesia diperkirakan kurang lebih 70.000 penderita mengalami gagal ginjal. angka tersebut diperkirakan terus meningkat dengan pertumbuhan sekitar 10% setiap tahun. dari 70.000 dari gagal ginjal kronik tersebut terdeteksi menderita gagal ginjal kronik tahap terminal yang menjalani hemodialisa hanya 4000 sampai 5000 pasien dari total seluruh penderita gagal ginjal hemodialisa merupakan solusi alternatif dialisis yang digunakan ketika ginjal tidak mampu lagi unt u k membuang sisa-sisa zat metabolisme dari dalam tubuh. sejauh 44 jurnal ners vol. 9 no. 1 april 2014: 43–48 ini hemodialisa (cuci darah) tidak begitu terkenal di kalangan masyarakat luas. sering hemodialisa diartikan yang salah sebagian masyarakat bahwa hemodialisa merupakan tindakan pengobatan yang menyembuhkan pasien dari penyakit gagal ginjal setelah beberapa kali dilakukan hemodialisa. salah satu keuntungan proses jalannya t i nd a k a n t e r sebut a d ala h d a r a h ya ng mengandung hasil sisa-sisa metabolisme dengan konsentrasi tinggi dilewatkan pada membran semipermeabel yang terdapat dalam dialyser. sisa metabolism tubuh seperti ureum dan kreatinin dapat disaring melalui proses difusi, sehingga terpisah dari darah bersih dan kadar ureum kreatinin akan menurun. keadaan tersebut juga dapat mengembalikan status fisiologi ginjal menjadi lebih baik dengan mempertahankan kemampuan fungsi ginjal untuk mengeksresikan sisa produk nitrogen, toksin dan obat-obatan, mampu untuk menangani beban air dan elektrolit dengan efisien, keseimbangan asam basa, dan mampu memprodu ksi er it ropoetin. kalau mesin ini terganggu maka tubuh akan keracunan dari sampah hasil metabolisme tubuh, sehingga akan menimbulkan bentuk penyakit akibat bagian-bagian tubuh terganggu oleh menumpuknya racun (syamsir & broto, 2007). namun, penur unan jumlah nefron menimbulkan retensi terutama sisa-sisa produk yang tergantung kepada tingginya kecepatan fi ltrasi glumerulus untuk diekskresi. karena itu, pemeriksaan uji fungsi ginjal perlu dilakukan untuk membantu menegakkan diagnosa, memantau pengobatan dan perjalanan penyakit serta membuat prognosis. tes uji fungsi ginjal yang sering dilakukan antara lain tes pemekatan urin, klirens kreatinin, kreatinin serum, dan ureum serum. namun demikian penelitian ini dibatasi pada pengukuran kreatinin serum untuk menentukan perubahan nilai kritis kemampuan laju fi ltrasi glomerulus pada asuhan keperawatan pasien dengan hemodialisa. kreatinin serum merupakan masalah yang paling menonjol yang dapat dianalisa seberapa jauh kemampuan fungsi ginjal. konsentrasi normal urea dalam darah adalah 26 mg/dl, tetapi pada pasien infusiensi ginjal berat dapat meningkat sampai 300 mg/dl. pada konsentrasi normal kreatinin darah adalah 1,1 mg/dl, tetapi pada pasien ini meningkat sampai sepuluh kali lipat. pasienpasien yang menjalani terapi dialisa 1 tahun kenyataanya lebih bertahan dibandingkan pada pasien yang menjalani terapi lebih dari 3 tahun (long, 2006). berdasarkan studi pendahuluan yang dilakukan di ruang hemodialisa rumah sakit umum daerah dr. moewardi surakarta tahun 2013 ditemukan 180 orang yang dilakukan hemodialisa, kurang lebih 11.1% pasien kemampuan fungsi ginjal mampu bertahan 3 sampai 4 tahun, 27.8% pasien kemampuan fungsi ginjal mampu bertahan selama 2 tahun dan 61.1% pasien masih bertahan selama 1 tahun. untuk mendeteksi indikasi komplikasi dini dan tingkat keparahan kemampuan fungsi ginjal setelah hemodialisa dilakukan pemer i ksaan analisa darah. hasil dar i pengukuran tersebut menunjukkan bersihan darah menjadi turun dan bahkan sebaliknya. berdasarkan uraian subtansi tersebut, perlu dilakukan penelitian tentang per ubahan kritis kemampuan laju filtrasi glomerulus pada asuhan keperawatan pasien gagal ginjal kronik yang dilakukan hemodialisa dalam mendekteksi tingkat keparahan fungsi ginjal. hasil penelitian yang dilakukan oleh (saryono, 2006) menunjukkan bahwa dari 52 sampel pasien dengan gagal ginjal kronis yang akan melakukan hemodialisis memiliki tinggi ureum dan kreatinin. frekuensi dilakukan dialisis selama seminggu cenderung menurunkan ureum dan tingkat kreatinin. menurut (guyton, 2006) salah satu cara untuk mendeteksi gangguan fungsi ginjal yang dilakukan menggunakan uji glomeruli. lebih lanjut dijelaskan bahwa kelainan fungsi glomeruli secara sederhana biasanya dilihat dari kadar ureum, dan k reatinin darah. perkumpulan nefrologi indonesia (pernefri) menganjurkan bahwa unt uk mengetahui perkiraan keparahan gangguan fungsi ginjal menggunakan glomerulus fi ltrate rate (gfr) dengan rumus cockcroft-gault yang dihitung berdasarkan kadar kreatinin dan menggunakan data usia, berat badan, jenis kelamin dan etnis. 45 deteksi keparahan fungsi ginjal (martono dan satino) bahan dan metode pe n el it i a n i n i d i l a k u k a n u nt u k mengetahui kemampuan kritis laju filtrasi glome r u lu s pa d a a su ha n ke per awat a n pasien gagal ginjal kronik yang dilakukan hemodialisa unt uk mendekteksi tingkat keparahan fungsi ginjal dengan rancangan quasi eksperimen menggunakan pendekatan retrospektif. populasi pada penelitian ini adalah semua pasien gagal ginjal kronik yang dilakukan hemodialisa. sampel pada penelitian ini dilakukan observasi sebanyak 2 kali sebelum dan sesudah dilak u kan hemodialisa terhadap 33 pasien gagal ginjal kronik di ruang hemodialisa rsud dr. moewardi surakarta. teknik analisa data untuk mengetahui per ubahan nilai kritis kemampuan laju fi ltrasi glomerulus ginjal pada asuhan keperawatan pasien yang dilakukan hemodialisa menggunakan uji t berpasangan. sedangkan pengukuran kemampuan laju fi ltrasi glomerulus penelitian ini menggunakan rumus cockroft-gault yaitu: gfr= 186x(kreatinin ser um)-1,154x (umur)-0,203x(0,742 jika wanita)x (1,210, jika kulit hitam) (cockroft, 1976). l e bi h l a nj u t d ijel a s k a n b a hw a perhitungan gfr (glomerulus fi ltration rate) tersebut dapat diklasifi kasikan sebagai berikut: 1) nilai gfr>90 (stadium i) artinya pasien masih memiliki fungsi ginjal normal, tetapi berada pada stadium dengan risiko meningkat ditandai kerusakan ginjal atau proteinuria, fungsi ginjal masih normal, 2) nilai gfr antara 60– 89 (stadium ii) ditandai dengan fungsi ginjal mengalami penurunan ringan, 3) nilai gfr antara 30-59(stadium iii) ditandai fungsi ginjal mengalami penurunan sedang, 4) nilai gfr 15-29 (stadium iv) ditandai fungsi ginjal mengalami penurunan sedang dan 5) nilai gfr < 15 (stadium v) pasien dinyatakan gagal ginjal terminal. hasil ha sil det ek si t i ng k at ke pa r a ha n kemampuan laju filtrasi glomerulus ginjal sebelum dilakukan hemodialisa pada penelitian ini dinyatakan gagal ginjal terminal atau pada stadium 5, hal ini karena laju fi ltrasi glomerulus kurang dari 15. distribusi frekuensi laju fi ltrasi glomerulus pasien sebelum dilakukan hemodialisa dijelaskan pada tabel 1. hasil deteksi kemampuan laju fi ltrasi glomerulus setelah dilakukan hemodialisa pada penelitian ini adalah ada peningkatan kemampuan kritis laju fi ltrasi glomerulus atau ada perubahan secara kritis dari stadium 5 menjadi stadium tabel 1. distribusi frekuensi gfr sebelum hemodialisa. pre hemodialisa umur (th) l/ p bb (kg) serum kreatinin perhitungan gfr 50 p 48 10.4 4.18 41 p 55 11.3 3.96 51 l 71 17.2 3.14 55 l 58 12.6 4.43 56 l 70 7.4 8.16 64 l 67 10.3 5.42 52 p 62 10.5 4.10 53 p 44 12.4 3.37 35 p 41 8.8 5.45 49 l 64 22.8 1.70 50 p 55 9.1 4.88 44 l 56 14.5 3.94 35 l 53 15.6 3.79 32 l 55 8.3 8.00 47 l 70 18.7 2.15 57 p 47 8.3 5.28 56 p 55 6.4 7.16 38 l 68 21.3 2.61 57 p 45 10.2 4.16 34 l 55 22.8 2.46 65 l 60 9.3 6.08 32 l 55 15.4 3.92 35 p 45 26.1 1.55 55 p 48 11.2 3.77 63 p 51 8.6 4.97 46 p 60 4 12.81 62 p 55 7.2 6.12 52 l 55 10.4 5.59 40 l 50 9.6 6.47 44 l 51 8.4 7.40 23 p 45 17.7 2.65 41 p 60 11.4 3.92 55 l 68 14.5 3.77 gfr: glomurulus filtration rate 46 jurnal ners vol. 9 no. 1 april 2014: 43–48 4 karena nilai gfr diantara 15-29. rincian per ubahan tersebut adalah 45.5% pasien masih terdeteksi gagal ginjal secara terminal mengalami ada dan 54.5% pasien terdeteksi ada perubahan gfr ke arah yang lebih baik yaitu stadium 4 yang ditandai fungsi ginjal mengalami penurunan tingkat sedang. dist r ibu si f rek uensi laju f ilt r asi glomerulus setelah dilakukan hemodialisa di jelaskan pada tabel 2. sebaran data dan homogenitas data fi ltrasi glomerulus berdasarkan umur, berat badan, jenis kelamin dan nilai kreatinin serum berdistribusi normal dan homogen karena nilai p>0.05 seperti yang dijelaskan pada tabel 3. tabel 3. h a s i l u j i n o r m a l i t a s d a n homogenitas uji kreatinin gfr pre test post tes pre test post test kolmogorov smirnov z 0.189 0.051 0.455 0.559 one way anova 0.340 0.572 0.189 0.709 hasil uji statistik menunjukkan bahwa perubahan kritis kemampuan laju filtrasi glomerulus pada asuhan keperawatan pasien dengan gagal ginjal kronik yang dilakukan hemod ialisa ter ja d i pen i ng k at a n gfr secara signifi kan dibuktikan nilai p =0.013 dengan beda rata-rata sebesar 9.18. hasil uji t perubahan kritis kemampuan laju fi ltrasi glomerulus dijelaskan tabel 4. tabel 4. rangkuman hasil uji t t test mean p p< 0.05 pre post test 13.95 4.77 0.013 0.013<0.05 pembahasan banyak faktor yang mempengaruhi n i l a i l aju f i lt r a si g lome r u lu s (gf r) seseorang salah satunya adalah faktor usia. semakin bertambahnya umur manusia akan mempengaruhi fisiologis organ ginjal. hal ini sesuai dengan pendapat (smeltzer & bare, 2002) yang menjelaskan bahwa, umur atau usia merupakan faktor yang dapat mempengaruhi kesehatan seseorang. lebih lanjut dijelaskan bahwa semakin bertambahnya usia, maka organ ginjal mengalami penurunan massa ginjal sebagai akibat kehilangan beberapa nef ron sehingga terjadi penur unan laju filtrat glomerulus. penurunan laju filtrasi glomer ulus (a k ibat tid a k ber f u ngsi nya tabel 2. distribusi frekuensi gfr setelah hemodialisa. pre hemodialisa umur (th) l/ p bb (kg) serum kreatinin perhitungan gfr 50 p 48 3.2 16.30 41 p 55 4.7 10.89 51 l 71 3.4 20.40 55 l 58 8.4 7.07 56 l 70 5.1 12.53 64 l 67 4.2 15.26 52 p 62 4.2 11.81 53 p 44 3 17.35 35 p 41 3.4 9.00 49 l 64 12.4 3.43 50 p 55 3.7 13.78 44 l 56 4.3 7.11 35 l 53 3.1 24.49 32 l 55 4.2 17.57 47 l 70 3.3 15.93 57 p 47 4.8 9.94 56 p 55 3.8 13.06 38 l 68 3.6 13.26 57 p 45 3.1 16.46 34 l 55 10.8 5.84 65 l 60 4.2 11.89 32 l 55 7.8 8.60 35 p 45 3.2 17.52 55 p 48 9.1 4.79 63 p 51 5.9 7.68 46 p 60 3.1 17.19 62 p 55 3.1 16.18 52 l 55 6.4 9.79 40 l 50 7.3 8.87 44 l 51 4.1 16.93 23 p 45 2.7 23.21 41 p 60 6.7 7.23 55 l 68 3.1 22.35 47 deteksi keparahan fungsi ginjal (martono dan satino) glomeruli) berdampak pada klirens kreatinin akan menurun dan kadar kreatinin serum akan meningkat. kemudian akan berlanjut dengan kegagalan ginjal secara progresif. hal ini juga sesuai dengan pendapat yang disampaikan (wilson dan price, 2006) yang menjelaskan bahwa bahwa penurunan massa otot yang terjadi pada individu yang lebih tua menyebabkan penurunan kecepatan pada produksi kreatinin karena itu didapatkan konsentrasi kreatinin serum normal meskipun bersihan serum kreatinin terganggu. fa k tor kedu a ya ng be r penga r u h terhadap laju fi ltrasi glomerulus/ gfr adalah jenis kelamin. faktor jenis kelamin laki laki sangat beresiko terjadinya gangguan fungsi ginjal, hal ini disebabkan struktur dan anatomi saluran perkemihan yang panjang dan juga aliran urine yang lama, sehingga beresiko menempelnya sampah atau sisa metabolisme pada saluran kemih. kondisi tersebut memicu terjadinya obstr uksi pada salurah kemih sehingga terjadi ref luks fan resiko infeksi pada ginjal. hal ini sesuai pendapat (huether, 2006) yang menjelaskan bahwa anatomi saluran kemih laki-laki jauh lebih panjang daripada perempuan. hal ini memungkinkan resiko terjadinya pengendapan zat-zat yang terkandung dalam urin lebih banyak dibanding perempuan. pengendapan dengan proses yang lama dapat membentuk batu baik pada saluran kemih maupun pada ginjal. bila gangguan fungsi ginjal ini berlangsung secara progresif dapat menimbulkan gagal ginjal pada tahap terminal. bila ditinjau dari jenis kelamin dan status fi siologi. laki-laki memiliki nilai ureum serum paling tinggi sebesar 8 pasien berada pada kategori sedang dan berat, nilai kreatinin serum sebesar 3 pasien pada kategori tinggi dan nilai klirens kreatinin dengan 16 pasien pada kategori berat. hal ini sesuai dengan penelitian yang dilakukan oleh (kaliahpan, 2010) yang menyatakan bahwa pria mempunyai blood ureum nitrogen rata-rata sedikit lebih tinggi dari wanita karena tubuh pria memiliki lean body mass yang lebih besar. pada orang sehat yang mengkonsumsi makanan banyak protein, nitrogen urea darah biasanya berada diatas batas rentang normal. (smeltzer & bare 2002), menyatakan bahwa laki-laki juga lebih banyak mempunyai kebiasaan yang dapat mempengaruhi kesehatan seperti merokok, minum kopi,alkohol, dan minuman suplemen yang dapat memicu terjadinya penyakit sistemik yang dapat menyebabkan penurunan fungsi ginjal. hal ini didukung dengan penelitian yang dilakukan (sennang, sulina badji dan harjoeno, 2005) yang menyatakan bahwa terjadi perbedaan kadar kreatinin dan klirens kreatinin laki-laki lebih tinggi secara bermakna dari pada perempuan, meskipun secara statistik perbedaan ini tidak bermakna. nilai laju fi ltrasi glomerulus rate laki-laki lebih tinggi daripada perempuan oleh karena massa ginjal laki-laki relatif lebih besar daripada perempuan. faktor ketiga yang mempengar uhi laju fi ltrasi glomerulus adalah berat badan. (su h a r t o, 2 0 0 4) m e njel a s k a n b a hw a penambahan berat badan karena cairan (overfl uid) menjadi salah satu prognosis gagal ginjal yang mempengaruhi waktu survival, artinya semakin besar penambahan berat badan maka semakin rendah tingkat keselamatan. pengukuran dan penilaian kelebihan volume cairan yang terjadi dapat dilakukan dengan memonitor asupan dan haluaran cairan dan penimbangan berat badan. pemasukan dan pengeluaran cairan harus dimonitor dengan tepat secara berkala. faktor yang mempengaruhi kemampuan fungsi ginjal juga ditentukan oleh kadar kreatinin serum. (smeltzer & bare, 2002), menjelaskan bahwa menurunnya laju fi ltrasi glomerulus rate berdampak pada menurunnya kadar klirens kreatinin dan peningkatan kadar kreatinin serum. kreatinin merupakan produk fraksi protein (k reatin) yang digunakan sebagai energi didalam otot. kreatinin akan dibebaskan ke dalam darah ketika otot aus, karena dipakai bekerja atau pada saat terjadi kerusakan otot. selain itu, kadar ureum dalam darah akan meningkat. ureum berasal dari protein makanan yaitu dari gugus amida dalam asam amino/ peptida yang menghubungkan asam amino. nh2 yang dibebaskan dari gugus tersebut akan berubah menjadi amonia (nh3) beracun menjadi ureum yang relatif tidak begitu toksik. ureum sebagai sampah metabolik harus diekskresikan dari dalam 48 jurnal ners vol. 9 no. 1 april 2014: 43–48 tubuh melalui ginjal. oleh karena itu, ureum selalu terdapat didalam urine dan diluar tubuh ureum berubah menjadi nh3 kembali, sehingga urine yang dibiarkan akan berbau amonia. hasil deteksi nilai laju fi ltrasi glomerulus ginjal setelah dilakukan hemodialisa adalah ada perubahan nilai kritis dari stadium gagal ginjal terminal kearah stadium fungsi ginjal yang mengalami penurunan tingkat sedang, hal ini dibuktikan nilai p=0,013 dan beda rata rata sebesar 9,18. perubahan ini dimulai ketika darah yang mengandung sisa-sisa metabolisme dengan konsentrasi yang tinggi dilewatkan pada membran semipermeabel yang terdapat dalam dialyser. melalui proses difusi, sisa-sisa metabolisme seperti ureum dan kreatinin dapat disaring sehingga terpisah dari darah bersih. selaput membran yang semipermeabel dapat dilewati oleh molekul dengan ukuran tertentu. zat dengan berat molekul kecil yang terdapat pada dialisat akan dapat mudah berdifusi kedalam darah selama proses dialisis. molekul ukuran kecil seperti ureum, kreatinin dan air dapat dengan mudah melewati selaput membran ini melalui tehnik reverse osmosis sehingga dapat menahan urea, natrium dan klorida. setelah darah selesai dicuci pada dialiser, selanjutnya darah yang bersih dialirkan kembali ke tubuh pasien melalui venous line sehingga proses ini dapat membuang sisa metabolisme dalam tubuh seperti ureum dan kreatinin. simpulan dan saran simpulan hasil penelitian menunjukkan bahwa pasien yang dilakukan hemodialisa dapat memperbaiki laju fi ltrasi glomerulus (gfr) kearah lebih baik, serta mampu mendeteksi dan mencegah tingkat keparahan kemampuan fungsi ginjal. saran se mu a p a sie n ya ng me ng a l a m i gagal ginjal kronik pada stadium terminal diharapkan dapat mengikuti dan mematuhi program hemodialisa secara rutin dengan memperhatikan stabilisasi berat badan, faktor usia, dan jenis kelamin agar tidak terjadi tingkat keparahan fungsi ginjal yang lebih buruk. kepustakaan cockroft d and gault m. 1976. prediction of creatinin clearence from serum creatinine. nephron: 31–41. guyton ac, hall je. 2006. texbook of medical physiology, 11th ed, philadelpia: elseiver inc. huether, s.e & mc cance, k.l. 2006. pathophysiology the biologic basis for disease in adult and children (3nd ed vol 2). st louis missouri: mosby year book. kaliahpan, p. 2010. perubahan kadar ureum dan kreatinin sebelum dan sesudah hemodialisa pada penderita gagal ginjal di rsud dr. pirngadi medan, tesis tidak dipublikasikan fakultas kedokteran. universitas sumatera utara. long, b. c., 2006. perawatan medikal bedah (suatu pendekatan proses kepera watan). jilid 3. ba ndu ng: yayasan ikatan alumni pendidikan keperawatan. pernefri. 2003. konsesnsus dialisis. sub bagian ginjal dan hipertensi-bagian ilmu penyakit dalam. jakarta: fkuirsudn dr. cipto mangunkusumo. saryono, h. 2006. kadar ureum dan kreatinin darah pada pasien yang menjalani terapi hemodialisis. sennang, n., sulina, badji, a., hardjoeno. 2005. laju filtrasi glomerulus pada orang dewasa tes klirens kreatinin menggunakan persamaan cockroftgaulth dan modification of diet in renal disease. j. med. nus, 24(2). smeltzer, bare. 2002. buku ajar keperawatan medikal bedah. jakarta: egc. suharto., 2004. penerapan model ph cox pada studi pasien gagal ginjal kronis, diakses dari http://www.adln.lib.unair. ac.id, tanggal 11 juli 2013 jam 10.00 wib. syamsir, a & broto, h. 2007. vita health: gagal ginjal. jakarta : gramedia wilson, l.m and price, s.a. 2006. patofi siologi konsep klinis proses-proses penyakit. volume 2 edisi 6. jakarta. 261 asuhan keperawatan psikososial pada ibu nifas dalam menghadapi asi belum keluar pada 0-3 hari pascasalin (psychosocial nursing care for mother who can’t produce breast milk on 0-3 rd days of postpartum period) sherly jeniawaty*, sri utami*, queen khoirun nisa’ mairo* *poltekkes kemenkes surabaya email: sherlyjeniawaty@gmail.com abstrak pendahuluan: faktor utama pembentuk harapan adalah pengalaman masa lalu. asuhan keperawatan yang akrab akan meningkatkan tercapainya harapan yang realistis. pengalaman terdahulu memunculkan pengetahuan yang lebih rinci tentang layanan dan mempromosikan harapan tentang perawatan untuk periode post partum dan menyusui. penelitian ini bertujuan untuk mengeksplorasi pengalaman dan harapan asuhan keperawatan psikososial bagi ibu pada periode postpartum untuk menangani asi belum keluar di 0-3 hari setelah melahirkan di puskesmas tanah kali kedinding surabaya. metode: penelitian kualitatif ini menggunakan pendekatan hermaneutic-fenomenologis. subyek penelitian adalah wanita dengan periode postpartum lebih dari 3 hari sampai 2 minggu setelah melahirkan. sampel dipilih dengan teknik purposive sampling. data diolah menggunakan analisis collaizi. hasil: hasil dikelompokkan menjadi pengalaman merasa "keluhan fisik dan psikologis" ketika susu belum keluar, dan harapan pada perawatan psikososial untuk mengatasi asi belum keluar. diskusi: selanjutnya, disimpulkan bahwa keperawatan psikososial perawatan yang diberikan ketika susu belum keluar, bisa menjadi pengalaman ibu dalam rangka mencapai keberlanjutan keberhasilan menyusui. kata kunci: asi, pengalaman, harapan, asuhan keperawatan psikososial abstract introduction: the first factor as forming expectations was past experience. familiarity with nursing care services would increase the likelihood of a realist expectations. previous experience gave rise to more detailed knowledge about the services and promoting expectations about nursing care for post partum and breastfeeding period. th is study aimed to explore the experiences and expectations of psychosocial nursing care for mothers in the postpartum period in order to deal with breast milk has not come out in 0-3 days postnatal in public health center of tanah kali kedinding surabaya. method: this qualitatif study used hermaneutic-phenomenological approach. subjects were women with postpartum period was more of 3 days to 2 weeks after delivery. samples were selected by purposive sampling technique. data was processed using analysis of collaizi. results: results are grouped into the experience felt “physical and psychological complaints” when the milk has not come out, and expectation on psychosocial nursing care in order to deal with breast milk has not come out. discussion: furthermore, it was concluded that psychosocial nursing care given when the milk has not come out, can become mother’s experiences in order to achieve sustainability of successful breastfeeding. keywords: breast milk, experience, expectation, psychosocial nursing care pendahuluan mdgs yang memiliki target untuk mencapai kesejahteraan rakyat dan pembangunan masyarakat anggota deklarasi telah berakhir pada akhir 2015. setelah itu, indonesia harus melanjutkan perjuangan pembangunan dengan misi sdgs atau sustainable development goals (tujuan pembangunan berkelanjutan) tahun 2016-2030 yang salah satu target lanjutan dari mdgs yaitu meningkatkan tingkat pemberian asi eksklusif dalam 6 bulan pertama sampai setidaknya 50%. pusat data dan informasi (pusdatin) kemenkes 2015 menunjukkan cakupan asi eksklusif baru sebesar 54,3 persen dari target 80 persen, sedangkan riskesdas 2013 prosentase menyusui pada bayi 0 bulan adalah menyusui eksklusif (39,8%), menyusui predominan (5,1 %) dan menyusui parsial (55,1%). sdki tahun 2012 menunjukkan cakupan asi di indonesia mengalami peningkatan menjadi 42% dari 32% dari data sdki 2007. akan tetapi, perlu diketahui bahwa cakupan presentase ini masih dibawah 50% sebagaimana target cakupan yang ditentukan oleh who. saat ini angka kelahiran di indonesia yang mencapai 4,7 juta per tahun, sehingga bisa diambil kesimpulan bayi yang menerima asi tidak mencapai separuhnya (r. 2015) menurunnya angka pemberian asi dapat disebabkan oleh berbagai hal, baik yang berasal dari faktor ibu, bayi, maupun lingkungan. faktor yang berhubungan dengan ibu menjadi salah satu bagian penting dalam mailto:email:%20sherlyjeniawaty@gmail.com jurnal ners vol. 11 no. 2 oktober 2016: 261-268 262 menurunnya tingkat pemberian asi bagi bayinya. faktor yang dapat mempengaruhi ibu untuk tidak memberikan asi kepada bayinya antara lain produksi asi yang kurang, pemahaman ibu yang kurang tentang tata laksana laktasi yang benar, ibu ingin menyusui kembali setelah bayi diberi formula (relaktasi), bayi terlanjur mendapatkan prelakteal feeding (pemberian air gula/dekstrosa, susu formula pada hari hari pertama kelahiran), masalah pada ibu (puting lecet, puting luka, payudara bengkak, mastitis dan abses), ibu hamil lagi padahal masih menyusui, ibu bekerja, tingkat pendidikan dan adanya kelainan pada bayi (bayi sakit, abnormalitas bayi), serta faktor psikologis ibu. di indonesia banyak terjadi kegagalan dalam pemberian asi eksklusif karena kekeliruan dalam praktek pemberian asi dalam 3 hari pertama kelahiran bayi. tiga hari pertama kelahiran bayi merupakan masa yang sangat penting dalam keberhasilan pemberian asi, karena pada saat ini menentukan apakah pemberian asi eksklusif akan berhasil atau tidak, demikian juga untuk keberhasilan menyusui selanjutnya. penelitian ini dilakukan wilayah kerja puskesmas tanah kali kedinding surabaya karena termasuk puskesmas poned (pelayanan obstetri neonatal emergensi dasar) yang angka persalinannya lebih tinggi diantara 8 puskesmas poned lainnya (tanjungsari, simomulyo, balongsari, sememi, medokan ayu, banyu urip, jagir) dan puskesmas tanah kali kedinding untuk cakupan asi masih dibawah target propinsi jawa timur sebesar 75% dan target nasional sebesar 80% yaitu 54,95%. bidan memegang peranan kunci terkait pemberian asuhan fisik maupun psikis masa nifas yang mendukung peningkatan kondisi ibu kearah yang lebih positif, ibu yang berada pada kondisi kesulitan menyusui 0-3 hari pascasalin memerlukan seseorang yang dapat memberinya pemahaman tentang proses yang sedang dialaminya dan membantunya untuk tetap berada kondisi yang lebih stabil yang artinya ibu tetap memberikan asi secara eksklusif (moody et al. 2006). bahan dan metode jenis penelitian yang digunakan adalah penelitian kualitatif dengan pendekatan hermeneutika-fenomenologi. subjek penelitian adalah ibu nifas yang masa nifasnya lebih dari 3 hari dan maksimal 2 minggu setelah persalinan. sampel dipilih dengan purposive sampling. pengumpulan data untuk penelitian ini dilakukan melalui suatu wawancara mendalam antara peneliti dan sumber informasi, karena sumber data utama dalam penelitian dengan pendekatan fenomenologi berasal dari percakapan mendalam antara peneliti dan informan (polit & hungler 2001). analisis data menggunakan langkah analisa collaizi dan triangulasi. hasil analisis tema dilakukan pada semua data transkrip yang dikumpulkan dari wawancara mendalam terhadap informan. berdasarkan analisis tersebut didapatkan 11 kelompok tema, yaitu (1) pengalaman merasakan keluhan fisik saat asi belum keluar, (2) keluhan psikologis saat asi belum keluar, (3) upaya mengatasi saat asi belum keluar, (4) respon keluarga saat asi belum keluar, (5) pengalaman memperoleh asuhan kebidanan fisik saat asi belum keluar, (6) pengalaman dan persepsi memperoleh asuhan kebidanan psikososial saat asi belum keluar dan (7) harapan terhadap asuhan kebidanan psikososial saat asi belum keluar. pengalaman informan dalam menghadapi asi belum keluar, beberapa ibu merasakan keluhan fisik berupa nyeri pada payudara dan ada yang merasakan kosong pada payudara artinya tidak merasakan sakit pada payudara. seperti pernyataan informan berikut ini: “......hari pertama merasa nyerinya tidak seberapa hanya kemeng tapi asi belum keluar juga, setelah hari kedua bertambah sakit tapi tetap belum keluar, setelah hari ketiga sudah keluar tetapi sedikit....”(p1) keluhan nyeri pada payudara ini sekitar hari ketiga atau keempat sesudah ibu melahirkan, payudara sering terasa lebih penuh, tegang, serta nyeri. keadaan seperti itu disebut engorgement (payudara bengkak), yang disebabkan oleh adanya statis di vena dan pembuluh darah bening. ini merupakan tanda bahwa asi mulai banyak disekresi. jika dalam keadaan tersebut ibu menghindari menyusui karena alasan nyeri, lalu memberi prelacteal feeding (makanan tambahan) pada bayi, asuhan keperawatan psikososial pada ibu nifas (sherly jeniawati, dkk) 263 keadaan tersebut justru berlanjut. payudara akan bertambah bengkak atau penuh, karena sekresi asi terus berlangsung, sementara bayi tidak disusukan, sehingga tidak terjadi perangsangan pada puting susu yang mengakibatkan refleks oksitosin tidak terjadi dan asi tidak dikeluarkan, hal ini akan mengakibatkan asi tidak keluar. ada beberapa informan yang tidak merasakan keluhan pada payudaranya dan merasakan kalau payudaranya kosong setelah melahirkan. berikut pernyataan informan bila ditanya apa yang dikeluhkan secara fisik saat asi belum keluar oleh peneliti : “...... saya tidak merasakan susu saya sakit, ngrangsemi atau menteng-menteng, biasa saja, kosong rasanya, asi saya ndak keluar sama sekali...”(p8) namun setelah hari kedua dan ketiga ibu sudah mulai merasakan kalau nyeri pada sekitar payudara, pernyataan informan tersebut sebagai berikut: “......hari pertama sampai kedua tidak sakit pas hari ketiga baru ngrangsemi dan keluar asi sedikit...”(p3) walau asi sudah berproduksi sejak hamil 20 minggu, namun tidak keluar dari payudara, atau hanya keluar setetes-setetes yang ditemui saat hamil semakin besar adalah karena adanya hormone kehamilan yang menahannya, dan hormone kehamilan ini berpusat pada ari-ari. dimana saat ibu melahirkan, dan ari-ari ibu lepas dari rahim, lalu kadar hormone kehamilan yang turun, maka asi dapat keluar dari payudara ibu. namun terdapat jeda sampai 3 hari atau 72 jam pasca bersalin, karena sisa hormon kehamilan yang masih tersisa di pembuluh darah ibu dan akan semakin hilang dalam jangka waktu 3 hari pasca bersalin, selain keluhan nyeri payudara ada juga informan yang mengeluh lecet dan nyeri di sekitar puting, pernyataan informan tersebut adalah sebagai berikut : “......walah ngrangsemi bu, tapi belum keluar, menteng-menteng rasane sakit bu trus putingnya lecet malah nyeri rasanya tapi belum keluar susune malah yang keluar darah, perih nek disenggol bu.....”(p2) keadaan lecet pada puting dapat disebabkan oleh tekhnik menyusui yang kurang benar serta perawatan payudara yang menggunakan sabun, lotion, cream, alkohol yang dapat mengiritasi puting susu serta tali lidah (frenulum linguae) bayi pendek, sehingga menyebabkan bayi sulit mengisap sampai areola dan isapan hanya pada putingnya saja. keluarnya asi umumnya keluar setelah hari ketiga, namun ada beberapa informan yang mengalami bahwa asi nya baru keluar sekitar hari ke lima: “..asi saya ndak keluar sama sekali sampai hari ke lima, keluar sedikit tapi ndak keluar lagi sampai sekarang, sedih, bersalah, kecewa, rasane ndak bisa jadi ibu, padahal saya ingin menyusui karena saya tidak bekerja, sedih rasanya bu, tapi yah gimana lagi..”(p11). ibu memiliki kemampuan yang berbedabeda dalam memberikan asi akan tetapi pada dasarnya ibu memiliki kemampuan yang cukup untuk pasokan asi. beberapa ibu yang baru melahirkan terkadang baru dapat memberikan asi pada hari ketiga atau keempat setelah melahirkan. meskipun demikian umumnya kondisi keterlambatan asi hanya dialami oleh ibu dikelahiran bayi pertama. nyeri payudara dan perasaan asi kosong menjadi keluhan pada ibu saat asi belum keluar, beberapa juga mengeluh nyeri pada puting susunya sedangkan keluhan kelelahan fisik menjadi keluhan utama yang dialami oleh semua ibu menyusui pada saat mengalami asi belum keluar. pernyataan tersebut sebagai berikut : “.... setelah melahirkan kondisi saya gemetar, ndredek semua badan saya, rasane lemes bu, persalinannya dipacu jadi rasane kesel, asi saya belum keluar jadi ya ndak disusoni setelah nglahirkan....”(p4) pembahasan pengalaman merasakan keluhan fisik saat asi belum keluar hasil wawancara didapatkan beberapa ibu mengeluhkan kalau payudaranya terasa nyeri dan beberapa merasakan tidak nyeri, sedangkan untuk kelelahan, semua ibu yang mengeluh asi nya belum keluar merasakan kalau dirinya merasa kelelahan setelah melewati persalinan, ibu merasakan kalau dalam proses persalinannya berjalan lama, sehingga menguras tenaganya. secara umum faktor fisik kesehatan ibu menyusui dapat menyebabkan asi belum keluar secara langsung setelah proses persalinan. faktor fisik kesehatan ibu menyusui yang dirasakan ibu saat asi beum keluar antara lain jurnal ners vol. 11 no. 2 oktober 2016: 261-268 264 :kelelahan fisik, ibu merasakan lelah, capek setelah mengalami proses persalinan dari mulai proses kala 1 sampai dengan kala 2, kontraksi yang dialami dan dirasakan ibu tergantung dari koping ibu. ibu yang mengalami proses persalinan yang panjang, lelah, nyeri, akan mempengaruhi refleks oksitosin yang akhirnya menekan pengeluaran asi. proses persalinan yang panjang akan menyebabkan kelelahan fisik pada ibu, yang akan mempengaruhi pelepasan oksitosin dari neurohipofise sehingga terjadi blocking pada reflek let down (t et al. 1994). nyeri pada daerah payudara, perasaan nyeri yang hebat dapat menyebabkan timbulnya masalah yaitu asi tidak keluar, dan akan keluar bila dilakukan perawatan payudara serta penghisapan yang adekuat. keadaan nyeri payudara bila tidak segera ditangani akan menimbulkan masalah baru yaitu pengeluaran yang tidak lancar akibat sumbatan asi yang tidak dihisap bayinya, adakalanya bayi setelah lahir tidak mau menghisap dan masih tidak sadar, hal ini akibat efek pembiusan dan adanya kesulitan saat kelahiran. bayi baru lahir yang mengalami stres saat kehamilan dan persalinan bisa menjadi sangat lemah dan mengantuk untuk menghisap secara efektif pada susu, bahkan jika kapasitas laktasional dari ibu cukup, maka akan menimbulkan gangguan laktogenesis apabila pengeluaran tidak adekuat (guyton & hall 1996). pada payudara yang tidak ada rasa nyeri dan terasa kosong, ibu akan mendapatkan pengeluaran asi nya belum keluar lebih lama ada yang empat hari baru keluar, ada yang lima hari baru keluar,dan ibu yang merasakan nyeri pada payudara setelah melahirkan akan mendapati asi nya keluar hari berikutnya, artinya bila ibu merasa ngrangsemi atau merasakan nyeri pada payudaranya akan mendapatkan lebih cepat air susunya keluar lebih awal. pengalaman merasakan keluhan psikis saat asi belum keluar penelitian ini sejalan dengan hasil penelitian dewey (2001) dari ibu yang mengalami stres saat kehamilan dan persalinan mengalami masalah asi belum keluar saat masa nifas atau pascasalin. kadar hormon estrogen dan progesteron menurun segera setelah plasenta lahir, dua hormon yang bertanggung jawab dalam dalam proses laktasi adalah hormon prolaktin dan oksitosin. bila ibu dalam kondisi stress, kebingungan, pikiran kacau takut maupun cemas akan mempengaruhi pelepasan oksitosin dari neurohipofise sehingga terjadi bloking pada reflek let down. kondisi emosional distress yang dialami seorang ibu akan mempengaruhi pelepasan hormon adrenalin (epineprin) yang menyebabkan vasokonstriksi pembuluh darah alveoli, sehingga oksitosin tidak dapat mencapai mioepitelium (t et al. 1994). kondisi psikis bisa terganggu karena setelah melahirkan ibu memerlukan adaptasi pada peran baru dan tanggung jawab menjadi seorang ibu. dari kebiasaan ibu yang dapat tidur dengan nyenyak di malam hari, harus sering terbangun oleh tangisan bayi yang haus ataupun mengompol. keesokan harinya ibu harus menjalani aktifitas sebagai ibu rumah tangga, hal tersebut akan bertambah parah apabila tidak adanya dukungan keluarga untuk membantu merawat bayi dan mengerjakan pekerjaan rumah tangga. perasaan bersalah juga akan timbul ketika ibu merasa tidak bisa memberi asi pada bayinya. oleh karena itu, diharapkan ibu mampu beradaptasi dengan baik agar ibu bisa menjalani tanggung jawab barunya, tanpa ada perasaan tertekan ataupun bersalah. taking in, periode ini terjadi 1–2 hari sesudah melahirkan. ibu baru pada umumnya pasif dan tergantung, perhatiannya tertuju pada kekhawatiran akan tubuhnya sehingga cenderung pasif terhadap lingkungannya. ketidaknyamanan yang dialami antara lain rasa mules, nyeri pada luka jahitan, kurang tidur, kelelahan. hal yang perlu diperhatikan pada fase ini adalah istirahat cukup, komunikasi yang baik dan asupan nutrisi. gangguan psikologis yang dapat dialami oleh ibu pada fase ini adalah: kekecewaan pada bayinya, ketidaknyamanan sebagai akibat perubahan fisik yang dialami, rasa bersalah karena belum menyusui bayinya, kritikan suami atau keluarga tentang perawatan bayinya. taking hold, periode ini berlangsung pada hari 2–4 post partum, ibu menjadi perhatian pada kemampuannya orang tua yang sukses dan meningkatkan tanggung jawabnya terhadap bayi. ibu merasa khawatir akan ketidakmampuan dan rasa tanggung jawab dalam perawatan bayinya. perasaan ibu lebih sensitive sehingga mudah tersinggung. hal yang perlu diperhatikan adalah komunikasi yang baik, dukungan dan pemberian http://www.lusa.web.id/tag/ketidaknyamanan/ http://www.lusa.web.id/tag/nyeri/ http://www.lusa.web.id/tag/luka-jahitan/ http://www.lusa.web.id/tag/tidur/ http://www.lusa.web.id/tag/istirahat/ http://www.lusa.web.id/category/komunikasi-dan-konseling/ http://www.lusa.web.id/tag/nutrisi/ http://www.lusa.web.id/tag/gangguan/ http://www.lusa.web.id/tag/psikologis/ http://www.lusa.web.id/tag/ketidaknyamanan/ http://www.lusa.web.id/tag/perubahan-fisik/ http://www.lusa.web.id/tag/menyusui/ http://www.lusa.web.id/tag/keluarga/ http://www.lusa.web.id/tag/perawatan/ http://www.lusa.web.id/tag/perawatan/ http://www.lusa.web.id/tag/mudah/ http://www.lusa.web.id/category/komunikasi-dan-konseling/ http://www.lusa.web.id/tag/dukungan/ asuhan keperawatan psikososial pada ibu nifas (sherly jeniawati, dkk) 265 penyuluhan/pendidikan kesehatan tentang perawatan diri dan bayinya. tugas bidan antara lain: mengajarkan cara perawatan bayi, cara menyusui yang benar, cara perawatan luka jahitan, senam nifas, pendidikan kesehatan gizi, istirahat, kebersihan diri dan lain-lain. letting go, periode ini sangat berpengaruh terhadap waktu dan perhatian yang diberikan oleh keluarga ,ibu mengambil tanggung jawab terhadap perawatan bayi, depresi post partum umumnya terjadi pada periode ini fase ini merupakan fase menerima tanggungjawab akan peran barunya. fase ini berlangsung 10 hari setelah melahirkan. ibu sudah mulai dapat menyesuaikan diri dengan ketergantungan bayinya. terjadi peningkatan akan perawatan diri dan bayinya. ibu merasa percaya diri akan peran barunya, lebih mandiri dalam memenuhi kebutuhan dirinya dan bayinya. upaya mengatasi keluhan saat asi belum keluar upaya mengatasi asi belum keluar sesuai dengan pengalaman informan, terdiri dari beberapa macam yaitu dengan tindakan fisik, tindakan psikis dan tindakan spiritual. tindakan fisik yang dilakuakan informan yaitu dengan minum obat pelancar asi, perawatan payudara, pemberian nutrisi berupa makanan misalnya makan kacang tanah dan spriet, makan sayur luntas atau sayur sayuran dan pijat pada tubuh untuk menghilangkan kelelahan fisik. menurut (j 2015) mengatakan bahwa konsumsi sayuran beberapa makanan terbukti memperbanyak asi. yang umum digunakan adalah pepaya, daun katuk, buah pare, wortel, bayam, bawang putih dan kacang-kacangan adalah beberapa contoh makanan yang baik untuk ibu menyusui. cukupi kebutuhan gizi ibu dan sebisa mungkin hindari penggunaan suplemen atau obat-obatan sebagai cara memperbanyak asi. hal ini sejalan dengan pernyataan (varney et al. 2008) yang mengatakan banyak budaya memiliki galaktogogue (zat yang dianggap dapat meningkatkan suplai susu). tidak terdapat bukti bahwa konsumsi minuman herbal atau makanan tertentu akan meningkatkan suplai susu, bahkan jamu-jamu tertentu dapat membahayakan. herbal dan obat pelancar asi harus digunakan sama halnya dengan medikasi lain dan harus diresepkan hanya oleh orang-orang yang telah menjalani pelatihan khusus dalam penggunaan dan pemberian dosis yang tepat.untuk perawatan payudara mulai dari pemijatan dan melakukan senam payudara saat hamil dan pascamelahirkan, hal ini dapat membantu meningkatkan produksi asi saat ibu menyusui. tindakan psikis yang dilakukan berupa memberi motivasi, dukungan pada ibu saat mengalami masalah asi belum keluar, dukungan tersebut berupa nasehat dan tindakan untuk membantu perawatan sebagai seorang ibu dengan membantu menyiapkan makanan pendamping asi yaitu adanya tuntutan untuk segera menyusui yang membuat ibu tertekan. suasana hati yang nyaman dan gembira sangat mempengaruhi produksi asi. sebaliknya hati yang stress (misalnya baru beradaptasi dengan si bayi ketika baru pertama punya anak, tuntutan yang tinggi untuk segera dapat menyusui atau stress karena pekerjaan) dapat menghambat produksi asi (j 2015). tindakan spiritual merupakan pengalaman informan terakhir, hal ini berupa perasaan pasrah atas segala sesuatu yang terjadi yaitu dengan selalu memanjatkan doa agar proses perawatan yaitu pemberian asi berjalan lancar. respon keluarga saat asi belum keluar respon keluarga saat asi ibu belum keluar, yaitu dengan memberi dukungan emosional, dan memberi bantuan fisik, namun juga ada beberapa informan megatakan bahwa keluarga merasa bingung dan cemas. dukungan emosional dapat diperoleh dari keluarga terutama suami. tidak akan ada artinya motivasi yang kuat dari dalam diri si ibu untuk memberikan yang terbaik untuk buah hati yaitu asi, jika suami atau ayah si bayi beserta seluruh keluarga (orang tua/ mertua, saudara) tidak memberi dukungan (moody et al. 2006). memberi bantuan fisik pada ibu juga merupakan respon keluarga saat mengalami masalah asi. disini sebetulnya peran besar ayah. jika ayah mendukung maka asi akan lancar atau sebaliknya. mendukung bisa dengan berbagai cara mulai dari menyemangati istri hingga hal-hal lain seperti menyendawakan bayi setelah menyusui, menggendong bayi untuk disusukan ke ibunya serta membantu menyiapkan perawatan yang diperlukan ibu (j 2015). http://www.lusa.web.id/tag/pendidikan-kesehatan/ http://www.lusa.web.id/tag/perawatan/ http://www.lusa.web.id/ http://www.lusa.web.id/tag/perawatan-bayi/ http://www.lusa.web.id/tag/menyusui/ http://www.lusa.web.id/tag/perawatan/ http://www.lusa.web.id/tag/luka-jahitan/ http://www.lusa.web.id/tag/luka-jahitan/ http://www.lusa.web.id/tag/luka-jahitan/ http://www.lusa.web.id/category/askeb-iii-nifas/ http://www.lusa.web.id/tag/pendidikan-kesehatan/ http://www.lusa.web.id/category/gizi/ http://www.lusa.web.id/tag/istirahat/ http://www.lusa.web.id/tag/kebersihan/ http://www.lusa.web.id/tag/melahirkan/ http://www.lusa.web.id/tag/perawatan/ jurnal ners vol. 11 no. 2 oktober 2016: 261-268 266 bingung dan cemas juga merupakan respon yang dialami beberapa informan keluarga, hal ini merupakan termasuk respon negatif yang muncul saat asi ibu belum keluar.tuntutan yang tinggi dari keluarga untuk segera menyusui akan membuat suasana hati tidak nyaman dan tidak rileks, minimalisir perasaan stress, bantu ibu untuk rileks dan mengajak ibu untuk melakukan atau mengerjakan hal-hal yang menyenangkan perasaan ibu, mengajak memikirkan hal-hal yang gembira (j 2015). pengalaman memperoleh asuhan keperawatan fisik saat asi belum keluar pengalaman memperoleh asuhan kebidanan fisik saat asi belum keluar yaitu semua informan mengungkapkan adanya asuhan kebidanan yang diberikan bidan dengan menasehati untuk memberikan asi tanpa jadwal on demand, dan beberapa informan mengingat bahwa dirinya pernah diberikan nasehat untuk melakukan perawatan payudara serta pentingnya nutrisi dan asupan cairan. menyusui 2-3 jam, adalah cara terbaik memperbanyak asi, bayi yang baru lahir membutuhkan susu setiap 2-3 jam, tanpa peduli siang atau malam hari. produksi asi pada tubuh wanita mengikuti prinsip supply dandemand, artinya tubuh memproduksi asi sesuai dengan kebutuhan bayi. jadi bila ibu rutin menyusui setiap 2-3 jam sampai bayi kenyang, payudara akan mengirim perintah ke otak untuk memproduksi asi sebanyak kebutuhan tersebut. produksi asi akan bertambah dalam waktu 3-7 hari sesuai instruksi tersebut.bila ibu tidak konsisten dan jarang menyusui, produksi asi pun tidak akan terjadi atau berkurang. produksi asi dipengaruhi oleh hormon prolaktin yang jumlahnya ditentukan oleh seberapa banyak dan sering asi dikeluarkan dari payudara ibu, baik dengan menyusui atau memerah asi. sehingga apabila asi jarang dikeluarkan dengan sendirinya asi akan menurun atau berhenti.memompa asi bisa menjadi salah satu cara untuk memperbanyak produksi asi (varney et al. 2008). semua informan memang mengatakan diberi nasehat untuk sering menyusui oleh bidan, namun hal ini diakui oleh informan bahwa untuk menyusui bayinya, ibu kasihan untuk membangunkan bayinya dan merasa nyaman kalau anaknya tidur dulu, karena dirinya merasa lelah karena setelah melalui proses persalinan, dan ibu mengakui kalau untuk menyusui bayinya menunggu bayinya bangun sendiri. perawatan payudara merupakan salah satu asuhan kebidanan yang menurut beberapa informan yang dianjurkan oleh ibu saat mengalami asi belum keluar.perawatan payudara seperti melakukan pemijatan dan senam payudara serta kompres air hangat dan dingin, berfungsi untuk menjaga bentuk payudara dan merangsang serta meningkatkan produksi asi (dr. widodo j,2015). rangsangan otot-otot payudara diperlukan untuk memperbanyak air susu ibu dengan mengaktivasi kelenjar-kelenjarnya.otot-otot payudara terdiri dari otot-otot polos. dengan adanya rangsangan, otot-otot akan berkontraksi lebih dan kontraksi ini diperlukan dalam laktasi.rangsangan pada payudara dapat dilakukan dengan masase atau mengurut atau menyiram payudara dengan air hangat dan dingin secara bergantian (b.r 1997). namun pengalaman beberapa informan untuk caranya sering informan mengatakan kalau tidak tau caranya, dan jarang melakukannya. nutrisi dan asupan cairan sangat penting diperhatikan untuk ibu menyusui. pengalaman beberapa ibu saat asi belum keluar, asuhan kebidanan yang diberikan bidan yaitu dengan menganjurkan ibu untuk tidak tarak makanan dan minuman kecuali kalau ibu alergi terhadap makanan tertentu sebaiknya dihindari. makanan diperlukan oleh ibu dalam jumlah lebih banyak dari hamil sampai dengan menyusui, jadi ibu dianjurkan untuk tidak diet (walsh 2001). diet yang tidak sehat sehingga menyebabkan dehidrasi dapat mempengaruhi kualitas dan kuantitas asi. pastikan untuk selalu memenuhi kebutuhan nutrisi saat menyusui dan konsumsi air putih 8 gelas sehari. namun hal ini diakui informan kalau porsi untuk makanan tidak mengalami jumlah peningkatan sampai dua kali lipat. pengalaman dan persepsi memperoleh asuhan keperawatan psikososial saat asi belum keluar pengalaman memperoleh asuhan kebidanan psikososial saat asi belum keluar yaitu sebagian besar informan mengungkapkan adanya asuhan kebidanan yang diberikan bidan dengan melaksanakan imd setelah bayi lahir saat persalinan, rawat gabung, memberikan asuhan keperawatan psikososial pada ibu nifas (sherly jeniawati, dkk) 267 suport, mengizinkan suami serta keluarga untuk menemani, menciptakan suasana tenang dan nyaman, kemudian mengikutsertakan keluarga dalam perawatan ibu dan bayi. menempatkan bayi di payudara ibu segera setelah lahir atau inisiasi menyusui dini, hal ini dapat membantu pengeluaran plasenta secara alami, begitu plasenta keluar, hormon pembuat susu akan berproduksi yaitu prolaktin. hormon ini memicu payudara untuk memproduksi susu dan juga memiliki efek menenangkan dan merilekskan ibu.ada bukti bahwa bayi yang segera menyusu setelah lahir mempunyai kemungkinan dua kali lebih besar untuk tetap menyusu di akhir minggu kedua dibandingkan bayi yang menyusu lebih lambat (white,a,freeth, s,o’brien,m,1992) mendukung roming in atau rawat gabung akan membantu memberikan suasana yang menyenangkan, tenang dan nyaman akan membantu saat-saat berduaan dan terciptanya hubungan psikologis antara ibu dan bayi. ibu sebaiknya dijauhkan dari ketidaknyamanan psikologis seperti emosi, panik, kecemasan dan kekhawatiran berlebihan. ibu yang mengalami ganggua psikologis ini, sebaiknya berusaha dengan motivasi dan dorongan dari dirinya sendiri untuk mengatasi masalah-masalah psikologis yang timbul. ibu memerlukan bantuan dan dukungan dari berbagai pihak yang menolong ibu agar dapat melewati masa sulit yang dihadapinya, salah satunya adalah oleh petugas kesehatan (vivian, 2011). memberikan suport, mengizinkan suami serta keluarga untuk menemani, menciptakan suasana tenang dan nyaman, kemudian mengikutsertakan keluarga dalam perawatan ibu dan bayi. peran bidan sangat penting dalam memberikan asuhan kebidanan di dalam membantu seorang ibu untuk menyusui dengan nyaman dan menentukan keberhasilan menyusui selanjutnya secara eksklusif. wanita yang baru melahirkan atau pascasalin membutuhkan banyak dukungan emosional dan praktikal, pada hari-hari pertama di rumah bersalin maupun di rumah, dukungan ini tidak hanya bisa dari bidan sebagai petugas kesehatan tetapi juga didapat dari pasangan, keluarga atau teman. (jane moody, 2006) petugas kesehatan dalam memberikan dukungan kepada ibu menyusui, memiliki peran dalam penyuluhan dan memberikan dorongan kepada ibu dengan cara menyampaikan informasi tentang keberhasilan pemberian asi eksklusif, khususnya pengaruh sosial yang tidak mendukung pemberian asi seperti adanya larangan pemberian kolostrum. petugas kesehatan memberikan pengetahuan tentang manfaat pemberian asi, serta keuntungan bagi bayi dan ibu. keluarga dilibatkan untuk memberi dukungan kepada ibu, menciptakan suasana yang menyenangkan dan memberikan semangat yang besar bagi ibu untuk memberikan asi. keluarga harus menjauhkan permasalahan dari dalam hati ibu, menjaga emosi, kecemasan dan kepanikan yang berlebihan demi kelancaran dan keberhasilan pemberian asi (vivian 2011). harapan asuhan keperawatan saat menghadapi asi belum keluar harapan asuhan keperawatan psikososial saat asi belum keluar yaitu sebagian besar informan mengungkapkan ingin diberikan adanya asuhan keperawatan psikososial yang tidak memaksa dan disesuaikan dengan keadaan dirinya artinya diberikan pilihan, memberikan konseling sekaligus mempraktikkannya, dukungan dari petugas berupa kata-kata yang meyakinkan sehingga dapat membangun kepercayaan diri dalam menyusui bayinya, menginginkan sosok petugas yang mampu menenangkan dirinya sehingga sabar untuk tidak tergesa-gesa memberi formula tanpa ada indikasi, mendapatka pelayanan dari petugas yang ahlinya atau kompeten yang sudah berpengalaman, petugas cepat tanggap untuk segera memberikan solusi penyelesaian, jangan sampai ibu dan keluarga mengambil alternatif sendiri yang seharusnya tidak diperbolehkan diberikan pada bayinya. asuhan keperawatan yang diberikan 0-3 hari pascasalin akan menentukan keberhasilan menyusui dan menjadikan sebuah pengalaman serta harapan untuk menyusui selanjutnya. pengalaman pertama menyusui dapat menimbulkan perasaan yang sangat kuat, pengalaman yang sensual dan memuaskan, unik bagi setiap wanita dan bagi beberapa wanita, pengalamannya tidak bisa diungkapkan dengan kata-kata (j 2015). simpulan dan saran simpulan asuhan keperawatan psikososial harus selalu dipegang oleh petugas kesehatan dalam rangka keberhasilan menyusui secara eksklusif jurnal ners vol. 11 no. 2 oktober 2016: 261-268 268 saran pembentukan kelompok pendukung asi (kp-asi) perlu disosialisasikan dalam rangka peningkatan cakupan asi di wilayah kerja puskesmas tanah kalikedinding surabaya. bagi ibu menyusui, menumbuhkan keyakinan kuat atau kepercayaan dirinya bahwa mampu untuk menyusui dan sabar dalam menghadapi masalah asi belum keluar, memberi pengertian bahwa asi belum keluar 0-3 hari pascasalin adalah hal yang fisiologis, serta jangan tergesa-gesa untuk mengambil keputusan untuk memberi formula bila kondisi bayi normal. kepustakaan b.r, s., 1997. mayes midwifery, london: bailirre tindall. guyton & hall, 1996. fisiologi kedokteran, jakarta: egc. j, w., 2015. permasalahan pemberian asi. available at: www.asilaktasi.com. moody, j., jane, b. & karen, h., 2006. menyusui cara mudah, praktis & nyaman, jakarta: arcan. polit, d.f. & hungler, b.p., 2001. nursing research: principles and methods 6th ed., philadelphia: lippincott. r., w., 2015. cakupan asi 42 persen, ibu menyusui butuh dukungan. kompas. t, u. et al., 1994. influence of psychological stress on suckling-induced pulsatile oxytocin release. university of tokushima japan. varney, h., kriebs & carolyn, 2008. buku ajar asuhan kebidanan 4th ed., jakarta: egc. vivian, 2011. asuhan kebidanan pada ibu nifas, jakarta: salemba medika. walsh, l. v., 2001. midwifery, new york: saunders company. 6 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.23399 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research middle school students’ perception on a health promoting school to prevent bullying: a qualitative study masunatul ubudiyah, nursalam nursalam and tintin sukartini faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: bullying at school is an old phenomenon in the adolescent group. despite massive prevention programs, it has not yet resolved by teachers and schools, and this also can affect school climate aspects. the aim of this study was to explore students’ perceptions who are being bullying victims about health promoting schools to prevent bullying at school. methods: this study used a qualitative case study design. the research sample was 18 middle school students in grades 8 and 9 in east and west surabaya. a sample was recruited through snowball sampling. interview guidelines were used to collect the data through in-depth interviews. the data were subjected to thematic analysis. results: middle school students identified three main requirements related to prevent bullying were health education, health services, and healthy school environment. these themes were found among the participants with a bullying victim’s history. conclusion: health education, health services, and healthy school environment are the theme for preventing bullying cases at school. to prevent bullying requires collaboration from various parties, such as students, teachers and school policy makers to be able to apply the rules while in school. article history received: november 25, 2020 accepted: january 11, 2021 keywords bullying; health promoting school; adolescent contact tintin sukartini  tintin-s@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: ubudiyah, m., nursalam, n., & sukartini, t. (2021). middle school students’ perception on a health promoting school to prevent bullying: a qualitative study. jurnal ners, 16(1). 6-12. doi:http://dx.doi.org/10.20473/jn.v16i1.23399 introduction the role of a health promoting school is still massive and has not yet resolved bullying cases in indonesia, so that the involvement of the school’s role is very important. bullying at school is still a phenomenon or problem in adolescent groups around the world, although the prevalence varies between countries (bowes et al., 2019; låftman, östberg, & modin, 2017). bullying is a form of aggressive behavior designed to hurt other people, which occurs repeatedly or more than once and also causes an imbalance in power so that the victim finds it difficult to protect or defend themselves (smith, 2016). various types of bullying that occur in the adolescent group include physical, verbal, social, psychological, and cyberbullying (unicef, 2018). there are different types of bullying, namely, indirect or relational bullying (olweus, limber, & breivik, 2019). bullying has both short-term and long-term effects on students. bullying on adolescents students found in schools can affect social interactions, such as students feel insecure or unsafe (jan, 2015). furthermore, bullying has an impact on decreasing academic performance for victims of bullying at school (barrington, 2018). based on these problems, schools and school health organizations need to be involved in efforts to prevent bullying in schools. in southeast asian countries, indonesians reported higher rates of student bullying than in the philippines at 20.6% and 13.1%, respectively (sittichai & smith, 2015). in 2015, the indonesian ministry of social affairs reported that 40% of indonesian students or children experienced cases of planning suicide as a result of bullying that occurred in the 10-14 year age group (khidhir, 2019; ruangnapakul, salam, & shawkat, 2019). according to east java child protection agency data, there were 567 children involved as perpetrators and 408 children who were direct victims in 2019, with the highest prevalence in surabaya and tulung agung (puspita, 2019). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 7 bullying is the aggressive activity by someone to hurt, to offend or also to push another person, done repeatedly, and aims to show the strength of the perpetrator to the victim (pontes, pontes, ayres, & lewandowski, 2018). bullying at school is defined as aggressive behavior that occurs in a school environment that arises in students who are influenced by the power to bully their friends (shayo & lawala, 2019). the negative impact of bullying can affect several aspects, including physical and mental health (murshid, 2017). bullying can occur to the perpetrator, the victim and the surrounding environment; this will affect their autonomy so that a person will feel dissatisfied with their life, making social relationships unharmonious and decrease the ability to complete tasks (meriläinen, kõiv, & honkanen, 2019). previous research describes bullying prevention programs in schools by involving police officers (devlin, santos, & gottfredson, 2018); involving all of the school’s components (acosta et al., 2019); and teaching life skills to students (fekkes, 2016). in addition, many studies have revealed teachers’ perceptions about reporting cases of bullying (blust, 2016), teachers’ perceptions of bullying (ali, mobarki, mohamed, morsi, & hamouda, 2020; hayes, 2017). however, there has been no research on students’ perceptions of bullying and health promoting schools as one of the preventions of bullying in schools. indonesian health promoting school, often referred to as uks is an abbreviation of “usaha kesehatan sekolah” in bahasa. the minister of education and culture said that uks had been used as the spearhead of health services in schools centered on health education, health services and the development of a healthy school environment (kementerian pendidikan dan kebudayaan, 2012). accordingly, this study is expected to be able to provide an overview of solutions to prevent bullying in schools through health promoting school activities based on the experiences of victims of bullying at school. materials and methods this qualitative inquiry used a case study approach in order to have in-depth information about the informants. participants were taken in surabaya, the second metropolitan city in indonesia with a fairly high youth coverage, in particular eastern and western surabaya. consolidated criteria for reporting qualitative studies (coreq), a 32-item checklist, was used by researchers to assess and report the results (tong, sainsbury, & craig, 2007). the inclusion criteria specified are bullying victims aged 13-15 who are currently undergoing their middle school studies. participants have at least involved being victims of bullying in the past one month, either verbal, physical, relational bullying, or cyberbullying. recruitment for the sampling study was carried out through a general online assessment of bullying to determine whether participants experienced bullying and through a partnership between school teachers in surabaya as a liaison between students in schools. probable participants were explained about the research, data collection procedures and consent forms by online using google forms. data collection used pseudonyms to identify participants. potential respondents who agreed were recorded and documented by the researcher. participants were informed that their participation was voluntary, anonymous, and confidential; also, they could stop at any time. they were also told that the data submitted to researchers would not be disseminated and did not affect student learning outcomes. interviews were conducted using a general question guide regarding adolescent personal experiences on bullying at school. this interview also included questions about their opinions or perceptions about the prevention of bullying in schools through school health programs to find out what kind of school environment is ideal for preventing bullying. researchers used social media to gather data, ranging from video calls or using short message, the variations depending on the willingness of each respondent. interviews ranged from 45–110 minutes; the length of time during the interview depended on the participants’ desire to share their experiences. qualitative data from all respondents were recorded and transcribed by the first researcher and continued with the analysis process by all authors. in detail, the first step was to extract the data and ensure its accuracy for analysis. the next stage entailed identifying from the statements and keywords submitted by the respondents related to the general topic of bullying and then identifying and grouping according to the theme. a collection of themes was combined into a more general global theme. the data collection protocol has been approved by the ethics commission in the health sector at the faculty of nursing, universitas airlangga, certificate number no.2096-kepk. results there were 18 participants of age range 13-15 years old. the number of male and female participants was 6 and 12 students, respectively (n = 18, 33% male and 67% female). most of them have experienced verbal bullying, but not a few have experienced physical bullying as well as cyberbullying. bullying occurred at school outside of lessons, both among classmates or levels, see table 1. results from the thematic network analyses were grouped into three main themes identified from interviews with students: (1) health education (2) health services and (3) health school environment, see table 2. in order to better illustrate each theme, direct quotes for students were reported, respectively. m. ubudiyah et al. 8 | pissn: 1858-3598  eissn: 2502-5791 table 1. characteristic of participant (n=18) code age gender class type of bullying p1 14 female 8 verbal bullying p2 15 female 9 verbal bullying p3 14 female 8 cyberbullying; verbal bullying p4 13 male 8 verbal bullying p5 14 female 9 verbal bullying p6 14 female 8 cyber-bullying p7 14 female 8 cyber-bullying p8 13 female 8 verbal bullying p9 13 female 8 verbal bullying p10 13 male 8 verbal bullying; cyberbullying p11 15 female 9 verbal bullying p12 13 female 8 verbal bullying p13 14 male 8 physical bullying p14 13 male 8 cyber-bullying p15 14 female 8 verbal bullying p16 14 female 8 verbal bullying p17 13 male 8 cyberbullying; physical bullying p18 14 male 9 physical bullying *p = participants table 2. theme distribution of study themes sub-theme quotes health education media q1: “in my opinion, health education media is important, this interesting learning will be easy to understand and remember” (p1) q2: “schools are mostly monotonous, there are only posters, and i am not interested in seeing information on posters. i prefer to look at electronic media” (p3) method q3: “it has been done, but not frequently and continuously. usually through counseling by teachers at certain events” (p4) q4: “the counseling given was good, but my classmates also paid less attention, so they didn't know what bullying was and what the limits were” (p7) q5: “if using drama, it will definitely be more exciting and interesting, each student is able to analyze what happened to the perpetrators and victims of bullying. this will be more catchy and easier to remember” (p13) school program q6: “i think the health program only has a youth red cross, helping the teacher when a student fainted during the monday flag ceremony” (p11) q7: “in my opinion, the program is interesting, so it must be adjusted according to our age, there is an anti-bullying month program or other spiritual programs” (p2) health services students service providers q8: “i feel embarrassed, so i am more free to tell my own friends, for example, we have a problem” (p10) q9: “i had time to tell my teacher, but when i meet on other occasions i definitely feel insecure, so telling stories with friends seems more comfortable” (p8) teachers service providers q10: “the most influential in giving advice and motivation is my teacher” (p10) q11: “i feel safer, more comfortable, more relieved when i talk to my teacher, because the information is protected” (p15) q12: “teachers do not favoritism, so we are comfortable telling stories” (p6) q13: “i think that, what my teacher conveyed must be appropriate, and the information must be correct” (p2) screening q14: “in that school there is no mental health screening, usually physical health measures weight, is there any congenital disease, for example asthma, etc., but there is no bullying screening” (p2) q15: “actually, we better know from the beginning whether we are classified as the bully or not” (p14) q16: “maybe it could be during the student orientation period, that we checked one by one whether it was included in the bullying category, then we explained the information about bullying” (p17) jurnal ners http://e-journal.unair.ac.id/jners | 9 theme 1: health education health education is the most important thing in handling bullying cases, according to the problem, many people did not know about the boundaries that lead to bullying to students. the participants said that health education can increase their knowledge. this theme can be identified from the sub-themes of health promotion media, health promotion methods and school program. health promotion media must be adjusted to the age target and would be more attractive if it was based on electronics (quotes 1-2). health promotion method or health counseling with lectures seems less effective; at their age they prefer attractive education and all participants should be involve to participate in the promotion (quotes 3-5). another interesting thing is the school program; school programs related to health must be more creative and make activities that involve all students so that they can train cohesiveness and togetherness between students (quotes 6-7). theme 2: health services this health service theme shows more about the role of teachers and students in school when handling bullying cases. both of them show that they are interrelated and have an influence in preventing adolescents bullying in school. by the guidance of counseling or discussion booths, some students stated that they were more comfortable telling stories with the teacher because they felt it was easy to find solutions and information was protected (quotes 1013) and some of them were more comfortable telling stories with their own friends because they could tell honestly without feeling embarrassed between students (quotes 8-9). screening or assessment at the beginning is also an important value for students because it is able to detect early whether the individual is at low, medium or high risk of becoming a victim or perpetrator of bullying (quotes 14-16). theme 3: healthy school environment a healthy school environment is also an indicator in improving the students’ health status in schools. based on the results of the interviews, there are three main topics that affect the handling of bullying cases in schools, including the unsuitable school environment, competition for health education activities and school policies. these three aspects are considered capable of supporting bullying prevention programs in schools. the school environment they want is a safe, comfortable and conducive one, supported by direct monitoring from the school and optimizing development facilities (quotes 17-19). to support activities at school, participants said that health promotion about bullying needs to be intensified with a competition method that involves all students to train together (quotes 20-22). the policies or regulations established by each school already have standards in the prevention of juvenile delinquency, but need to be improved and tightened (quotes 23-26). themes sub-theme quotes healthy school environment lack of school environment q17: “sometimes there are schools with empty hallways, usually it was being high risk of becoming a place of bullying” (p18) q18: “in schools there should be cctv, to monitor student activities, it can be placed in the classroom or in a strategic place” (p10) q19: “supervision from the school should be even stronger, so students feel safe while at school” (p5) health promotion competition q20: “which is often contested is a class cleanliness competition, even though class cleanliness is just like that. when it comes to bullying, there should be an anti-bullying ambassador contest” (p9) q21: “other health promotions include competitions, poetry competitions or songs about bullying” (p3) q22: “yes, it was very important. in my opinion, making slogans or slogans catchier and easier to remember” (p16) school policy q23: “yes there must be, the rules in my school are mostly about discipline, for example punishment for students who are late, do not do homework, fight” (p4) q24: “if the rules for physical bullying such as fighting at school already exist, but if you make fun of it, it doesn't exist” (p13) q25: “if no one reports it, the teacher sometimes doesn't know, so you have to remind and report any bullying at school” (p8) q26: “in essence, the existing rules must be strengthened again, tightened again, because children in this era are very easy to violate” (p11) m. ubudiyah et al. 10 | pissn: 1858-3598  eissn: 2502-5791 discussion research on bullying prevention carried out in schools has been extensively documented; however, a deeper understanding of the trajectories and experiences across students about a development plan of bullying prevention-based health promoting school remains underexplored. this study aimed to generate insights on the students’ perceptions and the development of a health promoting school in preventing bullying in schools using multiinformants, in-depth, and a qualitative approach by students. information based on the support desired by students in preventing cases of bullying in schools includes health education, health services and healthy school environment. the results showed that media information, delivery information methods and school activities had a clear relationship to increase knowledge about bullying. recent study shows that, media information can significantly increase knowledge, so they are able to report bullying incidents through the student empathy approach (chaux, velásquez, schultzekrumbholz, & scheithauer, 2016). this mediation of empathy is in line with the findings that empathy therapy is able to reduce bullying behavior in the 1112 year age group (fatimatuzzahro & suseno, 2017). the results showed that classmates and teachers have an important role in preventing bullying cases. one of the important aspects in the school environment was the teacher’s role, where teachers who have a broader knowledge of the bullying phenomenon will be more effective in managing problems, and they have a more supportive attitude toward the victims (de luca, nocentini, & menesini, 2019; lester, waters, pearce, spears, & falconer, 2018). for instance, students indicated the support that should be given to victims of bullying and other students regardless of blood relations or closeness between schools. on the other hand, teachers have an important role to play in creating an effective learning environment; this can help students develop and control emotions and cognition in an adaptive way (black & allen, 2018). indirect effects of teacher emotional support on students' engagement and motivation indicated significant mediating effects of autonomy (ruzek et al., 2016). screening specifically for high-risk groups can assist the intervention process. a recent study shows that screening of risk behaviors significantly affects detecting risky behavior and identifying the need for intervention (kaess et al., 2014). in addition, screening helps prevent the development of adverse attitudes that are more severe and difficult to control (o’connor et al., 2018). another advantage of detection is that it guarantees that judgment is conveyed on the basis of the detection of preclinical status and clinical residual (seltzer, menoch, & chen, 2017). regarding the problem of implementing a health promoting school, students described the importance of creating a healthy and safe school environment; this can be realized through the application of regulations in schools. a handful of countries also have bullying prevention programs, and these can be integrated into health education standards, and / or teacher professional development (department of health and human services, 2018). in some cases, the term distinction is important because it will lead to different perceptions and meanings; the definition of bullying usually includes an imbalance of power as an element, while laws on harassment do not necessarily require such (cornell & limber, 2015). schools have a legal responsibility to maintain a safe environment that allows children and youth to continue their education and other services or opportunities available at the school, and minimize the incidence of bullying (national academies of sciences, engineering, 2016). conclusion this study seeks to identify students' needs for teacher social support and to include individual perspectives on bullying prevention in schools through a health school promoting approach. to our knowledge, this study is the only one that involves many students in researching bullying prevention from a student perspective. media and method to deliver information about bullying is a necessary part of bullying prevention. screening and type of social support, such as emotional support, rewarding and information, have an important role in preventing bullying in schools, from both teachers and students’ perspectives. in addition, strengthening can be done by establishing a safe and comfortable school environment through the implementation of school regulations, so that it is hoped that the number of bullying incidents in schools can be reduced. references acosta, j., chinman, m., ebenera, p., malone, p. s., phillips, a., & wilks, a. (2019). evaluation of a whole-school change intervention: findings from a two-year cluster-randomized trial of the restorative practices intervention. j youth adolesc, 48(5), 876–890. https://doi.org/10.1007/s10964-019-01013-2 ali, a., mobarki, s., mohamed, n., morsi, a., & hamouda, g. (2020). teachers ’ perception regarding bullying behavior in elementary schools at jizan city. 7(1), 742–751. barrington, k. (2018). how does bullying affect a student’s academic performance? retrieved from public school review website: https://www.publicschoolreview.com/blog/how -does-bullying-affect-a-students-academicperformance black, s., & allen, j. d. (2018). part 7: rewards, motivation, and performance. reference librarian, 59(4), 205–218. https://doi.org/10.1080/02763877.2018.14991 64 blust, k. e. (2016). middle school teachers’ jurnal ners http://e-journal.unair.ac.id/jners | 11 perceptions of bullying and their practices in reporting bullying incidents. proquest dissertations and theses, 254. retrieved from http://search.proquest.com/docview/18005338 25?accountid=10673%5cnhttp://openurl.ac.uk/ athens:_edu?url_ver=z39.882004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertati on&genre=dissertations+%26+theses&sid=proq: proquest+dissertations+%26+theses+global&at itle=&title bowes, l., aryani, f., ohan, f., haryanti, r. h., arsianto, y., budiyawati, h., … ulum, d. f. (2019). the development and pilot testing of an adolescent bullying intervention in indonesia – the roots indonesia program the development and pilot testing of an adolescent bullying intervention in. global health action, 12(1). https://doi.org/10.1080/16549716.2019.16569 05 chaux, e., velásquez, a. m., schultze-krumbholz, a., & scheithauer, h. (2016). effects of the cyberbullying prevention program media heroes (medienhelden) on traditional bullying. aggressive behavior, 42(2), 157–165. https://doi.org/10.1002/ab.21637 cornell, d., & limber, s. p. (2015). law and policy on the concept of bullying at school. american psychologist, 70(4), 333–343. https://doi.org/10.1037/a0038558 de luca, l., nocentini, a., & menesini, e. (2019). the teacher’s role in preventing bullying. frontiers in psychology, 10(aug). https://doi.org/10.3389/fpsyg.2019.01830 department of health and human services. (2018). laws, policies & regulations. retrieved from https://www.stopbullying.gov/resources/laws devlin, d. n., santos, m. r., & gottfredson, d. c. (2018). an evaluation of police officers in schools as a bullying intervention. evaluation and program planning, 71(march 2017), 12–21. https://doi.org/10.1016/j.evalprogplan.2018.07. 004 fatimatuzzahro, a., & suseno, m. n. (2017). efektivitas terapi empati untuk menurunkan perilaku. jurnal empati, 7(3), 362–378. fekkes, m. (2016). effects of the dutch skills for life program on the health behavior , bullying , and suicidal ideation of secondary school students. 116(1), 2–15. https://doi.org/10.1108/he-052014-0068 hayes, p. a. (2017). an examination of teachers’ perceptions of bullying in an urban elementary school. retrieved from http://www.bakeru.edu/images/pdf/soe/edd_t heses/hayespatricia.pdf jan, m. s. a. (2015). bullying in elementary schools : its causes and effects on students. 6(19), 43–57. kaess, m., brunner, r., parzer, p., carli, v., apter, a., balazs, j. a., … wasserman, d. (2014). riskbehaviour screening for identifying adolescents with mental health problems in europe. european child and adolescent psychiatry, 23(7), 611–620. https://doi.org/10.1007/s00787-013-0490-y kementerian pendidikan dan kebudayaan. (2012). pedoman pelaksanaan uks. khidhir, s. (2019). bullying in indonesia. retrieved from the asean post website: https://theaseanpost.com/article/bullyingindonesia låftman, s. b., östberg, v., & modin, b. (2017). school climate and exposure to bullying: a multilevel study. school effectiveness and school improvement, 28(1), 153–164. https://doi.org/10.1080/09243453.2016.12535 91 lester, l., waters, s., pearce, n., spears, b., & falconer, s. (2018). pre-service teachers: knowledge, attitudes and their perceived skills in addressing student bullying. australian journal of teacher education, 43(8), 30–45. https://doi.org/10.14221/ajte.2018v43n8.3 meriläinen, m., kõiv, k., & honkanen, a. (2019). bullying effects on performance and engagement among academics. employee relations, 41(6), 1205–1223. https://doi.org/10.1108/er-112017-0264 murshid, n. s. (2017). bullying victimization and mental health outcomes of adolescents in myanmar, pakistan, and sri lanka. children and youth services review, 76, 163–169. https://doi.org/10.1016/j.childyouth.2017.03.00 3 national academies of sciences, engineering, and m. (2016). preventing bullying through science, policy, and practice. https://doi.org/https://doi.org/10.17226/23482 . o’connor, e. a., perdue, l. a., senger, c. a., rushkin, m., patnode, c. d., bean, s. i., & jonas, d. e. (2018). screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: updated evidence report and systematic review for the us preventive services task force. jama journal of the american medical association, 320(18), 1910– 1928. https://doi.org/10.1001/jama.2018.12086 olweus, d., limber, s. p., & breivik, k. (2019). addressing specific forms of bullying: a largescale evaluation of the olweus bullying prevention program. international journal of bullying prevention, 1(1), 70–84. https://doi.org/10.1007/s42380-019-00009-7 pontes, n. m. h., pontes, m. c. f., ayres, c. g., & lewandowski, c. (2018). trends in bullying victimization by gender among us high school students. (august 2017), 1–9. https://doi.org/10.1002/nur.21868 puspita, r. (2019). the number of violence against children in east java has decreased during 2019. retrieved january 9, 2021, from https://republika.co.id/berita/daerah/jawatimur/q39k2h428/angka-kekerasan-terhadapanak-di-jatim-turun-selama-2019 ruangnapakul, n., salam, y. d., & shawkat, a. r. m. ubudiyah et al. 12 | pissn: 1858-3598  eissn: 2502-5791 (2019). a systematic analysis of cyber bullying in southeast asia countries. international journal of innovative technology and exploring engineering, 8(8), 104–111. ruzek, e. a., hafen, c. a., allen, j. p., gregory, a., mikami, a. y., & pianta, r. c. (2016). how teacher emotional support motivates students: the mediating roles of perceived peer relatedness, autonomy support, and competence. learning and instruction, 42(may), 95–103. https://doi.org/10.1016/j.learninstruc.2016.01.0 04 seltzer, m., menoch, m., & chen, c. (2017). opportunistic screening for exposure to bullying in the pediatric emergency department. global pediatric health, 4, 2333794x1771437. https://doi.org/10.1177/2333794x17714377 shayo, f. k., & lawala, p. s. (2019). does bullying predict suicidal behaviors among in-school adolescents? a cross-sectional finding from tanzania as an example of a low-income country. bmc psychiatry, 19(1), 1–6. https://doi.org/10.1186/s12888-019-2402-2 sittichai, r., & smith, p. k. (2015). bullying in southeast asian countries: a review. aggression and violent behavior, 23, 22–35. https://doi.org/10.1016/j.avb.2015.06.002 smith, p. k. (2016). bullying: definition, types, causes, consequences and intervention. social and personality psychology compass, 10(9), 519– 532. https://doi.org/10.1111/spc3.12266 tong, a., sainsbury, p., & craig, j. (2007). consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. international journal for quality in health care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042 unicef. (2018). bullying. retrieved from https://www.unicef.org/egypt/bullying 289 bagaimana keluarga melakukan pengkajian dan penanganan nyeri pasien kanker? (how do families assess and manage the pain of cancer patients?) titan ligita*, ariyani pradana dewi*, tri rina febriyanti* *prodi keperawatan fakultas kedokteran universitas tanjungpura pontianak jl. prof. hadari nawawi, pontianak (78121) e-mail: titan.ligita@gmail.com abstrak pendahuluan: pengkajian dan manajemen nyeri pasien kanker terus mengalami perkembangan dan perbaikan. strategi ini membutuhkan peran perawat dan keluarga pasien. pengkajian nyeri sangat penting untuk dilakukan sebelum melakukan penanganan nyeri yang efektif. keterlibatan keluarga dalam perawatan pasien dapat membantu perawat meningkatkan optimalisasi perawatan sehingga pasien terus dapat dipantau sepanjang waktu, bahkan saat perawat tidak berada di dekat pasien. namun, hingga saat ini masih sedikit informasi yang ditemukan terkait keterlibatan keluarga dalam mengatasi nyeri pasien baik itu dalam bentuk pengkajian nyeri maupun penanganan nyeri. tujuan dari penelitian ini adalah untuk mengeksplorasi bagaimana keluarga melakukan pengkajian dan manajemen nyeri pada pasien kanker. metode: penelitian ini menggunakan desain phenomenology. partisipan penelitian ini adalah anggota keluarga yang merawat pasien kanker di rumah. partisipan dipilih dengan metode purposive sampling. wawancara dilakukan kepada keluarga sebagai partisipan dengan memberikan pertanyaan-pertanyaan yang relevan sesuai dengan tema penelitian. penelitian ini dilakukan di wilayah pontianak dan sekitarnya. data penelitian di analisa dengan thematic analysis. hasil: ada beberapa tema yang ditemukan dari hasil wawancara pada partisipan, yaitu makna nyeri bagi keluarga, pengaruh nyeri terhadap keluarga, pengkajian nyeri oleh keluarga, penanganan nyeri oleh keluarga kepada pasien, faktor pendukung dan penghambat pengkajian nyeri, faktor pendukung dan penghambat penanganan nyeri pasien oleh keluarga serta informasi dan keterampilan yang dibutuhkan keluarga terkait penyakit pasien. diskusi: pengalaman keluarga dalam melakukan pengkajian dan manajemen nyeri pasien kanker sangat bermanfaat bagi pelayanan keperawatan dalam menentukan kebutuhan keluarga dan pasien untuk mengontrol nyeri yang dialami pasien. informasi yang akurat dari keluarga mengenai perkembangan pasien dapat membantu perawat dalam memutuskan tindakan keperawatan terbaik bagi pasiennya terutama dalam mengontrol nyeri yang pasien alami. penelitian berikutnya dapat berfokus pada pengembangan format pengkajian nyeri yang digunakan oleh keluarga untuk mengidentifikasi intensitas dan proses nyeri yang dialami keluarga. kata kunci: keluarga, pengkajian, penanganan nyeri, pasien kanker abstract introduction: pain assessment and pain management for patients living with cancer performed by nurses have been improved gradually. this strategy needs the roles of both nurses and families of patients living with cancer. prior to the application of effective pain management, it is vital to perform pain assessment. the involvement of families in patients care may assist nurses to optimize caring and thus the patients are monitored continuously. but, there is still limited study about the involvement of families in pain assessment and pain management. this study was aimed to explore how the family performed pain assessment and pain management for patients living with cancer. method: this was a phenomenology study and also used purposive sampling methods. participants were family members of patients living with cancer around pontianak indonesia. the datas were collected through in-depth interview in order to revealed some themes/ context and was analyzed through thematic analysis. result: the highlighted contexts in this study were the meaning of pain, the impact of pain, the process of pain assessment and pain management carried out by the families, as well as the facilitating factors and the barriers in assessing and managing the pain. discussion: experiences of the families in assessing and managing the pain may provide information for nurses about how to fulfil the needs of the family on skills needed. therefore, the consistency and continuity of pain assessment and pain management are important. consequently, the nurses must ensure that the family are ready to take care the patients, so that the pain control can be optimal dn side effects can be avoided. the accurity of information about the patients provided by the family may determine the nurse to make decisions in providing best practice for the patients in controlling their pain. keywords: family, assess, manage, pain, cancer patient pendahuluan sampai saat ini nyeri masih merupakan masalah besar yang dihadapi pasien kanker dimana nyeri prevalensi nyeri kanker paling sering terjadi pada pasien kanker dengan metastase atau kanker stadium akhir dengan intensitas nyeri bervariasi mulai dari nyeri sedang hingga berat (van den beuken 290 jurnal ners vol. 9 no. 2 oktober 2014: 289–296 van everdingen et al., 2007). nyeri kronik disebabkan oleh kanker yang tidak terkontrol atau akibat dari pengobatan kanker atau gangguan progresif lainnya akibat kanker yang diderita oleh pasien. nyeri kronis dapat mempengaruhi gaya hidup dan kualitas hidup pasien kanker (foley, 1999) seperti yang dikutip oleh laverty, (2005). nyeri kronis ini berlangsung lama, intensitas yang bervariasi dan biasanya berlangsung lebih dari enam bulan (mccaffery, 1986) seperti yang dikutip oleh potter dan perry (2006). menurut hasil studi kasus yang dilakukan texas pada tahun 2008, pengalaman klien akan gejala nyeri secara total dapat diidentif ikasi melalui pengkajian nyeri (virojphan and fedric, 2008). jadi dengan kata lain pengkajian nyeri merupakan kunci yang akan membuka jalan bagi perawat agar dapat menentukan manajemen nyeri yang efektif. pengkajian dan manajemen nyeri pasien kanker terus mengalami perkembangan dan perbaikan. merupakan hal yang penting untuk mengembangkan kemampuan keluarga dalam melaksanakan manajemen nyeri (yates et al., 2004). keterlibatan keluarga dalam pengkajian dan manajemen nyeri merupakan salah satu indikasi mulai dikembangkannya perawatan paliatif yang berbasis komunitas (yates et al., 2004). tidak banyak penelitian yang dilakukan terkait keterlibatan keluarga dalam pengkajian dan manajemen nyeri. keterlibatan keluarga dalam perawatan pasien dapat membantu perawat meningkatkan optimalisasi perawatan sehingga pasien terus dapat dipantau sepanjang waktu saat perawat tidak berada di dekat pasien. hampir 50% keluarga yang terlibat dalam perawatan adalah istri (mehta et al., 2010). dukungan yang diberikan keluarga dapat berupa dukungan pr a k t i kal ( practical support) maupu n emosional (emotional support) (richardson et al., 2007). dalam hal ini, pasien yang memiliki nyeri kronis tetap dipertahankan peran dan t angg u ng jawabnya melalui dukungan yang diberikan oleh keluarganya. adapun menurut richardson et al. (2007) dalam penelitiannya tersebut bahwa dukungan yang diberikan keluarga tergantung pada nyeri yang dirasakan, kebutuhan pasien akan nyeri, karakteristik keluarga serta peran dan tanggung jawab. walaupun virojphan dan fredic (2008) mengatakan bahwa anggota keluarga tidak selalu dapat berfungsi baik dalam menginter pretasikan makna nyeri pasien, sebaliknya laverty (2009) meyakinkan bahwa keterlibatan anggota keluarga dalam manajemen nyeri pasien sangat penting untuk memonitor proses pengkajian yang berkelanjutan. petugas kesehatan terutama perawat perlu memahami bagaimana keluarga menghadapi per masalahan gejala nyer i yang dirasakan pasien sehingga membantu perawat menentukan rencana perawatan yang efektif bagi pasien. selain itu, perawat perlu mendukung keluarga agar memberikan infor masi lengkap dan akurat mengenai fenomena nyeri yang dirasakan pasien sebagai bagian dari pemecahan masalah nyeri (mehta et al., 2010). masih sedikit informasi yang ditemukan terkait keterlibatan keluarga dalam mengatasi nyeri pasien baik itu dalam bentuk pengkajian nyeri maupun penanganan nyeri. tujuan dari penelitian ini adalah untuk mengeksplorasi bagaimana keluarga melakukan pengkajian dan manajemen nyeri. selain itu faktor pendukung dan penghambat dalam pengkajian dan manajemen nyeri pasien kanker yang dilakukan oleh keluarga akan diidentifikasi pula. bahan dan metode penelitian yang melibatkan partisipasi dari keluarga yang memiliki anggota keluarga dengan penyakit kanker ini menggunakan desain phenomenolog y. melalui desain phenomenology, kerangka kerja dibentuk sebagai upaya investigasi yang dilakukan oleh peneliti dalam upaya memahami fenomena yang terjadi dalam lingkup keperawatan (o’br ien, 20 03). o‘br ien (20 03) juga menambah kan bahwa pemahaman akan fenomena ini diteliti melalui pengalaman spesifik manusia dalam hal ini pasien agar perawat pada akhir nya akan memahami pengalaman manusia dalam kehidupannya. pengalaman ini diinter pretasikan secara lengkap sehingga dapat memperjelas makna 291 bagaimana keluarga melakukan pengkajian dan penanganan nyeri (titan ligita, dkk.) menjadi dan berada pada suatu kehidupan nyata sesuai dengan kondisi yang dialami pasien atau partisipan. di dalam penelitian kualitatif, sampel dalam penelitian disebut sebagai partisipan. pengalaman par tisipan akan fenomena ya ng ditelit i i n i ser t a kemampu a n nya mengkomunikasikan pengalaman tersebut merupakan dasar dipilihnya partisipan untuk terlibat dalam penelitian ini (o’brien, 2003). metode pemilihan partisipan pada penelitian ini menggunakan metode purposive sampling, yang menekankan bahwa partisipan dipilih karena memiliki ciri atau karakteristik yang sesuai dengan tujuan penelitian yaitu mengetahui bagaimana keluarga mengenal dan melakukan penanganan nyeri pada pasien dengan nyeri kanker. maka dari itu partisipan yang tepat adalah anggota keluarga yang merawat pasien kanker di rumah. penelitian ini dilakukan di wilayah pont ia na k d a n sek it a r nya. wawa nca ra dilakukan kepada keluarga sebagai partisipan dengan memberikan pertanyaan-pertanyaan yang relevan sesuai dengan tema penelitian. adapun tema-tema yang akan dieksplorasi adalah mengenai arti nyeri bagi keluarga, pengaruh nyeri pasien terhadap keluarga, tindakan yang keluarga lak u kan unt u k mengenal nyeri pasien, pengkajian nyeri pasien oleh keluarga, pengetahuan dimiliki dalam melakukan pengkajian nyeri, tindakan keluarga untuk mengatasi nyeri yang pasien rasakan, pengetahuan yang dimiliki keluarga dalam melakukan manajemen nyeri, faktor pendukung dan penghambat dalam melakukan pengkajian dan manajemen nyeri dan informasi yang diperlukan keluarga terkait pengkajian dan manajemen nyeri serta keterampilan yang diperlukan keluarga terkait pengkajian dan manajemen nyeri data yang telah diperoleh melalui interview ini di analisa dengan menggunakan thematic analysis. dalam thematic analysis, tema-tema utama diidentifikasi dan ditetapkan sebagai tahap-tahap sebagai berikut. pertama, mempersiapkan dan mengatur data yang akan di analisa. kemudian menyalin hasil rekaman ke dalam bentuk dokumen yang mudah dibaca. selanjutnya membaca secara berulang-ulang teks hasil wawancara untuk mendapatkan ga mba r a n seca r a u mu m mengenai isi wawancara. pada tema yang sudah ditentukan, informasi pada teks hasil wawancara akan diklasifikasikan sesuai dengan tema yang ada. selanjutnya data yang telah sesuai pada tema tersebut diinterpretasikan. interpretasi makna tersebut dapat juga dibandingkan dengan informasi yang diperoleh melalui literature lain atau hasil penelitian lain (creswell, 2003). pertimbangan etika dalam penelitian ini mer upakan hal yang sangat penting mengingat penelitian ini melibatkan keluarga yang memiliki pasien kanker. seperti yang diketahui bahwa pasien kanker merupakan pasien yang lemah (vulnerable) sehingga diperlu kan prosedu r pengambilan dat a (interview/wawancara) yang mengefisiensikan waktu. wawancara dapat dilakukan apabila ada persetujuan dari keluarga maupun pasien. sangat penting bagi tim peneliti unt uk menjelaskan tujuan dan peran partisipan. hal lain yang perlu ditegaskan adalah bahwa tim peneliti tidak akan membuka identitas par tisipan sehingga tim peneliti har us berusaha meyakinkan pada pasien maupun keluarga bahwa identitasnya tidak akan diketahui dan tim peneliti sangat menghargai kerahasiaan partisipan sehingga saat data/ informasi dari partisipan, akan dijelaskan dengan menggunakan kode tertentu yang hanya diketahui oleh tim peneliti (hanley and long, 2004). hasil partisipan diperoleh melalui ruang rawat bedah wanita dan ruang rawat bedah pria di rumah sakit dokter soedarso pontianak. adapun jumlah partisipan yang diperoleh melalui purposive sampling ini berjumlah lima orang yang merupakan keluarga terdekat pasien yang merawat pasien baik di rumah maupun di rumah sakit. k a r a k t e r i s t i k p a r t i s i p a n d a p a t digambarkan sebagai berikut. rentang usia partisipan yaitu antara 21 hingga 45 tahun, sedangkan pendidikan partisipan bervariasi mulai dari tingkat sekolah dasar hingga strata satu begitu juga dengan status pekerjaan 292 jurnal ners vol. 9 no. 2 oktober 2014: 289–296 responden diidentif ikasi sebagai pekerja swasta/wiraswasta, honorer hingga bekerja sebagai petani. adapun status hubungan partisipan dengan pasien adalah sebagai anak atau istri serta adik pasien. ada beberapa tema yang ditemukan dari hasil wawancara pada partisipan, yaitu makna nyeri bagi keluarga, pengaruh nyeri terhadap keluarga, pengkajian nyeri oleh keluarga, penanganan nyeri oleh keluarga kepada pasien, faktor pendukung dan penghambat pengkajian nyeri, faktor pendukung dan penghambat penanganan nyeri pasien oleh keluarga serta informasi dan keterampilan yang dibutuhkan keluarga terkait penyakit pasien. makna nyeri bagi keluarga dan pengaruh nyeri terhadap keluarga makna nyeri bagi keluarga dan pengaruh nyeri bagi keluarga dapat diidentifikasi melalui per nyataan pasien mengenai awal mula kejadian nyeri dan dampaknya bagi keluarga. nyerinya itu setelah kemo, di hari kedua, nah awal-awal dulu susah bangun. ibu ndak pernah nangis, lumayan kuat nahan nyeri cuma kadang agak susah berjalan. (p2) sedangkan pengaruh nyeri bagi keluarga dapat dilihat melalui pernyataan berikut ini. sama aja, ndak pengaruh. justrus sakit pun masih bisa dibawa kema-mana. kalau dulu ibu jualan di depan rumah, semenjak sakit tidak pernah lagi. (p2) saya ini adiknya yang kerja di ladang. karena dia belum menikah jadi saya yang urus. saya ada ladang, ndak dikerjakan, yang penting abang saya sembuh dulu. abang ada adikadik tapi anak-anaknya masih kecil jadi ndak bisa urus. (p3) aku sudah capek mengurus dia sendiri. padahal keluarga dia dekat tapi tidak mau lihat. kalau diajar berjalan, mau, tapi dia malas, tidak ada kemauan. tiap malam kesakitan jadi bisa tidak tidur semalaman. sudah mau dua tahun seperti ini. aku sudah sabar ini. (p5) pengkajian nyeri oleh keluarga pengkajian nyeri yang dilakukan oleh keluarga dapat diidentifikasi dengan mengetahui bagaimana keluarga mengenal nyeri yang pasien rasakan. ibu tidak pernah bilang kalau sakit. cuma pas awal ketahuan, saya curiga badannya lemah dan agak kurus. saya kenal dari kondisi fisik. cuma ibu kalau bilang lagi sakit sih jarang. saya juga tidak bertanya apa ibu sakit. ibu secara umum tidak pernah mengeluh sakit. (p2) liat dari wajahnya aja. dia tidak menjerit. paling pegang-pegang yang sakit tapi dia tidak bilang. aku nanya kalu sudah lihat dia kesakitan. aku tanya sakit ndak ? dia bilang sedikit-sedikit. dia ndak ngomong kalau sakit jadi saya tanya saja kenapa. (p3) saya tau bapak lagi kesakitan kalau bapak suka memegang bagian yang sakitnya (leher), kemudian kalau bapak tidak bisa beraktivitas dan tidak bisa makan. (p4) bapak ngomong kalau sakit. (p5) penanganan nyeri oleh keluarga kepada pasien penanganan nyeri oleh keluarga dieksplorasi untuk mengetahui sejauh mana keluarga memberikan pertolongan pada pasien dengan kemampuan keluarga. kalau nyeri, diberi ramuan dari daun-daunan yang mudah didapat. (p1) setelah sekian lama kira-kira dua tahun, ibu sesak nafas setelah itu baru dibawa ke dokter umum saja. ada diberikan resep anti nyeri. biasanya setelah kemoerapi diberikan tetapi efeknya tidak terlalu besar. karena kita orang awam, tidak ada lagi yang bisa dilakukan selain diberi obat yang diresepkan. ada juga pakai obat gosok atau balsem. (p2) 293 bagaimana keluarga melakukan pengkajian dan penanganan nyeri (titan ligita, dkk.) sering dibawa berobat ke kampung atau mantri. pertolongan pertama cuma obat yang diberikan oleh mantri. setelah merasa mantri tidak menyanggupi akhirnya dibawa ke rumah sakit. (p3) kalau sakit, tidak dibawa langusng ke puskesmas, di rumah saja. paling dikasih obat penahan sakit. kalu tidak ada efeknya, diberikan obat puyer. diberikan kalau sakit, kalau tidak sakit, tidak diminum. kalau obat tidak manjur, paling dipijit aja. (p5) faktor yang mempengaruhi pengkajian dan penanganan nyeri pasien kadang hanya melihat, karena saya berpikir tidak parah sakinta, paling dilihat saja. kalau ibu yang langsung bilang karena dia sudah tidak kuat lahi nahan sesak nafas. sakit yang dirasakan beda dengan yang biasa. biasa dari keluarga yang bilang obat ini bagus atau bapak membaca dari majalah. (p2) dari penyataan di atas dapat dieksplorasi faktor pendukung dalam melakukan pengkajian nyeri yaitu apabila nyeri tersebut diucapkan secara langsung oleh pasien. sedangkan faktor penghambat pengkajian nyeri dapat diidentifikasi dari pernyataan berikut ini. dia tidak ngomong kalau lagi sakit. tapi aku yang perhatikan. (p3) keluarganya sudah angkat tangan. padahal aku sudah minta bantuan. tapi suami aku tidak mau kerja sama, jadi payah aku jadinya. tidak bisa jalan kendalanya. padahal aku sudah ajarkan dia jalan. (p5) informasi dan keterampilan yang dibutuh kan keluarga terkait penyakit pasien informasi mengenai penyakit maupun penanganan pada pasien diperoleh melalui berbagai sumber. berikut ini pernyataan pasien mengenai hal tersebut. dari internet. informasi yang dibutuhkan tentang radioterapi. ingin tahu efek samping dari radioterapi. ingin juga mempelajari cara mengukur tekanan darah. (p2) pembahasan peran serta keluarga yang merawat pasien sangat penting dalam pelayanan keperawat an pada pasien kan ker yang mengalami nyeri. keluarga berperan dalam melakukan pengkajian nyeri serta membantu pasien meredakan nyeri baik itu dengan memberikan obat yang diresepkan dokter maupun memberikan tindakan selain obat yang pada akhirnya nanti dapat membantu tenaga kesehatan dalam melakukan pelayanan kesehatan kepada pasien kanker. makna nyeri serta pengaruhnya pada pasien dan keluarga perlu dipahami agar tenaga kesehatan dalam hal ini perawat dapat mengatisipasi tindakan yang perlu diberikan dalam memenuhi kebutuhan pasien maupun keluarga dalam meningkatkan rasa nyaman. pengalaman nyeri yang dirasakan oleh pasien dapat menjadi tanggung jawab bagi anggota keluarga yang mengur usnya yang har us dilakukannya sebagai bentuk keterlibatan keluarga dalam perawatan pasien. nyeri dapat mempengaruhi kehidupan pasien dan keluarga. dengan memiliki nyeri kronis, pasien dapat mengalami penurunan aktivitas (krein et al., 2007). hal yang sama bagi anggota keluarga yang merawat pasien kanker juga mengalami perubahan aktivitas, contohnya keluarga yang dahulunya bekerja, karena merasa memiliki rasa tanggung jawab untuk mengurus anggota keluarganya yang sakit, jadi ia tidak bekerja seperti biasa. hal ini disampaikan oleh hampir setiap keluarga dalam penelitian ini. yang menarik bahwa, bentuk tanggung jawab ini juga ditemukan pada penelitian mehta dan koleganya (2010), di mana sikap keluarga menerima bentuk tanggung jawab akan penanganan nyeri pasien sehingga keluarga terbiasa dengan kenyataan bahwa mereka bertanggung jawab atas kenyamanan anggota 294 jurnal ners vol. 9 no. 2 oktober 2014: 289–296 keluarga mereka. akan tetapi di dalam penelitian saat ini ada juga anggota keluarga yang merasa bahwa merawat pasien bukan hanya tanggung jawab dirinya akan tetapi juga tanggung jawab anggota keluarga lain. hal ini perlu menjadi pertimbangan sebab pengakuan terhadap kontribusi anggota keluarga akan perawatan yang diberikan akan meningkat kan hasil yang diharapkan bagi pasien (yates et al., 2004). peran keluarga tak hanya sebatas menemani pasien selama sakit. keterlibatan keluarga dalam perawatan pasien kanker yang mengalami nyeri dapat berupa mendiskusikan penanganan nyeri itu sendiri bersama pasien, memberikan pengobatan yang telah diresepkan sesuai jadwal dan dosis yang tepat serta melaporkan nyeri kepada tenaga kesehatan (yates et al., 2004). ketiga proses di atas hampir sama halnya dengan square process di mana anggota keluarga yang merawat pasien terlibat dalam pengkajian, membagi ilmu, membuat keput usan, perencanaan keperawatan, memberikan pelayanan serta melakukan konfirmasi atas tindakan yang dilakukan (mehta et al., 2010). mendiskusikan penanganan nyeri bersama pasien kanker merupakan hal yang perlu digarisbawahi sebab pasien yang lebih tahu dan berpengalaman akan kebutuhan serta intervensi yang tepat bagi nyeri yang dialaminya dalam waktu yang cukup lama (laverty, 2009). melaporkan nyer i kepad a tenaga kesehatan dan memberikan pengobatan kepada pasien merupakan bagian dari serangkaian tindakan pengkajian dan manajemen nyeri yang dapat dilakukan oleh anggota keluarga pa sien. pa d a penelit ia n i n i, t i nd a k a n pengkajian terhadap nyeri yang dialami oleh pasien tergambar dari bagaimana keluarga menanyakan apa yang dirasakan oleh pasien setelah keluarga melihat bahasa tubuh pasien, kondisi fisik pasien atau ekspresi wajah pasien yang menunjukkan bahwa pasien sedang berada dalam kesakitan. sebagian besar pasien tidak menyatakan bahwa ia sakit sehingga membaca tanda-tanda non verbal dari pasien sangat membant u keluarga menent ukan apakah pasien dalam keadaan sakit atau tidak. anggota keluarga bisa sangat yakin dengan hanya melihat atau mengobservasi pasien untuk melakukan pengkajian nyeri sehingga keluarga dapat menentukan apa yang akan dilakukan selanjutnya (mehta et al., 2010). mehta dan koleganya (2010) pun menambahkan bahwa penggunaan reaksi non verbal ini adalah untuk mengkonfirmasi reaksi verbal pasien atau sebaliknya yang dilakukan dengan cara sebagai berikut yaitu membaca reaksi non verbal pasien akan nyeri yang dialaminya dapat dilakukan dengan melihat perilaku pasien, mencatat ekspresi wajah, melihat tanda-tanda tertentu seperti pucat atau keringat berlebih serta membaca bahasa tubuh pasien. agar pelayanan keperawatan yang dilakukan benar-benar efektif dan sesuai kompetensi, diperlukan pengkajian nyeri secara komprehensif yang sistematis, rutin dan terfokus pada individu (curtiss, 2010). dalam penelitian ini, bentuk pengkajian yang dilakukan oleh keluarga masih jauh dari sempurna, di mana pengkajian yang dilakukan masih belum terfokus dan komprehensif. maka dari itu, peran perawat sangat penting di dalam mengajarkan dan memberikan informasi yang adekuat kepada keluarga maupun pasien tentang bagaimana cara mengenal ser ta melaporkan nyeri dengan tepat. setiap tindakan yang diberikan perlu dilakukan monitoring dan evaluasi sebab pengkajian merupakan proses yang berkelanjutan (laverty, 2009). keluarga pasien di dalam penelitian ini sangat mengandalkan obat-obatan yang diberikan oleh dokter maupun tenaga kesehatan lain. apabila setelah diberikan obat penahan sakit, pasien masih mengeluh kesakitan, keluarga memberikan pertolongan berupa pijatan. dari gambaran ini tercermin tindakan utama dalam penanganan nyeri adalah dengan pengobatan serta tindakan penanganan non medis atau non farmakologi yang diberikan kepada pasien oleh keluarga. penanganan nyeri dengan menggunakan obat penahan nyeri masih merupakan strategi yang masih paling efektif walaupun penggunaan teknik 295 bagaimana keluarga melakukan pengkajian dan penanganan nyeri (titan ligita, dkk.) distraksi, pijatan, perubahan posisi maupun terapi panas/dingin dapat juga meredakan nyeri akan tetapi teknik non farmakologi ini hanya efektif digunakan untuk nyeri ringan hingga nyeri sedang (mehta et al., 2010). maka dari itu mehta dan koleganya (2010) menambahkan bahwa keluarga yang merawat pasien perlu memahami bagaimana menentukan intensitas nyeri pasien dengan tepat sehingga ia dapat mengklasifikasikan nyeri pasien sesuai dengan tingkatannya. hambatan dalam melakukan pengkajian nyeri dapat berhubungan dengan ketepatan penanganan nyeri yang dilakukan oleh tenaga kesehatan maupun anggota keluarga yang merawat pasien. motivasi yang kurang di dalam manajemen atau terapi yang dijalani oleh pasien dapat menjadi salah satu faktor penghambat. selain itu, gangguan kognitif dapat menjadi faktor penghalang di dalam melakukan pengkajian nyeri di mana pasien tidak mampu dalam mengartikulasikan nyeri yang dialaminya (curtiss, 2010) sehingga berisiko terhadap kesesuaian terhadap ada atau tidaknya nyeri yang dialami pasien. kemudian, pasien yang tidak menyatakan kalau ia sedang mengalami nyeri juga dapat menjadi faktor penghambat dalam pengkajian nyeri. pasien yang enggan melaporkan nyeri nya bisa jadi karena ia terlalu berfokus pada penyakit yang dialaminya (laverty, 2009). apabila pengkajian yang dilakukan tidak lengkap atau komprehensif, akan terjadi risiko tinggi nyeri yang tidak tertangani dengan tepat (curtiss, 2010). faktor lain yang dapat mempengaruhi penanganan nyeri aga lebih efektif dalam dukungan keluarga. keluarga pasien merasa terbebani apabila merawat pasien sendiri. intervensi yang diberikan oleh beberapa anggota keluarga akan mengurangi beban keluarga yang bertanggung jawab merawat pasien (honea et al., 2007). aga r mela k u ka n peng kajia n d a n penanganan nyeri dengan tepat dan efektif, diperlu ka n i nfor masi lu as ya ng d apat membantu keluarga. walaupun di dalam penelitian ini, keluarga tampaknya belum dapat mengidentifikasi informasi secara spesifik mengenai nyeri akan tetapi informasi terkait penyakit yang mereka butuh kan bersumber pada anggota keluarga lain maupun melalui internet. hal yang serupa ditemukan pada penelitian laverty (2009) di mana informasi ber upa efek samping pengobatan nyeri, kejadian nyeri, serta tindakan yang dilakukan untuk menangani nyeri diperoleh melalui buku, internet maupun dari anggota keluarga yang lain. walaupun informasi yang ditemukan dari berbagai sumber tersebut bisa cukup lengkap, akan tetapi tetap saja keluarga masih memerlukan bimbingan tenaga kesehatan agar informasi yang diperoleh lebih dipahami secara benar sebab bisa jadi informasi yang diperoleh tersebut menggunakan istilah kesehatan yang sulit dipahami oleh keluarga maupun pasien. pengalaman pengkajian yang dilakukan keluarga dapat memberikan informasi bagi perawat mengenai kebutuhan keluarga akan keterampilan yang diperlukan. diperlukan adanya kesinambungan antara pengkajian yang dilakukan oleh keluarga dengan penanganan nyeri yang diberikan. bentuk penanganan nyeri yang diberikan melalui obat-obatan, mer upakan penanganan standar di mana peran keluarga adalah memberikan obat kepada pasien sesuai jadwal dan memberikan penanganan secara non medis. karena keluarga dalam penelitian ini belum menggunakan terapi non medis dalam penanganan nyeri secara ber variasi, peran perawat adalah mengenalkan serta kepada keluarga dan pasien mengenai teknik manajemen nyeri yang mudah diterapkan ketika nyeri pasien timbul. hal ini dikarenakan penggunaan terapi non medis ini dapat menambah efektivitas terapi obat penahan nyeri. untuk itu, perawat harus memastikan bahwa keluarga yang bertanggung jawab merawat pasien, benar-benar telah siap dalam menangani kondisi pasien selama di rumah agar kontrol nyeri lebih optimal dan efek samping yang tidak diinginkan dapat dicegah (mehta et al., 2010). diperlukan komunikasi yang efektif antara keluarga, pasien maupun tenaga kesehatan dalam hal ini perawat dalam memonitor perkembangan pasien terhadap proses penyakit dan nyeri yang menyertai. 296 jurnal ners vol. 9 no. 2 oktober 2014: 289–296 simpulan dan saran simpulan penelit ia n mengenai pengala ma n keluarga dalam melakukan pengkajian dan manajemen nyer i pasien kan ker sangat ber manfaat bagi pelayanan keperawatan di dalam menentukan kebutuhan keluarga dan pasien untuk mengontrol nyeri yang dialami pasien. informasi yang akurat dari keluarga mengenai perkembangan pasien dapat membantu perawat dalam memutuskan tindakan keperawatan terbaik bagi pasiennya terutama dalam mengontrol nyeri yang pasien alami. saran agar pelayanan keperawatan pada pasien kanker yang mengalami nyeri dapat dilakukan secara komprehensif maka perlu keterampilan yang memadai dalam melakukan pengkajian dan manajemen nyeri baik itu oleh tenaga kesehatan maupun keluarga sebagai perpanjangan tangan dari tenaga kesehatan dalam hal ini perawat. untuk itu masih diperlukan penelitian lanjutan mengenai pengembangan format pengkajian nyeri yang digunakan oleh keluarga untuk mengidentifikasi intensitas dan proses nyeri yang dialami keluarga. kepustakaan creswell, j. w. 2003. research design: qualitative, quantitative and mixed methods approaches. london: sage publications. cur tiss, c. p. 2010. challenges in pain assessment in cognitively intact and cognitively impaired older adults with cancer. oncology nursing forum, 37, 7–16. hanley, j. & long, b. 2004. a study of welsh mothers’ experiences of post natal depression. midwivery, 22, 147–57. honea, n. j., brintnall, r. a., given, b., sherwood, p., colao, d. b., somers, s. c. & northouse, l. l. 2007. putting ev ide nce i nt o pr a ct ice: nu r si ng assessment and interventions to reduce family caregiver strain and burden. clinical journal of oncology nursing, 12, 507–16. krein, s. l., heisler, m., piette, j. d., butchart, a. & kerr, e. a. 2007. overcoming the influence of chronic pain on older patients’ difficulty with recommended sel f-m a n age me nt a ct iv it ie s. t h e gerontologist, 47, 61–68. laver t y, d. 2009. the assessment and management of patients with chronic pain. cancer nursing practice, 8, 17–20. mehta, a., cohen, s. r., carnevale, f. a., ezer, h. & ducharme, f. 2010. family caregivers of palliative cancer patients at home: the puzzle of pain management. journal of palliative care, 26, 78–87. o’br ien, l. 20 03. phenomenolog y. i n schneider, z., elliot, d., lobiondowood, g. & haber, j. (eds.) nursing research: method, critical appraisal and utilisation. 2nd ed. sydney, mosby. richardson, j. c., ong, b. n. & sim, j. 2007. exper iencing ch ronic widespread pain in a family context: giving and receiving practical and emotional support. sociology of health & illness, 29, 347–65. van den beuken-van everdingen, m. h. j., de rijke, j. m., kessel, a. g., schouten, h. c., van kleef, m. & patijn, j. 2007. prevalence of pain in patients with cancer: a systematic review of the past 40 years. annals of oncology, 18. virojphan, p. & fedric, t. 2008. assessing pain in today’s global society. clinical journal of oncolog y nursing, 12, 675–77. yates, p., aranda, s., edwards, h. & nash, r. 2004. family caregivers’ experiences and involvement with cancer pain management. journal of palliative care, 20, 28–96. 176 model kompetensi kepemimpinan kepala ruang meningkatkan motivasi dan kinerja perawat pelaksana (model of the nurse unit manager leadership competence and performance enhancing motivation nurse implementing) putu widhi sudariani*, budi utomo**, rizki fitryasari*** *rsud kota mataram, jl. bung karno no.3 pagutan, 83117 **fakultas kedokteran universitas airlangga surabaya ***fakultas keperawatan universitas airlangga surabaya email: sudariani@gmail.com abstrak: pengantar: kompetensi kepemimpinan yang kurang sesuai kepada karyawan, dapat menurunkan motivasi, kinerja dan kepuasan kerja. penelitian ini bertujuan mengembangkan model kompetensi kepemimpinan kepala ruang sebagai upaya peningkatkan motivasi dan kinerja perawat pelaksana sehingga dapat meningkatkan pelayanan kesehatan. metode: fase pertama dalam penelitian ini adalah analitik observasional dengan 140 sampel, analisis data dengan parsial least square (pls), perumusan isu strategis menggunakan focus group discussion (fgd), kemudian membuat modul bersama pakar. fase kedua adalah quasi eksperimental dengan 32 sampel dibagi menjadi dua kelompok terdiri dari kelompok perlakuan dan kelompok kontrol. data analisis di tahap kedua ini menggunakan wilcoxon signed rank test dan mann whitney. hasil: tahap pertama yaitu ada pengaruh signifikan faktor internal (pengetahuan, keterampilan, dan nilai) terhadap kompetensi kepemimpinan (t=3,728>1,96), pengaruh signifikan faktor eksternal (budaya organisasi) terhadap kompetensi kepemimpinan (t=2,257>1,96), kompetensi kepemimpinan berpengaruh terhadap motivasi (t=3.432>1,96), kompetensi kepemimpinan berpengaruh terhadap kinerja (t=2,878>1,96). tahap kedua perhitungan wilcoxon signed rank test pda motivasi menunjukkan ada beda kelompok perlakuan pre-test dan post-test, uji mann-whitney ada pengaruh pengembangan model kompetensi kepemimpinan kepala ruang terhadap motivasi perawat pelaksana. uji wilcoxon signed rank test kinerja perawat pelaksana menunjukkan ada beda antara pre-test dan post-test, uji mann-whitney diperoleh ada pengaruh pengembangan model kompetensi kepemimpinan kepala ruang terhadap kinerja. diskusi: pengembangan model kompetensi kepemimpinan dapat meningkatkan motivasi dan kinerja perawat. kata kunci: kompetensi kepemimpinan, motivasi, kinerja, perawat abstract introduction: leadership competencies are unsuitable that given the leadership to employees, can decrease the motivation, performance and ultimately job satisfaction. this research was conducted to develop a leadership competency model as an effort to improve the motivation and performance of nurses so as to improve health services. methods: this research have two phase, phase one is analytic observational with 140 sample, analysis data with partial least square (pls), formulation of strategic issues using focus group discussion (fgd), then make a modul with some expertise. phase two is quasy experimental with 32 sample divided into two group, there are treatment group and control group. analysis data in phase two with wilcoxon signed rank test and mann whitney. result: phase one there is influence of internal factors (knowledge, skills, and values) to the leadership competencies (t = 3.728> 1.96), there is influence of external factors (cultural organizations) to the leadership competencies (t = 2.257> 1.96), competence leadership influence motivation (t = 3,432> 1,96), leadership competencies influence to performance (t = 2.878> 1.96). the second phase, calculation with wilcoxon signed rank test showed there is difference motivation in treatment group pre-test and post-test, mann-whitney test showed there is influence of development leadership competency model to the motivation of nurses. test wilcoxon signed rank test for performance of nurses showed there is difference between pre-test and post-test, mann-whitney test was obtained there is influence development of leadership competency model to the performance of nurses. discussion: development of leadership competency model can increase the motivation and performance of nurses. keyword: leadership competences, motivation, performance, nurses. pendahuluan kepemimpinan dalam keperawatan merupakan penggunaan keterampilan seorang pemimpin (perawat) dalam mempengaruhi perawat lain yang berada di bawah pengawasannya untuk pembagian tugas dan tanggung jawab dalam memberikan pelayanan asuhan keperawatan sehingga tujuan keperawatan tercapai (latif 2008 dalam maryanto, pujiyanto, tri, setyono 2013). gaya menajemen atau gaya kepemimpinan yang kurang pas atau kurang cocok dilaksanakan yang diberikan pimpinan kepada karyawannya, dapat menurunkan motivasi, kinerja dan akhirnya kepuasan kerja (kuswadi 2004). penelitian mengenai kinerja perawat telah dilakukan dengan mengaitkan berbagai variabel seperti motivasi, gaya kepemimpinan dan sebagainya. motivasi karyawan, kinerja menurun sementara absensi meningkat sebagai akibat dari gaya kepemimpinan otokratik dan laissez-faire (mtimkulu 2014), namun mailto:sudariani@gmail.com jurnal ners vol. 11 no. 2 oktober 2016 (176-185) 177 penelitian terkait kompetensi kepemimpinan kepala ruang belum ada di indonesia. data kepegawaian rsud kota mataram terkait penilaian kinerja yang dilakukan pada 50 orang perawat diperoleh pada tahun 2014 sebagian besar kinerja perawat dalam kategori cukup 29 orang (58%), dan kinerja perawat dalam kategori kurang sebanyak 10 orang (20%), bahkan terdapat 2 orang perawat (4%) tidak memenuhi standar kinerja sehingga dilakukan pemutusan hubungan kerja oleh kepegawaian rsud. studi pendahuluan terhadap motivasi perawat yang telah dilakukan pada bulan november 2015, kuesioner dilakukan pada 50 orang perawat rsud kota mataram, didapatkan data sebagian besar perawat memiliki motivasi cukup sebanyak 27 orang (54%) dan perawat dalam kategori kurang sebanyak 15 orang (30%). hasil wawancara dan observasi pada bulan september 2015 terhadap 15 kepala ruang di rsud kota mataram mengatakan bahwa 12 orang (80%) perawat belum mengikuti pelatihan manajemen bangsal. hasil wawancara terhadap kepala seksi keperawatan, pelatihan kompetensi kepemimpinan belum dilaksanakan dan standar operasional prosedur terhadap peran dan fungsi kepala ruang sedang dirancang, oleh karena itu pengembangan kompetensi kepemimpinan sebagai upaya peningkatan motivasi dan kinerja perawat pelaksana belum dapat dijelaskan. studi terdahulu tentang kompetensi kepemimpinan telah dilakukan oleh americans nursing association institute leadership pada tahun 2013 yang membagi kompetensi pemimpin menjadi tiga bagian yaitu adalah memimpin diri sendiri, orang lain dan organisasi (american nursing association 2013). indonesia memiliki standar kompetensi kepemimpinan untuk perawat ahli madya yaitu memberikan kontribusi untuk menciptakan lingkungan kerja yang positif, memahami manajemen penanganan konflik, mendukung kepemimpinan dalam tim dengan cara konsisten untuk meningkatkan rasa saling menghargai, hormat dan percaya diri diantara anggota tim. standar kompetensi kepemimpinan untuk ners yaitu memberikan advokasi dan bertindak untuk menciptakan lingkungan kerja yang positif, menyelesaikan konflik dengan pendekatan manajemen keperawatan serta memperhatikan perilaku organisasi, memberikan kontribusi untuk kepemimpinan tim dengan memperkuat tujuan sehingga dapat meningkatkan sikap saling menghargai dan percaya diri diantara anggota tim lainnya, memprioritaskan tugas dan mengelola waktu secara efektif, memberikan kontribusi pada hasil review dan modifikasi kebijakan dan prosedur organisasi terbaru, memberikan kontribusi terhadap pendidikan dan pengembangan profesional pembimbing klinik dan sejawat ditempat kerja, berperan serta aktif memberikan evaluasi dan tindak lanjut kepada organisasi di lingkungan kerja (ppni 2012). standar tugas pokok kepala ruang yang ditetapkan oleh depkes 2002 yaitu menyusun rencana kegiatan tahunan yang meliputi kebutuhan sumber daya (tenaga, fasilitas, alat dan dana), menyusun jadwal dinas dan cuti, menyusun rencana pengembangan staf, kegiatan pengendalian mutu, bimbingan dan pembinaan staf, koordinasi pelayanan, melaksanakan program orientasi, mengelola praktik klinik serta melakukan penilaian kinerja dan mutu pelayanan. kompetensi kepemimpinan digunakan dalam keterampilan seorang pemimpin (kepala ruang) dalam mempengaruhi staf perawat lain yang berada di bawah pengawasannya untuk pembagian tugas dan tanggung jawab dalam memberikan pelayanan asuhan keperawatan sehingga tujuan keperawatan tercapai (latif 2008 dalam maryanto et al., 2013). pengembangan model praktik keperawatan profesional, peran dan fungsi kepala ruang merupakan hal yang sangat penting, sehingga kompetensi kepemimpinan dan manajemen mutlak dibutuhkan (ilyas 2002). pengembangan kompetensi kepemimpinan keperawatan harus terus dilakukan untuk mendapatkan model yang ideal terhadap kemampuan pemimpin sebagai upaya dalam meningkatkan motivasi dan kinerja perawat yang pada akhirnya dapat meningkatkan kepuasan pelanggan (pasien). pembinaan, pengarahan oleh pimpinan (kepala ruangan) kepada perawat pelaksana, dan pengembangan motivasi, inisiatif dan keterampilan agar dapat melaksanakan tugasnya dengan baik dan lebih produktif, dalam hal ini pemimpin harus mampu menjelaskan, bekerjasama dan memonitor perilaku perawat sesuai dengan situasi yang ada untuk dapat meningkatkan kinerja perawat dalam melaksanakan tugasnya dengan baik (mutaaitin 2010). penelitian ini dilakukan untuk mengembangkan model kompetensi kepemimpinan sebagai upaya peningkatan motivasi dan kinerja perawat sehingga dapat meningkatkan pelayanan kesehatan. metode penelitian ini terdiri dari dua tahap. tahap pertama menggunakan analitik observasional digunakan untuk mengetahui hubungan sebab akibat antara dua variabel secara observasional, dimana bentuk hubungan dapat perbedaan, hubungan atau pengaruh, tahap ini akan dilakukan analisis terhadap faktor yang berhubungan dengan kompetensi kepemimpinan dan pengaruh kompetensi kepemimpinan terhadap motivasi dan kinerja perawat pelaksana. instrumen yang digunakan adalah kuesioner. perumusan isu stategis dengan fokus group discussion (fgd) bersama kepala seksi keperawatan, kepala ruang unit kerja, dan perawat kompetensi kepemimpinan kepala ruang (putu widhi sudariani, dkk) 178 pelaksana. penyusunan modul kompetensi kepemimpinan kepala ruang dilakukan bersama pakar. populasi terjangkau dalam penelitian adalah seluruh kepala ruang instalasi dan perawat pelaksana rumah sakit umum daerah kota mataram sebanyak 192 orang. sampel dalam penelitian tahap satu ini terdiri dari kepala ruang unit kerja dan perawat pelaksana. penetuan besar sampel dalam penelitian ini menggunakan rumus rule of the thumb yaitu 5-10 kali jumlah variabel bebas yang diteliti. besar sampel dalam penelitian tahap ini 140 responden. teknik pengambilan sampel menggunakan probability sampling, yaitu cluster sampling yang penetapan subjek diambil dari masing-masing wilayah kerja (emergency, rawat inap, rawat jalan, kamar operasi, dan intensif). tahap kedua pada penelitian ini menggunakan rancangan quasy experimental dengan randomisasi dan kontrol. tahap kedua ini terdapat dua kelompok yaitu kelompok kontrol yang tidak mendapatkan perlakuan (menerapkan kompetensi kepemimpinan kepala ruang seperti biasa) dan kelompok perlakuan yang memperoleh intervensi penerapan kompetensi kepemimpinan kepala ruang. tahap uji coba menggunakan modul kompetensi kepemimpinan kepala ruang hasil dari fgd dan diskusi bersama pakar. populasi terjangkau dalam tahap uji coba ini adalah seluruh kepala ruang dan perawat pelaksana di ruang rawat inap rumah sakit umum daerah kota mataram sebanyak 73 orang yang terbagi menjadi rawat inap kelas 1, 2, 3, vip/vvip. sampel dalam penelitian sebanyak 32 responden yang terdiri dari perawat pelaksana rawat inap kelas 3a dan 3b. teknik yang digunakan dalam tahap kedua ini yaitu teknik probability sampling jenis simple random sample dengan kriteria inklusi dan ekslusi. perbedaan motivasi dan kinerja perawat pelaksana kelompok kontrol dan perlakuan sebelum dan sesudah intervensi menggunakan uji wicoxon signed ranks test. hipotesis alternatif diterima bila p ≤ 0,05 dan pengaruh kompetensi kepemimpinan kepala ruang terhadap peningkatan motivasi dan kinerja perawat pelaksana kelompok kontrol dan perlakuan sesudah intervensi menggunakan uji mann whitney. hipotesis alternatif diterima apabila p≤0,05. hasil tahap i tabel 1. distribusi frekuensi faktor internal (individu) faktor internal skor (%) f (%) pengetahuan baik 76-100 102 73 cukup 56-75 28 20 kurang ≤55 10 7 keterampilan baik 76-100 66 47,14 cukup 56-75 72 51,42 kurang ≤55 2 1,43 pengalaman kerja ≥ 2 tahun 95 67,9 ≤ 2 tahun 45 32,1 nilai baik 76-100 80 57,14 cukup 56-75 58 41,43 kurang ≤55 2 1,43 demografi umur 17-25 tahun 26-35 tahun 36-45 tahun 32 104 4 22,9 74,3 2,8 suku sasak bali jawa lainnya 114 8 9 9 81,4 5,7 6,4 6,4 jenis kelamin laki-laki perempuan 36 104 25,7 74,3 agama hindu islam 8 132 5,7 94,3 jurnal ners vol. 11 no. 2 oktober 2016 (176-185) 179 tabel 2. distribusi frekuensi faktor eksternal (organisasi) faktor eksternal skor (%) f (%) faktor bawahan 1. status sosial pns 118 84,3 kontrak 22 15,7 2. pendidikan d3 keperawatan 81 57,9 s1 keperawatan 14 10 ners 45 32,1 faktor situasi (budaya organisasi) baik 76-100 83 59,29 cukup 56-75 51 36,43 kurang ≤55 6 4,29 tabel 3. distribusi frekuensi kompetensi kepemimpinan kepala ruang kompetensi kepemimpinan baik cukup kurang total f % f % f % f % memimpin diri sendiri 77 55 63 45 0 0 140 100 memimpin orang lain 73 52 67 48 0 0 140 100 memimpin organisasi 62 44 78 56 0 0 140 100 tabel 4. distribusi frekuensi motivasi perawat pelaksana motivasi baik cukup kurang total f % f % f % f % faktor motivator 67 47,8 68 48,5 5 4 140 100 faktor hygiene 54 38 81 58 5 4 140 100 tabel 5. distribusi frekuensi kinerja perawat pelaksana variabel sangat baik baik cukup kurang total f % f % f % f % f % sasaran kerja pegawai (skp) 16 11,43 27 19,29 87 62,14 10 7,14 140 100 sasaran perilaku (sp) 19 13,57 26 18,57 86 61,43 9 6,43 140 100 tabel 1 menunjukkan distribusi frekuensi faktor internal (individu) perawat. responden sebagian besar berpengatahuan baik, dan memiliki keterampilan yang cukup. responden memiliki pengalaman kerja sebagian besar lebih dari 2 tahun. variabel nilai sebagian besar memiliki nilai yang baik. data demografi menjelaskan sebanyak sebagian besar responden berada pada rentang usia 26-35 tahun dan suku terbanyak adalah suku sasak. tabel 2 menampilkan tentang faktor eksternal (organisasi) yang terdiri dari faktor bawahan yaitu status sosial, pendidikan perawat dan faktor situasi (budaya organisasi). status sosial sebagian besar adalah pns dan pendidikan sebagian besar adalah d3 keperawatan. faktor budaya organisasi menunjukkan bahwa sebagian besar responden memiliki budaya organisasi yang baik. tabel 3 menunjukkan sebagian besar kepala ruang memiliki kualitas baik dalam kompetensi kepemimpinan memimpin diri sendiri, sedangkan jumlah responden terendah berada pada kompetensi kepemimpinan memimpin organisasi. tabel 4 menunjukkan sebagian besar motivasi perawat pelaksana pada faktor hygiene dengan kategori cukup, sedangkan responden terendah yang memiliki kategori kurang berada pada faktor motivator dan faktor hygiene. tabel 5 menunjukkan sebagian besar kinerja perawat pelaksana pada sasaran kerja pegawai (skp) dan pada sasaran perilaku (sp) dalam kategori cukup. gambaran hasil pengujian pls tahap pemodelan dengan tujuan mengetahui pengaruh antar variabel. variabel karakteristik faktor internal (individu) yang terdiri dari pengetahuan, keterampilan, pengalaman, nilai/norma keyakinan, dan data demografi, faktor eksternal (organisasi) terdiri dari faktor bawahan, faktor situasi, variabel kompetensi kepemimpinan terdiri dari memimpin diri sendiri, memimpin orang lain, dan memimpin organisasi, variabel motivasi terdiri dari faktor kompetensi kepemimpinan kepala ruang (putu widhi sudariani, dkk) 180 motivator dan faktor hygiene, variabel kinerja terdiri dari sasaran kerja perawat (skp) dan sasaran perilaku (sp). pengujian ini menggunakan perbandingan uji t (t-test), apabila nilai t hitung lebih besar dari t tabel, t-value > 1,96 berarti pengujian signifikan, jika t-value < 1,96 berarti pengujian tidak signifikan. hasil pemodelan menunjukkan bahwa faktor internal berpengaruh signifikan terhadap kompetensi kepemimpinan, faktor eksternal berpengaruh signifikan terhadap kompetensi kepemimpinan, kompetensi kepemimpinan berpengaruh signifikan terhadap motivasi, dan kompetensi kepemimpinan berpengaruh positif terhadap kinerja. isu strategis yang didapatkan pada tahap ini yaitu faktor internal yang terdiri dari pengetahuan, keterampilan, dan nilai, faktor eksternal terdiri dari budaya organisasik, kompetensi kepemimpinan dan motivasi serta kinerja penelitian ini menggunakan metode fokus grup diskusi untuk memperkuat isu strategis dan juga solusi untuk kemudian sebagai dasar peneliti dalam menyusun rekomendasi kompetensi kepemimpinan kepala ruang sebagai upaya peningkatan motivasi dan kinerja perawat pelaksana. hasil atau temuan penting dalam focus group discussion (fgd) yaitu pada faktor internal (individu) didapatkan pebelajaran secara otodidak, pengetahuan perawat yang beraneka ragam, penempatan orang bau sebagai karu, belum ada referensi tentang kompetensi kepemimpinan kepala ruang, dan kurangnya pengetahuan perawat, dari segi keterampilan didapatkan bidang keperawatan belum membuat perencanaan dalam hal pelaksanaan pelatihan, sedangkan indikator nilai didapatkan kompetensi kepemimpinan memiliki nilai tinggi bagi kepala ruang, namun belum dilaksanakan sosialisasi terkait kompetensi kepemimpinan kepala ruang. faktor eksternal (budaya organisasi) didapatkan adanya tekanan budaya organisasi dalam institusi, terdapat pro dan kontra, dan kesenjangan antara visi misi rumah sakit dengan ruangan. kompetensi kepemimpinan diperoleh pemebelajaran secara otodidak, sistem manajemen bangsal belum diterapkan, referensi dalam menjalankan kompetensi karu belum optimal. variabel motivasi didapatkan perawat pelaksana kurang termotivasi dakam menjalankan perintah kepala ruang dan variabel kinerja diperoleh hasil belum konsisten antara reward dan punishment, kepala ruang memberikan pembelajaran ekstra terkait kinerja kepada perawat baru, belum ada sosialisasi dan pelatihan terkait asuhan keperawatan. tahap ii motivasi tabel 7 menyajikan distribusi frekuensi motivasi perawat pelaksana pada kelompok perlakuan dan kontrol sebelum dan sesudah intervensi. pada kelompok perlakuan faktor motivator sebagian besar memiliki jumlah nilai sama yaitu dengan kategori cukup. begitu juga dengan faktor hygiene memiliki nilai sebagian besar berada pada kategori frekuensi motivasi perawat pelaksana pada kelompok perlakuan dan kontrol setelah intervensi yaitu kelompok perlakuan memiliki faktor motivator dan faktor hygiene dengan kategori baik yang sama. gambar 1. structural model jurnal ners vol. 11 no. 2 oktober 2016 (176-185) 181 tabel 7. distribusi frekuensi motivasi perawat pelaksana pada kelompok perlakuan dan kontrol motivasi baik cukup kurang total f % f % f % f % pre-test 1. perlakuan faktor motivator faktor hygiene 6 7 37,5 43,75 10 9 62,5 56,25 0 0 0 0 16 16 100 100 2. kontrol faktor motivator faktor hygiene post-test 1. perlakuan faktor motivator faktor hygiene 2. kontrol faktor motivator faktor hygiene 6 4 12 12 6 2 37,5 25 75 75 37,5 12,5 10 11 4 4 10 13 62,5 68,75 25 25 62,5 81,25 0 1 0 0 0 6,25 0 6,25 0 0 0 1 16 16 16 16 16 16 100 100 100 100 100 100 a. faktor motivator wilcoxon kelompok perlakuan p=0,002 wilcoxon kelompok kontrol p=0,845 mann whitney post-test p=0,010 b. faktor hygiene wilcoxon kelompok perlakuan p=0,002 wilcoxon kelompok kontrol p=0,892 mann whitney post-test p=0,000 tabel 8. distribusi frekuensi kinerja perawat pelaksana pada kelompok perlakuan dan kontrol motivasi baik cukup kurang total f % f % f % f % pre-test 1. perlakuan sasaran kerja pegawai (skp) sasaran perilaku (sp) 8 5 50 31,25 8 11 50 68,75 0 0 0 0 16 16 100 100 2. kontrol sasaran kerja pegawai (skp) sasaran perilaku (sp) post-test 1. perlakuan sasaran kerja pegawai (skp) sasaran perilaku (sp) 2. kontrol sasaran kerja pegawai (skp) sasaran perilaku (sp) 5 5 12 11 5 5 31,25 31,25 75 68,75 31,253 1,25 11 11 4 5 11 11 68,75 68,75 25 31,25 68,75 68,75 0 0 0 0 0 0 0 0 0 0 0 0 16 16 16 16 16 16 100 100 100 100 100 100 a. sasaran kerja pegawai (skp) wilcoxon kelompok perlakuan p=0,010 wilcoxon kelompok kontrol p=0,317 mann whitney post-test p=0,006 b. sasaran perilaku (sp) wilcoxon kelompok perlakuan p=0,006 wilcoxon kelompok kontrol p=1,000 mann whitney post-test p=0,039 kelompok kontrol pada faktor motivator dan hygiene sebagian besar berada pada kategori cukup. pada faktor motivator pada kelompok perlakuan memiliki hasil yang signifikan sebelum dan sesudah, dimana berarti bahwa terdapat beda sebelum dan setelah diberikan intervensi. hal ini berkebalikan dengan kelompok kontrol, dimana tidak ada beda anatar sebelum dan setelah intervensi pada kelompok kontrol. hasil uji beda antara kelompok perlakuan dengan kelompok kontrol terdapat perbedaan yang signifikan, dimana berarti terdapat pengaruh kompetensi kepemimpinan kepala ruang terhadap motivasi (faktor motivator) perawat pelaksana. hasil uji dengan wilcoxon signed rank test faktor hygiene pada kelompok perlakuan menunjukkan terdapat perbedaan yang signifikan antara sebelum dan setelah dilakukan intervensi, hal ini berkebalikan dengan elompok kontrol. sedangkan hasil uji beda antara kelompok perlakuan dengan kelompok kontrol terdapat perbedaan yang signifikan, hal ini menunjukkan bahwa kompetensi kepemimpinan kepala ruang (putu widhi sudariani, dkk) 182 terdapat maka artinya terdapat pengaruh kompetensi kepemimpinan kepala ruang terhadap motivasi (faktor hygiene) perawat pelaksana. kinerja sasaran kerja pegawai pada kelompok perlakuan pre-test memiliki jumlah yang sama antara kategori baik dengan kategori cukup. sedangkan pada faktor sasaran perilaku pada saat pre-test jumlah terbanyak adalah pada kategori cukup. sedangkan pada kelompok kontrol baik sasaran kerja pegawai maupun sasaran perilaku memiliki julah yang sama dimana berada pada kategori baik dan cukup. hasil pada saat post test menunjukkan bahwa baik pada sasaran kerja pegawai (skp) maupun sasaran perilaku (sp) sebagian besar berada pada kategori baik, hal ini berkebalikan dengan kelompok kontrol dimana sebagian besar berada pada ketgori cukup. hasil uji beda pada faktor skp dan faktor sp sebelum dan setelah intervensi menunjukkan bahwa terdapat perbedaan yang signifikan antara sebelum dan setelah intervensi. kelompok kontrol baik pada faktor skp maupun sp ini tidak adanya perbedaan yang siginfikan antara sebelum dan setelah dilakukan intervensi. hal ini menunjukkan bahwa terdapat pengaruh kompetensi kepemimpinan kepala ruang terhadap kinerja (sasaran kerja pegawai dan sasaran perilaku) perawat pelaksana. pembahasan tahap 1 hasil uji statistik faktor internal menunjukkan bahwa ada pengaruh signifikan faktor internal terhadap kompetensi kepemimpinan kepala ruang (tabel 7). pengetahuan yang dimiliki sebagian besar berada pada kategori baik sebanyak 73%, keterampilan kepala ruang sebagian besar dalam kategori cukup sebesar 51,42% dan nilai berada dalam kategori baik sebesar 80%. pengetahuan kepala ruang dalam kompetensi kepemimpinan, memimpin diri sendiri masuk kedalam kategori kapasitas belajar dimana seorang kepala ruang paham terhadap peran dan fungsinya karena akan menjadi landasan dalam menjalankan kompetensinya. pengetahuan yang dimiliki oleh kepala ruang sebagian besar terdapat pada pengertian kepemimpinan bila dibandingkan dengan peran dan fungsi keperawatan, karena di rsud kota mataram belum ada referensi yang lengkap serta sosisalisasi terkait kompetensi kepemimpinan kepala ruang. pengetahuan memiliki dua fungsi utama, pertama sebagai latar belakang dalam menganalisa sesuatu hal, mempersepsikan dan menginterpretasikannya, yang kemudian dilanjutkan dengan pengambilan keputusan tindakan yang dianggap perlu. kedua, peran pengetahuan dalam mengambil tindakan yang perlu adalah menjadi latar belakang dalam mengartikulasikan beberapa pilihan tindakan yang mungkin dapat dilakukan, memilih salah satu dari beberapa kemungkinan tersebut dan mengimplementasikan pilihan tersebut, sehingga pengetahuan mengenai kompetensi kepemimpinan bagi seorang kepala ruang sangatlah penting sebagai dasar pengambilan keputusan dalam penerapan kompetensinya di ruangan (achterbergh & vriens 2002 dalam pribadi 2010). keterampilan kepala ruang digambarkan sebagian besar adalah cukup, pengalaman kerja yang dimiliki sebagian besar ≥ 2 tahun, namun bertolak belakang dengan pendapat (ferguson & brunner 1982 dalam chase 2010) bahwa keterampilan yang dimiliki kepala perawat dipengaruhi oleh pengalaman, semakin tinggi pengalaman yang dimiliki maka akan memberikan penghargaan yang lebih besar pula sehingga yang peran manajerial kepala perawat yaitu manajemen dan tujuan klinis, keterampilan manajemen dasar, dan unsur-unsur kunci dalam unit perawatan. hal tersebut dapat disebabkan karena seorang menjadi kepala ruang yang baru di rsud kota mataram cenderung belajar secara otodidak dan kepala ruang belum memperoleh pelatihan kompetensi kepemimpinan, selain itu pendidikan kepala ruang sebagian besar adalah d3, dimana pendidikan d3 merupakan pendidikan profesi pemula sehingga dalam pelaksanaannya membutuhkan pengalaman kerja yang cukup. pendidikan d3 keperawatan belum diajarkan bagaimana cara untuk memimpin dan mengelola hanya berbatas pada keterampilan pelayanan kesehatan. komponen faktor internal yang paling mempengaruhi kompetensi kepemimpinan adalah komponen nilai, nilai yang dimaksudkan adalah kompetensi kepemimpinan kepala ruang merupakan hal yang sangat penting dan menjadi acuan kepala ruang dalam melaksanakan peran dan fungsinya untuk peningkatan mutu pelayanan, selain itu kompetensi kepemimpinan kepala ruang memiliki nilai strategis bagi peningkatan motivasi dan kinerja perawat pelaksana. seorang pemimpin dalam memotivasi orang lain harus tahu diri, mengevaluasi keyakinan, dan nilai-nilai pribadi (bennis 1989 dalam smith 2012). perhitungan t-test pada faktor ekternal yaitu ada pengaruh signifikan faktor ekternal terhadap kompetensi kompetensi kepemimpinan. hasil fgd pada budaya organisasi didapatkan adanya tekanan budaya organisasi dalam institusi, beban kerja perawat, dan terdapat kesenjangan visi misi rumah sakit dan ruangan. budaya oganisasi dapat mempengaruhi kompetensi kepemimpinan kepala ruang dalam mencapai tujuan organisasi. penelitian terbaru menunjukkan bahwa budaya organisasi berkontribusi positif kepada kepemimpinan (wong & cummings 2007 dalam carter jurnal ners vol. 11 no. 2 oktober 2016 (176-185) 183 2016). hasil dari penelitian (kusumawati 2010) menyatakan bahwa ada pengaruh signifikan antara budaya organisasi terhadap kinerja dan kompetensi kepemimpinan. budaya organisasi tersebut terdiri dari misi, konsistensi, adaptabilitas, dan pelibatan jadi dalam budaya organisasi dimana keterlibatan karyawan relatif tinggi merupakan atribut untuk meningkatkan kinerja dan kepuasan pasien. hasil kuesioner faktor situasi (budaya organisasi) pada faktor ekternal di rsud kota mataram sebanyak 59,29% memiliki kategori baik, selanjutnya responden yang berada dalam kategori baik tersebut sebagian besar berada pada komponen konsistensi sebanyak 89 orang (63,67%), hal ini membuktikan bahwa konsistensi yang terdiri dari pedoman dalam pelaksanaan pelayanan dibuat tertulis, setiap perawat memiliki pemahaman yang baik tentang kebutuhan pasien, setiap kesalahan yang terjadi dievaluasi secara tertutup, penerapan nilai-nilai dalam bekerja seperti kedisiplinan, kekompakan, penghargaan, dan lain-lain telah dilaksanakan dengan maksimal. hal tersebut berbeda dengan hasil dari penelitian (deal and patterson 2007 dalam blakeman 2013) yaitu visi dan dari institusi merupakan hal yang paling penting dalam budaya organisasi. hasil perhitungan t-test (structural model) didapatkan ada pengaruh signifikan kompetensi kepemimpinan terhadap motivasi perawat pelaksana. faktor higyene merupakan sub variabel yang paling mempengaruhi motivasi perawat pelaksana. (herzberg 1966 dalam ghazi et al., 2013) mengembangkan teori dua faktor yaitu faktor higiene dan motivator. faktor hygiene meliputi: upah, kondisi kerja, keamanan kerja, status, prosedur perusahaan, mutu penyeliaan, mutu hubungan interpersonal antar sesama rekan kerja, atasan, dan bawahan, sedangkan faktor motivators meliputi: pencapaian prestasi, pengakuan, tanggung jawab, kemajuan, pekerjaan itu sendiri, kemungkinan berkembang. studi meta analisis menyelidiki berbagai literatur untuk dapat menunjang bahwa peningkatan moral dan karakteristik motivasi dari seorang pemimpin keperawatan erat kaitannya dengan pengoptimalan kualitas perawat dan hasil di rumah sakit. studi ini menyatakan bahwa kompleksitas hubungan interpersonal dalam lingkungan kerja klinis, dan isu kritis yang dihadapi perawat pada fungsi mereka sehari-hari menunjukkan bahwa moral, kepuasan kerja dan motivasi adalah bagian terpenting dalam peningkatan efisiensi kerja, output, kolegialitas, dan komunikasi antara staf (stapleton et al., 2007 dalam ezeukwu 2011). seorang pemimpin dapat mempengaruhi motivasi pada bawahan dengan cara menawarkan imbalan untuk dapat mencapai tujuan kinerja, menjelaskan jalur menuju tujuannya tersebut. salah satu bagian dari kompetensi kepemimpinan kepala ruang adalah memotivasi staf sehingga dapat mencapai tujuan yang telah ditentukan, apabila staf telah mencapai prestasi dan hasil kerja yang memuaskan, seorang kepala ruang dapat memberikan reward kepada stafnya, dan begitu sebaliknya. hasil penelitian kinerja didapatkan sebagian besar pada kategori cukup. hasil t-test menunjukkan bahwa ada pengaruh signifikan kompetensi kepemimpinan kepala ruang terhadap kinerja perawat pelaksana. hasil fgd pada penelitian ini terkait kinerja adalah kepala ruang memberikan pembelajaran ekstra kepada perawat baru. penelitian (miltner et al., 2015) saat melaksanakan fgd beberapa kepala keperawatan mengatakan bahwa strategi kepemimpinan yang proaktif dapat meningkatkan kinerja unit. kompetensi kepemimpinan pada kepala ruang memiliki nilai penting terhadap peningkatan kinerja ruangan, sehingga kepala ruang diharapkan paham terhadap kompetensi yang dimilikinya sebagai pemimpin, oleh sebab itu diperlukan adanya pelatihan atau penyegaran kembali terkait perfomance perawat dalam pelaksanaan tugasnya sebagai pelayan kesehatan. pendapat (de kluyver & pearce 2008 dalam olinger 2010) kinerja merupakan inti dan aset dari kompetensi kepemimpinan dalam suatu organisasi. perawat merupakan ujung tombak dari pelayanan kesehatan di rumah sakit, apabila kinerja unit dalam suatu organisasi/unit pelayanan kesehatan tinggi maka akan mempengaruhi kualitas dari organisasi tersebut, oleh sebab itu dibutuhkan leader atau kepala keperawatan yang mengetahui kompetensi kepemimpinan yang mereka harus miliki. kinerja sebagian besar dalam kategori cukup dapat disebabkan karena belum dilakukan pelatihan secara berkesinambungan, sehingga kepala ruang masih memberikan pengajaran ektra kepada perawat pelaksana terkait keterampilan, selain itu pada poin penelitian asuhan keperawatan sebagai peningkatan orientasi mutu pelayanan didapatkan asuhan keperawatan tiap ruang berbeda-beda karena belum ada pelatihan serta sosialisasi tentang standard nursing language di rsud kota mataram. tahap 2 uji satatistik wilcoxon faktor motivator dan faktor hygiene pada kelompok perlakuan setelah dilakukan intervensi adalah sama yaitu sebesar p=0,002 sehingga dapat disimpulkan ada beda motivasi responden sebelum dan sesudah intervensi kompetensi kepemimpinan kepala ruang pada kelompok perlakuan. hasil post-test kelompok perlakuan, sebagian besar motivasi perawat pelaksana berada pada kategori baik. uji mann-whitney faktor motivator dan faktor hygiene pada kelompok perlakuan dan kontrol post-test didapatkan ada pengaruh signifikan motivasi perawat pelaksana setelah kompetensi kepemimpinan kepala ruang (putu widhi sudariani, dkk) 184 mendapatkan intervensi kompetensi kepemimpinan kepala ruang pada kelompok perlakuan bila dibandingkan dengan kelompok kontrol yang tidak diberikan intervensi. beberapa penelitian mengungkapkan bahwa terdapat 7 kunci utama yang diidentifikasi dalam memotivasi yaitu imbalan keuangan (gaji atau tunjangan), pengembangan karir (dipromosikan), pendidikan berkelanjutan (memiliki kesempatan untuk mengambil kelas dan menghadiri seminar), infrastruktur rumah sakit (kondisi fisik, fasilitas kesehatan, lingkungan kerja), ketersediaan sumber daya (ketersediaan perawat dan alat medis bagi petugas kesehatan untuk melakukan pekerjaan mereka), manajemen rumah sakit (memiliki kerja yang positif, hubungan yang baik dengan manajemen dan petugas kesehatan lainnya) dan pengakuan/penghargaan (baik dari manajer, rekan kerja, maupun dari masyarakat) (willis-shattuck et al., 2008). penerapan dalam kompetensi kepemimpinan dilakukan melalui empat domain utama yang salah satunya dalam domain kompetensi interpersonal yaitu motivasi (rubino 2007 dalam graziadio 2013). lingkungan kerja yang nyaman serta pemberian motivasi pada dasarnya merupakan hak para karyawan dan kewajiban dari pihak perusahaan untuk mendukung kontribusi para karyawannya dalam rangka mencapai tujuan yang telah ditentukan (rezsa 2008 dalam melati 2011). motivasi perawat pelaksana setelah dilakukan intervensi kompetensi kepemimpinan kepala ruang meningkat, sebagaian besar kompetensi berada pada kategori baik hal ini disebabkan karena modul kompetensi disosialisasikan peneliti kepada kepala ruang kelompok perlakuan selama 1 bulan, setelah diberikan intervensi nilai motivasi pada kelompok perlakuan sebagian besar meningkat. kepala ruang telah menerapkan kompetensi kepemimpinannya dalam hal memotivasi perawat pelaksana seperti memberikan kesempatan kepada perawat pelaksana dalam pengembangan karir di bidang keperawatan, membuat kondisi kerja yang nyaman, rekan kerja memberikan semangat dan dukungan dalam pelaksanaan asuhan keperawatan. hasil penelitian pada kelompok perlakuan posttest didapatkan bahwa kinerja (skp) dan kinerja (sp) sebagian besar pada kategori baik. hasil uji wilcoxon signed rank test pada kelompok perlakuan didapatkan ada beda kinerja perawat pelaksana sebelum dan sesudah intervensi pada kelompok perlakuan. uji mann-whitney pada kelompok perlakuan dan kontrol post-test didapakan ada pengaruh signifikan kinerja perawat pelaksana setelah diberikan intervensi kompetensi kepemimpinan dibandingkan dengan kelompok kontrol yang tidak memperoleh intervensi. peningkatan kinerja karyawan di instansi pemerintah dapat ditempuh dengan beberapa cara, misalnya melalui pemberian kompensasi yang layak, pemberian motivasi, menciptakan lingkungan kerja yang kondusif, serta pendidikan dan pelatihan, oleh karena itu karyawan diharapkan dapat memaksimalkan tanggung jawab mereka setelah dibekali dengan pendidikan dan pelatihan yang berkaitan dengan implementasi pekerjaan mereka. kinerja pada dasarnya dipengaruhi oleh kondisi tertentu, yaitu kondisi yang berasal dari dalam individu yang disebut dengan faktor individual dan kondisi yang berasal dari luar individu yang disebut dengan faktor situasional. faktor individual meliputi pengalaman dan karakteristik psikologis yang terdiri dari motivasi, kepribadian, dan orientasi tujuan sedangkan faktor situasional meliputi kepemimpinan, prestasi kerja, hubungan sosial dan budaya organisasi (melati 2011). salah satu dari empat domain kompetensi kepemimpinan oleh (rubino 2007 dalam graziadio 2013) yaitu manajemen kinerja dan evaluasi yang terdapat pada domain kompetensi organisasi. de kluyver dan pearce 2008 dalam olinger 2010 menyatakan bahwa kinerja merupakan inti dan aset dari kompetensi kepemimpinan dalam suatu organisasi. modul kompetensi kepemimpinan diterapkan selama 1 bulan kepada kepala ruang. skor kinerja kelompok perlakuan sebagian besar meningkat, bila dibandingkan dengan kelompok kontrol. kompetensi kepemimpinan yang diterpakan dalam hal kinerja yang dilakukan meliputi dokumentasi asuhan keperawatan, pasien safety, health education pasien dan keluarga sesuai kasus, menghitung beban kerja perawat, timbang terima, kerja sama tim, dan lain-lain. simpulan dan saran simpulan model kompetensi kepemimpinan kepala ruang dipengaruhi oleh faktor internal dan eksternal. faktor internal merupakan faktor yang ada dalam diri pemimpin yang terdiri dari pengetahuan, keterampilan dan nilai, sedangkan faktor ekternal terdiri dari faktor bawahan (pendidikan) dan faktor organisasi (budaya organisasi). penerapan model kompetensi kepemimpinan kepala ruang mempengaruhi motivasi dan kinerja perawat pelaksana. faktor hygiene dalam motivasi merupakan yang paling besar mempengaruhi kompetensi kepemimpinan. faktor hygiene tersebut terdiri dari gaji, kondisi kerja, hubungan kerja, dan prosedur kerja. saran pengembangan model kompetensi kepemimpinan terkait memimpin diri sendiri, memimpin orang lain dan memimpin organisasi dapat digunakan sebagai salah satu referensi seorang pemimpin dalam menjalankan kompetensinya di lapangan, selain itu dapat jurnal ners vol. 11 no. 2 oktober 2016 (176-185) 185 dipertimbangkan sebagai sarana penilaian kepemimpinan keperawatan. kepustakaan american nursing association, 2013. competency model, available at: available at: http://analeadershipinstitute.org/doc-vault/aboutus/ana-leadership institute-competencymodel-pdf.pdf. blakeman, c., 2013. a nursing model of leadership pcactice and policy implementation: end-of-life care challenge. proquest llc. carter, s., 2016. the relationship between transformational leadership and organizational learning culture in magnet and non-magnet hospitals. proquest llc. chase, l., 1994. nurse manager competencies. the journal of nursing administration, 24, pp.56–64. ezeukwu, d., 2011. nurse leader competencies and their relationship to quality of nursing care: a case study. proquest llc. ghazi, sahsada & khan, s., 2013. resurrecting herzberg’s two factor theory: an implication to the university teachers. journal of educational and social research, 3(2). graziadio, gl., 2013. leadership competencies for effective hospital chief executive officers and chief medical officers in mexico. proquest llc, umi 1543405. hair, j.f. et al., 2012. the use of partial least squares structural equation modeling. strategic management research: a review of past practices and recommendations for future applications, long range planning (lrp), 45(45), pp.320–340. available at: http://www.sciencedirect.com/science/article/pii/s 0024630112000568. ilyas, y., 2002. kinerja: teori, penilaian, dan penelitian. in pusat kajian ekonomi kesehatan fakultas kesehatan masyarakat. depok: universitas indonesia. kusumawati, r., 2010. analisis pengaruh budaya organisasi dan gaya kepemimpinan terhadap kepuasan kerja untuk meningkatkan kinerja karyawan studi kasus di rs roemani semarang. available at: http://eprints.undip.ac.id/18652/1/ratna_kusuma wati.pdf. kuswadi, 2004. cara mengukur kepuasan karyawan, jakarta: pt. elex media koputindo. maryanto, pujiyanto, tri, setyono, s., 2013. hubungan gaya kepemimpinan kepala ruang dengan kepuasan kerja perawat di rumah sakit swasta di demak. jurnal managemen keperawatan, 1(2), pp.146–153. melati, ii., 2011. faktor-faktor yang mempengaruhi kinerja pegawai studi empiris pada kementerian keuangan kantor wilayah jawa tengah. available at: http://eprints.undip.ac.id/28660/1/skripsi05.pdf. miltner, r.s. et al., 2015. professional development needs of nurse managers. journal of continuing education in nursing, 46(6), pp.252–258 7p. available at: http://search.ebscohost.com/login.aspx?direct=true &db=c8h&an=103807275&site=ehostlive&scope=site. mtimkulu, d.s., 2014. an evaluation of the leadership styles of managers and their impact on human capital factors of motivation , performance and absenteeism of employees at selected hospitals in eastern free state , south africa. , 4(2). mutaaitin, 2010. hubungan gaya kepemimpinan situasional kepala ruangan dengan tugas perawat pelaksana dalam memberikan asuhan keperawatan kepada klien di ruang rawat inap rsud pasaman barat. universitas andalas. available at: http://repository.unand.ac.id/7467/. ppni, 2012. standar praktek keperawatan, perawat profesional, jakarta. pribadi, a., 2010. analisis pengaruh faktor pengetahuan, motivasi, dan persepsi perawat tentang supervisi kepala ruang terhadap pelaksanaan dokumentasi asuhan keperawatan di ruang rawat inap rsud kelet provinsi jawa tengah di jepara. available at: http://eprints.undip.ac.id/16228/1/agung_pribadi. pdf. smith, v., 2012. college of management and technology. proquest llc. willis-shattuck, m. et al., 2008. motivation and retention of health workers in developing countries: a systematic review. bmc health services research, 8, p.247. available at: http://www.ncbi.nlm.nih.gov/pubmed/19055827. yamin, s. & kurniawan, h., 2011. generasi baru mengolah data penelitian dengan partial least square path modeling, jakarta: salembainfotek. 164 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19003 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review pelvic floor muscle training (pfmt) to reduce urinary incontinence post radical prostatectomy in patients with prostate cancer: a systematic review dian retno pratiwi, firda yusniar, ika adelia susanti, tintin sukartini faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: pelvic floor muscle training (pfmt) is an important rehabilitative approach as it plays a crucial role in the male urinary mechanism and urinary continence as well as strength. the purpose of this study was to assess the effectiveness of pfmt in the treatment of urinary incontinence post radical prostatectomy in patients with prostate cancer. methods: studies were systematically identified by searching electronic databases with the keywords “pelvic floor muscle training” and “urinary incontinence” and “radical prostatectomy” and consisted of 103 articles from scopus, 60 articles from science direct, 34 articles from ebsco, and 195 articles from pro quest. the data sources were limited to articles published from 2011 to 2020 and those published in english. results: fifteen studies were included in this systematic review with inclusion criteria being patients diagnosed with prostate cancer, men with urinary incontinence after radical prostatectomy, types of study: randomized controlled study (rct) and protocol study, intervention: pfmt and main outcome: continence rate. twelve of fifteen articles suggest pfmt is significantly more effective than the standard care in improving recovery of continence in patients undergoing radical prostatectomy. conclusion: pfmt is effectively carried out with a duration of 10-45 minutes per day with 10 contractions in a lying, sitting, and standing position with three sets, time of contractions 5-10 seconds and relaxation 5-10 seconds. the benefits of this review are that pfmt is suitable, well accepted and achievable for the patients who experience incontinence after radical prostatectomy. article history received: feb 27, 2020 accepted: april 1, 2020 keywords pelvic floor muscle training; urinary incontinence; prostate cancer; prostatectomy contact dian retno pratiwi  dian.retno.pratiwi2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: pratiwi, d. r. p., yusniar, f., susanti, i. a., & sukartini, t. (2020). pelvic floor muscle training (pfmt) to reduce urinary incontinence post radical prostatectomy in patients with prostate cancer: a systematic review. jurnal ners, special issues,164-172. doi:http://dx.doi.org/10.20473/jn.v15i2.19003 introduction prostate cancer (pca) is a serious issue in the world and is the second most commonly diagnosed cancer in men (milios, ackland, & green, 2019; mottet et al., 2018). the new cases of pca were 358,989 deaths or 3.8% of all mortality caused by cancer in men in 2018 (bray et al., 2018). this problem may be asymptomatic at an early stage and show common symptoms such as difficult urination, urinary retention, and back pain (rawla, 2019). the best treatment to remove this disease is radical prostatectomy (rp) which has a success rate of around 97% at least five years after surgery. on the other hand, rp has a negative effect on the patient in that it can induce urinary incontinence (ui) and this can be provoked by several conditions such as exercise, positional change, lifting, bending, coughing, and sneezing (mottet et al., 2018). ui after prostatectomy prevalence one year after surgery, considering continence status as not using pads, ranges from 6.3%-52% (ficarra v, novara g, artibani w, 2009). ui after prostatectomy treatment is a clinical condition that makes patients feel distressed and increases risk of falls, fall-related injuries, skin problems, nursing home admissions, and prolonged hospital admissions (hu & wagner, 2005; lucioni, nitti, & stoffel, 2019; matsumoto & inoue, 2007). there are three types of ui: stress ui (sui), urge (uui), and mixed ui (mui) wall at https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:dian.retno.pratiwi-2019@fkp.unair.ac.id mailto:dian.retno.pratiwi-2019@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 165 inappropriate times. the last is mui and this condition can be interpreted as a mixture of sui and uui (abrams et al., 2018).based on the pathophysiology of ui, one of the factors is poor urethral support by the pelvic floor muscles and intrinsic sphincter deficiency. sui is the involuntary leakage of urine during exertion, such as coughing, laughing, or sneezing that increases abdominal pressure and puts stress on the bladder because of urine leakage (radzimińska et al., 2018). uui, commonly defined as overactive bladder, is usually caused by involuntary contractions of the detrusor muscles of the bladder. ui after radical prostatectomy may occur due to direct damage to the bladder neck urethral sphincter, and/or pelvic floor muscle during surgery (centemero et al., 2010). according to guidelines on prostate cancer from the european association of urology, one of the treatments to eliminate ui after radical prostatectomy is pfmt (mottet et al., 2018). pfmt is a treatment using two concepts: improving urethral resistance and pelvic organ support for muscle strength, tone, and resistance, along with improved neuronal aspects, producing morphologic and other specific changes in the long term and resulting in automatic contraction of that musculature (krishna dass, lo, khanuengkitkong, & tan, 2013; rodas & garcía-perdomo, 2018). using pfmt correctly contributes to better urethral contraction and improves pelvic floor muscle contraction (radzimińska et al., 2018). the purpose of this systematic review was to assess the effectiveness of pfmt in the treatment of urinary incontinence post radical prostatectomy in patients with prostate cancer. materials and methods data sources the present study is a systematic review using a randomized controlled trial method. a literature search was performed on the databases scopus, science direct, proquest, and ebsco in order to identify articles published from 2011 to 2020. the keywords to search those journals were “pelvic floor muscle training” and “urinary incontinence” and “radical prostatectomy”. study selection the feasibility of the study was assessed using the picot framework. the inclusion criteria were: (i) patient diagnosed with prostate cancer; (ii) men with urinary incontinence; (iii) patient without ui prior to radical prostatectomy (rp) surgery or transurethral resection of the prostate (turp); (iv) types of study: randomized controlled trials (rcts) and pilot rct (excluded studies included quasi-experimental trials); (v) type of intervention: pelvic floor muscle training or pelvic floor muscle exercise; (vi) main outcome: continence rate. titles/abstract screened (n=20) e li g ib il it y records identified through database searching (n = 392) • scopus: 103 • science direct: 60 • pro quest: 34 • ebsco: 195 in c lu d e d s c r e e n in g id e n ti fi c a ti o n records after duplicates removed (n= 98) full text articles assessed for eligibility (n =15) articles excluded, with reasons (n = 5 ) ▪ types of study ▪ intervention ▪ outcoes studies includes in quality synthesis (n =15 ) study included in the systematic review (n = 15) record excluded based on title and author (n =78 ) figure 1 flow diagram of the study selection process d. r. pratiwi et al. 166 | pissn: 1858-3598  eissn: 2502-5791 data extraction the following information was extracted from 15 articles: information on demographics, study design, outcome measures, sample size, intervention, control, pre-post-intervention mean, country and year of publication from each study. quality assessment the systematic review method was based on the prisma checklist (preferred reporting items for systematic reviews and meta-analyses) to strengthen reporting (figure 1) (liberati et al., 2009). results study selection a three-step strategy was used and the initial phase of the literature search in four databases with the table 1. summary of selected studies author design sample intervention result (glazener et al., 2011) rcts 788 respondents pfmt duration of intervention: 12 months duration pfmt: 10 minutes frequency: 3 sets per day evaluation of intervention: 4 times position: lying/supine, sitting and standing pfmt not effective in patients after radical prostatectomy and did not result in better short term or medium term continence rates or qol. (tienforti et al., 2012) rcts 32 respondents biofeedback and pfmt duration of intervention: 6 months duration pfmt: 10 minutes frequency: 3 sets per day (10 contractions and 10 relaxations) postion: lying/supine, sitting and standing evaluation of intervention: 3 times combination of pfmt and biofeedback more effective for recovery from ui after rp. (geraerts et al., 2013) rcts 180 respondents pfmt pre and post surgery duration of intervention: 26 weeks duration pfmt: 30 minutes frequency: 3 sets per day with 60 contractions per day position: lying/supine, sitting and standing evaluation of intervention: 4 times pfmt effective when performed pre surgery and post surgery. (santa mina et al., 2015) a pilot study randomized trial 88 respondents pfmt, pilates and hypopressives duration of intervention: 6 months duration pfmt: 30 minutes frequency: 2-3 sets per day with 60–180 contractions per day position: lying/supine, sitting and standing evaluation of intervention: 4 times this trial will provide the foundation of data for a future, large scale trial to definitively describe the effect of these advanced pelvic floor exercise modalities compared to conventional pelvic floor exercise regimen for men pca undergoing rp. (zhang et al., 2015) rcts 244 respondents pfmt, monitoring by telephone and support group duration of intervention: 3 months duration pfmt: 30 minutes frequency: 3 sets per day position: lying/supine, sitting and standing pfmt and monitoring can improve urinary continence and quality of life. jurnal ners http://e-journal.unair.ac.id/jners | 167 specified keywords then obtained 392 articles. these (pedriali, f.r., gomes, c.s., soares, l., urbano, m.r., moreira, e.h., averbeck, m.a.,&almeida, 2016) rcts 85 respondents pfmt, and pilates duration of intervention: 10 weeks duration pfmt: 10 minutes frequency: 3 sets per day with 10 contractions per day position: lying/supine, sitting and standing pfmt and pilates speed up continence recovery in ppui. (zhang et al., 2017) rcts 267 respondents pfmt duration of intervention: 6 months duration pfmt: 60 minutes evaluation of intervention: 3 times position: lying/supine, sitting and standing offering follow-up care during the survivorship period is essential for stopping or slowing regression of urinary function and qol in this patient population. (crowe et al., 2018) rcts 51 respondents pfmt with video animation duration of intervention: 3 months duration pfmt: 10 minutes frequency: evaluation of intervention: 3 times position: lying/supine, sitting and standing the model is a useful supplement to existing methods of instructing participants in pfm exercise techniques. (aydın sayılan & özbaş, 2018) rcts 60 respondents pfmt pre and post surgery duration of intervention: 6 months duration pfmt: 10 seconds/contraction frequency: 3 sets per day with 20-60 contractions per day evaluation of intervention: 4 times position: lying/supine, sitting and standing the decrease was statistically highly significant in the third and sixth months. pelvic muscle floor exercises are suitable for patients experiencing incontinence after radical prostatectomy. (gomes et al., 2018) rcts 104 respondents pfmt and pilates duration of intervention: 10 months duration pfmt: 45 minutes frequency: 3 sets per day with 10 contractions per day position: supine, sitting, and standing evaluation of intervention: 1 time position: lying/supine, sitting and standing the pilates method presented potential advantages in the endurance of pelvic floor muscle contraction and in the proportion of fully continent patients 4 months after surgery. (milios et al., 2019) rcts 97 respondents pfmt intervention pre-post surgery duration of intervention: 17 weeks duration pfmt: 30 minutes frequency: 2-6 sets per day, 10 120 contractions. slow and fast twitch muscle position: supine, sitting, and standing evaluation of intervention: 3 times pfmt commenced prior to prostate surgery enhanced postsurgical measures of pelvic floor muscle function, reduce ui and improved qol. (tantawy et al., 2019) rcts 61 respondents pfmt and whole body vibration training duration of intervention: 4 weeks duration pfmt: 10 second an effective modality for treating patients with stress urinary incontinence after prostatectomy. d. r. pratiwi et al. 168 | pissn: 1858-3598  eissn: 2502-5791 consisted of 103 articles from scopus, 60 articles from science direct, 34 articles from ebsco, and 195 articles from pro quest (figure 1). the second step was to review the abstract for eligibility criteria. we excluded some articles that did not match inclusion criteria. the third step was to review the full articles. full article were reviewed with the picot framework. relevant data regarding inclusion criteria (participants, interventions, and outcomes), risk of bias, and results were extracted. at the end of the process, 15 studies were included in this systematic review. overall, 14 studies were randomized controlled trials (rcts) and one study was a pilot study. characteristics of the study population population characteristics in all studies only included male patients with prostate cancer who had undergone radical prostatectomy (rp) and who reported urinary incontinence after surgery. the total sample in this study was 2.448 male patients. the sample size varied from 32 to 788 patients, with a total of 2,448 patients. the ages ranged from 40 to 80 years. several studies explained that the characteristic demographic data from all participants showed had no significant differences (p>0.05); this means that the data were homogenous between two or three groups in terms of age, body mass index, pathological state/cancer state (t2 stage) and gleason score (3-7 score). intervention all research was focused on evaluating the impact of the pelvic floor muscle training program on urinary incontinence in patients with radical prostatectomy separately or in combination. interventions were given 1-3 weeks pre surgery and 6-12 weeks postsurgery or after catheter removal. before the intervention was performed, all participants were given verbal, written (leaflet) and video simulation about pfmt instruction by a psychotherapist or urology nurse. duration of pfmt was 10-45 minutes per day with 10 contractions in a lying, sitting, and standing position with a frequency of three sets per day, time of contractions: 5-10 seconds and relaxation: 5-10 seconds. the intervention was for a minimum of 3 weeks (heydenreich et al., 2020), a maximum of 12 months (geraerts et al., 2013; glazener et al., 2011) contraction and 10 second relaxation frequency: 3-4 sets per day 15 times (repeated) slow and fast twitch muscle position: supine, sitting, and standing (heydenreich et al., 2020) rcts 184 respondents pfmt and relaxing therapy duration of intervention: 3 weeks duration pfmt: 30 minutes frequency: 3-4 sets per day position: lying, sitting, and standing evaluation of intervention: 2 times more effective than conventional continence training alone and it has a beneficial effect on measured quality of life and greater in patients with more incontinence. (laurienzo et al., 2018) rcts 123 respondents pfmt and electrical stimulation duration of intervention: 6 months duration pfmt: 30 minutes frequency: 2-3 sets per day position: lying, sitting, and standing evaluation of intervention: 3 times pfmt and electrical stimulation did not have an impact on the recovery of urinary continence and erectile function (oh et al., 2019) rcts 84 respondents pfmt and biofeedback. duration of intervention: 3 months duration pfmt: 10 minutes frequency: 4 sets per day, 10 second contraction and 10 second relaxation position: lying, sitting, and standing evaluation of intervention: 3 times intervention group showed a significantly smaller volume of urine loss at the 1 month follow up than the control group. rcts: randomized controlled trials; pfmt: pelvic floor muscle training; qol :quality of life jurnal ners http://e-journal.unair.ac.id/jners | 169 and the intervention time most widely used was 6 months (aydın sayılan & özbaş, 2018; laurienzo et al., 2018; tienforti et al., 2012; zhang et al., 2015, 2017). during intervention, the psychotherapist observed and evaluated pfmt with telephone and home visits to patients (zhang et al., 2015, 2017). an intervention group was compared or combined with other therapy such as biofeedback, electrical stimulation, whole-body vibration training, pilates, and relaxing therapy (glazener et al., 2011; gomes et al., 2018; heydenreich et al., 2020; laurienzo et al., 2018; oh et al., 2019; pedriali, f.r., gomes, c.s., soares, l., urbano, m.r., moreira, e.h., averbeck, m.a.,&almeida, 2016; tantawy, elgohary, abdelbasset, & kamel, 2019; tienforti et al., 2012). the intervention was evaluated at least one time (gomes et al., 2018; zhang et al., 2015) and at most three times (glazener et al., 2011; gomes et al., 2018; milios et al., 2019; tantawy et al., 2019; tienforti et al., 2012; zhang et al., 2017). clinical outcome discussion prostate cancer is a diagnosis of cancer that occurs in men and the prevalence increases due to age. typically, men diagnosed with localized prostate cancer requiring treatment are offered two potentially curative treatment options: rp or radiotherapy. the gold standard for the treatment of prostate cancer is rp, but it has a complication post rp which is ui (aydın sayılan & özbaş, 2018; crowe et al., 2018) which may go on for as long as 1-2 years after rp. investigators have proved that continence can be achieved faster with pfmt (geraerts et al., 2013). conventional pelvic floor muscle exercises are intended to improve urinary control by increasing the strength, endurance and coordination of the pelvic floor muscles and functional activation of the external urethral sphincter (campbell se, glazener cma, hunter kf, cody jd, 2012; macdonald r, fink ha, huckabay c, monga m, 2007) focused on the repeated maximal contraction of the muscles around the anus (hodges et al., 2019). in this review study, interventions were given 13 weeks pre surgery and 6-12 weeks post-surgery or after catheter removal. the pre-operative period provides an opportunity to intervene and minimize the impact of ui, with a recommendation for a 6-week period between prostate biopsy and subsequent rp surgery to avoid complications; patients can be referred for preoperative pfmt (wang w, huang qm, liu fp, 2014). for intervention pre-operatively, the psychotherapist or urology nurse gave pelvic floor muscle instructions and prescribed a daily pfmt program (milios et al., 2019). pfmt could be started immediately after removal of the bladder catheter and early intervention (within six months of surgery) yields better results when compared to later intervention (zermann dh, wunderlich h, reichelt o, 2000). the duration of pfmt should be between 10-45 minutes per day with 10 contractions in a lying or supine, sitting, and standing position with a frequency of three sets per day, time of contractions: 5-10 seconds and relaxation: 5-10 seconds. in gomes et al., pfmt was measured with the patients lying in a supine position with legs at an angle of 450. the end anal probe of the perineometer was used for all measurements, and active pelvic floor contraction (without contracting the abdominal, gluteal or adductor muscles) was performed for 15s, followed by 30s of rest, in order to avoid fatigue (gomes et al., 2018). milios et al. (2019) in their study, had exercise protocols in the intervention group which targeted the use of slow and fast twitch muscle fibers and the participants performed six sets of pelvic floor muscle exercises per day, with each set comprising 10 fast (1s duration) and 10 slow (10s duration for contractions with an equal rest time, providing a total of 120 contractions per day and all sets were performed in a standing posture, which resulted in improved post-surgical pelvic floor muscle function and decreased ui after 12 weeks. another study also used the pfmt intervention with slow and fast twitch fibers, performed each day in lying, sitting and standing positions; procedure begin same with intervention review this study, but the contraction and relaxation times were increased by 1 second for every week of training (tantawy et al., 2019). moreover, for most of the studies reviewed, pfmt was performed in supine, sitting and standing positions. contractions and relaxation were performed in coordination with breathing but involved maintenance of intraabdominal pressure and respiration (pedriali, f.r., gomes, c.s., soares, l., urbano, m.r., moreira, e.h., averbeck, m.a.,&almeida, 2016). the program had to be monitored, evaluated and followed up of training, so that the results could be maximized and psychotherapists or urology nurses had to have professional licenses. follow up care may reduce the need for hospital or clinical visits. patient long-term adherence to pfmt is crucial for enhancing positive treatment outcomes and evidence has shown that peer social support is effective. furthermore, usually psychotherapist or urology nurse uses telephone calls and they follow up with pfmt instructions, advice about consuming 200cc of noncaffeinated fluid with two or fewer caffeinated drinks daily, setting bladder voiding schedules, maintaining a balanced diet and performing daily exercise such as walking (zhang et al., 2017). furthermore, the psychotherapist is responsible for evaluating incontinence during the pfmt program. the results of this review study showed that exercises were evaluated 1–3 times and urinary continence was evaluated using 1-hour pad tests and 24-hour pad tests. for the result of the test, continence was defined as a loss of < 2g of urine or the use of one or less pad per day; this suggests that pfmt training strengthens the muscles and that bladder control can thus be acquired (aydın sayılan & özbaş, 2018). d. r. pratiwi et al. 170 | pissn: 1858-3598  eissn: 2502-5791 physiotherapist-guided pfmt may provide better outcomes than non-supervised exercise. the studies in our review included twelve out of fifteen articles which showed that pfmt is effective in reducing ui post rp. pfmt is suitable for patients experiencing incontinence after radical prostatectomy. preoperative pfmt is a treatment strategy which is significantly more effective than the standard care in improving recovery of continence in patients who have undergone rp (aydın sayılan & özbaş, 2018). another intervention is for pfmt to be combined with other therapy (pilates, relaxing therapy and biofeedback) and this can be more effective than pfmt only. the study on biofeedback and pfmt showed it is effective in improving the recovery of continence after open rp, at 3 and 6 months follow up, the rate of incontinence of patients, pad use and the number of incontinence episodes per patient, using a iciq-ui score of zero (zero frequency and no urine) (tienforti et al., 2012). the pilates method focuses on breathing and on the activation of deep stabilizing muscles of the trunk, in coordination with the pfm. the pilates method comprises exercise that are focused on pelvic stability, mobility and body alignment (aydın sayılan & özbaş, 2018). moreover, rest and relaxing the pelvic floor is as important as the training itself, and it is therefore part of every successful physiotherapeutic/ therapeutic exercise for continence treatment schemes. a patient suffering from post-prostatectomy urinary incontinence needs supervised training and constant monitoring of the pelvic floor muscle exercises (heydenreich et al., 2020). pfmt is effective when performed correctly according to procedure or protocol conclusion intensive pfmt interventions applied pre-post prostatectomy can strengthen the pelvic floor muscles and activate the function of the external urethral sphincter so it can control bladder and can reduce ui after rp. the advantages of pfmt are that it can perform at home and it is inexpensive. however, pfmt must be controlled by a physiotherapist to evaluate the procedures performed. the benefits of this review are that it shows that pfmt is suitable, well accepted and achievable for patients who experience incontinence after radical prostatectomy. conflict of interest the authors have declared no potential conflicts of interest with respect to the research and authorship. acknowledgement the authors of this study would like to thank the faculty of nursing airlangga university for providing the opportunity to present this study. references abrams, p., andersson, k. e., apostolidis, a., birder, l., bliss, d., brubaker, l., … wein, a. (2018). 6th international consultation on incontinence. recommendations of the international scientific committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. neurourology and urodynamics, 37(7), 2271– 2272. https://doi.org/10.1002/nau.23551 aydın sayılan, a., & özbaş, a. (2018). the effect of pelvic floor muscle training on incontinence problems after radical prostatectomy. american journal of men’s health, 12(4), 1007–1015. https://doi.org/10.1177/1557988318757242 bray, f., ferlay, j., soerjomataram, i., siegel, r. l., torre, l. a., & jemal, a. (2018). global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: a cancer journal for clinicians, 68(6), 394–424. https://doi.org/10.3322/caac.21492 campbell se, glazener cma, hunter kf, cody jd, m. k. (2012). conservative management for postprostatectomy urinary incontinence (review). cochrane database syst rev. centemero, a., rigatti, l., giraudo, d., lazzeri, m., lughezzani, g., zugna, d., … guazzoni, g. (2010). preoperative pelvic floor muscle exercise for early continence after radical prostatectomy: a randomised controlled study. european urology, 57(6), 1039–1044. https://doi.org/10.1016/j.eururo.2010.02.028 crowe, h., harbison, a., wootten, a., pillay, b., morrison, s., martin, m., … costello, a. (2018). evaluation of a video pelvic floor muscle exercise model prior to radical prostatectomy. urologic nursing, 38(1). https://doi.org/10.7257/1053816x.2018.38.1.27 ficarra v, novara g, artibani w, et al. (2009). retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. eur urol, 55, 1037–1063. geraerts, i., van poppel, h., devoogdt, n., joniau, s., van cleynenbreugel, b., de groef, a., & van kampen, m. (2013). influence of preoperative and postoperative pelvic floor muscle training (pfmt) compared with postoperative pfmt on urinary incontinence after radical prostatectomy: a randomized controlled trial. european urology, 64(5), 766–772. https://doi.org/10.1016/j.eururo.2013.01.013 glazener, c., boachie, c., buckley, b., cochran, c., dorey, g., grant, a., … n’dow, j. (2011). urinary incontinence in men after formal one-to-one pelvic-floor muscle training following radical prostatectomy or transurethral resection of the prostate (maps): two parallel randomised controlled trials. the lancet, 378(9788), 328– 337. https://doi.org/10.1016/s01406736(11)60751-4 jurnal ners http://e-journal.unair.ac.id/jners | 171 gomes, c. s., pedriali, f. r., urbano, m. r., moreira, e. h., averbeck, m. a., & almeida, s. h. m. (2018). the effects of pilates method on pelvic floor muscle strength in patients with postprostatectomy urinary incontinence: a randomized clinical trial. neurourology and urodynamics, 37(1), 346–353. https://doi.org/10.1002/nau.23300 heydenreich, m., puta, c., gabriel, h. h. w., dietze, a., wright, p., & zermann, d. h. (2020). does trunk muscle training with an oscillating rod improve urinary incontinence after radical prostatectomy? a prospective randomized controlled trial. clinical rehabilitation. https://doi.org/10.1177/0269215519893096 hodges, p., stafford, r., coughlin, g. d., kasza, j., ashton-miller, j., cameron, a. p., … hall, l. m. (2019). efficacy of a personalised pelvic floor muscle training programme on urinary incontinence after radical prostatectomy (matchup): protocol for a randomised controlled trial. bmj open, 9(5), 1–10. https://doi.org/10.1136/bmjopen-2018028288 hu, t. w., & wagner, t. h. (2005). health-related consequences of overactive bladder: an economic perspective. bju international, 96(suppl. 1), 43–45. https://doi.org/10.1111/j.1464410x.2005.05654.x krishna dass, a., lo, t. s., khanuengkitkong, s., & tan, y. l. (2013). diagnosis and conservative management of female stress urinary incontinence. gynecology and minimally invasive therapy, 2(2), 48–51. https://doi.org/10.1016/j.gmit.2013.02.005 laurienzo, c. e., magnabosco, w. j., jabur, f., faria, e. f., gameiro, m. o., sarri, a. j., … amaro, j. l. (2018). pelvic floor muscle training and electrical stimulation as rehabilitation after radical prostatectomy: a randomized controlled trial. journal of physical therapy science, 30(6), 825– 831. https://doi.org/10.1589/jpts.30.825 liberati, a., altman, d. g., tetzlaff, j., mulrow, c., gøtzsche, p. c., ioannidis, j. p. a., … moher, d. (2009). the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. bmj (clinical research ed.), 339. https://doi.org/10.1136/bmj.b2700 lucioni, a., nitti, v. w., & stoffel, j. t. (2019). american urological association ( aua )/ society of urodynamics , female pelvic medicine & urogenital reconstruction ( sufu ) incontinence after prostate treatment : aua / sufu incontinence after prostate treatment. 1–38. macdonald r, fink ha, huckabay c, monga m, w. t. (2007). pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. bju international, 100, 76–81. matsumoto, m., & inoue, k. (2007). predictors of institutionalization in elderly people living at home: the impact of incontinence and commode use in rural japan. journal of cross-cultural gerontology, 22(4), 421–432. https://doi.org/10.1007/s10823-007-9046-2 milios, j. e., ackland, t. r., & green, d. j. (2019). pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence. bmc urology, 19(1), 1–10. https://doi.org/10.1186/s12894-019-0546-5 mottet, n., bergh, r. c. n. van den, vice-chair, p. c., santis, m. de, gillessen, s., govorov, a., … willemse, p. m. (2018). eau-esur-estro-siog guidelines on prostate cancer/ guias europeas. european association of urology 2018, 1–145. oh, j. j., kim, j. k., lee, h., lee, s., jin jeong, s., kyu hong, s., … byun, s. s. (2019). effect of personalized extracorporeal biofeedback device for pelvic floor muscle training on urinary incontinence after robot-assisted radical prostatectomy: a randomized controlled trial. neurourology and urodynamics, (november). https://doi.org/10.1002/nau.24247 pedriali, f.r., gomes, c.s., soares, l., urbano, m.r., moreira, e.h., averbeck, m.a.,&almeida, s. h. . (2016). is pilates as effective as conventional pelvic floor muscle exercise in the conservative treatment of post-prostatectomy urinary incontinence? a randomised cpntrolled trial. neurourol urodyn., 35(april), 615–621. https://doi.org/10.1002/nau radzimińska, a., strączyńska, a., weber-rajek, m., styczyńska, h., strojek, k., & piekorz, z. (2018). the impact of pelvic floor muscle training on the quality of life of women with urinary incontinence: a systematic literature review. clinical interventions in aging, 13, 957–965. https://doi.org/10.2147/cia.s160057 rawla, p. (2019). epidemiology of prostate cancer. world j oncol., 16(2), 1077–1083. https://doi.org/10.14740/wjon1191 rodas, m. c., & garcía-perdomo, h. a. (2018). from kegel exercises to pelvic floor rehabilitation: a physiotherapeutic perspective. revista mexicana de urologia, 78(5), 402–411. https://doi.org/10.24245/revmexurol.v78i5.24 72 santa mina, d., au, d., alibhai, s. m. h., jamnicky, l., faghani, n., hilton, w. j., … matthew, a. g. (2015). a pilot randomized trial of conventional versus advanced pelvic floor exercises to treat urinary incontinence after radical prostatectomy: a study protocol. bmc urology, 15(1), 1–10. https://doi.org/10.1186/s12894-015-0088-4 tantawy, s. a., elgohary, h. m. i., abdelbasset, w. k., & kamel, d. m. (2019). effect of 4 weeks of wholebody vibration training in treating stress urinary incontinence after prostate cancer surgery: a d. r. pratiwi et al. 172 | pissn: 1858-3598  eissn: 2502-5791 randomised controlled trial. physiotherapy (united kingdom), 105(3), 338–345. https://doi.org/10.1016/j.physio.2018.07.013 tienforti, d., sacco, e., marangi, f., addessi, a. d., racioppi, m., gulino, g., … bassi, p. (2012). efficacy of an assisted low-intensity programme of perioperative pelvic fl oor muscle training in improving the recovery of continence after radical prostatectomy: a randomized controlled trial. bju international, 1004–1011. https://doi.org/10.1111/j.1464410x.2012.10948 wang w, huang qm, liu fp, m. q. (2014). effectiveness of preoperative pelvic floor muscle training for urinary incontinence after radical prostatectomy: a meta-analysis. bmc urol., 14(99). zermann dh, wunderlich h, reichelt o, et al. (2000). early post-prostatectomy pelvic floor biofeedback. j urol, 164, 783–784. zhang, a. y., bodner, d. r., fu, a. z., gunzler, d. d., klein, e., kresevic, d., … zhu, h. (2015). effects of patient centered interventions on persistent urinary incontinence after prostate cancer treatment: a randomized, controlled trial. journal of urology, 194(6), 1675–1681. https://doi.org/10.1016/j.juro.2015.07.090 zhang, a. y., fu, a. z., moore, s., zhu, h., strauss, g., kresevic, d., … bodner, d. r. (2017). is a behavioral treatment for urinary incontinence beneficial to prostate cancer survivors as a follow-up care? journal of cancer survivorship, 11(1), 24–31. https://doi.org/10.1007/s11764016-0557-0 466 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20510 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original article the use of olive oil for reducing the complaint of itching related to striae gravidarum in pregnant women nita dwi astikasari, riza tsalatsatul mufida, and shanty natalia faculty of nursing, health sciences institute strada, kediri, east java, indonesia abstract introduction:this study is regarding the incidence of complaints of itching made by pregnant women, one of which is caused by striae gravidarum. the appearance of striae gravidarum, already triggered by the occurrence of stretchmarks, is present on the surface of the skin due to radical weight loss over a short period of time. the purpose of this research was to learn about the use of olive oil to reduce the itching complaints of striae gravidarum among the expectant mothers in the village of anyer ponggok ringin blitar. methods: the research design used was true experimental research. the population examined was the total number of pregnant women in the village of ringin anyar, totaling 30 pregnant women. the final respondents totaled 27. the design used was a technical pre-post test control group. the method of sampling used was simple random sampling. the research instrument used was olive oil for 3 days. the research results were then analyzed using the wilcoxon and mann-whitney tests. results: the results of the analysis showed there to be no difference before or after being given the olive oil to treat the itching of the pregnant women in the village of ringin anyar ponggok blitar. the prevalence of events in puskesmas ponggok states that on june 2nd 2016, out of the 28 pregnant women who were examined, 17 of them experienced itching called striae gravidarum. conclusion: based on the results of the research, it is expected for all of the expectant mothers to keep their skin moist with olive oil at the beginning of the second trimester in order to reduce the rate of itching in pregnancy. article history received: feb 27, 2020 accepted: april 1, 2020 keywords pregnant women; itching;, olive oil contact nita dwi astikasari  nieta.strada@gmail.com  faculty of nursing, health sciences institute strada, kediri, east java, indonesia cite this as: astikasari,n. d., mufida, r. t.,& natalia (2020). the use of olive oil for reducing the complaint of itching related to striae gravidarum in pregnant women. jurnal ners, special issues, 466-469. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20510 introduction the benefits of olive oil have been known to maintain beauty. olive oil comes from the olive plants that grow in the mediterranean region which provides a lot of sun intensity. olive oil is very well known in the world of beauty, in addition to the culinary sphere and the health sector. this is due to the nutritional content of the olive oil (damayanti, 2016). in every 100 grams of olive oil there are the following nutritional values: energy-3701 kj (885 kcal), carbohydrates-og, fat-100g, saturated fat (14g), monounsaturated fat (73g), polyunsaturated fat (11g), omega-3 fats (11g) <1.5 g), omega-6 fat (3.5-21 g), protein 0 g, vitamin e 14 mg (93% of the recommended daily intake for adults) and vitamin k 62 mg (59% of recommended daily intake for adults). the benefits of olive oil include providing the skin's natural moisture, preventing premature aging, removing anti-inflammatory acne stains, controlling blood pressure, cholesterol, cancer prevention, stroke prevention, natural hair lotion and moisturizing for the purpose of hair growth (anonymous, 2014). in some articles, olive oil can also be used to deal with the problem of discomfort in pregnant women, especially itching in the abdominal area where there https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 467 is an emergence of striae gravidarum. this is because olive oil contains a lot of vitamin e which can moisturize the skin due to the onset of striae gravidarum. itching is an irritating skin sensation with marked discomfort that causes the compulsion to scratch it. according to dr. tjut nurul alam jacoeb sp. kk (k), generally pregnant women have more sensitive skin than women who are not pregnant. the skin stretches and eventually this causes striae. this eventually causes itching because the skin loses the dermis layer and so the skin loses moisture (contributor wikipedia, 2014). striae are a form of colorless scarring on the skin. over time, it might decrease but it won't disappear completely. striae are formed during pregnancy usually during the last trimester, sometimes appearing on the abdomen but also often occurring on the breasts, thighs, hips, lower back, and buttocks in medical terms known as striae gravidarum. the striae gravidarum that appears during pregnancy often causes annoying itching. skin problems like this are very common, especially in women who are pregnant. the itching felt on the surface of the abdominal skin is the first sign of the emergence of striae gravidarum. the itchy skin on the area that arises due to striae gravidarum occurs due to the skin losing moisture. the skin becomes dry so many pregnant women experience blisters or sores due to excessive scratching (contributor wikipedia, 2016). a research study by the british journal of dermatology shows that the incidence of striae gravidarum in pregnant women ranges from 50-90%. from the 27 skin samples taken from pregnant women, it states that striae gravidarum forms in more than one area around the abdomen and less in the hip area (manuaba, 2008). the prevalence of events in puskesmas ponggok states that on june, out of 27 pregnant women examined, 17 of them experienced itching called striae gravidarum. some of the pregnant women do not pay attention to these symptoms so many pregnant women experience blisters and sores on the skin due to excessive scratching because of the onset of itching (covas mi, 2006). the emergence of striae gravidarum is thought to be triggered by stretching the surface of the skin due to radical weight gain over a short time. according to dr. hardy suwita sp.kk, a specialist from satya nagara hospital, striae gravidarum will appear in the areas of skin that are easily stretched. the process of the formation of striae begins with the accumulation of fat under the skin. as is known, a large part of a woman's body is formed by fat which is concentrated in certain parts when the body weight increases drastically. the dermis layer that is above the fat layer stretches radically. the skin layer contains many blood vessels and young skin cells can be broken. this will bring out purple streaks accompanied by itching. this purple color appears as a result of the activity of skin pigmentation through melanocytes caused by tears in the dermis of the skin. these tears will change color to white as a sign of the formation of new tissue, which has a different color from the original skin color (nurcahyani, 2013) . olive oil for the treatment of striae during pregnancy is one of the best alternatives, and it is used to massage the area where there is an emergence of striae gravidarum. this will help to improve the blood circulation to the skin. leaving it for one hour allows the skin to absorb vitamins optimally. it is done regularly every day at least 2-3 times when the skin is moist, for example, after bathing (bawilan, 2009). based on this description, the researchers were interested in conducting research with the title "the use of olive oil (virgin olive oil) to reduce the complaint of itching related to striae gravidarum among the pregnant women in the village of ringin anyar ponggok blitar." materials and methods this research was a true experimental study with a pre-test control group design. this design involved two groups of subjects. one was given the experimental treatment (the experimental group) and the other was given nothing (the control group). the sample in this study was a portion of pregnant women who were experiencing itching due to striae gravidarum. the sampling technique was accidental sampling with a homogeneous sample as chosen by the researchers (nursalam, 2008). the research instrument used was the awarding of olive oil for 3 days. the research results were then analyzed using the wilcoxon test and the mann-whitney test. results differences in itching due to striae gravidarum among pregnant women before and after being given olive oil (virgin olive oil) based on table 4.1, it can be known that in the control group, the respondents with moderate itching tended to experience moderate itching before and after being given the olive oil (virgin olive oil) to the amount of 71.4% (5 respondents). the wilcoxon test obtained a p value = 0.157 (less than 0.05) so it can be concluded that there was no difference in itching before and after being given olive oil (virgin olive oil) in the control group in ringin anyar village, ponggok district, blitar regency. based on table 2, it shows that in the treatment group, the respondents with moderate itching tend to experience mild itching before and after being given the olive oil (virgin olive oil) which is equal to 42.9% (3 respondents). from the wilcoxon test result, a p value = 0.046 was obtained. differences in itching due to striae gravidarum among the pregnant women in the control and treatment groups based on table 3, it can be seen that the itching caused by striae gravidarum among the pregnant women in the control group is in the moderate n. d. astikasari, et al. 468 | pissn: 1858-3598  eissn: 2502-5791 category at 85.7% (6 respondents). the itching due to striae gravidarum for the pregnant women in the treatment group is in the moderate category at 57.1% (4 respondents). from the results of the mann whitney test, the p values = 0.044 (smaller than 0.05) so it can be concluded that there are differences in itching due to striae gravidarum among the pregnant women between the control group and the treatment group. this means that there is an effect due to giving olive oil (virgin olive oil) for the itching due to striae gravidarum. discussion itching due to striae gravidarum among the pregnant women before being given olive oil (virgin olive oil) from the results of the data collection looking at 14 pregnant women in ringin anyar village, ponggok district, blitar regency, it was found that in the control group and treatment group, most pregnant women experienced moderate itching before being given the olive oil (oil virgin olive oil) treatment at 86.7% (6 respondents). itching due to striae gravidarum among the pregnant women after being given olive oil (virgin olive oil) from the results of the data collection looking at 14 pregnant women in ringin anyar village, ponggok district, blitar regency, it was found in the control group, most of the pregnant women experienced moderate itching at 85.7% (6 respondents). in the treatment group, the majority of pregnant women experienced moderate itching after being given olive oil (virgin olive oil) which amounted to 57.1% (4 respondents). in the control group, it was found that pregnant women with moderate itching tended to still experience moderate itching before and after being given olive oil (virgin olive oil) equal to 71.4% (5 respondents). in the treatment group, pregnant women with moderate itching tend to experience mild itching after being given olive oil (virgin olive oil) equal to 42.9% (3 respondents). the wilcoxon test results obtained a p value = 0.157 (smaller than 0.05). it can be concluded that there was no difference in itching before and after being given olive oil (virgin olive oil) in the control group. the wilcoxon test results in the treatment group obtained a p value = 0.046 (smaller than 0.05) so it can be concluded that there were differences in itching before and after being given virgin olive oil in ringin anyar village, ponggok district, blitar regency. this indicates that the administration of olive oil (virgin olive oil) can reduce the itching due to striae gravidarum among pregnant women. effect of itching due to striae gravidarum among the pregnant women in the groups that were given and not given olive oil (virgin olive oil) based on the results of the study, itching due to striae gravidarum among the pregnant women in the control group in the moderate category amounted to 85.7% (6 respondents). itching due to striae gravidarum among the pregnant women in the treatment group in the moderate category amounted to 57.1% (4 respondents). from the results of the mann whitney test, the p value = 0.044 (smaller than 0.05). it can be concluded that there is a difference in itching due to striae gravidarum for pregnant women between the control group and the treatment group. this means that there is an influence of olive oil (virgin olive oil) against itching due to striae gravidarum among the pregnant women in ringin anyar village, ponggok district, blitar regency. this reinforces that olive oil (virgin olive oil) reduces the table 1. cross-tabulation between the itching before and after being given the virgin olive oil in the control group itching before after σ % σ % mild 1 14,3 0 0 medium 6 85,7 6 85,7 severe 0 0 1 14,3 wilcoxon signed rank test, p value= 0,157 table 2. cross-tabulation between the itching before and after being given virgin olive oil in the treatment group itching before after σ % σ % mild 0 14,3 3 42,9 medium 6 85,7 4 57,1 severe 1 14,3 0 0 wilcoxon signed rank test, p value= 0,046 table 3. differences in the percentage of itching due to striae gravidarum among the pregnant women post-itching control group treatment group mild 0 42.9 medium 85,7 57,1 severe 14,3 0 mann whitney test, p value= 0,044 jurnal ners http://e-journal.unair.ac.id/jners | 469 itching in pregnant women due to striae gravidarum. in the control group, the itchiness experienced by the pregnant women tended to be persistent and there was severe irritation due to constant scratching. the high content of vitamin e in olive oil is beneficial for skin health. it is known that vitamin e has been proven to maintain skin health and elasticity. diane irons, author of the "911 beauty secret: an emergency guide looking great at every age, size and budget", explains that the powerful antioxidant power of vitamin e also helps the production of collagen. this is what gives skin its elasticity and it also gives moisture back to the skin caused by strokes or scars, as in striae gravidarum (taavoni s, 2011). with regular treatment using olive oil to treat striae gravidarum, there will be a reduction in the incidence rate so as not to cause excessive itching. itching is not dangerous for either the mother or fetus. itching cannot cause infant death and it does not interference in the growth of the baby. however, good care is needed to avoid scars which can lead to a negative body image due to having unclean skin. in addition, a reduction in itching can be overcome by wearing clothes that are not too tight. the pregnant women should be in a relaxed state due to excessive anxiety, tension and emotional instability being a potential trigger for itching (yana, 2014). conclusion there is a difference in itching due to striae gravidarum among the pregnant women before and after being given olive oil (virgin olive oil) so it can be used to reduce the incidence of itching due to striae gravidarum during pregnancy. references anonymous. (2014). fakta stretch mark dan cara mengatasinya. bawilan, a. s. (2009). manfaat dan khasiat minyak zaitun. contributor wikipedia. (2014). stretchmarks. contributor wikipedia. (2016). zaitun. covas mi. (2006). komponen kecil minyak zaitun. damayanti. (2016). stretch marks. manuaba. (2008). ilmu kebidanan, penyakit kandungan & keluarga berencana untuk pendidikan bidan. nurcahyani. (2013). kenali penyebab (gatal) saat hamil. nursalam. (2008). konsep dan penerapan metodologi penelitian ilmu keperawatan. surabaya. taavoni s. (2011). efek minyak zaitun terhadap striae gravidarum dalam trimester kedua kehamilan. yana, y. (2014). manfaat minyakzaitun dan efek. ners vol 10 no 1 april 2015.indd 183 pemberdayaan kesehatan dan ekonomi perempuan penderita hiv/aids melalui life skill education (health empowerment, and economics of women with hiv/aids through life skills education) awatiful azza*, trias setyowati**, fauziyah*** * fakultas ilmu kesehatan universitas muhammadiyah jember ** fakultas ekonomi universitas muhammadiyah jember *** fakultas hukum universitas muhammadiyah jember email: awatiful.azza@yahoo.com abstrak pendahuluan: perempuan penderita hiv/aids mempunyai beban yang cukup berat. diskriminasi dan rendahnya status ekonomi menyebabkan semakin terpuruk dalam ketidakpastian hidup. tujuan penelitian adalah menyusun strategi pemberdayaan kesehatan dan ekonomi serta meningkatkan keterlibatan masyarakat dalam menerima kegiatan usaha perempuan penderita hiv/aids. metode: metode yang digunakan melalui pendekatan deskriptif, focus group disscusion. penyusunan desain strategi pemberdayaan kesehatan dan ekonomi melalui life skill education bagi perempuan dengan hiv/aids dikuatkan melalui pendekatan participatory action research (par). hasil: hasil penelitian menunjukkan status kesehatan perempuan penderita hiv yang terlibat berada pada fase i. umur penderita pada rentang yang cukup produktif antara 20–40 tahun. hampir 90% mereka tidak mempunyai penghasilan. hasil focus group disscusion (fgd) menunjukkan klien membutuhkan kegiatan yang dapat menghasilkan tambahan pendapatan, dan tidak membebani fi sik. kegiatan yang dipilih diantaranya menyulam, menjahit, salon dan memasak. hasil penelitian tentang respons masyarakat menyebutkan bahwa perempuan penderita hiv harus dilindungi oleh pemerintah dan masyarakat, walaupun mereka masih belum bisa menerima penderita di lingkungannya. kata kunci: pemberdayaan, perempuan dengan hiv/aids, life skill education abstract introduction: women with hiv/aids have a heavy burden. discrimination and the low economic status causes them worse off in the uncertainty of life. the purpose of the study to develop a health empowerment and economic and increase community involvement in the business activities of women with hiv/aids. methods: the method descriptive approach,focus group discussion. the preparation of the design strategies, health empowerment and economic through life skills education for women with hiv/aids strengthened through participatory action research (par). the results of this study showed that the health status of women with hiv who are involved in phase i. the average age of patients were at a fairly productive life span between 20–40 years. 90% they do not have income. the results of focus group discussions (fgd) indicates that the client requires additional activities that can generate income, but do not overload the physical. some of the selected activities include embroider and sew, salons and cooking. the results of research on public response associated with hiv/aids they mention that women with hiv should be protected by the government and the public, although on average they still can not accept people in their environment. keywords: empowerment, women with hiv/aids, life skill education pendahuluan epidemi hiv/aids menjadi beban berat setiap negara tanpa kecuali, dan sangat berpotensi menghancurkan pembangunan ekonomi di negara berkembang, termasuk indonesia (convention watch, 2007). di dunia dewasa ini jumlah orang yang terinfeksi hiv/aids mencapai 39,4 juta, dari data tersebut perempuan cenderung berpeluang besar tertular hiv/aids yaitu sekitar 17,6 juta penderita. data yang ada di indonesia menunjukkan jumlah penularan hiv/aids per hari 14 ribu, dan 6.000 kasus dialami oleh perempuan (hutapea, r, 2003). berdasarkan data yang ada tersebut, dinas kesehatan kabupaten jember jawa timur menetapkan status merah terhadap penyebaran hiv/aids. status ini ditetapkan karena terus meningkatnya penderita hiv/aids. layanan konseling dan tes hiv secara sukarela yang dilakukan di klinik vct rumah sakit daerah (rsd) dr. soebandi, rsd balung, klinik vct puskesmas puger jember merupakan salah satu program yang 184 jurnal ners vol. 10 no. 1 april 2015: 183–188 berhasil mengungkap banyaknya kasus hiv dan aids di kabupaten jember (azza, 2007). sampai dengan desember 2010 tercatat sebanyak 419 odha (orang dengan hiv dan aids), di mana 248 orang penderita hiv adalah perempuan. dampak yang ditimbulkan dari hiv/ aids tidak hanya masalah kesehatan, akan tetapi dampak psikososial juga mempunyai andil cukup besar terhadap kesejahteraan perempuan (riyanto, 2009). perempuan yang terkena hiv/aids, secara psikologi akan mengalami berbagai masalah, mulai dari kecemasan, keraguan, stress dan depresi. tek a n a n l i ng k u nga n ya ng ce nde r u ng disk riminatif akan membuat perempuan kehilangan penghargaan terhadap dirinya. bahaya yang ditimbulkan oleh hiv/aids akan menambah beban berat perempuan akibat stigma masyarakat yang cenderung memojok kan dan meng ucil kan nya dar i li ng k u nga n. sat u hal lag i ya ng perlu diperhatikan saat ini adalah dampak ekonomi dari seseorang yang terinfeksi hiv (azza, 2009). sebagian besar odha yang baru tahu stat usnya tidak berdaya dan tidak memiliki pekerjaan. banyak hal yang dapat dijadikan alasan mengapa banyak odha yang tidak memiliki pekerjaan, selain karena diskriminasi hal tersebut juga diakibatkan stat us kesehatan penderita odha yang cenderung mengalami penurunan (susilo c, 2005). perempuan membutuhkan rasa percaya diri dalam menjalani hidupnya dan mencapai harapan-harapannya, untuk itu dukungan dan kesempatan yang diberikan dalam membantu meningkatkan kemandirian perempuan dengan odha tersebut perlu mendapat apresiasi (antoni b, 2009). pemberdayaan ekonomi sebagai upaya untuk membantu perempuan dengan hiv/aids perlu dilaksanakan untuk meningkatkan status ekonomi dan mengurangi kemiskinan. bahan dan metode penelitian ini menggunakan pendekatan partisipatif baik pada sampel utama/primer yaitu penderita hiv/aids maupun pada sampel sekunder (masyarakat dan pengambil kebijakan tentang hiv/aids (nawawi h, 2003). ada dua tahapan pendekatan yang telah dilakukan oleh peneliti yaitu: pa d a t a h a p s a t u m e n g g u n a k a n pendekat a n desk r ipt if, pendekat a n i n i difokuskan untuk mendapatkan data awal d ala m pengemba nga n model life sk ill education. pada tahap ini peneliti telah mampu mengungkap data-data tentang kondisi dan status kesehatan serta sosial ekonomi perempuan pender it a h i v/a i ds, yang diperoleh melalui pendekatan wawancara pada penderita dan keluarganya serta lsm (lembaga swadaya masyarakat) yang mendampingi penderita. peneliti juga melakukan kegiatan focus group disscusion pada penderita pada tanggal 21 maret 2012 di pkm puger dan 29 maret 2012 di klinik vct rsud dr. soebandi jember. untuk menguatkan hasil temuan tentang pemberdayaan ekonomi perempuan penderita hiv/aids peneliti juga memperoleh data melalui kuesioner yang dibagikan pada penderita. tahap dua menggunakan pendekatan participatory action research (par) yaitu kegiatan untuk penyusunan desain strategi pemberdayaan kesehatan dan ekonomi melalui life skill education bagi perempuan dengan hiv/aids. pendekatan ini dilakukan setelah semua data awal terkumpul. penelitian ini telah dilak u kan di wilayah sumbersari yang terpusat di klinik vct rsud dr. soebandi jember dan klinik vct puger dengan sasaran pada perempuan yang termasuk dalam kelompok risiko tinggi penderita hiv/aids serta penderita hiv/ aids. penelitian ini mempunyai fokus untuk menyusun rumusan strategi yang tepat dalam pemberdayaan kesehatan dan ekonomi bagi perempuan penderita hiv/aids. kegiatan ini dilakukan melalui self assessment serta gali potensi bagi perempuan penderita hiv/ aids dengan mengg u nakan k uesioner, menggali respons masyarakat melalui focus group disscusion terhadap potensi yang dimiliki perempuan penderita hiv/aids. peneliti juga mengkaji kebijakan yang telah dilakukan pemerintah daerah selama ini terkait pemberdayaan kesehatan dan 185 pemberdayaan kesehatan dan ekonomi perempuan penderita hiv/aids (awatiful azza, dkk.) ekonomi perempuan penderita hiv/aids, dengan sumber data komisi pemberantasan hiv/aids, klinik vct, dan dinas sosial kabupaten jember. hasil hasil penelitian ini mampu mengungkap kondisi kesehatan perempuan penderita hiv/aids di kabupaten jember, stat us sosial ekonomi dan upaya yang dilakukan penderita dalam meningkatkan kualitas hidupnya. selain itu peneliti juga mendapatkan temuan-temuan yang cukup menarik terkait kebutuhan penderita akan kebebasan dalam bermasyarakat serta peran pemerintah dalam penemuan kasus dan penatalaksanaan bagi mereka yang sudah menderita hiv/aids. jumlah penderita hiv/aids cenderung meningkat di beberapa kabupaten termasuk jember, data sebelumnya sampai dengan oktober 2010 ditemukan 500 orang pengidap hiv/aids dengan usia yang cukup bervariasi. epide m i h i v/a i ds t e r sebut t e nt u nya menjadi beban berat setiap negara, dan sangat berpotensi menghancurkan pembangunan ekonomi di negara berkembang, termasuk indonesia. kondisi tersebut cukup memprihatinkan karena sampai dengan saat ini belum ada pengobatan yang mampu menyembuhkan penyakit hiv/aids, namun demikian pasien penderita hiv/aids memerlukan terapi terutama untuk mengobati penyakit oportunis. berikut adalah gambaran kondisi pasien hiv/ aids di kabupaten jember yang datang ke klinik vct dan mendapatkan pengobatan art: selain melalui st udi dok u menter, penelitian ini juga melibatkan 30 responden perempuan penderita hiv/aids yang berada di kecamatan sumbersari maupun puger. tabel di atas menunjukkan bahwa ratarata mereka berada pada usia yang masih cukup produktif yaitu antara 20–40 tahun. hasil penelitian menunjukkan bahwa 20 orang atau sekitar 80 % perempuan penderita hiv/ aids yang terlibat dalam penelitian ini berada pada fase i yaitu penderita sudah terinfeksi hiv namun masih asimtomatik (tanpa gejala). dalam fase ini umumnya seseorang yang telah terinfeksi hiv masih tampak dan merasa sehat-sehat saja, tanpa menunjukkan gejala apa pun bahwa ia sudah tertular hiv. hal tersebut dikuatkan dengan kondisi pasien yang masih stabil dengan aktivitas normal. tabel 1. jumlah odha di kabupaten jember periode 2004–2011 kecamatan jml odha kecamatan jml odha puger 90 silo 9 gumukmas 45 jenggawah 9 kaliwates 33 sumberbaru 10 wuluhan 31 ajung 8 sumbersari 28 rambipuji 8 patrang 27 semboro 7 umbulsari 25 arjasa 7 ambulu 25 jelbuk 5 kencong 25 pakusari 5 tanggul 18 kalisat 5 balung 20 mayang 4 jombang 16 sukorambi 4 bangsalsari 15 sumberjambe 2 asal jember 18 ledokombo 2 tempurejo 12 sukowono 1 mumbulsari 12 panti 10 jumlah 450 jumlah 86 536 sumber: surveilance dan klinik vct tabel 2. u s i a p e n d e r i t a h i v / a i d s d i kecamatan sumbersari usia jumlah prosentase 10–20 tahun 1 10% 21–30 tahun 6 60% 32–40 tahun 3 30% jumlah 10 100% tabel 3. u s i a p e n d e r i t a h i v / a i d s d i kecamatan puger usia jumlah prosentase 10–20 tahun 21–30 tahun 14 70 % 32–40 tahun 6 30% jumlah 20 100% 186 jurnal ners vol. 10 no. 1 april 2015: 183–188 penelitian ini mengungkapkan bahwa hampir 90% perempuan yang menjadi sampel dalam penelitian ini tidak bekerja. pembahasan dat a p e nel it ia n t e nt a ng kond isi penderita hiv tersebut sangat membebani keluarga karena rata-rata mereka berada pada rentang usia yang cukup produktif, apalagi disaat mereka dinyatakan positif menderita hiv/aids keluarga menjadi sangat protektif. perempuan mer upakan potensi pembangunan yang besar jika dikembangkan potensinya dengan baik agar menjadi pelaku pembangunan. data penelitian ini menemukan bahwa 90% sampel tidak bekerja, padahal hasil penelitian ini juga menemukan bahwa keluarga mereka hanya mempunyai penghasilan ratarata rp 500.000/bulan. klien mempunyai motivasi yang cukup tinggi terkait status kesehatannya, hal tersebut terbukti dengan frekuensi kunjungan ke klinik vct. klien cukup aktif baik hanya sekedar untuk bertemu dengan manajer kasus untuk mengetahui kondisi kesehatannya, klien juga datang untuk mendapatkan obat arv. namun, terkait dengan status sosial dan ekonomi perempuan penderita hiv/aids sangat memprihatinkan. perubahan fi sik yang dialami perempuan dengan hiv tersebut tentunya sangat mempengaruhi kemampuannya untuk dapat tetap mempertahankan kualitas hidupnya selain karena kondisi kesehatannya me rek a juga me ngala m i d i k sr i m i n a si terkait dengan penyak it nya. penelitian ini mengungkapkan bahwa hampir 90% perempuan yang menjadi sampel dalam penelitian ini tidak bekerja. over proteksi dari keluarga juga menyebabkan penderita tidak mampu bereksplorasi tentang aktivitasnya. kondisi tersebut semakin diperparah dengan efek dari terapi hiv/aids, beberapa efek samping dari terapi diantaranya adalah mual, mudah lelah dan anemia (depkes ri, 2003). walaupun demikian penderita cukup antusias dan mempunyai semangat yang tinggi untuk bisa menjadi bagian dari masyarakat dan dapat membantu mengurangi beban keluarga. beberapa program yang telah dilakukan peme r i nt a h d a e r a h k abupat e n jembe r melalui dinas kesehatan kabupaten dan komisi pemberantasan aids diantaranya: a) menurunkan kesakitan & kematian terkait hiv di kabupaten jember; b) meningkatkan pera n ser t a masya ra kat d alam ra ng ka penanggulangan hiv & aids. program tersebut dilakukan melalui: 1). mengurangi penularan hiv di kalangan populasi kunci yang berisiko tinggi, terutama kaum muda, melalui penyediaan layanan pencegahan kegiatan penjangkauan atau pendampingan untuk memberikan informasi dan pendidikan keterampilan tentang pencegahan hiv/aids serta promosi penerapan pola hidup sehat bagi populasi berisiko; 2). meningkatkan kualitas diagram 1. kondisi pasien yang mendapat art di klinik vct rsd dr. soebandi jember 187 pemberdayaan kesehatan dan ekonomi perempuan penderita hiv/aids (awatiful azza, dkk.) hidup odha melalui penyediaan layanan du k u ngan, perawat an, dan pengobat an dengan klinik vct, kegiatan pemeriksaan & pengobatan rutin masalah infeksi menular seksual (ims) bagi pekerja seks perempuan, laki-laki dan waria, mengontrol penularan i n fek si me nu la r sek su al ( i ms) aga r penularan ims pada sub populasi berisiko dapat dipersempit; 3). program layanan alat suntik steril (lass) bagi penasun (idu) di daerah endemis hiv/aids, pendekatan pragmatis dalam kesehatan masyarakat untuk merespons ledakan infeksi hiv/aids secara khusus di kalangan penasun (idu) termasuk paket layanan pengurangan dampak buruk yaitu layanan jarum dan alat suntik steril dan terapi rumatan metadon; 4). distribusi kondom terutama ditempat-tempat yang paling berisiko selain itu adalah kegiatan yang memberikan penekanan pada pendidikan dan promosi pemakaian kondom sebagai upaya menekan meluasnya penularan infeksi menular seksual (ims) termasuk hiv/aids; 5) koordinasi kelembagaan dalam rangka penur unan stigma dan diskriminasi. banyak penderita hiv yang cenderung menarik diri karena perlakuan dari masyarakat yang mengucilkannya. hal tersebut sangat berpengaruh terhadap kemampuan klien untuk mengembangkan potensi diri. klien merasa tidak berguna dan bahkan cenderung minder sehingga seringkali mereka menarik diri dari lingkungannya. hal tersebut diperberat dengan kebijakan yang dikaitkan dengan perlindungan penderita hiv, padahal secara sosial mereka sangat membutuhkan teman dan orang yang mempunyai nasib sama untuk bisa berdiskusi tentang kondisinya. penderita juga mengungkapkan keinginannya untuk mempu nyai pag uy uban pender it a hi v, sehingga mereka dapat saling berinteraksi untuk mengurangi beban pikiran terkait dengan kondisi kesehatannya. beberapa hasil gali potensi terhadap minat dan bakat yang dilakukan terhadap 30 perempuan penderita hiv/aids yang terlibat dalam penelitian ini adalah suatu usaha yang dapat membantu meningkatkan status ekonomi dan dapat dilakukan di rumah diantaranya adalah keterampilan menyulam dan menjahit, salon dan memasak. kegiatan gali potensi tersebut dipilih karena penderita ingin bahwa usaha yang dilakukannya tidak menyita tenaga/energi, karena penderita mudah sekali lemah dan lelah. keterampilan lain yang dibutuhkan penderita hiv/aids adalah pelatihan terkait dengan pengembangan usaha kecil menengah yaitu pelatihan wirausaha, management usaha, keterampilan teknis usaha, dan konsultasi usaha/peluang usaha. penelitian ini menunjukkan bahwa ma sya r a k at sud a h mu lai terbu k a d a n bisa menerima kehadiran penderita hiv, walaupun sebagian besar dari mereka masih mengucilkan. diskriminasi terhadap penderita hiv/aids masih dirasakan langsung oleh sebagian besar penderita maupun keluarganya. kondisi demikian membuat perempuan merasa dikucilkan. upaya yang dapat dilakukan untuk membantu merubah stigma dan diskriminasi antara lain, pemberian penyuluhan yang benar mengenai hiv/aids, penyebaran informasi yang benar tentang hiv/aids, pemberian pelayanan komprehensif, maupun pembentukan kelompok sebaya (pariani & purwaningsih, 2005). simpulan dan saran simpulan hasil penelitian tentang pemberdayaan kesehatan dan ekonomi perempuan penderita hiv/aids adalah status kesehatan penderita berada pada level i artinya kondisi penderita masih cukup stabil dan asimtomatik, sehingga mereka masih mempunyai kesempatan untuk dapat memberikan kontribusi pada keluarganya terkait dengan upaya meningkatkan status ekonominya (susilo k, 2006) rata-rata penderita berada pada usia yang sangat produktif yaitu antara 20-40 tahun, sehingga sangat mendukung pemberdayaan melalui penerapan model life skill education. banyak dukungan dan upaya yang telah dilakukan pemerintah, namun beberapa p e n a n g a n a n m a si h d i fok u s k a n p a d a peningkatan status kesehatan klien. hasil potensi menunjuk kan bahwa mereka membutuhkan keterampilan yang tidak mengganggu kondisi kesehatannya 188 jurnal ners vol. 10 no. 1 april 2015: 183–188 diantaranya adalah: menjahit, menyulam, salon dan memasak, serta keterampilan manajemen pengelolaan keuangan, pemasaran dan mencari peluang usaha terkait dengan respon masyarakat, mereka sudah dapat membuka diri dengan pender it a h i v/a i ds walaupu n ma si h membut u h ka n pemahama n-pemahama n tentang penyakit hiv. untuk bidang usaha penderita hiv yang dapat diterima masyarakat adalah usaha yang tidak berhubungan dengan makanan. saran perlu kerjasama dengan dinas terkait untuk mempertahankan status kesehatan p e r e mpu a n p e nd e r it a h i v/a i ds d a n membentuk paguyuban agar dapat mengurangi psikologis klien perlu d iupaya k a n keg iat a n ya ng produktif bagi perempuan penderita hiv/aids agar dapat mengurangi keterpurukan dari diskriminasi maupun status ekonomi melalui pelatihan keterampilan dan kewirausahaan melalui life skill education. pe me r i nt a h d a e r a h b eke r ja s a m a dengan lsm, dan masyarakat sebaiknya member ikan peluang kepada pender it a untuk dapat mengekplorasi potensi yang dimiliki perempuan penderita hiv agar dapat mengurangi beban psikologis maupun diskriminasi. daftar pustaka antoni, b. 2009. anti stigma dan diskriminasi. yayasan lembaga sabda (ylsa). azza, a. 2007. analisis kebijakan pemerintah daerah dalam penanganan hiv/aids. fakultas ilmu kesehatan universitas muhammadiyah jember azza, a. 2009. beban perempuan penderita hiv/aids dalam perspektif gender. fakultas ilmu kesehatan universitas muhammadiyah jember convention watch. 2007. hak azasi perempuan instrumen hukum untuk mewujudkan keadilan gender. jakarta: yayasan obor indonesia depkes, r i. 20 03. pedoman na sional perawatan, dukungan dan pengobatan bagi odha. buku pedoman untuk petugas kesehatan dan petugas lainnya. jakarta: ditjen ppm dan pi, depkes. hutapea, r. 2003. aids dan pms dan perkosaan. jakarta: rineka cipta nawawi, h. 2003. metodologi penelitian bidang social, yogyakarta, ugm pres pariani dan purwaningsih, 2005. kongres nasional i pni: pni sebagai pendekatan holi st i k d a la m m e n a n g g u la n g i penyakit di era mendatang. surabaya: gideon offset printing. r i y a n t o. 2 0 0 9. fa k t o r f a k t o r y a n g mempengar uhi k e sehatan mental pe n d e r ita hi v. pe nel it ia n t id a k dipublikasikan fpsi susilo, c. 2005. pengar uh penyuluhan terhadap penurunan stigma tentang hiv/aids di kabupaten situbondo. penelitian tidak dipublikasikan susilo, k. 2006. penyakit hubungan seksual d a n h i v/a i d s d a r i pe r s p e k t i f perempuan. program seri lokakarya kesehatan erempuan. ylki the ford foundation, jakarta. 236 model asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial pasien pasca seksio sesaria di rumah sakit (nursing care model based on knowledge management in preventing nosocomial infection after caesarean section in hospital) ahsan* *program studi ilmu keperawatan fakutas kedokteran universitas brawijaya jalan veteran malang telp. 0341-580993, 569117, 575857. fax 0341-564755 e-mail: ahsanfkub@yahoo.com abstrak pendahuluan: infeksi nosokomial merupakan salah satu indikator kualitas pelayanan kesehatan yang menjadi citra penentu institusi pelayanan kesehatan. asuhan keperawatan berbasis knowledge management dibangun dari identifikasi pengetahuan yang dibutuhkan, kinerja pencegahan infeksi nosokomial pasca sectio caesarea, komponen infeksi nosokomial terdiri dari hasil kultur luka. tujuan penelitian menyusun model asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial pasien pasca sectio caesarea di rumah sakit. metode: penelitian ini adalah penelitian observasional dengan rancangan quase experimental. populasi penelitian adalah semua tenaga keperawatan yang bekerja di instalasi rawat inap kebidanan rsud a dan rsud b sebanyak 46 orang dan sampel adalah total populasi. data dikumpulkan melalui kuesioner, lembar observasi, dan pemeriksaan kultur luka. analisis data yang digunakan uji t dan regresi logistic b 1,274 dan p=0,028 . hasil: hasil penelitian menunjukkan 1) ada perbedaan antara pelaksanaan knowledge management dalam pencegahan infeksi sebelum dan sesudah pelatihan; 2) ada perbedaan kinerja perawat dalam pencegahan infeksi nosokomial sebelum dan sesudah pelatihan; 3) terdapat hubungan yang signifikan kinerja perawat dalam pencegahan infeksi nosokomial terhadap kejadian infeksi; 4) tidak ada perbedaan yang signifikan pelaksanaan asuhan keperawatan terhadap kejadian infeksi nosokomial sebelum dan sesudah pelatihan. diskusi: kesimpulan pengembangan model asuhan keperawatan berbasis knowledge management sebagai sintesis atau induksi hasil temuan diarahkan pada 1) pengetahuan perawat tidak berpengaruh terhadap kinerja pencegahan infeksi nosokomial; 2) knowledge management berpengaruh positif terhadap kinerja pencegahan infeksi nosokomial; 3) pelaksanaan pencegahan infeksi merupakan kemampuan terintegrasi antara pengetahuan, keterampilan dan sikap perawat dalam melaksanakan kinerja dalam asuhan. kata kunci: model pencegahan, infeksi nosokomial, asuhan keperawatan, knowledge management, sectio caesarea abstract introduction: nosocomial infection is one indicator of the quality of health services in the community, which also determines the image of health care institutions becauseit was a major cause of morbidityand death rate (mortality) in hospital. nursing care based on knowledge management is established from identification knowledge which is required, prevention performance of nosocomial infections post section caesarea. nosocomial infections component consists of wound culture result. method: this study was an observational study with a quasi experimental design. the population was all of nursing staff who working in obstetrics installation in hospitals a and b as much as 46 people. sample was the total population. data was collected through questionnaire, observation sheets and examination of the wound culture. data was analyzed using t test b 1.274 dan p=0.028 result: the result showed that 1) there was difference in knowledge management implementation before and after training; 2) there was difference in nurse’s performance in preventing nosocomial infection before and after training; 3) there is significant relationship between nurse’s performance in preventing nosocomial infection and infection incidence; 4) there is no significant difference of nursing care impementation on nosocomial incidence. discussion: in conclusion, the development of nursing care based on knowledge management as a synthesis or induction of findings directed at 1) nurses’ knowledge does not affect the performance of the prevention of nosocomial infections; 2) knowledge management has a positive effect on the performance of the prevention of nosocomial infections; 3) implementation of infection prevention is integrated capabilities between knowledge, skills and attitudes of nurses in implementing performance in care . keywords: model prevention, nosocomial infections, nursing care, knowledge management, sectio caesarea 237 model asuhan keperawatan berbasis knowledge management (ahsan) pendahuluan infeksi nosokomial merupakan masalah penting di seluruh dunia dan terus meningkat setiap tahunnya (alvarado, 2000), berbagai upaya telah dilakukan tenaga keperawatan untuk mencegahnya salah satunya dengan penerapan universal precaution (perlindungan diri). angka kejadian infeksi nosokomial yang tinggi di amerika serikat terjadi 20 ribu kematian setiap tahunnya akibat infeksi nosokomial. di seluruh dunia 10% pada pasien rawat inap di rumah sakit mengalami infeksi yang baru dirawat atau sebesar 1,4 juta infeksi setiap tahunnya. di indonesia penelitian yang dilakukan dki jakarta pada tahun 1994 menunjukkan bahwa 9,8% pasien yang dirawat inap mendapatkan infeksi baru selama dirawat. di jogjakarta kejadian infeksi nosokomial rata-rata 4,26%, unt uk lama perawatan 4,43–11,2 hari, dengan rata-rata keseluruhan 6,7 hari (nursalam, 2011). rumah sakit sebagai industri jasa pelayanan kesehatan dapat meningkatkan pangsa pasarnya dalam memenuhi kualitas pelayanan yang bersifat customer-driven. hal ini akan memberikan keunggulan nilai dan customer value. merupakan kombinasi dari manfaat dan pengorbanan yang terjadi apabila pelanggan menggunakan suatu barang atau jasa guna memenuhi kebutuhan tertentu. apabila kualitas yang dihasilkan bersifat superior dan pangsa pasar yang dimilikinya besar, maka profitabilitasnya akan terjamin. jadi ada kaitan yang erat antara kualitas dan profitabilitas. b e b e r a p a k aji a n e m pi r i k t el a h membuktikan bahwa knowledge management b e r p e nga r u h sig n i f i k a n pa d a k i ne r ja organisasi (choi et al, 2008, yang et al, 2009) kinerja inovasi (liao & wu, 2010 dan keunggulan kompetitif (johannessen & olsen, 2003) chung, 2004). huang mengkaji suatu model system aplikasi penggunaan the analit yc heararchy prosess (ahp) method, menegaskan bahwa sistem berbasis k nowledge management dapat menjadi alat mengukur kepuasan kinerja, membuat perencanaan strategik, pengambilan keputusan berdasarkan informasi, membuat perencanaan perawatan kesehatan, memberikan wawasan dan rekomendasi, prediksi dan analisis untuk membantu manajer dalam membuat kebijakan dan analisis keputusan strategik atau membuat prediksi masa depan (abidi, 2001). asuhan keperawatan pasien dengan infeksi pada daerah operasi akan menjalani perawatan dua kali lebih lama di rumah sakit dari pada pasien yang tidak mengalami infeksi, dengan biaya dua kali lipat lebih besar (wilson, 2004). risiko terjadinya setelah pembedahan dipengaruhi beberapa faktor antara lain: jenis pembedahan, umur pasien, kondisi pasien, kompetensi perawat dalam perawatan pra dan pasca pembedahan serta perawatan luka. oleh karena itu diagnosis dini infeksi nosokomial sebaiknya didasarkan atas adanya keluhan nyeri pada daerah luka, warna kemerahan, adanya pembengkaan daerah luka, adanya nanah pada luka, serta hasil pemeriksaan bakteriologis berupa sediaan hapusan dengan pewar naan gram dan pembiakan kuman untuk mengetahui penyebab jenis bakteri dan menentukan pengobatannya (graham,2003). hal ini dapat dilakukan asuhan oleh perawat. rumah sakit merupakan salah satu mata rantai di dalam pemberian pelayanan kesehatan serta suatu organisasi dengan sistem terbu ka dan selalu ber interaksi dengan lingkungannya untuk mencapai suatu keseimbangan yang dinamis. rumah sakit mempunyai fungsi utama melayani masyarakat yang membutuhkan pelayanan kesehatan serta sebagai tempat penelitian. pencegahan infeksi nosokomial telah menjadi isu global dalam pelayanan kesehatan. menur ut nursalam (2008) indikator infeksi nosokomial meliputi adanya mikroorganisme pada jaringan atau cairan tubuh disertai gejala klinis baik lokal maupun sistemik. infeksi nosokomial adalah infeksi yang muncul selama seseorang dirawat di rumah sakit dan mulai menunjukkan suatu gejala selama seseorang tersebut dirawat atau setelah selesai dirawat. tenaga perawat yang merupakan the caring profession mempunyai kedudukan penting dalam menghasilkan kualitas pelayanan kesehatan di rumah sakit, karena pelayanan yang diberikan berdasarkan pendekatan biopsiko-sosial-spiritual merupakan pelayanan yang unik dilaksanakan selama 24 jam dan 238 jurnal ners vol. 9 no. 2 oktober 2014: 236–245 berkesinambungan mer upakan kelebihan tersendiri dibanding pelayanan lainnya (dep. kes. ri, 2001). hasil survei yang dilakukan pada tanggal 3 mei 2012 tentang kejadian infeksi nosokomial pasca sectio caesarea di ruang bersalin dan nifas rsud b didapatkan sebanyak 124 pasien (12,7%) pasien yang dirawat pasca sectio caesarea mengalami infeksi pada tahun 2010 dan sebanyak 156 pasien (13,8%) pada tahun 2011. hal ini mengalami peningkatan dari tahun sebelumnya serta lebih tinggi dari standar nasional dan internasional yang ditetapkan depkes dan who pada tahun 2000. dari hasil survey juga didapatkan dari 43 pasien menunjukkan kejadian infeksi pada hari ke-3 sebanyak 3 pasien (7,0%), kejadian infeksi hari ke-6 sebanyak 9 pasien (20,9%) dan kejadian infeksi hari ke-9 sebanyak 7 pasien (16,3%) dan kejadian terbesar pada hari ke-6 pasca operasi (20,9%). kejadian terbesar terjadi pada hari ke-6 pasca operasi. hal ini merupakan alasan pentingnya keuntungan pencegahan infeksi nosokomial pasca sectio caesarea. keuntungan pelaksanaan knowledge management dalam organisasi keperawatan akan mampu menfokuskan pada kebutuhan customer, mengendalikan, memprediksi setiap perubahan yang terjadi di lingkungan internal dan ekternal. selain itu dapat memperbaiki tingkat pengg unaan sumber daya yang menekan kan biaya serend ah mu ng k i n, mengelola integrasi proses antar bagian, memonitor secara sistematik aktivitas pada setiap proses kegiatan, menemukan kesalahan dalam proses dan memperbaikinya secepat mungkin, memahami proses setiap perubahan input menjadi output pada proses usaha, melakukan pengukuran pada setiap perubahan kondisi organisasi dengan benar. k n o w l e d g e m a n a g e m e n t d a l a m keperawatan merupakan suatu pendekatan holistik yang bertumpu pada pemahaman tugas organisasi untuk melakukan indentifikasi pengetahuan yang dibutuhkan, penemuan p e nge t a hu a n y a ng a d a , p e n a mb a h a n penget a hu a n , pencipt a a n penget a hu a n baru, menyimpan dan mengorganisasikan pengetahuan, berbagi pengetahuan ser ta m e n g g u n a k a n d a n m e n g a p l i k a s i k a n pengetahuan dalam pengkajian, diagnosis, implementasi serta evaluasi dalam keperawatan yang dikembangkan dari teori knowledge management (vucovic, 2001) dan standar asuhan keperawatan (depkes, 2001). masalah penelitian yang diangkat dalam penelitian ini adalah tingginya kejadian infeksi nosokomial pasca sectio caesarea di rsud b sebesar 13,8% pada tahun 2011 lebih tinggi dari standar nasional (6,6%) dan standar internasional (10%). tujuan akhir dari penelitian ini adalah untuk mengembangkan model pelaksanaan asuhan keperawatan berbasis knowledge management dalam meningkatkan pencegahan infeksi nosokomial pasien pasca sectio caesarea di rsud a dan b. metode penelitian ini merupakan penelitian e k s p e r i m e n t a l d e n g a n p e n d e k a t a n observasional dengan menggunakan dua tahapan. tahap 1 dengan tujuan menyusun model asuhan keperawatan berbasis knowledge management mengg unakan sur vey atau observasional, dengan rancang bangun crosssetioanal. tahap 2 bertujuan untuk simulasi model hasil tahap 1 dengan menggunakan perlakuan dengan rancang bangun quacy experiment (ada kelompok perlakuan dan control). penelitian ini dilakukan di intalasi ruang perawatan kebidanan yaitu di ruang bersalin, nifas dan poli kandungan (ruang brawijaya) rsud a, ruang dahlia dan bougenvil rsud b. pada tahap 1, populasi penelitian adalah semua tenaga keperawatan yang bekerja di instalasi kebidanan dan sejumlah pasien yang dirawat di rumah sakit a dan b pasca sectio caesarea. besar sampel adalah total populasi yaitu semua tenaga keperawatan yang bekerja di instalasi kebidanan sesuai kriteria sampel, dan sebagian pasien yang diasuh tenaga keperawatan pasca sectio caesarea yang diambil secara random sampling. besar sampel perawat di rumah sakit a adalah 20 orang dan rumah sakit b sebanyak 24 orang. 239 model asuhan keperawatan berbasis knowledge management (ahsan) pada tahap 2 sampel penelitian adalah sebagian besar tenaga keperawatan yang bekerja sebagai pelaksana langsung pada pasien dan bekerja pada shift pagi, siang dan malam di instalasi kebidanan dan sejumlah pasien yang dirawat di rumah sakit a dan b pasca sectio caesarea. jumlah sampel perawat pada tahap ini 15 perawat di rumah sakit a dan 15 perawat di rumah sakit b. untuk masing perawat atau bidan diambil secara random pasien yang dirawat sebagai pasien kelolaan untuk diperiksa hasil kinerja perawat dalam asuhan yaitu infeksi nosokomial (inos). analisis data menggunakan uji beda (ttest) pengetahuan tenaga keperawatan tentang asuhan keperawatan (x1), pelaksanaan asuhan keperawatan berbasis knowledge management (x2), kinerja asuhan keperawatan dalam pencegahan infeksi nosokomial (y1), dan kejadian infeksi nosokomial (y2) sebelum dan sesudah pelatihan pada kelompok perlakuan dan kelompok control. jika dalam pengujian ini diperoleh p-value <0,05 (alpha 5%), berarti pengujian signifikan, sebaliknya kalau p-value > 0,05 (alpha 5%), berarti tidak signifikan. hasil a n a l i s i s d i l a k u k a n d e n g a n menggunakan uji t-test dan untuk menentukan model menggunakan software patrial least square. peng ujian si mulasi k nowledge management dilakukan menggunakan uji ttest perubahan antara kelompok perlakuan dan kontrol. hasil penelitian lihat tabel 1. p r o s e s k n o w l e d g e m a n a g e m e n t pada setiap tahapan proses keperawatan terdiri dari penemuan pengetahuan yang ada, menggunakan dan mengaplikasikan penget ahu an, pencipt a a n penget ahu an, berbagi penget a hu a n, meny i mpa n d a n mengorga n isasi ka n penget ahu a n, ser t a m e n g g u n a k a n p e n g e t a h u a n d a l a m keperawatan. berdasarkan tabel 1 di bawah terdapat kesenjangan antara pengetahuan standar dengan pengetahuan aktual sebelum dan sesudah pelatihan pada semua variabel pengkajian, diag nosis, perenca na a n, i mplement asi, evaluasi. hasilnya kecenderungan ke arah positif terjadi peningkatan mean sesudah pelati han. hasil analisis menu nju k kan terdapat perbedaan yang cukup kuat pada sub variabel pengkajian, diagnosis, perencanaan, implementasi serta evaluasi. hal ini dapat d i s i m p u l k a n b a h w a s e m a k i n t i n g g i pengetahuan standar pengkajian, diagnosis, perencanaan, implementasi dan evaluasi dengan pengetahuan yang dibutuhkan maka semakin tinggi pengetahuan standarnya. ha sil obse r va si a k t iv it a s d ala m pencegahan infeksi nosocomial sesudah pelatihan pada masing-masing kelompok seperti terlihat pada tabel 2. berdasarkan hasil uji t test di atas menunjukkan bahwa terdapat perbedaan bermakna kinerja tenaga keperawatan dalam asuhan keperawatan pencegahan infeksi nosokomial pada kelompok perlakuan ratarata terjadi peningkatan mean dan delta t pada masing-masing sub variabel sesudah pelatihan. pela ksana an asu han keperawat an berbasis k nowledge management ( x 2) terhadap kejadian infeksi nosokomial pasca sectio caesaria (y2) dilakukan pengujian menggunakan uji regresi logistik. hasil uji regresi logistik pelaksanaan asuhan keperawatan berbasis knowledge management pada tabel 3. tabel 1. hasil uji pengetahuan standar dengan pengetahuan aktual dalam pelaksanaan asuhan keperawatan no sub variabel mean sebelum mean sesudah ∆ t p ket 1 pengkajian 3,5 5 -9,000 0,000 signifikan 2 diagnosis 3,2 4,7 -5,582 0,000 signifikan 3 perencanaan 3,10 5 -10.585 0,000 siginifikan 4 implementasi 3,40 4,90 -5,582 0,000 signifikan 5 evaluasi 4,80 5 -1,500 0,168 siginifikan 240 jurnal ners vol. 9 no. 2 oktober 2014: 236–245 berdasarkan hasil regresi logistik menunjukkan bahwa terdapat signifikansi antara kinerja dalam pelaksanaan asuhan keperawatan berbasis knowledge management terhadap kejadian infeksi nosokomial sebelum dan sesudah pelatihan. hasil analisis jalur model asuhan keperawatan berbasis knowledge management t e r h a d a p k i ne r ja p e nc eg a h a n i n fek si nosokomial dengan menggunakan software partial least square (pls) adalah: tabel 2. aktivitas dalam pencegahan infeksi nosokomial pada kelompok kontrol dan kelompok perlakuan sesudah pelatihan no sub variabel mean kelompok kontrol mean kelompok perlakuan ∆ t p ket 1 cuci tangan dengan benar 4,07 5,00 -7,897 0,000 signifikan 2 mencegah penularan dg menyiapkan alat secara steril 3,60 4,80 -6,148 0,000 signifikan 3 mencegah penularan melalui percikan ludah 4,07 5,00 -7,897 0,724 signifikan 4 perawatan luka secara steril 4,07 5,00 -7,897 0,724 signifikan 5 teknik pembalutan luka 4,07 5,00 -7,897 0,724 signifikan tabel 3. pelaksanaan askep berbasis knowledge management terhadap kejadian infeksi nosokomial variabel bβ p keterangan kinerja dalam pelaksanaan asuhan keperawatan berbasis knowledge managementterhadap kejadian infeksi nosokomial 1,274 0,028 signifikan pembahasan berdasarkan hasil penelitian bahwa kemampuan tenaga keperawatan dalam asuhan keperawatan berbasis knowledge management rata-rata dalam kategori baik atau sering pada komponen penemuan pengetahuan yang ada, menggunakan dan mengaplikasikan pengetahuan. kategori baik atau sering pada komponen penciptaan pengetahuan, kategori cukup pada komponen berbagi pengetahuan dan pada kategori kurang pada komponen m e n y i m p a n d a n m e n g o r g a n i s a s i k a n pengetahuan. gambar 1. model analisis jalur setelah indikator yang tidak valid dibuang 241 model asuhan keperawatan berbasis knowledge management (ahsan) hasil uji t menu nju k ka n ad a nya hubungan yang kuat antara asuhan keperawatan berbasis knowledge management dengan kinerja dalam pencegahan infeksi nosokomial. hal ini ditunjukkan adanya peningkatan mean sebelum pelatihan pada semua komponen rata-rata 1,3–4,4 dan menjadi 1,6–5 setelah pelatihan pada masing-masing komponen dan delta t -1,406 sampai dengan -8,573 dan p 0,000 sampai dengan 0,193. berdasarkan hasil penelitian bahwa kegiatan knowledge management dalam asuhan keperawatan pada tahap pengkajian dalam kategori baik atau sering pada komponen penemuan pengetahuan yang ada, perolehan atau penambahan pengetahuan, penciptaan pengetahuan bar u, berbagi pengetahuan, m e n g g u n a k a n d a n m e n g a p l i k a s i k a n pengetahuan. h a s i l a n a l i s i s p e n e l i t i a n j u g a menunjukkan ada hubungan faktor pengkajian dengan pelaksanaan asuhan keperawatan berbasis k nowledge management dalam pencegahan infeksi nosokomial pasca sectio caesarea rata-rata 3,6 – 4,0 dan menjadi 5 setelah pelatihan pada masing-masing komponen dan delta t -3,881 sampai dengan -11,000 dan p 0,000 sampai dengan 0,004. terdapat perbedaan asuhan keperawatan berbasis knowledge management dalam tahap pengkajian, untuk penemuan dan penambahan pengetahuan didapatkan data yang sama antara sebelum dan sesudah pelatihan. d ok u m e nt a si m e r u p a k a n a s p e k penting dalam asuhan keperawatan, karena dokumentasi yang baik, lengkap, akurat, dapat membantu memberikan bukti pertanggung jawaban yang kuat terhadap apa yang telah dilakukan oleh perawat. perawat akan terbebas dari kesalahan dan tuntutan dalam memberikan asuhan keperawatan bila telah melakukan asuhan sesuai standar yang ditetapkan. syarat dokumentasi yang baik menurut capernito (2000), terdiri kemampuan berkomunikasi, keterampilan mendokumentasikan, ser ta kepatuhan standar dokumentasi. berdasarkan pendapat denise (2007), dan nonaka and takeuchi (1995), sarvary (1999), choo (1998), davenport et al. (1998), dan zarif ian (1999), cut zur nali (2008) mengungkapkan model konseptual sistem knowledge management bahwa pengetahuan individual (individual knowledge) sebagai starting point bagi penciptaan pengetahuan keorganisasian. sejak informasi telah menjadi bahan dasar (raw material) dari pegangan pengetahuan individual, maka ia merupakan landasan dasar dari organisasi pengetahuan ( k nowledge organization). cut zu r nali (2008) menambahkan bahwa pengetahuan individual yang muncul merupakan kombinasi dari informasi, interpretasi, ref leksi, dan pengalaman dalam sebuah konteks yang pasti (certain context). selanjutnya perlu dipertimbangkan juga pentingnya mengaitkan informasi baru dengan pengetahuan yang ada. penemuan pengetahuan yang dibutuhkan t e r bu k t i b a hwa b e r hu bu ng a n d e ng a n pelaksanaan pencegahan infeksi nosokomial dengan menunjukkan bahwa kedua indikator yang valid dalam merefleksikan sub variabel penemuan pengetahuan dalam pelaksanaan knowledge management asuhan keperawatan pada pencegahan infeksi nosokomial pasca sectio caesaria. hasil analisis jalur pada gambar 1 menunjukkan ada pengaruh positif karakteristik penemuan pengetahuan yang dibutuhkan perawat terhadap pelaksanaan pencegahan infeksi nosokomial. menurut vucovic (2001), tahap awal identifikasi pengetahuan yang dibutuhkan dalam knowledge management bertujuan mengetahui posisi organisasi dalam mengelola pengetahuan saat ini. kegiatan ini meliputi identifikasi pengetahuan organisasi yang spesif ik dan berbeda setiap organisasi. ident if i k a si penget a hu a n i n i mel iput i pengetahuan yang ada baik yang tidak tampak atau tersembunyi (tacit), maupun pengetahuan yang tampak (explicit), tempat penyimpanan d a n bagai m a n a p e r a n a n p e nget a hu a n tersebut. hasil penelitian ini ada hubungan pelaksanaan penemuan pengetahuan yang ada dengan asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial, proses keperawatan mer upakan metode yang bersifat siklus yang selalu member ikan masu kan atas 242 jurnal ners vol. 9 no. 2 oktober 2014: 236–245 perkembangan pasien dan menjadi informasi lanjutan pada tahap dan waktu selanjutnya. hal ini sesuai yang dikemukakan capernito, (2000). hasil penelitian kemampuan responden t e nt a ng p e r ole h a n a t a u p e n a mb a h a n pengetahuan tentang asuhan keperawatan rata-rata dalam katagori baik atau sering pada komponen penemuan pengetahuan yang ada, perolehan atau penambahan pengetahuan, penciptaan pengetahuan baru, berbagi pengetahuan, menggunakan dan mengaplikasikan pengetahuan. sebaliknya yang selalu dilakukan responden adalah m e n g g u n a k a n d a n m e n g a p l i k a s i k a n pengetahuan, yang kadang-kadang atau kategor i cu k up ad alah perolehan at au penambahan pengetahuan, yang jarang atau kategori kurang baik adalah penciptaan pengetahuan. hasil observasi penelitian didapatkan bahwa hal yang masih jarang dilakukan responden pad a t a hap peroleha n at au penambahan pengetahuan dalam asuhan keperawatan adalah melakukan penilaian kinerja, melakukan koreksi spo, mekanisme kerja dalam asuhan. hasil penelitian asuhan keperawatan berbasis knowledge management pada tahap ini adalah dalam katagori baik. hasil analisis didapatkan ada hubungan faktor diagnosis dengan pelaksanaan asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial paska sectio caesaria rata-rata mean sebelum pelatihan 3,4 – 4,0 dan menjadi 5 setelah pelatihan pada masing-masing komponen dan delta t -3,250 sampai dengan -6,708 dan p 0,000 sampai dengan 0,010 . terdapat perbedaan asuhan keperawatan berbasis knowledge management dalam tahap diagnosis sebelum dan sesudah pelatihan. mo del konve r si p e ne mu a n at au penambahan pengetahuan menurut sangkala (2007) dari tacit knowledge dan explicit knowledge yaitu pengetahuan diubah melalui interaksi antar individu, yaitu belajar dari ahlinya, dengan observasi, peniruan, latihan, pengalaman. melalui proses pengkombinasian dengan mempertukarkan pengetahuan melalui pertemuan, percakapan, telepon, selanjutnya p e n g e t a h u a n d i s o r t i r, d i t a m b a h k a n , dikategorisasi dan dikontekstualisasikan kembali menjadi pengetahuan baru, nonaka (1995). melalui proses pengubahan melalui ide-ide dari tacit ke explicit knowledge, keduanya saling melengkapi dan diperluas melalui proses interaksi. perolehan atau penambahan pengetahuan t e r bu k t i b a hwa b e r hu bu ng a n d e ng a n pelaksanaan pencegahan infeksi nosokomial. menurut vucovic (2009), proses penemuan pengetahuan melibatkan pengetahuan internal ke dalam organisasi meliputi apa saja yang akan kita ketahui, proses pengumpulan pengetahuan (gathering), apakah pengetahuan ini dibutuhkan di bagian lain, kemampuan membawa pengetahuan ke organisasi dari sumber ekternal yang dikerjakan dengan berbagai cara antara lain menggabungkan pengetahuan internal lain dengan pengetahuan ekternal. ada perbedaan yang signifikan antara perolehan atau penambahan pengetahuan berbasis knowledge management dengan pencegahan infeksi nosokomial, karena penambahan pengetahuan akan meningkatkan kapasitas seseorang dalam kinerja yang pada akhirnya dapat meningkatkan kemampuan se se or a ng d a la m p e nc ega h a n i n fek si nosokomial. hasil penelitian tingkat kemampuan responden tentang pelaksanaan perencanaan dalam asu han keperawat an didapatkan rata-rata dalam katagori baik atau sering pada komponen penemuan pengetahuan yang ada, perolehan atau penambahan pengetahuan, penciptaan pengetahuan baru, berbagi pengetahuan, menggunakan dan mengaplikasikan pengetahuan. sebaliknya yang selalu dilakukan responden atau kategori sangat bai k ad alah mengg u na kan d an mengaplikasikan pengetahuan, yang kadangkadang dilakukan atau kategori cukup adalah berbagi pengetahuan, yang jarang dilakukan atau kategori kurang adalah menyimpan dan mengorganisasikan pengetahuan serta yang tidak pernah dilakukan atau kategori tidak baik adalah penciptaan pengetahuan baru. hasil analisis diperoleh ada hubungan faktor perencanaan dengan pelaksanaan 243 model asuhan keperawatan berbasis knowledge management (ahsan) asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial paska sectio caesaria rata-rata mean sebelum pelatihan 3,3–4,0 dan menjadi 5 setelah pelatihan pada masing-masing komponen dan delta t -3,161 sampai dengan -11,129 dan p 0,000 sampai dengan 0,012 . terdapat perbedaan asuhan keperawatan berbasis knowledge management dalam tahap perencanaan sebelum dan sesudah pelatihan. menurut nonaka, et al, (1995) penciptaan pengetahuan baru dalam organisasi dilakukan melalui empat tahapan yaitu sosialisasi, ekternalisasi, combinasi dan internalisasi (seci) yang secara organisasional dikelola menjadi bentuk siklus yang berlangsung terusmenerus. berdasarkan hasil analisis uji korelasi pearson menunjukkan terdapat hubungan yang signifikan (0,381) kali antara penciptaan penget ahuan bar u dengan pelaksanaan asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial, karena proses keperawatan yang benar selalu memberikan informasi yang baru, memperbaruhi data klien secara berkesinambungan sehingga penciptaan pengetahuan baru selalu dibutuhkan. hal ini sesuai pendapat vucovic (2009). penciptaan pengetahuan baru sangat mutlak diperlukan dalam asuhan keperawatan berbasis knowledge management untuk selalu memperbaiki pengetahuan dan kemampuan tenaga ke per awat a n, juga menget a hu i perkembangan pasien secara terus-menerus. hasil penelitian tingkat kemampuan responden tentang pelaksanaan menyimpan d a n m e ngo r g a n i s a si k a n p e nge t a hu a n dalam asuhan keperawatan rata-rata dalam kategori baik atau sering pada komponen penemuan pengetahuan yang ada, perolehan atau penambahan pengetahuan, penciptaan pengetahuan bar u, berbagi pengetahuan, m e n g g u n a k a n d a n m e n g a p l i k a s i k a n pengetahuan. sebaliknya yang selalu atau kategori sangat baik dilakukan responden adalah penemuan pengetahuan yang ada, yang kadang-kadang dilakukan atau kategori cukup adalah berbagi pengetahuan, yang jarang dilakukan atau kategori kurang dan tidak pernah dilakukan atau kategori kurang baik adalah penciptaan pengetahuan baru. hasil observasi penelitian didapatkan bahwa hal yang masih tidak pernah dilakukan responden pada tahap menyimpan dan mengorganisasikan pengetahuan adalah menyimpan dan mengarsipkan pengetahuan, berbagi pengetahuan dengan yang lain proses pembelajaran staf dengan memanfaatkan media maya, memutakhirkan pengetahuan. hasil analisis didapatkan ada hubungan faktor implementasi dengan pelaksanaan asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial paska sectio caesaria rata-rata mean sebelum pelatihan 3,5–4,2 dan menjadi 4,9–5 setelah pelatihan pada masing-masing komponen dan delta t -3,873 sampai dengan -9.000 dan p 0,000 sampai dengan 0,004. terdapat perbedaan bermakna asuhan keperawatan berbasis k nowledge management dalam tahap implementasi sebelum dan sesudah pelatihan. menur ut tannebaum (1998), untuk mencapai kesu ksesan, organisasi perlu me ng u b a h n i l a in i l a i or g a n i s a si d a n menetapkan fokus baru dengan menciptakan dan menggunakan aset intelektual melalui k n o w l e d ge m a n a ge m e n t (m a n aje m e n pengetahuan) untuk dapat bersaing secara efektif dalam lingkungan bisnis dan persaingan berbasis pengetahuan. hasil penelitian tingkat kemampuan responden tentang pelaksanaan berbagi pengetahuan dalam asuhan keperawatan rata-rata dalam kategori sering atau baik pada komponen pada komponen penemuan pengetahuan yang ada, perolehan atau pe na mba ha n pe nget a hu a n , pe ncipt a a n pengetahuan bar u, berbagi pengetahuan, m e n g g u n a k a n d a n m e n g a p l i k a s i k a n pengetahuan. sebaliknya yang selalu atau kategori sangat baik dilakukan responden adalah penemuan pengetahuan yang ada, yang kadang-kadang dilakukan responden atau kategori cukup dan jarang dilakukan responden atau kategori k urang adalah penciptaan pengetahuan baru. hasil observasi didapatkan hal yang masih belum dilakukan secara optimal oleh 244 jurnal ners vol. 9 no. 2 oktober 2014: 236–245 responden dalam hal berbagi pengetahuan, walaupun porsinya kecil yang jarang dilakukan adalah berbagi pengetahuan ke orang lain berbagi keterampilan, berbagi sikap dan pengalaman, belajar bersama-sama, bimbingan peran, bimbingan karier. ada hubungan faktor evaluasi dengan pelaksanaan asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial paska sectio caesaria rata-rata mean sebelum pelatihan 4,3– 4,8 dan menjadi 5 setelah pelatihan pada masing-masing komponen dan delta t -1,406 sampai dengan -4,583 dan p 0,001 sampai dengan 0,193. terdapat perbedaan asuhan keperawatan berbasis knowledge management dalam tahap diagnosis sebelum dan sesudah pelatihan. knowledge yang dimiliki oleh tiap perawat belum dapat disinergikan antara satu dengan lainnya. budaya saling berbagi pengetahuan belum terbentuk, sehingga kompetensi masing-masing perawat tidak dapat berkembang dan cender ung statis. pengetahuan dalam proses pembelajaran yang dimaksud seperti materi pelatihan, paper, artikel, solusi masalah dan latihan. bila perawat yang memiliki pengetahuan tersebut tidak lagi menjadi perawat, maka pengetahuan yang dimilikinya juga hilang. begitu pula dengan sarana penyimpanan knowledge berupa portal, basis data knowledge sudah tersedia tetapi belum dimanfaatkan secara maksimal (vucovic, 2009). pelatihan dan observasi dilaksanakan selama 1 bulan dengan dimulai dari pelatihan dan bimbingan pelaksanaan k nowledge management dalam asuhan keperawatan pasien pasca sectio caesaria. kegiatan ini dilakukan selama 2 jam dengan metode mempelajari modul, diskusi tanya jawab dilanjutkan bimbingan asuhan pada pasien kelolaan masing-masing selama 6 hari. bimbingan dilakukan oleh peneliti dibantu kepala ruangan dan wakil kepala ruangan cempaka pada setiap siklus dinas. materi yang diberikan dalam pelatihan adalah aspek asuhan keperawatan yang berbasis knowledge management, yang meliputi: pengkajian pasien, diagnosa keperawatan, perencanaan asuhan keperawatan, implementasi asuhan k e p e r a w a t a n , i m p l e m e n t a s i a s u h a n keperawatan, dan evaluasi asuhan keperawatan dalam hal pencegahan infeksi nosokomial. hasil observasi menunjukkan adanya peningkatan nilai rata-rata kinerja asuhan keperawatan berbasis knowledge management sebelum dan sesudah diberi pelatihan. simpulan dan saran simpulan pengembangan model asuhan keperawatan berbasis knowledge management sangat relevan dilaksanakan dalam asuhan keperawatan karena mempunyai kesamaan proses pembelajaran yang siklus dan berkesinambungan secara terus menerus serta saling melengkapi serta dapat disederhanakan sesuai model hasil penelitian. kinerja tenaga keperawatan dalam asuhan keperawatan pencegahan infeksi nosokomial pasien pasca sectio caesarea akan lebih meningkat bila diaplikasikan proses knowledge management dalam asuhan keperawatan. model asuhan keperawatan berbasis knowledge management dapat dikembangkan dan mempunyai kontribusi positif dalam menurunkan kejadian infeksi nosokomial di rumah sakit pemerintah. saran r u m a h s a k it p e r l u m el a k u k a n pengembangan model asuhan keperawatan b e rba sis k n owle dge m a n age m e n t d a n meningkatkan pengetahuan perawat dan bidan dengan memberikan pelatihan dan bimbingan serta pendidikan tentang pentingnya menjaga sterilitas dan pencegahan infeksi nosokomial. tenaga kesehatan ter utama perawat dan bidan perlu meningkatkan kemampuan pengetahuan, sikap dan keterampilan dengan banyak membaca, belajar dari sumber internal d an ek ter nal, mela k u kan dok u ment asi dan penyimpanan pengetahuan dengan memanfaatkan media elektronik, berbagai dengan belajar bersama, diskusi dan evaluasi kinerja. 245 model asuhan keperawatan berbasis knowledge management (ahsan) kepustakaan achpr. 1994. african commition of huma right relation, standar praktik luka operasi, infeksi nosokomial. alfarado. 2000. knowledge management dalam sangkala, suatu pengantar memahami bagaimana organisasi mengelola pengetahuan sehingga menjadi organisasi yang ungg ul. jakarta: raja grafindo. carpenito, l.j. 2000. rencana asuhan dan dokumentasi keperawatan, terjemahan. edisi ke-2 jakarta: egc. yang et al. 2009. the knowing organizzation how organization use information to construct meaning, create knowledge and decision making, new york, oxfort university press. depkes r i. 2001. inst r umen e valua si penerapan standar asuhan keperawatan di rumah sakit. jakarta: dit.jen yan medik doengos, m.e. 1998. penerapan proses keperawatan & diagnosa keperawatan, terjemahan, edisi ke-2 jakarta, egc. g i l l ie s, de e a n n. 1996. m a n a je m e n keperawatan suatu pendekatan sistem. philadelphia: wb souders company. kusumapraja. 2009. keselamatan pasien dan manajemen risiko klinis. rumah sakit panti rapih jakarta. marten son, malhora. 2000. knowledge management and bussines model innovation, hongkong: hershey idea, group publishing. nonaka, ikujiro, hirotaka takeuchi. 1995. knowledge creating company: how japaness companies create the dynamics of in novation. new york: oxford university pres. nursalam. 2008. proses dan dokumentasi k e p e r a w a t a n . ja k a r t a : sa le mb a medika. nursalam. 2011. manajemen keperawatan, aplikasi dalam praktik keperawatan profesional. jakarta: salemba medika. pot t e r & pe r r y. 20 05. fu n d a m e n t a l keperawatan, jakarta: egc. sangkala. 2007. knowledge management, suatu pengantar memahami bagaimana mengelola pengetahuan sehingga menjadi organisasi yang ungg ul. jakarta: pt rajagrafindo. vucovic. 2001. knowledge management, support, stanndart and ser vice of customer, a merican science and tecnologi asosiation, newyork. vucovic, oluic. 2009. aplication knowledge management, learning organization. bandung: pustaka unpad, tannebaum. 1998. manajemen keperawatan dengan pendekatan praktis. jakarta: erlangga. ners vol 10 no 1 april 2015.indd 104 modifikasi pompa asi sebagai terapi luka bertekanan negatif untuk mempercepat penyembuhan luka diabetes (modifi cation of breast pump as a negative pressure wound therapy for accelerating wound healing of diabetic ulcer) yunita sari*, saryono*, iwan purnawan*, hartono** *jurusan keperawatan, universitas jenderal soedirman, purwokerto ** jurusan fisika, universitas jenderal soedirman, purwokerto email: yunita-tky@umin.ac.jp/sasa.yunita@gmail.com abstrak pendahuluan: terapi luka bertekanan negatif/negative pressure wound therapy (npwt) saat ini dianggap sebagai terapi terbaik untuk penyembuhan luka diabetes. namun sayangnya alat ini belum terdapat di indonesia. tujuan: tujuan dari penelitian ini adalah untuk membuat alat npwt dengan menggunakan modifi kasi dari pompa asi, dan untuk mengetahui efeknya terhadap penyembuhan luka diabetes. metode: komponen utama dari alat npwt dibuat dari pompa asi digital. luka pada hewan coba dibagi menjadi dua kelompok, yaitu luka yang dirawat dengan npwt (kelompok perlakuan), dan luka yang tidak dirawat dengan npwt (kelompok kontrol). tekanan negatif yang digunakan dalam penelitian ini adalah 85 mmhg. tikus dikorbankan pada hari ke-7, dan jaringan luka dan kulit sekeliling luka diberi pewarnaan hematoksilin dan eosin. tingkat infl amasi, intensitas dari jaringan nekrotik dan penutupan luka dibandingkan antara kelompok perlakuan dan kontrol. hasil: tekanan dari npwt modifi kasi pompa asi berkisar antara 85–140 mmhg. ukuran luka pada kelompok perlakuan lebih kecil dibanding pada kelompok kontrol. intensitas infl amasi pada kelompok perlakuan juga lebih sedikit dibanding kontrol. diskusi: penelitian kami menunjukkan modifi kasi pompa asi dapat digunakan sebagai terapi luka bertekanan negatif, dan terbukti dapat menurunkan infl amasi dan jaringan nekrotik pada luka diabetes. penelitian lebih lanjut diperlukan untuk membuktikan efek dari alat ini pada subjek manusia. kata kunci: luka diabetes, pompa asi, tekanan negatif, penyembuhan luka abstract introduction: negative pressure wound therapy (npwt) is considered as the best treatment for accelerating wound healing, including diabetic ulcer. however, this device is still not available in indonesia. therefore, the purpose of this study were to make npwt by using modifi cation of breast pump, and to elucidate the effect of this device on acceleration of wound healing in diabetic ulcer. method: npwt was made by using digital breast pump. wounds were divided into two groups; wound-treated by npwt (experimental group) and wound-untreated by npwt (control). the negative pressure used for this study was 85 mmhg. rats were sacrifi ced on day 7, and wound samples and surrounding skin were stained with hematoxylin and eosyn. infl ammation, intensity of necrotic tissue, and wound closure were observed. result: the device could deliver a negative pressure at a range of 85–140 mmhg. wound size in the experimental group was smaller than in control group. infl ammation was also less in the experimental group than control group. discussion: the modifi cation of breast pump could be used as a negative pressure therapy for wounds, and has effect on reducing infl ammation and necrotic tissue. further study is needed to elucidate the effect of this device on human subject. keywords: diabetic wound, breast pump, negative pressure, wound healing pendahuluan d i a b e t e s mel it u s ( dm ) a d a l a h kondisi peningkatan kadar gula darah yang disebabkan karena kurangnya produksi insulin (armstrong, lavery, dan harkless, 1998). diabetes melitus saat ini merupakan ancaman yang serius bagi kesehatan manusia secara global. organisasi kesehatan dunia (who) menyatakan sedikitnya ada 171 juta penderita dm di dunia tahun 2006. diperkirakan insiden akan meningkat dua kali lipat pada tahun 2030 (waspadji, 2006). di indonesia, penderita dm juga mengalami peningkatan yang signifi kan, yaitu 8,4 juta jiwa pada tahun 1995, dan meningkat menjadi 14,7 juta jiwa pada tahun 2006. who menyatakan bahwa indonesia menempati urutan ke-4 terbesar dalam jumlah penderita dm di dunia (waspadji, 2006). salah satu komplikasi yang paling sering terjadi pada pasien dm adalah luka diabetes. menurut data dari international diabetic foot (2005), luka diabetes adalah 105 modifi kasi pompa asi sebagai terapi luka bertekanan negatif (yunita sari, dkk) penyebab utama dari amputasi ekstremitas bawah pada pender ita dm (a r mst rong et al., 1997). diperkirakan ada lebih satu juta amputasi di dunia per tahun karena luka diabetes. di indonesia, 30% dari penderita dm pernah mengalami amputasi karena luka kaki diabetes (waspadji, 2006). alasan utama terjadinya amputasi adalah luka yang sulit menyembuh. ba nya k t e r api d i la k u k a n u nt u k meningkatkan penyembuhan luka diabetes. di antaranya adalah perawatan luka dengan balutan luka yang lembab. namun, terapi ini sering memerlukan waktu yang panjang, terutama pada luka yang memiliki banyak komplikasi (nain et al., 2011). terapi yang lain adalah terapi dengan menggunakan growth factors seperti fgf, pdgf, and egf (loot et al., 2002). namun terapi ini kurang efektif pada luka yang parah karena terapi ini tergantung pada kerja dari reseptor-reseptor yang masih ada di luka terapi yang saat ini sangat populer dan menjadi banyak perhatian dari para peneliti adalah terapi luka yang berbasis tekanan negatif (non contact pressure wound theraphy/npwt) atau yang sering disebut sebagai vakum luka (vacuum-assisted closure/vac) (xie et al., 2010). terapi luka dengan npwt atau vakum luka merupakan metode non-invasif dalam penanganan luka dengan menempatkan lu ka pada r uang tertutup bertekanan negatif sehingga dapat membersihkan cairan luka yang berlebih dan bakteri-bakteri penyebab infeksi (kirby et al., 2009, nain et al., 2011). teknik penanganan luka dengan npwt telah terbukti dalam berbagai penelitian mampu meningkatkan proses penyembuhan luka melalui peningkatan aliran darah lokal ke area luka, mengurangi edema interstitial, m e n ge n d a l i k a n e k s u d a t , m e r a n g s a n g p e mb e nt u k a n ja r i nga n g r a nu la si d a n proliferasi sel, dan dalam waktu bersamaan mampu menghilangkan penghambat proses penyembu han lu ka (searle and mil ne, 2010). penelitian terdahulu dengan desain randomized control trial tentang efek npwt pada percepatan penyembuhan luka diabetes menunjukkan hasil yang konsisten, bahwa npwt mampu meningkatkan kecepatan penyembuhan luka diabetes pada pasien (xie et al., 2010). tekanan negatif pada npwt terbukti dapat mempercepat penyembu han lu ka dengan menarik cairan eksudat, memperbaiki sirkulasi, menarik dan membersihkan bakteri dari luka, meningkatkan proses proliferasi dan granulasi jaringan luka (morykwas, argenta, dan shelton, 1997; nain et al., 2011). namu n sayang nya alat ini belum dipasarkan di indonesia, serta pemakaiannya di rumah sakit membutuhkan biaya yang sangat besar. biaya yang dibutuhkan untuk satu kali pemakaian alat ini kira-kira mencapai £ 142, (rp 2.020.092 dalam rupiah). padahal, rata-rata pasien dengan luka diabetes membutuhkan terapi npwt tiga kali per minggu dalam waktu 2–3 bulan. di samping harga yang sangat mahal, berdasarkan pengalaman peneliti selama menggunakan alat ini di rumah sakit universitas tokyo, jepang, ukuran dari npwt relatif besar sehingga kurang praktis dalam penggunaannya. berdasarkan atas kelemahan-kelemahan di atas, peneliti bermaksud untuk membuat alat dengan prinsip kerja yang sama, namun dengan harga yang lebih ekonomis, dan dengan bahan dasar yang tersedia di indonesia dan memiliki ukuran yang lebih praktis. pada penelitian ini, peneliti akan membuat alat npwt dengan menggunakan modifi kasi dari pompa asi untuk menghasilkan tekanan yang negatif, serta menguji apakah alat ini mampu mempercepat penyembuhan luka diabetes pada hewan coba. tujuan dari penelitian ini adalah untuk membuat alat terapi luka berbasis tekanan negatif melalui modifi kasi dari pompa asi, dan menguji efektivitasnya untuk mempercepat penyembuhan luka pada tikus diabetes. metode alat dan bahan-bahan yang digunakan unt u k membuat terapi lu ka ber tekanan negatif dari pompa asi adalah pompa asi digital, slang transfusi darah, connector t, diafragma (penempel pada kaca), botol bekas tinta infus printer, lem plastic, trafo adaptor 106 jurnal ners vol. 10 no. 1 april 2015: 104–111 0,5a, potensiometer, rangka (casing), kabel secukupnya, tenol dan solder. daya hisap dari pompa asi yang dig u nakan adalah bersifat put us-put us (intermitten), sehingga untuk menghasilkan hisapan yang terus-menerus, maka bagian kat up ini dihilangkan. kemudian, daya hisap pompa asi divar iasi kan dengan memvariasikan tegangan listrik menggunakan potensiometer, sehingga dapat menghasilkan daya hisap dengan rentang 85–140 mmhg. kemudian, peneliti menggunakan adaptor dengan trafo 0,5 ampere untuk menjaga kuat arus dan tegangan yang stabil. kemudian trafo ditempatkan dalam rangka alat vakum luka dari pompa asi. setelah trafo tertata rapi, mesin pompa asi diambil dan rangka pompa asi dilepas, kemudian mesin pompa asi dipasang pada rangka alat vakum luka. bagian input untuk menghisap pada mesin dihubungkan dengan konektor yang dipasang pada rangka alat vakum dan diatur letaknya agar menjulur keluar supaya memudahkan pasang-lepas slang udara ke luka. slang udara yang panjang, dipotong pada bagian tengah dan dipasang botol penampung dari botol bekas tinta printer yang sudah dibersihkan. pada bagian ujung slang dipasang diafragma dari plastik yang elastis. semua tempat sambungan kemudian di lem dengan lem plastik dan dipastikan kedap udara. slang dihubungkan dengan konektor, kemudian diuji coba dengan tekanan tertentu. hewan coba dalam penelitian ini adalah tikus jantan galur wistar, dengan berat badan 160-200 miligram (usia 8 minggu). tikus diperoleh dari laboratorium farmakologi, fakultas farmasi universitas gadjah mada, yogyakarta. tikus diberi makan dan minum secara bebas atau ad-libitum. penelitian ini dilaksanakan di laboratorium hewan di jurusan keperawatan, universitas jenderal soedirman. prosedur dan protokol dari penelitian ini sudah mendapat persetujuan dari komite etik fakultas kedokteran dan ilmu-ilmu kesehatan, universitas jenderal soedirman, purwokerto. (nomor persetujuan etik adalah 007/kepk/ iii/2013) untuk menginduksi terjadinya dm, tikus disuntik secara intraperitoneal dengan menggunakan alloxan monohydrate (sigma aldrich, usa) dengan dosis 120 mg/kg berat badan. tikus diberi dua perlukaan, yaitu di bagian kanan dan kiri perut. luka di bagian kanan sebagai kelompok perlakuan, dan luka di bagian kiri sebagai kelompok kontrol. luka di kelompok perlakuan menerima perawatan standar (dibersih kan dengan nacl) dan dilakukan tindakan vakum dengan tekanan negatif sebesar 85 mmhg selama 2 jam setiap hari selama 7 hari, sedangkan luka di kelompok kontrol hanya menerima perawatan standar, tanpa diberikan perlakuan dengan menggunakan vakum. sebelum dilakukan perlukaan, rambut tikus dicukur terlebih dahulu. tikus diberi anestesi dengan ketamile, dengan dosis 25–30 mg/kg berat badan. metode perlukaan yang digunakan adalah modifi kasi dari metode yang ditemukan oleh asada (2012). setelah tikus diberikan perlukaan, luka dibersihkan dengan menggunakan normal saline 0,9%, kemudian busa poliuretane ditempelkan pada luka, setelah itu busa ditutup dengan dengan menggunakan balutan fi lm (bsn, jerman). corong dari alat vakum kemudian dipasang, kemudian corong dibalut sehingga menciptakan ruangan yang kedap udara. kemudian ujung selang pompa vakum dihubungkan dengan corong pada hari ke-7, tikus dibunuh dengan menggunakan overdosis ketamile. jaringan luka kemudian difi ksasi dengan menggunakan 10% formalin, kemudian didehidrasi pada alkohol dan xylene. kemudian jaringan dipotong dengan ketebalan 5-μm. jaringan gambar 1. komponen-komponen alat vakum. 107 modifi kasi pompa asi sebagai terapi luka bertekanan negatif (yunita sari, dkk) kemudian dideparafi n di xylene, kemudian direhidrasi di etanol, kemudian dicuci pada distilled water. kemudian irisan jaringan dilakukan pewarnaan hematoksilin dan eosin untuk menentukan kerusakan jaringan dan infl amasi. kemudian diobservasi di bawah mikroskop cahaya. hasil wou n d va c u u m ya ng d i ha sil k a n dalam penelitian ini adalah wound vacuum modifi kasi dari pompa asi yang mempunyai spesifikasi daya hisap yang bersifat terusmenerus (continue). casing/rangka kotak kecil disiapkan sebagai pelindung alat. untuk menjaga kuat arus dan tegangan yang stabil, dibuatlah adaptor dengan trafo 0,5 ampere, dan dipasang sedemikian rupa dengan posisi yang aman di dalam casing. setelah trafo tertata dengan rapi, mesin pompa asi diambil dan rangka dari pompa asi dilepas, kemudian mesin pompa asi dipasang pada rangka alat yang akan dibuat di sebelah trafo tersebut, dan dipasang baut untuk memfi ksasi. bagian input untuk menghisap pada mesin dihubungkan dengan penghubung yang dipasang pada rangka dan dipasang menjulur keluar untuk memudahkan pasang-lepas slang udara ke luka. setelah semua terpasang alat dicoba kembali. slang udara dipotong pada bagian tengah dan dipasang botol penampu ng dari botol bekas tinta printer yang sudah dibersihkan. pada bagian ujung slang dipasang diafragma dari plastik yang elastis. semua tempat sambungan di lem dengan lem plastik agar kedap udara. slang dihubungkan dengan konektor, kemudian diuji coba dengan tekanan tertentu. rangka pompa asi dimodif i kasi semenarik mungkin (gambar 4). kemudian alat diuji coba. setelah dibuat luka pada hewan coba, luka dirawat dengan perawatan standar. kemudian alat wound vacuum dipasang dan dinyalakan selama 4 jam/hari selama satu minggu. s e t i a p h a r i l u k a d i r a w a t d a n didok umentasikan (difoto) kondisi lu ka sebelum dirawat. foto kondisi luka dianalisis dan dibandingkan dari hari ke hari. hasil penggunaan alat wound vacuum menunjukkan alat bekerja optimal, tidak ada gangguan pada alat dan respon awal pada luka membaik. bagian rangka dibuat semenarik mungkin gambar 2. tikus yang sedang diberikan perlakuan dengan vakum luka gambar 3. pompa asi yang sudah dimasukan ke dalam casing. gambar 4. rangka alat vakum luka 108 jurnal ners vol. 10 no. 1 april 2015: 104–111 dengan pemasangan stiker pada bagian luar. alat ini diberi nama yusai wound vacuum. alat npwt selesai dibuat dan dilakukan uji coba pada hewan uji. saat ini, alat ini sudah mendapatkan nomor registrasi paten/haki (hak kekayaan intelektual) yaitu nomor p00201300659. gambar 6 menunjuk kan gambaran mak roskopik luka yang dirawat dengan menggunakan pompa asi (atas), dan luka yang tidak dirawat dengan menggunakan pompa asi. pada hari ke – 0 kelompok perlakuan dan kontrol menunjukkan gambaran yang sama, yaitu luka sedalam panniculus carnosus. pada hari ke ke-2, lapisan kuning atau slaf terlihat di kedua kelompok, namun terlihat lebih jelas pada kelompok kontrol. pada hari ke-4, lapisan slaf tebal menutupi permukaan luka pada kelompok kontrol, sedangkan luka pada kelompok perlakuan berwarna merah. pada hari ke -7, ukuran luka pada kelompok perlakuan lebih kecil daripada pada kelompok kontrol. di samping itu, slaf juga terlihat lebih sedikit dibanding pada kelompok kontrol. gambar 7 adalah gambaran mikroskopik hasil pewar naan dengan mengg u nakan hematoksilin dan eosin. pada tengah luka, terlihat bahwa intensitas inf lamasi lebih banyak, terlihat dengan intensitas sel pmn ( polimorphonuclear neutrophyl) yang lebih banyak di kelompok kontrol dibandingkan pada kelompok perlakuan. pada pusat luka, juga terlihat lapisan nekrotik pada yang tidak dijumpai pada kelompok perlakuan pembahasan penelit ia n i n i ad ala h mer upa ka n penelitian per tama dalam literatur yang membuat alat vakum luka bertekanan negatif dari modif ikasi pompa asi. alat yang dibuat memiliki kekuatan daya hisap dalam rentang 80 -150 mmhg. jangkauan rentang ini adalah rentang yang direkomendasikan dalam penggunaan npwt. dalam penelitian ini kami juga membuktikan bahwa vakum luka dari modifi kasi pompa asi ini mampu menurunkan infl amasi dan menurunkan slaf pada luka diabetes pada hewan coba. data makroskopis dan mikroskopis dalam penelitian ini menunjukkan bahwa gambar 5. penampakan dari depan dari yusai wound vaccuum gambar 6. gambaran makroskopis pada kelompok yang diberi perlakuan dengan pompa vakum dari modifi kasi pompa asi (atas) dan kelompok kontrol (bar = 1 cm) 109 modifi kasi pompa asi sebagai terapi luka bertekanan negatif (yunita sari, dkk) jaringan nekrotik terlihat lebih tebal pada kelompok kont rol d iba nd i ng k a n pa d a kelompok perlakuan, menunjukkan bahwa di kelompok perlakuan, eksudat lebih sedikit karena terhisap oleh alat vakum melalui selang vakum, sedangkan pada kelompok kontrol, kelebihan eksudat tidak terserap dengan baik sehingga mengakibatkan terjadinya maserasi pada daerah sekitar luka, dan jaringan nekrotik yang lebih banyak pada area pusat luka. penemuan ini sesuai dengan penelitian terdahulu yang menyatakan bahwa npwt dapat mempercepat penyembuhan luka dengan cara menarik cairan eksudat, memperbaiki sirkulasi, menarik dan membersihkan bakteri dari luka, meningkatkan proses proliferasi dan granulasi jaringan luka (morykwas, argenta, dan shelton, 1997, nain et al., 2011). dalam penelitian ini, kami memilih tekanan continues bukan tekanan yang bersifat putus-putus (intermitten). sebenarnya tekanan dengan menggunakan metode putus-putus juga dapat meningkatkan aliran darah. namun penelitian lain menyatakan bahwa tekanan yang bersifat putus-putus mengakibatkan rasa yang kurang nyaman bila dibandingkan dengan yang bersifat terus-menerus pada subjek percobaan, sehingga tekanan yang bersifat terus-menerus lebih direkomendasikan (argenta, morykwas, dan marks, 2006; morykwas, simpson, dan punger, 2006). p a d a p e n e l i t i a n i n i , p e n e l i t i menggunakan daya hisap sebesar 85 mmhg. alasan pemilihan tekanan sebesar 85 mmhg adalah sesuai dengan penelitian terdahulu yang menyatakan bahwa pemberian terapi npwt dengan pemberian tekanan antara 50 -125 m m hg m a m p u m e m p e r c e p a t penyembuhan luka dibandingkan dengan ya ng t id a k d iber i k a n per awat a n lu k a dengan menggunakan npwt (blur ne et al., 2008). penelitian lain juga menyatakan bahwa pemberian terapi luka npwt dengan tekanan 75-125 mmhg dapat mempercepat penyembuhan luka (nather et al., 2010). pada penelitian pendahuluan, peneliti ( pilot study) peneliti mencoba memberikan tekanan 125 mmhg, namun gambaran makroskopik menunjukkan bahwa terdapat sedikit edema pada luka yang diberikan tekanan 125 mmhg (data tidak dipublikasikan), sehingga peneliti menurunkan tekanan menjadi 85 mmhg. untuk dimasa yang akan datang, perlu adanya penelitian lanjutan untuk meneliti tentang efek dari npwt modifi kasi dari pompa asi dengan tekanan di bawah 125 mmhg dan di atas 85 mmhg. pada penelitian ini, tidak ditemukan adanya efek samping dalam penggunaan terapi luka vakum ini. seratus persen tikus survive ketika diberikan terapi ini. data mikroskopik d a n m a k r o skopi k ju g a me mbu k t i k a n bahwa terapi vakum ini dapat menurunkan infl amasi dan jumlah jaringan nekrotik. hal ini menunjukkan bahwa terapi vakum luka ini memungkinkan untuk diujicobakan pada gambar 7. pewarnaan hematoksilin dan eosin pada kelompok yang diberi perlakuan dengan pompa vakum dari modifi kasi pompa asi (atas) dan kelompok kontrol (magnifi kasi sama antara kelompok perlakuan dan kontrol) 110 jurnal ners vol. 10 no. 1 april 2015: 104–111 luka dm pada manusia di masa depan untuk mengetahui efektivitasnya pada penyembuhan luka diabetes pada manusia. simpulan dan saran simpulan penelit ia n i n i ad ala h mer upa ka n penelitian per tama dalam literatur yang membuat alat va k u m lu ka ber tekanan negatif dari modifikasi pompa asi. alat yang dibuat memiliki kekuatan daya hisap antara 80 –150 mmhg. jangkauan rentang ini adalah rentang yang direkomendasikan dalam penggunaan npwt. dalam penelitian ini kami juga membuktikan bahwa vakum luka dari modifi kasi pompa asi ini mampu menur unkan inf lamasi dan menur unkan jumlah jaringan nekrotik pada luka diabetes pada hewan coba. saran dalam penelitian ini, kami menguji efektivitas wound vacuum modifikasi dari pompa asi pada tekanan 85 mmhg. dimasa yang akan datang, perlu adanya penelitian lain yang menguji efektivitas alat ini pada tekanan yang lain dan pada pasien dengan luka diabetes kepustakaan a r mst rong, dg, et al., 1997. su rgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults. south med j,90, 384–389. armstrong, dg, lavery, la, and harkless. 1998. validation of a diabetic wound classifi cation system. the contribution of depth, infection, and ischemia to risk of amputation. diabetes care, 21(5), 855–859. argenta lc, morykwas mj, and marks, mw. 2006. vacuum-assisted closure: state clinic art, plast recontr surg 2006, 117 (supl): 121s-126s. asada m, et al. 2012. novel models for bacterial colonization and infection of full-thickness wounds in rats. wound repair regen. 20(4):601-610. blur ne, pa, et al. 2008. comparison of negatif pressure wound therapy using vacuum assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcer: multicenter randomized controlled trial. diabetes care 31 (4): 631–6 international diabetic foot. 2005. international working group on diabetic foot (online), (http://iwgdf.org/?option=com_cont ent&task=view&id=33&itemid=48, diakses tanggal 10 maret 2013, jam 08.00) kirkby, k a, wheeler m, jl, and farese jp., 2009. vacuum-assisted wound closure: application and mechanism of action, copendium: continuing for veterinarians, 31(12): e1-e7 morykwas, mj, argenta, lc, and shelton, be., 1997. vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. ann plast surge, 38 (6): 553–562 morykwas, mj, simpson, j, and punger, k. 2006. vacuum-assisted closure: state of basic research and physiologic foundation. plast recontr surg, 117 (suppl): 121s-126s. loot, ma, et al. 2002. fibroblasts derived from chronic diabetic ulcers differ in their response to stimulation with egf, igf-i, bfgf and pdgf-ab compared to controls. eur j cell biol, 81(3):153160. nain, ps, et.al. 2011. role of negative pressure wound therapy in healing of diabetic foot ulcers. j surg tech case rep. 3(1):17–22 nather a, et.al. 2010. effectiveness of vacuumassisted closure (vac) therapy in the healing of chronic diabetic foot ulcers. ann acad med singapore, 39(5):353–358. 111 modifi kasi pompa asi sebagai terapi luka bertekanan negatif (yunita sari, dkk) searle, r and milne j., 2010. tools to compare the cost of npwt with advanced wound care: an aid to clinical decision –making, wounds, vol. 6 no. 1. waspadji, s., 2006. komplikasi k ronik diabetes: mek anisme terjadinya, diagnosis dan strategi pengelolaan. jakarta: fk ui. who. 1994. prevention of diabetes mellitus, technical report series. 11–31. xie, x1, mcgregor, m, and dendukuri, n. 2010. the clinical effectiveness of negative pressure wound therapy: a systematic review. j wound care, 19(11): 490–5. http://e-journal.unair.ac.id/jners | 497 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20518 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review effect of leg exercise on the lower limb circulation of patients with diabetes mellitus: a systematic review ida trisnawati1, i ketut sudiana2, supriyanto supriyanto3 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 2faculty of medicine, universitas airlangga, surabaya, indonesia 3 nursing major, poltekkes kemenkes surabaya, surabaya, indonesia abstract introduction: hyperglycemia is one of the typical symptoms of patients with diabetes mellitus. this condition makes the patient very vulnerable to circulatory disorders in the lower extremities, especially in the legs. a lack of exercise of the feet can cause an increased risk of foot ulcers. this systematic review aims to systematically review the research evidence related to the effects of leg exercise on increasing the value of the anklebrachial index in patients with diabetes mellitus. methods: this study used a systematic review with the preferred reporting items for systematic reviews and meta-analysis (prisma) approach. we identified 85 articles from scopus, 34 from pubmed and 401 from proquest. the keywords used in the search were "foot exercise", "buerger allen exercise" and "diabetes mellitus". the inclusion criteria for this study were 1) interventions with a focus on the buerger allen exercise and 2) papers published in english. the deadline for publication was between 2014 and 2019. results: after going through the selection process, 8 articles were deemed to be relevant for inclusion in this systematic review. one effort to overcome the interference of lower limb circulation is through physical exercise in the form of leg exercises. the exercises that can be applied are buerger allen exercises. the simplest examination that can be done to detect any interference with lower limb circulation is to measure the value of the ankle brachial index (abi). conclusion: the advantage of this exercise is that it does not involve expensive costs and the risk of injury is low when doing exercises at home. article history received: feb 27, 2020 accepted: april 1, 2020 keywords ankle-brachial index; buerger allen exercise; diabetes mellitus; lower limb circulation contact ida trisnawati  ida.trisnawati2018@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: trisnawati,i., sudiana, i. k., supriyanto, s. (2020). effect of leg exercise on the lower limb circulation of patients with diabetes mellitus: a systematic review. jurnal ners, special issues, 497-507. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20518 introduction diabetes mellitus (dm) refers to a group of metabolic diseases with the characteristic of hyperglycemia that occurs due to abnormalities in insulin secretion, insulin action or both. hyperglycemia is a condition where there is an elevated level of glucose in the blood that exceeds normal limits. this condition is one of the typical signs of diabetes, although it may also be found in another state (perkeni, 2015). in 2015, the prevalence of diabetes in the world totals as many as 415 million people. this number is expected to increase in 2040 up to 642 million. the prevalence of dm in southeast asia may total as many as 87 million people. indonesia is one country in southeast asia where the prevalence of diabetes in 2015 amounted to 10 million people, ranked 7th in the world (idf, 2015). an increase in blood glucose that is not managed in a long time led to patients with diabetes mellitus impaired blood flow. this condition will affect the blood platelet function so then the patients are more at risk of developing peripheral arterial disease. this often affects the lower extremities, usually the feet (debra kohlman-trigoboff, ms, 2013). peripheral arterial disease is one of the causes https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ i.trisnawati et al. 498 | pissn: 1858-3598  eissn: 2502-5791 of diabetic ulcers on the feet (f. aguilar rebolledo, 2011). the prevalence of patients with diabetic ulcers on the feet around the world is around 15%. the risk of amputation is 30% and the mortality rate is 32% (idf, 2015). indonesia's health profile data based on indonesia's 2011 dm survey of those with diabetic ulcer complications was ranked 6th out of the 10 major illness of both outpatients and inpatients in the hospitals in indonesia. the mortality rate ranges from 17 23% due to ulcers. the amputation number ranges from 15 -30% and there is a 1-year mortality rate post-amputation for 14.8% of patients (kementrian kesehatan republik indonesia, 2012). the risk of lower extremity amputation is 46 times greater in patients with diabetes than those without diabetes. injuries and other problems in the feet are a major cause of illness (morbidity), disability (disability) and death (mortality) in patients with diabetes(armstrong, 1998). investigations that can be done to detect the peripheral circulatory disorder include assessing the ankle brachial index (abi). the abi examination is one of the non-invasive methods used to identify arterial insufficiency and it is recommended as a part of the assessment of individuals at risk of disease (migliacci, nasorri, ricciarini, & gresele, 2008). the abi measurement is conducted by comparing the ratio of systolic blood pressure of the foot (ankle) and the systolic blood pressure arm (brachial) (lippincott williams and wilkins, 2012). the abi examination has a sensitivity of 79% and a specificity of 96% in the diagnosis of peripheral arterial disease(hamonanganl, 2014). leg exercises are one of the activities that can be performed by patients with diabetes to prevent the occurrence of peripheral arterial disease. leg exercises that can be done include the buerger allen exercise. the buerger allen exercise is a combination of postural changes (leg elevation 45°. decreased feet. and sleeping on your back) as well as muscle pumping of the ankle which consists of two movements, namely dorsiflexion and plantarflexion (chyong-fang chang, chang, & chen, 2015). muscle pumping in the form of dorsiflexion and plantarflexion is done actively by moving the skeletal muscles actively, causing the muscles to stimulate blood vessel pressing (yollanda & widayati, 2016). muscle pumps can stimulate the endothelium to secrete or release nitric oxide (no) which will send a signal in the form of vascular smooth muscle relaxation. at the time there is smooth muscle cell relaxation in the blood vessels, the blood flow in the vasodilatation of the peripheral legs will become smooth(nurkhalis, 2014). this study aims to systematically review the research evidence related to the effect of leg exercises on increasing the value of the ankle-brachial index in patients with diabetes mellitus. materials and methods search strategy this study used a systematic review with the preferred reporting items for systematic reviews and meta-analysis (prisma) approach. the search for article sources used the scopus, pubmed, and proquest databases. the search focused on studies in english published between 2014 and 2019. the process of searching for articles was carried out from october 5th through to december 25th 2019. the keywords used in the search were "leg exercise", "buerger allen exercise" and "diabetes mellitus" to search for the relevant articles. we looked up the references in google scholar to filter the references taken into account. the broad search strategy was used to get all of the potential and relevant studies ready to review. study criteria the reviewers independently filtered the full text of the selected references without exception by title and abstract. this was to get as many articles as possible that were relevant. the inclusion criteria for this systematic review were 1) an intervention focused on the buerger allen exercise and 2) papers published in english. the selection was not limited by the methodological quality, population and yield. data extraction the reviewers extracted the data that contains information about 1) the first author, 2) the year of publication, 3) country of study, 4) the research location, 5) the time needed during the study, 6) the research sample, 7) the population characteristics used in the research, 8) the variables studied and 9) the characteristics of the intervention and the results. this was used to check the accuracy of the data extraction results. data synthesis the data synthesis contains information about the population used for the research, the applied interventions, the research designs and the research results summarized using narrative and tabular synthesis. the data limitations and the use of divergent variables in the research did not involve meta-analysis. results study search based on the results of the study search, as many as 520 potentially relevant articles were identified according to the established criteria. a total of 8 articles were systematically identified using the electronic database search and they fulfilled the inclusion criteria (figure 1). the articles identified consisted of 3 prospective control groups (lin et al., 2020)(lin et al., 2018)(chen et al., 2017), 2 jurnal ners http://e-journal.unair.ac.id/jners | 499 qualitative (huang, chang, lin, lin, & member, 2017)(chang-cheng chang et al., 2016)and 3 experimental queries (chyong-fang chang, chang, & hwang, 2015)(vijayabarathi & hemavathy, 2014)(mellisha & sc, 2016). the search articles were in the range of 2015 – 2020 for publication. to be specific, 6 articles were conducted in taiwan and 2 articles were conducted in chennai. the articles were published in english. the study was conducted in various places such as chang gung memorial hospital, chia-yi branch, among the rural chiayi county community residents and at rajiv gandhi government general hospital, chennai. study characteristics a total of 8 articles have been identified involving a total of 340 patients. the patients were divided into 3 groups including group a (no peripheral arterial disease [pad]), group b (pad without angioplasty) and group c (pad with angioplasty) (lin et al., 2020). patients without percutaneous transluminal angioplasty (pta) and those previous percutaneous experience (group a1) were paired with the previous pta patients (group a2) (lin et al., 2018). group a arterial occlusive disease (paod) with or without percutaneous transluminal angioplasty (pta) and group b non-paod (huang et al., 2017) also involved patients with unilateral or bilateral diabetic ulceration (chang-cheng chang et al., 2016)(chyongfang chang, chang, & hwang, 2015)(vijayabarathi & hemavathy, 2014)(mellisha & sc, 2016) (table 1). measurement the measurement variations from the selected studies aim to assess buerger's exercise regarding some of the physiological responses or clinical symptoms. the physiological indicator variables measured include tissue blood volume (hbt) (lin et al., 2020)(lin et al., 2018)(huang et al., 2017), oxyhemoglobin (hbo2) (lin et al., 2020)(lin et al., 2018)(chen et al., 2017), deoxyhemoglobin (hb) (lin et al., 2020)(chen et al., 2017) and tissue oxygen saturation (sto2) (lin et al., 2020)(huang et al., 2017). the indicator variables measured for the clinical symptoms include foot necrosis (in years) (lin et al., 2018), the degree of swelling, pain (wongbaker facing pain value scale, numerical pain value scale) (mellisha & sc, 2016), the abi of the foot (chyong-fang chang, chang, & hwang, 2015), promoting health behaviors (chyong-fang chang, chang, & hwang, 2015), mnsi values (chyong-fang chang, chang, & hwang, 2015) and the symptoms of foot discomfort (chyong-fang chang, chang, & hwang, 2015) (table 1). intervention characteristics some studies do not have a comparison group. all of the patients are collected and grouped according to the diagnosis of the disease. all patients were given the allen buerger exercise and the results were documented. this study aims to compare the interventions but using different participant characteristics. however, several other studies involve 2 groups, namely an intervention group and a comparison group. the study aimed to assess the benefits of the buerger allen exercise compared to the usual care. one study compared it with arterial reconstruction. the time of the intervention (period) of the selected study ranged from 5 days (mellisha & sc, 2016), 1 month (chyong-fang chang, chang, & hwang, 2015), 2 months (lin et al., 2018)(changid e n ti fi c a ti o n s c re e n in g e li g ib il it y in c lu d e d scopus (n = 85) pubmed (n = 34) proquest (n = 401) articles selected after identification (n = 43) articles selected according to the inclusion and exclusion criteria (n = 14) articles included ( n = 8 ) articles issued based on the inclusion and exclusion criteria (n = 29) articles were the same figure 1 – flowchart of the inclusion process i.trisnawati et al. 500 | pissn: 1858-3598  eissn: 2502-5791 cheng chang et al., 2016), 3 months (huang et al., 2017), 7 months (chen et al., 2017) and up to 1 year (lin et al., 2020) (table 2). the 8 studies contained an allen buerger exercise program which included intensity, duration, frequency and procedure. the exercise can be done every day (n = 6) and the intensity ranges up to 3 times a day at 4-hour intervals (8 am, 12 noon, and 4 pm) with each section repeated 3-6 times each session (mellisha & sc, 2016). the buerger allen training procedure is inconsistent within each study. for example, referring to the angle of the leg, the duration of each step and each section. discussion patients with dm are at risk of having impaired lower limb circulation, which is one of the causes of foot ulcers (f. aguilar rebolledo, 2011). this is due to the reduced sensation of local pain (neuropathy) making the patient unaware even to the point of ignoring the wounds that occur because they do not feel it. spontaneous ulcers arise often due to trauma, for example sand intruding, prickly thorns, blisters from the use of shoes, narrow sandals and hard materials. initially the ulcers are only small but then they expand. the wound will become ulcerated and produce an odor called gangrene (efa trisna & musiana, 2020). leg exercises are one form of physical exercise that focuses on the lower extremities that can be done by the diabetic patients to prevent the occurrence of peripheral arterial disease. the leg exercises that can be done include the buerger allen exercise. this exercise was first described by buerger in 1926 and it was later modified by allen in 1930(mellisha & sc, 2016)(arthur, 1928). the duration of each movement of this exercise varies according to the patient's ability in terms of application and the speed of the color change(bottomley, 2007). leg exercises actively stimulate the vascular endothelium to secrete or release nitric oxide. nitric oxide stimulates guanylate soluble cyclase (sgc) which causes an increase in the synthesis of cyclic gmp from guanosine triphosphate (gtp)(isral & sulastri, 2014). the increase in cyclic gmp will cause vascular smooth muscle relaxation. at the time of smooth muscle cell relaxation, the blood flow concerning the vasodilatation of the peripheral legs will become smooth(nurkhalis, 2014). this exercise has been used for 80 years as a strategy conducted to improve peripheral circulation (mellisha & sc, 2016)(arthur, 1928). however, little evidence has shown the effects of the buerger allen exercise on the peripheral circulation improvement or healing dfu. previous research suggests that exercise is beneficial for the patients in group a (no peripheral arterial disease [pad]). group b (pad without angioplasty) and group c (pad with angioplasty) (lin et al., 2020) involve patients without percutaneous transluminal angioplasty (pta). percutaneous previously (group a1) was found among the previous pta patients (group a2)(lin et al., 2018), which refers to the group with arterial occlusive disease (paod) with or without percutaneous transluminal angioplasty (pta). group b were non-paod(huang et al., 2017). the buerger allen exercises are an active postural exercise of the legs used to prevent peripheral vascular disease and to improve the circulation of the lower extremities(mellisha & sc, 2016). this exercise is a combination of postural changes (leg elevation 45°, decreased foot position and sleeping on your back) as well as the muscle pumping of the ankle which consists of two movements, namely dorsoflexion and plantarflexion (chyong-fang chang, chang, & hwang, 2015). this exercise should be continuously and repeatedly conducted to increase the muscle microvascular blood flow circulation(rosalesvelderrain, padilla, choe, & hargens, 2013). changes in gravity cause the emptying of the veins and an increased flow in the right atrium. this means that cardiac output can be increased (changcheng chang et al., 2016). this change will affect the distribution of fluids in the body by helping, in turn, to empty and fill the veins with blood. this can increase the rate of blood transportation through the blood vessels. ankle movements can strengthen the distal circulation due to the strength of the muscle contractions. movements in the form of dorsoflexion and plantarflexion can also help to avoid the use of the achilles’ tendon contracture or stiffness in the joints which can cause foot deformities (chang-cheng chang et al., 2016). the movement of the ankle can increase muscle strength and the ankle joints can increase the contraction of the small muscles in the calf veins, causing the pumping to increase the venous return to the heart. a contraction that occurs in the small muscles of diabetes can increase the supply of oxygenated blood and nutrients in the circulation of the patients with ulcers in the feet(piergiorgio francia, roberto anichini, alessandra de bellis, giuseppe seghieri, renzo lazzeri, ferdinando paternostro, 2015). lying in the supine position may improve the perfusion of the foot when the effect of gravity is withdrawn(chang-cheng chang et al., 2016). this method effectively improves the hemodynamic status of the patients experiencing foot problems in the lower extremities(tota kawasaki, tetsuji uemura, kiyomi matsuo, kazuyuki masumoto, yoshimi harada, takahiro chuman, 2013). the buerger allen exercise involves a variety of active movements especially in the area of the lower extremities and plantar area by applying the force of gravity. this is so then each phase of the movement must be done properly and regularly (jannaim, ridha dharmajaya, 2018). this exercise consists of several stages. (1) the patient performs exercises in the supine position. (2) the foot is lifted at an angle of 45 ° and 60 ° using a pillow for 3 minutes. elderly patients who cannot tolerate an altitude of 45 ° can elevate the feet to the maximum possible until the legs look pale(chang-cheng chang et al., 2016). (3) the patient sits on the edge of the bed with their feet jurnal ners http://e-journal.unair.ac.id/jners | 501 hanging off the bed. (4) exercising the legs using dorsoflexion and plantarflexion, and moving the legs in and out for 3 minutes. (5) the patient lying in the supine position with a blanket for 3 minutes(lin et al., 2020). the whole training cycle is repeated 3 to 6 times each session and each session is repeated at least 3 times a day [18]. the indications of the buerger allen exercise include: 1) patients with type 2 diabetes mellitus both male and female; 2) age over 35 years; 3) patients with diabetes mellitus have a low risk of diabetic foot ulcers (class 0-1 according to the wagner classification system); 4) no people who have diabetes mellitus with foot ulcers and gangrene which chronicles 5) people who do not have neurological diseases and poor cardiology (vijayabarathi & hemavathy, 2014). contraindications in the clients who have a change of physiological function such as dyspnea or chest pain, depression, worry or anxiety, the patients whose activity of daily living (adl) is poor or dependent and the patients with foot wounds who are a diabetic who are not able to perform a range of motion (rom ) actively or independently were excluded(chyong-fang chang, chang, & chen, 2015). impaired blood flow in the legs can be detected by measuring the ankle-brachial index (abi). abi is a diagnostic examination procedure of the lower extremity circulation in order to detect the presence of peripheral artery disease (pad) by comparing the highest systolic blood pressure of the ankle and the arm(ruth bryant, 2006). this check is done by measuring the blood pressure in the ankle region (foot) and in the brachial (arm) region. this requires a doppler probe(hamonanganl, 2014). abi has high sensitivity and it is both specific and accurate for lead diagnosis (hirsch et al., 2005)(grenon, gagnon, & hsiang, 2013). the tools used to examine the abi include a doppler probe and pressure cuff sphygmomanometer in order to measure systolic pressure and the ankle pressure (claudia rumwell, 2009)(grenon et al., 2013). the extremity systolic pressure measurement and the calculation of abi is a standard non-invasive assessment of the severity of the vasculopathy of the lower limbs. however, arterial stiffness-associated medial calcifications may interfere with the ankle pressure measurement(brooks et al., 2001)(tsai, tulsyan, jones, castronuovo, & carter, 2000)(quigley, faris, & duncan, 1991). in patients with circulatory disorders of the foot, it will be found that the limb blood pressure is lower than the arm blood pressure, which can be seen from the abi score(pessinaba et al., 2012). the abnormal condition can be obtained when the abi value is between 0.41 and 0.90, which indicates that there is a high risk of injury in the leg and that the patients will need follow-up treatment. an abi <0.4 indicates a necrotic foot, gangrene, ulcers and ulcers that need multi-disciplinary treatment(papdi, 2007). the low value of the abi score shows that the patient is at risk of foot ulcers. ulcers affect the severity of the condition of the patient (kristiani et al., n.d.). delays in early diagnosis can increase the risk of serious complications including disability and amputation (james f. mckinsey, 2012). the different stages of the exercise involve various joint movements or stretches that can increase the blood flow to the lower extremities in order to prevent peripheral arterial disease (kevser bayraktar, benjamin a lipsky , bulent m ertugrul, 2015). these exercises are easy to learn and they can be done at home via media images, a video or a live demonstration (chang-cheng chang et al., 2016). the exercises are easy to teach which will enhance the independence of the patient when performing physical exercises and resolving any complaints that may arise from dm(sandra pebrianti, 2017). this exercise does not incur a high cost and the physical activity has a lower risk of injury. the majority of diabetic patients can thus do the exercise at home. this systematic review is an attempt to synthesize the evidence showing that the buerger allen exercise can improve the circulation of the lower extremities. the studies reviewed varied including the participants, interventions, samples, methods, measurements and outcomes. the limitation of this systematic review is that the results may be biased by only displaying publications in english. studies in other languages may be missed as a result. several research articles show that many diabetes mellitus patients suffer from diabetic foot ulcers, thus they are at risk of amputation. diabetes treatment through foot exercises such as the buerger exercise will benefit the diabetic patients who have peripheral circulatory insufficiency characterized by a ankle-brachial index <0.9 or a michigan neuropathy screening index > 2. thus it is necessary to research the effects of the buerger exercise on peripheral disorders related to diabetes mellitus through evidence-based studies. conclusion some of the studies chosen did not exclusively focus on diabetes mellitus patients with ulcers. in this review, the buerger exercise can be beneficial for pad patients, for pad patients without angioplasty and for the pad patients without percutaneous transluminal angioplasty (pta). this includes previous percutaneous pta before arterial occlusive disease (paod) with or without percutaneous transluminal angioplasty (pta) and non-paod patients with unilateral or bilateral diabetic ulceration. although this study involved methodological limitations, we have tried to gather evidence supporting the benefits of the buerger-allen exercise. references armstrong, d. g. (1998). innovations in diabetic foot care : prevention , education and treatment. treatment strategies, (august 2014). i.trisnawati et al. 502 | pissn: 1858-3598  eissn: 2502-5791 arthur, a. w. (1928). recent advances in the treatment of circulatory disturbances of the extremities. 931–946. bottomley, j. m. (2007). the insensitive foot in u.k. geriatric rehabilitation (2nd ed cha). new york: elsevier. brooks, b., dean, r., patel, s., wu, b., molyneaux, l., & yue, d. k. (2001). tbi or not tbi : that is the question. is it better to measure toe pressure than ankle pressure in diabetic patients ? diabetic medicine, 528–532. chang, chang-cheng, chen, m., shen, j., lin, y. bin, hsu, w., & lin, b. (2016). a quantitative real-time assessment of buerger exercise on dorsal foot peripheral skin circulation in patients with diabetes foot. medicine, 1–5. chang, chyong-fang, chang, c., & chen, m. (2015). effect of buerger ’ s exercises on improving peripheral circulation : a systematic review. (february), 120–128. chang, chyong-fang, chang, m. s. n. c., & hwang, s. (2015). effects of buerger exercise combined health-promoting program on peripheral neurovasculopathy among community residents at high risk for diabetic foot ulceration. 145–153. chen, m., lin, b., su, c., lin, y., chen, m., shen, j., & chang, c. (2017). the application of wireless near infrared spectroscopy on detecting peripheral circulation in patients with diabetes foot ulcer when doing buerger ’ s exercise. (91), 1–6. https://doi.org/10.1002/lsm.22667 claudia rumwell, m. m. (2009). vascular technology: an illustrated review, fourth edition (4th ed.). pasadena: davies inc. debra kohlman-trigoboff, ms, a.-b. (2013). management of lower extremity the latest guidelines for nurse. tjnp: the journal for nurse practitioners, 9(10), 653–660. https://doi.org/10.1016/j.nurpra.2013.08.026 efa trisna & musiana. (2020). pengaruh senam kaki terhadap kadar glukosa darah dan nilai abi penderita dm. jurnal kesehatan, 9(november 2018), 439–444. f. aguilar rebolledo, j. m. t. s. and j. e. de la p. (2011). the pathogenesis of the diabetic foot ulcer : prevention and management. global perspective on diabetic foot ulcerations. grenon, s. m., gagnon, j., & hsiang, y. (2013). ankle – brachial index for assessment of peripheral arterial disease. 40(1), 19–21. hamonanganl, a. (2014). buku ajar ilmu penyakit dalam (jilid ii e; s. setiati, ed.). jakarta: interna publishing. hirsch, a. t., haskal, z. j., hertzer, n. r., bakal, c. w., creager, m. a., halperin, j. l., … riegel, b. (2005). acc / aha practice guidelines acc / aha 2005 practice guidelines for the management of patients with peripheral arterial disease ( lower extremity , renal , mesenteric , and abdominal aortic ) a collaborative report from the american association for vascular surgery / society for vascular surgery ,* society for cardiovascular angiography and interventions , society for vascular medicine and biology , society of interventional radiology , and the acc / aha task force on practice guidelines ( writing committee to develop guidelines for the management of patients with peripheral arterial disease ) endorsed by the american association of cardiovascular and pulmonary rehabilitation ; https://doi.org/10.1161/circulationaha.106. 174526 huang, y., chang, c., lin, p., lin, b., & member, s. (2017). quantitative evaluation of rehabilitation effect on peripheral circulation of diabetic foot. 2194(c), 1–7. https://doi.org/10.1109/jbhi.2017.2726540 idf. (2015). idf diabetes atlas. isral, g. n., & sulastri, d. (2014). hubungan aktivitas fisik dengan kadar nitric oxide ( no ) plasma pada masyarakat di kota padang. 3(2), 173–177. james f. mckinsey, g. v. s. (2012). diabetes and peripheral vascular disease (g. v. s. james f. mckinsey, ed.). jannaim, ridha dharmajaya, a. (2018). pengaruh buerger allen exercise terhadap sirkulasi ekstremitas bawah pada pasien luka kaki diabetik. jurnal keperawatan indonesia, 21(2), 101–108. https://doi.org/10.7454/jki.v21i2.652 kementrian kesehatan republik indonesia. (2012). profil kesehatan indonesia (m. drg.titi aryati soenardi, mkes iskandar zulkarnain, skm, mkes drg. vensya sitohang, m.epid boga hardana, s.si, ed.). jakarta: kementrian kesehatan republik indonesia. kevser bayraktar, benjamin a lipsky , bulent m ertugrul, y. t. (2015). does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers? world journal of experimental medicine, 5(2), 130–140. https://doi.org/10.5493/wjem.v5.i2.130 kristiani, a. l., sumangkut, r. m., limpeleh, h. p., bedah, b., bagian, s., vaskuler, b., & prof, r. (n.d.). hubungan ankle brachial index dengan keparahan ulkus pada penderita kaki diabetik. (dm), 171–177. lin, b., chang, c., su, c., li, j., chen, m., & chen, m. (2018). the assessment of buerger ’ s exercise on dorsal foot skin circulation in patients with vasculopathic diabetic foot ulcer by using wireless near-infrared spectroscope : a cohort prospective study. lin, b., chang, c., tseng, y., li, j., peng, y., & huang, y. (2020). using wireless near-infrared spectroscopy to predict wound prognosis in diabetic foot ulcers. (january). https://doi.org/10.1097/01.asw.0000613552.5 0065.d5 lippincott williams and wilkins. (2012). ankle brachial index quick reference guide for clinicians. j wound ostomy continence nurs., jurnal ners http://e-journal.unair.ac.id/jners | 503 39(april), 21–29. https://doi.org/10.1097/won.0b013e3182478d de mellisha, m. s. e. s., & sc, m. n. (2016). effectiveness of buerger allen exercise on lower extremity perfusion and pain among patients with type 2 diabetes mellitus in selected hospitals in chennai. 5(7), 1822–1826. migliacci, r., nasorri, r., ricciarini, p., & gresele, p. (2008). ankle – brachial index measured by palpation for the diagnosis of peripheral arterial disease. (november 2007), 228–232. https://doi.org/10.1093/fampra/cmn035 nurkhalis, a. p. (2014). pengaruh latihan fisik terhadap fungsi endotel. 109–118. papdi. (2007). buku ajar ilmu penyakit dalam (iv). jakarta: pusat penerbitan departemen ilmu penyakit dalam, fkui. perkeni, p. (2015). pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. pessinaba, s., mbaye, a., kane, a., guene, b. d., ndour, m. m., niang, k., … kane, a. (2012). dépistage de l ’ artériopathie oblitérante asymptomatique des membres inférieurs par la mesure de l ’ index de pression systolique dans la population générale de saint-louis ( sénégal ) ଝ screening for asymptomatic peripheral arterial occlusive disease of the. journal des maladies vasculaires, 37(4), 195–200. https://doi.org/10.1016/j.jmv.2012.05.003 piergiorgio francia, roberto anichini, alessandra de bellis, giuseppe seghieri, renzo lazzeri, ferdinando paternostro, m. g. (2015). diabetic foot prevention: the role of exercise therapy in the treatment of limited joint mobility, muscle weakness and reduced gait speed. italian journal of anatomy and embryology, 21–32. https://doi.org/10.13128/ijae-16470 quigley, f. g., faris, i. b., & duncan, h. j. (1991). a comparison of doppler ankle pressures and skin perfusion pressure in subjects with and without diabetes. clinical physiology, 21–25. rosales-velderrain, a., padilla, m., choe, c. h., & hargens, a. r. (2013). increased microvascular flow and foot sensation with mild continuous external compression. 1(2000), 1–6. https://doi.org/10.1002/phy2.157 ruth bryant, d. n. (2006). acute & chronic wounds: current management concepts (3rd editio). mosby. sandra pebrianti. (2017). buerger allen exercise dan ankle brachial index ( abi ) pada pasien ulkus kaki diabetik di rsu dr . slamet garut. indonesian journal of nursing science and practice, 94–110. tota kawasaki, tetsuji uemura, kiyomi matsuo, kazuyuki masumoto, yoshimi harada, takahiro chuman, t. m. (2013). the effect of different positions on lower limbs skin perfusion pressure. 46(3), 508–513. https://doi.org/10.4103/09700358.121995 tsai, f. w., tulsyan, n., jones, d. n., castronuovo, j. j., & carter, s. a. (2000). skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia. journal of vascular surgery, 32–36. https://doi.org/10.1067/mva.2000.107310 vijayabarathi, m., & hemavathy, v. (2014). buerger allen exercise for type 2 diabetes mellitus foot ulcer patients. 3(12), 17972–17976. https://doi.org/10.15680/ijirset.2014.031209 6 yollanda, a., & widayati, n. (2016). pengaruh therapeutic exercise walking terhadap sirkulasi darah perifer pada pasien diabetes melitus tipe 2 di kelurahan gebang kecamatan patrang kabupaten jember . circulation in patients with type 2 diabetes mellitus at gebang village of patrang sub-district jember regency ). 4(3). i.trisnawati et al. 504 | pissn: 1858-3598  eissn: 2502-5791 appendix table 1.characteristics of the main results no. author and title country, study design, setting and sample size design outcomes result 1 wireless using near-infrared spectroscopy to predict wound prognosis in diabetic foot ulcers (lin et al., 2020) taiwan. n = 50 patients were divided into 3 groups. group a (no peripheral arterial disease [pad]), group b (pad without angioplasty), and group c (pad with angioplasty). prospective control group tissue blood volume (hbt), oxyhemoglobin (hbo2), deoxyhemoglobin (hb) and tissue oxygen saturation (sto2). nirs may prove valuable for predicting wound healing by identifying the risk factors for poor injury prognosis such as decreased hemoglobin and blood volume tissue after exercise. 2 the assessment of buerger's exercise on the dorsal foot skin vasculopathy circulation in patients with diabetic foot ulcers by using wireless nearinfrared spectroscope: a prospective cohort study (lin et al., 2018) taiwan. n = 14 patients were divided into 2 subgroups: 8 patients without percutaneous transluminal angioplasty (pta) and a previous percutaneous experince (group a1) and 6 patients previously pta (group a2). prospective control group the condition of the injured patients, follow-up time and the concentration of hbo2 and total hemoglobin (hbt). hbo2 and hbt concentration increased significantly after the rehabilitation program consisting of sports training in group a (p = 0.024 in hbo2, in the hbt p = 0.02, n = 14) and group a2 (p = 0.021 in hbo2, p = 0.028 in the hbt, n = 6). the concentration in the a1 group had a significance limit that increased after exercise (p = 0.055 in hbo2, in the hbt p = 0.058, n = 8). most of the ulcers were completely healed (11/14 = 78.57%) or improve (3/14 = 21.43%). 3 quantitative evaluation of rehabilitation effect on peripheral circulation of diabetic foot (huang et al., 2017) taiwan. n = 30 patients were classified into 2 groups, namely group a with arterial occlusive disease (paod) with or without percutaneous transluminal angioplasty (pta) and group b with no paod. quantitative the concentration of total hemoglobin (hbt) and the relative and tissue oxygen saturation (sto2) the results showed that the relative concentrations of hbt and sto2 following the different groups are significant. besides, using rbfnn with the input of the relative concentrations of hbt and sto2 can effectively distinguish between the healthy group and diabetic group. 4 the application of wireless near infrared spectroscopy on detecting peripheral circulation in patients with diabetic foot ulcer when doing buerger's exercise (chen et al., 2017) taiwan. n = 30 patients with diabetic foot ulcers (dfu) were treated in the wound care center. they were divided into 2 subgroups based on duplex ultrasound or angiography. patients with dfu (group a) were enrolled in the study: 9 patients were in group a1 and 21 patients were in group a2. prospective control group peripheral hbo2 and hb total circulation in patients with diabetic foot ulcers. hbo2 concentration increased in the postexercise phase for all groups (p¼0.006 in group a1, p¼0.223 in group a2, p¼0.03 in group b). however, there are significant differences both before and after the exercise phase (p¼0.001 and p¼0.01, respectively) between groups a and b. 5 a quantitative realtime assessment of buerger exercise on foot dorsal skin peripheral circulation in patients with diabetic foot (chang-cheng chang et al., 2016) taiwan. n = 30 patients with unilateral or bilateral diabetic ulceration at chang gung memorial hospital, chia-yi branch quantitative spp real-time measurement the buerger-allen exercise significantly increased the level of tuition by more than 10 mm hg (n = 46, 58.3 vs 70.0mmhg, p <0.001). 6 combined effects of buerger exercise taiwan. n = 66. patients with type 2 diabetes in the rural quasiexperimental abi of the foot and promoting healthy after 12 months, the same number of participants (n = jurnal ners http://e-journal.unair.ac.id/jners | 505 program on healthpromoting peripheral neurovasculopathy among community residents at high risk for diabetic foot ulceration (chyong-fang chang, chang, & hwang, 2015) community who were residents chiayi county. one-group pretestposttest behaviors, values mnsi and the symptoms of leg discomfort. 25, 80.6%) reported a reduction in their discomfort. 7 buerger allen exercise for type 2 diabetes mellitus foot ulcer patients (vijayabarathi & hemavathy, 2014) n = 60. type 2 diabetes mellitus patients with foot ulcers in the government general hospital rajiv gandhi, chennai. quasiexperiment pre-assessment was done using the wagner wound assessment scale and the characteristics of the foot ulcer wounds had been previously assessed with the aid of a wound assessment examination in both the experimental group and the control on the first day. on average in the experimental group, the patients with diabetes showed a 24.6% improvement in wound healing whereas the control group, on average, showed that the patients with diabetes had wound healing only up to 5.3%. 8 effectiveness of buerger allen exercise on lower extremity perfusion and pain among patients with type 2 diabetes mellitus in selected hospitals in chennai (mellisha & sc, 2016) n = 60. type 2 diabetes mellitus patients with foot ulcers in the government general hospital rajiv gandhi, chennai. quasiexperiment the level of pain and lower limb perfusion the comparison of the pre and post-test findings showed that in the experimental group, the average score of lower extremity pain level was reduced from 4.33 to 1.30. pain reduction showed a statistically significant difference at the 1% level of significance (p = 0.001). the average score of the lower limb perfusion level increased from 44.50 to 52. this i shows a statistically significant difference at a significance level of 1% (p = 0.001). table 2 characteristics of the buerger-allen exercise no. author and title length angle / degree intensity / frequency procedure and duration 1 wireless using near-infrared spectroscopy to predict wound prognosis in diabetic foot ulcers (lin et al., 2020) 1 year 45 ° and 60 ° every movement in the buergerallen exercise is carried out for 3 minutes. first, the patients do exercises in the supine position. then their feet are raised between 45 ° and 60 °, supported by pillows for 3 minutes. in the third stage, the patient sits on the edge of the bed with their legs hanging off the bed. in the fourth phase, the patients perform leg exercises with alternate dorsiflexion and plantarflexion positions. they then move their legs in and out for 3 minutes. at the end of the fifth stage of the exercise, the patient lies in the supine position with a blanket for 3 minutes. i.trisnawati et al. 506 | pissn: 1858-3598  eissn: 2502-5791 2 the assessment of buerger's exercise on the dorsal foot skin vasculopathy circulation in patients with diabetic foot ulcers by using wireless near-infrared spectroscope: a prospective cohort study (lin et al., 2018) 8 weeks 45 ° 60 ° 3 times a day at home for at least 8 weeks the buerger-allen exercise contains 3 steps and 5 phases (phase 1: the supine position; stage 2: elevating the foot at 45 ° 60 ° is supported by the object for 3 minutes; stage 3: sitting on the edge of the bed with legs dangling; stage 4: repeat feet flexion/extension and then pronation/supination for 3 minutes; stage 5: lieing on the back and resting the feet on a warm blanket for 5 minutes). 3 quantitative evaluation of rehabilitation effect on peripheral circulation of diabetic foot (huang et al., 2017) 3 months 45 ° 60 ° every movement in the buerger allen exercise was carried out for 3 minutes. there are three steps to the buerger allen exercises. the patients start from a the supine position with their feet elevated at 45 ° 60 °. second, they perform leg exercises with dorsiflexion and plantar flexion, and move their legs in and out, lasting for 3 minutes in a sitting position. the final step is to lie down. 4 the application of wireless near infrared spectroscopy on detecting peripheral circulation in patients with diabetic foot ulcer when doing buerger's exercise (chen et al., 2017) january to august 2015 45 ° 60 ° every movement involved in the buerger allen exercises is carried out for 3 minutes. all of the participants were taught to do the buerger – allen exercises by trained research assistants. the subjects started in a supine position in the beginning (pre-exercise) followed by foot elevation at 45 ° 60 ° using a support cushion for 3 minutes in the second stage. in the third phase, the participants sat down at the end of the bed with the lower legs hanging down and then they do dorsiand plantar-flexion along with a movement in and out for 3 minutes. 5 a quantitative realtime assessment of buerger exercise on foot dorsal skin peripheral circulation in patients with diabetic foot (chang-cheng chang et al., 2016) october 2012 to december 2013 45 ° every movement in the buerger allen exercise is carried out for 3 minutes. the buerger allen exercises were taught to the patients in the clinic. first, the lower extremities are elevated to an angle of 45 ° and they are supported in this position until the skin becomes pale. second, the patient sits in a relaxed position with the legs and feet resting below the level of the remaining body parts. they conduct flexion/extension exercises and then individual foot pronation/supination for 3 minutes until redness appears. finally, the patient lays still for 5 minutes with both feet placed on the bed with a warm blanket for a few minutes. 6 combined effects of buerger exercise program on healthpromoting peripheral neurovasculopathy among community residents at high risk for diabetic foot ulceration (chyong-fang chang, chang, & hwang, 2015) march 2012 to april 2013 45 ° 60 ° the whole training cycle was repeated 3 to 6 times each session. each session was repeated at least 3 times a day. if diligently followed, this regime will result in a total exercise time > 81 (3 × 3 × the three steps for the buerger exercises are based on the previous interventions (allen, 1930; bottomley, 2007): the patient (a) maintains a supine position with both legs elevated at 45 ° 60 °, supported by pillows, the table or wall for 3 minutes; (b) sits on the edge of a bed or chair with the legs hanging down doing exercises involving dorsiflexion and plantar flexion position, moving the feet inward and outward, and then flexing and extending toes for 3 minutes; and (c) lays on his back for 3 jurnal ners http://e-journal.unair.ac.id/jners | 507 3 × 3) minutes per day. minutes. if at any time the patient feels discomfort (i.e., blanched), stopping the exercise or changing position is an option. 7 buerger allen exercise for type 2 diabetes mellitus foot ulcer patients (vijayabarathi & hemavathy, 2014) 15 days rate cuts are done every fifth day during the intervention period. post-foot ulcer wound assessment was carried out using the same checklist on the fifteenth day. pre-wound assessment was done by using a rating scale and the characteristics of the foot ulcer wounds were assessed on the first day. the control group received routine care. rate cuts were done every fifth day during the intervention period. 8 effectiveness of buerger allen exercise on lower extremity perfusion and pain among patients with type 2 diabetes mellitus in selected hospitals in chennai (mellisha & sc, 2016) 5 days exercise done for 3 times a day at intervals of 4 hours (8 am, 12 noon and 4 pm) for 5 days under the supervision of the investigators. for the experimental group, the researchers were shown the buerger allen exercises and they were asked to exercise 3 times a day at intervals of 4 hours (8 am, 12 noon and 4 pm) for 5 days under the supervision of investigators. 436 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19784 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research analysis of accuracy nursing care process implementation tejo trisno, nursalam nursalam, mira triharini faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: implementation of the nursing care process is still a problem in nursing services. the problem found in the nursing process is the accuracy of nurses in applying the nursing care process. the aim of this study to analyze the accuracy of the implementation of the nursing care process. methods: this study was as a descriptive analytics design with 100 respondents. samples were selected using cluster sampling. data were collected using a questionnaire that has been tested for validity and reliability. the variables included assessment, nursing diagnosis, nursing plan, nursing implementation, evaluation, and nursing documentation. data were analyzed in a descriptive form consisting of good, sufficient and fewer categories. the standard for implementing the accuracy of the nursing process is 100%. results: the result showed the accuracy of implementation nursing care, namely 64% assessments are sufficient, 69% of nursing diagnosis is sufficient, 59% of nursing plans are sufficient, 66% of nursing implementation is sufficient (), along with 60% of nursing care evaluation and 62% of nursing care documentation. conclusion: the accuracy of the nursing care process describes the quality and patient safety and is useful for patients, nurses, and the health team. further studies must be conducted to analyze factors related to accuracy of the implementation of the nursing care process. article history received: feb 27, 2020 accepted: april 1, 2020 keywords nursing care process; accuracy; implementation contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: trisno, i.,nursalam, n., & triharini, m. (2020). analysis of accuracy nursing care process implementation. jurnal ners, special issues, 436-439. doi: http://dx.doi.org/10.20473/jn.v15i2.19784 introduction nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse (tasew, mariye and teklay, 2019). documentation is an authentic record in the application of management of professional nursing care. professional nurses are expected to be able to face the demands of responsibility and accountability for all actions taken. public awareness of the law is increasing so that complete and clear documentation is needed (nursalam, 2014). nursing documentation is the principal clinical information source to meet legal and professional requirements. nursing documentation is evidence of recording and reporting of nurses is useful for the benefit of clients, nurses and healthcare team in providing health services with accurate and complete data written as a nurse's responsibility (pakudek, robot and hamel, 2017). nursing documentation is on the priority list in conducting quality nursing care. nurses in indonesia have been taught to prepare appropriate nursing records during their education. this is reemphasized again during their clinical training. on the other hand, despite the availability of evidence on the impact of insufficient documentation of patient care, nursing documentation problems in this context exist. recent national publications have clearly stated that nursing documentation in a number of hospitals in indonesia is far from ideal (kamil, rachmah and wardani, 2018). hence, the quality of nursing documentation in indonesia is still questionable. it can be seen from previous research conducted by sabila (2009) that, of 300 samples of medical records of nursing documentation, 69.3% were in the incomplete category as well as only 41.3% of nursing https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nursalam@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2.19784 jurnal ners http://e-journal.unair.ac.id/jners | 437 documentation in emergency ward were in good category. in addition, purwanti (2012) found that the percentage of complete nursing documentation was only 63% as well as the diagnosis and nursing care plan was only complete for 61%, and implementation and evaluation was only 75% (ahsan* and , ardhiles wahyu, elvira sari dewi, 2018). incomplete nursing documentation indicates that the nursing care process is not working properly and continuously. nursing documentation according to the standard of nursing language (standardized nursing language) is still a problem in the nursing profession, especially the uniformity in the use of diagnostic languages and nursing interventions. an instrument is needed to produce good diagnosis and intervention documentation (diana rachmania*, nursalam*, no date). the use of standardized nursing languages helps nurses understand patients’ needs with precision and speed. this study assesses the knowledge of standardized nursing languages (snl); how nurses perceive and utilize snl. materials and methods the study used descriptive research designs in order to systematically describe events and emphasize factual data rather than conclusions. this research was conducted from january to march 2020 in a private hospital in east java. this research was conducted by observing and interviewing 100 primary nurses in documenting nursing care in the medical record sheets obtained in total sampling. the inclusion criteria in this study were: 1) primary nurses who worked for more than two (2) years, 2) worked in the inpatient room, 3) nurse education. meanwhile, the exclusion criterion in this study was primary nurses who did not work in the inpatient unit. participants were recruited using cluster sampling technique. data was collected using 5sectioned selfstructured questionnaires whose validity and reliability had been previously ascertained (olatubi et al., 2018). the study assessed the documentation of nursing care before, during and after the standardized nursing language continuing education program (snlcep). it evaluated the differences in documentation of nursing care in different nursing specialty areas and assessed the influence of work experience on the quality of documentation of nursing care with a view to provide information on documentation of nursing care. the instrument used was an adapted scoring guide for nursing diagnosis, nursing intervention and nursing outcome (q-dio) (adubi, olaogun and adejumo, 2018). statistical tests inform the results of validity and reliability by cronbach's alpha on the appropriateness of nursing care assessments, nursing table 1. distribution of variables in the personal analysis of accuracy nursing care process implementation (n=100) characteristics of respondents n % gender male 33 33 female 67 67 age 21-25 years old 27 27 26-30 years old 64 64 31-35 year old 8 8 36-40 year old 1 1 education bachelor in nursing 100 100 length of working 2-5 years 79 79 6-10 years 19 19 11-15 years 1 1 > 15 years old 1 1 quality and safety training ever 77 77 never 23 23 table 2. distribution of variables in the personal analysis of accuracy of nursing care process implementation (n = 100) indicator categories total good enough less assessment 10 64 26 100 nursing diagnoses 6 69 25 100 planning/intervention 14 59 27 100 implementation 10 66 24 100 evaluation 10 60 30 100 nursing documentation 10 62 28 100 t. trisno et al. 438 | pissn: 1858-3598  eissn: 2502-5791 diagnoses, interventions, implementation, evaluation and documentation of nursing averaged results of 0.727 and results on the implementation of the highest values of 0.863, interventions of 0.784, and evaluations of 0.736. data obtained through observation sheets were carried out by researchers on the sheet of nursing care instruments in the patient's medical record. this observation sheet to evaluate nursing care instruments includes nursing assessment, nursing diagnosis, nursing planning/intervention, implementing nursing actions, nursing evaluation and nursing documentation. this research protocol was declared to have passed an ethics test by the health research ethics commission of the faculty of nursing, universitas airlangga with certificate number no: 19922-kekp on february 24, 2020 results table 1 informs about the characteristics of respondents in terms of age, sex, length of work, and education of nurses who work in inpatients in private hospitals. it is shown that the majority of nurses are aged 26-30 years (64%), most were women (67%), most had been working for 2-5 years (79%), and all nurses had educational background as bachelor in nursing (100%). table 2 shows the evaluation of implementation of nursing assessment, diagnosis, nursing care plan, implementation, evaluation and documentation. poor performance is shown in the less category, which are in the top three and including nursing evaluation (30%), then followed by nursing documentation (28%) and nursing care plan/intervention (27%). discussion evaluation of the implementation of the accuracy of nursing care standards in private hospitals in east java was measured using an observation sheet based on diagnosis standards, outcome standards and intervention standards as well as implementation and evaluation that have been determined by the indonesian national nurses association (inna or known as ppni). the accuracy of nursing care based on the standard of ppni is mostly moderate (69%), with 59% adequate nursing plan, 66% adequate nursing implementation and 60% evaluation of nursing care and 62% documentation of nursing care. the standard for applying accuracy to the nursing process is 100%. law no. 38 of 2014 concerning nursing emphasizes that nursing practice must be based on a code of ethics, service standards, professional standards, and operational procedure standards. on 29 december, 2016, ppni established nursing care standards by publishing the indonesian nursing diagnosis standards book (sdki), then continuing with the issuance of the indonesian nursing output standards (slki) and the indonesian nursing intervention standards (siki). standardization of nurse care is very important in improving the quality of nursing services in the current health era and the use of standardized standards is very necessary to improve services to patients. nursing care standards developed by the indonesian nurse profession organization (ppni) include indonesian nursing diagnosis standards, indonesian nursing intervention standards, and indonesian nursing output standards. conclusion based on the results of research and discussion, it can be concluded that the accuracy of nursing care is the competence of nurses in providing quality services. in implementing the nursing care standards for the idhs, siki and slki, they must comply with the guidelines for nursing care. conflict of interest no conflict of interest has been declared. acknowledgement acknowledgments to all research respondents and nursing leaders who were willing to take the time, energy, and provide information support to complete this research data. references adubi, i. o., olaogun, a. a. and adejumo, p. o. (2018) ‘effect of standardized nursing language continuing education programme on nurses’ documentation of care at university college hospital, ibadan’, nursing open, 5(1), pp. 37–44. doi: 10.1002/nop2.108. ahsan* and , ardhiles wahyu, elvira sari dewi, s. (2018) ‘analysis of nursing behavior factors in documentation of nursing care in emergency unit using theory of planned behavior’, international journal of indonesian national nurses association (ijinna), 1(1), pp. 64–79. doi: 10.32944/ijinna.v1i1.20. diana rachmania*, nursalam*, e. y. (no date) ‘pengembangan instrumen diagnosis & intervensi keperawatan berbasis standardized nursing language ( nanda-i , noc , nic ) ( development of nursing diagnosis & intervention instrument based on standardized nursing language ( nanda-i , noc , nic )) diana rac’, pp. 157–164. kamil, h., rachmah, r. and wardani, e. (2018) ‘what is the problem with nursing documentation? perspective of indonesian nurses’, international journal of africa nursing sciences. doi: 10.1016/j.ijans.2018.09.002. nursalam (2014) ‘manajemen keperawatan aplikasi keperawatan profesional edisi 4’, p. 342. olatubi, m. i. et al. (2018) ‘among nurses in three selected hospitals in’, (january), pp. 0–6. doi: 10.1111/2047-3095.12197. pakudek, k. h, robot, f. j. . and hamel, r. s. (2017) ‘dokumentasi asuhan keperawatan di instalasi rawat inap’, ejurnal keperawatan, 2(2), pp. 1–7. jurnal ners http://e-journal.unair.ac.id/jners | 439 tasew, h., mariye, t. and teklay, g. (2019) ‘nursing documentation practice and associated factors among nurses in public hospitals, tigray, ethiopia’, bmc research notes. biomed central, 12(1), pp. 1–6. doi: 10.1186/s13104-019-4661-x. http://e-journal.unair.ac.id/jners 25 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 25-30 http://dx.doi.org/10.20473/jn.v17i1.27744 original article open access anemia prevention behavior in female adolescents and related factors based on theory of planned behavior: a cross-sectional study halfie zaqiyah gusti puspitasari 1 , ni ketut alit armini 2,* , retnayu pradanie 2 , mira triharini 3 1 professional nursing program, faculty of nursing, universitas airlangga, surabaya, indonesia 2 basic nursing department, faculty of nursing, universitas airlangga, surabaya, indonesia 3 advanced nursing department, faculty of nursing, universitas airlangga, surabaya, indonesia *correspondence: ni ketut alit armini. address: unair campus c, mulyorejo, surabaya, east java, 60115, indonesia, email: nk.alita@fkp.unair.ac.id responsible editor: praba diyan rachmawati received: 6 july 2021 ○ revised: 15 april 2022 ○ accepted: 15 april 2022 abstract introduction: female adolescent is a group prone to iron deficiency anemia due to various factors such as having monthly menstruation and poor diet. therefore, anemia prevention behavior needs to be done from an early age to avoid prolonged health problems. the purpose of this study was to analyze the factors that correlated with anemia prevention behavior in female adolescents based on the theory of planned behavior. methods: this study used a descriptive correlational design with a cross-sectional approach. the population of this study is female adolescents in madiun city. purposive sampling was used to obtain 105 respondents. the instrument used was a questionnaire to measure the variables attitude, subjective norm, perceived beh avioral control, intention, and anemia prevention behavior. data analysis was performed using the spearman rho test with a level of significance ≤ 0.05. results: there is a relationship between attitudes (p = 0.003; r = 0.292), subjective norms (p = 0.006; r = 0.266), and perceived behavioral control (p = 0.002; r = 0.299) with the intention to prevent anemia and also perceived behavioral control (p = 0.003; r = 0.292) and intention (p = 0.000; r = 0.392) with anemia prevention behavior. conclusions: better attitude, subjective norm, perceived behavioral control, and intention possessed by a female adolescent will make better anemia prevention behavior too. therefore, support from various parties is needed to intensify the promotion of anemia prevention, education on early detection of anemia, especially for female adolescents, and further research to determine effective health promotion methods. keywords: adolescent; anemia; behavior; healthcare; prevention; healthy lifestyle introduction female adolescent is a group that is prone to anemia (andriastuti et al., 2020). anemia is a condition of changing morphology and reducing the number of blood cells and hemoglobin so that they are not sufficient to meet the physiological needs of the body (levy, de la cruz góngora and villalpando, 2016). in female adolescents, iron deficiency anemia is the largest cause of morbidity and mortality (who, 2017). several factors such as poor nutritional status, low socioeconomic status, comorbidities (malaria, thalassemia, etc.), impaired nutrient absorption, and irregular menstrual patterns will increase the chance of anemia (abioye and fawzi, 2020). in general, the prevalence of anemia in the world reaches 50-80% of the total population (kassebaum et al., 2016). in indonesia, the incidence of anemia reaches 23.7% with the prevalence of incidence in female adolescents aged 15-24 years old 32% (ministry of health indonesia, 2019). the incidence of anemia in female adolescents increases because every month they undergo menstruation, which causes an increase in iron expenditure (swati and sunita, 2021). in addition, many female adolescents are restricting food intake, causing an iron deficiency, and disrupting hormonal balance (abioye and fawzi, 2020). this is further exacerbated by the https://creativecommons.org/licenses/by/4.0/ mailto:nk.alita@fkp.unair.ac.id https://orcid.org/0000-0001-8347-0224 https://orcid.org/000-0002-7536-7849 https://orcid.org/0000-0003-0100-8680 https://orcid.org/0000-0001-7872-6256 puspitasari, armini, pradanie, and triharini (2022) 26 p-issn: 1858-3598  e-issn: 2502-5791 perception of barriers such as feeling that iron tablets consumption does not provide benefits, unattractive forms of packaging and iron tablets, peers who do not consume iron tablets and dislike for the taste of iron tablets (aprianti, sari and kusumaningrum, 2018). unsupportive behavior of female adolescents in anemia prevention efforts is influenced by knowledge levels, attitudes, perceptions, supporting environments, resources, and national policies (roche et al., 2018). the better the support provided by the family, the more adaptive the health behaviors performed by adolescents (annisa, mulyono and widyatuti, 2021). in addition, the presence of training, monitoring, availability of iron tablets, and strengthening health promotion can improve anemia prevention behavior (gosdin et al., 2020). some of the effects of anemia include decreased endurance, cognitive-developmental disorders, psychomotor disorders, and increased susceptibility to infection (spezia et al., 2018). in female adolescents, the long-term impact will be more dangerous because it increases the risk of premature infant birth, bleeding, and maternal mortality (levy, de la cruz góngora and villalpando, 2016; zekiye and rukiye, 2021). based on basic health research (riskesdas) 2018, the prevalence of anemia in adolescents is 32%, which means that 3-4 teenagers out of 10 suffer from anemia (ministry of health indonesia, 2018). according to findings, 23% of young girls and 12% of boys in east java had anemia (report of office of women’s empowerment, 2019). through circular letter number hk.03.03/v/0595/2016 concerning the provision of blood iron tablets to female adolescents and women of childbearing age, the government implements a program of giving one tablet per week throughout the year to female adolescents aged 12-18 years old (ministry of health indonesia, 2016). in east java province, as many as 29.7% of female adolescents aged 10-19 years old have received iron tablets, but their consumption success rate is still low (ministry of health indonesia, 2019). handling anemia in adolescents is increasingly difficult because of behaviors such as consuming tea after eating, improper eating patterns, and consuming less iron from animal sources, causing low body mass (mistry et al., 2017). implementing anemia prevention behavior from an early age is very important, especially for female adolescents to be able to prepare themselves well in facing pregnancy and childbirth. in the theory of planned behavior (tpb), it is explained that the good and bad attitudes, subjective norms, and perceived behavioral control possessed by individuals will affect the amount of intention they have, resulting in differences in behavior displayed (ajzen, 2005). the purpose of this study was to analyze factors related to anemia prevention behavior in adolescent girls based on tpb. materials and methods study design this study used a descriptive correlational design through cross-sectional approach conducted in madiun, east java in february 2021. respondent the participants involved was female adolescents selected by purposive sampling techniques. a total of 105 respondents met the inclusion criteria, and all were included in this research. the study's inclusion criteria were female adolescents aged 18-22 years old, have menstruation, and can use google form. the exclusion criterion is married female adolescents. instrument the instrument in this study used a questionnaire prepared by the researcher, based on the tpb component and parameter, to obtain demographic data information and measure the independent variables (attitudes, subjective norms, perceptions of behavioral control, intentions) and dependent variable (anemia prevention behavior) in female adolescents. demographic data consisted of name (initials), age, last education, age at first menstruation, menstrual pattern, knowledge about anemia, ever or not experiencing anemia, and sources of information about anemia. the number of statements on the questionnaire in each variable was attitude (n = 8), subjective norm (n = 7), perceived behavioral control (n = 7), intention (n = 6), and anemia prevention behavior (n = 7). all questions were measured using a 5-point likert scale with answer choices on the independent variable (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree) and the dependent variable (1 = never; 2 = rarely; 3 = sometimes; 4 = often; 5 = always). the final results on the scoring were categorized into good, enough, and less. the instrument has been tested on 20 young women with an age range of 18-24 to get the results of the validity test (r > 0.444) and reliability (cronbach's alpha attitude = 0.733; subjective norm = 0.704; perceived behavioral control = 0.636; intention = 0.727, anemia prevention behavior = 0.617). data collection data collection used online questionnaire by compiling a list of prospective respondents based on criteria and large samples that have been determined from female adolescents who are members of the madiun student organization. furthermore, the researchers explained the research to respondents and examined the google form filled out by the respondent to ensure that the data submitted were appropriate and recorded in the researcher’s database. data analysis the data were analyzed using the descriptive analysis method to determine the percentage and frequency distribution of the data and bivariate analysis to jurnal ners http://e-journal.unair.ac.id/jners 27 determine the relationship between the independent and dependent variables using the spearman rho test with α ≤ 0.05. if the value of p < 0.05 then h0 was rejected. it means there is a relationship between attitude, subjective norm, and perceived control behavior with the intention to prevent anemia, also there is a relationship between perceived control behavior and intention with anemia prevention behavior. ethical consideration this research has been reviewed and approved by the health research ethics commission, faculty of nursing, universitas airlangga with no. 2166-kepk. the ethical components considered in this study are informed consent, anonymity, and confidentiality. table 1 demographic characteristics of respondents (n = 105) characteristics parameter n % mean sd age 18 years old 19 years old 20 years old 21 years old 22 years old 7 28 29 28 13 6.7 26.7 27.6 26.7 12.4 20.11 1.13 last education senior high school diploma bachelor 98 5 2 93.3 4.8 1.9 age at first menstruation ≤12 years old >12 years old 62 43 59.1 40.9 12.32 1.28 length of menstruation 3-4 days 4-5 days 5-6 days 6-7 days >7 days 2 21 22 50 10 1.9 20 21 47.6 9.5 na na many change of sanitary pad in a day 2 times 3 times 4 times >4 times 13 53 24 15 12.4 50.5 22.9 14.3 3 times 0.88 know anemia yes no 103 2 98.1 1.9 na na have anemia no yes 53 52 50.5 49.5 na na source of anemia information family university social media school book internet hospital 17 12 25 47 1 2 1 16.2 11.4 23.8 44.8 1 1.9 1 na na know the guidelines for prevention and control of anemia yes no 10 95 9.5 90.5 na na table 2 relationship between attitudes, subjective norms, and perceptions of behavioral control with the intention to prevent anemia in female adolescent (n = 105) variable category intention spearman rho test less enough good n % n % n % p r attitude positive 7 6.7 28 26.7 18 17.1 0.003 0.292 negative 12 11.4 36 34.3 4 3.8 subjective norm good 3 2.9 10 9.5 12 11.4 0.006 0.266 enough 12 11.4 42 40.0 8 7.6 less 4 3.8 12 11.4 2 1.9 perceived control behavior good 2 1.9 17 16.2 14 13.3 0.002 0.299 enough 17 16.2 40 38.1 7 6.7 less 0 0 7 6.7 1 1.0 table 3 relationship between perceived behavioral control and intention with anemia prevention behavior in female adolescent (n =105) variable category anemia prevention behavior spearman rho test less enough good n % n % n % p r perceived control behavior good 4 3.8 24 22.9 5 3.8 0.003 0.292 enough 23 21.9 34 32.4 7 6.7 less 5 4.8 3 2.9 0 0 intention good 2 1.9 16 15.2 4 3.8 <0.001 0.392 enough 17 16.2 39 37.1 8 7.6 less 13 12.4 6 5.7 0 0 puspitasari, armini, pradanie, and triharini (2022) 28 p-issn: 1858-3598  e-issn: 2502-5791 results the majority of respondents in this study were 20 years old (27.6%) and the last education level was high school, namely 98 respondents (93.3%). in addition, as many as 62 respondents (59.1%) experienced their first menstruation at the age of 12 years old. most of the young women in this study experienced menstruation for 6-7 days each month (47.6%). during menstruation they changed sanitary pad twice (12.4%), three times (50.5%), four times (22.9%), and more than four times (14.3%). regarding knowledge about anemia, 103 respondents (98.1%) knew about anemia and 53 respondents (50.5%) said that they had anemia. schools are the main source of information for a female adolescent to gain knowledge about anemia, as many as 47 respondents (44.8%), followed by social media (n = 25; 27.8%), and families (n = 17; 16.2%). in addition, 95 respondents (97.5%) said they never knew about the guidelines for prevention and management of anemia, a guide in the form of a module issued by the ministry of health for adolescents and women of childbearing age to deal with anemia (table 1). based on table 2, it can be seen that there is a relationship between attitudes (p = 0.003; r = 0.292), subjective norms (p = 0.006; r = 0.266), and perceived behavioral control (p = 0.002; r = 0.299) with intention to prevent anemia and the relationship created has a moderate degree of strength. in the attitude variable, the highest number is found in respondents with negative attitudes and having enough intention to prevent anemia, namely 36 respondents (34.3%). furthermore, in the subjective norm variable, the highest number is found in respondents with enough subjective norms and having enough intention to prevent anemia, as many as 42 respondents (40%). meanwhile, in the perceived behavioral control variable, the highest number was found in respondents with enough behavioral control perceptions and had sufficient intention to prevent anemia, namely 40 respondents (38.1%). based on table 3, it can be seen that there is a relationship between perceptions of behavioral control (p = 0.003; r = 0.292) and intentions (p < 0.001; r = 0.392) with anemia prevention behavior and the relationship created has a moderate degree of strength. in the behavioral control perception variable, the highest number is found in respondents with enough behavioral control perceptions and realizing sufficient anemia prevention behavior as many as 34 respondents (32.4%). furthermore, in the intention variable, the highest number is found in respondents with enough intention or intention and realizing sufficient anemia prevention behavior, as many as 39 respondents (37.1%). discussions most female adolescents have enough behavior in preventing anemia and some are already in the good category. however, it was still found that some respondents fall into the category of lacking in anemia prevention behavior. behavioral differences embodied by these female adolescents can be influenced by several factors, namely, age, gender, health information received, knowledge, and income of parents to affect the level of health knowledge due to low interest in health literacy (fleary, joseph and pappagianopoulos, 2018). behavior is also influenced by repeated habits that form a cycle (jalambo et al., 2018). a person will display adaptive behavior when they know the benefits, have sufficient pressure or social drive, and support, both internal and external. tpb relates to attitudes, subjective norms, and perceived behavioral control that affect the magnitude of the intention to realize health behavior (ajzen, 2005).the main findings of this research show that attitudes, subjective norms, perceived behavioral control, and intention have strong relationship with anemia prevention behavior among female adolescents. there is a significant relationship between the attitude of female adolescents to prevent anemia. adolescents with a positive attitude will have better abilities in realizing health (guerin and toland, 2020). however, not all respondents with a positive attitude have good intentions in preventing anemia. some of them still have a negative attitude but have enough and good intentions to prevent anemia. this is related to the low level of knowledge of young women about signs and symptoms and how to prevent anemia. someone who knows is not necessarily able to realize the information they get in the form of behavior (fleary, joseph and pappagianopoulos, 2018). another factor that causes this to happen is the age of the respondent in the adolescent stage, making decisions about an action to be taken is influenced by differences in the level of psychological maturity, cognitive abilities, and symptoms of depression (mccue et al., 2019). health workers are an important part of being able to increase awareness and modify interventions for female adolescent so that they have knowledge, attitudes, and behaviors that support preventing anemia (nesrin, anwar and abdullah, 2021). subjective norms are also related to the intention to prevent anemia. this result is in line with research that states that adolescents have the intention to manifest health behaviors when they have high subjective norm support, especially from parents and peers (zhao et al., 2020). the incidence of anemia will increase two times higher if adolescents only live with one of their parents (father or mother) and 2.4 times higher if they live with their guardian (gonete et al., 2018). adolescents who receive emotional and instrumental support from teachers and friends will also be more concerned with their health condition because they have a positive influence (triana et al., 2019). the attention given by the people closest to them or those who are considered important and authorized, may not necessarily change the perspective of female adolescents to influence the intention to prevent anemia. in addition, adolescents jurnal ners http://e-journal.unair.ac.id/jners 29 have a high sense of ego so that they seem unruly and act selfishly, and do not think about the impact of the choices they make (krisnani and farakhiyah, 2017). on the other hand, there is a relationship between perceived behavioral control and the intention to prevent anemia. adolescents with a strong perception of behavioral control will have 3.906 times higher intention to comply with iron tablet supplement consumption (quraini, ningtyias and rohmawati, 2020). beliefs in the perception of behavioral control can be influenced by the support received and the habits that are carried out to form a recurrent value (triana et al., 2019). most of the respondents in this study have a perception of sufficient behavioral control and sufficient intensity of anemia prevention. this is due to the ability to meet the body's lack of nutrition to prevent anemia, especially during menstruation. in fact, during menstruation, adolescent girls will lose hemoglobin more quickly, so they need to increase their intake of nutrients, especially iron (masoud et al., 2020). however, this will be difficult if young women have low socioeconomic conditions, because they are related to the fulfillment of nutrition from the food that can be consumed daily (banayejeddi et al., 2019). perceived behavioral control is also directly related to anemia prevention behavior. some of the female adolescents in this study already had a good level of perception of behavioral control so that they would carry out anemia prevention behavior well. however, some female adolescents have a perception of sufficient behavioral control but can perform anemia prevention behavior well or vice versa. this is influenced by family support, information, communication, and the level of emotional quality (park and lee, 2020). in addition, the emergence of opportunities for adaptive behavior is higher when adequate health facilities are available. if individuals are aware that the perceived ease of accessing health services is higher than the barriers, it will form a positive perception of being able and utilizing the available facilities in realizing health behaviors (roche et al., 2018). intention also has a significant relationship with anemia prevention behavior. in tpb, there is a base rate term which states that individuals will tend to perform behaviors that are mostly done by others, and vice versa (ajzen, 2005). in addition, the good or bad health behavior that will be realized is also strongly influenced by various kinds of life contexts such as the environment, skills, and existing health programs (nagy-pénzes, vincze and biro, 2020). good intentions can arise because of health-related actions taken every day. female adolescents who regularly consume vegetables and fruit every day will meet their vitamin and iron needs (ahankari et al., 2017). awareness of the consumption of vegetables and fruit will arise from the knowledge that the older you get, the more your iron needs will increase (masoud et al., 2020). wrong dietary habits and consumption of unhealthy food (junk food) should be avoided (jalambo et al., 2018). female adolescents must also meet the necessary nutrients, not only macro but also micro (htet et al., 2016). in addition, female adolescents who get iron tablets from school or have independent supplies tend to consume iron tablets regularly (gosdin et al., 2020). this habit will directly or indirectly foster intention and shape anemia prevention behavior. the limitation of this research is that it is a crosssectional study that only emphasizes the measurement of variables at one time so that there is no follow-up on the results of observations. the parameters used in the study are few so that they have not been able to provide a more detailed description of the respondent's condition. in addition, the online data collection process made the researcher unable to see the respondent's physical condition (height, weight, signs of anemia, etc.), if they did not read the explanation, as well as the instructions for filling out the questionnaire properly. conclusions the better intention possessed by adolescent girls, the better anemia prevention behavior is carried out, while attitudes, subjective norms, and perceived behavioral control are factors that affect the quality of the intentions. the factor that most strongly influenced the quality of intention was the perceived behavioral control, while the most influential support came from the family. it is necessary to increase knowledge about anemia prevention behavior to female adolescents and their families as the main source of support for adolescents in adaptive behavior. in addition, further research is expected to be able to find effective methods in increasing knowledge and awareness for young women in realizing anemia prevention behavior from an early age. references abioye, a. i. and fawzi, w. w. (2020) ‘nutritional anemias’, present knowledge in nutrition (eleventh edition). boston, 2, pp. 503–521. doi: 10.1016/b978-0-12-818460-8.00027-7. ahankari, a. s. et al. (2017) ‘prevalence of iron-deficiency anaemia and risk factors in 1010 adolescent girls from rural maharashtra, india: a cross-sectional survey’, public health. elsevier ltd, 142, pp. 159–166. doi: 10.1016/j.puhe.2016.07.010. ajzen, i. (2005) attitudes, personality, and behavior. second edi. united kingdom: open university press. andriastuti, m. et al. (2020) ‘prevalence of anemia and iron profile among children and adolescent with low socio-economic status’, international journal of pediatrics and adolescent medicine. elsevier ltd, 7(2), pp. 88–92. doi: 10.1016/j.ijpam.2019.11.001. annisa, f., mulyono, s. and widyatuti, w. (2021) ‘family support on utilization of adolescent reproduction health services at the area of public healt service (puskesmas) of martapura’, enfermeria clinica, 31(2), pp. s153–s138. doi: doi.org/10.1016/j.enfcli.2020.12.008. aprianti, r., sari, g. m. and kusumaningrum, t. (2018) ‘factors correlated with the intention of iron tablet consumption among female adolescents’, jurnal ners, 13(1), p. 122. doi: 10.20473/jn.v13i1.8368. banayejeddi, m. et al. (2019) ‘implementation evaluation of an iron supplementation programme in high-school students: the puspitasari, armini, pradanie, and triharini (2022) 30 p-issn: 1858-3598  e-issn: 2502-5791 crosswise model’, public health nutrition, 22(14), pp. 2635–2642. doi: 10.1017/s1368980019001575. fleary, s. a., joseph, p. and pappagianopoulos, j. e. (2018) ‘adolescent health literacy and health behaviors : a systematic review’, journal of adolescence. elsevier, 62(march 2017), pp. 116–127. doi: 10.1016/j.adolescence.2017.11.010. gonete, k. a. et al. (2018) ‘prevalence and associated factors of anemia among adolescent girls attending high schools in dembia district, northwest ethiopia, 2017’, archives of public health. archives of public health, 76(1), pp. 1–9. doi: 10.1186/s13690-018-0324-y. gosdin, l. et al. (2020) ‘barriers to and facilitators of iron and folic acid supplementation within a school-based integrated nutrition and health promotion program among ghanaian adolescent girls’, current developments in nutrition. oxford university press, 4(9), pp. 1–11. doi: 10.1093/cdn/nzaa135. guerin, r. j. and toland, m. d. (2020) ‘an application of a modified theory of planned behavior model to investigate adolescents’ job safety knowledge, norms, attitude and intention to enact workplace safety and health skills’, journal of safety research. national safety council, 72(december), pp. 189–198. doi: 10.1016/j.jsr.2019.12.002. htet, m. k. et al. (2016) ‘folate and vitamin b 12 status and dietary intake of anaemic adolescent schoolgirls in the delta region of myanmar’, 116, pp. 36–41. doi: 10.1017/s0007114515001609. jalambo, m. o. et al. (2018) ‘prevalence and risk factor analysis of iron deficiency and iron-deficiency anaemia among female adolescents in the gaza strip , palestine’, (8), pp. 1–10. doi: 10.1017/s1368980018001568. kassebaum, n. j. et al. (2016) ‘the global burden of anemia’, hematology/oncology clinics of north america. elsevier inc, 30(2), pp. 247–308. doi: 10.1016/j.hoc.2015.11.002. krisnani, h. and farakhiyah, r. (2017) ‘meningkatkan kemampuan pengambilan keputusan pada remaja akhir dengan menggunakan metode realty therapy’, share social work jurnal, 7(2), pp. 1–79. levy, t. s., de la cruz góngora, v. and villalpando, s. (2016) ‘anemia: causes and prevalence’, encyclopedia of food and health, pp. 156– 163. doi: 10.1016/b978-0-12-384947-2.00029-5. masoud, m. s. et al. (2020) ‘the association between iron and vitamin d status in arab adolescents’, public health nutrition, 23(7), pp. 1208–1213. doi: 10.1017/s1368980019001113. mccue, r. et al. (2019) ‘the future and me : imagining the future and the future self in adolescent decision making’, cognitive development. elsevier, 50(december 2018), pp. 142–156. doi: 10.1016/j.cogdev.2019.04.001. ministry of health indonesia (2016) guidelines for the prevention and management of anemia in adolescent girls and women of childbearing age (wus). directorate of community nutrition and directorate general of public health, ministry of health, republic of indonesia. ministry of health indonesia (2018) report basic health research 2018. jakarta. ministry of health indonesia (2019) national report basic health research 2018. publishing institute for health research and development agency. mistry, s. k. et al. (2017) ‘an outline of anemia among adolescent girls in bangladesh: findings from a cross-sectional study’, bmc hematology. bmc hematology, 17(1), pp. 1–8. doi: 10.1186/s12878017-0084-x. nagy-p, g., vincze, f. and b, é. (2020) ‘does better health-related knowledge predict favorable health behavior in adolescents ?’, 17. nesrin, n. a.-b., anwar, m. e. and abdullah, m. k. (2021) ‘the impact of nutrition education on knowledge, attitudes, and practice regarding iron deficiensy anemia among female adolescent student in jordan’, heliyon, 7(2). doi: 10.1016/j.heliyon.2021.e06348. park, h. and lee, k. s. (2020) ‘the association of family structure with health behavior, mental health, and perceived academic achievement among adolescents: a 2018 korean nationally representative survey’, bmc public health. bmc public health, 20(1), pp. 1–10. doi: 10.1186/s12889-020-08655-z. quraini, d. f., ningtyias, f. w. and rohmawati, n. (2020) ‘compliance behavior of iron tablet suplement consumption to adolescent girls in jember, indonesia’, the indonesian journal of health promotion an health education, 8(2), pp. 154–162. doi: 10.20473/jpk.v8.i2.2020.154-162. report of office of women’s empowerment, c. p. and p. of e. j. p. (2019) no tit. roche, m. l. et al. (2018) ‘adolescent girls’ nutrition and prevention of anaemia: a school based multisectoral collaboration in indonesia’, bmj (online), 363, pp. 1–6. doi: 10.1136/bmj.k4541. spezia, j. et al. (2018) ‘prevalence of anemia in schools of the metropolitan region of curitiba, brazil’, hematology, transfusion and cell therapy. associação brasileira de hematologia, hemoterapia e terapia celular, 40(2), pp. 151–155. doi: 10.1016/j.htct.2017.11.007. swati, r. and sunita, m. (2021) ‘menstrual status and obstetrical history influencing prevalence of iron deficiency anemia among reproductive age women in rural area’, materials today: proceedings. doi: https://doi.org/j.matpr.2020.12.966. triana, r. et al. (2019) ‘understanding the protective factors (selfesteem, family relationships, social support) and adolescents’ mental health in jakarta’, enfermeria clinica. elsevier españa, s.l.u., 29(insc 2018), pp. 629–633. doi: 10.1016/j.enfcli.2019.04.096. who (2017) global accelerated action for the health adolescent: guidance to support country implementation. zekiye, k. and rukiye, d. (2021) ‘the impact of adolescent pregnancy on maternal an infant health in turkey: systematic review and metaanalysis’, journal of gynecology obstetrics and human reprofustion, 50(4). doi: 10.1016/j.jogoh.2021.102093. zhao, x. et al. (2020) ‘intention to drink and alcohol use before 18 years among australian adolescents: an extended theory of planned behavior’, addictive behaviors. elsevier, 111(february), p. 106545. doi: 10.1016/j.addbeh.2020.106545. how to cite this article: puspitasari, h. z. g., armini, n. k. a., pradanie, r., triharini, m. (2022) ‘anemia prevention behavior in female adolescents and related factors based on theory of planned behavior: a cross-sectional study’, jurnal ners, 17(1), pp. 25-30. doi: http://dx.doi.org/10.20473/jn.v17i1.27744 table2 table3 table1 abioye2020 ahankari2017 ajzen2005 andriastuti2020 annisa2021 aprianti2018 banayejeddi2019 fleary2018 gonete2018 gosdin2020 guerin2020 htet2016 jalambo2018 kassebaum2016 krisnani2017 levy2016 masoud2020 mccue2019 ministry2016 ministry2018 ministry2019 mistry2017 nagy2020 nesrin2021 park2020 quraini2020 report2019 roche2018 spezia2018 swati2021 triana2019 who2017 zekiye2021 zhao2020 pengaruh peer group support terhadap peningkatan pengetahuan, sikap, kepatuhan minum obat dan kualitas hidup klien tuberkulosis paru 19 nurse behavior in implementation of diabetes mellitus education based on theory of planned behavior nadia rohmatul laili*, sulistiawati**, ika yuni widyawati* *faculty of nursing, universitas airlangga **faculty of medicine, universitas airlangga email: nadiarohmatul28@gmail.com abstract introduction: education is the important component in self-management of diabetes mellitus patients. nurse as one of the health care provider should take an active role in giving adequate education. the aim of this study was to analyze factors influencing nurse’s behavior in implementation of diabetes mellitus education based on the theory of planned behavior. method: this study used cross-sectional design. population in this study were all nurses in the medicinal public hall whose were assigned to give education toward patients in 62 public health center in surabaya city in 2016. sampling technique used total sampling and 112 nurses obtained as samples. variables in this study consist of attitude, subjective norm, perceived behavioral control (pbc), intention and practice in dm education. data collection was using questionnaire and observation sheet and also analyzed using spearman rho with α 0,05. result: statistical analysis result shows there is a significant relationship between attitudes, subjective norm, perceived behavioral control (pbc) toward intention with p-value of 0,022; 0,048; and 0,000 respectively and there is no significant relationship between intention and practice of diabetes mellitus education with p-value 0,194. nurse’s attitudes, subjective norm, perceived behavioral control (pbc) had a positive effect toward intention of diabetes mellitus education, but intention had no effect toward practice of diabetes mellitus education in public health center. conclusion: theory of planned behavior (tpb) stated that individual behavior occurred because of intention that could be affected by attitude, subjective norm, and perceived behavioral control (pbc). the future study was expected to use a qualitative approach and related study regarding development of education media in public health center. keywords: education, nurse, diabetes mellitus, theory of planned behavior ____________________________________________________________________________________________________ introduction diabetes mellitus commonly referred to dm type 1 and dm type 2, is a chronic metabolic disease which requires complex patient involvement in management (powers et al. 2015). self-care for dm sufferer plays an important role in preventing and reducing complications, morbidity, and mortality of patients (rahim-williams 2011). one of the core components to improve the self-care of diabetes mellitus is education (formosa et al. 2012). education is a basic tool which is crucial to maintain the metabolic control in dm effective care (irons et al. 2007). inadequate patient education is the most influential factor to the lack of knowledge and skills of self-care management of patients (golchin 2008), which the former has an impact on the increased risk of complications and disruption of the economic aspects (parvaneh & abazari 2012). surabaya, which is divided into five regions, has 62 community health centers (public health center) with high number of diabetes sufferers visiting public health center, based on the report of health department of surabaya. the report shows those number in 2012, 2013 and 2014 as many as 21606, 16069 and 13513 people respectively. it indicates the rate of visitor for getting dm treatment declined sharply from 2012 to 2014. however, surabaya is still at the top of the city with the highest dm case in east java which reached twelve thousand cases per year, followed by bangkalan, malang, and lamongan (pranoto 2015). in indonesia, education modules has been developed for public and people with diabetes by health department of surabaya and perkeni in which the former contains the guidelines to educate dm. socialization for perkeni consensus book has been done, but the implementation of these recommendations is 2-45% only. based on reports from the international diabetes management practice study (idmps), there is only 36.1% of dm sufferer who obtained the education (soewondo 2011). nurses in primary care settings only organize diabetes education in general with the unstructured format in a short time even this is conducted with a variety of other chronic diseases (onuoha & ezenwaka 2014). based on preliminary studies conducted by researchers at one of public health center in surabaya through observation, dm education implemented in public health center only gave suggestion to restrict eating, take medication jurnal ners vol. 12 no. 1 april 2017: 19-26 20 regularly, and control every month to check up. moreover, educational materials given was same for all patients. not only the same method for all sufferer but also educational process did not use any media so that there was no simulation. the sufferer’s family also was not involved in that method. the nurse did not assess an evaluation of the education provided and did not observe the patient's ability to perform self-care. it represents that the nurses at public health center have not provided education in accordance with the standards set in indonesia referring to the health ministry and perkeni. there are causes of implementing education according to standards, such as the lack of preparation and plan of the organization or health service, interpersonal relationship is not effective, and lack of training program on dm (santos & torres 2012), lack of knowledge about guidelines for education (odili & eke 2010; jansink et al. 2010; santos & torres 2012), the educational ability of nurses (jansink et al. 2010), and limited of time, so many activities have short visit. facility for the implementation of education is also an obstacle of dm education. nurses as part of health workers are also required to have a general requirement to provide care and diabetes education, namely knowledge, attitudes, and skills (rodrigues et al. 2009). nurse has a key role with primary health care for type 2 in which nurses should help patients to understand the process disease during attack and possible complications so they can teach patients to be able to apply selfcare (macdonalds et al. 2013), so it is necessary to do research related to the behavior of nurses in the application of dm education. the theory that can be used in analyzing the behavior of nurses is the theory of planned behavior. theory of planned behavior (tpb). this theory has been proved to significantly predict the intention and improvement of behavior (wahyuni 2012), applying hand hygiene (white et al. 2015), observing the behavior of nurses related to patient safety (jayadi et al. 2013), treatment for sars patients (ko et al. 2004) and also doing counseling and prescription of emergency contraception (hauselt 2007). nevertheless, these studies have not explained the behavior of the nurses in application of dm education. several researches are also conducted by some nurses for inpatient which they have not applied yet. the study, focused on nurses in primary care or public health center related to the behavior for application of education dm, needs to be done considering the important role of nurses as health care providers and 90% of type 2 provided by the public health center (widyahening & soewondo 2012; barbara & bruce 2015). so, that can be relied upon in making the concept of the solution to address the needs of nurses in primary care or public health center in order to implement diabetes education effectively and properly methods this research used observational analytical research with cross sectional approach. the population was all nurses at public health center around surabaya to provide education for patients in 62 public health center in 2016. the sample of this research were all nurses at public health center to provide education for patients in 2016. the total amount of those populations and samples were 112 nurses. the sampling technique was total sampling. the independent variable were attitudes, subjective norms, and perceived behavioral controls. the dependent variables were the nurse's intentions and practice in the implementation of diabetes mellitus education. attitude, subjective norm, perceived behavioral control (pbc), and the intention are measured by using a questionnaire while the practice of dm education is measured by using observation sheet when dm education applied by nurses. the questionnaire for data collection has been tested for validity and reliability and has been declared valid and reliable. according to the public health center head, an educator role is the responsibility of the nurse in charge of the assessment and anamnesis of patients, so the researchers decided to make the nurse in charge of conducting studies and histories as respondent. filling out the questionnaire is made after researchers conducted observations. the collected data is processed and analyzed. normality test results indicates that the attitudes, subjective norms, and perceived behavioral control (pbc) normally distribute while intention and practice of distribution are abnormal thus bivariate analysis has been used by using spearman correlation test with α 0.05. nurse behavior on implementation of dm education (nadia rl. et.al.) 21 results the results of the study includes background factors, attitudes, subjective norms, perceived behavioral control (pbc), the intentions and nurses actions in implementing education diabetes mellitus, the influence of main factors (attitudes, subjective norms, perceived behavioral control) to the intention and its effects to the nurse action or practice of applying education. table 1 illustrates the personal information and background of respondents which are divided to ages, gender, education, work experience, respondent's salary, religion, tribe, and knowledge about dm. table 1. personal information and background the study of nurse behavior in implementation of diabetes mellitus education based on theory of planned behavior in public health center around surabaya in 2016 respondent characteristic n % age 21-30 year-old 26 23,2 31-40 year-old 42 37,5 41-50 year-old 34 30,4 >50 year-old 10 8,9 gender male 36 32,1 female 76 67,9 education sekolah perawat kesehatan 4 3,6 diploma of nursing 76 67,8 bachelor of nursing 32 28,6 work experience <1 year 1 0,9 1-5 year 28 25 6-10 year 50 44,6 >10 year 33 29,5 salary 1.000.000-2.999.900 11 9,8 3.000.000-4.999.900 66 58,9 >5.000.000 35 31,3 religion islam 100 89,2 katholik 3 2,7 kristen protestan 7 6,3 hindu 2 1,8 tribe jawa 102 91,1 madura 7 6,2 lain-lain 3 2,7 knowledge baik 91 81,3 cukup 20 17,8 kurang 1 0,8 the most participating category of respondents are 31-40 year-old for age, female for gender, diploma of nursing for education, 610 years for work experience, 3-5 million rupiahs for salary, moslem for religion, javanese for tribe, and good understanding of knowledge about dm. jurnal ners vol. 12 no. 1 april 2017: 19-26 22 most of the respondent’s attitudes during implementation of educational have majority in positive category with a percentage of 55.4%, subjective norms in moderate category with a percentage of 74.1%, perceived behavioral control (pbc) in moderate category that is equal to 97.3% and the majority of respondents (52.7%) have good intentions. most respondents (96.4%) included in the category are less action in dm education. statistical analysis using spearman correlation with p value=0.048 (<0.05) means there is a significant relationship between subjective norms and intention in the implementation of diabetes mellitus education. spearman correlation at 0.187 states that direction is a positive correlation with weak correlation. perceived behavioral control (pbc) and intention in the implementation of diabetes mellitus education also had a significant correlation (p-value = 0.000). spearman correlation at 0.558 indicates the positive correlation direction with moderate correlation. however, there was no relationship between the intention with practice in the implementation of diabetes mellitus education (p value=0.194). table 2. cross tabulation between attitude and intention in implementation of diabetes mellitus education based on theory of planned behavior in public health center around surabaya in 2016 attitude intention total good less n % n % n % positive 35 56,5 27 43,5 62 100 negative 24 48 26 52 50 100 total 59 52,7 53 47,3 112 100 spearman correlation coefficient rs=0,216 (p=0,022) table 3. cross tabulation between subjective norm and intention in implementation of diabetes mellitus education based on theory of planned behavior in public health center around surabaya in 2016 subjective norm intention total good less n % n % n % good 11 64,7 6 35,3 17 100 moderate 44 53 39 47 83 100 less 4 33,3 8 66,7 12 100 total 59 52,7 53 47,3 112 100 spearman correlation coefficient rs =0,187 (p=0,048) table 4. cross tabulation between perceived behavioral control (pbc) and intention in implementation of diabetes mellitus education based on theory of planned behavior in public health center around surabaya in 2016 perceived behavioral control intention total good less n % n % n % good 1 100 0 0 1 100 moderate 58 53,2 51 46,8 109 100 less 0 0 2 100 2 100 total 59 52,7 53 47,3 112 100 spearman correlation coefficient rs =0,558 (p=0,000) nurse behavior on implementation of dm education (nadia rl. et.al.) 23 table 5. cross tabulation between intention and practice in implementation of diabetes mellitus education based on theory of planned behavior in public health center around surabaya in 2016 intention practice total good less n % n % n % good 3 5,1 56 94,9 59 100 less 1 1,9 52 98,1 53 100 total 4 3,6 108 96,4 112 100 spearman correlation p=0,194 discussion statistical analysis showed a significant relationship between attitude and intention which means that the attitude of nurses about dm education affects their intention in implementing dm education. these results are consistent with research conducted by kortteisto et al. (2010) which states that the attitude is an important factor associated with the intention of health workers for using clinical practice reference. good intention tends to be influenced by the positive attitude of nurses. ko et al. (2004) also proved that a positive attitude contributes significantly in predicting the intention of nurses to perform maintenance on sars patients. this is in accordance with the theory of planned behavior stating that attitudes toward the behavior are a determining factor for the formation of intentions (ajzen 2005). attitude can affect a person intention to perform a behavior. an individual will intend to behave in certain ways when he/she vote positively. the attitude of nurses in the educational application of dm influenced by belief or conviction that a good and corresponding recommendation education dm will result in a good outcome for the patient. nurses also believe that dm education will be able to help the patients to perform self-care management well. good intention tends to be influenced by a positive attitude, but there are respondents who have a positive attitude have less intention, and also respondents who have a negative attitude have good intentions. this could be caused by subjective norms and perceived behavioral control, and every individual. they have its perception of factors which is affecting their intentions. in some situations, one or two factors can be used to explain the intention, and most of these three factors play a role in explaining the intention. in addition, every individual has consideration to decide what the most influential individuals in behavior is (ajzen 2005). the statistical test result shows a significant relationship between subjective norms and intention. intention nurse education in the application of dm is influenced by subjective norms (related parties) in implementing dm education at public health center. these results are consistent with research conducted kortteisto et. al. (2010) which states that the subjective norm is an important factor associated with health worker’s intention to use clinical practice reference. the results showed that most respondents had medium subjective norms for implementation of diabetes mellitus education at public health center. this may be caused by reference or party getting involved on individuals. the nurses would assume that the related parties did not show their hope to educate well and did not motivate nurses to educate as well as recommendations so that the nurses did not believe that other people or reference would approve or support their actions in implementing the education according to recommendations. nurses did not have a subjective norm that put pressure on themselves to educate dm. for example, there was no written regulations in detail and binding set the nurse’s responsibility of educating dm according to the recommendations, none of the patients or families who asked for education, no demands, motivation, and recognition from colleagues and other health professionals. good intention tends to be influenced by good subjective norms, but there are respondents who have a good subjective norms jurnal ners vol. 12 no. 1 april 2017: 19-26 24 while they have less intention. this could be caused by the attitudes and perceived behavioral control. in addition, lack of motivation, demands, monitoring, and evaluation from third-parties, such as the health department surabaya, public health center head, colleagues, or even other health professionals, make nurses think that the related parties do not want them to apply dm education as recommendation and not a problem for nurses if they do not apply dm education. therefore the nurses do not intend to educate dm based on recommendation. statistical analysis showed a significant relationship between perceived behavioral control (pbc) to the intention, which means the perceived behavioral control (pbc) affects to the intention of nurses in implementing diabetes mellitus education at public health center. the results are consistent with research conducted (wahyuni 2012) which states there is significant influence between the pbc and intention of nurses behavior. this indicates that the better pbc on individual, the better his or her intention because pbc has a motivational effect to the intention. the results showed that most respondents have perceived behavioral control (pbc) in medium category of diabetes mellitus education at public health center. perceived behavioral control tends to produce good intentions. some respondents had a good pbc but their intention is less or more. according to (azwar 2010) that in some situations, pbc is not realistic, as the condition when people faced the available resources changing or when a new element appears in that situation. such conditions is clearly seen there are internship students of nursing at public health center that have certain competencies demands including anamnesis and educate the patient so that the nurses have to adjust the current conditions as supervising students and not directly involved in nursing care to patients. this is predicted when the pbc is not directly proportional with the intention possessed. statistical analysis showed that there is no significant relationship between intentions and actions in the implementation of diabetes mellitus education, which means intention does not affect the actions of nurses. this research relates to another research kortteisto (2010) which states that primary care has a negative effect on the variable intention characterized by low rate of primary care health workers to run standard operational procedure rather than hospital health workers. the results of studies pointed out that there is no relationship between intentions and actions in implementing diabetes mellitus education. this relates to ajzen opinion (2005) that the accuracy intention in predicting the behavior is not certainly unconditional since it was found in some studies that intentions do not always produce that behavior. according to ajzen (2005), although many experts who have shown a strong relationship between intention and behavior, the study sometime also found a weak correlation between both of them. azwar (2010) stated that according to the theory of planned behavior, among the various beliefs, the availability of opportunities and resources are the reason to determine intention and attitude. this belief can be derived from the experience, and also it can be influenced by indirect information about the behavior, for example by looking at the experience of a friend or someone else, it is also be influenced by several other factors that reduce or increase the effect the difficulty committing acts. conclusion a positive attitude of nurses for implementation of diabetes mellitus education will lead good intentions in implementation of diabetes mellitus education. a good subjective norm will lead intentions in implementation of diabetes mellitus education. a good perceived behavioral control will lead to good intentions in the implementation of diabetes mellitus education. intention has no effect on the action of diabetes mellitus education implementation at public health center. it needs an association's standing for diabetes sufferer from every area or public health center in order to facilitate nurses to accommodate the dm education program and also activities based on patient empowerment and community to help the role of health professionals in diabetes management. need to do research with a qualitative approach to understand and obtain the information deeper about the weakness pf implementing dm education. it needs to do research related to the development of media education at public health center. nurse behavior on implementation of dm education (nadia rl. et.al.) 25 references ajzen, i., 2005. attitudes, personality, and behavior 2nd ed., berkshire: open university press. azwar, s., 2010. sikap manusia teori dan pengukurannya 2nd ed., yogyakarta: pustaka pelajar offset. barbara, d. & bruce, a., 2015. management of diabetes by primary health care nurses in auckland, new zealand. jprim health care, 7(1), pp.42–50. formosa, c., gatt, a. & chockalingam, n., 2012. the importance of diabetes foot care education in primary care setting. journal of diabetes nursing, 16(10), pp.410–414. golchin, m., 2008. knowledge and practice on insulin self-injection procedure in diabetic patients at qozvin diabetes unit. the journal of qazvin univ. of med. sci, 12(1), pp.8–11. hauselt, m., 2007. an application of the theory of planned behaviour on nurse mid wives’ intentions to counsel and prescribe emergency contraception. university of colorado. irons, b. et al., 2007. the need for a community diabetes education curriculum for healthcare professionals. journal of continuing education in nursing, 38(5), pp.227–231. available at: http://www.ncbi.nlm.nih.gov/pubmed/17 907667. jansink, r. et al., 2010. primary care nurses struggle with lifestyle counseling in diabetes care: a qualitative analysis. bmc family practice, 11(1), p.41. available at: http://www.biomedcentral.com/14712296/11/41. jayadi, m. et al., 2013. applying theory of planned behavior in predicting of patient safety behaviors of nurses. materia socio-medica, 25(1), pp.52–58. available at: http://www.pubmedcentral.nih.gov. ko, n. et al., 2004. applying theory of planned behavior to predict nurses intention and volunteering to care for sars patients in southern taiwan. the kaohsiung journal of medical sciences, 20(8), pp.389–398. available at: http://www.kjmsonline.com. kortteisto, t., kaila, m. & komulainen, j., 2010. healthcare professionals’ intentions to use clinical guidelines: a survey using the theory of planned behaviour. implementation science, 5(51). macdonalds, l. et al., 2013. nurse-patient communication in primary care diabetes management: an exploratory study. bmc nursing, 12(1), p.20. odili, v. & eke, i., 2010. knowledge of diabetes mellitus among registered nurses in benin city. international journal of health research, 3(3), pp.145–151. onuoha, p. & ezenwaka, c., 2014. diabetes patient need support to practise selfmonitoring of blood glucose levels. asian journal od sciense and technology, 5(12), pp.789–792. available at: http://www.journalajst.com. parvaneh & abazari, z., 2012. inadequate investment on management of diabetes education. res med, 17(8), pp.792–798. powers, m. et al., 2015. diabetes selfmanagement education and support in type 2 diabetes: a joint position statement of the american diabetes association, the american association of diabetes educators, and the academy of nutrition and dietetics. diabetes care, 38(13), pp.1–9. available at: http://care.diabetesjournals.org. pranoto, a., 2015. surabaya peringkat tertinggi diabetes. harian bhirawa, p.3. available at: https://issuu.com/harianbhirawacetak. rahim-williams, 2011. beliefs, behaviors, and modifications of type 2 diabetes selfmanagement among african american women. journal of the national medical association, 103(3), pp.203–215. rodrigues, f. et al., 2009. knowledge and attitude: important components in diabetes education. revista latinoamericana de enfermagem, 17(4), pp.468–473. santos, l. & torres, h., 2012. educational practices in diabetes mellitus: understanding the skills of health professionals. florianopolis, 21(8), pp.574–580. soewondo, p., 2011. current practice in the management of type 2 diabetes in indonesia: results from the international diabetes management practices study (idmps). journal of indonesians medical association, 61(12), pp.474–81. wahyuni, e.d., 2012. pengembangan perilaku jurnal ners vol. 12 no. 1 april 2017: 19-26 26 perawat dalam pendokumentasian asuhan keperawatan berbasis theory of planned behavior. universitas airlangga. white, k. et al., 2015. using a theory of planned behaviour framework to explore hand hygiene beliefs at the “5 critical moments” among australian hospitalbased nurses. bmc health services research, 15(1), p.59. widyahening, i. & soewondo, p., 2012. capacity for management of type 2 diabetes mellitus (t2 dm) in primary health centers in indonesia. j indon med assoc, 62(11), pp.439–443. http://e-journal.unair.ac.id/jners | 197 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19013 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review of supportive therapy effect on quality of life in cancer patients suharyono suhayono1, suhendra agung wibowo1, ira purnamasari1, tintin sukartini1 and la rahmat wabula2 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 nursing study programme stikes maluku husada, indonesia abstract introduction: supportive therapy is considered an important element in the treatment of cancer patients which is often associated with efforts to overcome life-threatening problems. however, the application of this intervention in clinical practice has not yet been fully carried out. this systematic review summarizes the evidence regarding the effect of supportive therapy in improving the quality of life (qol) of cancer patients. methods: the review was performed according to prisma guidelines. we searched four electronic databases to identify studies comparing patients who received specific protocol interventions with the control group. the keywords used are "supportive therapy" and "palliative supportive care" and "quality of life" or "health quality" or "health-related quality of life". the articles taken were published between 2016 and 2020. then 117,011 articles were obtained, consisting of 2,554 articles from pubmed, 570 articles from scopus, 25,748 articles from sciencedirect, and 88,139 from proquest. fifteen studies were included with title and abstract inclusion criteria following the desired topic. methodological quality was assessed using the downs and black tool. supportive therapy includes pain management, nutrition, elimination, blood index, and self-efficacy toward improving the quality of life of cancer patients, including symptom management counseling, complementary and integrative medicine (cim), disease preferences, prognostic perceptions, health status, emotional support, social needs and spiritual, and can be seen from the difference in the ability of cancer patients in the intervention and control groups. results: in the study, the average quality of life assessment was carried out at 12 weeks and six months after the intervention. seven7 of the 15 studies used qlq-c30 to measure the quality of life of patients with cancer, which was managed to validate and assess the quality of life in patients with cancer, whereas of the 15 studies evaluating results reported, patients reported differences in favor of the intervention group. conclusion: the overall methodology quality is good. several comparative studies have evaluated the impact of supportive therapy on the quality of life of cancer patients. the quality of this study is good and the results are acceptable in improving the quality of life of cancer patients undergoing chemotherapy treatment, and palliative care. article history received: feb 27, 2020 accepted: april 1, 2020 keywords supportive therapy; quality of life (qol); cancer patients contact suharyono suharyono  suharyono-2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: suharyono, s., wibowo, s. a., purnamasari, i., sukartini, t.,& wabula, l. r. (2020). a systematic review of supportive therapy effect on quality of life in cancer patients. jurnal ners, special issues, 197-207. doi:http://dx.doi.org/10.20473/jn.v15i2.19013 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. s. suharyono et al. 198 | pissn: 1858-3598  eissn: 2502-5791 introduction as a chronic disease, cancer is a disease that affects all members of the body. cancer does not only attack the main cancer cells, it will metastasize to other organs and tissues, resulting in malfunction of all organs. the impact on cancer depends on the cancer status itself. because until now no drug can cure cancer, one of the final effects of cancer is death. postoperative pain and discomfort, infection, and side-effects of postoperative adjuvant treatments contribute to eating difficulties and loss of appetite, which affects nutrition and quality of life (chasen & bhargava 2016). patients with advanced cancer have high rates of psychological distress, including depression, anxiety, and spiritual despair (breitbart et al., 2018). quality of life in cancer patients is influenced not only by conduit disorders, but also by disruptions in sleep and changes in daily living which impact the survival rate (chang et al., 2016). based on the results of research conducted by who and the world bank, it is estimated that 12 million people in the world have cancer each year. this number continues to increase every year and it is estimated that cancer patients will reach 26 million people in 2030. the incidence of cancer throughout the world varies according to race and status of the country; cancer is more common in countries with low to medium economic levels, which is around 70% of all cancer incidents in the world. incidence data, available through 2015, were collected by the surveillance, epidemiology, and end results program; the national program of cancer registries; and the north american association of central cancer registries. mortality data were collected by the national center for health statistics. in 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the united states. a rapid increase in cancer incidence occurs in poor and developing countries (siegel & miller, 2016). the supportive therapy is a proper management of cancer patients receiving treatments and is based on many factors, including an adequate collection of the information about symptoms and side effects. supportive therapies can significantly affect the quality of life (qol) of patients, and a proper description of subjective symptoms is crucial (siegel & miller, 2016). integrating methods in oncological care has resulted in positive effects on patientreported outcomes (pros), and is supported by international clinical guidelines. meta‐analyses indicate that, for instance, acupuncture and acupressure reduce nausea and pain, and aromatherapy has the potential to alleviate sleep and anxiety disorders. there is also recognized evidence that mind-body methods like yoga and meditation increase patients’ qol, and reduce fatigue and distress. there is benefit from a supportive care intervention, such as complementary nursing in oncology) (chang et al., 2020). the primary focus of cancer treatment has always been to increase overall and disease-free survival; however, quality of life has been increasingly recognized as an important endpoint. although there is an instinctive understanding of the term “quality of life”, there are multiple definitions, which gives testimony to the fact that it is a complex concept with many diverse facets and components. the standard dimensions used in qol questionnaires measure the presence or absence of specific symptoms or overall general health. various questionnaires and methodologies have been devised to understand patient preferences and priorities toward cancer treatment. in standard risk, patients are asked to choose between staying in a state of ill health for a specified period or choosing a treatment that may either cause their death or restore perfect health. figure 1. prisma flowchart showing included and excluded articles. jurnal ners http://e-journal.unair.ac.id/jners | 199 there may be a significant drop in qol after an intervention, but an overall better long‐term qol and increased life expectancy this systematic review aims to summarize the evidence regarding the effects of supportive therapy in improving the quality of life of cancer patients (shrestha et al., 2020). materials and methods search strategy this systematic review includes original journals that discuss the effect of supportive therapy on the quality of life of patients suffering from advanced cancer that requires palliative care and was conducted according to the prisma statement guidelines. a systematic literature search was carried out in several major databases such as pubmed, scopus, sciencedirect, and proquest, by entering keywords supportive therapy, quality of life, and cancer patients. there are no other restrictions that are used to maximize the literature search. a list of literature references is done manually. search results: full-text articles database assessed for eligibility are pubmed eight journals, scopus 24 journals, sciencedirect 18 journals, and proquest as many as 14 journals. the search was conducted to answer the research question of to what extent supportive therapy impacts quality of life on patient cancer outcomes in comparison to standard care. inclusion and exclusion criteria inclusion and exclusion criteria. studies were included in the review if they met the following criteria: (1) involved adult patients having cancer in all stadium with palliative care; (2) a specific protocol for supportive therapy in-hospital was used as an intervention; (3) a control group receiving structured protocol given standard care already in place at the hospital that was used as a comparator; (4) discuss the quality of life; (5) were published in english; (6) the studies used the randomized controlled trial (rct) method on the effect of supportive therapy on the quality of life of cancer patients with a limitation of the years used for the past five years (2016-2020); and (7) rct design studies must meet the pico criteria among the population used, which are patients cancer who are currently undergoing palliative care. studies were excluded if (1) they involved patients cancer but didn't review quality of life; (2) supportive therapy was not described by the author; (3) the study did not involve a control group, because we felt that we would not be able to separate the effects of supportive therapy versus standard care in hospital; (4) did not involve adult patients; (5) intervention did not explain specific protocol of supportive therapy to qol. outcome measures outcome measures of interest in this review included psychological management, nutritional needs, pain management, infection control and treatment of side effects. comparison in research consists of at least two groups, namely the intervention group and the control group. the outcome produced is a measurement of the qol of patients with cancer. measures of health status were collected directly from patients through questionnaires on quality of life. study selection and data extraction the research screened through the titles and abstracts of the articles yielded by the search strategy. irrelevant articles were excluded while remaining full-text articles were then screened independently against the selection criteria inclusion and exclusion. discrepancies were resolved by dealing within the research group. data were then extracted independently from the articles chosen by research into a standardized data collection form. in addition to the outcome measures of interest, the researcher made a summary of the characteristics of included studies information about the type of cancer, measuring instrument, total number of patients, study design, and follow-up. quality assessment the methodologic quality of each study was evaluated by investigators using the downs and black tool. this tool was chosen because it appraises the quality of both randomized controlled trials (rcts) and nonrandomized comparative studies and has been shown to have good internal consistency, test-retest reliability, inter-rater reliability, and criterion-related validity. the downs and black tool consists of 27 items divided into five subscales: reporting (10 items), external validity 9three items), internal validity-bias (seven items), confounding (six items), and power (one item). the tool generates an overall score with a maximum of 27 points (for testing results, the last item was scored 0 or 1). disagreements regarding the quality assessment were resolved by the research group (downs & black, 2016). results literature search the literature search yielded a total of 844 citations after the removal of duplicates. of these citations, 64 full-text articles were screened and 49 were excluded (fig). the main reasons for exclusion were intervention in the article was an editorial or review, the study did not involve a control group, supportive therapy not described by the author, the study did not involve a control group, and intervention did not explain specific protocol of supportive therapy to quality of life. fifteen full-text articles met our selection criteria and were included in the review. characteristics of the included studies fifteen studies involved cancer patients with different types of including advanced cancer, colorectal cancer, esophageal cancer, solid tumor cancer, ovarium cancer, breast cancer, and lung s. suharyono et al. 200 | pissn: 1858-3598  eissn: 2502-5791 table i. summary of characteristics of included studies reference type of cancer measuring instrument total of patients study design followup results (klafke et al., 2019) breast or gynecolog ic cancer eortc‐qlq‐ c30 126 rct 6 months significant group effect of 6.643 (1.65 11.64) (p = 0.010), indicating a difference between the two groups ig and cg in favor of the ig, was found in the secondary analysis for the global qol (temel et al., 2017) lung cancer (fact-g) (phq-9) 125 rct 12 weeks intervention patients (usual care) reported greater improvement in qol from baseline to week 24 (1.59-23.40; p5 .010), but not week 12 (0.39-21.13; p=0.339). (chang et al., 2020) esophage ctomy cancer eortc qlqc30 80 rct 1, 3 and 6 months the intervention group experienced significant improvements in nutrition, exercise capacity, and variables related to quality of life. the intervention group compared to controls (ci 0.09, 0.54, p < .01) (vanbutsel e et al., 2020) advanced cancer eortc qlq c30 185 rct 6 weeks and 12 weeks patients in the intervention group scored significantly higher on global health status/qol of the eortc qlq c30, at 6 months (difference: 5.9 [0.06; 11.1], p = 0.03), 3 (difference: 6.8 [1.0; 12.6], p = 0.02), and 1 month (difference: 7.6 [0.7; 14.5], p = 0.03). (pace et al., 2019) solid tumor cancer hrqol 80 rct 9 weeks and 13 weeks the addition of cbct to supportive oncology care programs to improve hrqol in both members of the survivor-caregiver dyad (y. zhou et al., 2017) ovarian cancer hrqol 144 rct 25 weeks there was a statistically significant improvement in the fatigue score (functional assessment of cancer therapy–fatigue) for exercisers (4.0, sd =1.1, 95% ci=1.8 to 6.2, p < .001). (breitbart et al., 2018) advanced cancer mqol 346 rct before interventi on 4 weeks, 8 weeks after treatment 16 weeks the effect of imcp was significantly greater than the effect of sp for quality of life and sense of meaning (d=0.19), but not for the remaining study variables. (uster et al., 2017) gastroint estinal metastati c lung cancer eortc-qlqc30 58 rct 3 and 6 months show good adherence to a combined nutrition and exercise program. the multimodal intervention did not improve overall qol. (malmströ m et al., 2016) oesophag eal cancer qlq-c30 120 rct 2 weeks, 2, 4 and 6 months after discharge proactive nurse-led telephone followup has a significant positive impact on the patients’ experience of received information (schuit et al., 2019) lung, breast, and colorectal cancer eortc qlqc15-pal 136 rct 3 months the intervention group has the knowledge, skills and confidence of patients to manage their own health and health services after being given access to oncokompas (jefford et al., 2016) colorectal cancer qol-c30 and qlq-cr29 221 rct 8 weeks and 6 months patients in the sc group were more satisfied with survivorship care than those in the uc group (significant differences in 10 of 15 items). jurnal ners http://e-journal.unair.ac.id/jners | 201 reference type of cancer measuring instrument total of patients study design followup results (qiu et al., 2020) esophage al cancer qlq-c30 96 rct 6 weeks there were significant differences in the changes of serum albumin and total protein between the two groups throughout the trial (p < 0.05). complications (radioactive esophagitis, skin symptom of complications) and quality of life were statistically different before and after the intervention (p < 0.05) (gok metin, karadas, izgu, ozdemir, & demirci, 2019) breast cancer qol 29 rct 12 weeks a significant reduction in the bfi scores was reported in the pmr and mm groups when compared with the cg at weeks 12 and 14 (p=.002). (k. zhou et al., 2016) breast cancer hrqol 90 rct 12 months this trial provides important evidence on the effectiveness of multimodal nursing interventions delivered by nurses in clinical settings. study findings inform strategies for scaling up comprehensive standard intervention programs on health management in the population of female patients with breast cancer. (duluklu & çelik, 2019) colorecta l cancer patients with permane nt colostom y sqols 30 rct 1 month as compared with the control group patients, the experimental group patients who used lavender essential oil in the ostomy bag experienced statistically significant less odor, a higher quality of life, and better adjustment to ostomy (all p < 0.05) *ig: intervention group, rct: randomized controlled trial, qol: quality of life, cbct: cognitively based compassion training, imcp: sp: supportive psychotherapy, uc: usual care, individual meaning-centered psychotherapy, bfi: brief fatigue inventory, pmr: progressive muscle relaxation, mm: mindfulness meditation, cg: control group. table 2. quality assessment scores of included studies, using downs and black checklist reference reporting (10) external validity (3) internal validity -bias (7) internal validity confounding (6) power (1) total klafke, n. et al., 2019 (germany) 10 2 7 6 1 26 temel, j. s. et al. 2016 (america) 9 2 6 5 1 24 chang y. l, et al., 2020 (taiwan) 9 2 7 5 1 24 vanbutsele, g. et al., 2020 (belgium) 10 3 7 5 1 26 pace, t. w. et al., 2019 (america) 8 2 6 5 1 23 zhou, y. et al., 2017 (england) 9 2 7 6 1 25 breitbart, w. et al., 2018 (amerika) 9 2 6 6 1 23 uster, a. et al,. 2017 (switzerland) 8 3 7 5 1 24 malmström, m. et al., 2016 (sweden) 8 3 6 6 1 24 schuit, a. s. et al., 2019 (amsterdam) 9 2 7 5 1 24 jefford ,m. et al., 2016 (australia) 8 2 6 5 1 22 s. suharyono et al. 202 | pissn: 1858-3598  eissn: 2502-5791 reference reporting (10) external validity (3) internal validity -bias (7) internal validity confounding (6) power (1) total qiu, y. et al,, 2020 (china) 10 2 7 6 1 26 metin, g. z. et al., 2019 (turkey) 9 2 7 6 1 25 zhou, k. et al., 2016 (china) 9 2 6 5 1 23 duluklu, b., 2019 (turkey) 9 3 7 5 1 25 table 3. supportive therapy of each study study intervention group control group klafke, n. et al., 2019 (germany) the integrated supportive care intervention consisted of complementary and integrative medicine (cim) applications and counseling for symptom management, as well as cim information material. routine care temel, j. s. et al., 2016 (america) early integrated palliative care (pc) in patients with lung and gi cancer. patients who were assigned to the intervention met with a pc clinician at least once per month until death. those who received usual care consulted a pc clinician upon request. chang, y. l. et al., 2020 (taiwan) exercise and nursing education health informatics program on quality of life, exercise capacity, and nutrition among patients following esophagectomy for esophageal cancer. usual post-surgery care vanbutsele, g. et al., 2020 (belgium) patients with advanced cancer and a life expectancy of approximately 1 year were randomly assigned to either early integrated palliative care (pc) into oncological care (intervention) or standard oncological care alone. standard oncological care alone pace, t. w. et al., 2019 (america) cbct (cognitively-based compassion training) to improve the primary outcome of depressive symptoms and secondary outcomes of other hrqol domains (anxiety, fatigue), biomarkers of inflammation and diurnal cortisol rhythm, and healthcare utilization-related outcomes in both cancer survivors and informal caregivers. only routine nursing care with their informal caregivers zhou, y. et al., 2017 (england) women’s activity and lifestyle in connecticut (walc) with ovarian cancer were randomly assigned to exercise for sixmonths telephone-delivered exercise intervention of primarily brisk walking to be associated with improved physical hrqol in women with ovarian cancer attention control breitbart, w. et al., 2018 (amerika) individual meaning-centered psychotherapy (imcp) with supportive psychotherapy (sp) and in improving spiritual wellbeing and quality of life and reducing psychological distress in patients with advanced cancer, quality of life, sense of meaning, spiritual wellbeing, reducing anxiety and desire for hastened death enhanced usual care (euc) uster, a. et al., 2017 (switzerland) combined nutrition and physical exercise program on cancer patients with metastatic or locally advanced tumors of the gastrointestinal and lung tracts. the group received a minimum of three standardized individual nutritional counseling sessions and participated in a 60-min exercise program twice a week. received their usual care. malmström, m. et al., 2016 (sweden) telephone supportive care program on quality of life (qol), received information and the number of healthcare contacts compared to conventional care following oesophageal resection for cancer. conventional care schuit, a. s. et al., 2019 (amsterdam) ehealth application ‘oncokompas’, supporting patients with incurable cancer in finding optimal palliative care, tailored to their quality of life and personal preferences the waiting list control group receives care as usual and will have access to oncokompas after three months. jurnal ners http://e-journal.unair.ac.id/jners | 203 cancer. all journals used the randomized control trial (rct) research design with measurement results in the form of quality of life of cancer patients based on the effectiveness of supportive therapy. the characteristics of these studies are summarized in table i, their quality assessment scores are shown in table ii and the downs and black checklist for the assessment of the methodological quality of randomized is in table iii (downs & black, 2016). in the current version of the checklist, the item score has been modified to 27, which refers to the strength of the study. instead of assessing according to the range of study strengths available, we judge whether or not the study does power calculations. thus, the maximum score for item 27 is 1 (power analysis is carried out). the range of downs and black scores is given the appropriate level of quality as previously reported: very good (26-28); good (20-25); fair (1519); and poor (<14). the reviewers' results were compared with external reviewers and differences resolved in a consensus meeting. the checklist can evaluate randomized and uncontrolled trials. the rcts had the highest methodologic quality (a score of 26/27 on the downs and black tool). the rct was the study with the lowest quality (score of 22/27). from 15 journals, the highest five rcts have methodologic quality (score of 24/27). the overall methodology quality is good. there were a total of 1,866 participants included in the 15 studies, including 531 advanced cancer patients, 319 lung cancer patients, 296 esophageal cancer patients, 251 colorectal cancer patients, 245 breast cancer patients, 144 ovarian cancer patients, and 80 solid tumor cancer patients. from 15 journals, data collection was carried out in america as many as three journals, china two journals, turkey two journals, taiwan one journal, germany one journal, switzerland one journal, belgium one journal, england one journal, sweden one journal, australia one journal and amsterdam one journal. supportive therapy interventions the 15 journals discuss supportive therapy in reducing the psychological influence of symptoms management counseling, complementary and integrative medicine, disease preferences, prognostic perceptions, health status, support for emotional, social, and spiritual needs. other supportive therapy is in the management of pain, nutrition, elimination, blood index, and self-efficacy to improve the quality of life of cancer patients. supportive treatment in cancer patients is very important, so it is not infrequently more important than surgery, radiation or chemotherapy treatment because supportive treatment is often associated with efforts to overcome life-threatening problems. this supportive treatment is not only needed in cancer patients undergoing curative treatment, but also in palliative treatment. the effects of cancer therapy is also one of the factors that influence the psychological condition of cancer patients. the painful effects of therapy, its long study intervention group control group jefford, m. et al., 2016 (australia) nurse-led supportive care package (survivor care) for survivors of colorectal cancer to improve psychological distress, supportive care needs (scns), and quality of life (qol) of patients with crc. the intervention, called survivor care (sc), comprised educational materials, needs assessment, survivorship care plan, end-of-treatment session, and three follow-up telephone calls usual care (us) by hospital standards qiu, y. et al., 2020 (china) patients with esophageal cancer treated with concurrent chemoradiation were randomized to an intervention group (treated with whole-course nutrition management from the nutrition support team) treated with the general nutritional method metin, g. z. et al,, 2019 (turkey) progressive muscle relaxation (pmr) and mindfulness meditation (mm) on fatigue, coping styles, and quality of life (qol) in patients with early breast cancer applied concurrently with adjuvant paclitaxel regimen standard care received only a single time attention-matched education (15-min) on breast cancer before the start of the paclitaxel regimen. zhou, k. et al., 2016 (china) multimodal standard nursing program (msnp) on hrqol in female patients with breast cancer. inpatient female patients with breast cancer from each hospital will receive either msnp plus routine nursing care immediately after recruitment. the intervention will be conducted by trained nurses for 12 months only routine nursing care duluklu, b., 2019 (turkey) the addition of lavender essential oil to the colostomy bag of the patients with permanent colostomy on the elimination of odor, quality of life, and ostomy adjustment. continued their routine practices about nutrition and stoma care for 1 month. s. suharyono et al. 204 | pissn: 1858-3598  eissn: 2502-5791 duration and the large medical expenses can aggravate the anxiety and depression of cancer patients. long-term effects of treatment that affect the function and appearance of the body are other important factors behind the decline in quality of life in cancer patients. an increase in quality of life means explaining that supportive therapy influences the quality of life of cancer patients who are undergoing chemotherapy, advanced stages, and palliative care. quality of life is also influenced by the focus of supportive therapy provided so that it can provide benefits for all cancer patients. quality of life measurement tools quality of life (qol) was determined via the european organization for research and treatment of cancer quality of life questionnaire version 3.0 (eortc qlq-c30) (uster et al., 2017). qol is measured by the global health status / qol scale of the eortc qlqc30, a two-item scale that is converted to a scale of 0100. (it was also measured by the single item scale and the keill quality summary score by the mcgill questionnaire (mqol) containing the domains (physical, psychological, existential/ spiritual, and social) equally. core instruments assess the overall quality of life in patients with cancer (qlq-c30) and specific diagnostic instruments assess quality of life among patients with cancer. all instruments use a likert scale and are changed linearly to a scale of 0-100 before statistical testing. the european organization in conducting cancer research and treatment (eortc) quality of life c-30 (qol-c30) is a selfadministered and validated questionnaire to assess hr-qol in patients with cancer. it consists of nine multi-item scales: five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, and nausea and vomiting), and global health and quality of life. hrqol-related outcomes include outcomes of psychological hrqol (depressive symptoms primary outcome), anxiety, positive affect, and self-compassion), physical hrqol (fatigue), and social hrqol (empathy, feelings of social connection/isolation, dyadic function) as well as global wellbeing (jefford et al., 2016). effect of supportive therapy on the quality of life of cancer patient results analysis of 15 journals that used supportive therapy for cancer patients in the form of psychological management, nutritional needs, pain management, and handling of side effects problems showed the effect of supportive therapy on the quality of life of cancer patients. assessments were carried out step by step at four time points: before intervention, mid-treatment (four weeks), eight weeks after treatment, and 16 weeks after treatment with outcome variables (quality of life, meaning, spiritual well-being, anxiety, and desire for accelerated death). the analyzed results on average found that the assessment of quality of life was carried out at six weeks, and 12 weeks after intervention supportive therapy was given. the results of this study proved to increase the qol of cancer patients. patients with cancer in these studies reported that after being given supportive therapy, the results show good quality of life. we have summarized the 15 studies and the results among them show improving spiritual wellbeing, reduced anxiety psychological and depression and desire for hastened death, sleep quality starts to improve, pain management, increased their nutrition intake and reported a decline in nausea and vomiting, and desire for prolonged death. the availability of material and social support has a direct influence on the ability of patients to effectively cope with cancer and on their quality of life (hughes et al., 2014). in different studies into the quality of life of cancer patients, it has been observed that changes in daily activities, in particular, in interpersonal relationships and in leisure time, have been consistently related to a depressed emotional state, negative assessment of qol tiredness, insomnia, and pain (foster et al., 2017). the study reported patients given supportive therapeutic interventions reported lower depression at week 24, controlling initial scores and improving the quality of life of patients. (adjusted mean difference, 21.17; 95% ci, 22.33 to 20.01; p = 0.048). the effect of the intervention varies based on the type of cancer likely to have a positive effect on their ability to cope with life, which might include remaining side effects and adverse symptoms for a long time. discussion changes in scores in the experimental and control groups occurred significantly. this means that, in the experimental group given supportive therapy, there was an increase in quality of life; conversely, in the control group that was not given supportive therapy, there was no increase in quality of life. high motivation, open and cooperative attitude in giving feedback during therapy is given, where patients will tell their experiences and feelings during the therapy process, also supports the achievement of the goals of this therapy. motivation in the form of a better future view is a very important factor in improving the quality of life of patients. this study was to analyze the effect that a supportive therapy intervention had on the quality of life on cancer patients. the procedure was structured to obtain an active commitment from the subjects to beneficial and rewarding activities in their lives, despite their illness. the conditions which define the quality of life of an oncological patient (symptoms, emotional state, and functioning) were evaluated using standardized qol questionnaires in each treatment session. the effects of the experimental intervention were measured for a control group that attended the same number of sessions of the same duration, but which were dedicated exclusively to evaluating quality of life. this strategy is considered an ideal way of eliminating the jurnal ners http://e-journal.unair.ac.id/jners | 205 possibility that the results of the intervention might be attributed simply to the extra attention patients taking part in the study received (rodríguez et al., 2014). supportive service needs are defined as requirements for patient care related to managing symptoms and side effects, empowering adaptation and coping abilities, optimizing understanding and information in decision-making, and minimizing bodily capacity deficits (maguire et al., 2015). quality of life is an important goal in the treatment of cancer; cancer treatment has a significant impact on physical, psychological, information and social wellbeing, thus requiring support for strong supportive service needs (baryam, durna & akin, 2014). the need for supportive services in this study was carried out for cancer patients. the supportive service needs are divided into five domains, namely the physical domain, the psychological domain, the domain of care support, the domain of health information and systems and the domain of sexuality. the results of the analysis of supportive service needs show that the need for physical domain supportive services is a requirement with the highest percentage. the effectiveness of supportive therapy can be seen from the differences in the ability of cancer patients in the intervention and control groups. increased ability to cope with depression in cancer patients who received supportive therapy group therapy was significantly higher than the increase in ability in the group who did not get therapy. this proves that supportive group therapy has a positive impact on patients' ability to improve their quality of life. we are aware that the study findings are limited by several factor characteristics of our patient sample, which consist of several different types of cancer, cancer stage of different patients, and duration of diagnosis. however, it is important to observe that these changes favor the intervention in assessing group quality of life during oncological treatment. this therapy enhances feelings of belonging, networking and social support as well as family support in cancer patients. which is the basis for the patient's interpersonal abilities. in addition, through this therapy, the patient increases personal abilities, especially increasing the effectiveness of the patient's self, hardiness, and resourcefulness. in line with the main goal of this therapy is as a container to express feelings and thoughts that are felt. through learning to convey feelings and listen to other people's complaints, patients become more able to respect themselves and others. by sharing experiences and listening to the experiences of others, patients learn to manage their emotions and feelings. active participation in expressive supportive group therapy means cancer patients get social support from other group members. cancer patients getting support not only from family, but also from fellow patients is felt to be very meaningful because they feel other people understand the pain, worry and fear they feel. having a social network and being able to ask for and receive support when needed is a vital step in the healing process. patients who receive social support are more likely to seek help and participate in therapy. other factors reported by ebc patients that contribute to reduced ability while coping with stressful events and causing deterioration in the quality of life include long-term treatment period, uncertainty about the disease progression, and physical and psychosocial problems. in this regard, previous reports emphasized that patients with cancer using ineffective emotional coping strategies had greater disease-related distress and showed poor adjustment to their treatment (lake et al., 2019). a previous report also indicated that lower quality of life was associated with ineffective emotional coping styles in patients with cancer (kershaw et al., 2004). this study has advantages in identifying the need for supportive services needed by cancer patients and can be the first step for health services to improve the quality of life of cancer patients. also, it shows the need to improve communication and provision of information from the hospital service structure so that, when patients need information about the cancer suffered, they can get accurate information from health workers. weaknesses in this study are different types of diagnosis of cancer patients with different stages and diverse supportive therapy given. but despite all these limitations, supportive therapy can provide a positive effect for cancer patients with evidence of improvement in their qol. considering the study limitations, it may have been overoptimistic in choosing overall qol as the primary endpoint. although it is highly relevant in clinical trials, qol is a complex phenomenon. in line with the present study, recently published trials and meta-analyses on exercise or nutritional interventions found no significant improvements in overall qol. however, a handful of promising studies that investigated qol in cancer outpatients do exist. these authors demonstrated that early individualized counseling is effective in improving qol and survival. furthermore, it is generally accepted that physical exercise reduces fatigue and improves qol and physical functioning. conclusion after reviewing related studies, it could be concluded that the impact of supportive therapy on the quality of life of cancer patients provides good benefits, such as meaning, spiritual wellbeing, reducing anxiety and the desire for accelerated death. the conclusion of this systematic review is that the quality of this study is good and the results are acceptable in improving the quality of life of cancer patients undergoing chemotherapy treatment, and palliative care. conflict of interest the author declared no competing interests. acknowledgement s. suharyono et al. 206 | pissn: 1858-3598  eissn: 2502-5791 the authors of this study would like to thank the faculty of nursing and also masters in nursing study program, for providing the opportunity to present this study. references a. shrestha, k., collins, c., martin, m. burton, s., walters., and l. wyld. (2019). quality of life versus length of life considerations in cancer patients : a systematic literature review,” no. may 2018, pp. 1367–1380 baryam, z., durna, z., & akin, s. (2014). quality of life during chemotherapy and satisfaction with nursing care in turkish breast cancer patients. european journal of cancer care, 23,675-684.doi: 10.1111/ecc.12185 blanco, c., markowitz, j. c., hellerstein, d. j., nezu, a. m., wall, m., olfson, m., … hershman, d. l. (2019). a randomized trial of interpersonal psychotherapy, problem solving therapy, and supportive therapy for major depressive disorder in women with breast cancer. breast cancer research and treatment, 173(2), 353–364. https://doi.org/10.1007/s10549-018-4994-5 breitbart, w., pessin, h., rosenfeld, b., applebaum, a. j., lichtenthal, w. g., li, y., … fenn, n. (2018). individual meaning-centered psychotherapy for the treatment of psychological and existential distress: a randomized controlled trial in patients with advanced cancer. cancer, 124(15), 3231– 3239. https://doi.org/10.1002/cncr.31539 c. fernández-rodríguez, e. villoria-fernández, p. fernández-garcía, and s. gonzález-fernández. (2017). effects of behavioral activation on the quality of life and emotional state of lung cancer and breast cancer patients during chemotherapy treatment chang, y. l., tsai, y. f., hsu, c. l., chao, y. k., hsu, c. c., & lin, k. c. (2020). the effectiveness of a nurse-led exercise and health education informatics program on exercise capacity and quality of life among cancer survivors after esophagectomy: a randomized controlled trial. international journal of nursing studies, 101, 103418. https://doi.org/10.1016/j.ijnurstu.2019.103418 chang, y.l., tsai, y.f., chao, y.k., wu, m.y. (2016). quality-of-life measures as predictorss of postesophagectomy survival of patients with esophageal cancer. qual. life res. 25 (2), 465–475. doi: 10.1007/s1113601510944 chasen, m.r., bhargava, r. (2010). a rehabilitation program for patients with gastroesophageal cancer –a pilot study". support care cancer 18 (2), s35–s40. doi: 10.10 07/s0 052001008287 duluklu, b., & çelik, s. ş. (2019). effects of lavender essential oil for colorectal cancer patients with permanent colostomy on elimination of odor, quality of life, and ostomy adjustment: a randomized controlled trial. european journal of oncology nursing, 42(march), 90–96. https://doi.org/10.1016/j.ejon.2019.08.001 downs sh, black n. (2016). the feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. j epidemiol community health 1998;52:377-84 foster, c., wright, d., hill, h., hopkinson, j., & roffe, l. (2009). psychosocial implications of living 5 years or more following a cancer diagnosis: a systematic review of the research evidence". european journal of cancer care, 18, 223-247. doi:10.1111/j.1365-2354.2008.01001.x gok metin, z., karadas, c., izgu, n., ozdemir, l., & demirci, u. (2019). effects of progressive muscle relaxation and mindfulness meditation on fatigue, coping styles, and quality of life in early breast cancer patients: an assessor blinded, three-arm, randomized controlled trial. european journal of oncology nursing, 42(september), 116–125. https://doi.org/10.1016/j.ejon.2019.09.003 hughes, s., jaremka, l. m., alfano, c. m., glaser, r., povoski, s. p., lipari, a. m., malarkey, w. b. (2014). social support predicts inflammation, pain, and depressive symptoms: longitudinal relationships among breast cancer survivors". psychoneuroendocrinology, 42, 38-44. doi:10.1016/j.psyneuen. 2013.12.016 jefford, m., gough, k., drosdowsky, a., russell, l., aranda, s., butow, p., … schofield, p. (2016). a randomized controlled trial of a nurse-led supportive care package (survivorcare) for survivors of colorectal cancer. the oncologist, 21(8), 1014–1023. https://doi.org/10.1634/theoncologist.20150533 klafke, n., mahler, c., von hagens, c., uhlmann, l., bentner, m., schneeweiss, a., … joos, s. (2019). the effects of an integrated supportive care intervention on quality of life outcomes in outpatients with breast and gynecologic cancer undergoing chemotherapy: results from a randomized controlled trial. cancer medicine, 8(8), 3666–3676. https://doi.org/10.1002/cam4.2196 kershaw, t., northouse, l., kritpracha, c., schafenacker, a., mood, d., coping strategies and quality of life in women with advanced breast cancer and their family caregivers. psychol. health 19 (2), 139–155, 2004. klafke, n., mahler, c., von hagens, c., uhlmann, l., bentner, m., schneeweiss, a., … joos, s. (2019). the effects of an integrated supportive care intervention on quality of life outcomes in outpatients with breast and gynecologic cancer undergoing chemotherapy: results from a randomized controlled trial. cancer medicine, 8(8), 3666–3676. https://doi.org/10.1002/cam4.2196 lake, b., fuller, h.r., rastall, s., usman, t. (2019). breast reconstruction affects coping mechanisms in breast cancer survivors". indian j. surg. 81 (1), 43–50. jurnal ners http://e-journal.unair.ac.id/jners | 207 maguire, r., kotronoulas, g., simpson, m., & paterson, c. (2015). gynecologic oncology a systematic review of the supportive care needs of women living with and beyond cervical cancer. gynecologic oncology, 136(3), 478–490. http://doi.org/10.1016/j.ygyno. 2014.10.030 malmström, m., ivarsson, b., klefsgård, r., persson, k., jakobsson, u., & johansson, j. (2016). the effect of a nurse led telephone supportive care programme on patients’ quality of life, received information and health care contacts after oesophageal cancer surgery—a six month rct-follow-up study. international journal of nursing studies, 64, 86–95. https://doi.org/10.1016/j.ijnurstu.2016.09.009 pace, t. w. w., dodds, s. e., sikorskii, a., badger, t. a., segrin, c., negi, l. t., … crane, t. e. (2019). cognitively-based compassion training versus cancer health education to improve health-related quality of life in survivors of solid tumor cancers and their informal caregivers: study protocol for a randomized controlled pilot trial. trials, 20(1), 1– 15. https://doi.org/10.1186/s13063-019-3320-9 qiu, y., you, j., wang, k., cao, y., hu, y., zhang, h., … lyu, q. (2020). effect of whole-course nutrition management on patients with esophageal cancer undergoing concurrent chemoradiotherapy: a randomized control trial. nutrition, 69, 1–9. https://doi.org/10.1016/j.nut.2019.110558 schuit, a. s., holtmaat, k., hooghiemstra, n., jansen, f., lissenberg-witte, b. i., coupé, v. m. h., … verdonck-de leeuw, i. m. (2019). efficacy and cost-utility of the ehealth application “oncokompas”, supporting patients with incurable cancer in finding optimal palliative care, tailored to their quality of life and personal preferences: a study protocol of a randomized controlled trial. bmc palliative care, 18(1), 1–11. https://doi.org/10.1186/s12904-019-0468-8 temel, j. s., greer, j. a., el-jawahri, a., pirl, w. f., park, e. r., jackson, v. a., … ryan, d. p. (2017). effects of early integrated palliative care in patients with lung and gi cancer: a randomized clinical trial. journal of clinical oncology, 35(8), 834–841. https://doi.org/10.1200/jco.2016.70.5046 uster, a., ruehlin, m., mey, s., gisi, d., knols, r., imoberdorf, r., … ballmer, p. e. (2017). effects of nutrition and physical exercise intervention in palliative cancer patients : a randomized controlled trial. clinical nutrition, (june), 1–8. https://doi.org/10.1016/j.clnu.2017.05.027 vanbutsele, g., van belle, s., surmont, v., de laat, m., colman, r., eecloo, k., … pardon, k. (2020). the effect of early and systematic integration of palliative care in oncology on quality of life and health care use near the end of life: a randomised controlled trial. european journal of cancer, 124, 186–193. https://doi.org/10.1016/j.ejca.2019.11.009 zhou, k., wang, d., he, x., huo, l., an, j., li, m., … li, x. (2016). effectiveness of a multimodal standard nursing program on health-related quality of life in chinese mainland female patients with breast cancer: protocol for a single-blind cluster randomized controlled trial. bmc cancer, 16(1), 1– 8. https://doi.org/10.1186/s12885-016-2726-y zhou, y., cartmel, b., gottlieb, l., ercolano, e. a., li, f., harrigan, m., … irwin, m. l. (2017). randomized trial of exercise on quality of life in women with ovarian cancer: women’s activity and lifestyle study in connecticut (walc). journal of the national cancer institute, 109(12), 1–7. https://doi.org/10.1093/jnci/djx072 vol 9 no 1 april 2014.indd 66 intervensi psikoedukasi meningkatkan kemampuan pralansia dalam penanganan hipertensi (psychoeducation intervention increase on the ability of the pre-senile hypertension management) nyoman sudja*, meirina* *program studi diii keperawatan politeknik kesehatan kemenkes bandung jl. dr. otten no.32 bandung 40171 e-mail: nyomansudja@yahoo.co.id abstrak pendahuluan: pertambahan usia berakibat pada kemunduran kemampuan dan perubahan fi sik, termasuk pada sistem kardiovaskuler. pada usia pralansia pembuluh darah kehilangan elastisitasnya sehingga tahanan vaskuler perifer meningkat sehingga terjadi hipertensi. penelitian ini bertujuan untuk mendapatkan gambaran tentang pengaruh psikoedukasi terhadap kemampuan pralansia dalam penanganan hipertensi. metode: desain penelitian adalah quasi eksperiment pre-post test with control group, dilakukan intervensi psikoedukasi dengan jumlah sampel sebesar 72 orang. hasil: terdapat perbedaan yang bermakna pengetahuan dan perilaku pralansia sebelum dan sesudah mendapatkan intervensi psikoedukasi pada kelompok intervensi ( p-value pengetahuan = 0,000, dan perilaku = 0,000). sedangkan pada kelompok kontrol tidak ada perbedaan pengetahuan (p=0,896), namun terdapat perbedaan bermakna pada perilaku pralansia (p=0,049). ada perbedaan pengetahuan dan perilaku pralansia setelah diberikan intervensi psikoedukasi (post test) pada kelompok intervensi dan kelompok kontrol ( p-value pengetahuan=0,001, perilaku=0,018). diskusi: psikoedukasi dapat meningkatkan kemampuan pralansia dalam penanganan hipertensi, sehingga diharapkan program ini merupakan salah satu bentuk intervensi yang dapat diterapkan terhadap kelompok pralansia di seluruh posbindu wilayah kota bogor. kata kunci: psikoedukasi, kemampuan, pralansia, hipertensi abstract introduction: increasing age in pre-senile, causes a deterioration abilities and physical changes, including the cardiovascular system. blood vessels lose their elasticity thus be increased peripheral vascular resistance that results in hypertension. this study aims to gain an idea of the effect on the ability of pre-senile people’s psychoeducation in the management of hypertension. method: quasi-experimental, the pre-post test with control group design, psychoeducation intervention with a sample size of 72 people . result: the results showed signifi cant difference of pre-aged knowledge and behavior before and after getting psychoeducation intervention in the intervention group (p-value = 0.000 knowledge, and behaviors = 0.000) . whereas in the control group there was no difference in knowledge (p-value = 0.896), but there are signifi cant differences in behavior of pre-senile people (p-value = 0.049). there are differences in knowledge and behavior after they were given psychoeducation intervention (post-test ) in the intervention group and the control group (p-value = 0.001 knowledge , behavior=0.018). discussion: psychoeducation had effect on the ability of pre-senile in the management of hypertension, so this program can be applied to groups of posbindu for pre-senile people throughout the areas of the city of bogor. key words: psychoeducation, skills, pre-senile, hypertension pendahuluan proses menua mengakibatkan berbagai perubahan baik secara fi sik, psikologis, sosial, maupun ekonomi. perubahan fi sik merupakan bentuk nyata dari proses menua yang dapat diamati secara langsung, dan terjadi pada semua sistem, terjadi penurunan berbagai fungsi tubuh (stanhope m. & lancaster, 2004). bertambahnya usia dan perubahan biologis pada pralansia, berakibat timbulnya kemunduran kemampuan dan perubahan fi sik, termasuk pada sistem kardiovaskuler akibat pembuluh darah kehilangan elastisitasnya sehingga tahanan vaskuler perifer menjadi men i ng kat ya ng berd a npa k ter jad i nya hipertensi (lueckenotte, 2000). hipertensi merupakan penyakit yang menempati urutan kelima dari penyakit yang menyebabkan kematian di dunia. hiper tensi memberi peluang 12 kali lebih besar bagi penderitanya untuk terserang stroke, 6 kali lebih besar untuk serangan jantung, serta 5 kali lebih besar kemungkinan meninggal karena gagal jantung. sedangkan kejadian hipertensi di 67 intervensi psikoedukasi meningkatkan kemampuan pralansia (nyoman sudja dan meirina) indonesia teridentifi kasi 5 kali lebih banyak dibandingkan dengan negara maju (sustrani, 2004). kota bogor, di mana jumlah penduduk lansia sebanyak 34.599 orang (3,62%), dengan jumlah kelompok lansia (posbindu) sebanyak 216. dari jumlah lansia yang dibina sebanyak 9726 orang, ditemukan 3155 orang (32,44%) mengalami hipertensi. sedangkan dari jumlah lansia yang ada, sebanyak 58,98% merupakan kelompok umur pralansia (dinkes kota bogor, 2009). hasil kajian penyakit hipertensi yang dilakukan minarti di kelurahan depok menunjukkan dari 155 lanjut usia, yang mengalami hipertensi sebesar 35,5%. sebagian besar pengetahuan nya tentang perawatan hipertensi masih kurang yaitu sebesar 50,9%, kebiasaan mengenai pola makan yang dikonsumsi setiap hari 54,5% sering mengonsumsi makanan berlemak, dan 45,5% masih mengonsumsi lauk yang asin, kebiasaan minum obat hipertensi 63,6% tidak teratur, serta 54,5% tidak melakukan olah raga. penatalaksanaan asuhan keperawatan yang dilakukan terhadap kelompok usia lanjut dengan hiper tensi, menu nju k kan terjadi peningkatan pengetahuan sebesar 70% (minarti, 2007). penyakit hiper tensi pada pralansia yang bersifat menahu n mengak ibatkan munculnya berbagai per masalahan, baik fisik maupun psikososial, dan berdampak pada diri pralansia ber upa respons stres yang berkelanjutan (miller, 2004). dampak stress dapat memicu peningkatan tekanan darah. kaplan (2004) mengungkapkan bahwa perawatan penyakit kardiovaskuler, selain modifikasi gaya hidup, manajemen stress, juga penting untuk mengontrol tekanan darah. kuswardani (2006) juga mengemukakan bahwa dalam penatalaksanaan hipertensi pada lanjut usia, beberapa pola hidup yang harus diperbaiki adalah: menurunkan berat badan jika ada kegemukan, mengurangi minum alkohol, meningkatkan aktivitas fi sik aerobik, mengurangi asupan garam, mempertahankan asupan kalium yang adekuat, mempertahankan asupan kalsium dan magnesium yang adekuat, menghentikan merokok, mengurangi asupan lemak jenuh dan kolesterol. pendekatan penyuluhan (counseling) dalam penanganan hipertensi, walau banyak sesi yang dilakukan dan pasien tetap minum obat anti hipertensi, namun hanya sedikit perubahan dalam gaya hidup, yang diikuti dengan sedikit penurunan tekanan darah. oleh karena itu, diperlukan st rategi inter vensi psi koedu kasi dalam memodifikasi gaya hidup dan pengelolaan stres pasien (kaplan, 2004). psikoedukasi merupakan pemberian informasi tentang pengelolaan penyakit dan aspek psikologik pasien (hasanat & ningrum, 2010). program inter vensi psikoedukasi mer upakan strategi pemberian informasi tentang penyakit dan cara perawatannya, latihan perilaku dalam mengatasi masalah, cara mengontrol ketegangan dan stres, serta strategi mengatasi masalah perilaku pasien (a nd ren & elmst ahl, 2005). beberapa h a si l p e nel it ia n me nu nju k k a n ba hwa intervensi psikoedukasi dapat menurunkan masalah kesehatan mental, khususnya dapat menurunkan kecemasan, depresi. program psikoedukasi juga bermakna sebagai upaya untuk melatih life skills pasien agar dapat menjalani pengobatan diabetes dengan lebih baik. psikoedukasi ini memiliki mak na melatih pasien mempelajari berbagai life skills, dan serangkaian kegiatan pelayanan kepada masyarakat (hasanat & ningrum, 2010). melalui intervensi psikoedukasi diharapkan dapat meningkatkan kemampuan pralansia dalam penanganan hipertensi yaitu terjadinya perubahan pengetahuan, sikap dan perilaku dalam penanganan hipertensi. penelitian ini bertujuan untuk mendapatkan gambaran tentang pengar uh psikoedukasi terhadap kemampuan pralansia dalam penanganan hipertensi. bahan dan metode desain penelitian yang digunakan adalah quasi experiment pre-post test with control group, dengan intervensi psikoedukasi. intervensi psikoedukasi dilakukan selama 5 mingg u (5 sesi) dengan memberikan i nfor masi tent ang hiper tensi d an cara penanganannya, latihan proses penyelesaian masalah yang menyangkut kehidupan sosial 68 jurnal ners vol. 9 no. 1 april 2014: 66–73 pribadi, masalah keluarga, masalah dalam penanganan hipertensi dan manajemen stres. populasi penelitian adalah pralansia yang mengalami hipertensi di wilayah kota bogor, sedangkan sampel penelitian adalah pralansia yang aktif datang ke posbindu, ber usia 45–59 tahun, bisa membaca dan menulis. strategi sampling menggunakan cluster multistage method yaitu pemilihan sampel berdasarkan kluster dengan beberapa tahapan random sesuai dengan wilayah geografi s dengan jumlah sampel sebanyak 72 pralansia (36 orang kelompok intervensi dan 36 orang kelompok kontrol). inst r umen yang dig unakan dalam p e ng u m pu l a n d at a b e r u p a k u e sione r yang dikembangkan oleh peneliti tentang kemampuan pralansia dalam penanganan hipertensi meliputi pengetahuan, sikap dan perilaku yang telah diuji coba. penelitian ini dilakukan di kecamatan bogor tengah dan kecamatan tanah sareal kota bogor dalam waktu tiga bulan. data yang telah terkumpul kemudian dianalisis menggunakan dependent t-test dan independent t-test. hasil k a r a k t e r i s t i k r e s p o n d e n d a l a m penelitian ini yaitu: umur responden pada kelompok intervensi rata-rata 54.28 dengan standar deviasi 4.73, dan pada kelompok kontrol hampir sama yaitu rata-rata 55.47 dengan standar deviasi 4.10. mayoritas jenis kelamin pada kedua kelompok yaitu perempuan. pendidikan responden pada kelompok intervensi lebih dari setengahnya (66,70%) berpendidikan rendah, sedangkan pada kelompok kontrol mayoritas (80,60%) berpendidikan rendah. mayoritas responden tabel 1. perbedaan pengetahuan, sikap dan perilaku sebelum dan sesudah intervensi model psikoedukasi pada kelompok intervensi dan kelompok kontrol di kota madya bogor, 2013 (n=72) variabel kelompok mean sd 95% ci t p value* pengetahuan intervensi sebelum sesudah selisih 19.92 23.39 3.47 3.37 1.99 -4.338(-2.607) 8.145 0.000 kontrol sebelum sesudah selisih 20.69 20.78 0.083 3.17 3.85 -1.3711.204 0.131 0.896 sikap intervensi sebelum sesudah selisih 35.89 37.06 1.17 7.71 7.62 -4.4242.089 0.727 0.472 kontrol sebelum sesudah selisih 35.94 35.97 0.03 5.12 5.43 -2.4602.405 0.023 0.982 perilaku intervensi sebelum sesudah selisih 14.39 16.33 1.94 2.03 1.26 -2.616(-1.273) 5.878 0.000 kontrol sebelum sesudah selisih 15.44 16.33 0.89 1.86 1.26 -1.774(-0.004) 2.039 0.049 *dependent t-test 69 intervensi psikoedukasi meningkatkan kemampuan pralansia (nyoman sudja dan meirina) berstat us kawin pada kedua kelompok, dan tinggal bersama anak/cucu. lebih dari separuhnya mempunyai status gizi normal yaitu 61,10% pada kelompok intervensi dan 58.30% pada kelompok kontrol. mayoritas responden (72,20%) pada kelompok intervensi mempunyai riwayat hipertensi dan saat ini sebanyak 41,70% menderita hipertensi tingkat sedang dan 11,10% menderita hipertensi berat. pada kelompok kontrol sebanyak 52,80% mempunyai riwayat hipertensi dan saat ini sebanyak 33,30% menderita hipertensi tingkat sedang dan 16,70% menderita hipertensi berat. hasil analisis bivariat menggunakan dependent t-test untuk mengetahui perbedaan pengetahuan, sikap dan perilaku pralansia dalam penanganan hipertensi sebelum dan sesudah intervensi model psikoedukasi pada kelompok intervensi dan kelompok kontrol, dapat dilihat pada tabel 1. hasil analisis menunjukkan bahwa rat a-rat a penget a hu a n responden pad a kelompok inter vensi sebelum inter vensi model psikoedukasi ( pre-test) yaitu 19.92 dan sesudah intervensi model (post-test) meningkat menjadi 23.39, dengan nilai p = 0.000. dapat disimpulkan bahwa ada perbedaan bermakna pengetahuan responden sebelum dan sesudah i nter vensi model psi koedu kasi. unt u k kelompok kontrol, rata-rata pengetahuan (pretest) yaitu 20.69, dan post-test hampir sama yaitu 20.78 dengan nilai p = 0,896 berarti tidak ada perbedaan pengetahuan responden pre dan post test pada kelompok kontrol yang tidak mendapat intervensi model. r at a-r at a si k ap re sp onde n pa d a kelompok inter vensi sebelum dilakukan intervensi model psikoedukasi ( pre-test) yaitu 35.89 dan sesudah intervensi model ( posttest) meningkat menjadi 37.06, dengan nilai p = 0,472. dapat disimpulkan bahwa tidak ada perbedaan sikap responden sebelum dan sesudah intervensi model psikoedukasi. untuk kelompok kontrol, rata-rata sikap pada pre-test yaitu 35.94, dan post-test hampir sama yaitu 35.97 dengan nilai p = 0,982 berarti tidak ada perbedaan sikap responden pre dan post-test pada kelompok kontrol yang tidak mendapat intervensi model. rata-rata perilaku responden pada kelompok inter vensi sebelum inter vensi model psikoedukasi ( pre-test) yaitu 14.39 dan sesudah intervensi model (post-test) meningkat menjadi 16.33, dengan nilai p = 0.000. dapat disimpulkan bahwa ada perbedaan bermakna perilaku responden sebelum dan sesudah i nter vensi model psi koedu kasi. unt u k kelompok kontrol, rata-rata sikap pada pretest yaitu 15.44 dan post-test yaitu 16.33 dengan nilai p = 0,049 berarti ada perbedaan bermakna perilaku responden pre dan post-test pada kelompok kontrol yang tidak mendapat intervensi model. selanjutnya, hasil analisis bivariat mengg unakan independent t-test unt u k mengetahui perbedaan pengetahuan, sikap dan perilaku pralansia dalam penanganan h ip e r t e n si s e s u d a h i nt e r ve n si mo d el psikoedukasi antar kelompok, dapat dilihat pada tabel 2. hasil analisis menunjukkan bahwa nilai rata-rata pengetahuan responden sesudah tabel 2. perbedaan pengetahuan, sikap dan perilaku sesudah intervensi model psikoedukasi pada kelompok intervensi dan kelompok kontrol di kota madya bogor, 2013 (n=72) variabel kelompok mean sd 95%ci t nilai p* pengetahuan intervensi 23.39 1.99 1.171–4.051 3.617 0.001kontrol 20.78 3.85 sikap intervensi 37.06 7.62 1.083–1.560 0.695 0.490kontrol 35.97 5.43 perilaku intervensi 17.00 1.069 0.116–1.217 2.415 0.018kontrol 16.33 1.265 *independent ttest 70 jurnal ners vol. 9 no. 1 april 2014: 66–73 intervensi model psikoedukasi pada kelompok intervensi 23.39, sedangkan pada kelompok kontrol 20.78 dengan nilai p = 0.001, berarti ad a perbed a an ber ma k na penget ahuan responden antara kelompok intervensi dan kelompok kontrol. rata-rata sikap responden sesudah intervensi model psikoedukasi pada kelompok intervensi 37.06, sedangkan pada kelompok kontrol 35.97 dengan nilai p = 0.490, berarti tidak ada perbedaan sikap responden antara kelompok intervensi dan kelompok kontrol. untuk perilaku, diperoleh nilai ratarata sesudah intervensi model psikoedukasi pada kelompok intervensi 17.00, sedangkan pada kelompok kontrol 16.33 dengan nilai p = 0.018, berarti ada perbedaan bermakna perilaku responden antara kelompok intervensi dan kelompok kontrol. pembahasan hasil penelitian menunjuk kan ada perbedaan bermakna pengetahuan responden sebelum dan sesudah inter vensi model psikoedukasi pada kelompok inter vensi, sedangkan pada kelompok kontrol tidak ada perbedaan. perubahan pengetahuan pralansia pada kelompok intervensi membuktikan secara empiris bahwa intervensi psikoedukasi dapat meningkatkan pengetahuan. pengetahuan adalah sesuat u yang berasal dar i hasil pengindaran seseorang yang didapatkan dari hasil pembelajaran. pada penelitian ini, pembelajaran diberikan melalui psikoedukasi. psikoedukasi dapat meningkatkan kemampuan kognitif karena dalam terapi mengandung unsur untuk meningkatkan pengetahuan individu tentang penyakit (supratik nya, 2006). psikoedukasi adalah suatu tindakan yang diberikan kepada individu dan keluarga untuk memperkuat strategi koping atau suatu cara khusus dalam menangani kesulitan perubahan mental (mottoghipour & bickerton, 2005). psikoedukasi adalah sebuah modalitas tritmen yang disampaikan oleh tenaga profesional, dengan mengintegrasikan dan mensinergikan antara psikoterapi dan intervensi edukasi (cartwright, 2007, dalam hasanat & ningrum, 2010). psikoedukasi mencakup berbagai kegiatan yang menggabungkan pendidikan dan kegiatan lain seperti konseling dan intervensi mendu k u ng. jenis inter vensi ter masu k pemberian informasi tentang pengobatan, gejala, sumber daya dan layanan pelatihan untuk memberikan perawatan dan mengatasi masalah terkait penyakit ser ta st rategi penyelesaian masalah. materi psikoedukasi yang diberikan dan didiskusikan dalam penelitian ini terkait dengan penyakit hipertensi, penyelesaian masalah dan penanganan stres, terbukti mampu meningkatkan kemampuan koping pralansia dalam mengatasi masalah. hal ini didukung oleh hasil pengamatan dalam pelaksanaan diskusi pada saat psikoedukasi, ditemukan sebanyak 90% responden aktif, responden juga mampu mempraktikkan kembali cara penanganan stres serta cara mengatasi masalah yang sedang dihadapi. setelah dilakukan psikoedukasi, sebagain responden mengatakan pengetahuannya bertambah tentang hipertensi dan berusaha untuk melakukan tindakan mengurangi merokok, mengurangi konsumsi garam, lemak, minum kopi, serta melaksanakan relaksasi progresif dan penanganan stres yang benar. hal ini tampak dalam daftar kegiatan yang dilakukan pralansia di mana mereka mampu melakukan cara penyelesaian masalah dan penanganan stres dengan benar melalui relaksasi progresif. didukung pula oleh hasil penelitian cartwright (2007, dalam hasanat & ningrum, 2010) bahwa psikoedukasi dapat mengurangi kecemasan, meningkatkan pengetahuan, harga diri dan kepatuhan dalam pengobatan. hasil penelitian menunjukkan tidak ada perbedaan sikap pralansia sebelum dan sesudah intervensi model psikoedukasi pada kelompok intervensi, demikian juga pada kelompok kontrol. ketidakbermaknaan sikap pralansia kemungkinan disebabkan oleh banyak faktor di mana untuk merubah sikap seseorang diperlukan intervensi secara terus menerus dalam waktu yang relatif lama, sedangkan pada penelitian ini intervensi yang diberikan hanya dalam waktu lebih kurang 5 minggu. hasil penelitian ini sesuai dengan teori notoatmodjo (2007), bahwa sikap sesorang dipengaruhi oleh pengalaman pribadi, kebudayaan, orang 71 intervensi psikoedukasi meningkatkan kemampuan pralansia (nyoman sudja dan meirina) lain yang dianggap penting, media massa, institusi pendidikan dan agama, serta faktor emosi dalam diri. dalam penelitian ini pada kelompok kontrol tidak dilakukan intervensi sehingga tidak memberikan pengaruh pada responden dalam perubahan sikap. jika dilihat dari karakteristik responden adalah pralansia, yang mana sikap sudah terbentuk sejak kanakkanak, sehingga sikap seseorang tersebut sulit berubah. sikap seseorang berhubungan dengan kebiasaannya sehari-hari, seperti beberapa responden mengatakan masih tetap minum kopi atau merokok, dan minum obat hanya jika tekanan darah meningkat. hasil penelitian ini juga tidak ditemukan perbedaan sikap responden antara kelompok intervensi dan kelompok kontrol. tidak adanya perbedaan sikap yang signifi kan disebabkan karena pendidikan responden yang rendah (75%), penghasilan di bawah umr (75%), serta kurangnya jaminan pelayanan kesehatan (jamkesmas, jamkesda) juga kebiasaan seharihari responden seperti; merokok, minum kopi, mengonsumsi makanan tinggi garam, mengonsu msi makanan yang berlemak (gorengan). hal tersebut sangat mempengaruhi sikap sesorang, begitu pula jika keinginan dan kemauan yang tidak mau merubah kebiasaan tersebut. tingkat pendidikan yang lebih tinggi ditemukan lebih sering menggunakan pelayanan kesehatan (stuart & laraia, 2006). fak tor pendidikan juga mempengar u hi kemampuan seseorang dalam menyelesaikan masalah yang dihadapinya. penatalakssanaan hiper tensi selain dengan obat-obatan (far makologis), juga memodifi kasi pola hidup dengan menurunkan berat badan jika kegemukan, mengurangi al kohol, mening katkan ak tivitas f isi k, mengurangi asupan garam, mempertahankan asupan kalium, kalsium dan magnesium yang adekuat, berhenti merokok, dan mengurangi asupan lemak (kuswardani , 2006). namun belum semua responden mampu merubah pola hidupnya kearah pola hidup sehat yang dit unjuk kan dengan sikap kurang memperdulikan kesehatannya dengan tetap merokok, tidak melakukan olah raga rutin dan masih makan makanan berlemak. hasil penelitian ditemukan perbedaan bermakna perilaku responden sebelum dan sesudah intervensi model psikoedukasi pada kelompok intervensi, demikian juga pada kelompok kontrol ditemukan perbedaan bermakna perilaku responden pre dan post test. perilaku seseorang dipengaruhi oleh faktor internal dan eksternal. menurut who, yang dikutip oleh notoatmodjo, (2007), perubahan perilaku dikelompokkan menjadi 3 (tiga), yaitu: 1) perubahan alamiah (natural change), yaitu perubahan akibat lingkungan fisik, sosial, budaya ataupun ekonomi di mana dia hidup dan beraktivitas; 2) perubahan terencana (planned change), yaitu perubahan yang terjadi karena memang direncanakan sendiri oleh individu; dan 3) perubahan karena kesediaan individu untuk berubah (readiness to change), yaitu perubahan yang terjadi apabila terdapat suatu inovasi atau program-program baru, maka yang terjadi adalah sebagian orang cepat mengalami perubahan perilaku dan sebagian lagi lamban. hal ini disebabkan setiap orang mempunyai kesediaan untuk berubah yang berbeda-beda. kebermaknaan hasil penelitian ini sesuai dengan pendapat notoatmodjo bahwa adanya perubahan perilaku pada kelompok intervensi disebabkan karena kesediaan atau kemauan dirinya yang tinggi untuk berubah, selain karena adanya intervensi psikoedukasi yang memicu keinginan responden untuk melakukan berbagai intervensi yang telah diajarkan. hal ini dipengaruhi pula oleh keingintahuan yang besar dari responden dalam penanganan hipertensi agar dapat meningkatkan kesehatannya. sedangkan pada kelompok kontrol, walaupun tidak diberikan intervensi, kemungkinan perubahan perilaku terjadi akibat per ubahan secara alamiah seper ti yang diungkapkan notoatmodjo di mana perubahan terjadi akibat lingkungan fi sik, sosial, budaya ataupun ekonomi di mana mereka hidup dan beraktivitas. kemungkinan keterpaparan informasi dari berbagai media informasi yang bisa diakses oleh responden dan karena sosialisasi yang dilakukan di lingkungan tempat tinggalnya sehingga mereka lebih mudah mendapatkan informasi terkait penanganan hipertensi. 72 jurnal ners vol. 9 no. 1 april 2014: 66–73 perubahan perilaku juga dipengaruhi oleh kebutuhan individu tersebut. seseorang dapat bertindak (berperilaku) positif terhadap objek demi pemenu han kebut u han nya, sebaliknya bila objek tidak dapat memenuhi kebut uhan nya maka ia akan ber prilaku negatif ( notoat modjo, 2007). pralansia sebagai responden dalam penelitian ini merasa psikoedukasi yang diberikan sangat dibutuhkan dalam penanganan hipertensi yang dideritanya. strategi untuk memdodifi kasi pola hidup sehat, latihan manajemen stres dan cara penyelesaian masalah yang diajarkan dirasakan sangat bermanfaat karena dapat diterapkan dalam kehidupan sehari-hari, sehingga tidak hanya tergantung pada obat-obatan. hal ini terlihat dari peningkatan perilaku responden setelah dilakukan intervensi psikoedukasi dari nilai rata-rata 14.39 menjadi 16.33. simpulan model psikoedukasi terbukti efektif meningkatkan pengetahuan dan perilaku pralansia dalam penanganan hipertensi. hal ini ditunjukkan dengan hasil penelitian bahwa ditemukan perbedaan bermakna pengetahuan r e s p o n d e n s e s u d a h i nt e r ve n si m o d el psikoedukasi diantara kelompok intervensi dan kelompok kont rol. demi k ian juga dengan perilaku pralansia dalam penanganan hipertensi ditemukan ada perbedaan yang bermakna setelah dilakukan intervensi model psikoedukasi di antara kelompok intervensi dan kelompok kontrol. sedangkan untuk variabel sikap tidak ditemukan perbedaan setelah dilakukan intervensi model psikoedukasi di antara kelompok intervensi dan kelompok kontrol karena perubahan sikap seseorang membutuhkan waktu yang relatif lama. saran hasil penelitian ini dapat dijadikan acu a n bag i per awat komu n it as d ala m menerapkan promosi kesehatan bagi pralansia yang mengalami hipertensi di masyarakat. pengembangan kelompok swabantu bagi pralansia mer upakan salah satu strategi intervensi pemberdayaan pralansia dimana mereka bisa saling berbagai perasaan dan pengalaman dalam penanganan hipertensi sehingga dapat meng u rangi st res yang dialami. disamping itu, keluarga sebagai si s t e m p e nd u k u ng b a g i l a n sia p e rlu d iberd aya ka n denga n mengemba ng ka n program pemberdayaan keluarga sehingga mampu merawat lansia dengan baik. perlu juga dilakukan penelitian lanjut terkait faktor-faktor yang berhubungan dengan sikap pralansia dalam penanganan hipertensi. daftar pustaka andren s. & elmstahl s., 2005. family caregivers subjective experiences of satisfaction in dementia care: asfects of burden, subjective health and sense of coherence, scand j. caring sci, 19, 157–168, 30 juli 2012. dinkes kota bogor, 2009. profi l kesehatan kota bogor. hasanat n. & ningrum r.r., 2010. program psikoedukasi bagi pasien diabetes untuk meningkatkan kualitas hidup, (online), (http://ugm.ac.id), diakses tanggal 22 juli 2012. kuswardani rat., 2006. penatalaksanaan hypertensi pada lanjut usia, (online), (http://ejournal. unud.ac.id), diakses tanggal 22 juli 2012. lueckenotte, annete g., 2000. gerontologic nursing, 2nd ed., philadelphia: mosby miller c.a., 2004. nursing for wellness in older adult: teory & practice, philadelphia: j.b. lippinocort co minarti, 2007. penatalaksanaan hipertensi pada usia lanjut dengan menggunakan teori orem dan model health belief di kelurahan depok, karya tulis ilmiah tidak dipublikasikan, fakultas ilmu keperawatan universitas indonesia. mottoghipour, y., & bickerton, 2005. the pyramid of family care: a framework for family invalvement with adult mental health srvices, toronto: prentice hall health kaplan,n.m., 2004. lifestyle modifi cations for prevent ion a nd t reat ment of h ip e r t e n sion , ju r n al of clinical hypertension, vol 6, issues 12, 20 juli 2012, http ://onlinelibrary.willy.com/ 73 intervensi psikoedukasi meningkatkan kemampuan pralansia (nyoman sudja dan meirina) notoatmodjo, 2007a. promosi kesehatan dan ilmu perilaku, jakarta : rinekacipta notoatmodjo, 2010b. promosi kesehatan: teori dan aplikasi, rineka cipta: jakarta stanhope, m., & lancaster j., 2004. community and public health nursing, 6th ed., usa: mosby stuart, g.w., & laraia, m., 2006. principles and practice of psychiatric nursing, (7thed). st. louis: mosby. supratiknya, a., 2006. merancang program dan modul psikoedukasi, yogyakarta: universitas sanata darma. sustrani l., alam s., & hadibroto i., 2004. hipertensi, jakarta: pt gramedia. http://e-journal.unair.ac.id/jners | 135 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.22399 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research nurses’ individual characteristics associated with five moments handwashing compliance maryana maryana and rima berti anggraini stikes citra delima bangka belitung, pangkal pinang, indonesia abstract introduction: the most effective way to control infection is to ensure that hospital staff carry out handwashing according to the protocols. this study aims to determine the characteristics of nursing individuals that affect the compliance of the five moments of handwashing in the hospital inpatient room. methods: the method used was a quantitative with a cross-sectional approach. the population was all nurses in five inpatient rooms totalling 84 nurses selected using purposive sampling. the dependent variable was the compliance of nurses' handwashing. the independent variables were the individual characteristics of the nurses, including knowledge, gender, age, attitude, motivation, skin condition, years of service, education, employment status, infrastructure, and type of room. the data were collected using a questionnaire and observation of handwashing compliance. the handwashing observation was based on the hospital guidelines, and the relationship between the variables was analyzed using chi square and logistic regressions test. results: the study indicates that there is a significant relationship between motivation, education, and room type on compliance with the five moments handwashing (p < 0.05). the most dominant factor was type of room, and there is no relationship between gender, age, years of work, skin condition, knowledge, attitude, employment status and infrastructures (p > 0.05). conclusion: it is hoped that nurses can increase self-motivation to wash their hands for five minutes while working, as a form of dedication at work and to protect patients and themselves from nosocomial infections. besides, hospital management needs to make efforts to increase the motivation of nurses. article history received: october 20, 2020 accepted: september 11, 2021 keywords five moments; handwashing compliance; nursing implementation contact maryana maryana  maryana385@yahoo.com  stikes citra delima bangka belitung, pangkal pinang, indonesia cite this as: maryana, m & anggraini, r., b. (2021). nursing individual characteristics affecting five moments handwashing compliance. jurnal ners, 16(2). 135-141. doi: http://dx.doi.org/10.20473/jn.v16i2.22399 introduction the incidence of nosocomial infections is increasing in both developed and developing countries. the cause of nosocomial-infections is mostly transient flora. microorganisms classified as transient flora are obtained by health workers when they are in direct contact with patients or with a contaminated environment. the source of cross-contamination in hospitals is the transfer of microorganisms from the hands of healthcare workers who make direct contact from one patient to another. the impact of the incidence of infection nosocomial can cause long days of stay, increase resistance to microorganisms, increase the burden of treatment costs, and, the most dangerous, death. one of the components to limit the spread of nosocomial infections is sufficient infection control. the most effective way to control contamination is to ensure that hospital staff perform hand hygiene according to the regulation (lankford et al., 2003; who, 2009). the word health organization (who), a long‐ standing leading authority in campaigning hand hygiene (hh), urges every country to strengthen infection prevention and control, and appeals for networking with stakeholders to take better action for the prevention of hais (saito, kilpatrick, & pittet, 2018). hais are still a substantial burden among infectious diseases, exceeding the burden of other infections such as influenza and tuberculosis (cassini, plachouras, eckmanns, abu sin, blank, ducomble, & suetens, 2016). nurses, doctors, and all people involved in patient care must perform infection prevention and control https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v16i2.22399 m. maryana et al. 136 | pissn: 1858-3598  eissn: 2502-5791 (duerink et al., 2006). hand hygiene is the most effective simple way and the most cost-reducing approach to nosocomial infections (hugonnet et al., 2002; kampf et al., 2009; sickbert‐bennett et al., 2016; von lengerke et al., 2017). nurses are professionals who play a significant role in hospital services and have contact with patients for a longer time, up to 24 hours straight. thus, nurses have a role in the incidence of nosocomial infections (nursalam, 2011). health workers generally know about the importance of washing hands to prevent infections. however, the implementation of handwashing that follows the standard procedure is still low among health workers (akyol, 2007; nurbaety et al., 2019). various previous studies stated that compliance with nurses’ handwashing was still low, not reaching 100% (jonker & othman, 2018; karuru et al., 2016; putri et al., 2018; ratnasari & dulakhir, 2016; umboh et al., 2017 ). based on previous research, it is known that the individual characteristics of nurses related to handwashing compliance include age, gender, length of work, knowledge, attitudes, motivation, and nurse education (anugrahwati & hakim, 2019; fauzi et al., 2015; zainaro & laila, 2020). based on the description above, this study aims to determine the individual characteristics of nurses that affect the compliance of the five moments handwashing in the inpatient room of pangkalpinang city with a quantitative approach. materials and methods this research is a quantitative study with a crosssectional approach. the dependent variable of the study is the nurses' compliance with handwashing in the inpatient room. the independent variables are individual characteristics, including knowledge, gender, age, attitude, motivation, skin conditions, length of work, education, employment status, infrastructure, and type of room. the population of the study were all associated nurses who work in the inpatient room, as many as 98 nurses. a total of 84 implementing nurses as research respondents was obtained using purposive sampling (icu = 14; picu = 16; non-surgical = 27; children = 12; surgery = 15) with the following inclusion criteria: (1) willing to be respondents, (2) not being assigned to the isolation room during the research. the covid-19 isolation room was not involved in the research because, when the study was taking place, there were no patients. thus, they could not estimate washing hands for the five moments. the procedure in this research began by arranging a permit to a government hospital in pangkal pinang city. it was followed by conducting a meeting to equate the perception of the research process. the meeting was performed by hospital infection prevention and control programs (ipc). four people assisted in the process of data collection. two students were as research assistants who were in charge of collecting questionnaires and documentation. two hospital ipc officers were responsible for observing the compliance of nurses' handwashing in the rooms. researchers also coordinated with all heads of room related to research activities. first, the researchers explained to the respondents about the objectives and procedure of the research and the guarantee of data confidentiality. nurses willing to sign the informed consent form as research respondents then filled out the questionnaire. the study questionnaire was adopted from previous researchers with modifications. the questionnaire covered the nurse's identity (name, age, gender, latest education, years of service, skin condition), room name, and handwashing infrastructure. the knowledge variable consists of 10 questions about the five moments handwashing and has passed the validity and reliability test. questionnaire validation and reliability test had been done at rsup ir. soekarno with the number of respondents as many as 20 people. cronbach's alpha test results obtained knowledge value (0.932), motivation (0.958), attitude (0.969) and were declared reliable. of the 10 questions and statements, all are declared valid with a calculated r value > r table (0.375). each correct answer is given a value of 1 and 0 if the answer is wrong. the attitude variable includes 10 statements consisting of eight positive statements and two negative statements using a likert scale. meanwhile, the motivation variable has 10 statements using a likert scale. for positive statements, the highest point is 5 in the ss category (strongly agree), while the highest point negative statement is 5 in the sts category (strongly disagree). the 84 nurses were then observed for the five moments of handwashing compliance in the room by the hospital ipc officers. the observation process was uninformed to the respondents, and only carried out once in 10 days, starting from 22nd to 31rd of august, 2020. furthermore, each research respondent is given a code, r01 for the first respondent up to r84. the questionnaire files and observation sheets were not accessible other than to the researchers. after data collection was complete, the study continued with data entry. incomplete nurse data were confirmed to the head of the room concerned. the relationship between individual characteristics and compliance with handwashing was tested using the chi-square test with a confidence degree of 95% (α = 0.05). meanwhile, the relationship between variables was analyzed using the multivariate analysis method using logistic regression test with spss version 20 software. results based on table 1, there are 11 characteristic components of individual nurses. the dominance of female gender nurses, age less than 40 years, vocational education, long working period, nonsensitive skin condition, and civil servant status. knowledge, attitude and motivation have equal value. jurnal ners http://e-journal.unair.ac.id/jners | 137 handwashing compliance most of the respondents (63.1%) in this study did not comply with the five-minute handwashing, as in table 2. the room with the highest level of compliance with washing hands was the icu & picu room, while in the normal inpatient room the level of compliance with washing hands was low, as shown in table 3. while the five most neglected moments are after touching patient surroundings, as in table 5. based on the statistical test in table 2, there are three variables with p-value < 0.05, namely motivation, education, and type of room. it shows that the three aspects affect the washing of hands by nurses in the room. furthermore, the or value of the motivation variable is 2.986, meaning that nurses who have high motivation have the opportunity to comply 2.98 times more than nurses with low motivation. based on the multivariate logistic regression test, the omnibus test section shows a pvalue of 0.0001 (<0.05), which means that there is an interaction between motivation, education and type of room on compliance with handwashing. based on table 6, it can be found that the most dominant variable is the type of room. discussion most of the respondents in this study did not comply with washing their hands for five moments. the research found only a small part of the individual characteristics of nurses that affect handwashing compliance, namely education and motivation. new findings from this research are that type of room was known to be significantly related to handwashing compliance, and to be the most dominant factor. the results of this study support previous research reporting that most nurses do not comply with handwashing (arifin & ernawaty, 2019; karuru et al., 2016; nurbaety et al., 2019). handwashing or hand hygiene is a general term that refers to the act of cleansing the hands five times, commonly called five moments. the five moments are: the moment before contact with the patient, before the cleaning procedure or aseptic, after procedures exposing to the body fluids, after contact with patients, and after contact with the area around the patient (who, 2009). permenkes no 27 tahun 2017, concerning infection prevention and control in health facility services, states that hand hygiene is one of the standard precautions that must be applied routinely in the care of all patients in the hospital. the hospital as a medical service unit cannot be separated from the activities of treatment and care for patients with various causes, one of which is infection. infections that occur in health services during treatment and medical procedures after ≥ 48 hours and after ≤ 30 days after leaving a health facility are called nosocomial infections or hospital-acquired infections (hai). according to petersen et al. (2010), hai causes a prolonged length of stay, thus harming patients and increasing treatment costs. hai is a worldwide problem because it is detrimental to patients and hospitals. lankford et al. (2003) state that one of the components to limit the spread of hai is to implement infection control. the most effective way to control infection is to ensure that hospital-staff practice hand hygiene following the standard. factors related to the compliance level of nurses' handwashing include individual-factors, i.e.: gender, age, facilities, attitudes, length of work (anugrahwati & hakim, 2019; arifin & ernawaty, 2019; fauzi et al., 2015; pratama et al., 2016). however, this study gave different results as to which of these factors did not table 1. characteristics of research respondents characteristics of respondents n % median age > 41 years ≤ 40 years 13 71 15.5 84.5 motivation low high 35 49 41.7 58.3 39.07 attitude negative positive 39 45 44.6 53.6 43.67 knowledge fair good 31 53 36.9 63.1 9.61 work period new old 10 71 11.9 88.1 infrastructure insufficient adequate 4 80 4.8 95.2 skin condition sensitive not sensitive 14 70 16.7 83.3 education vocational degree academic degree professional degree 63 6 15 75 7.1 17.9 employment status civil servant contract 63 21 75 25 gender male female 12 72 14.3 85.7 table 2. distribution of respondents’ handwashing handwashing compliance n % noncompliant 53 63.1 compliant 31 36.9 total 84 100 table 3. percentage distribution of respondents’ handwashing by type of room type of room handwashing compliance total noncompliant compliant n n % n % icu & picu 7 23.3 23 76.7 30 non-surgical 25 92.6 2 7.4 27 surgery 12 80 3 20 15 children 9 75 3 25 12 total 84 m. maryana et al. 138 | pissn: 1858-3598  eissn: 2502-5791 have a significant effect on the co mpliance of nurses' handwashing. the gender of nurses was dominantly females. however, there is no difference in the proportion of compliance with handwashing between female and male respondents. the age of nurses was mostly ≤ 40 years, but there was found no difference in the proportion of compliance with handwashing between nurses aged ≤ 40 years and nurses aged > 41 years. most of the nurses considered that the handwashing infrastructure was adequate in the patient room, and there was no difference in the proportion of compliance with handwashing among nurses who were considered supported by the infrastructure to be adequate and inadequate. these findings support previous research that found that the availability of facilities and infrastructure did not relate to handwashing compliance (yotlely, 2019). the researcher assessed the non-correlation because there were adequate handwashing facilities in the table 4. five moment handwashing by type of rooms five moment type of room (%) icu & picu non-surgical surgery children before touching a patient noncompliant 0 59.3 33.4 41.7 compliant 100 40.7 66.6 58.3 before clean/aseptic procedures noncompliant 0 22.3 13.4 25 compliant 100 77.7 86.6 75 after body fluid exposure/risk noncompliant 0 7.5 6.7 0 compliant 100 92.5 93.3 100 after touching a patient noncompliant 0 0 0 0 compliant 100 100 100 100 after touching the patient’s surroundings noncompliant 26.7 92.6 80 75 compliant 73.3 7.4 20 25 table 5. relationship of nurses’ individual characteristics toward handwashing compliance characteristics of individual respondents compliance with handwashing total or (95% ci) pvalue non-compliant compliant n % n % n % age > 41 years ≤ 40 years 7 46 53.8 64.8 6 25 46.2 35.2 13 71 100 100 0.643 (0.192-2.093) 0.537 attitude negative positive 27 26 77.1 53.1 8 23 22.9 46.9 35 49 100 100 0.584 (0.239-1.429) 0.339 knowledge fair good 20 33 64.5 62.3 11 20 35.3 37.7 31 53 100 100 1.102 (0.438-2.770) 1.000 work period new old 7 46 70 62.2 3 28 30 37.8 10 74 100 100 1.420 (0.339-5.945) 0.738 infrastructure insufficient adequate 4 49 100 61.3 0 31 0 38.3 4 80 100 100 1.633 (1.372-1.944) 0.292 skin condition sensitive not sensitive 8 45 57.1 64.3 6 25 42.9 37.5 14 70 100 100 0.741 (0.231-2.377) 0.840 education vocational degree academic degree professional degree 43 1 9 68.3 16.7 60 20 5 6 31.7 83.3 40 63 6 15 100 100 100 0.042 employment status civil servant contract 36 17 57.1 81 27 4 42.9 19 63 21 100 100 0.314 (0.95-1.040) 0.09 gender male female 9 44 75 61.1 3 28 25 38.9 12 72 100 100 1.909 (0.476-7.664) 0.521 motivation low high 27 26 77.1 53.1 8 23 22.9 46.9 35 49 100 100 2.986 (1.134-7.861) 0.043 type of room icu & picu non-surgical pediatric surgery room 7 25 9 12 23.3 92.6 75 80 23 2 3 31 76.7 7.4 25 20 30 27 12 15 100 100 100 100 0.0001 jurnal ners http://e-journal.unair.ac.id/jners | 139 room. there were hand rubs in each patient's bed, room corridor, and nurse station. the results showed that most of the nurses had a long working tenure, namely > 5 years, but there was no difference in the proportion of compliance with handwashing between nurses with a long tenure and nurses with a new tenure. the positive attitude of nurses is almost proportional to negative attitudes, and there is no difference in the proportion of compliance with handwashing between nurses with positive attitudes and nurses with negative attitudes. the same thing is found in the knowledge factor. most of the nurses have good knowledge of handwashing. however, there is no difference in the proportion of compliance in washing hands between nurses with adequate knowledge and nurses with less knowledge. this is also in line with previous research which found that knowledge was not related to handwashing cosmpliance (arifin & ernawaty, 2019; ratnasari & dulakhir, 2016; syamsulastri, 2017). nurses may have good knowledge about handwashing, but other factors can lead to difficulty implementing handwashing compliance, one of which is the high workload. from the research results, nurses in ordinary inpatient rooms (surgical, nonsurgical, children) were the most obedient to wash their hands at moment 3 (after being exposed to body fluids) and moment 4 (after touching the patient). however, the most neglected moment is moment 5 (after touching the patient's environment). it shows that nurses prioritize washing hands after exposure to patients. further research is needed regarding the workload of nurses in inpatient rooms. also, another finding from this study is that employment status does not correlate with nurse handwashing compliance. most of the nurses are civil servants, but there is no difference in the proportion of compliance in washing hands between nurses who are civil servants and nurses who are honorary status. also, most skin conditions are not sensitive to handwashing fluids. however, there is found no difference in the proportion of washing hands between nurses with sensitive skin conditions and nurses who are not sensitive to handwashing fluids. there were complaints from the respondent such as dry hands, but the researcher’s opinion is that the small number of nurses who have sensitive skin causes this variable to be unrelated. it is necessary to develop further research to find out more clearly. an interesting finding in this study is that nurses’ motivation affects compliance with nurses' handwashing. the number of nurses with high motivation is almost equal to those with low motivation. nevertheless, there is a difference in the proportion of compliance with handwashing between highly motivated nurses and those with low motivation. these findings support previous research where 'motivation' is significantly related to nurses' compliance with handwashing (ananingsih & rosa, 2016; fauzi et al., 2015; sani & pratiwi, 2017). nurses need to cultivate high motivation as a form of dedication and altruism to patients' needs for healing (nursalam, 2017). besides, nurse education was found to affect compliance with handwashing. there was a difference in the proportion of handwashing between nurses with vocational, academic, and professional education. one of the factors that can increase the productivity or performance of nurses is the formal education of nurses. education provides knowledge not only directly related to the implementation of tasks, but also a foundation for self-development and the ability to utilize all available facilities for smooth tasks (nursalam, 2017). the new finding from this study is that room type is related to the compliance of nurses' handwashing. there is a difference in the proportion of compliance with handwashing between intensive and nonintensive rooms (general inpatient care). based on table 6, it was found type of room to be the most dominant factor. of the five rooms studied, there were two types of intensive rooms and three general inpatient rooms. based on diagram 2, the highest handwashing compliance is in the intensive room, where moments 1 to 4 are 100%, but in moment 5 the compliance is 73.3%. meanwhile, in general, inpatient rooms, the non-compliance of handwashing was five moments higher. this finding supports previous research that the workplace influences compliance with hand hygiene, where icu nurses are more obedient than other wards (arini, 2016). further research is needed to be able to find a more specific cause. the researcher’s opinion is that not only individual characteristics should be highlighted in compliance with nurses' handwashing. other factors outside the nurses as individuals also contribute to handwashing compliance. they can be organizational characteristics, which include reward systems, training, and development, leadership, and organization culture. moreover, it is important to pay attention to aspects of job characteristics, including feedback, workload, and assignment methods. this study has several limitations, although attempts have been made to overcome them. researchers could not control nor directly see when respondents filled in answers or justify the truth of the answer given. in addition, observing the compliance of nurses’ handwashing was only done once in a period. conclusion most nurses do not comply handwashing. from 11 nurses’ individual characteristic factors, there were three factors related to the compliance of the nurse's hand washing, namely education, motivation and type of patient room. the research found type of room to be the dominant factor. however, knowledge, facilities, attitudes, age, gender, skin sensitivity conditions, and employment status do not relate to handwashing compliance. it is hoped that nurses can increase selfmotivation to perform the five moments of hand hygiene while working, as a form of dedication at m. maryana et al. 140 | pissn: 1858-3598  eissn: 2502-5791 work and to protect patients and themselves from nosocomial infections. the researcher also recommends that further researchers be able to identify more about other factors, including reward systems, training and development, leadership, organizational culture, feedback, workload, and assignment methods. thus, they can find the right intervention to increase compliance with the nurse's handwashing. acknowledgement acknowledgments are presented to the higher education service institution (lldikti) region ii of the ministry of research and technology who funded this research. references akyol, a. . (2007). hand hygiene among nurses in turkey: opinion adn practices. journal of clinical nursing, 16(3), 431–137. ananingsih, p. d., & rosa, e. m. (2016). kepatuhan 5 moment hand hygiene pada petugas di laboratorium klinik cito yogyakarta. jurnal medicoeticolegal dan manajemen rumah sakit, 5 (1), 16–24. https://doi.org/10.18196/jmmr.5102 anugrahwati, r., & hakim, n. (2019). faktor-faktor yang mempengaruhi kepatuhan perawat dalam melakukan hand hygiene five moment di rs hermina jatinegara. jurnal ilmiah keperawatan altruistik, 2(1), 41–48. arifin, a., & ernawaty, j. (2019). faktor-faktor yang berhubungan dengan kepatuhan hand hygiene mahasiswa profesi ners di ruangan rawat inap. jurnal kesehatan, 100–113. arini, m. (2016). health belief model pada kepatuhan hand hygiene di bangsal berisiko tinggi healthcare acquired infections (hais) (studi kasus pada rs x). jurnal medicoeticolegal dan manajemen rumah sakit, 5(2), 129–135. https://doi.org/10.18196/jmmr.5117 cassini, a., plachouras, d., eckmanns, t., abu sin, m., blank, h. p., & ducomble, t., suetens, c. (2016). burden of six healthcare‐ associated infections on european population health: estimating incidence‐based disability‐adjusted life years through a population prevalence‐based modelling study. plos medicine, 13 (10). duerink, d. ., farida, h., nagelkerke, n. j. ., wahyono, h., keuter, m., lestari, e. ., hadi, u., & van den broek, p. . (2006). preventing nosocomial infection: improving compliance with standard precautions in an indonesia teaching hospital. journal of hospital infection, 64(1), 36–43. fauzi, n., ahsan, & azzuhri, m. (2015). pengaruh faktor individu, organisasi dan perilaku terhadap kepatuhan perawat dalam melaksanakan hand hygiene di ruang rawat inap rumah sakit tk. ii dr. soepraoen malang. jurnal aplikasi manajemen, 13(4), 566–574. hugonnet, s., perneger, t. ., & d, p. (2002). alcohol‐ based handrub improves compliance with hand hygiene in intensive care units. archives of internal medicine, 162, 1037–1043. jonker, c., & othman, m. (2018). hand hygiene among hospital staff: a survey of knowledge, attitude, and practice in a general hospital in syria. jurnal keperawatan indonesia, 21(3), 139–149. https://doi.org/10.7454/jki.v21i3.513 kampf, g., löffler, h., & gastmeier, p. (2009). hand hygiene for the prevention of nosocomial infections. deutsches arzteblatt international, 106(40), 649–655. karuru, c. p., mogi, t. i., & sengkey, l. (2016). gambaran kepatuhan tenaga kesehatan dalam menerapkan hand hygiene di rawat inap rsup prof. dr. r d. kandou manado. e-clinic, 4(1), 2–5. https://doi.org/10.35790/ecl.4.1.2016.10942 lankford, m. ., zembower, t. ., trick, w. ., hacek, d. ., noskin, g. ., & peterson, l. . (2003). influence of role model and hospital design on the hand hygiene of health-care worker. emerging infectious disesase, 9(2), 217. nurbaety, baharuddin, a., amelia, a. r., & julianti, s. (2019). penerapan standar prosedur operasional (sop) hand hygiene pada tenaga kesehatan di instalasi rawat inap rumah sakit dr. tadjuddin chalid kota makasar. prosiding seminar nasional, 2. nursalam. (2011). manajemen keperawatan aplikasi dalam praktik keperawatan profesional (3rd ed.). salemba medika. nursalam. (2017). metodologi penelitian ilmu keperawatan : pendekatan praktis (p. puji lestasi (ed.); 4th ed.). salemba medika. petersen, m. ., holm, m. ., pedersen, s. ., lassen, a. ., & pedersen, c. (2010). incidence and prevalence of hospital-acquired infection in a cohort of patients admitted to medical departments. danish medical bulletin, 57(11), a4210-a. pratama, b. s., koeswo, m., & hariyanti, t. (2016). pengaruh kelengkapan handrub & poster terhadap kemauan perawat untuk berubah terkait hand hygiene pada rawat inap rs ananda blitar. jurnal aplikasi manajemen, 14(4), 757–766. https://doi.org/10.18202/jam23026332.14.4.16 putri, v. s., yusuf, a., tristiana, r. d., nursing, f., & airlangga, u. (2018). analysis of factors related to nursing student self wareness in doing screening for psychosocial problems. 15(3). ratnasari, d., & dulakhir. (2016). faktor-faktor yang berhubungan dengan kepatuhan perawat ruang rawat inap dalam pelaksanaan hand hygiene di rumah sakit anna medika kota bekasi tahun 2016. jurnal ilmiah kesehatan, 8. saito, h., kilpatrick, c., & pittet, d. (2018). the 2018 world health organization save lives: clean your hands campaign targets sepsis in health care. intensive care medicine, 44, 499–501. sani, f. n., & pratiwi, m. r. (2017). hubungan motivasi perawat dengan tingkat kepatuhan melakukan cuci tangan di rsi klaten. profesi (profesional islam) : media publikasi penelitian, 14(2), 11. jurnal ners http://e-journal.unair.ac.id/jners | 141 https://doi.org/10.26576/profesi.146 sickbert‐bennett, e. e., dibiase, l. m., schade willis, t. m., wolak, e. s., weber, d. j., & rutala, w. a. (2016). reduction of healthcare‐ associated infections by exceeding high compliance with hand hygiene practices. emerging infectious diseases, 22(9), 1628–1630. syamsulastri. (2017). faktor yang berhubungan dengan kepatuhan perawat dalam melakukan hand hygiene. respirstory unmuhpkn. umboh, f. ., doda, d. ., & kandau, g. . (2017). analisis faktor-faktor yang berhubungan dengan kepatuhan perawat melaksanakan hand hygiene dalam mencegah infeksi nosokomial di ruang rawat inap rumah sakit advent manado. von lengerke, t., lutze, b., krauth, c., lange, k., stahmeyer, j. t., & chaberny, i. f. (2017). promoting hand hygiene compliance. deutsches arzteblatt international, 114(3), 29–36. who. (2009). guide to implementation: a guide to implementation of the who multimodal hand hygiene improvement strategy. yotlely, a, s. (2019). analisis faktor yang berhubungan dengan kepatuhan perawat dalam penerapan kewaspadaan standar di rsud piru penelitian korelasional. repository unair. 162 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2 october 2020 http://dx.doi.org/10.20473/jn.v15i2.20556 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research reducing labor pain intensity within first stage active phase through hegu li 4 acupressure and quranic recital method nurul azizah, rafhani rosyidah, and hanik mahfudloh faculty of health science, universitas muhammadiyah sidoarjo, indonesia abstract introduction: labor pain is one of the greatest pains experienced by a woman in their life. the purpose of this study was to examine the effectiveness of acupressure and quranic recital on labor pain reduction. methods: the study design uses quasi-experiment with comparison between pretest and posttest on non-equivalent control group. samples were as many as 30 laboring mothers in each group, totaling 60 samples who had been chosen through consecutive sampling technique. the labor pain was assessed through the nrs (numeric rating scale) then analyzed univariately with mean and standard deviation, followed by independent t-sample statistical test such as bivariate analysis. results: the average pain reduction score in the hegu li 4 acupressure group was higher than the quranic recital of surah ar-rahman group. the acupressure group average pain reduction was 3.03 ± 0.718 while the quranic recital group was 2.57 ± 1.006. the difference in the average score of independent t-test was significant with the p < 0.007 and 95% c.i. -0.919-( -0.015) conclusion: hegu li 4 acupressure and quranic recital of surah ar-rahman treatments were promising and may be utilized to reduce labor pain intensity within labor’s first stage active phase. hegu li 4 acupressure group had a greater reduction in labor pain intensity than the quranic recital of surah ar-rahman group. this study suggests that hegu li 4 can be utilized to reduce labor pain as a non-pharmacological therapy. article history received: july 7, 2020 accepted: august 19, 2020 keywords active phase; hegu li 4 acupressure; labor pain intensity; quranic recital contact nurul azizah  nurulazizah@umsida.ac.id  faculty of health science, universitas muhammadiyah sidoarjo, indonesia cite this as: azizah, n., rosyidah, r., & mahfudloh, h. (2020). reducing labor pain intensity within first stage active phase through hegu li 4 acupressure and quranic recital method. jurnal ners, 15(2). 162-166. doi:http://dx.doi.org/10.20473/jn.v15i2.20556 introduction pain is a complicated and subjective experience, as it is within the scope of physiological and psychological interaction. labor pain is the greatest pain experienced by most woman in their lifespan (yazdkhasti & pirak, 2016). labor pain is the reaction between the uterine muscle contractions which normally happens in labor process. contraction is intended to give a push to the fetus and opening the birth canal. the resulting effect is that the majority of mothers cannot tolerate this kind of pain, and are mainly affected by stress, fear, tension, and pain (larasati & alatas, 2016). the increasing of mothers’ pain perceptiveness results in the mothers’ panic level and then begging for a quick labor process, some of them request pain relief medicine, others even request unneeded surgical operations out of fear (jones et al., 2012). heavy labor pain may induce weak uterine contraction, resulting in longer labor process and increasing the risk of hemorrhage (lozada et al., 2018). in indonesia, hemorrhages are one of the biggest contributing factors in the mothers’ fatality rate aside from preeclampsia/eclampsia and infection (kemenkes, 2018). labor pain can be reduced with pharmacological and nonpharmacological methods (asadi et al., 2015), and wider cervical opening will commonly heighten labor pain (hawkins, 2010). pharmacological methods have better effects in treating labor pain, but this treatment can only be done with authorized medical doctors while having more expensive costs (lozada et al., 2018). the non-pharmacological methods have minimal side effects with cheaper cost or even no https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:nurulazizah@umsida.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 163 additional costs while having the same effectiveness in reducing labor pain. even so, non-pharmacological methods need to be standardized (gayesi & brüggemann, 2010); non-pharmacological approaches, especially acupressure, still need to be researched and expanded further before becoming a standard in addressing labor pain (robinson et al., 2011). mothers’ pain experienced in the labor process is unique and natural. the administration and surveillance of labor pain, especially in the first stage active phase is crucial, as it is the determining point of whether the labor process is considered normal or must be ended with interventions because of complications from severe pain (zhang et al, 2010). the approach of labor pain management increasingly depends on pharmacological methods. because of side effects on mothers and fetuses, the use of nonpharmacological methods is also increasingly popular (schlaeger et al., 2017) according to a systematic review by rahimi et al. (2018), non-pharmacological methods are effective, but the processes are not well defined and standardized. acupressure is a non-pharmacological method to relieve pain and included in the traditional chinese medicine (tcm); it is considered as a non-invasive method and based on acupuncture principles (shahali & kashanian, 2010). tcm considers the human body as a united channel to transmit energy (meridian). each of specific points in human body pass through a meridian line (zhang et al., 2010). recent studies from schlaeger et al. (2017) and rahimi et al. (2018) showed that acupuncture could reduce pain and anxiety in the labor process. there are many acupressure points in human body, and every point has different effect in the body. acupressure could also increase the production of endorphin hormones which function as a painkiller. to reduce pain, there are several acupressure points that could be pressed. one of them is the li 4 (hegu) point (gönenç & terzioğlu, 2020). non-pharmacological therapy to relieve pain may also be administered through distraction techniques, one of which is listening to quranic verses. this therapy stimulates delta brainwave which makes the listener feel comfort and tranquil (wirakhmi et al., 2018). quran recital therapy with correct rhythm and pronunciations will result in the decrease of anxiety level, ghofar (2012) confirmed that 65% of therapy subjects felt a sense of tranquility and anxiety reduction, while elzaky (2011) concluded that listening to quranic recital of surah ar-rahman transmits a soundwave which affects the movements of human cells; it is also activates pain pressure lanes and is succeeded by electrical stimulation of the substantia grisea cerebri in waking the analgesic neurotransmitter (endorphin, encephalin, dinorphin) which acts as pain suppressor. surah ar-rahman is a chapter in the quran believed to have medicinal properties if being listened to repeatedly with the correct recital (wahida et al., 2015). surah arrahman also has repetitive verses which give accentuated rhythm to the listeners. as repetitive verses can be appealing and behave as hypnosis, so patients brainwaves will attune into the rhythm and increase the production of serotonin and endorphin, which gives relaxing, serene, and delighting effects (wahida et al., 2015). music may also be used to minimize labor pain, as music may give energy and subliminal commands through its rhythm; music with an appropriate tempo may help mothers to regulate their breathing in labor process. classical music is commonly used to distract pain perception. faradisi, (2012) proved that music could reduce anxiety, stress level, bad emotions and physical pain, and relax the muscles. our study aims to assess the effectivity of hegu li 4 acupressure point with quranic recital intervention of surah ar-rahman in reducing labor pain intensity within the first stage active phase materials and methods the study uses quasi experimental design with nonequivalent control group design, which means the subjects grouping was not random. in this design, we compare hegu li 4 acupressure group with surah arrahman quranic recital group. 30 laboring mothers were treated with hegu li 4 acupressure within 10 minutes in the hegu spot in the right/left hand, while the other 30 laboring mothers were treated with quranic recital of surah ar-rahman with mp3 device within 20 minutes. these two groups were compared with pretest, intervention, and posttest questionnaire. study population was the entirety of mothers within the first stage active phase labor process who fulfilled all inclusion criteria. the criteria were normal labor with gestational period ≥ 37 weeks old, single gestation, head presentation, no labor induction, within first stage active phase (4-6 cm cervical opening), adequate his (uterine contractions > 3 times in 10 minutes with contraction time > 40 seconds), labor process supported with the husband or family, and not using pharmacological administration in reducing pain. samples used are 30 figure 1. hegu li 4 pressure point n. azizah et al. 164 | pissn: 1858-3598  eissn: 2502-5791 laboring mothers in each group, amounting to 60 samples. samples were gathered using non-probability sampling with consecutive sampling technique, meaning that samples were chosen through determining subjects who fulfilled the study criteria and treated within a set elapsed time until the number of subjects was enough. data were collected with direct observations on mothers who were within labors’ first stage active phase; mothers were given pretests (preliminary observations) before proceeding with interventions of hegu li 4 acupressure in the first group and quranic recital of surah ar-rahman in the second group, followed by posttest (final observation). the intervention of hegu li 4 acupressure was done by the researchers, who had a level 4 acupressurist certificate of competency. enumerators gave information to the researchers if there were laboring mothers who met the criteria and were willing to become study respondents. the intervention of the quranic recital of surah ar-rahman was done by enumerators with the recorded recital provided by the researchers. the administrations of hegu li 4 acupressure and quranic recital were done after the mothers entered the delivery room, had cervical opening checked, and signed the informed consent. each administration was carried out for 20 minutes. both groups were given a numeric rating scale (nrs) pain scale to assess the difference between the value of pretest and posttest. data are presented within average standard deviation table and followed by normality test. data are further analyzed with independent t-test for bivariate regression using significance rate α = 0.05. results univariate analysis is used to analyze respondent characteristic distributions. using 60 mothers as respondents divided in two groups, distribution characteristics can be seen in table 1. from table 1 we can stipulate that the comparability of subjects are homogenous and comparable. all variables in table 1 do not have a significant difference (p > 0.05), implying that data are equitably distributed before the study progressed further. according to table 2 the average score of labor pain reduction in the quranic recital group is 2.57 ± 1.006, whereas the acupressure hegu li 4 group score is 3.03 ± 0.718. from the independent sample t-test, the resulting score is 0.919-(-0.015) with p < 0.007 under confidence interval of 95%. to summarize, the decrease of labor pain score is greater in the hegu li 4 acupressure group, implying the effectiveness of acupressure statistically and clinically. figure 2 summarizes the comparison of labor pain intensity between intervention groups. overall, two groups have a decreasing score in labor pain intensity from the pretest to posttest, but the hegu li 4 acupressure group has a greater decrease in labor pain than the quranic recital of surah ar-rahman group discussion acupressure intervention in hegu li 4 could increase the level of endorphin hormones. endorphin has an effect in pain relief (hamidzadeh et al., 2012). gate control theory explains that pain is transmitted by nerve fibers to the spinal cord before being transmitted to the brain. synapses in the dorsal horn act as a closed gate to maintain impulses before reaching the brain. according to gate control theory, nerve fibers which have small diameters and carry pain stimuli from the nerves to the same gate could hinder the transmission of pain impulses through closing the gate (kashanian & shahali, 2010). gate control theory also explains that, while labor is going on, pain impulses are transmitted from the uterus all along the large nerve fibers to the upper level of gelatinous substance in the spinal column and transmission cells project a pain message to the brain. the presence of stimuli renders the opposing message to become stronger and faster while transmitted in the gelatinous small nerve fibers, then table 1. respondents’ demographics and characteristics variables hegu li 4 acupressure mean ± sd quranic recital of surah ar-rahman mean ± sd p age 26.73 ± 4.386 25..63 ± 5.524 0.156 parity 1.60 ± 0.675 1.53 ± 0.123 0.804 anxiety 11.50 ± 5.557 11.93 ± 4.697 0.251 pain score before intervention 6.30 ± 0.988 6.33 ± 0.988 0.219 table 2. intervention effect to labor pain level interventions pain level pretest posttest mean 95% c.i. p pretest mean ± sd posttest mean ± sd quranic recital of surah ar-rahman 6.33 ± 1.184 3.77 ± 1.073 2.57 ± 1.006 -0.46 -0.919-(-0.015) 0.007 hegu li 4 acupressure 6.30 ± 0.988 3.27 ± 0.785 3.03 ± 0.718 jurnal ners http://e-journal.unair.ac.id/jners | 165 hindering the pain message so the brain does not process it (koyyalamudi et al., 2016). the administration of hegu li 4 acupressure is suspected to stimulate ad fibers which inject into medulla spinalis. this process makes a segmental inhibition from pain stimuli which is inducted by c fiber in the other side of medulla spinalis. the resulting message will stimulate mechanoreceptors (hamidzadeh et al., 2012). if the dominant impulses are induced from delta a and c membranes, it will open said defenses which make mothers to perceive pain. but, if the pain is transmitted to the brain, the higher cortex center in the brain will modify pain perception (schlaeger et al., 2017). existing pressure in the hegu li 4 could help endorphin discharge in the body. dabiri et al. (2014) also confirm that hegu li 4 acupressure could reduce the duration of labor’s first stage. music can be utilized to minimize labor pain, as music gives energy and a message through the music’s rhythm, so appropriate tempo can help mothers to regulate their breathing in labor. commonly used music in pain distraction is classical music. several studies prove that listening to music, especially classical music, can reduce the level of anxiety, stress, emotion, and physical pain. music can be utilized as a pain reduction by countering stress and loosening flexed muscles as a reaction to the pain (y.h. et al., 2010) according to wahida et al/ (2015), the application of quranic recital of surah ar-rahman as a therapy is proven effective in increasing the level of βendorphin, which reduces pain intensity to laboring mothers; a recital with slow tempo with deep appreciation can induce a relaxing sensation. βendorphin is a neuropeptide which consists of 31 amino acids produced by the hypophysis gland from the splitting of proopiomelanocortin (pomc) (kovalitskaya & navolotskaya, 2011). endorphin is produced naturally by the body and has the ability to inhibit pain transmission, so pain level is reduced (fraser & cooper, 2009). another contributing factor is the belief of alquran as a holy book which contains god’s commandments and life guidance for muslims. listening to quranic recital can give someone a feel of being closer to god’s presence, and unconsciously makes the listeners submit themselves to god, which boosts a relaxing feel, suppressing anxiety and increasing β-endorphin level as a pain suppressor (faradisi, 2012). quranic recital which contain human voice harmonic melody is a good healing instrument, as listening to harmonic melody can induce a comforting feel and naturally increase the endorphin level, affecting the suppression of stress, fear, and anxiety hormones (särkämö et al., 2014). as supported by this study, the therapy of quranic recital of surah arrahman for 25 minutes can reduce the first stage active phase labor pain. conclusion hegu li 4 acupressure and quranic recital of surah ar-rahman is proven to be used as a pain reductor in treating the first stage active phase labor pain. acupressure group has a greater pain reduction level than quranic recital group. the study result recommends that hegu li 4 acupressure can be utilized in addressing labor pain nonpharmacologically. references abdul ghofar, l. n. (2012). he influence of playing therapy and music therapy (listening al-qur’an : juz amma) to anxiety respond at toddler. faradisi, f. (2012). efektifitas terapi murotal dan terapi musik klasik terhadap penurunan tingkat kecemasan pasien pra operasi di pekalongan. jurnal psikologi stikes muhammadiyah pekajangan pekalongan. https://doi.org/10.1533/9780857096326.index fraser, d. m., & cooper, m. a. (2009). buku ajar bidan myles. jakarta: egc. gönenç, i. m., & terzioğlu, f. (2020). effects of massage and acupressure on relieving labor pain, reducing labor time, and increasing delivery satisfaction. the journal of nursing research : jnr. https://doi.org/10.1097/jnr.000000000000034 4 hamidzadeh, a., shahpourian, f., orak, r. j., montazeri, a. s., & khosravi, a. (2012). effects of li4 acupressure on labor pain in the first stage of labor. journal of midwifery and women’s health. https://doi.org/10.1111/j.15422011.2011.00138.x jones, l., othman, m., dowswell, t., alfirevic, z., gates, s., newburn, m., jordan, s., lavender, t., & neilson, j. p. (2012). pain management for women in labour: an overview of systematic reviews. cochrane database of systematic reviews. https://doi.org/10.1002/14651858.cd009234.pu b2 kashanian, m., & shahali, s. (2010). effects of acupressure at the sanyinjiao point (sp6) on the process of active phase of labor in nulliparas women. journal of maternal-fetal and neonatal medicine. https://doi.org/10.3109/14767050903277662 figure 2. comparison of labor pain decrease n. azizah et al. 166 | pissn: 1858-3598  eissn: 2502-5791 kovalitskaya, y. a., & navolotskaya, e. v. (2011). nonopioid effect of β-endorphin. in biochemistry (moscow). https://doi.org/10.1134/s0006297911040018 koyyalamudi, v., sidhu, g., cornett, e. m., nguyen, v., labrie-brown, c., fox, c. j., & kaye, a. d. (2016). new labor pain treatment options. in current pain and headache reports. https://doi.org/10.1007/s11916-016-0543-2 larasati, t., & alatas, f. (2016). dismenore primer dan faktor risiko dismenore primer pada remaja. majority. rahimi, f., goli, s., soltani, n., rezaei, h., & amouzeshi, z. (2018). effects of complementary therapies on labor pain: a literature review. modern care journal. https://doi.org/10.5812/modernc.69306 särkämö, t., tervaniemi, m., laitinen, s., numminen, a., kurki, m., johnson, j. k., & rantanen, p. (2014). cognitive, emotional, and social benefits of regular musical activities in early dementia: randomized controlled study. gerontologist. https://doi.org/10.1093/geront/gnt100 schlaeger, j. m., gabzdyl, e. m., bussell, j. l., takakura, n., yajima, h., takayama, m., & wilkie, d. j. (2017). acupuncture and acupressure in labor. in journal of midwifery and women’s health. https://doi.org/10.1111/jmwh.12545 shahali, s., & kashanian, m. (2010). effect of acupressure at the sanyinjiao point (sp6) on the process of active phase of labor in nulliparas women. journal of babol university of medical sciences. https://doi.org/10.1080/14767050903277662 wahida, s., andarini, s., & nooryanto, m. (2015). al qur ’ an surah arrahman recital therapy increase β -endorphin levels and reduce childbirth pain intensity on a. journal kedokteran brawijaya. wirakhmi, i. n., utami, t., & purnawan, i. (2018). comparison of listening mozart music with murotal al quran on the pain of hypertension patients. jurnal keperawatan soedirman. https://doi.org/10.20884/1.jks.2018.13.3.813 y.h., l., m.y., c., & h, c. c. (2010). effects of music therapy on labour pain and anxiety in taiwanese first-time mothers. journal of clinical nursing. yazdkhasti, m., & pirak, a. (2016). the effect of aromatherapy with lavender essence on severity of labor pain and duration of labor in primiparous women. complementary therapies in clinical practice. https://doi.org/10.1016/j.ctcp.2016.08.008 zhang, j., troendle, j., mikolajczyk, r., sundaram, r., beaver, j., & fraser, w. (2010). the natural history of the normal first stage of labor. obstetrics and gynecology. https://doi.org/10.1097/aog.0b013e3181d559 25 ners vol 10 no 1 april 2015.indd 147 analisis faktor pelaksanaan triage di instalasi gawat darurat (the factors associated with the triage implementation in emergency department) nur ainiyah*, ahsan**, mukhamad fathoni*** *prodi magister keperawatan peminatan gawat darurat fk universitas brawijaya **, *** staf pengajar magister keperawatan fakultas kedokteran universitas brawijaya e-mail: ainiyahannuri@gmail.com abstrak pendahuluan: triage merupakan proses memilah pasien menurut tingkat keparahannya. namun fenomena yang terjadi di igd di beberapa rumah sakit ternyata triage tidak dilaksanakan sehingga tidak semua kasus pasien yang datang di igd merupakan kasus yang mengancam jiwa akan tetapi ada juga yang termasuk pasien dengan false emergency. untuk meminimalkan masuknya pasien false emergency tersebut adalah dengan melaksanakan triage sehingga pelayanan igd dapat diberikan secara optimal. tujuan penelitian ini adalah menganalisis faktor yang berhubungan dengan pelaksanaan triage di instalasi gawat darurat rumah sakit a dan b. metode: desain penelitian ini adalah analitik korelasional dengan pendekatan cross sectional. populasi penelitian ini adalah instalasi gawat darurat dengan sampel penelitian yaitu perawat igd dan pasien yang datang ke igd. penelitian ini menggunakan total sampling untuk perawat igd (54 responden) dan accidental sampling untuk pasien (54 responden). pengambilan data dilakukan bulan juli-agustus 2014. instrumen yang digunakan adalah lembar observasi dan kuesioner. data penelitian dianalisis dengan menggunakan analisis multivariat regresi logistik dengan metode backward lr. hasil: faktor yang paling berhubungan dengan pelaksanaan triage adalah faktor kinerja (p value = 0,002), faktor pasien (p value = 0,011), faktor ketenagaan (p value = 0,017). diskusi: pihak rumah sakit dapat meningkatkan motivasi kerja, mengoptimalkan ketenagaan perawat dengan cara memberikan job description secara jelas dan meningkatkan kualitasnya dengan mengikuti pelatihan triage offi cer course. kata kunci: triage, faktor kinerja, faktor pasien, faktor ketenagaan abstract introduction: triage is defi ned as a process to sort patients based on the severity and emergency situation. in fact, emergency department (ed) in several hospitals in indonesia do not implement it, so not all patients come to emergency department due to a true emergency case but there are also a false emergency. implementing triage is important in order to decrease false emergency case and also increase ed service quality. the research goal was to analyze factors associated with the triage implementation in emergency department in hospitals (type a and b). methode: the research design was a cross sectional with corrrelative analysis. the research population was emergency department nurses and patients. samples were taken by total sampling for the nurses (54 respondents) and accidental sampling for patients (54 respondents). the research instruments were questionnaire and direct observation. the research datas were analized using multivariat logistic regression by backward lr. result: the result showed that the dominant factors correlated with the implementation of the triage was the performance factor (p value. 0,002), the patient factor (p value = 0.011), and the staffi ng factor (p value. 0.017). discussion: the hospital management can increase the work motivation,then optimize the nurses by giving a job description clearly and improve nursing service quality through triage offi cer course. keywords: triage, performance factor, patient factor, staffi ng factor pendahuluan triage diartikan sebagai proses memilah pasien menu r ut t i ng kat keparahan nya. fenomena yang terjadi di beberapa igd rumah sakit ternyata tidak semua kasus pasien yang datang merupakan kasus dengan kondisi gawat darurat yang mengancam jiwa, namun ada beberapa kasus yang termasuk pasien dengan kategori false emergency. salah satu cara untuk pasien false emergency adalah dengan melaksanakan triage di igd tersebut. andersson, omberg dan svedlund (2006) menyatakan bahwa perawat merupakan petugas kesehatan yang mempunyai peran dan tanggung jawab utama dalam melakukan triage di igd. kenyataannya, sistem triage di indonesia belum terstandar secara nasional, sehingga pelaksanaan triage antar rumah sakit menjadi berbeda. berdasarkan observasi yang dilakukan peneliti, petugas triage di beberapa rumah sakit di jawa timur dilakukan oleh profesi yang berbeda-beda, antara lain oleh 148 jurnal ners vol. 10 no. 1 april 2015: 147–157 dokter umum (dibantu oleh perawat) dan oleh perawat saja. penelitian fathoni, sangchan, songwatha (2013) di beberapa instalasi gawat darurat (igd) di jawa timur menunjukkan bahwa kemampuan kognitif perawat mengenai triage masih kurang, khususnya dalam hal menentukan prosedur dan manajemen penyakit pasien. selain itu, kemampuan psikomotor perawat mengenai triage juga masih berada dalam kategori sedang. berdasarkan observasi di igd rumah sakit a didapatkan gambaran bahwa jumlah perawat yang stand by di depan pintu igd sangat terbatas (hanya satu orang) dibantu dengan seorang mahasiswa keperawatan yang sedang menjalani praktek klinis. perawat tersebut bertugas untuk menanyakan keluhan pasien, memilah apakah termasuk trauma atau non trauma, mengantar pasien masuk r uang tindakan, dan member ikan kode triage. namun berdasarkan observasi peneliti kode triage ini tidak diberikan oleh perawat meskipun telah ada sosialisasi penerapan kode triage di dinding. data observasi lainnya menunjukkan bahwa perawat igd rumah sakit a juga tidak melakukan pemeriksaan fisik pasien di ruang triage (meskipun ada ruang khusus triage). selain itu, peralatan di ruang triage tampak terbatas dan kurangnya jumlah perawat yang bertugas setiap shift, di mana shift pagi hanya terdapat 9 orang perawat, padahal jumlah pasien pada shift tersebut sering melebihi kapasitas brankart yang ada (40 buah), sehingga ruangan igd menjadi sangat penuh (overcrowded). hasil observasi di atas menunjukkan bahwa permasalahan lingkungan kerja di instalasi tersebut sangat kompleks. pela k s a n a a n t r i a ge d ip e nga r u h i oleh beberapa faktor antara lain faktor kinerja ( performance), faktor pasien, faktor perlengkapan triage, faktor ketenagaan dan faktor model of caring yang digunakan di instalasi tersebut (australian triage process review, 2011). penelitian lain yang dilakukan oleh andersson, a.k., m. omberg, dan m. svedlund (2007) menyatakan bahwa faktor yang mempengaruhi triage decision making dibagi menjadi dua faktor yaitu faktor internal dan faktor eksternal. faktor internal mencerminkan keterampilan perawat dan kapasitas pribadi. faktor ekster nal mencerminkan lingkungan kerja, termasuk beban kerja tinggi, pengaturan shift, kondisi klinis pasien, dan riwayat klinis pasien. jika faktor-faktor tersebut diabaikan, maka pelaksanaan triage berjalan tidak optimal sehingga dapat menyebabkan kesalahan dalam pengambilan keputusan, serta mengakibatkan ketidakmampuan dan bahkan cacat permanen bagi pasien (gerdtz & bucknall, 2000). pelaksanaan triage sangat penting dilaksanakan dalam kondisi kegawatdaruratan, sehingga faktor yang berhubungan dengan pelaksanaan triage perlu diidentif ikasi serta diperlukan rekomendasi tindak lanjut untuk memperbaikinya, khususnya masalah peningkatan mutu dan jumlah tenaga perawat, ser t a melengkapi dan mengoptimal kan penggunaan perlengkapan triage. melalui pelaksanaan triage, kepuasan pasien di rumah sakit akan dapat tercapai serta kematian dan kecacatan pada kasus kegawatdaruratan dapat diminimalkan. tujuan penelitian ini adalah untuk menganalisis faktor yang berhubungan dengan pelaksanaan triage oleh tenaga kesehatan di igd rumah sakit a dan b. bahan dan metode penelitian ini menggunakan desain analitik korelasional dengan pendekatan cross sectional. populasi dalam penelitian ini adalah perawat dan pasien di igd rumah sakit a dan b dengan menggunakan total sampling untuk perawat (54 perawat) dan accidental sampling untuk pasien yang didampingi oleh keluarga (54 pasien). analisa data penelitian dilakukan dengan teknik univariat (ditampilkan dalam bentuk distribusi frekuensi), bivariat (uji chisquare) serta multivariat (uji regresi logistik dengan metode backward). hasil data penelitian berupa karakteristik responden disajikan dalam bentuk distribusi frekuensi, sedangkan data lainnya disajikan dalam bentuk tabulasi silang. 149 analisis faktor pelaksanaan triage (nur ainiyah, dkk.) tabel 1 menunjukkan bahwa sebagian besar perawat igd adalah laki-laki, sedangkan usia dominan sekitar 18–34 tahun yang menunjukkan usia dewasa dan usia produktif. latar belakang pendidikan perawat igd sebagian besar merupakan pendidikan tinggi (d3 keperawatan). tabel 2 menunjukkan bahwa sebanyak 35% perawat igd yang memiliki faktor kinerja baik melaksanakan triage secara optimal. di sisi lain, ada perawat yang memiliki faktor kinerja kurang baik (2%) namun dapat melaksanakan triage secara optimal. berdasarkan hasil uji fisher didapatkan bahwa ρ value = 0,000 (ρ < 0,05), sehingga h1 diterima berarti ada hubungan yang bermakna antara faktor kinerja dengan pelaksanaan triage oleh tenaga kesehatan. tabel 3 menunjukkan sebanyak 33% responden memiliki faktor pasien yang baik dan mendapatkan pelayanan triage yang optimal, sedangkan 4 % responden memiliki faktor pasien yang kurang baik namun tetap mendapatkan pelayanan triage yang optimal. berdasarkan hasil uji fisher didapatkan bahwa p value = 0,01 (ρ < 0,05), sehingga h1 diterima berarti ada hubungan yang bermakna antara faktor pasien dengan pelaksanaan triage oleh tenaga kesehatan. tabel 4 menunjukkan 2% responden memiliki faktor ketenagaan yang kurang baik dengan pelaksanaan triage optimal. di sisi lain, 35% responden dengan faktor ketenagaan baik menunjukkan pelaksanaan t riage opt i mal. uji fisher didapatkan p value = 0,011 (ρ < 0,05) sehingga h1 diterima berarti ada hubungan yang bermakna antara faktor ketenagaan dengan pelaksanaan triage oleh tenaga kesehatan. tabel 5 menu nju k kan bahwa 8% responden berpendapat faktor perlengkapan kurang baik namun pelaksanaan triage tetap optimal, 30% responden berpendapat faktor perlengkapan sudah baik dan pelaksanaan triagenya optimal. uji fisher menunjukkan p value = 0,010 (ρ < 0,05) sehingga h1 diterima tabel 1. karakteristik perawat igd variabel faktor kinerja frekuensi (f) prosentase (%) jenis kelamin laki-laki perempuan usia 18–34 35–49 pendidikan terakhir spk d3 kep s1 kep s2 kep 34 20 15 38 1 44 9 0 63 37 18 72 2 81 17 0 total 54 100 tabel 2. tabulasi silang faktor kinerja dan pelaksanaan triage di igd faktor kinerja pelaksanaan triage totalkurang optimal optimal f(%) f(%) kurang baik 20(37) 1(2) 21(39) baik 14(26) 19(35) 33(61) p value 0.000 tabel 4. hubungan faktor ketenagaan dengan pelaksanaan triage di igd faktor ketenagaan pelaksanaan triage total kurang optimal optimal f(%) f(%) kurang baik 12(22) 1(2) 13(24) baik 22(41) 19(35) 33(76) p value 0.011 tabel 3. tabulasi silang faktor pasien dan pelaksanaan triage di igd faktor pasien pelaksanaan triage total kurang optimal optimal f(%) f(%) kurang baik 19(35) 2(4) 21(39) baik 15(28) 18(33) 33(61) p value 0.01 150 jurnal ners vol. 10 no. 1 april 2015: 147–157 berarti ada hubungan faktor perlengkapan dengan pelaksanaan triage oleh tenaga kesehatan. tabel 6 didapatkan data bahwa faktor model keperawatan yang tidak lengkap 18 responden (37%) menunjukkan pelaksanaan triage yang dilakukan oleh tenaga kesehatan telah optimal dan 36 responden (67%) menu nju k kan pelaksanaan t riage yang dilakukan oleh tenaga kesehatan kurang optimal. uji chi square tidak menunjukkan ρ value karena data faktor model keperawatan sama (data yang didapatkan konstan), sehingga tidak dapat dihitung nilai statistiknya. penelitian ini menggunakan analisis multivariat regresi logistik karena variabel dependent pelaksanaan triage oleh tenaga kesehatan menggunakan skala data berupa kategori dikotomi yaitu optimal dan kurang optimal. syarat analisis multivariat adalah nilai p < 0,25 sehingga variabel yang memenuhi syarat untuk dilakukan analisis multivariat regresi logistik adalah faktor kinerja ( p value = 0.000), faktor pasien ( p value = 0,01), faktor ketenagaan ( p value = 0.011) dan faktor perlengkapan ( p value = 0.010). tabel 7 menunjukkan bahwa faktor yang paling berhubungan dengan pelaksanaan triage oleh tenaga kesehatan secara berurutan dimulai dari or yang paling kecil yaitu faktor kinerja (b = -3,803, p sig. 0,002), faktor ketenagaan (b= -2,986, p sig. 0,017), faktor pasien (b= -2,568, p sig. 0,011), dengan konstanta 1,747, sehingga didapatkan persamaan regresi, yaitu: p = 1,747 + -3,803 kinerja pasien + -2,986 tenaga+ -2,568 pembahasan berdasarkan tabel 2 didapatkan data bahwa faktor kinerja yang kurang baik tabel 6. tabulasi silang faktor model keperawatan dengan pelaksanaan triage di igd no faktor model keperawatan pelaksanaan triage totalkurang optimal optimal f(%) f(%) 1 lengkap 0 0 0 2 tidak lengkap 36(67) 18(37) 0 ρ value tabel 7. hasil analisis multivariat regresi logistik b df p or langkah 1a f kinerja -3.71 1 .003 0.24 f perlengkapan -.28 1 .776 0.75 f pasien -2.47 1 .019 0.84 f ketenagaan -2.96 .018 0.05 constant 1.794 1 .006 6.01 langkah 2a f kinerja -3.80 1 .002 0.02 f pasien -2.56 1 .011 0.07 f ketenagaan -2.98 1 .017 0.05 constant 1.747 .005 5.73 tabel 5. tabulasi silang faktor perlengkapan dengan pelaksanaan triage di igd faktor perlengkapan pelaksanaan triage totalkurang optimal optimal f(%) f(%) kurang baik 19(35) 4(8) 23(42) baik 15(28) 16(30) 31(58) p value 0,010 151 analisis faktor pelaksanaan triage (nur ainiyah, dkk.) sebanyak 1 responden (2%) melaksanakan triage optimal dan faktor kinerja yang baik 19 responden (35%) melaksanakan triage optimal. berdasarkan hasil uji fisher didapatkan bahwa ρ value = 0,000 (ρ < 0,05), sehingga h1 diterima berarti ada hubungan faktor kinerja dengan pelaksanaan triage oleh tenaga kesehatan. fa k t or k i ne r ja d ala m pe nel it ia n ini meliputi subvariabel kepemimpinan, perawatan kritis, hubungan interpersonal atau kolaborasi, pendidikan kesehatan atau teaching dan pengembangan profesi. responden yang mempunyai faktor kinerja baik ditunjukkan d a r i sebag ia n besa r responden ser i ng menerima kritikan yang diberikan kepada dirinya dan sering bersifat terbuka atas saran yang diberikan kepada orang lain. hal tersebut di atas menunjukkan bahwa responden memiliki sifat kepemimpinan hampir sama dengan gaya kepemimpinan partisipatif, seperti yang disampaikan oleh house dalam agustina (2009) yang menyatakan bahwa ada beberapa gaya kepemimpinan yang dimiliki seseorang antara lain gaya kepemimpinan partisipatif, suportif dan beberapa yang lain, sedangkan gaya kepemimpinan partisipatif adalah seorang pemimpin terbuka dalam menerima kritikan orang lain, memberikan kewenangan dan tanggung jawab kepada individu atau kelompok untuk mengambil sebuah keput usan. hal yang sama juga didapatkan dalam penelitian doran, amy sanchez, martin gevans, kathleen macmillan (2004) bahwa gaya kepemimpinan yang baik akan menciptakan lingkungan yang baik dan kinerja yang baik pula. k iner ja responden yang bai k ini kemungkinan disebabkan karena separuh perawat mempu nyai pengalama n ya ng cukup lama bekerja di igd (5–10 tahun), dengan pengalaman yang cukup lama, maka kemampuan menghadapi pasien dan kasus juga akan semakin banyak sehingga ketika melaksanakan tindakan perawatan dapat optimal. hal ini sesuai dengan penelitian fujino, tanaka m, yonemitsu y, kawamoto r. (2014) pada 1395 perawat yang bekerja di rumah sakit umum di jepang menunjukkan bahwa 1045 perawat (76%) menunjukkan bahwa semakin lama bekerja maka kinerja perawat menjadi semakin baik. kinerja responden yang baik juga d it u nju k k a n de nga n re sp onde n d apat melakukan perawatan baik kritis ataupun non kritis dengan baik yaitu sebagian besar mampu menggunakan perangkat mekanik atau penunjang, sebagian besar sering melakukan perawatan yang dibutuhkan oleh pasien kritis, hampir separuh perawat sangat sering bekerja dengan kompeten dalam situasi darurat. hal ini sesuai dengan penelitian wahyudi (2010) bahwa terdapat hubungan bermakna antara kemampuan praktik profesional dengan kinerja perawat p value = 0,03 (p < 0,05). kinerja reponden yang kurang baik ditunjukkan dari sebagian kecil responden masih sedikit yang mendapatkan bimbingan dari anggota tim lainnya dalam perencanaan asuhan keperawatan jika mengalami kesulitan, sebagian kecil responden member ikan dukungan emosional pada keluarga pasien yang akan meninggal, dari hal tersebut diketahui bahwa komunikasi interpersonal dengan pasien atau kolaborasi responden dengan dokter atau teman sejawat kurang baik sehingga kinerja yang dilaksanakan kurang baik pula. hal tersebut di atas sesuai dengan penelitian tanabe, motoko & yoshimi suzukamo & ichiro tsuji & sin-ichi izumi pada 112 perawat puskesmas yang dibagi menjadi 2 kelompok yaitu salah satunya sebagai kontrol. penelitian ini memberikan perlakuan berupa pelatihan keterampilan komunikasi dan hasilnya menunjukkan bahwa kinerja perawat meningkat secara signifi kan pada reponden yang lebih dahulu mendapatkan pelatihan daripada yang tidak diberikan pelatihan. kinerja responden yang kurang baik juga ditunjukkan dari sebagian kecil responden merasa kurang atau belum mampu menggunakan kesempatan belajar yang diberikan kepadanya untuk pengembangan diri dan profesional berkelanjutan. hal ini bertolak belakang dengan wilson (2012) bahwa standar pengembangan profesional kinerja perawat antara lain pelaksanaan tindakan sesuai etika, kepemimpinan dan standar pengembangan staf. 152 jurnal ners vol. 10 no. 1 april 2015: 147–157 penelitian lain yang hal ini telah dilakukan oleh dadashzadeh, abbas, farahnaz abdolahzadeh, azad rahman, mor teza ghojazadeh (2013) bahwa dalam penelitian kualitatifnya menyatakan bahwa faktor yang mempengaruhi pelaksanaan triage dibagi menjadi 3 kategori yaitu pertama faktor personil (keterampilan dan pengetahuan perawat), kedua faktor pasien dan ketiga adalah faktor non personil salah satunya adalah beban kerja. hal tersebut di atas dikuatkan pula oleh australian triage process review (2005) menyatakan bahwa kinerja mempengaruhi pelaksanaan triage. oleh karena itu dapat disimpulkan bahwa faktor kinerja berhubungan dengan pelaksanaan triage. h a s i l p e n e l i t i a n m e n u n j u k k a n bahwa ada hubungan faktor pasien dengan pelaksanaan triage oleh tenaga kesehatan. australian triage process review (2011) yang menyatakan bahwa faktor yang mempengaruhi pelaksanaan triage adalah faktor pasien yang meliputi kepuasan atau pengalaman pasien, karakteristik pasien, keamanan dan keselamatan pasien, lama waktu tunggu, serta antrian (queuing). faktor pasien baik dengan mendapatkan pelayanan atau pelaksanaan triage optimal, hal ini ditunjukkan dengan sebagian besar pasien sangat puas karena perawat segera berdiri dan mendekati pasien dan membantu berpindah atau menempati bed atau kursi roda, sebagian besar pasien merasa sangat puas karena perawat menanyakan keluhan yang dirasakan pasien dalam waktu kurang dari 5 menit, hampir seluruh pasien sangat puas karena perawat melakukan pemeriksaan tekanan darah, nadi dan suhu tidak lebih dari 5 menit, sebagian besar pasien sangat puas karena dokter melakukan pemeriksaan tidak lebih dari 10 menit. lama waktu tunggu dalam penelitian ini merupakan ketepatan waktu yang diberikan kepada pasien untuk mendapatkan pengobatan sesuai dengan kondisi pasien (status kegawatan pasien). hal tersebut di atas sesuai dengan parasuraman dalam yohana (2011) bahwa kemauan untuk memberikan pelayanan dengan cepat dan tepat berhubungan dengan kepuasan pasien. menurut tarlier (2004) bahwa hubungan responsiveness ini dibentuk berdasarkan 3 elemen yaitu respecst (hormat), trust (percaya), dan mutuality (pertolongan). responsiveness ini ditunjukkan dalam penelitian ini bahwa lebih dari separuh perawat segera datang dan berespons ketika pasien membutuhkan sesuatu atau memanggil perawat, sebagian besar responden menyatakan bahwa perawat mampu mengkaji dengan baik, hal ini sesuai dengan penelitian toma, g, wayne triner, louiseann mcnutt (2009) yang menyatakan bahwa kepuasan pasien berkorelasi kuat dengan keterampilan interpersonal tenaga kesehatan dalam melakukan pengkajian. faktor pasien baik juga ditunjukkan dengan separuh pasien puas karena perawat atau petugas menerima pasien dengan baik mulai dari pintu igd, sebagian besar pasien puas karena perawat atau dokter menjelaskan tentang kondisi dan pengobatan yang akan diterima, sebagian besar pasien juga sangat puas karena perawat juga mengikutsertakan pasien dalam pengambilan keputusan. hal ini menunjukkan bahwa informasi dan komunikasi interpersonal antara perawat atau petugas kesehatan dengan pasien berjalan dengan baik, dengan berjalannya komunikasi yang baik tersebut maka kepuasan akan tercapai, hal ini sesuai dengan penelitian salehi, lesley strawderman, laura ruff (2012) pada 722 pasien di rumah sakit australia menunjukkan bahwa ada hubungan yang kuat antara komunikasi dengan kepuasan pasien, hal yang sama juga dilakukan dalam penelitian nielsen (2004) bahwa dengan komunikasi akan dapat meningkatkan kepuasan. hal yang sama juga ditemukan dalam penelitian radtke (2013) yang melakukan observasi kepuasan pasien selama 3 bulan dan hasilnya menunjukkan terjadi peningkatan dari 75% menjadi 87% setelah perawat melak u kan komunikasi interpersonal kepada pasien selama operan. berdasarkan hasil penelitian chan j n and chau j. (2005) dan elder (2004) menu nju k k a n ba hwa ke pu a sa n pa sien berhubungan dengan pelaksanaan triage, 153 analisis faktor pelaksanaan triage (nur ainiyah, dkk.) dan salah satu cara meningkatkan kepuasan pasien adalah dengan menurunkan lama waktu tunggu. (walrath, jo m. ramona tomallobowman, jeanne m. maguire. 2004), dengan demikian dapat disimpulkan bahwa faktor pasien berhubungan dengan pelaksanaan triage oleh tenaga kesehatan. berdasarkan tabel 4 didapatkan data bahwa faktor ketenagaan yang kurang baik 1 responden (2%) menunjukkan pelaksanaan triage optimal sedangkan faktor ketenagaan yang baik 19 responden (35%) menunjukkan pelaksanaan triage optimal. berdasarkan hasil uji fisher didapatkan bahwa p value = 0,011 (ρ < 0,05) sehingga h1 diterima berarti ada hubungan faktor ketenagaan dengan pelaksanaan triage oleh tenaga kesehatan fa k t or ket e n aga a n ba i k de nga n pelaksanaan triage optimal ditunjuk kan dengan hasil perhitungan kebutuhan tenaga perawat berdasarkan rumus formula instalasi gawat darurat (raymond, 2011) didapatkan bahwa di igd tersebut membutuhkan 8 perawat sedangkan pada kenyataannya tenaga yang dimiliki adalah sejumlah 18 perawat hal ini menunjukkan bahwa ketenagaan yang dimiliki igd tersebut lebih dari kebutuhan. hal ini sesuai dengan penelitian jansen (2011) yang menunjukkan bahwa faktor yang mempengaruhi pelaksanaan triage yaitu salah satunya adalah jumlah tenaga dan pengaturan shift. faktor ketenagaan baik menunjukkan pelaksanaan triagenya optimal, selain dilihat dari segi kuantitas juga dilihat dari segi kualitas di mana kualitas perawatnya seluruhnya sudah pernah mengikuti bls, btls dan ppgd selain itu separuh dari tenaga perawat sudah bekerja selama 5–10 tahun di igd. hasil yang demikian ini sejalan dengan dilakukan oleh russo (2010) ya ng menu nju k ka n bahwa pendidikan dan pengalaman perawat mempengaruhi pengambilan keputusan triage. oleh karena itu dapat disimpulkan bahwa ada hubungan antara faktor ketenagaan dengan pelaksanaan triage oleh tenaga kesehatan. berdasarkan tabel 5 didapatkan data bahwa pendapat tentang faktor perlengkapan yang kurang baik didapat dari 4 responden (8%) menunjukkan pelaksanaan triagenya optimal sedangkan pendapat tentang faktor perlengkapan yang baik 16 responden (30%) menunjukkan pelaksanaan triagenya optimal. berdasarkan hasil uji fisher didapatkan bahwa p value = 0,010 (ρ < 0,05) sehingga h1 diterima berarti ada hubungan faktor perlengkapan dengan pelaksanaan triage oleh tenaga kesehatan. pendapat tentang faktor perlengkapan baik dan pelaksanaan triagenya optimal, hal ini ditunjukkan dengan responden menyatakan bahwa sebagian besar set uju pimpinan memonitor semua kegiatan yang dilakukan oleh staf, sebagian besar setuju pimpinan mudah diajak berkonsultasi, bersifat terbuka dan baik dalam mendiskusikan pelaksanaan tugas dengan stafnya, separuh responden setuju pimpinan mempunyai kemampuan penyelesaian masalah yang baik. faktor perlengkapan dalam hal ini subvariabel lingkungan kerja (kepemimpinan) m e n u n j u k k a n b a h w a k e p e m i m p i n a n merupakan bagian yang sangat penting yang dapat mempengaruhi pelayanan keperawatan serta dapat memberikan kualitas praktik keperawatan yang baik kepada pasien (huber, 2006). pendapat tentang faktor perlengkapan baik dan pelaksanaan triagenya optimal, juga ditunjukkan dengan sebagian besar responden menyatakan setuju bahwa ketersediaan sarana dan prasarana dalam jumlah yang cukup dan nyaman ketika memberikan pelayanan kepada pasien sebagian besar responden menyatakan sarana dan prasarana yang digunakan telah sesuai dengan perkembangan tek nologi kesehatan, sebagian besar setuju bahwa tersedia kesempatan untuk berkomunikasi antara pasien, perawat dan dokter, hampir separ uh perlengkapan f isik sarana dan prasarana sudah menunjukkan lengkap. berdasarkan hasil penelitian di atas menunjukkan bahwa lingkungan kerja terbagi menjadi dua yaitu pertama adalah lingkungan kerja fi sik (ketersediaan sumber daya atau sarana dan prasarana) dan lingkungan kerja non fisik yaitu yang berhubungan dengan lingkungan kerja, baik hubungan dengan 154 jurnal ners vol. 10 no. 1 april 2015: 147–157 atasan maupun hubungan dengan sesama rekan kerja, ataupun hubungan dengan bawahan (sedarmayanti dalam ghoffur, 2011). ketersediaan sumber daya merupakan salah satu dukungan yang digunakan perawat dalam memberikan pelayanan terhadap pasien secara optimal, seperti halnya dalam penelitian kualitatif jansen (2011) bahwa faktor salah satu faktor yang berpengaruh dalam pelaksanaan pedoman triage adalah sumber daya. hal ini didukung oleh penelitian yoon, philip, ivan steiner, gilles reinhardt (2003) bahwa salah satu faktor yang mempengaruhi lama waktu tunggu di igd adalah perlengkapan. pendapat tentang faktor perlengkapan baik dengan pelaksanaan triagenya optimal juga ditunjukkan dari sebagian besar setuju komunikasi antar perawat atau perawat dengan dokter berjalan dengan baik meskipun ketika terjadi kesulitan saat memberikan pelayanan pada pasien, separuh responden setuju pelayanan keperawatan dilakukan secara bersamaan dan saling membantu antar sesama tim, sebagian besar responden setuju adanya kesempatan untuk menyampaikan ide antar sesama rekan. hasil penelitian tersebut menunjukkan bahwa lingkungan kerja non fi sik dapat berupa hubungan komunikasi atau kerja sama antara staf atau antara perawat dan dokter, dengan kerja sama yang baik maka lingkungan menjadi kondusif sehingga pelayanan keperawatan dapat diberikan secara optimal, hal ini didukung oleh marlene & claudia (2003) menyatakan bahwa yang menjadi elemen penting dalam hubungan perawat dan dokter adalah kerja sama dan komunikasi dengan kerja sama yang baik berdasarkan observasi dalam penelitian ini didapatkan bahwa ketersediaan peralatan triage di ruang triage masih ada yang belum lengkap, hal ini disebabkan karena sebenarnya peralatan atau instrumen triage telah tersedia akan tetapi tidak ditempatkan di ruang triage tetapi ditempatkan di gudang peralatan dan ada juga yang ditempatkan di ruang tindakan. hal ini ber tolak belakang dengan penelitian geraci dalam gerdtz (2000) yang menunjuk kan bahwa faktor-faktor yang mempengaruhi pelaksanaan triage antara lain adalah fasilitas fi sik yang disediakan di ruang triage. penelitian ini juga menunjukkan bahwa sebagian kecil responden menyatakan bahwa perawat masih belum mempunyai kesempatan yang sama untuk mengikuti pelatihan. hal ini didukung oleh penelitian chen ym and johantgen me (2010), bahwa ada hubungan antara pengembangan profesional dengan kepuasan kerja, di mana kepuasan kerja merupakan sikap positif terhadap pekerjaan yang dilakukan, jika sikap positif ini muncul maka kinerja yang dilakukan juga menjadi optimal, kinerja yang dimaksud disini adalah pelaksanaan triage. berdasarkan australian system process review (2011) bahwa faktor perlengkapan mempengaruhi pelaksanaan triage. faktor perlengkapan meliputi perlengkapan atau peralatan triage, dukungan antar staf baik perawat dengan perawat ataupun perawat dengan dok ter. oleh karena it u d apat disimpulkan bahwa faktor perlengkapan berhubungan dengan pelaksanaan triage oleh tenaga kesehatan. berdasarkan tabel 6 didapatkan data bahwa faktor model asuhan keperawatan yang tidak lengkap 18 responden (37%) menunjukkan pelaksanaan optimal dan 36 responden (67%) menunjukkan pelaksanaan triage kurang opimal. berdasarkan hasil uji chi square tidak didapatkan besarnya ρ karena faktor model asuhan keperawatan di kedua igd yang sama sehingga data yang didapatkan tidak bervariasi atau konstan, sehingga tidak dapat dihitung nilai statistiknya. faktor model asuhan keperawatan yang tidak lengkap dalam penelitian ini ditunjukkan dengan igd mempunyai model asuhan yang dimiliki igd ini adalah resuscitation, gp clinic yaitu ketenagaan yang berada di igd adalah dokter umum, sedangkan dokter spesialis on call saja, meskipun sebenarnya igd ini sudah memilki dokter spesialis emergency yang hanya datang ketika shift pagi saja. model lain yang dimiliki oleh igd ini adalah maternal neonatal emergency care (early pregnancy units) serta melayani gawat medik dan gawat bedah (medical surgical assesment units). hal tersebut di atas kemungkinan disebabkan karena adanya keterbatasan sumber daya yang ada di masing-masing 155 analisis faktor pelaksanaan triage (nur ainiyah, dkk.) rumah sakit meliputi sumber daya manusia, fasilitas, kebijakan ser ta inf rast r u k t u r. australian triage process review (2011) menyatakan bahwa model asuhan keperawatan mempengaruhi pelaksanaan triage, seperti fast track, emergency short stay, pediatrics, psyciatrics emergency care centers, aged coordination and evaluation team, gp clinics, resusciation, medical surgical assesment units, and early pregnancy. jika memilki model asuhan keperawatan yang lengkap maka diharapkan setelah perawat atau dokter melakukan triage kepada pasien maka pasien akan segera dimasukkan sesuai dengan kasus atau kategori yang terjadi pada pasien tersebut. hal ini sesuai dengan mchugh, megan, kevin van dyke, mark mcclelland, mass (2011) menyatakan bahwa untuk meningkatkan jumlah pasien dan mengurangi penuhnya pasien di igd maka dilakukan dengan menggunakan model keperawatan salah satunya adalah dengan fast track. oleh karena model asuhan keperawatan yang dimiliki igd yang tidak bervariasi maka disimpulkan tidak diketahuinya hubungan antara model asuhan keperawatan dengan pelaksanaan triage. hasil penelitian pada tabel 7 dapat disimpulkan faktor yang paling berhubungan dengan pelaksanaan triage oleh tenaga kesehatan secara berurutan dimulai dari or yang paling kecil yaitu faktor kinerja, faktor ketenagaan dan faktor pasien. va r i a b e l p e r t a m a y a n g p a l i n g berhubungan dengan pelaksanaan triage oleh tenaga kesehatan adalah faktor kinerja. kinerja dipengaruhi oleh tiga faktor yaitu fak tor individu, fak tor organisasi, dan faktor psikologi. faktor individu terdiri dari kemampuan keterampilan, pengalaman dan latar belakang demografi, sedangkan faktor psikologi terdiri dari persepsi, sikap, ke pr iba d ia n d a n mot iva si, sed a ng k a n faktor organisasi, terdiri dari sumber daya, kepemimpinan/kebijakan, imbalan, struktur, pembagian pekerjaan ( job description). (gibson dalam firmansyah, 2009). beberapa faktor yang mempengaruhi kinerja tersebut telah ditemukan dalam penelitian ini yaitu bahwa sebagian besar me mpu nya i p e nga l a m a n ya ng c u k u p lama bekerja di igd (5-10 tahun), seluruh responden pernah mengikuti bls, btls dan ppgd sedangkan sebagian besar juga sudah mengikuti gels. hal ini sesuai dengan penelitian rahmati, hashem. mahboobeh azmoon, mohammad kalantari meibodi, najaf zare (2013) pada perawat igd di iran menunjukkan terjadi peningkatan kinerja setelah diberikan pelatihan tentang triage setelah 6 minggu. responden yang mempunyai kinerja baik akan tetapi pelaksanaan triagenya kurang optimal, hal ini kemungkinan disebabkan karena jumlah pasien yang sangat banyak dalam setiap shiftnya, hal ini menunjukkan beban kerja perawat yang tinggi, pembagian job description tenaga keperawatan masih belu m terkoordionasi secara maksimal seperti tenaga perawat merangkap sebagai petugas administrasi, tidak ada perawat yang bertanggung jawab secara khusus pada satu tingkat atau satu level tertentu. berdasarkan penelitian kualitatif yang dilakukan oleh cone, k.j. and r. murray, (2002) di temukan 4 tema utama yang mempengar uhi pelaksanaan triage yaitu sifat-sifat pribadi, karakteristik kognitif, karakteristik perilaku, dan pengalaman. salah satu bagian dari karakteristik perilaku kinerja perawat. penelitian yang juga dilakukan oleh andersson, a. k., omberg, m., & svedlund, m. (2006) yang diikuti oleh 81 ird yang ada di belanda yang terdiri dari manajer, perawat, dan dokter menunjukkan bahwa ada beberapa faktor yang mempengaruhi pelaksanaan pedoman triage yaitu kinerja perawat, tingkat pengetahuan, wawasan dan keterampilan, motivasi, dukungan, informasi dokter, pengaturan shift untuk implementasi, deskripsi tugas dan tanggung jawab, beban kerja dan sumber daya. variabel kedua yang berhubungan dengan pelaksanaan triage yang dilakukan oleh t e n aga ke seh at a n a d a la h fa k t or ketenagaan. faktor ketenagaan yang dimaksud dalam penelitian ini adalah jumlah perawat di igd, jumlah satu shift, pendidikan terakhir yang perawat yang bekerja di igd, pelatihan lanjutan yang pernah diikuti. hal ini didukung oleh penelitian dadashzadeh, abbas, farahnaz abdolahzadeh, rahmani, morteza ghojazadeh 156 jurnal ners vol. 10 no. 1 april 2015: 147–157 (2013) yang menunjukkan bahwa salah satu faktor yang mempengar uhi pelaksanaan triage adalah faktor personil yang meliputi keterampilan perawat (pengkajian, pendidikan dan pengalaman). simpulan dan saran simpulan berdasarkan hasil penelitian, dapat disimpulkan bahwa ada hubungan antara fa k t or k i ne r ja ( pe r for m a n c e) de nga n pelaksanaan triage oleh tenaga kesehatan, ada hubungan faktor pasien dengan pelaksanaan triage oleh tenaga kesehatan, ada hubungan faktor ketenagaan dengan pelaksanaan triage oleh tenaga kesehatan, ada hubungan faktor perlengkapan dengan pelaksanaan triage oleh tenaga kesehatan di instalasi gawat darurat serta tidak ada hubungan antara faktor model asuhan keperawatan dengan pelaksanaan triage di instalasi gawat darurat dikarenakan tidak bisa dilakukan uji statistik. faktor yang paling dominan yang berhubungan dengan pelaksanaan triage adalah faktor kinerja, faktor ketenagaan dan faktor pasien. saran diharapkan kepada pihak rumah sakit meningkatkan motivasi kerja, mengoptimalkan ketenagaan perawat dengan cara memberikan job description secara jelas, memperbaiki sistem management yang terkait dengan beban kerja perawat, serta meningkatkan kualitasnya dengan mengikuti pelatihan triage office course secara bergantian. kepustakaan andersson, a.k., omberg, m., & svedlund, m. 2006. triage in the emergency department a qualitative study of the factors which nurses consider when making decisions. british association of critical care nurse, 11, 136–145. agustina, r. 2009. hubungan antara gaya kepemimpinan dengan kreativitas karyawan: analisis pengarh mediasi pe mik ira n kreat if d a n m ot iva si intrinsik pada karyawan di industri media. fakultas ekonomi universitas indonesia. chan jn dan chau j., 2005. patient satisfaction with triage nursing care in hong kong. j adv nurs; 50(5): 498–507. chen ym and johantgen me., 2010. magnet hospit al at t r ibutes i n eu ropea n hospitals: a multilevel model of job satisfaction. int j nurs stud. 2010 aug; 47(8): 1001–12. c o n e , k . j. a n d r . m u r r a y. 2 0 0 2 . characteristics, insights, decision making, and preparation of ed triage nurses. journal of emergency nursing. 28(5): p. 401–406. dadashzadeh, a., farahnaz a., azad r., morteza g., 2013. factors affecting triage decision-making from the viewpoints of emergency department staff in tabriz hospitals, iran j crit care nurs; 6(4): 269–276. doran, d., amy s.m., martin g. e., kathleen m., linda m.h., dorothy p., susan s., a nton io v., 2004. impact of the manager’s span of control on leadership and performance. canadian health services research foundation. ontario ministry of health and longter m care nursing effectiveness, utilization and outcomes research unit, faculty of nursing, university of toronto. fathoni, m., hathairat s., praneed s., 2010. relationships between triage k n owle d g e , tr a i n i n g , wo r k i n g experiences and triage skills among emergency nu rses i n east java, indonesia. nurse media journal of nursing, 3, 1, 2013, 511–525. firmansyah, m. 2009. pengaruh karakteristik organisasi terhadap kinerja perawat d a l a m m e l a k s a n a k a n a s u h a n keperawatan untuk membantu promosi kesehatan di rumah sakit umum sigli. tesis. universitas sumatera utara. fujino y, tanaka m, yonemitsu y, kawamoto r. 2014. the relationship between characteristics of nursing performance and years of experience in nurses with high emotional intelligence. int j nurs pract. 2014 apr 8. doi: 10.1111/ijn. 12311. 157 analisis faktor pelaksanaan triage (nur ainiyah, dkk.) gerdtz m. f. 2003. triage nurses’ clinical decision making: a multi-method study of practice, processes and infl uences. school of nursing, faculty of medicine, d e nt i s t r y a nd he a lt h s e r v ic e s , university of melbourne, melbourne. ghofar, a., misbahuddin a., 2013. pengaruh lingkungan kerja terhadap kinerja perawat melalui kepuasan kerja sebagai variabel intervening (studi pada pera wat ruangan instalasi rawat inap kelas i, ii, iii-a, dan iii-b rumah sakit islam unisma malang). tesis. fakultas ekonomi dan bisnis universitas brawijaya. janssen, ma., vanachterberg, t., adriaansen, mj., kampshoff, cs., & mintjesdegroot, j., 2011. adherence to the gu ideli ne ‘tr iage i n emergency depar tments’: a sur vey of dutch emergency departments. j clin nurs, 20(17–18), 2458–2468. marlene dan claudia s., 2003. securing good nurse physician. jonm. 34(7): 34–38. radtke k. 2013. improving patient satisfaction with nursing communication using bedside shift report. clin nurse spec; 27(1): 19–25. rahmati, h., mahboobeh a., mohammad km., najaf z. 2013. effects of triage education on knowledge, practice and qualitative index of emergency room staff: a quasi-interventional study. bull emerg trauma 2013; 1(2): 69–75. russo, ta., 2010. factors affecting the process of clinical decision-making in pediatric pain management by e m e r ge n c y d e p a r t m e n t nu r s e s. dissertation. doctor of philosophy college of nursing. safari, sr., 2012. perceptions and challenges of using emergency triage assessment treatment guideline in emergency department at muhimbili national ho s pi ta l , ta n za n i a. m a s t e r s i n critical care and trauma dissertation. muhimbili university. salehi, a., lesley s., dan laura r., 2012. the importance of communication for patient satisfaction. department of industrial and systems engineering human systems engineer ing lab mississippi state university. http://www. iienet2.org/shs/details.aspx?id=18430 raymond hs. 2012. manajemen keperawatan. egc: jakarta. tanabe, m., yoshimi s., ichiro t., dan sinichi i., 2012. communication training i mprove s se n se of pe r for ma nce expectancy of public health nurses e ng a ge d i n l o ng-te r m eld e rly prevention care program. isrn nursing. 2012 (12), article id 430560, 8 pages. http://dx.doi.org/10.5402/2012/430560. tarlier ds. 2004. beyond caring: the moral and ethical bases of responsive nursepatient relationships. nurs philos; 5(3): 230–41. wahyudi. 2010. hubungan persepsi perawat tentang profesi keperawatan dan motivasi kerja t rehadap kinerja pera wat pelak sana di rsud dr. slamet garut. tesis. fakultas ilmu keperawatan. program pasca sarjana magister ilmu keperawatan kekhususan ke p e m i m pi n a n d a n m a n aje m e n keperawatan. universitas indonesia. walrath, jm., ramona tb., jeanne mm., 2004. emergency department: improving patient satisfaction. nurs econ. 2004; 22(2). wilson c. 2012. standards of professional performance for nursing professional development. j nurses staff dev. 28(1): 43–4. yoon, p., ivan s., gilles r., 2003. analysis of factors infl uencing length of stay in the emergency department. cjem.; 5(3): 155 161. , australian triage process review. 2011. health policy priorities principal commitee australian process review. microsoft word 28758-127568-1-le.docx http://e-journal.unair.ac.id/jners | 169 jurnal ners vol. 16, no. 2 october 2021 http://dx.doi.org/10.20473/jn.v16i2.28758 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effectiveness of a nurse-led team-based hypertension management among people with uncontrolled hypertension in a community hospital, thailand nongnut oba1 and navarat chutipanyaporn2 1 faculty of nursing, naresuan university, phitsanulok province, thailand 2 bang rakam hospital, bang rakam district, phitsanulok province, thailand abstract introduction: uncontrolled blood pressure of people with hypertension remains a major public health issue. the purpose of this research was to evaluate the effectiveness of a nurse-led team-based hypertension management program (nthmp) among people with uncontrolled hypertension. methods: this quasi-experimental one-group pre-posttest design research was done to evaluate the effectiveness of a nthmp in a community hospital in thailand. the sample was thirty people with uncontrolled hypertension who received outpatient care in a community hospital in thailand. they participated in three months nthmp which included 1) team-approached health education, 2) medication administration support, 3) motivation interviewing on behavioral adjustment and 4) home blood pressure monitoring for three months. outcomes of the program; systolic blood pressure, diastolic blood pressure, hospital admissions with signs of hypertensive urgency were analyzed by using frequency, percentage, mean, standard deviation, and repeated measured anova. results: the results indicated that people with uncontrolled ht had lower systolic blood pressures and diastolic blood pressure compared with baseline levels (p<0.001), and no hospital admissions. conclusion: this program provided evidence for nurses to manage blood pressure control in people with hypertension within a collaboration with multidisciplinary team members in the community hospital. article history received: july 30, 2021 accepted: november 29, 2021 keywords covid-19; online clinical learning; nursing student contact nongnut oba * nongnut@nu.ac.th + faculty of nursing, naresuan university, phitsanulok province, thailand cite this as: oba, n., & chutipanyaporn, n. (2021). the effectiveness of a nurse-led team-based hypertension management among people with uncontrolled hypertension in a community hospital, thailand. jurnal ners, 16(2). 169-176. doi:http://dx.doi.org/10.20473/jn.v16i2.28758 introduction hypertension (ht) exerts a staggering worldwide burden on human quality of life and healthcare system resources via contribution to increased mortality and risk of cardiovascular diseases, chronic kidney disease and stroke globally (world health organization, 2019). worldwide, raised blood pressure (bp) is estimated to cause 7.5 million deaths, about 12.8 % of the total of all deaths (basile & bloch, 2019). in general, lifestyle management is recommended for people with mild ht (average bp = 140–159/90– 99), low-risk for cardiovascular diseases and no co-morbidities (whelton et al., 2018). antihypertensive drug with lifestyle management was used for lowering bp in the moderate ht (flack & adekola, 2019; thai hypertension society, 2019). the new acc/aha hypertension guidelines indicated the goal of hypertensive care is that people with ht have an sbp of 130 mmhg or lower and dbp of 80 mmhg or lower (flack et al., 2019). however, the thai hypertension society indicated the patient’s bp should initially be lowered to under 140/90 mmhg and if the patient shows good tolerance to treatment then it should be further treated to <130/80 mmhg (thai hypertension society, 2019). therefore, people with ht who can manage their medication taking and behavioral life style well until they achieve a bp < 140/90 mmhg are defined as having controlled ht, while others having a bp > 140/90 mmhg two times continuous have uncontrolled ht. n. oba et al. 170 | pissn: 1858-3598 � eissn: 2502-5791 on the health disease control (hdc) dashboard of the ministry of public health (moph), data during 2017-2019, it was found that the prevalence rate of controlled ht was 35-50% in a cumulative data of district, provincial, and national levels (health data center, 2020). these data affected bang rakam hospital, a small community hospital in phitsanulok province, service area 2, moph which rethought and made a new plan to improve quality of hypertensive care. unhealthy lifestyle choices and non-adherence to medication are major causes of uncontrolled hypertension and are a high risk to progress to cardiovascular disease, chronic kidney disease and stroke that could threaten health and endanger life (williams et al., 2018). acute signs of very high blood pressure, which is called “hypertensive urgencies” have signs of stroke that threaten sudden death (bakris, 2019). practicing a healthy lifestyle; physical activity, healthy diet, restricted alcohol consumption, salt restriction, avoidance of tobacco use, and stress reduction and adherence to anti-hypertension medication are recommended in hypertension care (alsaigh et al., 2017; flack et al., 2019; whelton et al, 2018). promoting lifestyle behavior changes among people with ht aimed at lowering bp to normal level is herculean. in the review, it was found that health education and practice on the dash program (seangpraw et al., 2019), aerobic exercise training (bersaoui et al., 2020), supervised walking (mandini et al., 2018), mindfulness (ponte márquez et al., 2019), small group discussion and feedback about hypertension (thongdang & promsiripaiboon, 2015), and self-care management program (plaiyod, panpakdee, & taikerd, 2012) are helpful for lowering blood pressure among people with hypertension. self-monitoring blood pressure (smbp) significantly reduced office blood pressure and improved medication adherence (muhammad, jamial, & ishak, 2019). smbp at home may increase patient engagement and improve bp control (ho, carnagarin, matthews, & schlaich, 2018). smbp and cointerventions (including systematic medication titration, health education, or lifestyle counselling) leads to clinically significant bp reduction (tucker et al., 2017). a technique proved to have benefits to promote appropriate behaviors and decrease blood pressure levels among ht is motivational interviewing (mi). it was found that mi is powerful in reduction of sbp or dbp and weight reduction (ozpulat & emiroglu, 2017), improves the adherence to a low-sodium diet, adherence to self-care behaviors, regular use of antihypertensive medications, increases or maintains physical activity (silveira et al., 2019), evaluation of changes in daytime sleepiness, and cessation of smoking and cessation of drinking (dechkong, 2017). it elicited behavioral changes by helping clients to explore and resolve ambivalence (rollnick & allison, 2004). at the primary care level in district hospitals, the healthcare team of hypertension management includes a physician, pharmacist, physical therapist and professional nurse. at this setting, a nurse who trained to be nurse practitioner (np) usually acts as case manager, whereas the physician focuses on prescribing medication (proia et al., 2014). although hypertensive guidelines are recommended, a paradigm shift from fragmented care to a team approach is aimed at improving the quality of hypertensive care management (flack et al., 2019; thai hypertension society, 2019). team-based care was able to increase the proportion of people with controlled bp and reduced both sbp and dbp, especially when pharmacists and nurses were part of the team (american college of cardiology/american heart association task force, 2017). team approach could be kept viable on hypertension management, the organizational leader must be committed and willing to allocate the necessary resources (world health organization, 2019). people with ht should be active partners, working with the health team to create a self-individualized plan (patel et al., 2016). therefore, this research integrates concepts of hypertension management and team-based care to develop a nurse-led team-based hypertension management program (nthmp) aimed at improving blood pressure among people with uncontrolled ht. materials and methods a one-group quasi-experimental repeated measure design was used as protocol. the program’s effectiveness was tested by comparing the differences in sbp and dbp levels at before, the first and second month after the programmed interventions, and three months post-intervention of the sample. the number of hypertensive urgency and hospital admission by the sample post intervention was counted to calculate the effectiveness of the developed program. the population was uncontrolled ht of chronic care clinic in bang rakam hospital, a community hospital in phitsanulok province, service area 2, ministry of public health, thailand. they were 598 patients who met the inclusion criteria; 1) had bp>140/90 mmhg two times and over 2) received hypertensive medication, and 3) able to participate in the program. if they had ht complication such as stroke, chronic kidney disease, and heart disease, they were excluded. if they changed hypertensive medication and/or moved to receive another health serviced and/or could not participate in all activities of the program, they were withdrawn. the sample size calculation of polit and beck using power analysis was employed to reduce the risk of type i error. the minimum level of significance (α) to estimate the number of sample size was 0.05 with the power of 0.80 (1-ß), which would yield a sample size of n=30. they were 598 patients who met the inclusion criteria, the investigator used simple random sampling for sample selection. the researcher listed all of the population members initially, and then each member was marked from 1 to 598. random number jurnal ners http://e-journal.unair.ac.id/jners | 171 generator software, an internet application, was used for simple random sampling. the researcher followed the direction of generator software until receiving 30 selected numbers. the selected numbers were compared to an organized list for getting name and phone numbers of the sample. the professional nurse of the chronic care clinic who acted as coordinator, invited the selected sample to participate in the research project by phone call. if any sample was not willing to participate in the project, the researchers could select a new number by generator software. there were two types of instruments used in this research: an intervention instrument and a collected instrument. they were tentatively developed by focus group among health providers and people with uncontrolled ht which was the prior step of this research project (oba & chutipanyaporn, 2018). first, the intervention instrument was the care process of the nthmp or the program, including: team-approached health education it was designed at the time of opd visit divided into four sessions (30-45 min/session) for group health education. a physician taught on dash dietary practices, a physical therapist worked on increasing individualized physical activity, a pharmacist taught how to take medication correctly and regularly, and a thai traditional practitioner demonstrated stress reduction practices. after each session, there were open discussions on the practice which took around 15-20 minutes/session. medication taking support the pharmacist checked the remaining medication of participants at each visit. if the pharmacist found out that some participants took medicine irregularly, then she wrote a small note in the patient’s record for np and the physician reviews and educated them on how to take the antihypertensive drug correctly. home blood pressure monitoring (hbpm) the nurse practitioner demonstrated how participants can measure their own bp and suggested the time measured should be based on two measurements taken in the morning or two measurements taken at night over a preferred period of seven days. after learning from the np, the participant practiced to measure their blood pressure in the correct position, how to read the results, and how to record the outcome by writing in a notebook. motivation interviewing on behavioral adjustment the nurse practitioner applied the four steps of motivational interviewing (mi); engaging, focusing, evoking, and establishing, which was developed by miller and rollnick for helping participants explore and resolve their ambivalence problem as well as promoting behavioral adjustment (mcneil, addicks, & randall, 2017). second, the collecting instrument was a form for recording the participant’s office sbp and dbp at before, first month, second month, after the programmed interventions, and three months postintervention as well as the number of hypertensive urgencies experienced by each patient. this parameter was collected from their medical records. the intervention instrument and the collecting data were evaluated for content validity by three independent experts: a medical doctor, a lecturer, and professional nurse. a consensus form of agreement was developed with a scale ranging from +1 = not relevant, +2 = item need some revision, +3 = relevant but need minor revision, +4 = very relevant, and included an opened-ended option for expert suggestions. this consensus form was based on the content validity index (cvi) technique. the values of the cvi calculations for two research instruments were 1.00. researchers coordinated with the hospital director for asking permission to conduct the research. after permission was given, simple random sampling was used to find the participants as explained in detail in the samples section earlier. after respondents’ agreement via mobile phone, researchers made an appointment with them for clarifying the objectives, intervention, and signed their ethic consent at the chronic care clinic before staring the program. there were 30 people with uncontrolled ht participated in this research. the researchers ran the nthmp and collected the data at the chronic disease clinic as follow: at the first day of the program, after 30 participants’ baseline blood pressure levels (sbp and dbp) were collected by automatic blood pressure machine of chronic care clinic, two sessions of group health education, antihypertensive drug and selfmonitoring blood pressure demonstration were done in a hospital meeting room. the health educators were a pharmacist and researchers (np) which took 20 and 30 minutes, respectively. these two activities were completed before participants met the physician for routine check-up and medication prescribing. at first month visit, participants’ blood pressure was collected by the chronic care clinic automatic blood pressure machine . pharmacists checked each participant’s remaining antihypertensive medications and asked about how to take each medication. two sessions of group health education, dash diet and benefits of physical activity and muscle-strengthening practice were done in a hospital meeting room. the health educators were a physician and physical therapist which took 30 and 20 minutes, respectively. then, one by one, participants met the principle researcher who acted as np the counseling room of the chronic disease clinic. np review participants’ bp home records and applied individual face to face brief mi of around 5-15 minutes/participant before participants met the physician. at second month visit, the participants’ blood pressure was collected by the chronic care clinic automatic blood pressure machine. the pharmacists n. oba et al. 172 | pissn: 1858-3598 � eissn: 2502-5791 checked each participant’s remaining antihypertensive medications. one session of group health education, neck massage and foot soaking by thai traditional practitioner was done for 30 minutes in a hospital meeting room. then, the np reviewed participants’ bp records for identifying their performances. np performed brief mi with participants one by one before participants met the physician. at third month visit or after intervention, participants’ blood pressure was collected by the chronic care clinic automatic blood pressure machine. pharmacists checked each participant’s remaining antihypertensive medications and asked about how to take each medication. np reviewed participants’ bp records for identifying their behavioral change. np evaluated the participant behavioral adjustments and motivated them to continue their appropriate behaviors. therefore, the intervention was delivered for three months. there were no respondent drop out during the intervention. at three months post-intervention (three months after completing the intervention), thirty participants’ blood pressures were collected by the chronic care clinic automatic blood pressure machine. the sbp and dbp data were analyzed by using mean and standard deviation. the difference of the average mean of sbp and dbp was analyzed using repeated measured anova. the number of hypertensive urgencies and the number of admissions reported for the sample were counted and percentages were analyzed. ethics clearance for this research was obtained from the ethics committee for research and human studies of naresuan university in thailand (number coa no.240/2014, october 3, 2017). the researchers provided details of the study to the participants prior to obtaining informed consent. confidentiality was assured by code numbering in all data and only the lead investigator was able to identify names with individual participant responses. the researchers obtained written consent and participants understood they could withdraw from the study at any time without penalty to assure protection of participant rights. results table 1 shows personal data of 30 participants: mostly were male (63.3%) and female (36.7%). their ages were between 20-29 years (3.3%), 40-49 years (6.7%), 50-59 years (46.7%), and >60 years (43.3%). they finished primary school level (80.0%), secondary school level and technical school (10.0%), and bachelor’s degree level (10.0%). their occupations were farmer (56.7%), merchant (3.3%), general contractor (23.33%), office worker (13.3%) and unemployed (3.3%). they were diagnosed with ht for 1-5 years (76.7%), 6-10 years (20.0%) and >10 years (3.3%). table 2 displays the blood pressure before, first month, second month, after intervention, and three months post intervention of people with uncontrolled ht. the results showed both sbp and dbp were significantly lower than at before intervention levels (p<0.001). table 3 shows post intervention, blood pressure level ranges demonstrating greater the number of participants with levels of higher bp decreased. at three months postintervention both sbp and dbp are mostly still in the same range with at post table 1. demographic characteristic of participants in nurse-led team-based hypertension management program (nthmp) demographic characteristic number percent sex male female 19 11 63.3 36.7 age (year) 20-29 30-39 40-49 50-59 >60 1 3 14 13 3.3 6.7 46.7 43.3 education primary school secondary school / technical school bachelor’s degree 24 3 3 80.0 10.0 10.0 occupations farmer general contractor office worker merchant unemployed 17 7 4 1 1 56.7 23.4 13.3 3.3 3.3 duration of ht 1-5 years 6-10 years >10 years 23 6 1 76.7 20.0 3.3 jurnal ners http://e-journal.unair.ac.id/jners | 173 intervention. in addition, no participants were admitted into the hospital with signs and symptoms of hypertensive urgency until at three months post intervention. discussion the results indicated that people with uncontrolled ht had lower systolic blood pressures and diastolic blood pressure compared with baseline levels (p<0.001), and no hospital admissions. it indicates that nthmp could be able to lower risk of cardiovascular disease, chronic kidney disease, and stroke as well as improving quality of hypertensive care. the four reasons for this effectiveness of program are as follows: first, the nurse practitioner, a leader of nthmp, designed the group health education by inviting the healthcare team of a community hospital to provide knowledge and skills into four topics, dash diet, increasing physical activity, stress relaxation, and medication taking. these four topics were selected by evidence based which could be effective to lower blood pressure (dechkong, 2017; ozpulat et al. 2017; silveira et al., 2019). dash diet, a health education, was taught by a physician because there was no dietician position in small community hospitals in thailand. in the belief that a physician is knowledgeable in the treatment of diseases, participants obeyed and followed the advice of the physician, which allowed them to adjust their eating behaviors until their blood pressure levels were reduced. previous reviews found the modified dash diet (guo et al., 2021), progressive muscle relaxation technique (kep, 2018), and the mindfulness-based stress reduction program (mbsr) (lee et al., 2020) can markedly decreased systolic and diastolic blood pressure of hypertension patients. in addition, the intervention group who received a supportive educational program by an interdisciplinary health are team had significantly lower sbp and dbp than those of the control group (rerkluenrit, shi, & pramuansup, 2018). therefore, group health education of nthpm helped participants to have knowledge on diet consumption, adequate physical activities and stress relaxation technique which they could apply in their daily life and might result in blood pressure reduction. second, most of the participants in this research were low economic status. the nurse practitioner taught how participants could measure their own blood pressure and how to record and interpret the outcome. this research provided blood pressure machines for each participant to measure their blood pressure at home during intervention. home blood table 2. systolic blood pressure and diastolic blood pressure of people with uncontrolled ht before, first month, second month, after intervention, and three months post-intervention (n=30) blood pressure (mmhg) mean s.d. type iii ss df f p-value systolic bp before intervention 1st month 2nd month after intervention 3 months post-intervention 144.55 131.23 130.18 125.48 132.10 10.34 12.86 12.94 12.89 11.28 2818.26 1 25.46 0.000*** diastolic bp before intervention 1st month 2nd month after intervention 3 months post-intervention 90.38 78.85 78.55 74.38 79.03 5.06 7.98 11.18 8.29 7.63 2160.08 1 51.52 0.000*** *** p<0.001 table 3. amount and percentage of blood pressure among people with uncontrolled ht before, after intervention, and three months postintervention bp ranges (mmhg) before intervention after intervention three months postintervention n % n % n % systolic 101-120 12 40.0 8 26.7 121-140 13 43.3 16 53.3 17 56.7 141-160 15 50.0 1 3.3 5 16.6 161-180 2 6.7 1 3.3 total 30 100 30* 100 30 100 diastolic 61-70 8 26.7 2 6.7 71-80 16 53.3 16 53.3 81-90 21 70.0 4 13.3 9 30.0 91-100 9 30.0 2 6.7 3 10.0 total 30 100 30* 100 30* 100 *) no admission in hospital with signs and symptoms of hypertension urgency n. oba et al. 174 | pissn: 1858-3598 � eissn: 2502-5791 pressure records helped participants identify their current blood pressure and remind to adjust their diet and physical activities day to day. participants’ blood pressure records were reviewed by np at first, second and third month visit for clarifying daily bp at home. the participants who measured more blood pressure learned more on how to control behavioral change related to their blood pressure. there is supporting evidence that bp measurement at home helps remind patients to continuously take antihypertensive and leads to better control of bp (thai hypertension society, 2019). short-term home blood pressure monitoring significantly reduces office blood pressure and improves medication adherence (muhammad et al., 2019). smbp and cointerventions lead to clinically significant bp reduction (tucker, et al, 2017). so, hmbp helps participants to keep their blood pressure at target level and to prevent dangerous high blood pressure level. third, from systematic review and meta-analysis of non-adherence of antihypertensive drug, it was found that non-adherence to antihypertensive medications was noticed in 45% of the subjects studied and a higher proportion of uncontrolled bp (83.7%) (melaku et al., 2017). this research planned to solve non-adherence of antihypertensive drug by cooperating with a pharmacist who is a member of the health team, to monitor antihypertensive taking of participants at their second-third visits. these activities helped participants take antihypertensive drug correctly and effectively and to ensure that all participants had received the full range of antihypertensive drug which could be effective to decrease blood pressure. prior research found educational intervention alone may not improve patients’ bp control and medication adherence to antihypertensive medications. pharmacist-led interventions improved bp control and medication adherence through education, counseling, or a combination of both (reeves et al., 2020). the medication taking monitoring was done by a pharmacist to lower blood pressure of participants through education and counseling. fourth, from literature review, it was found that mi is powerful for behavioral change among persons with hypertension (dechkong, 2017; mcneil, addicks, & randall, 2017; silveira et al., 2019). in this research, np applied face to face brief mi around 5-15 minutes/participant to ensure that all participants understood the necessity of behavioral change. mi did not waste the participant's time because it was performed while the patient was waiting to see a doctor. similarly, a research found that motivational interviews can be used in the acquisition of a healthy nutrition habit by hypertensive individuals, the increase in their exercise levels, and regulation of blood pressure (ozpulat, et al, 2017). from meta– analysis reviews, interventions based on mi only or those with coaches were the most effective in hypertension improvement and mi (face to face delivered) was more effective than phone delivered (zomahoun et al., 2017). mi by np helped participants to confirm that they could have diet consumption, physical activities, and perform stress relaxation suitable for their lifestyle, which could lead to blood pressure reduction. hbpm was proven to have high potential to improve bp control but its devices are more expensive for low-income clients which is not affordable as well as a high gain of hospital support. this technique could be recommended to be applied in cases of high-income people with ht. nevertheless, the interested people may use selfblood pressure devices in sub-district health promotion hospitals (shph) nearby their homes. mi on behavioral adjustment is a good technique which helps participants by thinking and planning for their lifestyle changes. nurses in opds and nps in the primary healthcare system could learn the application of mi or be trained this technique via technology communication (it) or extraordinary learning resources and find out the proper time to play this role. it is a good opportunity of np in shph, which had no pharmacist working in order to work on medication taking support, especially in older adults and those with low health literacy. nthmp was applied in a small community hospital, which had lack of a dietitian who is the expert on diet consumption. np and physician take more time to work on diet lifestyle changes of the participants. conclusion the overall results showed that nthmp was effective in lowering sbp and dbp and prevented hypertensive urgency episodes among people with uncontrolled ht. nthmp is effective due to the design of the program, including team-approached health education, medication taking support, hbpm and mi on behavioral adjustment. the key successes of the program were participation among health providers and people with uncontrolled ht. to strengthen the program testing approach, a two-group pre-posttest experimental design should be applied. nurses in community hospitals/primary healthcare level could apply a nurse-led team-based hypertension management for people with uncontrolled ht by increasing other outcomes such as self-management skill, body mass index, and stress scale to clarify the approaches’ effects on lifestyle modification. to extend the role of nps on hypertensive care, a study on people with non adjusted antihypertensive drug to continue their lifestyle practices and prevent the complications should be done. acknowledgement this research was funded by fiscal year 2018 grants, naresuan university, mueng district. phitsanulok province, thailand (r2560b158). our special thanks go to all of the participants who participated in this jurnal ners http://e-journal.unair.ac.id/jners | 175 study and mr. kenje baris gunda bsn, rn, naresuan university, for his assistance in editing this article. references alsaigh sas, alanazi, m.d., alkahtani, m.a., alsinani, t.s.a., abdullah, a.a., alghamdi, t.a., alabdrabalrasol, e.a., & alzahrani, t.a. (2017). lifestyle modifications for hypertension management. the egyptian journal of hospital medicine, 70(12), 2152-2156. https://doi.org/10.12816/0045044. basile, j., & bloch, m. (2019). overview of hypertension in adults. uptodate. bersaoui, m., baldew, s.m., cornelis. n., toelsie, j., & cornelissen. v.a. (2020). the effect of exercise training on blood pressure in african and asian populations: a systematic review and meta analysis of randomized controlled trials. europian journal of preventive cardiology. 27(5), 457-472. https://doi.org/10.1177/2047487319871233. dechkong, t. (ed.). motivational interviewing for ncds; mi ncds. bangkok: beyond publishing; 2017. flack, j.m. & adekola, b. (2019). blood pressure and the new acc/aha hypertension guidelines. trends in cardiovascular medicine, 30,160–164. https://doi.org/10.1016/j.tcm.2019.05.003 guo, r., li, n., yang, r, liao, x-y., zhang, y., zhu, b-f., zhao, q.,….lei, y. (2021). effects of the modified dash diet on adults with elevated blood pressure or hypertension: a systematic review and metaanalysis. front. nutr. 8:725020. doi: 0.3389/fnut.2021.725020 health data center. (2020).the prevalence rate of well controlled patients with hypertension. available from https://hdcservice.moph.go.th/hdc/reports/repor t kpi.php? [in thai]. ho, j, k., carnagarin, r., matthews, v.b., & schlaich, m.p. (2019). self-monitoring of blood pressure to guide titration of antihypertensive medication a new era in hypertension management? cardiovascular diagnosis and therapy, 9(1), 94-99. https://doi.org/10.21037/cdt.2018.08.01 kep, d.a.s. (2018). the effect of progressive muscle relaxation techniques to decrease blood pressure for patients with hypertension in mataram. prim health care, 8(4) doi: 10.4172/21671079.1000309 lee, e.k.p., yeung, n.c.y., xu, z., zhang, d., yu, c.p. pong, c. & wong, s.y.s. (2020). effect and acceptability of mindfulness-based stress reduction program on patients with elevated blood pressure or hypertension: a meta-analysis of randomized controlled trials. hypertension, 76:1992–2001, https://doi.org/10.1161/hypertensionaha.12 0.16160 mandini, s., conconi, f., mori e, myers, j., grazzi, g, & mazzoni, g. (2018). walking and hypertension: greater reductions in subjects with higher baseline systolic blood pressure following six months of guided walking. peerj, e5471. https://doi.org/10.7717/peerj.5471 mcneil, d.w., addicks, s.h. & randall, c.l. (2017). motivational interviewing and motivational interactions for health behavior change and maintenance. oxford handbook online. scholar research review, https://doi.org/10.1093/oxfordhb/978019993529 1.013.21 melaku, a.t., abdulla, s., alemayehu, g.e., srikanth, b.a., ahmed, e.a. (2017). nonadherence to antihypertensive drugs: a systematic review and meta-analysis. medicine, 96(4) (e5641). https://doi.org/10.1097/md.0000000000005641 muhammad, j., jamial, m.m., & ishak, a. (2019). home blood pressure monitoring has similar effects on office blood pressure and medication compliance as usual care. korean journal of family medicine, 40, 335-34. https://doi.org/10.4082/kjfm.18.0026. oba, n. & chutipanyaporn, n. (2018). development of care service model for uncontrolled hypertensive patients. journal of nursing and health science, 12(1), 24-34. ozpulat, f. & emiroglu, o.n. (2017). the effect of the motivational interview method on the lifestyle of hypertensive individuals. new trends and issues proceedings on advances in pure and applied sciences, 8, 76-82. https://www.propaas.eu patel, p., ordunez, p., dipette, d., escobar, m.c., hassell, t., wyss, f., hennis, a., asma, s., …angell, s. (2016). improved blood pressure control to reduce cardiovascular disease morbidity and mortality: the standardized hypertension treatment and prevention project. the journal of clinical hypertension 18(2) https://doi.org/10.1111/jch.12861 ponte márquez, p.h., feliu-soler, a., solé-villa, m.j., matas-pericas, l., filella-agullo. d., ruizherrerias, m., soler-ribaudi, j., ….arroyo-díaz, j.a. (2019). benefits of mindfulness meditation in reducing blood pressure and stress in patients with arterial hypertension. journal of human hypertension, 33, 237-247. https://www.nature.com/articles/s41371-0180130-6 proia, k.k., thota, a.b., njie, g.j., finnie, r.k.c., hopkins, d.p., mukhtar, q., pronk, n.p., cooksey, t. (2014). team-based care and improved blood pressure control: a community guidesystematic review. american journal of preventive medicine, 47(1), 86-89. https://doi.org/10.1016/j.amepre.2014.03.004. reeves, l., robinson, k., mcclelland, t., adedoyin, c.a., broeseker, a., & adunlin, g. (2020). interventions in the management of blood pressure control and adherence to antihypertensive medications: a systematic review of randomized controlled trials. journal of n. oba et al. 176 | pissn: 1858-3598 � eissn: 2502-5791 pharmacy practice, 1-3. https://doi.org/10.1177/0897190020903573 rerkluenrit, j., shi, l., & pramuansup, r. (2018). the effects of a supportive educational program by an interdisciplinary health care team on health promotion behavior to heart failure prevention among patients with coronary artery disease and coexisting hypertension. journal of nursing and health care, 34(3), 40-47. rollnick, s. & allison, j. (2004). motivational interviewing. in n heather, s sciences, t. stockwell (eds.) the essential handbook of treatment and prevention of alcohol problems (pp. 105-116). west sussex: john wiley & sons ltd. seangpraw, k., auttama, n., tonchoy, p., & panta, p. (2019). the effect of the behavior modification program dietary approaches to stop hypertension (dash) on reducing the risk of hypertension among elderly patients in the rural community of phayao, thailand. journal of multidisciplinary healthcare, 12,109–118 https://doi.org/10.2147/jmdh.s185569 silveira, l.c.j., aliti, g.b., silva, e.m.d., pimentel, r.p., gus, m., & rabelo-silva, e.r. (2019). effect of motivational interviewing in hypertensive patients (midnight): study protocol for a randomized controlled trial. trials, 20,414. https://doi.org/10.1186/s13063-019-3486-1 thai hypertension society. (2019). 2019 thai guidelines on the treatment of hypertension. chiang mai: trick think publishing; 2019. thongdang, k., & promsiripaiboon, y. (2015). effect of group process to change health behavior of patients with hypertension at watpradoo health promotion hospital, muang district, surat thani province. community health development quarterly khon khen university, 3(2), 261-271. https://home.kku.ac.th/chd/index.php?option=co mattachments&task=download&id=118&lang=th tucker, k.l., sheppard, j.p., stevens, r., bosworth, h.b., bove, a.b., bray, e.p., earle, k., george, j.,godwin, m., green, b.b……mcmanus, r.j. (2017). self-monitoring of blood pressure in hypertension: a systematic review and individual patient data meta-analysis. plos medicine, 14(9) e1002389. https://doi.org/10.1371/journal.pmed.1002389. vol 9 no 1 april 2014.indd 19 bedside teaching: apakah metode ini efektif pada pembelajaran klinik mahasiswa keperawatan? (bedside teaching: is it effective methods in clinical nursing students learning?) fatikhu yatuni asmara* *program studi ilmu keperawatan fakultas kedokteran universitas diponegoro jl. prof. soedarto, sh, tembalang semarang 50275 telp. 62 24 76480919, fax. 62 24 76486849 e-mail: unie_nuzul@yahoo.com abstrak pendahuluan: pembelajaran klinik merupakan pusat dari pembelajaran mahasiswa ilmu kesehatan karena mahasiswa tidak hanya belajar tentang keterampilan klinis tetapi juga keterampilan bagaimana berkomunikasi dengan pasien di mana kedua kompetensi tersebut sangat berguna bagi mahasiswa ketika mereka terjun ke dunia kerja (spencer, 2003). beberapa metode pembelajaran dapat diterapkan dalam proses pembelajaran klinis; salah satunya adalah bedside teaching. tujuan dari penelitian ini adalah untuk mengobservsi implementasi bedside teaching pada mahasiswa, pembimbing, dan pasien. tujuan lainnya adalah untuk mengetahui respons mahasiswa, pembimbing, dan pasien dalam bedside teaching. metodologi: dalam penelitian ini peneliti melakukan observasi pelaksanaan bedside teaching khususnya terkait peran dan fungsi masing-masing komponen bedside teaching (mahasiswa, pembimbing, dan pasien) dalam setiap tahap pembelajaran, mulai dari persiapan, proses, dan evaluasi. kemudian dilanjutkan dengan wawancara untuk mengetahui respon mahasiswa, pembimbing, dan pasien terkait proses bedside teaching. hasil: hasil penelitian menunjukkan bahwa mahasiswa dan pembimbing merasa bahwa bedside teaching merupakan metode yang efektif karena dapat membantu mahasiswa untuk mencapai kompetensi klinis dan mengembangkan keterampilan komunikasi. selain itu pembimbing menyatakan bahwa bedside teaching dapat memfasilitasi dirinya untuk menjadi role model yang baik di depan mahasiswa. seperti halnya mahasiswa dan pembimbing, pasien juga merasakan keuntungan dari proses bedside teaching. pasien menyatakan bahwa dirinya memperoleh informasi terkait kasusnya melalui pelaksanaan bedside teaching, walaupun kesempatan untuk berdiskusi sangat terbatas. selama observasi, masing-masing komponen bedside teaching telah melakukan peran dan fungsi masing-masing, misalnya dalam tahap persiapan pembimbing telah meminta informed consent dari pasien secara lisan dan pasien memberikan persetujuannya, sementara siswa mempersiapkan materi. diskusi: penelitian selanjutnya dapat melakukan studi yang mendalam tentang persepsi mahasiswa, pembimbing dan pasien dalam bedside teaching dan strategi untuk mengembangkan bedside teaching menjadi metode pembelajaran yang lebih baik. kata kunci: bedside teaching, pembelajaran klinik, mahasiswa keperawatan abstract introduction: clinical learning is the centre of medical students education. students not only learn about practical skills but also communication with patient and other health care givers which both competencies are useful for students when they come into working world (spencer, 2003). there are variations of methods applied in clinical learning process; one of them is bedside teaching. the aim of this study was to observe the bedside teaching process which is held in group of students, teacher, and patient. another aim was to know responses of students, teacher, and patients to the bedside teaching process. method: the method which was applied in this study is observation in which bedside teaching process was observed related to the roles and function of each component of bedside teaching: students, teacher, and patient in each phase: preparation, process, and evaluation. then it was continued by interview to know the responses of students, teacher, and patient related to bedside teaching process. result: the result showed that both students and teacher felt that bedside teaching is an effective method since it helped students to achieve their competences in clinical setting and develop their communication skill. furthermore teacher stated that bedside teaching facilitated her to be a good role model for students. as well as students and teacher, patient got advantage from the bedside teaching process that she got information related to her case; however the time to discuss was limited. during the observation, each component of bedside teaching did their roles and function, such as: during the preparation teacher asked inform consent from patient, and patient gave inform consent as well while students prepared the material. discussions: suggestion for next research is conducting a deeper study about perception of students, teacher, and patient about bedside teaching process and the strategies to develop it to be better method. keywords: bedside teaching, clinical learning, nursing students 20 jurnal ners vol. 9 no. 1 april 2014: 19–25 pendahuluan b a g i m a h a s i s w a k e p e r a w a t a n , pembelajaran klinik adalah hal penting karena sarana yang memberikan kesempatan b a g i m a h a si s wa u nt u k m e n d a p a t k a n pengalaman merawat pasien secara langsung dengan berbagai kasus dibandingkan proses pembelajaran melalui buku atau diskusi di r uang kelas. spencer (2003) mengatakan bahwa pembelajaran klinik mer upakan pusat dari pembelajaran mahasiswa ilmu kesehatan karena mahasiswa tidak hanya belajar tentang keterampilan klinis tetapi juga keterampilan bagaimana berkomunikasi dengan pasien dimana kedua kompetensi tersebut sangat berguna bagi mahasiswa ketika mereka terjun ke dunia kerja. pembelajaran klinik juga akan membant u mahasiswa untuk belajar berdasarkan konteks. sebagai contoh, mahasiswa yang belajar keperawatan maternitas di ruang postpartum akan belajar bagaimana membant u ibu member i kan asi kepada bayinya, mulai dari posisi meyusui, stimulasi pengeluaran asi sampai hal yang har us ibu lakukan apabila asi sedikit keluar atau tidak keluar. mahasiswa juga berkomunikasi dengan ibu bagaimana pentingnya asi bagi bayi dan ibu. selanjutnya mahasiswa akan lebih mudah untuk mencapai kompetensi di keperawatan maternitas karena mahasiswa terbantu untuk mengingat kembali saat bertemu dengan ibu menyusui, atau dapat disebut mahasiswa belajar berdasarkan konteks (koens, et al., 2005). salah satu metode yang membantu mahasiswa untuk belajar berdasarkan konteks adalah bedside teaching; metode yang digunakan oleh pembimbing klinik selama ber tahun-tahun unt uk mentransfer ilmu mereka terutama pada psikomotor atau skill domain. menurut conigliaro (2009), bedside teaching merupakan proses pembelajaran dimana pembimbing, mahasiswa dan pasien bersama dengan tujuan untuk memperoleh i n fo r m a s i t e n t a n g s t a t u s k e s e h a t a n pasien, melakukan pemeriksaan fisik, dan mendiskusikan diagnosa dan perawatan pasien. hal yang sama diungkapkan oleh langlois (2000) bahwa bedside teaching didefi nisikan sebagai pembelajaran dengan adanya pasien. berdasarkan hal tersebut, untuk melakukan bedside teaching, harus ada pembimbing, mahasiswa dan pasien. oleh karena itu, banyak studi dilakukan u nt u k menget a hu i efek t if it a s be d sid e teaching sebagai metode pembelajaran. sebagian besar studi tersebut menyatakan bahwa bedside teaching adalah metode yang efektif dan menjadi pilihan mahasiswa untuk mempelajari keterampilan klinis. studi yang lain menyatakan tentang manfaat dari bedside teaching, sebagai contoh: nair (1997) menyatakan bahwa keseluruhan responden (100%) setuju bahwa bedside teaching adalah metode yang efektif untuk belajar keterampilan klinis. studi yang lain menyatakan bahwa kompetensi klinis dan komunikasi dapat dicapai mengg unakan bedside teaching sebagai metode pembelajaran (ramani, 2003). hal senada disampaikan oleh williams (2008) bahwa bedside teaching penting untuk dilakukan sebagai metode pada pembelajaran klinik. bedside teaching dipilih sebagai metode pembelajaran karena memiliki sisi positif yang dapat menguntungkan mahasiswa. salah satunya adalah menurut langlois (2000) yang menyatakan bahwa keuntungan bedside teaching untuk mahasiswa adalah mahasiswa dapat menggunakan semua indera mereka untuk mempelajari pasien sehingga dapat memperkuat pembelajaran klinik mereka, dan kesempatan untuk mengklarifi kasi data langsung kepada pasien mendorong mahasiswa untuk belajar keterampilan berkomunikasi. namun di sisi lain, bedside teaching juga mem ili k i kelema ha n ya ng d apat berefek pada proses pembelajaran. langlois (2000) menyatakan bahwa bedside teaching membut u h ka n wa k t u ya ng lebi h lama dibandingkan metode lain, beresiko untuk pasien ter utama tindakan yang invasif, dan membutuhkan keterampilan spesif ik terutama untuk pembimbing klinik. akan tetapi dengan mengaplikasikan manajemen waktu yang baik, meminta inform consent dari pasien dan meningkatkan keterampilan asuhan keperawatan pembimbing klinik 21 bedside teaching: apakah metode ini efektif (fatikhu yatuni asmara) dapat mengurangi sisi negatif dari bedside teaching. ada beberapa hal yang perlu diperhatikan saat menerapkan bedside teaching sebagai metode pembelajaran agar baik mahasiswa dan pasien mendapatkan keuntungan dari implementasi metode ini. langlois (2000) menyatakan implementasi bedside teaching memerlukan strategi, antara lain: pertama tujuan yang jelas harus dirumuskan sebelum datang ke pasien, kedua keterampilan klinis dan komunikasi har us diajarkan terlebih dahulu, ketiga observasi diajarkan selanjutnya, strategi terakhir adalah lingkungan yang kondusif dan nyaman harus tersedia untuk mahasiswa, pasien dan pembimbing. untuk itu perlu dilanjutkan dengan penerapan strategi bagi terciptanya lingkungan yang nyaman bagi pasien, seperti minta izin kepada pasien, lama waktu pembelajaran di depan pasien dibatasi, prosedur bedside teaching harus disampaikan kepada pasien, diskusi dipahami oleh pasien dengan bahasa yang sederhana, terdapat alokasi waktu untuk menjawab pertanyaan pasien, dan berterima kasih kepada pasien (langlois, 2000). apabila strategi tersebut d apat d ila k sa na k a n ma k a ma ha siswa , pasien, dan pembimbing dapat memperoleh keuntungan dari bedside teaching. studi ini bertujuan untuk mengobservsi implementasi bedside teaching pada mata ajar keperawatan mater nitas k hususnya pemeriksaan f isik pada pasien postnatal mengingat pemeriksaan fisik pada pasien potsnatal melibatkan area pribadi seperti payudara, puting, dan perineum. observasi dilakukan pada tiga komponen bedside teaching, yait u mahasiswa, pasien, dan pembimbing. obser vasi yang dilakukan pada mahasiswa bertujuan untuk melihat keuntungan yang bisa diperoleh mahasiswa, apakah mahasiswa dapat mencapai kompetensi klinis dan keterampilan berkomunikasi, apakah setiap mahasiswa memiliki kesempatan untuk re-demonstrasi keterampilan klinis. sedangkan observasi pada pasien dilakukan untuk melihat apakah pasien mendapatkan privasi sebelum dan selama proses bedside teaching, apakah pasien mendapatkan informasi terkait kondisi dan kasusnya, dan terakhir observasi pada pembimbing adalah untuk mengetahui apakah pembimbing berperan sebagai role model dan fasilitator bagi mahasiswa. observasi akan dilengkapi dengan wawancara untuk mengklarifi kasi dan mendapatkan informasi lain. bahan dan metode observasi dilakukan pada 1 kelompok bed sid e tea ching ya ng terd i r i d a r i 1 pembimbing, 5 mahasiswa, dan 1 pasien. mahasiswa yang terlibat adalah mahasiswa t i ng k at t iga ya ng seb elu m nya s ud a h mendapatkan teori tentang pemeriksaan fi sik pasien postnatal pada perkuliahan. observasi akan dilakukan mulai dari persiapan, proses, dan evaluasi menggunakan lembar observasi. selama persiapan, observasi dilakukan u nt u k mel i h at bagai m a n a m a h a siswa menyiapkan teori yang akan diajarkan, bagaimana mahasiswa menyiapkan materi dan alat, dan apakah pasien mendapatkan inform consent. selanjutnya selama proses bedside teaching, observasi dilakukan pada lama waktu dilaksanakan bedside teaching, metode apa yang digunakan oleh pembimbing, apakah mahasiswa memperoleh kesempatan untuk re-demonstrasi keterampilan, dan apakah pasien mendapatkan privasinya. terakhir adalah fase evaluasi, dimana observer mengamati apakah pembimbing memberikan kesempatan untuk berdiskusi, apakah pasien mendapatkan informasi terkait kasusnya, dan apakah mahasiswa mampu mencapai kompetensinya. setela h mela k sa na ka n obser vasi, wawancara semi struktur dilakukan untuk memperkaya informasi. wawancara dilakukan pada mahasiswa, pasien, dan pembimbing untuk melengkapi data dan juga mengklarifi kasi data selama observasi. selain itu, wawancara juga bertujuan untuk mengetahui persepsi pembimbing, mahasiswa, dan pasien terhadap pelaksanaan bedside teaching. hasil dan pembahasan tujuan dari studi ini adalah melakukan observasi bedside teaching pada keperawatan 22 jurnal ners vol. 9 no. 1 april 2014: 19–25 maternitas terutama pada pengkajian fisik pasien postnatal. hasil obser vasi akan disampaikan berdasarkan tiap komponen bedside teaching, yaitu: mahasiswa, pasien, dan pembimbing. sebelum melakukan bedside teaching, mahasiswa menyiapkan materi yang terkait dengan topik, dalam hal ini pemeriksaan fi sik pasien postnatal. persiapan penting dilakukan ka rena mer upa kan bagian d a r i proses pengalaman dalam bedside teaching sebelum masuk ke pasien (cox, 1993). tidak hanya materi, persiapan juga termasuk perumusan tujuan dilakukan bedside teaching karena mahasiswa akan kesulitan untuk mengikuti proses bedside teaching apabila mahasiswa tidak tahu apa yang harus dicapai. selain mahasiswa, pembimbing juga perlu untuk melakukan persiapan dengan meminta inform consent dari pasien untuk memastikan bahwa pasien setuju menjadi objek proses pembelajaran. menurut spencer (2003), inform concent akan membuat kita bekerja lebih efektif dan memperhatikan etika. berdasarkan observasi, pembimbing melakukan inform consent secara lisan dengan meminta izin kepada pasien untuk melakukan proses pembelajaran di depan pasien, dan melibatkan pasien. persiapan lain yang dilakukan adalah materi dan alat. pembimbing mempersiapkan materi yang akan diajarkan dan sekaligus menyiapkan alat bersama mahasiswa. bedside teaching menjadi efektif, baik pembimbing dan mahasiswa merasa nyaman apabila persiapan menjadi kunci dari kegiatan ini (ramani, 2003). komponen terakhir dalam persiapan adalah pasien. disamping member ikan persetujuan untuk dilakukan pembelajaran, pasien harus menyiapkan dirinya menjadi pasien yang kooperatif, karena peran pasien dalam bedside teaching besar. tidak hanya riwayat dan gejala fi sik, tetapi juga informasi yang dalam dan luas tentang masalah kesehatan akan disampaikan oleh pasien saat bedside teaching, dan sangat berguna bagi mahasiswa (spencer, 2003). berdasarkan wawancara, pasien mengatakan bahwa dia siap sebagai objek pembelajaran dan akan kooperatif. langkah selanjutnya adalah proses. dala m wa k t u 90 me n it , pembi mbi ng menerapkan metode demonstrasi dan redemonstrasi pada sat u pasien dan lima mahasiswa. menurut pembimbing, metode ini efektif karena dapat memberikan kesempatan kepada mahasiswa untuk mempraktekkan kembali keterampilan yang sudah dicontohkan atau diajarkan oleh pembimbing klinik. sebagaimana disampaikan oleh ramani (2003) bahwa mahasiswa dapat terikat dan terlibat dalam proses pembelajaran apabila dosen atau pembimbing memilih metode yang tepat. setelah melakukan pemeriksaan fi sik postnatal, pembimbing meminta salah satu mahasiswa untuk melakukan keterampilan tersebut dan meminta teman lain untuk memberikan masukan. pembimbing juga memberikan waktu bagi mahasiswa untuk mengajukan pertanyaan yang berhubungan dengan topik yang diajarkan. menu r ut pembi mbi ng, d ia ha r u s mem fa sil it a si mahasiswa dengan memberikan kesempatan u n t u k m e n d e m o n s t r a s i k a n p r o s e d u r dan bertanya tentang hal tersebut untuk membantu mahasiswa mencapai kompetensi. kenyataaannya, selama melakukan bedside teaching, pembimbing ber peran sebagai fasilitator (spencer, 2003). walaupun mahasiswa memperoleh kesempatan untuk mempraktekkan kembali pemeriksaan fisik postnatal, tidak semua mahasiswa mendapatkan kesempatan tersebut karena pertimbangan waktu dan etika. menjadi hal yang tidak nyaman bagi pasien untuk mendapatkan tindakan yang sama berulangulang. mahasiswa juga menyampaikan bahwa mereka mendapatkan kesempatan untuk bertanya tentang materi, dan pembimbing memberikan kesempatan kepada mahasiswa lain untuk menjawab sebelum pembimbing yang menjawab pertanyaan tersebut. penting bagi mahasiswa untuk berpartisipasi mulai dari obser vasi sampai melak ukan aktif karena dapat membantu mahasiswa untuk menunjukkan performa yang terbaik (dornan, et al., 2007). selanjutnya selama proses pemeriksaan f isik berlangsung, baik pembimbing dan mahasiswa menutup ruangan dan menggunakan selimut untuk menjaga privasi pasien. mereka 23 bedside teaching: apakah metode ini efektif (fatikhu yatuni asmara) juga menjelaskan tujuan dan langkah prosedur yang akan dilakukan. meminta izin kepada pasien untuk melakukan serangkaian tindakan bertujuan untuk menempatkan pasien pada zona nyaman. langlois (2000) menyampaikan bahwa salah satu cara untuk meningkatkan kenyamanan pasien adalah dengan meminta izin dan menjelaskan prosedur yang akan dilakukan. waktu yang dibutuhkan untuk melakukan pemeriksaan fi sik adalah 50 menit disertai diskusi singkat hasil pemeriksaan fi sik. diskusi dilakukan selama proses dengan tujuan membuat mahasiswa lebih paham dan dapat menghubungkan antara tindakan pemeriksaan fi sik dengan hasilnya. berdasarkan wawancara, pasien merasa nyaman sa at dila k u kan pemeriksaaan fi sik karena pembimbing dan mahasiswa memberikan privasi. langkah terakhir yaitu evaluasi. hal ini penting dilakukan untuk meyakinkan bahwa prosedu r yang dilak u kan sudah benar. berdasarkan observasi, mahasiswa mendapatkan kesempatan untuk melakukan diskusi akhir. akan tetapi diskusi tentang pasien dilakukan di ruang diskusi bukan di depan pasien. hal ini dapat menjaga privasi pasien. spencer (2003) mengatakan jika diskusi tentang pasien akan lebih baik dilakukan di ruang lain dibandingkan di depan pasien. be rd a s a rk a n wawa nca r a de nga n ma ha siswa , ma ha siswa mer a sa ba hwa bedside teaching merupakan metode yang efektif untuk transfer keterampilan dan prosedur. dengan terlibat di dalam bedside teaching, mahasiswa dapat mempraktekkan dan meningkatkan keterampilan mereka. dengan kata lain, bedside teaching dapat membantu mahasiswa mencapai kompetensi ter utama keterampilan atau psikomotor. nair (1997) menyampaikan bahwa 100% respondennya setuju bahwa bedside teaching adalah metode yang efektif untuk mempelajari keterampilan klinis. sayangnya, menurut mahasiswa, bedside teaching mulai jarang dilakukan karena jumlah pembimbing klinik yang memiliki kemampuan bedside teaching berkurang dan jumlah mahasiswa di ruangan meningkat. dornan (2007) mengungkapkan bahwa peningkatan jumlah mahasiswa dan isu tentang keamanan pasien berefek pada menurunnya kesempatan mahasiswa untuk mendapatkan pengalaman praktek klinik termasuk bedside teaching. ramani (2003) menyampaikan bahwa penyebab bedside teaching mulai jarang dilakukan karena menurunnya kemampuan pembimbing dalam mengaplikasikan metode bedside teaching. di sisi lain, pembimbing menyampaikan bahwa sulit baginya menjadi pembimbing yang mampu melakukan bedside teaching dengan baik karena tidak hanya menyampaikan materi, pembimbing juga harus menjadi role model yang baik bagi mahasiswa. bedside teaching memberikan kesempatan kepada pembimbing untuk menjadi role model karena pada saat itu pembimbing dapat menunjukkan kepada mahasiswa bagaimana bersikap profesional sebagai seorang perawat, dan ini lebih mudah dilakukan di setting klinik dibandingkan di ruang kelas (ramani, 2003). pembimbing dapat menunjukkan bagaimana membina hubungan saling percaya dengan pasien, bagaimana berkomunikasi dengan pasien, dan bagaimana menjawab pertanyaan pasien. pembimbing juga menyampaikan bahwa salah satu syarat untuk menjadi role model yang baik untuk mahasiswa adalah kompeten di keterampilan klinik. ada beberapa cara yang bisa dilakukan oleh pembimbing dalam meningkatkan keterampilannya dalam bedside teaching, antara lain mengikuti pelatihan staf untuk meningkatkan kemampuan dan keterampilan mengaplikasikan metode bedside teaching dan metode mengajar, membangun lingkungan belajar yang kondusif dimana kekurangan pembimbing dimaklumi dan pembimbing tidak harus menjadi sempurna, membiasakan untuk memberikan reward bagi pembimbing yang dapat menjalankan perannya sehingga dapat memicu pembimbing lain u nt u k melakukan hal yang sama (ramani, 2003). ide lain berasal dari lacombe (1997) bahwa ketika pembimbing menginginkan untuk mampu mengaplikasikan bedside teaching maka dia harus meningkatkan kemampuan untuk merumuskan diagnosa berdasarkan pemeriksaan fi sik. berdasarkan sudut pandang pasien, evalu asi t id a k dila k u ka n denga n bai k 24 jurnal ners vol. 9 no. 1 april 2014: 19–25 karena setelah bedside teaching dilakukan, pasien tidak mendapatkan informasi yang berkaitan dengan kasusnya. pembimbing dan mahasiswa yang melakukan pemeriksaan fi sik menyampaikan hasil pemeriksaan tetapi pasien tidak mendapatkan kesempatan untuk berdiskusi lebih jauh tentang kondisinya. salah satu cara untuk meningkatkan kepercayaan pasien kepada perawat dan mahasiswa adalah dengan meluangkan waktu untuk berdiskusi dengan pasien berdasarkan hasil pemeriksaan. hal senada disampaikan langlois (2000) bahwa menjawab pertanyaan pasien dan berterimakasih setelah selesai melakukan bed side teaching d apat men i ng kat ka n kenyamanan pasien. simpulan dan saran berd asa rka n hasil obser vasi d a n wawancara, mahasiswa dan pembimbing merasa bahwa bedside teaching merupakan met o de ya ng efek t i f sebagai met o de pembelajaran di kinik karena bedside teaching memberikan kesempatan kepada mahasiswa untuk meningkatkan keterampilan kinik dan komunikasi dengan pasien. selain itu pembimbing juga merasa diuntungkan dengan metode ini karena bedside teaching menjadi sarana bagi pembimbing untuk menjadi role model yang baik bagi mahasiswa. hal yang paling utama dirasakan oleh pasien dimana tabel 1. peran dan fungsi komponen bedside teaching di setiap tahap tahap komponen pembimbing mahasiswa pasien persiapan 1. m e l a k u k a n i n f o r m consent. 2. menyiapkan materi (topik, tujuan bedside teaching). 3. menyiapkan mahasiswa untuk bedside teaching. 1. menyiapkan materi. 2. m e m p e l a j a r i t u j u a n bedside teaching 3. menyiapkan alat 1. m e n e r i m a i n f o r m c o n s e n t d a r i pembimbing 2. menerima penjelasan tujuan dilaksanakan bedside teaching dan langkah-langkah atau prosedur. 3. mempersiapkan diri menjadi pasien yang kooperatif. proses 1. m e l a k u k a n b e d s i d e t e a c h i n g d e n g a n variasi metode, contoh: d e m o n s t r a s i d a n r e demonstrasi. 2. melakukan diskusi singkat di tengah proses. 3. memfasilitasi mahasiswa u n t u k m e l a k u k a n r e demonstrasi. 4. m e n y a m p a i k a n h a s i l p e m e r i k s a a n k e p a d a pasien. 1. mengikuti proses. 2. m e l a k u k a n r e demonstrasi. 3. b e r p a r t i s i p a s i a k t i f dalam diskusi. 1. kooperatif selama proses. 2. m e n e r i m a h a s i l penjelasan. 3. menanyakan hal-hal yang tidak diketahui sesuai dengan hasil pemeriksaan fi sik. akhir 1. memimpin diskusi terkait proses bedside teaching. 2. memfasilitasi mahasiswa u n t u k m e n g a j u k a n pertanyaan dan menjawab pertanyaan. berpartisipasi aktif dalam diskusi. tidak berperan. 25 bedside teaching: apakah metode ini efektif (fatikhu yatuni asmara) pasien mendapat penjelasan tentang kondisinya walaupun sedikit memperoleh kesempatan untuk bertanya lebih lanjut. unt u k memper tahan kan k ualitas bedside teaching perlu adanya keberlangsungan riset pada bedside teaching terutama pada tiga komponen bedside teaching, yaitu mahasiswa, pembimbing, dan pasien. oleh karena itu, saran untuk penelitian selanjutnya adalah melakukan penelitian yang mendalam tentang persepsi mahasiswa, pembimbing, dan pasien dalam bedside teaching dan strategi untuk meningkatkan kualitas bedside teaching berdasarkan pandangan mereka. kepustakaan conigliaro, r. 2009. bedside teaching. cecent ral. (on li ne). ht tp://w w w. cecentral.com/activity/2255. diakses tanggal 27september 2011 cox, k., 1993. planning bedside teaching-2. preparation before entering the wards. the medical journal of australia, 158, 355-358 dornan, t., boshuizen, h., king, n., dan scherpbier, a., 2007. experience-based learning: a model linking the processes and outcomes of medical students’ workplace learning. medical education, 41, 84-91. koens, f., mann, k.v., custers, j. f. m., dan ten cate, o. t. j., 2005 analyzing the concept of context in medical education. medical education, 39, 1243-1249. lacombe, m. a. 1997. on bedside teaching. annals of internal medicine, 126 (3): 217-220 langlois, j.p. dan thach, s. 2000. teaching at bedside. family medicine, 32 (8), 528-530. nair, b. r., coughlan, j. l., dan hensley, m. j., 1997. student and patient perspectives on bedside teaching. medical education, 31 (5), 341–346 ramani, s., 2003. twelve tips to improve bedside teaching. medical teacher, 25 (2), 112-115 ramani, s., orlander, j. d., strunin, l., dan barber, t. w., 2003. whither bedside teaching? a focus-group st udy of clinical teachers. academic medicine, 78 (4), 384-390 spencer, j. 2003. learning and teaching in the clinical environment. british medical journal, 326, 591-594 williams, k. n., ramani, s., fraser, b., orlander, j. d. 2008. improving bedside teaching: fi ndings from a focus group study of learners. academic medicine, 83 (3), 257-264. 183 peran usia dan lama infertilitas terhadap jumlah oosit yang didapat pada program fertilisasi in vitro (the role of advanced age and duration of infertility on oocyte number retrieved during in vitro fertilization) hendy hendarto* *dep/smf obsterti dan ginekologi fakultas kedokteran universitas airlangga/ rsud dr soetomo surabaya. e-mail: hndhendy@yahoo.com abstrak pendahuluan: jumlah oosit yang didapat pada program fertilisasi in vitro berhubungan dengan keberhasilan kehamilan. saat ini fertilisasi in vitro telah dipercaya sebagai terapi definitif untuk infertilitas. usia dan lama infertilitas merupakan faktor penting dalam infertilitas yang harus diteliti lebih lanjut. tujuan dari penelitian ini adalah untuk mengetahui peran usia dan lama infertilitas terhadap jumlah oosit yang didapat pada program fertilisasi in vitro. metode: penelitian ini menggunakan pendekatan analisis observasional, melibatkan wanita infertil yang mengikuti program fertilisasi in vitro di klinik fertilitas graha amerta rumah sakit dr. soetomo surabaya. total sampling digunakan selama 1 januari –30 juni 2014 dan didapatkan 66 responden. evaluasi meliputi usia, lama infertil, dan jumlah oosit yang didapat setelah mendapatkan stimulasi ovarium dengan injeksi anatgonis fsh dan gnrh. data dianalisis menggunakan anova test dengan level signifikansi ≤ 0,05. hasil: pada kelompok dengan usia < 35 tahun rerata jumlah oosit yang didapat adalah 9,43 ± 6,29 oosit, dan pada kelompok dengan usia ≥ 35 tahun rerata sebesar 6,03 ± 4,67 oosit. terdapat perbedaan yang signifikan pada kedua kelompok tersebut (p = 0,017). jumlah oosit yang didapat pada kelompok yang mengalami lama infertil 1–2 tahun, 3–4 tahun, dan ≥ 5 tahun berturut-turut adalah 13.40 ± 3.28 ; 8.64 ± 6.80 and 6.82 ± 5.45. terdapat perbedaan jumlah oosit yang signifikan dari 3 kelompok tersebut (p = 0,017). diskusi: semakin tua usia dan semakin lama durasi infertilitas memberikan kontribusi terhadap semakin berkurangnya jumlah oosit yang didapat pada program fertilisasi in vitro. kata kunci: usia, lama infertil, oosit, fertilisasi in vitro abstract introduction: the number of oocytes retrieved during in vitro fertilization related to the success of pregnancy. today in vitro fertilization has been considered as definitive therapy for infertility problem. age and duration of infertility is an important factor in infertility that should be evaluated in detail. the purpose of this study was to clarify the role of age and duration of infertility on the number of oocytes retrieved during in vitro fertilization. method: this was an analytic observational study, including infertile female patients who followed the in vitro fertilization program at fertility clinic graha amarta dr soetomo hospital surabaya. total sampling was conducted during january 1st-june 30th 2014 and found 66 study subjects. evaluation was performed on age, duration of infertility and the number of oocytes retrieved following ovarian stimulation using fsh and gnrh antagonist injection. all data were analyzed by anova test with level significance of ≤ 0.05. result: in the group of age <35 years the average number of oocytes retrieved was 9.43 ± 6.29 oocytes, and in the group of age ≥ 35 years averaged number was 6.03 ± 4.67 oocytes. there was significant differences of oocytes number retrieved between the two groups (p = 0.017). the number of oocytes retrieved in group of duration of infertility 1-2 years, 3-4 years and ≥ 5 years were 13.40 ± 3.28 ; 8.64 ± 6.80 and 6.82 ± 5.45, respectively. there was significant differences of oocytes number retrieved between the three groups of duration of infertility (p = 0.017). discussion:. the advanced of age and the longer duration of infertility may contribute to the incidence of the less number of oocytes retrieved in infertile women who follow in vitro fertilization. keywords: age, duration of infertility, oocyte, in vitro fertilization pendahuluan saat ini fer tilisasi in vit ro telah dipercaya sebagai terapi def initif untuk infertilitas. hampir semua kasus infertilitas dengan berbagai penyebab dapat ditangani menggunakan teknologi fertilisasi in vitro. tujuan utama terapi fertilisasi in vitro adalah mendapatkan sejumlah oosit matur siap fertilisasi, menghasilkan kehamilan tunggal yang sehat dan mendapatkan kelebihan embrio berkualitas bagus untuk simpan beku. stimulasi ovarium, merupakan salah satu bagian pada proses fertilisasi in vitro, menjadi langkah krusial untuk mendapatkan tujuan utama tersebut (arslan, 2005). 184 jurnal ners vol. 9 no. 2 oktober 2014: 183–186 kebe rha sila n fe r t il isa si i n v it ro ditentukan banyak faktor, salah satu faktor penting adalah usia istri. keterkaitan usia dengan infertilitas telah banyak dibicarakan. terjadi perubahan paradigm reproduksi berupa penundaan waktu menikah dan masa punya anak karena lebih mengutamakan pendidikan, karier dan kebutuhan finansial. pandangan baru tersebut berdampak pada peningkatan kejadian infertilitas setelah usia 35 tahun karena akselerasi penurunan kuantitas dan kualitas oosit. kegagalan kehamilan klinis berlanjut menjadi kelahiran hidup pada program fertilisasi in vitro meningkat dengan bertambahnya usia, yaitu 14% pada usia di bawah 35 tahun, 19% pada usia 35–37 tahun, meningkat menjadi 25% pada usia 38– 40 tahun dan menjadi 40% setelah usia 40 tahun (asrm, 2006). kualitas oosit dipengaruhi usia, kejadian aneuploidi rendah pada perempuan usia di bawah 35 tahun, tetapi meningkat menjadi 30% pada usia 40 tahun (liu, 2011). lama infertilitas merupakan salah satu faktor penyebab infertilitas. semakin lama waktu infertilitas berpotensi mengganggu psikologis pasien sehingga kemungkinan berdampak pada funsi ovarium. makin lama masa menikah tanpa anak berkontribusi juga pada kemungkinan adanya lebih dari satu faktor infertilitas yang berperan. keadaan tersebut bisa berisiko peningkatan kegagalan mendapatkan kuantitas dan kualitas oosit sesuai harapan (alhassan, 2014). tujuan penelitian ini adalah mempelajari peran usia dan lama infertilitas terhadap jumlah oosit yang didapat pada pasien perempuan infertil yang menjalani program fertilisasi in vitro. bahan dan metode desain penelitian yang digunakan pada penelitian ini adalah observasional analitik dengan subyek penelitian adalah pasien perempuan yang mengikuti program fertilisasi in vitro di klinik fertilitas graha amerta rsud dr soetomo surabaya. penentuan sampel dilakukan dengan cara total sampling dan dilaksanakan selama 6 bulan mulai tanggal 1 januari sampai 30 juni 2014. dilakukan wawancara pada subyek penelitian untuk mendapatkan data usia dan lama infertilitas, selanjutnya dilakukan evaluasi keterkaitan dengan jumlah oosit yang didapat setelah dilakukan stimulasi ovarium. semua perlakuan stimulasi ovarium memakai metode yang sama yaitu memakai injeksi folicle stimulating hormone dan gonadotropin releasing hormone (gnrh) antagonist. jumlah oosit yang didapat dihitung saat dilakukan panen sel telur (ovum pick-up). semua data dianalisis menggunakan program spss for windows. hasil jumlah subjek penelitian yang ikut penelitian ini adalah 66 orang. berdasarkan usia subyek penelitian dibagi menjadi dua kelompok yaitu kelompok usia < 35 tahun sebanyak 35 orang dan usia ≥ 35 tahun sebanyak 31 orang. selanjutnya dihitung rerata jumlah oosit yang didapat saat tindakan panen sel telur, hasilnya pada kelompok usia < 35 tahun rerata jumlah oosit yang didapat adalah 9,43±6,29 oosit, sedang pada kelompok usia ≥ 35 tahun rerata 6,03±4,67 oosit. didapatkan perbedaan bermakna jumlah oosit yang didapat antara kedua kelompok diatas (p=0,017). berdasarkan data lama infer tilitas subyek penelit ian dibagi menjadi t iga kelompok, yaitu kelompok lama menikah 1–2 tahun, lama menikah 3–4 tahun dan lama gambar 1. rerata jumlah oosit yang didapat pada kelompok usia <35 tahun (9,43±6,29 oosit) dan usia ≥ 35 tahun (6,03±4,67 oosit) (p=0,017) 185 peran usia dan lama infertilitas (hendy hendarto) menikah ≥ 5 tahun. didapatkan data bahwa lama infertilitas subjek penelitian ≥ 5 tahun sebanyak 75,7% (50 orang), lama infertilitas 3–4 tahun sebanyak 11 orang (16,6%) dan lama infertilitas 1–2 tahu sebanyak 5 orang (7,7%). evaluasi terhadap jumlah oosit yang didapat berdasarkan lama infertilitas adalah sebagai berikut: kelompok lama infertilitas 1-2 tahun didapatkan rerata jumlah oosit 13,40±3,28; kelompok lama infertilitas 3– 4 tahun rerata jumlah oosit yang didapat 8,64±6,80; dan kelompok lama infertilitas ≥ 5 tahun didapatkan rerata oosit yang didapat 6,82±5,45. terdapat perbedaan bermakna jumlah oosit yang didapat pada ketiga kelompok lama infertilitas tersebut (p=0,04). dengan menggunakan uji lsd post hoc untuk mengevaluasi lebih dalam pada kelompok lama i nfer tilit as did apat kan data bahwa terdapat perbedaan bermakna jumlah oosit yang didapat antara kelompok lama infertilitas 1–2 tahun dan ≥ 5 tahun (p=0,014). pembahasan pada pelaksanaan program fertilisasi in vitro jumlah oosit yang didapat menjadi penting karena terkait dengan keberhasilan terjadinya kehamilan. terdapat beberapa data yang menyebutkan bahwa angka kehamilan terbaik diperoleh bila jumlah oosit yang didapat sebanyak 10–15 atau 7–16 (sunkara, 2011). pada penelitian ini dicoba melihat peran usia dan lama infertilitas terhadap jumlah oosit yang didapat pada program fertilisasi in vitro. usia merupakan faktor determinan penting pada keberhasilan konsepsi perempuan, yang selanjutnya akan menurun secara gradual terutama setelah usia 35 tahun. walaupun belum ada patokan yang tepat dan diterima secara universal untuk usia lanjut pada bidang reproduksi, usia 35 tahun dianggap sebagai batas pemisah keadaan baik-bur uk oosit (maheshwari, 2008). pada penelitian yang kami lakukan ini subyek penelitian dibagi menjadi dua kelompok yaitu usia < 35 tahun dan usia ≥ 35 tahun. didapatkan hasil bahwa pada usia ≥ 35 tahun jumlah oosit yang didapat secara bermakna lebih sedikit (6,82±5,45) dibandingkan dengan jumlah oosit pad usia < 35 tahun (9,43±6,29). hasil penelitian ini mendukung pendapat bahwa peningkatan usia akan berpengaruh pada maturasi oosit. hasil ini sama dengan penelitian yang dilakukan sunkara dkk yang mendapatkan pada kelompok usia di atas 35 tahun jumlah oosit yang didapat akan menurun. keadaan ini tentu perlu mendapat perhatian agar para tenaga kesehatan menginformasikan kepada masyarakat unt uk tidak menunda masa reproduksi sampai diatas 35 tahun karena berakibat penurunan kuantitas dan kualitas oosit. para petugas kesehatan juga har us memperhatikan lama infertilitas pasangan suami istri. lama infertilitas adalah waktu yang diperlukan untuk terjadinya konsepsi dan merupakan faktor utama penentu saat 1-2 tahun 3-4 tahun > 5 tahun gambar 2. persentase lama infertilitas: 1–2 tahun = 7,7%; 3–4 tahun = 16,6% dan ≥5 tahun = 75,7% gambar 3. rerata jumlah oosit yang didapat pada kelompok lama infertilitas 1–2 tahun (13,40±3,28), 3–4 tahun (8,64±6,80) dan ≥ 5 tahun (6,82±5,45) (p=0.04) 186 jurnal ners vol. 9 no. 2 oktober 2014: 183–186 dimulainya investigasi dan terapi infertilitas. telah diasumsikan bahwa makin lama interval lama infertilitas, makin rendah probabilitas terjadinya konsepsi (brosens, 2004). pada penelitian ini telah didapatkan hasil bahwa rerata jumlah oosit yang didapat pada kelompok lama infertilitas 1–2 tahun adalah 13,40±3,28, 3– 4 tahun sebanyak 8,64±6,80 dan lama infertilitas ≥ 5 tahun sebanyak 6,82±5,45. didapatkan perbedaan bermakna antara ketiga kelompok di atas. makin lama interval lama menikah, makin sedikit jumlah oosit yang didapat. evaluasi lebih detil dengan uji post hoc didapatkan perbedaan bermakna pada kelompok lama infertilitas 1–2 tahun dan ≥ 5 tahun a l h a s s a n p a d a p e n e l i t i a n n y a mendapatkan hasil lama infertilitas mempunyai korelasi positif bermakna dengan skor beck depression inventory. lama infertilitas lebih dari 3 tahun tanpa anak berhubungan dengan kejadian depresi yang tinggi (alhassan, 2014). stres dan depresi dapat mengganggu fungsi ovarium melalui poros hipotalamus-hipofisisadrenal sehingga terjadi gangguan haid, amenore dan infertilitas (berga, 2007; marcus, 2001). berdasar keterangan di atas dapat dipikirkan bahwa makin lama interval lama menikah tanpa anak akan menimbulkan stres yang berpotensi mengganggu fungsi ovarium sehingga menyebabkan penurunan jumlah oosit dan selanjutnya akan mempengaruhi keberhasilan program fertilisasi in vitro. dari hasil penelitian ini seyogyanya para petugas kesehatan memberikan informasi tentang pentingnya memperhatikan faktor usia dan lama infertilitas kepada pasangan infertil untuk menghindari terjadinya kegagalan pada program fertilisasi in vitro. simpulan dan saran simpulan bertambah tua usia dan makin lama infertilitas akan ber peran pada kejadian makin sedikit jumlah oosit yang didapat pada perempuan infertil yang mengikuti program fertilisasi in vitro. saran me mb e r i i n fo r m a si d a n s ege r a merujuk pasangan infertil agar tidak terjadi keterlambatan karena faktor usia dan lama infertilitas yang berisiko terjadi kegagalan penanganan infertilitas. kepustakaan alhassan a, ziblim ar and muntaka. 2014. a survey on depression among infertile women in ghana. bmc women’s health 14, 42: 1–6 american society for reproductive medicine (asrm). 2006. aging and infertility in women. fertil steril 86(4), 248–251 arslan m, bocca s, mirkin s, barroso g, stadtmauer l, sergio oehninger s. 2005. controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of elizabeth carr. fertil steril_ 84: 555– 569. berga sl and loucks tl. 2007. stress induced anovulation. elsevier inc. all rights reserved. 615–630 brosens i, gordts s, valkenburg m, puttemans p, campo r and gordts s. 2004. investigation of the infertile couple: when is the appropriate time to explore female infertility? hum reprod 19, 8: 1689–1692. liu k, case a. 2011. advanced reproductive age and fertility. j obstet gynaecol can 33(11): 1165–1175 maheshwari a, hamilton m and bhattacharya s. 2008. effect of female age on the diagnostic categories of infertility. hum reprod .23, 3: 538–542 marcus, m. d., loucks, t. l. and berga, s. l. 2001. psychological correlates of functional hypothalamic amenorrhea. fertil steril 76, 310–316. sunkara sk, rittenberg v, raine-fenning n, bhattachar ya s, zamora j, and coomarasamy a. 2011. association between the number of eggs and live birth in ivf treatment: an analysis of 400 135 treatment cycles. hum reprod 0, 0: 1–7 246 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2.19025 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license systematic review a systematic review of complementary therapy for treating osteoarthritis ira purnamasari , suharyono suharyono, suhendra agung wibowo, idham soamole faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: osteoarthritis (oa) is a chronic progressive disease that is often experienced by the elderly resulting in pain and joint stiffness which then causes movement or mobility disorders. complementary therapy eases osteoarthritis with a traditional technique known as nonpharmacological treatment. the aim of this systematic review is to identify the effectiveness of several complementary therapies as osteoarthritis management. methods: the review was performed according to prisma guidelines. we searched from pubmed, scopus, proquest, and sciencedirect databases. the search identified 14 relevant journals from the 19,123 articles published between 2016 and 2020, and all studies used the randomized control trial (rct). results: complementary therapies consisted of flaxseed poultice compress, acupressure, acupuncture therapy, cumin black oil compress, aromatherapy massage, ginger oil massage, lavender oil massage, sensorimotor exercise, application of heat, exercises with elastic bands, ultrasound therapy, geotherapy combination kinesiotherapy, phonophoresis therapy, and stimulation of compression. conclusion: the effectiveness of these therapies can be seen from the different results of osteoarthritis patients who received the intervention and the control group. the decrease in the total index womac and lequesne, vas and increase in the physical function of patients with osteoarthritis who received the complementary therapy are significantly higher than the control group. it proved that the complementary therapy has positive impact as management of osteoarthritis pain. the effects of complementary therapy have an influence on pain, joint stiffness, and physical function limitations in osteoarthritis patients. article history received: feb 27, 2020 accepted: april 1, 2020 keywords complementary therapy; osteoarthritis pain contact ira purnamasari  ira.purnamasari2019@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: purnamasari, i., suharyono, s., wibowo, s. a., & soamole, i. (2020). a systematic review of complementary therapy for treating osteoarthritis. jurnal ners, special issues, 246-251. doi:http://dx.doi.org/10.20473/jn.v15i2.19025 introduction osteoarthritis (oa) is one of the commonly seen pathologies in elderly. the result of this disease in the elderly is chronic pain in foot and leg joints. oa is the most commonly seen form of arthritis and is a degenerative joint disease characterized by joint pain and dysfunction due to the pathologic changes in all joint structures. the most frequent involvements of joint are knee, hip, fingers, lumbar and cervical spine (tuna, babadag, ozkaraman, & balci alparslan, 2018). osteoarthritis (oa), also known as degenerative arthritis or osteoarthrosis, is the most common musculoskeletal disorder that leads to disability in activities of daily living (adl), particularly in the elderly [3]. it is already one of the ten most disabling diseases in developed countries as reported by the who. oa can affect any joint, but the knees are among the most vulnerable. common risk factors for developing oa include obesity, age increase, race, previous joint injury, hormonal problems, overuse of the joint, and job. a major risk factor reported is age, such that the prevalence of oa rises remarkably from 4% in the 18-24 years age group to 85% in the 75-79 years age group. approximately 27 million americans https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v15i2. jurnal ners http://e-journal.unair.ac.id/jners | 247 have oa and its prevalence will increase to 70 million in the coming decades (nasiri & mahmodi, 2018). previous studies have generally found clients with osteoarthritis. this study also discusses weaknesses that may occur due to muscular atrophy. the study also illustrates that elderly with knee osteoarthritis have decreased muscular strength and standing balance resulting in an increased incidence of falls. quadriceps femoris muscle weakness often causes the knee joint to not be able to contract entirely, which causes a buildup of load on the joint that causes damage to the articular cartilage of the knee joint (alnahdi, zeni, & snyder-mackler, 2012). anti-inflammatory and analgesic drugs are commonly used in the current treatment of oa as a standard method for pain management of patients with knee oa. in elderly patients, standard pharmacological treatment may not be sufficient to alleviate pain because of concomitant diseases and interactions among the multiple simultaneously taken drugs. the high costs and adverse effects of using multiple analgesics may be another important concern. there is a need for an inexpensive, selfimplemented, nontoxic, natural method that alleviates the symptoms of oa, requires minimum material and is free of the adverse effects of traditional medical or surgical procedures (tosun et al., 2017). one of the main goals of the management of patients with oa is to minimize disability in adl. treatment strategies for oa include pharmacological and non-pharmacological treatments as well as surgical interventions as the last expedient. pharmacological treatments have side-effects and surgical interventions are of high economic costs. in this line, complementary therapies have taken a step forward toward self-sufficiency and have attracted the attention of researchers as they both promote health and reduce complications and costs. the aim of this systematic review is to identify the effectiveness of several complementary therapies as osteoarthritis management (nasiri & mahmodi, 2018). materials and methods searching strategy for studies this systematic review contains an original journal that discusses the complementary effect on pain, joint stiffness, and physical limitations of osteoarthritis patients. reviews are carried out in accordance with prisma guidelines. a systematic literature search was carried out in key databases such as pubmed, scopus, proquest, and sciencedirect by including keywords complementary therapy, healing, joint stiffness, physical surgery, and osteoarthritis patients. there were no other restrictions used to maximize the literature search. list of literature references was done manually. search results of fulltext articles databases assessed for eligibility are pubmed eight journals, scopus 24 journals, sciencedirect 18 journals, and proquest as many as 14 journals. a search was conducted to answer research questions about which complementary therapies affect osteoarthritis patients compared to standard care. inclusion and exclusion criteria studies were included in the study if they met the following criteria: (1) adult patients are osteoarthritis patients in all types of osteoarthritis with standard care; (2) a specific protocol for complementary therapy in-hospital was used as an intervention; (3) a control group receiving structured protocol given standard care already in place at the hospital that was used as a comparator; (4) complementary therapy in osteoarthritis patients; (5) were published in english; (6) the studies used the randomized controlled trial (rct) method on the effect of complementary therapy on pain, joint stiffness, and physical limitations of osteoarthritis patients with the years used for the last five years (2016-2020); (7) rct design studies must meet pico criteria among populations used, which are patients with all types of osteoarthritis who are undergoing pharmacological therapy. the study was excluded if (1) they involved patients with osteoarthritis but didn’t review complementary therapy; (2) complementary therapy was not described by the author; (3) the study did not involve a control group, because we felt that we would not be able to separate the effects of complementary therapy versus standard care in hospital; (4) did not involve adult patients; (5) intervention did not explain the specific protocol of complementary therapy. outcome measures interventions in the use of complementary therapies include flaxseed poultice compress, acupressure, acupuncture therapy, cumin black oil compress, aromatherapy massage, ginger oil massage, lavender oil massage, sensorimotor exercise, application of heat, exercises with elastic bands, ultrasound therapy, geotherapy combination kinesiotherapy, phonophoresis therapy, and stimulation of compression. comparisons or comparisons in the study consisted of at least two groups, namely the intervention group and the control group. the results produced were measured with the womac scale, auscan oa hand index, and the vas pain scale. study selection the research screened through the titles and abstracts of the articles yielded by the search strategy. irrelevant articles were excluded while remaining full-text articles were then screened independently against the selection criteria for inclusion and exclusion. discrepancies were resolved within the research group. data were then extracted independently from the articles chosen by researches into a standardized data collection form. in addition to the outcome measures of interest, the researcher made a summary of the characteristics of included studies information about the type of osteoarthritis, i. purnamasari et al. 248 | pissn: 1858-3598  eissn: 2502-5791 measuring instrument, total of patient, study design, and follow-up. results literature search the review was performed according to prisma guidelines. we searched from pubmed, scopus, proquest, and sciencedirect databases. the search found 19,123 articles published between 2016 and 2020. the literature search yielded a total of 844 citations after the removal of duplicates. of these citations, 64 full-text articles were screened and 50 were excluded (fig). the main reasons for exclusion were intervention is the article was an editorial or review, the study did not involve a control group, complementary therapy was not described by the author, the study did not involve a control group, and intervention did not explain specific protocol of complementary therapy to osteoarthritis. fourteen full-text articles met our selection criteria and were included in the review. characteristics of the included studies from 14 journals, data collection was carried out in turkey for five journals, iran for two journals, egypt for one journal, korea for one journal, china for one journal, brazil for two journals, thailand for one journal, and japan for one journal. the total number of participants in the literature was 851 participants. all journals involved patients with various types of osteoarthritis patients, namely knee, hand, and hip osteoarthritis. all research journals were designed with randomized controlled trials with measurement results in the form of pain, joint stiffness, and physical limitations based on the effectiveness of complementary therapy. complementary therapy interventions of the 14 journals discussing complementary therapies, these consisted of flaxseed poultice compress, acupressure, acupuncture therapy, cumin black oil compress, aromatherapy massage, ginger oil massage, lavender oil massage, sensorimotor exercise, application of heat, exercises with elastic bands, ultrasound therapy, geotherapy combination kinesiotherapy, phonophoresis therapy, and stimulation of compression. in addition, the effects of pharmacological therapy are also one of the factors that influence the condition of osteoarthritis patients. consumption of nsaid drugs in the long term will have side effects on the liver and kidneys. the mildest side effects that may occur are nausea, stomach pain and dyspepsia while the most serious are lesions, bleeding and even perforation in the digestive tract (tosun et al., 2017). a decrease in the lequesne index score, womac scale, pain scale, and increased joint function explain that complementary therapy has an influence on osteoarthritis patients. complementary therapy is expected to benefit all patients with osteoarthritis to better understand the strength and effects of therapy that must be undertaken. osteoarthritis measurement tools western ontario and mcmaster universities osteoarthritis index (womac) is a tool that assesses the functional disability related to oa. it consists of three parts and 24 items. pain is assessed in the first part, stiffness in the second and physical functioning in the third. five-point likert scales (0 none, 1 light, 2 mild, 3 severe, 4 and 5 very severe) are used in item scoring. the total possible scores in each part are, 20, 8, and 68, respectively. the total scores of each part are calculated separately; total score of the first part (pain 5 0–20) is multiplied by 0.5, total score in the second part (stiffness 5 0–8) is multiplied by 1.25, figure. 1: prisma flowchart showing included and excluded articles. jurnal ners http://e-journal.unair.ac.id/jners | 249 and total score of the third part (functioning 5 0–68) is multiplied by 0.147. in the end, the adjusted scores of each part are calculated to range between 0 and 10. the total womac score is calculated by summing the adjusted scores of each part. a higher score means that higher pain, more stiffness, and more functional loss in activities of daily living were experienced by the participants (nasiri & mahmodi, 2018). visual analogue scale (vas) is a commonly used assessment instrument to measure variables ranging across a continuum of values, such as pain severity. two extreme descriptions of the parameter are written on the two ends of a 10cm line, and the patient is asked to mark where his or her state is on the line. for instance, “no pain” and “severe pain” can be written on the two ends of a line as extreme descriptions of the amount of pain felt by the patient, and the patient is then asked to indicate his or her pain experience. the vas score is determined by measuring the distance from no pain to the point that the patient has marked (nasiri & mahmodi, 2018). discussion changes in scores in the experimental and control groups occurred significantly. this means that the experimental group was given complementary therapy to reduce the severity of osteoarthritis, whereas in the control group that was not given complementary therapy there was no decrease in the severity of osteoarthritis. there are two mechanisms of osteoarthritis pain involved, namely the mechanism of peripheral osteoarthritis pain and the mechanism of central oa pain that involves changes in the brain and spinal cord. as with other pain conditions, there is an increasing amount of evidence that the central mechanism of pain and sensitization plays an important role. in fact, in chronic conditions and advanced disease, there are interactions between the central and peripheral systems of the nociceptive system in oa pain. clinically, central mechanism sensitization is associated with joint pain that induces pain in response to stimuli that normally do not induce pain (allodynia), with activation of a wider area of pain and longer duration of pain. sensitization of this central mechanism has been confirmed by quantitative sensory testing (qst) and mri analysis. several studies have analyzed pain thresholds and pain sensitivity to different stimuli, which produce positive results for central sensitization. conversely, the stimulus that causes pain is more related to the part of the brain that processes somatosensory nociception. other findings show that different types of osteoarthritis pain can be related to activation of different brain regions. spontaneous and spontaneous pain can be related to the medialprefrontal limbic cortex area, the area of the brain involved with emotional conditions (alfredo, junior, & casarotto, 2020). effect of flaxseed poultice compress application on pain and hand functions of patients with hand osteoarthritis: the flaxseed plant contains a significant amount of alpha-linolenicacidandomega3fattyacids.these fatty acids inhibit arachidonic acid and prevent the inflammatory response of neutrophils. thus, flaxseed causes a reduction in the synthesis of prostaglandin and leukotriene. the use of flaxseed plants for patients with arthritis is thought to be important in reducing oa symptoms because of these effects of flaxseed (savaş, alparslan, & korkmaz, 2019). the effect of acupressure and acupuncture therapy on pain, stiffness and physical functioning of knee osteoarthritis: acupuncture and acupressure are different types of complementary and alternative medicine and are used for management of oa of the knee [16]. regarding the pathobiology of the acupuncture, it is stated that acupressure stimulates the triggers in immune system and results in the secretion of β endorphin, which, in turn, induces vasodilation and decreases the pain. acupressure follows the same mechanism that acupuncture does, since the pressure is applied to the same body points used in acupuncture. by applying pressure to specific points on the body, improvement in the body systems functioning is stimulated [15]. the effect of black cumin oil on pain in osteoarthritis: studies on the analgesic effect of nigella sativa (black cumin) oil have shown that the use of the oil may have an effect on the pain. in a randomized controlled trial, named the effectiveness of topical black cumin oil in the treatment of cyclic mastalgia, it has been found that black cumin oil is significantly effective in reducing the pain compared to placebo. in this trial, 2g of black cumin oil have been topically applied to mastalgia area. it has been observed that the oil has no side effect on patients (tuna et al., 2018). effect of sensorimotor training on balance in knee osteoarthritis: sensorimotor training is a special form of proprioceptive and balance exercise that was designed for management of patients with chronic musculoskeletal pain syndromes. it is based on the concept that,, instead of emphasizing the isolated strength of a group of muscles around a joint, we should realize the importance of the central nervous system in regulating movement in order to reach proper firing patterns for maintaining joint stability (ahmed, 2011). effect of heat and a home exercise program for pain and function level in knee osteoarthritis: heat application has been found to have positive effects on pain, function level, and life quality in studies conducted with knee oa patients. applying heat to the knee joint reduces stiffness and pain by increasing blood flow and creates a relaxing effect. heat application is recommended to be conducted for 20 to 30 minutes every day of the week. when the application therapeutic effect time is exceeded, obstruction in tissues and vasoconstriction in veins develop, which leads to an adverse rather than the desired effect. additionally, when heat application is i. purnamasari et al. 250 | pissn: 1858-3598  eissn: 2502-5791 carried out for a long time, the risk of burns may arise (karadağ, taşci, doğan, demir, & kiliç, 2019). effect of resistance exercise using elastic band: among the treatments focused on relieving pain and improving movement function, exercise therapies are known to be effective. among these therapies, resistance band exercises that can increase muscular strength against the retraction force of the band have been found to be effective. resistance band exercises stimulate the proprioception and deliver information about the position and movement of joints to the cerebrum to help maintain more accurate positions. they are also good for the elderly because they are low-impact exercises (sim, 2016). effect of continuous and pulsed therapeutic ultrasound: ultrasound, with its analgesic and antispasmodic effects on muscles, is a widely used non-pharmacological treatment method for osteoarthritis. ultrasound can be applied in two different modes: continuous and pulsed. thermal effects are predominant with the continuous application mode, which is advised for the treatment of chronic cases. the thermal effects include increases in the blood flow, capillary permeability, tissue metabolism, fibrous tissue extensibility, muscle relaxation and the pain threshold. in the pulsed application mode, the heat that occurs within the tissue with the first stimuli by ultrasound waves disappears until the second stimuli occurs; the mechanical effect and deep penetration in the tissue provide a micromassage effect, and the degree of heat in the tissue does not change. pulsed ultrasound is preferred for the treatment of acute and subacute cases. the non-thermal effects include increases in chemical activity and fluid flow and a change in the permeability of cell membranes, which all provide analgesic effects (alfredo et al., 2020). effect geotherapy combined with kinesiotherapy: exercise therapy has been shown to improve muscle strength, flexibility and proprioception, thus relieving the symptoms of oa. kinesiotherapy is a therapeutic exercise including stretching, isotonic, isometric, and isokinetic strengthening. natural products are used in herbal medicine and geotherapy and have been tested in some rheumatic diseases. geotherapy is defined as the therapeutic use of clays and natural earth materials composed by different minerals, such as lamellar silicates of magnesium and aluminum, quartz, feldspar, carbonates, metallic oxides and calcium (marcon et al., 2019). effect of phonophoresis of phyllanthus amarus nanoparticle gel: phonophoresis is the use of ultrasound to deliver drug therapeutics by absorption and permeation through the skin. several studies showed that phonophoresis of nsaids relieved inflammation and symptoms of pain in many pathological conditions, including shoulder pain, myofascial pain, and knee oa. many thai herbs, including phyllanthus amarus, have antiinflammatory and antioxidant properties, which have been shown to reduce pain (pinkaew, kiattisin, wonglangka, & awoot, 2020). effect of continuous compression stimulation. lower pressure-pain thresholds have also been correlated with higher pain intensity, higher disability scores, and poorer quality of life. these data suggest that an improvement in the pressure-pain threshold may partially relieve the pain in knee osteoarthritis. other evidence indicates that massage therapy can improve the pressure-pain threshold and muscle spasm (tanaka, umehara, kawabata, & sakuda, 2018). based on a systematic review of several journals that address the effects of complementary therapy on pain, joint stiffness, and physical limitations of osteoarthritis patients, according to the authors a more effective therapy is massage therapy because complementary therapies such as massage can reduce the pain threshold (pehlivan & karadakovan, 2019). components of massage that are useful for reducing pain consist of three movement techniques, namely efflurage, tapotement and friction, which have the potential to stimulate, soften, and lengthen muscle fibers. movement stimulation in the massage technique decreases the production of inflammatory cytokines tnf-α and interleukin-6 (il-6) and decreases heat shock protein 27 (hsp 27) phosphorylation, thereby, reducing cell stress from myofiber injury resulting from excessive use of muscle in activity (efe arslan, kutlutürkan, & korkmaz, 2019). massage is proven to increase pain threshold in clients who experience diototic pain. this is explained through the gate control theory of melzack and wall (cited in perrot, 2015) which explains how harmless stimuli such as stroking movements or rubbing on the skin can provide pain relief (tosun et al., 2017). signals in thick nerve fibers are produced by stiffening which can inhibit signal delivery by nociceptive neurons (hypoalgesia). it also explains how the brain uses control of the delivery of nociceptive signals to the spinal cord through the path from the brain stem to the spinal cord (nasiri & mahmodi, 2018). massage therapy using ginger oil is considered more efficient because the costs incurred are relatively cheaper compared to essential oils or other aromatherapy oils such as lavender oil and black cumin oil, which are more expensive. the process of making raw materials is cheap and easy to obtain and the process of distillation or extraction of oil is easier. conclusion the effect of complementary therapy has an influence on pain, joint stiffness, and physical function limitations in osteoarthritis patients. complementary therapy is management of osteoarthritis without causing adverse effects that can harm the patient. based on a systematic review of several journals that address the effects of complementary therapy on pain, joint stiffness, and physical limitations of osteoarthritis patients, according to the authors a more effective therapy is massage therapy because jurnal ners http://e-journal.unair.ac.id/jners | 251 complementary therapies such as massage can reduce the pain threshold. conflict of interest no conflicts of interest have been declared. acknowledgement authors of this study would like to thank the faculty of nursing and also master of nursing programme for providing the opportunity to present this study. we would also like to show our gratitude to dr. tintin sukartini, s.kp.,m.kes from universitas airlangga for sharing their pearls of wisdom with us during the course of this systematic review, and we thank the reviewers for their insights. references ahmed, a. f. (2011). effect of sensorimotor training on balance in elderly patients with knee osteoarthritis. journal of advanced research, 2(4), 305–311. https://doi.org/10.1016/j.jare.2011.02.001 alfredo, p. p., junior, w. s., & casarotto, r. a. (2020). efficacy of continuous and pulsed therapeutic ultrasound combined with exercises for knee osteoarthritis: a randomized controlled trial. clinical rehabilitation. https://doi.org/10.1177/0269215520903786 alnahdi, a. h., zeni, j. a., & snyder-mackler, l. (2012). muscle impairments in patients with knee osteoarthritis. sports health, 4(4), 284–292. https://doi.org/10.1177/1941738112445726 efe arslan, d., kutlutürkan, s., & korkmaz, m. (2019). the effect of aromatherapy massage on knee pain and functional status in participants with osteoarthritis. pain management nursing, 20(1), 62–69. https://doi.org/10.1016/j.pmn.2017.12.001 karadağ, s., taşci, s., doğan, n., demir, h., & kiliç, z. (2019). application of heat and a home exercise program for pain and function levels in patients with knee osteoarthritis: a randomized controlled trial. international journal of nursing practice, 25(5), 1–9. https://doi.org/10.1111/ijn.12772 marcon, f., carolina, m., barros, c., cristina, k., carvalho, d., toral, i., … vargas, d. o. (2019). journal of bodywork & movement therapies geotherapy combined with kinesiotherapy is ef fi cient in reducing pain in patients with osteoarthritis. (xxxx). nasiri, a., & mahmodi, m. a. (2018). aromatherapy massage with lavender essential oil and the prevention of disability in adl in patients with osteoarthritis of the knee: a randomized controlled clinical trial. complementary therapies in clinical practice, 30, 116–121. https://doi.org/10.1016/j.ctcp.2017.12.012 pehlivan, s., & karadakovan, a. (2019). effects of aromatherapy massage on pain, functional state, and quality of life in an elderly individual with knee osteoarthritis. japan journal of nursing science, 16(4), 450–458. https://doi.org/10.1111/jjns.12254 pinkaew, d., kiattisin, k., wonglangka, k., & awoot, p. (2020). phonophoresis of phyllanthus amarus nanoparticle gel improves functional capacity in individuals with knee osteoarthritis: a randomized controlled trial. journal of bodywork and movement therapies, 24(1), 15–18. https://doi.org/10.1016/j.jbmt.2019.04.013 savaş, b. b., alparslan, g. b., & korkmaz, c. (2019). effect of flaxseed poultice compress application on pain and hand functions of patients with hand osteoarthritis. clinical rheumatology, 38(7), 1961–1969. https://doi.org/10.1007/s10067019-04484-7 sim, j. o. (2016). effects of resistance exercise using elastic band on range of motion, function and shoulder pain among patients with rotator cuff repair. korean journal of adult nursing, 28(5), 491–500. https://doi.org/10.7475/kjan.2016.28.5.491 tanaka, r., umehara, t., kawabata, y., & sakuda, t. (2018). effect of continuous compression stimulation on pressure-pain threshold and muscle spasms in older adults with knee osteoarthritis: a randomized trial. journal of manipulative and physiological therapeutics, 41(4), 315–322. https://doi.org/10.1016/j.jmpt.2017.09.011 tosun, b., unal, n., yigit, d., can, n., aslan, o., & tunay, s. (2017). effects of self-knee massage with ginger oil in patients with osteoarthritis: an experimental study. research and theory for nursing practice, 31(4), 379–392. https://doi.org/10.1891/1541-6577.31.4.379 tuna, h. i., babadag, b., ozkaraman, a., & balci alparslan, g. (2018). investigation of the effect of black cumin oil on pain in osteoarthritis geriatric individuals. complementary therapies in clinical practice, 31(june 2017), 290–294. https://doi.org/10.1016/j.ctcp.2018.03.013 96 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.22560 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of psychoeducation on self-efficacy and motivation for taking treatment in breast cancer patients (ca mammae) hanik endang nihayati, laeli nurhanifah and ilya krisnana faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: besides being a physiological problem, breast cancer is also a psychological problem. breast cancer patients are prone to anxiety, depression, stress, fear, and other psychological problems. prolonged psychological problems that are not resolved lead to impaired self-confidence and motivation to undergo treatment, which has a negative impact on health. psychoeducation as a psychological therapy as well as providing education is used as a therapy that aims to overcome the psychological problems of breast cancer patients. methods: this study used a quasi-experimental research design. the population in this study was breast cancer patients (ca mammae) at prof. dr. margono soekardjo purwokerto. the sample of this study was 50 respondents obtained with purposive sampling technique. the independent variable of this study is psychoeducation and the dependent variables are self-efficacy and motivation. data were collected using a general self-efficacy questionnaire and intrinsic motivation inventory as well as an observation sheet. data were analyzed using the paired t-test and independent t-test statistical tests with a level of significance α ≤ 0.05. results: there was an effect of psychoeducation to self-efficacy and motivation (p = 0.000; p = 0.000). conclusion: this study shows that psychoeducation affects self-efficacy and motivation to undergo treatment in breast cancer patients (ca mammae). psychoeducation provides information related to breast cancer and stress management methods so that it can increase self-efficacy and motivation to undergo treatment for breast cancer patients. article history received: october 11, 2020 accepted: april 13, 2021 keywords breast cancer (ca mammae); psychological; psychoeducation; psychological management contact hanik endang nihayati  hanik-e-n@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: nihayati, h. e., nurhanifah, l., & krisnana, i. (2021). the effect of psychoeducation on self-efficacy and motivation for taking treatment in breast cancer patients (ca mammae). jurnal ners, 16(1). 96-100. doi:http://dx.doi.org/10.20473/jn.v16i1.22560 introduction psychological problems in the form of anxiety or depression should not occur in breast cancer patients (ca mammae) because it will have a negative impact on disease progression and adherence to treatment, in addition to greater stress it can lead to the risk of emotional confusion (wu et al., 2018). self-efficacy contributes to motivation in a number of ways including breast cancer patients set goals others set for themselves, how much effort they put in, how long they endure adversity, and how resistant they are to failure (bandura, 1994). the low level of self-efficacy and motivation to undergo treatment is a determining factor in the success of treatment. self-efficacy in general has a positive relationship with optimism, self-esteem, internal control and motivation and a negative relationship with anxiety, depression, and trauma. cancer patients who have high self-efficacy can significantly adapt to life changes better than those who have low self-efficacy (jerusalem & mittag, 1995 cited in sanaei et al., 2014). based on research conducted by mudigdo and murti (2016), someone with high self-efficacy will also have an effect on improving the quality of life, role function, emotional function, and social function. cancer will become a world health problem until it reaches 22 million cases in 2032 and breast cancer is included in the largest number of cases (momenimovahed & salehiniya, 2019). in 2012, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 97 breast cancer was the highest type of cancer, mostly experienced by women, with 1.7 million new cases and an estimated 521,900 deaths (american cancer society, 2015). in the united states, the mortality rate for breast cancer sufferers in 2017 was 40,610 patients of all age levels, while the incidence rate of breast cancer was 316,120 sufferers of all age levels (hodge et al., 2015). in indonesia, the number of breast cancer cases in 2013 reached 61,682 cases. the percentage of new breast cancer cases was 43.3% and the death rate was 12.9% (torre et al., 2015). meanwhile, in central java, the number of breast cancer cases in 2013 reached 11,511 with the highest number of cases in indonesia (deprtemen kesehatan republik indonesia, 2013). in banyumas district alone in 2012 there were 133 cases of breast cancer (dinas kesehatan provinsi jawa tengah, 2014). based on this description, the importance of psychoeducational interventions for the psychological impact of breast cancer patients that have an impact on self-efficacy and increase motivation to undergo treatment in breast cancer patients is needed. with the existence of stages of psychoeducation, including identifying problems (breast cancer), providing knowledge related to breast cancer, and stress management, it is hoped that self-efficacy and motivation to undergo breast cancer treatment will increase. materials and methods population of this research was patients with breast cancer undergoing chemotherapy in margono soekardjo purwokerto hospital. the sample of this research was based on inclusion and exclusion criteria. the inclusion criteria consisted of female gender, age range 18-60 years, breast cancer stage iiii. the exclusion criteria in this study were critical patients, and patients with mental disorders. the procedure involved taking informed consent as agreement between researcher and patient. in the first week, the researcher used gse and motivation instrument to both groups as pretest. in the second week, the researcher conducted psychoeducation to the treatment group. in the third week, the researcher conducted posttest to both groups. the research used a quantitative quasi-experimental research design. the sampling technique used in this study is a non-probability sampling method, namely purposive sampling. statistical tests used paired t-test and independent t-test. the sample size in this study was 50 respondents (25 treatment group, 25 control group). results demographic characteristics data describe things related to research respondents. there are five variables in the demographic data characteristics of respondents. the description of the distribution of demographic characteristics (table 1), the results of self-efficacy (table 2) and motivation (table 3) are as follows. in table 1, demographic data show that breast cancer respondents (ca mammae) in the treatment group are more in the age range 41-50 years (30.6%) as well as in the treatment group (33, 3%). in the treatment group, there is more elementary education (41.7%) as well as the control group (44.4%). in the treatment group those who were married amounted to 61.1% while in the control group it amounted to 58.3%. respondents in the treatment group and the control group mostly did not work, namely 33.3%, respectively. table 2 shows the level of self-efficacy in the treatment group before the intervention was carried out with as many as 12 people in the high category and after the intervention this increased to 15 people. this high category has the largest number of respondents compared to the low and medium categories. whereas, in the control group, the level of self-efficacy before the intervention with the high category was nine people and after the intervention was 10 people. however, the low category has the highest number of respondents after treatment, namely 13 people. in the paired t-test in the treatment group, the value p = 0.000 was obtained using the critical limit (𝛼)0.05, which means that there is a significant difference between the value of selfefficacy before and after psychoeducation therapy. table 3 shows the level of motivation of the treatment group before intervention in the high category as many as nine people and after the intervention this increased to 15 people. however, the medium category in the treatment group was more than the low and high categories, namely as many as 14 people. whereas in the control group the level of motivation before the intervention with the table 1. characteristics of breast cancer survivors (n=25) respondent characteristics treatment control n (%) n (%) age group(year) 18-30 31-40 41-50 51-60 1 (2.8) 4 (11.1) 11 (30.6) 9 (25.0) 1 (2.8) 3 (8.3) 12 (33.3) 9 (25.0) education primary intermediate secondar university 15 (41.7) 4 (11.1) 3 (8.3) 3 (8.3) 16 (44.4) 5 (13.9) 3 (8.3) 1 (2.8) marital status single married widowed 0 (0.0) 22 (61.1) 3 (8.3) 1 (2.8) 21 (58.3) 3 (8.3) occupation not working traders civil servants others 16 (44.4) 1 (2.8) 3 (8.3) 5 (13.9) 16 44.4 1 2.8 1 2.8 7 19.4 25 100 stage one two three 2 (5,6) 12 (33.3) 11 (30.6) 3 (8.3) 12 (33.3) 10 (27.8) h. e. nihayati et al. 98 | pissn: 1858-3598  eissn: 2502-5791 high category was 12 people and after the intervention was 11 people. the medium category is the largest category after the intervention with a total of 14 respondents. paired t-test with critical limits (α) 0.05, in the treatment group after psychoeducation therapy was 0.000, less than 0.05; this means that there is a significant difference between the motivation values before and after psychoeducation therapy. the result of the paired t-test motivation in the control group was p = 0.103 with a critical limit (α) of 0.05; this means that there is no significant difference between the motivation values before and after psychoeducation therapy because the p-value is greater than α. discussion self-efficacy psychoeducation is effective in improving attitudes because it includes several theories and practices (lukens & mcfarlane, 2004; snethen & warman, 2018; taylor-rodgers & batterham, 2014). psychoeducation is important because it can increase the knowledge and cognitive abilities of clients and families so that it can reduce anxiety or stress (beshai et al., 2019; stuart, 2014). the results of the study based on the category of the level of self-efficacy showed that, in the treatment group, it was found that the self-efficacy of undergoing treatment for breast cancer patients, mostly before the intervention (pretest), had high self-efficacy, while after the study, the level of self-efficacy was fixed. low levels of self-efficacy can occur before psychoeducation intervention is carried out, because breast cancer patients think that they have little hope of recovery, so they think that treatment is not optimal. this is related to the statement "if i want to try hard, i can solve the problem related to my current illness". most of the statements in this questionnaire chose to strongly disagree with the reason that most of them had tried various kinds of treatment but the results obtained were not completely satisfactory. apart from that, in the statement "whatever happens i am ready to handle it", most of the respondents strongly disagree because they think that they are not ready to accept the harsh reality that will happen to them someday. after the psychoeducation intervention was carried out, agreement as to the statement "if i want to try hard, i can solve the problem related to my current illness" is proven by their statement that they will undertake alternative medicine. in the statement "whatever happens, i am ready to handle it", most of the respondents chose to answer disagree, they are still adapting to current cancer conditions. the increasing level of self-efficacy is also influenced by the information obtained through psychoeducation (reins et al., 2019; shah et al., 2014). this statement is evidenced by the results of the posttest in the treatment group after being given psychoeducation intervention, which shows that the level of self-efficacy is increasing. this also shows that psychoeducation intervention has an effect on selfefficacy. motivation in this study, the motivation to undergo breast cancer treatment in general showed a change, namely the treatment group showed an increase in respondents who had a motivation level for treatment as indicated by the percentage of the mean value after the posttest. psychoeducation is a combination of psychotherapy table 2 .the results of self-efficacy before and after being given psychoeducation therapy in the treatment and control groups of breast cancer patients (ca mammae) (n=25). self efficacy (n=50) treatment control pre test post test pre test post test n % n % n % n % low 5 20 0 0 6 24 2 8 moderate 8 32 10 40 10 40 13 52 high 12 48 15 60 9 36 10 40 paired t-test p = 0.000 p = 0.083 independent t-test p = 0.000 table 3. motivation results before and after being given psychoeducation therapy in the treatment and control groups of breast cancer patients (ca mammae) (n=25). motivation (n=50) treatment control pre test post test pre test post test n % n % n % n % low 7 28 0 0 0 0 0 0 moderate 9 36 14 56 13 52 14 56 high 9 36 11 44 12 48 11 44 paired t-test p = 0.000 p = 0.103 independent t-test p = 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 99 and educational interventions (anchan & janardhana, 2020; hudak & gallo, 2010; petre et al., 2021) by looking at potential threats or life development and explaining individual coping strategies to adapt critically in the patient’s life, namely through education or what is called psychoeducation (brown, 2011). psychoeducation is important because it can affect a person's psychology and have a big effect on the ability to respond (abedini et al., 2020; alvidrez et al., 2005). researchers argue that psychoeducation is an extrinsic motivation that comes from research. researchers provide information related to breast cancer and teach how to manage stress. researchers are said to be the source of increased extrinsic motivation because they are one of the external factors forming motivation. the level of motivation before and after the psychoeducation intervention was different. the existence of this difference is based on the statement of respondents who mostly chose to strongly disagree before the intervention was carried out, namely the statement "i believe cancer treatment is beneficial for me" and the statement "i feel happy if i do cancer treatment and feel close to cancer treatment" (barnes et al., 2018; gür et al., 2017). respondents thought that taking medication would waste a lot of money while the amount of money needed was so great and they themselves were still experiencing economic difficulties. after a psychoeducational intervention, the statement "i believe cancer treatment is beneficial for me" was agreed. conclusion the conclusion of the research regarding the effect of psychoeducation on self-efficacy and motivation to undergo treatment in breast cancer patients (ca mammae) is that the level of self-efficacy pre and post psychoeducation intervention in breast cancer patients (ca mammae) shows a significant difference between treatment groups and control, or, in other words, psychoeducation can increase self-efficacy in undergoing treatment in breast cancer patients. the pre and post motivation level of psychoeducation intervention in breast cancer patients (ca mammae) showed a significant difference between the treatment group and the control group, or in other words, psychoeducation could increase motivation to undergo treatment in breast cancer patients. healthcare professionals should be more aware of the psychology of patients within this group of breast cancer patients in order to meet their needs. references abedini, m., olfati, f., oveisi, s., bahrami, n., astrologo, l., & chan, y. h. (2020). examining the effect of a brief psychoeducation intervention based on selfregulation model on sexual satisfaction for women with breast cancer: a randomized controlled trial. european journal of oncology nursing, 47, 101673. https://doi.org/10.1016/j.ejon.2019.101673 alvidrez, j., areán, p. a., & stewart, a. l. (2005). psychoeducation to increase psychotherapy entry for older african americans. the american journal of geriatric psychiatry, 13(7), 554–561. https://doi.org/10.1097/00019442-20050700000003 american cancer society. (2015). a guide to chemotherapy. american cancer society. https://www.cancer.org/treatment/treatmentsand-side-effects/treatmenttypes/chemotherapy.html anchan, v., & janardhana, n. (2020). transformation of attitude through brief psychoeducation program for the husbands of women with postpartum psychiatric disorders. asian journal of psychiatry, 51, 101841. https://doi.org/10.1016/j.ajp.2019.101841 bandura, albert. (1994). self-efficacy. in v.s. ramachaudran (ed.), encyclopedia of human behaviour (pp. 71–81). academic press. barnes, r. d., ivezaj, v., martino, s., pittman, b. p., paris, m., & grilo, c. m. (2018). examining motivational interviewing plus nutrition psychoeducation for weight loss in primary care. journal of psychosomatic research, 104, 101–107. https://doi.org/10.1016/j.jpsychores.2017.11.01 3 beshai, s., watson, l. m., meadows, t. j. s., & soucy, j. n. (2019). perceptions of cognitive-behavioral therapy and antidepressant medication for depression after brief psychoeducation: examining shifts in attitudes. behavior therapy, 50(5), 851–863. https://doi.org/10.1016/j.beth.2019.01.001 brown, l. p. (2011). nurse education in practice revisiting our roots : caring in nursing curriculum design. nurse education in practice, 11(6), 360– 364. https://doi.org/10.1016/j.nepr.2011.03.007 deprtemen kesehatan republik indonesia. (2013). riset kesehatan dasar. https://doi.org/1 desember 2013 dinas kesehatan provinsi jawa tengah. (2014). profil kesehatan provinsi jawa tengag. gür, f., can gür, g., & okanlı, a. (2017). the effect of the cognitive-behavioral model-based psychoeducation and exercise intervention on quality of life in alcohol use disorder. archives of psychiatric nursing, 31(6), 541–548. https://doi.org/10.1016/j.apnu.2017.07.005 hodge, f. s., itty, t. l., cadogan, m. p., martinez, f., & pham, a. (2015). the cultural constructs of cancerrelated fatigue among american indian cancer survivors. supportive care in cancer. https://doi.org/10.1007/s00520-015-2902-7 hudak, & gallo. (2010). keperawatan kritis (6th ed.). egc. lukens, e. p., & mcfarlane, w. r. (2004). psychoeducation as evidence-based practice: considerations for practice, research, and policy. brief treatment and crisis intervention, 4(3), 205– h. e. nihayati et al. 100 | pissn: 1858-3598  eissn: 2502-5791 225. https://doi.org/10.1093/brieftreatment/mhh019 momenimovahed, z., & salehiniya, h. (2019). epidemiological characteristics of and risk factors for breast cancer in the world. breast cancer: targets and therapy, volume 11, 151–164. https://doi.org/10.2147/bctt.s176070 mudigdo, a., & murti, b. (2016). the effect of selfefficacy , family support , and socio-economic factors on the quality of life of patients with breast cancer at dr . moewardi hospital , surakarta. 1(3), 182–194. petre, l. m., gemescu, m., & bulgari, d. (2021). using artistic activities within experiential psychotherapy to alleviate the psychological consequences of female infertility. the arts in psychotherapy, 73, 101758. https://doi.org/10.1016/j.aip.2021.101758 reins, j. a., boß, l., lehr, d., berking, m., & ebert, d. d. (2019). the more i got, the less i need? efficacy of internet-based guided self-help compared to online psychoeducation for major depressive disorder. journal of affective disorders, 246, 695– 705. https://doi.org/10.1016/j.jad.2018.12.065 sanaei, h., ali, s., & jamshidifar, z. (2014). effectiveness of mindfulness training on selfefficacy of patients infected by breast cancer. procedia social and behavioral sciences, 159, 426–429. https://doi.org/10.1016/j.sbspro.2014.12.400 shah, l. b. i., klainin-yobas, p., torres, s., & kannusamy, p. (2014). efficacy of psychoeducation and relaxation interventions on stress-related variables in people with mental disorders: a literature review. archives of psychiatric nursing, 28(2), 94–101. https://doi.org/10.1016/j.apnu.2013.11.004 snethen, c., & warman, d. m. (2018). effects of psychoeducation on attitudes towards individuals with pedophilic sexual intrusive thoughts. journal of obsessive-compulsive and related disorders, 19, 92–98. https://doi.org/10.1016/j.jocrd.2018.10.001 stuart, g. w. (2014). principles and practice of psychiatric nursing-e-book. elsevier health sciences. taylor-rodgers, e., & batterham, p. j. (2014). evaluation of an online psychoeducation intervention to promote mental health help seeking attitudes and intentions among young adults: randomised controlled trial. journal of affective disorders, 168, 65–71. https://doi.org/10.1016/j.jad.2014.06.047 torre, l. a., bray, f., siegel, r. l., ferlay, j., lortettieulent, j., & jemal, a. (2015). global cancer statistics, 2012. ca: a cancer journal for clinicians, 65(2), 87–108. https://doi.org/10.3322/caac.21262 wu, p., chen, s., huang, w., & chang, s. (2018). effects of a psychoeducational intervention in patients with breast cancer undergoing chemotherapy. 00(0), 1–14. 294 faktor personal, self efficacy dan upaya pencegahan kanker serviks pada perempuan usia produktif (personality factor, self efficacy and prevention of cervical cancer among childbearing age women) ni ketut alit armini*, iqlima dwi kurnia*, fani lailatul hikmah* *faculty of nursing universitas airlangga kampus c jl. mulyorejo surabaya, telp. 031 5913754, email: nk.alita@fkp.unair.ac.id abstrak pendahuluan: kanker serviks menjadi penyebab utama morbiditas dan mortalitas di seluruh dunia. program pencegahan kanker serviks yang kurang baik menyebabkan keterlambatan penanganan sehingga sebagian besar responden mengalami kanker serviks stadium lanjut. penelitian bertujuan untuk mengetahui hubungan faktor personal, self efficacy dengan upaya pencegahan kanker serviks pada wanita usia produktif. metode: desain penelitian ini adalah deskriptif korelatif dengan pendekatan cross sectional. populasinya adalah semua wanita usia produktif di wilayah puskesmas kenjeran surabaya. besar sampelnya adalah 64 responden wanita usia produktif dengan menggunakan probability simple random sampling. variabel independen adalah faktor personal dan self efficacy. variable dependen adalah upaya pencegahan primer dan sekunder. data dianalisis menggunakan uji statistik spearman’s rho untuk mengetahui variable yang berhubungan dengan upaya pencegahan kanker serviks. hasil: hasil penelitian menunjukkan hubungan antara faktor personal dan upaya pencegahan kanker serviks menghasilkan p = 0,025 (α ≤ 0,05). sedangkan variable hubungan self efficacy dengan upaya pencegahan kanker serviks pada wanita usia produktif menghasilkan p = 0,094 (α ≤ 0,05). diskusi: faktor personal berhubungan dengan upaya pencegahan kanker serviks pada wanita usia produktif sedangkan self efficacy tidak berhubungan dengan upaya pencegahan kanker serviks pada wanita usia produktif. untuk peneliti selanjutnya dapat menggunakan variabel lain dari teori health promotion model untuk melakukan upaya pencegahan kanker serviks. kata kunci : wanita usia produktif, kanker servik, self efficacy, faktor personal. abstract introduction: cervical cancer is a major cause of morbidity and mortality worldwide. bad cervical cancer prevention program cause delays in treatment. thus, leading most of the respondents had cervical cancer in advance stadium. the study aims to determine the correlation of personal factors, self efficacy in the prevention of cervical cancer in women of childbearing age. methods: the study design was descriptive correlative with cross sectional approach. the population were all women of childbearing age in puskesmas kenjeran surabaya. samples were 64 respondents gathered by using simple random sampling. the independent variable were the personal factor and self efficacy. the dependent variable was the primary and secondary prevention efforts. data were analyzed using spearman's rho test to determine the variables which associated with the prevention of cervical cancer. results: the results showed the correlation between personal factors and prevention of cervical cancer with p = 0.025 (α ≤ 0.05). while self efficacy had no correlation with the prevention of cervical cancer with p = 0.094 (α ≤ 0.05). discussion: personal factors related to the prevention of cervical cancer in women of childbearing age, while self efficacy is not related to the prevention of cervical cancer in women of childbearing age. for the next researcher to use other variables of the theory health promotion model to take steps to prevent cervical cancer. keywords: women of childbearing age, cervical cancer, self efficacy, personal factors. introduction cancer affects all levels of society from low and upper economic level, old and young, low or high educated (depkes 2011). risk population requires prevention efforts as early as possible in order to implement healthy behavior (anthony m et al 2010). cervical cancer is a malignant tumor that grows in the the lowest part of the uterus and could attached to the top of the vagina. nursing theory focuses on prevention and promotion of health behaviors is the health promotion model (hpm) by nolla j pender (2002). the theory encourages the use of integrative model of health, which takes a broad view on the biopsychosocial phenomenon of human health. clinical indicators in the theory were interpersonal behaviors, social support, socioeconomic status, mood, complaints, hormone levels, antibody status. human responses determine indicators of healthy or unhealthy. hpm theory is a theory that explains and predicts the interaction between environmental factors and perceptions that can affect health. cervical cancer is a major cause of morbidity and mortality in the world, according to world health organization (who) estimates that in 2012 the incidence of cancer is about 14 million new cases and 7.6 mailto:nk.alita@fkp.unair.ac.id jurnal ners vol. 11 no. 2 oktober 2016: 294-299 295 million deaths. figures cervical cancer incidence varies greatly. cervical cancer is the second most common cancer to strike women in developing countries is expected in 2012 about 270,000 women die from cervical cancer. in indonesia, the prevalence of cervical cancer cases is quite high. globocan based on data from 2008, found 20 cases of cervical cancer deaths every day. the disease is also a top ten cause of death in indonesia (herman 2014). nationally, the prevalence of cancer in the population of all ages in indonesia in 2013 was 1.4 ‰ or estimated to be around 347 792 people. yogyakarta province had the highest prevalence of cancer, which amounted to 4.1 ‰. based on the estimated number of cervical cancer is the cancer with the highest prevalence in indonesia in 2013, which amounted to 0.8 ‰ of cervical cancer. based on the estimated number of cervical cancer are highest in the province of east java and central java province. the incidence of cervical cancer in surabaya each year has decreased, the estimation surabaya city health office in 2011 approximately 17.97%, in 2012 amounted to 17.13%, and 14.31% in 2013. according to previous research, the behavior of cervical cancer prevention is affected because of their holistic and complex interaction of the individual with the environment in the surrounding areas (chusairi,a & hartini 2003) these things that influence the decision to take precautions. in addition there are other factors that can influence the behavior of prevention, namely internal and external factors of patients, such as beliefs, spiritual encouragement, confidence, financial condition and culture that had been used in the search for prevention efforts. cultural backgrounds have an important influence on aspects of community life, including their beliefs, behaviors, perceptions, emotions and attitudes to the disease that has significance for health (herman 2014). self-efficacy affects the motivation and confidence of every woman to perform on cervical cancer prevention. who said in developing countries cervical cancer is ranked top among various types of cancer that causes death in women in the world who attack the childbearing age. the main cause of cervical cancer is infection human papilloma virus (hpv). hpv infection can strike women, ranging from 20-year-old woman until women are no longer in the childbearing age. some of the risk factors of infection hpv among others, women who married at the age of 18 years are at risk 5-fold infected with hpv, women with sexual activity high and have multiple partners, smokers, have a history of venereal disease, parity (number of births) , use of oral contraceptives in the long term. there is a significant relationship between the level of education, occupation, income, knowledge and attitudes of women efa with a pap smear in banda aceh (nurhasanah, 2008). health promotion model is a model for nurses to explore the complex biopsychosocial processes, which motivates people to behave in certain ways, which is intended to improve the health status (tommey, a.m & alligood 2006). decrease the severity of cervical cancer is very important, especially the prevention of cervical cancer in women of childbearing age. communities with low socioeconomic have less opportunity to do prevention by pap smear (wilopo 2010). iva test and pap smears in women of childbearing age are still not maximized due to fear and shame to double check the cervix rechildbearing organs against health workers (candraningsih 2011). method this research used descriptive correlational design with cross sectional approach. population of study were 193 people and the samples were 64 people. the sampling technique used in this study was simple random sampling. the independent variables in this study were personal factors (biological, psychological, and sociocultural) and self efficacy. the dependent variable in this study was primary and secondary prevention. instrument used in this study was a questionnaire. personal factors questionnaires associated with a domain statement to measure biological, psychological, and sociocultural containing 10 items of questions with answer choices strongly agree, agree, neutral, disagree, strongly disagree. self-efficacy questionnaire containing 10 items of questions with answer choices strongly agree, agree, neutral, disagree, strongly disagree. questionnaires primary and secondary prevention efforts related to healthy check regularly, avoiding smoking, regular physical activity, a balanced diet, adequate rest, stress management which contains 6 questions with answer choices often, rarely, never. this research was conducted in faktor personal, self efficacy dan upaya pencegahan kanker (ni ketut alit armini, dkk) 296 puskesmas kenjeran surabaya. any data will be measured using spearman's rho that if the set value of significance  ≤ 0,05. result table 1. respondent characteristic (n=64) no responden f % 1 age 18-35 years old 36 56,3 36-50 years old 28 43,7 2 activity wife 39 60,93 comerce 8 12,5 labour 4 6,25 swasta 13 20,31 3 education not school 3 4,68 elementary 19 29,6 jhs 23 35,9 shs 17 26,5 university 2 3,125 4 salary ≤rp. 3.045.000 58 90,6 >rp. 3.045.000 6 9,4 table 2. reproduction history (n=64) no characteristic criteria f % 1 child 0-2 children 47 73,4 >2 children 17 26,5 2 information about cancer no 42 65,6 yes 22 34,4 3 check iva/pap smear no 63 98,5 yes 1 1,5 4 vaksin hpv no 64 100 according to the table 1 above concerning the characteristics of respondents shows that in the age range 18-35 years there are 36 mother with a frequency (56.3%). ages 18-35 have the opportunity to multiply to cervical cancer prevention efforts. most jobs of most respondents is to be a housewife mother with a frequency of at least 39 (60.93%). most housewives around puskesmas kenjeran have good social relationships so that health information about cervical cancer prevention can be seen easily. last education respondents, 35.9% (23 persons) have smp. this resulted in a lack of information obtained in formal education, so that could affect prevention efforts. family income in one month there were 90.6% (58 people) ≤ rp 3.045.000 million. this has an impact on the behavior of primary and secondary prevention efforts of local residents kenjeran phc surabaya. according to the table 2 on the rechildbearing history of respondents that the number of children, knowledge of cervical cancer, iva examination / pap, hpv vaccine. there were 73.4% (47 persons) have 0-2 children, from these results indicate that the risk of cervical cancer due to high parity, is able to reduce the incidence of cervical cancer in the region kenjeran surabaya. 65.6% (42 people) had lack of knowledge about cervical cancer, 98.4% (63 people) have never done iva examination / pap smear, and 100% (64 people) have never done the hpv vaccine. those data indicates that the majority of women in childbearing age have less prevention efforts. table 3. personal factor, self efficacy, cervical cancer prevention (n=64) variable cathegory f % personal factor negative 30 47 positive 34 53 self efficacy weak 43 67 strong 21 33 prevention less 31 48 good 33 52 table 3 shows personal factor in cervical cancer prevention at kenjeran health center of surabaya. most of the respondents had positive personal factors leading to good prevention behavior. 43 (67%) respondents had weak self efficacy. respondents who had weak selfefficacy will affect both primary and secondary prevention of cervical cancer. most of the respondents had never received counseling about cervical cancer is that it can improve healthy behaviors for the prevention of cervical cancer increases. table 4. correlation between personality factor and cervical cancer prevention personality factor prevention total bad good f % f % σ % negative 19 61,2 11 33,3 30 46,8 positive 12 38,8 22 66,7 34 53,2 total 31 100 33 100 64 100 spearman rho p = 0,025 r = 0,280 table 4 indicates that personality factor had less correlation with cervical cancer prevention behavior. respondents who had positive personality behavior tended to had good prevention behavior, but still a few number of respondents who had negative personal factor also had good prevention behavior. tabel 5. correlation between self efficacy and cervical cancer prevention self effiacy prevention total bad good jurnal ners vol. 11 no. 2 oktober 2016: 294-299 297 f % f % σ % weak 24 77,4 19 57,5 43 67,1 strong 7 22,6 14 42,5 21 32,9 total 31 100 33 100 64 100 spearman rho p = 0,094 r = 0,211 there were no correlation between self efficacy and prevention behavior of cervical cancer. it can be seen from the data on table 5 that majority women in childbearing age had weak self efficacy but they had good prevention behavior. discussion most respondents had positive personal factors and good prevention. personal factors can improve a woman to take steps to prevent cervical cancer. one of the components in the personal factor is age. the demographic data were obtained that majority of respondents were aged 18-35 years and 36-50 years old. age affects prevention by increasing knowledge acquired. at the middle age, people will be more actively involved in community and social life (rahayu, et al 2014). good prevention among 22 respondents can be also caused by followed the cervical cancer education. respondents were mostly as housewives were able to influence the level of knowledge for social interaction into successful healthy behavior of each individual. social and cultural interaction increased the prevention of cervical cancer because it can provide an emotional benefit or affect the behavior included in preventive medicine (supartiningsi 2003). personal factors related to the prevention of cervical cancer because inividu with positive personal factors such as avoiding marriage under 18 years of age, not using hormonal birth control in the same period of 5 years, avoiding cigarette smoke, can increase an individual effort to prevent cervical cancer. there are several reasons that make the 12 respondents have bad prevention behavior despite having good personal factors. it can be seen through their perception, that pap smear test only need to be performed by women who had unsafe sexual behavior (changing sexual parters). based on demographic data there are 42 respondents who did not know about cervical cancer, 63 respondents had never perform pap smears and nearly all respondents never do hpv vaccines. this is because women of childbearing age have not received information about the prevention of cervical cancer so that respondents can not manage stress well and are reluctant to undertake secondary examination of cervical cancer. but there are 11 respondents with a negative personal factors but has a good prevention efforts. in this research, many respondents already implemented primary prevention in their daily behavior, such as avoiding smoking, doing regular physical activity, implementing a healthy diet and adequate rest. all these behaviors may reduce the incidence of cervical cancer. the action has not been done by the respondent in the prevention of cervical cancer was the pap smear and acetic acid visual inspection (avi test). family support and cadres to implement the health actions were very influential in the local area. there was a correlation between personal factors and prevention of cervical cancer, because of personal factors will positively lead to the improvement of health and prevention behavior. it would also require regular counseling program so that every woman of childbearing age in kenjeran can understand aboutb cervical cancer prevention and undertake primary prevention behaviors in their daily lives, as well as secondary prevention with avi examination or a pap smear regularly. the results showed self-efficacy is not related to the prevention of cervical cancer in women of childbearing age in puskesmas kenjeran surabaya. some respondents did not understand how to prevent cervical cancer in women of childbearing age. most respondents have a poor self-efficacy and a small portion of respondents have a strong self-efficacy. recapitulation of self-efficacy questionnaire indicated that the respondents were sure to do the primary and secondary prevention of cervical cancer, so that respondents could improve self efficacy and eliminated anxiety to do prevention. self-efficacy is the belief to take the desired action, self-efficacy is a person's background to perform an action or control certain situations (bandura 1994). experience and family support also affects the primary and secondary prevention of cervical cancer. the majority of respondents have 0-2 children and a small proportion of respondents have more than two children, thereby increasing the risk of cervical cancer. motivation, self-efficacy, and self-confidence is an important part of healthy behaviors faktor personal, self efficacy dan upaya pencegahan kanker (ni ketut alit armini, dkk) 298 (rosenstock 1976). self-efficacy plays a role in creating healthy behaviors in a person. there were respondents who had selfefficacy is weak but able to take steps to prevent cervical cancer. this caused by a low educational background hence lack of knowledge about prevention of cervical cancer. in addition there were respondents who had strong self-efficacy but less prevention efforts. the respondents did not know about cervical cancer prevention, have a rest period of less than 8 hours per day and can not manage stress. when viewed from the level of anxiety, the respondents had lower levels of anxiety. this may affect the prevention of respondents. despite having self-efficacy is less but still there is a sense to maintain health and prevention, especially primary prevention of cervical cancer. respondents who have strong selfefficacy and good prevention efforts as many as 14 people. one supporting factor is the level of education. most respondents were middle and high school graduates. education is a tool that can be used to improve behavior in social life. the level of education effect in response to a stressor that comes from outside. people who have a higher education will provide a more rational response than the low education or no education at all. secondly, information obtained from formal and non formal education can increase knowledge. information emerging from cognitive can provide the foundation for the formation of knowledge. according erfandi (2009) factors that affect a person's level of knowledge among others, education, media, environment, experience, age, socio-cultural and economic. based on the interview, respondents are sure to maintain good health and will take steps to prevent cervical cancer as early as possible. this indicates that respondents have a good self-efficacy. respondents perform various prevention efforts because they feel uncomfortable if the risk for cervical cancer. there is a relationship between preventive behaviors with good self-efficacy, due to the high value of self-efficacy individuals able to direct people to behave. on average respondents experiencing high anxiety before performing a secondary examination of cervical cancer. this causes the respondents are reluctant to undergo examinations and pap smears avi related to the prevention of cervical cancer. strong self-efficacy will increase confidence, reduce anxiety levels, improving preventive behaviors in yourself. conclusion and recommendation conclusion women of childbearing age who have positive personal factors tend to have good prevention behavior while those who have strong self-efficacy lean to have less cervical prevention behavior of cervical cancer. recommendation health provider at puskesmas kenjeran needs to improve the knowledge among women of child bearing age, because good knowledge will increase good prevention behavior of cervical cancer. health education can be held among the cadres (community health volunteer), so they can spread the knowledge through their community and reduce the incidence of cervical cancer. reference anthony m et al, 2010. stroke prvnton: awaeeness of risk factors for stroke among african american resident in the missisipi delta region. journal of the national medical assosiation, 102(2), pp.84–89. bandura, a., 1994. self-efficacy. in v.s ramachaudran (ed), encyclopedia of human behavior, new york: acadmc press. candraningsih, 2011. hubungan tingkat pengetahuan wus tentang kanker serviks dengan praktek deteksi dini kanker serviks di bps is manyaran semarang. available at: http//ejournal.ac.id/index.php/ilmukepera watan/search. chusairi,a & hartini, n., 2003. health seeking behavior pada penderita paliatif, surabaya: airlangga. depkes, 2011. kejadian kanker serviks. available at: <http://depkes.go.id. herman, 2014. kesadaran untuk deteksi dini kanker serviks masih rendah. media release. 4 juli. yayasan kanker indonesia. available at: .<http://yayasankankerindonesia.org/201 4/kesadaran-untuk-deteksi-dini-kankerserviks-masih-rendah/>.. rahayu s, 2010. peran kader paguyupan perempuan waspada kanker (ppwk) dalam mei=ningkatkan kesadaran jurnal ners vol. 11 no. 2 oktober 2016: 294-299 299 masyarakat untuk deteksi dini kanker servik. universitas 11 maret. rosenstock, i.m., 1976. the health belief model and preventive health behavior. health education monographs, supartiningsi, 2003. peran ganda perempuan , sebuah analisis filosofi kritis. jurnal filsfat. tommey, a.m & alligood, m.., 2006. nursing theorists and their work.six edition.st. louis missouri, mosby.verralls,s six editio., wilopo, 2010. epidemiologi dan pencegahan kanker leher rahim. available at: http://chnrl.net/mkia-kr/files/cacervictexfinal.pdf. 148 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.29650 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research teenagers’ safety smartphone use model based on health promotion theory rizki fitryasari, rr dian tristiana, and ah yusuf faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: smartphones and teenagers in the age of technology are two very close things. uncontrolled use of smartphones can create serious problems for teenagers, namely addiction. this research aims to build a safe smartphone use model for teenagers using a health promotion theory. methods: this study was an explanatory study with a cross-sectional approach. the study population was 11-18 year old teenagers in surabaya, indonesia who use smartphones actively. the respondents were 185 teens recruited by simple random sampling. variables include teenager factors, technology factors, environmental factors, teenagers’ thinking, self-control, commitment, and the level of smartphone use. the instrument used was an on-line questionnaire distributed through social media and then analyzed with partial least squares. the statistical afforded material for focus group discussion followed by 15 teenagers, 15 parents and 5 health workers in order to improve the model. results: the results showed that the level of smartphone use was affected by selfcontrol (t=2.303; p=0.022) and commitment (t=2.967; p=0.003). self-control is influenced by adolescent factors (t=3.065; p=0.002), environmental factors (t=2.934; p=0.004) and teenagers’ thinking (t=2.522; p=0.012), also self-control affects teenagers’ commitment for using smartphones (t=3.953; p=0.000). conclusion: the model formed emphasizes the importance of establishing selfcontrol through adolescent thinking and environment factors so that they can commit to using smartphones safely. article history received: september 2, 2021 accepted: november 14, 2021 keywords addiction; commitment; safety smartphone’s use; teenagers; teenagers’ thinking contact rizki fitryasari  rizki-f-p-k@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: fitryasari, r., tristiana, r., d., & yusuf, a. (2021). teenagers’ safety smartphone use model based on health promotion theory. jurnal ners, 16(2). 148-154. doi: http://dx.doi.org/10.20473/jn.v16i2.29650 introduction the use of smartphones by teenagers in the era of the covid-19 pandemic is a necessity because all teenagers have undertaken on-line learning for school. teenagers use smartphones actively as a means of meeting the needs of interaction with peers and most importantly for online school learning activities (lenhart, 2015). teenagers are required to be able to use smartphones appropriately and wisely so that they do not experience gadget addiction, especially smartphones (cocorada, maican, cazan, & maican, 2018). the number of smartphones in use in the world today is about six billion and is forecast to grow by several hundred million in the pandemic era (o’dea, 2021). in indonesia, 90% of high schools students own and use a smartphone (machmud, 2018; nurhayati, 2021). teenagers in the city of surabaya are detected using smartphones for more than 10 hours per day, which can be grouped into excessive smartphone use. teenagers who use smartphones with high intensity have the potential to refuse activities because they tend to withdraw from social interaction (fitryasari, tristiana, & yusuf, 2020). self-control is the main key so that adolescents do not experience addiction (fauzi, yusuf, & mundakir, 2019). good self-control will determine the right decision-making behavior, because the ability to read the situation and be selective about environmental influences fosters good self-control abilities (bandura, 2002; gufron & riswanita, 2010). adolescents aged 12-25 years are in a transitional phase from childhood to early adulthood and are required to be able to go through an adaptation process to be able to control themselves towards true adulthood (kementerian kesehatan ri, 2015; prawirohardjo & sarwono, 2005). the ability of selfcontrol helps adolescents to filter out various adverse situations and conditions (gufron & riswanita, 2010). smartphone addiction can occur due to an https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v16i2.29650 jurnal ners http://e-journal.unair.ac.id/jners | 149 individual's failure to control himself (sun, liu, & yu, 2018). the ability of adolescents to control the use of smartphones in this study uses the perspective of the health promotion model theory which focuses on the formation of self-control that affects adolescent commitment by conditioning existing thoughts through interpersonal stimulation from the environment, including health workers (murdaugh, parsons, & pender, 2018). the novelty in this model is adding the variables of self-control ability and interpersonal stimulation of health workers so that adolescents are able to form a high commitment to healthy behavior, using smartphones safely. previous studies state that self-control in children and adolescents can be a predictor of the level of smartphone use and prevent addiction (lee, 2015; servidio, 2019; troll, friese, & loscheldera, 2021). this study aims to build a safe smartphone use model for adolescents based on health promotion theory. materials and methods this study used an explanatory research design with a cross sectional approach. the study population was teenage smartphone users in surabaya during the covid-19 pandemic. respondents were obtained through a purposive sampling technique and obtained 185 teenagers as research samples. respondents were selected based on inclusion criteria of teenagers aged 11-18 years, actively using smartphones, and participating in online learning from school. variables include teenager factors, technology factors, environmental factors, teenagers thinking, self-control, commitment, and the level of smartphone use. the research was conducted in two stages. the first stage is a meta-analysis of teenagers’ factors, technological factors (smartphones), environmental factors, teenagers thinking, selfcontrol, commitment, and level of smartphone use. the results of the meta-analysis obtained structural models and strategic issues. the results of the first stage became the material for the second stage of research. focus group discussion (fgd) involving teenagers, parents, and health workers. the data was then compiled to develop a safety smartphone use model for adolescents. the instrument used for the first phase of research is a questionnaire developed by the researcher based on the previous questionnaire and theory. the teenagers factor instrument consists of demographic data (gender and age) and emotional intelligence questionnaire. the emotional intelligence questionnaire adopted from goleman (2003) consists of five indicators: recognizing one's own emotions, managing emotions, motivating oneself, recognizing other people's emotions and building relationships (killian, 2012). technological factors consist of instruments to determine ownership of internet and smartphone-based tools, access to smartphone use and social media. ownership of internet-based devices and smartphones includes indicators of the number of smartphone devices owned, types of devices and types of data packages used to access smartphones. access to smartphone use consists of three indicators, namely the length of smartphone use in one day, the most frequent time to access a smartphone, and the reason for using a smartphone. social media consists of the types of social media that are often accessed and the activities carried out while accessing social media. the technological factor questionnaire was developed from a questionnaire developed by oktario (2017). the environmental factor instrument consisted of a questionnaire about parental and teacher control, demands for schoolwork, peer influence and interpersonal stimulation from health workers. the questionnaire on parental and teacher control was modified from li, li, & newman (2013) which consisted of indicators of attention, restriction and supervision. the school assignment demand questionnaire was developed from alfin (2017) which has been modified and consists of online school material indicators, online assignments, and online exams. the researcher modified the peer influence questionnaire based on the concept of peer function according to santroc (2003). the interpersonal stimulation questionnaire from health workers was compiled from the concept of the role of health workers (potter & perry, 2007). table 1. respondents’ characteristics teenagers characteristics category n(%) school ownership public 134 (72.4) private 51 (27.6) home area (in surabaya) east 83 (44.9) north 16 (81.6) west 45 (24.3) south 11(5.9) central 30 (16.2) school area (in surabaya) east 69 (37.3) north 20 (10.8) west 34 (18.4) south 12 (6.5) central 49 (26.5) school grades 7th 2 (1.1) 8th 4 (2.2) 9th 6 (8.6) 10th 21 (11.4) 11th 121 (65.4) 12th 21 (11.4) table 2. distribution of teenagers’ factor variable category n(%) gender male 125 (67.6) female 60 (32.4) age (years) 13 5 (2.7) 14 12 (6.5) 15 17 (9.2) 16 101 (54.6) 17 34 (18.4) 18 16 (8.5) emotional intelligence low 85 (45.9) high 100 (54.1) r. fitryasari et al. 150 | pissn: 1858-3598  eissn: 2502-5791 the adolescent self-thinking instrument consists of four indicators, consist of benefits, obstacles, beliefs, and the impact of smartphone use on adolescents. this instrument was developed based on the concept of health promotion and a smartphone using a questionnaire (murdaugh et al., 2018; van deursen, bolle, hegner, & kommers, 2015). the adolescent self-control instrument consists of three indicators, namely cognitive control, behavioral control, and decision making modified from the self control model and a smartphone using a questionnaire (li et al., 2013; van deursen et al., 2015). the smartphone use instrument was developed from the smartphone addiction scale instrument according to haug (2015). all questionnaires have been tested for reliability and validity as a pilot sample on 30 respondents. the test results show that the components of the questionnaire are valid and reliable (p>0.73). data collection at the first stage was performed using an online questionnaire via a google form and is distributed through social media. a written explanation of the objectives, benefits and procedures of the research is clearly informed. all respondents who agreed to participate in the study had to obtain parental consent by signing an online informed consent, and consent was confirmed by telephone. the second stage of the research was fgd which involved 15 teenagers, 15 parents and 5 health workers. the fgd was conducted by describing the results of the first phase of the research and discussing the main questions (table 1). analysis of the data obtained in the first stage was analyzed using the partial least square (pls) test. pls is used to analyze the influence between variables which is determined by the t-statistic value (t>1.96), while the direction of influence is determined by the path coefficient (-/+). the result will be used as material (question) for fgd. the data of the fgd were recorded, transcribed, and analyzed using the braun and clarke thematic analysis approach. these stages were understanding the data, generating initial codes, searching for themes, reviewing themes, defining, and naming themes and producing the report. the results were then compiled to develop the models. ethics clearance has been approved and obtained from the ethics committee of the faculty of nursing universitas airlangga with the number: 2018-kepk. results the characteristics of the respondents are described in table 1, the majority of teenagers attend public schools located in east and central surabaya, most are currently studying at the 11th grade (2nd of senior high school) and live in eastern and western surabaya. tables 2, 3 and 4 describe the distribution of research variables. table 2 describes the teenagers’ factors, most of them were male and aged 16 years with varying levels of emotional intelligence from low to high. table 3 details that almost all teenagers have a smartphone-based device, especially mobile phones with monthly data packages used and also home wifi. respondents on average use smartphones for more than 8 hours a day, especially during the noon-day and night. the reasons for using smartphones mostly were to communicate, do schoolwork, access social media, and browse information. the most frequently accessed social media by respondents are whatsapp and instagram. most smartphone usage activities are for browsing and giving comments or likes on social media. table 4 illustrates that the influence of parents, demands for school assignments and table 3. distribution of technology’s factor variable category n(%) smartphone ownership amount 1 134 (72.4) 2 47 (25.4) >2 4 (2.2) device type handphone 184 (99) laptop 49 (26.5) tablet 9 (4.8) data packaged used daily 10 (5.4) weekly 14 (7.5) monthly 98 (52.97) home-wifi 92 (49.7) access smartphone use length of use (hour/day) mean 8.04 sd 5.05 most frequent time morning 37 (2.0) noon 86 (46.5) afternoon 65 (35.1) evening 120 (64.86) midnight 30 (16.2) reason for use school assignment 159 (85.9) browsing 155 (83.7) communication 163 (88.1) social media 159 (85.9) leisure time 141 (76.2) playing game 98 (52.9) business 36 (19.4) self-actualization 19 (10.2) lifestyle 28 (15.1) watching korean movies 1 (0.5) social media access application facebook 21 (11.3) whatsapp 167 (90.3) line 68 (36.7) instagram 160 (86.4) snap-chat 16 (8.6) you tube 133 (71.8) tiktok 22 (11.8) frequent activity status update 53 (28.6 photo upload 28 (15.1 comment/like 112 (60.5 profile update 31 (16.7) browsing 162 (87.5) chatting 9 (4.8) jurnal ners http://e-journal.unair.ac.id/jners | 151 interpersonal stimulation from health workers according to respondents has a high value as an environmental factor in smartphone use, while the influence of teachers has a low value. meanwhile, teenagers’ thinking, which consists of four categories, has almost all high scores related to the benefits, barriers, beliefs, and consequences of using smartphones. teenagers’ self-control variables both cognitively and behaviorally are dominated by high criteria, although there is a small proportion of teenagers’ cognitive control with low scores. meanwhile, the youths’ commitment to decision making in the use of smartphones is high. smartphone users are described in the level of gadget addiction which is described in six indicators with the dominance of low addiction levels in almost all categories, however obtained data shows that the tolerance indicator has a number that needs to be considered because it is classified as a high addiction level. based on table 5, the research hypothesis can be explained. teenagers’ factors have an effect on increasing teenagers thinking (t=3.97; 0.293; p=0.000), increasing self-control (t=3.065; 0.272; p=0.002) and increasing teenagers’ commitment (t=2.244; 0.165; p=0.025), but has no effect on smartphone use (t=0.933; p=0.351). technological factors have an effect on decreasing self-control (t=4.094; -0.248; p=0.000) and increasing the use of smartphones (t=10.331;0.612; p=0.000) however, it has no effect on teenagers’ thinking (t=0.519; p=0.604) and commitment (t=0.25; p=0.803). environmental factors have an effect on increasing thinking (t=3.294; 0.224; p=0.001) and self-control (t=2.934; 0.217; p=0.004), but have no effect on commitment (t=0.940; p=0.348) and smartphone table 4. distribution of environmental factor, teenager’s thinking, self-control, commitment, and smartphone usage variable category (n(%)) low middle high environmental factor parent’s influence 24 (13) 47 (25.4) 114 (61.6) teacher’s influence 89 (48.1) 45 (24.3) 51 (27.6) school assignment demand 4 (2.2) 65(35.1) 116 (62.7) peer’s influence 47 (25.4) 71 (38.4) 67 (36.2) health worker’s interpersonal stimulation 61 (33) 45 (24.3) 79 (42.7) teenager’s thinking advantages 3 (1.6) 182 (98.4) barriers 9 (4.9) 176 95.1) belief 0 (0) 185 (100) effect 4 (2.2) 181(97.8) self-control cognitive 30 (16.2) 81 (43.8) 74 (40) behavior 5 (2.7) 53 (28.6) 127 (68.6) commitment decision-making 6 (3.2) 57 (30.8) 122 (65.9) level of gadget addiction impaired physical activity 55 (29.7) 94 (50.8) 36 (19.5) overuse 87 (47) 68 (36.8) 30 (16.2) withdrawal 92 (49.7) 61 (33) 32 (17.3) anticipatory 113 (61.1) 56 (30.3) 16 (8.6) cyberspace oriented 91 (49.2) 61 (33) 33 (17.8) tolerance 39 (21.1) 81 (43.8) 65 (35.1) table 5. final model of hypothesis test on the development of teenagers’ safety smartphone use model variable path-coefficient t p-value teenager’s factor (x1) → teenager’s thinking (y1) 0.293 3.970 0.000 significant teenager’s factor (x1) → self-control (y2) 0.272 3.065 0.002 significant teenager’s factor (x1) → commitment (y3) 0.165 2.244 0.025 significant teenager’s factor (x1) → smartphone usage (y4) -0.055 0.933 0.351 insignificant technology’s factor (x2) → teenager’s thinking (y1) 0.039 0.519 0.604 insignificant technology’s factor (x2) → self-control (y2) -0.248 4.094 0.000 significant technology’s factor (x2) → commitment (y3) 0.024 0.250 0.803 insignificant technology’s factor (x2) → smartphone usage (y4) 0.612 10.331 0.000 significant environment factor (x3) → teenager’s thinking (y1) 0.224 3.294 0.001 significant environment factor (x3) → self-control (y2) 0.217 2.934 0.004 significant environment factor (x3) → commitment (y3) -0.092 0.940 0.348 insignificant environment factor (x3) → smartphone usage (y4) -0.030 0.476 0.634 insignificant teenager’s thinking (y1) → self-control (y2) 0.218 2.522 0.012 significant teenager’s thinking (y1) → smartphone usage (y4) -0.073 1.114 0.266 insignificant self-control (y2)→ commitment (y3) 0.372 3.953 0.000 significant self-control (y2)→ smartphone usage (y4) -0.183 2.303 0.022 significant commitment (y3 → smartphone usage (y4) -0.201 2.967 0.003 significant r. fitryasari et al. 152 | pissn: 1858-3598  eissn: 2502-5791 use(t). =0.476; p=0.634). teenagers’ thinking has an effect on increasing teenagers’ self-control (t=2.522; 0.218; p=0.012) but has no effect on smartphone use (t=1.114; p=0.266). self-control has an effect on increasing commitment (t=3.953; 0.372; p=0.000) and decreasing smartphone use (t=2.303; -0.183; p=0.022). commitment has an effect on reducing the use of smartphones in teenagers (t = 2.967; -0.201; p = 0.003). the findings can be explained whereby the model emphasizes the importance of establishing self-control through teenagers’ thinking so they can commit to using a smartphone safely. teenagers’ thinking will be formed through controlling environmental factors, especially the influence of peers and interpersonal stimulation from health workers and by optimizing teenagers’ individual factors, especially emotional intelligence. based on figure 1, it can be explained that teenagers’ factors and environmental factors affect the formation of teenagers thinking by 19.3%, and together with technological factors can increase the formation of self-control by 28.8%. meanwhile, teenagers’ commitment is built from teenagers’ factors and self-control of 17.7%. eventually, technology factors, self-control and teenagers’ commitment control the use of smartphones by 52.1% in teenagers during the fgd, it can be concluded that several things that must be developed in this model are: 1) assess teenagers’ factors, technology and the environment, 2) identify the level of teenagers’ thinking, self-control ability and teenagers’ commitment related to smartphone use, 3) provide stimulation to create positive teenagers thinking and self-control in the safe use of smartphones, 4) build a table 6. result of development model of teenagers’ safety smartphone use variable things to develop teenagers’ factor assessing teenager emotional intelligence, especially self-emotional management, selfmotivation in smartphone use technology factor assessing smartphone’s access (availability of devices and internet data packages, length of screen time, types of content and reasons for use) that can be used by teenagers environment factor assessing the important role of peers (content accessed, activity on social media), information provided by health workers and parental control in smartphone use teenagers’ thinking identify level of the teenager’s understanding of the benefits, beliefs, barriers and impacts of smartphone use related to academic and non-academic activities stimulating positive teenager thinking in the safe use of smartphones teenagers’ self-control identify the level of teenager self-control abilities, both cognitive and behavioral in smartphone use stimulating teenager self-control in using smartphones safely commitment identify the teenager’s commitment especially decision making based on usage priorities building a positive commitment of youth in using smartphones safely smartphone’s use identify the frequency of use in one day and the level of dependence of teenagers in smartphone use figure 1. the development of teenagers’ safety smartphone use model jurnal ners http://e-journal.unair.ac.id/jners | 153 positive commitment for using smartphones safely (table 6). discussion the safe use of smartphones in teenagers in was determined by two important variables with a negative relationship, namely teenager self-control and teenager commitment. high self-control and commitment can reduce or limit the use of smartphones in teenagers. self-control as a result of cognitive considerations that are embodied in behavior in achieving certain goals (gufron & riswanita, 2010). teenagers in this study had high self-control in using smartphones with the aim of doing school assignments and communicating with family, friends, and teachers. in addition, teenagers in the fgd process also stated that it is very important to limit the time they use smartphones in one day because they realize that using the device too much can affect their physical condition, such as eyes feeling tired, laziness in doing other activities and being bound to always using a smartphone. understanding the main purpose of using internetbased tools is to form good self-control behaviorally so that teenagers are able to use smartphones without becoming addicted. the results of this study are in line with the results of research on school-age teenagers in south korea, that self-control is related to the level of smartphone addiction (cocorada et al., 2018; sok, 2019; sun et al., 2018). good self-control also fosters teenager’s commitment in making decisions to use smartphones with clear goals. the data also shows that more than 80% of teenagers use smartphones to do schoolwork and search for information on the internet (lenhart, 2015; muflih, hamzah, & purniawan, 2017). data collection was carried out during the covid-19 pandemic, where all teenagers went to school online (using internet-based tools). this situation strongly leads teenagers to use smartphones for the sake of learning at school and not just for the sake of having fun or spending their free time. during the fgd, teenagers said they were committed to being disciplined in limiting the use of smartphones by installing an application that functioned to remind them of the length of time of use, asking parents for help to remind them if they were too active with smartphones, teenagers were also very happy to remind each other not to use a smartphone for too long outside of school activities. self-control in teenagers is influenced by teenagers’ thoughts related to the benefits, barriers, beliefs, and consequences of smartphone use. thought is the beginning of the process of selfregulation. the inability to build self-regulation can lead to the risk of smartphone addiction in teenagers (van deursen et al., 2015). self-regulation helps teenagers to be able to identify the problems they face and determine the selection of appropriate actions in solving problems (alhidayah, 2017; bandura, 2002). teenagers in this study think about the benefits and believe that the use of smartphones is very helpful in completing school assignments, communicating, and interacting virtually with family, friends, and teachers. variations in the internet network that are not smooth are expressed as obstacles experienced and related understanding due to the use of smartphones that are not related to completing school assignments fosters self-regulation skills in the form of self-control in smartphone use. the obstacles faced are one of the triggers for the creativity of smartphone users (chun, 2018). the results also explain that teenagers use smartphones for pleasure, such as interacting through social media, playing games, and filling their spare time, but the thoughts are formed that smartphone use should be used for learning activities which make teens have good selfcontrol and are committed to limiting their time of use of smartphones without having to experience heavy gadget addiction. teenagers’ thinking as the basis for the formation of self-control is influenced by teenager factors and environmental factors. one of the dominant environmental factors is the presence of interpersonal stimuli, in the form of information about the use of smartphones from outside the teenager. the majority of information sources are from parents, internet, schools (school health unit) and health workers who come to school. teenagers are an age who are thirsty for information and getting information from the right sources will help them have the right mindset regarding smartphone use. the findings of this study support the health promotion model theory, that the right input of information on individuals will foster thoughts related to benefits, beliefs, consequences, and obstacles in deciding an action. this study explains that sources of information from parents, schools (uks) and health workers are sources of appropriate and accountable information. during the fgd the youth conveyed that the information they received and was very helpful for teenagers, including how to use smartphones, good content or sites for teenagers to access related to school assignments, seeking entertainment, increasing knowledge, how to limit smartphone use, information about the impact of excessive smartphone use, and how to overcome dependence on smartphone use. teenagers who get the right information will be helped in developing the right thinking. although thinking does not directly make teenagers use smartphones safely, the thoughts help teenagers have good self-control to commit and decide to use smartphones safely and not experience addiction. the limitation of this study was that it only involved teenagers in big cities who have wide and good internet access, so it requires additional respondents in small cities to be more generalized for all teenagers in both big and small cities in indonesia. however, the results of this study have highlighted that good self-control can be one of the factors that prevents smartphone addiction in teenagers. conclusion r. fitryasari et al. 154 | pissn: 1858-3598  eissn: 2502-5791 the model emphasizes the importance of self-control in forming teenagers’ commitment to using smartphones. high self-control is the result of teenager thinking that will be formed through controlling environmental factors, especially the influence of peers and interpersonal stimulation from health workers and by optimizing teenagers’ individual factors, especially emotional intelligence. this model can be the basis for providing guidelines for the safe use of smartphones for teenagers. references alhidayah. (2017). the influence of smartphone use intensity toward social interaction in collage students. jurnal riset, 2(2). bandura, a. (2002). self efficacy : the exercise of control. w. h. freeman & company. chun, j. s. (2018). conceptualizing effective interventions for smartphone addiction among korean female adolescents. children and youth services review, 84(november 2017), 35–39. https://doi.org/10.1016/j.childyouth.2017.11.013 cocorada, e., maican, c. i., cazan, a. m., & maican, m. . (2018). assessing the smartphone addiction risk and its associations with personality traits among adolescents. children and youth services review 93, 345–354. fauzi, m., yusuf, a., & mundakir. (2019). predictive risk factors of smartphone addiction in adolescents: a systematic review. journal ners, 14(3). https://doi.org/http://dx.doi.org/10.20473/jn.v1 4i3.17110 fitryasari, r., tristiana, r. d., & yusuf, a. (2020). teenager ’ s thought is related to self-control in safe smartphone use during the covid-19 pandemic. journal of global pharma technology, 12(9), 280– 286. gufron, m. n., & riswanita, r. (2010). psychology theorys. ar ruzz media. haug, s., castro, r. p., kwon, m., filler, a., kowatsch, t., & schaub, m. p. (2015). smartphone use and smartphone addiction among young people in switzerland. journal of behavioral addictions, 4(4), 299–307. https://doi.org/10.1556/2006.4.2015.037 kementerian kesehatan ri. (2015). rencana strategis kementerian kesehatan ri tahun 2015-2019 (keputusan menteri kesehatan republik indonesia nomor hk.02.02/menkes/52/2015. killian, k. (2012). development and validation of the emotional self-awareness questionnaire: a measure of emotional intelligence. journal of marital and family therapy, 38(3), 502–514. https://doi.org/10.1111/j.17520606.2011.00233.x lee, j. (2015). effects of self-control and school adjustment on smartphone addiction among elementary school students. international journal of contents, 11(3). lenhart, a. (2015). mobile access shifts social media use and other online activities. pew research center: internet, science & tech. li, x., li, d., & newman, j. (2013). parental behavioral and psychological control and problematic internet use among chinese adolescents: the mediating role of self-control. cyberpsychology, behavior, and social networking, 16(6), 442–447. https://doi.org/10.1089/cyber.2012.0293 machmud, k. (2018). the smartphone use in indonesian schools : the high school. journal of arts & humanities, 7(3), 33–40. https://doi.org/10.18533/journal.v7i3.1354 muflih, m., hamzah, h., & purniawan, w. a. (2017). smartphone user and social interaction in senior high school. idea nursing journal, 8(1). murdaugh, c. l., parsons, m. a., & pender, n. j. (2018). health promotion in nursing practice (8th ed.). pearson. nurhayati, h. (2021). number of smartphone users in indonesia from 2017 to 2020 with forecasts until 2026. statista. o’dea, s. (2021). smartphone users worldwide 20162021. statista. oktario, a. (2017). relationship between smartphone use intensity and motivation in collage students. thesis. universitas sanata dharma. potter, p. ., & perry, a. . (2007). fundamental nursing: concepts, process, and practice (6th editio). mosby year book. prawirohardjo, & sarwono. (2005). midwivery science. bina pustaka. servidio, r. (2019). self-control and problematic smartphone use among italian university students: the mediating role of the fear of missing out and of smartphone use patterns. current psychology, 40, 4101–4111. https://doi.org/10.1007/s12144019-00373-z sok, s. r. (2019). differences of self-control , daily life stress , and communication skills between smartphone addiction risk group and general group in korean nursing students. 1–9. sun, j., liu, q., & yu, s. (2018). child neglect, psychological abuse and smartphone addiction among chinese adolescents: the roles of emotional intelligence and coping style. computers in human behavior, 90(september 2017), 74–83. https://doi.org/10.1016/j.chb.2018.08.032 troll, e., friese, m., & loscheldera, d. (2021). how students’ self-control and smartphone-use explain their academic performance. computers in human behavior, 117. https://doi.org/https://doi.org/10.1016/j.chb.20 20.106624 van deursen, a. j. a. m., bolle, c. l., hegner, s. m., & kommers, p. a. m. (2015). modeling habitual and addictive smartphone behavior: the role of smartphone usage types, emotional intelligence, social stress, self-regulation, age, and gender. computers in human behavior, 45, 411–420. https://doi.org/10.1016/j.chb.2014.12.039 548 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, special issue 2020 http://dx.doi.org/10.20473/jn.v15i2(si).20531 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of a combination of group therapy and support on the self-efficacy and deviant behavior of adolescents winda kusumawardani, nursalam nursalam , and hanik endang nihayati faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: the purpose of this study was to investigate the effect of combination therapy and supportive group therapy on the self-efficacy and deviant behavior among adolescents. methods: the design of this study was quasi-experimental (pre-post test with a control group design). the population was based on the inclusion criteria of young men aged 15-19 years old in high school in surabaya and the exclusion criteria was adolescents with physical disabilities, mental disorders and illness. a sample of 62 respondents (31/31) was collected using purposive sampling. the independent variable was a combination of group therapy and supportive therapy. the dependent variable was selfefficacy and deviant behavior. the intervention was given 4 times over 4 weeks and the control group was given a standard intervention. the data was collected using a self-efficacy questionnaire. the analysis was conducted using manova. results: . in the intervention and control groups, there was a significant difference between self efficacy and deviant behavior in the adolescents before and after the intervention with a value of 0,000 (p <0.05). the increase in self-efficacy in the intervention group can be seen from the magnitude of the sub-variables. the deviant behavior variable decreased. conclusion: the increase in the self-efficacy intervention group was due to the presence of facilities that helped the students to find information and explore their potential. the decrease in the deviant behavior variables is due to their increased knowledge and the positive support from their peer groups. article history received: feb 27, 2020 accepted: april 1, 2020 keywords therapeutic group therapy; supportive group therapy; self efficacy;, deviant behavior; adolescents contact nursalam nursalam  nursalam@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: kusumawardani, w., nursalam, n., & nihayati, h. e. (2020). the effect of a combination of group therapy and support on the self-efficacy and deviant behavior of adolescents. jurnal ners, special issues, 548-552. doi: http://dx.doi.org/10.20473/jn.v15i2(si).20531 introduction deviant behavior in adolescents is still a major problem in society (kementerian kesehatan ri, 2013) in the large population of adolescents. around the world, the adolescents total around 1.2 billion or 18% of the world's population (who, 2017). in indonesia, 25% were aged 10-24 years old and in east java, 15.64% of the total population were adolescents (badan pusat statistik, 2014; depkes ri, 2012). it also means that there is an increase in the deviant behavior of adolescents. this deviant behavior includes role confusion, free sex, game addiction, crime, mood disorders, bullying and the use of addictive substances (who, 2018). this can occur because of the low adolescent confidence in their selfability (low self-efficacy) when it comes to completing the tasks and challenges that exist. this means that the individual youths experience apathy and pessimism (cepukiene, pakrosnis, & ulinskaite, 2018). the adolescents are unable to complete the developmental tasks in their appropriate phase. the impact that results is failure in the next phase of development (alligood, 2017). various attempts were made to stimulate the stages of development of adolescents in order to increase their self-efficacy and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 549 to prevent deviant behavior. up until now, there has not been found to be an intervention that explores the character of self-assessing positive aspects, support and the obstacles owned by individuals both internally and externally. group therapy is a therapy conducted for individuals in a group that provides mutual support from the fellow group members during the period of development. the period of recovery strengthens the temporary defenses and integrates with the impaired capacity (keliat & akemat, 2014) by stimulating the 10 aspects of development in adolescents, namely biology, psychosexual, cognitive, language, moral, spiritual, psychosocial, emotional, talent and creativity (fik ui, 2015). group therapy provides effective results when it comes to increasing selfefficacy (bahari, keliat, & gayatri, 2010). there is no previous research that shows that group therapy is effective at preventing deviant behavior so this needs to be combined with other therapies, namely supportive therapy. this is because supportive therapy emphasizes negative coping responses(stuart, 2013) adolescents with negative coping will be easily affected by deviant behavior (stuart & sundeen, 2013). the implementation of supportive combination group therapy in the form of support and educative learning in adolescents consisted of several information-giving sessions with a health promotion model approach (pender, murdaugh, & parsons, 2010). both of these combination therapies stimulate the developmental stages found in adolescents. they also explore the positive aspects of adolescents and the barriers often experienced by adolescents. they then provide solutions and support from their fellow group members and form a commitment (alligood, 2017). the purpose of this study was to analyze the effect of supportive combination group therapy on self-efficacy and deviant behavior. materials and methods research design this study was quantitative research with a quasiexperimental research design (pre-posttest with a control group design) (nursalam, 2017). this research was conducted between november 2019 and january 2020 in surabaya high school. participant recruitment this study involved 62 respondents divided into 2 intervention groups and a control group (31/31) obtained through purposive sampling. the inclusion criteria in this study were 1) adolescent boys willing to become respondents, 2) adolescents aged 14-19 years, 3) adolescents undergoing high school education (high school). meanwhile, the exclusion criteria in this study were 1) adolescents with physical disabilities, 2) adolescents with a mental disorder and 3) adolescents who were sick. data collection the independent variable was group therapy with peer support. the dependent variables were selfefficacy and deviant behavior in adolescents. the intervention group received group therapy as a part of supportive combination therapy while the control group received the standard activities that exist in the school. group supportive combination therapy was given over 4 meetings at a duration of 60-90 minutes for each meeting. this was done once a week for 4 weeks. the data was obtained through a self-efficacy questionnaire and deviant behavior modification questionnaire. ten questions were used to assess adolescent self-efficacy consisting of the subvariables of magnitude, generality and strength. the categories were low self-efficacy = 10-19, moderate self-efficacy = 20-29 and high self-efficacy = 30-40. for the deviant behavior questionnaire, there were 20 questions for each sub-variable of deviant behavior: physical victims, material casualties, social deviant behavior and behavior against status. the categories were mild deviant behavior = 20-49, moderate deviant behavior = 50-79 and severe deviant behavior 80-100. this instrument was tested for validity on 7 adolescents in a surabaya high school. each item in the question had a validity of (r> 0.754), so the instrument or question items correlate significantly to the total score (declared to be valid). the reliability test used cronbach's alpha with a selfefficacy value 0.913> α and a deviant behavior value 0.947> α . this suggests that all items are reliable and that all of the tests consistently have strong reliability. the demographic data includes gender, age, specialization, living together and the activities that the adolescents participate in. descriptive analysis was used to examine the respondent’s characteristics. the analysis of influence was done using the wilcoxon sign rank test, paired t-test and the mannwhitney test. the analysis of the relationship of the two variables related to group therapy in combination with support was analyzed using manova. this research protocol has been declared to have passed an ethical test conducted by the health research ethics commission of the faculty of nursing, airlangga university, with ethical certificate number 1812-kepk issued on 31st october 2019. results the descriptive statistical analysis of the respondent's characteristics has been shown in table 1. this study involved 62 male adolescents from a surabaya high school divided into the intervention and control groups. the descriptive statistical analysis of the self-efficacy and deviant behavior among adolescents has been shown in table 2. table 3 indicates the analysis of the relationship of the two variables with the group therapy and combination supportive for each group. table 1 shows that in the intervention and control groups, 62 people (100%) were male and the highest w. kusumawardani et al. 550 | pissn: 1858-3598  eissn: 2502-5791 age range distribution was for the 15-17 year old range, totaling 57 people (88.7%). regarding specialization, the science class had the highest number of students at 37 people (59.7%). on average, the teenagers lived together with their parents (62.9%), totaling 37 teenagers. however, not all had a complete set of parents. there were orphans and teenagers from broken homes. the number of teenagers who participated in the activity totaled 35 people (56.5%), and most of them were attending a sports club. table 2 shows that the intervention group obtained a mean value for the self-efficacy pre-test of 21.23 ± 3.106.after the group therapy support and combination therapy was conducted for 4 weeks, the mean value of the self-efficacy post-test was 31.71 ± 4.368 in the intervention group. the delta value of 10.48 was obtained. the wilcoxon test results in the intervention group showed that there were significant differences in the self-efficacy before and after the group therapy supportive combination with a value of 0,000 (p <0.05). table 5.7 shows that after testing the data analysis using the mann whitney test, a p value of 0,000 was obtained. this means there was a difference in the post-self efficacy values between the two treatment groups and the control group. the intervention group obtained the result indicating that the mean value of the pre-test for deviant behavior was 48.94 ± 8,095. after conducting the group therapy supportive combination for 4 weeks, the mean value of the self-efficacy post-test was 38.61 ± 10.016 in the intervention group. this obtained a delta value of -10.33. the paired t-test results in the intervention group showed that there were significant differences between the deviant behavior before and after the group therapy in supportive combination with a value of 0,000 (p <0.05). table 5.8 shows that after testing the data analysis using the mann-whitney test, a p value of 0,000 was obtained. this means that there were differences in the post-deviant behavior values between the 2 treatment groups and the control group. table 3 shows that testing the variancecovariance similarity individually for each variable shows the value of the box test. the result was table 1. characteristics of the respondents (n=62) characteristics group total % inter control n % n % age 11-14 15-17 18-20 1 29 1 3.2 93.5 1.6 2 28 3 6.5 83.9 9.7 3 57 4 4.8 88.7 6.5 gender male female 31 0 100 0 31 0 100 0 62 0 100 0 adolecent activity joined adolecent activities never joined adolecent activities 20 11 64.5 35.5 15 16 48.4 51,6 35 27 56.5 43.5 caregiver parents sibling self 18 10 3 58.1 32.3 9.7 21 8 2 67.7 25.8 6.5 39 18 5 62.9 29 8.1 specialization ipa ips 19 12 61.3 38.7 18 13 58.1 41.9 37 25 59.7 40.3 table 2. pre and posttest results in the intervention and control groups variable group pre-test (mean ±sd) post-test (mean ±sd) delta p value self-efficacy intervention 21.23 ± 3.106 31.71±4.368 10.48 0,000 control 22.81 ± 5.069 22.97 ±4.950 0,1 0.665 p-value mann whitney 0,298 0,000 deviant behavior intervention 48.94 ± 8.095 38.61 ±10.016 -10,33 0.000 control 54.10 ± 9.981 54.29 ±9.459 0,19 0,314 p value mann-whitney 0,047 0,000 table 3. results of a multivariate analysis of self-efficacy and deviant behavior variable group sd box test levine test manova partial eta squared information self-efficacy intervention 4,368 0,875 0,378 0,000 0,475 significant control 4,950 significant deviant behavior intervention 10,016 0,997 0,000 0,401 significant control 9,459 significant jurnal ners http://e-journal.unair.ac.id/jners | 551 significant. the box test value was 0.875. this means that the variance-covariance of all of the variables was the same for each group. assuming that the similarity of the variance-covariance matrix has been fulfilled, the manova analysis process can proceed. the hypothesis test shows the significance figures for the intervention group and the control group as tested by the pillai trace, wilks lamda, hotteling t and roys lagest root procedures. the result was <0.05. the p-value has a significant value. this means that the hypothesis test is accepted, that is, there is a simultaneously effect from the group therapy in a supportive combination on the self-efficacy and deviant behavior of adolescents. the results of the statistical tests found that all of the variables of self-efficacy and deviant behavior in the intervention and control groups had a significant influence on the group therapy supportive combination (p <0.05). discussion the administration of a combination of group therapy and peer support increases self-efficacy and reduces the deviant behavior of adolescents. the assessment related to the increase in adolescent selfefficacy can be seen from the sub variable magnitude (individuals can perform different tasks by sharing the level of difficulty), generality (the mastery of individuals in the occupied field) and strength (trying to achieve their goals) (cepukiene et al., 2018). the increased self-efficacy of adolescents is caused by a combination of the supportive group therapy and shared learning methods, discussions, educational games and support groups. these collectively influence a person's behavioral skills when taking action for themselves (chang, yuan, & chen, 2018; yendork & somhlaba, 2015). these results are in line with the research which states that the combination of therapeutic and supportive group therapy given once a week for 4 weeks affects the adolescent’s selfconfidence when presenting ideas and completing challenges that can help the teens have confidence in their potential (lavik, veseth, frøysa, binder, & moltu, 2018). the deviant behavior carried out by the respondents is in line with the definition given by the indonesian ministry of health. this includes role confusion, depression, free sex, game addiction, crime, mood disorders, intimidation and the use of addictive substances (kementrian kesehatan, 2014). the respondents' changes can be seen in the subvariables off deviant behavior that cause physical or psychological harm to others. this is in addition to material casualties, socially deviant behavior and status challenges (hockenberry & wilson, 2018),(prasetya, 2018). the decrease in the deviant behavior of adolescents is due to their active participation in group therapy activities combined with supportive group therapy that includes biological, psychosexual, moral, spiritual, cognitive, language, psychosocial, emotional, emotional and talent stimulation. it explores the aspects of internal support and the obstacles that are external to the adolescents (bluth & eisenlohr-moul, 2017). forming a supportive and positive environment can have a significant influence when it comes to reducing the deviant behavior of adolescents. for the adolescents who undergo standard school activities, they do not experience changes in their selfefficacy and deviant behavior. the results of this study prove that a supportive combination of group therapy affects self-efficacy and deviant behavior. both of these combination therapies stimulate the stages of adolescent development and explore the positive aspects of human fibrous adolescents that are safe both internally and externally [19], [25]. this can improve their self-efficacy and lessen the deviant behavior of adolescents. conclusion the conclusion of this study is that the combination of group therapy and support is an effective, easy and fun educational therapy that is proven to improve self-efficacy and prevent deviant behavior in adolescents. contributing to the improvement of health education for adolescents, it is hoped that the adolescents can read the guidelines and learn to stimulate their personal development. references alligood, m. r. (2017). pakar teori keperawatan dan karya mereka, edisi indonesia ke-8 volume 2 (8th ed.; a. y. s. hamid & k. ibrahim, eds.). indonesia: mosby elsevier. badan pusat statistik. (2014). statistik pemuda indonesia. https://doi.org/bps:4103008 bahari, k., keliat, b. a., & gayatri, d. (2010). pengaruh terapi kelompok terapeutik terhadap perkembangan identitas remaja di kota malang. bluth, k., & eisenlohr-moul, t. a. (2017). response to a mindful self-compassion intervention in teens: a within-person association of mindfulness, selfcompassion, and emotional well-being outcomes. journal of adolescence, 57, 108–118. https://doi.org/10.1016/j.adolescence.2017.04. 001 cepukiene, v., pakrosnis, r., & ulinskaite, g. (2018). outcome of the solution-focused self-e ffi cacy enhancement group intervention for adolescents in foster care setting. children and youth services review, 88(march), 81–87. https://doi.org/10.1016/j.childyouth.2018.03.0 04 chang, c., yuan, r., & chen, j. (2018). children and youth services review social support and depression among chinese adolescents : the mediating roles of self-esteem and self-e ffi cacy. children and youth services review, 88(march), 128–134. https://doi.org/10.1016/j.childyouth.2018.03.0 01 w. kusumawardani et al. 552 | pissn: 1858-3598  eissn: 2502-5791 depkes ri. (2012). infodating reproduksi remaja. jakarta: kementrian kesehatan ri. fik ui. (2015). modul terapi keperawatan jiwa. mental health nursing, 437–438. hasanah, u. (2017). pengaruh terapi kelompok terapeutik remaja dan akademi keperawatan dharma wacana metro email : emailnyauus@gmail.com. 9(1). hockenberry, m. j., & wilson, d. (2018). wong’s nursing care of infants and children-e-book. elsevier health sciences. keliat, b. a., & akemat. (2014). keperawatan jiwa: terapi aktivitas kelompok. in cetakan 2016, (2nd ed.). jakarta: egc. kementerian kesehatan ri. (2013). menkes: remaja indonesia harus sehat. kementrian kesehatan, r. (2014). pedoman standar nasional pelayanan kesehatan peduli remaja (pkpr). lavik, k. o., veseth, m., frøysa, h., binder, p. e., & moltu, c. (2018). ‘nobody else can lead your life’: what adolescents need from psychotherapists in change processes. counselling and psychotherapy research, 18(3), 262–273. https://doi.org/10.1002/capr.12166 nursalam. (2017). metodologi penelitian ilmu keperawatan pendekatan praktis (edisi 4; p. p. lestasi, ed.). jakarta: salemba medika. pender, n. j., murdaugh, c. l., & parsons, m. a. (2010). health promotion in nursing practice. 6th prentice hall. in upper saddle river, nj. pearson. prasetya, g. (2018). perilaku menyimpang kaum santri pondok pesantren nurul ummahat kotagede yogyakarta. 信阳师范学院, 10(2), 1– 15. stuart, g. w. (2013). principle and practice of psychiatric nursing, 10th edition. in st. louis. canada: mosby elsevier. stuart, g. w., & sundeen, s. j. (2013). buku saku ilmu keperawatan jiwa (5th ed.). jakarta: egc. who. (2017). leaving no adolescent behind in health and development in indonesia. in 5 september 2017. who. (2018). reaching every adolescent: regional workshop on strengthening gender, equity, rights and social determinants of health. widianti, e., keperawatan, f. i., magister, p., & keperawatan, i. (2011). pengaruh terapi logo dan terapi suportif kelompok terhadap ansietas remaja di rumah tahanan lembaga pemasyarakatan wilayah provinsi jawa barat. miscellaneous. yendork, j. s., & somhlaba, n. z. (2015). problems , coping , and efficacy : an exploration of subjective distress in orphans placed in ghanaian orphanages problems , coping , and efficacy : an exploration of subjective distress in orphans placed in ghanaian orphanages. 5024(april 2016). https://doi.org/10.1080/15325024.2014.94916 0 300 intervensi keperawatan truncal control exercise terhadap fungsi ekstremitas atas, keseimbangan, dan berjalan pada klien pascastroke (nursing intevention truncal control excercise of the functional capabilities of the upper limb, balance and walk clients post stroke) kusnanto * ganda ardiansyah * harmayetty * fakultas keperawatan universitas airlangga email: ganz.301285@gmail.cm abstrak: pendahuluan: klien pascastroke akan mengalami gangguan postural tubuh yang dapat mempengaruhi keseimbangan, kemampuan berjalan dan fungsi ekstremitas atas. truncal control exercise memperbaiki dan memelihara postural tubuh yang baik. rehabilitasi pascastroke masih berfokus pada latihan tungkai atas dan bawah hemiplegia dibandingkan perbaikan postural tubuh. metode: jenis penelitian menggunakan quasy eksperimental dengan desain control group pretest – postest. besar sampel didapatkan dengan tehnik consequetive sampling terdiri dari 20 responden (n-perlakuan = 10 dan n-kontrol = 10). variabel independen adalah truncal control exercise. variabel dependen adalah fungsi ekstremitas atas, keseimbangan, dan berjalan. data dikumpulkan dengan menggunakan lembar observasi dan ceklist. analisa data menggunakan independent t-test dan paired t-test dengan α = 0,05. hasil: hasil uji statistik kelompok perlakuan dan kontrol didapatkan p-value kemampuan fungsional ekstremitas atas = 0,270 dan p-value performance fungsi ekstremitas atas = 0,289. hasil uji statistik kelompok perlakuan dan kontrol didapatkan p-value keseimbangan = 0,017. hasil uji statistik kelompok perlakuan dan kontrol didapatkan p-value berjalan = 0,026. diskusi: intervensi keperawatan truncal control exercise kurang efektif terhadap perubahan fungsi ekstremitas atas, tetapi efektif terhadap keseimbangan dan berjalan klien pascastroke. intervensi keperawatan truncal control exercise dapat dilanjutkan sebagai bentuk tindakan kolaboratif bagi perawat medikal bedah dengan fisioterapi untuk mengoptimalkan program rehabilitasi klien pascastroke dengan masalah keseimbangan dan berjalan di klinik maupun rumah klien. kata kunci : truncal control exercise, fungsi ekstremitas atas, keseimbangan, berjalan. abstract introduction: poststroke clients will have impaired postural body that can have affect to their balance, ability to gait and function of the upper limb. truncal control exercise can improve and maintain body postural be good. rehabilitation poststroke still focusing on upper and lower limbs exercise of hemiplegia compared postural body’s repair. methods: this type of research used experimental with quasy control group pretest – postest design. the number of samples obtained with consecutive sampling techniques that appropriate criteria research consists of 20 respondents (n = 10 treatment-and n-control = 10). the independent variable is the truncal control exercise. the dependent variable is the function of the upper limb, balance, and gait. data were collected by using observation and checklist sheets. data were analyzed using independent t-test and paired t-test with α = 0,05. results: the results of statistical tests performed in the treatment group and the control was obtained p-value of the functional capabilities of the upper limb = 0.270 and p-value of performance of upper limb function = 0.289. the results of statistical tests performed in the treatment group and the control was obtained p-value of balance = 0.017. the results of statistical tests performed in the treatment group and the control was obtained p-value of gait = 0.026. discussion: nursing interventions truncal control exercise have less effective results to changes in upper limb function, but it is effective to balance and walk clients pascastroke. nursing interventions truncal control exercise can be continued as a form of collaborative action for medical-surgical nurse with physiotherapy to optimize rehabilitation programs of posstroke clients with balance and gait problems in clinic or home’s client. keywords : truncal control exercise, upper limb function, balance, gait _______________________________________________________________________________________________ pendahuluan stroke merupakan penyebab kelumpuhan nomor satu dan penyebab kematian nomor tiga setelah penyakit jantung koroner dan penyakit kanker (feigin et al. 2009). kelumpuhan fisik pasca stroke disebabkan oleh gangguan postural tubuh yang dapat mempengaruhi keseimbangan, kemampuan berjalan dan meningkatkan risiko jatuh klien serta gangguan aktivitas fungsional sehari-hari yang terkait dengan peran vital fungsi ekstremitas atas. (weerdesteyn et al. 2008; saeys et al. 2012; aprile et al. 2006; wee et al. 2015). truncal control exercise memperbaiki dan memelihara postural tubuh yang baik dalam melakukan gerak serta menjadi dasar untuk semua gerakan pada lengan dan tungkai. rehabilitasi pasca stroke masih berfokus pada latihan tungkai atas dan jurnal ners vol. 11 no. 2 oktober 2016: 300-310 301 bawah hemiplegia dibandingkan perbaikan postural tubuh (karthikbabu et al. 2011; irfan 2012). who (2010), ditemukan dari 10 juta klien stroke menunjukkan bahwa sebanyak 5 juta orang mengalami kematian dan 5 juta orang lainnya mengalami kelumpuhan fisik yang permanen pasca stroke (mozaffarian et al. 2015). hasil penelitian didapatkan bahwa di antara 160 responden, 53 responden (33%) dilaporkan mengalami jatuh selama periode 1 tahun pasca stroke dan dari 53 klien, 37 klien (70%) terjatuh di rumah, dengan usia rata–rata klien adalah 71 tahun. (schmid et al. 2013). laporan riskesdas tahun 2007 didapatkan bahwa kelumpuhan fisik berdasarkan penyakit yang diderita menunjukkan peningkatan dari 3896 klien stroke, 1622 klien mengalami kelumpuhan fisik permanen dengan prevalensi klien stroke di indonesia yang meningkat dari 8,3 per 1000 penduduk menjadi 12,1 per 1000 penduduk pada hasil laporan riskesdas 2013 (depkes ri 2008; depkes ri 2014). gangguan keseimbangan, kelemahan otot dan penurunan fleksibilitas jaringan lunak pada klien stroke disebabkan gangguan fungsi serebellum-vestibular dan lesi sel saraf upper motor neuron yang terjadi saat serangan stroke yang berdampak kelemahan fungsi gerak pada seluruh ekstremitas, kedua ekstremitas atau sebagian ekstremitas (smeltzer et al. 2010; ganong 2013). keterlambatan aktifitas otot dan pembentukan gerakan pada ekstremitas atas-bawah mempengaruhi stabilitas tubuh dalam merespon keseimbangan yang menyebabkan klien pasca stroke mengalami gangguan postural hingga klien dapat terjatuh saat memulai gerakan berdiri dan berjalan serta gangguan aktivitas fungsional sehari-hari akibat penurunan kemampuan fungsi ekstremitas atas klien (irfan 2012; saeys et al. 2012; wee et al. 2015). kemampuan kontrol postural dibutuhkan dalam seluruh aspek gerakan fungsional tubuh dan terkait dengan peran dasar dalam keseimbangan postur sehingga gerak ekstremitas atas-bawah menjadi terkontrol dan efisien (lalonde & strazielle 2007; karthikbabu et al. 2011). otot–otot trunk memegang peran yang terintegrasi dalam stabilisasi postur tubuh. mobilitas gerak ekstremitas hanya dapat dilakukan dengan stabilitas postur tubuh yang memadai (irfan 2012; saeys et al. 2012). pendekatan the mauk model of poststroke recovery diharapkan menjadi ruang bagi keperawatan untuk mengakomodasi bentuk intervensi keperawatan truncal control exercise terhadap fungsi ekstremitas pada klien pasca stroke. bahan dan metode jenis penelitian menggunakan quasy eksperimental dengan desain control group pretest – postest. kelompok perlakuan dilakukan intervensi keperawatan truncal control exercise dan kelompok kontrol dilakukan intervensi sesuai dengan program rumah sakit. pada kedua kelompok diawali dengan pre test dan setelah dilakukan intervensi diadakan post test. populasi penelitian adalah klien stroke infark yang dirawat di ruang soka rsud nganjuk pada bulan 23 mei – 16 juli 2016. besar sampel didapatkan dengan tehnik consequetive sampling yang sesuai kriteria penelitian terdiri dari 20 responden (n-perlakuan = 10 dan nkontrol = 10). kriteria penelitian adalah kriteria inklusi yang digunakan dalam penelitian ini adalah sebagai berikut : klien pasca stroke infark (≥72 jam pasca serangan stroke), mempunyai riwayat serangan pertama, berusia 45 60 tahun, mengalami hemiparese (ekstremitas atas dan bawah), mempunyai tekanan darah sistolik ≤ 140 mmhg (untuk klien tanpa riwayat gagal ginjal kronik) dari hasil observasi 24 jam terakhir selama 4 kali pengukuran tekanan darah. klien pasca stroke dengan nilai/skor screening : derajat kecacatan stroke 1-3, streamlined wolf motor function test ≥ 6, berg balance scale test ≥ 14, dan tinetti test ≥ 0. variabel independen adalah truncal control exercise. variabel dependen adalah fungsi ekstremitas atas, keseimbangan, dan berjalan. data dikumpulkan dengan menggunakan lembar observasi dan ceklist dari the streamlined wolf motor function (fungsi ekstremitas atas), berg balance scale test (keseimbangan), dan tinetti testsubsection gait (berjalan). analisa data deskriptif untuk mengetahui distribusi frekuensi meliputi mean, sd, uji normalitas, dan uji homogenitas dari fungsi ekstremitas atas, keseimbangan, dan berjalan pada kelompok perlakuan dan kontrol. analisa inferensial untuk distribusi data normal menggunakan independent t-test dan paired ttest dengan α = 0,05. analisa inferensial untuk intervensi keperraatan truncal control exercise (kusnanto, dkk) 302 distribusi data tidak normal menggunakan mann-whitney test dan wilcoxon test dengan α = 0,05. hasil penelitian pada tabel 1 terlihat bahwa pada kelompok perlakuan sebelum dilakukan truncal control exercise, 6 orang klien pascastroke mempunyai nilai kemampuan fungsional ekstremitas atas dibawah sama dengan 12 (60%) dan rerata nilai 11,20. sesudah dilakukan truncal control exercise selama 24 hari, nilai kemampuan fungsional ektremitas atas menunjukkan peningkatan . responden yang mengalami peningkatan nilai kemampuan fungsional ekstremitas atas sesudah dilakukan intervensi berada diatas nilai 12, yaitu sebanyak 8 orang (80%) dengan rerata nilai 14,40. hasil berbeda ditunjukkan kelompok kontrol. pada kelompok kontrol sebelum dilakukan intervensi sesuai standar rumah sakit, 6 orang klien pascastroke juga mempunyai nilai kemampuan fungsional ekstremitas atas dibawah sama dengan 12 (60%) dan rerata nilai 11,00. sesudah klien pascastroke menjalani intervensi sesuai dengan standar rumah sakit, nilai kemampuan fungsional ekstremitas atas kelompok kontrol juga mengalami peningkatan. klien pascastroke yang mengalami peningkatan nilai kemampuan fungsional ekstremitas atas sesudah dilakukan intervensi sesuai standar rumah sakit berada diatas nilai 12, yaitu hanya 5 orang (50%) dengan rerata nilai 13,50. hasil analisis pada tabel 1 menunjukkan bahwa hasil uji analisis perbedaan selisih kemampuan fungsional ekstremitas atas sesudah intervensi antara kelompok perlakuan dan kontrol, didapatkan p-value = 0,270 yang berarti tidak terdapat perbedaan perubahan kemampuan fungsional ekstremitas atas antara kelompok perlakuan dan kontrol. pada tabel 2 terlihat bahwa pada kelompok perlakuan sebelum dilakukan intervensi truncal control exercise, 5 orang mempunyai waktu performance fungsi ekstremitas atas kurang dari sama dengan 9 detik dan rerata waktu 8,98 detik. sesudah dilakukan truncal control exercise selama 24 hari, 6 orang mempunyai waktu performance fungsi ekstremitas atas kurang dari sama dengan 9 detik dan rerata waktu 8,52 detik. pada kelompok kontrol sebelum dilakukan intervensi sesuai standar sumah sakit, 10 orang mempunyai waktu performance fungsi ekstremitas atas diatas 9 detik dengan rerata waktu 9,99 detik. sesudah dilakukan intervensi sesuai dengan standar rumah sakit, 3 orang mempunyai waktu performance fungsi ekstremitas atas kurang dari sama dengan 9 detik dengan rerata waktu 9,73 detik jurnal ners vol. 11 no. 2 oktober 2016: 300-310 303 hasil analisis ditunjukkan pada tabel 2 yang menunjukkan bahwa hasil uji analisis perbedaan selisih rerata waktu performance fungsi ekstremitas atas sebelum dan sesudah intervensi antara kelompok perlakuan dan kontrol, didapatkan nilai p = 0,289. hasil nilai p > 0,05 berarti tidak terdapat perbedaan selisih rerata waktu performance fungsi ekstremitas atas antara kelompok perlakuan dan kontrol. pada tabel 3 terlihat bahwa sebelum dilakukan intervensi truncal control exercise, kelompok perlakuan didapatkan 5 orang mempunyai nilai keseimbangan dibawah dari sama dengan 30 dan nilai rerata keseimbangan adalah 25,50. sesudah dilakukan intervensi truncal control exercise selama 24 hari, didapatkan bahwa 9 orang kelompok perlakuan mempunyai nilai keseimbangan diatas 30 dengan rerata nilai sebesar 37,60. hasil kelompok kontrol sebelum dilakukan intervensi sesuai standar rumah sakit, 8 orang mempunyai nilai keseimbangan dibawah sama dengan 30 dan rerata nilai keseimbangan sebesar 23,50. sesudah dilakukan intervensi, didapatkan bahwa 7 orang kelompok kontrol mempunyai nilai keseimbangan diatas 30 dengan rerata nilai sebesar 33,70. hasil analisis ditunjukkan pada tabel 3 yang menunjukkan bahwa hasil uji analisis perbedaan rerata selisih nilai keseimbangan setelah intervensi antara kelompok perlakuan dan kontrol dengan menggunakan independent t-test didapatkan nilai p = 0,017 yang berarti terdapat perbedaan perubahan keseimbangan antara kelompok perlakuan dan kontrol. pada tabel 4 terlihat bahwa sebelum dilakukan intervensi truncal control exercise, kelompok perlakuan didapatkan 7 orang mempunyai nilai kemampuan berjalan dibawah sama dengan 8 dan nilai rerata kemampuan berjalan adalah 7,90. sesudah dilakukan intervensi truncal control exercise selama 24 intervensi keperraatan truncal control exercise (kusnanto, dkk) 304 hari, didapatkan bahwa 8 orang kelompok perlakuan mempunyai nilai kemampuan berjalan diatas 8 dengan rerata nilai sebesar 10,20. hasil kelompok kontrol sebelum dilakukan intervensi sesuai standar rumah sakit, 10 orang mempunyai nilai kemampuan berjalan dibawah dari sama dengan 8 dan rerata nilai keseimbangan sebesar 7,00. sesudah dilakukan intervensi, didapatkan bahwa 4 orang kelompok kontrol mempunyai nilai kemampuan berjalan diatas 8 dengan rerata nilai sebesar 8,60. hasil analisis ditunjukkan pada tabel 4 yang menunjukkan bahwa hasil uji analisis perbedaan rerata selisih nilai kemampuan berjalan setelah intervensi antara kelompok perlakuan dan kontrol dengan menggunakan uji mann-whitney didapatkan nilai p = 0,026 yang berarti terdapat perbedaan perubahan kemampuan berjalan antara kelompok perlakuan dan kontrol. pembahasan hasil penelitian sebelum dilakukan intervensi truncal control exercise pada kelompok perlakuan menunjukkan bahwa hampir seluruh responden bisa melakukan tugas yang diberikan antara lain meletakkan tangan ke meja dan meletakkan tangan ke box dengan gerakan perlahan, tetapi untuk tugas meraih dan mengambil ke depan, mengangkat kaleng serta mengangkat pensil, sebagian besar responden melakukan gerakan masih dipengaruhi sinergi derajat pada siku lengan yang lemah dan gerakan dilakukan secara perlahan. tugas dari penilaian swmft yang sulit dilakukan responden adalah melipat handuk, yang ditunjukkan dari 10 orang kelompok perlakuan saat melipat handuk menggunakan lengan yang lemah masih membutuhkan bantuan lengan yang sehat untuk sedikit menyesuaikan diri atau merubah posisi. kondisi yang sama juga terlihat pada kelompok kontrol. hasil sesudah dilakukan intervensi keperawatan truncal control exercise didapatkan bahwa sebagian besar klien pascastroke saat melakukan tugas yang diberikan sudah mampu melakukan gerakan secara normal, tetapi masih sedikit lambat dan koordinasi motorik halus kurang stabil, seperti meletakkan tangan ke meja, meletakkan tangan ke box, meraih – mengambil ke depan, mengangkat kaleng dan mengangkat pensil. sedangkan untuk tugas melipat handuk, hampir seluruh klien pascastroke dapat melakukan meski dengan gerakan yang perlahan. penelitian yang terkait langsung antara pengaruh intervensi truncal control exercise dengan fungsi ekstremitas atas pada klien pascatroke memang belum ditemukan peneliti. hasil penelitian yang ditemukan peneliti hanya terkait penguatan kontrol otot trunk dengan pemberian restrain dalam peningkatan fungsi ekstremitas atas, yaitu penelitian yang dilakukan wee et al. (2015) dengan desain cross sectional study, didapatkan bahwa klien pascastroke dengan hemiplegia yang jurnal ners vol. 11 no. 2 oktober 2016: 300-310 305 mendapatkan penguatan terhadap kontrol trunk, melalui pengukuran the streamlined wolf motor function test dtemukan terjadi penurunan waktu performance sebesar 1,83 detik dan peningkatan kemampuan fungsional ekstremitas atas sebesar 0,1 poin (wee et al., 2015). hasil penelitian ini menunjukkan bahwa setengah klien pascastroke mempunyai manifestasi klinis yang sama yaitu hemiparesis kanan-kiri atas-bawah. hemiparesis terjadi karena disfungsi upper motor neuron dalam korteks serebri, substansia alba subkortikal, kapsula interna, batang otak, atau medula spinalis dan lower motor neuron dalam nukleus motorik pada batang otak dan kornu anterior medula spinalis saat serangan stroke iskemik akut terjadi (kowalak et al., 2011). secara teori, truncal control exercise dapat memperkuat otot-otot trunk yang akan melatarbelakangi stabilisasi otot inti dari tubuh sehingga dapat meningkatkan pergerakan segmen proksimal dan distal dari ekstremitas atas (gjelsvik 2014; wee et al., 2015). latihan stabilisasi otot trunk didapatkan memiliki efek pada stabilisasi bahu yang diikuti peningkatan gerakan siku, pergelangan tangan dan jari. trunk yang stabil memberikan dasar yang kuat untuk gerakan awal yang dihasilkan ekstremitas atas (kim et al., 2011; bae et al., 2013; miyake et al., 2013) stabilisasi postural tubuh akan meningkatkan kinerja otot-otot inti salah satunya yaitu kontraksi intra abdominal pressure pada otot abdominalis, didukung oleh stabilisasi bahu yang meningkat saat truncal control exercise akan mendukung inisiasi proses impuls motorik untuk melakukan gerakan yang lebih stabil sehingga dapat meningkatkan pergerakan siku, pergelangan tangan dan jari-jari untuk perbaikan fungsi ekstremitas atas. hasil uji statistik tidak menunjukkan perbedaan secara bermakna dan belum ada penelitian yang terkait secara langsung antara intervensi keperawatan truncal control exercise dan fungsi ekstremitas atas dengan menggunakan desain penelitian randomized control trial. kesimpulan hipotesis pertama adalah intervensi keperawatan truncal control exercise tidak berpengaruh terhadap fungsi ekstremitas atas pada klien pascastroke. opini dalam penelitian ini didukung teori mekanisme pemulihan stroke melalui kortikospinal lateral yang mengungkapkan bahwa traktus kortikospinal merupakan jalur saraf utama yang memperantarai pergerakan terampil volunter. terdapat dua jalur traktus kortikospinal yang terpisah. bagian yang terbesar melintasi traktus kortikospinal lateral yang terbentuk sebanyak 75-90% dan serat kortikospinal melintasi pada medula menyebabkan fungsi utama pada kortikospinal lateral untuk mengontrol perototan (musculature) pada bagian distal mempengaruhi pergerakan motorik halus pada klien pascastroke (jang 2007; takeuchi & izumi 2013). kelemahan ekstremitas atas klien pascastroke terjadi pada 70-80% dan dapat terus menetap pada 4% klien. pemulihan ekstremitas atas yang mengalami kelemahan terjadi dalam tiga bulan pertama setelah mengalami serangan stroke (rabadi et al., 2008). hasil penelitian setelah dilakukan intervensi keperawatan truncal control exercise menunjukkan bahwa terdapat perbedaan secara bermakna rerata selisih nilai keseimbangan antara kelompok perlakuan dan kontrol. hasil observasi penilaian dengan berg balance scale test sebelum intervensi didapatkan bahwa sebagian klien pascastroke pada kelompok perlakuan dan kelompok kontrol masih mampu melakukan semua prosedur tugas dari item bbs dengan nilai skor 2 yaitu membutuhkan bantuan minimal dan waktu yang terbatas. pada hasil observasi penilaian bbs pada kelompok perlakuan didapatkan data bahwa sesudah dilakukan intervensi truncal control exercise ada 4 orang mendapatkan nilai maksimal dengan mampu mandiri dan stabil melakukan item prosedur berg balance scale test yaitu duduk tak tersangga dengan tangan melipat selama 2 menit dan hampir seluruh klien pascastroke mendapatkan nilai skor 3 dari setiap item prosedur berg balance scale test, yang berarti mampu melakukan item prosedur secara stabil dan mandiri dengan pengawasan dan alat bantu. hasil observasi penilaian bbs kelompok kontrol didapatkan data bahwa sesudah dilakukan intervensi sesuai program rumah sakit, hampir seluruh klien pascastroke masih berada pada nilai skor 2 untuk penilaian item berg balance scale test, yang berarti masih membutuhkan bantuan minimal dan waktu yang berbatas dalam menyelesaikan item prosedur. hasil penelitian ini sejalan dengan penelitian randomized control trial yang intervensi keperraatan truncal control exercise (kusnanto, dkk) 306 dilakukan oleh saeys et al. (2012) pada 33 orang klien yang mengalami hemiparesis menunjukkan bahwa truncal exercise secara bermakna dapat meningkatkan keseimbangan berdiri klien pascastroke (saeys et al., 2012). hasil penelitian randomized control trial yang dilakukan kilinc et al. (2016) pada 22 klien pascastroke yang mengalami hemiparesis menunjukkan bahwa metode bobath pendekatan truncal exercise secara bermakna dapat meningkatkan keseimbangan klien pascastroke daripada latihan konvensional (kilinç et al., 2016). hasil penelitian ini dan juga hasil penelitian lain yang mendukung, dapat disimpulkan bahwa intervensi keperawatan truncal control exercise dapat meningkatkan keseimbangan klien pascastroke secara bermakna. kesimpulan penelitian ini didukung oleh pendapat yang dikemukakan oleh verheyden et al. (2006) yang menyatakan bahwa truncal exercise difokuskan untuk meningkatkan stabilisasi truncal yang merupakan inti komponen penting dari keseimbangan dan terkoordinasi dengan penggunaan ekstremitas dalam melakukan aktivitas fungsional sehari-hari (verheyden et al., 2006). stabilisasi postural tubuh dengan latihan truncal control exercise akan diikuti perubahan letak centre of gravity (cog) sehingga tubuh mampu memprediksi respon terhadap gravity dan ground reaction force (grf), yang memungkinkan tubuh tetap seimbang melalui penyesuaian terhadap base of support (bos) dan centre of gravity (cog). fasilitasi motor learning dan motor relearning klien pascastroke menjadi faktor penting dalam pembentukan koneksi fungsional antara sistem penunjang kontrol postural sehingga dapat terbentuk stabilisasi lumbar dan menstimulasi kontrol neuromuskuler, kekuatan dan daya tahan otot yang penting sebagai penjaga stabilitas dinamis dari tulang belakang sehingga terjadi perbaikan keseimbangan, terutama peningkatan keseimbangan duduk klien pascastroke. hasil penelitian setelah dilakukan intervensi keperawatan truncal control exercise menunjukkan bahwa terdapat perbedaan rerata selisih nilai kemampuan berjalan antara kelompok perlakuan dan kontrol. hasil penilaian kemampuan berjalan dengan menggunakan tinetti test – subsection gait kelompok perlakuan sebelum dilakukan intervensi truncal control exercise didapatkan data bahwa pada intruksi kesimetrian melangkah seluruh klien pascastroke mempunyai jarak melangkah kaki kanan-kiri yang tidak sama dan ada 4 orang klien pascastroke memulai inisiasi berjalan dengan ragu. sesudah dilakukan intervensi truncal control exercise didapatkan hasil penilaian tinetti test – subsection gait bahwa nilai kesimetrian melangkah hampir seluruh klien pascastroke sudah mempunyai jarak melangkah kaki kanan-kiri yang sama dan seluruh responden menginisiasi berjalan tanpa ragu. hasil penelitian sesudah dilakukan truncal control exercise juga didapatkan data bahwa hampir seluruh klien pascastroke terjadi peningkatan item instruksi berjalan lurus tanpa menggunakan alat bantu. hasil penelitian ini sejalan dengan penelitian randomized control trial yang dilakukan oleh saeys et al. (2012) pada 33 orang pascastroke yang mengalami hemiparesis menunjukkan bahwa truncal exercise selain dapat meningkatkan keseimbangan berdiri, secara bermakna juga meningkatkan kemampuan berjalan klien pascastroke (saeys et al., 2012). hasil penelitian randomized control trial yang dilakukan kilinc et al (2016) pada 22 responden pascastroke yang mengalami hemiparesis menunjukkan bahwa metode bobath pendekatan truncal exercise selain meningkatkan keseimbangan, secara bermakna juga dapat meningkatkan kemampuan berjalan klien pascastroke daripada latihan konvensional (kilinç et al., 2016). hasil penelitian ini dan juga hasil penelitian sebelumnya, peneliti berkesimpulan bahwa intervensi keperawatan truncal control exercise dapat meningkatkan kemampuan berjalan klien pascastroke secara bermakna. kesimpulan peneliti ini didukung oleh pendapat yang dikemukakan oleh verheyden et al. (2006) bahwa sekelompok otot truncal berperan penting mempertahankan postur yang stabil melawan gravitasi yang dapat memberikan kestabilan bagian proksimal dari ekstremitas dan kepala. kestabilan proksimal merupakan prasyarat terjadinya gerakan leher dan ekstremitas yang baik (verheyden et al., 2006). lamoth et al. (2008) juga mengemukakan bahwa latihan core stabilty dengan berbasis pada kontrol trunk dapat meningkatkan ayunan posterior panggul dan jurnal ners vol. 11 no. 2 oktober 2016: 300-310 307 perpindahan centre of gravity selama fase ayunan melangkah. koordinasi kelompok trunk (transversus abdominis dan oblikus internal) memiliki efek pada parameter berjalan karena menstabilisasi tulang belakang, daerah lumbopelvik, dan semua segmen trunkus-pelvis saat menapakkan kaki, meskipun adaptasi fleksibel dalam perubahan kecepatan berjalan tidak berpengaruh dengan latihan core stabilty. peningkatan stabilitas postural tubuh terutama otot trunk bawah dan panggul menghasilkan shiftness dari lumbar spine sekaligus memberikan postural support dapat meningkatkan kemampuan keseimbangan statis, keseimbangan dinamis, dan kontrol gerakan spine sehingga dapat menyebabkan gaya berjalan lebih stabil (chung et al., 2013; irfan 2012). truncal control exercise menjadikan pola aktivasi yang sinergis dalam terbentuknya base of support pada seluruh trunk dan otot spinalis. pembentukan base of support yang baik juga dipengaruhi gabungan struktur hip dan pelvic dari keduanya. hip dan pelvic terdapat gabungan kelompok otot besar yang merupakan stabilisator dari trunk sampai dasar kaki dan menyediakan power untuk gerakan melangkah ke depan. intervensi truncal control exercise ini dapat meningkatkan kemampuan berjalan terutama kesimetrian melangkah dari kedua kaki dan kemampuan berjalan lurus tanpa menggunakan alat bantu. hasil uji statistik yang membandingkan sebelum-sesudah intervensi antara kelompok perlakuan dan kontrol didapatkan bahwa tidak ada perbedaan truncal control exercise terhadap fungsi ekstremitas atas, ada perbedaan intervensi keperawatan truncal control exercise terhadap keseimbangan dan berjalan pada klien pascastroke. penelitian disimpulkan bahwa intervensi keperawatan truncal control exercise kurang efektif terhadap perubahan fungsi ekstremitas atas, tetapi efektif terhadap keseimbangan dan berjalan klien pascastroke. intervensi keperawatan truncal control exercise lebih efektif terhadap perubahan keseimbangan daripada perubahan kemampuan berjalan pada klien pascastroke, dikarenakan mempunyai nilai p-value keseimbangan lebih kecil daripada p-value berjalan hasil kesimpulan peneliti sejalan dengan penelitian yang dilakukan verheyden et al. (2006) mengenai kemampuan trunk pascastroke dan hubungannya dengan keseimbangan, berjalan, dan kemampuan fungsional pada 51 klien pascastroke. hasil penelitian dengan analisis regregsi linear multivariat didapatkan bahwa keseimbangan lebih signifikan dibandingkan dengan berjalan dan kemampuan fungsional. penelitian randomized control trial yang dilakukan verheyden et al. (2009) juga mendukung hasil penelitian ini. verheyden et al. (2009) melakukan penelitian terkait latihan peningkatan performa trunk pada 33 klien pascastroke, berdasarkan hasil general linear repeated measures model didapatkan bahwa keseimbangan lebih signifikan dibandingkan kemampuan kontrol trunk dan berjalan. peneltian pre-post design yang dilakukan karthikbabu et al. (2011) mengenai peran rehabilitasi kontrol trunk terhadap kemampuan kontrol trunk, keseimbangan, dan berjalan pada 15 klien pascastroke. hasil penelitian menyatakan bahwa rerata effect size index (d) dari kontrol trunk (d = 1,75) dan keseimbangan (d = 1,65) lebih besar daripada berjalan (d = 0,65). truncal exercise akan menstimulasi sensorimotor akan meningkatkan neuroplasticity otak yang diikuti reorganisasi cortical maps, sehingga terjadi pemulihan sel saraf pendukung kemampuan fungsional. input somatosensoris ke cortex motorik menyebabkan terjadinya motor re-learning yang diikuti pemulihan motor (gerakan). sel saraf sensori dan motorik yang telah pulih akan meningkatkan kemampuan kelompok otot core (otot spine, abdominalis, dan pelvic) sehingga kontrol trunk klien meningkat. stabilitas terhadap otot trunk dan memiliki efek pada stabilisasi bahu yang diikuti peningkatan gerakan siku, pergelangan tangan dan jari. trunk yang stabil memberikan dasar yang kuat untuk gerakan awal yang dihasilkan ekstremitas atas (kim et al., 2011; bae et al., 2013; miyake et al., 2013). stabilitas kontrol trunk juga akan meningkatkan stabilisasi postural tubuh. stabilisasi postural tubuh akan diikuti perubahan letak centre of gravity (cog) sehingga tubuh mampu memprediksi respon terhadap gravity dan ground reaction force (grf), yang memungkinkan tubuh tetap seimbang melalui penyesuaian terhadap base of support (bos) dan centre of gravity (cog). aktivasi kelompok otot abdominalis, diafragma dan pelvic floor yang saling intervensi keperraatan truncal control exercise (kusnanto, dkk) 308 bersinergi dalam memperbaiki stabilisasi postural tubuh akan menghasilkan kekakuan (stiffness) dari lumbar spine, sekaligus memberikan postural support untuk meningkatkan kontrol gerakan spine. kontrol spine yang adekuat akan memperkuat power klien pascastroke dalam melakukan gerakan ayunan dan melangkah selama gerakan berjalan (irfan 2012). hasil analisis untuk efek truncal control exercise terhadap fungsi ekstremitas atas tidak bermakna dan dari hasil data tabulasi fungsi ekstremitas atas dan teori yang mendukung, truncal control exercise juga dapat berefek terhadap fungsi ekstremitas atas. hal ini dikarenakan klien pascastroke telah memasuki tahap rehabilitasi dan intervensi dilakukan di rumah yang mendukung proses pemulihan fungsi neurologis menjadi lebih baik dan kondisi klien pascastroke lebih stabil. faktor lain seperti motivasi dan dukungan keluarga menjadi penting dalam mengembalikan fungsi ekstremitas atas, keseimbangan dan berjalan klien pascastroke. kondisi jauh berbeda terjadi di rumah sakit, dimana klien pascastroke dalam tahap fase akut stroke, sehingga keadaan organ-organ masih dalam tahap adaptasi (warlow et al., 2007). perawat memiliki peran yang sangat penting dalam penatalaksanaan klien stroke secara umum. diagnosa keperawatan dan intervensinya merupakan arahan yang sesuai dalam manajemen perawatan klien stroke. prinsip rehabilitasi lanjut klien pascastroke dengan pendekatan problem solving. pendekatan ini mengarahkan perawat bahwa setiap klien stroke memiliki karakteristik tertentu dan menentukan bentuk yang spesifik dengan mengacu pada prinsip dasar rehabilitasi yang sama. tugas dan wewenang perawat dalam proses rehabilitasi klien stroke berdasarkan undang-undang keperawatan nomor 38 tahun 2014 bab v tentang praktik keperawatan menyatakan bahwa perawat bertugas sebagai pemberi asuhan keperawatan yang dapat dilakukan melalui praktek mandiri dengan berpegang teguh kode etik, standar pelayanan, standar profesi, dan standar prosedur operasional. tugas dan wewenang perawat didukung filosofi kristin l. mauk dengan teori the mauk model of poststroke recovery yang berpandangan bahwa klien pascastroke sering menghadapi masalah fisik, psikososial dan emosional setelah meninggalkan rumah sakit. discharge planning perawatan pascastroke di rumah, masih diberikan ketika klien dan keluarga belum mampu untuk belajar menerima konsekuensi dampak stroke di rumah. pendekatan the mauk model of poststroke recovery menjadi ruang bagi keperawatan untuk mengakomodasi bentuk intervensi keperawatan truncal control exercise. pada rehabilitasi klien pascastroke, mauk (2006) menjelaskan bahwa perawat dapat mengidentifikasi fase recovery dari klien pascastroke yang terdiri dari 6 fase (agonizing, fantasizing, realizing, blending, framing, dan owning) dan dapat memberikan pelayanan keperawatan sesuai dengan kebutuhan klien. truncal control exercise dapat dilakukan pada klien pascastroke yang mengalami pemulihan stroke fase blending. selama fase blending, klien memulai untuk mengolah bentuk kehidupan pascastroke sesuai kemampuan klien dan merupakan waktu yang ideal bagi perawat untuk memberikan instruksi tentang self care dan truncal control exercise dapat diberikan karena motivasi klien untuk belajar secara umum masih tinggi. pada fase blending, perawat dapat menekankan klien bahwa kekuatan yang tampak dalam diri dapat mendorong harapan serta mendorong ketekunan dan motivasi klien selama rehabilitasi. perawat secara aktif mempromosikan keterlibatan keluarga. fokus tindakan keperawatan pada fase blending adalah mengajari dengan memasukkan seluruh skill yang dibutuhkan untuk penyesuaian hidup pascastroke di rumah dan penguatan skill yang diberikan dapat diawali dengan pemberian latihan truncal control exercise pada klien pascastroke. pelaksanaan truncal control exercise yang mempunyai keterkaitan dan sinergi erat dalam proses asuhan keperawatan dapat melatarbelakangi perawat untuk lebih meningkatkan aspek keilmuan terkait patofisiologi sistem muskuloskeletal dan aspek kolaborasi dengan fisioterapis melalui sharing berbagai tehnik dasar gerakan fisioterapi. keterbatasan jumlah fisioterapis di rumah sakit yang belum sebanding dengan jumlah perawat dapat teratasi melalui kolaborasi yang baik antara perawat dan fisioterapis dalam pelaksanaan perawatan klien pascastroke untuk mencapai peningkatan kualitas pelayanan kesehatan yang optimal. simpulan dan saran jurnal ners vol. 11 no. 2 oktober 2016: 300-310 309 simpulan intervensi keperawatan truncal control exercise kurang efektif terhadap perubahan fungsi ekstremitas atas, tetapi efektif terhadap keseimbangan dan berjalan klien pascastroke. intervensi keperawatan truncal control exercise lebih efektif terhadap perubahan keseimbangan daripada perubahan kemampuan berjalan pada klien pascastroke. saran intervensi keperawatan truncal control exercise dapat dilanjutkan sebagai bentuk tindakan kolaboratif bagi perawat medikal bedah dengan fisioterapi sehingga dapat mengoptimalkan program rehabilitasi klien pasca stroke yang mengalami masalah fungsi ekstremitas atas, keseimbangan, dan berjalan di klinik maupun rumah klien. kepustakaan alghwiri, a.a., 2015. the correlation between depression , balance , and physical functioning post stroke. journal of stroke and cerebrovascular diseases, pp.1–5. available at: http://dx.doi.org/10.1016/j.jstrokecerebro vasdis.2015.10.022. aprile, i. et al., 2006. predictive variables on disability and quality of life in stroke outpatients undergoing rehabilitation. neurology science, 27, pp.40–46. bae, s.h. et al., 2013. effects of trunk stabilization exercises on different support surfaces on the cross-sectional area of the trunk muscles and balance ability. , 25(6), pp.741–745. cabanas, r., cuchi, g.u. & bagur-calafat, c., 2013. trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. neurorehabilitation, 33(4), pp.575–592. chung, e.-j. et al., 2013. the effects of core stabilization exercise on dynamic balance and gait function in stroke patients. journal of physical therapy science, 25(7), pp.803–6. available at: http://www.pubmedcentral.nih.gov/article render.fcgi?artid=3820398&tool=pmcent rez&rendertype=abstract. depkes ri, 2014. riset kesehatan dasar (riskesdas) 2013, jakarta: badan penelitian dan pengembangan kesehatan. available at: www.depkes.go.id. feigin, v.l. et al., 2009. worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. the lancet neurology, 8(4), pp.355–369. available at: http://dx.doi.org/10.1016/s14744422(09)70025-0. gjelsvik, b., 2014. trunk control in stroke : aspects of measurement, relation to brain lesion, and change after rehabilitation. , pp.1–104. herdman, t.h. (ed) & kamitsuru, s. (ed), 2014. nanda international nursing diagnoses: definitions and classification 2015-2017. nursing diagnoses 20152017 : definitions and classification. irfan, m., 2012. fisioterapi bagi insan stroke 1st ed., yogyakarta: graha ilmu. jang, s.h., 2007. a review of motor recovery mechanisms in patients with stroke. neurorehabilitation, 22, pp.253–259. karatas, m. et al., 2004. trunk muscle strength in relation to balance and functional disability in unihemispheric stroke patients. american journal of physical medicine & rehabilitation, 83(2), pp.81–87. available at: http://content.wkhealth.com/linkback/ope nurl?sid=wkptlp:landingpage&an=000 02060-200402000-00001. karthikbabu, s. et al., 2011. role of trunk rehabilitation on trunk control, balance and gait in patients with chronic stroke: a pre-post design. neuroscience &amp; medicine, 02(02), pp.61–67. kilinç, m. et al., 2016. the effects of bobathbased trunk exercises on trunk control, functional capacity, balance, and gait: a pilot randomized controlled trial. stroke rehabilitation, 23(1), pp.50–58. available at: http://www.tandfonline.com/doi/abs/10.1 179/1945511915y.0000000011#.v6igsh kxhu8. kim, y., kim, e. & gong, w., 2011. the effects of trunk stability exercise using pnf on the functional reach test and muscle activities of stroke patients. journal of physical therapy science, 23, pp.699–702. kowalak, j.p., welsh, w. & mayer, b., 2011. buku ajar patofisiologi r. komalasari, a. o. tampubolon, & m. ester, eds., intervensi keperraatan truncal control exercise (kusnanto, dkk) 310 jakarta: egc. lalonde, r. & strazielle, c., 2007. brain regions and genes affecting postural control. progress in neurobiology, 81(1), pp.45–60. available at: http://www.sciencedirect.com/science/art icle/pii/s0301008206001407. mauk, k.l., 2006. nursing interventions within the mauk model of poststroke recovery. rehabilitation nursing, 31(6), pp.257–264. available at: http://myaccess.library.utoronto.ca/login? url=http://search.ebscohost.com/login.asp x?direct=true&db=cin20&an=20092865 55&site=ehost-live. michaelsen, s.m. et al., 2001. effect of trunk restraint on the recovery of reaching movements in hemiparetic patients. the american heart association. available at: http://stroke.ahajournals.org. miyake, y. et al., 2013. core exercises elevate trunk stability to facilitate skilled motor behavior of the upper extremities. journal of bodywork and movement therapies, 17, pp.259–265. mozaffarian, d. et al., 2015. aha statistical update heart disease and stroke statistics — 2015 update a report from the american heart association writing group members, national stroke association, 2015. impact of stroke women and stroke. available at: http://www.stroke.org/understandstroke/impact-stroke/women-and-stroke. price, s.a. & wilson, l.m., 2006. patofisiologi: konsep klinis prosesproses penyakit edisi 6 volume 2 6th ed., jakarta: rgc. rai, r.k. et al., 2014. efficacy of trunk rehabilitation and balance training on trunk control , balance and gait in post stroke hemiplegic patients : a randomized controlled trial. journal of nursing and health science, 3(3), pp.27– 31. saeys, w. et al., 2012. randomized controlled trial of truncal exercises early after stroke to improve balance and mobility. neurorehabilitation and neural repair, 26(3), pp.231–238. takeuchi, n. & izumi, s.i., 2013. rehabilitation with poststroke motor recovery: a review with a focus on neural plasticity. stroke research and treatment, 2013. verheyden, g. et al., 2009. additional exercises improve trunk performance after stroke: a pilot randomized controlled trial. neurorehabilitation and neural repair, 23, pp.281–286. available at: http://nnr.sagepub.com. verheyden, g. et al., 2006. trunk performance after stroke and the relationship with balance , gait and functional ability. clinical rehabilitation, 11, pp.451–458. wee, s.k. et al., 2015. effect of trunk support on upper extremity function in people with chronic stroke and people who are healthy. physical therapy journal, 95(august), pp.1163–1171. weerdesteyn, v. et al., 2008. falls in individuals with stroke. journal of rehabilitation research & development, 45(8), pp.1195–1213. 54 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 1, april 2021 http://dx.doi.org/10.20473/jn.v16i1.24751 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research contributing factors of cyberbullying behavior among youths during covid-19 ira kusumawaty1, yunike yunike1, yeni elviani1 and hidayat arifin2 1 politeknik kesehatan kemenkes palembang, indonesia 2 faculty of nursing, universitas padjadjaran, indonesia abstract introduction: the use of information technology during the covid-19 period is inevitable and can lead to cyberbullying. mental and life health conditions can be threatened due to being the victim of cyberbullying. this study aims to determine the factors that contribute to the formation of cyberbullying behavior among youths in south sumatra, indonesia. methods: a cross-sectional study was undertaken. the population was youths in south sumatra, indonesia with a total sample of 213 respondents who were determined based on purposive sampling. the data collection was done by distributing questionnaires via google forms. the questionnaire was developed based on the concept of cyberbullying behavior inclusive of repetition, power imbalance, deliberation and aggression. the data was analyzed using anova and manova. results: in the study, we found that gender contributes the most to shaping cyberbullying behavior (p=0.000), followed by the parent’s occupation (p=0.018). conclusion: it is necessary to establish an interconnected system between parents, youth groups and the education sector to avoid cyberbullying behavior. the ability of youths to adapt constructively to the increasing advancement of information technology and to use it wisely is something urgent that needs to be observed so then the cyberbullying cycle can be eradicated. article history received: january 18, 2021 accepted: march 28, 2021 keywords covid-19; cyberbullying; behavior, youth contact ira kusumawaty  irakusumawaty@poltekkes palembang.ac.id  politeknik kesehatan kemenkes palembang, indonesia cite this as: kusumawaty, i., yunike, y., elviani, y., & arifin, h. (2021). contributing factors of cyberbullying behavior among youths during covid-19. jurnal ners, 16(1). 54-59. doi:http://dx.doi.org/10.20473/jn.v16i1.24751 introduction covid-19 has had a wide impact on various groups regardless of age, socioeconomic level, education level and gender. the use of online communication tools is an inevitable condition and the youth group is the largest group utilizing the internet or online media in their daily life (oliveira et al., 2018). the number of internet users in indonesia has exceeded 200 million, which is more than 75% of the population (eloksari, 2020). the continuous use of online media with a negative internal motivation can encourage someone to engage in cyberbullying (cong et al., 2018; sittichai & smith, 2015; swearer & hymel, 2015). youths are the largest group of information technology users, so they have the biggest likelihood of being involved in cyberbullying (grunin et al., 2020; messias et al., 2014). as a form of psychological disorder, cyberbullying began to occur after the development of traditional bullying into bullying that occurs due to technological improvements (notar et al., 2013; ronis & slaunwhite, 2019). freedom is a feeling that youths experience when in cyberspace due to the ease of making friends or interacting with many parties. this characteristic is why teenagers are often trapped in the cycle of cyberbullying. oppression, harassment, humiliation and violence are the consequences that often arise due to the uncontrolled use of communication technology (chan et al., 2021; lópez-castro & priegue, 2019). it is known that on average, among the 25% of victims of bullying, 10% have experienced being bullied online, in addition to by telephone at nearly 10% and via text message almost exceeding the percentage of 8% (notar et al., 2013). cyberbullying involves bullying through the use of electronic venues such as instant messaging, e-mail, chat rooms, websites, online games, social https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 55 networking sites, and text messaging (wade & beran, 2011). furthermore, cyberbullying is an emerging public health concern among youths with established links to physical and mental health problems. intimidation has been carried out by the cyberbullying perpetrators by utilizing technology in the form of text messages, e-mails, chat rooms, social networking sites, web or online games. cyberbullying is becoming a global social and school problem. multiple studies worldwide have reported cyberbullying prevalences among students (notar et al., 2013; wade & beran, 2011). cyberbullying has continued to escalate unexpectedly to the point of becoming a worldwide problem. many studies have tried to explain the causes of cyberbullying. the results of the research by (baldry et al., 2015; hellfeldt et al., 2020) show that individual social conditions are associated with cyberbullying and that there is only a slight difference between the victims of bullying in terms of gender. facebook users report higher rates of extroverts and lower levels of awareness than non-users (burešová et al., 2015; sindermann et al., 2020). one indicator of the possibility of being a cyberbullying actor is a lack of empathy for the victims of cyberbullying. (balakrishnan & fernandez, 2018; doane et al., 2014) bullying is more common among boys than girls (sharma et al., 2017). cyberbullying is generally related to differences in power between the perpetrator and the victim. the victim is the party that has less power, meaning that they are unable to fight the perpetrator (auemaneekul et al., 2020; chan et al., 2021). this condition results in the development of serious problems, not only regarding their physical health conditions but also their mental health (messias et al., 2014; selkie et al., 2016). based on (grunin et al., 2020), due to the use of social media, the victim’s social emotional condition is disturbed. the sad condition occurs where only 5.1% have reported cyberbullying, 5% have reported being the victims of bullying and only 9.5% have reported being either the perpetrator or victim of cyberbullying (hemphill & heerde, 2014). if cyberbullying is not immediately addressed, it can cause mental health problems. suicide cases have been reported as a result of cyberbullying (grunin et al., 2020; notar et al., 2013) and more than 10% of cases of suicide are due to cyberbullying(messias et al., 2014). almost 50% of victims did not report the abuse they experienced and only 10% of victims told their parents about the bullying (li, 2010). the physical, psychological, and academic documentation correlates the two types of bullying as they resemble one another (domínguez-hernández et al., 2018; notar et al., 2013). consistent with the research on traditional bullying, the possible negative effects of cyberbullying were the most pronounced for the cyber-bully/victim participants, especially males. these individuals generally reported experiencing more negative physical, psychological and academic effects due to electronic bullying than those in other groups (messias et al., 2014; notar et al., 2013). in order to find the best solution, this study aims to determine the factors that contribute to the formation of cyberbullying behavior among youths in south sumatra, indonesia. materials and methods the study used a cross-sectional design, and the research process was ongoing for 6 months from march to august 2020. the population in this study consisted of youths who used online media the most living in the south sumatra province. the total sample was 213 respondents obtained using the purposive sampling technique. the inclusion criteria were youths aged 15 to 25 years old who use gadgets every day with a willingness to be respondents in the study. respondents who could not complete join the study and those who did not complete the questionnaire were excluded. the questionnaire included of age, education level, youth status, residence, gender and the parent’s occupation as the independent variables and cyberbullying behavior as the dependent variable. cyberbullying behavior was categorized into four groups, namely low, moderate, high and very high cyberbullying behavior. the questionnaire used was a modification of the cyberbullying behavior scale developed by (langos, 2012) which includes repetition, a power imbalance, and deliberate and aggression components. each component was assessed using 8 statements with a likert scale (strongly to strongly disagree). the questionnaire consisted of 32 questions (17 favorable and 15 unfavorable statements). validity and reliability tests were carried out with a cronbach’s alpha score of 0.931. the data collection process carried out was through the distribution of the google form survey through a whatsapp group. this, in turn, was disseminated to other whatsapp groups. on the first sheet of the google form, the researcher includes the title, research objectives, respondent criteria, informed consent form and rewards. rewards were given in the form of pulses for the respondents who were willing to be involved in the research. the data was then collected, screened, and compiled for further analysis. the analysis in the study was assisted by the ibm spss 25 software. furthermore, the data was analyzed using the anova and manova tests with a significance level of 0.05. ethical clearance was issued by the ethics committee of politeknik kesehatan palembang number: 277/kepk/adm2/vi/2020. to ensure the confidentiality of the information submitted, the respondents only needed to write their initials. in addition, the research was not compulsory to engage in, so the respondents were able to resign at any time.of the faculty of medicine, airlangga university on april 27, 2020. i. kusumawaty et al. 56 | pissn: 1858-3598  eissn: 2502-5791 results table 1 shows the diversity of the characteristics of the research respondents. the majority of the respondents were aged 15-18 years old and female with a mostly high school level of education. most were the oldest child. the respondents predominantly lived with their parents. the majority of the respondent’s parents had a permanent occupation. from the results of this study, we found that most respondents experienced low cyberbullying behavior, followed by high cyberbullying behavior. the anova statistical test shows there is a significant relationship between residence, gender and the parent’s occupation with cyberbullying behavior. on the other hand, there is no significant relationship between age, education level and the youth’s status with cyberbullying behavior (table 2). the manova analysis shows that the variables of gender and the parent’s occupation are more likely to be linked to cyberbullying behavior (table 3). table 1. characteristic respondents (n=213) category n % age 15-18 years old 134 62.91 19-25 years old 79 37.09 gender male 70 32.86 female 143 67.14 education level secondary education 3 1.41 high education 210 98.59 youth status the oldest child 85 39.91 the middle child 64 30.05 the youngest child 64 30.05 residence rent 43 20.19 live with parents 158 74.18 live with relatives 12 5.63 parent’s occupation permanent 164 77 temporary 49 23 cyberbullying behavior low 77 36.15 moderate 54 25.35 high 69 32.39 very high 13 6.10 table 2. the relationship between the independent variable and the dependent variable independent variables model sum of square mean square f p age regression residual 0.440 196.039 0.440 0.929 0.474 0.492 education level regression residual 0.022 196.457 0.022 0.931 0.023 0.879 youth status regression residual 1.377 195.102 1.377 0.925 1.489 0.224 residence regression residual 3.674 192.805 3.674 0.914 4.021 0.046 gender regression residual 35.917 160.562 35.917 0.761 47.200 0.000 parent’s occupation regression residual 4.577 191.902 4.577 0.909 5.033 0.026 table 3. variables that are most closely related to bullying behavior dependent variable type iii sum of squares df mean square f p parent’s occupation 1.763 3 0.588 3.416 0.018 gender 9.883 3 3.294 18.553 0.000 residence 1.649 3 0.550 2.353 0.073 age 0.335 3 0.112 0.473 0.702 education level 0.004 3 0.001 0.088 0.966 youth status 3.521 3 1.174 1.710 0.166 jurnal ners http://e-journal.unair.ac.id/jners | 57 discussion in this study, we found that gender and the parent's occupation result in a greater likelihood of experiencing cyberbullying behavior. there are seven characteristics of cyberbullying consisting of conveying negative information indirectly through electronic applications intended to hurt the victim. it can occur repeatedly with an ongoing impact. the perpetrator can be either an individual or part of a group. the identity of the perpetrator is often hidden and it occurs all of the time (cong et al., 2018). the use of information technology cannot be separated from the teenagers' lives, especially during the covid19 period which requires that everything be done online. this condition provides opportunities for cyberbullying behavior as a behavior that is often engaged in by youths based on certain motivations (cong et al., 2018; swearer & hymel, 2015). the desire to take revenge, to divert their feelings and to make their feelings more comfortable are some of the internal motivations for cyberbullying (chan et al., 2021; slaninova et al., 2011). in other words, feelings of frustration and aggression encourage youths to engage in virtual bullying. in this study, gender was found to be a factor related to cyberbullying behavior. there is a tendency for there to be a difference in the behavior patterns when the youths are female when utilizing technological advances compared to male youths. several studies have explained that male youths have a higher tendency to bully (grunin et al., 2020; wiguna et al., 2018). in this study, the variable of living with their family was one of the drivers of cyberbullying behavior. however, this condition involves a very long process. the previous research (chan et al., 2021; paisi-lazarescu, 2014) explains the relationship between life with their family and the possibility of cyberbullying behavior. this is possible because during the covid-19 period, there were health protocols that must be adhered to avoid crowds, including staying at home more often. girls are at a higher risk of committing suicide than boys as a result of being the victim of cyberbullying (shireen et al., 2014). the socioeconomic condition of the family in this study was found to be related to cyberbullying behavior. the family socio-economic condition is determined by the family work status and specifically, the parent’s occupation. the results of this research reveal that socio-economic conditions have an effect on the increasing number of cyberbullying cases (grunin et al., 2020; lópez-meneses et al., 2020). this can occur because the socioeconomic condition of the family, which can be determined by the amount of family income, affects how the family meets the needs of its family members, including the youths. the ease with which youths obtain the desired facilities encourages character building, particularly among those who always experience ease when getting what they desire. this indirectly contributes to the character building of youths through friendship. being accustomed to always getting something that they crave in the family encourages youths to get the same treatment in their friendships. when a friend is unable to fulfill this wish, there will be a compulsion of will so then the wish can be fulfilled by the friend. as the characteristics of youths include the freedom to express their will and feelings, they do not have the maturity to anticipate their impact on the resulting behavior (burešová et al., 2015). various studies discussing the effects of cyberbullying in the literature have identified in the form of suicidal ideas and attempts as a symptom of various psychiatric disorders. there is also the emergence of depression and excessive anxiety, including an addiction to illegal substances. these varied conditions lead the perpetrator to intimidate the victim. this condition is very much influenced by the sex (grunin et al., 2020) and age group of the perpetrator and victim respectively (burešová et al., 2015). however, in this study, age was not associated with cyberbullying behavior because the majority of respondents were in the same age range. the incidence of cyberbullying is very much influenced by the environment where the perpetrator is, such as school. it is known that there is a positive effect following the school’s involvement in overcoming the suicide attempts of victims due to cyberbullying. it is necessary to establish a psychological support program for the victims of bullying and to enforce strict rules against the perpetrators of bullying. the victims of bullying are weak individuals who are physically and psychologically incapable, socially isolated, always alone, insecure and have low self-confidence. all children can become victims of bullying, and the youths who are victims of bullying commonly have the characteristic of being easily anxious with low self-esteem (balakrishnan & fernandez, 2018; palermiti et al., 2017). some of the traits of youths who have the potential to become the victims of bullying include isolation and having no friends, easily experiencing anxiety, feeling insecure and being less able to make friends, not having the courage to defend themselves, crying easily, giving up easily, possibly experiencing violence at home and having learning difficulties. several limitations have been found in this study. collecting the data during the covid-19 pandemic required the researchers to use a google form as the researchers could not meet face to face with the respondents. the researchers also did not conduct indepth interviews related to cyberbullying behavior, which is useful when seeking to further explore the problem of cyberbullying. conclusion youths are a group that is vulnerable to becoming either the perpetrators or victims of cyberbullying. covid-19 has created a situation where the fulfillment of their daily needs is mostly obtained through cyberspace. different approaches are needed i. kusumawaty et al. 58 | pissn: 1858-3598  eissn: 2502-5791 regarding males and females when regulating and monitoring the use of information technology so as not to increase the number of victims of bullying through technological advances. it is necessary to create a harmonious atmosphere of togetherness at home, so then the youths can find comfort among their family members. this will allow the emotional atmosphere formed by the youth's psychology to be formed optimally. a massive project is needed that involves their parents, the education sector and the youth's closest environment to develop their mental health condition optimally. the establishment of a cyberbullying prevention project is expected to improve the coping mechanisms of youths today. references auemaneekul, n., powwattana, a., kiatsiri, e., & thananowan, n. (2020). investigating the mechanisms of theory of planned behavior on cyberbullying among thai adolescents. journal of health research, 34(1), 42–55. https://doi.org/10.1108/jhr-02-2019-0033 balakrishnan, v., & fernandez, t. (2018). self-esteem, empathy and their impacts on cyberbullying among young adults. telematics and informatics, 35(7), 2028–2037. https://doi.org/10.1016/j.tele.2018.07.006 baldry, a. c., farrington, d. p., & sorrentino, a. (2015). “am i at risk of cyberbullying”? a narrative review and conceptual framework for research on risk of cyberbullying and cybervictimization: the risk and needs assessment approach. aggression and violent behavior, 23, 36–51. https://doi.org/10.1016/j.avb.2015.05.014 burešová, i., vrbová, m., & čerňák, m. (2015). personality characteristic of adolescent selfharmers. procedia social and behavioral sciences, 171, 1118–1127. https://doi.org/10.1016/j.sbspro.2015.01.274 chan, t. k. h., cheung, c. m. k., & lee, z. w. y. (2021). cyberbullying on social networking sites: a literature review and future research directions. information and management, 58(2), 103411. https://doi.org/10.1016/j.im.2020.103411 cong, t. van, ngoc, n. p. h., weiss, b., luot, n. van, & dat, n. b. (2018). definition and characteristics of “cyberbullying” among vietnamese students. vnu journal of science: education research, 34(4). https://doi.org/10.25073/25881159/vnuer.4212 doane, a. n., pearson, m. r., & kelley, m. l. (2014). predictors of cyberbullying perpetration among college students: an application of the theory of reasoned action. computers in human behavior, 36, 154–162. https://doi.org/10.1016/j.chb.2014.03.051 domínguez-hernández, f., bonel, l., & martínezgonzález, a. (2018). a systematic literature review of factors that moderate bystanders’ actions in cyberbullying. cyberpsychology, 12(4 special issue). https://doi.org/10.5817/cp20184-1 eloksari, e. (2020). indonesian internet users hit 196 million, still concentrated in java: apjii survey. the jakarta post. grunin, l., yu, g., & cohen, s. s. (2020). the relationship between youth cyberbullying behaviors and their perceptions of parental emotional support. international journal of bullying prevention. https://doi.org/10.1007/s42380-020-00080-5 hellfeldt, k., lópez-romero, l., & andershed, h. (2020). cyberbullying and psychological wellbeing in young adolescence: the potential protective mediation effects of social support from family, friends, and teachers. international journal of environmental research and public health, 17(1). https://doi.org/10.3390/ijerph17010045 hemphill, s. a., & heerde, j. a. (2014). adolescent predictors of young adult cyberbullying perpetration and victimization among australian youth. journal of adolescent health, 55(4), 580– 587. https://doi.org/10.1016/j.jadohealth.2014.04.01 4 langos, c. (2012). cyberbullying: the challenge to define. cyberpsychology, behavior, and social networking, 15(6), 285–289. https://doi.org/10.1089/cyber.2011.0588 li, q. (2010). cyberbullying in high schools: a study of students’ behaviors and beliefs about this new phenomenon. journal of aggression, maltreatment and trauma, 19(4), 372–392. https://doi.org/10.1080/10926771003788979 lópez-castro, l., & priegue, d. (2019). influence of family variables on cyberbullying perpetration and victimization: a systematic literature review. social sciences, 8(3). https://doi.org/10.3390/socsci8030098 lópez-meneses, e., vázquez-cano, e., gonzálezzamar, m. d., & abad-segura, e. (2020). socioeconomic effects in cyberbullying: global research trends in the educational context. international journal of environmental research and public health, 17(12), 1–31. https://doi.org/10.3390/ijerph17124369 messias, e., kindrick, k., & castro, j. (2014). school bullying, cyberbullying, or both: correlates of teen suicidality in the 2011 cdc youth risk behavior survey. comprehensive psychiatry, 55(5), 1063– 1068. https://doi.org/10.1016/j.comppsych.2014.02.0 05 notar, c. e., padgett, s., & roden, j. (2013). cyberbullying : a review of the literature. journal of educational research, 1(1), 1–9. https://doi.org/10.13189/ujer.2013.010101 oliveira, f. r., de menezes, t. a., irffi, g., & oliveira, g. r. (2018). bullying effect on student’s performance. economia, 19(1), 57–73. https://doi.org/10.1016/j.econ.2017.10.001 jurnal ners http://e-journal.unair.ac.id/jners | 59 paisi-lazarescu, m. (2014). psychological variables of aggression at teenagers. procedia social and behavioral sciences, 127, 743–747. https://doi.org/10.1016/j.sbspro.2014.03.347 palermiti, a. l., servidio, r., bartolo, m. g., & costabile, a. (2017). cyberbullying and self-esteem: an italian study. computers in human behavior, 69, 136–141. https://doi.org/10.1016/j.chb.2016.12.026 ronis, s., & slaunwhite, a. (2019). gender and geographic predictors of cyberbullying victimization, perpetration, and coping modalities among youth. canadian journal of school psychology, 34(1), 3–21. https://doi.org/10.1177/0829573517734029 selkie, e. m., fales, j. l., & moreno, m. a. (2016). cyberbullying prevalence among us middle and high schoole-aged adolescents: a systematic review and quality assessment. journal of adolescent health, 58(2), 125–133. https://doi.org/10.1016/j.jadohealth.2015.09.02 6 sharma, d., kishore, j., sharma, n., & duggal, m. (2017). aggression in schools: cyberbullying and gender issues. asian journal of psychiatry, 29, 142–145. https://doi.org/10.1016/j.ajp.2017.05.018 shireen, f., janapana, h., rehmatullah, s., temuri, h., & azim, f. (2014). trauma experience of youngsters and teens: a key issue in suicidal behavior among victims of bullying? pakistan journal of medical sciences, 30(1), 206–210. https://doi.org/10.12669/pjms.301.4072 sindermann, c., duke, é., & montag, c. (2020). personality associations with facebook use and tendencies towards facebook use disorder. addictive behaviors reports, 11(october 2019), 100264. https://doi.org/10.1016/j.abrep.2020.100264 sittichai, r., & smith, p. k. (2015). bullying in southeast asian countries: a review. aggression and violent behavior, 23, 22–35. https://doi.org/10.1016/j.avb.2015.06.002 slaninova, g., haviger, j., novotna, l., sochorova, p., & vackova, m. (2011). relationship between cyberbullying and readiness for aggressive behavior in middle adolescence. procedia social and behavioral sciences, 29, 567–573. https://doi.org/10.1016/j.sbspro.2011.11.277 swearer, s. m., & hymel, s. (2015). understanding the psychology of bullying: moving toward a socialecological diathesis-stress model. american psychologist, 70(4), 344–353. https://doi.org/10.1037/a0038929 wade, a., & beran, t. (2011). cyberbullying: the new era of bullying. canadian journal of school psychology, 26(1), 44–61. https://doi.org/10.1177/0829573510396318 wiguna, t., irawati ismail, r., sekartini, r., setyawati winarsih rahardjo, n., kaligis, f., prabowo, a. l., & hendarmo, r. (2018). the gender discrepancy in high-risk behaviour outcomes in adolescents who have experienced cyberbullying in indonesia. asian journal of psychiatry, 37(july), 130–135. https://doi.org/10.1016/j.ajp.2018.08.021 ners vol 10 no 1 april 2015.indd 189 model manajemen perawatan untuk meningkatkan kepatuhan minum obat dan status gizi pasien tb paru (a nursing management model to increase medication adherence and nutritional status of patients with pulmonary tb) eka mishbahatul mar’ah has*, elida ulfi ana*, ferry efendi*, retno indarwati*, joni haryanto*, makhfudli* *prodi pendidikan ners fakultas keperawatan, universitas airlangga jln. mulyorejo (kampus c unair) e-mail: eka.m.has@fkp.unair.ac.id abstrak pendahuluan: angka drop out yang tinggi, pengobatan yang tidak adekuat, dan resistensi terhadap obat anti tuberkulosis (oat) masih menjadi kendala dalam pengobatan tb paru. manajemen perawatan penderita tb paru di rumah secara aktif dapat dilakukan melalui telenursing. n-smsi merupakan salah satu bentuk intervensi keperawatan komunitas, dengan cara mengirimkan pesan singkat untuk mengingatkan minum obat dan nutrisi kepada penderita tb paru. tujuan penelitian ini adalah untuk menjelaskan pengaruh model manajemen perawatan n-smsi (ners-short message service intervention) terhadap peningkatan kepatuhan minum obat dan status gizi pasien tb paru. metode: penelitian ini merupakan studi prospektif. populasi adalah pasien tb paru baru fase intensif di wilayah kerja puskesmas pegirian surabaya. sampel diambil dengan teknik purposive sampling, sejumlah 30 orang, dibagi menjadi kelompok perlakuan dan kontrol. variabel independen dalam penelitian ini adalah n-smsi. variabel dependennya adalah kepatuhan minum obat yang dikumpulkan dengan kuesioner dan status gizi yang dinilai dengan pengukuran berat badan (kg). data kemudian diuji dengan wilcoxon signed rank test, mann withney, dan independent t-test dengan α ≤ 0.05. hasil: uji wilcoxon signed rank test menunjukkan ada perbedaan status gizi kelompok perlakuan sebelum dan sesudah intervensi dilihat dari berat badan (kg), dengan p = 0,001. begitu pula dengan kelompok kontrol, dengan p = 0.002. hasil uji mann whitney menunjukkan tidak ada perbedaan status gizi yang berarti antara kelompok perlakuan dan kelompok kontrol, yang ditunjukkan dengan nilai p = 0,589. sedangkan hasil uji independent t-test menunjukkan ada perbedaan kepatuhan antara kelompok perlakuan dan kelompok kontrol, dengan p = 0.031. kesimpulan: model manajemen perawatan n-smsi dapat meningkatkan kepatuhan minum obat pasien tb paru. model ini dapat dikembangkan oleh petugas kesehatan sebagai alternatif metode yang digunakan untuk meningkatkan kepatuhan minum obat pada pasien tb paru. penelitian selanjutnya diharapkan memodifi kasi model manajemen perawatan pasien tb paru yang dapat meningkatkan status gizi pasien tb paru secara signifi kan. kata kunci: model manajemen perawatan, kepatuhan pengobatan, status nutrisi, pasien dengan tb paru abstract introduction: high dropout rate, inadequate treatment, and resistance to medication, still become an obstacle in the treatment of pulmonary tb. pulmonary tb patient care management at home can be done actively through telenursing. n-smsi (ners-short message service intervention) is one of community nursing intervention, in which community nurses send short messages to remind patients to take medication and nutrition. the aim of this study was to analyze the effect of nursing management model n-smsi to increased medication adherence and nutritional status of patients with pulmonary tb. method: this study was used prospective design. the populations were new pulmonary tb patient at intensive phase, at puskesmas pegirian surabaya. samples were taken by purposive sampling technique; consist of 30 people, divided into treatment and control groups. the independent variable was n-smsi. the dependent variables were medication adherence collected by using questionnaire and nutritional status by using measurement of body weight (kg). the data were then analyzed by using wilcoxon signed rank test, mann whitney, and independent t-test with α ≤ 0.05 result: the results of wilcoxon signed rank test had showed difference in the nutritional status of the treatment group before and after intervention, with p = 0.001. it’s similar with the control group, with p = 0.002. mann whitney test results had showed no signifi cant difference in nutritional status between treatment and control group, as indicated by the value of p=0.589. while independent t-test had showed difference in compliance between treatment and control group, with p=0.031. conslusion: n-smsi can improve medication adherence of patient with pulmonary tb. this model can be developed by nurse as alternative methods to improve medication adherence in patients with pulmonary tb. further research should modify nursing management model which can improve the nutritional status of patient with pulmonary tb. keywords: nursing care management model, medication adherence, nutritional status, patient with pulmonary tb 190 jurnal ners vol. 10 no. 1 april 2015: 189–193 pendahuluan tb paru merupakan penyakit menular ya ng d isebabka n oleh m ycoba cterium tuberculosis. tb paru tersebar di seluruh dunia dan menjadi masalah kesehatan, terutama di negara berkembang, dengan angka morbiditas dan mortalitas yang cukup tinggi (depkes ri, 2001). sasaran program penanggulangan tb paru adalah tercapainya penemuan pasien baru bta positif paling sedikit 70% dari perkiraan dan menyembuhkan 85% dari semua pasien tersebut, serta mempertahankannya (depkes ri, 2009). akan tetapi, sampai saat ini hasilnya belum memuaskan. angka drop out yang tinggi, pengobatan yang tidak adekuat, dan resistensi terhadap oat masih menjadi kendala dalam pengobatan tb paru (hariadi, 2004). menurut depkes ri (2009), kegagalan program tb selama ini terutama diakibatkan oleh tidak memadainya tata laksana kasus, di antaranya pelayanan tb kurang terakses oleh masyarakat, penemuan kasus yang tidak standar, tidak dilakukan pemantauan selama pengobatan, sehingga gagal menyembuhkan kasus yang telah terdiagnosis. selain itu, kemiskinan masyarakat dan rendah nya komitmen politik, serta pendanaan tur ut berkontribusi terhadap kegagalan tersebut. ma najeme n pe r awat a n pe nde r it a tb par u di r umah memegang peranan penting dalam meningkatkan konversi bta sputum dan status gizi, ter utama dalam fase perawatan intensif, sehingga tingkat kesembuhan penderita meningkat. selama ini, proses pemantauan penderita tb paru di komunitas dilakukan secara pasif oleh petugas kesehatan, yaitu saat pasien kontrol ke puskesmas. pengobatan penderita tb paru harus tepat jenis, jadwal, dan dosis untuk dapat bekerja secara optimal dan mencegah resisten obat. penderita tb paru dan keluarga juga memerlukan dukungan informasi seputar tatalaksana gizi, karena gizi menjadi faktor penunjang dalam percepatan penyembuhan. oleh karena itu, peran aktif perawat komunitas dalam manajemen perawatan penderita tb di rumah sangat diperlukan. manajemen perawatan penderita tb paru di rumah secara aktif dapat dilakukan melalui telenursing. telenursing didefi nisikan sebagai suatu proses pemberian manajemen dan koordinasi asuhan ser ta pemberian layanan kesehatan melalui tehnologi informasi dan telekomunikasi (cna, 2013). menurut wula nd a r i (2012), ba hwa pengg u na a n telenursing mampu meningkatkan perilaku pender ita dalam pencegahan penularan tb paru. akan tetapi, metode telenursing ini cukup mahal. oleh karena itu, peneliti mencoba mengembangkan model baru yang lebih murah yaitu melalui n-smsi (nersshort message services). n-smsi merupakan salah satu bentuk intervensi keperawatan komunitas, di mana perawat komunitas mengirimkan sms kepada penderita tb paru. sms berisi pesan pengingat minum obat dan nutrisi, dikirim setiap hari, dengan frekuensi yang disesuaikan dengan jadwal minum obat penderita tb paru. sms yang dibangun berbasis website, menginduk pada suatu provider email, sehingga metode ini tidak memerlukan biaya yang besar. bahan dan metode pe nel it ia n i n i me r u p a k a n s t u d i prospektif. populasi target dalam penelitian ini adalah seluruh penderita tb paru baru fase intensif di wilayah kerja puskesmas pegirian, kota surabaya. sampel diambil dengan teknik purposive nonrandomized sampling dengan kriteria inklusi berikut: 1) penderita tb paru berusia 21-60 tahun; 2) penderita memiliki telepon seluler; 3) penderita bisa membaca dan menulis. sedangkan, kriteria eksklusinya, antara lain: 1) penderita tb paru yang menolak menjadi responden; dan 2) penderita tb paru dengan penyakit penyerta, seperti hiv, kanker, dan dm. sampel sejumlah 30 orang, dibagi menjadi kelompok perlakuan (15 orang) dan kelompok kontrol (15 orang). variabel independen dalam penelitian ini adalah n-smsi. variabel dependennya adalah kepatuhan minum obat yang dikumpulkan dengan kuesioner dan status gizi yang dinilai dengan pengukuran berat badan (kg). data kemudian diuji dengan wilcoxon signed rank test, mann withney, dan independent t-test dengan α≤0.05. 191 model manajemen perawatan (eka mishbahatul mar’ah has, dkk.) tabel 1. tabulasi berat badan (kg) responden no. resp kelompok perlakuan kelompok kontrol sebelum sesudah perubahan sebelum sesudah perubahan 1 45 48 +3 50 52 +2 2 44 46 +2 44 46 +2 3 40 44 +4 51 51 0 4 25 27 +2 49 49 0 5 55 56 +1 48 50 +1 6 40 43 +3 45 46 +1 7 54 57 +3 54 55 +1 8 48 50 +2 58 60 +2 9 55 58 +3 50 51 +1 10 55 60 +5 43 44 +1 11 48 52 +4 48 50 +2 12 46 47 +1 41 41 0 13 44 46 +2 44 45 +1 14 56 60 +4 46 48 +2 15 54 59 +5 50 53 +3 wilcoxon signed rank test p = 0,001 wilcoxon signed rank test p = 0,002 mann whitney p = 0,589 hasil tabel 1, menunjukkan hasil uji wilcoxon signed rank test ada perbedaan status gizi kelompok perlakuan sebelum dan sesudah intervensi dilihat dari berat badan (kg), dengan p=0.001. begitu pula dengan kelompok kontrol, dengan p=0.002. hasil uji mann whitney menunjukkan tidak ada perbedaan status gizi yang berarti antara kelompok perlakuan dan kelompok kontrol, yang ditunjukkan dengan nilai p=0.589. tabel 2 , me nu nju k k a n ha sil uji independent t-test ada perbedaan kepatuhan antara kelompok perlakuan dan kelompok kontrol, dengan p=0.031. pembahasan tabel 1 menunjuk kan bahwa baik responden pada kelompok perlakuan dan kelompok kontrol mengalami peningkatan berat badan. pada kelompok perlakuan, kenaikan berat badan tertinggi 5 kg dan tabel 2. tabulasi kepatuhan responden no. resp perlakuan kontrol 1 100 100 2 100 100 3 100 66,7 4 100 66,7 5 100 100 6 100 100 7 100 100 8 100 100 9 100 100 10 100 100 11 100 100 12 66,7 66,7 13 100 100 14 100 100 15 100 100 mean = 97,78 sd = 8,60 mean = 93,34 sd = 13,8 independent t-test t-hitung = 1,058 df = 28 p = 0,031 192 jurnal ners vol. 10 no. 1 april 2015: 189–193 terendah 1 kg. sementara pada kelompok kontrol, kenaikan berat badan tertinggi 3 kg dan ada 3 responden yang berat badannya tetap. me n u r u t s a l i m a r, d k k (2 0 0 9), penyuluhan dapat meningkatkan pengetahuan tentang gizi dan secara tidak langsung mempengaruhi status gizinya. pada penelitian ini, kelompok perlakuan diberikan manajemen perawatan tb paru di rumah dengan n-smsi, sedangkan kelompok kont rol diber ikan pelayanan sesuai dengan standar yang dilakukan di puskesmas pegirian. responden pada kelompok perlakuan mendapatkan penyuluhan kesehatan tentang gizi melalui pesan singkat setiap hari 1 kali selama periode intensif (2 bulan). adanya intervensi yang mengingatkan pasien untuk mengonsumsi makanan yang bergizi dapat membantu pasien untuk lebih meningkatkan berat badannya. akan tetapi, ada tidaknya pesan tersebut tidak menjadi masalah, karena petugas kesehatan juga selalu melakukan penyuluhan kesehatan pada pasien saat pasien melakukan kunjungan untuk pengambilan obat. di samping itu, menurut mansjoer (2001), pasien tb paru yang sudah mengonsumsi oat biasanya berat-badannya berangsur-angsur meningkat. pada penelitian ini, responden adalah pasien tb paru fase intensif yang sudah terpapar dengan pengobatan. oleh karena itu, kelompok kontrol pun dapat mengalami peningkatan berat badan. meskipun poin peningkatannya masih lebih rendah bila dibandingkan dengan kelompok perlakuan. berdasarkan tabel 2 diketahui bahwa ada pengaruh kepatuhan model manajemen perawatan n-smsi (ners-short message service intervention) terhadap peningkatan kepatuhan minum obat pasien tb paru. hal ini dikarenakan pasien diberikan pesan pengingat minum obat 15 menit sebelum waktu minum obatnya, sehingga pasien selalu ingat waktu m i nu m obat. menu r ut senewe (2002), pasien yang merasakan adanya dukungan dan perhatian dari petugas kesehatan untuk pengobatannya. penderita yang mendapat penyuluhan kesehatan dari petugas kesehatan mempunyai kemungkinan 4,19 kali untuk teratur atau patuh berobat dibandingkan penderita yang tidak mendapat penyuluhan kesehatan. menurut fawcett (2010), salah satu t i nd a ka n keperawat a n u nt u k mer uba h perilaku pasien yang tidak baik adalah melalui eksternal regulator dan mekanisme kontrol. perawat membantu pasien untuk mencapai respons perilaku baru dengan secara rutin memberikan regulasi eksternal dan kontrol. telenursing didefi nisikan sebagai suatu proses pemberian manajemen dan koordinasi asuhan serta pemberian layanan kesehatan melalui teknologi informasi dan telekomunikasi (cna, 2013). telenursing memungkinkan perawat untuk mengontrol pasien, meskipun pasien dan perawat tidak bertemu setiap hari. teknologi yang dapat digunakan dalam telenursing sangat bervariasi, salah satunya: telepon seluler (scotia, 2008). n-smsi merupakan salah satu bentuk intervensi keperawatan komunitas, di mana perawat komunitas mengirimkan pesan singkat melalui telepon seluler (sms) kepada penderita tb paru. sms berisi pesan pengingat minum obat dan nutrisi, dikirim setiap hari, dengan frekuensi yang disesuaikan dengan jadwal minum obat penderita tb paru. sms yang dibangun berbasis website, menginduk pada suatu provider email, sehingga metode ini tidak memerlukan biaya yang besar. metode ini dapat digunakan sebagai salah satu alternatif manajemen perawatan untuk pasien tb paru di rumah. keuntungan lain yang dirasakan pasien adalah, pasien merasa ada perhatian dari perawat, ada dukungan informasi yang diberikan oleh perawat, sehingga semakin men i ng kat ka n kom it men pasien u nt u k menuntaskan pengobatan. simpulan dan saran model manajemen perawatan n-smsi (ners-short message service intervention) dapat meningkatkan kepatuhan minum obat pasien tb paru. hal ini dikarenakan pasien diberikan pesan pengingat minum obat 15 menit sebelu m wak t u minu m obat nya, sehingga pasien selalu ingat waktu minum obat. 193 model manajemen perawatan (eka mishbahatul mar’ah has, dkk.) model manajemen perawatan n-smsi (ners-short message service intervention) tidak berpengaruh terhadap peningkatan status gizi pasien tb paru yang dinilai dengan berat badan (kg). hal ini dikarenakan ada banyak faktor yang lebih mempengaruhi status gizi pasien tb paru. model manajemen perawatan n-smsi (ners-short message service intervention) dapat dikembangkan oleh petugas kesehatan sebagai alternatif metode yang digunakan untuk meningkatkan kepatuhan minum obat pada pasien tb paru. penelitian selanjutnya diharapkan memodifi kasi model manajemen perawat an pasien t b par u yang dapat meningkatkan status gizi pasien tb paru secara signifi kan. kepustakaan cna. 2013. telehealth: the role of the nurses. retrieved november 12, 2013, from www.cna-aiic.ca: http://www.cna-aiic. ca/~/media/cna/page%20content/.../ ps89_telehealth_e.pdf depkes ri. 2009. kmk no. 364 tentang penanggulangan tuberkulosis. depkes ri. 2001. pedoman penanggulangan tuberkulosis di indonesia (ppti). jakarta: depkes ri. d e pke s r i. 2012 . s t ra t e g i n a si o n a l penanggulangan tb di indonesia 20102014. retrieved maret 21, 2013, from www.pppl.depkes.go.id: http://www. pppl.depkes.go.id/stratnas_tb.pdf fawcett. 2010. introduction to theoritical nursing knowledge. chicago: jones and bartlett learning. hariadi, s. 2004. tuberculosis treatment in the public and private sector potential for collaboration . simposium nasional tb update iii 2004, pp. 22–23. surabaya. mansjoer. 2001. kapita selekta kedokteran, edisi 3. jakarta: media aesculapius. salimar, d k k. 2009. peran peny ulu han dengan menggunakan leafl et terhadap per ubahan pengetahuan dan sikap ibu balita gizi kurang. pgm 32 (2), 122–130. scotia. 2008. telenursing practice standards. retrieved maret 21, 2013, from www. crnns.ca: www.crnns.ca/documents/ telenursingpractice2008.pdf ‎ s e n e w e . 2 0 0 2 . fa k t o rf a k t o r y a n g mempengar uhi kepat uhan berobat penderita tb paru di puskesmas depok. buletin penelitian kesehatan, vol. 30, no. 1 , 31–38. wulandari, n. 2012. penggunaan telenursing untuk meningkatkan perilaku penderita dalam mencegah penularan tb paru. surabaya: tesis universitas airlangga. tidak dipublikasikan. 112 peran keluarga dan kualitas hidup pasien kanker serviks (the role of family and quality of life in patients with cervical cancer) tiyas kusumaningrum*, retnayu pradanie*, esti yunitasari*, sih kinanti** *divisi keperawatan maternitas, fakultas keperawatan universitas airlangga **ruang merak rsud dr. soetomo surabaya email: tiyas-k@fkp.unair.ac.id abstrak pendahuluan. diagnosis kanker serviks telah menjadi beban besar baik bagi pasien dan keluarga. untuk pasien, kanker serviks menghilangkan beberapa peran mereka sebagai istri dan ibu. kebanyakan pasien kanker dengan stadium lanjut memiliki skor kualitas hidup rendah yang menunjukkan mereka memiliki masalah. keluarga harus mengurus orang-orang tercinta mereka berurusan dengan diagnosis, pengobatan, dan efek samping dari kanker serviks. keluarga sebagai pengasuh mungkin tidak siap untuk melakukan peran itu. tujuan dari penelitian ini adalah untuk mengidentifikasi korelasi tugas kesehatan keluarga pada kualitas hidup pada pasien dengan kanker serviks. metode. penelitian ini menggunakan desain cross-sectional. populasi dalam penelitian ini adalah semua pasien dengan kanker serviks dan keluarga mereka di bangsal ginekologi rs dr soetomo surabaya. data diambil dengan wawancara terstruktur menggunakan fact cx untuk kualitas hidup dan kuesioner tugas kesehatan keluarga. analisis regresi linier diaplikasikan dengan tingkat signifikansi ≤0.05. hasil. sebagian besar keluarga memiliki tugas kesehatan keluarga tingkat sedang, sedangkan mayoritas pasien juga memiliki kualitas hidup tingkat sedang. tidak ada korelasi yang signifikan antara tugas kesehatan keluarga pada kualitas hidup pada pasien dengan kanker serviks. diskusi. kualitas hidup pada pasien dengan kanker serviks tidak terpengaruh secara langsung oleh tugas kesehatan keluarga mereka. meskipun demikian pasien merasa bersyukur bahwa keluarga mereka sangat mendukung selama pengobatan kanker mereka. kata kunci: tugas keluarga kesehatan, kenyataannya cx, dukungan keluarga, kualitas hidup, kanker serviks abstract introduction. cervical cancer diagnosis has been a major burden both for patients and their family. for patients, cervical cancer obliterated some of their role as a wife and a mother. most patients with advance cancer have low score of quality of life indicating they have problems. family must take care of their beloved ones dealing with the diagnosis, treatment, and side effects of cervical cancer. family as a caregiver might be ill prepared to undertake that role. the objective of this research was to identify the correlation of family health task on quality of life in patients with cervical cancer. methods. this research employed cross-sectional design. population in this research was all patients with cervical cancer in gynecology ward dr soetomo hospital in surabaya. participant for this research were patients with cervical cancer and their family. data were taken by structured interview using fact cx for quality of life and family health task question form. linear regression analysis was applied with level of significance ≤0.05. results. most family had moderate level of family health task while most patients also have moderate level of quality of life. unfortunately there are no significance correlations of family health task on quality of life in patients with cervical cancer. discussion. quality of life in patient with cervical cancer was not affected directly by their family health task. nonetheless patient gratefully thanks family for their support during their cancer treatments. keywords: family health task, fact cx, family support, quality of life, cervical cancer ____________________________________________________________________________________________________ pendahuluan kanker serviks merupakan jenis kanker ginekologis paling sering terjadi pada wanita (cunningham 2005). penderita kanker serviks terutama pada stadium lanjut mempunyai berbagai keluhan yaitu nyeri panggul, kelelahan, perdarahan spontan, penurunan nafsu makan, sesak napas, konstipasi, dan kesulitan berkemih (dunleavey 2009). dukungan keluarga sangat dibutuhkan pasien kanker serviks dalam menghadapi kehidupan paska diagnosis kanker dan penanganannya. terdapat lima tugas kesehatan keluarga sebagai bagian dari fungsi keluarga dalam perawatan kesehatan antara lain; keluarga mampu mengenali permasalahan yang ada, mampu mengambil keputusan tindakan kesehatan yang tepat, mampu merawat anggota keluarga yang sakit, mampu memelihara kesehatan lingkungan, dan mampu menggunakan fasilitas kesehatan yang tersedia (basavanthappa 2008). angka kejadian kanker serviks sangat tinggi terutama di negara berkembang. perkiraan angka kejadian kanker serviks di usa pada tahun 2010 adalah 12.200 kasus baru, dan 4.210 kematian (nci 2010). kejadian kanker serviks per tahun di indonesia sejumlah 13.762 kasus dan 7.493 kematian. kanker serviks merupakan kanker ketiga terbanyak mailto:tiyas-k@fkp.unair.ac.id jurnal ners vol. 11 no. 1 april 2016: 112-117 113 yang terjadi pada wanita di indonesia, serta kanker kedua yang paling sering terjadi pada wanita usia 15 tahun sampai dengan 44 tahun (who 2010). menurut data dinas kesehatan jawa timur pada tahun 2011 terdapat 901 perempuan dengan diagnosa neoplasma ganas serviks, dengan jumlah pasien rawat inap sebanyak 790 kasus (dinkes & ppmk 2012). berbagai upaya peningkatan kondisi pasien paska kemoterapi telah banyak dilakukan. pemberian penyuluhan selama perawatan pada pasien kanker serviks dan keluarga sudah dilaksanakan di ruang rawat pasien kanker serviks. pada beberapa pasien, penyuluhan diterima dengan baik namun pada kebanyakan pasien tetap mengalami penurunan kondisi paska kemoterapi. usia pasien kanker serviks umumnya diatas 35 tahun dan berpendidikan rendah sehingga sulit untuk menerima informasi yang cukup banyak dalam satu waktu penyuluhan. keluarga diharapkan berperan aktif untuk dapat membantu pasien kanker serviks memahami informasi yang diberikan petugas kesehatan serta terlibat dalam perawatan pasien baik di rumah maupun di rumah sakit. keterlibatan keluarga dalam membantu pasien menghadapi proses pengobatan kanker serviks dapat membantu pasien kanker serviks mencapai kualitas hidup yang optimal. bahan dan metode design penelitian yang digunakan adalah cross-sectional. pengamatan atau pengukuran setiap variabel dalam penelitian ini hanya akan dilangsungkan satu kali saja dan tidak ada pengukuran atau observasi ulang maupun lanjutan. populasi pada penelitian ini adalah seluruh keluarga penunggu pasien kanker serviks di ruang merak rsud dr. soetomo pada bulan oktober sampai dengan november 2013 berjumlah 48 orang. responden yang berpartisipasi dalam penelitian ini berjumlah 28 orang yang dipilih berdasarkan kriteria inklusi dan eksklusi. mayoritas responden keluarga adalah perempuan sedangkan untuk responden pasien seluruhnya berjenis kelamin perempuan. teknik pengambilan sampling yang digunakan adalah consecutive sampling. variabel dalam penelitian ini adalah lima tugas kesehatan keluarga (pengetahuan, kemampuan pengambilan keputusan kesehatan, kemampuan memelihara lingkungan sehat, kemampuan menggunakan fasilitas kesehatan, dan kemampuan merawat keluarga) dan kualitas hidup pasien kanker serviks. instrumen yang digunakan dalam penelitian ini adalah kuesioner lima tugas kesehatan keluarga dan kuesioner fact cx untuk mengukur kualitas hidup pasien kanker serviks. wawancara terstruktur berdasarkan kuesioner tersebut diterapkan pada pasien maupun keluarga. hal ini dilakukan karena permintaan responden yang merasa bahwa mereka akan lebih memahami jika kuesioner tersebut ditanyakan oleh peneliti. data yang didapatkan diolah menggunakan uji statistik linear berganda. hasil sebagian besar responden keluarga dalam penelitian ini telah mendapatkan informasi tentang kanker serviks. informasi yang dimiliki keluarga biasanya didapatkan dari petugas kesehatan di rsud dr soetomo. informasi yang banyak dipahami oleh responden adalah tentang definisi kanker serviks dan kegawatan penyakit tersebut sedangkan informasi tentang penanganan dan efek samping pengobatan belum dipahami dengan baik. responden pasien mayoritas adalah pasien kanker serviks yang berada pada stadium iib. kemampuan keluarga menjalankan lima tugas kesehatan keluarga mayoritas pada tingkat baik. pada komponen penggunaan layanan kesehatan dan keterampilan keluarga dalam merawat pasien kanker serviks, kemampuan keluarga merata pada tingkat baik, cukup, dan kurang. sebagian besar pasien kanker serviks mempunyai kualitas hidup pada tingkat baik dan cukup namun tidak ada tingkat kualitas hidup ppasien yang dominan dalam penelitian ini. komponen kualitas hidup pasien kanker serviks yang mempunyai rerata skor terendah adalah komponen keadaan fisik. pada komponen keadaan fisik pasien banyak mengeluhkan tentang pengeluaran cairan keputihan atau perdarahan pervaginam serta masalah yang ditimbulkan oleh cairan tersebut seperti gatal, dan bau tidak sedap. pasien kanker serviks menyatakan bahwa mereka mendapat dukungan dari keluarga dalam menghadapi penyakit dan pengobatannya. pada komponen perhatian khusus tidak ada pasien yang menyatakan ingin hamil lagi. rerata usia pasien lebih dari 35 tahun dan atau telah memiliki jumlah anak yang cukup. peran keluarga dan kualitas hidup (tiyas kusumaningrum, dkk.) 114 hasil regresi variabel lima tugas kesehatan keluarga terhadap nilai skor fact cx (quality of life) adalah sebesar 0,301. hal ini menunjukkan terdapat hubungan yang rendah antara variabel lima tugas kesehatan keluarga dengan quality of life pasien kanker serviks di ruang merak rsud dr. soetomo. hasil analisis determinasi menunjukkan hasil r 2 adalah 0,091 yang berarti bahwa sumbangan pengaruh lima tugas kesehatan keluarga terhadap variabel quality of life adalah sebesar 9,1%. hasil regresi menunjukkan bahwa f hitung adalah 0,340 sedangkan jika dibandingkan dengan f tabel adalah 2,964. nilai f hitung lebih kecil dari nilai f tabel mengindikasikan bahwa tidak ada pengaruh lima tugas kesehatan keluarga dengan nilai quality of life pasien kanker serviks. pengujian koefisien regresi variabel lima tugas kesehatan keluarga dilakukan untuk mengetahui adanya pengaruh secara parsial dari variabel tersebut dengan nilai kualitas hidup pasien kanker serviks (fact cx). tabel distribusi t dicari pada α=0.25 (uji dua sisi) dengan df=n-k-1 yaitu 17. dengan pengujian dua sisi didapatkan t tabel yaitu 2,1098. hasil t hitung untuk seluruh variabel lima tugas kesehatan keluarga menunjukkan nilai dibawah t tabel. perbandingan t hitung dan t tabel tersebut menunjukkan bahwa tiap variabel lima tugas kesehatan keluarga secara parsial tidak berpengaruh secara signifikan terhadap nilai fact cx. konstanta menunjukkan nilai 80,587 berarti bahwa jika nilai semua komponen lima tugas kesehatan keluarga adalah 0 maka skor fact cx adalah 80,587. pembahasan penelitian ini menunjukkan hasil bahwa sebagian besar responden yang merupakan keluarga penunggu pasien kanker serviks yang dirawat di ruang merak rsud dr. soetomo memiliki skor lima tugas kesehatan keluarga dalam kategori cukup. kemampuan keluarga yang baik dalam melaksanakan lima tugas kesehatan keluarga dapat menjadikan keluarga sebagai pemberi perawatan yang efektif bagi anggota keluarga yang sakit (friedman et al. 2003). keluarga yang dapat menjalankan fungsi perawatan kesehatan untuk keluarga yang sakit dapat membantu anggota keluarga yang sakit mencapai kondisi yang lebih baik secara fisik maupun psikologis. jenis informasi yang diterima oleh responden sangat beragam namun sebagian besar tentang definisi penyakit kanker serviks dan kondisi lanjut yang mungkin dialami oleh pasien jika tidak segera melakukan perawatan. setiap keluarga maupun pasien kanker mempunyai kebutuhan yang beragam akan informasi yang diinginkan tentang penyakit yang sedang dihadapi. informasi tentang diagnosis dan penatalaksanaan medis merupakan hal yang diharapkan pada masa awal penegakan diagnosis pasien kanker, sedangkan informasi tentang topic non medis seperti cara koping dan membina hubungan yang baik dengan pasien kurang diminati (adams et al. 2009). sebuah review tentang pencarian informasi oleh keluarga pasien kanker yang dilakukan oleh mccarthy (2011) memperlihatkan hasil bahwa keluarga mencari informasi tentang kesehatan pasien melalui empat cara. cara tersebut antara lain mendampingi pasien saat kontrol, membuat janji bertemu dengan petugas kesehatan bersama dengan pasien, langsung menemui petugas kesehatan, dan membawa hadiah untuk petugas kesehatan. dari keseluruhan responden hanya tujuh orang responden yang menyatakan belum mendapatkan informasi tentang kanker serviks (mccarthy 2011). sebagian responden yang menyatakan belum mendapatkan informasi menjelaskan bahwa mereka percaya dengan segala tindakan yang akan dilakukan oleh petugas kesehatan dan mereka merasa lebih cemas jika mengetahui lebih banyak tentang penyakit pasien. sebuah penelitian tentang kebutuhan keluarga akan informasi yang dilakukan oleh andreassen menunjukkan bahwa diantara keluarga pasien kanker, sebagian kecil memang tidak menginginkan banyak informasi. tingkat pengetahuan keluarga tentang penyakit kanker serviks dapat dipengaruhi oleh cara keluarga memperoleh informasi serta latar belakang pendidikan keluarga serta aspek psikologis yang perlu untuk dilakukan penelitian lebih lanjut (andreassen et al. 2005). sebagian pasien kanker serviks di indonesia datang pada stadium yang lanjut dan membutuhkan penatalaksanaan medis yang cepat sehingga keluarga tidak mempunyai banyak pilihan dan waktu dalam memutuskan hal yang harus dilakukan untuk anggota keluarga yang sakit. sebagian responden dalam penelitian ini bergender perempuan namun diantara mereka menyeatakan tidak menemui banyak kesulitan dalam memutuskan rencana perawatan kesehatan untuk anggota keluarga jurnal ners vol. 11 no. 1 april 2016: 112-117 115 mereka. hampir seluruh responden perempuan adalah wanita bekerja yang mendapatkan penghasilan perbulan dari pekerjaan mereka sebagai cara mereka membantu perekonomian keluarga. sebagian besar responden menyatakan bahwa setiap keputusan yang mereka ambil untuk anggota keluarga yang sakit kanker serviks adalah hasil dari musyawarah yang dilakukan dengan anggota keluarga yang lain meskipun pada akhirnya keputusan tetap berada pada responden. perempuan yang mempunyai pekerjaan tetap dan penghasilan yang setara dengan laki-laki dalam keluarga cenderung mempunyai kesetaraan dalam menyampaikan pendapat dan ikut andil dalam keputusan dalam keluarga. peran anggota keluarga lain dalam membantu mempertimbangkan keputusan yang tepat sangat diperlukan sehingga keluarga yang bertanggung jawab atas pasien kanker serviks yakin akan keputusan yang diambil dan tidak merasa menyesal pada keputusan yang telah mereka buat. petugas kesehatan baik dokter maupun perawat juga memegang peranan untuk memberi gambaran pada responden tentang kondisi kesehatan pasien kanker serviks sehingga dengan informasi yang diberika oleh petugas kesehatan, keluarga dapat mengambil keputusan yang tepat yang telah disertai dengan pertimbangan sebelumnya tentang baik buruknya penatalaksanaan yang akan diterapkan pada pasien kanker serviks. sebagian besar responden keluarga sudah mampu untuk membuang sampah pada tempatnya, menguras tempat penampungan air seperti bak mandi dan wadah air minum, keluarga juga telah menyediakan tempat sampah di dalam rumah, dan membersihkan tempat buang air sesuai kebutuhan serta menyediakan dan menggunakan sabun antiseptik di kamar mandi mereka. meskipun sebagian besar responden sudah mampu menjaga kebersihan lingkungan, terdapat tiga responden yang tidak mempunyai kakus pribadi. satu responden menggunakan kamar mandi umum dan dua responden tidak menggunakan kakus namun menggunakan lobang pembuangan untuk buang air. sebagian besar responden meskipun menyediakan tempat sampah di dalam rumah namun tempat sampah yang ada tidak mempunyai penutup tempat sampah yang memungkinkan binatang untuk masuk. menggunakan air bersih, mencuci tangan menggunakan sabun, menggunakan jamban sehat, dan membersihkan tempat penampungan air merupakan empat dari sepuluh indikator perilaku hidup bersih dan sehat yang disingkat menjadi phbs (setyani 2013). lingkungan memberikan pengaruh yang besar pada resiko dan kejadian kanker (kerrigan & kelly 2010). pasien kanker serviks yang mendapatkan kemoterapi ataupun radioterapi akan mengalami kondisi kesehatan yang menurun karena efek samping kanker serviks yang menurunkan imunitas tubuh pasien kanker serviks (dunleavey 2009). keluarga diharapkan dapat menjaga keberrsihan lingkungan tempat pasien kanker serviks dirawat sehingga pasien kanker yang lebih rentan mendapatkan penyakit lain karena penurunan kondisinya dapat terhindar dari kesakitan akibat lingkungan yang tidak bersih. skor penggunaan layanan kesehatan berimbang antara kategori baik, cukup, dan kurang. mayoritas responden adalah perempuan dan perempuan merupakan tokoh penting dalam program kesehatan keluarga di indonesia. hal ini terbukti pada jumlah kader posyandu yang mayoritas adalah perempuan. sebagian besar responden menyatakan telah menggunakan fasilitas pelayanan kesehatan milik pemerintah yang disediakan di sekitar wilayah tempat tinggal mereka, namun hanya beberapa dari mereka berperan aktif dalam program yang dicanangkan oleh pelayanan kesehatan tersebut. para responden tersebut berperan aktif karena mereka adalah kader atau didalam keluarga yang satu rumah menjadi kader posyandu. kader kesehatan memang dipilih dari anggota masyarakat untuk meningkatkan kepercayaan diri masyarakat dalam meningkatkan derajat kesehatan lingkungan tempat tinggalnya (effendy 1998). sebagian besar responden yang kurang aktif hanya memanfaatkan puskesmas atau rumah sakit pemerintah untuk berobat saat sakit ataupun meminta surat rujukan untuk dilanjutkan ke rumah sakit pemerintah dengan tipe yang lebih tinggi. kurangnya pemanfaatan tempat pelayanan kesehatan primer dan daerah oleh responden disebutkan bahwa responden sering menunda pengobatan atau pergi ke klinik umum karena khawatir mendapatkan pelayanan yang lama di puskesmas atau rs daerah. sebagian kecil responden juga masih lebih memilih obat paten dibandingkan dengan obat generic yang disarankan pemerintah dan tersedia secara murah atau gratis di tempat pelayanan kesehatan milik pemerintah. kurangnya minat masyarakat menggunakan layanan kesehatan milik pemerintah pernah peran keluarga dan kualitas hidup (tiyas kusumaningrum, dkk.) 116 diteliti pada tahun 2001 dengan hasil bahwa sebagian besar masyarakat yang menggunakan layanan kesehatan milik pemerintah merasa kurang puas dengan pelayanan yang diberikan dibandingkan dengan pelayanan di klinik atau rs swasta (setyowati & lubis 2003). terdapat kecenderungan bahwa responden dengan keluarga pasien kanker serviks yang mempunyai keterbatasan fisik dan skor kualitas hidup rendah mempunyai keterampilan merawat lebih baik dibandingkan dengan responden yang keluarga menderita kanker serviks mempunyai kondisi fisik yang lebih baik. pasien kanker serviks stadium lanjut mendapatkan penanganan seperti kemoterapi dan radioterapi yang memberikan efek samping kelemahan pada pasien (dunleavey 2009). pasien kanker yang berada pada stadium lanjut membutuhkan perhatian dan perawatan lebih dari keluarga (given et al. 2001). keluarga dengan pasien kanker serviks yang mengalami kelemahan akan mendapatkan pengalaman dalam membantu segala aktivitas pasien selama di rumah. keluarga yang terbiasa membantu kegiatan pasien maka dalam penilaian keterampilan memberi performa yang lebih baik jika dibandingkan dengan keluarga yang belum memiliki pengalaman membantu aktivitas pasien. rerata terendah dari keseluruhan komponen fact cx adalah skor keadaan fisik pasien kanker serviks. terdapat lebih dari dealapan pasien kanker serviks yang mempunyai skor kurang dari 10. sebagian besar pasien menjawab bahwa mereka sering merasa tidak bertenaga, kadang hilang nafsu makan, selalu merasakan nyeri dengan skala nyeri yang beragam, dan terganggu dengan eefek samping pengobatan seperti mual, muntah, kelemahan dan perubahan penampilan. pengobatan kanker selalu memberikan efek samping pada pasien yang beragam tergantung dari tipe kanker serta jenis obat atau terapi yang diberikan (catane et al. 2006). hasil analisis statistic menunjukkan bahwa lima tugas kesehatan keluarga tidak berhubungan dengan kualitas hidup pasien kanker serviks baik secara bersama-sama maupun secara parsial. sebagian besar responden dengan pasien kanker serviks yang memiliki keterbatasan dalam melaksanakan aktivitas fisik dan berada pada stadium lebih lanjut mempunyai skor tugas kesehatan yang lebih baik dibandingkan dengan responden yang memiliki anggota keluarga pasien kanker serviks yang berada pada stadium awal atau seri pengobatan awal kanker serviks. keluarga yang memiliki anggota keluarga mengalami kanker akan berusaha merawat pasien sesuai dengan kebutuhan pasien, namun kurangnya pengalaman dapat menyebabkan keluarga tidak siap dalam menghadapi perubahan peran tersebut (given et al. 2001). keluarga dengan pasien kanker serviks yang belum mengalami keterbatasan fisik belum pernah membantu aktivitas pasien secara langsung, perawatan yang mereka berikan terbatas pada mengantar pasien ketika control ataupun berobat, memberi dukungan moral, serta mengingatkan jadwal minum obat pasien. keluarga yang telah merawat pasien kanker serviks yang mempunyai kondisi buruk akan belajar dari pengalaman mereka dan menerapkan kembali yang mereka pelajari pada situasi yang sama. pengalaman keluarga tersebut tentu tidak semua sesuai dengan peran yang diharapkan. keluarga perlu disiapkan dan diinformasikan tentang peran mereka untuk merawat pasien kanker serviks dan hal tersebut disediakan oleh tempat pelayanan kesehatan (given et al. 2001). edukasi dan keterlibatan pada keluarga penting untuk diberikan oleh setiap petugas kesehatan sehingga keluarga mampu merawat pasien sesuai kebutuhan (friedman et al. 2003). simpulan dan saran simpulan kemampuan keluarga menjalankan lima tugas kesehatan keluarga tidak secara langsung mempengaruhi kualitas hidup pasien kanker serviks. komponen seperti keadaan fisik, sosial, emosi, peran serta perhatian lain terkait sistem reproduksi lebih berperan untuk menentukan level dari kualitas hidup pasien kanker serviks. kemampuan keluarga melaksanakan lima tugas kesehatan keluarga meskipun tidak berpengaruh secara langsung dalam membentuk skor kualitas hidup pasien kanker serviks dapat membantu pasien kanker serviks mendapatkan kualitas hidup yang lebih baik. saran penelitian ini merekomendasikan kepada perawat dan institusi pelayanan kesehatan khususnya pemerintah baik pusat jurnal ners vol. 11 no. 1 april 2016: 112-117 117 maupun daerah untuk meningkatkan keterlibatan keluarga dalam perawatan kesehatan bagi pasien kanker serviks dengan memberikan informasi dan pelatihan keterampilan yang tepat. penelitian selanjutnya sebaiknya menggunakan instrument yang lebih tepat dan lebih sesuai untuk responden dengan kultur dan bahasa indonesia untuk mempermudah dan meningkatkan validitas pengukuran variabel kemampuan keluarga melakukan lima tugas kesehatan keluarga dan juga pengukuran kualitas hidup pasien kanker serviks. kepustakaan adams, e., boulton, m., & watson, e. (2009). the information needs of partners and family members of cancer patients: a systematic literature review. [review]. patient education and counseling, 77, 8. doi: 10.1016/j.pec.2009.03.027 basavanthappa. (2008). community health nursing: jaypee brothers, medical publishers. catane, r., cherny, n. i., kloke, m., tanneberger, s., & schrijvers, d. (2006). handbook of advanced cancer care. oxon, united kingdom: taylor & francis. cunningham, g. (2005). williams obstetrics (22 ed.). new york: mcgraw-hill. dinkes. (2012). kegiatan pengendalian kanker di jawa timur (ppmk, trans.) (pp. 5). surabaya: dinas kesehatan provinsi jawa timur. dunleavey, r. (2009). cervical cancer : a guide for nurses. chichester: john wiley & sons ltd. effendy, d. n. (1998). dasar-dasar keperawatan kesehatan masyarakat: egc. friedman, m. m., bowden, v. r., & jones, e. (2003). family nursing: research, theory & practice: prentice hall. given, b. a., given, c. w., & kozachik, s. (2001). family support in advanced cancer. ca a cancer journal for clinicians, 51(4), 19. kerrigan, d., & kelly, j. (2010). understanding cancer and the environment. retrieved from nci. (2010). cervical cancer. maryland, usa: national cancer institute. setyani, s. (2013). terapkan 10 indikator phbs dalam lingkungan keluarga. retrieved from http://www.promkes.depkes.go.id/inde x.php/topik-kesehatan/106-terapkan10-indikator-phbs-dalam-lingkungankeluarga setyowati, t., & lubis, a. (2003). pemanfaatan pelayanan kesehatan dan jaminan pemeliharaan kesehatan (susenas 2001). buletin penelitian kesehatan, 31(4), 9. who. (2010). indonesia: human papiloma virus and related cancers, fact sheet 2010. barcelona, spanyol: who/ico hpv information centre. http://www.promkes.depkes.go.id/index.php/topik-kesehatan/106-terapkan-10-indikator-phbs-dalam-lingkungan-keluarga http://www.promkes.depkes.go.id/index.php/topik-kesehatan/106-terapkan-10-indikator-phbs-dalam-lingkungan-keluarga http://www.promkes.depkes.go.id/index.php/topik-kesehatan/106-terapkan-10-indikator-phbs-dalam-lingkungan-keluarga http://www.promkes.depkes.go.id/index.php/topik-kesehatan/106-terapkan-10-indikator-phbs-dalam-lingkungan-keluarga 214 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.21388 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research determinants of nutritional status among pregnant women: a transcultural nursing approach ni ketut alit armini, nurul hidayati, and tiyas kusumaningrum faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract introduction: pregnant women experiencing poor nutritional status remains a problem which is still commonly found in surabaya. poor nutritional status is one of the causes of increased mortality in pregnant women. the mother's education and occupation, family income, number of children, and family shape are associated with the incidence of nutritional status in pregnant women. the purpose of this study was to explain the factors related to the nutritional status of pregnant women based on transcultural nursing theory. methods: his study uses a cross-sectional design. the population were pregnant women at the public health center tanah kali kedinding surabaya indonesia, 104 respondents were selected using a consecutive sampling technique. the independent variables were technological, religious, family support, cultural values, political & legal, economic, and educational, while the dependent variable was the incidence of nutritional status in pregnant women. the data was obtained using questionnaires and mid upper arm circumstance (muac) measurements. the data was analyzed using the spearman rho test. results: there was a relationship between technological (p=0.001 ; r=0.332), family support (p=0.000 ; r=0.379), cultural values (p=0.000 ; r=0.702), political & legal (p=0.000 ; r=0.387), economic (p=0.031 ; r=0.212), and educational (p=0.020 ; r=0.228) factors with nutritional status in pregnant women. discussion: technological, family support, cultural values, political & legal, economic, and educational factors influenced the nutritional status of pregnant women. the cultural factor was the most dominant in influencing the nutritional status of pregnant women. article history received: 13 august, 2020 accepted: november 7, 2020 keywords women; pregnant; health; nutritional; transcultural contact ni ketut alit armini  k.alita@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: armini, n. k. a., hidayati, n., & kusumaningrum, t. (2020). determinants of nutritional status among pregnant women: a transcultural nursing approach. jurnal ners, 15(2). 214 221. doi:http://dx.doi.org/10.20473/jn.v15i2.21388 introduction in indonesia, the prevalence of gdm is around 14% of all pregnant women, and 10-25% of the total cases handled are undiagnosed or diagnosed gdms (dewi et al., 2020). according to medical record department, sardjito hospital of yogyakarta, the prevalence of gdm in indonesia is approximately 1,93,6 on inpatient disease index of gdm in the last 10 years from 2012-2013. many pregnant women experience nutritional problems, especially malnutrition such as a chronic energy deficiency (blondin & logiudice, 2018). chronic energy deficiency (ced) is one of the causes of increased mortality in mothers (bhutta et al., 2008). many factors affect the incidence of ced, one of which is a less diverse diet and fewer portions (rubina shaheen, 2016). chakona & shackleton (2019) stated that the causes of a lack of variety in food intake consumed by mothers included the taboo culture of food. in some regions in indonesia there are https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:k.alita@fkp.unair.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 215 still many pregnant women who adhere to the belief in abstinence from consuming certain types of food that are required during pregnancy (triharini, nursalam, et al., 2018). the culture affects all aspects of life including health (diana et al., 2019). in addition to cultural factors, there are also several factors related to the health of pregnant women, namely education, income, family members (serbesa, iffa, & geleto, 2019), type of residence, mother's age, and parity (islam, islam, bharati, aik, & hossain, 2016). the results of a nutritional status survey in indonesia in 2016 amounted to 16.2% of pregnant women experiencing ced. this shows that there is an increase in ced problems in pregnant women, as much as 2.9% from the previous year, and in the same year the intake of nutritional consumption is still relatively low, at 26.3% of pregnant women whose consumption is good and meets energy adequacy (kemenkes, 2017). the results of the demographic health survey (dhs) in 2018 recorded that the proportion of pregnant women aged 15-49 years with upper arm circumference <23.5 cm was 17.3%. the amount of pregnant women who experienced ced in east java was 19.59% and surabaya city was ranked the second-highest among other districts and cities at 33%. data obtained from the health report surabaya city in 2018 of 681 mothers who had a pregnancy check at the tanah kali kedinding public health center found 145 (21.3%) pregnant women who experienced ced. based on a preliminary study conducted on 10 february 2020 through interviews with 10 pregnant women who had a pregnancy check at the policlinic of public health center tanah kali kedinding, it was found that 20% of pregnant women experience poor nutritional status. based on interviews, 40% of pregnant women still believe in food restrictions, 50% of pregnant women have less family support, and all pregnant women say they do not know about government policies related to nutrition fulfilment programs for pregnant women. beliefs about the culture that can affect health in indonesia are still very rich and varied. some people still believe in the culture of food prohibition for pregnant women, which can accidentally eliminate some important nutrients that should be consumed by pregnant women (parmar, khanpara, kartha, resident, & shah, 2013). food restrictions are believed to be the cause of why mothers become malnourished (ipa, prasetyo, & kasnodihardjo, 2016). the problem of malnutrition experienced by the mother during pregnancy has serious consequences for the mother and the baby in both the short and long term. short-term effects on the mother can cause a risk of abnormalities and complications, namely anemia, bleeding, and cause labor difficulties and bleeding after delivery. in infants malnutrition can cause low birth weight and preterm birth, which has a long-term impact as in the future the child will be at risk of experiencing mental and physical disorders during growth and development (demelash, id, & dadi, 2019). the cultural dimension of pregnant women in the city of surabaya is still quite strong, therefore an analysis of the problem using the transcultural approach is needed. transcultural nursing was chosen because it depicts humans who are not separated from cultural backgrounds and social structures, views, history and environmental context. the purpose of this study was to analyze the factors related to nutritional status in pregnant women based on transcultural nursing theory. materials and methods this research was a phenomenological approach qualitative research. data collection was carried out through in-depth interviews with a voice recorder and field notes. participants were selected based on research needs with the principle of appropriateness and adequacy. participants in this research were mothers who delivered to a maximum of 1 year with a history of gdm. the data collection was finished in the twelve participant when the categorization of data was saturated. in addition, the availability of time and resources in research is also taken into consideration in ending data collection. this research instrument was the researchers themselves. purposive sampling technique with sampling criterion was used. the inclusion criteria in this study were 1). mothers who have given birth for a maximum of the last 1 year and were treated at dr. sardjito with a history of dmg. 2) living in the special region of yogyakarta province. 3). the maternal age of delivery was less than 18–45 years. 4). maternal gestational age was less than 32 weeks and more than 40 weeks. 5). willing to become a participant by agreeing the informed consent. the exclusion criterion was poor pregnancy outcome (stillbirth and severe defects). data analysis used the colaizzi method. the inclusion of additional steps were 1). transcribing all the subjects’ descriptions. 2). extracting significant statements (statements that directly relate to the phenomenon under investigation). 3). creating formulated meanings. 4). aggregating formulated meanings into theme clusters. 5). developing an exhaustive description (that is, a comprehensive description of the experience as articulated by participants). 6). additional step was researcher’s interpretative analysis of symbolic representations from the articulation of the symbolic representation (which occurred during participant interview). 7). identifying the fundamental structure of the phenomenon. 8). returning to participants for validation (edward & welch, 2011). data were collected between december 2013 and february 2014. nursing theory of maternal role attainment (shrestha et al., 2019) was used as a reference to analyse life experience of mother with gdm. the validity of the data in this research was tested and included the credibility, dependability, and conformability. the study was declared to have n. k. a. armini et al. 216 | pissn: 1858-3598  eissn: 2502-5791 passed the ethical review by the research ethics committee, faculty of medicine, gadjah mada university. method the design of this study was descriptive-analytic. a cross-sectional study approach was used, whereby the researcher measures the data of the independent and dependent variables one at a time. population, samples, and sampling the population in this study was all pregnant women who visited ante natal care in the working area of the public health center tanah kali kedinding during the last 3 months from december 2019 to february 2020, totaling 260 pregnant women. samples were selected using a consecutive sampling technique. 104 pregnant women were found to fit the inclusion criteria, namely pregnant women who had a mother and child health book and exclusion criteria, namely pregnant women with mental disorders. variable the independent variables in this study are the use of technology, religiosity, family support, cultural, political & legal values, economics, and education as seven dimension of transcultural nursing. the dependent variable is the nutritional status of pregnant women. measurement the instruments used in this study were a questionnaire and muac measurement using tape to determine the nutritional status of pregnant women based on the mother and the child’s health book. the questionnaire in this study was taken and modified from the (yunitasari, pradanie, & susilawati, 2016) research questionnaire. the questionnaire consisted of 38 questions about the use of technology, including access to print and electronic media, access to health services, access to infrastructure, religiosity, including ways of looking at grace, ways of treatment or religious habits that have a positive effect on health, family support including emotional support, information support, facilities, cultural values including perceptions about health workers, cultural references, beliefs related to meeting nutritional needs, maternal habits, political & legal aspects including knowledge of regulations and policies, attitudes towards regulations and policies, economic factors including family income, and education aspects including the mother's education. the questionnaire was given in the form of close-ended questions, namely dichotomy questions (technology and political, & legal utilization questionnaire) and the questions were measured using a likert scale (questionnaire of religiosity, family support, cultural values). pregnant women are said to have a good value in seven factors in the transcultural nursing dimension if the score is >50% and less if the value scores ≤50%. the nutritional status of pregnant women is based on the measurement of the midupper arm circumference (muac) listed in the mch handbook. the category of nutritional status was less if the muac was <23.5 cm, the nutritional status was good if the muac was >23.5 cm. this questionnaire was tested for validity and reliability on 21 pregnant women with different populations and obtained valid results from all questionnaires. procedure conducting the research began with obtaining permission from the relevant parties. researchers collected data from 1-29 april 2020 using two methods, the first before the emergence of the covid19 outbreak. the researcher collected data at the public health center tanah kali kedinding surabaya every day mother, specifically from child health services (monday-wednesday). for the second method, after the covid-19 pandemic emergency was announced, the researcher collected data online through an online form by contacting each respondent using the telephone numbers obtained from the public health center. the researcher contacted the respondents and explained to the respondent the purpose, benefits of the study and obtained informed consent from the respondent. the researcher explained to the respondent how to fill out the questionnaire. the researcher checked the questionnaire had been completed before it was collected by the researcher. analysis the collected data were analyzed using the spearman rho statistical test with a significance level of p<0.05. if the results of p<0.05, h1 is accepted, meaning that there is a significant relationship between the independent variable and the dependent variable. if p≥0.05 then h0 is accepted, meaning that there is no relationship between the independent variable and the dependent variable. the strength of the variable relationship is expressed in a positive coefficient if r = +1, meaning there is a very strong positive relationship, if r = -1 this means there is a very strong negative relationship, and if r = 0 then there is no relationship. ethical clearance this research was conducted following research ethics and received a certificate of ethics from the ethics committee of the faculty of nursing, universitas airlangga with no. 1944-kepk. results socio-demographic characteristics (table 1) show that the majority of respondents and husbands of respondents aged 20-35 years were 88 (84.6%) and jurnal ners http://e-journal.unair.ac.id/jners | 217 82 (78.8%), but there were still some pregnant women who were less than 20 years old and over 35 years. maternal age <20 years or> 35 years is a highrisk age to be able to experience ced and tends to give birth to lbw babies. in the occupational category, 75 (72.1%) respondents were housewives, and for 70 (67.3%) the husband’s work was private. 35 (33.7%) -risk age to be able to experience ced and tends to give birth to lbw babies. in the occupational category, 75 (72.1%) respondents were housewives, and for 70 (67.3%) the husband’s work was private. 35 (33.7%) respondents had 1 child. mothers with a high number of births can experience various health problems for both mothers and their babies. 61 table 1. demographic distribution of respondents (n=104) demographic sub characteristics category frequency (f) percentage (%) mother's age (years) < 20 3 2.9 20-35 88 84.6 >35 13 12.5 husband's age (years) < 20 2 1.9 20-35 82 7.8 >35 20 19.2 mother’s occupation housewife 75 72.1 private employee 26 25 etc. 3 2.9 husband’s occupation civil servants 7 6.7 private employee 70 67.3 entrepreneur 16 15.4 etc. 11 10.6 number of children 0 34 32.7 1 35 33.7 2 22 21.2 ≥ 3 13 12.5 family form nuclear family 43 41.3 extended family 61 58.7 number of family members 2 11 10.6 3 13 12.5 4 21 20.2 ≥ 5 59 56.7 table 2. the relationship between the use of technology, religiosity, family support, cultural values, political & legal, economics, education and nutritional status of pregnant women (n=104) variable category nutritional status of pregnant women total significance less good f % f % n % technology utilization less 7 6.7 6 5.8 13 12.5 p = 0.001 r = 0.332 good 13 12.5 78 75 91 87.5 religiosity less 3 2.9 6 5.8 9 8.7 p = 0.266 r = 0.110 good 17 16.3 78 75 95 91.3 family support less 8 7.7 6 5.8 14 13.5 p= 0.000 r = 0.379 good 12 11.5 78 75 90 86.5 culture value less 13 12.5 2 1.9 15 14.4 p = 0.000 r = 0.702 good 7 6.7 82 78.8 89 85.6 politics & legal less 11 10.6 12 11.5 23 22,1 p = 0.000 r = 0.387 good 9 8.7 72 69.2 81 77,9 economy less 16 15.4 45 43.3 61 58.7 p= 0.031 good 4 3.8 39 37.5 43 41.3 r = 0.212 education low 10 9.6 20 19.2 30 28.8 p =0.020 high 10 9.6 64 61.5 74 71.2 r = 0.228 n. k. a. armini et al. 218 | pissn: 1858-3598  eissn: 2502-5791 (58.7%) respondents lived with their large family. large families can influence the culture and habits of mothers during pregnancy, mothers who live with large families tend to obey and hold fast the beliefs which family and ancestors have taught for generations. table 2 shows that most of the pregnant women who were in the good categories in utilizing technology, religiosity, family support, cultural values, legal politics, and education are in good nutrition status. it appears that some mothers’ economic status lacks good nutritional status. components of transcultural nursing related to the nutritional status of pregnant women include technology utilization factors (p = 0.001), family support (p = 0.000), cultural values (p = 0.000), political and legal (p = 0.000), economy (p = 0.031 ), education (p = 0.020). however, religiosity is not related to the nutritional status of pregnant women. discussion the nutritional status of pregnant women is one indicator by which to measure the nutritional status of the community. if nutritional consumption for pregnant women is not balanced with the needs of the body this can cause nutritional deficiencies. nutrient deficiencies in pregnant women are still very high in indonesia, this is indicated by the high mmr caused by ced during pregnancy (moh ri, 2009). the results of this study indicate that there are still some pregnant women (19.2%) experiencing poor nutritional status, it shows that there are still some pregnant women who have poor nutritional status with a muac less than 23.5 cm. transcultural nursing was depicts humans who are not separated from cultural backgrounds and social structures, views, history and environmental context. the seven transcultural components of nursing studied include technology, religiosity, family support, cultural, political & legal values, economics, and education(leininger & mcfarland, 2002). the data shows that there is a relationship between the use of technology with nutritional status in pregnant women. most pregnant women in the good category for technology use tend to have good nutritional status. similar research shows that information obtained by pregnant women from print or electronic media will increase the mother's knowledge about the importance of consuming nutritious food so that it can motivate mothers to regularly consume healthy and nutritious food(triharini, armini, & nastiti, 2018). the majority of pregnant women in this study were housewives. housewives spend more time at home. this can be used to utilize technology appropriately to find information about nutritional status and proper food during pregnancy and can also be used to make nutritious foods by utilizing modern equipment (such as blenders, refrigerators, etc.) to meet their nutritional needs. the education level of the majority of pregnant women also influences the appropriate utilization of technology in pregnant women. according to (krishnaswamy, 2001), the use of technology is strongly influenced by human resources or the human brain. the higher the level of education, the better the mastery and use of technology; this will have an impact on the health of the nutritional status of mothers during pregnancy. almost all pregnant women in the category of good religiosity have a good nutritional status. based on the results of the analysis, there is no relationship between religiosity and nutritional status in pregnant women. this is because almost all pregnant women have the same beliefs, causing no difference in the religious level of pregnant women. fitriani (2016) states that a person is said to have good religiosity by not only claiming to have religion (having religion), but also must have religious knowledge, religious beliefs, observe religious rituals, and behavior (religious morality). this has been seen in the majority of pregnant women. the results of this study also showed that many aspects of a pregnant mother's religiosity were positive. almost all pregnant women trust and are always grateful for the pregnancy they are experiencing, always pray for their health and the prospective baby, and follow the religious community’s “majelis ta‟lim” and want to share with others in need. this shows that pregnant women are already good at applying religious values related to the health of their nutritional status. although one's religiosity also influences the perspective of health, one's belief in a particular religion does not have a significant impact on nutritional status during pregnancy. almost all pregnant women have a good level of religiosity, but not all have good nutritional status, there are still pregnant women in the category of malnutrition. this is because several other factors can have an influence, such as utilizing health services and not paying attention to the religious aspects they believe, but rather paying attention to other factors such as beliefs in the cultural values they hold. family support is one of the factors related to nutritional status in pregnant women. there is a relationship between family support and nutritional status in pregnant women. the majority of pregnant women get positive family support and have a good nutritional status. pregnant women who get positive family support get the highest support in the emotional support aspect of the family, motivating pregnant women to consume nutritious food. according to (triharini, nursalam, et al., 2018) family support involves meaningful social relationships and can have a positive influence on the recipient. lack of family support can cause pregnant women to be negative in determining health care for themselves, especially related to the fulfilment of nutritional intake during pregnancy. negative family support in this study shows that families rarely listen jurnal ners http://e-journal.unair.ac.id/jners | 219 to the complaints of pregnant women, forbid the consuming of some food, do not allow them to be seen by health workers, and do not provide costs to go to health workers. family support is also seen as a reinforcing factor for the formation of health behaviors (alit armini, tristiana, & ose tokan, 2017). this finding shows that information about nutritional status in pregnant women also involves the family, so it can be a good supporting component for pregnant women. there is a relationship between cultural values and nutritional status in pregnant women. pregnant women with good cultural value categories have good nutritional status. nearly half of pregnant women still have some incorrect beliefs about culture related to fulfilling nutrition during pregnancy (taboo culture). this result is supported by research parmar et al., (2013) which shows that there are still many pregnant women who believe in old, unscientific culture during pregnancy that can affect the nutrition of pregnant women. culture is a view of the life of an individual or group concerning the values, beliefs, norms, patterns, and practices that are learned, shared and passed down between generations (diamond-smith, gupta, kaur, & kumar, 2016). this is evidenced by the general data of pregnant women, the majority of whom live with large families, so the influence of the previous generation is still strong in influencing the daily activities of pregnant women. however, in this study, some pregnant women did not believe in a culture related to pregnancy. this is done as a form of adherence to the advice and suggestions from parents because they are afraid of karma if they are not obedient to what is ordered by their parents. the results of this study also showed that there were still some pregnant women who had negative cultures and habits. negative cultural values are beliefs that do not lead or refer to health (yunitasari, pradanie & susilawati, 2016). some pregnant women also still smoke. they had the habit of smoking before they became pregnant, so the habit was continued even though they were pregnant. (nurdin, hadju, ansariadi, zulkifli, & arundhana, 2018) mentioned that there are several causes of pregnant women smoking, namely the habit before pregnancy, the desire to smell the smoke of cigarettes during pregnancy, and that they will feel satisfied when smoking; pregnant women who smoke also have the support of their husbands. negative behavior of pregnant women is supported by the environment, which is a unifying tool in society. there is a relationship between politics & law with nutritional status in pregnant women who work in the public health center tanah kali kedinding, surabaya indonesia. most of the pregnant women in both categories had political and legal knowledge. a similar study by muttaqin (2018) also shows that knowledge of policies and regulations possessed by pregnant women is directly proportional to the attitude towards fulfilling nutrition in their infants. politics & law in this study related to the knowledge of pregnant women is related to the allocation of funds and balanced nutritional foods that are recommended during pregnancy. the majority of pregnant women understand the rules and policies on the recommendation of balanced nutrition. this shows that the socialization of regulations and policies related to nutrition status carried out in the working area of the tanah kali kedinding health center is good. however, it is suspected that socialization has not reached all pregnant women. this is because there are still some pregnant women who do not understand the rules and policies regarding balanced nutrition. more than half of pregnant women have less economic status. the results of this study also showed that pregnant women in the undernutrition category lived in households with low monthly family income. there is a relationship between economic factors and nutritional status in pregnant women. economic factors were identified as important predictors related to the nutritional status of pregnant women. similar research conducted by hundera et al., (2015) shows that monthly income is significantly related to the nutritional status of pregnant women. family economic status is a prerequisite for getting adequate food intake and improving nutritional status for pregnant women. more than half of pregnant women have an income above the minimum wage of >rp.4,200,000 and are in the category of good nutritional status. economic status is closely related to the income obtained; high income is usually the amount and type of food consumed, which will also be higher (triharini, armini, et al., 2018). most pregnant women work as housewives. this causes pregnant women to not have a fixed income every month, which can help their husbands to find additional sources of income. if the source of income in the family is low, it will affect the fulfilment of primary needs, one of which is nutritious food which will later have an impact on the family's health status (adams et al., 2018) there is an equal number of pregnant women with poor nutritional status categories with low education and pregnant women with good nutritional status categories with higher education. there is a relationship between maternal education and nutritional status in pregnant women. education plays an important role in the nutritional status of pregnant women, as this education influences nutrition and is associated with the ability of pregnant women to make better decisions for themselves and their children. a study at miso health center, ethiopia shows that the prevalence of malnutrition is much higher among pregnant women with low education (serbesa et al., 2019). n. k. a. armini et al. 220 | pissn: 1858-3598  eissn: 2502-5791 pregnant women with a high education will be more careful about what they eat than those with low education. other research by chandra et al., (2019) shows that there is a relationship between the level of education, with the incidence of nutritional status in pregnant women associated with anemia; renjani & misra (2017) also shows that there is a relationship between the level of education with the incidence of ced. pregnant women with low education have a 13.2 times greater chance of experiencing ced compared to pregnant women with high education. person's knowledge is influenced by several things, one of which is education (lee, newton, radcliffe, & belski, 2018). the higher the education, the easier it will be to receive information from outside. however, this does not mean that a person with low education is low in knowledge either. although some pregnant women have a primary school education and graduate from a junior high school, they have good nutritional status during pregnancy. this study also shows that there are a small proportion of pregnant women who have high education but who are also identified as having poor nutritional status. this may be due to the existence of health behaviors that are formed from various factors that work together, so that even though a person has higher education, his health behavior may be lacking (leininger, 2002). limitation of the study: research on the dimensions of transcultural nursing and nutritional status of pregnant women was carried out in a crosssectional approach, only describing a momentary state. the number of samples for validity and reliability testing was 21 pregnant women. as the mid-upper arm circumference is an indicator of nutritional status anthropometry., the change in muac measurement results is usually very small and measured over a long time, thus reflecting chronic nutritional status conclusion the nutritional status of pregnant women is reviewed based on the theory of transcultural nursing related to the factors of technology utilization, family support, cultural values, knowledge about politics & legal, family economics, and education of pregnant women but there is no relationship with the factor of religiosity. pregnant women who can take advantage of technology, get optimal family support, positive cultural negotiations, good legal political understanding, economic status and adequate education will be able to maintain good nutritional status during pregnancy. further research on the nutritional status of pregnant women needs to be carried out longitudinally by measuring the pregnant woman's weight and blood hemoglobin levels. the government needs to increase awareness in preventing and overcoming nutritional problems in pregnant women by considering the existing culture in society. references adams, k. p., lybbert, t. j., vosti, s. a., ayifah, e., arimond, m., adu-afarwuah, s., & dewey, k. g. (2018). unintended effects of a targeted maternal and child nutrition intervention on household expenditures, labor income, and the nutritional status of non-targeted siblings in ghana. world development, 107, 138–150. https://doi.org/10.1016/j.worlddev.2018.02.025 alit armini, n. k., tristiana, r. d., & ose tokan, a. (2017). husband’s support is needed to prevent postpartum depression. 3(inc), 4–7. https://doi.org/10.2991/inc-17.2017.7 bhutta, z. a., ahmed, t., black, r. e., cousens, s., dewey, k., giugliani, e., … shekar, m. (2008). what works? interventions for maternal and child undernutrition and survival. the lancet, 371(9610), 417–440. https://doi.org/10.1016/s0140-6736(07)616936 blondin, j. h., & logiudice, j. a. (2018). pregnant women’s knowledge and awareness of nutrition. applied nursing research. https://doi.org/10.1016/j.apnr.2017.11.020 chakona, g., & shackleton, c. (2019). food taboos and cultural beliefs influence food choice and dietary preferences among pregnant. nutrients, 11, 1–18. chandra, f., junita, d., & fatmawati, t. y. (2019). tingkat pendidikan dan pengetahuan ibu hamil dengan status anemia. jurnal ilmiah ilmu keperawatan indonesia, 9(04), 653–659. https://doi.org/10.33221/jiiki.v9i04.398 demelash, h., id, d., & dadi, a. f. (2019). burden and determinants of malnutrition among pregnant women in africa : a systematic review and metaanalysis. journal plos one, 14(9), 1–19. https://doi.org/https://doi.org/10.1371/journal. pone.0221712 diamond-smith, n. g., gupta, m., kaur, m., & kumar, r. (2016). determinants of persistent anemia in poor, urban pregnant women of chandigarh city, north india. food and nutrition bulletin, 37(2), 132–143. https://doi.org/10.1177/0379572116637721 diana, r., khomsan, a., anwar, f., christianti, d. f., kusuma, r., & rachmayanti, r. d. (2019). dietary quantity and diversity among anemic pregnant women in madura island, indonesia. journal of nutrition and metabolism, 2019. https://doi.org/10.1155/2019/2647230 fitriani, a. (2016). peran religiusitas dalam meningkatkan psychological well being. al-adyan, 11(1), 57–80. https://doi.org/https://doi.org/10.24042/ajsla.v 11i1.1437 hundera, t., wirtu, d., gemede, h., & kenie, d. (2015). nutritional status and associated factors among lactating mothers in nekemte referral hospital and health centers, ethiopia. international journal of nutrition and food sciences, 4(2), 216. https://doi.org/10.11648/j.ijnfs.20150402.23 jurnal ners http://e-journal.unair.ac.id/jners | 221 ipa, m., prasetyo, d. a., & kasnodihardjo. (2016). praktik budaya perawatan dalam kehamilan persalinan dan nifas pada etnik baduy dalam. (april), 25–36. islam, a., islam, n., bharati, p., aik, s., & hossain, g. (2016). socio-economic and demographic factors influencing nutritional status among early childbearing young mothers in bangladesh. bmc women’s health, 16(58), 1–9. https://doi.org/10.1186/s12905-016-0338-y kemenkes. (2017). hasil pemantauan status gizi ( psg ) tahun 2016. krishnaswamy, k. (2001). perspectives on nutrition needs for the new millennium for south asian regions. biomedical and environmental sciences, 14(1–2), 66–74. lee, a., newton, m., radcliffe, j., & belski, r. (2018). pregnancy nutrition knowledge and experiences of pregnant women and antenatal care clinicians: a mixed methods approach. women and birth, 31(4), 269–277. https://doi.org/10.1016/j.wombi.2017.10.010 leininger, m., & mcfarland, m. r. (2002). transcultural nursing: concepts, theories, research & practice (third edit). united states of america: the mcgraw-hill companies. muttaqin, a. (2018). analisis faktor yang berhubungan dengan status gizi balita berdasarkan teori transcultural nursing di desa srowo kecamatan sidayu kabupaten gresik. skripsi fakultas keperawatan universitas airlangga. nurdin, m. s., hadju, v., ansariadi, zulkifli, a., & arundhana, a. i. (2018). determinants of anaemia among pregnant women in jeneponto regency. pakistan journal of medical and health sciences, 12(1), 429–434. parmar, a., khanpara, h., kartha, g., resident, p. g., & shah, c. u. (2013). a study on taboos and misconceptions associated with pregnancy among rural women of surendranagar district 1. 4(2), 2–5. renjani, r. s., & misra. (2017). faktor-faktor yang berhubungan dengan kejadian kekurangan energi kronis ( kek ) pada ibu hamil di wilayah kerja puskesmas krueng barona jaya kabupaten aceh besar. journal of healthcare technology and medicine, 3(2), 254–270. https://doi.org/https://doi.org/10.33143/jhtm.v 3i2.416 rubina shaheen, l. l. (2016). quality of life among pregnant women with chronic energy deficiency in rural bangladesh. health policy, 78(2–3), 128– 134. serbesa, m. l., iffa, m. t., & geleto, m. (2019). factors associated with malnutrition among pregnant women and lactating mothers in miesso health center , ethiopia. european journal of midwifery, 1–5. https://doi.org/https://doi.org/10.18332/ejm/1 10131 triharini, m., armini, n. k. a., & nastiti, a. a. (2018). effect of educational intervention on family support for pregnant women in preventing anemia. belitung nursing journal, 4(3), 304–311. https://doi.org/10.33546/bnj.332 triharini, m., nursalam, sulistyono, a., adriani, m., armini, n. k. a., & nastiti, a. a. (2018). adherence to iron supplementation amongst pregnant mothers in surabaya, indonesia: perceived benefits, barriers and family support. international journal of nursing sciences, 5(3), 243–248. https://doi.org/10.1016/j.ijnss.2018.07.002 yunitasari, e., pradanie, r., & susilawati, a. (2016). early marriage based on transcultural nursing theory in kara village sampang. jurnal ners, 11(2015), 164–169. https://doi.org/10.20473/jn.v11i22016.164169 merawat pasien gangguan jiwa (ah. yusuf, dkk) 230 kompetensi perawat dalam merawat pasien gangguan jiwa (nursing competencies in taking care patient with mental disorders) ah. yusuf, rizki fitryasari, hanik endang nihayati, rr. dian tristiana fakultas keperawatan universitas airlanggakampus c unair jl. mulyorejo surabaya email: ah-yusuf@fkp.unair.ac.id abstrak pendahuluan: kompetensi yang dimiliki perawat dapat menjadi sebuah kemampuan yang baik apabila didukung oleh persepsi perawat yang positif tentang kompetensi itu sendiri. penelitian ini bertujuan untuk menggambarkan kompetensi perawat dalam merawat pasien gangguan jiwa dan hambatan yang ditemukan dalam pelaksanaan kompetensi tersebut. metode: penelitian menggunakan desain kualitatif dengan pendekatan fenomenologi deskriptif. populasi penelitian adalah perawat yang bekerja di rumah sakit jiwa, sampel penelitian diperoleh dengan purposive sampling, partisipan terdiri dari 17 perawat yang bekerja di dua rumah sakit jiwa terbesar di jawa timur. metode pengumpulan data menggunakan wawancara mendalam dan focus group discussion (fgd). alat pengumpulan data yang digunakan adalah media player (mp-4), pedoman fgd dan catatan lapangan. data diolah dengan analisis tematik menurut colaizzi. hasil: hasil penelitian meliputi 8 tema, yaitu bahwa persepsi perawat tentang kompetensi perawat rsj dalam merawat pasien gangguan jiwa adalah melaksanakan asuhan keperawatan, melaksanakan standar prosedur operasional (spo) di ruangan dan melaksanakan terapi modalitas keperawatan jiwa. sementara perawat menjumpai hambatan saat mengaplikasikan kompetensi dalam pelaksanaan dokumentasi keperawatan, keterbatasan fasilitas, kurang efektifnya pelakasanaan manajemen ruangan, keterbatasan sumber daya manusia serta kondisi pasien yang dirawat. diskusi: temuan penelitian dapat dimanfaatkan oleh perawat sebagai bahan untuk mengembangkan desain format dokumentasi pasien gangguan jiwa yang lebih efektif dan diharapkan manajemen rumah sakit untuk lebih memperhatikan aspek pengarahan dan supervisi dalam pelaksanaan kompetensi perawat. penelitian yang disarankan untuk dikembangkan berdasarkan temuan penelitian adalah melihat hubungan pelaksanaan supervisi keperawatan terhadap peningkatan kinerja dan kepuasan perawat kata kunci : kompetensi, perawat, gangguan jiwa. abstract introduction: competences of the nurse can be a good ability when supported with a positive perception of nurses about the competence itself. this study describe the nurse competencies in taking care patients with mental disorders and barriers in the implementation of these competencies. methods: this study design used qualitative descriptive phenomenology. population was nurse who worked at the mental hospital. participants were 17 nurses from two mental hospital in east java which obtained by purposive sampling. data was collected by indepth interview and focus group discussion (fgd). equipment tools used media player, fgd guidelines and field notes. the data were analyzed by thematically analysis based colaizzi. result: the results produce eight themes. the nurse's perception of competence in caring for patients with mental disorders are implementing nursing care, standard procedures operational (spo) and nursing modality therapy. while nurses encounter obstacles when applying competence in the implementation of nursing documentation, limited facilities, the lack of effectiveness management system, limited human resource and the condition of the patient. discussion: the findings of this study can be used by nurses as a material to develop documentation formats more effectively and hospital management are expected to pay more attention to aspects of the guidance and supervision of the implementation of competence. research suggested based on the findings is to analyze the relationship between supervision and nurse’s performance and satisfaction keyword: nurse, competencies, mental disorder pendahuluan pelayanan keperawatan merupakan bagian tidak terpisahkan dari pelayanan kesehatan yang berperan dalam mencapai derajat kesehatan yang optimal pada tatanan individu, keluarga dan masyarakat. pelayanan keperawatan di rumah sakit sebagai ujung tombak yang mampu menjadi daya ungkit yang besar dalam upaya pembagunan kesehatan (depkes ri, 1999). profesionalisme perawat, khususnya pelayanan keperawatan di rumah sakit dimulai dari komitmen dan internalisasi perawat terhadap profesi keperawatan itu sendiri. perawat dituntut memiliki kemampuan intelektual, teknikal, dan interpersonal serta bertanggung jawab terhadap tindakan yang dilakukan. kompetensi perawat berhubungan erat dengan kemampuan dan motivasi kerja yang kuat dalam memberikan pelayanan. kompetensi yang dimiliki perawat, tercermin pada pelaksanaan tugas keperawatan dalam pelayanan kepada pasien, tidak terkecuali pada perawat di rumah sakit jiwa (rsj). kompetensi perawat jiwa dapat diperoleh melalui proses pendidikan formal maupun pelatihan dalam lingkup kesehatan jiwa. kompetensi yang dimiliki seoarang perawat mailto:ah-yusuf@fkp.unair.ac.id mailto:ah-yusuf@fkp.unair.ac.id jurnal ners vol. 11 no. 2 oktober 2016: 230-239 231 dapat menjadi sebuah kemampuan yang maksimal apabila didukung dengan persepsi perawat yang positif tentang kompetensi itu sendiri. hasil wawancara pada beberapa perawat di rsj di jawa timur terkait pandangan perawat tentang profesi dan kemampuan kerja perawat di rsj menunjukkan keanekaragaman fakta. ada yang menyampaikan bahwa selama ini perawat masih berpikiran sebagai pembantu dokter, tidak jelas bidang garapnya, kurang percaya diri bila berhadapan dengan profesi kesehatan yang lain, belum sepenuh hati dalam menjalankan aktivitas keperawatan, belum optimal berinteraksi dengan pasien,terlalu banyak tugas dokumentasi dan masih belum memahami secara tuntas pemberian asuhan keperawatan secara holistik. sementara disisi lain ada perawat yang memiliki pandangan positif bahwa menjadi perawat di rsj merupakan tugas mulia dan merasa senang ketika pasien yang dirawat mampu mandiri dan diijinkan pulang dari rsj. pihak rsj juga sangat menyadari keberagaman pandangan perawat tersebut dan sudah berupaya untuk meminimalkan dampak yang terjadi terutama terhadap kinerja perawat. pihak manajemen rsj sering melakukan pertemuan rutin dengan perawat, banyak berdiskusi dengan jajaran pimpinan rsj dan mengirim perawat untuk mengikuti pelatihan serta menerapakan sistem reward. fenomena dan fakta terhadap profesi perawat tersebut merupakan permasalahan yang menarik untuk ditelusuri, sehingga peneliti ingin mendapatkan gambaran secara kualitatif terkait persepsi perawat rsj terhadap kompetensi merawat pasien gangguan jiwadan hambatan yang dirasakan selama mengaplikasikan kompetensi tersebut. bahan dan metode penelitian menggunakan desain kualitatif dengan pendekatan fenomenologi deskriptif untuk menggambarkan kompetensi perawat dalam pasien gangguan jiwa. kompetensi perawat diukur berdasarkan persepsi perawat rsj tentang kinerja yang harus dimiliki selama bekerja di rsj. populasi penelitian adalah perawat yang bekerja di rsj menur dan lawang, pemilihan sampel menggunakan purposive sampling yaitu metode pemilihan sampel yang sesuai dengan tujuan penelitian. seluruh partisipan penelitian adalah perawat yang bekerja di rsj dengan kriteria: telah bekerja minimal 1 tahun, berpendidikan minimal diii keperawatan, mampu berkomunikasi dengan baik serta sehat fisik dan mental saat dilakukan pengambilan data. partisipan terdiri dari 10 perawat dari rsj menur dan 7 perawat dari rsj lawang. metode pengumpulan data yang digunakan adalah indepth interview dan focus group discussion (fgd). alat pengumpulan data yang digunakan adalah media player (mp-4), pedoman wawancara, catatan lapangan dan diri peneliti. fgd dilaksanakan menjadi dua kelompok, yaitu kelompok perawat rsj menur dan kelompok rsj lawang di tempat dan waktu yang berbeda dengan menggunakan stimulasi pertanyaan yang sama.data yang diperoleh dari hasil fgd dan field note dibuat transkrip verbatim selanjutnya proses analisa dalam penelitian ini menggunakan sembilan langkah menurut colaizzi. hasil peneliti mengidentifikasi 8 tema sebagai hasil penelitian. proses pemunculan tema tersebut diuraikan berdasarkan tujuan penelitian.tujuan penelitian pertama adalah persepsi perawat tentang kompetensi perawat dalam merawat pasien gangguan jiwa, terdiri dari 3 tema, yaitu melaksanakan asuhan keperawatan, melaksanakan standar prosedur operasional (spo) di ruangan dan melaksanakan terapi modalitas keperawatan jiwa. tujuan penelitian 2 adalah hambatan yang ditemui dalam mengaplikasikan kompetensi sebagai perawat jiwa meliputi 5 tema, yaitu hambatan dalam pelaksanaan dokumentasi keperawatan, fasilitas yang terbatas, kurang efektifnya pelakasanaan manajemen di ruangan, kondisi sumber daya manusia yang dimiliki serta kondisi pasien yang dirawat. persepsi tentang kompetensi perawat dalam merawat pasien gangguan jiwa tema 1. memberikan asuhan keperawatan jiwa memberikan asuhan keperawatan jiwa kepada pasien merupakan kompetensi yang dilakukan perawat rsj terdiri dari tahapan asuhan keperawatan dan format dokumentasi askep. tahapan dalam memberikan asuhan keperawatan meliputi pengkajian, perencanaan, implementasi dan evaluasi. merawat pasien gangguan jiwa (ah. yusuf, dkk) 232 “…mulai dari pengkajian sampai evaluasi….” “..asesmen sampai evaluasi….” “…tahapnya pengkajian, perencanaan, implementasi dan evaluasi” pengkajian yang dilakukan dibedakan berdasarkan lokasi pasien dirawat, seperti pengkajian untuk pasien gangguan jiwa dewasa, napza, anak atau geriatri. “..ada format asesmen awal…asesmen dewasa…poli dan igd..” “…asesmen unit khusus seperti napza, anak remaja, geriatri…” aspek yang dikaji meliputi alasan masuk, predisposisi, presipitasi, psikososial, status mental, mekanisme koping dan kebutuhan persiapan pulang. seperti yang dinyatakan oleh informan di bawah ini. “…dikaji dulu alasan masuk, predisposisi, psikososial, status mental, kebutuhan pulang, persiapan pulang…” “…anamnese status mentalnya dulu….” perencanan asuhan keperawatan dilakukan secara manual berdasarkan 10 standar asuhan keperawatan yang meliputi masalah keperawatan halusinasi, waham, isolasi sosial, harga diri rendah, resiko bunuh diri, perilaku kekerasan, defisit perawatan diri: mandi, makan, eliminasi, berhias. sementara di rsj lawang telah dilakukan sistem komputerisasi khususnya untuk di bagian rawat jalan. “…sepuluh diagnosa keperawatan….” “…..sepuluh sak….” “…sistem online untuk igd (nic noc)…” implementasi yang dilakukan menggunakan pendekatan strategi pelaksanaan yang dilaksanakan sesuai dengan perencanaan yang telah di susun. evaluasi asuhan keperawatan dilaksanakan dengan membuat catatan perkembangan setiap shift yang diisi oleh perawat pelaksana dengan format soap, sementara perawat yang berperan sebagai ketua tim akan melakukan evaluasi berdasarkan catatan perkembangan ke catatan terintergasi dengan format sbar. “….cppt diisi dalam bentuk pakem yaitu soap…..” “….kita pakai soap….” “….untuk komunikasi antardisiplin diisi katim (sbar)…” format yang digunakan dalam melakukan asuhan keperawatan di rsj menur maupun lawang menggunakan format standar yang telah di modifikasi dan disesuaikan dengan kebutuhan akreditasi rumah sakit. beberapa jenis dokumentasi yang dikembangkan meliputi catatan perkembangan, catatan terintegrasi dan pengkajian resiko khususnya pada pasien dengan perilaku kekerasan. cara pengisian format pengkajian dan intervensi juga mengalami modifikasi menjadi lebih sederhana dengan model checklist. “….catatan perkembangan….” “….cppt…” “….pake model check list….” tema 2 melaksanakan standar prosedur operasional (spo) perawat di rsj menjalankan sejumlah spo dalam merawat pasien gangguan jiwa. beberapa jenis spo menjadi wajib untuk dipahami dan dijalankan seluruh perawat melalui proses sosialisasi secara bertahap dari kepala ruangan ke perawat ruangan. spo yang sudah tersedia meliputi spo tentang pengisian format dokumentasi keperawatan dan ditambahkan spo sesuai dengan kebutuhan akreditasi rumah sakit dan saat ini sedang dikembangkan spo untuk keamanan pasien dan perawat. “ …standar operasional prosedur untuk askep sudah ada…” “….spo tersosialisasi rutin setiap rapat rutin…” tema 3 melakukan terapi modalitas keperawatan jiwa. kompetensi melaksanakan terapi modalitas keperawatan disampaikan berdasarkan jenis, pelaksana, waktu, fasilitas, tempat dan metode. jenis yang paling sering dilaksanakan adalah terapi aktifitas kelompok (tak) dengan berbagai topik dan pendidikan kesehatan keluarga di rumah sakit (pkrs) dan di masyarakat. “…berjalan rutin (tak)…” “…tak rutin…” “…pendidikan ke keluarga sesuai sp (obat)…” kedua jenis terapi modalitas tersebut dilakanakan baik oleh perawat ruangan maupun mahasiswa perawat yang telah terjadwal secara rutin. fasilitas pendukung untuk kedua terapi modalitasi ini sudah cukup memadai seperti adanya spo, format dokumentasi, leaflet dan alat terapi. tak dilaksanakan di ruangan maupun ruang rehabilitasi, sementara pkrs dilakukan di jurnal ners vol. 11 no. 2 oktober 2016: 230-239 233 ruang yang terdapat keluarga diijinkan untuk menunggu seperti rawat jalan, ruang akut dan juga di lingkungan masyarakat yang menjadi wilayah kerja rsj. metode yang dikembangkan dalam pemberian terapi modalitas berdasarkan tujuan, modifikasi cara, tahapan dan bentuk terapi. tak dapat diberikan dengan tujuan menciptakan lingkungan yang terapeutik atau mengajarkan life skill pada pasien, sehingga bentuk kegiatan tak di modifikasi untuk mencapai tujuan dan diberikan bertahap sesuai dengan kemampuan yang dicapai oleh pasien. persepsi perawat rsj tentang hambatan yang dijumpai selama menerapkan kompetensi dalam merawat pasien gagguan jiwa. tema 4. dokumentasi keperawatan perawat rsj dalam membuat dokumentasi keperawatan menemui beberapa hambatan seperti ketidaklengkapan jenis format sak yang seharusnya ada, misalnya format di ugd, picu, poli jiwa anak dan spo khusus untuk adl pasien. hal ini sesuai yang disampaikan oleh partisipan “…format pengkajian di ugd masih belum ada….” “….lembar untuk mengkaji jiwa anak masih belum ada…” “…..belum ada standar operasional prosedur untuk adl pasien…” “…rs belum ada pijakan paten untuk membuat picu…instrument untuk keperawatan masih belum ada….” format yang digunakan masih dalam proses pengembangan dan evaluasi sehingga terkadang menimbulkan berbagai persepsi yang beragam dan berdampak pada hasil pengisian yang juga beranekaragam. “….pengisian format pengkajian masih indonesia raya….” “….banyak yang tidak mengerti…..” kondisi tersebut dirasakan menjadi hambatan terutama apabila harus berkomunikasi dengan disiplin ilmu yang lain seperti dengan pihak medis, psikolog maupun okupasi terapis. ketidaklengkapan juga masih dijumpai pada simbol khusus yang perlu untuk dimodifikasi, misalnya untuk mengkaji masalah nyeri pada pasien gangguan jiwa belum ditemukan model yang tepat. “…kami masih bingung bagaimana sih triage untuk pasien jiwa….” “….karena ada akreditasi rs, ada yang namanya patient safety….nah…kami belum ada format untuk masalah nyeri pada pasien jiwa…..” ketidaklengkapan juga termasuk banyak komponen format yang tidak terisi sesuai spo dan kosong tidak diisi. “…banyak yang kosong…” “…banyak yang tidak diisi…” pengisian data dokumentasi yang menjadi hambatan dan perlu perhatian khusus adalah validitas data yang dituliskan oleh perawat. subjektivitas perawat dalam menuliskan evaluasi asuhan keperawatan masih mendominasi sehingga evaluasi yang ada di catatan perkembangan kurang menggambarkan kondisi pasien secara rinci. tema 5. fasilitas fasilitas yang tersedia di rsj masih menjadi salah satu hambatan yang dirasakan saat perawat akan menerapkan tindakan sesuai dengan spo yang ada. seperti spo untuk menerapkan asuhan keperawatan adl mandi pada pasien belum ditunjang dengan kelengkapan alat mandi dan fasilitas kebersihan pribadi pasien. sehingga perawat banyak melakukan modifikasi sesuai dengan ketersediaan yang ada. “…tidak ada sabun, handuk,…” “..pasien tidak punya alat mandi sendiri….” tema 6. manajemen ruangan pelaksanaan manajemen di ruangan terutama aspek perencanaan masih menjadi hambatan yang mempengaruhi kinerja asuhan keperawatan pada perawat ruangan. deskripsi tugas yang tidak jelas terutama dalam pelaksanaan terapi modalitas seperti tak dan pkrs menimbulkan ketidaknyamanan diantara perawat pelaksana sehingga mempengaruhi kinerja perawat. selain itu keterbatasan kewenangan perawat untuk melakukan terapi modalitas yang tidak dipayungi oleh kebijakan rumah sakit dan ruangan membuat jenis terapi modalitas yang dapat dilaksanakan baru sebatas tak dan pkrs. aspek pengawasan dalam manajemen ruangan juga menjadi hambatan bagi perawat ruangan dalam menjalankan kompetensi sebagai perawat secara optimal. kegiatan tak di ruang rehabilitasi telah dilakukan evaluasi, namun tidak tersampaikan kepada perawat pengelola pasien dan masih kurangnya aspek pengawasan untuk menindaklanjuti hasil evaluasi tersebut membuat kemajuan kemampuan pasien tidak menjadi bagian dari merawat pasien gangguan jiwa (ah. yusuf, dkk) 234 evaluasi perawat ruangan. selain itu sistem reward yang masih belum sesuai dengan kinerja pelaksanaan terapi modalitas seperti tak, menjadi salah satu alasan perawat untuk tidak bekerja secara maksimal. tema 7. sumber daya manusia pelaksanaan kompetensi perawat di rsj dirasakan menemui hambatan akibat dari keberagaman kondisi sumber daya manusia yang tersedia. tingkat pendidikan yang bervariasi dari tingkat spk, diii, s1 ners, magister dan spesialis mempengaruhi tingkat pengetahuan perawat dalam menerapkan asuhan keperawatan. perbedaan persepsi masih sering ditemukan dalam hal menentukan diagnosa keperawatan dan menuliskan di format dokumentasi keperawatan. masa kerja perawat yang juga bervariasi juga menjadi kendala dimana perawat yang masih baru perlu mempelajari kebiasaan yang telah ada dan seni dalam mengatasi permasalahan selama berhadapan dengan pasien gangguan jiwa. jumlah perawat yang terbatas apabila di bandingkan dengan jumlah pasien, terutama pada shift sore dan malam hari di ruang akut menyebabkan beban kerja perawat yang tinggi. beban kerja perawat selain akibat dari ketidak seimbangan tersebut juga akibat dari beberapa perawat harus menjabat secara struktural sehingga waktu banyak tersita untuk kegiatan selain di ruang rawat. selain itu duplikasi beberapa format dokumentasi keperawatan yang harus dilengkapi selama merawat pasien masih menjadi hambatan untuk dapat bekerja secara efisien meskipun beberapa format sudah dimodifikasi dengan bentuk yang lebih sederhana. tema 8 kondisi pasien perawat rsj dalam menjalankan kompetensi sebagai perawat ruangan juga mendapatkan hambatan akibat dari ketidakpatuhan pasien dalam menjalani program pengobatan di rumah sakit. kondisi penyakit yang dialami pasien gangguan jiwa membuat pasien memiliki pola pikir, pengendalian emosi dan perilaku yang unik, sehingga perawat harus memiliki kemampuan untuk mengarahkan agar pasien mau mengikuti program terapi yang telah direncanakan bersama tim kesehatan yang lain. bagi sebagian perawat ketidakpatuhan merupakan tantangan tersendiri, namun tetap menjadi faktor penghambat dalam menjalankan peran dan fungsi sebagai perawat di tatanan rsj. pembahasan kompetensi perawat merupakan tingkatan kinerja (performance) dasar perawat dalam tatanan klinis yang harus dimiliki perawat untuk dapat mengaplikasikan pengetahuan, keterampilan, pengambilan dan penguasaan dalam melaksanakan tugas sebagai seorang perawat. kompetensi merupakan campuran dari sebuah keterampilan (skill) dengan karakteristik personal (hye-won & mi-ran 2014; mohtashami et al. 2013). hasil penelitian ini didapatkan beberapa tema terkait dengan kompetensi perawat dalam merawat pasien dengan gangguan jiwa. tema 1 memberikan asuhan keperawatan jiwa asuhan keperawatan adalah tindakan mandiri perawat profesional atau ners melalui kerjasama yang bersifat kolaboratif, baik dengan klien maupun tenaga kesehatan lainnya dalam upaya memberikan asuhan keperawatan yang holistik sesuai dengan wewenang dan tanggung jawabnya pada berbagai tatanan pelayanan termasuk praktik keperawatan individu dan berkelompok (nursalam, 2003 dalam muhith, 2015). hasil penelitian menunjukkan tahapan yang dilakukan dalam melakukan asuhan keperawatan adalah pengkajian, perencanaan, implementasi dan evaluasi. berdasar ruang lingkup dan standar praktik keperawatan jiwa, ruang lingkup dan standar praktik dibagi menjadi dua yaitu standar praktik dan standar kinerja professional (professional performance). standar praktik merujuk pada perawatan yang klien terima dari perawat kesehatan jiwa yang telah teregistrasi dan berdasarkan proses keperawatan. standar praktik ini meliputi pengkajian, diagnosis, perencanaan, implementasi dan evaluasi (ballard 2012). secara garis besar tahapan yang dilakukan sudah sesuai dengan standar praktik keperawatan. pengkajian yang dilakukan dibedakan berdasar lokasi yaitu unit napza, unit anak dan remaja, dan unit geriatri. masing-masing unit memiliki kekhususan terkait fokus pengkajian yang harus dilakukan. pengkajian dilakukan perawat untuk mendapatkan data subyektif dan data obyektif termasuk di dalamnya obeservasi klien selama proses wawancara. pengkajian juga meliputi keluhan utama atau masalah utama, kondisi fisik secara umum, status kesehatan mental dan emosional, riwayat keluarga dan klien, sistem dukungan dalam keluarga, jurnal ners vol. 11 no. 2 oktober 2016: 230-239 235 kelompok sosial atau komunitas, adl (activity daily living), kebiasaan kesehatan dan kepercayaan, penyalahgunaan obat, penggunaan obat, hubungan interpersonal, resiko menciderai diri sendiri dan orang lain, koping, kepercayaan dan spiritual dan faktor lain yang mempengaruhi kemampuan klien untuk berfungsi dan berespons pada perawatan (ballard 2012; yusuf et al. 2014). perencanaan dilakukan secara manual dan terkomputerisasi. pelaksanaan dengan cara manual memang lebih banyak menghabiskan waktu perawat.proses implementasi sama-sama menggunakan sp (strategi pelaksanaan). tahapan evaluasi masih ada beberapa hal yang berbeda seperti jenis format evaluasi dan cara mengisi. hasil penelitian (rutledge et al. 2013) menyatakan bahwa perawat jiwa mampu melakukan pengkajian pada pasien dengan gangguan jiwa namun tidak percaya diri dalam memberikan intervensi terkait perawatan pasien. tema 2 melaksanakan standar prosedur operasional (spo) hasil penelitian didapatkan terkait spo berupa jenis dan pelaksanaan. jenis spo berisi tentang asuhan keperawatan pada klien dan beberapa dimodifikasi disesuaikan dengan jci terkait akreditasi rsj. sebuah spo adalah suatu set instruksi yang memiliki kekuatan sebagai suatu petunjuk atau direktif. hal ini mencakup proses pelayanan yang memiliki suatu prosedur pasti atau terstandardisasi, tanpa kehilangan keefektifannya. spo lebih spesifik dari guideline dan dijelaskan dengan lebih detail. spo menjelaskan kriteria tertentu secara komprehensif tentang langkah-langkah suatu kondisi klinis tertentu (rao et al. 2011). spo juga sesuai dengan rumah sakit masingmasing. setiap sistem manajemen kualitas yang baik selalu didasari oleh sop yang kemudian disosialisasikan kepada seluruh pihak yang berkompeten untuk melaksanakannya secara rutin. sosialisasi rutin ini perlu dilakukan agar perawat mengetahui dan mampu mengaplikasikan keterampilannya sesuai spo yang telah dibuat. spo diperlukan untuk memastikan bahwa strategi implementasi tidak diabaikan. spo sebaiknya tersedia di tempat konsultasi pasien, di unit rawat jalan serta di ruang rawat inap serta tempat yang berkaitan dengan perawatan pasien (rao et al. 2011). tema 3 melakukan terapi modalitas keperawatan jiwa. terapi modalitas yang dilakukan jenisnya berupa tak (terapi aktivitas kelompok) dan pkrs (penyuluhan). pemberian terapi baik psikofarmaka maupun keperawatan yang tepat dan akurat saja tidaklah cukup pada klien gangguan jiwa, tetapi harus disusul atau bahkan paralel dengan terapi modalitas salah satunya dengan tak yang secara kontinue dan teratur sampai berfungsinya kembali perilaku normatif yang stabil atau dalam istilah keperawatan perilakunya adaptif (susana, 2007). pelaksanaan yang rutin diharapkan akan meningkatkan hasil di pasien. pelaksana terapi modalitas adalah perawat dan mahasiswa keperawatan. pelaksana terapi modalitas harus mengetahui proses dan cara pelaksanaan terapi modalitas. sedangkan ect dilakukan oleh dokter dengan perawat memberikan asistensi. waktu pelaksanaan tak adalah rutin dan terjadwal sedangkan untuk pkrs sesuai dengan kebutuhan klien. edukasi dan pemberian informasi sudah dilakukan, namun belum berupa psikoterapi. hal ini berkaitan dengan tingkat pengetahuan perawat dan belum adanya spo tentang pelaksanaannya. fasilitas pendukung dalam pelaksanaan terapi modalitas ini berupa leaflet, format dokumentasi dan adanya spo. tempat pelaksanaan di dalam rumah sakit dan luar rumah sakit. metode pemberian berdasarkan dari tujuan, modifikasi, dan bertahap. tema 4. dokumentasi keperawatan pelaksanaan dokumentasi keperawatan menemui hambatan dalam bentuk ketidaklengkapan format standar asuhan keperawatan (sak) terutama untuk ruangan dengan karakteristik khusus dan perbedaan persepsi perawat dalam proses pendokumentasian. dokumentasi keperawatan sangat penting (iyer & comp, 2005) menurut ana (2000 dalam nursalam, 2008) dokumentasi merupakan pernyataan bahwa perawat bertanggung jawab dalam melakukan asuhan keperawatan, termasuk dalam mengumpulkan data, mengkaji status kesehatan klien, menentukan rencana asuhan keperawatan, mengevaluasi efektivitas asuhan dan mengkaji ulang serta merevisi kembali rencana asuhan keperawatan. keberadaan ruangan dengan karakteristik khusus di rsj seperti ruang gawat darurat(ugd), ruang intensif (picu), ruang khusus anak, geriatri dan ruang khusus napza, menjadikan perlu untuk dikembangkan format dokumentasi khusus yang menjawab merawat pasien gangguan jiwa (ah. yusuf, dkk) 236 kebutuhan tersebut. format khusus telah dicoba untuk dikembangkan untuk proses traigedi ugd, namun masih belum jelas untuk mengukur tingkat kegawatan pasien. format standar asuhan keperawatan di ruang picu dan poli khusus anakmasih belum lengkap karena dalam proses pengembangan termasuk cara pengisian dengan benar. dinamika perubahan dan perkembangan format dokumentasi menuntut perawat untuk mudah beradaptasi dan segera memahami perubahan tersebut. kenyataan yang dihadapi belum 100% format dokumentasi keperawatan tersisi lengkap dan benar, hal tersebut bisa disebabkan oleh perbedaan persepsi perawat dalam pengisian format. persepsi merupakan proses dimana individu menyeleksi dan memilih aspek khusus dari berbagai situasi yang diterima lalu mengorganisasikannya dalam sebuah pola yang diwujudkan dalam bentuk sikap dan perilaku.perbedaan informasi yang diterima oleh perawat terkait pengisian format dapat menyebabkan cara pengisian yang berbeda bahkan kebingungan sehingga perawat cenderung tidak mengisi format dengan lengkap. sehingga setiap perubahan format yang terjadi harus dilakukan secara terencana dan tersosialisasi dengan baik di seluruh personil perawat yang berdinas di ruangan rawat pasien. hambatan lain yang ditemukan dalam melakukan dokumentasi adalah validitas data yang dituliskan masih berdasarkan rutinitas.pelaksanaan asuhan keperawatan masih bersifat rutin sehingga tidak sesuai prioritas masalah dan kebutuhan pasien, sementara evaluasi hanya melakukan evaluasi formatif yaitu evaluasi yang dilakukan setelah dilaksanakan intervensi keperawatan tertentu, namun jarang melakukan evaluasi sumatif sehingga perkembangan atau kemajuan masalah keperawatan tidak ditindaklanjuti. hal ini sangat prinsip sehingga bila tidak dilakukan akan mempengaruhi kinerja perawat secara keseluruhan dalam merawat pasien. kinerja perawat khususnya dalam melakukan dokumentasi keperawatan dapat dipengaruhi oleh motivasi(budiawan, suarjana & wijaya, 2015). salah satu bentuk motivasi adalah adanya reward dan punisment yang efektif. situasi yang didapatkan bahwa dokumentasi berdasarkan rutinitas yang telah dilakukan oleh perawat belum bersentuhan dengan aspek motivasi baik yang bersifat reward maupun punishment, sehingga perawat tidak merasakan bahwa dokumentasi yang telah dilakukan merupakan kinerja yang harus diperbaiki. sehingga kemampuan dokumentasi asuhan keperawatan di rsj menjadi aspek yang perlu diperhatikan untuk menunjang pencapaian kompetensi perawat dalam melaksanakan asuhan keperawatan secara menyeluruh. tema 5. fasilitas fasilitas yang tersedia di rsj mesih menjadi salah satu hambatan yang dirasakan saat perawat akan menerapkan tindakan sesuai dengan spo yang ada. perawat dalam melaksanakan spo untuk merawat pasien gangguan jiwa membutuhkan dukungan fasilitas rumah sakit. fasilitas yang dibutuhkan sebaiknya diidentifikasi dan direncanakan berdasarkan kebutuhan (depkes ri, 2008). dalam upaya tersebut dibutuhkan perencanaan dari kepala ruangan untuk menyusun sumber daya yang dimiliki dan dibutuhkan, menentukan strategi sehingga tujuan dapat tercapai(simamora, 2012). pelaksanaan kegiatan asuhan keperawatan yang sering terkendala dengan fasilitas ruangan adalah pemenuhan kebutuhan kebersihan diri yang belum dapat dilaksanakan sesuai dengan spo yang ada. keterbatasan peralatan mandi seperti sabun, shampo, handuk, sikat dan pasta gigi untuk setiap pasien menstimulasi perawat untuk melakukan modifikasi sehingga kebutuhan tersebut dapat terpenuhi. kondisi pasien gangguan jiwa yang belum dapat menjaga barang pribadi untuk kebersihan diri menjadi faktor yang harus dipertimbangkan agar kebutuhan kebersihan diri pasien dapat terpenuhi. tema 6. manajemen ruangan manajemen ruangan yang telah dilakukan dengan baik masih perlu mendapatkan perhatian dalam aspek perencanaan, khususnya terkait dengan deskripsi tugas dalam pelaksanaan terapi modalitas keperawatan seperti tak dan pkrs. uraian tugas tenaga perawatan sangat penting dan bermanfaat untuk membantu tenaga perawatan mengetahui dengan pasti tugasnya, apa yang akan dicapai dan mencegah tumpang tindih maupun terlupakannya suatu tugas (depkes ri, 1999). deskripsi tugas sebagai pelaksana kegiatan tak dan pkrs yang tidak jelas dan tidak terjadwal dengan baik menimbulkan ketidaknyamanan diantara perawat pelaksana, perawat yang jurnal ners vol. 11 no. 2 oktober 2016: 230-239 237 berperan sebagai pemimpin kegiatan berpusat pada beberapa orang saja, sementara dampak finansial dikenakan untuk seluruh perawat. kondisi tersebut menyebabkan ketimpangan dimana perawat yang tidak bertugas menjadi enggan untuk bergantian menjadi pemimpin tak maupun pkrs. situasi tersebut menumbuhkan ketidaknyamanan dan mempengaruhi kinerja perawat. selain itu keterbatasan kewenangan perawat untuk melakukan terapi modalitas yang tidak dipayungi oleh kebijakan rumah sakit dan ruangan membuat jenis terapi modalitas yang dapat dilaksanakan baru sebatas tak dan pkrs. kepala ruangan memiliki kewenangan untuk merencanakan dan menentukan jenis kegiatan asuhan keperawatan yang akan diselenggarakan sesuai kebutuhan pasien (depkes ri, 1999). kegiatan terapi modalitas merupakan salah satu kebutuhan pasien gangguan jiwa untuk mengembalikan fungsi sosial yang hilang akibat proses penyakit. beberapa jenis terapi modalitas seperti terapi kognitif, terapi perilaku dan terapi keluarga merupakan kebutuhan bagi pasien gangguan jiwa, dilain sisi adanya pembatasan kewenangan bahwa terapi modalitas tersebut hanya boleh dilakukan oleh ners spesialis jiwa (konsesnsus konferensi nasional keperawatan jiwa) menjadi kendala karena jumlah ners spesialis yang sangat terbatas, terutama di rsj. sehingga diperlukan adanya kebijakan rumah sakit yang dapat memfasilitasi kepala ruangan untuk dapat merencanakan kebutuhan terapi modalitas sesuai dengan kebutuhan pasien. aspek pengawasan dalam manajemen ruangan juga menjadi hambatan bagi perawat ruangan dalam menjalankan kompetensi sebagai perawat secara optimal. kepala ruangan berperan dalam melakukan pengawasan dan penilaian pelaksanaan asuhan keperawatan yang telah ditentukan termasuk sistem pencatatan dan pelaporan asuhan keperawatan dan kegiatan yang dilakukan di ruang rawat (depkes ri, 1999). kegiatan tak di ruang rehabilitasi telah dilakukan dan hasil evaluasi kemampuan juga telah didokumentasikan, namun tidak tersampaikan kepada perawat pengelola pasien. belum efektifnya fungsi pengawasan yang sudah dilaksanakan tidak memberikan dampak bagi perawat untuk menindaklanjuti hasil evaluasi yang telah ada. kepala ruangan perlu untuk meningkatakan kegiatan supervisi dalam rangka pengawasan sehingga dapat meningkatkan kinerja perawat (mandagi, umboh & rattu, 2015). hasil supervisi tersebut dapat diikuti oleh sistem reward dan punisment yeang jelas, sehingga akan dirasakan efektif dan memberikan dampak yang jelas terhadap kinerja perawat ruangan. tema 7. sumber daya manusia pelaksanaan kompetensi perawat di rsj dirasakan menemui hambatan akibat dari keberagaman kondisi sumber daya manusia yang tersedia. tingkat pendidikan yang bervariasi di rsj dari tingkat spk, diii, s1 ners, magister dan spesialis mempengaruhi tingkat pengetahuan perawat dalam menerapkan asuhan keperawatan. pendidikan merupakan salah satu kebutuhan dasar manusia yang diperlukan untuk pengembangan diri dimana semakin tinggi tingkat pendidikan, semakin mudah mereka menerima serta mengembangkan pengetahuan dan teknologi (grossmann, 1999) dan mendukung mendukung produktivitas kerja (arfrida, 2003). pencapaian kinerja asuhan keperawatan dengan situasi variasi tingkat pendidikan harus didukung dengan persamaan persepsi terhadap pekerjaan yang akan dilakukan. hambatan yang ditemui, bahwa perbedaan persepsi masih sering ditemukan dalam hal menentukan diagnosa keperawatan dan cara menuliskan di format dokumentasi keperawatan perlu dijembatani dengan kegiatan penyamaan persepsi serta didukung oleh ketersediaan format dokumentasi dan manual pengisian yang jelas dan terstandar. perbedaan dan variasi masa kerja perawat juga mempengaruhi pencapaian kinerja perawat. pengalaman bekerja menumbuhkan sikap kerja, kecakapan dan ketrampilan kerja yang berkualitas (harsiwi, 2003) dan mempengaruhi kinerja perawat (faizin & winarsih, 2008). perawat di rsj dengan masa kerja kurang dari 3 tahun perlu mempelajari kebiasaan yang telah ada dan seni dalam mengatasi permasalahan selama berhadapan dengan pasien gangguan jiwa. sementara perawat yang sudah bekerja lebih dari 5 tahun juga perlu mendapatkan informasi terkait penanganan pasien yang efektif berdasar kemajuan informasi dan teknologi, sehingga pelaksanaan asuhan keperawatan pasien gangguan jiwa menjadi lebih optimal. ketersediaan jumlah perawat rsj apabila di bandingkan dengan jumlah pasien, terutama pada shift sore dan malam hari merawat pasien gangguan jiwa (ah. yusuf, dkk) 238 menyebabkan beban kerja perawat yang tinggi.kurniadi (2013) menyebutkan bahwa beban kerja perawat rsj dipengaruhi oleh kondisi pasien yang selalu berubah, jumlah rerata jam perawatan yang dibutuhkan untuk pelayanan langsung pasien dan dokumentasi asuhan keperawatan serta banyaknya tugas tambahan yang harus dikerjakan oleh perawat sehingga dapat mempengaruhi kinerja perawat tersebut. ketidakseimbangan jumlah perawat dan pasien yaitumenyebabkan waktu pelayanan langsung ke pasien dirasakan terbatas terutama pada shift sore dan malam hari. sementara shift pagi, meskipun jumlah perawat yang bertugas lebih banyak, tetapi beberapa perawat harus merangkap sebagai pejabat struktural atau sebagai penanggung jawab dalam kegiatan rumah sakit, sehingga waktu banyak tersita untuk kegiatan selain di ruang rawat. selain itu duplikasi beberapa format dokumentasi keperawatan yang harus dilengkapi selama merawat pasien, meskipun beberapa format sudah dimodifikasi dengan lebih sederhana, menyebabkan semakin terbatasnya jumlah waktu dalam pelayanan langsung ke pasien. situasi dan kondisi tersebut dirasakan sebagai beban oleh perawat dan dapat mempengaruhi kinerja perawat dalam melaksanakan asuhan keperawatan pada pasien gangguan jiwa. tema 8 kondisi pasien perawat rsj dalam menjalankan kompetensi sebagai perawat ruangan juga mendapatkan hambatan akibat dari ketidakpatuhan pasien dalam menjalani program pengobatan di rumah sakit. kepatuhan merupakan tingkat perilaku klien dalam hal pengobatan yang terkait kemauan mengikuti saran petugas kesehatan (k yngas , duff y & kroll , 2000) . pasi en ga nggua n j i wa ce nder ung me ngal a mi ke ti da kpa tuh an terhadap pengobatan yang telah direncanakan oleh perawat, seperti tak dan terapi rehabilitasi saat pasien masih menjalani rawat inap di rsj. gangguan jiwa yang bersifat kronis dan membutuhkan pengobatan dalam jangka waktu lama menumbuhkan ketegangan dan tingkat kejenuhan pasien sehingga menyebabkan ketidakpatuhan. hussar (1995) menjelaskan bahwa pasien dengan penyakit kronis kemungkinan besar menunjukkan sikap kooperatif yang rendah terhadap pengobatan akibat dari perasaan rendah diri akan lamanya pengobatan. perawat sebagai tenaga kesehatan memiliki peranan penting untuk menjadikan pasien patuh terhadap proses pengobatan. parashos & xiromeritis (2000) menyebutkan 54% pasien gangguan jiwa patuh terhadap pengobatan akibat adanya hubungan saling percaya antara pasien dan tenaga kesehatan. hubungan saling percaya dapat dibina melalui kepedulian dan ketulusan perawat dalam memahami kondisi sakit pasien. selain itu perawat harus memiliki strategi unik untuk menciptakan kondisi yang nyaman dan tidak menimbulkan kejenuhan selama pemberian tak dan terapi rehabilitasi, sehingga pasien mau mengikuti program terapi yang telah direncanakan bersama tim kesehatan yang lain. perawat harus memiliki persepsi positif terhadap perilaku pasien dan tidak menyerah untuk melaksanakan tak dan terapi rehabilitasi sebagai bagian dari komptensi perawat di tatanan rsj. simpulan dan saran simpulan persepsi perawat tentang kompetensi perawat dalam merawat pasien gangguan jiwa adalah melaksanakan asuhan keperawatan, melaksanakan standar prosedur operasional (spo) di ruangan dan melaksanakan terapi modalitas keperawatan jiwa. perawat dalam mengaplikasikan kompetensi sebagai perawat jiwa menjumpai hambatan dalam pelaksanaan dokumentasi keperawatan, keterbatasan fasilitas, kurang efektifnya pelakasanaan manajemen ruangan, keterbatasan sumber daya manusia serta kondisi pasien yang dirawat. saran temuan penelitian ini dapat dimanfaatkan oleh perawat sebagai bahan untuk mengembangkan desain format dokumentasi pasien gangguan jiwa yang lebih efektif dan diharapkan manajemen rumah sakit untuk lebih memperhatikan aspek pengarahan dan supervisi dalam pelaksanaan kompetensi perawat. penelitian yang disarankan untuk dikembangkan berdasarkan temuan penelitian adalah melihat hubungan pelaksanaan supervisi keperawatan terhadap peningkatan kinerja dan kepuasan perawat. jurnal ners vol. 11 no. 2 oktober 2016: 230-239 239 kepustakaan arfrida, 2003. ekonomi sumber daya manusia, jakarta: ghalia indonesia. ballard, k.a., 2012. issues and trends in psychiatric mental health nursing. in psychiatric nursing. jones and barlett publisher, pp. 21– 38. available at: http://nursing.jbpub.com/book/psychiatric. budiawan, i.n., suarjana, i.k. & wijaya, i.p.g., 2015. hubungan kompetensi , motivasi dan beban kerja dengan kinerja perawat pelaksana di rumah sakit jiwa provinsi bali. public health and preventive medicine archive, 3(2). depkes ri, 1999. pedoman uraian tugas tenaga keperawatan di rumah sakit, jakarta: direktorat pelayanan medik. depkes ri, 2008. standar pelayanan minimal rumah sakit, jakarta: departemen kesehatan republik indonesia. faizin, a. & winarsih, 2008. hubungan tingkat pendidikan dan lama kerja perawat dengan kinerja perawat di rsu pandan arang kabupaten boyolali. berita ilmu keperawatan, 1(3), pp.137–142. grossmann, m., 1999. the human capital model of the demand for health, cambridge: national bureau of economic research. harsiwi, a.m., 2003. hubungan kepemimpinan transformasional dan karekteristik personal pemimpin. journal bisnis dan ekonomi, 5(1). hussar, s.a., 1995. patient compliance in remington: the science and practice of pharmacy 2nd ed., philadephia: the philadelphia collage of pharmacy and science. hye-won, k. & mi-ran, k., 2014. nursing competency as experienced by hospital nurses in a clinical nursing unit. international journal of bio-science and biotechnology, 6(4), pp.235–244. iyer, p.w. & comp, n.h., 2005. dokumentasi keperawatan: suaru proses pendekatan proses keperrawatan 3, ed., jakarta: egc. kurniadi, a., 2013. manajemen keperawatan dan prospektifnya: teori, konsep dan aplikasi, jakarta: badan penerbit fkui. kyngas, h., duffy, m.e. & krol, t., 2000. review conceptual analysis of compliance. journal of clinical nursing, 5(3). mandagi, f.m., umboh, j.m.l. & rattu, j.a.m., 2015. analisis faktor-faktor yang berhunungan dengan kinerja perawat dalam menerapkan asuhan keperawatan di rsu bathesda gmim tomohon. jurnal ebiomedik, 3(3). mohtashami, j. et al., 2013. competency-based curriculum education in mental health nursing. open journal of nursing, 3, pp.545–551. available at: (http://www.scirp.org/journal/ojn/). muhith, a., 2015. pendidikan keperawatan jiwa: teori dan aplikasi m. bendetu, ed., yogyakarta: cv andi offset (penerbit andi). nursalam, 2008. proses dan dokumentasi keperawatan: konsep dan praktik, jakarta: salemba medika. parashos, i.a. & xiromeritis, k.o., 2000. the problem of non-compliance in skizofrenia: opinion of patients and their relatives. journal of clinical nursing, 4(3). rao, t.s.s., radhakrishnan, r. & andrade, c., 2011. standard operating procedures for clinical practice. indian journal of psychiatry, 15(1), pp.1–3. rutledge, d.n. et al., 2013. hospital staff nurse perceptions of competency to care for patients with psychiatric or behavioral health concerns. journal for nurses in professional development, 29(5), pp.255–262. available at: www.jnpdonline.com. simamora, h., 2012. manajemen sumber daya manusia 3rd ed., bandung: pustaka setia. yusuf, a., fitryasari, r. & nihayati, h.e., 2014. buku ajar keperawatan jiwa 1st ed., surabaya: salemba. microsoft word editorial vol 15 no 2.docx jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.23583 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license editorial research utilization and evidence-based practice in education and nursing practice yulis setiya dewi1* and smriti kana mani2 1 faculty of nursing universitas airlangga, indonesia 2 west bengal university of health sciences, india *corresponding author: dr. yulis setiya dewi, s. kep., ns., m. ng. faculty of nursing universitas airlangga, indonesia email: yulis.sd@fkp.unair.ac.id it is widely recognized that nursing is a science and art that have changed and improved over time. the nursing profession remains core to some interdisciplinary and discipline-specific practices that may need reformation and adjustment to achieve excellent services. space is needed to recognize and explore knowledge that comes from nursing areas and reflect on it, also finding new approaches to discuss concepts that are not easily accommodated in many different disciplines. in this editorial, we will discuss ways of improvement, namely research utilization and evidence-based practice in nursing. let us move swiftly to make these new ideas and skills commonplace. research utilization is a part of evidence-based practice (ebp), which refers to applying research results as the basis to make decisions, conduct new procedures, and new policies. most clinical decisions are based on up to date clinical knowledge and information. in addition, integrating evidence-based practice while teaching research to nursing students can help improve research knowledge, especially among those who have recently been exposed to nursing research. for nursing students, it is a good opportunity to learn about ebp incorporated into the nursing educational curriculum, combining teaching, research appraisal, application and evaluation in practice. research utilization is about translating a new empirical finding from research into practice. research utilization emphasizes in its translating empirically-derived knowledge into actual clinical and education application. evidencebased practice is broader than research utilization because it assimilates research results and other fields of science. barriers to research utilization may include rural isolation, lack of qualified nursing research, very specific findings, lack of nursing research consultants and difficulty to find good publications. in nursing practice, education and science, evidence-based practice has been implemented widely. ebp refers to integration to recognize, assess and use research findings, patients’ values, expert opinions, guidelines for practice and many other scientific relevant information and then judicially apply these in clinical practice. what skills are needed for ebp? there should be critical thinking to support ideas, inferences and beliefs. secondly, critical appraisal skills for available evidence, which is important to determine qualified evidence. thirdly, communication skills, which are always needed to convince about the scientific ideas and findings. fourthly, information and technology literacy, as both are important nowadays to reach worth, valuable data and other information. finally, the quality for improvement and nursing transformation may waive the evidence that is effective, safe, and efficient. developing recommendations for valuable contribution can be maximized to launch the initiatives of improvement where nurses can take the opportunity to do so. the improvement may include redesigning curriculum, developing of a structural model and implementation model, espousing practice and engaging in science for research. therefore, research utilization and ebp become the federal ingenuities and considered opportunities to enhance existing healthcare with the new blood of improvement. 329 analisis kinerja perawat pembimbing klinik dengan pendekatan teori kinerja dan indikator kompetensi (analysis of nurse's clinical education performance based on work theory and the indicator of competence) srinalesti mahanani*, yulis setiya dewi**, widji soeratri*** * stikes rs baptis kediri jl. mayjen panjaitan, no. 3b, kediri, telp. +62 354 683470 **fakultas keperawatan universitas airlangga ***fakultas farmasi universitas airlangga e-mail: nalesti.mahanani@gmail.com abstrak pendahuluan: pembelajaran klinis adalah suatu proses transformasi seorang mahasiswa untuk menjadi perawat profesional. perawat pembimbing klinik berkontribusi dalam meningkatkan kualitas pembelajaran klinis karena memiliki berbagai peran mulai dari perencanaan, pelaksanaan dan evaluasi praktik pembelajaran klinis . peningkatan kualitas pembelajaran praktik klinis, dapat dicapai dengan meningkatkan kinerja perawat pembimbing klinik. tujuan dari penelitian ini adalah untuk mengetahui pengaruh variabel psikologis dan variabel organisasi terhadap kompetensi dan kinerja perawat pembimbing klinik. metode: sampel penelitian ini adalah pendidik klinis perawat yang bekerja di bangsal rawat inap di rumah sakit baptis kediri. penelitian ini dilakukan melalui dua tahap. tahap i mengukur kompetensi dan kinerja perawat pembimbing klinik oleh kepala ruang dan mahasiswa, serta variabel psikologis dan variabel organisasi oleh perawat pembimbing klinik. pengambilan data dilakukan dengan menggunakan kuesioner. tahap ii melakukan focused group discussion untuk mendiskusikan tentang variabel yang mempengaruhi kompetensi dan kinerja perawat pembimbing klinik. data diolah menggunakan partial least square dengan α = 0,05, path koefisien = 0,5 dan t tabel = 1,96. hasil: hasil penelitian menunjukkan bahwa kinerja perawat pembimbing klinik dapat ditingkatkan dengan cara meningkatkan kompetensi individu yang ditunjukkan dengan koefisien path = 0.600 dan t = 6.741. sedangkan kompetensi individu akan meningkat dengan adanya peningkatan aspek psikologis perawat pembimbing klinik yang meliputi persepsi, kepribadian, motivasi, kemampuan belajar dan sikap dengan koefisien path sebesar = 0,518 dan t = 2,715. peningkatan aspek psikologis sebanding dengan peningkatan variabel organisasi yang meliputi sumber daya organisasi, imbalan, struktur organisasi dan desain pekerjaan dengan koefisien path sebesar = 0,825 dan t = 19,658. diskusi: kesimpulan penelitian ini adalah bahwa peningkatan kompetensi dan kinerja perawat pembimbing klinik dapat diupayakan dengan peningkatan kualitas aspek psikologis. aspek psikologis akan dapat ditingkatkan melalui peningkatan variabel organisasi. kata kunci: kompetensi, kinerja, perawat pembimbing klinik abstract introduction: clinical learning is a process of transformation of the student to become a professional nurse. clinical nurse educator contributes to improve the quality of clinical learning because of variety of roles ranging from planning, implementing and evaluating learning clinical practice. improving the quality of clinical practice learning, can be reached by improving the performance of clinical nurse educator. the aim of this study was to know the effect of psychological variables and organizational variables to the competence and performance of clinical nurse educators. sample was clinical nurse educators who work inpatient wards at kediri baptist hospital inpatient wards. method: this study was conducted in two stages. phase i measure the competence and performance of clinical nurse educator by supervisor and students, as well as psychological variables and organizational variables by using questionnaires. phase ii was done by focused group discussion to discuss about the variables that affect clinical nurse educator performance. data processed using partial least square with α = 0.05, path coefficient = 0.5 and t table = 1.96. result: the results of this research is showed that performance nurse educator can be improved by increasing individual competence with path coefficient= 0.600 and t = 6.741. the individual competence will be increase by improving pscychological aspect nurse educator such as perception, personal aspect, motivation, learning skill and attitude with path coefficient = 0.518 and t = 2.715. psycological aspect can be increasing by improving organization variable such as organization resource, salary, organization structure and job description with path coefficient = 0.825 and t = 19.658. discussion: the conclusion of this result that increase of nurse educator competence and performance can be effort by improving psycological aspect and organizational variable keywords: competence, performance, clinical nurse educator jurnal ners vol. 9 no. 2 oktober 2014: 329–338 330 pendahuluan pembelajaran klinik adalah kegiatan belajar mengajar yang dilakukan pada tatanan pelayanan kesehatan di rumah sakit (keliat, 2000). kegiatan pembelajaran klinik sangat penting bagi mahasiswa program pendidikan keperawatan. menurut ewan dalam martono (2009) pembelajaran klinik mer upakan jantung dari proses pendidikan pada program pendidikan keperawatan. pengalaman belajar klinik atau lapangan pada pendidikan tinggi keperawat a n mutla k d iperlu ka n u nt u k menumbuhkan dan membina kemampuan dan sikap keperawatan profesional. program pengalaman belajar klinik (pbk) merupakan suatu proses transformasi mahasiswa yang akan menjadi seorang perawat professional (martono, 2009) hasil penelitian yang dilakukan oleh erawati (2010) di rs baptis kediri menjelaskan bahwa ada hubungan positif yang signifikan antara motivasi dan beban kerja dengan kinerja pembimbing klinik. berdasarkan hasil studi pendahuluan yang dilakukan di rs baptis kediri pada tanggal 31 januari 2014 terhadap kinerja perawat pembimbing klinik didapatkan hasil wawancara dengan 2 orang manajer keperawatan didapatkan data bahwa perawat pembimbing klinik yang ada di rs baptis kediri seluruhnya memiliki tugas rangkap baik sebagai perawat fungsional maupun struktural yaitu sebagai kepala ruang, wakil kepala ruang dan sebagai supervisor sehingga cukup disibukkan dengan kegiatan pelayanan perawatan dan pendampingan kepada mahasiswa menjadi kurang optimal. sedangkan berdasarkan penilaian manajer terhadap masing-masing i nd iv idu p e r awat p e mbi mbi ng k l i n i k disampaikan bahwa secara umum pembimbing klinik dinilai telah memiliki tanggung jawab yang baik dalam melaksanakan bimbingan kepada mahasiswa namun penilaian terhadap kompetensi individu berupa pengetahuan dan keterampilan melaksanakan pengajaran masih kurang. penampilan kinerja perawat pembimbing klinik juga belum optimal dalam merencanakan, melaksanakan dan mengevaluasi proses pembimbingan klinik. dalam upaya meningkatkan kinerja perawat pembimbing klinik tersebut, rs baptis kediri telah menyelenggarakan pelatihan pembimbing klinik namun belum dilakukan evaluasi terhadap efektivitas hasil pelatihan tersebut. pembentukan seorang perawat profesional secara utuh dalam bidang pengetahuan, sikap dan keterampilan sangatlah dipengaruhi oleh keseimbangan antara pendidikan dan pelayanan keperawatan. berdasarkan hasil evaluasi bimbingan klinik dan perkembangan profesional pada mahasiswa keperawatan ditemukan bahwa bimbingan klinik memiliki pengaruh besar terhadap perkembangan identitas profesional mahasiswa keperawatan (azisah, 2012). pengetahuan yang di dapat calon perawat atau peserta didik di kelas dan laboratorium idealnya dapat diterapkan seutuhnya di tempat praktek. dalam kegiatan pembelajaran klinik terjadi proses interaksi antara mahasiswa, pasien dan pembimbing klinik. bimbingan klinik dapat membantu peserta didik dalam mengembangkan kemampuan praktek profesionalnya, untuk itu perawat pembimbing klinik harus membekali diri dengan pengetahuan dan keterampilan dalam melakukan bimbingan yang efektif dan berkualitas. (yusiana, 2011). martono (2009) menguraikan bahwa peran perawat pembimbing klinik dalam kegiatan pembelajaran klinik sangat berarti sekali agar pelaksanaan pembelajaran menjadi efektif. pembimbing praktek klinik mempunyai kontribusi meningkatkan kualitas pembelajaran praktek klinik, karena memiliki berbagai peran mulai dari merencanakan, melaksanakan dan mengevaluasi pembelajaran praktek klinik. peningkatan mutu pembelajaran praktek klinik, dapat ditempuh dengan cara meningkatkan kinerja perawat pembimbing klinik. ewan (1994) dalam martono (2009) menyatakan bahwa seorang pembimbing praktek klinik harus memiliki kompetensi memberikan pelayanan keperawatan kepada pasien, mulai dari mengkaji masalahmasalah pasien sampai memberikan tindakan mengevaluasi efektivitas tindakan tersebut, sehingga dapat menjadi contoh bagi mahasiswa di tempat pelayanan tersebut. teori kinerja mendasar yang diungkapkan gibson analisis kinerja perawat pembimbing klinik (srinalesti mahanani, dkk.) 331 (1987) menyebutkan bahwa kinerja individu dipengaruhi oleh variabel individu, psikologi dan variabel organisasi. zu h r ia n a (2012) me nge mu k a k a n bahwa untuk mencapai prestasi kerja dan kesuksesan sebuah organisasi serta kontribusi pribadi karyawan terhadap organisasinya maka diperlukan kompetensi individu untuk melaksanakan peran dan tugasnya. kompetensi adalah kemampuan kerja setiap individu yang mencakup aspek pengetahuan, keterampilan dan sikap kerja yang sesuai dengan standar yang ditet apkan. perawat pembi mbi ng klinik memiliki berbagai kompetensi yang menjadi modal dalam mengoptimal kan kinerjanya. salminen (2012) menyebutkan secara deskriptif bahwa kompetensi perawat pendidik tersebut diantaranya adalah (1) kompetensi sebagai perawat; (2) kompetensi pengajaran pedagogika; (3) kemampuan melakukan evaluasi; (4) faktor personal; dan (5) hubungan dengan mahasiswa. berdasarkan uraian tersebut peneliti akan melakukan penelitian tentang analisa kinerja perawat pembimbing klinik dengan pendekatan teori kinerja dan indikator the competence of nurse educators bahan dan metode penelitian ini dilakukan kepada perawat pembimbing klinik di ruang rawat inap rs baptis kediri pada bulan april-juni 2014. jenis penelitian analitik korelasional dengan desain studi observasional. adapun jumlah sampel dalam penelitian ini adalah 17 orang. penelitian ini dilakukan melalui dua tahap. tahap i untuk mengukur dan menganalisa kinerja perawat pembimbing klinik oleh kepala ruangan dan mahasiswa, serta mengukur variabel individu, variabel psikologi dan variabel organisasi perawat pembimbing klinik. tahap ii adalah melakukan focused group discussion dengan perawat pembimbing klinik, kepala ruang dan supervisor / komite keperawatan tentang variabel yang mempengaruhi kinerja yaitu pada tanggal 6 dan 11 juni 2014. pengambilan d at a d ila k u k a n denga n mengg u na k a n kuesioner. terdapat 4 buah kuesioner yang terdiri dari 2 buah kuesioner kepada kepala r uang dan mahasiswa tentang evaluasi kompetensi dan kinerja perawat pembimbing klinik serta 2 buah kuesioner yang diberikan kepada perawat pembimbing klinik untuk mengukur variabel psikologi dan variabel organisasi. instrumen yang digunakan untuk mengevaluasi kompetensi perawat pembimbing klinik mengadopsi instrument evaluation of requirement of nurse teacher (ernt) dibuat oleh salminen yang telah diujicobakan pada perawat pembimbing klinik di finlandia dan dipublikasikan melalui jurnal nurse education today pada tahun 2012. instrumen yang digunakan untuk mengevaluasi kinerja, aspek psikologis dan variabel organisasi disusun oleh peneliti berdasarkan indikator sesuai dengan literatur. sebelum digunakan, keempat instrumen tersebut telah terlebih dahulu dilakukan uji validitas dan reliabilitas. pengolahan data dilakukan dengan metode statistic partial least square (pls) dengan t-standar : 1,96, jika nilai t value > 1,96 (alpha 5%) berarti pengujian signifikan dan jika nilai t-value < 1,96 (alpha 5%) berarti tidak signifikan. hasil aspek psikologis yang diidentifikasi dari perawat pembimbing klinik adalah persepsi, kepribadian, motivasi, dan kemauan belajar. rerata aspek psikologis pembimbing klinik dalam kategori cukup (tabel 1). sikap perawat pembimbing k lini k dibedakan menjadi positif dan negatif, di mana sebagian besar perawat pembimbing klinik di rs baptis kediri mempunyai sikap positif (tabel 2). aspek organisasi meliputi sumber daya organisasi, imbalan, struktur organisasi, dan desain pekerjaan. hasil identifikasi aspek organisasi mempunyai rerata cukup (tabel 3). hasil analisis hubungan antar variabel disajikan pada tabel 4. b e r d a s a r k a n h a s i l p e n g o l a h a n pemodelan, didapatkan hasil bahwa terdapat pengaruh yang signifikan aspek psikologis terhad ap kompetensi denga n besa r nya koef isien estimate dari aspek psikologis terhadap kompetensi adalah 0,518 sedangkan nilai t hitung adalah 2,715 (>1,96). variabel jurnal ners vol. 9 no. 2 oktober 2014: 329–338 332 organisasi ber pengar uh terhadap aspek psikologis dengan koefisien estimate sebesar 0,825 sedangkan nilai t hitung adalah 19,658 (>1,96). besarnya koefisien estimate dari variabel organisasi terhadap kompetensi adalah 0,244 sedangkan nilai t hitung adalah 1,036 (>1,96) sehingga disimpulkan bahwa tidak terdapat pengaruh yang signifikan variabel organisasi terhadap kompetensi. sedangkan kompetensi berpengaruh terhadap kinerja tabel 1. aspek psikologis perawat pembimbing klinik di rs baptis kediri no sub variabel baik cukup kurang f % f % f % 1 persepsi 5 29,41 11 64,70 1 5,89 2 kepribadian 6 35,30 11 64,70 0 0 3 motivasi 5 29,41 12 70,59 0 0 4 kemauan belajar 2 11,76 10 58,83 5 29,41 tabel 2. sikap perawat pembimbing klinik di rs baptis kediri no kategori jumlah persentase 1 positif 17 100 % 2 negatif 0 0 % total 17 100 % tabel 3. aspek organisasi perawat pembimbing klinik di rs baptis kediri no sub variabel baik cukup kurang f % f % f % 1 sumber daya organisasi 4 23,52 12 70,59 1 5,89 2 imbalan 1 5,89 10 58,83 6 35,28 3 struktur organisasi 2 11,76 15 88,34 0 0 4 desain pekerjaan 4 23,52 12 70,59 1 5,89 tabel 4. analisis uji hipotesis penelitian analisis kinerja perawat pembimbing klinik dengan pendekatan teori kinerja dan indikator the competence of nurse educator di rs baptis kediri no hubungan antar variabel coeffisien path uji (t tabel: 1,96) keterangan 1 aspek psikologis  kompetensi 0,518 2,715 signifikan 2 variabel organisasi  kompetensi 0,244 1,036 tidak signifikan 3 va r i a b e l o r g a n i s a s i  a s p e k psikologis 0,825 19,658 signifikan 4 kompetensi  kinerja 0,600 6,471 signifikan dengan koefisien estimate sebesar 0,600 dan nilai t hitung adalah 6,741 (>1,96). berdasarkan pemodelan tersebut, maka diketahui bahwa variabel organisasi mempengaruhi aspek psikologis dan selanjutnya mempengaruhi kompetensi dan kinerja. pembahasan penilaian aspek sikap pada perawat pembimbing klinik adalah sebagian besar responden memiliki sikap pada kategori cukup yaitu sebanyak 12 orang (70,59%) dan masih terdapat responden dengan sikap yang baik namun memiliki kompetensi k u rang (4 responden). sikap (attitude) adalah kesiapsiagaan mental, yang dipelajari dan diorganisasi melalui pengalaman dan analisis kinerja perawat pembimbing klinik (srinalesti mahanani, dkk.) 333 gambar 1. hasil bootstrapping pada analisis kinerja perawat pembimbing klinik dengan pendekatan teori kinerja dan indikator the competence of nurse educator mempunyai pengar uh ter tentu atas cara tanggap seseorang terhadap orang lain, obyek atau situasi yang berhubungan dengannya (gibson, 1986). menurut notoatmodjo (2009) sikap adalah respons tertutup seseorang terhadap stimulus atau obyek tertentu yang sudah melibatkan faktor pendapat dan emosi yang bersangkutan. menurut gibson (1986) komponen yang menentukan sikap adalah afeksi, kognisi dan perilaku dan selanjutnya sikap membentuk afek, kognisi dan perilaku. s p e n c e r d a l a m k a r t i n i (2 011) menyebutkan ciri dari kompetensi tidak hanya niat dan kemampuan yang ada tetapi keahlian dan keterampilan yang diwujudkan dalam sikap dan nilai sehari-hari dalam melakukan pekerjaannya. sagala (2009) menyebutkan bahwa kompetensi adalah perpaduan dari penguasaan pengetahuan, keterampilan, nilai dan sikap yang diref leksikan dalam kebiasaan ber pikir dan bertindak dalam melaksanakan t ugas dan peker jaan nya. kompetensi mer upakan gabu ngan dar i kemampuan, pengetahuan, sikap, kecakapan, sifat, pemahaman, apresiasi yang mendasari karakteristik seseorang untuk berunjuk kerja dalam melaksanakan tugas atau pekerjaan g u na mencapai standar k ualitas dalam pekerjaan nyata. penilaian aspek psikologis pada sub variabel persepsi didapatkan hasil lebih dari 50% (64,7%) responden memiliki persepsi dengan kategori cukup. berdasarkan hasil diskusi yang dilakukan, persepsi perawat pembimbing klinik k hususnya persepsi terhadap sikap proaktif mahasiswa dan persepsi terhadap kesiapan mahasiswa dalam proses pembelajaran klinik belum optimal p e r s e p s i a k a n m e m p e n g a r u h i kompetensi dan kinerja individu, hal ini diperkuat dengan hasil tabulasi silang bahwa responden yang memiliki persepsi kurang dalam melaksanakan tugasnya juga memiliki kompetensi ada kategori kurang. pada saat diskusi, institusi pendidikan menyatakan telah membekali mahasiswa dengan ilmu keperawatan sesuai dengan kurikulum dan telah melakukan ujian laboratorium sebelum periode praktik sehingga disepakati bahwa institusi pendidikan dan perawat pembimbing k l i n i k perlu mela k u k a n re vie w pa d a mahasiswa setiap awal periode praktik penilaian pada sub variabel motivasi didapatkan hasil bahwa sebagian besar responden memiliki motivasi pada kategori cukup yaitu sebanyak 12 orang (70,59%). m a’a r u f (2 010) m e nye b u t k a n b a hw a motivasi adalah suatu keadaan dari dalam jurnal ners vol. 9 no. 2 oktober 2014: 329–338 334 yang member kekuatan, yang menggiatkan at au ya ng me ng ge r a k k a n , k a r e n a nya disebut “penggerakan” atau motivasi yang mengarahkan atau menyalurkan perilaku ke arah tujuan-tujuan. pada hasil pengukuran sub variabel belajar didapatkan lebih dari 50% responden memiliki kemauan belajar pada kategori cukup yaitu sebanyak 10 orang (58,83 %) dan terdapat responden yang memiliki kemauan belajar pada kategori kurang yaitu sebanyak 5 orang (29,41%). hasil validasi dengan perawat pembimbing klinik didapatkan data perawat pembimbing klinik mengaku bahwa setelah menyelesaikan pendidikan dan bekerja di rumah sakit, frekuensi belajar menurun karena merasa melakukan tugas rutinitas sehingga stimulus belajar menjadi kurang. hasil ini berbeda dengan penelitian yang dilakukan salminen (2012) di turku yang mendeskripsikan bahwa mahasiswa dan pimpinan menilai perawat pembimbing klinik telah menggunakan literatur dan hasil penelitian secara aktif dalam upaya meningkatkan kualitas pembimbingan klinik dengan sangat baik. hal ini mengindikasikan bahwa perawat pembimbing klinik di turku telah mengembangkan dan menerapkan budaya belajar dengan sangat baik. gibson dalam teorinya menyatakan bahwa belajar merupakan salah satu proses f u ndamental yang mendasar i per ilak u. sebagian besar perilaku dalam organisasi adalah perilaku yang diperoleh dengan belajar. belajar dapat didefinisikan sebagai proses terjadinya perubahan yang relatif tetap dalam perilaku sebagai akibat dari praktek. belajar merupakan suatu proses terjadinya beberapa perubahan tertentu dalam perilaku. jenis dan metode pembelajaran yang ber var iasi dapat menjadi solusi dalam meningkatkan kemauan belajar perawat pembimbing klinik. melalui proses diskusi disepakati bahwa perawat pembimbing klinik perlu meningkatkan motivasi internal dalam mengembangkan pengetahuan, diklat perlu memfasilitasi dengan menyelenggarakan pertemuan/pelatihan tentang perkembangan ilmu keperawatan terkini ser ta institusi pendidikan menyatakan siap untuk membantu dalam menyediakan materi dan sebagai narasumber dalam pelaksanaan pelatihan perawat pembimbing klinik. hasil penelitian ini sesuai dengan teori kinerja gibson yang menyatakan bahwa meskipun organisasi memberikan efek tidak langsung terhadap perilaku dan kinerja individu. melalui penelitian ini dibuktikan bahwa variabel organisasi akan memberikan pengaruh terhadap kinerja individu melalui variabel moderat yaitu aspek psikologis. hasil penelitian ini berbeda dengan hasil yang didapatkan oleh nasution (2009) yaitu bahwa desain pekerjaan dan kepemimpinan tidak memiliki pengaruh terhadap kinerja individu, namun hasil penelitian ini didukung oleh nugroho (2006) yang menyebutkan d ala m penelit ia n nya ba hwa mesk ipu n variabel kepemimpinan tidak berpengaruh secara langsung terhadap kinerja namun budaya organisasi mempunyai pengaruh yang signifikan sebagai suatu variabel moderat, artinya semakin baik kepemimpinan yang didu k u ng oleh budaya organisasi yang baik maka semakin tinggi kinerja individu, artinya variabel organisasi akan memberikan kontribusi terhadap kinerja individu. hasil pengukuran variabel organisasi berad a pad a kategor i cu k up. va r iabel organisasi meliputi sumber daya, desain pekerjaan, imbalan dan struktur organisasi dan kepemimpinan. sebagian besar responden memiliki sumber daya organisasi pada kategori cukup yaitu sebanyak 12 orang (70,59 %) dan terdapat responden dengan sumber daya organisasi pada kategori kurang yaitu sebanyak 1 orang (5,89 %), manajemen menyampaikan bahwa penataan bimbingan klinik masih belum optimal baik dalam sdm maupun sarana prasarana dikarenakan penataan perawat pembimbing klinik baru diawali pada beberapa tahun terakhir dan bersamaan dengan persiapan pengajuan akreditasi. tindak lanjut yang perlu dilakukan adalah mempertahankan dan melanjutkan perencanaan penataan sdm dan sarana prasarana dalam pembelajaran klinik. perawat pembimbing klinik mengatakan bahwa sistem yang berjalan sudah baik, hanya saja merasa imbalan yang diterima kurang analisis kinerja perawat pembimbing klinik (srinalesti mahanani, dkk.) 335 sesuai dengan beban kerja. hasil pengukuran sub variabel imbalan didapatkan hasil bahwa lebih dari 50 % responden memiliki imbalan pada kategori cukup yaitu sebanyak 10 orang (58,83%) dan terdapat responden yang memiliki imbalan pada kategori kurang yaitu sebanyak 6 orang (35,28 %). imbalan menjadi sub variabel yang penting karena imbalan mampu (1) menarik orang yang berkualitas untuk bergabung dalam organisasi; (2) mempertahankan karyawan agar tetap datang bekerja, dan (3) memotivasi karyawan untuk mencapai tingkat prestasi yang tinggi. setiap orang memiliki harapan yang berbeda terhadap bentuk imbalan yang akan diterimanya. imbalan yang disukai setiap orang berbeda dalam beberapa hal, tergantung pada karir seseorang, umur dan situasi yang berbeda. imbalan ekstrinsik memuaskan karena imbalan tersebut mengarah pada imbalan lain. terdapat beberapa imbalan ekstrinsik yang mengarah pada imbalan yang lebih disukai, misalnya uang yang merupakan bentuk imbalan ekstrinsik yang mengarah pada hal-hal lain seperti prestise, otonomi, kekbasan, keamanan dan naungan. da la m prose s d isk u si, i n st it u si pendidikan memberikan wawasan bahwa pada rumah sakit lain imbalan yang diterima cukup tinggi karena perawat pembimbing klinik yang ditetapkan oleh rumah sakit tersebut dapat memprioritaskan tugasnya sebagai pembimbing klinik (tidak hanya mengoreksi dokumentasi askep) sehingga proses pembimbingan berjalan dengan optimal. perawat pembimbing klinik menyatakan akan siap untuk bekerja dengan lebih baik asalkan diimbangi dengan imbalan yang sebanding. manajemen rumah sakit merasa kesulitan untuk penataan tenaga seperti rumah sakit lain di mana seorang perawat pembimbing klinik tidak difungsikan sebagai perawat pelaksana utama sehingga yang dapat ditawarkan adalah akan diberikan imbalan yang sebanding namun diharapkan perawat pembimbing klinik dapat melaksanakan dengan seimbang kedua tugas yaitu sebagai pelaksana dan pembimbing klinik. manajemen juga menyampaikan bahwa telah disusun rancangan penetapan imbalan perawat pembimbing klinik berdasarkan penghitungan beban kerja. tindak lanjut yang perlu dilakukan adalah manajemen rumah sakit dan institusi pendidikan perlu melakukan finalisasi rancangan penetapan imbalan perawat pembimbing klinik berdasarkan penghitungan beban ker ja, mengimplement asi kan nya serta melakukan evaluasi kinerja perawat pembimbing klinik sub variabel kepemimpinan terhadap perawat pembimbing klinik di rs baptis kediri berada pada kategori cukup (58,83%). penelitian ini membuktikan bahwa variabel organisasi tidak mempengar u hi secara langsung terhadap kinerja sebab metode kepemimpinan yang diterapkan di rs baptis kediri tetap dapat membuat mereka nyaman sehingga meningkatkan motivasi dalam bekerja. aspek psikologis yang diukur dalam penelitian ini meliputi sikap, persepsi, kepribadian, belajar dan motivasi sedangkan variabel organisasi meliputi sumber daya, imbalan, struktur organisasi, kepemimpinan dan desain pekerjaan. dua dari sepuluh sub variabel independen tersebut yaitu beban kerja dan motivasi pernah diteliti oleh erawati (2010) kepada perawat pembimbing klinik di rs baptis kediri dengan hasil yang senada dengan penelitian ini yaitu beban kerja tidak berpengaruh secara langsung terhadap kinerja namun terdapat pengaruh positif motivasi dan beban kerja secara bersama-sama terhadap kinerja perawat pembimbing klinik. pengar uh yang signif ikan variabel organisasi terhadap aspek psikologis sesuai dengan pernyataan kopelman yang dikutip oleh ilyas (2001) bahwa ada empat determinan ut a ma d ala m produ k t iv it as orga n isasi termasuk didalamnya adalah prestasi kerja. faktor determinan tersebut adalah lingkungan, karakteristik organisasi, karakteristik kerja dan karakteristik individu. karakteristik kerja dan karakteristik organisasi akan mempengaruhi karak ter istik individu seper ti imbalan, penetapan tujuan akan meningkatkan motivasi kerja, sedangkan prosedur seleksi tenaga kerja serta latihan dan program pengembangan akan meningkatkan pengetahuan, keterampilan dan kemampuan dari individu. selanjutnya variabel karakteristik kerja yang meliputi jurnal ners vol. 9 no. 2 oktober 2014: 329–338 336 penilaian pekerjaan akan meningkatkan motivasi individu untuk mencapai prestasi kerja yang tinggi. hasil pengolahan data ini juga didukung dengan per nyataan perawat pembimbing klinik yaitu bahwa perawat pembimbing klinik merasa bahwa motivasi dan sikap dalam proses pembimbingan klinik sangat dipengaruhi oleh kurang sebandingnya antara beban kerja dengan imbalan yang diterima sebagai perawat pembimbing klinik khususnya jika dibandingkan dengan imbalan yang diterima perawat pembimbing klinik di rumah sakit lain. siagian (2004) menyebutkan bahwa imbalan erat kaitannya dengan prestasi kerja seorang karyawan. imbalan merupakan salah satu faktor eksternal yang mempengaruhi motivasi eksternal seseorang, di samping faktor eksternal lain yang menjadi indikator dalam variabel organisasi. stoner dalam bogar (2012) merupakan faktor eksternal yang mempengar uhi motivasi seseorang. dalam penelitian ini dapat disimpulkan bahwa variabel organisasi mempengaruhi aspek psikologis dalam peningkatan kompetensi yang pada akhir nya akan meningkatkan kinerja perawat pembimbing klinik. hasil penelitian ini diperkuat dengan pernyataan perawat pembimbing klinik di rs baptis kediri yang mengungkapkan bahwa mereka bekerja cenderung didasarkan pada aspek psikologis dengan konsep pelayanan memberikan yang terbaik dalam bekerja sesuai kemampuan yang dimilikinya artinya baik buruknya kinerja tidak sepenuhnya bergantung pada sistem organisasi yang dijalankan namun bergantung dari sikap, kepribadian dan motivasi internal. namun perawat pembimbing klinik tidak memungkiri bahwa kestabilan organisasi sangat mempengaruhi psikologis mereka. h a si l p e ng u k u r a n s u b va r ia b el kompetensi perawat pembimbing klinik oleh kepala ruang dan mahasiswa adalah terdapat tiga sub variabel dengan kategori kurang yaitu kompetensi sebagai perawat, kemampuan pedagogik dan kemampuan melak u kan evaluasi, sedangkan dua sub variabel berupa faktor personal dan hubungan dengan peserta didik berada pada kategori baik. hasil ini sesuai dengan deskripsi hasil penelitian yang dilakukan oleh salminen (2012) terhadap perawat pembimbing klinik di turku, yaitu bahwa berdasarkan hasil evaluasi dar i mahasiswa didapatkan hasil bahwa kompetensi perawat pembimbing klinik melak u kan evaluasi berada pada kategori kurang. per ma sala ha n belu m opt i mal nya kompetensi perawat pembimbing klinik k h u s u s ny a d a l a m t ig a s u b v a r i a b el penelitian ini yait u kompetensi sebagai p e r awat , ke m a mpu a n p e d a gog i k d a n kemampuan melakukan evaluasi senada dengan hasil penelitian elgicil (2007) yang dilakukan di turkey yaitu bahwa mayoritas permasalahan praktik terkait komperensi perawat pembimbing klinik diantaranya ketidakmampuan perawat pembimbing klinik dalam mengajarkan pengkajian, mayoritas perawat pembimbing klinik cender u ng menghakimi, memberikan umpan balik negatif, tidak mampu berkomunikasi dengan baik, tidak mampu memberikan arahan kepada mahasiswa dan beban kerja berlebih. kompetensi perawat pembimbing klinik yang diukur dalam penelitian ini sesuai dengan indikator yang diidentifikasi oleh nabavi (2010) dalam penelitiannya. nabavi menyimpulkan bahwa perawat pembimbing klinik yang efektif adalah individu yang yang memiliki kompetensi professional diantaranya adalah kemampuan dalam menjiwai ilmu keperawatan, mampu secara reflektif mengevaluasi diri dan mahasiswa, mampu membuat suasana belajar klinis menjadi nyaman, dan melaksanakan asuhan keperawatan yang berorientasi pada pasien serta mampu berperan sebagai role model bagi mahasiswa. sasongko (2008) menyebutkan bahwa kompetensi adalah keseluruhan kemampuan, penget ahuan, si kap dan per ilak u yang ditunjukkan secara konsisten oleh individu untuk menghasilkan kinerja unggul pada suatu jabatan atau bidang pekerjaan tertentu. kompetensi pembimbing klinik adalah per sya r at a n kema mpu a n m i n i mal d a n kewenangan yang harus dimiliki pembimbing klinik untuk dapat melaksanakan tugas/ peker jaan sesuai st andar pembelajaran praktek klinik. dengan demikian kompetensi analisis kinerja perawat pembimbing klinik (srinalesti mahanani, dkk.) 337 p e mbi mbi ng k l i n i k me mpu nyai a nd i l atau kontribusi terhadap kinerja seorang p e m b i m b i n g k l i n i k d a l a m k e g i a t a n pembelajaran praktek klinik (mar tono, 2009). hasil penelitian ini sesuai dengan penelitian yang dilakukan oleh martono (2009) yaitu bahwa ada pengaruh antara kompetensi terhadap kinerja perawat pembimbing klinik di rsud sragen. martono (2009) menyebutkan bahwa kinerja pembimbing klinik akan meningkat bilamana kompetensi pembimbing klinik meningkat, hal ini membuktikan bahwa adanya hubungan yang linier antara kompetensi dengan kinerja. sasongko (2008) dalam penelitiannya juga membuktikan bahwa ada pengaruh antara kompetensi terhadap kinerja tenaga penjualan sehingga disimpulkan bahwa dalam upaya meningkatkan kinerja karyawan dapat dilak u kan dengan meningkatkan kompetensi. mcashan (dalam mulyasa 2004) menyatakan bahwa kompetensi yang dikuasai oleh seseorang akan menyebabkan orang tersebut dapat melakukan tindakan dengan sebaik-baiknya. hasil penelit ia n i n i disi mpul ka n bahwa semakin tinggi kompetensi perawat pembimbing klinik maka akan meningkatkan kinerjanya, hal ini memperkuat pernyataan sagala dalam kartini (2001) yaitu bahwa k o m p e t e n s i a d a l a h p e r p a d u a n d a r i pengetahuan, keterampilan, nilai dan sikap yang direfleksikan dalam kebiasaan berpikir dan bertindak dalam melaksanakan tugas dan pekerjaannya. ia menambahkan bahwa kompetensi mer upa ka n gabu nga n d a r i kemampuan, pengetahuan, kecakapan, sikap, sifat, pemahaman, apresiasi dan harapan yang mendasari karakteristik seseorang untuk berunjuk kerja dalam melaksanakan tugas atau pekerjaan guna mencapai standar kualitas dalam pekerjaan nyata. simpulan dan saran simpulan hasil penelitian ini menunju k kan bahwa kinerja perawat pembimbing klinik dapat ditingkatkan dengan cara meningkatkan kompetensi individu. sedangkan kompetensi individu akan meningkat dengan adanya peningkatan aspek psikologis perawat pembimbing klinik yang meliputi persepsi, kepribadian, motivasi, kemampuan belajar dan sikap. peningkatan aspek psikologis sebanding dengan peningkatan variabel organisasi yang meliputi sumber daya organisasi, imbalan, struktur organisasi dan desain pekerjaan saran perlunya peningkatan kualitas variabel organisasi untuk meningkatkan aspek psikologis yang secara berkesinambungan akan meningkatkan kompetensi dan kinerja perawat pembimbing klinik. upaya peningkatan variabel organisasi yang dapat dilakukan dengan melakukan sistem pengelolaan perawat pembimbing klinik, menjalin koordinasi baik dengan institusi pendidikan maupun dengan perawat pembimbing klinik, serta melakukan inventarisasi topik pelatihan yang dibutuhkan oleh perawat pembimbing klinik dan menyelenggarakan pelatihan secara rutin kepustakaan a zisa h d a n k h ilyat ul., 2012. ti ng kat kepuasan bimbingan klinik mahasiswa keperawatan. journal nursing study vol 1 no 1 tahun 2012, 219–224. azwar s., 2007. penyusunan skala psikologi. yogyakarta: pustaka pelajar offset erawati,. 2010. hubungan motivasi dan beban kerja pembimbing praktek klinik keperawatan dengan kinerja pembimbing klinik di rs baptis kediri. surakarta: tesis. program pascasarjana universitas sebelas maret gibson, 2001. organisasi, struktur, perilaku dan proses. jakarta: erlangga guzman, 2008. understanding the persona of clinical instructors: the use of students’ doodles in nursing research. journal nurse education today 2008 ilyas, y., 2002. kinerja, teori penilaian dan penelitian. jakarta: fkm ut ilyas, y., 2001. kinerja: teori, penilaian, dan penelitian. depok: pusat kajian ekonomi kesehatan fakultas kesehatan masyarakat ui. jurnal ners vol. 9 no. 2 oktober 2014: 329–338 338 k a r t i n i , 2 011. fa k t o r f a k t o r y a n g mempengaruhi kompetensi profesional guru di smk negeri 1 losarang kabupaten indramayu; jakarta: tesis. program pascasarjana fik universitas indonesia keliat, b.a., 2000. metoda bimbingan klinik di rumah sakit. jakarta: rineka cipta lusiani, 2006. hubungan karakteristik individu dan sistem penghargaan dengan kinerja perawat menurut pe r se p si pe ra wa t pe la k sa n a d i rs sumber waras. jakar ta. tesis program pascasarjana fik universitas indonesia. ma’ar uf, n.a., 2010. pengaruh motivasi terhadap peningkatan kompetensi bidang desa di kabupaten malang; tesis. pusat penelitian sistem dan pengembangan kebijakan kesehatan mangkunegara, a.p., 2004. manajemen sumber daya manusia perusahaan. bandung: rosdakarya mangatua, f., 2007. analisis produktivitas kerja dan motivasi pekerja akibat aktivitas pemberdayaan karyawan. derema jurnal manajemen vol.2 no.2 martono, h., 2009. pengaruh kompetensi dan motivasi pembimbing klinik terhadap kinerja pembimbing praktek klinik di rsud kabupaten sragen. surakarta: tesis. program pascasarjana universitas sebelas maret mulyasa, e., 2004. kurikulum berbasis kompetensi: konsep, karakteristik dan implementasi. bandung: pt remaja rosdakarya nabavi, 2010. professional approach: the key feature of effective clinical educator in iran. journal nurse education today 2010 notoatmodjo, s., 2009. pengembangan sumber daya manusia. jakarta: rineka cipta. robbins, s., 2008. perilaku organisasi. jakarta: penerbit salemba empat sagala, s., 2010. supervisi pembelajaran. bandung: alfabeta salminen, 2012. the competence and the cooperation of nu rse educators. journal nurse education today 2012 sasongko, h., 2008. analisis faktor-faktor ya ng mempenga r uhi kompeten si tenaga penjualan untuk meningkatkan kinerja penjualan; semarang: tesis. program pascasarjana universitas diponegoro setyowati d., 2010. determinan kinerja perawat di ruang rawat inap rs tni al dr,martoharjo; jakar ta: tesis. program pascasarjana universitas indonesia siagian, s.p., 2004. teori motivasi dan aplikasinya. yogyakarta: andi offset stikes rs baptis kediri, 2013. laporan akademik semester genap kediri tulak, g.t., 2013. hubungan pengawasan kepala ruangan dengan kinerja pembimbing klinik dalam penerapan nilai-nilai profesionalisme mahasiswa tahun 2013. makasar: tesis. fakultas kedokteran universitas hasanuddin uniplaita, y.e.o., 2003. analisis kinerja pe mbimbing klinik berd a sa rk a n persepsi mahasiswa poltekes terhadap bimbingan di rumah sakit umum dr. haulusy ambon. yogyakarta: tesis. program pascasarjana ugm. yusiana, m.a., 2011. evaluasi penerapan pembelajaran klinik keperawatan metode bedside teaching dan metode penugasan klinik berdasarkan model evaluasi cipp (context, input, process, product) di rumah sakit baptis kediri. surabaya : tesis. fakultas kesehatan masyarakat universitas airlangga zuhrina, 2012. pengaruh kompetensi yang terdiri dari pengetahuan, keterampilan dan sikap serta motivasi terhadap kinerja pegawai di pdam tirtanadi caba ng pa d a ng bula n . me d a n: program pascasarjana universitas sumatera utara http://e-journal.unair.ac.id/jners | 183 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.29952 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effects of aerobic exercise on depression and cd4 counts in people living with hiv untung sujianto universitas diponegoro, semarang, indonesia abstract introduction: hiv patients often experience psychological and physical disorders which greatly affect the adherence of people living with hiv/aids (plwha). this study aimed to assess the effects of aerobic exercise on the levels of depression and cd4 cell count of hiv patients. methods: this study used a pre-post quasi-experimental design with a control group. the sampling technique was consecutive sampling, with a total sample of 52 hiv respondents. depression level was measured using the beck depression inventory (bdi), while cd4 count was measured using the pyma analyser. the aerobic exercise intervention was given three times a week with a duration of 20-30 minutes each for four weeks. the collected data were analysed using a paired sample t-test and an independent sample t-test. results: the results showed a significant difference in the mean value of depression before and after the intervention of aerobic exercise (m = 25.15 and m = 22.46, respectively) with p = 0.001. similarly, there was a significant difference in the mean of cd4 counts between the control group (m = 303.38) and the intervention group (m = 305.38) after the intervention with p = 0.031. conclusion: aerobic exercise is effective in reducing depression levels and increasing cd4 counts in hiv patients. immune system cells circulate more rapidly and there is a boost in the production of macrophages, cells that can attack bacteria. article history received: october 6, 2021 accepted: november 17, 2021 keywords aerobic exercise; depression; cd4 count; hiv contact untung sujianto  untung71@fk.undip.ac.id  universitas diponegoro, semarang, indonesia cite this as: sujianto, u. (2021). effects of aerobic exercise on depression and cd4 counts in people living with hiv. jurnal ners, 16(2). 183-187. doi: http://dx.doi.org/10.20473/jn.v16i2.29952 introduction human immunodeficiency virus (hiv) is a virus that attacks the immune system and which can be contagious and deadly. hiv can occur due to several risk factors, including alternating drug injection equipment (drugs, alcohol, psychotropic substances and additives), free sex (heterosexual, homosexual) without a condom, transmission from infected mothers to children, perinatal and through transfusions (kemenkes, 2017). various impacts can arise for hiv sufferers such as physical, social, emotional and spiritual problems. most people living with hiv/aids (plwha) experience changes in emotional status, one of which is depression. demirel et al. (2018) stated that 31% of hiv/aids sufferers in turkey experienced depression and up to 19% of them experienced mental disorders. the prevalence of depression in indonesia is quite high, around 17-27%. furthermore, approximately 5-10% of the general population experiences depression. the causes of depression in plhwa patients are low cd4 count, adherence to art, lack of physical activity, and community stigma (demirel et al., 2018) hiv directly destroys cd4 t cells (cluster of differentiation 4) which functions as body immunity and causes a primary infection which further accelerates the decrease in the number of cd4 lymphocytes in the blood. if the virus attacks cd4 t cells until their number drops below 200 per microliter, the body’s immunity will be lost and become aids. dianatisanab et al. (2018) stated that a cd4 cell count of <500 cells/ml or <200 cells/ml in plwha will cause severe depression. factors that influence cd4 counts in plwha are baseline cd4 counts, medication adherence level, depression, and tuberculosis infection (dianatinasab et al., 2018). the number of people infected with hiv in 2012 was 35.3 million people and increased in 2018 to 37.9 million people worldwide; most of these people were at the age of 15-49 years old (unaids, 2019). in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v16i2.29952 u. sujianto et al. 184 | pissn: 1858-3598  eissn: 2502-5791 indonesia, there were 640,443 plwhas in 2018. the indonesian ministry of health stated that the number of hiv/aids cases had reached 18,442 cases in 33 provinces with 3,708 deaths (kemenkes, 2017). aerobic exercise is a physical activity that uses leg and arm muscle movements which are known to have many benefits. regular movement can increase the release of neurotransmitters that is mediated by activation of brain-derived neurotrophic factor (bdnf). increased bdnf, vegf, and igf-1 as neurotrophic factors in the hippocampus are useful for nerve cell growth, increase regulation of stress hormones, namely cortisol on the hypothalamicpituitary-adrenal (hpa) axis and decrease the release of pro-inflammatory cytokines so that depressive symptoms can be reduced and cells in the immune system will circulate more quickly in the body. there may also be a boost in the production of macrophages, which are cells that attack bacteria, which can increase cd4 counts in plwhas (nosrat et al., 2017). a study by heissel et al. (2019) found that to assess aerobic exercise activity for depression and cd4 cell count, the evaluation could be done at week four. the study showed different results between the control group (smd = -0.84, 95% ci = -1.57, -0.11, p = 0.02) and the intervention group (smd = 0.90, 95% ci = -1.63, -0.30, p = 0.004, p < 0.001). exercise can reduce symptoms of depression and anxiety in plwha. this therapy can also affect the cd4 count of hiv patients (heissel et al., 2019). the results of the study by nosrat et al. (2017) showed significant differences in depression levels in both groups (f = 2.63, p = 0.05) and (f = 7.40, p < 0.001), with greater increases in resistance training compared to the control. meanwhile, a study by dianatisanab et al. (2018) found that after the aerobic exercise intervention programme, a significant difference in cd4 cell count was found between the two groups (p = 0.01). this means that aerobic exercise is effective in reducing levels of depression and increasing the cd4 count of hiv patients (nosrat et al., 2017) this study differs from previous studies in the type and design of the study, population, number of samples, place of study, and the variables measured. the researchers conducted the quasi-experimental research with a pre-post-test design with a control group. the population involved were males and females. the number of samples was also different, namely 52 patients diagnosed with hiv stage 1 and 2. these patients had their cd4 count checked first and were assessed for depression levels using beck depression inventory (bdi) before receiving aerobic exercises. research variables have never been carried out in a study that involves two variables, namely depression and cd4 cell count. providing aerobic exercise interventions to increase circulation in hiv patients is easy, effective and economical for all patients to do and has no side effects. based on these descriptions, the researchers were interested in conducting a study to investigate the effects of aerobic exercise on depression levels and cd4 cell counts in hiv patients. materials and methods this study used a quantitative method with a prepost-test design with a control group. the sample size was calculated using a sample size formula to test the hypothesis for a mean of two populations (notoatmodjo, 2005). this study involved 26 respondents each in the intervention and control groups, with a total of 52 respondents. these respondents were hiv patients undergoing outpatient treatment at the voluntary counselling and testing (vct) clinic. a consecutive sampling technique was used to recruit the samples. consecutive sampling is a sampling technique that is performed by selecting all individuals encountered and meeting the criteria until the desired sample size is met (jannaim & asrizal, 2018). the inclusion criteria of this study were: 1) hiv patients at stage 1 and ii; 2) age >18 years old; 3) able to communicate well; 4) at least those who have been adhering to taking arv drugs >6 months; 5) patients with a cd4 count >200 / ml; 6) patients who come with a companion who lives in the same house; and 7) patients who were depressed (moderate, severe). before conducting the research, the researcher first composed a research permit and research ethics approval letter from the health research ethics committee of the faculty of medicine, diponegoro university which was addressed to the vct clinic sobat kupang. the health research ethics committee of the health polytechnic, ministry of health kupang approved the study with a reference number of lb.02.03/1/0062/2020. after obtaining the research permit, the researchers began to conduct the study. the researcher gave the beck depression inventory questionnaire and filled it out to measure the level of depression. the instrument was written in the indonesian language and had been tested for its validity and reliability with a cronbach’s alpha of 0.923, meaning that the measuring instrument was very reliable. the cd4 count was assessed using pima analyzer before and after the intervention in both groups. the researchers identified respondents based on the predetermined criteria. the researchers explained the procedure for the research process, namely the first meeting of all samples was carried out by filling out a questionnaire on the demographic data of the respondents, assessing the level of depression, checking cd4 counts and teaching aerobic exercise techniques for 20-30 minutes. this aerobic exercise intervention was given once at the beginning of the meeting, after which the researcher gave the sop and the video of this exercise to be performed at home and monitored by a companion who lived in the same house as the respondents. furthermore, the respondents filled out the checklist sheet that was provided by the researcher after the initial intervention. the exercise jurnal ners http://e-journal.unair.ac.id/jners | 185 was carried out three times a week for four weeks. the aerobic exercise in this study consisted of threemovement sessions, namely: 1) warm-up; slowly approaching the extent of joint movement, then hold for 8 counts in 10 seconds and finally relax, until the respondent feels a sufficient stretch without pain for 5-10 minutes involving the joints and muscles of the upper, in the lower body as well as the left and right sides of the body, without bouncing and breathing regularly; 2) core movements; raising hands forward, upward, sideways, backward, hand movements opening and crossing, pushing and pumping forward, upward and sideways, punching hand movements, forward, sideways, upward, downwards and crosses, one-handed or two-handed swinging motion, clapping, among others, the hands’ clap, hands pat the thighs and shoulders; walk in the place, take a step or two, jump a foot or two to the side, forward and back, raise the knee, kick, back, forward, and sideways; and 3) cooling (grace et al., 2015). the data was processed into a computer program system. the results were analysed using univariate and bivariate analysis. univariate analysis was carried out on respondent characteristics data (gender, age, education, marital status, number of opportunistic infections (ois), type of arv, risk factors, initial cd4 count), while bivariate analysis was performed on the results of the beck depression inventory value and cd4 count in the control group and the intervention group using the dependent samples t-test and independent samples t-test. results respondent characteristics the results showed that the majority of respondents were aged 26-46 years old (n = 43; 65.4%), male (n = 27; 51.9%), high school graduates (n = 23; 44.2%), and unmarried (n = 31; 59.6%). furthermore, 29 respondents had the type of arv drug with the evafirenz (efv) based type (55.8%) and the other 23 had nevirapine (nvp) based medicine (44.2%). as many as 51 respondents (98.1%) did not experience opportunistic infections or opportunistic infections <2, while the remaining (1.9%) had opportunistic infections ≥ 2 types of infections. depression level before the aerobic exercise intervention the incidence of depression among hiv patients as shown in table 1 was 23.1% in the intervention group and 19.2% in the control group. the overall mean of depression before the intervention was 25.15, which means that the level of major depression has the lowest score of 16 and the highest score of 36. from the results of the p-value in table 1, it could be concluded that the incidence of depression between the control group and the intervention group is equivalent or has the same variance with a p-value >0.05. after the aerobic exercise intervention in the intervention group, the average level of depression was mild depression (42.3%) while in the control group, the highest level of depression was moderate depression (50.0%). the mean value of depression in the intervention group was 22.46, indicating a mild level of depression level, while in the control group, the mean value was 25.00, indicating a moderate level of depression. a significant change in the level of depression after the aerobic exercise intervention was indicated by a p-value <0.001. table 1. differences in the depression level between intervention and control groups (preand post-test; n = 52) type of group depression category frequency mean mean difference sd difference dependent t-test pvalue before (%) after (%) before (sd) after (sd) intervention mild 4 (15.4) 11 (42.3) 25.15 (5.48) 22.46 (5.62) -2.69 0.14 0.001 moderate 16 (61.5) 10 (38.5) severe 6 (23.1) 5 (19.2) control mild 5 (19.2) 6 (23.1) 24.12 (5.99) 25.00 (6.99) 0.88 1.00 0.179 moderate 16 (61.5) 13 (50.0) severe 5 (19.2) 7 (26.0) independent t-test p-value 0.341 0.001 table 2. differences in cd4 counts between the intervention and control groups (preand post-test; n = 52) type of group category n % mean mean difference sd difference dependent ttest p-value before (sd) after (sd) intervention increase 19 73.1 300.46 (58.70) 305.46 (61.36) 5.00 2.66 0.031 standing 4 15.4 decrease 3 11.5 control increase 12 34.6 302.81 (62.98) 303.38 (61.40) 0.57 -1.58 0.523 standing 5 19.2 decrease 9 46.2 independent t-test p-value 0.890 0.000 u. sujianto et al. 186 | pissn: 1858-3598  eissn: 2502-5791 differences between the intervention and control groups the depression level of hiv patients who received the aerobic exercise intervention decreased significantly by -2.69 with a p-value <0.05. meanwhile, in the control group that did not receive the intervention, there was no significant change; the change was 0.88 with a p-value >0.05. based on these results, it can be concluded that there was a significant change in the level of depression before and after the aerobic exercise in the intervention group. cd4 cell counts before the aerobic exercise intervention the intervention group and the control group had cd4 values of >200ml/dl. the overall mean of cd4 cell count of hiv patients before the intervention was 300.4 for the intervention group and 302.81 for the control group. from the results of the p-value, it can be concluded that the incidence of depression between the control group and the intervention group is equivalent or has the same variance with pvalue >0.05. after the aerobic exercise intervention there were differences in the cd4 counts between the control group and the intervention group after receiving aerobic exercise intervention. in the intervention group, the average cd4 count was 305.46, while in the control group, the average cd4 count was 303.38. a significant change in the cd4 cell counts after the aerobic exercise was indicated by a pvalue <0.001. differences between the intervention and control groups the analysis of differences in the mean values of cd4 counts between the control group and the intervention group showed that the cd4 count of hiv patients who received the aerobic exercise intervention increased significantly by 5.00 with a pvalue <0.05. meanwhile, in the control group who did not receive the aerobic exercise intervention, there was no significant change. the change was 0.57 with a p-value >0.05. discussion aerobic exercise on the level of depression after the aerobic exercise intervention was carried out in the intervention group, the results of the tests showed that the depression level of hiv patients was significantly different. so, it could be concluded that aerobic exercise intervention was proven to be able to reduce depression levels in hiv patients. the results of this study are in line with the research conducted by heissel et al. (2019) which showed that there were significant differences in the level of depression before and after the intervention with a pvalue of 0.000. andreany stated that there was an effect of aerobic exercise on the level of depression with a pvalue of 0.0002, which means that it was significant for the level of depression. physical exercise that is performed can increase endorphin activity. increasing endorphins will strengthen the body’s natural immunity and improve mood and encourage body activity. psychologically, the ability to show movement during exercise will increase selfconfidence and self-esteem which affects mood. regular physical exercise can help with faster recovery from stressors, thereby decreasing depression symptoms (al-qahtani et al., 2018). conceptually, a stressful situation in an individual will stimulate the hypothalamus to release neuropeptides that will activate the ans (autonomic nerve system) and the pituitary to secrete corticosteroids and catecholamine which are hormones that react to stressful conditions. increased levels of glucocorticoids will interfere with the immune system which causes the cd4 to decrease and make individuals more susceptible to infections and health conditions. increased levels of glucocorticoids will interfere with the immune system which causes the patient’s cd4 to decrease and makes the patient more susceptible to infection and worsening health conditions (benton & karnik, 2019). there are several ways to handle depression in patients, one of which is to provide training in the form of therapy, such as exercising and developing constructive copings to prevent depression in hiv patients (safira et al., 2014). aerobic exercise on the cd4 counts after the aerobic exercise intervention was carried out in the intervention group, the results of the tests showed that the cd4 count of hiv patients was significantly different. the results of this study are in line with research conducted by dianatinasab et al. (2018) which showed the effect of aerobic exercise on increasing cd4 cell count (p<0.001). similarly, yasirin et al. (2014) also stated in their study that there was an effect of aerobic exercise in the intervention group with a cd4 count of 1.7 cells / mm3. in the paper published by the journal of the american medical association, it is stated that there is no drug now or in the future that promises to definitely provide and maintain health better than a habit of living constantly with exercises (yasirin et al., 2014). metabolism is also related to endurance. substances that function to maintain the stability of the body’s immunity also come from the metabolic process. the results of protein metabolism function to maintain endurance. protein substances come from foods that are eaten. the increase in cd4, which is part of the immune system, includes the impact of protein metabolism. aerobic exercise can increase metabolism in the body, including protein metabolism, so that it has an impact on the quality of the immune system. immune jurnal ners http://e-journal.unair.ac.id/jners | 187 system cells circulate rapidly in the body and there may also be a temporary boost in the production of macrophages cells that attack bacteria. a decrease in cd4 cells from hiv sufferers who are not normal must be balanced with treatment in the form of drugs as well as exercise to increase metabolism in the body (naoroibam et al., 2016). the results of this study prove the research hypothesis which states that giving aerobic exercise interventions can reduce depression levels and increase cd4 counts in hiv patients. this study has limitations since it did not control for several confounding variables, such as other comorbidities or the use of drugs in hiv patients that may affect the patient’s level of depression and cd4 cell count. conclusion based on the results of this study, it can be concluded that there is a significant change in the level of depression after the application of aerobic exercise between the control group and the intervention group with a p-value of < 0.05. similarly, there is a significant difference in cd4 cell counts between the intervention group and the control group after the intervention with a mean difference of 5.00 and 0.57, respectively. they were significant mean differences in the mean values of depression and cd4 counts between the intervention group and the control group before and after the intervention of aerobic exercises. aerobic exercise had effects on reducing depression levels and increasing cd4 counts in hiv patients. for the nursing profession it is recommended that nurses to be able to provide one alternative action, namely aerobic exercise in reducing depression levels and increasing cd4 cell counts. nurses can increase their knowledge and skills by learning various nonpharmacological therapies as independent actions of nurses. families can be involved in the exercise so that they can assist the patient in doing the exercise. for further researchers the results of this study can be used as a basis for further researchers to conduct more studies by controlling the confounding variables and adding a larger sample size with a longer period of intervention. references al-qahtani, a. m., shaikh, m. a. k., & shaikh, i. a. (2018). exercise as a treatment modality for depression: a narrative review. alexandria journal of medicine, 54(4), 429–435. https://doi.org/10.1016/j.ajme.2018.05.004 benton, t. d., kee ng, w. y., leung, d., canetti, a., & karnik, n. (2019). depression among youth living with hiv/aids. child and adolescent psychiatric clinics of north america, 28(3), 447–459. https://doi.org/10.1016/j.chc.2019.02.014 demirel, o. f., mayda, p. y., yıldız, n., sağlam, h., koçak, b. t., habip, z., kadak, m. t., balcıoğlu, & kocazeybek, b. (2018). self-stigma, depression, and anxiety levels of people living with hiv in turkey. european journal of psychiatry, 32(4), 182–186. https://doi.org/10.1016/j.ejpsy.2018.03.002 dianatinasab, m., fararouei, m., padehban, v., dianatinasab, a., alimohamadi, y., beheshti, s., aminilari, z., & aminilari, m. (2018). the effect of a 12-week combinational exercise program on cd4 count and mental health among hiv infected women: a randomized control trial. journal of exercise science and fitness, 16(1), 21–25. https://doi.org/10.1016/j.jesf.2018.02.001 grace, j. m., semple, s. j., & combrink, s. (2015). exercise therapy for human immunodeficiency virus/aids patients: guidelines for clinical exercise therapists. journal of exercise science and fitness, 13(1), 49–56. https://doi.org/10.1016/j.jesf.2014.10.003 heissel, a., zech, p., rapp, m. a., schuch, f. b., lawrence, j. b., kangas, m., & heinzel, s. (2019). effects of exercise on depression and anxiety in persons living with hiv: a meta-analysis. journal of psychosomatic research, 126(august), 109823. https://doi.org/10.1016/j.jpsychores.2019.1098 23 jannaim, j., dharmajaya, r., & asrizal, a. (2018). pengaruh buerger allen exercise terhadap sirkulasi ektremitas bawah pada pasien luka kaki diabetik. jurnal keperawatan indonesia, 21(2), 101–108. https://doi.org/10.7454/jki.v21i2.652 kemenkes. (2017). laporan perkembangan hiv-aids. 1–565. naoroibam, r., metri, k., bhargav, h., nagaratna, r., & nagendra, h. (2016). effect of integrated yoga (iy) on psychological states and cd4 counts of hiv-1 infected patients: a randomized controlled pilot study. international journal of yoga, 9(1), 57. https://doi.org/10.4103/0973-6131.171723 nosrat, s., whitworth, j. w., dunsiger, s. i., santabarbara, n. j., & ciccolo, j. t. (2017). acute effects of resistance exercise in a depressed hiv sample: the exercise for people who are immunocompromised (epic) study. mental health and physical activity, 12, 2–9. https://doi.org/10.1016/j.mhpa.2016.12.002 notoatmodjo, s. (2005). metodologi penelitian kesehatan (vol. 205, issue 25). https://doi.org/2005 safira, n., lubis, r., & rasmaliah, r. (2014). faktorfaktor yang berhubungan dengan kepatuhan penderita hiv/aids mengonsumsi obat antiretroviral (arv) di klinik voluntary counseling and testing (vct) rsup h. adam malik medan tahun 2014. portal garuda, 1–10. unaids. (2019). 2018 global hiv statistics. 2(1), 1–6. yasirin, a., rahayu, s., junaidi, s., & artikel, i. (2014). latihan senam aerobik dan peningkatan limfosit cd4 pada penderita hiv. 3(3), 1–6. http://e-journal.unair.ac.id/jners | 173 jurnal ners vol. 15, no. 2, october 2020 http://dx.doi.org/10.20473/jn.v15i2.19494 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effectiveness of health education and nutrition rehabilitation toward community empowerment for children aged less than 5 years with stunting: a quasiexperimental design eli amaliyah1 and mulyati mulyati2 1d3 keperawatan, universitas sultan ageng tirtayasa, banten, indonesia 2d3 keperawatan universitas faletehan, banten, indonesia abstract introduction: globally, more than one child in four under the age of five is too short for their age. although attempts to reduce stunting have succeeded globally, stunting rates in indonesia have unfortunately remained largely stagnant. however, few studies have been conducted in indonesia, particularly in banten to develop and evaluate the education program combining with nutrition rehabilitation intervention to reduce stunting. the purpose of this study was to test effectiveness of education and nutrition rehabilitation to increase community empowerment for stunting in serang banten. methods: this study was conducted using a quasi-experimental design with the reversed-treatment non-equivalent control group design. the study used 200 people as research samples. the analysis tools used include descriptive statistics and paired t tests results: the results of this study showed that education and nutrition rehabilitation effectively to increased community empowerment in overcoming children with stunting (p<0.05). conclusion: nutrition education and rehabilitation management needs to be improved in an effort to reproduce the status of malnutrition or malnutrition into normal nutritional status, particularly in serang city. article history received: may 25, 2020 accepted: august 23, 2020 keywords health education; nutrition rehabilitation; community empowerment; stunting contact eli amaliyah sholehmalikul088@gmail.com  d3 keperawatan, universitas sultan ageng tirtayasa, banten, indonesia cite this as: amaliyah, e., mulyati, m. (2020). effectiveness of health education and nutrition rehabilitation toward community empowerment for children aged less than 5 years with stunting: a quasi-experimental design. jurnal ners, 15(2). 173-177. doi:http://dx.doi.org/10.20473/jn.v15i2.19494 introduction globally, more than one child in four under the age of five is too short for their age (unicef, 2013). low height-for-age or stunting represents failure to attain a minimum stature correlated with present and future growth and development and is a main chronic undernutrition indicator. stunting means poverty and unhealthy working conditions. in 2012, nearly 33 percent of urban residents in the developing world lived in the suburbs and this is expected to reach two billion people living in slum communities in less developed countries by 2030 (united nations, 2012). in the developing world, more than 100,000 people shift to slums each day. actually, almost 1.5 billion citizens live in urban suburbs without proper access to healthcare, clean water and sanitation (british red cross, 2012). evidence indicates that children living in the slums are much more likely than children who live somewhere else in the city to suffer from malnutrition, including stunting (awasthi & agarwal, 2003; ghosh & shah, 2004). stunting is a result of chronic undernutrition during the most important periods of early life growth and development. stunted children suffer from compromised development with irreversible adult consequences and face a high risk of morbidity and mortality (dewey & begum, 2011; mcdonald et al., 2013). stunting in children can be measured by anthropometry using physical growth data. development faltering often happens between the ages of three months and 18 to 24 months (victora et al., 2010). stunting prevalence rises very rapidly between 12 and 24 months (40 percent to 54 percent), continues to rise until 36 months of age (58 percent), and then remains relatively stable until 5 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ e. amaliyah et al. 174 | pissn: 1858-3598  eissn: 2502-5791 years of age (55 percent) (bhutta et al., 2013). indonesia is the fifth highest country in stunting prevalence among children under five in asia (who, 2018). in 2018, as many as 30.8 percent of children under five in indonesia experienced stunting and banten province was the fifth province to become a priority of stunting handling in java island (kemenkes ri., 2018). in banten, the stunting rate has increased significantly from year to year, in 2018 as many as 60,806 cases of stunting were identified. the who hypothesis on the history, causes, and consequences of childhood stunting, which was published in 2013, identifies numerous factors directly leading to stunted growth and development (stewart et al., 2013). while the who framework was based on global data analysis, the framework used to evaluate the contributors of stunting at the national level is critical as national health policies are often based on the available national and sub-national data. the who stunting framework defines community and social factors as 'contextual' and classifies them into six groups: (1) political economy; (2) health and healthcare; (3) education; (4) society and culture; (5) farming and food systems; and (6) water, sanitation and climate. the current evidence of correlation between these factors and stunting is minimal (stewart et al., 2013), and various background variables (e.g. population density, per capita national income, level of democracy (pridmore & hill, 2009) are measured at the national level and are, therefore, not appropriate for household or community level research. according to the who conceptual framework for determinants of a child, stunting showed that household and family factors–low maternal height, premature birth, short birth length, low maternal education, and low household wealth— are important proximate determinants of child stunting in indonesia (beal et al., 2018). although attempts to reduce stunting have succeeded globally (lundeen et al., 2014), notably in ethiopia and the state of mahrastrata, india (haddad et al., 2014), stunting rates have unfortunately remained largely stagnant in sub-saharan africa and south asia (bhutta et al., 2013). achieving global health goals of the who in 2025 to minimize stunting by 40 percent in children under the age of five would rely on sustained efforts to prevent stunting within slums. in indonesia, currently, the government program in handling stunting has been carried out through two approaches, namely specific and sensitive nutrition interventions (kemenkes ri., 2018). however, the stunting program is still not implemented optimally and here is less involvement of community to participate in stunting reduction, as evidenced by the continued increase in the stunting rate. so, we need an approach or intervention that is able to involve community participation outside the health sector. community empowerment is the participation of all community members in solving community problems (bierman et al., 2014). there are several interventions to prompt community participation, one of which is education. the results of previous studies indicate that education is an effective way to increase knowledge, which will have an impact on increasing behavior to participate in problem solving (notoatmodjo, 2014). however, educational education alone is not enough to sustain sustainable participants. decreases in the stunting can be accomplished through measures based on facts. strong evidence was found in the lancet series on maternal and child undernutrition for a range of measures that are effective in supporting children's health (bhutta et al., 2013). by integrating and scaling up to 90 percent of these documented nutritionspecific interventions, stunting could be reduced by 20 percent, representing 33.5 million fewer stunted children (bhutta et al., 2013; fenske et al., 2013; milman et al., 2005; remans et al., 2011). specifically, proposed strategies to address the underlying causes of stunting would concentrate on improving nutrition and avoiding associated diseases. however, few studies have been conducted in indonesia, particularly in banten, to develop and evaluate the education program combining with nutrition rehabilitation intervention to reduce stunting. therefore, the purpose of this study was to primarily test the effectiveness of health education and nutrition rehabilitation toward community empowerment for children aged less than 5 years with stunting. materials and methods study design this study was conducted using a quasi-experimental design with the reversed-treatment non-equivalent control group design with pre-test and post-test conducted in serang city, banten. intervention group was provided education and rehabilitation nutrition for two week and control group only provided with education through leaflet with the topic focus on general information about stunting and its prevention. in the first week, the cadre received two sessions of comprehensive workshops, each session was two hours and the topics were regarding general information about stunting, prevention, and treatment and discussion about their ability to help children aged less than 5 years in recovery from stunting and preventing relapse. workshops were delivered in bahasa indonesia using tutorial and discussion methods. in the second week, the cadre was provided with rehabilitation training in two sessions (each session was two hours) with the topic about nutrition intervention that can be done by the cadre, for example modification of nutrition for children, and cooking class, and also discussing about how to empower their ability to help children with undernutrition. before the workshop session began, all participants received a pre-test regarding their understanding through group discussion about stunting and most of them showed similar understanding about malnutrition. jurnal ners http://e-journal.unair.ac.id/jners | 175 sample the sample in this study was a cadre and other volunteers that were listed officially in the public health center in serang city, banten province, indonesia. the inclusion criteria in this study were age over 18 years old, able to communicate, and willing to be respondent. inactive cadre means those who registered in the database in the public health centre but did not involve in activities provided by the community health centre more than three times. exclusion criterion was inactive cadre. the sample size was calculated using g-power software version 3.1.6 assuming t-test, α = 0.05, effect size = 0.15 (cohen, 1992), power level = 0.80. so that the total sample recruited was 100 cadres for each group. convenience sampling was used to select participants. instrument the demographic characteristics were collected, including age, gender, and education level. community empowerment was measured using a self-developed instrument constructed from four indicators, namely contribution of thought, contribution of funds, contribution of personnel, and contribution of facilities. this instrument was developed based on our previously unpublished qualitative study. this instrument included a likert scale with 1 indicating never and 5 indicating always. after discussion with an expert, finally the instrument measured only three aspects, contribution of thought, contribution of personnel, and contribution of funds with total 15 items, five items for each indicator. the content validity index ranged from 0.64 to 0.79. the cronbach’s alpha in the current study was 0.68. data collection procedure prior to this research, an ethics permit was obtained from the affiliated university (eb20346). after permission was obtained, the researcher explained the objectives, inclusion and exclusion criteria, procedures and ethical protection to midwives and cadres. cadres helped choose samples according to the criteria. respondents who met the criteria were then given an explanation of the intervention and after that signed the informed consent sheet. before intervention, respondents filled out the questionnaire first and then intervened with education and rehabilitation for two weeks. after completion of the intervention, a post-test was taken again. data analysis normality test with kolmogorov smirnov was first done to see whether the data distribution was normal or not. when the data were normal, the univariate analysis used the mean and standard deviation to describe the demographic characteristics and variable of community empowerment. paired sample t-test was used to see the difference before and after the intervention. data processing was performed using spss software version 22. results table 1 shows that the average age of the control and control group is over 30 years, mostly women, with junior high school education. there was no significant difference between intervention and control group in terms of age, gender, and education level, which mean that both intervention and control groups had similar characteristics even without random sampling. in the intervention group, the mean of community empowerment score before intervention was 11.11 (sd=4.88), and after intervention there was an increased score of community empowerment as much as 4.17, with mean score after intervention of 13.50 (sd=2.22). according to the results of paired ttest, it showed a significant improvement of community empowerment after intervention with pvalue 0.000 (table 2). while, in the control group, the mean of community empowerment score before intervention was 13.42 (sd=6.60), and after intervention there was an increased score of community empowerment as much as 0.09, with table 1. demographic characteristics of respondent (n=200) variables intervention group (n=100) control group (n=100) p-value age, mean (sd) 34.4 (3.3) 33.4 (3.4) 0.142 gender male 30 (30) 27 (27) 0.078 female 70 (70) 73 (73) education level 0.271 elementary school 35 (35) 37 (37) junior high school 55 (55) 49 (49) senior high school 10 (10) 14 (14) university 0 0 tabel 2. differences in community empowerment before and after intervention in both groups (n=200) group before intervention mean (sd) after intervention mean (sd) mean different p-value for paired t test p-value for independent t test intervention group 11.11 (4.88) 13.50 (2.22) 4.17 0.000 0.001 control group 13.42 (6.60) 13.49 (3.29) 0.09 0.922 e. amaliyah et al. 176 | pissn: 1858-3598  eissn: 2502-5791 mean score after intervention of 13.49 (sd=3.29). according to the results of paired t-test, it showed nonsignificant improvement of community empowerment after intervention with p-value 0.922. in addition, independent t-test showed that the intervention group had significant improvement in the score of community empowerment after intervention compared to the control group, with pvalue 0.001. discussion there is a significant improvement of community empowerment in stunting prevention after being given intervention. these results are consistent with astama et al. (2012), that prevention through nutrition education and rehabilitation is an alternative model for tackling under-fives’ malnutrition based on community empowerment through four elements, namely: (1) education, (2) pmt together , (3) health checks, medications and micronutrients and (4) fostering community participation to contribute in the form of food, energy, or money. the implications of this result are nutrition education and rehabilitation by helping, facilitating, and motivating mothers of under-fives and with poor nutrition, failing to improve their child's nutritional status, and changing behavior in caring for children and providing food to children. the obstacles are the low level of society and the lack of public knowledge about the importance of overcoming malnutrition in children under five which has an impact on brain growth and development in children. we found that community empowerment before intervention among two groups showed a low score. this result is not in accordance with previous study finding that the development paradigm that is highly developed now is the empowerment paradigm, which consists of community participation (abadi, 2014). it was also explained that community participation is the participation of all community members in solving community problems (abadi, 2014). the results are also not in accordance with aidha (2012), that the level of community participation, both from the scope of the program and from the results of measurements on the community, shows the same results i.e. the level of community participation is below the established national standard of 80 percent. if the d / s coverage is below 80 percent then it is said that community participation for monitoring growth and weight development is very low. thus, support from family and community will influence the actions of mothers in utilizing community health activity to improve family health, especially weighing children under five, examining sick children and others. our study may have several limitations. first, measurement of community empowerment still needs to be tested for its construct validity. second, our study was carried out for only two weeks after ending of the impact evaluation and termination, which may be considered as a relatively short period. nevertheless, this period was sufficient to examine how intervention exposure changed even shortly after the ending. further research on the effects of longer duration of sustainability is needed. third, our study of sustained outcomes was focused on the effects among the target population of the nutrition interventions. we did not examine the policy and regulatory institutions or organizational levels in connection to sustained service delivery, which was undertaken by a separate study. conclusion in conclusion, education and nutrition rehabilitation through workshop and training in two sessions for two weeks was effective to increase community empowerment for stunting reduction. nutrition education and rehabilitation management needs to be improved in an effort to reproduce the status of malnutrition into normal nutritional status, particularly in serang city. community empowerment management needs to be improved by instilling awareness to be involved in dealing with toddlers with malnutrition and of malnutrition being the normal nutritional status. this study provides a new approach for prevention of stunting in indonesia that can be basic evidence for healthcare policy to improve prevention programs on stunting with the local community and widely provide cultural training for all communities through cadres as a first line of the healthcare system in indonesia. references abadi, t. (2014). performance e-government untuk peningkatan partisipasi masyarakat dalam pembangunan infrastruktur di kabupaten sidoarjo. jurnal kawistara, 4. https://doi.org/10.22146/kawistara.6379 aidha, z. (2012). analisis implementasi pemberdayaan masyarakat dalam strategi promosi kesehatan dan pengaruhnya terhadap partisipasi masyarakat dalam pencegahan gizi buruk pada balita di kecamatan helvetia medan. jurnal ilmiah penelitian kesehatan, 2(2). http://jurnal.uinsu.ac.id/index.php/kesmas/ar ticle/view/1123/889 astama, d., widodo, a. k. m. k. a., & ambarwati, s. k. n. e. m. k. w. n. (2012). pengaruh pendidikan kesehatan pada ibu-ibu kader pemberdayaan keluarga dan kemasyarakatan (pkk) dalam mengubah pengetahuan dan sikap tentang pencegahan demam berdarah dengue di desa pucangan kartasura. awasthi, s., & agarwal, s. (2003). determinants of childhood mortality and morbidity in urban slums in india. indian pediatrics, 40(12), 1145– 1161. beal, t., tumilowicz, a., sutrisna, a., izwardy, d., & neufeld, l. m. (2018). a review of child stunting determinants in indonesia. maternal & child nutrition, 14(4), e12617. https://doi.org/10.1111/mcn.12617 jurnal ners http://e-journal.unair.ac.id/jners | 177 bhutta, z. a., das, j. k., rizvi, a., gaffey, m. f., walker, n., horton, s., webb, p., lartey, a., & black, r. e. (2013). evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? lancet (london, england), 382(9890), 452–477. https://doi.org/10.1016/s01406736(13)60996-4 bierman, g., abadi, m., & torgersen, m. (2014). understanding typescript (vol. 8586). https://doi.org/10.1007/978-3-662-442029_11 british red cross. (2012). learning from the city: british red cross urban learning project scoping study. dewey, k. g., & begum, k. (2011). long-term consequences of stunting in early life. maternal & child nutrition, 7 suppl 3(suppl 3), 5–18. https://doi.org/10.1111/j.17408709.2011.00349.x fenske, n., burns, j., hothorn, t., & rehfuess, e. a. (2013). understanding child stunting in india: a comprehensive analysis of socio-economic, nutritional and environmental determinants using additive quantile regression. plos one, 8(11), e78692. https://doi.org/10.1371/journal.pone.007869 2 ghosh, s., & shah, d. (2004). nutritional problems in urban slum children. indian pediatrics, 41(7), 682–696. haddad, l., nisbett, n., barnett, i., & valli, e. (2014). maharashtr_s child stunting declines: what is driving them? findings of a multidisciplinary analysis. kemenkes ri. (2018). hasil utama riskesdas 2018. (k. ri. (ed.)). lundeen, e. a., stein, a. d., adair, l. s., behrman, j. r., bhargava, s. k., dearden, k. a., gigante, d., norris, s. a., richter, l. m., fall, c. h. d., martorell, r., sachdev, h. s., & victora, c. g. (2014). height-for-age z scores increase despite increasing height deficits among children in 5 developing countries. the american journal of clinical nutrition, 100(3), 821–825. https://doi.org/10.3945/ajcn.114.084368 mcdonald, c. m., olofin, i., flaxman, s., fawzi, w. w., spiegelman, d., caulfield, l. e., black, r. e., ezzati, m., & danaei, g. (2013). the effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries. the american journal of clinical nutrition, 97(4), 896–901. https://doi.org/10.3945/ajcn.112.047639 milman, a., frongillo, e. a., de onis, m., & hwang, j.-y. (2005). differential improvement among countries in child stunting is associated with long-term development and specific interventions. the journal of nutrition, 135(6), 1415–1422. https://doi.org/10.1093/jn/135.6.1415 notoatmodjo, s. (2014). promosi kesehatan dan ilmu perilaku (cetakan ii). rineka cipta. pridmore & hill. (2009). addressing the underlying and basic causes of child undernutrition in developing countries : what works and why ? evaluation study 2009 / 2 addressing the underlying and basic causes of child undernutrition in developing countries : what works and why ? foreign affairs, 2(april), 1–97. remans, r., pronyk, p. m., fanzo, j. c., chen, j., palm, c. a., nemser, b., muniz, m., radunsky, a., abay, a. h., coulibaly, m., mensah-homiah, j., wagah, m., an, x., mwaura, c., quintana, e., somers, m. a., sanchez, p. a., sachs, s. e., mcarthur, j. w., & sachs, j. d. (2011). multisector intervention to accelerate reductions in child stunting: an observational study from 9 sub-saharan african countries. american journal of clinical nutrition, 94(6), 1632–1642. https://doi.org/10.3945/ajcn.111.020099 stewart, c. p., iannotti, l., dewey, k. g., michaelsen, k. f., & onyango, a. w. (2013). contextualising complementary feeding in a broader framework for stunting prevention. maternal & child nutrition, 9 suppl 2(suppl 2), 27–45. https://doi.org/10.1111/mcn.12088 unicef. (2013). improving child nutrition. the achievable imperative for global progress. https://reliefweb.int/report/world/improving -child-nutrition-achievable-imperative-globalprogress#:~: united nations. (2012). the millennium development goals report 2012. https://www.un.org/millenniumgoals/pdf/md g report 2012.pdf victora, c. g., de onis, m., hallal, p. c., blössner, m., & shrimpton, r. (2010). worldwide timing of growth faltering: revisiting implications for interventions. pediatrics, 125(3), e473-80. https://doi.org/10.1542/peds.2009-1519 who. (2018). global nutrition report 2018 executive summary. 12. https://doi.org/10.2499/9780896295643 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license editorial combatting pseudoscience amidst the covid-19 pandemic gading ekapuja aurizki faculty of nursing, universitas airlangga *corresponding author: gading ekapuja aurizki faculty of nursing, universitas airlangga email: gading-e-a-10@fkp.unair.ac.id amid the covid-19 pandemic, it is natural for people to want to know about the causing virus, its transmission, prevention, the government’s response and other relevant information through the information channels. in the past, before science developed, people considered the plague as a manifestation of the anger of the gods. along with the times, people began to open up to science. while there are still some superstitious societies, most believe in scientific arguments. unfortunately, high expectations and enthusiasm for science are often not accompanied by a critical attitude and increased interest in reading. there is a tendency for people to cherry-pick the information. cherry-picking can distort knowledge due to bias in the selection of information sources. this can lead people to fall into pseudoscience or “bad science”—to borrow ben goldacre's term. both pseudoscience and bad science are things that sound scientific but are not or have a scientific basis but are interpreted haphazardly. during the covid-19 pandemic, much scientific-sounding information and analysis are milling about. some of the initial examples are the interpretation of the covid-19’s low case fatality rate (cfr), claims of traditional ingredients to prevent covid-19, herd immunity discourse, to the vaccines adverse effects. covid-19 was initially considered harmless with a low cfr, some even equating it with the common cold. however, instead of being similar to the common cold, covid-19 is feared to have an impact like the 1918 flu pandemic, which claimed estimated millions of lives worldwide because of its swift spread (petersen et al., 2020). in addition, when the covid-19 outbreak had not been detected in indonesia, there was a view that indonesians were immune to coronaviruses because of a diet rich in spices. some researchers even took advantage of this moment to promote their findings of ingredients that can ward off the coronavirus by increasing the immune system. however, so far, there has been no publication about the results of testing for these materials, specifically for covid-19 patients, and how significant the effects are when compared to other materials that already exist. so, the claim is only a claim. in the era of information technology, when most people have been out of superstition, worrying is not the clash between science and mystical views but between actual science and bad science or pseudoscience. in his book the death of expertise, tom nichols wrote that one could not become an expert just by reading a lot. without having the correct analytical method, ordinary people will not process information into knowledge. that is why any information circulating must be sourced from experts in the field. this makes the statement about covid-19 spreading in the community very dynamic. therefore, it is essential to keep updated with the latest information from trusted sources, as well as a crosscheck to other sources before concluding. references petersen, e., koopmans, m., go, u., hamer, d.h., petrosillo, n., castelli, f., storgaard, m., al khalili, s. and simonsen, l. 2020. comparing sars-cov-2 with sars-cov and influenza pandemics. the lancet infectious diseases. 20(9), pp.e238–e244. jurnal ners vol. 16, no. 2, october 2021 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:gading-e-a-10@fkp.unair.ac.id http://e-journal.unair.ac.id/jners 83 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 83-88 http://dx.doi.org/10.20473/jn.v17i1.32565 original article open access the effects of illness script method on clinical reasoning of undergraduate nursing students: a quasi-experimental study gede arya bagus arisudhana 1,* 1 stikes bina usada bali, bali, indonesia *correspondence: gede arya bagus arisudhana . address: padang luwih street, tegal jaya, dalung, kuta utara, bali, indonesia. email: aryabagus08@gmail.com responsible editor: praba diyan rachmawati received: 5 january 2021 ○ revised: 26 april 2022 ○ accepted: 27 april 2022 abstract introduction: the improvement of clinical reasoning in nursing students is a benchmark for students' abilities in carrying out nursing care. disease script-based learning can help students recognize the information. the purpose of this study was to determine the effect of illness scripts on the clinical reasoning ability of nursing students . methods: the research design used was a quasi-experimental with a non-equivalent control group. a consecutive sampling technique was applied. the number of samples in each group is 35 respondents, the outcome was measured using clinical reasoning assessment tools. data were analysed using wilcoxon signed rank test. results: the results of this study indicate that there is an increase in the clinical reasoning ability of nursing students in the experimental group from the average value of 40.6 to 50.3. most of the respondents in the experimental group had clinical reasoning at the intermediate learner level. the results of the wilcoxon test showed that the z-count value in the experimental group was 5.092 with a p-value < 0.001. conclusions: the primary finding in this study is that there is an effect of the illness script method on the clinical reasoning of undergraduate nursing students. the application of illness scripts in the nursing learning process at as early stage as possible is very relevant. this model helps students in increasing critical thinking about patient nursing problems. keywords: critical thinking; efficacy; learning strategy; nursing study introduction clinical reasoning is defined as an ability of decisionmaking, problem-solving, critical thinking, and clinical judgment (hunter and arthur, 2016). good clinical reasoning skills improve the performance of safe and effective nursing care delivery (alamouti et al., 2020). several studies have found that nurses with poor clinical reasoning skills were incompetent to synthesize a patient's worsening prognosis, leading to decisionmaking errors in inpatient care (graan, johanna and williams, 2017; guerrero, 2019). according to world health organization data, about 5% of outpatients experience diagnostic errors (world health organization., 2019). some of the patients’ diagnostic errors as caused by a lack of clinical reasoning (world health organization, 2016). study from iran showed the average score of clinical reasoning skills of nursing students is too weak at about 46% (alamouti et al., 2020). in indonesia, the accuracy of nursing diagnoses reaches 64% as a-sufficient category (trisno, nursalam and triharini, 2020). research has found that the accuracy of nursing diagnoses is related to good clinical reasoning ability (paans et al., 2012). clinical reasoning ability needs to improve since taking formal nursing education. nursing students are required to be agile in clinical reasoning. clinical reasoning is a cognitive process and strategy used to identify, diagnose, and make clinical decisions regarding a patient's condition. based on the cognitive perspective theory, it's explained the importance of cognitive structure in clinical reasoning. it consists of knowledge about pathophysiology, patient complaints, signs, symptoms, and other clinical information relevant to the context of the disease (schmidt, norman and boshuizen, 1990). various learning methods have been implemented https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0001-5278-7608 arisudhana (2022) 84 p-issn: 1858-3598  e-issn: 2502-5791 to improve cognitive structures in nursing students' clinical reasoning and are still unclear (brown, tyo and mccurry, 2019). a few educational models to improve the knowledge structure of clinical reasoning such as reflection and feedback models (choi et al., 2020), contextual learning (yauri, nash and ramsbotham, 2019) and problem-based learning (ju and choi, 2017) were applied but still cannot overcome the knowledge structure clinical reasoning of undergraduates students. these learning approaches only produce hypotheses in the assessment process, problem formulation, diagnosis and outcome criteria, and intervention (levett-jones et al., 2010). the reasoning process is very conceptual, and the thought process is slow (peters et al., 2017). a strategy is needed to provide the ability to organize their specific knowledge and more efficiently, called script (boushehri, arabshahi and monajemi, 2015). undergraduate nursing students often struggle to develop these requisite skills (blakey, guinea and saghafi, 2017). scientific evidence found that interventions are underway to enhance clinical reasoning named illness script (lee et al., 2010). in medical education, illness scripts have a role in improving clinical reasoning abilities. however, studies in nursing education regarding the application of illness scripts in clinical reasoning are few. a study showed illness scripts proved to be effective and active learning strategies in improving clinical reasoning. the illness script needs to be adapted to nursing education (lee and bagnardi, 2010). the qualitative studies found that the illness scripts increased nurses' knowledge about patient problems and medical components of the disease scripts were also relevant in nursing (vreugdenhil et al., 2022). illness scripts play a role in recognizing information, comparing, and predicting information from a disease (lubarsky et al., 2015). an illness script is a specific script about the disease that consists of enabling conditions, faults, and consequences. based on illness scripts theory, the reasoning process is led by the structure of knowledge in memory. it can easily interpret the prognosis of a complex health condition (lubarsky et al., 2015). students need to understand the process of organizing knowledge about clinical and biomedical to improve the quality of nursing care. therefore, it is the main reason to investigate the impact of illness scripts training on the clinical reasoning of undergraduate nursing students. this study aims to determine the effects of illness script methods on the clinical reasoning skill of nursing students. materials and methods study design this quantitative study used a quasi-experimental approach with a control group pretest-posttest design. this design involves two groups of participants, and outcome data are collected before and after implementing an intervention. this design called controlled trials without randomization involves an intervention but lacks randomization (polit and beck, 2012). the independent variable in this study is the illness script method. illness script means disease schemas into knowledge memory consisting of epidemiology, time course, pathophysiology, and medical conditions. the illness script stimulation is applied in the learning process. the dependent variable in this study is clinical reasoning. clinical reasoning is defined as a complex and consequential cognitive process in managing and evaluating a patient's health problem (pelaccia et al., 2011). this research was carried out during the covid-19 pandemic, with a policy of limiting distance and use of personal protective equipment. classes were carried out in a hybrid manner, where the intervention group conducted face-to-face learning meetings outside the network. the control group carried out face-to-face learning meetings online. the experimental group was given an illness script stimulation intervention, while the control group received a standard intervention carried out in the learning process. pretest was conducted on both groups before being given the intervention. the intervention was given once a week for 14 weeks. the posttest was carried out after the illness script stimulation intervention at week 14. respondent the population covered in this study were all second level nursing students. the number of samples in this study was 70 people, 35 respondents to each group. the sample size was determined by using a hypothesis test on the mean of two independent groups (sastroasmoro and ismael, 2014). a consecutive sampling technique was applied. the sample criteria in this study were determined based on the representative characteristics of the affordable population. after the prospective respondents met the inclusion and exclusion criteria of the study, then the researcher asked the prospective respondents' willingness to participate after receiving an explanation of the aims, objectives, benefits, research procedures, as well as the rights and obligations of being a respondent. for prospective respondents who were willing, the researcher then asked them to sign an informed consent form, then randomly divided them into experimental groups and control groups. the sample inclusion criteria of the respondents were: the students completing the medical surgical nursing course 1; completing the basics nursing science courses; a minimum grade point average 3. the exclusion criteria for this study are the students who are not willing to complete 14 face-to-face meetings. jurnal ners http://e-journal.unair.ac.id/jners 85 intervention the intervention given is the illness script. in the learning process, practice is not carried out to the hospital, case stimulation is carried out theoretically and in laboratory practice. the intervention was carried out during the learning process. the duration of the intervention was once a week until 14 weeks. the illness script method steps are happened in series (lee and bagnardi, 2010; lee et al., 2010). first step. the tutor will provide stimulation in the lecture by introducing an overview of the disease scenario from the patient's clinical condition. students simulate the clinical details of anatomy and physiology, etiology, pathophysiology, physical, and examination. the main components of the illness script are enabling conditions (such as age, sex, current medication, previous medical history, occupation, risk behavior, hereditary, and environment affect the probability of someone getting a disease); fault (pathophysiological malfunctioning); and clinical consequences (complaints, signs, and symptoms) (yazdani and abardeh, 2019). second step. students identify possible conditions, errors, and clinical consequences. students were guided to identify key findings and assist them. students are allowed to explore relevant journals and references to strengthen literacy in simulated cases. third step. students will represent and compose illness scripts based on their ability to memorize the information. students represent illness script for three probable illnesses, inclusive of epidemiology, time course, signs and symptoms, pathophysiology, and pharmacology. fourth step. student will analyze the illness script, looking for differentiating features. fifth step. students prioritizing care for the patient and determining how to evaluate the effectiveness of care. instrument the instrument used in this research is clinical reasoning assessment tools (crat). the validity test of the crat instrument showed good and stable validities with an accuracy value of 72%. crat is also stable in the reliability test, with a cronbach’s alpha value of 0.821 (arisudhana et al., 2019). the clinical reasoning dimensions used in this measuring instrument are according to the theory proposed by schmidt, norman and boshuizen in 1990 and harasym, tsai and hemmati in 2008 (yazdani and abardeh, 2020). the dimensions are dispersed knowledge structure (dk), elaborated causal network (ec), encapsulation knowledge structure (ek), and illness script knowledge structure (is) (yazdani and abardeh, 2020). the four dimensions turn into 25 statements in vignette form. each has four answer choices. answers that represent dispersed knowledge (dk) a score of 0, elaborated knowledge structure (ec) a score of 1, encapsulation knowledge structure (ek) a score of 2, and illness script knowledge structure (is) a score of 3. the minimum score of all 25 items is 0, and the maximum value is 75. furthermore, clinical reasoning is interpreted into four categories according to the theory proposed by drefyus and drefyus in 1980 and benner’s theories in 2005 (yazdani and abardeh, 2020). the clinical reasoning categories based on the calculation of the mean value are the expert category (score > 58.3), advance beginner (score 51-58.3), novice (score 42-50) and surface learner (score < 42). the level of clinical reasoning based on the knowledge structure model starts from the surface learner to the expert level. in the first level, surface learners were defined as students only focused on understanding the main points and memorizing them. they don't like the material, feel pressured and rush to retain information. they only focus on memorizing information and do not understand the meaning behind the materials. they cannot remember information effectively (gopakumar et al., 2016). research has found that students who adopt surface learning will receive less information (gurpinar et al., 2013). in the second level, a novice learner is defined as a student who does not have experience and understanding of clinical situations. novice learners have difficulty understanding the clinical situation, such as difficulties paying attention first (benner, kyriakidis and stannard, 2011). in the third level, advanced beginner learners had high awareness of feedback on any knowledge gained (benner, kyriakidis and stannard, 2011). at this level, nursing students have good attention to learning materials. the student was active and had a good ability to identify aspects of clinical conditions (benner, kyriakidis and stannard, 2011). the fourth level is defined as students at the expert learner level who have good skills in developing strategies for information management and improving practical skills (benner, kyriakidis and stannard, 2011). data collection respondents willing to participate in this study filled out a characteristic questionnaire with the assistance of the researcher. for both experimental and control groups, filling out questionnaires on the characteristics of respondents was done by online method. the next stage, respondents in both groups were asked to attend outside the network to campus to pretest clinical reasoning variables with clinical reasoning assessment tools. after the pretest, the experimental group received the illness script method in the learning process, while the control group used the conventional methods. the illness script method is an intervention in the learning process in the form of disease script stimulation with the dimensions of enabling factors, faults, and clinical consequences while the conventional method is a standard intervention in the learning process without case stimulation. the experimental group received an intervention for 14 weeks online, while the control group received a standard arisudhana (2022) 86 p-issn: 1858-3598  e-issn: 2502-5791 intervention for 14 weeks online. at week 15, both groups conducted a posttest using clinical reasoning assessment tools. analysis the data analysis used bivariate and univariate tests. a univariate test used analysis of the respondent characteristics such as ages, gender, grade point averages, senior high school background, and distribution of level clinical reasoning. a bivariate test was carried out on clinical reasoning variables using the wilcoxon signed-rank test (α = 0.05). ethical consideration this study was conducted in badung regency bali province over 14 weeks in 2021. this research has been reviewed and declared ethically feasible by the health research ethics commission of stikes bina usada bali based on the ethics pass certificate number: 362/ea/kepk-bub-2020. researchers maintain the confidentiality of all information obtained from questionnaire. as a guarantee of anonymity, the respondent's name was not put in the questionnaire. data are not disseminated to anyone to enforce the principle of non-maleficence. results table 1 shows age average in the experimental group is 20 years old, and the control group is 20.14 years old. gender in the experimental and control groups is dominated by females, 86% and 88%, respectively. the educational background of both groups is majority senior high school at about 22% and 24%, respectively. the p-value in the experimental group was said to be significant with a p-value < 0.001 (p<0.05). in the control group, the p-value shows 0.069 (p>0.05), which means that the intervention is not significantly giving some effect. the results of the comparison test of the pre-post difference between groups got a p-value <0.001. it showed that the illness script learning method had a significant effect on clinical reasoning skills. table 3 shows that, after receiving treatment in each group, it is known that 31 respondents (89%) in the experimental group had an intermediate level of clinical reasoning. in the control group, 18 respondents (51%) had a novice level of clinical reasoning. discussion illness script content is presented in case vignettes. there was an increase in the average value of clinical reasoning in the experimental group who received illness script-based learning materials. students in the experimental group had better abilities than students in the control group in understanding epidemiology, pathophysiology, and medical conditions. a study found that illness scripts can help students recognize information, compare, and predict prognoses of a disease. illness script describes the information process being structured and retrieved from long-term memory to interpret, analyze and envision new information (lubarsky et al., 2015). illness scripts worksheet is a form of case-based learning with a knowledge-oriented approach to the patient's clinical condition. few studies were found that improving clinical reasoning skills used intervention as knowledge-oriented (chamberland et al., table 1. respondent characteristics (n = 70) variable mean±sd n (%) experiment control experiment control age 20±0.54 20.14±0.60 grade point average 3.56±0.20 3.55±0.18 gender male female 5(14%) 30(86%) 4(12%) 31(88%) senior high school background senior high school vocational high school 22(63%) 13(27%) 24(69%) 11(22%) table 2. the effects of illness script method on clinical reasoning of undergraduate nursing students (n = 70) variable group mean±sd z p-value control clinical reasoning pre 39.8±2.5 -1.523 0.128 post 40.8±3.1 experiment pre 40.6±3.02 -5.092 <0.001 post 54.3±3.7 table 3. level of clinical reasoning (n = 70) clinical reasoning level control group n (%) experimental group n (%) pretest posttest pretest posttest surface learner novice intermediate expert 29(83) 6(17) 17 (49) 18 (51) 25(71) 10(29) 31 (89) 4 (11) jurnal ners http://e-journal.unair.ac.id/jners 87 2011; 2013; schmidt and mamede, 2015; keemink et al., 2018). based on script theory, illness scripts make it possible to integrate acquired information with existing knowledge, understand irregular and complex patterns of symptoms, identify similarities and differences in conditions between diseases, and predict the likelihood of disease progression. knowledge will enhance through experience and learning. teaching clinical reasoning using illness scripts can help students improve their skills in making diagnoses and interpreting clinical data (lubarsky et al., 2015). in the nursing process, providing stimulation based on illness script affects students' cognition of a patient's clinical condition and increases reasoning level. meanwhile, another impact of reasoning enhanced students' proficiency in performing nursing care. good levels of clinical reasoning include the process of revealing visible problems, determining nursing care goals, identifying appropriate actions, and evaluating the achievements of evidence-based nursing care. nursing practice emphasizes good skills in assessment and comprehensive decision-making skills through critical thinking processes. making decisions based on clinical conditions was the noteworthy element in nursing practice (mccartney, 2017). the study found that the illness script was an interesting method as a form of learning approach and stimulating students' critical thinking (lee and bagnardi, 2010). in the concept of critical thinking, clinical reasoning has a broader nature. clinical reasoning was a way for nurses to observe patient status, process relevant data/records, understand patient problems, plan and implement nursing care, evaluate outcomes, and reflect on results. the barometer of clinical reasoning includes control, recognition, and response to significant information, specific symptoms, use of questions that lead to pathophysiological reasons, asking questions in a chronological direction, focusing on agreement with the patient, summarizing, and understanding body semantics. these skills were learned by undergraduate nursing students, requiring involvement and willpower during practice. to acquire these skills, students must improve their critical thinking skills and understanding of care (mccartney, 2017). illness script also helps students understand the difficulty of learning materials (lee and bagnardi, 2010). through illness script stimulation, the process of applying the knowledge, skills, and expertise of nursing students in the form of clinical reasoning gets better. a nurse needs to be guided by appropriate clinical reasons to get good results and prevent the risk of harm to patient safety (guerrero, 2019). this study contributes to outlining the illness script in the context of nursing and relates to the clinical reasoning in nursing. this study has several limitations. first, the participants were recruited from a single institution, perhaps limiting the generalizability of our findings. second, the sample size is relatively smaller than necessary. third, some variables cannot be measured, such as study habits and literacy levels which can affect the reasoning process. conclusions the use of illness scripts in nursing education is very relevant. effective and innovative teaching approaches are needed in nursing education. based on the results of this study, the use of illness scripts is effective to improve the ability of nursing students in filtration of clinical information, analysis, clinical reasoning process, and making clinical decisions. this method helps educators evaluate the readiness of nursing students to face the nurse competency test and the objective structured clinical examination. in particular, this approach can assist in preparing nursing students for practices that require collaboration with multiple health disciplines. the main finding of this research is the influence of disease text on the clinical reasoning of undergraduate students. the illness script can improve students' ability to memorize information, and increase knowledge, enhance clinical performance in the quality of nursing diagnoses, interventions, and outcomes. using a clinical reasoning knowledge structure's model approach can help identify the stage of development of nursing students' thinking processes since the first semester. acknowledgement this the researcher would like to thank the ministry of education, culture, and higher education of the republic of indonesia for providing research grant funding in the novice lecturers scheme. the researcher also thanks stikes bina usada bali for their support and providing all the teaching facilities during the blended learning process. references alamouti, h. d. et al. (2020) ‘clinical reasoning in nursing students’, advances in nursing and midwifery, 29(4), pp. 24–30. doi: 10.29252/anm-29791. arisudhana, g. a. b. et al. (2019) ‘the clinical reasoning ability of fourth-year nursing students on medical surgical nursing problems’, journal center of research publication in midwifery and nursing, 3(1), pp. 58–62. doi: 10.36474/caring.v3i1.135. benner, p., kyriakidis, p. h. and stannard, d. (2011) clinical wisdom and interventions in acute and critical care. 2nd edn, clinical wisdom and interventions in acute and critical care. 2nd edn. new york: springer publishing company. doi: 10.1891/9780826105745. blakey, n., guinea, s. and saghafi, f. (2017) ‘transforming undergraduate nursing curriculum by aligning models of clinical reasoning through simulation’, research and development in higher education: curriculum transformation, 40, pp. 25–37. boushehri, e., arabshahi, k. s. and monajemi, a. (2015) ‘clinical reasoning assessment through medical expertise theories: past, present and future directions’, medical journal of the islamic republic of iran, 29(1). brown tyo, m. and mccurry, m. k. (2019) ‘an integrative review of clinical reasoning teaching strategies and outcome evaluation in nursing education’, nursing education perspectives, 40(1), pp. 11–17. doi: 10.1097/01.nep.0000000000000375. arisudhana (2022) 88 p-issn: 1858-3598  e-issn: 2502-5791 chamberland, m. et al. (2011) ‘the influence of medical students’ selfexplanations on diagnostic performance’, medical education, 45(7), pp. 688–695. doi: 10.1111/j.1365-2923.2011.03933.x. chamberland, m. et al. (2013) ‘students’ self-explanations while solving unfamiliar cases: the role of biomedical knowledge’, medical education, 47(11), pp. 1109–1116. doi: 10.1111/medu.12253. choi, s. et al. (2020) ‘effects of reflection and immediate feedback to improve clinical reasoning of medical students in the assessment of dermatologic conditions: a randomised controlled trial’, bmc medical education. bmc medical education, 20(146), pp. 1–9. doi: 10.21203/rs.3.rs-24301/v1. gopakumar, a. et al. (2016) ‘learning approach among health sciences students in a medical college in nepal: a cross-sectional study’, advances in medical education and practice, 7, pp. 375–376. doi: 10.2147/amep.s109646. graan, a. c. van, johanna, m. and williams, s. (2017) ‘sciencedirect a conceptual framework to facilitate clinical judgement in nursing : a methodological perspective’, health sa gesondheid. elsevier ltd, 22, pp. 275–290. doi: 10.1016/j.hsag.2017.01.004. guerrero, j. g. (2019) ‘practice rationale care model : the art and science of clinical reasoning , decision making and judgment in the nursing process’, open journal of nursing, 9(2), pp. 79–88. doi: 10.4236/ojn.2019.92008. gurpinar, e. et al. (2013) ‘do learning approaches of medical students affect their satisfaction with problem-based learning?’, american journal of physiology advances in physiology education, 37(1), pp. 85– 88. doi: 10.1152/advan.00119.2012. hunter, s. and arthur, c. (2016) ‘nurse education in practice clinical reasoning of nursing students on clinical placement : clinical educators ’ perceptions’, nurse education in practice. elsevier ltd, 18, pp. 73–79. doi: 10.1016/j.nepr.2016.03.002. ju, h. and choi, i. (2017) ‘the role of argumentation in hypotheticodeductive reasoning during problem-based learning in medical education: a conceptual framework’, interdisciplinary journal of problem-based learning, 12(1), pp. 11–14. doi: 10.7771/1541-5015.1638. keemink, y. et al. (2018) ‘illness script development in pre-clinical education through case-based clinical reasoning training’, international journal of medical education, 9(february), pp. 35–41. doi: 10.5116/ijme.5a5b.24a9. lee, a. et al. (2010) ‘medical student education using illness scripts to teach clinical reasoning skills to medical students’, medical student education, 42(4), pp. 255–261. lee, j. d. and bagnardi, m. (2010) ‘student self-efficacy of learning using illness scripts’, journal nursing education perspectives, 37(6), pp. 323–324. doi: 10.4172/2167-1168.1000126. levett-jones, t. et al. (2010) ‘nurse education today the “ five rights ” of clinical reasoning : an educational model to enhance nursing students ’ ability to identify and manage clinically “ at risk ” patients’, nurse education today, 30, pp. 515–520. doi: 10.1016/j.nedt.2009.10.020. lubarsky, s. et al. (2015) ‘using script theory to cultivate illness script formation and clinical reasoning in health professions education’, canadian medical education journal, 6(2), pp. e61–e70. doi: 10.36834/cmej.36631. mccartney, m. (2017) ‘margaret mccartney: nurses must be allowed to exercise professional judgment’, bmj (online), 356, pp. 3–4. doi: 10.1136/bmj.j1548. paans, w. et al. (2012) ‘do knowledge, knowledge sources and reasoning skills affect the accuracy of nursing diagnoses? a randomised study’, bmc nursing, 11, pp. 1–12. doi: 10.1186/1472-6955-11-11. pelaccia, t. et al. (2011) ‘an analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory’, medical education online, 16(1), pp. 1–9. doi: 10.3402/meo.v16i0.5890. peters, a. et al. (2017) ‘examining the influence of context and professional culture on clinical reasoning through rhetoricalnarrative analysis’, qualitative health research, 27(6), pp. 866–876. doi: 10.1177/1049732316650418. polit, d. f. and beck, c. t. (2012) nursing research: generating anf assessing evidence for nursing practice. 9th edn. hongkong: wolters kluwer health l lippincott william & wilkins. sastroasmoro, s. and ismael, s. (2014) dasar-dasar metode penelitian klinis. 5th edn. edited by s. sastroasmoro and s. ismael. jakarta: sagung seto. schmidt, h. g. and mamede, s. (2015) ‘how to improve the teaching of clinical reasoning: a narrative review and a proposal’, medical education, 49(10), pp. 961–973. doi: 10.1111/medu.12775. schmidt, h. g., norman, g. r. and boshuizen, h. p. a. (1990) ‘a cognitive perspective on medical expertise: theory and implications’, acad med, 65(10), pp. 611–621. doi: 0.1097/00001888-19901000000001. trisno, t., nursalam, n. and triharini, m. (2020) ‘analysis of accuracy nursing care process implementation’, jurnal ners, eissn(2), p. 2020. vreugdenhil, j. et al. (2022) ‘illness scripts in nursing: directed content analysis’, journal of advanced nursing, 78(1), pp. 201–210. doi: 10.1111/jan.15011. world health organization. (2019) patient safety, who news room. world health organization (2016) diagnostic errors: echnical series on safer primary care. geneva: world health organization. yauri, i., nash, r. and ramsbotham, j. (2019) ‘improving student nurses’ clinical-reasoning skills: implementation of a contextualised, guided learning experience’, jurnal keperawatan padjadjaran, 7(2), pp. 154–165. doi: 10.24198/jkp.v7i2.1166. yazdani, s. and abardeh, m. h. (2019) ‘five decades of research and theorization on clinical reasoning: a critical review’, advances in medical education and practice, 10, pp. 703–716. doi: 10.2147/amep.s213492. yazdani, s. and abardeh, m. h. (2020) ‘a novel model of clinical reasoning: cognitive zipper model’, journal of advances in medical education & profesionalism, 8(2), pp. 61–71. doi: 10.30476/jamp.2020.82230.1050.received. . how to cite this article: arisudhana, g. a. b. (2022) ‘the effects of illness script method on clinical reasoning of undergraduate nursing students: a quasi-experimental study’, jurnal ners, 17(1), pp. 83-88. doi: http://dx.doi.org/10.20473/jn.v17i1.32565 table1 table3 alamouti2020 arisudhana2019 benner2011 blakey2017 boushehri2015 brown2019 chamberland2011 chamberland2013 choi2020 gopakumar2016 graan2017 guerrero2019 gurpinar2013 hunter2016 ju2017 keemink2018 lee2010 lee2010q levett2010 lubarsky2015 mccartney2017 paans2012 pelaccia201 peters2017 polit2012 sastroasmoro2014 schmidt2015 schmidt1990 trisno2020 vreugdenhil2022 world2019 world2016 yauri2019 yazdani2019 yazdani2020 http://e-journal.unair.ac.id/jners 103 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 103-109 http://dx.doi.org/10.20473/jn.v17i2.33638 original article open access a qualitative description of nurses’ problems to monitor and supervise vital signs in covid-19 patients in isolation room tri yahya christina 1,2 * , suhartini ismail 3 , meira erawati 4 1 master of nursing student, nursing department, faculty of medicine, universitas diponegoro, indonesia 2 indriati solo baru hospital, central java, indonesia 3 emergency and critical care nursing division, nursing department faculty of medicine, universitas diponegoro indonesia 4 pediatric nursing division, nursing department faculty of medicine, universitas diponegoro indonesia *correspondence: suhartini ismail. address: prof. sudarto street no.13, tembalang, semarang, central java, indonesia. email: suhartini.ismail@fk.undip.ac.id responsible editor: yulis setiya dewi received: 13 february 2022 ○ revised: 28 april 2022 ○ accepted: 23 may 2022 abstract introduction: changes and deterioration of the condition of corona virus disease-19 (covid-19) patients are unknown and can even lead to the death of the patient in the isolation room. this study focuses on identifying the problem of nurses monitoring and supervising the vital signs of covid-19 patients in the isolation room. methods: a descriptive qualitative study was conducted in january 2022 at a private hospital in sukoharjo, central java. ten participants who met the inclusion criteria were involved through purposive sampling. the semi-structured interview guidelines were developed by the researcher, and they used them to obtain the data. interviews were recorded using a recorder device. the data from the interviews were recorded verbatim and analyzed using inductive content analysis following elo and kyngas’s method. the member checking and thick description were done to maintain the validity of the data. results: three main themes were found from the emerging data, including 1) the comparison of nurses and patients is not ideal with patients’ conditions that cannot be predicted, 2) personal protective equipment (ppe) and monitoring tools have not reached the appropriateness target, and 3) the demand for high-technology vital sign monitoring devices was not feasible. conclusions: the problems being faced by the nurses in monitoring and supervising the vital signs of covid-19 patients in the isolation room need innovative tools. therefore, it is important for policymakers and related parties to create high-technology solutions for the isolation rooms to improve nursing service effectively and ensure the safety of both the patients and the nurses. keywords: attitude; covid-19 patients; isolation room; monitoring; supervision; vital signs introduction coronavirus disease 2019 (covid-19), which is also known as sars-cov-2, was reported to have emerged in december 2019 in wuhan, china. this epidemic quickly spread outside china, causing the whole world to experience an emergency response, especially in health services (nishiura et al., 2020). the disease transmission runs very easily through aerosols and droplets, which makes the number of cases continue to increase rapidly (rahman et al., 2020). since medication for the covid-19 virus has not yet been found, the health workers can be effective in caring for the patients by conducting continuous monitoring and identifying the deterioration of the patient's condition (pimentel et al., 2020; sharma et al., 2020). in accordance with the recommendation of the https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-0392-5389 https://orcid.org/0000-0002-6714-3212 https://orcid.org/0000-0003-2861-4293 christina, ismail, and erawati (2022) 104 p-issn: 1858-3598  e-issn: 2502-5791 ministry of health of indonesia in 2020, patients with confirmed covid-19 from moderate to severe degrees must be admitted to a hospital for isolation and periodic monitoring, including monitoring of general conditions, vital signs, and laboratory check-up (indonesia ministry of health, 2020). those monitored were pivotal to predict the patient’s conditions and detect the changes in health outcomes during the isolation phase in covid19 patients (connor and pilar camargo plazas, 2021). one of the things being monitored for the covid-19 patients is their vital signs. therefore, the nurses who work in the isolation room should catch up on how to monitor the patients and report the patients' health outcomes (yuki and sophia, 2020). the assessment of vital signs gives indication that the body is functioning in an acceptable condition or has health problems. moreover, the monitoring of the vital signs also provides information to the healthcare providers in support of the objective data in the nursing process. indeed, covid-19 patients with severe conditions requiring advance monitoring can be seen every one to two hours (noviestari et al., 2020; yuki and sophia, 2020). previous research conducted by rao et al. (2021) and joo and liu (2021) has explored the experiences, challenges, and obstacles of various healthcare providers in treating covid-19 patients from different treatment rooms. they found that caring for the covid19 patients is a challenging practice, with insufficient support, concerns about family, and emotional and psychological stress. otherwise, they felt focusing on infection risk at the expense of high-quality care, struggling with dynamic and unfamiliar challenges, being overwhelmed and exhausted by personal protective equipment (ppe), information overload and confusion, and being overstretched by additional responsibilities at work were also issues. the healthcare facilities to take care of covid-19 patients still lack innovation. the assessment and reporting of the data were not digitally recorded. it is evidence that finding the right solution to the problems is difficult. the perspective of nurses who have experience caring for covid-19 patients in the isolation room of the hospital where the study was conducted, indicated that the flow of covid-19 patients due to this outbreak made the nursing services hectic. when the pandemic broke out, healthcare providers were not ready for health services and treatment availability. the capacity of the isolation room was for 24 patients, but the condition should be able to handle up to 29 patients. the ironic situation when the nurses are taking care of the patients is that there are only three or four nurses on duty per shift. even with the health facilities available in the patient's room, such as oxygen central, digital blood pressure, oxygen saturation, and more, the time to monitor and supervise the patients still lacks. due to the limited admission in the intensive care unit (icu), the isolation room was forced to care for patients with severe conditions. in addition, the transmission of the covid-19 virus requires the nurses to take care of the patients with personal protective equipment (ppe). the flow of covid-19 patients in the isolation room made some patients not get maximum monitoring and supervision, so that changes and deterioration of the patient's condition were difficult to detect early (pimentel et al., 2020). based on the researchers’ experience, monitoring, and supervision of the vital signs of covid-19 patients in the isolation room is manual and conventionally recorded. in the setting of the hospital, we found that there were 78% of covid-19 patients admitted to the isolation room. some of the patients became severely ill and required advanced nursing care in the icu. however, since in the icu there is no bedside, those patients should be taken care of in the isolation room. therefore, we conducted the study to identify nurses' problems in monitoring and supervising covid-19 patients’ vital signs in the isolation room. materials and methods this study is a descriptive qualitative study that describes the problems facing nurses in monitoring and supervision the vital signs of covid-19 patients at the isolation room. this research was conducted in the covid-19 isolation room of the private hospital in sukoharjo, central java in january 2022. the researchers ensured that the health protocols were applied by wearing masks, hand sanitizers, and keeping a distance from participants during research data collection. the sampling technique was carried out by purposive sampling (polit and beck, 2015). ten nurses who work in the isolation room participated in this study. to encourage the participants, the researchers communicated with the head nurses and head team to ask for the nurses who met the inclusion criteria. inclusion criteria in this study were: 1) nurses had work experience of at least 6 months, 2) taking care of the covid-19 patients in isolation room for at least 2 weeks. the exclusion criterion of the study was that if the participants were not available to complete the interview process due to their duty to take care of the patients. informed consent was explained to the participants before the interview. the interview guidelines used in this study were developed by the jurnal ners http://e-journal.unair.ac.id/jners 105 researcher. we constructed the interview guidelines based on the research questions and objectives as well as the research concepts and phenomena. the interview questions consist of: 1) what do you do in monitoring covid-19 patients in the isolation room? 2) what does the manager do in supervising covid-19 patients in the isolation room? 3) what are the obstacles faced by nurses in monitoring vital signs of covid-19 patients in the isolation room? 4) what are the obstacles faced by nurses in supervising vital signs of covid-19 patients in the isolation room? 5) is there any innovation in monitoring and supervision vital signs other than manually? all the interview processes required 45-60 minutes for each participant. the results of the interviews were recorded using a tape recorder and were verbatim. the data were then analyzed to obtain the themes according to the research objectives. content analysis of the research data was with an inductive approach following the elo and kyngas method. the data analysis consisted of an open coding process, coding sheets, grouping, categorization, and abstraction (elo and kyngäs, 2008). an example of the data analysis process is shown in table 1. to ensure trustworthiness, the researchers conducted data validity by conducting a member check to know the participants' validation of the interview results. transferability was tested by comparing the results of this study with similar studies to explain the concept of the phenomena. to verify the emergent themes from the data, the researchers consulted an external expert to justify the theoretical and methodological discussion (korstjens and moser, 2018). to guarantee the ethical consideration for this study, research ethics approval from sultan agung islamic hospital with the number of ethical clearance 37/kepkrsisa/xii/2021 was required. the researchers also followed the rules of ethics for human subject guidance based on the council for international organizations of medical sciences (cioms) in collaboration with the world health organization (2016). anonymity, beneficence, justice, and do not harm were practiced by researchers in the data gathering process. the participants could withdraw from this study at any time if they felt uncomfortable and there were no consequences. results characteristics of the participants the characteristics of participants include age, sex, education level, work experience, and time to take care of the covid-19 patients in the isolation room. all participants were female nurses, with an age range of mostly 26 to 35 years old (80%). the participants’ education background was 80% graduated from diploma iii and had work experience as nurses for 10 years (50%). the time spent by participants taking care of covid-19 patients in the isolation room was within 46 months (50%). table 2 shows the demographic characteristics of the participants. this study found three main themes in nurses' problems in monitoring and supervision of covid-19 patients’ vital signs in the isolation room. they are: 1) the comparison of nurses and patients is not ideal with patients’ conditions that cannot be predicted, 2) personal protective equipment (ppe) and monitoring tools have not reached the appropriateness target, and table 1 depicts an example of the data analysis process participant statement coding theme “the imbalance between the number of patients and the nurses' resources makes nurses not optimal in monitoring the vital signs of covid-19 patients in the isolation room.” (p2) the comparison of unideal patients and nurses the comparison of nurses and patients is not ideal with patients’ conditions that cannot be predicted “when monitoring the vital signs, there are unexpected activities, such as a patient who suddenly experiences a deterioration in their condition. the unexpected activities often cause the patient's vital signs to not be monitored properly. nurses must be in a hurry or not be on time to monitor the vital signs of the patients.” (p8) unpredictable situations and conditions “i had an experience when i was on my shift. that day, i did not assess the patient’s saturation because a device was running out. i have reported it to the head nurse, but that time cannot be fixed promptly as it is a hospital regulation. we suggest the patient’s family bring the oximetry to check their own saturation." (p6) there is no monitoring of vital signs with high technology. the demand for hightechnology vital signs monitoring devices was not feasible sub-theme 1. the condition of isolated patients requires personal monitoring device sub-theme 2. the monitor devices that are connected to the nurse station directly "in the patient room, there are no vital signs devices that are continuously attached to the patient, so we cannot monitor the patient's vital signs directly from the nurse station. the deterioration of the patient’s condition somehow delays response.” (p10) the absence of monitoring patients’ vital signs with high technology connected to the nurse station christina, ismail, and erawati (2022) 106 p-issn: 1858-3598  e-issn: 2502-5791 3) the demand for high-technology vital sign monitoring devices was not feasible. theme 1: the comparison of nurses and patients is not ideal with patients’ conditions that cannot be predicted the participants explained that the comparison of nurses and patients was not ideal under the conditions. the worsening of the patient's condition could not be predicted because of the obstacles to monitoring the vital signs of covid-19 patients in the isolation room. the nurse-patient ratio is not ideal due to the lack of nurses compared to the high rate of admission of covid19 patients and the workload of nursing care. this condition is exacerbated by unpredictable conditions such as unexpected activities or deterioration of the patient's condition. the statement was expressed by four participants as follows: “the imbalance between the number of patients and the nurses' resources makes nurses not optimal in monitoring the vital signs of covid-19 patients in the isolation room.” (p2) “when monitoring the vital signs, there are unexpected activities, such as a patient who suddenly experiences a deterioration in their condition. the unexpected activities often cause the patient's vital signs to not be monitored properly. nurses must be in a hurry or not be on time to monitor the vital signs of the patients.” (p8) “here, we (the nurses) work in the isolation room based on the managerial setting. the comparison between nurses and patients is not ideal. sometimes we feel that what we do in monitoring the patients does not complete due to the limited sources of information between patients and nurses.” (p9) “nurses should have approximately 30 minutes in the patient room to complete the treatment for a patient. all monitoring and supervision of patients in the isolation room are done on paper. we can imagine what a load of work this is here.” (p10) theme 2: personal protective equipment (ppe) and monitoring tools have not reached the appropriateness target participants argued that personal protective equipment (ppe) and monitoring devices had not yet reached the appropriateness target. quality standards, such as comfort and protection, should be met by the ppe target. however, the ppe that was provided for them was still low quality, so they felt uncomfortable wearing it. in addition, the supply of the devices for vital signs monitoring was limited compared to the number of patients whose vital signs should be continuously assessed. four participants expressed it as follows “because of the quality standard of ppe, we have problems assessing the respiratory rate of covid-19 patients. if we use it, we feel discomfort and somehow perspire.” (p1) “for monitoring the vital signs of covid-19 patients in the isolation room, it is constrained by the equipment of vital signs devices that are still lacking.” (p3) “the problem for nurses in monitoring and supervision of covid-19 patients’ vital signs in the isolation room is that the devices provided are still lacking. we use the old instruments that the hospital provided. in the reality of this situation, we need innovation and technology-based monitoring to monitor the patients.” (p9) “the use of ppe makes it difficult for nurses to feel the pulse and see the patient's breathing. this is due to the use of gloves that must be doubled and google glass often condenses, thus limiting nurses in monitoring the vital signs of covid-19 patients.” (p10) theme 3: the demand for high-technology vital signs monitoring devices was not feasible the need for high-technology devices to monitor vital signs is not feasible yet in this setting. two subthemes emerge from the data, namely, that isolated patients require personal monitoring devices, and those monitoring devices are connected directly to the nurse station sub-theme 1. the condition of isolated patients requires a personal monitoring device table 2. participant characteristics (n = 10) demographic characteristic n % sex female 10 100 age (year) 17-25 2 20 26-35 8 80 education background d3 nursing program 8 80 certified nurse profession 2 20 work experience (year) 1-5 6-10 5 5 50 50 time to take care of covid-19 patients in the isolation room (months) 1-3 3 30 4-6 5 50 10-12 2 20 jurnal ners http://e-journal.unair.ac.id/jners 107 monitoring of the vital signs of covid-19 patients in the isolation room should follow the regulation of one device per patient. however, the situation might not be accomplished because the devices were often in error, such as running out of battery and out of service. one of the factors that cause frequent battery runout and device errors is the sterilization process and too frequent use, considering that these devices must be used alternately for all patients. digital blood pressure, thermometer, and oximetry instruments, for example, must be calibrated to ensure the feasibility and accuracy of the data measured. the statement was expressed by three participants as follows: “for example, we (the nurse) should check the digital thermometer and the oximetry before using it. the devices are out of service due to a low battery charge and high utilization for all patients. therefore, we need to check two or three times before and after assessing the patient's vital signs to record the right data.” (p2) “i had an experience when i was on my shift. that day, i did not assess the patient’s saturation because a device was running out. i have reported it to the head nurse, but that time cannot be fixed promptly as it is a hospital regulation. we suggest the patient’s family bring the oximetry to check their own saturation.” (p6) “a digital sphygmomanometer actually needs calibration to ensure actual data recorded is accurate. nevertheless, the calibration devices are undone.” (p9) sub-theme 2. the monitoring devices that are connected to the nurse station directly while caring for covid-19 patients in the isolation room, there is no monitor that can be connected to the nurse station. it is evident that the nurses find it difficult to do monitoring and supervision if they enter the patient’s bedside. the nurse imagines what would happen if the monitoring and supervision of the patients’ vital signs were synchronized in a good system, so the vital signs data would remain objective and accurate. closed-circuit television (cctv) is not a basis to check a patient’s condition to date. the patient’s room even has no cctv; thus, some patients are not monitored optimally and there are even delays in knowing the deterioration of the patient's condition. four participants said the following: “the patient’s bedside is not equipped with cctv, so the nurses cannot control the patient’s mobility around. thus, we should enter the room and check the patients.” (p1) “because there is no integrating monitor installed on the patient’s bedside continuously, the vital signs of the patients somehow failed to be recorded on time and to date.” (p3) "the difficulty for nurses in monitoring the vital signs of covid-19 patients in this isolation room is that there are no vital sign devices that are continuously installed on the patient and connected to the nurse station’s monitor." (p8) "in the patient room, there are no vital signs devices that are continuously attached to the patient, so we cannot monitor the patient's vital signs directly from the nurse station. the deterioration of the patient’s condition somehow delays the response.” (p10) discussions this study aims to identify nurses' problems in monitoring and supervising the vital signs of covid-19 patients in the isolation room. the results of the study indicate three main themes that indicate the problems underpinning nursing services in the hospital. the need for technology-based to measure the vital signs and record them was also present in this study's results. therefore, the development of the tools of digital or technology-based care for covid-19 patients cannot be delayed. the theme of the comparison of nurses and patients’ radio in conditions that cannot be predicted confirmed that the high ratio of nurses to patients meant there was not the ideal situation of one nurse to one patient. they can’t provide more responsibilities when monitoring covid-19 patients who are being treated in the isolation room (gonzález-gil et al., 2020; kang and shin, 2020; maben and bridges, 2020). a shortage of nurse resources and an overflow number of patients result in an inability to perform regular and timely monitoring and reduce the quality of care (tan mn, rn et al., 2020). the unpredictable situation is also felt to be a problem for nurses in monitoring and supervising the vital signs of covid-19 patients in the isolation room. this is due to unexpected responsibilities and the ratio between the nurses and the patients was not ideal. for example, if one of the patients experiences a critical condition, the hectic situation becomes more chaotic. patients with covid-19 have a higher risk of deterioration and severity than sufferers of other viruses, so many patients experience a sudden christina, ismail, and erawati (2022) 108 p-issn: 1858-3598  e-issn: 2502-5791 deterioration. this increases the nurses' workload in monitoring and supervising covid-19 patients in the isolation room (pimentel et al., 2020). the nurses’ workload resulted in physiological and psychological responses such as anxiety, stress, and difficulty sleeping (ismail, ridlo and rochana, 2021). joo and liu (2021) argued that unexpected tasks when caring for covid-19 patients are the obstacles for nurses in monitoring covid-19 patients in the isolation room. nurses must do other work and even complete the duties of other health team members (lee and lee, 2020; schroeder et al., 2020). moreover, this pandemic has made the care of covid-19 patients increase in direct care time, missed treatment time, and waiting time for nurses' duties by 27%, 311%, and 44%, respectively (qureshi et al., 2021). the results of the study also stated that ppe and monitoring devices had not reached the appropriateness target. the result of the study was in line with tallulembang, widaniand bandur's (2020) finding that the limited supply of ppe, care devices, or facilities were the obstacles for nurses in implementing nursing care. atay and cura (2020) also agreed that one of the barriers for nurses in monitoring covid-19 patients was the use of ppe. as the ppe and monitoring devices were necessary in assessing the vital signs of covid-19 patients, it was necessary for the manager to provide good quality ppe and supply the vital signs tools appropriately (boskoski et al., 2020). the participants explained that the monitoring of vital signs in covid-19 patients was still done manually by nurses. it is because there were no vital signs monitoring device connected to the nurse's station. these results are in line with previous research which stated that technology-based monitoring of vital signs for the covid-19 in the isolation room cannot be provided automatically and remotely. nurses must remain present with patients if they wish to monitor the patients’ vital signs (giménez-espert, prado-gascó and soto-rubio, 2020; lee and lee, 2020). based on the results of the study, it is important to provide high technology to monitor vital signs in the isolation room. the technology based on monitoring and supervision of the patient’s condition can influence the quality of nursing care. it is better for the healthcare division to develop high-tech medical devices that can be the right solution in caring for covid-19 patients (sera et al., 2020). this research has several strengths, including: 1) the data taken are from the nurses who were taking care of covid-19 patients directly, so that they can deliver the real information through monitoring and supervision of the vital signs of those kinds of patients; 2) this study focuses on describing the nurses’ problems in monitoring and supervision of the covid-19 patients’ vital signs in the isolation room. meanwhile, the weakness of this study was noted as this is a descriptive qualitative approach, which means the phenomena, or the problem might not have been explored deeply enough yet. the sample took 10 nurses and was conducted in one hospital where the equipment needs more new stock. moreover, the obstacles faced during the research were those of the interview thus, the situation was not clear to hear. to limit the barriers of communication, we did clarification after the interview process, which we explained in trustworthiness conclusions covid-19 patients are challenging for nurses now, particularly to monitor and supervise their vital signs while patients are in the isolation room. the findings of this study have illustrated the problems and what the impact on the entire patient’s health outcomes is. the health outcomes of covid-19 patients are to improve their quality of life. the improvement of the quality of life of the patients should be based on the quality of nursing care that is provided by the nursing team and healthcare providers. the nurses should know how to solve the problems by doing continuous monitoring and supervision in caring for the covid-19 patients, and the nursing manager should be aware of the nurses' work thoroughly. this study highlights that there exist problems for nurses in monitoring and supervising vital signs of covid-19 patients in isolation rooms, and that the problems might remain the same with other nurses outside the setting. these problems are related to time, devices, and resources. therefore, it is necessary to develop a high-technology-based vital signs monitoring device to monitor and supervise the vital signs of covid19 patients in the isolation room. moreover, the monitoring can be completed automatically, and the data recorded in real time. there is definitely no paperbased method to support a green economy and green digitalization. references atay, s. and cura, ş. ü. (2020) ‘problems encountered by nurses due to the use of personal protective equipment during the coronavirus pandemic: results of a survey’. doi: 10.25270/wmp.2020.10.1216. boskoski, i. et al. (2020) ‘since january 2020 elsevier has created a covid-19 resource centre with free information in english and mandarin on the novel coronavirus covid19 . the covid-19 resource centre is hosted on elsevier connect , the company ’ s public news and information’, (january). doi: 10.1016/j.gie.2020.04.048. jurnal ners http://e-journal.unair.ac.id/jners 109 connor, d. m. and pilar camargo plazas (2021) ‘reflections on vital sign measurement in nursing practice’, nursing philosophy, 22(1), pp. 1–9. doi: 10.1111/nup.12326. council for international organizations of medical sciences (cioms) in collaboration with the world health organization (2016) international ethical guidelines for health-related research involving humans, biomedical research. elo, s. and kyngäs, h. (2008) ‘the qualitative content analysis process’, journal of advanced nursing, 62(1), pp. 107–115. doi: 10.1111/j.1365-2648.2007.04569.x. giménez-espert, m. del c., prado-gascó, v. and soto-rubio, a. (2020) ‘psychosocial risks, work engagement, and job satisfaction of nurses during covid-19 pandemic’, frontiers in public health, 8, pp. 1–10. doi: 10.3389/fpubh.2020.566896. gonzález-gil, m. t. et al. (2020) ‘nurses’ perceptions and demands regarding covid-19 care delivery in critical care units and hospital emergency services’, intensive and critical care nursing. doi: 10.1016/j.iccn.2020.102966. indonesia ministry of health (2020) protocol of covid-19 treatment. jakarta. ismail, s., ridlo, m. and rochana, n. (2021) ‘a qualitative description of nurses ’ psychological responses in caring for covid-19 patients : an indonesian context abstract :’, pp. 136–142. doi: 10.2174/1874434602115010136. joo, j. y. and liu, m. f. (2021a) ‘nurses’ barriers to caring for patients with covid-19: a qualitative systematic review’, international nursing review, 68(2), pp. 202–213. doi: 10.1111/inr.12648. joo, j. y. and liu, m. f. (2021b) ‘nurses’ barriers to caring for patients with covid-19: a qualitative systematic review’, international nursing review. doi: 10.1111/inr.12648. kang, y. and shin, k. r. (2020) ‘covid-19: korean nurses’ experiences and ongoing tasks for the pandemic’s second wave’, international nursing review, 67(4), pp. 445–449. doi: 10.1111/inr.12644. korstjens, i. and moser, a. (2018) ‘series: practical guidance to qualitative research. part 4: trustworthiness and publishing’, european journal of general practice. doi: 10.1080/13814788.2017.1375092. lee, n. and lee, h. j. (2020) ‘south korean nurses’ experiences with patient care at a covid-19-designated hospital: growth after the frontline battle against an infectious disease pandemic’, international journal of environmental research and public health, 17(23), pp. 1–22. doi: 10.3390/ijerph17239015. maben, j. and bridges, j. (2020) ‘covid-19: supporting nurses’ psychological and mental health’, journal of clinical nursing, 29(15–16), pp. 2742–2750. doi: 10.1111/jocn.15307. nishiura et al. (2020) ‘the extent of transmission of novel coronavirus in wuhan, china, 2020’, journal of clinical medicine. doi: 10.3390/jcm9020330. noviestari, e. et al. (2020) dasar-dasar keperawatan, elseiver singapura. pimentel, m. a. f. et al. (2020) ‘trajectories of vital signs in patients with covid-19’, resuscitation. doi: 10.1016/j.resuscitation.2020.09.002. polit and beck (2015) nursing research: generating and assessing evidence for nursing practice 10th edition, wolters kluwer health. qureshi et al. (2021) xploring the impact of covid-19 on nurse workload and quality of care via chapter computerized simulation. springer international publishing. rahman, h. s. et al. (2020) ‘the transmission modes and sources of covid-19: a systematic review’, international journal of surgery open. doi: 10.1016/j.ijso.2020.08.017. rao, h. et al. (2021) ‘frontline interdisciplinary clinician perspectives on caring for patients with covid-19 : a qualitative study’. doi: 10.1136/bmjopen-2021-048712. schroeder, k. et al. (2020) ‘nursing perspectives on care delivery during the early stages of the covid-19 pandemic: a qualitative study’, international journal of nursing studies advances. doi: 10.1016/j.ijnsa.2020.100006. sera, w. et al. (2020) ‘applications of digital technology in covid19 pandemic planning and response’, the lancet digital health, 2(8), pp. e435–e440. doi: 10.1016/s2589-7500(20)30142-4. sharma, s. k. et al. (2020) ‘clinical nursing care guidance for management of patient with covid-19’, journal of the pakistan medical association, pp. s118–s123. doi: 10.5455/jpma.29. tallulembang, a., widani, n. l. and bandur, a. (2020) ‘experience of nurses in providing nursing care for covid-19 patients in dki jakarta’, tallulembang ,ni luh widani ,agustinus bandur, 4(1), pp. 74–91. doi: https://doi.org/10.31934/mppki.v4i1.1392. tan mn, rn, n. r. et al. (2020) ‘experiences of clinical first-line nurses treating patients with covid-19: a qualitative study’, journal of nursing management, 28(6), pp. 1381–1390. doi: 10.1111/jonm.13095. yuki, m. f. and sophia (2020) ‘covid-19 pathophysiology: a review’, clinical immunology, 215(april 2020). doi: 10.1016/j.clim.2020.108427. how to cite this article: christina, t. y., ismail, i., and erawati, m. (2022) ‘a qualitative description of nurses’ problems to monitor and supervise the vital signs in covid19 patients at the isolation room’, jurnal ners, 17(2), pp. 103109. doi: http://dx.doi.org/10.20473/jn.v17i2.33638 table1 table2 joo2021 atay2020 boskoski2020 conor2021 elo2008 giménez2020 gonzales2020 imh2020 ismail2021 kangshin2020 korstjens2018 lee2020 maben2020 nishiura2020 noviestari2020 pimentel2020 polit2015 qureshi2021 rahman2020 rao2021 schroeder2020 sera2020 sharma2020 tallulembang2020 tan2020 yuki2020 162 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 16, no. 2 october 2021 inpress http://dx.doi.org/10.20473/jn.v16i2.29811 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research nurses’ role in taking care of gestational diabetes mellitus patients: a qualitative study tri ismu pujiyanto and indah wulaningsih universitas karya husada semarang, central java, indonesia abstract introduction: gestational diabetes mellitus (gdm) is becoming one of the major public health problems. it is important to screen the gdm and for the case to be managed by nurses. nurses are needed to care for pregnant women with gdm, and the work experience of nurses is directly related to the assistance and quality of care provided. however, nurses face some barriers in understanding the gdm and providing good management thereof. this study explored the experiences of nurses of caring for gdm patients. methods: this study was a phenomenological approach qualitative research. participants were 10 nurses who provide care for pregnant women with gdm selected by purposive sampling technique with sampling criteria. data analysis used the colaizzi method. results: there were five categories, e.g. empathy, inspiration to find ways to treat patients very well, feeling of ambivalence, self-preservation to develop potential, and the impact on the nurses of caring for gdm. conclusion: sustaining the nursing workforce and improving their working experiences are essential to meet the care needs of pregnant women with gdm. nurses should understand to promote empathy, and there is a need to improve the job satisfaction and morale of nurses. at the institutional level, policy makers should make efforts to improve the nursing clinical practice environment, increase the nursing management role, the maternity nursing education and training, achieve a proper skill mix of the health workforce, and, overall, attract, prepare and sustain nurses regarding caring for pregnant women with high risk gdm. article history received: september 08, 2021 accepted: october 21, 2021 keywords nurses’ role experience; caring; gestational diabetes mellitus; patients contact tri ismu pujianto  tri.ismu2021@gmail.com  universitas karya husada semarang, central java, indonesia cite this as: pujianto, t. i., & wulaningsih, i. (2021). nurses’ role in taking care of gestational diabetes mellitus patients: a qualitative study. jurnal ners, 16(2). 162-168. doi:http://dx.doi.org/10.20473/jn.v16i2.29811 introduction gdm is defined as glucose intolerance with onset or first recognition during pregnancy. the definition does not require any return to normal glucose levels following delivery. thus, gdm simply represents relatively high glucose levels at one point in the life of a young woman (buchanan et al., 2012). gdm is a form of hyperglycemia. in general, hyperglycemia results from an insulin supply that is inadequate to meet tissue demands for normal blood glucose regulation. studies conducted during late pregnancy, when, as discussed below, insulin requirements are high and differ only slightly between normal and gestational diabetic women, consistently reveal reduced insulin responses to nutrients in women with gdm. studies conducted before or after pregnancy, when women with prior gdm are usually more insulin resistant than normal women (also discussed below), often reveal insulin responses that are similar in the two groups or reduced only slightly in women with prior gdm. however, when insulin levels and responses are expressed relative to each individual’s degree of insulin resistance, a large defect in pancreatic ß cell function is a consistent finding in women with prior gdm (buchanan et al., 2012; plows et al., 2018). gdm also adds an intrauterine environmental risk factor to an increased genetic risk for the development of obesity, diabetes and/or metabolic syndrome in childhood. as regard mother complications, gdm is a strong risk factor for the development of permanent diabetes later in life (40% in 10 subsequent. years) and gdm in successive pregnancies (35%), increasing with the age and https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id jurnal ners http://e-journal.unair.ac.id/jners | 163 weight of the mother. an important intervention on long-term metabolic benefits for both mother and offspring has been attributed to breastfeeding. in the offspring a protective role was seen against excessive fat accumulation, protection against childhood infections, cardiovascular diseases and type 2 diabetes, while in women an association between lactation and low concentrations of glucose and insulin and a better tolerance to glucose was seen and a significant delay in the appearance of type 2 diabetes in women with gdm (alia et al., 2019). although obstetricians-gynecologists (obs/gyns) serve many women as their primary care provider and are often the sole physician that women see regularly during their reproductive years, a pregnancy complicated by gdm should alert not only ob/gyns, but also other primary care providers to take the preventive actions during the interand postpartum periods. appropriate early postpartum care for women with prior gdm includes screening for continued abnormal glycaemia and risk for progression to diabetes. however, this care should also include ongoing (lifelong) counseling on the risk for future pregnancies complicated by gdm, the risk for progression to diabetes over the life of the woman, and on the importance of lifestyle changes to reduce these risks. the national diabetes education program (ndep) recommends that all providers who care for women with prior gdm screen all women as well as provide or refer these patients to early treatment and prevention interventions (oza-frank et al., 2014). the impact of gdm will be seen after several years if it is not handled now and triggers an increase in the incidence of gdm. therefore, screening or early detection is needed to capture gdm so that it can be managed as well as possible, especially in mothers with risk factors. early detection will help pregnant women to improve maternal welfare both during and after pregnancy (djihanga & muflilah, 2020). a study related to the experience of pregnant women with gdm explained the inability to achieve optimal maternal roles in patients with gdm (wulaningsih et al., 2020). early detection in health services, especially for antenatal care, is also one of the work programs of the american diabetes association (ada) to prevent complications that may occur during the delivery process later (djihanga & muflilah, 2020). nurses understand the importance of gdm screening. all of the nurses who encounter patients with high risk can assist in teaching and preparing for treatment (djihanga & muflilah, 2020). however, gdm screening is often missed because patients do not seek to achieve systematic health services for the implementation of screening. patients come to a health facility when they have experienced the effects of gdm on their pregnancy. in addition, resources and facilities in health facilities are also often limited so that the practice of comprehensive anc examination is not in accordance with the theoretical concept because it only focuses on physical examination, history taking, leopold maneuver and laboratory examination of hb, leukocytes, proteinuria. meanwhile, gds examinations and even fasting gds were not examined. this is related to the competence of resources and workload experienced by health workers, especially nurses (sahu et al., 2021; wulaningsih et al., 2020). nurses should understand their role in caring for patients. regulatory agencies and accrediting bodies expect clinical staff nurses to understand their roles in all aspects of care, including caring for patients. nurses should be knowledgeable about three major areas related to patients: (a) human subjects protection, including informed consent and the role of the institutional review board; (b) requirements of study participation; and (c) procedures for reporting conflicts between protection of the patient and requirements of study participation (connelly, 2009). based on the background of this study, the aim of this study was to analyze nurse role experience of caring for gestational diabetes mellitus patients. materials and methods this was a phenomenological approach qualitative research. data collection was carried out through indepth interviews with a voice recorder and field notes. participants were selected based on research needs with the principle of appropriateness and adequacy. participants in this research were nurses taking care of gdm patients. the data collection was finished in the ten participants when the categorization of data was saturated. data saturation was reached when there is enough information to replicate the study when the ability to obtain additional new information has been attained, and when further coding is no longer feasible. besides, the availability of time and resources in research is also taken into consideration in ending data collection. this research instrument was the researchers themselves. purposive sampling technique with sampling criteria was used. the inclusion criteria in this study were 1). nurses who have provided care for high-risk mothers with gdm. 2) living in the central java province. 3). willing to become a participant by agreeing to informed consent. the exclusion criterion was nurses on leave. data analysis used the colaizzi method. the inclusion of additional steps as follows: 1). transcribing all the subjects’ descriptions. 2). extracting significant statements (statements that directly relate to the phenomenon under investigation). 3). creating formulated meanings. 4). aggregating formulated meanings into theme clusters. 5). developing an exhaustive description (a comprehensive description of the experience as articulated by participants). 6). additional stepresearcher interpretative analysis of symbolic representations from the articulation of the symbolic representation (which occurred during participant interview). 7). identifying the fundamental structure of the phenomenon. 8). returning to participants for validation (edward & welch, 2011). t. i. pujianto et al. 164 | pissn: 1858-3598  eissn: 2502-5791 data were collected between november 2019 and february 2020 using in-depth interview with nurses who care for diabetes patients. interviews were conducted by one of the research team who already had a basic understanding of qualitative research. before selected as a participant, participants were given the research information about title, purpose, benefit, participant participation, reward and more information if there was an adverse event, then they gave a statement of informed consent as to voluntary participation. the validity of the data in this research was tested and included credibility, dependability, and conformability. the study was declared to have passed the ethical review by the research ethics committee, faculty of health and nursing science, karya husada university. data were collected using interview guide and participants answered the questions for 30-45 minutes. data were collected once meeting with the participant. before the indepth interview, the author-built trust from the participant, so they gave truthful information about their experience. after data were collected, we analyzed the keywords and themes found from the research. results based on the criteria for inclusion participating as many as 10 nurses were obtained. in-depth interviews were conducted with participants and showed mixed results about nurses’ role experience of caring for gdm. this study obtained as many as five themes of the sub-categories, which have been arranged as below. table 1 and table 2 shows the characteristics of participants were predominantly female (60.0%) and the age was majority 20-30 years (60.0%). diploma was the highest education level in the participants (60.0%), the experience of nursing was dominated in range 6-10 years (70.0%). muslim was the highest religion in participants and 90.0% of participants were in married status. the themes are shown in table 3. theme 1: empathy nurses have a sense of empathy for the patients they treat with gdm. nurses have awareness in carrying out their duties and functions in providing nursing care. the following are participant answers expressed as follows: p2-10: “every patient has the same right to get optimal nursing care, so i have to provide holistic care.” p5-15: “i can feel the suffering of patients with gdm, being pregnant with a condition where there is an increase in blood sugar levels can make the mother experience anxiety, sadness. so i need to provide better service.” table 1. list and characteristics of participants participant age gender education work experience religion marital status p1 25 male bachelor 1 years muslim married p2 24 female bachelor 2 years muslim married p3 30 female bachelor 2 years muslim married p4 20 female diploma 9 years christian single p5 29 male diploma 7 years muslim married p6 32 female diploma 11 years christian married p7 37 male diploma 17 years muslim married p8 31 male diploma 14 years muslim married p9 23 female bachelor 2 years muslim married p10 49 female diploma 10 years muslim married table 2. socio-demographic characteristics of participants characteristics n % age 20-30 years 31-40 years 41-50 years 6 3 1 60.0 30.0 10.0 gender male female 4 6 40.0 60.0 education level diploma bachelor 6 4 60.0 40.0 work experience 1-5 years 6-10 years > 10 years 2 7 1 20.0 70.0 10.0 religion muslim christian 8 2 80.0 20.0 marital status married single 9 1 90.0 10.0 jurnal ners http://e-journal.unair.ac.id/jners | 165 theme 2: inspiration to find ways to treat patients very well nurses thought that they must be able to find better ways to treat patients with gdm, stated by the participants as follows: p6-15: “i always think how to find a way to encourage patients with high risk especially gdm, to help them through difficult times during pregnancy.” p5-15: “the best service must be provided to patients with gdm, nurses must change their perspective to find something new in providing nursing care to high-risk patients.” theme 3: feeling of ambivalence nurses have contrasting feelings about themselves and the patients whom they care for. the following are participants’ statements: p8-16: “carrying out the role as a nurse is not easy, there are many challenges but in the main is understanding patients who have different characters. sometimes i feel uncomfortable when treating patien ts who can't be given advice, that's where my emotional feelings arise.” p1-15: “often there is a feeling of ambivalence in caring for high-risk patients, there are many problems within the patient that must be resolved but it is difficult to contradict my feelings.” theme 4: self-preservation to develop potential nurses realize that this profession is a noble profession to continuously develop existing competencies and potentials. this is stated by the participants as follows: p7-13: “i am very proud to be a nurse, when caring for patients i feel i can develop my own potential to provide the best service.” p1014: “caring for high-risk patients, espe cially gdm, made me realize that, as a nurse, i must be able to preserve myself to develop my potential in order to provide optimal nursing care.” theme 5: the impact on the nurses of caring for gdm the actual service of nurses has a positive impact on many aspects of practice, as stated by the participants as follows: p3-16: “efforts made by nurses have a positive impact on patients and families, including psychology the patient does not experience anxiety during pregnancy with gdm.” p5-12: “the smallest thing to provide services to patients with high risk has a very significant impact, where patients feel capable and confident that they will recover." discussion theme 1: empathy pregnancy is a normal physiological process. the majority of pregnancy is accepted by the mother as something that has to be lived with. but the experience of the mother diagnosed with diabetes during pregnancy is a special experience for the mother and a serious challenge to maintain and undergo pregnancy. therefore, it is very necessary to do prenatal care for the mother and fetus to align processes to avoid pregnancy complications and decrease the incidence of morbidity or perinatal and maternal mortality (schellinger et al., 2017). the nurses spoke about several experiences that captured the meaning of the theme of “empathy,” and was illustrated with descriptions of the caring for gdm patients. abby described the feelings she experienced concerning maternity patients when she “provides holistic care.” this was also described as “so i need to provide better service.” empathy can be thought of as an individual’s identification with and response to an event (wilson & kirshbaum, 2011). empathy can further be viewed as an emotion felt by nurses when they place themselves in the patient’s situation, personifying the experience and treating the patient as they would want to be treated. empathy table 3. thematic analysis of the participants keyword sub theme theme the patient is the same feeling patient’s suffering awareness in carrying out duties empathy optimal nursing care holistic care giving better service providing nursing care give best service patient’s condition inspiration to find ways to treat patients very well finding something new help mother with high risk high risk pregnancy caring is not easy have to understand patient uncomfortable feeling finding many challenges feeling of ambivalence finding many problems difficult solving emotional feeling proud to be nurse giving optimal caring develop competencies self-preservation to develop potential helping patient and family provide service to patient positive impact of many aspects the impact on the nurses of caring for gdm t. i. pujianto et al. 166 | pissn: 1858-3598  eissn: 2502-5791 involves alleviation of pain, avoidance of suffering, and promotion of a new level of health (mattsson et al., 2013) and nurses will try to deliver patient care so these concepts can be achieved. the result of this study shows that the cause of gdm is due to hereditary factors, immunological factors, and diabetes acquired during pregnancy. empathy is needed by nurses in providing care to high-risk patients, gdm. empathy toward patients and families contributes to the emotions of caring provided by nurses. theme 2: inspiration to find ways to treat patients very well diabetes is a common complication of pregnancy. patients can be separated into two, namely those who had previously known diabetes and those who are diagnosed with diabetes during pregnancy (gestational). maternal factors obtained in mothers with gdm are hypertension, preeclampsia, and increased risk of caesarean section (huang et al., 2020). maternal glucose levels are unstable and can cause fetal death in utero, which is a typical occurrence in women with diabetes. a fetus exposed to hyperglycemia tends to asphyxia and acidosis although the exact mechanism is unclear, but is thought ketoacidosis has close links with the death of the fetus. when maternal or blood glucose levels are within normal limits, the death of the fetus in the uterus is rare (alberico et al., 2017). hyperinsulinemia that occurs in the fetus will increase the metabolic rate and oxygen needs to deal with situations such as hyperglycemia, ketoacidosis, pre-eclampsia and vascular disease, which can reduce blood flow and oxygenation placenta-utero fetus. the frequency of fetal death in utero or stillbirth ranges from 15-20%. an attempt to avoid the sudden death of the fetus in the womb is to terminate the pregnancy a few weeks before term (alia et al., 2019). some of the things above explain that gdm patients need to receive good care. nurses have intuition and inspiration to treat patients well. inspiration was identified when nurses observed the strength and resilience they detected in their maternity patients. inspiration can also be felt by nurses in the experience of caring for gdm patients. “the best service must be provided to patients with gdm, nurses must change their perspective to find something new in providing nursing care to high-risk patients.” the statement about inspiration to find ways to treat patients very well is a process of being mentally stimulated to do or feel something, creating a motivating reaction typically experienced when facing challenges in the process of goal attainment (straume & vitterso, 2012). theme 3: feeling of ambivalence maintaining the pregnancy did not make the mother desperate to retain the fetus and mother’s health. various efforts have been made to maintain the mother and the fetus in good condition and wellbeing. the experience of the mother to keep the extra pregnancy is to maintain fetal maturity by way of checkups to the hospital (alia et al., 2019). another effort made by the mother is doing movement exercises during pregnancy, doing routine blood sugar control and continuously making efforts at healthcare treatment (alia et al., 2019; dhingra & ahuja, 2016). nurses discussed struggling with their feelings during their experiences of caring for high risk gdm patients. feelings of ambivalence were described by questioning why nurses were subjected to the contrasting feelings about themselves and the patients whom they care, when a participant stated “carrying out the role as a nurse is not easy, there are many challenges in the main is understanding patients who have different characters. sometimes i feel uncomfortable when treating patients who can't be given advice, that's where my emotional feelings arise.” each nurse participant discussed similar issues related to ambivalence, the issues the struggles nurses when faced with their own emotions in relation to this, ambivalence may be emotionally distressing when nurses are asked to behave in a manner contradictory to their beliefs. ambivalence is defined as the state of having mixed feelings, mixed beliefs, or contradictions of thoughts and feelings (petty & krosnick, 2014). when discussing ambivalence in patient care, nurses described a sense of doubt as to whether or not the care rendered was appropriate for the situation. in nursing care view, a holistic human being is an individual. in a holistic concept, the human figure is seen as a whole, which is able to adapt as a whole. theme 4: self-preservation to develop potential women with a history of dm should use effective contraception to reduce pregnancy which is accompanied by hyperglycemia. long-term management with low-dose combined oral contraceptives did not appear to increase the risk of diabetes after pregnancy. an intra-uterine device (iud) is the most effective contraceptive as it is metabolically neutral. conversely, the use of progestin-containing contraceptives during lactation may increase the risk of diabetes (kiley & griffin, 2015). nurses’ interviews revealed thoughts of “trying to manage, just taking care of today, so that you could go back to caring for the woman pregnant with gdm,” illustrating self-preservation. one discussed her feelings about being able to continue with practicing in this specialty: “caring for high-risk patients, especially gdm, made me realize that, as a nurse, i must be able to preserve myself to develop my potential in order to provide optimal nursing care.” self-preservation can be defined as self-protection from harm, regarded as a basic human instinct of survival and is a coping strategy that allows for an understanding and processing of what takes place in our world. the construct of self-preservation helps jurnal ners http://e-journal.unair.ac.id/jners | 167 nurses deal with the emotional demands of patients, their families, and patient outcomes, either good or bad. self-preservation is part of the process nurses employ to shield themselves from what can deeply hurt them. research studies found distancing and disconnecting from patients facing a troubling situation is common with nurse self-preservation and self-protection (lipp, 2011). theme 5: the impact on the nurses of caring for gdm according to the nurses interviewed, caring for high risk gdm patients had an impact on them, both physically and psychologically. it makes them scared of becoming sick. consequently, the nurses reported feeling that they had high motivation, both physically and psychologically. discussing about the impact of practice, one said : “the smallest thing to provide services to patients with high risk has a very significant impact, where patients feel capable and confident that they will recovery.” nurses’ experiences with practical knowledge affect the nursing process. expert nurses with practical knowledge have more positive attitudes toward patients than do less experienced nurses (spencer et al., 2012). nurses should have more training to receive quality improvement education and continued training to improve their professional capabilities. moreover, their working spirit needs to be regularly regenerated to inspire them to take care of older people. furthermore, nurses should be aware of the psychological and physical impact of caring for older people, and there is a need to revitalize nurses’ positive experiences and feelings to improve their job satisfaction. conclusion in this study, nurses showed complex experience for taking care of patients with high risk of gdm. they expressed the view that the patients were somewhat more experienced. the attitude of nurses caring for gdm patients gave the impact of themselves and patients. implications of the findings allow for the opportunity to hear stories about nurses and their patients. personal and emotional stories of lived experiences provide the ability to create strategies to improve quality of life for the patient and for nurses, as well as adding to the identity of the practice of nursing. references alberico, s., erenbourg, a., hod, m., yogev, y., hadar, e., neri, f., ronfani, l., maso, g., & group, the g. (2017). immediate delivery or expectant management in gestational diabetes at term: the ginexmal randomised controlled trial. bjog: an international journal of obstetrics & gynaecology, 124(4), 669–677. https://doi.org/10.1111/14710528.14389 alia, s., pugnaloni, s., borroni, f., mazzanti, l., giannubilo, s. r., ciavattini, a., & vignini, a. (2019). impact of gestational diabetes mellitus in maternal and fetal health: an update. diabetes updates, 5(3), 1–6. https://doi.org/10.15761/du.1000129 buchanan, t. a., xiang, a. h., & page, k. a. (2012). gestational diabetes mellitus: risks and management during and after pregnancy. nature reviews. endocrinology, 8(11), 639–649. https://doi.org/10.1038/nrendo.2012.96 connelly, l. m. (2009). staff nurses’ responsibilities when caring for patients in a research study. medsurg nursing, 18(6), 385–388. dhingra, a., & ahuja, k. (2016). lifestyle modifications for gdm. jpma. the journal of the pakistan medical association, 66(9 suppl 1), s34-8. djihanga, a. y., & muflilah. (2020). screening diabetes mellitus gestasional di negeri berkembang. jurnal keperawatan, 12(2), 217–222. edward, k. leigh, & welch, a. (2011). the extension of colaizzi’s method of phenomenological enquiry. contemporary nurse, 39(2), 163–171. https://doi.org/10.5172/conu.2011.39.2.163 huang, y., zhang, w., go, k., tsuchiya, k. j., hu, j., skupski, d. w., sie, s. y., & nomura, y. (2020). altered growth trajectory in children born to mothers with gestational diabetes mellitus and preeclampsia. archives of gynecology and obstetrics, 301(1), 151–159. https://doi.org/10.1007/s00404-020-05436-2 kiley, j. w., & griffin, l. r. (2015). contraceptive care after gestational diabetes: considerations for clinical practice. diabetes management, 5(6), 457– 472. https://doi.org/10.2217/dmt.15.37 lipp, a. (2011). self-preservation in abortion care: a grounded theory study. journal of clinical nursing, 20, 892–900. mattsson, j., forsner, m., castren, m., & arman, m. (2013). caring for children in pediatric intensive care units: an observation study focusing on nurses’ concerns. nursing ethics, 20(5), 528–538. oza-frank, r., ko, j., wapner, a., rodgers, l., bouchard, j., & conrey, e. (2014). improving care for women with a history of gestational diabetes: a provider perspective. maternal & child health journal, 18(7), 1683–1690. https://doi.org/https://doi.org/10.1007/s10995 -013-1410-y petty, r. e., & krosnick, j. a. (2014). attitude strength: antecedents and conse quences. new york, ny: psychology press. plows, j. f., stanley, j. l., baker, p. n., reynolds, c. m., & vickers, m. h. (2018). the pathophysiology of gestational diabetes mellitus. international journal of molecular sciences, 19(11), 1–21. https://doi.org/10.3390/ijms19113342 sahu, b., babu, g. r., gurav, k. s., karthik, m., ravi, d., lobo, e., john, d. a., oakley, l., oteng-ntim, e., nadal, i. p., & kinra, s. (2021). health care professionals’ perspectives on screening and management of gestational diabetes mellitus in public hospitals of south india – a qualitative t. i. pujianto et al. 168 | pissn: 1858-3598  eissn: 2502-5791 study. bmc health services research, 21(1), 1–17. https://doi.org/10.1186/s12913-021-06077-0 schellinger, m. m., abernathy, m. p., amerman, b., may, c., foxlow, l. a., carter, a. l., barbour, k., luebbehusen, e., ayo, k., bastawros, d., rose, r. s., & haas, d. m. (2017). improved outcomes for hispanic women with gestational diabetes using the centering pregnancy© group prenatal care model. maternal and child health journal, 21(2), 297–305. https://doi.org/10.1007/s10995-0162114-x spencer, k., carr, a., & doherty, m. (2012). patient and provider barriers to effective management of gout in general practice: a qualitative study. ann rheum dis, 71(9), 1490–1495. https://doi.org/https://doi.org/10.1136/annrhe umdis-2011-200801 pmid: 22440822. straume, l. v, & vitterso, j. (2012). happiness, inspiration and the fully functioning person: separating hedonic and eudaimonic well-being in the work place. the journal of positive psychology, 7(5), 387–398. wilson, j., & kirshbaum, m. (2011). effects of patient death on nursing staff: a literature review. british journal of nursing, 20(9), 559–563. wulaningsih, i., hapsari, e. d., pangastuti, h. s., & priharjo, r. (2020). life experience of pregnant woman with gestational diabetes mellitus in maternal role attainment in special region of yogyakarta. jurnal ners, 15(2), 199. https://doi.org/10.20473/jn.v15i2.19306 http://e-journal.unair.ac.id/jners 89 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, 89-101 http://dx.doi.org/10.20473/jn.v16i1.34402 systematic review open access the relationship between genital hygiene behaviors and genital infections among women: a systematic review afriza umami1,2,* , edit paulik1 , regina molnár1 , and bhisma murti3 1 department of public health, albert szent-györgyi medical school, university of szeged, szeged, hungary 2 stikes muhammadiyah bojonegoro, bojonegoro, indonesia 3 masters program in public health, universitas sebelas maret, surakarta, indonesia. *correspondence: afriza umami. address: stikes muhammadiyah bojonegoro, indonesia. email: umami.afriza@med.u-szeged.hu responsible editor: retnayu pradanie received: 18 march 2022 ○ revised: 19 april 2022 ○ accepted: 20 april 2022 abstract introduction: genital hygiene is an important part of women’s health and is essential for protecting reproductive health. women adopt many genital hygiene behaviors, which will have direct and indirect effects on genitals and possible sexually transmitted infections. this systematic literature review aimed to know the types of gen ital hygiene behaviors practiced by women and assess the relationship between genital hygiene behavior and genital infection. methods: a systematic search of the electronic databases, pubmed, ovid, web of science, scopus, sciencedirect, jstor, and sage, for literature published between january 2001 and 2021. the keywords used were “genital hygiene behavior” and “genital infections” and “women or female.” the inclusion criteria focused on genital hygiene behavior and the incidence of genital infection. the included full papers with observational research methods followed the prisma guidelines. after reading the full content of the included studies, key themes and concepts were extracted and synthesized. results: in total 383 articles were screened. five articles met the inclusion criteria and were analyzed. the analysis revealed four categories related to genital hygiene behavior among women: underwear hygiene, bathing habits, menstrual hygiene, and coital hygiene. genital infections included bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. the review showed that incorrect and inadequate genital hygiene behavior increases the risk of vaginal infection. conclusion: a higher incidence of genital infections occurred in women with improper genital hygiene practices. it is necessary for health professionals to educate women about good genital hygiene practices in order to reduce the rate of genital infections. keywords: genital hygiene behaviors; genital infection; systematic review; women’s health introduction genital hygiene plays a key role in preventing genital infections. early identification of genital infections, appropriate treatment measures, and necessary preventive measures are essential to protect and improve women's health (hamed, 2015). genital infection is a serious female health problem, which is related to a negative impact on sexual and family life (sevil et al., 2013). in this case, genital infection has become a serious public health problem, which is common in both developed and developing countries. about 1 million women around the world suffer from genitourinary system infections, such as urinary tract infections and bacterial vaginosis, and 75% of them have had genital infections. the prevalence of bacterial vaginosis (bv) has been found to be 8%–75%, the prevalence of vulvar vaginal candidiasis (vvc) is 2.2%–30%, and the prevalence of trichomoniasis (vt) is 0%–34% (karadeniz, 2019). more than one million sexually transmitted infections (stis) are spread worldwide every day (world health organization, 2021). the factors that cause female genital infections vary widely. the closeness of the urethra, vagina, and anus to https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0001-6590-1465 https://orcid.org/0000-0002-3446-4327 https://orcid.org/0000-0002-8606-080x https://orcid.org/0000-0001-9405-3872 umami, paulik, molnár and murti (2022) 90 p-issn: 1858-3598  e-issn: 2502-5791 each other is the most important factor in the susceptibility to genital infection, and certain factors will increase the risk of its occurrence (calik et al., 2020). the understanding of reproductive health issues varies greatly among countries, societies, and individuals. socioeconomic status, race, religious belief, and education level all affect women's views and behaviors on reproductive health. in particular, feminine hygiene habits are different among women with a high prevalence of behavioral defects, and these behavioral defects easily make them susceptible to vulvovaginitis (attieh et al., 2016). genital infections do not always threaten women’s lives, but their symptoms can lead to serious illnesses (hilber, francis, et al., 2010). these infections can lead to ectopic pregnancy, sepsis, cervical cancer, infertility and congenital infections of the newborn (centers for disease control and prevention, 2019). care and treatment of women’s vagina and genitals can reduce their susceptibility to sexually transmitted infections (stis) and other sexual and reproductive diseases (myer et al., 2005). a qualitative study has linked women’s intravaginal practices and sexuality, and demonstrates that women in the four countries. indonesia, mozambique, south africa, and thailand, actively use a variety of practices to achieve a desired vaginal state. moreover, that study discusses types of vaginal practices, products used in vaginal practices and health consequences arising from these practices (hilber, hull, et al., 2010). the data obtained indicated that the prevalence rate of bv is relatively high and could be influenced by hygiene behavior and certain socio-demographic characteristics, which indicated that genital behavior needs attention (bahram et al., 2009). behavioral factors such as vaginal douching or menstrual hygiene practices have been suggested as important factors that might influence vaginal infections (cottrell, 2001; cottrell & close, 2008; ott et al., 2009). differences in vaginal practices, exposure measurements, study design, study populations, and statistical analysis definitions and classifications can explain these conflicting results (brown & brown, 2000; hilber, francis, et al., 2010; hilber, hull, et al., 2010). various personal hygiene methods can be very harmful to health (9). in this case, unhealthy and dangerous practices can be attributed to improper cleaning of the genital area after using the toilet and poor handwashing habits. frequent genital cleaning, lack of adequate underwear, insufficient attention to menstrual hygiene, sterile childbirth or artificial abortion as a method of family planning can increase the risk of genital infections (felix et al., 2020; karadeniz, 2019). to get a contextual understanding of the genital hygiene behavior needed to be carried out by women, a simple brief information sheet and knowledge of what behaviors need to be considered is needed. although there are a few studies on women's specific hygiene habits in the united states, egypt and turkey and other countries, they are still rare (attieh et al., 2016). information about the literature review toward genital hygiene behavior is lacking. therefore, we conducted the current study with a systematic literature review with the following objectives: (1) to determine what types of s c r e e n in g title screening (n = 366) (not relevant) excluded (n = 165) abstract screening (n = 201) records identified through database searching (n = 383) id e n ti fi c a ti o n duplicates excluded (n = 17) not relevant abstracts excluded (n= 185) e li g ib il it y full text-screening (n = 16) included full texts in result synthesis (n = 5) full-text articles excluded (n = 11) 2 inappropriate study design 9 non-relevant topics in c lu d e d figure 1 prisma flow of the selection process. jurnal ners http://e-journal.unair.ac.id/jners 91 genital hygiene behaviors are practiced by women; (2) the relationship between genital hygiene behavior and genital infection. materials and methods search strategy the primary question guiding this review was: “how does oss enhance physical activity among adolescents?” meanwhile, the secondary question was: “what are the characteristics of oss utilised to enhance physical activity among adolescents?” the present systematic review was conducted in accordance with the prisma flow diagram guidelines (moher et al., 2015). the authors searched electronic databases for literature published between 2001 and january 2021, only articles published in english were considered. a high-sensitivity search strategy was used to search the following databases: pubmed; ovid; web of science; scopus; sciencedirect; jstor and sage. relevant articles, which included the search term (genital hygiene behavior) and (genital infections or sexually transmitted infections) and (women or female) in the title, were identified. keywords were combined with the boolean operator and to limit the searches. an overview of the search terms can be found in table 1. inclusion and exclusion criteria the inclusion criteria were full paper articles with observational research methods. the exposure given was genital hygiene behavior, the research subjects were women with genital infection. the exclusion criteria in this study were non-observational studies, female populations under 15 years, the articles were not full text and were not published in english. operational definition of variable a genital hygiene behavior: a behavior or method of individual care to maintain cleanliness and health of their reproductive organs to achieve physical and psychological well-being. genital hygienic practices include external washing, intra-vaginal cleansing, preand post-coital care, menstrual hygiene, and external application. genital infections can be caused by bacteria, fungi, parasites, or viruses growing in and around vagina and vulva (the area surrounding the vagina). symptoms are such as soreness, itchiness, and an unusual vaginal discharge. common types of vaginal infections are yeast infections, bacterial vaginosis, and trichomoniasis, a sexually transmitted infection. procedure the studies were assessed according to the eligibility criteria and the selection process was divided into two phases. data were managed by transferring references to a reference management tool (mendeley). for further documentation the review manager, covidence.org (the cochrane collaboration, melbourne, australia), was used (helfer et al., 2015). documentation of the selection process was done with management tools. as a first step, the duplicates from the initial search results were removed. the initial search results were filtered by title table 1 overview of the search terms #genital hygiene behaviors #genital infections #related genital hygiene behaviors sexually transmitted diseases associated genital hygiene practices vulvovaginal health impacts reproductive health practices vulvovaginal disorder outcomes intimate feminine hygiene genital problems feminine hygiene practices genital infection vaginal hygiene practices reproductive health intravaginal practices table 2 quality assessment first author (year) s tu d y p u rp o se 1 l it e ra tu re 2 d e si g n sample outcome e x p o su re 7 result c o n c lu si o n 1 1 n d e sc ri b e 3 s iz e 4 m e a su re 5 v a li d 6 s ta ti st ic a l8 a n a ly si s9 c li n ic a l1 0 sevil (2013) y y cross-sectional 1057 y n/a y y y y y y y bahram (2009) y y cross-sectional 500 y n/a y y y y y y y bitew (2017) y y cross-sectional 210 y n/a y y y y y y y calik (2019) y y cross-sectional 266 y n/a y y y y y y y hamed (2015) y y case-control 200 y n/a y y y y y y y 1 was the purpose stated clearly?; 2 was relevant background literature reviewed?; 3 was the sample described in detail?; 4 was sample size justified?; 5 were the outcome measures reliable?; 6 were the outcome measures valid?; 7 exposure was described in detail?; 8 results were reported in terms of statistical significance?; 9 were the analysis method(s) appropriate?; 10 clinical importance was reported?; 11 conclusions were appropriate given study methods and results. umami, paulik, molnár and murti (2022) 92 p-issn: 1858-3598  e-issn: 2502-5791 and abstract. after comparison and approval of the first screening process, the full text that met the requirements was analyzed. playback of the title, abstract, and full text were reviewed. if no full text was available, the article was excluded. the process was tracked in flow diagram according to prisma (figure 1). quality assessment the authors independently rated the methodological quality of selected studies using the critical review forms which, developed by canchild (mcmaster university, canada), is a tool for conducting critical reviews of outcome measures and journal articles (law et al., 1998a, 1998b). the quality of the studies was assessed with several questions with the answers "yes / no / not addressed" according to the criteria of the canchild critical review form (law et al., 1998a, 1998b). after careful analysis of the quality related to results, the articles containing the highest quality and content for the work were included. the quality assessment of the studies can be found in table 2. one researcher undertook this assessment independently, with a random 10% of the articles reviewed by a second researcher. there were no discrepancies in the application of the risk of bias assessment found when the random sample of articles was compared by a second reviewer. data analysis this systematic review adopted thematic synthesis. the five studies were read thoroughly to identify critical points and themes. we found the theme, which was type of genital hygiene behavior commonly practiced by women, and subtheme, which was underwear hygiene, bathing habits, menstrual hygiene and coital hygiene. for the analysis of the themes, we followed the braun and clark approach (braun and clarke, 2006). the first phase, familiarization, entails the reading and re-reading of the entire dataset. this is necessary to be able to identify appropriate information that may be relevant to the research question. in the second phase, we did the coding on the subthemes found. the coding process was performed to produce concise descriptive or interpretive labels that may be relevant to the research question. phase three was generating themes, namely the type of genital hygiene behavior commonly practiced by women. phase four reviewed potential themes, wherein we did not find any other potential themes. phase five was defining and naming the theme while phase six involved producing the report in which we wrote and reported the findings from a review of the analyzed articles (table 3). the papers were synthesized under the following subheadings: author, research aims, design and data collection, sample number and characteristics, type of genital hygiene behavior, type of genital infection, and research findings (appendix 1). independent reviewers extracted the data related to genital hygiene behavior carried out by women as well as stis, or symptoms associated with genital infections results the search identified 383 publications. after duplicates were excluded (n = 17), a total of 366 publications was identified according to the search strategy. some irrelevant titles were excluded (n = 165) and 185 abstracts did not meet the criteria, so they needed to be excluded. examples of articles that did not meet the following criteria were not available in full text, use a language other than english, and not quantitative research. the full text was obtained for the remaining 16 articles which were eligible. after a detailed review, only five articles were found to meet the inclusion criteria and were selected for analysis. of the eleven excluded articles, two had inappropriate study designs and the others had irrelevant topics. see figure 1 for the selection process prisma flow. description of study a total of five studies were included in the review. the studies consisted of four cross-sectional studies, and one case-control study. the total sample analyzed was 2,233 respondents, from women aged 15 years to more than 60 years. the target population was students, married women, and non-pregnant women, as well as female patients undergoing treatment at the gynecology department. the studies were conducted in turkey with the number of sample 1,057 female students with the mean age of 21.03 ± 1.70 years and another study from turkey showed 266 married women, the mean age of 38.5 ± 7.9 (min = 20, max = 49); in iran 500 non-pregnant women aged between 15 and 45 (mean age 36 years) were enrolled; in ethiopia the respondents were 210 female patients aged between 15 and 64 years, and the last study conducted in egypt was a case control study with a total 200 women. a study conducted by bahram (2009) showed that 16.2% of women experienced bv, 6.6% vt, and 4.8% vvc. meanwhile, bitew et al.'s study (2017) showed that 48.6% of women experienced bv and 51.4% did not experience. type of genital hygiene and genital infections eight most of the data collection techniques were carried out by questionnaires to assess genital hygiene behavior. it was found that several types of genital hygiene behavior were carried out by women, specifically underwear hygiene, bathing habits, menstrual hygiene, table 3 types of hygiene behavior performed by women theme type of genital hygiene behavior subthemes underwear hygiene bathing habits menstrual hygiene coital hygiene jurnal ners http://e-journal.unair.ac.id/jners 93 and coital hygiene practices (appendix 1). in addition, to determine genital infection, women had a history of genital infection that had been diagnosed by a physician with a genital infection within the past six months (hamed, 2015; sevil et al., 2013). a diagnosis was made to determine genital infection through a pap smear test (calik et al., 2020) and specimen collection for genital infection culture (bahram et al., 2009; bitew et al., 2017). genital infectious diseases obtained from the review were bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis (bahram et al., 2009; bitew et al., 2017) (appendix 1). some studies did not explain in detail the types of genital infections suffered by women, they only explained that women had experienced genital infections (but did not specify what type of disease) (sevil et al., 2013) and the symptoms experienced by women, such as pathological vaginal discharge (calik et al., 2020) and vaginal infections (hamed, 2015). outcomes from the five studies, four themes related to genital hygiene behavior were identified: underwear hygiene, bathing habits, menstrual hygiene, and coital hygiene. meanwhile, three types of genital infections were identified based on data obtained from respondents: bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis (appendix 1). sevil et al. (2013) examined the relationship between genital hygiene practices and genital infections in a group of university students, including 1057 female students aged between 17 and 27 years old. this study used a questionnaire developed in line with the purpose of the study to evaluate the relationship between genital hygiene practices and genital infection in a group of university students. some of the questions that respondents were asked about genital hygiene were (a) underwear hygiene and bathing habits, which consisted of five questions including the type of underwear used (hosiery/cotton, satin/flannel), the frequency of changing underwear (once a week, twice-three times a week, daily), daily pads (yes, none), bathing position (standing, sitting, sometimes sitting, sometimes standing), bathing frequency (daily/once every 2-3 days, weekly/once every fifteen days); (b) the toilet hygiene practice had six questions, which were genital area cleaning, type of genital area cleaning, agent used for genital area cleaning (water, soaps, cosmetics), drying genital area, material used for drying the genital area (toilet roll, cloth), frequency of cleaning genital hair, hand washing; (c) menstrual hygiene, consisting four questions, including the materials used during menstruation (pad, cloth), the frequency of changing materials during menstruation (per day), bathing during menstruation (yes, no) and the use of perfume for unpleasant odors during menstruation. students who were diagnosed with genital infections by a physician in the past six months were considered "students with a history of genital infections." of the 1,057 female students included in this study, there were 137 (13.0%) who had a history of genital infections. an assessment of underwear and bathing habits of students with genital infection history did not demonstrate any relationships between the frequency of changing underwear and infection history (χ2 = 5.404; p = 0.067). the frequency of genital infections was higher among those who used hosiery/cotton underwear and daily pads (χ2 = 5.602; p = 0.018 and χ2 = 8.490; p = 0.004, respectively). history of genital infections was significantly more common among those who bathed in the sitting position and in those who bathed once a week (χ2 = 49.570; p < 0.001 and χ2 = 25.534; p < 0.001, respectively). genital infection was significantly less common among those who told that they practiced genital cleaning (χ2 = 62.263; p < 0.001), while they were more common among those who described that they cleaned the genitals randomly (χ2 = 14.350; p = 0.001), used soap (χ2 = 10.170; p = 0.004), did not dry the genital area (χ2 = 48.657; p < 0.001), used cloth for drying (χ2 = 30.006; p < 0.001), performed frequent genital area cleaning with materials such as razor (χ2 = 15.918; p < 0.001) and did not always pay attention to hand washing (χ2 = 12.733; p = 0.002). the frequency of genital infections was significantly higher among those who used cloth and those who did not bathe during menstruation (χ2 = 46.042; p < 0.001 and χ2 = 8.984; p = 0.003, respectively). the cross-sectional study by bahram et al. (2009) included 500 non-pregnant women between the ages of 15 and 45 years. this study aimed to determine the prevalence of bv and the effects of sexual and genital hygiene practices and sociodemographic in nonpregnant women. to diagnose bv, vaginal swabs were heat-fixed, gram-stained and examined with an oil immersion objective (1000x magnification) and analyzed according to the standardized quantitative morphological classification method of nugent. the diagnosis of vulvar vaginal candidiasis has been suggested in women who presented with symptoms and/or signs of vaginitis, e.g., vaginal discharge, itching, external dysuria, and vulvovaginal erythema. trichomoniasis was diagnosed by visualizing mobile trichomonads in the wet dissection smear immediately after sampling. all laboratory evaluations were carried out by microbiologists. the questions on genital hygiene were (a) menstrual hygiene (bathing during menstruation, genital douching during menstruation, use of sanitary napkins, changing sanitary napkins after each urination, sexual abstinence during menstruation); (b) individual vaginal hygiene (regular underwear changing, underwear washing with hot water, use of loose underwear, ironing underwear, front-to-back cleaning of genitalia, use of private umami, paulik, molnár and murti (2022) 94 p-issn: 1858-3598  e-issn: 2502-5791 bathroom, personal bathroom amenities, bathroom hygiene, sun drying bathroom amenities, shaving genital hair); (c) hygiene during intercourse (genital douching before intercourse, urination after intercourse, frequency of intercourse). the prevalence of rtis was 27.6%, including 16.2% for bv, 6.6% for vt, and 4.8% for vvc. there was a significant correlation between menstrual and individual vaginal hygiene and bv (p < 0.01 and p < 0.001). in contrast to coital hygiene, no significant correlation was observed between bv and coital hygiene. the data obtained suggest that the prevalence rate of bv is relatively high and could be influenced by hygienic behaviors and certain socio-demographic characteristics. bitew et al. (2017) conducted a cross-sectional study among 210 patients to assess the relationship between the prevalence of bv and genital hygiene behavior. gramstained vaginal swabs were examined microscopically and sorted by the nugent method; bacteria causing aerobic vaginitis were characterized and their antimicrobial susceptibility pattern determined. questionnaires on genital hygiene behavior included the number of pants worn daily (1-2 pants/day, one pants for 2-4 days); frequency of vaginal baths/day (1-3, ≥4). the overall prevalence of bv was 48.6%. the prevalence of bv was lower among patients who changed pants more frequently (two per day) than among those who changed their pants less frequently (one pants for 2–4 days) (aor = 0.367; 95% ci = 0.201 to 0.672; p = 0.001). patients who bathed their vaginal region more frequently were less affected than those who did not bathe their vaginal area as much (aor = 1.847; 95% ci = 1.013 to 3.370; p = 0.045). this study found that the prevalence of bv was high and was affected by individual hygiene. a cross-sectional study by calik et al. (2020) recruited 66 married women aged 20 to 49 years. the data were collected using a questionnaire, the genital hygiene behavior inventory (ghbi), a gynecological examination and the pap smear test. a specialist performed a pap smear for the gynecological examination of the women and the results were recorded by the researcher after 20 days. this study used a questionnaire in the form of ghbi and with a four-level item, and was developed by ege and eryılmaz (2005) to determine the genital behaviors of women aged between 15 and 49 years of age. the inventory was single-dimensional and included 24 positive and three negative items, consisted of three subdimensions including “general hygiene,” “menstrual hygiene”, and “abnormal finding awareness.” each item contained the alternative answer “never”, “sometimes”, “frequently”, and “always”. in the inventory, the lowest and highest total points were 27 and 108 points, respectively. the high total points indicated good behavior in term of genital hygiene. of the women who reported having vaginal discharge (54.9%), 45.1% had abnormal discharge and odor (34.6%) and burning sensation (35%); speculum examination showed that 42.6% had a pathological discharge and the incidence of genital infections in vaginal cytology was 79%. it was found that 71.4% of women had pathological or non-pathological discharge; the mean ghbi score for women was 70.27 ± 10.05. it was found that the average ghbi value for women was slightly above the moderate value and that improper genital hygiene practices increased the risk of vaginal infection in women. at the same time, a significant relationship was found between genital discharge complaints and ghbi score hygiene behaviors (p = 0.009). hamed (2015), in his case-control study, evaluated the impact of genital hygiene practices on the incidence of vaginal infections and developed a care factsheet as a prevention message for women at risk, and not pregnant. case group: women diagnosed with vaginal infection (n = 100). control group: women without vaginal infection (n = 100). respondents were asked to complete a genital hygiene behavior questionnaire, which consisted of the following questions: (a) genital hygiene practices (type of underwear, frequency of underwear changes, external washing of the genital area, daily use of pads, drying after going to the toilet; (b) menstrual hygiene practices (bathing during menstruation, hand washing before and after using the toilet, type of material used during menstruation, frequency of changing pads, procedures for treating dirty sanitary pads); (c) sexual intercourse hygiene practices (genital care before intercourse, genital care after intercourse, use of local contraceptives, use of chemicals and lubricants during intercourse, use of douching after intercourse). to assess the gynecological history, this was based on the presence of symptoms associated with a vaginal infection, the history of contraceptives and the presence of gynecological problems. per-vaginal examination and investigations were done to obtain pertinent data about vaginal infection. the diagnosis of vaginal infection was determined by a physician. the results of this study show that women who suffered from vaginal infection were less likely to use cotton underwear and changed them less frequently (χ2 = 10.1; p = 0.006 and χ2 = 20.7; p = 0.001, respectively). meanwhile, they were more apt to use the incorrect technique in washing the genital area (χ2 = 26.5; p = 0.001), use intra-vaginal cleansing or douching (χ2 = 7.3; p = 0.007) keeping their genital area moist or using reused cloth for drying it (χ2 = 7.3; p = 0.007). women in the study group were less likely to bathe themselves, washing hands before and after using the toilet and used reusable cloth to absorb menstrual blood (χ2 = 6.7; p = 0.009, p = 0.010 and p = 0.001, respectively). meanwhile, almost one-fourth (24.0%) of the respondents in the case group less frequently changed their perineal pad and washed their reused cloth (37.0%) (p = 0.023 and p = 0.001, respectively). almost one third jurnal ners http://e-journal.unair.ac.id/jners 95 of women in the case group did not perform preor postcoital care compared to those in the control group (χ2 = 33.8; p = 0.001, and χ2 = 26.8; p = 0.001 respectively). discussion the minimum age in this review is 15 years at which age a young girl can choose self-care, both personal hygiene and female organs. adolescence is a period of the rapid growth of physical and emotional changes (michael et al., 2020). it is the stage of life when a person enters puberty, but adolescents are found to lack basic information about their bodies. it is still regarded as taboo in a developing country, but today’s young people are caught between the conservative culture and the fascinating western culture due to the influence of the media (deshmukh & chaniana, 2020). underwear hygiene in this review, three of the five papers reviewed asked questions related to underwear hygiene behavior. the questions often arising regarding the cleanliness of underwear are type of underwear used and frequency of changing underwear. the type and cleanliness of underwear and the frequency of replacement are essential factors determining the risk of genital infection (sevil et al., 2013). many women who use underwear follow the trend where the type of material used cannot absorb sweat. it is a business trend to make nylon and synthetic lingerie more attractive, especially for young women (ruiz et al., 2019). however, felix et al. (2020) argued that nylon absorbs less sweat than cotton underwear, makes the crotch damp, and increases the risk of reproductive tract infections, so women must be wise in choosing the type of fabric in daily use. cotton underwear is preferable to synthetic materials because cotton is breathable and allows air to circulate the external genitals. the ventilation helps to prevent the buildup of microorganisms and helps maintain healthy skin around the vaginal area (hamed, 2015). however, one article in this review stated that the frequency of genital infections was higher in those who wore the hosier/cotton type of underwear (sevil et al., 2013). the use of underwear is significant and needs to be considered. based on the middle east and central asia (meca) guidelines on female genital hygiene recommends wearing loose-fitting cotton underwear, minimizing wearing tight clothes, and changing underwear frequently (arab, almadani, tahlak, chawla, ashouri, tehranian, ghasemi, taheripanah, gulyaf, & khalili, 2011; chen et al., 2017). likewise, the royal college of obstetricians and gynecologists ‘(rcog) guidance on vulvar skincare provides recommendations for women to wear loose-fitting silk or cotton underwear and avoid close-fitting clothes (chen et al., 2017; hilber, francis, et al., 2010). clothing is one of the critical factors in the prevention of vulvovaginitis. bacteria and yeast thrive in moist or damp places. therefore, clothing that increases local heat and moisture, such as nylon underwear and tight-fitting garments, including leotards, tights, rubber pants, skintight jeans, nylon underclothing, and tight-fitting diapers, can contribute to vaginal infections and prepubertal vulvovaginitis (klebanoff et al., 2010). bathing habits three studies stated that genital hygiene practices include bathing and toilet habits, such as bathing frequency, bathing position, agent used for genital area cleaning, and the material used for drying the genital area (bahram et al., 2009; bitew et al., 2017; sevil et al., 2013). the female genitals are constantly exposed to factors that affect homeostasis and especially the ph of the skin; these interfering factors include endogenous or physiological factors and exogenous or iatrogenic factors; endogenous factors are moisture, sweat (sweat), sebum secretion, anatomical wrinkles, genetic predisposition, and age; exogenous factors include soap, cosmetics, tight clothing, bathing habits, shaving, and applying topical creams or powders to the skin (arab et al., 2011). a study by sevil showed that history of genital infections was significantly more common among those who bathed in the sitting position. this result is supported by demir et al. (2020) that it is one of the personal hygiene habits that also contribute to genital cleansing. women who often take a bath in the form of showers do not need additional applications in genital hygiene. bathing by sitting on the stool may induce vaginal infection and urinary tract infection if the stool sitting is not hygienic (demir et al., 2020). on the other hand, bahram et al. (2009) stated there was a significant correlation between bathing in standing position and the incidence of bacterial vaginosis. in addition to bathing positions affecting the incidence of genital infections, other possibilities can also be influenced by cleaning materials or products such as soap/shampoo used when bathing because changes in the ph of hygiene products will affect the ph of the vagina. women who bathed their vaginal region more frequently were less affected by bacterial vaginosis than those who did not bathe their vaginal area as much (bitew et al., 2017). routine washing of the vulva is desirable to prevent the accumulation of vaginal discharge, sweat, urine, and fecal contamination to prevent offensive body odor. although vulvar cleansing may be a helpful adjunct to medical treatment, vulvar cleansing products are not designed to treat infections. there has, however, been a surge in intimate hygiene products for cleanliness and odor control. still, some may upset ph in the vulvovaginal area, which will affect the composition of the normal vulvovaginal microbiota needed for protection against infection (chen et al., 2017). umami, paulik, molnár and murti (2022) 96 p-issn: 1858-3598  e-issn: 2502-5791 menstrual hygiene current studies classify menstrual hygiene practices, including the material used during menstruation, frequency of changing the material during menstruation (per day), bathing during menstruation, genital douching during menstruation (bahram et al., 2009; hamed, 2015; sevil et al., 2013). the frequency of genital infections was significantly higher among those who used cloth and those who did not want a bath during menstruation (p<0.001 and p=0.003, respectively) (bahram et al., 2009). similar results from torondel et al. (2018) showed that women who used reusable sanitary napkins were more likely to get candida and bv infections than women who used disposable sanitary napkins. in addition, regular body washing during menstruation was associated with a lower risk of bv. unhygienic menstrual hygiene management (mhm) practices can create abnormally moist conditions in the vulvovaginal area, which can promote opportunistic infections such as candida. once infected, it can be difficult to remove candida from clothing without proper cleaning and drying. menstrual blood causes changes in vaginal ph (alkaline ph), but the relationship between vaginal microbiology and menstruation is complex. in one study, it was stated that the menstrual sample had been shown to contain the highest number of bacteria at the lowest concentration (amabebe & anumba, 2018). good menstrual hygiene helps protect the intimate health of bacterial infections, skin irritation and other health problems. research conducted by anand et al. (2025) on reproductive tract infections (rti) shows that the causes of rti symptoms may be different and are not limited to unhealthy menstrual practices, although this can be one of the causes of reproductive morbidity. awareness, accessibility, and confidentiality are some of the main concerns that require immediate attention to promote the use of sanitary napkins during menstrual periods (anand et al., 2015). during menstruation, the blood vessels in the uterus are very susceptible to infection because blood and sweat come out and stick to the vulva, which can cause the genital area to become moist. in moist conditions, fungi, and bacteria in the genital area will thrive, this causes itching and infection in the area. one of the complaints felt during menstruation is itching caused by candida fungi, which will thrive during menstruation and can cause vaginal discharge and which can be caused by wearing cloth pad or disposable sanitary napkins. coital hygiene from the synthesis on coital hygiene, it was found that several female behaviors that are often practiced are genital douching before and after intercourse, urination after intercourse, and frequency of intercourse. hamed (2015) said, in his case-control study, that almost onethird of women in the case group did not perform pre or post-coital care compared to those in the control group with statistically significant difference (p=0.001). moreover, bitew et al. (2017) argued that genital hygiene behaviors such as douching before and after intercourse significantly affect the incidence of vaginal infections. according to verstraelen et al. (2010), the simplest explanation for this coital effect on the vaginal microflora is that unprotected sexual intercourse changes the physicochemical environment of the vagina and, thus, also influences the vaginal microflora. in particular, the alkaline prostate content of the ejaculate increases the vaginal ph, which remains elevated for up to eight hours after intercourse (verstraelen et al., 2010). post-coital intravaginal cleansing (ivc) could counteract the protective effect of a vaginal microbicide (gafos et al., 2013). the female genitals are conducive to allowing bacteria, secretions, sweat, menstruation, urine, and feces to pass into the vagina during intercourse. the lack of ventilation can lead to infection; it is important to be careful in this zone (amabebe & anumba, 2018). postcoital intravaginal cleansing is an important practice for some women in terms of managing their sexual health and sexuality (hilber et al., 2012) to increase their confidence with their partner and manage unwanted vaginal odor. the practice of coital hygiene is very dependent on the individual and their partner. support from the sexual partners is needed to improve good coital hygiene behavior in the prevention of genital infections among women (umami et al., 2021). this systematic review found that the incidence of genital infections is more common in women with inadequate genital hygiene (bahram et al., 2009; bitew et al., 2017; calik et al., 2020; hamed, 2015; sevil et al., 2013). the prevalence of bacterial vaginosis is high and is influenced by individual hygiene (11,26). inappropriate genital hygiene practices (calik et al., 2020) increased the risk of vaginal infection in women. the present systematic review shows that clothing can cause alterations in the vaginal microbiota due to temperature variation, local humidity (calik et al., 2020; sevil et al., 2013), and compromised ventilation of the external genitalia, altering the genital ecosystem and causing irritation, an allergic reaction, or discharge (felix et al., 2020). sexual intercourse leads to bv if the sexual partner's natural genital chemistry changes the balance of the vagina and causes bacteria to grow. limitation limitation of this study included the search was restricted to english and full text. there may be relevant information that is published in other languages. this evidence synthesis is based on observational studies only. cross-sectional data often lack directionality and do not provide information on mechanistic associations or causal effects between genital hygiene behavior and genital infection. in addition, poor data quality is a concern, such as the lack of diagnostic data regarding jurnal ners http://e-journal.unair.ac.id/jners 97 genital infections, and some studies only state genital infection from symptoms, prior history of genital infection based on physician diagnoses. due to the small number of papers, the five studies we reviewed were not strong enough to provide evidence of an association between genital hygiene and genital infection. there is a possibility of publication bias because we only used articles in english, presenting the possibility that articles using other languages also discuss the same topic as this study. however, we believe that the research protocol was methodologically strong to ensure a reliable study selection. for further research, it is hoped that more articles can be reviewed so as to reduce publication bias by including articles in both english and non-english languages and can use meta-analysis to find out better evidence in analyzing the relationship between genital hygiene and genital infection. for professional health workers, in health services, clinics and community, they can provide health education for women, especially in implementing good and correct genital hygiene behaviors. conclusion hygiene behaviors that are often practiced by women such as underwear hygiene, bathing habits, menstrual hygiene, and coital hygiene seem to be an important factor associated with the incidence of genital infections in women. women need to practice proper personal hygiene to avoid harmful behavior in order to prevent the rate of genital infections due to wrong hygiene practices. these factors are in line with treatment goals centered on personal and reproductive hygiene care. acknowledgement the author(s) would like to thank the university of szeged klebelsberg library which has provided support in proofreading; the department of public health university of szeged which provided suggestions and discussions for ideas in the research view; and stikes muhammadiyah bojonegoro for publication funding references amabebe, e., & anumba, d. o. c. (2018). the vaginal microenvironment: the physiologic role of lactobacilli. frontiers in medicine, 5(jun), 1–11. https://doi.org/10.3389/fmed.2018.00181 anand, e., singh, j., & unisa, s. (2015). menstrual hygiene practices and its association with reproductive tract infections and abnormal vaginal discharge among women in india. sexual and reproductive healthcare, 6(4), 249–254. https://doi.org/10.1016/j.srhc.2015.06.001 arab h, almadani l, tahlak m, chawla m, ashouri m, tehranian a, ghasemi a, taheripanah, gulyaf m, khalili a, h. e. (2011). the middle east and central asia guidelines on female genital hygiene. b m j middle east, 19(april). attieh, e., maalouf, s., roumieh, d., abdayem, p., abitayeh, g., & kesrouani, a. (2016). feminine hygiene practices among female patients and nurses in lebanon. reproductive health, 13(1), 1–6. https://doi.org/10.1186/s12978-016-0182-4 bahram, a., hamid, b., & zohre, t. (2009). prevalence of bacterial vaginosis and impact of genital hygiene practices in non-pregnant women in zanjan, iran. oman medical journal, 24(4), 288–293. https://doi.org/10.5001/omj.2009.58 bitew, a., abebaw, y., bekele, d., & mihret, a. (2017). prevalence of bacterial vaginosis and associated risk factors among women complaining of genital tract infection. international journal of microbiology, 2017(ii). https://doi.org/10.1155/2017/4919404 brown, j. e., & brown, r. c. (2000). brown 2000_traditional intravaginal practices and the heterosexual transmission of disease a review.pdf. sexually transmitted diseases, 27(4), 183–187. calik, k. y., erkaya, r., ince, g., & yildiz, n. k. (2020). genital hygiene behaviors of women and their effect on vaginal infections. clinical and experimental health sciences, 10, 210–216. https://doi.org/10.33808/clinexphealthsci.565845 centers for disease control and prevention. (2019). stds in women and infants 2018 sexually transmitted diseases surveillance. chen, y., bruning, e., rubino, j., & eder, s. e. (2017). role of female intimate hygiene in vulvovaginal health: global hygiene practices and product usage. women’s health, 13(3), 58–67. https://doi.org/10.1177/1745505717731011 cottrell, b. h. (2001). vaginal douching. journal of obstetric gynecologic and neonatal nursing, 32(1), 12–18. https://doi.org/10.1177/0884217502239796 cottrell, b. h., & close, f. t. (2008). vaginal douching among university women in the southeastern united states. journal of american college health, 56(4), 415–421. https://doi.org/10.3200/jach.56.44.415-422 demir, i̇., öztürk, g. z., & uzun, a. (2020). analyzing the relationship between genital hygiene behaviors in women and urinary tract infection in any period of life. ankara medical journal, 20(4), 982– 992. https://doi.org/10.5505/amj.2020.37640 deshmukh, d. d., & chaniana, s. s. (2020). knowledge about sexual and reproductive health in adolescent school-going children of 8th, 9th, and 10th standards. journal of psychosexual health, 2(1), 56–62. https://doi.org/10.1177/2631831819898916 ege, e., & eryilmaz, g. (2005). development of genital hygiene behaviors (ghbi). journal of anatolian nursing health, 67–75. felix, t. c., borges de araújo, l., von dolinger de brito röder, d., dos, r., & pedroso, s. (2020). evaluation of vulvovaginitis and hygiene habits of women attended in primary health care unitsof the family. international journal ofwomen’s health, 12, 49–57. https://doi.org/10.2147/ijwh.s229366 gafos, m., pool, r., misiwe, •, mzimela, a., beauty, h., • n., mccormack, s., & elford, j. (2013). the implications of post-coital intravaginal cleansing for the introduction of vaginal microbicides in south africa. https://doi.org/10.1007/s10461-013-0676-9 hamed ag. (2015). the impact of genital hygiene practices on the occurrence of vaginal infection and the development of a nursing fact sheet as prevention massage for vulnrable women. iosr journal of nursing and health science, 4(6), 55–64. https://doi.org/10.9790/1959-04655564 hilber, a. m., hull, t. h., preston-whyte, e., bagnol, b., smit, j., wacharasin, c., & widyantoro, n. (2010). a cross cultural study of vaginal practices and sexuality: implications for sexual health. social science and medicine, 70(3), 392–400. https://doi.org/10.1016/j.socscimed.2009.10.023 hilber, a. m., kenter, e., redmond, s., merten, s., bagnol, b., low, n., & garside, r. (2012). vaginal practices as women ’ s agency in subsaharan africa : a synthesis of meaning and motivation through meta-ethnography. social science & medicine, 74(9), 1311–1323. https://doi.org/10.1016/j.socscimed.2011.11.032 karadeniz, h. (2019). the analysis of genital hygiene behaviors of women who applied to women’s illnesses and birth policlinic. erciyes medical journal, 41(4), 402–408. https://doi.org/10.14744/etd.2019.37132 klebanoff, m. a., nansel, t. r., brotman, r. m., zhang, j., yu, k. f., schwebke, j. r., & andrews, w. w. (2010). personal hygienic behaviors and bacterial vaginosis. sexually transmitted diseases, 37(2), 94–99. https://doi.org/10.1097/olq.0b013e3181bc063c law, m., stewart, d., pollock, n., letts, l., bosch, j., & westmorland, m. (1998a). critical review from-quantitative studies. law, m., stewart, d., pollock, n., letts, l., bosch, j., & westmorland, m. (1998b). guidelines for critical review form quantitative studies. michael, j., iqbal, q., haider, s., khalid, a., haque, n., ishaq, r., & saleem, f. (2020). knowledge and practice of adolescent females about menstruation and menstruation hygiene visiting a public healthcare institute of quetta , pakistan. bmc women’s health, 20(4), 1–8. https://doi.org/10.1186/s12905-019-0874-3 moher, d., shamseer, l., clarke, m., ghersi, d., liberatî, a., petticrew, m., shekelle, p., stewart, l. a., & group, p.-p. (2015). preferred reporting items for systematic review and meta-analysis protocols umami, paulik, molnár and murti (2022) 98 p-issn: 1858-3598  e-issn: 2502-5791 (prisma-p) 2015 statement. https://doi.org/10.1186/2046-4053-41 myer, l., denny, l., telerant, r., de souza, m., wright, t. c., & kuhn, l. (2005). bacterial vaginosis and susceptibility to hiv infection in south african women: a nested case-control study. journal of infectious diseases, 192(8), 1372–1380. https://doi.org/10.1086/462427 ott, m. a., ofner, s., & fortenberry, j. d. (2009). beyond douching : use of feminine hygiene products and sti risk among young women. journal of sexual medicine, 6, 1335–1340. https://doi.org/10.1111/j.1743-6109.2008.01152.x ruiz, c., giraldo, p. c., sanches, j. m., reis, v., beghini, j., laguna, c., & amaral, r. l. (2019). daily genital cares of female gynecologists: a descriptive study. revista da associacao medica brasileira, 65(2), 171–176. https://doi.org/10.1590/1806-9282.65.2.171 sevil, s., kevser, o., aleattin, u., dilek, a., & tijen, n. (2013). an evaluation of the relationship between genital hygiene practices, genital infection. gynecology & obstetrics, 03(06), 187. https://doi.org/10.4172/2161-0932.1000187 umami, a., sudalhar, s., lufianti, a., paulik, e., & molnár, r. (2021). factors associated with genital hygiene behaviors in cervical cancer patients in surakarta , indonesia. 11(april), 94–103. verstraelen, h., verhelst, r., vaneechoutte, m., & temmerman, m. (2010). the epidemiology of bacterial vaginosis in relation to sexual behaviour. bmc infectious diseases, 10. https://doi.org/10.1186/1471-2334-10-81 world health organization. (2021). sexually transmitted infections (stis). how to cite this article: umami, a., paulik, e., molnár, r., and murti, b. (2020) ‘the relationship between genital hygiene behaviors and genital infections among women: a systematic review’, jurnal ners, 17(1), 89-101. doi: http://dx.doi.org/10.20473/jn.v17i1.34402. jurnal ners http://e-journal.unair.ac.id/jners 99 appendix 1 summary of articles included in the systematic review author year country aims design and data collection sample number and characteristics type of genital hygiene behavior type of stis/genital infection research findings sevil et al. (2013) turkey to evaluate the relationship between genital hygiene practices and genital infection in a group of university students cross-sectional study; questionnaire 1,057 female students. a mean age of 21.03 ± 1.70 years. 1. underwear hygiene and bathing habits (type of underwear used, frequency of changing underwear, daily pads, bathing position, bathing frequency). 2. toilet hygiene practices (genital area cleaning, type of genital area cleaning, agent used for genital area cleaning, drying genital area, material used for drying the genital area, frequency of cleaning genital area hair, hand washing) 3. menstrual hygiene practices (material used during menstruation, frequency of changing the material during menstruation (per day), bathing during menstruation, using perfume for malodor during menstruation). in this study, students diagnosed by a physician with a genital infection within the past six months were considered as “students with history of genital infection” with the answers “yes/no 1. an assessment of underwear and bathing habits of students with genital infection history did not demonstrate any relationships between the frequency of changing underwear and infection history (χ2=5.404; p=0.067). frequency of genital infections was higher among those who used hosiery/cotton underwear and daily pads (χ2=5.602; p=0.018 and χ2=8.490; p=0.004, respectively). history of genital infections was significantly more common among those who bathed in the sitting position and in those who bathed once a week (χ2= 49.570; p<0.001 and χ2= 25.534; p<0.001, respectively) 2. genital infection was significantly less common among those who told that they practiced genital cleaning (χ2= 62.263; p<0.001), while they were more common among those who described that they cleaned the genital randomly (χ2= 14.350; p=0.001), used soap/shampoo (χ2= 10.170; p=0.004), did not dry the genital area (χ2= 48.657; p<0.001), used cloth for drying (χ2= 30.006; p<0.001), performed frequent genital area cleaning with materials such as razor (χ2= 15.918; p<0.001) and did not always pay attention to hand washing (χ2= 12.733; p=0.002) 3. the frequency of genital infections was significantly higher among those who used cloth and those who did not bathe during menstruation (χ2= 46.042; p<0.001 and χ2= 8.984; p=0.003, respectively) bahram et al. (2009) iran to determine the prevalence of bacterial vaginosis and impact of sexual and genital hygiene practices cross-sectional study; questionnaire; gynecological examination 500 non-pregnant women aged between 15 and 45 (mean age 36 years) 1. menstrual hygiene (bathing during menstruation period, genital douching during menstruation period, using sanitary pad, pad change after each urination, sexual abstinence during menstruation period) reproductive tract infection (rti) (27.6%); bacterial vaginosis (bv) (16.2%), trichomoniasis (6.6%), vulvovaginal candidiasis (vvc) (4.8%). there was a significant correlation between menstrual and individual vaginal hygiene and bv (p<0.01 and p<0.001) respectively. in contrast, no significant correlation was umami, paulik, molnár and murti (2022) 100 p-issn: 1858-3598  e-issn: 2502-5791 and sociodemographic characteristics in non-pregnant women 2. individual vaginal hygiene (regular underwear changing, underwear washing with hot water, sunlight drying of underwear, use of loose underwear, ironing underwear before use, dryness of underwear during day, front to back douching and cleaning of genital area, use of private bathroom, use of personal bathing equipment, sanitation of bathroom before use, bathing in standing position, sun drying of bathing equipment, shaving of genital hair) 3. coital hygiene (genital douching before intercourse, urination after intercourse, frequency of intercourse (less than 7 times a week)) observed between bv and coital hygiene bitew et al (2017) ethiopia to determine the prevalence of bacterial vaginosis and associated risk factors among women attending gynecology and antenatal clinics cross-sectional study; face-to face interviews using a structured questionnaire 210 female patients aged between 15 and 64 years. 1. number of pants used per day (1-2 pants/day; one pants for 2-4 days) 2. frequency of vaginal bathing per day (1-3; ≥4) bacterial vaginosis (n=102 (48.6%)); non-bacterial vaginosis (n= 108 (51.4%)) 1. the prevalence of bacterial vaginosis was lower among patients who changed pants more frequently (two per day; 36.9%) than among those who changed their pants less frequently (one pants for 2–4 days; 57.6%) aor= 0.367 ci 95% 0.2010.672; p=0.001 2. patients who bathed their vaginal region more frequently were less affected than those who did not bath their vaginal area as much (prevalence rate of 40.2% versus 53.9%) aor= 1.847 ci 95% 1.013-3.370; p=0.045 calik et al. (2019) turkey identifying women’s genital hygiene behaviors and the effects of these behaviors on vaginal infections cross-sectional study; face-to-face interviews, and a questionnaire of the genital hygiene behavior inventory (ghbi) 266 married women, the mean age of 38.5 ± 7.9 (min: 20, max: 49) the genital hygiene behavior scale, which was designed as a self-report measure in the 5-point likert scale, consisted of three subdimensions including “general hygiene,” “menstrual hygiene,” and “abnormal finding awareness” with 27 items in total. the highest score that can be gotten from the test form is 108 and the lowest score is 27. the high total points showed good behavior related to genital hygiene 1. genital discharge complaints 146 women (54.9%); no genital discharge complaints 120 women (45.1%) 2. the speculum examination showed that 42.6% had pathological discharge and the incidence of genital infection was 79% in the pap smear 3. pap-smear test results: a. candida b. trichomonas vaginalis c. bacterial vaginosis d. mixed infections e. normal discharge 1. the mean ghbi score of the women in the study was found to be 70.27 ± 10.05 2. at the same time, a significant relationship was found between genital discharge complaints and ghbi score hygiene behaviors (p=0.009) 3. the study showed that incorrect and inadequate genital hygiene behavior increases the risk of vaginal infection. hamed a.g. (2015) egypt to assess the impact of genital hygiene practices on the occurrence of vaginal infection, and to develop a case-control study; a structured interview and assessment sheet total 200 women. 1. case group: women diagnosed as having vaginal infection (n=100) a mean age of 27.7±6.3 1. genital hygienic practices (type of underwear, frequency of underwear change, internal vaginal cleaning or douching, external washing of the genital area, cleansing genital area with hand, direction of cleaning the genital area, use daily pads, drying after using toilet vaginal infection (the presence of symptoms associated with vaginal infection) 1. women who suffered from vaginal infection were less likely to use cotton underwear and changed them less frequently (χ2= 10.1; p=0.006 and χ2= 20.7; p=0.001, respectively). meanwhile, they were more apt to use jurnal ners http://e-journal.unair.ac.id/jners 101 nursing fact sheet as a prevention message for vulnerable women 2. control group: women free from vaginal infection (n=100) a mean age of 25.5±4.8 2. menstrual hygienic practices (bathing during menstrual period, washing hands before and after using the toilet, type of material used during menstrual period, frequency of changing pads, method of dealing with dirty pad) 3. coital hygienic practices (genital care before intercourse, genital care after intercourse, using of local contraceptive, use of chemical substance and lubricant during intercourse, use of vaginal douching after sexual intercourse) symptoms: vaginal discharge (80%); dysuria, offensive odor, and dyspareunia (62%, 60% and 54% respectively) the incorrect technique in washing the genital area (χ2= 26.5; p=0.001), use intra-vaginal cleansing or douching (χ2= 7.3; p=0.007) and keeping their genital area moist or using reused cloth for drying it (χ2= 7.3; p=0.007) 2. women in the study group were less likely to bath themselves, washing hands before and after using the toilet and used reusable cloth to absorb menstrual blood (χ2= 6.7; p=0.009, p=0.010 and p=0.001, respectively). meanwhile, almost one fourth (24.0%) of the respondents in the case group less frequently changed their perineal pad and washes their reused cloth (37.0%) (p= 0.023 and p=0.001, respectively) 3. almost one third of women in the case group did not perform preor post-coital care compared to those in the control group (χ2= 33.8; p=0.001, and χ2= 26.8; p=0.001 respectively) table1 table2 table3 bai_2016 amabebe2018 anand2015 arab2011 attieh2016 bahram2019 bitew2017a brown2000 calik2020 cdc2019 chen2017 cottrell2001 cottrell2008 demir2020 deshmukh2020 ege2005 felix2020 gafos2013 hamed2015 hilber2010 hilber2012 karadeniz2019 klebanoff2010 law1998a law1998b moher2015 myer2005 ott2009 ruiz2019 sevil2013 umami2021 verstraelen2010 who2021 appendix1 190 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 190-195 http://dx.doi.org/10.20473/jn.v17i2.25408 original article open access analysis factors related to prisoner’s resiliency in rutan perempuan kelas iia surabaya citra danurwenda rahmah 1 * , rizky fitryasari 1 , and retnayu pradanie 1 1 faculty of nursing universitas airlangga, surabaya, indonesia *correspondence: rizky fitryasari. address faculty of nursing universitas universitas airlangga, surabaya, indonesia. email: citrahmah@gmail.com responsible editor: laily hidayati received: 11 february 2021 ○ revised: 29 october 2022 ○ accepted: 29 october 2022 abstract introduction: staying in prison as a female prisoner will affect her physical and psychological conditions. psychologically, the emotional state and mental health of women are different from men, and the prevalence of poor mentality among female prisoners is higher. such a situation can be avoided if the prisoners have good resilience. one of the efforts to increase resilience is to know the factors related to resilience through this research. methods: this is a correlational study with cross-sectional approach. the population was all prisoners and detainees in rutan perempuan kelas iia surabaya with a sample size of 115 respondents. the variables of this study are individual factors (detention status, recidivism, length of detention, latest education, previous employment, and criminal acts committed), emotional regulation, social support, stigma, and resilience. the data were collected using a questionnaire and analyzed using multiple linear regression. results: there is a relationship which shows that emotional regulation (p = 0.012; r = 1.223), social support (p = 0.003; r = 1.363) can increase resilience while stigma (p = 0.010; r = -1.383) can reduce the level of resilience in prisoners and prisoners. meanwhile, individual factors were not associated with resilience (p = 0.596; 0.627; 0.298; 0.170; 0.857; 0.457). conclusions: increasing resilience in prisoners and detainees can be achieved by increasing emotional regulation and social support as well as reducing stigma against prisoners and detainees by doing the active participation of prisoners and detainees, detention center officers, and families or people closest to inmates and holding a positive activity within the prison. keywords: emotional regulation; prisoner; resiliency; social support; stigma introduction crime is a form of behavior that violates social rules applied by legal entities. anyone can commit crimes. both men and women can occur at the age of children, adolescents, adults, and even the elderly (raisa & ediati, 2016). a person forced to stay in prison because he is serving a sentence will affect his physical and psychological condition (tomar, 2013). they will find it difficult to adjust their lives and follow the rules, be separated from their families, lose goods and services, lose the freedom to live outside, or lose their sexual patterns. that will cause a person to get pressure from living in a detention center which causes them to become stressed (fajarani & ariani, 2017). female prisoners and detainees have the same rights and obligations as male prisoners and detainees. however, female prisoners and detainees' psychological, emotional, and mental health differ from male prisoners and detainees (ardilla & herdiana, 2013). the prevalence of poor mental well-being among female prisoners is higher among the general prison population (who, 2014). in addition, fajarani & ariani (2017) shows that as many as 80% of female prisoners experience mild stress. the pilot study was conducted at rutan perempuan kelas iia surabaya by interviewing two detainees who https://creativecommons.org/licenses/by/4.0/ mailto:citrahmah@gmail.com https://orcid.org/0000-0003-4181-1283 https://orcid.org/0000-0002-7164-2997 https://orcid.org/0000-0003-0100-8680 jurnal ners http://e-journal.unair.ac.id/jners 191 said that most of the residents usually cried a lot in the first week of detention because they had never faced a situation like this before. however, as time goes on with the activities held in the detention center, they will become more accustomed to the state of the detention center. prison officials said that in the first one to two months of detention, the prisoners usually did not accept the situation and showed several negative responses, such as excessive sad behavior. they facilitated counseling with a psychiatrist so that prisoners could accept the situation and could continue to live their lives well inside the detention center. this situation can be avoided if the prisoners have an excellent resilience level. resilience can affect mental health. people with high levels of resilience tend to have better mental conditions (kowalkowska et al., 2017). knowing the factors related to resilience is an effort to increase resilience and prevent a decrease in mental welfare in prisoners and detainees. materials and methods this research is quantitative with a correlational design and a cross-sectional approach. this study assessed the independent and dependent variables only once at a time, with no follow-up. the sampling technique is the probability sampling method with a simple random sampling technique. the number of respondents in this study was 115 with criteria, namely prisoners and detainees at rutan perempuan kelas iia surabaya who were detained for more than three months. the independent variables in this study are demographic factors (detention status, recidivism, length of detention, latest education, previous employment, and criminal acts committed), emotional regulation, social support, and stigma, while the dependent variable in the study is the resiliency of prisoners and detainees. data collection in this study used a demographic questionnaire, the emotion regulation questionnaire (erq) to measure emotional regulation, the enrichd social support inventory (essi) to measure social support, the self-stigma scale-short (sss-s) to measure stigma, and connor davidson resilience scale (cd-risc) to measure resilience. the instrument used in this study has been tested for validity and reliability by the researcher and has asked the owner permission to use their questionnaire as an instrument in this study. before collecting the data, prospective respondents were selected according to predetermined criteria. then the prospective respondents were collected to listen to an explanation of the purpose and benefits of doing this research. if the prospective respondents were willing to participate, then the respondents would be given informed consent to become research respondents. respondents filled out the questionnaire in the room provided. during filling out the questionnaire, the respondent was accompanied by the researcher so the respondent could ask if there was a question that was not understood. before the respondent leaves the room, the researcher will re-check the completeness of filling out the questionnaire so that if there is incomplete data, the respondent can immediately complete it. this research has gone through an ethical test and was declared ethically worthy by the health research ethics committee of the faculty of nursing, universitas airlangga (certificate number 1878-kepk). this research took place at rutan perempuan kelas iia surabaya from table 1 characteristics of prisoners and prisoners' respondents characteristic frequency percentage (%) age < 25 years 26-35 years 36-45 years 46-55 years > 56 years 25 47 26 15 2 21,7 40,9 22,6 13,0 1,7 115 100,0 detention status detainee prisoner 67 48 58,3 41,7 115 100,0 recidivism been detained never been detained 6 109 5,2 94,8 115 100,0 length of detention 3-6 months > 6 months 63 52 54,8 45,2 115 100,0 latest education uneducated primary school secondary school high school diploma/college 0 13 19 55 28 0 11,3 16,5 47,8 24,3 115 100,0 previous employment unemployed student entrepreneur employees civil servants labor etc. 16 5 31 48 0 1 14 13,9 4,3 27,0 41,7 0 0,9 12,2 115 100,0 criminal acts committed narcotics theft embezzlement fraud child human rights violations etc. 55 11 29 3 4 13 47,8 9,6 25,2 2,6 3,5 11,5 115 100,0 rahmah, fitriyasari, and pradanie (2022) supremo, bacason, and sañosa (2022) 192 p-issn: 1858-3598  e-issn: 2502-5791 november 2019 – january 2020. the data analysis used in this study was a logistic regression statistical test (p ≤ 0.05). results 47 respondents in the age range 26-35 years old took the highest proportion (40.9%) compare to other range and most of the respondents were detainee (58.3%). in addition, almost all respondents had never been detained before (94, 8%) and they lived in the remand center for less than six months (54.8%). furthermore, 47.8% respondents (n = 55) just graduated from high school, 48 respondents (41.7%) were previously private workers, and as many as 55 respondents (47.8%) detain because of a narcotics case (table 1). out of 5 parameters of resiliency, control ability was the highest with 70.4% respondent showed high control abilities. in contrast, almost half of the respondents have low ability to tolerate the adverse effects of stress and low in personal competence, high standard and tenacity (tabel 2). the logistic regression test results on individual factors showed that the detention status variable was p = 0.596; recidivism variable p = 0.627; length of detention variable p = 0.298; education variable p = 0.170; previous employment p = 0.857; and the variable of criminal acts committed p = 0.453 not related to the resilience of prisoners and detainees at rutan perempuan kelas iia surabaya with a significant p-value <0.05. the results of the logistic regression test showed that the emotional regulation variable was associated with a value (p = 0.012) and value (r = 1.223), which means that the higher the emotional regulation, the higher the level of resilience in prisoners and detainees. the social support variable has a value (p = 0.03) and a value (r = 1.363), which means that the higher the social support, the higher the level of resilience of prisoners and detainees. the stigma variable is related to value (p = 0.010) and value (r = -1.383), which means that the lower the stigma, the higher the level of resilience of prisoners and detainees discussions individual factors the analysis of this research shows no relationship between detention status and the resilience of prisoners and detainees. that occurs because the treatment and facilities available to prisoners and detainees are not differentiated, so neither the status of prisoners nor detainees affects the prisoners' resilience level. this study also shows no relationship between recidivism and resilience in prisoners and detainees. according to the researchers, recidivists should have better resilience than non-recidivists because they already have experience dealing with the same stressors. research conducted by anggraini, hadiati, and a.s. (2019) said that non-recidivists had a higher stress level than recidivists but had low resilience. the results showed no relationship between the length of detention and the resilience of prisoners and detainees. according to anggraini, hadiati, and a.s. (2019), length of detention is related to resilience due to the duration of prisoners and detainees exposed to stressors and time to adjust. the absence of a relationship between the length of detention and resilience in this study may be because the length of detention in this study is less specific, so there is no difference. this research also shows no relationship between education and work with the resiliency of prisoners and detainees. this statement contradicts the research of anggraini et al. (2019), which states that education affects an individual's ability to absorb new information and the learning process so that higher resilience can be obtained for prisoners and detainees with a higher education level. this study is different because many respondents dropped out of school, so there is bias in the research results. based on the analysis, this research also shows no relationship between criminal acts and the resilience of prisoners and detainees. according to the researcher, the criminal acts committed are not related to resilience because all types of criminal acts can be a stressor for prisoners and detainees. meanwhile, according to table 2 distribution of resilience indicators among respondents parameters of resiliency category ∑ high low personal competence, high standards, and tenacity 64 (55,7%) 51 (44,3%) 115 tolerance of negative affect and strengthening effects of stress 62 (53,9%) 53 (46,1%) 115 positive acceptance of change and secure relationships 77 (67%) 38 (33%) 115 control 81 (70,4%) 34 (29,6%) 115 spiritual influences 79 (68,7%) 36 (31,3%) 115 table 2 the results of the analysis on the factors that influence the resilience variable b (r) sig. (p) exp (b) detention status 0,258 0,596 1,294 recidivism 0,525 0,627 1,690 length of detention -0,524 0,298 0,592 latest education -0,373 0,170 0,689 previous employment -0,025 0,857 0,975 criminal acts committed -0,124 0,457 0,884 emotion regulation 1,223 0,012 3,397 social support 1,363 0,003 3,909 stigma -1,383 0,010 0,251 jurnal ners http://e-journal.unair.ac.id/jners 193 research conducted by anggraini, hadiati, and a.s. (2019), the level of resilience of prisoners and detainees with narcotics cases is lower due to the absence of a detoxification process. that is different from the research conducted by researchers because in this research place, if some prisoners or detainees need detoxification, they will be transferred to the rehabilitation center. emotion regulation based on the analysis of this study shows that there is a relationship between emotional regulation and resilience in prisoners and detainees. this statement is in line with previous studies which show that the higher a person's emotional regulation ability, the higher the level of resilience (widuri, 2012; rizki, 2016; sukmaningpraja & santhoso, 2016). research conducted by marsha et al. (2019) said that prisoners and detainees who cannot control their negative emotions and accept the fact that they have to stay in prison tend to be alone and have difficulties solving problems. according to researchers, the ability to regulate emotions is crucial for prisoners and detainees to be resilient because resilience means they must be able to control their emotions when faced with a stressor or problem. this opinion is in line with the opinion of kay (2016), which states that by understanding an effective emotional regulation strategy, an individual can reduce negative emotions and increase positive emotions, which is essential in increasing resilience. according to research by britt et al. (2016), all definitions of resilience involve emotionally tricky experiences and the ability to bounce back. to be able to bounce back from this challenging experience, the person must be able to control their emotions. thus, it can be concluded that there is a relationship between the ability to regulate emotions with the resilience level. the results showed that more than half of the respondents used an emotional regulation strategy to suppress their emotional expression by not showing their true feelings. this finding is in line with research conducted by rizki (2016), which also shows that prisoners and detainees tend to hide sadness or disappointment and other emotions they feel. so that we need a media or place to help prisoners and detainees so that they can positively express their emotions. in this case, the detention center officers can provide and monitor empowerment activities and free time as a forum for inmates and detainees who, whether they realize it or not, have helped them to vent their emotions. social support this study shows a relationship between social support and the resilience of prisoners and detainees. this statement is in line with research conducted by (raisa & ediati, 2016; tunliu, aipipidely, and ratu, 2019; hafidah & margaretha, 2020), which states that the higher social support, the higher a person's level of resilience. research by marsha, erlyani & fauzia (2019) also states that subjects whose families rarely visit have not handled their problems and negative emotions optimally. that is in line with research by riza & herdiana (2012), which states that social support from family or closest people also helps build resilience. researchers believe that prisoners and detainees need social support to become resilient because social support can create an environment that makes prisoners and detainees feel understood. it can help them deal with stressors or their problems and adapt and make it a motivation to get back up and carry out daily activities in the detention center. the researcher's opinion is in line with the statement of hidayat and nurhayati (2019), which states that with social support, individuals will feel support and hope that makes them able to deal with stress, adjust themselves, and rise again. the study results indicate that the social support most prisoners and detainees feel is emotional support obtained from family and relatives who visit prisoners and detainees. research by meyers et al. (2017) suggests that there are two types of visitors, supportive visitors, and unsupportive visitors. prisoners and detainees who are met by supportive visitors are less likely to commit offenses in the detention center, have good mental health, and have high expectations for social support when they are released so as not to become recidivists. the visitation program at the detention center is significant for prisoners and detainees. the detention center can organize the visitation program properly so that the detention center can become a healthier and safer community stigma based on the analysis, this study shows the relationship between stigma and resilience in prisoners and detainees. this statement is in line with the research by crowe, averett, and glass (2016), which states that the higher the stigma a person feels, the lower the level of resilience. fitryasari et al. (2018), stated that stigma is a risk factor if it is not regulated correctly to achieve a resilient condition. according to researchers, the more prisoners and detainees feel a high stigma, the lower their resilience level because stigma can cause prisoners rahmah, fitriyasari, and pradanie (2022) supremo, bacason, and sañosa (2022) 194 p-issn: 1858-3598  e-issn: 2502-5791 and detainees to close themselves or be isolated by the environment so that they cannot seek or get help in overcoming stressors or problems they are experiencing. this opinion is in line with the research of corrigan and rao (2013), which states that stigma can lead to a state of social isolation. according to caie (2012), stigma makes it difficult for prisoners and detainees to build meaningful relationships that can help them return to their communities as active and productive people. crowe, averett, and glass (2016), in their research, stated that stigma could cause an individual to refuse someone's presence or help, resulting in them being unable to achieve a resilient state. the results showed that behavior was the highest indicator of stigma felt by prisoners and detainees. selfstigmatizing behavior is an advanced stage that leads to self-insult and withdrawal from social interactions that are negatively associated with self-esteem (mak & cheung, 2010). in this case, reducing the level of selfstigmatizing behavior could increase the self-esteem of prisoners and detainees. one of the activities to increase self-esteem in prisoners and detainees is activity group therapy activities. yusuf et al. (2007) showed an increase in self-confidence, which is shown by the ability to identify positive aspects of self, solve problems, and accept situations. of course, that must be done with the active participation of prisoners and detainees, family and relatives, and prison officials so that selfstigmatizing behavior does not continue and makes prisoners and detainees resilient. conclusions based on the results and discussion, it is known that to be resilient, prisoners and detainees must be able to control their emotions in facing problems and get sufficient social support because social support can create an environment where prisoners and detainees feel helped to adjust. besides, to increase resilience, the stigma on prisoners and detainees must be lowered so that prisoners and detainees do not close themselves and can seek help in overcoming the problems they are experiencing. in this case, the detention center is essential in improving emotional regulation and social support and reducing stigma on control and detainees. the detention center can carry out empowerment activities, help the prisoners and detainees to release the energy through exercise, increase the visit quota, and provide group activity therapy. references anggraini, d., hadiati, t., & a.s., w. s. (2019). perbedaan tingkat stres dan tingkat resiliensi narapidana yang baru masuk dengan narapidana yang akan segera bebas. jurnal keokteran diponegoro, 8(1), 148–160. ardilla, f., & herdiana, i. (2013). penerimaan diri pada narapidana wanita. jurnal psikologi kepribadian dan sosial, 2(01). britt, t. w., shen, w., sinclair, r. r., grossman, m. r., & klieger, d. m. (2016). how much do we really know about employee resilience? industrial and organizational psychology, 9(2), 378– 404. https://doi.org/10.1017/iop.2015.107 caie, j. (2012). climbing the walls: prison mental health and community engagement. british journal of nursing, 21(11). corrigan, p. w., & rao, d. (2013). on the self-stigma of mental illness: stages, disclosure, and strategies for change. canadian journal of psychiatry, 57(8), 464–469. https://doi.org/10.7748/ns.24.19.64.s57 crowe, a., averett, p., & glass, j. s. (2016). mental illness stigma, psychological resilience, and help seeking: what are the relationships? mental health & prevention, 4(2), 63–68. https://doi.org/10.1016/j.mhp.2015.12.001 fajarani, a. s., & ariani, n. p. (2017). tingkat stres dan harga diri narapidana wanita di lembaga pemasyarakatan kelas ii a kota bogor. jurnal riset kesehatan, 9(2), 26–33. fitryasari, r., yusuf, a., nursalam, tristiana, r. d., & nihayati, h. e. (2018). international journal of nursing sciences family members’ perspective of family resilience’s risk factors in taking care of schizophrenia patients. international journal of nursing sciences, 5, 255–261. https://doi.org/10.1016/j.ijnss.2018.06.002 hafidah, a. nurul, & margaretha, m. (2020). faktor resiliensi klien pemasyarakatan dalam perspektif teori bioekologi bronfenbenner: pentingnya faktor dukungan sosial. psyche: jurnal psikologi, 2(1), 52–68. https://doi.org/10.36269/psyche.v2i1.161 hidayat, n., & nurhayati, s. r. (2019). the effect of social support and hope on resilience in adolescents. humaniora, 10(3), 219. https://doi.org/10.21512/humaniora.v10i3.5852 kay, s. a. (2016). emotion regulation and resilience: overlooked connections. industrial and organizational psychology, 9(2), 411– 415. https://doi.org/10.1017/iop.2016.31 kowalkowska, e. s.-, justyna, s., & r, m. w. (2017). resilience as a predicator of mental health of incarcerated women. pxychiatria polska, 51(3), 549–560. mak, w. w. s., & cheung, r. y. m. (2010). self-stigma among concealable minorities in hong kong: conceptualization and unified measurement. american journal of orthopsychiatry, 80(2), 267–281. https://doi.org/10.1111/j.19390025.2010.01030.x marsha, g. c., erlyani, n., & fauzia, r. (2019). resiliensi pada narapidana rasuah. jurnal kognisia, 2(2), 13–17. meyers, t. j., wright, k. a., young, j. t. n., & tasca, m. (2017). social support from outside the walls: examining the role of relationship dynamics among inmates and visitors. journal of criminal justice, 52(july), 57–67. https://doi.org/10.1016/j.jcrimjus.2017.07.012 raisa, & ediati, a. (2016). hubungan antara dukungan sosial dengan resiliensi pada narapidana di lembaga pemasyarakatan kelas iia wanita semarang. jurnal empati, 5(3), 537–542. riza, m., & herdiana, i. (2012). resiliensi pada narapidana laki-laki di lapas klas 1 medaeng. jurnal psikologi kepribadian dan sosial, 1(03), 142–147. rizki, b. m. (2016). emotion regulation strategy and resilience of female prisoners. international conference on health and wellbeing, 84–93. sukmaningpraja, a., & santhoso, f. h. (2016). peran regulasi emosi terhadap resiliensi pada siswa sekolah berasrama berbasis semi militer. gadjah mada journal of psychology, 2(3), 184–191. tomar, s. (2013). the psychological effects of incarceration on inmates: can we promote positive emotion in inmates. in delhi psychiatry journal (vol. 16, issue 1, pp. 66–72). tunliu, s. k., aipipidely, d., & ratu, f. (2019). dukungan sosial keluarga terhadap resiliensi pada narapidana di lembaga pemasyarakatan klas iia kupang. journal of health and behavioral jurnal ners http://e-journal.unair.ac.id/jners 195 science, 1(2), 68–82. who. (2014). prisons and health (s. enggist, l. møller, g. galea, & c. udesen (eds.)). widuri, e. l. (2012). regulasi emosi dan resiliensi pada mahasiswa tahun pertama. humanitas: jurnal psikologi indonesia, 9(2), 147– 156. https://doi.org/10.26555/humanitas.v9i2.341 yusuf, a., fityasari, r., sulistyawati, w., studi, p., ilmu, s., fakultas, k., universitas, k., & jl, a. (2007). terapi aktivitas kelompok (tak) stimulasi persepsi meningkatkan harga diri anak di lembaga pemasyarakatan. jurnal ners, 2(2). how to cite this article: rahmah, c. d., fitriyasari r., and pradanie, r. (2022) ‘analysis factors related to prisoner’s resiliency in rutan perempuan kelas iia surabaya’, jurnal ners, 17(2), pp. 190-195. doi: http://dx.doi.org/10.20473/jn.v17i2.25408 table1 table2 table3 anggraini ardilla britt caie corrigan crowe fajarani fitryasari hafidah hidayat kay kowalkowska mak marsha meyers raisa riza rizk sukmaningpraja tomar tunliu who widuri yusuf appendix1 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 tindakan tradisional: sirep (joni haryanto, dkk) 277 tindakan tradisional: sirep mempengaruhi kadar kortisol, ifn- and il-10 pada lansia dengan gangguan tidur (traditional actions: sirep influence cortisol, ifn- and il-10 in elderly with sleep disorders) joni haryanto*, suhartono taat putra** *fakultas keperawatan, universitas airlangga, kampus c mulyorejo surabaya, 60115 **fakultas kedokteran, universitas airlangga e-mail: joni.h.unair@gmail.com abstrak pendahuluan: sirep merupakan salah satu tindakan tradisional orang jawa timur indonesia khususnya suku tengger. sirep dengan menggunakan mantra untuk memenuhi kebutuhan tidur manusia. lansia di indonesia adalah seseorang yang memiliki usia lebih dari 60 tahun. lansia pada umumnya sering mengalami gangguan pemenuhan kebutuhan tidur namun efek keperawatan sirep sebagai immunomodulator terhadap kadar kortisol, ifn- dan il-10 masih belum diketahui. tujuan penelitian teridentifikasi karakteristik samples, immunomodulator dan sleep hygiene lansia di panti lanjut usia tulungagung. metode: populasi sebanyak 70 lansia dengan jumlah sampel 43 lansia. penelitian ini melibatkan 23 lansia sebagai kelompok yang diberikan intervensi keperawatan sirep selama 6 bulan (usia rata-rata, 69,6 ± 5,2 tahun) dan 20 kontrol (65,8 ± 5,4 tahun). kebutuhan tidur dengan tidur dapat diobservasi dengan mengevaluasi tingkat kortisol, ifn-grα and il-10. biologi molekuler dari sampel ditentukan dengan menggunakan analisis elisa. data statistik dianalisis menggunakan anova dan t-test. hasil: setelah intervensi selama 6 bulan, terdapat perubahan yang signifikan kortisol dalam serum (p=0,0001) dan uji beda intervensi dengan kontrol juga significant (p=0,0013). perubahan kadar ifn- dalam serum significant (p=0,0003) dan uji beda intervensi dengan kontrol juga significant (p=0,0164), sedangkan perubahan kadar il-10 dalam serum significant (p=0,0003) dan uji beda intervensi dengan kontrol no significant (p=0,1143). diskusi: hasil penelitian ini sesuai hipotesis bahwa keperawatan sirep dapat meningkatkan modulator imun pada lansia. namun, modulator imun menunjukkan sedikit perbaikan dalam kelompok intervensi keperawatan sirep, hal ini menunjukkan bahwa diperlukan intervensi yang lebih lama lagi dan lebih sering. kata kunci: sirep, kebutuhan tidur lansia, tingkat kortisol, tingkat ifn- , tingkat il-10 abstract introduction: sirep, is one of the traditional intervention of people in east java indonesia, especially tengger tribe using spells to meet the needs of human sleep. elderly in indonesia is someone who has more than 60 years of age. elderly in general often experience sleep disturbances fulfillment, but the effects of nursing sirep as an immunomodulator to the levels of cortisol, ifn-rα and il-10 is still unknown in nursing perspective. method: the population of this study were 70 elderly with the number of respondents were 43 elderly. they were divided into two groups for 23 elderly with 6-month sirep intervention (mean age, 69.6 ± 5.2 years) as an experiment group and 20 elderly as control group (65.8 ± 5.4 years). the need of sleep is implemented to evaluate the sample of immune modulation, cortisol levels, ifn-rα and il10. the molecular biology of the samples was determined using elisa analysis. the statistical analysis of the data used determine anova and t-test. results: after the 6 -month intervention, there re is significant changes in serum cortisol levels (p = 0.0001) and a different test with a control intervention was also significant (p = 0.00 1 3). significant changes in serumlevels of ifn-rα is (p = 0.0003) and a different test with a control intervention is also significant (p = 0.016 4), while the change in the levels of il-10 in serum is significant (p = 0.0003) and test different intervention with no significant control (p = 0.1143). discussion: this study supports the hypothesis that sirep can improve immune modulator in elderly. however, immune modulator showed a slight improvement in the nursing intervention of sirep group, suggesting that a longer or more frequent sessions of intervention might have an effect. key word: sirep, elderly sleep needs, cortisol level, ifn- level, il-10 level introduction world health organization (who, 2005) reports that elderly population is estimated at 9,11% of the total world population. elderly in indonesia amounted to 11.34% of the population. in east java, the number of elderly at about 11, 40%, where is the second highest number after yogyakarta which is at about 13.04%. (united nation 2004; avidan a 2005). in addition, the number population of east java is greater than yogyakarta. elderly population majority stays in folk home elderly (rahayu 2002; huang wf 2005) elderly generally have a sleep less than 5 hours per day and the prevalence of sleep disorder is about 30-40% in the elderly aged 60-69 years (hashimoto r, meguro k, lee e, kasai m, ishii h 2006; lumbantobing 2004; hister a 2006). folk home elderly in tulungagung, east java indonesia has 70 elderly aged over mailto:joni.h.unair@gmail.com jurnal ners vol. 11 no. 2 oktober 2016: 277282 278 60 years, whom 43 elderly suffered from sleep disorder. sleep disorder in elderly is associated with the severity of the disease in elderly. the purpose of this research was to identify characteristics of the samples, immunomodulator, and sleep hygiene folk home elderly elderly in tulungagung. the survey from duke university center for demographic studies (1998) reports that the number of sleeps elderly disturbed ataround 90.4% (prijosaksono 2002). philip et al (1999) reports that 85% elderly suffered from failure of nighttime sleep (warwicker, p. , goodship, t. h., & goodship 1997). elderly frequently experience insomnia, sleep rhythm disorders, namely shortening phase rapid eyes movement sleep (rem), also accompanied by elongation phase of non-rapid eyes movement sleep (n rem) (risch, n., & merikangas 1996; hayflick l 2004). sleep disturbance affects the human circadian cycle. sleep disorder also causes the decrease of immunity. lymphocyte t is the conductor of the immune system, t lymphocytes proliferates and differentiates into cytotoxic t lymphocytes (tc), lymphocytes t helper (th), lymphocytes t regulatory (tr) and lymphocyte t suppressor (ts). the process of autoimmune diseases in elderly and degenerative diseases is a common example. the quality and quantity of sleep in elderly is bad. so that, elderly easily overcome the state of multiple deseases (kirkwood 2005; wei yh 1998; wei yh 2002) immunity is affected by the human leukocyte antigen (hla). changes in sleep patterns associated with mutations of genes. a person with the sleep disorder narcolepsy with cataplexy are hla dqb1 *0602 allele. human leukocyte antigen is a gene associated with foreign materials as antigens of the body, which consists of three loci that are hla class 1 consisting of a, b and c, hla class 2 consisting of dr, dq and dp, whereas hla class 3 for cytokines and complement (kirkwood 2005; wei yh 1998; wei yh 2002) the significance of hla dqb *0602 allele is a gene associated antigen recognition by t lymphocytes in the locus 1 and 2 on the allele * 0602 is a type of genes of people with the sleep disorder narcolepsy with cataplexy (kirkwood 2005; wei yh 2002) cortisol is a stress hormone, and increases when the elderly has sleep disorder which can suppress the body's immunity, namely ifn and il-10. as a result, the elderly experience multiple diseases. (davis 1995; fogel j 2003) material and method a quasy experimental design was used in this study to compare pre-post test intervention in the treatment group: sirep intervention (for cortisol level, ifn-grα and il-10 in serum) and control groups in folk home elderly in tulungagung east java indonesia. the population in this study was respondents with sleep disorder in the folk home elderly in tulungagung east java indonesia. sample of this study were taken using simple random sampling and the inclution criteria was elderly with sleep disorder. the sample size was 43 elderly divided into an 23 respondent in intervention group and 20 respondent in a control group. independent variable in this study was traditional intervention in east java indonesia: sirep. dependent variable was cortisol level, ifn-grα and il-10 in serum. analysis of the study used enzyme linked immnunosorbent assay (elisa) which is technique indicator using enzyme with better sensitivity. data in this study was ratio scale, so that to measure the change in pre and post sirep nursing intervention and control group used anova meanwhile the comparison of post intervention and control used t test or mann-whitney u test with a level significance α = 0.05. result the results of this study showed that 23 sample in the traditional east java of sirep indonesia group [mean age ± standard deviation (sd) [69.6 ± 5.2 years] and 20 in the control group (65.8 ± 5.4 years). there were no adverse events in either group. table 1 shows the baseline characteristics of samples. the average rate of traditional east java of sirep attendance was 95%. there was no significant difference in the baseline characteristics, age (p=0,079), weight (p=0.075), education (years) (p=0,077), long in folk home (p=0.122), and body mass index (p=0.783) between the two groups. there are differences between the intervention group and control group in a significant sleep disorder (p =0.001). tindakan tradisional: sirep (joni haryanto, dkk) 279 table 1 baseline characteristics of the two groups intervention control p n mean + sd n mean + sd age (year) 23 69.6 ± 5.2 20 65.8 ± 5.4 0.079 weight (kg) 23 50.2 ± 5.4 20 49.8 ± 6.6 0.075 education 23 4.5 + 9.2 20 5.1 + 1.9 0,077 long in folk home 23 12.3 + 4.8 20 10.9 + 3.2 0,122 sleep disorder 23 98.02 +12.58 20 88.31 + 5.46 0.001 body mass index 23 21.0 ± 2.8 20 20.9 ± 3.0 0.783 sd = standard deviation table 2 immunomodulator in two groups at baseline and after 6 months baseline after 6 month intervention control p intervention control p n mean + sd n mean + sd n mean + sd n mean + sd cortisol 23 18.95 + 2.13 20 18.98 + 2.26 0.115 23 10.15 + 1.05 20 14.85 + 2.26 0.001 ifn-rα 23 445.36 + 45.3 20 416.00 + 35.3 0.082 23 499.36 + 122.1 20 422.80 + 121.0 0.016 il-10 23 24.09 + 3.44 20 25.70 + 3.64 0.211 23 29.45 + 5.72 20 26.00 + 5.44 0.114 table 3 sleep hygiene in two groups at baseline and after 6 months baseline after 6 month intervention control p intervention control p n mean + sd n mean + sd n mean + sd n mean + sd quality 23 88.32+ 6.16 20 86.62+6.16 0.311 23 98.02+12.58 20 88.31+ 5.47 0.001 quantity 23 55.63+ 6.32 20 57.63+ 6.62 0.126 23 63.59+ 7.64 20 65.75+ 6.42 0.691 problem 23 12.89 + 12.65 20 12.11 + 11.02 0.097 23 09.19 + 10.65 20 11.77 + 10.35 0.003 needs 23 25.98 + 8.82 20 27.01 + 7.91 0.182 23 18.88 + 7.88 20 26.21 + 8.76 0.003 table 2 reports a repeated measurement method, independent t-test was immunomodulator on the samples of test did not show a significant difference between the traditional east java of sirep and control groups (il-10) and show a significant different between the traditional east java of sirep and control groups after 6 moth intervention cortisol level (p=0,001) and ifn-rα (p=0.016). tables 3 shows a repeated measurement method, independent t-test was sleep hygiene in elderly on folk home elderly tulungagung east java indonesia. the test shows significant different between the traditional east java of sirep and control groups quality sleep, sleep problems and needs of sleep. discussion cortisol level the initial conditions of elderly before getting traditional interventions east java indonesia (sirep) have average levels of cortisol in serum (18.95 + 2.13), while the control group with high levels of serum cortisol (18.98 + 2.26) showed no significant difference between two groups: p = 0.115) using independent t-test analysis. after 6 months of intervention is given every two weeks, both groups showed a significant difference, with a confidence level (α = 0.05) then (p = 0.001). client's condition as samples with the baseline data as in table 1 above, that among the intervention group and the control group no significant difference. only sleep disorder variable that there is a difference between intervention and control groups, namely (p = 0.001). elderly frequent sleep disturbances and an increase in serum cortisol levels due to physical and psychological stress. seniors who experience insomnia associated with high cortisol levels, ifn-rα and il-10 producer, namely as macrophages, nk cells and t lymphocytes. sirep can improve sleep quality and quantity of sleep. the pray of sirep suggestively clients can improve the sleep disorder, so the client easily initiate sleep and serum cortisol levels can balance (yayasan bali galang 2002). sirep an act of personal communication that is effective and able to raise the level of suggestibility, so clients get a sleep disorder and achieved strong expectation condition serum cortisol elderly clients become balance (yayasan bali galang 2003). cortisol is balanced to facilitate the development of jurnal ners vol. 11 no. 2 oktober 2016: 277282 280 immunity of the body, so it is possible clients achieve optimal health status. the sirep spells make the client be sure and suggests, so that the limbic system in the brain to respond to influence the pre-frontal order hypothalamus secretes corticotrophin relasing factors balanced. corticotropine generated capable of stimulating the pituitary to produce acth and cortisol-secreting adrenal medulla in balance. conditions of cortisol in the balance is the right amount to maintain healthy body immunity quality. ifn-rα level levels of cytokines ifn-rα level produced by such cell monocite, macrophage, nk cells and t lymphocytes. activities of cells is strongly influenced by the quality and quantity of sleep elderly. levels of ifn-rα level before intervention was quiet (445.36 + 45.3) and showed not significant different of ifn-rα level with control group (416.00 + 35.3) much from the levels of ifn-rα level in a statistical test independent t-test with a significance level (α = 0.05) and outcome (p = 0.082). after 6 months of intervention sirep given once every 2 weeks between the intervention group and control group with a significant difference (α = 0.05) and the result (p = 0.016). sirep to improve the quality and quantity of sleep. activities of monosite, macrophages, nk cells and t lymphocytes can release ifn-rα level. sleeps hygiene can facilitate the activity of ifn-rα produced of cells such as monosite, macrophages, nk cells and t lymphocytes. a sirep able to create a healthy sleep to elderly clients who active ifnrα level experience sleep disturbances, so the cells that produce ifn-rα level and increase levels of the cytokine ifn-rα indicated the health of elderly people with the sleep disorder will improve ifn-rα. sirep can increase levels of ifn-rα level il-10 level cytokine il-10 are produced by t lymphocytes, the t halper 2 as an indicator of the activity of lymphocytes t as endurance. clients elderly who experience sleep disturbances before give the sirep intervention had higher levels of il-10 with a mean (24.09 + 3.44) in the intervention group and the control group (25.70 + 3.64) between the two is not significant difference, namely (p= 0.211). after 6 months of intervention sirep given every two weeks, then there is no difference between the two intervention groups fallen with the control group, with a significance level (α = 0.05) then (p = 0.114). although there are differences between the levels of il10 prior to the intervention by 6 months after the intervention (p = 0.003). according to albright (2003) someone who is experiencing chronic insomnia will mutate the gene hla dqb allele *0602 so that the activity of t lymphocytes decreased activity halper 2 and il-10 produced no maksimal (ann salat, d.h. 2005). sirep is not able to increase the activity of cells that produce cytokines il-10 significantly, but the pray of sirep capable of improving sleep hygiene clients who experience sleep disturbances. sleep hygiene sleep hygiene is a combination of quality and quantity of sleep, compared with sleep problems and sleep needs of elderly clients. condition sleep quality of elderly before the given intervention fallen between the intervention group and control group, both groups there was no significant difference is (p = 0.311), sedanagkan after 6 months given intervention fallen into two groups there is a significant difference, namely (p = 0.001). the quantity of sleep before being given the actions fallen between the two groups, the intervention fallen to the control group no significant difference, namely (p = 0.126), whereas after 6 months given intervention fallen once every 2 weeks is also no significant difference is (p = 0.691) , problems sleeping elderly, before being given fallen, both groups between the intervention group and control group was not significant difference is (p = 0.097), whereas after 6 months of administration fallen once every 2 weeks both groups significant difference is (p = 0.003), sleep needs of elderly, before being given fallen, both groups between the intervention group and control group no significant difference, namely (p = 0182), whereas after 6 months given intervention fallen given every two weeks, there were significant differences between the intervention groups fallen with the control group (p = 0.003). according to philip et al (1999) in his research 85% elderly failure nighttime sleep. tindakan tradisional: sirep (joni haryanto, dkk) 281 elderly often suffer from insomnia, sleep rhythm disorders, namely shortening phase repid eyes movement sleep (rem), also accompanied by elongation phase of non-repid eyes movement sleep (n-rem) (hipolide, d.c., suchecki, d., pimentel de carvalho pinto, a., chiconelli faria, e., tufik, s., luz 2006; cohen-mansfield j 1997). has fallen spells that can improve suggestions and expectations are high for the client, so easily happen personal communication with the sub conscious mind and pre-frontal be comfortable. sirep to improve the quality and quantity of sleep elderly who have sleep disorders. sirep also able to reduce sleep problems and the needs of elderly sleep with the sleep disorder. sirep is an activity that promotes effective communication into the pre-frontal, so that the hypothalamus secreting neurotransmitters like corticotropine relasing factors that can generate activity for secreting adenocorticotropic pituitary and adrenal glands hormone cortisol menskresi within reasonable limits. conclussion and recommendation conclussion this study supports the hypothesis that sirep can improve immune modulator in elderly. however, immune modulator showed a slight improvement in the nursing intervention of sirep group, suggesting that a longer or more frequent sessions of intervention might have an effect. recommendation the results of these studies clearly sirep generating modules with spells can be used to improve the quality and quantity of sleep, also decrease cortisol levels, ifn-rα and il-10, then we recommend to be used as a standard module and nursing care beds meet the needs of elderly clients, either level health facilities level i, level ii health facilities and health facility level iii. acknowledgments this study was supported by grants-inaid for comprehensive research on aging and the elderly commissions in east java indonesia and faculty of nursing universitas airlangga surabaya indonesia. reference ann salat, d.h., et. al, 2005. age-related changes in prefrontal white matter measured by diffusion tensor imaging. n y acad sci,, 1064, pp.37–49. avidan a, 2005. epidemiology, assesment and treatment of insomnia in the elderly patient. cohen-mansfield j, w.p., 1997. management of verbally disruptive behaviors in nursing home residents. j gerontol ser a biol sci med sci., 52. davis, 1995. panduan relaksasi & reduksi stres e. iii, ed., jakarta: egc. fogel j, 2003. behavioral treatments for insomnia in primary care setting. hashimoto r, meguro k, lee e, kasai m, ishii h, y.s., 2006. effect of age and education on the trail making test and determination of normative data for japanese elderly people: the tajiri project. psychiatry clin neurosci, 60(422e8). hayflick l, 2004. the not-so-close relationship between biological aging and ageassociated pathologies in humans. j gerontol a biol sci med sci, 59. hipolide, d.c., suchecki, d., pimentel de carvalho pinto, a., chiconelli faria, e., tufik, s., luz, j., 2006. paradoxical sleep deprivation and sleep recovery: effects on the hypothalamic-pituitaryadrenal axis activity, energy balance and body composition of rats. j. neuroendocrinol, 18, pp.231–238. hister a, 2006. growth hormones and the effect on sleep., mediresource. inc. toronto. huang wf, l.i., 2005. patterns of sleep-related medications prescribed to elderly outpatients with insomnia in taiwan. drugs aging, 22. kirkwood, 2005. understanding the odd science of aging. cell., 120(437e447). lumbantobing, 2004. sleep disorder. edisi.136 ed., jakarta. prijosaksono, a., 2002. mengatasi insomnia, surabaya: fakultas ilmu sosial dan ilmu politik universitas airlangga. rahayu, 2002. karakteristik penyakit pada usia lanjut. naskah lengkap temu ilmiah nasional 1 dan konferensi kerja iii, perhimpunan gerontologi medik indonesia (pergemi), semarang: badan penerbit universitas diponegoro. risch, n., & merikangas, k., 1996. the future of genetic studies of complex human diseases. aaas-weekly paper edition, 273, pp.1516– 1517. united nation, 2004. in: world population to 2300, new york: bernan assoc. warwicker, p. , goodship, t. h., & goodship, j.a., 1997. three new polymorphisms in the human complement factor h gene and promoter region. immunogenetics,, 46, pp.437–438. jurnal ners vol. 11 no. 2 oktober 2016: 277282 282 wei yh, 1998. oxidative stress and mitochondrial dna mutations in human aging. proc soc exp biol med, 217(53e63.). wei yh, l.h., 2002. oxidative stress, mitochondrial dna mutation, and impairment of antioxidant enzymes in aging. exp biol med (maywood)., 227(671e682). yayasan bali galang, 2002. lontar usada pamugpug, denpasar: fakultas sastra. universitas udayana. yayasan bali galang, 2003. usada kuranta bolong, denpasar: fakultas sastra. universitas udayana. vol 9 no 1 april 2014.indd 26 efek orlistat, ekstrak biji kopi hijau, dan kombinasinya terhadap kadar adiponektin dan profil lipid (the effect of orlistat, green coffee bean extract, and its combinations on lipid profi le and adiponectin levels) joko setyono*, dwi adi nugroho*, mustofa*, saryono* *fakultas kedokteran dan imu kesehatan, universitas jenderal soedirman kampus fkik unsoed berkoh, jl. dr. gumbreg / jl. medika purwokerto, e-mail: sarbiokim@gmail.com abstrak pendahuluan: prevalensi obesitas diperkirakan meningkat mencapai 19,1% dari penduduk usia 15 tahun ke atas. penelitian ini bertujuan untuk mengetahui perbedaan efek anti-obesitas orlistat, ekstrak biji kopi hijau (coffea canephora robusta), dan kombinasinya terhadap kadar adiponektin dan profi l lipid. metode: penelitian ini merupakan penelitian true experimental post test only with control group design dengan rancangan acak lengkap (ral). hewan coba dikelompokkan menjadi 6 kelompok, yaitu 1(kontrol negatif), kelompok 2 (kontrol positif), kelompok 3 (kelompok tikus obesitas yang diberi orlistat dosis 15,9 mg/kgbb),kelompok 4 (kelompok tikus obesitas yang diberi ekstrak etanol biji kopi hijau dosis 400 mg/kgbb), kelompok 5 (kelompok tikus obesitas yang diberi ekstrak air biji kopi hijau dosis 400 mg/kgbb), dan kelompok 6 (kelompok tikus obesitas yang diberi kombinasi orlistat dosis 15,9 mg/kgbb dan ekstrak etanol biji kopi hijau dengan dosis 400 mg/kgbb). profi l lipid dan kadar adiponektin diukur dengan spektrofotometer pada serapan 500nm. data yang diperoleh diuji dengan one-way anova dilanjutkan dengan analisis post hoc least signifi cant difference (lsd) dengan α=0,05. hasil: pemberian ekstrak etanol kopi hijau lebih efi sien dalam menurunkan kadar ldl, meningkatkan hdl, dan menurunkan kadar kolesterol total secara signifi kan pada tikus putih yang diinduksi diet hfd, namun tidak ada perbedaan dalam menurunkan trigliserid. kombinasi ekstrak etanol kopi hijau dengan orlistat menunjukkan efek peningkatan kadar adiponektin yang paling tinggi dibandingkan dengan kelompok perlakuan lain. diskusi: ekstrak etanol kopi hijau mudah berdifusi melalui epitel saluran pencernaan. kopi hijau mengandung senyawa aktif asam klorogenat yang mampu meningkatkan metabolisme tubuh, meningkatkan oksidasi asam lemak, menurunkan kadar trigliserid di hepar, dan menginhibisi kerja enzim amilase dan lipase pankreas pada intestinal. selain asam klorogenat, kandungan polifenol pada kopi juga berpotensi menurunkan akumulasi lemak viseral. sediaan ekstrak dengan pelarut etanol memungkinkan proses absorpsi dilakukan secara efi sien dan cepat sehingga efek yang ditimbulkan lebih optimal. kata kunci: obesitas, orlistat, kopi hijau, profi l lipid, adiponektin abstract introduction: obesity prevalence is estimated increases, reached 19.1% of the population aged 15 years and over. this study aimed to determine the differences of the antiobesity effect of orlistat, an extract of green coffee beans (coffea canephora robusta), and its combination to the adiponectin levels and lipid profi le. method: this research was true experimental post -test only with control group design with completely randomized design (crd). experimental animals (rattus novergicus) were divided into 6 group, group 1 ( negative control ), group 2 ( positive control ), group 3 was group of obese rats fed orlistat dose of 15.9 mg/kg, group 4 was the group of obese rats were fed ethanol extract of green coffee beans dose of 400 mg/kg, group 5 was the group of obese rats were given water extract of green coffee beans dose of 400 mg/kg, and group 6 was group of obese rats were fed a combination of orlistat dose of 15.9 mg/kg and ethanol extract of green coffee beans at a dose of 400 mg/kg. lipid profi les and adiponectin levels were measured with a spectrophotometer at 500nm absorbance. the data were analyzed by one-way anova, and then post hoc least signifi cant difference (lsd) with α = 0.05. result: ethanol extract of green coffee is more effi cient in lowering ldl cholesterol, increasing hdl cholesterol, and lowering the total cholesterol levels on hfd diet-induced mice, but there was no difference in lowering triglycerides . the combination of ethanol extract of green coffee with orlistat showedthe increasing of adiponectin levels were highest than the other treatment groups. discussion: the ethanol extract of green coffee readily diffuses through the digestive tract epithelium. green coffee contains chlorogenic acid active compounds that can increase the body’s metabolism, increase fatty acid oxidation, reduce levels of triglycerides in the liver, and working to inhibit lipase and amylase pancreaticenzymes. in addition to chlorogenic acid, polyphenol content in coffee is also potentially reduce visceral fat accumulation. preparations extract by ethanol allows the absorption process is done effi ciently and quickly. keywords: obesity, orlistat, greencoffee, lipid profi le, adiponectin 27 efek orlistat, ekstrak biji kopi hijau (joko setyono, dkk) pendahuluan prevalensi kelebihan berat badan di dunia pada penduduk usia dewasa mencapai lebih dari 1,4 milyar dengan 500 juta jiwa diantaranya mengalami obesitas (who, 2013). survei yang dilakukan organisation for economic co-operation and development (oecd) pada tahun 2009 menunjukkan bahwa indonesia menduduki peringkat ke-4 di asia dengan prevalensi obesitas mencapai 2,4%. berdasarkan data riset kesehatan dasar tahun 2007, prevalensi obesitas di indonesia mencapai 19,1% dari penduduk usia 15 tahun ke atas (departemen kesehatan ri, 2008). selain obesitas, indonesia juga dihadapkan d e ng a n kek u r a ng a n nut r i si s eh i ng g a menempatkan indonesia sebagai negara berkembang dengan dua beban malnutrisi (atmarita, 2005; romling & qaim, 2011). prevalensi obesitas diperkirakan meningkat sejalan dengan usia, peningkatan populasi, urbanisasi, perubahan ekonomi, diet, dan gaya hidup (shayo & mugusi, 2011; kelly et al., 2008). prevalensi obesitas penduduk dunia diperkirakan meningkat dari 9,7% (573 juta jiwa) pada tahun 2005 menjadi 4445% (± 1,12 milyar jiwa) pada tahun 2030 (kelly et al., 2008). jumlah ini akan terus meningkat (mccormick et al., 2007) dan akan menambah beban kesehatan dan ekonomi terutama di negara berkembang (popkin, adair, & ng, 2012). obesitas diar tikan sebagai sebuah penyakit yang disebabkan oleh ketidakseimbangan energi akibat dari asupan kalori yang melebihi kebutuhan tubuh (conway & rene, 2004). ketidakseimbangan ini mengakibatkan akumulasi lemak tubuh (ouchi et al., 2012). a k u mulasi lemak t ubu h berlebih berkaitan dengan beberapa penyakit dengan morbiditas kronik seperti diabetes mellitus tipe ii, penyakit jantung koroner, hipertensi, kanker, dan dislipidemi (ashrafi , 2007; kumar et al., 2010; downey, 2013).penderita obesitas juga memiliki risiko kematian tiga kali lebih tinggi dibandingkan dengan orang dengan berat badan normal (adams et al., 2006). sejauh ini, belum ada terapi tunggal yang mampu mengobati obesitas. obesitas membutuhkan intervensi gaya hidup, terapi farmakologis, dan suplemen penurun berat badan (singh et al., 2011). terapi farmakologis pada obesitas bertujuan untuk menurunkan absorpsi kalori, meningkatkan konsumsi kalori sel, dan atau keduanya. penurunan absorpsi energi merupakan aspek krusial pada terapi obesitas (tseng, cypess, & kahn, 2010). orlistat merupakan salah satu agen terapeutik pada obesitas yang memiliki kemampuan menur unkan absor psi kalori di intestinal (kaplan, 2005). penggunaan orlistat seringkali tidak efektif dikarenakan memerlukan waktu konsumsi yang lama (harlpern et al., 2010), masih memerlukan kombinasi agen terapeutik lain, dan adanya efek samping (bray, 2008; melnikova & wages, 2006). selain pengobatan medis, modif ikasi gaya hidup dan terapi herbal kini masih menjadi pilihan utama dari beberapa intervensi yang bertujuan untuk menurunkan berat badan (singh et al., 2011). kopi merupakan salah satu minuman alami yang dikonsumsi secara luas di seluruh dunia (shimoda, seki, & aitani, 2006). salah satu jenis kopi yang dikonsumsi secara tradisional adalah coffea canephora robusta (onakpoya, terry, & ernst, 2011). beberapa penelitian menunjukkan bahwa kopi memiliki potensi terapeutik pada penyakit degeneratif (shimoda, seki, & aitani, 2006). senyawa aktif kopi memiliki efek sebagai anti-hiperglikemia, anti-oksidan, peningkatan sensitivitas insulin (downey, 2013) dan mencegah terjadinya penyimpanan lipid dan karbohidrat (shimoda, seki, & aitani, 2006). ekstrak kopi hijau berpotensi menurunkan akumulasi lipid (cho et al., 2010) dan glukosa dalam tubuh melalui beberapa mekanisme (li et al., 2009). salah satu senyawa aktif kopi hijau, asam klorogenat, mampu meningkatkan metabolisme tubuh (murase et al., 2011), meningkatkan oksidasi asam lemak (li et al., 2009; cho et al., 2010), menurunkan kadar trigliserid di hepar (shimoda, seki, & aitani, 2006), dan menginhibisi kerja enzim amilase (narita & inouye, 2009) & lipase pankreas pada intestinal (ong, hsu, & tan, 2012). selain asam klorogenat, kandungan polifenol pada kopi juga berpotensi menurunkan akumulasi lemak viseral (nagao et al., 2009). 28 jurnal ners vol. 9 no. 1 april 2014: 26–34 sampai saat ini belum ada penelitian mengenai efek terapeutik kopi terhadap profi l lipid dan kadar adiponektin yang berpengaruh terhadap kejadian obesitas. penelitian ini bertujuan untuk mengetahui perbedaan efek anti-obesitas orlistat, ekstrak biji kopi hijau (coffea canephora robusta), dan kombinasinya terhadap kadar adiponektin dan profi l lipid. bahan dan metode hewan coba berupa tikus putih (rattus norvegicus) jantan galur sprague dawley berumur 3 minggu, berat badan 100-150 gram dan berjumlah 25 ekor dalam keadaan normal dan sehat yang diperoleh dari laboratorium hewan coba, fkik, umy. hewan coba dipelihara dalam kandang sesuai standar, makanan dan minuman diberikan secara ad libitum. bahan-bahan yang digunakan dalam penelitian ini terdiri dari bahan pakan tikus, ekstrak biji kopi hijau, orlistat, dan aquadestilata. bahan pakan tikus dalam bentuk pelet dengan dua komposisi, yaitu (1) normal fat diet (nfd) dengan 64,2% karbohidrat, 30,7% protein, & 5,1% lemak; (2) high fat diet (hfd) dengan 17,4% karbohidrat, 42,9% protein, & 39,7% lemak . bahan pakan 1 diberikan selama aklimatisasi dan bahan pakan 2 sebagai pakan induksi obesitas (prunet-marcassus et al., 2003). induksi dilakukan setelah aklimatisasi. induksi obesitas dilakukan dengan memberikan asupan hfd selama 7 hari ad libitum. pemberian makanan dalam bentuk pelet. setelah 7 hari, tikus ditimbang (lim et al., 2012). induksi dianggap berhasil apabila berat badan tikus yang diinduksi memiliki berat badan lebih tinggi minimal 20 gram dibandingkan kelompok yang tidak diinduksi. setelah induksi berhasil, tikus dikelompokkan secara random (prunet-marcassus et al., 2003). ekstrak biji kopi hijau diberikan dengan dosis 400 mg/kgbb. dosis ini merupakan dosis yang berpotensi anti-obesitas (shimoda, seki, & aitani, 2006). simplisia biji kopi diperoleh dari tanaman yang tumbuh di dataran tinggi sumatera utara pada ketinggian 1000-1800 mdpl dengan distributor “goldenways coffee” no. p-irt: 6.10.1275.06.363 dari dinas kesehatan kota medan. biji kopi kemudian dideterminasi di laboratorium biologi, ugm. ekstrak diberikan dalam bentuk ekstrak etanol yang dibuat di laboratorium kimia, fmipa, ugm. orlistat (ratiopharm®) dalam sediaan tablet 60 mg, dan aquadestilata. penelitian ini merupakan penelitian true experimental post test only with control group design dengan rancangan acak lengkap (ral). hewan coba dikelompokkan menjadi: 1) kelompok 1, kontrol negatif yaitu kelompok tikus normal (hanya mendapatkan sonde aquadestilata). 2) kelompok 2, kontrol positif yaitu kelompok tikus yang diinduksi obesitas (hanya mendapatkan sonde aquadestilata). 3) kelompok 3, kelompok tikus obesitas yang diberi orlistat dengan dosis 15,9 mg/kgbb (sung et al., 2011). 4) kelompok 4, kelompok tikus obesitas yang diberi ekstrak etanol biji kopi hijau dengan dosis 400 mg/kgbb (shimoda et al., 2006). 5) kelompok 5, kelompok tikus obesitas yang diberi ekstrak air biji kopi hijau dengan dosis 400 mg/kgbb (shimoda et al., 2006). 6) kelompok 6, kelompok tikus obesitas yang diberi kombinasi orlistat dengan dosis 15,9 mg/kgbb dan ekstrak etanol biji kopi hijau dengan dosis 400 mg/kgbb. perlakuan diberikan selama 14 hari (shimoda et al., 2006) dalam bentuk larutan dan diberikan dengan volume 5 ml sesuai dengan volume maksimal pemberian perlakuan peroral pada tikus dengan berat badan 100 gram (kusumawati, 2004). jumlah ulangan ditentukan dengan rumus federel (hanafi ah, 2004), dan setiap perlakuan membutuhkan 5 pengulangan sehingga penelitian memerlukan 25 ekor tikus.variabel yang diamati pada penelitian ini adalah: prof il lipid: kadar trigliserid (tg), kolesterol total (tc), highdensity lipoprotein (hdl), dan low-density lipoprotein (ldl) setelah perlakuan; kadar adiponektin setelah perlakuan dan berat badan dan kadar glukosa darah puasa (gdp) tikus sebagai parameter pendukung yang diukur setiap 2 hari. 29 efek orlistat, ekstrak biji kopi hijau (joko setyono, dkk) sebelu m dilak u kan uji hipotesis, normalitas data diuji dengan uji saphiro-wilk dan varians data dengan uji homogenity of variance. jika uji saphiro-wilk menunjukkan distribusidan varians data normal, maka uji hipotesis parametrik yang digunakan adalah one-way anova dilanjutkan analisis post hoc least signifi cant difference (lsd). uji statistik dilakukan dengan taraf kepercayaan 95% (α=0,05). hasil penelitian kelomp ok ya ng d i i nd u k si h f d memiliki rerata berat badan (bb) lebih tinggi dibandingkan dengan kontrol negatif (gambar 1). hasil uji one-way anova diperoleh nilai f= 3,075 dan p= 0,035 ( pvalue<0.05), hal ini berarti bahwa terdapat perbedaan yang bermakna berat badan hewan coba yang diberi diet hfd dengan diet normal. uji post hoc lsd terhadap kelompok 2, 3, 4, 5, dan 6 memberikan hasil tidak terdapat perbedaan rerata bb diantara kelompok tersebut ( pvalue>0.05). rerata kadar kolesterol total terendah terjadi pada kelompok 4 (yang diberi ekstrak etanol biji kopi hijau) sebesar 92,75 mg/dl, sedangkan tertinggi pada kelompok 6 yaitu sebesar 170,25 mg/dl (gambar 2). berdasarkan uji one-way anova diperoleh nilai f= 6,4 dan p= 0,001 ( pvalue<0.05), oleh karena itu ho ditolak dan ha diterima, artinya terdapat perbedaan kadar kolesterol total yangbermakna antara kelompok kontrol negatif dan kelompok perlakuan. berdasarkan uji post hoc duncan, terdapat dua subset yaitu kelompok 1 dan 4 berbeda signifi kan dengan kelompok 2, 3, 5, dan 6. kelompok kontrol negatif mempunyai rerata kolesterol total yang tidak berbeda nyata dengan rerata kolesterol kelompok yang diberi ekstrak etanol kopi hijau. namun demikian, hasil ini menunjukkan bahwa pemberian ekstrak etanol kopi hijau dapat menghambat peningkatan kolesterol total tikus putih yang diinduksi diet hfd. rerata kadar ldl terendah sebesar 19,11 mg/dl (kelompok kontrol negatif) dan tertinggi sebesar 59,98 mg/dl (pada kelompok yang diberi kombinasi ekstrak etanol kopi hijau dengan orlistat) (gambar 3). berdasarkan uji one-way anova diperoleh nilai f= 9,973 dan p= 0,0001 ( pvalue<0.05), oleh karena itu ho ditolak dan ha diterima, artinya terdapat perbeda an kadar kolesterol ldl yang bermakna antara kelompok kontrol negatif dan kelompok perlakuan. gambar 1. grafi k berat badan hewan coba setelah induksi gambar 2. grafi k rerata kadar kolesterol total di antara kelompok perlakuan. gambar 3. rerata kadar ldl di antara kelompok perlakuan. 30 jurnal ners vol. 9 no. 1 april 2014: 26–34 berdasarkan hasil penelitian diketahui bahwa terdapat perbedaan yang signifi kan pada kadar ldl kelompok kontol positif, kelompok perlakuan orlistat, ekstrak etanol kopi hijau, dan ekstrak air kopi hijau terhadap kadar ldl kelompok perlakuan kombinasi etanol dan orlistat dimana kadar ldl nya mencapai 60 mg/dl. berdasarkan uji post hoc duncan, kelompok yang diberi orlistat dan kelompok yang diberi ekstrak etanol kopi hijau terdapat dalam satu subset, sehingga tidak ada perbedaan diantara kelompok tersebut. namun demikian, kelompok yang diberi ekstrak etanol kopi hijau lebih memiliki efek menurunkan terhadap kadar ldl dibandingkan dengan kelompok yang diberi ekstrak air kopi hijau dan kombinasi orlistat dengan ekstrak etanol kopi hijau. rerata kadar trigliserida ter tinggi terdapat pada kelompok yang diberi ekstrak etanol kopi hijau dan orlistat yaitu 109 mg/dl, sedangkan terendah pada kelompok kontrol negatif yaitu sebesar 70,25 mg/dl (gambar 4). hasil analisis uji one-way anova diperoleh nilai f= 1,718 dan p= 0,182 ( pvalue>0.05), yang berarti bahwa tidak ada perbedaan kadar trigliserida yang signifi kan di antara kelompok perlakuan. hal ini menunjukkan bahwa tidak ada kelompok perlakuan yang memiliki efek yang signif ikan dalam menurunkan kadartrigliserida dibandingkan kelompok kontrol positif. namun kombinasi orlistat dengan ekstrak etanol biji kopi hijau mampu menghambat hidrolisis trigiserida lebih tinggi dibanding kelompok lain. gambar 4. rerata kadar trigliserida di antara kelompok perlakuan. gambar 5. rerata kadar hdl di antara kelompok perlakuan. rerata kadar hdl tertinggi terdapat pada kelompok perlakuan yang diberi ekstrak etanol kopi hijau yaitu sebesar 11,83 mg/dl, sedangkan terendah terdapat pada kelompok kontrol negatif dan perlakuan yang diberi kombinasi ekstrak etanol kopi hijau dan orlistat yaitu sebesar 7,05 mg/dl (gambar 5). berdasarkan hasil uji one-way anova diperoleh nilai f= 7,347 dan p= 0,001 ( pvalue<0.05), artinya bahwa didapatkan perbedaan kadar hdl darah yang signifi kan antara kelompok negatif dan kelompok perlakuan kombinasi ekstrak kopi hijau dengan orlisat dengan kelompok perlakuan lainnya. hasil ini menunjukkan bahwa pemberian orlisat, ekstrak etanol kopi hijau,dan ekstrak air kopi hijau memiliki efek yang signifikan terhadap kadar hdl dibandingkan dengan kontrol negatif dan pemberian kombinasi ekstrak ethanol kopi hijau dan orlistat. pemberian ekstrak etanol kopi hijau mempunyai efek terbaik dalam meningkatkan kadar kolesterol hdl dibanding kelompok lain. rerata kadar adiponektin tertinggi terdapat pada kelompok perlakuan yang diberi kombinasi ekstrak etanol dan orlistat yaitu sebesar 1,99 mg/dl, sedangkan terendah terdapat pada kelompok kontrol positif yaitu sebesar 0,15 mg/dl (gambar 6). berdasarkan uji one-way anova diperoleh nilai f= 18,656 dan p= 0,0001 ( pvalue<0.05), artinya bahwa terdapat perbedaan kadar adiponektin yang signifi kan pada kelompok negatif, dan kelompok perlakuan terhadap kontrol positif. hasil ini menunjukkan bahwa perlakuan 31 efek orlistat, ekstrak biji kopi hijau (joko setyono, dkk) pemberian orlistat, ekstrak etanol kopi hijau, ekstrak air kopi hijau dan kombinasi ekstrak etanol kopi hijau dengan orlistat memberikan efek terhadap kadar adiponektin dibandingkan dengan kelompok kontrol positif. namun demi k ian, efek yang ditimbul kan oleh kombinasi ekstrak etanol kopi hijau dan orlistat lebih besar dalam meningkatkan kadar adiponektin. pembahasan induksi obesitas pada hewan coba dapat dilakukan melalui manipulasi neuroendokrin, genetik, dan diet. metode yang ser ing dig u nakan adalah metode indu ksi diet menggunakan diet tinggi lemak atau hfd. metode induksi ini dinilai lebih baik karena paling mendekati dengan kondisi peningkatan berat badan pada manusia (diemen et al., 2006). penambahan propylthiouracil (ptu) dengan konsentrasi 0.01% ditujukan agar peningkatan berat badan induksi terjadi secara signifi kan. propylthiouracil merupakan obat antitiroid yang berfungsi menurunkan kadar tiroksin. penurunan kadar tiroksin menyebabkan peningkatan kadar lemak tubuh yang disebabkan oleh penurunan intake energi dan peningkatan leptin (iossa et al., 2001). hal ini membuktikan bahwa hfd ditambah ptu 0.01% mampu memicu obesitas. kesimpulan tersebut didukung oleh iossa et al. (2001) bahwa kondisi hipotiroid yang disertai diet tinggi lemak akan memicu terjadinya obesitas dengan persentase lemak tubuh lebih tinggi daripada kondisi eutiroid. o b e s i t a s d i s e b a b k a n o l e h ketidakseimbangan energi akibat asupan kalori berlebih dan penggunaan yang minim sehingga mengakibatkan akumulasi lemak tubuh (conway & rene, 2004; ouchi et al., 2012). akumulasi lemak ini berkaitan dengan gangg uan pada reg ulasi ner uoendok r in dan metabolisme. gangguan metabolisme diperankan oleh lipoprotein lipase (lpl). lipoprotein lipase merupakan enzim yang berperan penting dalam hidrolisis lemak. kelainan pada enzim ini akan mengakibatkan peningkatan tg, ldl, vldl, dan penurunan hdl (ruel et al., 2003). ekstrak etanol kopi hijau merupakan sediaan yang paling mudah diabsorpsi sehingga memberikan efek kerja yang paling efi sien. dibandingkan dengan kelompok perlakuan lain, ekstrak etanol kopi hijau mudah berdifusi melalui epitel saluran pencernaan. kopi hijau mengandung senyawa aktif asam klorogenat yang mampu meningkatkan metabolisme tubuh (murase et al., 2011), meningkatkan oksidasi asam lemak (li et al., 2009; cho et al., 2010), menurunkan kadar trigliserid di hepar (shimoda, seki, & aitani, 2006), dan menginhibisi kerja enzim amilase (narita & inouye, 2009) dan lipase pankreas pada intestinal (ong, hsu, & tan, 2012). selain asam klorogenat, kandungan polifenol pada kopi juga berpotensi menurunkan akumulasi lemak viseral (nagao et al., 2009). oleh karena itu ekstrak etanol kopi hijau dapat menurunkan kadar kolesterol total secara signifikan dibanding kelompok perlakuan lain. sediaan ekstrak dengan pelarut etanol memungkinkan proses absorpsi dilakukan secara efi sien dan cepat sehingga efek yang ditimbulkan lebih optimal. pemberian ekstrak etanol kopi hijau juga mampu meningkatkan hdl secara signifi kan. pada penelitian ini, kombinasi orlistat dengan ekstrak etanol biji kopi hijau mampu menghambat hidrolisis trigiserida lebih tinggi dibanding kelompok lain. namun tidak ada kelompok perlakuan yang memiliki efek yang signifikan dalam menurunkan kadar trigliserida dibandingkan kelompok kontrol gambar 6. rerata kadar adiponektin di antara kelompok perlakuan. 32 jurnal ners vol. 9 no. 1 april 2014: 26–34 positif. orlistat menghambat kerja enzim lipase pan k reas pada intestinal dengan membentuk ikatan kovalen dengan sisi aktif residu serin (burton et al., 2006). inaktivasi lipase pankreas menyebabkan berhentinya proses hidrolisis tg menjadi asam lemak dan monogliserid (isido & cordido, 2010). selain menginhibisi proses hidrolisis tg, orlistat juga meningkatkan pembuangan lemak melalui feses hingga 30% (enc et al., 2009). mekanisme neuroendokrin diperankan oleh leptin dan adiponektin yang merupakan hormon yang disintesis oleh sel lemak jaringan adiposa (kumar et al. 2010). sintesis leptin dipengaruhi oleh ketersediaan lemak pada jaringan adipose (vassallo, 2007). apabila akumulasi lemak tubuh inadekuat, akan terjadi penurunan leptin dan peningkatan asupan kalori (kumar et al., 2010). adiponektin memiliki efek yang berlawanan dengan leptin. hormon ini memicu fosforilasi oksidatif dan menginaktivasi acet yl coencyme a carboxylase, enzim utama dalam sintesis asam lemak. adiponektin juga menurunkan infl ux asam lemak ke hepar dan menurunkan kadar tg total hepar, menginhibisi glukoneogenesis (kumar et al., 2010), dan meningkatkan sensitivitas insulin (matsuzawa et al., 2004). a d i p o n e k t i n b e r p e r a n d a l a m menurunkan kadar trigliserida total di hepar, menghambat proses glukoneogenesis (kumar et al., 2010), dan meningkatkan sensitivitas insulin (matsuzawa et al., 2004). dengan demikian peningkatan adiponektin akan menurunkan berat badan tubuh. kombinasi orlistat dengan esktrak etanol kopi hijau memperkuat efek terhadap peningkatan kadar adiponektin. orlistat menghambat kerja enzim lipase pankreas pada intestinal sehingga menyebabkan berhentinya proses hidrolisis tg menjadi asam lemak dan monogliserid (isido & cordido, 2010). simpulan dan saran pemberian ekstrak etanol kopi hijau lebih ef isien dalam menu r un kan kadar kolesterol ldl, meningkatkan kolesterol hdl, menurunkan trigliserida dan menurunkan kadar kolesterol total tikus putih yang diinduksi diet hfd. namun demikian, kombinasi ekstrak etanol kopi hijau dengan orlistat menunjukkan efek peningkatan kadar adiponektin yang paling tinggi dibandingkan dengan kelompok perlakuan lain. perlu penelitian lebih lanjut dosis yang paling efektif dan uji toksisitas dari ekstrak etanol kopi hijau dalam menurunkan profi l lipid dan marker obesitas lainnya dalam upaya menurunkan berat badan. kepustakaan adams, kf., schatzkin, a., harris, tb., kipnis, v., mouw, t., ballard-barbash, r., hollenbeck, a., & leitzmann, mf. 2006. overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. the new england journal of medicine, 355 (8): 763-88 ashrafi , k. 2007. obesity and the regulation of fat metabolism.the c. elegans research community, hal. 2 at mar ita. 2005. nutrition problems in indonesia. an integrated international seminar and workshop on lifestylerelat e d dise a se s. ga dja h ma d a university bray, ga. 2008. lifestyle and pharmacological approaches to weight loss: effi cacy and safety. the journal of clinical endocrinology & metabolism,93: s81– 8 burton, me., shaw, lm., schentag, jj. & evans, we. 2006. applied pharmacokinetics & pharmacod ynamics: principles of therapeutic dr ug monitoring. mar yland: lippincott williams & wilkins, hal. 517 cho as, jeon sm, kim mj,. yeo, j., seo, ki., choi, ms., & lee, mk. 2010. chlorogen ic acid ex h ibits a nt iobesity property and improves lipid metabolism in high-fat diet-inducedobese mice. food and chemical toxicology,48 (3): 937-43 conway, b. & rene, a. 2004. obesity as a disease: no lightweight matter. obesity reviews, 3: 145-51 departemen kesehatan republik indonesia (ri). 2008. riset kesehatan dasar: laporan nasional 2007. jakar t a: 33 efek orlistat, ekstrak biji kopi hijau (joko setyono, dkk) balai penelitian dan pengembangan kesehatan, hal. 50 diemen vv., tridande en., & trindande mrm. 2006. experimental model to induce obesity in rats. acta cirurgica brasileira, 21 (6): 425-9 downey, m. 2013. green coffe extract: unique obesity intervention. prohealth, inc. (www.prohealth.com) enc, fy., ones, t., akin, hl., dede, f., turoğlu, ht., ulfer, g., bekiroğlu, n., haklar, g., rehfeld, jf., holst, jj., ulusoy, n., & imeryüz, n. 2009. orlistat accelerates gastric emptying andattenuates gip release in healthy subjects. american journal of physiology-gastrointestinal and liver physiology,296: 482–489 halpern, b., oliveira, esl., faria, am., halpern, a., de melo, me., cercato, c., & mancini, mc. 2010. combinations of drugs in the treatment of obesity. pharmaceuticals, 3: 2398-415 hanafi ah, ka. 2004. rancangan percobaan: teori & aplikasi, edisi ketiga: jakarta: pt. raja grafi ndo persada, hal. 8 & 34 iossa s., lionetti l., mollica mp., crescenzo r., barletta a., & liverini, g. 2001. fat ba la nc e a nd se r u m l e pt i n concentrations in normal, hypothyroid, and hyperthyroid rats. international journal of obesity, 24: 417-25 isido, ml. & ordido, f. 2010. approved and pff-label uses of obesity medications, and potential new phar macologic treatment options. pharmaceuticals, 3: 125-45 kaplan, lm. 2005. pharmacological therapies for obesity. gastroenterology clinics of north america, 34: 91–104 kelly, t., yang, w., chen, c., reynolds, k., & he, j. 2008.global burden of obesity in 2005 and projections to 2030. international journal of obesity, 32: 1431-37 kumar, v., abbas, ak., fausto, n., & aster, jc. 2010. robbins and cotran phatologic basis of disease, eigth edition. philadelphia: saunders, an imprint of elsevier, inc. kusumawati, d. 2004. bersahabat dengan hewan coba. yogyakarta: gadjah mada university press, hal. 2, 8, & 88 li, sy., chang, cq., ma, fy., & yu, cl. 2009. modulating effects of chlorogenic acid on lipids and glucose metabolism and expression of hepatic peroxisome proliferator-activated receptor-alpha in golden hamsters fed on high fat diet. biomedical and environmenal sciences,22: 122-9 lim, dw., song, m., park, j., park, sw., kim, nh., gaire, bp., choi, h., & kim, h. 2012. anti-obesity effect of ht048, a herbal combination, in high fat dietinduced obese rats. molecules, 17: 14765-77 matsuzawa, y., funahashi, t., kihara, s., & shimomura, i. 2004, adiponectin and metabolic syndrome.arteriosclerosis, thrombosis, and vascular biology, 24: 29-33 mccormick, b., stone, i.and cor porate analytical team. 2007. economic costs of obesity and the case for goverment intervention. obesity reviews, 8 (1): 161-4 melnikova, i. & wages, d. 2006.anti-obesity t he r apie s. na t u re re vie ws d r ug discovery, 5: 369–70 murase, t., misawa, k., minegishi, y., aoki, m., ominami, h., suzuki, y., shibuya, y., & hase, t. 2011. coffee polyphenols suppress diet-i nduced body fat accumulation by dow n reg ulating srebp-1c and related molecules in c57bl/6j mice. american journal of physiolog y-endocrinolog y and metabolism,300: e122-33 nagao, t., ochiai, r., watanabe, t., kataoka, k., komikado, m., tokimitsu, i., & tsuchida, t. 2009. visceral fat-reducing effect of continuous coffe beverage consumption in obese subjects. japan pharmacological therapy, 37: 333-44 narita, y. & inouye, kj. 2009. kinetic analysis and mechanism on the inhibition of chlorogenic acid and its components against porcine pancreas alphaamylase isozymes i and ii. journal of agricultural and food chemistry, 57: 9218-25 onakpoya, i., terry, r., & ernst, e. 2011. the use of green coffee extract as a weight loss supplement: a systematic review 34 jurnal ners vol. 9 no. 1 april 2014: 26–34 and meta-analysis of randomized clinical tr ials. gast roenterolog y research and practice, 2011: 1-6 ong, kw., hsu, a., & tan, bk. 2012. chlorogenic acid stimulates glucose transpor t in skeletal muscle via apmk activation: a contributor to the benefi cial effects of coffee on diabetes. plos one, 7 (3): e32718 organisation for economic co-operation and development. 2011. health at a glance 2011-oecd indicator. oecd publishing (www.oecd.org), hal. 55 ouchi, n., ohashi, k., shibata, r., & murohara, t. 2012. adipocytokinesis and obesity-linked disorders.nagoya journal of medical sciences, 74: 19-30 popkin, bm., adair, ls. & ng, sw. 2012. now and then: the global nutrition transition: the pandemic of obesity in developing countries. nutrition reviews, 70 (1): 3-21 prunet-marcassus, b., desbazeille, m., bros, a., louche, k., delagrance, p., renard, p., casteilla, l., & penicaud, l. 2003. melatonin reduces body weight gain in sprague dawley rats with dietinduced obesity. endocrinology, 144 (12): 5347-52 romling c. & qaim, m. 2011. direct and indirect determinants of obesity: the case of indonesia. global food, 4: 126 ruel il., gaudet d., perron p., bergeron j., julien p., & lamarche, b. 2003. effect of obesity on hdl and ldl particle sives in carriers of the null p207l or defective d9n mutation in the lipoprotein lipase gene: the quebec lipd study. international journal of obesity, 27: 631-7 shayo, ga. & mugusi, fm. 2011.prevalence of obesity and associated risk factors among adults in konindoni municipal district, dar es salaam tanzania. biomedical central: public health, 11: 365 shimoda, h., seki, e., & aitani, m. 2006. inhibitory effect of green coffee bean extract on fat accumulation and body weight gain in mice. biomedical central: complementary and alternative medicine, 6: 1-9 singh, n., bhatia, v., chawla, & kumar, d. 2011. herbal fight for obesity: a review. international journal of pharmaceutical research and development, 3 (4): 193201 tseng, y., cypess, am., & kahn, cr. 2010. cellular bioenergetics as a target for obesity therapy.macmillan publishers limited, 9: 465-82 vassallo, j. 2007. pathogenesis of obesity. jour nal of the malta college of pharmacy practice, 12: 19-22 world health organization (who). 2013. obesity and overwight. (www.who. int) http://e-journal.unair.ac.id/jners | 111 jurnal ners vol. 16, no. 2 october 2021 http://dx.doi.org/10.20473/jn.v16i2.25701 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of thinking like a nurse simulation as an online clinical learning method on nursing students’ satisfaction and confidence during the covid-19 pandemic dian fitria, jehan puspasari and puspita hanggit lestari stikes rs husada, jakarta, indonesia abstract introduction: corona virus disease (covid-19) was declared as a pandemic by the world health organization (who) resulting in changes in existing patterns of life. this impact also affects the world of education, including nursing vocational education. nursing vocational education must be able to design online methods for the clinical competency with existing facilities and infrastructure. the online clinical method can describe the achievements achievable in clinical facilities so as to build students’ satisfaction and confidence. methods: this research used quasi-experimental pre-posttest without control group method by providing clinical learning thinking like a nurse simulation. the research sample consists of 110 diploma students with purposive sampling method. simulation focuses on clinical judgment, communication skills, and skill simulations by adopting clinical practice in hospitals. assessment is measured using simulation design scale (sds) and student satisfaction and self-confidence in learning scale (scls). pair t test with level of significance 0.05 is used to process data. results: it is found that there is an increase in students’ satisfaction and confidence using the clinical simulation method of “thinking like a nurse” having an average 40.69%. meanwhile, online clinical learning methods has an average increase of 114%. there is an effect of thinking like a nurse simulation method on students’ satisfaction and self-confidence (p < 0.05). conclusion: this research is recommended to add to the reference for online nursing clinical learning methods during covid-19. determining the ratio between students and lecturers in online clinic learning can be considered for further research. article history received: march 16, 2021 accepted: july 06, 2021 keywords covid-19; online clinical learning; nursing student contact dian fitria  dianfitriafanani@gmail.com  stikes rs husada, jakarta, indonesia cite this as: fitria, d., puspasari, j., & lestari, p. h. (2021). the effect of thinking like a nurse simulation as an online clinical learning method on nursing students’ satisfaction and confidence during the covid-19 pandemic. jurnal ners, 16(2). 111-118. doi:http://dx.doi.org/10.20473/jn.v16i2.25701 introduction the determination of the status of covid-19 spread as a pandemic on 11 march 11 by the world health organization (who) resulted in all learning activities turned online. the decree of the minister of education and culture through a circular number 4 of 2020 gave an order to carry out the learning and teaching process from home starting from 24 march, 2020 to reduce the acceleration of the spread of the covid-19 virus. all educational institutions were forced to adapt very quickly. the learning and teaching process from home had to be carried out immediately to achieve the students’ competencies. simple online methods, such as through chat, voice record, video record, online meeting applications, email, to learning via web were specially designed by educational institutions. all institutions thought hard to be able to provide effective online learning for their students, including educational institutions with diploma nursing program (al-balas et al., 2020). educational institutions can no longer send students to gain learning experiences through clinical practices since the emergence of covid-19. however, the closure of these educational practices cannot stop the teaching and learning process. it is not easy to transform learning at clinical institutions into an https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id d. fitria et al. 112 | pissn: 1858-3598  eissn: 2502-5791 online effort, so preparation is required to design appropriate methods so that clinical learning outcomes in knowledge and skills can still be achieved (de metz & bezuidenhout, 2018) the three main competencies obtained from learning methods at clinical institutions are the ability of students to carry out clinical judgments, communication skills, and nursing procedure skills. learning methods that are carried out online must be done through very well-made simulations so that they are representative to achieve nursing knowledge and clinical judgment (letcher, roth, & varenhorst, 2017). clinical judgment is the key to caring and decision-making for intervention on patients based on existing assessments and data, (yuan, williams, & man, 2014), and reduced evidence-based experience in conducting clinical judgment can cause students to lack critical skills in nursing process and real problem solving for patients (konrad, fitzgerald, & deckers, 2020a). online clinical learning has been carried out and evaluated in clinical courses in the even semester 2019/2020. the method used is to provide cases, group discussion, online case presentations, and videos on nursing action procedures. this method is not sufficiently representative of students who do not acquire experience doing clinical judgment, communication skills, and nursing procedure skills. unrepresentative methods of learning have an impact on students’ satisfaction and self-confidence. some issues that make online learning dissatisfied are less time to practice procedural skills, numerous tasks, insufficient group discussions, technical learning, and network problems (shih, chen, chen, & wey, 2013a). dissatisfaction may produce anxiety in students and cause them to doubt their abilities, causing further impact, namely from decreased academic achievement to student retention (abdous, 2019). confidence is very important for all individuals since it affects the performance of the work done and the results of the work. therefore, it is very important to build nurses' confidence with effective online learning methods so that they have satisfaction with the clinical learning process that is carried out online. based on this description, the researchers develop a “thinking like a nurse” method adapted and modified based on the clinical judgment for the nurse learning model (tanner, 2006). the process shall have three main stages to train skills in conducting clinical judgment, namely noticing, interpreting and response, and reflection. (tanner, 2006). noticing is the first stage; the lecturers provide simple cases and students are trained to complete the assessment and the necessary supporting data, as if the student met a new patient at the hospital. in this phase, the students are triggered to think critically about the data that must be studied, diagnostic data on supporting patients, and a flow of thinking on the reason why the data are needed to be completed. the interpreting stage is the stage where students are able to interpret the data obtained through the noticing stage; making diagnosis and designing the interventions to be carried out and knowing the rationality of implementing these interventions. the responding stage is carried out where students evaluate the actions taken. in this method, researchers include the process of communication and nursing procedure skills while students will be trained to think critically in overcoming patient problems according to their developmental conditions; besides that, students will also be trained to carry out activities in the nursing room such as handover, situation, background, assessment, recommendation (sbar), preconference, and post-conference. a self-reflection process carried out in the learning process will help students understand learning outcomes; the reflection process carried out will also increase professional development, personal growth, empowerment, and facilitated learning this research is expected to produce appropriate online clinical learning methods and to increase students’ satisfaction and confidence. the result of this study can be used as a reference for online nursing clinical learning methods during covid-19. materials and methods the method used in this study is a “quasi-experimental pre-posttest without control group” using statistical tests with paired t-test. the sampling technique uses a nonprobability sampling with a purposive sampling method with a sample size of 110 students with the inclusion criteria of students who attended mental and maternity clinical lectures with a supervisor who is a member of the research team and the sampling process was carried out for five days for each class with lectures fully accompanied for two sessions and two session student group discussions. independent variable in this research is online clinical method. the simulation design scale (sds) instrument by jeffries and rizzolo (2006) with cronbach’s alpha 0.96 was used to assess the method using questionnaires assessed using a likert scale of 1-5. the dependent variable of this research is satisfaction and self-confidence. the instrument used, namely the questionnaire, is the student satisfaction selfconfidence in learning scale (scls) by jeffries and rizzolo (2006) with a cronbach’s alpha value of 0.94. the satisfaction assessment component consists of satisfaction on the learning method, the variety of materials provided, the facilities in the processes of learning, motivation, and suitability of the simulation process with the competencies to be achieved (jeffries & rizzolo, 2006). in measuring satisfaction and selfconfidence, the researchers use the concept put forward by jeffries and rizzolo (2006). self-confidence is assessed through the aspects of mastery of the material provided, the need for the material presented, the availability of learning resources, and a place to look for learning sources, both sources for questions and sources of reference. the first stage of research implementation is to conduct a literature study and identification of research problems. the second stage is a pre-test to measure the level of satisfaction and self-confidence and an assessment of the design of the simulation method used jurnal ners http://e-journal.unair.ac.id/jners | 113 by students who have participated in online clinical table 1. stages of implementing online “thinking like nurse” clinical learning method stages lecturers’ activities students’ activities explanation of learning methods explains the clinical learning process using the “thinking like a nurse” simulation clinical judgment: noticing (days 1-3) determination work schedule groups morning and evening shares medical records (simulations) and formulas to use divides trigger cases (cases will be provided on the first day and changes in the patient's condition will be given on the following day until the patient is discharged). patients are treated for 3 days have discussion on the cases acquired pre-conference hand over day 1simulation: asks questions 1. which follow-up studies should be done? 2. why are they done? 3. what diagnostic tests should be done? 4. what is the purpose of the examination? day 2the simulation provides the progress of the case. simulation with questions: 1. what causes the change in the patient's condition? 2. describe any further assessments to carry out day 3 simulated patient preparation for discharge. 1. what are the discharge preparations made by the nurse for the patient? 2. what is the rationale for such preparation? 3. what forms should the nurse prepare? fills in the assessment; fills in the initial patient’s assesment form to the ward (day 1) carries out further assessment (day 2) prepares the patient to return home (day 3) performs self-reflection clinical judgment: interpreting (days 2 and 3) simulation: through questions 1. what are the characteristic limitations of the diagnosis offered? 2. which is the priority problem? enforcing nursing diagnosis performs self-reflection simulation: through questions 1. why are there such planning and outcome criteria? making plans and criteria for nursing care outcomes performs self-reflection clinical judgment: responding (days 2 and 3) simulation (discussion on zoomeeting) 1. lecturers provide the results of nursing actions taken by students 2. the lecturer provides an overview of the patient’s condition after the intervention 3. the lecture provide advices for student about nursing care delivered, sbar hand over, and documentation. 1. carrying out the actions to be performed in accordance with the action documentation planning on the documentation sheet. 2. situation, background, assesment, recommendation (sbar) exercise 3. communications 4. performs self-reflection 5. creating documentation of nursing actions 6. filling out the integrated patient progress notes form (documentation) 7. handover exercise simulation: through questions 1. what should you do if the next condition of patient ......? (lecture explain progress patient condition) 2. which your next priority implementation for patient? making plans and criteria for next nursing care outcomes reflecting (day 3) simulation (discussion on zoomeeting) lecture motivates self-reflection by asking question about students understand learning outcomes; the reflection process carried out. 1. self-reflection (while treating patients from admission to discharge) 2. post-conference simulation: through questions 1. what the lesson learnt today? 2. how the feeling? 3. what the learning outcone you can get today? 4. what should you improve for your self? making self reflection communication and nursing procedure skills (days 4 to 5) provides nursing procedures that will be trained in accordance with the agreement on the discussion of responding implementation divide nurse-patient 1. creates patient-nurse scenarios for cases that have been created for 3 days. 2. performs self-reflection d. fitria et al. 114 | pissn: 1858-3598  eissn: 2502-5791 by students who have participated in online clinical learning without the “thinking like a nurse” method followed by the provision of the “thinking like a nurse” simulation method and the third stage carries out a posttest to measure the level of satisfaction and selfconfidence of students and an assessment of “thinking like a nurse” learning method with the activities as provided in table 1 stages of implementing online the “thinking like a nurse” clinical learning method. this study has passed the ethical test by the health research ethics commission of the faculty of nursing, the airlangga university, number 2118kepk. data were collected through questionnaires and did not cause any harm to the respondents. ethical requirements and respondent rights have been fulfilled throughout the research process. results the results of satisfaction and self-confidence assessment (table 2) show that the mean value before the intervention is 37.28 with a median value of 27.50. meanwhile, the mean satisfaction and selfconfidence of respondents after the intervention is 52.45 with a median value of 52. the table above also illustrates that there is a difference of 15.17 in the mean before and after intervention with a mean increase of 40.69%. hence, it can be concluded that there is a difference in the mean and an increase in the mean of the respondents’ satisfaction and confidence before the intervention and after the intervention. based on table 3, it is found that the mean of the respondents’ online clinical learning method before the intervention is 37.58 with a median value of 27.50. meanwhile, the mean of clinical learning method by respondents after intervention is 80.46 with a median value of 80. hence, it can be concluded that there is a difference in the average online clinical learning method before the intervention and after the intervention. the table above also illustrates that there is a difference of 52.9 in the mean before and after with a mean increase of 114%. hence, it can be concluded that there is a difference in the mean and an increase in the mean of the respondents’ satisfaction and confidence before the intervention and after the intervention. in examining the effect of providing online clinical learning methods with the “thinking like a nurse” method, it was found the students’ average satisfaction and self-confidence before and after the effect of providing online clinical learning methods with the “thinking like a nurse” method on students’ satisfaction and self-confidence is 15.16, and the difference between these differences is between table 2. average satisfaction and confidence before and after the intervention (n=110) variables mean median sd min-max mean difference 95% ci average increase percentage (%) satisfaction and confidence before intervention 37.28 27.50 12.3 26-52 15.17 0.41-0.59 40.69 satisfaction and confidence after intervention 52.45 52.00 5.2 38-65 0.62-0.80 table 3. average online clinical learning methods before and after intervention (n=110) variables mean median sd min-max mean difference 95% ci average increase percentage online clinical learning methods before intervention 37.58 27.50 12.8 26-52 52.9 0.38-0.57 114 online clinical learning methods after intervention 80.47 80 6.7 61-100 0.61-0.79 table 4. the effect of providing online clinical learning methods with “thinking like a nurse” method on students’ satisfaction and self-confidence (n=110) variables mean sd se 95% ci p value lower upper respondents’ satisfaction and confidence before and after the intervention 15.16 13.07 1.246 12.70 17.63 <0.000 table 5 .the effect of giving the “thinking like a nurse” simulation method on online clinical learning methods (n=110) variables mean sd se 95% ci p value lower upper respondents' online learning methods before and after the intervention 42.9 14.03 1.345 40.24 45.54 <0.000 jurnal ners http://e-journal.unair.ac.id/jners | 115 17.63 and 12.70 (95% confidence interval of the lower and upper differences), sig (2-tailed) of <0.000. hence, it can be concluded that there is a mean difference in students’ satisfaction and confidence between before and after the “thinking like a nurse” simulation; therefore, there is an effect of the “thinking like a nurse” simulation method on students’ satisfaction and self-confidence. based on table 5, the results show that the average online clinical learning method for students before and after the “thinking like a nurse” simulation is 42.9, and the difference between these differences is between 45.54 and 40.24 (95% confidence interval of the lower and upper differences), sig (2-tailed) of <0.000. hence, it can be concluded that there is an average difference between the online clinical learning method for students before and after the “thinking like a nurse” simulation; therefore, there is an effect of the “thinking like a nurse” simulation method on the online clinical learning method. discussion the “thinking like a nurse” method is a design adapted from tanner (2006) and konrad, fitzgerald, and deckers (2020). the stages of this online method are divided into three, namely clinical judgment, communication, and procedure skills simulation. this method is designed since, based on adam (2015), the clinical online learning method must cover three cognitive aspects (knowledge, comprehension, critical thinking), psychomotor (skill development), and affective (emotional & behavioral response) (adams, 2015). this method is designed as an effort to respond to the covid-19 pandemic which makes nursing students unable to practice in hospitals. for the first semester during the covid-19 pandemic and before the application of this clinical method, online clinical activities were carried out with case provision in which students were asked to produce preliminary reports on three-day nursing care and presentation of the case and continuing with cases’ question and answer sessions. through the method, students only reached satisfaction and confidence with a mean of 37.28 with a mean value of the online clinical learning method used before the intervention of 37.58. the interaction of the old method is less interaction between lecturer and student, and the method cannot describe the situation in the hospital. student satisfaction and confidence are low due to the learning process, which is not optimal for presenting clinical learning experiences conducted online. the procedure performed is still oriented toward training students to be able to provide nursing care; but is not yet at the application of simulation stage and, with this method, students only gain knowledge without any clinical learning experiences such as communicating with patients or simulating nursing actions. this is in line with the results of research conducted by al-balas et al. (2020) saying that the clinical medical practice method during a pandemic must include three aspects, namely knowledge, nursing care practice, and representative experience in caring for patients performed online by simulating nursing actions (albalas et al., 2020). the results of research by mcgann et al. (2020) state that the online clinical method will be effective if it is not only in the form of knowledge on nursing care, but when it is followed by providing feedback on simulated procedures, providing videos, and practicing communication with patients, and by so doing can increase self-confidence of the students (mcgann et al., 2020). another study states that students’ dissatisfaction in learning is due to anxiety on seven things felt by students, namely unclear online learning technique mechanisms, the absence of face-to-face session, high risk of distraction to social media during online learning, minimum feedback, unsupportive online learning environment, and the absence of interaction with friends such as in the classroom (abdous, 2019). the research results of chen et al. (2013) show several issues that cause dissatisfaction in online learning, i.e., less time to practice procedural skills, abundance of tasks, insufficient group discussions, technical learning, and network problems (shih et al., 2013b). in the previous method, students only work on the given cases, make a path of flow, and ask and answer questions on nursing care provided; students could not see changes in the patients’ condition such as students caring for patients in the ward. after the intervention using the “thinking like a nurse” method adapted and modified from tanner (2006) and konrad, fitzgerald, and deckers (2020) in five days as an online clinical learning method, the average students’ satisfaction and confidence increase to 52.45 with an increase of 40.69% from the condition before the intervention (konrad et al., 2020a; tanner, 2006). likewise, the mean value for the online clinical learning method used after the intervention is 80.47; this value increases 114% from the previous method. this is because the “thinking like a nurse” method provides students with experiences on caring for patients, but it is done online. the noticing stage is the first stage in the clinical judgment process. lecturers provide simple cases and students are trained to complete the assessment and the necessary supporting data, as if the student met a new patient at the hospital. in this phase, the students are triggered to think critically about the data that must be studied, diagnostic data on supporting patients, and a flow of thinking on the reason why the data are needed to be completed. the management of trigger cases by students is the key to optimal online learning processes (konrad et al., 2020b; kyrkjebø, 2006). learning feedback is immediately provided by the lecturer after students complete the data to know whether the assessment data really needs to be studied before the students make diagnosis. the lecturer also provides the results of the assessment completed on the patient. the focus of the first day on this assessment provides clarity to students on the competencies in nursing assessment d. fitria et al. 116 | pissn: 1858-3598  eissn: 2502-5791 skills. this is consistent with a research from kim et. al. (2020) that giving the right feedback will increase students’ confidence during online learning. the interpreting stage is the stage where students are able to interpret the data obtained through the noticing stage, making diagnosis and designing the interventions to be carried out and knowing the rationality of implementing these interventions. lecturers discuss the rationality of diagnosis and planning. in the third stage, the responding stage is carried out where students evaluate the actions taken. the three stages of clinical judgment, namely noticing, interpreting, and responding, are carried out by the interaction of lecturers and students for three days and performed in stages. in each learning process, the lecturer provides feedbacks and triggers for students to think critically. through this method, students know whether each stage of the nursing care that they make is appropriate or not, and know the rationale for each action. feedback obtained after each process is the interaction between students and lecturers; this can increase satisfaction and the method becomes more effective because one of the reasons for dissatisfaction with online learning is the lack of interaction with lecturers and students (d’aquila, wang, & mattia, 2019; de metz & bezuidenhout, 2018; singh et al., 2021) the nursing care given every day is made based on the development or changes in the patient’s condition provided by the lecturer as a trigger for nursing care for the next day. therefore, students are continuously trained to think critically in designing nursing care such as in clinical practice. this is in accordance with the good learning components according to jeffries and rizollo (2006), including competence (objectives, material preparation, trigger cases), support (learning resources; motivation provided by the lecturer), problem solving (opportunities to ask questions, ease of finding sources to solve problems), feedback (providing constructive feedback, and selfreflection processes), and accuracy (accuracy with real life conditions) (jeffries & rizzolo, 2006). this method is also a student-centered clinical learning method that can increase student satisfaction and confidence when the process is able to motivate, the presence of lecturers for interaction and collaboration with students, clear learning activities, and students understand the right goals, competencies, and deadlines (tartavulea, albu, albu, petre, & dieaconescu silvia, 2020). in the second stage of the “thinking like a nurse” method after clinical judgment, namely communication skills, students will be trained to do handover and patient process reports to doctors using sbar either during handover or on the phone. students practice handover with other students for managed cases. the supervisor observes the handover process carried out by the students; the components mentioned are the completeness of the data being transferred and the next action to be taken. input is also provided by peers between groups. this stage is carried out because, according to o’neil, fisher, rietschel, and fisher (2018), three principles that must be fulfilled in online learning are easy to access, easy to navigate, and easy to interact with others. it is also stated that communication is the core of online learning because it is with this communication that interactions will be built between students and students, student and lecturers, and students with trigger cases on learning (o’neil, fisher, rietschel, & fisher, 2018). increasing interaction and communication in learning will increase discipline, independent learning ability, selfmotivation, level of participation, time management and being active in learning (reinckens, philipsen, & murray, 2014). the third stage consists of students performing peer-to-peer simulation and practicing selected actions for one of the diagnoses. this action is performed online by students. actions taken to be simulated are assessment, education, or independent nursing actions. the simulation of providing education to fellow students with the patient nurse scenario is the most effective online clinical action simulation method (rodríguez, navarro, pino, & maroto, 2020). simulations of nursing actions with scenarios that are played online are parts of the student-centered learning method and are able to increase students’ satisfaction and self-confidence (englund, olofsson, & price, 2017). in this stage, the lecturer also provides videos of nursing procedures that are not possible to be performed by online role play. all actions taken are documented in a simulated medical record prepared and designed in accordance with the standards of teaching hospitals commonly used as practice venues. these three stages produce average increase in students’ satisfaction and confidence. in this clinical learning method, students are motivated to carry out nursing care according to the patient’s development, perform communication for nurse-nurse and nursepatient, and are trained to foster a sense of caring and empathy in caring for patients. soundy et al. (2021) state that there are three aspects that students must be trained in in order to increase self-confidence in caring for patients, namely the experience of patient nurse interaction, patient empowerment, and training in caring and empathy (soundy et al., 2021). the same thing is revealed in the study that selfconfidence in learning is influenced by eight factors, namely mastery or understanding of certain materials or expertise, materials according to needs, increased psychomotor abilities, availability of reference sources, and the ability to solve existing problems (franklin, burns, & lee, 2014). clear and continuous feedback can increase satisfaction and self-confidence so that individuals will be able to perform cognitive functions to seek efforts to move closer to goals through various ways and be able to set specific goals for themselves with self-regulation abilities (luthans, 2007). every day, at the end of an online work meeting, students reflect themselves on clinical learning activities. it is designed to increase students’ jurnal ners http://e-journal.unair.ac.id/jners | 117 satisfaction and confidence. the self-reflection process carried out in the learning process will help students understand learning outcomes; it will also increase professional development, personal growth, empowerment, and facilitated learning (langley & brown, 2010). good understanding of learning outcomes by students through self-reflection prevents them from experiencing helplessness, burnout, and burdens (suliman, abu-moghli, khalaf, zumot, & nabolsi, 2021). this learning method also enhances the role of the lecturers as facilitator; the lecturers are in charge of not only providing trigger cases, but also listening to the results of solving cases by students on the last day. in this method, the lecturers understand and participate in online clinical learning interactions. this becomes one of the reasons for students’ satisfaction and confidence since they know where to ask and are trained to think critically. schroeder, shogren, and terras (2020) state that online students need instructors to provide personal presence, by being engaging, approachable, understandable, patient, and passionate about the subject. this method does not only focus on students processing cases with a nursing care approach, but also on the interaction between lecturers and students (schroeder, shogren, & terras, 2020). the limitation of this research is that it hasn’t considered yet the ratio of students and lecturers based on the ratio on clinical setting; nevertheless, the number of students is divided into several small groups in team teaching. conclusion based on this research, it can be concluded that the provision of the online clinical learning method of “thinking like a nurse” has an influence on students’ satisfaction and self-confidence. this method is designed with the urgency of the impact of covid-19 causing students to be unable to do clinical practices in hospitals. this design provides a student clinical learning experience, such as learning in a hospital, where students manage patients through nursing care for five days until the patient is discharged. this design is also developed for students to maintain communication skills and nursing procedures, as well as interactions between patient-nurses and nursespeers. from this method, they learnt three aspects that students must be trained in in order to increase self-confidence in caring for patients, namely the experience of patient nurse interaction, patient empowerment, and training in caring and empathy (soundy et al., 2021). this method is designed to achieve the clinical online learning method criteria which must cover three cognitive aspects (knowledge, comprehension, critical thinking), psychomotor (skill development), and affective (emotional & behavioral response) (adams, 2015). this research is expected to be able to provide a reference contribution to nursing vocational education to develop online clinical learning methods. this method is also expected to be adopted by nursing vocational education institutions in achieving clinical learning competence. the “thinking like a nurse” method can anticipate changes in hospital practice regulations that have re-accepted students in a limited number, so that it can be used as blended learning. this method also needs to be re-developed by taking into account the number of students and the number of lecturers to get a more optimal process. this research is recommended to determine the ratio between students and lecturers in online clinic learning and can be considered for further research. references abdous, m. (2019). influence of satisfaction and preparedness on online students’ feelings of anxiety. internet and higher education, 41(january), 34–44. https://doi.org/10.1016/j.iheduc.2019.01.001 al-balas, m., al-balas, h. i., jaber, h. m., obeidat, k., albalas, h., aborajooh, e. a., … al-balas, b. (2020). correction to: distance learning in clinical medical education amid covid-19 pandemic in jordan: current situation, challenges, and perspectives (bmc medical education, (2020), 20, 1, (341), 10.1186/s12909-020-02257-4). bmc medical education, 20(1), 1–8. https://doi.org/10.1186/s12909-020-02428-3 d’aquila, j.m., wang, d. and mattia, a. (2019). are instructor generated youtube videos effective in accounting classes? a study of student performance, engagement,motivation, and perception. journal of accounting education, 47, pp.63-74. de metz, n., & bezuidenhout, a. (2018). an importance-competence analysis of the roles and competencies of e-tutors at an open distance learning institution. australasian journal of educational technology, 34(5), 27–43. https://doi.org/10.14742/ajet.3364 englund, c., olofsson, a. d., & price, l. (2017). teaching with technology in higher education: understanding conceptual change and development in practice. higher education research and development, 36(1), 73–87. https://doi.org/10.1080/07294360.2016.11713 00 franklin, a. e., burns, p., & lee, c. s. (2014). nurse education today psychometric testing on the nln student satisfaction and self-con fi dence in learning , simulation design scale , and educational practices questionnaire using a sample of pre-licensure novice nurses. ynedt, 34(10), 1298–1304. https://doi.org/10.1016/j.nedt.2014.06.011 jeffries, p.r., rizzolo, m. a. (2006). designing and implementing models for the innovative use of using simulation to teach nursing care of ill adults and children: a national, multi-site, multimethod study. national league for nursing. new york, ny. d. fitria et al. 118 | pissn: 1858-3598  eissn: 2502-5791 kim, j. w., myung, s. j., yoon, h. b., moon, s. h., ryu, h., & yim, j. j. (2020). how medical education survives and evolves during covid-19: our experience and future direction. plos one, 15(12 december), 1–13. https://doi.org/10.1371/journal.pone.0243958 konrad, s., fitzgerald, a., & deckers, c. (2020a). nursing fundamentals à supporting clinical competency online during the covid-19 pandemic. teaching and learning in nursing, 000, 17–20. https://doi.org/10.1016/j.teln.2020.07.005 konrad, s., fitzgerald, a., & deckers, c. (2020b). nursing fundamentals à supporting clinical competency online during the covid-19 pandemic, 000, 17–20. https://doi.org/10.1016/j.teln.2020.07.005 kyrkjebø, j. m. (2006). classroom and clinic : getting it wrong and getting it right, 45(3). langley, m. e., & brown, s. t. (2010). perceptions of the use of reflective learning journals in online graduate nursing education. nursing education perspectives, 31(1), 12–17. https://doi.org/10.1043/1536-5026-31.1.12 letcher, d. c., roth, s. j., & varenhorst, l. j. (2017). simulation-based learning : improving knowledge and clinical judgment within the nicu, 284–290. luthans, y. & a. (2007). psychological capital: developing the human competitive edge. oxford university press. mcgann, k. c., melnyk, r., saba, p., joseph, j., glocker, r. j., & ghazi, a. (2020). implementation of an elearning academic elective for hands-on basic surgical skills to supplement medical school surgical education. journal of surgical education, 1–11. https://doi.org/10.1016/j.jsurg.2020.11.014 nancy e. adams. (2015). bloom’s taxonomy of cognitive learning objectives nancy. j med lib assoc, 103 (3)(july), 152–153. https://doi.org/doi: http://dx.doi.org/10.3163/1536-5050.103.3.010 o’neil, c. a., fisher, c. a., rietschel, m. j., & fisher, c. a. (2018). interacting and communicating online. developing online learning environments in nursing education, 99–110. https://doi.org/10.1891/9780826199140.0008 reinckens, j., philipsen, n., & murray, t. l. (2014). nurse practitioner: is online learning for you? journal for nurse practitioners, 10(9), 700–705. https://doi.org/10.1016/j.nurpra.2014.07.015 rodríguez, d. j., navarro, m. del m. t., pino, f. p. del, & maroto, o. a. (2020). simulated nursing video consultations: an innovative proposal during covid-19 confinement. clinical simulation in nursing, (5 august 2020). https://doi.org/10.1016/j.ecns.2020.08.004 schroeder, s., shogren, m., & terras, k. (2020). student connectivity in online programs: role of the nurse faculty. journal for nurse practitioners, (xxxx). https://doi.org/10.1016/j.nurpra.2020.09.005 shih, h., chen, s. e., chen, s., & wey, s. (2013a). the relationship among tertiary level efl students ’ personality , online learning motivation and online learning satisfaction. procedia social and behavioral sciences, 103, 1152–1160. https://doi.org/10.1016/j.sbspro.2013.10.442 shih, h., chen, s. e., chen, s., & wey, s. (2013b). the relationship among tertiary level efl students ’ personality , online learning motivation and online learning satisfaction, 103, 1152–1160. https://doi.org/10.1016/j.sbspro.2013.10.442 singh, h. k., joshi, a., malepati, r. n., najeeb, s., balakrishna, p., pannerselvam, n. k., … ganne, p. (2021). a survey of e-learning methods in nursing and medical education during covid-19 pandemic in india. nurse education today, 99(november 2020), 104796. https://doi.org/10.1016/j.nedt.2021.104796 soundy, a., hemmings, l., gardiner, l., rosewilliam, s., heneghan, n. r., cronin, k., & reid, k. (2021). elearning communication skills training for physiotherapy students: a two phased sequential mixed methods study. patient education and counseling, (xxxx), 1–9. https://doi.org/10.1016/j.pec.2021.01.022 suliman, w. a., abu-moghli, f. a., khalaf, i., zumot, a. f., & nabolsi, m. (2021). experiences of nursing students with the unprecedented abrupt online learning forced by the national curfew due to covid-19: a qualitative research study. nurse education today. https://doi.org/https://doi.org/10.1016/j.nedt.2 021.104829 tanner ca. (2006). thinking like a nurse: a researchbased model of clinical judgment in nursing. journal nurse education, june 45(6), 204–211. https://doi.org/10.3928/01484834-2006060104 tartavulea, c. v., albu, c. n., albu, n., petre, r. i., & dieaconescu silvia. (2020). online teaching practices and the effectiveness of the educational process in the wake of the covid-19 pandemic. amfiteatru economic, 22((25)), 920–936. https://doi.org/10.24818/ea/2020/55/920 yuan, h. bin, williams, b. a., & man, c. y. (2014). nursing students’ clinical judgment in highfidelity simulation based learning: a quasiexperimental study. journal of nursing education and practice, 4(5), 7–15. https://doi.org/10.5430/jnep.v4n5p7 http://e-journal.unair.ac.id/jners | 31 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.3478 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research nurses education and motivation towards nursing documentation devi mediarti1, rehana rehana1 and abunyamin abunyamin2 1 department of nursing polytechnic of health palembang, south sumatra, indonesia 2 general hospital of palembang bari, south sumatra, indonesia abstract introduction: nursing documentation is an integral part that cannot be separated from healthcare as a responsibility and accountability of nurses. high education and motivation are needed to achieve good nursing documentation. the aim of this study was to know the correlation between education and motivation of nurses towards intensive care nursing documentation. methods: the design used was an analytical survey with a cross-sectional approach. the population was nurses in intensive care of palembang bari hospital with as many as 46 nurses and 44 samples obtained with total sampling. data were collected by questionnaire and observational and were analyzed by chi-square. independent variables are education and motivation of nurses and the dependent variable is nursing documentation. results: there was a correlation between education (p=0.035) and motivation (p=0.040) of nurses towards nursing documentation. conclusion: high education and motivation of nurses influenced towards the quality of nursing education. the nursing manager of the hospital is recommended affording the opportunity to support human resources in the hospital, especially for nurses to participate in education, in accordance with the demands of legislation in nursing education, and to organize the training of nursing documentation. article history received: january 27, 2017 accepted: may 07, 2018 keywords education; motivation; nurses; nursing documentation contact devi mediarti  devi@poltekkespalembang.ac.id  department of nursing polytechnic of health palembang, south sumatra, indonesia cite this as: mediarti, d., rehana, r., & abunyamin, a. (2018). nurses education and motivation towards nursing care documentation. jurnal ners, 13(1), 31-35. doi:http://dx.doi.org/10.20473/jn.v13i1.3478 introduction nursing is a professional service form of basic needs given to individual health and sick conditions, which include physical disorder, psychological and social, in order to achieve the optimal health status. the basic form of fulfillment in individuals can be either improved existing capabilities, prevention, repair and rehabilitation of sick condition as perceived by individuals (alligood and tomey, 2006). nursing is an integral part that cannot be separated from the overall healthcare effort. nursing is a study that learns of the cause of the nonfulfillment of basic human needs and makes effort to satisfy such basic human needs in response to the patient (nursalam, 2008). professional nursing service is based on nursing as a science process. that is, nursing care as a scientific method of nursing patients’ problems – and solving these to improve patient outcomes, which should be documented (aziz, 2003). nursing documentation is an activity of recording, reporting and maintenance that is associated with managing of clients in order to maintain a number of facts from an event in time (nursalam, 2008). documentation is evidence of recording and reporting that is owned by nurses in a useful record for the importance of clients, nurses and the medical team in providing health services on the basis of accurate and complete data written as a nurse’s responsibility (suprapto, 2013). nursing documentation can be used as the responsibility and accountability of the various possible problems experienced by the patient or client and consists of satisfaction or dissatisfaction of the healthcare provided (nursalam 2008). nursing documentation that is timely, accurate and complete is not only important to cover and protect nursing, but it is also important to help patients and clients to get better nursing care (depkes, 1996). implementation of nursing documentation is a measure to determine, monitor and conclude https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:devi@poltekkespalembang.ac.id http://dx.doi.org/10.20473/jn.v13i1.3478 d. mediarti et al. 32 | pissn: 1858-3598  eissn: 2502-5791 organized nursing care services in hospitals (setiadi, 2012). a study in indonesia carried out by the department of health mataram west nusa tenggara province in 2013 showed that 71.60% of nursing documentation was incomplete (dinas kesehatan nusa tenggara barat, 2013). nursing documentation in the south sumatera province in the inpatients unit of general hospital of prabumulih 2012 showed that 65.62% of nursing documentation was incomplete and 34.37% of nursing documentation was complete (zakiroh, 2013). the phenomenon of incomplete nursing documentation was influenced by many factors, among them individual nurse’s characteristics, including education, age, sex, length of service and knowledge. psychological factors include motivation and organization factors. (gibson and ivancevich 2002 cited in nursalam, 2008). the results of interviews with nurses who served in the intensive care room found that many nurses, while on duty in the room, didn’t properly complete the nursing documentation. education influenced the implementation of nursing documentation strongly. nurses with different levels of education will have different quality of documentation, because the higher the level of education, the cognitive abilities and skills will increase as well (notoatmodjo, 2003). performance of hospitals is influenced by its nursing service. nursing service is highly dependent on nurses’ performance, in which the nurses’ performances were strongly influenced by the motivation of nurses in nursing documentation. this is in accordance with davis’s opinion (1998 cited in abdullah, 2012), who said that among the factors which may affect the achievement of nurses’ performance in nursing documentation was ability and motivation. in the results of a preliminary study conducted by researchers, data from general hospital of palembang bari obtained total nurses, dental nurses and midwives throughout hospitalization amounting to 290 people. for the number of nurses who served in the installation intensive care there were 46 people with a total capacity of 15 beds. incompleteness of medical records of all inpatient status of general hospital of palembang bari in 2013 was 40.03%, in 2014 it was 30%, and in 2015 31.8%. (medical records of general hospital of palembang bari). based on the description, the researchers were interested in conducting research with the title “nurses education and motivation towards nursing documentation”. the purpose of the study was to know the correlation between education and motivation of nurses towards nursing documentation. the gap analysis of the study could not check the completeness of nursing documents and appropriate nursing language, because the data were collected by questionnaire. materials and methods this study used analytic survey with cross – sectional approaches. the data in this study were obtained using a questionnaire and observation sheets and analyzed by chi square. total population in this study were all nurses who served in the installation intensive care unit of general hospital of palembang bari 2016 with as many as 46 nurses and 44 samples obtained with a total sampling technique appropriate to the inclusion criteria. the inclusion criteria were: 1) willing to be a respondent, 2) not in a period of sickness, permit, or suspension, 3) being in place during research. independent variables were nurses’ education and motivation and the dependent variable was nursing documentation. this study was conducted in the installation intensive care of general hospital of palembang bari between 20 – 25 april 2016. results the result of this study will be explained based on the information presented in the tables. the result of this study was analyzed by univariate and bivariate using chi–square. the result showed respondent’s characteristics in installation intensive care general hospital, nurses’ education and motivation towards nursing documentation. table 1 shows that nursing documentation with good category were 31 respondents (70.5%), respondents with low education were 30 respondents (68.2%). respondents with strength motivation category were 28 (63.6% table 1 distribution of respondents’ characteristics in installation intensive care general hospital of palembang bari on april 2016 characteristics n % nursing documentation good not good 31 13 70.5 29.5 total 44 100 education high (bachelor) low (diploma) 14 30 31.8 68.2 total 44 100 motivation strength weak 28 16 63.6 36.4 total 44 100 jurnal ners http://e-journal.unair.ac.id/jners | 33 table 2 shows that respondents with higher education (bachelor) undertook good nursing documentation with as many as 13 respondents (92.9%) out of 14 respondents, higher if compared with respondents with lower education (diploma), which served in documentation of nursing with as many as 18 respondents (60%) from 30 respondents. chi–square analysis obtained p – value 0.035 < α (0.05) which means there was correlation between nurses’ education towards nursing documentation. odds ratio (or) = 8.667, which means chance of nursing with high education is 8.677 times better in documentation of nursing than nurses with low education. table 3 shows that respondents with strong motivation during nursing documentation with good category were 23 respondents (82.1%). chi – square analysis obtained p – value 0.040 < α (0.05), which means there was correlation between nurses’ motivation towards nursing documentation. odds ratio (or) = 4.600, which means nurses strong motivation was 4.600 times better in nursing documentation than nurses with weak motivation. discussion the independent, complex role of a school nurse requires accurate documentation of assessments, interventions and outcomes. consistent documentation by all school nurses is crucial to study the impact of nursing interventions on student’s health and success in school. while standardized nursing languages are available, the actual use of these languages by school nurses is in the infancy stages of implementation. this national survey of school nurses reveals diverse practices in school nursing documentation. the result of study conducted by kay and yearous (2011) shows the implementation of nursing language (nanda, noc, nic) will allow school nurses to document more consistently, base practice decisions on evidence, and improve the health and academic success of students in schools. it means that, starting from school, nurses must have optimal education of nursing documentation. nursing documentation is an important part of clinical documentation. a thorough nursing documentation is a precondition for good patient care and for efficient communication and cooperation within the healthcare professional team (ammenwerth, et al., 2001). nursing documentation is an indicator of the performance of nursing while performing nursing care that can be seen from the implementation of nursing documentation. without nursing documentation, all of the nursing implementation done by nurses has no meaning in terms of responsibility and accountability (dellefield, 2006). nursing documentation is one of the efforts required to establish and maintain accountability of nurses and nursing (webster new world dictionary cited in marelli, 2007). nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. to exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents (saranto and kinnunen, 2009). the implementation of nursing documentation a measure in determining, monitoring and concluding nursing care service organized by the hospital (fischbach, 1991 in setiadi, 2012). education is greatly influenced the implementation of nursing documentation. nurses with different levels of education will have different quality of documentation, because the higher the level of education, the cognitive abilities and skills will increase as well (notoatmodjo, 2003). wawan and dewi (2010) stated that the higher a person’s education, the more easily to receive information, so that they can make a decision to do the documentation. whereas siagian (2010) states table 2 distribution of nurses’ education towards nursing documentation in installation intensive care general hospital of palembang bari on april 2016 education nursing documentation total % good not good n % n % high (bachelor) low (diploma) 13 18 29.5 40.9 1 12 4.1 27.3 14 30 31.8 68.2 total 31 70.5 13 29.5 44 100 p-value = 0.035 or = 8.667 table 3 distribution of nurses’ motivation towards nursing documentation in installation intensive care general hospital of palembang bari on april 2016 motivation nursing documentation total % good not good n % n % strength weak 23 8 52.3 18.2 5 8 11.4 18.2 28 16 63.6 36.4 total 31 70.5 13 29.5 44 100 p-value = 0.040 or = 4.6 d. mediarti et al. 34 | pissn: 1858-3598  eissn: 2502-5791 that higher education would increase the motivation, desire and intellectual maturity in the application of the complete documentation. gibson and ivancevich (1995) state that higher education levels generally lead to someone being more able and willing to accept responsibility. this will affect the completeness of the nursing documentation. nursing services are highly dependent on the performance of nurses, which is strongly influenced by the performance of nurse’s motivation (broderic and coffey 2013). this is in accordance with the opinion of davis (1997) cited in abdullah, 2012) who said that the factors that may affect the achievement of the nurses’ performance in nursing documentation include capability and motivation. nursing documentation requires nurses motivation that comes from the heart, to create nurses’ strong motivation, and the need to be aware of the need and importance of nursing documentation (swanburg, 2000). proper motivation will encourage the employees to do as much as possible in carrying out their duties because they believe that the success of the organization in achieving the goals and targets of various personal interests of members will be fulfilled also (siagian, 2010). ilyas (2001) said that if someone is motivated and concerned they will strive to improve achievement. the result of this study showed that there was significant correlation between nurses’ education towards nursing documentation in installation intensive care general hospital of palembang bari 2016. the result of a study conducted by pratiwi et al. (2013) regarding the correlation of education levels and long period of works towards the completeness of nursing documentation in general hospital of tugumulyo, tugurejo, semarang, showed that there was significant correlation between education levels towards the completeness of nursing documentation. researchers assumed that the education level of nurses had an important role in quality of nursing documentation as a good or not good indicator of nursing service in hospitals that will improve the quality of the hospital so that appropriate care quality standards will be achieved. the result is that a higher level of a nurse’s education will improve the quality of nursing documentation in the nurse’s work areas. this is because the level of education will affect the cognitive ability and intellectual maturity and motivation of the nurses (voyer et al., 2014). the current study conducted by tuinman et al. (2017) found inaccuracies in the content and coherence of nursing documentation in long-term institutional care. this may complicate communication between health professionals, data extraction by managers for quality and reimbursement purposes and also jeopardize residents’ safety and wellbeing. taking into account the increasing acuity levels of residents, managers should reconsider whether the available nursing staff and resources are sufficient to provide for accurate nursing documentation. investments in resources (e.g., time, structured (electronic) careplans) may be required to facilitate accurate documentation. furthermore, the reasoning skills of nursing staff should be investigated and trained, tailored to their educational background and scope of practice, to ensure that they competently perform their careplanning job responsibilities. implementation of professional standards in accordance with legal requirements and regular audits may further enhance the quality of nursing documentation. the result of the study conducted by the researcher showed that there was correlation between nurses’ motivation towards nursing documentation in installation intensive care general hospital of palembang bari 2016. the study conducted by pakudek et al. (2014) about the correlation of nurses’ motivation towards nursing documentation in installation inpatient c of rsup prof. dr. kandou manado, showed that there was significant correlation between nurses’ motivation towards nursing documentation. the researcher assumed that the level of nurses’ motivation had an important role in quality of nursing documentation, as good or not good indicators of a nurse’s service in the hospital, which will improve the quality of the hospital so that appropriate care quality standards will be achieved. in our opinion, a high acceptance of the nursing process, a careful preparation of predefined care plans (at least partly based on standardized vocabulary), together with elementary measures, such as organizational preparation, good project management, inclusion of future users in the preparation process, and sufficient technical equipment with integration into the hospital information system, are important preconditions for the success of nursing process documentation (ammenwerth et al., 2001). this confirms the results of other studies. in addition, the nursing terminology and the nursing care plans must be regularly maintained and updated, taking into account the development of skills and experiences of the users (wang et al., 2011). as a result, the higher level of a nurse’s education will improve the quality of nursing documentation in the nurse’s work areas. this is because the level of a nurse’s motivation will influence their performance and the motivation to give the nurses a direction of interest in doing their job. conclusion education and motivation of nurses have significant relationship to the nursing documentation in hospital intensive care unit. this was due to the high level of education and a strong motivation level which will provide quality nursing care. the hospital management is expected to provide opportunities and encourage hospital human jurnal ners http://e-journal.unair.ac.id/jners | 35 resources, especially for nurses to be able follow appropriate education hierarchically. this is in accordance with the demands of legislation governing nursing education, and it should hold trainings on documentation. future research is expected to add methodology, sample, variables and other factors related to the nursing documentation in the installation intensive care. references alligood, m. and tomey, a. (2006). nursing theorist and their work. 6th ed. st. louis: mosby elsiver, inc. ammenwerth, e., kutscha, u., kutscha a., mahler, c., eichstädter, r. and haux, r. (2001). nursing process documentation systems in clinical routine—prerequisites and experiences. international journal of medical informatics, 64, pp.187–200. aziz, a.a. (2003). riset keperawatan dan teknik penulisan ilmiah, jakarta: salemba medika. broderic, m. and coffey, a. (2013). person-centered care in nursing documentation. international journal of older people nursing, 8, pp.309–318. [online] available at: http://dx.doi.org/10.1111/opn.12012. (accessed: august 8, 2016). davis, k. (1997). human behavior at work. organization behavior. 8th ed. singapore: mc. graw-hill. international. dellefield, m. (2006). interdisciplinary care planning and the written care plan in nursing homes: a critical review. gerontologist, 46, pp.128–133. depkes, r. (1996). konsep dan proses keperawatan, jakarta: departemen kesehatan. fischbach, f. (1991). documenting care communication, the nursing process and documentation standards, philadelphia: f.a davis company. gibson, j. and ivancevich, j. (1995). organisasi, perilaku, struktur, proses, jakarta: binarupa aksara. ilyas, y. (2001). kinerja: teori, penilaian, dan penelitiann, depok: pusat kajian ekonomi kesehatan fkm ui. kay, s. and yearous, g. (2011). school nursing documentation: knowledge, attitude, and barriers to using standardized nursing languages and current practices. lowa research online. [online] available at: htp://ir.uiowa.edu/etd/3411 (accessed: august 8, 2016). kelengkapan pengisian dokumentasi pengkajian asuhan keperawatan di rsud tugurejo semarang. stikes telogorejo2. marelli, m. (2007). dokumentasi keperawatan 3rd ed., jakarta: egc. notoatmodjo, s. (2003). pendidikan dan perilaku kesehatan, jakarta: rineka cipta. nursalam, n. (2008). pendidikan dalam keperawatan, jakarta: salemba medika. pakudek, k.h., robot, f.j. and hamel, r. s. (2014). hubungan motivasi perawat dengan pelaksanaan dokumentasi keperawatan di instalasi rawat inap c rsup prof dr. kandou manado. jurnal keperawatan, 2(2). pratiwi, p.p., suryani, m. and sayono, (2013). hubungan tingkat pendidikan dan lama kerja dengan saranto, k. and kinnunen, u., (2009). evaluating nursing documentation e research designs and methods: systematic review. j adv nurs, 65, pp.464–476. setiadi, (2012). konsep dan penulisan dokumentasi keperawatan: teori dan praktik, yogyakarta: graha ilmu. siagian, s.p. (2010). teori motivasi dan aplikasinya, jakarta: rineka cipta. suprapto, (2013). dokumentasi keperawatan, yogyakarta: nuha medika. swanburg, r. 2000. pengantar kepemimpinan dan manajemen keperawatan, jakarta: egc. tuinman, a., de greef, m.h.g., krijnen, w.p., paans, w. and roodbol, p.f. (2017). accuracy of documentation in the nursing care plan in longterm institutional care. geriatric nursing, 20, pp.1–6. [online] available at: http://dx.doi.org/10.1016/j.gerinurse.2017.04.0 07 (accessed: august 8, 2016). voyer, p., mccusker, j. and cole, m. (2014). nursing documentation in long-term care settings: new empirical evidence demands changes be made. clinical nursing research, 23, pp.442–461. [online] available at: http://dx.doi.org/10.1177/1054773813475809 (accessed: august 8, 2016). wang, n., hailey, d. and yu, p. (2011). quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. journal of advanced nursing, 67 (9), pp.1858– 1857. [online] available at: http://dx.doi.org/10.1111/j.13652648.2011.05634.x (accessed: august 8, 2016). wawan, a. and dewi, m. (2010). teori dan pengukuran pengetahuan, yogyakarta: nuha medika. zakiroh, n. (2013). hubungan antara asuhan keperawatan di instalasi rawat inap rumah sakit muhammadiyah palembang. stikes muhammadiyah palembang. http://dx.doi.org/10.1016/j.gerinurse.2017.04.007 http://dx.doi.org/10.1016/j.gerinurse.2017.04.007 http://dx.doi.org/10.1177/1054773813475809 http://dx.doi.org/10.1111/j.1365-2648.2011.05634.x http://dx.doi.org/10.1111/j.1365-2648.2011.05634.x http://e-journal.unair.ac.id/jners 1 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 1 http://dx.doi.org/10.20473/jn.v17i1.35400 editorial open access transforming nurses from frontline to front leaders: lesson learned from the pandemic ferry efendi1,* 1 faculty of nursing, universitas airlangga, indonesia *correspondence: ferry efendi. address: unair campus c mulyorejo, surabaya city 60115, indonesia. email: ferry-e@fkp.unair.ac.id the coronavirus disease 2019 (covid-19) pandemic has changed all aspects of life, including the way people work and interact with each other. during the pandemic, several essential industries, not to mention healthcare workers, have had to endure the chaotic or lifethreatening situation to keep working at desks to ensure that the pandemic can be tackled. their actions are initially a kind of contribution that is rarely noticed by the public, but they have begun to be recognized as the new everyday heroes. nurses are the frontline workers among other health workers who face the covid-19 virus or other deadly infectious disease. nurses directly provide essential healthcare services where they are most needed, both in hospital and community settings. not only physical energy will be exploited, but mental sacrifices can also be affected. this phenomenon has been proven by the increase in mortality rate among nurses worldwide. the international council of nurses’ latest data showed that more than 1500 nurses have died from covid-19 in 2020 (international council of nurses, 2020) and up to 180,000 health and care workers could have died from covid-19 in 2021 (world health organization, 2021). this crisis emerged the demand for nurses who intend and are able to substitute for those who have fallen. this challenging situation leads nurses to be capable of managing the crisis and, at the same time, they can be the new leaders on the frontline. the lesson learned that can be recorded from the covid-19 pandemic, is that nurses as the frontline workers continue to manage a tough healthcare facilities environment in order to save many people from covid19. they are potential candidates being front leaders as they have had experienced treating clients and community in quite complex ways during the pandemic. because of that, it is essential to perceive them as future leaders such as by providing greater policy support at a national level. equal opportunity to contribute to policy making process would create a solid environment for nurses. standardized regulation on decent job and salaries also needs to be developed in order to protect the welfare of nurses. it goes without saying that nurse’s salary in indonesia varies across sectors, even though the nurses are often going beyond their duties, many of them have been expected to accomplish more with less appreciation. these unfair situations should be transformed into a good situation by equipping the nurses with decent salaries equal to other frontline health workers. talent management of nurses also needs to be developed at national level to accommodate regeneration and succession as a leader. this strategy will impact on how nurses can have the same benchmark as other health professions both regionally and nationally. a recent call from the world health organization (2020) mandated three pillars of essential aspects, namely, investment, education, jobs and leadership. this pandemic has opened an opportunity for nurses to move up the leadership ladder and expand the leadership position in every setting. to sum up, we might call the frontline nurses’ personnel as heroes in the pandemic era; however, just labelling them without also considering what they have to say eliminates any chance of progress. concrete policy implementation is crucial, investing in the education sector is inevitable, and bottom-up coordination is critical in ensuring that frontline views are heard. regardless of whether or not things are optimal, frontline nurses show up and perform their duties as do any leader who serves and protects clients and community. references international council of nurses. (2020, october 28). icn confirms 1,500 nurses have died from covid-19 in 44 countries and estimates that healthcare worker covid-19 fatalities worldwide could be more than 20,000 | icn international council of nurses. https://www.icn.ch/news/icn-confirms-1500-nurses-have-diedcovid-19-44-countries-and-estimates-healthcare-worker-covid world health organization. (2021, october 20). health and care worker deaths during covid-19. https://www.who.int/news/item/20-102021-health-and-care-worker-deaths-during-covid-19 world health organization, icn, & nursingnow. (2020). state of the world’s nursing 2020: investing in education, jobs and leadership. world health organisation. https://www.paho.org/es/documentos/situacion-enfermeriamundo-2020-resumen-orientacion https://creativecommons.org/licenses/by/4.0/ mailto:ferry-e@fkp.unair.ac.id https://orcid.org/0000-0001-7988-9196 icn2020 who2021 who2020 138 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, pp. 138-143 http://dx.doi.org/10.20473/jn.v17i2. 36860 original article open access the incidence and factors predicting survival among preterm infants with respiratory distress syndrome admitted to neonatal intensive care unit naphaklacha pholanun1,* , boonjai srisatidnarakul1 , and joy longo2 1 faculty of nursing, thammasat university, bangkok, thailand 2 college of nursing, florida atlantic university, florida, usa *correspondence: boonjai srisatidnarakul. address: faculty of nursing, thammasat university, bangkok, thailand. email: jenjaisri@gmail.com responsible editor: ferry efendi received: 22 may 2022 ○ revised: 8 september 2022 ○ accepted: 30 september 2022 abstract introduction: respiratory distress syndrome (rds) or hyaline membrane disease (hmd) is the most common cause of neonatal morbidity and mortality in preterm infants. the aims of the study were to determine the incidence of rds in preterm infants in thailand and to identify factors predicting survival of preterm infants with rds. methods: a retrospective cohort study was conducted with 820 preterm infants from january 2016 to december 2019 in the neonatal intensive care units (nicus) of a tertiary hospital located in the north of thailand. data were collected from hospital medical records. the incidence of rds was analyzed. binary logistic regression was used to predict factors related to survival of preterm infants with rds. results: the incidence of rds in infants born at <37 weeks’ gestation was 44.15% of all preterm infants. this study showed that birth weight and length of stay could significantly predict survival of preterm infants with rds (p<0.05). conclusions: the current study found that the incidence remains a problem, while birth weight and length of stay predicted survival of preterm infants with rds. these findings provide nurses and other healthcare providers with information to anticipate care required in the nicu to improve survival of preterm infants. this information can be used to plan care for the infant and to educate and support parents. keywords: incidence, survival, preterm infant, respiratory distress syndrome introduction a primary concern of preterm infants remains a challenge as approximately 15 million are born preterm per year (who, 2018). prematurity can lead to many physical health issues that contribute to morbidity and mortality in preterm infants (who, 2017). around 1 million preterm infants die each year from complications such as pneumonia, sepsis, necrotizing enterocolitis, and respiratory distress syndrome (liu et al., 2016; who, 2017). rds is the most common cause of morbidity and mortality in preterm infants (reuter, moser and baack, 2014; fraser, 2015). moreover, rds is the most common cause for preterm infants to be hospitalized in neonatal intensive care units for invasive or non-invasive respiratory support (moya et al., 2019). evidence indicates that rds occurs in approximately 5% of near-term infants, 30% of infants less than 30 weeks of gestational age, and 60% of premature infants less than 28 weeks of gestational age (pramanik, rangaswamy and gates, 2015). in thailand, evidence indicates that the incidence of rds occurs in approximately 50 % of preterm infants (sangpanit et al., 2020). respiratory distress syndrome (rds), also known as hyaline membrane disease (hmd), is the most common https://creativecommons.org/licenses/by/4.0/ mailto:jenjaisri@gmail.com http://orcid.org/0000-0002-1992-6618 http://orcid.org/0000-0002-9320-0655 https://orcid.org/0000-0001-9822-0885 jurnal ners http://e-journal.unair.ac.id/jners 139 respiratory disorder in infants (fraser, 2015). it is caused by a deficiency of alveolar surfactants, which cover the alveolar surface, leading to atelectasis (warren and anderson, 2010), ventilation-perfusion inequality, and hypoventilation (pramanik, rangaswamy and gates, 2015). rds is divided into three levels; mild, moderate, and severe rds (qari et al., 2018). the clinical features of rds, including dyspnea, tachypnea, nasal flaring, inspiratory stridor, grunting, and cyanosis, appear immediately after birth or within 48-72 hours (qari et al., 2018). the administration of surfactant, a natural lipoprotein, into the alveoli may relieve an infant’s respiratory distress syndrome (donn and sinha, 2006; bahadue and soll, 2012). although this treatment improves pulmonary function, a lack of alveolar growth from immaturity can reduce the surface area for gas exchange and lead to mortality (bahadue and soll, 2012). according to a literature review, previous studies examined that factors of gestational age (ga), birth weight, mother’s age, route of delivery (mekasha et al., 2020), rds level, surfactant and length of stay (saboute et al., 2015), were associated with survival rates of preterm infants with rds. although there are studies regarding prematurity and rds from other countries, information about infants born in thailand is scarce. therefore, the purpose of this study was to: 1) determine the incidence of rds in preterm infants and 2) examine factors that predict survival of preterm infants with rds in thailand. materials and methods this study was a retrospective cohort study of preterm infants hospitalized in the nicus of a tertiary hospital located in the north of thailand because there is the highest rate of preterm births in thailand. the study was conducted in a tertiary care center which serves as a referral center for hospitals from the seven provinces located in the northern region of thailand. data were collected from electronic health records. the sample consisted of preterm infants < 37 weeks gestational age, both being diagnosed as rds and not diagnosed as rds, who were admitted to the nicus of the tertiary hospital for at least one day from january 1, 2016 to december 31, 2019. preterm infants who had congenital abnormalities, congenital heart disease, and incomplete data were excluded. for preterm infants who were diagnosed with rds, they were divided into three groups: mild, moderate, and severe table 1 diagnoses of all participants (n=820) disease numbers percent rds mild rds moderate rds severe rds 362 116 153 93 44.15 14.15 18.65 11.35 ttnb 251 30.61 birth asphyxia (ba) 86 10.49 sepsis 37 4.51 pneumonia 27 3.29 others 57 6.95 total 820 100.00 figure 1. the flow diagram of the study medical records of preterm infants from january 1, 2016, to december 31, 2019 (n=1021) included (n=820) excluded (n=201) congenital abnormally congenital heart disease missing data ttnb (251 cases) birth asphyxia (86 cases) sepsis (37 cases) pneumonia (27 cases) others (57 cases) rds (362 cases) mild (116 cases) moderate (153 cases) severe (93 cases) mortality survival (299 cases) death (63 cases) pholanum, srisatidnarakul, and longo (2022) 140 p-issn: 1858-3598  e-issn: 2502-5791 rds. rds severity was determined by the neonatal physicians at the target hospital. mild rds is defined as partial pressure of oxygen (po2) of 50-80 mmhg and fraction of inspired oxygen (fio2) of less than 0.3, while moderate rds is defined as po2 of 50-80 mmhg and fio2 of 0.4-0.6 and requires continuous positive airway pressure (cpap) (luerti et al., 1987). severe rds is defined as po2 less than 50 mmhg or pco2 higher than 60 mmhg with fio2 at 0.4-1.0 and ventilation (luerti et al., 1987). data as predicting factors of this study were collected and recorded from electronic health records (ehr), including survival, gestational age (ga), mother’s age, route of delivery, birth weight (bw), rds level, surfactant dose, and length of hospital stays (los) of preterm infants with rds. the software package spss version 24 was used to perform the statistical analysis. the incidence of rds in this study was calculated as the number of preterm infants with rds divided by the total number of admitted preterm infants during the study period. chisquare test was used to examine correlation between predicting factors and survival of preterm infants with rds. in addition, probability of factors affecting survival of preterm infants with rds were analyzed using multivariate logistic regression analyses. p-value less than 0.05 was considered statistically significant. ethical approval for the study was obtained from the institutional review board (irb) of the university (project no.068/2563) and the hospital (project no.229/63). after ethical approvals were obtained, a researcher contacted the staff at the her department of the hospital who were responsible for keeping ehrs in order to explain the objectives, and the procedure for the study, and to seek assistance with obtaining the data. the ehrs of every preterm infant who were admitted to the nicus of the tertiary hospital for at least one day from january 1, 2016 to december 31, 2019 were reviewed by the researchers. the preterm infants’ data, including the demographic data and data related to rds, were reviewed for study variables. the preterm infants whose ehr were incomplete on study variables and had congenital abnormalities or congenital heart disease were excluded. the researchers recorded the data of all qualifying preterm infants in a specific data collection sheet in excel program that the researchers developed and rechecked again before analyzing via spss program. results incidence of rds among preterm infants for the study, 1,021 preterm infants’ charts were reviewed. of these, 201 preterm infants were excluded from the study due to congenital heart disease, congenital anomalies, and missing data (figure 1). therefore, 820 preterm infant charts were included (figure 1). of these, 56.3% were male, 51.46% were moderate to late preterm infants (ga 32 to less than 37 weeks) and 41.22% were born with birth weight greater than 1,500 grams. for the mothers, 62.3% were between the ages of 20 and 35 years old, and 53.90% delivered vaginally. as many as 362 out of 820 (44.15%) preterm infants were diagnosed with rds. other common causes of admission were transient tachypnea of the newborn (ttnb), birth asphyxia, sepsis, apnea and pneumonia (table 1). moreover, the results revealed that 45.58% of preterm infants with rds were very preterm (ga 2832 weeks), 42.82% had birth weight at 1,000-1500 grams. 86.7% received one dose of surfactant and 32.04% were admitted to the hospital between 31-60 days. factors predicting survival of preterm infants with rds for total number of preterm infants with rds were 362; 299 cases (82.60%) survived, and 63 cases (17.4%) table 2 correlations between factors and survival of preterm infants with rds independent variables survival group non-survival group p value number (299) number (63) ga at birth (weeks) (mean=30.29, sd=2.70) (mean=26.28, sd=3.06) <0.001 less than 28 28 <32 32< 37 44 149 106 42 16 5 mother’s age (years) (mean=28.15, sd=7.89) (mean=26.75, sd=8.33) 0.087 <20 20 – 35 >35 101 131 67 29 23 11 route of delivery vaginal delivery cesarean section 167 132 40 23 0.160 birth weight (grams) (mean=1447.80, sd=521.03) (mean=867.06 , sd=291.70) <0.001 <1,000 1,000-1,499 ≥1,500 48 142 109 48 13 2 rds level mild rds moderate rds severe rds 113 123 63 3 30 30 <0.001 surfactant dose 1 dose ≥2 doses 268 31 46 17 <0.001 length of stay (days) (mean=46.76, sd=38.22) (mean=20.24, sd=37.71) <0.001 1-15 16-30 31-60 >60 58 52 111 78 45 8 5 5 jurnal ners http://e-journal.unair.ac.id/jners 141 did not. the study identified significant correlation between seven factors, including ga at birth, mother’s age, route of delivery, birth weight, rds level, surfactant dose, and length of hospital stay, and survival of preterm infants with rds. the results showed that ga at birth, birth weight, rds level, surfactant dose, and length of stay statistically significantly related to survival of preterm infants with rds between the groups in terms of (p<0.05). discussions in the current study, we have reviewed the incidence of rds in preterm infants admitted to nicus in the northern region of thailand. the results of this study found that 44.15% of the overall preterm infants suffered from rds, which is quite similar to a study by caner et al. (2015) who reported an incidence rate of 40.6%. however, the incidence of rds in this study is lower than some previous studies. saboute et al. (2015) presented the incidence of rds to 65.5% of preterm infants while zhang et al. (2015) reported the incidence of rds in 50%. most preterm infants of the current study (45.58%) were very preterm infants (ga 28-32 weeks), which is similar to saboute et al., (2015) and zhang et al. (2015). in saboute et al.’s (2015) study, 52.1% of participants were very preterm (28-32 weeks) while zhang et al. (2015) reported the incidence of rds in preterm infants with ga less than 30 weeks at 50%. prematurity is a major cause of rds. infants whose ga is less than 37 weeks have immature lungs and surfactant deficiency, which can lead to rds (fraser, 2015). premature infants who have lower ga have higher rate of rds than ones who have higher ga (margoushy, 2017). the findings of this study confirm that rds can occur in preterm infants, especially those with a lower ga. therefore, preventing preterm birth is the most important for healthcare providers and necessary approach to prevent rds in infants. in addition, this study found that birth weight and length of hospital stay could statistically significantly predict the survival of preterm infants with rds from thailand (p<0.001) (table 3). for birth weight, preterm infants with rds and low birth weight tend to be 20 times more likely to not survive than preterm infants with rds and higher weight. this result is similar to a study by intayote et al. (2019) which indicated that preterm infants with rds who had low birth weight had a lower survival rate than those who have normal weight. the present research study is also consistent with studies by wang et al. (2017) and rojsanga (2018) which reported that birth weight positively affected an infant’s survival. previous studies indicated that survival of infants was very low in infants less than 1000 grams (vilanova et al., 2019; west, 2021). the findings of the present study found that the majority of the survival group (47.5%) had birth weight at 1,0001,499 grams whereas those of the non-survival group (76.2%) had birth weight less than 1,000 grams (table 2). this result confirms that birth weight affects survival of preterm infants. this might be possible because low birth weight preterm infants have low growth and immature organ development. this can increase complications and death (belay et al., 2022). therefore, birth weight of preterm infants with rds could predict survival of preterm infants with rds. in addition, the findings of this study suggested that the length of stay could be 35 times more likely to significantly predict survival of preterm infants with rds (p<0.001). the result is different from a previous study which illustrated that there was no significant relationship between los and survival among preterm infants with rds (saboute et al., 2015), but it is consistent with a study by karunarathna (2018). the finding demonstrates that prolonged los can influence increased survival of preterm infants with rds. this is likely to due to the fact that most of the non-survival group of this study died early. the data of the present study (table 2) demonstrated that most of the nonsurvival group had shorter length of stays (1-15 days) and more severe rds than the survival group whereas the majority of the survival group had longer length of stays (31-60 days) and milder and more moderate rds than the non-survival group. severe rds can cause death in preterm infants at an earlier stage, especially within the first two to three weeks of birth (patel et al., 2017; van beek et al., 2021). this can influence short length of hospital of non-survival preterm infants. another reason might be that the survival group might receive appropriate and timely interventions, such as surfactant therapy and continuous respiratory support. therefore, the length of stay could be a predictor of survival of preterm infants with rds. however, we do not have detailed data for an in-depth explanation of this result. further studies about length of stay and table 3 multivariate logistic regression of factors for survival of preterm infants with rds predicting factors odds ratios 95%ci p-value gestational age at birth 0.080 0.807-1.333 0.788 birth weight 20.404 1.003-1.007 <0.001 surfactant 0.182 0.379-1.864 0.669 mild rds 3.839 0.268-1.925 0.147 moderate rds 3.219 0.051-1.140 0.073 severe rds 3.733 0.033-1.025 0.053 length of stay 35.516 1.031-1.061 <0.001 pholanum, srisatidnarakul, and longo (2022) 142 p-issn: 1858-3598  e-issn: 2502-5791 survival of preterm infants with rds need to be conducted to clearly confirm this relationship. this study has some limitations. firstly, it was conducted in a single tertiary hospital. this might limit the generalization of the findings. therefore, further studies should be conducted in multiple settings with a prospective study. in addition, there might be other factors that affect survival of preterm infants with rds, such as prenatal factors, that are not considered in this study. therefore, future research studies should consider these factors. conclusions the results of this study have shown that rds is frequent in preterm infants and incidence was inversely associated with gestational age. moreover, factors predicting survival of preterm infants with rds were birth weight and length of stay. birth weight and length of stay can increase probability of survival of preterm infants with rds. the findings of this study about incidence and factors predicting rds in preterm infants may be important data for healthcare professionals in increasing awareness of rds in preterm infant and searching appropriate care to prevent rds in preterm infants or improve survival in preterm infants with rds. prevention of preterm birth is a crucial role of maternity nurses by screening, educating, and counselling pregnant women throughout pregnancy. in addition, helping preterm infants with rds increase body weight and length of stay are roles that nurses in nicus should consider. acknowledgment we would like to thank the director and the staff at the electronic health record department of buddhachinnaraj hospital, thailand, for allowing us to collect data for this research. conflict of interest no conflict of interest has been declared by the authors. references bahadue, f. l. and soll, r. (2012). early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. cochrane database of systematic reviews, 14(11). doi: 10.1002/14651858.cd001456.pub2. belay, d. m., worku, w. z., wondim, a., hailemeskel, h. s. and bayih, w. a. (2022). predictors of survival among preterm neonates admitted to felege hiwot comprehensive specialized hospital, northwest ethiopia. frontiers in pediatrics, 10, p.800300. https://doi.org/10.3389/fped.2022.800300 caner, i., tekgunduz, k. s., temuroglu, a., demirelli, y. and kara, m. (2015). evaluation of premature infants hospitalized in neonatal intensive care unit between 2010-2012. the eurasian journal of medicine, 47(1), pp. 13-20. donn, s. m., and sinha, s. k. (2006). minimizing ventilator induced lung injury in preterm infants. archives of disease in childhood fetal and neonatal edition, 91(3), pp. 226-230. fraser, d. (2015). the high-risk newborn and family. in hockenberry, m. j. and wilson, d. (eds.). wong’s nursing care of infants and children (10th ed.). st. louis, ms: mosby, pp. 336-412. intayote, k., et al. (2019). risk factors for death among preterm infants with respiratory distress syndrome at lampang hospital. journal of health science, 28(1), pp.108-116. karunarathna, m. (2018). predicting icu death with summarized patient data. ieee 8th annual computing and communication workshop and conference (ccwc). doi: 10.1109/ccwc.2018.8301645. liu, l., oza, s., hogan, d., chu, y., perin, j., zhu, j., lawn, j. e., cousens, s., mathers, c. and black, r. e. (2016). .global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the sustainable development goals. lancet, 388(10063), pp. 3027-3035. luerti, m., lazzarin, a., corbella, e. and zavattini, g. (1987). .an alternative to steroids for prevention of respiratory distress syndrome (rds): multicenter controlled study to compare ambroxol and betamethasone. journal of perinatal medicine, 15(3), pp. 227-238. mekasha, a., tazu, z., muhe, l., abayneh, m., gebreyesus, g., girma, a., berhane, m., mcclure, e. m., goldenberg, r. l. and nigussie, a. k. (2020). factors associated with the death of preterm babies admitted to neonatal intensive care units in ethiopia: a prospective, cross-sectional, and observational study. global pediatric health, 7, pp. 1-9. moya, f. r., mazela, j., shore, p. m., simonson, s. g., segal, r., simmons, p. d., gregory, t. j., guardia, c. g., varga, j. r., finer, n. n. and preterm neonate early respiratory management prospective observational study investigators. (2019). prospective observational study of early respiratory management in preterm neonates less than 35 weeks of gestation. bmc pediatrics, 19, p. 147. https://doi.org/10.1186/s12887-019-1518-3 patel, r. m., rysavy, m. a., bell, e. f. and tyson, j. e. (2017). survival of infants born at periviable gestational ages. clinics in perinatology, 44(2), pp.287-303. pramanik, a. k., rangaswamy, n. and gates, t. (2015). neonatal respiratory distress: a practical approach to its diagnosis and management. pediatric clinic of north america, 62(2), pp. 453– 469. qaril, s. a., alsufyani, a., muathin, s. and el margoushy, n. (2018). prevalence of respiratory distress syndrome in neonates. the egyptian journal of hospital medicine. 70(2), pp. 257-264. reuter, s., moser, c. and baack, m. (2014). respiratory distress in newborn. pediatric in review, 35(10), pp. 417-429. rojsanga, w. (2018).effect of surfactant therapy in premature infants with moderate to severe respiratory distress syndrome in udonthani hospital. udonthani hospital medical journal, 26(1), pp. 56-63. saboute, m., kashaki, m. , bordbar, a. , khalessi, n. and farahani, z. (2015). the incidence of respiratory distress syndrome among preterm infants admitted to neonatal intensive care unit: a retrospective study. open journal of pediatrics, 5, pp. 285-289. http://dx.doi.org/10.4236/ojped.2015.54043 sangpanit, t., tinamas, p., khunkaew, a. and khunkaew, s. (2020). 5key to success in nursing care of the premature babies with jurnal ners http://e-journal.unair.ac.id/jners 143 respiratory distress syndrome. royal thai navy medical journal, 47(3), pp. 723-733. van beek, p. e., groenendaal, f., broeders, l., dijk, p. h., dijkman, k. p., van den dungen, f., van heijst, a., van hillegersberg, j. l., kornelisse, r. f., onland, w., schuerman, f., van westeringkroon, e., witlox, r. and andriessen, p. (2021). survival and causes of death in extremely preterm infants in the netherlands. archive of disability children and fetal neonatal education, 106, pp.251-257. doi:10.1136/archdischild-2020-318978 vilanova, c. s., hirakata, v.n., costa de souza buriol, v., nunes, m., goldani. m.z. and da silva, c.h. (2019). the relationship between the different low birth weight strata of newborns with infant mortality and the influence of the main health determinants in the extreme south of brazil. population health metrics, 17, p. 15. wang, s., liou, j-y., chen, c-y., chou, h-c., hsieh, w-s. and tsao, pn. (2017). risk factors for extubation failure in extremely low birth weight infants. pediatrics and neonatology, 58(2), pp. 145150. warren, j. and anderson, j. (2010). newborn respiratory disorders. pediatrics reviews, 31(12), pp. 487-496. west, b. a. (2021). survival rate and length of stay of preterm babies less than 1500 grams in a neonatal unit in port harcourt, nigeria. international journal of contemporary pediatrics, 8(2), pp. 213218. doi: https://dx.doi.org/10.18203/2349-329.ijcp20210104 world health organization. (2017). preterm birth. available at: http://www.who.int/mediacentre/factsheets/fs363/en/ (accessed: 16 november 2020). world health organization. (2018, february 19). preterm birth. available at: http://www. who.int/news-room/factsheets/detail/preterm-birth (accessed: 19 february, 2020) zhang, z., chen, l. and ni, h. (2015). the effectiveness of corticosteroids on mortality in patients with acute respiratory distress syndrome or acute lung injury: a secondary analysis. scientific reports, 5, p. 17654, doi: 10.1038/srep17654. how to cite this article: pholanum, n., srisatidnarakul, b., and longo, j. (2022) ‘the incidence and factors predicting survival among preterm infants with respiratory distress syndrome admitted to neonatal intensive care unit’, jurnal ners, 17(2), pp. 138-143. doi: http://dx.doi.org/10.20473/jn.v17i2. 36860 vol 9 no 1 april 2014.indd 83 pengembangan model pelayanan asuhan keperawatan bayi berat lahir rendah (the development of nursing care services model for low birth weight infants) dessie wanda*, yeni rustina*, happy hayati*, fajar tri waluyanti* *fakultas ilmu keperawatan universitas indonesia kampus ui depok jawa barat 16424 e-mail: dessie@ui.ac.id, abstrak pendahuluan: bayi berat lahir rendah (bblr) mengalami berbagai masalah selama periode peralihan dari intra uterus ke ekstra uterus oleh karena fungsi organ yang immatur. hal ini yang menyebabkan bblr menjadi penyebab kematian kedua di indonesia terutama pada tujuh hari pertama kehidupan bayi. masalah dapat berlanjut di rumah ketika bayi sudah dipulangkan. tujuan penelitian ini adalah untuk mengembangkan model pelayanan asuhan keperawatan pada bblr dan menguji model tersebut. metode: penelitian ini menggunakan desain penelitian kualitatif dan kuantitatif. desain ini dipilih untuk memfasilitasi peningkatan dalam sistem pelayanan kesehatan yang melibatkan perawat dan tenaga kesehatan lain. hasil: pelayanan asuhan keperawatan oleh tim keperawatan terhambat oleh beberapa faktor misalnya: tingkat pengetahuan perawat yang bervariasi, aktivitas pendidikan kesehatan yang tidak optimal, standar operasional prosedur yang tidak lengkap, dilema etik, fungsi paramedis dan sistem dokumentasi. model ini dikembangkan berdasarkan teori conservation and becoming a mother/maternal role attainment, prinsip family-centered care dan masukan dari para pakar hasil focus group discussion. pembahasan: hasil penelitian ini diharapkan dapat meningkatkan kualitas asuhan keperawatan pada bblr untuk mencapai kepuasan perawat dan orangtua dalam memberikan asuhan kepada bayi sehingga dapat menurunkan angka kematian bayi. kata kunci: bayi berat lahir rendah, pelayanan keperawatan, model asuhan keperawatan abstract introduction: low birth weight (lbw) infants deal with various problems during transitional period from intra-uterine and extra-uterine because of immature organs’ functions. this leads to lbw as the second death cause in indonesia, particularly in the fi rst seventh days of infants’ lifes. the problem continues to occur at home when the infants have discharged. this research was aimed to develop the nursing care services model for lbw infants and to test the model. method: the research design was an action research using quantitative and qualitative approach. this design was chosen as it facilitated improvement in health care system, which was involving nurses and other health providers. results: nursing care services provided by the nursing team are hindered by several factors, such as various level of nurses’ knowledge, not optimal health education activities, incomplete standard operational procedure, ethical dilemma, paramedic functions, and documentation system. this model was developed based on conservation and becoming a mother/maternal role attainment theory, family-centered care principles, and input from the experts through focus group discussion. discussion: the result of this research is going to increase the quality of nursing care for lbw infants by achieving nurses’ and parents’ satisfaction in giving care for their infants which can lead to lower infant death rate. key words: model, low birth weight infant, nursing services, action research pendahuluan kelahiran bayi berat lahir rendah ( bblr)/premat u r meny u mba ng a ng k a kematian bayi yang tinggi di indonesia. kela h i r a n bblr /premat u r mer upa k a n penyebab kematian nomor dua pada bayi baru lahir usia 0-7 hari (kematian perinatal) yaitu sebesar 32,3% (depkes, 2008). usia bblr 7 hari pertama merupakan periode kritis dimana bayi harus melalui berbagai penyesuaian kehidupan di luar kandungan. penatalaksanaan segera setelah lahir yang mencakup dukungan respirasi, kehangatan, dan pencegahan infeksi memegang peranan penting dalam memfasilitasi proses adaptasi bayi. bblr juga mempunyai risiko untuk mengalami keterlambatan dalam pertumbuhan dan perkembangannya. oleh sebab itu, bblr harus mendapatkan asuhan keperawatan yang komprehensif tidak saja memperhatikan aspek fi siknya, tetapi juga aspek psikologis termasuk kedekatannya dengan orang tua. asuhan yang berpusat pada keluarga ( family-centered care) 84 jurnal ners vol. 9 no. 1 april 2014: 83–90 akan memberikan rasa aman, meningkatkan kemampuan dalam merawat diri dan bayinya, dan mempromosikan kesejahteraan ibu dan bayi, dengan memperhatikan keyakinan, nilai, tradisi, budaya yang dianut keluarga (straight, 2001) dan dapat meningkatkan kepercayaan diri orang tua pada saat bayinya akan pulang dari rumah sakit (cooper, et al., 2007). setelah bayi pulang dari rs, bayi masih dihadapkan pada berbagai masalah kesehatan. ketidakmampuan orang tua dalam merawat bayi, dan terputusnya asuhan dari rumah sakit ke komunitas menyebabkan kesehatan bayi tidak dapat terpantau secara optimal. bblr mengalami rawat ulang pada dua minggu pertama pasca pulang dari rumah sakit disebabkan karena aspirasi, diare, dan sepsis (rustina, 2005). hal ini berarti bahwa apabila orang tua dilibatkan dalam asuhan selama bayi dirawat dapat meningkatkan kepercayaan diri orang tua dalam merawat bayinya di r umah. asuhan keperawatan lanjutan di komunitas juga penting dilakukan untuk deteksi dini masalah yang timbul pada bblr dan memfasilitasi pertumbuhan dan perkembangan bayi. pengembangan model pelayananasuhan keperawatan pada bblr dengan ruang lingkup di rumah sakit dan komunitas menjadi penting untuk mengurangi risiko rawat ulang pada bblr. artikel ini memberikan gambaran pengembangan model pelayanan-asuhan keperawatan dengan tahapan kegiatan dimulai dengan identifi kasi masalah atau kebutuhan akan perubahan, perencanaan solusi, dan pengembangan model. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah action research, yang menggunakan pendekatan kualitatif dan kuantitatif. desain ini dipilih karena action research memfasilitasi untuk perbaikan suatu sistem pelayanan (streubert & carpenter, 2011). action research terdiri dari empat tahapan yaitu identifikasi masalah (tahap i), pengembangan model (tahap ii), uji coba model (tahap iii), dan evaluasi efektifitas model (tahap iv). artikel ini berfokus pada action research tahap i, ii, dan iii. popu la si d ala m penelit ia n t a hap ini adalah tenaga kesehatan yang terkait dalam pelayanan bblr di unit pelayanan perinatologi rsupn cm dan tenaga kesehatan lain. kriteria partisipan dari kelompok perawat adalah perawat primer dan kepala ruangan; sedangkan partisipan dari kelompok tenaga kesehatan lain dan penunjang adalah farmasis, petugas laboratorium, dan petugas gizi yang dipilih secara purposif. metode yang digunakan pada tahap identifi kasi masalah adalah diskusi kelompok terfok us, st udi dok umentasi, dan st udi literatur. partisipan dalam diskusi kelompok terfokus mencakup sembilan orang partisipan pada kelompok perawat dan tujuh orang partisipan pada kelompok tenaga kesehatan lain dan penunjang. pada tahap kedua yaitu pengembangan model didasarkan pada hasil identif ikasi masalah, studi literatur, dan masukan pakar. tahap ketiga dilakukan uji coba model dengan melibatkan perawat rumah sakit dan perawat puskesmas. hasil ta h a p i : i d e n t i f i k a s i m a s a l a h a t a u kebutuhan tujuan penelitian tahap satu yaitu teridentifikasinya masalah atau kebutuhan berdasarkan data yang terk u mpul dar i berbagai sumber dan metode pengumpulan data. berdasarkan hasil dari diskusi kelompok terfokus dan ditambah dengan hasil studi dokumentasi diperoleh gambaran permasalah terkait pengetahuan perawat, pelaksanaan pendidikan kesehatan, standar prosedur operasional, dilema etik, f ungsi tenaga penunjang, dan sistem pendokumentasian. masalah pertama yang teridentifi kasi adalah terkait pengetahuan perawat. pelayanan keperawatan di ruang perinatologi sudah mengikuti standar yang ada. perawat pun sudah mengetahui perkembangan dalam asuhan keperawatan berdasarkan evidence based, seperti developmental care (asuhan perkembangan), dan perawatan metode 85 pengembangan model pelayanan asuhan keperawatan (dessie wanda, dkk.) kang u r u (pm k). pember ian asi yang merupakan makanan utama bagi bayi juga digalakkan. namun, pelaksanaannya masih terkendala berbagai faktor. faktor yang mempengaruhi keberhasilan pemberian asi berdasarkan keluhan orang tua adalah asi-nya tidak keluar, walaupun demikian perawat terus menggalakkan pemberian asi. selanjutnya, masalah yang ditemukan adalah terkait pelaksanaan pendidi kan kesehatan. pendidikan kesehatan sebagai bagian dari proses perencanaan pulang telah diberikan, tetapi masih terkendala dengan keterbatasan materi edukasi dan dokumentasi pendidikan kesehatan. hal ini mengakibatkan informasi yang disampaikan ke orang tua menjadi tidak sama. hal lai n yang ditemu kan ad alah kebutuhan perawatan akan adanya standar prosedur operasional (spo). pelaksanaan intervensi keperawatan memerlukan suatu acuan, sehingga dalam pelaksanaanya tidak membuat kebingungan pemberi asuhan. beberapa kebingungan yang dikemukakan oleh perawat karena ada perbedaan pandangan antar tenaga kesehatan yaitu tatalaksana pemberian minum pada bayi baru lahir khususnya terkait metode pemberian minum, tatalaksana pmk terkait posisi bayi, dan kriteria berat badan untuk penyapihan bayi dari inkubator. masalah selanjutnya yang ditemukan adalah terkait dilema etik saat pemberian pelayanan-asuhan keperawatan pada bblr. bblr tidak jarang memerlukan perawatan yang lama, namun demikian terkadang bayi dibawa pulang paksa oleh keluarga walaupun bayi masih memerlukan bantuan pemenu ha n nut r isi melalui i n f us at au pemenuhan kebutuhan oksigen dengan alat bantu pernapasan. di satu pihak perawat harus menyelamatkan kehidupan bayi, tetapi di lain pihak perawat juga harus menghargai hak keluarga dalam memutuskan perawatan untuk anaknya. te n aga p e nu nja ng me m fa si l it a si keberhasilan asuhan sesuai lingkup kerjanya, seperti memberi informasi kepada orang tua beberapa hal yang harus dilakukan apabila mau masuk ke ruang bayi, menyiapkan susu sesuai instruksi, memfasilitasi orang tua untuk konsultasi dengan dokter yang merawatnya, mengorientasikan tempat (apotik, laboratorium, bank darah). keluhan yang disampaikan lebih terfokus pada deskripsi tugas masing-masing tenaga penunjang yang kadang tidak sesuai dengan yang seharusnya. a s u h a n ke p e r awat a n juga p e rlu ditunjang oleh sistem pendokumentasian yang memadai. dokumen sudah mengacu pada standar joint comission international (jci). namun, format pengkajian yang digunakan tidak spesifi k untuk neonatus. hal ini terjadi karena mengacu pada jci dimana kebijakannya adalah satu format yang harus dapat digunakan untuk semua anak. hal ini mengakibat ada beberapa data terkait masalah neonatus yang tidak mungkin terisi atau terfasilitasi. tahap ii: pengembangan model model pelayanan-asuhan keperawatan bblr dikembangkan berdasarkan masalah ya ng t e r ide nt i f i k a si, m a su k a n pa k a r, studi literatur dengan mengacu pada teori keperawatan konservasi dari myra e. levine dan teori becoming a mother atau maternal role attainment dari roman t. mercer, serta konsep family-centered care. teori dari mercer dijadikan dasar dalam pengembangan model ini dengan mengintegrasikan teori kon se r va si d a la m p e mb e r ia n a s u h a n keperawatan dan melengkapinya dengan asuhan lajutan di komunitas. rancangan awal model yang telah dikembangkan dibahas dalam suatu kegiatan pra workshop untuk mendapat masukan dari para pakar. pra workshop dilaksanakan dengan mengundang partisipan (individual) yang mempunyai pengalaman bekerja di world health organization (who), kementrian kesehatan, puskesmas, dan rumah sakit yang diwakili oleh perawat dua rumah sakit rujukan di jakarta. tujuan umum dari pra workshop ini adalah teridentifi kasinya garis besar komponen pelayanan/asuhan keperawatan. beberapa masukan penting yang didapat dari pra-workshop adalah pelayanan bayi baru lahir khususnya terkait dengan kompetensi perawat perlu mendapat perhatian. hasil survei mengindikasikan bahwa perlu ada intervensi khusus pada perawat yang bekerja di ruang 86 jurnal ners vol. 9 no. 1 april 2014: 83–90 perinatologi karena kompetensi yang didapat di pre-service masih kurang. sistem komunikasi ant ara r u mah sak it dengan puskesmas belu m ber jalan dengan bai k, sehingga identif ikasi adanya bblr di komunitas dilakukan dengan cara menggerakkan kader untuk mengidentifikasi adanya bblr dan melaporkan ke puskesmas untuk dilakukan kunjungan rumah. informasi lain yang didapat adalah alur pelayanan. alur bayi untuk dirawat bisa dari gawat darurat dan bisa juga dari poliklinik. petugas yang menerima bayi saat masuk ruang rawat kadang-kadang petugas administrasi kadang-kadang perawat. hal ini berarti bahwa belum ada uraian tugas yang pasti. berd asa rka n hasil pra-work shop, model kemudian dikembangkan kembali. hasil perbaikan model disampaikan pada kegiatan workshop yang melibatkan para calon ners spesialis keperawatan anak untuk mendapatkan masukan. model terdiri dari 2 komponen, yaitu asuhan keperawatan selama di rumah sakit, dan asuhan pasca rawat. model asuhan keperawatan selama di rumah sakit, bayi dirawat di unit perinatologi rumah sakit rujukan dapat berasal dari ruang bersalin rumah sakit tersebut, rumah sakit lain, puskesmas, atau dari rumah. pintu masuk perawatan di rumah sakit untuk bayi yang berasal dari luar rumah sakit dapat berasal dari poliklinik anak atau dari unit gawat darurat (ugd). di ugd dilakukan triase untuk menentukan tingkat bantuan yang diperlukan bayi. ada 3 tingkatan/level pelayanan yaitu level i (pelayanan dasar), level ii (high care/perawatan khusus), level iii (intensive care/perawatan intensif). asuhan keperawatan ditujukan untuk meningkatkan kesehatan bayi baru lahir, meningkatkan kemampuan ibu dalam merawat bayinya, sehingga kepuasan ibu akan perannya dapat tercapai (mercer dalam alligood, 2010). pencapaian tujuan asuhan dipengaruhi oleh berbagai faktor yaitu karakteristik bayi dan faktor lingkungan (ball, bindler, & cowen, 2010). faktor lingkungan bayi termasuk karakteristik orang tua, perawat yang memberikan asuhan, faktor lingkungan ruang rawat dan lingkungan masyarakat, serta budaya yang dianut keluarga (mercer d ala m a l l igood , 2010). me rce r lebi h lanjut menjelaskan karaktersitik bayi dan karakteristik orang tua saling berhubungan satu dengan yang lain. karakteristik bblr meliputi usia bayi, usia gestasi, kemampuan berespons, dan kemampuan bayi memberi isyarat. karakteristik orang tua mencakup: usia, tingkat pendidikan, pengetahuan, keyakinan yang dianut, dan persepsi terhadap penyakit. bayi berat lahir rendah mempunyai keterbatasan dalam menghasilkan energi. prinsip konservasi energi berdasarkan teori konservasi dari levine (alligood, 2010) perlu diimplementasikan oleh semua tenaga yang terlibat dalam asuhan agar konservasi energi dapat dilakukan secara optimal, integritas struktur, integritas personal, dan intergitas sosial bayi dapat diper tahankan bahkan ditingkatkan. perawat yang memberikan asuhan kepada bayi dan keluarga disesuaikan dengan standar ketenagaan berdasarkan tingkat pelayanan keperawatan yang dikeluarkan oleh kemkes ri (2011) yang mencakup tingkat kompetensi atau prasyarat baik sebagai perawat pelaksana maupun sebagai kepala ruangan dan rasio antara perawat dengan bayi. proses keperawatan merupakan pendekatan yang digunakan dalam mencapai tujuan asuhan keperawatan dengan penekanan pada penerapan prinsip konservasi dan family centered care dalam melakukan intervensi keperawatan. intervensi keperawatan merujuk pada nursing intervention classifi cation/nic (bulechek, butcher, & dochterman, 2008). kebutuhan akan pembelajaran didasarkan atas hasil penelitian (rustina, 2002) dan kebutuhan orang tua yang anaknya dirawat di nicu (gardner, et. al., 2011). lingkungan perawatan bayi harus dibuat sedemikian rupa agar bayi dapat beristirahat dan menyimpan energinya untuk pemulihan dan menaikan berat badan. pencahayaan ruangan diatur redup, kebisingan ruangan harus diturunkan, manipulasi bayi dikurangi dengan mengatur rentang waktu tertentu yang disebut touching time yaitu setiap 2-3 jam sekali. upaya tersebut ditujukan agar bayi 87 pengembangan model pelayanan asuhan keperawatan (dessie wanda, dkk.) dapat istirahat dan tidur. pada saat bayi tidur, persyarapan bayi akan berkembang (graven & browne, 2008). model yang kedua adalah asuhan lanjutan pasca pulang dari rumah sakit. saat bayi pulang, keluarga diberi resume perawatan. resume ini digunakan sebagai surat pengantar untuk melakukan asuhan lanjutan pasca rawat ( follow up care), sehingga pemberi asuhan dapat memahami kondisi bayi sebelumnya dan informasi yang telah ibu dapatkan untuk merawat bayinya. follow-up care merupakan salah satu komponen akreditasi rumah sakit (jci, 2011). penanggungjawab perencanaan pulang (discharge planner atau dapat juga dilakukan oleh perawat primer) memberi informasi kepada dinas kesehatan tentang kepulangan bayi dengan mengirimkan informasi melalui short message service (sms). rumah sakit harus mempunyai nomor kontak dari petugas yang bertanggungjawab terhadap pemantauan pelayanan di komunitas. dinas kesehatan beker jasa ma denga n puskesmas u nt u k menugaskan tenaga kesehatan di wilayah tempat tinggal klien u nt u k melak u kan kunjungan rumah. tahap iii: uji coba model kegiatan yang dilakukan pada tahap ini adalah sosialisasi model kepada staf ruangan, pelatihan dan bimbingan. sosialisasi juga dilakukan kepada perawat dari puskesmas yang akan terlibat dalam uji coba dan dinas kesehatan. beberapa klarifi kasi dari peserta dikemukakan, sehingga persamaan persepsi dapat dicapai. pelatihan perawat yang dilaksanakan mencakup modul: alur perawatan, family-centered care, asuhan keperawatan pada bblr, edukasi/konseling pada ibu yang memiliki bblr, perencanaan pulang berbasis web, dan follow-up care. kegiatan sosialisasi dengan dinas kesehatan propinsi dki dan beberapa perawat pu skesmas meng hasil ka n rekomend asi terkait komponen asuhan pasca pulang yang didalamnya termasuk sistem komunikasi antara r umah sakit dengan puskesmas. sistem komunikasi antara rumah sakit dengan perawat di komunitas dikembangkan agar terjadi kesinambungan asuhan dan bayi mendapat asuhan lanjutan pasca rawat. pada awalnya informasi terkait kepulangan bayi direncanakan dikirim dari rumah sakit oleh perawat penangg ung jawab perencanaan pulang (discharge planner) melalui dinas kesehatan di wilayah tempat tinggal bayi melalui pesan singkat. isi pesan mencakup nama bayi dan nama orang tua, berat lahir dan berat ketika pulang, usia gestasi, alamat lengkap rumah (termasuk nomor telpon bila ada), pesan khusus, seperti jadwal kontrol, intervensi khusus (misal: pmk). perubahan dalam sistem komunikasi dilakukan karena dinas kesehatan mer upakan pemegang kebijakan, sementara teknis pelaksanaan asuhan adanya di puskesmas. kegiatan pendampingan dilakukan mencak up pengisian for mulir bersamasama diskusi terkait hal-hal yang masih membingungkan memberi contoh ketika orang tua datang mengingatkan apa yang harus dilakukan kepada bayi atau ketika orang tua datang. pengisian perencanaan pulang berbasis web diajarkan dan dipraktekan. refl eksi dan evaluasi dilakukan selama pendampingan. pemantauan terhadap pelaksanaan komunikasi antara r umah sakit dan puskesmas juga dilakukan. kegiatan uji coba juga melibatkan perawat puskesmas di wilayah dki jakarta. hasil uji coba mengidentifi kasi bahwa ada kesulitan dalam menemukan alamat orang tua bayi karena nama yang tertera dalam status bayi tidak dikenal di lingkungan dimana keluarga tersebut tinggal. oleh sebab itu direkomendasikan agar isi pesan singkat, selain mencantumkan nama lengkap sesuai yang tercantum dalam status bayi juga perlu disertai dengan nama panggilan, sehingga akan lebih mudah menemukan alamat dengan batuan masyarakat. saat melakukan kunjungan r umah, perawat puskesmas melakukan pengisian formulir pemantauan berat badan, panjang badan, lingkar kepala, frekuensi nafas, kondisi kesehatan bayi; melakukan intervensi keperawat a n d asa r seper t i pent i ng nya kebersihan (pencegahan infeksi), pemberian asi. apabila ditemukan masalah kesehatan 88 jurnal ners vol. 9 no. 1 april 2014: 83–90 yang perlu penanganan lebih lanjut, perawat harus melakukan rujukan atau menyarankan agar bayi dibawa ke layanan kesehatan. format pemantauan bayi dirasakan oleh para perawat puskesmas cukup sederhana dan mudah diaplikasikan. pembahasan pel ay a n a n a s u h a n ke p e r aw a t a n merupakan suatu sistem, sehingga kualitas asuhan yang diberikan sangat tergantung dari kesiapan dan kondisi masing-masing komponen yang menu njang nya. fak tor pemberi pelayanan, sarana dan prasarana, kerjasama orang tua sangat penting. proses pember ian asuhan keperawatan dengan menggunakan pendekatan proses keperawatan perlu ditunjang oleh pengetahuan perawat yang memadai, kepatuhan terhadap standar operasional prosedur, serta kerjasama dengan tenaga kesehatan lain dan orang tua. dengan demikian, kerjasama dengan semua pihak terkait pelayanan asuhan keperawatan sangat penting. action research memfasilitasi per ubahan yang ter us mener us dengan melibatkan berbagai pihak terkait (dengler, et al., 2012). keterlibatan staf dalam penelitian d a p at me m fa si l it a si ke b e rl a ng s u ng a n perubahan yang dilakukan. pada penelitian ini, perawat, tenaga kesehatan lain, dan tenaga penunjang dilibatkan sejak identifi kasi masalah sampai dengan penyelesaian masalah. streubert dan carperter (2011) mengemukakan bahwa apabila suatu upaya perubahan merupakan bagian dari penelitian yang melibatkan para praktisi di suatu tatanan tertentu, perubahan tersebut akan menjadi bagian dari perubahan yang dilaksanakan oleh para praktisi tersebut secara terus menerus dalam praktiknya seharihari. ide nt i f i k a si m a sala h me r upa k a n lang kah awal d alam mela k u kan suat u perubahan. diskusi terfokus dipilih untuk mendapatkan informasi secara menyeluruh dari kelompok dengan memfasilitasi setiap individu untuk berdiskusi berdasarkan ide orang lain. diskusi terfokus sangat berguna apabila akan melakukan pengkajian kebutuhan (leung & savithiri, 2009) sebagai awal dalam merumuskan rencana intervensi. m o d e l d i k e m b a n g k a n d e n g a n m e n g i n t e g r a s i k a n ko n s e p d a n t e o r i keperawatan. teori becoming a mother atau becoming a mother sangat tepat digunakan karena sebagai middle range theory, teori ini sangat spesifi k bagi pencapaian kesehatan bayi baru lahir dengan memperhatikan kemampuan orang tua dalam hal ini ibu (alligood, 2010). ibu dan keluarga merupakan bagian yang sangat penting dalam kehidupan bayi baru lahir dan tidak terpisahkan, sehingga konsep family centered care atau asuhan yang berpusat pada keluarga sangat tepat diintegrasikan dalam model ini. hasil penelitian mengidentifi kasi bahwa implementasi family centered care member ikan kepuasan kepada keluarga terhadap asuhan yang diberikan (neal, et. al., 2007). implementasi family centered care juga memberikan dampak positif terhadap tingkat stres, tingkat kenyamanan, dan percaya diri keluarga yang bayinya dirawat di nicu (cooper, et. al., 2007). model i n i d i ke mba ng k a n u nt u k memfasilitasi pertumbuhan dan perkembangan bayi bahkan mencegah terjadinya kematian melalui persiapan dan pemberyaan orang tua agar memiliki kompetensi dan kepercayaan diri menjalani peran sebagai ibu dalam merawat bayinya. kesehatan bayi juga dipengaruhi oleh lingkungan, hal ini sejalan dengan teori yang digagas oleh t. mercer yang menyebutkan bahwa lingkungan mempengaruhi penerimaan dan kesiapan menjalani peran ibu (alligood, 2010). orang tua mempunyai hak untuk dekat dengan bayinya, tetapi keselamatan bayi juga lebih penting. membuka inkubator yang terlalu sering selain akan membuat bayi hipotermi, juga bayi berisiko untuk infeksi karena tangan orang tua atau tenaga kesehatan yang kotor. oleh sebab itu, edukasi terhadap orang tua sangat penting. edukasi terhadap orang tua harus diberikan secara bertahap. edukasi yang diberikan secara bertahap dapat membantu para orang tua lebih memahami informasi yang disampai kan d an apabila karena terpaksa anaknya dibawa pulang sebelum 89 pengembangan model pelayanan asuhan keperawatan (dessie wanda, dkk.) wakt unya, orang t ua sudah mempunyai sedikit pengetahuan untuk merawat bayinya di rumah. kejadian rawat ulang dapat dihindari apabila orang tua dipersiapkan dengan optimal melalui proses perencanaan pulang. orang tua dipersiapkan untuk mampu merawat bayinya melalui suatu proses perencanaan pulang. perencanaan pulang telah diidentifi kasi dapat menurunkan rawat ulang dan meningkatkan percaya dir i orang t ua dalam merawat bayinya di r umah (smith, et al., 2009). perencanaan pulang yang terorganisir dan diimplementasikan dengan baik merupakan keberhasilan awal dari suatu asuhan lanjutan ( follow-up care) (allen, donahue, & porter, 2002). perawat memegang peranan penting dalam mempersiapkan orang tua agar mampu secara mandiri untuk merawat bayinya di rumah. oleh sebab itu, persiapan perawat di r umah sakit telah dilakukan melalui pelatihan dan pendampingan agar mempunyai kemampuan untuk memberikan asuhan yang terbaik kepada bayi dan keluarganya. perilaku perawat yang dapat membantu orang tua untuk memenuhi kebutuhan dasarnya adalah dukungan emosional, pemberdayaan keluarga, kebijakan r uangan yang memungkinkan orang tua hadir, dan pendidikan kesehatan bagi orang tua (cleveland, 2008). cleveland mengidentifi kasi 6 kebutuhan orang tua yang bayinya dirawat di neonatal intensive care unit (nicu), yaitu: informasi yang akurat tentang perawatan bayinya, melihat dan melindungi bayinya, kontak dengan bayi, orang tua dipersepsikan positif oleh perawat di ruangan, asuhan yang bersifat individual, dan hubungan terapetik dengan perawat ruangan. hal perlu menjadi perhatian bukan hanya perawat, tetapi juga tenaga kesehatan lain yang terkait. kesiapan tenaga kesehatan di rumah sakit har us didu k ung oleh kemampuan tenaga kesehatan di komunitas dalam hal ini di puskesmas, sehingga kesinambungan asu han dapat ber jalan secara optimal. melalui pelayanan yang berkesinambungan juga masalah pada bblr yang seharusnya tidak perlu terjadi dapat dihindarkan serta per t umbuhan dan perkembangan bblr juga dapat dipantau. per ubahan perilaku memerlukan upaya yang terus menerus dan dilaksanakan secara ber tahap, sehingga pendampingan memegang peranan penting. pada tahap uji coba model, diskusi dan pend a mpi nga n t er u s d ila k u k a n u nt u k memfasilitasi perubahan perilaku. evaluasi dan refl eksi merupakan bagian yang sangat penting dalam suatu action research untuk mengidentifi kasi tahapan yang telah dicapai dan bant uan apa yang diperlu kan atau dimodifi kasi (mcintosh, 2009). perawat memegang peranan penting dalam peni ng kat an k ualit as pelayanan kesehat a n seca r a keselu r u ha n melalu i pemberian asuhan keperawatan. tantangan yang dihadapi oleh perawat saat ini dan juga pemerintah adalah belum terlaksananya asuhan keperawatan lanjutan pasca rawat di rumah sakit. perubahan dalam pelayanan kepada bblr ini perlu ditujang oleh kerjasama antara rumah sakit dan sumber-sumber yang ada di masyarakat, seperti layanan yang ada di masyarakat serta pemegang kebijakan akan pelayanan lanjutan. bblr atau bayi prematur dan bayi r isiko tinggi karena masalah keluarga mer upakan dua kategori yang direkomendasikan oleh american academy of pediatrics (2008) untuk dilakukan asuhan lanjutan. sistem komunikasi antara rumah sakit-puskesmas-keluarga memegang peranan penting dalam mensukseskan asuhan bayi berat lahir rendah pasca pulang dari rumah sakit. simpulan dan saran simpulan model pelayanan-asuhan keperawatan bayi berat lahir rendah dikembangkan untuk meningkatkan kesehatan bayi bar u lahir melalui asuhan yang berkesinambungan. tim kesehatan memegang peranan penting dalam meningkatkan kesehatan bayi baru lahir dengan peran dan fungsinya masing-masing. action research dipilih untuk meningkatkan pelayanan asuhan keperawatan, sekaligus mengevaluasi dampaknya terhadap kesehatan bayi maupun kepuasan orang tua dengan melibatkan semua pihak yang terkait. 90 jurnal ners vol. 9 no. 1 april 2014: 83–90 saran kesinambungan asuhan dari rumah sakit ke asuhan di komunitas merupakan suatu tantangan untuk dilaksanakan dan ditingkatkan. oleh sebab itu, metode komunikasi yang efektif seperti penggunaan pesan singkat dari rumah sakit ke penanggungjawab asuhan di komunitas merupakan salah satu alternatif yang perlu diaplikasikan. kepustakaan allen, m.c., dohohue, p.k., & porter, m. 2002. follow-up of the nicu infant. in: g.b. merenstein & s.l. gardner. (eds), handbook of neonatal intensive care (5th ed). st. louis: mosby inc. alligood, m. r. 2010. nursing theor y: utilization & aplication (4t h ed.). missouri: mosby. american academy of pediatrics. 2008. hospital discharge of the high-risk neonate: com mit te on fet us and newborn, pediatrics, 122, 11-19. badan perencanaan pembangunan nasional ( b a p p e n a s ) . 2 010 . l a p o r a n pencapaian pembangunan milenium di indonesia 2010. jakarta. bulechek, g.m. butcher, h.k. & dochterman, j.m. 20 08. nursing inter vention classifi cation (nic) (5th ed.). st. louis, mo: mosby. cooper, l.g., gooding, j.s., gallagher, j.m sternesky, l., ledsky, r., & berns, s.d. 2007. impact of a family-centered care initiative on nicu care, staff and families, journal of perinatology, 27, s32-s37. cleveland, l. m. 2008. parenting in the neonatal intensive care unit, jognn, 37(6), pp. 666-691. dengler, k.a., wilson, v., redshaw, s., & scarfe, g. 2012. appreciation of a child’s journey: i m p l e m e n t a t i o n of a cardiac action research project. nursing research and practice, doi: 10.1155/2012/145030. d e p a r t e m e n k e s e h a t a n r . i . 2 0 0 8 . laporan hasil riset kesehatan dasar (riskesdas) nasional 2007. jakarta: departemen kesehatan ri. gardner, s.l. carter, b.s., enzman_hines, m., hernandez, j.a. 2011. merenstein & gaerdner’s handbook of neonatal intensive care (7th ed). st. louis: mosby. graven, s.n. & browne, j.v. 2008. sleep and brain development: the critical role of sleep in fetal and early neonatal brain development. newborn and infant nursing review, december, 173-179. joint commission international/jci. 2010. joi n t c o m mi s si o n in te r n a t i o n a l acreditation standards for hospitals (4th ed). illinois: joint commission international kementrian kesehatan republik indonesia., 2011. standar pelayanan keperawatan ne on at u s d i sa r a n a ke seh at a n. jakarta. leung, f., savithiri, r. 2009. spotlight on focus groups, can fam physician, 55(2), 218-219. neal, a., frost, m., kuhn, j., green, a., gance-cleveland, b., & kersten, r. 2007. family centered care within a n i n fa nt-todd ler u n it, pediat ric nursing, 33(6), 481-485. rustina, y. 2002. information needs of indonesian mothers in caring for their preterm infants. research repor t: unpublished. rustina, y. 2005. educational program for enhancing parental competency and outcomes of preter infants, dissertation. chiang mai university. rustina, y., nursasi, a. y., fitriyani, p., budiati, t., & syahreni, e. 2011. maternal experience in caring for their preterm infants at home. presented at the 8th international nursing conference seoul, south korea, 28 october 2011. smith, v. c., young, s., pursley, d.m., mc cormick, m. c., & zupancic, j.a. f. 2009. are families prepared for discharge from the nicu?, journal of perinatology, 29, 623-629. stright, b. r. 2001. maternity newborn nursing (3rd ed). philadelphia: lippincott. streubert, h.j., & carpenter, d.r., 2011. q ualitative research in n ursing: advancing the human imperative (5th ed). philadelphia: lippincott. 210 media pornografi dan pengaruh teman sebaya dalam perilaku seks remaja (pornographic media and peer’s influence towards sexual behavior among teenagers) murdiningsih * , rosnani ** , hidayat arifin *** * lecturer; department of midwifery, polytechnic of health palembang ** lecturer; department of nursing polytechnic of health palembang *** bachelor student; faculty of nursing universitas airlangga email: murdiningsih@poltekkespalembang.ac.id abstrak pendahuluan: masalah yang terkait dengan perilaku seksual yang tidak aman pada remaja disebabkan oleh hubungan seksual pranikah dengan pasangan usia mereka sendiri. peningkatan kejadian seks pranikah disebabkan oleh perkembangan melalui penggambaran media adegan seks dalam bentuk televisi, majalah, klip video, media online, dan film. di musi banyuasin terdapat 7.754 siswa sma serta banyak siswa yang putus sekolah karena hamil diluar nikah. tujuan penelitian adalah untuk mengetahui hubungan media pornografi dan pengaruh teman sebaya terhadap perilaku seksual pada remaja di sekolah tinggi. metode: penelitian observasional dengan cross sectional dan pendekatan kuantitatif. populasi adalah siswa sma di kabupaten musi bayuasin. teknik pengambilan sampel adalah menggunakan multistage random sampling diperoleh 393 sampel. analisis bivariat, chi-square. hasil: menunjukkan adanya korelasi antara pengaruh teman sebaya dengan perilaku seksual remaja memiliki p-value (0,000). tidak ada hubungan antara media pornografi dengan perilaku seksual karena hasilnya lebih dari pvalue (0,05). diskusi: diperlukan untuk diberikan pengetahuan dan bantuan kepada remaja tentang positif dan kreatif hal dan pengawasan orang tua untuk anak-anak mereka untuk memiliki teman dan menghindari perilaku seksual yang tidak aman. kata kunci: pengaruh teman sebaya, media pornografi, perilaku seks tidak aman, remaja abstract introduction: the problems associated with unsafe sexual behavior in teenagers are caused by premarital sexual intercourse with a partner of their own age. increased incidence of premarital sex is caused by the development through media depictions of sex scenes in the form of television, magazines, video clips, online media, and films. in musi banyuasin there are 7754 high school students, many students have dropped out of school because they get pregnant before marriage. the aim study was to investigate the correlation between pornographic media and the influence of peers towards teenager’s sexual behavior in high school. method: observational research with cross sectional and quantitative approach. the population was high school students in musi banyuasin regency. sampling technique was using multistage random sampling obtained 393 samples. bivariate analysis, chi-square result: the result showed a correlation between the influence of peers with adolescent sexual behavior has p-value (0,000). there was no relationship between media pornography with sexual behavior because the result more than p-value (0,05). discussion: necessary to be given knowledge and assistance to teenagers about positively and creatively thing and supervision of parents to their children in order to have friends and avoid unsafe sexual behavior. key words: the influence of peers, pornographic media, unsafe sexual, adolescent _______________________________________________________________________________________________________ introduction various institutions in indonesia for the period of 1993-2002, found that five to tenth percent of teenagers aged 16-24 years have had sexual intercourse before marriage (hasmi 2011). one of the problems caused by premarital sex is an unwanted pregnancy. pregnancy at a young age, in terms of reproductive health, is a kind of high risk both in pregnancy and childbirth. psychologically, sex before marriage is also bringing the perpetrators experienced changes (kusmiran & eny 2012). the globalization of information through the media in the form of sexual exploitation on television, magazines, videos, online media and movies encourage teenagers assume that free sex activities may be done by anyone, anywhere regardless of the norms and ethics (annisa et al. 2013). another factor that led to premarital sexual behavior in teenagers according to (oktiva & yayuk, 2010) in (kencana & rida, 2011) is a peer influence. teenagers are very influenced by their peer groups, so they must follow all the pressures from their peers when they want to maintain their status in the group. this behavior is an attempt to meet the needs of teens in relationships with others, especially if those needs are not met within the family (notoadmodjo, 2010). reproductive health survey data of indonesian adolescent and the national family planning coordinating board (bkkbn) showed mailto:murdiningsih@poltekkespalembang.ac.id jurnal ners vol. 11 no. 2 oktober 2016: 210-212 211 as many as 5912 women aged 15-19 years at national level had sexual intercourse. while men in the same age totally 6578, or 3.7% have had sex. but surprisingly the case of pre-marital sex is actually happening in the countryside. urban 0.9%, while rural 1.7% (bkkbn 2012). child protection commission (kpa) in 2008 showed 62.7% of middle and high school teenagers have had sex before marriage, 93.7% of teenagers had done kissing, oral sex and genital stimulation. then 97% of teenagers had watched a porn movie, 25% of teenagers had an abortion because because of unwanted pregnancy (kumalasari & inthan 2013). method the study was used cross-sectional approach. the populations were teenagers aged 15-18 years who were students of high school in the musi banyuasin regency in 2014 amounted to 7754 students. the total samples obtained were 393 students. data were analyzed using chi square test and kolmogorov smirnov. result table 1. distribution of correlation between influence of peers with sexual behavior among teenagers influence of peers sexual behavior total % good bad n % n % influenced uninfluenced 39 89 21 43 147 118 79 57 186 207 100 100 p-value = 0,000 or =0,352 table 2. distribution of correlation between exposure of pornographic media with sexual behavior pornography exposure sexual behavior total % good bad n % n % ever never 200 65 65,8 73 104 24 34,2 27 304 89 100 100 p-value = 0,248 or =0,710 based on table 1 and 2, majority teenagers were had good sexual behavior (67.4%), influenced by their peer group (52.7%), and have been exposed to pornography (77.4%). using chi square test, the p-value for the correlation between peer influence and sexual behavior among teenagers was 0.000 with odds ratio (or) 0.352. it means students were included influence 0.35 times more likely to sexually behave well. the correlation between pornography exposure and sexual behavior had the p-value 0.248 that indicates no correlation between those variables. the or was 0.710 which means students were included ever seen pornographic media 0.71 times more likely to sexually behave well. disscussion based on table 1, there was correlation beetwen influenced of peers with unsafe sexual behaviour of teenagers. it was becaue teenagers were not stay with parents, so the have more time with their peers and have pottential to influence unsafe sexual behavior because less control of parents. the research had similar result with (maryatun & nur 2013) that teenagers at sma muhammadiah surakarta iii had correlation beetween peers with unsafe sexual behavior (p-value 0,001; or 19,723). based on (nugroho et al. 2015)’s research, the subjects were teeangers in courtship. even thought major teenagers in courtship have’nt risk in unsafe sexual behavior category, but there were teenagers in courtship had unsafe sexual behavior. peers, teacher, and parrents must support teenager by giving suggestion, advice, and good verbal communication. parrents have important roles in education and monitoring of teenagers sexual behavior. based on (eka 2012)’s research, showed teenagers with good education in family about sexual behavior that will caused good sexual behavior as many as 62,1%. table 2 showed that there was no correlation bettwen pornography media with saxual behavior. it was supported by many factors: the location of musi banyuasin is suburbs; limited internet access; limited media to operate internet; at school teenagers were banned use handphone. the research had similar result with (abadi & rizky 2015) that there was no correlation between pornography media access with sexual behavior, it was because the location at suburbs of malang. media pornografi dan pengaruh teman sebaya (murdiningsih, dkk.) 212 base on (ririn et al. 2011), this result was different and explained there was correlation between information resource (internet, tv, handphoe, vcd, porn video, poster, etc.) with sexual behavior (p-value 0,022). the similar result of (annisa et al. 2013), there was correlation between access of pornographic media with sexual behavior before married (pvalue 0,022). pratiwi & ayu (2014) had explained that need the government’s role to block sites or pornographic content in the internet and supported with (amelia & hafied 2011) that there were three things to help how pornography or pornographic sites can be removed include: self-controlling; the existence of the regulation or policy; and in cooperation with the satellite operator and provider in indonesia conclusion and recommendation conclusion more leisure time of teenagers with peers can give effect to do unsafe sexual behavior (masturbation, kiss, hug, hold or touch sensitive parts, petting, oral sex and intercourse). recommendation parents and families need to provide care and controlled to teenagers who don’t stay at home (lodging house) or stay at home, so teenagers are more selective in choosing friends to avoid unsafe sexual behavior. referencies abadi & rizky, a., 2015. hubungan mengakses pornografi melalui fasilitas handphone dengan perilaku seksual remaj usia 16 – 19 tahun di smk muhammadiyah 2 kota malang. amelia, c.r. & hafied, c., 2011. kebijakan pemerintah republik indonesia dalam mengatasi situs porno pada media maya. jurnal komunikasi kareba, 1(3). annisa, u., hikmah & endang, s.n., 2013. hubungan kases media pornografi internet dengan sikap seksual pranikah pada remaja kelas ix di sma negeri 1 bambanglipuro bantul yogyakarta. bkkbn, 2012. survei demografi dan kesehatan indonesia, jakarta. eka, s.d., 2012. hubungan pendidikan seks dalam keluarga dengan perilaku seksual remaja di sma n 3 bukittinggi. jurnal kesehatan masyarakat stikes prima nusantara bukittinggi, 3(2). hasmi, e., 2011. meeting reproductive health needs of adolescent in indonesia. journal of adolescent reproductive and sexual health unesco. available at: http://www.unescobkk.org/ips/arh. kumalasari & inthan, 2013. kesehatan reproduksi untuk mahasiswa kebidanan dan keperawatan, jakarta: salemba medika. kusmiran & eny, 2012. kesehatan reproduksi remaja dan wanita, jakarta: salemba medika. maryatun & nur, h., 2013. hubungan antara pengaruh teman sebaya dengan perilaku seksual pranikah pada remaja si smk batik 1 surakarta. gaster, 10(2). nugroho, dwi, r.a. & devy, s.r., 2015. dukungan sosial yang mendorong perilaku pacaran berisiko pada remaja sma di kota surabaya. jurnal promkes, 3(1). pratiwi & ayu, r., 2014. analisis kriminologis peredaran gambar pornografi yang dilakukan melalui media game online di kalangan siswa di bandar lampung. ririn, d., noor, s.a. & azzizah, g., 2011. kajian perilaku sex pranikah remaja sma di surakarta. jurnal kesehatan, 4(2), pp.111–119. 2 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 2-7 http://dx.doi.org/10.20473/jn.v16i1.29655 original article open access sociodemographic correlates of older adult acceptance of the covid-19 vaccine arlene supremo1,* , sillmark bacason , alexander rex sañosa 1 biliran province state university, philippines *correspondence: arlene supremo. address: biliran province state university, philippines. email: arlene.supremo1986@gmail.com responsible editor: praba diyan rachmawati received: 2 september 2021 ○ revised: 3 january 2022 ○ accepted: 3 february 2022 abstract introduction: an increase of the covid-19 global statistics in late 2019 prompted the swift manufacturing of vaccines to protect people, especially older adults, from the debilitating effects of the disease. this study aimed to determine the socio-demographic correlates of older adults and their relationship with covid-19 vaccine acceptance. methods: this correlational study invited the entire population of older adults to answer the survey. in total, 89 elderly individuals participated in face-to-face interviews because of the old age limitations. the tool used consisted of two parts. the first part determined the socio-demographic correlates. the second part assessed the level of acceptance of the covid-19 vaccine. rank biserial and spearman rho were used to measure the correlations between the socio demographic variables and covid-19 vaccine acceptance. results: the respondents were predominantly female (n = 45; 50.56%), with an elementary level of education (n = 48; 53.93%), below php 10,000.00 for monthly family income (n = 77; 86.52%), unemployed (n = 79; 88.76%), and roman catholic (n = 87; 97.75%). generally, older adults will not accept the covid-19 vaccine. specifically, older adults will not accept the vaccine if it has less than a 50% effectiveness (n = 51; 57.30%) and if they have existing medical conditions (n = 51; 57.30%). finally, the findings suggest that employment status has a significant negative relationship with the acceptance of the covid-19 vaccine (r = -0.357, p = 0.0001). conclusions: 47.19% to 57.30% of older adults will not accept the covid-19 vaccine. national and local government units need to intensify their vaccination campaigns to persuade the public to engage with the free covid-19 vaccines. keywords: acceptance; covid-19; hesitancy; pandemic; vaccine; vulnerable introduction the novel coronavirus (covid-19) pandemic, which started in wuhan, china, is a global threat, with more than 3 million new reported cases in march 2021 (world health organization, 2021). the high statistics in terms of the number of covid-19 cases prompted nations worldwide to develop mitigating policies to curb the surge of new infections. the health policies include the mandatory wearing of face masks and other personal protective equipment (ppe), as well as isolation and quarantine protocols, granular and community lockdowns, physical distancing, limiting through to prohibiting super spreading interactions like prayer meetings, social gatherings, and personal meetings, and hand sanitization. these non-pharmacological interventions have slowed the rate of coronavirus transmission (el-elimat et al., 2020). however, pharmacological interventions such as vaccination remain the best solution to prevent covid-19 infection (chakraborty & parvez, 2020). scientists from around the world raced against time to develop potential vaccines against coronavirus. in 2020, the who (2021) reported that at least seven vaccines were available for administration. vaccines are considered helpful in protecting an individual from coronavirus infection through immunity development (cdc, 2021). in the philippines, the department of health (doh, 2021) conducted an initial vaccine rollout of the chinese-made sinovac and uk-made astrazeneca vaccines to healthcare frontline workers. among those who most need the covid-19 vaccine is the older population group, specifically individuals 65 years old and above, aside from frontline healthcare workers. this group was identified by the who (2021) as among the high-risk individuals clustered together with healthcare providers and persons with co-morbidities https://creativecommons.org/licenses/by/4.0/ http://orcid.org/0000-0002-9795-1042 http://orcid.org/0000-0003-4849-353x http://orcid.org/0000-0002-4697-1123 jurnal ners http://e-journal.unair.ac.id/jners 3 because they comprise the majority of the morbidity and mortality cases of the disease. the centers for disease and control prevention (cdc, 2020) recommended that the older population should be included in the first layer of recipients of the covid-19 vaccine since the risk of severe illness from the infection increases with age. with the availability of the covid-19 vaccine, the next concern that must be overcome by the health authorities and government is its acceptability by older adults as vaccine recipients. understanding the perspectives of the vaccine recipients is essential when determining the best strategy to maximize vaccine uptake. this milestone in the vaccine roll-out for the older adult population sought to prevent an increase in the disease's morbidity and mortality cases. locally, the older adults’ acceptance and hesitancy regarding the covid-19 vaccines have remained unexplored. according to the report by the biliran provincial health office (bpho, 2020), there was a low level of compliance with routine immunizations such as the pneumococcal and flu vaccines by older adults. because of this, a considerable number of older adults were vulnerable to acquiring the infection. this study, therefore, sought to investigate the level of acceptance of covid-19 vaccination among older adults. specifically, this study has been undertaken to determine the sociodemographic profile of older adults in terms of age, sex, education level, monthly income, employment status, and religion. furthermore, this study wanted to determine the level of acceptance of covid-19 vaccination among the older adults residing in one of the regions in the philippines. after determining the sociodemographic profile and level of acceptance of older adults, the causal relationship between the variables was established. materials and methods study design this study was a correlational research study in terms of its design. correlational research is concerned with establishing relationships between two or more variables in the same population or between the same variables in two populations. curtis, comiskey, and dempsey (2016) emphasized that exploring the relationships among the variables is a significant part of research in nursing. understanding the associations and relationships among human phenomena is a consistent impetus for scientific inquiry in all social science disciplines. this impetus transcends even the most polarized paradigmatic distinctions between various research methods (fitzgerald et al., 2004). since the study’s goal was to measure and explore the degree of relationship between the demographic characteristics of the older adults and their acceptability of the covid-19 vaccine, it was appropriate to utilize a correlational research design. respondent the covid-19 coronavirus pandemic is a global health disaster of the 21st century. this pandemic has caused untold fear and suffering for older adults across the world. according to the world health organization (who) as cited in the paper by chee (2020), older adults in aged care homes are at a higher risk of infection due to living in an enclosed environment with others. older people are more susceptible to covid-19 infection, caused by a defective immune response to infectious challenges (benksim, addi, & cherkaoui, 2020). in addition, comorbid illnesses, malnutrition, drugs, and stress predispose the elderly to an increased risk of coronavirus by declining their immune function (benksim, addi, & cherkaoui, 2020). hence, this study sought the participation of the older adults in the community of barangay imelda. in the municipality of naval, barangay imelda is held to be one of those barangays with the greatest number of older adults. the barangay is also the barangay furthest away from the urban center of naval. this confirms their information inaccessibility regarding the benefits of the covid-19 vaccine. for these reasons, the elderly in this barangay were relevant when it came to providing the data needed for this study. the researchers used the list of the elderly provided by the barangay health unit as its sampling frame. the elderly listed reached 126 in total. due to the small population, the researchers used complete enumeration as its sampling technique. however, only 89 were surveyed because only those who were still able to process information were included in the study. table 1 socio-demographic profile of the older adults (n=89) demographic variable n % sex male 44 49.44% female 45 50.56% educational attainment did not attend school 2 2.25% pre-school level 3 3.37% pre-school graduate 2 2.25% elementary level 48 53.93% elementary graduate 31 34.83% junior high school level 2 2.25% college level 1 1.12% family income below php 10,000.00 77 86.52% php 10,000.00 php 19,000.00 12 13.48% employment status employed 10 11.24% unemployed 79 88.76% religion roman catholic 87 97.75% iglesia filipina independiente 1 1.12% others 1 1.12% supremo, bacason, and sañosa (2022) 4 p-issn: 1858-3598  e-issn: 2502-5791 excluding the few who were not capable of answering the survey increased the reliability of the results. instrument the study developed a questionnaire that would capture its objectives. this self-made questionnaire consisted of 13 items and was pilot tested in barangay p.s. eamiguel. the internal consistency of the items was measured using cronbach’s alpha. the alpha coefficient for the 13 items was 0.992, suggesting that the items had a relatively high internal consistency. to note, a reliability coefficient of 0.70 or higher is considered “acceptable” in most social science research situations. this includes research situations in the field of health and nursing. the research instrument was divided into two. the first section contained the questions on the demographic profile: (1) sex, (2) educational attainment, (3) family income, (4) employment status, and (5) religion of the respondents. the second section contained the 13 items capturing the acceptance of the older adults of the covid-19 vaccines. the details of the items are presented in table 2. furthermore, the respondents rated the variable “acceptance to covid-19 vaccines” using a fivepoint likert scale (definitely not = 1, probably not = 2, probably = 3, very probably = 4, definitely = 5). data collection initially, the researchers sought ethical clearance from the research and innovation office of the biliran province state university, and permission from the local government unit before the conducting of the study. informed consent was secured with an emphasis on the study's intention and coverage. subsequently, the researchers sought assistance from the barangay health office to be provided with a list of older adults in the community. the list was then used as a reference to identify and locate the residences of the older adults in the barangay. before letting the respondents answer the survey, transmittal letters were given to each of the respondents. after receiving approval through the signing the consent form to survey them, the researcher gave them the survey questionnaire. all of this happened in a face-to-face set-up. the survey lasted last for a week. a repetition of the barangay visits was done until the data was completed. since the number of respondents was manageable, the researchers were also those who conducted the survey. they did not seek the help of research assistants or enumerators from the research office of the university. to emphasize, the survey followed the inter-agency task force (iatf) guidelines for covid-19 when visiting the residences of the respondents. data analysis after gathering the data, the researchers encoded the responses in microsoft excel to summarize the data. the responses to some of the variables, particularly those used for profiling, were coded accordingly. consequently, the researchers produced a descriptive summary with the table 2 covid-19 vaccine acceptance statement definitely very probably probably probably not definitely not if a vaccine against covid-19 that has less than 50% effectiveness is available in the market, i will accept it. 9 8 9 12 51 if a vaccine against covid-19 that has more than 50% effectiveness in the market, i will accept it. 19 5 9 11 45 if a vaccine against covid-19 has known minor side effect (such as dizziness, lightheadedness, fever, flu-like symptoms (cold, sneezy, body malaise), body pain) and is available on the market, i will accept it. 13 13 7 8 48 i will accept a covid-19 vaccine if my other family members will take the vaccine shot too. 24 5 9 6 45 i will accept a covid-19 vaccine if my friends and significant others will take the vaccine shot too. 24 9 3 5 48 i will accept a covid-19 vaccine if it was recommended by the local health authorities. 26 7 2 8 46 i will accept a covid-19 vaccine if it was recommended by the national health authorities. 25 9 5 7 43 i will accept a covid-19 vaccine if it was proven safe and effective by the government. 27 6 6 6 44 i will accept a covid-19 vaccine if information about the vaccine is provided by trusted health professionals before vaccination starts. 23 11 7 6 42 i will accept a covid-19 vaccine if information about the vaccine is seen on online platforms such as facebook, instagram, etc. 8 12 10 9 50 i will accept a covid-19 vaccine even if i have existing medical health problems (diabetes, hypertension, rheumatoid arthritis, etc). 13 7 8 10 51 i will accept a covid-19 vaccine despite my old age. 26 5 2 9 47 i will accept a covid-19 vaccine even if i am fearful of the vaccination outcome. 21 6 4 8 50 jurnal ners http://e-journal.unair.ac.id/jners 5 encoded data to determine the completeness of all observations. the study used spss version 25 to analyze and determine the correlation of the demographic variables in relation to the acceptability of the older adults in terms of the covid-19 vaccine variable. the statistical tools used to measure the correlations of the variables were the rank biserial and spearman rho. rank biserial was used to determine the degree of relationship between the sex and acceptance of the older adults of the covid 19 vaccine and between employment status and the acceptance of the older adults of the covid 19 vaccine. meanwhile, spearman rho was used to measure the other three demographic variables (age, educational attainment, and religion) in relation to the acceptance of the older adults of the covid 19 vaccine. sex and employment status were run using a different statistical tool of correlation because their data was discrete and nominal in nature. the authors used the p-values of the correlation coefficients to reject or accept the null hypotheses at a significance level of 0.05 and below. data collection initially, the researchers sought ethical clearance from the research and innovation office of the biliran province state university, and permission from the local government unit before the conducting of the study. informed consent was secured with an emphasis on the study's intention and coverage. subsequently, the researchers sought assistance from the barangay health office to be provided with a list of older adults in the community. the list was then used as a reference to identify and locate the residences of the older adults in the barangay. before letting the respondents answer the survey, transmittal letters were given to each of the respondents. after receiving approval through the signing the consent form to survey them, the researcher gave them the survey questionnaire. all of this happened in a face-to-face set-up. the survey lasted last for a week. a repetition of the barangay visits was done until the data was completed. since the number of respondents was manageable, the researchers were also those who conducted the survey. they did not seek the help of research assistants or enumerators from the research office of the university. to emphasize, the survey followed the inter-agency task force (iatf) guidelines for covid-19 when visiting the residences of the respondents. ethical consideration this study strictly followed the principles of ethical standards when conducting the research. the researchers obtained ethical clearance from the university internal review panel before the actual conducting of the study. before the data collection process, the researchers provided transmittal letters to the mayor, barangay captain, and municipal health officer. three basic principles were observed in the conducting of this study: the principles of respect for persons, beneficence, and justice. privacy and confidentiality were strictly observed throughout. the respondents in this study were informed of the purpose of the research and provided a clear description of the extent of their involvement and the risks, benefits, and rights of being a study respondent. they were also given the study’s strengths related to the actual determination of the acceptance level of older adults for covid-19 vaccination. however, the actual implementation of the study was constrained due to strict adherence to the covid-19 protocols, such as the wearing of a face mask, physical distancing, and limited hand hygiene. a standard form of informed consent was read, elaborated on, and explained in the language that the respondents understood to secure the elements of adequate information and comprehension. the respondents were not coerced, forced, or bribed to participate in this study to secure the element of voluntary participation. the respondents were of legal age and not of unsound mind as declared by the court to secure the element of competency and they qualified based on the inclusion criteria of the study. it was emphasized that they could withdraw from the study at any time during the conducting of the research. the respondents were reminded that they could stop participating in the study at any time without any danger of repercussions. all data gathered in this study is considered private and confidential. all materials gathered were handled with utmost care. the anonymity of the respondents was preserved. no identifying data was exposed in the report of the study including any names, addresses, etc. all data was destroyed upon the completion and publication of this study. compensation or the giving of tokens to respondents poses an ethical dilemma. nonetheless, this study recognizes the ethical principles of justice and respect and the respondent’s time and effort will be given due credit and recognition. before starting the interview, a token was offered to the respondents. the respondents table 3 employment status and covid-19 vaccine acceptance statement correlation coefficient p-value decision q1 -0.414** 0.000 reject ho q2 -0.383** 0.000 reject ho q3 -0.286** 0.007 reject ho q4 -0.315** 0.003 reject ho q5 -0.305** 0.004 reject ho q6 -0.317** 0.003 reject ho q7 -0.311** 0.003 reject ho q8 -0.288** 0.006 reject ho q9 -0.317** 0.002 reject ho q10 -0.342** 0.001 reject ho q11 -0.394** 0.000 reject ho q12 -0.344** 0.001 reject ho q13 -0.357** 0.001 reject ho *<0.05 **<0.01 supremo, bacason, and sañosa (2022) 6 p-issn: 1858-3598  e-issn: 2502-5791 were informed that the interview tokens were given based on their assessed needs. lastly, there was no known potential conflict of interest for this study. results out of the 89 respondents who participated in the study, 45 (50.56%) were female and 44 (49.44%) were male. most of the respondents had reached the elementary level of education, totaling 48 (53.93%). concerning family income, many older adults belong to a family that receives a monthly revenue of less than php 10,000.00 per month as most of them are unemployed (88.76%). roman catholicism (97.75%) is the predominant religion of the group. the older adults will definitely not accept the vaccine in the circumstances presented in table 2. however, more older adults will definitely not accept the vaccine if it has less than 50% effectivity and if they have existing medical conditions such as diabetes, hypertension, and rheumatoid arthritis at 51% and 57%, respectively. regarding understanding the correlation between the socio-demographic correlates and the acceptance of the covid-19 vaccine, only the employment status of older adults, particularly those who were unemployed, showed a significant correlation. the majority of the sociodemographic correlates (sex, educational attainment, family income, and religion) had a negative correlation with covid-19 vaccine acceptance. discussions the covid-19 pandemic has wreaked havoc on the global economy since its first occurrence in wuhan, china. because of the negative pandemic effects, the who and its partners, especially drug manufacturers, have raced against time to develop a vaccine that will help reduce the statistics of covid-19 infection (who, 2021). the available covid-19 vaccines ready for administration include sinovac astrazeneca, moderna, sputnik v, and pfizer. however, successful vaccines will still rely on the uptake of the population (zigron et al., 2021). as of july 7, 2021, the who (2021) reported that 3,032,056,355 people have received the covid-19 vaccine out of the 7,753,000,000 total population around the world (world bank group, 2021). in the philippines, the covid-19 vaccination rollout began in march 2021 to eligible priority groups which included older adults (department of health, 2021). the acceptance of these older adults of the available covid-19 vaccines has been studied here in relation to their sociodemographic profile. the covid-19 vaccine acceptance of the older adults showed that most people belonging to this population group will definitely not accept the vaccine. among the notifiable response where most older adults did not show acceptance of the covid-19 vaccine was if the vaccines had less than 50% effectiveness. harapan et al. (2020) and alqudeimat et al. (2021) described in their studies that acceptance is relative to the effectiveness of a certain covid-19 vaccine. the higher the effectiveness, the more people will definitely accept the vaccine. therefore, the government must put out effective strategies that will persuade the population to avail the free covid-19 vaccines if the one purchased has been known to have low effectiveness. furthermore, older adults who have existing comorbidities such as diabetes and hypertension expressed their unwillingness to accept the covid-19 vaccine. the previous literature showed a similar finding that people with underlying medical conditions are hesitant and resistant to accepting the covid-19 vaccines (murphy, 2021). unacceptance was linked to the medical contraindication of vaccines and the fear of vaccine side effects. this result is counterintuitive to the somatic benefit-risk analysis where people with health problems should take extra protective measures from infectious diseases. older adults with existing health problems are considered vulnerable to covid-19 infection (cdc, 2021), therefore they need the vaccine more. the unacceptance of the covid-19 vaccine from this group might hamper the achievement of herd immunity where more people are expected to be fully vaccinated. upon studying the relationship between the sociodemographic correlates of the older adults in relation to their willingness to accept the covid-19 vaccine, only unemployment showed a significant correlation. this information revealed a contrasting result to those of the available studies in the literature where unemployed individuals are less likely to accept the covid-19 vaccines (malik et al., 2020; echoru et al., 2021). malik et al. (2020) reported that vaccine acceptance is directly proportional to literacy level. the higher the education level, the more accepting an individual is of the covid-19 vaccine. strikingly, the study shared the same result as the study by el-elimat et al. (2020). their study reported that unemployed participants were more accepting of the covid-19 vaccines than the employed participants. this is not a perplexing finding as most of the respondents in the study were unemployed due to old age. most of them were retired individuals receiving pensions. others were supported by their family. limitations in relation to the conducting of this study were identified. one limitation was the research locale, wherein all study participants lived in a mountainous barangay. a different finding may have been gathered if the study encompassed a wider coverage of older adults – those living in rural-upland, rural-coastal, and urban areas, respectively. also, the study was conducted when covid-19 vaccines were still undergoing clinical trial. as more studies proving the safety and effectiveness of the jurnal ners http://e-journal.unair.ac.id/jners 7 covid-19 vaccines emerge, the respondents might change their perception regarding acceptance. conclusions generally, the results of this study highlight the need to improve the level of knowledge and increase the trust in the covid-19 vaccines to expedite their uptake in the older adult population. educating them on the benefits of the covid-19 vaccine is an essential milestone in preventing further morbidity and mortality cases of the covid-19 disease, considering their high-risk category. moreover, the local government should intensify its public awareness campaigns to reach everyone in the community. providing rewards or incentives can also be a strategy to improve the level of vaccine uptake. references al-qerem, w. et al. (2021). ‘covid-19 vaccination acceptance and its associated factors among a middle eastern population’. frontiers in public health, 9, 34. retrieved from https://doi.org/10.3389/fpubh.2021.632914. alqudeimat, y. et al. (2021). ‘acceptance of a covid-19 vaccine and its related determinants among the general adult population in kuwait’. medical principles and practice, 30(3), 262-271. baldacchino, g. (2006). ‘islands, island studies, island studies journal; island studies journal, 1(1), 3–18. retrieved march 29, 2021, from https://islandstudies.ca/sites/vre2.upei.ca.islandstudies.ca/files/u2/i sj-1-1-2006-baldacchino-pp3-18.pdf benksim, a., et al. (2020). ‘vulnerability and fragility expose older adults to the potential dangers of covid-19 pandemic’. iranian journal of public health, 49(1), 122-124. retrieved march 29, 2021, from https://www.researchgate.net/publication/340984493_vulnerabilit y_and_fragility_expose_older_adults_to_the_potential_dange rs_of_covid-19_pandemic biliran provincial health office. (2020). needs assessment survey of barangay imelda naval. bpho: naval. biliran. burns, a. (1999). ‘collaborative action research for english language teachers’. cambridge university press. centers for disease control and prevention. (2021). what older adults need to know about covid-19 vaccines. retrieved from https://www.cdc.gov/coronavirus/2019ncov/vaccines/recommendations/older-adults.html centers for disease control and prevention. (2021). benefits of getting a covid-19 vaccine. retrieved from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccinebenefits.html. centers for disease control and prevention. (2021). covid-19: people with certain medical conditions. retrieved from https://www.cdc.gov/coronavirus/2019-ncov/need-extraprecautions/people-with-medical-conditions.html. chakraborty, r. et al. (2020). ‘covid-19: an overview of the current pharmacological interventions, vaccines, and clinical trials’. biochemical pharmacology, 114184. https://doi.org/10.1016/j.bcp.2020.114184 chee, s. y. (2020). ‘covid-19 pandemic: the lived experiences of older adults in aged care homes’. millennial asia, 11(3), 299-317. doi: 10.1177/0976399620958326 curtis, e. et al. (2016). ‘importance and use of correlational research. nurse researcher’, 23(6), 20–25. doi:10.7748/nr.2016.e1382 department of health. (2021). when will the covid-19 vaccines be available to me? retrieved from https://doh.gov.ph/vaccines/whenwill-the-covid-19-available-to-me echoru, i. et al. (2021). ‘sociodemographic factors associated with acceptance of covid-19 vaccine and clinical trials in uganda: a cross-sectional study in western uganda’. bmc public health, 21(1), 1-8. https://doi.org/10.1186/s12889-021-11197-7 el-elimat, t. et al. (2020). ‘acceptance and attitudes toward covid19 vaccines: a cross-sectional study from jordan’. medrxiv. https://doi.org/10.1101/2020.12.22.20248676 fitzgerald, s. m. et al. (2004). ‘correlational designs in rehabilitation research’. journal of vocational rehabilitation, 20(2), 143–150. hair, j. f. et al. (2010). ‘multivariate data analysis (7 ed.)’. pearson prentice hall. harapan, h. et al. (2020). ‘acceptance of a covid-19 vaccine in southeast asia: a cross-sectional study in indonesia’. frontiers in public health, 8. doi: 10.3389/fpubh.2020.00381 malik, a. a. et al. (2020). ‘determinants of covid-19 vaccine acceptance in the us’. eclinicalmedicine, 26, 100495. doi: 10.1016/j.eclinm.2020.100495 murphy, j. et al. (2021). ‘psychological characteristics associated with covid-19 vaccine hesitancy and resistance in ireland and the united kingdom’. nature communications, 12(1), 1-15. https://doi.org/10.1038/s41467-020-20226-9 world bank group. (2021). population, total. retrieved from https://data.worldbank.org/indicator/sp.pop.totl. world health organization. (2021). covid-19 vaccines. retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus2019/covid-19-vaccines world health organization. (2021). weekly epidemiological update on covid-19–16 march 2021. retrieved from https://www.who.int/publications/m/item/weekly-epidemiologicalupdate---16-march-2021 world health organization. (2020). coronavirus disease (covid-19): vaccines. retrieved from https://www.who.int/news-room/q-adetail/coronavirus-disease-(covid-19)vaccines?adgroupsurvey={adgroupsurvey}&gclid=cjwkcajwgog cbhaleiwa7fuxkugtjuy2fbi1hxby_dq9t0rsrwtdzdc008bt todz1nnh0_4umn-ytbocklqqavd_bwe zigron, a. et al. (2021). ‘covid-19 vaccine acceptance among dental professionals based on employment status during the pandemic’. frontiers in medicine, 8, 13. doi: 10.3389/fmed.2021.618403. how to cite this article: supremo, a., bacason, s., and sañosa, a. a. (2022) ‘sociodemographic correlates of older adult acceptance of the covid-19 vaccine’, jurnal ners, 17(1), pp. 2–7. doi: http://dx.doi.org/10.20473/jn.v16i1.29655 https://doi.org/10.3389/fpubh.2021.632914 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/older-adults.html https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/older-adults.html https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html https://doi.org/10.1016/j.bcp.2020.114184 https://doh.gov.ph/vaccines/when-will-the-covid-19-available-to-me https://doh.gov.ph/vaccines/when-will-the-covid-19-available-to-me https://doi.org/10.1016/j.eclinm.2020.100495 https://data.worldbank.org/indicator/sp.pop.totl https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines?adgroupsurvey=%7badgroupsurvey%7d&gclid=cjwkcajwgogcbhaleiwa7fuxkugtjuy2fbi1hxby_dq9t0rsrwtdzdc008bttodz1nnh0_4umn-ytbocklqqavd_bwe https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines?adgroupsurvey=%7badgroupsurvey%7d&gclid=cjwkcajwgogcbhaleiwa7fuxkugtjuy2fbi1hxby_dq9t0rsrwtdzdc008bttodz1nnh0_4umn-ytbocklqqavd_bwe https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines?adgroupsurvey=%7badgroupsurvey%7d&gclid=cjwkcajwgogcbhaleiwa7fuxkugtjuy2fbi1hxby_dq9t0rsrwtdzdc008bttodz1nnh0_4umn-ytbocklqqavd_bwe https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines?adgroupsurvey=%7badgroupsurvey%7d&gclid=cjwkcajwgogcbhaleiwa7fuxkugtjuy2fbi1hxby_dq9t0rsrwtdzdc008bttodz1nnh0_4umn-ytbocklqqavd_bwe https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines?adgroupsurvey=%7badgroupsurvey%7d&gclid=cjwkcajwgogcbhaleiwa7fuxkugtjuy2fbi1hxby_dq9t0rsrwtdzdc008bttodz1nnh0_4umn-ytbocklqqavd_bwe https://dx.doi.org/10.3389%2ffmed.2021.618403 benksim2020 table1 table2 table2n table3 alqudeimat2021 chee2020 benskim2020 cdc2021vaksin chakraborty2020 doh2021 echoru2021 elimat2020 bpho2020 fitzgerald2004 harapan2020 malik2020 murphy2021 worldbank2021 who2021vaksin who2021epid zigron2021 bai_2016 appendix1 http://e-journal.unair.ac.id/jners 9 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 9-15 http://dx.doi.org/10.20473/jn.v18i2.26785 original article open access the correlation between parents interaction conflict with online game addiction in adolescents iqlima dwi kurnia 1 * , bangun mukti ardi 1 , ilya krisnana 1 , aria aulia nastiti 1 , pratuma rithpho 2 , and yuni sufyanti arief 1 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 faculty of nursing, naresuan university, phitsanulok, thailand *correspondence: iqlima dwi kurnia. address: faculty of nursing, universitas airlangga, surabaya, east java, indonesia. email: iqlima.dwi.k@fkp.unair.ac.id responsible editor: ferry efendi received: 5 september 2021 ○ revised: 11 february 2023 ○ accepted: 14 february 2023 abstract introduction: the prevalence of online game addiction has increased among adolescents in indonesia. this study aimed to analyze the correlation between parent conflict and online game addiction among adolescents. methods: this study used a cross-sectional, correlational design. the inclusion criteria in this study were as follows: (1) adolescents between the ages of 13-19 and who were male, and (2) adolescents who were willing to become respondents. eighty adolescents were approached according to the inclusion criteria, and 73 respondents were eligible for this study. the data collection method used was a questionnaire filled out by adolescents. the questionnaire was adapted to adolescents and to determine adolescents' perceptions of interaction conflict. statistical analysis was performed using spearman’s rank test with α=0.05. results: parental interaction conflict was positively related to online game addiction among adolescents (p = 0.004). the majority of respondents who experienced online game addiction in the fair category had low interaction conflicts with their parents. conclusions: conflict of interaction with parents can cause adolescents to become addicted to online games. parents are expected to engage in good interactions in accordance with the stages of adolescent development. parents should be able to complete their problem interactions well. keywords: conflict interaction, mental health, addiction, game online, adolescent introduction the rapid development of technology, such as information, communication, and entertainment, is currently being used by teenagers. one of its uses is to play online games (karaca et al., 2020). online game addiction is a compulsive psychological state, or uncontrollable dependence on online games played over computer networks, usually via the internet, that occurs among adolescents (lee and kim, 2017), and causes serious problems. for example, addiction to online games has a wide range of negative effects on daily life and can interfere with psychological balance, sleep quality, and academic achievement (montag, schivinski, and pontes, 2021). online game addiction can be seen from the use of time for (on average) 20-25 hours a week, and the average time spent playing online games is more than four hours per day (fitri, emria, and lira erwinda, 2018). previous research shows that online game addiction has a negative impact on the psychological state of compulsive or uncontrollable dependence (mun and lee 2022; rosendo-rios, trott, and shukla, 2022). gaming is just another recreational activity, but it can be a problem when people lose control of it (young, 2016) https://creativecommons.org/licenses/by/4.0/ mailto:iqlima.dwi.k@fkp.unair.ac.id https://orcid.org/0000-0002-6836-034x https://orcid.org/0000-0001-8076-9036 https://orcid.org/0000-0002-7942-1195 https://orcid.org/0000-0003-3034-355x https://orcid.org/0000-0003-3664-8426 kurnia, ardi, krisnana, nastiti, rithpho, and arief (2023) 10 p-issn: 1858-3598  e-issn: 2502-5791 and it becomes a mental disorder (brink, 2017). in previous studies, attention deficit, depression, low selfesteem, and negative interpersonal relationships have been found to be predictors of addictive and problematic online game use in children and adolescents (mun and lee 2022). in addition, parental factors, including parent-child relationships and parental attachment, are also significantly associated with online game addiction in adolescents (kim, k., and kim, 2015). however, research that further discusses the conflict between parent and child interaction and online game addiction is still lacking. the results of previous studies in china mentioned that parental factors, including parent-child relationship and parental attachment, are also significantly associated with adolescent online game addiction, and that parental psychological problems are critical risk factors for the development of internalizing and externalizing problems in children and adolescents (xu, cui, and lawrence, 2020). based on the results of a study conducted in tangerang, it was shown that a lack of interaction in the family can cause online games in adolescents to become a daily necessity (yudha, 2015). shearman and dumlao in japan show that the relationship between family communication and adolescents deteriorates (ozmete and bayoglu, 2009). conflict between parents and adolescents can have a negative impact on adolescent behavior (doorn et al., 2008). previous research has shown that depression and low family monitoring are discriminative factors for internet addiction (zhang et al., 2022a) the global population of internet users has increased (qiu et al., 2022). collaborative research between the association of internet services indonesia (apjii, 2014) shows indonesia ranks fourth after china, india, and japan in terms of the number of internet users, with 88 million internet users per day, which is 34.1% of the total population in indonesia. this represents a 4,300% growth over the last 16 years. looking at children between the ages of 8 and 18, it was found that 88% played games electronically and 68% indicated that they played at least weekly, and 23 % daily (zhang et al., 2022a). previous research concluded that adolescents who have negative parent-child relationships and conflict interactions tend to divert their attention to online games to obtain emotional needs that cannot be obtained from the family (qiu et al., 2022). research by fuadi (2016) in surabaya, showed there to be three 3 levels of addiction: 41.7% for medium addiction, 25% for low addiction, and 25% for high addiction. assistance and the application of parenting efforts influence the level of problems that arise from online gaming addiction (joung, 2014). online gaming is a psychosocial problem commonly found in children and adolescents (rahmawati, bahar, b, and salam, 2013) and players will play continuously (addiction) regardless of how long they spend (choi et al., 2018). internet addiction is a common disorder (ahmed et al., 2022), and consists of at least three subtypes: excessive gaming, sexual preoccupation, and e-mail/text messaging (block, 2008). previous research shows that the impact of online game addiction includes a loss of interpersonal relationships, failure to cope with responsibilities, impaired aspects of life, and poor health (lin, 2015). the attitude of parents toward their child, closeness of the family, and their exposure to domestic violence will cause online game addiction (wu et al., 2022). the behavior that appears due to the game’s excessive online nature needs the interventions of the family to prevent online game addiction, and for parents to intensively communicate with their children (kim et al., 2003; piotrowski et al., 2015). however, studies that explain the relationship between parent-interaction conflict and online gaming among adolescents have not yet been conducted. the purpose of this study was to explain the relationship between parent-conflict interactions with online game addiction in adolescents. the results of this study will provide a better perspective on the concept of interaction between parents and children, and will increase perspectives to minimize conflict interactions that occur between children and parents, as well as serve educators who mediate between parents and children in solving problems related to interaction conflict. materials and methods the design of this study was correlational, using a cross-sectional approach intended to determine the relationship between independent variables and the dependent variable. the sampling method used was purposive. the independent variable in this study was parent-conflict interaction. the questions in the questionnaire were adjusted to be completed by the adolescents to examine adolescents' perceptions of perceived interaction conflict. the dependent variable in this study was online game addiction. the study population consisted of adolescents who were online game users at gamercamp (gc) in surabaya. the sample size of this study was 62 adolescents in surabaya. the reason we use the gamercamp site is because, based on the results of a preliminary study in several gamercamps, the site in jurnal ners http://e-journal.unair.ac.id/jners 11 klampis is the most visited by adolescents and is the largest in surabaya with strategic internet café location supported by cheap rates of rp. 4,000.00 per hour. this is also due to the large number of pcs, reaching 64 pcs with an average connection speed of 65.00 mbps. the inclusion criteria in this study were as follows: (1) adolescents between the ages of 13 – 19 and who were male, and (2) adolescents who were willing to become respondents. the exclusion criterion was adolescents who played online games for the first time. the subject recruitment process in the gc klampis surabaya was conducted from 10:00 am to 9 pm within 1 month, according to the inclusion criteria. researchers assume that gamers who have visited for the second time have an interest and desire to continue playing online games, which in turn can lead to addiction because the reference source that researchers use is said to be addicted to online games as seen from the use of time (on average) between 20-25 hours a week. eighty adolescents were approached according to the inclusion criteria and there were 73 respondents included. after receiving an explanation of the study, parents who agreed to their children as research respondents and adolescents who were willing resulted to 62 respondents. the researcher gave an explanation to the adolescents about the goals, benefits and risks, the principles of confidentiality, the fact that it was voluntary, compensation and the involvement of the adolescents in the study itself. after that, the researchers distributed approval sheets to the adolescents for them to give to their parents. an explanation of the study was also given to their parents along with the informed consent sheet, and informed consent was signed by the parents. the independent variable in this study was the conflict of parents’ interactions, while the dependent variable in this study was online game addiction. the internet addiction test (iat) was used to assess online game addiction. the questionnaire was translated into indonesian and tested for its validity and reliability. all items of the questionnaire had good validity scores, and the reliability test had a cronbach’s α score of 0.756. the questionnaire detail had six parameters: salience, excessive use, neglect work, anticipation, lack of control and neglect social life. the questionnaire consisted of 20 statements with the following interpretation of the scores: 0-30 = not addicted; 31-49 = mild addiction; 5079 = moderate addiction; 80-100 = severe addiction. the instrument used to assess conflict interactions between parents and adolescents is the parents conflict interaction & adolescent questionnaire, which is filled by adolescents to see adolescents’ perceptions of perceived interaction conflict. adolescents who are able to feel the interaction conflict that occurs are not seen from the perspective of parents because of their higher level of subjectivity. the questionnaire was completed independently by the adolescents. adolescent answers are feelings experienced in relation to the conflict interaction that has been applied by parents. parent conflict interaction was measured using the parents conflict interaction and adolescents questionnaire developed by lestari (2009). the questionnaire has three main indicators: habits and social life, which also include relationships with family and social conventions. the second indicator is responsibility and the last is the achievement of the school. the parents conflict interaction and adolescent questionnaire was tested for its validity and reliability. all questionnaire items had good validity scores, and reliability testing showed a cronbach’s α of 0.450. the questionnaire consisted of 13 questions based on three parameters: social habits and life, responsibilities and school achievements. the interpretation of scores is high interaction conflict = average mark value and low interaction conflict = average mark value. before carrying out the data research, the researcher explained the purpose of the study, benefits, confidentiality of data, compensation, and voluntary elements for adolescents to accept or refuse to become respondents. adolescents were of an age where they already have the cognitive ability to understand the explanation and so can give an informed consent. the researcher asked for permission from the gamercamp site owner to carry out the research and went to the gamercamp every day from 10 am to 9 pm after obtaining approval from internet cafe owners. the researcher gave an explanation to the adolescents about the goals, the benefits and risks, the principles of confidentiality, the fact that it was voluntary, compensation and the involvement of the adolescents in the study itself. subsequently, the researchers distributed approval sheets to the adolescents to give them to their parents. on the parental consent sheet, the researcher asked for the parents' telephone numbers to crosscheck and ensure that the parents had agreed to their child as a research respondent. an explanation of the study was also given to their parents along with an informed consent sheet which they. the next step was to distribute the questionnaires to the adolescents, and both the parent-adolescent interaction conflict questionnaire and iat were carried out for 30 minutes. after the respondent completed the kurnia, ardi, krisnana, nastiti, rithpho, and arief (2023) 12 p-issn: 1858-3598  e-issn: 2502-5791 questionnaire, it was returned to the researcher and the completeness of the answers was checked. in this way, if there were incomplete data (demographic data), it could be resolved immediately. after all respondents filled out the questionnaire, the researchers gave them souvenirs in the form of stationery and education about the wider use of online games. the results of the data obtained were then used to conduct descriptive and inferential analyses. the descriptive data analysis was about the percentage or frequency distribution, mean, and standard deviation, and the inferential analysis used spearman’s rho test correlation with α=0.05. this research was assessed using ethical standards and it was certified with ethical approval no. 294 kepk on january 12, 2017, issued by the faculty of nursing of universitas airlangga. results table 1 shows that most respondents were adolescents aged 17 19 years old (53 people; 85.5%). the majority consisted of senior high school students (40 people, 64.5%). the adolescents playing at gc internet corner had one sibling (27 people; 43.5%). most of the respondents were the first children (27 people; 43.5%). the respondents were closer to their friends, both at home and at school (26 people; 41.9%), and most of the respondents who played online games did so for 3 6 hours per day (30 people; 48.4%). table 2 illustrates that most respondents had a conflict with their parents in the low category (33 people; 53.2%). table 2 shows that most respondents were in the categories of low addiction (31 people; 50%) and medium addiction (20 people; 32.3%). table 2 shows that most respondents who experienced online game addiction had a level of conflict interaction with their parents that was in the high category (13 people; 21%). the cross-tabulation data also show that there were three people (4.8%) who did not experience online game addiction who had a high level of interaction conflict with their parents. the relationship between the parents’ interaction conflict and online game addiction in adolescents, based on the non–parametric spearman rho test, had a significance level of α ≤ 0.05. the analysis showed a p value of 0.004. this means that there is a relationship between parents’ interaction conflict and online game addiction in adolescents at the gc internet corner in klampis, surabaya. in addition, the alternative hypothesis shows that there is a relationship based on a correlation coefficient (r) of 0.360. this means that there is a weak and positive correlation coefficient, indicating that the relationship between the two variables is in the same direction, with the same high value. the findings from this study found that respondents who had high interaction conflicts with their parents had addiction to online games with high categories. conflicts occur due to demands from parents who want their children to be better. the respondent's parents will be angry and punished if the respondent is caught skipping school and gets bad grades in school. in addition, the parents of the respondents always demanded that their children study. a small percentage of the respondents thought that their parents were old-fashioned. this is because their parents still apply the education system table 1 demographic characteristic characteristic n % age of respondents 13 16 years 17 19 years 9 53 14.5 85.5 total 62 100 education junior high school senior high school no school (never gone to school) 17 40 5 27.4 64.5 8.1 total 62 100 number of sibling s do not have 1 2 more than 2 10 27 17 8 16.1 43.5 27.4 12.9 total 62 100 child order: 1 2 more than 2 27 22 13 43.5 35.5 21 total 62 100 nearest person with respondents friends, both at home and at school brother and /or sister parents 26 12 24 41.9 19.4 38.7 total 62 100 frequent type of online game played war game game strategy game on social media 46 16 2 74.2 22.6 3.2 total 62 100 duration of playing online game less than 3 hours 26 hours 6 12 hours 29 30 3 46.8 48.4 4.8 total 62 100 table 2 cross-tabulation of parents parents’ interaction conflict addiction to online gametotal high moderate fair no addiction n % n % n % n % n % high low 0 0 0 0 13 7 21 11.3 13 18 21 29 3 8 4.8 12.9 29 33 46.8 53.2 total 0 0 20 32.3 31 50 11 17.7 62 100 significance (p): 0,004 spearman's rho correlation coefficient (r): 0.360 jurnal ners http://e-journal.unair.ac.id/jners 13 from their days, as well as respondents think that their parents in educating them do not follow the developments of the times. respondents said that their parents always regulated their personality without giving them the opportunity to develop it. with this finding, it is hoped that parents can better understand the characteristics of their children according to their growth and development age, so that a harmonious relationship can be established. discussions in this study, it was hypothesized that high levels of parental interaction conflict can cause adolescents to become addicted to online games at high levels. the findings of this study revealed that most respondents who experienced a fair category of online game addiction had low interaction conflicts with their parents. the results of this study are in accordance with several previous research results that the parents’ interaction conflict is the reinforcing factor that influences and shapes the behavior of adolescents when playing online games, leading to addiction. the higher the stress level and the less support from the family, the greater the risk of depression in adolescents will be increased (nursalam, 2009). early adolescence is a time when conflict between adolescents and parents increases. this increase can occur because of several factors that have been discussed, which involve adolescent maturation and maturation of parents (wu et al., 2022). the results of this study show that there is a relationship between parental interaction with online game addiction in adolescents (zhang et al., 2022b). this is consistent with previous research showing that negative parent-child relationships will lead to reduced communication between parents and children, resulting in alienation, interaction conflict, and compensation behavior of adolescents seeking emotional warmth and support through online games (qiu et al., 2022). the results showed that almost half of the respondents experienced high interaction conflict with their parents. conflict with their parents increases in early adolescence and involves daily activities such as tidying the bedroom, dressing neatly, going home before a certain hour, not talking too long on the phone and so on (liu et al., 2020). adolescents experience social transition changes in their individual relationships with others, especially in terms of their emotions, personality, and social role context in development (qiu et al., 2022). during this period of change and transition, adolescents face new conditions and are under social pressure, whereas during childhood they are less prepared (griffiths, 2022). good family interactions can reduce conflicts that may occur between children and their parents (nursalam, alit and fauziningtyas, 2009). parent–child conflict interaction is one of the predictors of game online addiction, improving parent–child interaction can contribute to weaken online game addiction (gonzalez-buesoet et al., 2018) another factor that also affects parental interaction conflict is the age of the respondents, who in this study were mostly aged 17–19 years (late teenagers). stanley hall cited in santrock (2003), states that being a teenager is a time when storms and stress come out; it is a time of problem. adolescents experience a period of identity crisis that includes identity diffusion/confusion, moratorium, foreclosure, and identity achievement (griffiths, 2022). self-actualization is achieved when players are able to achieve the highest level of the game. in fact, in the process of achieving this, teenagers can put aside their daily activities, as well as their patterns of interaction with their parents (santrock, 2003). the characteristics of young people who experience problems are adolescents who experience resistance and challenge with their parents, as well as conflicts within themselves, which are often the root cause of contradictions and interaction conflicts with their parents (yilmaz et al., 2023). most respondents were close to their friends, both at home and at school. this can cause conflicts when respondents interact with their parents. they like gathering or playing online games with friends (durak et al., 2022). they also revealed that the person nearest to the respondent was their friend, both at home and at school. according to previous research, adolescents will be closer to their friends during this developmental period (wang et al., 2022). adolescents prefer to hang out with their friends, and when they experience interaction conflict with their parents, they prefer to get together with their friends (wang et al., 2021). the tabulation data showed that a major cause of conflict was the demands of parents who wanted their children to be better. the parents would be angry and punish their child if the respondent was caught skipping class or if they were getting bad grades in school. in addition, parents demanded that their children study at any time. a small percentage of the respondents thought that their parents were old-fashioned because they were still applying the system of education that was used in their own era. the respondents mentioned that their parents always regulated their personality without giving them the opportunity to develop it. previous research has shown that children grow and thrive in kurnia, ardi, krisnana, nastiti, rithpho, and arief (2023) 14 p-issn: 1858-3598  e-issn: 2502-5791 beneficial environments with supportive relationships. a good relationship will positively affect their development, including adjustment, prosperity, prosocial behavior, and value transmission. fostering interaction with the child's parent requires good communication to be in place (bittman, rutherford, and brown, 2015). according to imanuel (2009), gender is one of the factors that can influence online game addiction. gender significantly influences the personal factors involved in playing online games. several studies have shown that men play games more than women do because men are more inclined to fantasize and want to feel the adrenaline rush. adolescents, have the greatest influence in terms of online game addiction, because youth is a stage where they are between the phases of childhood and adulthood through physical and psychological changes. as a result, when adolescents experience various conflicts related to themselves, they begin to question their self-concept, think about their ideal characteristics, and compare themselves with others’ ideal standards (efendi, 2009). the data obtained by the researchers at surabaya consisted of a sample of all males. the respondents also believed that online gaming was fun during the conflict. furthermore, it relates to another indicator (young, 2011), namely, mood modification. mood modification refers to the happiness and peacefulness experienced when addictive behaviors arise. the game was used to cope with or escape from problems. a small proportion of the respondents said that their friends complained when they played online games. however, the respondents who were depressed or anxious offline did not feel so after returning to playing online games. the results indicate that there is a relationship between parenting and addiction to online gaming. protective parents can cause adolescents to seek refuge while playing online games. in addition, research conducted by (nursalam, armini and fauziningtyas, 2009) mentioned that the pattern of bad interactions between parents and their children can lead to delinquency in adolescents. conclusions parental interaction conflict is related with online game addiction. parental interaction conflicts can influence and shape respondents' behavior in playing online games as an escape mechanism for dealing with conflicts with parents, which, if not controlled, can lead to addiction. parents are expected to engage in good interactions in accordance with the stages of adolescent development. parents should be able to complete their problem interactions well. nurses can provide training and counseling to parents to improve communication, interaction, and relationships with children to increase the fulfillment of children's emotional needs, so that the use of online games can be reduced. conflict of interest there is no conflict of interest. references ahmed, gellan k. et al. 2022. “relation between internet gaming addiction and comorbid psychiatric disorders and emotion avoidance among adolescents: a cross-sectional study.” psychiatry research 312(january): 114584. apjii. 2014. “profil pengguna internet indonesia 2014 p. ui, ed.” bittman, michael, leonie rutherford, and jude brown. 2015. “old media and children ’ s outcomes.” australian journal of education 55(2): 161–75. block jj. 2008. “editorial issues for dsm-v: internet addiction.” the american journal psychiatry. 165(3): 306–7. van den brink, wim. 2017. “icd-11 gaming disorder: needed and just in time or dangerous and much too early?” journal of behavioral addictions 6(3): 290–92. choi, jiyun et al. 2018. “effect of the online game shutdown policy on internet use, internet addiction, and sleeping hours in korean adolescents.” journal of adolescent health 62(5): 548–55. van doorn, m.d, branje, j.t. & meeus, h.j. 2008. “conflict resolution in parent-adolescent relationships and adolescent delinquency. adolescence.” the journal of early. efendi, ferry, and makhfudli makhfudli. 2009. keperawatan kesehatan komunitas : teori dan praktik dalam keperawatan,. jakarta: salemba medika. fitri, emria, lira erwinda, et al. 2018. “konsep adiksi game online dan dampaknya terhadap masalah mental emosional remaja serta peran bimbingan dan konseling.” jurnal konseling dan pendidikan 4(3): 211–19. gonz´alez-bueso, v., santamaría, j. j., fern´, and j. andez, d., merino, l., montero, e., & ribas. 2018. “association between internet gaming disorder or pathological video_game use and comorbid psychopathology: a comprehensive review.” international journal of environmental research and public health. 15(4): 668. griffiths, mark d. 2022. “online gaming addiction in youth: some comments on rosendo-rios et al. (2022).” addictive behaviors 130: 107311. imanuel, n. 2009. “gambaran profil kepribadian pada remaja yang kecanduan game online dan yang tidak kecanduan game online.” depok: fakultas psikologi universitas indonesia. joung, chung. s & k. 2014. risk factors for smoking behaviors among adolescents. korea. korea. karaca, semra et al. 2020. “investigation of the online game addiction level, sociodemographic characteristics and social anxiety as risk factors for online game addiction in middle school students.” community mental health journal 56(5): 830–38. kim, i. j., ge, x., conger, r. d., brody, g .h., & gibson, f.x. 2003. “parenting behaviours and the occurrence and co-occurrence of deppressive symptoms and conduct problems among african american children.” journal of family psychology. kim, k., & kim, k. 2015. “internet game addiction, parental attachment, and parenting of adolescents in south korea.” journal of child & adolescent substance abuse 24(6): 366–371. lee, c., & kim, o. 2017. “predictors of online game addiction among korean adolescents.” addiction research and theory. 25(1): 58– 66. lin, l.y. et al. 2015. “effects of television exposure on developmental skills among young children.” infant behavior and development 38: pp.20–26. liu, x., luo, y., liu, z. z., yang, y., liu, j., & jia, c. x. 2020. “prolonged jurnal ners http://e-journal.unair.ac.id/jners 15 mobile phone use is associated with poor academic performance in adolescents.” cyberpsychology, behavior, and social networking 23(5): 303–311. montag, christian, bruno schivinski, and halley m. pontes. 2021. “is the proposed distinction of gaming disorder into a predominantly online vs. offline form meaningful? empirical evidence from a large german speaking gamer sample.” addictive behaviors reports 14. https://pubmed.ncbi.nlm.nih.gov/34938849/ (march 9, 2023). mun, il bong, and seyoung lee. 2022. “a longitudinal study of the impact of parental loneliness on adolescents’ online game addiction: the mediating roles of adolescents’ social skill deficits and loneliness.” computers in human behavior 136. nursalam, alit, ni ketut, and rista fauziningtyas. 2009. “family social support reduces post judegement stress in teenagers.” jurnal ners 4(2): 182–89. ozmete, e. & bayoglu, a.s. 2009. “parent-young adult conflict: a measurement of frequency and intensity of conflict issues.” the journal of international social research 2(8). piotrowski, j.t., vossen, h.g.m. & valkenburg, p.m. 2015. “media and child development. in international encyclopedia of the social & behavioral sciences.” elsevier: 1–10. qiu, caixia et al. 2022. “parent-child relationship and smartphone addiction among chinese adolescents: a longitudinal moderated mediation model.” addictive behaviors 130(november 2021): 107304. rahmawati, bahar, b, & salam, a. 2013. “hubungan antara karakteristik ibu, peran petugas kesehatan dan dukungan keluarga dengan pemberian asi eksklusif di wilayah kerja puskesmas bonto cani kabupaten bone.” fkm universitas hasanuddin makassa. rosendo-rios, veronica, sangeeta trott, and paurav shukla. 2022. “systematic literature review online gaming addiction among children and young adults: a framework and research agenda.” addictive behaviors 129. santrock, j.w. 2003. adolescence: perkembangan remaja. keenam. jakarta: erlangga. wang, peng et al. 2022. “reciprocal associations between shyness, depression, and internet gaming disorder among chinese adolescents: a cross-lagged panel study.” addictive behaviors 129(july 2021): 107256. wang, xunyi, mohamed abdelhamid, and g. lawrence sanders. 2021. “exploring the effects of psychological ownership, gaming motivations, and primary/secondary control on online game addiction.” decision support systems 144(january 2021): 113512. wu, yu qing et al. 2022. “childhood psychological maltreatment and internet gaming addiction in chinese adolescents: mediation roles of maladaptive emotion regulation strategies and psychosocial problems.” child abuse and neglect 129(april 2021): 105669. xu, fuzhen, wei cui, and peter j. lawrence. 2020. “the intergenerational transmission of anxiety in a chinese population: the mediating effect of parental control.” journal of child and family studies 29(6): 1669–78. yildiz durak, hatice, esra kidiman demi̇rhan, and mahmut citil. 2022. “examining various risk factors as the predictors of gifted and non-gifted high school students’ online game addiction.” computers and education 177(november 2021). yilmaz, ramazan, sema sulak, mark d. griffiths, and fatma gizem karaoglan yilmaz. 2023. “an exploratory examination of the relationship between internet gaming disorder, smartphone addiction, social appearance anxiety and aggression among undergraduate students.” journal of affective disorders reports 11(january): 100483. young, k. s, n. de a. 2011. internet addiction: a handbook and guide to evaluation and treatment, new jersey: john wiley & sons, inc. yudha, w. 2015. “pola komunikasi orang tua dengan anak pecandu game online (studi kasus game online let’s get rich di sma muhammadiyah 25 pamulang tangerang selatan).” zhang, wanling et al. 2022a. “demographic characteristics, family environment and psychosocial factors affecting internet addiction in chinese adolescents.” journal of affective disorders 315(july): 130–38. how to cite this article: kurnia, i. d., ardi, b. m., krisnana i., nastiti, a. a., rithpho, p., and arief, y. s. (2023) ‘the correlation between parents interaction conflict with online game addiction in adolescents’, jurnal ners, 18(1), pp. 9-15. doi: http://dx.doi.org/10.20473/jn.v18i1.26785 246 efek mie pisang dan sukun terhadap glukosa darah sewaktu (the effect of banana and breadfruits noodles on glucose levels) nursalam, rista fauziningtyas, candra panji asmoro, kusnanto, meryana adriani fakultas keperawatan unair/ kampus c unair, mulyorejo, surabaya email: nursalam@fkp.unair.ac.id abstrak pendahuluan: kesadaran masyarakat terhadap gaya hidup sehat menyebabkan perubahan pada pemilihan bahan makanan untuk dikonsumsi. penambahan tepung pisang dan sukun meningkatkan kadar serat pada mie. tujuan penelitian ini adalah untuk menentukan komposisi tepung pengganti pada mie yang berefek pada peningkatan gds paling rendah. metode: desain penelitian ini adalah control group pretest posttest design. sampel didapatkan sebanyak 58 orang mahasiswa fakultas keperawatan unair yang memenuhi kriteria inklusi dan eksklusi. 58 sampel dibagi menjadi 3 kelompok, yaitu mie a (kontrol), b (subtitusi 30%) dan c (subtitusi 20%). pemeriksaan gds dilakukan sebelum pemberian mi dan 60 menit setelah pemberian mi. analisa data yang digunakan adalah dengan anova one way. hasil: berdasarkan uji anova one way didapatkan p=0,000 (p<0,050) yang berarti ada perbedaan hasil pada ke tiga kelompok tersebut. kenaikan tertinggi nilai gds adalah pada kelompok mi a dan terendah kelompok mi b. diskusi: penambahan tepung pisang dan sukun pada mie dapat menurunkan kenaikan nilai gds responden bukan penderita dm. penelitian lebih lanjut perlu dilakukan untuk mengetahui kandungan mi dengan tepung pisang dan sukun dan respon gds pada penderita dm. kata kunci: mie, tepung, pisang, sukun, gula darah, diabetes abstract introduction: public awareness of healthy lifestyles cause a change in the selection of foodstuffs for consumption. bananas and breadfruit flour additions increase the fiber content on the noodles. the purpose of this study was to determine the composition of noodles flour substitute on the effect on an increase in the lowest glucose levels. methods: the research design was pretest posttest control group design. sample obtained as many as 58 students of the faculty of nursing university of airlangga who meet the inclusion and exclusion criteria. 58 samples were divided into three groups, namely noodles a (control), b (substitution 30%) and c (substitution 20%). glucose levels examination carried out before eating noodles and 60 minutes after eat it. the data analysis of this study was the one-way anova. results: based on the one-way anova test was obtained p = 0.000 (p <0.050), which means no differences in outcomes in all three groups. the highest increasing of glucose levels is group a and the lowest in group b. discussion: the addition of banana and breadfruit flour on the noodles can reduce the increase in the glucose levels after eat it. further research needs to be done to determine the content of noodles with a banana and breadfruit flour and glucose’s responses in patients with diabetic mellitus. keyword : noodles, flour, banana, breadfruit,glucose, diabetic mellitus. pendahuluan penyakit degeneratif menimbulkan permasalahan bagi negara di seluruh dunia. beban pembiayaan untuk perawatan dan pengobatan penyakit degeneratif menyebabkan kerugian hingga miliar dolar (world health organization, 2016). kemajuan ilmu kesehatan yang sangat pesat belum dapat menyelesaikan permasalahan tersebut. sampai saat ini penyakit degeneratif telah menjadi penyebab kematian terbesar di dunia (handajani, roosihermiatie, & maryani, 2010). sebanyak kurang lebih 17 juta jiwa meninggal lebih awal setiap tahun akibat penyakit degeneratif. di beberapa negara dengan pendapatan nasional rendah dan sedang kematian akibat penyakit degeneratif mencapai 80%. negara tersebut antara lain yaitu brazilia, kanada, cina, india, nigeria, pakistan, rusia, inggris, dan tanzania (handajani et al., 2010). salah satu penyakit degeneratif yang paling banyak di derita adalah diabetes mellitus (dm). pada tahun 2014 sebanyak 422 juta orang di seluruh dunia menderita dm (world health organization, 2016). penduduk indonesia di atas 20 tahun sebanyak 125 juta, dengan prevalensi dm sebesar 4,6% maka diperkirakan pada tahun 2000 jumlah penderita dm berjumlah 5,6 juta orang. sedangkan pada tahun 2020 akan didapatkan sekitar 8,2 juta penderita dm (handajani et al., 2010). oleh karena itu dibutuhkan upaya untuk menanggulangi permasalahan tersebut. salah satu upaya yang dapat dilakukan adalah dengan merubah gaya hidup menjadi lebih sehat. kesadaran masyarakat terhadap gaya hidup sehat menyebabkan perubahan pada pemilihan bahan makanan untuk dikonsumsi. mailto:nursalam@fkp.unair.ac.id jurnal ners vol. 11 no. 2 oktober 2016: 246-250 247 berbagai penyakit degeneratif seperti diabetes mellitus, stroke, serangan jantung telah membuat masyarakat semakin waspada terhadap makanan yang dikonsumsi (ningrum, nisa, & pangastuti, 2013). salah satu penyakit degeneratif yang disebabkan karena pola konsumsi makanan yang tidak sehat adalah dm. makanan yang dapat menjadi pemicu dm adalah makanan berlemak, berminyak, mengandung banyak gula dan tinggi karbohidrat, serta kurang serat (umar, bodhi, & kepel, 2013). diabetes mellitus adalah gangguan kronis dari metabolisme karbohidrat , protein, dan lemak. gangguan ini terjadi akibat perbedaan antara jumlah insulin yang dibutuhkan oleh tubuh dan jumlah insulin yang tersedia. sel beta pankreas memproduksi insulin dan cpeptida, yang disimpan dalam granul sekresi dari sel beta dan dilepaskan ke dalam aliran darah pada saat kadar glukosa darah meningkat. insulin mengangkut glukosa dan asam amino melintasi membran sel tubuh, terutama sel otot dan lemak. mekanisme ini akan meningkatkan penyimpanan hati glikogen, bahan penyimpanan karbohidrat kepala, dan membantu dalam metabolisme trigliserida, asam nukleat, dan protein (sommers, johson, & beery, 2007). faktor resiko penyakit dm type 2 adalah obesitas, olahraga yang tidak teratur, gaya hidup dan konsumsi makanan yang tidak sehat dan riwayat keluarga dengan dm (kurnawan, 2010; world health organization, 2016). dm dapat dicegah dengan mengontrol berat badan, meningkatkan latihan dan aktifitas, merubah gaya hidup yang lebih sehat dan konsumsi makanan seimbang. pemilihan makanan sehat perlu dilakukan untuk menjaga kadar glukosa darah. salah satu makanan yang dapat menjaga glukosa darah adalah makanan dengan tinggi serat. serat belum lama ini diketahui dapat membantu meregulasi kadar glukosa darah (saputro & estiasih, 2015). namun dengan tingginya aktivitas masyarakat beberapa dekade ini masyarakat juga membutuhkan makanan yang mudah diolah. salah satu bahan makanan yang digemari masyarakat indonesia dan mudah diolah adalah mi (koswara, 2009). mi berbahan tepung terigu diketahui memiliki indeks glikemik (ig) yang sangat tinggi yaitu 85 (witono, kumalaputri, & lukmana, 2012). bahan makanan dengan ig tinggi akan meningkatkan kadar glukosa dengan cepat (arif & budiyanto, 2013). kondisi yang tidak boleh terjadi pada penderita dm. sehingga peneliti berupaya untuk mencari bahan lain yang dapat digunakan sebagai bahan baku pembuatan mi. sukun diketahui memiliki ig rendah sekitar 23-60 dengan kandungan pati yang cukup tinggi. selain itu sukun juga memiliki kandungan vitamin dan juga mineral yang lebih jika dibandingkan dengan tepung terigu (prahandoko, 2013). pisang memiliki nilai ig 59 dan kandungan serat 0,6 g/100g, serta vitamin dan mineral yang juga lebih dibandingkan dengan tepung terigu. selain itu pisang diketahui memiliki kandungan kalium (witono et al., 2012). kalium diketahui berfungsi untuk membantu kerja insulin membuka membran sel dan memasukkan glukosa ke dalam sel tubuh (smeltze & bare, 2004). kedua bahan tersebut merupakan bahan makanan yang banyak terdapat di indonesia dan harga terjangkau (safriani et al., 2013). bahan dan metode penelitian penelitian ini telah mendapatkan sertifikat layak etik dari komisi etik fakultas keperawatan unair dengan nomor 216-kepk riset yang dilakukan merupakan quasy experiment yang berdesain control group pretest postttest design (clamp, gough, & land, 2004). peneliti memberikan 3 macam mi kepada 3 kelompok, yaitu mie dengan bahan tepung terigu, mie berbahan tepung pisang dan sukun sebanyak 30% dan 20%. kemudian peneliti mengukur glukosa darah sewaktu (gds) sebelum dan sesudah pemberian mi dengan stick glukometer merk nesco. perlakuan dilakukan pada saat sarapan pagi yaitu jam 07.00. pengambilan darah untuk posttest dilakukan 60 menit setelah perlakuan (ningrum et al., 2013). pre test diambil sebelum perlakuan. subjek penelitian diminta untuk tidak mengkonsumsi makanan apapun setelah bangun tidur, hanya diperbolehkan minum air putih. penentuan sampel menggunakan purposive sampling (budijanto, 2013; clamp et al., 2004) dan dilakukan pada bulan agustus-september 2016. subjek penelitian berjumlah 58 orang mahasiswa fkp unair yang dibagi menjadi 3 kelompok, yaitu kelompok a (kelompok kontrol berjumlah 19 orang), kelompok b (mi dengan tepung subtitusi 30%), dan kelompok c (mie dengan tepung subtitusi 20%). pemilihan efek mie instan dan sukun terhadap gula darah sewaktu (nursalam, dkk) 248 subjek penelitian ditentukan dengan kriteria inkulusi dan eksklusi. kriteria inklusi yang ditetapkan adalah, imt normal yaitu 18,522,9, usia 20-30 tahun (kurnawan, 2010). kriteria eksklusi yang ditentukan oleh peneliti adalah penderita diabetes mellitus (dm), sirosis hepatis (sh), gagal ginjal kronis (ggk), penyakit infeksi yang mempengaruhi metabolisme (tbc), kanker/ tumor. mengkonsumsi obat-obatan dan perokok (ningrum et al., 2013). bahan yang digunakan di dalam penelitian antara lain mi kontrol dengan komposisi: telur, tepung terigu, tepung tapioka, garam, minyak, air, kaldu ayam bubuk. mi dengan tepung subtitusi 30%, komposisi: telur, tepung terigu, tepung tapioka, garam, minyak, air, kaldu ayam bubuk, tepung pisang dan sukun dengan berat 30% dari berat tepung terigu. mie dengan tepung subtitusi 20%, komposisi: telur, tepung terigu, tepung tapioka, garam, minyak, air, kaldu ayam bubuk, tepung pisang dan sukun dengan berat 20% dari berat tepung terigu. (koswara, 2009; nasution, 2005). ketiga mi diolah seperti mi ayam dengan tambahan bawang putih, bawang merah, gula garam, minyak bawang, ayam, daun bawang dan selada. tiap jenis mie disajikan dengan berat 100 gr. alat yang digunakan antara lain glukometer dan strip stick merk nesco, jarum, alkohol swab, timbangan berat badan, pengukur tinggi badan. hasil yang didapatkan dalam penelitian ini dianalisa menggunakan uji paired t test untuk mengetahui ada perbedaan antara nilai gds pre test dan post test di setiap kelompok. uji one way annova digunakan untuk mengetahui perbedaan pada 3 kelompok perlakuan. hasil karakteristik responden responden yang dipilih berjumlah 58 orang, 46 orang perempuan dan 12 orang lakilaki. semua responden dalam status gizi yang baik ditentukan dengan nilai imt dalam rentang normal dan tidak menderita penyakit yang mempengaruhi metabolisme tubuh. karakteristik sampel berupa umur, berat badan, tinggi badan, imt dan kondisi kesehatan dikumpulkan untuk mengetahui responden yang memenuhi kriteria inklusi dan eksklusi. kriteria untuk penyakit yang diderita oleh responden diketahui dengan cara menanyakan kepada responden mengenai penyakit yang diderita saat ini dan riwayat penyakit keluarga penderita. anamnesis ini diperlukan untuk mengetahui kemungkinan subjek memiliki resiko dm. umur rata-rata responden adalah 22,8 tahun, dengan rata-rata berat badan 52,1 kg dan tinggi badan 161 cm dengan imt 20,1. respon gds terhadap mie a, b dan c rerata nilai gds pre test dan post test menunjukkan rerata nilai gds sebelum diberikan perlakuan tertinggi adalah kelompok mie a, yaitu 71, 84 mg/dl dan terendah pada kelompok mie c yaitu 71,21 mg/dl. hasil analisa menggunakan anova one way didapatkan nilai p= 0,960 (p<0,050), artinya rerata nilai gds pada ketiga kelompok (mie a, b dan c) sama atau tidak ada perbedaan. setelah 60 menit pemberian mie a, b dan c dilakukan pemeriksaan gds kembali sebagai nilai posttest. dari pemeriksaan gds diketahui (tabel 1) bahwa kelompok yang memiliki rerata nilai gds tertinggi adalah mie a (kontrol) dan trendah pada mie b (subtitusi 30%) yaitu 77,70 mg/dl. hasil hasil analisa dengan uji menggunakan anova one way, yaitu p= 0,000 (p<0,050), artinya rerata nilai gds pada ketiga kelompok (mie a, b dan c) ada perbedaan yang signifikan. rata-rata kenaikan gds tabel 1. rerata kenaikan gds dalam 60 menit setelah pemberian mie a, b dan c jenis mie f mean mi a (kontrol) 19 +25.7 mi b (subtitusi 30%) 20 +6.2 mi c (subtitusi 20%) 19 +12.2 total 58 +14.8 jurnal ners vol. 11 no. 2 oktober 2016: 246-250 249 setelah 60 menit pemberian mie a, b dan c dilakukan pemeriksaan gds diketahui rerata kenaikan gds tertinggi adalah pada kelompok yang diberikan mi a yaitu 25,7 mg/dl dan terendah pada kelompok mie b yaitu 6,2 mg/dl. pembahasan berdasarkan tabel 2 diketahui bahwa rerata nilai gds posttest terdapat perbedaan yang sangat signifikan diantara ketiga kelompok dengan pemberian mi a, b dan c. lebih jauh dijelaskan pada tabel 3 bahwa perbedaan tersebut terlihat pada kenaikan gds setelah konsumsi mi. kenaikan gds terendah pada mi b yaitu mie dengan subtitusi tepung pisang dan sukun sebesar 30% dari jumlah tepung terigu. respon kenaikan glukosa darah dipengaruhi oleh 2 hal utama yaitu kondisi tubuh responden dan bahan makanan yang dikonsumsi. pada penelitian ini responden yang terlibat memiliki kondisi tubuh yang sama yaitu yang memnuhi kriteria inklusi dan eksklusi. responden dengan nilai imt dalam rentang normal (18-22,5) dan tidak memiliki riwayat penyakit (dm, sh, tbc, kanker/tumor dan ggk) diharapkan memiliki metabolime yang baik. selain itu pemilihan usia responden 2030 tahun bertujuan tidak terjadi kenaikan kadar glukosa darah. pada usia lebih dari 30 tahun, kadar glukosa darah akan naik 1-2 mg%/tahun pada saat puasa dan akan naik sebesar 5,6-13 mg%/tahun pada 2 jam setelah makan.1,3 (kurnawan, 2010). faktor lain yang mempengaruhi respon kenaikan kadar glukosa darah adalah dari bahan makanan. faktor ini dirinnci sebagai berikut kadar serat, perbandingan amilosa dan amilopektin, daya cerna pati, kadar lemak dan protein, dan cara pengolahan. masing-masing komponen tersebut memberikan kontribusi dan saling berpengaruh hingga menghasilkan respons glikemik yang berbeda (arif & budiyanto, 2013). kandungan serat pangan yang tinggi berkontribusi pada glukosa darah. serat larut yang berbentuk viskus dapat memperpanjang waktu pengosongan lambung (kusharto, 2006). serat utuh dapat bertindak sebagai barier pada pencernaan, sehingga memperlambat laju makanan pada saluran pencernaan dan menghambat aktivitas enzim. kondisi ini membuat proses pencernaan pati menjadi lambat dan respons glukosa darah pun akan lebih rendah (arif & budiyanto, 2013). bahan makanan yang memilikikadar lemak yang tinggi cenderung memperlambat laju pengosongan lambung, sehingga laju pencernaan makanan pada usus halus juga lambat. sementara itu, kadar protein yang tinggi kemungkinan dapat merangsang sekresi insulin sehingga glukosa darah terkendali (arif & budiyanto, 2013). berdasarkan keperawatan komplementer makanan dapat digunakan sebagai terapi atau media perawatan, dikenal dengan istilah “functional food and nutraceutical”. makanan yang dikonsumsi perlu diketahui fungsi di dalam tubuh, baik sebagai bahan makanan yang mengoptimalkan kesehatan maupun sebagai bahan makanan untuk mencegah penyakit. hal yang perlu diperhatikan dalam penggunaan makanan sebagai media terapi dan perawatan adalah harus berdasarkan evidence (snyder & lindquist, n.d.). artinya perlu dilakukan penelitian pada kandungan bahan makanan dan reaksi di dalam tubuh, baik tubuh yang sehat maupun yang sedang sakit. beberapa jenis bahan makanan yang telah terbukti dapat digunakan sebagai media terapi dan perawatan adalah probiotics, coenzyme q10, glucosamine, chondroitin sulfate, dan collagen hydrolysate (untuk osteoarthitis), teh hijau dan lain sebagainya simpulan & saran simpulan penggantian tepung terigu dengan tepung sukun terbukti dapat menurunkan kenaikan glukosa darah sewaktu pada responden bukan penderita dm. subtitusi tepung pisang dan sukun sebnyaka 30% memberikan efek kenaikan gds paling sedikit. kondisi ini dapat dipengaruhi oleh kadar serat dan kalium yang lebih tinggi pada tepung pisang dan sukun apabila dibandingkan dengan tepung terigu. saran peneliti menyarankan untuk penelitian selanjutnya dapat dilakukan penelitian kandungan mie dengan subtitusi tepung pisang dan sukun. selain itu perlu dilakukan penelitian lebih lanjut mengenai efek pemberian mi tepung pisang dan sukun terhadapa efek mie instan dan sukun terhadap gula darah sewaktu (nursalam, dkk) 250 kadar glukosa darah penderita diabetes mellitus. perawat dapat berkolaborasi dengan ahli gizi untuk membuat mie dengan penambahan tepung sukun dan pisang, sehingga dapat digunakan sebagai alternatif makanan untuk diet dm. kepustakaan arif, a. bin, & budiyanto, a. (2013). glicemic index of foods and its affecting factors. j litbang pert, 32(2). budijanto, d. (2013). populasi, sampling, dan besar sampel. retrieved september 20, 2016, from http://www.risbinkes.litbang.depkes.go.id /2015/wpcontent/uploads/2013/02/samplingdan-besar-sampel.pdf clamp, c. g. l., gough, s., & land, l. (2004). resources for nursing research (4th ed.). london: sage publication ltd. handajani, a., roosihermiatie, b., & maryani, h. (2010). faktor-faktor yang berhubungan dengan pola kematian pada penyakit degeneratif di indonesia. buletin penelitian sistem kesehatan, 13, 42–53. koswara, s. (2009). teknologi pengolahan mie. kurnawan, i. (2010). diabetes melitus tipe 2 pada usia lanjut. public health, 576– 584. kusharto, c. m. (2006). serat makanan dan kesehatan. jurnal gizi dan panga, 1(november), 45–54. nasution, e. z. (2005). pembuatan mie kering dari tepung terigu dengan tepung rumput laut yang difortifikasi dengan kacang kedelai. jurnal sains kmia, 9(2), 87–91. ningrum, d. r., nisa, f. z., & pangastuti, r. (2013). indeks glikemik dan beban glikemik sponge cake sebagai jajanan berbasis karbohidrat pada subyek bukan penyandang diabetes melitus in prosiding seminar nasional food habit and degenerative diseases (pp. 109–119). prahandoko, t. p. (2013). pengaruh substitusi tepung sukun (. safriani, n., moulana, r., studi, p., hasil, t., pertanian, f., & kuala, u. s. (2013). pemanfaatan pasta sukun (artocarpus altilis) pada pembuatan mie kering, (2), 17–24. saputro, p. s., & estiasih, t. (2015). pengaruh polisakarida larut ir (pla) dan serat pangan umbi-umbian terhadap glukosa darah: kajian pustaka: effect of water soluble pollysacarides and dietary fiber tubers on blood glucose : a review. jurnal pangan dan agroindustri, 3(2), 756–762. smeltze, s. c., & bare, b. (2004). textbook of medical-surgical nursing (10th ed.). new york: lipincot williams & wilkins. snyder, m., & lindquist, r. (n.d.). complementary / alternative therapies in nursing (5th ed.). nee york: springer link. sommers, m. s., johson, s. a., & beery, t. a. (2007). diseases and disorders a nursing therapeutics manual (3rd ed.). philadelphia: f.a. davis company. umar, f. a., bodhi, w., & kepel, b. j. (2013). gambaran gula darah darah pada remaja obes di minahasa 1. jurnal e-biomedik (ebm), 1(1), 265–269. witono, j. ., kumalaputri, a. j., & lukmana, h. s. (2012). optimasi rasio tepung terigu, tepung pisang dan tepung ubi jalar, serta konsentrasi zat aditif pada pembuatan mie. . world health organization. (2016). global report on diabetes. http://doi.org/isbn 978 92 4 156525 7 ners vol 5 no 1 april 2010_akreditasi 2013.indd 55 analisis faktor tingkat keberhasilan pemberian asi eksklusif pada ibu menyusui (factor analysis about exclusive breastfeeding achievement level among mothers who provide breastmilk to their children) tiyas kusumaningrum*, catur puji lestari*, agus sulistyono** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax (031) 5913257. e-mail: tiyaskusumaningrum@gmail.com ** lab/smf/irna obstetri dan ginekologi rsud dr. soetomo surabaya abstract introduction: the number of mother who breastfeed their babies exclusively in indonesia is low. it caused by many factors such as high intensity of formula milk advertisement, lack of awareness about the importance of breastfeeding, working mother, social culture, family support and the role of health care provider. the purpose of this research was to analyze factors related with successfulness level of exclusive breastfeeding. method: design used in this research was analytic retrospective. the population were all mothers at pacarkeling public health center area. sample obtained through purposive sampling. total sample was 61 respondents. independent variables were knowledge, information and promotion, family support, social cultural, role of health provider, work/occupation, education and breast physiology anatomy. the dependent variable was exclusive breastfeeding. result: the result indicated that exclusive breastfeeding achievement level was related with information and promotion (r = 0.271), family support (r = 373), health care provider role (r = 231), mother occupation (r = 251), anatomy and physiology of breast (r = 293), while the knowledge (r = 108), social cultural (r = 180) and education (r = 093) not signifi cantly related. discussion: in conclusion, there was a positive correlation between information and promotion, family support, health care provider role, mother’s occupation, anatomy and physiology of breast with successfulness level of exclusive breastfeeding. while the knowledge, social cultural and education did not indicate signifi cant result. therefore it is suggested to increase the quantity and quality of information and promotion about exclusive breastfeeding to the society, health care provider and pregnant and breastfeeding mother. keywords: breasfeeding, knowledge, exclusive breastfeeding pendahuluan pemberian air susu ibu (asi) eksklusif sejak lahir hingga usia 6 bulan penting untuk kelangsungan hidup dan pertumbuhan optimal bayi (lawrence, 2005). world health organization (who) merekomendasikan semua bayi harus mendapatkan asi secara eksklusif sejak lahir sampai berusia 6 bulan. asi eksklusif merupakan pemberian asi saja sampai bayi berusia 6 bulan, tanpa tambahan cairan ataupun makanan lain selain asi. pemerintah indonesia khususnya departemen kesehatan mengadopsi pola pemberian asi eksklusif seperti rekomendasi who yang tertuang dalam sk menkes 2004 sebagai salah satu program perbaikan gizi bayi. program yang ingin dicapai dalam indonesia sehat 2010 adalah 80% ibu menyusui memberikan asi eksklusif (depkes ri, 2005). hasil penelitian amirudin dan rosita (2006), pemberian asi eksklusif di jawa timur hanya 9,3%, angka tersebut sangat jauh dengan standart nasional. menurut depkes ri pemberian asi eksklusif di indonesia belum dilaksanakan sepenuhnya karena faktor sosial budaya, kurangnya kesadaran akan pentingnya asi, pelayanan kesehatan dan petugas kesehatan yang belum sepenuhnya mendukung peningkatan pemberian asi, gencarnya promosi susu formula dan ibu bekerja. hasil pengumpulan data awal pada 2–6 mei 2009 di posyandu wilayah kerja jurnal ners vol. 5 no. 1 april 2010: 55–61 56 puskesmas pacarkeling didapatkan dari 36 ibu menyusui dengan rentang usia balita 7 bulan–2 tahun, 10 ibu menyusui (27,7%) memberikan asi eksklusif, 3 ibu menyusui (8,3%) memberikan pisang sebagai makanan tambahan dan 23 ibu menyusui (63,8%) memberikan susu formula, hal ini menunjukkan bahwa persentase pemberian asi eksklusif di posyandu wilayah kerja puskesmas pacarkeling masih jauh di bawah standart nasional asi eksklusif. oleh karena itu perlu analisis yang menunjukkan besar keterkaitan antara faktor sosial budaya, pengetahuan, informasi dan pelayanan dari petugas kesehatan, gencarnya promosi susu formula dan ibu bekerja dengan pemberian asi eksklusif. praktek pemberian asi eksklusif masih rendah. survei demografi dan kesehatan indonesia (sdki) tahun 2002–2003, pemberian asi eksklusif pada bayi di bawah usia dua bulan hanya mencakup 64% dari total bayi yang ada. persentase tersebut menurun seiring dengan bertambahnya usia bayi yaitu, 46% pada bayi usia 2–3 bulan, 14% pada bayi usia 4–5 bulan, dan 13% bayi di bawah dua bulan telah diberi susu formula dan satu dari tiga bayi usia 2–3 bulan telah diberi makanan tambahan. survei yang dilaksanakan pada tahun 2002 oleh nutrition & health surveillance system (nss) kerja sama dengan balitbangkes dan helen keller international di 4 perkotaan (jakarta, surabaya, semarang, makasar) dan 8 perdesaan (sumbar, lampung, banten, jabar, jateng, jatim, ntb, sulsel) menunjukkan bahwa cakupan asi eksklusif 4–6 bulan di perkotaan antara 4–12%, sedangkan di pedesaan 4–25%. studi di jakarta menunjukkan bahwa praktek pemberian asi eksklusif hingga usia 4–6 bulan adalah 8,5%, hingga usia 6 bulan adalah 7,8%, dan 46% memilih memberikan susu formula (dinas kesehatan propinsi dki jakarta, 2005). pemberian asi eksklusif yang rendah merupakan salah satu pemicu rendahnya status gizi bayi dan balita. data susenas m e n u n j u k k a n k a s u s g i z i b u r u k t e r j a d i peningkatan 6,3% (tahun 1989) menjadi 11,4% (tahun 1995). pada tahun 1999 sekitar 1,7 juta balita di indonesia menderita gizi buruk berdasarkan indikator berat badan terhadap umur (bb/u). sampai akhir tahun 1999 terdapat sekitar 24.000 balita gizi buruk tingkat berat. kasus gizi buruk yang meningkat, menunjukkan bahwa pemberian asi eksklusif sangat penting untuk pemenuhan gizi balita. pemberian asi eksklusif yang rendah menunjukkan bahwa, untuk mempraktekkan pemberian asi sesuai dengan anjuran, yaitu segera setelah melahirkan sampai pada periode 6 bulan pertama, ibu menyusui menghadapi banyak hambatan yang berhubungan dengan pelayanan yang diperoleh di tempat persalinan (who, 1998; taveras et al., 2003; bps dan orc macro, 2003; septiari et al., 2006) dan dukungan yang diberikan oleh anggota keluarga di rumah (lawrence, 2005). praktek pemberian asi eksklusif dipengaruhi oleh budaya, persepsi yang tidak benar tentang menyusui, dan promosi asi eksklusif (fenglian et al., 2007). kekurangan gizi pada bayi disebabkan karena selain makanan yang kurang juga karena asi banyak diganti dengan susu formula dengan cara dan jumlah yang tidak sesuai kebutuhan bayi (siregar, 2005). pemberian asi eksklusif yang rendah meningkatkan kejadian penyakit infeksi seperti diare, otitis media, dan infeksi saluran pernafasan bagian atas pada anak di bawah usia 2 tahun (suharyono, 1989). pemberian asi eksklusif penting untuk tumbuh kembang bayi yang optimal baik fisik, mental dan kecerdasan, maka perlu perhatian agar dapat terlaksana dengan benar. berbagai faktor yang memengaruhi pemberian asi eksklusif perlu diketahui sehingga dapat terjalin suatu kerja sama yang baik antara ibu menyusui, lingkungan, dan petugas kesehatan agar mendukung keberhasilan pemberian asi eksklusif. bahan dan metode penelitian ini dilakukan dengan metode analitik dengan rancangan retrospektif. pada penelitian ini dinilai faktor pengetahuan ibu, peran petugas kesehatan, pekerjaan ibu, sumber informasi, sosial budaya, pendidikan dan dukungan keluarga pada masa lalu terhadap tingkat keberhasilan pemberian asi eksklusif di posyandu wilayah kerja puskesmas pacarkeling surabaya. tingkat keberhasilan asi eksklusif (tiyas kusumaningrum) 57 populasi dalam penelitian ini adalah ibu menyusui yang terdata di posyandu wilayah kerja puskesmas pacarkeling surabaya yang terdiri dari 26 posyandu. pengambilan sampel 61 ibu pada penelitian ini dilakukan dengan teknik purposive sampling berdasarkan kriteria inklusi ibu menyusui dengan usia bayi 7 bulan sampai 1 tahun. kriteria eksklusi yang dipakai antara lain ibu dengan kondisi yang tidak memungkinkan untuk menyusui seperti hiv/aids, hepatitis b, tb paru atau kondisi bayi yang tidak bisa menyusu seperti sumbing palatum, atresia koanal, deformitas fasial, dan kelainan gastrointestinal. penelitian dilakukan selama 18 juni sampai 14 juli 2009. variabel independen dalam penelitian ini adalah faktor-faktor yang berhubungan dengan tingkat keberhasilan pemberian asi eksklusif yaitu pengetahuan, dukungan keluarga, informasi dan promosi kesehatan, anatomi dan fisiologi payudara ibu, pendidikan, pekerjaan ibu, dan peran petugas kesehatan. variabel dependen dalam penelitian ini tingkat keberhasilan pemberian asi eksklusif. instrumen yang digunakan berupa kuesioner diambil dari instrumen penelitian hany f (2007), muhtar (2005) dengan modifikasi berdasarkan teori akre (1994) dan soetjiningsih (1997). kuesioner tersebut terdiri dari 9 item pertanyaan tentang pengetahuan ibu (pengertian asi, komposisi asi, manfaat a s i d a n t e k n i k m e n y u s u i ) , d u k u n g a n keluarga (dukungan emosional, penghargaan, informasi dan instrumental), informasi dan promosi (petugas kesehatan, media masa dan masyarakat), sosial budaya (adakah anjuran masyarakat tentang asi, kolostrum dan penyapihan), peran petugas kesehatan (komunikasi, informasi dan edukasi), anatomi dan fisiologi payudara (adanya kelainan pada payudara ibu), serta tingkat keberhasilan asi eksklusif (usia balita mulai diberikan makanan tambahan). data yang diperoleh selanjutnya dianalisis dengan menggunakan teknik statistik korelasi spearmen rho dengan tingkat signifikasi α≤0,05. hasil distribusi data demografi responden didapatkan dari 61 responden sebagian besar ibu yang datang ke posyandu balita berumur 20–35 tahun sebanyak 48 responden (79%), umur >35 tahun sebanyak 11 responden (18%) dan ibu umur <20 tahun sebesar 2 responden (3%). tingkat pendidikan terakhir yang pernah di capai dengan persentase terbanyak pada tingkat sma sebesar 30 responden (49%), kemudian smp 16 responden (26%), sd 8 responden (13%) dan persentase terkecil adalah tingkat perguruan tinggi 7 responden (12%). pekerjaan ibu didapatkan 47 responden (77%) ibu tidak bekerja atau sebagai ibu rumah tangga, 11 responden (18%) sebagai pegawai dan 3 responden (5%) berwiraswasta sebagai pedagang. pendapatan keluarga ibu terbanyak adalah sedang dengan jumlah rp500.000–rp1.000.000 per bulan mencapai 29 responden (47%), kemudian pendapatan >rp1.000.000 per bulan sebesar 18 responden (30%) dan keluarga yang berpendapatan rendah <rp500.000 sebanyak 14 responden (23%). balita yang berusia 7 bulan sampai 1 tahun pada posyandu balita wilayah puskesmas pacarkeling terbanyak merupakan anak pertama yaitu 28 responden (46%), kemudian anak kedua mencapai 23 responden (38%), anak ketiga sebanyak 7 responden (11%), dan anak keempat sebesar 3 responden (5%). kunjungan balita ke posyandu dengan persentase terbanyak selalu atau tiap bulan rutin melakukan kunjungan ke posyandu sebesar 38 responden (62%), kemudian sering datang ke posyandu sebanyak 18 responden (30%) dan 5 responden (8%) menyatakan jarang berkunjung ke posyandu. pengetahuan tentang asi pada ibu yang berhasil memberikan asi eksklusif adalah baik, sebanyak 33 responden (54,1%) pada ibu yang berhasil memberikan asi eksklusif mempunyai pengetahuan yang baik dan 1 responden (1,7%) mempunyai pengetahuan yang cukup. ibu yang tidak berhasil memberikan asi eksklusif juga mempunyai pengetahuan yang baik yaitu mencapai 25 responden (40,9%) dan sebanyak 2 responden (3,3%) mempunyai pengetahuan yang kurang. informasi tentang asi eksklusif yang didapatkan dengan persentase terbanyak pada kategori cukup baik pada ibu yang berhasil memberikan asi eksklusif maupun yang tidak berhasil memberikan asi eksklusif. pada jurnal ners vol. 5 no. 1 april 2010: 55–61 58 ibu yang berhasil memberikan asi eksklusif informasi yang baik mencapai 6 responden (9,8%), informasi cukup 26 responden (42,6%) dan 2 (3,3%) responden menyatakan informasi yang didapat kurang. ibu yang tidak berhasil memberikan asi eksklusif menyatakan informasi yang didapatkan baik sebanyak 3 responden (4,9%), informasi cukup sebanyak 16 responden (26,3%) dan 8 responden (13,1%) mendapatkan informasi yang kurang. dukungan keluarga yang baik pada ibu yang memberikan asi eksklusif. pada ibu yang berhasil memberikan asi eksklusif dukungan keluarga yang baik diberikan pada 28 responden (45,9%) dan cukup pada 6 responden (9,9%). pada ibu yang tidak berhasil dukungan keluarga yang baik juga diberikan pada 13 responden (21,3%), cukup sebanyak 12 responden (19,6%), dan kurang pada 2 responden (3,3%). sosial budaya di sekitar ibu yang berhasil memberikan asi eksklusif maupun yang tidak berhasil memberikan menyusui dikategorikan baik. pada ibu yang berhasil memberikan asi eksklusif menunjukkan sosial budaya yang baik dinyatakan oleh 25 responden (40,9%), sosial budaya cukup oleh 9 responden (14,8%), sedangkan pada ibu yang tidak berhasil memberikan asi eksklusif sosial budaya yang baik diperoleh dari 16 responden (26,3%), cukup oleh 8 responden (13,1%) dan kurang baik diperoleh dari 3 responden (4,9%). k e b e r h a s i l a n a s i e k s k l u s i f m e m b u t u h k a n a d a n y a p e r a n p e t u g a s kesehatan yang baik, hal ini dapat dilihat dari 20 responden (32,8%) menyatakan peran petugas kesehatan yang baik dan 14 responden (22,9%) menyatakan peran petugas cukup. ibu yang tidak berhasil memberikan asi eksklusif menunjukkan peran petugas kesehatan terbanyak adalah cukup, hal ini diketahui dari 13 responden menyatakan peran petugas cukup, 7 responden (11,5%) menyatakan baik dan 7 responden (11,5%) menyatakan kurang. dari 34 responden yang berhasil memberikan asi eksklusif 26 responden (42,6%) anatomi dan fisiologi payudara ibu positif atau mendukung pemberian asi dan 8 responden (13,1%) anatomi dan fisiologi payudara negatif atau tidak mendukung pemberian asi. 27 responden yang tidak berhasil memberikan asi eksklusif menunjukkan 13 responden (21,3%) menyatakan anatomi dan fisiologi payudara positif dan 14 responden (23%) menyatakan anatomi dan fisiologi payudara negatif. hasil uji korelasi spearman rho untuk mengetahui adanya hubungan antar variabel dapat dilihat pada tabel 1. pembahasan perbandingan antara ibu yang berhasil memberikan asi eksklusif lebih besar dibandingkan dengan yang tidak asi eksklusif. hal tersebut dikarenakan ada beberapa faktor yang mendukung ibu untuk memberikan asi secara eksklusif. faktor tersebut meliputi faktor dari bayi sendiri di mana tidak ada kelainan anatomis pada mulut bayi dan faktor dari ibu meliputi anatomi dan fisiologi payudara, makanan ibu dan pengetahuan ibu. pengetahuan ini dipengaruhi oleh tingkat pendidikan ibu, pekerjaan ibu, dukungan keluarga selama ibu hamil sampai menyusui, sosial budaya setempat yang memberikan berbagai macam anjuran dalam menyusui, informasi dan promosi baik dari media koran, televisi, radio serta peran petugas kesehatan sendiri selama tabel 1. berbagai faktor yang memengaruhi tingkat keberhasilan asi eksklusif faktor uji spearman rho keterangan pengetahuan ibu tentang asi p = 0,0409 tidak ada hubungan informasi dan promosi p = 0,035 ; r = 0,271 ada hubungan, kekuatan rendah dukungan keluarga p = 0,003 ; r = 0,373 ada hubungan, kekuatan rendah sosial budaya p =0,164 tidak ada hubungan peran petugas kesehatan p = 0,001 ; r = 0,413 ada hubungan, kekuatan rendah anatomi fi siologi payudara p = 0,002 ; r = 0,293 ada hubungan, kekuatan rendah keterangan: p = signifi kansi r = koefi sien korelasi tingkat keberhasilan asi eksklusif (tiyas kusumaningrum) 59 ibu melahirkan sampai menyusui. salah satu peran petugas kesehatan yang nyata adalah pengelolaan laktasi di ruang bersalin untuk menunjang keberhasilan menyusui (siregar, 2004). keberhasilan asi eksklusif dipengaruhi oleh informasi dan promosi sehingga perlu ditunjang dengan adanya sosialisasi. hal ini membutuhkan kerja sama dari berbagai bidang seperti pemerintah dengan mencanangkan program menyusui secara eksklusif, peran petugas kesehatan dalam memberikan pendidikan kesehatan mengenai manajemen laktasi kepada ibu yang melahirkan. pendidikan kesehatan dapat dilakukan oleh petugas kesehatan dengan menempelkan poster menyusui di rumah sakit dan puskesmas dan membagikan selebaran bagi pasien agar membantu masyarakat untuk selalu ingat akan pesan yang benar tentang asi eksklusif (siregar, 2004). h a s i l p e n e l i t i a n i n i d i d a p a t k a n pengetahuan tidak berhubungan dengan pemberian asi eksklusif dikarenakan banyak faktor yang memengaruhi pemberian asi eksklusif. pengetahuan saja tanpa adanya kesadaran akan pentingnya asi dan motivasi menjadikan ibu tidak memberikan asi secara eksklusif. selain itu pemberian asi eksklusif membutuhkan waktu yang relatif lama yaitu 6 bulan tanpa tambahan makanan atau minuman lain selain asi, maka perlu ada faktor lain yang mendukung ibu dalam memberikan asi saja sampai usia bayi 6 bulan. faktor tersebut antara lain informasi dan promosi baik informasi tentang asi eksklusif maupun susu formula atau bubur sebagai makanan tambahan bayi yang seharusnya diberikan pada bayi usia minimal 6 bulan, dukungan keluarga, peran petugas kesehatan dan anatomi fisiologi payudara ibu. informasi dan promosi tentang asi yang baik akan memberikan ibu rasa percaya diri dan nyaman dalam memberikan asi eksklusif. hasil penelitian krystyra, (2004) didapatkan bahwa ada hubungan antara informasi dan promosi dengan tingkat keberhasilan pemberian asi eksklusif di polandia. pada responden yang mendapatkan informasi dan promosi susu formula lebih sering persentase pemberian asi akan semakin menurun. kegagalan pemberian asi karena peningkatan sarana komunikasi dan transportasi yang memudahkan periklanan distribusi susu buatan baik di desa dan perkotaan. distribusi, iklan dan promosi susu buatan berlangsung terus dan bahkan meningkat tidak hanya di televisi, radio dan surat kabar melainkan juga ditempat-tempat praktek swasta dan klinik-klinik kesehatan masyarakat di indonesia (siregar, 2004). kurangnya sosialisasi petugas kesehatan khususnya pada rumah bersalin sehingga, beberapa rumah sakit memberikan susu formula pada bayi yang baru lahir (cairan prelaktal) sebelum ibu mampu memproduksi asi hal ini menjadikan bayi tidak mau menghisap puting susu ibu karena perbedaan puting dot dan puting ibu atau lebih dikenal dengan binggung puting. dukungan keluarga juga berperan penting dalam keberhasilan asi eksklusif. menurut roesli utami, (2000) suami merupakan bagian yang vital dalam keberhasilan atau kegagalan menyusui karena suami juga membantu dalam proses perawatan bayi. dukungan keluarga berhubungan dengan keberhasilan pemberian asi eksklusif karena keluarga sebagai unit terkecil dari masyarakat di mana ibu menghabiskan waktu terbanyak untuk merawat bayinya. dukungan dari semua anggota keluarga yang berupa psikologis dan instrumental sangat dibutuhkan terlebih lagi dukungan dari suami atau ayah bayi. suami menurut banyak studi, telah diketahui berperan dalam memengaruhi keputusan untuk menyusui, inisiasi praktek menyusui dan lamanya pemberian asi, serta menjadi faktor risiko praktek pemberian susu formula. pada penelitian ini faktor sosial budaya tidak berhubungan dengan tingkat keberhasilan pemberian asi eksklusif. hal tersebut dikarenakan masih ada beberapa ibu yang menganut budaya yang masih berkembang di masyarakat tentang kebiasaan membuang kolostrum (susu pertama) karena anggapan kolostrum tersebut menyebabkan penyakit bagi si bayi. budaya modern dan perilaku masyarakat mendesak para ibu untuk segera menyapih anaknya dan memilih air susu buatan sebagai jalan keluarnya. (siregar, 2004). hasil penelitian amirudin dan rosita, (2007) didapatkan bahwa faktor keluarga jurnal ners vol. 5 no. 1 april 2010: 55–61 60 dan kebudayaan sangat memengaruhi ibu untuk menyusui bayinya secara eksklusif atau tidak. ibu yang baru melahirkan lebih percaya kepada kebiasaan-kebiasaan masyarakat dan orang tuanya yang dilakukan secara turuntemurun daripada mengaplikasikan informasi dari petugas kesehatan, berbeda dengan hasil penelitian ini bahwa sosial budaya masyarakat tidak berhubungan hal ini disebabkan oleh adanya faktor anatomi fisiologi payudara yang tidak mendukung untuk menyusui, pekerjaan, promosi susu formula, serta adanya perbedaan daerah di mana penelitian amirudin dilakukan di daerah desa di makasar sedangkan pada penelitian ini dilakukan pada wilayah surabaya yang sarana informasi, transportasi serta kemudahan dalam memperoleh susu formula dan makanan tambahan bayi yang lainnya. peran petugas kesehatan berhubungan dengan tingkat keberhasilan pemberian asi eksklusif. peran petugas meliputi komunikasi, informasi dan edukasi yang cukup dan baik selama proses menyusui memberikan dampak yang baik terhadap keberhasilan pemberian asi eksklusif. peranan petugas kesehatan khususnya di rumah sakit di mana ibu ditolong dalam melahirkan sangat menentukan tentang cara pemberian asi yang baik. peranan petugas kesehatan sangat diperlukan dalam hal penyuluhan mengenai cara merawat dan membersihkan payudara dan agar ibu tetap terus menyusui anaknya agar asi-nya keluar dan memberi penerangan agar ibu tidak memberi susu kaleng kepada bayi/anak serta nasihat tentang gizi, makanan yang bergizi untuk ibu menyusui. hasil penelitian nurcholish (2005) bersama program appropriate technology in health (path) di daerah cirebon, kediri, cianjur, blitar tahun 2003 diketahui promosi d a l a m b e r b a g a i b e n t u k k e p a d a s a r a n a kesehatan serta tenaga kesehatan, baik dokter maupun bidan untuk turut serta memasarkan produk susu formula sehingga pemberian asi eksklusif rendah, lain halnya pada penelitian ini didapatkan peran petugas setempat yang baik untuk mendukung keberhasilan pemberian asi eksklusif, hal ini dapat diketahui dengan diterapkannya konsep baru tentang pemberian asi eksklusif dan mengenai hal-hal yang berhubungan dengan ibu hamil, ibu bersalin, ibu menyusui dan bayi baru lahir untuk tetap memberikan asi, di samping itu juga sikap sementara penangung jawab ruang bersalin dan perawatan di rumah sakit, rumah bersalin yang berlangsung untuk mengusahakan agar ibu mampu memberikan asi kepada bayinya, serta diterapkannya pelayanan rawat gabung disebahagian besar rumah sakit /klinik bersalin (siregar, 2004). a n a t o m i d a n f i s i o l o g i p a y u d a r a berhubungan dengan tingkat keberhasilan pemberian asi eksklusif. anatomi dan fisiologi payudara yang mendukung sangat berpengaruh terhadap keberhasilan menyusui hingga 6 bulan. pada proses penyusuan bayi, puting menonjol kedepan dan masuk dalam mulut bayi oleh tekanan bibir bayi pada aerolanya dan akan lebih masuk ke dalam mulut bayi oleh hisapannya. jika puting ke dalam dan tidak tampak atau disebut inversi, keadaan ini dapat mengganggu keberhasilan asi eksklusif karena bayi mengalami kesulitan meraih aerola dan mendapatkan susu dari duktus (shelov, 2004). puting yang baik dan normal dapat digerakkan bebas. pada puting yang terbenam oleh perlekatan atau puting masuk ke dalam akan menimbulkan kesukaran dalam menyusui sehingga untuk menyusui dibutuhkan alat hollow nipple shield yang ditempelkan pada aerola (solihin, 2003). simpulan dan saran simpulan faktor yang memengaruhi tingkat keberhasilan asi eksklusif adalah informasi dan promosi yang didapatkan oleh ibu menyusui, dukungan keluarga, peran petugas kesehatan serta anatomi fisiologi payudara ibu menyusui. saran sehubungan dengan adanya faktor yang memengaruhi tingkat keberhasilan asi eksklusif tersebut, maka disarankan agar melibatkan keluarga dalam upaya pencapaian asi eksklusif. meningkatkan peran petugas kesehatan dalam informasi dan promosi mengenai pentingnya asi eksklusif. tingkat keberhasilan asi eksklusif (tiyas kusumaningrum) 61 kepustakaan akre, j., 1994. pemberian makan tambahan untuk bayi. jakarta: perinasia. amirudin r. dan rosita, 2006. promosi susu formula menghambat pemberian asi eksklusif pada bayi usia 6–11 bulan. artikel epidemiologi. departemen kesehatan republik indonesia, 2001. buku panduan manajemen laktasi: dit gizi masyarakat-depkes ri. departemen kesehatan republik indonesia, 2006. pedoman penyelenggaraan pelatihan konseling menyusui dan p e l a t i h a n f a s i l i t a t o r k o n s e l i n g m e n y u s u i . j a k a r t a : d e p a r t e m e n kesehatan. departemen kesehatan republik indonesia, 2005. pedoman umum pemberian makanan pendamping asi. jakarta: departemen kesehatan indonesia. departemen kesehatan republik indonesia, 1994. modul manajemen laktasi. jakarta: direktorat jendral departemen kesehatan. heny, f., 2007. hubungan perilaku ibu pasca salin dalam manajemen laktasi dengan produk dan pengeluaran asi di praktik bidan desa ny. hamilatul ru desa karangsambilagih kecamatan sugio lamongan. skripsi tidak dipublikasikan. surabaya: universitas airlangga. krystyra, m., et al., 2004. factors affecting exclusive breastfeeding in polan. soz praventivmed. lawrence, 1991. breast feeding: a cause for action. (online), (http://www. breastfeeding.com/all_about/ruth_ lawrence_bio.html., diakses tanggal 13 april 2009, jam 9:49 wib). roesli, u., 2001. panduan menyusui. jakarta: perinasia. shelov, s., 2004. panduan lengkap perawatan u n t u k b a y i d a n b a l i t a . j a k a r t a : arcan. s i r e g a r, a . , 2 0 0 4 . f a k t o rf a k t o r y a n g memengaruhi pemberian asi pada ibu melahirkan. (online), (http://library. usu.ac.id/download/fkm/fkm-arifin. pdf., diakses tanggal 16 april 2009, jam 10:11 wib). soetjiningsih, 1997. asi: petunjuk untuk tenaga kesehatan. jakarta: egc. suharyono, dkk., 1989. air susu ibu tinjauan dari berbagai aspek. jakarta: balai penerbit fkui. ners vol 5 no 1 april 2010_akreditasi 2013.indd 10 jus jambu biji menurunkan kadar kolesterol pada lansia penderita hipertensi (guava juice reduces cholesterol level for elderly with hypertension) dian rahma afitasari*, ah. yusuf**, fery effendi** * puskesmas kecamatan panekan magetan. e–mail : dira_toti@yahoo.com ** fakultas keperawatan universitas airlangga surabaya. abstract introduction: hypertensive disease is closely related to high cholesterol level, which may act as one of causes of death in elderly. the objective of this study was to analyze the effect of guava juice on the reduction of cholesterol level of hypertensive elderly at community health center, pacar keling, surabaya. method: quasy–experimental was used in this study. sample comprised of 14 respondents who met the inclusion criteria. the independent variable was guava juice and the dependent variable was cholesterol level. data were collected using questionnaire and observation. data were analyzed by paired t–test and independent t–test with signifi cance level of α < 0.05. result: the result showed that guava juice gave a signifi cant effect to cholesterol level of elderly with hypertension (p = 0.000). discussion: it can be concluded that guava juice can reduce cholesterol level in elderly with hypertension. the reduction of cholesterol level may result from vitamin c, pectin, and potassium contained in guava juice, which have effect on cholesterol regulation in the body. guava juice can be provided as daily diet for elderly. further studies are suggested to investigate other variables, such as diet consumed, age, activity, and obesity. keywords: guava juice, cholesterol, elderly, hypertensive elderly pendahuluan l a n s i a m e n u r u t u n d a n g u n d a n g kesehatan no. 23 tahun 1992 pasal 19 ayat 2 adalah seseorang yang karena usia mengalami perubahan biologis, fisik, kejiwaan dan sosial. perubahan ini memberikan pengaruh pada seluruh aspek kehidupan. berbagai perubahan fisiologis akibat proses penuaan akan dialami oleh lansia yang di antaranya mengarah pada gangguan sistem kardiovaskuler, termasuk terjadinya hipertensi. kasus hipertensi juga semakin sering dijumpai di masyarakat. pada tahun 2008 ini dari keseluruhan lansia yang ada di puskesmas pacar keling surabaya tercatat sekitar 9.609 orang, yang menderita hipertensi sekitar 526 orang (0,05%), dan ada 387 orang lansia yang tercatat mempunyai kadar kolesterol lebih dari normal atau hiperkolesterol (rekam medik puskesmas pacar keling, 2008). lansia sangat rentan menderita penyakit jantung dengan manifestasi yang beraneka ragam. penyakit jantung koroner (pjk), aritmia, dan hipertensi merupakan penyakit lazim yang berkaitan dengan jantung pada lansia. sekitar 75 persen penderita infark miokard akut (ima) merupakan lansia, 5 persen lansia sehat (tanpa penyakit jantung) ternyata mengalami fibrilasi atrium, sedangkan setengah dari populasi lansia mengalami hipertensi. tekanan sistolik dan diastolik akan meningkat linear dari mulai dewasa hingga 65 tahun, sedangkan di atas usia tersebut tekanan sistolik akan tetap bertambah namun justru terdapat penurunan pada tekanan diastolik. akibatnya, terjadi hipertensi sistolik pada sebagian besar lansia (hendriawan, 2006). hasil survei kesehatan rumah tangga (1995) menunjukkan prevalensi penyakit hipertensi atau tekanan darah tinggi di indonesia cukup tinggi, yaitu 83 per 1.000 anggota rumah tangga. data dari the national health and nutrition examination survey 11 menunjukkan bahwa 54,3% individu berusia antara 65–74 tahun menderita hipertensi. pada populasi umum, pria lebih banyak yang menderita penyakit ini daripada wanita (39% pria dan jus jambu biji menurunkan kadar kolesterol lansia (dian rahma afi tasari) 11 31% wanita). kajian british regional heart yang melibatkan hampir 8000 orang yang berusia antara 40 dan 59 tahun, juga menegaskan kaitan antara kolesterol tinggi dan peningkatan risiko penyakit jantung koroner dan hipertensi (povey, 2001). hasil penelitian menunjukkan bahwa bila kadar kolesterol darah meningkat dari 150 mg% menjadi 260 mg%, maka risiko penyakit jantung koroner akan meningkat tiga kali lipat (sanif, 2008). penyakit hipertensi semakin berkembang selain karena proses menua (aging procces), juga terkait erat dengan pola makan, terutama konsumsi makanan yang mengandung lemak dan kolesterol (astawan, 2006). kolesterol yang meningkat dapat berisiko menimbulkan penyakit jantung dan tekanan darah tinggi karena terjadi proses pengapuran dan penimbunan kolesterol di dalam pembuluh darah. endapan lemak tersebut akan tersangkut dan terkumpul pada dinding yang menyebabkan arteri menjadi keras menjadi atherosklerosis. atherosklerosis merupakan kolesterol yang menumpuk pada dinding pembuluh darah terutama pembuluh darah arteri yang disebut dengan plak. jika plak yang terbentuk dalam pembuluh darah cukup besar, ditambah dengan faktor-faktor risiko atherosklerosis yaitu seperti kadar kolesterol tinggi, diabetes melitus, hipertensi, merokok, kegemukan, kurang olah raga dan stres, maka akan mudah terjadi penyumbatan pembuluh darah yang dapat berakibat fatal bagi penderita. jika plak menyumbat pembuluh darah koroner jantung atau pembuluh darah utama pada otak, maka dapat menyebabkan kematian mendadak, serangan jantung dan stroke (nicholls et al., 2007). produksi kolesterol yang rendah dapat memperlambat pembentukan plak (fatty plaque) dan juga dapat mengurangi ukuran plak yang sudah ada. pengobatan dengan pektin dapat membantu mencegah terjadinya serangan jantung dan mengurangi jumlah kematian. pengobatan secara farmakologis dapat memengaruhi sistem organ yang ada dalam tubuh. hal tersebut perlu dipertimbangkan karena pada lansia telah terjadi penurunan imunitas atau daya tahan tubuh. pemberian obat tradisional atau alamiah untuk mengatasi berbagai masalah tersebut (khususnya penyakit hipertensi) menjadi sangat penting dan efektif bagi lansia (mickey, 2007). penelitian yang dilakukan singh medical hospital and research center morrabad, india, menunjukkan bahwa jambu biji dapat menurunkan kadar kolestreol total dan trigliserida darah serta tekanan darah pada penderita hipertensi. jambu biji dikatakan buah yang sangat istimewa karena memiliki kandungan zat gizinya yang tinggi, seperti vitamin c, potasium, dan besi. selain itu, juga kaya zat non gizi, seperti serat pangan, komponen karotenoid, dan polifenol. buah jambu biji bebas dari asam lemak jenuh dan sodium, rendah lemak dan energi, tetapi tinggi akan serat pangan (astawan, 2006). di samping berfungsi sebagai antioksidan, vitamin c memiliki fungsi menjaga dan memacu kesehatan pembuluh kapiler. jambu biji kaya serat, khususnya pektin (serat larut air). manfaat pektin antara lain menurunkan kolesterol dengan cara mengikat kolesterol dan asam empedu dalam tubuh serta membantu mengeluarkannya (yuan, 2008). jambu biji juga mengandung kalium yang berfungsi meningkatkan keteraturan denyut jantung, mengaktifkan kontraksi otot, mengatur pengiriman zat-zat gizi lainnya ke sel-sel tubuh, mengendalikan keseimbangan cairan pada jaringan dan sel tubuh serta menurunkan kadar kolesterol total dan trigliserida darah, serta menurunkan tekanan darah tinggi (direktorat jenderal tanaman pangan dan hortikultura, 1996). bahan dan metode desain penelitian yang digunakan adalah quasy experiment dengan rancangan penelitian pre–post test control group design yaitu ke-2 kelompok antara kelompok yang tidak diberikan jus jambu biji (kelompok control) dan kelompok yang diberikan jus jambu biji (kelompok perlakuan) diawali dengan pre-test (pemeriksaan darah), setelah kelompok perlakuan diberi jus jambu biji kemudian diadakan pemeriksaan darah kembali (post-test). populasi pada penelitian ini adalah lansia penderita hipertensi yang berobat ke puskesmas keliling puskesmas pacar keling surabaya wilayah gubeng masjid. kriteria jurnal ners vol. 5 no. 1 april 2010: 10–14 12 inklusi yang ditetapkan adalah lansia usia ≥55 tahun dan mempunyai kadar kolesterol tinggi 200–350 mg/dl yang kemudian ditentukan sampel melalui metode purposive sampling dan didapatkan sample sebesar 14 orang lansia. variabel independen dalam penelitian ini adalah pemberian jus jambu, sedangkan variabel dependennya adalah kadar kolesterol. pemberian jus jambu biji 2 × 1 gelas perhari selama 2 minggu, sekali pemberian 150 gr jambu biji segar ditambah 100 cc air matang. kadar kolesterol diukur menggunakan instrumen pengukuran bio–fisiologis in–vitro dengan mengambil spesimen darah dari penderita dengan nilai yaitu normal (mg/dl) ≤200 mg/dl, tinggi (mg/dl) >200 g/dl. data yang didapatkan kemudian ditabulasi dan dianalisis dengan menggunakan paired t test dan independent t test dengan tingkat kemaknaan α > 0,05. hasil hasil penelitian menunjukkan bahwa sebelum perlakuan dari 14 responden dalam dua kelompok baik kelompok perlakuan dan kelompok kontrol didapatkan kadar kolesterol tertinggi 326 mg/dl dan kadar kolesterol terendah sebesar 203 mg/dl, sedangkan kadar kolesterol setelah perlakuan dari 14 responden baik pada kelompok perlakuan dan kelompok kontrol adalah kadar tertinggi 263 mg/dl dan terendah 152 mg/dl. hasil pemeriksaan kadar kolesterol sebelum dan sesudah pemberian jus jambu biji dosis 300 gram/hari pada kelompok perlakuan didapatkan bahwa dari ketujuh responden mengalami penurunan kadar kolesterol darah dengan hasil uji statistik paired t-test p = 0,000. uji statistik dengan independent t-test menunjukkan bahwa tingkat signifikansi p = 0,000 artinya terdapat pengaruh pemberian jus jambu biji pada kelompok perlakuan terhadap perubahan kadar kolesterol pada lansia penderita hipertensi dengan hiperkolesterol. pembahasan p e m b e r i a n o b a t t r a d i s i o n a l a t a u alamiah untuk mengatasi berbagai penyakit menjadi sangat penting dan efektif bagi lansia (mickey, 2007). penelitian yang dilakukan singh medical hospital and research center morrabad, india, menunjukkan bahwa jambu biji dapat menurunkan kadar kolestreol total dan trigliserida darah serta tekanan darah pada penderita hipertensi. jambu biji mengandung serat pangan yang disebut pektin, yang merupakan jenis serat yang bersifat larut di dalam air. serat yang bersifat larut di dalam air memiliki peran besar dalam menurunkan kadar kolesterol, yaitu mengikat kolesterol dan asam empedu dalam tubuh, serta membantu pengeluarannya melalui proses buang air besar. jambu biji terbukti dapat menurunkan kolesterol maupun trigliserida darah karena murah dan mudah didapat (dalimartha, 2005). kadar kolesterol sesudah perlakuan terjadi penurunan dibanding sebelum. hal ini disebabkan karena jambu biji diharapkan memiliki peran dominan dalam menurunkan kadar kolesterol dengan mengandung berbagai zat yang dibutuhkan oleh tubuh, di antaranya vitamin c, serat (pectin) dan kalium. kandungan zat tersebut diketahui mampu mengatasi kenaikan kadar kolesterol darah pada penderita hipertensi. pemberian jus jambu biji dengan dosis 300 gram/hari memiliki efek dalam penurunan kadar kolesterol darah. dosis pemberian dan respons yang diterima tubuh untuk setiap individu berbeda. beberapa faktor yang berkaitan dengan efek dan respons setiap responden yang diberikan jus jambu biji antara lain jenis makanan dan diet sehari-hari, aktivitas atau olahraga, umur dan jenis kelamin. pengaturan makan beperan dalam membatasi jumlah kolesterol yang masuk ke dalam tubuh. tubuh dapat menghasilkan kolesterol yang diperlukan di dalam tubuh yaitu oleh organ hati. makan makanan yang mengandung terlalu banyak lemak jenuh dapat menyebabkan kolesterol tinggi (oetoro, 2007). membatasi jumlah kolesterol yang dikonsumsi memang masih penting. namun, kolesterol makanan bukanlah benar-benar penjahat seperti yang selama ini diduga orang. penjahat utamanya adalah kolesterol yang bersirkulasi dalam darah. tingkat kolesterol darah yang tinggi sangat menaikkan risiko penyakit jantung. tapi jumlah kolesterol dalam jus jambu biji menurunkan kadar kolesterol lansia (dian rahma afi tasari) 13 makanan sendiri tidak banyak memengaruhi kadar kolesterol dalam darah. rata-rata orang memproduksi sekitar 75% kolesterol darah dalam hati, sementara hanya sekitar 25% kolesterol yang diserap dari makanan. zat paling berpengaruh besar terhadap kadar kolesterol darah adalah campuran lemak yang terdapat dalam makanan. berolah-raga secara teratur dapat menurunkan kadar kolesterol total dan meningkatkan kadar kolesterol hdl. olahraga membantu membakar kolesterol atau lemak dalam tubuh menjadi energi (ary, 2009). setelah menginjak usia 20, kolesterol secara alami akan menigkat. pada laki-laki, tingkat kolesterol umumnya melemah setelah usia 50 tahun. pada kaum perempuan, tingkat kolesterol tetap rendah sampai datangnya menopause, yang setelahnya meningkat sama dengan laki-laki. pada umumnya, penyakit hipertensi lebih didominasi kaum laki-laki. menurut the american heart association, satu dari 10 perempuan di amerika menderita penyakit hipertensi. di negara berkembang termasuk indonesia, diperkirakan relatif sama kaum perempuan yang mengidap penyakit hipertensi dan stroke. tingginya kadar kolesterol total terutama dalam fraksi low density lipoprotein (ldl) dalam darah merupakan salah satu faktor pemicu timbulnya penyakit hipertensi. pada perempuan sebelum mengalami menopause terlindung dari ancaman penyakit jantung/ hipertensi berkat hormon estrogen. estrogen membantu memelihara arteri sehingga bebas dari penebalan pembuluh darah arteri yang disebabkan oleh kadar kolesterol yang tinggi. perempuan yang sudah mengalami menopause produksi estrogen semakin berkurang, diikuti dengan kecenderungan bertambah tingginya kadar kolesterol ldl plasma dan penurunan kolesterol hdl. kolesterol tinggi khususnya kolesterol ldl mempercepat timbulnya plague dan merupakan salah satu faktor pemicu penyakit hipertensi (oetoro, 2007). kolesterol begitu fundamental sebagai penyebab aterosklerosis. aterosklerosis menjadi pilar komplikasi hipertensi dan penyakit jantung akibat proses kerusakan menahun pada permukaan sisi dalam pembuluh nadi. perusakan itu salah satunya berawal dari terpaan kontaminasi zat radikal bebas yang secara bersama-sama ldl kolesterol dan trigliserida membentuk plague. dengan menurunkan produksi kolesterol, dapat memperlambat pembentukan plak (fatty plaque) dan juga dapat mengurangi ukuran plak yang sudah ada. intervensi dengan memberikan jus jambu biji yang mengandung pektin dapat membantu mencegah terjadinya serangan jantung dan mengurangi risiko kematian. penelitian ini menggunakan jambu biji merah (psidium guajava). jambu biji merah banyak mengandung vitamin c yang berfungsi sebagai antioksidan. selain itu jambu biji juga mengandung vitamin b, a, kalsium, fosfor, besi dan pektin. meskipun bisa dikonsumsi langsung, tetapi kandungan nutrisi paling tinggi diperoleh jika jambu biji dibuat jus atau sari buah. kandungan nutrisi yang terdapat dalam jambu biji (100 mg) adalah kalori 49 kal, vitamin a2, vitamin b1, vitamin c, kalsium, hidrat arang, fosfor, besi, protein, lemak, dan air. kandungan vitamin c dan pektin pada jambu biji cukup tinggi tapi kandungan vitamin c jambu biji lebih tinggi daripada buah-buahan lainnya, sebagian besar vitamin c jambu biji terkonsentrasi pada kulit dan daging bagian tabel 1. analisis pengaruh pemberian jus jambu biji terhadap penurunan kadar kolesterol pada lansia penderita hipertensi. perlakuan selisih kontrol selisih mean 262,14 193,14 262,14 mean 212,71 224,57 11,86 sd 37,610 34,754 37,610 sd 5,964 21,839 paired t-test p = 0,000 paired t–test p = 0,179 independent t-test p = 0,000 keterangan: mean = rerata sd = standar deviasi p = signifi kansi jurnal ners vol. 5 no. 1 april 2010: 10–14 14 luarnya yang lunak dan tebal. dalam jambu biji, potasium berfungsi meningkatkan keteraturan denyut jantung, mengaktifkan kontraksi otot, mengatur pengiriman zat-zat gizi lainnya ke selsel tubuh, mengendalikan keseimbangan cairan pada jaringan sel tubuh, serta menurunkan tekanan darah tinggi (hipertensi). jambu biji juga merupakan sumber serat pangan (dietary fiber). serat pangan bermanfaat untuk mencegah divertikulosis, aterosklerosis, gangguan jantung dan hipertensi. selain itu pemberian health education (he) selama penelitian berlangsung perlu dipertimbangkan dalam membentuk perilaku sehat lansia yang mendukung upaya penurunan kadar kolesterol. simpulan dan saran simpulan jus jambu biji dapat menurunkan kadar kolesterol pada penderita hipertensi. saran peneliti memberikan saran untuk tim kesehatan yang bertugas di puskesmas pacar keling dapat merekomendasikan penggunaan jus jambu biji sesuai dengan dosis dalam diet sehari-hari lansia hipertensi dengan hiperkolesterolemia, untuk penelitian selanjutnya disarankan mempertimbangkan variabel yang lain, seperti :diet, usia, aktivitas, dan obesitas. kepustakaan ardyansyah, a., 2003. buku kesehatan usia lanjut. puslitbang pelayanan dan teknologi kesehatan badan litbangkes depkes ri. surabaya: depkes ri, astawan, m., 2008. vitamin c terbaik dari jambu, (online), (http://www. kompas. com, diakses tanggal 19 november 2008, jam 20.10 wib). b e c k , m . , 2 0 0 0 . i l m u g i z i d a n d i e t h u b u n g a n n y a d e n g a n p e n y a k i t – penyakit untuk perawat dan dokter. yogyakarta: yayasan essentia medica. dalimartha, setiawan, 2001. 36 resep tumbuhan obat untuk menurunkan kolesterol. jakarta: penebar swadaya. direktorat jendral tanaman pangan dan hortikultur, 2008. kandungan dan manfaat jambu biji, (online), (http:// www.zona sehat.com, diakses tanggal 12 november 2008, jam 14.40 wib). hardywinoto, d. dan setiabudi, t., 1999. panduan gerontologi tinjauan dari berbagai aspek. jakarta: pt. gramedia pustaka utama. m a n s j o e r, a r i f , 1 9 9 9 . k a p i t a s e l e k t a kedokteran. ed. ii. jilid i. jakarta: media aesculapius. povey, r., 2002. memantau kadar kolesterol anda. jakarta: arcan. sanif, e., 2008. kolesterol biang penyakit j a n t u n g , ( o n l i n e ) , ( h t t p : / / w w w medicastore.com. diakses tanggal 16 november 2008, jam 09.16 wib). soestyo, b., 2003. ilmu penyakit jantung. surabaya: airlangga university press. suyono, s., 2001. ilmu penyakit dalam, jilid ii. jakarta: balai penerbit fkui. takasihaeng, j., 2002. hidup sehat di usia l a n j u t . j a k a r t a : p e n e r b i t h a r i a n kompas. wahyudi, n., 2000. keperawatan gerontik. jakarta: egc. wa t s o n , r o g e r, 2 0 0 3 . b u k u p e d o m a n pembinaan kesehatan lansia. jakarta: egc. yuan, 2008. jambu biji cegah jantungan, (online), (http://www. decha care.com, diakses tanggal 13 november 2008, jam 15.35 wib). ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 107 latihan active lower range of motion menurunkan tanda dan gejala neuropati diabetikum (active lower range of motion reduce the sign and symptom of diabetic neuropathy) ika yuni widyawati*, dewi irawaty**, luknis sabri*** *program magister ilmu keperawatan kekhususan keperawatan medikal bedah fakultas ilmu keperawatan universitas indonesia, kampus ui depok email: iy.widyawati@gmail.com ** fakultas ilmu keperawatan universitas indonesia *** fakultas kesehatan masyarakat universitas indonesia abstract introduction: the aimed of this study for the 56 members of persadia surabaya was to determine the effect of active lower range of motion exercise on the signs and symptoms of diabetic neuropathy in type ii diabetes mellitus's patients. method: a quasy experimental pre-post test design with a consecutive sampling technique was used in this study. result: the results showed that there was a signifi cant differences between control and treatment groups for muscle strength with p value 0.047 but not for tendon refl exes, protective sensation, ankle brachial index and diabetic polyneuropathy complaints. discussion: it can be concluded that active lower range of motion exercise has an effect on muscle strength in patients with type ii of diabetes mellitus with microvascular complications. keywords: active lower range of motion exercise, muscle strength, diabetic neuropathy pendahuluan diabetes mellitus (dm) merupakan kumpulan gejala metabolik yang ditandai oleh adanya peningkatan kadar glukosa darah sebagai akibat defi siensi insulin baik absolut maupun relatif (smeltzer dan bare, 2003; lemone dan burke, 2008; american diabetes association [ada], 2010). roglic, et al. (2005) mengemukakan bahwa dm merupakan salah satu penyakit serius yang dapat menimbulkan berbagai komplikasi dan kematian. kurang lebih 60–70% penderita dm dapat mengalami neuropati dan mengalami peningkatan risiko seiring dengan peningkatan usia, lama menderita dm, kadar gula darah yang tidak terkontrol, hiperkolesterol, hipertensi dan kelebihan berat badan (lemone dan burke, 2008). poliklinik diabetes rsu dr. soetomo surabaya mencatat 30,6% penderita dm yang menjalani rawat jalan mengalami neuropati simtomatik. neuropati diabetikum merupakan suatu kondisi kerusakan saraf akibat adanya gangguan metabolisme kadar gula darah (silbernagl dan lang, 2002; lewis, et al., 2005; lemone dan burke, 2008). neuropati yang paling sering terjadi pada pasien dm adalah neuropati sensorimotor (ada., 2010; lewis, et al., 2005) dan disusul dengan neuropati otonom (ada, 2010; meijer, et al., 2003; simmons dan feldman, 2002). neuropati diabetikum tidak dapat dipisahkan dari komplikasi mikrovaskuler lain yaitu retinopati dan nefropati (boulton, et al., 1985). frykberg (2006) dan worley (2006) menjelaskan bahwa gangguan sensorik pada neuropati diabetikum akan menyebabkan penurunan sensasi nyeri pada kaki. gangguan motorik akan mengakibatkan terjadinya atrofi otot kaki dan menimbulkan deformitas sehingga merubah titik tumpu kaki, sedangkan gangguan yang bersifat otonomik akan menyebabkan penurunan sensasi pada saraf simpatis yang berdampak pada gangguan aliran darah ke kaki. manifestasi gangguan pembuluh darah yang muncul antara lain nyeri (pada malam hari), ujung kaki terasa dingin, denyut arteri melemah sampai hilang, kaki jurnal ners vol. 5 no. 2 oktober 2010: 107–117 108 menjadi pucat bila dinaikkan (smeltzer dan bare, 2003; frykberg, 2006; worley, 2006). ketiga gangguan baik sensorik, motorik dan otonom mengakibatkan timbulnya ulkus diabetikum. penderita dm yang mengalami ulkus diabetikum telah dibuktikan secara klinis memiliki riwayat neuropati perifer (hampton, 2006). pencegahan dan penanganan neuropati diabetikum serta perbaikan sirkulasi perifer ditujukan untuk mencegah penderita dm mengalami ulkus diabetikum. pencegahan dan penanganan faktor risiko penyebab ulkus diabetikum dengan baik akan menurunkan risiko amputasi pada penderita dm, yang berarti pula menurunkan biaya karena hospitalisasi yang lama (terzi, 2008). perawat (sebagai bagian dari tim multidisiplin) turut berperan dalam memonitoring berbagai faktor risiko penyebab ulkus diabetikum (termasuk neuropati diabetikum) dan memberikan intervensi untuk mencegah agar faktor risiko tersebut tidak terjadi. berbagai intervensi untuk mencegah atau memperlambat munculnya neuropati diabetikum pun telah banyak dikembangkan melalui penelitian. intervensi yang pernah diteliti antara lain senam kaki, masase kaki serta latihan rentang gerak sendi secara aktif ( active range of motion [rom] exercise). penelitian oleh nursiswati (2007) dan mulyati (2009) telah membuktikan adanya pengaruh senam kaki maupun masase kaki secara mekanik (menggunakan alat bantu) terhadap penurunan gejala neuropati sensori diabetik. bentuk intervensi lain yaitu latihan rom, sampai saat ini lebih banyak dikaitkan pada kasus muskuloskeletal maupun neurologi seperti stroke, sedangkan pada penderita dm masih sangat minim. goldsmith, lidtke dan shott (2002) dalam penelitiannya memperoleh hasil bahwa latihan rom dapat menurunkan tekanan kaki bagian plantar pada penderita dm. rathnayake (2009) menyebutkan bahwa latihan otot secara progresif dapat meningkatkan kekuatan otot pada penderita dm dengan neuropati motorik. latihan rom diharapkan dapat menjadi salah satu alternatif tindakan untuk pasien dm dengan neuropati diabetikum dan atau penyakit pembuluh darah vaskuler perifer. beberapa penelitian telah membuktikan bahwa rom dapat menurunkan tekanan kaki, namun belum diketahui apakah rom berpengaruh terhadap tanda dan gejala neuropati diabetikum pada penderita dm tipe ii khususnya kekuatan otot, refl ek tendon, sensasi proteksi, ankle brachial index (abi) dan keluhan polineuropati perifer. bahan dan metode penelitian ini menggunakan quasy experimental pre-post test design. kelompok intervensi merupakan kelompok yang diberikan intervensi latihan rom bagian bawah secara aktif, sedangkan kelompok kontrol merupakan kelompok yang melakukan aktivitas daerah kaki seperti biasa tanpa tambahan latihan rom. populasi dalam penelitian ini adalah anggota persatuan diabetes indonesia (persadia) unit rsu dr. soetomo surabaya yang menderita dm tipe ii. pemilihan sampel menggunakan teknik consecutive sampling. pengambilan data dilaksanakan di persadia unit rsu dr. soetomo surabaya pada bulan mei sampai dengan juni 2010. sampel ditetapkan dengan beberapa kriteria inklusi yaitu penderita dm tipe ii > 5 tahun dengan komplikasi mikrovaskuler, rutin menggunakan terapi dm dengan jenis yang sama, berdomisili di daerah surabaya dan sekitarnya, usia > 50 tahun, memiliki kadar gula darah terkontrol, jenis kelamin lakilaki dan wanita, tidak mengalami gangguan pendengaran maupun bicara, dan bersedia menjadi responden. berdasarkan kriteria tersebut diperoleh 28 orang untuk masingmasing kelompok, namun 2 orang pada kelompok intervensi dinyatakan drop out. pengumpulan data pada penelitian ini meliputi 2 tahapan yaitu tahap pertama responden diminta untuk melakukan pengisian data demografi dengan mengisi kuesioner, tahap kedua dilakukan dengan menggunakan metode kunjungan rumah untuk pemeriksaan kekuatan otot, refl ek tendon, sensasi proteksi, pengukuran abi, tinggi badan dan berat badan (bb) sebagai data untuk menghitung body mass index (bmi) dan keluhan polineuropati diabetikum dari setiap responden pada kedua kelompok. latihan active lower range of motion (ika yuni widyawati) 109 responden pada kelompok intervensi diberikan latihan active rom dengan dosis 2× sehari selama 6 hari (dalam 1 minggu) selama 4 minggu pengamatan dengan intensitas untuk masing-masing gerakan pada tiap sendi yaitu 10 kali. pada akhir minggu ke-4 atau setelah 24 hari perlakuan peneliti melakukan penilaian akhir untuk kekuatan otot, refl ek tendon, sensasi proteksi, abi dan keluhan polineuropati perifer pada kedua kelompok. analisis data meliputi analisis univariat dan analisis bivariat. analisis bivariat yang dilakukan meliputi paired t-test, pooled t-test, mc. nemar test, chi square dan sperman's rho. hasil karakteristik responden pada kelompok intervensi menunjukkan 88,5% memiliki riwayat genetik dm, 23,1% memiliki riwayat hipertensi, 30,8% memiliki nilai bmi lebih, 73,1% dengan kadar trigliserida tinggi dan seluruh responden tidak mempunyai kebiasaan merokok yang berisiko. karakteristik responden pada kelompok kontrol 85,7% memiliki riwayat genetik dm, 21,4% memiliki riwayat hipertensi, 17,8% memiliki nilai bmi lebih, 57,1% dengan kadar trigliserida tinggi dan seluruh responden tidak mempunyai kebiasaan merokok yang berisiko. hasil penelitian ini menunjukkan bahwa persentase responden yang mempunyai kebiasaan merokok baik pada kelompok intervensi maupun kelompok kontrol adalah sama (100%), dengan demikian kedua kelompok tersebut merupakan kelompok dengan responden yang homogen sehingga variabel kebiasaan merokok ini tidak lagi disertakan untuk analisis statistik selanjutnya. perbedaan rerata pengukuran awal dan akhir untuk kekuatan otot (p value 0,001) dengan selisih rerata 0,34; reflek tendon (p value 0,022) dengan selisih rerata 0,19; sensasi proteksi (p value 0,000) dengan selisih rerata 2,20 dan abi (p value 0,004) dengan selisih rerata 0,05, sedangkan untuk keluhan polineuropati diabetikum diperoleh p value 0,031. ti d a k t e r d a p a t p e r b e d a a n y a n g bermakna kekuatan otot pada kelompok kontrol pengukuran awal dan akhir dengan p value 0,326 dan refl ek tendon dengan p value 0,083 pada nilai α = 0,05, namun terdapat perbedaan yang bermakna pada sensasi proteksi dengan p value 0,004 dan abi dengan p value 0,022 pada nilai α = 0,05. keluhan polineuropati diabetikum pengukuran awal dan akhir pada kelompok kontrol menunjukkan bahwa tidak terdapat perbedaan yang bermakna antara keluhan polineuropati diabetikum pengukuran awal dan akhir pada kelompok kontrol (p value 1,000; α = 0,05). hasil analisis kekuatan otot, reflek tendon, sensasi proteksi, abi dan keluhan polineuropati diabetikum antara kelompok intervensi dan kontrol pada pengukuran awal didapatkan bahwa tidak terdapat perbedaan yang bermakna pada pengukuran awal antara kelompok intervensi dan kontrol untuk rerata kekuatan otot (p value 0,105), refl ek tendon (p value 0,887) dan abi (p value 0,615), sedangkan terdapat perbedaan yang bermakna rerata sensasi proteksi pada pengukuran awal antara kelompok intervensi dengan kontrol (p value 0,000) pada nilai α = 0,05. keluhan polineuropati diabetikum antara kelompok intervensi dan kontrol pada pengukuran awal menunjukkan bahwa tidak terdapat perbedaan yang bermakna untuk keluhan polineuropati diabetikum pada pengukuran awal antara kelompok intervensi dan kontrol dengan p value 0,382. terdapat perbedaan yang bermakna rerata kekuatan otot pada pengukuran akhir antara kelompok intervensi dan kontrol (p value 0,047), tidak terdapat perbedaan y a n g b e r m a k n a u n t u k r e f l e k t e n d o n (p value 0,338), sensasi proteksi (p value 0,067) dan abi (p value 0,296). tidak terdapat perbedaan yang bermakna untuk keluhan polineuropati diabetikum pada pengukuran akhir antara kelompok intervensi dan kontrol (p value 0,111). pembahasan rerata kekuatan otot kelompok intervensi meningkat dari 4,58 menjadi 4,92 dan terdapat perbedaan yang bermakna antara pengukuran awal dan akhir dengan p value = 0,001 dan jurnal ners vol. 5 no. 2 oktober 2010: 107–117 110 α = 0,05. hasil penelitian ini sejalan dengan penelitian sebelumnya oleh astrid (2008) yang menunjukkan hasil bahwa kekuatan otot dan kemampuan fungsional meningkat (p value = 0,000), meskipun karakteristik responden dan jenis penyakit berbeda. penelitian yang mengkaitkan antara latihan rom pada pasien dm masih sangat minim, meskipun terdapat penelitian dengan intervensi yang tujuannya sama dengan tujuan latihan rom yaitu senam kaki dan masase kaki, di mana keduanya bermanfaat untuk melancarkan peredaran darah dan meningkatkan kekuatan otot. penelitian lain yang sejenis yaitu penelitian yang dilakukan oleh goldsmith, lidtke dan shott (2000) tentang pengaruh latihan rom pasif dan aktif terhadap mobilitas sendi dan tekanan kaki, menunjukkan hasil bahwa latihan yang diberikan meningkatkan mobilitas sendi dan menurunkan tekanan pada bagian plantar kaki pasien dm dengan rerata penurunan 4,2%. active lower rom dapat meningkatkan kekuatan otot penderita dm tipe ii dengan komplikasi mikrovaskuler (neuropati diabetikum). hasil penelitian ini pun menunjukkan perbedaan yang bermakna rerata skor kekuatan otot pengukuran akhir antara kelompok intervensi dan kelompok kontrol dengan p value = 0,047 dan α = 0,05. hal ini menunjukkan bahwa perbedaan yang ada sangat tipis antara kelompok yang melakukan active lower rom dengan kelompok yang tidak melakukan. menurut frykberg (1991), individu (baik dengan dm maupun tanpa dm) yang melakukan latihan seperti stretching, active range of motion exercise atau teknik mobilisasi sendi secara spesifi k dapat meningkatkan dan menjaga mobilitas dari ankle, kaki dan jarijari kaki. tabel 1. analisis perbedaan kekuatan otot, refl ek tendon, sensasi proteksi dan abi kelompok intervensi pada pengukuran awal dan pengukuran akhir variabel mean sd se p value kekuatan otot awal akhir selisih 4,58 4,92 0,34 0,50 0,27 0,23 0,09 0,05 0,04 0,001 refl ek tendon awal akhir selisih 1,77 1,96 0,19 0,43 0,19 0,24 0,08 0,04 0,04 0,022 sensasi proteksi awal akhir selisih 2,38 4,58 2,20 1,58 1,39 0,19 0,31 0,27 0,04 0,000 abi awal akhir selisih 0,92 0,97 0,05 0,12 0,08 0,19 0,02 0,02 0,00 0,004 keterangan: sd = standar deviasi, se = standar error tabel 2. analisis perbedaan keluhan polineuropati diabetikum kelompok intervensi pada pengukuran awal (pre) dan pengukuran akhir (post) variabel keluhan polineuropati (post) n p valuetidak terjadi terjadi n % n % keluhan polineuropati (pre): tidak terjadi terjadi 18 6 69,2 23,1 0 2 0,0 7,7 18 8 0,031 total 24 2 26 keterangan: n = jumlah responden, n = jumlah total latihan active lower range of motion (ika yuni widyawati) 111 tabel 3. analisis perbedaan kekuatan otot, refl ek tendon, sensasi proteksi dan abi kelompok kontrol pada pengukuran awal dan pengukuran akhir variabel mean sd se p value kekuatan otot awal akhir selisih 4,81 4,73 0,08 0,42 0,46 0,04 0,08 0,09 0,01 0,326 refl ek tendon awal akhir selisih 1,81 1,92 0,09 0,42 0,31 0,11 0,08 0,06 0,02 0,083 sensasi proteksi awal akhir selisih 4,85 5,42 0,57 2,10 1,89 0,21 0,39 0,36 0,03 0,004 abi awal akhir selisih 0,89 0,94 0,05 0,11 0,13 0,02 0,02 0,02 0,00 0,022 keterangan: sd = standar deviasi, se = standar error tabel 4. analisis perbedaan keluhan polineuropati diabetikum kelompok kontrol pada pengukuran awal (pre) dan pengukuran akhir (post) variabel keluhan polineuropati (post) n p valuetidak terjadi terjadi n % n % keluhan polineuropati (pre): tidak terjadi terjadi 17 1 60,71 3,57 3 7 10,71 25 20 8 1,000 total 18 10 28 keterangan: n = jumlah responden, n = jumlah total tabel 5. analisis perbedaan kekuatan otot, refl ek tendon, sensasi proteksi dan abi antara kelompok intervensi dan kelompok kontrol pada pengukuran awal (pre) variabel kelompok mean sd se p value kekuatan otot intervensi (n = 26) 4,58 4,81 0,50 0,42 0,99 0,08 0,105 kontrol (n = 28) refl ek tendon intervensi (n = 26) 1,77 0,43 0,08 0,887 kontrol (n = 28) 1,81 0,42 0,08 sensasi proteksi intervensi (n = 26) 2,38 1,58 0,31 0,000 kontrol (n = 28) 4,85 2,10 0,39 abi intervensi (n = 26) 0,92 0,12 0,02 0,615 kontrol (n = 28) 0,89 0,11 0,02 keterangan: sd = standar deviasi, se = standar error jurnal ners vol. 5 no. 2 oktober 2010: 107–117 112 tabel 6. analisis perbedaan keluhan polineuropati diabetikum antara kelompok intervensi dan kelompok kontrol pada pengukuran awal (pre) variabel kelompok intervensi kelompok kontrol p value n % n % keluhan polineuropati (pre): tidak terjadi terjadi 8 18 30,8 69,2 8 20 28,6 71,4 0,635 total 26 100 28 100 keterangan: n = jumlah responden, n = jumlah total tabel 7. analisis perbedaan kekuatan otot, refl ek tendon, sensasi proteksi dan abi antara kelompok intervensi dan kelompok kontrol pada pengukuran akhir (post) variabel kelompok mean sd se p value kekuatan otot intervensi (n = 26) kontrol (n = 28) 4,92 4,73 0,27 0,46 0,05 0,09 0,047 refl ek tendon intervensi (n = 26) 1,96 0,19 0,04 0,338 kontrol (n = 28) 1,92 0,31 0,06 sensasi proteksi intervensi (n = 26) 4,58 1,39 0,27 0,067 kontrol (n = 28) 5,42 1,89 0,36 abi intervensi (n = 26) 0,97 0,08 0,01 0,296 kontrol (n = 28) 0,94 0,13 0,02 keterangan: sd = standar deviasi, se = standar error tabel 8. analisis perbedaan keluhan polineuropati diabetikum antara kelompok intervensi dan kelompok kontrol pada pengukuran akhir (post) variabel kelompok intervensi kelompok kontrol p value n % n % keluhan polineuropati (post): tidak terjadi terjadi 2 24 7,7 92,3 10 18 35,7 64,3 0,111 total 26 100 28 100 keterangan: n = jumlah responden, n = jumlah total peneliti berasumsi bahwa hasil penelitian yang menunjukkan beda yang tipis antara kelompok intervensi dan kelompok kontrol disebabkan oleh beberapa faktor yaitu kedua kelompok mempunyai rutinitas yang sama yaitu melakukan olahraga (senam diabetes) rutin yang dilaksanakan setiap hari sabtu. peneliti juga memperoleh informasi dari beberapa responden bahwa beberapa responden selain mengikuti senam diabetes di persadia, mereka juga aktif mengikuti senam diabetes yang diadakan di wilayah tempat tinggal masing-masing (dengan hari yang berbeda), senam lansia, maupun jenis senam yang lain (contoh: taichi). faktor berikutnya menurut peneliti adalah rutinitas olahraga (senam diabetes) yang dilakukan oleh responden. peneliti tidak mengkaji lebih dalam tentang rutinitas masing-masing responden baik pada kelompok intervensi maupun kelompok kontrol, demikian juga sebaran responden yang rutin atau tidak rutin dalam kedua kelompok tersebut. faktor lain yang menurut peneliti turut memengaruhi hasil adalah jenis latihan latihan active lower range of motion (ika yuni widyawati) 113 yang juga dilakukan oleh kelompok kontrol (jalan, jogging atau senam kaki). keberagaman jenis latihan yang dilakukan oleh kelompok kontrol ini bagi peneliti turut berperan dalam memengaruhi kekuatan otot responden dalam kelompok kontrol, karena beberapa latihan yang dilakukan responden dalam kelompok kontrol sebenarnya merupakan latihan fl eksibilitas sama seperti latihan rom. dapat disimpulkan bahwa hasil penelitian ini membuktikan hipotesis penelitian yang menyatakan bahwa kekuatan otot berbeda pada kelompok intervensi h a s i l p e n e l i t i a n m e n u n j u k k a n peningkatan rerata skor refl ek tendon kelompok intervensi dari 1,77 menjadi 1,96 dan terdapat perbedaan yang bermakna antara pengukuran awal dan pengukuran akhir dengan p value = 0,022 dan α = 0,05. neuropati yang terjadi pada penderita dm berhubungan dengan kerusakan saraf baik sensorik maupun motorik. sumpio (2000) menjelaskan bahwa manifestasi klinis yang muncul pada neuropati sensorik dan motorik disebabkan karena adanya kerusakan pada myelin akibat proses demyelinisasi. teori menerangkan bahwa gangguan metabolik akibat dari hiperglikemia dan atau defi siensi insulin pada satu atau lebih komponen seluler pada saraf menyebabkan terjadinya gangguan fungsi dan struktural. gangguan ini akan menyebabkan kerusakan jaringan saraf dan mengakibatkan defisit neurologis (lewis, et al., 2005; price dan wilson, 2006; frykberg, 2006). penelitian lain yang secara khusus membahas active lower rom dengan refl ek tendon masih sangat minim. peneliti berasumsi bahwa perbaikan refl ek tendon yang ditunjukkan pada hasil penelitian ini dapat dikaitkan dengan adanya perbaikan pada vaskularisasi ankle responden. seperti peneliti paparkan di atas bahwa latihan rom bermanfaat dalam melancarkan peredaran darah khususnya pada area yang dilibatkan dalam latihan (dalam hal ini adalah area lower extremity). peredaran darah yang lancar pada area tersebut menghambat proses demyelinisasi sel-sel saraf, di mana proses demyelinisasi tersebut merusak axon. dengan demikian apabila sel-sel saraf dalam kondisi baik maka proses transmisi impuls terutama pada sel reseptor salah satunya tendon pun adekuat. hasil penelitian ini membuktikan bahwa rerata skor refl ek tendon berbeda antara pengukuran awal dan akhir. hasil penelitian ini menunjukkan bahwa tidak terdapat perbedaan yang bermakna rerata skor refl ek tendon pengukuran akhir antara kelompok intervensi dan kontrol dengan p value = 0,338 dan α = 0,05. hal ini terjadi karena peneliti tidak melakukan kontrol secara ketat pada kelompok kontrol terutama pada jenis latihan yang mereka lakukan. dapat disimpulkan bahwa refl ek tendon tidak berbeda antara kelompok intervensi dan kontrol. hasil analisis menunjukkan rerata skor sensasi proteksi kelompok intervensi pada pengukuran awal adalah 2,38. neuropati sensorik ditandai oleh adanya nyeri pada kaki atau tungkai bawah yang memberat pada malam hari, perestesia dan sensasi abnormal (boulton, et al., 2005; lemone dan burke, 2008). menurut boulton, et al. (2005) pada beberapa penderita neuropati diabetikum keluhan utama yang dirasakan adalah mati rasa pada kaki, hal inilah yang menyebabkan penderita neuropati sensorik mengalami kehilangan sensori terhadap nyeri, vibrasi, tekanan dan panas. menurut almazini (2009) pada penderita neuropati diabetikum terjadi perlambatan kecepatan konduksi saraf yang disebabkan oleh hiperglikemia intraseluler kronik yang menyebabkan pembentukan agen pengglikasi yang dikenal dengan produk akhir glikosilasi tahap lanjut. h a s i l p e n e l i t i a n m e n u n j u k k a n peningkatan rerata sensasi proteksi kelompok intervensi dari 2,38 menjadi 4,58 dan hasil penelitian ini menunjukkan terdapat perbedaan yang bermakna antara pengukuran awal dan pengukuran akhir dengan p value = 0,000 dan α = 0,05. penelitian yang dilakukan oleh nursiswati (2007) dan mulyati (2009) memperoleh hasil yang sama yaitu terdapat perbedaan rerata penurunan sensasi proteksi kaki. neuropati diabetikum disebabkan karena peningkatan kadar gula darah yang kronis yang berakibat terjadinya demyelinasi multifokal dan hilangnya akson (axonal loss) sehingga penderita dm dengan neuropati akan kehilangan sensasi dalam merasakan nyeri, panas, vibrasi dan tekanan. dengan kata lain jurnal ners vol. 5 no. 2 oktober 2010: 107–117 114 ujung-ujung saraf penderita tidak lagi sensitif dalam proteksi terhadap kondisi yang berisiko, yang terdeteksi dengan pemeriksaan sensasi proteksi dengan menggunakan siemmes weinstein monofi lament 10 g. hasil penelitian ini menunjukkan bahwa tidak ada perbedaan yang bermakna rerata skor sensasi proteksi pada pengukuran akhir antara kelompok intervensi dan kontrol dengan p value 0,067 dan α = 0,05. peneliti berpendapat bahwa hal ini bisa terjadi karena pada kelompok kontrol meskipun tidak diberikan latihan active lower rom, responden dalam kelompok tersebut tetap dianjurkan untuk melakukan aktivitas latihan lain selain olahraga rutin (setiap sabtu) seperti jalan, jogging atau bahkan senam kaki. h a s i l p e n e l i t i a n m e n u n j u k k a n peningkatan rerata skor abi kelompok intervensi dari 0,92 menjadi 0,97 dan terdapat perbedaan yang bermakna pengukuran awal dan akhir dengan p value 0,004 dan α = 0,05. hal ini berbeda dengan hasil penelitian yang dilakukan oleh mulyati (2009) yang menunjukkan tidak terdapat perbedaan yang bermakna rerata skor abi pasien pada kelompok intervensi sebelum dan sesudah dilakukan masase kaki secara manual (p value 0,155). hasil penelitian lain yang dilakukan oleh castro-sanches, et al. (2010) bahwa penderita dm tipe ii (dengan peripheral arterial disease) mengalami perbaikan nilai tekanan darah arteri dan nilai abi setelah diberikan terapi gabungan antara latihan dan masase. penelitian tersebut memang tidak menggunakan responden penderita dm tipe ii dengan neuropati diabetikum, namun asumsi peneliti bahwa tujuan latihan dan masase yang diterapkan oleh castro-sanches, et al. sama dengan tujuan latihan active lower rom yaitu melancarkan peredaran darah. kondisi peredaran darah yang lancar menghambat proses penebalan membran kapiler, peningkatan ukuran dan jumlah sel endotel kapiler, sehingga diameter lumen pembuluh darah tetap adekuat khususnya pembuluh darah perifer. dampaknya adalah adanya perbaikan pada nilai tekanan darah sistolik baik brachial maupun ankle. hasil penelitian ini menunjukkan bahwa tidak ada perbedaan yang bermakna rerata skor abi pada pengukuran akhir antara kelompok intervensi dan kontrol dengan p value 0,296 dan α = 0,05. peneliti berpendapat bahwa hal ini bisa terjadi karena pada kelompok kontrol juga melakukan latihan yang juga mempunyai manfaat yang sama dengan latihan active lower rom. hasil analisis menunjukkan terdapat 23,1% (6 orang) di mana pada saat pengukuran awal terjadi keluhan polineuropati namun pada saat pengukuran akhir terjadi penurunan angka keluhan polineuropati menjadi 7,7% (2 orang). persentase responden yang mengalami penurunan keluhan polineuropati diabetikum meskipun kecil namun cukup bermakna. mengacu pada teori yang peneliti paparkan sebelumnya penderita dm mengalami masalah atau berisiko terjadi komplikasi terutama disebabkan karena hiperglikemia. pada kapiler pasien dm terjadi penebalan membran dasar dan peningkatan ukuran dan jumlah sel endotel kapiler yang menyebabkan diameter lumen pembuluh darah menjadi kecil yang disebabkan oleh adanya proses demyelinisasi (lewis, et al., 2005; frykberg, 2006). saraf pada penderita dm tampak mengalami peningkatan kerentanan baik terhadap faktor seluler dan faktor imun humoral, termasuk aktivasi limfosit, deposisi imunoglobulin dan aktivasi komplemen, sehingga mudah mengalami peradangan yang disertai keluhan nyeri, terasa panas, dan seterusnya. latihan berfungsi melancarkan peredaran darah, di mana aliran darah yang lancar ini tentunya akan memudahkan nutrien masuk ke dalam sel dan secara langsung latihan pada penderita dm membantu meningkatkan sensitivitas reseptor insulin sehingga kadar gula darah menjadi stabil, dengan demikian kerusakan sel-sel (khususnya saraf) lebih jauh dapat dihindari. hasil penelitian ini pun menunjukkan bahwa terdapat perbedaan yang bermakna keluhan polineuropati kelompok intervensi pada pengukuran awal dan akhir dengan p value 0,031 dan α = 0,05 namun tidak terdapat perbedaan kejadian keluhan polineuropati diabetikum antara kelompok intervensi dan kontrol pada pengukuran awal dengan p value 0,635 dan α = 0,05 sedangkan pada pengukuran akhir dengan p value = 0,111 dan α = 0,05. latihan active lower range of motion (ika yuni widyawati) 115 hasil analisis menunjukkan bahwa terdapat hubungan bmi dengan kekuatan otot pada kelompok intervensi (p value 0,041; α = 0,05). nilai hubungan sebesar negatif 0,403 yang berarti semakin tinggi nilai bmi maka kekuatan otot semakin rendah, atau sebaliknya semakin rendah nilai bmi maka kekuatan otot semakin tinggi. penelitian cross-sectional yang dilakukan oleh rolland, et al. (2004) tidak menemukan hubungan bmi dengan penurunan kekuatan otot pada pasien wanita lansia dengan obesitas. secara umum terdapat hubungan antara massa dan kekuatan otot (frontera, et al., 1991 dalam rolland, et al., 2004), dengan kata lain berat badan berhubungan secara positif dengan kekuatan otot. kekuatan otot dipengaruhi oleh berbagai faktor, antara lain obesitas dan kebugaran fi sik yang rendah (sternfeld, et al., 2002 dalam rolland, et al., 2004). aktivitas fisik meningkatkan kekuatan otot dan massa otot (roubenoff, et al., 2000 dalam rolland, et al., 2004). dapat disimpulkan bahwa terdapat hubungan bmi dengan kekuatan otot. hasil analisis lain menunjukkan bahwa terdapat hubungan bmi dengan keluhan polineuropati diabetikum (pnp) pada kelompok intervensi (p value 0,041; α = 0,05). nilai hubungan sebesar positif 0,403 yang berarti semakin tinggi nilai bmi maka keluhan polineuropati semakin tinggi, demikian sebaliknya. penelitian oleh tesfaye et al. (2005) memperoleh hasil bahwa hipertensi, merokok, obesitas dan peningkatan kadar trigliserida (yang kesemuanya merupakan faktor risiko penyakit kardiovaskuler) serta adanya penyakit kardiovaskuler yang menyertai penderita dm berhubungan dengan adanya neuropati. hasil penelitian lain yang dilakukan oleh straub, et al. (1994) menunjukkan bahwa obesitas memengaruhi neuropati sensorimotor dan otonom. penelitian yang dilakukan oleh selim, et al. (2008) menunjukkan bahwa nilai bmi berhubungan dengan penurunan aliran darah otak dan peningkatan cerebrovascular resistance. penyakit diabetes dan hipertensi sangat berkaitan dengan masalah yang muncul pada pembuluh darah. hal ini membuktikan bahwa obesitas memang berhubungan dengan sensasi proteksi penderita dm dengan komplikasi mikrovaskuler. penderita dm pun berisiko mengalami masalah akibat defi siensi insulin dan peningkatan kadar gula darah, di mana kadar gula darah yang tinggi menyebabkan konsentrasi glukosa yang tinggi di saraf. menurut almazini (2009) hal itu kemudian menyebabkan konversi glukosa menjadi sorbitol yang dikatalisasi oleh aldose reductase. kadar fruktose saraf juga meningkat. fruktose dan sorbitol saraf yang berlebihan menurunkan ekspresi dari kotransporter sodium atau myoinositol sehingga menurunkan kadar myoinositol. penderita dm pun mengalami perubahan iskemik mikrovaskuler yang meliputi penebalan membran basal kapiler, hiperplasia sel endotelial, infark dan iskemia neuronal. seluruh faktor tersebut akan mengakibatkan kerusakan pada saraf sehingga konduksi saraf melambat yang memengaruhi refl ek tendon. pada akhirnya dapat disimpulkan bahwa terdapat hubungan bmi dengan keluhan polineuropati diabetikum. terdapat hubungan antara riwayat hipertensi dengan refl ek tendon pada kelompok kontrol dengan p value 0,045 (α = 0,05). nilai hubungan sebesar negatif 0,382 yang berarti adanya riwayat hipertensi maka skor refl ek tendon semakin rendah, atau sebaliknya tidak adanya riwayat hipertensi maka skor refl ek tendon semakin tinggi. sampai saat ini belum ada penelitian yang secara spesifi k membahas tentang hubungan riwayat hipertensi dengan reflek tendon, namun demikian peneliti berasumsi bahwa hal ini disebabkan karena penderita dm yang disertai riwayat hipertensi mengalami perubahan pada vaskuler. perubahan vaskuler dan otot jantung berdampak pada penurunan aliran darah ke seluruh organ termasuk sel-sel saraf. penderita dm pun berisiko mengalami masalah akibat defi siensi insulin dan peningkatan kadar gula darah, di mana kadar gula darah yang tinggi menyebabkan konsentrasi glukosa yang tinggi di saraf. hal itu kemudian menyebabkan konversi glukosa menjadi sorbitol. fruktose dan sorbitol saraf yang berlebihan menurunkan ekspresi dari kotransporter sodium/myoinositol sehingga menurunkan kadar myoinositol. penderita dm pun mengalami perubahan jurnal ners vol. 5 no. 2 oktober 2010: 107–117 116 i s k e m i k m i k r o v a s k u l e r y a n g m e l i p u t i penebalan membran basal kapiler, hiperplasia sel endotelial, infark dan iskemia neuronal. seluruh faktor di atas akan mengakibatkan kerusakan pada saraf sehingga konduksi saraf melambat yang memengaruhi refl ek tendon. hasil analisis juga menunjukkan bahwa terdapat hubungan kadar trigliserida dengan skor kekuatan otot pada kelompok kontrol (p value 0,030; α = 0,05). nilai hubungan sebesar positif 0,411 yang berarti semakin tinggi kadar trigliserida maka skor kekuatan otot semakin tinggi, demikian sebaliknya. peneliti berasumsi bahwa peningkatan trigliserida dapat terjadi bukan hanya karena konsumsi makanan yang mengandung tinggi lemak namun disebabkan oleh proses glukoneogenesis yang terjadi pada penderita dm. proses glukoneogenesis merupakan proses di mana tubuh berusaha untuk membentuk cadangan glukosa baru dengan melakukan pemecahan zat nutrisi berupa lemak dan protein. terdapat hubungan kadar trigliserida dengan keluhan polineuropati perifer pada kelompok kontrol (p value 0,002; α = 0,05). nilai hubungan sebesar negatif 0,559 yang berarti semakin tinggi kadar trigliserida maka keluhan polineuropati perifer semakin rendah, atau sebaliknya semakin rendah kadar trigliserida maka keluhan polineuropati semakin tinggi. pada penderita dm, kadar gula darah yang tinggi akan meningkatkan viskositas pembuluh darah yang berdampak pada aliran darah yang tidak lancar termasuk ke sel-sel saraf, demikian pula halnya dengan kadar trigliserida karena peningkatan kadar trigliserida akan mempersempit lumen pembuluh darah, sehingga aliran darah terganggu dan menimbulkan berbagai gangguan mikrovaskuler. simpulan dan saran simpulan terdapat perbedaan yang bermakna nilai kekuatan otot, refl ek tendon, sensasi proteksi, abi dan keluhan polineuropati perifer pada kelompok intervensi antara pengukuran awal dan pengukuran akhir. terdapat perbedaan yang bermakna nilai kekuatan otot pada pengukuran akhir antara kelompok kontrol dan kelompok intervensi, namun tidak terdapat perbedaan yang bermakna nilai refl ek tendon, sensasi proteksi, abi dan keluhan polineuropati perifer pada pengukuran akhir antara kelompok kontrol dan kelompok intervensi. saran adekuasi tata laksana dm, neuropati diabetikum dan pencegahan komplikasi lebih lanjut khususnya intervensi keperawatan secara komprehensif berdasarkan pada bukti ilmiah (evidence based practise) dapat dilakukan. peneliti berharap latihan rom bawah secara aktif ini nantinya juga dapat menjadi salah satu alternatif latihan fl eksibilitas yang dianjurkan kepada penderita dm tipe ii untuk mengurangi tanda dan gejala neuropati diabetikum atau mencegah agar komplikasi neuropati tidak terjadi. kepustakaan almazini, p., 2009. patogenesis neuropati pada diabetes mellitus, (online), (http://www.myhealing.wordpress.com., diakses tanggal 05 januari 2010). american diabetes association, 2010. standards of medical care in diabetes 2010. diabetes care. 33 (1), s11-s61, doi:10.2337/dc10-s011. a s t r i d , m . , 2 0 0 8 . p e n g a r u h l a t i h a n range of motion (rom) terhadap kekuatan otot, luas gerak sendi dan kemampuan fungsional pasien stroke di rs sint carolus jakarta. tesis tidak dipublikasikan. jakarta: fik ui. boulton, a.j.m., 2005. diabetic neuropathies (a statement by the american diabetes association). diabetes care. 28 (4), 956–962,(online), (http://www.care. diabetesjournals.org., diakses tanggal 15 februari 2010). castro-sánchez, a.m., et al., 2010. effi cacy of a massage and exercise programme on the ankle-brachial index and blood pressure in patients with diabetes mellitus type 2 and peripheral arterial disease: a randomized clinical trial. latihan active lower range of motion (ika yuni widyawati) 117 medicina clínica [med clin (barc)], 134 (3), 107–110. frykberg, r.g., 1991. the high risk foot in diabetes mellitus. new york: churchill livingstone inc. frykberg, r.g., et al., 2006. a supplement to: ankle and foot surgery. the journal of diabetic foot disorders, 45 (5). s1s66.(online),(http://www.acfas.org/pdf/ diabeticcpg-small.pdf., diakses tanggal 15 february 2010). goldsmith, j.r., lidtke, r.h., dan shott, s., 2002. the effects of range-of-motion therapy on the plantar pressures of patients with diabetes mellitus. journal of the american podiatric medical association. 92 (9), 483–490, (online), (http://www.japmaonline.org,diakses tanggal 15 february 2010). hampton, s., 2006. caring for the diabetic patient with a foot ulcer. british journal of nursing. 15 (15), (online), (http:// web.ebscohost.com/ehost/pdf., diakses tanggal 15 februari 2010). lewis, et al., 2005. medical surgical nursing, assessment and management of clinical problem. new south wales: mosby inc. lemone, p dan burke, k., 2008. medical surgical nursing: critical thinking in client care 4 ed. new jersey: pearson education inc. meijer, j.w.g., et al., 2003. clinical diagnosis of diabetic polyneuropathy with the diabetic neuropathy symptom and diabetic neuropathy examination scores. diabetes care. 26, 697–701. mulyati, l., 2009. pengaruh masase kaki secara manual terhadap sensasi proteksi, sensasi nyeri dan abi pada pasien dm tipe ii di rsu daerah curup bengkulu. tesis tidak dipublikasikan.jakarta: fik ui. nursiswati, 2007. pengaruh latihan kaki terhadap gejala neuropati perifer pada asuhan keperawatan pasien dengan dm tipe ii di rsud bekasi. tesis tidak dipublikasikan. jakarta: fik ui. price dan wilson, 2006. patofi siologi konsep klinis proses-proses penyakit edisi 6. jakarta: egc. rathnayake, t., 2009. peripheral neuropathy: exercise therapy. evidence summaries joanna briggs institute. proquest document id:1937745051. roglic, et al., 2005. the burden of mortality attributable to diabetes. diabetes care. 28, 2130–2135, (online), (http://www. who.int., diakses tanggal 15 februari 2010). rolland, y., et al., 2004. muscle strength in obese elderly women: effect of recreational physical activity in a crosssectional study. american journal of clinical nutrition. 79, 552–557. selim, m., et al., 2008. the effects of body mass index on cerebral blood flow velocity. clinical autonomy res. 18 (6), 331–338. silbernagl, s. dan lang, f., 2007. teks dan atlas berwarna patofi siologi. jakarta: egc. simmons, z. dan feldman, e.l., 2002. update on diabetic neuropathy. current opinion in neurology. 15, 595–603, (online), (http://anesthesia,stanford. e d u / p a i n / n e u r o p a t h i c % 2 0 p a i n / diabetic%20neuropathies.pdf., diakses tanggal 29 februari 2010). smeltzer, s.c., dan bare, b., 2003. brunner and suddarth's textbook of medicalsurgical nursing (10th ed.). philadelphia: lippincott williams and wilkins. sumpio, b.e., 2000. foot ulcers. primary care, 343 (11), 787-793, (online), (http://www.nejm.org., diakses tanggal 13 februari 2010). terzi, a., 2008. the nurse's role in the prevention of diabetic foot ulcers [greek]. nosileftiki, 47 (1), (online),(http://web. ebscohost.com., diakses tanggal 16 februari 2010). worley, c.a., 2006. neuropathic ulcers: diabetes and wounds, part ii. differential diagnosis and treatment. dermatology nursing. 18 (2), (online), (http://web. ebscohost.com/ehost/pdf., diakses tanggal 25 februari 2010). ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 154 analisis kepuasan kerja perawat berdasarkan iklim organisasi (the analysis of job satisfaction nurse based on organizational climate) nursalam *, yety elina*, erna dwi wahyuni* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257 e-mail: nursalam_psik@yahoo.com abstract introduction: organizational climate is a perception of the organization's members about their organization and it will be able to infl uence their attitude. conducive organizational climate is important to improve job satisfaction. nurse's job satisfaction is needed to increase quality of health service care. the purpose of the study is to analyze the correlation between organizational climate and job satisfaction of nurse. method: this study was a quantitative research that used a descriptive method with cross sectional survey design. the population was all nurses in irna bedah of rsud kabupaten sampang that consists of 15 people. the sample were 11 people recruited by using purposive sampling. the data was collected by using organizational climate questionnaire and job satisfaction questionnaire, interval scale was used with likert scoring. the statistic analysis used spearman's rho and content analysis. result: the result of the statistic test shows that organizational climate had p = 0.003 which reveals that there was a correlation between organizational climate and job satisfaction of nurse in irna bedah of rsud kabupaten sampang, with r2 = 0.799 (within a range 0.60–0.799). it means that both variable had a strong positive correlation. discussion: in conclusion, there was a positive correlation between organizational climate and job satisfaction with strong correlation. the writer suggests the next researchers to study dimension of organizational climate from pines (1982), and factors to infl uence job satisfaction from mcclelland (1962) so that they will be able to compare the correlation between organizational climate and job satisfaction by using another theory. keywords: organizational climate, job satisfaction pendahuluan era globalisasi mendorong semua aspek kehidupan semakin unggul, termasuk di dalamnya aspek kesehatan. begitu pula rumah sakit yang merupakan salah satu fasilitas pelayanan kesehatan. rumah sakit sebagai organisasi yang menyediakan pelayanan kesehatan memiliki karakteristik organisasi yang tidak sama dengan organisasi lainnya. adanya perbedaan karakteristik organisasi tersebut menyebabkan iklim kerja yang ada di rumah sakit berbeda dengan organisasi lainnya, terutama pada perawat yang merupakan mayoritas tenaga kerja di sebuah rumah sakit (djojodibroto, 1997 dalam utami, 2009). faktor manajemen keperawatan mempunyai andil signifikan dalam peningkatan mutu pelayanan kesehatan termasuk di dalamnya yaitu iklim organisasi. iklim organisasi akan berpengaruh langsung terhadap keberadaan karyawan dalam organisasi karena menyangkut aktivitas kerja karyawan. jika iklim organisasi sesuai, menyenangkan, dan kondusif bagi karyawan maka karyawan bergairah dalam melakukan aktivitas kerjanya sehingga prestasi kerja karyawan akan meningkat (laily, 2008). kepuasan kerja menggambarkan keadaan emosional yang menyenangkan dan mencintai pekerjaan (fathoni, 2006). kepuasan kerja bagi perawat merupakan hal yang sangat penting karena menyangkut masalah hasil kerja perawat yang merupakan salah satu langkah dalam meningkatkan mutu pelayanan keperawatan kepada pasien (utami, 2009). oleh karena itu, iklim kerja yang kondusif diperlukan untuk meningkatkan kepuasan kerja perawat sehingga akan memunculkan perbaikan kerja perawat itu analisis kepuasan kerja perawat berdasarkan iklim organisasi (nursalam) 155 sendiri yang pada akhirnya akan meningkatkan kualitas dari pelayanan kesehatan rumah sakit (utami, 2009). namun lain halnya dengan iklim organisasi yang ada di irna bedah rsud kabupaten sampang pada tanggl 28 april 2010. dalam organisasi tersebut belum menerapkan supervisi keperawatan, kepala ruangan dipegang oleh seorang dokter, tidak terdapat audit keperawatan, belum ada sistem pemberian imbalan atas prestasi kerja, serta belum terdapat sistem yang mendukung pengembangan riset keperawatan. keadaan iklim organisasi yang kurang mendukung terhadap kepuasan kerja perawat tersebut mendorong peneliti untuk melakukan penelitian di irna bedah rsud kabupaten sampang, apakah terdapat hubungan antara iklim organisasi dengan kepuasan kerja perawat. i r n a b e d a h r s u d k a b u p a t e n sampang memiliki tenaga perawat sebanyak 15 orang dengan lulusan pendidikan s1 sebanyak 2 orang, d3 sebanyak 13 orang, dan spk sebanyak 1 orang. bor pasien tahun 2007–2009 berturut-turut yaitu 56,1%; 62,8%; 68,2% walaupun mengalami peningkatan, namun tetap di bawah standar nasional (standar nasional: 75–85%), avlos tahun 2007–2009 berturut-turut yaitu 2,9 hari; 3,1 hari; 3,3 hari sedangkan standar nasional: 7–10 hari). ruangan ini menerapkan metode makp tim. hasil survei awal yang dilakukan tanggal 28 april 2010 kepada 11 orang perawat di irna bedah rsud kabupaten sampang, didapatkan sebesar 54,5% perawat menyatakan bahwa strategi komunikasi antarstaf hanya pada rapat rutin. sebesar 63,6% perawat berpendapat bahwa tidak terdapat sistem penilaian kinerja perawat ( supervisi keperawatan), audit keperawatan belum terlaksana. sebanyak 63,6% perawat menyatakan organisasi belum mempunyai mekanisme pengembangan karir (promosi jabatan) yang jelas dan adil. aturan dan kebijakan yang diterapkan di tempat kerja, sebesar 27,3% menyatakan belum jelas dan adil. sebesar 36,4% perawat menyatakan bahwa penerapan sanksi terhadap pelanggaran disiplin kurang tegas. sebanyak 81,8% menyatakan bahwa belum terdapat sistem pemberian penghargaan/imbalan oleh organisasi terhadap prestasi kerja perawat. perawat merasa bosan dengan pekerjaan yang bersifat rutinitas dan kurang tantangan, sebesar 27,3% yang menyatakan demikian. tidak terdapat sistem yang mendukung pengembangan riset keperawatan (penelitian), sebanyak 63,6% perawat menyatakan hal tersebut. organisasi mendukung pengembangan keterampilan dan pengetahuan perawat dengan mengikutsertakan perawat dalam pelatihan dan seminar secara rutin, hanya 27,3% perawat yang mendukung pernyataan tersebut. perawat merasa ada konfl ik dalam organisasi yang dapat memengaruhi semangat kerja, pernyataan ini didukung oleh 54,5% perawat. sebesar 36,4% perawat menyatakan organisasi memberi kesempatan untuk mencoba ide-ide baru dalam pencapaian tujuan organisasi. selanjutnya, sebesar 63,6% perawat menyatakan bahwa organisasi belum memenuhi kebutuhan perawat dalam bekerja, serta berdasarkan hasil wawancara terhadap empat orang perawat yang bertugas di irna bedah rsud kabupaten sampang menyatakan ketidakpuasannya terhadap sistem reward dan struktural organisasi. adanya faktor-faktor pemicu ketidakpuasan kerja perawat tersebut dapat menyebabkan penurunan semangat kerja, menimbulkan rasa bosan, stres, frustrasi kerja serta berbagai akibat negatif lainnya, sehingga akan berdampak pada penurunan produktivitas organisasi dan keterhambatan organisasi dalam mencapai tujuan. iklim organisasi yang kurang kondusif, misal kurangnya etos kerja, motivasi kerja, kepuasan kerja, disiplin kerja, efi siensi kerja, keterlibatan kerja dapat menyebabkan terjadinya stres kerja dan frustrasi kerja (fathoni, 2006). oleh karena itu, organisasi diharapkan dapat menciptakan iklim organisasi yang kondusif sehingga dapat membuat para karyawan menjadi bersemangat dan bekerja lebih efi sien (laily, 2008). hasil penelitian terdahulu di antaranya penelitian yang dilakukan oleh utami (2009) melakukan penelitian di ruang rawat inap rs pku muhammadiyah karanganyar, m e n y e b u t k a n b a h w a s e b a n y a k 6 2 , 2 % mempersepsikan iklim organisasi baik, dan 37,8% mempersepsikan iklim organisasi sedang. dimensi iklim organisasi yang dipersepsikan paling baik adalah tekanan pada prestasi, hal ini berarti perawat mempunyai motivasi jurnal ners vol. 5 no. 2 oktober 2010: 154–163 156 yang tinggi untuk berprestasi. sedangkan yang menempati urutan paling rendah adalah dimensi sentralisasi keputusan. sebanyak 70,3% perawat mempunyai kepuasan kerja sedang, sebanyak 24,3% mempunyai kepuasan kerja tinggi terhadap teman sekerja, serta 5,4% mempunyai kepuasan kerja rendah terhadap kompensasi. penelitian lain dilakukan oleh hamdie (2007) di rsud h. boejasin kabupaten tanah laut kalimantan selatan menyebutkan iklim organisasi dapat memprediksikan kepuasan kerja sebesar 16% dengan hubungan kategori sedang, dimensi yang signifikan terhadap kepuasan kerja bagi profesi perawat adalah kepemimpinan, tanggung jawab, dan imbalan. pada penelitian kali ini, peneliti ingin menguatkan hasil penelitian terdahulu mengenai hubungan iklim organisasi dengan kepuasan kerja perawat. adapun perbedaan penelitian ini dengan penelitian sebelumnya, yaitu peneliti menggunakan modifikasi indikator enam dimensi iklim organisasi oleh litwin dan stringer (1968) dalam prasetyo (2003) sebagai penilaian, sedangkan untuk penilaian tingkat kepuasan kerja perawat, peneliti menggunakan teori hirarki kebutuhan maslow (1954) dalam nursalam (2008) yang dimodifi kasi dengan teori dua faktor herzberg (1959) dalam ivancevich (2006). kepuasan kerja perawat secara langsung maupun tidak langsung dapat berdampak pada peningkatan kinerja perawat. herzberg dalam strauss dan sayles (1986) menyatakan bahwa adanya penyebab-penyebab kepuasan menyebabkan produktivitas yang lebih tinggi. penyebab-penyebab ketidakpuasan, misal pemberian upah yang tidak adil, kondisi kerja yang kurang mendukung, kurangnya objektivitas pengawas, hubungan interpersonal yang buruk, tidak ada kesempatan promosi, serta tidak diberi kewenangan dalam pekerjaan dapat mengakibatkan produksi yang lebih rendah. apabila dalam bekerja perawat diberi kewenangan dalam pengambilan keputusan, teman sekerja yang mudah diajak berkoordinasi, perhatian dari pimpinan dengan memberi penghargaan atas keberhasilannya, tantangan dan risiko yang dibebankan berkaitan dengan pencapaian tujuan organisasi serta kejelasan organisasi dalam kebijakan dan tanggung jawab yang diterapkan akan membuat perawat merasakan kepuasan dalam bekerja (laily, 2008). di mana perawat yang merasa puas akan memberikan asuhan keperawatan dengan sebaik-baiknya dikarenakan perawat merasa harapannya telah terpenuhi (utami, 2009). oleh sebab itu perlu dianalisis adanya hubungan iklim organisasi dengan kepuasan kerja perawat di ruang irna bedah rsud kabupaten sampang agar pihak manajemen dapat menentukan strategi solusi yang tepat dalam menciptakan iklim organisasi yang kondusif dan sesuai dengan tujuan rumah sakit serta tujuan para perawat di ruang irna bedah rsud kabupaten sampang melalui upaya keterbukaan, demokrasi dalam organisasi, saling menghargai serta gaya kepemimpinan yang berpihak pada perawat. bahan dan metode rancangan yang digunakan dalam penelitian ini yaitu cross sectional. populasi pada penelitian ini adalah semua tenaga perawat di irna bedah rsud kabupaten sampang sebanyak 15 orang perawat. penelitian ini menggunakan sampel tenaga perawat irna bedah rsud kabupaten sampang sebanyak 11 orang yang memenuhi kriteria inklusi sebagai berikut perawat yang berdinas saat penelitian dilakukan, perawat yang bersedia untuk diteliti, dan perawat dengan masa kerja lebih dari satu tahun. variabel dependen penelitian ini adalah kepuasan kerja perawat, sedangkan variabel independen adalah iklim organisasi. kuesioner terstruktur digunakan sebagai instrumen dalam penelitian ini, di mana peneliti memodifi kasi sumber yang sudah ada untuk dimensi iklim organisasi dari litwin dan stringer (1968) dalam prasetyo (2003). kepuasan kerja menggunakan modifikasi aplikasi antara teori hirarki kebutuhan maslow (1954) dalam nursalam (2008) dengan teori dua faktor herzberg (1959) dalam ivancevich (2006). uji statistik yang digunakan dalam penelitian in adalah meggunakan korelasi spearman's rho dengan derajat kemaknaan atau tingkat signifi kan p < 0,01. kekuatan hubungan kedua variabel dapat ditentukan dengan melihat dari koefi sien korelasinya. analisis kepuasan kerja perawat berdasarkan iklim organisasi (nursalam) 157 hasil hasil dalam penelitian ini menunjukkan bahwa perawat di irna bedah rsud kabupaten sampang sebagian besar merasakan iklim organisasi adalah kondusif yaitu sebanyak 9 orang (82%), dari segi dimensi struktur menunjukkan bahwa 8 orang (73%) responden merasakan iklim organisasi kondusif pada dimensi struktur. tiga orang responden yang menilai iklim organisasi tidak kondusif merasakan hambatan terbesar dimensi struktur berada pada kategori aturan. sedangkan dari dimensi tanggung jawab 10 orang (91%) responden merasakan iklim organisasi kondusif pada dimensi tanggung jawab. satu orang responden yang menilai iklim organisasi tidak kondusif merasakan hambatan terbesar dimensi tanggung jawab berada pada kategori aturan. 9 orang (82%) responden merasakan iklim organisasi kondusif pada dimensi imbalan. dimensi risiko pada iklim organisasi menunjukkan bahwa 9 orang (82%) responden merasakan iklim organisasi kondusif, pada dimensi toleransi menunjukkan bahwa 9 orang (82%) responden merasakan iklim organisasi kondusif. hasil dari segi dimensi konfl ik menunjukkan 9 orang (82%) responden merasakan iklim organisasi kondusif. perawat irna bedah rsud kabupaten sampang sebagian besar merasakan kepuasan kerja yaitu sebanyak 9 orang (82%). 10 orang (91%) responden merasakan kepuasan kerja pada faktor gaji. 10 orang (91%) responden merasakan kepuasan kerja pada faktor kondisi kerja. 7 orang (64%) responden merasakan kepuasan kerja pada faktor pengawasan. 7 orang (64%) responden merasakan kepuasan kerja pada faktor pengawasan. 8 orang (73%) responden merasakan kepuasan kerja pada faktor promosi. hasil hubungan antara iklim organisasi dengan kepuasan kerja menunjukkan bahwa 9 orang (82%) menyatakan iklim organisasi kondusif dan memiliki kepuasan kerja, serta tidak ada responden yang menilai iklim organisasi kondusif tapi tidak memiliki kepuasan kerja. sedangkan responden yang menilai iklim organisasi tidak kondusif dan merasakan ketidakpuasan kerja yaitu sebanyak 2 orang (18%), serta tidak ada responden yang menilai iklim organisasi tidak kondusif tapi memilki kepuasan kerja. hasil uji statistik dengan menggunakan uji korelasi spearman's rho didapatkan koefi sien korelasi 0,799 (berada dalam rentang 0,60 sampai 0,799) yang berarti bahwa kedua variabel memiliki hubungan yang kuat. nilai p = 0,003 (≤ 0,01) hal ini menunjukkan bahwa h1 diterima dan h0 ditolak yang membuktikan bahwa ada hubungan antara iklim organisasi dengan kepuasan kerja di irna bedah rsud kabupaten sampang. pembahasan dimensi iklim organisasi yang dirasakan paling kondusif berada pada dimensi tanggung jawab yang ditunjukkan dengan perawat merasa mempunyai kesempatan untuk membuat keputusan sendiri di mana keputusan yang telah dibuat tidak selalu diperiksa kembali dan dapat dipercaya oleh pimpinan, hal ini menunjukkan bahwa perawat irna bedah rsud kabupaten sampang mengetahui dengan pasti tugas dan tanggung jawabnya. dimensi iklim organisasi yang paling tidak kondusif berada pada dimensi struktur di mana ditunjukkan dengan penerapan aturan-aturan organisasi yang dirasakan masih terlalu kaku, aliran tugas dan wewenang di irna bedah rsud kabupaten sampang belum membantu perawat dalam menyelesaikan tugas, kebijakan yang diambil pemimpin (karu) belum sejalan dengan kepentingan perawat, serta perencanaan dan pengaturan kerja yang belum jelas untuk mencapai standar kerja. iklim organisasi menurut litwin dan wilson (1978) dalam timpe (1992) merupakan serangkaian sifat lingkungan kerja yang dapat diukur berdasarkan persepsi kolektif dari orang-orang yang hidup dan bekerja di dalam lingkungan tersebut serta diperlihatkan untuk memengaruhi motivasi dan perilaku mereka. oleh karena itu, iklim organisasi yang kondusif diharapkan dapat menciptakan motivasi serta perilaku positif pada setiap anggota organisasi. tanggung jawab adalah kewajiban seseorang untuk melaksanakan fungsi yang ditugaskan dengan sebaik-baiknya sesuai dengan pengarahan yang diterima (hardjito, jurnal ners vol. 5 no. 2 oktober 2010: 154–163 158 1997). hal ini sesuai dengan kondisi di tempat penelitian di mana perawat mengetahui dengan pasti tugas dan tanggung jawabnya. sedangkan struktur organisasi merupakan cara organisasi untuk menyusun orang-orang dalam menciptakan sebuah organisasi. struktur dapat juga diartikan sebagai kepentingan bagaimana orang-orang akan dikelompokkan untuk menyelesaikan pekerjaannya. semakin tinggi penstrukturan suatu organisasi maka lingkungan akan terasa semakin kaku, tertutup dan penuh ancaman. sebaliknya semakin besar otonomi dan kebebasan serta semakin banyak perhatian manajemen terhadap pekerjaan individu, maka akan semakin baik, penuh kepercayaan dan bertanggung jawab atas iklim organisasi (robbins, 1996). namun, irna bedah rsud kabupaten sampang belum mempunyai struktur formal dalam organisasi. sehingga belum ada pembagian karyawan secara struktural dan fungsional. keadaan seperti ini tidak sesuai dengan standar pelayanan keperawatan pada standar 1 tentang falsafah dan tujuan, pada poin 4 menjelaskan bahwa bagan struktur organisasi harus memperlihatkan secara jelas garis komando, tanggung jawab, kewenangan dan hubungan kerja dalam pelayanan keperawatan serta hubungan dengan unit lainnya (wijono, 2000). selain itu, kepala ruangan di irna bedah rsud kabupaten sampang masih dipegang oleh seorang dokter. hal ini tidak sesuai dengan standar 3 tentang staf dan pimpinan, pada poin 1 menyatakan bahwa pelayanan keperawatan dipimpin oleh seorang perawat yang mempunyai kualifi kasi manajer, serta lebih lanjut dijelaskan pada poin 2 bahwa kepala keperawatan mempunyai kewenangan atau bertanggung jawab bagi berfungsinya pelayanan keperawatan (wijono, 2000). di mana karyawan harus memahami kebijakan dan bekerja dengan pengetahuan dari prosedur-prosedur pekerjaan khususnya yang menguntungkan mereka. hal ini merupakan tanggung jawab manajer untuk berperan sebagai guru dan sumber dalam area ini (rowland dan rowland, 1999). iklim organisasi yang kondusif sangat penting untuk meningkatkan perilaku positif dan motivasi perawat di irna bedah rsud kabupaten sampang. motivasi yang tinggi diharapkan dapat meningkatkan efektivitas kinerja perawat sehingga dapat meningkatkan kualitas pemberian pelayanan keperawatan. faktor kepuasan kerja tertinggi yang dirasakan oleh responden yaitu berada pada faktor gaji, kondisi kerja, dan pekerjaan itu sendiri. sedangkan faktor ketidakpuasan kerja tertinggi yaitu berada pada faktor pengawasan. kepuasan kerja terhadap faktor gaji ditunjukkan dengan sistem penggajian di tempat kerja yang jelas berdasarkan apbd tk ii, kesesuaian gaji dengan tingkat pendidikan, kesesuaian gaji dengan golongan pangkat, serta pemberian insentif tambahan atas prestasi atau kerja ekstra. hal ini sesuai dengan faktor kepuasan menurut rowland dan rowland (1999) bahwa karyawan menginginkan gaji yang adil bila dibandingkan dengan gaji institusi perawatan kesehatan yang bersaing dengan komunitas secara umum. selanjutnya, robbins (1996) menguatkan bahwa karyawan menginginkan sistem upah dan kebijakan promosi yang mereka persepsikan sebagai adil, tidak meragukan, didasarkan pada tuntutan pekerjaan, tingkat keterampilan individu, dan standar pengupahan komunitas sehingga kemungkinan besar akan dihasilkan kepuasan. pemenuhan gaji akan menimbulkan kepuasan pada individu sebab gaji merupakan kebutuhan fi siologis atau kebutuhan dasar bagi perawat (maslow, 1954 dalam sutarto, 1991). kepuasan kerja terhadap faktor kondisi kerja ditunjukkan dengan cukup tersedianya peralatan dan perlengkapan yang mendukung pekerjaan, tersedianya fasilitas penunjang (kamar mandi, tempat parkir, kantin, tempat ibadah, dan lain-lain), kondisi ruangan kerja yang baik (ventilasi udara, kebersihan, penerangan dan kebisingan), serta adanya jaminan atas kesehatan/keselamatan kerja. hal ini sesuai dengan standar pelayanan keperawatan pada standar 4 mengenai fasilitas dan peralatan bahwa fasilitas dan peralatan harus memadai untuk mencapai tujuan pelayanan keperawatan (wijono, 2000). kebutuhan keselamatan dan keamanan pada kondisi kerja menurut maslow (1954) dalam sutarto (1991) ada yang bersifat material berupa tempat berteduh (gedung), ada yang bersifat semi material seperti kebutuhan analisis kepuasan kerja perawat berdasarkan iklim organisasi (nursalam) 159 pensiun, jaminan hari tua, asuransi, serta berupa nonmaterial seperti kebutuhan yang berupa rasa aman di tempat kerja, keyakinan tidak akan mendapat imbalan buruk karena pendapat-pendapatnya yang berhubungan dengan tata cara kerja. k e p u a s a n k e r j a t e r h a d a p f a k t o r pekerjaan itu sendiri ditunjukkan dengan adanya kebebasan/otonomi melakukan suatu metode sendiri dalam menyelesaikan pekerjaan, kesempatan untuk meningkatkan kemampuan kerja melalui pelatihan atau pendidikan tambahan, serta kesesuaian pekerjaan dengan tingkat pendidikan perawat. berdasarkan standar pelayanan keperawatan pada standar 6 tentang pengembangan staf dan program pendidikan, dinyatakan bahwa harus ada program pengembangan dan pendidikan berkesinambungan agar setiap keperawatan dapat meningkatkan kemampuan profesional (wijono, 2000). banyak orang menginginkan kesempatan untuk menemukan, membangun, menguasai dan menggunakan kemampuan mereka sendiri untuk pengembangan seluasluasnya pekerjaan dan kehidupan pribadi mereka. begitu pula dengan perawat yang secara khusus memperhatikan kesempatan perkembangan, termasuk pendidikan yang berkelanjutan dan kesempatan untuk tumbuh dalam organisasi (rowland dan rowland, 1999). kebutuhan pemuasan diri misalnya kebutuhan untuk mengembangkan secara maksimal kemampuan, kreativitas, kemahiran, mengembangkan secara penuh segala potensi yang ada pada diri seseorang (sutarto, 1991). perawat ingin menjadi seperti yang mereka inginkan untuk mencapai potensi mereka menjadi perawat yang efektif, kreatif, dan memenuhi standar kinerja personal (swansburg dan swansburg, 2001). faktor ketidakpuasan kerja tertinggi yaitu berada pada faktor pengawasan. hal ini ditunjukkan dengan ketidakobjektifan pengawas dalam melakukan pengawasan, kurang adanya ketegasan pengawas dalam menegakkan disiplin, serta pengawas kurang mampu membuat keputusan. dalam penelitian ini, responden menyatakan ketidakpuasannya pada faktor pengawas karena di irna bedah rsud kabupaten sampang belum dilaksanakan sistem pengawasan terhadap kinerja perawat karena terbatasnya sumber daya manusia yang handal. apabila pengawasan/supervisi keperawatan tidak dilaksanakan, maka evaluasi dan pengendalian mutu terhadap asuhan keperawatan tidak terlaksana secara optimal. menurut nursalam (2008), supervisi berguna untuk meningkatkan pengetahuan, keterampilan dan sikap para pelaksana kegiatan agar program terlaksana baik. objektivitas dalam melakukan pengawasan dan pengendalian hanya dapat dipertahankan apabila standar, prosedur kerja, dan kriteria yang jelas diketahui oleh yang diawasi atau yang mengawasi (siagian, 1995). penilaian dan umpan balik harus dilakukan secara teratur berdasarkan waktu serta harus adil. manajer harus mencoba metode-metode penilaian yang teliti (rowland dan rowland, 1999). oleh karena itu, sistem penilaian terhadap staf keperawatan harus dilaksanakan dan didokumentasikan berdasarkan pada uraian tugas staf dan dapat mengidentifi kasi keunggulan dalam penampilan dan keperluan peningkatan karier sehingga kepuasan kerja pada faktor pengawasan dapat terpenuhi. coleman (1982) dalam muhammad (2005), kepuasan merupakan respons seseorang sebagai pengaruh terhadap bermacam-macam lingkungan kerja yang dihadapinya termasuk respons terhadap komunikasi organisasi, supervisor, kompensasi, promosi, teman sekerja, kebijaksanaan organisasi, dan hubungan interpersonal dalam organisasi. berdasarkan data yang didapat dari lapangan, bor tahun 2007–2009 berturut-turut yaitu 56,1%; 62,8%; 68,2% walaupun mengalami peningkatan namun tetap di bawah standar nasional (standar nasional: 75–85%), avlos tahun 2007–2009 berturut-turut yaitu 2,9 hari; 3,1 hari; 3,3 hari sedangkan standar nasional: 7–10 hari), hal ini dapat mengidentifi kasikan bahwa pelayanan keperawatan di irna bedah rsud kabupaten sampang kurang optimal. salah satu faktor penyebabnya yaitu kurangnya kepuasan kerja perawat. perbedaan hasil penelitian dengan hasil awal pengambilan data antara lain disebabkan oleh adanya responden baru/berbeda dengan responden pada saat pengambilan data awal. hal ini dikarenakan adanya perbedaan jam jurnal ners vol. 5 no. 2 oktober 2010: 154–163 160 dinas responden pada saat penelitian. selain itu, perbedaan hasil tersebut dipengaruhi oleh perubahan kebijakan-kebijakan dan perbaikan manajemen rumah sakit dalam proses mengikut akreditasi rumah sakit sehingga perbaikan dan penyesuaian sistem, program, aturan, serta manajemen terus dilakukan. kepuasan kerja perawat sangat penting dipenuhi karena menyangkut hasil kerja/ produktivitas perawat itu sendiri. di mana perawat yang merasa puas akan bekerja dengan sebaik-baiknya dikarenakan mereka merasa keinginannya telah terpenuhi. semakin banyak faktor-faktor kepuasan yang terpenuhi, maka perawat akan semakin merasa puas. dengan demikian, diharapkan produktivitas perawat akan semakin baik. hambatan yang dirasakan perawat terhadap enam dimensi iklim oganisasi berdasarkan kategori manajer, aturan, dan sumber daya adalah sebagai berikut: kategori manajer, hambatan terbesar dirasakan pada dimensi konflik yang ditunjukkan dengan manajer kurang tegas dalam mengatasi konfl ik, kurang keterbukaan manajer dalam setiap permasalahan, belum ada penyelesaian konfl ik secara optimal, manajer sulit menerima pendapat orang lain. sedangkan hambatan terkecil yang dirasakan perawat pada kategori manajer yaitu berada pada dimensi toleransi sebesar 18% yang ditunjukkan dengan kurang keterbukaan antara atasan dengan staf. kategori aturan, hambatan terbesar berada pada dimensi tanggung jawab yang ditunjukkan dengan pembagian tanggung jawab belum adil dan masih subjektif, serta pembagian job description yang belum jelas. perawat tidak merasakan hambatan kategori aturan yaitu pada dimensi konfl ik. kategori sumber daya, hambatan terbesar berada pada dimensi risiko yang ditunjukkan dengan adanya kesenjangan antara perawat lama dan baru, serta sering adanya perbedaan pendapat. hambatan terkecil pada kategori sumber daya berada pada dimensi tangung jawab dan imbalan. pada dimensi tanggung jawab, hambatan kategori sumber daya ditunjukkan dengan adanya senioritas. pada dimensi imbalan, hambatan kategori sumber daya ditunjukkan dengan adanya kesenjangan antara perawat lama dengan yang baru dalam pemberian imbalan. harapan yang diinginkan perawat terhadap enam dimensi iklim oganisasi berdasarkan kategori manajer, aturan, dan sumber daya adalah kategori manajer, harapan terbesar dirasakan pada dimensi struktur yaitu peraturan ditingkatkan menjadi lebih baik, penerapan aturan diatur dan didukung langsung oleh atasan, serta adanya profesionalisme. harapan terkecil pada kategori manajer berada pada dimensi tanggung jawab yaitu pembagian tanggung jawab yang jelas dan adil, pembagian kerja sesuai dengan kemampuan, job description, dan tupoksi. kategori aturan, harapan terbesar yang diinginkan perawat berada pada dimensi tanggung jawab dan dimensi imbalan. pada dimensi tanggung jawab, harapan yang diinginkan yaitu pembagian kerja sesuai dengan kemampuan, jobdescription yang jelas, pengoptimalan tupoksi, serta pembagian tanggung jawab lebih jelas dan adil. sedangkan pada dimensi toleransi, perawat tidak mempunyai harapan untuk kategori aturan. kategori sumber daya, harapan terbesar yang diinginkan perawat berada pada dimensi toleransi sebesar yaitu selalu terjalin hubungan interpersonal serta kerja sama yang baik. harapan terkecil kategori sumber daya berada pada dimensi struktur, tanggung jawab, imbalan, serta konfl ik. pada dimensi struktur, tanggung jawab, imbalan, responden menuliskan tidak ada harapan, sedangkan pada dimensi konfl ik, responden berharap tidak ada konfl ik antarteman. hambatan yang dirasakan perawat t e r h a d a p e n a m f a k t o r k e p u a s a n k e r j a berdasarkan kategori manajer, aturan, dan sumber daya adalah sebagai berikut: kategori manajer, hambatan terbesar dirasakan pada faktor pengawasan yang ditunjukkan dengan belum adanya pengawasan terfokus perawat, serta kurang transparansi. perawat tidak merasakan hambatan kategori manajer pada faktor gaji, kondisi kerja, serta pekerjaan itu sendiri. kategori aturan, hambatan terbesar berada pada faktor gaji yang ditunjukkan dengan belum sesuai umk/umr, merasa kurang puas, tidak ada reward untuk yang berprestasi, serta kurang adil dan merata. perawat tidak merasakan hambatan kategori aturan pada faktor pengawasan dan pekerjaan itu sendiri. analisis kepuasan kerja perawat berdasarkan iklim organisasi (nursalam) 161 kategori sumber daya, hambatan terbesar dirasakan perawat pada faktor pekerjaan itu sendiri yang ditunjukkan dengan belum ada pelatihan/seminar secara rutin, pengikutsertaan pelatihan/seminar terbatas pada orang-orang tertentu, serta adanya senioritas. harapan yang diinginkan perawat t e r h a d a p e n a m f a k t o r k e p u a s a n k e r j a berdasarkan kategori manajer, aturan, dan sumber daya adalah kategori manajer, harapan terbesar yang diinginkan berada pada faktor pengawasan yang diinginkan yaitu ada supervisi untuk meningkatkan prestasi kerja, pengawasan yang jelas dan tegas, serta supervisi langsung oleh atasan. perawat tidak mempunyai harapan kategori manajer pada faktor gaji. kategori aturan, harapan terbesar berada pada faktor gaji sebesar 100% yang diinginkan yaitu sesuai dengan umk/umr, adanya kenaikan gaji, ada reward untuk yang berprestasi, serta adil dan merata. perawat tidak mempunyai harapan kategori aturan pada faktor pengawasan dan hubungan interpersonal. kategori sumber daya, harapan terbesar berada pada faktor hubungan interpersonal sebesar 73% yang dinginkan yaitu terjalin hubungan interpersonal yang baik, kerja sama dan kekeluargaan yang lebih baik. teori dua faktor herzberg (1959) dalam ivancevich dkk. (2006) menjelaskan apabila context faktor (gaji, kondisi kerja, kualitas pengawasan teknis, kualitas hubungan interpersonal, promosi, pekerjaan itu sendiri, dan prosedur perusahaan) tidak terpenuhi, tidak ada ataupun tidak sesuai maka dapat membuat karyawan merasa tidak puas (dissatisfied). ketidakterpenuhinya context faktor akan menyebabkan tenaga kerja banyak mengeluh dan merasa tidak puas, tetapi bila dipenuhi maka karyawan akan berada pada posisi tidak lagi tidak puas (bukan berarti puas) atau tepatnya dalam keadaan posisi netral. perilaku positif atau yang diinginkan harus dihargai atau diperkuat. penghargaan memberikan motivasi, meningkatkan kekuatan d a r i s u a t u r e s p o n s a t a u m e n y e b a b k a n pengulangannya. penguatan yang terus-menerus mempercepat penampilan kerja. perilaku organisasi yang tidak diinginkan tidak boleh diberi penghargaan (skinner dalam swansburg dan swansburg, 2001). teori harapan vroom dalam swansburg dan swansburg (2001) menyatakan bahwa kebanyakan perilaku secara sukarela dikendalikan oleh seseorang dan karenanya termotivasi. ada harapan kinerjausaha, atau keyakinan seseorang bahwa ada kesempatan bagi usaha tertentu untuk menuju pada suatu tingkat kinerja tertentu. harapan atau keyakinan tentang hasil kinerja akhir dari seseorang akan mempunyai hasil akhir tertentu. peran manajer sangat penting untuk mengatasi hambatan-hambatan yang dirasakan serta mewujudkan harapan-harapan yang diinginkan perawat terhadap organisasi. selain itu, mutu hubungan interpersonal yang berjalan dengan serasi dan harmoni diperlukan agar segala permasalahan yang menjadi hambatan dalam pekerjaan dapat diselesaikan dengan mudah sehingga kepuasan dapat terpenuhi (tampubolon, 2004). s i m a m o r a ( 2 0 0 1 ) d a l a m k u s n a n (2003) mengartikan iklim organisasi sebagai lingkungan internal atau psikologi organisasi. iklim organisasi memengaruhi praktik dan kebijakan sumber daya manusia yang diterima oleh anggota organisasi. menurut gibson dkk. (1987) iklim organisasi merupakan seperangkat prioritas lingkungan kerja yang dipersepsikan karyawan secara langsung atau tidak langsung yang dianggap sebagai faktor utama dalam memengaruhi perilaku karyawan. iklim organisasi dapat memengaruhi kepuasan kerja yang dapat dilihat melalui perilaku anggotanya. perilaku positif akan ditunjukkan oleh anggota yang merasa puas, begitu pula sebaliknya respons ketidakpuasan akan ditampakkan oleh anggota dengan perilaku yang cenderung negatif. selain itu, sikap yang diproyeksikan oleh manajemen puncak melalui manajer individual adalah sebuah faktor penting. kepuasan kerja karyawan banyak dipengaruhi oleh sikap pimpinan dalam kepemimpinan. kepemimpinan partisipatif memberikan kepuasan kerja bagi karyawan, karena karyawan ikut aktif dalam memberikan pendapatnya untuk menentukan kebijaksanaan perusahaan. kepemimpinan otoriter mengakibatkan ketidakpuasan kerja karyawan (fathoni, 2006). sebaiknya manajemen lebih banyak memberikan umpan balik, otonomi, dan jurnal ners vol. 5 no. 2 oktober 2010: 154–163 162 identitas serta membantu terciptanya iklim organisasi yang berorientasi prestasi, di mana karyawan merasa lebih bertanggung jawab atas pencapaian pada tujuan organisasi dan kelompok. simpulan dan saran simpulan perawat irna bedah rsud kabupaten sampang sebagian besar merasakan iklim organisasi kondusif. dimensi tanggung jawab dirasakan paling kondusif, sedangkan dimensi struktur dirasakan paling tidak kondusif, perawat irna bedah rsud kabupaten sampang sebagian besar merasakan kepuasan kerja. faktor kepuasan gaji, kondisi kerja, dan pekerjaan itu sendiri merupakan faktor kepuasan kerja tertinggi, sedangkan faktor kepuasan pengawasan merupakan faktor kepuasan kerja yang dirasakan paling rendah, perawat merasakan hambatan terbesar iklim organisasi berada pada dimensi risiko untuk kategori sumber daya. harapan terbesar perawat berada pada dimensi struktur untuk kategori manajer. perawat merasakan hambatan dan harapan terbesar kepuasan kerja berada pada faktor gaji untuk kategori aturan dan iklim organisasi mempunyai hubungan dengan kepuasan kerja perawat di irna bedah rsud kabupaten sampang dengan kategori hubungan kuat. sehingga iklim organisasi yang kondusif penting untuk meningkatkan kepuasan kerja perawat. saran iklim organisasi yang kondusif perlu ditingkatkan dalam upaya peningkatan kepuasan kerja perawat di irna bedah rsud kabupaten sampang dengan cara learning and growth organization (inovasi, perbaikan dan pembelajaran, produk baru, efi siensi, dan penetrasi), sehingga dapat mengurangi risiko, konflik, serta faktor-faktor ketidakpuasan, pembentukan struktur formal di irna bedah sangat diperlukan guna terciptanya stabilitas organisasi melalui pembagian tanggung jawab serta aliran tugas yang jelas dan sesuai standar dalam upaya pencapaian tujuan organisasi, perlu adanya sistem pemberian imbalan yang dapat meningkatkan kepuasan kerja perawat, di mana imbalan tidak hanya bersifat materi dan pemberian pujian dan penghargaan atas keberhasilan perawat menyelesaikan pekerjaan dengan baik sangat membantu meningkatkan kepuasan kerja perawat. kepustakaan fathoni, a., 2006. organisasi dan manajemen sumber daya manusia. jakarta: rineka cipta. gibson, j.l., ivancevich, j.m., dan donnelly, j.h., 1987. organisasi dan manajemen: perilaku, struktur, proses. edisi keempat. jakarta: erlangga. hamdie, t., 2007. hubungan antara iklim organisasi dengan kepuasan kerja bagi karyawan rsud h. boejasin kabupaten tanah laut kalimantan selatan. tesis tidak dipublikasikan. yogyakarta: universitas gadjah mada. hardjito, d., 1997. teori organisasi dan teknik pengorganisasian. jakarta: pt raja grafi ndo parsada. ivancevich, j.m. dkk., 2006. perilaku dan manajemen organisasi. jilid 1. edisi ketujuh. jakarta: erlangga. kusnan, 2008. pengaruh iklim organisasi, etos kerja, dan disiplin kerja dalam m e n e n t u k a n e f e k t i v i t a s k i n e r j a garnisun tetap iii surabaya, (online), (http://www.damandiri.or.id., diakses tanggal 17 desember 2009, jam 10.10 wib). laily, n., 2008. pengaruh karakteristik individu dan karakteristik pekerjaan serta iklim organisasi terhadap kepuasan kerja dan motivasi serta kinerja manajer menengah industri pupuk nasional di indonesia. disertasi tidak dipublikasikan. surabaya: universitas airlangga. muhammad, a., 2005. komunikasi organisasi. jakarta: bumi aksara. nursalam, 2008. manajemen keperawatan: aplikasi dalam praktik keperawatan profesional. edisi 2. jakarta: salemba medika. p r a s e t y o , a . , 2 0 0 3 . p e n g a r u h i k l i m organisasi terhadap kepuasan kerja dan kinerja karyawan (studi pada pt analisis kepuasan kerja perawat berdasarkan iklim organisasi (nursalam) 163 "x" di driyorejo gresik). tesis tidak dipublikasikan. surabaya: universitas airlangga. robbins, s.p., 1996. perilaku organisasi: konsep, kontroversi, aplikasi. jilid 2. jakarta: prenhallindo. rowland, h.s., dan rowland, b.l., 1999. nursing administration handbook. california: an aspen publication. sutarto, 1991. dasar-dasar organisasi. yogyakarta: gadjah mada university press. swansburg, r.c., dan swansburg, l.c., 2001. pengembangan staf keperawatan: suatu komponen pengembangan sumber daya manusia. jakarta: egc. ta m p u b o l o n , m . p. , 2 0 0 4 . p e r i l a k u keorganisasian: organization behavior. jakarta: ghalia indonesia. timpe, a.d., 1992. kinerja: seri manajemen sumber daya manusia 6. jakarta: pt elex media komputindo. utami, d.r.r. budi, 2009. hubungan iklim organisasi dengan kepuasan kerja perawat pelaksana di ruang rawat inap rs pku muhammadiyah karanganyar, (online), (http://www.skripsistikes. wordpress.com., diakses tanggal 29 maret 2010, jam 11.05 wib). wijono, d., 2000. manajemen mutu pelayanan kesehatan: teori, strategi dan aplikasi. vol 2. surabaya: airlangga university press. microsoft word front matters 16.1.docx p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no. 58/dikti/kep/2013 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief ferry efendi, s.kep., ns., m.sc., phd editor: prof. dr. ah. yusuf, s.kp., m.kes. dr. esti yunitasari, s.kep., ns., m.kep. assistant professor pei-lun hsieh dr. yulis setiya dewi, s.kep.ns., m.ng dr. rizki fitryasari, s. kep., ns., m. kep. dr. ilya krisnana, s.kep., ns., m.kep. retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. technical editor: masunatul ubudiyah, s.kep., ns., m.kep. rifky octavia pradipta, s.kep., ns., m.kep. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 16 no. 1 april 2021. 1. rr dian tristiana, s.kep., ns., m.kep. universitas airlangga, indonesia 2. dr meidiana dwidiyanti, s.kp, m.sc universitas diponegoro, indonesia 3. bayhakki, m.kep, sp.kmb, phd universitas riau, indonesia 4. dr. yuni arief, s. kp., m. kes. universitas airlangga, indonesia 5. dr. yulis dewi, s.kep.ns., m.ng. universitas airlangga, indonesia 6. dr. muhammad miftahussurur, m.kes., sp.pd-kgeh., ph.d universitas airlangga, indonesia 7. riris andriati, s.kep., ns., m.kep. sekolah tinggi ilmu kesehatan widya dharma husada tangerang, indonesia 8. rista fauziningtyas, s.kep., ns., m.kep. universitas airlangga, indonesia 9. anna kurniati, s.km, ma bppsdmk, ministry of health, indonesia 10. budi santoso, s.kep,. ns., m. kep, sp.kep.kom. poltekkes kemenkes palembang, indonesia 11. dr. sirikanok klankhajhon, phd, rn naresuan university, phitsanulok, thailand 12. ni ketut armini, s. kp., m. kes. universitas airlangga, indonesia 13. dr. mira triharini, s. kp., m. kep universitas airlangga, indonesia 14. rosnani rosnani, s. kp., m. kep., sp. mat poltekkes kemenkes palembang 15. saryono, s.kp., m.kes universitas jenderal soedirman, indonesia 16. ns. sri padma sari, mns universitas diponegoro, indonesia 17. erni astutik s.k.m., m.epid universitas airlangga, indonesia 18. asst. prof. dr. pratuma rithpho, msn., rn naresuan university, phitsanulok, thailand 19. dr. dwi ananto wibrata, sst, m.kes. poltekkes kemenkes surabaya universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no. 58/dikti/kep/2013 table of content 1. depression and the quality of life among filipino chemotherapy patients pearl irish v. de paz 1-5 2. middle school students’ perception on a health promoting school to prevent bullying: a qualitative study masunatul ubudiyah, nursalam nursalam, tintin sukartini 6-12 3. implementation of chest compression for cardiac arrest patient in indonesia: true or false rendi editya darmawan, untung sujianto, nana rochana 13-16 4. a correlation between working environment and job experience toward culture shock among indonesian nurses in japan erwin yektiningsih, asti melani astari, yulian wiji utami 17-25 5. a normative behavior of pre-travel health consultation and the associated factors among travelers i gede nova ariawan, kadek eka swedarma, ni putu emy darma yanti 26-34 6. familial experiences of caring for schizophrenia patients during the covid-19 pandemic: a qualitative study indriati indriati, wien soelistyo adi, tuti anggarawati, yuni astuti, delisa alfriani 35-40 7. capacities and needs assessment on health emergency management in biliran province, philipines willard n. riveral, john anthony d. ramagos, marian madelyn m. collera, jeremy b. ohiman 41-48 8. premarital counseling affects primigravidas’ knowledge and attitude on reproductive and sexual health rika ortiningsih, kasiati kasiati, samsriyaningsih handayani 49-53 9. contributing factors of cyberbullying behavior among youths during covid19 ira kusumawaty, yunike yunike, yeni elviani, hidayat arifin 54-59 10. analysis of factors affecting the mental health crisis of coronavirus disease infection in java island diah priyantini, nursalam nursalam, tintin sukartini 60-66 11. family coping strategies to improve the health of family members living with schizophrenia sugeng mashudi, ah yusuf 67-73 12. potential loss among infant feeding options azniah syam, musni musni, andi nurzakiah amin, imelda iskandar 74-80 13. nurse manager competency model in a teaching hospital setiawan setiawan, dewi elizadiani suza, farida linda sari siregar 81-88 14. exploring the elderly care system: a view from community in thailand amaraporn puraya, duangporn piyakong, sugritta wongwiggan, roongtiva boonpracom 89-95 15. the effect of psychoeducation on self-efficacy and motivation for taking treatment in breast cancer patients (ca mammae) hanik endang nihayati, laeli nurhanifah, ilya krisnana 96-100 editorial social capital in community nursing profession: rural vs. urban communities najla a barnawi assistant professor, college of nursing-riyadh, ksau-hs email: barnawin@ksau-hs.edu.sa social capital is a complex, socially constructed phenomenon and essential in community nursing, basically considering the rurality variations versus urbanity discourse. applying sociological theory in rurality and urbanity discourse provides a deeper insight into the microscopic and macroscopic factors that concern social capital. sometimes social capital is used as a core concept of micro-sociological theory to illustrate the social network where the human interactions are the major components. therefore, networking in social capital aims to enhance trust and civism. in such a view, the nurse community interpersonal ties and skills are essential to sustain social capital. it distinguishes the civism characteristics between rural versus urban population. a network and trust relationship, for instance, maintains the social capital of rural communities more than urban ones because of the vital kinship status, which constructs the civism of urban communities. this indicates that interpersonal relationships, which construct rural communities' networks, create a powerful societal supportive system. however, the out-migration of younger communities negatively impacts the interpersonal and kinship status, threatening rural social capital sustainability. accordingly, it is logical to assume that social capital is more substantial in rural communities, though it is only sustained within the older generation. indeed, aging and a higher morbidity rate leads the older population to be more isolated from younger, especially the middle-age generations. in contrast, network and interpersonal relationships in urban communities seem to be more casual than in rural communities. based on that view, urbanization changes the pattern of networking and interpersonal relationships. this leads the younger population to seek alternatives to sustain interpersonal relationships, such as social media networking. however, these alternatives may not support the real meaning of civism and trust relationships. therefore, and from a microscopic view, some controversies impact social capital sustainability in urban communities. alternatively, social capital is a significant concept of a macro-sociological theory wherein that lens, societal and cultural construct, and collective human actions within a society are major social capital components. several scholars emphasize the importance of social ties and shared norms to societal wellbeing and economic efficiency. such a concept illustrates the social inequality and hierarchical social structures among rural and urban communities. therefore, it is logical to classify social capital sustainability at a mesoscopic level into economic sustainability and ethnic/cultural sustainability. these factors are overlapped with each other, though all of them are influenced by geographical and nongeographical factors. the low and unstable economic status in rural communities negatively impacts the sustainability of social capital finical status. the industrialization of agriculture increases the low-rate wages jobs among the rural population and evidence asserts that manufactured and industrialized agriculture shifts social capital financial status from rural areas to urban and suburban areas. indeed, the degree of unstained social capital varies between rural communities based on geographical location as well. for example, residents in rural areas, especially those with low income, are more isolated from taking the benefits of the minimal types of social services. furthermore, considering the state exchange of the affordable care act (aca), it is vital to address the potential disparities among rural communities in states that follow this legislation versus those which do not. this leads to inequalities in accessing and utilizing the most needed social services, such as healthcare. there are various assumptions about the role of ethnic diversity in social capital. some argue that it harms social capital at the community level, where ethnically diverse neighborhoods in urban communities decrease the social capital acculturation in urban and suburban communities more than rural communities. in contrast, some evidence highlights the association between ethnic diversity and trust, explaining an insignificant one percent of neighborhood-level fluctuation. the differential effect of diversity on neighborhood norms is less apparent once other factors, such as neighborhood poverty, are considered. however, there has also been found to be a slightly negative impact of diversity on social norms. therefore, it is logical to consider ethnic diversity as a factor that has other contextual variables. pendampingan ibu hamil trimester iii (slamet r. yuwono, dkk) 311 pendampingan ibu hamil trimester iii meningkatkan praktek pemberian asi dan status gizi balita 0-4 bulan (iii rd trimester pregnant women mentoring improve breastfeeding practice and nutritional status of 0-4 months children) slamet riyadi yuwono*, taufiqurrahman*, ni ketut sri sulendri** *jurusan gizi poltekkes kemenkes surabaya, jalan pucang jajar tengah no.56, surabaya 60282 ** jurusan gizi poltekkes kmenkes mataram email : s_riyadiyuwono@yahoo.com abstrak pendahuluan: hasil riskesdas 2010 menunjukkan bahwa cakupan tertinggi terdapat pada bayi kelompok umur 0 bulan (39,8 %) dan terendah pada bayi dengan kelompok umur 5 bulan (15,3 %). prevalensi balita stunting (pendek+sangat pendek) di propinsi ntb adalah 43,7% angka tersebut berada di atas angka nasional (36,5%), dan secara umum masalah balita stunting (pendek+sangat pendek) di provinsi ntb masih cukup tinggi karena memiliki prevalensi di atas 20%. untuk itu peneliti melakukan penelitian untuk mencari model pendampingan yang tepat,sebaagai salah satu upaya untuk mengatasi masalah status gizi. metode: disain penelitiannya adalah rancangan penelitian eksperimen sederhana dengan jenis post-test only control group design. penelitian akan dilaksankan di madiun-jawa timur dan mataram-ntb, mulai april s/d oktober 2015. hasil: ada perbedaan yang signifikan praktek pemberian asi eksklusif dari ibu yang mendapatkan pendampingan dengan metode home visit dengan ibu yang tidak mendapat pendampingan. bayi dari ibu yang mendapatkan pendampingan mempunyai peluang/kesempatan untuk menyusui asi saja sebesar 9,333 kali lebih tinggi dibandingkan bayi dari ibu yang tidak mendapat pendampingan. z-score balita dari ibu yang mendapat pendampingan mempunyai nilai sedikit lebih tinggi dibandingkan yang tidak mendapat pendampingan, namun secara statistik tidak terdapat perbedaan yang signifikan status gizi balita 0-3 bulan dari kedua kelompok. pembahasan: sehubungan dengan hasil tersebut direkomenadasikan untuk menggunakan model pendampingan “home visit pada ibu hamil trimester 3” agar praktek pemberian asi eksklusif meningkat. kata kunci: pendampingan ibu hamil trimester iii, home visit,asi, status gizi abstract introduction: results of riskesdas in 2010 showed that the highest coverage was on 0 month age group infants (39,8%) and the lowest was on 5 months age group infants (15,3). prevalence of stunted chlidren (short + very short) in ntb (west nusa tenggara) province is 43,7%. that rate is above the national rate (36,5%) and in general, stunted children problem in ntb province is still quite high because of the prevalence is over 20%. therefore, the researchers conducted research to find exact mentoring model as an effort to solve nutritional status problems. methods: the research design was simple experimental research design with the type of post-test only control group design. the research was conducted in madiun-east java and mataram-ntb started from april until october 2015. result: there was a significant difference in exclusive breastfeeding practice between mothers who received the mentoring through home visit method with mothers who did not receive the mentoring. infants of mothers who received the mentoring had opportunity / chance to breastfeed 9,333 times higher than infants of mothers who did not receive the mentoring. discussion: z-score of infants of mothers who received the mentoring had sligtly higher score than infants of mothers who did not receive the mentoring, but statistically there was no significant difference in 0-3 months infants nutritional status between both group. in connection with those results, it is recommended to use the mentoring model of “home visit to 3 rd trimester pregnant women” in order to increase the exclusive breastfeeding practice. keywords: 3 rd trimester pregnant women mentoring, home visit, nutritional status. introduction data of who showed concern rate which known as 2/3 phenomenon, that was mass infants (0-1 years old) mortalities occurred on neonatal period (0-28 days new born infants). those early neonatal mortalities were occurred on the first day of birth. the underlying cause of 54% infants’ mortality was malnutrition. data of world health organization (who) show there are 170 million children have malnutrition in worldwide, including 3 million of them die each year due to malnutrition. according to data o national health survey (susenas) in 2010, it is known that only 33,6% of infants in indonesian who received exclusive breastfeeding. this means there are still about 2/3 infants in indonesia who are less lucky. so, a campaign of exclusive breastfeeding increment is needed and encouraging local government and private sectors to support that. there are several factors that cause the low coverage of mailto:s_riyadiyuwono@yahoo.com jurnal ners vol.11 no. 2 oktober 2016: 311-314 312 exclusive breastfeeding in indonesia such as the dissemination of information among health workers and people which not optimal, that was only 60% of people who know the information about breastfeeding and only 40% of trained health workers who are able to give breastfeeding counseling. data of riskesdas (2013) showed that female infants aged 0-5 months was found stunting of 22,4% and raised to 27,3% on age of 6-11 months. data in ntb showed the stunting infants prevalence (short+very short) was 43,7% which it was the top 3 prevalence of 33 provinces in indonesia. that rate was above national average rate which of 37,2%.. based on the description above, it is necessary to study a method or model in order to be guidance so the trained breastfeeding counselors or pmba counselors are able to proactively conduct the activities and fulfill the target of breastfeeding increment in achieving better nutritional status of children. because of that, authors are interested to conduct the research about “effect of iii rd trimester pregnant women mentoring toward breastfeeding practice and nutritional status of 0-4 months children”. material and method the design of this research was pre experimental research with post-test only control group design. population in this research was all 3 rd trimester pregnant women on april 2015 from chosen health center area in madiun – east java and mataram – ntb. each location was randomly chosen of 2 health center which had breastfeeding counselor assistants and willing to be breastfeeding counselor assistants for 3 rd trimester pregnant women ; 63 samples were taken from the beginning of the research were able to analyze and until the end of the research were 61 pregnant women. results according to table 1, it was known that women who received the mentoring and women who did not receive the mentoring almost had similiar percentage in initiation of early breastfeeding of 60% and 58,1%. statistic test results obtained p value of 1,000, it meant that there was no significant difference in initiation practice of early breastfeeding between women who received the mentoring and women who did not receive the mentoring. analysis results obtained or = 9,333, it meant that infants of mothers who received the mentoring had opportunity / chance to only breastfeed by 9,333 times higher than infants of mothers who did not receive mentoring. statistic test results obtained p value of >0,05 which meant that there was no significant difference of z score average between infants of mothers who received the mentoring with infants of mothers who did not received the mentoring, neither on waz, haz nor whz index (table 3). table 1 initiation practice of early breastfeeding on control group and treatment group in 2015 home visit methode mentoring initiation practice of early breastfeeding p value or95% ci no yes 0. no 1. yes 12 (40,0%) 13 (41,9%) 18 (60,0%) 18 (58,1%) 1,000 *) 0,923 (0,333-2,562) chi-square test *). table 2 effect of home visit method mentoring to 3 rd trimester pregnant women of breastfeeding practice in 2015 home visit method mentoring practice of exclusive breastfeeding p value or95% ci no yes 0. no 1. yes 15 (50,0%) 3 (9,7%) 15 (50,0%) 28 (90,3%) 0,002 *) 9,333 (2,323-37,442) chi-square test*) pendampingan ibu hamil trimester iii (slamet r. yuwono, dkk) 313 table 3. nutritional status of 0-3 months infants in control group and treatment group in 2015 nutritional status mentoring group mean standard dev p value waz 0 month 0. no 1. yes 0. -0,43913 1. -0,37423 0,701804 0,845018 0,746*) haz 0 month 0. no 1. yes 0. -0,01230 1. -0,05835 0,792721 1,071007 0,850*) whz 0 month 0. no 1. yes 0. 0,3508 1. 0,4850 1,44625 0,90937 0,655**) waz 3 months 0. no 1. yes 0. 0,1596 1. 0,3136 1,06688 0,97504 0,558*) haz 3 months 0. no 1. yes 0. -0,1969 1. -0,1605 0,89779 0,67739 0,859*) whz 3 months 0. no 1. yes 0. 0,3508 1. 0,4850 1,44625 0,90937 0,668*) independent test*) and mann withney**) discussion the home visit method mentoring conducted to the treatment group significantly increase the mean value of knowledge, attitude and action of respondents by analyzing the results of scoring in both groups. comparison test using independent t-test in both groups who received the post test obtained the results of p=0,001 which meant that there was significant influence of 3 rd trimester pregnant women mentoring using home visit method toward the changes in knowledge, attitudes and actions of the respondents on the treatment group compared with control group. it was because of home visit was intensive with light materials and humanistic approach. more individual approach allowed a better interaction between the mother and family to more freely to ask, as stated by (notoatmodjo 2007) that short term health education can bring the changes and improvement in individual, group or community. analyses were also conducted on attitudes scoring results and it obtained op=0,001 which meant there was significant difference of increment in respondent’s attitude towards exclusive breastfeeding in the treatment group. attitudes can’t be seen, but can be early interpreted in introvert behavior. attitudes are emotional reactions toward social stimulus. according to newcomb in notoatmodjo (2007) attitude is a readiness or willingness to act, which predisposes the action of behavior, not the implementation of certain motives. attitude is a readiness for react to objects in the environment. the analysis on action scoring results were also obtained average value in the treatment group which higher than the control group. the results of the analysis of comparison test between the treatment and control groups obtained p value of 0,001 which meant that there were significant difference of the actions in both groups. it was in line with the increment that occurred in knowledge and positive attitude so that the action of exclusive breastfeeding also became easier. the results of cross tabulation percentage of exclusive breastfeeding in both groups (table 1) showed that 90.3% of respondents who have been mentored were successful in providing exclusive breastfeeding in infants until the age of 3 months, while in the group without mentoring only 50% who provided exclusive breastfeeding. these results are consistent with studies conducted ambarwati, r; muis sf; dan susantini (2013) that breastfeeding counseling as an incentive to increase exclusive breastfeeding up to 3 months and is reinforced by studies conducted by fatma s; purwita (2013) who said that the counseling effect on relactation in nursing mothers who did early weaning in clinics ms. munir banda aceh. changes in behavior are influenced by three factors predisposing, reinforcing and driving on a person's behavior may change if there is an imbalance between the driving force and anchoring force. some of the things that influence is the readiness of health workers to socialize exclusive breastfeeding is key to the success of lactation. the results of international research that was published by lancet, 1999 also shows that the faster contact with the counselor postpartum mother has a jurnal ners vol.11 no. 2 oktober 2016: 311-314 314 very close relationship in promoting breastfeeding and duration of exclusive breast feeding her baby. several studies have shown that the attitude of health workers greatly influence the selection of baby food by his mother (green 1991). zainal, e; sutedja, e; dan madjid (2014) asserts that knowledge and mother attitude is positively correlated with the implementation of exclusive breastfeeding. therefore, the activities of counseling assistance counseling methods should be as often as possible to reinforce positive behavior in terms of the creation of this exclusive breastfeeding by lactating mother. the results of or calculation showed that the mothers who received the mentoring had 9.3 times greater chance to provide exclusive breastfeeding compared with the mothers who did not receive the mentoring. this could be because after the mentoring, 3 rd trimester pregnant women already had enough knowledge and positive attitudes. the positive results of the changes in knowledge, attitudes and actions, had yet not gave influence to the practice of early initiation of breastfeeding (imd) and nutritional status, due to both groups had relatively similar nutritional status until children reached 3 months. the fact above was caused by 2 things, first the women who gave birth at health center had the risk of failure in imd, which caused by low commitment of health care in that program, especially the officers who provided services. the second factor was caused by a childbirth case. conclusion and recommendation conclussion there was a significant difference of breastfeeding practice between mothers who received mentoring using home visit method with mothers who did not receive mentoring. the infants of mothers who received mentoring have a chance/ opportunity by 9.3 times higher to breastfeed until the age of 4 months compared with the infants of mother who did not receive mentoring. zscore of infants from mothers who received mentoring has slightly higher score than those who did not received mentoring. recommendation the using of “home visit on 3 rd trimester pregnant women” mentoring model to increase the practice of exclusive breastfeeding until the baby reach age of 4 months, can be considered as an alternative program to increase the success of exclusive breastfeeding. references ambarwati, r; muis sf; dan susantini, p., 2013. pengaruh konseling laktasi intensif terhadap pemberian air susu ibu (asi) eksklusif sampai 3 bulan; jurnal gizi indonesia, 2(1). fatma s; purwita, e. dan h., 2013. pengaruh metode konseling terhadap laktasi pada ibu menyusui yang melakukan penyapihan dini di klinik erni munir kota banda aceh., banda aceh. green, l.., 1991. health promotion planning an educational and environmental approach 2nd ed., usa: mayfield publishing company. kemenkes ri, (2010). rencana aksi pembinaan gizi masyarakat 20102014,jakarta. direktorat jendral pembinaan kesehatan masyarakat kementrian kesehatan ri. kemenkes ri(2013),riset kesehatan dasar notoatmodjo, s., 2007. kesehatan masyarakat ilmu dan seni, jakarta: rineka cipta. notoatmodjo, s. (2010).metodologi penelitian kesehatan. rineka cipta. jakarta zainal, e; sutedja, e; dan madjid, t., 2014. hubungan antara pengetahuan ibu, sikap ibu , imd dan peran bidan dengan pelaksanaan asi eksklusif serta faktorfaktor yang mempengaruhi peran bidan pada imd dan asi eksklusif., ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 195 penurunan kadar kolesterol dengan terapi bekam (the effect of cupping therapy on cholesterol reduction in patients with hypercholesterolemia) zahid fikri*, nursalam*, eka misbahatul m* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257. email: zaner10@yahoo.com abstract introduction: hypercholesterolemia is a risk factor causes of death at younger ages. hypercholesterolemia may increase the risk of atherosclerosis, coronary heart disease, pancreatitis (pancreas infl ammation in organs), diabetes mellitus, thyroid disorders, liver disease and kidney disease. many patients with hypercholesterolemia using cupping therapy. cupping therapy is alternative treatment process of throwing dirty blood from the body through the skin surface. the objective of this study was to determine the effect of cupping therapy to decrease cholesterol levels in patients with hypercholesterolemia. method: design used in this study was quasy experimental design. the population is all patients with hypercholesterolemia in the health center plaza gresik. the total sample is 18 respondents, taken according to inclusion criteria. independent variable is the cupping therapy. the dependent variable was the decrease in cholesterol levels. data were collected using a questionnaire and observation of cholesterol. data were analyzed using independent t-test and paired t tests with signifi cance level α < 0.05. result: the results show that cholesterol levels in patients with hypercholesterolemia treated groups decreased majority. independent statistical analysis using t-test showed p = 0.001 and with the paired t-test p value = 0.003. discussion: this result means that there are signifi cant effects of cupping therapy on cholesterol reduction in patients with hypercholesterolemia aged 45 years and over. further research needs to be done in control diet, lifestyle and daily activities for the success of cupping therapy. keywords: hypercholesterolemia, cupping therapy pendahuluan hiperkolesterol merupakan faktor risiko kematian di usia muda. laporan badan kesehatan dunia pada tahun 2002, tercatat sebanyak 4,4 juta kematian akibat hiperkolesterol atau sebesar 7,9% dari jumlah total kematian di usia muda. hiperkolesterol ialah keadaan di mana kadar kolesterol dalam tubuh melebihi keadaan normal (oetoro, 2007). hiperkolesterol dapat meningkatkan risiko terkena aterosklerosis, penyakit jantung koroner, pankreatitis (peradangan pada organ pankreas), diabetes melitus, gangguan tiroid, penyakit hepar dan penyakit ginjal (indratni, 2009). faktor penyebab hiperkolesterol di antaranya, faktor keturunan, konsumsi makanan tinggi lemak, kurang olahraga dan kebiasaan merokok (setiati, 2009). penanganan diperlukan untuk mengendalikan kadar kolesterol darah sebagai upaya mencegah terjadinya dampak lebih lanjut dari hiperkolesterol. penanganan nonfarmakologis dapat dilakukan dengan terapi nutrisi (pembatasan jumlah kalori dan lemak, diet tinggi serat), peningkatan aktivitas fi sik (jalan cepat, lari kecil, bersepeda 3–5 kali setiap minggu, selama 30–60 menit) serta terapi alternatif (terapi bekam). bekam merupakan pengobatan alternatif religi yang berasal timur tengah. teknik pengobatan bekam adalah suatu proses membuang darah kotor dari dalam tubuh melalui permukaan kulit (jide, 2008). pemberian obat penurun lipid dilakukan jika penanganan secara nonfarmakologis gagal (adam, 2006). banyak masyarakat yang menderita hiperkolesterol menggunakan terapi bekam. fakta membuktikan separuh kematian setiap tahun di amerika disebabkan jurnal ners vol. 5 no. 2 oktober 2010: 195–200 196 oleh aterosklerosis, dan lebih dari 500.000 orang meninggal setiap tahun karena infark miokardial (atinia, 2006). world heart report tahun 2003, 29% kematian di asia tenggara disebabkan penyakit kardiovaskuler. indonesia termasuk negara yang diteliti, menunjukkan 200 dari 100.000 penduduknya meninggal karena penyakit kardiovaskuler (rachmawati, 2007). survei kesehatan rumah tangga (skrt) tahun 2004, prevalensi hiperkolesterol di indonesia pada usia 25 tahun hingga 34 tahun sebesar 9,3 persen sementara pada usia 55 tahun hingga 64 tahun sekitar 15,5 persen dengan kadar kolesterol darah lebih dari 200 mg/dl (rachmawati, 2007). angka kejadian hiperkolesterol di indonesia sebesar 13,4% untuk untuk wanita dan 11,4% untuk pria (monica, 1988). penelitian yang dilakukan monica pada tahun 1994 terjadi peningkatan untuk penderita hiperkolesterol di indonesia menjadi 16,2% untuk wanita dan 14% untuk pria (monica, 1994). angka kejadian hiperkolesterol di puskesmas alun-alun gresik sebanyak 20 orang dari 29 orang pada bulan april terakhir. pengobatan komplementer dan alternatif ( complementary and alternative medicine) termasuk bekam atau hijamah akhir-akhir ini menjadi lebih populer di masyarakat dan mendapatkan kredibilitas dalam dunia biomedis kesehatan (hill, 2003). survei menunjukkan bahwa sekitar sepertiga dari penduduk inggris (ernst, 1996) dan sedikit lebih tinggi di amerika serikat (wootton dan sparber, 2001) menggunakan bekam dalam mengatasi berbagai masalah kesehatan seperti hipertensi, sakit kepala, low back pain, rehabilitasi stroke, dan hiperkolesterol (lee, 2001). sebesar 80 persen dari kolesterol di dalam darah diproduksi oleh tubuh sendiri (siswono, 2001). kolesterol tidak dapat beredar secara mandiri dalam pembuluh darah, maka diperlukan sarana pengangkutan untuk dapat mencapai bagian-bagian tubuh yang membutuhkan. kolesterol dapat terikat pada protein yang berupa lipoprotein. kolesterol dibawa melalui aliran darah dalam dua komponen protein, yaitu lipoprotein berdensitas rendah low density lipoprotein (ldl) dan lipopretin berdensitas tinggi ( high density lipoprotein) (hdl). ukuran ldl lebih besar dari ukuran hdl, karena ldl memiliki ukuran partikel lebih besar. hal tersebut memungkinkan lebih mudah tersangkut di lapisan dinding arteri. lipoprotein ldl yang tersangkut di arteri semakin banyak maka semakin besar risiko terkena penyakit jantung koroner jika tidak diimbangi dengan kadar hdl yang tinggi (majid, 2009). herbalis ge hong (281–341 m) dalam bukunya a handbook of prescriptions for emergencies menggunakan tanduk hewan untuk membekam/mengeluarkan bisul yang disebut teknik "jiaofa". pada kurun abad ke-18 (abad ke-13 hijriyah), orang-orang di eropa menggunakan lintah (al 'alaq) sebagai alat untuk bekam (dikenal dengan istilah leech therapy) dan masih dipraktikkan sampai dengan sekarang. pengobatan bekam terbukti bermanfaat karena orang yang melakukan pengobatan dengan bekam dirangsang pada titik saraf tubuh seperti halnya pengobatan akupuntur. akupuntur yang dihasilkan hanya perangsangan, sedangkan bekam selain dirangsang juga terjadi pergerakan aliran darah. amani (2004) menyatakan bahwa mekanisme kerja terapi bekam terjadi di bawah kulit dan otot yang terdapat banyak titik saraf. titik-titik ini saling berhubungan antara organ tubuh satu dengan lainnya sehingga bekam dilakukan tidak selalu pada bagian tubuh yang sakit namun pada titik simpul saraf terkait. penelitian uji profi l lipoprotein yang dilakukan terhadap sampel darah bekam yang diambil secara acak menunjukkan kolesterol total tertinggi 492 mg/dl, terendah 141,6 mg/dl (majid, 2009). penelitian tersebut menunjukkan bahwa terapi bekam sangat efektif bagi pasien dengan kadar ldl di atas kisaran normal (majid, 2009). terapi bekam dapat menjadi solusi (terapi) alternatif pada pasien hiperkolesterol untuk menurunkan kadar kolesterol darah. penelitian praktisi bekam membuktikan bahwa sudah banyak penyakit bisa disembuhkan, salah satu di antaranya yaitu penggunaan bekam dalam menurunkan kolesterol (majid, 2009). terapi bekam telah banyak dilakukan oleh masyarakat muslim di berbagai negara, khususnya di indonesia. penerapan terapi bekam baru terbatas pada tataran keyakinan atas kebenaran sabda rasulullah saw.; belum penurunan kadar kolesterol dengan terapi bekam (zahid fikri) 197 didukung bukti-bukti ilmiah, sehingga universalitasnya terkadang masih diragukan sejumlah orang (majid, 2009). bahan dan metode desain dalam penelitian ini yaitu quasy experiment (rancangan penelitian eksperimen semu). populasi pada penelitian ini yaitu masyarakat gresik yang menderita hiperkolesterol di puskesmas alun-alun gresik dengan besar sampel 20 orang, diperoleh dengan menggunakan teknik purposive sampling yang memenuhi kriteria inklusi sebagai berikut: kadar kolesterol > 200, umur 45–60 tahun, jenis kelamin laki-laki. variabel independen dalam penelitian ini adalah yaitu bekam. instrumen yang digunakan untuk mengukur variabel independen adalah standard operasional prosedur (sop) terapi bekam. sedangkan variabel dependen adalah penurunan kadar kolesterol, instrument yang digunakan untuk mengukur adalah menggunakan alat glukotes 3 in 1 yang kemudian dicatat dalam lembar observasi. hasil p e n g a r u h t e r a p i b e k a m t e r h a d a p penurunan kadar kolesterol pada pasien hiperkolesterol, menunjukkan pada kelompok perlakuan, saat pra-test memiliki rerata kadar kolesterol 238,7 mg/dl dengan standar deviasi sebesar 24,062. pada post-test rerata kadar kolesterol responden 207,9 mg/dl dengan standar deviasi 39,232. pada kelompok kontrol saat pra-test memiliki rerata kadar kolesterol 248,6 mg/dl dengan standar deviasi 17,636. pada post-test rerata kadar kolesterol responden 264,7 mg/dl dengan standar deviasi 14,457. analisis menggunakan uji statistik independent t-test menunjukkan p = 0,001 dan dengan paired t-test didapatkan nilai p = 0,003. hasil tersebut berarti bahwa terdapat pengaruh signifikan terapi bekam terhadap penurunan kadar kolesterol pada pasien dengan hiperkolesterol umur 45 tahun ke atas. pembahasan hasil pemeriksaan kadar kolesterol pada kelompok perlakuan sebelum diberikan terapi bekam menunjukkan bahwa 6 responden memiliki kadar kolesterol tinggi dan 3 orang sangat tinggi. kelompok kontrol diketahui bahwa 3 orang memiliki kadar kolesterol tinggi dan sangat tinggi sebanyak 6 orang. rerata sebesar 248,6 mg/dl dan standar deviasi sebesar 17,636. kadar kolesterol tinggi disebabkan oleh beberapa faktor yaitu faktor yang bisa dikontrol dan faktor yang tidak bisa dikontrol. faktor yang bisa dikontrol yaitu jenis makanan atau diet sehari-hari. tubuh dapat menghasilkan kolesterol yang diperlukan di dalam tubuh yaitu oleh organ hati. data hasil juga menunjukkan paling banyak responden mengkonsumsi makanan hewani yang banyak mengandung lemak. peningkatan kadar kolesterol disebabkan oleh banyaknya asupan makanan yang berasal dari lemak karena kolesterol merupakan bagian dari lemak. makanan yang mengandung banyak lemak dapat menyebabkan kolesterol meningkat (oetoro, 2007). pengaturan pola makan berperan dalam membatasi jumlah kolesterol yang masuk ke dalam tubuh. faktor yang tidak bisa dikontrol yaitu usia. data menunjukkan bahwa lebih dari 50% responden berusia 51–55 tabel 1. distribusi kadar kolesterol kelompok perlakuan dan kontrol pada pasien dengan hiperkolesterol perlakuan delta kontrol delta pre post pre post mean 238,7 207,9 -30,78 248,6 264,7 16,11 sd 24,062 39,232 17,636 14,457 paired t-test p = 0,003 p = 0,347 independent t-test post (p = 0,001) jurnal ners vol. 5 no. 2 oktober 2010: 195–200 198 tahun. bertambahnya usia bisa menyebabkan peningkatan kadar kolesterol. kolesterol mulai meningkat sejak usia 20 tahun dan terus meningkat sampai usia 60–65 tahun. sebelum usia 50 tahun total kolesterol pada laki-laki lebih tinggi dibanding perempuan pada usia yang sama tetapi kondisi ini berbalik setelah usia 50 (elfri, 2009). hasil pemeriksaan kadar kolesterol terhadap 9 responden pada kelompok perlakuan setelah diberikan terapi bekam menunjukkan bahwa mayoritas mengalami penurunan kadar kolesterol. rerata sebesar 207,9 mg/dl dan standar deviasi 39,232 sedangkan delta sebesar –30,78. rerata penurunan kadar kolesterol pada kelompok perlakuan 30,78 mg/dl. mayoritas responden mengalami penurunan akibat efek terapi bekam. terapi bekam mengeluarkan zat toksik termasuk kolesterol yang tidak terekskresikan oleh tubuh melalui permukaan kulit dengan melukai kulit dan penghisapan. terapi bekam juga memberikan efek relaksasi dan vasodilatasi pada pembuluh darah sehingga bisa melancarkan peredaran darah. pemberian terapi bekam dilakukan pada titik-titik meridian untuk menurunkan hiperkolesterol yaitu titik khl1, un2, un3, ak1 dan ak2. pemberian terapi bekam pada titik-titik meridian yang tepat maka akan terjadi proses pada kapiler dan arteriola, peningkatan jumlah leukosit, limfosit dan sistem retikulo-endothelial, pelepasan acth, kortison, endorphin, enkefalin dan faktor humoral lain yang juga menimbulkan efek antiperadangan, penurunan serum lemak trigliserida, fosfolipida, kolesterol total khususnya kolesterol ldl, merangsang lipolisis jaringan lemak dan menormalkan kadar glukosa dalam darah (umar, 2010). p e n e l i t i a n y a n g t e l a h d i l a k u k a n sebelumnya terhadap sampel darah bekam yang diambil secara acak dari 7 probandus yang diterapi bekam, teramati kolesterol tertinggi 492 mg/dl dan terendah 141,6 mg/dl. kadar lipoprotein tertinggi 130 mg/dl, terendah 102,8 mg/dl, kadar hdl tertinggi 46 mg/dl dan terendah 20,6 mg/dl. total kolesterol 492 mg/dl jauh melebihi angka normal yang mendemonstrasikan bahwa telah terjadi akumulasi kolesterol dalam sel darah rusak yang terekstrak selama terapi bekam. tingginya level kolesterol mengakibatkan kerusakan sel karena proses fi siologis dalam sel tidak dapat berjalan optimal bahkan terjadi kemungkinan sel menjadi tidak berfungsi. k a d a r l i p o p r o t e i n l d l s e b e s a r 320 mg/dl merupakan angka yang dapat mematikan (letal) jika terdapat dalam pembuluh darah manusia secara merata. kondisi pembuluh darah semacam itu akan mengakibatkan terjadinya aterosklerosis (penyumbatan pada pembuluh darah karena timbunan plak lipoprotein ldl). jika aterosklerosis terjadi, ada dua kemungkinan yang akan terjadi atau dua kemungkinan tersebut dapat terjadi semua. kemungkinan pertama adalah terjadi gangguan fungsi jantung karena pembuluh darah koroner tertutup oleh plak (plaque). jantung tidak lagi mendapatkan suplai darah. kemungkinan kedua yaitu terjadi stroke karena pembuluh darah yang mensuplai darah pembawa nutrisi ke otak tidak dapat berfungsi dengan baik, sehingga akan terjadi kematian sel-sel otak secara masal (majid, 2009). penurunan kolesterol dapat memperlambat pembentukan plak ( fatty plaque) dan juga dapat mengurangi ukuran plak yang sudah ada. intervensi dengan memberikan terapi bekam dapat membantu mencegah terjadinya serangan jantung, stroke, dan mengurangi risiko kematian. d a t a y a n g d i p e r o l e h d a r i h a s i l pemeriksaan kadar kolesterol darah terhadap 9 responden pada kelompok kontrol 2 orang mengalami penurunan sebesar 1–3 mg/ dl dan sisanya yaitu 7 orang mengalami kenaikan sebesar 11–50 mg/dl. rerata sebesar 264,7 mg/dl dan standar deviasi 14,457 sedangkan delta sebesar 16,11. kenaikan kadar kolesterol yang terjadi pada kelompok kontrol bisa disebabkan karena jenis makanan yang banyak mengandung lemak. gambar 5.8 menunjukkan bahwa responden paling banyak mengkonsumsi makanan yang berasal dari hewan (daging, telur dan olahan susu). asupan makanan yang mengandung kolesterol bisa meningkatkan kadar kolesterol (budiana, 2008). kolesterol sebenarnya merupakan salah satu komponen lemak. lemak merupakan salah satu zat gizi yang sangat diperlukan oleh tubuh kita sebagai salah satu sumber energi yang memberikan kalori paling tinggi. penurunan kadar kolesterol dengan terapi bekam (zahid fikri) 199 kolesterol yang kita butuhkan tersebut secara normal diproduksi sendiri oleh tubuh dalam jumlah yang tepat. faktor-faktor yang bisa menyebabkan jumlah kolesterol meningkat, seperti asupan makanan yang mengandung terlalu banyak lemak jenuh yang berasal dari lemak hewani, telur dan yang disebut sebagai makanan cepat saji ( junk food). kurang berolahraga dan kebiasaan merokok juga meningkatkan risiko hiperkolesterol. kolesterol dalam tubuh yang berlebihan akan tertimbun di dalam dinding pembuluh darah dan menimbulkan suatu kondisi yang disebut aterosklerosis yaitu penyempitan atau pengerasan pembuluh darah. kolesterol begitu fundamental sebagai penyebab aterosklerosis. aterosklerosis menjadi pilar komplikasi hipertensi dan penyakit jantung akibat proses kerusakan menahun pada permukaan sisi dalam pembuluh nadi. perusakan itu salah satunya berawal dari terpaan kontaminasi zat radikal bebas yang secara bersama-sama kolesterol dan trigliserida membentuk plague. kondisi ini merupakan penyebab terjadinya penyakit jantung yang di dalamnya termasuk hipertensi dan stroke (oetoro, 2007). lemak jenuh ( saturated fats) menaikkan kadar kolesterol darah total lebih dari kolesterol makanan karena cenderung menaikkan baik kolesterol hdl baik, maupun kolesterol ldl jahat. efek totalnya negatif, penting membatasi konsumsi lemak jenis ini. lemak jenuh ditemukan terutama dari lemak hewani, seperti dalam daging, seafood, keju, susu, es krim, kulit unggas dan kuning telur. makanan nabati juga mengandung lemak jenuh tinggi, seperti kelapa, minyak kelapa, dan minyak kelapa sawit (euisry, 2008). hasil pemeriksaan kadar kolesterol sebelum dan sesudah pemberian terapi bekam pada kelompok perlakuan, hasil uji statistik dengan independent t-test menunjukkan bahwa tingkat signifi kansi p = 0,001 artinya terdapat pengaruh terapi bekam pada kelompok perlakuan terhadap penurunan kadar kolesterol pada pasien dengan hiperkolesterol umur 45 tahun ke atas, hal ini dapat dilihat dari uji statistik dengan paired t-test pada kelompok perlakuan didapatkan nilai p = 0,003 yang berarti terdapat pengaruh signifikan terapi bekam terhadap penurunan kadar kolesterol pada pasien dengan hiperkolesterol umur 45 tahun ke atas. sedangkan pada kelompok kontrol (tidak diberikan terapi bekam) menunjukkan nilai p = 0,347. penelitian yang dilakukan peneliti tentang pengaruh terapi bekam terhadap penurunan kadar kolesterol pada pasien dengan hiperkolesterol di puskesmas alunalun gresik teramati kolesterol tertinggi 292 mg/dl dan terendah 215 mg/dl. hasil menunjukkan bahwa setelah diberikan terapi bekam terjadi penurunan kadar kolesterol tertinggi yaitu sebesar 82 mg/dl dan terendah 10 mg/dl. penurunan kadar kolesterol tersebut merupakan hasil dari terapi bekam yang diberikan oleh peneliti tanpa membatasi atau mengubah jenis makanan yang dikonsumsi, pola makan, gaya hidup dan aktivitas seharihari dari responden. temuan penelitian ini secara nyata membuktikan bahwa terapi bekam mampu mengeluarkan kadar kolesterol berlebih dalam darah. keluarnya kadar kolesterol dalam darah dengan terapi bekam diharapkan dapat memperlancar aliran darah dalam pembuluh darah sehingga memperlancar suplai nutrisi dan oksigen ke seluruh tubuh. simpulan dan saran simpulan te r a p i b e k a m m e n u r u n k a n k a d a r kolesterol pada pasien hiperkolesterol umur 45 tahun ke atas. saran pasien dengan hiperkolesterol dapat m e n j a g a k a d a r k o l e s t e r o l n y a d e n g a n melakukan terapi bekam secara rutin 5 hari, 10 hari atau 15 hari sekali, ditambah dengan menjaga jenis makanan yang dikonsumsi (mengurangi makanan hewani), gaya hidup sehat dan olahraga rutin minimal 1 minggu s e k a l i . p e t u g a s k e s e h a t a n m e l a k u k a n penyuluhan dan pembagian leaflet tentang pentingnya pemeriksaan kolesterol secara rutin supaya masyarakat terutama pasien dengan hiperkolesterol termotivasi untuk melakukan kontrol pemeriksaan kadar kolesterol secara rutin baik melalui kegiatan posyandu maupun jurnal ners vol. 5 no. 2 oktober 2010: 195–200 200 pelayanan yang ada di puskesmas. puskesmas mengadakan pemeriksaan kolesterol gratis bagi masyarakat dengan kartu jamkesmas maupun asuransi kesehatan. puskesmas perlu mengadakan program terapi bekam tiap 1 bulan sekali. penelitian lebih lanjut perlu dilakukan pengontrolan dalam pola makan, gaya hidup dan aktivitas sehari-hari untuk keberhasilan terapi bekam yang diberikan. kepustakaan adam, j.m.f., 2006. buku ajar penyakit dalam jilid iii edisi 4. jakarta: departemen ilmu penyakit dalam fk ui. aiman, 2009. bekam: hasil pemeriksaan medis dan laboratorium pasien pasien yang diobati dengan metode hijamah (cupping therapy), (online), (http:// quantumbekam.wordpress.com, diakses tanggal 24 maret 2010, jam: 7.54 wib). jide, 2008. bekam al-hijamah. (online), (http://wordpress.com, diakses tanggal 9 april 2010 jam 21.15 wib). kenzie, mc., 2006. kesehatan masyarakat. suatu pengantar. jakarta: egc. khomsan, a. 2006. solusi makanan sehat. jakarta: raja grafi ndo persada, majid, b., 2009. mujarab! teknik penyembuhan penyakit dengan bekam. jakarta: pt. buku kita. mihail, 2010. biomagnetic women's suction c u p p i n g . ( o n l i n e ) , ( h t t p : / / w w w. itmonline.org/arts/cupping.htm, diakses tanggal 24 maret 2010 jam 06.48 wib). nursalam, 2008. konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika. notoatmodjo, s., 2005. metodologi penelitian kesehatan. jakarta: pt rineka cipta. oetoro, s., 2007. cara cerdas menyikapi kolesterol. (online), (http://www. medicastore.com/kolesterol/, diakses tanggal 18 april 2010 jam 01.45 wib). price, s.a., 2005. patofi siologi edisi 6. jakarta: egc. setiati, e., 2009. bahaya kolesterol, mengenal, m e n c e g a h d a n m e n a n g g u l a n g i kolesterol. yogyakarta: dokter books. siswono, 2001. bahaya kolesterol tinggi. (online), (www.gizi.net, diakses tanggal 9 april 2010 jam 21.11 wib). umar, aw., 2010. sembuh dengan satu titik. solo: al-qowam. yasin, s.a., 2008. bekam sunnah nabi dan mukjizat medis. solo: al-qowam. issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief ferry efendi, s.kep., ns., m.sc., ph.d editor: prof. angeline bushy, phd, rn, phcns-bc, faan prof. ching-min chen, rn, dns prof. eileen savage, bns., msc., p.hd. prof. josefina a. tuazon, rn, mn, drph dr. david pickles dr. farhan alshammari dr. chong mei chan, scm, bnsc, msc, phd dr. sonia reisenhofer assistant professor pei-lun hsieh prof. dr. ah. yusuf, s.kp., m.kes. yulis setiya dewi, s.kep.ns., m.ng. dr. esti yunitasari, s.kep., ns., m.kep.. dr. rizki fitryasari, s. kep., ns., m. kep. dr. ilya krisnana, s.kep., ns., m.kep. retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. quality control: gading ekapuja aurizki, s.kep., ns., m.sc technical editor: rifky octavia pradipta, s.kep., ns., m.kep. editorial address: faculty of nursing universitas airlangga campus c, mulyorejo street 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 811-3287-877 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. http://e-journal.unair.ac.id/index.php/jners acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 17 no. 1 april 2022. 1. anna kurniati, s.km, ma, ph.d. bppsdmk, ministry of health, indonesia 2. awatiful azza, s.kep., ns., m.kep. sp. kep. mat universitas muhammadiyah jember 3. dianis wulan sari, s. kep., ns., mhs., ph.d. universitas airlangga, indonesia 4. erni astutik s.k.m., m.epid. universitas airlangga, indonesia 5. lukman handoyo, s.kep., ns., m.kep. stikes widya darma husada 6. dr. mira triharini, s. kp., m. kep universitas airlangga, indonesia 7. qorinah estiningtyas sakilah adnani, sst, m.keb, ph.d. universitas padjadjaran, bandung 8. rr dian tristiana, s.kep., ns., m.kep. universitas airlangga, indonesia 9. rosnani rosnani, s. kp., m. kep., sp. mat. poltekkes kemenkes palembang 10. dr. sarni maniar berliana, m.si politeknik statistika stis 11. dr.siti nurkholifah, skm., m.kep., sp.kom poltekkes kemenkes surabaya 12. dr. yuni sufyanti arief, s. kp., m. kes. universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 table of content jurnal ners vol. 17 no. 1 april 2022 1. editorial: transforming nurses from frontline to front leaders: lesson learned from the pandemic ferry efendi 1 2. sociodemographic correlates of older adult acceptance of the covid-19 vaccine arlene supremo, sillmark bacason , alexander rex sañosa 2-7 3. the effect of basic trauma and cardiac life support training in increasing the competence of emergency room nurses anisha calista prakoeswa, fitri arofiati, nur hidayah 8-13 4. indonesians’ readiness in facing long-term covid-19 pandemic yuyun setyorini, yopi harwinanda ardesa, rendi editya darmawan 14-18 5. the association between self-control and satisfaction in life among filipino older adults laarni a. caorong 19-24 6. anemia prevention behavior in female adolescents and related factors based on theory of planned behavior: a cross-sectional study halfie zaqiyah gusti puspitasari, ni ketut alit armini, retnayu pradanie, mira triharini 25-30 7. knowledge and attitudes toward covid-19 vaccination among student nurses from saudi arabia romeo mostoles jr., richard maestrado, joyce buta, hamdan mohammad albaqawi, evalynne rondilla, salman alsaqri, sandro villareal 31-35 8. relationship between stress, anxiety, and depression with suicidal ideation in adolescents heni dwi windarwati, retno lestari, satrio agung wicaksono, mira wahyu kusumawati, niken asih laras ati, shofi khaqul ilmy, ari dwi sulaksono, desi susanti 36-41 9. the correlation between parental communication pattern, self-esteem, and moral disengagement with cyberbullying behavior in early adolescents: a cross-sectional study dian octavia, rian maylina sari, diah merdekawati, rara marisdayana, rian yuliyana 42-46 10. development assessment instrument postpartum patients with severe preeclampsiaeclampsia based on need for help and self-care models endah suprihatin , sri hardi wuryaningsih 47-54 11. factors associated with compliance in implementing health protocols to prevent covid-19 in indonesia: a cross-sectional study ambar dwi erawati 55-60 12. self-care differences in covid-19 pandemic situation ni putu wulan purnama sari, jintana artsanthia 61-66 13. pandemic in indonesian older people: the implication for sleep deprivation, loss of appetite, and psychosomatic complaints susiana nugraha, asyifa robiatul adawiyah, yuna trisuci aprilia, lisna agustina, tresna putri asih handayani, tri budi w. rahardjo 67-73 14. factors associated with the implementation of covid-19 health protocols among indonesian older adults living in rural areas: a cross-sectional study nurul maurida, prestasianita putri, wike rosalini 74-82 15. the effects of illness script method on clinical reasoning of undergraduate nursing students: a quasi-experimental study gede arya bagus arisudhana 83-88 16. the relationship between genital hygiene behaviors and genital infections among women: a systematic review afriza umami, edit paulik, regina molnár, bhisma murti 89-101 vol 6 no 1 april 2011_akreditasi 2013.indd 42 dampak psikososial akibat bencana lumpur lapindo (psychosocial impact of lapindo mud disaster) mundakir program studi s1 keperawatan fakultas ilmu kesehatan universitas muhammadiyah surabaya e-mail: cak_mudz@yahoo.co.id abstract introduction: lapindo mud disaster that occurred since 29 may 2006 is considered as the longest disaster that occurred in indonesia. this disaster has caused damage and lost of property which has been affecting the viability of the residents of the affected areas. psychosocial well being is one af the impacts of disaster. research was conducted using qualitative design with descriptive phenomenology method. the purpose required of this research was to identify the psychological impact, social impact, and hope for the settlement of problems and health services. method: number of participants were involved in this research based on the saturation of data was 7 people. this study used purposive sampling technique using the key informant. procedure of data collection techniques using depth interviews with a semi-structured form of used questions. the digital voice record was utilized to record the interviews, and verbatim transcripts made and analyzed using the methods of colaizi (1978, in daymon and dolloway, 2008). result: this study revealed 9 theme of core and 2 additional theme. nine the core theme is emotional changes, cognitive changes, coping mechanism, changes in family function, changes in social relationships, social support, hope to the problem to the government and pt lapindo, physical health service needs and psychological health. discussion: while two additional theme that is risk and growth trouble, and distres spiritual. conclusion of this research society of victim of mud of lapindo experience of impact of psikosoial and hope to government and pt lapindo settle the payment phase ii (80%) and also provide service of health of physical and also psikososial. this research recommend the importance of intervention of psikososial to society of victim and research of continuation after society of victim take possession of new residences. keywords: psychosocial impact, disaster, lapindo mud pendahuluan peristiwa meluapnya lumpur lapindo di sidoarjo sejak 29 mei 2006 merupakan fenomena yang khas, baik dari sisi penyebab, l a m a k e j a d i a n , m a u p u n p e n a n g a n a n penghentian luapan lumpur. peristiwa ini telah mengakibatkan korban jiwa manusia, kerusakan lingkungan, kerugian harta benda, dan dampak psikologis serta dampak sosiologis yang akan dialami akibat program relokasi. perpindahan penduduk ketempat baru atau relokasi ini akan membawa pengaruh yang signifikan pada proses dan struktur masyarakat, hubungan sosio-kultural, ekonomi, kekeluargaan dan pranata sosial juga akan mengalami kemunduran atau ketidakteraturan lagi bahkan sangat potensi untuk terjadi konfl ik sosial di tempat yang baru (mirdasy, 2007). masyarakat korban luapan lumpur lapindo, ditinjau dari wilayah atau areanya dikelompokkan menjadi lima, yaitu daerah bencana, daerah bencana terdampak, daerah bencana menyusul, daerah bencana langsung dan daerah bencana tidak langsung (mangoenpoerojo, 2008). berbagai bentuk respon psikologis dan sosial yang dialami masyarakat korban berbeda tergantung pada persepsi dan mekanisme koping yang digunakan. dalam konteks bencana ini, fenomena dampak psikososial akibat lumpur lapindo belum bisa dijelaskan secara mendalam terutama bagi daerah bencana terdampak yang hingga kini sebagian masyarakatnya masih bertempat tinggal di sekitar luapan lumpur lapindo. dampak psikososial akibat bencana lumpur lapindo (mundakir) 43 penelitian ini fokus pada daerah bencana terdampak yaitu desa pajarakan kecamatan jabon sidoarjo. selain desa pajarakan, yang termasuk daerah bencana terdampak adalah desa besuki barat, dan desa kedungcangkring. dari tiga desa tersebut terdapat 1.666 keluarga atau 6.094 jiwa. penentuan desa terdampak dilakukan pada bulan juli 2008 setelah tiga desa tersebut dinyatakan tidak layak huni oleh badan penanggulangan lumpur di sidoarjo (bpls). dengan penentuan status sebagai desa terdampak berarti masyarakat di desa tersebut harus meninggalkan tanah dan rumahnya karena daerah tersebut akan di jadikan penampung lumpur. penelitian ini fokus pada masalah psikososial yang terjadi pada usia dewasa (20–50 tahun) dan usia lanjut. pada tahap usia dewasa akan terjadi ”konflik” antara generativity vs stagnation. generativity adalah kepedulian yang tinggi, lebih luas daripada intimacy. perkembangan yang baik pada fase ini akan memunculkan sikap responsif, peduli dan partisipatif terhadap kebutuhan orang lain atau lingkungan. sedangkan stagnation merupakan terbatasnya atau tidak adanya kepedulian kepada orang lain. p e r k e m b a n g a n p s i k o s o s i a l p a d a usia lanjut menurut erikson masuk tahap integeritas diri versus putus asa (ego integrity versus despair). perkembangan periode ini dimulai pada usia 45/60 tahun ketika mulai meninggalkan aktivitas di masyarakat. perkembangan yang baik pada masa ini diwujudkan dengan integeritas diri yang baik, lebih matang, dan tidak takut mati karena telah melalui kehidupan dengan baik. namun bila hidup yang dilalui tidak semestinya, maka akan muncul perasaan putus asa, penyesalan dan marah dengan dirinya sendiri karena merasa gagal menjalani hidup. kondisi masyarakat korban saat ini memang tidak dalam ancaman kematian, namun perubahan yang dialami akibat lumpur dan ketidakpastian masa depan menyebabkan rentan terhadap masalah kesehatan, baik masalah kesehatan fi sik, psikis, sosial, budaya dan spiritual. berdasarkan pertimbangan dan realita yang terjadi pada masyarakat korban lumpur lapindo, maka peneliti melakukan penelitian dengan desain kualitatif fenomenologi deskriptif dengan alasan dampak psikososial merupakan pengalaman hidup yang sifatnya subyektif, masing-masing individu berbeda, dan tindakan masing-masing individu hanya dapat dipahami melalui pemahaman terhadap dunia kehidupan individu masing-masing. penelitian ini secara umum bertujuan untuk mengidentifi kasi dampak psikososial akibat bencana lumpur lapindo di desa pajarakan kecamatan jabon sidoarjo. sementara secara khusus bertujuan untuk mengidentifi kasi bentuk-bentuk respons psikologis yang dialami anggota masyarakat akibat bencana lumpur lapindo; bentuk-bentuk respon sosial yang dialami anggota masyarakat akibat bencana lumpur lapindo; dampak psikososial yang dialami anggota masyarakat akibat bencana lumpur lapindo; harapan masyarakat korban terhadap penyelesaian masalah psikososial akibat bencana lumpur lapindo, harapan masyarakat terhadap peran tenaga kesehatan (khususnya perawat) baik dari instansi pemerintah maupun swasta (lsm, ormas, dan sebagainya) untuk mengatasi masalah kesehatan akibat bencana lumpur lapindo. hasil penelitian diharapkan menjadi salah satu bukti ilmiah tentang dampak psikososial masyarakat korban lumpur lapindo sebagai masukan untuk penyelesaian masalah secara tepat, sehingga perlu mendapatkan perhatian dan penyelesaian masalah secara tepat supaya tidak menimbulkan dampak yang lebih besar. bahan dan metode p e n e l i t i a n i n i d i l a k u k a n d e n g a n menggunakan desain penelitian kualitatif dengan metode fenomenologi deskriptif. populasi yang menurut sugiono (2007) dalam penelitian kualitatif diistilahkan sebagai situasi sosial (social situation) dalam penelitian ini adalah masyarakat desa pajarakan yang mengalami dampak psikososial akibat lumpur lapindo. sampel dalam penelitian ini adalah anggota masyarakat desa pajarakan yang mengalami masalah psikososial. proses seleksi sampel dilakukan dengan teknik purposive sampling, yaitu teknik pengambilan sampel jurnal ners vol. 6 no. 1 april 2011: 42–49 44 atau sumber data dengan pertimbangan tertentu sebagaimana yang diinginkan peneliti, dengan kriteria inklusi sebagai bisa membaca dan menulis, berusia antara 20 tahun sampai dengan 65 tahun, sedang mengalami masalah psikososial, yang dibuktikan dengan penilaian status kejiwaan, dengan skor penilaian kuesioner < 60, mampu berkomunikasi menggunakan bahasa indonesia atau bahasa jawa dengan baik, bersedia menjadi partisipan. partisipan dalam penelitian ini telah memenuhi kriteria inklusi. jumlah partisipan dalam penelitian ini adalah 7 orang yang terdiri dari 6 laki-laki dan 1 perempuan. hasil penilaian berdasarkan kuesioner status kesehatan jiwa yang diberikan kepada masingmasing partisipan (p) diperoleh skor p1 = 46; p2 = 52; p3 =55; p4 = 56; p5 = 41; p6 = 58; dan p7=56. berdasarkan hasil skor kuesioner tersebut berarti semua partisipan memenuhi syarat sebagai partisipan dalam penelitian ini. te k n i k p e n g u m p u l a n d a t a y a n g digunakan adalah triangulasi (gabungan) dari beberapa teknik, yaitu wawancara mendalam (indepth interview) dan kuesioner. teknik wawancara mendalam (indepth interview) dilakukan dengan cara mengajukan pertanyaan terbuka (open – ended interview), yaitu memberikan kesempatan kepada partisipan untuk menjelaskan sepenuhnya pengalaman mereka tentang fenomena yang sedang diteliti (speziale dan carpenter, 2003), yaitu pengalaman partisipan selama mengalami korban lumpur lapindo. pertanyaan dalam wawancara disusun dan dikembangkan berdasarkan tujuan penelitian, yaitu bentuk-bentuk respons atau dampak psikis dan sosial yang dialami masyarakat korban, serta harapannya terhadap masalah psikososial yang dialami selama ini. disamping wawancara mendalam, alat pengumpulan data yang digunakan adalah kuesioner. peneliti menggunakan kuesioner untuk mengidentifikasi masalah-masalah kesehatan mental yang dialami masyarakat korban lumpur lapindo. daftar pertanyaan dalam kuesioner dimodifi kasi dari instrumen yang dikembangkan oleh smit (2005), mengenai gejala-gejala psikososial hopkins dan dsm iv. jumlah pertanyaan dalam kuesioner 30 soal dalam bentuk skala likert. untuk jawaban selalu akan diberi skor 1, hampir selalu skor 2, kadangkadang skor 3, dan tidak pernah skor 4. penilain status kesehatan mental ditentukan dengan jumlah skor yang diperoleh. jika mendapat skor antara 91–120 berarti mempunyai kesehatan mental yang sangat baik. skor antara 61–90 tergolong baik atau rata-rata. skor antar 30–60 berarti buruk dan skor antar 0–30 adalah sangat buruk. teknik analisis data yang digunakan dalam penelitian ini yaitu menggunakan 7 (tujuh) langkah-langkah dari colaizi (1978), dalam daymon dan dolloway (2008) sebagai berikut. pertama, membuat transkrip data untuk mengidentifi kasi pernyataan-pernyataan yang bermakna dari partisipan. kedua, transkrip yang telah dibuat, dibaca berkali-kali dan fokuskan pada kalimat-kalimat dan frasefrase yang secara langsung terkait dengan masalah yang diteliti untuk dihubungkan dengan tujuan khusus penelitian yang ingin didapatkan. ketiga, merumuskan makna. keempat, mengulangi proses yang sudah dilakukan untuk masing-masing wawancara atau catatan tertulis, kemudian kelompokkan semua makna yang berbeda-beda itu ke dalam makna tema-tema tertentu atau sub-sub tema. kelima, sediakan uraian analitis yang terperinci menyangkut perasaan-perasaan dan perspektif partisipan yang terdapat dalam tema-tema. keenam, merumuskan uraian mendalam menyangkut keseluruhan fenomena yang diteliti, dan mengidentifi kasi struktur pokok atau esensi dari bentuk-bentuk yang diteliti (dalam hal ini adalah dampak psikososial yang dialami anggota keluarga akibat lumpur lapindo). ketujuh, yang merupakan langkah terakhir adalah memberi check atau membawa kembali hasil temuantemuan peneliti kepada partisipan. setelah dianalisis, data dipaparkan dalam bentuk hasil penelitian dan pembahasan. hasil hasil penelitian merupakan deskripsi dari data yang diperoleh dengan tujuan untuk mendapatkan pemahaman yang mendalam dampak psikososial akibat bencana lumpur lapindo (mundakir) 45 dan bermakna secara psikologis dan sosial (psikososial) dari partisipan sebagai masyarakat korban bencana lumpur lapindo. hasil penelitian ini disajikan dua bagian. bagian pertama menyajikan uraian tentang karakteristik partisipan, dan bagian kedua menyajikan hasil analisis setiap tema yang muncul dari perspektif partisipan tentang dampak psikososial yang dialami setelah terjadi bencana lumpur lapindo. peneliti menghentikan pengumpulan data hanya pada 7 partisipan di atas karena data atau informasi yang peneliti dapatkan sudah mencapai saturasi data atau sudah memperoleh data yang diinginkan peneliti dan jawaban partisipan sudah tidak berkembang, dengan kata lain data yang disampaikan partisipan satu dengan yang lainnya mengalami kesamaan. bagian kedua mengenai hasil análisis tema. penelitian ini menghasilkan 9 tema inti dan 2 tema tambahan. tema inti berorientasi pada tujuan khusus penelitian. pada tujuan khusus pertama tentang dampak psikologis, ditemukan tiga tema yaitu tema 1 perubahan emosi, tema 2 perubahan kognitif, tema 3 mekanisme koping. tujuan khusus kedua mengenai dampak sosial juga ditemukan tiga tema yaitu tema 4 perubahan fungsi keluarga, tema 5 perubahan hubungan sosial kemasyarakatan, tema 6 dukungan sosial. tujuan khusus ketiga mengenai harapan penyelesaian masalah ditemukan satu tema yaitu tema 7 harapan penyelesaian masalah kepada pemerintah maupun pt lapindo, sedangkan tujuan khusus keempat tentang kebutuhan pelayanan kesehatan bagi masyarakat korban ditemukan dua tema yaitu tema 8 kebutuhan pelayanan kesehatan fi sik, tema 9 kebutuhan pelayanan kesehatan psikososial. di samping sembilan tema inti yang mengacu pada tujuan khusus, dalam penelitian ini juga ditemukan dua tema tambahan yaitu tema tambahan 1 risiko dan gangguan perkembangan; tema tambahan 2 distres spiritual. pembahasan g a m b a r a n d a m p a k p s i k o s o s i a l masyarakat korban lumpur lapindo, di jelaskan dalam bentuk tema-tema yang diperoleh dari hasil analisis karakteristik partisipan dan hasil wawancara terhadap partisipan. tema 1 yaitu perubahan emosi, perubahan emosi dalam penelitian ini ditunjukkan oleh adanya gejala depresi, kecemasan, kemarahan, dan harga diri rendah. depresi yang dialami partisipan merupakan salah satu dampak psikologis yang disebabkan karena adanya kehilangan. respon spikologis yang terungkap dari mayoritas masyarakat korban bencana lumpur lapindo saat ini adalah marah, depresi dan menerima (acceptance). hal ini karena penelitian dilakukan setelah hampir tiga tahun masyarakat korban menjalani bencana, sementara durasi/waktu memengaruhi respon masyarakat korban terhadap bencana yang dialami, sebagaimana temuan penelitian chou (2007) tentang dampak pascabencana gempa bumi chi-chi di yu chi taiwan. dari penelitian tersebut ditemukan prevalensi ptsd menurun dari 8,3% pada 6 bulan sampai 4,2% pada 3 tahun setelah gempa bumi. di samping depresi, masyarakat korban juga mengalami kecemasan. perasaan cemas tabel 1. karakteristik partisipan masyarakat korban lumpur lapindo di desa pajarakan jabon sidoarjo tahun 2009 karakteritik p1 p2 p3 p4 p5 p6 p7 usia 63 59 47 38 46 30 34 th jenis kelamin lk lk lk lk lk pr lk pendidikan sr sr smp sma sr sma smp agama islam islam islam islam islam islam islam pekerjaan petani penjahit dagang satpam buruh dagang dagang jumlah anak 3 3 2 3 2 3 jurnal ners vol. 6 no. 1 april 2011: 42–49 46 muncul terutama pada malam hari, turun hujan dan jebolnya tanggul untuk penampungan l um pur. situasi ter sebut menimbulkan kecemasan karena masyarakat korban merasa terancam dan trauma terhadap kejadian yang pernah dialami yaitu mengalirnya lumpur ke rumah mereka pada saat mereka sedang tidur nyenyak. menurut tomoko, o (2009) salah satu penyebab timbulnya reaksi trauma adalah adanya ancaman terhadap keselamatan dan terjadi secara mendadak. selain depresi dan kecemasan, respon marah juga terjadi pada masyarakat korban bencana lumpur lapindo. temuan penelitian ini menunjukkan pernyataan marah sering dilakukan pada awal terjadinya bencana dan sebelum keputusan presiden no. 48 tahun 2008 tentang dimasukkannya desa pajarakan sebagai area terdampak yang akan mendapatkan ganti rugi dari pemerintah, dan kemarahan setelah keputusan presiden karena uang ganti rugi tahap ii (80%) tidak kunjung dibayar. bentuk perubahan emosi lain yang terjadi pada masyarakat korban adalah timbulnya perasaan rendah diri. perasaan ini berhubungan dengan kondisi perubahan kebiasaan seharihari yang mereka alami seperti memberi suguhan/hidangan kalau ada tamu. hal ini selaras dengan konsep dasar pemeliharaan kesehatan jiwa bagi korban bencana yang dilansir oleh tomoko (2009), dari hyogo care centre menyebutkan sebagian besar reaksi emosional masyarakat korban bencana berasal dari masalah kehidupan sehari-hari yang ditimbulkan oleh bencana. tema 2 adalah perubahan kognitif, temuan penelitian ini menyatakan adanya perubahan kognitif yang terjadi yaitu penurunan daya pikir. adanya perubahan kognitif pada masyarakat korban seperti tidak mampu berpikir jernih, menjadi ragu-ragu karena tidak ada kepastian, dan pikiran mereka terpecahpecah dengan persoalan-persoalan lain yang mereka hadapi ini sesuai dengan temuan norris, fh (2008) bahwa salah satu dampak dari bencana adalah terjadinya perubahan kognitif dengan ciri pikiran kacau, salah persepsi, menurunnya kemampuan untuk mengambil keputusan, menurunnya daya konsentrasi dan daya ingat, mengingat hal-hal yang tidak menyenangkan, dan menyalahkan diri sendiri. tema 3 mengenai mekanisme koping temuan dalam penelitian ini, mekanisme koping yang digunakan dapat dikategorikan mekanisme adapatif dan maladaptif atau tidak efektif. mekanisme koping yang adapatif di antaranya berdo’a (pendekatan spiritual), memendam perasaan (represi) dan mengalihkan perhatian agar dapat melupakan masalah yang terjadi, atau dengan meminta bantuan saudara. sementara yang tidak efektif seperti menghujat, mengancam melakukan demonstrasi terus, membuntu atau memblokir jalan, dan melampiaskan emosi kepada anakistrinya meskipun cara maladaptif ini hanya bersifat sementara. tema 4 adalah perubahan fungsi keluarga, temuan dalam penelitian ini, masyarakat korban mengalami perubahan fungsi keluarga, yaitu perubahan pada fungsi sosial dan fungsi ekonomi. fungsi sosial terkait dengan hubungan kekeluargaan yang merenggang. kondisi ini berbeda dengan hasil penelitian garhapung, a (2006) pada korban bencana tsunami di pangandaran jawa barat yang menyebutkan bahwa setelah terjadi bencana, banyak dukungan yang diperoleh dari keluarga, teman, tetangga, rekan bisnis, masyarakat dan juga pemerintah. hubungan mereka semakin erat karena merasa mengalami ”penderitaan” yang sama. sementara perubahan pada fungsi ekonomi, terjadi karena orang tua tidak lagi mempunyai penghasilan atau pendapatan. padahal pendapatan atau penghasilan menentukan status ekonomi keluarga (stanhope dan lancaster, 1996). status ekonomi yang rendah merupakan gambaran kemiskinan dan ini sangat terkait dengan status kesehatan (stone, mcquire dan eigsti, 2002). hal ini berarti perubahan atau masalah fungsi ekonomi dapat menyebabkan masalah fungsi keluarga yang lain misalnya fungsi perawatan kesehatan. tema 5 adalah perubahan hubungan sosial kemasyarakatan. hasil penelitian menunjukkan solidaritas masyarakat korban melemah dan kepedulian sosial menurun. menurut mirdasy (2007), dampak disintegrasi sosial, tercerai-berainya masyarakat, dan dampak psikososial akibat bencana lumpur lapindo (mundakir) 47 hancurnya budaya pasca-terjadinya bencana sangatlah serius, meskipun tidak kasat mata dan tidak bisa dikuantifikasi. selain itu, rusaknya komunitas, hancurnya struktur tatanan masyarakat, tercerai-berainya jaringan formal dan informal, perkumpulan-perkumpulan, merupakan kehilangan modal sosial yang sangat mahal. tema 6 yaitu dukungan sosial. hasil penelitian menunjukkan masyarakat korban mengakui besarnya pengaruh dukungan yang diberikan oleh istri atau suami mereka dan dukungan dari tokoh agama maupun tokoh masyarakat. hasil penelitian stuart dan laraia (2005) menjelaskan bahwa dengan adanya dukungan sosial, penderita gangguan arteri koronaria mengalami kematian setelah lebih dari 5 tahun sebanyak 50% dibanding yang tidak mempunyai dukungan sosial yang hanya 20%. dengan demikian faktor dukungan sosial tidak hanya dapat memengaruhi aspek psikologis saja namun juga aspek biologis yaitu meningkatkan fungsi sistem imun dan proses biologi lain dalam tubuh. tema 7 adalah harapan penyelesaian masalah kepada pemerintah maupun pt lapindo. masyarakat korban sangat berharap agar masalah yang mereka alami selama ini segera terselesaikan. harapan besar itu ditujukan kepada pemerintah dan pt lapindo. kepada pemerintah agar bersikap tegas terhadap kebijakan yang sudah diputuskan sebagaimana yang tercantum dalam perpres no. 48 tahun 2008, dan adanya perhatian kepada anak-anak terutama mengenai perubahan psikologis yang terjadi pada anak, serta perlunya relokasi yang melibatkan semua warga masyarakat untuk tinggal bersama dalam satu lokasi. sementara kepada pt lapindo masyarakat berharap anggota masyarakat dilibatkan dalam proyek pembangunan tanggul. tema 8 adalah kebutuhan pelayanan kesehatan fisik. temuan penelitian ini menunjukkan kebutuhan masyarakat terhadap pelayanan kesehatan meliputi kebutuhan udara sehat, kebutuhan air sehat, dan kebutuhan tindakan medis. kebutuhan masyarakat terhadap layanan kesehatan ini sesuai dengan penelitian domino, dkk. (2003) kepada masyarakat korban hurricane yang mengalami perubahan besar dalam pola perawatan dibandingkan pada awal krisis. domino juga menjelaskan bahwa bencana dapat meningkatkan insiden penyakit dan cidera akut serta tingkat distres sehingga meningkatkan kebutuhan layanan kesehatan. tema 9 adalah kebutuhan pelayanan kesehatan psikososial. temuan penelitian menunjukkan bahwa partisipan menginginkan adanya pihak yang menilai status kesehatan jiwa terutama pada anak dan menghendaki adanya penyuluhan tentang cara menghadapi perubahan perilaku anak maupun remaja. selaras dengan temuan penelitian ini, domino, dkk. (2003) menjelaskan bahwa setelah australia mengalami banjir, prosentasi orang berkonsultasi kepada tenaga kesehatan meningkat tiga kali lebih tinggi dibanding pada kondisi sebelum bencana. temuan tersebut menunjukkan bahwa pascabencana masyarakat korban mengalami berbagai masalah kesehatan yang perlu perhatian dan pertolongan. sebagaimana rekomendasi dari zelller, jl (2008) bahwa anak-anak yang mengalami trauma pascabencana harus menjadi prioritas kesehatan masyarakat. p e n e l i t i a n d e n v e r, d k k . ( 2 0 0 6 ) menyebutkan salah satu kelompok yang mempunyai kebutuhan paling spesifi k yakni para remaja. tema tambahan 1 yaitu risiko dan terjadinya gangguan perkembangan temuan penelitian ini menunjukkan telah terjadi perubahan perilaku anak dan perilaku remaja. perubahan perilaku anak diatas sesuai dengan temuan penelitian williams, r (2007) tentang dampak psikososial yang dialami anak-anak tk pascaserangan wtc. secara langsung atau tidak anak-anak tersebut mengalami trauma yang menyebabkan masalah perilaku klinis. selain williams, zeller, jl (2008) juga meneliti tentang dampak masalah perilaku anak setelah serangan wtc, sehingga zeller mengusulkan perlunya memprioritaskan pelayanan kesehatan masyarakat terutama pada anak tk. penelitian lain yang dilakukan johson (2008) terhadap korban banjir katrina di as ditemukan sembilan juta anak-anak yang kekurangan layanan kesehatan dan anak kelas empat sd yang tidak bisa membaca mencapai 60–0%. masalah perilaku remaja korban lumpur jurnal ners vol. 6 no. 1 april 2011: 42–49 48 lapindo terjadi akibat tidak adanya aktivitas positif dan kurangnya perhatian atau role model dari orang tua. kurangnya aktivitas positif akan memperkuat perasaan atau perilaku negatif dan memperlemah perilaku positif (tomoko, 2009). sementara itu temuan parslow, dkk. (2006) menunjukkan bahwa pengalaman trauma dapat memicu peningkatan penggunaan tembakau pada remaja dan mengakibatkan timbulnya gejala ptsd. tema tambahan 2 distres spiritual temuan penelitian ini menggambarkan adanya penurunan aktivitas spiritual yang dialami masyarakat korban. menurut hpna (2005) distres spiritual didefi nisikan sebagai suatu gangguan kepercayaan atau sistem nilai yang dapat memengaruhi keseluruhan hidup seseorang. sedangkan nanda (2007) mendefinisikan distres spiritual adalah kelemahan kemampuan untuk mengalami dan mengintegrasikan maksud atau makna dan tujuan dalam hidup melalui hubungan dengan diri, orang lain, seni, musik, literatur, alam, dan atau kekuatan lebih besar dibanding diri sendiri. simpulan dan saran simpulan masyarakat korban bencana lumpur lapindo mengalami dampak psikologis seperti perubahan emosi, dan perubahan kognitif. dampak psikologis ini dipengaruhi oleh durasi terjadinya bencana, kualitas dan kuantitas kehilangan yang dialami, serta faktor internal individu korban dalam menggunakan mekanisme koping yang digunakan serta dukungan sosial yang ada. dampak sosial yang terjadi pada masyarakat korban antara lain adanya perubahan fungsi keluarga, perubahan hubungan sosial masyarakat, risiko gangguan perkembangan anak dan remaja, penurunan aktivitas spiritual, kehilangan mata pencaharian, dan dukungan social yang ada. hal ini merupakan kerugian modal sosial yang dialami masyarakat korban khususnya dapat disebabkan oleh adanya perubahan emosi atau sebaliknya. h a r a p a n m a s y a r a k a t u n t u k terselesaikannya masalah akibat bencana lumpur lapindo merupakan hak masyarakat korban untuk mendapatkan kehidupan layak dan sejahtera sebagaimana yang diatur dalam uud 1945 dan deklarasi pbb tentang hak asasi manusia. dengan demikian, kebutuhan masyarakat korban akan layanan kesehatan baik layanan kesehatan fi sik maupun psikososial merupakan kebutuhan yang umum dibutuhkan oleh masyarakat paska mengalami korban, dan selayaknya dipenuhi oleh pemerintah maupun pt lapindo. saran institusi pendidikan keperawatan untuk mengembangkan pengajaran tentang masalah kesehatan jiwa masyarakat terutama bagi masyarakat yang sedang atau pascamengalami bencana, dengan cara menjadikan wilayah masyarakat yang sedang atau pascabencana sebagai wilayah praktik keperawatan kesehatan jiwa. p e l a y a n a n k e p e r a w a t a n s u p a y a mengembangan instrumen pengkajian dan intervensi kepada masyarakat pascabencana untuk menghindari atau mengurangi perubahan psikologis dan sosial yang terjadi. di samping itu perlu adanya standart asuhan keperawatan pada klien korban bencana, baik pada klien individu, keluarga, kelompok, maupun masyarakat. organisasi profesi (ppni), supaya ada penetapan regulasi yang jelas, legal dan dapat diterima oleh semua pihak berdasarkan standar kompetensi yang dimiliki perawat termasuk kompetensi perawat bencana, serta perlunya perlindungan hukum kepada perawat bencana. sedangkan untuk penelitian keperawatan, perlu adanya penelitian dampak psikososial masyarakat korban setelah menempati tempat tinggal baru (relokasi), penelitian dampak psikososial bagi anak-anak dengan menggunakan pendekatan lain, misalnya etnografi , grounded theory, riset tindakan dan sebagainya, atau dengan menggunakan desain kuantitatif. pemerintah kabupaten sidoarjo, perlu memberikan perhatian serius kepada masyarakat korban, terutama masalah kesehatan baik masalah kesehatan fi sik maupun kesehatan jiwa, melalui tenaga keperawatan dengan cara dampak psikososial akibat bencana lumpur lapindo (mundakir) 49 melibatkan dan memberi kewenangan untuk memberikan layanan keperawatan kesehatan jiwa. daftar pustaka chou, f.h., et al., 2007. post-traumatic stress disorders risk factors; research in the area of post-traumatic stress disorders risk factors. mental health weekly digest. atlanta: aug 6, 2007, (online), (http://proquest.umi.com/pqdweb?did =1313357761&sid=9&fmt=3&clienti d=45625&rqt=309&vname=pqd. diakses tanggal 16 juni 2009). daymon, c., dan holloway, i., 2008. riset kualitatif dalam public relations & marketing communications. yogyakarta: pt benteng pustaka. domino, m., et al., 2003. disasters and the public health safety net: hurricane floyd hits the north carolina medicaid program. american journal of public health. 93(7), (online), (http://proquest. umi.com/pqdweb?did=415740721&sid =7&fmt=4&clientid=45625&rqt=3 09&vname=pqd., diakses tanggal 16 juni 2009). gaharpung, a., 2007. studi fenomenologi tentang respons psikososial kehilangan dan berkabung pada individu yang mengalami gempa bumi dan tsunami di pangandaran kabupaten ciamis. tesis. tidak dipublikasikan. dwiputri, r., 2007. sigmund freud: mekanisme pertahanan diri, (online), (http://www. bahas.multiply.com., diakses tanggal 13 juli 2009). kozier, b., dkk., 2004. fundamentals of nursing; concepts, process, and practice. seventh edition. new jersey: prentice-hall. kubler-ross, e., 1969. on death and dying. new york: macmillan. hpna, 2005. spiritual distress, (online), (http://www.hpna.org/patienteducation. asp. diakses tanggal 13 juli 2009). mangoenpoerojo, r.b., 2008. kerugian bangsa akibat lumpur lapindo. bandung: visibuku infi indonesia. mccubbin, h.i., dan thompson, a.i., 1991. family assessment inventories for research and practice. madison: university of wisconsin. mirdasy, 2007. bernafas dengan lumpur. yogyakarta: m.i press. stuart, g.w., dan laraia, m.t., 2005. principles and practice of psychiatric nursing. 7th edition. st louis: mosby. stanhope dan lancaster, 2002. commuinity health nursing. promoting health agregates, families, and individuals, st. louis: mosby. s t o n e , m a r q u i r e , d a n e i g s t i , 2 0 0 2 . comprehensive community health n u r s i n g f a m i l y, a g g re g a t e , a n d community practice, st. louis: mosby tomoko, o., 2009. e-learning disaster. jakarta: fik ui. wi l l i a m s , r . , 2 0 0 7 . t h e p s y c h o s o c i a l consequences for children of mass violence, terrorism and. international review of psychiatry. 19(3), (online), (http://proquest.umi.com/pqdweb?did =1326177211&sid=5&fmt=2&clienti d=45625&rqt=309&vname=pqd., diakses pada tanggal 16 mei 2009) zeller, j.l., 2008. impact of conjoined exposure to the world trade center attacks and to other traumatic events on the behavioral problems of preschool children. jama, 299(14), (online), (http://proquest.umi.com/pqdweb?did =1469376171&sid=3&fmt=2&clienti d=45625&rqt=309&vname=pqd., diakses pada tanggal 16 mei 2009) 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 pengaruh peer group support terhadap peningkatan pengetahuan, sikap, kepatuhan minum obat dan kualitas hidup klien tuberkulosis paru 142 jigsaw puzzle improve fine motor abilities of upper extremities in post-stroke ischemic clients kusnanto, eska dwi prajayanti, harmayetty faculty of nursing, universitas airlangga, kampus c mulyorejo surabaya, 60115 email: eska_ners2012@yahoo.com abstract introduction: ischemic stroke is a disease caused by focal cerebral ischemia, where is a decline in blood flow that needed for neuronal metabolism, leading to neurologic deficit include motor deficit such as fine motor skills impairment. therapy of fine motor skills disorders is to improve motor function, prevent contractures and complications. these study aimed to identify the effect of playing jigsaw puzzle on muscle strength, extensive motion, and upper extremity fine motor skills in patients with ischemic stroke at dr. moewardi hospital, surakarta. methods: experimental quasi pre-posttest one group control. the number of samples were 34 respondents selected using purposive sampling technique. the samples were divided into intervention and control groups. the intervention group was 17 respondents who were given standard treatment hospital and played jigsaw puzzle 2 times a day for six days. control group is one respondent given by hospital standard therapy without given additional jigsaw puzzle game. evaluation of these research is done on the first and seventh day for those groups result: the results showed that muscle strength, the range of joint motion and fine motor skills of upper extremities increased (p = 0.001) significantly after being given the jigsaw puzzle games. these means playing jigsaw puzzle increase muscle strength, the range of joint motion and upper extremity fine motor skill of ischemic stroke patients. discuss and conclusion: jigsaw puzzle game administration as additional rehabilitation therapy in upper extremity fine motor to minimize the occurrence of contractures and motor disorders in patients with ischemic stroke. jigsaw puzzle game therapy capable of creating repetitive motion as a key of neurological rehabilitation in ischemic stroke. this study recommends using jigsaw puzzle game as one of intervention in the nursing care of ischemic stroke patients. keywords: ischemic stroke, upper extremity fine motor, jigsaw puzzle introduction stroke is a disease that caused by the presence of ischemia (inadequate blood flow) or bleeding in the brain that leads to neurological changes, the death of brain cells, and function loss in movement, sensations, and emotions (black and hawks 2005; lewis et al. 2007). stroke is leading cause of disability in both developed and developing countries (american hearth association, 2010). a residual symptom of ischemic stroke is a blockage in the middle of cerebral artery lead to extremity weakness, especially fingers (ringleb 2011; kochanek et al. 2011). the long-term weakness of the fingers may result in muscle strength loss, decreased the range of motion and function loss of the movement, leading to interruption of fingers fine motor skills (american stroke association (asa) 2013; warlow, et al., 2007, eng & harris, 2009). about 55% of ischemic stroke clients experienced residual symptoms such as hand weakness, especially fingers (ward, et al. 2015; kochanek et al. 2011). treatment of disability in upper extremity is more difficult than lower extremity. thus, seriously impact on rehabilitation progress in stroke. then, proper treatment is needed to prevent permanent disability especially during the acute phase of stroke 48 hours post-stroke where the appropriate treatment can affect 33% of patients recovery within three months (foley, et al., 2013; ikawati 2010). the decline in muscle cells function and impulse transmission impairment in motor neuron leads to inaccuracy and fingers coordination impairment in integrating the function of muscles, bones, and nerves. disorders of the fingers coordination are called fine motor disorders (american stroke association, 2013). appropriate stimulation was given by rehabilitation with repetitive motions therapy (neistadt 1986). repetitive exercises can be done using a jigsaw puzzle games. jigsaw puzzle game is a puzzle game that consists of gripping, holding and manipulating objects using concentration and coordination between eyes and hands (neistadt 1986; foley dl, morley ki, madden paf, et al. 2010). major depression and the metabolic syndrome.twin research and human genetic; 13(4): 347-58. howed that using the puzzle as treatment can stimulate the motor nerves in brain injury and giving rise the jurnal ners vol. 12 no. 1 april 2017: 142-150 143 potential action as initial process of muscle contraction. preliminary studies conducted in january 2016 in dr. moewardi hospital, surakarta. the data showed that 5 of 6 clients suffered from fine motor skills impairment such as not being able to hold a cup, grasping the ball and adjusting buttons. the assessment using the modified motor assessment scale (mmas). measurements of fingers muscle strength using hand dynamometer on six clients of ischemic stroke who were treated for more than six days in dr. moewardi hospital. the score obtained from 5 female clients were below 18.50 to 24.00, while one female client has score below 18.00. the range of motion measurements of 6 clients is done using goniometer. the result showed that five clients suffered from finger extension where score obtained is below 300. physical rehabilitation is an exercise used range of motion (rom) that focuses on muscle strength. exercise to stimulate fingers strength have not done. thus six clients suffered in fine motor impairment. a fine motor impairment that often occurs in ischemic stroke needs proper nursing interventions to minimize the client's dependency in performing daily activities such as eating, drinking and dressing while undergoing treatment at the hospital. these study wants to prove the effect of jigsaw puzzles game to improve fine motor of upper extremity on post-ischemic stroke clients in dr. moewardi hospital, surakarta. methods the design of this research is quasiexperiment using the pre-post test in the control group. this design is used to compare the results of the intervention of two groups: intervention and comparison groups. the population is all 58 clients ischemic stroke who were treated in stroke care unit in dr. moewardi hospital, surakarta. the sample used is 17 of the treatment group and 17 of the control group. the research was conduct for a month. the independent variable is playing jigsaw puzzle. the dependent variable is muscle strength, extensive motion, upper extremity fine motor skills. research instruments are using hand grip dynamometer to measure muscle strength, goniometer for a range of joint motion and modified motor assessment scale (mmas) for measuring upper extremity fine motor. result table 1. results of respondent equality analysis based on the frequency of attacks showed that between intervention and control groups had an equal frequency of attacks. seen from the results of the statistical test with pvalue 0.366 (alpha = 0.05) that there is no significant differences of group respondents (equivalent) based on the frequency of attacks. respondent equality analysis results based on age in table 1 shows that between treatment and control group had an equal age. seen from the results of the statistical test with p-value 0.155 (alpha = 0.05) that there is no significant differences (equivalent) in group respondents by age. respondent equality analysis results based on the affected extremity in table 1 showed that between intervention and control groups had equal affected extremity. seen from the results of the statistical test with pvalue 0.366 (alpha = 0.05) that there is no significant differences (equivalent) in group respondents based on the affected stroke extremity. table 2 showed that mean difference in fingers muscle strength after jigsaw puzzle games for six days in men of intervention group is 7.217 with standard deviation 1.790, and mean difference of comparison group is 1,550 with standard deviation 1.693. statistical test by using independent t-test obtained pvalue 0.001 and alpha 0.05, means that there is a significant effect of jigsaw puzzle games against the mean difference in fingers muscle strength of intervention and comparison groups in the male. the mean difference in female fingers muscle strength after jigsaw puzzle game of intervention group 3.600 and standard deviation 0.761 while meaning the difference in comparison group 1,218 with standard deviation 0.560. statistical test by using independent t-test obtained p-value 0.001 with alpha 0.05, means that there is a significant effect of jigsaw puzzle games against the mean difference in fingers muscle strength in intervention and comparison groups in the female. jigsaw puzzle improve fine motor abilites (kusnanto et.al) 144 table 1 clients observation results based on age, gender, frequency of attacks, the affected extremity in ischemic stroke clients table 2 difference score of fingers muscle strength between intervention with comparison group after jigsaw puzzle intervention for six days variables group n mean difference ± standard deviation p muscle strength male intervention 6 7,217 1,790 0,001 comparison 6 1,550 1,693 female intervention 11 3,600 0,761 0,001 comparison 11 1,218 0,560 table 3 showed that mean difference in the range of motion of the fingers after jigsaw puzzle game for six days in intervention group 6.65 with standard deviation 2.029, while the comparison group 2.82 with standard deviation 2.942. statistical test using independent t-test obtained p-value 0.001 with alpha 0.05, means that there is a significant effect of jigsaw puzzle games against the mean difference in the range of motion of the fingers between intervention and comparison groups. table 4 showed that mean difference of upper extremity fine motor after jigsaw puzzle game for six days in intervention group 3.29 with standard deviation 0.588, while the comparison group 0.94 with standard deviation 0.772. statistical test using independent t-test obtained p-value 0.001 with alpha 0.05, means that there is a significant effect of jigsaw puzzle games against mean difference upper extremity fine motor between intervention and comparison groups. client characteristics intervention group comparison group total p f(x) % f(x) % n % gender 0,640 male 6 35.3 6 35.3 12 35,3 female 11 64.7 11 64.7 22 64,7 total 17 100.0 17 100.0 34 100 the frequency of attacks 0,366 the first attack 10 58,8 8 47,1 18 52,9 the second attack 7 41,2 9 52,9 16 47,1 total 17 100,0 17 100,0 34 100 age 0,155 36-45 0 0 6 35,3 6 17,6 46-55 10 58,8 5 29,4 15 44,1 56-65 7 41,2 6 35,3 13 38,3 total 17 100,0 17 100,0 34 100,0 the affected upper extremities 0,366 right 8 47,1 10 58,8 18 52,9 left 9 52,9 7 41,2 16 47,1 total 17 100,0 17 100,0 34 100,0 jurnal ners vol. 12 no. 1 april 2017: 142-150 145 table 3 results of the mean difference in range of motion of the fingers in intervention and comparison group after jigsaw puzzles intervention for six days variables group n mean ± standard deviation p-value range of motion of the fingers intervention 17 6,65 2,029 0,001 comparison 17 2,82 2,942 table 4 results of the mean difference of upper extremity fine motor between intervention and comparison group after jigsaw puzzle intervention for six days discussion based on the results of the study before jigsaw puzzle games intervention indicated that the score of muscle strength between male and female had a different range of score. at 11 females clients in intervention group had score of muscle strength below 18.00 which means that all females in these study experienced a decrease in muscle strength and less category, means that there is a lack of muscle movement or weak areas in accordance with the dictates like the palm face down, or straight twisted but if detained a bit was not able to move. at six males clients in the intervention group had a score of muscle strength below 27.00 means in less category. the same condition is also seen in comparison group before intervention by hospital standard. a score of muscle strength of the fingers on the 11 females and six males also included in less category. the decreasing of muscle strength of the fingers is caused by the failure of sensory nerves to deliver impulses to motor nerves lead to the failure of potential action in the muscle. decreased muscle strength in ischemic stroke occurs largely due to component central nervous system failure in impulse conduction mechanism resulting mild to severe weakness effect on the contralateral side and caused limitations in movement (lemone & burke 2004). research conducted by misbach & soertidewi (2011) said that from data survey of 28 hospitals in indonesia about 95% clients of after ischemic stroke decreased in muscle strength. muscle strength is muscle ability to withstand the load both external and internal. the muscle strength of the fingers is associated with neuromuscular system relates to how large the ability of the nervous system to activate the muscles to perform contractions. the fewer muscle fibers are activated, produced smaller muscle strength (irfan, 2010). one key success of physical therapy in ischemic stroke with decreased muscle strength is a repetitive movement that will result in more activated muscle fibers. repetitive movements will be able to activate the motor unit, thus causing repetitive muscle contractions (neistadt 1986). repetitive movements that specific to the hand movement is effective as the initial response to muscles and brain activity (neistadt 1986). proper selection of media that contains coordination between the nervous system, musculoskeletal system, motor and sensory systems are capable of accelerating the development of fine motor skills. puzzle is one of the media used to rehabilitation nursing interventions in ischemic stroke a jigsaw puzzle is a game that requires coordination of the fingers and eyes to compose divided picture into an integral part (alajlan 2009) at 17 client of interventions group play jigsaw puzzle game two times a day for six days showed the increasing of muscle strength score. at 11 female clients, muscle strength scores increased above of 18.00. after jigsaw puzzle game 11 clients demonstrated fair category of muscle strength, means that muscles able to contract but can not move the body against gravity, but when gravity is removed by changing the body position, muscles can move the full body. increased muscle strength also occurred in the male intervention group. after six clients play jigsaw puzzle games showed an increase in muscle strength score above of 27.00. after jigsaw puzzles intervention 5 respondents were in fair category, means that the muscles able to variables group n mean± standard deviation p-value upper extremity fine motor intervention 17 3,29 0,588 0,001 comparison 17 0,94 0,772 jigsaw puzzle improve fine motor abilites (kusnanto et.al) 146 contract but can not move the body against gravity, but when gravity is removed by changes in body position, muscles can move the full body, and 1 client in fair category means that the muscles of the fingers able to contract and move the full body against gravity. effect of jigsaw puzzle games on muscle strength of the fingers is evidenced by statistical test using paired t-test, showed that female intervention group p-value ≤ 0,05 = 0.001, means that there is the effect of jigsaw puzzle game on the muscle strength of the fingers in a female with ischemic stroke who experience decreased muscle strength. an intervention group of male p-value ≤ 0.05 = 0.001, means that there is the effect of jigsaw puzzle games on muscle strength of the fingers in ischemic stroke who experience decreased muscle strength. different conditions showed in the comparison group. about 3 of 11 females clients had scored above 18.00 or in fair category after standardized hospital intervention. about 3 of 6 males client remains in the poor category. this condition occurs because the hospital standard therapy given to a range of motion therapy of the fingers conducted once a day without any additional therapy. effect of hospital standard therapy to the muscle strength of the fingers is evidenced by statistical test using paired t-test, showed that female intervention group p-value ≤ 0,05 = 0.001, means that there is the effect of standardized hospital therapy on the muscle strength of the fingers in women with ischemic stroke who experienced decreased muscle strength. in male intervention group p-value ≥ 0.05 = 0.075, means that there is no effect of standardized hospital therapy on muscle strength of the fingers in men with ischemic stroke who experienced muscle strength decreased. the muscle strength of the fingers in the intervention group of jigsaw puzzles game show greater improvement than hospital standardized therapy. these happened because jigsaw puzzle games stimulated muscles contraction causing ca2+ lines open in sarcoplasmic reticulum then stimulate potential actions ( shen li, 2014). potential actions that continuously occur may activate many motor units in muscle fibers. those will continue to contract muscles and then muscle strength increases. repetitive active movements in jigsaw puzzle game are expected to increase muscle strength. the more active movements when the rehabilitation, the results obtained will be more optimal. supported research conducted by (prok 2016) said that there is significant correlation between fingers active movement exercises effect to increase the muscle strength of the fingers on stroke client. the same results conducted by fatkhurrohman (2011) also pointed out that upper extremities exercise on hemiparesis by moving fingers three times a day for seven days would increase the muscle strength of the fingers. those were proved by statistical test results p = 0.001. differences in muscle strength values in intervention and comparison groups can be seen from the difference value of muscle strength that had been increased in each client. from the statistical test by independent t-test showed that female group p-value ≤ 0.05 = 0.001, means that jigsaw puzzle games had more effect on muscle strength increase than standardized hospital therapy. the same thing is also shown in the male group p-value ≤ 0.05 = 0.001. on recurrent attacks client will face longer rehabilitation process. this rehabilitation process is due to sudden occlusion of blood vessels that previously normal in the first attack allegedly as a result of the progression of stenosis/occlusion of blood vessels that increase the risk of vascular disruption event (shin et al. 2017). it means that more attacks frequency on ischemic stroke leading to longer rehabilitation process than the first attack. (wirawan 2009) said that long rehabilitation process is influenced by the severity and extent of the lesion of the brain affected by stroke attack. based on the results of the study before jigsaw puzzle games intervention indicated that 11 female clients in the intervention group had a range of motion value measured at the metacarpalphalange (mcp). at the time of the finger extension under 100 were included in a poor category means that the joint can move, but there were obstacles. at six male clients comprehensive mcp joint motion value is under 100 were included in a poor category means that the joint can move, but there were obstacles. the same condition is also seen in the comparison group before hospital standard intervention. the range of joint motion mcp value of finger extension on 11 female clients and six male clients were also included in the jurnal ners vol. 12 no. 1 april 2017: 142-150 147 poor category, means that the joint can move, but there were obstacles such as pain in the finger joints when performed extension. this barrier occurs due to joints had not being moved in a long time. the range of joint motion is the maximum capacity that can be achieved by the joint (yuliastati. 2011). decreased muscle strength also contributed to the decline of the joint range of motion. this happened because the bones and joints of the motor system coordinate with each other to produce movement. the force produced by the muscle strength produce synovial fluid to lubricate the joints and formed a layer between the surfacerelated films that separates the cartilage to not rub against each other, so the range of motion will increase (kushartanti, 2007). jigsaw puzzle game is improving the muscle strength of the fingers, also increased the range of motion. improvement in range of joint motion occurred on eight clients those in fair category, means that joints capable of full moving and against gravity without resistance. the range of joint motion is one of the fine motor component other than muscle power. effect of jigsaw puzzle games against the range of joint motion of the fingers is evidenced by the statistical test using wilcoxon signed rank test which showed that female intervention group p-value ≤ 0,05 = 0.001, means that there is effect of jigsaw puzzle game on range of joint motion of the fingers in women with ischemic stroke who experienced decreased muscle strength. in the male intervention group p-value ≤ 0.05 = 0.001, means that there is the effect of jigsaw puzzle games on a range of joint motion of the fingers in men with ischemic stroke who experienced decreased muscle strength. in contrast to the comparison group was given hospital standard intervention. the effect of hospitals standardized therapy to range of joint motion of the fingers is evidenced by statistical test using wilcoxon signed rank test, showed that female intervention group pvalue ≤ 0,05 = 0.001, means that there is effect of standardized hospital therapy to range of joint motion of the fingers in women with ischemic stroke clients that experience decreased range of joint motion. in male intervention group p-value ≥ 0.05 = 0.075, means that there is no effect of the hospital standardized therapy to a range of joint motion of the fingers in a male client with ischemic stroke that decreased the range of joint motion. mcp range of joint motion differences between intervention and comparison groups can be seen from the difference in value between each client. statistical test using mannwhitney test showed that p-value ≤ 0,05 = 0.001, means that jigsaw puzzle games more influential on the increase of mcp range of joint motion when extention than hospital standardized therapy. the repetitive motion produced by jigsaw puzzle games able to increase the range of motion of the fingers then increase the mcp joint motion. repetitive motions of mcp joint will cause the cartilage surface between two bones friction against each other. emphasis on cartilage due to the movement will push the water out of the matrix of cartilage into the synovial fluid, the activity at the joints will maintain synovial fluid which is a joint lubricant so that the joint can move to the maximum (winters 2004). supported research conducted by victoria et.al (2014) revealed that active exercise on the fingers could increase the range of joint motion of the fingers, by activating more muscle fibers on the fingers. based on the research revealed that the intervention group of 11 female clients upper extremity fine motor’s score is below of 2. in the intervention group of 6 male clients also demonstrated value of upper extremity fine motor skills below of 2, means that the average client conditions have not been able to open the top of the pen and put it again (client took the top of the pen is placed far edge of the table and brought closer back near the body). these study showed that the weaker muscle strength and the smaller range of joint motion would result in decreased fine motor skills of the upper extremities. yudanto (2012) said that the development of fine motor skills parallel with the development of the nervous system and muscles, so fine motor skills is determined by the maturity in integral function of body systems, especially the nervous system and body movement (bones, muscles, and joints). decreased muscle strength and range of joint motion that occurs continuously also cause fine motor skills disturbances (eng & harris, 2009). this is because fine motor skills are organizing between muscles and joints with the nervous system (yudanto, 2012). so, if there is no movement or stimulation that stimulates muscle contraction will cause fine motor skills disturbances. therefore, to increase the fine jigsaw puzzle improve fine motor abilites (kusnanto et.al) 148 motor skills is necessary to provide stimulation which includes nerve coordination, muscle movement, and joint movement. so, that will provide balance in the development of fine motor coordination. one of the motion stimulation which includes three aspects is through jigsaw puzzle game. jigsaw puzzle game is a puzzle game that requires precise coordination of sensory and motor systems to install parts of a puzzle as expected picture. neistadt (1986) stated that the puzzle game performed on the client with a head injury could improve fine motor skills of the fingers so that the client can perform daily activities. puzzle exercises used to develop eye contact, attention and concentration as well as the eye coordination, hand, and train concepts. giving jigsaw puzzle two times a day for six days led to an increase in upper extremity fine motor skills. of the 17 clients, both men and women had fine motor value above of 2, means the client can draw horizontal and vertical lines are alternately 10 times within 20 seconds (at least five lines must be touched and stopped in a vertical line. the line is made should be about 10 cm). mean difference between fine motor skills value in intervention group before and after the jigsaw puzzle game is evidenced by the statistical test using wilcoxon signed rank test showed p ≤ 0,05 = 0.001, means the provision of additional therapy such as jigsaw puzzle effect on the improvement of fine motor skills of the upper extremity. jigsaw puzzle game is a game that requires fingers and eye coordination to develop an image that split into several parts. jigsaw means eliminating a pattern in the image sequence so that game would be repeated to find that section. thus the players being motivated and encouraged to continue to arrange and find the missing pattern repeatedly. this repetition is expected to train the client fine motor skills (alajlan, 2009). research conducted by maureen (2004) argued that the game using the puzzle as the media for six days were carried out at 45 clients can stimulate motor nerves with a head injury and risen the potential action as initial process of muscle contraction. in these studies indicated p-value = 0.01 (α = 0.05), means that there is a significant effect on using puzzle media to improve fine motor skills in upper extremity in head injury clients. jigsaw puzzle games could motivate clients to discipline in the exercise. images are presented in this game attract clients to play arranging piece into a series of corresponding images continuously. wirawan (2009) revealed that client self-motivation is one factor that influences the outcome of the rehabilitation process. this statement is supported by research conducted by ariyadi (2010) said that high motivation of client in ischemic stroke rehabilitation process would produce good and fast outcome, interesting media used to increase client self-motivation (hariandja, 2013) a similar study conducted by smith (2000) of 44 pre-school children using puzzle and 81% pre-school children increased fine motor skills. wijanarko (2008) said that by giving a puzzle game for children aged 4-5 years can improve fine motor skills. in contrast to the comparison group given hospital standardized intervention showed that before the intervention, upper extremity fine motor value is below 2 in both male and female clients. after standardized hospital therapy, the value increasing of fine motor skills occurred in 15 clients, both male, and female, while two clients were not increased fine motor skills. after standardized hospital therapy, only four clients that had fine motor skills value above 2. differences in fine motor skills value in comparison group before and after hospital standardized therapy evidenced by statistical test using wilcoxon signed rank test showed p ≤ 0,05 = 0.01, means that the provision of standardized hospital therapy affects the increasing of upper extremity fine motor skills. differences value between the increasing of fine motor skills of upper extremity also can be seen between intervention and comparison groups. value difference of fine motor upper extremity in intervention group reaches 23.29 higher than comparison group increased only by 0.94. this difference proved that jigsaw puzzle games could improve upper extremity fine motor skills in intervention group larger than the comparison group. difference score in upper extremity motor between given and not given in additional jigsaw puzzle therapy was because of difference in duration and intensity of therapy. lack of motivation during exercise also contribute to the success of therapy (wirawan 2009). hariandja (2013) said that the key success of neurological rehabilitation is duration and intensity of exercise. jurnal ners vol. 12 no. 1 april 2017: 142-150 149 a jigsaw puzzle is a game that requires coordination of fingers and eyes to develop an image that split into several parts. jigsaw means eliminating a pattern in image sequence that game would be repeated to find that image section. thus the players being motivated and encouraged to continue arranging and finding the missing pattern repeatedly. the repetition is expected to train the client fine motor skills (alajlan 2009). active movements that repeatedly occur in this game is expected to increase muscle strength. as a more active movement that occurs during rehabilitation exercises, the results obtained will be more optimal. if cell membrane produced by the cell membrane is strong enough, the potential action will flow rapidly into all cell membranes. muscles as locomotor active have irritability indicated by responding process to stimuli (recognize and respond to stimuli/stimulus) the muscles directly without relying on usual neural tissue that activates muscles. therefore, if skeletal muscle cells or muscle fibers are given a stimulus above or normal threshold, then the muscle cell will fully contract. otherwise, if the stimulus of the muscle is under threshold/ subminimal, the muscle cells will not contract at all. subminimal threshold stimulus may cause contraction response with the condition given in fast and several times (feriyawati 2005). jigsaw puzzle games using interesting images, inexpensive and safe, so clients are interested and eager to perform the therapy. an interesting and inexpensive therapy used to improve motivation during the acute phase of post-stroke rehabilitation is needed for disciplined in client therapeutic process. supporting research conducted by prok (2016) said that there is a significant correlation between active motion exercises effect on hand grasping the ball toward increasing muscle strength of the fingers on stroke client. in intervention group given grasping the ball three times a day for seven days. the comparison group gave according to hospital standard therapy one times a day. both groups showed an increase in muscle strength of the fingers but with grasping the ball as additional therapy, the difference in muscle strength seen more significant with p-value 0.001. other supporting studies is research conducted by maureen (2004), suggested that puzzles therapy more effective than using conventional therapies. there are significant differences in fine motor skills and muscle strength in clients who were treated using puzzle and conventional. in these study, explained that clients more interested using puzzle for therapy even though the duration is longer. clients feel challenged to finish the puzzles. conclusions intervention using jigsaw puzzle games can improve upper extremity fine motor skills on the client after ischemic stroke. the increase in fine motor skills of upper extremities followed by increasing of muscle strength of the fingers and increase the range of motion in metacarpalphalange (mcp). continuing jigsaw puzzle game as one independent action for medical-surgical nurses especially neurology nurse so that clients can minimize muscle stiffness after ischemic stroke. further research conducted by group clients based on gender. can be used as one of the additional hospital therapy in the rehabilitation process after ischemic stroke with low cost, materials that are safe for the client and easily obtained. giving a strong motivation and family support is an important factor in patients rehabilitation process after ischemic stroke with upper extremity fine motor impairment. references alajlan, n., 2009. solving square jigsaw puzzles using dynamic programming and the hungarian procedure naif alajlan advanced lab for intelligent systems research, department of computer engineering,. , 6(11), pp.1941–1947. black,j.m., dan hawks,j.h.2005. medical surgical nursing. new york. elsevier fatkhurrohman m. 2011. teknologi stimulasi elektrik (elektrical stimulation) bagi pasien yang mengalami kelemahan otot dan nyeri. keperawatan medikal bedah fik-ui feriyawati, l., 2005. anatomi sistem saraf dan perannya dalam regulasi kontraksi otot rangka. foley dl, morley ki, madden paf, et al. 2013. major depression and the jigsaw puzzle improve fine motor abilites (kusnanto et.al) 150 metabolic syndrome.twin research and human genetic; 13(4): 347-58. hariandja, 2013 identifikasi kebutuhan akan sistem rehabilitasi berbasis teknologi terjangkau untuk penderita stroke di indonesia, lembaga penelitian dan pengabdian kepada masyarakat universitas katolik parahyangan. haris j e, eng j j., 2009. paretic upper limb strength best explains arm activity in people with stroke http://ptjournal.apta.org/content/87/1/8 8.full.pdf+html. diakses pada tanggal 16 april 2016. irfan, muhammad. 2010. fisioterapi bagi insan stroke. yogyakarta : graha ilmu ikawati, z., 2010. farmakologi molekuler, yogyakarta: ugm press. kochanek, k.d. et al., 2011. national vital statistics reports deaths : final data for 2009. , 60(3). kushartanti (2007) pengaruh latihan range of motion (rom) terhadap fleksibilitas sendi lutut pada lansia di panti wreda wening wardoyo ungaran, nurse media journal of nursing vol 1, no.2. li, shen et al. “infarction of the corpus callosum: a retrospective clinical investigation.” ed. jeroen hendrikse. plos one 10.3 (2015): e0120409. pmc. web. 2 june 2017. lemone, p.t. & burke, k.m., 2004. medical-surgical nursing: critical thinking in client care, pearson prentice hall: new jersey. lewis, s.l. et al., 2007. assessment and management of clinical problems volume 2., pennsylvania: w.b saunders. neistadt, m.e., 1986. the effects of different functional fine motor with brain injury. prok, w., 2016. pengaruh latihan gerak aktif menggenggam bola pada pasien stroke diukur dengan handgrip dynamometer. , 4(april). ringleb, s. i., dhakal, a., anderson, c. d., bawab, s. and paranjape, r. (2011), effects of lateral ligament sectioning on the stability of the ankle and subtalar joint. j. orthop. res., 29: 1459–1464. doi:10.1002/jor.21407 smithjane case.2000. effects of occupational therapy services on fine motor and functional performance in preschool children. american journal of occupational therapy. vol 54, 372-380 shin, d.h., lee, p.h. & bang, o.y., 2017. mechanisms of recurrence in subtypes of ischemic stroke. , 62. warlow, c.p., dennis, m.s., gijn, v.j., hankey, g j., sandercock, p.a., bamford, j.m., 2007. stroke, in : a practical guide to management. 1st ed. london: blackwell science wijanarko, h., 2008. efektifitas alat permainan edukatif puzzle terhadap perkembangan motorik halus anak usia 4-5 tahun berdasarkan ddst, semarang: thesis. universitas diponegoro. winters, m., 2004. passive versus active stretching of hip flexor muscles in subjects with limited hip extension: a randomized clinical trial. wirawan, r.p., 2009. rehabilitasi stroke pada pelayanan kesehatan primer, jakarta: smf rehabilitasi medis rs fatmawati. victoria, arlies z, et al. 2014. pengaruh latihan lateral prehension grip terhadap peningkatan luas gerak sendi (lgs) jari tangan pada pasien stroke di rsud dr. h soewondo kendal. stikes telogorejo semarang yudanto (2010). stimulasi gerak dasar siswa sekolah dasar kelas bawah. jurnal pendidikan jasmani indonesia, volume 4, nomor 2, nopember 2007. fik uny yuliastati., 2011. pengaruh latihan rentang gerak sendi terhadap kekuatan otot dan luas gerak sendi anak dengan tuna grahita sedang di sekolah luar biasa kota bogo, thesis. universitas indonesia. jakarta. vol 6 no 1 april 2011_akreditasi 2013.indd 93 terapi kelompok terapeutik anak dengan orang tua dan guru meningkatkan perkembangan mental anak usia sekolah (school aged therapeutic group therapy in childrenparents andteachers increased mental development of school-age) dian istiana*, budi anna keliat**, tuti nuraini** * stikes yarsi mataram ntb jl. tgh. ali batu lingkar selatan, lombok, ntb – indonesia e-mail: istianadian@ymail.com ** fakultas ilmu keperawatan universitas indonesia, kampus ui depok abstract introduction: school aged called as intelectual time in industrial development stage. industrial development stage is important in human development stages. the purpose of this tudy was to know the effect of school aged therapeutic group therapy to mental development. method: the design wa quasi experimental pre-post test with control group. one hundred and sixteen children at 9–11 years old were used as sample of this study that divided to 38 children on fi rst intervention group (childparents), 36 children on second intervention group (child-teacher) and 40 children on control group. result: result of the study showed that cognitive, psychomotor and industrial development ability had increased signifi cantly after therapeutic group therapy was given (p-value < 0.005) in intervention group. discussion: the study was recomended in child-parents and child-teacher to increase mental development in school aged children. keywords: industrial development, mental health, school aged children, school aged therapeutic group therapy pendahuluan undang-undang no. 3 tahun 1966 menyatakan bahwa kesehatan jiwa adalah suatu kondisi yang memungkinkan perkembangan fi sik, intelektual dan emosional yang optimal dari seseorang dan perkembangan itu berjalan selaras dengan keadaan orang lain. kesehatan jiwa dipengaruhi oleh berbagai faktor antara lain otonomi dan kemandirian, memaksimalkan potensi diri, menoleransi ketidakpastian hidup, harga diri, menguasai lingkungan, orientasi realitas serta manajemen stres (videbeck, 2008). faktor-faktor tersebut berinteraksi secara tetap sehingga kesehatan jiwa seseorang merupakan keadaan yang dinamik atau selalu berubah karena dipengaruhi pula oleh lingkungan, pengalaman seseorang dalam menghadapi masalah, mekanisme koping serta dukungan sosial. indonesia dari sekitar 1000 anak berusia 4–15 tahun, yang mengalami masalah mental dan emosional sebanyak 140 anak. jawa barat menduduki tingkat tertinggi untuk masalah kesehatan jiwa dibandingkan daerah lain di indonesia. persentase penderita gangguan mental emosional sebesar 20% dengan kata lain bahwa dari setiap 100 penduduk di jawa barat terdapat 20 orang yang mengalami gangguan mental emosional. data di atas menggambarkan jumlah orang yang mengalami masalah mental emosional sangat banyak sehingga diperlukan adanya upaya untuk mencegah agar tidak mengalami gangguan jiwa. upaya pencegahan gangguan jiwa dilakukan melalui tiga level yaitu primer, sekunder, tersier yang diuraikan dalam empat tindakan psikiatrik; krisis, akut, pertahanan dan promosi kesehatan (stuart dan laraia, 2005). pelayanan kesehatan jiwa tersebut dilakukan untuk mempertahankan kesehatan individu sepanjang hayat sejak masa konsepsi sampai lansia, dilakukan sesuai tingkat tumbuh kembang dari bayi sampai lansia. perkembangan individu dimulai sejak dalam jurnal ners vol. 6 no. 1 april 2011: 93–99 94 kandungan kemudian dilanjutkan ke-8 tahap mulai bayi (0–18 bulan), toddler (1,5–3 tahun), pra sekolah (3–6 tahun), sekolah (6–12 tahun), remaja (12–18 tahun), dewasa muda (18–35 tahun), dewasa tengah (35–65) tahun, dan tahap terakhir yaitu dewasa akhir (> 65 tahun) (wong, 2009). dalam tahapan perkembangan tersebut terdapat periode penting yaitu masa usia sekolah. anak usia sekolah dikenal dengan fase berkarya vs rasa rendah diri. masa ini berada di antara usia 6–12 tahun adalah masa anak mulai memasuki dunia sekolah yang lebih formal, pada anak usia sekolah tumbuh rasa kemandirian anak, anak ingin terlibat dalam tugas yang dapat dilakukan sampai selesai (wong, 2009). hambatan atau kegagalan dalam mencapai kemampuan tugas perkembangan di atas dapat menyebabkan anak merasa rendah diri sehingga pada masa dewasa, anak dapat mengalami hambatan dalam bersosialisasi (keliat, helena, dan farida, 2011). lingkungan sekolah merupakan lembaga pendidikan formal yang secara sistematik melaksanakan program bimbingan, pengajaran, dan latihan dalam rangka membantu siswa agar mampu mengembangkan potensinya baik yang menyangkut aspek moral-spiritual, intelektual, emosional, maupun sosial (yusuf, 2009). lingkungan keluarga dalam hal ini orang tua pada masa ini bertugas mempelajari bagaimana cara untuk beradaptasi dengan perpisahan anak atau yang lebih sederhana, melepaskan anak (friedman, 2010). lingkungan teman sebaya memberi sejumlah hal penting bagi anak usia sekolah karena melalui hubungan teman sebaya anak belajar bagaimana menghadapi dominasi dan permusuhan, berhubungan dengan pemimpin dan pemegang kekuasaan serta menggali ide-ide dan lingkungan fi sik (wong, 2009). lingkungan sekolah, keluarga dan teman sebaya saling memengaruhi satu dan lainnya dalam menciptakan perkembangan mental anak usia sekolah. upaya pemerintah indonesia untuk m e n g o p t i m a l k a n p e r k e m b a n g a n a n a k usia sekolah yaitu memberikan pelayanan kesehatan non-formal, fasilitas pelayanan yang melaksanakan posyandu, usaha kesehatan sekolah (uks). usaha kesehatan sekolah merupakan salah satu mata rantai yang penting dalam meningkatkan kualitas fi sik penduduk dengan ruang lingkup tercermin dalam tiga program pokok usaha kesehatan sekolah (trias uks) meliputi penyelenggaraan pendidikan kesehatan; pelayanan kesehatan di sekolah; pembinaan lingkungan kehidupan sekolah sehat baik fi sik, mental, sosial maupun lingkungan (tim pembina uks, 2007). upaya pemerintah tersebut tidak dapat berjalan dengan baik tanpa ditunjang oleh peran serta guru sebagai pendidik di sekolah dan orang tua sebagai pendidik di rumah. upaya mengoptimalkan perkembangan anak bagi para pendidik yang berada di sekolah hendaknya guru mendidik atau membimbing anak/remaja agar mereka dapat mengembangkan potensi dirinya seoptimal mungkin, sedangkan orang tua atau siapa saja yang berkepentingan dalam pendidikan anak, perlu dan dianjurkan untuk memahami perkembangan anak (yusuf, 2009). pemahaman yang baik tentang perkembangan anak bagi pendidik dan orang tua akan sangat membantu dalam memberikan stimulasi/rangsangan yang tepat terhadap pertumbuhan dan perkembangan anak usia sekolah sehingga menciptakan perkembangan anak yang baik dan terhindar dari gangguan jiwa. pelayanan kesehatan dalam keperawatan mulai diarahkan bukan hanya pada setting rumah sakit dan pelayanan kesehatan di masyarakat (puskesmas) yang lebih berorientasi pada upaya promotif dan preventif. pada setting komunitas, perawat community mental health nursing (cmhn) bertanggung jawab memberikan asuhan keperawatan jiwa komunitas pada kelompok keluarga yang sehat jiwa, keluarga yang berisiko mengalami gangguan jiwa serta keluarga yang memiliki anggota keluarga yang mengalami gangguan jiwa. perawat memberikan pelayanan bukan hanya di puskesmas tetapi juga pada institusi seperti pada tempat pelayanan panti sosial, sekolah atau bahkan di tempat-tempat penitipan anak-anak yang ada di komunitas. pelayanan kesehatan dalam keperawatan diberikan di samping melalui asuhan keperawatan juga dalam berbagai bentuk terapi baik bagi individu, keluarga dan kelompok. terapi kelompok terapeutik anak usia sekolah (dian istiana, dkk) 95 berbagai terapi yang dapat diberikan perawat kepada anggota keluarga berupa terapi keluarga, terapi kelompok seperti edukasi kelompok, psikoedukasi kelompok, terapi supportif, kelompok swa bantu, dan terapi kelompok terapeutik. (stuart dan laraia, 2005). sedangkan untuk anak, berbagai terapi juga bisa diberikan sesuai dengan tahap perkembangan anak, seperti, terapi bermain, terapi kelompok, terapi lingkungan (hamid, 2009). salah satu terapi kelompok yang diberikan untuk mengoptimalkan perkembangan anak adalah terapi kelompok terapeutik (tkt). terapi kelompok terapeutik membantu anggotanya mencegah masalah kesehatan, mendidik dan mengembangkan potensi anggota kelompok dan meningkatan kualitas antaranggota kelompok untuk mengatasi masalah dalam kehidupan (keliat dan akemat, 2005). terapi ini diberikan pada semua tingkat usia sesuai dengan tahap tumbuh kembangnya dan dapat dilakukan secara berkelompok maupun indvidu bertujuan menstimulasi perkembangan secara individu. terapi kelompok terapeutik pada orang tua dan guru yang mempunyai anak usia sekolah dilakukan untuk membantu orang tua dan guru mengatasi masalah yang dialami terkait tumbuh kembang, sharing pengalaman dalam memberikan stimulasi perkembangan anak dan belajar bagaimana stimulasi sesuai perkembangan anak untuk membantu mengoptimalkan perkembangan mental anak usia sekolah. penelitian tkt pada anak usia sekolah telah dilakukan oleh walter (2010) terhadap perkembangan industri anak usia sekolah di panti sosial asuhan anak kota bandung, ditemukan hasil adanya peningkatan secara bermakna terhadap perkembangan industri anak sekolah setelah mendapat terapi kelompok terapeutik. penelitian ini belum optimal karena penelitian tersebut hanya dilakukan terhadap anak usia sekolah yang ada di panti, tidak melibatkan guru dan orang tua. berdasarkan data pokok pendidikan kota depok tahun 2011 jumlah siswa sekolah dasar negeri (sdn) di kecamatan pancoran mas sebanyak 22.707 dari 40 sd yang tersebar di 6 kelurahan dengan kelurahan dengan jumlah siswa sd terbanyak adalah kelurahan depok jaya (18 sdn, 8717 orang siswa), depok (8 sdn, 4846 orang siswa), pancoran mas (6 sdn, 2917 orang siswa), rangkapan jaya baru (4 sdn, 2705 orang siswa), mampang (3 sdn, 2565 orang siswa), dan rangkapan jaya baru (1 sdn, 954 orang siswa). data di atas memberikan gambaran bahwa kelurahan dengan jumlah siswa sd terbanyak adalah kelurahan depok jaya, depok dan pancoran mas. pelayanan kesehatan yang diberikan oleh puskesmas di daerah tersebut hanya terkait dengan pelayanan kesehatan fi sik saja, namun belum menyentuh aspek kesehatan mentalnya. hal inilah yang mendorong peneliti untuk melakukan penelitian yang dilaksanakan untuk memberikan stimulasi perkembangan mental anak usia sekolah. penelitian ini dilakukan dalam upaya mengembangkan terapi kelompok terapeutik pada anak sekolah dengan melibatkan orang tua sebagai pendidik utama di rumah dan guru sebagai pendidik utama di sekolah dalam upaya menstimulasi dan mengoptimalkan perkembangan mental anak usia sekolah (fase industri). bahan dan metode penelitian ini menggunakan jenis penelitian kuantitatif dengan desain yang digunakan adalah ”quasi experimental prepost test with control” dengan intervensi tkt. penelitian dilakukan untuk mengetahui kemampuan pengetahuan anak usia sekolah tentang stimulasi perkembangan anak usia sekolah, kemampuan psikomotor dalam stimulasi perkembangan anak usia sekolah dan perkembangan industri pada kelompok intervensi yaitu intervensi tkt anak usia sekolah pada kelompok anak-orang tua (intervensi 1), anak-guru (intervensi 2) dengan kelompok yang tidak diberikan tkt (kelompok kontrol). sampel penelitian ini anak sekolah di sekolah dasar negeri wilayah kelurahan depok (sdn depok 3 dan sdn depok 4) dan depok jaya (sdn depok baru 4 dan sdn depok baru 07) kota depok dengan jumlah sampel 116 orang murid kelas 4 dan 5 yang dipilih secara simple random sampling. kriteria inklusi responden pada penelitian ini jurnal ners vol. 6 no. 1 april 2011: 93–99 96 adalah: anak usia sekolah (9 sampai 11 tahun), bisa membaca dan menulis, bersedia menjadi responden, anak yang sudah melampaui masa perkambangan usia prasekolah (dengan indikator usia anak). sekolah dasar yang digunakan untuk penelitian adalah sebagai berikut: di kelurahan depok jaya adalah sdn depok baru 4 dan sdn depok baru 7 sebagai kelompok intervensi 1, sdn depok baru 3 dan sdn jaya 3 sebagai kelompok kontrol, sedangkan di kelurahan depok adalah sdn depok 3 dan sdn depok 4 sebagai kelompok intervensi 2. waktu penelitian selama 3 bulan. k u e s i o n e r y a n g d i g u n a k a n p a d a penelitian ini terdiri dari empat kuesioner: kuesioner a (data demografi), kuesioner b (pengetahuan anak usia sekolah tentang stimulasi anak usia sekolah), kuesioner c (kemampuan psikomotor anak usia sekolah dalam melakukan stimulasi perkembangan), dan kuesioner d (perkembangan industri anak usia sekolah). analisis bivariat yang digunakan adalah independent t-test, paired t-test, dan chi square. analisis multivariat menggunakan uji anova dan regresi linier ganda. hasil k a r a k t e r i s t i k u s i a a n a k s e k o l a h keseluruhan memiliki rata-rata usia 9,97 tahun dengan usia termuda 9 tahun dan tertua 11 tahun. jenis kelamin yang terbanyak adalah laki-laki sejumlah 58 orang (74,4%). pendidikan orang tua yang terbanyak adalah pendidikan tinggi sejumlah 72 orang (78,1%). orang tua yang bekerja sebanyak 69 orang (56,5%) dan jumlah saudara kandung yang terbanyak adalah lebih dari 3 orang sebanyak 65,4% dari keseluruhan responden. setelah dilakukan tkt anak sekolah pada anak-orang tua (kelompok intervensi 1) dan anak-guru (kelompok intervensi 2) didapatkan pengetahuan anak usia sekolah pada kelompok intervensi 1 adalah 33,95 (97%), kelompok intervensi 2 sebesar 32,87 (93,91%) dan kelompok kontrol sebesar 31,33 (89,51%) dengan nilai p-value < 0,05 yang dapat disimpulkan bahwa ada perbedaan bermakna tindakan tkt pada ketiga kelompok (grafi k 1). kemampuan psikomotor anak usia sekolah dalam menstimulasi perkembangannya adalah setara pada ketiga kelompok setelah dilakukan tkt. hasil yang didapat pada kelompok intervensi 1 adalah 87,54 (72,95%), kelompok intervensi 2 sebesar 94,55 (78,79%), sedangkan pada kelompok kontrol sebesar 8 0 , 4 5 ( 6 7 , 0 4 % ) d e n g a n n i l a i p v a l u e < 0,05, maka dapat disimpulkan bahwa ada perbedaan yang sangat bermakna peningkatan kemampuan psikomotor dalam menstimulasi perkembangan industri di antara ketiga kelompok (grafik 2). hasil penelitian menunjukkan adanya peningkatan yang bermakna antara perkembangan industri anak sebelum dan setelah mendapatkan tkt anak sekolah pada kelompok intervensi 1 sebesar 77,62 (77,62%), kelompok intervensi 2 83,61 (83,61%) sehingga meningkat secara bermakna bila dibandingkan dengan kelompok yang tidak mendapatkan tkt (grafi k 3). k a r a k t e r i s t i k a n a k u s i a s e k o l a h yang berkontribusi terhadap pengetahuan, kemampuan psikomotor dan perkembangan usia industri anak usia sekolah adalah usia.     grafi k 1. perbandingan peningkatan kemampuan pengetahuan anak pada kelompok intervensi dan kontrol terapi kelompok terapeutik anak usia sekolah (dian istiana, dkk) 97 pengaruh usia terhadap pengetahuan anak setelah dikontrol oleh variabel lain adalah sebesar 28% (intervensi 1) dan 27% (intervensi 2). pengaruh usia anak terhadap kemampuan psikomotor anak adalah sebesar 49% (intervensi 1) dan 45% (intervensi 2). pengaruh usia terhadap perkembangan industri anak setelah dikontrol variabel lain adalah sebesar 43% (intervensi 1) dan 55% (intervensi 2). pembahasan hasil penelitian menunjukkan bahwa kemampuan pengetahuan anak usia sekolah meningkat setelah tkt. terapi kelompok terapeutik anak usia sekolah memberikan pengetahuan pada anak usia sekolah tentang kemampuan pengetahuan anak sekolah yang harus dimiliki, senada dengan pendapat notoatmojo (2010), bahwa pengetahuan diperoleh dari pengalaman sendiri, orang lain dan pengetahuan yang diberikan oleh orang lain (peneliti). berdasarkan hasil penelitian kemampuan psikomotor anak usia sekolah dalam menstimulasi perkembangannya meningkat setelah dilakukan tkt. kemampuan psikomotor anak usia sekolah pada kegiatan tkt distimulasi dengan melakukan permainan s e h i n g g a d e n g a n l a t i h a n k e m a m p u a n psikomotor anak meningkat. hal ini senada dengan pendapat tohirin (2005), bahwa latihan keterampilan motorik dapat meningkatkan kemampuan menguasai kemampuan tertentu. hasil penelitian pada kelompok yang mendapat tkt terjadi peningkatan kemampuan perkembangan industri yang signifi kan selama kurun waktu 1 bulan. asumsi peneliti bahwa perbedaan peningkatan perkembangan industri pada kelompok intervensi 1 (anak-orang tua) dengan intervensi 2 (anak-guru) karena orang tua memiliki waktu lebih banyak daripada guru dalam memberikan stimulasi perkembangan anak usia sekolah. penelitian ini menyimpulkan bahwa kemampuan pengetahuan, psikomotor dan perkembangan industri anak usia sekolah meningkat setelah tkt. hasil tersebut sesuai dengan pendapat townsend (2005) menyatakan bahwa terapi kelompok terapeutik mengajarkan cara yang efektif untuk mengatasi situasi atau krisis perkembangan, dan menurut stuart dan laraia (2005) terapi kelompok terapeutik dapat membantu anak usia sekolah dalam memenuhi kebutuhannya (tugas perkembangan) secara positif. grafi k 1. perbandingan peningkatan kemampuan pengetahuan anak antara kelompok intervensi dan kontrol grafi k 1. perbandingan peningkatan perkembangan industri anak anatara intervensi dan kontrol jurnal ners vol. 6 no. 1 april 2011: 93–99 98 hasil penelitian juga menunjukkan ada kontribusi usia anak terhadap kemampuan pengetahuan tentang stimulasi, kemampuan psikomotor dan perkembangan industri anak. perkembangan industri anak dipengaruhi berapapun usianya, sesuai dengan tingkat perkembangan. salaby (1994) menyatakan bahwa semakin lanjut usia seseorang semangkin meningkat kedewasaan teknis dan tingkat kedewasaan psikologisnya menunjukkan kematangan jiwa, dalam arti semakin bijaksana, mampu berpikir secara rasional, mengendalikan emosi dan bertoleransi terhadap orang lain. keterbatasan penelitian ini terletak pada pelaksanaan penjelasan tkt pada orang tua dan guru, karena pada saat jadwal pelaksanaan kegiatan tersebut ada beberapa orang tua dan guru yang berhalangan hadir. simpulan dan saran simpulan terapi kelompok terapeutik anak usia sekolah berpengaruh terhadap kemampuan pengetahuan anak usia sekolah tentang stimulasi perkembangan sedangkan yang tidak dilakukan terapi kelompok terapeutik tidak berpengaruh terhadap kemampuan pengetahuan anak dalam kurun waktu 1 bulan. terapi kelompok terapeutik anak usia sekolah berpengaruh terhadap kemampuan psikomotor anak usia sekolah tentang stimulasi perkembangan sedangkan yang tidak dilakukan terapi kelompok terapeutik tidak berpengaruh terhadap kemampuan psikomotor anak dalam kurun waktu 1 bulan. terapi kelompok terapeutik anak usia sekolah berpengaruh terhadap perkembangan industri anak usia sekolah sedangkan yang tidak dilakukan terapi kelompok terapeutik tidak berpengaruh terhadap perkembangan industri anak dalam kurun waktu 1 bulan. faktor yang berkontribusi terhadap kemampuan pengetahuan, psikomotor dan perkembangan industri adalah usia anak sedangkan jenis kelamin, pendidikan orang tua, pekerjaan orang tua, jumlah saudara kandung tidak berkontribusi dengan kemampuan pengetahuan, psikomotor dan perkembangan industri anak usia sekolah. saran saran untuk dinas kesehatan adalah s e b a i k n y a d i n a s b e k e r j a s a m a d e n g a n mahasiswa spesialis keperawatan jiwa melakukan pelatihan kepada perawat puskesmas khususnya yang bertanggung jawab terhadap pelayanan kesehatan jiwa untuk diterapkan diwilayah kerja masing-masing dan adanya supervisi yang berjenjang dan terjadual untuk pelaksanaan terapi kelompok terapeutik, yang dilakukan oleh tenaga puskesmas yang sudah mendapatkan pelatihan terapi kelompok terapeutik. d i n a s k e s e h a t a n j u g a h e n d a k n y a melakukan kerja sama lintas sektoral antara dinas kesehatan, dinas sosial dan dinas pendidikan nasional dengan sekolah dengan melakukan pelatihan pada guru-guru sekolah dasar, guru-guru bp untuk meningkatkan dan mengoptimalkan perkembangan anak, terutama anak usia sekolah, karena anak merupakan aset bangsa yang paling berharga dan sebagai penerus generasi bangsa. perawat spesialis keperawatan jiwa hendaknya menjadikan terapi kelompok terapeutik sebagai salah satu kompetensi yang harus dilakukan pada pelayanan kesehatan jiwa di masyarakat khususnya klien yang sehat jiwa (berbasis komunitas). pihak pendidikan tinggi keperawatan hendaknya mengembangkan terapi pada kelompok sehat dalam upaya meningkatkan kemampuan kelompok dalam memberikan stimulasi perkembangan sesuai dengan tahapan usia pada semua tahapan usia. selain itu, pendidikan tinggi hendaknya menggunakan modul terapi kelompok terapeutik yang sudah dibuat oleh peneliti dan pakar keperawatan jiwa dalam melakukan terapi kelompok terapeutik. pihak pendidikan tinggi keperawatan juga sebaiknya menggunakan evidence based dalam mengembangkan teknik pemberian asuhan keperawatan jiwa pada semua tatanan pelayanan kesehatan dalam penerapan terapi kelompok terapeutik sesuai dengan tahap perkembangan. peneliti berikutnya diharapkan dalam melakukan terapi kelompok terapeutik sebaiknya menggunakan waktu lebih lama sehingga terapi kelompok terapeutik dapat terapi kelompok terapeutik anak usia sekolah (dian istiana, dkk) 99 membudaya dan dalam melakukan terapi kelompok terapeutik anak sekolah sebaiknya pada kelompok usia yang sama (usia 10 tahun). peneliti selanjutnya juga diharapkan dapat melakukan terapi kelompok terapeutik remaja yang diberikan pada anak-orang tua dan anak guru dan dalam melakukan terapi kelompok terapeutik sebaiknya menggunakan pengumpul data untuk menghindari terjadinya hasil penelitian tidak bias. kepustakaan ayuningsih, 2010. psikologi perkembangan anak. jakarta: pustaka larasati. friedman, w.m., vicky, r.b., dan elaine, g.j., 2010. keperawatan keluarga riset, teori dan praktik. jakarta: egc. h a m i d , 2 0 0 9 . b u n g a r a m p a i . a s u h a n keperawatan kesehatan jiwa, jakarta: egc. keliat dan akemat, 2005. keperawatan jiwa terapi aktivitas kelompok. jakarta: egc. keliat, b.a., helena, n., farida, p., 2011. manajemen keperawatan psikososial & kader kesehatan jiwa. jakarta: egc. notoatmojo, s., 2010. metodologi penelitian kesehatan. jakarta: rineka cipta. salaby, r.m., 1994. masalah anak dan penanggulangannya. medan: pustaka widyasarana. stuart, g.w., dan laraia, m.t., 2005. principles and practice of psychiatric nursing. (7th edition). st louis: mosby. tim pembina uks pusat uks, 2007. pedoman pembinaan dan pengembangan usaha kesehatan sekolah. jakarta. tohirin, 2005. psikologi pembelajaran pendidikan agama islam. jakarta: pt raja gravindo persada. townsend, c.m., 2005. essentials of psychiatric mental health nursing. (3th ed.). philadelphia: f.a. davis company. videbeck, s.l., 2008. psychiatric mental health nursing. (3rd edition). philadhelpia: lippincott williams and wilkins. walter, 2010. pengaruh terapi kelompok terapeutik terhadap kemampuan kognitif, psikomotor dan perkembangan industri anak usia sekolah dalam memenuhi tugas perkambangan di panti sosial asuhan anak kota bandung. tesis tidak dipublikasikan. wong, d.l., et al., 2009. buku ajar keperawatan pediatrik. jakarta: egc. yusuf, s., 2009. psikologi perkembangan anak dan remaja. bandung: pt remaja. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 vol 9 no 1 april 2014.indd 111 tingkat nyeri dan prostaglandin-e2 pada ibu inpartu kala i dengan tindakan counter-pressure (pain level and prostaglandin-e2 using counter-pressure during 1st stage of labor) sri rejeki*, ariawan soejonoes**, soenarjo***, amin husni**** *departemen keperawatan maternitas fakultas keperawatan dan kesehatan universitas muhammadiyah semarang. jl. kedung mundu raya 18 semarang. hp:08122800206 **bagian obstetri gynecologi konsultan rs dr. karyadi/undip semarang ***bagian anestesi konsultan rs dr karyadi/undip semarang **** bagian patologi anatomic konsultan syaraf rs. dr. kariadi/undip semarang e-mail: ii_rejeki@yahoo.com abtrak pendahuluan: peningkatkan pembentukan pg-e2 dapat menimbulkan kontraksi uterus sebagai penyebab nyeri persalinan. nyeri persalinan yang lama dapat mengancam kehidupan janin dan ibu. beberapa penelitian melaporkan mengatasi nyeri dengan farmakoterapi sering mengakibatkan efek samping pada fetus. untuk itu diperlukan metode yang mempunyai efektifi tas kuat tetapi minimal dalam efek samping, serta tidak mempengaruhi kontraksi uterus dan kemajuan persalinan. counter-pressure adalah metode non farmakoterapi sebagai alternatif untuk mengurangi nyeri persalinan. tujuan penelitian ini adalah untuk menganalisis peran counter-pressure dalam mengatasi nyeri persalinan sebagai indikator adalah tingkat nyeri persalinan dan kadar pg-e2. metodologi: desain penelitian adalah quasi experimental designs dengan jenis nonequivalent control group design. sebanyak 52 primigravida dalam proses persalinan kala i dengan consecutive sampling terpilih sebagai sampel yang terbagi menjadi 26 untuk perlakuan dan 26 sebagai kontrol. hasil: terdapat penurunan yang signifi kan tingkat nyeri pada perlakuan counterpressure (p=0,000). tidak terdapat perubahan kadar pg-e2 pada perlakuan counter-pressure (p=0,095). diskusi: metode counter-pressure sangat signifi kan menurunkan tingkat nyeri persalinan. metode counter-pressure tidak mempengaruhi perubahan pg-e2. kata kunci: tingkat nyeri, pg-e2, counter-pressure abstract introduction : increased the forming of pg-e2 able to trigger uterus contraction and cause of labor pain. the longer a woman experiences with labor pain the more dangerous for the mother and the baby. so, it is necessary the solutions for labor pain problem. some studies reported that giving some medicines to relieve the pain often have many side effects on fetus. it is necessary to fi nd a method which is not only effective but also has minimal side effect and it doesn’t affect on uterus contraction and labor progression. counter-pressure become preferences to reduce labor pain. the purpose of this study is to analyze counter-pressure in relieving the labor pain. the labor pain level, pg-e2 level become the indicators of this study. method: this study was quasi-experimental designs, by using a nonequivalent control group design. as many as 52 primigaravidas in labor progression phase i, with consecutive sampling were chosen as samples. they were divided into 2 groups; 26 subjects with counter-pressure treatment and 26 subjects as control. result: there were a very signifi cant decline of labor pain phase i level on counter-pressure treatment (p=0.000)). there was no change of pg-e2 level on the counter pressure treatment (p=0,095), but there is change on control. discussion: counter-pressure method is very signifi cant in declining the labor pain level. counter-pressure method do not affect both the pg-e2. key words: pain level, pg-e2, counter-pressure pendahuluan sebagian besar (90%) persalinan disertai rasa nyeri (oxorn, dc). rasa nyeri pada persalinan lazim terjadi dan merupakan proses yang melibatkan fisiologis dan psikologis ibu. nyeri merupakan penyebab frustrasi dan putus asa, sehingga beberapa ibu sering merasa tidak akan mampu melewati proses persalinan (niven & gijsbers, 1994; potter & ann griffi n, 2006). murray melaporkan kejadian nyeri pada 2.700 ibu bersalin, 15% mengalami nyeri ringan, 35% dengan nyeri sedang, 30% dengan nyeri hebat dan 20% persalinan disertai nyeri sangat hebat (murray, et al., 2002). nyeri persalinan dapat menimbulkan st res, dimana pada proses selanjut nya menyebabkan pelepasan hormon katekolamin 112 jurnal ners vol. 9 no. 1 april 2014: 111–117 dan steroid (niven & gijsbers, 1994). hormon ini menstimulasi terjadinya ketegangan otot polos dan vasokont riksi pembuluh darah sehingga terjadi penurunan kontraksi uterus, penurunan sirkulasi uteroplasenta, pengurangan aliran darah dan oksigen ke uterus, serta timbulnya iskemia uterus yang membuat impuls nyeri bertambah banyak dan meningkatkan rasa nyeri (niven & gijsbers, 1994; potter & ann griffi n, 2006). nyeri yang menyertai kontraksi uterus mempe nga r u h i mek a n isme f u ngsional me nyebabk a n re spon st re s f isiolog is. nyeri persalinan yang lama menyebabkan hiperventilasi sehingga frekuensi pernafasan d apat mencapai 60 –70 kali per men it sehingga menurunkan kadar paco2 ibu dan meningkatnya ph. apabila kadar paco2 ibu rendah, maka kadar paco2 janin juga rendah sehingga menyebabkan deselerasi denyut jant ung janin. nyeri juga menyebabkan aktivitas uter us tidak terkoordinasi dan akan mengakibatkan persalinan lama, yang akhirnya dapat mengancam kehidupan janin dan ibu. selain itu nyeri yang lama dan tak tertahankan akan menyebabkan meningkatnya tekanan sistol sehingga berpotensi terhadap adanya syok kardiogenik (anita, et al., 2002; jatmika, 2003). impuls rasa nyeri persalinan kala i ditransmisikan melalui saraf spinalis torakal bawah (t10 -12) dan saraf spinalis lumbal atas (l1). serat aferen saraf ini berasal dari korpus uteri dan serviks. impuls sensorik dari uterus diteruskan melalui sinaps dalam kornu posterior medula spinalis segmen torakal 10, 11,12 dan lumbal 1. kelompok sel saraf tertentu didalam medula spinalis, batang otak dan korteks serebri memiliki kemampuan untuk mengatur impuls nyeri melalui suatu mekanisme inhibisi (gate control theory) (mender & rosemar y, 2003). menu r ut teori gate control sensasi nyeri dihantar sepanjang saraf sensoris menuju ke otak dan hanya sejumlah sensasi atau pesan tertentu dapat dihantar melalui jalur saraf ini pada saat bersamaan (jatmika, 2003; mender & rosemary, 2003). selama persalinan kala i, sensasi nyeri dihasilkan oleh dilatasi serviks dan segmen bawah rahim serta distensi uterus. intensitas nyeri persalinan kala i akibat dari kontraksi uterus involunter dirasakan dari pinggang dan menjalar ke dinding abdomen dengan, kualitas nyeri yang dapat bervariasi (mender & rosemary, 2003). nyeri persalinan yang tidak tertahankan mendorong ibu bersalin mencari beberapa alternatif untuk mengatasi nyeri, diantaranya menggunakan obat penawar nyeri seperti analgetik dan sedatif (zulkarnain, 2005). obatobat tersebut dapat memberikan efek samping yang merugikan misalnya fetal hipoksia, risiko depresi per nafasan neonatus, penur unan frekuensi denyut jantung dan peningkatan suhu tubuh ibu serta dapat menyebabkan perubahan pada janin (anita, et al., 2002). beberapa teori persalinan menjelaskan bahwa mekanisme persalinan diakibatkan oleh p e r uba h a n biok i m ia a nt a r a lai n peningkatan perbandingan kadar hormon estrogen dan progesteron sehingga terjadi penurunan progesteron, peningkatan kadar prostaglandin, peningkatan reseptor oksitoksin pada miomet rium, penambahan volume uterus mengakibatkan iskemia pada otot-otot uterus dan menyebabkan gangguan sirkulasi uteroplasenter sehingga plasenta mengalami degenerasi. selain itu tekanan kepala bayi membantu dilatasi daerah servik uteri dan perineum (bobak, 2005). faktor lain yang juga banyak disebut merupakan mediator inisiasi persalinan adalah tumor necrosis factor-alpha(tnfα), interleukin-1β(il-1β) dan interleukin-6 ( jaffe, 1999). interleukin6 dapat ditemukan pada plasenta, desidua, khorion dan cairan amniotik. dilaporkan pada percobaan invitro bahwa pemberian il-6 pada kultur sel amnion dan desidua manusia akan meningkatkan pembentukan prostaglandin (jaffe, 1999 ; rusmin, 2006). pe r a n g s a n g a n s e l a m n i o n d a n kor ion dengan i l -1β, i l 6 d an t n fα meningkatkan produksi prostaglandin-e2 (pg-e2) dan prostaglandin-f2α(pgf-2α) dari metabolisme asam arakidonat melalui enzim prostaglandinsintase-2(pghs-2). pghf2α bersama estrogen akan meningkatkan pembentukan gap junction dan reseptor oksitoksin sehingga menyebabkan pemendekan 113 tingkat nyeri dan prostagladin-e2 pada ibu inpartu kala i (sri rejeki, dkk) se r at ot ot seh i ngga t e r ja d i kont r a k si miometrium. pg-e2 merupakan suatu zat yang paling efektif untuk menginduksi dilatasi servik (rusmin, 2006; cuningham, et al., 2001). prostaglandin tampaknya melunakkan serviks dengan meningkatkan proteoglikan dan mengubah sifat-sifat biofi sika kolagen. pen i ng kat a n prost agla nd i n pg -e2 d a n pgf2α endomet r iu m dengan kont raksi uterus, menyebabkan iskemia dan rasa sakit. metaanalisis obat ains (anti imf lamasi nonsteroid) secara su kses menghambat pembent u k a n prost agla nd i n, seh i ngga me ng h i la ng k a n r a sa nye r i d isme nore pada 75–85% kasus (murray, et al., 2002). pada kehamilan aterm prostaglandin dan interleukin-6 (il-6) diproduksi pada desidua setelah dilatasi ser vik, kemudian akan didistribusikan pada cairan amnion dan vagina (bobak, 2005). berbagai metode dilakukan unt uk mengurangi nyeri persalinan, terutama metode dengan far makoterapi, tetapi penelitian mengurangi nyeri persalinan dengan non fa r m a kot e r api m a si h sa ngat t e rbat a s. beberapa penelitian mengurangi nyeri dengan farmakoterapi didapatkan obat-obat yang digunakan dapat memberikan efek samping yang merugikan meliputi fetal hipoksia, resiko depresi per nafasan neonatus, penur unan frekuensi denyut jantung dan peningkatan suhu tubuh ibu serta dapat menyebabkan per ubahan pada janin(graw hill, 2001). untuk itu diperlukan metode yang mempunyai efektifitas kuat tetapi minimal dalam efek samping, serta tidak mempengaruhi kontraksi uterus dan kemajuan persalinan. counterpressure (cp) adalah metode non farmaka sebagai alternatif untuk mengurangi nyeri persalinan. counter-pressure dengan menekan regio sakralis dilaporkan dapat mengurangi rasa nyeri saat kontraksi rahim. dengan memakai metode cp ini jalur saraf untuk persepsi nyeri melalui jalur saraf yang berasal dari jaringan lunak dihambat atau dikurangi. selain itu juga perlu dibuktikan apakah metode tersebut dapat mempengaruhi pg-e2 sebagai neurotransmitter dalam proses persalinan. metode r a nca nga n penelit ia n i n i a d ala h quasy experimental design dengan jenis nonequivalent cont rol g roup de sig n. subyek dalam penelitian ini yaitu ibu dalam proses persalinan kala i. melalui tehnik consecutive sampling, maka didapatkan 52 ibu primigravida dalam proses persalinan kala i yang memenuhi kriteria inklusi, yang kemudian terbagi menjadi 2 kelompok yaitu kelompok perlakuan dan kelompok kontrol. kedua kelompok dilakukan pengkajian t i ng kat nyer i d a n pengambila n cai ra n servikovaginal sebelum dan sesudah tindakan pada kelompok perlakuan yaitu dengan metode counter-pressure, sedangkan pada kelompok kontrol tidak dilakukkan perlakuan. tingkat nyeri persalinan diukur dengan numeric rating scale (nrs), sedangakan pg-e2 diperiksa dari cairan servikovaginal. hasil penelitian ini dilakukan pada ibu primigravida dalam proses persalinan normal kala i fase aktif di rumah sakit umum daerah soewondo kendal. pemilihan lokasi penelitian didasarkan pada jumlah persalinan, homogenitas, kultur pasien dan kemudahan perlakuan dan pengamatan dalam penelitian. pengambilan subyek dilakukan selama sembilan bulan, yaitu pada bulan september 2011 sampai dengan bulan mei 2012. sebanyak 52 subyek yang terbagi dalam 2 kelompok, yaitu 26 subyek dengan perlakuan counterpressure (cp), dan 26 subyek masuk dalam kelompok kontrol dimana dalam kelompok ini subyek penelitian tidak mendapat perlakukan. setiap subyek penelitian diberikan informed concernt dan dimintakan ijin penelitian kepada subyek penelitian. tabel 1. rerata umur responden (n=52) perlakuan mean±sd p cp 25,77±3,141 0,842* kontrol 25,38±3,612 total 25.50±3,979 median: 25,00 min. umur: 17,00 max. umur: 39,00, *uji kruskal wallis 114 jurnal ners vol. 9 no. 1 april 2014: 111–117 uji nor malitas data umur dengan kolmogorov-smirnov didapatkan data tidak berdistribusi normal (p= 0,001). maka uji perbedaan umur dengan menggunakan kruskal wallis diperoleh p=0,842, disimpulkan tidak ada perbedaan umur pada perlakuan 1 dan kelompok kontrol. t i n g k a t n y e r i d i u k u r d e n g a n menggunakan numeric rating scale sebelum dan sesudah perlakuan yang diambil rata-rata dari 3 kali pada kelompok perlakuan. dari tabel 3 dapat dilihat bahwa sebagian besar responden pada tingkat nyeri sedang sampai tingkat nyeri berat. didapatkan ada penurunan tingkat nyeri pada 2 kelompok. dari hasil analisis uji dengan wilcoxon didapatkan ada perbedaan tingkat nyeri sebelum dan sesudah perla k u a n counter-pressure ( p= 0,000) sedangkan pada kelompok control sedikit ada perbedaan (p= 0,041). disimpulkan ada perbedaan sangat ber makna tingkat nyeri sebelum dan sesudah pada kelompok perlakuan, dan bermakna pada kelompok kontrol kadar prostaglandin-e2 (pg-e2) diukur dengan tes elisa. dari tabel 5 dapat dilihat ada penurunan kadar pg-e2 pada kelompok perlakuan dan didapatkan tidak ada perbedaan pg-e2 , tetapi pada kelompok kontrol ada sedikit peningkatan dan ada perbedaan kadar pg-e2 (p=0,000). pembahasan usia mempengaruhi seseorang berespon terhadap nyeri. berdasarkan dari rerata umur responden adalah 26 tahun menunjukkan mayoritas pada kelompok umur 20-30 tahun, selain responden rata-rata berada pada usia produktif, juga secara fi siologis dimungkinkan masih kuat menahan nyeri persalinan. namun demikian bila dilihat dari usia minimal (17 tahun) dan maksimal (39 tahun), data ini menunjukkan masih ada usia yang beresiko tabel 2. dekripsi karakteristik dasar tingkat nyeri dan pg-e2 variabel perlakuan mean±sd p tingkat nyeri cp 8,96±0,528 0,001* kontrol 8,23±0,951 pg-e2 cp 18,925±3,7595 0,000* control 16,267±6,294 *) uji kruskal wallis, **) uji anova tabel 3. rerata tingkat nyeri persalinan kala i sebelum dan sesudah perlakuan perlakuan sebelum mean±sd sesudah mean±sd ∆ p counter-pressure 8,96±0,528 6,96±0,774 2,00 0,000* kontrol 8,23±0,951 7,88±1,033 0,35 0,041 total 8,67±0,777 7,42 ±1.042 1,25 *) uji korelasi wilcoxon tabel 4. rerata kadar pg-e2 sebelum dan sesudah perlakuan perlakuan sebelum mean±sd sesudah mean±sd ∆ p cp 18,925±3,7595 17,584±3,687 1.3410 0,095** kontrol 16,267±6,294 16.439±5.926 -,1717 0,000* total 18,475±4,980 16,735±5,223 1,7397 **) uji wilcoxon, *) paired t test 115 tingkat nyeri dan prostagladin-e2 pada ibu inpartu kala i (sri rejeki, dkk) untuk melahirkan yaitu usia aman untuk melahirkan berada pada rentang usia di atas 20 tahun sampai dengan di bawah 35 tahun. hasil uji perbedaan umur dengan menggunakan kruskal wallis diperoleh p= 0,842 sehingga dapat disimpulkan bahwa tidak ada perbedaan umur pada perlakuan dan kontrol. rerata tingkat nyeri persalinan kala i fase aktif yang diukur dengan menggunakan numeric rating scale didapatkan sebagian besar responden berada pada tingkat nyeri sedang sampai tingkat nyeri berat yaitu rentang nilai 4 sampai 10. rata-rata ada penurunan tingkat nyeri setelah perlakuan dan kontrol. dari hasil analisis uji dengan wilcoxon didapatkan ada perbedaan tingkat nyer i sebelu m d a n sesud ah perla k u a n counter-pressure (p= 0.000) dengan delta: 2,00 demikian juga pada kontrol didapatkan ada perbedaan (p=. 0.041) dengan delta: 0,35. dari hasil tersebut disimpulkan ada perbedaan yang sangat bermakna tingkat nyeri sebelum dan sesudah pada kelompok perlakuan dengan cp dan perubahan bermakna pada kelompok kontrol dimana p < 0,05. dilihat dari perbedaan nilai (delta) didapatkan delta kontrol (0,35) lebih kecil dibandingkan dengan delta perlakuan (2,00). hal ini menunjukkan selisih perbedaan yang memperlihatkan kemaknaan dari perubahan nilai tingkat nyeri, dapat diartikan kelompok perlakuan lebih banyak ada penurunan tingkat nyeri dibanding dengan kelompok kontrol. untuk melihat pengaruh perlakuan digunakan uji hipotesis dengan uji kruskal wallis. hasil uji kruskal wallis diperoleh p= 0.000, maka dapat disimpulkan: ada pengaruh metode counter-pressure terhadap perubahan tingkat nyeri persalinan kala i. nyeri merupakan sensasi yang bersifat subyek t if d a n mer upa ka n pengala ma n e m o s i o n a l d a n s e n s o r i y a n g t i d a k menyenangkan yang muncul dari kerusakan jaringan secara aktual atau potensial. nyeri merupakan pengalaman mekanisme protektif bagi tubuh dan menyebabkan individu bereaksi untuk menghilangkan rangsang nyeri (raja, dougherty, 1999; dawood, 2006; harel, 2006). hal yang memu ngk i n kan adanya pengaruh perlakuan counter-pressure pada regio sakralis adalah bahwa aspek penting dari nyeri adalah nosiseptif, sebuah peristiwa elektrokimiawi yang melibatkan aktivasi jalur saraf tertentu sebagai respon terhadap stimulus yang potensial menimbulkan ker usakan jaringan, secara klinis, derajat nosiseptif menjadi tanda dari ker usakan jaringan. sebaliknya, nyeri adalah sebuah pengalaman subyektif yang mungkin melibatkan aktivasi jalur saraf aferen atau komponen lainnya, seperti pemprosesan somatosensori atau faktor psikososial (melzack, et al., 1984) pikiran dan emosi dapat mempengaruhi persepsi nyeri (ridolf, et al., 2001). melalui mekanisme penghambat (gate cont rol theor y) persepsi nyeri ini dapat diat ur sehingga sebelum mencapai susunan saraf pusat stimulus nyeri dapat diperbesar oleh serabut kecil atau diperkecil oleh serabut besar (molyata, 2010; vane, et al., 1998; melzack, 1984). counter-pressure ber peran dalam memicu serabut besar sehingga menghambat stimulus nyeri sebelum mencapai ke susunan saraf pusat (melzack, 1984; melzack, 1981). t i n d a k a n p e r l a k u a n d e n g a n metode counter-pressure yang dilakukan menunjukkan adanya pendekatan psikologis dan sosial, karena adanya kedekatan dan sentuhan yang diberikan kepada pasien memungkinan ia merasa lebih diperhatikan sehingga mempengaruhi penurunan derajat tingkat nyeri. berdasar hasil penelitian didapatkan penur unan kadar pg-e2 pada kelompok perlakuan, tetapi sedikit peningkatan pada kelompok kontrol. hasil uji wilcoxon diperoleh ada perbedaan kadar pg-e2 pada kelompok kontrol (p=0,000), tetapi didapatkan tidak ada perbedaan pg-e2 pada kelompok dengan perlakuan counter-pressure (p=0.095). hasil uji kruskal wallis di peroleh p=0,000, sehingga dapat disimpulkan bahwa terdapat pengaruh kombinasi metode counterpressure dan relaksasi pernafasan terhadap perubahan kadar pg-e2 pada proses persalinan kala i. 116 jurnal ners vol. 9 no. 1 april 2014: 111–117 penurunan pg-e2 sebagai penyebab kont r a k si ute r u s d i mu ng k i n k a n d apat menurunkan nyeri persalinan, sebagaimana beberapa penelitian membuktikan bahwa peningkatan kadar prostaglandin berperan penting pada terjadinya nyeri haid, yaitu terjadi spasme miometrium. terjadinya spasme miometrium dipacu oleh zat dalam darah haid, mirip lemak alamiah yang kemudian diketahui sebagai prostaglandin, kadar zat ini meningkat pada keadaan nyeri haid dan ditemukan di dalam otot uterus (raja & dougherty, 1999). d i t e m u k a n k a d a r p g e 2 d a n pgf2α sangat tinggi dalam endometrium, miometrium dan darah haid wanita yang menderita nyeri haid primer. prostaglandin menyebabkan peningkatan aktivitas uterus dan serabutserabut saraf terminal rangsang nyeri. prostaglandin dan peningkatan kepekaan miometrium menimbulkan tekanan intra uterus sampai 400 mmhg dan menyebabkan kontraksi miometrium yang hebat. atas dasar itu disimpulkan bahwa prostaglandin yang dihasilkan uter us ber peran dalam menimbulkan hiperaktivitas miometrium. kontraksi miometrium yang disebabkan oleh prostaglandin akan mengurangi aliran darah, sehingga ter jadi iskemia sel-sel miometrium yang mengakibatkan timbulnya nyeri spasmodik. jika prostaglandin dilepaskan dalam jumlah berlebihan ke dalam peredaran darah, maka akan timbul efek sistemik seperti diare, mual, muntah (dawood, 2006). simpulan dan saran simpulan counter-pressure sangat ber peran dalam menurunkan tingkat nyeri persalinan, metode counter-pressure tidak mempengaruhi perubahan kadar pg-e2. saran rasa nyeri sangat subyektif dan banyak faktor yang mempengaruhinya, salah satu faktor adalah status obstetri untuk itu agar memperoleh deskripsi yang lebih lengkap maka sampel penelitian dapat diperluas pada ibu inpartu multigravida. kepustakaan anita a, ocviyanti d, wisnuwardhani sd, handaya, (2002). gambaran intensitas nyeri pada persalinan menggunakan metode vas dan vrs. mogi. 26(4): hal; 189-250 bobak im. (2005). maternit y nursing. ( wijaya nt i, m a & a nug r a h , pi pe ne r jema h). cal ifor n ia: mosby. (sumber asli diterbitkan 1995). cu ningham fg, gant n f, leveno k j. parturitian, (2001). williams obstretics, 21sted. mc dawood, m. 2006. primary dysmenorrhea ad v a n c e s i n pa t h og e n e si s a n d management. journal obstetric and gynaecology, 108(2). graw hill medical publishing division. newyork, 2001;252-86 harel, zeev md. (2006). dysmenorrhea in adolescents and young adults: etiology and management .j pediatr adolesc gynecol 19:363-71 jaffe rb. (1999). neuroendocrine-metabolic regulation of pregnancy. reproductive endocrinology, 4th ed. w.b. saunders company.; 751-84 jatmika w. (1999). hubungan skor kecemasan dengan lama persalinan kala i. tesis. bagian obstetri ginekologi: fk undip semarang melzack, r, kinch r, dobkin p, lebrun m, taenzer p. (1984). severity of labour pain: infl uence of physical as well as psychologic variables. can med assoc j, 130:579–84 melzack, r, taenzer p, feldman p, kinch ra. (1981). labour is still painful after prepared childbirth training. can med assoc j;125:357–63 melzack, r. (1984). the myth of painless childbirth (the john j. bonica lecture). pain;19:321–37 mender, rosemary. (2003). nyeri persalinan, jakarta: egc. molyata. (2010). paket penyuluhan dan senam hamil mengurangi stres dan nyeri serta mempercepat penyembuhan persalinan, (online), ht t p://w w w.u ns.ac.id /c p/ penelitian.php?act=det&ida=271, murray, sharon, s., emily, s., mckinney, trula myers gorrie. (2002). foundation of 117 tingkat nyeri dan prostagladin-e2 pada ibu inpartu kala i (sri rejeki, dkk) maternal-newborn nursing. 3rd ed. w.b. saunders company..p. 125-35 niven, c., gijsbers, k. (1994). a study of labor pain using the mcgill pain questionnaire, soc sci med;19:1347-51. oxorn, d.c. (1986). obstetric analgesia and anesthesia, in oxorn-foote human labor & birth. 5th ed, appleton-century –crofts. potter, p, ann, griffi n p. (2006). fundamental of nursing; concep process and prectice, 4th ed missoury: mosby year book inc. st louis.. hal. 1504-8. raja, s.n., dougherty, p.m. (1999). pain and the neurophysiology of somatosensory processing. in : benzon ht, raja sn, borsook d, molloy re, strichartz g, eds. essentials of pain medicine and regional anesthesia. new york: churchill livingstone.; 2-11. ridolf, ray, franzen, ifana e, susane r. (2001). shiatsu untuk wanita. jakarta: arcan. rusmin, i. (2006). hubungan kadar il-6 serum pada kehamilan preterm dengan te r ja din ya pe rsalin a n . bag /sm f obstetri dan gynekologi fk andalas blu rs. dr. m. djamil. padang. vane, j.r., bakhle, y.s., botting, r.m. (1998). cyclooxygenases 1 and 2. annu rev pharmacol toxicol, 38, 97-120 zulkarnain, adil. (2003). pengaruh pemberian ketorolac untuk mengurangi nyeri pada persalinan kala i fase aktif; tesis. bagian/smf obsgyn fk ugm rsup dr. sardjito yogyakarta. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 147 praktik kolaborasi perawat-dokter dan faktor yang memengaruhinya (collaboration practice between nurses and physician and the affecting factors) wiwin martiningsih poltekkes kemenkes malang prodi keperawatan blitar jl. dr. sutomo 56 blitar, e-mail: wiwin_martiningsih@yahoo.co.id abstract introduction: collaboration is basically discuss about togetherness, cooperation, sharing tasks, equality, responsibility, and accountability. purpose of this research was to learn the collaboration practice beetwen nurses and physician and the factors affecting. method: design of this research was correlational and comparational study, and population were the physician who work in ngudi waluyo blitar hospitals, intensive cooperation with the nurse in the room, not holding structural positions and not studying, there are 19 peoples taken by total population and nurses who work in ngudi waluyo hospitals, not holding structural positions (head of division or head of section), having relationship with the physician and the samples were 31 peoples taken by probability proportional to size (pps). methods of data collection by giving questionnaire about the characteristics of respondents (nurses and physician) and practice of collaboration scale. data characteristics and attitudes of nurses and physicians about the practice of collaboration is analyzed with descriptive statistics, to know the differences between nurses and physicians attitude using mann whitney u test. to know affecting characteristic with nurses and physician attitude by multivariate analysis. result: results of mann whitney test p value is 0.611, which means that there is no difference between nurses and physician attitude in practice collaboration, and result of multivariate analysis the infl uence of nurse characteristics (age, education, functional potition, length of working) with attitude are 0.460 or 46%, while 54% infl uenced by other factors, and the infl uence of physician characteristics (age, education, length of working) with attitude are 0.435 or 43.5%, while 56.5% infl uenced by other factors. discussion: further need to study other factors that infl uence and research by observation the impact of collaboration between the nurse with physician on the service quality. keywords: attitude, collaboration, nurse, physician pendahuluan perawat dan dokter memiliki kepuasan dan kebanggaan tersendiri dalam berkarya. tetapi mereka sering dihadapkan pada masalah yang sama yaitu mereka tidak dapat berkolaborasi dengan baik sehingga menghambat usaha mereka untuk membantu klien. salah satu tujuan kolaborasi adalah memberikan pelayanan kesehatan yang berkualitas dengan menggabungkan keahlian unik dari masing-masing profesi, untuk menggabungkan keahlian unik ini dibutuhkan kesadaran dan kemampuan dari masing-masing profesi, kurangnya kesadaran dan kemampuan dalam berkolaborasi dapat menimbulkan dampak yang buruk terhadap kualitas layanan yang diberikan. banyak faktor yang memengaruhi atau menghambat pelaksanaan kolaborasi diantaranya adalah faktor sosial, institusional, faktor ekonomi, kemampuan klinik dan kemampuan menjalin hubungan interpersonal (siegler, 2000), dalam memahami konsep kolaborasi para ahli teori organisasi menurut sullivan (1998) mengusulkan bahwa perilaku dalam penanganan konfl ik dapat digunakan untuk menilai praktik kolaborasi yang dapat dilihat dari 2 dimensi yaitu tingkat ketegasan atau asertif dan kerja sama atau kooperatif. ketegasan berarti bahwa sampai tingkat mana satu pihak berupaya untuk memenuhi kepentingannya sendiri, dan kerja sama yang berarti suatu tingkat tertentu di mana salah satu jurnal ners vol. 6 no. 2 oktober 2011: 147–155 148 pihak berupaya untuk memuaskan kepentingan pihak lain. kolaborasi akan terjalin dengan baik apabila komponen ketegasan dan kerja sama yang dimiliki perawat dan dokter adalah baik, sehingga masing-masing berkeinginan untuk memuaskan sepenuhnya kepentingan dari semua pihak (saling menguntungkan). apabila ketegasan lebih dominan dari unsur kerja sama yang muncul hanyalah sebuah persaingan, sedangkan apabila kerja sama lebih dominan dari ketegasan, seseorang akan tampak takut dan cenderung pada akomodasi atau menerima instruksi begitu saja. keperawatan sebagai salah satu profesi mempunyai kewenangan yang jelas, disiplin ilmu yang berbeda dengan profesi lain, kedudukan perawat sejajar dengan profesi kesehatan lain. sebagai mitra masing-masing profesi harus menghargai profesi lain, konsep ini harus ditanamkan dalam masing-masing profesi kesehatan, sejak dibangku pendidikan sampai dengan di lingkungan profesional. hasil penelitian menjelaskan bahwa praktik kolaborasi perawat dengan dokter berimbas pada penurunan biaya perawatan 25%, dan penurunan lama hari perawatan 39,8% (sulivan, 1998). pendidikan keperawatan di indonesia yang diawali dari pendidikan yang bersifat vokasional (spk atau sekolah perawat kesehatan, diii keperawatan, div keperawatan) berkembang ke arah pendidikan keperawatan yang bersifat profesional yaitu pendidikan s1 keperawatan, s2 keperawatan, bahkan doktor di bidang keperawatan, diharapkan dengan meningkatnya pendidikan akan diikuti dengan peningkatan kompetensi klinis dan kemampuan berkolaborasi. beberapa kebijakan diambil oleh rumah sakit agar terjadi harmonisasi antar tim pemberi layanan kesehatan seperti ronde bersama, pertemuan bersama pada hari-hari yang telah disepakati atau bentuk kegiatan lain yang tujuannya adalah menyamakan persepsi atau bekerja sama untuk menyelesaikan masalah, namun demikian hanya beberapa institusi atau rumah sakit yang mampu secara rutin melakukan kegiatan ini. hasil wawancara peneliti dengan 2 pejabat struktural dan 2 perawat rsud ngudi waluyo kabupaten blitar, yang merupakan rs tipe b non pendidikan bahwa kolaborasi perawat dan dokter belum berjalan sesuai yang diharapkan, karena masing-masing pihak cenderung mengutamakan kepentingan hubungan dengan pasien, kurang memperhatikan hubungan perawat dengan dokter. sebenarnya standar operasional prosedur (sop) tentang kolaborasi tim kesehatan sudah ada, yang kegiatannya dapat dilihat saat pelaksanaan ronde keperawatan, atau kegiatan lain yang melibatkan tim kesehatan ini, tetapi pelaksanaannya juga belum optimal, kemungkinan penyebabnya karena selama ini beberapa dokter menganggap bahwa perawat belum kompeten untuk diajak berkolaborasi, selain itu usulan yang disampaikan oleh perawat cenderung kurang dianggap dan belum ada manfaatnya, untuk mengantisipasi hal ini pimpinan rsud ngudi waluyo sudah berupaya meningkatkan kemampuan masingmasing perawat melalui pelatihan-pelatihan, seminar dan pendidikan jalur formal. hal ini ditunjukkan dengan pendidikan minimal perawat di rsud ngudi waluyo adalah d iii keperawatan, berdasarkan informasi di atas peneliti berkeinginan mempelajari bagaimana para pemberi layanan menyikapi praktik kolaborasi ini, apakah ada perbedaan sikap antara dokter dan perawat dan faktor apa yang mempengaruhinya. bahan dan metode penelitian ini menggunakan studi komparasi antara sikap perawat dan sikap dokter tentang praktik kolaborasi, serta studi korelasi antara karakteristik perawat dan dokter terhadap sikap perawat dan dokter tentang praktik kolaborasi. sampel dalam penelitian ini adalah dokter yang bekerja di rsud ngudi waluyo kabupaten blitar yang intensif bekerja sama dengan perawat di ruangan, tidak memegang jabatan struktural dan tidak menjalankan tugas belajar sebanyak 19 orang yang diambil secara total dan perawat yang bekerja di rsud ngudi waluyo kabupaten blitar, tidak memegang jabatan struktural (kepala bidang atau kepala seksi), mempunyai hubungan kerja praktik kolaborasi dengan dokter, yang seluruhnya berjumlah 150 orang. teknik pengambilan sampel praktek kolaborasi perawat-dokter (wiwin martiningsih) 149 secara probability proportional to size (pps), besar sampel 31 orang (diambil dari 20% populasi). identifi kasi praktik kolaborasi perawat dengan dokter menggunakan instrumen yang terbagi dalam dua skala yaitu skala praktik kolaborasi untuk dokter dan skala praktik kolaborasi untuk perawat (siegler, 2000), yang telah diuji validitas dan reliabilitasnya, selain itu responden juga harus mengisi alasan terhadap jawaban yang diberikan melalui kuesioner terbuka. data karakteristik perawat dan dokter serta data sikap perawat dan dokter tentang praktik kolaborasi dianalisis dengan menggunakan statistik deskriptif, sedangkan untuk mengetahui perbedaan sikap perawat dengan sikap dokter tentang praktik kolaborasi dianalisis dengan mann whitney test dengan tingkat kemaknaan p ≤ 0,05, dan untuk mengetahui pengaruh karakteristik perawat dan dokter terhadap sikap perawat dan dokter tentang praktik kolaborasi perawat dengan dokter dianalisis dengan metode analisis multivariate menggunakan structural equation modelling (sem), dengan perangkat lunak analysis of moment structure (amos) versi 5. hasil usia perawat sebagian besar > 30 tahun (77,4%) dan selebihnya antara 20–30 tahun 22,6%, sedang jenis kelamin terbanyak adalah perempuan 61,3%, pendidikan diii keperawatan 71%, jabatan fungsional terbanyak adalah perawat penyelia 41,9%, lama kerja sedang sampai dengan lama sebanyak 90,3%, tempat kerja terbanyak di ruang penyakit dalam 22,5%. usia dokter sebagian besar > 30 tahun (89,4%) dan selebihnya antara 20–30 tahun (10,6%), sedang jenis kelamin terbanyak adalah laki-laki (63,2%), pendidikan s2/spesialis (52,6%), jabatan fungsional dokter pertama, dokter muda dan madya masingmasing sama 26,3%, lama kerja sedang sampai dengan lama sebanyak 79,0%, tempat kerja terbanyak di ird 31,6%. gambar 1 menunjukkan bahwa sikap tentang praktik kolaborasi terbanyak adalah berunding 58% untuk perawat dan 42% untuk dokter, hanya 2 (6%) pada perawat dan 1 (5%) pada dokter yang menunjukkan sikap menghindar. tidak ada sikap bersaing, menghindar–bersaing, dan akomodasi baik pada perawat maupun dokter. hasil uji man whitney didapatkan p value 0,611, yang berarti bahwa tidak ada perbedaan antara sikap perawat dengan sikap dokter tentang praktik kolaborasi perawat dengan dokter. hasil rekapitulasi jawaban perawat maupun dokter atas 19 pertanyaan dari skala praktik kolaborasi 3 urutan teratas sikap yang sering ditunjukkan perawat adalah meminta masukan sejawat untuk memperkuat sistem pendukung, menceritakan kesulitan pasien, dan melakukan negosiasi menentukan tanggung jawab masing-masing, sedangkan pada dokter adalah menyampaikan apabila tindakan perawat kurang tepat, memberi saran cara pendekatan yang bermanfaat, dan menekankan pentingnya bidang medis maupun keperawatan pada pasien. sikap perawat dengan dokter yang k e t e g a s a n 54 bersaing (skor 2) perawat = 0 dokter = 0 bersaing-kolaborasi (skor 3) perawat = 1 (3%) dokter = 0 kolaborasi (skor 4) perawat = 3 (10%) dokter = 4 (21%) 39 24 menghindar-bersaing (skor 1) perawat = 0 dokter = 0 berunding (skor 2) perawat = 18 (58%) dokter = 8 (42%) akomodasi-kolaborasi (skor 3) perawat = 4 (13)% dokter 3 (16%) 9 menghindar (skor 0) perawat = 2 (6%) dokter = 1 (5%) menghindar-akomodasi (skor 1) perawat = 3 (10%) dokter = 3 (16%) akomodasi (skor 2) perawat = 0 dokter = 0 10 25 44 60 kerjasama gambar 1. diagram sikap perawat dan dokter berdasar skala praktik kolaborasi (ketegasan dan kerjasama) siegler dan whytney jurnal ners vol. 6 no. 2 oktober 2011: 147–155 150 paling jarang dilakukan adalah menjelaskan lingkup keahlian masing-masing dan diskusi bidang mana termasuk keperawatan dan mana termasuk medis. terdapat 4 variabel yang berpengaruh secara signifikan terhadap sikap perawat yaitu usia, pendidikan, jabatan fungsional dan lama kerja, hasil analisis menggunakan sem dengan amos versi 5, menunjukkan besarnya pengaruh karakteristik perawat (usia, pendidikan, jabatan fungsional, dan lama kerja) secara bersama-sama terhadap sikap perawat adalah 0,460 atau 46%, sedangkan sisanya 54% dipengaruhi oleh faktor lain. terdapat 3 variabel yang berpengaruh secara signifi kan terhadap sikap dokter yaitu: usia, pendidikan dan lama kerja. hasil analisis menggunakan sem dengan amos versi 5, besarnya pengaruh karakteristik dokter (usia, pendidikan dan lama kerja) secara bersamasama terhadap sikap dokter berdasar hasil analisis adalah 0,435 atau 43,5%, sedangkan sisanya 56,5% dipengaruhi oleh faktor lain. pembahasan hasil penelitian menunjukkan bahwa sikap perawat dan dokter tentang praktik kolaborasi terbanyak adalah berunding atau kompromi. kompromi atau berunding merupakan suatu situasi di mana tiap-tiap pihak pada suatu konflik bersedia untuk melepaskan sesuatu. kedua unsur yang terlibat menyerah dan menyepakati hal yang telah dibuat. menurut sullivan, kompromi atau berunding menjadi pilihan ketika tujuan yang akan diselesaikan benar-benar merupakan perselisihan tidak berguna, lawan dalam konfl ik memiliki komitmen untuk mencapai hasil akhir yang berbeda, dan dilakukan ketika penyelesaian diperlukan secara cepat. melihat konsep di atas sikap berunding ini bagi perawat dan dokter merupakan tindakan yang paling tepat dilakukan saat ini, karena perawat dan dokter mengerti bahwa keterbatasanketerbatasan yang mereka miliki baik dalam hal waktu, tenaga dan kemampuan (terutama perawat) masih merupakan permasalahan yang patut diselesaikan secara bertahap. sesuai dengan hasil penelitian, beberapa ungkapan baik oleh perawat maupun dokter, mendukung permasalahan ini. hal keterbatasan waktu beberapa perawat mengatakan "dokter terbatas waktunya", dokter dan perawat juga mengungkapkan "tergantung waktu dan situasi". tentang keterbatasan kemampuan tabel 1. pengaruh karakteristik perawat secara parsial terhadap sikap perawat tentang praktik kolaborasi karakteristik perawat p kesimpulan usia jenis kelamin pendidikan jabatan fungsional lama kerja ruang tempat kerja 0,000 0,365 0,000 0,013 0,000 0,915 ada pengaruh tidak ada pengaruh ada pengaruh ada pengaruh ada pengaruh tidak ada pengaruh tabel 2. tabel pengaruh karakteristik dokter secara parsial terhadap sikap dokter tentang praktik kolaborasi karakteristik dokter p kesimpulan usia jenis kelamin pendidikan jabatan fungsional lama kerja ruang tempat kerja 0,000 0,174 0,015 0,059 0,000 0,225 ada pengaruh tidak ada pengaruh ada pengaruh tidak ada pengaruh ada pengaruh tidak ada pengaruh praktek kolaborasi perawat-dokter (wiwin martiningsih) 151 ada perawat yang mengatakan" sungkan untuk memberi saran" atau ungkapan perawat " hanya pada dokter yang mau menerima pendapat kita". sikap perawat dan dokter tentang praktik kolaborasi hanya sedikit yang menghindar. menurut sullivan menghindar merupakan mencoba sekadar mengabaikan suatu masalah dan menghindari orang-orang lain yang tidak sependapat dengannya. menghindari konfl ik menjadi pilihan yang baik ketika terdapat lebih dari satu isu kepentingan, kurangnya kesempatan untuk menyelesaikan kebutuhan dan urusan, karena harus memberikan orang lain kesempatan untuk memenangkan konfl ik, karena butuh informasi tambahan, dan terkadang untuk meminimalkan kerugian. seperti ungkapan perawat "dokter paling begitu saja", atau ungkapan dokter "membiarkan semua apa adanya". sikap berunding yang merupakan pilihan sikap terbanyak ± 50% dari jumlah responden baik pada dokter maupun perawat memiliki skor 2 maksudnya bahwa seseorang hanya membutuhkan 2 balok untuk mencapai skor 4 (kolaborasi), sedangkan bila bersikap menghindar (skor 0) harus memindahkan 4 balok untuk menuju kolaborasi. tentunya memindahkan 2 balok lebih mudah daripada 4 balok. ini artinya lebih mudah mengubah sikap berunding untuk menuju kolaborasi dari pada sikap menghindar. beberapa perawat dan dokter sudah memiliki sikap kolaborasi (skor 4) walau hanya 10% pada perawat dan 21% pada dokter, hal ini menunjukkan sudah ada perawat atau dokter yang melaksanakan praktik kolaborasi dengan baik, oleh karena itu perlu adanya reward bagi mereka, sehingga semangat untuk berkolaborasi akan dapat dipertahankan. hasil yang didapat dalam penelitian ini, perawat atau dokter yang mendapatkan skor < 2 (16% untuk perawat dan 21% untuk dokter), setidaknya harus berupaya untuk mulai berubah, karena skor < 2 berarti cenderung ke arah menghindar. alasan-alasan yang diungkapkan dalam jawaban kuesioner terbuka akan menjadi gambaran para pengambil kebijakan dan pasangan kolaborasi sebagai faktor penyebab lemahnya pelaksanaan kolaborasi, sehingga dapat dicarikan solusinya. sikap yang sering ditunjukkan perawat adalah meminta masukan sejawat untuk memperkuat sistem pendukung, menceritakan kesulitan pasien, sedangkan pada dokter adalah menyampaikan apabila tindakan perawat kurang tepat dan memberi saran cara pendekatan yang bermanfaat, sedangkan sikap perawat dan dokter yang paling jarang dilakukan adalah menjelaskan lingkup keahlian masing-masing dan diskusi bidang mana termasuk keperawatan dan mana termasuk medis, karena dianggap masing-masing profesi sudah jelas tentang peran dan fungsinya masing-masing, keberanian mengambil sikap pada dokter dalam hal ini masih dominan karena dokter kebanyakan berani mengingatkan jika tindakan kurang tepat, dan memberi saran cara pendekatan yang bermanfaat. perawat seharusnya juga bersikap demikian, tidak hanya kompromi yang dilakukan tetapi juga harus berani mengatakan tidak apabila tidak sesuai dengan standar yang ada. hasil penelitian berdasarkan uji mann whitney tidak ada perbedaan antara sikap perawat dan sikap dokter tentang praktik kolaborasi perawat dengan dokter, dengan nilai p = 0,611, hasil ini didukung oleh distribusi sikap perawat maupun dokter dalam diagram skala praktik kolaborasi yang hampir sama dan dapat dilihat pada gambar 1, yang menunjukkan distribusi sikap terbanyak baik pada perawat maupun dokter adalah berunding, hanya sedikit perawat dan dokter yang menunjukkan sikap menghindar dan sikap kolaborasi, tidak ada sikap bersaing, menghindar – bersaing, dan akomodasi baik pada perawat maupun dokter. melihat fakta ini jelas bahwa baik perawat dan dokter punya sikap yang sama tentang praktik kolaborasi. mereka memahami bahwa profesi mereka berbeda tetapi kerja sama harus tetap dilakukan sesuai dengan wewenang dan tanggung jawab masing-masing profesi, walau masih didominasi oleh sikap berunding, selain itu perawat dan dokter juga mengenali, menyadari adanya pengetahuan dan keterampilan yang overlapping. sifat caring juga telah tertanam dalam diri perawat dan dokter, salah satunya adalah adanya sikap altruistic (mementingkan kepentingan orang lain daripada diri sendiri) jurnal ners vol. 6 no. 2 oktober 2011: 147–155 152 (feist, 2008). hal ini didukung dengan jawaban beberapa perawat dan dokter pada kuesioner terbuka pada komponen ketegasan terdapat beberapa jawaban yang disampaikan yaitu masalah adalah tanggung jawab bersama, semuanya demi kebaikan pasien, saling mengerti peran masing-masing, sedangkan pada komponen kerja sama yang intinya ingin mencapai konsensus bersama, beberapa jawaban perawat dan dokter adalah agar jelas wewenang masing-masing, sebagai mitra kerja, agar suasana kerja nyaman, untuk kebaikan pasien. perawat dan dokter menyadari bahwa kolaborasi merupakan proses interpersonal di mana dua orang atau lebih membuat suatu komitmen untuk berinteraksi secara konstruktif untuk menyelesaikan masalah klien dan mencapai tujuan, target atau hasil yang ditetapkan. para individu harus mengenali dan mengartikulasikan nilai-nilai yang membuat komitmen ini menjadi terwujud. kemampuan mewujudkan komitmen untuk berinteraksi secara konstruktif tergantung dari persamaan persepsi, tentang tujuan bersama, kompetensi klinik, dan kemampuan interpersonal, humor, kepercayaan, menghargai dan menghormati pengetahuan dan praktik keilmuan yang berbeda. usia berpengaruh terhadap sikap perawat dan dokter tentang praktik kolaborasi berdasar analisis statistik, hasil ini didukung data usia perawat dan dokter sebagian besar adalah dewasa menengah (30–60 tahun), dengan sikap yang banyak mengarah ke berunding sampai kolaborasi. sesuai dengan teori perkembangan erik erikson, tahap perkembangan dewasa, merupakan waktu ketika manusia mulai m e n g a m b i l t e m p a t d i m a s y a r a k a t d a n mengasumsikan sebuah tanggung jawab bagi apapun yang dihasilkan masyarakat. usia dewasa menengah adalah mencapai generativitas yaitu pembangkitan ide-ide baru, memberikan instruksi-instruksi ke orang lain dengan cara yang sesuai dengan budaya. untuk orang dewasa yang matang motivasi ini bukan sekadar kebutuhan tapi juga merupakan dorongan untuk memberikan kontribusi untuk menjamin kontinuitas di masyarakat. dalam tahap ini perhatian merupakan kekuatan dasar masa dewasa (feist, 2008). masa ini perawat dan dokter harus bisa menentukan tugas mana yang dapat dilakukan secara individual, yang harus dilakukan bersama-sama, dan apa yang diharapkan dalam interaksi (lindeke, 2005). mereka juga mengerti bahwa kolaborasi merupakan suatu pengakuan keahlian seseorang oleh orang lain di dalam maupun di luar profesi orang tersebut. pada usia ini masing-masing pasangan kolaborasi membuat suatu komitmen untuk berinteraksi secara konstruktif untuk menyelesaikan masalah klien dan mencapai tujuan, target atau hasil yang ditetapkan. faktor pendidikan juga berpengaruh terhadap sikap perawat dan dokter dalam berkolaborasi. dalam teori, edukasi sebagai institusi sosial tertua, merupakan pengarahan formal dari pengalaman belajar. fungsi edukasi adalah sosialisasi, transmisi pengetahuan kultural seperti nilai (value) dan kepercayaan (belief). membantu individu memilih dan belajar peran sosial serta mempertemukan antara bakat (talent) dan kemampuannya (ability) dengan kebutuhan spesialisasi pekerjaan. selain itu edukasi juga berhubungan dengan stratifi kasi sosial yaitu membantu menentukan posisi di masa depan dalam struktur sosial. peningkatan tingkat pendidikan cenderung membuat individu lebih toleran dan lebih demokratik, karena orang yang memiliki tingkat pendidikan lebih tinggi akan lebih mudah mengenali dan menganalisis bermacam kenyataan atau implikasi tindakan yang tidak benar (sarwono dan soeroso, 2001). kurikulum pendidikan keperawatan menunjukkan bahwa adanya pembelajaran tentang konsep-konsep kepemimpinan, kerja sama, manajemen konfl ik, komunikasi interpersonal mendukung kemampuan perawat dalam berkolaborasi, walaupun pendidikan perawat terbanyak adalah diii keperawatan, namun jenjang ini dikategorikan profesional pemula, yang akan dapat mendukung pelaksanaan kolaborasi. pengaruh pendidikan terhadap sikap dokter tentang praktik kolaborasi adalah signifi kan tetapi mempunyai nilai negatif artinya bahwa makin tinggi pendidikan dokter, sikap tentang praktik kolaborasi pada dokter justru semakin menurun. data yang mendukung adalah adanya dokter dengan pendidikan spesialis namun skor sikap 0 (menghindar). kemungkinan hal praktek kolaborasi perawat-dokter (wiwin martiningsih) 153 ini disebabkan karena tidak adanya waktu atau kesempatan untuk berkolaborasi, karena dengan tingginya pendidikan dokter dalam hal ini spesialis, beban yang diemban juga makin besar dan semakin sibuk, sesuai dengan ungkapan beberapa perawat dalam kuesioner terbuka bahwa adanya alasan "keterbatasan waktu dokter", selain itu adanya jawaban dokter "membiarkan semua, seperti apa adanya saja, atau adanya jawaban dokter " bila perawat konsul saja". melihat adanya pengaruh pendidikan terhadap sikap tentang kolaborasi, untuk mempersiapkan pelaksanaan praktik kolaborasi, dalam kurikulum seharusnya diajarkan tentang dinamika kelompok, teori peran, teori organisasi, teori perubahan, strategi negosiasi, selain itu mahasiswa sebaiknya diajari tentang contoh-contoh kegiatan kolaborasi dan nonkolaborasi dari pengalaman klinis dan dijelaskan faktor penghambat dan kesuksesan pelaksanaan kolaborasi, serta sosialisasi kolaborasi melalui seminar antardisiplin ilmu atau peer learning. ada pengaruh jabatan fungsional perawat terhadap sikap perawat tentang praktik kolaborasi, tetapi mempunyai nilai negatif, artinya bahwa makin tinggi jabatan fungsional perawat, sikap perawat tentang praktik kolaborasi makin menurun. hal ini didukung data adanya perawat penyelia dan pertama (minimal gol. iiia) dengan sikap menghindar-akomodasi (skor 1), padahal ada beberapa perawat dengan jabatan fungsional di bawahnya mendapatkan skor 3 (sikap akomodasi-kolaborasi). jabatan dipandang sebagai komponen demografi yang penting, peningkatan jabatan akan menyebabkan peningkatan komitmen terhadap organisasi yang salah satunya adalah komitmen untuk mau berkolaborasi, namun faktor situasi juga perlu diperhatikan, walau jabatan tinggi, tetapi pasangan dalam kolaborasi tidak punya komitmen yang sama, akan mengakibatkan menurunnya minat untuk berkolaborasi. pendapat lain, bahwa sikap/kepuasan dalam bekerja dipengaruhi oleh kedudukan/jabatan, bahwa umumnya manusia beranggapan bahwa seseorang yang bekerja pada jabatan yang lebih tinggi akan merasa lebih puas daripada yang jabatannya lebih rendah, sesungguhnya hal tersebut tidaklah selalu benar (sarwono dan soeroso, 2001). melihat fakta ini, pembagian tugas sesuai dengan wewenang dan jabatan harus dilakukan, tidak harus melihat sisi senioritas tetapi dipertimbangkan tentang kemampuan yang dimiliki. ada pengaruh lama kerja dengan sikap perawat dan dokter tentang praktik kolaborasi, yang mempunyai nilai negatif, berarti bahwa makin lama perawat atau dokter bekerja sikap tentang praktik kolaborasi makin menurun, yang didukung data adanya perawat dengan masa kerja > 6 tahun (lama) tetapi menunjukkan sikap menghindar (skor 0) dan menghindar akomodasi (skor 1), sedangkan pada dokter adanya data sikap dokter menghindar (skor 0) dan menghindarakomodasi (skor 1) pada masa kerja sedang (4–6 tahun), sementara beberapa dokter dengan masa kerja baru mempunyai sikap akomodasi-kolaborasi (skor 3). pertumbuhan pekerjaan dapat dialami oleh seseorang hanya apabila menjalani proses belajar sehingga berpengalaman, diharapkan orang yang bersangkutan memiliki sikap kerja yang bertambah maju ke arah positif, memiliki kecakapan (pengetahuan) kerja dan keterampilan kerja yang bertambah dalam kualitas dan kuantitas, dan dengan tingginya frekuensi dua orang berjumpa dan bekerja sama, kemungkinan akan tumbuh rasa suka antara satu dengan lainnya. namun demikian tidak semua individu akan bersikap demikian tergantung banyak faktor, adanya kejadian yang tidak diinginkan akan meninggalkan kesan mendalam dalam diri individu atau peristiwa yang memberikan kesan kuat pada individu yaitu peristiwa traumatik. seperti terungkap dalam jawaban perawat "akan mengingatkan dokter apabila tindakan kurang tepat dan hanya pada dokter yang mau menerima pendapat kita", atau jawaban perawat berikut "takut dikatakan menggurui". terwujudnya suatu kolaborasi tergantung pada beberapa kriteria yaitu adanya rasa saling percaya dan menghormati, saling memahami dan menerima keilmuan masingmasing, memiliki citra diri positif, memiliki kematangan profesional yang setara (yang timbul dari pendidikan dan pengalaman), mengakui sebagai mitra kerja bukan bawahan, dan keinginan untuk bernegosiasi. bila kedua jurnal ners vol. 6 no. 2 oktober 2011: 147–155 154 profesi memahami hal ini, hambatan-hambatan dalam kolaborasi dapat diminimalisir. melihat fakta ini kewajiban pengambil kebijakan adalah memotivasi dan memberikan reward bagi mereka yang sudah lama bekerja agar mereka tetap punya motivasi dalam bekerja, dan tidak mengalami titik kejenuhan dalam bekerja. faktor jenis kelamin tidak berpengaruh secara signifi kan terhadap sikap perawat dan dokter, hal ini didukung data bahwa jenis kelamin pada sampel perawat terbanyak adalah perempuan tetapi untuk dokter adalah laki-laki, faktanya mereka mempunyai sikap yang sama tentang kolaborasi. pendapat yang dulunya mengatakan dokter cenderung pria, fi siknya biasanya lebih besar tidak sesuai lagi dengan perkembangan saat ini, karena semakin banyak juga perempuan kini menekuni bidang medis dan keperawatan (siegler dan whitney, 2000). r u a n g t e m p a t k e r j a j u g a t i d a k berpengaruh terhadap sikap perawat maupun sikap dokter dalam berkolaborasi, didukung oleh data walaupun mereka berada pada ruang yang berbeda kolaborasi harus tetap dilakukan. penelitian ini variabel karakteristik perawat yang berpengaruh terhadap sikap perawat tentang praktik kolaborasi adalah usia, pendidikan, jabatan fungsional dan lama kerja, setelah dilakukan uji statistik secara bersama faktor ini mempunyai pengaruh terhadap sikap perawat tentang kolaborasi sebesar 0,460 atau 46%, sedangkan sisanya 54% dipengaruhi oleh faktor lain. sedangkan variabel karakteristik dokter yang berpengaruh terhadap sikap dokter tentang praktik kolaborasi adalah usia, pendidikan dan lama kerja, ketiga faktor ini secara bersama-sama mempunyai pengaruh sebesar 0,435 atau 43,5%, sedangkan sisanya 56,5% dipengaruhi oleh faktor lain. melihat hasil penelitian ini bagi peneliti berikutnya diharapkan dapat menggali selain faktor di atas, dan perlunya peningkatan jumlah sampel dalam penelitian. keluhan-keluhan yang muncul dalam kuesioner terbuka, diharapkan pimpinan rumah sakit dapat mengambil kebijakan untuk penyelesaiannya, agar praktik kolaborasi dapat berjalan dengan baik. fenomena yang ada cenderung mengatakan perawat kurang terampil, sulit diajak diskusi, karena dokter merasa pendidikan mereka belum sejajar, belum dapat tergali dalam penelitian ini, kemungkinan disebabkan karena kuesioner praktik kolaborasi yang digunakan banyak menggali tentang konsep ketegasan dan kerja sama yang difokuskan pada komunikasi atau hubungan interpersonal antara perawat dan dokter, belum menggali tentang kemampuan yang berkaitan dengan keterampilan/tindakan keperawatan pada intervensi fisiologis. untuk menggali fenomena ini perlu kiranya melakukan indepth interview dan focus group discussion (fgd) pada masing-masing profesi, sehingga mereka dapat bebas mengungkapkan pendapat dan persepsi masing-masing, karena telah dibuktikan dalam penelitian sebelumnya dalam siegler dan whitney (2000), bahwa inti sesungguhnya dari konfl ik antara perawat dan dokter terletak pada perbedaan sikap profesional mereka terhadap pasien dan cara dokter dan perawat berkomunikasi mengenai kesan masing-masing. manfaat dari penelitian ini dengan tidak adanya perbedaan sikap antara perawat dengan dokter, berarti bahwa praktik kolaborasi antara perawat dan dokter sebetulnya dapat dijalankan dan tidak ada halangan bagi perawat maupun dokter untuk melaksanakannya. rumah sakit harus memfasilitasi sarana prasarana kolaborasi, menyediakan waktu untuk mendukung kegiatan kolaborasi, dan membuat kebijakan terkait pelaksanaan kolaborasi. permasalahan atau keluhan-keluhan yang muncul dari masing-masing profesi harus difasilitasi untuk penyelesaiannya, salah satu teknik atau cara yang dapat dilakukan menurut robert (2001) adalah identifi kasi area interdependensi yang tepat untuk kolaborasi, tetap membuka jalur komunikasi di antara setiap orang yang terlibat masalah maupun dalam rangkaian tindakan, biarkan tim mengetahui secepatnya bahwa kerja sama tim tersebut membawa dampak positif terhadap keberhasilan individu, dan menciptakan suasana kerja yang kondusif. dari faktor karakteristik yang berpengaruh terhadap sikap dokter yaitu usia, pendidikan, dan lama kerja, diketahui bahwa pendidikan arah pengaruhnya adalah negatif, pendidikan yang tinggi tidak diimbangi peningkatan sikap tentang praktek kolaborasi perawat-dokter (wiwin martiningsih) 155 kolaborasi. sesuai fakta yang ada keterbatasan waktu, beban yang makin besar dan kesibukan merupakan salah satu penyebabnya, dan juga kemungkinan karakter individu tersebut, pengambil kebijakan harus menciptakan situasi yang kondusif, agar tingginya pendidikan seseorang dapat dimanfaatkan seoptimal mungkin yang diimbangi dengan perilaku yang mendukung pelaksanaan kolaborasi. lama kerja juga mempunyai pengaruh negatif terhadap sikap dokter, sama halnya dengan perawat, titik kejenuhan atau hubungan yang tidak kondusif menjadi faktor penyebabnya. pemberian reward, melakukan refreshing bersama, dan peningkatan kemampuan melalui seminar ataupun pelatihan-pelatihan, merupakan salah satu solusi yang dapat diambil. simpulan dan saran simpulan sikap perawat dan dokter tentang praktik kolaborasi perawat dengan dokter sebagian besar ditunjukkan dalam rentang berunding sampai dengan kolaborasi, tidak ada perbedaan antara sikap perawat dengan sikap dokter tentang praktik kolaborasi, karakteristik yang berpengaruh terhadap sikap perawat tentang praktik kolaborasi adalah usia, pendidikan, jabatan fungsional, dan lama kerja, sedangkan pada dokter adalah usia, pendidikan dan lama kerja. saran b a g i i n s t i t u s i p e n d i d i k a n p e r l u pengembangan kurikulum tentang konsep praktik kolaborasi dan mempraktikannya dalam tatanan nyata atau saat praktik klinik dan lapangan, mengajarkan pada peserta didik bahwa pelayanan kesehatan bukan hanya kegiatan dependent tetapi banyak kegiatan interdependent dan independent yang harus dilakukan secara profesional, sesuai dengan standar praktik yang ada, perlunya penekanan materi soft skill dalam proses pembelajaran dan diaplikasikan dalam praktik, sehingga akan terjalin hubungan interpersonal yang baik untuk mendukung pelaksanaan kolaborasi. bagi rumah sakit peningkatan kualitas dan kuantitas sumber daya manusia (sdm) melalui pendidikan tetap perlu dilakukan, baik melalui seminar maupun pelatihan-pelatihan terutama bagi perawat agar dapat melakukan kolaborasi secara optimal, perlunya secara rutin dilakukan pertemuan melalui kegiatan bulanan atau triwulan antara profesi perawat dan dokter, agar terjalin komunikasi yang lebih optimal sebagai dasar pelaksanaan kolaborasi, perlunya support dari pimpinan rumah sakit untuk memotivasi perawat dan dokter agar mendukung pelaksanaan kolaborasi, melalui kegiatan-kegiatan di ruangan misal ronde bersama, atau refreshing bersama untuk membangun hubungan interpersonal, bagi organisasi profesi: perlunya kedua organisasi profesi (ppni dan idi) duduk bersama untuk menyamakan persepsi tentang tugas dan wewenang masing-masing profesi dan identifi kasi area interdependensi. kepustakaan feist, jest dan feist, g., 2008. theories of personality. yogyakarta: pustaka pelajar lindeke, linda, sieckert, dan ann, 2005. nursephysician workplace collaboration. journal of issues in nursing, (online), (http://www.medscape.com., diakses tanggal 15 april 2010). maddux, robert, b., 2001. team building (kiat membangun tim handal). jakarta: erlangga. rs. ngudi waluyo, 2010. laporan tahunan. blitar: rs. ngudi waluyo. siegler, l., eugenia, fay, whitney, w., 2000. kolaborasi perawat dokter, perawatan orang dewasa dan lansia. jakarta: egc sulivan, toni, j., 1998. collaboration a health care imperative. usa: the mcgrawhill companies. s l a m e t d a n s o e r o s o , a m i l u h u r, 2 0 0 1 . determinasi demografi terhadap perilaku karitatif keorganisasian. 6 (1), (online), (http://journal.uii.ac.id/index.php/jsb., diakses 15 juni 2010). 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 pengalaman keluarga (hanik endang, dkk) 283 pengalaman keluarga merawat klien gangguan jiwa pasca pasung (family experience in taking care of client mental disorders post restraint) hanik endang nihayati, dwi adinda mukhalladah, ilya krisnana fakultas keperawatan universitas airlangga mulyorejo kampus c unair surabaya email: azzam_psik@yahoo.com abstrak pendahuluan: pasca pasung sendiri adalah orang yang sudah terbebas dari pemasungan. penelitian ini bertujuan untuk mendapatkan gambaran tentang pengalaman keluarga dalam merawat klien gangguan jiwa pasca pasung. masalah terbesar yang timbul pada keluarga yang memiliki pengalaman merawat klien gangguan jiwa pasca pasung antara lain selalu mendampingi klien dalam kegiatan sehari-hari dan memastikan klien meminum obat. metode: penelitian ini menggunakan studi fenomenologi dengan 6 partisipan yang di wawancara mendalam. partisipan adalah anggota keluarga yang merawat klien gangguan jiwa pasca pasung yang diperoleh melalui purposive sampling. hasil: setelah lepas pasung, klien gangguan jiwa juga mengalami kemajuan dibandingkan saat dipasung. walaupun ada kemajuan, keluarga tetap mengamati perkembangan fisiknya, memberikan kegiatan kepada odgj, dan membawa ke pelayanan kesehatan. selain itu, keluarga mengalami hambatan selama merawat klien gangguan jiwa pasca pasung dan ada juga yang tidak mengalami hambatan. selama merawat klien, keluarga selalu berharap terjadi perubahan status kesehatan klien dan perubahan kesehatan. keluarga juga mendukung supaya klien gangguan jiwa cepat sembuh. diskusi: pengalaman keluarga merawat klien gangguan jiwa pasca pasung yaitu merasa bersyukur karena setelah lepas pasung keadaan klien semakin membaik. keluarga juga rutin memeriksakan klien ke petugas kesehatan. selain itu, keluarga tidak akan memasung lagi klien gangguan jiwa tersebut. keluarga membutuhkan intervensi untuk memperkuat mekanisme koping selama menghadapi berbagai masalah dalam merawat klien gangguan jiwa pasca pasung. kegiatan tersebut dapat direalisasikan melalui penyediaan jasa konseling dan petugas kesehatan selalu mengkontrol keluarga serta klien tersebut. kata kunci: pengalaman keluarga, gangguan jiwa, pasung abstract introduction: post restraint is a person who is free from restraint. this study aims to describe about family experience in taking care of client mental disorders post restraint. the biggest problem in the family who has experience taking care of client mental disorders post restraint, among others, always assisting client in their daily activities and ensuring client are already taking the drugs. method: this study used phenomenology design with six partisipan using indepth interview. the participant of this study was a member family caring for client mental disorders post restraint. this study employs the purposive sampling method. result: after his release restraint , clients of mental disorders has also increased compared to when the restraint. despite progress, the family still observe physical development , provide activities to odgj , and bring to healthcare. families experiencing barriers for taking care of client mental disorders post restraint and some are not experiencing barriers. during the care of the clients , the family hopes a change in the client's health status and health change. the family also supports so that clients with mental disorders speedy recovery. discussion: family experience in taking care of client mental disorders post restraint are grateful that after restraint off the client state is getting better. the family also regularly check the client to the health worker. in addition, families will no longer restraint clients such mental disorders. family need an intervention for strengthen coping mechanisms for dealing with various problems in caring for clients with mental disorders after restraint. these activities can be realized through the provision of counseling services and health workers always control the family as well as the client. key words: family experience, mental disorders, restraint pendahuluan gangguan jiwa berat ini merupakan bentuk gangguan dalam fungsi alam pikiran berupa disorganisasi (kekacauan) dalam isi pikiran yang ditandai antara lain oleh gejala gangguan pemahaman (delusi, waham), gangguan persepsi, serta dijumpai daya realitas yang terganggu yang ditandai dengan perilaku aneh (ferry & makhfudli, 2009). pemasungan penderita gangguan jiwa adalah tindakan masyarakat terhadap penderita gangguan jiwa (biasanya yang berat) dengan cara dikurung, dirantai kakinya dimasukan kedalam balok kayu sehingga kebebasannya menjadi hilang. pemasungan dilakukan oleh masyarakat disebabkan oleh beberapa alasan, yaitu masyarakat dan keluarga takut orang dengan gangguan jiwa (odgj) akan bunuh diri dan mencederai orang lain, ketidakmampuan keluarga merawat odgj, dan juga karena pemerintah tidak memberikan pelayanan kesehatan jiwa dasar pada odgj yang berada di komunitas (minas & diatri, 2008). pasca pasung sendiri adalah orang yang sudah terbebas dari pemasungan. walaupun odgj sudah bebas dari pemasungan, beban pada keluarga klien odgj belum selesai. hasil mailto:azzam_psik@yahoo.com jurnal ners vol. 11 no. 2 oktober 2016: 283-287 284 evaluasi dari 9 orang klien yang sudah lepas dari pemasungan, kemandirian mereka dalam perawatan diri sudah cukup optimal sehingga intervensi yang diberikan lebih berfokus kepada cara mempertahankan kepada status kemandirian tersebut (sari, 2009). berdasarkan data dari world health organisasi (who) ada sekitar 450 juta orang di dunia yang mengalami gangguan jiwa. hasil riset kesehatan dasar (riskesdas) tahun 2013, menunjukkan bahwa prevalensi gangguan mental emosional yang ditunjukkan dengan gejala-gejala depresi dan kecemasan adalah sebesar 6% untuk usia 15 tahun ke atas atau sekitar 14 juta orang. sedangkan, prevalensi gangguan jiwa berat, seperti schizophrenia adalah 1,7 per 1000 penduduk atau sekitar 400.000 orang. prevalensi gangguan jiwa di jawa timur pada gangguan jiwa berat (psikosa/skizofrenia) sebanyak 0,22% dan gangguan mental emosional sebesar 6,5%. data dari dinas kesehatan kabupaten jember tahun 2014 menyebutkan jumlah klien gangguan jiwa di kabupaten jember sebanyak 17.451 orang. kementerian kesehatan memperkirakan jumlah odgj yang mengalami pemasungan di seluruh indonesia mencapai lebih 18 ribu jiwa. proporsi keluarga yang memiliki odgj psikosis dan pernah melakukan pemasungan 14,3% atau sekitar 237 keluarga dari 1.655 keluarga yang memiliki odgj yang dipasung dan terbanyak pada keluarga di pedesaan (18,2%) (riskesdas, 2013). prosentase keluarga yang memiliki odgj yang dipasung di jawa timur sebanyak 16,3% (riskesdas, 2013). menurut data dari dinas kesehatan kabupaten jember, kasus pasung di kabupaten jember sampai pada tahun 2016 sebanyak 124 kasus dan pada wilayah kerja puskesmas rambipuji ada 10 kasus pasung yang 7 diantaranya ada di desa pecoro. beban yang ditanggung oleh keluarga yang hidup bersama penderita gangguan jiwa berat meliputi beberapa faktor, baik secara ekonomi maupun sosial. selain itu, beban yang ditangguang keluarga berupa beban subjektif dan objektif, pengalaman stress seumur hidup, sehingga membuat koping tidak efektif (yusuf, 2012). kurangnya pengetahuan tentang gangguan jiwa serta motivasi keluarga untuk melakukan perawatan yang tepat pada klien gangguan jiwa menjadikan beban keluarga semakin kompleks. pada awalnya, odgj ini dipasung selama bertahun-tahun oleh keluarga. akhirnya, oleh perangkat desa dan pemerintah kabupaten jember odgj di lepas pasungnya. setelah terlepas dari pasung, puskesmas rambipuji memberikan pengobatan kepada klien tersebut. upaya lain puskesmas rambipuji sendiri kepada klien pasca pasung adalah perawat selalu mengunjungi rumah klien tersebut untuk mengontrol obatnya masih tersedia atau tidak dan mengontrol klien tersebut apakah rutin meminum obat yang diberikan. selain itu, klien pasca pasung sudah bisa diajak berkomunikasi, sudah mulai berani untuk keluar rumah, dan berkebun bersama keluarga. upaya pemerintah mengatasi masalah pemasungan dengan mencanangkan indonesia bebas pasung 2014 sudah cukup baik. hal ini dilakukan agar orang yang dipasung bisa bebas, karena kegiatan pasung adalah kegiatan yang melanggar hak asasi manusia. metode penelitian penelitian ini menggunakan desain riset kualitatif, yaitu suatu proses penelitian dan pemahaman yang berdasarkan pada metodologi yang menyelidiki suatu fenomena sosial dan masalah manusia. pendekatan yang digunakan dalam penelitian ini adalah fenomenologi, yaitu cabang dari filosofi yang menekankan pengalaman manusia sebagai objek penelitian. dalam penelitian kualitatif tidak menggunakan istilah populasi, tetapi oleh spradley dinamakan “social situtation” atau situasi sosial yang terdiri atas tiga elemen yaitu: tempat (place), pelaku (actors), dan aktivitas (activity) yang berinteraksi secara sinergis. sampel dalam penelitian kualitatif bukan dinamakan responden, tetapi sebagai narasumber, atau partisipan, informan, teman dan guru dalam penelitian. pengambilan sampling dalam penelitian ini menggunakan teknik sampling secara purposive sampling. purposive sampling adalah suatu teknik penetapan sampel dengan cara memilih sampel diantara populasi sesuai dengan yang dikehendaki peneliti (tujuan/masalah dalam penelitian), sehingga sampel tersebut dapat mewakili karakteristik populasi yang telah dikenal sebelumnya (nursalam, 2008). peneliti menggunakan alat bantu pengumpul data berupa alat perekam berupa video kamera atau recorder dan catatan lapangan. jika partisipan tidak bersedia menggunakan video kamera, peneliti merekam wawancara menggunakan recorder. pada penelitian ini peneliti melakukan wawancara di desa pecoro kecamatan rambipuji kabupaten jember. tahap penelitian berupa wawancara akan membutuhkan waktu satu pengalaman keluarga (hanik endang, dkk) 285 minggu yang dimulai awal bulan juni 2016 dan pengolahan data awal minggu ketiga bulan juni 2016. peneliti melakukan analisis data dalam beberapa tahap (hasbiansyah, 2008) yaitu: tahap awal, tahap horizonalization, dan tahap cluster of meaning. prinsip etik berdasarksn pedoman nasional etik penelitian kesehatan (pnepk) tahun 2004 terdiri atas tiga prinsip yaitu menghormati seseorang (respect for persons), kemanfaatan (beneficence), dan keadilan (justice). ada empat kriteria untuk memperoleh keabsahan data yaitu derajat kepercayaan (credibility), keteralihan (transferability), kebergantungan (dependability), dan kepastian (cofirmability) (guba dan lincoln (1994) dalam moleong, 2010). hasil hasil menelitian ini menunjukkan bahwa 6 partisipan dalam penelitian ini semua berjenis kelamin perempuan, beraga islam, suku madura dengan usia 48-80 tahun. dalam fikiran beberapa keluarga, jika tidak dipasung dan klien ditinggal bekerja klien gangguan jiwa akan jalan-jalan, marahmarah, dan mencelakai orang lain sehingga keluarga tidak tenang. selama merawat klien gangguan jiwa yang dipasung, anggota keluarga saling membantu dalam merawat klien tersebut. jika keluarga ada yang bekerja, maka anggota keluarga yang lainnya yang membantu merawat memenuhi kebutuhan klien seperti makan dan minum. selain itu, keluarga juga menceritakan sekalipun klien tersebut dipasung, klien juga bisa menciderai dirinya sendiri. contohnya, klien akan memukulkan kepalanya ke tembok. pengalaman keluarga yang lainnya dalam merawat klien gangguan jiwa saat dipasung dirasakan sebagai beban psikologis. beban psikologis dinyatakan oleh partisipan dalam bentuk takut, khawatir, berat/sulit. perasaan takut disini disebabkan misalnya klien akan marah-marah dan menciderai orang lain yang ada disekitarnya. perasaan khawatir juga dirasakan partisipan karena takut klien jika jalan-jalan dan partisipan takut jika dia mendapat masalah. perasaan berat/sulit dirasakan partisipan karena tidak bisa bekerja. partisipan tidak bisa bekerja karena selalu memikirkan klien jika ditinggal bekerj oleh partisipan. penelitian ini menyebutkan keluarga merasakan beban psikologis yang dinyatakan dalam bentuk takut, khawatir, berat/sulit selama merawat klien gangguan jiwa saat dipasung. beban psikologis ini merupakan akumulasi dari perasaan takut, khawatir, berat/sulit terhadap perilaku klien. partisipan mengungkapkan sekarang klien pasca pasung sudah bisa bekerja, membantu memenuhi kebutuhan anggota keluarga, dan membantu partisipan mengerjakan pekerjaan rumah. bekerja yang dimaksud adalah klien sudah bisa mendapatkan penghasilan sehingga bisa membantu memenuhi keperluan keluarga. klien juga bisa membantu mengerjakan pekerjaan rumah seperti menyapu, mengepel, menjaga warung, dan lain-lain. keluarga juga tak lupa untuk memeriksakan klien ke pelayanan kesehatan dan mengambil obat untuk klien. pengalaman keluarga yang lain selama merawat klien gangguan jiwa pasca pasung adalah keluarga merasakan perasaan bersyukur. perasaan ini muncul karena selama pasca pasung, klien mengalami perubahan kearah yang lebih baik. partisipan juga mengungkapkan bahwa ini cobaan dari allah dan partisipan harus melalui ujian ini dengan penuh kesabaran. hasil penelitian ini menyebutkan bahwa keluarga mampu mengidentifikasi adanya gangguan terhadap perkembangan fisiknya. menurut peneliti, anggota keluarga seharusnya mengenali perubahan kesehatan anggota keluarga lainnya sekecil apapun perubahan itu. pembahasan kondisi orang dengan gangguan jiwa (odgj) pasca pasung yang belum pulih total menjadi dasar pertimbangan keluarga untuk menyajikan variasi kegiatan dalam bentuk aktivitas apapun. aktivitas ini dapat menurunkan kejenuhan dan mengisi waktu luang odgj. penelitian ini juga menemukan beberapa upaya keluarga dalam memberikan perawatan bagi odgj pasca pasung dengan memenuhi aturan perawatan yang disarankan dokter atau petugas kesehatan lainnya. hambatan adalah hal yang ditemui dan menimbulkan kesulitan bagi keluarga selama merawat klien gangguan jiwa pasca pasung. pada penelitian ini, peneliti menemukan ada partisipan yang mengalami hambatan dan ada juga yang tidak mengalami hambatan. keluarga yang tidak mengalami hambatan mengungkapkan bahwa klien sekarang sudah bisa kerja, sudah bisa mandiri, dan sudah bisa ditinggal oleh orang tuanya. peneliti mendapatkan keluarga yang mengalami hambatan dalam hal pekerjaan dan pengobatan. jurnal ners vol. 11 no. 2 oktober 2016: 283-287 286 hasil penelitian ini mengidentifikasi bahwa cara menghadapi hambatan adalah dengan cara membujuk klien dan modifikasi dalam meminum obat. partisipan membujuk klien untuk bekerja agar bisa memenuhi kebutuhan klien. partisipan lainnya adalah dengan cara pendampingan dalam pengobatan. partisipan memastikan klien meminum obatnya dengan cara memodifikasi cara meminum obatnya. pemberdayaan keluarga merupakan salah satu cara juga yang digunakan untuk menghadapi permasalahan selama merawat klien gangguan jiwa pasca pasung. salah satu pemberdayaan keluarga yang ditemukan dalam penelitian ini adalah pembagian peran. penelitian ini mengidentifikasi harapan keluarga selama merawat klien gangguan jiwa pasca pasung antara lain harapan akan status kesehatan klien dan perubahan kesehatan klien. keluarga selalu menaruh harapan bahwa klien bisa sembuh total seperti dahulu lagi. keluarga tidak menginginkan apa-apa selain klien tersebut sembuh seperti dahulu. ketika klien sudah sembuh, partisipan juga menginginkan klien bekerja lebih baik lagi. simpulan dan saran simpulan setelah lepas pasung, klien gangguan jiwa juga mengalami kemajuan dibandingkan saat dipasung. keluarga merasa sangat besyukur sekali dengan keadaan yang sekarang. keluarga dalam merawat klien gangguan jiwa pasca pasung sebaiknya menggunakan metode-metode untuk mencapai tujuan kesehatan keluarga. metode merawatnya adalah dengan mengamati perkembangan fisiknya. selain mengamati perkembangan fisiknya, keluarga juga memberikan kegiatan kepada klien gangguan jiwa pasca pasung. gangguan jiwa pasca pasung, ada keluarga yang tidak mengalami hambatan dan ada juga keluarga yang mengalami hambatan. hambatan tersebut muncul pada saat tertentu saja. tetapi hambatan tersebut bisa dilalui oleh keluarga. ketika hambatan itu datang, keluarga memiliki cara tersendiri untuk melewatinya. selama merawat klien gangguan jiwa pasca pasung, keluarga menyampaikan harapan yang berhubungan dengan perkembangan klien. perkembangan klien itu berupa perubahan status kesehatan klien dan perubahan kesehatan. perkembangan klien ke arah yang lebih baik memang menjadi harapan utama keluarga yang merawat klien gangguan jiwa pasca pasung. selain itu, dari penelitian ini dapat disimpulkan juga bahwa keluarga tidak akan memasung lagi klien gangguan jiwa tersebut. keluarga juga mendukung supaya klien gangguan jiwa cepat sembuh. misalnya dengan cara tidak lupa untuk memberi obat kepada klien gangguan jiwa dari petugas kesehatan. saran pihak rumah sakit atau perawat jiwa, hendaknya melakukan intervensi untuk memperkuat mekanisme koping keluarga selama menghadapi berbagai masalah dalam merawat klien gangguan jiwa pasca pasung. kegiatan tersebut dapat direalisasikan melalui penyediaan jasa konseling dan petugas kesehatan selalu mengkontrol keluarga serta klien tersebut. pihak pelayanan kesehatan sebaiknya menyusun program untuk menurunkan stigma di masyarakat guna memperkuat sistem dukungan sosial bagi keluarga yang merawat klien gangguan jiwa pasca pasung. hal tersebut dapat diwujudkan melalui penyebaran leaflet dan penyuluhan. perawat seharusnya dapat memanfaatkan penelitian ini sebagai pedoman untuk mengembangkan pendekatan dalam hal mengajarkan keluarga untuk memilih strategi ko p i n g ya n g t e p a t serta memberdayakan kondisi psikologis keluarga selama merawat klien gangguan jiwa pasca pasung. peneliti disarankan untuk melanjutkan dan menggali lebih dalam tentang pemberdayaan keluarga dalam mengelola berbagai beban yang dihadapi sebagai dampak yang dirasakan dalam merawat klien gangguan jiwa pasca pasung melalui penelitian kualitatif. selain itu, pola koping keluarga untuk menghadapi berbagai masalah dalam merawat klien gangguan jiwa pasca pasung dapat digali lebih jauh melalui penelitian kualitatif. kepustakaan efendi, f & makhfudli. 2009. keperawatan kesehatan komunitas teori dan praktik dalam keperawatan. jakarta : salemba medika hasbiansyah, o. 2008. pendekatan fenomenologi : pengantar praktikpenelitian dalam ilmu sosial dan komunikasi. mediator. vol 9 (1) hal. 171-172 minas, h., & diatri, h. 2008. pasung: physical restraint and confinement of the mentally ill in the pengalaman keluarga (hanik endang, dkk) 287 community. international journal of mental health systems. vol 2(1), 1-5. doi: 10.1186/17524458-2-8 moleong, l j. 2010. metodologi penelitian kualitatif. bandung: pt remaja rosdakarya offset nursalam. 2008. konsep dan penerapan metodologi penelitian ilmu keperawatan pedoman skripsi, tesis, dan instrumen penelitian keperawatan edisi 2. jakarta : salemba medika sari, h. 2009. pengaruh family psychoeducation terhadap beban dan kemampuan keluarga dalam merawat klien pasung di kabupaten bireun. thesis. depok : universitas indonesia yusuf, a., putra s.t., & probowati, y. 2012. peningkatan coping keluarga dalam merawat pasien gangguan jiwa melalui terapi spiritual direction, obedience, dan acceptance (doa). jurnal ners. vol 7 (2) 8 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 8-13 http://dx.doi.org/10.20473/jn.v17i1.33754 original article open access the effect of basic trauma and cardiac life support training in increasing the competence of emergency room nurses anisha calista prakoeswa 1,* , fitri arofiati1, nur hidayah1 1 muhammadiyah yogyakarta university, indonesia *correspondence: anisha calista prakoeswa. address: brawijaya street, kasihan district, bantul regency, yogyakarta 55183, indonesia. email: anisha.calista.psc20@mail.umy.ac.id responsible editor: ferry efendi received: 17 february 2022 ○ revised: 3 march 2022 ○ accepted: 23 march 2022 abstract introduction: nurses on duty in the emergency room (er) play an important role in the early identification of a lifethreatening patient condition, immediate action, and the subsequent care of critically ill patients. continuous training and improvement need to be done to improve the er nurses’ competency. this research aimed to analyze the differences in nurses’ competencies. methods: this quantitative study employed a quasi-experiment design. the sample size comprised 50 nurses of er in surabaya with a total sampling technique. variables used on this study were demographical data as the independent variables and dependent variables including knowledge, attitude and skills. intervention was given by two methods, online training for knowledge and attitude, while offline training for skill improvement. after ensuring the distribution and homogeneity of the data, a paired t-test was employed for parametric statistical data analysis. results: there were differences in pre-test and post-test scores in the domain of knowledge, attitude and skill (p = 0.000), respectively. the mean of knowledge, attitude, and skills had increased significantly. hence, the training is proven to improve those competencies as well as the sub-topic items. conclusions: basic trauma and cardiac life support (btcls) training has improved nurse competency; it is advised to hold this training, especially in the er. indeed, it can improve healthcare services quality and improve patient safety at health facility. in addition, future research can modify the training time, training delivery methods, and content of btcls training materials to adjust with the current situation of the covid-19 pandemic. keywords: attitude; competency; emergency nurse; knowledge; skill; training introduction the nurse plays a crucial role in determining health services in hospitals, not only because nurses work on the frontline, but also being a majority compared to other health workers (who, 2020). by implementing professional nursing care, good quality health services can be accomplished. nurses who work in the emergency room (er) must adopt critical situations and provide nursing care with speed and accuracy that is different with other nursing situations (laoh and rako, 2014). nurses on duty in the er play a vital role in the early identification of a life-threatening patient condition, immediate action, and the subsequent care of critically ill patients (cunningham et al., 2017). compared to other patient care units, the er and icu are places where the number of critically injured patients is the most, so it is essential to ensure that nurses working in these units have adequate competence (sankar et al., 2013). nurses must perform continuous self-development by increasing knowledge, attitudes, and skills to provide proper emergency services. training is the effort to ensure that nurses have competency in emergency cases. this method is an option that does not require much cost but can provide the expected effect even if it is carried out by utilizing limited resources (cunningham et al., 2017). the competence of nurses in handling emergency cases is essential to increase the success rate, accuracy, and quality of emergency service in treating patients (mason et al., 2005). therefore, competency in handling emergency cases is one of the most important factors determining healthcare service quality (li et al., 2016). https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-2759-6428 https://orcid.org/0000-0002-1029-5477 jurnal ners http://e-journal.unair.ac.id/jners 9 corona virus disease 2019 (covid-19) is a global crisis that happened in late 2019 and rapidly spread all over the world (yie et al., 2021). in this constraint, nurses are included in the first line in hospitals that provide healthcare services (buchan et al., 2019). therefore, a nurse must have sufficient understanding in recognizing covid-19 disease, including identifying the pathogen, signs and symptoms, how it spreads, how to break the chain of infection, and the treatment that must be given appropriately (burnett, 2018; corless et al., 2018). nurses' competency regarding covid-19 disease will contribute to their environment because their competence will provide health protection for themselves and the surrounding community. the efforts to improve the nurses' competency are an investment during the covid-19 pandemic (ridley, sanderson and haines, 2021). this effort not only provides positive outcomes in dealing with the covid-19 pandemic but also prepares for another outbreak that may occur in the future (purba, 2020). to maximize healthcare personnel's capabilities and increase protection, vigilance, and control against covid-19 infection, hospitals should provide training for nurses, either on-site or online (wu et al., 2020). the online training was an effective method for improving the competency of nursing workforce either in academic or clinical setting (wong and greenhalgh, 2013; tobase et al., 2017; vaona et al., 2018). dr. soetomo hospital surabaya routinely conducted emergency nursing training once a year and was designed for nurses to handle emergency problems. this training used an appropriate approach by referring to scientific foundations and good nursing processes. hence, the training participant is expected to be able to demonstrate life saving skills, minimize organ damage, and reduce patient mortality and disability. this training was provided to new nurses who will be transferred or assigned to the er. competence is a set of abilities for individuals to carry out a job correctly and consists of knowledge, attitudes, and skills. however, research regarding the effect of the training using online and onsite approach toward nurse’s competency has not been done. this study aimed to analyze the differences in nurse competencies, in terms of knowledge, attitude, skills, in er after attending btcls training. materials and methods study design this quantitative research employed a quasiexperimental study, using a one-group pre-test-post-test design, with btcls training as an intervention. btcls training was held on 12-16 september 2021 and combining both offline and online sessions to reduce physical interaction during the covid-19 pandemic. before the training, the first observations (pre-test) measured the participants' competencies (knowledge, skills, and attitudes). then the second observation (posttest) was made again after the training by re-measuring the participants' competencies (knowledge, skills, and attitudes). the first three days of btcls training were conducted online. the first day of btcls training includes participant registration, technical meeting, health protocol presentation as well as knowledge competency pre-test, while the second and third day of btcls training consisted of online lecture materials that includes the role of emergency nurses in improving quality profession during the pandemic, basic life support, trauma of thorax and abdomen, triage, electrocardiogram (ecg) and acute coronary syndromes, burns, and fluid therapy. all of the online sessions of btcls training were held by zoom meetings. the fourth and fifth day of btcls training were conducted offline while maintaining health protocols. all of the participants and instructors took antigen swab test before the offline sessions of btcls training. participants were divided into small groups following the six stations namely basic life support skills, initial assessment, transport skills, airway and breathing skills, ecg skills, and advanced life support skills. on the fourth day, the instructors held the pre-test of both the attitudes and skills of the participants during each station before giving out the demonstrations of the right methods for attitudes and skills. and lastly, the participants went through posttest for knowledge, attitudes, and skills on the fifth day. respondent the sample size comprised 50 nurses with a total sampling technique. the participants worked in er dr. soetomo hospital surabaya. the independent variable in this study was btcls training. the dependent variable is nurses' competence, which consists of knowledge, skills, and attitudes. instrument instruments for assessing knowledge, skills, and attitudes were obtained from the official assessment, education and training board of the regional supervisory of the indonesian national nurses association (ppni) east java; hence there was no need to test for validity and reliability (zúñiga et al., 2016; stevanin et al., 2017). the knowledge assessment consists of 35 multiple choice questions according to the material contained in the btcls training. meanwhile, attitude and skill measurement are shaped as a checklist for the participant's emergency care completeness, and the btcls training assessors assessed it. the assessors were competent assessor whose having field experience on btcls and has been recognized as certified assessor in this area. each assessment for knowledge, skill, and attitude is considered good if the total score is > 75% and not good if the score is < 75%. prakoeswa, arofiati, and hidayah (2022) 10 p-issn: 1858-3598  e-issn: 2502-5791 btcls training is a nursing training to handle emergency problems caused by trauma and cardiovascular disorders. the training aims to enable nurses to provide life support to save lives and minimize patients' disability and organ damage. nurse competency is the ability of each nurse to handle emergency cases under training standards. the competency consists of (1) knowledge: what nurses know about handling emergency cases; (2) attitude: how nurses handle emergency patients; (3) skill: nurses' ability to handle emergency patients according to applicable standards and procedures. knowledge competency data are nominal. meanwhile, the measurement scale for skill and attitude is ordinal data. data collection this research was divided into three stages, namely the preparation stage, implementation, and the final stage. the preparation stage is a preliminary study. the researcher conducted interviews with the director of medical & nursing services, the director of professional education & research, the head of ed's nurse, and the head of the nursing division. interviews were conducted to overview existing training and evaluation of emergency nursing throughout this period. then further discussions were held with representatives from the indonesian emergency and disaster nurses association (hipgabi) to determine emergency nursing training tailored to the covid-19 pandemic situation. data analysis the researcher identified the participants and conducted preliminary observations (pre-test). furthermore, recording and documentation were accomplished during btcls training. the final observation (post-test) was conducted to see the effect of the training. in addition, the researcher also conducted additional interviews with the btcls training organizers. the final stage was data analysis using the spss program. the researcher first looked at the distribution and homogeneity of the data. a paired t-test was employed for parametric statistical data analysis. table 1 btcls training participants based on age, gender, education, and length of work characteristics n % gender male 26 52 female 24 48 age 25 – 30 years 11 22 31 – 35 years 27 54 36 – 40 years 7 14 > 40 years 5 10 unit 1st floor er 25 50 contagious er 7 14 er-roi 2 4 aster hcu 4 8 hcu pandan ii 1 2 others 11 22 education level bachelor 21 42 associate degree (d3) 27 54 associate degree (d4) 2 4 period of employment < 1 year 11 22 1-5 year(s) 8 16 > 5 years 31 62 figure 1. boxplot graph of nurses’ competency before and after btcls training jurnal ners http://e-journal.unair.ac.id/jners 11 ethical consideration in addition, at the implementation stage, the researcher also obtained ethical clearance from the health research ethics committee, dr. soetomo surabaya hospital. this research was conducted with ethical principles: informed consent, anonymity, and confidentiality. this study received ethical clearance from the ethics commission, with letter number 0240/kepk/vii/2021, valid for one year since first issued on august 23rd, 2021. results the normality test of the three competencies shows that the data obtained are normally distributed. kolmogorov-smirnov test results for pre-test knowledge p = 0.200, post-test knowledge p = 0.200, pre-test attitude p = 0.116, post-test attitude p = 0.200, pre-test skill p = 0.107, and post-test skill p = 0.094. the homogeneity and normality test are assumptions of the hypothesis test formula for the t-test and anova. before testing the data by t-test and anova, the assumptions of normality and homogeneity must be met. the next test is the homogeneity test, which determines the data variance. levene’s test results are as follows, knowledge p = 0.199, attitude p = 0.127, and skill p = table 2 results of the preand post-data analysis training of btcls of nurses in dr. soetomo hospital surabaya variable δ mean δ std. deviation t p-value knowledge (preand post-test data) 12.940 4.181 21.881 0.000 attitude (preand post-test data) 14.300 5.273 19.176 0.000 skill (preand post-test data) 14.380 5.102 19.928 0.000 table 3 results of the preand post-data analysis competencies in detail btcls training of nurses in dr. soetomo hospital surabaya variable δ mean δ std. deviation t p-value knowledge trauma 0.127 0.175 5.144 0.000 life support 0.154 0.187 5.844 0.000 cardiac 0.313 0.210 10.540 0.000 attitude orientation phase 0.458 0.447 7.240 0.000 show a listening attitude 0.197 0.368 3.775 0.000 provide an opportunity to ask questions or clarify 0.700 1.015 4.876 0.000 documents according to standard 0.760 1.333 4.030 0.000 termination phase 0.907 0.771 8.316 0.000 wash your hands according to standard 1.060 1.163 6.443 0.000 aseptic and antiseptic principles for sterile procedures 1.100 2.092 3.718 0.001 protection with universal precautions 1.100 2.092 3.718 0.001 handling medical and non-medical waste 0.500 1.515 2.333 0.024 skills preparation 0.850 0.649 9.264 0.000 assessing patients 0.820 0.569 10.185 0.000 airway 0.825 0.552 10.577 0.000 breathing 0.845 0.463 12.916 0.000 circulation 0.830 0.519 11.316 0.000 disability 0.713 0.522 9.669 0.000 exposure 0.750 0.672 7.892 0.000 foley catheter 0.927 0.592 11.068 0.000 gastric tube 0.873 0.466 13.251 0.000 heart monitor 0.760 0.797 6.743 0.000 pulse oximetry, x-ray 0.520 0.707 5.202 0.000 secondary survey 0.667 0.738 6.390 0.000 prakoeswa, arofiati, and hidayah (2022) 12 p-issn: 1858-3598  e-issn: 2502-5791 0.088. the three competencies have the same variance, and the assumption of homogeneity has been met. table 2 show the results of the btcls training effect on nurse competencies (knowledge, attitude, and skills). in column ‘p,’ the effect is marked with a significance value below 0.05. there are differences in the pre-test and post-test scores of the nurse competency test. each competency has a significance value of less than 0.000. hence, this quasi-experimental research hypothesis concludes that btcls training significantly affects nurses’ knowledge, attitude, and skills. the mean of knowledge has increased significantly by 12.94. this pattern also occurs in other nurse competencies: attitude and skills. the results show that the post-test scores of the majority of nurses are improved. the boxplot graph explains an increase in the post-test scores on knowledge, attitude, and skills compared to the pre-test scores (figure 1). table 3 shows differences in post-test knowledge and pre-test knowledge in trauma, life support, and cardiac. each of these categories has a p-value below alpha (0.05). furthermore, the table also shows the difference of posttest attitude and pre-test attitude in the categories of orientation, listening, an opportunity to ask questions or clarify, standardized documents, termination, hand washing, aseptic and antiseptic principles, protection, and handling of medical and non-medical waste. finally, the table describes the differences in each category of questions on skill competence. all categories of skill competency questions, including airway, breathing, circulation, disability, exposure, foley catheter, gastric tube, heart monitor, pulse oximetry and x-ray, and secondary survey showed significant differences discussions this research showed that there were significant differences between knowledge before and after training. this finding aligns with ha and nuntaboot's (2020) research on nursing education and training as predictors of nurse competence. however, the difference is that the research results emphasize on narrative views’ of participants on the training (ha and nuntaboot, 2020). this finding also parallels with prior research conducted by fong et al. (2021). it is more relevant since the same methodology -quasi-experimental without a control groupwas employed to examine the effect of orientation on nurse competence especially focus on increased knowledge (fong et al., 2021). item analysis was also accomplished in this study, with good results in knowledge (trauma, life support, and cardiac). there was a significant difference in the percentage of trainees who answered correctly. structured training is required in order to increase the competency of health workers in health facilities, including nurses. this research demonstrated that there were significant differences between attitudes before and after training. this finding supports prior research on emergency, that training affects the knowledge and skills of healthcare personnel (yildiz, selimen and dogan, 2014; ameh et al., 2016). however, the difference is that those studies only examined partial competencies (yildiz, selimen and dogan, 2014; ameh et al., 2016). this study also included item analysis, which yielded positive findings in terms of attitude. there was a significant difference in the percentage of trainees who behave correctly in the orientation phase, listening attitude, opportunity to ask questions/clarification for patients, documents according to standards, termination phase, washing hands, aseptic principles and antiseptic, universal precaution protection, and handling medical and non-medical waste. future training in increasing attitude should consider the general and specific competency of nurses. this research revealed that there were significant differences between skills before and after training. this finding confirms prior research conducted by kim and shin (2016) in the area of maternal and child emergency nursing. overall, this research on improving the emergency nurses' competency supports research from ojifinni, motara and laher (2019) to include basic life support (bls) and cardiopulmonary resuscitation (cpr) in the formal training to improve nurse competency. park and kim (2017) also put forward the same suggestion to conduct specific education and training regarding an emergency training to improve the nurses' competency. in this study, item analysis was also performed, and the results were positive for nurses' skill competency. there was a highlighted finding for nurses who acted correctly on preparation, assessing patients, airway, breathing, circulation, disability, exposure, foley catheter, gastric tube, heart monitor, pulse oximetry, x-ray, and secondary survey. skill of nurses should be viewed as critical competency as it is related to patient safety and improving the quality of healthcare. this study has several limitations, including without using a control group; since this research is the first to be conducted to assess the increase in knowledge, attitude, skills, and a category of questions at the research locus. hence, it is hoped that further research can be conducted with re-assessments within a certain period (three months, six months, or one year) so that training can be refreshed to adjust with the needs of nurses. conclusions there was an increase in emergency nurses' competency in term of knowledge, attitude, and skill after attending the btcls training. repeated educational programs can improve these three domains as well as the contents of the domain. for future btcls training, recommendations include training time, training delivery methods, and content of btcls training materials. in addition, future research can modify the jurnal ners http://e-journal.unair.ac.id/jners 13 training method as an intervention group and add a control group to the standard training method. references ameh, c.a. et al. (2016) ‘knowledge and skills of healthcare providers in sub-saharan africa and asia before and after competency-based training in emergency obstetric and early newborn care’, plos one, 11(12), pp. 1–14. doi:10.1371/journal.pone.0167270. buchan, j. et al. (2019) a critical moment: nhs staffing trends, retention and attrition, the health foundation. burnett, e. (2018) ‘effective infection prevention and control: the nurse’s role’, nursing standard [preprint]. doi:10.7748/ns.2018.e11171. corless, i.b. et al. (2018) ‘expanding nursing’s role in responding to global pandemics 5/14/2018’, nursing outlook, 66, pp. 412–415. cunningham, c. et al. (2017) ‘developing an emergency nursing short course in tanzania’, african journal of emergency medicine, 7(4), pp. 147–150. doi:10.1016/j.afjem.2017.08.002. fong, h.c. et al. (2021) ‘a competency-based orientation (cbo) protocol enhances competency among newly hired perianesthesia nurses’, journal of perianesthesia nursing, 36(5), pp. 445–451. doi:10.1016/j.jopan.2020.09.017. ha, d.t. and nuntaboot, k. (2020) ‘factors influencing competency development of nurses as perceived by stakeholders in vietnam’, belitung nursing journal, 6(4), pp. 103–110. doi:10.33546/bnj.1119. laoh, j. and rako, k. (2014) ‘gambaran pengetahuan perawat pelaksana dalam penanganan pasien gawat darurat di ruangan igd blu rsup. prof. dr. r. d kandou manado’, jurnal ilmiah perawat manado, 3(2), p. 92833. li, s.-m. et al. (2016) ‘research progress in disaster nursing competency framework of nurses in china’, chinese nursing research, 3(4), pp. 154–157. doi:10.1016/j.cnre.2016.11.003. mason, s. et al. (2005) ‘developing assessment of emergency nurse practitioner competence a pilot study’, journal of advanced nursing, 50(4), pp. 425–432. doi:10.1111/j.1365-2648.2005.03408.x. ojifinni, k., motara, f. and laher, a.e. (2019) ‘knowledge, attitudes and perceptions regarding basic life support among teachers in training’, cureus, 11(12). doi:10.7759/cureus.6302. park, h. and kim, j. (2017) ‘factors influencing disaster nursing core competencies of emergency nurses’, applied nursing research, 37, pp. 1–5. purba, a.k. (2020) ‘how should the role of the nurse change in response to covid-19?’, nursing times, 116(6), pp. 25–28. ridley, e.j., sanderson, a.f. and haines, k.j. (2021) ‘surge capacity for critical care specialised allied health professionals in australia during covid-19’, australian critical care, 34, pp. 191–193. sankar, j. et al. (2013) ‘knowledge and skill retention of in-service versus preservice nursing professionals following an informal training program in pediatric cardiopulmonary resuscitation: a repeatedmeasures quasiexperimental study’, biomed research international, 2013. doi:10.1155/2013/403415. stevanin, s. et al. (2017) ‘the multidimensional nursing generations questionnaire: development, reliability, and validity assessments’, journal of nursing management, 25(4), pp. 287–296. doi:10.1111/jonm.12465. tobase, l. et al. (2017) ‘the effects of an online basic life support course on undergraduate nursing students’ learning’, international journal of medical education, 8, pp. 309–313. doi:10.5116/ijme.5985.cbce. vaona, a. et al. (2018) ‘e-learning for health professionals’, the cochrane database of systematic reviews, 1(1), pp. cd011736–cd011736. doi:10.1002/14651858.cd011736.pub2. who (2020) state of the world’s nursing 2020: investing in education, jobs and leadership. geneva: world health organization. wong, g. and greenhalgh, t. (2013) internet-based learning for training health care professionals in-service. london: queen mary university of london. wu, x. et al. (2020) ‘contingency nursing management in designated hospitals during covid‐19 outbreak’, annals of global health, 86(1), pp. 1–5. doi:10.5334/aogh.2918. yie, k.y. et al. (2021) ‘using social network analysis to identify spatiotemporal spread patterns of covid-19 around the world: online dashboard development’, international journal of environmental research and public health, 18(5), pp. 1–15. doi:10.3390/ijerph18052461. yildiz, t., selimen, d. and dogan, d. (2014) ‘a study comparing the pre and post-training knowledge of emergency department nurses in turkey for the diagnosis of physically abused women’, journal of family violence, 29(5), pp. 519–525. doi:10.1007/s10896-014-96083. zúñiga, f. et al. (2016) ‘evidence on the validity and reliability of the german, french and italian nursing home version of the basel extent of rationing of nursing care instrument’, journal of advanced nursing, 72(8), pp. 1948–1963. doi:10.1111/jan.12975. how to cite this article: prakoeswa, a. c., arofiati, f., and hidayah, n. (2022) ‘the effect of basic trauma and cardiac life support training in increasing the competence of emergency room nurses’, jurnal ners, 17(1), pp. 8–13. doi: http://dx.doi.org/10.20473/jn.v17i1.33754 figure1 table2 table3 ameh2016 buchan2019 burnet2018 corless2018 cunningham2017 fong2021 ha2020 laoh2014 li2016 mason2005 ojifinni2019 park2017 purba2020 ridley2021 sankar2013 stevanin2017 tobase2017 vaona2018 who2020 wong2013 wu2020 yie2021 yildiz2014 zúñiga2016 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 vol 8 no 2 oktober 2013.indd 349 model peningkatan quality of nursing work life untuk menurunkan intention to quit perawat di rumah sakit premier surabaya (quality of nursing work life improvement model to decrease nurse intention to quit in premier surabaya hospital) jany prihastuty*, nyoman anita damayanti**, nursalam*** * rumah sakit premier surabaya, jalan nginden intan barat blok b surabaya **fakultas kesehatan masyarakat universitas airlangga kampus c mulyorejo surabaya ***fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya e-mail: jani.jp@gmail.com abstrak pendahuluan: quality of nursing work life (qnwl) adalah hal yang membutuhkan perhatian dengan pendekatan manajemen sumber daya manusia. tujuan dari penelitian ini adalah melakukan pengembangan model untuk meningkatkan qnwl agar menurunkan niat perawat untuk berhenti dari rumah sakit premier surabaya. metode: desain yang digunakan dalam struktur adalah explanative study. variabel independen adalah faktor internal (faktor individu , faktor konsep sosial dan lingkungan , faktor operasional , faktor administrasi) dan variabel dependen dari penelitian ini adalah niat untuk berhenti, untuk variabel moderator adalah qnwl, sedangkan teknik yang digunakan adalah random sampling. jumlah sampel adalah 160 perawat, diambil sesuai dengan kriteria inklusi. penelitian ini dilakukan di rumah sakit premier surabaya dari bulan oktober 2012–juli 2013. data dikumpulkan dengan menggunakan kuesioner terstruktur. data dianalisis dengan menggunakan uji regresi linier berganda dengan tingkat signifi kansi ≤ 0,05. hasil: hasil penelitian menunjukkan, qnwl dipengaruhi oleh hubungan antara interprofessional, bagian dari variabel faktor konsep sosial dan lingkungan, monitoring supervisi bagian dari faktor variabel operasional, pengembangan karir bagian dari variabel faktor administrasi. niat untuk berhenti dipengaruhi oleh hubungan antara perawat, antar-departemen dan antar-profesional yang merupakan bagian dari variabel faktor konsep sosial dan lingkungan serta gaji dan tunjangan bagian dari variabel faktor administrasi dengan nilai signifi kan p = 0,005. diskusi: dapat disimpulkan hubungan baik antar-profesional, monitoring supervisi, dan pengembangan karir yang baik mempengaruhi qnwl. kata kunci: qnwl, human resource management (hrm), niat untuk berhenti. abstract introduction: quality of nursing work life (qnwl) is a thing that needs attention by human resource management approach. the purpose of this research was to provide develop model to increase qnwl in order to lower nurse’s intention to quit the premier hospital surabaya. methods: design used in the structure was explanatory research. the independent variables was internal factors (individual factors, social and environment conceptual factors, operational factors, administrative factors) where as the dependent variable from this study was intention to quit, and moderator variables qnwl random sampling technique. total sample was 160 nurses, taken according to inclusion criteria. the research was conducted in premier hospital surabaya from october 2012 july 2013. data were collected by using structured questionnaire. data were then analyzed by using multiple linear regression test with level of signifi cance of ≤ 0.05. result: the results showed, qnwl was infl uenced by relationships inter-professional part of variabel social and environment conceptual factors, supervision monitoring part of variabel operational factors, career development part of variabel administrative factors. intention to quit infl uenced by relationships between nurses, inter-departmental and inter-professional part of variabel social and environment conceptual factors and salaries and benefi ts part of variabel administrative factors with signifi cant value p = 0.005. discussion: it can be concluded good inter-professional relation, supervision monitoring , and good career development affected qnwl. good relationships between nurses, inter-departmental and inter-professional led to lower intention to quit. low salary and benefi ts led nurse’s intention to quit getting stronger. keywords: qnwl, hrm (human resource management), intention to quit pendahuluan di era globalisasi dan kompetisi antar r umah sakit, peranan sdm sangat besar terutama perawat sebagai salah satu tenaga kesehatan utama. dalam lingkup perumah sakitan, suasana kerja yang tidak kondusif, lingkungan pekerjaan, beban kerja secara langsung dan tidak langsung menghambat 350 jurnal ners vol. 8 no. 2 oktober 2013: 349–356 proses pelayanan professional bila tidak diangani dengan baik. kepedulian terhadap kondisi perawat, menumbuhkan loyalitas untuk melayani lebih baik. kualitas pelayanan terbaik yang diberikan kesempatan berkembang k u rang baik perawat dipengar u hi oleh quality of nursing work life (qnwl) yang merupakan elemen penting dalam pelayanan bidang kesehatan (brooks dan clarke, 2010). rumah sakit premier surabaya (rsps) bagian dari ramsay health care indonesia (rhci), bertekad memberikan pelayanan yang terbaik bagi perawat, karyawan dan pengguna jasa kesehatan. qnwl mempunyai dampak, bila tidak tertangani dengan baik, akan mengakibatkan perawat keluar dari pekerjaan. beberapa alasan perawat keluar dari pekerjaannya karena faktor kualitas kehidupan kerja perawat, gaji dan keuntungan kurang baik seperti penghargaan. perawat di rsps merasakan gaji kurang mencukupi, 15% perawat menyatakan hal ini dan keuntungan berupa penghargaan kurang baik, 17% perawat menyatakan hal ini. faktor ini mempengaruhi rendahnya qnwl, sedangkan qnwl ini mempengaruhi produktivitas dan komitmen karyawan dalam meningkatkan kemajuan organisasi. kontribusi terbaik kar yawan dapat diperoleh ketika hubungan antara karyawan dengan lingkungan kerjanya juga baik (meylina, 2007). manfaat positif dari qnwl termasuk penurunan ketidakhadiran, penurunan pergantian tenaga kerja yang keluar dan masuk, serta peningkatan kepuasan kerja. kajian masalah dalam penelitian ini mengadopsi beberapa faktor yang mempengaruhi qnwl menurut o”brien-pallas and a. baumann (1992) yang kemudian dikembangkan oleh b. brooks and a. anderson (2005). tujuan penelitian ini menyusun model peningkatan qnwl pada perawat di rsps. manfaat penelitian ini secara teoritis dapat memberikan masukan dan informasi bagi perkembangan ilmu keperawatan khususnya dan manajemen r umah sakit tentang kualitas kehidupan kerja perawat, sehingga dapat memberikan pelayanan yang optimal. secara praktis dapat menjadi masukan bagi organisasi rumah sakit dalam mengoptimalkan dan mengelola sumber daya manusia terutama bidang keperawatan, sehingga dapat merekomendasikan faktor yang paling berpengaruh terhadap qnwl dan dapat menekan intention to quit di rumah sakit. bahan dan metode rancangan penelitian ini adalah explanatory dengan teknik random sampling. sampel penelitian perawat di rsps yang memenuhi kriteria inklusi sebanyak 160 perawat. variabel independen dalam penelitian ini adalah individual factors, social and environment conceptual factors, operational factors, administrative factors. variabel dependen adalah intention to quit, variabel moderator adalah qnwl yang memiliki empat dimensi; work lifehome life balance, work desig n dimensions, work context dimensions, work world dimensions. penelitian dilakukan di rumah sakit premier surabaya. penelitian dilaksanakan selama 9 bulan, mulai bulan oktober 2012 sampai juli 2013. metode pengambilan data menggunakan kuesioner yang telah diuji validitas dan reliabilitasnya. data yang diperoleh ditabulasi dan dianalisis dan dilakukan uji statistik regresi linier berganda, kemudian didapat isu strategis dan dilakukan focus group discussion (fgd). hasil kara k ter isti k perawat di rsps terbanyak berusia 26–35 tahun, mayoritas jenis kelamin perempuan dan sebagian besar status sudah menikah. pendidikan terbanyak saat ini diploma 3 keperawatan dan posisi terbanyak sebagai junior yang belum berpengalaman di rumah sakit ataupun klinik dengan masa kerja terbanyak di rsps 1–5 tahun . hasil penelitian tentang social and environt ment conceptual factors ya ng dirasakan perawat di rsps yang meliputi komunikasi, kepemimpinan, hubungan antar perawat, hubungan antar bagian, hubungan antar profesi berjalan baik. berdasarkan tabel 1. variabel interprofesi relations berpengaruh positif terhadap qnwl yang berarti semakin baik hubungan antar profesi, qnwl akan meningkat. pengawasan 351 model peningkatan quality of nursing work life (jany prihastuty, dkk) tabel 1. hasil uji regresi linier pengaruh social and environment conceptual factors, operational factors, administrative factors terhadap qnwl perawat di rsps mei 2013 no variabel social and environment conceptual factor, operational factors, administrative factors hasil beta sig. (p) keterangan social and environment conceptual factor 1 komunikasi 0.76 .405 tidak signifi kan 2 kepemimpinan -027 .751 tidak signifi kan 3 nurse relation .036 .627 tidak signifi kan 4 interdepartemen relations .111 .132 tidak signifi kan 5 interprofesi relations 215 .004 signifi kan operational factors 1 staffi ng .133 .091 tidak signifi kan 2 schedule .067 .382 tidak signifi kan 3 kompetisi -.077 .290 tidak signifi kan 4 pengawasan supervisor .172 .030 signifi kan administrative factors 1 pengembangan karir .167 .047 signifi kan 2 gaji .145 .096 tidak signifi kan tabel. 2 hasil uji regresi linier, pengaruh social and environment conceptual factors, operational factors, administrative factors terhadap intention to quit no variabel hasil uji regresi linier beta sig (p) keterangan social and environment conceptual factors 1 komunikasi -.145 .161 tidak signifi kan 2 kepemimpinan .026 .788 tidak signifi kan 3 nurse relation .169 .041 signifi kan 4 interdepartemenrelations -.199 .017 signifi kan 5 interprofesi relations .189 .023 signifi kan operational factors 6 staffi ng .047 .593 tidak signifi kan 7 schedule .045 .598 tidak signifi kan 8 kompetisi .075 .380 tidak signifi kan 9 pengawasan supervisor .059 .511 tidak signifi kan administrative factors 10 karir .047 .620 tidak signifi kan 11 gaji -.264 .007 signifi kan tabel. 3 hasil uji regresi linier pengaruh dimensi qnwl terhadap intention to quit perawat di rsps mei 2013 no variabel quality of nursing work life hasil beta sig (p) keterangan 1 work life home life balance -.166 .036 signifi kan 2 work design dimensions -.052 .586 tidak signifi kan 3 work context dimensions -.022 .816 tidak signifi kan 4 work world dimensions .071 .376 tidak signifi kan 352 jurnal ners vol. 8 no. 2 oktober 2013: 349–356 supervisor ber pengar uh positif terhadap qnwl yang berarti semakin baik pengawasan yang dilakukan supervisor, qnwl akan meningkat. pengembangan karir berpengaruh positif terhadap qnwl yang berarti semakin baik pengelolaan pengembangan karir perawat, qnwl akan meningkat. tampak pada tabel 2 dari uji regresi linier berganda, untuk melihat pengaruh social and environment conceptual factors, operational factors, administrative factors terhadap intention to quit, didapatkan hasil signifikan. dari variabel social and environment conceptual factors; komunikasi dan kepemimpinan tidak berpengaruh terhadap intention to quit, hubungan antar perawat, berpengaruh positif terhadap intention to quit, yang berarti semakin baik hubungan antar perawat kecenderungan untuk keluar lebih sedikit. hubungan antar departemen berpengaruh negatif terhadap intention to quit, artinya hubungan antar departemen yang tidak baik akan memperbesar peluang perawat untuk keluar. hubungan antar profesi berpengaruh positif terhadap intention to quit artinya, semakin baik hubungan antar profesi akan mengurangi kecenderungan perawat untuk keluar. operational factors tidak berpengaruh terhadap intention to quit. pengembangan karir tidak berpengaruh terhadap intention to quit. gaji dan keuntungan berpengaruh negatif terhadap intention to quit, gaji yang dirasakan rendah akan memperbesar peluang perawat untuk keluar. qnwl tidak berpengaruh langsung terhadap intention to quit, namun qnwl yang terdiri dari empat dimensi, masing-masing akan dilihat pengaruhnya terhadap intention to quit melalui uji regresi linier berganda. yang hasilnya berdasarkan tabel 3 menunjukkan work life home life balance berpengaruh negatif dan signifi kan terhadap intention to quit, yang berarti semakin ada ketidaksesuaian atau ketidakseimbangan antara pekerjaan dengan kehidupan di rumah, akan mempengaruhi peningkatan perawat untuk cenderung keluar dari pekerjaannya. sedangkan work design dimensions yang menca k up rancangan pekerjaan tentang komposisi antara job desk dan pekerjaan yang dilakukan perawat tidak berpengaruh terhadap intention to quit. work context dimensions tentang lingkungan kerja dan dampaknya terhadap pekerjaan perawat tidak berpengaruh terhadap intention to quit, work world dimensions tidak berpengaruh terhadap intention to quit. berdasarkan gambar diatas dapat dijelaskan yang mempengar u hi qn w l adalah interprofesion relations sebagai variabel social and environment conceptual factors, pengawasan super visor sebagai variabel operational factors, pengembangan karir sebagai variabel administrative factors. intention to quit dipengar uhi oleh nurse relations, interdepartemen relations and interprofesion relations yang ketiganya variabel social and environment conceptual factors, gaji dan keuntungan merupakan variabel dari administrative factors, sedangkan dari qnwl adalah work life -home life balance yang ikut berpengaruh terhadap intention to quit. pembahasan in d i v i d u a l fa c t o r s p e r awat d i rsps. perawat yang berusia kurang dari 35 tahun memiliki qnwl tinggi. perawat tersebut mempunyai kemampuan unt u k menyeimbangkan pekerjaan dengan kehidupan social and environment conceptual factors: 1. komunikasi 2. kepemimpinan 3. nurse relations 4. interdepartemen relations 5. interprofesi relations operational factors: 1. staffing 2. schedule 3. pengawasan supervisor 4. kompetisi . administrative factors: 1.pengembangan karir 2.gaji dan keuntungan qnwl: 1. work life home life balance 2. work design dimensions 3. work contxt dimensions 4.work world dimensions intention to quit gambar 1. pengaruh social and environment conceptual factor, operational factors, administrative factors terhadap qnwl dan intention to quit 353 model peningkatan quality of nursing work life (jany prihastuty, dkk) di rumah lebih tinggi dibandingkan perawat yang berusia di atas 35 tahun. berdasarkan hasil penelitian usia dengan tekanan kerja dari hari (2012), didapatkan bahwa usia yang tinggi dalam arti semakin lama bekerja maka kepuasan kerja semakin tinggi. berkaitan antara usia dengan kepuasan kerja, akan mengalami peningkatan kepuasan kerja pada usia 30-an, lalu menurun pada usia 40-an dan meningkat lagi pada usia 50-an sampai mereka pensiun. berhubungan dengan tekanan kerja semakin tinggi usia dalam arti lama bekerja, maka tekanan kerja rendah, sedangkan faktor ini turut mempengaruhi qnwl. perawat berjenis kelamin perempuan memiliki qnwl tinggi, yaitu lebih mampu menyeimbangkan pekerjaan dengan kehidupan di rumah dibandingkan perawat laki-laki. status perkawinan, perawat yang belum menikah memiliki qnwl tinggi, yaitu lebih mampu menyeimbangkan pekerjaan dengan kehidupan di rumah dibandingkan perawat yang sudah menikah. posisi keperawatan, perawat yang mempunyai posisi keperawatan lebih rendah memiliki qnwl tinggi, yaitu lebih mampu menyeimbangkan pekerjaan dengan kehidupan di rumah, dan masih dipengaruhi emosional yang belum stabil serta adanya harapan yang tinggi, sehingga dalam menyikapi permasalahan lebih realistis dan rasional. berdasarkan masa kerja, perawat yang masa kerjanya lebih lama memiliki qnwl tinggi, yaitu lebih mampu menyeimbangkan peker jaan dengan kehidupan di r u mah dibandingkan yang masa kerja lebih pendek. perawat yang belum mempunyai pengalaman bekerja memiliki qnwl tinggi, yaitu lebih mampu menyeimbangkan pekerjaan dengan kehidupan di rumah dibandingkan perawat ya ng pengala ma n ker ja lebi h ba nya k. karyawan baru cenderung datang di tempat kerja dengan harapan tinggi. pel a k s a n a a n p e m b e r i a n a s u h a n keperawatan, pada perawat berpengalaman selain melakukan perawatan secara personal, juga mendapat tanggung jawab lebih untuk membantu dan menjadi penanggung jawab dalam setiap shift. dalam hal bersikap lebih tenang tidak emosional dalam menghadapi situasi yang menekan sekalipun. perawat yang berpendidikan rendah memiliki qnwl tinggi, yaitu lebih mampu m e n y e i m b a n g k a n p e k e r j a a n d e n g a n kehidupan di rumah dibandingkan perawat yang berpendidikan tinggi. karena perawat dengan tingkat pendidikan yang lebih tinggi berpengharapan dapat berpenghasilan lebih tinggi di perusahaan/pekerjaan lain perawat yang berpendidikan tinggi lebih mempunyai bekal ilmu pengetahuan u nt u k mampu memberikan asuhan keperawatan secara profesional dan dapat menjelaskan setiap unsur asuhan perawatan yang diberikan dengan penuh percaya diri. pendidikan yang tinggi membantu perawat berpikiran lebih rasional dan realistis dalam menghadapi suatu permasalahan. menu r ut her zberg, fa k tor-fa k tor yang dapat meningkatkan kepuasan kerja antara lain bila seseorang mencapai prestasi (achievement), pengakuan prestasi (recognition for accomplishment), hal ini dapat dicapai melalui tingkat pendidikan yang memadai (nursalam, 2001). dilihat dari posisi keperawatan, perawat yang mempunyai posisi keperawatan lebih rendah memiliki qnwl tinggi, tenaga yang lebih senior cenderung puas dengan pekerjaannya karena mereka lebih mampu menyesuaikan diri dengan lingkungan kerja berdasarkan pengalaman nya. selain it u dengan memegang posisi atau jabatan yang lebih tinggi, dari aspek emosional lebih stabil, sehingga dalam menyikapi permasalahan lebih realistis dan rasional. social and environment conceptual factor bentuk hubungan antar profesi dengan perawat professional masa depan dengan memberikan pelayanan keperawatan melalui berkomunikasi secara lengkap, adekuat dan cepat, artinya setiap melakukan komunikasi secara lisan maupun tulis dengan teman sejawat dan tenaga kesehatan lainnya harus memenuhi ketiga unsur diatas dengan didukung fakta yang memadai (nursalam, 2001). komunikasi ant ar perawat dan komu ni kasi dengan departemen ataupun antar profesi menunjang keberhasilan pelayanan. keperawatan sebagai 354 jurnal ners vol. 8 no. 2 oktober 2013: 349–356 bagian terintegrasi dari upaya pemberian jasa kesehatan tidak terlepas dari kerja sama dengan departemen dan profesi lain. supervisor di rsps adalah perawat senior atau kepala ruangan yang bertugas secara bergantian menjadi duty manager (manajer yang bertugas). sebagai seorang supervisor diperlukan fi gur kepemimpinan yang baik dan kuat. teori kepemimpinan sudah dimulai sejak abad 20 dan semakin berkembang serta perlu memperhatikan unsur psikologi, ilmu politik dan pengalaman yang bervariasi akan membuat seseorang makin menjadi pemimpin yang sukses (porter, 2003). berfokus pada kepercayaan dan tujuan yang lebih spesifik tentang suatu kualitas yang akan didapat dari individu untuk menjadi pemimpin yang lebih baik (marquis & huston, 2006). kepemimpinan memainkan peranan yang sangat dominan dalam keberhasilan o r g a n i s a s i d a l a m m e nyel e n g g a r a k a n berbagai kegiatannya terutama terlihat dalam kinerja para pegawainya (siagian, 2009). dilihat dari bagaimana seorang pemimpin dapat mempengar uhi bawahannya untuk bekerjasama menghasilkan pekerjaan yang efektif dan efi sien. pelatihan tentang kepemimpinan di rsps sudah menjadi agenda rutin untuk diajarkan pada kalangan manajer. tetapi untuk staf di keperawatan belum berjalan terutama spesif i kasi. dengan ad a nya penet apan kompetensi ter masuk grading pelevelan perawat, diharapkan akan ada kesempatan untuk mendapatkan pelatihan kepemimpinan untuk membantu kaderisasi perawat untuk menjadi pemimpin, sehingga nilai-nilai kepemimpinan dapat juga dipahami oleh staf perawat dari awal. kepemimpinan yang baik dapat membantu psikologis perawat dengan baik. perasaan dilindungi dan mendapat arahan ataupun pengawasan secara tepat dari seorang pemimpin, akan membawa dampak positif. perawat merasa diperhatikan dan membantu menciptakan lingkungan yang kondusif. kepemimpinan yang tidak sepenuhnya otoriter dibangun dengan demokrasi dan kekeluargaan akan menciptakan kualitas kerja yang baik. operational factors mencakup staffi ng didefinisikan dalam penelitian ini adalah sumber daya manusia. tenaga perawat yang ada disesuaikan dengan jumlah dan komposisi perawat dalam satu shift dengan kesesuaian jumlah dan kategori pasien, meliputi rasio perawat dengan pasien. pembenahan terkait dengan rasio kecukupan perawat dibandingkan dengan jumlah pasien dan pembenahan tersebut bisa diibaratkan sebagai bentuk strategi dalam keselamatan pasien. shekelle (2013) m e ny a t a k a n b a hwa r a sio ke c u k u p a n perawat memili k i hubu ngan yang erat dengan penurunan kematian di rumah sakit. kepmenkes nomor 81/menkes/sk/1/2004 tentang penyusunan perencanaan sumber daya manusia kesehatan dapat dijadikan r ujukan unt uk mengevaluasi kecukupan tenaga kesehatan untuk peningkatan dan pemantapan perencanaan, pengadaan tenaga kesehatan, pendayagunaan dan pemberdayaan profesi kesehatan. perencanaan kebutuhan sumber daya manusia (sdm) kesehatan perlu disesuaikan dengan kebutuhan operasional dan berorientasi pada jangka panjang. sdm kesehatan merupakan bagian tidak terpisahkan dari pelayanan kesehatan terutama pelayanan keperawatan. ketidaksesuaian antara rasio perawat dengan pasien maupun komposisi perawat dalam setiap tugas jaga akan mempengaruhi kualitas dari pelayanan yang diberikan. tanggung jawab perawat senior terhadap perawat medior dan junior membuat beban mental bagi perawat dalam memberikan asuhan keperawatan dan berdampak pada keselamatan pasien. beban kerja adalah frekuensi rata-rata masing-masing jenis pekerjaan dalam jangka waktu tertentu, di mana dalam memperkirakan beban kerja dari organisasi dapat dilakukan berdasarkan perhitungan atau pengalaman (peraturan pemerintah ri nomor 97 tahun 2000). beban kerja perawat adalah seluruh kegiatan/aktivitas yang dilakukan oleh seorang perawat selama bertugas di suatu unit pelayanan keperawatan (marquish dan huston, 2000). berdasarkan dua pengertian beban kerja perawat adalah seluruh kegiatan atau aktivitas yang dilakukan perawat dengan jenis pekerjaan dan beratnya pekerjaan yang ditetapkan dalam 355 model peningkatan quality of nursing work life (jany prihastuty, dkk) satuan waktu tertentu di suatu unit pelayanan keperawatan. beban kerja dibedakan menjadi beban kerja kuantitatif dan kualitatif. beban kerja kuantitatif menunjukkan adanya jumlah pekerjaan yang besar yang harus dilakukan misalnya jam kerja yang tinggi, derajat tanggung jawab yang besar, tekanan kerja sehari-hari dan sebagainya. beban kerja kualitatif menyangkut kesulitan tugas yang dihadapi (putrono, 2002). secara kuantitatif perawat di rsps saat ini sudah terpenuhi, tetapi secara kualitatif perawat belum terpenuhi. jumlah perawat junior lebih banyak dibandingkan senior dan medior. perawat senior selain sebagai penanggung jawab tim juga bertanggung jawab terhadap perawat baru. keadaan ini menyebabkan bimbingan ataupun pengawasan yang diberikan menjadi tidak optimal. untuk mengatasi hal ini diperlukan pembimbing klinik atau clinical instructor (ci) untuk membantu perawat baru agar siap memberikan pelayanan. bimbingan diperlukan agar perawat baru terlepas dari beban unit, sehingga waktu dan kualitas pelayanan menjadi lebih baik. schedule didefinisikan jadwal dinas yang dibuat untuk mengatur jam kerja perawat, terbagi dalam 3 shift, termasuk perawat yang bertugas sebagai penanggung jawab tiap shift. penjadwalan ini menentukan pola jam kerja masuk dan libur mendatang perawat dalam suatu unit. jadwal dinas dikeperawatan terbagi beberapa variasi sesuai kebutuhan operasional. saat ini ada yang menggunakan sistem 5–2, artinya 5 hari kerja 2 hari libur, tetapi ada juga yang 6 hari kerja 1 hari libur. bagi yang mendapat dinas shift, dampak dari jumlah pasien yang banyak dan komposisi yang kurang seimbang, mengakibatkan staf perawatan yang sehar usnya pulang pada waktunya, menjadi sering memanjang jam di nasnya, karena har us menyelesai kan pelayanan perawatan, agar aman diserahkan untuk diteruskan pada shift berikut, sehingga bagi yang dinas sore, seharusnya jam 22.15 sudah dapat meninggalkan unitnya, baru selesai sampai jam 22.30–23.00. dari sisi penghargaan, di rsps staf yang bekerja lebih 1 jam dari jam dinas terhitung lembur, namun staf perawatan merasakan kelelahan fi sik dan mental. ad m i n i s t ra t i v e fa c t o r s mel iput i penjenjangan kar ir perawat juga dapat dijadikan landasan dalam proses promosi, mutasi dan rotasi perawat. dengan adanya kejelasan dalam pengelolaan jenjang karir perawat, maka akan berpengaruh terhadap kepuasan dan kinerja perawat. dalam hal ini di rsps sedang ditata pembuatan grading yang mengacu pada sistem pengembangan karir di ramsay health care indonesia. pengembangan kar ir ber pengar u h positif terhadap qnwl yang berarti semakin baik pengelolaan pengembangan karir perawat maka qnwl akan meningkat. sdm terutama perawat merupakan tulang punggung rumah sakit dalam memberikan pelayanan. evaluasi gaji sangat diperlukan, terutama kebijakan atau peraturan yang jelas tentang penghargaan untuk masing-masing kategori perawat yang berbeda, termasuk area perawat menjalankan pekerjaan. antara r uang rawat inap dan ruang intensive care, tentunya ada perbedaan penghargaan dari segi tuntutan kompetensi yang harus dimiliki oleh seorang perawat. nilai individu mengenai kerja dan hasil dapat digunakan sebagai informasi untuk memperkirakan faktor yang mempengaruhi kepuasan kerja (soeroso, 2002). robins menyatakan bila upah diberikan secara adil sesuai tuntutan pekerjaan, tingkat keterampilan individu dan standar pengupahan komunitas, kemungkinan besar menghasilkan kepuasan pada pekerja (robbins, 2001). kecender ungan unt uk keluar atau intention to quit adalah suatu intensi yang hanya sebatas keinginan atau niat untuk meninggalkan organisasi. ini menyangkut sikap umum seseorang terhadap pekerjaannya, yang didasarkan atas penilaian terhadap aspek pekerjaannya. keluar nya perawat menyebabkan lumpuhnya aktivitas organisasi (kreisman, 2002). kesulitan menarik orang baru dengan memiliki kemampuan yang setara memerlukan waktu, selama jabatan kosong atau belum mendapat karyawan pengganti, dapat membuat pemulihan kinerja organisasi menjadi sulit (kreisman, 2002). 356 jurnal ners vol. 8 no. 2 oktober 2013: 349–356 simpulan dan saran simpulan model qn w l d ipe nga r u h i oleh inter profesi relations sebagai var iabel social and environment conceptual factors, pengawasan super visor sebagai variabel operational factors, pengembangan karir sebagai variabel administrative factors. intention to quit dipengar uhi oleh nurse relations, interdepartemen relations and interprofesi relations yang ketiganya variabel social and environment conceptual factors, gaji dan keuntungan merupakan variabel dari administrative factors. dimensi qnwl yang ikut berpengaruh terhadap intention to quit adalah work life -home life balance. saran manajemen memiliki komitmen dengan kepala ruangan masingmasing unit perawatan dan perawat yang ada di rsps secara bersamasama untuk melaksanakan program peningkatan qnwl secara bertahap dengan membangun lingkungan yang lebih kondusif, komunikasi lebih terbuka, kepemimpinan yang dapat menjadi panutan, kesesuaian job desk dengan beban kerja, melakukan penghitungan beban kerja perawat untuk masing-masing unit dan menganalisis beban kerja tenaga perawat yang ada menentukan grading dan kompetensi perawat, membuka kesempatan perawat untuk berkembang, membangun kerja sama yang baik antar perawat, departemen dan profesi , mengidentifi kasi dan mengevaluasi program pengelolaan sdm, mengevaluasi sistem penjenjangan karir, menyusun standar baku rotasi perawat, agar tenaga perawatan dapat efektif dan efi sien, dan sesuai keahliannya ter masuk evaluasi gaji dan keunt ungan perawat, sistem pengangkatan karyawan baru dan kebijakan perawat yang keluar dari rs. bag i per awat tet ap member i k a n pelayanan dengan caring dan bangga menjadi perawat yang berdedikasi serta mempunyai komitmen bagi kesehatan dan keselamatan pasien. kepustakaan brooks, b. a., anderson, m. a., 2005. defi ning quality of nursing work life. nursing economics, 23 nov/ dec, 319–326. brooks, b. a., anderson, b., 2007. assesing the nursing quality of work life. nursing administration quarterly, 152–157. clarke, p. n., brooks, b., 2010. quality of nursing worklife. nursing science quarterly, 23 (4), 301–305. sumarto, 2002. meningkatkan komitmen dan kepuasan untuk menyur utkan niat keluar (online) (http://puslit2.petra. a c.id /ejou r n al /i ndex.php/m a n /a r t icle/ viewfile/17968/17879) diakses tanggal 14 juni 2013, jam 09.00 wib). meylina, 2007. studi deskriptif kualitas kehidupan kerja karyawan pt hanurda bersaudara di surabaya. surabaya. surabaya: ubaya. nursalam, 2011. manajemen keperawatan. jakarta: salemba medika. peraturan pemerintah ri nomor 97 tahun 2000 – 097-00 pdf. putrono, 2002. beban kerja, (online), (http:// repository.usu.ac.id/bitstream/123456789/3 3834/4/chapter%20ii.pdf diakses tanggal 14 juni 2013, jam 20.00 wib). robbin stephen p, 2001. perilaku organisasi k o n s e p k o n t r o v e r s i a p l i k a s i . prenhalindo. jakarta: edisi indonesia. shekelle, 2013. ratio kecukupan perawat\: sebuah sistematik review strategi keselamatan pasien, (online), (http:// www.mutupelayanankesehatan.net/index. php/component /content /a r t icle/22/558 diakses tanggal 20 juni 2013, jam 13.00 wib). siagian, s.p, 2009. manajemen sumber daya manusia. cetakan ketujuh belas. jakarta. soeroso, 2002. penataan sistem jenjang karir berdasar kompetensi untuk meningkatkan kepuasan kerja dan kinerja perawat di umah sakit ekplanasi volume 6 nomor 2 edisi september 2011, (online), (www.kopertis6.or.id/ journal/index.php/eks/.../84/73 ‎ diakses tanggal 14 juni 2013, jam 18.00 wi 192 aromacare melati meningkatkan pemenuhan kebutuhan tidur pada lansia (aromacare of jasmine increased sleep needs in elderly) heri kusnaidi*, joni haryanto*, makhfudli* *fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya e-mail: ckoess@gmail.com abstract introduction: sleep disorder is one of the problems that faced by elderly. progress of sleep change from time to time, sleep patterns during the aging experience different than younger people. sleep patterns in elderly decreases according with increasing age and degenerative processes that occur in physiological. aroma of jasmine is the one of method to increase sleep needs, but giving the aroma of jasmine with nursing intervention that called aromacare to reduce sleep disorder is never investigated. method: this study used quasy experiment pretest and posttest design. the population were elderly with sleep disorder in tresna werdha puspakarma service home elderly mataram. the samples were recruited using purposive sampling, total samples were 14 respondents, according to inclusion and exclusion criteria. the independent variable was aromacare of jasmine and the dependent variable was sleep in elderly. data were collected using structure questionnaire. data were analyzed by using wilcoxon sign rank test and mann whitney test to fulfi llment adequacy of sleep based on quantity, paired t test and independent t test to fulfi llment adequacy of sleep on quantity with signifi cance α ≤ 0.05. result: result showed that aromacare of jasmine increase of fulfi llment of the need of sleep in quality (p < 0.016) and also effect the need of sleep in quantity (p < 0.001). discussion: it can be concluded that aromacare of jasmine has signifi cantly effect on sleep need of the elderly. further research should measure the effect of aromacare of jasmine on fulfi llment of the need of sleep with the rate of melatonin and eeg (electro encephalo gram). keyword: elderly, aromacare of jasmine, sleep pendahuluan tidur merupakan salah satu kebutuhan dasar fi siologis manusia yang terjadi secara alami dan merupakan suatu proses perbaikan tubuh. perkembangan tidur berbeda dari waktu ke waktu, biasanya pola tidur pada masa penuaan mengalami perubahan-perubahan daripada orang yang lebih muda (stanley and beare, 2007). pola tidur pada lansia semakin berkurang sesuai dengan bertambahnya usia dan proses degeneratif yang terjadi secara fi siologis. menurut stanley and beare (2007), gangguan pemenuhan tidur dialami 50% orang yang berusia 65 tahun ke atas atau lebih yang tinggal di rumah dan 66% orang yang tinggal di fasilitas perawatan jangka panjang dan gangguan pemenuhan kebutuhan tidur yang terbanyak yang dialami oleh lansia adalah susah untuk memulai tidur. perawat sebagai pemberi asuhan keperawatan dapat mengurangi keluhan tidur pada lansia dengan memberikan lingkungan yang tenang dan nyaman dengan menggunakan aroma-aroma relaksan seperti aroma melati (jasmine). aromacare merupakan pemberian aroma-aroma relaksasi untuk meningkatkan relaksasi dengan pendekatan asuhan keperawatan melalui metode induksi, namun pengaruh aromacare melati (jasmine) terhadap pemenuhan kebutuhan tidur pada lansia masih belum bisa dijelaskan. tidur mengalami perubahan seiring dengan pertambahan usia. efisiensi tidur (jumlah waktu tidur berbanding dengan waktu berbaring di tempat tidur) semakin berkurang. sementara kebutuhan tidurpun semakin menurun, karena dorongan homeostatik untuk tidur juga berkurang. tidur merupakan salah satu kebutuhan biologis yang harus aromacare melati (jasmine) (heri kusnaidi) 193 dipenuhi oleh setiap orang selain makan dan bernapas. sebagian besar waktu hidup seseorang dihabiskan dengan tidur (prasadja, 2009). luce & seagal mengungkapkan bahwa faktor usia merupakan faktor terpenting yang berpengaruh terhadap kualitas tidur. telah dikatakan bahwa keluhan terhadap kualitas tidur sering dengan bertambahnya usia. pada kelompok lanjut 40 tahun hanya dijumpai 7% kasus yang mengeluh masalah tidur (hanya dapat tidur tidak lebih dari 5 jam sehari). hal yang sama dijumpai pada 22% kasus pada kelompok usia 70 tahun. demikian pula, kelompok lanjut usia lebih banyak mengeluh terbangun lebih awal dari pukul 05.00 pagi. selain itu, terdapat 30% kelompok usia 70 tahun yang banyak terbangun di waktu malam hari. angka ini ternyata tujuh kali lebih besar dibandingkan dengan kelompok usia 20 tahun (fitri, 2009). berdasarkan data awal yang didapatkan peneliti di panti sosial tresna werdha puspakarma mataram ditemukan bahwa sebanyak 22 lansia (28%) dari 82 lansia yang ada, mengeluh sering bangun pada malam hari dan tidak puas dalam tidurnya. ada dua tahap yang harus dilalui dalam tidur yaitu tidur rem (rapid eye movement) dan nrem (non-rapid eye movement). nrem kemudian dibagi lagi menjadi empat tingkat, dengan tingkat tidur yang makin dalam yaitu nrem 1, nrem 2, nrem 3, dan nrem 4. perubahan yang terjadi adalah episode tidur rem pada lansia cenderung memendek dan terdapat penurunan yang progresif pada tahap tidur nrem 3 dan 4. beberapa lansia hampir tidak memiliki tahap 4 atau tidur yang dalam. seorang lansia akan terbangun lebih sering di malam hari dan membutuhkan waktu yang lebih banyak untuk kembali tertidur (potter dan perry, 2005). perubahan pola tidur pada lansia disebabkan perubahan sistem saraf pusat yang memengaruhi pengaturan tidur. kerusakan sensorik yang umum dengan penuaan, dapat mengurangi sensitivitas terhadap waktu yang mempertahankan irama sirkardian (potter dan perry, 2005). aktifnya saraf simpatis membuat lansia tidak dapat santai atau relaks sehingga tidak dapat memunculkan rasa kantuk. secara fi siologis, jika seseorang tidak mendapatkan tidur yang cukup untuk mempertahankan kesehatan tubuh, dapat terjadi efek-efek seperti pelupa, konfusi, dan disorientasi, terutama jika deprivasi tidur terjadi dalam jangka waktu yang lama. akibatnya, lansia semakin berisiko mengalami jatuh dan depresi yang berkepanjangan (stanley dan beare, 2007). hal ini dapat diatasi dengan mengatur waktu tidur, ikuti petunjuk sleep hygiene dan cobalah untuk lebih berpikiran positif. tenaga perawat yang merupakan "the caring profession" memegang peranan penting dalam mengurangi gangguan tidur lansia (kasnalia, 2010). seorang perawat dapat melakukan asuhan keperawatan dengan m e m b e r i k a n l i n g k u n g a n y a n g n y a m a n untuk pemenuhan tidur seseorang. ruangan dan keadaan sekeliling yang nyaman akan menyebabkan tidur nyenyak. salah satu cara yang dapat dilakukan adalah dengan menggunakan aroma-aroma yang menimbulkan relaksasi seperti aroma melati (jasmine). aroma bunga melati dapat meningkatkan efi siensi tidur seseorang dan mengurangi pergerakan seseorang ketika tidur, meningkatkan kualitas tidur seseorang tanpa penambahan waktu tidur (raudensberg, 2005). selain itu, aroma melati (jasmine) mempunyai efek sedatif terhadap aktivitas saraf otonom dan keadaan jiwa seseorang (kuroda, 2005). caring merupakan fenomena universal yang berkaitan dengan cara seseorang berpikir, berperasaan dan bersikap ketika berhubungan dengan orang lain, sedangkan aromacare merupakan penggunaan konsep caring yang digunakan sebagai dalam asuhan perawatan klien yang mengalami gangguan tidur dengan pendekatan menggunakan aroma-aroma relaksan. pemberian aroma melati (jasmine) dengan diiringi pemberian asuhan keperawatan selama ini tidak pernah dilakukan dalam mengatasi gangguan kebutuhan tidur pada lansia. oleh karena itu, berdasarkan uraian di atas peneliti tertarik untuk melakukan penelitian mengenai pengaruh aromacare melati (jasmine) terhadap pemenuhan kebutuhan tidur lansia di panti sosial tresna werdha puspa karma mataram. jurnal ners vol. 6 no. 2 oktober 2011: 192–200 194 bahan dan metode jenis penelitian ini adalah penelitian eksperimen semu (quasy experimental) bentuk pre post design. rancangan ini untuk mengungkapkan hubungan sebab akibat dengan melibatkan kelompok kontrol di samping kelompok eksperimental. tetapi pemilihan kedua kelompok tidak menggunakan teknik acak. dalam rancangan ini kelompok eksperimental diberikan perlakuan sedangkan kelompok kontrol tidak. kelompok perlakuan diawali dengan pretest, dan setelah pemberian perlakuan diadakan pengukuran kembali (posttest). populasi dalam penelitian ini adalah lansia yang mengalami gangguan pemenuhan kebutuhan tidur di panti sosial tresna werdha puspakarma mataram. teknik sampling dalam penelitian ini menggunakan teknik purposive sampling. sampel ditentukan berdasarkan kriteria inklusi, yaitu karakteristik umum subjek penelitian dari suatu populasi target yang terjangkau dan akan diteliti (nursalam, 2009). kriteria inklusi dalam penelitian ini adalah lansia yang kooperatif, bersedia menjadi responden, lansia yang mengkonsumsi obat-obatan analgesik, obat tidur, atau terapi insomnia lain, sedangkan kriteria eksklusi dalam penelitian ini adalah lansia yang tidak suka dengan aroma melati (jasmine), lansia yang alergi terhadap aroma melati (jasmine), lansia yang tidak mengalami gangguan penciuman dan pendengaran, lansia yang mengalami gangguan kejiwaan, lansia yang mengalami poliuri. variabel independen pada penelitian ini adalah aromacare melati (jasmine) dan variabel dependen yaitu pemenuhan kebutuhan tidur pada lansia secara kualitas dan kuantitas. instrumen yang digunakan dalam pemenuhan tidur dalam hal kualitas adalah dengan menggunakan pittsburg sleep quality index (psqi) yang terdiri dari 9 pertanyaan pribadi dan 5 pertanyaan untuk pasangan atau teman tidur, dengan penilaian jika jumlah skor 0 = sangat baik, 1–7 = agak baik, 8–14 = agak buruk, 15–21 = sangat buruk, sedangkan instrumen yang digunakan untuk menilai kuantitas tidur adalah lembar observasi lamanya tidur. pada penelitian ini peneliti hanya menggunakan 9 pertanyaan pribadi pada psqi. pemberian aromacare melati (jasmine) ini menggunakan standar operasional prosedur (sop) dengan panduan peneliti dan observasi. bahan yang digunakan dalam aromacare ini adalah aroma melati dan burner aromaterapi. penelitian diawali dari mengidentifi kasi responden yang sesuai dengan kriteria inklusi dan ekslusi. kemudian peneliti memberi lembar inform consent kepada responden yang sesuai dengan kriteria inklusi dan ekslusi sebagai persetujuan untuk menjadi sampel dalam penelitian ini. setelah itu peneliti melakukan pre-test dengan menggunakan lembar kuesioner pemenuhan kebutuhan tidur psqi yang telah dimodifikasi dan dilakukan pengukuran lama tidur responden menggunakan lembar observasi lamanya tidur dengan cara wawancara. kemudian peneliti membagi responden menjadi dua kelompok, yaitu kelompok perlakuan dan kelompok kontrol. p e m b e r i a n p e n d i d i k a n k e s e h a t a n mengenai pemberian aromacare melati (jasmine) diberikan kepada lansia yang pada kelompok perlakuan sehari sebelum dilakukan intervensi. pada hari pertama hingga hari ke empat belas, pemberian aromacare melati (jasmine) dilakukan pada malam hari, yaitu 15–30 menit sebelum lansia beranjak ke tempat tidur. selama di tempat tidur pasien akan diberikan pengantar secara verbal sambil diberikan aroma melati (jasmine). peralatan yang digunakan adalah burner aroma melati (jasmine). setelah itu, jika lansia telah siap beranjak ke tempat tidur, yang minyak aroma melati (jasmine) diteteskan pada mangkok pada burner keramik dan ditambahkan air sebanyak 3/4 dari mangkok, kemudian lilin dinyalakan di bawah mangkok sehingga aroma melati keluar. peneliti lalu meminta lansia untuk berbaring di tempat tidurnya dengan posisi yang senyaman mungkin sambil menghirup aroma melati (jasmine) dan diberikan pengantar secara verbal. aroma yang ditimbulkan akan bertahan selama lebih kurang 4 jam. dalam 2 minggu, peneliti akan memberikan intervensi. setelah dilakukan pemberian intervensi aromacare melati (jasmine) selama 2 minggu, pada hari ke empat belas lansia diberikan lembar kuesioner aromacare melati (jasmine) (heri kusnaidi) 195 untuk mengetahui pemenuhan kebutuhan tidur pada lansia setelah diberikan intervensi tersebut. analisa data menggunakan uji wilcoxon sign test untuk mengetahui pemenuhan kebutuhan tidur secara kualitas, paired t test untuk mengetahui pemenuhan kebutuhan tidur secara kuantitas, mann whitney untuk mengetahui perbandingan kualitas tidur lansia dan independent t test untuk mengetahui perbandingan kuantitas tidur. hasil hasil pengumpulan data pada lansia yang mengalami gangguan pemenuhan kebutuhan tidur diketahui bahwa pada kelompok perlakuan mayoritas lansia berusia 60–74 tahun yaitu sebanyak 5 orang (71%), pada kelompok kontrol sebagian besar lansia juga berusia 75–90 tahun yaitu sebanyak 5 orang (71%). distribusi responden menurut jenis kelamin didapatkan bahwa pada kelompok perlakuan lansia berjenis kelamin perempuan yaitu sebanyak 4 orang (57%), pada kelompok kontrol lanjut usia berjenis kelamin perempuan yaitu sebanyak 4 orang (57%). hasil uji statistik perubahan kualitas pemenuhan kebutuhan tidur lansia sebelum (pre-test) dan sesudah (post-test) pada kelompok yang diberikan perlakuan dan kontrol. hasil uji statistik wilcoxon signed rank test pada kelompok perlakuan menunjukkan p = 0,016 artinya ada pengaruh pemberian aromacare melati (jasmine) terhadap pemenuhan kebutuhan tidur lansia secara kualitas, sedangkan pada kelompok kontrol diperoleh hasil p = 0,577 artinya tidak ada perbedaan kualitas tidur antara hasil pre test dan post-test. tabel 2. pemenuhan kebutuhan tidur lansia kelompok perlakuan dan kelompok kontrol berdasarkan kuantitas sebelum dan sesudah diberikan aromacare melati (jasmine) no lama tidur (jam) perlakuan kontrol pre post pre post 1 2 3 4 5 6 7 3 3 4 4 3 3 3 6 4 5 6 5 6 5 3 5 3 2 3 5 4 2 5 3 2 3 5 4 paired t test p = 0,001 p = 0,356 independent t test p = 0,006 hasil uji statistik mann whitney test p = 0,023 yang berarti bahwa ada perbedaan post-test kualitas tidur pada kelompok perlakuan dan kelompok kontrol. hasil uji statistik pemenuhan kebutuhan tidur lansia secara tabel 1. pemenuhan kebutuhan tidur lansia kelompok perlakuan dan kelompok kontrol berdasarkan kualitas sebelum dan sesudah diberikan aromacare melati (jasmine) no. skor psqi perlakuan kontrol pre ket. post ket. pre ket. post ket. 1 2 3 4 5 6 7 15 14 12 16 12 16 11 sangat buruk agak buruk agak buruk sangat buruk agak buruk sangat buruk agak buruk 8 11 9 9 9 11 8 agak buruk agak buruk agak buruk agak buruk agak buruk agak buruk agak buruk 15 10 16 14 17 11 13 sangat buruk agak buruk sangat buruk agak buruk sangat buruk agak buruk agak buruk 15 10 16 16 15 10 12 sangat buruk agak buruk sangat buruk sangat buruk sangat buruk agak buruk agak buruk wilcoxon signed p = 0,016 p = 0,577 rank test mann whitney p = 0,023 jurnal ners vol. 6 no. 2 oktober 2011: 192–200 196 kuantitas kelompok perlakuan dan kelompok kontrol. dari hasil uji statistik paired t test pada kelompok perlakuan p = 0,001 yang artinya ada perbedaan kuantitas (lama tidur) pre dan post intervensi, sedangkan pada kelompok kontrol didapatkan p = 0,356 yang artinya tidak ada perbedaan kuantitas (lama tidur) antara hasil pre test dan post-test. pembahasan hasil penelitian menggambarkan bahwa pada pre test responden, baik pada kelompok perlakuan dan kontrol memiliki kualitas tidur agak buruk dan sangat buruk, di mana pada kelompok kontrol, sebanyak 3 orang memiliki kualitas tidur sangat buruk dan 4 orang memiliki kualitas tidur agak buruk. sedangkan pada kelompok perlakuan, 3 orang memiliki kualitas tidur sangat buruk dan 4 orang memiliki kualitas tidur agak buruk. berikut ini akan dibahas mengenai data usia dan jenis kelamin yang dapat memengaruhi pemenuhan kebutuhan tidur lansia yang meliputi kualitas dan kuantitas tidurnya. distribusi responden berdasarkan umur diketahui bahwa 5 orang responden pada kelompok perlakuan yaitu berusia 60–74 tahun dan 2 orang responden berusia 75–90 tahun, dan pada kelompok kontrol 2 responden berusia 60–74 tahun dan 5 orang responden berusia 75–90 tahun. fakta ini sesuai dengan apa yang dipaparkan oleh prasadja (2009) bahwa tidur mengalami perubahan seiring dengan pertambahan usia. efisiensi tidur (jumlah waktu tidur berbanding dengan waktu berbaring di tempat tidur) semakin berkurang. sementara kebutuhan tidur pun semakin menurun, karena dorongan homeostatik untuk tidur pun berkurang. hal ini juga didukung oleh pendapat potter dan perry (2005) yaitu kualitas tidur kelihatan menjadi berubah pada kebanyakan lansia. kualitas tidur menunjukkan adanya k e m a m p u a n i n d i v i d u u n t u k t i d u r d a n memperoleh jumlah istirahat yang sesuai dengan kebutuhannya (hidayat, 2008). salah satu faktor yang menyebabkan perubahan kualitas tidur pada lansia adalah umur. pada lansia terjadi perubahan pada gelombang otak, meningkatnya frekuensi terbangun di malam hari atau meningkatnya fragmentasi tidur karena seringnya terbangun pada malam hari hal ini akan membuat lansia merasa letih dan tidak bugar pada saat bangun tidur. hal inilah yang membuat kualitas tidur pada lansia cenderung berubah. pada penelitian ini, kebanyakan lansia mengeluh kualitas tidurnya terganggu karena susah memulai tidur dan memerlukan waktu yang lama untuk bisa tidur pulas. hasil uji statistik pemenuhan kebutuhan tidur lansia secara kuantitas kelompok perlakuan dan kelompok kontrol dapat dilihat bahwa sebagian besar responden pada kedua kelompok hanya dapat tidur tidak lebih dari 5 jam sehari yaitu 14 orang (100%). hal ini sesuai dengan pernyataan luce and segal yang mengungkapkan bahwa faktor usia merupakan faktor terpenting yang berpengaruh terhadap kuantitas tidur. telah dikatakan bahwa keluhan terhadap kuantitas tidur sering dengan bertumbuhnya usia. pada kelompok lanjut 40 tahun hanya dijumpai 7% kasus yang mengeluh masalah tidur (hanya dapat tidur tidak lebih dari 5 jam sehari). hal yang sama dijumpai pada 22% kasus pada kelompok usia 70 tahun. demikian pula, kelompok lanjut usia lebih banyak mengeluh terbangun lebih awal dari pukul 05.00 pagi. selain itu, terdapat 30% kelompok usia 70 tahun yang banyak terbangun di waktu malam hari. angka ini ternyata tujuh kali lebih besar dibandingkan dengan kelompok usia 20 tahun (fitri, 2009). hal ini dibuktikan dari hasil data dari penelitian di mana rerata responden pada penelitian mengatakan bangun sebelum pukul 04.00 wib dan sering terbangun pada malam hari. seringnya terbangun pada malam hari dan kesulitan untuk memulai tidur menyebabkan lama tidur berkurang pada lansia. distribusi responden berdasarkan jenis kelamin dapat diketahui bahwa sebagian besar responden, yaitu sebanyak 8 orang berjenis kelamin wanita mengalami gangguan tidur. pada usia lanjut, wanita lebih banyak mengalami insomnia, dibandingkan pria yang lebih banyak menderita sleep apnea atau kondisi medis lain yang dapat mengganggu tidur. gangguan tidur pada usia lanjut biasanya aromacare melati (jasmine) (heri kusnaidi) 197 muncul dalam bentuk kesulitan untuk tidur dan sering terbangun atau bangun terlalu awal (prasadja, 2009). jenis kelamin merupakan status gender dari seseorang yaitu laki-laki dan perempuan. wanita secara psikologis memiliki mekanisme koping yang lebih rendah dibandingkan dengan laki-laki dalam mengatasi suatu masalah. adanya gangguan secara fisik maupun secara psikologis tersebut maka wanita akan mengalami suatu kecemasan, jika kecemasan itu berlanjut maka akan mengakibatkan seseorang lansia wanita lebih sering mengalami kejadian insomnia dibandingkan dengan laki-laki. fase biologis dari kehidupan wanita seperti menopause, dan faktor hormonal membuat wanita lebih banyak mengalami gangguan tidur, wanita lebih mudah mengalami berbagai gangguan tidur daripada pria, seperti insomnia, begitu juga dengan lansia yang berusia di atas 60 tahun akan mengalami gangguan tidur yang lebih buruk karena adanya faktor-faktor stres psikologis seperti menopause, perubahan-perubahan fi sik akan meningkatkan kecemasan lansia. pemberian aromaterapi melati (jasmine) dengan pendekatan asuhan keperawatan melalui proses sugesti yang disebut aromacare i n i d i m a k s u d k a n u n t u k m e n i n g k a t k a n pemenuhan kebutuhan tidur pada lansia. pemberian aromaterapi melati (jasmine) sendiri dapat meningkatkan kualitas pemenuhan tidur pada seseorang di mana lansia dapat berpartisipasi dalam pelayanan kesehatannya dan mempraktikkan pemberian aromaterapi melati untuk mendapatkan istirahat secara teratur. pengidentifikasian dan penanganan gangguan pola tidur lansia adalah tujuan penting perawat. sebab, memperoleh kualitas tidur terbaik adalah penting untuk membantu pemenuhan kebutuhan klien. dalam hal ini, perawat diharapkan dapat mendidik klien untuk memenuhi kebutuhan tidurnya melalui proses interpersonal dan terapeutik. artinya suatu hasil proses kerja sama manusia (perawat) dengan manusia lain (klien) supaya menjadi tetap sehat. dalam ilmu komunikasi, proses interpersonal didefinisikan sebagai proses interaksi secara simultan dengan orang lain dan saling pengaruh-memengaruhi satu dengan lainnya dengan tujuan untuk membina suatu hubungan (siregar, 2009). p e p l a u m e n g g a m b a r k a n p r o s e s interpersonal sebagai metode transformasi energi atau perubahan pola tidur klien oleh perawat yang terdiri dari empat fase yaitu fase orientasi, tahap ini ditandai di mana perawat melakukan kontak awal untuk membangun kepercayaan (membina hubungan saling percaya) dan kemudian mengumpulkan data awal mengenai kualitas dan kuantitas tidur lansia, fase identifi kasi, perawat mendiskusikan masalah dan menjelaskan tindakan yang akan dilakukan, fase eksplorasi, fase ini merupakan inti hubungan dalam proses interpersonal. dalam hal ini perawat membantu klien dengan memberikan aromacare melati (jasmine) serta proses sugesti untuk membantu memperbaiki kualitas dan kuantitas tidur lansia. adanya perkembangan hubungan antara perawat dan klien, akan membuat kedua belah pihak mendapatkan keuntungan. klien mendapatkan keuntungan dengan memanfaatkan pelayanan yang tersedia untuk memenuhi kebutuhannya d a n p e r a w a t m e m b a n t u k l i e n d a l a m hal mengatasi perubahan tidurnya yang berhubungan dengan masalah kesehatannya, fase resolusi, secara bertahap klien telah dapat melepaskan diri dari perawat. keempat fase tersebut di atas yang diaplikasikan dalam kegiatan aromacare ternyata memberi dampak yang sangat positif terhadap hasil penelitian. fakta tersebut sesuai dengan teori interpersonal menurut hildegard e. peplau bahwa seorang perawat berusaha memandirikan seorang klien melalui serangkaian proses pengembangan di mana seorang perawat membimbing pasien dari rasa ketergantungan yang tinggi menjadi interaksi yang saling tergantung dalam sosial. pemaparan ini menunjukkan bahwa teori hildegard e. peplau berfokus pada individu, perawat, dan proses interaktif yang menghasilkan hubungan antara perawat dan klien. hasil uji statistik wilcoxon untuk pretest dan post-test pada kelompok perlakuan didapatkan nilai signifikasi 0,016 yang menunjukkan ada pengaruh pemberian a ro m a c a re m e l a t i ( j a s m i n e ) t e r h a d a p jurnal ners vol. 6 no. 2 oktober 2011: 192–200 198 pemenuhan kebutuhan tidur lansia secara kualitas, sedangkan pada kelompok kontrol yang tidak diberikan intervensi menunjukkan tidak ada perbedaan kualitas tidur antara hasil pretest dan post-test. hasil uji statistik mann whitney test p = 0,023 yang berarti bahwa ada pengaruh aromacare melati (jasmine) terhadap kualitas pemenuhan kebutuhan tidur lansia. hasil uji statistik pemenuhan kebutuhan tidur lansia secara kuantitas pada kelompok perlakuan dan kelompok kontrol. hasil uji statistik paired t test pada kelompok perlakuan p = 0,001 yang artinya ada perbedaan kuantitas (lama tidur) pre dan post intervensi, sedangkan pada kelompok kontrol didapatkan p = 0,356 yang artinya tidak ada perbedaan kuantitas (lama tidur) antara hasil pre-test dan post-test. hal ini sesuai dengan hasil penelitian yang dilakukan raudensberg yang menyatakan aroma bunga melati dapat meningkatkan efi siensi tidur seseorang dan mengurangi pergerakan seseorang ketika tidur, meningkatkan kualitas tidur seseorang tanpa penambahan waktu tidur (raudensberg, 2005). kandungan senyawa linalool yang berfungsi sebagai zat sedatif yang ada pada aroma melati (jasmine) akan meningkatkan relaksasi pada seseorang, selain itu pemberian sugesti merupakan salah satu teknik relaksasi kepada seseorang yang dapat meningkatkan respons relaksasi dari tubuh seseorang sehingga menyebabkan seseorang lebih cepat memulai tidur dan mempertahankan tidurnya sehingga tercapai kualitas tidur yang maksimal. aroma melati (jasmine) yang mengandung akan disampaikan menuju nukleus olfactorius anterior melalui nervus olfaktorius dan bulbus olfaktorius, di mana senyawa tersebut akan sampai ke hipotalamus yang berhubungan dengan sistem saraf otonom. oleh karena itu, stimulasi olfaktorius bisa memengaruhi aktivitas saraf otonom melalui hipotalamus. selanjutnya hipotalamus mempunyai hubungan dengan amigdala terkait emosi (perasaan). inhalasi dari partikel aroma melati (jasmine) dapat menurunkan aktivitas vasokonstriktor simpatis pada otot dan menurunkan tekanan darah. selain itu, kandungan senyawa pada aroma melati (jasmine) dapat meningkatkan aktivitas saraf parasimpatis dan menurunkan heart rate seseorang, dan adanya kandungan sedatif (linalool) dapat meningkatkan relaksasi seseorang. adanya kandungan linalool pada aroma melati (jasmine) akan merangsang hipotalamus untuk menghasilkan zat-zat sedatif dalam tubuh seperti endorfi n, enkefalin, serotonin sehingga dapat memunculkan rasa gembira, senang, dan rileks. produksi serotonin dapat menghasilkan respons peningkatan melatonin sehingga dapat memengaruhi pemenuhan kebutuhan tidur pada lansia. hal ini akan meningkatkan relaksasi individu sehingga dapat tidur dengan nyenyak dan terjadi peningkatan pada kualitas dan kuantitas tidurnya. pemberian aromacare menyebabkan responden pada kelompok perlakuan mengalami peningkatan kuantitas tidur. hal ini dibuktikan dengan bertambahnya kuantitas tidur rerata responden antara 1–3 jam. responden pada kelompok perlakuan juga mengatakan lebih cepat tidur (< 30 menit) setelah dilakukan intervensi. sebelum dilakukan intervensi, beberapa responden mengaku lebih susah untuk memulai tidur setelah bangun pada malam hari akan tetapi setelah dilakukan intervensi rerata responden bisa tidur lagi lebih cepat sehingga hal inilah yang meningkatkan kuantitas tidur pada kelompok perlakuan. hal ini disebabkan oleh masih adanya efek dari aroma melati (jasmine). dengan demikian dapat meningkatkan kuantitas pemenuhan kebutuhan tidur. perubahan pola tidur pada lansia disebabkan perubahan sistem saraf pusat yang memengaruhi pengaturan tidur. kerusakan sensorik yang umum dengan penuaan, dapat mengurangi sensitivitas terhadap waktu yang mempertahankan irama sirkardian (potter dan perry, 2005). aktifnya saraf simpatis membuat lansia tidak dapat santai atau relaks sehingga tidak dapat memunculkan rasa kantuk. melalui latihan distraksi yang diberikan melalui proses sugesti, lansia dilatih untuk dapat memunculkan respons relaksasi sehingga dapat mencapai keadaan tenang. respons relaksasi ini terjadi melalui penurunan bermakna dari kebutuhan zat oksigen oleh tubuh, yang selanjutnya aliran darah akan lancar, neurotransmiter aromacare melati (jasmine) (heri kusnaidi) 199 penenang akan dilepaskan, sistem saraf akan bekerja secara baik otot-otot tubuh yang relaks menimbulkan perasaan tenang dan nyaman. perasaan tenang dan nyaman akan memudahkan lansia untuk tidur terlelap. simpulan dan saran simpulan pemberian aromacare melati (jasmine) dapat meningkatkan pemenuhan kebutuhan tidur lansia yang ada di panti di panti sosial tresna werdha puspakarma mataram baik secara kualitas maupun kuantitas. saran pemberian aromacare melati (jasmine) dapat dijadikan salah satu program untuk mengatasi gangguan pemenuhan kebutuhan pada lansia yang ada di panti. bagi perawat yang ada di pelayanan kesehatan dapat dijadikan aromacare melati (jasmine) salah satu intervensi keperawatan untuk mengatasi gangguan pemenuhan kebutuhan tidur pada lansia. bagi responden dan masyarakat, dapat dijadikan salah satu alternatif untuk digunakan masyarakat/ lansia untuk mengatasi gangguan pemenuhan kebutuhan tidur. perlunya dilakukan penelitian lebih lanjut tentang pengaruh aromacare melati (jasmine) terhadap pemenuhan kebutuhan tidur dengan mengukur kadar melatonin dan melalui pemeriksaan electro ensephalo gram (eeg). kepustakaan asmadi, 2008. konsep dasar keperawatan, egc: jakarta, hlm. 132–135. currentnursing, 2010. theory of interpersonal r e l a t i o n s , ( o n l i n e ) , ( h t t p : / / currentnursing. com/nursing_theory/ interpersonal_theory., html., diakses pada tanggal 30 november 2011, jam 20.00). fitri, m., 2009. gangguan tidur pada lansia, (online),(http://www.stikeskabmalang. files.wordpress.com., diakses pada tanggal 12 november 2011, jam 22.00). hidayat, a.a., 2008, pengantar kebutuhan dasar manusia edisi 2: aplikasi konsep dan proses keperawatan, jakarta, salemba medika, hlm. 127. inoue, n., kuroda, k., sugimoto, a., kakuda t. , f u s h i k i , t. , 2 0 0 3 . d i ff e r e n t autonomic nervous responses according to preference for the odor of jasmine tea. biosci biotechnol biochem, 67:1206– 1214, (online), (http://www.jstage. jst.go.jp/article/bbb/67/6/67_1206/_ article/-char/en., diakses pada tanggal 07 februari 2012, jam 15.30 wib). kasnalia, 2010. hubungan perilaku caring perawat dengan tingkat kecemasan pasien kanker serviks di ruang iv rumah sakit umum daerah pirangadi medan, (online), (http://www.scribd. com., diakses pada tanggal 11 desember 2011, jam 20.30). kuroda, k., et al., 2005. sedative effects of the jasmine tea odor and (r)-()-linalool, one of its major odor components, on autonomic nerve activity and mood states, (online), (http://www. springerlink.com., diakses pada tanggal 14 november 2010). stanley, m., beare, p.g., 2007. buku ajar keperawatan gerontik, 2nd edition, jakarta: egc, hlm. 447–450. nursalam, 2009. konsep dan metodologi penelitian ilmu keperawatan: pedoman skripsi, tesis, dan instrumen penelitian keperawatan, jakarta: penerbit salemba medika, hlm. 77–100, 114. potter, p.a., perry, a.g., 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktik, 4th edition,vol 2, jakarta: egc, hlm. 274, 1470–1480. prasadja, a., 2009. ayo bangun! dengan bugar karena tidur yang benar., jakarta: hikmah, hlm. 9–10, 40–41, 65–84, 117–122. raudensberg, b., 2005. positive effects o f o d o r a n t a d m i n i s t r a t i o n o n humans: a review. (online), (http:// w w w. s e n s e o f s m e l l . o r g / r e s e a r c h / b.raudenbush-positive-effects-ofodors-on-humans.pdf., diakses pada tanggal 14 november 2011, jam16.00) rusli, m.s., 2010. sukses memproduksi minyak atsiri, jakarta: agromedia pustaka, hlm. 3–6, 52–53 jurnal ners vol. 6 no. 2 oktober 2011: 192–200 200 siregar, elisa, 2009. model keperawatan menurut hildegard peplau, (online), (http://www. elisasiregar. wordpress. com., diakses pada tanggal 10 januari 2012, jam 21.00). smyth, c.e., 2008. evaluating sleep quality in older adult, (online), (http://www. nursingcenter.com., diakses pada tanggal 11 desember 2011, jam 16.00). 81 coping mechanism of career women with breast cancer rosnani department of nursing polytechnic of health palembang jl. merdeka 10 a palembang, telp: (0711) 35106 email: rosnani@poltekkespalembang.ac.id abstract introduction: patients with cancer may experience psychological disorders such as depression, anxiety, anger, helplessness, and unappreciated, so in certain situations require defense mechanisms (coping mechanism) to oppose or resist feelings of anxiety, fear or stress that haunt her. the aim of this study was to know the coping mechanism of career women with breast cancer reviewed by phenomenology in palembang 2016. method: type of this study was a qualitative study with a phenomenological approach. total samples were 8 participants with inclusion criteria: career women, productive age range, health physic and physiologic. independent variable was a coping mechanism, and the dependent variable was breast cancer. the instrument used the voice recorder, and interview guides. data analyze used verbatim transcript with credibility, dependability, and confirmability. result: the results showed that working women who have breast cancer have a coping strategy that is adjusted to the psychological condition and physical reactions of the therapy in progress. psychologically, the coping mechanism is in the form of rejecting, drawing closer to allah swt, seeking the opinion of other health workers, discussing conditions with spouse and family, seeking alternative treatment and asking for doctor's direction. the coping mechanism of the body's reaction to therapy is done by taking medicine according to the rules and remember allah swt. conclusions: need the support of the coping mechanism in patients with breast cancer and nursing care approach with the pattern of coping mechanisms with the involvement of the family. key words: coping mechanism, breast cancer, career women introduction cancer is the third cause of death globally in 12.5%. this amount exceeds the combined death toll of hiv / aids, tuberculosis and malaria. 7 million of deaths caused by cancer (depkes 2015). at least 1.2 million us residents diagnosed with cancer each year, but the incidence rate is higher in developing countries, including indonesia (smeltzer & bare 2009). in indonesia, the prevalence rate of cancer was quite high. in asean, indonesia was on second ranks after vietnam with 135 thousand cases of cancer each year (whodalam kemenkes 2014). the data from information health ministry center showed the prevalence of cancer was 100 thousand each year (kemenkes 2014) breast cancer was the most experienced by women after cervical cancer and other cancers. breast cancer was the height cause of death followed by cervical cancer in the second. an estimated 1.2 million women diagnosed with breast cancer and more than 700thousand died, besides every year seem to be more than 250thousand new cases of breast cancer and ranks first among cancers in women with other cancers (siswono 2007). in indonesia, breast cancer was the first ranks cause of death for women followed by cancer of the cervix (cervical) with an incidence of 26 per 10 thousand women (depkes 2015). data from (ipksi 2011) showed that indonesian women on range 40-45 had cervical cancer each day. general hospital of dr. mohammad hoesin palembang is a type a hospital and the referral hospital for south sumatra province. based on data from the last visit to patients with cancer was 965 patients covering all types of cancer, especially breast cancer and cervical cancer (rsmh 2015). since the last decade of action towards cancer were surgery, radiation, and chemotherapy. the purpose of chemotherapy is healing, control, and palliative used to establish medication used for the aggressiveness of plan therapy (prawiroharjo 2008). all measures of treatment cause physical changes that indirectly affect psychosocial changes. based onsutandyoin (fachlevy et al. 2013), patients with chemotherapy treatment will experience physical complaints, followed by an emotional setback, social relations disorder, and reduced of communication mailto:rosnani@poltekkespalembang.ac.id jurnal ners vol. 12 no. 1: 81-87 82 between husband and wife. besides the action of cancer (chemo, radiation, and surgery) will give effect on the esteem, role and body image, identity, sexuality, and the well-being of the patient. besides of it, the patient will stress with a diagnosis of cancer that was potentially life-threatening. the changes were very burdensome for the patient, because of that, the treatment of patients with cancers should be done multidiscipline formulated comprehensive in science, and provide a variety of support facilities so that patients can adapt to the conditions and the changes. the possibility of psychological disorders such as depression, anxiety, anger, helplessness, and unappreciated experienced by 23% 60% of patients with cancers (lubis & hasnida 2009). the situation may cause more severe suffering, weaken the function of organs and can be demoralizing to undergo a series of treatment regimens (duanne & ellen 2013). patients with cancer in certain situations require coping mechanisms to oppose or resist feelings of anxiety, fear or stress that haunt her. one of the conceptual model affecting nursing is the roy adaptation model. the main idea of roy adaptation model was a system of human adaptation as a bio-psychosocial. humans respond holistically to the changes in their environment. roy considers patient has an adaptability in addressing the problem. nurses in roy adaptation model were required to assess the adaptability of the patient through the regulator or cognator coping mechanisms and recognize the inability of patients who need help. in roy adaptation model external and internal environment, human was a stimulus (stimuli adaptation level) that would provide a response through a mechanism of coping (coping mechanism) in the form of coping regulator and cognator which will give effect (effectors) on physiological function and cognition (psychosocial) include self-concept, function role, and dependence, it will generate (output) whether the patient can adapt to the changes that occur (adaptive) or failure to adapt (ineffective).the nurse's role in facilitating the patient in order to adapt is to optimize the social support that exists around the patient. according to (sheriden & radmacher 1992) and (taylor 1999) divided support into five consists of an instrumental support, informational, emotional, support selfesteem and social support groups. based on the above considerations, a qualitative research with descriptive phenomenology method is needed to answer questions about how the response of women career during the experience of cancer; how was the journey of cancer is perceived by women career, how the experiences of women career during therapy and coping mechanisms for women experiencing cancer. method this type of this study was a qualitative research with a phenomenological method. this research was conducted in the house participants domiciled in palembang, november 2016 instruments used in this study was a voice recorder, interview guidelines, and field notes. participants of this study were women career were diagnosed with cancer in palembang, with purposive sampling technique, which was in qualitative research was often referred to as judgmental, theoretical or purposeful sampling. the total sample in this study were eight participants. criteria inclusion for participants in this study includes women career, productive age, patients with good physical and mental health condition. the independent variables in this study were coping mechanism, and the dependent variables in this study were breast cancer. the data analysis methods from a verbatim transcript based on (colaizzi 1978) in (fain 1999). results knowledge of breast cancer the patient's baseline knowledge of breast cancer chemotherapy was important information for determining the treatment that chosen by the participants. participants have heard about breast cancer before they undergo treatment. the statements of participants: “ever, ummm breast cancer was malignant bumps that grow in the breast” (p3). the knowledge that obtained by participants come from sources that less accurate. knowledge usually obtained from coping mechanism of career women with breast cancer (rosnani) 83 friends, family, neighborhood, and online media. the statements of participants: “i saw on the internet, and searching on google…” (p2) the source knowledge that inaccurate can lead to a negative perception. the results of the interview participants describe that breast cancer is a disease that frightening disease. the statements of participants: “breasts were throbbing, the feels like was shocked, i felt it like between life and death ...” (p5) coping mechanism coping mechanism carried by patients vary widely starting from the first time the cancer was diagnosed in the face of distress they experienced until it had gone through therapy. the coping strategies include refuse, draw closer to allah, seek the opinion of other health personnel (second opinion), to discuss the situation experienced by couples/families, looking for a wide variety of alternative treatments, ask for referrals doctor who diagnoses related actions to be carried out. a. denial denial response occurred in patients in the form of crying, worried thinking about the impact of treatment, embarrassed. “when doctors explained about my disease, i felt there was wrong...” (p8). “…sometime when i remembered about my disease, how about the prognosis, sometimes my tears drop, because of the disease…” (p1). “…afraid, because this disease was death….” (p6) “…no, i embarrassed, but now is not, this disease was not disgraced…” (p2). b. closed to allah swt “everything has arranged by allah swt. i am grateful to allah to tell in advance to me about my age limit, which may not all people get the information” (p4) c. seek the opinion of other health professionals “…after the doctor said i had cancer, i did not immediately believe what the doctor said, i see a doctor and then another while wondering also with a midwife that i know” (p8). d. discuss the conditions experienced towards couples and families “…the first time that i give to know is my husband. i do not have kids ... i sincere after my husband knows about my disease, he wants to get married again. but my husband did not want (p5). “this disease, never made me desperate, it seems to want to die... then my children said if i death whit who i will stay?” (p7). e. looking for an alternative treatment “i think if i took chemotherapy, would definitely bother to manage .... family will bother, i should be in the hospital ... while my private employees, if not present, can not be a salary. although i have insurance, fees for hospital fro more it costs, so ... i wondered alternative” (p1). f. request a referral doctor “…i immediately wrote to follow what the doctor's advice... as already explained everything, stages, and effects….” (p7). “doctor advised me to chemo, directly yes i follow it... although i heard it was many side effects of chemotherapy, all depended by my body” (p6). the side effects of treatment the impact of treatment that experienced by the participants, depending on the type of therapy and therapy stages undergone by participants. physical side effects are generally perceived in advanced breast patients with cancers who undergo chemotherapy are: nausea, vomiting, anorexia, hair loss, fatigue, bone marrow suppression such as anemia. psychological side effects feeling trauma therapy. the statements of participants: “when i came home, my body warm...” (p3) “emmm how to explain it. i felt my body sick, aches, weakness, and difficult to walk....” (p5) “always nausea until my appetite loss....” (p7) “when the sick cam, ouughh i felt that i won't chemo anymore...” (p4) coping mechanisms do participants experience a reaction time of therapy done by jurnal ners vol. 12 no. 1: 81-87 84 taking medicines according to the rules and the remembrance of allah: “to solve it only by that way, drink medicine, and ask to doctor for the same medicine...” (p5) “i preferred to istighfar, and surrendered to allah...” (p6). family’s support the entire family of the patient to provide support to patients, tailored to the capabilities of each family, from the moral and material support. from each of the support obtained, a positive impact on participant to continue his life. “my husband loved me, he always accompanied and fulled my daily needed. my husband told that i couldn't work because of sick, so he will handle to work.” (p5). “my children hug me when i look to take a rest because of sickness, their action that i strength… i must be tough for them” (p7). expectations towards family and closest people participants express to have hope for the family to be able to help him continue the task of surrogate mother for her children and her husband to get a good wife. “sometimes… i want surrogate women to take my position as mother and wife”(p8) the hope of participant the hope of participants with this illness that can get through this disease properly. if she should die because of the illness, she wanted to die in the midst of the family. “i want to heal as normal…” (p5) “i felt… all effort i have done… if i was gone, i want besides my family" (p2). discussion based on the results which have been mentioned in the previous section, the individual experiences when first diagnosed with cancer can lead to changes and actual or potential problems in various aspects. problems that arise can be either physical or psychological aspect. the problems associated with the physical aspects of the disease may be related complaints such as pain, bleeding, sleeplessness, physical discomfort, and limitations in performing daily activities. while issues related to psychological aspects may be the emergence of negative emotions such as shock, sadness, fear, and anger, and also appeared despair even to suicide. there are also issues related to financial and job changes. it is also in line with previous research which states that at the time of the first diagnosis, the patient will have problems with daily living activities, financial problems along with employment problems, in addition to issues related to physical (pascoe et al. 2004) and then based on (the royal marsde hospital 2014), person with cancer may experience one or more of the following problems: anxiety, the uncertainty about the future, anger, difficulty of adjustment, the problem of family communication, changes in body image, depression, difficulty making decisions, taboo for a balance the demands of the condition of his illness and treatment for a patient. various problems experienced by the patient underlying them to find a way out of the problem. to obtain these solutions, patients need the various aspects of support. in this study identified a variety of patient needs related to their efforts in solving the problem. the needs include family support, social environment support, the support of health professionals, disease-related information, a desire to be able to regulate emotion existing instrumental needs, spiritual needs and responsibilities of the role. the spiritual aspect was the domain that considered the important and a source of strength that was most often mentioned by the subjects in this study. (gockel et al. 2007) explained that the spiritual aspect was an important part of the counseling dimension. then (gockel et al. 2007) also explained that patients with cancer looked at the spiritual aspect can improve recovery and improve the condition of 7-stage cancer. stage include: (1) transparency, (2) changing / shifting spiritual perspective, (3) accept the conditions / going within (4) connects to the spirit (5) clarify (6) setting the intention of healing and (7) follow a guide to a restoration of the condition. patients coping towards problems that faced by patients with cancers also mentioned. coping mechanism of career women with breast cancer (rosnani) 85 coping performed by different patients, but it also evident there was some similarities. schetter, feinstein and (taylor et al. 1997) explained that the coping performed patients with cancer would be different depending on the issue or cancerous conditions are experienced. for example, if the patient had no complaints or physical discomfort, then coping adaptive to the type of coping focused on a problem (problem-focused), while for the problems associated with the ambiguity of the future, coping adaptive coping focused on emotions by regulating emotions such as diverting or avoid negative thinking. there were two factors that become the main determinant in the coping selection of patients with cancer, there was the cancer situation that experienced, and a factor of patient perception towards stress factors encountered. thus, the more the situation experienced, the more forms of coping performed by patients with cancer (taylor et al. 1997). beside of that, there were several factors that can determine the patient's coping taken as socioeconomic level, gender, age, and religious beliefs (billing & moos 1984). socio-economic levels were associated strongly and consistently against certain coping methods that taken, they tend to choose to cope focused on a problem (problemfocused coping) rather than avoiding everyday problems. in this study, the majority of participants come from socio-economic and low education levels. in this group, they were more likely to accept the condition without digging deeper coping variations that can be taken. in this study also explained that participants were individuals who live in a family community, which was attached to their roles as wives or partners for a husband and as the mother of the children whose age varies. the role as spouse and mother are also known to impact individual lives of cancer. spousal support, child, and family can strengthen the patient in dealing with cancerous conditions. participants many say that the spousal support was very meaningful and give strength to continue to live a life with cancer and its treatment often leaves them tired and painful. (hagedorn et al. 2008) in their study explained that the spousal could be a key role in helping make decisions about treatment should be performed, providing emotional and instrumental support, in addition to the pair also affect the adjustment of the patient toward cancer. (mcclure et al. 2010) stated that patients with cancer in the early diagnosis, however, will experience depression due to the disease, however, if an individual who has cancer it has a partner who has a positive belief in solving the problem, then that patients with cancers tend to have very low levels of depression. beside of this, the role of partner to patients with cancers, otherwise patients may also affect the emotional life and also the welfare of his partner. so, the patient and her partner will influence each other in dealing with the impact of cancer on their lives both emotionally and practically everyday activities. besides the implications of the spouse, child figure also plays an important role for cancer patients. there were a few participants in the study who had no spouse, they look at the key role in a child and the other support system such as close family or other relationships that are already considered family as a child living in the boarding house boarding house belongs to the patient. related to the impact on children, cancer conditions can have an impact on the welfare of children. the main factors that cause an impact on children's age and sex of the child (ohayon & braun 2010). potential impact showed psychological distress, anxiety, loneliness, lack of assistance, and guilty, and children tend not to declare his attention directly but to express it through their behaviors cause difficulties in school and problems with friends (ohayon & braun 2010) furthermore, participants express also that they feel have hope again after hearing the experience of other patients who have same cancer and managed to survive and live a daily life well. group of patients with the same cancer experience can be a great encouragement to continue to be optimistic on medication for that group to give a real picture of the success of cancer treatment. hagedorn, et al (2008) explained that support informal and formal social group was the force that most affect patient adaptation to the diagnosis and treatment of cancer. informal support from other patients who have the same diseases, family members, and health care team may influence adaptation to the jurnal ners vol. 12 no. 1: 81-87 86 conditions of his cancer patients, especially in patients with breast cancer. informal social support among the same patient have breast cancer influence positively on mobility after mastectomy and may increase perceptions of health and body image, and has been proven to reduce the negative feelings. then in his research concluded that women who followed a formal group therapy with other cancer patients were found to survive longer than those who do not follow the group therapy session (van den borne et al. 1986). conclusion there were seven coping strategies that develop in cancer patients newly diagnosed in this study was among others refused, denial, draw closer to allah, seek the opinion of other health professionals (second opinion), to discuss the situation experienced by couples/ families, looking for various kinds of treatment alternatives, ask for referrals doctor who diagnoses related actions to be carried out. copying mechanism while the therapy consists of drink medicine as routine and remember of allah swt. need the support of the coping mechanism in breast cancer patients and nursing care approach with the pattern of coping mechanisms with the involvement of the family. references billing, a.g. & moos, r.h., 1984. coping stress and social resources among adult with unipolar depression. journal of personality and social psychology, 46(4), pp.877–891. van den borne, h., pruyn, j.f. & van dan de may, k., 1986. self help in cancer patients: a review of studies on the effect of contracts between fellow patients. patient education & counseling, 8, pp.367–385. colaizzi, p., 1978. "psychological research as a phenomenologist views it", in goulding, christina, grounded theory, ethnography and phenomenology, wolverhampton business school., united kingdom: wolverhampton university. depkes, r., 2015. estimasi dan proyeksi hiv/aids di indonesia. available at: http://pppl.depkes.go.id/_asset/_downloa d/estimasi & proyeksi hiv aids di indonesia th 2011-2016.pdf [accessed november 21, 2016]. duanne, s.p. & ellen, s.s., 2013. theories of personality tenth edit. a. jessica, h. travis, & n. mary, eds., united states of america\: jon-david hague. fachlevy, andi & faizal, 2013. faktor risiko kanker ovarium di rsup wahidin sudirohusodo makasar. fkm unhas, 3(2). fain, j.., 1999. nursing research: principle and methods, 6th editions, philadelphia: lippincott, william & wilkins. gockel, i. et al., 2007. resection of the mesopancreas (rmp): a new surgical classification of a known anatomical space. world j surg oncol, 25(5), p.44. hagedorn, m. et al., 2008. distress in couples coping with cancer: a meta-analysis and critical review of role and gender effects. psyco bull., 134(1), pp.1–30. hospital, t.r.m., 2014. data of royal marsden hospital, united kingdom. ipksi, 2011. ikatan peduli kanker serviks indonesia. kemenkes, r., 2014. survey kesehatan rumah tangga (skrt), jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan. lubis, n.l. & hasnida, 2009. terapi perilaku kognitif pada pasien kanker, medan: usu: press. mcclure, k.. et al., 2010. social problem solving and depression in couples coping with cancer. ohayon, i.h. & braun, m., 2010. being a parent and coping with cancer: intervention development. journal of palliative and supportive care, 9, pp.149–152. pascoe, s. et al., 2004. measuring and appraising capacity in fisheries: framework, analytical tolls and data aggregation., usa: fao fisheries circular. prawiroharjo, s., 2008. ilmu kebidanan, jakarta: yayasan bina pustaka sarwono prawirohardjo. rsmh, 2015. data rsup mohammad hoesin palembang, palembang. sheriden, c.l. & radmacher, s.a., 1992. coping mechanism of career women with breast cancer (rosnani) 87 health psycology: challenging the biological model, new york: john wiley & sons, inc. siswono, 2007. kanker payudara bisa dideteksi sendiri. available at: http://www.gizi.net/cgibin/berita/fullnew.cgi?newsid101055207 4,29807. [accessed january 1, 2016]. smeltzer, s.c. & bare, b.g., 2009. buku ajar keperawatan medikal bedah brunner & suddarth, jakarta: egc. taylor, s.e., 1999. health psychology 4th ed., boston: mc. graw-hill. international. taylor, s.e., peplau, l.a. & sears, d.o., 1997. social psycology, prentice hall: new jersey. vol 8 no 1 april 2013.indd 27 pengembangan model asuhan keperawatan pendekatan cope (creating opportunity for parent empowerment) dalam penurunan stres hospitalisasi orang tua anak terdiagnosis kanker (nursing care model development by cope approach for reducing parent’s hospitalization stress with cancer children) ilya krisnana fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya 60115 telp/fax: (031) 5913754, e-mail: ilyakrisnana28@gmail.com abstrak pendahuluan: stres hospitalisasi pada anak dapat berdampak pada orang tua. pemberdayaan orang tua merupakan aspek penting dalam asuhan untuk menurunkan stress hospitalisasi. tujuan penelitian ini adalah untuk mengembangkan model asuhan keperawatan untuk penurunan stress hospitalisasi melalui pendekatan cope (creating opportunity for parent empowerment) pada orang tua anak terdiagnosis kanker. metode: design yang digunakan adalah explanative study dengan metode cross sectional. populasi pada penelitian ini adalah orang tua yang memiliki anak terdiagnosis kanker yang dirawat di ruang hematologi anak rsud dr. soetomo surabaya. penelitian ini dilaksanakan pada tanggal 31 mei 2012. sampel diambil berdasarkan kriteria inklusi yang telah ditetapkan yaitu; anak usia toddler and pra sekolah, mrs pertama di bona 1 dan bona 2, dapat membaca dan menulis, tidak pada kondisi kritis. variabel independen penelitian ini yaitu faktor antecedens (sikap, status sosial ekonomi, motivasi), difusi inovasi dan empowerment (pengetahuan, partisipasi, keterampilan dan lingkungan). variabel dependen yaitu stres hospitalisasi orang tua. data dikumpulkan menggunakan kuesioner dan observasi. hasil data yang terkumpul dianalisis menggunakan pls (partial least square) dengan loading factor=0,5 and t-statistic=1,96. hasil: hasil penelitian menunjukkan bahwa faktor anteceden berpengaruh terhadap proses difusi inovasi. motivasi merupakan factor terkuat yang mempengaruhi proses difusi inovasi (path coeffi cient=0.450;t-stat=5.278). proses difusi inovasi berpengaruh terhadap variabel empowerment ( path coeffi cient=0,487; t-stat=6,507). pembahasan: partisipasi orang tua dalam perawatan fi sik maupun emosional anak dengan informasi yang adekuat dapat meningkatkan kepercayaan diri orang tua dalam merawat anak sehingga dapat meminimalkan stres. lingkungan merupakan faktor terkuat dalam membentuk empowerment orang tua untuk meminimalkan stres hospitalisasi dengan path coeffi cient=0,360 and t-statistik=4,980. kata kunci: empowerment, stress hospitalisasi, difusi inovasi, kanker pada anak abstract introduction: hospitalization stress on child affect on their parents. parent empowerment is the important aspect to develop in nursing care for reducing hospitalization stress. the objective of this study was to develop the nursing care model of reduction hospitalization stress through the cope (creating opportunity for parent empowerment) approach on the parent whose child was diagnosed cancer. method: this study used explanative research with cross sectional design. the population were parents whose child was diagnosed cancer in pediatric hematological ward rsud dr. soetomo surabaya, conducted on 3–15th may 2012. sample were 30 mother who met inclusion criteria: 1) toddler and preschool age, 2) fi rst time admition on bona 1 or bona 2, 3)read and write well and 4) noncritical condition. the independent variable were antecedens (attitude, social economic status, motivation), diffusion of innovation, empowerment (knowledge, participation, skill and environment). the dependent variable was parent’s hospitalization stress. data were collected by using questionnaires and observation. the data were analyzed by pls (partial least square) with 28 jurnal ners vol. 8 no. 1 april 2013: 27–40 loading factor =0.5 and t-statistic=1.96. result: the result showed that antecedens factors affected to cope diffusion of innovation process. motivation was the strongest factor to infl uence the diffusion and innovation process (path coeffi cient=0.450;t-stat=5.278). the diffusion of innovation process affected to empowerment variable (path coeffi cient=0.487; t-stat=6.507). discussion: it can be concluded that environment was the strongest factor as the compiler component of empowerment. environment include physical and non-physical component. empowerment affected to parent’s hospitalization stress with path coeffi cient=0.360 and t-statistik=4.980. keywords: empowerment, hospitalization stress, diffusion of innovation, children cancer penyakit kanker pada anak tertinggi adalah all (leukemia limfoblastik akut). terjadi peningkatan pada tahun 2009 ke tahun 2010. empat kasus kanker pada anak yang lain adalah neu roblastoma, lnh (limfoma non hodgkin), retinoblastoma dan wilms tumor. hasil survey di ruang bona 2 rsud dr soetomo khusus ruang hematologi menunjukkan bahwa 80% anak mengalami stress hospitalisasi. anak usia toddler menunjukkan respons hospitalisasi saat dilakukan injeksi adalah menangis dan berteriak untuk menolak tindakan dan berteriak untuk mengusir perawat. respons hospitalisasi pada anak toddler menunjukkan reaksi menangis, meminta penghentian prosedur injeksi yang dilakukan oleh perawat. oleh karena anak menangis dan berteriak saat dilakukan tindakan orang tua menjadi cemas dan berusaha mengatakan kepada perawat untuk melakukan tindakan secara pelan. orang tua tidak menunjukkan upaya untuk menenangkan anak dengan distraksi melalui permainan akan tetapi hanya berupa kata-kata yang meminta anak untuk tenang. hasil wawancara 100% orang tua mengatakan sedih, cemas dan bingung dengan kondisi anak. orang tua juga mengatakan belum paham sepenuhnya tentang penyakit kanker yang dialami oleh anak dan penyebabnya. respons stres dijumpai pada keluarga atau orang tua. orang tua yang memiliki anak mengalami kanker menunjukkan peningkatan gejala distress psikologis (kazak, 2005). distres psiklogis pada orang tua sangat terkait dengan timbulnya stress pada anak (robinson, et al., 2007 dalam hus, 2009). niven (2005) menyatakan bahwa pada saat stres akan terjadi peningkatan kortisol yang dapat menghambat pendahuluan seorang anak yang terdiagnosis kanker akan menjalani beberapa prosedur tindakan yang lama dan menyakitkan. selama proses hospitalisasi akibat kanker anak dan orang tua dapat mengalami berbagai kejadian atau tindakan penanganan yang menurut berbagai penelitian ditunjukkan dengan pengalaman yang sangat traumatik dan penuh dengan stress (supartini, 2004 dalam arif, 2007). permasalahan psikologis yang dialami oleh anak yaitu shock, stres, ketakutan, marah dan depresi (simon, 2005). anak yang mengalami stres selama dalam masa perawatan, dapat membuat orang tua menjadi stres dan stres orang tua akan membuat tingkat stres anak semakin meningkat (supartini, 2004). reaksi stress hospitalisasi orang tua dipengaruhi oleh keseriusan penyakit, pengalaman hospitalisasi, sumber pendukung, dll. (wong, 2009). hasil penelitian menunjukkan orang tua gejala stress paska trauma mulai dari 12-80% (yalug, et al., 2011). berdasarkan sumber data dari yayasan o n kolog i a na k i ndonesia t a hu n 2012 angka kejadian kanker di dunia pada anak umumnya adalah 140 penderita baru per satu juta per tahun anak di bawah umur 18 tahun. sedangkan di seluruh indonesia, dengan jumlah penduduk 220 juta jiwa diperkirakan terdapat kurang lebih 11.000 kasus baru per tahun. kanker pada anak membutuhkan pengobatan dan perawatan di rumah sakit (hospitalisasi). stres hospitalisasi pada anak dapat disebabkan oleh faktor nyeri, perpisahan dan kehilangan kontrol (wong, 2009). respons stres yang ditunjukkan oleh anak meliputi menangis, menjerit, agresif, penolakan dan terus memanggil orang tua (wong, 2009). 29 pengembangan model asuhan keperawatan pendekatan cope (ilya krisnana) pembentukan antibodi dan menur unkan pembentukan sel darah putih. penurunan antibodi akan menurunkan imunitas tubuh. stres pada orang tua dapat menur unkan imunitas sehingga risiko terkena penyakit sangat mudah (nursalam & susilaningrum, 2005). asuhan keperawatan pada anak tidak dapat terlepas dari keluarga. keluarga yang mend apat kan ana k terdiag nosis tahu n pertama setelah anak terdiagnosis leukemia merupakan tahap terjadinya distress psikologis yang tinggi (pai, et al., 2007 dalam hus, 2009), orang tua dapat mengalami perasaan tidak percaya bahwa anak telah menderita penyakit yang merupakan keganasan pada anak. rasa tidak percaya orang tua ditunjukkan dengan keinginan untuk mendapatkan informasi yang sedetailnya dan lebih cenderung untuk mengulang per mintaan kebut uhan akan informasi. reaksi kebutuhan akan informasi merupakan respons shock dari orang tua atas penyakit anak (leukemia/bmt program of bc, 2011). keluarga dalam hal ini orang tua anak yang menjalani hospitalisasi menjadi elemen pusat dari keperawatan anak yang disebut dengan family centered care (nethercott, 1993; evans, 1994 dalam hutchfi eld, 1999). salah satu prinsip dalam fcc adalah pemberdayaan (empowerment) anak dan keluarga untuk menemukan kekuatan diri, menumbuhkan rasa percaya diri dan menentukan pilihan dan keputusan dalam kesehatan. penerapan pemberdayaan (empowerment) orang tua di rumah sakit telah dikembangkan oleh melnyk, et al. dalam bentuk cope (creating opportunity for parent empowerment) di bidang keperawatan kritis anak/ neonatal intensive care unit (nicu) dan pediatric intensive care unit (picu) yang merupakan educational-behavioral intervention program (program intervensi pendidikan perilaku). hasil penelitian yang dilakukan oleh melnyk, et al. (2004) menunjuk kan hasil bahwa penerapan cope dapat menurunkan stress orang tua dan peningkatan partisipasi orang tua dalam perawatan secara fisik maupun emosional anak. m e n c e g a h a t a u m e m i n i m a l k a n perpisahan dengan orang tua merupakan tujuan utama pada anak dirawat di rumah sakit (hospitalisasi) (wong, 2009). salah satu pendekatan terbaik adalah menganjurkan orang tua untuk tetap bersama dan berpartisipasi dalam perawatan anak (wong, 2009). perawat mempunyai peran yang sangat penting sebagai care giver, educator dan collaborator untuk memfasilitasi upaya meningkatkan pemahaman orang tua tentang penyakit dan perawatan anak melalui prinsip family centered care yaitu melalui pemberdayaan (empowerment) orang tua. program cope (creating opportunity for parent empowerment) merupakan inovasi baru yang memerlukan penyebaran (difusi) secara tepat. proses difusi inovasi dipengaruhi oleh karakteristik individu: sikap terhadap perubahan, status sosial ekonomi, motivasi (rogers, 1995). inovasi cope yang sesuai dengan kebutuhan orang tua bertujuan untuk meningkatkan pemahaman orang tua melalui edukasi tentang penyakit dan keterlibatan orang tua dalam perawatan fisik maupun emosi. pemberian informasi tentang respons perilaku normal anak saat hospitalisasi dapat menurunkan stres orang tua (wong, 2009). pemberdayaan orang tua meliputi: peningkatan pengetahuan, partisipasi, keterampilan dan lingkungan yang kondusif bagi perawatan anak. bahan dan metode penelitian ini menggunakan bentuk penelitian ini adalah ekplanatif. populasi d ala m penelit ia n i n i ad ala h ibu ya ng memiliki anak terdiagnosis kanker di ruang hematologi anak (bona 1 dan 2) rsud dr. soetomo surabaya. populasi pada penelitian ini berjumlah 69 orang. sampel ditentukan berdasarkan kriteria inklusi meliputi; ibu yang memiliki anak terdiagnosis kanker usia toddler dan prasekolah, ibu yang memiliki anak terdiagnosis kanker pertama mrs di ruang hematologi anak rsud dr. soetomo surabaya, ibu yang dapat membaca dan menulis dan ibu yang memiliki anak terdiagnosis kanker tidak dalam keadaan k ritis atau gawat darurat. jumlah responden ditentukan berdasar quota sampling yaitu 30 responden. variabel independen dalam penelitian ini 30 jurnal ners vol. 8 no. 1 april 2013: 27–40 adalah karakteristik orang tua (anteceden) (sikap terhadap per ubahan, status sosial ekonomi (pendidikan, pekerjaan, penghasilan), motivasi), proses difusi inovasi, dan komponen pemberdayaan (pengetahuan, partisipasi, keterampilan dan lingkungan). sedangkan variable dependen dalam penelitian ini adalah stres hospitalisasi orang tua. instrumen stres menggunakan dass-21 (depression-anxietysress scale) yang dikemukakan oleh lovibond & lovibond (1995) yang telah diterjemahkan oleh damanik (2010). kuesioner dass yang telah diterjemahkan ke dalam bahasa indonesia telah dilakukan uji validitas dan reliabilitas. hasil uji validitas menunjukkan bahwa dari ke 21 item pada dass-21, sebanyak 22 pertanyaan dengan hasil valid. hasil uji reliabilitas menggunakan uji cronbach alpha menunjukkan α=0,97. angka ini menujukkan bahwa kuesioner reliable untuk digunakan mengukur stres. instrumen untuk karakteristik orang tua yaitu sikap, pendidikan, pekerjaan, penghasilan dan motivasi berbentuk kuesioner yang telah dilak u kan uji validitas dan reliabilitas. kuesioner motivasi diadopsi dari teori motivasi david clarence mcclelland yang terdiri atas kebutuhan untuk berprestasi, kekuasaan dan kebutuhan untuk berafi liasi dengan orang lain. instrumen difusi inovasi diadopsi dari teori difusi inovasi rogers. kuesioner pemberdayaan orang tua terdiri atas pengetahuan orang tua tentang kanker, partisipasi orang tua dalam perawatan anak terkait kebutuhan dasar selama anak dirawat. kuesioner keterampilan berisi tentang prosedur pengukuran suhu disesuaikan dengan standar prosedur operasional, sedangkan prosedur tepid sponge bath diadopsi dari potter & perry (2005). penelitian ini dilaksanakan pada tanggal 3–15 mei 2012 di ruang rawat inap hematologi anak rsud dr. soetomo surabaya. d a t a y a ng d ip e r ole h d i a n a l i si s menggunakan model persamaan structural berbasis variance atau component based yang disebut pls ( partial least square). model analisis jalur semua variabel dalam pls terdiri atas rangkaian hubungan yaitu: 1) inner model mengkhususkan hubungan antar variabel laten (structural model ), 2) outer model yang mengkhususkan hubungan antara variabel laten dengan indikator. model pengukuran atau outer model dengan indikator refl ektif dievaluasi berdasarkan hasil validity dan reliability indikator. indikator dianggap valid jika memiliki nilai outer loading di atas 0,5 dan nilai t-statistic diatas 1,96. pengujian hipotesis dilakukan dengan uji statistik t. jika hasil pengujian didapatkan nilai t>1,96 berarti pengujian signifikan, dan jika nilai t<1,96 berarti hasil tidak signifi kan hasil penelitian hasil tingkat stress hospitalisasi orang tua berada pada 5 tingkat yaitu mulai dari normal, ringan, sedang, berat dan sangat berat. tingkat stres normal atau tidak stress menduduki persentase yang paling besar yaitu 43,3% (13 orang). namun terdapat responden yang mengalami tingkat stres berat (6,7%) dan sangat berat (6,7%). tingkat stres orang tua sangat bervariasi dengan kecenderungan untuk berespon secara normal dalam menghadapi penyakit anak (tabel 1). hasil pengujian hipotesis tabel 2 menunjukkan bahwa indikator pendidikan yang mer upakan karakter istik individu menunjuk kan pengar uh yang signif ikan terhadap penerimaan terhadap proses difusi inovasi dengan kekuatan pengaruh yang positif namun dengan kekuatan hubungan yang relatif lemah (0,168). hasil tersebut menunjukkan bahwa tingkat pendidikan yang tinggi dapat berpengaruh terhadap respons penerimaan inovasi baru program cope dalam perawatan anak (t-statistik>1,96). namu n dengan kekuatan hubungan yang rendah yaitu <0,5 dapat berarti pada kondisi lain dapat muncul pula bahwa responden dengan pendidikan yang rendah dapat menerima program cope yang ditawarkan. hipotesis terbukti. pekerjaan yang dimiliki oleh responden memiliki pengar uh terhadap penerimaan proses d if usi i novasi prog ra m cope. pekerjaan memiliki pengaruh yang positif terhadap proses penerimaan difusi inovasi program cope (t-statistik >1,96). pekerjaan dalam karakteristik sosial yang dianggap tinggi oleh masyarakat dapat menunjukkan 31 pengembangan model asuhan keperawatan pendekatan cope (ilya krisnana) respons penerimaan yang tinggi pula terhadap inovasi baru cope. pengaruh positif pekerjaan terhadap difusi inovasi memiliki nilai yang relatif rendah<0,5. hal ini menunjukkan bahwa seseorang dengan jenis pekerjaan apa pun memiliki peluang untuk dapat menerima program cope. hipotesis terbukti. penghasilan berpengaruh signifikan terhadap proses difusi inovasi (t-statistik >1,96) namun dengan pengar uh negatif. hasil ini menunjukkan bahwa semakin tinggi penghasilan semakin rendah penerimaan terhadap inovasi baru. kekuatan pengaruh penghasilan terhadap difusi inovasi dalam kategori lemah sehingga dapat berarti bahwa masih terdapat kemungkinan bahwa responden dengan penghasilan tinggi pada suatu saat dapat menerima inovasi program cope. hipotesis terbukti si k a p me m i l i k i p e ng a r u h ya ng signifikan terhadap proses difusi inovasi program cope (t-statistik >1,96). akan tetapi pengar uh tersebut bersifat negatif dengan kekuatan pengaruh yang relatif lemah <0,5. responden yang memiliki sikap positif dapat menunjuk kan respons penerimaan yang negatif. oleh karena keuatan hubungan bersifat rendah <0,5 maka berarti responden dengan sikap negatif terhadap perubahan dapat pula menerima proses difusi inovasi program cope. hipotesis terbukti. motivasi memiliki pengar uh yang signifi kan terhadap proses penerimaan difusi inovasi cope (t-statistik >1,96). pengaruh motivasi terhadap proses difusi inovasi cope bersifat positif sehingga dapat diambil makna bahwa semakin tinggi motivasi seseorang maka semakin tinggi pula penerimaan seseorang terhadap cope. jadi hipotesis terbukti. difusi inovasi memiliki pengaruh yang signifi kan terhadap empowerment dengan sifat pengaruh positif (t-statistik >1,96). empowerment terdiri atas 4 indikator penyusun yaitu pengetahuan, partisipasi, keterampilan, lingkungan. ketiga indikator yaitu pengetahuan, partisipasi dan lingkungan memiliki faktor loading yang melebihi 0,5 sehingga dapat diartikan bahwa indikator tersebut merupakan indikator penyusun yang kuat bagi pembentukan empowerment orang tua. sedangkan indikator keterampilan orang tua memiliki kekuatan pengaruh yang kurang dari faktor loading yaitu 0,197 sehingga kekuatan pengaruh keterampilan bagi orang tua sebagai pembentuk empowerment relatif lemah. lingkungan merupakan indikator empowerment yang memilik i kek uatan p e nga r u h ya ng pal i ng k u at t e rh a d ap empowerment. lingkungan memiliki koefi sien 0,787. empowerment memiliki pengaruh yang signifi kan terhadap stress hospitalisasi dengan pengaruh yang positif (t-statistik >1,96). tabel 3. measurement model (path coefi cients) antar-variabel penyusun model penurunan stress hospitalisasi di ruang hematologi anak rsud dr. soetomo surabaya hubungan antar variabel path koefi sien t-statistik keterangan pendidikan terhadap difusi inovasi 0,168 1,987 signifi kan pekerjaan terhadap difusi inovasi 0,130 2,36 signifi kan penghasilan terhadap difusi inovasi -0,109 2,720 signifi kan sikap terhadap difusi inovasi -0,213 3,103 signifi kan motivasi terhadap difusi inovasi 0,450 5,278 signifi kan difusi inovasi terhadap empowerment 0,487 6,507 signifi kan empowerment terhadap stress hospitalisasi 0,360 4,980 signifi kan tabel 2. stres hospitalisasi orang tua (ibu) yang memiliki anak terdiagnosis kanker di ruang hematologi anak rsud dr. soetomo surabaya, 3–15 mei 2012 tingkat stress f % normal 13 43,3 ringan 8 26,7 sedang 5 16,6 berat 2 6,7 sangat berat 2 6,7 total 30 100 32 jurnal ners vol. 8 no. 1 april 2013: 27–40 semakin tinggi empowerment/pemberdayaan pada orang tua dapat berpengaruh pada status derajat distress yang dialami oleh orang tua. kekuatan pengaruh dalam kategori rendah yaitu <0,5 (faktor loading) sehingga dapat berarti bahwa tingkat pemberdayaan yang terlalu tinggi atau penyerahan perawatan anak secara penuh bagi orang tua justru dapat berdampak terhadap stress hospitalisasi orang tua. hasil path koefi sien antar indikator dan variabel penyusun model penurunan stress hospitalisasi juga disajikan dalam bentuk gambar untuk memperjelas koefi sien antar variabel. variabel dan indikator yang memiliki nilai koefi sien paling tinggi merupakan variabel yang paling kuat dibandingkan variabel lain yang dapat mempengaruhi penurunan stress hospitalisasi. sedangkan nilai path koefi sien terkecil merupakan variabel yang memiliki kekuatan paling lemah dalam mempengaruhi variabel lain. pembahasan stres hospitalisasi merupakan kondisi yang dapat dialami oleh anak maupun orang tua. stres bagi anak saat di rumah sakit dapat diakibatkan oleh akibat perpisahan, kehilangan kontrol dan nyeri akibat penyakit maupun tindakan selama di rumah sakit. sedangkan bagi orang t ua st res dapat diakibatkan oleh keseriusan ancaman terhadap anak, pengalaman sebelumnya dengan sakit atau hospitalisasi, prosedur medis yang terlibat dalam diagnosis dan pengobatan, system pendukung yang ada, kekuatan ego pribadi, kemampuan koping sebelu m nya, st ress tambahan pada system keluarga, keyakinan budaya dan agama, pola komunikasi di antara anggota keluarga (wong, 2009). tingkat stres hospitalisasi orang tua yang memiliki anak dengan penyakit kanker bervariasi mulai dari tingkat stress normal atau tidak stress sampai tingkat sangat berat. tingkat stress normal pada orang tua terletak pada aspek atau pertanyaan mengenai apakah orang tua menjadi mudah marah semenjak anak sakit. pertanyaan tersebut memiliki nilai rerata jawaban paling rendah. orang tua cenderung untuk menerima dengan sabar terhadap penyakit anak. menurut kazak (2005) respons stress yang ditunjukkan oleh orang tua selama prosedur diagnostik merupakan respons yang normal secara kontekstual. orang tua yang dipilih menjadi responden adalah orang tua dari anak yang mrs pertama kali di ruang perawatan hematologi anak dengan penyakit kanker. kondisi ini mempunyai arti bahwa saat dilakukan penelitian merupakan periode untuk pelaksanaan prosedur diagnostik untuk menetapkan diagnosis pasti anak. tingkat stres empower m (x3) stres hospit (y) difusi inovasi (x2) koef=0,168/tst=1,987 (s) koef=0,130/tst=2,36( s) koef= -0,213/tst=3,103 (s) koef=-0,109/tst=2,72 (s) koef=0,450/tst=5,278 (s) koef=0,487/tst=6,507 (s) koef=0,662 koef=0,601 koef=0,787 koef=0,360/t-st= 4,980 (s) pendidikan pekerjaan penghasilan sikap motivasi pengetahuan partisipasi lingkungan gambar 1. uji measurement model penurunan stres hospitalisasi orang tua di ruang hematologi anak rsud dr. soetomo surabaya 33 pengembangan model asuhan keperawatan pendekatan cope (ilya krisnana) hospitalisasi orang tua dipengaruhi oleh stress tambahan yang dialami orang tua, misalnya dari aspek pembiayaan rumah sakit bagi anak. pada penelitian ini tingkat status sosial ekonomi responden merupakan golongan status sosial ekonomi rendah. penghasilan responden sebagian besar dalam kategori <rp1.000.000,-. jumlah ini merupakan di bawah standar upah minimum kota surabaya. bahkan terdapat hampir separuh responden dengan penghasilan kurang dari rp500.000,-. selain itu jenis pembiayaan responden adalah mayoritas menggunakan askes maskin. kondisi ini dapat diartikan bahwa pelayanan yang diberikan telah sesuai dengan harapan orang tua. yohana (2009) menyatakan bahwa pasien memiliki harapan bahwa perhatian tenaga kesehatan baik dokter atau perawat yang diberikan kepadanya tanpa membedakan status sosial ekonomi dan pembiayaan. kondisi tersebut dapat disebabkan oleh karena pelayanan yang diberikan kepada orang tua di ruang hematologi bersifat sama kepada semua pasien. perawat di ruang hematologi memberikan pelayanan tanpa membedakan status sosial ekonomi dari pasien dan keluarga. kondisi tersebut membentuk persepsi yang baik bagi orang tua sehingga dapat menurunkan tingkat stress yang ada pada orang tua. tingkat stress sangat berat terkait dengan pertanyaan bahwa responden merasa sulit bersantai sejak anak sakit. kondisi ini menggambarkan bahwa sejak anak mengalami sakit kanker dan dirawat di rumah sakit, orang tua menjadi konsentrasi penuh dengan penyakit anak. orang tua harus menunggui anak selama dirawat sehingga kesempatan untuk refreshing ataupun rekreasi dengan anggota keluarga lain terlewatkan. selain itu responden yang mempunyai tingkat stress sangat berat merupakan responden dengan pekerjaan semula adalah karyawan swasta namun oleh karena anak sakit sehingga ibu harus keluar dari pekerjaan dan sepenuhnya menunggui anak di rumah sakit. kondisi ini sejalan dengan penelitian yang dilakukan oleh war ner (2011) yang menu nju k kan bahwa tingkat stress orang tua lebih tinggi dibandingkan dengan orang lain oleh karena stressor tambahan yang berupa single parent atau meninggalkan pekerjaan karena merawat anak. tingkat stress berat juga direspons oleh responden berkaitan dengan gejala menjadi tidak sabar dengan pelayanan yang lama. berdasar hasil diskusi orang t ua mengatakan bahwa orang tua terkadang mengalami kondisi bahwa anak mengalami keluhan namun keluhan ibu kepada petugas kesehatan tidak segera ditangani. gejala mudah marah dapat berlangsung menjadi gejala f r ust asi yang mer upakan gejala kemarahan berat. perhatian perawat atau petugas kesehatan lain terhadap keluhan yang disampaikan oleh pasien merupakan factor yang dapat menentukan mutu dari pelayanan. persepsi pasien dan keluarga terhadap mutu pelayanan yang dirasa dapat berdampak kepada kepuasan. kondisi yang berlawanan dengan harapan yaitu ketidakpuasan orang tua terhadap pelayanan dapat menjadi suatu stressor (yohana, 2009). ketidakpuasan atau kekecewaan orang tua ditunjukkan dengan kemarahannya kepada perawat, dokter petugas rumah sakit dan bahkan marah kepada tuhan (bmt program of bc., 2011). gejala mudah marah merupakan bagian dari gejala post traumatic stress dissorder (ptsd). berdasar atas review yang dilakukan oleh yalug (2011) terhadap penelitian-penelitian yang mengkaji munculnya ptsd pada orang tua bekisar antara 6,2–34,6%. diagnosis ptsd merupakan bagian dari diagnosis psikiatri yaitu pada dsm iv. gejala ptsd yang muncul harus menjadi perhatian bagi perawat. perawat dapat berperan sebagai educator untuk memberikan pengertian tentang cara mengatasi munculnya stress pada orang tua. perawat dapat membentuk dukungan bagi orang tua yang berasal dari keluarga maupun dari sesama orang tua anak penderita kanker. hasil uji statistik menunjukkan bahwa difusi inovasi berpengaruh signifi kan terhadap pemberdayaan dengan nilai t-statistik 6,507 (>1,96) dengan sifat hubungan positif. cope mer upakan prog ram inovasi education behavioural intervention yang bertujuan untuk membentuk pemberdayaan bagi orang tua. upaya pemberdayaan bagi orang tua meliputi pengetahuan, partisipasi, keterampilan dan 34 jurnal ners vol. 8 no. 1 april 2013: 27–40 lingkungan (who, 2008). upaya peningkatan p a r t i sip a si o r a ng t u a d a l a m a s u h a n keperawatan kepada anak harus diterapkan oleh perawat anak. partisipasi orang tua dapat terlaksana melalui pemberdayaan orang tua dalam perawatan anak. upaya pemberdayaan orang tua merupakan komponen utama dalam fi losofi keperawatan anak yang berpusat pada keluarga ( family centered care) yaitu enabling dan empowering. pemberdayaan orang tua bertujuan untuk menumbuhkan sikap mandiri bagi orang tua untuk mendapatkan perawatan yang berkelanjutan. pengetahuan merupakan modal dasar dalam manusia berperilaku secara benar. pengetahuan dasar responden dikategorikan menjadi tiga yaitu baik, cukup dan kurang. hasil penelitian menunjukkan pengetahuan dengan kategori baik menempati persentase paling besar. pengetahuan dengan nilai paling tinggi pada aspek pengetahuan orang tua tentang pelaksanaan cuci tangan. cuci tangan merupakan aspek penting bagi keluarga saat melakukan perawatan kepada anak. berdasar hasil diskusi orang tua mengatakan bahwa cuci tangan selalu dilakukan oleh orang tua sebelum merawat anak, tidak hanya sebelum makan saja seperti yang tercantum dalam kuesioner. pemberdayaan kepada pasien dapat terlaksana setelah pasien mendapatkan informasi yang cukup dan manfaat dari informasi yang didapat sehingga membentuk tanggung jawab atas pemahaman yang dimiliki untuk terlibat dalam perawatan kesehatan (who, 2008). langkah pelaksanaan cuci tangan telah diinformasikan oleh rumah sakit melalui poster yang dipasang di ruangan. orang tua dapat mempelajari langkah mencuci tangan dengan cara melihat poster yang dipasang di dekat wastafel untuk mencuci tangan. pengetahuan dalam kategori kurang terkait dengan penyebab penyakit kanker. lebih dari separuh responden menjawab salah tentang penyebab kanker. orang tua masih menganggap bahwa kanker disebabkan oleh nyamuk. saat diskusi, orang tua juga menanyakan penyebab kanker, karena orang tua merasa bahwa selama ini mereka merawat anak dengan baik, sehingga mereka terkejut saat anak terdiagnosis kanker. berdasarkan hasil disk usi orang t ua mengi ngi n kan penjelasan tentang penyakit anak sesaat anak mrs, dengan demikian orang tua dapat memahami secara benar tentang penyakit anak. pengetahuan terhadap suatu penyakit berkaitan dengan penerimaan orang tua t e r h a d a p i nova si. r e s p o n s m e n e r i m a diimbangi dengan pengetahuan yang baik dari responden. sebagian besar responden yang menerima terhadap proses difusi inovasi memiliki pengetahuan yang baik individu perlu untuk mengetahui informasi tentang inovasi melalui berbagai media baik melalui media massa maupun secara interpersonal (rogers, 1995). pengetahuan yang baik menunjang pelaksanaan inovasi dengan baik pula oleh karena itu sebelum pelaksanaan inovasi orang tua harus mengetahui tentang inovasi yang ditawarkan terutama manfaat dan peran yang bisa diambil dalam perawatan anak. masyarakat dapat terhindar dar i penyakit jika pengetahuan tentang kesehatan dapat ditingkatkan, sehingga perilaku dan keadaan lingkungan sosialnya menjadi sehat (notoatmodjo, 2003). komponen pemberdayaan yang kedua adalah partisipasi. tanpa partisipasi dan kerja sama yang baik antara orang tua dan perawat serta tenaga medis yang lain, maka keberhasilan perawatan pada anak jauh dari harapan. tingkat partisipasi aktif dan pasif memiliki persentase yang hampir sama, hanya selisih dua responden. partisipasi aktif memiliki persentase yang sedikit lebih besar dari partisipasi aktif. partisipasi aktif orang tua berkaitan dengan keikutsertaan orang tua untuk menjaga kebersihan badan ( personal hygiene) anak. orang tua membersihkan badan anak sehari dua kali. kegiatan untuk membersihkan badan dalam bentuk seka atau spon yaitu dengan membasuh seluruh badan anak dengan waslap atau handuk yang dibasahi. teknik ini merupakan tindakan yang baik yang dilakukan oleh ibu untuk menjaga kebersihan badan anak. personal hygiene mer upakan tindakan unt u k memelihara kebersihan dan kesehatan seseorang untuk kesejahteraan fi sik dan psikis (robert, 2008). kebersihan badan anak merupakan aspek yang 35 pengembangan model asuhan keperawatan pendekatan cope (ilya krisnana) penting untuk mencegah anak pada kondisi risiko infeksi. komplikasi utama pada anak dengan kanker terutama leukemia adalah neutropenia (wong, 2009). neutropenia merupakan keadaan yang dapat mengarah pada keadaan infeksi, sehingga memerlukan tindakan pencegahan yang ketat melalui personal hygiene. hasil penelitian menunjukkan dari ke lima kegiatan, par tisipasi orang t ua dalam meminta anak untuk bermain saat tindakan invasif/penyuntikan mer upakan kegiatan partisipasi yang paling rendah oleh orang tua. berdasarkan hasil diskusi orang t ua mengatakan bahwa orang t ua tidak mengetahui tindakan yang harus dilakukan selama penyuntikan. kegiatan yang selama ini dilakukan oleh orang tua adalah meminta anak untuk tenang tanpa menggunakan alat permainan. partisipasi mer upakan kunci keberhasilan pemberdayaan (who, 2008). partisipasi orang tua berkaitan erat dengan latar belakang intelegensi atau kemampuan kognitif seseorang (who, 2008). hasil penelitian ini menunjukkan bahwa responden yang cenderung memiliki partisipasi pasif adalah responden dengan tingkat pendidikan sekolah dasar. sebaliknya responden dengan pendidikan yang lebih tinggi yaitu slta memilki tingkat partisipasi aktif. pendidikan dalam diri seseorang menjadi dasar dalam manusia berperilaku secara baik dan benar. hasil penelitian berkaitan dengan karakteristik individu pendidikan, terdapat satu orang yang status pendidikannya tidak sekolah. responden dengan status pendidikan tersebut memiliki par tisipasi pasif dalam perawatan anak. umur, budaya, latar belakang, kepribadian dan tingkat intelegensi menjadi karakter kunci dalam pembentukan partisipasi pasien (who, 2008). penerimaan terhadap difusi inovasi berkaitan dengan partisipasi orang tua. orang tua yang tidak dapat menerima inovasi cope memiliki partisipasi pasif dengan persentase yang lebih besar. orang tua dengan respons menerima terhadap inovasi cope dapat memperkuat upaya pemberdayaan melalui peningkatan partisipasi dalam perawatan anak. penerimaan terhadap inovasi cope dapat berkaitan dengan aspek triability (dapat diuji coba) (rogers, 1995). program cope merupakan upaya partisipasi orang tua dalam perawatan dasar anak misalnya personal hygiene, penerapan terapi bermain yang tidak terlalui rumit bagi orang tua untuk di uji coba dan dilakukan setiap hari. kondisi ini memudahkan orang tua untuk berpartisipasi aktif dalam perawatan anak secara f isik maupun emosional. upaya p e mb e rd aya a n or a ng t u a di r umah sakit dapat diperkuat dengan peningkatan keterampilan yang dimiliki oleh orang tua. keterampilan yang baik dan benar menunjang keberhasilan asuhan keperawatan anak. perawat dapat bekerja sama secara penuh dengan orang tua setelah adanya pembekalan keterampilan. hasil penelitian menunjukkan bahwa keterampilan orang tua dalam kategori baik mencakup sebagian besar responden. keterampilan responden diukur melalui observasi oleh peneliti saat orang tua melakukan tindakan pengukuran suhu tubuh anak. semua tahap dalam pengukuran suhu aksila dilaksanakan dengan baik oleh orang tua. tahap persiapan dan penyelesaian pada bagian mencuci tangan memiliki persentase paling kecil. orang tua lebih banyak tidak mencuci t a nga n sebelu m d a n sesud a h pengukuran suhu. orang tua dapat memiliki persepsi bahwa saat pengukuran suhu tidak ada anggota badan yang kontak secara khusus dan dalam waktu lama dengan anggota badan. menurut potter & perry (2005) menuliskan prosedur untuk pengukuran suhu diawali dengan mencuci tangan sebelum penukaran dan setelah selesai pengukuran juga dilakukan cuci tangan. pengukuran suhu anak mer upakan kegiatan rutin yang sederhana dan dilakukan minimal empat kali dalam sehari. pengukuran suhu anak menggunakan alat ukur thermometer aksila. kegiatan ini termasuk keterampilan yang sederhana yang dapat diajarkan oleh perawat kepada orang tua. hasil diskusi menunjukkan bahwa orang tua mendapatkan pengajaran dari perawat cara pengukuran suhu tubuh. namun demikian masih terdapat responden yang memiliki tingkat keterampilan dalam kategori cukup yaitu satu responden. 36 jurnal ners vol. 8 no. 1 april 2013: 27–40 responden tersebut tidak dapat menerima terhadap adanya suatu inovasi. menerima atau tidak menerima terhadap suatu inovasi merupakan bagian dari tahap pengambilan keputusan. pada tahap pengambilan keputusan individu mengambil konsep inovasi dan me m i k i rk a n at au me mp e r t i mba ng k a n keuntungan maupun kerugian dari penggunaan inovasi dan mengambil langkah untuk akan mengadopsi atau menolak inovasi (rogers, 1995). individu yang tidak dapat menerima adanya inovasi dapat menganggap inovasi sebagai suatu beban karena dibutuhkan tenaga dan pikiran yang lebih untuk memahami suatu keterampilan. pemberdayaan kepada orang tua tidak dapat terlepas dari kondisi lingkungan baik secara fi sik maupun psikis. lingkungan fi sik dapat berupa fasilitas dan kondisi ruangan yang dapat mendukung partisipasi orang tua. kondisi psikis berupa komunikasi yang dibangun antara orang tua dengan tenaga medis khususnya perawat. kondisi lingkungan dikategorikan menjadi sangat mendukung, cukup mendukung dan kurang mendukung. kondisi lingkungan yang sangat mendukung dipersepsikan oleh hampir separuh jumlah responden. kondisi lingkungan yang sangat mendukung adalah dari fasilitas peralatan yang dimiliki oleh rsud dr. soetomo. sebagian besar responden mempersepsikan bahwa fasilitas yang digunakan sangat baik dan lengkap. rsud dr. soetomo merupakan rumah sakit pemerintah dengan tipe a. hal ini berkaitan dengan ketersediaan fasilitas yang digunakan oleh rumah sakit. rumah sakit dr. soetomo menjadi rujukan bagi indonesia timur, sehingga sarana dan prasarana yang digunakan dengan kualitas dan kuantitas yang baik. lingkungan yang cukup mendukung dipersepsikan oleh separ uh dari jumlah responden. lingkungan yang cukup mengarah pada lingkungan nonfisik yaitu informasi yang diberikan oleh perawat. pemberian informasi merupakan bagian dari protap setiap pelaksanaan prosedur tindakan keperawatan yaitu penjelasan tujuan dan manfaat dari tindakan. lingkungan non fisik memiliki tingkat cukup oleh karena tidak setiap tindakan akan diberikan informasi oleh perawat. hal ini selaras dengan hasil diskusi bahwa orang tua menginginkan meskipun tindakan dalam kategori tindakan rutin, informasi merupakan hal yang penting yang berhak didapatkan oleh orang tua. kondisi lingkungan non fi sik ini sangat menunjang keberhasilan dalam pemberdayaan orang tua. lingkungan yang kondusif berarti proses yang mendorong individu untuk dapat mengembangkan dan mempraktikkan dalam kondisi komunikasi yang terbuka dan bebas dari suatu hambatan dalam melaksanakan perawatan kesehatan (rogers, 1995). penerimaan terhadap inovasi cope ber pengar uh terhadap penilaian kondisi lingk ungan perawatan yang mer upakan bagian dari komponen pemberdayaan. orang tua yang menerima terhadap inovasi cope menilai bahwa lingkungan sangat mendukung untuk upaya pemberdayaan. sifat inovasi observability (dapat diamati) dapat menjadi factor yang berpengaruh terhadap penilaian kondisi li ng k u nga n. li ng k u nga n ya ng kondusif dalam upaya penerapan inovasi cope dapat dilihat melalui kelengkapan fasilitas yang disediakan oleh rumah sakit. fasilitas yang lengkap mempermudah pelaksanaan pemberdayaan orang tua. empowerment memiliki pengar uh terhadap st ress hospit alisasi. hasil uji statistik menunjukkan bahwa empowerment memiliki pengaruh yang signifi kan terhadap stress hospitalisasi dengan nilai t-statistik (4,980). pemberdayaan terhadap orang tua dapat diciptakan melalui program cope yang mer upakan education-behavioural intervention. program cope membentuk pemberdayaan kepada orang tua melalui intervensi keperawatan yang mengandung unsur edukasi dan per ubahan perilaku. pengetahuan yang dimiliki oleh orang tua dapat menjadi komponen penting dalam upaya pemberdayaan orang tua melalui cope. edwinson, et al. (1988) dalam ygge (2004) menyatakan bahwa orang tua yang memiliki pengetahuan baik dan persiapan yang baik pula akan menurunkan tingkat distress dan dapat berdampak pada penurunan tingkat stress anak. pengetahuan orang tua dalam program 37 pengembangan model asuhan keperawatan pendekatan cope (ilya krisnana) cope diberikan secara lisan maupun secara tertulis. informasi tertulis bertujuan untuk menguatkan pemahaman yang dimiliki oleh orang tua. hasil penelitian yang dilakukan oleh melnyk (2004) dalam penerapan cope menunjukkan bahwa pengetahuan yang baik mengenai penyakit anak dan perilaku yang dialami anak selama menjalani hospitalisasi dapat menguatkan tingkat kepercayaan orang tua bahwa mereka mampu untuk mengatasi stres hospitalisasi yang dialami oleh anak melalui perawatan emosional (emotional care). emotional care orang tua kepada anak dapat untuk menurunkan stres hospitalisasi anak adalah dengan menerapkan terapi bermain. meminta anak untuk melakukan permainan saat tindakan invasif merupakan upaya untuk menurunkan tingkat stress anak dan secara tidak langsung akan menurunkan stress orang tua. hasil penelitian agnesha (2011) menu nju k ka n ba hwa sa at a na k mendapatkan tindakan invasif orang tua akan menunjukkan gejala distress psikologis (cemas) pada tingkat berat hampir separuh d a r i responden d a n terd apat beberapa responden yang menunjukkan gejala panik. hasil penelitian menunjukkan bahwa masih banyak orang tua yang tidak mengetahui bahwa permainan saat anak diberikan tindakan invasif merupakan bagian dari partisipasi orang tua dalam perawatan emosional anak. peningkatan partisipasi orang tua dalam perawatan anak merupakan aspek penting dalam upaya menurunkan stress hospitalisasi orang tua. melnyk (2004) melakukan penelitian stress orang tua saat anak dilakukan tindakan bone marrow transplantation menunjukkan bahwa pada saat tersebut orang tua dapat menunjukkan gejala ptsd oleh karena orang tua merasa tidak dapat memberikan perawatan yang lebih seperti saat anak menjalani rawat jalan. partisipasi orang tua yang minimal dalam perawatan anak dapat meningkatkan tingkat stress orang tua dan perasaan tidak berdaya dan tidak dapat membantu anak (helplessness) dengan baik. partisipasi aktif meningkatkan kemampuan orang tua dalam perawatan anak sehingga orang tua memiliki keyakinan bahwa anak telah mendapatkan perawatan yang tepat oleh orang tua. orang tua dapat mengambil peran untuk perawatan anak pada tindakan rutinitas dan tindakan yang tidak membahayakan serta tidak memerlukan pemahaman tingkat tinggi. perawatan yang dapat diberikan misalnya dengan personal hygiene, peningkatan nutrisi, dan penurunan respons emosional anak akibat hospitalisasi dengan permainan yang disesuaikan dengan tahap perkembangan anak. stres dapat muncul jika orang tua merasa tidak memiliki keterampilan yang baik dan benar dalam perawatan anak. berdasar hasil diskusi didapat bahwa orang tua mengalami kebingungan dalam keterampilan untuk penurunan suhu anak saat demam. penggunaan suhu air dan cara yang tepat untuk menurunkan suhu anak sangat diperlukan oleh orang tua. perawat dapat berperan sebagai edukator untuk memberikan contoh dan demonstrasi cara kompres yang benar. coyne (1995) dalam ygge (2004) menyatakan bahwa orang tua lebih memilih untuk berpartisipasi dalam perawatan anak untuk mengoptimalkan kesejahteraan emosional anak akan tetapi orang t ua memiliki masalah dalam hal kurangnya informasi kecemasan dan perasaan kesendirian. lingkungan merupakan komponen yang penting dalam menciptakan pemberdayaan bagi orang tua. lingkungan dapat berupa lingkungan fi sik maupun non fi sik (who, 2008). lingkungan fi sik merupakan fasilitas atau sarana yang disediakan oleh rumah sakit dalam perawatan anak. fasilitas yang baik dalam kualitas maupun kuantitas menciptakan keyakinan bagi orang tua akan pelayanan yang diberikan dan dapat mempercepat kesembuhan anak. peningkatan kepercayaan orang tua terhadap pelayanan keperawatan dapat menurunkan tingkat stres hospitalisasi orang tua. lingk ungan nonf isik ber upa pola komunikasi antara perawat dengan orang tua dan sistem komunikasi dua arah dan terbuka yang dibentuk. komunikasi merupakan aspek penting dalam perawatan anak dan orang tua. nobile dan drotar (2003) dalam ygge (2004) menunjukkan bahwa terdapat hubungan antara penyediaan informasi yang efektif bagi orang 38 jurnal ners vol. 8 no. 1 april 2013: 27–40 tua dengan tingkat kepuasan orang tua terhadap pelayanan yang diberikan. semakin banyak kekurangan dalam komunikasi yang dirasakan oleh orang tua maka penurunan kepuasan pelayanan akan terjadi (marino & marino, 2000 dalam ygge, 2004). peningkatan stress orang tua dapat muncul akibat kesalahpahaman pola komunikasi antara perawat dengan orang tua. hal ini selaras dengan hasil diskusi bahwa orang tua mengalami kondisi kesalahan dalam komunikasi yaitu cara melakukan kompres secara benar. tenaga medis awal menyarankan untuk kompres menggunakan air biasa akan tetapi tenaga medis yang lain menyalahkan tindakan yang dilakukan oleh orang tua atas saran dokter yang pertama. kondisi kesalahan dalam informasi ini dapat menambah stress dan kebingungan orang tua. hasil uji statistik menunjukkan bahwa koefi sien jalur antara empowerment dan stress hospitalisasi bersifat positif. hasil ini bermakna bahwa semakin tinggi pemberdayaan orang tua dapat berpengaruh terhadap semakin tingginya tingkat stress hospitalisasi orang tua. selaras dengan penelitian darbyshire (1993) dalam ygge (2004) mengemukakan bahwa terdapat kesalahan dalam komunikasi antara perawat dengan orang tua yaitu perawat enggan untuk berbagi informasi dengan orang tua, namun jika perawat mengetahui bahwa orang tua memiliki pengetahuan dan kemampuan yang baik, perawat memberikan peran yang terlalu banyak sehingga dapat memberatkan bagi orang tua. hal ini berarti bahwa penerapan empowerment bagi orang tua harus dibangun dalam lingkungan yang saling mendukung dan saling percaya. pemberdayaan yang diberikan harus disesuaikan dengan kebutuhan dan kemampuan orang tua. pemberdayaan yang tepat dapat menurunkan stress orang tua dan meningkatkan kepuasan terhadap pelayanan keperawatan yang diberikan. o r a ng t u a meng i ng i n k a n keterlibat a n d ala m per awat a n a na k sesu ai denga n kemampuan yang mereka miliki. pelibatan orang tua yang melebihi kemampuan dapat menimbulkan stress yang lebih tinggi (ygge, 2004). lingkungan mer upakan indikator terk u at sebagai pembent u k komponen empowerment. lingkungan nonfi sik dalam perawatan anak memiliki pengaruh yang kuat dalam munculnya stress hospitalisasi orang tua. penjelasan atau pemberian informasi merupakan aspek penting yang diharapkan oleh orang tua. informasi yang kurang dan kesalahan informasi dapat memicu timbulnya stress bagi orang tua. sebagai contoh adalah ketidaksesuaian antara metode penurunan demam yang disampaikan oleh dua tenaga kesehatan dapat memicu munculnya stress bagi orang tua. simpulan tingkat stress hospitalisasi orang tua bervariasi mulai dari tingkat stress normal sampai dengan sangat berat. tingkat stress normal orang tua terkait dengan minimalnya stressor tambahan yang dialami oleh keluarga terutama terkait dengan pembiayaan yaitu penggunaan askes maskin pada sebagian besar responden. karakteristik motivasi mempu nyai per a na n ya ng k u at u nt u k membentuk penerimaan orang tua terhadap cope. penerimaan orang tua terhadap inovasi cope yang ditawarkan menjadi penentu bagi terbentuknya pemberdayaan bagi orang tua. semakin baik respons penerimaan orang tua terhadap inovasi cope yang ditawarkan maka akan semakin baik pula pemberdayaan yang terbentuk. pemberdayaan (empowerment) yang terbentuk dapat menentukan tingkat stress hospitalisasi orang tua. lingkungan mer upakan indikator utama yang dapat menent ukan keberhasilan empowerment yang dapat berdampak pada tingkat stress hospitalisasi orang tua. saran berdasarkan hasil penelitian maka saran yang diberikan adalah rumah sakit diharapkan dapat menerapkan upaya empowerment bagi orang tua melalui penataan komponen pemberdayaan yang dibutuhkan terutama partisipasi dan lingkungan yang kondusif. orang t ua dilibatkan dalam perawatan fi sik dasar anak seperti; personal hygiene, pengukuran suhu, penurunan demam anak, pemberian nutrisi dan perawatan anak yang 39 pengembangan model asuhan keperawatan pendekatan cope (ilya krisnana) lain secara sederhana untuk kemandirian orang tua, perawat anak dapat menerapkan empowerment melalui penciptaan lingkungan yang kondusif terutama lingkungan nonfi sik. perawat berperan sebagai educator untuk membentuk sistem komunikasi yang terbuka melalui pen i ng kat a n penget a hu a n d a n pemahaman orang tua tentang perawatan bagi anak serta pemberian informasi dalam setiap tindakan yang dilakukan. pemberian informasi dapat dilakukan secara lisan dan diperkuat dengan informasi secara tertulis, orang tua diharapkan dapat melaksanakan upaya pemberdayaan secara penuh melalui peningkatan pemahaman tentang penyakit anak, peningkatan partisipasi dalam perawatan anak secara fi sik maupun emosional melalui penerapan terapi bermain dalam waktu yang tepat misalnya saat dilaksanakan tindakan invasif (suntik) dan saat waktu luang untuk menghibur anak sehingga stress hospitalisasi anak berkurang dan peneliti selanjutnya d i h a r a p k a n d a p a t m e nyele n g g a r a k a n penelitian pada kasus penyakit kronik yang membutuhkan perawatan jangka panjang dengan partisipasi orang tua sebagai penentu keberhasilan perawatan misalnya; anak dengan gangguan mental, diabetes mellitus pada anak, gagal ginjal kronik dan sebagainya. perawatan penyakit k ronik pada anak memerlukan pemberdayaan orang tua secara penuh baik selama di rumah sakit maupun perawatan lanjutan di rumah. kepustakaan agnesha, m., 2011. tingkat kecemasan orang tua terhadap pemasangan infus pada anak usia prasekolah di ruang iii rsud dr. pirngadi medan. skripsi, fakultas keperawatan, universitas sumatera utara. arif, sy., 2007. efektivitas penurunan stres hospitalisasi anak dengan terapi bermain dan terapi musik. jurnal ners, 2(2), hal. 72–78. damanik, ed., 2010. pengujian validitas dan reliabilitas analisis item dan pembuat norma dass: penelitian pada kelompok sampel yogyakarta dan bantul yang mengalami gempa bumi 2010, (online), (htt p://www. digilib.ui.ac.id /opac/themes/libr i2/ detail.jsp?id=94859, diakses tanggal 21 februari 2012). hus, ma., 2009. parents and children coping with pediatric cancer: associations between parent and child anxiety, and parent-child communication. thesis, nashville tennessee: vanderbilt university. hutchfi eld, k., 1999. family centered-care as a concept analysis. journal of advanced nursing, 29(5), pp. 1178–1187. k a z a k , e a ., 2 0 0 5. ev i d e n c e b a s e d interventions for survivors of childhood cancer and their families. journal of pediatric psychology, 30 (1), (online), ( ht t p://jpe psy.ox fordjou r n als.org., diakses tanggal 8 desember 2011). pp. 29–39. l e u k e m i a / b m t p r o g r a m o f b c . , 2 0 11 . c o p i n g a n d s u p p o r t e m o t i o n a l e f f e c t s o f c a n c e r common emotions. diakses tanggal 11 o k t o b e r 2 010. h t t p: // w w w. leu kemiabmt program.org /patients_ a nd _ fa m i ly/c o pi ng _ a nd _ s u p p or t / emotional_effects_of_cancer/common_ emotions.html. lovibond, sh. dan lovibond, pf., 1995. manual for the depression anxiety st ress scales. (2nd ed.). syd ney: psychology foundation. melnyk, bm. dan feinstein, nf., 2009. reducing hospital expenditures with the cope (creating opportunities for parent empowerment) program for parents and premature infants: an analysis of direct healthcare neonatal intensive care unit costs and savings, nursing administration quarterly [nurs adm q, 33(1), pp. 32–7. muscari, me. (2005). perkembangan anak. jilid 1. jakarta: egc. melnyk, bm., crean, hf., feinstein, nf. dan fairbanks, e., 2008. maternal anxiety and depression after a premature infant's discharge from the neonatal intensive care unit: explanator y effects of the creating opportunities for parent empowerment program. nursing research [nurs res], 57(6), pp. 383–94. 40 jurnal ners vol. 8 no. 1 april 2013: 27–40 melnyk, bm. dan feinstein, nf., 2006. reducing premature infants' length of stay and improving parents' mental health outcomes with the creating opportunities for parent empowerment (cope) neonatal intensive care unit program: a randomized, controlled trial. pediatrics. 118(5): e1414–27. mel nyk , bm , e t a l., 20 0 4. cr e at i ng opportunities for parent empowerment: program effects on the mental health/ coping outcomes of critically ill young children and their mothers, pediatrics, 113(6): e597–607. notoatmodjo, s., 2003. pendidikan dan perilaku kesehatan. jakarta: rineka cipta. hal: 133–142. nursalam, rekha & utami, 2005. asuhan keperawatan bayi dan anak. jakarta: salemba medika. hal: 17,25–30,74–84. niven, n., 2002. psikologi kesehatan pe n g a n t a r u n t u k pe r a w a t d a n profesional kesehatan lain. jakarta: egc. hal. 53–54. potter & perry, 2005. buku ajar fundamental keperawatan: konsep, proses dan praktik. jakarta: egc. robert l. & callison, 2008. personal hygiene. diakses tanggal 21 april 2011, dari http://www.healthlink.com/bjc_index. asp/personal-hygiene. rogers, me., 1995. difussion of inovation. ed. 4th new york: the free press. rutter, et al., 2005. the effects of gender and grade level on the motivational needs of family and consumer sciences. journal of family and consumer sciences education, 23(2), pp. 19-26. simon, h., 2005. leukemia. diakses tanggal 12 oktober, 2010, dari (http://healthguide. howstuffworks.com/acute-lymphocyticleukemia-in-depth.htm/printable). supartini, 2004. buku ajar konsep dasar keperawatan anak. jakarta: egc. hal. 81–85. thomas, r., 1994. atlas bantu pedriatri. jakarta: hipokrates. who, 2009. who guidelines on hand hygiene in health care. geneva: who press. pp. 191–193. wong, et al. (2009). buku ajar keperawatan pediatric. volume 1. jakarta: egc. hal. 336–480. wong, et al., 20 03. pe d om a n klini s keperawatan pediatrik. edisi 4, jakarta: egc. hal. 103–126. yalug, i. et al., 2011. post-traumatic stress disorder and post-traumatic stress symptoms in parents of children with cancer: a review. neurology, psychiatry and brain research, 17, pp. 27–31. yayasan onkologi anak indonesia, 2012. diakses tanggal 10 februari 2012, dari http://www.yoai-foundation.org/profi l. php. ygge, bm., 2004. parental involvement in pediatric hospital care: implication for cinical practice and quality of care. dissertation, faculty of medicine: acta universitatis upsalienisis. pp. 6–9. yohana, e., 2009. analisis harapan dan kepuasan pasien rawat inap penyakit d ala m terha d ap mut u pelaya na n dokter spesialis. tesis. magister ilmu kesehatan masayarakat universitas diponegoro. hal. 46–61. zhou, fl., et al., 2006. relationship between oxidative stress and depression in patients with acute leukemia. zhongguo shi yan xue ye xue za zhi, 14(5), pp. 872–5, diakses tanggal 11 okt 2010, dari http://www.ncbi.nlm.nih. gov/pubmed/17096879. vol 8 no 2 oktober 2013.indd 226 pemberdayaan keluarga dalam peningkatan self efficacy dan self care activity keluarga dan penderita tb paru (family empowerment in increasing self-effi cacy and self-care activity of family and patients with pulmonary tb) muhtar* *prodi keperawatan bima, politeknik kesehatan kemenkes mataram jl. kesehatan v no. 10 mataram 83121, nusa tenggara barat email: muhtarbima@gmail.com abstrak pendahuluan: manajemen diri dan tindak lanjut perawatan di rumah adalah kunci dari manajemen tb paru yang komprehensif. salah satu cara untuk meningkatkan self-effi cacy dan self care activity yaitu pemberdayaan keluarga. penelitian ini bertujuan untuk membuktikan pengaruh pemberdayaan keluarga terhadap peningkatan self-effi cacy dan self care activity penderita tb paru dan keluarga. metode: penelitian ini merupakan quasy eksperiment dengan nonrandomized control group pre-posttest design. populasi adalah keluarga yang tinggal dengan penderita tb paru, yang tercatat di puskesmas paruga dan mpunda. sampel diperoleh 32 orang, dibagi menjadi kelompok perlakuan dan kontrol. data dikumpulkan dengan kuesioner. data kemudian dianalisis dengan menggunakan wilcoxon sign rank test, mannwhitney test, dan spearman rho dengan tingkat signifi kansi 5%. hasil: hasil uji wilcoxon signed rank dan mannwhitney menunjukkan nilai p < 0,005. hal ini menunjukkan bahwa pemberdayaan keluarga berpengaruh terhadap self effi cacy (p = 0,001) dan self care activity (p = 0,001) penderita tb paru; self effi cacy dan self care activity (p = 0,002), serta peran keluarga (p = 0,001). sementara hasil uji spearman rho menunjukkan hubungan yang signifi kan antara self effi cacy dan self care activity. diskusi: pemberdayaan keluarga mempengaruhi pengetahuan dan keterampilan keluarga dalam perawatan penderita tb paru. peran keluarga sangat penting dalam meningkatkan self effi cacy dan self care activity. penelitian selanjutnya diharapkan mampu mengembangkan intervensi keperawatan lain yang dapat meningkatkan self effi cacy, self care, kepatuhan berobat, dan kualitas hidup penderita tb paru. kata kunci: pemberdayaan keluarga, self effi cacy, self care activity, tb paru abstract introduction: self-management and follow-up care at home is the key to a comprehensive pulmonar y tb management. one way to increase patient’s self-effi cacy and self-care activity is family empowerment. this study was aimed to prove the infl uence of family empowermant in increasing self-effi cacy and self-care activity family and pulmonary tb patients. method: this research used quasy experiment with non-randomized control group pre-posttest design. population was family who lived with pulmonary tb patient, listed at puskesmas paruga and mpunda. samples were 32 respondents, divided into treatment and control group. data were collected using questionnaire. data were analyzed by using wilcoxon sign rank test, mann-whitney test, and spearman rho with level of signifi cance 5%. result: the results of wilcoxon signed rank test and mann-whitney test showed value of p < 0.05. it means family empowerment had infl uenced on patient’s self effi cacy (p = 0.001), self-care activity (p = 0.001), family’s self effi cacy and self care activity (p = 0.002), and family’s role (p = 0.001). while, spearman’s rho analysis revealed p = 0.001, which means self-effi cacy has signifi cant relationship with self-care acitivity. discussion: family empowerment affects family knowledge and action in the treatment of pulmonary tb patients. family have an important role to improve patient’s self-effi cacy and self-care activity. further research should develop nursing interventions, which useful for the improvement of self-effi cacy, self-care, medication adherence, and quality of life patients with pulmonary tb. keywords: family empowerment, self-effi cacy, self-care activity, pulmonary tb pendahuluan tuberkulosis (tb) adalah penyakit i n fek si ya ng d isebabk a n oleh ba k ter i mycobacterium tuberc ulosis. t b pa r u sebagian besar diderita oleh laki-laki, pada kelompok usia produktif (who, 2011). tb paru merupakan penyakit infeksi dengan angka kematian tertinggi. tb paru juga masih menjadi penyebab kematian ketiga tertinggi di dunia, setelah penyakit kardiovaskuler dan saluran pernapasan (who, 2011). sebag ia n b e sa r k a su s t b pa r u ditemukan di asia dan afrika. indonesia saat ini menduduki ranking keempat negara dengan 227 pemberdayaan keluarga dalam peningkatan self effi cacy dan self care activity (muhtar) resisten obat, pengendalian pada kelompok marginal dan rentan, peningkatan akses terhadap kualitas dan ketersediaan obat, me mp e rlu a s laya n a n p e r awat a n ya ng berkualitas, memberdayakan masyarakat dan keluarga melalui mobilisasi sosial, pendidikan kesehatan, dan cara-cara efektif u nt u k melakukan perawatan tb di komunitas, serta meningkatkan kemandirian penderita dalam aktivitas perawatan (who, 2006). pe mb e r d aya a n kelu a r g a ( fa m il y empowerment) merupakan suatu proses atau upaya untuk menumbuhkan pengetahuan, kesadaran, dan kemauan keluarga dalam memel i ha r a d a n men i ng k at k a n st at u s kesehatan (notoatmodjo, 2007). pemberdayaan keluarga sesuai diterapkan di kota bima, mengingat dari segi struktur sosial masyarakat yang sebagian besar masih t radisional, dengan pola hubungan dan interaksi sosial yang erat di antara sesama anggota keluarga (andarmoyo, 2012). pemberdayaan keluarga diharapkan dapat menumbuhkan pengetahuan, pemahaman, bah kan self eff icacy yang tinggi dari penderita dan keluarganya. selfeffi cacy merupakan salah satu kemampuan pengaturan diri individu untuk membentuk perilaku yang relevan pada tugas atau situasi khusus (bandura, 1978), seperti tugas-tugas perawatan diri selama menjalani pengobatan tb paru yang biasanya berlangsung sampai 6 bulan. perawat memegang peranan penting dalam mengubah perilaku penderita dan keluarga, sehingga terjadi keseimbangan dan kemandirian dalam aktivitas perawatan diri. orem (1971) dalam tomey & alligood (2010), berpandangan bahwa setiap orang mempunyai kemampuan dalam memenuhi kebutuhan dasarnya secara mandiri. perawat adalah agen yang mampu membantu klien dalam mengembalikan perannya sebagai self care agency. perawat sebagai pendidik dan konselor dapat memberikan bantuan berbentuk supportive-educative system, yang ditujukan untuk meningkatkan kemampuan penderita dalam melakukan perawatan secara mandiri dan kepat u han pengobatan. kepat u han penderita terhadap pengobatan tb sangat penting untuk pengendalian penularan yang beban tb tertinggi di dunia, setelah india, cina, dan afrika selatan. estimasi prevalensi kasus tb adalah sebesar 600,000 dan estimasi insidensi berjumlah 450,000 kasus baru per tahun, dengan jumlah kematian mencapai 65,000 orang per tahun (who, 2012). laporan ditjen pp & pl menunjukkan case detection rate (cdr) tb paru 2011 sebesar 82,2%, dengan jumlah kasus baru sebanyak 194.780 kasus, ser ta cak upan penderita yang dinyatakan sembuh 80,4% dan pengobatan lengkap 6,3%, dengan angka success rate (sr) sebesar 86,7% (kemenkes ri, 2012). cdr tb paru kota bima, ntb, pada 2011 masih jauh di bawah standar nasional. pada 2011, cdr tb paru sebesar 46,15%, dengan insidensi 190,1 per 100.000 penduduk dan prevalensi tb par u sebesar 192 per 100.000 penduduk, serta angka kematian akibat tb paru 9,8 per 100.000 penduduk. tingkat kesembuhan dan pengobatan lengkap tb juga masih tergolong rendah, yaitu pengobatan lengkap tb sebesar 37,01%, kesembuhan sebesar 59,06% dari 127 penderita yang diobati, dengan angka sr sebesar 96,06% (dinkes kota bima, 2011). penyakit tb paru memiliki dampak ya ng s a ng at b e s a r d a la m keh id u p a n penderitanya, baik fisik, mental, maupun kehidupan sosial. secara fi sik, penyakit tb paru yang tidak diobati secara benar akan menimbulkan komplikasi, seperti penyebaran infeksi ke organ lain, malnutrisi, batuk darah berat, resistensi obat, dan lain-lain (smeltzer & bare, 2001). secara ekonomi, penyakit tb paru mempengaruhi produktivitas penderita, di mana penderita kehilangan rata-rata waktu kerja 3–4 bulan per tahun, sehingga pendapatannya menurun sekitar 20 –30%. selain it u, secara sosial penderita juga mendapatkan pengucilan akibat stigma negatif dari masyarakat (depkes ri, 2007). berbagai upaya pengendalian tb paru telah dieksplorasi dan dipromosikan oleh who. berbagai kegiatan komplementer dan inovatif yang memberdayakan sumber nasional atau internasional juga telah dilaksanakan. misalnya, kolaborasi pengendalian tb paru dan hiv, strategi pengelolaan penderita 228 jurnal ners vol. 8 no. 2 oktober 2013: 229–239 efektif. kepatuhan pengobatan merupakan masalah kompleks yang melibatkan sistem pelayanan kesehatan, proses perawatan, perilak u tenaga kesehatan dan k ualitas komunikasinya dengan penderita, sikap masyarakat, dan perilaku penderita itu sendiri (jakubowiak et al., 2008). perawatan lanjutan dan mandiri di r umah oleh keluarga penderita penyakit kronis merupakan kunci penatalaksanaan penya k it ya ng komprehensif ( eg waga et al., 2009). kemandirian dan kepatuhan pengobatan terjadi jika individu memiliki pengetahuan, keterampilan, dan self effi cacy untuk melakukan perilaku pengelolaan tb dan perawatan diri di rumah. hasil penelitian lewis dan newell (2009) menunjuk kan bahwa peni ngkat an komu ni kasi ant ara penyedia layanan kesehatan dan penderita, pemberdayaan individu, serta pengetahuan dan pemahaman penderita tentang program pengobatan, dapat meningkatkan kepercayaan diri (self eff icacy) penderita tb dalam perawatan dan pengobatan. hasil penelitian kholifah et al (2012) menyimpulkan bahwa penerapan model adaptif conservation dapat meningkatkan pengetahuan penderita tb paru dan keluarga, meningkatkan dukungan keluarga, kelompok dan masyarakat pada penderita tb paru, dukungan perawat pada kepatuhan berobat penderita tb paru, serta meningkatkan kepatuhan berobat penderita tb paru. salah satu upaya untuk meningkatkan self effi cacy dan kemampuan self care penderita tb par u adalah melalui pemberdayaan keluarga ( family empowerment). hal ini berdasarkan hasil penelitian moattari et al (2012) yang menunjukkan bahwa kombinasi pemberdayaan individu dan sesi konseling kelompok men i ng k at k a n selfef f ica c y, kualitas hidup, gejala klinis, serta kadar hemoglobin dan hematokrit pada penderita hemodialisis. didukung pula oleh hasil penelitian hulme (1999) yang membuktikan bahwa pemberdayaan merupakan intervensi keperawatan interaktif yang dirancang untuk membantu keluarga mengoptimalkan sumber daya keluarga, sehingga meningkatkan kemampuan anggota keluarga untuk merawat dan mempertahankan kehidupan keluarganya secara efektif. oleh karena itu, penelitian ini ditujukan untuk menganalisis pengaruh pemberdayaan keluarga terhadap peningkatan self-effi cacy dan self care activity keluarga dan penderita tb paru, di kota bima, nusa tenggara barat. bahan dan metode pe nel it ia n i n i me r upa k a n qua s y experiment dengan desain penelitian non randomized cont rol g roup pre-posttest design. populasi adalah keluarga yang tinggal bersama penderita tb paru, yang terdaftar dan sedang menjalani program pengobatan tb di puskesmas paruga dan mpunda. sampel diperoleh 32 orang, dibagi menjadi kelompok perlakuan dan kontrol. peneliti memberikan perlakuan berupa pemberdayaan keluarga, dengan melakukan peny u lu ha n, bi mbi nga n / konseli ng d a n demonstrasi terkait konsep penyakit tb, cara perawatan, cara pencegahan penularan, serta pengobatan tb paru yang melibatkan penderita dan keluarga, selama ± 1 jam setiap pertemuan, 6 kali pertemuan dalam 6 minggu, sesuai kesepakat an dengan responden. instrumen pendukung lain dalam penelitian ini berupa sak, booklet, lembar balik, dan bahan demonstrasi perawatan mandiri tb paru. peng u mpula n d at a mengg u na ka n kuesioner tentang self effi cacy dan self care activity keluarga, peranan keluarga dalam meningkatkan self eff icacy dan self care activity penderita, self effi cacy penderita, dan self care activity penderita tb paru. analisis data menggunakan uji wilcoxon sign rank, mann-whitney, serta korelasi spearman rho dengan tingkat kepercayaan 5%. hasil berdasarkan tabel 1, diketahui bahwa hasil uji wilcoxon signed rank ada perbedaan self effi cacy dan self care activity keluarga pada penderita tb paru sebelum dan setelah pemberdayaan, dengan p = 0,001. sedangkan kelompok kontrol yang tidak mendapatkan 229 pemberdayaan keluarga dalam peningkatan self effi cacy dan self care activity (muhtar) i nter vensi, tid a k menu nju k kan ad anya perbedaan, dengan nilai p = 0,245. hasil uji mann-whitney menunjukkan nilai p = 0,002, yang berarti ada perbedaan yang bermakna antara hasil post test pada kelompok perlakuan dan kelompok control. hal ini berarti, ada pengaruh pemberdayaan terhadap self effi cacy dan self care activity keluarga. berdasarkan tabel 2, diketahui bahwa hasil uji wilcoxon signed rank test pada kelompok perlakuan menunjukkan adanya perbedaan peranan keluarga dalam membantu meningkatkan self-eff icacy dan self care activity penderita tb paru setelah intervensi, dengan nilai p = 0,001. sedangkan pada kelompok kontrol tidak menunjukkan adanya perbedaan, dengan nilai p = 0,314. hasil uji mann-whitney test diperoleh nilai p = 0,001, yang berarti ada perbedaan yang bermakna antara hasil post test pada kelompok perlakuan dan kelompok kontrol. hal ini berarti bahwa ada pengaruh pemberdayaan terhadap peranan keluarga dalam meningkatkan self-effi cacy dan self care activity penderita tb paru. h a s i l p e n el i t i a n p a d a t a b el 3 menunjukkan self-effi cacy penderita tb paru kelompok perlakuan sebelum pemberdayaan sebagian besar dalam kategori cukup, setelah pemberdayaan sebagian besar dalam kategori baik. pada kelompok kontrol hasil pre dan post test menunjukkan sebagian besar dalam kategori cukup. hasil uji wilcoxon signed rank test pada kelompok perlakuan menunjuk kan adanya perbedaan self-effi cacy penderita tb paru sebelum dan sesudah intervensi, dengan nilai p = 0,001. sedangkan pada kelompok kontrol tidak menunjukkan adanya perbedaan, dengan nilai p = 0,586. hasil uji mannwhitney test menunjukkan nilai p = 0,001, yang berarti ada perbedaan yang bermakna antara hasil post test pada kelompok perlakuan dan kelompok kontrol. hal ini berarti, ada pengaruh pemberdayaan keluarga terhadap self effi cacy penderita tb paru. h a si l p e n el it i a n p a d a ta b el 4 menunjukkan self care activity penderita tb paru, pada kelompok perlakuan sebelum pemberdayaan sebagian besar dalam kategori cukup, dan setelah pemberdayaan menjadi sebagian besar dalam kategori baik. sementara pada kelompok kontrol hasil pre dan post test menunjukkan sebagian besar dalam kategori cukup. hasil uji wilcoxon signed rank test, pada kelompok perlakuan menunjuk kan adanya perbedaan self care activity penderita tb paru setelah intervensi pemberdayaan keluarga, dengan nilai p = 0,001, sedangkan pada kelompok kontrol tidak menunjukkan adanya perbedaan dengan nilai p = 0,293. hasil uji mann-whitney test menunjukkan nilai p = 0,001, yang berarti ada perbedaan yang bermakna antara hasil post test pada kelompok perlakuan dan kelompok kontrol. hal ini berarti, ada pengaruh pemberdayaan keluarga terhadap self care activity penderita tb paru hasil uji statistik dengan spearman’s rho menu nju k kan ad a hubu ngan yang signifi kan antara self effi cacy dan self care activity, dengan p = 0.001. nilai koefisien korelasi sebesar 0,822 juga menunjukkan tabel 1 distribusi frekuensi self effi cacy dan self care activity keluarga dalam perawatan penderita tb paru self effi cacy dan self care activity keluarga dalam perawatan penderita tb paru kelompok perlakuan kelompok kontrol pre test post test pre test post test f % f % f % f % baik cukup kurang 3 5 8 18,8 31,2 50,0 9 7 0 56,2 43,8 0,0 3 4 9 18,8 25,0 56,2 4 5 7 25,0 31,2 43,8 jumlah 16 100,0 16 100,0 16 100,0 16 100,0 wilcoxon signed rank test p = 0,001 p = 0,245 mann-whitney test p = 0,002 230 jurnal ners vol. 8 no. 2 oktober 2013: 229–239 tabel 2. distribusi frekwensi peranan keluarga dalam meningkatkan self effi cacy dan self care activity penderita tb paru peranan keluarga dalam meningkatkan self effi cacy dan self care activity penderita tb paru kelompok perlakuan kelompok kontrol pre test post test pre test post test f % f % f % f % baik cukup kurang 3 13 0 18,8 81,2 0,0 16 0 0 100,0 0,0 0,0 6 10 0 37,5 62,5 0,0 8 7 1 50,0 43,8 6,2 jumlah 16 100,0 16 100,0 16 100,0 16 100,0 wilcoxon signed rank test p = 0,001 p = 0,314 mann-whitney test p = 0,001 tabel 3. distribusi frekuensi self effi cacy penderita tb paru self effi cacy penderita tb paru kelompok perlakuan kelompok kontrol pre test post test pre test post test f % f % f % f % baik cukup kurang 2 9 5 12,5 56,2 31,2 11 5 0 68,8 31,2 0,0 4 7 5 25,0 43,8 31,2 3 12 1 18,8 75,0 6,2 jumlah 16 100,0 16 100,0 16 100,0 16 100,0 wilcoxon signed rank test p = 0,001 p = 0,586 mann-whitney test p = 0,001 tabel 4. distribusi frekuensi self care activity penderita tb paru self care activity penderita tb paru kelompok perlakuan kelompok kontrol pre test post test pre test post test f % f % f % f % baik cukup kurang 2 8 6 12,5 50,0 37,5 11 5 0 68,8 31,2 0,0 4 8 4 25,0 50,0 25,0 3 11 2 18,8 68,8 12,5 jumlah 16 100,0 16 100,0 16 100,0 16 100,0 wilcoxon signed rank test p = 0,001 p = 0,293 mann-whitney test p = 0,001 adanya hubungan positif yang sangat kuat di antara keduanya. pembahasan hasil penelitian (tabel 1) menunjukan adanya pengaruh kegiatan pemberdayaan terhadap peningkatan self effi cacy dan self care activit y keluarga, yang berdampak pada meningkatnya kemampuan keluarga untuk mendukung dan perpartisipasi dalam perawatan penderita tb paru. berdasarkan hasil observasi selama intervensi, perubahan self effi cacy dan self care activity keluarga tampak dari adanya peningkatan pengetahuan keluarga dalam hal pengertian, cara penularan, pencega ha n penula ra n, ser t a t i nd a ka n perawatan mandiri yang dapat dilakukan oleh keluarga. tindakan mandiri tersebut, di antaranya membantu menyiapkan pot tempat 231 pemberdayaan keluarga dalam peningkatan self effi cacy dan self care activity (muhtar) pembuangan dahak bagi penderita, membantu menjemur kasur, bantal, dan selimut penderita di bawah si na r mat aha r i, meny iapka n makanan yang bergizi, serta memberikan kompres hangat ketika penderita demam. perubahan lainnya yang ditunjukkan oleh keluarga adalah adanya keterlibatan keluarga dalam pengobatan penderita yaitu dengan mengingatkan penderita untuk selalu menelan obat secara teratur. temu a n i n i sesu ai denga n ha sil penelitian sebelumnya oleh tribble et al (2008), bahwa proses dinamis dari pemberdayaan keluarga dalam bidang kesehatan dapat meningkatkan pengetahuan dan inisiatif perawatan diri dengan mengandalkan kekuatan klien dan faktor pendu k u ng nya, u nt u k kemandirian yang lebih besar. hasil penelitian nygårdh et al (2011) mengatakan bahwa kemampuan dan kesadaran keluarga akan tanggung jawab terhadap perawatan anggota keluarga dengan penyakit kronis tergantung pada keterlibatan anggota keluarga dalam pemberdayaan. temuan tersebut menekankan perlunya perspektif keluarga dan pentingnya lingkungan keluarga yang mendukung bagi penderita tb paru. sesuai pula dengan hasil pengamatan peneliti di mana karakteristik keluarga dan pola hubungan keluarga yang ada di kota bima yang menganut sistem keluarga besar (extended family) yang memunginkan terciptanya cinta kasih, kehangatan, saling menerima, saling mengasuh, serta saling mendukung antar sesama anggota keluarga. peningkatan self effi cacy dan self care activity keluarga dalam perawatan penderita tb paru pada kelompok perlakuan tidak terlepas dari adanya pemberian pengetahuan tentang konsep penyakit, pengobatan, dan aktifi tas perawatan mandiri penderita penyakit tb paru yang diberikan selama perlakuan dengan metode peny ulu han kesehat an, bimbingan, dan konseling, serta demonstrasi cara-cara perawatan mandiri penderita tb paru di rumah. hal ini sejalan dengan lewin (1970) dalam notoatmodjo (2007) yang mengatakan bahwa perubahan pengetahuan pada dasarnya merupakan proses belajar, dan akan lebih efektif apabila stimulus yang diberikan sesuai dengan kebutuhan individu, dilakukan secara intensif dan berkelanjutan. dalam penelitian ini, pemberdayaan keluarga dan penderita tb paru dilakukan sebanyak 6 (enam) kali kunjungan r umah kepada kelompok perlakuan. pemberdayaan keluarga ber t ujuan menumbuhkan pengetahuan, pemahaman, serta kesadaran kesehatan bagi keluarga ( notoat modjo, 2007). pengetahuan dan kesadaran tentang cara-cara memelihara dan meningkatkan kesehatan adalah awal dari pemberdayaan kesehatan. kemampuan ini diperoleh melalui proses belajar. belajar itu sendiri merupakan proses yang dimulai dengan adanya alih pengetahuan dari sumber belajar kepada subjek belajar. dalam hal ini kemampuan keluarga dalam memelihara dan meningkatkan kesehatan anggotanya diperoleh melalui proses belajar dari petugas kesehatan yang memberikan informasi kesehatan kepada keluarga. pengetahuan yang sudah dimiliki keluarga tentang penyakit tb paru, cara penularan, pencegahan, perawatan, pengobatan dan kompli kasinya akan menimbul kan kemauan atau kehendak (self effi cacy) untuk melakukan tindakan kesehatan berupa perilaku hidup sehat (self care activity). m e n u r u t g r e e n (19 8 0) d a l a m notoatmodjo (2007), untuk dapat mewujudkan perilaku hidup sehat ditunjang oleh faktorfaktor antara lain: (1) faktor predisposisi, yaitu faktor-faktor yang mempermudah atau mempredisposisi terjadinya perilaku keluarga, antara lain pengetahuan dan sikap keluarga terhadap kesehatan, tradisi, dan kepercayaan keluarga terhadap hal-hal yang berkaitan dengan kesehatan, sistem nilai yang dianut keluarga dan masyarakat, tingkat pendidikan, ser ta tingkat sosial ekonomi keluarga; (2) faktor pemungkin, adalah faktor yang memungkinkan atau yang memfasilitasi perilaku atau tindakan keluarga, antara lain ketersediaan sarana dan prasarana atau fasilitas pelayanan kesehatan masyarakat. untuk dapat berperilaku sehat keluarga memerlukan sarana dan prasarana pendukung, misalnya puskesmas, puskemas pembantu, rumah sakit, dokter praktek, klinik perawatan dan lainlain; (3) faktor penguat, adalah faktor-faktor yang mendorong atau memperkuat terjadinya 232 jurnal ners vol. 8 no. 2 oktober 2013: 229–239 perilaku keluarga, antara lain faktor sikap dan perilaku tokoh masyarakat (toma), tokoh agama (toga), sikap, dan perilaku petugas kesehatan termasuk perawat, undang-undang, peraturan-peraturan baik dari pusat maupun daerah yang terkait dengan kesehatan. dalam penelitian ini, faktor predisposisi yang dapat berpengaruh terhadap pengetahuan dan tindakan keluarga dalam perawatan pender ita tb par u seper ti faktor usia, tingkat pendidikan, dan jenis pekerjaan telah dikendalikan dari awal, di mana faktorfaktor tersebut pada kelompok perlakuan dan kelompok kontrol sudah sebanding, sehingga faktor yang paling mungkin menyebabkan meningkatnya self effi cacy dan self care activity keluarga penderita tb paru pada kelompok perlakuan adalah faktor pengetahuan dan sikap keluarga terhadap kesehatan yang berubah sebagai akibat dari perlakuan (pemberdayaan keluarga) yang diberikan. faktor pemungkin untuk terbentuknya self efficacy dan self care activity keluarga pada penderita tb paru dalam penelitian ini antara lain tempat tinggal responden yang tidak terlalu jauh dari puskesmas (jarak paling jauh tempat tinggal kelompok perlakuan dari puskesmas adalah ±2 km), adanya fasilitas kesehatan lain seperti pustu dan praktek dokter swasta yang tersebar hampir di seluruh kelurahan yang ada di wilayah puskesmas paruga sangat menunjang terbentuknya self effi cacy dan self care activity keluarga dalam perawatan penderita tb paru. faktor lain yang juga berpengaruh adalah adanya kader-kader kesehatan yang tersebar di semua kelurahan yang ada menjadi faktor penguat bagi terbentuknya self effi cacy dan self care activity keluarga dalam perawatan penderita tb paru. ta b e l 2 m e n u n j u k k a n a d a n y a peningkatan yang bermakna pada kelompok perlakuan. peranan keluarga dalam membantu meningkatkan self-eff icacy dan self care activity penderita tb paru. berdasarkan hasil observasi selama penelitian, perubahan pada peranan keluarga dapat dilihat dari adanya dukungan yang terus-menerus dari keluarga kepada penderita tb dalam hal mengawasi dan mengingatkan penderita untuk menelan obat secara teratur, mengingatkan penderita untuk menutup mulut ketika batuk, mengingatkan penderita untuk tidak meludah sembarangan, membantu membersihkan kamar dan tempat tidur penderita, membuka jendela dan ventilasi setiap pagi, ser ta membant u mengantar penderita ke puskesmas untuk kontrol rutin dan mengambil obat. hasil tersebut menunjukkan adanya keterlibatan dan peran aktif keluarga dalam perawatan penderita tb paru setelah mendapatkan pemberdayaan keluarga. hal ini sesuai dengan hasil penelitian sebelumnya yang mengatakan bahwa dalam konteks perawatan intensif, keterlibatan dalam proses perawatan merupakan aspek penting dari pemberdayaan anggota keluarga (wahlin et al., 2009). hasil penelitian lainnya menekankan pentingnya saling menghormati, kemitraan yang setara, dan partisipasi aktif dalam keperawatan sebagai bentuk pemberdayaan keluarga dan penderita (nygårdh et al., 2011). meningkatnya peran serta aktif keluarga dalam perawatan penderita tb paru merupakan hasil dari meningkatnya pengetahuan keluarga tentang konsep penyakit, pengobatan, cara perawatan, serta aktifi tas perawatan mandiri di rumah yang dapat dilakukan oleh penderita dan keluarga. keluarga merupakan support system utama bagi penderita tb paru. dengan meningkatnya pengetahuan dan tindakan keluarga akan meningkatkan pula peranan keluarga dalam memberikan dukungan kepada penderita. hal ini sesuai dengan hasil penelitian kholifah et al. (2012) yang menyimpulkan bahwa penerapan model adaptif conservation dapat meningkatkan pengetahuan penderita tb paru dan keluarga; meningkatkan dukungan keluarga, kelompok, dan masyarakat pada penderita tb paru; dukungan perawat pada kepatuhan berobat penderita tb paru; serta meningkatkan kepatuhan berobat penderita tb paru. p e m b e r i a n p e r l a k u a n b e r u p a pemberdayaan keluarga dengan metode pendidikan kesehatan, bimbingan dan konseling serta demonstrasi cara-cara perawatan penderita tb paru dapat meningkatkan peranan keluarga dalam membantu meningkatkan self-effi cacy dan self care activity penderita tb paru. hal ini sesuai dengan pendapat friedman (1998), bahwa keluarga berfungsi sebagai kolektor dan 233 pemberdayaan keluarga dalam peningkatan self effi cacy dan self care activity (muhtar) desiminator (penyebar) informasi yang dapat menekan munculnya suatu stressor karena informasi yang diberikan dapat menyumbangkan aksi sugesti yang khusus pada individu. levine (1973) menyatakan bahwa interaksi individu dengan lingkunganya merupakan sebuah sistim terbuka dan memberikan kemudahan jaminan integritas di semua dimensi kehidupan. peningkatan interaksi keluarga yang dilakukan merupakan dukungan sosial dari keluarga yang dapat mengembangkan koping yang positif pada penderita tb paru. berbagai upaya yang telah dilakukan selama proses pemberdayan yang bertujuan meningkatkan peran serta keluarga dalam p e r awat a n p e nde r it a t b a nt a r a lai n , menga nju rk a n ke pa d a kelu a rga u nt u k menyediakan tempat dahak dari wadah tersendiri yang berisi larutan desinfektan, memodifi kasi lingkungan yang sehat yang menunjang perawatan penderita tb paru dari segi kebersihan, kecukupan ventilasi dan paparan sinar matahari, serta penataan perabot. pengamatan peneliti pada waktu kunjungan awal ke rumah penderita tb paru didapatkan d at a kelu a rga k u r a ng mempe rhat i k a n kebutuhan sehari-hari penderita tb paru, misalnya belum tersedianya tempat dahak, pemenuhan kebutuhan makan dan minum yang bergizi dan lingkungan rumah yang belum memadai. keluarga menyamakan kebutuhan penderita tb paru dengan kebutuhan anggota keluarga lainya. data dari hampir seluruh responden semuanya tidak mempunyai tempat pembuangan dahak tersendiri, penderita tb paru lebih banyak meludah di got atau halaman rumah. upaya lainya yang dilakukan selama pemberdayaan keluarga adalah meningkatkan interaksi keluarga dengan mengumpulkan anggota keluarga yang tinggal serumah dan memberikan infor masi tentang penyakit penderita (tb paru), menjelaskan perlunya dukungan seluruh anggota keluarga terhadap kesembuhan penderita dan bagaimana cara memberikan dukungan sesuai kapasitas yang dimiliki keluarga. dengan demikian setiap anggota keluarga akan berkontribusi memberikan dukungan meskipun hanya dengan per tanyaan sederhana, misalnya menanyakan kondisi penderita hari ini, apakah obat nya sudah diminum, kapan kontrol lagi dan sebagainya. hal ini sesuai dengan hasil penelitian kholifah et al. (2012) bahwa interaksi keluarga melalui komunikasi yang dilakukan keluarga dapat memberikan dukungan secara emosional pada penderita tb paru yaitu meliputi perhatian, adanya kepercayaan, mendengarkan, dan didengarkan. dukungan emosional dari keluarga dapat meningkatkan self effi cacy penderita tb paru, glanz et al. (2008) mengatakan bahwa atribut yang berada dalam self eff icacy meliputi kognitif dan afektif, ser ta pengendaian diri. dukungan emosional yang diberikan menyebabkan penderita memiliki mental dan emosional yang kuat untuk menjalani hidup dengan berbagai keterbatasan yang ada setelah menderita penyakit tb paru. komponen penting dalam pemberdayaan adalah advocacy (perlindungan). memberikan perlindungan dapat diartikan keluarga dapat melaksanakan tugas kesehatan keluarga salah satunya merawat anggota keluarga yang sakit (friedman, 1998), sehingga penderita mendapatkan dukungan dalam menjalani pengobatan sampai dinyatakan sembuh. bentuk dukungan yang diberikan dapat berupa dukungan emosional, misalnya rasa empati, kepedulian dan perhatian, atau berupa materi seperti menyiapkan sumber-sumber nutrisi yang memadai bagi penderita tb, menyiapkan uang bagi penderita tb untuk biaya transportasi ketika berobat ke puskesmas, atau menolong dengan mengambilkan obat ke puskesmas pada waktu yang diperlukan. hasil penelitian menunjukkan selfef f icac y pender it a t b pa r u kelompok perlakuan setelah pemberdayaan mengalami peningkatan (tabel 3), yang berar ti ada pengaruh pemberdayaan keluarga terhadap self eff icacy penderita tb par u di kota bima, ntb. self effi cacy yang dimiliki oleh penderita tb paru sebelum perlakuan antara lain masih ada penderita yang menyakini bahwa penyakitnya adalah penyakit keturunan dan tidak bisa disembu h kan, ada juga penderita yang menyakini bahwa penyakit tb terjangkit sebagai akibat dari sihir. sebagian besar penderita tb merasa malu dan takut 234 jurnal ners vol. 8 no. 2 oktober 2013: 229–239 dikucilkan oleh masyarakat karena menderita tb paru. setelah diberikan pemberdayaan keluarga, self effi cacy penderita tb mengalami perubahan antara lain dalam hal keyakinan penderita akan kesembuhan penyakitnya, perubahan keyakinan akan penyebab dan cara penularan tb par u, serta semangat penderita untuk menjalani pengobatan sampai tuntas. perubahan lainnya dari self effi cacy penderita antara lain penderita sudah tidak merasa malu lagi terhadap penyakit yang diderita, bahkan ada beberapa penderita yang berkeinginan menjadi kader kesehatan untuk mempromosikan penyakit tb setelah sembuh dari penyakitnya. hasil penelitian lainnya yang terkait langsung dengan intervensi yang sama dengan penelitian ini belum peneliti temukan, namun beberapa intervensi yang pada prinsipnya mampu meningkatkan pengetahuan, sikap dan keterampilan seperti intervensi peer group support, discharge planning pada penderita rawat inap dapat meningkatkan self effi cacy. penelitian bond et al. (2010), menunjukkan bahwa intervensi peer support, telephone peer dapat menurunkan depresi, meningkatkan aspek psikososial meliputi kualitas hidup dan self effi cacy. penelitian lainnya mengatakan bahwa intervensi pemberdayaan penderita melalui discharge planning akan menghasilkan peningkatan secara signifi kan terhadap self eff icacy, kemampuan pengelolaan stres, penyediaan duk ungan, dan kemampuan pengambilan keputusan yang tepat dalam pengelolaan penyakit (funnell et al., 2009). terbentuknya self effi cacy yang tinggi pada kelompok perlakukan tidak terlepas dari pemberdayaan yang diberikan, penggunaan metode bimbingan dan konseling selama pemberdayaan ber peran penting dalam meningkatnya self effi cacy penderita tb paru. selama kegiatan konseling memungkinkan penderita untuk mengekspresikan perasaan terkait penyakitnya, keberhasilan yang pernah dicapai maupun hambatan-hambatan yang dialami selama menjalani program pengobatan tb semuanya terungkap selama kegiatan konseling. sesuai dengan teori conservation dari levine (1989) di dalam tomey & alligood (2010) bahwa pemberian konseling dapat meningkatkan integritas individu, melalui usaha u nt u k mend apat kan penga k uan, kehormatan, martabat, harga diri, reputasi, kepercayaan dan emosional yang stabil dalam melakukan tindakan yang diajarkan sesuai dengan norma dan etika. faktor lain nya yang ber pengar u h terhadap peningkatan self efficacy dalam penelitian ini adalah keterlibatan kader kesehat a n ya ng d i rek r ut oleh pet ugas puskesmas dari beberapa penderita tb yang telah berhasil sembuh. para kader tersebut dengan bahasa yang sederhana menceritakan bagaimana pengalaman mereka selama me nja d i pe nde r it a t b, mela k sa na k a n pengobatan tb secara teratur sampai habis masa pengobatan dan bagaimana pahitnya menderita penyakit tb. keterlibatan para kader yang sebelumnya pernah menderita tb sengaja peneliti libatkan pada pertemuan ke-4 dan ke-5 dalam kegiatan pemberdayaan (kunjungan rumah). sesuai dengan pendapat bandura (1978), bahwa self effi cacy seseorang dipengar uhi oleh beberapa faktor salah satunya vicarious experience, yaitu seseorang dapat belajar dari pengalaman orang lain, dan meniru perilaku mereka untuk mendapatkan seperti apa yang diperoleh orang lain. self eff icacy akan meningkat jika mengamati keberhasilan yang telah dicapai oleh orang lain. sebaliknya self effi cacy akan menurun apabila individu mengamati seseorang yang memiliki kemampuan setara dengan dirinya mengalami kegagalan. pengaruh yang diberikan faktor ini terhadap self effi cacy adalah berdasarkan kemiripan orang yang diamati dengan diri pengamat itu sendiri. semakin orang yang diamati memiliki kemiripan dengan dirinya, maka semakin besar potensi self efficacy yang akan disumbangkan oleh faktor ini. bentuk lain dari upaya meningkatkan self efficacy adalah melalui verbal persuasion (bandu ra, 1978). persuasi verbal yang diberikan selama kegiatan pemberdayaan juga berpengaruh terhadap meningkatnyan self effi cacy penderita, berbagai arahan yang telah diberikan diikuti oleh penderita dan keluarganya. besarnya pengaruh yang dapat diberikan oleh pemberi persuasi dipengaruhi adanya rasa percaya kepada pemberi persuasi, 235 pemberdayaan keluarga dalam peningkatan self effi cacy dan self care activity (muhtar) serta kriteria kerealistisan tentang apa yang dipersuasikan. berdasarkan pengamat an peneliti selama penelitian, salah satu faktor yang mempengaruhi self effi cacy penderita tb paru adalah persepsi individu terhadap penyakit dan tingkat keparahan yang dialami. hal ini sesuai denga hasil penelitian yang dilakukan oleh walker (2007) yang menyatakan bahwa terdapat hubungan yang positif antara persepsi dan self effi cacy penderita, yaitu jika persepsi baik maka self effi cacy meningkat. menurut edberg (2010) salah satu cara untuk membuat persepsi yang baik adalah melalui pendidikan kesehatan, karena pendidikan kesehatan akan memberikan penderita pengetahuan yang benar terhadap penyakitnya, sehingga akan memberikan persepsi yang benar mengenai kemu ng k i na n t i ng kat kesulit a n d ala m pengelolaan penyakit (magnitude), luasnya permasalah yang dihadapi (generality), dan memberikan penderita pemahaman tentang kekuatan (strength) yang dimilikinya untuk menghadapi permasalah dalam pengelolaan penya k it nya ya ng pa d a a k i r nya a k a n membangun self effi cacy penderita. uraian di atas diperkuat oleh bandura (1978) ya ng me nyat a k a n b a hwa se lf effi cacy seseorang dapat diperoleh, diubah, ditingkatkan atau diturunkan melalui salah satu atau kombinasi empat faktor, yaitu performance accomplishment, vicarious experience, verbal persuasion dan emotional arousal. pemberian pemberdayaan keluarga melalui metode pendidi ka n kesehat an, bimbingan dan konseling serta demonstrasi cara-cara perawatan penderita tb par u, akan memfasilitasi empat faktor tersebut. hal ini sesuai dengan pendapat hulme (1999) yang mengatakan bahwa dalam proses family empowerment dilak u kan dengan cara memberikan dukungan informasi yang diperlukan oleh penderitauntuk membuat keput usan yang tepat dalam perawatan dirinya, membina kerja sama atau kolaborasi antara penderita dan petugas kesehatan, dan membantu penderita memecahkan masalah yang dihadapinya. proses pemberdayaan keluarga melalui metode bimbingan dan konseling akan mengajak penderita berbagi pengalaman terkait penyakitnya, pemberian informasi yang tepat dan langkah-langkah yang seharusnya dilak u kan oleh pender ita dalam upaya pengobatan dan pencegahan penularan tb paru. selain itu selama proses pemberdayaan, p e n d e r i t a d i b e r i k e s e m p a t a n u n t u k mendapatkan pengalaman dari orang lain dalam hal ini kader kesehatan yang merupakan ma nt a n pender it a t b, ser t a ber t u k a r pengalaman dengan petugas kesehatan dalam hal ini perawat (petugas tb paru di puskesmas) dan peneliti. kesempatan untuk pengungkapan perasaan dan berbagi pengalaman akan menumbuhkan keyakinan dalam diri penderita (self effi cacy) bahwa dirinya mampu untuk melakukan tindakan yang diperlukan dalam pengelolaan penyakitnya. hasil penelitian (table 4) menunjukanself care activity penderita tb paru kelompok perlakuan setelah pemberdayaan mengalami peningkatan, yang berarti ada pengar uh pemberdayaan keluarga terhadap self care activity penderita tb paru di kota bima, ntb. sebelum dilakukan pemberdayaan peneliti menemukan perilaku perawatan diri penderita tb masih kurang, antara lain kebiasaan penderita yang meludah sembarangan seperti di halaman rumah atau got, tidak adanya wadah khusus penampungan dahak yang dapat membunuh kuman (ada sebagian penderita yang menampung dahak di dalam kaleng bekas yang diisi pasir), penataan kamar tidur, kasur, bantal dan perabot yang tidak sehat, serta pencahayaan ruangan yang tidak memadai. setelah dilakukan pemberdayaan terjadi perubahan dalam self care activity penderita antara lain penderita membuang dahak dalam pot khusus yang berisi cairan anti kuman; penataan perabot dan kebersihan kamar; kasur, bantal, dan selimut penderita dijemur di bawah sinar matahari secara rutin setiap minggu. dalam hal keterampilan perawatan khusus penderita mampu mempraktikkan teknik napas dalam dan batuk efektif untuk mengeluarkan dahak. hasil penelitian tersebut menunjukkan bahwa pemberdayaan keluarga yang diberikan melalui pendidikan kesehatan, bimbingan dan konseling serta demonstrasi cara-cara 236 jurnal ners vol. 8 no. 2 oktober 2013: 229–239 perawatan mandiri penderita tb paru dapat meningkatkan self care activity penderita tb paru. hasil ini sesuai dengan penelitian yang mengatakan bahwa penerapan model information–motivation–behavioral skills (i m b) pad a pender it a d iabetes, d apat meningkatkan komunikasi yang efektif antara petugas-penderita, meningkatkan dukungan sosial, dan meningkatkan self-effi cacy dan keterampilan dalam melakukan perawatan diri penderita diabetes, dan perilaku ini secara langsung terkait dengan kontrol lipid (gao et al., 2013). hasil penelitian lainnya mengatakan ba hwa pen i ng kat a n a k ses ke fasilit as perawatan, pendidikan penderita, keterlibatan keluarga dalam perawatan dan penguatan keterlibatan keluarga dan masyarakat dalam penanggulangan tb berdampak positif pada keterlambatan pengobatan dan perilak u pencarian perawatan (healthcare-seeking behavior) penderita tb (ukwaja et al., 2013). menurut orem (1971) dalam tomey & alligood, (2010), self care adalah penampilan dari aktivitas individu dalam melakukan perawatan diri sendiri untuk mempertahankan kehidupan, kesehatan dan kesejahteraan. self care yang dilakukan secara efektif dan menyeluruh dapat membantu menjaga integritas struktur dan fungsi tubuh serta berkontribusi dalam perkembangan individu. seorang individu dalam melakukan aktivitas perawatan diri (self care activit y) har us mempunyai kemampuan dalam perawatan diri yang disebut sebagai self care agency. individu yang terlibat aktif dalam self care memiliki tuntutan kemampuan bertindak, yaitu kekuatan untuk bertindak secara mandiri untuk mengendalikan faktor yang memengaruhi fungsi diri dan perkembangan mereka (orem, 1991). tindakan ini memerlukan pengetahuan, pengambilan keputusan dan tindakan untuk berubah. tujuan dari pemberdayaan keluarga adalah kemandirian keluarga dan penderita dalam memenuhi kebutuhan perawatan diri (self care), baik self care secara fi sik, self care psikologis, self care sosial dan self care spiritual. kemandirian tersebut dapat dicapai kalau penderita memiliki kemampuan dalam perawatan diri (self care agency). pemberdayaan keluarga dengan penderita tb paru seperti yang ditunjukkan dalam hasil penelitian pada kelompok perlakuan memberikan dampak yang sangat besar dalam meningkatkan pengetahuan penderita tentang konsep penyakit tb paru, pengobatan penyakit tb paru serta cara perawatan mandiri penderita penyakit tb paru, yang semuanya berujung pada meningkatnya kemandirian penderita tb paru. peningkatan kemampuan perawatan diri (self care activity) pada kelompok perlakuan tidak terlepas dari proses belajar penderita dan keluarganya selama dilakukan pemberdayaan. kombinasi metode pelaksanaan pemberdayaan antara pendidikan kesehatan, bimbingan, dan konseling, serta demonstrasi berperan penting dalam meningkatnya kemampuan perawatan diri penderita tb paru. selama kegiatan pemberdayaan responden selalu berperan aktif terutama ketika dilakukan demonstrasi, dengan sangat antusias penderita dan keluarga selalu memperhatikan setiap tindakan yang didemonstrasikan. hal ini sesuai dengan hasil penelitian yang dilakukan oleh suhardiningsih (2012), yang mengatakan bahwa u nt u k bertindak dalam perawatan diri dibutuhkan keterampilan, keyakinan akan keberhasilan diri (self efficacy), semangat dan motivasi yang tinggi untuk selalu berusaha mencapai tujuan yang diinginkan. peran perawat adalah memberikan keterampilan kepada penderita tb paru, menguatkan faktor psikologis dengan cara meningkatkan kemampuan kognitif baik dengan membangkitkan motivasi penderita maupun menstimulasi self effi cacy penderita bahwa mereka memiliki kemampuan dan sumber daya, karena pada dasarnya self care merupakan perilaku yang dapat dipelajari, dan setiap individu memiliki potensi untuk belajar dan berkembang. penyakit tb paru adalah stressor bagi individu, maka individu yang tadinya normal atau sehat kemudian diganggu oleh penyakit yang dideritanya, maka individu akan ter motivasi unt uk mengembalikan keseimbangan kepada kondisi normal melalui upaya perawatan mandiri dan teratur selama menjalani program pengobatan tb paru. hasil uji menunjukkan ada hubungan yang bermakna antara self-effi cacy dan self 237 pemberdayaan keluarga dalam peningkatan self effi cacy dan self care activity (muhtar) care acitivity dengan hubungan yang kuat dan positif pada penderita tb paru di kota bima, ntb. hasil penelitian ini sesuai dengan penelitian sebelumnya yang dilakukan oleh rondhianto (2011), yang mengatakan bahwa terdapat hubungan yang positif antara self effi cacy dan self care behavior pada penderita dm tipe 2, di mana peningkatan self effi cacy akan berpengaruh pada peningkatan self care behavior. hasil penelitian lainya mengatakan bahwa ada hubungan antara keyakinan (selfeffi cacy) perawatan kaki dengan perilaku kaki perawatan yang sebenarnyapada penderita neuropati perifer (perrin et al., 2009). self efficacy secara sederhana dapat diartikan sebagai keyakinan akan keberhasilan diri. secara harafiah menurut glanz et al. (2008), self memiliki makna diri atau identitas individu, sedangkan effi cacy adalah kekuatan untuk menghasilkan efek. sinonim dari effi cacy meliputi efektifi tas, kesadaran, dan produktifi tas. kombinasi dari makna tersebut menunjukan kesadaran akan kemampuan seseorang menjadi efektif dan mengendalikan tindakan. atribut yang berada di dalam self efficacy meliputi kognitif dan afektif, serta pengendalian diri. keyakinan tentang kemampuan seseorang untuk melakukan perilaku yang diperlukan untuk menggunakan kendali (self eff icacy) memainkan peran sentral dalam terbentuknya berbagai perilaku kesehatan dalam hal ini aktifi tas perawatan mandiri (self care activit y) pengelolaan penyakit tb paru. bandura (1978) menyatakan bahwa peran self effi cacy dalam fungsi tubuh manusia sangatlah besar yaitu mempertahankan dan meningkatkan tingkat motivasi seseorang, keadaan afektif dan tindakan berdasarkan tujuan yang ingin dicapai. dengan alasan ini, bagaimana seseorang berperilaku dapat diprediksi melalui keyakinan yang dipegang, pengetahuan serta keterampilan yang dimiliki oleh individu. hal ini berhubungan dengan keyainan diri, kepercayaan diri bahwa mereka bisa mencapai tujuan yang mereka inginkan. me nu r ut ba ndu r a (1978), su at u perubahan tingkah laku hanya akan terjadi apabila adanya perubahan self effi cacy pada individu yang bersangkutan. self efficacy akan mempengaruhi empat proses dalam diri manusia, yaitu proses kognitif, motivasional, afektif dan seleksi. dari segi proses kognitif, self effi cacy akan mempengaruhi bagaimana pola pikir yang dapat mendorong atau menghambat perilaku seseorang. sebagian besar individu akan berpikir dahulu sebelum melakukan suatu tindakan. seseorang dengan self effi cacy yang tinggi akan cender ung ber perilaku sesuai dengan yang diharapkan dan memiliki komitmen untuk mempertahankan perilakiu tersebut. self effi cacy yang tinggi mendorong pembentukan pola pikir untuk mencapai kesuksesan, dan pemikiran akan kesuksesan akan memunculkan kesuksesan yang nyata, sehingga akan semakin memperkuat self effi cacy seseorang. proses motivasional akan memotivasi diri sendiri dalam melakukan perilaku yang didasari oleh aktifi tas kognitif. berdasarkan teori motivasi, seseorang dapat termotivasi oleh harapan yang diinginkannya. d i s a m pi n g it u , ke m a m p u a n u n t u k memengaruhi diri sendiri dengan mengevaluasi penampilan pribadinya merupakan sumber utama motivasi dan pengaturan diri. self effi cacy merupakan salah satu hal terpenting dalam mempengar uhi diri sendiri untuk membentuk sebuah motivasi. self efficacy juga mempengaruhi tingkatan pencapaian tujuan, kekuatan untuk berkomitmen, seberapa besar usaha yang diperlukan, dan bagaimana usaha tersebut ditingkatkan ketika motivasi menurun. dari segi proses afektif, self effi cacy juga berperan penting dalam mengatur kondisi afektif. self effi cacy mengatur emosi seseorang melalui beberapa cara, yaitu seseorang yang percaya bahwa mereka mampu mengelola ancaman tidak akan mudah tertekan oleh diri mereka sendiri, dan sebaliknya seseorang dengan self effi cacy yang rendah cenderung memperbesar risiko yang dapat mendorong munculnya depresi. berdasarkan ketiga proses pengembangan self efficacy berupa proses kognitif, motivasional dan afektif memungkinkan seseorang untuk membentuk sebuah lingkungan yang membantu dan bagaimana mempertahankannya. dengan memilih lingk u ngan yang sesuai akan membantu pembentukan diri dan pencapaian tujuan. 238 jurnal ners vol. 8 no. 2 oktober 2013: 229–239 bandu ra (1989) juga menyat akan bahwa perilaku manusia dipengaruhi oleh pikiran, dan tujuan individu dipengaruhi oleh kemampuan pencapaian diri. individu dengan self effi cacy yang tinggi cenderung untuk menentukan tujuan yang lebih tinggi, komitmen terhadap tantangan yang lebih sulit dan berusaha keras mencapai tujuan yang diinginkan. self effi cacy tidak berhubungan dengan keterampilan khusus yang dimiliki seseorang, tetapi lebih kepada penilaian dari apa yang bisa individu lakukan dengan keterampilan khusus tersebut. konsep self effi cacy memiliki implikasi terhadap praktik keperawatan. kunci untuk meningkatkan self effi cacy adalah membantu penderita dalam hal ini penderita tb par u untuk belajar memodif ikasi perilaku yang maladaptif melalui pengubahan penguatan pengetahuan dan keterampilan untuk berperilaku sehat (ziegler, 2005). perilaku pada umumnya dipelajari melalui pembelajaran observasional dan diajarkan melalui pemodelan, sebagai contoh penderita tb paru yang diajarkan t e nt a ng t ek n i k bat u k efek t i f melalu i demonstrasi untuk menunjukkan tindakan nyata dari keterampilan tersebut. modifi kasi perilaku melibatkan perubahan kepercayaan penderita terhadap kekuatan dari self effi cacy, dan intervensi dilakukan sebagai cara untuk memfasilitasi perubahan perilaku (bandura, 1978). simpulan dan saran simpulan p e m b e r d a y a a n k e l u a r g a d a p a t meningkatkan self eff icacy dan self care activit y keluarga dan penderita tb par u dalam perawatan penderita tb paru selama di rumah. semakin tinggi self effi cacy seseorang berdampak pada peningkatan self care activity orang tersebut. saran me r e ko m e n d a si k a n p el a k s a n a a n pemberd aya a n kelu a rga d ala m bid a ng kesehatan dalam rangka pelaksanaan program pemberantasan penyakit menular, khususnya tb paru melalui kegiatan penyuluhan rutin denga n mengg u na k a n berbagai med ia pembelajaran seperti leafl et, booklet, poster, dan spanduk. penelitian lanjutan juga perlu dilak ukan dalam upaya mengeksplorasi dan mengembangkan berbagai intervensi ke p e r awat a n ya ng b e r m a n fa at d a la m meningkatkan self effi cacy, kemandirian dalam self care, kepatuhan berobat, serta kualitas hidup penderita tb paru. kepustakaan andarmoyo, s., 2012. keperawatan keluarga; konsep teori, proses dan praktik kepera watan. yog yakar t a: g raha ilmu. bandura, a., 1978. self-effi cacy : toward a unifi ying theory of behavioral change. psychological review, 84, pp. 191–215. bond, g.e., burr, r.l., wolf, f.m. & feldt, k., 2010. the effects of a web-based intervention on psychosocial wellbeing among adults aged 60 and older with diabetes : a randomized trial. the diabetes educator, 36, pp. 446–456. de pkes r i, 20 07. ped oma n na sion al penanggulangan tuberkulosis, edisi 2 cetakan i. jakarta: depkes ri. depkes ri, 2008. hasil riset kesehatan dasar (riskesdas) nusa tenggara barat 2007. jakarta: badan penelitian dan pengembangan kesehatan. edberg, m., 2010. buku ajar kesehatan masyarakat : teori sosial dan perilaku. jakarta: penerbit buku kedokteran egc. egwaga, s. et al., 2009. patient-centred tuberculosis treatment delivery under programmatic conditions in tanzania: a cohort study. bmc medicine, 7, p. 80. friedman, m.m., 1998. keperawatan keluarga teori dan praktik; alih bahasa, ina debora r.l., yoakim asy. 3rd ed. jakarta: penerbit buku kedokteran egc. funnell, m.m. et al., 2009. national standards fo r d i a b e t e s s e l fm a n a g e m e n t education. diabetes care, 32. gao, j., wang, j., zhu, y. & yu, j., 2013. va l i d a t io n of a n i n fo r m a t io n – motivation– behavioral skills model of self-care among chinese adults with 239 pemberdayaan keluarga dalam peningkatan self effi cacy dan self care activity (muhtar) type 2 diabetes. bmc public health, 13, p. 100. glanz, k., rimer, b.k. & viswanath, k., 2008. health behavior and health education: theory, research, and practice. 4th ed. san francisco: jossey-bass a wiley imprint. hulme, p.a., 1999. family empowerment : a nursing intervention with suggested outcomes for families of children with a chronic health condition. journal of family nursing, 5, pp. 33–50. jakubowiak, w.m. et al., 2008. impact of socio-psychological factors on treatment adherence of tb patients in russia. tuberculosis, 88, pp. 495–502. kemenkes ri, 2012. profi l data kesehatan in d o n e si a ta h u n 2011. ja k a r t a: kementer ian kesehat an republi k indonesia. kholifah, s.n., minarti & yumni, h., 2012. model adaptif conservation (acm) d a la m me n i ng k at k a n d u k u nga n keluarga dan kepatuhan berobat pada penderita tb paru di wilayah kota surabaya. jurnal ners, 7, pp. 59–66. levine, m., 1973. introduction to clinical nursing. philadelphia, pa: f.a. davis company. lewis, c.p. & newell, j.n., 2009. improving t uberculosis ca re i n low i ncome countries – a qualitative st udy of patients’ understanding of patient support” in nepal. bmc public health, 9, p. 190. moattari, m., ebrahimi, m., sharifi, n. & rou zbeh, j., 2012. the effect of empowerment on the self-eff icacy, qu alit y of life a nd cli n ical a nd laboratory indicators of patients treated with hemodialysis: a randomized controlled trial. health and quality of life outcomes, 10: 115, pp. 1–10. notoatmodjo, s., 2007. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta. nygårdh, a., wikby, k., malm, d. & ahlstrom, g., 2011. empowerment in outpatient care for patients with chronic kidney disease from the family member’s perspective. bmc nursing, 10, p. 21. perrin, b.m., swerissen, h. & payne, c., 2009. the association between foot-care self efficacy beliefs and actual foot-care behaviour in people with peripheral neuropathy: a cross-sectional study. journal of foot and ankle research, 2. rondhianto, 2011. tesis : pengaruh diabetes self management education dalam discharge planning terhadap self ef f icacy dan self care behavior penderita diabetes mellitus tipe 2. surabaya. smeltzer, s.c. & bare, b.g., 2001. buku ajar keperawatan medikal-bedah brunner & suddarth: alih bahasa agung waluyo. jakarta: penerbit buku kedokteran egc. suhardiningsih, a.v.s., 2012. ringkasan disertasi: peningkatan kemampuan perawatan diri pada penderita stroke iskemik pasca mendapatkan asuhan keperawatan self-care regulation model. surabaya. tomey, a.m. & alligood, m.r., 2010. nursing theorists and their work, seventh edition. mosby elsevier. tribble, d.s.c. et al., 2008. empowerment interventions, knowledge translation and exchange: perspectives of home care professionals, clients and caregivers. bmc health services research, 8, p. 177. ukwaja, k.n. et al., 2013. healthcare-seeking behavior, treatment delays and its determinants among pulmonary tb patients in rural nigeria: a crosssectional study. bmc health services research, 13, p. 25. wahlin, i., ek, a.c. & idvall, e., 2009. empowerment from the perspective of next of kin in intensive care. j clin nurs, 18, pp. 2580–2587. walker, 2007. imporetance of illness belief and self effi cacy for parient with coronary heart disease. joernal of advanced nursing, 48, pp. 216–25. who, 2006. the stop tb strategy : building on and enhancing dots to meet the tbrelated millennium development goals. genewa: world health organization. who, 2011. global tuberculosis control: who report 2011. geneva, switzerland: who press. who, 2012. global tuberculosis report 2012. geneva, switzerland: who press. ziegler, s.m., 2005. theory directed nursing practice. 2nd ed. new york: springer. 110 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, oktober 2022, p. 110-114 http://dx.doi.org/10.20473/jn.v17i2.34982 original article open access effect of caring behaviour approach to improve nurses’ caring character in medical-surgical wards abu bakar1,* , siti nur qomariah2 , and iswati iswati2 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 nursing program, stikes adi husada, surabaya, indonesia *correspondence: abu bakar. address: faculty of nursing, universitas airlangga, surabaya, indonesia. email: abu.bakar@fkp.unair.ac.id responsible editor: yulis setiya dewi received: 12 april 2022 ○ revised: 22 agustus 2022 ○ accepted: 29 agustus 2022 abstract introduction: nurses are the leading line of professional healthcare. many studies of caring include factors that are influential or related, but there has been no intervention to improve the caring character of nurses. the purpose was to prove the effect of the caring behaviour approach on the improvement of nurses’ caring character. methods: this study used a quasi-experimental design. the sample size of 100 nurses working in medical-surgical wards of four hospitals in gresik city was separated into 50 nurses in intervention group and 50 nurses control group by cluster sampling. the caring behaviour approach was given to nurses in the intervention group and nurses in the control group performed their usual care as regulation in nursing care of each hospital. caring behaviour approach was modification of education and mentoring about islamic caring and caring behaviour nurses to patients and family. data collection of nurses’ caring character variable used caring behaviour inventory, consisting of: deference to others, assurance of human presence, positive connectedness, professional knowledge-skills, and attentiveness to others’ experience. data analysis used paired t-test and independent t-test at significant level α ≤ 0.05. results: nurses between intervention group and control group had similar demographical data in gender and nursing education. caring behaviour approach had significant influence to improve the nurses’ caring character. there were significant differences of nurses’ caring character between the two groups. conclusions: nurses’ caring character should be supervised regularly to assess the performance of nurses, to improve also maintain good caring behaviour. keywords: approach; behaviour; caring; character; medical surgical nursing introduction the world health organization on global patient safety action plan 2021-2030 stated that the purpose of the action plan is to provide strategic direction for all stakeholder for eliminating avoidable harm in healthcare and improving patient safety in different practice domains through policy actions on safety and quality of health services, as well as for implementation of recommendations at the point of care (who, 2021). now, community users of healthcare services are more critical of the problems that occur. hospital accreditation 2012 version of kars (hospital accreditation committee) puts patients and families as a service centre with the motto "patient-centred care". assessment is of the accreditation of the hospital where the most important is nursing service. the caring theory was introduced long ago by jean watson in 1985 (watson, 2008). people are more aware of their rights, obligations and demand the best professional nursing services (qomariah & rahmawati, 2018). the complicated health problems in indonesia have an impact on the demands and needs of people/community on health services https://creativecommons.org/licenses/by/4.0/ http://orcid.org/0000-0002-3692-4841 http://orcid.org/0000-0001-8218-3952 https://orcid.org/0000-0001-8602-8538 bakar, qomariah, and rahmawati (2022) jurnal ners http://e-journal.unair.ac.id/jners 111 including nursing services. based on previous research conducted from four hospitals in gresik city, caring is something that is missing in nurses. patients and families often complain that nurses are less caring, and pay less attention to fulfilling the needs of patients and families. the data survey showed that nurses often work according to daily routine; nurses have less concern for the needs of patients/ families and the environment (qomariah & rahmawati, 2018). the caring theory, which is the body of nursing knowledge, is only a theory and has not been applied properly in the order of nursing (kilic & oztunq, 2015). the number of nurses that work in a hospital is about 60% of the total staff throughout the hospital, which means the nurses must contribute to improving the quality of care (qomariah & rahmawati, 2018). caring behaviour will allow for harmonious interpersonal relationships between nurse-clients who assist in meeting client needs, which ultimately provides a sense of comfort to the client (bakar, 2018). the caring theory was introduced in 1985 by jean watson, who mentioned carative factors as the core guide to nursing (tomey & alligood, 2014). the ten (10) elements of the carative factors are: humanisticaltruistic, honesty and hope value systems, sensitivity to one's personal and others’ needs, sense of help, mutual trust between peers, expressing positive and negative feelings, creative, transpersonal teaching and learning process, a supportive, protective and corrective physical-social-spiritual-mental environment, help in meeting human needs, and spiritual and existential powers (mariyanti et al., 2015) research on caring has found among others: 1) caring behaviour of nurse got a high score on every inpatient room and highest value in the second classroom (ramadhan et al., 2019). there was a difference of perspective and caring scale by nurses and patients (thomas et al., 2019). by presenting disability creation process (dcp) pertaining to a caring approach in rehabilitation, a strongly linked perspective was revealed, which contributes to patient safety (amalina, 2020). there was a significant relationship between caring nurses’ with patient satisfaction on nursing services and behaviour. caring of nurses is also affected by medical diagnosis and surgical procedures (rafii et al., 2008). caring behaviour approach is a modification between islamic caring (bakar, 2017) and caring behaviour nurses (rafii et al., 2008). nurses are the frontline of professional healthcare. many studies of caring include factors that are influential or related, but there are few study which investigated the intervention to improve the caring character of nurses. this research aim was to improve caring character of nurses using caring behaviour approach. materials and methods study design quasi-experimental with two groups pre-test and post-test design was conducted in four (4) hospitals in gresik city, east java, indonesia in july-august 2017. participant sampling technique used non-probability type of cluster sampling of each hospital and the inclusion criteria were: nurses who work in medical surgical wards and implement caring to the patients. the sample size of this research was 100 nurses (50 intervention group and 50 control group). participant nurses recruited by head of nursing manager of each hospital were separated into control/ intervention groups. to minimise selection bias in one hospital, researchers and head of nursing manager applied the same criteria to every group from gender, age, education of nurses, and length of work as nurses. variables dependent variable was nurses’ caring character with subvariables deference to others, assurance of human presence, positive connectedness, professional knowledge-skills, and attentiveness to others’ experience (rafii et al., 2008). instruments nurses’ caring character was measured by the head of nursing manager to minimise bias. instruments to measure nurses’ caring character used caring behaviour inventory questionnaire (rafii et al., 2008). caring behaviour inventory (cbi) questionnaire consisting of 42 items question with five subscales: respectful deference to others (12 items), assurance of human presence (12 items), positive connectedness (9 items), professional knowledge and skills (5 items), and attentiveness to others’ experience (4 items). the assessment uses a four points likert scale to elicit responses (1=never; 2=occasionally; 3=usually; 4=always). nurses’ caring character is described as the total points from every item question, the score ranged from 42 to 168. cronbach's alpha reliability test results = 0.904. this shows a reliable caring behaviour questionnaire (cbi). the result of validity test using pearson correlation obtained the significance of all items of questions <0.05 which means that the caring behaviour inventory questionnaire is valid. bakar, qomariah, and rahmawati (2022) 112 p-issn: 1858-3598  e-issn: 2502-5791 intervention given to the nurses in the intervention group was caring behaviour approach. caring behaviour approach was a modification between islamic caring (bakar, 2017) and caring behaviour nurses (rafii et al., 2008). nurses in the control group performed their usual care as nursing competencies standard or regulation in nursing care in each hospital. data collection data collection began with informed consent to all nurses and pre-test using caring behaviour inventory questionnaire. nurses in the intervention group were given a caring behaviour approach, a modified method of education about islamic caring and caring behaviour in nurses, and also mentoring performing of caring behaviour to patients and family. it was implemented over four weeks. focus group discussions were held to educate about islamic caring and caring behaviour for two hours. the discussions presented caring behaviour approach consisting of background of the problem, the history of caring theory, the factors that influence implementation of caring behaviour from the previous research results compared with the theory, and the spiritual caring (bakar, 2017). then, nurses in the intervention group were given training and mentoring to apply the caring behaviour approach to the patients and family for two weeks, accompanied by a nurse supervisor and researchers. they were given the module of caring behaviour approach consisting of all five caring character sub-items: respect for individual differences, nurse attendance, positive relationships, knowledge and skills, and other caring behaviours. nurses met researchers and expert senior professional nurses as head of nursing manager at each hospital to evaluate progress and report about their caring character every three days for 30-60 minutes. after the intervention, all of respondents had post-test using caring behaviour inventory questionnaire three days later. data analysis pre-test and post-test with ratio and the data homogeneity and normal distribution of the two groups were analysed by paired t-test statistic with significance level α ≤ 0.05. meanwhile, the effectiveness of caring behaviour approach was explained by comparing the nurses’ caring character between the control group and intervention group then analysed used independent ttest statistics with significance level α ≤ 0.05. ethical consideration ethical permission number 071/336/437.76.21 by the year 2017 was obtained from the ethical review board committee of government hospital in gresik city, indonesia. at the beginning of this study, participants fulfilled informed consent and demographic data. the researchers kept data of each participant secret by using a code. results participants between intervention group and control group had a similar characteristic in gender and nursing education, which is most of the nurses were female and most had the academy of nursing education. the average age intervention group and control group was adult and productive age. characteristics of nurses in the control group and intervention group showed similar average length of work more than 10 years (table 1). table 2 shows the effect of caring behaviour training on increasing nurse caring characters. before the caring behaviour training showed the lowest caring behaviour value = 120, the value of caring behaviour that often appeared = 131, and the maximum value of caring behaviour = 165. the average value of caring behaviour was 141.16 with a standard deviation of 14.11. after the caring behaviour training, it showed the lowest caring behaviour value = 125, the value of caring behaviour that often appears and the maximum value shows the same result of 168. the average value of caring behaviour is 156.60 with a standard deviation of 15.97. the results of the paired t-test statistical test obtainedρvalue= 0.000, which means that there was a significant influence on the education and training of the caring table 1 characteristics of nurses in gresik city hospital (n =100) characteristics intervention group (1) n (%) intervention group (2) n (%) 1. gender a. male b. female 7 (14) 43 (86) 15 (30) 35 (70) 2. nursing education a. bachelor b. academy 21 (42) 29 (58) 16 (38) 34 (62) 3. length of work a. 5-10 years b. 11-15 years c. 16-20 years d. ≥ 21 years 34 (68) 10 (20) 4 (8) 2 (4) 10 (20) 8 (16) 17 (34) 15 (30) 4. age (m ± sd) 31.29 ± 6.3 41.57 ± 3.9 table 2 influence of caring behaviour approach to caring character intervention group (n=100) nurse’s caring character pre-test post-test m ± sd 141.16 ± 14.11 156.60 ± 15.97 mo (q1; q3) 131 (130.25; 156.50) 168 (147.25; 168) min-max 120-165 125-168 ρ-value 0.000 bakar, qomariah, and rahmawati (2022) jurnal ners http://e-journal.unair.ac.id/jners 113 behaviour in nurses on increasing nurses' caring behaviour in gresik city regional hospital. the control group that did not carry out caring behaviour training obtained a mean value = 10.76, the value that often appeared = 114, the minimum value = 84, and the maximum value of nurse caring behaviour = 114. the results of the independent t-test obtained ρ = 0.000 which means that there is a significant difference in the character of caring nurses between the control group and the treatment group. the group given the caring behaviour training showed higher scores compared to the group that did not do the intervention (table 3). discussions this study showed that most of the nurses had sufficient caring character and a few showed good caring character before intervention. caring nurse behaviour is sufficient because nurses don’t have adequate ability and skills about caring nurses. the nurse does the daily routine, is an extension of the doctor's instruction, and is not yet caring. in addition, researchers argue that most nurses are educated in academic nursing, who only rely on skills without understanding and applying existing nursing science. this finding is different with previous study in that students in the first year are already able to perform expressive caring and show highest caring behaviour level in the second and third years (rafii et al., 2008). a similar finding showed that caring behaviour was lower among nurses working in jimma university specialised hospital; factors associated lower caring behaviour were job satisfaction, working environment and improving conducive management (oluma & abadiga, 2020). various nursing theories and philosophy exist as a foundation for the formation of the body of knowledge for nursing. nursing as a complement to the healthcare team as well as the healthcare team itself requires the contribution of nursing (kilic & oztunq, 2015). there were 12 nurses who showed good caring behaviour before intervention. it can be explained by the researchers that the research result of the previous stage of the caring behaviour of the nurse was influenced by factors such as intrinsic motivation, extrinsic motivation, personality, age, length of work, and income. while the factors of ability, skill, gender, level of education, headroom leadership style, room material resources, and model of professional nursing care do not directly affect the caring behaviour of nurses (qomariah & rahmawati, 2018). the factor of how someone behaves / what is done consists of the following variables: deference to others, assurance of human presence, positive connectedness, professional knowledge-skills, and attentiveness to others’ experience (rafii et al., 2008). there are several caring characters that were often not applied by nurses: providing guidance, teaching, health education to patients. according to the 2012 kars hospital accreditation, the patient has the right to be given information and health services. now, patients and their family tend to be more critical, want to know about the disease and their treatment so they will be happy and satisfied if they are given an explanation from nurses (thomas et al., 2019). after the intervention caring behaviour approach, it showed significant improvement in caring character, most nurses showed good caring behaviour (66%, 33 people in the intervention group) and a small number of sufficient caring nurses. however, there were some nurses who showed the value of caring character was still not sufficient as many as 10 nurses. some caring characteristics that didn’t apply were spending time with clients, and helping clients meet their basic needs (permana & hilmi, 2021). some nurses answered the caring character questionnaire assuming that if nurses spend time with client then they will never rest during work hours. each hospital has a regulation of working hours and hours of rest, respectively, so the nurses should spend their work time to work, helping patients professionally. in addition, there is a caring behaviour that shows a low value of monitoring patient condition. monitoring, in this case, re-evaluates the patient's condition at the end of the shift after the patient has been performed nursing actions, whether independent or interdependent. in accordance with the concept there were at least, inpatient wards which performed three times observation vital signs: tension, pulse, temperature, and respiration. patients with certain conditions require more frequent observation. some patients and families state that monitoring is only done once a day. it is especially experienced in hospitalised patients with class iii wards. this is consistent with the results of previous studies showing the class of care related to the caring behaviour of nurses (faramawy & kader, 2022). other studies mention the demographics of the wards class table 3 differences of caring character between intervention group and control group (n=100) nurse’s caring character control group intervention group m ± sd 106.76 ± 8.21 156.60 ± 15.97 mo (q1; q3) 114 (100.75; 113.25) 168 (147.25; 168) min-max 84-114 125-168 ρ-value 0.000 bakar, qomariah, and rahmawati (2022) 114 p-issn: 1858-3598  e-issn: 2502-5791 does not affect the caring behaviour of the nurse. the caring behaviour of nurses shows good results in all patients (abu sharour, 2021). caring nurse behaviour should not discriminate tribe, religion, race, and class of wards. each patient should get the same nursing service right for all, the only thing that distinguishes is the facility gained according to the ward’s class. independent t-test statistical results obtained pvalue= 0.000. this shows the caring character of the nurses among the group conducted by caring behaviour approach is very different/ higher than the control group. therefore, the results of this study proved to be effective, and can be applied in the hospital to improve the nurse’s caring character. caring is the basic body knowledge of nurses. nurses can improve knowledge of caring by seeking information either through formal or informal education and apply caring behaviour as a whole and continuously in every activity of daily health services. limitations of this research were: 1) the intervention of caring behaviour approach based on nurse religion were only muslims, so that there is need of a modified caring behaviour approach to apply in all religions; 2) it did not discuss the subvariables of nurses' caring character; 3) the control group only took post data and did not evaluate nurses' caring character in the control group. conclusions caring behaviour approach is not only about caring theory, it has a significant effect on the caring character of nurses. caring character of nurses in each hospital can be improved by implementing training and accompaniment of caring behaviour approach considering factors that influence the formation of caring character in order to get maximum results. limitation of the research was not involving the factor of nurses’ character. the results of this research can be considered for implementation and for more in-depth research references abu sharour, l. (2021). nurses’ self-efficacy, confidence and interaction with patients with covid-19: a cross-sectional study. disaster medicine and public health preparedness. https://doi.org/10.1017/dmp.2021.1. amalina, s. f. (2020). patient experiences of nurse caring behaviors based on swanson’s theory in indonesian hospital. enfermeria clinica, 30. https://doi.org/10.1016/j.enfcli.2019.07.113. bakar, a. (2017). nurses ’ spirituality improves caring behavior. international journal of evaluation and research in education (ijere, 6(1), 23–30. https://doi.org/10.11591/ijere.v6i1.6343. bakar, a. (2018). the development of islamic caring model to improve psycho-spiritual comfort of coronary disease patients. indian journal of public health research and development, 9(10). https://doi.org/10.5958/0976-5506.2018.01362.1. faramawy, m. a. e. a., & kader, a. i. a. e. (2022). covid-19 anxiety and organizational commitment among front-line nurses: perceived role of nurse managers’ caring behavior. nursing practice today, 9(1). https://doi.org/10.18502/npt.v9i1.7328. kilic, m., & oztunq, g. (2015). comparison of nursing care perceptions between patients who had surgical operation and nurses who provided care to those patients. international journal of caring sciences, 8(3), 625–632. mariyanti, h., nursalam, n., & kurniawati, n. d. (2015). model of caring behavior improvement to achieve the competence in critical care nursing. jurnal ners, 10(1). https://doi.org/10.20473/jn.v10i12015.158-164. oluma, a., & abadiga, m. (2020). caring behavior and associated factors among nurses working in jimma university specialized hospital, oromia, southwest ethiopia, 2019. bmc nursing, 19(1). https://doi.org/10.1186/s12912-020-0407-2 permana, b., & hilmi, n. (2021). caring behavior of nurse managers: a literature review. kne life sciences. https://doi.org/10.18502/kls.v6i1.8743. qomariah, s. n., & rahmawati, r. (2018). factors influence character of caring nurses’ at hospitals in gresik. in unej e-proceeding (pp. 67–75). universitas jember. rafii, f., hajinezhad, m. e., & haghani, h. (2008). nurse caring in iran and its relationship with patient satisfaction. australian journal of advanced nursing, 26(2), 75–84. ramadhan, g., mahfud, m., & zulpahiyana, z. (2019). the relationship of nurse’s workload and caring in internal disease ward and surgery ward in regional public hospital. jurnal ners dan kebidanan indonesia, 6(1). https://doi.org/10.21927/jnki.2018.6(1).65-71. thomas, d., newcomb, p., & fusco, p. (2019). perception of caring among patients and nurses. journal of patient experience, 6(3). https://doi.org/10.1177/2374373518795713. tomey, a. m., & alligood, m. r. (2014). nursing theorists and their work (a. m. tomey & m. r. alligood (eds.); 8th edn). elsevier. watson, j. (2008). nursing the philosophy and science of caring (revised). university press of colorado. who. (2021). global patient safety action plan 2021–2030:towards eliminating avoidable harm e health care, world health organization. how to cite this article: bakar, a., qomariyah, s. n., and iswati, i. (2022) ‘effect of caring behaviour approach to improve nurses’ caring character in medical-surgical wards’, jurnal ners, 17(2), pp. 110-114. doi: http://dx.doi.org/10.20473/jn.v17i2. 34982 p-issn: 1858-3598  e-issn: 2502-5791 153 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 153-160 http://dx.doi.org/10.20473/jn.v17i2.38147 original article open access effectiveness of symptom management training on caregiving preparedness and burden of family caregivers in-home palliative care: a quasiexperimental study erna rochmawati 1 * and akbar u saun 1 1 faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, yogyakarta, indonesia *correspondence: erna rochmawati. faculty of medicine and health sciences, universitas muhammadiyah yogyakarta, yogyakarta, indonesia. email: erna.rochmawati@umy.ac.id responsible editor: praba diyan rachmawati received: 28 august 2022 ○ revised: 17 october 2022 ○ accepted: 21 october 2022 abstract introduction: family caregiving preparedness remains a problem, particularly for those who live in rural areas. such conditions can cause a high burden for the family caregivers. the purpose of this study was to determine the effectiveness of providing home-based palliative care training for family caregivers (hbpc-fc) on caregiving preparedness and burden. methods: this was a quasi-experimental study using a pre-post-test with the control group. there were 50 family caregivers (n=25 in the intervention group, n=25 in the control group) involved. the preparedness for caregiving was measured using the caregiving inventory (cgi) and the burden was measured using caregiving burden scale questionnaires. results: after four weeks of the hbpc-fc program, caregiving preparedness improved significantly in the intervention group. statistically significant differences in caregiving burden were also found between-group where caregiving burden in the intervention group decreased significantly (p < 0.05). the hbpc-fc program had positive outcomes for family caregivers. conclusions: home-based palliative care training on symptom management could be utilized as a form to improve family caregivers’ readiness in providing care for patients at home. keywords: caregiving preparedness; caregiving burden; family caregiver; symptom management; training program introduction providing care to patients with palliative care is a complex process involving not just one family member but the whole family. therefore, in palliative care, a family-oriented approach is an integral part, as demonstrated by the who definition of palliative care (who, 2010). the family has an important role in the palliative care setting. family caregivers are individuals who provide physical, psychological, and psychosocial support as well as support related to health management (hudson et al., 2012). the family caregivers can have direct kinship or friendship. in general, family caregivers could be the spouse, child, or parents of the patients (committee on family caregiving for older adults; board on health care services; health and medicine division; national academies of sciences, 2016). the majority of patients with palliative care needs prefer to care at home throughout their illness trajectory (wu, huang, & tsao, 2020). most patients with palliative care needs suffer from more than one physical symptom such as pain, fatigue, and dyspnea (pidgeon et al., 2016; rojas-concha, hansen, petersen, & groenvold, 2020). in addition to physical symptoms, the patients also often experience psychological and https://creativecommons.org/licenses/by/4.0/ mailto:erna.rochmawati@umy.ac.id https://orcid.org/0000-0003-2193-6812 https://orcid.org/0000-0003-4030-7923 rochmawati and saun (2022) supremo, bacason, and sañosa (2022) 154 p-issn: 1858-3598  e-issn: 2502-5791 spiritual problems that require more support from their immediate family caregivers in addition to physical symptoms. such situations may create anxiety, challenges, and burden for family caregivers and kristanti, effendy, utarini, vernooij-dassen, and engels (2019) authors found that family members of patients with life-limiting illnesses such as cancer and dementia stated that they feel confused about how to manage patients' symptoms and their anxiety related to the quality of their care. grant et al. (2013) stated that the burden experienced by family members who care for patients at home is defined as a problem, difficulty, or detrimental impact. such a situation will affect the quality of the family's life to carry out its activities so interventions such as education in the family are needed (grant et al., 2013). caring for a sick family member at home can be a challenge for families as most do not have a health education background. caregivers' preparedness is important to minimize the impact of caregiving (williams, 2018). inadequate training across illness trajectory, particularly cancer, is associated with lower self-efficacy and a higher burden in caregiving (gutierrez-baena & romero-grimaldi, 2022; havyer, van ryn, wilson, & griffin, 2017). family caregivers, particularly in rural areas, reported unmet support needs, particularly informational (brazil, kaasalainen, williams, & dumont, 2014). indonesia is a developing country, with 45.3% of the population living in rural areas (central bureau of statistics (bps), 2020). caring for a sick family member is seen as an obligation in indonesian culture (effendy et al., 2014; rochmawati, wiechula, & cameron, 2016). study identifies that caregiver preparedness, particularly in rural areas, is still lacking (rochmawati & pawitasari, 2021). while there is a national program for patients with chronic illness particularly hypertension and diabetes mellitus. primary health care does not have a specific program to improve family readiness in providing home care for people with a life-limiting illness. in addition, a literature search related to training for families caring for patients with palliative care needs only found two studies. the one identified the need for families who care for hiv / aids patients to get an education at home (ibrahim, haroen, & pinxten, 2011) while the other focused more on providing training for caregivers in addressing patients' basic needs (kristanti et al., 2017). further, study found that the provision of training improved caregivers’ quality of life (kristanti et al., 2017). from the available literature, it is not clear whether there is an hbp c-fc program to improve readiness in caregiving among family caregivers in rural areas in indonesia. this study was guided by the framework of family involvement in palliative care that was developed by andershed and ternestedt (2001). the framework considers the family as the unit of care. this conceptualizes five assumptions in terms of relatives' involvement in palliative care. first, the concept is ‘to know,’ a crucial part of involvement as it is considered to be both a part of the prerequisite for involvement and also a part of family involvement. in this concept, the family caregivers get ‘to know’ by either being informed or actively seeking any information by themselves. family caregivers who had adequate resources would have confidence. second, the involvement was affected by the length of the illness. andershed and ternestedt (2001) argued that family caregivers’ involvement could be promoted; adequate resources and a humanistic attitude of healthcare professionals could promote involvement and make meaningful involvement. the third assumption focused on negative factors that could affect the involvement. several factors such as inadequate resources, lack of communication, and a negative attitude could reduce family caregivers’ confidence in their daily lives. the fourth assumption indicated the importance of healthcare professionals’ attitudes in addition to respect in relative involvement. support from healthcare professionals could help the relatives get ‘to know’ and attain information so that the caring situation becomes more manageable. fifth, a ‘partnership' is the highest level of involvement. this should improve healthcare professionals’ chances to support relatives in the way they choose. in our study, the assumption of ‘to know’ is defined as training to be given to the family caregivers to improve their readiness and could also lead to reducing their burden in caregiving. in the study, we followed the caregiving preparedness framework from andershed and ternestedt (2001) which encompasses three concepts of knowing, being, and doing. we applied an educational approach that could increase caregivers’ knowledge (knowing), on knowing, ability in providing care (doing), and managing stressors of caregiving (being). teaching areas to enhance family caregivers' skills included selfcare, basic needs, pain, and symptom management, and spiritual support. this is based on a previous study conducted in a rural area in canada that identified the most prevalent needs were caring for the patient's pain, jurnal ners http://e-journal.unair.ac.id/jners 155 fatigue, body, and nourishment, and caregivers’ personal needs (robinson, et al., 2012). the existing literature emphasizes the importance of educational preparation for family members (borneman et al., 2011; ibrahim et al., 2011). in addition, a framework developed by andershed and ternestedt (2001) proposes that interventions should focus on promoting preparedness. the provision of training or education is suggested for families because of its benefit in strengthening their capacity, particularly for managing symptoms at home (putranto & rochmawati, 2020). support programs and increasing caregiver preparedness are priorities for intervention studies in caregiving (harrop, byrne, & nelson, 2014; lambert et al., 2019). support programs include home care, practical training, and caregiver coaching. home-based education for caregivers of patients with a life-limiting illness is important and suggested in a limited-resource setting (kizza & muliira, 2019; williams, 2018). therefore, the current study aimed to investigate the effect of providing hbpc-fc training for family caregivers in rural areas on their preparedness and burden of caregiving with the following hypotheses: 1. mean scores of caregiving readiness in the intervention group would be significantly higher than that of the control group measured at week 4 of the intervention program and would be significantly higher than pre-intervention. 2. mean scores of the caregiving burden in the intervention group would be significantly lower than that of the control group measured at week 4 of the intervention program and would be significantly lower than pre-intervention materials and methods a quasi-experimental with data collection at baseline and immediately after training was employed for the study. we reported using the consolidated standards of reporting trials (consort) guideline. sample and setting the sample was relatives who were the primary caregivers of patients with a life-limiting illness. the sample size was calculated using g*power, with the level of significance () = .05, power of test = .80, and an estimated effect size of 0.9 (rivera, elliott, berry, & grant, 2008). following the calculation, we added 10% to anticipate potential dropouts. given the possible attrition rate, a minimal sample size of 50 was considered adequate. we recruited 50 family caregivers divided into 25 people in the intervention group and 25 people in the control group (figure 1). eligible family caregivers were as follows: being a primary family caregiver of the patient; 18 years or older; not diagnosed with life-limiting illness; and willing to spend time for the training. figure 1 the flow diagram of the study assessed for eligibility (n= 231) analyzed (n= 25) excluded from analysis (n=0) lost to follow-up (n= 0) allocated to intervention group (n= 25) lost to follow-up (n= 0) allocated to control group (n= 25) analyzed (n=25) excluded from analysis (n=0) allocation analysis follow-up quota sampling (n= 50)) enrolment rochmawati and saun (2022) supremo, bacason, and sañosa (2022) 156 p-issn: 1858-3598  e-issn: 2502-5791 ethical considerations the semi-structured in-depth interview method was we conducted the study after approval from the university ethics committee in research (no.023/eckepk/ii/2019). we recruited family caregivers using data from the primary health care center. the researchers explained the study to the family caregivers and included study objectives, process, potential benefits, and risks. following that, participants who agreed to be involved in the study provided their consent. we assured the participants that they could withdraw at any time and this would not affect the healthcare service. we kept all participants’ data confidential without individual identification in any form. research instruments the research instruments consisted of three parts: (i) a demographic information questionnaire; (ii) caregiving preparedness; and (iii) caregiving burden). the demographic information questionnaire was developed to obtain the participants’ age, gender, relationship to the patients, and type of employment. in addition, we also developed illness-related questions: type of disease, length of illness, and availability of support. we assessed family caregivers' preparedness using the caregiving inventory (cgi) developed by merluzzi et al. (2011) we received permission to use and translate the cgi. the cgi consists of 21 items and is categorized into four subscales that include: managing medical information, caring for the care recipient; caring for oneself, and managing difficult interactions and emotions. the questionnaire has a 9-point likert scale (1 = “not at all confident” to 9 = “totally confident”), with a higher score reflecting a higher preparedness in caregiving. the cgi was translated into indonesian, with a reliability score of 0.856 (rochmawati & pawitasari, 2021). caregiving burden was measured using zarrit burden index (zbi). we utilized the indonesian version of zbi with a cronbach’s alpha score of 0.93 (tristiana, et al., 2019). the zbi has 22 items rated on a 5-point likert scale that ranges from 0 (never) to 4 (nearly always). the sum score ranges between 0–88, with higher scores, indicating a greater burden. a score of 61or more was considered a high burden. data on caregiving preparedness and burden were collected at baseline and upon completion of the intervention table 1 schedule, content and activities of hbpc-fc training time contents method week 1 (12 hours) basic needs (personal hygiene, discussion of medication regimen for patient). pain control (assessment, pain medication management and nonpharmacological interventions). trust establishment program overview teaching and providing information breathing exercise providing feedback and encouragement week 2 (12 hours) symptom management: nausea loss of appetite teaching, demonstrating evaluating participant’s understanding, providing feedback and encouragement week 3 (12 hours) dyspnea management spiritual support teaching demonstrating deep breathing exercise asking participants to redemonstrate providing feedback and encouragement program evaluation table 2 characteristics of the family caregivers characteristic intervention group control group n % n % gender female 21 84 22 88 male 4 16 3 12 age 26-35 y 7 28 3 12 36-45 y 7 28 13 52 46-55 y 6 24 6 24 56-65 y 4 16 3 12 >65 y 1 4 0 0 relationship with patient spouse 11 44 7 28 children 9 36 15 60 parents 1 4 0 0 sibling 3 12 2 8 other (niece) 1 4 1 4 support from other family member yes 18 72 21 84 none 7 28 4 16 employment government employee 1 4 0 0 private employee 5 20 2 8 self-employed 5 20 3 12 housewife 13 52 19 76 other 1 4 1 4 length of caregiving <1 year 7 28 2 8 >1 year 18 72 23 92 patient’s medical diagnose diabetes stroke cancer copd heart failure 7 4 4 6 4 28 16 16 24 16 5 5 6 6 3 20 20 24 24 12 jurnal ners http://e-journal.unair.ac.id/jners 157 data collection procedures we conducted the study in february 2020-may 2020. we divided the caregivers’ group based on the location of their homes. the intervention group received hbpc-fc which was delivered in the form of one-on-one training using the structured module, while the control group did not receive any training during the study. after obtaining written consent and completing baseline assessments, the researchers' scheduled one-on-one sessions with the caregivers for training. the researchers were postgraduate students in nursing. the hbpc-tc training was conducted at the caregiver’s home. the training was offered based on the family caregivers’ availability to participate. the researchers delivered the hbpc-fc training to the intervention group for three weeks. in the study, we provided education to enhance family caregivers' skills, including self-care, basic needs, pain, and symptom management, and spiritual support. this is based on a previous study conducted in a rural area in canada that identified the most prevalent needs were caring for the patient's pain, fatigue, body, nourishment, and caregivers’ personal needs (robinson et al., 2012). table 1 shows detailed contents and methods in our hbpc-fc training. in the first week, we trained family caregivers on patients' basic needs (personal hygiene, discussion of medication regimen for patients) and pain control (assessment, pain medication management, and nonpharmacological interventions). each meeting ranged from 1-2 hours. we provided information on managing nausea, such as providing small and frequent meals, and maintaining preferred meals, fatigue (an example is pleasant activity scheduling), and loss of appetite in the second week of the training. in the third week, we trained the participants to manage dyspnea and provide spiritual support for patients. we taught strategies for managing psychological distress by conducting deep breathing and progressive muscle relaxation data analysis statistical analysis was performed using spss 23.0 (spss inc., chicago, il, usa). descriptive statistics were utilized to describe participants’ demographic and background variables. all tests were performed, assuming p < 0.05 to be statistically significant. independent t-tests were used to measure the statistical difference of the mean scores of caregiving preparedness and burden. wilcoxon signed ranks test was used to test the difference in caregiving burden and preparedness in the experimental group between preand post-intervention. results in the current study, a total of 50 family caregivers were divided into intervention group (25 participants) and control group (25 participants). none of the family caregivers withdrew from the study. the comparison of demographic and clinical findings of the study population is displayed in table 2. overall, there were no significant differences in the study participants' demographic characteristics and disease-related data. the data showed that most family caregivers were female both in the intervention and control group. most of the caregivers were the patient's spouse or children (intervention group: 80%, control group: 88%). the majority of caregivers in the intervention group were 2635 years and 36-45 years. the primary caregivers in both groups had support from other family members. table 3 shows the difference in outcomes after three weeks of hbpc-fc training intervention in the intervention and control group. the family’s preparedness in providing caregiving increased significantly in the intervention group. there is also a table 3 preparedness and burden of providing care to patient at home pre-post-test in intervention and control group variable intervention group min-max meansd control group min-max meansd p-value caregiving preparedness pre-test post-test 55-94 84-174 66.5310.947 131.5629.551 50-92 51-90 68.129.382 71.209.513 0.000 caregiving burden pre-test post-test 57-93 24-71 79.328.966 41.3215.569 61-87 68-87 78.527.332 79.845.778 0.000 table 3 preparedness and burden of providing care between groups variables intervention (n=25) control (n=25) t test p-value caregiving preparedness 131.56 (29.55) 71.20(9.51) 9.72 * .000 caregiving burden 41.32 (15.57) 79.84(5.77) 11.59 *.000 *correlation is significant at the 0.05 level (2-tailed). rochmawati and saun (2022) supremo, bacason, and sañosa (2022) 158 p-issn: 1858-3598  e-issn: 2502-5791 significant difference between the intervention and control groups regarding caregiving preparedness (table 3). the caregiving burden decreased significantly in the intervention group. statistically significant differences in caregiving burden were found between groups (p < 0.05). discussions the findings of previous studies are similar to this study (duimering et al., 2020; petruzzo et al., 2019). the majority of family caregivers in our study were female. this study was undertaken to assess the effectiveness of hbpc-fc training for family caregivers in rural areas on their caregiving preparedness and burden. providing training at home is suggested in limited-resource settings (kizza & muliira, 2019). in indonesia, where the study was conducted, the resource is still limited in some areas, particularly rural areas. therefore, we conducted a hbpc-fc training session for family caregivers at their home as suggested by previous study. in addition, due to the characteristics of the family caregivers, the researcher followed suggestions from two previous studies to provide information for families in simple language; we also provided written instruction on administrating medication and evaluating symptoms (dionne-odom et al., 2018; el osta & bruera, 2015). findings from the study have highlighted that caregiving preparedness among family caregivers in the intervention group was significantly improved by hbpcfc training. we conducted the intervention in the form of one-on-one training. such form of intervention was highlighted by participants in hendrix et al. (2016) study). previous related studies in the field confirm the results of the present study (chi, et al., 2016; hendrix et al., 2016; mollica, et al., 2017). for example, in their study, hendrix et al. (2016) delivered enhanced training that included two components symptom management for patients and managing stress for family caregivers and found that the training significantly improved the caregiving preparedness. the two components were similar to materials of hbpc-fc training that we provided in our study. further, many studies indicate that caregiving preparedness is associated with other positive outcomes. for example, although we did not measure in our study, previous study indicates that a higher preparedness associates with higher competence and quality of life (winterling, kisch, alvariza, årestedt, & bergkvist, 2021). family caregivers experienced a high burden due to the lack of real support in managing patient symptoms at home. the caregiving burden mean scores in both groups before the intervention were considered high. this is different to the previous study. a cross-sectional survey of family caregiver’s burden in a specialized palliative care unit in malaysia found that the caregiving burden was low (ahmad et al., 2020). the difference could be due to different setting, as, in our study, the family caregivers provided care to the patients at home where they cared for the patients 24/7. following the hbpc-fc training, we found the caregiving burden score in the intervention group had decreased compared to the baseline values. this suggests that hbpc-fc training was instrumental in influencing the caregiving burden. furthermore, similar results are found in previous study. although, previous study focused on caring specifically for patients with cancer, it was shown that education training had a direct impact on the perception of burden among family caregivers (mollica et al., 2017). support is needed by family and it can be provided in several forms such as training or café meeting (finley, 2018). our study showed that hbpc-fc significantly decreases family caregivers' burden. this confirms the previous study that lack of receipt of training increases the burden among family caregivers (hendrix et al., 2016; mollica et al., 2017). in addition, a systematic review found that experimental interventions slightly reduce caregivers’ burden (gonzález-fraile et al., 2021). the study has several limitations. first, we conducted our study with primary family caregivers at home. there was variety in terms of supports of family caregivers at home (availability of other members to be a proxy caregiver) that could contribute to a different level of caregiving burden. secondly, the type of disease and complexity of the patient's symptoms varied, thus the needs and burden could also vary. conclusions a three-week hbpc-fc training is an effective approach to improve caregiving preparedness and reduce the caregiver burden of the family caregivers in rural areas. for nursing practice, particularly in community and adult nursing, nurses can provide hbpcfc training for family caregivers in the current practice. in addition, primary healthcare nurses can implement sustainable empowerment for caregivers or partnerships with community health workers to assist palliative patient care. further studies can adopt technology to support caregivers, such as developing mobile apps that can be used to increase caregivers' preparedness and reduce the level of family stress in providing care independently. jurnal ners http://e-journal.unair.ac.id/jners 159 references ahmad zubaidi, z. s., ariffin, f., oun, c. t. c., & katiman, d. (2020). caregiver burden among informal caregivers in the largest specialized palliative care unit in malaysia: a cross sectional study. bmc palliat care, 19(1), 186. doi:10.1186/s12904-020-00691-1 andershed, b., & ternestedt, b. m. (2001). development of a theoretical framework describing relatives' involvement in palliative care. journal of advanced nursing, 34(4), 554-562. borneman, t., koczywas, m., sun, v., piper, b. f., smith-idell, c., laroya, b., . . . ferrell, b. (2011). effectiveness of a clinical intervention to eliminate barriers to pain and fatigue management in oncology. journal of palliative medicine, 14(2), 197-205. brazil, k., kaasalainen, s., williams, a., & dumont, s. (2014). a comparison of support needs between rural and urban family caregivers providing palliative care. the american journal of hospice & palliative care, 31(1), 13-19. doi:10.1177/1049909112474712 central bureau of statistic (bps). (2020). percentage of urban population by province, 2010-2035. retrieved from https://www.bps.go.id/statictable/2014/02/18/1276/persentase -penduduk-daerah-perkotaan-menurut-provinsi-2010-2035.html chi, n. c., demiris, g., lewis, f. m., walker, a. j., & langer, s. l. (2016). behavioral and educational interventions to support family caregivers in end-of-life care: a systematic review. the american journal of hospice & palliative care, 33(9), 894-908. doi:10.1177/1049909115593938 committee on family caregiving for older adults; board on health care services; health and medicine division; national academies of sciences, e., and medicine,. (2016). families caring for an aging america. in e. j. chulz r (ed.), amily caregiving roles and impacts. washington national academy. retrieved from https://www.ncbi.nlm.nih.gov/books/nbk396398/. dionne-odom, j. n., taylor, r., rocque, g., chambless, c., ramsey, t., azuero, a., . . . bakitas, m. a. (2018). adapting an early palliative care intervention to family caregivers of persons with advanced cancer in the rural deep south: a qualitative formative evaluation. journal of pain and symptom management, 55(6), 1519-1530. doi:https://doi.org/10.1016/j.jpainsymman.2018.02.009 duimering, a., turner, j., chu, k., huang, f., severin, d., ghosh, s., . . . fairchild, a. (2020). informal caregiver quality of life in a palliative oncology population. supportive care in cancer, 28(4), 16951702. doi:10.1007/s00520-019-04970-3 effendy, c., vissers, k. c., osse, b. h. p., tejawinata, s., vernooijdassen, m., & engels, y. (2014). comparison of problems and unmet needs of patients with advanced cancer in a european country and an asian country. pain practice. el osta, b., & bruera, e. (2015). models of palliative care delivery. . in e. bruera, i. higginson, c. f. von gunten, & t. morita (eds.), textbook of palliative medicine. florida: press taylor and franciss. finley, j. p. (2018). caregiver café: providing education and support to family caregivers of patients with cancer
. clinical journal of oncology nursing, 22(1), 91-96. doi:10.1188/18.cjon.91-96 gonzález-fraile, e., ballesteros, j., rueda, j. r., santos-zorrozúa, b., solà, i., & mccleery, j. (2021). remotely delivered information, training and support for informal caregivers of people with dementia. cochrane database syst rev, 1(1), cd006440. doi:10.1002/14651858.cd006440.pub3 grant, m., sun, v., fujinami, r., sidhu, r., otis-green, s., juarez, g., . . . ferrel, b. (2013). family caregiver burden, skills preparedness, and quality of life in non-small-cell lung cancer. oncology nursing forum, 1(40), 337-346. doi:doi:10.1188/13.onf.337-346. gutierrez-baena, b., & romero-grimaldi, c. (2022). predictive model for the preparedness level of the family caregiver. international journal of nursing practice, e13057. doi:10.1111/ijn.13057 harrop, e., byrne, a., & nelson, a. (2014). "it's alright to ask for help": findings from a qualitative study exploring the information and support needs of family carers at the end of life. bmc palliat care, 13(1), 1-17. doi:10.1186/1472-684x-13-22 havyer, r. d., van ryn, m., wilson, p. m., & griffin, j. m. (2017). the effect of routine training on the self-efficacy of informal caregivers of colorectal cancer patients. supportive care in cancer, 25(4), 1071-1077. doi:10.1007/s00520-016-3494-6 hendrix, c. c., bailey, d. e., jr., steinhauser, k. e., olsen, m. k., stechuchak, k. m., lowman, s. g., . . . tulsky, j. a. (2016). effects of enhanced caregiver training program on cg self-efficacy preparedness. supportive care in cancer, 24(1), 327-336. doi:doi: 10.1007/s00520-015-2797-3 hudson, p. l., lobb, e. a., thomas, k., zordan, r. d., trauer, t., quinn, k., . . . summers, m. (2012). psycho-educational group intervention for family caregivers of hospitalized palliative care patients: pilot study. journal of palliative medicine, 15(3), 277281. doi:10.1089/jpm.2011.0347 ibrahim, k., haroen, h., & pinxten, l. (2011). home-based care: a need assessment of people living with hiv infection in bandung, indonesia. the journal of the association of nurses in aids care, 22(3), 229-237. kizza, i. b., & muliira, j. k. (2019). the influence of a home-based education intervention on family caregivers' knowledge and selfefficacy for cancer pain management in adult patients within a resource-limited setting. journal of cancer education, 34(6), 1150-1159. doi:10.1007/s13187-018-1421-x kristanti, m. s., effendy, c., utarini, a., vernooij-dassen, m., & engels, y. (2019). the experience of family caregivers of patients with cancer in an asian country: a grounded theory approach. palliative medicine, 33(6), 676-684. doi:10.1177/0269216319833260 kristanti, m. s., setiyarini, s., & effendy, c. (2017). enhancing the quality of life for palliative care cancer patients in indonesia through family caregivers: a pilot study of basic skills training. bmc palliat care, 16(1), 4. doi:10.1186/s12904-016-0178-4 lambert, s. d., ould brahim, l., morrison, m., girgis, a., yaffe, m., belzile, e., . . . loiselle, c. g. (2019). priorities for caregiver research in cancer care: an international delphi survey of caregivers, clinicians, managers, and researchers. supportive care in cancer, 27(3), 805-817. doi:10.1007/s00520-018-4314-y merluzzi, t. v., phillip, e. j., vachon, d. o., & heitzmann, c. a. (2011). assessment of self-efficacy for caregiving: the critical role of selfcare in caregiver stress and burden. palliative & supportive care, 9(5), 15-24. doi:doi:10.1017/s1478951510000507 mollica, m. a., litzelman, k., rowland, j. h., & kent, e. e. (2017). the role of medical/nursing skills training in caregiver confidence and burden: a cancors study. cancer, 123(22), 4481-4487. doi:10.1002/cncr.30875 petruzzo, a., biagioli, v., durante, a., emberti gialloreti, l., d'agostino, f., alvaro, r., & vellone, e. (2019). influence of preparedness on anxiety, depression, and quality of life in caregivers of heart failure patients: testing a model of path analysis. patient education and counseling, 102(5), 1021-1028. doi:10.1016/j.pec.2018.12.027 pidgeon, t., johnson, c. e., currow, d., yates, p., banfield, m., lester, l., . . . eagar, k. (2016). a survey of patients' experience of pain and other symptoms while receiving care from palliative care services. bmj support palliat care, 6(3), 315-322. doi:10.1136/bmjspcare-2014-000748 putranto, d., & rochmawati, e. (2020). mobile applications for managing symptoms of patients with cancer at home: a scoping review. international journal of nursing practice, 26(4), e12842. doi:10.1111/ijn.12842 rivera, p. a., elliott, t. r., berry, j. w., & grant, j. s. (2008). problemsolving training for family caregivers of persons with traumatic brain injuries: a randomized controlled trial. archives of physical medicine and rehabilitation, 89(5), 931-941. doi:10.1016/j.apmr.2007.12.032 robinson, c. a., pesut, b., & bottorff, j. l. (2012). supporting rural family palliative caregivers. j fam nurs, 18(4), 467-490. doi:10.1177/1074840712462065 rochmawati, e., & pawitasari, y. (2021). perceived caregiving preparedness and quality of life among indonesian family caregivers of patients with life-limiting illness. international journal of palliative nursing. rochmawati, e., wiechula, r., & cameron, k. (2016). current status of palliative care services in indonesia: a literature review. int nurs rev 63(2), 180-190. doi:https://doi.org/10.1111/inr.12236 rojas-concha, l., hansen, m. b., petersen, m. a., & groenvold, m. (2020). which symptoms and problems do advanced cancer patients admitted to specialized palliative care report in addition to those included in the eortc qlq-c15-pal? a register-based rochmawati and saun (2022) supremo, bacason, and sañosa (2022) 160 p-issn: 1858-3598  e-issn: 2502-5791 national study. supportive care in cancer, 28(4), 1725-1735. doi:10.1007/s00520-019-04976-x tristiana, d., triantoro, b., nihayati, h. e., yusuf, a., & abdullah, k. l. (2019). relationship between caregivers’ burden of schizophrenia patient with their quality of life in indonesia. j. psychosoc. rehabil. ment. health, 6(2), 141-148. doi:10.1007/s40737-01900144-w who. (2010). who definition of palliative care. retrieved from http://www.who.int/cancer/palliative/definition/en/ williams, a. m. (2018). education, training, and mentorship of caregivers of canadians experiencing a life-limiting illness. journal of palliative medicine, 21(s1), s45-s49. doi:10.1089/jpm.2017.0393 winterling, j., kisch, a., alvariza, a., årestedt, k., & bergkvist, k. (2021). preparedness for family caregiving prior to allogeneic hematopoietic stem cell transplantation. palliative and supportive care, 1-8. doi:10.1017/s1478951521001346 wu, m.-p., huang, s.-j., & tsao, l.-i. (2020). the life experiences among primary family caregivers of home-based palliative care. the american journal of hospice & palliative care, 37(10), 816822. doi:10.1177/1049909120907601. how to cite this article: rochmawati, e. and saun, a. u. (2022) ‘exploring family understanding of schizophrenia: a qualitative study among rural families in east java, indonesia’, jurnal ners, 17(2), pp. 153-160. doi: http://dx.doi.org/10.20473/jn.v17i2.38147 88 ekspresi protein er (estrogen receptor) pada kanker payudara derajat keganasan baik, sedang dan buruk (protein expression er (estrogen receptor) in breast cancer degree of malignancy mild, moderate, and severe) imam susilo departemen patologi anatomi, fakultas kedokteran universitas airlangga rsud dr. soetomo, jl. mayjen. prof. dr. moestopo no. 47 surabaya, indonesia e-mail: imam90.idaf@gmail.com abstract introduction: mammary carcinoma is the most common malignancy and main mortality cause in women. hormonal status (er and pr expression) was long used as patient suitability for hormonal therapy. however, lately there have been many patients with er and pr negative. this study wanted to prove the relevance of protein expression of er (estrogen receptor) with the histopathological degree of malignancy of breast invasive ductal cancer and the prognosis of breast cancer with er protein expression of positive and negative. method: in this retrospective and cross sectional analytical study retrieved data about hormonal status (er expression) and histopathological grading of infi ltrating ductal carcinoma patients. this study consisted of 201 patients with mammary carcinoma who referred to medical records department pathology anatomic of faculty medicine airlangga university/ dr. soetomo general hospital surabaya on 1 january 2010–31 december 2010 and their medical record suitable with inclusion criterias. the data was categorized into several groups based on the er expression result. results: most of the sample was in 41–50 year age group (37.31%), and 54, 7% of them were in poor expression. the relationship of estrogen receptor (er) with the degree of histopathology infi ltrating ductal carcinoma patients, obtained p-value = 0.001 (p < 0.5) and the 2 × 2 table is only moderate and severe degrees compared with the results of er expression results obtained p = 0.001 (p < 0.5) and odds ratio of 0.362 (ci: 0194-0675). discussion: this study found signifi cant correlation between er expression with histopathological grading of infi ltrating ductal carcinoma patients. keywords: infi ltrating ductal carcinoma, er expression, histopathological grading pendahuluan kanker payudara adalah penyebab kematian terbanyak karena kanker pada perempuan. data dunia yang dirilis who pada tahun 2008 yaitu sejumlah 460.000. disampaikan pula oleh who, bahwa tiap tahunnya terdapat 1,2 juta orang terdiagnosis mengidap kanker payudara. di negara-negara yang memiliki penghasilan tinggi, merupakan penyebab kematian utama pada perempuan umur 20–59 tahun. insiden kanker payudara di asia adalah 20 orang diantara 100.000 penduduk. badan registrasi kanker (brk) indonesia pada tahun 1998, menyatakan bahwa insiden kanker payudara menempati urutan ke-2 terbanyak dari jumlah seluruh keganasan pada perempuan di seluruh pusat patologi anatomi di indonesia, dengan jumlah 2.617 kasus (susilo i, 2006). karsinoma duktal invasif (idc) adalah jenis yang paling banyak dari kanker payudara. sekitar 80% dari semua kanker payudara adalah karsinoma duktal invasif. sampai sekarang faktor prognosis masih belum dapat memberikan informasi yang kuat terhadap risiko dan terapi yang akurat (stendahl, 2004). diagnosis dini pada penderita karsinoma duktal invasif payudara selama ini adalah menggunakan pemeriksaan histopatologik, dengan melakukan penilaian terhadap derajat keganasan karsinoma duktal invasif payudara, ekspresi protein er (estrogen receptor) (imam susilo) 89 yaitu dengan menggunakan sistem bloom dan richardson. sistem tersebut berdasarkan pada bentukan tubulus (kelenjar), derajat pleomorfi sitas inti dan tingkat aktivitas mitosis sel tumor. derajat bentukan tubulus, pleomorfi sitas inti dan tingkat aktivitas mitosis sel tumor, dinilai dalam skor 1, 2 dan 3 (rosai, 2004; schinitt, 2010). untuk menentukan terapi pada karsinoma duktal invasif payudara tidak hanya diperlukan derajat keganasan histopatologik, tetapi juga perjalanan penyakit tersebut. estrogen receptor (ers1) adalah ligan-activated transkripsion factor yang termasuk golongan reseptor hormon superfamili the nuclear dari molekul reseptor yang dapat mengikat 17 β-estradiol. terdapat 2 reseptor yang dikenal sampai sekarang yaitu erα dan erβ. kedua ers secara luas ditampilan dalam jenis jaringan yang berbeda, namun terdapat beberapa perbedaan penting dalam pola ekspresinya (couse, 1997). erα dapat ditemukan dalam sel kanker endometrium, payudara, stroma ovarium, dan hipotalamus (yaghmaie, 2005). pada laki-laki, protein erα ditemukan dalam sel epitel duktus eferen (hess, 2003). ekspresi protein erβ terdapat dalam ginjal, otak, tulang, jantung, paru-paru, mukosa usus, prostat, dan sel endotel (babiker, 2002). penelitian ini bertujuan untuk melihat hubungan antara ekspresi er dengan derajat keganasan histopatologis baik, sedang dan buruk karsinoma duktal invasif payudara dengan menggunakan analisis data imunohistokimia er. penelitian ini diharapkan dapat diperoleh pertanda tumor untuk memperkuat diagnosis dan terapi karsinoma duktal invasif payudara. bahan dan metode jenis penelitian yang digunakan adalah analitik observasional dengan pendekatan cross-sectional, dengan pengamatan dan analisis terhadap satu saat pada variabel penelitian yang peristiwanya sudah terjadi. variabel bebas adalah ekspresi er, sedangkan variabel tergantung adalah derajat keganasan histopatologis baik, sedang dan buruk karsinoma duktal invasif payudara.variabel yang dikendalikan dalam penelitian ini adalah cara pembuatan bahan pemeriksaan yang dilakukan menurut standart baku di departemen/smf/ instalasi patologi anatomi fk unair/rsud dr. soetomo surabaya, dengan memakai standart ’nottingham modifi cation of bloom and richardson system’ untuk menilai derajat keganasan histopatologis karsinoma duktal invasif payudara. populasi penelitian adalah data rekam medik semua penderita karsinoma payudara di departemen/smf/instalasi patologi anatomi fakultas kedokteran universitas airlangga/ rumah sakit umum daerah dr. soetomo surabaya, yang berisi hasil pengamatan mikroskopis derajat keganasan histopatologis baik, sedang dan buruk karsinoma duktal invasif payudara serta pemeriksaan imunohistokimia dengan menggunakan antibodi terhadap protein er, selama periode 1 januari 2010 sampai 31 desember 2010 yang memenuhi kriteria inklusi secara mikroskopis adalah karsinoma duktal invasif payudara secara total sampling. parameter derajat keganasan histopatologis yang digunakan adalah sistem bloom dan richardson modifikasi elston yang dikenal dengan `nottingham modifi cation of bloomrichardson system’. dalam sistem ini selain bentukan tubulus dan derajat pleomorfi sitas inti, juga ditambahkan dengan tingkat aktivitas mitosis sel tumor. ekspresi er diamati secara visual pada daerah imunoreaktif dengan mikroskop cahaya binokuler merk olympus pembesaran 400 kali, serta menggunakan nilai cut off sebesar 10% (le, 2005). selanjutnya data yang diperoleh dan yang telah terkumpul dianalisis dengan menggunakan metode chi-square untuk mengetahui hubungan antara ekspresi er dengan derajat keganasan histopatologis karsinoma duktal invasif payudara. hasil data rekam medik dari departemen patologi anatomi fakultas kedokteran universitas airlangga/rumah sakit umum daerah dr. soetomo surabaya periode 1 januari 2010–31 desember 2010 didapatkan 201 kasus karsinoma duktal invasif payudara yang memenuhi kriteria inklusi penelitian. jurnal ners vol. 7 no. 1 april 2012: 88–93 90 tabel 1. distribusi derajat keganasan histopatologis karsinoma duktal invasif payudara grade grade histo pa frequency percent valid percent cumulative percent valid 1 (baik) 23 11.4 11.4 11.4 2 (sedang) 68 33.8 33.8 45.3 3 (buruk) 110 54.7 54.7 100.0 total 201 100.0 100.0 tabel 2. distribusi ekspresi protein er karsinoma duktal invasif payudara ekspresi protein er frequency percent valid percent cumulative percent valid negatif 108 53.7 53.7 53.7 positif 93 46.3 46.3 100.0 total 201 100.0 100.0 tabel 3. ekspresi protein er pada berbagai derajat keganasan histopatologis karsinoma duktal invasif payudara ekspresi er total – + grade baik jumlah 10 13 23 % er 9,3% 14,0% 11,4% sedang jumlah 27 41 68 % er 25,0% 44,1% 33,8% buruk jumlah 71 39 110 % er 65,7% 41,9% 54,7% total jumlah 108 93 201 % er 100,0% 100,0% 100,0% sampel yang diteliti sebanyak 201 sampel menunjukkan rentang umur pasien dengan kasus karsinoma duktal invasif payudara antara 29 hingga 80 tahun, dengan rentang terbanyak umur 41 hingga 50 tahun yaitu 37,31%. derajat keganasan histopatologis sebanyak 23 kasus (11,4%) derajat keganasan baik, 68 kasus (33,68%) sedang dan 110 kasus (54,7%) buruk (tabel 1). hasil pemeriksaan imunohistokimia ekspresi er, menunjukkan 93 kasus (46,3%) dengan er positif dan 108 kasus (53,7%) er negatif (tabel 2). kasus karsinoma duktal invasif payudara sebanyak 201 kasus yang memenuhi kriteria inklusi, semuanya menjadi sampel penelitian, karena penelitian ini menggunakan total sampling. hasil ekspresi protein er positif terbanyak pada karsinoma duktal invasif payudara derajat sedang yaitu sebanyak 41 kasus (44,1%), kemudian derajat buruk sebanyak 39 kasus (41,9%) dan paling sedikit pada derajat baik sebanyak 13 kasus atau 14% dari total kasus. analisis statistik dengan menggunakan chi-square test, didapatkan nilai p = 0,003 (p < 0,05) yang berarti ada hubungan bermakna antara ekspresi estrogen receptor dengan derajat keganasan histopatologik (tabel 4). ekspresi protein er (estrogen receptor) (imam susilo) 91 gambar 1. ekspresi protein er negatif k a r s i n o m a d u k t a l i n v a s i f payudara, mikroskop cahaya b i n o k u l e r m e r k o l y m p u s pembesaran 400× gambar 2. e k s p r e s i p r o t e i n e r p o s i t i f k a r s i n o m a d u k t a l i n v a s i f payudara, mikroskop cahaya b i n o k u l e r m e r k o l y m p u s pembesaran 400× pembahasan total data yang terkumpul (201 kasus) dari penelitian ini menunjukkan rentang umur penderita karsinoma duktal invasif payudara antara 29 hingga 80 tahun, dengan rentang terbanyak pada umur 41 hingga 50 tahun yaitu sebanyak 77 kasus atau 37,30% dari total kasus, berkurang pada rentang usia 51 hingga 60 tahun yaitu 55 kasus atau 27,36% dari total kasus. serta hanya ada 1 kasus (0,49%) pada usia diatas 80 tahun. data tersebut berlawanan dengan gambaran data dari hasil penelitian pada tahun 2006 di tempat yang sama, yaitu instalasi patologi anatomi fk unair rsud. dr. soetomo surabaya, yang menyebutkan bahwa kelompok umur terbanyak adalah kelompok umur 51 60 tahun dengan angka 36,6% (susilo i, 2006). beberapa literatur mengatakan bahwa karsinoma payudara jarang ditemukan pada usia di bawah 25 tahun, dan insidennya makin meningkat seiring dengan pertambahan usia, sebagian besar karsinoma payudara ditemukan pada usia lebih dari 50 tahun, dan insiden tampak sedikit berkurang pada fase sesudah menopause (rosai, 2010). derajat histopatologik sampel pada penelitian ini, memakai standar pengukuran ‘nottingham modifi cation of bloom-richardson system’, dengan melihat gambaran formasi tubulus, plemorfisitas inti serta aktivitas mitosis sel tumor (lester, et al., 2010). hasil yang didapat dari penelitian ini menunjukkan bahwa derajat keganasan karsinoma duktal invasif payudara terbanyak ialah derajat buruk yaitu mencapai 110 kasus atau 54,7% dari total sampel, disusul 68 kasus (33,6%) dari sedang dan 23 kasus (11,4%) baik. data tersebut sesuai dengan yang diungkapkan oleh beberapa penelitian sebelumnya. penelitian tersebut menunjukkan sebagian besar penderita karsinoma duktal invasif payudara terdiagnosis sebagai kelompok derajat keganasan buruk, sedangkan kelompok derajat baik merupakan kelompok paling sedikit (susilo, 2006) hasil penelitian menunjukkan bahwa er positif paling banyak ditemukan pada karsinoma duktal invasif payudara derajat keganasan sedang yaitu sebanyak 41 kasus atau 44,1% dari total kasus, kemudian derajat keganasan buruk sebanyak 39 kasus (41,9%) dan paling sedikit adalah derajat keganasan baik sebanyak 13 kasus atau 14% dari total kasus setelah dilakukan dengan analisis statistik dengan menggunakan chi-square test, didapatkan nilai p = 0,003 (p < 0,05) yang berarti ada hubungan secara bermakna antara ekspresi estrogen receptor dengan derajat keganasan histopatologik tumor. hasil imunohistokimia er didapatkan hasil bahwa p = 0,001 (p < 0,5) dan odds ratio sebesar 0,362 (ci: 0,194–0,675). dari hasil or 0,362 dapat disimpulkan bahwa risiko pada kelompok dengan penderita dengan hasil histopatologik derajat keganasan sedang pada hasil imunohistokimia er negatif ialah 0,362 kali lebih besar dari pada jurnal ners vol. 7 no. 1 april 2012: 88–93 92 kelompok dengan hasil imunohistokimia er positif. kemudian pada derajat histopatologik derajat keganasan buruk memiliki kesimpulan bahwa risiko pada kelompok penderita dengan histopatologik derajat keganasan buruk pada hasil imunohistokimia er positif ialah 0,314 kali lebih besar daripada kelompok dengan hasil imunohistokimia er negatif. pada data tersebut menunjukkan hampir sejalan dengan pendapat fisher, et al., yang menyatakan bahwa ekspresi er berhubungan secara signifikan dengan derajat pleomorfi sitas inti yang tinggi dan derajat keganasan histopatologik yang buruk, tidak adanya nekrosis, dan usia pasien yang lebih tua (rosai, 2010). penelitian ini juga memperkuat hasil penelitian yang dilakukan oleh nishimura, et al. hasil penelitian tersebut memperlihatkan bahwa terdapat korelasi yang kuat antara hasil pemeriksaan imunohistokimia reseptor er dengan derajat keganasan histopatologik. hasil penelitian tersebut menunjukkan bahwa paling banyak ekspresi er positif pada derajat kegasan baik sedangkan paling sedikit ialah derajat buruk. pada analisis statistic, menunjukkan bahwa yang paling berpengaruh secara signifi kan adalah derajat pleomorfi sitas inti sel tumor, sedangkan gambaran formasi tubulus tidaklah bernilai signifi kan secara statistik. simpulan dan saran simpulan terdapat hubungan yang bermakna antara ekspresi protein er dengan derajat keganasan histopatologik. risiko pada kelompok dengan penderita derajat keganasan histopatologik sedang pada ekspresi protein er negatif dengan 0,362 kali lebih besar dari pada kelompok dangan ekspresi protein er positif. pada derajat keganasan histopatologik buruk, kelompok penderita dengan ekspresi protein er positif memiliki risiko 0,314 kali lebih besar daripada kelompok dengan ekspresi protein er negatif. informasi yang didapatkan yaitu pleomorfi sitas inti sel paling menentukan derajat keganasan histopatologik tumor. saran adanya hubungan antara ekspresi protein er dengan derajat keganasan histopatologik k a r s i n o m a d u k t a l i n v a s i f p a y u d a r a menunjukkan bahwa protein er berperan dalam jalur karsinogenesis. dengan demikian dapat direkomendasikan bahwa ekspresi protein er dapat dipakai secara luas, sebagai faktor penunjang diagnosis dan prognosis, khususnya stadium sedang dan berat, untuk lebih meningkatkan keberhasilan penanganan kanker payudara. penelitian selanjutnya diperlukan data yang lebih banyak serta dilakukan dalam waktu berkelanjutan pada wilayah yang lebih luas, sehingga dapat dijadikan studi epidemiologi yang baik. kepustakaan babiker, f.a., et al., 2002. estrogenic hormone action in the heart: regulatory network and function. cardiovasc. res, 53(3), 709–19. couse, j.f., et al., 1997. tissue distribution and quantitative analysis of estrogen receptoralpha (eralpha) and estrogen receptorbeta (erbeta) messenger ribonucleic acid in the wild-type and eralpha-knockout m o u s e . e n d o c r i n o l o g y, 1 3 8 ( 11 ) , 4613–21. hess, r.a., 2003. estrogen in the adult male reproductive tract: a review. reproductive biology and endocrinology, 1(52), 52. lee, a., et al., 2007. expression of c-erbb2, cyclin dl and estrogen receptor and their clinical implications in the invasive ductal carcinoma of the breast. japan journal of clinical oncology, 37(9), 708–714. lester, s.c., 2010. the breast in robbins and cotrans pathology basic of disease, 8th ed. pensylvania: elsevier saunders. rosai, j., 2010. breast, in rosai and ackerman’s surgical pathology, 9th ed. philadelphia: elsevier. schnitt, s.j., millis, r.r., et al., 2010. the breast in sternberg’s diagnostic ekspresi protein er (estrogen receptor) (imam susilo) 93 surgical pathology, 4th ed. phyladelphia: lippincott williams and wilkins, p. 285. stendahl, m., et al., 2004. cyclin d1 overexpression is a negative predictive factor for tamoxifen response in postmenopausal breast cancer patients. cancer research uk. british journal of cancer, 90, 1942–194 & 2004. susilo, i., 2006. ekspresi protein c-erb2, p53, prb dan mib-1 pada karsinoma duktal invasif payudara in situ, invasif dan metastasis. disertasi tidak dipublikasikan. surabaya: program pascasarjana universitas airlangga. surabaya. xf le, franz, pruefer, robert bast, 2005. her2-targeting antibodies modulate the cyclin-dependent kinase inhibitor p27kip1 via multiple signaling pathways. cell cycle, 4(1), 87–95. yaghmaie, f., et al., 2005. caloric restriction reduces cell loss and maintains estrogen receptor-alpha immunoreactivity in the pre-optic hypothalamus of female b6d2f1 mice. neuro endocrinol, 26(3), 197–203. 37 faktor risiko timbulnya diabetes mellitus pada remaja smu (the risk factors of diabetes mellitus in adolescent senior high school in malang city) dyah widodo*, ekowati retnaningtyas*, ibnu fajar* poltekkes kemenkes malang, jl. besar ijen no. 77c kota malang 65112, e-mail: dyah_widodo@yahoo.com abstract introduction: diabetes mellitus is a disease caused by a hormonal disorder that affects insulin. 5.7% of the total population of indonesia, including teenagers is a big challenge for the health sector to do the step in anticipation of the complexity of health problems caused by diabetes mellitus in indonesia. this study aims to analyze the risk factors of diabetes mellitus in adolescent senior high school in the city of malang. method: this research was correlational research design, sampled in this study was partly teenagers is high school class in malang city area drawn at random sampling with a large sample of 375 respondents. research conducted at government senior high school 6 and 9 (smu negeri 6 and smu negeri 9) in the city of malang, in may–august, 2011. data collection techniques using questionnaires; measurements: weight, height, abdominal circumference/waist, blood pressure and food consumption survey (recording of present food intake) of the diet for three days. data was analyzed by descriptive and analytic spearman rho correlation with alpha 0.05. result: the results showed that a bmi (body mass index) and waist circumference (central obesity) related to the risk of diabetes mellitus in teens senior high school in malang with 0.000 p-values < α 0.05. however, there is no relationship between blood pressure, physical activity, frequency of fruit and vegetable consumption, family history of diabetes mellitus and the risk of diabetes mellitus in teens senior high school in malang. discussion: recommended for teens to pay attention to healthy eating and balanced, in order to awake the ideal body weight and abdominal circumference are normal, so that avoid the risk of diabetes mellitus. keywords: risk factor, diabetes mellitus, teenagers pendahuluan diabetes mellitus (dm) dan penyakit lain yang dikenal sebagai non-communicable disease mulai menonjol sebagai salah satu sebab morbiditas dan mortalitas di negara-negara yang sedang berkembang. penyakit-penyakit tersebut akan menimbulkan suatu beban bagi pelayanan kesehatan dan perekonomian negara pada saat sekarang dan dikemudian hari, baik secara langsung maupun tidak langsung (soeparman, 1987). penyakit-penyakit yang tidak menular tapi menahun, seperti dm, hipertensi, kegemukan dan penyakit jantung di negara-negara yang sedang berkembang termasuk indonesia yang merupakan sebab utama morbiditas dan mortalitas di masyarakat barat, sekarang sudah mulai merupakan masalah juga di negara-negara yang sedang berkembang. studi who (1995) dan pusat kesehatan dasar (riskesdas) (2007) menunjukkan bahwa prevalensi dm 1985 1,7 meningkat menjadi 5,7 di tahun 2007. dari segi usia, pada umur 40–59 tahun menduduki peringkat tertinggi, disusul pada umur 60–79 tahun peringkat kedua dan 20–39 tahun pada peringkat ketiga. kondisi ini hampir sama antara negara berkembang dan negara maju. data dan riskesdas tahun 2007 diketahui bahwa jumlah total penderita dm adalah 5,7% dari total penduduk indonesia, di mana dm yang terdiagnosis secara jelas (diagnosed dm) hanya 1,5%, sementara itu yang belum terdiagnosis (undiagnosed dm) sebanyak 4,2%. hal ini menunjukkan bahwa kondisi penyakit dm jurnal ners vol. 7 no. 1 april 2012: 37–46 38 seperti fenomena gunung es, di mana kondisi yang tergambarkan secara jelas sesungguhnya hanyalah bagian permukaannya saja. data dari idf montreal (2009) jumlah penduduk yang menderita dm untuk usia 20–79 tahun pada tahun 2010, india menempati urutan teratas dengan 50,8 miliar. sementara itu indonesia adalah 7,0 miliar. dengan jumlah tersebut indonesia menempati peringkat ke sembilan dunia di bawah india, china, usa, rusia, brazil, jerman, pakistan dan jepang. namun prediksi di tahun 2030 indonesia naik di peringkat keenam di bawah brazil dengan angka 12,0 miliar, dengan jumlah penderita yang diprediksikan menjadi 87,0 miliar (rudijanto, 2010). peningkatan angka penderita dm ini melonjak tajam ini perlu mendapatkan perhatian yang serius dari berbagai pihak terutama bidang kesehatan. etiopatologi terjadinya dm diperkirakan karena suatu sebab yang multifaktorial, antara lain keturunan, virus yang menimbulkan kerusakan sel beta pankreas, pola makan, kegemukan, pola aktivitas, dan lingkungan. salah satu contoh hasil riskesdas (2007) diketahui bahwa aspek kegemukan memiliki kontribusi terhadap dm, di mana hubungan indeks massa tubuh (imt) dengan dm hanya 4,4% pada orang dengan imt normal, namun pada orang obesitas menjadi 9,1%. dm dikenal sebagai penyakit gangguan metabolisme maupun kelainan vaskuler yang dapat menimbulkan komplikasi yang sangat komplek pada sistem tubuh. dm sering disebut sebagai the great imitator, karena penyakit ini dapat mengenai semua organ tubuh dan menimbulkan berbagai macam keluhan (soeparman, 1987). menyimak uraian pada alinea terdahulu berarti akan menjadi tantangan yang besar bagi bidang kesehatan untuk melakukan langkah antisipasi terhadap kompleksnya masalah kesehatan akibat dm di indonesia. negara eropa telah mempunyai sebuah road map untuk riset dm (road map for diabetes research in europe) yang dipublikasikan pada 7 september 2010 (euradia, 2010). pada penelitian ini, peneliti ingin menerapkan road map tersebut dengan meneliti sebagian faktor risiko khususnya yang ada di frindrisk score yang meliputi usia, body mass index (bmi), lingkar perut atau pinggang (central obesity), kebiasaan aktivitas fi sik di saat bekerja dan santai termasuk aktivitas sehari-hari, konsumsi buah dan sayur tekanan darah, konsumsi obat-obatan untuk tekanan darah secara rutin, riwayat anggota keluarga atau kerabat yang terdiagnosis dm (tipe 1 atau tipe 2 (frindrisk score terlampir) dan beberapa faktor risiko lain untuk timbulnya dm yaitu riwayat ditemukannya kadar yang tinggi untuk gula darahnya, riwayat kehamilan dengan dm, riwayat penyakit jantung dan kardiovaskuler. responden yang dipilih adalah remaja smu kelas x di kota malang dengan harapan agar dapat dibuat prediksi munculnya dm lebih dini berdasarkan faktor risiko yang ada (penelitian tahap i). rencana selanjutnya pada tahun kedua penelitian (penelitian tahap ii), peneliti akan memberikan intervensi atau perlakuan penelitian untuk mencegah munculnya dm pada remaja yang berisiko. tujuan penelitian ini adalah menganalisis faktor risiko timbulnya dm pada remaja smu di kota malang, khususnya faktor bmi, tekanan darah, kebiasaan aktivitas fisik, frekuensi konsumsi buah dan sayur, riwayat dm keluarga, waist circumference (central obesity) dengan risiko timbulnya dm pada remaja sma di kota malang. bahan dan metode desain penelitian ini adalah analitik korelasional, yaitu mencari hubungan antara faktor-faktor yang berisiko terhadap timbulnya dm pada remaja di smu kota malang. sampel pada penelitian ini adalah sebagian remaja smu klas 1 di kota malang. teknik sampling yang digunakan adalah area random sampling, yaitu mengambil sampel dengan cara acak sederhana untuk sekolah smu dan kelas yang ada di kota malang. besar sampel penelitian adalah 375 responden. lokasi penelitian di smu negeri 6 dan smu negeri 9 di kota malang, penelitian dilaksanakan pada bulan mei–agustus 2011. variabel penelitian ini adalah bmi tekanan darah, kebiasaan aktivitas fi sik, konsumsi buah dan sayur, riwayat dm keluarga, lingkar perut/ pinggang (central obesity), faktor risiko dm. faktor risiko timbulnya diabetes mellitus (dyah widodo) 39 definisi operasional untuk masingmasing variabel yaitu bmi adalah rata-rata berat badan dalam kg yang dapat disanggah per m2 tinggi badan; tekanan darah adalah tekanan darah sistolik dan diastolik yang diukur sesaat pada saat pengumpulan data dengan satua mmhg; kebiasaan aktivitas fi sik adalah kegiatan yang menggerakkan anggota badan yang biasa dilakukan selama 24 jam mulai dari bangun pagi sampai tidur kembali; konsumsi buah dan sayur adalah frekuensi makan berbagai jenis sayur dan buah yang dihitung per hari, per minggu atau per bulan; riwayat dm keluarga adalah riwayat anggota keluarga atau kerabat yang terdiagnosis dm (tipe 1 atau tipe 2; lingkar perut/pinggang (central obesity) adalah ukuran melingkar pada perut melewati umbilikus dalam satuan sentimeter; faktor risiko dm adalah berbagai aspek yang mendukung timbulnya penyakit dm yang dihitung berdasarkan findrisk score (rudijanto, 2010) yang meliputi usia, bmi (normal, overweight, obese), wrc (central obesity), aktivitas fi sik, konsumsi buah dan sayur, obat tekanan darah dan riwayat dm. penelitian ini menggunakan instrumen berupa angket, lembar observasi, lembar recording of present food intake, standar opersional prosedur (sop): recording of present food intake, pengukuran antropometri (pengukuran tb, bb, lingkar perut), pengukuran tekanan darah dan peralatan yang meliputi timbangan berat badan, meteran, tensi meter, stetoskop. teknik pengumpulan data pada penelitian ini adalah pengisian angket, yaitu untuk aspek demografi dan riwayat sakit, pengukuran: berat badan, tinggi badan, lingkar perut/pinggang, tekanan darah yang dicatat pada lembar observasi, survei konsumsi pangan (recording of present food intake) tentang pola makan selama 3 hari yang sebelumnya dijelaskan terlebih dahulu dengan menggunakan food model dan responden diberikan catatan tentang ukuran rumah tangga untuk setiap jenis makanan. analisis data menggunakan analisis deskriptif frekuensi atau persentase dan analisis inferensial yaitu analisis korelasional untuk data ordinal spearman rho dengan alpha 0,05. keseluruhan uji statistik dilakukan dengan menggunakan komputer. hasil k a r a k t e r i s t i k r e s p o n d e n a d a l a h setengahnya responden berumur 15 tahun (43,5%) dan 16 tahun (47,2%) dan sebagian besar responden berjenis kelamin pria (61,1%). hasil penelitian menunjukkan bahwa sebagian besar responden mempunyai bmi atau imt kurang dari 25 yang berarti normal yaitu 338 orang (90,1%) dan sebagian kecil dengan bmi > 25–30 20 orang (5,3%) yang tergolong dalam berat badan lebih dan bmi > 30 sebanyak 17 orang (4,5%) yang tergolong dalam obesitas. hasil pengukuran lingkar pinggang s e b a g i a n b e s a r r e s p o n d e n ( 9 1 % a t a u 342 remaja) mempunyai lingkar pinggang atau waist circumference (central obesity) yang tidak berisiko terhadap penyakit dm (skor 0). hasil pengukuran tekanan darah didapatkan sebagian besar responden (99%) atau 342 orang mempunyai tekanan darah normal. hasil kuesioner didapatkan lebih dari setengahnya responden mempunyai kebiasaan berolah raga (56%) atau 210 remaja dan kurang dari setengahnya tidak berolahraga (44%) atau 165 remaja. sebagian besar responden (72% atau 269 remaja) setiap hari mengkonsumsi buah dan sayur. jika disimak dari ada atau tidaknya riwayat dm, didapatkan bahwa sebagian besar responden (76% atau 285 remaja) tidak ada riwayat dm. penghitungan skor risiko dm (skor findrisk dm) diketahui bahwa sebagian besar responden (79,2% atau 297 remaja) berisiko rendah terhadap penyakit dm; 19,2% atau 72 remaja mengarah pada risiko; 1,3% atau 5 remaja mempunyai risiko sedang dan 0,3% atau 1 remaja mempunyai risiko tinggi terhadap timbulnya penyakit dm. hasil uji korelasi spearman rho dengan alpha 0,05 antara body mass index (bmi) dengan risiko timbulnya dm didapatkan nilai p 0,000 < alpha 0,05. hal ini berarti ada hubungan antara bmi dengan risiko timbulnya dm pada remaja sma di kota malang atau ho ditolak (tabel 1). hasil uji korelasi spearman rho dengan alpha 0,05 antara tekanan darah sistole dan diastole dengan risiko timbulnya dm didapatkan nilai p 0,128 > alpha 0,05. hal ini berarti tidak ada hubungan tekanan darah sistole dengan jurnal ners vol. 7 no. 1 april 2012: 37–46 40 risiko timbulnya dm pada remaja sma di kota malang atau ho diterima (tabel 2). hasil uji korelasi spearman rho dengan alpha 0,05 antara aktivitas fi sik dengan risiko timbulnya dm didapatkan nilai p 0,565 > alpha 0,05. hal ini berarti tidak ada hubungan antara aktivitas fi sik dengan risiko timbulnya dm pada remaja sma di kota malang atau h0 diterima (tabel 3). hasil uji korelasi spearman rho dengan alpha 0,05 antara frekuensi konsumsi buah dan sayur dengan risiko timbulnya dm didapatkan nilai p 0,266 > alpha 0,05. hal ini berarti tidak ada hubungan frekuensi konsumsi buah dan sayur dengan risiko timbulnya dm pada remaja sma di kota malang atau h0 diterima (tabel 4). hasil uji korelasi spearman rho dengan alpha 0,05 antara riwayat anggota keluarga yang terdiagnosis dm dengan risiko timbulnya dm didapatkan nilai p 0,865 > alpha 0,05. hal ini berarti tidak ada hubungan riwayat anggota keluarga yang terdiagnosis dm dengan risiko timbulnya dm pada remaja sma di kota malang atau h0 diterima (tabel 5). hasil uji korelasi spearman rho dengan alpha 0,05 antara lingkar pinggang atau waist circumference (central obesity) dengan risiko timbulnya dm didapatkan nilai p 0,000 < alpha 0,05. hal ini berarti ada hubungan waist circumference (central obesity) dengan risiko timbulnya dm pada remaja sma di kota malang atau h0 ditolak (tabel 6). pembahasan hubungan bmi dengan risiko timbulnya dm pada remaja sma di kota malang dm adalah penyakit metabolik dengan karakteristik peningkatan kadar gula di dalam darah/hiperglikemi (hyperglycemia) yang dihasilkan dari gangguan sekresi insulin, kerja insulin atau keduanya american diabetes association (ada), 2005 dalam smeltzer & bare, 2008; soegondo, soewondo & subekti, 2007). salah satu faktor risiko dm adalah usia ≥ tabel 1. hasil uji korelasi indeks massa tubuh dengan skor findrisk dm imt risdm spearman’s rho imt correlation coefi cient 1.000 .325** sig.(2-tailed) . .000 n 375 375 tabel 2. hasil uji korelasi tekanan darah dengan skor findrisk dm td risdm spearman’s rho td correlation coefi cient 1.000 .079 sig.(2-tailed) . .128 n 375 375 tabel 3. hasil uji korelasi kebiasaan beraktivitas dengan skor findrisk dm aktif risdm spearman’s rho aktif correlation coefi cient 1.000 .030 sig.(2-tailed) . .565 n 375 375 tabel 4. hasil uji korelasi indeks massa tubuh dengan skor findrisk dm bhsayur risdm spearman’s rho bhsayur correlation coefi cient 1.000 .058 sig.(2-tailed) . .266 n 375 375 faktor risiko timbulnya diabetes mellitus (dyah widodo) 41 45 tahun atau usia lebih muda, terutama dengan imt > 23 kg/m2. menurut supariasa, idn, et al., 2002. imt atau bmi adalah suatu cara penilaian terhadap berat badan. imt diperoleh dari perbandingan antara berat badan dalam kilogram (kg) dan tinggi badan dalam meter kuadrat (m²) (imt > 23 kg/m2 menurut himpunan studi obesitas indonesia (hisobi) dan kriteria asia pasifi k tergolong dalam berat badan lebih. berat badan lebih dapat digolongkan menjadi pra obes, obes tingkat i, obes tingkat ii. berbeda dengan skor findrisk, imt 25–30 kg/m2 baru dianggap mempunyai berat badan lebih. menurut virgianto dan purwaningsih (2006) obesitas sering dianggap sebagai kelainan pada umur pertengahan. obesitas yang muncul pada masa remaja 30% akan berlanjut pada waktu dewasa menjadi obesitas persisten. obesitas yang terjadi pada masa remaja perlu mendapat perhatian, sebab bila berlanjut hingga dewasa akan sulit diatasi secara konvensional (diet dan olah raga) serta membawa masalah bagi kehidupan sosial dan emosi yang cukup berarti bagi remaja. responden remaja di smu kota malang sebagian besar (90,1%) didapatkan imt < 25 kg/m2 yang tergolong dalam kategori normal. namun demikian perlu diwaspadai karena 5,3% dalam kategori berat badan lebih dan 4,5% obesitas. p e n y e b a b b e r a t b a d a n l e b i h d a n beberapa faktor bersama-sama menyumbang keberadaan atau mempertahankan kondisi patologis, situasional, development, cultural dan atau problem lingkungan adalah penurunan kebutuhan energi, pola makan salah, kelebihan tabel 5. hasil uji korelasi riwayat dm dengan skor findrisk dm riwdm risdm spearman’s rho riwdm correlation coefi cient 1.000 -.009 sig.(2-tailed) . .865 n 375 375 tabel 6. hasil uji korelasi waist circumference (central obesity) dengan skor findrisk dm wc risdm spearman’s rho wc correlation coefi cient 1.000 .273** sig.(2-tailed) . .000 n 375 375 intake energi, kepercayaan/keyakinan/persepsi yang salah terhadap makanan, zat gizi dan masalah tertentu terkait dengan zat gizi, aktivitas fi sik kurang dan peningkatan stres psikologi. hasil uji korelasi spearman rho dengan alpha 0,05 antara bmi dengan risiko timbulnya dm didapatkan nilai p 0,000 < alpha 0,05. hal ini berarti ada hubungan antara bmi dengan risiko timbulnya dm pada remaja sma di kota malang. risiko adalah faktor yang terkait dengan penyebab tetapi risiko ini bukan berarti penyebab secara langsung. oleh karena itu pengelolaan nutrisi seimbang perlu dilakukan secara dini agar remaja terhindar dari penyakit dm. dengan pemenuhan nutrisi seimbang dan sesuai kebutuhan tubuh maka akan didapatkan berat badan yang ideal. menurut persagi (1999), pola makan sehari yang dianjurkan di indonesia adalah makanan seimbang yang terdiri atas. sumber zat tenaga, misalnya: roti, mie bihun, jagung, ubi, singkong, tepung-tepungan, gula dan minyak. sumber zat pembangun, misalnya: ikan, telur, ayam, daging, susu, kacang-kacangan, tahu, tempe dan oncom. sumber zat pengatur, misalnya: sayur-sayuran terutama sayuran berwarna dan kuning, sayuran kacang-kacangan dan buah-buahan. beberapa aspek diduga mendukung munculnya masalah kegemukan. orang gemuk cenderung makan bila ia merasa ingin makan, bukan makan pada saat ia lapar. pola makan berlebih inilah yang menyebabkan mereka sulit untuk keluar dari kegemukan jika sang individu tidak memiliki kontrol diri dan motivasi yang kuat untuk mengurangi berat badan. pengaruh emosional seringkali juga berpengaruh, di jurnal ners vol. 7 no. 1 april 2012: 37–46 42 mana orang cenderung makan lebih banyak apabila mereka tegang atau cemas. selain itu, faktor lingkungan juga memengaruhi seseorang menjadi gemuk. jika seseorang dibesarkan dalam lingkungan yang menganggap gemuk adalah simbol kemakmuran dan keindahan maka orang tersebut akan cenderung menjadi gemuk. hubungan tekanan darah dengan risiko timbulnya dm pada remaja sma di kota malang salah satu faktor risiko dm adalah hipertensi (tekanan darah ≥ 140/90 mmhg). tekanan darah adalah tegangan atau tekanan yang dilakukan oleh darah untuk melawan dinding arteri (lemone & burke, 2008). tekanan arteri sistemik terdiri dari: tekanan sistolik dan diastolik. tekanan sistolik merupakan tekanan darah maksimal ketika darah dipompakan dari ventrikel kiri. tekanan sistolik normal berkisar antara 100–130 mmhg. tekanan diastolik merupakan tekanan darah pada saat jantung relaksasi. tekanan diastolik menggambarkan tahanan pembuluh darah yang harus di hadapi oleh jantung. range normal diastolik berkisar antara 60–90 mmhg. responden remaja di smu kota malang sebagian besar (98,7%) remaja berada dalam kisaran tekanan darah normal, sehingga kondisi ini perlu tetap dipertahankan. disatu sisi ternyata ada 1,3% responden yang mempunyai tekanan darah di atas normal atau tergolong dalam hipertensi. di usia yang masih remaja, tekanan darah yang tinggi perlu diwaspadai dan mendapatkan penanganan yang teliti agar tidak terjadi masalah kesehatan yang lebih serius yang merupakan komplikasi dari hipertensi. hasil uji korelasi spearman rho dengan alpha 0,05 antara tekanan darah sistole dan diastole dengan risiko timbulnya dm didapatkan nilai p 0,128 > alpha 0,05 maka dapat disimpulkan bahwa tidak ada hubungan tekanan darah dengan risiko timbulnya dm pada remaja sma di kota malang. m u n c u l n y a p e n y a k i t d m p e r l u diantisipasi pada remaja, di mana salah satunya adalah dengan deteksi tekanan darah sebagai salah satu faktor risiko, meskipun dari hasil uji statistik menunjukkan tidak ada hubungan. apabila sudah aktual terjadi dm maka perlu dikelola dengan baik. menurut smeltzer dan bare (2000) tujuan pengelolaan dm adalah mencoba menormalkan aktivitas insulin dan kadar glukosa dalam darah untuk mengurangi terjadinya penyulit menahun seperti penyakit serebrovaskuler, penyakit jantung koroner, penyakit pembuluh darah tungkai, penyulit pada mata, ginjal dan saraf. hubungan kebiasaan aktivitas fisik dengan risiko timbulnya dm pada remaja sma di kota malang berdasarkan hasil penelitian diketahui bahwa lebih dari setengahnya responden biasa berolah raga (56%) atau 210 remaja dan kurang dari setengahnya tidak berolahraga (44%) atau 165 remaja. berarti kedua kondisi tersebut berada pada kondisi yang relatif berimbang, meskipun yang terbiasa berolahraga lebih sedikit di atas persentase yang tidak berolahraga. menurut sugondo (2006) faktor genetik, lingkungan, kebiasaan makan, kurangnya aktivitas fi sik (aktivitas ringan) dan kemiskinan/ kemakmuran memengaruhi berat badan. aktivitas menentukan kebutuhan gizi seseorang ditentukan oleh aktivitas yang dilakukan seharihari. makin berat aktivitas yang dilakukan, kebutuhan zat gizi makin tinggi, terutama energi. kurang gerak atau olah raga, tingkat pengeluaran energi tubuh sangat peka terhadap pengendalian berat tubuh. pengeluaran energi tergantung dari dua faktor: tingkat aktivitas dan olah raga secara umum, angka metabolisme basal atau tingkat energi yang dibutuhkan untuk mempertahankan fungsi minimal tubuh. hasil uji korelasi spearman rho dengan alpha 0,05 antara aktivitas fi sik dengan risiko timbulnya dm didapatkan nilai p 0,565 > alpha 0,05. hal ini berarti tidak ada hubungan antara aktivitas fisik dengan risiko timbulnya dm pada remaja sma di kota malang atau h0 diterima. dari data hasil penelitian memang didapatkan relative tidak ada perbedaan antara yang mempunyai kebiasaan aktivitas dan tidak, sehingga kemungkinan hal inilah yang menyebabkan tidak adanya hubungan antara aktivitas fi sik dengan risiko timbulnya dm pada faktor risiko timbulnya diabetes mellitus (dyah widodo) 43 remaja sma di kota malang. namun demikian langkah antisipasi terhadap kemungkinan timbulnya dm pada remaja melalui pemenuhan kebutuhan aktivitas fi sik tetap diperlukan. menurut sumosardjuno dalam maulana (2008) olah raga raga yang disarankan untuk pasien dm dilakukan 6 hari seminggu dalam porsi sedang. jenisnya aerobik seperti berjalan kaki atau senam, selama 20–45 menit/hari. beberapa penelitian memperlihatkan keterkaitan kuat antara prevalensi dm tipe 2 dan kurangnya aktivitas fisik. dampak kurangnya aktivitas fisik memperlihatkan manifestasi yang nyata pada populasi yang terbiasa untuk melakukan aktivitas fi sik yang berat. hal ini sesuai dengan gibney (2009) yang menyebutkan bahwa latihan fi sik memperbaiki sensitivitas insulin serta meningkatkan asupan glukosa oleh otot. dengan begitu secara tidak langsung latihan fi sik memberikan efek yang menguntungkan bagi metabolisme karbohidrat pada diabetisi maupun orang-orang yang bukan diabetisi. gibney (2009) menyebutkan bahwa aktivitas fisik didefinisikan sebagai setiap gerakan tubuh yang dihasilkan oleh otot rangka yang menyebabkan pengeluaran energi. aktivitas fi sik yang teratur dianggap sebagai komponen penting dari gaya hidup sehat. barubaru ini, kesan ini telah diperkuat dengan bukti ilmiah baru yang menghubungkan aktivitas fi sik teratur untuk beragam manfaat kesehatan fi sik dan mental. beberapa pengaruh peningkatan aktivitas fisik (gibney, 2009) yaitu: aktivitas fisik langsung memperbaiki sensitivitas otot-otot terhadap insulin, sehingga gula lebih mudah ditimbun dalam otot daripada dibiarkan meningkat dalam peredaran darah, aktivitas fi sik mempunyai efek yang baik bila dilakukan secara teratur 3–5 kali seminggu, aerobik bisa meningkatkan metabolisme dan menguatkan jantung serta pembuluh darah, membantu menurunkan berat badan dan mempertahankan berat badan. peningkatan aktivitas fisik dalam intensitas sedang memberi hasil dalam program pencegahan dan pengobatan dm dan meningkatkan aktivitas fi sik sehari-hari dengan membuat jadwal untuk berolahraga. hubungan frekuensi konsumsi buah dan sayur dengan risiko timbulnya dm pada remaja sma di kota malang responden remaja di smu kota malang sebagian besar responden (71,7%) mengkonsumsi buah dan sayur setiap hari dan 28,3% tidak mengkonsumsi buah dan sayur setiap hari. kondisi ini menunjukkan pola remaja akan pemenuhan kebutuhan vitamin, mineral dan serat. hasil uji korelasi spearman rho dengan alpha 0,05 antara frekuensi konsumsi buah dan sayur dengan risiko timbulnya dm didapatkan nilai p 0,266 > alpha 0,05. hal ini berarti tidak ada hubungan frekuensi konsumsi buah dan sayur dengan risiko timbulnya dm pada remaja sma di kota malang atau h0 diterima. faktor pendukung kondisi ini kemungkinan karena pola makan buah dan sayur baru menimbulkan dampak nyata pada tubuh setelah terjadi dalam kurun waktu yang lama. permasalahan gizi yang timbul pada masa remaja dipicu oleh beberapa faktor yaitu kebiasaan makan yang buruk yang tertanam sejak kecil, pengaturan makan yang salah, kesukaan yang berlebihan terhadap satu jenis makanan terlebih lagi jika makanan tersebut minim gizi. menurut lisdiana, (1997) setiap makhluk hidup akan membutuhkan makanan untuk dapat tetap bertahan hidup. pada umumnya sebagian besar makhluk hidup akan merasa lapar dan lemas apabila kekurangan makanan. secara umum, tujuan makan menurut ilmu kesehatan adalah memperoleh energi yang berguna untuk pertumbuhan, mengganti sel tubuh yang rusak, mengatur metabolisme tubuh serta meningkatkan daya tahan tubuh terhadap serangan penyakit. sayur-sayuran terutama sayuran berwarna dan kuning, sayuran kacang-kacangan dan buah-buahan merupakan sumber zat pengatur. kurangnya konsumsi sayur dan buah akan mengganggu pengaturan metabolisme dalam tubuh seseorang. hal ini sesuai dengan atmatsier (2003) yang menyatakan bahwa makanan diperlukan tubuh untuk melakukan fungsinya, yaitu menghasilkan energi membangun dan memelihara jaringan serta mengatur proses-proses kehidupan. jurnal ners vol. 7 no. 1 april 2012: 37–46 44 hubungan riwayat dm keluarga dengan risiko timbulnya dm pada remaja sma di kota malang responden remaja di smu kota malang sebagian besar responden (75,5%) tidak didapatkan riwayat dm dalam keluarganya, namun 20,3% kakek/neneknya mempunyai riwayat dm dan yang orangtuanya menderita dm ada 4,3%. hasil uji korelasi spearman rho dengan alpha 0,05 antara riwayat anggota keluarga yang terdiagnosis dm dengan risiko timbulnya dm didapatkan nilai p 0,865 > alpha 0,05. hal ini berarti tidak ada hubungan riwayat anggota keluarga yang terdiagnosis dm dengan risiko timbulnya dm pada remaja sma di kota malang atau h0 diterima. kondisi ini berbeda dengan smeltzer & bare (2000) yang menyebutkan bahwa faktor-faktor risiko dm adalah riwayat keluarga, usia, kelompok etnis dan berat badan. hasil uji statistik menunjukkan tidak ada hubungan, namun kondisi ini perlu mendapatkan perhatian karena kecenderungan remaja menderita dm dari faktor keturunan cukup tinggi. menurut lemone dan burke (2008) menyebutkan bahwa penyakit dm yang paling pokok terjadi hiperglikemi kronis (tingginya kadar gula dalam darah) yang diakibatkan gangguan sekresi insulin, dalam kerja insulin atau keduanya. penyakit dm diklasifi kasikan berdasarkan penyebab kurangnya insulin dan tingkat keparahan kekurangan insulin. klasifikasi penyakit dm dan karakteristik diabetes mellitus (dm) tipe 1 (5–10% dari kasus yang terdiagnosa) yang disebut dm juvenile atau insulin-dependent diabetes mellitus (iddm), dm tipe 2 (90–95% dari kasus yang terdiagnosa) atau disebut non-insulin-dependent diabetes mellitus (niddm), dm tipe lain (1–2% dari kasus yang terdiagnosa) kondisi hiperglikemi disebabkan: kelainan genetik fungsi sel beta. hiperglikemi terjadi pada usia awal (biasanya sebelum 25 tahun) tipe ini disebut maturity-onset diabetes of the young (mody), kelainan genetik kerja insulin, penyakit eksokrin pankreas, endocrinopathies: akromegali, hipertiroid, aldosteronoma, cushing’s disease, obat atau bahan kimia, infeksi (rubella, cytomegalovirus), sindrom genetik lain yang berhubungan dengan dm (syndrome down, syndrom klinefelter, syndrom turner, penyakit huntington dan yang lain), dm gestasional (gestational diabetus mellitus/gdm) (2– 5% dari kasus kehamilan) insulin di dalam tubuh diperlukan untuk transport glukosa ke dalam sel. kekurangan insulin pada dm, dari kurang produksi atau adanya masalah dalam penggunaan insulin yaitu sel reseptor, yang mencegah penggunaan glukosa untuk energi. tanpa insulin, tubuh akan memecah lemak dan protein tubuh. tingkat counterregulatory hormone meningkat sehingga membentuk glukosa dari sumber lain: penurunan glycogenesis (konversi glukosa menjadi glikogen), peningkatan glycogenolysis (konversi glycogen menjadi glukosa), peningkatan gluconeogenesis (pembentukan glukosa dari sumber nonkarbohidrat seperti asam amino dan laktat), peningkatan lypolisis (pemecahan tigliserida menjadi gliserol dan asam lemak bebas), peningkatan ketogenesis (pembentukan keton dari asam lemak bebas) dan proteolisis (pemecahan protein dengan pelepasan asam amino dalam otot) (ignatavicius & workman, 2006) sehingga terjadi akumulasi glukosa di dalam darah, yang disebut hyperglycemia. u m u m n y a s e s e o r a n g d i d i a g n o s a menderita dm atau dilakukan pemeriksaan setelah muncul gejala khas dari dm seperti poliuri, polidipsi dan poliphagi atau saat berobat untuk penyakit lain seperti saat akan dilakukan pembedahan, pasien baru mengetahui menderita dm. faktor-faktor risiko dm pada seseorang (smeltzer dan bare, 2000) riwayat keluarga, usia, kelompok etnis dan berat badan. oleh karena riwayat keluarga menjadi faktor risiko dm, maka para remaja yang memiliki kakek atau nenek menderita dm dan terlebih lagi yang memiliki orang tua dm harus melakukan langkah antisipasi untuk pencegahan dan deteksi secara dini akan munculnya penyakit ini. hubungan waist circumference (central obesity) dengan risiko timbulnya dm pada remaja sma di kota malang lingkar pinggang merupakan salah satu indikator kegemukan. responden remaja di smu kota malang sebagian besar (91,2%) didapatkan lingkar pinggang atau waist circumference (central obesity) yang tergolong normal. namun faktor risiko timbulnya diabetes mellitus (dyah widodo) 45 demikian ada 6,4% lebih gemuk dan 2,4% mengarah pada obesitas. hasil uji korelasi spearman rho dengan alpha 0,05 antara lingkar pinggang atau waist circumference (central obesity) dengan risiko timbulnya dm didapatkan nilai p 0,000 < alpha 0,05. hal ini berarti ada hubungan waist circumference (central obesity) dengan risiko timbulnya dm pada remaja sma di kota malang atau ho ditolak. 19,2% atau 72 remaja mengarah pada risiko dm; 1,3% atau 5 remaja mempunyai risiko sedang dan 0,3% atau 1 remaja mempunyai risiko tinggi terhadap timbulnya penyakit dm, meskipun sebagian besar responden (79,2% atau 297 remaja) berisiko rendah terhadap penyakit dm menurut skor findrisk dm. dengan demikian sangat diperlukan langkah antisipasi mencegah timbulnya penyakit dm antara lain melalui pengaturan pola makan sehat, aktivitas yang seimbang, kontrol terhadap kondisi kesehatan sebelum masalah kesehatan menjadi parah. simpulan dan saran simpulan ada hubungan bmi dengan risiko timbulnya dm pada remaja smu di kota malang. tidak ada hubungan tekanan darah dengan risiko timbulnya dm pada remaja smu di kota malang, tidak ada hubungan kebiasaan aktivitas fisik dengan risiko timbulnya dm pada remaja smu di kota malang, tidak ada hubungan frekuensi konsumsi buah dan sayur dengan risiko timbulnya dm pada remaja smu di kota malang, tidak ada hubungan riwayat dm keluarga dengan risiko timbulnya dm pada remaja smu di kota malang, dan ada hubungan waist circumference (central obesity) dengan risiko timbulnya dm pada remaja smu di kota malang. saran perlu memperhatikan pola makan yang sehat dan seimbang bagi remaja smu, cukup sayur dan buah agar terjaga berat badan yang ideal dan lingkar perut yang normal sehingga terhindar dari risiko penyakit dm. selain itu aktivitas fisik harus tetap dilakukan secara berimbang dengan istirahat agar kondisi tubuh tetap sehat. khusus bagi remaja yang mempunyai riwayat keluarga menderita dm, sebaiknya selain menjaga pola hidup sehat juga melakukan langkah antisipasi serta deteksi secara dini melalui pemeriksaan laboratorium kadar gula darah. kegiatan kontrol berat badan, tinggi badan dan lingkar perut perlu dilakukan secara berkala setiap bulan melalui kegiatan uks sebagai langkah monitoring kesehatan dan antisipasi deteksi dini risiko timbulnya penyakit dm. selain itu perlu dilakukan kegiatan penyuluhan tentang penyakit dm dan pencegahannya melalui bekerja sama dengan puskesmas, dinas kesehatan atau institusi pendidikan tinggi di bidang kesehatan. demikian juga kegiatan olahraga di sekolah harus tetap dijadwalkan secara rutin sebagai sarana beraktivitas bagi siswa agar terjadi keseimbangan dengan aktivitas belajar yang lebih banyak dilakukan dengan duduk. perlu melakukan kegiatan penyuluhan tentang pencegahan penyakit dm melalui di sekolah-sekolah smu yang bekerja sama dengan puskesmas, dinas kesehatan atau institusi pendidikan tinggi di bidang kesehatan. perlu bekerja sama dengan sekolahsekolah smu untuk kegiatan program uks berupa penyuluhan tentang pencegahan penyakit dm. selain itu perlu menggalakkan deteksi dini penyakit dm berupa pemeriksaan kadar gula darah di sekolah-sekolah smu. kepustakaan atmatsier, sunita, 2003. prinsip dasar ilmu gizi. jakarta: pt gramedia pustaka utama. e u r a d i a , 2 0 1 0 . d i a m a p a r o a d m a p for diabetes research in europe, a support action funded by the european commision under the 7th framework programme, 7 sept. 2010. gibney, michael j., et al., 2009. gizi kesehatan masyarakat (public health nutrition) alih bahasa, hartono andry. jakarta: egc. jurnal ners vol. 7 no. 1 april 2012: 37–46 46 ignatavicius, d.d., and workman, m.l., 2006. medical surgical nursing 5th ed. st louis, missouri: elsevier saunders. instansi gizi rssa., 2008. buku pedoman praktis diagnosa gizi dalam proses asuhan gizi terstandar. lemone, p. and burke, k., 2008. medical surgical nursing critical thinking in client care 4th ed. canada: pearson education, inc. lisdiana. 1997. waspada terhadap kelebihan dan kekurangan gizi. jakarta: trubus agriwidya. persagi. 1999. penuntun diit. jakarta: pt gramedia pustaka utama. r u d i j a n t o , a . 2 0 1 0 . p e n c e g a h a n d a n penatalaksanaan diabetes mellitus melalui pendekatan komunitas dalam pidato pengukuhan jabatan guru besar dalam ilmu penyakit dalam – endokrin pada fk unibraw. malang. smeltzer dan bare, 2008. brunner and suddarh’s textbook of medical – surgical nursing 8th ed, philadelphia: lippincott williams & wilkin soeparman. 1987. ilmu penyakit dalam, jilid i, edisi ii, jakarta: balai penerbit fkui. soegondo, s., 2006. obesitas dalam buku ajar ilmu penyakit dalam jilid 3. edisi keempat. hal. 1941–1945. jakarta: balai penerbit fkui. soegondo, s., soewondo, p., dan subekti, i., 2009. penatalaksanaan diabetes mellitus terpadu. balai penerbit fkui. jakarta. suhardjo. 1996. berbagai cara pendidikan gizi. jakarta: bumi aksara. supariasa, idn., dkk. 2002. penilaian status gizi, jakarta: penerbit egc. vol 8 no 1 april 2013.indd 81 pengembangan model loyalitas mahasiswa keperawatan pada pendidikan tinggi keperawatan (model development of nursing student loyalty in politeknik of health) hammad*, nursalam**, ninuk dian k.** *poltekkes banjarmasin jurusan keperawatan jl. hm cokrokusumo no. 3a kelurahan sei besar banjarbaru kalimantan selatan 70714 e-mail: hammad.martapura@gmail.com **fakultas keperawatan universitas airlangga abstrak pendahuluan: loyalitas mahasiswa keperawatan adalah permasalahan penting untuk diperhatikan oleh institusi pendidikan tinggi keperawatan agar bisa terus bersaing di tengah pertumbuhan dan perkembangan institusi pendidikan keperawatan di masa sekarang ini. loyalitas mahasiswa terkait erat dengan kepuasan mahasiswa pada layanan yang diberikan oleh institusi pendidikan keperawatan di samping dipengaruhi oleh perceived value, harapan dan quality assurance pendidikan tinggi keperawatan. tujuan penelitian ini adalah mengembangkan suatu model loyalitas mahasiswa keperawatan pada pendidikan tinggi keperawatan di poltekkes banjarmasin. metode: penelitian ini merupakan penelitian eksplanatif dengan pendekatan cross sectional. populasi adalah mahasiswa di jurusan keperawatan poltekkes banjarmasin dengan besar sampel sebanyak 112 orang mahasiswa yang diambil dengan teknik proportional random sampling. data dikumpulkan melalui pemberian kuesioner dan data dianalisis dengan partial least square (pls). hasil: hasil penelitian menunjukkan bahwa terdapat pengaruh customer expectation terhadap quality assurance pendidikan tinggi keperawatan, terdapat pengaruh customer expectation terhadap perceived value mahasiswa, terdapat pengaruh customer expectation terhadap customer satisfaction, terdapat pengaruh quality assurance terhadap perceived value mahasiswa, tidak terdapat pengaruh quality assurance terhadap customer satisfaction, terdapat pengaruh perceived value terhadap customer satisfaction, terdapat pengaruh customer satisfaction terhadap customer loyalty. pembahasan: pengembangan model loyalitas mahasiswa keperawatan dikembangkan melalui peningkatan kepuasan mahasiswa yang dibentuk oleh perceived value di mana perceived value dibangun dari dua aspek yaitu harapan mahasiswa dan quality assurance pendidikan tinggi, quality assurance pendidikan tinggi kesehatan tidak berpengaruh langsung terhadap peningkatan kepuasan mahasiswa, akan tetapi secara tidak langsung dengan membentuk perceived value mahasiswa, kepuasan mahasiswa pada pendidikan tinggi keperawatan mempunyai pengaruh paling dominan terhadap loyalitas mahasiswa dibandingkan oleh aspek lain dalam model loyalitas mahasiswa. model loyalitas ini dapat digunakan untuk meningkatkan loyalitas mahasiswa pada pendidikan kesehatan dimana peningkatan loyalitas menekankan pada peningkatan kepuasan mahasiswa. penelitian lebih lanjut agar dapat menganalisis pengaruh word to mouth (getok tular) terhadap loyalitas mahasiswa. kata kunci: loyalitas mahasiswa, pendidikan tinggi keperawatan abstract introduction: loyalty of nursing student is an important factor that nursing education should pay attention in order to compete with other nursing educations; involved by perceived value, expectation, and quality assurance in nursing higher education. the purpose of this study was to develop a loyalty model of nursing student in nursing higher education. methods: this study was an explanatory research with cross sectional approach. population were nursing student in poltekkes banjarmasin, with 112 samples which is selected by proportional random sampling. 82 jurnal ners vol. 8 no. 1 april 2013: 81–87 data was collected by giving questionnaire and analyzed by partial least square. result: result of this study indicates that was an effect of costumer expectation on quality assurance in nursing higher education, there was effect of costumer expectation on perceived value in nursing student, there was an effect of customer expectation on student satisfaction (4) there was effect of quality assurance in nursing higher education, there wasn’t any affect of quality assurance in nursing higher education on student satisfaction, there was effect of perceived value in nursing student on student satisfaction, there was effect of student satisfaction on student loyalty. discussion: overall result of this research were, student loyalty in nursing higher education developed by student satisfaction. student satisfaction formed by perceived value. perceived value developed from two aspects quality assurance, and student expectation, quality assurance of higher education wasn’t directly effect to student sasfaction. however, indirectly effect through student perceived value. student satisfaction in nursing higher education was stronger effect than any other variable in this loyalty model. loyalty model in this research can be use for improvement student loyalty on health education that focused on improvement student satisfaction without deny the other aspect. further research is needed to analyze word of mouth effect on student loyalty. keywords: nursing student loyalty, nursing bachelor, student satisfaction pendahuluan persaingan bisnis saat ini sangatlah kuat baik antara pelaku bisnis usaha dari swasta dan negeri, maupun pelaku bisnis dalam negeri dengan pihak luar (internasional). berbagai cara dilakukan agar mampu memberikan kepuasan kepada para pelanggan, diantaranya dengan memberikan produk yang mutunya lebih baik, harga lebih murah, penyerahan produk yang lebih cepat dan pelayanan yang lebih baik daripada pesaing akan menyebabkan pelanggan menjadi lebih puas. masyarakat sekarang menyadari bahwa mereka mempunyai hak mendapatkan pelayanan yang lebih baik dari biaya yang telah dikeluarkan dan keinginannya harus sesuai dengan harapan yang diinginkan sehingga dalam rangka pemenuhan kebutuhan dan keinginan tersebut akan diiringi oleh tingkat kepuasan (nugroho dan puriarta, 2011). loyalitas menur ut dick dan basu (1994) merupakan integrasi antara loyalitas pelanggan dengan pendekatan perspektif sikap yang dipengaruhi oleh norma sosial dan faktorfaktor yang bersifat situasional. loyalitas menurut dick dan basu (1994) merupakan variabel yang muncul dengan didahului faktor anteseden yaitu adanya pengaruh dari proses kognitif, afektif dan konatif. hasil akhir dari loyalitas adalah adanya konsekuensi yang dihasilkan yaitu motivasi untuk mencari informasi produk/jasa, word to mouth dan resisten to counterpersuasion. data penerimaan mahasiswa poltekkes banja r masi n dengan tahu n 2011–2012 menu nju k ka n ba hwa pend af t a r pali ng banyak adalah pada jurusan keperawatan dengan jumlah pendaf tar pada rentang tiga tahun terakhir rata-rata sebanyak 1971 orang pendaftar dengan realisasi 159 orang mahasiswa. data pada tahun terakhir yaitu pada tahun 2011–2012 menunjukkan jurusan keperawatan mengalami penurunan pendaftar dari 757 menjadi 623. data pada tahun terakhir ini perlu diwaspadai karena jumlah perguruan tinggi kesehatan dar i wak t u ke wak t u bukanlah semakin sedikit, tetapi semakin terus bertambah dan menjamur dengan berbagai kelebihan yang ditawarkan kepada masyarakat sebagai konsumen dari penyedia jasa layanan pendidikan kesehatan. su r vei kepuasan mahasiswa yang dilakukan sistem penjaminan mutu pada jurusan keperawatan tahun 2012 menunjukkan tingkat kepuasan mahasiswa paling rendah berada pada masalah sarana dan prasarana yang berhubungan dengan fasilitas pendidikan yaitu 50% responden memiliki kepuasan sedang. tingkat kepuasan sedang ini harus diperhatikan karena menurut kotler (2006) bahwa dari 25% pelanggan yang merasa tidak puas, hanya 5% persen yang mengeluhkan 83 pengembangan model loyalitas mahasiswa keperawatan (hammad, dkk.) ketidakpuasan nya. masalah sarana dan prasarana sangat mempengar uhi proses belajar mengajar dan pencapaian hasil yang diharapkan dari pembelajaran. di samping it u penilaian mahasiswa atau perceived value mahasiswa terhadap pendidikan tinggi diantaranya juga dapat dipengaruhi dari unsur penilaian sarana prasarana (ryu dan han, 2010). kuo dan ye (2009) juga menyatakan bahwa kepuasan peserta didik mempunyai pengaruh yang signifi kan terhadap loyalitas peserta didik dan harus disikapi oleh pihak instit usi dengan meningkatkan qualit y institution dan institution image. sehingga tujuan umum penelitian adalah pengembangan model loyalitas mahasiswa keperawatan pada pendidikan tinggi keperawatan. bahan dan metode penelitian ini menggunakan penelitian eksplanatif yaitu pengumpulan data tanpa mela k u ka n i nter vensi at au perla k u a n. rancang bangun yang digunakan yaitu cross sectional yaitu pengumpulan data variabel penelitian hanya dilakukan sekali saja. data yang dikumpulkan adalah data primer dan sekunder. populasi dalam penelitian ini adalah mahasiswa keperawatan di jurusan keperawatan poltekkes banjarmasin. sampel yang diambil sebanyak 112 orang yang diambil dengan metode proportional random sampling. data dari variabel customer expectation, quality assurance, perceived value, customer satisfaction dan customer loyalty dikumpulkan melalui kuesioner. analisis data menggunakan partial least square (pls). hasil penilaian customer expectation pada jurusan keperawatan poltekkes banjarmasin menunjukkan bahwa untuk harapan mahasiswa mayoritas adalah pada kategori terpenuhi yaitu terutama indikator overall expectation 63 orang (56.25%),. hanya sebagian kecil yaitu sejumlah 2 orang (1.79 %) yang menyatakan bahwa harapannya kurang terpenuhi yaitu pada indikator expectation to meet your needs dan sebanyak 2 orang (1.79%) pada indikator reliability. penilaian kualitas pendidikan (quality assurance) didapatkan hasil mayoritas pada kategori baik oleh mahasiswa adalah yaitu pada kualitas evaluasi paling besar yaitu sebanyak 72 orang (64%). penilaian pada kategori kurang baik paling rendah adalah pada kualitas sarana dan prasarana yaitu 23 orang (20%) menilai kualitas sarana prasarana sangat tidak baik p e r c e i v e d va l u e m a h a s i s w a menunjukkan mayoritas pada kategori baik yaitu paling besar adalah pada y1.1 (quality vs price) sebanyak 63 orang (56.25%) menilai baik. hanya sebagian kecil mahasiswa yang mempunyai perceived value yang kurang baik terhadap pendidikan keperawatan di poltekkes banjarmasin yaitu sebanyak 2 orang (1.79%) pada price vs quality dan pada 2 orang (1.79%) pada great deal. kepuasan mahasiswa mayoritas adalah pada kepuasan terhadap dosen yaitu sebanyak 67 orang (60 %). penilaian ketidakpuasan mayoritas adalah pada kepuasan sarana dan prasarana yaitu 17 orang (15%). l o y a l i t a s (c u s t o m e r l o y a l t y) d ii n for masi ka n ba hwa u nt u k loyalit as mahasiswa hampir sama besar nya, dan mayoritas berada pada tingkatan ‘loyal’ yaitu pada loyalitas afektif sebanyak 52 orang (46%). hanya sebagian kecil yang tidak loyal yaitu sebanyak 1 orang (0.89%) pada loyalitas aksi. pengujian hipotesis dilakukan dengan analisis model struktural pada masing-masing jalur baik pada jalur pengar uh langsung maupun pengaruh tidak langsung melalui variabel mediasi. pembahasan hasil penelit ia n pad a ga mba r 1 menunjukkan bahwa ada pengaruh signifi kan customer expectation terhadap qualit y assurance pendidikan tinggi keperawatan di poltekkes banjarmasin. upaya pemenuhan s t a n d a r ole h polt e k ke s b a nja r m a si n ditunjukkan oleh deskripsi variabel customer expectation yang dinilai mahasiswa mayoritas berada pada kategori terpenuhi terutama indikator overall expectation (penilaian bahwa 84 jurnal ners vol. 8 no. 1 april 2013: 81–87 gambar 1. analisis uji model pengembangan model loyalitas mahasiswa terhadap pendidikan tinggi keperawatan di poltekkes banjarmasin tabel 1. tabel rekapitulasi hasil uji hipotesis pengembangan model loyalitas mahasiswa keperawatan pada pendidikan keperawatan di poltekkes banjarmasin tahun 2013 no pengaruh antar-variabel p value path coeffi cients keterangan 1 harapan mahasiswa dengan quality assurance pendidikan tinggi keperawatan <0,002 0,283 signifi kan 2 harapan mahasiswa dengan perceived value mahasiswa <0,001 0,541 signifi kan 3 harapan mahasiswa dengan kepuasan mahasiswa <0,004 0,254 signifi kan 4 quality assurance pendidikan tinggi keperawatan dengan perceived value mahasiswa <0,002 0,239 signifi kan 5 quality assurance pendidikan tinggi keperawatan dengan kepuasan mahasiswa <0,571 0,042 tidak signifi kan 6 perceived value mahasiswa dengan kepuasan mahasiswa <0,001 0,510 signifi kan 7 kepuasan mahasiswa dengan loyalitas mahasiswa <0,001 0,719 signifi kan institusi telah memenuhi harapan mahasiswa) yaitu sebanyak 63 orang (56,25%) dan quality assurance dinilai mahasiswa mayoritas berada pada kategori baik terutama pada kualitas evaluasi yaitu sebanyak 72 orang (64%) di mana kualitas evaluasi dinilai mahasiswa transparan, dan dapat benar-benar mengukur pengetahuan dan keterampilan mahasiswa. adanya pengaruh harapan terhadap q ualit y assurance pend id i ka n ti ngg i keperawatan di poltek kes banjar masin didukung oleh per nyataan erevelles dan leavitt 1992, dalam tjiptono 2011 bahwa customer expectation merupakan prediksi terhadap kemungkinan atribut atau kinerja dari suatu produk. pernyataan dari fornell et al. (1996 ) dalam wibowo dan mulyono (2009) juga menyatakan bahwa customer expectation mer upakan suatu peramalan (forecast) dari kemampuan perusahaan untuk memberikan kualitas yang baik di waktu yang akan datang dan berhubungan positif dengan kualitas ( perceived quality) dan juga dengan nilai pelanggan. hasil penelitian disimpulkan bahwa apabila harapan mahasiswa terpenuhi dengan baik maka berarti bahwa kualitas 85 pengembangan model loyalitas mahasiswa keperawatan (hammad, dkk.) gambar 2. temuan model loyalitas mahasiswa keperawatan pada pendidikan tinggi keperawatan berbasis model konsep quality assurance pendidikan tinggi, customer satisfaction dan customer loyalty. input, proses dan output akan dinilai baik pula oleh mahasiswa. pernyataan ini menunjukkan bahwa institusi pendidikan keperawatan poltekkes banjarmasin telah mampu memenuhi standar yang diinginkan oleh mahasiswa sebagai penerima layanan jasa pendidikan. hasil penelitian menginformasikan bahwa ada pengaruh signifikan customer expectation mahasiswa terhadap perceived value mahasiswa pada pendidikan tinggi keperawatan di poltekkes banjarmasin. customer expectation mahasiswa mayoritas berada pada kategori terpenuhi terutama pada indikator overall expectation yaitu sebanyak 63 orang (56,25%) dan perceived value mahasiswa mayoritas pada kategori baik yaitu paling besar adalah pada quality vs price sebanyak 63 orang (56,25%). hasil bahwa ad a penga r u h ya ng signifi kan antara harapan mahasiswa dengan perceived value mahasiswa sesuai dengan model konsep jcsi (2010) yang menyatakan bahwa ada hubungan sig nif ikan antara harapan mahasiswa dengan perceived value mahasiswa. harapan mahasiswa dapat terpenuhi dengan baik di mana standar yang diinginkan mahasiswa terhadap institusi dapat terpenuhi yaitu di mana dosen dapat memenuhi standar penampilan yang baik, standar kemampuan mengajar dan metode yang sesuai harapan, sikap yang baik dari staf akademik dan juga dosen, standar yang terpenuhi dari lingkungan belajar mengajar baik di kelas maupun praktek, maka perceived value mahasiswa juga akan baik di mana mahasiswa akan menilai bahwa pelayanan yang diberikan institusi sesuai dengan harga/biaya yang dibayar. hasil a nalisis jalu r terbu k t i ad a pengaruh signifi kan customer expectation terhadap customer satisfaction mahasiswa pendidikan tinggi keperawatan di poltekkes banjarmasin. ke s e nja ng a n d a r i s t a nd a r ya ng d ii ng i n k a n ma ha siswa bai k d a r i seg i pembelajaran, tenaga dosen dan administrasi, dan sarana dan prasarana penunjang akan menimbulkan kesenjangan kepuasan oleh mahasiswa terhadap sarana prasarana, dosen, kepuasan terhadap pembelajaran dan kepuasan terhadap layanan staf akademik yang cepat dan tanggap terhadap keluhan mahasiswa. pengaruh quality assurance pendidikan tinggi keperawatan terhadap perceived value hasil analisis jalur menunjukkan bahwa ada pengaruh signifi kan quality assurance (input, proses, output) institusi keperawatan di poltekkes banjarmasin terhadap perceived value mahasiswa. perceived value adalah penilaian keseluruhan oleh pelanggan atas kegunaan sebuah produk berdasarkan pada persepsi apa yang diterima dan apa yang diberikan yang 86 jurnal ners vol. 8 no. 1 april 2013: 81–87 berarti bahwa perceived value dibentuk setelah pelanggan menilai kualitas suatu produk barang/jasa (parasuraman, et al., 1985). wo o d r u f f d a n g a r d i a l (2 0 0 2) menyimpulkan perceived value merupakan evaluasi dari hasil kinerja suatu penyedia produk jasa dengan harapan yang dimiliki oleh pelanggan dan akan memicu pelanggan untuk mengeksplorasi, memelihara atau mengakhiri hubungan dengan supplier dan jika supplier tidak mengantisipasi perubahan customer's value, hal ini dapat mengakibatkan putusnya hubungan antara pelanggan dengan supplier atau penyedia jasa layanan. pengaruh quality assurance pendidikan tinggi keperawatan terhadap customer satisfaction hasil analisis jalu r menu nju k kan bahwa tidak ada pengaruh signifi kan quality assurance pendidikan tinggi keperawatan di poltekkes banjarmasin terhadap customer satisfaction (dosen, sarana dan prasarana, proses pembelaja ra n d a n laya na n st af akademik). johnson, et al. (2001) dalam henning (2009) berpendapat bahwa pada kenyataannya di lapangan sering terjadi bahwa, faktor quality assurance tidak memengar uhi kepuasan pelanggan. milfelner, boris, dan korda (2000) meng uatkan bahwa relationship antara quality assurance dan customer satisfaction adalah sangat lemah dan tidak signifi kan dan menunjukkan tidak mempunyai pengaruh langsu ng terhadap kepuasan pelanggan serta bisa direject dari penyusunan model loyalitas. a su m si ya ng d id apat k a n ba hwa pengaruh quality assurance tidak secara langsung mempengaruhi customer satisfaction; tetapi mempengaruhi secara tidak langsung melalui jalur variabel perceived value. pengaruh perceived value terhadap customer satisfaction perceived value mahasiswa pada layanan pendidikan tinggi keperawatan di poltekkes banjarmasin berpengaruh terhadap kepuasan mahasiswa baik kepuasan terhadap dosen, sarana dan prasarana, proses pembelajaran dan layanan staf akademik. kepuasan mahasiswa terjadi karena mahasiswa telah menilai keseluruhan dari suatu pengalaman pembelian dan konsumsi atas barang maupun jasa layanan pendidikan keperawatan yang telah dirasakan selama menempuh perkuliahan. apabila kenyataan yang dirasakan melebihi harapan (positif disconfi rmation) kemungkinan akan mengarah pada peningkatan kepuasan mahasiswa, dan apabila jauh dar i harapan (negatif disconfi rmation) mengakibatkan penurunan kepuasan mahasiswa. pengaruh customer satisfaction terhadap customer loyalty hasil analisis jalur menunjukkan bahwa hubungan antara 2 (dua) variabel ini signifi kan dan paling kuat di antara jalur hubungan antar variabel lainnya. ryu dan han (2010) menyatakan bahwa kepuasan terhadap physical environment seperti facility aesthetics, lighting, dan layout mempunyai pengaruh yang signifi kan terhadap terhadap kepuasan. menurut kuo dan ye (2009) kepuasan peserta didik harus disikapi oleh pihak institusi dengan meningkatkan quality institution dan institution image. h a si l d id a p a t b a hw a ke p u a s a n mahasiswa mayoritas puas terutama pada kepuasan terhadap dosen dan loyalitas mayoritas pada loyalitas afektif di mana loyalitas ini dipengaruhi oleh unsur perasaaan dan rasa nyaman oleh mahasiswa. i ni menunjukkan bahwa mahasiswa keperawatan di poltekkes banjarmasin merasakan adanya ikatan emosional pada institusi pendidikan keperawatan di poltek kes banjar masin. perasaan nyaman tidak hanya dirasakan dari lingkungan perkuliahan fi sik yang tenang dan menunjang perkuliahan, tetapi adanya rasa aman dari lingkungan kampus dan dukungan masyarakat terhadap kegiatan mahasiswa keperawatan juga menimbulkan perasaan yang menyenangkan mahasiswa. rasa nyaman juga diciptakan juga oleh adanya lingkungan non fi sik yaitu sikap emphaty dan responsiveness dari dosen di mana dosen menunjukkan 87 pengembangan model loyalitas mahasiswa keperawatan (hammad, dkk.) perhatian pada permasalahan yang dialami mahasiswa saat kuliah atau praktek di lapangan dengan memberikan supervisi dan bimbingan yang maksimal. masukan pendapat dan diskusi dengan mahasiswa juga sering dilakukan untuk meningkatkan mutu pembelajaran. simpulan dan saran simpulan pe n g e m b a n g a n m o d el loy a l it a s mahasiswa keperawatan dikembangkan melalui peningkatan kepuasan mahasiswa. loyalitas akan terbentuk kalau kepuasan mahasiswa dipenuhi. quality assurance pendidikan tinggi keperawatan tidak berpengaruh langsung terhadap peningkatan kepuasan mahasiswa, akan tetapi secara tidak langsung dengan membentuk perceived value mahasiswa. kepuasan mahasiswa pada pendidikan tinggi keperawatan mempunyai pengaruh paling dominan terhadap loyalitas mahasiswa karena kepuasan terkait perasaan nyaman dan terpenuhinya harapan mahasiswa. saran model loyalitas ini menunjuk kan perlu nya pen i ng kat an kepuasan d alam rangka meningkatkan loyalitas mahasiswa pada institusi pendidikan kesehatan. untuk meningkatkan loyalitas mahasiswa pada institusi pendidikan kesehatan perlu penekanan pada peningkatan kepuasan mahasiswa dengan tidak mengesampingkan aspek quality assurance institusi, harapan mahasiswa, dan perceived value mahasiswa penelitian lebih lanjut perlu untuk menganalisis pengaruh word of mouth terhadap loyalitas mahasiswa. kepustakaan dick, as. dan basu k., 1994. customer l oy a lt y: tow a r d a n i nt eg r a t e d fr a mework . jo u r n a l of ac a d e m y marketing science, 22(2), 101. henning, j., 2009. acsi model: strengths and weaknesses. akses tanggal 10 april 2013. http://blog.vovici.com/blog/ bid/18165/acsi-american-customersatisfaction-index-model-strengthsand-weaknesses. jcsi, 2010. japanese customer satisfaction index, (online), (http://www.jpcnet. jp/eng/research/index.htm., diakses tanggal 10 november 2012). kotler, p. and keller, kl., 2007. marketing management. new jersey: pearson education inc. kuo, ky. and ye, dk., 2009. the causal relationship between service quality, corporate image and adults' learning satisfaction and loyalty: a study of professional training programmes in a taiwanese vocational institute. journal total quality management & business excellence, 20(7). milferner, b., snoj, b., korda, ap., 2000. measurement of perceived quality, perceived value, image, and satisfaction inter relations of hotel ser vices: comparison of tourists from slovenia and italy. slovenia. paper faculty of economics and business, maribor. 605–624. parasuraman, a., zeithaml, va., berry, ll, journal of marketing, 49 (fall 1985): 41–50. ryu, k. and han, d., 2010. infl uence of physical environ ment on disconf ir mation, customer satisfaction, and customer loyalty for first-time and repeat customers in upscale restaurants. international chr ie conferencerefereed track, paper 13. tjiptono, f., 2011. manajemen dan strategi merk. yogyakarta. andi offset. wibowo, aji. dan mulyono, f., 2009. dampak ekspektasi pelanggan, persepsi kualitas, dan persepsi nilai terhadap kepuasan pelanggan, serta implikasinya terhadap kepuasan pelanggan. jurnal ekonomi fakultas unpar, 13(1), 64–95. woodruff, rb., gardial, sf., 2002. exploring the phenomenon of customers’ desired value change in a business-to-business context. journal of marketing, 66(4), 102–117. ners vol 5 no 1 april 2010_akreditasi 2013.indd 15 latihan rom lengan meningkatkan kekuatan otot pada pasien pasca-stroke (range of motion exercise of arms increases the mucle strength for post stroke patients) judi nurbaeni*, i ketut sudiana**, harmayetty** *rsud dr. soedono madiun jl. dr sutomo 59 madiun telp./fax (0351) 464325. e–mail: nurbaenijudi@yahoo.co.id **fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya abstract introduction: someone attached by stroke can’t do their activity fl uently because stroke can cause the weakness of motor and sensor function. this condition cause physical defect and give effect in social and economic too, because someone who suffered stroke usually still in productive age. the objective of this study was to examine the effect of arm range of motion in the muscle strength of post stroke patient. method: pre experimental pre–post test design was used in this study. population of this study was post stroke patient in wijayakusuma ward dr. soedono hospital and total samples were 11 respondents. independent variable was arm range of motion exercise, dependent variable was strength of arm muscle. data were collected by observation with manual muscle testing of lovelt, naniel and worthinghom and then analyzed using wilcoxon signed rank test with signifi cant level of α ≤ 0.05. result: the result showed that 11 respondents had increased their strength of muscle (p = 0.04). discussion: it can be concluded that the strength of muscle increased after get arm range of motion exercise. when range of motion had been done ca+ will be activated by cell so that happen integrity of muscle protein. if ca+ and troponin had been activated, actin and myosin would have been defensed, so that can moved the skeletal and followed by muscle contraction, expand, outgrow and had a tonus. this condition can showed the strength of muscle. keywords: arm range of motion, stroke, strength of arm muscle pendahuluan kebutuhan aktivitas (pergerakan) adalah salah satu tanda kesehatan yaitu adanya kemampuan seseorang melakukan aktivitas seperti berdiri, berjalan, dan bekerja. salah satu faktor yang memengaruhi aktivitas pergerakan adalah karena kondisi di mana seseorang tidak mampu melakukan pergerakan secara mandiri oleh adanya gangguan fungsi motorik. stroke adalah penyakit neurologis terbanyak yang dapat mengakibatkan masalah kesehatan yang serius dan berdampak pada kecacatan, kematian dan ekonomi keluarga, akibat dari adanya disfungsi motorik dan sensorik. stroke merupakan sindrom klinis yang awal timbulnya mendadak, progresif, berupa defisit neurologis fokal dan atau global yang berlangsung 24 jam atau lebih atau langsung menimbulkan kematian, dan semata-mata disebabkan oleh gangguan aliran darah otak non traumatik (arief, 2000). adanya bekuan atau lesi pada pembuluh darah otak akan menimbulkan obstruksi aliran darah sehingga sel-sel saraf otak mengalami iskemia. sel-sel saraf yang mengalami iskemia dalam beberapa menit akan mengalami kerusakan yang irriversibel dan akhirnya akan mengalami disfungsi. lokasi dan besarnya disfungsi sel saraf otak akan menentukan jenis defisit neurologis yang terjadi. defisit neurologis dapat berupa disfungsi motorik dan atau defisit sensorik. disfungsi motorik yang paling umum adalah hemiplegi yaitu terjadinya paralysis atau kelemahan fungsi motorik pada salah satu sisi. kelemahan fungsi motorik ini dapat disebabkan karena pecahnya pembuluh jurnal ners vol. 5 no. 1 april 2010: 15–20 16 darah otak dan timbul lesi pada bagian fungsi motorik otak sehingga terjadi defisit neurologis pada sisi yang berlawanan (mahar, 1994). adanya hemiplegi ini menyebabkan penderita stroke setelah fase penyembuhan akan timbul kecacatan dan kelemahan beberapa fungsi motorik yang bervariasi. kelemahan fungsi motorik yang dapat terjadi antara lain: kelemahan menggerakkan kaki, kelemahan menggerakkan tangan, ketidakmampuan bicara dan ketidakmampuan fungsi-fungsi motorik lainnya. kondisi ini mengakibatkan terjadinya penurunan fungsi individu secara ekonomi dan sosial, karena stroke banyak terjadi pada usia produktif (muttaqin, 2008). pertolongan dan pengobatan pasien stroke ditujukan untuk meningkatkan aliran darah otak, mencegah kematian dan meminimalkan kecacatan yang ditimbulkan (mahar, 1994). rehabilitasi dan latihan range of motion (rom) merupakan salah satu terapi lanjutan pada pasien stroke setelah fase akut telah lewat dan memasuki fase penyembuhan. mobilisasi dini dalam bentuk latihan range of motion sebagai bagian dari rehabilitasi mempunyai peranan yang besar untuk mengembalikan kemampuan penderita untuk kembali bergerak, memenuhi kebutuhan sehari-harinya, sampai kembali bekerja. mobilisasi adalah merupakan suatu aspek yang terpenting pada fungsi fisiologis karena hal itu esensial untuk mempertahankan kemandirian seseorang (carpenito, 2000). a m e r i c a n h e a r t a s s o c i a t i o n menyebutkan bahwa setiap tahun terjadi 750.000 kasus stroke baru di amerika. dari data tersebut menunjukkan bahwa setiap 45 menit ada satu orang amerika yang terkena serangan stroke. terdapat kira-kira 2 juta orang bertahan hidup dari stroke yang mempunyai kecacatan, dari angka ini 40% memerlukan bantuan dalam aktivitas kehidupan sehari-hari (smeltzer dan bare, 2002). menurut yayasan stroke indonesia terdapat kecenderungan meningkatnya jumlah penyandang stroke di indonesia dalam dasawarsa terakhir, bahkan menurut survey tahun 2004, stroke merupakan pembunuh nomor satu di rumah sakit pemerintah di seluruh penjuru indonesia. peningkatan jumlah penderita stroke di indonesia identik dengan wabah kegemukan akibat pola makan kaya lemak atau kolesterol yang melanda seluruh dunia tidak terkecuali di indonesia. di indonesia stroke merupakan penyakit nomer tiga yang mematikan setelah penyakit jantung dan kanker, diperkirakan ada 500.000 penduduk yang terkena stroke. jumlah penderita stroke di indonesia kian meningkat dari tahun ke tahun, sekitar 28,5% penderita meninggal dunia (david, 2002). hasil rekam medis di rsu dr. soedono madiun selama kurun waktu 2 tahun terakhir angka kejadian penyakit stroke dapat digambarkan sebagai mana berikut ini tahun 2007 telah dirawat sejumlah total 122 dan penderita meninggal sejumlah 29 orang, dengan gambaran penderita menurut usia adalah 8 orang (usia 25–44 tahun), 74 orang (usia 45–64 tahun). tahun 2008 dirawat penderita stroke sejumlah total 140 orang meninggal 27 orang. sedangkan gambaran jumlah penderita menurut umur 4 orang (usia 25–44 tahun) 87 orang (usia 45–64 tahun). dari data di atas dapat diambil kesimpulan bahwa kurun waktu 2 tahun terakhir jumlah penderita stroke meningkat tajam dengan angka kematian ± 20% total penderita. menurut gambaran usia stroke 75% terjadi di usia produktif, di mana seseorang masih dalam saat untuk aktif bekerja dan banyak aktivitas. sedangkan gambaran penderita menurut jenis kelamin dalam kurun waktu 2 tahun terakhir adalah pada tahun 2007 perbandingan penderita l:p=74:48, sedangkan tahun 2008 perbandingan l:p= 95:45. stroke sebagai salah satu penyakit g a n g g u a n p e m b u l u h d a r a h o t a k d a p a t mengakibatkan cacat fisik yang disebut hemiplegi (kelumpuhan separo), 80–85% penderita stroke adalah stroke tipe iskemik yang terjadi akibat obstruksi atau bekuan disatu atau lebih arteri besar pada sirkulasi serebrum. sel-sel saraf yang mengalami iskemi, 80% (cbf 10 ml/100 gr jaringan otak/menit) akan mengalami kerusakan irreversibel dalam beberapa menit. otak tidak bisa menyimpan darah atau oksigen dan membutuhkan pasokan konstan untuk berfungsi secara normal. otak membutuhkan arteri yang membawa darah dan oksigen. ketika arteri diblokir sel-sel otak tidak berfungsi dan mati dengan cepat. itu sebabnya rom lengan terhadap kekuatan otot (judi nurbaeni) 17 sebuah stroke iskemik mengarah ke beberapa komplikasi seperti gangguan fisik misalnya kehilangan fungsi motorik berupa hemiplegia, dan hemiparese. kehilangan fungsi komunikasi berupa disartria, afasia, apraksia. gangguan persepsi visual, gangguan visual spasial, kehilangan fungsi sensori, dan masih banyak lagi (harun, 1998). pasien yang mengalami keterbatasan fisik akibat hemiplegi atau hemiparese, tidak mampu memenuhi kebutuhan aktivitas perlu diberi latihan rentang gerak sesuai kondisi guna memperbaiki kemampuan otot untuk berkontraksi ataupun relaksasi. latihan rentang gerak atau rom yang selama ini telah diberikan sebetulnya melatih otot dan sendi untuk beraktivitas yang mana karena serangan stroke fungsinya menjadi turun. dengan memberikan latihan yang ditingkatkan diharapkan bisa mendapat hasil yang lebih baik. proses kontraksi otot terjadi akibat dari interaksi antara actin dan myosin, sehingga otot mampu berkontraksi. otot bekerja dengan cara berkontraksi sehingga otot akan memendek, mengeras dan bagian tengahnya menggelembung (membesar). karena memendek maka tulang yang dilekati oleh otot tersebut akan tertarik atau terangkat. keadaan ini dikenal dengan kekuatan otot. strength otot lengan atau kekuatan otot lengan merupakan sumber dasar dalam melakukan semua kegiatan aktivitas kehidupan pasien (lily, 2003). kekuatan otot pada penderita stroke dapat segera dilatih melalui latihan rom setelah pasca serangan stroke berlalu. latihan dapat dilakukan baik secara aktif maupun secara pasif dan aktif. dampak latihan rom yang tidak segera dilakukan pada pasien stroke sedini mungkin adalah terjadinya atrofi sel-sel otot, penurunan kemampuan kontraksi otot, kekakuan sendi, nyeri saat pergerakan dan secara keseluruhan akan berakibat ketidakmampuan untuk bergerak atau beraktivitas. kondisi ini akan memperparah keadaan pasien dan menimbulkan kecacatan. bahan dan metode desain yang digunakan pada penelitian ini adalah pra eksperimental (one group pre–post test design) yaitu responden penelitian hanya satu kelompok yang dilakukan pengukuran terlebih dahulu sebelum mendapat perlakuan, yaitu latihan rom lengan kemudian setelah menerima perlakuan dilakukan pengukuran kembali untuk mengetahui akibat dari perlakuan tersebut. populasi dalam penelitian ini adalah pasien paska stroke yang dirawat di irna wijayakusuma rumah sakit umum dr. soedono madiun dengan jumlah sampel sebesar 11 responden, yang diperoleh dengan teknik pengambilan sampel yaitu purposive sampling atau pengambilan sampel sesuai dengan kriteria inklusi yang telah ditentukan oleh peneliti. kriteria inklusi yang digunakan yaitu stroke hemiplegi iskemik serangan pertama yang dirawat di irna wijayakusuma, usia 40–65 tahun, telah melewati masa kritis dan masuk fase penyembuhan (hari ke-7 paska serangan). variabel bebas (independent) dalam penelitian ini adalah latihan rom lengan yang diberikan sebanyak 2 kali/hari yang pelaksanaannya disesuaikan standar operasional prosedur dari latihan rom lengan, sedangkan variabel tergantung dalam penelitian ini adalah kekuatan otot lengan yaitu keadaan di mana terdapat tonus otot, kemampuan untuk menahan gravitasi dan ada kemampuan untuk menerima tahanan. instrumen yang digunakan untuk mengukur kekuatan otot adalah dengan menggunakan manual muscle testing menurut lovelt, naniel dan worthinghom dengan pemberian skor sebagai berikut derajat 0: paralise total, derajat 1: kontraksi otot hanya diketahui dari palpasi, derajat 2: otot hanya mampu menggerakkan persendian tidak dapat melawan gravitasi, derajat 3: otot mampu menggerakkan sendi, mampu menahan gravitasi, tetapi tidak bisa menerima tahanan, derajat 4: kemampuan otot seperti derajat 3 tetapi mampu menahan beban ringan, jurnal ners vol. 5 no. 1 april 2010: 15–20 18 derajat 5: kekuatan otot normal. data yang didapat kemudian ditabulasi dan dianalisis menggunakan wilcoxon signed rank test dengan tingkat kemaknaan α ≤ 0,05. hasil kekuatan otot responden pasien paska stroke berkisar antara 2–3–4 sebelum dilakukan latihan rom. skala 4 sebesar 18,18%, skala 3 adalah 36,36% dan skala 2 adalah sebesar 45,45%. hasil tersebut menunjukkan bahwa sebelum diberikan perlakuan rom lengan responden terbanyak berada pada skala kekuatan otot 2. tabel 1. data kekuatan otot pre dan post diberikan rom lengan pre pemberian rom lengan post pemberian rom lengan selisih perubahan mean 2,73 4,45 1,727 sd 786 522 wilcoxon sign rank test p = 0,04 keterangan: mean = rerata sd = standar deviasi p = signifi kansi rerata kekuatan otot dari 11 responden menunjukkan adanya perubahan rerata sebelum diberikan perlakuan dan setelah diberikan p e r l a k u a n , y a i t u m e n u n j u k k a n a d a n y a penambahan rerata kekuatan otot. setelah dilakukan uji statistik dengan menggunakan wilcoxon sign rank test dengan tingkat kemaknaan α ≤ 0,05 didapatkan hasil p = 0,04. hasil ini menunjukkan bahwa adanya pengaruh yang signifikan pemberian rom lengan terhadap peningkatan kekuatan otot pada pasien pasca-stroke. pembahasan m e n u a m e r u p a k a n s u a t u p r o s e s m e n g h i l a n g n y a s e c a r a p e r l a h a n l a h a n kemampuan jaringan untuk memperbaiki, mengganti diri dan mempertahankan struktur dan fungsi normalnya. menua ditandai dengan kehilangan secara progresif lean body mass (lbm) atau jaringan aktif tubuh yang dimulai pada usia 40 tahun, disertai dengan menurunnya metabolisme basal sebesar 2% setiap tahunnya. penurunan kekuatan otot mengakibatkan orang sering merasa letih dan merasa lemah, daya tahan tubuh menurun karena terjadi atrofi, perubahan metabolisme lemak ditandai dengan naiknya kadar kolesterol total dan trigliserida. menurut hartanto (2009) insiden stroke akan meningkat secara eksponensial menjadi dua hingga tiga kali lipat setiap decade di atas usia 50 tahun. terdapat data yang menyebutkan 1 dari 3 orang yang berusia 60 tahun akan menderita stroke. data pada penelitian ini menunjukkan bahwa angka kejadian stroke tertinggi berada diusia di bawah 60 tahun, hal ini diduga karena pada usia pertengahan seseorang berada pada tahap aktivitas yang tinggi dan ditunjang pula oleh tingkat stres yang yang tinggi sehingga memicu kejadian penyakit stroke. sedangkan kejadian stroke menurut jenis kelamin pada penelitian ini ditemukan bahwa 72,7% terjadi pada laki-laki, dan 27,3% hal ini disebabkan jenis kelamin juga diartikan sebagai energi psikis yang bekerja, bergerak, bersifat dinamis selaras dengan motif perilaku individu. seperti pendapat hartanto (2009) pria lebih berisiko terkena stroke serangan pada pria umumnya terjadi pada usia lebih muda. pada laki-laki pemicu kejadian stroke diduga dari faktor kebiasaan merokok, minum-minuman beralkohol, obesitas, dan dari faktor psikis yang mana laki-laki rentan untuk terjadinya stres karena tuntutan pekerjaan ataupun tuntutan kebutuhan yang mana laki-laki adalah sebagai pencari kebutuhan finansial untuk keluarga. perempuan meskipun juga tidak luput dari faktor pencetus stroke namun perempuan masih dapat diuntungkan bilamana masih dalam tahap produktif karena adanya estrogen, yang mana dapat mencegah kejadian stroke. perubahan hormonal pada tubuh perempuan ini berakibat munculnya gejala-gejala seperti nyeri sendi dan sakit pada punggung, pengeringan pada vagina (sehingga sakit saat melakukan hubungan seksual), sulit menahan kencing, gangguan mood dan emosi tinggi sehingga menimbulkan stres, selain itu penurunan kadar estrogen juga rom lengan terhadap kekuatan otot (judi nurbaeni) 19 mengakibatkan kecenderungan peningkatan tekanan darah, pertambahan berat badan dan peningkatan kadar kolesterol. pada jangka panjang keluhan akibat menurunnya kadar estrogen ini dapat menyebabkan osteoporosis, penyakit jantung koroner, stroke. kekuatan merupakan sumber dasar dalam melakukan pemenuhan kebutuhan aktivitas. hasil penelitian ini menunjukkan bahwa kekuatan otot terbanyak pada penderita paska stroke sebelum dilakukan rom adalah skala 2 yang dapat diartikan otot lengan hanya mampu menggerakkan sendi namun tidak dapat melawan gravitasi. m a h a r ( 1 9 9 4 ) m e n g a t a k a n p a d a penderita stroke yang mengalami hemiparese akan mengalami transport aktif ca+ terhambat sehingga ca+ dalam retikulum sarkoplasma meningkat. kalsium dipompa dari retikulum dan berdifusi kelepuh-lepuh kemudian kalsium disimpan di retikulum, apabila konsentrasi kalsium diluar sarkoplasma meningkat maka interaksi antara aktin myosin akan berhenti dan otot melemah. sehingga terjadi penurunan kekuatan otot, otot menjadi lemah tidak mampu menggerakkan sendi, pada kadaan lebih lanjut dapat terjadi kontraktur. mahar (1994) mengatakan bahwa otot merupakan jaringan yang kegiataanya dapat digalakkan, dan kegiatannya adalah berkontraksi yaitu memendekkan dirinya. karya otot dimanfaatkan untuk memindahkan bagian-bagian skelet yang berarti bahwa suatu gerakan terjadi. sewaktu serat otot rangka berada dalam keadaan beristirahat kepala myosin dihambat untuk berikatan dengan filamen aktin. tanpa mengikat aktin, atp miosin tidak dapat diuraikan dan otot idak berkontraksi. kepala myosin dihambat untuk berikatan dengan molekul aktin karena adanya dua protein lain yang membentuk filamen tipis yaitu troponin dan tropomiosin. kontraksi suatu otot terjadi apabila jembatan silang miosin berikatan dengan tempat-tempat spesifik di protein aktin. apabila hal ini terjadi, maka sebuah molekul atp yang terdapat di kepala miosin terurai oleh miosin atpase (enzim) dan terjadi pembebesan energi. energi digunakan untuk mengayunkan jembatan–silang, sehingga filamen aktin dan miosin bergeser satu sama lain. hal ini memendekan otot (menyebabkan kontraksi). selama kontraksi otot panjang filamen aktin dan miosin tidak berubah, tetapi pita i dan zona h memendek. setiap kontraksi otot melibatkan beberapa siklus berulang pergeseran filamen. setiap kontraksi menimbulkan tegangan pada otot untuk bekerja. hasil penelitian yang dilakukan, kekuatan otot penderita paska stroke yang mengalami hemiparese setelah dilakukan latihan rom mengalami peningkatan kekuatan otot, yaitu terbesar terjadi peningkatan menjadi skala 4. seperti diketahui skala 4 untuk kekuatan otot adalah mampu menahan gravitasi dan mampu menahan tahanan kurang maksimal. sedangkan skala 5 adalah kekuatan otot normal, atau otot mampu mempertahankan posisi dengan melawan gravitasi dan tahanan maximal. dengan dilakukan rom kekuatan otot meningkat hal ini disebabkan pada saat dilakukan rom untuk memobilisasi sendi maka kegiatan ini akan merangsang sel untuk mengaktifkan ca+ sehingga terjadi integritas protein otot. jika ca+ dan troponin diaktifkan maka aktin dan myosin dipertahankan agar otot dapat berfungsi, menggerakkan skeletal. gerakan skeletal akan diikuti oleh kontraksi otot, sehingga otot mengembang, membesar dan timbul tonus. akhirnya dapat muncul kekuatan otot dan imobilisasi dapat dihilangkan, kontraktur sendi dapat dicegah. latihan adalah aktivitas fisik untuk m e m b u a t k o n d i s i t u b u h m e n i n g k a t k a n kesehatan dan mempertahankan kesehatan jasmani (potter dan perry, 2002). rom adalah latihan gerakan sendi yang memungkinkan terjadinya kontraksi dan pergerakan otot, di mana klien menggerakan masing-masing persendiannya sesuai gerakan normal baik secara aktif ataupun pasif. pasien yang mengalami keterbatasan mobilisasi seperti pada pasien stroke dan keterbatasan anggota gerak atas khususnya sangat efektif untuk mendapatkan latihan rom untuk mencegah keterbatasan lebih lanjut seperti kontraktur. hal ini disebabkan karena dengan adanya latihan gerak sendi yang berupa gerakan yang melibatkan aktivitas sekelompok otot maka akan timbul tonus otot yaitu suatu keadaan jurnal ners vol. 5 no. 1 april 2010: 15–20 20 normal dari tegangan otot yang berupa gerakan kontraksi dan relaksasi yang mana memungkin tubuh mencapai gerakan fungsional dan mencegah kelemahan otot. stroke sebagai salah satu penyakit pembuluh darah otak dapat menimbulkan cacat fisik yang disebut hemiparese. kata hemiparese yang berati kelumpuhan separo. bila yang terganggu belahan otak kanan, akan memberikan kelemahan pada sisi kiri dan begitu juga sebaliknya bila yang terganggu otak kiri yang maka sisi badan kanan yang lemah. kelemahan ada yang bersifat sementara, ringan dan berat. ini semua tergantung dari keadaan sel-sel otak dan luas dan tidaknya lokasi yang terkena. ketahanan fisik yang menurun karena bertambahnya usia dan adanya penyakit lain yang berakibat menambah berat strokenya. penderita hemiplegi luas gerak sendi pada sisi yang lemah menjadi menurun dan terbatas karena semua struktur otot, otototot, permukaan sendi, dan saraf mengalami perubahan. ini disebabkan kurang mobilisasi atau inaktivitas. di dalam memelihara range of motion maka luas gerak sendi harus selalu digerakkan untuk memperoleh hasil yang baik. simpulan dan saran simpulan latihan rom lengan terbukti dapat meningkatkan kekuatan otot pasien paska stroke melalui mekanisme perangsangan sel untuk mengaktifkan ca+ sehingga terjadi integritas protein otot. jika ca+ dan troponin diaktifkan maka aktin dan myosin dipertahankan agar otot dapat berfungsi, menggerakkan skeletal. gerakan skeletal akan diikuti oleh kontraksi otot, sehingga otot mengembang, membesar dan timbul tonus. saran latihan rom sebanyak 2× perhari diterapkan pada pasien paska stroke dengan penjadwalan yang teratur. perawat harus lebih intensif untuk memberikan latihan rom kepada pasien paska stroke. selain itu ruang pelayanan keperawatan perlu memberlakukan protap latihan kepada pasien paska stroke kepustakaan carpenito, l.j., 2000. diagnosa keperawatan: aplikasi dalam praktik klinis. jakarta: egc. hartanto, o.s., 2009. pencegahan primer stroke iskemik dengan mengendalikan faktor risiko. pidato guru besar, universitas sebelas maret. harun, 1998. buku ajar ilmu penyakit dalam jilid i edisi ke-3. jakarta: balai penerbit fkui. lily, i.r., 2003. buku kuliah neurologi. jakarta: gaya baru. mahar, m., 1994. neurologi klinis dasar. jakarta: media aesculapius. muttaqin, arif, 2008. asuhan keperawatan k l i e n d e n g a n g a n g g u a n s i s t e m persarafan. jakarta: pt gramedia pustaka utama. potter dan perry, 2002. buku ajar fundamental keperawatan konsep, proses, praktek. jakarta: egc. s m e l t z e r d a n b a r e , 2 0 0 2 . b u k u a j a r keperawatan medikal bedah brunner dan suddarth. edisi 8. jakarta: egc. vol 8 no 2 oktober 2013.indd 295 kepatuhan bidan desa terhadap standart pelayanan antenatal di jawa timur (antenatal care services standart compliance of village midwife in east java province) purwaningsih*, ni ketut alit a*, esti y*, mira t*, cholicul h** *fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya 60115 ** fakultas psikologi universitas airlangga e-mail: purwaningsih1@gmail.com abstrak pendahuluan: angka kematian ibu yang tinggi memerlukan perhatian untuk melaksanakan program-program perbaikan dan peningkatan kesehatan ibu. menurut data dari east java health offi ce aki selama 2009 terdapat kelahiran hidup sejumlah 260/100.000. indikator implementasi pemantauan ibu dapat dilihat dari cakupan angka k1 (kunjungan ibu hamil pada kehamilan pertama) dan k4 (kontak minimal 4 kali selama kehamilan untuk perawatan antenatal). metode: penelitian ini dilakukan dengan desain observasional cross-sectional, merupakan studi untuk mempelajari dinamika korelasi antara faktor risiko dan efek, dengan pendekatan observasi atau pengumpulan data sekaligus pada suatu saat (titik waktu pendekatan). hasil: variabel yang terkait dengan standar kepatuhan bidan desa dalam melaksanakan anc di provinsi jawa timur adalah tingkat pengetahuan (p) = 0,014 dan infrastruktur yang diperlukan untuk anc (p) = 0,000. variabel lain tidak menunjukkan hubungan yang signifi kan seperti: umur (p) = 0,121, status (p) = 0,831, masa kerja (p) = 0,147, pendidikan (p) = 0,153, pelatihan (p) = 0,664, motivasi (p) = 0,525, supervisi (p) = 0,887, dan manfaat (p) = 0,663. diskusi: dinas kesehatan kabupaten/kota harus melakukan penyegaran pada perawatan antenatal di bidan perlu dilakukan, karena ada orang-orang yang memiliki tingkat yang cukup pengetahuan dan kurang. sarana dan prasarana yang mendukung pelaksanaan antenatal care (anc) harus difasilitasi secara efektif, untuk mendukung kinerja bidan dalam menerapkan standar pelayanan antenatal care. kata kunci: bidan desa, standar pelayanan antenatal care, anc abstract introduction: the high maternal mortality rate (mmr) require attention to implementing improvement programs and improving maternal health. according to data from east java health offi ce aki during 2009 were 260/100,000 live births. indicators of maternal monitoring imple can be seen from fi gure k1 coverage (visit pregnant women in the fi rst pregnancy) and k4 (contact at least 4 times during pregnancy for antenatal care). methods: this study was conducted with the observational design of the “cross-sectional”, is a study to learn the dynamics of the correlation between risk factors with effects, with the approach, observation or data collection at once at some point (time point approach). result: variable associated with compliance standards of village midwives in implementing the anc in the province of east java is the level of knowledge (p) = 0.014 and the infrastructure required to anc (p) = 0.000. other variables did not show a signifi cant relationship such as: age (p) = 0.121, status (p) = 0.831, period of employment (p) = 0.147, education (p) = 0.153, training (p) = 0.664, motivation (p) = 0.525, supervision (p) = 0.887, and rewards (p) = 0.663. discussion: district health offi ce/city should do a refresher on antenatal care in midwife needs to be done, since there are those who have a suffi cient level of knowledge and less. facilities and infrastructure that support the implementation of antenatal care (anc) should be facilitated effectively, to support midwives performance in implementing standards of care antenatal care. keyword: village midwife, standards, antenatal care, anc pendahuluan ti n g g i ny a a n g k a ke m a t i a n i b u (aki) perlu mendapat perhatian dengan mela k sa na k a n prog r a m perbai k a n d a n peningkatan kesehatan ibu. profi l kesehatan indonesia tahun 2009 menunjukkan aki cenderung mengalami penurunan. menurut data dinas kesehatan jawa timur aki selama 2009 sebanyak 260/100.000 kelahiran. angka ini menurun dibanding 2007, yakni 320/100.000 kelahiran. tahun 2015, di target aki turun sampai 112. salah satu kegiatan program adalah pemantauan kesehatan ibu hamil melalui kunjungan ante natal care (anc). indikator pelaksanaan pemantauan ibu hamil dapat dilihat dari angka cakupan k1 (kunjungan ibu hamil yang per tama kali pada masa kehamilan) dan k4 (kontak 296 jurnal ners vol. 8 no. 2 oktober 2013: 295–300 minimal 4 kali selama masa kehamilan untuk mendapatkan pelayanan antenatal). c a k u p a n k l d i b a w a h 7 0 % (dibandingkan jumlah sasaran ibu hamil dalam kurun waktu satu tahun) menunjukkan keterjangkauan pelayanan antenatal yang rendah sedangkan cakupan k4 di bawah 90% (dibandingkan jumlah sasaran ibu hamil dalam kurun waktu satu tahun) menunjukkan kualitas pelayanan antenatal yang belum memadai (dinas kesehatan jawa timur, 2008). ada 7 (tujuh standar) pelaksanaan anc meliputi pengukuran tinggi badan, berat badan, monitor tekanan darah, pengukuran tinggi fundus uteri, imunisasi tt, tablet fe, dan konseling tentang kondisi dan tanda bahaya kehamilan (depkes ri, 2006). data dinas kesehatan propinsi jawa timur tahun 2007, cakupan k4 untuk propinsi jawa timur adalah sebesar 82,74%, sedangkan target nya sebesar 86%. pada tahun 2009 terdapat 12.025 bidan, di mana sebanyak 10.253 bidan bertugas di puskesmas yang tersebar di kabupaten dan kota di jawa timur. bidan yang ditempatkan di desa diharapkan mendukung percepatan penurunan angka kematian ibu melalui pelayanan kesehatan pada ibu hamil, melahirkan dan nifas. a n c m e r u p a k a n k o m p o n e n pelayanan kesehatan ibu hamil terpenting u nt u k menu r u n kan angka kematian an bayi. pemeriksaan kehamilan juga terbukti mempunyai kedudukan yang sangat penting dalam upaya meningkatkan kesehatan mental dan f isik kehamilan unt uk menghadapi pe r sal i n a n ( ma nu aba , 20 07). melalu i pemer i ksaan tersebut dapat ditet apkan kesehat a n ibu ha m il, kesehat a n ja n i n dan hubungan keduanya sehingga dapat direncanakan pertolongan persalinan yang tepat. pemeriksaan kehamilan juga dapat membantu menurunkan angka kematian ibu maupun angka kematian bayi (manuaba, 1998) karena dengan melakukan pemeriksaan kehamilan secara teratur maka penyebab kematian ibu hamil dan anak dapat dicegah (salmah, 2006). bahan dan metode pe nel it ia n i n i d i la k u k a n se ca r a observasional dengan desain ”cross sectional”, yaitu suatu penelitian untuk mempelajari dinamika korelasi antara faktor-faktor risiko dengan efek, dengan pendekatan, observasi atau pengumpulan data sekaligus pada suatu saat (point time approach). pada jenis ini variabel independen dan dependen dinilai secara simultan pada satu saat, jadi tidak ada tindak lanjut. studi ini akan mengidentifi kasi prevalensi atau efek suatu fenomena (variabel dependen) dihubungkan dengan penyebab (variabel independen). populasi terjangkau pada penelitian ini meliputi bidan desa yang bertugas di 4 (empat) kabupaten/kota wilayah provinsi jawa timur meliputi kota surabaya, kabupaten sidoarjo, kabupaten mojokerto, dan kabupaten gresik. besar sampel menggunakan rumus penentuan besar sampel berdasarkan proporsi di setiap kabupaten/kota diperoleh besar sampel sebanyak: 30 bidan desa. teknik pengambilan sampel menggunakan metode consecutive sampling. kepatuhan bidan desa dalam melaksanakan pelayanan antenatal care (anc) diidentifi kasi melalui kuesioner yang diisi oleh ibu hamil yang melaksanakan anc, di mana jumlah responden ibu hamil di setiap kabupaten/kota sebanyak 20 orang ibu hamil yang anc. kuesioner untuk ibu hamil yang melaksanakan anc, dan instrumen pengamatan/observasi terkait pelaksanaan anc di unit kia. tahapan penelitian yang dilakukan adalah mengidentifikasi kepatuhan bidan desa terhadap standar pelayanan anc di jawa timur, mengidentifi kasi upaya yang telah dilakukan untuk meningkatkan kepatuhan bidan desa terhadap standar pelayanan anc di jawa timur, menganalisis hubungan predisposing factor dengan kepatuhan bidan desa terhadap standar pelayanan anc, menganalisis hubungan enabling factor dengan kepatuhan bidan desa terhadap standar pelayanan anc, menganalisis hubungan reinforcing factor dengan kepatuhan bidan 297 kepatuhan bidan desa terhadap standart pelayanan antenatal (purwaningsih, dkk.) desa terhadap standar pelayanan antenatal care, memberikan rekomendasi hasil agar dapat meningkatkan kepatuhan bidan desa dalam melaksanakan anc di jawa timur. berdasarkan data yang diperoleh dilakukan tabulasi dan analisis data dengan menggunakan uji statistik korelasi spearman’s rho untuk mengetahui hubungan faktor-faktor dengan kepatuhan bidan desa dalam melaksanakan antenatal care. dalam penelitian ini peneliti menggunakan pula analisis isi (content analyse), yaitu analisis yang menggambarkan pesan atau informasi yang jelas dari proses wawancara dengan responden tentang variabelvariabel yang diteliti. analisis isi tersebut peneliti gunakan untuk mendukung hasil uji secara kuantitatif. hasil propinsi jawa timur angka kematian bayi (akb) pada tahun 2004 sebesar 39,60 per 1000 kelahiran hidup dan turun menjadi 36,65 per 1000 kelahiran hidup pada tahun 2005, sedangkan pada tahun 2006 turun lagi menjadi 34 per 1000 kelahiran. kematian bayi di jawa timur masih cukup tinggi karena sebagian besar masyarakat enggan membawa bayinya yang masih berumur di bawah 1 (satu) bulan ke fasilitas kesehatan untuk pemeriksaan kesehatannya. tingkat pengetahuan bidan desa tentang anc menunjukkan bahwa sebagian besar bidan desa di 4 (empat) kabupaten/ kota seperti surabaya, sidoarjo, mojokerto, gresik telah memiliki tingkat pengetahuan yang baik tentang anc, namun ternyata masih ada bidan desa yang tingkat pengetahuan tentang ancnya perlu ditingkatkan karena masih pada kategori cukup dan kurang. motivasi bidan desa dalam melaksanakan anc menunjukkan bahwa hampir selur uh bidan desa di 4 kabupaten/kota memiliki motivasi yang positif dalam melaksanakan anc, namun ada bidan desa yang motivasinya masih perlu dibina untuk menjadi positif. supervisi pelayanan anc di 4 kabupaten/kota menunjukkan bahwa, di kota surabaya dan kabupaten gresik sebagian gambar 1. distribusi pengalaman pelatihan bidan desa gambar 2. distribusi pengetahuan bidan desa tentang anc gambar 3. distribusi motivasi bidan desa gambar 4. distribusi pelaksanaan supervise anc pada bidan desa 298 jurnal ners vol. 8 no. 2 oktober 2013: 295–300 gambar 5. distribusi identifi kasi pemeriksaan kehamilan gambar 6. distribusi fasilitas sarana prasarana anc gambar 10. d i s t r i b u s i i n t e r v e n s i d a s a r kebidanan pada ibu anc gambar 7. distribusi usia kehamilan ibu anc gambar 8. distribusi anamnesia kehamilan ibu anc gambar 9. distribusi pelayanan kebidanan pada ibu anc besar responden memberikan jawaban bahwa supervisi belum dilaksanakan, meskipun ada responden yang menjawab bahwa supervisi sudah dilaksanakan. sedangkan di kabupaten mojokerto dan sidoarjo menunjukkan bahwa sebagian besar supervisi dilaksanakan, namun masih ada responden yang belum mendapatkan supervisi. saat memasang manset untuk mengukur tekanan darah. seluruh bidan desa telah melaksanakan pelayanan kebidanan pada ibu yang melaksanakan anc. pengukuran tinggi fundus uteri sangat penting untuk memantau tumbuh kembang janin selama di dalam kandungan ibu. deteksi kesejahteraan janin di dalam kandungan dengan menggunakan 299 kepatuhan bidan desa terhadap standart pelayanan antenatal (purwaningsih, dkk.) laenec atau dopler mer upakan tindakan untuk mengantisipasi terjadinya fetal distress atau gawat janin. intervensi dasar kebidanan mencakup tindakan pemberian suplementasi zat besi (fe) dan memberikan imunisasi tt. sebagian besar bidan desa telah melaksanakan intervensi pemberian suplementasi zat besi (fe), dengan memberitahukan kegunaan dan cara meminumnya, meskipun ada bidan desa yang hanya memberikan fe tanpa memberitahukan cara mengonsumsinya yang tepat. pada intervensi pemberian imunisasi tt sebagian bidan desa masih menggunakan protap lama, tetapi ada bidan desa yang sudah menggunakan protap pemberian imunisasi tt yang baru. variabel yang berhubungan dengan kepatuhan bidan desa dalam melaksanakan standar anc di provinsi jawa timur adalah tingkat pengetahuan bidan desa (p) = 0,014 dan prasarana yang diperlukan untuk anc ( p) = 0,0 0 0. va r iable lai n nya t id a k menunjuk kan hubungan yang signif ikan seperti: usia (p) = 0,121, status (p) = 0, 831, masa kerja (p) = 0,147, pendidikan (p) = 0,153, pelatihan (p) = 0,664, motivasi (p) = 0,525, supervisi (p) = 0,887, dan penghargaan (p) = 0,663. pembahasan sebagian besar bidan desa di provinsi jawa timu r, yang diwakili oleh bidan desa yang bertugas di 4 kabupaten/kota (surabaya, sidoarjo, mojoker to, gresik) patuh melaksanakan standar pelayanan anc, meskipun ternyata ada sebagian kecil yang belum patuh. kepatuhan seorang petugas kesehatan berhubungan dengan perilaku. walgito (1994) mendefi nisikan perilaku atau aktivitas ke dalam pengertian yang luas yaitu perilaku yang tampak (overt behavior) dan perilaku yang tidak tampak (innert behavior), demikian pula aktivitas-aktivitas tersebut di samping aktivitas motorik juga aktivitas emosional dan kognitif. keberadaan petugas tenaga kebidanan yang benar-benar menguasai pengoperasian alat, perawatan, kemauan untuk selalu belajar menambah pengetahuan dan kreatif serta perubahan perilaku perawat ke arah yang lebih baik sangat dibutuhkan dalam pelaksanaan anc. keterampilan bidan merupakan salah satu faktor yang mendukung dalam tercapainya cakupan pelayanan kebidanan. pelatihan yang baik akan meningkatkan pengetahuan, dan keterampilan sehingga memungkinkan bidan desa memperbaiki dan meningkatkan kualitas kerjanya ter utama mengenai kepat uhan terhadap standar pelayanan antenatal care. menur ut penelitian roger (1974) seperti dikutip notoatmodjo (2003) mengungkapkan bahwa sebelum orang mengadopsi perilaku baru di dalam dirinya terjadi proses berurutan yakni: kesadaran (awareness), orang tersebut menyadari dalam arti mengetahui terlebih dahulu terhadap stimulus (objek); tertarik (interest), orang mulai ter tar ik dengan stimulus; evaluasi (evaluation), menimbangmenimbang terhadap baik/tidaknya stimulus tersebut bagi dirinya, hal ini berarti sikap responden sudah lebih baik lagi; d) mencoba (trial), orang telah mulai mencoba perilaku bar u; menerima (adoption), subjek telah berperilaku baru sesuai dengan pengetahuan, kesadaran dan sikapnya terhadap stimulus. sa r a n a pr a s a r a n a ya ng t e r se d ia untuk pelayanan anc berhubungan sangat ber makna dengan kepatuhan bidan desa dalam melaksanakan pelayanan anc. sarana prasarana disiapkan oleh dinas kesehatan yang diadakan secara bertahap melalui dana yang disiapkan oleh pemerintah daerah, maupun pemerintah pusat. tidak semua sarana tersebut tabel 2 analisis faktor kepatuhan bidan dalam melaksanakan standar anc di jawa timur spearmen rho corelation r p usia -0,170 0,121 status 0,023 0,831 masa kerja 0,159 0,147 pendidikan 0,156 0,153 pelatihan -0,047 0,668 penghargaan -0,048 0,664 pengetahuan -0,266 0,014 motivasi 0,070 0,525 supervisi -0,016 0,887 penghargaan 0,203 0,063 prasarana -0,436 0,000 300 jurnal ners vol. 8 no. 2 oktober 2013: 295–300 tersedia dengan cukup , terutama untuk sarana polindes. kebija ka n kesehat a n d i p rov i nsi jawa timur dalam mencapai target cakupan pelayanan antenatal melalui pelatihan yang diberikan kepada bidan desa, pertemuan dengan bidan koordinator secara berkala, penyediaan sarana, dan sosialisasi program anc kepada masyarakat. monitoring pelaksanaan anc dilakukan secara berjenjang mulai pertemuan bidan desa dengan bidan koordinator di puskesmas, pelaporan dan koordinasi melalui kasubdin kesehatan ibu dan anak di dinas kesehatan. untuk mencapai target sasaran pelaksanaan antenatal care bidan desa juga bekerja sama dengan kader kesehatan yang ada di desa untuk mensosialisasikan tentang pentingnya anc pada ibu hamil. pelaksanaan anc bidan desa diawasi dan mendapat bimbingan seorang bidan koordinator yang dit u nju k oleh kepala puskesmas. supervisi dilakukan bukan untuk mencari kesalahan bidan desa, tetapi untuk memberikan penghargaan kepada bidan di desa. koordinator yang bertanggung jawab pada super visi dan monitoring program pelayanan kesehatan khususnya antenatal care diharapkan memiliki nilai kepemimpinan, pembinaan terhadap bidan desa, dan mampu membangun kerja sama. sumber daya manusia (sdm) terutama bidan desa merupakan aset utama organisasi kesehatan dalam memberikan pelayanan anc pada ibu hamil. simpulan dan saran simpulan pengetahuan responden tentang anc sebagian besar dalam kategori baik. motivasi responden dalam melaksanakan pelayanan antenatal care semuanya tinggi. sebagian besar responden telah mendapatkan supervisi dari instansi terkait pelaksanaan antenatal care, meskipun ternyata masih ada responden yang belum mendapatkan supervisi secara efektif. sebagian besar responden pernah mendapatkan penghargaan dalam bentuk pujian ataupun sertifi kat dalam melaksanakan tugas, meskipun masih ada responden yang belum pernah mendapatkan penghargaan. sebagian besar bidan desa di jawa timur khususnya di 4 kabupaten/kota patuh melaksanakan standar pelayanan antanatal care. korelasi bermakna ditemukan pada variabel pengetahuan dan sarana – prasarana terhadap kepatuhan bidan desa dalam melaksanakan pelayanan anc. saran dinas kesehatan kabupaten / kota hendaknya melakukan penyegaran tentang anc pada bidan desa perlu dilakukan, mengingat masih ada yang memiliki tingkat pengetahuan cukup dan kurang, sarana dan prasarana yang menunjang pelaksanaan anc perlu difasilitasi secara efektif, untuk menunjang kinerja bidan desa dalam melaksanakan standar pelayanan anc, masih diperlukan adanya komunikasi dan diskusi yang baik antar staf dalam melaksanakan pelayanan anc, sebagai bentuk pembelajaran bersama untuk menuju ke arah yang lebih baik. supervisi perlu dilakukan secara teratur kepada bidan desa dalam melaksanakan pelayanan antenatal care oleh instansi dan petugas kesehatan yang berwenang dan kompeten. kepustakaan depar temen kesehatan. 2002. pedoman pe m a n t a u a n wi l a y a h s e t e m p a t kesehatan ibu dan anak (pws-kia). jakarta. ma nu aba , i.b.g. 1998. ilmu pen ya k it kandungan dan keluarga berencana untuk pendidikan bidan. jakar ta: penerbit buku kedokteran egc manuaba, i.b.g. 2001. kapita selek ta pe n a tala k sa n a a n rut in ob stet r i ginekologi dan kb. jakarta: penerbit buku kedokteran egc notoatmodjo. 2002. metodologi penelitian kesehatan. edisi revisi. jakar ta: rineka cipta sulaiman, s. 1998. obstet ri fisiologi. ba n d u n g: ba g i a n ob ste t r i d a n ginek ologi. fa k ult as kedok tera n universitas padjadjaran winardi, b. 1990. pengaruh berat badan dan per ubahan berat badan ibu hamil terhadap kehamilan, tinjauan kepustakaan. surabaya 131 profil pasien di gawat darurat medik anak di rsud dr. soetomo surabaya 2011 (profi le of patients at pediatric emergency services soetomo hospital surabaya) ira dharmawati,* arina setyaningtyas,* neurinda permata kusumastuti* *departemen ilmu kesehatan anak rsud dr. soetomo universitas airlangga surabaya, jl. mayjen. prof. dr. moestopo 6–8 surabaya e-mail: iradharmawati@yahoo.com abstract introduction: installation service system at the emergency department (ed) soetomo hospital is a coordinated and integrated system under one roof. include emergency medical and emergency surgery in a very important component of health services at each hospital. the information published on the patient profi le and the usefulness of emergency care services indeveloping countries and developed countries is still very rare. this study aimed to describe the characteristic of patients attending the ed at soetomo hospital surabaya. method: this study was a retrospective study. the profi le of patients visiting the ed for 1 year were recorded and presented descriptively. result: the total number of patients visiting the hospital was 5,835, with a monthly average of 486 patients. the children at the age of 1–5 years presented the largest age group (33.6%). the main diagnosis was respiratory tract infection (31%), diarrhea (17.%), followed by seizure (12.4%). the overall mortality rate was 1.7%. discussion: respiratory tract infection in children at the age of 1–5 years still count as a major problem at soetomo hospital surabaya. keywords: pediatric, emergency department, mortality pendahuluan instalasi gawat darurat (igd) adalah sarana penunjang kegiatan pelayanan kegawat daruratan dari berbagai disiplin ilmu di rumah sakit. sebagai pusat rujukan (top referral system) untuk jawa timur dan indonesia timur, rsud dr. soetomo juga mempunyai igd yang dilengkapi dengan fasilitas rawat inap sehingga lebih dikenal dengan nama instalasi rawat darurat (ird). sistem pelayanan di ird merupakan sistem yang terkoordinir dan terpadu di bawah satu atap serta memberikan pelayanan kegawatdaruratan medik dan bedah secara optimal dengan cepat, tepat dan cermat yang berkualitas untuk life saving dan life support. pelayanan penderita gawat darurat di ird dilaksanakan memakai sistem triage yang memilah penderita berdasarkan tingkat kegawatan dan prioritas penanganan dengan menggunakan label warna yaitu: penderita sangat gawat/mengancam jiwa (biru), penderita gawat darurat (merah), penderita darurat tetapi tidak gawat (kuning) dan bukan penderita gawat (hijau). penderita anak dengan kegawatdaruratan medik yang dibawa ke ird akan ditangani sesuai dengan tingkat kegawatannya. label warna biru ditangani di kamar resusitasi, label warna merah ditangani di kamar periksa medik kesehatan anak, label kuning ditangani di kamar terima atau di kamar periksa medik kesehatan anak, dan label hijau ditangani di kamar periksa jaga depan. diharapkan dengan sistem tersebut pelayanan kesehatan menjadi lebih efektif dan efi sien serta akan meningkatkan kualitas dari pelayanan kesehatan di ird. kenyataannya, sejak diresmikan (tahun 1995) sampai dengan saat ini belum pernah ada informasi yang terpublikasi tentang analisis data pelayanan gawat darurat penderita anak dan data angka kematian penderita anak dengan kegawatdaruratan medik di ird. analisa data tersebut sangat diperlukan untuk mengidentifi kasi kegagalan dan keberhasilan 132 jurnal ners vol. 7 no. 2 oktober 2012: 131–135 pelayanan, serta dapat dibandingkan dengan pelayanan di tempat lain. penelitian ini bertujuan untuk mengevaluasi karakteristik dan keluaran, serta gambaran epidemiologi dari penderita anak dengan kegawatdaruratan medik yang datang ke ird rsud dr. soetomo surabaya. harapan dari penelitian ini adalah dengan mengetahui angka kejadian dan profi l klinis pasien anak yang datang ke ird rsud dr. soetomo maka diharapkan dapat tercapai pelayanan keperawatan yang komprehensif. bahan dan metode penelitian ini menggunakan rancangan de sk r ipt if d a r i pa sie n ya ng t e rd af t a r mengunjungi ird anak rsud dr. soetomo surabaya mulai bulan januari–desember 2011. penelitian ini dilakukan di ird anak rsud dr. soetomo melayani anak mulai 0–15 tahun, 24 jam sehari, dan 7 hari dalam 1 minggu. pasien pertama kali diperiksa oleh dokter peserta program pendidikan spesialis (ppds) senior yang stase di ird pagi dan sore. ird rsud dr. soetomo melayani pemeriksaan laboratorium, radiologi dan dapat dilakukan terapi nebulisasi, suction, tranfusi komponen darah, dan berbagai macam terapi injeksi (baik intra muscular maupun intra venous) yang dibutuhkan untuk terapi kegawatdaruratan. dat a d id apat d a r i lemba r rekam medik. rekam medik diperiksa dahulu untuk mengetahui kelengkapan dan keakuratannya. data yang diambil adalah karakteristik demograf i meliputi usia, jenis kelamin, karakteristik klinis meliputi gejala, diagnosis dan keluaran dalam 24 jam pertama, dan keluaran termasuk yang dipulangkan dari ird, masuk rumah sakit untuk rawat inap maupun kematian. d a t a d i t a b u l a s i d a n d i a n a l i s a mengg unakan f rek uensi dan persentase dengan spss versi 16.0. hasil penelitian dilaksanakan selama 1 tahun dengan jumlah pasien yang datang ke ird gambar 1. distribusi jumlah pasien yang datang setiap bulan gambar 2. karakteristik jenis kelamin pasien 133 profi l pasien di gawat darurat medik anak (ira dharmawati, dkk.) anak adalah 5.835. gambar 1 menunjukkan distribusi pasien yang datang setiap bulan selama satu tahun. rerata jumlah pasien yang datang ke instalasi rawat darurat setiap bulan adalah 486 dengan jumlah tertinggi pada januari (n-559) dan terendah september (n-374). kelompok usia terbanyak adalah anakanak prasekolah (usia 1 tahun sampai 5 tahun) sebesar 1.956 (33,5%) (gambar 3). kelompok neonatus sebanyak 10,9%, kelompok bayi usia 29 hari-1 tahun berjumlah 30,4%, kelompok anak usia 5–10 tahun sebesar 16,3%, dan kelompok anak > 10 tahun sebesar 8,9%. di antara 5.835 subyek, 3.445 (58,5%) adalah laki-laki. jumlah pasien yang terbanyak dirawat dengan kasus respirologi yaitu infeksi saluran napas sebesar 31%, kasus onkologi 19,9%, diare 17,4%, kejang 13,5%, kasus neonatus sebesar 8,4%, infeksi dengue 6,5%. kelainan infeksi saluran nafas (n-1811) terbanyak adalah infeksi saluran pernapasan atas 54,2% (n-975), disusul kemudian pneumonia 25,7% (n-462) dan asma bronkial 14,2% (n-256). kasus lainnya adalah aspirasi benda asing 0,22% (n-4), bronkiolitis 2,5% (n-46), dan tb paru 2,7% (n-49). kasus gastroenterologi terdapat 1039 pasien dengan infeksi saluran pencernaan, 1000 pasien (96,2%) diare akut, 10 pasien (0,002%) konstipasi, 10 pasien (0,002%) nyeri perut berulang, dan 19 pasien (0,018%) dengan gastritis. gangguan pencernaan lain seperti obstruksi usus 1,8% (n-88). pada kelompok kasus neurologis, kejang merupakan gejala yang paling sering yaitu sekitar 95% (n-724) dari 762 kasus. kelompok ini mencakup epilepsi, kejang demam dan gambar 3. distribusi jumlah pasien berdasarkan usia gambar 4. gambaran diagnosis pasien yang meninggal dalam 24 jam pertama 134 jurnal ners vol. 7 no. 2 oktober 2012: 131–135 tabel 1. distribusi pasien berdasarkan 10 penyakit terbanyak < 1 bln 1–12 bln 1–5 th > 5 tahun > 10 tahun total ispa 50 588 725 307 141 1811 diare 47 532 349 55 17 1000 kejang 11 263 335 88 27 724 kasus neonatus 445 22 16 5 2 490 infeksi dengue 5 37 120 132 83 377 onkologi 6 33 56 56 34 185 pjb 19 52 41 28 18 158 kasus bedah 19 41 12 11 5 88 isk 0 22 29 16 9 76 hemofi lia 3 6 16 16 28 69 status epileptikus serta penyakit lainnya yang mempunyai gejala klinis kejang (meningitis, ensefalitis). kasus lain nya adalah abses otak, sindrom guillian barre, lesi ruang intrakranial, paraplegia dan lain-lain. neonatus sebanyak 490 kasus, 1,8% (n-9) kasus dengan sepsis neonatorum, 2,8% (n-14) ikterus neonatorum, 3,4% (n-7) kelainan bawaan, 3,2% (n-16) kasus dengan bayi berat badan lahir rendah atau prematur, dan lainlainnya. kasus onkologi terdapat 185 kasus, 49,7% (n-92) dengan leukemia. ada 158 kasus (2,7%) dengan penyakit jantung bawaan dan 88 kasus (1,5%) dengan kasus bedah. tid a k lebi h d a r i 24 ja m 6 4,2% (n-3.748) pasien sudah dipindahkan dan dirawat di bangsal anak, 30,5% (n-1.778) dipulangkan dari instalasi rawat darurat, 3,6% (n-210) pulang atas keinginannya sendiri dan 1,7% (n-99) anak-anak meninggal dalam waktu 24 jam. gambar 5. menunjukkan diagnosis utama pasien yang meninggal dalam waktu 24 jam pertama penatalaksanaan. kasus kematian terbanyak adalah sepsis dengan gagal nafas sebesar 35,3% (n-35) dan meningoencephalitis 25,3% (n-25). kematian pada kelompok neonatus sebesar 17,2% (n-17). pembahasan p rof il k a r a k ter ist i k pa sien ya ng datang ke ird diperlukan perencanaan dan evaluasi yang tepat dalam upaya peningkatan aspek integral dari pelayanan kesehatan (bazaar, et al., 2012; mccarthy pl, 2008). penelitian ini menggambarkan karakteristik p a sie n ya ng d a t a ng ke i r d r su d dr. soetomo selama 1 tahun. jumlah kunjungan pasien ke ird rsud dr. soetomo selama masa studi adalah 5.835 pasien. studi yang lain, tunisia melaporkan total 45.000 pasien anak yang datang ke ird dalam 1 tahun (matoussi, et al., 2007). jumlah pasien yang besar dapat menunjukkan bahwa tidak semua pasien yang datang benar-benar dalam keadaan gawat darurat, tetapi mereka membutuhkan pelayanan primer. hal ini bisa disebabkan karena akses yang mudah ke pelayanan gawat darurat dan tersedia 24 jam. anak-anak pada kelompok usia 1–5 tahun merupakan jumlah terbesar dari kunjungan ke ird (33,6%). hal ini tidak sesuai dengan studi yang dilakukan di turki, di mana kelompok neonatus dan bayi menyumbang jumlah terbesar dari kunjungan ke ird (47%) dan amerika serikat (57,7%) (karabocuoglu, et al., 1995; alpern, et al.,2006). infeksi saluran nafas merupakan hampir setengah dari semua pasien yang datang ke ird, diikuti kemudian dengan diare, kasuskasus neonatologi dan neurologi. hal ini konsisten dengan pola morbiditas pada anak yang dirawat di sebagian besar rumah sakit lain. hampir 40% pasien yang datang ke ird mengalami infeksi saluran pernafasan atas. hal ini menggambarkan penggunaan yang tidak tepat pelayanan gawat darurat untuk kasus yang tidak gawat darurat, sehingga diperlukan pendidikan tenaga kesehatan dan masyarakat tentang pengelolaan pasien di pusat kesehatan primer agar dapat menurunkan beban kerja di ird. kejang, meningitis dan meningoensefalitis adalah kasus neurologi 135 profi l pasien di gawat darurat medik anak (ira dharmawati, dkk.) yang banyak dijumpai sepanjang tahun (salaria, 2003; health, 1999). pada studi kami, sebagian besar pasien adalah anak laki-laki (58,5%). hal ini sesuai dengan studi di india yang menunjukkan lakilaki lebih besar (73%) (salaria, 2003). dalam waktu tidak lebih dari 24 jam 64,2% pasien sudah bisa dipindahkan untuk dirawat di bangsal anak. studi ini tidak sebanding dengan studi di australia di mana hanya 24% pasien (acworth, et al., 2009) dan di amerika serikat 12% pasien (mccaig, dan burt, 2003). hal ini mungkin disebabkan karena di australia dan amerika untuk keadaan yang masih awal atau ringan sudah dibawa ketempat pelayanan kesehat an, ter masu k tempat pelayanan gawatdarurat rumahsakit. kasus kematian dalam waktu 24 jam pertama sebesar 1,7% kasus. hal ini sesuai dengan penelitian di india, di mana kasus kematian yang terjadi berkisar 2% (singhi, jain dan gupta, 2003). simpulan dan saran simpulan studi ini menunjukkan bahwa anakanak usia 1–5 tahun adalah kelompok terbesar yang datang ke ird dan infeksi saluran napas merupakan infeksi terbanyak. saran perlu dilak u kan penelitian secara b e r k e s i n a m b u n g a n u n t u k m e n y u s u n perencanaan dan evaluasi yang tepat dalam upaya peningkatan pelayanan kesehatan. kepustakaan acwor th j., babl f., borland m., et al. 2009. patterns of presentation to the australian and new zeland pediatric emergency research network. emerg med australas, 21: 59–66. alpern, er., stanley, rm., gorelick, mh., et al. 2006. epidemiology of a pediatric emergency medicine research network: the pecarn core data project. pediatr emerg care, 22: 689–99. bazaar, hm., salma el houchi, hanaa ibrahim rady. 2012. profi le of patients visiting the pediatric emergency aervice in an egyptian university jospital. pediatremer care, 28: 148–52. burt, cw., middleton, kr. 2007. factors associated with ability to treat pediatric emergencies in us hospitals. pediatr emerg care, 23: 681–9. health, bw., coffey, js., malone, p., et al. 2000. pediatric offi ce emergencies and emergency preparedness in a small rural state. pediatrlcs, 106: 1391–6. karabocuoglu, m., kartoglu, u., molzan, j, et al. 1995. analysis of patients admitted to the emergency unit of a university children's hospital in turkey. turk pediatr, 37: 209–16. matoussi, n., fitouri, z., maarouf i, n., et al. 2007. epidemiologic prof ile and management pediatric medical emergencies consultants of tunisian child's hospital, tunis med, 85, 843–8. mccar thy, pl. 2008. evaluation of the sick child in the off ice and clinic. in: kliegman, rm., behrman, re., jenson, hb., et al., eds. nelson text book of pediatrics. 18th ed. philadelphia: wb saunders co, pp. 60: 363. mccaig, lf, burt, c., w. 2003. national hospital ambulatory medical care survey: 2001 emergency department summary. adv data, 335: 1–29. salaria, m, singhi, sc. 2003. profi le of patients attending pediatric emergency service at chandigarh, indian j pediatr, 70: 621–4. singhi, s., jain, v., gupta, g. 2003. pediatric emergencies at a tertiary care hospital in india. j trop pediatr, 49: 207–11. vol 8 no 1 april 2013.indd 135 bauran pemasaran dengan bed occupancy ratio (bor) (marketing mix by bed occupancy ratio (bor)) abdul muhith, m. himawan saputra, nursalam *stikes majapahit mojokerto, jln. raya gayaman km. 02 mojoanyar mojokerto **fakultas keperawatan universitas airlangga e-mail: cua_muhith@yahoo.co.id abstrak pendahuluan: bed occupancy ratio (bor) di rsi arafah mojosari selama 3 tahun terakhir di bawah rata-rata, dan merupakan angka yang terendah di rs di daerah mojosari. tujuan dari penelitian ini yaitu untuk mengidentifi kasi hubungan antara marketing mix dengan bor di rsi arafah mojosari. metode: sampel pada penelitian ini yaitu 44 responden yang diambil dengan teknik stratifi ed random sampling. data penelitian yang dikumpulkan menggunakan kuesioner dan dianalisis menggunakan uji fisher exact. hasil: hasil penelitian membuktikan bahwa lebih dari 50% responden menyatakan bahwa marketing mix dikembangkan oleh manajemen rumah sakit. hasil penelitian yang lain menunjukkan bahwa sebagian besar responden memiliki nilai bor yang tidak seimbang. uji fisher exact menunjukkan dengan nilai p=0,02<0,05 sehingga h0 di tolak, yang artinya terdapat hubungan antara marketing mix dengan bor di rsi arafah mojosari. pembahasan: rumah sakit yang mampu mengembangkan bauran pemasaran yang sangat baik, dapat menarik konsumen untuk menggunakan layanan rawat inap di rumah sakit, dengan nilai bor akan meningkat dengan peningkatan penggunaan layanan rawat inap. manajemen rumah sakit harus mampu merumuskan strategi bauran pemasaran yang baik yang tujuan pemasaran rumah sakit dapat dicapai. kesesuaian antara kualitas pelayanan dan tingkat pelayanan harus dibenahi, selain itu tingkat media promosi dapat menarik pasien untuk rawat inap kata kunci: pemasaran, marketing mix, bor abstract introduction: bed occupancy ratio (bor) in rsi arafah mojosari during the last three years are at under ideal rate and the lowest of the three existing hospitals in the area of mojosari. the purpose of this study was to determine the relationship marketing mix with bed occupancy ratio in rsi arafah mojosari. methods: this research uses analytic methods with crossectional approach. variables in the study is marketing mix and bed occupancy ratio (bor). the population in this study were all patients hospitalized in the rsi arafah mojosari. samples amounted 44 respondents taken by the stratifi ed random sampling technique. data were collected using the questionnaire and analyzed using fisher's exact test. result: the results obtained more than 50% of respondents (59.1%) rate well against the marketing mix is developed by the hospital management and the majority of respondents (79.5%) are in the treatment room that has a number bor is not ideal. fisher exact test test results obtained probabililty value=0.02<0.05 so that h0 is rejected, which means there is a relationship marketing mix with the bed occupancy ratio in rsi arafah mojosari. discussion: hospitals which able to develop the marketing mix very well, can attract consumers to use inpatient services at the hospital, with that bor value will increase as the increased use of inpatient services. hospital management must be able to formulate a good marketing mix strategy that hospital marketing objectives can be achieved. conformity between service quality and service rates must be addressed, otherwise it extent of media promotions can attract patients to inpatient services keywords: marketing, marketing mix, bed occupancy ratio 136 jurnal ners vol. 8 no. 1 april 2013: 135–141 pendahuluan bed occupanc y ratio at au bor mer upa ka n sala h sat u i nd i kator ya ng menggambarkan tinggi rendahnya tingkat pemanfaatan tempat tidur r umah sakit, perhitungannya adalah persentase pemakaian tempat t idu r pa d a sat u sat u a n wa k t u tertentu, sehingga dapat diketahui gambaran penggunaan tempat tidur di rumah sakit tersebut dalam kurun waktu tertentu. angka bor suatu rumah sakit dapat meningkat dan menurun, angka ini berbanding lurus dengan penggunaan tempat tidur di rumah sakit (mpkpk, 2009). faktor-faktor yang mempenga r u h i bor d apat d ibed a k a n menjadi faktor internal rumah sakit dan faktor eksternal rumah sakit. faktor internal rumah sakit misalnya budaya rumah sakit, sistem informasi, sarana prasarana, sumber daya manusia, pemasaran, citra, dan lain-lain. faktor eksternal misalnya letak geografi s, keadaan sosial ekonomi konsumen, budaya masyarakat, pemasok, pesaing, kebijakan pemerintah daerah, dan peraturan-peraturan lain (austin dalam hanna, 2004). hasil studi pendahuluan yang telah dilakukan pada tanggal 16–21 mei 2011, diperoleh data tentang bor rsi arafah mojosari selama 3 tahun terakhir. bor rumah sakit ini selalu mengalami penurunan di tiap tahunnya. bahan dan metode rancangan penelitian menggunakan pendekatan cross sectional, sedangkan hipotesis penelitian ini yaitu terdapat hubungan bauran pemasaran (marketing mix) dengan bed occupancy ratio (bor) rsi arafah mojosari. variabel independen dalam penelitian ini yaitu bauran pemasaran (marketing mix) dan variabel dependen adalah bed occupancy ratio (bor). populasi pada penelitian ini yaitu seluruh pasien yang melakukan layanan rawat inap di rsi arafah mojosari. sampel penelitian yaitu sebagian pasien yang melakukan layanan rawat inap di rsi arafah mojosari. teknik sampling menggunakan stratified ramdom sampling. kriteria inklusi yang digunakan dalam penelitian ini yaitu pasien yang ada di rsi saat dilakukan penelitian dan sudah mendapatkan pelayanan rawat inap minimal 1×24 jam, bersedia diwawancarai, dan pasien dengan kondisi sadar dan dapat melakukan komunikasi dengan baik. sedangkan kriterian eksklusi pada penelitian ini yaitu pegawai rumah sakit dan pasien peserta asuransi. lokasi penelitian di rsi arafah kecematan mojosari, waktu penelitian ini yaitu mulai dari bulan juli hingga agustus 2011. teknik pengumpulan dan instrumen data menggunakan kuesioner check list dan teknik analisa data menggunakan uji chi square fi sher exact. hasil lebih dari 50% responden (59,1%) menyat a ka n ba hwa bau ra n pemasa ra n (marketing mix) yang ada di rsi arafah tidak baik. nilai bor pada masing paviliun yang ada di rsi arafah mojosari, paviliun mekah memiliki nilai bor 49%, paviliun madinah 62%, paviliun mina 30%, dan paviliun muzdalifah 17%. pada hasil penelitian didapatkan bahwa dari 44 responden, sebagian besar responden (79,5%) menempati ruang perawatan yang nilai bor nya tidak ideal. hasil penelitian menunjukkan bahwa dari 44 responden didapatkan lebih dari 50% responden yang menyatakan bahwa bauran pemasaran rsi tidak baik berada pada ruang perawatan yang mempunyai angka bor tidak ideal (56,8%) dan hanya ada satu responden yang ada pada ruang perawatan dengan angka bor ideal. hasil uji statistic dengan menggunakan uji fisher exact test dengan tingkat nilai kemaknaan α 0,05. hasil uji fisher exact test d id apat k a n nilai probabilitas = 0,02<0,05 sehingga h1 diterima yang artinya terdapat hubungan antara bauran pemasaran (marketing mix) dengan bed occupancy ratio (bor) rsi arafah mojosari. pembahasan bauran pemasaran (marketing mix) rsi arafah mojosari hasil penelitian menunjukkan bahwa lebih dar i 50% responden menyatakan ba hwa bau ra n pemasa ra n rsi a rafa h 137 bauran pemasaran dengan bed occupancy ratio (abdul muhith, dkk) mojo s a r i t id a k b a i k y a it u s e b a nya k 26 orang responden (59,1%). bauran pemasaran (marketing mix) adalah seperangkat alat pemasaran yang digunakan perusahaan untuk terus-menerus mencapai tujuan pemasarannya di pasar sasaran (kotler, 2009). saputra (2008) menyatakan “bauran pemasaran mengacu pada panduan strategi produk, distribusi, promosi dan penentuan harga yang bersifat unik yang dirancang untuk menghasilkan pertukaran yang saling memuaskan dengan pasar yang dituju”. bauran pemasaran merupakan segala upaya yang dapat dilakukan oleh suatu perusahaan untuk memengaruhi permintaan pasar sasarannya terhadap produk/jasanya. kemungkinan aktivitas itu dapat dirumuskan menjadi empat variabel, oleh mccarthy disebut sebagai 4p dari pemasaran: produk ( product), harga ( price), tempat ( place), dan promosi ( promotion) (kotler dan keller, 2009). bauran pemasaran yang dinilai negatif oleh responden memberikan pertanda bahwa usaha pemasaran jasa yang dilakukan oleh manajemen rumah sakit tidak berjalan dengan baik. sekumpulan komponen alat pemasaran yang dikembangkan oleh rsi arafah tidak berjalan sesuai harapan. bermacam-macam alasan mengapa hal itu bisa terjadi, masalah itu tentunya berasal dari masalah yang muncul dari tiap komponennya. sehingga secara keseluruhan berimbas pada bauran pemasaran yang ada di rsi arafah, pada akhirnya yang merasakan efek dari itu adalah pasien pengguna dari rsi arafah mojosari. komponen pertama dari bauran pemasaran adalah produk. fakta dari hasil kuesioner pada point produk, didapatkan lebih dari 50% responden (65,9%) menilai tidak baik produk yang ditawarkan, dengan kata lain produk yang ditawarkan oleh rumah sakit, khususnya pada layanan rawat inap dinilai tidak baik oleh responden. parameter pada point produk yang mempunyai nilai total terendah adalah tentang mutu layanan yang diberikan perawat pada pasien. secara konsept ual produ k adalah pemahaman subjektif dari produsen atas sesuatu yang bisa ditawarkan sebagai usaha untuk mencapai sesuai dengan kompetensi dan kapasitas organisasi serta daya beli pasar. produk adalah segala sesuatu yang dapat ditawarkan untuk memuaskan suatu kebutuhan dan keinginan (ngadiman, 2010). dalam penelitian ini produk yang ditawarkan oleh rumah sakit adalah segala sesuatu yang terkait dengan pelayanan rawat inap pasien antara lain, ketersediaan dokter/perawat jaga setiap kali diperlukan, pelayanan yang diberikan, fasilitas bed yang disediakan, alur pelayanan rawat inap rs. inti dari pelayanan rawat inap adalah pelayanan perawatan pada pasien itu sendiri. perawat yang bertugas dan bersinggungan dengan pasien merupakan ujung tombak dari layanan rawat inap sehingga pokok perhatian dari manajemen rumah sakit yaitu bentuk dari pelayanan perawat yang diberikan oleh perawat. perawat harus mengerti apa alasan utama seorang pasien memutuskan untuk menggunakan jasa rawat inap di rumah sakit tersebut, yakni kesembuhan. rumah sakit harus dapat menemukan kebutuhan esensial yang tersembunyi di balik setiap layanan. tujuannya tidak lain agar keuntungan atau manfaat dari suatu pelayanan, bukan sekedar atributnya atau fi turnya, dapat dijelaskan pada konsumen. komponen yang kedua adalah harga, pada point harga, didapatkan bahwa lebih dari 50% responden (65,9%) menilai tidak baik. parameter yang memiliki nilai total terendah pada point harga adalah pada pernyataan tentang keterjangkauan tarif layanan rawat inap di rsi a rafah mojosar i. hal ini menunjukkan rata-rata responden ragu-ragu dan bahkan ada responden yang tidak setuju dengan pernyataan bahwa tarif rawat inap rsi arafah terjangkau. harga adalah apa yang harus diberikan oleh konsumen untuk mendapatkan suatu produk, harga sering merupakan elemen yang paling fl eksibel di antara elemen bauran pemasaran (lamb et al. dalam saputra, 2008). pada umumnya rumah sakit menghadapi masalah yang rumit bila berhadapan dengan harga pelayanan (disebut tarif ). pada waktu-waktu ter tentu, tarif pelayanan harus dinaikkan agar biaya untuk penyelenggaraan pelayanan tersebut minimal dapat tetap ditutup (tercapainya cost recover). kenaikan tarif ini pun harus dilakukan secara hati-hati agar rumah sakit tidak kehilangan 138 jurnal ners vol. 8 no. 1 april 2013: 135–141 klien/pasiennya (hartono, 2010). akan sulit berada pada persimpangan antara misi sosial yang diusung oleh fungsi dasar rumah sakit (humanisme) dengan kenyataan biaya yang tinggi dalam menjalankan fungsi r umah sakit secara menyeluruh. oleh karenanya dibutuhkan pertimbangan yang matang dalam menentukan tarif layanan di rumah sakit, bent u k t angg u ng jawab keluarga merawat lansia tergambar melalui nilai yang masih berlaku dalam masyarakat bahwa anak wajib memberikan kasih sayang kepada orangtuanya sebagaimana pernah mereka dapatkan sewak t u mereka masih kecil sebagai bentuk balas budi anak kepada orang tua. anak masih merasa berkewajiban dan mempunyai loyalitas menyantuni orang tua mereka yang sudah tidak dapat mengurus dirinya sendiri. ini menunjukkan bahwa sistem nilai budaya yang menjunjung tinggi pengabdian terhadap orang tua, masih ada di masyarakat indonesia khususnya layanan rawat inap rumah sakit, karena kesalahan perhit ungan dan per timbangan akan berdampak pada kelangsungan kegiatan rumah sakit. keterjangkauan biaya rumah sakit merupakan idaman bagi masyarakat pengguna, namun hal ini juga har us disesuaikan dengan besar pengeluaran rumah sakit dan juga harus disesuaikan dengan mutu layanan yang diberikan. komponen yang ke tiga yaitu tempat pelayanan/saluran distribusi. lebih dari 50% responden menilai tidak baik pada komponen tempat pelayanan/saluran distribusi yang ada di rsi arafah mojosari. pada point tempat layanan/saluran distribusi parameter yang memiliki nilai terendah adalah tentang kebersihan dari fasilitas toilet rumah sakit. hal ini membuktikan bahwa kebersihan rumah sakit perlu dipertanyakan. saputra (2008) menyatakan “salu ran dist r ibusi adalah serangkaian organisasi yang saling tergantung yang terlibat dalam proses untuk menjadikan produk atau jasa siap digunakan atau dikonsumsi”. craven dalam saputra (2008) menyatakan “salu ran dist r ibusi adalah jaringan organisasi yang melakukan fungsi-fungsi yang menghubungkan produsen dengan konsumen akhir”. penampilan tempat usaha tur ut membantu menentukan citra tempat usaha. elemen utama dari penampilan tempat yaitu suasana (atmosphere), yaitu pesan keseluruhan yang disampaikan oleh tata letak fi sik dan dekorasi. suasana dapat menciptakan perasaan santai ataupun sibuk, kesan mewah atau efesiensi, sikap ramah ataupun dingin, terorganisir ataupun kacau. tata letak tempat yaitu kunci keberhasilan, tata letak direncanakan sehingga semua ruang digunakan secara efekif, termasuk loronglorongnya, perlengkapan tetap, pemajangan barang dan wilayah bukan penjualan. tata letak yang efektif tidak hanya menjamin kenyamanan dan kemudahan, melainkan juga mempunyai pengaruh besar pada pola lalu lintas konsumen dan perilaku pembelian (hartono, 2010). rumah sakit merupakan tempat yang berbahaya dan rentan akan terjadinya infeksi silang (infeksi nosokomial) d i ma na or a ng ya ng sed a ng d i r awat, keadaannya bukan bertambah baik malah akan bertambah buruk. oleh karenanya harus dilakukan kontrol penuh akan kebersihan sa n it asi r u ma h sa k it u nt u k mencega h terjadinya infeksi nosokomial. kaitannya dengan hal bauran pemasaran adalah pada citra yang diberikan dari hal itu, akan muncul stigma atau anggapan yang melekat pada rsi arafah bahwa rsi arafah adalah rumah sakit yang jorok dan bau. secara langsung hal itu berakibat pada kurang nyamannya pasien dan keluarga pasien saat rawat inap di rsi arafah. lebih jauh dengan munculnya stigma tersebut akan menurunkan citra rsi arafah di mata masyarakat yang nantinya dapat menurunkan per mintaan akan layanan rawat inap di rsi arafah mojosari. komponen terakhir yaitu promosi, lebih dari 50% responden menilai komponen promosi di rsi arafah mojosari tidak baik. pada point promosi, parameter yang memiliki nilai terendah yaitu pernyataan tentang media komunikasi yang dikembangkan oleh rsi arafah, dalam hal ini media promosi yang dimuat di surat kabar atau disiarkan melalui radio. promosi adalah suatu bentuk komunikasi pemasaran, yang dimaksud dengan komunikasi pemasaran adalah aktivitas pemasaran yang berusaha menyebarkan infor masi, mempengar uhi/ 139 bauran pemasaran dengan bed occupancy ratio (abdul muhith, dkk) membujuk, dan atau mengingatkan pasar sasaran atas perusahaan dan produk agar bersedia menerima, membeli, dan loyal pada produk yang ditawarkan perusahaan yang ditawarkan perusahaan yang bersangkutan (tjiptono dalam fama, 2010). satu hal yang tidak boleh dilupakan dalam penyelenggaraan pengiklanan untuk promosi yaitu etika bisnis dan aturan-aturan yang berkaitan. sonny keraf dalam hartono (2010) menyebutkan adanya empat prinsip yang dapat digunakan sebagai rambu-rambu dalam pengiklanan atau promosi layanan rumah sakit. pertama, iklan atau promosi tidak boleh menyampaikan informasi palsu dengan maksud untuk memperdaya konsumen. kedua, iklan atau promosi wajib menyampaikan semua informasi tentang pelayanan yang ditawarkannya. keempat, iklan atau promosi tidak boleh mengarah pada tindakan yang ber tent angan dengan moralit as seper ti pelecehan seksual, perendahan mar tabat manusia, dan lain-lain. kelu a sa n me d ia promosi sa ngat mempengaruhi jangkauan dari promosi yang sedang dikembangkan, logikanya semakin luas media promosi maka akan semakin luas jangkauan dari promosi yang dilakukan, sehingga akan lebih banyak yang mendapatkan infor masi tentang promosi r umah sakit. media promosi yang semakin sempit yang dikembangkan maka semakin sedikit yang menerima informasi tersebut. rumah sakit dapat meluaskan media informasinya dengan cara memasang iklan tentang infor masi layanan rumah sakit di radio-radio lokal dan koran. bed occupancy ratio (bor) rsi arafah mojosari 1–7 agustus 2011 pada hasil penelitian dapat diketahui angka bor pada tiap ruang perawatan yang ada di rsi arafah mojosari mulai tanggal 1–7 agustus 2011. angka tersebut dapat dikelompokkan menurut kriteria ideal dan tidak ideal, di mana untuk angka bor yang kurang dari 60% dikatakan tidak ideal, sedangkan untuk angka bor lebih dari 60–80% dikatakan ideal. pada hasil penelitian tersebut di atas, setelah dikelompok kan menu r ut k r iter ia ideal dan tidak ideal didapatkan bahwa sebagian besar responden (79,5%) menempati ruang perawatan yang kriteria bor nya tidak ideal. bed occupancy ratio (bor) menurut huffman dalam mpkpk (2010) adalah “the ratio of patient service days to inpatient bed count days in a period under consideration”. depkes ri (2005) menyatakan bahwa bor adalah persentase pemakaian tempat tidur pada satuan waktu tertentu. indikator ini memberikan gambaran tinggi rendahnya tingkat pemanfaatan tempat tidur rumah sakit. persentase ini menunjukkan sampai berapa jauh pemakaian tempat tidur yang tersedia di rumah sakit dalam jangka waktu tertentu. bila nilai ini mendekati 100 berarti ideal tetapi bila bor rumah sakit 60–80% sudah bisa dikatakan ideal, karena nilai parameter bor yang ideal adalah antara 60–85% (depkes ri, 2005). bor antara rumah sakit yang berbeda tidak bisa dibandingkan oleh karena adanya perbedaan fasilitas rumah sakit, tindakan medik, perbedaan teknologi intervensi (mpkpk, 2009; manajemen rumkit, 2010). angka bor terkait dengan lama hari perawatan yang ada. angka hari perawatan yang semakin rendah maka semakin rendah nilai bor yang ada. rendahnya angka hari perawatan dapat disebabkan oleh minimnya pemakaian tempat tidur juga karena pasien rawat inap merasa tidak nyaman sehingga pasien merasa bahwa dia har us pindah perawatan ke rs yang lain. hubungan bauran pemasaran (marketing mix) dengan bed occupancy ratio (bor) rsi arafah mojosari hasil penelitian menunjukkan bahwa dari 44 responden didapatkan lebih dari 50% responden menilai bauran pemasaran di rsi arafah mojosari tidak baik, kemudian lebih dari 50% responden yang menyatakan bauran pemasaran di rsi arafah mojosari tidak baik, berada pada ruang perawatan yang memiliki kriteria bor tidak ideal. hasil tabulasi silang selanjutnya dilakukan perhitungan menggunakan uji fisher exact test dengan tingkat nilai kemaknaan α: 0,05. uji fisher 140 jurnal ners vol. 8 no. 1 april 2013: 135–141 exact test digunakan karena ada salah satu data yang memiliki frekuensi harapan kurang dari 5 (25%), oleh karena itu menggunakan uji fisher exact test. hasil α hitung: 0,02<0,05 maka h0 ditolak dan h1 diterima yang artinya ada hubungan antara bauran pemasaran (marketing mix) dengan bed occupancy ratio bor rsi arafah mojosari. faktor-faktor yang mempengaruhi bor dapat dibedakan menjadi faktor internal r umah sakit dan faktor eksternal rumah sakit. faktor internal rumah sakit misalnya: budaya rumah sakit, sistem informasi, sarana prasarana, sumber daya manusia, pemasaran, citra, dan lain-lain. faktor eksternal misalnya: letak geografi s, keadaan sosial ekonomi konsumen, budaya masyarakat, pemasok, pesaing, kebijakan pemerintah daerah, dan peraturan-peraturan lain (hanna, 2004). banyak hal yang dapat ber pengaruh atas nilai bor rsi arafah mojosari, salah satunya yaitu pemasaran. bauran pemasaran merupakan alat pemasaran yang dikembangkan untuk manajer pemasaran untuk mendukung kegiatan pemasaran yang dilakukan. bor rsi arafah mojosari yang mempunyai nilai tidak ideal dapat disebabkan oleh kegagalan bauran pemasaran yang dikembangkan oleh manajemen rsi arafah mojosari. gabungan dari produk, harga, tempat pelayanan/saluran distribusi dan promosi yang dikembangkan oleh rsi arafah mojosari tidak mampu membuat pasien atau calon pasien memilih untuk melakukan perawatan inap di rsi arafah mojosari, sehingga menyebabkan angka penggunaan rumah sakit rendah dan pada akhirnya berdampak pada rendahnya angka bor di rsi arafah mojosari. tabel 1. distribusi frekuensi responden tentang bauran pemasaran (marketing mix) di rsi arafah mojosari pada tanggal 1–7 agustus 2011 no. bauran pemasaran (marketing mix) frekuensi (f) persentase (%) 1. 2. baik tidak baik 18 26 40,9 59,1 jumlah 44 100 tabel 2. distribusi frekuensi angka bor (bed occupancy ratio) tiap paviliun (ruang rawat inap) di rsi arafah mojosari pada tanggal 1–7 agustus 2011 no. paviliun (ruang rawat inap) nilai bor 1. 2. 3. 4. mekah madinah mina muzdalifah 49% 62% 30% 17% tabel 3. distribusi frekuensi kriteria angka b o r ( b e d o c c u p a n c y r a t i o ) b e r d a s a r k a n r u a n g p e r a w a t a n responden di rsi arafah mojosari pada tanggal 1–7 agustus 2011 no. nilai bor frekuensi (f) persentase (%) 1. 2. ideal tidak ideal 9 35 20,5 79,5 jumlah 44 100 tabel 4. tabulasi silang hubungan bauran pemasaran (marketing mix) dengan bed occupancy ratio bor di rsi arafah mojosari pada tanggal 1–7 agustus 2011 no. bauran pemasaran bor totalideal tidak ideal f % f % f % 1 baik 8 18,2 10 22,7 18 40,9 2 tidak baik 1 2,3 25 56,8 26 59,1 total 9 20,5 35 79,5 44 100 p: 0,02. nilai α: 0,05. jadi p<α 141 bauran pemasaran dengan bed occupancy ratio (abdul muhith, dkk) simpulan dan saran simpulan bauran pemasaran rsi arafah mojosari dinilai tidak baik, angka bor rsi arafah mojosari pada tanggal 1–7 agustus 2011 memiliki angka bor yang tidak ideal. hasil uji menunjukkan ada hubungan antara bauran pemasaran (marketing mix) dengan bed occupancy ratio rsi arafah mojosari. saran bagi rumah sakit, banyak hal yang harus dibenahi dalam rangka pengembangan dari kegiatan pemasaran. evaluasi alat pemasaran rumah sakit merupakan langkah awal yang harus dilakukan, sehingga akan diketahui keberhasilan alat pemasaran yang sudah dikembangkan. manajemen rumah sakit harus mampu mengoptimalkan segala keunggulan yang dipunyai oleh rumah sakit untuk menutup kekurangan yang juga melekat pada rumah sakit, memaksimalkan setiap kesempatan dan mengantisipasi ancaman yang timbul dari pesaing. kesesuaian mutu layanan rumah sakit dengan tarif yang dipatok merupakan langkah pertama yang harus dibenahi. peningkatan mutu layanan perawatan menjadi keharusan jika rumah sakit menghendaki tarif rawat inap tinggi. keluasan media promosi rumah sakit juga harus mendapat sorotan, karena dengan itu masyarakat akan mengetahui bentuk layanan dan fasilitas yang ada di rumah sakit. kepustakaan farna, soraya isti, 2009. ”pengaruh bauran pemasaran jasa terhadap keputusan pembelian konsumen pada gardenia cafe medan”. skripsi fakultas ekonomi t id a k dipubli kasi ka n. un iversit as sumatera utara. hanna, henny, 2004. “analisis faktor – faktor yang mempengaruhi bed occupancy ratio (bor) unit st rok e center r.s. islam jakarta”. tesis magister ad minist rasi rumah sakit dalam program studi kajiaan administrasi rumah sakit tidak dipublikasikan. universitas indonesia. ha r tono, ba mba ng, 2010. manajemen pemasaran untuk rumah sakit. jakarta: rineka cipta. kotler, ph ilip & kev i n keller, 20 09. manajemen pemasaran, (13rd . ed.) (penerjemah bob sabran). jakarta: erlangga. manajemenrumkit, 2010. indikator mutu pelayanan rumah sakit, (online), (ht t p://manajemen r u m k it.blogspot. com/2010/04/indikator-penilaian-mutupelayanan.html diakses pada tanggal 23 mei 2011). mpkpk, 2009. perhitungan bor, alos, toi, bto, gdr, ndr, (online), (http:// mpkpk 2008.blogspot.com /2009/01/ perhit u ngan-bor-avlos-toi-bto -gd rndr.html diakses pada tanggal 20 mei 2011). ngadiman, dkk., 2008. marketing untuk smk jilid 1 & 2. jakarta: direktorat pe m b i n a a n s e k o l a h m e n e n g a h k e j u r u a n , d i r e k t o r a t j e n d e r a l manajemen pendidikan dasar dan menengah, departemen pendidikan nasional. saputra, h., 2008. pengaruh strategi bauran pe m a sa ra n te rh a d a p ke p ut u sa n pembelian teh celup sariwangi oleh konsumen rumah tangga di kota medan. tesis magister sains dalam program studi ilmu manajemen tidak dipublikasikan. program pascasarjana universitas sumatra utara. vol 9 no 1 april 2014.indd 91 spiritual emotional freedom technique (seft) menurunkan stres pasien kanker serviks (spiritual emotional freedom technique decreasing stress on patiens with cervical cancer) desmaniarti, z.*, nani avianti* *program studi diii keperawatan politeknik kesehatan kemenkes bandung jl. dr. otten no.32 bandung 40171, telp/hp: (+62)82115111218 e-mail: desmaniarti@gmail.com abstrak pendahuluan: kanker serviks dikenal sebagai penyakit yang mematikan. angka kejadian kanker serviks terbanyak ke dua di seluruh dunia termasuk di indonesia, begitu pula di rsup dr. hasan sadikin bandung, kanker serviks menduduki peringkat pertama (62,27%) dibandingkan lima jenis keganasan obgyn lainnya (suspek tumor ganas ovarium 16,12 %, kanker ovarium 11,76% kanker vulva 8,65 % dan kanker endometrium 1,19%) (destiana, 2012). kemoterapi sebagai salah satu pilihan terapi untuk pasien kanker serviks menimbulkan berbagai efek samping antara lain rambut rontok, kuku menghitam, mual dan muntah, sehingga hal ini membuat pasien menjadi stress. seft (spiritual emotional freedom technique) bermanfaat untuk mengatasi emosi negatif melalui perpaduan teknik yang menggunakan energi psikologis, kekuatan spiritual, dan doa. seft efektif karena didalamnya terdapat beberapa teknik terapi yang terangkum dan dipraktikkan secara sederhana, terapi tersebut meliputi diantaranya; do’a, nlp (neuro linguistic programming), hypnotherapy, visualisasi, meditasi, relaksasi, imagery dan desensitisasi (zainudin, 2008). tujuan penelitian ini adalah menjelaskan terjadinya penurunan stres pada pasien kanker serviks di ruang obgyn rsup dr. hasan sadikin bandung. dengan adanya penurunan stres diharapkan pasien kanker serviks dapat menjalani pengobatan kanker dengan lebih baik. metode: penelitian ini menggunakan quasy experiment pre-post test randomized control group desain. pasien kanker serviks stadium i sampai iii yang menjalani kemoterapi diseleksi dengan purposive sampling dan dibagi menjadi dua kelompok, masing-masing kelompok berjumlah 34 orang. kelompok perlakuan diberikan seft dalam tiga kali putaran selama 30 menit. sebelum dan sesudah intervensi pasien diberikan kuesioner tentang stres. data dianalisis dengan dependent t-test, dan independent t-test. hasil: hasil penelitian menunjukkan bahwa stres pada pasien kanker serviks turun secara bermakna setelah intervensi. pembahasan: seft dapat menurunkan stres pada pasien kanker serviks yang menjalani kemoterapi di rsup dr. hasan sadikin bandung. kata kunci: seft (spiritual emotional freedom technique), stres, kanker serviks, kemoterapi abstract introduction: cervical cancer is known as one of deadly disease. the global incidence of cervical cancer is the second largest in the entire world, including in indonesia. rsup dr. hasan sadikin bandung, cervical cancer ranked fi rst (62.27%) compared with other fi ve types of obstetry and gynecology malignancies (suspected malignant ovarian tumors 16.12%, ovarian cancer 11.76%, vulva cancer 8.65% and endometrial cancer 1.19%) (destiana, 2012). chemotherapy as one of cancer treatment causes various side effects include hair loss, nails blackened, nausea and vomiting, that could makes patient stressful. seft ( spiritual emotional freedom technique ) is useful to overcome negative emotions through a combination technique that uses psychological energy, spiritual strength, and praying. seft is an effective intervention in manage stress, there are some techniques that practiced simply such as praying, nlp (neuro linguistic programming), hypnotherapy, visualisation, meditation, relaxation, imagery and desensitisasi (zainuddin, 2008). the purpose of this study was to explain reducing stress on patiens with cervical cancer through spiritual emotional freedom technique (seft) at rsup dr. hasan sadikin bandung. improvements on patient’s stress will lead to a better result on cervical cancer therapy. methods: this study was used quasy experiment pre-post test randomize control group design. patient with cervical cancer at stadium i to iii that taking chemotherapy was selected by using purposive sampling and divided into two groups. each group contains 34 patients. intervention group was given seft in three round. each round took 30 minutes. before and after intervention patients was given questionnaire. the data were analyzed using paired t-test and independent t-test. result: the result of this research showed that patient’s stress getting lower signifi cantly after intervention. discussion: seft could reduced stress on patients with cervical cancer that taking chemotherapy at rsup dr. hasan sadikin bandung. key words: seft (spiritual emotional freedom technique), stress, cervical cancer, chemotherapy 92 jurnal ners vol. 9 no. 1 april 2014: 91–96 pendahuluan k a n ke r se r v i k s d i ke n al sebagai penyakit yang mematikan. angka kejadiannya terbanyak ke dua di seluruh dunia termasuk di indonesia. rumah sakit hasan sadikin (rshs) bandung mencatat pada tahun 2012 kanker serviks menduduki peringkat pertama sejumlah 784 kasus (62,27%) dibandingkan lima jenis kanker obgyn lainnya, antara lain suspek tumor ganas ovarium /stgo sejumlah 203 kasus (16,12%), kanker ovarium sejumlah 148 kasus (11,76%) kanker vulva sejumlah 109 kasus (8,65%) dan kanker endometrium sejumlah 15 kasus (1,19%) (destiana, 2012). pe ny a k it k a n ke r s e r v i k s t i d a k menimbulkan gejala di awal stadium (hartati, 2010). gejala awal kadang hanya berupa keputihan, namun pada stadium lanjut timbul keluhan lain seperti keluarnya darah atau cairan berbau tidak sedap, perdarahan spontan dari vagina, nyeri saat bersenggama, keputihan terus menerus, nyeri/kesulitan berkemih serta nyeri perut bagian bawah atau kram panggul. apabila mencapai stadium lanjut penyakit ini tidak dapat dioperasi karena telah bermetastase (samadi, 2011). salah satu terapi kanker serviks adalah kemoterapi. namun kemoterapi menyebabkan beberapa efek samping berupa perubahan fi sik diantaranya rambut rontok, kuku menghitam, mual dan muntah yang dapat menimbulkan stres pada pasien. stres ini ditandai adanya gejala sedih, gelisah, sulit konsentrasi, sulit tidur, otot-otot tubuh terasa tegang, badan terasa lemas, letih dan tidak berdaya, serta kesulitan dalam beraktifi tas (bintang, 2012). kondisi tubuh yang tidak menyenangkan akibat stres dapat menyebabkan menurunnya produktifi tas kerja (diahsari, 2001). penelitian tentang stres pada pasien kanker yang menjalani kemoterapi telah d i la k u k a n. pe nel it ia n bi nt a ng (2012) menunjukkan bahwa 10% pasien kanker m e ng a l a m i s t r e s s e d a ng d a n 2 , 86% mengalami stres berat. secara fisik stres dapat menyebabkan ketidakseimbangan kimia tubuh seperti adrenalin, epinephrin dan nor epineprin. kondisi ini terjadi akibat gangguan keseimbangan sistem energi t ubuh dan peningkatan aktifi tas sistem saraf simpatis. p a s i e n y a n g m e n g a l a m i s t r e s membutuhkan intervensi keperawatan agar pasien dapat menjalani kehidupannya dengan nyaman. selama ini intervensi keperawatan di indonesia dalam mengatasi stres yang dig u nakan lebih banyak dalam bent u k psikoterapi, teknik relaksasi ataupun distraksi. namun seiring perkembangan zaman dan meningkatnya kebutuhan pelayanan kesehatan, maka dikembangkan terapi komplementer untuk mengatasi stres. terapi komplementer dalam keperawatan bukanlah hal yang baru. florence nightingale menyatakan telah menggunakan terapi komplementer dalam perawatan pasien, diantaranya terapi musik untuk perawatan holistik pasien. seiring berjalannya waktu, internasional council of nurses project dan national intervention c l a s s i f i c a t i o n p r o je c t m e m a s u k k a n terapi komplementer ke dalam intervensi keperawatan, meliputi terapi music, imagery, progressive muscle relaxation, journaling, reminiscence dan massage (hidayati et al., 2012). seft (spiritual emotional freedom technique) merupakan per paduan teknik yang menggunakan energi psikologis dan kekuatan spiritual serta doa untuk mengatasi emosi negatif. seft langsung berurusan dengan “gangguan sistem energi tubuh” untuk menghilangkan emosi negatif dengan menyela r a sk a n kembal i sistem energ i tubuh. seft efektif mengatasi stres karena didalamnya terdapat beberapa teknik terapi yang terangkum dan dipraktikkan secara sederhana, terapi tersebut meliputi do’a, n lp (neuro ling uistic prog ramming ), hypnotherapy, visualisasi, meditasi, relaksasi, imagery dan desensitisasi (zainudin, 2008). penelitian yang mendukung keefektifan seft telah dilakukan oleh rowe (2005; dalam zainudin, 2008), yaitu eft (emotional freedom technique). rowe mengevaluasi tingkat stres 102 peser ta pelatihan eft dengan alat ukur psychological distress scl90-r (sa-45), dan hasilnya menunjukkan penurunan tingkat stres yang signifikan. selain it u,penelitian ulumi (2014) juga menunjukkan bahwa eft dapat menurunkan 93 spiritual emotional freedom technique (desmaniarti, z. dan nani avianti) kecemasan pasien kanker payudara secara signifi kan p= 0,000 . namun seft ini sendiri belum pernah digunakan dalam kasus kanker serviks, sehingga pengaruh seft terhadap penurunan stres pasien kanker serviks belum dapat dijelaskan. bahan dan metode penelitian ini menggunakan quasy experiment pre dan post test randomize control group design. (dahlan, 2011). penelitian dilaksanakan di rumah sakit umum pusat (rsup) dr. hasan sadikin bandung, yaitu di ruang obgyn gedung kemuning lantai iii, pada bulan juni 2013 sampai dengan september 2013. sampel penelitian ini adalah pasien kanker serviks sejumlah 68 orang yang terbagi dalam dua kelompok, yaitu kelompok perlakuan 34 orang dan kelompok kontrol 34 orang. pengambilan sampel dilakukan secara purposive sampling (arikunto, 2005) dengan kriteria inklusi (1) pasien terdiagnosa kanker serviks stadium i sampai iii; (2) pasien yang sedang menjalani kemoterapi; (3) mengalami emosi negatif/gejala stres seper ti sedih, gelisah, sulit tidur, letih dan lemah, kurang nafsu makan serta berdebar-debar; (4) pasien dengan skor emosi negatif minimal 5 dari rentang skala 1-10 (kriteria: skor 1-2/ringan, 3-5/sedang, 6-8/berat, 9-10/sangat berat); (5) mampu mendengar; dan (6) kooperatif. data yang dikumpulkan adalah data primer yaitu skor stres pasien kanker serviks sebelum dan sesudah perlakuan melalui angket tentang stres yang dikembangkan oleh destiana dari teori robert j.v. amberg dengan nilai validitas r 0,486 – 0,785, sedangkan nilai reliabilitasnya adalah 0,926 (destiana, 2012). pelaksanaan penelitian diawali dengan mengidentifi kasi pasien kanker serviks yang akan dijadikan responden penelitian, yaitu dengan mengeksplor semua perasaan emosi negatif atau gejala stres yang pasien alami. pasien yang mencapai skor stres minimal 5 diberikan penjelasan penelitian dan informed consent serta dilakukan pre test. selanjutnya responden dibagi menjadi dua kelompok, yaitu kelompok kontrol dan kelompok perlakuan. kelompok perlakuan mendapatkan bimbingan seft secara individual yang berisi penjelasan tentang pengertian, tujuan dan manfaat seft untuk pasien kanker serviks. dalam seft, peneliti menekankan bahwa peneliti dan pasien hanya berusaha, sedangkan perasaan tenang serta kesembuhan hanya diperoleh dari tuhan yang maha kuasa; diser tai keyakinan penuh bahwa hanya allah/tuhan yang menenangkan dan menyembuhkan. peneliti juga menekankan bahwa keberhasilan seft sangat tergantung dari “keikhlasan” menerima kondisi yang dihadapi dan “kepasrahan” pada yang maha kuasa. langkah ber i k ut nya responden diminta untuk mengikuti instruksi peneliti diawali dengan meminta responden berdoa, dilanjutkan dengan latihan inti seft yang terdiri dari the set-up, the tune-in, the tapping (zainudin, 2008). langkah pertama adalah the set-up. responden dibimbing untuk mengucapkan kalimat “ya allah/tuhan meskipun saya …….. (keluhan atau perasaan negatif pasien), saya ikhlas menerima perasaan saya ini, saya pasrahkan padamu ketenangan batin saya” dengan penuh khusuk, ikhlas dan pasrah sebanyak 3 kali, sambil menekan dada kiri (titik yang dirasa nyeri) atau daerah “sore spot” atau dapat dilakukan dengan mengetuk ringan dengan dua jari pada bagian “karate chop”. the set up bertujuan untuk memastikan aliran energi tubuh terarah dengan tepat dan untuk menetralisir emosi negatif yang timbul karena menderita kanker serviks. langkah kedua adalah the tune-in. responden diarahkan memikirkan sesuatu atau peristiwa spesifi k yang dapat membangkitkan emosi negatif (gejala st res) yang ingin dihilangkan, bersamaan dengan ini hati dan mulut mengatakan “yaa allaah/ ya tuhan… saya ik hlas… saya pasrah”. bersamaan dengan tune-in responden diminta melakukan langkah ketiga, the tapping, yaitu mengetuk ringan dengan dua ujung jari pada titik-titik energi meridian tubuh sambil terus tune-in yang diakhiri dengan relaksasi pernafasan yaitu “tarik nafas panjang lewat hidunghembuskan lewat mulut sambil mengucap rasa syukur beberapa kali. semua langkah di atas dilakukan sebanyak 3 kali putaran selama 30 menit. setelah selesai, responden diminta mengemukakan perasaan yang dirasakan saat 94 jurnal ners vol. 9 no. 1 april 2014: 91–96 melakukan seft serta kendala yang dihadapi. selain itu, dikaji pula perasaan responden setelah dilakukan seft (dalam skala 1-10), dan diakhiri dengan post test. pada kelompok kontrol, peneliti dibantu oleh dua orang perawat ruangan (pendidikan diii keperawatan) melakukan tindakan penanganan stres seperti yang biasa dilakukan oleh perawat ruangan berupa psikoterapi dan atau teknik relaksasi pernafasan. di akhir penelitian dilakukan post test dengan mengisi angket tentang stres. data yang telah terkumpul diolah dan dianalisis secara statistik. analisis data univariat menggunakan mean dan standar deviasi untuk melihat rerata skor stres pasien sebelum dan sesudah intervensi, sedangkan untuk membedakan rerata skor stres sebelum dan sesudah intervensi menggunakan paired t-test. untuk membandingkan perbedaan rerata skor stres pada kelompok perlakuan dengan kelompok kontrol dilakukan dengan independent t-test. hasil hasil analisis uji normalitas kolmogorov smir nov menunjukkan bahwa data hasil penelitian berdistribusi normal dengan selisih rerata pre test dan post test 10,49 dan standar deviasi 12,034, p=0,005. hasil analisis statistik paired t-test menunjukkan terjadi penurunan stres pada kedua kelompok, namun rerata penurunan skor stres pada kelompok perlakuan lebih besar daripada kelompok kontrol. rerata skor stres pada kelompok perlakuan sebelum intervensi sebesar 50,79 dan setelah intervensi 31,29 (tabel 1), sehingga diperoleh penurunan rerata skor stres 19,59 dengan standar deviasi 6,929 (p=0,000) (tabel 2). pada kelompok kontrol rerata stres sebelum intervensi sebesar 47,03 dan setelah intervensi 45,56 (tabel 1), sehingga diperoleh rerata penurunannya 1,47 dengan standar deviasi 8,863 (p =0,340) (tabel 2). hasil independent t-test menunjukkan bahwa seft bermakna menurunkan stres pasien kanker serviks dengan perbedaan rerata selisih pre-posttest sebesar 18,02, p-value 0,000 (95 % ci 14,11721,882). pembahasan stres merupakan salah satu bentuk emosi negatif yang dialami oleh seseorang dan dapat mengganggu keamanan ser ta kenyamanan dalam melaksanakan tugas kehidupan sehari-hari (agoes, 2003). stres pada pasien kanker serviks terjadi akibat ketidakmampuan pasien dalam mengatasi ancaman psikologis yang ditimbulkan oleh kondisi penyakit kanker serviks yang dikenal sebagai penyakit mematikan (nelson, 2008). menurut hasil penelitian destiana (2012) terhadap 97 pasien kanker serviks, diperoleh hasil bahwa semua pasien mengalami stres dengan derajat yang ber var iasi, antara lain 70,1% mengalami stres berat, 19,6% tabel 1. skor stres pasien kanker serviks kelompok perlakuan dan kelompok kontrol kelompok rerata standar deviasi nilai minimummaksimum perlakuan pre test 50,79 7,372 32 – 65 post test 31,29 8,141 22 – 59 kontrol pre test 47,03 11,000 28 – 76 post tes 45,56 13,187 21 – 86 tabel 2. selisih skor stres sebelum dan sesudah intervensi pada kelompok perlakuan dan kelompok kontrol kelompok rerata selisih skor stres pre dan post test standar deviasi nilai minimummaksimum p value perlakuan 19,50 6,929 4 – 34 0,000 kontrol 1,47 8,863 -32 – 24 0,340 95 spiritual emotional freedom technique (desmaniarti, z. dan nani avianti) mengalami stres sedang dan 10,3% mengalami stres ringan. hasil penelitian ini menunjukkan pasien kanker serviks yang menjalani kemoterapi mengalami stres, dan setelah mendapatkan intervensi seft tampak terjadi penurunan st res. sebelum mendapatkan inter vensi pasien mengalami stres dengan rerata skor 50,79 berada pada tingkat sedang dan cukup membahayakan bagi pasien karena lapangan persepsi pasien mulai menyempit dan mempengaruhi aktifi tas sehari-hari yang tentunya dapat memperburuk status kesehatan pasien itu sendiri. hal ini dapat disebabkan oleh adanya koping yang destruktif, sebagaimana dikemukakan oleh fitriana dan ambarini (2012) bahwa salah satu bentuk mekanisme koping destruktif pada pasien antara lain menilai negatif penyakit yang diderita dimana pasien menganggapnya sebagai ancaman kehidupan dan penyakit yang mematikan. menurut penelitian destiana (2012), 69,1% p a sie n k a n ke r s e r v i k s me ng g u n a k a n mekanisme koping yang destruktif dan hanya 30,9% pasien menggunakan koping yang konstruktif. di samping itu, penggunaan koping yang destruktif dapat disebabkan oleh adanya beberapa sumber koping yang tidak efektif dan tidak adekuatnya sumber koping yang dimiliki pasien, antara lain kemampuan personal, dukungan sosial, asset/material dan keyakinan positif yang dimiliki pasien kanker serviks. selain koping yang destruktif, stres pasien kanker juga dipicu oleh timbulnya beberapa gejala penyakit yang baru dirasakan saat penyakit memasuki stadium lanjut. hasil penelitian menunjukkan 65,7% responden berada pada stadium ii a, b dan 35,3% pada stadium iii a, b, sehingga pasien kanker serviks stadium lanjut baru menunjukkan gejala yang lebih berat dari sebelumnya seperti nyeri perut bagian bawah menjalar ke pinggang, keputihan dan perdarahan per vaginam yang tidak kunjung sembuh. pada stadium lanjut, pengobatan penyakit kanker serviks menjadi lebih sulit dan kompleks, sehingga stres pun tidak dapat dihindari. spiritual emotional freedom technique (seft) merupakan salah satu teknik terapi yang dapat menurunkan emosi negatif pasien termasuk stres dan gejala yang menyertai. saat pelaksanaan seft, pasien diminta menceritakan semua perasaan negatif yang dialami selama menderita kanker serviks, dan bersamaan dengan hal itu terjadi katarsis atau proses pengeluaran perasaan/beban emosi negatif pada pasien. stuart dan laraia (2005) menyatakan bahwa teknik katarsis dapat dilakukan dengan menceritakan masalah yang sedang dihadapi sehingga perasaan menjadi lebih rileks dan tenang. di samping itu, saat pelaksanaan seft, pasien juga diminta berdoa kepada tuhan, sehingga hati menjadi tenang, sebagaimana dikemukakan oleh larry dossey dalam zainudin (2008) bahwa doa efektif menurunkan stres. zainudin (2008) menyatakan bahwa gangguan emosi atau adanya penyakit dapat menyebabkan ketidakseimbangan energi tubuh. dalam praktek seft, pasien diminta mengetuk ringan pada 18 titik seft sambil “tune in” atau membayangkan peristiwa yang menyebabkan emosi negatif, sehingga aliran energi tubuh berjalan normal dan kembali seimbang. selain itu dalam terapi seft terdapat berbagai jenis terapi komplementer lain seperti meditasi, visuaisasi, nlp (neuro linguistic programming), em dr ( eye movement desensitization reprocessing), sugesti dan relaksasi, yang keseluruhannya dapat meningkatkan endorphin dan membuat otak berada di gelombang alfa sehingga timbul kondisi rileks dan tenang (sentanu, 2007). kondisi rileks yang ditimbulkan setelah seft juga dapat menurunkan intensitas nyeri pasien kanker serviks, sehingga mengurangi stres pasien. hal ini sesuai penelitian dewi, ropi, dan agustina (2004) yang menunjukkan latihan relaksasi pre operasi efektif menurunkan intensitas nyeri pasien post operasi. dalam praktek seft, aspek spiritual pasien lebih diperhatikan melalui penekanan pada aspek khusuk, ikhlas dan pasrah, serta pasien diyakinkan bahwa hasil yang akan diperoleh tergantung keikhlasan, kepasrahan, dan keyakinan pasien kepada tuhan. semakin ikhlas, semakin pasrah, dan semakin yakin tuhan yang menyembuhkan atau menenangkan hati, maka hasilnya semakin optimal. 96 jurnal ners vol. 9 no. 1 april 2014: 91–96 simpulan dan saran simpulan berdasarkan hasil penelitian yang telah dilakukan dapat disimpulkan bahwa seft dapat menurunkan stres pasien kanker serviks yang menjalani kemoterapi. meskipun penurunan stres terjadi pada kedua kelompok responden, namun tampak rerata penurunan stres pada kelompok perlakuan lebih besar dibandingkan dengan kelompok kontrol. saran perawat dapat menggunakan seft sebagai alternatif tindakan keperawatan dalam menangani stres pasien kanker serviks yang menjalani kemoterapi, sehingga pasien kanker serviks dapat menjalani pengobatan secara optimal. kepustakaan agoes, h., 2003. teori dan management stres. surabaya: refi ka aditama. bintang, y.a., 2012. gambaran tingkat kecemasan, stres dan depresi pada pasien kanker yang menjalani kemoterapi pada salah satu rs di kota bandung, student e-journals. (1), (online) (http:// w w w.ju r nal. u npad.ac.id /ejou r nal / article/view/719/768/., diakses tanggal 22 april 2013, jam 11.00 wib). dahlan, s., 2011. besaran sampel dan teknik pengambilan sampel. jakarta: salemba medika. dewi, k.n., ropi, h., dan agustina, h.r., 2004. pengaruh atihan relaksasi pre operasi terhadap intensitas nyeri post operasi pada pasien post operasi bedah sedang di rsud dr slamet garut. majalah keperawatan, nursing journal of padjadjaran university, 5 ( x ) 104-106. destiana, f., 2012. hubungan mekanisme koping dengan tingkat stres pasien kanker serviks di ruang obgyn gedung kemuning lantai iii rs hasan sadikin bandung, karya tulis ilmiah, tidak dipublikasikan. politeknik kesehatan kemenkes bandung. diahsari, e.y., 2001. kontribusi stres pada produktifi tas kerja. anima, indonesian psychological journal vol. 16: 360 – 371 fitriana, n., dan ambarini, 2012. kualitas hidup pada penderita kanker serviks yang menjalani pengobatan radioterapi. jurnal psikologi klinis dan kesehatan mental, vol 1. no.12 hartati, 2010. cegah dan deteksi kanker serviks. jakarta: gramedia. hidayati, n. o., hamid, a. y.s., dan hariyati, t. s., 2012. pengaruh emotional freedom technique (eft) terhadap peningkatan harga diri narapidana perempuan di lembaga pemasyarakatan kelas iia bogor. majalah keperawatan, nursing journal of padjadjaran university, 13 (2) 94-114. nelson, e.l., lari, b.w., dan kathryn, o., 2008. stress, immunity, and cervical ca ncer: biobehav ioral o utcomes of a ra ndom i zed cli n ical trail. journal american association for cancer researc. 14 (7), (online), (http://clincancerres.aacjournals.org/ content /14/7/2111.f ull.pdf ).,diakses tanggal 27 april 2013 jam 13.00 wib samadi, h. p., 2010. yes, i know everything about kanker ser viks :menjalani, mencegah dan bagai mana anda menjalani pengobatan. jakarta: egc. sentanu, e., 2007. quantum ikhlas, teknologi aktivasi kekuatan hati (the power of positif feeling), jakarta: elex media komputindo stuart, g.w. dan laraia, 2005. principles and practice of psychiatric nursing, sixth edition. st.louis. mosby year book u lu m i, m.n., 2014. penga r uh tera pi emotional freedom tchnique terhadap penurunan kecemasan pasien kanker payudara di rsud prof dr. margono soekarjo purwokwero,skripsi tidak dipublikasikan. purwokerto: universitas soedirman. zainuddin, a.f., 2008. spiritual emotional freedom technique (seft) for healing + success happiness + greatness. jakarta: afzan publishing 170 respons fisik, psikologis dan sosial pria akseptor kb vasectomy di kartasura sukoharjo jawa tengah (meǹ s physical, psychological and social response to vasectomy acceptor of family planning program in sukoharjo central java) winarsih nur ambarwati fakultas ilmu kesehatan universitas muhammadiyah surakarta e-mail: ambarwati76@gmail.com abstract introduction: indonesia is on the fourth position in the world as the most populated nation in 2009. great number of people with lack of skill would give potential burden in the nation development. generally, the outcome of indonesian family planing program(fpp) acceptor to indonesian women is suffi cient which is ranging to 59 percent of the total 60,3 percent of participants but if compared to men's participation in is still insignifi cant. husband's participation as participant is still low 1.3% consisted of 0.9 percent condom user, 0.4 percent vasectomy user. to describe experiences of indonesian men following vasectomy in relation to their physical, psychological and social responses to vasectomy. method: the research design of this research uses descriptive qualitative study. the sample selection was done using theoretical sampling technique. the data collection instrument of grounded theory research is the researcher herself, while other instruments are namely fi eld report, audiotape, videotape, and notes. the data analysis is utilized colaizzi`s method. result: numbers of participants were 7 persons. physical change after the vasectomy surgery is on general physical change (there is no change felt, the body's stamina raises, healthier, less energy, or weary) and physical change on reproduction organ is none. sexual ability has no change, it increases, it also decreases. the sexual satisfaction is the same, more satisfi ed, or less satisfi ed. the characteristic change of spermatid is the same, there is change (lesser quantity, more dissolved), and ignore it. all participants said that they feel more comfortable in doing sex after vasectomy surgery. most participants feel confi dence of their sexual ability. the participants' perspective had no difference and feel difference, or there is a change. most participants stated that vasectomy is the right decision, but few felt disappointed. the social environment response toward men as the acceptor of vasectomy is that the society support it and few contradict it. discussion: vasectomy no hazard to physic, psycology, social, and wife. vasectomy is a good one of methode contraception to men keywords: men acceptor, vasectomy, physical, psychological, social pendahuluan jumlah penduduk indonesia berdasarkan sensus tahun 2010 yang dilakukan oleh badan pusat statistik indonesia adalah 237.556.363 orang, yang terdiri dari 119.507.580 lakilaki dan 118.048.783 perempuan. indonesia menduduki peringkat ke empat di dunia jumlah sebagai negara dengan penduduk terbanyak pada tahun 2009. laju pertumbuhan penduduk indonesia sebesar 1,49 persen per tahun. ratarata tingkat kepadatan penduduk indonesia adalah sebesar 124 orang per km². penambahan jumlah penduduk yang besar mempunyai implikasi yang sangat luas terhadap program pembangunan. penduduk yang besar dengan kualitas yang relatif kurang memadai sangat ber potensi memberikan beban dalam pembangunan. permasalahan kependudukan dan keluarga kecil di indonesia adalah masih tingginya laju pertumbuhan penduduk, masih tingginya tingkat kelahiran pendudu k, k urang nya pengetahuan dan kesadaran pasangan usia subur tentang hak-hak, reproduksi, masih rendahnya usia 171 respons fisik, psikologis dan sosial (winarsih nur ambarwati) perkawinan pertama, rendahnya partisipasi pria dalam ber-kb dan masih kurangnya maksimalnya akses dan kualitas pelayanan kb, serta masih rendahnya institusi daerah dalam pelaksanaan kb (bkkbn, 2003). i ndonesia mer upa k a n sala h sat u negara yang meratifikasi hasil konferensi k e p e n d u d u k a n d a n p e m b a n g u n a n (internasional conference on population and development/icpd) tahun 1994 di kairo, disepakati paradigma baru program kb dari pendekatan pengendalian fertilitas menjadi lebih kepada pendekatan kesehatan reproduksi dengan lebih memperhatikan hakhak reproduksi, pemberdayaan perempuan dan kesetaraan gender. hal ini mengandung ar ti bahwa dalam pelaksanaan keluarga berencana dan kesehatan reproduksi selalu diupayakan untuk memperhatikan kepentingan perempuan dan laki-laki secara seimbang. pelaksanaan program kb oleh pemerintah belum mendapatkan hasil yang optimal, hal ini di antaranya ditunjukkan dari target kb nasional belum tercapai. capaian akseptor kb perempuan di indonesia secara umum cukup memuaskan yaitu mencapai 59 persen dari total 60,3 persen peserta kb, namun jika dibandingkan dengan keikutsertaan kb pria masih sangat jauh dari yang diharapkan. partisipasi suami sebagai peserta kb masih sangat rendah yaitu 1,3% yang terdiri dari pemakai kondom 0,9 persen, vasectomi 0,4 persen. banyak pemicu rendahnya partisipasi pria dalam kb. beberapa penyebab utamanya adalah faktor kurang fokusnya program kb terhadap kaum pria, minimnya metode kb yang dapat dipilih oleh pria. faktor-faktor lain yang menyebabkan rendahnya partisipasi pria dalam keluarga berencana dan kesehatan reproduksi antara lain: pengetahuan, sikap dan paktek serta kebutuhan klien, faktor lingkungan: sosial, budaya masyarakat, agama dan keluarga/istri, keterbatasan informasi, dan aksesibilitas terhadap pelayanan kontrasepsi pria dan keterbatasan jenis kontrasepsi pria (bkkbn, 2003). secara umum masyarakat di wilayah kartasura dan khususnya para suami masih banyak menggangap bahwa kb adalah urusan perempuan. para suami masih belum bisa menerima konsep kb dengan baik karena mereka belum mendapatkan bukti yang cukup bahwa kb tidak akan mempengaruhi kesehatan dan vitalitas pria serta pengaruh anggapan masyarakat yang masih meyakini mitos-mitos yang tidak benar. ketakutan dan kekhawatiran akan efek samping kb pada pria khususnya metode operasi vasectomy, pandangan masyarakat dapat menyebabkan para suami ragu-ragu dan sulit mengambil keputusan yang tepat. hal ini terjadi karena tidak adanya data atau infor masi yang jelas tentang dampak atau pengalaman menjadi akseptor kb vasektomi dan segala pengaruhnya terhadap fi sik dan psikologis serta sosial pria akseptor kb. minimnya informasi tentang dampak kb vasektomi juga disebabkan sangat minimnya penelitian yang dilakukan khususnya dampak vasektomi terhadap fi sik, psikologis dan sosial pria. peneliti ter tarik unt uk melakukan penelitian kualitatif tentang tentang respons fi sik, psikologis dan sosial pria yang menjadi akseptor kb. peneliti memilih penelitian kualitatif dengan rancangan. study grounded theory sesuai digunakan untuk mengeksplorasi proses sosial yang terjadi dalam interaksi manusia (speziale dan car penter, 2003). study grounded theory menjelaskan kejadian yang ada dan mengeksplorasi data yang banyak ditemukan, sehingga memudahkan peneliti untuk memahami apa yang terjadi. penggunaan metode ini sebagai usaha untuk mengurangi kesalahan yang diperoleh dari partisipan terhadap informasi yang diharapkan (polit, beck, dan hungler, 2001). penelitian dengan grounded theory bertujuan untuk menemukan suatu penjelasan secara teori tentang suat u fenomena secara lengkap (speziale dan carpenter, 2003). dari penelitian ini diharapkan didapatkan data yang valid tentang respons fi sik, psikologis dan sosial pria yang menjadi akseptor kb vasektomi. bahan dan metode penelitian ini menggunakan metode kualitatif dengan pendekatan grounded theory. jumlah partisipan dalam penelitian kualitatif 172 jurnal ners vol. 7 no. 2 oktober 2012: 170–176 adalah 7 orang. pemilihan sampel dilakukan dengan teknik theoretical sampling. alat pengumpulan data dari penelitian grounded theory adalah peneliti sendiri sedangkan alat-alat lainnya seperti catatan lapangan, audiotape, videotape dan alat tulis. validasi peneliti sebagai alat penelitian dilakukan oleh peneliti sendiri meliputi pemahaman tent ang metode k ualit atif, peng uasa an wawasan terhadap bidang yang diteliti, dan kesiapan peneliti memasuki objek penelitian. pertimbangan etik yang digunakan untuk mengatasi resiko atau dampak yang muncul pada penelitian adalah autonomy, privacy, confidentiality, anonymity, dan protection from discomfort. analisis data dengan metode colaizzi`s. hasil partisipan dalam penelitian ini sebanyak 7 orang. sebanyak 5 orang berpendidikan sekolah dasar dan dua orang berpendidikan sma. stat us sosial ekonomi dua orang menengah dan lima orang sosial ekonomi rendah. lama vasektomi dua orang kurang dari satu tahun, satu orang 2 tahun dan empat orang lebih dari 5 tahun. empat orang responden adalah mantan pamong desa tiga orang warga biasa, hal ini menunjukkan bahwa kepersertaan menjadi akseptor kb vasektomi dapat disebabkan karena peran sosial di masyarakat di mana sebagai tokoh masyarakat mempunyai kewajiban sebagai suri tauladan bagi masyarakatnya. hampir seluruh partisipan alasan lain karena sebagai pamong desa juga karena alasan istri tidak cocok menggunakan kb perempuan enam partisipan istrinya gagal kb atau tidak cocok kb. enam orang berdomisili di pedesaan dan satu orang di perkotaan. perubahan kondisi fisik perubahan fi sik yang dirasakan oleh par tisipan setelah operasi vasektomi di temukan dua tema yaitu perubahan fisik secara umum dan perubahan fi sik pada organ reproduksi. perubahan fisik secara umum setelah operasi tidak ada perubahan yang dirasakan, badan stamina lebih meningkat, lebih sehat, tenaga kurang atau mudah lelah. perubahan pada organ reproduksi setelah operasi semua partisipan mengatakan tidak ada perubahan. kemampuan seksual setelah operasi ditemukan tiga tema yaitu tidak ada perubahan, kemampuan seksualnya meningkat, kemampuan seksualnya menurun. kepuasan dalam hubungan seksual paska operasi vasektomi semua partisipan mengatakan lebih nyaman melakukan hubungan seksual setelah operasi vasektomi. perubahan karakteristik air mani setelah operasi vasektomi ditemukan ada tiga yaitu sama saja, ada perubahan dan tidak memperhatikan. satu partisipan yang menyatakan sama saja mengatakan tidak ada perubahan. perubahan kondisi psikologis k e ny a m a n a n d a l a m m el a k u k a n hu bu ng a n s ek s u a l. s e mu a p a r t i sip a n me ngat a k a n lebi h nya ma n mela k u k a n hubungan seksual setelah operasi vasektomi. keyakinan dalam melak u kan hubungan seksual, sebagian besar partisipan merasa yakin akan kemampuan seksualnya. cara pandang terhadap diri sendiri. cara pandang partisipan ditemukan dua tema yaitu tidak ada perubahan dan merasa berbeda/ada perubahan dalam dirinya. apakah vasektomi merupakan keputusan yang tepat ditemukan dua tema yaitu vasektomi adalah keputusan yang tepat dan menyesal telah melakukan vasektomi. perasaan terhadap pasangan ditemukan dua tema yaitu lebih sayang terhadap istri dan merasa bingung dengan perasaannya. respons sosial respons lingkungan sosial terhadap pria akseptor kb vasektomi ditemukan dua tema yaitu masyarakat mendukung dan menolak atau kurang setuju. pembahasan perubahan fi sik yang dirasakan oleh par tisipan setelah operasi vasektomi di temukan dua tema yaitu perubahan fisik secara umum dan perubahan fi sik pada organ reproduksi. perubahan fisik secara umum setelah operasi tidak ada perubahan yang 173 respons fisik, psikologis dan sosial (winarsih nur ambarwati) dirasakan, badan stamina lebih meningkat, lebih sehat, tenaga kurang atau mudah lelah. per ubahan pada organ reproduksi setelah operasi semua partisipan mengatakan tidak ada perubahan. hasil penelitian ini tidak sesuai dengan perubahan patofi siologi pascaoperasi vasektomi, perubahan terjadi pada semua area saluran genital pada bagian proksimal. dampak terhadap histolog y testicular setelah vasektomi dilaporkan pada semua binatang percobaan. pathological histological ditemukan meliputi degerasi dari sperma, penebalan dari basement membranes dan meningkatnya phagocytosis oleh sertoli cells. quantitative morphometric analysis dari testicular histology dari pria setelah vasektomi menunjuk kan dilatasi dari seminiferous tubules, interstitial f ibrosis (tandon dan sabanegh jr, 2008). mcmahon et al. (1992) menemukan dalam penelitiannya chronic testicular pain dilaporkan pada 33% pria setelah vasektomi, dengan 5% datang ke petugas kesehatan untuk mencari bantuan. choe dan kirkemo (1996) mengidentifi kasi chronic scrotal pain sebanyak 18,7% pada pasien setelah vasektomi, di mana berdampak atau mempengar uhi kualitas hidupnya sebanyak 2,2%. ha mpi r semu a responden d ala m penelitian ini menyatakan kurang begitu memperhatikan perubahan anatomi pada organ reproduksi secara detail hal ini disebabkan sebagia n responden tela h lupa ka rena vasektomi lebih dari 5 tahun, faktor lain dapat dipengaruhi oleh masyarakat indonesia ter utama jawa merasa k u rang nyaman membicarakan hal-hal yang dianggap kurang nyaman dibicarakan dengan orang lain. keluhan nyeri punggung, perut, dan badan tidak enak dan tidak nyaman pada organ reproduksi sampai sekarang (empat bulan) dikeluhkan oleh satu partisipan. ahmed et al., (1997) salah satu masalah yang dirasakan setelah vasektomi adalah chronic testicular pain, di mana nyeri dirasakan intermittend atau constant pada bagian unilateral atau bilateral selama sama dengan atau lebih tiga bulan setelah operasi vasektomi. chronic testicular atau scrotal pain adalah salah satu komplikasi yang yang dapat terjadi setelah vasektomi dengan insiden yang tidak diketahui (manikandan et al, 2003). nyeri atau ketidaknyamanan setelah vasectomy merupakan salah satu alasan bagi pasien untuk mendatangi petugas kesehatan dan menjadi alasan untuk menolak vasektomi. temuan ini menjadi penting diperhatikan oleh petugas kesehatan untuk selalu memberikan informasi yang sejelas-jelasnya kepada pasien mengenai efek samping dan kemungkinan yang terjadi setelah vasektomi agar pasien siap (mcmahon, et al., 1992). kemampuan seksual pria kemampuan seksual setelah operasi d itemu ka n t iga tema yait u t id a k a d a perubahan, kemampuan seksualnya meningkat, kemampuan seksualnya menurun. partisipan yang menyatakan tidak ada perubahan pada umumnya mereka kurang memperhatikan perubahan yang terjadi dan menganggap bahwa bila istri tidak komplain berarti tidak ada masalah dan tidak menganggap masalah seksual sebagai masalah yang perlu dibahas, yang penting melakukan hubungan seksual antara suami dan istri adalah menunaikan kewajiban. pasangan suami dan istri dalam budaya jawa kurang terbuka dalam urusan kepuasan seksual dan jarang mengangkat pembicaraan hubungan seksual antara suami dan istri. melakukan hubungan seksual dalam budaya jawa adalah melaksanakan kewajiban melayani suami, bahkan ketika istri tidak berkeinginan melakukan hubungan seksual, bahkan istri kurang memperhatikan kebutuhan seksualnya. partisipan yang menyatakan kemampuan seksualnya lebih baik diartikan sebagai kemampuan melakukan hubungan seksual mampu bertahan lebih lama daripada sebelum operasi, melakukan hubungan lebih sering. kemampuan seksual yang meningkat dapat dipengaruhi oleh kesehatan secara umum yang baik. partisipan yang menyatakan kemampuan seksualnya banyak turun terjadi sampai saat ini (empat bulan). partisipan yang mengalami penurunan kemampuan seksual ini menjadi akseptor kb vasektomi karena terpaksa, karena kondisi sosial ekonomi yang sangat kurang, takut anak-anaknya tidak dapat membiayai, 174 jurnal ners vol. 7 no. 2 oktober 2012: 170–176 tidak punya pekerjaan pasti, sehingga terpaksa ikut kb vasektomi karena istri tidak cocok menggunakan pilihan kb perempuan. kepuasan seksual pria kepuasan seksual pria setelah operasi vasektomi ditemukan tiga tema yaitu sama saja, lebih puas dan kurang puas. partisipan yang merasa sama saja pada umumnya menganggap hubungan seksual antara pasangan suami istri adalah menunaikan kewajiban. mereka tidak memperhatikan perubahan dalam hal kepuasan seksual karena dianggap tidak penting. budaya masyarakat jawa kurang lazim membicarakan tentang hubungan seksual antara pasangan. partisipan yang paling banyak menyatakan lebih puas, lebih akrab, lebih mesra, lebih dekat. satu partisipan yang yang menyatakan kurang puas karena kemampuan seksualnya menurun. perubahan karakteristik air mani per ubahan karakter istik air mani setelah operasi vasektomi ditemukan ada tiga yaitu sama saja, ada perubahan dan tidak memperhatikan. satu partisipan yang menyatakan sama saja mengatakan tidak ada perubahan. partisipan yang paling banyak mengatakan ada perubahan yaitu jumlah lebih sedikit, lebih encer. studi literatur menyarankan bahwa tidak ada kesepakatan waktu yang pasti untuk melakukan pemeriksaan semen analysis. semua ejakulasi potensial fertile spermatozoa segera setelah vasektomi, di mana dengan cepat sperma menjadi immobile dalam beberapa hari, biasanya tiga minggu setelah prosedur pembedahan (edwards, 1993). dua par tisipan mengatakan tidak memperhatikan sampai sejauh it u yang penting bagi mereka sudah diniati, sehingga apapun perubahannya diterima, sehingga tidak memperhatikan jika tidak menyebabkan masalah. perubahan psikologis pria setelah operasi vasektomi kenyamanan dalam melakukan hubungan seksual semua partisipan mengatakan lebih nyaman melakukan hubungan seksual setelah operasi vasektomi. gambaran kenyamanan yang dirasakan adalah merasa lebih semangat, lebih enjoy, lebih aman, sangat menikmati, lebih bebas, lebih tenang. perasaan bebas dan aman menurut partisipan disebabkan karena resiko terjadinya kehamilan sudah tidak ada lagi, sehingga lebih nyaman dan menikmati dan dapat melakukan hubungan lebih sering tanpa disertai kekhawatiran terjadi hamil. semua par tisipan mengatakan menu r ut pengetahuannya setelah operasi vasektomi tidak mungkin hamil lagi. penelitian de knijff et al (1997) nonmotile sperm 33% pada pasien setelah 12 minggu pasca vasektomi, dengan waktu rata-rata azoospermia adalah 6,36 bulan. azoospermia adalah kriteria untuk dikatakan sterile. berdasarkan literatur ini dapat kita simpulkan bahwa seorang lakilaki dengan jumlah sperma sedikit (<1×106) dengan nonmotile sperm setelah vasectomy sangat sedikit resiko terjadinya kehamilan. jamiesson et al. (2004) dalam penelitiannya menemukan dan merekomendasikan tiga bulan setelah vasektomi sebaiknya atau setelah 20 kali ejakulasi supaya menghindari intercourse atau sebaiknya menggunakan temporary contraception sampai azoospermia terbukti secara hasil dokumentasi pemeriksaan hasil laboratorium. pasangan sebaiknya diberikan informasi bahwa kondisi steril tidak langsung terjadi dalam waktu yang singkat setelah vasektomi. keyakinan dalam melakukan hubungan seksual sebagian besar partisipan merasa yakin akan kemampuan seksualnya. satu partisipan merasa tidak yakin karena kemampuan seksualnya menurun. cara pandang terhadap diri sendiri cara pandang partisipan ditemukan dua tema yaitu tidak ada perubahan dan merasa berbeda/ada perubahan dalam dirinya. sebagian besar partisipan merasa tidak ada perubahan dalam memandang dirinya sendiri. merasa yakin dan percaya bahwa tidak ada yang berubah dalam dirinya setelah operasi vasektomi. satu partisipan merasa dirinya 175 respons fisik, psikologis dan sosial (winarsih nur ambarwati) berubah karena merasa tidak lagi seperti dulu kemampuan seksualnya. kelu han yang dilaporkan partisipan sebagian bukan merupakan komplikasi dari vasectomy. hal ini dapat muncul akibat depresi atau perubahan yang dirasakan dalam dirinya seperti perasaan imoptensi. hal ini sesuai dengan penelitian nigam et al. (1997) gangguan psikosomatis, depresi perasaan impotensi dapat muncul pada orang yang mengalami komplikasi. apakah vasektomi merupakan keputusan yang tepat a p a k a h v a s e k t o m i m e r u p a k a n keputusan yang tepat ditemukan dua tema yaitu vasektomi adalah keputusan yang tepat dan menyesal telah melakukan vasektomi. sebagian besar par tisipan menyat akan vasektomi adalah keputusan yang tepat karena merasa tidak ada masalah setelah vasektomi hasil penelitian ini sesuai dengan cristensen dan maples jr (2005) di mana pasien yang vasektomi selama satu tahun sedikit sekali yang mengadukan keluhan. hampir semua hasil penelitian fokus pada konsekuensi vasektomi terhadap kondisi psikososial dengan hasil kesejahteraan secara psikologis sangat baik untuk kedua pasangan baik suami maupun istri. para suami melaporkan sangat senang dengan keputusan vasektomi yang diambil (wiest dan janke, 1974). partisipan yang menyesal melakukan vasektomi karena merasakan per ubahan kemampuan seksual dan sering sakit secara umum. dalam interview yang lebih dalam pasangan suami istri partisipan ini terdapat konfl ik karena keputusan untuk vasektomi adalah cender ung kemauan ist r i suami melakukan vasectomy karena terpaksa. setelah operasi karena banyak keluhan menyebabkan partisipan merasa menyesal. penolakan pada suami biasanya diketahui dari keluhan istri. konfl ik yang terjadi di antara pasangan yang terjadi sebelumnya biasanya menjadi faktor resiko penolakan dan penyesalan (jamieson et al., 2002). perasaan terhadap pasangan perasaan terhadap pasangan ditemukan dua tema yaitu lebih sayang terhadap istri dan merasa bingung dengan perasaannya. sebagian besar partisipan merasa lebih sayang, lebih dekat, lebih bagus hubungannya, kualitas hubungan meningkat. respons sosial respons lingkungan sosial terhadap pria akseptor kb vasektomi ditemukan dua tema yait u masyarakat mendukung dan menolakatau kurang setuju. sebagian besar partisipan tinggal di daerah pedesaan di mana bentuk respons masyarakat yang mendukung ber upa t id a k mengejek at au menola k keputusan partisipan, menjadi tempat bertanya bagi yang ingin tahu, menjadi contoh atau publik fi gur sebagai akseptor kb pria teladan tingkat daerah. bagi masyarakat yang kurang setuju menyoroti cara yang digunakan sebagai metode kb. simpulan dan saran simpulan sebagian besar pria yang menjadi akseptor kb vasektomi tidak merasakan perubahan fi sik secara umum dan pada organ repproduksi yang merugikan. reaksi psikologis sangat dipengaruhi respons fi sik dan pasangan yang dialami, sehingga memberikan reaksi psikologis yang berbeda-beda. secara umum masyarakat memberikan dukungan terhadap program kb pria khususnya vasektomi. saran vasektomi dapat menjadi salah satu pilihan metode kontrasepsi yang aman bagi suami. sebelum melakukan vasektomi sebaiknya petugas kesehatan memberikan konsultasi yang cukup kepada pasangan, sehingga pasangan menjadi memahami dan siap. kepustakaan ahmed, i., rasheed, s., white, c., shaikh, n.a., 1997. the incidence of postvasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management, british journal of urology, 79: 269– 270. 176 jurnal ners vol. 7 no. 2 oktober 2012: 170–176 bkkbn, 2003. peningkatan partisipasi pria dalam keluarga berenana da kesehatan reproduksi di indonesia, cukilan data program keluarga berencana nasional, nomor: 252 tahun xxx. c h o e , j. m ., k i r k e m o , a . k ., 19 9 6 . questionnairebased outcomes study of nononcological post-vasectomy complications. j urol, 155: 1284–6 christensen, r.e., maples, jr. d.c., 2005. postvasectomy semen analysis: are men following up?: evidence-based clinical practice, j am board fam pract, 18: 44–7. de knijff, d.w.w., vrijhof, h.j.e.j., arends, j., janknegt, r.a., 1997 persistence or reappearance of nonmotile sperm after vasectomy: does it have clinical consequences?. fertile steril, 67: 332–5. edwards, i.s. 1993. earlier testing after vasectomy, based on the absence of motile sperm. fertil steril, 59: 431– 6. indonesia demographic and health survey, 2002/3. national family plan ning coordinating board, ministry of health, jakarta, indonesia, and orc macro, calverton, maryland usa. jamieson, d.j., costello, c., tussell, j., hillis, s.d., marchbanks, p.a., peterson, h.b., 2004. the risk of pregnancy after vasectomy. the american college of obstetrians and gynecologists, 103(5). mcmahon, a.j., buckley, j., taylor, a., lloyd, s.n., deane, r.f., kirk, d., 1992. chronic testicular pain following vasectomy. br j urol, 69: 188–91. manikandan, r., srirangam, s.j., perason, e, collins, g.n., 2003. early and late morbidity after vasectomy: a comparison of ch ronic scrot al pain at 1 and 10 yers, b j u i n t e r n a t i o n a l, 93: 571–574. nigam, p., goyal, b.m., kumar, r., sri vasta, r.p., 1997. post vasectomy sex-disorder. the medicine and surgery, 6: 10. polit, d.f. dan hungler, b.p., 1999. nursing research: principles and metods. (6th ed0. philadelpia: lippincott williams and wilkins. speziale, h.j.s. dan carpenter, d.r., 2003. q ualitative research in n ursing, advancing the humanistic imperative, 3th ed, lippincot william and wilkins. tandon, s., sabanegh, jr. e., 2008. chronic pain after vasectomy: a diagnostic and treatment dilemma. b j u i n t e r n a t i o n a l, 102, 166–169. wiest, w.m., janke, l.d., 1974. review artikle: a methodological critique of research on psychological effects of vasectomy. psychosomatic medicine, 36(5). ners vol 5 no 1 april 2010_akreditasi 2013.indd 62 pola menyusui dan pemberian makanan tambahan meningkatkan status gizi balita usia 7–24 bulan (the pattern of breastfeeding and providing supplement increase nutritional status for 7–24 month children) esti yunitasari*, hesti permanasari*, retnayu pradanie* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257, e-mail: esty.yun_ners@unair.ac.id abstract introduction: infants grow and develop rapidly therefore they tend to suffer from malnutrition when they couldn’t get adequate nutrition. the infant nutrient status is infl uenced by many factors such as the breastfeeding pattern and the providing supplement meal pattern. the purpose of this study was to analyze correlation between breastfeeding and providing supplement with 7–24 month child nutritional status. method: this study used cross sectional design. population was mothers who were breastfeeding and providing supplemental meal to their infants age 7 to12 months at nuri posyandu, in kademangan puskesmas. samples consisted of 16 mothers with their infants, enrolled based on inclusion criteria. the independent variables were breastfeeding pattern and providing supplement meal pattern. the dependent variable was the nutritional status of the infant age 7 to 12 month. data were collected by questionnaire and the infant weight was interpreted using road to health card (kms) then analyzed by spearman’s rank test with signifi cance level of α ≤ 0.05. result: result showed a strong correlation between breastfeeding pattern and nutritional status of the infant age 7 to 12 months (p = 0.001) and adequate correlation was also found between the providing supplement meal pattern and the nutritional status of the infant of 7 to 12 months (p = 0.036). discussion: in conclusion, both of breastfeeding and providing supplement meal correctly have correlation to the good infant nutritional status. further studies should use other designs that enable data to be collected more than once to obtain better reliability in accuracy. keywords: growth record, weight, posyandu, breastmilk pendahuluan gizi merupakan salah satu faktor penting yang menentukan tingkat kesejahteraan keluarga. satu indikator yang digunakan untuk mengetahui status gizi masyarakat adalah status gizi balita. balita merupakan kelompok yang rentan terhadap masalah kesehatan dan gizi, kelompok umur inilah yang paling sering menderita akibat kekurangan gizi karena pada masa ini terjadi pertumbuhan dan perkembangan yang pesat sehingga memerlukan gizi yang tinggi pula (sediaoetama, 2000). pemberian asi dan pemberian makanan tambahan sangat dibutuhkan pada balita usia 7–12 bulan, karena asi masih merupakan salah satu makanan yang memiliki kandungan gizi yang tinggi dan pada usia tersebut pemberian asi saja sudah tidak mencukupi lagi kebutuhan gizi yang terus berkembang sehingga dibutuhkan pemberian makanan tambahan (muzakki, 2009). menurut kerangka yang disusun oleh who, terjadinya kekurangan gizi dalam hal ini gizi kurang dan gizi buruk lebih dipengaruhi oleh beberapa faktor baik faktor langsung maupun faktor tidak langsung. faktor-faktor yang memengaruhi status gizi secara langsung antara lain asupan makanan (pola menyusui dan pola pemberian makanan tambahan) dan keadaan kesehatan. faktor-faktor yang memengaruhi status gizi secara tidak langsung antara lain ekonomi (pendapatan), pendidikan ibu, pengetahuan ibu, sosial budaya, sanitasi lingkungan, fasilitas pelayanan. makanan untuk anak harus mengandung kualitas dan pola menyusui dan makanan tambahan (esty y.) 63 kuantitas cukup untuk menghasilkan kesehatan yang baik. cara menyusui dan pemberian makanan tambahan yang baik dan benar oleh ibu di indonesia umumnya sangat minim (sulastri, 2007). penelitian yang dilakukan oleh suparman di posyandu dusun cangkir puskesmas driyorejo kabupaten gresik pada tahun 2007 didapatkan hasil 6 (50%) orang yang melakukan tindakan yang kurang dalam menyusui dan memberikan makanan tambahan, 4 (33%) orang dengan tindakan yang cukup dalam menyusui dan memberikan makanan tambahan dan 2 (17%) orang dengan tindakan yang baik dalam menyusui dan memberikan makanan tambahan. cara pemberian asi yang kurang benar tersebut dapat terlihat dari beberapa aspek misalnya perawatan payudara yang salah, frekuensi menyusui yang kurang, cara dan posisi menyusui yang tidak tepat, konsumsi gizi ibu yang kurang sehingga produksi asi kurang optimal. sedangkan pola pemberian makanan yang kurang benar dapat terlihat dari beberapa aspek misalnya waktu pemberian yang terlalu dini, jenis dan bahan makanan yang tidak sesuai dengan usia balita, frekuensi makan yang kurang, pengolahan makanan yang tidak tepat dan penyimpanan yang kurang higiene. permasalahan dalam pola menyusui dan pola pemberian makanan tambahan tersebut dapat ditimbulkan apabila perilaku ibu dalam menyusui dan pemberian makanan tambahan yang kurang baik. perilaku ibu yang kurang baik tersebut dapat disebabkan karena kurang pengetahuan, adanya mitosmitos yang menyesatkan, kurangnya informasi tentang menyusui dan pemberian makanan tambahan yang baik dan benar, fasilitas posyandu yang tidak memadai, serta sikap dan perilaku petugas kesehatan yang negatif (notoatmojo, 2007). penelitian yang dilakukan oleh suparman di posyandu dusun cangkir puskesmas driyorejo kabupaten gresik pada tahun 2007 didapatkan hasil 6 (50%) orang yang melakukan tindakan yang kurang dalam menyusui dan memberikan makanan tambahan, 4 (33%) orang dengan tindakan yang cukup dalam menyusui dan memberikan makanan tambahan dan 2 (17%) orang dengan tindakan yang baik dalam menyusui dan memberikan makanan tambahan, sedangkan penelitian yang dilakukan oleh endang fauziyah susilawati pada tahun 2005 di dusun taraban desa taraban kecamatan larangan kabupaten pamekasan didapatkan hasil bahwa dari 31 orang balita: tidak ada (0%) balita dengan gizi buruk, 1 (3,2%) balita dengan gizi kurang, 14 (45,2%) balita dengan gizi sedang, 16 (51,6%) balita dengan gizi baik. hasil penelitian dari posyandu nuri puskesmas kademangan kabupaten bondowoso pada tanggal 10 juni 2009 sampai 7 juli 2009 didapatkan dari 16 ibu yang menimbang anaknya di posyandu: 2 (12,5%) balita dengan gizi buruk, 1 (6,25%) balita dengan gizi kurang, 9 (56,25%) balita dengan gizi baik dan 4 (25%) balita dengan gizi lebih, dari data tersebut meskipun data yang didapat paling banyak balita dengan gizi baik tetapi ada beberapa balita yang mengalami kep berat dan kep ringan. permasalahan gizi harus ditangani sedini mungkin karena apabila tidak akan dapat menyebabkan gangguan tumbuh kembang pada bayi, seperti (1) pertumbuhan fisik terganggu (gizi berpengaruh terhadap pertumbuhan dan perkembangan anak). (2) pertumbuhan otak atau kecerdasan terlambat (pertumbuhan otak dan perkembangan intelektual paling terganggu jika kekurangan gizi). (3) perkembangan psikis atau mental terganggu (anak dengan gizi buruk mempunyai kesulitan dalam hubungan antar personil). masa balita merupakan masa yang sangat penting dalam kehidupan karena status gizi dan kesehatan masa ini turut menentukan status masa dewasa. anak yang kekurangan gizi akan menyebabkan kondisi malnutrisi yang akan menghambat pertumbuhan dan perkembangan anak, meningkatkan kepekaan terhadap penyakit, anak mudah terkena infeksi, dan jika sakit membutuhkan waktu yang lama untuk sembuh (pudjiadi, 1997). gizi buruk akibat asupan gizi makanan yang tidak adekuat, akan menyebabkan mobilisasi berbagai cadangan makanan untuk menghasilkan kalori demi penyelamatan hidup, dimulai dengan pembakaran cadangan karbohidrat kemudian cadangan lemak serta protein dengan melalui proses katabolik. kalau terjadi stres katabolik (infeksi) maka kebutuhan akan protein akan meningkat, sehingga dapat menyebabkan jurnal ners vol. 5 no. 1 april 2010: 62–69 64 defisiensi protein yang relatif, kalau kondisi ini terjadi pada saat status gizi masih di atas –3 sd (–2 sd s.d. 3 sd), maka terjadilah kwashiorkor (malnutrisi akut/ decompensated malnutrition). bila stres katabolik ini terjadi pada saat status gizi di bawah –3 sd, maka akan terjadilah marasmik-kwashiorkor. kalau kondisi kekurangan ini terus dapat teradaptasi sampai di bawah –3 sd maka akan terjadilah marasmik (malnutrisikronik/ compensated malnutrition). pada kep dapat terjadi: gangguan pertumbuhan, atrofi otot, penurunan kadar albumin serum, penurunan hemoglobin, penurunan sistem kekebalan tubuh, penurunan berbagai sintesa enzim (hidajat, 2007). gizi buruk dan penyakit infeksi dapat dihindari apabila ibu cukup pengetahuan dan perilaku ibu tentang menyusui dan pemberian makanan tambahan yang tepat waktu dan mengatur makanan bayi, serta tata cara menyusui dan pemberian makanan tambahan (departemen kesehatan, 2002). banyak faktor yang menyebabkan terjadinya gangguan pemenuhan nutrisi tersebut pada usia bayi antara lain: dipengaruhi oleh pola menyusui dan pemberian makanan tambahan yang tidak baik. faktor-faktor yang memengaruhi status gizi terbagi menjadi beberapa faktor baik secara langsung maupun tidak langsung. faktorfaktor langsung yang memengaruhi status gizi antara lain asupan makanan (pola menyusui dan pola pemberian makanan tambahan) dan keadaan kesehatan. faktor-faktor yang memengaruhi status gizi secara tidak langsung antara lain ekonomi (pendapatan), pendidikan ibu, pengetahuan ibu, sosial budaya, sanitasi lingkungan, fasilitas pelayanan. untuk mencapai tumbuh kembang optimal, di dalam global strategi for infant and young child feeding, who/unicef merekomendasikan empat hal penting yang harus dilakukan yaitu; pertama memberikan air susu ibu kepada bayi segera dalam waktu 30 menit setelah bayi lahir, kedua hanya memberikan air susu ibu (asi) saja atau pemberian asi secara eksklusif sejak lahir sampai bayi berusia 6 bulan, ketiga memberikan makanan tambahan sejak bayi berusia 6 sampai 24 bulan atau lebih, keempat meneruskan asi sampai anak berusia 24 bulan atau lebih. rekomendasi who/unicef di atas yaitu sejalan dengan rencana pembangunan jangka panjang dan menengah nasional (rpjpmn) bidang kesehatan, antara lain dengan memberikan prioritas kepada perbaikan kesehatan dan gizi bayi dan anak. untuk mencapai taget di atas, dilakukan sejumlah kegiatan yang bertumpu kepada perubahan perilaku dengan cara mewujudkan keluarga sadar gizi (kadarzi). melalui penerapan perilaku keluarga sadar gizi, keluarga didorong untuk memberikan asi eksklusif pada bayi sejak lahir sampai berusia 6 bulan dan memberikan makanan tambahan yang cukup dan bermutu kepada bayi dan anak usia 6–24 bulan. untuk mengatasi kasus kurang gizi memerlukan peranan dari keluarga, praktisi kesehatan, maupun pemerintah. pemerintah harus meningkatkan kualitas posyandu terutama perbaikan dalam hal penyuluhan gizi dan kualitas pemberian makanan tambahan. (departemen kesehatan, 2006). bahan dan metode penelitian ini menggunakan metode penelitian korelasional yaitu mengkaji hubungan antara variabel. penelitian korelasional bertujuan mengungkapkan hubungan antar variabel diakui oleh variasi variabel lain. jenisnya penelitian ini adalah cross sectional (hubungan dan asosiasi) yang menekankan pada waktu pengukuran atau observasi data variabel independen dan dependen hanya satu kali (nursalam, 2008). populasi dalam penelitian ini adalah ibu yang menyusui dan memberi makanan tambahan, balita usia bulan yang disusui dan diberi makanan tambahan di posyandu nuri puskesmas kademangan. survei yang dilakukan peneliti didapatkan populasi ibu yang menyusui dan memberi makanan tambahan sebanyak 24 ibu dan populasi balita yang menyusu dan diberi makanan tambahan sebanyak 24 balita. penelitian ini teknik pengambilan sampel (sampling) yang digunakan adalah purposive sampling. kriteria inklusi pada ibu dalam penelitian ini adalah ibu yang menyusui balitanya dan ibu yang memberikan makanan tambahan pada balitanya, sedangkan pada pola menyusui dan makanan tambahan (esty y.) 65 balita yaitu balita yang minum asi, balita yang diberi makanan tambahan, balita yang datang ke posyandu dan balita yang tidak diberi susu formula, dari kriteria tersebut maka sampel pada penelitian ini adalah 16 orang ibu dan 16 balita. variabel independen dalam penelitian ini adalah pola menyusui dan pola pemberian makanan tambahan. sedangkan variabel dependennya adalah status gizi balita usia 7–24 bulan. data diperoleh dengan mengisi lembar kuesioner tentang pola menyusui dan pola pemberian makanan tambahan. responden diberi 28 soal dengan rincian 14 soal pola menyusui dan 14 soal pola pemberian makanan tambahan. pada soal pola menyusui digunakan dichotomy question di mana responden menjawab ya dan tidak. untuk soal pemberian makanan tambahan juga menggunakan dichotomy question. kuesioner pertanyaan pola menyusui dan pola pemberian makanan setiap jawaban yang benar diberi nilai 1 dan jawaban yang salah diberi nilai nol. jumlah jawaban yang benar dibandingkan dengan jumlah keseluruhan soal selanjutnya dipersentase, kemudian data tersebut diklasifikasikan menjadi tiga bagian yaitu kurang baik: <55%, cukup baik: 56–75%, baik: 76–100%. data status gizi balita ditentukan berdasarkan data hasil penimbangan bb anak balita dan umurnya (indeks bb menurut umur) kemudian diklasifikasikan menurut direktorat jendral bina kesehatan masyarakat depkes ri 1996 yaitu: di bawah garis merah = gizi buruk, daerah dua pita kuning (di atas garis merah) = gizi kurang, dua pita hijau muda dan dua pita warna hijau tua (di atas pita kuning) = gizi baik, dua pita warna hijau muda, dua pita warna kuning (paling atas), dan di atasnya = gizi lebih. kemudian data diolah dengan uji statistik correlation spearman rho dengan tingkat signifikasi α ≤0,05. hasil terdapat hubungan yang signifikan antara pola menyusui dengan status gizi balita usia 7–12 bulan. hal ini ditunjukkan dengan uji hubungan didapatkan nilai kemaknaan p = 0,001 dengan koefisien korelasi 0,728 yang berarti semakin baik pola menyusui maka semakin baik pula status gizi balita usia 7–12 bulan (tabel 1). dari tabulasi silang tersebut terlihat bahwa dari 3 ibu dengan pola menyusui kurang, 2 di antaranya memiliki balita dengan kep berat dan 1 di antaranya memiliki balita dengan kep ringan, dari 2 ibu dengan pola menyusui yang cukup semuanya memiliki balita dengan gizi baik, dan dari 11 ibu dengan pola menyusui yang baik 7 di antaranya memiliki balita dengan gizi baik dan 4 di antaranya memiliki balita dengan gizi lebih. tabel 2 menunjukkan bahwa terdapat hubungan yang signifikan antara pola pemberian makanan tambahan dengan status gizi balita usia 7–12 bulan. hal ini ditunjukkan dengan uji hubungan didapatkan nilai kemaknaan p = 0,036 dengan koefisien korelasi 0,528 yang berarti derajat kekuatan hubungan pola pemberian makanan tambahan dengan status gizi sedang. dari tabulasi silang tersebut terlihat bahwa dari 3 ibu dengan pola pemberian makanan tambahan kurang, 2 di antaranya memiliki balita dengan kep berat dan 1 di antaranya memiliki balita dengan kep ringan, dari 6 ibu dengan pola pemberian makanan tambahan yang cukup, 4 di antaranya memiliki balita dengan gizi baik dan 2 di antaranya memiliki gizi lebih, dan dari 7 ibu dengan pola pemberian makanan tambahan yang baik, 5 di antaranya memiliki balita dengan gizi baik dan 2 di antaranya memiliki balita dengan gizi lebih. pembahasan terdapat 2 hal yang akan dibahas pada pembahasan ini yaitu hubungan pola menyusui dengan status gizi balita usia 7–12 bulan dan hubungan pola pemberian makanan tambahan dengan status gizi balita usia 7–12 bulan. hasil analisis data terungkap bahwa pola menyusui berhubungan dengan status gizi balita usia 7–12 bulan dan derajat kekuatannya kuat. distribusi responden berdasarkan pola menyusui dengan persentase terbanyak adalah pola menyusui yang baik sedangkan status gizi balita usia 7–12 bulan dengan persentase terbanyak adalah gizi baik. jurnal ners vol. 5 no. 1 april 2010: 62–69 66 menyusui adalah suatu proses yang terjadi secara alami. air susu ibu (asi) sangat berguna untuk pertumbuhan dan perkembangan bayi dan selain itu manfaat terpenting dari asi, yaitu memberi nutrisi terbaik, meningkatkan daya tahan tubuh, meningkatkan kecerdasan, dan tentu saja sangat berguna dalam meningkatkan jalinan kasih sayang. zat-zat gizi yang terkandung di dalam asi antara lain: kolostrum yang mengandung zat kekebalan terutama iga untuk melindungi bayi dari berbagai penyakit infeksi terutama diare, protein tinggi di mana perbandingan komposisi antara whey dan casein 65:35 sehingga menyebabkan protein asi lebih mudah diserap, taurin yang berfungsi sebagai neuro-transmitter dan berperan penting untuk proses maturasi sel otak, decosahexanoic acid (dha) dan arachidonic acid (aa) yang diperlukan untuk pembentukan sel-sel otak yang optimal (departemen kesehatan, 2005). pola menyusui yang baik dan benar diperlukan untuk menunjang status gizi balita. tindakan ibu yang berkaitan dengan menyusui dengan benar, yaitu meliputi cara perawatan payudara, kebersihan dalam menyusui, cara menyendawakan, produksi asi, posisi, lama dan frekuensi dimaksudkan supaya asi dapat dikonsumsi dan diserap oleh balita secara optimal. hal tersebut sejalan dengan penelitian yang dilakukan oleh peneliti di mana pola menyusui ibu posyandu nuri, puskesmas kademangan kabupaten bondowoso mayoritas baik, yaitu dari 16 orang ibu: 12 orang (75%) di antaranya melakukan perawatan payudara, 12 orang (75%) di antaranya mencuci tangan sebelum menyusui, 13 orang (81,25%) di antaranya mengatur posisi menyusui senyaman mungkin baik berdiri, duduk maupun berbaring, 16 orang (100%) di antaranya tidak membatasi lamanya menyusui, 14 orang (87,5%) di antaranya tidak menjadwal waktu menyusui, 14 (87,5%) orang di antaranya menyendewakan bayi setelah menyusui yaitu dengan meletakkan bayi pada bahu ibu, 14 orang (87,5%) di antaranya mengkonsumsi tabel 1. hubungan pola menyusui dengan status gizi balita usia 7–12 bulan di posyandu nuri puskesmas kademangan pola menyusui status gizi kep berat kep ringan gizi baik gizi lebih σ % σ % σ % σ % kurang 2 12,5 1 6,25 2 12,5 1 6,25 cukup 0 0 0 0 0 0 0 0 baik 0 0 0 0 0 0 0 0 total 2 12,5 1 6,25 9 56,25 4 25 spearman’s rank koefi sien korelasi (r) = 0,728 signifi kasi (p) = 0,001 keterangan: σ = jumlah % = persentase tabel 2. hubungan pola menyusui dengan status gizi balita usia 7–12 bulan di posyandu nuri puskesmas kademangan pola pemberian makanan tambahan status gizi kep berat kep ringan gizi baik gizi lebih σ % σ % σ % σ % kurang 2 12,5 1 6,25 2 12,5 1 6,25 cukup 0 0 0 0 0 0 0 0 baik 0 0 0 0 0 0 0 0 total 2 12,5 1 6,25 2 12,5 1 6,25 spearman’s rank koefi sien korelasi (r) = 0,528 signifi kasi (p) = 0,036 keterangan: σ = jumlah % = persentase pola menyusui dan makanan tambahan (esty y.) 67 makanan lebih banyak dibandingkan saat tidak menyusui. di antara para responden terdapat 3 orang ibu yang pola menyusuinya kurang baik, hal tersebut dapat dikarenakan perilaku mereka yang kurang baik dalam menyusui. perilaku mereka yang kurang baik dapat disebabkan karena beberapa hal misalnya dari faktor pendidikan di mana dari 3 orang ibu tersebut 1 di antaranya tingkat pendidikannya rendah yaitu sd. tingkat pendidikan ini menentukan bagaimana seseorang memiliki kemampuan baca tulis dan menyerap informasi sebanyak banyaknya. tingkat pendidikan di sini bukan satu-satunya faktor yang menentukan baik buruknya pola menyusui ibu, hal tersebut dapat terlihat dari 3 orang ibu, 2 di antaranya tingkat pendidikannya smp dan sma di mana seharusnya dengan latar belakang pendidikan yang cukup mampu dalam menerima informasi yang sebanyak-banyaknya, perilaku mereka dalam pola menyusui haruslah baik. faktor lain yang memungkinkan terjadinya pola menyusui yang kurang adalah penghasilan keluarga di mana dari 3 orang ibu yang menyusui, semuanya memiliki tingkat penghasilan keluarga yang rendah. tingkat penghasilan keluarga ini akan menentukan bagaimana ibu mampu membeli pangan dalam jumlah dan kualitas yang diperlukan dalam menyusui sehingga produksi asi dapat lebih optimal baik secara kualitas maupun kuantitas yang pada akhirnya dapat meningkatkan status gizi balita. analisis data terlihat bahwa pola pemberian makanan tambahan berhubungan dengan status gizi balita usia 7–12 bulan tetapi derajat kekuatannya sedang. distribusi responden berdasarkan pola pemberian m a k a n a n t a m b a h a n d e n g a n p e r s e n t a s e terbanyak adalah pola pemberian makanan yang baik sedangkan status gizi balita usia 7–12 bulan dengan persentase terbanyak adalah gizi baik. pemberian asi ikut memegang peranan dalam pembangunan manusia yang berkualitas. bertambahnya umur bayi, bertambah pula kebutuhan akan zat-zat gizi. oleh karena itu mulai umur 6 bulan, selain asi, bayi perlu diberi makanan lain. makanan ini disebut makanan tambahan atau makanan pendamping asi (mp-asi), yang diberikan kepada bayi sampai umur 24 bulan perlu diperhatikan pola pemberian makanan tambahan yang meliputi umur pertama kali diberi makanan tambahan, pemilihan jenis dan bahan makanan tambahan, frekuensi dan porsi pemberian makanan tambahan, serta cara penyimpanan dan kebersihan makanan tambahan (departemen kesehatan, 2000). pemberian mp-asi yang terlalu dini (sebelum bayi berumur 6 bulan) menurunkan konsumsi asi dan gangguan pencernaan/diare. namun bila pemberian mp-asi terlambat, bayi sudah lewat usia 6 bulan dapat menyebabkan hambatan pertumbuhan anak. pemberian mp-asi pada periode umur 6–24 bulan sering tidak tepat dan tidak cukup baik kualitas maupun kuantitasnya. frekuensi pemberian mp-asi yang kurang dalam sehari juga akan berakibat kebutuhan gizi anak tidak terpenuhi. kebersihan dalam memberikan makanan tambahan yaitu kurangnya menjaga kebersihan terutama pada saat menyediakan dan memberikan makanan pada anak maka akan berdampak pada kondisi kesehatan anak, di mana kondisi kesehatan ini berpengaruh terhadap status gizi balita (departemen kesehatan, 2000). penelitian yang dilakukan oleh peneliti menunjukkan bahwa dari 16 orang terdapat 9 orang (56,25%) memberikan makanan tambahan pada saat bayi berusia kurang dari 6 bulan, 14 orang (87,5%) memberikan porsi makanan tambahan yang kurang dari 3 kali per hari pada balitanya, dan 14 orang (87,5%) memberikan makanan yang kaya akan gizi misalnya ibu menambah makanan dengan sumber lemak misalnya kaldu untuk menambah rasa enak dan menambah kalori makanan. ibu memberikan sumber protein misalnya tahu, ayam, daging, ikan. ibu memberikan sumber karbohidrat misalnya nasi tim yang dilumatkan, kentang yang direbus dan dihancurkan, biskuit yang dicampur dengan susu. ibu juga memberikan sumber vitamin seperti yang terkadung dalam buah dan sayur misalnya wortel, bayam, pisang, pepaya. sebagian besar ibu mencampur sumber karbohidrat, protein, lemak dan vitamin dengan cara mencampur dan mengetim bahan makanan tersebut jadi satu kemudian dilumatkan dengan menggunakan saringan jurnal ners vol. 5 no. 1 april 2010: 62–69 68 kawat. dalam mengubah kepadatan makanan ibu menambahkan air supaya makanan tersebut lebih encer ketika dilumatkan dengan saringan berkawat akan tetapi ada beberapa ibu yang dalam mengubah kepadatan makanan tersebut yang terlalu encer sehingga makanan bayi cenderung mengandung kadar air yang lebih akan tetapi nutrisinya kurang. di antara para responden ibu terdapat 3 orang ibu yang pola pemberian makanan tambahannya kurang baik, hal tersebut dapat dikarenakan perilaku mereka yang kurang baik dalam memberikan makanan tambahan. perilaku ibu yang kurang baik tersebut dapat disebabkan oleh beberapa faktor yaitu faktor pendidikan dan penghasilan. latar belakang pendidikan ibu yang hanya setingkat sd dan segi finansial yang kurang akan berpengaruh terhadap pengetahuan ibu tentang variasi makanan yang bergizi (makanan yang mengandung karbohidrat, protein, lemak, vitamin) kurang dan menyebabkan daya beli bahan pangan bagi balita juga berkurang sehingga menyebabkan tidak tersedianya makanan baik dari segi kualitas, kuantitas dan variasi. pola menyusui maupun pola pemberian makanan tambahan pada ibu di posyandu nuri puskesmas kademangan keduanya dipengaruhi oleh perilaku ibu. perilaku menyusui pada ibu dapat dipengaruhi oleh beberapa faktor. menurut lawrence green perilaku dipengaruhi oleh 3 faktor utama yaitu faktor predisposisi (pengetahuan, sikap, tradisi dan kepercayaan, tingkat pendidikan, dan tingkat sosial ekonomi), faktor pemungkin (prasarana atau fasilitas kesehatan) dan faktor reinforcing (sikap dan perilaku petugas kesehatan) (notoatmojo, 2007). faktor pendidikan mempunyai peranan penting bagi status gizi balita. jika dilihat dari data yang diperoleh menunjukkan bahwa paling banyak responden ibu dengan latar belakang pendidikan smp dan sma. latar belakang pendidikan yang cukup tentunya a k a n b e r p e n g a r u h d e n g a n k e m a m p u a n seseorang untuk mengadopsi informasi yang diberikan baik dari tenaga kesehatan (dokter, perawat dan bidan) maupun dari media cetak/elektronik. faktor sosial budaya jika berdasarkan penelitian yang telah dilakukan kurang berpengaruh terhadap perilaku ibu dalam menyusui dan pemberian makanan tambahan. berdasarkan penelitian mayoritas suku bangsa ibu adalah madura, sedangkan yang lainnya adalah suku jawa dan warga keturunan arab. perbedaan suku tersebut tidak menimbulkan perbedaan dalam perilaku ibu. pada umumnya mereka mengetahui cara-cara menyusui dan memberikan makanan tambahan yang baik dan benar. jika dilihat dari faktor sosial ekonomi juga tidak terlalu memberikan pengaruh yang berarti bagi status gizi balita. hal ini bisa dilihat dari persentase terbanyak adalah ibu dengan jumlah penghasilan keluarga per bulan sebanyak rp500.000,00 dan mereka juga hanya sebagai ibu rumah tangga. hal ini dimungkinkan karena meskipun dengan pendapatan yang rendah mereka mampu memberikan makanan bergizi meskipun tidak mahal bagi balita mereka dan sebagai ibu rumah tangga mereka mempunyai waktu yang banyak untuk mengasuh anak, dalam hal ini adalah menyusui dan memberikan makanan tambahan. dilihat dari beberapa faktor tersebut faktor yang paling berpengaruh dalam perilaku ibu adalah latar belakang pendidikan. faktor pendidikan berhubungan dengan kemampuan baca tulis dan kesempatan seseorang menyerap informasi sebanyak-banyaknya. wanita dengan tingkat pendidikan tinggi akan lebih mudah menerima informasi dan pengetahuan. tingginya pengetahuan ibu akan mendukung perubahan sikap dan perilaku hidup sehat, termasuk dalam hal menyusui dan pemberian makanan tambahan (indarwati, 2009). ketidaktahuan tentang perilaku menyusui dan pemberian makanan bayi dan anak, dan adanya kebiasaan yang merugikan kesehatan, secara langsung dan tidak langsung menjadi penyebab utama terjadinya masalah kurang gizi pada anak, khususnya pada umur di bawah 2 tahun (baduta). oleh karena itu keadaan ini memerlukan penanganan tidak hanya dengan penyediaan pangan, tetapi dengan pendekatan yang lebih komunikatif sesuai dengan tingkat pendidikan dan kemampuan masyarakat (departemen kesehatan, 2000). pola menyusui dan makanan tambahan (esty y.) 69 simpulan dan saran simpulan pola menyusui meningkatkan status gizi balita usia 7–12 bulan. ibu yang memiliki pola menyusui yang baik, status gizi balitanya akan baik, begitu juga dengan pola pemberian makanan tambahan berhubungan dengan status balita usia 7–12 bulan. ibu yang memiliki pola pemberian makanan yang baik, status gizi balitanya baik pula. saran peneliti memberikan beberapa saran terkait dengan hasil penelitian yang ada yaitu ibu sebaiknya rutin dalam membawa balitanya ke posyandu sehingga status gizi balita dapat terus dipantau dan apabila ada masalah dengan status gizi balita maka akan lebih cepat ditangan, untuk para kader sebaiknya harus lebih disiplin dan teratur dalam pencatatan kegiatan posyandu supaya apabila suatu saat dibutuhkan data-data mengenai kegiatan posyandu dapat digunakan sebagaimana mestinya. petugas kesehatan sebaiknya mengadakan perbaikan dalam program penyuluhan yang telah berjalan sehingga ibu-ibu lebih banyak mengetahui informasi yang jelas dan benar tentang gizi khususnya tentang pola menyusui dan pola pemberian makanan tambahan sehingga status gizi keseluruhan balita di posyandu nuri puskesmas kademangan kabupaten bondowoso dalam keadaan gizi baik dan informasi yang diberikan harus sesuai dengan latar pendidikan ibu sehingga mudah diterima, bagi penelitian selanjutnya sebaiknya menggunakan instrumen yang telah diuji validitas dan reabilitasnya supaya didapatkan data hasil penelitian yang valid. dan menggunakan desain penelitian yang lain sehingga pengumpulan data yang diambil tidak 1 kali saja seperti halnya pada desain korelasi dengan pengumpulan data cross sectional. kepustakaan departemen kesehatan republik indonesia, 2000. pedoman pemberian makanan pendamping asi (mp-asi). jakarta: depkes. departemen kesehatan republik indonesia, 2002. pedoman umum gizi seimbang. jakarta: depkes. departemen kesehatan republik indonesia, 2006. pemberian umum pemberian makanan pendamping asi lokal. jakarta: depkes. hidajat, boerhan, 2007. kurang energi protein (kep), (online), (http://www.pediatric. com., diakses tanggal 12 mei 2009. jam 14.30 wib). indarwati, 2009. struktur keluarga dan lama ibu menyusui di wilayah kerja puskesmas grogol sukoharjo, (online), (http://www.stikessolo.co.cc/web_ documents/struktur_keluarga.pdf., diakses tanggal 12 juni 2009, jam 19.00 wib). muzakki, ahmad, 2009. makanan bayi dan balita, (online), (http://www. ahmadmuzakki.blogdetik.com., diakses tanggal 3 juni 2009. jam 19.30 wib). notoatmodjo, soekidjo, 2007. ilmu kesehatan masyarakat prinsip-prinsip dasar. jakarta: rineka cipta. pudjiadji, solihin, 1997. ilmu gizi klinis pada anak. jakarta: fkui. soediaoetama, ahmad j., 2000. ilmu gizi untuk mahasiswa dan profesi. jakarta: dian rakyat. sulastri, 2009. gambaran pola pemberian makanan pendamping asi dan tumbuh kembang anak usia 0–24 bulan di kelurahan labuhan deli kecamatan medan marelan tahun 2004, (online), (http://www.library.usu.ac.id., diakses tanggal 12 mei, jam 15.00 wib). http://e-journal.unair.ac.id/jners 3 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 3-8 http://dx.doi.org/10.20473/jn.v18i2.27086 original article open access coping strategies and family support to the adjustment of adolescents who have parents working as migrant workers praba diyan rachmawati 1 * , rizki fitryasari 1 , dewita pramesti 2 , deena clare thomas 3 , and yuni sufyanti arief 1 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 mitra keluarga satelit hospital, surabaya, indonesia 3 faculty of medicine and health sciences, universiti malaysia sabah, sabah, malaysia *correspondence: praba diyan rachmawati. address: faculty of nursing, universitas airlangga, surabaya, indonesia. email: praba-d-r@fkp.unair.ac.id responsible editor: ferry efendi received: 27 may 2021 ○ revised: 26 october 2022 ○ accepted: 14 february 2023 abstract introduction: adolescents often have difficulty adjusting to their surroundings. coping and family support are also associated with this adjustment. however, the relationship between the aforementioned factors and adjustment among adolescents with parents who work as migrant workers remains unclear. this study aimed to analyze the relationship between coping and family support with the adjustment of adolescents who have parents who work as migrant workers. methods: this is a cross-sectional study. a total of 70 early adolescents with parents working as migrant workers were recruited from the total sample. in this study, coping strategies and family social support were assigned as independent variables, while the dependent variable was the adjustment of adolescents who had parents as migrant workers. the questionnaire was used to measure the outcome of interest and tested for validity and reliability. the data analysis in this study used spearman rho. spearman’s rho correlation with alpha, α set ≤ 0.05, was used to analyze the data. results: the results indicate that coping strategies (p = 0.018; r = 0.283) and family support (p = 0.001; r = 0.380) were associated with adolescent adjustment. conclusions: both coping strategies and family support contribute to the adjustment of adolescents whose parents work as migrant workers. there is a need to increase the priority of psychosocial counseling for adolescents who have parents working as migrant workers and educate their families to increase attention and support appropriate adolescent development. keywords: coping strategies, family support, adolescent, migrant workers, mental health introduction indonesia is one of several countries with a high population of migrant workers (umami and turnip, 2019). in 2017, the national authority for the placement and protection of indonesian overseas workers (bpnp2tki) reported that the population of migrant workers increased exponentially to 261, 820 in all sectors. consequently, many people have to leave their families and children in their hometowns and work as migrant workers (lam and yeoh, 2019a). these children are usually called “left-behind children” (umami and turnip, 2019), and, as they grow and reach adolescence, they are cared for by other parents, relatives, or caregivers. the separation of parents and children for a long period of time (hoang and yeoh, 2012; moyce and https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-9020-2356 https://orcid.org/0000-0002-7164-2997 https://orcid.org/0000-0001-9268-8516 https://orcid.org/0000-0003-3664-8426 rachmawati, fitryasari, pramesti, thomas, and arief (2023) 4 p-issn: 1858-3598  e-issn: 2502-5791 schenker, 2018) leaves a deep scar, especially to children, adjusting to enter their adolescence phase. a previous study on adolescents’ adjustment factors reported that social-emotional problems are common among adolescent children (hirvonen et al., 2018). adolescents who experience problems in emotional development are those who do not live with their parents working as migrant workers, which causes them to live separately from their parents for a long time (garver, 2017). adolescents are in a transition period from children to adults; they need a process of adjustment that is good for both the teenager and his family, such as dealing with stress, frustration, and conflict (santrock, 2011). in indonesia, the phenomenon in one of the subdistricts where the research was conducted was that many middle-aged adolescents did not live with their parents because their parents had to work as indonesian migrant workers. a previous study reported that adolescents whose parents work as migrant workers have a poorer quality of life than their children (wong, chang and he, 2009). children perceive this phenomenon through the manifestation of psychoemotional problems such as anger, anxiety, and poor performance at school (garver, 2017). however, adolescents perceive and react differently to this phenomenon. according to the 2017 kendal district teaching and learning center (pkbm) survey, this district was second-ranked in central java, with a high dropout rate of 4,024 teenagers. juvenile delinquency is one of the factors that cause school dropout. juvenile delinquency occurs because of the failure of adolescents to adapt to their environment and daily relationships. adolescent social-emotional adjustment is related to attention, parental support, and adolescent coping characteristics (bullock et al., 2018). working as a migrant worker demands high responsibility and sacrifices to live separately from their family for a long period of time (hoang and yeoh, 2012; moyce and schenker, 2018). consequently, parents may face more complex problems (hoang and yeoh, 2012; lam and yeoh, 2019a), which is a transition period from child to adult. therefore, more research is required. inappropriate parent-child interactions will affect adolescent self-adjustment, which impacts emotional stability and the adolescent's adaptation process in preparing for adulthood (martínez et al., 2021). early adolescents who experience failure in adjustment behave poorly in education, have an aggressive attitude, are very unconfident in themselves, feel insecure, and have feelings of giving up easily (hurlock, 2006). adjustment problems that occur in adolescents with parents who work as migrant workers are very urgent and important to be addressed and it is necessary to understand the relationship between family support and adolescent coping strategies with adolescent adjustment to parents as migrant workers, so that it can be used as a basis for developing relevant interventions to prevent negative impacts on adolescent development. the purpose of this study was to analyze the relationship between family support and adolescent coping strategies and adolescent adjustment to parents who work as migrant workers. materials and methods the research design used in this study was crosssectional. adolescents who attend junior high schools and whose parents worked as migrant workers for at least three years at one of the junior high schools in patebon district, kendal regency, central java, indonesia, were included in this study. this research took place in an area where many adolescents were discovered abandoned by their parents who work as migrant workers abroad. seventy samples were obtained using the total sampling technique. the study examined two types of variables: independent variables, which included coping strategy and family social support, while the dependent variable was self-adjustment in adolescents who had parents as migrant workers. instruments the instrument used in this study was a questionnaire consisting of a coping strategy questionnaire, a family support questionnaire, and a self-adjustment questionnaire. the coping strategy questionnaire was adapted from lazarus' theory and developed by (carver, c.s; weintroub, j.,k; sceiner. m., 1989). this questionnaire, which consisted of 15 questions, was modified by the researcher according to table 1 respondent characteristics (n=70) respondent characteristics n % sex male 33 47.1 female 37 52.9 age 13 years old 6 8.6 14 years old 34 48.6 15 years old 30 42.9 parent education primary school 21 30 junior high 42 60 high school 7 10 living with aunt and uncle 15 21.4 brother 11 15.7 grandmother 44 62.9 jurnal ners http://e-journal.unair.ac.id/jners 5 the research objectives. the family support questionnaire was adapted based on the parameters of langford et al. (1997) and wittenberg-lyles et al. (2014), consisting of 15 questions about emotional, instrumental, informational, and appraisal, and modified by the researcher. the researcher modified the self-adjustment questionnaire based on schneider’s (1964) parameters, which consisted of 20 questions. all questionnaires were tested for validity and reliability and deemed valid and reliable. the results of the reliability test of cronbach's alpha value on coping strategies were 0.761, and cronbach's alpha value on parental family support was 0.754, cronbach's alpha value on self-adjustment was 0.752. procedure researchers obtained data from teachers on the respondents of adolescents who have parents who are migrant workers. before the respondent took part in this study, the respondent’s guardian signed a letter of consent after being explained the purpose of the study by the researcher. then, when collecting data, the researcher, assisted by a counselling guidance teacher (bp), collected adolescents in secondand third-level classes to complete the questionnaire. the researcher explained the procedures for filling out the questionnaire in advance and asked if it was not clear. the time taken to complete the questionnaire was approximately 15-20 minutes. data analysis the statistical test used in this study was the spearman rho correlation. ethical clearance this study was approved by the health research ethics committee of the faculty of nursing, universitas airlangga, with the code of ethics number 1531-kepk. results the characteristics of the respondents in this study indicated that the male respondents were 33 (47.1%) and 37 (52.9%) were female. almost half of the respondents were 14 years of age (48.6%). most of the respondents' parents had completed junior high school education, with 42 students (60%). more than half of the total number of respondents lived with their grandmothers, with as many as 44 (62.9%) respondents (table 1). the results of this study indicate that the highest average adolescent coping strategy is one that focuses on emotions (1.87 ± 0.63), while the aspect with the highest average score on adolescent family support with parents who work as migrant workers is instrumental support (2.11 ± 0.73). this study shows that the highest self-adjustment of adolescents is the aspect of being able to be realistic and objective (2.03 ± 0.74). the results of the correlation test between coping strategies and self-adjustment showed that the significance value of the spearman’s rho correlation test was p = 0.018 (p <0.005), indicating that there is a relationship between coping strategies and self-adjustment in adolescents whose parents work as migrant workers. the value of the correlation coefficient (r) is 0.283, which means that coping strategies and adolescent adjustment are related. a positive correlation coefficient indicates that table 2 the relationship between coping strategies and family support with adolescents' adjustment to their parents working as migrant workers (n=70) indicator mean sd p-value r coping strategy 0.018 0.283 coping strategies focus on problems 1.79 0.65 coping strategies focus on emotions 1.87 0.63 family support 0.001 0.380 informational support 1.94 0.75921 instrumental support 2.11 0.73313 appraisal or award support 1.90 0.72532 emotional support 1.96 0.87536 adjustment able to control emotions and have patience 1.94 0.63442 have a good self-defense structure 1.73 0.50852 able to learn from experience 1.86 0.74767 able to be realistic and objective 2.03 0.74155 rachmawati, fitryasari, pramesti, thomas, and arief (2023) 6 p-issn: 1858-3598  e-issn: 2502-5791 the better the coping strategy, the better the adjustment. the relationship between family support and self-adjustment showed that the significance value on the spearman’s rho correlation test was p = 0.001 (p <0.05). it can be concluded that there is a relationship between family support and self-adjustment among adolescents whose parents are migrant workers. the correlation coefficient value was 0.380, indicating that the relationship between family support and adjustment was sufficient. the correlation coefficient was positive, which means that increasing family support increases the level of adolescent adjustment (table 2). discussions the coping strategies of adolescents who live separately from their parents because their parents have to work as migrant workers abroad affect their adjustment. in this study, there was a significant positive correlation between the coping strategies chosen by teenagers and their adolescent adjustment. adolescent adjustment may increase if coping strategies increase. similar to the results of previous research, adolescents with good coping strategies also have good emotional maturity (lee et al., 2017). the conditions that occur in adolescents with parents who work as migrant workers abroad in this study, even though adolescents do not live at home with their parents, show they can still manage stress well so that they can adapt well to themselves and the surrounding environment. coping strategy is a way to cope with and manage the stress that is being experienced (stephenson and delongis, 2020); the coping strategies that adolescents of parents who work as migrant workers those that focus on problems and those that focus on emotions. this situation is in line with the results of previous research, which states that adolescent coping strategies to overcome their conflicts focus on overcoming problems and emotional control (sang ayu ketut tri semaraputri, 2018). both coping strategies are capable of dealing with stress experienced by adolescents. problem-focused coping strategies mean that adolescents deal with stress by directly focusing on solving problems. in contrast, emotion-focused coping strategies mean that adolescents choose to control their emotions without forcing them to change their existing conditions (fabick, 2011). this study indicates that the majority of adolescents have coping strategies that focus on emotions rather than being problem-focused coping strategies. this is in line with previous research, which states that coping strategies for emotional control are related to selfadjustment (ghofiniyah and setiowati, 2017). adolescents who have to live separately from their parents because their parents work as migrant workers experience loneliness, longing for their parents, sadness, and feelings of being neglected (hoang et al., 2014), they do not have the power to change the existing situation; they said that their parents worked abroad for their education and they would live with them in the future (lam and yeoh, 2019b), so that adolescents tend to control their emotions more than having to solve problems or change circumstances. emotion-focused strategies are such as rejection, venting emotions, anger, confusion, apathy, or seeking social support if this condition is uncontrolled and receives inappropriate support it can lead to maladaptive responses (baker and berenbaum, 2007; garver, 2017). emotional-focused coping is usually more at risk for maladaptive outcomes (schneider, king and delfabbro, 2018). this maladaptive response leads to unsuccessful adjustments that can trigger juvenile delinquency or risky adolescent behaviour (bullock et al., 2018; schneider, king and delfabbro, 2018) not all adolescents in this study used emotion-focused coping strategies, it was also found adolescents with problemfocused coping strategies. when using problem-focused coping strategies, adolescents tended to express feelings directly about an event that caused stress, adolescents were realistic and objective and could adjust well. previous research has shown that adolescents with problem-focused coping strategies are more adaptable than those with emotion-focused coping strategies (lee et al., 2017). problem-focused coping strategies result in good mental health (mullis and chapman, 2010). this study also found that adolescents with parents who work as migrant workers will have good adjustment if they have good family support. the results of this study are in line with previous research that stated that proper family interaction and support affected emotional stability, which also had an impact on adolescent adjustment (martínez et al., 2021), as well as the lack of support from the family, which has the potential to cause symptoms of depression in adolescents who also suffer from depression. this will affect the subsequent development of adolescents (roche, bingenheimer and ghazarian, 2016). adolescents who have to live separately from their parents need more attention from families who care at home; these teenagers lose attention and closeness to their parents; they need support in undergoing a difficult developmental and transitional period in adolescence (krisnana et al., 2019). if they do not jurnal ners http://e-journal.unair.ac.id/jners 7 receive appropriate support, they risk getting support from a negative social environment, which has the potential to lead to maladaptive behaviour (baker and berenbaum, 2007; ani et al., 2020). adolescents in this study received support from their families in the form of information, instrument, appraisal, and emotional support. the results of this study are in line with the research of panewaty and indrawati (2018), which states that adolescent selfadjustment family support includes emotional, information, instrumental, and appraisal support that affect adolescents' social adjustment (panewaty and indrawati, 2020). the higher the perceived social support, the higher the adolescents’ social adjustment. conversely, the more negative the parents’ social support, the lower the adolescents’ social adjustment. social support from close family members influences adolescents’ adaptation. adolescents need parental social support, such as emotional support, information support, instrumental support, and appraisal support, to adapt to their environment (marhamah and hamzah, 2017). in this study, adolescents who did not live with their parents were more likely to receive instrumental support from their families than those who did not. instrumental support is more evidently provided to children or adolescents to meet their daily needs compared to the need for appreciation or emotion; instrumental support tends to be more visible than other support, such as parents of an adolescent who work far away from abroad to improve the family economy (lam and yeoh, 2019b); parents provide money and the closest family tries to meet the physical or instrumental needs of adolescents, such as daily school needs, housing, clothing, health, and others (moskal and tyrrell, 2015; fellmeth et al., 2018) the limitation of this study is that it has not separated and analyzed further who the parents working as migrant workers are, whether father, mother, or both, thus requiring further research to identify it. conclusions coping strategies and appropriate family support can affect adolescents’ adjustment. it requires educationbased intervention and special counselling for families and adolescents who have parents with migrant workers, so that they have good parenting styles according to the development of adolescents. in addition, the components related to adolescents who live separately from their parents who work abroad, such as teachers or the nearest health facility, must focus on paying attention to the mental health problems of adolescents with this condition. it is also necessary to pay attention to the physical and mental health of their immediate family. those caring for children whose parents have left and are working far abroad, are such as elderly grandmothers, grandfathers, or other families, so that it is hoped that they can optimize care and good quality of life for adolescents and the families who care for them. conflict of interest there is no conflict of interest. references ani, a., rachmawati, p. d., efendi, f., kristiawati, & hidayati, l. (2020). the differences in the stimulation and personal social development of school-aged children between children who raised by their grandparents and parents respectively. journal of global pharma technology, 12(1), 142–150. baker, j. p., & berenbaum, h. (2007). emotional approach and problem-focused coping: a comparison of potentially adaptive strategies. cognition & emotion, 21(1), 95–118. https://doi.org/10.1080/02699930600562276 bullock, a., liu, j., cheah, c. s. l., coplan, r. j., chen, x., & li, d. (2018). the role of adolescents’ perceived parental psychological control in the links between shyness and socio-emotional adjustment among youth. journal of adolescence, 68, 117–126. https://doi.org/https://doi.org/10.1016/j.adolescence.2018.07.0 07 carver, c.s; weintroub, j.,k; sceiner. m., f. (1989). assesing coping strategies: a theoritically based approach. journal of personality and social psychology, 56(2), 267–283. fabick, s. d. (2011). coping: emotion and problem-focused. the encyclopedia of peace psychology. https://doi.org/10.1002/9780470672532.wbepp067 fellmeth, g., rose-clarke, k., zhao, c., busert, l. k., zheng, y., massazza, a., sonmez, h., eder, b., blewitt, a., lertgrai, w., orcutt, m., ricci, k., mohamed-ahmed, o., burns, r., knipe, d., hargreaves, s., hesketh, t., opondo, c., & devakumar, d. (2018). health impacts of parental migration on left-behind children and adolescents: a systematic review and meta-analysis. the lancet, 392(10164), 2567–2582. https://doi.org/10.1016/s01406736(18)32558-3 garver, g. (2017). female migrant workers and their families: abused and abandoned | iu south bend undergraduate research journal. undergraduate research journal, 17, 129–134. ghofiniyah, e. and setiowati, e. a. (2017) ‘hubungan antara kematangan emosi dan keterampilan sosial dengan penyesuaian diri pada santri pondok pesantren daar al furqon kudus’, proyeksi, 12(1), pp. 5–6. doi: http://dx.doi.org/10.30659/jp.12.1.1-16. hirvonen, r., väänänen, j., aunola, k., ahonen, t., & kiuru, n. (2018). adolescents’ and mothers’ temperament types and their roles in early adolescents’ socioemotional functioning. international journal of behavioral development, 42(5), 453–463. https://doi.org/10.1177/0165025417729223 hoang, l. a., lam, t., yeoh, b. s. a., & graham, e. (2014). transnational migration, changing care arrangements and left-behind children’s responses in south-east asia. https://doi.org/10.1080/14733285.2015.972653, 13(3), 263– 277. https://doi.org/10.1080/14733285.2015.972653 hoang, l. a., & yeoh, b. s. a. (2012). sustaining families across transnational spaces: vietnamese migrant parents and their leftbehind children. http://dx.doi.org/10.1080/10357823.2012.711810, 36(3), 307– 325. https://doi.org/10.1080/10357823.2012.711810 hurlock, e. b. (2006). social psychology (2nd ed.). psychological bulletin. https://doi.org/10.1037/h0052329 krisnana, i., rachmawati, p. d., arief, y. s., kurnia, i. d., nastiti, a. a., https://doi.org/10.1080/02699930600562276 https://doi.org/https:/doi.org/10.1016/j.adolescence.2018.07.007 https://doi.org/https:/doi.org/10.1016/j.adolescence.2018.07.007 https://doi.org/10.1002/9780470672532.wbepp067 https://doi.org/10.1016/s0140-6736(18)32558-3 https://doi.org/10.1016/s0140-6736(18)32558-3 http://dx.doi.org/10.30659/jp.12.1.1-16 https://doi.org/10.1177/0165025417729223 https://doi.org/10.1080/14733285.2015.972653 https://doi.org/10.1080/10357823.2012.711810 https://doi.org/10.1037/h0052329 rachmawati, fitryasari, pramesti, thomas, and arief (2023) 8 p-issn: 1858-3598  e-issn: 2502-5791 safitri, i. f. n., & putri, a. t. k. (2019). adolescent characteristics and parenting style as the determinant factors of bullying in indonesia: a cross-sectional study. international journal of adolescent medicine and health. https://doi.org/10.1515/ijamh2019-0019 lam, t., & yeoh, b. s. a. (2019a). under one roof? left-behind children’s perspectives in negotiating relationships with absent and return-migrant parents. population, space and place, 25(3), e2151. https://doi.org/10.1002/psp.2151 lam, t., & yeoh, b. s. a. (2019b). parental migration and disruptions in everyday life: reactions of left-behind children in southeast asia. https://doi.org/10.1080/1369183x.2018.1547022, 45(16), 3085–3104. https://doi.org/10.1080/1369183x.2018.1547022 langford, c. p. h., bowsher, j., maloney, j. p., & lillis, p. p. (1997). social support: a conceptual analysis. journal of advanced nursing, 25(1), 95–100. https://doi.org/10.1046/j.13652648.1997.1997025095.x lee, j. h., seo, m., lee, m., park, s. y., lee, j. h., & lee, s. m. (2017). profiles of coping strategies in resilient adolescents. psychological reports, 120(1), 49–69. https://doi.org/10.1177/0033294116677947 marhamah, f. and hamzah, h. b. (2017) ‘the relationship between social support and academic stress among first year students at syiah kuala university’, psikoislamedia : jurnal psikologi, 1(1), pp. 149–172. doi: 10.22373/psikoislamedia.v1i1.1487. martínez, i., murgui, s., garcia, o. f., & garcia, f. (2021). parenting and adolescent adjustment: the mediational role of family selfesteem. journal of child and family studies, 30(5), 1184–1197. https://doi.org/10.1007/s10826-021-01937-z/figures/4 moskal, m., & tyrrell, n. (2015). family migration decision-making, step-migration and separation: children’s experiences in european migrant worker families. http://dx.doi.org/10.1080/14733285.2015.1116683, 14(4), 453– 467. https://doi.org/10.1080/14733285.2015.1116683 moyce, s. c., & schenker, m. (2018). migrant workers and their occupational health and safety. https://doi.org/10.1146/annurev-publhealth-040617-013714, 39, 351–365. https://doi.org/10.1146/annurev-publhealth040617-013714 mullis, r. l., & chapman, p. (2010). age, gender, and self-esteem differences in adolescent coping styles. http://dx.doi.org/10.1080/00224540009600494, 140(4), 539– 541. https://doi.org/10.1080/00224540009600494 roche, k. m., bingenheimer, j. b., & ghazarian, s. r. (2016). the dynamic interdependence between family support and depressive symptoms among adolescents in ghana. international journal of public health 2016 61:4, 61(4), 487–494. https://doi.org/10.1007/s00038-015-0781-9 panewaty, d. f. and indrawati, e. s. (2020) ‘hubungan antara dukungan sosial orangtua dengan penyesuaian sosial pada siswa dalam asuhan nenek di smp negeri 1 ngraho kabupaten bojonegoro’, jurnal empati, 7(1), pp. 145–154. doi: 10.14710/empati.2018.20172. sang ayu ketut tri semaraputri. (2018). peran problem focused coping dan konsep diri terhadap penyesuaian diri pada remaja akhir yang menjadi pengurus organisasi kemahasiswaan di fakultas kedokteran universitas udayana. 5(1), 35–47. santrock, john w. (2011). perkembangan anak edisi 7 jilid 2. (translate : sarah genis b). jakarta: erlangga. schneider, l. a., king, d. l., & delfabbro, p. h. (2018). maladaptive coping styles in adolescents with internet gaming disorder symptoms. international journal of mental health and addiction, 16(4), 905–916. https://doi.org/10.1007/s11469-017-97569/tables/3 stephenson, e., & delongis, a. (2020). coping strategies. the wiley encyclopedia of health psychology, 55–60. https://doi.org/10.1002/9781119057840.ch50 umami, r. and turnip, s. s. (2019) ‘emotional and behavioral problems among left-behind children in indonesia.’, indian journal of psychological medicine, 41(3), pp. 240–245. doi: 10.4103/ijpsym.ijpsym_370_18. wittenberg-lyles, e., washington, k., demiris, g., oliver, d. p., & shaunfield, s. (2014). understanding social support burden among family caregivers. health communication, 29(9), 901. https://doi.org/10.1080/10410236.2013.815111 wong, f. k. d., chang, y. l., & he, x. s. (2009). correlates of psychological wellbeing of children of migrant workers in shanghai, china. social psychiatry and psychiatric epidemiology, 44(10), 815–824. https://doi.org/10.1007/s00127-009-0003y/tables/3. how to cite this article: rachmawati, p. d., fitryasari, r., pramesti, d., thomas, d. c., and arief, y. s. (2023) ‘coping strategies and family support to the adjustment of adolescents who have parents working as migrant workers ’, jurnal ners, 18(1), pp. 3-8. doi: http://dx.doi.org/10.20473/jn.v18i1.27086 https://doi.org/10.1515/ijamh-2019-0019 https://doi.org/10.1515/ijamh-2019-0019 https://doi.org/10.1002/psp.2151 https://doi.org/10.1080/1369183x.2018.1547022 https://doi.org/10.1046/j.1365-2648.1997.1997025095.x https://doi.org/10.1046/j.1365-2648.1997.1997025095.x https://doi.org/10.1177/0033294116677947 https://doi.org/10.1007/s10826-021-01937-z/figures/4 https://doi.org/10.1080/14733285.2015.1116683 https://doi.org/10.1146/annurev-publhealth-040617-013714 https://doi.org/10.1146/annurev-publhealth-040617-013714 https://doi.org/10.1080/00224540009600494 https://doi.org/10.1007/s00038-015-0781-9 https://doi.org/10.1007/s11469-017-9756-9/tables/3 https://doi.org/10.1007/s11469-017-9756-9/tables/3 https://doi.org/10.1002/9781119057840.ch50 https://doi.org/10.1080/10410236.2013.815111 https://doi.org/10.1007/s00127-009-0003-y/tables/3 https://doi.org/10.1007/s00127-009-0003-y/tables/3 microsoft word hasinuddin qc 2 20-12-2021.docx http://e-journal.unair.ac.id/jners | 193 jurnal ners vol. 16, no. 2, october 2021 http://dx.doi.org/10.20473/jn.v16i2.30637 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research parents' psychological aspect in caring for the child during covid-19 pandemic m. hasinuddin1, rusana rusana2, ulva noviana1, heni ekawati1, nurul aini3 and sandeep poddar4 1stikes ngudia husada madura, madura, indonesia 2stikes al-irsyad al-islamiyyah cilacap, cilacap indonesia 3universitas muhammadiyah malang, malang, indonesia 4lincoln university college, selangor, malaysia abstract introduction: covid-19 is unprecedented, especially for parents with children aged 2-12 years old who are prone to infection due to their activities. the psychological condition of parents will be affected as they are worried about their children being infected with covid-19. methods: this study aims to identify and analyse the psychological aspects of parents who are caring for children during the covid-19 pandemic. results: the results showed that as many as 236 parents (80.9%) showed an emotional anxiety response. the social reaction to the covid-19 situation was more likely to be a positive response (73.8%) rather than a negative response. conclusion: the reactions that occur in parents who have pre-school and school-aged children regarding the covid-19 were anxiety and worry. reactions arise due to the information obtained being less verifiable, namely social media. article history received: october 12, 2021 accepted: december 16, 2021 keywords child; caring; pandemic; psychosocial; parent contact m. hasinuddin * hasin3333.nhm@gmail.com + stikes ngudia husada madura, madura, indonesia cite this as: hasinuddin, m., rusana, r., noviana, u., ekawati, h., aini, n., & poddar, s. (2021). parents' psychological aspect in caring for the child during covid-19 pandemic. jurnal ners, 16(2). 193-197. doi:http://dx.doi.org/10.20473/jn.v16i2.30637 introduction the world health organization (who) has reported more than 2 million cases of corona virus disease (covid-19) in more than 210 countries and regions, resulting in 195,755 people dying and 781,109 people recovering (bhattacharya et al., 2020; nakoe et al., 2020). in indonesia, two cases of confirmed covid-19 were announced in march 2020, and it increased significantly to reach 1790 confirmed cases, in which there were 113 new cases per day, with 170 deaths, and 112 people recovered (djalante et al., 2020; ministry of health, 2020). the unpredicted covid-19 situation has created stress, and it is likely to affect people (world health organization, 2020), especially parents caring for children in the school-aged group (brown et al., 2020; moscardino et al., 2021). a previous study has proven that the covid-19 emergency resulted in a worrying period for families, increasing difficulties in managing daily activities, especially free time and structured activities (colizzi et al., 2020). since the phenomenon of the covid-19 pandemic affects people's psychological and daily lives (buzzi et al., 2020), family living conditions suddenly change in the home environment, and, thus, the role of parents' education for children is more important than ever. children expect parents who can provide support and pay attention to their development and provide new learning experiences, especially for toddlers and pre-schoolers (jiao et al., 2020). many parents also have to work from home, so managing time to work and accompanying children becomes very problematic. this situation can significantly increase the risk of experiencing stress and negative emotions in parents, with the effect of decreasing the welfare of children (sprang & silman, 2013). m. hasinuddin et al. 194 | pissn: 1858-3598 � eissn: 2502-5791 the psychological wellbeing of parents and children is a major concern with the quarantine regulation due to covid-19. this creates fear and anxiety in both parents and children (liu et al., 2020). most of the studies conducted during the pandemic and since the beginning of the covid-19 outbreak examined the psychological consequences on the general population, especially on the elderly and children (brooks et al., 2020). a survey in china found that the psychological effects on children during the covid-19 pandemic, such as fear, inattention and irritability, were the most severe symptoms (jiao et al., 2020). several factors influence the psychological response of parents and children including structural aspects of the home and family as well as the environment. the subjective experience of parents, stress and adjustment to quarantine, affect the welfare of parents and children which can make parents stressed and can interfere with children's wellbeing (abidin, 1992; madigan et al., 2018; wong et al., 2021). the covid-19 pandemic increases the psychological problems of parents, especially stress at the individual and community level, which has a negative impact on the emotional wellbeing and behavior of children and parents (dalton et al., 2020). this study aims to identify and analyse the psychological aspects of parents who are caring for children during the covid-19 pandemic. materials and methods a cross-sectional approach was used in this study. the samples were taken by purposive sampling technique which consisted of parents or guardian with children aged 2-12 years as many as 325 people, from more than seven provinces in indonesia. the inclusion criteria of the participants in this study were: (1) parents or guardians who have children in aged 2-12 years old; (2) living together with the children and caring for them; (3) being able to fill in the google form; and (4) agreeing with the terms and conditions of this research. meanwhile, those who were not eligible for the inclusion criteria will be excluded from this study. the dependent variable of this study was parents’ psychological aspects and caring for children in the school age group was the independent variable. the data were collected online in july 2020 by utilising google forms as a tool to distribute the questionnaire. we reached the participants through whatsapp groups by sharing the google form link. the questionnaire instrument contains the characteristics, beliefs and sources of information as well as the psychosocial (emotional and social) responses of the respondents. the used instrument in this study was a questionnaire which was developed from the instrument protocol from health department ((kemenkes, 2020). several questions were directed to measure the socio-demography of participants, in particular: child’s age, child’s gender, origin, parental status. specific questions related to the psychological response were (1) the belief of covid19 existence divided into two categories: believe and do not believe; (2) information resource consisted two options: social media and health worker; (3) psychological response or emotion was measured into unconcern and anxiety; and (4) social response included positive and negative. data were analysed by univariate analysis, bivariate with chi-square and multivariate using linear regression. all data analysis was performed statistically using spss version 26 for windows (spss, inc, chicago, ill) and significance was set at p<0.05. the research has been approved by the research ethics committee of stikes ngudia husada madura (681/kepk/stikes-nhm/ec/vii/2020) on july, 23rd 2020. results most of the respondents were mothers (88.0%), from east java (70.8%), which was classified as the red zone for the spread of covid-19. the majority of participants believed in the existence of covid-19 (94.5%), sources of information about covid-19 were from social media (42.8%). respondents in this study had children of pre-school age (44.3%) with sex mostly male (53.2%). most of the respondents were likely to have experienced psychological responses table 1. characteristics of respondents (n= 325) characteristic n % child’s age: toddler 202 62.2 school age 123 37.8 child’s gender: male 173 53.2 female 152 46.8 origin: east java 230 70.8 central java 36 11.1 west java 26 8.0 jakarta 9 2.8 bali 9 2.8 diy 4 1.2 south sumatera 3 0.9 the other 8 2.4 parent status: parents (mother or father) 319 98.2 another guardian 6 1.8 the belief of covid-19 existence believe 307 94.5 do not believe 18 5.5 information source: social media 249 76.6 health worker 76 23.4 psychological response/ emotional: unconcern 62 19.1 anxiety 263 80.9 social response: positive 240 73.8 negative 85 26.2 jurnal ners http://e-journal.unair.ac.id/jners | 195 (anxiety) (80.9%) rather than unconcern response (19.1%). social response to the covid-19 situation was more likely to be positive response (73.8%) than negative response (26.2%). detailed information about the characteristics of respondents is depicted in table 1. the analysis of the relationship between parental status and respondent's belief with psychological responses showed that there were 261 (81.8%) and 258 (84%) participants who experienced an anxiety emotional response, worried that a family member had contracted covid-19. the results of statistical tests showed that there was a significant relationship between parental status and respondents' psychological responses (p-value = 0.014) as depicted in table 2. in addition, the belief of covid-19 existence showed a significant value among parents who believe compared to those who do not believe (pvalue=0.001). discussion the covid-19 situation has been a stressor for families as the disease is creating uncertainty and novelty (brown et al., 2020; chung et al., 2020). the life condition of families has been restricted and led to experience some stressors and emotional feelings (morelli et al., 2020). the stressors come from several factors including managing children for 24 hours, having had to work from home, the reduction of wages and the fear of covid-19 infection (morelli et al., 2020; spinelli et al., 2020). these impacts influence the family system and stimulate parenting stress; even those who are not exposed to the virus can feel the indirect effect of the covid-19 pandemic (bavel et al., 2020; chung et al., 2020). our study proved that two psychological factors (parental status and the belief of covid-19 existence) have shown a significant association with the parental condition when caring for their children during the pandemic. the status of parents is highly likely to have an association with the psychological state of parents caring for their children (p=0.014; x2=83) in which most parents felt anxiety about the exposure of children to the covid-19 virus. this finding has correlation with a previous study that most of parents reported high level of anxiety of covid-19 infecting their children when they do physical outdoors activities (mccormack et al., 2020). the parents’ anxiety encouraged them to make some restrictions for their children, particularly limited access to the public areas, and this drove the parents to follow the health recommendations, such as physical distancing (tremblay et al., 2016). long-term effect of the parents’ anxiety is the child's boredom and the desire to get out of the house, which triggers the parents to be more frustrated in caring for them. then, this situation will turn into a family stress and harsh parenting. to prevent the forecast stress situation, it is better for the parents to manage their psychological care by balancing the way they handle their anxiety about the situation and their children’s wellbeing. the role of health practitioners is needed to be a consultant for the parents on how to cope with this situation. the second significant factor is the parents’ perception about the existence of covid-19 itself. in present study, we evaluate that the more parents believe about the covid-19 pandemic, the more they felt worry about the disease. generally, the covid-19 pandemic has a psychological effect and becomes a heavy stressor. a common response in times of crisis is anxiety which arises because of fear or feeling uncomfortable. anxiety about the spread of covid-19 can happen to parents as they hear news or information related to the increasingly rapid spread of the corona virus and the increasing number of table 2. the relationship between respondent status and the psychological (emotional and social) response of parents during the covid-19 pandemic (n=325) variables psychological response (emotional) x2 p-value unconcern anxiety n (%) n (%) child’s gender: male female 35(20.2%) 27(17.8%) 138 (79.8%) 125 (82.2%) 1.174 0.672 parental status: parent another guardian 58(18.2%) 4 (66.7%) 261 (81.8%) 2 (33.3%) 0.111 0.014* child’s age: toddlers pre-school 33 (16.3%) 29 (23.6%) 169 (83.7%) 94 (76.4%) 0.633 0.143 the belief of covid-19 existence: believe do not believe 49 (16%) 13 (72.2%) 258 (84.0%) 5 (27.8%) 0.073 0.001* information source social media health worker 48 (19.3%) 14 (18.4%) 201 (80.7%) 62 (81.6) 1.058 1.000 * chi-square test, p<0.05 m. hasinuddin et al. 196 | pissn: 1858-3598 � eissn: 2502-5791 patients. a qualitative study stated that participants were afraid of contracting covid-19 both for themselves and their families (sumakul & ruata, 2020). another study has also proved that the anxiety of covid-19 tends to make people feel fear and the common concern of the fear is because of the health condition of their loved ones (mertens et al., 2020). the gender of children has not shown any significant relevance with the psychological parents in caring for their children during the pandemic. theoretically, the gender of children influences the way parents treat, communicate and behave to the children by which the tendency is to be more protective to a girl than boy (mascaro et al., 2017). from this phenomenon, we can assume that under some circumstances, such as crisis and pandemic, the psychological effect on parents, specifically the anxiety feeling, will equally appear both for sons and daughters. aside from gender, the age of children was also not considered as a factor related to the psychological state of parents. the parents showed the same psychological response when caring for toddlers and school age children. the reason for this is because parents and children have a strong inner and emotional connection. thus, parents will feel more worried if their child is sick or contracted with a disease regardless how old their children are. according to the information source, this study confirmed that there is no relationship between the psychological status of parents with how the get to know the information about covid-19. in fact, various information about covid-19 has spread massively from various media rather other sources (ahmadi et al., 2021; prasetyawati et al., 2021). social media through electronic media presents various kinds of news, both actual, trusted and hoax news or information. fake news or hoax news is news that is spread by certain parties with various interests. there are several factors that make a person or group believe in the spread of hoax news, especially about the trending covid-19. the factors in question are limited knowledge and if the news is in accordance with the opinion of the recipient or reader (chumairoh, 2020). conclusion the psychological state of parents caring for children during covid-19 pandemic has been correlated by two factors: the parental status and the belief of covid-19 existence. the reactions that occur in parents who have pre-school and school-aged children regarding covid-19 are anxiety and worry. this study suggests that managing the psychological health of parents is essential while caring for children during a crisis situation, such as a pandemic since it will correlate with the parenting pattern and can prevent harsh parenting. it is a must for health practitioners to provide psychological education sessions for the parents about how to cope with the stressors when caring for children in a pandemic situation. references abidin, r. r. (1992). the determinants of parenting behavior. journal of clinical child psychology, 21(4), 407–412. https://doi.org/10.1207/s15374424jccp2104_12 ahmadi, m. i., gustian, d., & sembiring, f. (2021). analisis sentiment masyarakat terhadap kasus covid-19 pada media sosial youtube dengan metode naive bayes jumlah kasus aktif. jurnal sains komputer & informatika (j-sakti), 5(september), 807–814. https://doi.org/http://dx.doi.org/10.30645/jsakti.v5i2.378 bavel, j. j. v., baicker, k., boggio, p. s., capraro, v., cichocka, a., cikara, m., crockett, m. j., crum, a. j., douglas, k. m., druckman, j. n., drury, j., dube, o., ellemers, n., finkel, e. j., fowler, j. h., gelfand, m., han, s., haslam, s. a., jetten, j., … willer, r. (2020). using social and behavioural science to support covid-19 pandemic response. in nature human behaviour (vol. 4, issue 5, pp. 460–471). https://doi.org/10.1038/s41562-020-0884-z bhattacharya, s., basu, p., & poddar, s. (2020). changing epidemiology of sars-cov in the context of covid-19 pandemic. journal of preventive medicine and hygiene, 61(2), e130– e136. https://doi.org/10.15167/24214248/jpmh2020.61.2.1541 brooks, s. k., webster, r. k., smith, l. e., woodland, l., wessely, s., greenberg, n., & rubin, g. j. (2020). the psychological impact of quarantine and how to reduce it: rapid review of the evidence. in the lancet (vol. 395, issue 10227, pp. 912–920). https://doi.org/10.1016/s0140-6736(20)304608 brown, s. m., doom, j. r., lechuga-peña, s., watamura, s. e., & koppels, t. (2020). stress and parenting during the global covid-19 pandemic. child abuse and neglect, 110. https://doi.org/10.1016/j.chiabu.2020.104699 buzzi, c., tucci, m., ciprandi, r., brambilla, i., caimmi, s., ciprandi, g., & marseglia, g. l. (2020). the psycho-social effects of covid-19 on italian adolescents ’ attitudes and behaviors. 4–11. chumairoh, h. (2020). ancaman berita bohong di tengah pandemi covid-19. vox populi, 3(1), 22. https://doi.org/10.24252/vp.v3i1.14395 chung, g., lanier, p., & wong, p. y. j. (2020). mediating effects of parental stress on harsh parenting and parent-child relationship during coronavirus (covid-19) pandemic in singapore. journal of family violence. https://doi.org/10.1007/s10896-020-00200-1 colizzi, m., sironi, e., antonini, f., ciceri, m. l., bovo, c., & zoccante, l. (2020). brain sciences psychosocial and behavioral impact of covid-19 in autism spectrum disorder : an online parent survey. brain sciences journal, 10(341), 1–15. https://doi.org/doi:10.3390/brainsci10060341 dalton, l., rapa, e., & stein, a. (2020). protecting the psychological health of children through effective jurnal ners http://e-journal.unair.ac.id/jners | 197 communication about covid-19. in the lancet child and adolescent health (vol. 4, issue 5, pp. 346–347). https://doi.org/10.1016/s23524642(20)30097-3 djalante, r., lassa, j., setiamarga, d., sudjatma, a., indrawan, m., haryanto, b., mahfud, c., sinapoy, m. s., djalante, s., rafliana, i., gunawan, l. a., surtiari, g. a. k., & warsilah, h. (2020). review and analysis of current responses to covid-19 in indonesia: period of january to march 2020. progress in disaster science, 6. https://doi.org/10.1016/j.pdisas.2020.100091 jiao, w. y., wang, l. n., liu, j., fang, s. f., jiao, f. y., pettoello-mantovani, m., & somekh, e. (2020). behavioral and emotional disorders in children during the covid-19 epidemic. in journal of pediatrics (vol. 221, pp. 264-266.e1). https://doi.org/10.1016/j.jpeds.2020.03.013 kemenkes. (2020). protokol dukungan kesehatan jiwa dan psikosial (dkjps) anak dan remaja pada masa. kementerian kesehatan republik indonesia. liu, j. j., bao, y., huang, x., shi, j., & lu, l. (2020). mental health considerations for children quarantined because of covid-19. in the lancet child and adolescent health (vol. 4, issue 5, pp. 347–349). https://doi.org/10.1016/s23524642(20)30096-1 madigan, s., oatley, h., racine, n., fearon, r. m. p., schumacher, l., akbari, e., cooke, j. e., & tarabulsy, g. m. (2018). a meta-analysis of maternal prenatal depression and anxiety on child socioemotional development. in journal of the american academy of child and adolescent psychiatry (vol. 57, issue 9, pp. 645-657.e8). https://doi.org/10.1016/j.jaac.2018.06.012 mascaro, j. s., rentscher, k. e., hackett, p. d., mehl, m. r., & rilling, j. k. (2017). child gender influences paternal behavior, language, and brain function. behavioral neuroscience, 131(3), 262–273. https://doi.org/10.1037/bne0000199 mccormack, g. r., doyle-baker, p. k., petersen, j. a., & ghoneim, d. (2020). parent anxiety and perceptions of their child’s physical activity and sedentary behaviour during the covid-19 pandemic in canada. preventive medicine reports, 20. https://doi.org/10.1016/j.pmedr.2020.101275 mertens, g., gerritsen, l., duijndam, s., salemink, e., & engelhard, i. m. (2020). fear of the coronavirus (covid-19): predictors in an online study conducted in march 2020. journal of anxiety disorders, 74. https://doi.org/10.1016/j.janxdis.2020.102258 ministry of health. (2020). covid-19 situation. morelli, m., cattelino, e., baiocco, r., trumello, c., babore, a., candelori, c., & chirumbolo, a. (2020). parents and children during the covid-19 lockdown: the influence of parenting distress and parenting self-efficacy on children’s emotional well-being. frontiers in psychology, 11. https://doi.org/10.3389/fpsyg.2020.584645 moscardino, u., dicataldo, r., roch, m., carbone, m., & mammarella, i. c. (2021). parental stress during covid-19: a brief report on the role of distance education and family resources in an italian sample. current psychology, 40(11), 5749–5752. https://doi.org/10.1007/s12144-021-01454-8 nakoe, r., s lalu, n. a., & mohamad, y. a. (2020). perbedaan efektivitas hand-sanitizer dengan cuci tangan menggunakan sabun sebagai bentuk pencegahan covid-19. jambura journal of health sciences and research, 2(2), 65–70. https://doi.org/10.35971/jjhsr.v2i2.6563 prasetyawati, n. d., sudaryanto, s., & usmaningrum, d. u. (2021). peran media dalam upaya meningkatkan pengetahuan dan tindakan pencegahan coronavirus disease (covid 19). jurnal inovasi penelitian, 1(8), 1609–1617. spinelli, m., lionetti, f., pastore, m., & fasolo, m. (2020). parents’ stress and children’s psychological problems in families facing the covid-19 outbreak in italy. frontiers in psychology, 11(july), 1–7. https://doi.org/10.3389/fpsyg.2020.01713 sprang, g., & silman, m. (2013). posttraumatic stress disorder in parents and youth after health-related disasters. disaster medicine and public health preparedness, 7(1), 105–110. https://doi.org/10.1017/dmp.2013.22 sumakul, y., & ruata, s. c. n. (2020). kesejahteraan psikologis dalam masa pandemi covid-19. journal of psychology “humanlight,” 1(1). tremblay, m. s., carson, v., chaput, j. p., connor gorber, s., dinh, t., duggan, m., faulkner, g., gray, c. e., grube, r., janson, k., janssen, i., katzmarzyk, p. t., kho, m. e., latimer-cheung, a. e., leblanc, c., okely, a. d., olds, t., pate, r. r., phillips, a., … zehr, l. (2016). canadian 24-hour movement guidelines for children and youth: an integration of physical activity, sedentary behaviour, and sleep. applied physiology, nutrition and metabolism, 41(6), s311–s327. https://doi.org/10.1139/apnm2016-0151 wong, m. c. s., wong, e. l. y., huang, j., cheung, a. w. l., law, k., chong, m. k. c., ng, r. w. y., lai, c. k. c., boon, s. s., lau, j. t. f., chen, z., & chan, p. k. s. (2021). acceptance of the covid-19 vaccine based on the health belief model: a population-based survey in hong kong. vaccine, 39(7), 1148–1156. https://doi.org/10.1016/j.vaccine.2020.12.083 world health organization. (2020). mental health and psychosocial considerations during the. mental health and psychosocial consiederations during the covid19 outbreak, january, 1–6. volume 17  issue 1  april 2022 1 editorial: transforming nurses from frontline to front leaders: lesson learned from the pandemic ferry efendi 2-7 sociodemographic correlates of older adult acceptance of the covid-19 vaccine r arlene supremo, sillmark bacason , alexander rex sañosa 8-13 the effect of basic trauma and cardiac life support training in increasing the competence of emergency room nurses anisha calista prakoeswa, fitri arofiati, nur hidayah 14-18 indonesians’ readiness in facing long-term covid-19 pandemic yuyun setyorini, yopi harwinanda ardesa, rendi editya darmawan 19-24 the association between self-control and satisfaction in life among filipino older adults laarni a. caorong 25-30 anemia prevention behavior in female adolescents and related factors based on theory of planned behavior: a cross-sectional study halfie zaqiyah gusti puspitasari, ni ketut alit armini, retnayu pradanie, mira triharini 31-35 knowledge and attitudes toward covid-19 vaccination among student nurses from saudi arabia romeo mostoles jr., richard maestrado, joyce buta, hamdan mohammad albaqawi, evalynne rondilla, salman alsaqri, sandro villareal 36-41 relationship between stress, anxiety, and depression with suicidal ideation in adolescents heni dwi windarwati, retno lestari, satrio agung wicaksono, mira wahyu kusumawati, niken asih laras ati, shofi khaqul ilmy, ari dwi sulaksono, desi susanti 42-46 the correlation between parental communication pattern, self-esteem, and moral disengagement with cyberbullying behavior in early adolescents: a cross-sectional study dian octavia, rian maylina sari, diah merdekawati, rara marisdayana, rian yuliyana 47-54 development assessment instrument postpartum patients with severe preeclampsia-eclampsia based on need for help and self-care models endah suprihatin , sri hardi wuryaningsih 55-60 factors associated with compliance in implementing health protocols to prevent covid-19 in indonesia: a cross-sectional study ambar dwi erawati 61-66 self-care differences in covid-19 pandemic situation ni putu wulan purnama sari, jintana artsanthia 67-73 pandemic in indonesian older people: the implication for sleep deprivation, loss of appetite, and psychosomatic complaints susiana nugraha, asyifa robiatul adawiyah, yuna trisuci aprilia, lisna agustina, tresna putri asih handayani, tri budi w. rahardjo 74-82 factors associated with the implementation of covid-19 health protocols among indonesian older adults living in rural areas: a cross-sectional study nurul maurida, prestasianita putri, wike rosalini 83-88 the effects of illness script method on clinical reasoning of undergraduate nursing students: a quasiexperimental study gede arya bagus arisudhana 89-101 the relationship between genital hygiene behaviors and genital infections among women: a systematic review afriza umami, edit paulik, regina molnár, bhisma murti ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 201 efektivitas konseling kelompok dalam perbaikan tindakan pencegahan dbd (effectivitas of group conseling on improving patient behavior for prevention dpd) mira utami ningsih*, abu bakar**, makhfudli*** *program studi ilmu keperawatan fakultas keperawatan universitas airlangga email: miracle_zir@yahoo.com ** fakultas keperawatan universitas airlangga *** fakultas keperawatan universitas airlangga abstract introduction: dengue hemorrhage fever is a disease with prevalence that keep on higher and spread wider. prevention and control of dhf are affected by environment and social-behavioral factors. so that, some efforts are needed to increase people awareness in prevention of dhf by giving health education. this study was aimed to fi nd out the difference effectiveness of elucidation and group counseling method to emendation of patriarch behavior in dhf prevention. method: this study used pre-post test design. the population is patriarch in monjok pemamoran village rt 01. samples were 40 patriarchs taken by purposive sampling. independent variables were elucidation and group counseling. dependent variables were patriarch behavior including knowledge, attitude and practice. data were collected using questionnaire and observation sheet then analyzed using wilcoxon signed rank test and mann whitney u-test. result: the result revealed that there are signifi cant effect of elucidation and group counseling to emendation of patriarch behavior in dhf prevention. except in patriarch’s practice, there were no difference effectiveness of elucidation and group counseling to emendation of patriarch’s knowledge and attitude. there was difference effectiveness of elucidation and group counseling method to emendation of patriarch’s practice in prevention of dhf. discussion: from this study in can be concluded that, both elucidation and group counseling can affect patriarch’s behavior in prevention of dhf but group counseling method is more effective. that’s why, it is hoped that paramedic can apply that method to society in purpose to increase prevention and control of dhf and prevents the outbreak. keywords: dengue hemorrhagic fever, elucidation, group counseling, behavior pendahuluan demam berdarah dengue (dbd) merupakan masalah kesehatan masyarakat di indonesia karena angka kejadian yang terus meningkat dan penyebarannya semakin luas (sungkar, 2007). satu-satunya cara untuk mencegah penyakit ini adalah dengan memutus rantai transmisi penyakit yang disebut vektor control yang dipengaruhi oleh lingkungan dan faktor socio-behavioral (fathi dkk, 2005). menurut kepala bidang pengendalian penyakit dan lingkungan dinas kesehatan ntb, penyebab utama mewabahnya penyakit dbd di mataram terutama pada saat musim hujan yang ditambah tingkat kesadaran dan perilaku masyarakat untuk menjaga kebersihan lingkungan masih rendah, sehingga perlu terus-menerus dilakukan sosialisasi kepada masyarakat tentang penyakit dbd, bahayanya dan bagaimana cara mencegahnya (awaludin, 2010). peningkatan kesadaran masyarakat tentang pentingnya pemberantasan penyakit dbd dapat dilakukan dengan cara peningkatan pengetahuan, sikap dan tindakan masyarakat tentang pencegahan dbd melalui promosi kesehatan (suharto dkk, 2003). salah satu hal yang memengaruhi promosi kesehatan adalah metode yang digunakan. jurnal ners vol. 5 no. 2 oktober 2010: 201–209 202 metode promosi kesehatan yang dapat dilakukan untuk meningkatkan perilaku pencegahan dbd di antaranya ialah penyuluhan dan konseling. selama ini, metode yang sering digunakan untuk sosialisasi pencegahan dbd di daerah endemik adalah dengan penyuluhan. menurut penelitian fathi dkk (2005) di daerah endemik dbd yaitu di mataram, tidak ada peran penyuluhan penyakit dbd yang bermakna terhadap kejadian luar biasa (klb) penyakit dbd di kota mataram. sedangkan dengan menggunakan metode konseling kelompok, suharto dkk (2003) dalam penelitiannya tentang metode konseling kelompok dan curah pendapat di kabupaten magetan, menyatakan bahwa metode konseling kelompok dapat meningkatkan perilaku pencegahan dbd. penyuluhan kesehatan merupakan kegiatan pendidikan kesehatan yang dilakukan dengan menyebarkan pesan, menanamkan keyakinan, sehingga masyarakat tidak saja sadar, tahu dan mengerti tetapi juga mau dan bisa melakukan suatu anjuran yang ada hubungannya dengan kesehatan (surayani, 2005). sedangkan mengenai konseling, menurut redman dan thomas (1985) dikutip oleh friedman (1998), konseling sangat berhubungan erat dengan penyuluhan, tetapi berbeda. mengajar dan konseling telah dilukiskan sebagai dua titik pada ujung kontinum yang berbeda, dengan perspektif ini, mengajar dipandang sebagai metode pilihan ketika bekerja dengan keluarga/ masyarakat yang membutuhkan informasi lebih spesifi k dan terstruktur. konseling yang terletak pada satu ujung kontinum cocok jika bekerja dengan keluarga/masyarakat yang lebih banyak membutuhkan dukungan serta dorongan untuk menggunakan keterampilanketerampilan memecahkan masalah (friedman, 1998). namun perbedaan efektivitas metode penyuluhan dan metode konseling kelompok dalam meningkatkan perilaku pencegahan dbd di daerah endemik belum dapat dijelaskan. indonesia meskipun sudah lebih dari 35 tahun, dbd bukannya terkendali, tetapi semakin mewabah. sejak januari sampai maret 2004, klb dbd di indonesia telah menyerang 39.938 orang dengan angka kematian 1,3 persen (soeroso, 2008). propinsi yang terus mengalami peningkatan angka kejadian dbd adalah dki jakarta, jawa barat, kalimantan timur, sulawesi utara, sulawesi selatan, bali, nusa tenggara timur dan nusa tenggara barat (sungkar, 2007). di nusa tenggara barat kasus dbd dari januari sampai dengan desember 2005 terdapat 1.040 kasus, dengan kematian mencapai 15 orang. jumlah sebenarnya jauh lebih tinggi daripada jumlah yang tercatat ini (taufi k dkk., 2007). sedangkan pada tahun 2010, terjadi peningkatan kasus secara signifi kan. sejak januari 2010 sampai februari 2010 telah tercatat 571 kasus dbd. wilayah yang paling tinggi penderita dbd adalah kota mataram sebanyak 368 kasus, diikuti lombok barat 52 kasus, lombok timur 46 kasus, sumbawa barat 31 kasus. selanjutnya lombok tengah 24 kasus, kota bima 13 kasus, kabupaten sumbawa 11 kasus, dompu 11 kasus, lombok utara sembilan kasus dan bima enam kasus. dinas kesehatan ntb telah menetapkan kota mataram sebagai daerah klb penyakit dbd (awaludin, 2010). menurut data dari studi pendahuluan, didapatkan data peningkatan pasien dbd berobat ke puskesmas mataram yaitu dari 58 orang pada tahun 2009 menjadi 87 orang pada tahun 2010 dari kelurahan monjok. jumlah ini mencapai hampir seperempat dari jumlah kejadian dbd keseluruhan di kota mataram pada tahun 2010. dari jumlah tersebut, 48 orangnya berasal dari lingkungan monjok pemamoran yang terdiri dari 5 rt. rt terbanyak penderita dbd adalah rt 01 yaitu sebanyak 12 penderita. menurut awaludin (2010), jika tidak diantisipasi dengan melakukan pencegahan, jumlah penderita dbd di ntb khususnya di mataram dapat meningkat dari tahun sebelumnya didasari oleh kondisi iklim yang tidak menentu seperti hujan yang turun tidak teratur. peningkatan jumlah pasien dbd dapat berdampak tidak hanya pada derajad kesehatan masyarakat yang dapat menyebabkan kematian, namun juga aspek sosial ekonomi. keluarga yang salah satu anggotanya menderita penyakit dbd tentu saja dirugikan dalam hal ekonomi. soegijanto (2008) dalam penelitiannya di jawa timur menyatakan bahwa untuk merawat pasien dbd, keluarga memerlukan tambahan biaya rp. 184.000 sampai 1.040.000 dalam efektivitas konseling kelompok dalam perbaikan tindakan (mitra utami ningsih) 203 waktu tujuh hari padahal masa rawat pasien dbd bisa lebih dari 7 hari dan keluarga dengan penderita dbd rata-rata berpenghasilan hanya 200–400 ribu rupiah per bulan. kerugian tersebut belum termasuk kerugian akibat tidak masuk kerja, tidak masuk sekolah, gangguan aktivitas sosial dan pengaruh sakitnya terhadap orang-orang yang berhubungan dengan penderita dbd. kerugian-kerugian tersebut juga sangat mungkin terjadi di daerah endemik seperti kota mataram. m a s a l a h d i a t a s d i a t a s i d e n g a n diperlukannya penerapan metode sosialisasi y a n g p a l i n g t e p a t d a n e f e k t i f d a l a m meningkatkan kesadaran masyarakat dan mengubah perilaku masyarakat dalam upaya pencegahan kejadian dbd. keluarga sebagai unit terkecil dari masyarakat dan ujung tombak pencegahan dbd perlu diberdayakan secara optimal (suharto dkk., 2003). menurut effendi dan makhfudli (2009), keluarga dipandang sebagai sumber daya kritis untuk menyampaikan pesan-pesan kesehatan, di mana dalam hal ini keluarga sebagai unit terkecil dalam masyarakat berperan dalam penyampaian pesan betapa pentingnya usaha pencegahan agar terhidar dari wabah. setiap keluarga perlu dilibatkan dalam upaya pencegahan khususnya bagi kepala keluarga mengingat sebagian besar struktur keluarga di indonesia adalah patriakal di mana dominasi pengambil keputusan ada pada suami (setyowati dkk., 2008). sehingga perlu ditentukan metode yang paling efektif dalam membantu keluarga untuk mengembangkan pengetahuan, kesehatan mental serta perubahan sikap dan perilaku. berdasarkan uraian tersebut maka peneliti tertarik untuk meneliti perbedaan efektivitas metode penyuluhan ceramah tanya jawab dan metode konseling kelompok terhadap perbaikan perilaku kepala keluarga dalam pencegahan dbd di kota mataram. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah pre post test design. populasi dalam penelitian ini yaitu kepala keluarga di lingkungan monjok pemamoran, kota mataram sebanyak 51 orang. sampel yang digunakan dalam penelitian ini yaitu kepala keluarga di lingkungan monjok pemamoran, kota mataram yang memenuhi kriteria inklusi yaitu: berusia 25–50 tahun, pendidikan minimal sd dan bisa membaca dan menulis belum pernah mendapatkan penyuluhan maupun konseling kelompok tentang dbd dalam dua bulan terakhir; keluarga dengan lingkungan berisiko menjadi tempat penyebaran vektor nyamuk yaitu adanya kontainer buatan ataupun alami yang dapat menjadi habitat larva di dalam maupun di luar rumah; dan bersedia menjadi responden dan mengikuti kegiatan penelitian sampai selesai. lokasi penelitian ini adalah di lingkungan monjok pemamoran, kota mataram. pelaksanaan penelitian dan pengambilan data dilakukan selama 3 minggu, pada tanggal 23 desember 2010–14 januari 2011. variabel independen dalam penelitian ini yaitu penyuluhan dan konseling kelompok. variabel dependen yaitu perilaku pencegahan dbd oleh kepala keluarga meliputi pengetahuan, sikap dan praktik pencegahan dbd. instrumen yang digunakan dalam pengumpulan data pengetahuan dan sikap kepala keluarga adalah kuesioner yang dimodifikasi dari konsep pencegahan dbd menurut who (2009). sedangkan untuk data praktik kepala keluarga dalam pencegahan dbd menggunakan lembar observasi. pengumpulan data dilakukan mulai dari mengumpulkan daftar nama-nama kepala keluarga kemudian menentukan kelompok kepala keluarga yang diberi penyuluhan (kelompok 1) dan kepala keluarga yang diberi konseling kelompok (kelompok 2) masingmasing 20 orang. proporsi kepala keluarga berdasarkan usia dan tingkat pendidikan dibagi sama antara kedua kelompok perlakuan tersebut. selanjutnya dilakukan pre-test untuk mengumpulkan data pengetahuan dan sikap kepala keluarga dan mengobservasi perilaku kepala keluarga sebelum dilakukan penyuluhan maupun konseling kelompok. pre-test ini dilakukan dengan mendatangi rumah masing-masing kepala keluarga, peneliti juga sekaligus memberitahukan jadwal dilakukan penyuluhan dan konseling kelompok. sehari setelah dilakukan pre-test, peneliti melakukan penyuluhan kepada kelompok 1. penyuluhan jurnal ners vol. 5 no. 2 oktober 2010: 201–209 204 dilakukan hanya satu kali kemudian dilakukan post-test untuk mengetahui pengetahuan dan sikap setelah diberikan penyuluhan dan seminggu kemudian peneliti kembali mendatangi rumah kepala keluarga untuk mendapatkan data tindakan pencegahan dbd menggunakan lembar observasi. kelompok 2 diberikan konseling kelompok, di mana sepuluh orang kepala keluarga dikumpulkan menjadi satu kelompok konseling dan dilakukan berdasarkan tahapan konseling setiap 3 hari sekali. setelah pertemuan terakhir dilakukan post-test untuk mengetahui pengetahuan dan sikap kepala keluarga dengan menggunakan kuesioner. selanjutnya, seminggu setelah kegiatan konseling yang terakhir, peneliti mengunjungi rumah masingmasing kepala keluarga untuk menilai praktik/ tindakan kepala keluarga menggunakan lembar observasi. penelitian ini menggunakan uji wilcoxon signed rank test dengan tingkat kemaknaan α ≤ 0,05 untuk menguji data pengetahuan, sikap dan tindakan kepala keluarga pada pre-test dan post test. penelitian ini juga menggunakan uji mann whitney u-test dengan tingkat kemaknaan α £ ≤ 0,05 untuk menguji data pengetahuan, sikap dan tindakan kepala keluarga yang diberikan penyuluhan (kelompok 1) dan kepala keluarga yang diberikan konseling kelompok (kelompok 2). hasil data menunjukkan pada kelompok 1, dari 20 responden pada pre-test didapatkan sebagian kepala keluarga (55%) berpengetahuan baik, hanya sebagian kecil kepala keluarga (30%) memiliki sikap baik dan tidak ada (0%) kepala keluarga yang tindakannya masuk kategori baik, sebagian besar (60%) kepala keluarga tindakannya masuk kategori cukup. sedangkan pada post-test didapatkan sebagian besar kepala keluarga berpengetahuan baik (95%), sebagian besar kepala keluarga memiliki sikap baik (80%) dan sebagian besar kepala keluarga (65%) tindakannya masuk kategori cukup. data menunjukkan pada kelompok 2, dari 20 responden pada pre-test didapatkan sebagian kepala keluarga (55%) berpengetahuan baik, sebagian besar responden (75%) memiliki sikap cukup baik dan sebagian besar responden (70%) tindakannya masuk kategori baik. sedangkan pada post-test didapatkan seluruh responden (100%) berpengetahuan baik, sebagian besar responden (85%) memiliki sikap baik, dan sebagian besar responden (65%) yang tabel 1. pengetahuan kepala keluarga sebelum dan sesudah diberikan penyuluhan dan konseling kelompok tentang upaya pencegahan dbd. no kategori penyuluhan konseling kelompok sebelum sesudah sebelum sesudah jumlah % jumlah % jumlah % jumlah % 1 baik 11 55 19 95 11 55 20 100 2 cukup 9 45 1 5 9 45 0 0 3 kurang 0 0 0 0 0 0 0 0 uji statistik wilcoxon sign rank test p = 0,002 wilcoxon sign rank test p = 0,001 mann whitney pre-test p = 1,000 mann whitney post-test p = 0,317 efektivitas konseling kelompok dalam perbaikan tindakan (mitra utami ningsih) 205 tindakannya masuk kategori cukup. hasil analisis menggunakan wilcoxon signed rank test didapatkan p = 0,002 untuk pengetahuan, p = 0,002 untuk sikap dan p = 0,014 untuk tindakan pada kelompok 1. hasil ini menunjukkan bahwa penyuluhan berpengaruh terhadap perbaikan pengetahuan, sikap dan tindakan kepala keluarga dalam pencegahan dbd. hasil analisis wilcoxon signed rank test pada kelompok 2 didapatkan p = 0,001 untuk data pengetahuan, sikap dan tindakan. hasil ini menunjukkan bahwa konseling kelompok berpengaruh terhadap perbaikan pengetahuan, sikap dan tindakan kepala keluarga dalam pencegahan dbd. hasil analisis mann whitney u-test data hasil post-test kedua kelompok didapatkan p = 0,317 untuk pengetahuan, p = 0,681 untuk sikap dan p = 0,008 untuk tindakan pencegahan dbd. hasil ini menunjukkan bahwa tidak ada perbedaan efektivitas penyuluhan dan konseling kelompok dalam perbaikan pengetahuan dan sikap kepala keluarga tetapi ada perbedaan signifi kan efektivitas kedua metode tersebut terhadap perbaikan tindakan kepala keluarga, di mana konseling kelompok lebih efektif dalam meningkatkan tindakan kepala keluarga dalam melakukan pencegahan dbd. pembahasan hasil penelitian didapatkan bahwa pengetahuan, sikap dan tindakan kepala keluarga dalam pencegahan dbd meningkat baik pada kelompok yang diberi penyuluhan maupun yang diberi konseling kelompok. tidak ada perbedaan signifikan efektivitas kedua metode terhadap perbaikan pengetahuan dan sikap kepala keluarga namun ada perbedaan signifikan efektivitas metode penyuluhan dan konseling kelompok terhadap perbaikan tindakan pencegahan. peningkatan pengetahuan pada kelompok yang diberi penyuluhan dalam penelitian ini sesuai dengan pendapat azwar dalam suryani (2005), yang menyatakan bahwa penyuluhan kesehatan adalah kegiatan yang dilakukan dengan menyebarkan pesan sehingga tabel 2. sikap kepala keluarga sebelum dan sesudah diberikan penyuluhan dan konseling kelompok tentang upaya pencegahan dbd no kategori penyuluhan konseling kelompok sebelum sesudah sebelum sesudah jumlah % jumlah % jumlah % jumlah % 1 baik 6 30 16 80 5 25 17 85 2 cukup 17 70 4 20 15 75 3 15 3 kurang 0 0 0 0 0 0 0 0 uji statistik wilcoxon sign rank test p = 0,002 wilcoxon sign rank test p = 0,001 mann whitney pre-test p = 0,727 mann whitney post-test p = 0,681 tabel 3. tindakan kepala keluarga sebelum dan sesudah diberikan penyuluhan dan konseling kelompok tentang upaya pencegahan dbd no kategori penyuluhan konseling kelompok sebelum sesudah sebelum sesudah jumlah % jumlah % jumlah % jumlah % 1 baik 0 0 2 10 0 0 7 35 2 cukup 12 60 13 65 14 70 13 65 3 kurang 8 40 5 25 6 30 0 0 uji statistik wilcoxon sign rank test p = 0,014 wilcoxon sign rank test p = 0,001 mann whitney pre-test p = 0,814 mann whitney post-test p = 0,008 keterangan: p = signifi kansi, % = persentase jurnal ners vol. 5 no. 2 oktober 2010: 201–209 206 masyarakat tahu dan mengerti. melalui penyuluhan, seseorang dapat menerangkan dan menjelaskan suatu ide, pengertian atau pesan lisan kepada sekelompok sasaran sehingga memperoleh informasi tentang kesehatan. sedangkan peningkatan pengetahuan kepala keluarga yang mendapatkan konseling kelompok dalam penelitian ini sesuai dengan konsep konseling yang diungkapkan oleh tamsuri (2007) bahwa konseling merupakan kegiatan yang bertujuan untuk meningkatkan pengetahuan dengan memberi arahan pada klien atau keluarga termasuk membantu mereka menyelesaikan masalahnya. p e n i n g k a t a n p e n g e t a h u a n k e p a l a keluarga pada kedua kelompok perlakuan d a p a t d i s e b a b k a n k a r e n a p e r s e p s i d a n perhatian mereka terhadap informasi yang diberikan pada penyuluhan maupun konseling kelompok. persepsi tersebut terbentuk dari hasil penginderaan di mana semua responden berada pada rentang usia 25–50 tahun, saat fungsi panca indera masih cukup baik untuk menerima stimulus atau informasi dari luar. hal ini juga didukung oleh tingkat pendidikan responden, yang walaupun presentasi terbanyak untuk masing-masing tingkat pendidikan adalah sd (32%) namun lebih dari separuh (52%) responden berpendidikan menengah ke atas dan berpendidikan tinggi. tidak adanya perbedaan efektivitas penyuluhan dengan konseling kelompok terhadap pengetahuan kepala keluarga dapat dipahami karena kedua metode tersebut memang sama-sama merupakan metode pendidikan kesehatan yang dapat meningkatkan pengetahuan seseorang melalui proses belajar. sebaran responden yang telah diseimbangkan antara kelompok penyuluhan dan kelompok konseling berdasarkan usia dan tingkat pendidikan melalui proses matching juga mengurangi kesenjangan antarkedua kelompok. hal ini menyebabkan kondisi dan kemampuan responden untuk menyerap informasi dari kedua metode pendidikan kesehatan tersebut relatif sama, sehingga tidak ada perbedaan signifi kan peningkatan pengetahuan setelah diberikan penyuluhan maupun konseling kelompok. tidak adanya perbedaan efektivitas metode konseling kelompok dan penyuluhan dalam perbaikan sikap kepala keluarga tidak sesuai dengan teori friedman (1998) yang menyatakan bahwa konseling kelompok lebih banyak terjadi proses belajar afektif (emosional) sehingga lebih mampu memengaruhi sikap atau afektif. menurut notoatmodjo (2010), sikap merupakan reaksi atau respons yang masih tertutup dari seseorang terhadap suatu stimulus atau objek, sikap juga merupakan respons tertutup seseorang terhadap stimulus atau objek tertentu yang sudah melibatkan faktor pendapat dan emosi yang bersangkutan. menurut anwar (2009), sikap dapat dipengaruhi oleh beberapa faktor yaitu faktor predisposisi, faktor pendukung, dan faktor pendorong. faktor predisposisi antara lain adalah pengetahuan, kepercayaan, keyakinan, nilai-nilai dan sebagainya. faktor predisposisi peningkatan sikap kepala keluarga adalah pengetahuan yang juga telah meningkat setelah diberikan penyuluhan maupun konseling kelompok. kepala keluarga telah mengetahui dan memahami tentang dbd serta pentingnya pencegahan dbd. perubahan sikap yang terjadi pada kedua kelompok responden juga dapat dipengaruhi oleh faktor pendorong yaitu pemberian pendidikan kesehatan melalui penyuluhan maupun konseling kelompok. seperti yang telah diketahui bahwa perubahan sikap dapat dilakukan dengan strategi pendidikan. dengan pemberian informasi-informasi kesehatan akan meningkatkan pengetahuan masyarakat dan menimbulkan kesadaran mereka yang selanjutnya menyebabkan orang bersikap sesuai dengan pengetahuan yang dimilikinya. penyuluhan dan konseling kelompok yang diberikan tidak hanya bisa dijadikan sebagai media penyampaian informasi tetapi juga bisa membantu responden menyusun rencana dalam membuat keputusan yang tepat sehingga diharapkan berdampak positif bagi responden dalam menumbuhkan sikap yang baik tentang dbd dan pencegahannya. dari uraian tersebut dapat dipahami mengapa penyuluhan dan konseling kelompok samasama dapat meningkatkan sikap responden dan tidak ada perbedaan efektivitas di antara kedua metode tersebut. metode penyuluhan dan konseling kelompok terbukti sama efektif dalam efektivitas konseling kelompok dalam perbaikan tindakan (mitra utami ningsih) 207 meningkatkan pengetahuan dan sikap kepala keluarga dalam penelitian ini namun konseling kelompok lebih efektif dalam meningkatkan tindakan pencegahan dbd. penyuluhan kesehatan, menurut azwar dalam suryani (2005) merupakan kegiatan yang dilakukan dengan manyebarkan pesan sehingga masyarakat tidak saja tahu dan mengerti, tetapi juga mau dan bisa melakukan suatu anjuran yang ada hubungannya dengan kesehatan. keunggulan dari strategi pembelajaran dengan penyuluhan menggunakan metode ceramah dan tanya jawab yaitu memungkinkan banyak orang yang dapat mendengarkan dan memperoleh pengetahuan. sedangkan kelemahannya dalam keberhasilan pembelajaran kurang mengikutsertakan peserta untuk aktif, serta perubahan sikap dan perilaku peserta relatif sulit diukur karena yang diinformasikan kepada peserta pada umumnya lebih menyentuh pengetahuan (sudjana, 2005). namun demikian, penyuluhan tetap dapat meningkatkan tindakan responden sebagaimana yang telah ditunjukkan dari hasil uji statistik dalam penelitian ini. breckler dan wiggins dalam defi nisi mereka mengenai sikap mengatakan bahwa sikap yang diperoleh lewat pengalaman akan menimbulkan pengaruh langsung terhadap tindakan berikutnya. kondisi apa, waktu apa dan situasi bagaimana saat individu tersebut harus mengekspresikan sikapnya merupakan bagian dari determinan-determinan yang sangat berpengaruh terhadap konsistensi antara sikap dengan pernyataannya dan antara pernyataan sikap dengan tindakannya (anwar, 2009). dalam konsep konseling, pemberian konseling bertujuan membantu klien mengenal diri sendiri, menerima diri secara realistis dapat memutuskan pilihan dan rencana yang lebih bijaksana sehingga dapat berkembang secara konstruktif di lingkungannya. hal ini berarti bahwa individu tidak hanya memperoleh pengetahuan dan sikap dari konselor maupun kelompoknya namun juga dari pengalamannya sendiri yang akan menimbulkan pengaruh langsung terhadap konsistensi terhadap pernyataan sikap dengan tindakannya. warner dan de fleur yang dikutip anwar (2009) menyatakan dalam postulat konsistensinya yang ketiga tentang sikap, hubungan sikap dan tindakan sangat ditentukan oleh faktor-faktor situasional tertentu. normanorma peranan, keanggotaan kelompok, kebudayaan dan sebagainya merupakan kondisi ketergantungan yang dapat mengubah hubungan sikap dan tindakan (anwar, 2009). berkaitan dengan faktor keanggotaan kelompok yang diungkapkan oleh warner dan de fleur, konseling kelompok memberikan kesempatan pada anggota konseling untuk belajar dengan dan dari orang lain untuk mampu memahami pola pikiran dan perilakunya sendiri serta orang lain. sebuah kelompok merupakan kesempatan untuk mendapatkan dukungan dan memampukan anggotanya untuk mencoba dan berusaha meningkatkan sikap dan tindakannya dalam menghadapi masalah. kelompok penyuluhan dalam peningkatan tindakan responden dapat dipengaruhi oleh pengetahuan dan sikap mereka yang telah meningkat. sikap mereka yang baik adalah predisposisi bagi tindakan mereka dalam melakukan tindakan pencegahan dbd dengan baik. terdapatnya responden yang tindakannya masih kurang dapat disebabkan karena berbagai faktor yang memengaruhi seseorang saat akan mengekspresikan sikapnya. pada responden yang diberikan konseling kelompok, sikap dan tindakan mereka tidak hanya dipengaruhi oleh pengetahuan dari fasilitator atau konselor tetapi juga oleh dukungan dan alternatif pemecahan masalah yang mereka dapatkan dari anggota kelompok lainnya. dukungan dari anggota kelompok dapat meningkatkan tindakan pencegahan dbd. dari uraian tersebut dapat dipahami bagaimana konseling kelompok dapat memengaruhi tindakan responden dengan lebih efektif daripada metode penyuluhan walaupun kedua metode pembelajaran atau pendidikan kesehatan tersebut sama-sama mampu meningkatkan tindakan responden dalam pencegahan dbd di lingkungannya. p e n y u l u h a n d a p a t m e n i n g k a t k a n perilaku kepala keluarga dalam pencegahan dbd. kepala keluarga yang telah diberikan penyuluhan memiliki perilaku yang baik dalam mencegah dbd. hal ini terjadi karena terjadi peningkatan pengetahuan, sikap dan tindakan. hal yang sama terjadi pada kelompok yang diberikan konseling kelompok. terjadi jurnal ners vol. 5 no. 2 oktober 2010: 201–209 208 perubahan perilaku kepala keluarga dalam pencegahan dbd di mana kepala keluarga memiliki perilaku yang baik tentang pencegahan dbd. perbedaan tingkat efektivitas metode penyuluhan dan konseling kelompok terhadap perilaku kepala keluarga dapat terjadi karena perbedaan metode di mana konseling kelompok memungkinkan kepala keluarga mendapat pengetahuan yang lebih spesifi k, mendapat dukungan untuk bersikap positif dari anggota konseling lainnya serta mendapat dukungan atau bantuan dalam melakukan tindakan pencegahan dbd. simpulan dan saran simpulan konseling kelompok lebih efektif dari pada penyuluhan dalam perbaikan tindakan kepala keluarga mencegah dbd di lingkunganya. saran penulis memberikan saran sebaiknya usaha promotive dan preventive terhadap kejadian dbd dilakukan dengan metode pembelajaran yang lebih efektif untuk meningkatkan tindakan pencegahan dbd seperti konseling kelompok yang dalam penelitian ini terbukti lebih efektif, perlu dilakukan penelitian lebih lanjut tentang faktorfaktor yang mempengeruhi efektivitas suatu metode pendidikan sehingga dapat diterapkan di lingkungan dengan karakteristik masyarakat tertentu yang sesuai. berkaitan dengan kelemahan penelitian, maka untuk penelitian selanjutnya sebaiknya menggunakan teknik cluster sampling, dan peneliti diharapkan dapat lebih memahami tentang metode pendidikan kesehatan. kepustakaan anwar, s., 2009. sikap manusia, teori dan pengukurannya. jakarta: pustaka pelajar. awaludin, 2010. penderita dbd di ntb mencapai 571 orang, (online), (http:// www.antaramataram.com., diakses tanggal 14 oktober 2010, jam 12.00 wib). effendi, f.m., 2009). keperawatan kesehatan komunitas: teori dan praktik dalam k e p e r a w a t a n . j a k a r t a : s a l e m b a medika,. fathi, keman, s., wahyuni, c.u., 2005. peran faktor lingkungan dan perilaku terhadap penularan demam berdarah dengue di kota mataram. jurnal kesehatan lingkungan. 2 (1), 1–10. friedman, marilyn m., 1998. keperawatan keluarga teori dan praktik. edisi 3. jakarta: egc. notoatmodjo, 2010. teori perilaku kesehatan. jakarta: rineka cipta. setyowati, s., murwani a., 2008. asuhan keperawatan keluarga: konsep dan aplikasi kasus. yogyakarta: mitra cendika press. soegijanto, s., 2008. demam berdarah dengue. edisi 2. surabaya: airlangga university press. soeroso, s., 2008. demam dengue adalah penyakit infeksi oleh virus yang sudah lebih dari 100 tahun dikenal di indonesia, (online), (http://www.depkes. go.id., diakses tanggal 15 oktober 2010, jam 12.30 wib). sudjana, s., 2005. metode dan teknik pembelajaran partisipasif. bandung: falah production. suharto, agung, sofi ati, qomarudin, 2003. promosi kesehatan metode konseling kelompok dan curah pendapat dalam meningkatkan pengetahuan, sikap dan perilaku pemberantasan dbd di puskesmas sidokerto kabupaten magetan. sains kesehatan, 16 (3), 465, 477. sungkar, s., 2007, pemberantasan demam berdarah dengue: sebuah tantangan y a n g h a r u s d i j a w a b . m a j a l a h kedokteran indonesia, 57 (6), 167– 170. suryani, s., 2005. pendidikan kesehatan bagian dari promosi kesehatan. edisi 1. yogyakarta: fitramaya. efektivitas konseling kelompok dalam perbaikan tindakan (mitra utami ningsih) 209 taufik, 2007. peranan kadar hematokrit, jumlah trombosit dan serologi igg – igm antidhf. jurnal penyakit dalam, 8 (2), 105–111. world health organization. 2009. dengue: guidelines for diagnosis, treatment, prevention and control, (online),(http:// www.searo.who.int., diakses tanggal 29 oktober 2010, jam 16.00 wib). 27 consumption of fruit and vegetable with risk of obesity in school-age children agnes sevelina anggraeni, tintin sukartini, kristiawati faculty of nursing universitas airlangga kampus c jl.mulyorejo surabaya 60115, telp. 031 5913754 email: agnessevelina@ymail.com abstract introduction: the problem of obesity in children aged 5-12 years in indonesia is still high, east java is one of the provinces that have higher prevalence of obesity than the national average (riskesdas 2013). consumption of fruit and vegetables affects the level of obesity’s risk, but nowadays fruit and vegetable consumption in school-age children are low. this study was aimed to determine the correlation between consumption patterns of fruits and vegetables with the risk of obesity in school-age children in ketabang i surabaya elementary school. method: this research uses the descriptive correlation method with cross sectional approach. the population of this research is students in grade 4 and 5. purposive sampling technique used to select 69 respondents as samples. the independent variable in this study is the consumption pattern of fruit and vegetable, while the dependent variable is the risk of obesity. the data were analyzed with chi-square test. result: the results of this research showed that most of respondents consume less fruit and vegetable (52%). the number of respondents who are obese is 20%, while the number of respondents who have high risk is 13%. statistical analysis showed that the consumption pattern of fruits and vegetables has a correlation with the risk of obesity (p = 0.009). discussion: there was a significant relationship between the consumption patterns of fruit and vegetables with risk of obesity in school -age children in ketabang i surabaya elementary school. further studies should examine the appropriate interventions to overcome the problem of obesity in school-age children. keywords: consumption pattern of fruit and vegetables, risk of obesity, school-age children. __________________________________________________________________________________ introduction obesity in children is a serious medical problem that affects children in the developed and developing countries because obesity potentially cause comorbidities and increased the risk of some chronic diseases (vash, 2015). the prevalence of overweight and obesity in children and adult increased at the end of the 20th century spread evenly in all over the countries in the world (bray & bouchard, 2014). nowadays, children tended to prefer fast food with the reason that it feels good, and a tendency consumption of fruit and vegetable is low that can cause fatness on child, whereas on the childhood period is really important to consume fruits and vegetables because it can help the children to apply a healthy food consumption pattern to controls and organizes weight (dewi 2013). fruits and vegetables can minimize the risks of obesity in children, because fruits and vegetables can burn fat without makes many calories (cdc 2011). in indonesia, problems of fatness in school age children (5 to 12 years) are still high (18.8%), consisting of overweight 10.8% and obese 8.8%. east nusa tenggara have the lowest prevalence of overweight (8.7%) and the highest prevalence is in jakarta (30,1%). there are 15 provinces with prevalence of obesity that above the national average, that provinces are central kalimantan, east java, banten, east kalimantan, bali, west kalimantan, north sumatra, riau, jambi, papua, bengkulu, bangka belitung, lampung and jakarta (riskesdas, 2013). research by nutrition institutions survey and national health about prevalence of obesity in 2008 to the children in primary schools and play group in ten cities in indonesia consecutively from the highest are jakarta (25%), semarang (24,3%), medan (17.75%), denpasar (15.7%), surabaya (13.4%), palembang (12.2%), padang (7.1%), manado (5.3%), yogyakarta (4%) and solo (2.1%). mean prevalence of overweight in ten cities has reached 12.7% (wahyu, 2009). obesity can cause the various diseases, such as heart disease, hypertension, diabetes type 2, metabolic syndrome, hipercolesterol, asthma, sleep disorder, orthopedic complication, and mental disorder (paxon, 2010). obesity also has adverse indirect effects to the decline in cognitive function most likely due to the impact of illnesses that suffered by the obese children (diabetes, obstructive sleep apnea syndrome (osas), problems of respiration), problem related to psychosocial (inferiority, self isolation, and depression) and also social maturity (wendt, 2009). mailto:agnessevelina@ymail.com jurnal ners vol. 12 no. 1 april 2017: 27-32 28 researcher did a survey to 586 students in sdn ketabang i surabaya and obtained the results of 3.75 % high risk to obesity and 14.6 % are obese. the results of the interviews from 20 students known that 25% did not like to eat vegetable, 5% did not like to eat fruit, and 5 % did not like to eat fruits and vegetables. among 25 % of children that does not like ate vegetables, two children are having nutritional status of belonging to the obesity, whereas 18 students who have been were interviewed has low risk category. the reason of the students who was not like to eat fruit or a vegetable is because it has bad taste. based on that background, the purpose of this study is to investigate the correlation between consumption pattern of fruits and vegetables with the risk of obesity in schoolage children in ketabang i surabaya elementary school. method this research using descriptive correlational design with cross sectional approach, where the data was taken in the same time. this method chosen to define the relationship between consumption patterns of fruits and vegetables with risk of obesity in school age children. this study was conducted in ketabang i surabaya elementary school. the affordable population on this research are the students from 4th and 5th grade in ketabang i surabaya elementary school as much as 218 students. the students from 4th and 5th grade were chosen to be samples because the obesity prevalence from that grade is the highest among al of the grades in ketabang i surabaya elementary school. the number of respondents that needed as samples for the research is 75 respondents. the number of the respondents were taken from the classroom with the highest prevalence of risk to obesity and obesity among 4th and 5th grade in ketabang i surabaya elementary school. students who selected to be sample are 29 students from 4b class, 8 students from 4a class, and 38 students from 5b class. sampling techniques that used in this research is purposive sampling. to minimize the bias, the inclusion criterias were: 1) 4th and 5th grade of ketabang i surabaya elementary school. 2) students that able to understand and answer the written questions. 3) students who has been approved by their parents / teachers to be respondents in this study. the exclusion criterias are: 1) students who have allergic to particular fruit and vegetables. 2) students who is sick while the data being collected the independent variable in this research is consumption patterns of fruits and vegetables, while the dependent variable in this research was risk of obesity that known from the bmi (body mass index) according to age. the instrument that used in this research is semiquantitative food frequency questionnaire that adapted and modified from nhanes (2005-2006), the eating pattern questionnaire used to obtain data relating consumption patterns fruits and vegetables qualitatively, adapted and modified from eating pattern questionnaire prochildren (2003) for measuring consumption patterns of fruits and vegetables over a week, and who anthroplus to know the bmi of the children according to age. primary data that gathered through questionnaire such as identity, attitude and consumption of fruits and vegetables. the data about consumption frequency of fruits and vegetables obtained through food frequency questionnaire. the data about nutritional status were known through measurement of the height and weight, and calculation of body mass index according to age. secondary data that needed were description of the school like the number of the students, the names of students, class, sex, and school overview that obtained from the administration staff in ketabang i surabaya elementary school. data collection was done by conducting anthropometry measurement, structured interview using food frequency questionnaire, and deploy eating pattern questionnaire to the students. this activity was conducted alternately from one class to another class. the researcher explain about the research to the prospective respondents, provides informed consent to the teacher of the respondents. the teacher considered to be agree that the student become the respondents of this research after signed the informed consent. after filling the informed consent, researcher doing the measurement of height and weight, body mass index according to age calculated by using application who anthroplus. after that researchers conducted interviews on child to know the frequency and the amount of consumption of fruits and vegetables by using consumption of fruits and vegetables (agnes savelina a., et.al.) 29 semiquantitative food frequency questionnaire. the interviews were conducted alternately on every respondents. at the time of interview researchers used simple daily conversation so easy to understand by the respondents. the time that needed to interview every student is about 5-10 minutes. next, researchers share a questionnaire that contained about risk of obesity analysis on children and consumption patterns of fruits and vegetables, respondents were accompanied by the researchers while filling the questionnaire. the data that obtained from the answer of the questionnaire during was put into tabulation then analyzed use chi square statistical tests. after the data collected processed, so the next stage is to do the interpretation of the results. result at ketabang i surabaya elementary school there is a canteen that sells foods for the students, but the kind of food that sold there contain high calories. in front of the schools gate there are also many food retailer, kind of food that sold also contain high calories and unhygienic. this situation makes the students had no choice to buy a healthy and nourishing food at school because of the lack of availability of nutritious food at school, eventhough school-age children need a balanced nutrition to support optimal development and growth. table 1. distribution of demographic characteristic of the respondents no. demographic data category f % 1 sex male 33 48% female 36 52% total 69 100% 2 age 10 years 17 25% 11 years 31 45% 12 years 21 30% total 69 100% the number of respondents based on sex are 33 male students (48 %) and 36 female students (52 %). respondents in this research is aged 10-12 years, and the respondents who was 11 years old has the most frequency, 31 students (45%). table 2. distribution of the respondents based on fruits and vegetables consumption no. consumption of fruits and vegetables f % 1 less 36 52% 2 good 33 48% total 69 100% consumption of fruits and vegetables are categorized as good if the number of fruits and vegetables consumed are ≥ 400 grams per day. consumption of fruits and vegetables are categorized as less if the number of fruits and vegetables consumed are <400 grams per day (who 2007). the consumption of fruits and vegetables was calculated by using semiquantitative food frequency questionnaire, from 69 respondents, there are 52% consumed less fruits and vegetables, and 48% have good consumption of fruit and vegetables. tabel 3. distribution of the respondents based on risk of obesity no risk of obesity f % 1 low risk 46 67% 2 high risk 9 13% 3 obesity 14 20% total 69 100% most of the respondents included in a low risk category (67%), followed by obesity (20%), and the lowest is high risk category (13%). in table 4 can be seen that consumption of fruit and vegetable in the good category be greater among respondents who have low risk to obesity, namely 40.6 %. in the majority of respondents with high risk to obesity show consumption of fruits and vegetables is low, namely 10.1 %. among the respondents who was obese consumption of fruits and vegetables that categorized as less as many as 15.9 %. the results of statistical tests shows the p value is 0.009, so it can be said that there was a meaningful relationship between consumption patterns of fruits and vegetables with the risk of obesity. jurnal ners vol. 12 no. 1 april 2017: 27-32 30 tabel 4. coreelation fruits and vegetables consumption with risk of obesity using chi square test fruits & vegetables consumption risk of obesity p value low risk high risk obesity f % f % f % less 18 26.1 7 10.1 11 15.9 0.009 good 28 40.6 2 2.9 3 4.3 total 46 66.7 9 13 14 20.3 discussion the mean of daily fruits and vegetables consumption among students in ketabang i surabaya is enough to fulfill suggestion from the who namely ≥ 400 grams per day, but if considered from the individual consumption, the majority of respondents consumed less fruits and vegetables. lack of fruits and vegetables consumption in children can be influenced by many factors, one of them is preference to fruits and vegetables. in this research, preference of fruits and vegetables means pleasure of the respondents towards fruits and vegetables. respondents’s preference of fruits and vegetables most affected by a taste. negative preference of vegetable quite high compared with negative preference of fruit. the respondents that like all fruits and vegetables said that their parents provide fruits and vegetables everyday at home, while the respondents that does not like fruits and vegetables did not specify the reason why they do not love fruits and vegetable, they only reason that fruits and vegetables have a bad taste. the research’s results show that students in ketabang i surabaya elementary school mostly love fruit than vegetable. researchers thought that taste and the availability of fruit at home impact on the consumption patterns of fruit and vegetable.this is corresponse with the results of the study conducted by kronel (2011) that concludes that the main reason for the children and teenage dislike to consume fruits and vegetables is the taste, also the availability and access of fruits and vegetables at home affect consumption patterns of fruits and vegetables. table 3 shows that the respondents with the low risk has the highest frequency, followed by obesity, and the high risk has the lowest frequency. there were few respondents with high risk and obesity, nevertheless attention must be given to them because it can be bad for health. the impact that appear as the of effect obesity are heart disease, hypertension, diabetes type 2, metabolic syndrome, hipercolesterol, asthma, sleep disorder, orthopedic complication, and mental disorder (paxon, 2010). the incidence of high risk to obesity in ketabang i surabaya elementary school has the potential to raise incidence obesity if it is not done by appropriate treatment and precautionary. data from the research results known that there is meaningful relations between consumption patterns of fruits and vegetables with the risk of obesity in school age children in ketabang i surabaya elementary school. this result is in accordance with the research of sartika (2011) which indicates the presence of meaningful relations between consumption patterns of fruits and vegetables with risk of obesity on 5-15 years children in indonesia. the same with the research of nuraeni (2013) indicates that school age children who obese are rarely and consume less fruits and vegetables compared with the child who is not obesity in yogyakarta and bantul. children that rarely and consume less fruits and vegetables can increase the risk of obesity. fruits and vegetables are the food that contain low density of energy that can manage an ideal weight. fruits and vegetables are the source of various essential nutrient, as potassium, vitamin c, folic acid, fiber, and many phytochemical (cdc, 2008). fruits and vegetables also content high amounts of fibers. fibers play an important role in the process of digestion. fibers fill the place in gaster and give satiety and decrease intraluminal pressure of the intestines. soluble fibers can slow down the intestines absorption of fat and glucose (mustofa, 2015). water-soluble fibers as pectin and several hemiselulose having the ability to hold water and may form a viscous liquid in the gastrointestine tract, so that the high fibers foods having longer time to digest in the stomach. then fibers will pull the water and give satiety longer so that can prevent to consuming more food. food that contain higher raw fiber usually contain low calories, low sugar, and low fat that can help to reduce consumption of fruits and vegetables (agnes savelina a., et.al.) 31 the risk of obesity (ichsan et al., 2015). this is in accordance with the results of the study of santoso (2011) explained that water-soluble fibers can control weight or overweight (obesity). the enhancement in public consumption of fruits and vegetables inversely proportional to the changes in weight, the results of substitution examination sensitivity analysis suggest to replace 5% calories over the other food to 5% calories over the fruit or vegetables (bertola et al., 2015). replacing high density foods ith low density food in the same amount can produce lower calories, while in the same amount of calories a person can consume more low density food compared with high density food (hss, 2010). it can be concluded that by consume more fruits and vegetables, risks to be obese will be lower. the research results that shown in table 4 can be known that the respondents who consume less fruits and vegetables mostly having low risk to obesity. consumption patterns of fruits and vegetables are not the only cause of obesity in school-age children, but there are various factors that cause obesity. this is also expressed in the results of the study of sartika (2011) who showed that risk factors of obesity in children aged 5-15 years in indonesia are characteristic of the child, smoking habit and sports, consumption of fruits and vegetables habits, intake of energy and protein, and the history of obesity parents. according to the ministry of health (2012) the main cause of fatness and obesity is environmental factors of the imbalance between food consumption pattern, eating behavior, and physical activity. bad eating pattern as consume large portions (more than need) , high-energy food, high fat , high carbohydrates , and low fiber is the main cause of the fatness and obesity. the research of guo (2013) said that a short duration of sleep, passing breakfast, and parents who obese are the risk factors of obesity in school age children. factors that related with the occurrence of obesity are consumption of high calories food that increased the risk to be overweight, consumption of sweet snacks, less physical activity, and spare time that often used to watch television and playing video games (aballa, 2010). the research result of school age children in bangladesh explained that the factors that related to obesity in school age children is the obesity history of the parents, less physical activities at home, and high sedentary activities (zaman & ahmed, 2013). some factors that can cause obesity in school age children are biologic factors and genetic, physical factors include activity pattern and diet, environment factors including social, economy, culture, and physic (solomon et al. , 2014). conclusion the respondents in ketabang i surabaya elementary school partially consumed fruits and vegetables less than the recommendation from who, ≥400 gram per day. the majority of respondents in ketabang i surabaya elementary school has low risk towards obesity. consumption pattern of fruits and vegetables related to the risk of obesity in school age children. fruits and vegetables that contains fibers can help to maintain weight. the school is expected to supply fruits and vegetables in school by selling foods and drinks in the canteen. the school also can held a program to eat fruits and vegetables at certain event to motivate the students on consuming fruits and vegetables. parents can introduce various kind of fruits and vegetabless to children since young age. parents should also provide fruits and vegetables at home everyday to support the increasement of fruits and vegetables consumption in children. nurse can do routine examination to monitor nutrition status of the children trough health unit in school. the nurse are expected to give education towards the students and parents, and informed about the recommendation of fruits and vegetables consumption. further studies should examine the appropriate interventions to overcome the problem of obesity in school-age children. references aballa, l.a., 2010. prevalence and risks factors for obesity among school aged children in nairobi province, kenya. kenyatta university. bertola, m. et al., 2015. changes in intake of fruits and vegetables and weight change in united states men and women followed for up to 24 years: analysis from three prospective cohort studies. journal plos medicine. bray, g.a. & bouchard, c., 2014. handbook of obesity, boca raton: crc press. jurnal ners vol. 12 no. 1 april 2017: 27-32 32 cdc, 2011. strategies to prevent obesity and other chronic diseases, atlanta: departement of health and human service. dewi, yessica, 2013. studi deskriptif: persepsi dan perilaku makan buah dan sayuran pada anak obesitas dan orang tua, volume 2 nomor 1 : calyptra guo, x. et al., 2013. prevalence and risk factors of being overweight or obese among children and adolescents in northeast china. international pediatric research foundation, 74(4), pp.443– 449. hss, 2010. obesity facts: fruit and vegetable intake in alaska. alaska division of public health. ichsan, b., wibowo, b.h. & sidiq, m.n., 2015. penyuluhan pentingnya sayuran bagi anak-anak di tk aisyiyah kwadungan, trowangsan, malangjiwan, colomandu, karanganyar, jawa tengah. warta, 18, pp.29–35. kemenkes, 2012. pencegahan dan penanggulangan kegemukan dan obesitas pada anak sekolah, jakarta: kementrian kesehatan ri. kronel, r. et al., 2011. determinants of fruit and vegetable consumption among children and adolescents: a review of literature. part ii: qualitative study. international journal of behavioral nutrition and physical activity, 8(112). mustofa, s., 2015. manfaat serat bagi kesehatan. biokimia kedokteran. available at: http://staff.unila.ac.id/syazilimustofa/201 5/03/26/manfaat-serat-bagi-kesehatan/. nuraeni, i., 2013. perbedaan konsumsi buah dan sayur pada anak sekolah dasar yang obes dan tidak obes. ejournal almaata, 1(2). paxon, christina., 2010. childhood obesity.new jersey : princeton – brookings riset kesehatan dasar., 2013, riset kesehatan dasar, jakarta : badan litbangkes depkes ri. santoso, a., 2011. serat pangan (dietary fiber) dan manfaatnya bagi kesehatan. magistra, 75, pp.35–40. sartika, r.a.d., 2011. faktor risiko obesitas pada anak 5-15 tahun di indonesia. jurnal makara kesehatan, 15, pp.37–43. solomon et al., 2014. pediatric skills for occupational therapy assistants, philadelphia: elsevier mosby. vash, p. d., 2015. the childhood obesity epidemic, (p. xvii), oakville: apple academic press. wahyu, g.g., 2009. obesitas pada anak, jakarta: bfirst. wendt, m.h.d., 2009. economic, environmental, and endowment effects on childhood obesity and school performance, tesis: university of minnesota. zaman, s. & ahmed, t., 2013. risk factors associated with overweight and obesity among urban school children and adolescents in bangladesh: a casecontrol study. bmc pediatrics. issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief ferry efendi, s.kep., ns., m.sc., ph.d editor: prof. angeline bushy, phd, rn, phcns-bc, faan prof. ching-min chen, rn, dns prof. eileen savage, bns., msc., p.hd. prof. josefina a. tuazon, rn, mn, drph dr. david pickles dr. farhan alshammari dr. chong mei chan, scm, bnsc, msc, phd dr. sonia reisenhofer assistant professor pei-lun hsieh prof. dr. ah. yusuf, s.kp., m.kes. yulis setiya dewi, s.kep.ns., m.ng. dr. esti yunitasari, s.kep., ns., m.kep.. dr. rizki fitryasari, s. kep., ns., m. kep. dr. ilya krisnana, s.kep., ns., m.kep. retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. quality control: gading ekapuja aurizki, s.kep., ns., m.sc technical editor: rifky octavia pradipta, s.kep., ns., m.kep. editorial address: faculty of nursing universitas airlangga campus c, mulyorejo street 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 811-3287-877 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners mailto:ners@journal.unair.ac.id http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. http://e-journal.unair.ac.id/index.php/jners acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 17 no. 2 october 2022. 1. anna kurniati, s.km, ma, ph.d. bppsdmk, ministry of health, indonesia 2. awatiful azza, s.kep., ns., m.kep. sp. kep. mat universitas muhammadiyah jember 3. chlara yunita prabawati universitas muhammadiyah surabaya, indonesia 4. dianis wulan sari, s. kep., ns., mhs., ph.d. universitas airlangga, indonesia 5. erni astutik s.k.m., m.epid. universitas airlangga, indonesia 6. lukman handoyo, s.kep., ns., m.kep. stikes widya darma husada 7. dr. ninuk dian k. s. kep. ns., manp. universitas airlangga, surabaya, indonesia 8. qorinah estiningtyas sakilah adnani, sst, m.keb, ph.d. universitas padjadjaran, bandung 9. dr. rizki fitryasari, s.kep., ns., m.kep. universitas airlangga, indonesia 10. rosnani rosnani, s. kp., m. kep., sp. mat. poltekkes kemenkes palembang 11. rr dian tristiana, s.kep., ns., m.kep. universitas airlangga, indonesia 12. saldy yusuf, s.kep. ns, mhs., etn. universitas hassanuddin, indonesia 13. dr. sarni maniar berliana, m.si politeknik statistika stis 14. dr. yuni sufyanti arief, s. kp., m. kes. universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 table of content jurnal ners vol. 17 no. 2 october 2022 1. contemporary in nursing: issues and challenges hema malini 102 2. a qualitative description of nurses’ problems to monitor and supervise vital signs in covid-19 patients in isolation room tri yahya christina, suhartini ismail, meira erawati 103-109 3. effect of caring behaviour approach to improve nurses’ caring character in medicalsurgical wards abu bakar, siti nur qomariah, iswati iswati 110-114 4. the effect of online learning on student satisfaction in nursing education during the covid-19 pandemic nurul hikmatul qowi, suratmi suratmi, virgianti nur faridah, trijati puspita lestari, rizky asta pramestirini, nanda rifky tri pamungkas, karsim karsim 115-120 5. nurses’ perspectives of families ‘needs of the maternal critically ill cases in woman health hospital: an educational program howieda fouly, jennifer debee, manal mohamed abd elnaeem 121-130 6. analysis of the causes of low-birth-weight infants in terms of nutritional status and maternal health history sri utami, rekawati susilaningrum 131-137 7. the incidence and factors predicting survival among preterm infants with respiratory distress syndrome admitted to neonatal intensive care unit naphaklacha pholanun, boonjai srisatidnaraku, joy longo 138-142 8. correlation of spiritual health and depression among young adults in a state university in southern philippines sitty aizah mangotara, ashley bangcola 143-152 9. effectiveness of symptom management training on caregiving preparedness and burden of family caregivers in-home palliative care: a quasi-experimental study erna rochmawati, akbar u saun 153-160 10. five cs as reflective learning attitude among philippines nursing students joel rey u. acob, yulis setiya dewi, hidayat arifin 161-167 11. factors associated with duration of mechanical ventilationat intensive care unit dr. soebandi: a retrospective study rahmawati dimas sumarlan, baskoro setioputro, rismawan adi yunanto 168-175 12. the relationship between disease severity and functional status of post-covid-19 patientsin banda aceh, indonesia budi yanti, siti hajar 176-182 13. stigma and discrimination against breast cancer survivors in indonesia: an interpretive phenomenology study ida ayu made ari santi tisnasari, tuti nuraini, yati afiyanti 183-189 14. analysis factors related to prisoner’s resiliency in rutan perempuan kelas iia surabaya citra danurwenda rahmah, rizky fitryasari, retnayu pradanie 190-195 15. fracture patient experience in undergoing traditional massage therapy (topu bara) in maluku province: phenomenology study la rakhmat wabula, syahfitrah umamity, endah fitriasari, ellen lombonaung, arindiah puspa windari, fahrunnissa tehupelasury 196-201 196 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 196-201 http://dx.doi.org/10.20473/jn.v17i2.27190 original article open access fracture patient experience in undergoing traditional massage therapy (topu bara) in maluku province: phenomenology study la rakhmat wabula1* , syahfitrah umamity1 , endah fitriasari1 , ellen lombonaung1, arindiah puspa windari1 , and fahrunnissa tehupelasury1 1 stikes maluku husada, ambon, maluku, indonesia *correspondence: la rakhmat wabula. address: stikes maluku husada, maluku, indonesia. email: la.rakhmat.wabula.stikesmh@gmail.com responsible editor: rizki fitryasari received: 31 may 2021 ○ revised: 28 october 2022 ○ accepted: 28 october 2022 abstract introduction: in indonesia, especially among the maluku people, there was a culture of seeking traditional fracture treatment, namely "topu bara." their belief has been passed down from generation to generation who believe that conventional medicine (topu bara) can cure the problem of fractures experienced by sufferers the study aimed to explore patient's fracture healing experience in topu bara methods: the method used wasa phenomenological study that used deep interviews from august to september 2021 the participants were taken by purposive sampling, adults aged 21 to 59-years old, and were in the second or more of healing series data originated from 15 participants interviews were recorded, transcribed verbatim, and subjected to collaizi analysis. results: the results of the study found 7 themes, including causes of fracture, time events, action taken directly after inside, pain experiences during handling in "topu bara" therapy, coping of the patients, pain management, and advice given by healer to other participants. conclusions: most of them stated that safety and comfort were the priority for fracture healing the concept of culture in the behavioral alteration of fracture healing can have an impact on the participants. keywords: family; educational program; perspectives; maternal critically ill patient fracture, traditional healing, topu bara, transcultural nursing introduction fracture is a crucial problem that is difficult for health professionals to handle treatment failure often occurs so it is deemed necessary for proper treatment fractures have a high prevalence rate common causes of fracture are accidents traffic accidents, work accidents, and other accidents (nadler et al., 2014). worldwide, road injuries cause disproportionately more than 1.3 million deaths and many more disabilities each year (yuniar & nasution, 2017). based on studies conducted by mirhadi et al. (2013), the average incidence of fractures associated with traffic accidents was 14.5 and 4.2 per 100,000 people (sugiharto et al., 2016). according to the world health organization (who), india ranks first as the country with the highest number of deaths due to traffic accidents. meanwhile, indonesia ranks 5th (sudayasa et al., 2018). indonesia is reported to have experienced an increase in the number of traffic accidents by more than 80% (darmawan, 2013). in indonesia, the death toll from traffic accidents reaches 120 people per day (akhrani & ardyaningrum, 2019). the prevalence of injury by province from 2007-2018 increased gradually with all age categories including in 2007 around 7.5% (arie, 2017), increased in 2013 to 8.2% (roma, 2013), and lastly in 2018 to 9.2%. injury events can occur anywhere, such as on roads, homes and neighborhoods, schools, or workplaces (mirhadi et https://creativecommons.org/licenses/by/4.0/ mailto:la.rakhmat.wabula.stikesmh@gmail.com https://orcid.org/0000-0003-0684-3685 https://orcid.org/0000-0001-6079-7427 https://orcid.org/0000-0001-8580-0266 https://orcid.org/0000-0002-0233-9556 jurnal ners http://e-journal.unair.ac.id/jners 197 al., 2013). traffic accidents according to 35 provinces and the highest characteristics are in the north sulawesi region (3.5%), and maluku itself ranks 30th (2.0%). types of fractures suffered, are namely in the tibia, hip, femur, ankle, and knee (kemenkes ri, 2018). fractures are indirectly treated by medical treatment. however, this is not following the reality in society (agarwal-harding et al., 2015). most people prefer alternative medicine, where they believe that massage therapy (topu bara) can solve the fracture problem in patients without surgery or plate placement. massage is an effort to relax the stiff part of the muscle because it has not been moved for a long time before exercise therapy (kautsar, 2018). the proportion of utilization of traditional health services in indonesia is 31.4 percentile, and in the maluku area is 14.5 percentile (kemenkes ri, 2018). while topu bara therapy is a typical name from the maluku region for one of the traditional therapies for patients with fracture problems, in the java area it is known as a denial putting therapy (maelissa et al., 2020). in indonesia, sangkal putung therapy is still widely used in the community; this is supported by research in central java that people prefer to seek treatment for alternative treatments of sangkal putung compared to modern hospitals that are easily accessible and have advanced developments in orthopedic and radiological surgery (kautsar, 2018). based on a preliminary study in february 2021, it was found that, in the maluku region, four areas have topu bara treatment, including liang (ambon city), masohi (central maluku regency), kamarian (west seram regency), and namlea (buru regency). on average per day, there are about 10-16 people who come for treatment. patients who received treatment experienced fractures in the tibia, hip, ankle, and knee areas, and the average number of patients came without complications. topu bara's treatment has never received a warning from the local government before. based on the results of interviews conducted by researchers in february 2021, data from three participants showed that the reason those who had experienced fractures and underwent topu bara massage therapy was due to the fast-healing process, saturation, and ineffective medical services; information related to this treatment was obtained from relatives/family. based on the results of the interview, the researcher wanted to explore the experiences of fracture patients who underwent traditional massage therapy in maluku province. materials and methods study design we used a phenomenological study using in-depth interviews. this methodology allowed researchers to explore the phenomenon (yuniar & nasution, 2017) of fracture sufferers who decided to go to traditional topu bara massage for fracture healing. these can be identified through clinical nursing problems and asking researchable questions (suarilah et al., 2017). likewise, sudayasa et al. (2018), suggest that self-interest can be the driving force needed to formulate research questions. to some extent, the practitioner then needs to identify and develop an interest in potential changes in practice problems, which are usually stimulated by patient preferences and dissatisfaction, quality improvement data, practitioner inquiries, evaluation data, or new research data (mulyono, 2017). the data collection process was for two months from august to september 2021. for this study, the participants were taken by purposive sampling, adults aged 21 to 55-years old and were in the second or more of healing series visiting. data originated from 15 participants. interviews were recorded, transcribed verbatim, and analyzed. there are seven participants taken by purposive sampling, aged 21 to 55-years old and already treated with topu bara for less than two times, more and almost finished. respondent for this study, participants were taken by purposive sampling. the inclusion criteria in this study included: adults aged 25 to 55 years and ranked second or more in the series of healing visits. exclusion criterion was: those who do not have a history of fractures with a history of topu bara treatment. data come from 15 participants, recorded interviews, transcribed verbatim, and analyzed using the collaizi method. data analysis the data analysis method was adopted from collaizi (1978) (maelissa et al., 2020) as below: describing the phenomenon under study by trying to understand the phenomenon of the patient's experience as well as coping strategies they adopt through the study of literature. in addition, researchers were trying to dive in and immerse themselves in a state of participant's experience taking alternative healing by topu bara. transcribing data interviews enabled to describe the experience of patients with fractures who went for topu bara. thus, collecting descriptions of the phenomenon through the opinion of participants and reading those data two to three times thoroughly until able to wabula, umamity, fitriasari et al (2022) 198 p-issn: 1858-3598  e-issn: 2502-5791 understand the experience of patients. additionally, reading the entire descriptions of the phenomena that have been submitted by participants. for understanding the experiences of the participants, the entire transcript of the interview was read, and significant statements selected and following the goals for analysis. significant data were identified by re-reading the statement and trying to find keywords that were the core of the statement. every keyword was studied and then grouped into categories. this is followed by re-reading the entire existing category, comparing, and looking for similarities between these categories, and eventually grouping similar categories into themes. passed through to the theme found in the data it was then written into a description of the relevant experience of participants. participants were then asked to read the description of the study. this was done to determine whether the description that had been developed by researchers followed the state of the respondent's experience. analyzed data obtained during validation to the participants was put in the final description to enable the readers to recognize the experience of participants as perceived during the topu bara fracture healing process. data collection the researchers conducted research in four locations for topu bara treatment located in the maluku region, including liang (ambon city), masohi (central maluku regency), kamarian (west seram regency), and namlea (buru regency). participants were interviewed while undergoing treatment with the therapist. the average length of the interview ranged from 45-60 minutes per participant. ten questions were asked to the participants by conducting in-depth interviews. the opening question posed to the participants was "how long have you been on topu bara treatment?" the interviews were stopped when the data were saturated. when collecting data, there were 15 participants due to data saturation. all data taken from the interviews were recorded, transcribed, and validated by double-checking the participants. thus, valid data are then analyzed. ethical consideration all the participants gave their informed consent to be involved in this study. this study has been registered and passed the research ethics committee of the health research ethics commission of the faculty of nursing, stikes maluku husada with letter number rk. 089/kepk/stik/viii/2021. results the participants of this research are described in table 1. they are in the second and more visit to traditional massage therapy (topu bara) in maluku province. there are seven themes identified from the results of qualitative data analysis collected through indepth interviews. theme 1: causes of fracture almost half of the participants had fractures by falls and traffic accidents. "my father knew well the father of the healer. i was around ten when i fell from a mango tree and my father took me here and i was satisfied with the result. my leg was normal after that (he exposed his right leg), i had no difficulties. even though not all my extended family agreed to go to this topu bara (for fracture healing, another family member went to another traditional massage), i am sure this one is the most suitable for me." (rj, 31-year-old with fractured left ankle). theme 2: time events a small percentage of participants experienced more than a year. almost all of them suffered a closed fracture less than three months ago. there was one of the participants experienced a fracture one week ago. those participants were already getting treatment table 1. the charateristics of participants participants age sex employee status type of fracture reason ab 54 female midwife right hip traffic accident jd 21 female college student right knee fall ds 37 female housewife right carpus fall da 47 male motorcycle taxi driver left tibia traffic accident gh 59 female civil servant left clavicle traffic accident hs 43 male army right ankle fall jk 46 male government employee lumbar fall gi 55 male fisherman right knee fall dk 42 male fisherman right ankle fall hn 33 male motorcycle taxi driver left tibia traffic accident mn 22 male college student right tibia traffic accident rj 31 male nurse left ankle fall hi 46 male fisherman left tibia traffic accident bd 27 female housewife right hip traffic accident hi 34 male fisherman left tibia traffic accident jurnal ners http://e-journal.unair.ac.id/jners 199 at the time of the interview which was at their third visit. although each visit always brought positive progress, i.e., the range of motion that extends and pain are reduced, it was not denied that the pain was still present when the healer did massage. overall, everything written above did not deter the participants to stop coming for treatment. "i broke a bone in my left leg while working as a motorcycle taxi driver for 2-3 months ago, when i was driving a motorcycle when it hit a tree." (da, 47-year-old with fractured left tibia). theme 3: almost taken directly after inside almost no participant went directly to the traditional topu bara massage therapy location, where the interview was taken, at the time after the incident for healing. one participant went straight to other than traditional massage therapy. most headed to the hospital. less than half of them rushed to the traditional massage therapy after being less satisfied with the handling of service and they got suggestions as to the traditional massage therapy directly by the physician. "this was not my first experience going to topu bara to get treatment for my clavicle; i had gone to another traditional massage. it seemed i was a topu bara's adventure.hahaha (laugh). i heard too many suggestions, so i compared what my friend said, and which one was the best based on my personal views. finally, this topu bara helped me much." (gh, 59-yearold with fracture left clavicle). theme 4: pain experiences during handling in traditional massage therapy (topu bara) almost all participants said a similar statement when they began therapy/massage as a part of fracture treatment by a healer at the traditional topu bara massage therapy center, starting from the pain of mild to severe. one participant said that he combined the traditional massage therapy treatment with physiotherapy at one of the state hospitals. this respondent stated very significant progress in the healing process. the pain was present when the massage was processed by the healer. however, pain can be reduced to the level of mild pain after the massage is finished. "that was a magic power or something like that. in my religion (islam), a selected person may be given by allah (god) that kind of ability; they were able to cure without medication. i heard the healer always start with prayer before and after doing massage." (tn da, 47yearold, fractured left tibia) theme 5: coping of the patients almost all the participants had positive responses to the treatment they got from traditional massage therapy. there were no statements from the respondents that they would stop the treatment process any time when they had no intention as to the outcome. "three days ago, after she finished (the healer) with massage, she told me that the bone was joined well. i was very grateful to hear that. i wish (now) she will inform me that the bone conjunctions were strengthening than before. my fracture is more difficult to be healed compared to others (because of that) i was suggested to immobilize this knee. at home, my husband and sons help me with my daily needs." (gi, 55-year-old, fractured right knee). theme 6: pain management medication such as painkillers oral was suggested by the healer. the healer informed the participant the name of the analgesic oral and topical to buy at the medication store. in addition, the healer also recommended some multivitamins to support bone union and encouraged avoiding certain foods. "you must know this kind of analgesic? (she showed a blister of analgesic to reduce pain), feel free to ask all patients here (at topu bara), they should bring the similar thing." (ds, 37-year-old with fracture right carpus) "look! this ointment is burning my skin (showing his right hip). the healer recommended me to have this. i bought it from medicine store. it is limited, so the price was a bit expensive." (ab, 54-yearold, fracture right hip). theme 7: advice given by healer to other patients the first participant was advised by the healer to go to a physician when they first arrived at traditional massage therapy. participants thought that traditional massage therapy was advisable because it not only solved the physical problem but also psychological and/or spiritual problems caused by fracture almost all of the participants declared that the severity of a fracture should be attended by a medical professional first before traditional massage therapy. "before i went to topu bara for treatment, i was previously treated at a doctor. but after two months of wabula, umamity, fitriasari et al (2022) 200 p-issn: 1858-3598  e-issn: 2502-5791 treatment, it showed no cure. so, i was advised by my family to try the treatment at topu bara. initially the therapist suggested that you must first believe that the fracture you experienced could heal after undergoing the topu bara treatment. i was not allowed to undergo topu bara therapy at other therapists. before treatment, the therapist first reads a prayer as a healing ritual." (hs, 43year-old, right ankle). discussions traditional massage therapy (topu bara) as an alternative for fracture healing was recommended by family, relatives, and close friends. no one participant came to traditional massage therapy on her/his initiative. a positive statement from previous patients became a strong motivation to make a final decision regarding fracture healing (sudayasa et al., 2018). the healer as the center of the healing process of fracture at a topu bara center practiced a supernatural approach through massage which was perceived by participants. they believed that every healer at a topu bara center had that kind of power. they expressed that, during this massage process, participants experience a pain sensation. to reduce pain, the healer recommended the name of an oral or topical painkiller. although they did not exactly know the series of visits needed for bone recovery, all participants said that they wanted to get well soon so they followed what the healer suggested. the healer sometimes informed about the bone healing process after the massage was finished. everything that comes from the healer during the healing process was perceived positively by participants. implicit in the results of interviews was sources of hope and advice conveyed such as others suffered the same fracture. it was not merely because of lack of funds for medical treatment (table 1) as all participants were financially independent, but they came to a topu bara center for various considerations and reasons. family, relatives, and close friends who suggested them to have topu bara treatment were fully attentive and followed the result of every visit. further, during the waiting time for healing, most participants talked to each other and shared their experiences. participants perceived that situation was not found in any hospital. it has been stated that perception is the major social aspect so that people are freed from using services of an alternative based on their perspectives (mulyono, 2017). in addition, treatment by a healer at a topu bara center as perceived by the public works, most stating that cost was not relevant. almost all of the respondents knew the suitability of the herb used in techniques and they believed the herb is very useful in fracture healing (suarilah et al., 2017). additionally, based on the background of participants, demographics, economic, religion and culture, and economic, vary from middle to high economic level, muslim, and maluku province. further, even though the coverage of health insurance provided by indonesia’s government was fully funded for any hospital service, it does not replace the existence of topu bara. generally, participants believed in the medical services, but they are also searching for an alternative treatment that did not only focus on the physical problem as they perceived it. it is stated that negative perception makes public attitudes toward complementary medicine negative (agarwal-harding et al., 2015). it has been expressed by a participant that a topu bara healer was able to provide a sense of confidence that they will recover. the spiritual characteristic was a basic that bridged the participant’s expectation as to the bone recovery (mirhadi et al., 2013). this was the less than they got when going to the medical service. conclusions it can be concluded that participants put safety and comfort as a priority when they decide to get help for fracture. pain which is commonly expressed by people with fractures decreases effectively when painkillers are combined with a safe and comfortable atmosphere and work in balance. in topu bara during the healing process, people with fractures experienced holistic care that combined multiple approaches of culture, cure, and care. topu bara as an alternative for fracture healing has been well-developed from generation to generation. the benefits of topu bara as an alternative treatment for fractures have been widespread in various ethnic groups and levels of society in indonesia. this research was conducted in maluku province as a reference for health services for eastern indonesia. further studies are needed to be explored considering cultural values and ethical practices. references agarwal-harding, k. j., meara, j. g., greenberg, s. l. m., hagander, l. e., zurakowski, d., & dyer, g. s. m. (2015). estimating the global incidence of femoral fracture from road traffic collisions. j bone joint surg am., 97(31), 1–9. akhrani, l. a., & ardyaningrum, y. (2019). attitude toward complementary and alternative medicine (cam) as sangkal putung patient satisfaction. atlantis press, 304(acpch 2018), 26–29. https://doi.org/10.2991/acpch-18.2019.6 arie, m. j. h. (2017). fracture treatment by bonesetters in central ghana: patients explain their choices and experiences. tropical jurnal ners http://e-journal.unair.ac.id/jners 201 medicine and international health, 12(4), 564–574. https://doi.org/10.1111/j.1365-3156.2007.01822.x darmawan, r. (2013). pengalaman, usability, dan antarmuka grafis: sebuah penelusuran teoritis. itb journal of visual art and design, 4(2), 95–102. https://doi.org/10.5614/itbj.vad.2013.4.2.1 kautsar, m. (2018). study of health-seeking behavior towards the practice of sangkal putung for bone fracture and the making of medical discrimination in cikendung village, pemalang regency, central java indonesia. kne social sciences, 3(5), 388. https://doi.org/10.18502/kss.v3i5.2345 kemenkes ri. (2018). hasil utama riset kesehata dasar (riskesdas). journal of physics a: mathematical and theoretical, 44(8), 1–200. https://doi.org/10.1088/1751-8113/44/8/085201 maelissa, s. r., lesilolo, o. f., & molle, l. p. (2020). persepsi pasien fraktur terhadap terapi non farmakologi topu bara. molucca medica, 12(4), 32–37. https://doi.org/10.30598/molmed.2020.v13.i2.32 mirhadi, s., ashwood, n., & karagkevrekis, b. (2013). factors influencing fracture healing. trauma, 15(2), 140–155. https://doi.org/10.1177/1460408613486571 mulyono, n. (2017). penelitian praktek pengobatan tradisional patah tulang sistem cimande. meida litbangkes, vii. nadler, s. f., weingand, k., & kruse, r. j. (2014). the physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. pain physician, 7(3), 395–399. https://doi.org/10.36076/ppj.2004/7/395 roma, s. (2013). kualitas hidup klien yang mengalami fraktur ekstremitas bawah dengan pemasangan open reduction internal fixation (orif). journal of chemical information and modeling, 53(9), 1689–1699. sudayasa, i. p., kusumawati, p. a., paddo, j., bittikaka, y., salam, n. m., & sahidin, i. (2018). identifikasi kajian filosofis penyehat tradisional pijat patah tulang. teknologi terapan berbabsis kearifan lokal (snt2bkl), 1(1), 570–580. sugiharto, f., supriyono, s., & rasyad, a. (2016). transfer of knowledge keterampilan pengobatan tradisional pijat sangkal putung. jurnal pendidikan: teori, penelitian, dan pengembangan, 1(9), 1864–1868. https://doi.org/10.17977/jp.v1i9.6862 yuniar, d. p., & nasution, z. (2017). perilaku pemagang pengobatan sangkal putung. jurnal pendidikan : teori, penelitian, dan pengembangan, 2(sangkal putung), 1656–1661. how to cite this article: wabula, l. r., umamity, s., fitriasari, e., lombonaung, e., windari, a. p., and tehupelasury, f. (2022). ‘fracture patient experience in undergoing traditional massage therapy (topu bara) in maluku province: phenomenology study’, jurnal ners, 17(2), pp. 196–201. doi: http://dx.doi.org/10.20473/jn.v17i2.27190 wabula, umamity, fitriasari et al (2022) 202 p-issn: 1858-3598  e-issn: 2502-5791 jurnal ners http://e-journal.unair.ac.id/jners 203 appendix ii. family information needs from nurses' perspectives before and after receiving the training program family needs items (items 15 to 23) information needs not important n (%) slightly important n (%) important n (%) very important n (%) to know about the types of staff members taking care of the patient before after p value 2 (7.1) 0 (0) 10 (35.7) 1 (3.6) 11 (39.3) 11 (39.3) 5 (17.9) 16 (57.1) 0.000 to know how the patient is being treated medically before after p value 2 (7.1) 0 (0) 6 (21.4) 5 (17.9) 14 (50.0) 6 (21.4) 6 (21.4) 17 (60.7) 0.000 to be assured that the best care possible is being given to the patient before after p value 1 (3.6) 0 (0) 0 (0) 2 (7.1) 11 (39.3) 11 (39.3) 16 (57.1) 15 (53.6) 0.000 to have a place to be alone while in the hospital before after p value 11 (39.3) 0 (0) 11 (39.3) 0 (0) 4 (14.3) 9 (32.1) 2 (7.1) 19 (67.9) 0.000 to know precisely what is being done for the patient before after p value 3 (10.7) 3 (10.7) 10 (35.7) 8 (28.6) 7 (25.0) 11 (39.3) 8 (28.6) 6 (21.4) 0.000 to feel accepted by the hospital staff before after p value 1 (3.6) 1 (3.6) 5 (17.9) 4 (14.3) 10 (35.7) 8 (28.6) 12 (42.9) 15 (53.6) 0.000 to have someone to help with financial problems before after p value 0 (0) 0 (0) 11 (39.3) 1 (3.6) 11 (39.3) 12 (42.9) 6 (21.4) 15 (53.6) 0.000 to have a telephone near the waiting room before after p value 6 (21.4) 0 (0) 5 (17.9) 5 (17.9) 13 (46.4) 13 (46.4) 4 (14.3) 10 (35.7) 0.000 to have a pastor visit before after p value 14 (50.0) 2 (7.1) 7 (25.0) 4 (14.3) 3 (10.7) 12 (42.9) 4 (14.3) 10 (35.7) 0.000 fouly (2022) 204 p-issn: 1858-3598  e-issn: 2502-5791 appendix iii. family proximity and assurance needs from nurses' perspectives before and after receiving the training program family needs items (items 24 to 32) proximity or closeness not important n (%) slightly important n (%) important n (%) very important n (%) to talk about the possibility of the patient's death before after p value 3 (10.7) 3 (10.7) 3 (10.7) 8 (28.6) 15 (53.6) 11 (39.3) 7 (25.0) 6 (21.4) 0.000 to have another person with you when visiting the critical care unit before after p value 10 (35.7) 0 (0) 6 (21.4) 9 (32.1) 9 (32.1) 13 (46.4) 3 (10.7) 6 (21.4) 0.000 to have someone concerned with patient health before after p value 2 (7.1) 5 (17.9) 1 (3.6) 10 (35.7) 10 (35.7) 7 (25.0) 15 (53.6) 6 (21.4) 0.000 to be assured it is all right to leave the hospital for a while before after p value 8 (28.6) 0 (0) 5 (17.9) 3 (10.7) 12 (42.9) 14 (50.0) 3 (10.7) 11 (39.3) 0.000 to talk to the same nurse every day before after p value 14 (50.0) 3 (10.7) 7 (25.0) 8 (28.6) 6 (21.4) 10 (35.7) 1 (3.6) 7 (25.0) 0.000 to feel it is all right to cry before after p value 5 (17.9) 10 (35.7) 9 (32.1) 12 (42.9) 9 (32.1) 4 (14.3) 5 (17.9) 2 (7.1) 0.000 to be told about other people that could help with problems before after p value 1 (3.6) 0 (0) 6 (21.4) 7 (25.0) 13 (46.4) 10 (35.7) 8 (28.6) 11 (39.3) 0.000 to have a bathroom near the waiting area before after p value 1 (3.6) 2 (7.1) 4 (14.3) 1 (3.6) 15 (53.6) 17 (60.7) 8 (28.6) 8 (28.6) 0.000 to be alone at any time before after p value 9 (32.1) 0 (0) 10 (35.7) 2 (7.1) 8 (28.6) 8 (28.6) 27 (96.4) 18 (64.3) 0.000 family assurance needs items (items 33 to 39) to be told about transfer plans while they are being made before after p value 7 (25.0) 6 (21.4) 6 (21.4) 5 (17.9) 10 (35.7) 13 (46.4) 5 (17.9) 4 (14.3) 0.000 to be told about someone to help with family problems before after p value 15 (53.6) 4 (14.3) 6 (21.4) 5 (17.9) 4 (14.3) 12 (42.9) 3 (10.7) 7 (25.0) 0.000 to have explanations given that is understandable before after p value 1 (3.6) 0 (0) 3 (10.7) 3 (10.7) 14 (50.0) 11 (39.3) 10 (35.7) 14 (50.0) 0.000 to have visiting hours start on time before after p value 3 (10.7) 0 (0) 10 (35.7) 1 (3.6) 14 (50.0) 12 (42.9) 1 (3.6) 15 (53.6) 0.000 to be told about chaplain services before after p value 3 (10.7) 3 (10.7) 8 (28.6) 8 (28.6) 3 (10.7) 7 (25.0) 4 (14.3) 10 (35.7) 0.000 to help with patient's physical care before after p value 6 (21.4) 0 (0) 9 (32.1) 3 (10.7) 12 (42.9) 15 (53.6) 1 (3.6) 10 (35.7) 0.000 ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 118 beban perempuan penderita hiv/aids dalam perspektif gender (the woman burden of hiv/aids patient in gender perspective) awatiful azza fakultas ilmu kesehatan universitas muhammadiyah jember jl. karimata 49 jember 68121 e-mail: awatiful. azza@yahoo. com abstract introduction:epidemic hiv/aids becomes heavy burden in every country without exception and hardly potency breaks the economic development in developing countries including indonesia. method: the method which use on this research was deskriptif kuantitatif. this condition causes women who generally not guilty exactly very susceptible in infection by hiv/aids and accounts a real heavy burden from disease impact received by it either in social environment and also family. result: most all the psychological experienced of respondents change from lightest storey to heaviest. lack of ability was caused by a lot public still have not comprehended about hiv/aids and more tends to discriminates patient and even asks patient to move. giving of emotion support, psychological, facility, treatment and curative and information support, it's expressed that most of public was less in giving support. discussion: the effort that is must be done by local government kabupaten jember relates to handling of hiv/aids for example prevention and invention of case and manage of patient which has expressed positive of hiv/aids by entangling all society not to restrain from they environment. keywords: the woman burden, hiv/aids, gender perspective pendahuluan epidemi hiv/aids menjadi beban berat setiap negara tanpa kecuali, dan sangat berpotensi menghancurkan pembangunan ekonomi di negara berkembang, termasuk indonesia. dewasa ini jumlah orang yang terinfeksi hiv/aids di dunia mencapai 39,4 juta, dari jumlah tersebut 17,6 juta penderita adalah perempuan. perempuan cenderung berpeluang besar tertular hiv/ aids. data menunjukkan jumlah penularan hiv/aids perhari 14 ribu, dan 6. 000 kasus dialami oleh perempuan (hutapea, 2003). di indonesia pada tahun 2005 jumlah penderita hiv/aids mencapai 9200 penderita baik lakilaki maupun perempuan (convention watch, 2007). sebelumnya penyebaran hiv/aids di indonesia baru terjadi di 28 propinsi, sejak tahun 2006 penyebaran hiv/aids sudah terjadi disemua propinsi. data tentang hiv/aids saat ini, dinas kesehatan kabupaten jember jawa timur menetapkan status merah terhadap penyebaran hiv/aids. status ini ditetapkan karena terus meningkatnya penderita hiv/aids. data yang ditemukan dari tahun 2001 sampai 2007 terdapat 102 penderita hiv/aids dengan jumlah kematian sebanyak enam orang, hal tersebut menempatkan kabupaten jember dalam urutan keenam dari epidemi penyebaran hiv/aids di jawa timur setelah surabaya, malang, banyuwangi, tulungagung, dan sidoarjo. risiko perempuan terinfeksi hiv/aids, 2–4 kali lebih besar dibanding laki-laki. hal tersebut disebabkan oleh bentuk anatomi dari alat kelamin perempuan lebih luas dibanding laki-laki. kemungkinan penularan infeksi dapat melalui sperma saat berhubungan seksual. konsentrasi hiv di dalam sperma yang lebih tinggi kemudian masuk ke dalam cairan vagina saat berhubungan seksual. kondisi ini menyebabkan kaum perempuan yang umumnya tidak bersalah justru sangat rentan terinfeksi hiv/aids (hutapea, 2003). beban perempuan penderita hiv/aids dalam perspektif gender (awatiful azza) 119 faktor yang dapat memperparah kondisi perempuan penderita hiv/aids di antaranya adanya perlakuan diskriminasi, termasuk pendidikan yang kurang memadai, upah yang sangat rendah dan prospek kerja yang tidak berpihak pada perempuan, kekerasan, pelecehan dan eksploitasi yang dilakukan kaum laki-laki. perlakuan yang cenderung diskriminasi tersebut akan menyebabkan perempuan menjadi sangat rentan terhadap hubungan seks yang tidak diinginkan dan tidak aman, baik di dalam maupun di luar pernikahan. selain itu perempuan sering diabaikan dalam mendapatkan akses pengetahuan dan pendidikan tentang seksualitas dan kesehatan seksual, sehingga akan berdampak pada kualitas kesehatan perempuan yang cenderung berisiko terhadap munculnya beberapa penyakit, yang tentunya risiko tersebut juga akan dapat dialami anak-anak yang dilahirkannya. dampak yang ditimbulkan dari hiv/ aids tidak hanya masalah kesehatan, akan tetapi dampak psikososial juga mempunyai andil cukup besar terhadap kesejahteraan perempuan. perempuan yang terkena hiv/ aids, secara psikologi akan mengalami berbagai masalah, mulai dari kecemasan, keraguan, stress dan depresi. tekanan lingkungan yang cenderung diskriminatif akan membuat perempuan kehilangan penghargaan terhadap dirinya. bahaya yang ditimbulkan oleh hiv/aids akan menambah beban berat perempuan akibat stigma masyarakat yang cenderung memojokkan dan mengucilkannya dari lingkungan. stigma pada perempuan dengan hiv/aids selalu dihubungkan dengan perilaku marginal seperti perilaku pekerja seks dan pengguna napza. perempuan yang positif terinfeksi hiv dihadapkan pada kenyataan bahwa anaknya juga positif hiv, hal tersebut dapat menjadi beban ganda yang harus ditanggung oleh perempuan. keadaan ini memberi konsekuensi psikologis yang besar bagi perempuan dengan hiv/aids untuk dapat melihat diri mereka sendiri, yang kemudian akan membawa mereka dalam beberapa kasus pada keadaan depresi, kurang percaya diri dan putus asa. stigma dan diskriminasi yang terkait dengan hiv/aids akan memengaruhi masyarakat dalam merespons keadaan secara konstruktif guna menghadapi dampak yang diakibatkan oleh penyakit ini. stigma dan diskriminasi yang dikaitkan dengan hiv/aids merupakan penghalang utama bagi upaya lanjut dalam pencegahan infeksi dan pelayanan yang memadai, dukungan dan perawatan, serta pengurangan dampak buruk dari infeksi hiv/aids. kebijakan dan dukungan pemerintah serta masyarakat yang berpihak pada perempuan dapat menjadi kekuatan dalam upaya untuk meningkatkan rasa percaya dirinya. kajian mengenai penderita hiv/aids sangat berbeda antara laki-laki dan perempuan. perempuan lebih berat menanggung dampak penyakit yang diterimanya baik dalam lingkungan sosial maupun keluarga yang sebelumnya mungkin tidak pernah terbayangkan akan menderita hiv/aids. bahan dan metode penelitian ini menggunakan pendekatan deskripif kuantitatif dengan tujuan untuk memberikan gambaran tentang beban psikologis dan sosial perempuan penderita hiv/aids dalam perspektif gender. metode kuantitatif adalah prosedur penelitian yang menghasilkan data dekriptif berupa bilangan/numerik dari variabel yang dapat diamati. deskriptif mengidentifikasi suatu peristiwa, variabel, mengembangkan teori, dan operasional dari variabel (burn dan groves, 1991). pendekatan ini digunakan karena dapat memberikan data yang lebih objektif sesuai dengan harapan peneliti, sehingga responden maupun masyarakat yang menjadi sampel dapat mengungkapkan tentang permasalahan yang dialami perempuan penderita hiv/aids. penelitian ini dilakukan di beberapa kecamatan di kabupaten jember jawa timur, terutama diwilayah yang ditemukan kasus hiv/aids, di antaranya wilayah patrang, dan sumbersari. pertimbangan dalam menentukan lokasi penelitian tersebut untuk melihat dukungan yang telah diberikan masyarakat pada penderita hiv/aids. mengkaji kebijakan yang telah dilakukan pemerintah daerah untuk menjawab kecenderungan peningkatan kasus hiv/aids yang menempatkan kabupaten jember dalam jurnal ners vol. 5 no. 2 oktober 2010: 118–126 120 urutan keempat dari epidemi penyebaran hiv/ aids di jawa timur setelah surabaya, malang, dan sidoarjo. sumber data dalam penelitian ini adalah perempuan penderita hiv/aids dan masyarakat yang ada di sekitarnya, selain itu data juga didapatkan dari pelayanan kesehatan dan informan yang terkait. pengumpulan data dilakukan dengan dua cara yaitu pengumpulan data primer dan pengumpulan data sekunder. pengumpulan data primer diperoleh melalui subjek penelitian yaitu perempuan penderita hiv/aids dengan menggunakan kuesioner, dinas kesehatan kabupaten jember maupun rsd dr. soebandi melalui wawancara. data sekunder diperoleh melalui masyarakat yang ada di sekitar perempuan penderita hiv/aids dengan menggunakan kuesioner, data juga diperoleh melalui kontak personal langsung di lapangan maupun menggunakan studi dokumenter. penelitian diawali dengan mengajukan perijinan kepada badan kesatuan bangsa dan perlindungan masyarakat, dan dinas kesehatan kabupaten jember. prosedur p e n g u m p u l a n d a t a d i l a k u k a n s e t e l a h menetapkan partisipan sesuai dengan kriteria. pada pengumpulan data primer, peneliti bekerja sama dengan konselor yang ada di klinik vct rsud dr. soebandi jember. hal tersebut dilakukan untuk memberi rasa nyaman reponden, sehingga responden akan lebih leluasa dalam mengisi kuesioner sesuai dengan kondisi psikologis yang dialaminya saat itu. peneliti memberikan informed concent untuk mendapatkan persetujuan tertulis dari partisipan yang dilakukan dengan membubuhkan tanda tangan di lembar persetujuan yang telah disediakan. pada pengumpulan data sekunder peneliti memilih beberapa masyarakat yang ada di sekitar penderita sebagai sampling untuk mengetahui berbagai reaksi dan stigma yang diberikan terhadap perempuan penderita hiv/aids, selain itu juga untuk mengetahui berbagai bentuk dukungan masyarakat terhadap perempuan penderita hiv/aids. sumber data lain yang dikumpulkan untuk dapat menjawab tujuan peneliti yaitu studi dokumenter yang diperoleh dari dinas kesehatan jember dan komisi penanggulangan aids (kpa), serta wawancara langsung tentang dukungan pemerintah daerah dalam perlindungan perempuan penderita hiv/aids. jumlah sampel pada penelitian ini adalah: data primer data diambil dari penderita hiv/aids yang melakukan kunjungan di klinik vct rsd dr. soebandi jember 60 responden yang diambil dengan tekhnik purposif sampling dalam kurun waktu 3 bulan yang dimulai pada bulan juli–september 2009. data sekunder data diambil dari masyarakat. jumlah sampel yang diambil sebanyak 250 responden yang dipilih secara random dan terbagi pada dua kecamatan yaitu kecamatan patrang dan sumbersari. data dikumpulkan melalui penyebaran kuesioner maupun observasi dan studi dokumenter, maka data perlu diolah untuk menjawab tujuan dari penelitian. tiga tahap analisa data dengan menggunakan metode diskriptif kuantitatif yang pertama yaitu persiapan, melakukan pengecekan kelengkapan kuesioner yang sudah diisi oleh responden, melakukan pengecekan isian data, serta analisa hasil wawancara dan studi dokumenter sebagai data pendukung. kedua adalah tabulasi data, langkah yang dilakukan dalam tabulasi data adalah pemberian skor, dan kode dari data yang sudah terkumpul sehingga memudahkan analisa data. penerapan data sesuai dengan pendekatan penelitian pendekatan yang digunakan pada penelitian ini yaitu pendekatan diskriptif, sehingga peneliti hanya menggunakan persentase untuk menyimpulkan dari data yang sudah dikumpulkan untuk menjawab tujuan penelitian. data yang diperoleh dari wawancara maupun dokumen disajikan dalam bentuk naratif. hasil penelitian ini mengungkapkan bahwa pada dukungan emosi, sekitar 175 (70%) responden kurang memberikan dukungan psikologis dan emosi pada perempuan yang didiagnosis hiv/aids, dan hanya 30% saja masyarakat yang memberikan dukungan. banyak upaya yang dilakukan pemerintah kabupaten jember dalam memberikan bantuan pada penderita hiv/aids, namun karena stigma yang sudah terlanjur melekat dan beban perempuan penderita hiv/aids dalam perspektif gender (awatiful azza) 121 kultur keagamaan yang kuat, maka terkadang program yang dicanangkan pemerintah daerah belum mampu memberikan jalan keluar yang signifikan bagi penderita dan keluarganya. untuk dukungan fasilitas, sebagian responden (55%) mengatakan bahwa mereka tidak mampu memberikan dukungan fasilitas perawatan dan pengobatan selama perempuan menderita hiv/aids, baik berupa sarana prasarana selama perawatan maupun biaya jika dibutuhkan. untuk dukungan informasi, hasil penelitian ini mengungkapkan bahwa sebagian besar masyarakat kurang dalam memberikan dukungan informasi. hanya 46% atau sekitar 116 orang saja dari mereka yang memberikan dukungan informasi pada perempuan penderita hiv/aids. kondisi tersebut disebabkan kurang pahamnya masyarakat tentang penatalaksanaan penderita hiv/aids, hal tersebut dapat dilihat dari status pendidikan responden yang sebagian besar memiliki pendidikan sd dan sma, selain itu responden juga kurang mendapat informasi dari petugas kesehatan/lingkungannya baik berupa penyuluhan maupun demonstrasi langsung tentang perawatan penderita hiv di rumah. hasil penelitian tentang stigma pada p e n d e r i t a h i v / a i d s , m e n g u n g k a p k a n bahwa sekitar 69% atau 173 responden masih memberikan stigma yang buruk dan diskriminasi bagi penderita hiv. stigma tersebut di antaranya bahwa perempuan penderita hiv merupakan orang yang melanggar aturan dan mempunyai perilaku menyimpang, selain itu perempuan penderita hiv/aids harus dijauhi dan sebaiknya tidak boleh keluar rumah agar tidak menularkan penyakitnya pada orang lain. pembahasan aids atau acquired immune defi ciency syndrome, merupakan kumpulan gejala penyakit akibat penurunan sistem imun atau kekebalan tubuh oleh virus hiv (nursalam, 2007). virus hiv terdapat di dalam cairan tubuh yaitu darah, sperma, cairan vagina dan air susu ibu (murni, s, 2003). sistem imun tubuh kita memerangi penyakit dengan berbagai cara. mula-mula diproduksi sel-sel darah putih yang meringkus dan menghancurkan kuman penyakit seperti bakteri, virus dan jamur. limfosit adalah senjata utama dari sistem imun. hiv menyerang sistem imun dengan menyerbu dan menghancurkan sel darah putih, yang sering disebut dengan sel t. hiv cenderung menyerang sel-sel yang mempunyai antigen permukaan cd4, terutama limfosit t4 yang memegang peranan penting dalam mengatur dan mempertahankan sistem kekebalan tubuh. selain limfosit t4, virus juga dapat menginfeksi sel monosit dan makrofag, sel langerhans pada kulit, sel denrit pada kelenjar limfe, makrofag pada alveoli paru, sel retina, sel servick uteri, dan sel mikroglia otak. virus yang masuk ke dalam limfosit t4 selanjutnya mengadakan replikasi sehingga banyak dan akhirnya menghancurkan sel limfosit itu sendiri. kelumpuhan sistem kekebalan tubuh ini mengakibatkan timbulnya berbagai infeksi oportunistik dan keganasan yang merupakan gejala-gejala klinis aids. orang yang terinfeksi hiv/aids akan mengalami beberapa tahapan yaitu asimtomatik, tahap tanpa ada gejala-gejala. pada tahap ini penderita terlihat sehat dan normal, sel darah putih masih dapat mengatasi gangguan dari luar, tetapi penderita dapat menularkan virus itu kepada orang lain. simtomatik, tahap di mana gejala penyakit mulai timbul akibat lemahnya kekebalan tubuh, opportunistik. tahap ini merupakan transisi dari hiv menuju aids, dan gejala klinis minor mulai dapat dilihat. seperti: diare berkepanjangan, batuk 3 bulan lebih, mulai timbul penyakit kulit, berat badan berkurang, tbc, bronkhitis. full blown aids: tahap di mana seseorang sudah kehilangan sistem kekebalan tubuhnya, pada keadaan ini kemampuan penderita untuk bertahan hidup sudah sangat rendah, karena metabolisme tubuh sudah rusak dan hancur. tidak banyak yang dapat dilakukan pada tahap ini. proses transmisi atau penularan hiv dari ibu ke bayi diperkirakan sudah berlangsung sejak bayi dalam kandungan, yakni melalui plasenta, akan tetapi risiko terbesar penularan justru terjadi saat persalinan dan sesudah persalinan. hal ini terjadi karena virus berkembang subur di daerah vagina. saat persalinan, bayi mengalami kontak yang erat dengan vagina sebagai jalan lahir. darah yang dikeluarkan saat persalinan pun akan mengenai tubuh bayi. jika ada luka jurnal ners vol. 5 no. 2 oktober 2010: 118–126 122 pada bayi, virus hiv dari darah ibu bisa masuk melalui luka. penularan hiv pada bayi juga dapat melalui pemberian asi. pemberian susu formula lebih sering direkomendasikan pada ibu pengidap hiv/aids. keadaan ini sekarang sangat sulit dilakukan, harga susu formula yang mahal akan menjadi masalah tersendiri bagi ekonomi keluarga yang tentunya kemiskinan bagi keluarga mempunyai dampak yang sangat besar pada perempuan, belum lagi rendahnya pemahaman tentang kebersihan saat memberikan susu formula yang dapat menyebabkan risiko diare pada bayi. beberapa penderita menampakkan gejala yang menyerupai mononukleosis infeksiosa dalam waktu beberapa minggu setelah terinfeksi. gejala berupa demam, ruamruam, pembengkakan kelenjar getah bening dan rasa tidak enak badan yang berlangsung selama 3–14 hari. sebagian gejala akan hilang meskipun kelenjar getah bening tetap membesar. penderita menunjukkan gejala-gejala infeksi hiv dalam waktu beberapa tahun sebelum terjadinya infeksi atau tumor yang khas untuk aids. gejala tersebut meliputi pembengkakan kelenjar getah bening, penurunan berat badan, demam yang hilang timbul, perasaan tidak enak badan, lelah, diare berulang, anemia, dan thrush (infeksi jamur di mulut) (departemen kesehatan republik indonesia, 2003). manifestasi klinis infeksi hiv dapat disebabkan hiv-nya sendiri (sindrome retroviral akut dimensia hiv), infeksi oportunitis atau kanker yang terkait aids. perjalanan penyakit hiv dibagi dalam tahap-tahap berdasar keadaan klinis dan jumlah cd4 (mansjoer, 2000). gangguan klinis lain yang diakibatkan oleh hiv adalah hiv wasting syndrom berat badan turun lebih dari 10%, diare kronis dan demam lebih dari 1 bulan, yang tidak disebabkan oleh penyakit lain. ensepalopati hiv. gangguan kognitif dan atau disfungsi motorik yang mengganggu hidup seharihari dan bertambah buruk dalam beberapa minggu yang tidak disertai penyakit penyerta lain selain hiv (nursalam, 2007). sampai dengan saat ini penderita hiv/aids selalu mendapatkan stigma yang melekat dalam diri mereka. stigma tentang penderita hiv/ aids lebih cenderung berkonotasi negatif dan memojokkan perempuan. masyarakat menilai bahwa penyakit hiv/aids biasanya dianggap sebagai penyakit yang diderita oleh orang-orang yang melanggar aturan, sebagai perempuan pekerja seks komersial (psk), tidak taat beragama, orang-orang yang dikutuk tuhan dan pendapat lainnya yang relatif sulit dipertanggungjawabkan secara ilmiah, padahal kenyataan yang ada tidak selalu demikian. keadaan ini memberi konsekuensi psikologis yang besar bagi perempuan dengan hiv/aids untuk dapat melihat diri mereka sendiri dan anak yang dilahirkannya, yang kemudian akan membawa mereka dalam beberapa kasus pada keadaan depresi, kurang percaya diri dan putus asa. diskriminasi dan pemberian stigma oleh masyarakat juga akan melanggar hakhak perempuan seperti yang terdapat dalam undang-undang republik indonesia no. 39 tahun 1999 tentang hak asasi manusia terutama pada pasal 3 dan 4. serta undang-undang republik indonesia no. 24 tentang perempuan dan kesehatan, pasal 12 berisi konvensi penghapusan segala bentuk diskriminasi terhadap perempuan (convention watch, 2007). perempuan juga dihadapkan pada kenyataan bahwa anak yang akan dilahirkannya berisiko menderita hiv/aids, tentunya hal itu akan menambah beban perempuan dalam menjalani kehidupannya. perubahan yang terjadi pada perempuan penderita hiv/aids selain secara biologis, perempuan juga rentan secara sosiologisgender. perempuan dianugerahi kodrat untuk melahirkan, kondisi tersebut menyebabkan perempuan mempunyai beban berat terhadap kondisinya maupun keturunannya. pada beberapa kasus, infeksi pada anak berbeda dengan orang dewasa. hiv pada bayi secara langsung dapat menyerang susunan saraf pusat yaitu sumsum tulang belakang dan otak, sehingga dapat menghambat proses pertumbuhan dan perkembangan. permasalahan hiv/aids sangat berbeda dengan penyakit-penyakit lainnya. dampak hiv/aids bukan hanya masalah kesehatan, namun juga bersinggungan dengan sendi-sendi permasalahan psikososial, agama, ekonomi dan budaya. pemberian stigma tertentu terhadap perempuan penderita hiv/ aids, membuat para penderita kehilangan beban perempuan penderita hiv/aids dalam perspektif gender (awatiful azza) 123 haknya untuk diterima dalam masyarakat. produktivitas mereka menurun dikarenakan penolakan lapangan kerja, yang kemudian akan membawa perempuan pada keadaan depresi dan kurangnya rasa percaya diri. diskriminasi terhadap orang dengan hiv/aids atau terhadap orang yang diduga terinfeksi hiv, sangat jelas merupakan pelanggaran hak asasi manusia. hiv/aids dianggap sebagai penyakit yang diderita oleh orang-orang yang melanggar aturan, yang tidak taat beragama, orang-orang yang dikutuk tuhan dan pendapat lainnya yang relatif sulit dipertanggungjawabkan secara ilmiah. stigma dan diskriminasi akan memengaruhi kapasitas masyarakat dalam merespons keadaan secara konstruktif. dampak pemberian stigma dapat menimbulkan rasa malu, bersalah, dan pengucilan terhadap odha, dan juga karena pikiran-pikiran negatif dapat menyebabkan seseorang terpaksa melakukan hal-hal yang dapat merugikan orang lain, misalnya tidak memberikan layanan atau memenuhi hak mereka (pariani dan purwaningsih, 2005). d a m p a k h i v / a i d s d i k a l a n g a n perempuan dapat dipengaruhi secara langsung oleh budaya dan dibentuk secara sosial oleh peranan mereka di dalam masyarakat. budaya patriarkhi memposisikan perempuan sebagai warga kelas dua, apalagi bagi perempuan pengidap penyakit seksualitas (hiv/aids). perempuan ditempatkan dalam kebijakan yang kurang mendukung kondisinya, bahkan seringkali perempuan penderita hiv/aids justru dieksploitasi melalui media. sikap dan nilai budaya yang selama ini dianut masyarakat menganggap ibu rumah tangga tidak menjadi bagian dari kelompok yang rentan terhadap hiv/aids. masyarakat tidak memperhatikan bahwa alat reproduksi perempuan tanpa kesalahannya lebih rentan terhadap infeksi. kondisi kekurangan dari segi pendapatan, kekuasaan dan kekayaan, telah menjadikan perempuan tidak berupaya maksimal untuk menghindarkan diri mereka dari bahaya hiv/aids. perasaan rendah diri perempuan, menjadikan mereka sering mengalami kesulitan untuk melihat hal positif tentang apa yang dilakukan, khawatir akan hidup, dan tidak ingin mengambil risiko, cenderung tidak mendapat pujian karena suksesnya, mengira kegagalan merupakan tanggung jawab mereka, dan bukti baginya telah berbuat dengan kurang baik, merasakan lebih rendah dari orang lain, tidak termotivasi untuk meningkatkan diri, tetapi bertahan dan melawan terhadap kegagalan dari semua perbuatannya. mereka tidak bahagia dan tidak merasa cukup dengan diri sendiri, dan tidak menyesuaikan diri dengan baik, mengalami tekanan, keputusasaan dan bunuh diri (susilo, 1996). ketidakadilan gender terutama di negaranegara berkembang, mengarah pada perilaku berisiko tinggi dalam penularan hiv/aids misalnya, dalam banyak kebudayaan perempuan tidak bebas untuk menolak seks atau melakukan seks aman dengan menggunakan kondom. laki-laki menganggap posisi kekuasaan dan kontrol atas perempuan, meminimalkan jumlah masukan dan persetujuan dari perempuan. perempuan kurang memiliki akses untuk mendapatkan pekerjaan dan pendidikan, sehingga seringkali, seks dengan perdagangan adalah salah satu dari beberapa pilihan bagi perempuan mencoba untuk mendapatkan uang dan dukungan mereka dan anak-anak. p e n g i d a p h i v / a i d s s e b e n a r n y a mengalami tekanan psikologis yang berlapislapis. mereka harus menerima perlakuan yang sangat tidak humanis dari lingkungan sekitar. orang merasa takut bila bertemu atau bahkan bersentuhan dengan penderita hiv/aids (riyanto, 2009). temuan dari penelitian ini, mengindikasikan bahwa hampir semua responden mengalami perubahan psikologis tersebut dari tingkat yang paling ringan sampai yang paling berat dan tergantung sudah berapa lama mereka didiagnosis menderita hiv/aids. respons psikologis tersebut di antaranya adalah ketakutan, kehilangan, duka cita, rasa bersalah, depresi, menolak, cemas, marah, tindakan untuk bunuh diri, kehilangan harga diri, obsesi, dan aspek spiritual. kondisi tersebut di atas diperparah dengan kurangnya penderita mendapatkan dukungan dari lingkungannya. kurangnya kemampuan memberikan dukungan pada perempuan penderita hiv/aids disebabkan bahwa masyarakat masih banyak yang belum memahami tentang hiv/aids baik penularan maupun bagaimana cara merawat penderita selama di rumah. masyarakat lebih jurnal ners vol. 5 no. 2 oktober 2010: 118–126 124 sering mendiskriminasikan penderita dengan menjauhi dan bahkan meminta penderita untuk pindah. stres adalah respons fi siologis, psikologis, dan perilaku dari seseorang untuk mencari penyesuaian terhadap tekanan yang sifatnya internal maupun eksternal. gangguan psikologis merupakan bagian dari kehidupan. apapun yang terjadi pada fisik maupun di sekeliling yang merupakan gelombanggelombang kehidupan, menuntut kita untuk menyesuaikan diri. stres merupakan reaksi awal dari penyesuaian diri tersebut. sedikit stres membuat manusia menjadi waspada dan ini dibutuhkan agar kita mampu memotivasi diri, menyesuaikan diri, dan segera mencari cara untuk mengatasi stres tersebut. masalah yang sering muncul pada psikologis wanita dengan hiv/aids adalah gangguan konsep diri. konsep diri didefi nisikan sebagai ide, fi kiran, kepercayaan, dan pendirian individu yang memengaruhi individu tersebut dalam berhubungan dengan orang lain (stuart dan sunden, 1991). konsep diri dipelajari melalui kontak sosial dan pengalaman berhubungan dengan orang lain. pandangan individu tentang dirinya d i p e n g a r u h i o l e h b a g a i m a n a i n d i v i d u mengartikan pandangan orang lain tentang dirinya. keluarga mempunyai peranan penting dalam konsep diri, pengalaman awal kehidupan dalam keluarga merupakan dasar pembentukan konsep diri. tingkatan dan rentang konsep diri meliputi aktualisasi, konsep diri positif, harga diri rendah pandangan terhadap diri, minder, rasa bersalah, menolak diri, psikosomatis, peragu, gangguan berhubungan, menarik diri, curiga, merusak diri, melukai orang lain. kekacauan identitas: gangguan hubungan interpersonal, merupakan masalah dalam berinteraksi. depersonalisasi perasaan tidak nyata karena ketidakmampuan membedakan stimulus dari luar dengan dalam dirinya. tidak dapat membedakan dirinya dengan orang lain. s t i g m a t i s a s i d a n d i s k r i m i n a s i mengakibatkan orang dengan hiv bukan saja sulit untuk mencari pekerjaan, tetapi juga telah membuat banyak penderita hiv kehilangan pekerjaan, perumahan bahkan menghadapi berbagai hinaan, serta perlakuan yang tidak manusiawi. media sudah banyak melaporkan penderitaan mereka yang disingkirkan oleh masyarakat. kurangnya pengetahuan masyarakat tentang hiv/aids, mengakibatkan terjadinya tindakan diskriminasi. hasil penelitian tentang stigma pada penderita hiv/ aids, mengungkapkan bahwa sekitar 69% atau 173 responden masih memberikan stigma yang buruk dan diskriminasi bagi penderita hiv. stigma tersebut di antaranya bahwa perempuan penderita hiv merupakan orang yang melanggar aturan dan mempunyai perilaku menyimpang, selain itu perempuan penderita hiv/aids harus dijauhi dan sebaiknya tidak boleh keluar rumah agar tidak menularkan penyakitnya pada orang lain. h i v m e r u p a k a n e p i d e m i y a n g m e n g a n c a m k e s e h a t a n d a n k e h i d u p a n generasi penerus bangsa, yang secara langsung membahayakan perkembangan sosial dan ekonomi, serta keamanan negara. hasil penelitian ini mampu mengungkapkan adanya upaya yang telah dilakukan pemerintah daerah kabupaten jember berkaitan dengan penanganan hiv/aids. upaya tersebut meliputi pencegahan dan penemuan kasus, serta penatalaksanaan penderita yang sudah dinyatakan positif hiv/aids yaitu pencegahan ada beberapa upaya yang dilakukan yaitu: intervensi perubahan perilaku, manajemen infeksi menular seksual (ims), dan penemuan kasus dengan membuka klinik vct dan klinik manajemen infeksi menular seksual (ims), perawatan, dukungan dan pengobatan odha, monitoring dan surveilans hal yang paling penting dari semua upaya yang dilakukan pemerintah adalah penyelarasan serta keseimbangan antara pencegahan penularan hiv/aids dan pengembangan sikap empati serta rasa persaudaraan antarsesama tanpa diskriminasi harus seiring sejalan dengan kondisi masyarakat sekitar. simpulan dan saran simpulan perbedaan kondisi dan posisi perempuan terhadap laki-laki tersebut menempatkan perempuan berada dalam kondisi dan posisi yang lemah karena sejak semula sudah dipolakan. adanya diskriminasi dalam budaya adat atau beban perempuan penderita hiv/aids dalam perspektif gender (awatiful azza) 125 karena lingkungan keluarga, masyarakat yang tidak mendukung adanya kesetaraan dan kemandirian juga sangat dirasakan oleh perempuan. keadaan tersebut di atas berdampak pada respons psikologis perempuan disaat mereka dinyatakan positif menderita hiv/aids. perempuan pengidap hiv/aids sebenarnya mengalami tekanan psikologis yang berlapis-lapis. setelah berkutat pada penyakit, mereka harus menerima perlakuan yang sangat tidak humanis dari lingkungan sekitar. upaya yang telah dilakukan pemerintah daerah kabupaten jember berkaitan dengan penanganan hiv/aids. upaya tersebut meliputi pencegahan dan penemuan kasus, s e r t a p e n a t a l a k s a n a a n p e n d e r i t a y a n g sudah dinyatakan positif hiv/aids yaitu pencegahan meliputi intervensi perubahan p e r i l a k u , m a n a j e m e n i n f e k s i m e n u l a r seksual (ims), untuk penemuan kasus dibuka klinik vct dan klinik manajemen infeksi. perawatan, dukungan dan pengobatan odhameliputipengobatan anti retroviral (art), perawatan dan pengobatan paliatif, mempunyai pelayanan vct. pencegahan dan pengobatan infeksi oportunistik, bekerjasama dengan rumah sakit dan tergantung pada penyakit penyerta yang diderita pasien hiv/ aids. dukungan psikologis dan sosio ekonomi. bekerja sama dengan lintas sektor baik tokoh masyarakat maupun dinas sosial terkait. pendampingan yang dilakukan oleh puskesmas di mana penderita berdomisili. monitoring dan surveilans. saran saran pada penelitian yaitu meningkatkan pengetahuan dan fungsi keluarga untuk pendampingan dan fasilitator bagi perempuan penderita hiv/aids, perlu meningkatkan keterlibatan tokoh masyarakat dan pemuka a g a m a d a l a m m e m b a n t u m e m b e r i k a n motivasi, komunikasi dan edukasi yang dapat meningkatkan kesadaran masyarakat dalam upaya mencegah penularan hiv/aids dan mengurangi reaksi masyarakat terhadap stigma dan diskriminasi terhadap penderita hiv/ aids terutama perempuan, bantu penderita untuk meningkatkan harga dirinya dengan pendampingan dan membentuk kelompok terapi, sehingga dapat meminimalkan masalah psikologis yang tentunya dapat meningkatkan koping mekanisme serta memperbaiki status imun dan yang tidak kalah penting dapat membantu sesama penderita dalam melewati masa-masa sulit pada awal diagnosis, perlu upaya yang lebih giat dalam meningkatkan peran serta pemerintah pusat dan daerah sehingga mampu melampaui cakupan target program yang telah ditetapkan dengan bekerja sama lintas program dan sektor, serta keterlibatan tokoh masyarakat dan keluarga penderita, perlunya meningkatkan pengetahuan tentang hiv/aids sejak bangku sekolah dasar (sd) agar bisa menimbulkan kesadaran tentang penyakit ini sejak dini. kepustakaan antoni, b., 2009. anti stigma dan diskriminasi. yayasan lembaga sabda (ylsa). adriana, dkk., 1998. hak reproduksi perempuan yang terpasung. jakarta: pustaka sinar harapan bekerja sama dengan pusat kajian wanita universitas indonesia dan the ford foundation. anis, m., 2005. meningkatnya kekerasan terhadap perempuan, (online), (http:// www. mailarchive. com.,diakses tanggal 11 februari 2009). anita, hendartini dan saparinah, 2006. implementasi pasal 12 undang-undang no. 7 tahun 1984 pelayanan kehamilan, persalinan dan pascapersalinan. yogyakarta: surviva paski, nitiprayan. budianto, m. dkk., 2002. analisis wacana: dari linguistik sampai dekonstruksi. yogyakarta: kanal. convention watch, 2007. hak azasi perempuan instrumen hukum untuk mewujudkan keadilan gender. jakarta: yayasan obor indonesia. departemen kesehatan republik indonesia, 2003. pedoman nasional perawatan, dukungan dan pengobatan bagi odha. buku pedoman untuk petugas kesehatan dan petugas lainnya. jakarta: ditjen ppm dan pi, depkes. ekosusilo, t., 1999. pedoman penulisan karya ilmiah. semarang: effhar offset jurnal ners vol. 5 no. 2 oktober 2010: 118–126 126 h a d i , t. , 2 0 0 7 . h a k r e p ro d u k s i d a n ketidakadilan gender, (online), (http:// www. pikiran-rakyat. com, diakses tanggal 23 januari 2009). hudatoriq, 2006. stop-aids, (online), (http:// www. hudatoriq. web., diakses tanggal 20 september 2007). hutapea, r., 2003. aids dan pms dan perkosaan. jakarta: rineka cipta. lily, vi, 2004. transmisi hiv dari ibu ke anak. majalah kedokteran indonesia. merawati, 2003. workshop: tak mudah menghapus stigma dan diskriminasi, (online), (http://www. indomedia com/ bpost/htm., diiakses tanggal 20 juli 2009). metro balikpapan, 2007. mencegah hiv/aids dengan komitmen terpadu, (onlie), (http://www. metrobalikpapan. co. id., diakses tanggal 20 september 2007). murni, s, 2003. hidup dengan hiv/aids seri buku kecil. jakarta: yayasan spiritia. najlah, n., 2004. perempuan-dogma dan hiv/aids, (online), (http://najlah. blogspot. com, diakses tanggal 24 oktober 2007). nasution, t., 2004. buku penuntun membuat tesis, skripsi, disertasi, makalah. jakarta: bumi aksara. nursalam dan kurniawati, 2007. asuhan keperawatan pada pasien terinfeksi hiv/aids. jakarta: salemba medika. pariani dan purwaningsih, 2005. kongres nasional i pni: pni sebagai pendekatan holistik dalam menanggulangi penyakit di era mendatang. surabaya: gideon offset printing. riyanto, 2009. faktor-faktor yang memengaruhi kesehatan mental penderita hiv. skripsi tidak dipublikasikan. fpsi. s u s i l o , k . , 1 9 9 6 . p e n y a k i t h u b u n g a n seksual dan hiv/aids dari perspektif perempuan. program seri lokakarya kesehatan perempuan. jakarta: ylki the ford foundation. syaiful, p., 1999. pers meliput aids. jakarta: pustaka sinar harapan. the american psycological association, 2001. publication manual of the american psychologikal association. (5th ed). washington, dc: american psycologikal assosiation. who, 1996. petunjuk penatalaksanaan perawatan untuk orang-orang terinfeksi hiv. dep. kes ri dir. jend ppm dan plp. _____, 2007. dua puluh tahun penanganan hiv/aids diakui belum maksimal, (online), (http://www. media-indonesia. com., diakses tanggal 12 agustus 2009). ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 164 tingkat stres kerja dan perilaku caring perawat (work stress level and caring behaviour of nurses) retno lestari*, kumboyono*, luthfi a dyta* *jurusan keperawatan fakultas kedokteran universitas brawijaya, jl. veteran malang 65145 e-mail: retno.lestari98@gmail.com abstract introduction: a nurse who experience burnout feelings will infl uence their motivation, and quality performance. this situation is probably affecting a decline in work quality towards the caring behaviour demonstrated by nurses to their patiens, particularly for a nurse who are working in the long-stay installation room facing directly to patient's problems. the purpose of this research is to identify the work stress level of nurse towards the nurse's caring behaviour in the long-stay installation room (irna) in general hospital in malang. method: this research used descriptive – correlational, the sampling was non probability purposive sampling with 93 nurses as the corresponds. the data was analyzed by operating correlation pearson, with a signifi cance of p < 0.05. result: the result found that there was a substantial correlation between the work stress level and the nurse's caring behaviour with p = 0.008 and r = -0.274, and it was a negative correlation. discussion: it means that when the stress level of nurses will declined, the nurse's caring behavior automatically will be amplifi ed. conversely, if the stess level of nurses intensively increased, the nurse's caring behaviour become decreased. thus, this research is needed to be analyzed further in order to asses the quality of caring behaviour by expanding the connected indicator and variable. it is aimed to improve the professionalism and quality of nurses in giving the best service to patients this research need to be continued further in order to asses the quality of nurse's caring behavior by expanding the variable, which is related to internal factors, such as knowledge, perception, emotion, ect and also connected to external factors, such as environment, both physically and non physically like: climate, human being, social economic, culture and ect. keywords: stress level of work, the nurse's caring behaviour pendahuluan perilaku caring menurut watson (1979) berfokus pada human science dan human care yang dilaksanakan berdasarkan 10 carative faktor yaitu pembentukan nilai humanistikaltruistik, menanamkan kepercayaan dan harapan, mengembangkan sensitivitas pada diri sendiri dan orang lain, membangun hubungan saling membantu dan percaya, meningkatkan dan menerima pengekspresian perasaan baik positif maupun negatif, menggunakan metode pemecahan masalah yang sistematik dalam pengambilan keputusan, meningkatkan pengalaman belajar dan mengajar interpersonal, menyediakan dukungan, melindungi dan atau memperbaiki lingkungan mental, fi sik, sosiokultural dan spiritual, membantu memenuhi kebutuhan dasar manusia, menghargai kekuatan eksistensial dan fenomenologikal. s t r e s a d a l a h f e n o m e n a y a n g memengaruhi semua dimensi dalam kehidupan seseorang (potter dan perry, 2005). stres kerja yang terjadi dapat menimbulkan dampak secara langsung maupun tidak langsung terhadap aspek fi sik dan psikologis (istijianto, 2005). pekerjaan seorang perawat merupakan pekerjaan yang memiliki stres yang tinggi, karena dalam bekerja, perawat berhubungan langsung dengan berbagai macam pasien dengan diagnosa penyakit dalam respons yang berbeda-beda (ilmi, 2003). tingkat stres kerja dan perilaku caring perawat (retno lestari) 165 tingginya stres yang dialami perawat dalam bekerja menjadikan perawat jenuh dan bosan, akhirnya berpengaruh terhadap produktivitas kerja dan penurunan kinerja perawat (hudak dan gallo, 1997). perawat yang bekerja di ruang rawat inap di rumah sakit mengeluhkan adanya beban kerja yang tinggi. beberapa perawat mengeluhkan seringnya terjadi keluhan dari pasien. hal ini didukung dengan data mengenai keluhan pasien bulan januari sampai november tahun 2007 di rumah sakit malang menunjukkan bahwa keramahan, kesabaran, perhatian perawat masih sering dikeluhkan pasien. kepekaan, kecepatan dan ketepatan menaggapi permasalahan pasien juga masih kurang (laporan umpan balik kepuasan pelanggan rumah sakit dr. saiful anwar malang januari–november 2007). oleh karena itu sikap dan perilaku perawat sangat memengaruhi kondisi dan respons kepuasan pasien. bahan dan metode penelitian ini merupakan penelitian deskriptif korelasional, dengan metode pendekatan penelitian adalah "cross sectional" jumlah sampel penelitian yang digunakan dalam penelitian adalah 93 orang dengan menggunakan instrument berupa kuesioner stres kerja dan perilaku caring perawat. analisis data yang digunakan adalah uji statistik pearson dengan derajat kemaknaan p ≤ 0 , 0 5 a r t i n y a a d a h u b u n g a n y a n g bermakna. hasil hasil penelitian ini menunjukkan bahwa rerata untuk tingkat stres kerja perawat adalah 13 yang menunjukkan tingkat stres ringan, sedangkan untuk perilaku caring perawat menunjukkan rerata 70 yang menunjukkan perilaku caring cukup baik. analisa data dengan menggunakan uji korelasi pearson (product moment), menunjukkan bahwa antara tingkat stres kerja perawat dengan perilaku caring perawat di instalasi rawat inap rumah sakit ada korelasi dengan (r = –0,274 dan p = 0,008) yang sifnifi kan (p < 0,05) dengan arah korelasi yang negatif. artinya, semakin tinggi tingkat stres kerja perawat dalam menjalankan tugasnya sebagai perawat maka perilaku caring yang mereka tunjukkan cenderung semakin kurang baik, begitu juga sebaliknya semakin rendah tingkat stres kerja perawat maka semakin baik perilaku caring perawat yang diberikan pada pasien. tabel 1. deskripsi statistik tingkat stres kerja perawat variabel min-maks mean median 95% ci stres kerja 1-29 12,8280 13 11,5241–14,1318 tabel 2. diskripsi statistik perilaku caring perawat variabel min-maks mean median 95% ci perilaku caring perawat 4-97 70,9677 72 67,5183–74,4172 tabel 3. deskripsi rerata nilai tingkat stres kerja perawat dan perilaku caring perawat jumlah skor keterangan stres kerja perawat perilaku caring perawat stres kerja perawat perilaku caring perawat rerata 13 70 ringan cukup baik jurnal ners vol. 5 no. 2 oktober 2010: 164–170 166 pembahasan stres kerja adalah perasaan tertekan yang dialami oleh karyawan dalam menghadapi pekerjaan atau dengan kata lain adalah sesuatu yang terlihat sebagai ancaman baik nyata maupun imajinasi, di mana persepsi berasal dari perasaan takut atau marah. ditempat kerja, perasaan ini dapat muncul berupa sikap pesimis, tidak puas, produktivitas rendah dan sering tidak hadir. emosi, sikap dan perilaku yang memengaruhi stres dapat menimbulkan masalah kesehatan, namun ketegangan dapat dengan mudah muncul akibat kejenuhan yang timbul dari beban kerja yang berlebihan. pada kenyataannya, setiap pekerjaan memiliki tingkat tantangan dan kesulitan yang berbedabeda. manajemen stres kerja yang efektif dapat mempertahankan rasa pengendalian diri dalam lingkungan kerja, sehingga beberapa urusan akan diterima sebagai tantangan bukan ancaman (national safety council, 2003). hasil penelitian yang dilakukan tentang variabel stres kerja perawat dalam memberikan perilaku caring, dapat diketahui bahwa perawat di instalasi rawat inap rumah sakit mempunyai tingkat stres kerja secara fisik dan psikologis yang tergolong ringan. hal ini mengindikasikan bahwa mekanisme koping perawat di instalasi rawat inap tergolong baik dan mampu mengendalikan serta mengatasi stres yang muncul pada saat bekerja, sehingga dalam memberikan perilaku caring pada pasien tergolong baik. sumber data yang telah diolah didapatkan bahwa dari 93 perawat yang menjadi responden 100% mengalami stres yang tergolong ringan baik secara fi sik dan psikologis. dari data juga ditunjukkan di mana 95% confi dence interval titik terendah adalah 11,5241 dan titik tertinggi adalah 14,1381. hal tersebut tentunya tidak terlepas dari usia perawat yang juga dalam segi psikologis berpengaruh terhadap sikap dan perilaku, karena berhubungan dengan karakteristik usia dan tugas perkembangannya. dalam penelitian ini kategori usia yang digunakan adalah usia dewasa awal (20–30 tahun) dan usia dewasa (30–65 tahun). dari data hasil penelitian didapatkan bahwa jumlah usia dewasa awal adalah 47 (51%) perawat dan usia dewasa adalah 46 (49%) perawat. dengan data tersebut menujukkan sebagian besar perawat yang berada di instalasi rawat inap rumah sakit adalah yang berusia dewasa awal, di mana dewasa awal (20–30 tahun) mempunyai karakteristik yaitu merupakan usia produktif, masa pengaturan, masa komitmen dan adanya kemampuan untuk menyatukan identitas diri dengan identitas orang lain tanpa ketakutan kehilangan identitas itu. sedangkan untuk tugas perkembangannya yaitu pada dewasa awal merupakan masa bekerja, mulai membina keluarga, mengambil tanggung jawab sebagai warga negara. berdasarkan data tersebut menunjukkan, bahwa perawat di instalasi rawat inap rumah sakit mempunyai kemampuan untuk menghadapi segala permasalahan yang muncul sebagai suatu stresor yang akan memengaruhi perilaku caring pada pasien. sedangkan untuk masa dewasa mempunyai karakteristik yaitu merupakan masa transisi masa berbahaya dan masa stres. perawat yang menjadi responden juga berasal dari berbagai macam latar belakang seperti status pendidikan terakhir menunjukkan bahwa 5 (5%) perawat adalah s1 dan 88 (95%) perawat adalah d3. pada tingkat pendidikan ini menunjukkan sebagian besar adalah berpendidikan sebagai d3, di mana d3 keperawatan merupakan termasuk jenjang pendidikan tingkat profesional pemula, karena ciri-ciri perawat profesional adalah lulusan pendidikan tinggi keperawatan, minimal diploma tiga keperawatan (d3), mampu melaksanakan asuhan keperawatan berdasarkan pendekatan proses keperawatan, melaksanakan asuhan keperawatan sendiri, mentaati kode etik keperawatan serta mampu mengembangkan ilmu pengetahuan dan teknologi keperawatan (perguruan tinggi mh thamrin, 2007). dari data dan karakteristik tersebut menunjukkan bahwa sebagian besar perawat sudah memiliki tingkat pendidikan yang tinggi, sehingga berpengaruh terhadap pola pikir, sikap dan tindakan. sedangkan untuk masa kerja menunjukkan perawat yang bekerja >3 tahun sebanyak 72 (77%) perawat dan 21 (23%) perawat bekerja sekitar 1–3 tahun. pengkategorian lama kerja tersebut berdasarkan pada peningkatan jenjang tingkat stres kerja dan perilaku caring perawat (retno lestari) 167 karir perawat yaitu terdapat perawat klinik 1, perawat klinik 2, perawat klinik 3, perawat klinik 4 dan perawat klinik 5. untuk perawat yang tingkat penddidikannya d3 (diploma) maka untuk naik ke perawat klinik 2 harus mengikuti ujian kompetensi apabila sudah bekerja selama tiga tahun, begitu juga untuk naik ke tingkat selanjutnya. sedangkan untuk perawat dengan tingkat pendidikan s1 untuk menjadi perawat klinik 2 hanya dengan masa kerja 1 tahun bisa mengikuti ujian kompetensi kenaikan tingkat, (hamid, 2004). dan dari data hasil penelitian berdasarkan karakteristik lama kerja menunjukkan bahwa sebagian besar perawat instalasi rawat inap rumah sakit lama kerjanya adalah >3 tahun, dan hal tersebut menunjukkan bahwa jenjang karir untuk perawat sudah mencapai perawat klinik 2. di mana kualitas kerjanya sudah mencapai jenjang karir yang mampu mengatasi, mengendalikan dan mengantisipasi timbulnya stres saat memberikan perilaku caring pada pasien, sehingga dapat menurunkan angka terjadinya keluhan pasien. d a t a s t a t u s k a r y a w a n r e s p o n d e n menunjukkan bahwa 25 (27%) perawat bekerja sebagai honorer dan 68 (73%) perawat sebagai pekerja tetap (pns). data di atas memberikan makna bahwa status karyawan berhubungan dengan jabatan seseorang dalam suatu hirarki struktur keorganisasian yaitu studi menunjukkan semakin tinggi urutan organisasional posisi seseorang, maka semakin tinggi statusnya dalam lembaga tersebut, semakin tinggi status seseorang akan semakin tinggi penghargaan diri seseorang, dan semakin tinggi harga diri seseorang, maka semakin baik kesehatan mental dan fi sik seseorang (gillies, 1996), selain itu menurut charles (1992) perawat dalam tingkat yang berbeda menggunakan strategi koping yang berbeda. pernyataan di atas dapat disimpulkan bahwa status karyawan berhubungan dengan kondisi mental dan fi sik seseorang sehingga berpengaruh pada kemampuan seseorang untuk beradaptasi terhadap segala permasalahan atau stres yang dialami, dan menunjukkan bahwa perawat di instalasi rawat inap rumah sakit banyak yang mampu mengendalikan segala permasalahan dan stres yang terjadi karena didukung oleh kesehatan mental dan fi sik yang adekuat. b e r d a s a r k a n d a t a j e n i s k e l a m i n responden menunjukkan bahwa perawat laki-laki berjumlah 36 (39%), sedangkan perawat perempuan berjumlah 57 (61%). data jenis kelamin menunjukkan bahwa jenis kelamin berkorelasi dengan daya tahan dalam menghadapi stres, yaitu menurut jacken (2005) terdapat perbedaan respons fisiologis yang ditunjukkan antara laki-laki dan perempuan terhadap terjadinya stres, yaitu pada laki-laki stres mendorong sistem saraf simpatetik dan menyebabkan tingginya kortisol. sedangkan pada perempuan stres lebih banyak mendorong mekanisme vagus yang terkait dengan sistem saraf parasimpatetik dengan respons rileks, dan mengeluarkan lebih banyak oksitosin (hormon penenang yang muncul bersamaan dengan estrogen) dan endorphin di dalam otak yang menghambat respons fi ght or fl ight. dari pernyataan di atas dapat disimpulkan bahwa pada perempuan lebih bisa bertahan terhadap stres daripada laki-laki. dari data tersebut diketahui bahwa perawat yang terbanyak adalah perawat perempuan, di mana pada perempuan lebih bisa menghadapi stres dengan tenang sehingga tidak menimbulkan tingkat stres yang tinggi. mc farlane (1976) mengatakan caring merupakan suatu aktivitas yang membantu secara berurutan. leininger (1981) mengatakan bahwa caring merupakan suatu yang bersifat bantuan ( assistive), dukungan ( supportive) atau tindakan fasilitatif untuk individu atau kelompok lainnya dalam mengantisipasi kebutuhan untuk menjadi lebih baik/cara hidupnya. griffi n (1983) mengatakan bahwa caring adalah suatu aspek aktivitas tetapi juga menegaskan sikap dan perasaan yang menyokongnya (kyle, 1995). dari pengertian di atas dapat disimpulkan bahwa caring adalah suatu aktivitas membantu orang lain disertai sikap peduli, memberikan dukungan serta rasa hormat dan menghargai orang yang dibantu. h a s i l p e n e l i t i a n y a n g d i l a k u k a n mengenai variabel perilaku caring perawat di instalasi rawat inap rumah sakit diketahui bahwa perawat dalam memberikan perilaku caring tergolong baik, yang ditunjukkan dari jurnal ners vol. 5 no. 2 oktober 2010: 164–170 168 data yaitu 40 (43,01%) perawat yang menjadi responden hal tersebut karena didukung oleh berbagai faktor di antaranya pengalaman perawat dalam profesi keperawatan yang sudah banyak ditunjukkan oleh adanya data status karyawan dan masa kerja, karena berdasarkan american nurse association (ana) 1965 bahwa komponen caring yaitu caring for kegiatan dalam memberikan asuhan keperawatan atau prosedur keperawatan membantu memenuhi kebutuhan dasar. caring about kegiatan yang berkaitan dengan berbagi pengalaman. selain itu, menurut teori perilaku ajzen (1985) yang menentukan ketekunan dan perilaku tertentu adalah keyakinan, dan keyakinan itu berasal dari pengalaman dengan perilaku yang bersangkutan di masa lalu dan dipengaruhi oleh adanya informasi yang tidak langsung. sedangkan sekitar 35 (37,63%) perawat, perilaku caring yang ditunjukkan tergolong cukup baik, dan perilaku caring yang tergolong kurang baik terjadi pada sekitar 18 (14,35%) perawat. perilaku caring yang kurang baik itu dipengaruhi adanya beban kerja yang terlalu tinggi hal itu diperkuat dengan adanya keluhan perawat di instalasi rawat inap rumah sakit malang terhadap adanya beban kerja yang tinggi, sehingga banyak keluhan pasien di instalasi rawat inap tentang keramahan, kesabaran, perhatian perawat yang masih kurang (laporan umpan balik kepuasan pelanggan rumah sakit dr. saiful anwar malang 2007). melalui uraian di atas, menunjukkan bahwa dapat diketahui perilaku caring yang ditunjukkan oleh perawat di instalasi rawat inap rumah sakit tergolong baik dengan data yang berasal dari tiap responden menunjukkan 40 (43%) perawat berperilaku caring baik. hal ini mengindikasikan selain perawat memiliki tingkat stres yang ringan juga mampu bersikap baik dalam berperilaku caring pada pasien, sehingga mampu melaksanakan tugas dan kewajibannya secara profesional sesuai dengan kemampuan dan skill yang berkualitas. sehingga dengan perilaku caring yang diberikan dapat meningkatkan kepuasan pasien terhadap pelayanan yang diberikan dan menurunkan tingkat keluhan pasien. teori mengenai stres kerja menunjukkan bahwa faktor penyebab atau sumber stres kerja adalah faktor internal dan eksternal, faktor internal terdiri dari pendidikan, motivasi, pengetahuan, hubungan interpersonal, sikap dan perilaku, kreativitas dan kondisi kesehatan dalam bekerja. sedangkan faktor eksternal adalah lingkungan kerja, tingkat penghasilan, jaminan sosial manajemen, efi siensi tenaga kerja, kesempatan berprestasi dan teknologi. stresor yang ada akan mengakibatkan terjadinya stres pada seseorang apabila mekanisme kopingnya tidak mampu beradaptasi terhadap stresor, dan berpengaruh pada kondisi fi sik dan psikologis orang tersebut. selain itu stresor yang muncul akan memengaruhi perilaku caring yang diberikan pada pasien yang merupakan kewajiban dalam melaksanakan pekerjaan sebagai perawat. sedangkan mengenai perilaku caring dipengaruhi oleh berbagai faktor yaitu faktor internal dan faktor eksternal. faktor internal yaitu pengetahuan, persepsi, emosi, motivasi dan sebagainya yang berfungsi untuk mengolah rangsangan dari luar dan faktor eksternal meliputi lingkungan sekitar, baik fi sik maupun non fi sik seperti: iklim, manusia, sosial, ekonomi, kebudayaan dan sebagainya (notoatmodjo, 1997). adanya hubungan antara tingkat stres kerja perawat terhadap perilaku caring perawat yaitu menurut gray-toft dan anderson (1981) dalam charles (1992), menyatakan bahwa perawat yang tidak mampu menghilangkan stres akan berdampak pada menurunnya penampilan kerja dan memburuknya pelayanan terhadap pasien. dalam pelayanan kesehatan, perawat yang mengalami stres berat akan mengalami kejenuhan dan kehilangan motivasi dalam bekerja. tingginya stres yang dialami perawat dalam bekerja menjadikan perawat jenuh dan bosan, akhirnya berpengaruh terhadap produktivitas kerja dan penurunan kinerja perawat (hudak dan gallo, 1997). menurut survei ppni tahun 2006, sekitar 50,9% perawat yang bekerja di empat provinsi di indonesia mengalami stres kerja, sering pusing, tidak bisa istirahat karena beban kerja yang terlalu tinggi dan menyita waktu, serta gaji rendah tanpa dibarengi insentif yang memadai tapi keadaan tingkat stres kerja dan perilaku caring perawat (retno lestari) 169 yang paling memengaruhi stres perawat adalah kehidupan kerja (hamid, 2006). penelitian yang dilaksanakan oleh yustina kristianingsih mengenai hubungan perilaku caring perawat dan tingkat kepuasan di ruang bedah dalam rsk budi rahayu blitar di mana hasil penelitiannya menunjukkan bahwa perilaku caring mempunyai hubungan yang positif terhadap kepuasan pasien. selain itu berdasar pada penelitian yang dilakukan oleh henida mengenai hubungan tingkat stres kerja dengan kinerja perawat di ruang rawat inap rumah sakit islam malang menunjukkan adanya hubungan yang kuat antara tingkat stres kerja terhadap kinerja perawat. hasil analisa data dan hasil pengujian dengan menggunakan uji korelasi pearson, teori dan hasil penelitian sebelumnya, menunjukkan hasil bahwa, antara tingkat stres kerja dengan perilaku caring perawat di instalasi rawat inap rumah sakit mempunyai hubungan yang signifi kan (bermakna) dan sesuai dengan teori yang ada dan sejalan dengan penelitian sebelumnya. selain itu, perilaku caring yang diberikan perawat pada pasien juga tergantung pada lingkungan di mana perawat tersebut bekerja, karena dengan lingkungan kerja yang nyaman merupakan hal yang menentukan dan kekuatan yang lebih besar bagi seorang perawat untuk berperilaku caring. sehingga apabila seseorang merasa tertekan dan merasa tidak nyaman terhadap lingkungan di mana orang tersebut bekerja maka akan menimbulkan stres kerja yang berdampak pada penurunan kualitas dan mutu pelayanan keperawatan yang profesional. emosi, sikap dan perilaku yang memengaruhi stres dapat menimbulkan masalah kesehatan baik secara langsung, personal, interaktif, perilaku sehat dan perilaku sakit (taylor, 1991). stres yang disebabkan oleh pekerjaan akan berpengaruh terhadap hasil kerja perawat tersebut dalam melaksanakan pekerjaannya. dengan menyadari bahwa dalam setiap pekerjaan, dalam kenyataannya memiliki tingkat kesulitan dan tantangan yang berbedabeda, maka setiap perawat di instalasi rawat inap rumah sakit akan menyikapi dan memandang segala hal yang bersifat negatif tanpa menimbulkan suatu beban dan tekanan yang berat sehingga mereka terhindar dari stres. selain itu, penerapan manajemen rumah sakit tentang lingkungan kerja perawat yang efektif akan mempertahankan rasa pengendalian diri dalam lingkungan kerja, sehingga beberapa hal yang bersifat negatif dianggap sebagai suatu tantangan. selain itu mekanisme koping perawat yang bisa beradaptasi terhadap segala tekanan yang negatif akan mampu menghindarkan perawat dari stres kerja yang berdampak pada kualitas perilaku caring perawat. simpulan dan saran simpulan tingkat stres kerja dengan perilaku caring perawat di instalasi rawat inap rumah sakit mempunyai hubungan yang signifi kan. hasil dari nilai koefi sien determinan dalam penelitian ini 7,5%. interperetasinya menunjukkan bahwa variabel tingkat stres kerja hanya 7,5% yang memengaruhi perilaku caring perawat, sedangkan 92,5% dipengaruhi oleh variabel lain. saran menyusun program kegiatan berupa pelatihan peningkatan motivasi bagi perawat dan memfasilitasi adanya diskusi dengan tim kesehatan lain dalam rangka menurunkan tingkat stres kerja perawat dan pengaturan mengenai pelaksanaan kerja perawat untuk lebih menekankan pelaksanaan caring dalam merawat pasien sehingga dapat memberikan pelayanan yang terbaik bagi pasien. dibuat suatu sistem penghargaan dan kontrol terhadap pelayanan yang diberikan oleh perawat pada pasien apakah perawat sudah berperilaku caring atau belum. berdasarkan dokumentasi tersebut akan diketahui mengenai tingkat kualitas perilaku caring yang dilaksanakan oleh perawat. kemudian perawat akan memperoleh penghargaan berupa insentif yang sesuai dengan pelayanan keperawatan yang diberikan. bagi penelitian selanjutnya menilai kualitas perilaku caring dengan selain dengan koesioner juga menggunakan metode observasional, dengan teknik penelitian kualitatif untuk memperoleh data yang lebih jurnal ners vol. 5 no. 2 oktober 2010: 164–170 170 signifikan dan menilai kualitas perilaku caring yang diberikan oleh perawat dengan memperluas variabel yaitu variabel yang memengaruhi kualitas perilaku caring berupa adanya adanya faktor eksternal meliputi lingkungan sekitar, baik fisik maupun non fi sik seperti: iklim, manusia, sosial, ekonomi, kebudayaan dan sebagainya. kepustakaan ajzen, i., 1985. from intentions to actions: a theory of planned behavior. in j. kuhl and j. beckman (eds.), action-control: from cognition to behavior (pp. 11– 39). heidelberg, germany: springer. charles, a., 1992. psikologi sosial untuk perawat. alih bahasa sally, l. jakarta: egc. gillies, ann, 1996. manajemen keperawatan pendekatan suatu sistem. alih bahasa dika sukmana, rika widya sukmana. chicago: universitas illinois. griffi n, a.p., 1983. a philosophical analysis of caring in nursing, journal of advanced nursing. hamid, a.y.s., 2006. 50,9 persen perawat alami stres kerja. jakarta: ppni. hudak dan gallo, 1997. keperawatan kritis pendekatan holistik. vol. 1. jakarta: egc. istijanto, m.m., 2005. cara praktis mendeteksi dimensi-dimensi kerja karyawan. jakarta: pt gramedia pustaka utama. ilmi, b., 2003. jurnal pengaruh stres kerja terhadap prestasi kerja dan identifi kasi manajemen stress yang digunakan perawat, (online),(http://adln.lib. unair.ac.id/go.php., diakses tanggal 1 desember 2007, jam 13.30) jacken, a., 2005. jinakkan stres. next media bandung. kyle,v.t., 1995. concept of caring: review of the literatur. journal advanced of nursing. leininger, m.m., 1981. caring, an essential human need: proceedings of the three national caring conferences. michigan: wayne state university press. mc farlane, j.k., 1976. a charter for caring, journal of advanced nursing, vol. 1, issue 3, 187–196. national safety of council, 2003. manajemen stres. jakarta: egc. notoadmodjo, s., 2002. metode penelitian kesehatan. jakarta: rineka cipta. perguruan tinggi m.h. thamrin, 2007. program studi keperawatan d3, (online),(http:// www.thamrin.ac.id/program_studi.php., diakses tanggal 10 desember 2007, jam 10.00). perry dan potter, 2004. fundamentals of nursing: concepts, process, and practice, 4th edition. missouri: mosby year book inc. watson, j., 2004. theory of human caring, (online), (http://www2.uchsc.edu., diakses tanggal 1 november 2007, jam 10.00). vol 6 no 1 april 2011_akreditasi 2013.indd 100 studi fenomenologi: kebijakan pemerintah dalam pemberian jaminan pemeliharaan kesehatan bagi masyarakat miskin yang mengalami masalah kesehatan jiwa (fenomenology study: the goverment policy to giving public health insurance in a poor society who have a mental health disorders) achir yani s. hamid*, mustikasari*, ria utami panjaitan*, purwadi** * fakultas ilmu keperawatan, universitas indonesia, kampus baru ui depok e-mail: ayanihamid@yahoo.co.id dan achir@ui.ac.id ** seksi kesehatan keluarga bidang kesehatan masyarakat dinas kesehatan provinsi dki abstract introduction: limited of government’s budget for psychiatric patients has contributed to the expenses should be paid from out of pocket of the poor patients. the purpose of this research was to describe the government policy on health social security insurance for the poor people experiencing psychiatric problems in dki jakarta. method: qualitative research method was used with phenomenology approach to identify and describe the themes relevant to government public policy in providing health insurance for poor people with mental health problems. an in-depth interview and focus group discussion were used to collect data from different informants: service user, healthcare provider, local government policy maker. the qualitative data was analyzed using content analysis. result: the study revealed the following themes: from user perspective (understanding of psychiatric disorder, social security network/jpkm, right and obligation, the advantage and barrier for receiving services, expectation from care provider, social support and expected future direction); from the perspective of healthcare provider (understanding of social security network/jpkm, types of provided health services, recording and reporting, referral system, cost, and the criteria of poor people), from local government and health offi ce perspective (understanding of jpkm for poor family, scope of work, working procedure, recording and reporting, cost, accountability, poor people criteria, the relationship between central government policy with local government policy. discussion: the fi nding of this study recommend the need for leveling socialization of jpkm, the budget transparences, improving the healthcare providers’ knowledge on the mental health psychiatric problems and its needs. keywords: jpkm, poor people, mental health-psychiatric problems pendahuluan pemerintah hanya mengalokasikan kurang dari 1% dari anggaran kesehatan di indonesia untuk menangani masalah kesehatan, jika dibandingkan dengan thailand yang mengalokasikan dana untuk penyakit jiwa sebesar 3%, australia 8% dan negara maju di atas 10%, persentase anggaran kesehatan jiwa di indonesia sangat kecil, bahkan yang terkecil di asia (dahuri, 2005). jika menilik pada status kesehatan jiwa masyarakat menurut pbb (undp) dapat dilihat melalui indikator indeks pembangunan manusia yang meliputi tiga ranah utama yaitu kesehatan, pendidikan dan ekonomi. indonesia menduduki peringkat 105 dari 180 negara di dunia dengan anggaran kesehatan hanya 3–3,5 persen dari anggaran pendapatan dan belanja negara (apbn). jika dibandingkan standar anggaran minimal menurut who yaitu 5% dari apbn, maka untuk negara maju dana kesehatan dan pendidikan sudah mencapai 30–40% apbn. padahal pembiayaan bidang kesehatan khususnya kesehatan jiwa merupakan investasi yang besar di bidang sumber daya manusia, yaitu memberikan peluang untuk hidup produktif studi fenomenologi (achir yani s. hamid, dkk.) 101 dan sejahtera yang berpengaruh terhadap peningkatan perekonomian dan kesejahteraan bangsa (kompas, 2001; oey, 2007). gangguan jiwa menimbulkan beban jauh lebih besar pada lingkup nasional, dari penyakit fisik, seperti kanker, gangguan jantung maupun infeksi yang dapat dicegah, yaitu tuberkulosis dan malaria (kompas, 2001). dki jakarta dan depok merupakan daerah perkotaan yang padat penduduk, hampir 25–37% penduduk tinggal di daerah perkotaan. pada tahun 2020 lebih dari 50% penduduk akan tinggal di kota. krisis ekonomi yang dialami, khususnya oleh penduduk dki jakarta menyebabkan meningkatnya jumlah pengangguran dan pengemis serta meningkatnya jumlah penderita gangguan jiwa terutama jenis ansietas (gangguan kecemasan). baru 8,3% dapat mengakses pengobatan yang memadai (bersedia berobat), sebagian besar lainnya enggan dan tidak punya biaya (brojonegoro, 2000). jika melihat pada tarif pelayanan kesehatan di puskesmas di sejumlah kota mulai naik, hal ini dikarenakan harga obat dan peralatan medis yang naik juga. hal ini tentu saja semakin mempersulit askes warga miskin pada layanan kesehatan (sulekale, 2003). d i r j e n d . k e s e h a t a n m a s y a r a k a t departemen kesehatan dan kesos dalam pelita tahun 2001 menyatakan bahwa hanya 16% penduduk indonesia memiliki jaminan pemeliharaan kesehatan yang cukup baik, sedangkan sisanya 84% belum memiliki jaminan kesehatan yang memadai. angka tersebut akan bertambah buruk dengan menyusulnya krisis ekonomi pada masyarakat miskin. sedangkan faktor kesehatan merupakan faktor pendorong utama untuk peningkatan produktivitas bangsa. sejak dihapuskannya uu no. 9/1996 mengenai kesehatan jiwa dan dilebur menjadi uu no. 23/1992 tentang kesehatan, nasib rumah sakit jiwa (rsj) semakin tidak jelas. di mana sebagian besar rsj di daerah yang dikelola pemda telah berubah fungsi dan dijadikan sebagai sumber pendapatan (revenue) dan melayani kesehatan umum. jika menilik pasien dan keluarga yang datang ke rsj sebagian besar adalah keluarga miskin, rasanya tidak mungkin rsj dijadikan sebagai pendapatan (revenue) seperti rs umum. dari 34 rsj dan 1 rsko hanya 5 (lima) yang dikelola pemerintah dan sisanya dikelola pemda, di mana 7 rsj di daerah tidak mendapat anggaran dari pemda (dahuri, 2005). kementerian kesehatan ri (2011) telah mengeluarkan secara resmi petunjuk teknis jaminan persalinan pada tahun 2011, sementara belum ada kejelasan untuk jaminan penanganan masalah kesehatan jiwa di indonesia. sedangkan pedoman pelaksanaan jaminan kesehatan masyarakat yang dikeluarkan oleh kementerian kesehatan juga masih mengatur secara umum (kementerian kesehatan republik indonesia, 2010). who melaporkan bahwa pada tahun 2001 sekitar 450 juta orang mengalami gangguan kesehatan jiwa atau syaraf (neuropsychiatric disorder atau mental disorder). sekitar 27% dari jumlah itu menimpa asia tenggara termasuk indonesia (suara karya, 2001). sebagian besar penderita gangguan jiwa tidak mendapatkan perawatan yang memadai karena stigma dan rasa malu yang menahan mereka untuk memanfaatkan pelayanan sehingga terjadi pengucilan dan berakhir dengan kematian (brundtland, 1999 dalam kompas, 2001). k o n d i s i i n i d i p e r b e r a t d e n g a n rendahnya anggaran pelayanan kesehatan jiwa disebabkan karena kebijakan pemerintah yang kurang mendukung. sementara who m e r e k o m e n d a s i k a n p e r l u n y a t e r s e d i a perawatan gangguan mental pada pelayanan kesehatan dasar didukung ketersediaan obat psikotropika yang memadai, perbaikan dan kebijakan program, peningkatan sumber daya manusia, penelitian, serta memantau kesehatan mental masyarakat (brundtland, 1999 diakses kompas, 2001). penelitian ini ingin menganalisis kebijakan pemerintah tentang pemberian j a m i n a n p e m e l i h a r a a n k e s e h a t a n b a g i masyarakat miskin yang mengalami masalah kesehatan jiwa di dki jakarta. bahan dan metode p e n e l i t i a n i n i m e n g g u n a k a n metode riset kualitatif dengan pendekatan jurnal ners vol. 6 no. 1 april 2011: 100–111 102 fenomenologi yaitu suatu metode ilmiah untuk mendeskripsikan fenomena tertentu. jenis pendekatan fenomenologi yang digunakan a d a l a h f e n o m e n o l o g i d e s k r i p t i f y a n g menguraikan tentang kebijakan pemerintah dengan pemberian jaminan pemeliharaan kesehatan bagi masyarakat miskin yang mengalami masalah kesehatan jiwa di dki jakarta. dalam proses pengumpulan data, peneliti merupakan alat pengumpulan data dan mendengarkan deskripsi yang diberikan individu selama wawancara berlangsung. peneliti kemudian mempelajari data yang telah ditranskripkan dan ditelaah berulangulang, kemudian mengidentifikasi esensi dari fenomena yang diteliti dan dieksplorasi hubungan dan keterkaitan antarelemenelemen tertentu dengan fenomena tersebut. selanjutnya peneliti mengkomunikasikan dan memberikan gambaran tertulis tentang elemen penting berdasarkan pada pengklasifi kasian dan pengelompokan fenomena. elemen atau esensi penting diuraikan secara terpisah dan kemudian dalam konteks hubungannya terhadap satu sama lain. populasi yang diteliti adalah pengguna pelayanan kesehatan, pemberi pelayanan kesehatan dan penentu kebijakan pemerintah (kebijakan pemerintah daerah) di dki jakarta. penetapan sampel pengguna pelayanan kesehatan dan pemberi pelayanan kesehatan menggunakan teknik purposive sampling (polit dan beck, 2006; fain, 2004; gillis dan jackson, 2002; streubert dan carpenter, 1999). berikut ini sampel yang diambil dari populasi. sampel penelitian yang diambil meliputi penentu kebijakan yaitu dinas kesehatan provinsi dki jakarta yang meliputi 1 partisipan sebagai advokasi/kebijakan, suku dinas kesehatan kotamadya di 5 wilayah: 5 partisipan. kemanusiaan pemberi pelayanan kesehatan yaitu puskesmas sebagai operator/provider yang terdiri dari 5 dokter dan 5 perawat di 5 wilayah dki jakarta. selanjutnya pengguna pelayanan kesehatan yaitu masyarakat sebagai penerima pelayanan kesehatan yaitu masyarakat yang memiliki anggotanya mengalami gangguan kesehatan jiwa sebanyak 10 partisipan di 5 wilayah dki jakarta. kriteria pengguna pelayanan kesehatan adalah masyarakat miskin yang memiliki kartu gakin, keluarga atau anggota keluarga yang pernah mendapatkan pelayanan kesehatan khususnya masalah kesehatan jiwa, berobat ke puskesmas, didiagnosa medis mengalami masalah kesehatan jiwa oleh dokter puskesmas, 5) pernah mendapatkan jaminan pemeliharaan kesehatan (jpkm), bisa membaca dan menulis. kriteria pemberi pelayanan kesehatan (perawat dan dokter puskesmas) adalah perawat dan dokter yang bekerja di puskesmas, memberikan pelayanan kesehatan jiwa. penelitian dilakukan pada bulan agustus 2007 sampai dengan januari 2008 di lima wilayah dki jakarta yaitu jakarta timur, jakarta pusat, jakarta selatan, jakarta utara dan jakarta barat. keterangan lolos kaji etik diperoleh dari komite etik penelitian fakultas ilmu keperawatan universitas indonesia setelah menelaah ringkasan proposal penelitian terkait dengan aspek etik dan proteksi hak subyek penelitian. pengumpulan data dilakukan oleh pengumpul data yang sudah dilatih. data dikumpulkan dengan menggunakan openended interview, sehingga memberikan kesempatan pada partisipan untuk menjelaskan pengalaman mereka secara mendalam dan komprehensif tentang fenomena yang diteliti, yaitu mengidentifi kasi pengalaman pengguna pelayanan kesehatan, pemberi pelayanan kesehatan dan penentu kebijakan kesehatan tentang kebijakan pemerintah dalam pemberian j a m i n a n p e m e l i h a r a a n k e s e h a t a n b a g i masyarakat miskin yang mengalami masalah kesehatan gangguan jiwa. data kualitatif dari hasil wawancara kemudian direkam menggunakan taperecorder dan dianalisis. data kualitatif dari hasil wawancara dan catatan lapangan hasil observasi ditranskrip d a l a m b e n t u k v e r b a t i m d a n d i a n a l i s i s untuk mengidentifi kasi tema. analisis data menggunakan tahapan menurut colaizzi. hasil hasil penelitian disajikan berdasarkan tujuan penelitian yaitu mengidentifi kasi temastudi fenomenologi (achir yani s. hamid, dkk.) 103 tema tentang kebijakan pemerintah dalam pemberian jaminan pemeliharaan kesehatan bagi masyarakat miskin yang mengalami masalah kesehatan jiwa di dki jakarta ditinjau dari perspektif pengguna pelayanan, pemberi pelayanan dan penentu kebijakan pemerintah adalah kebijakan pemerintah daerah. pengguna pelayanan kesehatan pengguna pelayanan kesehatan terdiri dari 9 partisipan dengan karakteristik yaitu rerata usia pertisipan adalah lanjut usia, status dalam keluarga sebagai orang tua (bapak dan ibu), perempuan, suku terbanyak sunda dan berpendidikan terendah sd. lama anggota keluarga mengalami masalah gangguan kesehatan jiwa lebih dari 5 tahun dan lama keluarga merawat dari mulai sakit atau sesuai dengan lamanya sakit anggota keluarga. sedangkan hanya ada satu partisipan yang usianya muda dengan status dalam keluarga sebagai kakak perempuan, berpendidikan sma dan suku sunda. anggota keluarga mengalami gangguan kesehatan jiwa lebih dari 5 tahun dengan lama perawatan yang dilakukan keluarga sama dengan masa gangguan. perpektif pengguna pelayanan kesehatan ini terdiri dari beberapa tema-tema, di mana tema pertama adalah pemahaman masalah gangguan kesehatan jiwa, pemahaman tentang masalah gangguan kesehatan jiwa terdiri dari 3 sub-tema yaitu persepsi gangguan kesehatan jiwa, penyebab masalah gangguan kesehatan jiwa dan tindakan pertama kali yang dilakukan partisipan dalam mengatasi masalah gangguan kesehatan jiwa. sebagian besar partisipan mengatakan gangguan kesehatan jiwa terjadi karena kemasukan jin, dan perlu dicek darahnya, akibat stres, dan banyak pikiran. hanya sebagian kecil partisipan yang sudah lebih dari sepuluh tahun merawat anggota keluarga yang gangguan jiwa menyatakan bahwa penyebab kambuh sakit jiwa karena terlambat minum obat. manifestasi perilaku sangat bervariasi mulai dari jika ditegur tidak menjawab, tertawa sendiri, bicara tidak jelas, melamun, senang mengurung diri di kamar atau menyendiri hingga mengamuk. respons pertama kali yang dilakukan keluarga yaitu membawa anggota keluarga yang mengalami gangguan kesehatan jiwa ke kyai, dukun atau orang pintar, tetapi ada juga yang langsung membawa ke dokter atau rumah sakit jiwa. tema kedua yaitu pemahaman tentang jaminan pelayanan kesehatan masyarakat khususnya gakin/sktm ada 4 sub-tema yaitu sumber informasi pertama kali didapat oleh partisipan, manfaat dari jpkm (gakin/ sktm), prosedur pembuatan jpkm (gakin/ sktm) dan penggunaan jpkm (gakin/ sktm). masyarakat pertama kali mendapatkan informasi tentang jpkm ketika mereka ke puskesmas dan walaupun ada juga yang baru tahu ketika mereka ke posyandu. hampir semua partisipan mengungkapkan bahwa perawat sebagai sumber informasi pertama tentang jpkm ketika mereka ke puskesmas. perawat juga memberikan informasi dalam perannya sebagai tetangga, atau perawat di rs. jiwa dan bekerja di puskesmas. manfaat memiliki kartu gakin/ sktm adalah bisa berobat dan tidak perlu bingung karena sudah terdaftar di puskesmas. pembuatan kartu dilakukan dengan meminta surat dari kelurahan kemudian ke kecamatan lalu ke walikota, selanjutnya akan diperoleh kartu keluarga miskin (gakin). setelah dapat kartu ditunjukkan ke puskesmas atau dokter yang ada di puskesmas untuk mendapatkan pelayanan kesehatan. sedangkan penggunaan kartu gakin digunakan setiap kali berobat dan puskesmas langsung melayani serta kartu gakin hanya berlaku untuk satu orang artinya tidak dapat digunakan oleh orang lain (sesuai dengan nama yang tertera). tema ketiga adalah hak dan kewajiban menerima jpkm (gakin/sktm), hak yang diperoleh menurut sebagian besar partisipan adalah mendapatkan pelayanan kesehatan yang baik dan kewajiban yang diharapkan dari partisipan mengantar anggota keluarga yang sakit untuk berobat. selain itu, kewajiban untuk memperpanjang surat dan mengikuti peraturan. tema keempat tentang pelayanan kesehatan yang diterima, seluruh partisipan menyatakan bahwa pelayanan kesehatan yang diterima berupa pengobatan untuk semua jenis penyakit termasuk masalah gangguan kesehatan jiwa. jurnal ners vol. 6 no. 1 april 2011: 100–111 104 tema kelima adalah kemudahan yang diperoleh, sebagian besar partisipan menyatakan bahwa kemudahan yang mereka peroleh berupa kemudahan untuk mengambil obat, sedangkan hanya sebagian kecil partisipan yang menyatakan bisa memeriksakan anak, dan tidak membayar biaya pemeriksaan. te m a k e e n a m a d a l a h h a m b a t a n hambatan, hambatan yang ditemukan partisipan sebagian besar dalam menerima pelayanan adalah obat dan pelayanan membuat kartu. tema ketujuh adalah harapan ke depan, hampir seluruh partisipan mengatakan hal yang sama tentang harapannya ke depan yaitu anggota keluarga yang sakit bisa sembuh, dan ada sebagian kecil partisipan menyatakan pentingnya diberi obat. tema kedelapan yaitu saran-saran, sebagian besar partisipan menyatakan pelayanan pembuatan kartu diperbaiki (tidak bayar) dan hanya satu partisipan menyatakan obat-obat yang diberikan jangan berbeda-beda karena membingungkan. tema kesembilan adalah dukungan m a s y a r a k a t h a m p i r s e l u r u h p a r t i s i p a n mengatakan hal yang sama tentang bentuk dukungan masyarakat yaitu sebagian besar masyarakat khususnya tetangga berdekatan langsung menolong. hanya sebagian kecil saja yang menyatakan bahwa tetangga tidak peduli, mereka sibuk dengan urusan masing-masing. pemberi pelayanan kesehatan k a r a k t e r i s t i k p e m b e r i p e l a y a n a n kesehatan di puskesmas yang terbanyak adalah menjabat sebagai koordinator gakin dengan kisaran usia dari dewasa muda hingga lanjut usia awal, dengan pendidikan s1 kedokteran dan d-iii keperawatan. lama bertugas di puskesmas antara 2 tahun sampai dengan 23,5 tahun, sebagian besar perempuan. p e m b e r i p e l a y a n a n k e s e h a t a n menghasilkan beberapa tema. tema pertama yaitu pemahaman tentang jpkm (gakin/ s k t m ) . p e m a h a m a n t e n t a n g j a m i n a n pelayanan kesehatan masyarakat khususnya gakin/sktm ada tiga sub tema yaitu pengalaman pemberian jpkm (gakin/ sktm), prosedur pemberian kartu dan siapa yang memberikan jpkm (gakin/sktm). sebagian besar pertisipan mengatakan bahwa bagi masyarakat miskin diawali dengan nama kartu sehat (jpk gakin) dari pemerintah, dan untuk dki bernama gakin. hampir seluruh paryisipan mengatakan bahwa prosedur pemberian kartu berdasarkan data bps, sedangkan bagi yang tidak punya dibuatklan sktm. sebagian besar partisipan menyatakan bahwa orang yang memberikan dana adalah pemda dki jakarta untuk wilayah jakarta. tema kedua adalah jenis pelayanan kesehatan yang diberikan. pemahaman tentang jenis pelayanan kesehatan di puskesmas kelurahan dan kecamatan. hampir seluruh partisipan menyatakan bahwa jenis pelayanan kesehatan yang diterima dari puskesmas kelurahan adalah pelayanan kesehatan dasar, poli umum, poli gigi, imunisasi dan kb. hanya satu partisipan yang menyatakan jenis pelayanan kesehatan yang diberikan di puskesmas kelurahan adalah pelayanan promotif, prefentif dan rehabilitatif. sedangkan jenis pelayanan kesehatan yang diberikan puskesmas kecamatan adalah rujukan artinya yang membutuhkan dokter spesialis, dan laboratorium serta persalinan. tidak ada yang menspesifi kasikan pelayanan untuk masalah kesehatan jiwa. tema ketiga pencatatan dan pelaporan. empat sub-tema yang muncul dari tema pencatatan dan pelaporan, yaitu bentuk pencatatan, prosedur laporan, isi laporan yang dibuat dan alur pengiriman laporan bulanan. hampir semua partisipan menyatakan bahwa pencatatan berbentuk formulir. prosedur laporan yang biasa dilakukan menurut seorang partisipan yaitu melalui pelaporan dari puskesmas yang diawali dari puskesmas kelurahan yang wajib ditandatangani kemudian diserahkan kepada kepala puskesmas kecamatan. adapun isi laporan yang dibuat menurut sebagian besar partisipan adalah penyakit yang dialami dalam satu bulan, kunjungan harian sebagai pasien baru dan lama, serta jenis pelayanan yang diberikan. untuk alur pengiriman laporan menurut semua partisipan berupa laporan bulanan yang dikirim ke puskesmas kecamatan kemudian diteruskan ke suku dinas pelayanan kesehatan untuk direkapitulasi dan diserahkan kepada dinas kesehatan. studi fenomenologi (achir yani s. hamid, dkk.) 105 tema keempat sistem rujukan. sistem rujukan memunculkan 3 sub-tema, yaitu mekanisme sistem rujukan, tempat rujukan dan kasus yang dirujuk. mekanisme sistem rujukan menurut seluruh partisipan. diawali keluarga dan pasien gangguan jiwa datang ke puskesmas kelurahan. jika tidak bisa ditangani maka ke puskesmas kecamatan, baru terakhir dirujuk ke rumah sakit jiwa. menurut seluruh seluruh partisipan tempat yang biasa dirujuk untuk kasus masalah gangguan kesehatan jiwa adalah rumah sakit jiwa grogol karena merupakan rumah sakit jiwa milik pemerintah. pada umumnya kasus yang dirujuk merupakan kasus kelainan jiwa yang tidak bisa diatasi seperti skizofrenia. tema kelima adalah biaya. tema biaya terdiri dari 3 sub-tema, yaitu pihak yang menetapkan biaya, hambatan dalam biaya dan pengelolaan biaya di puskesmas. menurut seluruh partisipan yang menetapkan biaya adalah dinas kesehatan dengan pembayaran sistem kapitasi. sedangkan untuk masalah kesehatan jiwa disubsidi dari pemerintah daerah dki jakarta. sebagian besar partisipan melaporkan keterlambatan dana dari pemerintah sampai di tingkat puskesmas karena terlambatnya turun anggaran dari pemerintah. pengelolaan biaya dilakukan tim khusus di puskesmas dibawah tanggung jawab kepala puskesmas. tema keenam adalah kriteria masyarakat miskin. sebagian besar partisipan mengatakan bahwa kriteria masyarakat miskin mengacu kepada 14 variabel kriteria miskin mengacu kepada standar bpps (gakin) dan standar pemerintah daerah (kombinasi gakin dan sktm) yang akan mendapatkan kartu jpkm (gakin). penentu kebijakan pemerintah (pemerintah daerah) responden penentu kebijakan pemerintah pada penelitian ini terdiri dari suku dinas kesehatan khususnya suku dinas pelayanan kesehatan dan dinas kesehatan dki jakarta. berikut ini tema dan sub-tema yang disajikan berdasarkan penentu kebijakan pemerintah pada dua tingkat tersebut. karakteristik dari suku dinas pelayanan kesehatan yang menjadi partisipan dalam penelitian yang terbanyak adalah laki-laki, menjabat sebagai koordinator gakin, usia dewasa, lama bekerja ≥2 tahun dan pendidikan s1. rencana 5 wilayah dki jakarta hanya satu yaitu wilayah jakarta yang belum bersedia untuk menjadi partisipan. tema pertama adalah pemahaman tentang jpk bagi masyarakat miskin. pemahaman tentang jaminan pelayanan kesehatan bagi masyarakat miskin meliputi kriteria pemberian jpk bagi masyarakat miskin yang mengalami masalah gangguan kesehatan jiwa yaitu yang memiliki kartu gakin dan sktm. tema kedua ruang lingkup. ruang l i n g k u p y a n g m e n y a n g k u t s u k u d i n a s pelayanan kesehatan meliputi dua sub-tema, yaitu tugas pokok fungsi (tupoksi) suku dinas dalam penanganan masalah gangguan jiwa bagi masyarakat. sesuai tupoksi suku dinas berperan sebagai pembina pengawasan dan pengendalian serta audit. penyelesaian masalah dilakukan secara berjenjang yaitu dari puskesmas kelurahan, puskesmas kecamatan, suku dinas kesehatan. tema ketiga yaitu alur kerja/prosedur supervisi/koordinasi pemberian jpkm di mana terdiri dari mekanisme penanganan masalah dan masalah kesehatan jiwa yang perlu dikoordinasikan. mekanisme penanganan masalah menurut partisipan menunggu laporan dari puskesmas. tema keempat pencatatan dan pelaporan di mana menurut partisipan mengikuti ketentuan dinas kesehatan di mana pencatatan berasal dari puskesmas dan mencatat keluhan masyarakat setiap bulan, sedangkan untuk laporan dibuat tiap tiga bulan. pelaporan dilakukan secara berjenjang dari puskesmas kecamatan dilaporkan ke suku dinas kesehatan untuk selanjutnya ke dinas kesehatan. tema kelima biaya. tema biaya ini muncul 3 subtema utama, yaitu monitor dan audit dana, audit gakin dan audit sktm. menurut partisipan monitor dan audit dana dilakukan oleh dinas kesehatan. audit gakin menurut partisipan lebih kepada verifikasi ulang program kartu gakin. audit sktm berupa verifi kasi pemberian sktm. t e m a k e e n a m m e r u p a k a n pertanggungjawaban. pertanggungjawaban jurnal ners vol. 6 no. 1 april 2011: 100–111 106 terhadap pelaksanaan jpk gakin dan sktm terdiri dari sosialisasi pertanggungjawaban dan laporan pertanggungjawaban biaya. laporan sosialisasi dibuat setelah selesai kegiatan yang berisi spj transportasi, notulen hasil kegiatan, laporan hasil kegiatan. pelaporan dilakukan ke pemda dki. untuk pertanggungjawaban biaya jpk gakin diserahkan ke dinas kesehatan. tema ketujuh merupakan kriteria masyarakat miskin. sebagian besar partisipan mengatakan bahwa kriteria masyarakat miskin mengacu kepada 7 variabel kriteria masyarakat miskin yang mendapatkan jpk gakin, yaitu memiliki rumah dengan luas lantai kurang dari 8 m2, tidak dapat membeli pakaian dalam setahun, tidak punya air bersih untuk minum dan mandi, jenis lantai hunian sebagian besar tanah, fasilitas jamban tidak ada, kepemilikan aset kursi tidak ada, konsumsi lauk-pauk dalam seminggu tidak bervariasi, kemampuan membeli pakaian minimal satu set per tahun. responden dari dinas kesehatan dki jakarta menunjukkan hasil wawancara yang diwakili oleh kepala seksi jpkm dan asuransi dengan pendidikan s1 kedokteran dan s2 manajemen, yang berusia 42 tahun, perempuan dengan lama bekerja 5 tahun. tema pertama pemahaman jaminan pemeliharaan kesehatan (jpk). jaminan pemeliharaan kesehatan (jpk) gakin menurut partisipan diberikan kepada masyarakat sesuai dengan kriteria bps. bagi yang tidak memiliki jpk, maka diberikan sktm. hal ini dilakukan karena pemerintah daerah (dki jakarta) memfokuskan bantuan pada masyarakat miskin. tema kedua adalah dasar hukum/acuan. jpk gakin diberlakuan menggunakan dasar hukum yaitu surat keputusan gubernur sebagai kepala pemerintah daerah dki sudah dianggap cukup kuat, jelas dan rinci. tema ketiga ruang lingkup. cakupan pelayanan pemberian jpk gakin menurut partisipan adalah puskesmas dan rumah sakit. tidak ada perbedaan perlakuan antara rs umun dan rs. jiwa. tema keempat adalah prosedur kerja. mekanisme kerja pemberian jpk gakin dari dinas kesehatan ke suku dinas ke puskesmas kecamatan ke puskesmas kelurahan. tema kelima adalah biaya. tema ini terdiri dari 5 sub-tema yaitu alokasi biaya, alokasi sosialisasi, sumber biaya, laporan keuangan dan pencairan dana. alokasi biaya jpk gakin berdasarkan kapitasi. kalau kartu gakin pakai kapitasi yaitu satu kapitasi dihargai 700 rupiah (dana diserahkan kepada puskesmas) sumber dananya dari apbd. bagi yang tidak memiliki kartu gakin dibiayai anggaran alokasi dana sosialisasi berdasarkan pengajuan ke dprd jika sudah disetujui, baru kemudian didistribusikan ke wilayah. sumber biaya berasal dari apbd dengan bendahara dinas kesehatan dan mempunyai rekening sendiri. pencairan dana paling lama 2 bulan, dengan klaim maksimal 2 bulan. tema keenam adalah tugas pokok dan fungsi (tupoksi), menurut partisipan tupoksi dinas kesehatan sebagai regulator, suku dinas kesehatan sebagai audit, puskesmas sebagai pelaksana. tema ketujuh adalah kriteria masyarakat miskin. kriteria masyarakat miskin mengacu kepada data bps yang kemudian dilakukan validasi oleh dinas kesehatan melalui puskesmas masing masing. pengguna kartu gakin harus memenuhi kriteria bahwa benarbenar dalam kondisi miskin, dan ada di bps saat divalidasi. bagi mereka yang belum tercatat di bps juga perlu mencatatkan keluarganya dan memiliki sktm. kriteria miskin meliputi: tempat tinggal dengan luas lantai < 8 m2, tidak dapat membeli pakaian setahun, tidak punya air bersih untuk minum dan mandi, jenis lantai hunian sebagian besar tanah, fasilitas jamban atau wc tidak ada, kepemilikan aset kursi tidak ada, konsumsi lauk-pauk dalam seminggu tidak bervariasi, kemampuan membeli minimal satu setel pakaian per tahun. te m a k e d e l a p a n p e n c a t a t a n d a n pelaporan, menurut partisipan mekanisme pencatatan dan pelaporan baik untuk gakin maupun sktm dilakukan oleh suku dinas kesehatan, yaitu dengan melaporkan warga yang punya gakin atau sktm ke suku dinas kesehatan, kemudian dilaporkan ke dinas kesehatan, untuk kemudian bps menyerahkan laporan tersebut ke 5 wilayah untuk dicek ulang kesesuaiannya. studi fenomenologi (achir yani s. hamid, dkk.) 107 pembahasan pemahaman masyarakat tentang masalah gangguan kesehatan jiwa dilihat dari berbagai perspektif, ternyata hampir sama yaitu pasien jiwa menakutkan dan perlu dijauhi karena bisa membahayakan. hal ini sejalan dengan stigma yang berkembang di masyarakat bahwa pasien jiwa perlu dijauhi dan tidak perlu diajak bicara (stuart dan laraia, 2001). masyarakat mempersepsikan bahwa gangguan kesehatan jiwa karena kemasukan jin. penyebab gangguan jiwa menurut hampir seluruh partisipan sebagai akibat stres, banyak pikiran (bagi yang belum menggunakan pelayanan kesehatan) dan hanya sebagian kecil saja yang menyatakan penyebab kambuh sakit jiwa karena terlambat minum obat (bagi yang sudah menggunakan pelayanan kesehatan jiwa). manifestasi perilaku menarik diri cukup predominan, walaupun ada juga yang berperilaku mengganggu lingkungan. mayoritas masyarakat menggunakan upaya alternatif tradisi daripada mencari bantuan pada tenaga kesehatan profesional. pemahaman ini diasumsikan sangat berhubungan dengan tingkat pendidikan responden yang rendah dan kondisi ekonomi yang kurang mumpuni. hasil penelitian ini menunjukkan masih banyak masyarakat yang belum membawa anggota keluarga yang mengalami masalah gangguan kesehatan jiwa ke pelayanan kesehatan karena ketidaktahuan atau kurangnya sosialisasi tentang masalah gangguan jiwa dan pelayanan kesehatan yang tersedia. penyebab lain masyarakat enggan datang ke pelayanan k e s e h a t a n , k a r e n a b a n y a k m a s y a r a k a t menanggung masalahnya sendiri agar tidak diketahui orang lain. bagi mereka gangguan mental/jiwa merupakan tragedi personal sebagai dampaki stigma yang menimbulkan rasa malu, hingga pengucilan dari masyarakat (brundtland, 1999; kompas, 2001) d a m p a k y a n g a k a n t i m b u l d a r i permasalahan di atas adalah meningkatnya trend masalah kesehatan jiwa yaitu mulai dari hilangnya hari produktif, biaya perawatan yang harus dikeluarkan, sampai ke stigma, pengucilan, dan diskriminasi yang harus ditanggung penderita dan keluarga, sedangkan jika dilihat dari beban yang ditimbulkan penyakit jiwa jauh melebihi penyakit lain seperti kanker, gangguan jantung maupun infeksi seperti tuberkulosis dan malaria (brundtland, 1999; kompas, 2001; oey 2005). jaminan pemeliharaan kesehatan masyarakat (jpkm) khususnya masyarakat miskin adalah pemberian pemeliharaan kesehatan bagi masyarakat miskin yang terjangkau dan memberikan dampak pada peningkatan kesehatan (departemen kesehatan, 2006). menurut dirjend. kesehatan masyarakat departemen kesehatan dan kesos dalam pelita (2001) menyatakan bahwa hanya 16% penduduk indonesia memiliki jaminan pemeliharaan kesehatan yang cukup baik, sedangkan 84% belum memiliki jaminan kesehatan yang memadai. angka tersebut akan bertambah buruk dengan menyusulnya krisis ekonomi pada masyarakat miskin, sedangkan faktor kesehatan merupakan faktor pendorong utama untuk peningkatan produktivitas bangsa. p e n g g u n a p e l a y a n a n k e s e h a t a n (masyarakat) melaporkan bahwa pemahaman mereka tentang jpkm (gakin/ sktm) pertama kali diperoleh dari perawat yang bekerja di posyandu, puskesmas dan rumah sakit jiwa. manfaat yang dirasakan dari partisipan yang memiliki kartu gakin/ sktm adalah bisa berobat dan tidak perlu bingung karena sudah terdaftar di puskesmas, adapun prosedur pembuatan kartu tidak terlalu sulit dengan membawa surat dari walikota dengan cara mengurus surat dari kelurahan, kecamatan lalu ke walikota, lalu akan mendapatkan kartu miskin (gakin). setelah dapat kartu ditunjukkan ke puskesmas atau dokter yang ada di puskesmas untuk mendapatkan pelayanan kesehatan. sedangkan penggunaan kartu gakin digunakan setiap kali berobat ke puskesmas atau pelayanan kesehatan jiwa lainnya, di mana kartu gakin hanya berlaku untuk satu orang artinya tidak dapat digunakan oleh orang lain (sesuai dengan nama yang tertera). kedekatan dan intensitas kontak perawat terhadap masyarakat menempatkan perawat pada posisi kunci untuk menjadi informan yang baik tentang sumber dana yang tersedia bagi masyarakat. hasil penelitian tersebut tidak terlepas dari upaya yang dilakukan pemerintah melalui jurnal ners vol. 6 no. 1 april 2011: 100–111 108 kementerian kesehatan ri adalah menjamin akses penduduk miskin terhadap pelayanan kesehatan, yaitu tahun 1998–2001 pemerintah mengembangkan program jaring pengamanan sosial (jps-bk), program dampak pengurangan subsidi energi (pdpse) tahun 2001, program kompensasi bahan bakar minyak (pkps-bbm) tahun 2002-2004. program-program tersebut menyebabkan beban bagi rumah sakit (rs) dan puskesmas meningkat karena dana langsung disalurkan ke rs dan puskesmas sehingga rs dan puskesmas berperan ganda yaitu sebagai pemberi pelayanan kesehatan (ppk) dan mengelola pembiayaan atas pelayanan kesehatan yang diberikan. kemudian pada tahun 2004 pemerintah mengembangkan program pemeliharaan kesehatan bagi masyarakat miskin berbasis asuransi sosial yang dikelola oleh pt askes (persero) meliputi pelayanan kesehatan dasar di puskesmas dan jaringannya serta pelayanan kesehatan rujukan di rs. tahun 2005 mekanisme diubah menjadi pembiayaan upaya kesehatan masyarakat (ukm) dan pelayanan kesehatan dasar di puskesmas dan jaringannya langsung disalurkan ke puskesmas. sedangkan pelayanan kesehatan rujukan bagi masyarakat miskin di rs dikelola pt askes (persero) (departemen kesehatan, 2006). khusus dki jakarta belum menggunakan aseskin tetapi lebih pada kartu gakin/ sktm. hal ini didasarkan pada studi kelayakan yang dilakukan dinas kesehatan bahwa premi yang diberikan aseskin sangat kecil yaitu rp5.000,00 dirasakan tidak cukup karena premi yang diperlukan untuk dki jakarta antara rp10.000,00–rp15.000,00 yang pada akhirnya diputuskan mengelola sendiri dan tidak mengikuti kebijakan pemerintah. hasil penelitian dari pemberi pelayanan kesehatan (petugas kesehatan) didapatkan bahwa bagi masyarakat miskin diawali dengan nama kartu sehat (jpk gakin) dari pemerintah, dan untuk dki bernama gakin. prosedur pemberian kartu berdasarkan data bps, sedangkan bagi yang tidak punya dibuatkan sktm. dana jpkm diberikan oleh dinas kesehatan dan dana yang mengalami masalah kesehatan jiwa untuk masyarakat miskin diberikan oleh pemda dki jakarta untuk wilayah jakarta. alasan utama memberikan jpk gakin kepada masyarakat miskin, karena sebagian besar masyarakat yang tinggal di wilayah dki jakarta adalah masyarakat miskin yang sangat membutuhkan bantuan. berdasarkan sensus penduduk yang terakhir pada tahun 2000 diperkirakan jumlah penduduk lebih dari 206 juta dan sebagian besar penduduk indonesia hidup di pulau jawa (59%) khususnya dki jakarta. data bps menunjukkan jumlah penduduk dki jakarta per juli 2005 sebanyak 7,47 juta orang (bpps, 2007). estimasi pada tahun 2020 lebih dari 50% dari penduduk akan tinggal di kota. penyebabnya karena kemudahan memperoleh informasi, kemudahan mencari pekerjaan, lengkapnya fasilitas dan teknologi serta kemudahan akses ke pelayanan kesehatan (hampir 140% ada di sektor perkotaan dan 39% di sektor pedesaan). faktor-faktor kemiskinan meliputi faktor internal dan faktor eksternal. faktor internal yaitu keterbatasan wawasan, kurangnya keterampilan, kesehatan yang buruk dan etos kerja yang rendah. sedangkan faktor eksternal adalah kebijakan pembangunan yang keliru, korupsi yang menyebabkan berkurangnya a l o k a s i a n g g a r a n u n t u k k e s e j a h t e r a a n masyarakat miskin (sulekale, 2003). hasil penelitian kriteria masyarakat miskin di dki jakarta mengacu kepada 14 variabel kriteria miskin menurut bps yang akan mendapatkan kartu jpk gakin. upaya yang dilakukan pemerintah khususnya dki jakarta adalah dengan memberikan pelayanan gakin/sktm hal ini disebabkan karena masih sedikit yaitu 20% dari penduduk termiskin belum mendapatkan akses ke pelayanan kesehatan (oey, 2007) jika melihat pada tarif pelayanan kesehatan di puskesmas pada beberapa kota mulai meningkat. hal ini sebagai akibat harga obat dan peralatan medis yang naik juga. kondisi ini tentu saja makin mempersulit bantuan dana kesehatan bagi warga miskin terkait layanan kesehatan (brojonegoro, 2007). dki jakarta sebagai kota metropolitan dan ibu kota negara mengalokasikan biaya untuk layanan kesehatan bagi masyarakat miskin. penetap besaran biaya gakin adalah dinas kesehatan dengan pembayaran sistem studi fenomenologi (achir yani s. hamid, dkk.) 109 kapitasi. sedangkan untuk masalah kesehatan jiwa disubsidi dari pemda dki jakarta. permasalahan yang sering timbul di puskesmas sebagai pelaksana pemberi jpkm dana sering terlambat turun. padahal puskesmas diberi kebebasan mengelola biaya tersebut. sedangkan dari pandangan penentu kebijakan (dinas kesehatan) pencairan dana biasanya hanya memerlukan waktu 2 bulan. semua pelayanan kesehatan dasar, poli umum, poli gigi, imunisasi dan kb dan jenis pelayanan kesehatan yang diberikan puskesmas kecamatan adalah rujukan artinya yang membutuhkan dokter spesialis, dan laboratorium serta persalinan mendapatkan bantuan jpkm. jika melihat dari jenis pelayanan kesehatan yang diberikan masih berfokus pada masalah kesehatan secara umum. sedangkan untuk masalah kesehatan jiwa biasanya langsung dirujuk jika tidak dapat diselesaikan penanganan di puskesmas khususnya puskesmas kecamatan. hal ini sejalan dengan pernyataan dari pemberi pelayanan kesehatan yaitu hampir sebagian besar pasien yang mengalami masalah gangguan kesehatan jiwa langsung dirujuk ke rs. jiwa, khususnya untuk kasus kelainan jiwa yang tidak bisa diatasi misalnya skizofrenia dan pasien yang mengamuk. pencatatan dan pelaporan diperlukan untuk mempermudah pelaksanaan jpkm, dimana pencatatan yang digunakan sudah ada dalam bentuk formulir. prosedur laporan yang biasa dilakukan diawali dari puskesmas kelurahan dan wajib ditandatangani, kemudian diserahkan kepada puskesmas kecamatan. isi laporan yang dibuat tentang penyakit yang dialami dalam satu bulan, kunjungan harian bagi pasien baru dan lama, serta jenis pelayanan yang diberikan. alur pengiriman laporan bulanan dikirim ke puskesmas kecamatan kemudian diteruskan ke suku dinas pelayanan kesehatan untuk direkapitulasi dan diserahkan kepada dinas kesehatan. proses ini sesuai dengan tupoksi dalam jpk gakin yaitu dari dinas kesehatan sebagai regulator, kemudian ke suku dinas kesehatan sebagai audit, terakhir ke puskesmas sebagai pelaksana. p e m e l i h a r a a n j a m i n a n k e s e h a t a n gangguan jiwa berdampak pada tingginya angka penderita kesehatan jiwa tidak diimbangi fasilitas pelayanan kesehatan jiwa yang memadai di rumah sakit jiwa (rsj) di indonesia karena rendahnya anggaran pelayanan kesehatan jiwa (kompas, 2001). rendahnya anggaran pelayanan kesehatan jiwa disebabkan karena kurangnya perhatian dan kebijakan pemerintah, padahal tidak ada masyarakat dari suatu negara apa pun yang bebas dari gangguan jiwa. sebenarnya kemajuan ilmu pengetahuan dan teknologi menunjukkan bahwa gangguan mental dan perilaku sebagai hasil interaksi kompleks antara faktor biologi, psikologi dan sosial dapat diatasi. misalnya dengan perawatan yang lebih baik > 60% pasien depresi bisa pulih seperti sediakala, napza sebesar 60%, penderita epilepsi bebas serangan kejang 73% dan pasien skizofrenia menjalani hidup tanpa kambuh sebesar 77%. (brundtland, 1999 dalam kompas, 2001). simpulan dan saran simpulan persepsi masyarakat tentang gangguan kesehatan jiwa karena kemasukan jin. penyebab gangguan jiwa menurut hampir seluruh partisipan adalah karena stres, banyak pikiran (bagi yang belum menggunakan pelayanan kesehatan) dan hanya sebagian kecil saja yang menyatakan penyebab kambuh sakit jiwa karena terlambat minum obat (bagi yang sudah menggunakan pelayanan kesehatan jiwa). perilaku akibat stres yang terjadi adalah sangat bervariasi mulai dari jika ditegur tidak menjawab, ketawa sendiri, bicara meracau, melamun, senang dikamar/mengurung diri di kamar/menyendiri hingga mengamuk. tindakan partisipan pertama kali untuk mengobati anggota yang mengalami masalah gangguan kesehatan jiwa sebagian besar adalah pergi ke kyai/dukun/orang pintar dan yang lainnya pergi ke dokter atau rumah sakit jiwa. p r o s e d u r p e m b u a t a n k a r t u t i d a k terlalu sulit dengan membawa surat dari walikota dengan cara mengurus surat dari kelurahan, kecamatan lalu ke walikota maka akan mendapatkan kartu miskin (gakin). setelah dapat kartu ditunjukkan ke puskesmas atau dokter yang ada di puskesmas untuk mendapatkan pelayanan kesehatan. sedangkan jurnal ners vol. 6 no. 1 april 2011: 100–111 110 penggunaan kartu gakin digunakan setiap kali berobat ke puskesmas atau pelayanan kesehatan jiwa lainnya, di mana kartu gakin hanya berlaku untuk satu orang artinya tidak dapat digunakan oleh orang lain (sesuai dengan nama yang tertera). khusus dki jakarta belum menggunakan aseskin tetapi lebih pada kartu gakin/ sktm. hal ini didasarkan pada studi kelayakan yang dilakukan dinas kesehatan bahwa premi yang diberikan aseskin sangat kecil yaitu rp5.000,00 dirasakan tidak cukup karena premi yang diperlukan untuk dki jakarta antara rp10.000,00–rp15.000,00 yang pada akhirnya diputuskan mengelola sendiri dan tidak mengikuti kebijakan pemerintah. alokasi biaya bagi masyarakat miskin di mana untuk gakin yang menetapkan biaya adalah dinas kesehatan dengan pembayaran sistem kapitasi. sedangkan untuk masalah kesehatan jiwa disubsidi dari pemda dki jakarta. permasalahan yang sering timbul di puskesmas sebagai pelaksana pemberi jpkm adalah sering terlambat. padahal puskesmas diberi kebebasan mengelola biaya tersebut. sedangkan dari pandangan penentu kebijakan (dinas kesehatan) mengatakan bahwa pencairan dana biasanya tidak lama yaitu 2 bulan. pencatatan dan pelaporan dalam bentuk formulir. prosedur laporan yang biasa dilakukan adalah mulai dari puskesmas kelurahan dan wajib ditandatangani kemudian diserahkan kepada puskesmas kecamatan. adapun isi laporan yang dibuat penyakit satu bulan, kunjungan harian baik pasien baru dan lama, dan jenis pelayanan yang diberikan. alur pengiriman laporan yaitu laporan bulanan dikirim ke puskesmas kecamatan kemudian di teruskan ke suku dinas pelayanan kesehatan untuk di rekap dan diserahkan kepada dinas kesehatan. hal ini sesuai dengan tupoksi dalam jpk gakin yaitu dari dinas kesehatan sebagai regulator, suku dinas kesehatan sebagai audit, puskesmas sebagai pelaksana. kriteria miskin menurut bps yang akan mendapatkan kartu jpk gakin yaitu luas bangunan 8 m2, alas rumah tanah, dinding rumah dari panan, pagar rumah dari papan atau bambu, tidak memiliki sumber air minum sendiri, tidak memiliki jamban sendiri, beli baju sekali setahun atau tidak dapat beli, tidak mampu mengkonsumsi protein dalam seminggu, ada anak yang sekolah, tidak memiliki aset rumah tangga seperti kursi tamu, tidak memiliki warung, tidak memiliki kendaraan bermotor, dan lain-lain saran saran bagi penentu kebijakan agar lebih mensosialisasikan secara berjenjang tentang kebijakan yang menyangkut pelayanan kesehatan jiwa bagi masyarakat miskin. membuat kebijakan agar meningkatkan besaran anggaran pelayanan kesehatan bagi masyarakat dengan masalah gangguan kesehatan jiwa dengan peruntukan yang jelas. selain itu perlu menempatkan tenaga kesehatan jiwa yang professional dengan cost sharing yang rasional untuk menangani masalah gangguan kesehatan jiwa, dan memastikan ketersediaan obat yang diperlukan. saran bagi pemberi pelayanan kesehatan agar dapat memberikan penanganan pada masyarakat yang mengalami masalah gangguan kesehatan jiwa melalui penyuluhan kesehatan, konseling, kunjungan rumah, mengembangkan kerja sama dengan rt, rw, lurah dan kecamatan dalam menanggulangi masalah kesehatan jiwa melalui pemberian penyuluhan pada masyarakat dan membantu pembuatan kartu bagi masyarakat miskin. untuk itu diperlukan pelatihan tentang perawatan pasien dengan gangguan jiwa dan pemberdayaan keluarga dan penyebaran informasi yang berguna untuk memandirikan pasien dan keluarga. pelatihan hendaknya dilakukan terutama bagi perawat yang selalu dekat dan kontak yang intens dengan masyarakat. saran bagi masyarakat diharapkan dapat bekerja sama dan saling mendukung untuk mengatasi masalah gangguan kesehatan jiwa di wilayah masing-masing, proaktif mencari informasi melalui media cetak, elektronik dan forum diskusi tentang untuk meningkatkan pengetahuan dan memudahkan akses pemanfaatan sumber yang tersedia dalam menangani masalah gangguan kesehatan jiwa termasuk meminimalkan stigma dan dampaknya. sangat bermanfaat apabila dilakukan penelitian lanjut menggunakan studi fenomenologi (achir yani s. hamid, dkk.) 111 metode riset kuantitatif dengan mengembangkan instrumen berdasarkan tema yang dihasilkan sebagai indikator pengukuran. kepustakaan bpps, 2007 dalam www.perspektif.net/article. php?article_id=174 diakses 8 februari 2007) brojonegoro, bps., 2000. pencapaian mdgs dan prioritas pembangunan ekonomi indonesia. makalah disajikan dalam lokakarya dewan guru besar universitas indonesia. tidak dipublikasikan. brundtland, 1999. kesehatan jiwa: pemahaman b a r u , h a r a p a n b a r u , ( o n l i n e ) , (http://www.kompas.com/kompascetak/0110/12/nasional/pema25.htm., diakses tanggal 12 februari 2007). d a h u r i , 2 0 0 5 . h u m a n i o r a k e s e h a t a n , (online),(http://www.mediaindo.co.id/ berita.asp., diakses tanggal 23 juni 2005). departemen kesehatan, 2006. pedoman pelaksanaan jaminan pemeliharaan keehatan masyarakat miskin. jakarta: departemen kesehatan ri. fain, j.a., 2004. reading, understanding and applying nursing research. second edition. philadelphia: f.a. davis company, page 219–241. gillis dan jackson, 2002. research for nurses: method and interpretation. philadelphia: f.a. davis, page 224–256. kementrian kesehatan republik indonesia, 2 0 11 . p e t u n j u k te k n i s j a m i n a n persalinan. jakarta: kemkes. ri. kementerian kesehatan republik indonesia, 2010. pedoman pelaksanaan jaminan kesehatan masyarakat (jamkesmas). jakarta: kemkes. ri. kompas, 2001. kesehatan jiwa, (online), (http://www.litbang.depkes.go.id/ p u b l i k a s i _ b p p k / m a s k e s _ b p p k / triwulan3/gangguan%20jiwa.htm., diakses tanggal 12 februari 2007). oey, m., 2007. kemiskinan pedesaan: ketimpangan fasilitas sosial ekonomi. makalah lokakarya dewan guru besar universitas indonesia. tidak dipublikasikan. pelita, 2001. kesehatan jiwa, (online), (http:// www.litbang.depkes.go.id/publikasi_ b p p k / m a s k e s _ b p p k / tr i w u l a n 2 / gangguan%20jiwa.htm., diakses tanggal 12 februari 2007). polit, d.f., dan beck, c.t., 2006. essensial o f n u r s i n g r e s e a rc h : m e t h o d s , appraisal and utilization. sixth edition. philadelphia: lippincott williams and wilkins, page 209–233. stuart, g.w., dan laraia, m.t., 2001. principles and practice of psychiatric nursing. seventh edition. st. louis: mosby inc. streubert, h.j., dan carperter, d.r., 1999. qualitative research in nursing: advancing the humanistic imperative. second edition. philadelphia: p.a. lippincott. s u a r a k a r y a , 2 0 0 1 . g a n g g u a n j i w a , (online),(http://www.litbang.depkes. go.id/publikasi_bppk/maskes_bppk/ triwulan4/gangguan%20jiwa.htm., diakses tanggal 12 februari 2007). sulekale, 2003. pemberdayaan masyarakat miskin di era otonomi daerah. http:// ekonomirakyat.org/edisi_14/artikel_ 2.htm., diakses tanggal 14 maret 2005). vol 6 no 1 april 2011_akreditasi 2013.indd 50 modul anticipatory guidance merubah pola asuh orang tua yang otoriter dalam stimulasi perkembangan anak (anticipatory guidance module changes the authoritaritative parenting of parents in stimulating children development) m. hasinuddin*, fitriah ** * stikes ngudia husada madura, jl re martadinata bangkalan telp/fax: (031) 3091871, e-mail: hasin_nhm@yahoo.com ** poltekkes surabaya prodi kebidanan bangkalan abstract introduction: anticipatory guidance is a method used by nurses to help parents provide the development of behavior change towards a better understanding of their children. the purpose of this study was to analyze the provision modul of anticipatory guidance to parents and their effects on patterns of authoritarian parenting in stimulating development in kindergarten dharmawanita bangkalan regency. method: the design in this study was experimental pre post test with control group. the population was the parents of students in dharmawanita bangkalan kindergarten in 2010. respondents were 15 people in the treatment group and 15 people in control group who meet the inclusion criteria. data collected by using a questionnaire. data then analyzed using wilcoxon and mann whitney test. result: the result showed that the differences in upbringing the parents before and after the anticipatory guidance given p value of 0.001, whereas in the control group there was no difference with a p value of 0.083. to fi nd out the difference of counselling terms between treatment and control groups were performed by mann whitney test with p-value (0,004) < α (0.05). discussion: based on these results we can conclude that modul of anticipatory guidance has an impact on the upbringing of parents in stimulating growth in children in kindergarten dharmawanita bangkalan. research on the effect of anticipatory guidance by the nurse to child development is necessary as a follow up of this research by considering the factors that infl uence the development of the child itself. keywords: modul of anticipatory guidance, developmental children pendahuluan orang tua memegang peranan utama dan pertama bagi pendidikan anak. mengasuh, membesarkan dan mendidik anak merupakan tugas mulia yang tidak lepas dari berbagai halangan dan tantangan, sedangkan guru di sekolah merupakan pendidik yang kedua setelah orang tua di rumah. pada umumnya murid atau siswa adalah merupakan insan yang masih perlu dididik atau diasuh oleh orang yang lebih dewasa dalam hal ini adalah ayah dan ibu, jika orang tua sebagai pendidik yang pertama dan utama ini tidak berhasil meletakkan dasar kemandirian maka akan sangat berat untuk berharap sekolah mampu membentuk siswa atau anak menjadi mandiri. pengasuhan sebagai upaya pemenuhan kebutuhan dasar anak dalam rangka 'membesarkan' mereka, sangat besar perannya terhadap tumbuh kembang anak. upaya ini meliputi upaya pemenuhan kebutuhan biomedis, kasih sayang, dan stimulasi, di lain pihak, lingkungan merupakan faktor penentu proses tumbuh-kembang anak dan corak asuhnya. secara garis besar lingkungan terdiri dari, faktor ibu sebagai tokoh utama ekosistem mikro, faktor sosial ekonomi, dan faktor pemukiman. laporan dari unicef, setiap anak harus mendapatkan haknya untuk hidup layak untuk masa depan mereka, karena masa depan dunia tergantung pada mereka. setiap tahun, 10 juta bayi dilahirkan ke dunia ini dan mereka akan menjadi anak yang dewasa nantinya. setiap tahun, banyak dari mereka yang tidak modul anticipatory guidance (hasinuddin) 51 mendapatkan haknya dalam hal kasih sayang, gizi, perlindungan dan keamanan, kebutuhan untuk tumbuh dan berkembang. hampir 10 juta anak meninggal sebelum usia 10 tahun dan lebih dari 200 juta anak tidak berkembang sesuai potensi mereka karena adanya kesalahan dalam pengasuhan yang merupakan kebutuhan dasar anak untuk tumbuh dan berkembang secara optimal (unicef, 2010). di negara sedang berkembang, 45% dari populasi adalah anak berumur kurang dari 15 tahun dan di antaranya 20% adalah balita. hasil riset tentang perkembangan anak di indonesia menunjukkan bahwa sebanyak 17–20% anak menderita masalah perkembangan, emosi dan perilaku (basoeki, 2009). berdasarkan observasi yang dilakukan dengan menggunakan check list pola asuh pada bulan februari tahun 2010 di tk dharmawanita kabupaten bangkalan, dari 10 orang tua, peneliti menemukan adanya bentuk pola pengasuhan orang tua yang cenderung otoriter dalam mendidik anaknya. sebanyak 37% orang tua menganggap bahwa anak harus selalu menuruti kemauan orang tua, 30% orang tua yang masih memberikan hukuman fi sik kepada anak, dan anak ditakuti dengan hukuman, padahal pola asuh orang tua yang paling baik untuk perkembangan anak adalah pola asuh demokratis (augustine, 2010). hasil observasi tentang karakteritik anak di tk dharmawanita kabupaten bangkalan pada 10 orang anak ditemukan sebanyak 27% anak cenderung penakut, 17% anak pendiam, dan 23% anak kurang berinisiatif terutama dalam mencoba hal-hal yang baru. orang tua seringkali keliru dalam memperlakukan anak karena ketidaktahuan mereka akan cara membimbing dan mengasuh yang benar. apabila hal ini terus berlanjut, maka pertumbuhan dan perkembangan anak dapat terhambat. pakar emotional intelligence dari radani edutainment, hanny muchtar darta, mengatakan bahwa pengaruh pola asuh orang tua mempunyai dampak besar pada kehidupan anak di kemudian hari. biasanya terjadi ketika anak di bawah lima atau enam tahun dan di bawah 11 tahun. semua orang tua mempunyai tujuan yang sangat baik untuk anaknya, namun, kebanyakan orang tua tidak memahami dampak jangka panjang akibat dari pola asuh yang tidak tepat. pola asuh terdiri dari pola asuh otoriter, demokratis, dan permisif. pola asuh yang tepat dan efektif sangat penting peranannya dalam pengembangan psikologi anak karena bisa membentuk kepribadian anak di masa depan. kehidupan awal anak dimulai dari orang tua dan rumahnya, sehingga orang tua bertanggung jawab terhadap masa depan anak karena semua tergantung orang tua saat pertama kali menetapkan tujuan dan harapan terhadap anaknya di masa depan. jika sampai terjadi kesalahan dalam pola asuh, efeknya tidak hanya akan dirasakan oleh anak, tetapi orang tua juga pasti akan ikut merasakannya. orang tua pasti akan kecewa jika anaknya tidak bisa memenuhi harapannya hanya karena kepribadian anaknya tidak berkembang dengan baik karena salah pola asuh. untuk jangka panjang, efek yang akan dirasakan anak akibat salah pola asuh antara lain adalah anak akan kehilangan arah dan pegangan dalam menapaki kehidupannya. anak akan bingung kepada siapa dia akan berpegang, pada ayahnya atau ibunya, karena mereka berdua adalah orang tuanya. anak juga bisa kehilangan kesempatan untuk menerima, menerapkan dan mengadaptasi nilai-nilai yang diturunkan orang tuanya secara maksimal dan mantap. pada akhirnya, anak bisa menjadi orang yang tidak jujur pada dirinya sendiri, lebih suka mencari aman daripada menyelesaikan masalah, tidak kreatif, dan lain sebagainya. kesenjangan generasi juga bisa terjadi jika orang tua salah menerapkan pola asuh pada anaknya. perasaan dendam, tidak menghormati atau menghargai orang tua, juga bisa terjadi karena hal ini. dampak lain dari pola asuh orang tua dalam mendidik anak yang tidak tepat adalah gangguan perkembangan pada anak yang dapat meliputi perkembangan motorik kasar, motorik halus, perkembangan bahasa dan sosialisasi anak. meski begitu semua itu tidak bisa digeneralisasi pasti akan terjadi pada setiap orang tua yang salah menerapkan pola asuh pada anaknya, karena banyak juga yang terjadi justru sebaliknya. semua kembali pada karakter dan lingkungan di mana anak tersebut tumbuh dan berkembang. bisa saja anak itu jurnal ners vol. 6 no. 1 april 2011: 50–57 52 malah tumbuh menjadi anak yang lebih arif dan bijaksana dalam menghadapi orang tuanya. namun menurut augustine, hasil penelitian ilmu psiko dinamika keluarga mengungkapkan bahwa salah satu faktor yang membuat orang menjadi terganggu kesehatan mentalnya adalah salah pola asuh. karena itu, sedini mungkin, orang tua harus bisa lebih bijaksana dalam menerapkan pola asuh. oleh karena itu dalam penelitian ini. peneliti menekankan pada pola asuh orang tua yang otoriter karena dampaknya yang dapat menghambat perkembangan optimal pada anak. sebagai bagian dari tenaga kesehatan profesional, perawat mempunyai peran yang penting dalam membantu memberikan bimbingan dan pengarahan pada orang tua (anticipatory guidance), sehingga setiap fase dari kehidupan anak yang kemungkinan mengalami trauma dan ketakutan yang abstrak pada usia prasekolah dapat dibimbing secara bijaksana. pemberian anticipatory guidance akan efektif apabila diberikan dalam bentuk pelatihan menggunakan modul. modul merupakan uraian terkecil bahan belajar yang akan memandu fasilitator atau pelatih menyampaikan bahan belajar dalam proses pembelajaran yang sesuai secara terperinci. berdasarkan fenomena di atas, maka peneliti tertarik untuk meneliti tentang pengaruh pemberian modul pelatihan anticipatory guidance terhadap pola asuh orang tua dalam memberikan stimulasi perkembangan anak di tk dharmawanita kabupaten bangkalan. bahan dan metode jenis penelitian ini adalah penelitian eksperimen dengan pendekatan menggunakan pre post test with control group design. jumlah anak di tk dharmawanita kabupaten bangkalan pada tahun 2010 adalah 98 orang. populasi sasaran dalam penelitian ini adalah responden yang mempunyai pola asuh otoriter dalam memberikan stimulasi perkembangan pada anak di tk dharmawanita kabupaten bangkalan. karena jumlah sampel ≤ 15, maka diambil sampel minimal sebesar 15 orang pada masing-masing kelompok (kelompok kontrol dan kelompok perlakuan). pada penelitian ini peneliti menggunakan pengumpulan data dengan simple random sampling. i n s t r u m e n d a l a m p e n e l i t i a n i n i menggunakan modul pelatihan, kuesioner dan format wawancara untuk mengumpulkan data tentang pola asuh orang tua. untuk menjaga validitas dan reliabilitas dari kuesioner pola asuh orang tua yang dibuat oleh peneliti, diadakan uji validitas terlebih dahulu menggunakan korelasi pearson product moment dan uji reliabilitas menggunakan alfa cronbach yang dilaksanakan di tk dharmawanita kecamatan burneh sebanyak 15 orang responden. hasil uji validitas menunjukkan bahwa r hitung terkecil 0,8286 > r tabel (0,514) sehingga semua item pertanyaan dinyatakan valid, sedangkan nilai alpha (0,8476) > r tabel (0,514) sehingga semua item pertanyaan dinyatakan reliabel. p e n e l i t i a n i n i d i l a k u k a n d i t k dharmawanita kabupaten bangkalan pada bulan juni – juli tahun 2010. intervensi berupa pendampingan keluarga dengan menggunakan modul dilakukan di rumah masing-masing keluarga sesuai dengan konrak yang sudah disepakati. uji statistik: perubahan pola asuh sebelum dan sesudah dilakukan intervensi dan perubahan pola asuh pada kelompok kontrol digunakan uji wilcoxon, sedangkan untuk menganalisis perbedaan menggunakan uji mann withney dengan tingkat kepercayaan yang diinginkan 0,01, dan kriteria pengujiannya apabila p-value lebih kecil atau sama dengan α maka ho di tolak dan ha diterima artinya ada perbedaan antara pola asuh orang tua dalam memberikan stimulasi perkembangan anak antara yang diberikan modul pelatihan anticipatory guidance dengan yang tidak diberi. hasil mayoritas responden yang diberikan bimbingan antisipasi (anticipatory guidance) mengalami perubahan pola asuh dalam memberikan stimulasi perkembangan pada anak usia pra sekolah di tk dharmawanita kabupaten bangkalan yaitu sebanyak 11 orang (73,3%). dari kelompok perlakuan tersebut, modul anticipatory guidance (hasinuddin) 53 masih terdapat 4 orang (11%) responden yang tidak mengalami perubahan pola asuh. hasil uji statistik menunjukkan nilai rata-rata kelompok perlakuan sebelum intervensi (33,20) setelah diintervensi menjadi 2,274. hasil uji wilcoxon menunjukkan α (0,01) > p-value (0,001) yang berarti terdapat perbedaan pola asuh sebelum dan sesudah dilakukan intervensi berupa bimbingan antisipasi oleh perawat. r e s p o n d e n y a n g t i d a k d i b e r i k a n bimbingan antisipasi (anticipatory guidance) yaitu sebanyak 15 responden, 12 orang (80%) tidak mengalami perubahan pola asuh dalam memberikan stimulasi perkembangan pada anak usia pra sekolah di tk dharmawanita kabupaten bangkalan. pada kelompok kontrol, terdapat 3 (20%) orang tua yang mengalami perubahan pola asuh yang awalnya otoriter menjadi non otoriter. berdasarkan uji statistik, nilai rata-rata kelompok perlakuan pada observasi i (33,27) setelah observasi ii menjadi 32,00. hasil uji wilcoxon menunjukkan α (0,01) > p-value (0,098) yang berarti bahwa tidak terdapat perbedaan pola asuh pada kelompok yang tidak diberikan bimbingan antisipasi oleh perawat. tabel di atas menunjukkan bahwa pada kelompok perlakuan, responden mayoritas mengalami perubahan pola asuh yaitu sebanyak 11 orang (73,3%), sedangkan pada kelompok kontrol mayoritas tidak ada perubahan pola asuh yaitu sebanyak 12 orang (80%). hasil uji statistik menggunakan uji mann whitney didapatkan α (0,05) > p-value = 0,004. hal ini berarti terdapat perbedaan pola asuh antara kelompok yang diberikan bimbingan antisipasi (anticipatory guidance) dengan kelompok yang tidak diberikan bimbingan antisipasi (anticipatory guidance). tabel 1. perubahan pola asuh orang tua dalam memberikan stimulasi perkembangan pada anak di tk dharmawanita kabupaten bangkalan pada kelompok yang diberikan bimbingan antisipasi. no pola asuh orang tua selisih nilai sebelum intervensi sesudah intervensi x = 33,20 sd = 2,274 x = 28,60 sd = 2,667 hasil uji wilcoxon: p-value = 0,001 tabel 2. perubahan pola asuh orang tua dalam memberikan stimulasi perkembangan pada anak di tk dharmawanita kabupaten bangkalan yang tidak diberikan bimbingan antisipasi no pola asuh orang tua selisih nilai observasi i observasi ii x = 33,27 sd = 1,831 x = 32,00 sd = 2,591 hasil uji wilcoxon: p-value = 0,098 tabel 3. tabulasi silang perubahan pola asuh orang tua dalam memberikan stimulasi perkembangan pada anak di tk dharmawanita kabupaten bangkalan ada perubahan pola asuh tidak ada perubahan pola asuh total (%) f % f % kelompok perlakuan 11 73,3 4 26,7 100 kelompok kontrol 3 20 12 80 100 total 14 46,7 16 53,3 100 α = 0,01 uji mann whitney: p-value = 0,004 jurnal ners vol. 6 no. 1 april 2011: 50–57 54 pembahasan h a s i l p e n e l i t i a n d i d a p a t k a n d a t a bahwa dari 15 responden yang diberikan m o d u l p e l a t i h a n b i m b i n g a n a n t i s i p a s i (anticipatory guidance) sebanyak 11 orang (73,3%) mengalami perubahan pola asuh yang sebelumnya otoriter menjadi nonotoriter. tetapi masih ada 4 orang responden (26,7%) yang tidak mengalami perubahan pola asuh. hal ini dapat disebabkan karena faktor persepsi orang tua yang beranggapan bahwa pola asuh otoriter adalah bentuk yang paling baik dalam mendidik anak untuk menjadi disiplin. pola pengasuhan ini juga mereka terapkan seperti yang pernah diterima waktu mereka dididik oleh orang tuanya dulu. hal ini sesuai dengan pendapat rosa dan agustin (2010) bahwa latar belakang keluarga orang tua akan memengaruhi pola asuh yang diberikan, orang tua akan menyamakan diri mereka dengan pola asuh yang dipergunakan oleh orang tua atau keluarga besar mereka dulu. orang tua menganggap bahwa pola asuh orang tua mereka yang terbaik, maka ketika mempunyai anak mereka kembali memakai pola asuh yang mereka terima. responden yang tetap memberikan pola asuh otoriter meskipun telah diberikan modul pelatihan anticipatory guidance, jenis kelamin anaknya adalah perempuan semua. dalam menerapkan pola pengasuhan kepada anak perempuan mereka berpandangan bahwa anak perempuan harus dijaga lebih ketat sehingga cenderung menggunakan pola asuh yang otoriter. responden yang mengalami perubahan pola asuh setelah diberikan modul pelatihan anticipatory guidance, perubahan pola asuh yang diberikan pada umumnya adalah pola asuh demokratis. hal ini dapat dipengaruhi oleh beberapa faktor diantaranya faktor pendidikan orang tua. hasil penelitian tentang tingkat pendidikan ibu yang memiliki anak di tk dharmawanita kabupaten bangkalan sebagian besar adalah pendidikan sma. pendidikan ini nampaknya menjadi salah satu faktor yang menyebabkan adanya perubahan pola asuh pada orang tua yang diberikan modul pelatihan anticipatory guidance oleh perawat. hal ini sesuai dengan pendapat joko, (2009) yang menyatakan bahwa keluarga adalah lingkungan pendidikan pertama anak. cara mendidik dalam keluarga, memengaruhi reaksi anak terhadap lingkungan. tingkat pendidikan orang tua akan berpengaruh pada pola pikir dan orientasi pendidikan anak. semakin tinggi pendidikan orang tua akan melengkapi pola pikir dalam mendidik anaknya. orang tua dengan tingkat pendidikan yang cenderung rendah lebih memilih pola asuh tipe laissez faire atau pola asuh otoriter. sedangkan orang tua dengan tingkat pendidikan yang cenderung tinggi lebih memilih pola asuh tipe demokratis. usia dari orang tua dan anak juga bisa mempengaruhi orang tua dalam memilih suatu bentuk pola asuh bagi anaknya. hasil penelitian menunjukkan bahwa usia ibu yang memiliki anak usia 4–6 tahun di tk dharmawanita kabupaten bangkalan sebagian besar adalah usia dewasa muda. hal ini sesuai dengan pendapat rosa dan agustin (2010) yang menyatakan bahwa orang tua yang usianya masih muda cenderung untuk memilih pola sosialisasi yang demokratis atau permisif dibanding dengan mereka yang sudah lanjut usia. hasil penelitian menunjukkan bahwa orang tua yang diberikan modul pelatihan anticipatory guidance dapat memberikan pola asuh yang positif dalam memberikan stimulasi perkembangan bahasa pada anak. pola asuh yang kreatif, inovatif, seimbang, dan sesuai dengan tahap perkembangan anak akan menciptakan interaksi dan situasi komunikasi yang memberi kontribusi positif terhadap keterampilan berbahasa anak. dengan kata lain, kealamian pemerolehan bahasa tidak dibiarkan mengalir begitu saja, tetapi direkayasa sedemikian rupa agar anak mendapat stimulus positif sebanyak dan sevariatif mungkin. dengan demikian, diharapkan anak tidak akan mengalami kesulitan ketika memasuki tahap pembelajaran bahasa untuk kemudian menjadi sosok yang terampil berbahasa (fithriani, 2008). hasil penelitian berdasarkan kuesioner d a n w a w a n c a r a m e n u n j u k k a n t e r d a p a t p e r u b a h a n p o l a a s u h o r a n g t u a d a l a m memberikan stimulasi perkembangan personal sosial dan kemandirian anak. kemandirian pada anak berawal dari keluarga yang sangat dipengaruhi oleh pola asuh orang tua. di modul anticipatory guidance (hasinuddin) 55 dalam keluarga, orang tualah yang berperan dalam mengasuh, membimbing dan membantu mengarahkan anak untuk menjadi mandiri. mengingat masa anak-anak dan remaja merupakan masa yang penting dalam proses perkembangan kemandirian, maka pemahaman dan kesempatan yang diberikan orang tua kepada anak-anaknya dalam meningkatkan kemandirian amatlah krusial. keluarga merupakan pilar utama dan pertama dalam membentuk anak untuk mandiri. orang tua yang tetap menerapkan pola asuh otoriter meskipun sudah diberikan bimbingan antisipasi menyatakan bahwa mereka cenderung takut untuk membiarkan anak mereka melakukan aktivitas yang berisiko misalnya mencoba permainan baru yang sifatnya menantang. orang tua masih beranggapan bahwa aktivitas tersebut lebih cocok untuk anak laki-laki saja. hasil penelitian menunjukkan bahwa pada kelompok kontrol, cenderung tidak terdapat perubahan pola asuh. tetapi dari 15 responden masih terdapat 3 orang (20%) yang mengalami perubahan pola asuh meskipun mereka tidak modul pelatihan anticipatory guidance. masih adanya responden yang mengalami perubahan pola asuh meskipun tidak diberikan bimbingan antisipasi dapat disebabkan karena mereka mendapatkan informasi dari orang lain dalam hal ini adalah orang tua yang mendapatkan bimbingan antisipasi dari perawat (kelompok perlakuan). berdasarkan hasil wawancara dengan 2 orang responden yang mengalami perubahan pola asuh tanpa diberi modul pelatihan anticipatory guidance menyatakan bahwa mereka mulai menyadari pola asuh yang mereka terapkan selama ini kurang sesuai untuk perkembangan anak mereka, sedangkan 1 orang responden lainnya yang juga mengalami perubahan pola asuh tanpa diberi bimbingan antisipasi menyatakan banyak mendapat informasi tentang pola asuh dari teman kerjanya dan dari buku/majalah. hal ini juga berhubungan dengan pekerjaan orang tua sebagai pegawai negeri sipil di mana cenderung mudah untuk mendapatkan informasi-informasi yang berhubungan dengan pola asuh dan perkembangan anak. hasil penelitian menunjukkan bahwa sebagian besar responden yang tidak diberi perlakuan tidak mengalami perubahan pola asuh. hal ini dapat disebabkan oleh faktor tingkat pendidikan orang tua di mana sebagian besar adalah pendidikan menengah. tinggi rendahnya jenjang pendidikan yang dikecap orang tua juga menentukan pola asuh dalam sebuah keluarga. hal ini sesuai dengan pendapat rosa dan agustin (2010) bahwa semakin tinggi dan maju pendidikan orang tua, biasanya semakin baik pula keputusan mereka dalam menerapkan suatu pola asuh pada anak-anaknya. orang dewasa yang telah mengikuti kursus persiapan perkawinan, kursus kesejahteraan keluarga, atau kursus pemeliharaan anak, cenderung untuk menggunakan pola yang demokratis. ini terjadi karena mereka menjadi lebih mengerti tentang anak dan kebutuhan-kebutuhannya. orang tua yang tradisional cenderung lebih menggunakan pola yang otoriter dibandingkan orang tua yang lebih modern. hasil penelitian menunjukkan bahwa pada kelompok kontrol, jenis kelamin anak di tk dharmawanita kabupaten bangkalan sebagian besar adalah perempuan. hal ini sesuai dengan pendapat rosa dan agustin (2010) bahwa orang tua juga biasanya memperlakukan anak-anak mereka sesuai dengan jenis kelaminnya. misalnya terhadap anak perempuan mereka harus menjaga lebih ketat sehingga menggunakan pola yang otoriter. sedang terhadap anak laki-laki cenderung lebih permisif atau demokratis. pada orang tua yang memiliki anak laki-laki, mereka cenderung tetap menerapkan pola asuh otoriter karena beranggapan bahwa anak laki-laki harus mendapatkan pengasuhan yang lebih ketat supaya nanti kalau sudah besar tidak menjadi orang yang nakal. status sosial ekonomi juga mempengaruhi orang tua dalam menggunakan pola sosialisasi mereka bagi anak-anaknya, misalnya jika orang tuanya adalah orang yang terpandang di suatu lingkungan, maka biasanya orang tua akan menerapkan pola otoriter karena ingin anak-anaknya menurut padanya, sehingga pandangan orang lain pada orang tuanya tetap baik (rosa dan augustine, 2010). berdasarkan hasil pengamatan dan wawancara pada jurnal ners vol. 6 no. 1 april 2011: 50–57 56 saat penelitian, orang tua yang cenderung mempertahankan pola pengasuhan yang otoriter adalah mereka yang dianggap terpandang di daerah tersebut. selain hal tersebut, pekerjaan orang tua sebagai perangkat desa dan tokoh masyarakat juga menyebabkan orang tua cenderung memiliki pola asuh yang otoriter. hasil penelitian menunjukkan bahwa pemberian modul pelatihan anticipatory guidance oleh perawat mempunyai pengaruh yang signifikan terhadap perubahan pola asuh orang tua dalam memberikan stimulasi perkembangan pada anak usia 4–6 tahun di tk dharmawanita kabupaten bangkalan. hal ini ditunjukkan dengan adanya perubahan pola asuh pada kelompok yang mendapatkan modul pelatihan, sedangkan kelompok yang tidak mendapatkan modul pelatihan cenderung tidak mengalami perubahan pola asuh. k o n s e p a n t i c i p a t o r y g u i d a n c e m e n j e l a s k a n b a h w a u s i a a n a k a n a k dapat mengalami trauma di setiap tahap perkembangan mereka, misalnya ketakutan yang tidak jelas pada anak-anak pra sekolah yang dapat menimbulkan dampak negatif bagi perkembangan anak. syahreni (2009) m e n d e f i n i s i k a n a n t i c i p a t o r y g u i d a n c e sebagai metode yang digunakan perawat untuk membantu orang tua menyediakan pengembangan perubahan perilaku ke arah lebih baik untuk memahami anak-anak mereka. orang tua mempunyai tantangan untuk memberikan pembinaan, kedisiplinan, kemandirian, meningkatkan mobilitas, dan keamanan. dalam hal ini peran perawat dibutuhkan untuk memberikan bimbingan antisipasi kepada orang tua. petunjuk antisipasi bisa diartikan petunjuk-petunjuk yang perlu diketahui terlebih dahulu agar orang tua dapat mengarahkan dan membimbing anaknya secara bijaksana, sehingga anak dapat bertumbuh dan berkembang secara normal (nursalam, 2005). dalam upaya untuk memberikan bimbingan dan arahan pada masalah-masalah yang kemungkinan t i m b u l p a d a s e t i a p f a s e p e r t u m b u h a n dan perkembangan anak, ada petunjukpetunjuk yang perlu dipahami oleh orang tua. orang tua dapat membantu untuk mengatasi masalah anak pada setiap fase pertumbuhan dan perkembangannya dengan cara yang benar dan wajar. pemberian modul pelatihan anticipatory guidance ini, peneliti melibatkan peran serta aktif dari ibu karena sesuai dengan pendapat rosa dan agustin (2010) bahwa ibu lebih berperan sebagai orang yang bisa memenuhi kebutuhan anak, merawat keluarga dengan sabar, mesra dan konsisten, mendidik, mengatur dan mengendalikan anak, sehingga diharapkan ibu bisa menjadi contoh dan teladan bagi anak. tapi, semua itu tidak bisa digeneralisasi atau bersifat konstekstual, semua itu harus disesuaikan kembali kepada karakter, komitmen dan tujuan ayah dan ibu dalam membentuk keluarga dan anak-anaknya di masa depan. pendampingan oleh perawat (anticipatory guidance), peran orang tua sangat penting karena pengasuhan mempunyai peranan yang sangat besar dalam menentukan perkembangan anak nanti ke depannya. orang tua perlu memahami prinsip-pinsip pengasuhan yang baik agar anak menjadi pribadi yang memiliki perkembangan yang baik sesuai dengan harapan orang tua. disini peran perawat sangat penting untuk mendampingi orang tua dalam menentukan pola pengasuhan yang baik. perawat perlu memperhatikan karakteristik keluarga dan tipe keluarga karena hal itu akan banyak memengaruhi keberhasilan dalam pemberian anticipatory guidance oleh perawat. anak sebagai objek asuhan orang tua dan indikator yang utama dalam menilai keberhasilan perawat memberikan anticipatory g u i d a n c e d a l a m k e l u a r g a m e r u p a k a n fokus utama karena keberhasilan dalam pendampingan ini akan ditunjukkan melalui perubahan perkembangan menjadi ke arah yang lebih baik. perawat perlu memperhatikan karakteristik anak dan kemampuan anak saat ini karena hal ini juga ikut menentukan perkembangan anak kedepannya nanti. selain keluarga dan anak yang menjadi dasar dalam pemberian anticipatory guidance, lingkungan juga memiliki pengaruh yang besar dalam keberhasilan perawat memberikan anticipatory guidance dalam suatu keluarga. lingkungan modul anticipatory guidance (hasinuddin) 57 yang kondusif dan mendukung anak menuju perkembangan yang optimal akan sangat baik bagi perkembangan anak untuk kedepannya nanti. sebaliknya lingkungan yang cenderung kurang memberikan pengasuhan atau role model yang baik akan sangat berbahaya dalam perkembangan anak nanti terutama bagi anakanak usia prasekolah. lingkungan sosial dari luar keluarga dapat memengaruhi perkembangan anak seperti televisi, day care centre, perwakilan pemerintah, perubahan sekolah, dan institusi agama. orang tua kebingungan menentukan kapan memberi semangat atau mengendalikan partisipasi mereka. perawat mengatur rencana bertemu orang tua untuk mempercepat mempelajari dan memperbesar harga diri orang tua melalui bimbingan antisipasi. simpulan dan saran simpulan pola asuh orang tua dalam memberikan stimulasi perkembangan pada anak di tk dharmawanita kabupaten bangkalan yang diberikan modul pelatihan anticipatory guidance oleh perawat mayoritas mengalami perubahan dari pola asuh otoriter menjadi pola asuh non otoriter. pola asuh orang tua dalam memberikan stimulasi perkembangan pada anak di tk dharmawanita kabupaten bangkalan yang tidak diberikan modul pelatihan anticipatory guidance oleh perawat mayoritas tidak mengalami perubahan pola asuh otoriter. modul pelatihan anticipatory guidance mempunyai pengaruh terhadap perubahan pola asuh orang tua dalam memberikan stimulasi perkembangan anak di tk dharmawanita kabupaten bangkalan. saran i n s t i t u s i p e n d i d i k a n d i t i n g k a t pendidikan tinggi keperawatan hendaknya dapat memperluas kajian tentang pentingnya upaya-upaya peningkatan tumbuh kembang anak terutama sebagai upaya preventif dalam peningkatan derajat kesehatan di masyarakat. bagi pelayanan kesehatan terutama di puskesmas perlunya peningkatan bimbingan antisipasi bagi keluarga yang mempunyai masalah dalam hal pengasuhan anak sebagai bagian dari progam kesehatan ibu anak (kia) melalui pelatihan dengan menggunakan modul yang telah di standarisasi. perlunya dilakukan penelitian lebih lanjut tentang pengaruh bimbingan antisipasi oleh perawat bagi perkembangan anak sebagai tindak lanjut dari penelitian ini dengan memperhatikan faktor-faktor yang mempengaruhi perkembangan anak itu sendiri dan dalam jumlah sampel yang lebih besar. kepustakaan augustine, 2010. cerdas mulai 0 tahun, (online), (http://www.carisuster.com. diakses tanggal 8 maret 2010). budiarti, y.r., dan basoeki, l., 2005. pengaruh pola asuh ibu terhadap keparahan gejala adhd. proposal thesis tidak dipublikasikan. surabaya: universitas airlangga. fithriani, p., 2008. pengaruh pola asuh terhadap perkembangan bahasa, (online), (http:// mradhi.com/linguistik/pengaruh-polaasuh-terhadap-perkembangan-bahasaanak.html). nursalam, utami, dan susilaningrum, 2005. asuhan keperawatan bayi dan anak (untuk perawat dan bidan). jakarta: salemba medika. syahreni, 2009. anticipatory guidance. jakarta: universitas indonesia. vol 9 no 1 april 2014.indd 118 prediksi penderita gangguan jiwa dipasung keluarga (prediction of mental disorders deprived by family) sri mugianti*, suprajitno* jurusan keperawatan poltekkes malang e-mail: bedonku@yahoo.co.id abstrak pendahuluan: keluarga merupakan tempat utama dan pertama untuk memenuhi kebutuhan dasar manusia, memiliki lima tugas di bidang kesehatan. ketidakmampuan keluarga melaksanakan tugasnya akan menjadi masalah pada anggota keluarga yang menderita gangguan jiwa, sehingga memungkinan terjadi pemasungan. tujuan penelitian ini adalah merumuskan kemungkinan pemasungan penderita gangguan jiwa oleh keluarga. metode: desain penelitian ini adalah cross sectional. subyek penelitian sebanyak 45 keluarga yang memiliki anggota keluarga penderita gangguan jiwa berasal dari empat kluster di puskesmas bacem ponggok dan sutojayan kabupaten blitar, yang dipilih dengan teknik cluster random sampling secara rapid survei. analisis menggunakan regresi nominal dengan α = 0,05. hasil: dua tugas keluarga yang berpengaruh terjadinya pemasungan pasien yaitu kemampuan keluarga merawat dengan nilai signifi kan 0,009 dan kemampuan keluarga memanfaatkan sarana pelayanan kesehatan dengan nilai signifi kan 0,034. kemungkinan pasien gangguan jiwa dipasung oleh keluarga diformulasikan dalam sebuah rumus. diskusi: besar pengaruh kedua tugas keluarga sebesar 37,1% (nagelkerke sebesar 0,371) sedangkan 62,9% dipengaruhi oleh faktor lain. untuk memperkecil kejadian pasung diharapkan keluarga merawat penderita dengan ikhlas, kasih sayang, dan memanfaatkan sarana pelayanan kesehatan. kata kunci: lima tugas keluarga, gangguan jiwa, pemasungan abstract introduction: the family was the place and the fi rst to meet the basic needs of human beings, has fi ve tasks in health. the inability of the family perform its tasks will be a problem in a family member suffering from a mental disorder, so allow the deprivation occurred. the aim of this study was to formulate the possibility of deprivation of people with mental disorders by family. method: the study design was cross sectional. study subjects by 45 families who have family members with mental disorders from four clusters at health centres of bacem ponggok and sutojayan of kabupaten blitar, selected by cluster random sampling with rapid survey. analysis using nominal regression with α = 0.05. result: two tasks the family that affect was deprived of the ability of families caring for patients with signifi cant value 0.009 and the ability of families utilizing health care facilities with signifi cant value of 0.034. the possibility of patients to be deprived by family was formulated. discussion: infl uences family task was 37.1% (nagelkerke = 0.371) whereas 62.9% infl uenced by other factors. to minimize the occurrence of deprived be expected to treat patients with a family of faith, love, and use of health service facilities. key words: fi ve tasks family, mental disorder, deprivation pendahuluan keluarga merupakan tempat pertama dan utama unt uk memenuhi kebut uhan dasar manusia. sesuai hirark hi maslow kesehatan jiwa merupakan kebutuhan dasar mulai kebutuhan dasar sampai aktualisasi diri. peran keluarga menjadi penting untuk menemukan dan mengenali masalah keluarga yang berkaitan dengan gangguan jiwa. hasil riskesdas 2007 menunjukkan gangguan jiwa berat 0,46%, gangguan mental emosional 11,6 %. data tersebut merupakan data kesehatan jiwa tanpa bencana, sedangkan menur ut world health organization (who) tahun 2005 terdapat masalah kesehatan jiwa akibat bencana dengan gangguan jiwa berat 3–4%, gangguan mental emosional 15–20% dan stress ringan sampai berat 20–50%. gangguan jiwa berdampak penurunan produktivitas, peningkatan biaya perawatan, dan cenderung menimbulkan permasahan baru misalnya resiko perceraian pada pasangan suami istri, resiko terjadi penganiayaan dan penyiksaan pada kondisi amuk. pemahaman yang masih rendah terhadap gangguan jiwa di masyarakat, dan pandangan miring terhadap penderita gangguan jiwa dengan masih lekatnya stigma yang diberikan menjadikan 119 prediksi penderita gangguan jiwa (sri mugianti dan suprajitno) keluarga penderita gangguan jiwa semakin tidak mampu membuat keputusan yang tepat untuk mengasuh penderita gangguan jiwa. keperawatan jiwa komunitas merupakan upaya yang digunakan untuk membantu masyarakat dalam menyelesaikan masalahmasalah kesehatan jiwa akibat konfl ik atau bencana (keliat dkk, 2006). upaya tersebut akan berjalan lancar bila didukung dengan pemberdayaan keluarga yang merupakan unit terkecil dari masyarakat. lima tugas keluarga di bidang kesehatan harus dipahami dan dilakukan oleh keluarga untuk mendapatkan hasil perawatan optimal. peran tersebut adalah mengenali gangguan kesehatan jiwa, mengambil keputusan yang tepat, merawat penderita gannguan jiwa, memodif ikasi lingkungan, dan memanfaatkan fasilitas kesehatan (suprajitno, 2004). prevalensi gangguan jiwa di wilayah kabupaten blitar sampai dengan trimester awal 2013 sejumlah 786 penderita tercatat dalam register puskesmas dan menjalani perawatan tersebar di 21 puskesmas (laporan pemegang program kesehatan jiwa dinas kesehatan kabupaten blitar). penderita gangguan jiwa yang dipasung menunjukkan peningkatan tahun 2011 sebanyak 8 orang sedangkan tahun 2012 menjadi 14 orang. hasil wawancara dengan pemegang program kesehatan jiwa puskesmas ponggok terdapat 42 penderita, lama gangguan jiwa kurang dari 2 bulan atau akut sebanyak 2 orang, kurang dari satu tahun sebanyak 5 orang, dan sisanya lebih dari dua tahun. pada tahun 2012 terdapat dua orang penderita mengalami amuk menyerang orang lain (keluarga). keadaan amuk menjadi normal kembali setelah penderita mendapatkan pengobatan dari puskesmas. kemampuan keluarga untuk membuat keputusan sangat bervariasi, yaitu: penderita gangg uan jiwa ditempat kan di tempat ter pencil dan diikat, penderita dibiarkan berkeliaran, dan penderita dibawa berobat ke layanan kesehatan. pengobatan oleh keluarga tergantung dari pemahaman, kemauan, dan keberdayaan keluarga dalam melaksanakan tugas di bidang kesehatan. r u m u s a n m a s a l a h n y a a d a l a h bagaimanakah rumus kemungkinan penderita dipasung oleh keluarga berdasarkan lima tugas keluarga di bidang kesehatan. tujuan khusus yang dirumuskan adalah: (1) menentukan tugas keluarga yang berpengaruh terhadap kemampuan keluarga mengasuh penderita gangg uan jiwa, (2) menganalisis besar pengar u h t ugas keluarga yang ter pilih terhadap kemampuan keluarga mengasuh penderita gangguan jiwa, dan (3) merumuskan persamaan fungsi kemungkinan penderita gangguan jiwa diperlakukan keluarga. secara teoritis diharapkan sebagai data dasar untuk melakukan pengembangan ilmu keperawatan khususnya dan ilmu kesehatan pada umumnya. secara praktis diharapkan sebagai upaya meningkatkan pemahaman pelaksanaan lima tugas keluarga di bidang kesehatan agar keluarga mampu membuat keput usan yang tepat u nt u k mengasu h penderita gangguan jiwa sehingga terjadi pemenu ha n kebut u ha n rasa ama n d a n kesejahteraan penderita gangguan jiwa yang tinggal di keluarga. bahan dan metode desain yang digunakan adalah cross sectional. subjek yang diteliti sebanyak 45 keluarga yang memiliki anggota keluarga penderita gangguan jiwa berasal dari empat k luster di p uskesmas bacem ponggok dan sutojayan kabupaten blitar. metode sampling yang digunakan cluster random sampling secara rapid su r vei. var iabel bebasnya adalah lima tugas keluarga di bidang kesehatan meliputi kemampuan mengenal masalah kesehatan, kemampuan mengambil keputusan, kemampuan merawat, kemampuan memodifi kasi lingkungan, dan kemampuan memanfaatkan saran pelayanan kesehatan. variabel tergantungnya adalah kemampuan keluarga mengasuh anggota keluarga yang menderita gangguan jiwa. alat pengumpulan data menggunakan kuesioner yang dikembangkan dari toeri tugas keluarga di bidang kesehatan, selanjutnya kuesioner 120 jurnal ners vol. 9 no. 1 april 2014: 118–125 diisi oleh anggota keluarga yang mengasuh pe nde r it a ga ngg u a n jiwa set iap ha r i. pengumpulan data dilakukan pada bulan juli–nopember 2013. analisis menggunakan regresi nominal dengan α = 0,05. hasil keadaan keluarga yang merawat pasien gangguan jiwa digambarkan seperti tabel 1. hasil analisis uji statistik menggunakan regresi nominal dengan metode entered yaitu dilakukan sekali analisis regresi terhadap var iabel dependen dan semua var iabel independen yang dipilih secara serentak. hasil regresi logistik dan nilai β variabel independen yang signifi kan seperti pada tabel 4, kesesuaian model fungsi seperti pada tabel 5, dan nilai pengaruh variabel independen secara bersama seperti pada tabel 6. dari tabel 4 dapat dibuat tabel 2. tabulasi silang antara tempat dan rutinitas periksa pasien gangguan jiwa rutinitas periksa total ya tidak tempat periksa puskesmas 25 55,6% 9 20,0% 34 75,6% bukan 0 0,0% 11 24,4% 11 24,4% total 25 55,6% 20 44,4% 45 100,0% tabel 3. perlakuan keluarga pada penderita gangguan jiwa no. perlakuan pada pasien f % 1 dibiarkan aktivitas sendiri 21 46,7 2 dipasung 2 4,4 3 diatur aktivitasnya 22 48,9 total 45 100,0 tabel 4. nilai regresi logistik dan β variabel independen dengan metode entered model effect(s) model fi tting criteria effect selection test nilai β kejadian dipasungχ2 df sig 0 intercept 75,951 -19,712 1 rawat 66,513 9,438 2 0,009 -37,209 2 sarana 59,734 6,779 2 0,034 -19,010 tabel 1. keadaan keluarga dengan pasien gangguan jiwa no. keadaan keluarga f % 1 hubungan keluarga: ibu bapak anak suami / istri kakak adik bukan keluarga inti 14 4 4 8 9 4 2 31,1 8,9 8,9 17,8 20,0 8,9 4,4 2 pengertian keluarga tentang gangguan jiwa: gangguan pikiran saraf terganggu tidak dapat tidur perilaku aneh orang gila depresi tidak tahu 18 4 1 4 10 7 1 40,0 8,9 2,2 8,9 22,2 15,6 2,2 121 prediksi penderita gangguan jiwa (sri mugianti dan suprajitno) tabel 6. nilai pseudo r-square cox and snell nagelkerke mc fadden 0,303 0,371 0,214 tabel 5. nilai kesesuaian model fungsi model model fi tting criteria likelihood ratio test χ2 df sig intercept only 75,951 ---final 59,734 16,217 4 0,003 fungsi kemungkinan pasien gangguan jiwa dipasung oleh keluarga adalah sebesar kemungkinan (dipasung) 1 1 + β(19,712-37,209*rawat-19,010*sarana) sebagai contoh jika nilai kemampuan merawat anggota yang gangguan jiwa sebesar 0 dan kemampuan menggunakan sarana pelayanan kesehatan 0 maka kemungkinan pasien gangguan jiwa dipasung oleh keluarga sebesar 36 kali jika keluarga memiliki nilai minimal 1 pada kedua variabel tersebut. pada sampel 26 jika nilai kemampuan merawat anggota yang gangguan jiwa sebesar 0 dan kemampuan menggunakan sarana pelayanan kesehatan 1 maka kemungkinan pasien gangguan jiwa dipasung oleh keluarga sebesar 3 kali jika keluarga memiliki nilai minimal 1 pada kedua variabel tersebut. nilai pseudo r-square untuk pengaruh kedua variabel independen secara bersama terhadap variabel dependen kemungkinan pasien gangguan jiwa dipasung oleh keluarga yaitu pada tabel 6. b e r d a s a r k a n t a b e l 6 , v a r i a b e l independen yait u kemampuan merawat anggota yang gangguan jiwa dan kemampuan menggunakan sarana pelayanan kesehatan ha nya ber penga r u h terha d ap keja d ia n pemasungan pasien gangguan jiwa adalah sebesar 37,1% sedangkan 62,9% dipengaruhi oleh faktor lain. berdasarkan hasil penelitian dimungkinkan faktor lain yang mempengaruhi pemasungan pasien gangguan jiwa adalah pengertian keluarga tentang gangguan jiwa atau faktor lain. pembahasan kejadian pemasungan di masyarakat indonesia dimungkinkan belum tahunya masyarakat atau keluarga yang memiliki anggota keluarga menderita gangguan jiwa. secara sederhana masyarakt perlu diberikan pengertian tentang pemasungan, yaitu segala tindakan pengikat an dan pengekangan fi sik yang dapat mengakibatkan kehilangan kebebasa n seseora ng. da r i penger t ia n tersebut, pemasungan termasuk penelantaran, bertentangan dengan rasa kemanusiaan, dan melanggar ham (hak azasi manusia) penderita gangguan jiwa. undang undang ( u u) nomor 36 tahun 2009 tentang kesehatan khususnya bab ix pasal 144 – 151 tentang kesehatan jiwa menegaskan bahwa upaya kesehatan jiwa ditujukan untuk menjamin orang dapat menikmati kehidupan kejiwaan yang sehat, bebas dari ketakutan, tekanan dan gangguan lain yang dapat mengganggu kesehatan jiwa. pemasungan penderita gangguan jiwa di indonesia telah dilarang untuk dilakukan berdasarkan uu nomor 23 tahun 1966 tentang kesehatan jiwa menyatakan bahwa pasien dengan gangguan jiwa yang terlantar mendapatkan perawatan dan pengobatan pada suatu tempat perawatan. uu tersebut ditindaklanjuti dengan surat menteri dalam negeri nomor pem.29/6/15, tertanggal 11 nopember 1977 yang dit ujukan kepada gubernur kepala daerah tingkat i seluruh indonesia, meminta kepada masyarakat untuk tidak melakukan pemasungan terhadap penderita gangguan jiwa dan menumbuhkan kesadaran masyarakat untuk menyerahkan perawatan penderita di rumah sakit jiwa. pemasungan penderita gangguan jiwa masih juga dilakukan oleh keluarga saat ini. keadaan tersebut bertentangan dengan deklarasi menteri kesehatan ri pada 10 122 jurnal ners vol. 9 no. 1 april 2014: 118–125 oktober 2010 yaitu menuju indonesia bebas pasung. alasannya melanggar uu yang dimiliki negara indonesia, karena gangguan jiwa dapat disenbu h kan dan pender it a gangguan jiwa berhak mendapatkan layanan pengobatan dan perlakuan yang manusiawi. sehingga, indonesia bebas pasung memiliki makna upaya untuk membuat indonesia bebas secara nasional dari adanya praktik pasung dan penelantaran terhadap penderita gangguan jiwa. berdasarkan hasil regresi logistik dan nilai β variabel independen yang signifi kan adalah t ugas keluarga merawat anggota keluarga yang menderita gangguan jiwa dan memanfaatkan sarana/fasilitas kesehatan dengan nilai signifi kansi 0,009 dan 0,034. tugas keluarga dalam merawat pasien gangguan jiwa merupakan tugas ketiga dari lima tugas keluarga di bidang kesehatan. tugas ketiga ini secara statistik berpengaruh sebesar nilai –37,209 terhadap kejadian pemasungan penderita gangguan jiwa oleh keluarga. merawat anggota keluarga yang sakit mer upakan sesuat u yang alamiah terjadi pada sebuah keluarga. seberapapun t i ng kat pemahaman kelua rga terhad ap gangguan jiwa, seberapa tepat pembuatan keputusan dan seberapapun keberdayaan keluarga, tugas merawat anggota keluarga yang sakit merupakan wujud bahwa fungsi keluarga tersebut berjalan, hal ini terutama terkait dengan f ungsi keluarga menur ut friedman (1992) yaitu (1) fungsi cinta kasih: memberikan kasih sayang dan rasa aman, memberikan perhatian diantara anggota keluarga, (2) fungsi melindungi: melindungi anak dari tindakan-tindakan yang tidak baik, sehingga anggota keluarga merasa terlindung dan merasa aman, dan (3) fungsi reproduksi: mener uskan ketur unan, memelihara dan membesarkan anak, memelihara dan merawat anggota keluarga. bila dikaitkan dengan hasil penelitian tampak bahwa orang terdekat yang merawat pasien gangguan jiwa sesuai sampel penelitian hampir 100% adalah keluarga inti, hanya 4.4% saja dirawat bukan oleh keluarga inti, namun masih ada hubungan kekerabatan. merawat anggota keluarga yang sakit merupakan bentuk rasa kasih sayang, ikatan yang terjadi antar anggota keluarga. bentuk kegiatan perawatan pada hal sederhana memungkinkan dilakukan oleh keluarga, menimbulkan rasa spontan perawatan oleh anggota keluarga yang lain, sehingga dapat disimpulkan kemampuan keluarga melakukan tugas untuk merawat anggota keluarga yang sakit akan memperkecil kemungkinan pasien gangguan jiwa dipasung. menurut pkmrs rs jiwa radjiman wediodiningrat lawang, merawat penderita gangguan jiwa di keluarga merupakan upaya rehabilitasi. rehabilitasi bertujuan untuk mengoptimalkan kemampuan atau upaya untuk membantu mencapai kualitas hidup yang optimal bagi pender ita gangg uan jiwa. rehabilitasi akan membantu proses penyembuhan dan kembalinya kepercayaan diri penderita gangguan jiwa. di samping itu diperlukan peran serta masyarakat yang dekat dengan keluarga karena masyarakat dapat membantu proses rehabilitasi dengan m e n e r i m a d a n m e n d o r o n g p e n d e r it a melakukan aktifitas sosial sesuai dengan keadaannya. peran serta masyarakat aktif yang diperlukan, jika menemukan kasus pasung pada orang dengan gangguan jiwa di sekitar tempat tinggalnya diharap segera melapor ke (1) kader kesehatan, (2) fasilitas layanan kesehatan terdekat (puskesmas, rumah sakit umum, atau rumah sakit jiwa), atau (3) dinas kesehatan setempat. merawat penderita gangguan jiwa di keluarga, seharusnya tidak diartikan seperti merawat penderita yang sakit dan dirawat inap di rumah sakit. merawat yang sebenarnya pada penderita gangguan jiwa adalah jika keluarga atau masyarakat tidak mengabaikan, menelantarkan, mengucilkan, mengolokolok, atau bahkan memasung. jika keadaan tersebut dilakukan disebut perilaku keluarga atau masyarakat yang salah. perilaku salah mungkin didasarkan pada persepsi yang salah. persepsi yang salah dan benar tentang penderita gangguan jiwa ditabelkan seperti tabel 7. tugas keluarga kelima di bidang kesehatan yaitu keluarga memanfaatkan fasilitas pelayanan kesehatan memiliki pengaruh sebesar –19,010 untuk kemungkinan 123 prediksi penderita gangguan jiwa (sri mugianti dan suprajitno) pemasungan oleh keluarga dilakukan pada penderita gangguan jiwa. pemanfaatan fasilitas pelayanan kesehatan dapat berbentuk bantuan petugas kesehatan atau pelayanan fasilitas kesehatan yang dibutuhkan keluarga ketika keluarga tidak mampu merawat sendiri anggota keluarga yang sakit dapat dipenuhi. sarana pelayanan kesehatan yang dapat berperan pada lini pertama adalah pusat kesehatan masyarakat (puskesmas). fungsi puskesmas diantaranya sebagai pusat pemberdayaan masyarakat dan keperawatan kesehatan masyarakat. puskesmas sebagai pusat pemberdayaan masyarakat ber pean unt uk memberikan pemahaman bahwa penderita gangg uan jiwa dapat disebut orang dengan masalah kejiwaan (odmk). odmk yang berat dan kronis seperti skizofrenia dan gangguan bipolar adalah termasuk kelompok yang rentan mengalami pengabaian hak-haknya. who dalam pernyataannya mengenai kesehatan jiwa, menyatakan bahwa, gangguan jiwa mempengaruhi cara berpikir dan berperilaku, kemampuan untuk melindungi kepentingan dir inya dan kemampuan mereka u nt u k mengambil keputusan; seseorang dengan gangguan jiwa berhadapan dengan stigma, disk riminasi dan marginalisasi. stigma m e nye b a b k a n m e r e k a t id a k m e n c a r i pengobatan yang sangat mereka butuhkan, atau mereka akan mendapatkan pelayanan yang bermutu rendah; marginalisasi dan disk r iminasi juga meningkatkan r isiko tabel 7. persepsi kepada penderita gangguan jiwa persepsi salah persepsi benar bukan penyakit tetapi guna-guna. penyakit medis sama dengan diabetes dan hipertensi dan juga bisa diobati oleh dokter. tidak bisa sembuh gejalanya banyak yang bisa membaik dan bahkan sebagian bisa sembuh sempurna. penyebabnya lemah mental penyebabnya kompleks, kombinasi dan neurokimia otak yang tidak seimbang, genetic dan lingkungan. saya tidak mungkin menderita sakit ini penyakit ini tidak kenal golongan, semua orang punya resiko menderita sakit ini. penderita berbahaya bagi sekitar faktanya,mereka banyak yang menjadi korban. seperti kita, penderita juga bisa emosi jika diejek atau diperlakukan tidak adil. penderita tidak bisa diharapkan saat ini banyak pilihan pengobatan. dengan dukungan masyarakat dan keluarga, mereka bisa hidup aktif dan produktif. kami tidak bisa membantu kesembuhan penderita banyak yang bisa anda lakukan. mulailah dengan bersikap dan berbicara yang baik dengan mereka. kekerasan pada hak-hak individu, hak politik, ekonomi, sosial dan budaya. peran puskesmas, diharapkan juga m e ny a m p a i k a n b a hw a odm k t id a k diperbolehkan dipasung dan diterlantarkan. sehingga, peran serta masyarakat diharapkan ma mpu u nt u k mengenal i k a su s-k a su s gangguan jiwa di masyarakat, pemasungan yang ada di lingkungan dan mendorong anggota masyarakat unt u k berobat dan kontrol. upaya puskesmas untuk menuju indonesia bebas pasung diperlukan juga upaya d an peran pemer i nt ah. karena, pemerintah dan pemerintah daerah bukan hanya menemukan kasus-kasus pasung untuk kemudian melepaskan tetapi juga har us memberikan edukasi pada masyarakat untuk tidak melakukan pemasungan. keperawatan kesehatan masyarakat sebagai sala h sat u f u ngsi p u skesma s diharapkan mampu menjangkau pelayanan kesehatan sampai kepada masyarakat baik dalam pelayanan dalam gedung atau pelayanan luar gedung. pada tabel 2, pasien gangguan jiwa menggunakan sarana puskesmas sebagai tempat berobat adalah 75,6% dan sebanyak 55,6% mengg unakan sarana puskesmas sucara rutin. program kesehatan jiwa di puskesmas bukan merupakan program utama puskesmas, namun kemungkinan faktor yang mempengar u hi keluarga memanfaatkan p uskesmas sebagai tempat pengobat an ka rena kelu a rga merasa t id a k ma mpu merawat anggota keluarga yang menderita 124 jurnal ners vol. 9 no. 1 april 2014: 118–125 ga ngg u a n jiwa denga n mema n fa at k a n jamkesmas dan jamkesda. hal ini didukung hasil penelitian idwar (2009) tentang perilaku masyarakat dalam penanganan gangguan jiwa di kota langsa provinsi nanggroe aceh darussalam (dalam http://repository.usu.ac.id/ handle/123456789/28087) menunjukkan bahwa pemanfaatan sarana kesehatan dilakukan setelah keluarga terlebih dahulu membawa penderita gangguan jiwa ke dukun dan tidak mengalami penyembuhan. pera n p uskesmas sa ngat pent i ng dan utama di masyarakat, sehingga sekjen depkes dalam peringatan hari kesehatan jiwa sedunia tahun 2010 menyampaikan bahwa puskesmas diberdayakan sehingga mampu menjadi ujung tombak pelayanan kesehatan jiwa serta juga harus menyediakan pengobatan yang diperlukan. demikian juga, rumah sakit umum har us menyediakan tempat tidur sehingga bisa merawat odmk yang memerlukan perawatan. rumah sakit jiwa selain sebagai pusat rujukan juga harus mampu menjadi pusat pembinaan kesehatan jiwa bagi layanan kesehatan di wilayahnya. namun, untuk gangguan jiwa berat pengobatan awal dapat dilakukan di puskesmas kemudian pengobatan lanjutan dapat dilakukan dengan rawat inap di rumah sakit umum / rumah sakit jiwa. rawat inap akan dilakukan sampai kondisi kejiwaan menjadi stabil, mampu minum obat secara teratur dan tidak ada kecender ungan melakukan tindakan yang membahayakan diri sendiri, keluarga maupun kepentingan umum. setelah dilakukan perawatan di rumah sakit, pengobatan dapat dilanjutkan di puskesmas dengan pengawasan pengobatan oleh keluarga maupun partisipasi masyarakat melalui kader kesehatan/kelompok swabantu. menu r ut widowat i (2013) upaya pelayanan kesehatan jiwa di indonesia mencakup atas 3 kategori: pelayanan kesehatan jiwa yang ter integ rasi pada pelayanan kesehatan umum (primer, sekunder, dan tersier), pelayanan kesehatan jiwa berbasis masyarakat dan pelayanan kesehatan jiwa di institusi khusus (rsj, bag psikiatri rs pendidikan dan klinik-klinik superspesialis), namun penerapan pelayanan kesehatan jiwa dilapangan masih terpusat pada pelayanan kesehatan jiwa di institusi khusus. pemahaman bahwa pelayanan kesehatan jiwa dapat dilakukan pada sarana kesehatan yang tersedia seperti puskemas, balai kesehatan masyarakat, rsu ternyata sangat rendah, bahkan pada petugas kesehatan. simpulan dan saran simpulan b e r d a s a r k a n a n a l i si s h a si l d a n pembahasan diperoleh simpulan (1) ada dua tugas keluarga yang signifikan yaitu kemampuan keluarga merawat pasien dan kemampuan keluarga memanfaatkan sarana pelayanan kesehatan mer upakan fak tor yang mempengaruhi kemampuan keluarga mengasuh pasien gangguan jiwa, (2) rumus kemungkinan pasien gangguan jiwa dipasung oleh keluarga berdasarkan dua tugas tugas keluarga yang berpengaruh adalah kemungkinan (dipasung) 1 1 + β(19,712-37,209*rawat-19,010*sarana) dan (3) dua tugas keluarga yaitu kemampuan keluarga merawat pasien dan kemampuan keluarga memanfaatkan sarana pelayanan kesehatan berpengaruh sebesar 37,1% (nagelkerke sebesar 0,371) sedangkan 62,9% dipengaruhi oleh faktor lain. saran keluarga dapat menciptakan suasana nya ma n d a n a ma n ber a d a d i tenga htengah keluarganya karena mer upakan tempat terbaik bagi penderita gangguan jiwa. selain pengobatan medis, penderita juga membutuhkan perhatian, pengertian, dukungan, cinta dan kasih saying. perhatian dan kasih sayang tulus keluarga dan orangorang terdekatnya akan sangat membantu proses pemulihan kondisi jiwa pasien. pelayanan kesehat an jiwa masya ra kat, dijadikan upaya utama, untuk menfasilitasi keluarga mencari pengobatan dan rujukan perawatan gangguan jiwa. 125 prediksi penderita gangguan jiwa (sri mugianti dan suprajitno) kepustakaan baker, maureen, 2001. families, labour, & love. australia: allen & unwin. depkes ri, 2008. riskesdas 2007. jakarta: badan penelitian dan pengembangan departemen kesehatan ri. depkes ri., 2006, keperawatan jiwa teori dan tindakan keperawatan, jakarta. direktorat jenderal bina pelayanan medik friedman, marilyn m., 1998. family nursing: research, theory, & practice. stamford: appleton & lange. hawari, 2007. pendekatan holistik pada gangguan jiwa skizofrenia. jakarta: fkui. indonesia bebas pasung. http://rsjlawang. blogspot.com/2012/03/indonesia-bebaspasung.html juliansyah, 2009. stigma penderita gangguan jiwa. diakses melalui http:// perawat psi k iat r i. blogspot. com / ment al disorder. html keliat, b.a. dkk, 1991. tingkah laku bunuh diri. jakarta: arcan. maramis, w.f, 2004. catatan ilmu kedokteran jiwa (edisi tujuh). surabaya: airlangga universitas. menuju indonesia bebas pasung. http://buk. depkes.go.id/index.php?option=com_c ontent&view=article&id=87:menujuindonesia-bebas-pasungmervyn, harold, 2001. kiat keluarga sehat. jilid 2. bandung: indonesia publishing house. sant rock w. joh n, 2003. adolenscence (perkembangan remaja). jakar ta: erlangga s o e k r a m a , 2 0 01. pe n i n g k a t a n d a n pemeliharaan kesehatan jiwa serta pe n a ng g ula nga n s t re s. ja k a r t a: yayasan purna bhakti negara. swanson, janice m. & mary a. nies, 1997. community health nursing: promoting the health of aggregates. philadelphia: wb saunders company. tow n se nd . mc., 20 05. e s se n t i a l s of psychiatric mental health nursing (3th ed). philadelphia: f a davis company. videbeck, s.l., 2008. buku ajar keperawatan jiwa. bandung: refi ka aditama walkinson, greg, 2002. seri kesehatan bi m b i n ga n d o k t e r p a d a s t r e s . terjemahan oleh christine pangemanan. jakarta: dian rakyat. widowat i, 2013. era ke sehata n jiwa masyarakat (communitymental health) sesuai pertemuan di bali desember 2012. artikel dalam http://rsjsoerojo. co.id/era_community_mental_health_ kesehatan_ jiwa_masyarakat_sesuai_ p e r t e m u a n _ d i _ b a l i _ d e s e m b e r _ berita112.html willis s, 2005. remaja & masalahnya. bandung: alfabeta. wright, lorraine m. & maureen leahey, 1994. nurses and families: a guide to family assessment and intervention, 2nd edition. philadelphia: fa davis company yosep. i., 2007. keperawatan jiwa. bandung: refi ka aditama. http://e-journal.unair.ac.id/jners 67 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 67-73 http://dx.doi.org/10.20473/jn.v17i1.33885 original article open access pandemic in indonesian older people: the implication for sleep deprivation, loss of appetite, and psychosomatic complaints susiana nugraha 1,* , asyifa robiatul adawiyah 1 , yuna trisuci aprilia 1 , lisna agustina 2, tresna putri asih handayani 3, tri budi w rahardjo 1 1 faculty of health sciences, universitas respati, indonesia 2 faculty of nursing ichsan medical centre, (imc) bintaro, school of health sciences, banten, indonesia 3 master student, faculty of health sciences, universitas respati, indonesia *correspondence: susiana nugraha. address: bambu apus i street no.3 cipayung, east jakarta, indonesia. email: susiana.nugraha@urindo.ac.id responsible editor: rizki fitryasari received: 22 february 2022 ○ revised: 27 april 2022 ○ accepted: 28 april 2022 abstract introduction: during the covid-19 pandemic, many individuals were concerned about being infected. meanwhile, the older people felt isolated due to the detrimental effect on their mental and physical health. therefore, this study aimed to identify the mental health issues suffered by the older people during the covid-19 pandemic, the implication for sleep deprivation, loss of appetite, and psychosomatic complaints. methods: this was a descriptive-analytic study using a cross-sectional approach to find the mental health impact of the covid-19 pandemic. the population of this study was older people (those aged ≥60 years) living in urban areas in west java and jakarta. the sample size was measured with the lemeshow formula using a 95% confidence interval. a total of 259 older people participated in this study in cluster random sampling selection. questionnaires were distributed to study participants consisting of sociodemographic characteristics, general anxiety disorder, history of chronic illness, covid-19 related psychological concern, self-reported losing appetite, self-reported sleep deprivation and psychosomatic assessment. statistical analysis used descriptive and logistic regression analysis. results: the average age of study participants is 65.3 years old (sd ± 6.8; min-max = 60 to 89 years old). multivariable logistic regression model showed that sleep deprivation is significantly associated with non -college education background (or = 2.28; 95% ci = 1.23 to 4.61), anxiety (or = 7.09; 95% ci = 3.57 to 14.08), and the existence of chronic illness (or = 2.75; 95% ci = 1.44 to 5.26). subsequently, the psychosomatic symptom was associated with anxiety (or = 5.27; 95% ci = 2.75 to 10.11) and chronic illness (or = 2.80; 95%ci = 1.47 to 5.32). loss appetite was associated with noncollege education background (or = 2.50; 95% ci = 1.16 to 5.41), anxiety (or = 10.41; 95% ci = 5.01 to 21.63), and the existence of chronic illness (or = 3.60; 95% ci = 1.72 to 7.55). the analysis showed that none of the covid-19 related fear is associated with a sleep disorder, loss of appetite, and psychosomatic symptoms. conclusions: sociodemographic factors, anxiety and medical factors contribute to the risk of mental health issues in older adults during the covid-19 pandemic, implication for sleep deprivation, loss of appetite, and psychosomatic complaints. keywords: covid-19 pandemic; losing appetite; mental health; sleep deprivation; psychosomatic symptoms introduction indonesia and almost all countries in the world have been facing a global covid-19 pandemic since 2020 (world health organization, 2020). the pandemic situation has a remarkable effect on people's lives, social relations, and sociodemographic issues. the fastspreading infectious disease has been causing universal awareness, anxiety, and distress, as natural psychological responses to the randomly changing condition (world health organization, 2020). a special concern needs to be addressed to the vulnerable groups such as older people. https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-6723-742x https://orcid.org/0000-0002-9339-0305 https://orcid.org/0000-0001-8578-4374 https://orcid.org/0000-0002-6210-3596 nugraha, adawiyah, aprilia, agustina, handayani, and rahardjo (2022) 68 p-issn: 1858-3598  e-issn: 2502-5791 the mental health issues over the pandemic have become a concern in the global health context. a study in american society reported that new measures such as self-isolation and quarantine had affected people's usual activities, routines, and livelihoods, leading to increased loneliness, anxiety, depression, insomnia, substance abuse, and self-harm or suicidal behavior (american psychiatric association, 2020) in the community. during the pandemic, older people face significant fallout concerning their physical and psychological wellbeing. these adults experienced disproportionately greater adverse effects during this pandemic, including severe complications and higher mortality (liu, chen, lin, & han, 2020). the indonesian government reported that 46% of fatality cases are suffered by older people (covid‑19 response acceleration task force, 2022). these high number of fatalities in older people are a result from aging process causing gradual decline in physical capacity and decline in immune function thus placing the older people in a high-risk group during the covid-19 pandemic (setiati, 2014). older adults are advised to reduce their social connections as much as possible. the government advises them to stay at home and reduce face-to-face interactions with others, avoiding contact with friends and family to minimize the spread of covid-19 (ministry of health, 2020). hence, this policy creates a dilemma for the older people and their family members. they feel lonely and, at the same time, worried about being infected. furthermore, concerns about disruptions to their daily routines and access to care, difficulty adapting to technologies like telemedicine, and social isolation exacerbate existing mental health conditions (armitage and nellums, 2020). a survey conducted by the center for family and ageing studies (cefas) in 2020 identified three mental health issues suffered by older people in community-dwelling during the pandemic, including sleep deprivation, loss of appetite, and psychosomatic symptoms (nugraha et al., 2020). this study further intended to find the contributing factors of three mental health issues during the pandemic: the implication for sleep deprivation, loss of appetite, and psychosomatic symptoms. materials and methods design and participants this was a descriptive-analytic study using a crosssectional approach to find the mental health impact of the covid-19 pandemic. participants from west java and dki jakarta (age 60 years old or more) were invited to participate in this study. the recruitment process was using older people community associations. sample sizes were counted using lemeshow formula for crosssectional methods with 95% degree of the confidence interval and counted 384 samples. subjects were selected using cluster random sampling, with inclusion criteria including: those aged 60 years old or more, having no communication constraint, able to speak and read bahasa indonesia, and agree to participate in this study. trained staff performed face-to-face interviews to collect detailed information from all participants with the covid-19 prevention protocol. a total sample of 259 satisfied study analysis and were included in this study; 125 people were excluded due to incomplete response, confirming 67.4% response rate. instruments one set of questionnaires was distributed to the older people or their family members after study participants signed an informed consent and received brief study explanation from the researcher. the questionnaire consists of sociodemographic characteristics, including age, gender, and education background, checklist for chronic illness adapted from geriatric comprehensive assessment (gca). the self-reported individual concern about the pandemic was measured with a checklist that consists of the following questions: “i am afraid of getting infected;” “i am worried about the increasing number of cases;” “i am worried my family member will be affected;” “i am worried of unable to perform religious activities;” “i am worried on the difficulties to unite with my family” with “yes” and “no” as a possible answer. the anxiety disorders were assessed with the indonesian version of general anxiety disorders (gad-7) questionnaire. it explores the psychological condition of the older people by asking whether they were bothered by the following problems over the last two weeks, such as (1) feeling nervous, anxious, or on edge; (2) unable to stop worrying; (3) worrying too much about different things; (4) trouble relaxing; (5) being restless and hard to sit still; (6) becoming easily irritable; (7) feeling afraid (johnson et al., 2019). the outcome variable sleep deprivation was assessed with the self-reported experience in: difficulty to start sleeping, waking up suddenly, short sleep time (less than 6 hours) with four possible answers for each question (0 = not at all; 1 = several days; 2 = more than a week; 3 = nearly every day) (han, kim and shim, 2012). the perception of losing appetite was assessed using the following question: “please tell us first how your eating behavior is affected by certain emotional states and situations by circling a number on the scale below. the scale ranges from 1 to 9, where 1 represents much less food intake than usual, 9 much more than usual, and 5 the same as usual.” this measure was adopted from emotional appetite questionnaire (emaq) (nolan, halperin and galiebter, 2010). the perceived psychosomatic symptoms were measured with: “in the past two weeks, have you felt unwell, like have a fever, stomach discomfort, chill, jurnal ners http://e-journal.unair.ac.id/jners 69 dizziness” and scored (0 = not at all; 1 = several days; 2 = more than a week; 3 = nearly every day) adapted from the psychosomatic problem scale (pbs) (frisenstam et al., 2017). data analysis statistical analysis consists of descriptive-analytic to explore the sociodemographic characteristics of the participants and the prevalence of anxiety, self-reported sleep deprivation, self-reported losing appetite, and selfreported psychosomatic symptoms. the bivariate chisquare analysis was employed to assess the independent variable and outcome variables. furthermore, a logistic regression analysis was conducted to identify factors contributing to mental health impact among older people. ethical consideration the study was conducted according to the guidelines of the declaration of helsinki, and informed consent was obtained from all subjects involved. the study participants have obtained written informed consent to publish this paper approved by the institutional review board of the university of respati indonesia with ethical approval number: 023/sk.kepk/unr/v/2020. results a total of 259 older people participated in this study after conducting surveys among older people and their family members from may to june 2020. approximately 67.45% response rate or 259 responses are eligible for data analysis. as shown in table 1, the average age of study participants is 65.3 years old (sd ± 6.8; min-max = 60 to 89 years old), three-quarters of study participants are female, more than one-third have a college degree, and more than half of study participants have one or more chronic illness. according to the anxiety measurement using generalized anxiety disorder, 26.3% of the older people are categorized as having anxiety during the covid-19 pandemic. concerns about the covid-19 condition are dominated by the fear of being infected as much as 88% followed by the increasing number of cases. assessment on the mental health related issues identified the sleep deprivation as the most issues reported by study participants followed by self-reported psychosomatic symptom and self-reported in eating disorder identified by emotional appetite status. appendix 1 describes the bivariate association between risk factor of sleep deprivation, psychosomatic symptom, and loss of appetite. among older people who suffer from anxiety disorder, 60.3% of them complained of having sleep deprivation, 55.9% of them reported psychosomatic symptoms, and 57.4% of them suffer from losing appetite (p-value < 0.0001). approximately 40% of study participants who have chronic illness are likely to suffer from sleep deprivation, 34.3% lose their appetite, and 38.6% are identified as having psychosomatic symptoms (p < 0.01). furthermore, 38.8% of older people that are worried about the increasing number of covid19 cases suffered from sleep deprivation (p < 0.05), and 58% are unable to unite with their family (p = 0.05), while 41.9% lose their appetite (p = 0.045). the multivariable logistic regression model showed (appendix 2) that sleep deprivation is associated with non-college education background (or = 2.28; 95% ci = 1.23 to 4.61), anxiety (or = 7.09; 95% ci = 3.57 to 14.08), and the existence of chronic illness (or = 2.75; 95% ci = 1.44 to 5.26). the psychosomatic symptom was associated with anxiety (or = 5.27; 95% ci = 2.75–10.11) and chronic illness (or = 2.80; 95% ci = 1.47 to 5.32). loss of appetite was associated with non-college education background (or = 2.50; 95% ci = 1.16 to 5.41), anxiety (or = 10.41; 95% ci = 5.01 to 21.63), and the existence of chronic illness (or = 3.60; 95% ci = 1.72 to 7.55). the analysis showed that none of the covid-19 related fear is associated with a sleep disorder, loss of appetite, and psychosomatic symptoms. discussions the great pandemic of 2020 has been a unique stressor that has affected communities all around the world (world health organization, 2020). this study highlighted mental health issues in older adults during the covid-19 pandemic, implication for sleep deprivation, losing appetite, and self-reported table 1 sociodemographic characteristics of the participants (n = 259) variables n % age 60-70 years old 217 83.8 70 years old or more 42 16.2 gender male 65 25.1 female 194 74.9 education non-college degree 172 66.4 college degree 87 33.6 the existence of chronic illness none 116 44.8 having one or more chronic illness 143 55.2 generalized anxiety disorder (gad) non-anxiety 191 73.7 with anxiety 68 26.3 to what extent do you worry about covid-19? i am worried about getting infected 230 88.8 i am worried about the increasing number of cases 105 40.5 i am worried my family members will be infected 97 37.5 i am worried of being unable to unite with family 31 12.0 i am worried of being unable to perform religious activities 13 5.0 mental health-related issues sleep deprivations 80 30.9 psychosomatic symptom 75 29.0 losing appetite 65 25.1 nugraha, adawiyah, aprilia, agustina, handayani, and rahardjo (2022) 70 p-issn: 1858-3598  e-issn: 2502-5791 psychosomatic symptoms. several predictors show a statistically significant association with sleep deprivation, losing appetite, and psychosomatic complaints in this study. this study identified the older people with anxiety, an existing chronic disease, and low education background (non-college degree) as likely to have greater sleep deprivation during the covid-19 pandemic. apart from the disease’s effect, these psychological problems are also triggered by social distancing following the government regulation to stay at home and prohibition of going home for family gatherings in celebration of religious events (ministry of health, 2020). as a result of these policies, the older people lost their daily routines, such as regularly meeting friends and family and causing the older people to feel lonely. this can be a stressful mental health condition triggered by loneliness due to social isolation (bergman et al., 2020). more than 80% of the study participants reported that they are afraid of being infected by the covid-19 while worrying about the increasing number of cases. these concerns can trigger a higher stress levels and lead to anxiety disorder that may affect deterioration of the normal sleep pattern (han, kim and shim, 2012). the body's circadian rhythm regulation between sleep and awakening is regulated by two components, namely the circadian component (~24 hours) and the homeostatic component (cardinali et al., 2020). the circadian timing system is controlled by sunlight exposure, social adaptation, and environmental problems with daily routines such as waking up at a certain time, exercising, eating, socially engaging, and recreational activities. during the pandemic, some activities have changed due to limitations at certain times. this condition causes the older adult with anxiety to experience sleep deprivation. anxiety is an emotional memory with theta frequency that may influence the rapid eye movement (essien et al., 2018). the complex interplay between sleep deprivation and anxiety could worsen the mental health condition. furthermore, lower education background is likely to increase the stress level. previous study identified the reverse association between education background and the stress level (johnson et al., 2019). one can assume that older people with higher education have better knowledge to cope with the pandemic and easily identify accurate information. in contrast, older people with lower-level education are likely vulnerable to wrong news (hoax), which may increase their anxiety level. moreover, those with a college education background have a good circle of friendship to share accurate information. this finding proves that low level of education is also associated with a lack of sense of control and resilience (niemeyer et al., 2019) during the pandemic situation. anxiety, the existence of chronic illness and a noncollege education background are significantly associated with self-reported losing of appetite. an australian study explains that those who felt a high level of the adverse impact of the pandemic restrictions had significantly increased odds of being bothered by poor appetite (owen et al., 2021). the covid-19 pandemic makes older adults worry about being infected and vulnerable to stress. emotional eating is most commonly reported in anxiety. stress can suppress appetite, and loss of appetite is a common feature of depression (simmon et al., 2016). older adults with decreased physiological conditions interfere with their appetite. furthermore, those with chronic diseases during the covid-19 pandemic felt more anxious because they had comorbidities such as hypertension and diabetes mellitus, which can increase the risk of developing severe and fatal covid-19 (fang, karakiulakis and roth, 2020). chronic illness can interfere with appetite through impaired agility and pain. it interferes with the eating process, which takes longer to reduce appetite. psychosomatic symptoms are reported by nearly 29% of the study participants. this finding is in line with previous study on the mental health impact of the pandemic. this study identified a statistically significant association between self-reported psychosomatic symptom with anxiety and chronic illness. psychosomatic symptoms are decreased psychological state, hence negatively impacting physiological function (somatic) (levenson, 2007). this occurs due to dysfunction or structural damage to organs by activating the involuntary nervous system and biochemical responses (levenson, 2007). older adults with anxiety are likely to have psychosomatic symptoms because pain and anxiety should be recognized as physiological problems associated with neurobiochemical changes (satsangi and brugnoli, 2018). neuro-biochemistry is associated with stress resulting from stimulation of the sympathetic nervous system, specifically the fight-orflight response. in acute stress especially in the covid-19 pandemic, this response triggers the release of catecholamines, including norepinephrine-epinephrine (ne) and cortisol, from the adrenal glands. in prolonged or chronic stress, the sympathetic nervous system creates a continuous stimulus of the fight-or-flight response (levenson, 2007). the secretion of catecholamines occurs continuously under prolonged stress conditions because catecholamines, such as ne, act as neurotransmitters in the brain. these substances can change cognition and other mental condition such as poor concentration, mood variations, tension, depression, and anxiety. at the same time, long-term stress-induced cortisol secretion from the adrenal glands can reduce immune function (satsangi and brugnoli, 2018). the increasing number of cases and a lot of uncertain issues spread around the older people, produce significant stressors that may increase stress level of older people and are likely to increase their psychosomatic complaints. the strength of this study is that it captures the state of the covid-19 pandemic related to mental health jurnal ners http://e-journal.unair.ac.id/jners 71 issues, and its associated factors. to the best of our knowledge, this is one of the few studies examining the association of mental health issues focusing on the implication for sleep deprivation, loss of appetite, and psychosomatic complaints with covid-19. on the other hand, this study has many limitations that may arise from sample distribution and lower response rate. selection bias could be present in the data collection, because, in the pandemic situation, researchers should limit their contact to older people, and wearing certain personal protective equipments, which may become communication barriers for older people with decreasing visual and hearing capacity. another limitation is due to the fact that we did not identify other factors that could become potential confounding that may distort the association between independent and dependent variables. conclusions this study identified mental health issues suffered by the older people during the covid-19 pandemic. anxiety and chronic illness were identified as the risk factors for all mental health issues such as sleep deprivation, loss of appetite, and psychosomatic symptom. additionally, lower education attainment is likely to increase the risk of sleep deprivation and loss of appetite two times above higher education. these results have implications for delivering adequate education on covid-19 through trustworthy information to alleviate fear and boost understanding among individuals with poor education and chronic illnesses. awareness of these contributing factors and implementation of coping strategies and interventions may help safeguard older people as vulnerable group from psychological complications that impact quality of life and health span. understanding the factors and mechanisms that drive older people’s resilience can guide intervention approaches for other people. in addition, increasing components of wisdom like emotional regulation, empathy, and compassion can reduce any mental health issues. further research should be conducted to understand the psychological and mental health effects of the ongoing covid-19 pandemic among the older population. references american psychiatric association (2020) new poll: covid-19 impacting mental well-being: americans feeling anxious, especially for loved ones; older adults are less anxious, covid impacting mental health. armitage, r. and nellums, l. b. (2020) ‘covid-19 and the consequences of isolating the elderly’, the lancet public health. the author(s). published by elsevier ltd. this is an open access article under the cc by 4.0 license, 2667(20), p. 30061. doi: 10.1016/s24682667(20)30061-x. bergman, y. s. et al. (2020) ‘covid-19 health worries and anxiety symptoms among older adults: the moderating role of ageism’, international psychogeriatrics, 32(11), pp. 1371–1375. doi: 10.1017/s1041610220001258. cardinali, d. p. et al. (2020) ‘elderly as a high-risk group during covid19 pandemic: effect of circadian misalignment, sleep dysregulation and melatonin administration’, sleep and vigilance. springer singapore, 4(2), pp. 81–87. doi: 10.1007/s41782-02000111-7. covid‑19 response acceleration task force (2022) situasi terkini virus covid 19 (current situation of pandemic of covid-19), peta sebaran covid 19 (covid-19 distribution map). essien, s. k. et al. (2018) ‘sleep duration and sleep disturbances in association with falls among the middle-aged and older adults in china: a population-based nationwide study’, bmc geriatrics. london: biomed central, 18. doi: http://dx.doi.org/10.1186/s12877018-0889-x. fang, l., karakiulakis, g. and roth, m. (2020) ‘are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection?’, the lancet. respiratory medicine, 8. doi: https://doi.org/10.1016/ s2213-2600(20)30116-8. frisenstam, k. l. et al. (2017) ‘self-reported psychosomatic complaints in swedish children, adolescents, and young adults living in rural and urban areas: an internet-based survey’, jmir public health and surveillance, 3(1), pp. 1–13. doi: 10.2196/publichealth.5902. han, k. s., kim, l. and shim, i. (2012) ‘stress and sleep disorder’, experimental neurobiology, 21(4), pp. 141–150. doi: 10.5607/en.2012.21.4.141. johnson, s. u. et al. (2019) ‘psychometric properties of the gad-7 in a heterogeneous psychiatric sample’, frontiers in psychology, 10(july), pp. 1–8. doi: 10.3389/fpsyg.2019.01713. levenson, j. (2007) essentials of psychosomatic medicine. united state of america: american psychiatric publishing, inc.. liu, k., chen, y., lin, r., & han, k. (2020) . ‘clinical features of covid19 in elderly patients: a comparison with young and middle-aged patients’, journal of infection, 80, pp. e14–e18. ministry of health (2020) guideline for prevention and control of corona virus diseases (covid-19). ministry of health of the republic of indonesia. niemeyer, h. et al. (2019) ‘education and mental health: do psychosocial resources matter?’, ssm population health. elsevier, 7(september 2018), p. 100392. doi: 10.1016/j.ssmph.2019.100392. nolan, l. j., halperin, l. b. and galiebter, a. (2010) ‘emotional appetite questionnaire. construct validity and relationship with bmi’, appe, 54(2), pp. 314–319. doi: 10.1016/j.appet.2009.12.004.emotional. nugraha, s. et al. (2020) hasil survey kecemasan lansia di masa pandemi covid 19. jakarta. owen, a. j. et al. (2021) ‘poor appetite and overeating reported by adults in australia during the coronavirus-19 disease pandemic: a population-based study’, public health nutrition, 24(2), pp. 275– 281. doi: 10.1017/s1368980020003833. satsangi, a. k. and brugnoli, m. p. (2018) ‘anxiety and psychosomatic symptoms in palliative care: from neuro-psychobiological response to stress, to symptoms’ management with clinical hypnosis and meditative states’, annals of palliative medicine, 7(1), pp. 75–111. doi: 10.21037/apm.2017.07.01. setiati, s. (2014) ‘geriatric medicine, sarkopenia, frailty, dan kualitas hidup pasien usia lanjut: tantangan masa depan pendidikan, penelitian dan pelayanan kedokteran di indonesia’, ejournal kedokteran indonesia, 1(3). doi: 10.23886/ejki.1.3008. simmon, k. et al. (2016) ‘depression-related increases and decreases in appetite reveal dissociable patterns of aberrant activity in reward and interoceptive neurocircuitry’, american journal of psychiatry, 173(4), pp. 418–428. doi: 10.1176/appi.ajp.2015.15020162.depression-related. world health organization (2020a) coronavirus disease 2019 (covid19) situation report 51, covid-19 situation report. geneva. doi: 10.1001/jama.2020.2633. world health organization (2020b) mental health and psychosocial considerations during the covid-19 outbreak, no. who/2019ncov/mentalhealth/2020.1). world health organization. how to cite this article: nugraha, s., adawiyah, a. r., aprilia, y. t., agustina, l., handayani, t. p. a., and rahardjo, t. b. w. (2022) ‘pandemic in indonesian older people: the implication for sleep deprivation, loss of appetite, and psychosomatic complaints’, jurnal ners, 17(1), pp. 67–73. doi: http://dx.doi.org/10.20473/jn.v17i1.33885 http://dx.doi.org/10.20473/jn.v17i1.33885 nugraha, adawiyah, aprilia, agustina, handayani, and rahardjo (2022) 72 p-issn: 1858-3598  e-issn: 2502-5791 appendices appendix 1 the association of sociodemographic factors with sleep deprivation, loss of appetite, and psychosomatic symptom variables sleep deprivation loss of appetite psychosomatic symptoms no = 0 n (%) yes = 1 n (%) p-value no = 0 n (%) yes = 1 n (%) p-value no = 0 n (%) yes = 1 n (%) p-value gender female 40 (62.5) 24 (37.5) 0.298 159 (74.6) 54 (25.4) 0.998 150 (70.4) 63 (29.6) 1.000 male 134 (70.5) 56 (29.5) 30 (73.2) 11 (26.8) 29 (70.7) 12 (29.3) age 60-70 years 146 (68.5) 67 (31.5) 1.000 45 (70.3) 19 (29.7) 0.482 40 (62.5) 24 (37.5) 0.145 >70 years 28 (68.3) 13 (31.7) 144 (75.8) 46 (24.2) 139 (73.2) 51 (26.8) education background college degree 109 (65.3) 58 (34.7) 0.180 120 (71.9) 47 (28.1) 0.275 116 (69.5) 51 (30.5) 0.773 non-college degree 64 (74.4) 22 (25.6) 68 (79.1) 18 (20.9) 62 (72.1) 24 (27.9) anxiety disorder category non anxiety 147 (79.0) 39 (21.0) <0.0001 160 (86.0) 26 (14.0) <0.0001 149 (80.1) 37 (19.9) <0.0001 with anxiety 27 (39.7) 41 (60.3) 29 (42.6) 39 (57.4) 30 (44.1) 38 (55.9) having chronic illness no 90 (78.9) 24 (21.1) 0.002 97 (85.1) 17 (14.9) 0.001 93 (81.6) 21 (18.4) 0.001 yes 84 (60.0) 56 (40.0) 92 (65.7) 48 (34.3) 86 (61.4) 54 (38.6) to what extent do you worry about covid-19? i am worried about getting infected 155 (68.9) 70 (31.1) 0.876 169 (75.1) 56 (24.9) 0.626 162 (72.0) 63 (28.0) 0.204 i am worried about the increasing number of cases 80 (76.2) 25 (23.8) 0.038 81 (77.1) 24 (22.9) 0.489 80 (76.2) 25 (23.8) 0.124 i am worried my family members will be infected 66 (71.7) 26 (28.3) 0.486 74 (80.4) 18 (19.6) 0.131 68 (73.9) 24 (26.1) 0.446 i am worried of being unable to perform religious activities 7 (53.8) 6 (46.2) 0.389 9 (69.2) 4 (30.8) 0.745 9 (69.2) 4 (30.8) 1.000 i am worried of being unable to unite with family 14 (45.2) 17 (54.8) 0.005 18 (58.1) 13 (41.9) 0.045 19 (61.3) 12 (38.7) 0.324 jurnal ners http://e-journal.unair.ac.id/jners 73 appendix 2 multivariable logistic regression model examining the mental health impact of covid-19 pandemic in older people (n = 259). variables sleep deprivation loss of appetite psychosomatic symptoms crude or (95%ci) aor (95%ci) crude or (95%ci) aor (95% ci) crude or (95%ci) aor (95% ci) gender female (ref) 1 1 1 1 1 1 male 0.69 (0.38 to 1.26) 1.20 (0.60 to 2.38) 0.76 (0.403 to 1.42) 1.05 (0.50 to 2.23) 0.61 (0.34 to 1.11) 1.53 (0.78 to 3.01) age ≥70 years old (ref) 1 1 1 1 1 1 <70 years old 1.01 (0.49 to 2.07) 1.50 (0.65 to 3.47) 1.08 (0.51 to 2.30) 1.31 (0.53 to 3.24) 0.99 (0.47 to 2.05) 1.21 (0.53 to 2.77) education background college degree (ref) 1 1 1 1 1 1 non-college degree 0.64 (0.362 to 1.15) 2.28 (1.13 to 4.61)* 0.68 (0.36 to 1.26) 2.50 (1.16 to 5.41)* 0.88 (0.50 to 1.56) 1.45 (0.75 to 2.80) general anxiety category non-anxiety (ref) 1 1 1 1 1 1 with anxiety 5.72 (3.14 to 10.43)* 7.09 (3.57 to 14.08)* 8.27 (4.39 to 15.61)* 10.41 (5.01 to 21.63)* 5.10 (2.80 to 9.29)* 5.27 (2.75 to 10.11)* having chronic illness no (ref) 1 1 1 1 1 1 yes 0.86 (0.38 to 1.94) 2.75 (1.44 to 5.26)* 2.98 (1.60 to 5.55)* 3.60 (1.72 to 7.55)* 2.78 (1.55 to 4.98)* 2.80 (1.47 to 5.32)* to what extent do you worry about covid-19? i am afraid of being affected 0.86 (0.38 to 1.94) 0.95 (0.64 to 1.40) 0.74 (0.32 to 1.71) 0.71 (0.45 to 1.12) 0.55 (0.25 to 1.22) 1.20 (0.82 to 1.76) i am worried about the increasing number of cases 0.53 (0.31 to 0.93) 0.51 (0.17 to 1.53) 0.78 (0.44 to 1.40) 0.34 (0.10 to 1.25) 0.62 (0.35 to 1.09) 0.69 (0.23 to 2.06) i am worried my family members will be affected 0.40 (0.95 to 0.85)* 0.99 (0.83 to 1.17) 0.90 (0.80 to 1.02) 0.86 (0.70 to 1.06) 0.95 (0.85 to 1.06) 1.00 (0.84 to 1.19) i am worried of being unable to perform religious activities 1.18 (0.89 to 1.56) 1.14 (0.76 to 1.71) 1.07 (0.79 to 1.45) 0.84 (0.53 to 1.35) 1.02 (0.75 to 1.37) 1.02 (0.67 to 1.56) i am worried of being unable to unite with my family 1.76 (1.20 to 2.57)* 1.60 (0.86 to 2.98) 1.54 (1.04 to 2.27)* 1.04 (0.51 to 2.11) 1.27 (0.86 to 1.87) 1.18 (0.63 to 2.20) *p-value < 0.05 table1 apa2020 armitage2020 bergman2020 cardinali2020 essien2018 fang2020 frisenstam2017 hankim2012 johnson2019 levenson2007 liuchen2020 ministri2020 nolan2010 nugraha2020 owen2021 satsangi2018 setiati2014 simmon2016 who2020a who2020b appendix1 appendix2 156 penurunan tingkat depresi pada lansia dengan pendekatan bimbingan spiritual (reduction of depression in elderly with spiritual guidance approach) syaifuddin kurnianto*, purwaningsih**, hanik endang nihayati** *akper lumajang, jalan brigjend katamso lumajang, 67311, e-mail: syaifuddin_kurnianto@yahoo.com **fakultas keperawatan universitas airlangga abstract introduction: depression is mental disorder which comes from complicated stress, it can happen for everyone including the elderly. this problem is frequently not considered as the main point of view to think because it is regarded to get good condition by its way without having serious treatment. on the reality, depression which doesn't get serious treatment to solve well, it can danger the life of the elderly. the purpose of this study was to prove the infl uence of result in the spiritual guidance in accordance with islamic religion for the changing score (rank) depression of the elderly who lived in the region of rt 04 kedung tarukan wetan surabaya. method: design used in this study was pre experimental design. population for this study were all of the elderly who lived in the region of rt 04 kedung tarukan wetan surabaya. total sample were 10 respondents, taken according to inclusion criteria. the independent variable was the spiritual guidance in accordance with islamic religion where as the dependent variable was the changing score (rank) of depression. data were collected by using structured questionnaire. data were then analyzed using wilcoxon sign rank test with level of signifi cance of ≤ 0.05. result: the result showed, after giving spiritual guidance in accordance with islamic religion, the score (rank) of depression for elderly to decrease than before giving spiritual guidance in accordance with islamic religion with signifi cant value p = 0.005. discussion: it can be concluded that spiritual guidance in accordance with islamic religion having strong infl uence for the changing score (rank) of depression of the elderly before and after it had done. it was suggested for the competence person in rt 04 kedung tarukan wetan surabaya to do this activity continuously as one of the way to prevent and to solve depression for the elderly who lived in the region of rt 04 kedung tarukan wetan surabaya. keywords: spiritual guidance in accordance with islamic religion, score (rank) of depression, elderly pendahuluan proses penuaan merupakan suatu proses alamiah yang tidak dapat dicegah dan merupakan hal yang wajar dialami oleh orang yang diberi karunia umur panjang, di mana semua orang berharap akan menjalani hidup dengan tenang, damai, serta menikmati masa pensiun bersama anak dan cucu tercinta dengan penuh kasih sayang (hamid, 2007). tidak semua lanjut usia dapat mengecap kondisi idaman ini. proses menua tetap menimbulkan permasalahan baik secara fi sik, biologis, mental maupun sosial ekonomi (nugroho, 2000). permasalahanpermasalahan ini dapat memicu terjadinya depresi pada lanjut usia. stres lingkungan, menurunnya kemampuan beradaptasi dan rendahnya nilai spiritual yang dimiliki lansia juga sering mendukung terjadinya depresi. depresi pada lanjut usia telah menjadi masalah utama yang dihubungkan dengan kematian dan kejadian bunuh diri (jones, 2003). hasil penelitian menyebutkan 15% lanjut usia memiliki kecenderungan bunuh diri karena depresi (subrata, 2003). risiko bunuh diri pada lanjut usia wanita yang mengalami depresi dua atau tiga kali lebih tinggi daripada lanjut penurunan tingkat depresi pada lansia (syaifuddin) 157 usia laki-laki (jones 2003). bila hal ini tidak disikapi dengan benar dapat membahayakan lanjut usia. faktor psikologis yang positif (bebas dari stres, cemas dan depresi) melalui fungsional sistem limbik dapat menimbulkan coping mechanism yang positif. respons individu terhadap stres, dengan coping mechanism yang positif dan efektif dapat menghilangkan atau meredakan stres penyebab depresi. berkaitan dengan hal tersebut, terapi psikoreligius memegang peran penting sebagai faktor psikologis yang bersifat positif (hawari, 2005). bimbingan spiritual menurut ajaran islam dapat dijadikan sebagai terapi psikoreligius. namun, sampai saat ini pengaruh bimbingan spiritual menurut ajaran islam terhadap perubahan score (tingkat) depresi pada lanjut usia belum dapat dijelaskan. prevalensi depresi pada lanjut usia, sekitar 12–36% lanjut usia yang mengalami rawat jalan mengalami depresi. angka ini meningkat menjadi 30–50% pada lanjut usia dengan penyakit kronis dan perawatan lama yang mengalami depresi (mangoenpresodjo, 2004). menurut kaplan (1997), kira-kira 25% komunitas lanjut usia dan pasien rumah perawatan ditemukan adanya gejala depresi pada lanjut usia. depresi menyerang 10–15% lanjut usia 65 tahun ke atas yang tinggal di institusi, dengan sekitar 50–75% penghuni perawatan jangka panjang memiliki gejala depresi dari tingkatan ringan sampai sedang (stanley dan beare, 2007). data hasil studi pendahuluan yang dilaksanakan peneliti pada bulan mei 2009 terhadap lanjut usia di wilayah rt 04 kedung tarukan wetan ditemukan bahwa 37% lanjut usia warga rt 04 mengalami depresi yang di ukur dengan menggunakan geriatric depression scale short form. lanjut usia yang mengalami depresi tersebut mempunyai skala religi (yang diukur dengan menggunakan skala dimensi relegi versi dadang hawari) dengan rincian 20% mempunyai skala religi > 40%, 60% mempunyai skala religi yang berada pada rentang 40–55%, 20% mempunyai skala religi yang berada pada rentang 56–75%. kurang matangnya perkembangan fi losofi s agama lanjut usia serta tidak adanya media bagi lanjut usia untuk mencurahkan segala perasaan dan kegundahannya merupakan kondisi yang akan mempertahankan depresinya, karena dia akan terus menekan segala bentuk perasaan negatifnya ke alam bawah sadar. perasaan-perasaan negatif akan muncul dalam benak lanjut usia, perasaan kecewa, tidak dihargai, sedih, dendam, marah dan sebagainya (syamsuddin, 2006). lanjut usia pun akan semakin rentan terkena gangguan kesehatan. dengan menggunakan pendekatan psychoneuroimunology dapat dijelaskan bahwa depresi yang dialami lanjut usia akan memodulasi sistem imun melalui jalur hipothalamic-pituitary-adrenocortical (hpa) axis dan sistem limbik (yang mengatur emosi dan learning process). kondisi depresi tersebut akan menstimulasi hypothalamus untuk melepaskan neuropeptida yang akan mengaktivasi autonomic nerve system (ans) dan hypofi se untuk mengeluarkan kortikosteroid dan katekolamin yang merupakan hormonhormon yang bereaksi terhadap kondisi depresi. peningkatan kadar glukokortikoid akan mengganggu sistem imunitas. bila depresi dapat dikendalikan maka modulasi sistem imun menjadi lebih baik. depresi yang lama dan berkepanjangan akan berdampak pada penurunan sistem imun dan mempercepat progresivitas terjadinya gangguan kesehatan pada lanjut usia. jika keadaan ini tidak segera diatasi maka akan menurunkan kualitas hidup lanjut usia (amir, 2005). depresi pada lanjut usia perlu dilakukan penanganan yang tepat. bimbingan spiritual menurut ajaran islam sebagai sarana yang berfungsi untuk penentram batin, lepas dari emosi negatif dan memiliki dampak yang signifikan diharapkan dapat memberikan solusi. bimbingan spiritual ini dilakukan selama delapan hari (delapan kali pertemuan) dengan durasi setiap pertemuan ± 60 menit. dengan pemberian intervensi yang dilakukan secara intensif diharapkan dapat merubah mental, pikiran dan emosi maupun psikis lanjut usia sehingga terjadi perubahan score (tingkat) depresi pada lanjut usia. berdasarkan pernyataan di atas peneliti mengangkat sebuah masalah yang hendak diteliti yaitu pengaruh bimbingan spiritual menurut ajaran islam terhadap perubahan score (tingkat) depresi jurnal ners vol. 6 no. 2 oktober 2011: 156–163 158 pada lanjut usia sebagai pendekatan baru dalam bidang keperawatan gerontik untuk menangani masalah depresi yang dihadapi para lanjut usia khususnya yang tinggal di wilayah rt 04 kedung tarukan wetan surabaya. bahan dan metode desain yang digunakan dalam penelitian ini adalah pra eksperimental (one group prepost-test design). desain penelitian ini adalah mengungkapkan hubungan sebab akibat antara variabel dependen (perubahan score (tingkat) depresi) dengan hasil manipulasi intervensi bimbingan spiritual menurut ajaran islam dengan cara melibatkan satu kelompok subjek (lanjut usia) di wilayah rt 04 kedung tarukan wetan surabaya. kelompok subjek (lanjut usia) diobservasi tingkat depresinya sebelum dilakukan intervensi bimbingan spiritual menurut ajaran islam, kemudian diobservasi lagi tingkat depresinya setelah diberikan intervensi bimbingan spiritual menurut ajaran islam. pengujian sebab akibat dilakukan dengan cara membandingkan hasil pre-test dan post-test. populasi terjangkau yang digunakan adalah lanjut usia yang berada di wilayah rt 04 kedung tarukan wetan surabaya. jumlah lanjut usia di wilayah rt 04 kedung tarukan wetan surabaya adalah 27 orang. penelitian ini menggunakan teknik purposive sampling yaitu penetapan sampel dengan memilih sampel sesuai dengan yang dikehendaki oleh peneliti yang disesuaikan dengan kriteria inklusi dan eksklusi yang telah dirancang oleh peneliti, sehingga pemilihan lanjut usia sebagai sampel penelitian dapat mewakili karakteristik lanjut usia di wilayah rt 04 kedung tarukan wetan surabaya yang telah diketahui sebelumnya (saat observasi awal). kriteria inklusi (karakteristik umum subjek penelitian yang akan diteliti) adalah lanjut usia berusia lebih atau sama dengan 60 tahun, jenis kelamin laki-laki dan perempuan, dan mampu membaca al-qur'an. sedangkan kriteria eksklusi adalah lanjut usia yang mengalami sakit berat dan penurunan kesadaran, dan pernah menjadi responden pada penelitian yang sama. sampel penelitian ini adalah seluruh lanjut usia yang tinggal di wilayah rt 04 kedung tarukan wetan surabaya (populasi terjangkau) yang memenuhi kriteria inklusi dan eksklusi. sampel dalam penelitian ini sebanyak 10 orang. penelitian ini menggunakan variabel bebas bimbingan spiritual menurut ajaran islam, sedangkan variabel tergantung adalah score (tingkat) depresi pada lanjut usia. peneliti menggunakan dua instrumen pada penelitian ini untuk masing-masing variabel. pada variabel independen, peneliti menggunakan satuan acara kegiatan (sak). instrumen ini berisi tentang seluk beluk kegiatan yang akan dilakukan yang terdiri dari analisis situasional; tujuan penelitian yang terbagi menjadi tujuan instruksional umum dan khusus; materi yang akan diberikan: metode yang digunakan dalam menyampaikan materi; alat-alat yang digunakan; setting tempat; rencana kegiatan dan terakhir evaluasi. satuan acara kegiatan ini sebagai pedoman peneliti dalam melakukan kegiatan agar tidak menyimpang dari konsep yang telah dibuat yang menyebabkan hasil yang diharapkan tidak signifi kan. untuk melakukan pengumpulan data (variabel dependen) peneliti menggunakan instrumen yang sudah ada sebagai pedoman pengumpulan data berupa kuesioner geriatric depression scale short form yaitu alat ukur depresi pada lanjut usia yang terdiri dari 15 pertanyaan tertutup atau dengan jawaban "ya" dan "tidak". pertanyaan dalam geriatric depression scale short form bertujuan menggambarkan keadaan atau perasaan yang sedang dialami lanjut usia dan keadaan tersebut berkaitan dengan tanda dan gejala depresi pada lanjut usia. indikasi depresi atau tidak mengalami depresi didasarkan pada jumlah skor hasil jawaban lima belas pertanyaan geriatric depression scale (gds) short form dengan total skor 0–5 menunjukkan tahap tidak depresi, 6–10 menunjukkan tahap pradepresi, > 10 menunjukkan tahap depresi. gds dipilih dalam penelitian ini karena memiliki sensitivitas 84% dan spesifi sitas 95%, sehingga memiliki tingkat akurasi yaitu sensitivitas dan spesifi sitas maksimum. penurunan tingkat depresi pada lansia (syaifuddin) 159 lokasi penelitian dilakukan di rt 04 kedung tarukan wetan surabaya pada tanggal 14–21 agustus 2009. analisis pengaruh antara variabel bimbingan spiritual menurut ajaran islam dengan variabel score (tingkat) pada lanjut usia untuk mengetahui efek perlakuan menggunakan uji wilcoxon sign rank test, dengan tingkat kemaknaan p < 0,05. hasil uji statistik dengan metode wilcoxon sign rank test menunjukkan bahwa tingkat signifi kasi p = 0,005, terdapat pengaruh yang signifi kan bimbingan spiritual menurut ajaran islam terhadap perubahan score (tingkat) depresi pada lanjut usia yang menetap di wilayah rt 04 kedung tarukan wetan surabaya. hasil rerata yang semula nilainya 11,4 menjadi 5,4. nilai rerata score (tingkat) depresi sebelum diberi perlakuan bimbingan spiritual menurut ajaran islam adalah 11,4 yang menunjukkan responden atau lanjut usia mengalami depresi. nilai rerata score (tingkat) depresi menunjukkan penurunan setelah diberikan bimbingan spiritual menurut ajaran islam dengan nilai 5,4 yang menunjukkan responden mengalami penurunan score (tingkat) depresi. pembahasan sebelum diberikan bimbingan spiritual menurut ajaran islam, score (tingkat) depresi pada lanjut usia (responden) yang menetap di wilayah rt 04 kedung tarukan wetan surabaya berdasarkan hasil pengukuran kuesioner gds short form menunjukkan skor > 10. mayoritas responden yang mengalami depresi berdasarkan kuesioner gds short form adalah lanjut usia dengan jenis kelamin perempuan. depresi pada lanjut usia terus menjadi masalah kesehatan mental yang serius. gejala-gejala depresi ini sering berhubungan dengan penyesuaian yang terhambat terhadap kehilangan dalam hidup dan stresor (friedman, 1998). mangoenprasodjo (2004) menyatakan bahwa penyebab depresi pada lanjut usia merupakan perpaduan interaksi yang unik dari berkurangnya interaksi sosial, kesepian, masalah sosial ekonomi, perasaan rendah diri karena penurunan kemampuan diri, kemandirian dan penurunan fungsi tubuh serta kesedihan ditinggal orang yang dicintai, faktor kepribadian, genetik dan faktor biologis penurunan neuron-neuron dan neurotransmiter di otak. perpaduan ini sebagai faktor terjadinya depresi pada lanjut usia. kompleksitasnya perubahan-perubahan yang terjadi pada lanjut usia, sehingga seringkali pada lanjut usia dianggap sebagai hal wajar terjadi. bongsoe (2007) menjelaskan bahwa wanita lebih rentan terkena depresi. kejadian depresi pada sebagian lanjut usia di wilayah rt 04 kedung tarukan wetan surabaya menjadi sebuah fenomena yang menunjukkan bahwa kehidupan lanjut usia di wilayah rt 04 kedung tarukan wetan surabaya masih perlu ditingkatkan, hal ini dikarenakan kejadian depresi yang menyerang lanjut usia dapat menurunkan kualitas hidup lanjut usia. mereka tidak dapat menjalani masa tuanya dengan hidup tenang, damai, serta menikmati masa pensiun bersama anak dan cucu tercinta dengan penuh kasih sayang dikarenakan depresi yang mereka derita. belum dijalankannya program kesehatan lanjut usia dari puskesmas setempat yang berupa posyandu lansia oleh pengurus rt 04 kedung tarukan wetan surabaya yang bertujuan untuk membina atau membantu lanjut usia dalam mencapai tingkat sehat dan sejahtera yang optimal di masa tuanya dapat menjadi faktor pendukung adanya kejadian depresi pada lanjut usia di wilayah rt 04 kedung tarukan wetan surabaya, hal ini dikarenakan para lanjut usia tersebut tidak mempunyai tempat untuk mendapatkan informasi atau pengetahuan tentang perkembangan kesehatannya, baik tabel 1. score (tingkat) depresi pada lanjut usia pre post mean 11,4 5,4 sd 0,69921 1,50555 p = 0,005 wilcoxon sign ranks test jurnal ners vol. 6 no. 2 oktober 2011: 156–163 160 fi sik maupun mental yang dapat menjadi bekal berharga dalam menempuh masa tuanya. selain itu, belum berjalannya progam kesehatan tersebut menyebabkan kontrol secara rutin atau berkala terhadap kesehatan fi sik maupun kesehatan mental lanjut usia di wilayah rt 04 kedung tarukan wetan surabaya belum ada, sehingga hal ini memungkinkan adanya kejadian depresi pada lanjut usia yang menetap di wilayah rt 04 kedung tarukan wetan surabaya tidak terdeteksi. k u r a n g n y a k e g i a t a n a t a u a c a r a bermanfaat yang diadakan bagi lanjut usia seperti senam kesehatan lanjut usia atau kegiatan semisalnya yang bersifat rekreatif bersama-sama, baik yang diadakan oleh keluarga maupun pengurus rt 04 kedung tarukan wetan surabaya, sehingga lanjut usia cenderung mengisi aktivitas sehari-hari dengan hanya tiduran, menonton televisi, atau hanya duduk sendiri. hal tersebut dapat memicu timbulnya rasa kejenuhan, kesepian, tidak berdaya dan tidak mampu melakukan apa-apa. bila hal seperti tersebut di atas tetap dibiarkan dapat memperparah keadaan depresi lanjut usia yang menetap di wilayah rt 04 kedung tarukan wetan surabaya. meskipun selama ini terdapat kegiatan pengajian rutin setiap bulan di wilayah rt 04 kedung tarukan wetan surabaya, tapi jumlah lansia yang mengikuti atau menghadiri pengajian tersebut sangatlah sedikit, kurang lebih 4–5 orang setiap bulannya, disamping itu, dalam pelaksanaan pengajian rutin tersebut, tidak didampingi atau tidak diasuh oleh seseorang yang benarbenar ahli atau mampu dalam memberikan bimbingan spiritual bagi peserta pengajian rutin, sehingga pengajian tersebut kurang begitu memberikan efek psikologis yang positif yang dapat menimbulkan mekanisme koping yang positif dalam menghadapi stresor yang bisa menyebabkan depresi. walaupun para lanjut usia tersebut tinggal bersama dengan keluarga, tidak menjadi sebuah jaminan dapat mengatasi kejadian depresi yang menyerang lanjut usia tersebut. ketiadaan dukungan yang positif dari keluarga mereka dalam menghadapi segala perubahan yang terjadi pada diri lanjut usia di masa senjanya seperti kehilangan pasangan hidup, pensiun, menurunnya kondisi fisik, kesehatan bahkan ketidakmampuan aktivitas sehari-hari atau perubahan lain yang merupakan stresor bagi lanjut usia dapat membuat lanjut usia merasa tidak mempunyai tempat untuk berbagi bahkan terkadang membuat lanjut usia merasa dilupakan, merasa disingkirkan serta tidak dibutuhkan lagi. keadaan ini membuat para lanjut usia cenderung memendam perasaan dan kegundahannya ke dalam alam bawah sadar yang menyebabkan dalam diri lanjut usia akan muncul perasaan-perasaan negatif, kecewa, tidak dihargai, sedih, dendam, marah dan sebagainya yang mungkin dapat berperan dalam terjadinya depresi pada lanjut usia yang menetap di wilayah rt 04 kedung tarukan wetan surabaya. kejadian depresi di wilayah rt 04 kedung tarukan wetan surabaya mayoritas menyerang lanjut usia berjenis kelamin wanita daripada lanjut usia berjenis kelamin pria. hal ini dikarenakan mereka lebih mudah untuk sedih, sensitif, marah serta menangis. disamping itu, karakteristik wanita yang lebih mengedepankan emosional daripada rasional juga berperan dan ketika menghadapi sebuah masalah, wanita cenderung menggunakan perasaannya. ketidakmampuan lanjut usia wanita dalam mengendalikan kelemahannya tersebut dapat menjadi bumerang bagi diri mereka sendiri dalam menghadapi stresor yang tinggi dalam hidup bermasyarakat secara heterogen. disamping itu, hilangnya pekerjaan atau kehilangan seseorang yang dicintai dapat menyebabkan wanita jatuh dalam kesedihan yang mendalam, kekecewaan yang diikuti rasa sesal, bersalah dan seterusnya, yang pada gilirannya akan jatuh dalam keadaan depresi. didukung lagi jika lansia mempunyai kecerdasan emosional yang rendah, maka lansia akan menjadi mudah cemas, menyendiri, sering takut, merasa tidak dicintai, merasa gugup, sedih dan cenderung mudah terkena depresi dalam menghadapi stresor-stresor. setelah diberikan bimbingan spiritual menurut ajaran islam didapatkan 5 responden (50%) tidak mengalami depresi dengan score gds short form berada dalam rentang 0–5 dan 5 responden (50%) dalam kriteria pra-depresi dengan rentang skor 6–10. menurut sukardja penurunan tingkat depresi pada lansia (syaifuddin) 161 (2000), cara mengatasi depresi mental adalah dengan diberi bimbingan mental, kalau perlu dengan bantuan ahli agama. aktivitas spiritual dapat berpengaruh positif dalam penurunan stres (potter dan perry, 2005). kegiatan bimbingan spiritual menurut ajaran islam yang dilakukan oleh peneliti dapat memberi sebuah solusi terhadap permasalahan depresi pada lanjut usia yang tinggal di wilayah rt 04 kedung tarukan wetan surabaya. melalui stimulasi sistem limbik, bimbingan spiritual menurut ajaran islam yang dilakukan oleh peneliti ini bertujuan untuk menghadirkan rasa senang, kepuasan dan ketenangan (rileks) pada diri lansia. di samping itu, stimulasi tersebut juga bertujuan menghasilkan proses kognisi yang memunculkan proses adaptasi bagi lansia terhadap keadaannya melalui mekanisme koping yang positif. dengan mempunyai koping yang positif dalam menghadapi stresor, maka stresor tidak akan menimbulkan stres yang berakibat lansia menjadi depresi, tetapi stresor tersebut justru menjadi stimulan yang mendatangkan kebaikan dan prestasi. responden yang telah mengikuti kegiatan bimbingan spiritual menurut ajaran islam mengalami perubahan skor (tingkat) depresinya meskipun perubahan skor tersebut tidak sama merata. kejadian perubahan skor yang tidak sama merata ini mungkin disebabkan adanya perbedaan kemampuan pada masing-masing lansia dalam menerima dan memahami materi bimbingan spiritual menurut ajaran islam yang akhirnya berpengaruh terhadap mekanisme koping yang dihasilkan setelah mengikuti bimbingan spiritual menurut ajaran islam dalam menghadapi stresor-stresor mereka. di samping itu, hal ini menunjukkan bahwa adanya kegiatan-kegiatan yang bermanfaat seperti kegiatan bimbingan spiritual menurut ajaran islam atau mungkin kegiatan bermanfaat lainnya dapat membantu lanjut usia dalam m e n g a t a s i d e p r e s i n y a . k a r e n a d e n g a n mengikuti kegiatan-kegiatan tersebut, lanjut usia menjadi mempunyai aktivitas yang dapat menghilangkan kejenuhannya, kesepian, tidak berdaya dan tidak mampu melakukan apa-apa. mereka tidak hanya tinggal diam di rumah, mereka dapat berinteraksi dengan rekan-rekan sejawatnya, yang mana hal ini bisa menjadi dukungan sosial yang dapat digunakan lanjut usia dalam menghadapi stresor-stresornya. keadaan setelah mengikuti kegiatan bimbingan spiritual menurut ajaran islam ini dapat bertahan dan akan semakin membaik jika keluarga atau orang-orang terdekat juga memberi dukungan positif yang penuh terhadap keadaan yang dialami lanjut usia. hal ini dapat membantu munculnya penguatan harapan terhadap kondisi yang dialami lanjut usia. dengan adanya penguatan tersebut lanjut usia lebih dapat menerima setiap keadaan yang dialami pada masa tuanya dengan ikhlas. ada pengaruh pemberian bimbingan spiritual menurut ajaran islam terhadap perubahan score (tingkat) depresi sebelum dan sesudah diberikan bimbingan spiritual menurut ajaran islam pada lanjut usia yang menetap di wilayah rt 04 kedung tarukan wetan surabaya. hal ini ditunjukkan oleh hasil statistik uji wilcoxon sign rank test dengan nilai signifi kasi p = 0,005. aktivitas spiritual dapat berpengaruh positif dalam penurunan stress (potter dan perry, 2005). membaca dan mendengarkan ayat suci al-quran mempunyai dampak positif yang signifikan terhadap perubahan fisiologi dan psikologi manusia (soleh, 2005). pendekatan keagamaan yang dilakukan melalui bimbingan spiritual menurut ajaran islam dapat membantu munculnya koping positif yang memengaruhi persepsi dan emosi lanjut usia dalam memandang masalah. pemikiran-pemikiran dari ajaran agama mengandung tuntunan bagaimana dalam kehidupan di dunia ini manusia terbebas dari rasa tegang, cemas, depresi dan sebagainya, sehingga dapat meningkatkan kemampuan lanjut usia beradaptasi terhadap segala perubahan dan stres lingkungan yang seringkali menyebabkan depresi. simpulan dan saran simpulan ada pengaruh pemberian bimbingan spiritual menurut ajaran islam terhadap perubahan score (tingkat) depresi pada lanjut usia yang menetap di wilayah rt 04 kedung tarukan wetan surabaya sebelum dan sesudah jurnal ners vol. 6 no. 2 oktober 2011: 156–163 162 diberikan bimbingan spiritual menurut ajaran islam. nilai rerata score (tingkat) depresi menunjukkan penurunan setelah diberikan bimbingan spiritual menurut ajaran islam. saran jajaran pengurus rt 04 kedung tarukan wetan surabaya perlu menyelenggarakan bimbingan spiritual menurut ajaran islam (sebagaimana yang telah dilakukan peneliti) kepada lanjut usia yang menetap di wilayah rt 04 kedung tarukan wetan surabaya dengan mengoptimalkan pengajian yang selama ini telah diselenggarakan oleh jajaran pengurus rt 04 kedung tarukan wetan surabaya. pengoptimalan pengajian tersebut dapat ditempuh dengan cara menyertakan seorang instruktur atau pembimbing (ustadz atau kyai) dari pondok pesantren, departemen agama atau majelis ulama indonesia yang mampu memberikan bimbingan spiritual pada pengajian tersebut untuk membantu lanjut usia dalam mengatasi atau mencegah terjadinya depresi. jajaran pengurus rt 04 kedung tarukan wetan surabaya juga perlu meningkatkan intensitas pelaksanaan pengajian yang selama ini diselenggarakan satu bulan sekali menjadi lebih dari satu kali dalam sebulan, puskesmas pacarkeling dan jajaran pengurus rt 04 kedung tarukan wetan surabaya perlu segera untuk menjalin kerja sama dalam rangka mewujudkan terlaksananya program kesehatan lansia dari puskesmas pacarkeling yang meliputi posyandu lansia dan senam kesehatan lansia di wilayah rt 04 kedung tarukan wetan surabaya. kepustakaan amir, n., 2005. diagnosis dan penatalaksanaan depresi pasca stroke. cermin dunia kedokteran no. 149 kesehatan jiwa, (online), (http://www.kalbefarma.com/ cdk., diakses tanggal 29 april 2006, jam 18.30 wib). bongsoe, s., 2007. tiga belas persen orang usia lanjut alami depresi, (online), (http://www.waspada.co.id., tanggal 22 agustus 2009, jam 12.58 wib). friedman, m., 1998. keperawatan keluarga ed. 3, alih bahasa ina debora. jakarta: egc, hlm. 29, 228, 229. hamid, a., 2007. penduduk lanjut usia d i i n d o n e s i a d a n m a s a l a h kesejahteraannya, (online), (http:// www.depsos.go.id., tanggal 26 april 2009. jam 20.50 wib). hamid, a.y., 2000. aspek spiritual dalam keperawatan. jakarta: widya medika, hlm. 2–3, 5–7, 11–26. hawari, d., 1996. al-qur'an ilmu kedokteran jiwa dan kesehatan jiwa. jakarta: pt. dharma bhakti prima yasa, hlm. 46, 54–57, 59, 65. hawari, d., 2005. dimensi religi dalam praktik psikiatri dan psikologi. jakarta: balai penerbit fkui, hlm. 113–160. jones, e., d., n.d., r.n., 2003. reminiscence t h e r a p y f o r o l d e r wo m e n w i t h d e p r e s s i o n , e f f e c t o f n u r s i n g intervention classifi cation in assisted living long term care. journal of gerontologi nursing 29, page 26–36. kaplan, 1997. synopsis of psychiatry, jilid 2, alih bahasa widjaja kusuma. jakarta: binarupa aksara, hlm. 435–441, 877, 887–889. mangoenprasodjo, 2004. sehat di usia tua. yogyakarta: thinkfresh, hlm. 126–127, 129, 131 nugroho, 2000. keperawatan gerontik. jakarta: egc, hlm. 1, 18–20, 27, 29, 116. potter dan perry, 2005. buku ajar fundamental keperawatan; konsep, proses dan praktik ed. 4, alih bahasa yasmin asih. jakarta: egc, hlm. 732, 738–739, 752. soleh, m., 2005. tahajud manfaat praktis d i t i n j a u d a r i i l m u k e d o k t e r a n . yogyakarta: forum studi himanda, hlm. 10–11, 13, 14, 18, 19, 20, 24–26, 31, 33– 36, 48–50, 53–54, 173, 174, 175, 179, 180, 181, 182–183, 190, 193–195. stanley dan beare, 2007. buku ajar keperawatan gerontik ed. 2, alih bahasa juniarti dan kurnianingsih. jakarta: egc, hlm. 43, 166–170, 367, 368. subrata, 2003. dari acara jumpa seusias e n y u m a n l a n s i a i t u p a n c a r k a n kebahagiaan, (online), (http://www. penurunan tingkat depresi pada lansia (syaifuddin) 163 balipost.co.id/balipostcetak/2003/9/18/ b15.htm., diakses tanggal 30 april 2006. jam 19.15 wib. sukardja, i., 2000. onkologi klinik ed 2. surabaya: airlangga university press, hlm. 167–168, 281, 294–295. syamsuddin, 2006. depresi pada lansia, (online), (http://www.depsos.go.id., diakses tanggal 26 april 2009, jam 19.18 wib). 136 gambaran klinis penderita difteri anak di rsud dr. soetomo (clinical features of children with diphtheria on soetomo hospital) dwiyanti puspitasari, erna supatmini, dominicus husada departemen ilmu kesehatan anak, rsud dr. soetomo surabaya, jl. mayjen. prof. dr. moestopo 6–8 surabaya, email: ... abstract introduction: diphtheria is an important disease in children that could lead to fatal disease. east java province was declared to have diphtheria outbreak in 2011 with increasing morbidity and mortality, including on soetomo hospital. our paper aimed to describe the profi le of diphtheria cases in children admitted at dr sutomo hospital. method: this descriptive study reviewed all medical records of diphtheritic patients admitted to dr. soetomo hospital, january 2004–december 2010, of concerns were clinical presentations, age, sex, immunizations status, complications, and outcomes. result: from 148 diphtheria cases, 22.3% were bacteriologically proven; 53.4% were male with sex ratio 1.1:1. the age proportion of ≤ 5 years old, 5≤ 10 years old, and > 10 years old were 61.5%, 31.8%, and 6.7%. fever occurred in 99% cases, sore throat, stridor and bullneck occurred respectively in 62.2%, 39.9%, and 29.7% cases. there were 56.8% severe and 41.9% moderate diphtheria. subjects were immunized in 84%, but none of them have adequate immunization. myocarditis, being one of the commonest complications occurred in 11.4% cases and tracheostomy was the second (4.0%). all of the death cases (7.9%) were unvaccinated and in severe form. discussion: the mostly prevalent clinical manifestations in diphtheria children were fever and sore throat. half of the cases came with severe diphtheria and most cases were inadequately vaccinated. death occurred in the unvaccinated and severe form. keywords: diphtheria, clinical profi le, children, mortality pendahuluan difteri adalah penyakit saluran nafas atas akut sangat menular yang disebabkan oleh kuman corynebacterium diphtheriae (c. diphtheria). kuman ini menghasilkan toksin yang menyebar sistemik dan menyebabkan kerusakan pada epitel saluran nafas, jantung, ginjal, saraf otak dan saraf tepi. kuman c. diphtheria sendiri berbiak dan berkolonisasi di saluran nafas atas, tidak menyebar, namun dapat menimbulkan sumbatan jalan nafas atas, hingga kematian. difteri masih menjadi masalah serius di beberapa negara di dunia. meskipun vaksinasi difteri telah rutin dilaksanakan diseluruh dunia sejak tahun 70-an, masih terjadi laporan kejadian luar biasa (klb) difteri terutama di negara berkembang hingga tahun 1990an (magdei, et al., 2000; quick, et al., 2000; pantukosit, et al., 2008). indonesia tidak lepas dari masalah difteri. jawa timur dinyatakan klb difteri pada 2011, dengan jumlah kasus hingga akhir 2011 tercatat 665 kasus dengan kematian 20 kasus (dinkes jatim, 2011). gejala klinis difteri bervariasi dari ringan hingga berat, dan tergantung pada organ yang terkena. difteri pada rongga mulut (tonsil-faring-laring) merupakan bentukan paling sering (> 90%). gejalanya seringkali tidak khas: diawali nyeri telan, demam ringan, tidur ngorok, pembesaran kelenjar getah bening leher dengan atau tanpa bullneck, stridor hingga tanda-tanda sumbatan jalan nafas atas. pemeriksaan fi sik yang teliti dengan melihat rongga mulut penderita adalah hal mutlak dalam mendiagnosis difteri, terutama difteri tonsil/faring (buescher, 2007). st ud i i n i ber t uju a n mempelaja r i mengenai profi l gambaran klinis pasien difteri yang dirawat di ruang isolasi anak rsud dr. soetomo surabaya. dengan mengetahui gambaran klinis pada penderita difteri anak 137 gambaran klinis penderita difteri anak (dwiyanti puspitasari, dkk.) diharapkan dapat meningkatkan kewaspadaan akan penyakit difteri dan komplikasinya, sehingga dapat melakukan identifi kasi kasus dan pelayanan keperawatan yang komprehensif dapat dicapai. bahan dan metode penelitian ini merupakan penelitian deskriptif retrospektif pada seluruh anak yang dirawat dengan diagnosis difteri di ruang isolasi anak rsud dr. soetomo dari januari 2004 hingga desember 2010. data diambil dari rekam medis penderita, bila rekam medis tidak ditemukan maka penderita diekslusi. diagnosis difteri dibuat secara klinis berdasarkan anamnesis dan pemeriksaan fi sik tanpa memperhatikan hasil kultur. penderita difteri secara rutin diterapi dengan penisilin prokain. alternatif untuk terapi tersebut adalah eritromisin. antibiotika tambahan diberikan pada infeksi tumpangan. jumlah anti diphtheria serum (ads) yang diberikan tergantung derajat keparahan difteri sesuai protokol di dept/smf ilmu kesehatan anak fk unair/rsud dr. soetomo. difteri ringan bila menderita difteri nasal, konjungtiva, atau kulit, dan mendapat ads 20.000 iu. difteri sedang bila menderita difteri tonsil, atau faring dan mendapat ads 40.000–60.000, difteri berat bila menderita komplikasi difteri, bullneck, pseudomembran yang meluas, dan mendapat ads 100.000 iu. pemberian ads dilakukan segera ketika diagnosis difteri dibuat. terapi tambahan lain tergantung dari komplikasi yang terjadi. pengumpulan data yang dimasukkan dalam lembar pengumpul data (lpd) antara lain presentasi klinis, usia, jenis kelamin, status imunisasi, keparahan difteri, gambaran klinis, pemeriksaan kultur difteri dari hapusan hidung dan tenggorok, komplikasi yang timbul selama masuk rumah sakit, dan keluaran pasien selama dirawat. st at us imu nisasi di kat akan vaccinated bila pernah mendapatkan imunisasi difteri setidaknya 1 kali, bila tidak pernah sama sekali dikelompokkan dalam unvaccinated. data deskriptif yang disajikan dalam studi ini menggunakan nilai frekuensi, interval (range), dan prosentase (%). hasil sejumlah 148 penderita anak (pasien keseluruhan) dengan difteri dimasukkan dalam studi ini. tidak ada penderita yang dieksklusi. tabel 1. data karakteristik 148 penderita difteri jumlah kasus n (%) usia (tahun) mean ± sd (range) 5,11 ± 0,24 rasio jenis kelamin (laki-laki:perempuan) 1,14:1 lama sakit sebelum mrs (hari) mean 0 – < 5 ≥ 5 4,96 ± 2,41 77 (52) 71 (48) tempat tinggal surabaya luar surabaya 84 (56,8) 64 (43,2) derajat difteri difteri ringan difteri sedang difteri berat 2 (1,4%) 62 (41,9%) 84 (56,7%) status imunisasi dpt unvaccinated vaccinated 23 (15,5) 125 (84,5) status gizi buruk kurang atau baik 6 (4,1) 142 (95,9) 138 jurnal ners vol. 7 no. 2 oktober 2012: 136–141 jenis kelamin terdiri dari 79 (53,4%) lakilaki dan 69 (46,6%) perempuan. terdapat 91 (61,5%) penderita berusia kurang dari 5 tahun, 47 (31,8%) berusia 5–10 tahun, dan 10 (6,7%) berusia > 10 tahun, dengan rata-rata usia 5,11 tahun. sebagian besar, 77 (52%) penderita datang ke rumah sakit sebelum hari kelima sakit. karakteristik penderita difteri lebih lanjut dapat dilihat di tabel 1. sebagia n besa r (125/148, 84,4%) penderita datang dengan lokasi pseudomembran di tonsil bilateral dan sisanya tonsil unilateral, faring, laring, dan konjungtiva. hampir seluruh penderita datang dengan klinis panas, tetapi hanya 29 (19,6%) dengan klinis suara parau. dari seluruh penderita yang dilakukan kultur corynebacterium diphtheriae didapatkan hasil positif pada 34 pasien (22,9%). komplikasi tersering yang didapatkan adalah miokarditis (17/148, 11,5%). ena m (4%) pender it a menjalani trakeostomi. sebelas penderita (7,4%) meninggal dunia, dengan penyebab kematian miokarditis (9/81,8%). pembahasan penelitian ini menunjukkan dari 148 kasus difteri terdiri dari 53,4% laki-laki dan tabel 2. gejala klinis penderita difteri jumlah kasus n = 148 letak membran, n (%) tonsil unilateral tonsil bilateral faring laring mata 19 (12,8) 125 (84,4) 6 (4,0) 3 (2,0) 1 (0,06) gambaran klinis, n (%) demam nyeri tenggorok parau stridor bullneck 147 (99,3) 92 (62,2) 29 (19,6) 59 (39,9) 44 (29,7) kultur positif, n (%) corynebacterium diphtheria 33 (22,3) komplikasi, n (%) miokarditis sumbatan jalan nafas acute kidney injury (aki) 17 (11,5) 6 (4,0) 6 (4,0) meninggal, n (%) 11 (7,4%) 46,6% perempuan. hasil ini sesuai dengan studi terdahulu dan yang menyebutkan tidak ada perbedaan bermakna jenis kelamin pada kejadian difteri (top, 1976; pancharoen, et al., 2002). penderita difteri terbanyak pada usia di bawah 5 tahun yaitu 61,5% diikuti dengan usia 5–10 tahun sebanyak 31,8% dan sisanya pada usia lebih dari 10 tahun. hal ini sesuai dengan studi di delhi, yang mendapatkan gambaran serupa, dengan 93% penderita berusia kurang dari 9 tahun (sharma, et al., 2007). sedangkan laporan penelitian klb di usa dan negaranegara bekas rusia menemukan pergeseran epidemiologi usia penderita difteri dari usia sebelum sekolah menjadi usia sekolah dan dewasa yang menggambarkan rendahnya antibodi pada kelompok umur tersebut, sehingga saat klb kelompok ini menjadi rentan terhadap difteri (naiditch, 1954; jukka, 2003). inkubasi difteri terjadi pada hari ke 2–7 (interval 1–10 hari) setelah paparan di mana transmisinya bisa berupa partikel droplet nuklei dari pernafasan atau bisa juga melalui kontak langsung dengan kulit pasien karier difteri. manifestasi klinis umum yang terjadi pada difteri adalah panas badan dan nyeri telan. awalnya nyeri telan merupakan gejala awal 139 gambaran klinis penderita difteri anak (dwiyanti puspitasari, dkk.) yang tidak menyebabkan orang tua membawa anaknya ke dokter tetapi panas yang terjadi kemudian membuat seorang anak dibawa ke dokter. pada studi ini didapatkan bahwa panas badan terjadi pada hampir semua kasus (99,3%), diikuti nyeri telan (62,2%), dan stridor (39,9%). pseudomembran mer upakan tanda k has difteri yang terbentuk dari sel-sel leukosit, fi brin, jaringan nekrosis dan kuman difteri yang melekat kuat dengan jaringan di bawahnya dan akan mengeluarkan darah jika berusaha dilepaskan. pada penelitian ini, 84,4% pseudomembran terdapat pada kedua sisi tonsil, 12,8% pada satu tonsil tetapi lebih dari setengah luas tonsil atau meluas keluar tonsil. terdapat 6 kasus dengan pseudomembran di faring, 3 kasus di laring yang sebagian besar merupakan perluasan dari difteri tonsil. adanya satu kasus difteri di konjungtiva merupakan hal yang sangat jarang terjadi pasca era imunisasi dpt, yang mengindikasikan t i n g g i ny a k a s u s d i f t e r i d a n k u m a n c. diphtheria yang beredar di masyarakat. data dari dinas kesehatan provinsi jawa timur tahun 2011 juga melaporkan mulai munculnya kasus difteri di luar saluran nafas seperti difteri kulit, konjungtiva dan urogenital (vagina) yang setelah era imunisasi sudah menghilang (dinas kesehatan jawa timur, 2011). diagnosis difteri terutama berdasarkan gejala klinis dan konfirmasi laboratorium ber upa hasil kultur c. diphtheria hanya ditemu kan pada 23,3%. st udi di india mengemukakan bahwa diagnosis difteri secara klinis perlu mendapat perhatian atau sangat penting karena rendahnya temuan positif kuman c. diphtheria. jika terjadi keterlambatan diagnosis selama 48–72 jam akan menimbulkan komplikasi yang serius bagi pasien (ray, 1998). difteri merupakan penyakit yang dapat dicegah dengan imunisasi. di indonesia, program imunisasi yang telah digalakkan mulai tahun 1970-an, telah berhasil menurunkan angka kejadian difteri. imunisasi kombinasi dtp (diphtheria toxoid, tetanus toxoid, dan pertussis) dimulai saat seseorang berusia 6 minggu kemudian diulang 2× interval tiap 4 minggu kemudian di-booster setahun setelah imunisasi terakhir dan saat usia 5 tahun. di jawa timur termasuk di rsud dr. soetomo, terjadi peningkatan kejadian difteri dimulai tahun 2004 sampai 2009, hal ini bisa disebabkan oleh banyak hal antara lain gagalnya cakupan imunisasi, kelangkaan ads dan resistensi kuman terhadap antibiotik pada saat itu, vaksin yang tak imunogenik karena beku, dan tidak dilakukannya imunisasi ulangan (booster) pada usia 2 tahun. studi ini menemukan bahwa tidak ada pasien yang menjalani imunisasi lengkap (adequately vaccinated), 84,5% kasus tidak diimunisasi lengkap atau tidak di booster (inadequately vaccinated ) dan 15,5% tidak diimunisasi (u n va c ci n a te d ) d i m a n a ke se mu a nya merupakan difteri berat. studi di thailand dan india mendapatkan hampir 2/3 penderita tidak pernah mendapatkan imunisasi dpt (pancharoen, 2002; ray, 1998). pada studi kami, sekitar 85% penderita sudah pernah diimunisasi tetapi tidak adekuat, akan tetapi pengambilan data imunisasi hanya berdasarkan anamnesis orangtua, tanpa menunjukkan kartu imunisasi, sehingga bias ingatan sangat mungkin terjadi. perlu dilakukan studi lebih lanjut untuk mengetahui kadar protektif antibodi difteri setelah mendapat imunisasi, ketepatan pemberian imunisasi serta rantai penyimpanan vaksin. prinsip tata laksana medikamentosa difteri yang terpenting adalah pemberian ads sesuai derajat severitasnya dan antibiotik untuk mengeliminasi kuman sampai 95%, tetapi tetap bukan sebagai pengganti ads. selain itu, isolasi pasien, bed rest total, serta cukup cairan dan elektrolit merupakan penunjang yang penting dalam tatalaksana difteri (buescher, 2007). hasil penelitian menunjukkan 56,7% penderita datang dalam kondisi difteri berat; bisa dikarenakan luas pseudomembran yang ekstensif, adanya bullneck ataupun komplikasi lain. diperlukan pemeriksaan f isik yang menyeluruh dengan membuka mulut dan memeriksa faring pada semua penderita anak, terlebih bila datang dengan keluhan demam dan nyeri telan. dengan semikian, diharapkan difteri dapat terdeteksi dini, sehingga penderita tidak terlambat terdiagnosis dan mendapatkan terapi. 140 jurnal ners vol. 7 no. 2 oktober 2012: 136–141 asuhan keperawatan pada penderita difteri yang dirawat meliputi asuhan dalam pember ian a ds, antibioti ka penicillin prokain dan atau antibiotika lain, pemberian kortikosteroid bila diperlukan, dan tatalaksana pengambilan sampel usap tenggorok atau hidung, serta ekg. perlu juga dilakukan diagnosis keperawatan dan tatalaksananya pada hal-hal berikut, yaitu kemungkinan ket id a kefek t ifa n be r si ha n jala n n afa s karena obstruksi jalan nafas, adanya resiko penyebarluasan infeksi dari organisme virulen, perubahan nutrisi kurang dari kebutuhan karena nafsu makan menur un sekunder, efek toksin kuman, kemungkinan penyulit miokarditis, resiko tinggi cidera karena perubahan sensori/persepsi penglihatan, dan kemungkinan gangguan mobilitas fi sik yaitu penurunan fungsi motorik sekunder karena adanya neuropati. secara umum, prognosis difteri adalah baik. mortalitas biasanya terjadi karena kegagalan jantung dan respirasi yang terjadi pada 4 minggu awal sakit. pada studi ini, didapatkan 17 (11,5%) pasien mengalami miokarditis dengan 8 di antaranya meninggal, sehingga elektrokardiogram (ekg) harus dilaksanakan pada saat awal dirawat dan setiap 2 hari setelah seminggu sakit agar bisa mendeteksi lebih dini adanya miokarditis. simpulan dan saran simpulan anak-anak dengan penyakit difteri pada umumnya datang dengan keluhan panas dan nyeri telan. separuh penderita datang dengan kondisi difteri berat, dan sebagian besar penderita sudah pernah mendapat imunisasi dpt, tetapi tidak adekuat. kematian umumnya terjadi pada difteri berat dan yang tidak pernah diimunisasi dpt. saran daerah di mana kasus difteri banyak t e r ja d i, p e nt i ng u nt u k mela k s a n a k a n pemeriksaan fi sik yang menyeluruh, termasuk melihat faring penderita, karena gejala difteri yang tidak khas. penemuan kasus yang dini akan memperbaiki prognosis penderita, karena semakin cepat diagnosis ditegakkan dan diberikan terapi yang adekuat, semakin sedikit jumlah toksin yang sudah masuk ke jaringan, sehingga kemungkinan komplikasi juga semakin rendah. peningkatan cakupan imunisasi dasar dpt dan pemberian booster atau ulangan dpt pada umur 18 bulan diharapkan dapat menekan morbiditas dan mortalitas infeksi difteri. kepustakaan buescher, e.s., 2007. diphtheria. dalam: kliegman r.m., dk k. (ed). nelson textbook of pediatrics. edisi ke-18. philadelphia: w.b saunders company, hlm. 1153–7. dinas kesehatan propinsi jawa timur, 2012. data difteri 2011 dinas kesehatan propinsi jawa ti mu r (d at a tidak dipublikasikan). jukka, l., 2003. studies on the epidemiology a n d cli ni cal ch a ra cte r i st i c s of diphtheria during the russian epidemic of the 1990 s. diser t asi tampere university. tampere university press, (online), (http://acta.uta.fi/english/teos. php?id=8914, diakses tanggal 1 mei 2012, jam 12.00 wib) magdei, m., melnic, a., benes, o., dkk., 2000. epidemiology and control of diphtheria in the republic of moldova, 1946–1996. j infect dis.; 181(suppl 1): s47–54. naiditch, m.j., bower, a.g., 1954. diphtheria. a study of 1.433 cases observed during a ten-year period at the los angeles cou nt y hospit al. am j m ed, 7, 229–45. pancharoen, c., mekmullica, j., thisyakorn u., 2002. clinical features of diphtheria in thai children: a historic perspective. southeast asian j trop med public health, 22, 352–4. pantukosit, p., arpornsuwan, m., sookananta, k., 2008. a diphtheria outbreak in buri ram, thailand. southeast asian j trop med public health, 39, 690–6. quick, m.l., sutter, r.w., kobaidze, k., dkk., 2000. epidemic diphtheria in the republic of georgia, 1993–1996: risk factors for fatal outcome among hospitalized patients. j infect dis, 181(suppl 1), 130–7. 141 gambaran klinis penderita difteri anak (dwiyanti puspitasari, dkk.) ray, s.k., das, gupta, s., saha, i. 1998. a report of diphtheria surveillance from a rural medical college hospital. j indian med assoc, 96, 236–8. sharma, n.c., banavaliker, j.n., ranjan. r, d k k., 2007. bacter iological & epidemiological character istics of diphtheria cases in and around delhi – a retrospective study. indian j med res, 126, 545–52. top, f.h., wehrle, p.f., 1976. diphtheria. in: communicable and infectious disease, 8th ed. st. louis: mosby co, hlm. 223–38. vol 8 no 2 oktober 2013.indd 357 indeks remunerasi tenaga keperawatan (nursing remuneration index) suprajitno* * jurusan keperawatan poltekkes malang jl. besar ijen no 77c malang 65112 e-mail: bedonku@yahoo.co.id abstrak pendahuluan: perawat memiliki beberapa variabel , yang dapat digunakan sebagai dasar remunerasi. tujuan dari penelitian ini adalah untuk mengembangkan indeks remunerasi keperawatan di rumah sakit ngudi waluyo wlingi menggunakan pendekatan statistik. metode: desain penelitian adalah deskriptif, yaitu studi yang terbagi menjadi dua level. level pertama adalah survei dan focus group discussion (fgd) dan level kedua adalah menilai rumus indeks remunerasi dengan simulasi. subjek untuk survei adalah seluruh perawat yang memiliki status dipekerjakan oleh negara (pns) di rumah sakit ngudi waluyo wlingi dari tahun 2011 sedangkan untuk fgd adalah eksekutif manajemen dan perawat. subjek untuk survei adalah 117 perawat, sedangkan untuk fgd terdapat dua eksekutif manajemen dan sepuluh perawat. analisis data dilakukan dengan menggunakan software amos. hasil: indeks remunerasi dibentuk oleh tiga faktor di tempat bekerja, pekerjaan tambahan yang diukur dengan pekerjaan tambahan sehari-hari dan panjangnya sebagai pengaman, dan jenis intervensi keperawatan yang diukur dari jumlah intervensi keperawatan dalam kategori sederhana, ringan, sedang, berat, dan intervensi keperawatan khusus. rumus indeks remunerasi adalah (0.252 x bekerja kategori tempat) + (0,226 x indeks pekerjaan tambahan) + (0,218 x jenis indeks intervensi keperawatan). diskusi: penilaian yang sesuai dengan menggunakan goodness of fi t index 0.827, yang berarti 82,7% dari rumus indeks remunerasi dapat dijelaskan oleh faktor-faktor di tempat kerja, pekerjaan tambahan, dan jenis intervensi keperawatan, sedangkan 17,3% dijelaskan oleh faktor lain. kata kunci: rumah sakit, perawat, indeks remunerasi abstract introduction. nurses have some variables, which can be used as basic of the remuneration. the aim of the study was to develop nursing remuneration index in the hospital of ngudi waluyo wlingi using statistics approach. methods. research design was descriptive, study that is divided into two levels. the fi rst level was surveying and focus group discussion and the second level was assessing the remuneration index formula by simulation. the subject for surveying was the whole nurses who have state employ status at hospital of ngudi waluyo wlingi on 2011 while for the focus group discussion was the executive management and nurses. subject for surveying were 117 nurses, while for focus group discussion was two executive management and ten nurses. the data analysis was by using amos software. result. remuneration index formed by three factors were worked place, additional job which was measured by the daily additional job and the length as observer, and kind of nursing interventions which were measured from the amount of nursing intervention in the category of simple, mild, moderate, severe, and special nursing intervention. resulting formula of remuneration index was (0.252 x worked place categories) + (0.226 x additional job index) + (0.218 x kind of nursing intervention index). discussion. fit assessment by using goodness of fi t index was 0.827, which mean 82.7% of the remuneration index formula can be explained by factors of workplace, additional job, and kind of nursing intervention, while 17.3% was explained by other factors. key word: hospital, nurses, remuneration index pendahuluan a s u h a n k e p e r a w a t a n d a p a t memberikan kont ribusi kepada layanan kesehatan yaitu meningkatkan kepuasan pasien yang pada akhirnya berdampak pada meningkatnya jumlah pasien atau keluarga yang mempercayakan layanan kesehatannya kepada rumah sakit. kepuasan pasien yang mendapat layanan perawat akan memberikan informasi kepada pasien atau keluarga pasien sebagai pengguna atau pelanggan. sehingga diharapkan dapat meningkatkan pendapatan sarana layanan kesehatan. peningkatan pendapatan dimungkinkan juga a k a n me n i ng k at k a n keu nt u nga n (benefit) sarana layanan kesehatan. upaya yang perlu dilakukan pihak pengelola untuk mempertahankan pelayanan kesehatan adalah 358 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 mengembalikan sebagian pendapatan kepada pemberi layanan kesehatan dalam bentuk insentif atau bonus di luar penghasilan rutin, yang juga diberikan kepada tenaga keperawatan. pengembalian sebagian pendapatan kepada tenaga keperawatan yang memberikan layanan kesehatan tidak hanya didasarkan salah satu kategori yang dimiliki tenaga keperawatan, tetapi perlu mempertimbangkan s elu r u h a s p ek y a ng d i m i l i k i t e n a g a keperawatan. upaya demikian disebut dengan remunerasi (remuneration). remunerasi mempunyai defi nisi kompensasi yang diterima untuk pelayanan yang per nah diberikan (compensation for services), yang dapat disebut sebagai insentif. pemberian remunerasi sebagai insentif pada tenaga keperawatan diharapkan dapat meminimalkan kesenjangan, diperlukan penilaian setiap komponen yang dimiliki oleh tenaga keperawatan baik yang berhubungan kinerja profesi dan tugas tambahan yang dimiliki dalam setiap menjalankan kewajiban. beberapa variabel yang dapat dipertimbangkan d a l a m m e m b e d a k a n k i n e r j a t e n a g a keperawatan yaitu pendidikan formal yang dimiliki, pendidikan kompetensi keahlian, jabatan fungsional, lama bekerja pada institusi pelayanan kesehatan, tempat bekerja, prestasi yang pernah diperoleh, kewenangan tambahan, jenis tindakan, rotasi dinas yang dijalani, dan jam pekerjaan yang dilaksanakan. sedangkan tugas tambahan yang dapat dipertimbangkan dalam pemberian insentif yaitu kedudukan sebagai penanggung jawab pekerjaan tertentu, tugas yang diperoleh untuk kegiatan institusi, dan tugas tambahan lain yang berhubungan dengan institusi bekerja. secara statistika, setiap variabel agar dapat dilihat besar peranan perlu diberikan satuan ukuran numerik. variabel tenaga keperawatan yang mempunyai kemiripan sifat dapat dijadikan sebagai faktor indeks remunerasi dalam penentuan insentif sebagai jasa pelayanan. setiap faktor secara bersamasama dan mempunyai nilai tertentu dapat menyusun besaran yang disebut indeks, dan yang dimaksud dengan indeks adalah statistik komposit atau disebut juga indeks komposit. pengembangan indeks dapat dilakukan dengan pendekatan statistika, di mana statistika me mpu nyai ke m a mpu a n me nga n al isis variabel berskala penjenjangan (ordinal). peran variabel tenaga keperawatan teramati dalam faktor dibaca dari nilai loading factor (lambda) yang dihasilkan dengan analisis faktor konfi rmatori. variabel teramati atau manifes disebut valid sebagai indikator jika mempunyai nilai signifi kansi kurang dari 0,05. secara keseluruhan untuk menilai kesesuaian formula indeks remunerasi menggunakan nilai goodness of fi t index. formula indeks remunerasi merupakan penjumlahan faktor dengan bobot yang dihasilkan analisis fi rst order pada amos. sehingga, dilakukan penelitian tentang indeks remunerasi tenaga keperawatan, yang dimaksud remunerasi dalam penelitian ini adalah pemberian insentif. tujuan umum penelitian ini adalah merumuskan formula indeks remunerasi tenaga keperawatan dengan pendekatan statistika sebagai cara unt uk pemberian insentif. sedangkan tujuan khususnya adalah, memilih variabel tenaga keperawatan yang merupakan indikator dari faktor indeks remunerasi dengan pendekatan statistika, mengembangkan faktor indeks remunerasi berdasarkan indikator tenaga keperawatan dengan metode linier structural relation, mengembangkan formula indeks remunerasi tenaga keperawatan, dan menilai formula indeks remunerasi tenaga keperawatan dengan melakukan simulasi. bahan dan metode jenis penelitian ini adalah deskriptif yang dilaksanakan dalam dua tahap. tahap pertama yaitu mengumpulkan data variabel tenaga keperawatan sebagai variabel manifes (teramati) yang dilanjutkan diskusi kelompok terfokus dengan pihak direksi dan tenaga keperawatan. tahap kedua yaitu menilai for mula indeks remunerasi dengan cara simulasi. subjek penelitian untuk survei sebanyak 117 orang tenaga keperawatan yang berstatus pegawai negeri sipil yang bekerja di rumah sakit umum (rsu) ngudi waluyo wlingi pada tahun 2011. subjek penelitian ini dipilih 359 indeks remunerasi tenaga keperawatan (suprajitno) secara sampling acak sederhana, yang bekerja di unit rawat jalan (poliklinik), unit rawat inap, dan unit rawat darurat/critical care. subjek penelitian untuk diskusi kelompok terfokus terdiri dari dua orang jajaran direksi dan 10 orang tenaga keperawatan. variabel tenaga keperawatan yang dikumpulkan datanya sebanyak 11 variabel yaitu (1) pendidikan formal yang dimiliki dinilai angka kredit sesuai sk men pan nomor 94 tahun 2001, (2) pelatihan kompetensi keahlian yang dilakukan selama tiga tahun terak hir, (3) jabatan fungsional perawat yang dimiliki sesuai sk men pan nomor 94 tahun 2001, (4) lama bekerja perawat di rumah sakit, (5) tugas tambahan yang dimiliki tenaga keperawatan yang dihitung sebagai penjumlahan skor tenaga keperawatan dan tugas tambahan sebagai pembimbing praktik, kepala ruang perawatan, wakil kepala ruang perawatan, (6) lama hari sebagai pengamat, (7) prestasi yang pernah diperoleh 3 tahun terakhir yang dikelompok kan tingkat kabupaten, provinsi, atau nasional, (8) tempat bekerja sehari-hari yang dikelompokkan poliklinik, unit rawat inap, atau unit rawat darurat/critical care, (9) jumlah jenis tindakan keperawatan yang dilakukan dikalikan skor pengelompokan tindakan sederhana, tindakan ringan, tindakan sedang, tindakan besar, at au tindakan khusus, (10) rotasi dinas yang dialami yang dikelompokkan dinas pagi, dinas sore, dinas malam, atau dinas mendadak, dan (11) jumlah jam izin atau meninggalkan dinas. alat pengumpulan data yang digunakan dalam tahap pertama dan kedua penelitian adalah kuesioner, formulir isian, dan daftar hadir harian. cara pengumpulan data tahap per t a ma denga n wawa nca ra la ngsu ng, pemeriksaan bukti, menyalin jadwal dinas, dan tenaga keperawatan memberikan tally pada kolom tindakan keperawatan yang sesuai. pengumpulan data dilakukan pada bulan juni sampai dengan agustus 2011 di rumah sakit umum ngudi waluyo wlingi. a nalisis d at a u nt u k menent u ka n variabel tenaga keperawatan yang menyusun indikator dan merumuskan indeks remunerasi tenaga keperawatan secara linier structural relation menggunakan bantuan perangkat lunak amos. setiap faktor akan mempunyai bobot yang dihasilkan dari fi rst order analisis dengan amos. formula indeks remunerasi t e n a g a ke p e r awat a n ya ng d i h a si l k a n berbent uk persamaan str ukt ural. unt uk menilai kesesuaian formula indeks remunerasi digunakan goodness of fi t index (gfi). hasil akhir tahap pertama penelitian adalah formula indeks remunerasi dalam bentuk persamaan struktural. tahap kedua penelitian adalah melakukan simulasi dibandingkan dengan pemberian insentif yang pernah dijalani tenaga keperawatan. hasil penelitian selama dilakukan pengumpulan data pada bulan juni sampai dengan agustus 2011 tenaga keperawatan tidak ada yang izin selama memberikan pelayanan keperawatan. sehingga setiap tenaga keperawatan yang menjadi sampel penelitian jumlah jam izin dalam sebulan adalah nol jam. selama bekerja di rsu ngudi waluyo wlingi, tenaga keperawatan telah mendapat insentif tambahan rutin setiap bulan di luar gaji rutin yang diterima. persepsi perawat tentang keadilan, jumlah, dan kenaikan insentif yang pernah diterima digambarkan dalam tabel 4. terdapat 3 isu strategis yang merupakan hasil diskusi kelompok terfokus di rumah sakit ngudi waluyo wlingi. isu strategis yag pertama yaitu tempat kerja dengan solusi yang ditawarkan yaitu pengelompokan tempat kerja disesuaikan dengan kesepakatan yang telah ada di rumah sakit ngudi waluyo wlingi, yaitu unit rawat jalan (di poliklinik), unit rawat inap (di ruang perawatan bukan kritis atau darurat dan pavilyun), dan unit rawat darurat atau critical care (di instalasi gawat darurat, intensive care unit, kamar operasi, perinatologi, kamar bersalin). isu strategis yang kedua adalah lama bekerja. solusi yang ditawarkan untuk isu tersebut: 1) perlu dipertimbangkan untuk dianalisis yaitu lama bekerja di rumah sakit umum ngudi waluyo wlingi dan lama bekerja sebagai tenaga keperawatan, 2) lama kerja di rumah sakit umum ngudi waluyo wlingi dapat menggambarkan seberapa besar peran tenaga keperawatan untuk memberikan 360 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 klontribusi pada kemajuan rumah sakit, 3) lama bekerja sebagai tenaga keperawatan dapat menggambarkan kemampuan tenaga keperawatan yang bekerja pada tempat tertentu. tenaga keperawatan, meski tidak lama bekerja di rumah sakit tetapi mempunyai tabel 1. karakteristik tenaga keperawatan rsu ngudi waluyo wlingi bulan juni s.d. agustus 2011 no. karakteristik .f % 1 pendidikan: d-3 keperawatan s-1 keperawatan/ners 105 12 89,7 10,3 2 pelatihan kompetensi: memiliki tidak memiliki 0 117 0,0 100,0 3 jabatan fungsional: belum mempunyai jabatan perawat pelaksana perawat pelaksana lanjutan perawat penyelia perawat pratama perawat muda perawat madya 1 64 33 13 5 1 0 0,9 54,7 28,2 11,1 4,3 0,9 0,0 4 lama bekerja: ≥ 27 tahun 26–22 tahun 21–17 tahun 16–12 tahun 11–7 tahun 6–2 tahun ≤ 2 tahun 6 18 18 30 25 20 1 5,1 15,4 15,4 25,7 21,4 17,1 0,9 5 tugas perawat sehari-hari: hanya sebagai perawat perawat + pembimbing praktik perawat + wakil kepala ruang perawat + kepala ruang perawat + wakil kepala ruang + pembimbing praktik + pengamat perawat + kepala ruang + pembimbing praktik + pengamat 89 2 1 8 9 8 76,1 1,7 0,9 6,9 7,6 6,9 6 prestasi yang dimiliki pada tingkat: kabupaten provinsi nasional 0 0 0 0,0 0,0 0,0 7 tempat bekerja tenaga keperawatan: unit rawat jalan (poliklinik) unit rawat inap unit rawat darurat/critical care 8 54 55 6,8 46,2 47,0 kompetensi yang dimiliki dari tempat bekerja lama. isu strategis ketiga yait u tentang tugas sebagai pengamat. sebagai pengamat mempunyai waktu dinas yang lebih panjang yaitu 15 jam (16.00 – 07.00 esok hari) dan tidak diperbolehkan meninggalkan dinas 361 indeks remunerasi tenaga keperawatan (suprajitno) tabel 2. jumlah tindakan keperawatan yang dilaksanakan tenaga keperawatan rsu ngudi waluyo wlingi bulan juni s.d. agustus 2011 no. jenis tindakan keperawatan jumlah tindakan per individu per bulan (kali) tenaga keperawatan yang melakukan (orang) minimal maksimal 1 tindakan keperawatan sederhana 1 271 114 2 tindakan keperawatan ringan 5 308 116 3 tindakan keperawatan sedang 3 248 114 4 tindakan keperawatan besar 2 85 41 5 tindakan keperawatan khusus 1 20 5 tabel 3. jumlah hari dinas sestiap bulan sesuai rotasi tenaga keperawatan rsu ngudi waluyo wlingi bulan juni s.d. agustus 2011 no. rotasi dinas jumlah orang jumlah hari dinas frekuensi % minimal maksimal 1 pagi 117 100,0 2 25 2 sore 81 69,2 2 8 3 malam 84 70,9 1 8 sebelumnya. mempunyai tanggung jawab besar yait u menggantikan kepala r uang pelayanan keperawatan dan kepala bidang keperawatan sehingga harus mengkoordinir kegiatan pelayanan keperawatan. peran sebagai pengamat perlu diberikan skor besar karena sifat dinas dapat terencana (sesuai jadwal) atau mendadak. lama hari dinas sebagai pengamat tabel 4. persepsi perawat tentang keadilan, jumlah, dan kenaikan insentif di rsu ngudi waluyo wlingi no. persepsi tentang insentif yang diterima .f % 1 keadilan: tidak adil kurang adil adil 18 79 20 15,4 67,5 17,1 2 jumlah yang diterima: tidak sesuai kurang sesuai sesuai 16 75 26 13,7 64,1 22,2 3 kenaikan: berkurang tetap naik 32 78 7 27,4 66,7 6,0 perlu dipertimbangkan skor sendiri, dengan alasan meskipun mempunyai surat keputusan sebagai pengamat belum tentu dalam satu bulan diberikan tugas terencana sebagai pengamat kecuali mendadak. model awal analisis indeks remunerasi tenaga keperawatan seperti gambar 1 di bawah ini. setelah dilakukan analisis dengan menilai variabel yang signifi kan, pada analisis yang keempat diperoleh model akhir yang digambarkan oleh gambar 2. hasil analisis akhir menggunakan perangkat lunak amos setelah dilakukan perbaikan model dengan cara model generating yaitu menggabungkan antara teori dan fakta yang diperoleh, digambarkan seperti gambar 2. nilai kesesuaian model akhir indeks goodness of f it index (gfi) remunerasi tenaga keperawatan adalah sebesar 0,827. formula indeks remunerasi dibuat dalam bentuk persamaan struktural. berdasarkan hasil analisis pada model akhir (gambar 2) menggunakan perangkat lunak amos dan diperoleh nilai loading factor (λ) seperti pada tabel 7, sehingga dapat disusun formula 362 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 gambar 1 model awal indeks remunerasi tenaga keperawatan keterangan gambar 1: t : tempat kerja tenaga keperawatan pf : pendidikan formal tenaga keperawatan tertinggi yang dimiliki lk1 : jabatan fungsional keperawatan yang dimiliki saat ini lk2 : lama kerja sebagai tenaga keperawatan setelah memiliki ijazah pf lk3 : lama kerja sebagai tenaga keperawatan di rsu ngudi waluyo wlingi tg1 : tugas tambahan sehari-hari sebagai tenaga keperawatan tg2 : lama hari sebagai pengamat td1 : skor tindakan keperawatan kelompok sederhana yang dilaksanakan td2 : skor tindakan keperawatan kelompok ringan yang dilaksanakan td3 : skor tindakan keperawatan kelompok sedang yang dilaksanakan td6 : skor tindakan keperawatan kelompok besar dan khusus dn1 : skor dinas pagi dn2 : skor dinas sore dn3 : skor dinas malam : variabel yang diukur/observed variable : variabel laten/variabel yang tidak dapat diukur secara langsung gambar 2 model akhir indeks remunerasi keperawatan keterangan gambar 2: t : kempat kerja perawat tg1 : tugas tambahan sehari-hari sebagai perawat tg2 : lama hari sebagai pengamat td1 : skor tindakan keperawatan kelompok sederhana yang dilaksanakan td2 : skor tindakan keperawatan kelompok ringan yang dilaksanakan td3 : skor tindakan keperawatan kelompok sedang yang dilaksanakan td6 : skor tindakan keperawatan kelompok besar dan khusus (rumus) untuk menghitung indeks remunerasi sebagai berikut: indeks remunerasi = ( 0 , 2 5 2 x k a t e g o r i te m p a t k e r j a ) + ( 0 , 2 2 6 x i n d e k s tugas tambahan) + (0,218 x indeks jenis tindakan) penjelasan: kategori tempat kerja dikelompokkan menjadi (1) unit rawat jalan (poliklinik), (2) unit rawat inap, dan (3) unit rawat darurat/critical care indeks tugas tambahan = (0,702 x tugas tambahan sehari-hari perawat) + (1,000 x skor jumlah hari pengamat) indeks jenis tindakan = (0,471 x skor tindakan sederhana) + (0,681 x skor tindakan ringan) + (1,000 x skor tindakan sedang) + (0,278 x skor tindakan besar dan khusus) 363 indeks remunerasi tenaga keperawatan (suprajitno) simulasi formula indeks remunerasi diterapkan pada 33 orang tenaga keperawatan dengan pembanding besar insentif yang diterima oleh tenaga keperawatan. distribusi frekuensi kenaikan atau penurunan insentif setelah dihitung dengan for mula indeks remunerasi adalah sebagai berikut: pembahasan dalam george (1989) yang menulis tentang teori keperawatan orem yang dikenal dengan self-care requisites bahwa pasien yang membutuhkan pelayanan keperawatan dikelompokkan menjadi tiga kategori yaitu (1) the wholly compensatory nursing systems; (2) the partly compensatory nursing system; dan (3) the supportive-educative system. the wholly compensator y nursing system, menggambarkan situasi individu pasien di mana individu tidak mampu memenuhi kebutuhan individu secara mandiri dan sangat tergantung kepada tenaga keperawatan, tidak mampu mengontrol aktivitas pergerakan (ambulasi) yang perlu dilakukan sendiri, dan mendapatkan pengobatan intensif untuk penyembuhan keadaan sakitnya. the partly compensatory nursing system, menggambarkan suatu situasi individu pasien di mana perawat membantu memenuhi kebutuhan pasien yang tidak dapat dipenuhi sendiri dan pasien masih mempunyai kemampuan untuk melakukan aktivitas pergerakan (ambulatori) meskipun terbatas. the supportive-educative system, menggambarkan di mana situasi individu pa sien mempu nyai kema mpu a n u nt u k memenuhi kebutuhannya sendiri dan hanya diperlukan dukungan dari perawat. tabel 5. nilai signifi kansi hasil analisis tahap 1 (model awal) sampai tahap 4 (model akhir) no. variabel nilai sinifi kansi dari analisis tahap 1 (model awal) tahap 2 tahap 3 tahap 4 (model akhir) 1 tempat kerja 0,008 0,010 0,004 0,004 2 pendidikan formal 0,330 ------3 lama bekerja 0,033 0,057 0,105 --4 tugas tambahan 0,114 0,027 0,034 0,004 5 jenis tindakan keperawatan 0,027 0,014 0,014 0,014 6 dinas 0,247 0,286 ----tabel 6. nilai regresi hasil analisis model akhir indeks remunerasi tenaga keperawatan regression weight standardized regression estimated probability remunerasi tempat kerja (t) 0,237 0,006 0,252 remunerasi tugas tambahan 0,078 0,014 0,226 remunerasi jenis tindakan 0,004 0,028 0,218 tg1 tugas tambahan 1,000 0,702 tg2 tugas tambahan 2,604 0,000 1,000 td1 jenis tindakan 1,000 *) 0,471 td2 jenis tindakan 2,263 0,000 0,681 td3 jenis tindakan 3,827 0,000 1,000 td6 jenis tindakan 0,967 0,006 0,278 adil remunerasi 1,000 *) 0,984 jumlah remunerasi 0,864 0,000 0,817 naik remunerasi 0,285 0,000 0,298 keterangan: *) nilai default dari perangkat lunak amos 364 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 selama penelitian, ruang pelayanan keperawatan yang didasarkan pada teori orem dikelompokkan menjadi tiga kelompok yaitu (1) unit rawat jalan; (2) unit rawat inap; dan (3) unit rawat darurat/critical care. pengelompokan r uang pelayanan keperawatan didukung pula hasil diskusi kelompok terfokus dengan tenaga keperawatan. pelayanan keperawatan di unit rawat jalan yang meliputi delapan poliklinik, merupakan tempat pelayanan di mana pasien mempunyai kecenderungan dapat melakukan aktivitas sendiri (berjalan) dan tenaga keperawatan berkewajiban memberikan dukungan dan pendidikan kepada pasien untuk mempertahankan dan meningkatkan kesehatan. pasien yang mendapat pelayanan di poliklinik, di samping mampu melakukan ambulatori juga mampu melakukan tindakan keperawatan sendiri selama di rumah, misalnya mampu menyediakan obat (oral), mampu merawat luka, mampu memenuhi kebersihan diri, dan kebutuhan lain. pel ay a n a n ke p e r awa t a n d i u n it rawat inap, pasien sebenarnya mempunyai kemampuan unt uk melak ukan aktivitas bergerak (ambulatori) sendiri dan hanya beberapa kebutuhannya yang tidak dapat dipenuhi sendiri. beberapa kebutuhan harus mendapatkan bantuan dari perawat misalnya ada luka pada tempat tertentu, diperlukan obat (suntik) yang tidak mungkin dilakukan sendiri, perlu pengawasan secara berkala (tiap jam), atau tindakan pemeriksaan lanjutan untuk memperbaiki kesehatan pasien. keadaan ini menggambarkan bahwa pasien mempunyai kemampuan tetapi ada beberapa yang perlu diberikan bantuan oleh tenaga keperawatan. pasien yang dirawat di unit pelayanan keperawatan kritis (critical care)/darurat secara keseluruhan (total) sangat tergantung dan perlu mendapat bantuan dari tenaga keperawatan dan tenaga kesehatan profesional lain. keadaan pasien pada pelayanan keperawatan kritis/emergensi ada yang mengalami masalah kesadaran, keterbatasan aktivitas secara total, dibatasi secara total aktivitas yang boleh dilakukan. sedangkan pada pasien bayi baru lahir, secara teoritis dan fakta memang tidak mampu melakukan pemenuhan kebutuhan sendiri, seluruhnya harus dibantu. setelah dilak u kan analisis model akhir dengan menghilangkan variabel laten eksogen yang tidak signifikan, kontribusi variabel tempat kerja untuk menentukan indeks remu nerasi tenaga keperawat an mempunyai nilai regresi sebesar 0,237 dan nilai signifi kansi sebesar 0,006 yang kurang dari alpha (tabel 7). dari pengamatan yang dilakukan selama penelitian tidak terjadi perbedaan kegiatan keperawatan yang dilakukan antara tenaga keperawatan yang mempunyai pendidikan d-3 keperawatan dan s-1 keperawatan/ners. seharusnya dilakukan pembedaan kegiatan keperawatan berdasarkan pendidikan formal tenaga keperawatan. seharusnya, pembedaan kegiatan tenaga keperawatan perlu dilakukan karena kompetensi lulusan pendidikan sesuai pendidikan for mal yang dimiliki tenaga keperawatan jelas berbeda antar jenjang pendidikan. menurut grossmann (1999), pendidikan mer upakan salah sat u kebut uhan dasar manusia yang diperlukan untuk pengembangan diri. semakin tinggi tingkat pendidikan, semakin mudah mereka menerima ser ta mengembangkan pengetahuan dan teknologi, sehingga akan meningkatkan produktivitas yang pada akhir nya akan meningkatkan keseja hter a a n kelu a rga. aga r per awat termotivasi untuk meningkatkan kinerjanya, s e b a i k nya p e r u s a h a a n (r u m a h s a k it) menggunakan keterampilan sebagai dasar perhitungan kompensasi. berdasarkan analisis, faktor pendidikan didapatkan nilai signifi kansi sebesar 0,330 yang mana lebih besar dari alpha yang ditetapkan sebesar 0,05. ketidaksignikanan variabel tersebut, dimungkinkan variabel tabel 7. distribusi frekuensi kenaikan insentif menggunakan formula no. keadanan frek % terendah tertinggi 1 naik 16 48,5 68.797 327.438 2 turun 17 51,5 12.837 636.621 365 indeks remunerasi tenaga keperawatan (suprajitno) tenaga keperawatan tentang pendidikan formal digunakan dasar untuk pengangkatan perawat sebagai calon pegawai negeri sipil dan secara fakta tidak terdapat pembedaan kegiatan keperawatan yang dilaksanakan di ruang perawatan. lama kerja sebagai tenaga keperawatan merupakan variabel yang dianalisis, keadaan i n i a k a n mengga mba rk a n kema mpu a n tenaga keperawatan yang dimiliki karena semakin lama bekerja akan memiliki suatu kemampuan lebih yang tidak dimiliki oleh tenaga keperawatan baru. kemampuan yang dimiliki tenaga keperawatan sejak dinyatakan lulus dari pendidikan disebut kemampuan profesional yang dikelompokkan menjadi tiga yaitu kemampuan intelektual, kemampuan teknikal, dan kemampuan inter personal. ketiga kemampuan tersebut sangat diperlukan dalam memberikan pelayanan keperawatan, yang pada dasarnya kemampuan tersebut tidak dapat dibentuk dalam waktu yang cepat. hasil studi lazer dan wikstrom (1977) yang ditulis oleh rivai dan ella (2009) yang dimaksud kemampuan intelektual adalah kemampuan untuk memahami kompleksitas per usahaan (r umah sakit). kemampuan teknikal yaitu kemampuan menggunakan pengetahuan, metode, teknik, dan peralatan yang dipergunakan untuk menyelesaikan tugas (sesuai asuhan keperawatan). kemampuan interpersonal yaitu kemampuan untuk bekerja sama dengan orang lain, memotivasi orang lain, dan melakukan negoisasi. jelaslah bahwa ketiga kemampuan yang dimiliki tenaga keperawatan perlu dimiliki dan diulang dalam waktu yang lama, sehingga semakin lama menjadi tenaga keperawatan maka akan memiliki ketiga kemampuan yang baik. lama bekerja di rumah sakit, akan menggambarkan sejauh mana kontribusi setiap tenaga keperawatan terhadap kemajuan rumah sakit tempat bekerja. diyakini, semakin lama seseorang bekerja pada suatu tempat semakin besar pula kontribusi yang diberikan orang tersebut. hasil penelitian faizin dan winarsih (2008) didapatkan bahwa ada hubungan lama kerja perawat terhadap kinerja perawat di rumah sakit umum pandan arang kabupaten boyolali, ditunjukkan dengan nilai chi-square sebesar 19,99 dan nilai signifi kan 0,000. hasil analisis diperoleh nilai regresi sebesar 0,149 dan nilai signifi kansi sebesar 0 ,105 m e n u nj u k k a n b a hw a v a r i a b el lama ker ja tidak sig nif ikan atau tidak berkontribusi terhadap indeks remunerasi. ketidaksignifi kanan dimungkinkan karena tiga variabel yang diukur yaitu jabatan fungsional yang dimiliki, lama bekerja sebagai tenaga keperawatan, dan lama bekerja di rumah sakit memiliki hubungan yang kuat. seperti hasil penelitian mahesa (2010) bahwa lama bekerja tidak berhasil memoderasi antara motivasi kerja dengan kinerja karyawan. hal ini karena karyawan yang mempunyai masa kerja yang lama, akan bertahan dengan kondisi dan mempertahankan pekerjaan saat ini. karyawan yang lama masa kerjanya, kurang ada motivasi untuk berkembang serta karyawan yang sudah lama bekerja tidak mempunyai keinginan untuk meningkatkan kemampuan. tugas tambahan mer upakan suat u kegiatan yang dilaksanakan berdasarkan peran yang dimiliki tenaga keperawatan. dalam penelitian ini variabel tugas tambahan disusun dari tugas tenaga keperawatan yang harus dilaksanakan setiap hari dalam pelayanan keperawatan dan lama hari dinas tenaga keperawatan sebagai pengamat. kriteria tugas tambahan setiap hari dikategorikan sebagai perawat saja, pembimbing praktik, sebagai pemimpin ruangan (kepala atau wakil kepala ruang), dan pengamat. set iap tenaga ke per awat a n ya ng memberikan pelayanan keperawatan, secara umum berperan sebagai (1) pemberi asuhan keperawatan, (2) advokat klien, (3) pendidik, (4) koordinator pelayanan bagi klien, (5) kolaborator, (6) pembaharu, dan (7) pengelola asuhan keperawatan (ppni, 1999). peran yang berhubungan dengan pemenuhan kebutuhan pasien dalam pelaksanaannya menggunakan metode asuhan keperawatan dengan lima tahapan yaitu (1) pengkajian, (2) merumuskan diagnosa keperawatan, (3) perencanaan, (4) implementasi, dan (5) evaluasi. setiap kegiatan asuhan keperawatan yang dilakukan sebagai akuntabilitas, tenaga keperawatan perlu 366 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 mendokumentasikan setiap tahapan pada rekam asuhan keperawatan pasien. jumlah pasien yang dirawat di ruang pelayanan perawatan tidak sama antar tenaga keperawatan, dengan mempertimbangkan kemampuan profesional (intelektual, teknikal, inter personal) tiap tenaga keperawatan, kewenangan yang dimiliki, tingkat kedewasaan individu, dan kemampuan menyelesaikan masalah. tugas sebagai pembimbing praktik kepada praktikan (mahasiswa) keperawatan merupakan tugas yang tidak kalah pentingnya sebagai pember i asu ha n keperawat a n. dalam nursalam (2011) pbp mer upakan suat u pendekatan metode pembelajaran yang efektif dan ef isien unt uk melatih praktikan memberikan asuhan keperawatan pada tatanan nyata pelayanan keperawatan sehingga dapat meningkatkan kepekaan, ketelitian, dan ketekunan praktikan yang pada akhirnya menumbuhkan sikap, tingkah laku, pengetahuan, dan keterampilan profesional praktikan. peran perawat yang harus dilakukan sebagai pembimbing praktik adalah sebagai model peran (role model) bagi praktikan dalam menerapkan keterampilan profesional, menerapkan etik yang berbudaya, melakukan komu n i k a si, d a n membe r i k a n a su ha n keperawatan yang benar dan bertanggung jawab. tu g a s m e m b i m b i n g p r a k t i k a n memerlukan waktu tersendiri yang perlu dikelola tenaga keperawatan dikarenakan proses pembimbingan praktikan mempunyai empat tahapan yaitu (1) pre conference, (2) middle conference, (3) bimbingan di dekat pasien, dan (4) post conference dengan praktikan. tugas berikut yang harus dilakukan oleh tenaga keperawatan adalah sebagai pemimpin di ruang pelayanan keperawatan. tugas tersebut dilaksanakan karena dalam r uang pelayanan keperawat an terdapat keg i a t a n m e n gelol a t e n a g a p e r aw a t , mengelola tenaga non keperawatan, mengelola administrasi, mengelola pasien, mengelola tindakan penunjang kebutuhan pasien, dan memfasilitasi hubungan antara individu yang ada di ruang pelayanan keperawatan. tugas mengelola tersebut disebut sebagai koordinator ruang pelayanan keperawatan yang secara sederhana disebut kepala ruangan yang dibantu oleh wakil kepala ruangan. gillies (1996) menuliskan bahwa manajer lini pertama unit rawat pasien disebut kepala perawat atau manajer rawat pasien, pada rsu ngudi waluyo wlingi disebut kepala ruangan. kepala ruangan merupakan manajer mempu nyai pe r a n sebagai pem i mpi n. ke pala r u a nga n d ala m mela k sa na k a n peran kepemimpinan ter masuk kegiatan m e n g a r a h k a n , m e n s u p e r v i s i , d a n mengkoordinasikan usaha dari individu yang berbeda. tanggung jawab utama kepala r uangan adalah pengambilan keput usan (gillies, 1996). terry (2006) menuliskan fungsi dasar manajemen adalah planning– organizing – actuating – controlling yang disingkat poac, dalam bahasa indonesia berar ti perencanaan –pengorganisasian – menggerakkan–mengawasi. tugas tenaga keperawatan yang lain sebagai pengamat. secara faktual peran pengamat sangat penting dalam pelayanan keperawatan. dalam pengelolaan wakt u dinas perawat, saat dinas pagi hari tenaga keperawat an mempu nyai manajer pada tingkat ruang pelayanan keperawatan yaitu kepala ruangan dan pada tingkat institusi rumah sakit yaitu kepala bidang perawatan yang dibantu oleh kepala sub bidang mutu asuhan keperawatan dan kepala sub bidang pelayanan keperawatan. pada saat tenaga keperawatan dinas sore dan malam keberadaan manajer tidak ada sehingga diputuskan secara institusi perlu adanya tenaga keperawatan dengan tugas tambahan sebagai pengamat. tugas pengamat adalah sebagai manajer dengan kegiatan poac pada situasi yang terbatas dan perlu melaporkan kegiatan yang telah dilakukan pada hari berikutnya kepada kepala bidang keperawatan secara tertulis. peran sebagai pengamat yang besar tersebut diberikan kepada tenaga keperawatan yang memenuhi kriteria. kriteria sebagai penga mat yait u mempu nyai kesehat a n yang baik, mempunyai pengalaman kerja sebagai tenaga keperawatan minimal 15 t ahu n, mempu nyai ser tif i kat pelat i han kegawatdaruratan, dan mempunyai komitmen 367 indeks remunerasi tenaga keperawatan (suprajitno) untuk peningkatan pelayanan keperawatan. waktu dinas yang disepakati sebagai pengamat sebanyak 11 jam (16.00 – 07.00 esok hari) yang mana merupakan waktu panjang dengan tugas sebagai manajer dan tanggung jawab utama menetapkan keputusan untuk pelayanan keperawatan. lama hari perawat sebagai pengamat tidak banyak hanya berkisar 1–3 hari setiap bulan. tugas tambahan sebagai var iabel eksogen yang berkontribusi terhadap indeks remunerasi disusun oleh tugas sehari-hari sebagai perawat, pembimbing praktik, kepala atau wakil kepala ruang, atau pengamat, dan skor jumlah hari sebagai pengamat. berdasarkan hasil analisis pada model awal (gambar 2) untuk menentukan kontribusi variabel eksogen t ugas terhadap indeks remunerasi didapatkan nilai regresi sebesar 0,059 dan nilai signifi kansi sebesar 0,114 (tabel 6) yang mana nilai ini lebih besar dari alpha yang ditetapkan sebesar 0,05. meski tidak signifikan pada tahap ini tidak dilakukan penghilangan variabel eksogen tugas tambahan tersebut karena variabel eksogen pendidikan dan dinas mempunyai nilai tidak signifi kan yang besar dibanding variabel eksogen tugas tambahan (tabel 6). hasil analisis diperoleh nilai regresi variabel eksogen tugas sebesar 0,078 dan nilai signifi kansi sebesar 0,014 yang mana nilai tersebut kurang dari nilai alpha yang ditetapkan sebesar 0,05. tolak ukur pelayanan keperawatan yang dapat digunakan adalah asuhan keperawatan. asu ha n ke per awat a n ber t uju a n u nt u k mempertahankan dan meningkatkan derajat kesehatan yang optimal dengan memodifi kasi lingkungan sedemikian rupa, sehingga klien dapat meningkatkan tanggung jawabnya secara mandiri secepat mungkin dan dapat mencapai kemampuan hidup sehat dan produktif secara optimal sesuai kondisi kesehatannya (ppni, 1999). dalam ppni (1999) disebutkan bahwa tindakan keperawatan dikelompokkan menjadi (1) treatment keperawatan, (2) observasi keperawatan, (3) pendidikan kesehatan, dan (4) treatment medik yang dilakukan oleh tenaga keperawatan (sebagai tugas limpah). ketiga tindakan keperawatan pertama disebut dengan tindakan mandiri dan tindakan keperawatan keempat disebut dengan tindakan kolaborasi. tindakan keperawatan mandiri dipahami sebagai tindakan yang dapat dilakukan secara otonomi keilmuan yang telah dimiliki oleh perawat sejak lulus dari pendidikan formal. tindakan keperawatan kolaborasi dipahami sebagai tindakan yang perlu ada permintaan dari medik (dokter), dengan kriteria bahwa tenaga keperawatan yang melaksanakan mempunyai kewenangan dan telah mendapat p elat i h a n u nt u k mela k u k a n t i nd a k a n tersebut. tindakan keperawatan dalam penelitian ini dikelompokkan menjadi lima kategori yaitu (1) tindakan keperawatan sederhana, (2) tindakan keperawatan ringan, (3) tindakan keperawatan sedang, (4) tindakan keperawatan besar, dan (5) tindakan keperawatan khusus. pengelompok a n t i nd a k a n ke per awat a n didasarkan pengelompokan tindakan yang berlaku pada rs universitas airlangga sesuai perat uran rektor universitas airlangga surabaya nomor 28/h3/pr /2011 tanggal 29 november 2011 tentang tarif pelayanan kesehatan pada rumah sakit universitas ai rlangga. macam dan jenis ti nda kan keperawatan sederhana, ringan, sedang, besar, dan khusus. t i n d a k a n k e p e r a w a t a n y a n g dilaksanakan oleh tenaga keperawatan sebelum dianalisis diberikan bobot berbeda, yaitu bobot 1 untuk tindakan keperawatan sederhana, bobot 2 untuk tindakan keperawatan ringan, bobot 3 untuk tindakan keperawatan sedang, bobot 5 untuk tindakan keperawatan besar, dan bobot 7 untuk tindakan keperawatan khusus. pembobotan tindakan dilakukan dengan alasan bahwa semakin tinggi bobot tindakan semakin membutuhkan pengetahuan yang cukup, mempunyai keterampilan yang baik, merupakan tindakan kompleks yang memerlukan pelatihan tertentu agar trampil, memahami tindakan dar urat yang perlu dilakukan, dan mempunyai kewenangan untuk pendelegasian tindakan. pada model ak hir diperoleh nilai signifi kansi faktor jenis tindakan sebesar 0,028 (tabel 7) merupakan nilai yang kurang dari nilai 368 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 apha yang ditetapkan sebesar 0,05 dengan nilai regresi sebesar 0,004. armstrong dan helen murlis (1998) menuliskan bahwa seberapa jauh besarnya gaji mengikuti hasil bisnis. perdapat ini dapat diartikan imbalan atau insentif yang diberikan sebagai remunerasi merupakan hasil kerja yang dilakukan setiap individu tenaga keperawatan dalam melaksanakan tindakan keperawatan. dinas mer upakan kewajiban yang harus dilakukan oleh tenaga keperawatan yang telah terikat sebagai pegawai untuk memberikan pelayanan keperawatan. waktu dinas tenaga keperawatan secara umum didistribusikan dalam tiga shift dinas yang memberikan pelayanan selama 24 jam sehari, 7 hari seminggu, dan 52 minggu setahun. pada tempat tertentu yaitu poliklinik waktu dinas perawat hanya pada pagi hari selama 7 jam sehari 6 hari seminggu. perawat yang berada di kamar operasi sentral waktu dinas hanya pagi hari selama 7 jam sehari 7 hari seminggu dan berkewajiban siap (stand by) mendapatkan tugas mendadak yang diperlukan pada kamar operasi (on call). jadwal dinas perawat dalam teori manajemen keperawatan merupakan kegiatan pengaturan staf. pendapat aydelotte yang dikutip swansburg (2000) yaitu metodologi pengaturan staf keperawatan harus merupakan proses yang teratur, sistematis, berdasarkan rasional, diterapkan untuk menentukan jumlah dan jenis personel tenaga keperawatan yang dibut u h kan u nt u k member i kan asu han keperawatan pada standar yang ditetapkan sebelumnya pada kelompok pasien dalam situasi tertentu. hasil akhir adalah perkiraan bentuk dan jumlah staf yang diperlukan untuk memberikan perawatan pada pasien. p e n g a t u r a n d a n p e n j a d w a l a n dinas staf pelayanan keperawatan selalu memper timbangkan jumlah pasien yang dirawat, status ketergantungan pasien (wholly, partly, supportive-educative), keperluan pribadi perawat, dan peraturan kepegawaian yang berlaku umum (libur hari besar dan minggu). penjadwalan dinas perawat secara umum dibagi menjadi dinas pagi, sore, malam, dan lama hari pengamat. setiap jadwal mempunyai jumlah waktu (jam) kerja yang berbeda yaitu 7 jam untuk dinas pagi (07.00–14.00), 6 jam untuk dinas sore (14.00–20.00), 11 jam untuk dinas malam (20.00–07.00), dan 15 jam untuk dinas pengamat (16.00–07.00). jumlah hari dinas setiap perawat adalah sama dalam satu bulan yang disusun pada awal bulan dengan fl eksibilitas yang tinggi antar perawat sehingga memungkinkan perawat untuk bertukar dinas. dalam swansburg (2000) dituliskan pola yang dikembangkan untuk pengaturan jadwal dinas harus mencerminkan kebijakan, faktor beban kerja, dan keinginan staf. jumlah tenaga keperawatan dinas pagi cenderung lebih banyak jika dibandingkan dengan dinas sore dan malam. perbedaan tersebut dikarenakan setiap pagi hari di samping memberikan asuhan keperawatan kepada pasien, tenaga keperawatan juga m e m pu ny a i t u g a s a d m i n i s t r a si y a ng berhubungan dengan pasien. tugas tersebut adalah rekapitulasi jumlah keluar masuk pasien lama dan bar u, mempersiapkan tindakan keperawatan yang menu njang untuk kegiatan medis lain (pemeriksaan laborator iu m, operasi), mempersiapkan keperluan administrasi pasien keluar rumah sakit, dan melaksanakan kegiatan organisasi rumah sakit yang mendukung individu perawat maupun organisasi (contoh: rapat). perbedaan jumlah tenaga keperawatan yang berdinas pada pagi, sore, atau malam di ruang rawat inap dan emergensi (kecuali kamar operasi sentral) dibedakan dalam lima kategori pasien. lima kategori pasien menurut johnson (1984) yang ditulis kembali oleh gillies (1996) yaitu kategori i adalah pasien yang dapat melakukan aktivitas sendiri, kategori ii adalah pasien yang perlu perawatan minimal, kategori iii adalah pasien yang membutuhkan bantuan perawat 2 kali setiap aktivitas, kategori iv adalah pasien yang membutuhkan bantuan perawat lebih dari 2 kali setiap aktivitas, dan kategori v adalah pasien yang membutuhkan perhatian dan observasi secara terus menerus dari tenaga keperawatan. setiap kategori pasien mempu nyai wak t u sendir i yang dihitung berdasarkan kebutuhan dan keadaan pasien. secara rata-rata tenaga keperawatan yang berdinas pada ruang rawat inap dan emergensi (kecuali kamar operasi sentral) 369 indeks remunerasi tenaga keperawatan (suprajitno) setiap harinya dihitung dengan menggunakan rumus yang ditemukan arndt dan huckabay pada tahun 1975 (gillies, 1996). rumus untuk menghitung kebutuhan tenaga keperawatan dalam satu ruang pelayanan perawatan yaitu: hasil analisis dari variabel eksogen dinas, diperoleh nilai regresi sebesar -0,097 dan nilai signifikansi sebesar 0,286 yang nilainya lebih besar dari alpha yang ditetapkan sebesar 0,05. ketidaksignifi kanan kontribusi variabel eksogen dinas terhadap variabel endogen indeks remunerasi, secara fakta ditunjukkan jumlah tenaga keperawatan yang berdinas pagi, sore, malam tidak seimbang. berdasar jumlah tenaga keperawatan pada ruang rawat inap dan darurat (kecuali kamar operasi sentral) rata-rata tenaga keperawatan yang dinas pagi sebanyak 7 – 10 orang, dinas sore sebanyak 3 orang, dinas malam sebanyak 2 orang, dan sisanya libur (dinas, izin, cuti). alasan lain, beberapa tenaga keperawatan tidak melaksanakan dinas sore dan malam kecuali dinas sebagai pengamat karena yang bersangkutan diberikan tugas tambahan sebagai kepala r uang perawatan, wakil kepala ruang perawatan, pembimbing praktik keperawatan, atau tugas lain dari institusi yang perlu dilaksanakan pagi hari. i ndek s a d ala h su at u n i lai ya ng merepresentasikan suatu perubahan indikator. remunerasi dalam rivai dan ella (2009) disebut kompensasi adalah sesuatu yang diterima karyawan sebagai pengganti kontribusi jasa mereka pada perusahaan dan merupakan biaya utama atas keahlian atau pekerjaan dan hasil analisis pada model akhir (gambar 2) diperoleh nilai sig nif ikansi var iabel eksogen tempat kerja, tugas tambahan, dan jenis tindakan yang kurang dari alpha yang ditetapkan sebesar 0,05; nilai unstandardized regression berurut-turut 0,237; 0,078; dan 0,004; dan standardized regression berurutan sebesar 0,252; 0,226; dan 0,218 (lihat tabel 7). nilai hasil analisis kontribusi variabel eksogen terhadap variabel endogen indeks remunerasi yang signifi kan secara statistika digunakan sebagai penyusun formula indeks remunerasi tenaga keperawatan rsu ngudi waluyo wlingi yaitu: indeks remunerasi = (0,252 x tempat kerja) + (0,226 x indeks tugas tambahan) + (0,218 x indeks jenis tindakan). armstrong dan murlis (2003) menulis bahwa faktor kompleksitas tugas dan tanggung jawab terhadap orang yang dilakukan perawat kesehatan mempunyai bobot 7 dan 8 dalam skala 1 sampai 10. sesuai hasil penelitian komplek sit as t ugas d apat d isejaja rka n dengan tugas tambahan sehari-hari tenaga keperawatan yang mana tugas tambahan sebagai pembimbing praktik, kepala atau wakil kepala ruang perawatan, dan pengamat dilaksanakan dalam wak t u bersamaan. tangg u ng jawab terhadap orang dapat diasumsikan bahwa tindakan keperawatan berdasar jenis tindakan merupakan suatu tindakan yang har us dilak u kan secara bertanggung jawab terhadap pasien, profesi kesehatan lain, institusi, maupun profesi. pemberian insentif tenaga keperawatan di rumah sakit perlu menggunakan prinsip proporsionalit as ya ng mengga mba rka n keadilan. proporsionalitas dapat diartikan setiap orang mendapat hak sesuai dengan kewajiban. dengan formula indeks remunerasi tenaga keperawatan akan menggambarkan semakin berisiko tempat kerja, semakin kompleks peran yang dilakukan, dan semakin r umit jenis tindakan keperawatan yang dilakukan akan memberikan nilai indeks yang semakin besar. pemberian remunerasi dalam bentuk insentif yang dilakukan oleh rumah sakit kesetiaan dalam bisnis perusahaan pada abad ke-21. jika kedua pengertian digabung menjadi indeks remunerasi, dapat diartikan suatu kompensasi yang berubah akibat perubahan i ndi kator. dijelaskan pula kompensasi langsung terdiri dari pembayaran karyawan dalam bentuk upah, gaji, bonus, atau komisi. 370 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 dapat meningkatkan kepuasan kerja setiap pegawai yang berkontribusi terhadap pemberi pelayanan kesehatan yang mana salah satunya pemberian pelayanan keperawatan. dalam rivai dan ella (2009) menurut job descriptive index (jdi) faktor penyebab kepuasan kerja ialah (1) bekerja pada tempat yang tepat, (2) pembayaran yang sesuai, (3) organisasi dan manajemen, (4) supervisi pada pekerjaan yang tepat, dan (5) orang berada dalam pekerjaan yang tepat. lebih lanjut dituliskan, perusahaan (rumah sakit) harus benar-benar memperhatikan kepuasan kerja karena manusia (tenaga keperawatan) berhak diberlakukan dengan adil dan hormat, yang mana pandangan ini menurut perspektif kemanusiaan. penggunaan formula indeks remunerasi tenaga keperawatan secara tidak langsung dapat menggambarkan kinerja setiap tenaga keperawatan yang selanjutnya menggambarkan suatu keadilan kompensasi dalam bentuk insentif yang diterima. rivai dan ella (2009) menuliskan salah satu kegunaan penilaian kinerja adalah untuk penyesuaian kompensasi. penilaian kinerja membant u pengambil keputusan dalam penyesuaian ganti rugi, menentukan siapa yang perlu dinaik kan upah-bonus atau kompensasi lain. penentuan insentif yang diterima tenaga keperawatan menggunakan perhitungan indeks remunerasi menggambarkan konpensasi yang diterima berdasar kinerja individu tenaga keperawatan. pember ian insentif berdasarkan indeks remunerasi yang dapat ditujukan kepada seluruh tenaga kesehatan dan non kesehatan yang memberikan pelayanan kepada pasien. strategi bisnis rumah sakit akhirnya d apat menggambarkan potensi su mber pendapatan dan jumlah pendapatan yang diproyeksi setiap tahun bah kan sampai lima tahun sebagai strategi bisnis jangka pendek. bukan hanya sumber pendapatan saja, pemanfaatan atau pengeluaran juga perlu dituliskan secara transparansi. sebagai korporasi, rumah sakit dalam perencanaan pengeluaran perlu mempertimbangkan tentang investasi jangka panjang dan pendek, biaya penyusutan aset, biaya sarana dan prasarana, biaya pegawai ter masuk insentif, biaya promosi, dan biaya cadangan. biaya yang harus ditanggung oleh rumah sakit sebagai korporasi harus seimbang dengan pendapatan. besar insentif yang diterima oleh tenaga keperawatan perlu diselaraskan dengan kemampuan korporasi (rumah sakit) yaitu apakah berdasarkan pendapatan korporasi atau persentase pengeluaran yang direncanakan. secara umum, korporasi yang sehat adalah korporasi yang dapat memprediksi penghasilan dan menggunakan penghasilan secara efektif dan ef isien, meskipun secara perat uran diperbolehkan menerima hibah. diharapkan pengelolaan pendapatan dan pengeluaran diselenggarakan secara fl eksibel berdasarkan kesetaraan antara volume kegiatan pelayanan dengan jumlah pengeluaran, mengikuti praktek bisnis yang sehat. penilaian kesesuaian model digunakan nilai goodness of fi t index (gfi) yaitu sebesar 0,827 (tabel 8). nilai gfi merupakan nilai yang dipergunakan untuk menentukan kesesuaian analisis mengg u nakan perangkat lu nak amos dengan metode maximum likelihood estimation, yang mempunyai nilai kurang atau sama dengan 1. nilai gfi mempunyai analogi dengan multiple r square in multiple regressions (arbuckle, 2010). sehingga formula indeks remunerasi 82,7% dapat dijelaskan oleh faktor tempat kerja, tugas tambahan, dan jenis tindakan, sedangkan 17,3% dijelaskan oleh faktor lain. hasil simulasi formula indeks remunerasi tenaga keperawatan yang diterapkan pada tenaga keperawatan diperoleh penurunan nilai simpangan baku menggunakan formula sebesar 95,624 dari yang pernah diterima sebesar 223.649 menjadi sebesar 128.025, sedangkan nilai keragaman menggunakan for mula menur un sebesar 13,20 dengan dari yang pernah diterima sebesar 30,88% menjadi sebesar 17,68% (tabel 9). berdasarkan simpangan baku dan keragaman yang kecil dari penggunaan formula dibanding sebelumnya dapat menggambarkan bahwa perbedaan indeks remunerasi kecil, memungkinkan dapat mengurangi kesenjangan yang terjadi antar tenaga keperawatan. perbedaan nyata (tabel 2) tampak dalam tugas tambahan dan jenis tindakan yang dilakukan tenaga keperawatan. 371 indeks remunerasi tenaga keperawatan (suprajitno) metode pember ian insentif tanpa menggunakan formula indeks remunerasi memungkinkan tenaga keperawatan cenderung pasif untuk memberikan asuhan keperawatan kepada pasien. pengamatan yang dilakukan selama penelitian diperoleh bahwa tenaga keperawatan yang mendapat tugas tambahan sebagai kepala atau wakil kepala r uang perawatan jika tidak mendapat tugas sebagai pembimbing praktik cenderung berdiam diri atau jika ada tindakan keperawatan selalu melimpahkan kepada tenaga keperawatan yang masih muda dan dianggap yunior. menu r ut ma r toyo (2007) pr i nsip kompensasi yaitu keadilan dan kelayakan. keadilan bu kanlah berar ti har us sama rata, tanpa pandang bulu, tetapi har us dapat terkait adanya hubu ngan antara pengorbanan (input) dengan output. menurut konsep kead ila n tersebut, pener i ma a n berdasar indeks remunerasi sangat baik karena mempertimbangkan variabel tenaga keperawatan. tenaga keperawatan yang bekerja pada kamar operasi, instalasi gawat darurat, atau intensive care unit yang termasuk dalam kelompok emergensi mempunyai skor yang lebih tinggi dibandingkan tempat kerja yang terkelompok dalam rawat inap dan poliklinik. berdasarkan tempat ker ja tenaga keperawatan dapat digambarkan semakin berisiko tempat kerja semakin besar pula nilai indeks. kenyataan, tenaga keperawatan di ruang rawat darurat atau critical care d ip e rlu k a n t e n aga ke p e r awat a n ya ng mempunyai pengetahuan dan keterampilan tertentu agar dapat memberikan pertolongan dan bantuan kepada pasien cepat dan tepat. pengetahuan dan keterampilan tersebut diperoleh melalui suatu kegiatan pelatihan yang membutuhkan waktu lama. ditinjau dari tugas tambahan tenaga keperawatan skor tenaga keperawatan yang mendapat peran tambahan secara berjenjang berbed a apalagi mempu nyai t a ngg u ng jawab sebagai pengamat yang secara fakta membut u h ka n wa k t u d a n kema mpu a n tersendiri. berdasar tindakan keperawatan yang dilaksanakan semakin tampak perbedaan besar indeks tenaga keperawatan yang berpengaruh juga pada besaran insentif yang diterima. ditinjau dari tempat kerja tenaga keperawatan terdapat perbedaan pada jenis dan jumlah tindakan keperawatan yang dilaksanakan maka berbeda pula indeks remunerasi akhir. keadaan yang demikian memu ngk in kan keadilan dalam tenaga keperawatan diperoleh dan dapat mengurangi kesenjangan. sehingga prinsip keadilan dalam pemberian insentif menggunakan indeks remunerasi dapat digunakan. p r i n sip ke du a d ala m pembe r ia n kompensasi adalah kelayakan. kelayakan menurut kompensasi dapat berarti seseorang yang melakukan jasa maka akan mendapat imbalan yang layak atau pantas. dalam simulasi, khususnya jenis tindakan keperawatan yang dilakukan tenaga keperawatan dapat menggambarkan semakin besar dan khusus jenis tindakan yang dilaksanakan semakin besar skor yang dimiliki dan semakin besar pengar uhnya kepada indeks remunerasi. martoyo (2007) menuliskan makin tinggi pengorbanan semakin tinggi penghasilan yang diharapkan; dapat dimaknai bahwa t i nd a ka n keperawat a n ya ng dila k u ka n berdasarkan jenis dan jumlah merupakan suatu pengorbanan yang diberikan tenaga keperawatan. bentuk pengorbanan bukan hanya tindakan keperawatan yang dilakukan termasuk kesabaran dan empati kepada pasien saat melakukan. tabel 4 menunjukkan persepsi tenaga keperawatan tentang keadilan, jumlah, dan kenaikan insentif yang negatif dan dipertegas pula kesenjangan yang disampaikan secara lisan, penggunaan formula indeks remunerasi dapat menjawab berapa besar nilai indeks remunerasi yang dimiliki setiap tenaga keperawatan yang berdampak terhadap besaran nominal yang akan diterima. dari hasil simulasi, jika tenaga keperawatan tidak melakukan tindakan keperawatan berdasar jenis dan jumlah, hanya mempunyai indeks yang cenderung kecil yang berasal dari tempat kerja dan tugas tambahan. karena tempat kerja dan tugas tambahan cenderung mempunyai skor dan indeks yang tetap, berbeda dengan indeks jenis tindakan yang sangat dipengaruhi 372 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 oleh jenis dan jumlah tindakan keperawatan yang dilakukan. penelitian yang dilakukan dengan pendekatan statistika, mempunyai kelebihan yaitu variabel tenaga keperawatan yang bersifat kualitatif dapat dikuantifi kasi sehingga memungkinkan untuk dihitung dan dapat dijadikan sebagai penyusun faktor. kumpulan faktor yang secara statistika dapat diterima melalui analisis dapat dikompositkan sehingga membentuk satu nilai yang disebut indeks. indeks akan menggambarkan secara sendiri keadaan sampel, sehingga setiap individu memiliki nilai indeks berbeda tergantung nilai variabel yang menyusun faktor. sebelas variabel teramati yang diukur dari tenaga keperawatan, secara statistika terdapat enam variabel yang dapat digunakan untuk menyusun faktor. enam variabel dapat menyusun tiga faktor yaitu faktor tugas tambahan disusun oleh tugas tambahan seharihari perawat dan lama hari sebagai pengamat. faktor kedua yaitu jenis tindakan keperawatan yang disusun oleh jenis tindakan keperawatan sederhana, ringan, sedang, dan berat-khusus. sedang satu variabel yaitu tempat kerja sebagai faktor secara langsung menyusun indeks remunerasi. ad a nya t e mu a n ba r u p e nel it ia n berupa formula indeks remunerasi tenaga keperawatan diharapkan semua variabel tenaga keperawatan dapat dikuantif ikasi sehingga dapat diperhitungkan seberapa besar kontribusi terhadap indeks remunerasi. sebagai awal, yaitu tempat kerja dan tugas tambahan dikuantifi kasi sehingga jika dihitung secara statistika mempunyai kontribusi secara numerik. penggunaan formula indeks remunerasi memungkinkan besaran insentif yang diterima oleh tenaga keperawatan rumah sakit bersifat objektif. meskipun tenaga keperawatan mempunyai tempat kerja sama, jika tugas tambahan yang dimiliki oleh setiap tenaga keperawatan berbeda memungkinkan insentif yang diterima akan berbeda. tugas tambahan merupakan suatu tugas yang harus dilaksanakan oleh tenaga keperawatan setelah memenuhi persyaratan yang ditetapkan dan tugas tambahan yang dilaksanakan semakin besar nilai semakin besar konsekuensi dan tanggung jawab. jenis tindakan keperawatan yang dilakukan berasal dari perencanaan asuhan ke p e r awat a n , seh i ng ga set iap t e n aga keperawatan akan melaksanakan tindakan keperawatan yang berbeda. jenis tindakan keperawatan disusun bertingkat dari mulai sederhana sampai yang khusus, merupakan tindakan keperawatan yang secara kewenangan dan kemampuan tidak dapat dikerjakan oleh semua tenaga keperawatan. pengelompokan dila k u kan sesuai dengan kompleksit as tindakan dan waktu mengerjakan. tenaga keperawatan baru ditempatkan pada tempat kerja yang tidak membutuhkan tindakan keperawatan besar dan khusus. semakin lama bekerja tenaga keperawatan m e n d a p a t p el a t i h a n d a n p e n d id i k a n t a mba h a n u nt u k d apat mela k sa n a k a n tindakan keperawatan besar dan khusus. sebagai konsekuensi melaksanakan tindakan keperawatan yang kompleks dan membutuhkan waktu lama semakin besar pula nilai yang perlu diperoleh tenaga keperawatan. berdasarkan tugas tambahan, semakin besar tanggung jawab yang dilakukan tenaga keperawatan akan mendapat skor tinggi. dan semakin kompleks jenis tindakan keperawatan yang dilakukan akan semakin besar pula skor yang diperoleh. semakin besar skor tugas tambahan dan jenis tindakan keperawatan maka akan semakin besar pula indeks remunerasi yang dimiliki dan semakin besar pula insentif yang diterima. simpulan dan saran simpulan simpulan yang dapat dibuat adalah tempat kerja tenaga keperawatan, tugas tambahan, jumlah hari sebagai pengamat, d a n jen is t i nd a ka n keperawat a n ya ng dikelompokkan dalam kategori tindakan keperawatan sederhana, ringan, sedang, besar, dan khusus digunakan sebagai variabel tenaga keperawatan untuk pengembangan indikator indeks remunerasi dan variabel tersebut sesuai dengan ilmu keperawatan. faktor 373 indeks remunerasi tenaga keperawatan (suprajitno) indeks remunerasi yang sesuai adalah tempat kerja, tugas tambahan, dan jenis tindakan yang masing-masing memberikan kontribusi sebesar 0,252; 0,226, dan 0,218. semakin berisiko tempat kerja, semakin kompleks tugas tambahan, dan semakin banyak tindakan keperawatan yang dikerjakan semakin besar remunerasi yang diterima. saran for mula indeks remunerasi tenaga keperawatan ini dapat diterapkan di rumah sakit dengan didasarkan asas keadilan dan mempertimbangkan kemampuan keuangan rumah sakit. pemberian remunerasi tenaga keperawatan dapat diberikan dalam bentuk peningkatan pendidikan formal, pelatihan kompetensi, dan studi banding. penerapan formula indeks remunerasi tenaga keperawatan diperlukan landasan hukum pelaksanaan dan perat uran tek nis bagi r umah sakit. sebagian penghasilan rumah sakit hendaknya didayagunakan untuk investasi pengembangan sarana dan prasarana sebagai upaya praktik bisnis yang sehat. mempertimbangkan variabel lain yaitu beban kerja tenaga keperawatan sebagai indikator indeks remunerasi. kepustakaan arbuckle, j.l., 2010. ibm spss® amos™ 19 user’s guide. url: http://www.spss. com. armstrong, m. & murlis, h., 2003. manajemen i m b a l a n: s t r a t e g i d a n p r a k t i k remunerasi, cetakan kedua. jakarta: bhuana ilmu populer. byr ne, b.m., 1998. structural equation modelling with lisrel, prelis, and simplis: basic concepts, application, and programing. new jersey: lawrence erlbaum associates, inc., publicher. depkes ri, 2006. pedoman pengembangan sistem jenjang karir profesional perawat. jakarta: depkes. fahad, f. al-m., 2005. the effects of nursing care on overall patient satisfaction and its predictive value on returnto-provider behavior a survey study. quality management in helath care journal; april-june 2005; vol. 14, no. 2; p. 116–125. faizin, a. dan winarsih, 2008. hubungan tingkat pendidikan dan lama kerja perawat dengan k iner ja perawat di rsu pandan arang kabupaten boyolali. berita ilmu keperawatan issn 1979-2697, vol. 1 no. 3, september 2008: 137–142. surakarta: universitas muhamadiyah surakarta. gillies, d.a., 1996. manajemen keperawatan: suatu pendekatan sistem. edisi kedua. alih bahasa: dika sukmana dan rika widya sukmana. jakarta: egc. grossmann, m., 1999. the human capital model of the demand for health. ca mbr idge: nat ion a l bu r e au of economic research. haidar, e., 2008. evaluating patient satisfaction with nurse practitioners. nursing times journal; july 2008; vol 104, no. 26; p. 32– 33. mahesa, d., 2010. analisis pengaruh motivasi dan kepuasan kerja terhadap kinerja karyawan dengan lama kerja sebagai variabelmoderating. skripsi. semarang: fa k u l t a s e k o n o m i u n i v e r s i t a s diponegoro semarang. martoyo, s., 2007. manajemen sumber daya manusia, edisi tiga cetakan pertama. yogyakarta: bpfe. nursalam, 2011. manajemen keperawatan: aplikasi dalam praktik keperawatan profesional. jakarta: salemba medika. perat uran rektor universitas airlangga su r abaya nomor 28/ h 3/ pr /2011 tanggal 29 nopember 2011 tentang tarif pelayanan kesehatan pada rumah sakit universitas airlangga. ppni, 1999. kepera watan dan prak tik keperawatan. jakarta: pengurus pusat ppni. ppni, 2001. pedoman umum penyelenggaraan pendidikan berkelanjutan bagi perawat. jakarta: pengurus pusat ppni. rivai, v. & ella, j.s., 2009. manajemen sumber daya manusia untuk perusahaan. jakarta: rajawali press. s w a n s b u r g , r .c ., 2 0 0 0. pe n g a n t a r k e p e m i m p i n a n & m a n a j e m e n keperawatan untuk perawat klinis, alih bahasa: suharyati samba. jakarta: cv egc. 374 jurnal ners vol. 8 no. 2 oktober 2013: 357–374 terry, g.r., 2006. asas-asas manajemen, cetakan kelima, penerjemah: winardi. bandung: alumni. terry, g.r., 2006. prinsip-prinsip manajemen, cetakan kedelapan, penerjemah: j. smith d.f.m. jakarta: bumi aksara. 190 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.3582 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the association of pornographic media exposure and nutritional status with early menarche deswita deswita, randy refnandes and mella gustriyani putri faculty of nursing, universitas andalas, sumatera barat, indonesia abstract introduction: the adolescent menarche period has shifted to a younger age because of several factors, including a girl’s nutritional status and exposure to pornographic media. the purpose of this study is to determine the relationship between pornographic media exposure and nutritional status with the age of menarche in girls in elementary school. methods: this research used a descriptive cross-sectional design. 121 respondents were selected by proportional random sampling. nutritional status data was collected by measuring body mass index, while the usage of media exposure and the age of menarche were both identified using questionnaires. all data was analysed using the chi-square test. results: there was a significant relationship between the age of menarche with the exposure to mass media (p=0.000) and nutritional status (p=0.000). conclusion: the age of menarche in adolescent girls is associated with nutritional status and media exposure. article history received: february 9, 2018 accepted: december 19, 2018 keywords age of menarche; pornographic media exposure; nutritional status contact deswita deswita  deswita@nrs.unand.ac.id  faculty of nursing, universitas andalas, sumatera barat, indonesia cite this as: deswita, d., refnandes, r., & putri, mg. (2018). the association of pornographic media exposure and nutritional status with early menarche. jurnal ners, 13(2), 190-193. doi:http://dx.doi.org/10.20473/jn.v13i2.3582 introduction proverawati & misaroh (2009) defines menarche as the beginning stage of menstruation in a girl experiencing puberty, indicating that the child has entered the stage of sexual organ maturity in her body. in the last 100 years, the age of menarche has shifted to a younger age. aryal (2005) stated that a hundred years ago, the age of girls in nepal who experienced menarche ranged from 15 to 19 years. nowadays, most girls experience menarche between the ages of 10 and 16. on average, the age is 12.5 years old (heys et al., 2007). the average age to experience menarche in the uk, according to proverawati & misaroh (2009), is at 13.1 years old. meanwhile, the average age to experience menarche in france is lower, at 12.8 years old (de la rochebrochard, 2000). several studies have shown this. this has decreased from an average age of 14 years old due to girls experiencing earlier development (silva, 2005). however, over the last 20 years in moscow, the age of menarche has risen from 12.5 years old to 13 years old. this is especially the case for those weighing less than normal and with those who are more active (kabir, torkan, & hakemi, 2007). in indonesia, this emerging trend of the age of menarche dropping is continued. a 2010 indonesian health survey concluded that the average age of menarche in indonesian girls is at 13 years old (riskesdas, 2010). several studies have shown the decrease in the age of menarche in indonesian girls. the average age of menarche has decreased from 13 years to 10 years in 2009 (talma et al., 2013; wulandari & ungsianik, 2013). the study was conducted on elementary school and junior high students in east jakarta and it proposed that menarche had already occurred at 12.3 years of age. putra, ermawati, & amir (2016) conducted a study at a junior high school in padang, and showed that the age of menarche has decreased from 9 years old to 15 years old. experiencing menarche at an early age will affected the physical development of adolescent girls and could cause non-communicable diseases. studies show that early puberty (as measured by age of menarche) may increase the risk of breast cancer. according to unicef (2011) menarche at earlier stage will form the start of an adolescent girl’s sexual exploration. girls will begin to find interest in the opposite sex, which beforehand was not the case. an earlier menarche will also increase the chances of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i2.3582 jurnal ners http://e-journal.unair.ac.id/jners | 191 endometrial hyperplasia, uterine cancer and breast cancer, as this stage of life is related to progressive oestrogen-dominated hormonal issues (al-agha, alabbad, tatwany, & aljahdali, 2015). it could also cause certain psychological and emotional problems such as anxiety, fear and depression (kabir et al., 2007). in a study of depressive symptoms among primary school students, there was a large discrepancy in results between girls who reached menarche at early age and boys (trépanier et al., 2013). experiencing an early menarche is related to both endogenous and exogenous factors. according to soetjiningsih (2004) the decrease in the age of menarche is associated with the nutritional status of adolescents, and according to manuaba (2012) it is associated with the exposure of sensory stimulating information in mass media, tv and other sources. there are several research studies that have been conducted to investigate the correlation between nutritional status and an early menarche in adolescent girls (susanti & sunarto, 2012). these studies have proved there are significant links (wulandari & ungsianik, 2013). there is limited evidence that has proved that pornographic media exposure may be related to a trend in earlier menarche. the progressive improvement of technology has risen impacts on most human aspects. one study conducted amongst junior high school students showed there was no significant relationship amongst the two variables (dwi kisswardhani, 2014), but the study focused on junior high students, not adolescents, and also didn’t specify pornographic media. based on the description above, a focus on how media exposure containing adult, vulgar or indulgent content affects menarche at an earlier age needs to occur. currently, the government handles public health and protection by providing programmes that tackle reproductive health issues. these programmes include counselling that aims to fulfil the reproductive rights of adolescents (bkkbn, 2012). the purpose of this study was to identify the correlation between pornographic media exposure and nutritional status with age of menarche. materials and methods the design of study used a descriptive analytic method by using a cross sectional method approach. this study observed both independent and dependent variables, measured simultaneously. the population of the study was all of the female students at grade iv, v and vi in a public school in padang. the sample size was 174 girls. the sampling method used a proportional random sampling technique. a stadiometer was used to measure the height of the students, and a scale to measure each girl’s weight. the data was processed by the body mass index (bmi) calculation to thus obtain the nutritional status data. in regard to the age of menarche and pornographic media exposure, the data was obtained using questionnaires consisting of 19 questions. data has been analysed by using the chi-square test. the confidentiality of the students was protected by the use of a de-identified database that did not contain any student identifying information. all data in the de-identified database was kept confidential and stored on secure servers that could only be accessed from password protected computers. ethical approval for the study was received from the ethics committee of universitas andalas on the10th july 2015 with certificate number 245/kepk/2015. results table 1 shows that the highest group size contained girls that were 10 years of age (35.5%). less than half of respondents have experienced menarche (43.0%), and some experienced early menarche (24.8%). the table illustrates that less than half of respondents had been exposed to pornographic media (57.9%). more than half of respondents had a normal nutrition status (63.6%), and 30.6% of girls were overweight. table 2 shows that the chi-square analysis results obtained the p-value = 0.000. this result indicates that there is a significant relationship between pornographic media exposure and the age of menarche in a student. table 3 shows that the chi-square analysis results obtained the p value = 0.000. this indicates that there is a significant correlation between nutritional status and the age of menarche of students. students who have a good nutritional status will experience menarche at an expected age, and those adolescents who have nutritional problems may experience it at an age not regarded as usual. discussion the results identified a significant relationship between an exposure to pornographic media with the age of menarche in adolescent girls. the results of this study are in accordance with a statement, which said the cause of early menstruation can also table 1. demographic characteristics of the respondents (n=121) variables f % age 8 5 4.1 9 33 27.3 10 43 35.5 11 33 27.3 12 7 5.8 age of menarche early 30 24.8 normal 22 18.2 late/non-menarche 69 57.0 pornographic media exposure exposed 51 42.1 not exposed 70 57.9 nutritional status low 7 5.8 normal 77 63.6 overweight 37 30.6 d. deswita et al. 192 | pissn: 1858-3598  eissn: 2502-5791 be affected either by the conversation or visual stimuli (tv, movies or internet) of material that can be considered adult or vulgar (proverawati & misaroh, 2009). the stimulation of the ears and eyes subsequently stimulates the reproductive and genital systems to accelerate genital maturation. the study conducted by buzney & decaro (2012) also found psychosocial factors affected the age of menarche, which included access to westernised content. in an earlier study, it was stated that the linkage between pornographic media exposure accelerated puberty in adolescents which then indirectly leads to an earlier age of menarche (ayuningtyas, 2013). in this study, the survey explained that the media provide most of the information containing sexual imagery, and also proved that adolescents often have easy access to prohibited content. this social factor contributed to the rapid growth of adolescent girls, decreasing the age of menarche and potentially allowing risky physical development. the results also identified a significant relationship between nutritional status and the age of menarche. in recent study of obese adolescent girls, it was found that the nutritional status could lead to an earlier menarche (lusiana & dwiriani, 2007). nutrition also affects sexual maturity in girls who have experienced their first menstruation earlier than average. these girls tend to experience more severe and frequent periods compared with those who have not menstruated at the same age. in contrast, adolescent girls whose experience menarche later weight less than adolescent girls menstruating at a normal age, irrespective of height. in general, in girls of a same age, those menstruating earlier will have a higher body mass index (bmi), and those menstruating later will have a smaller score bmi (soetjiningsih, 2004). excessive nutritional fulfilment brings adolescent girls to experience biological hormonal changes earlier, and this could also cause an acceleration of sexual maturation development. bogin (2011) stated that menarche does tend to occur earlier in adolescent girls around 20 to 30 percent above the ideal body weight, and later in adolescent girls with malnutrition. the leptin protein hormone is a form of a fat cell that plays a major role in the metabolism mechanism. it is secreted by the fat cells that have the primary function of controlling body fat and weight tissue. leptin then triggers the release of the follicle stimulation hormone (fsh) and luteinising hormone (lh) in the ovaries, resulting in follicular maturation and oestrogen formation. oestrogen causes negative feedback against fsh, resulting in the reduction of fsh production. the decrease in fsh levels causes late follicular growth and impacts the decreasing of oestrogen levels. the decreasing oestrogen levels cause the proliferation of endometrial blood vessels to discontinue. therefore, the endometrial layer undergoes desquamation, resulting in the bleeding and the intangible vagina flow known as the first menstruation (menarche). the occurrence of the first menstrual cycle in adolescent girls directly affects the ability to reproduce. in overweight adolescent girls, there is an increasing of leptin secretion which can accelerate menarche (ong et al., 2007). this study reveals that nutritional status and pornographic media exposure of adolescent girl students will affect the age of menarche. this study highlighted is due to nutritional factors and exposure to media with insufficient content has shifted the sexual maturity. a healthy and balanced diet providing adequate nutrition and a restriction on pornographic media exposure would improve the normal growth and developmental status of the adolescent girl, and ultimately achieve the goal of approaching menarche at the normal age. conclusion pornographic media exposure and nutritional status are strongly associated with an early menarche in adolescent girls. the increasing frequency of inappropriate content accessed by adolescents stimulates rapid maturation among girls, and is associated with an early menarche. meanwhile, nutritional status also contributes to the biological growth and development of adolescent girls. further study should be conducted to identify the appropriate strategies to respond to the early menarche phenomenon and adolescent sexual development. table 2. relationship between pornographic media exposure and age of menarche pornographic media exposure age of menarche total p value early normal not menarche f % f % f % f % exposed not exposed 19 11 37.3 15.7 17 5 33.3 7.1 15 54 29.4 77.1 51 70 100 100 0.000 total 30 24.8 22 18.2 69 57.0 121 100 table 3. correlation between nutritional status (bmi) and the age of menarche nutritional status (bmi) age of menarche total p value early normal not menarche f % f % f % f % low normal overweight 1 5 24 14.3 6.5 64.9 4 56 9 57.1 72.7 24.3 2 16 4 28.6 20.8 10.8 7 77 37 100 100 100 0.000 total 30 24.8 69 57 22 18.2 121 100 jurnal ners http://e-journal.unair.ac.id/jners | 193 references al-agha, a. e., alabbad, s., tatwany, b., & aljahdali, a. (2015). menarche age of mothers and daughters and correlation between them in saudi arabia. reprod syst sex disord, 4(3), 1000153. doi:10.4172/2161-038x.1000153. aryal, t. r. (2005). a probability model to describe the distribution of age at menarche in nepal. nepal journal of science and technology, 6(1). ayuningtyas, r. (2013). hubungan status gizi dengan usia menarche pada siswi smp negeri 1 jember. universitas jember [online] available at: http://repository.unej.ac.id/bitstream/handle/1 23456789/9993/ratih%20ayuningtyas%20%20 062310101002_1.pdf?sequence=1 (accessed: january 22, 2019). bkkbn, d. k. k. (2012). survey demografi dan kesehatan indonesia 2012. jakarta: kementrian kesehatan rl. [online] available at: http://kesga.kemkes.go.id/images/pedoman/sd ki%202012-indonesia.pdf (accessed: january 22, 2019). bogin, b. (2011). puberty and adolescence: an evolutionary perspective. encyclopedia of adolescence, vol. 1, pp. 275-286. doi: 10.1016/6978-0-12-373915-5-000033-4. buzney, c. d., & decaro, j. a. (2012). explanatory models of female pubertal timing: discordances between cultural models of maturation and the recollection and interpretation of personal developmental experiences. culture, medicine, and psychiatry, 36(4), 601–620. doi: 10.1007/s11013-012-9277-8. de la rochebrochard, e. (2000). age at puberty of girls and boys in france: measurements from a survey on adolescent sexuality. population: an english selection, 51–79. dwi kisswardhani, a. (2014). hubungan antara status gizi, tingkat paparan media massa dan faktor keturunan dengan usia menarche pada siswi di smp negeri 1 subah kabupaten batang. diss, universitas muhammadiyah surakarta. heys, m., schooling, c. m., jiang, c., cowling, b. j., lao, x., zhang, w., … lam, t. h. (2007). age of menarche and the metabolic syndrome in china. epidemiology, vol. 18, no. 6, 740–746. kabir, a., torkan, f., & hakemi, l. (2007). evaluation of age at menarche and relevant factors in physically active iranian girls. int j endocrinol metab; 2: 52-60. lusiana, s. a., & dwiriani, c. m. (2007). age of menarche, food consumption, and nutritional status of female elementary school children in bogor. jurnal gizi dan pangan, 2(3), 26–35. [online] available at: http://dx.doi.org/10.25182/jgp.2007.2.3.26-35. (accessed: january 22, 2019). manuaba, i. b. g. (n.d.). fajar manuaba, ibg. 2007. pengantar kuliah obstetri. ong, k. k., northstone, k., wells, j. c. k., rubin, c., ness, a. r., golding, j., & dunger, d. b. (2007). earlier mother’s age at menarche predicts rapid infancy growth and childhood obesity. plos medicine, 4(4), e132. [online] available at: https://doi.org/10.1371/journal.pmed.0040132. (accessed: january 22, 2019). proverawati, a., & misaroh, s. (2009). menarche menstruasi pertama penuh makna. yogyakarta: nuha medika, 25–26. putra, r. n. y., ermawati, e., & amir, a. (2016). hubungan indeks massa tubuh (imt) dengan usia menarche pada siswi smp negeri 1 padang. jurnal kesehatan andalas, 5(3). [online] available at: http://jurnal.fk.unand.ac.id/index.php/jka/articl e/view/575/464 (accessed: january 22, 2019). riskesdas. (2010). riset kesehatan dasar (riskesdas) 2010. jakarta: kemenkes ri, 50–52. [online] available at: http://kesga.kemkes.go.id/images/pedoman/ris kesdas%202010%20nasional.pdf (accessed: january 22, 2019). silva, p. d. (2005). menarche and lifestyle. wisconsin medical journal, 104(7), 24. soetjiningsih, s. (2004). tumbuh kembang remaja dan permasalahannya. sagung seto. jakarta, 320. susanti, a. v., & sunarto, s. (2012). faktor risiko kejadian menarche dini pada remaja di smp n 30 semarang. journal of nutrition college, 1(1), 125-126. [online] available at: doi:http://dx.doi.org/10.14710/jnc.v1i1.67. (accessed: january 22, 2019). talma, h., schönbeck, y., van dommelen, p., bakker, b., van buuren, s., & hirasing, r. a. (2013). trends in menarcheal age between 1955 and 2009 in the netherlands. plos one, 8(4), e60056. [online] available at: https://doi.org/10.1371/journal.pone.0060056. (accessed: january 22, 2019). trépanier, l., juster, r.-p., marin, m.-f., plusquellec, p., francois, n., sindi, s., … andrews, j. (2013). early menarche predicts increased depressive symptoms and cortisol levels in quebec girls ages 11 to 13. development and psychopathology, 25(4pt1), 1017–1027. doi: 10.1017/s0954579413000345. unicef. (2011). adolescence in tanzania. dar es salaam: united nations children’s fund tanzania. [online] available at: https://www.unicef.org/adolescence/files/tanz ania_adolescent_report_final.pdf (accessed: january 22, 2019). wulandari, s., & ungsianik, t. (2013). status gizi, aktivitas fisik, dan usia menarche remaja putri. jurnal keperawatan indonesia, 16(1), 55–59. [online] available at: doi:https://doi.org/10.7454/jki.v16i1.20. (accessed: january 22, 2019). http://repository.unej.ac.id/bitstream/handle/123456789/9993/ratih%20ayuningtyas%20%20062310101002_1.pdf?sequence=1 http://repository.unej.ac.id/bitstream/handle/123456789/9993/ratih%20ayuningtyas%20%20062310101002_1.pdf?sequence=1 http://repository.unej.ac.id/bitstream/handle/123456789/9993/ratih%20ayuningtyas%20%20062310101002_1.pdf?sequence=1 http://dx.doi.org/10.25182/jgp.2007.2.3.26-35 https://doi.org/10.1371/journal.pmed.0040132 https://doi.org/10.1371/journal.pone.0060056 http://e-journal.unair.ac.id/jners 47 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 47-54 http://dx.doi.org/10.20473/jn.v17i1.35029 original article open access the development of assessment instrument for postpartum patients with severe preeclampsiaeclampsia based on need for help and self-care models endah suprihatin 1,* , sri hardi wuryaningsih 2 1 health polytechnic of the ministry of health, surabaya, indonesia *correspondence: endah suprihatin. address: pucang jajar tengah street no.56, kertajaya,surabaya city, east java 60282, indonesia. email: endah.atin@poltekkesdepkes-sby.ac.id responsible editor: retnayu pradanie received: 15 april 2022 ○ revised: 25 april 2022 ○ accepted: 26 april 2022 abstract introduction: one of the causes of the high mortality rate of patients with severe preeclampsia-eclampsia in the postpartum period is the inaccurate assessment of the patient's need for help and independence in self-care. this study aimed to develop specific assessment instruments for postpartum patients based on wiedenbach’s need for help and orem’s self-care models. methods: this study used a research and development (r&d) approach. the samples were 30 midwives and 100 documents of postpartum patients with preeclampsia from airlangga university hospital, surabaya, and 30 midwives from haji hospital surabaya. data were collected through document tracking and interviews. data were analyzed with r&d methods. results: the results showed that the mean rank value of the new assessment instrument was higher (29.72) than the old assessment instrument (19.93). a significant difference was found between the new assessment instrument and the old assessment instrument (wilcoxon test value -5.379 with p < 0.001). the new instrument had functionality, efficiency, and usability for assessment of the need for help and self-care of postpartum patients with severe preeclampsia and eclampsia. conclusions: postpartum patients with severe preeclampsia-eclampsia should be assessed by the specific assessment instruments based on wiedenbach’s need for help and orem’s self-care models. keywords: assessment instruments; eclampsia; need for help; postpartum; self-care; severe preeclampsia introduction preeclampsia and eclampsia are one of the main causes of maternal and fetal mortality and morbidity in addition to bleeding and infection (triad complications) (shamsi, saleem and nishter, 2013). in 2019, the maternal mortality rate of east java province reached 89.81 per 100,000 live births. the most common cause of maternal death in surabaya is preeclampsia-eclampsia, which is 26.90% (ministry of health, 2021). preeclampsia is a widespread disorder of endothelial or vascular malfunction resulting in vasospasm after 20 weeks of gestation, resulting in decreased organ perfusion and endothelial activation, leading to hypertension, non-dependent edema, and proteinuria. it is called severe preeclampsia if the systolic blood pressure is ≥ 160 mmhg and diastolic blood pressure ≥ 110 mmhg accompanied by proteinuria of more than 5g / 24 hours (peres, mariana and cairrão, 2018). eclampsia is an advanced condition of severe preeclampsia that is not resolved properly, leading to seizures. about 75% of eclamptic seizures occur before delivery, 50% within the first 48 hours after delivery, and can occur after 6 weeks postpartum. eclampsia can lead to coma and even death, either before or after childbirth (bernstein et al., 2017). the rate of caesarean sections in cases of severe preeclampsia is estimated to be high (around 70% or more in preterm pregnancies), because many obstetricians prefer performing caesareans in women with preeclampsia, even with a reassuring fetal status (ferreira et al., 2016). postpartum patients with severe preeclampsia-eclampsia are most at risk of infection due to childbirth with caesarean section, at risk of bleeding due to decreased ability of uterine https://creativecommons.org/licenses/by/4.0/ mailto:endah.atin@poltekkesdepkes-sby.ac.id https://orcid.org/0000-0002-9226-6556 https://orcid.org/0000-0002-2094-6034 suprihatin and wuryaningsih (2022) 48 p-issn: 1858-3598  e-issn: 2502-5791 contractions due to administration of mgso4 and at risk of postpartum depression due to infant loss and inability to adapt to hormonal changes (frawley et al., 2020; hoedjes et al., 2011; peres et al., 2018; stern et al., 2014). several studies on the experiences of patients who received emergency treatment for severe preeclampsia indicated that patients felt that their lives were threatened, felt discomfort, tried to reduce discomfort, worried about the failure of treatment measures, felt close to death, felt that they did not get full support, expected friendly service and yearned for better conditions. the sense of loss can cause emotional distress to the mother, and leave a deep sense of grief. it is found that the patient expresses the need for professional support or social support (frawley et al., 2020). to minimize the impacts, the needs and self-care of postpartum patients with severe preeclampsia and eclampsia should be identified as early as possible (frawley et al., 2020). assessment of the need and selfcare of postpartum patients with severe preeclampsia and eclampsia is essential for professionals to meet the need and self-care of patients. thus, an appropriate assessment instrument based on need and self-care of postpartum patients is needed. based on a preliminary study on obstetric wards in several hospitals in surabaya, there was no specific assessment instrument for postpartum patients with severe preeclampsia and eclampsia. wiedenbach’s "need for help" model reveals that nurses are people who can help postpartum clients with preeclampsia-eclampsia overcome problems and improve their welfare through their actions, thoughts, feelings, words, writing, and body movements, while postpartum clients with preeclampsia-eclampsia are recipients of assistance (need for help) from health professionals either in the form of care, advice or education. three goals put forward by wiedenbach in helping clients are: (1) preventing maternal emergency, (2) reducing anxiety due to loss, (3) building effective coping in dealing with emergencies and losses by collaborating and coordinating with other health teams so that clients get actioned appropriate treatment procedures. in addition, orem’s "self-care" model sees that every individual has the ability and potential to care for himself and achieve prosperity (alligood, 2018). in this case, the modification of wiedenbach’s need for help and orem’s self-care models can allegedly be applied to overcome the physical and psychological crisis and emergency problems of postpartum patients due to preeclampsia and eclampsia and help postpartum patients and their families achieve independence in selfcare and baby care according to their abilities (rahayu, 2015). the development of assessment instruments has been carried out in several previous studies. based on international joint commission accreditation standards, there is only a general nursing assessment instrument, not specifically for postpartum patients (rachmania, sunaringtyas and widayati, 2019). the development of maternal assessment instrument has been done in brazil which is tracing about the quality of life of the mother and her baby, not identifying about emergency care needs as an impact of preeclampsia and eclampsia (zubaran et al., 2009). another study was conducted in turkey aimed to compare the various existing instruments and determine which instrument is the most suitable for assessing the antenatal and postpartum period for turkish society (çakşak et al., 2018). similar studies found the evaluation of changes in postnatal care using the parents' postnatal sense of security (ppss) instrument. the study evaluated two models of postnatal care using a questionnaire incorporating the ppss instrument. the ppss can be used by mothers and fathers in the postpartum period to identify the sense of security of parents in the postnatal period (kvist and persson, 2009). however, those studies have not linked with the assessment instrument in postpartum with preeclampsia-eclampsia. to overcome the limitation and the weakness of the previous studies, the current study aimed to develop an assessment instrument for postpartum patients with severe preeclampsia-eclampsia based on wiedenbach’s need for help and orem’s self-care models according to research with r&d design. this study is expected to identify the need for help and self-care of such patients by nurses and midwives in the emergency and maintenance period. thus the risk of morbidity and mortality due to severe preeclampsia and eclampsia can be reduced significantly. materials and methods study design the study used a research and development (r&d) design, a method used to produce certain products and test the effectiveness of these products (yoshikawa, 2012). the purpose of using this method was to develop an assessment instrument in postpartum patients with pre-eclampsia based on wiedenbach’s need for help and orem’s self-care models. the research was conducted in two stages, namely the development stage and the trial stage. at the development stage, the study used a qualitative research design and was carried out in the obstetric ward and the medical record section of airlangga university hospital, surabaya. data collection was carried out by interviewing and tracing the contents of postpartum patient documents with preeclampsia-eclampsia. the trial stage used a quasi-experimental, and the respondents were 60 midwives who were in charge for postpartum patients with preeclampsia in the obstetric ward of airlangga university hospital, surabaya, and haji hospital, surabaya. jurnal ners http://e-journal.unair.ac.id/jners 49 respondent at the development stage, the participants were 30 midwives and 30 postpartum patients with severe preeclampsia-eclampsia, as well as 100 medical records stored in airlangga university hospital, surabaya. in the trial stage, the respondents were 60 midwives and 120 postpartum patients with preeclampsia in the obstetric ward of airlangga university hospital and haji hospital. the respondents were selected using purposive sampling technique, which is a sample selection method based on the predetermined criteria: midwives who have experience caring for postpartum patients at least 1 year, as well as postpartum patients who have preeclampsiaeclampsia and are not admitted to the intensive care unit. instrument the data were collected using some instruments based on the two stages. in the development stage, the instruments used were observation sheets, interview guidelines, and documentation. in the trial stage, the instrument used was a questionnaire to test the effect of the instrument of assessment of postpartum mothers with severe preeclampsia and eclampsia based on the "need for help" and "self-care" models. data collection the development stage began with a search for the availability of assessment instruments used by health workers in conducting studies of postpartum patients with preeclampsia-eclampsia. at this stage, in-depth interviews and documentation studies were carried out on the use of the assessment format, which had been used for the past 1 year. in-depth interviews were conducted with 30 midwives to explore their opinion on the instrument for assessing postpartum patients with severe preeclampsia that has been used so far. the media used at this stage was an interview guide that had been prepared based on the "need for help" and "self-care" models. to trace the documentation that used so far, a checklist was used. the results of in-depth interviews showed that the instruments provided by the hospital were general for all obstetric patients, not specific for postpartum patients with preeclampsia-eclampsia, so that often the risk of emergency due to preeclampsia was not detected. the results of the qualitative analysis in the first stage were used as a basis for developing thhe new assessment instruments for postpartum patients with preeclampsia based on wiedenbach’s need for help and orem’s selfcare models. after the new assessment instruments for the postpartum patients were arranged, a focus group discussion (fgd) was then carried out by involving researchers, patients, midwives, and experts on the preparation of the instruments. the results of the fgd were used to make improvements to the development of the assessment instrument. at the second stage, it began with the midwife filling out a questionnaire about the old assessment instrument. then the midwife was introduced to the new assessment instrument. after understanding about how to use the new assessment instrument, the midwife tried to conduct an assessment using the new instrument on two patients. after using the new assessment instrument, the midwife was asked to fill out a questionnaire about it. data analysis at the development stage, data were analyzed using qualitative method. the analysis consists of three activities that occur simultaneously: data reduction, data presentation, data withdrawal conclusion/verification. in this case, it was carried out to obtain conclusions about the use of assessment instruments that have been used so far. at the trial stage, data were analyzed using the wilcoxon test with the significance level < 0.001, because the result of the normality test of the post-test was not normal (sugiyono, 2019). in this research, the validity test used the validity of the construction (construct validity) by asking for opinions from experts (experts’ judgments). instruments were made according to the aspects to be measured which were then consulted with experts to determine an opinion whether the instrument was feasible or not. in addition, testing the validity of the instrument was carried out using the product moment correlation technique. if the results of r count > r table have a significance level 5% it will be declared valid. in this study, the reliability of the instruments that have been compiled was tested by using the cronbach’s alpha technique. if coefficient reliability (r11) is 0.7, then the instrument is declared reliable (sugiyono, 2019). ethical consideration prior to conducting the research, the research proposal was reviewed and received ethical approval from the health research ethics commission team at airlangga university hospital no. 136/keh/2019 and haji hospital surabaya no.073/34/kom.etik/2019. results the results of the development stage are described in table 1, table 2, and table 3, while the trial stage can be seen in table 4, table 5, and table 6. the results of the evaluation of the old assessment instruments in the obstetric ward are shown in table 1. the finding showed that 5 of the 10 essential assessment components based on wiedenbach’s need for help and orem’s self-care models were not found. the old assessment instrument is (1) not specific assessment, (2) does not identify the risk of bleeding as an effect of administration of magnesium sulfate, (3) does not identify the ability to meet basic needs, (4) does not identify self-care abilities, and (5) does not identify parental readiness. four components were partially suprihatin and wuryaningsih (2022) 50 p-issn: 1858-3598  e-issn: 2502-5791 table 1 evaluation of old instrument instrument standards information category there is a focus or specific assessment format for postpartum patients with severe preeclampsia/eclampsia the assessment format is not specific for postpartum patients with severe preeclampsia/eclampsia, still mixed with other cases (antepartum, intrapartum, and gynecology) not appropriate based on wiedenbach’s need for help model, the assessment of postpartum patients with severe preeclampsia/eclampsia should be sufficient to detect signs of eclampsia impending: 1. headache complaint 2. complaints of epigastric pain 3. complaints of vision impairment 4. complaints of nausea, vomiting 5. help needed to deal with impending eclampsia in the hospital and after being discharged in the assessment format there is already a complaint assessment of dizziness and nausea and vomiting, but it is not specific for signs of impending eclampsia partially suitable based on wiedenbach’s need for help model, the assessment of postpartum patients with severe preeclampsia/eclampsia should be sufficient to identify fluid balance: 1. intake 2. output 3. assistance needed for fluid balance in the hospital and after hospital discharge in the assessment format, there is already an assessment of fluid intake and output suitable based on wiedenbach’s need for help model, the assessment of postpartum patients with preeclampsia/eclampsia should be sufficient to identify signs of magnesium sulfate therapy poisoning: 1. respiratory depression (rr <12 times/minute) 2. tendon reflexes disappear 3. declining awareness 4. help needed to overcome magnesium sulfate intoxication in the assessment, there has been an assessment of breathing, awareness, but there is no assessment of tendon reflexes partially suitable based on wiedenbach’s need for help model, the assessment of postpartum patients with preeclampsia/eclampsia should be sufficient to identify the risk of bleeding as an effect of the administration of magnesium sulfate 1. uterine contractions 2. height of the uterine fundus 3. characteristics of vaginal discharge 4. assistance needed to deal with the risk of bleeding in the hospital and after being discharged in the assessment format, there is no assessment of uterine contractions, the height of the uterine fundus, or characteristics of vaginal discharge for postpartum not appropriate based on wiedenbach’s need for help model, the assessment of postpartum patients with preeclampsia/eclampsia should be sufficient to identify the risk of pulmonary edema as a hypoalbumin effect 1. fluid restriction 2. lung sounds 3. respiration rate (rr) 4. assistance needed to deal with the risk of pulmonary edema in the hospital and after hospital discharge in the assessment, there is an assessment of lung sounds and rr, but there is no assessment of fluid restriction partially suitable based on wiedenbach’s need for help model, the assessment of postpartum patients with preeclampsia/eclampsia should be sufficient to identify the ability to meet basic needs 1. oxygenation 2. nutrition 3. elimination 4. mobilization 5. rest and sleep 6. assistance needed to meet basic needs in the hospital and after being discharged in the assessment, there is an assessment of nutrition, but there is no assessment of oxygenation, elimination, mobilization, health, and sleep, and the assistance needed not appropriate jurnal ners http://e-journal.unair.ac.id/jners 51 table 1 evaluation of old instrument (continuos) instrument standards information category based on wiedenbach’s need for help model, the assessment of postpartum patients with preeclampsia/eclampsia should be sufficient to identify comfort 1. pain scale 2. causes of pain 3. the ability and habit of dealing with pain 4. assistance needed for comfort in the hospital and after being discharged in the assessment, there is an assessment of the scale of pain but there is no assessment of the causes of pain, as well as the ability and habits to deal with the pain partially suitable based on wiedenbach’s need for help and orem’s self-care models, the assessment of postpartum patients with preeclampsia/eclampsia should be sufficient to identify abilities to meet basic care 1. personal hygiene 2. perineal care 3. wound care 4. knowledge of postpartum danger signs 5. help is needed about self-care in the hospital and after being discharged in the study, there was no assessment of personal hygiene, milk production and breastfeeding, and perineal care/wound care not appropriate based on wiedenbach’s need for help and orem’s self-care models, the assessment of postpartum patients with preeclampsia/eclampsia should be sufficient to identify parental readiness 1. mental readiness 2. readiness of knowledge about baby's needs and care 3. breast production and breastfeeding 4. support system 5. rocks needed for baby care in the hospital and after hospital discharge in the assessment format, there is no assessment of parental readiness not appropriate table 2 first focus group discussion results strategic issues causes fgd results researcher study specific assessment instrument for postpartum with severe preeclampsia-eclampsia 1. the unavailability of a special assessment instrument for postpartum patients with severe preeclampsia/eclampsia 2. the instrument of the outpatient assessment is made public for all cases treated in the midwifery ward development of specific assessment instruments for postpartum patients with severe preeclampsia/eclampsia development of a special assessment instrument is needed to identify the needs, abilities, independence, and assistance needed by postpartum patients with severe preeclampsia -eclampsia. self-management support there are no instruments that show the self-management data of postpartum patients with severe preeclampsia/eclampsia who need support development of an instrument to explore the self-management data of postpartum patients with severe preeclampsia/eclampsia who need support development of the instrument needs to be done in the obstetric ward to overcome the emergency conditions and improve the ability and independence of postpartum patients with severe preeclampsia/eclampsia decision support no instrument shows the decision support in the form of a written list of things that must be studied about the needs, abilities, and assistance needed by postpartum patients with severe preeclampsia/eclampsia development of instrument which includes: 1. list of patient needs 2. list of patient abilities 3. list of assistance the patient needs development of an instrument is needed to overcome the emergency conditions and improve the ability and independence of postpartum patients with severe preeclampsia/eclampsia service system design no instrument shows the things that need to be studied about the needs, abilities, and assistance needed by postpartum patients with severe preeclampsia/eclampsia 1. development of instrument that includes a list of patient needs 2. list of patient abilities 3. list of assistance the patient needs development of an instrument is needed to overcome the emergency conditions and improve the ability and independence of postpartum patients with severe preeclampsia/eclampsia clinical information clinical information such as signs of eclampsia impending, self-care ability, parental readiness has not been systematically arranged systematic development of clinical information 1. subjective data 2. objective data development of instrument is carried out to determine the patient's development and arrange further selfmanagement strategies suprihatin and wuryaningsih (2022) 52 p-issn: 1858-3598  e-issn: 2502-5791 table 3 results of expert discussions instrument component feedback specific or focus assessment instrument for postpartum patients with severe preeclampsia-eclampsia 1. self-management support specific data based on the model need for help and self-care 2. decision support data that examines the management of postpartum patients with severe preeclampsia/eclampsia which includes: 1. symptoms of impending eclampsia 2. fluid balance 3. signs of magnesium sulfate poisoning 4. risk of pulmonary edema 5. risk of bleeding 6. self-care ability 7. comfort 8. parental readiness 9. meeting basic needs 3. service system design development of instruments is needed to improve the alarm warning to detect early and overcome emergencies and improve the ability of postpartum patients with severe preeclampsia/eclampsia in the obstetric ward 4. clinical information an instrument is available that examines data about: 1. symptoms of impending eclampsia 2. fluid balance 3. signs of magnesium sulfate poisoning 4. risk of pulmonary edema 5. risk of bleeding 6. self-care ability 7. comfort 8. parental readiness 9. meeting basic needs table 4 normality test results pre post kolmogorov-smirnov z 1.133 1.701 asymp. sig. (2-tailed) 0.153 0.006 information normal abnormal table 5 statistical test results group n mean rank z score p-value old instrument 100 19.93 -5.379 <0.001 new instrument 100 29.72 table 6 second fgd results strategic issues cause fgd results researcher specific assessment instrument or focus for postpartum patients with severe preeclampsia/eclampsia it cannot be applied directly to postpartum patients with severe preeclampsia/eclampsia it has been done even though it has not been a supplementary document the assessment instrument of the postpartum patient with severe preeclampsia/eclampsia based on the "need for help" and "self-care" models can already be used in the obstetric ward to get complete information from the patient jurnal ners http://e-journal.unair.ac.id/jners 53 compliant, namely (1) detecting signs of impending eclampsia, (2) signs of magnesium sulfate therapy poisoning, (3) the risk of pulmonary edema as a hypoalbumin effect, and (4) comfort. there is only one component which was suitable, namely about fluid balance. therefore, the old instrument is insufficient to assess the need for help and self-care of postpartum patients with severe preeclampsia/eclampsia. the results of the fgd in the first stage are shown in table 2. the finding showed that, based on five aspects of strategic issues, the development of an instrument to assess postpartum patients with severe preeclampsia or eclampsia was needed. the fgd recommendations are the approval of the development of a specific assessment instrument for postpartum patients with severe preeclampsia/eclampsia. furthermore, a new assessment instrument was developed for postpartum patients with severe-eclamptic preeclampsia based on wiedenbach’s need for help and orem’s self-care models. the results of discussions with experts on the four elements are shown in table 3. the finding showed that the development of assessment instruments is needed to improve the alarm warning to detect early and overcome emergencies and improve the ability of postpartum patients with severe preeclampsia/eclampsia in the obstetric ward. recommendations from an expert discussion on the instrument for the study of postpartum patients with severe preeclampsia/eclampsia were: 1) the development of a specific assessment tool for postpartum patients with severe preeclampsia/eclampsia, and 2) the components of the instrument should include: selfmanagement support, decision support, service system design, and clinical information. before further analysis was carried out, the normality of the data was tested with the kolmogorov smirnov test because the data are more than 50. the data normality test can be seen at table 4 and the test result at table 5. in this study, the results of the pre-test data normality test were normally distributed, while the post-test was not normal. so that the statistical test used is the wilcoxon signed rank test. the old assessment instrument was rated lower with a mean rank of 19.93, while the new assessment instrument was with a mean rank value of 29.72. the wilcoxon test results obtained a value of 5.379 with p < 0.001. so there is a significant difference between the old assessment instrument and the new postpartum patient assessment instrument. the results of the second stage fgd are shown in table 6. the finding shows the assessment instrument can be used in obstetric wards to get the more complete information from the patients. in addition, the experts recommended to improve the instruments by adding data components about the medication that patients should continue at home. this is important because treatment with antihypertensive drugs is recommended for severe postpartum hypertension. discussions the results of this study illustrate that an instrument carried out to assess postpartum patients with severe preeclampsia/eclampsia was inadequate. some previous studies have described that postpartum patients with preeclampsia are at risk for experiencing emergencies, namely eclampsia, bleeding, and dyspnea (cairns et al., 2017; nice, 2019; kvist & persson, 2009; magee et al., 2014;rana et al., 2019; rawlins et al., 2018). based on the results of previous research, it illustrates that the need for help and self-care models are effective to be applied to patients with maternal complications, both physical and psychological. this model can be used in patients with preeclampsia, bleeding, preterm labor, and in patients with postpartum depression (machmudah, 2015; rahayu, 2015; wulandari and setyowati, 2015; dwi susanti et al., 2016). the results of this study illustrate that the assessment instruments that have been used so far are still general and not entirely specific to identifying the special needs of preeclamptic patients. based on the input from the experts, the development of instruments for postpartum patients with severe preeclampsia/eclampsia using the "need for help" concept proposed by wiedenbach with the goals in helping clients are: 1) to prevent maternal emergencies, 2) reduce anxiety due to loss, and 3) develop effective coping by collaborating and coordinating with other health teams so clients can get appropriate action and handling procedures. in addition, the self-care theory by orem, which believes that every individual has the ability and potential to care for themselves and achieve prosperity, was also used to develop the instruments. changes that occur during the postpartum period cause a decrease in the client's independence to meet their needs. nurses play a role in helping to increase the independence of clients to meet their self-care needs through a learning process or exercise in the form of self-care, creating an environment that facilitates the achievement of independence. the statistical test showed that there is a significant difference between the old assessment instrument and the new one, which was considered more effective. based on the results of data analysis from the results of filling out the questionnaire, almost all respondents gave the opinion that the assessment instrument for postpartum patients with severe preeclampsia-eclampsia based on wiedenbach’s need for help and orem’s self-care models met the criteria of functionality, efficiency, and usability. the effectiveness of using the need for help and self-care models in providing nursing care has been illustrated in the results of previous studies in different cases (çapik et al., 2015; ferreira et al., 2016; hajira irshad ali, 2018). conclusions the assessment instruments in obstetric ward have not been specific for postpartum patients with severe suprihatin and wuryaningsih (2022) 54 p-issn: 1858-3598  e-issn: 2502-5791 preeclampsia/eclampsia, while the new instrument has been developed for postpartum patients with severe preeclampsia-eclampsia based on wiedenbach’s need for help and orem’s self-care models through fgd and expert discussion. the new assessment instruments met the criteria of functionality, efficiency, and usability. for stakeholders, midwives recommend the use of the assessment instrument of the postpartum patients with severe preeclampsia-eclampsia based on wiedenbach’s need for help and orem’s self-care models in the obstetric ward setting. acknowledgment thanks are conveyed to the nurses/midwives in the obstetrics ward and management, as well as postpartum patients both at the airlangga university hospital and the haji hospital surabaya. funding source the research was provided financial support by poltekkes kemenkes surabaya. references alligood, m. r. (2018) nursing theorists and their work. 9th edn. st. louis, mo: elsevier inc. cairns, a. e. et al. (2017) ‘postpartum management of hypertensive disorders of pregnancy: a systematic review’, bmj open. bmj publishing group. doi: 10.1136/bmjopen-2017-018696. çakşak, a. et al. (2018) ‘tools for assessing parenting in the prenatal and postpartum period in turkey’, new trends and issues proceedings on advances in pure and applied sciences, (10), pp. 104–109. doi: 10.18844/gjpaas.v0i10.3750. çapik, a. et al. (2015) the effect of the care given usıng orem’s self-care model on the postpartum self-evaluation, international journal of caring sciences. dwi susanti, h. et al. (2016) ‘wiedenbach need for help and swanson caring model on nursing care of prolonged second stage of labour’, 7(1). ferreira, m. b. g. et al. (2016) ‘nursing care for women with preeclampsia and/or eclampsia: integrative review’, revista da escola de enfermagem. escola de enfermagem de universidade de sao paulo, pp. 320–330. doi: 10.1590/s0080-623420160000200020. frawley, n., east, c. and shaun brennecke (2020) ‘women’s experiences of preeclampsia: a prospective survey of preeclamptic women at a single tertiary centre’, j obstet gynaecol, 20(1), pp. 65– 69. doi: 10.1080/01443615.2019.1615040. hajira irshad ali, b. (2018) ‘application of orem self care deficit theory on psychiatric patient’, ann nurs pract, 5(1), p. 1093. health ministry (2021) ‘profil kesehatan propinsi jawa timur 2019’,date accessed 25 may 2021. hoedjes, m. et al. (2011) ‘postpartum depression after mild and severe preeclampsia’, journal of women’s health, 20(10), pp. 1535–1542. doi: 10.1089/jwh.2010.2584. kvist, l. j. and persson, e. k. (2009) ‘bmc pregnancy and childbirth evaluation of changes in postnatal care using the " parents ’ postnatal sense of security " instrument and an assessment of the instrument ’ s reliability and validity’, 10, pp. 1–10. doi: 10.1186/14712393-9-35. machmudah (2015) ‘penerapan model konsep need for help dan self care pada asuhan keperawatan ibu pre eklampsia berat dengan terminasi kehamilan’, jurnal keperawatan maternitas, 3(1), pp. 16– 26. magee, l. a. et al. (2014) ‘diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary’, journal of obstetrics and gynaecology canada. elsevier inc, 36(5), pp. 416– 438. doi: 10.1016/s1701-2163(15)30588-0. nice. hypertension in pregnancy: diagnosis and management nice guideline (2019). peres, g., mariana, m. and cairrão, e. (2018) ‘pre-eclampsia and eclampsia: an update on the pharmacological treatment applied in portugal’, journal of cardiovascular development and disease. mdpi ag, 5(1), p. 3. doi: 10.3390/jcdd5010003. peter s. bernstein, james n. martin, john r. barton, laurence e. shields, maurice l. druzin, barbara m. scavone, jennifer frost, christine h. morton, catherine ruhl, joan slager, eleni z. tsigas, sara jaffer, m. k. m. (2017) ‘consensus bundle on severe hypertension during pregnancy and the postpartum period’, journaljognn journal of obstetric, gynecologic, and neonatal nursing, 46(5), pp. 776–787. doi: 10.1016/j.jogn.2017.05.003. rachmania, d., sunaringtyas, w. and widayati, d. (2019) ‘pengembangan instrumen pengkajian m3 (method) dalam manajemen keperawatan berbasis standar akreditasi joint comission international’, the indonesian journal of health science, 11(2), pp. 143–154. rahayu, k. d. (2015) ‘theory implementation of need for help wiedenbach and self care orem in pregnancy case with tuberculosis multi drug resistance’, jmcrh, 1(118–129). rana, s. et al. (2019) ‘preeclampsia: pathophysiology, challenges, and perspectives’, circulation research. lippincott williams and wilkins, 124(7), pp. 1094–1112. doi: 10.1161/circresaha.118.313276. rawlins, b. et al. (2018) ‘screening and management of pre-eclampsia and eclampsia in antenatal and labor and delivery services: findings from cross-sectional observation studies in six subsaharan african countries’, bmc pregnancy and childbirth. biomed central ltd., 18(1). doi: 10.1186/s12884-018-1972-1. shamsi, u., saleem, s. and nishter, n. (2013) ‘epidemiology and risk factors of preeclampsia ; an overview of observational studies’, al ameen j med sci, 6(4), pp. 292–300. stern, c. et al. (2014) ‘the impact of severe preeclampsia on maternal quality of life’, quality of life research. kluwer academic publishers, 23(3), pp. 1019–1026. doi: 10.1007/s11136-013-0525-3. sugiyono (2019) metodologi penelitian kuantitatif, kualitatif, dan r&d. 1st edn. bandung: alvabeta. wulandari, p. and setyowati (2015) ‘penerapan model keperawatan’, versi online / url: http://ejournal.umm.ac.id/index.php/keperawatan/article/view/2346, 5(2), pp. 173–177. yoshikawa, h. (2012) design methodology for research and development strategy ─ realising a sustainable society ─. zubaran, c. et al. (2009) ‘an assessment of maternal quality of life in the postpartum period in southern brazil: a comparison of two questionnaires’, clinics, 64(8), pp. 751–756. doi: 10.1590/s180759322009000800007. how to cite this article: suprihatin, e., wuryaningsih, s. r. (2022) ‘development assessment instrument postpartum patients with severe preeclampsia-eclampsia based on need for help and self-care models’, jurnal ners, 17(1), pp. 47-54. doi: http://dx.doi.org/10.20473/jn.v17i1.35029 table1 table2 table3 table4 table5 table6 alligood2018 cairns2017 çakşak2018 çapik2015 dwi2016 ferreira2016 frawley2020 hajira2018 health2017 hoedjes2011 kvist2009 magee2014 machmudah2015 hypertension2019 peres2018 peter2017 rachmania2019 rahayu2015 rana2019 rawlins2018 shamsi2013 stern2014 sugiyono2019 wulandari2015 yoshikawa2012 zubaran2009 94 profil kasus keracunan pada anak di ird rsud dr soetomo surabaya tahun 2011 (clinical profi le of children presenting with intoxication on emergency departement soetomo hospital in 2011) ira dharmawati, neurinda permata kusumastuti, arina setyaningtyas departemen ilmu kesehatan anak, fakultas kedokteran universitas airlangga kampus a jl. mayjen prof. dr. moestopo surabaya email: neurindapermata@yahoo.com abstract introduction: acute poisoning in children is an important pediatric emergency and is a world wide problem, the majority of these poisoning incidents are unintentional and preventable. based on data from who, the mortality of children under 4 years varies between 0.3–7% per 100,000 population in some countries in the world. the incidence, clinical profi le and the type of poison and the output of poisoning cases in children in surabaya until now there is no defi nitive data. the objective of the study was to study the clinical profi le and outcome of childhood poisoning and intoxication in soetomo hospital. method: design used in the study was a retrospective study done in children between 1 month and 18 years old of age who were admitted in emergency departement soetomo hospital with diagnosis of acute poisoning between january until desember 2012. patients were profi led according to age, sex, poison consume and outcome. result: there were 12 patients enrolled in the study. male: female ratio was 2:1. the mean age of presentation was 53 months. hydrocarbon poisoning was the commonest poisoning seen in (41.7%) patients followed by organophospat (33.3%) poisoning. during treatment, 58.3% received antibiotics, 25% patients who poisoning with organophosphat received antidots and 50% from all sample received antagonist histamin h2 because of stomached. overall survival was 91,6%. discussion: hydrocarbon is the commonest agent involved in childhood poisoning. overall, the outcome is good with 91,6% survival in our hospital. keywords: child, intoxication, clinical profi le, outcome pendahuluan keracunan pada anak merupakan masalah kegawatan yang penting dan merupakan masalah di dunia (wilkerson, 2005). saat ini keracunan pada anak telah menjadi subjek penelitian yang cukup besar dalam dekade terakhir di amerika serikat, eropa, australia dan inggris (singh, 1995). penyebab dari keracunan sangat bervariasi di setiap negara, tergantung dari faktor demografi , status sosial, tingkat pendidikan, kepercayaan dan kebiasaan di masyarakat (who, 1988; wilkerson, 2005). menurut pusat pengendalian racun amerika, keracunan pada anak masih menempati urutan tertinggi (63,2%) dibanding dengan dewasa, dengan prevalensi tertinggi pada kelompok usia 1 tahun (15,9%) dan 2 tahun (16,8%) (bronstein, 2011). sebagian besar karena kecelakaan akibat kelalaian orang tua saat mengawasi anak dan kelalaian penyimpanan bahan berbahaya di rumah. tertelan atau terminum merupakan cara tersering yang terjadi pada proses keracunan, kurang lebih terjadi pada 70% kasus (reith, 2001). berdasarkan data dari who, mortalitas anak di bawah 4 tahun bervariasi antara 0,3–7% per 100.000 populasi di beberapa negara di dunia (reith, 2001). tetapi untuk di surabaya, masih belum ada data yang pasti. tujuan dari penelitian ini adalah untuk mengetahui angka kejadian, profi l klinis dan jenis racun serta keluaran kasus keracunan pada anak yang datang ke ird rsud dr, soetomo surabaya selama periode tahun 2011. harapan dari penelitian ini adalah dengan mengetahui angka kejadian, profi l klinis dan profi l kasus keracunan pada anak (ira dharmawati, dkk) 95 jenis racun serta keluaran kasus keracunan pada anak, dapat dicapai pelayanan keperawatan yang komprehensif pada pasien anak dengan keracunan dengan menggunakan proses perawatan yang bertujuan mempertahankan vitalitas kehidupan pasien serta mencegah penyerapan racun dengan cara menghambat absorbsi dan menghilangkan racun dalam tubuh. bahan dan metode penelitian ini merupakan penelitian retrospektif. semua anak yang masuk ke ird dan unit perawatan intensif anak rsud dr. soetomo dengan keluhan tertelan atau terminum zat beracun antara bulan januari sampai dengan desember 2011 dilakukan identifi kasi dari rekam medik. semua kasus anak usia 1 bulan sampai dengan 18 tahun dengan riwayat keracunan dimasukkan dalam penelitian ini. tidak ada kriteria eksklusi dari penelitian ini. data yang diambil adalah: usia, jenis kelamin, gejala klinis, jenis racun, dan keluaran (pulang sehat, pulang paksa atau meninggal). data dianalisis dengan menggunakan uji statistik secara deskriptif dan inferensial. data ditampilkan dalam bentuk persentase dan signifikansi dari keluaran terhadap faktor-faktor yang memengaruhi. hasil selama periode penelitian sejak januari 2011 sampai dengan desember 2011 didapatkan 12 pasien yang masuk dengan diagnosis klinis keracunan. jumlah tersebut hanya 0,2% dari total 5.853 pasien yang datang ke ird selama tahun 2011. dari 12 pasien tersebut didapatkan 8 laki-laki dan 4 perempuan, perbandingan laki-laki dan perempuan 2:1. rerata usia pasien adalah 53 bulan, bervariasi mulai 14 bulan sampai 120 bulan. pasien termuda pada penelitian ini (usia 14 bulan) terkena racun organofosfat. seluruh pasien yang terdiagnosis keracunan tersebut dilakukan perawatan di unit perawatan intensif, 1 pasien harus menggunakan alat bantu napas (ventilator). distribusi jenis racun menunjukkan bahwa penyebab keracunan tersering adalah hidrokarbon (41,7%), diikuti dengan organofosfat (33,3%). sebagian besar adalah anak laki-laki. sebanyak 50% kasus mendapatkan antidot dan sisanya tidak terdapat antidot. selama tabel 1. distribusi kasus berdasarkan jenis kelamin dan usia kelompok usia kasus % laki-laki % perempuan % 0–5 tahun 9 75 6 50 3 25 6–10 tahun 3 25 2 16,7 1 8,3 total 12 100 8 66,7 4 33,3 tabel 2. distribusi kasus berdasarkan jenis racun, lama rawat inap dan jenis kelamin jenis racun jumlah kasus % lama rawat inap (mean) laki perempuan organo fosfat 4 33,3 2,75 hari 4 0 hidrokarbon 5 41,7 4,8 hari 3 2 obat (haloperidol) 2 16,7 8 hari 0 2 detergen 1 8,3 4 hari 1 0 total 12 100,0 4,6 hari 8 4 jurnal ners vol. 7 no. 1 april 2012: 94–98 96 perawatan 58,3% mendapatkan antibiotika, 16,7% mendapatkan anti konvulsan dan 50% mendapat antagonis histamin h2. tabel 3. jenis racun dan keluaran subjek jenis racun keluaran 1 organofosfat sembuh 2 haloperidol sembuh 3 organofosfat sembuh 4 detergen sembuh 5 hidrokarbon sembuh 6 hidrokarbon pulang paksa 7 hidrokarbon sembuh 8 hidrokarbon sembuh 9 haloperidol sembuh 10 hidrokarbon sembuh 11 organofosfat sembuh 12 organofosfat sembuh pembahasan keracunan pada anak merupakan salah satu kegawatdaruratan pada praktik pediatri. anak sangat berisiko mengalami keracunan karena perilaku mereka yang selalu ingin tahu dan suka bereksplorasi, sering memasukkan tangan ke dalam mulut dan semua yang dipegang. bermain dekat dengan tanah juga memperbesar eksposur mereka terhadap racun. anak usia 2–3 tahun memiliki mobilitas dan kecerdikan yang memungkinkan mereka untuk mengakses setiap laci maupun lemari yang terkunci di rumah. perawatan pasien anak dengan keracunan adalah suatu bentuk pelayanan perawatan yang komprehensif pada pasien yang mengalami keracunan dengan menggunakan proses perawatan yang bertujuan mempertahankan vitalitas kehidupan pasien serta mencegah penyerapan racun dengan cara menghambat absorbsi dan menghilangkan racun dalam tubuh. a s u h a n k e p e r a w a t a n p a d a k a s u s keracunan ditujukan pada pengkajian, di mana diarahkan pada masalah yang mendesak seperti jalan napas, sirkulasi yang mengancam jiwa, adanya perdarahan, adanya gangguan asam basa, status kesadaran pasien. selain itu asuhan keperawatan ditujukan juga pada riwayat kesehatan dari pasien seperti riwayat keracunan, bahan racun yang digunakan, berapa lama setelah keracunan, ada masalah lain sebagai pencetus keracunan atau sindroma toksik yang ditimbulkan penelitian ini sebanyak 9 anak berusia di bawah 5 tahun mengalami keracunan secara tidak sengaja (kecelakaan). hal ini sesuai dengan hasil yang didapat oleh budhathoki dkk. di mana gambar 1. gejala yang terjadi akibat dari keracunan kejang muntah nyeri abd miosis kesadaran turun sesak kejang hipersalivation pembersih kaca hidrokarbon haloperidol organoposfat profi l kasus keracunan pada anak (ira dharmawati, dkk) 97 dari hasil penelitian 2/3 anak yang berusia 5 tahun teracuni secara tidak sengaja (kecelakaan) (budhathoki, 2009). begitu pula dengan hasil peneltian yang dilakukan di oslo, di mana dari hasil pengamatan selama 2 tahun, 81% sampel anak berusia 8 tahun teracuni karena kecelakaan (tidak sengaja) (erguvan, 2007). hidrokarbon merupakan penyebab terbanyak keracunan pada penelitian ini (41,7%). hasil penelitian ini sesuai dengan penelitian di nepal, di mana sebagian besar penyebab keracunan adalah kerosen (hidrokarbon) yaitu sebanyak 43% (opawoye, 1998). begitu pula dengan penelitian yang dilakukan oleh singh dkk. sebanyak 25,3% disebabkan karena hidrokarbon (reith, 2001). hal ini mungkin disebabkan karena hidrokarbon masih banyak digunakan untuk keperluan rumah tangga, seperti memasak dan penerangan. penyebab keracunan tersering kedua pada penelitian ini adalah organofosfat, yaitu sebanyak 33,3%. di mana hasil penelitian budhathoki dkk. menunjukkan bahwa sebagian besar karena organofosfat (45,1%) (budhathoki, 2009). sedangkan penelitian yang dilakukan di india oleh singh dkk. menunjukkan 10% karena organofosfat (singh, 1995). pada penelitian ini gejala klinis yang paling sering dialami oleh anak dengan keracunan adalah muntah, lebih dari 50% mengalami gejala ini. gejala lain yang sering adalah nyeri perut, sesak, kesadaran menurun, hipersalivasi, miosis dan kejang. karena hidrokarbon merupakan penyebab utama keracunan pada penelitian ini, maka tanda-tanda klinis yang paling sering menyerupai tanda-tanda klinis keracunan hidrokarbon. terapi yang diberikan selama perawatan sangat bervariasi, hal ini disebabkan disesuaikan dengan jenis racun dan keadaan klinis masingmasing pasien. sebanyak 58,3% sampel mendapatkan antibiotika, 25% anak yang keracunan organofosfat mendapatkan terapi atropin sebagai antidot. sebanyak 50% dari seluruh sampel mendapatkan terapi antagonis histamin h2, karena mengalami nyeri perut. pada penelitian ini 91,6% sampel dipulangkan dalam keadaan sembuh dan 1 pasien (8,4%) pulang paksa, tidak didapatkan pasien yang meninggal. hasil ini tidak jauh berbeda dengan hasil dari penelitian yang dilakukan di rumah sakit di lalitpoor, jumlah kematian pada anak dan dewasa hanya 4,5% (opawoye, 1998). begitupula di rumah sakit bir dan nepal medical college teaching hospital di kathmandu (ghai, 2004). simpulan dan saran simpulan hidrokarbon merupakan penyebab terbanyak dari keracunan pada anak pada penelitian ini. data perbandingan menunjukkan bahwa sesuai dengan negara maju, di negara berkembang seperti indonesia penyebab keracunan adalah barang-barang rumah tangga. di mana sebagian besar gejala yang didapatkan adalah seperti gejala keracunan hidrokarbon, yaitu muntah, nyeri perut. secara keseluruhan, keluaran dari perawatan sampel pasien penelitian ini baik, dengan 91,6% sampel dipulangkan dalam keadaan sembuh. karena sebagian besar diketahui secara cepat oleh orang tua dan segera dibawa ke rumah sakit. perawatan komprehensif dan cepat yang diberikan oleh tenaga medis di rumah sakit menunjang keberhasilan penanganan pasien anak dengan keracunan. saran perlu dilakukan penelitian lebih lanjut tentang profi l klinis dan keluaran dari pasien anak dengan keracunan di beberapa rumah sakit besar di surabaya, sehingga akan lebih mewakili angka kejadian dan profi l keracunan pasien anak di surabaya. kepustakaan bronstein, ac., et al., 2011. 2010 annual report of the aamerican associatian of poison control centers national poison data system (npds): 28th annual report. clin toxicol (phila); 49: 910–41. budhathoki, s., et al., 2009. clinical profi le and outcome of children presenting with poisoning or intoxication: a hospital based study. nepal med coll j; 11(3): 170–175. erguvan, m., et al., 2007. mushroom poisoning. indian j pediatr; 74: 847–57 jurnal ners vol. 7 no. 1 april 2012: 94–98 98 ghai, o.p., gupta, p., 2004. poisonings and accidents. in: ghai essential pediatrics 6th ed. ghai op, gupta p, paul vk (eds). new delhi. cbs publishers and distributors. opawoye, a.d., haque, t., 1998. insecticide organophosphorus compound poisoning in children. ann saudi med; 18: 171–72. reith, d.m., pitt, w.r., hockey, r. 2001. childhood poisoning in queensland: an analysis of presentation and admission rates. j paediatr child health; 37: 446–50. singh, s., singhi, s., sood, n.k., kumar, l., walia, bns. changing pattern of childhood poisoning (1970–1989): experience of a large north indian hospital. indian pediatr 1995; 32: 331–6. wilkerson, r., northington, ld., fisher, w. 2005. ingestion of toxic substances by infants and children. what we don’t know can hurt. crit care nurse; 25: 35–44. world health organitation, 1988. world health statistics annual. geneva. 41 modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan** *faculty of nursing, universitas airlangga **nurse practitioner, mental hospital dr. radjiman wediodiningrat lawang email: ah-yusuf@fkp.unair.ac.id abstract introduction: schizophrenia is a disease which affects the brain, causing impaired perception, thought, emotion, movement, and behavior, such as self-care deficit. self-care deficit is an impaired ability to bathing, dressing, eating and toileting. modeling participant is a technique required to address the problem of self-care deficit where clients are taught and trained to meet the needs of self-care. the purpose of this study was to analyze the influence of participants modeling on self-care ability in schizophrenic clients with self-care deficit. method: this study used quasi-experimental design. sampling was carried out with total sampling to all affordable population comprising 20 respondents in dr. radjiman wediodiningrat mental hospital, lawang. this study analyzed by wilcoxon signed rank test and mann-whitney test with a significance level of p < 0.05. result: the results showed the influence of participants modeling on self-care ability in schizophrenic clients with self-care deficit. wilcoxon signed rank test in treatment group showed p = 0.005 and control group showed p = 0,206. mann-whitney test showed p = 0.030. modeling participant improved self-care ability in schizophrenic clients with self-care deficit. analysis: modeling participant will improve cognitive, self-confidence and motivation of schizophrenic clients so that their ability to bathing, dressing, eating and toileting will increase. discussion: modeling participant can be applied as a technique to improve self-care ability in schizophrenic clients with self-care deficit. for further research can be explored further implementation of the modeling of participants in the group activity therapy. keywords: modeling participant, self-care, schizophrenia. introduction schizophrenia is a disease which affects brain, causing impaired perception, thought, emotion, movement, and behavior (videbeck 2008). symptoms of schizophrenia include delusions, hallucinations, affective flattening or blunt, poor of speaking or meaning, blocking, self-care deficit, low motivation, and selfwithdrawal from social (sadock & sadock 2010). schizophrenic client disorders such as behavior derangement, perceptive, cognitive disability will cause the client can’t take care of himself adequately. the inability to care for himself will emergence of self-care deficit problem. self-care deficit is a common problem in schizophrenic clients, both being treated at hospital and community. direja (2011) states that the self-care deficit is an impaired ability to perform self-care activities (bathing, dressing, eating, toileting). inability to perform self-care activities without intervention by the nurse, the schizophrenic client will get a higher risk of social isolation or low self-esteem. general nursing interventions addressing self-care deficit problems are taught and trained the client to meet the needs of self-care includes bathing, dressing, eating and drinking properly and also bowel or urinate correctly (rochmawati et al. 2013). those nursing actions are implemented through nursing care, but it still found a schizophrenic client with self-care disorder. schizophrenia affects approximately 24 million people worldwide (world health organization 2014). the prevalence of severe mental disorders (psychosis/schizophrenia) in indonesia is 1.7 per mil. the prevalence of severe mental disorders in east java was 2.2 per mil (badan penelitian dan pengembangan kesehatan kementerian kesehatan ri 2013). base health research (riskesdas) in 2013, the prevalence of people with mental emotional problem in population over 50 years old found approximately 6%, or about 16 million people, people with severe mental disorders about 400 thousand and 57 thousand people with severe mental disorder have been deprived by the family (kemenkes 2014). schizophrenic client with social isolation about 72% and 64% experiencing decreased ability to take care themselves (eating, bathing and dressing) (surtiningsrum 2011). the percentage of nursing problems by deficit self-care in february 2008 at marzoeki mahdi hospital bogor reaches 80% (perendrawati 2008). initial data has retrieved by researchers from medical record of dr. radjiman wediodiningrat mental hospital lawang, the data shown the schizophrenic client who was treated at 28 inpatient room in october 2014 were 567 clients, 70% were male, and 30% were female. mailto:ah-yusuf@fkp.unair.ac.id jurnal ners vol. 12 no. 1 april 2017: 41-48 42 preliminary studies conducted by researchers at the kenari room obtain data that 17 out of 41 clients or 41% of clients who were treated had self-care deficit, while in kakak tua room were 31%. nursing interventions for schizophrenic clients with self-care deficit in kenari room dr. radjiman wediodiningrat mental hospital lawang is nursing care and behavioral therapy. nursing care includes self-care teaching and motivating clients to perform self-care, but still found schizophrenic clients with impaired ability to take care of themselves. self-care deficit is a situation where experiencing barriers to perform self-care activities, such as bathing, changing clothes, eating and eliminating. barriers/interference ability to take care of themselves at schizophrenic client caused by cognitive or perceptual disturbances (wilkinson & ahern 2013). several disturbance were experienced by the schizophrenic client such as behavior derangement, perceptive, cognitive disability and it will cause the client can’t take care of themselves. clients can be very preoccupation with delusions or hallucinations idea until they fail for carrying out daily activities (videbeck 2008). if self-care deficit is not treated immediately, it will lead to some new problems and worsen. teaching techniques required to improve self-care ability through demonstrations by the model. ormrod (2009) states, as humans we have the ability to imitate others since we were born. a schizophrenic client experiencing cognitive, perceptive and behavior impairment, so it will be easier for them to improve self-care ability by mimicking models in modeling participants. according to bandura in ningsih & sutjiono (2011), modeling participants accelerate behavior changes level, attitudes facing of alarming stimuli. modeling technique was done by a therapist/nurse through demonstration to the client about what to do (nasir & muhith 2011). modeling technique has several kinds; live models, symbolic models, multi-model (dual characterizations), self-model, modeling participants (junaedi & nursalim 2011). modeling participants is a way to learn new behaviors through observation from a model, add information through cognitive processes to get output appropriate behavioral changes were modeled (iswanti 2012). iswanti research (2012), shown differences in medication adherence in the intervention group who received behavior therapy of modeling participants, whereas the control group was no differences in medication adherence. ningsih and sutijono (2011) research concluded that modeling participant strategy influence improve students skill in class. this indicates that the participant modeling can be used as a therapy to improve the ability of the client. one of nursing intervention in self-care deficit consists of knowledge and ability improvement to perform self-care (wilkinson & ahern 2013). main element of modeling participants consist of rational, modeling, guided participation and strengthening is needed as a technique to implementing the nursing interventions. client knowledge can be enhanced through rational, clients are taught how to care themselves through modeling and guided participation. bandura states that learning can be obtained through direct experience, indirectly by observing the behavior of others and their consequences (corey 2009). lastly, clients will be motivated to perform self-care activities through strengthening elements. participants are expected to change behavior from maladaptive become adaptive through modeling participant and increase self-care ability. based on these, researchers want to know the influence of modeling participants in a schizophrenic client with self-care deficit in dr. radjiman wediodiningrat mental hospital lawang. method this study analyzes the influence of modeling participants in a schizophrenic client with self-care deficit. the research design is quasi-experiment design. the affordable population in this study are 29 respondents of schizophrenic clients with self-care deficit in kenari and kakak tua room at dr. radjiman wediodiningrat mental hospital lawang. the sampling technique in this study is nonprobability with total sampling technique. the sample consists of affordable population taken by inclusion and exclusion criteria were 20 respondents then divided into treatment group and control group. independent variables in this study are modeling participants. the dependent variable is self-care ability. data was analyzed by wilcoxon signed rank test to compare client's self-care ability in a schizophrenic client with self-care deficits before and after modeling participants, modelling participants towards self care deficit (ah yusuf et.al) 43 significance level established p <0.05. mannwhitney is used to determine differences in self-care ability of schizophrenic client with self-care deficit in treatment group and control group with significance level established p <0.05. results self care ability before modeling participant treatment 10% 70% 20%20% 70% 10% 0% 20% 40% 60% 80% good moderate low treatment control figure 1 self care ability before modeling participants treatment. figure 1 shows self-care ability of schizophrenic client with self-care deficit before modeling participants intervention, both in control group and treatment group was 70% in enough category. although they can take care of themselves, respondents still need help in caring for their activities. majority bathing ability of respondents need help such as prepare necessary equipment (towels, soap, adequacy of water), watering all the body, rub whole body with soap thoroughly, showering water and rinse entire body until clean, and dry off with a towel. some respondents independently have the ability to enter and out from the bathroom. this is because some equipment for bathing include towels are often lost or discarded by respondents or taken by other clients who are less cooperative. respondents are just soaking and scrubbing front part of the body only, while the back and legs are not wetted and rubbed with soap. some respondents did not bathe with soap and did not wear a towel after have bathed. respondent’s self-care ability in dressing, need assistance while preparing necessary dressing equipment, gain or change clothes, choose appropriate clothes, cleaning whiskers, and retains appearance at a satisfactory level. respondents tend to be assisted in dressing and rarely given an opportunity to do it independently. in eating ability of respondents require assistance in preparing equipment and food. the ability of respondent‘s bowels/urinate need help to go to the toilet, wipe after a bowel/urinate with clean water, and flush toilets cleanly and not smell. many respondents are urinated no in the bathroom, not wipe and flush the toilet after a bowel /urinate. respondents argued lazy to do so. self-care ability after modeling participant treatment 100% 0% 0% 60% 30% 10% 0% 50% 100% 150% good moderate low treatment control figure 2 self-care ability of respondents after modeling participant treatment figure 2 shows that self-care ability of control group after given the treatment was 60% in good level. whereas treatment group was 100%. modeling participant effect in self-care ability. based on table 1 the results of wilcoxon signed rank test showed an increased selfcare ability in treatment group before and after modeling participant with p = 0.005 means p <α, then h1 accepted which means modeling participant effect was significant to self-care ability. the different result obtained in control group amount p = 0.206 means p> α> 0.05, then h1 rejected which means modeling participants effect was not significant to selfcare ability in the control group. mann-whitney test results showed p = 0.030 means p <α <0.05, thus self-care ability level after treatment shown significant differences between control and treatment group so it can conclude that modeling participant influence self-care ability in the schizophrenic client. jurnal ners vol. 12 no. 1 april 2017: 41-48 44 table 1 self-care ability level before and after given modeling participant treatment in control and treatment group at dr. radjiman wediodiningrat mental hospital lawang no criteria treatment treatment before before before after σ % σ % σ % σ % 1 good 1 10 10 100 2 20 6 20 2 moderate 7 70 0 0 7 70 3 70 3 low 2 20 0 0 1 10 1 10 total 10 100 10 100 10 100 10 100 statistics p = 0.005 wilcoxon signed rank test p = 0.206 wilcoxon signed rank test p = 0.030 mann-whitney test discussion schizophrenia is a disease affecting brain causes strange and disturbing of perceptions, thoughts, emotions, movement, and behavior (videbeck 2008). symptoms of schizophrenia include delusions, hallucinations, affective flattening or blunt, poor speech or meaning, blocking, self-care deficit, lack of motivation and social withdrawal (sadock & sadock 2010). clients can be very preoccupation with delusions or hallucinations and failed to carry out basic activities in daily life (videbeck, 2008). schizophrenic disturbance such as behavior disorders, perceptual, cognitive disability will cause client can not take care of himself adequately. it can be seen from negative and positive symptoms. clients did not care about individual, events, and activities. the client was not happy in joining life and activity, including self-care activities. clients also experience loss of motivation and did not have the willing. inability to take care of himself will emergence of self-care deficit problem. respondents with self-care in enough and less level were 41% aged 36-45 years. according to mariner level of self-care ability of person affected by age, stage of development, life experiences, socio-cultural background, health, and available resources (andayani 2012). states age is related to experience in dealing various kinds of stressors, the ability to use support resources and skills in coping mechanisms (stuart & laraia 2005; perendrawati 2008). stressor encountered in adulthood age is more complex than other age ranges, but adulthood is better selecting their basic needs and make a decision or take action which can improve their condition. the education level of all respondents with less self-care ability are elementary school level. factors affecting hygiene is knowledge. personal hygiene knowledge is very important because a good knowledge can improve health level (potter 2006; kozier 2010). clients also need motivation to maintain self-care. person with higher education will get more knowledge about self-care so the motivation to care for themselves higher. stuart & laraia (2005), stating that education becomes a benchmark of client's ability to interact effectively. education affects client's ability to make decisions, utilize surrounding information, receive feedback and skills, and motivation to solve problem itself. respondents with enough and less selfcare ability in this study 82% were not working. townsend (2005) in parendrawati (2008) suggest that low socioeconomic is one of the social factors lead to high rates of mental disorders including schizophrenia. work problems related to poverty, inadequate facilities, inadequate need of food, and housing, low health care quality of family members will trigger to limited coping on stressful situations. respondents were not working have economic problems or low economic status. economic problem was leading risk of developing schizophrenia. economic conditions also affect to the fulfillment of daily needs, including needs their care. all respondents with less self-care ability level were unmarried status. dantas et. al. (2011) suggest that the incidence of schizophrenia is most occurs in not married status. the family role is very important to help and to support of client’s self-care, so clients with not married status possible get the support from family to resolve their health problems. most respondent amounts 76% with enough, and less self-care ability level were 1-2 modelling participants towards self care deficit (ah yusuf et.al) 45 times treated. research of andayani (2012) concluded that there is a significant correlation between frequency of respondents treated and self-care ability. stuart and laraia (2005) states that timing and duration of schizophrenic client exposure by stressor impact in the independence of self-care. a new schizophrenic client while first time exposing stressor require intensive efforts as primary prevention. respondents with 1-2 times treated require intensive effort involving backup sources which owned by individuals, preventing self-care deficit becomes more difficult to overcome. respondents with enough and less selfcare ability level as many 82% are schizophrenia hebephrenic clients. schizophrenia hebephrenic characteristic is irresponsible and unpredictability behavior, mannerism, tendency to be alone, hollow and empty feeling. affective, encouragement impulse, and thought processes disorders prominent (amin 2009). these symptoms will influence to client’s self-care ability. as many as 66% of respondents with less self-care ability receive combination therapy of typical and atypical antipsychotics. typical antipsychotic overcomes positive signs of schizophrenia such as delusions, hallucinations, thought disorder, and other psychotic symptoms, but does not have a visible effect on negative signs. atypical antipsychotics can reduce psychotic symptoms and useful to reduce negative symptoms such as not having the wish and motivation, social withdrawal and anhedonia (videbeck, 2008). schizophrenia handling is not only by psychopharmacy but also by nursing care. the goal of nursing care in self-care deficit client is improving client’s knowledge and self-care ability. the majority of client’s self-care ability before given modeling participant treatment are enough level and adequate enough to take care of them, but should be helped and motivated by the nurse. this is due to client’s condition who are still experiencing positive and negative symptoms of schizophrenia such as hallucinations, fragmented thoughts or ideas, careless feeling of people, activities, events, tendency to be very little speaking or poor meaning, unenjoyment living, activities, or relationships, loss of motivation to act or perform the tasks, lack of desire, ambition or motivation, dull or limited circumstances emotional feeling, social withdrawal. all respondents of treatment group after modeling participant treatment has increased to be a good level of self-care ability. the age range respondents of treatment group are 18-55 years or adulthood. according to siagian (1995) in parendrawati (2008), the older person related to technical maturity, psychological maturity which shows the soul maturity, it means more wisdom, able to think rationally, control emotions and considerate of others. respondent age affects to decision-making ability and take action for self-care improvement. as many as 90% of respondents in the treatment group with good self-care ability ever get one time of care frequency. stuart and laraia (2005) states that timing and duration of stressor exposure influence the achievement of self-care independent in schizophrenic clients. a new schizophrenic client when first time exposed stressor requires intensive efforts as primary prevention. modeling participant is one of intensive efforts to prevent self-care deficit problems from becoming more complex. the treatment group was trained intensively to take care for themselves as bathing, dressing, eating, and bowel/urinate and trained to practice these capabilities. self-care ability of control group in enough and less level have 2-3 times treated frequency and unmarried status. this indicates the client tendency to relapse due to lack of family support. unmarried respondents lived with their parents, but the case is the parents too old, so an intensive effort to overcome self-care deficit problems at home are less than optimal. as many as 70% of respondents in the treatment group with good self-care ability have elementary school education level. ajzen and fishbein (1980) in parendrawati (2008) suggests the ‘theory of reasoned’ which cognitive process is people basis to decide or take appropriate behavior, systematically using nearby available information. the nurse duties as an educator are providing self-care knowledge on the schizophrenic client. in this study, respondents were taught how to take care of themselves well so that respondent can improve their self-care ability. self-care ability in treatment group increases significantly at 20% respondents, which previously in less ability level to be good ability level. type of drugs taken by respondents is typical and atypical combination therapy. typical antipsychotic overcomes positive signs of schizophrenia such as jurnal ners vol. 12 no. 1 april 2017: 41-48 46 delusions, hallucinations, thought disorder, and other psychotic symptoms, but does not have a visible effect on negative signs. atypical antipsychotics can reduce psychotic and negative symptoms such as low motivation, social withdrawal, and anhedonia (littrell & littrell, 1998, in videbeck, 2008). the main goal of combination therapy is improving the effectiveness of antipsychosis and treatment outcome in resistant patients, strengthen antipsychosis potential effect, reducing the risk of side effects in certain combinations (revenger 2010). giving antipsychotics may reduce negative symptoms and positive symptoms, moreover support a better understanding of modeling participants. in the control group are found 10% respondents who experience decreased self-care ability. these respondents get typical antipsychotic. typical antipsychotic overcomes positive signs of schizophrenia such as delusions, hallucinations, thought disorder, and other psychotic symptoms, but does not have a visible effect on the negative signs (littrell & littrell, 1998, in videbeck, 2008). atypical antipsychotics are better in improving the performance of client function than typical antipsychotics because it affects larger negative symptom improvement (revenger, 2010). antipsychotic treatment affects schizophrenia symptoms, so it will influence respondents to understand the modeling participants. in general, self-care ability of the treatment group and the control group had increased. it because both treatment group and control group respondents get nursing care and psychopharmacy therapy. increasing self-care ability in the control group was not significant compared treatment group. modeling participants in the treatment group were given two times in meeting for each topic as bathing, dressing, eating, and bowel/urinate. every topic is given in a single day. models in this study is schizophrenic clients with independent self-care ability and one same room with respondent. researchers also conducted demonstrations to restrengthening of topics were taught. the main focus of nursing care in self-care deficit client consists of two things: increase client’s selfcare knowledge and ability, and assist clients on their limitations and give caring which client can’t do (wilkinson & ahern 2013). purwanto (1999) in parendrawati (2008) characteristic of learning is the change in people who learn, changes appears from not capable to be able. modeling participants is a technique used in the treatment group to improve knowledge and ability. researchers the model who have similarity characteristics with respondents so can motivate treatment groups to perform selfcare independently, and changes in self-care ability became significantly. modeling participant implementation purpose improving cognitive, self-confident, and motivation through implementing basic components of modeling participant such rational, modeling, guided participation and successful experience/reinforcement. modeling participants as techniques used to form a new behavior, improve skills and minimize avoidable behavior. in this study, new behaviors and skills which improved is the selfcare ability (iswanti 2012). modeling participants also help clients performing a new behavior which obtains through appropriate way and time (junaedi & nursalim 2011). researchers are applying modeling participants to change the maladaptive behavior of respondents to be more adaptive. modeling participants consist of four topics; bathing, dressing, eating, toileting. one topic is given in one day, and every topic is repeated twice. in practice, researchers explain the benefits of proper self-care (bathing, dressing, eating, and toileting) also related tools which needed. it makes respondents get a better understand about the importance of self-care. furthermore, independent schizophrenia model demonstrates self-care ability and respondent are giving attention. researchers also demonstrate self-care ability again as reinforcement. the model who has to resemble character with respondent increase respondent motivation. these explanation and demonstration improve respondent-cognitive ability as knowing benefits and proper self-care manner. respondent is practicing self-care ability such as bathing, dressing, eating, bowel/urinate guided by researchers. researchers also give positive feedback when respondents successfully practice self-care ability properly. some respondents get difficulties when practicing self-care ability, but researchers continue to guide and motivate them by the state that model which respondent friends can do. it increases respondents self-confidence and motivation to try again. modelling participants towards self care deficit (ah yusuf et.al) 47 increased self-care ability in treatment groups after given modeling participant was appropriated with iswanti study (2012), which indicates differences adherence medication in the treatment group who received behavior therapy as modeling participants, whereas no differences in the control group. research of ningsih & sutjiono (2011) concluded modeling participant strategy increase student opinion ability in class. bandura (1969) in corey (2009), states that learning can be obtained through direct experience, also can be obtained indirectly by observing other person behavior and consequences. there are two types of learning through observation, first learning through observation can be occurred by other people circumstances/conditions. second; learning through imitate observation by model behavior (boeis 2007; winarto 2011). respondents are schizophrenic clients with cognitive and perceptions disorder, so it will be easier for respondents to learn by watching and imitating. in modeling participants, respondents learn to observe model behavior who schizophrenic client with independent self-care performance. the most efficient model was using the therapist as a model, but bigger advantage gained when use model who similar with the client (ningsih & sutjiono 2011; junaedi & nursalim 2011). the using of collaborative models by researchers and schizophrenic client give greater advantage such motivation and confidence, respondents prefer imitate their friends whose schizophrenic in the same room. in this research, there were two models who have gone home before the research end. these improve respondent motivation indirectly, motivation to improve their self-care ability because if they have independence as a model then will go home quickly. implementation of modeling participants affects self-care ability through the learning process. gibson stated that ability is something learned, allows a person to do something as well, both in intellectually and physically (syarifuddin 2012). respondents were taught self-care as well. thus self-care ability both physically and cognitively were increased. modeling participants are one form of modeling which the key element in modeling process (winarto 2011). while according to bastable (2002) modeling participants is attention, recall (retention), reproduction of motion (reproduction), and motivation. attention means before imitating the model, respondent should pay attention or observe model behavior to learn. recall (retention) is the ability to retain information is essential for the learning process. clients must record this event in their memory. reproduction of motion (reproduction) means after client knows and learn a behavior, clients can show their ability or produce which stored in the form of behavior. mental exercise, direct application, and corrective feedback reinforce this behavior imitation. motivation; motivation is important as client’s driving to continue doing something. vicarious reinforcement and punishment influence this process. learning process in modeling participants improves self-care ability in the treatment group. conclusion there are significant differences of respondent self-care ability in treatment group before and after given modeling participants. modeling participants can be used as supporting therapy to improve self-care ability in a schizophrenic client with self-care deficit problem. references amin, m., 2009. peran daerah tempat tinggal terhadap kejadian penyakit skizofrenia pada penderita gangguan jiwa yang dirawat inap di rumah sakit dr ernaldi bahar provinsi sumatera selatan tahun 2007. universitas indonesia. available at: http://lib.ui.ac.id/opac/ui/. andayani, s., 2012. hubungan karakteristik klien skizofrenia dengan tingkat kemampuan perawatan diri di ruang rawat inap psikiatri wanita rumah sakit marzoeki mahdi bogor. universitas indonesia. available at: http://lib.ui.ac.id/opac/ui/detail.jsp?id=203 11742&lokasi=lokal. badan penelitian dan pengembangan kesehatan kementrian kesehatan ri, 2013. riset kesehatan dasar, available at: www.litbang.depkes.go.id. bastable, s.b., 2002. perawat sebagai pendidik: prinsip-prinsip pengajaran dan pembelajaran, jakarta: egc. boeis, k.k. et. al., 2007. praktik keperawatan profesional: konsep & perspektif, jakarta: egc. corey, g., 2009. teori dan praktek konseling jurnal ners vol. 12 no. 1 april 2017: 41-48 48 dan psikologi, bandung: pt refika aditama. dantas et. al., 2011. insight controlled for cognition in deficit and nondeficit schizophrenia. schizophrenia reseach, 128, pp.124–126. available at: http://www.elsevier.com/locate/schres. direja, a.h.s., 2011. buku ajar asuhan keperawatan jiwa, yogyakarta: nuha medika. iswanti, d.i., 2012. pengaruh terapi perilaku modeling partisipan terhadap kepatuhan minum obat pada klien penatalaksanaan regimen terapeutik tidak efektif di rsjd dr. amino gondohutama semarang. universitas indonesia. available at: http://lib.ui.ac.id/opac/ui/detail.jsp?id=203 00661&lokasi=lokal. junaedi, h. & nursalim, m., 2011. penerapan strategi modeling partisipan untuk meningkatkan keterampilan komunikasi antar pribadi siswa. psikologi pendidikan dan bimbingan, 12(1). available at: http://ejournal.unesa.ac.id/index.php/ jurnal_ppb/article/view/5424/baca-artikel. kemenkes, 2014. naskah undang-undang kesehatan jiwa disetujui, available at: http://www.depkes.go.id/article/view/201 407200002/naskah-undang-undangkesehatan-jiwa-disetujui.html. kozier, b., 2010. buku ajar fundamental keperawatan konsep proses dan praktik, jakarta: egc. nasir, a. & muhith, a., 2011. dasar-dasar keperawatan jiwa: pengantar dan teori, jakarta: salemba medika. ningsih, p. & sutjiono, 2011. penerapan strategi modeling partisipan untuk meningkatkan kemampuan mengungkapkan pendapat. psikologi pendidikan dan bimbingan, 12. available at: http://ejournal.unesa.ac.id/index.php/jurna l_ppb/article/view/5436/baca-artikel. ormrod, j.e., 2009. psikologi pendidikan membantu siswa tumbuh dan berkembang jilid 2, jakarta: penerbit erlangga. perendrawati, d.p., 2008. pengaruh terapi token ekonomi pada klien defisit perawatan diri di rumah sakit dr marzuki mahdi bogor. universitas indonesia. available at: http://lib.ui.ac.id/opac/ui/detail.jsp?id=126 565 &lokasi=lokal. potter, p.a., 2006. buku ajar fundamental keperawatan: konsep, proses, dan praktik, jakarta: egc. revenger, m.j., 2010. perbandingan performa fungsi pasien skizofrenia yang mendapat terapi tunggal dengan terapi kombinasi antipsikotika di rumah sakit cipto mangunkusumo (periode desember 2011 mei 2012). universitas airlangga. available at: http://lib.ui.ac.id/opac/ui/. rochmawati, d., keliat, b. & wardani, i., 2013. manajemen kasus spesialis jiwa defisit perawatan diri pada klien gangguan jiwa di rw 02 dan rw 12 kelurahan baranangsiang kecamatan bogor timur. jurnal keperawatan jiwa, 1(2), pp.107–120. available at: portalgaruda.org/?ref=browse&mod=view issue&journal=5090 vol 1, no 2 (2013): jurnal keperawatan jiwa. sadock, b. & sadock, v., 2010. kaplan & sadock buku ajar psikiatri klinis, jakarta: egc. stuart, g. & laraia, 2005. principles and practice of psyhiatric nursing, st louis: mosby year b. surtiningsrum, a., 2011. pengaruh terapi suportif terhadap kemampuan bersosialisasi klien isolasi sosial di rumah sakit jiwa daerah dr. amino gondohutomo semarang. universitas indonesia. syarifuddin, 2012. pendidikan dan pemberdayaan masyarakat, medan: perdana publishing. videbeck, s., 2008. buku ajar keperawatan jiwa, jakarta: egc. wilkinson, j. & ahern, n., 2013. buku saku diagnosis keperawatan: diagnosis nanda intervensi nic kriteria hasil noc, jakarta: egc. winarto, j., 2011. teori belajar sosial albert bandura. available at: http://edukasi.kompasiana.com/ 2011/03/12/teori-belajar-sosial-albertbandura-346947.html. world health organization, 2014. schizophrenia. available at: http://www.who.int/mental_health/manag ement/ schizophrenia /en/#. vol 8 no 2 oktober 2013.indd 301 peningkatan mutu pada pasien jamkesmas di puskesmas indonesia (model of an increasing quality of nursing service (satisfaction) for poor patient in public health center indonesia nursalam*, pratiwi*, laily hidayati* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya 60115 email: nursalam@fkp.ua.ac.id abstrak pendahuluan: mutu pelayanan keperawatan di puskesmas merupakan salah satu bentuk jasa pelayanan yang harus diperhatikan dan disesuaikan dengan persepsi pelanggan. tujuan dari penelitian ini adalah untuk menjelaskan hubungan antara rekomendasi dari orang lain, kebutuhan customer, dan pengalaman masa lalu terhadap mutu pelayanan keperawatan berdasarkan perspektif pelanggan dengan penjelasan theory of service qualiti (servqual). metode: jenis penelitian ini adalah deskriptif dengan desain survei. populasi penelitian adalah seluruh pelanggan puskesmas perawatan ngletih kota kediri dengan jumlah sampel sebanyak 46 responden yang ditentukan secara simple random sampling. data dikumpulkan dengan menggunakan kuesioner modifi kasi dari theory of service quality parasuraman dan dianalisis menggunakan uji regresi logistik biner dengan tingkat signifi kansi p < 0,05. hasil: hasil penelitian menunjukkan bahwa rekomendasi dari orang lain (p = 0,011), kebutuhan customer (p = 0,033), dan pengalaman masa lalu (p = 0,009) berhubungan terhadap mutu pelayanan keperawatan. variabel pengalaman masa lalu memiliki peluang paling besar untuk membentuk persepsi pelanggan terhadap mutu pelayanan keperawatan yang baik. ketiga variabel tersebut memiliki peluang sebesar 78,26% untuk membentuk persepsi pelanggan terhadap mutu pelayanan yang baik secara bersama-sama. diskusi: pelanggan mendapat rekomendasi dari orang lain, dapat terpenuhi kebutuhannya, dan memiliki pengalaman yang baik karena pelayanan keperawatan yang bermutu di puskesmas. sebaliknya, apabila pelanggan mendapat pengalaman buruk dan kebutuhannya tidak terpenuhi, mereka tidak akan merekomendasikan kepada orang lain untuk menggunakan jasa pelayanan keperawatan di puskesmas dan persepsi pelanggan terhadap mutu pelayanan keperawatan yang baik tidak akan terbentuk. kata kunci: mutu pelayanan keperawatan, pasien miskin, puskesmas abstract introduction: nursing care quality in a health center was one form of services that had to be considered and adjusted based on customer perception. the purpose of this study was to analyse the model of quality nursing service based on the customer perspective using the theory of service quality (servqual) for poor patient in public health center in indonesia. method: the study was a descriptive survey design. the respondents were all patients at puskesmas ngletihkediri. there were 46 respondents who had been chosen by simple random sampling. research variables were the recommendation of others, customer needs, past experiences and the quality of nursing care. data were collected using a questionnaire that was modif ied from the theory of service quality by parasuraman and analyzed using binary logistic regression test with a signifi cance level of p < 0.05. results: the results showed that the recommendation from others (p = 0.011), customer requirements (p = 0.033), and past experiences (p = 0.009) were related to the quality of nursing care. past experience variables had the greatest chance to determine the quality of nursing care at puskesmas ngletih to be good. three variables had a chance of 78.26% to form a customer’s perception of good service quality all at once. discussion: it can be concluded that the customers get the recommendation of others, can fulfi ll their needs, and have good experiences because of a good nursing care quality in the health center. on the other hand, if the customers get bad experiences and their needs are not met, they will not recommend to others to use the services of nursing services at the health center and customers’ perception about the good quality of nursing care will not be formed. keywords: quality nursing service, poor patient, public health center pendahuluan sebagai ujung tombak pelayanan dan pembangunan kesehatan di indonesia maka puskesmas perlu mendapatkan perhatian terutama berkaitan dengan mutu pelayanan kesehatan puskesmas. (retnowati, 2008). dalam sistem rujukan yang ideal, pasien mengunjungi layanan kesehatan tingkat pertama, yang dimulai dari puskesmas dan jaringannya atau layanan kesehatan tingkat 302 jurnal ners vol. 8 no. 2 oktober 2013: 301–308 pertama lainnya terlebih dahulu sebelum menuju ke layanan kesehatan di tingkat kedua ataupun tingkat ketiga, yang terdiri dari rumah sakit kelas d sampai kelas a. dengan demikian sejak awal pasien dengan kasus ringan sudah dapat disaring pada layanan kesehatan tingkat dasar dan yang tidak dapat ditangani di tingkat dasar di rujuk ke layanan kesehatan tingkat selanjutnya secara berjenjang. kondisi ini akan membentuk suatu piramida berjenjang yang mengerucut pada tingkat tertinggi pada rumah sakit kelas a (dinkes jatim, 2013). oleh karena itu mutu dari puskesmas harus lebih diperhatikan guna memenuhi harapan pelanggan. pasien akan mengeluh bila pelayanan keperawatan yang diberikan, dirasa tidak memberikan nilai kepuasan bagi dirinya (ppni, 2006). m u t u p e l a y a n a n k e p e r a w a t a n merupakan faktor yang paling penting untuk membentuk kepercayaan pelanggan atau pasien kepada layanan kesehatan sehingga tercipta loyalitas mereka. pentingnya peningkatan mutu pelayanan puskesmas adalah untuk membangun persahabatan yang mendorong hubungan dengan pasien sehingga puskesmas tidak ditinggalkan oleh pasiennya (azwar, 2008). persepsi positif yang terbentuk pada pelanggan terhadap mutu pelayanan akan menumbuhkan kepercayaan dan keputusan untuk mempergunakan layanan kesehatan tersebut (chang, 2013). pengukuran dan manajemen mut u merupakan hal yang paling penting dalam industri pelayanan, termasuk di dalamnya pelayanan kesehatan. terdapat berbagai unsur dalam mutu yang sangat kompleks dan saling mempengaruhi satu sama lain, sehingga memiliki tingkat kesulitan tersendiri untuk mengetahui dan mengevaluasinya (piligrimiene, 2008). parasuraman (2001) menyatakan bahwa konsep kualitas layanan adalah suatu penger tian yang kompleks tentang mut u, tentang memuaskan atau tidak memuaskan. konsep kualitas layanan dikatakan bermutu apabila pelayanan yang diharapkan lebih kecil daripada pelayanan yang dirasakan (bermutu). dikatakan konsep kualitas layanan memenuhi harapan, apabila pelayanan yang diharapkan sama dengan yang dirasakan (memuaskan). demikian pula dikatakan persepsi tidak memenuhi harapan apabila pelayanan yang diharapkan lebih besar daripada pelayanan yang dirasakan (tidak bermutu). l ebi h jela snya r a ng k ut i (20 03) menyatakan bahwa kesenjangan terjadi apabila pelanggan mempersepsikan pelayanan yang diterimanya lebih tinggi daripada desired service atau lebih rendah daripada adequate service kepentingan pelanggan tersebut. dengan demikian, pelanggan dapat merasakan sangat puas atau sebaliknya sangat kecewa. hasil pengumpulan data awal pada tanggal 14 maret 2013 di unit rawat jalan puskesmas “x” jumlah kunjungan yang cenderung mengalami penurunan kurang lebih sebesar 10% pada unit rawat jalan puskesmas perawatan ngletih kota kediri. pada tahun 2011 terjadi penurunan yang cukup signifi kan, jumlah pengunjung sebanyak 43.515 turun menjadi 42.179 di tahun 2011, diikuti sedikit peningkatan di tahun 2012 namun belum juga dapat mencapai atau melampaui banyaknya pengunjung di tahun 2010 sebelum nya. pada tahun 2013 sendiri terjadi penurunan kunjungan dari bulan januari hingga bulan maret. masyarakat telah memiliki respons yang kurang baik terhadap layanan yang tersedia. hal ini bisa disebabkan oleh mutu pelayanan yang diterima seperti bukti fi sik atau fasilitas fi sik yang kurang memadai dan kurang lengkap, kehandalan perawat dalam menangani pasien, ketanggapan perawat dan petugas layanan, jaminan dan kepastian akan solusi atas permasalahan kesehatan yang dihadapi, bahkan bentuk perhatian atau empati yang tulus dari perawat. jumlah kunjungan yang cender ung menurun tersebut dapat mengindikasikan kurang tercapainya mutu pelayanan yang di harapkan pelanggan dengan layanan yang diberikan oleh puskesmas. sehingga pelanggan atau masyarakat beralih pada pelayanan kesehatan yang lebih baik guna memenuhi harapan dan mencapai kepuasan. pemanfaatan puskesmas memang tidak bisa lepas dari faktor kebutuhan personal dari pelanggan. sehingga baik atau tidaknya mutu pelayanan yang didapatkan tidak menjadi prioritas utama. 303 peningkatan mutu pada pasien jamkesmas di puskesmas indonesia (nursalam, dkk.) kajian lebih lanjut mengenai mutu pelayanan berdasarkan perspektif pelanggan perlu dilakukan sehingga penyedia layanan bisa memiliki pemahaman yang sama dan dapat memenuhi per mintaan pelanggan tersebut. langkah pertama untuk mengatasi kesenjangan antara persepsi pasien dan persepsi penyedia jasa pelayanan kesehatan atau puskesmas adalah mengidentif ikasi atau mengenal kebutuhan pasien dan faktor faktor apa saja yang berpengaruh terhadap mutu pelayanan yang diterimanya. dengan mengenal hal tersebut maka akan memberikan suatu pemahaman yang lebih baik mengenai mutu pelayanan yang telah diterima oleh pasien sehingga puskesmas akhirnya dapat memahami bagaimana gambaran harapan pasien terhad ap pelaya na n ya ng tela h diberikan. perspektif mutu layanan kesehatan menurut l.d brown seperti dikutip oleh imbalo s. pohan (2006), pasien/masyarakat melihat layanan kesehatan yang bermutu sebagai layanan kesehat an yang dapat memenuhi kebutuhan yang dirasakannya dan diselenggarakan dengan cara yang sopan dan santun, tepat waktu, tanggap dan mampu menyembuhkan keluhannya serta mencegah berkembangnya atau meluasnya penyakit. perspek t if pember i laya na n kesehat a n (provider) mengaitkan layanan kesehatan yang bermutu dengan ketersediaan alat, prosedur kerja atau protokol, kebebasan profesi dalam setiap melakukan layanan kesehatan sesuai dengan teknologi kesehatan mutakhir, dan bagaimana keluaran (outcome) atau hasil layanan kesehatan itu. tujuan dar i penelitian ini adalah untuk menjelaskan hubungan rekomendasi d a r i or a ng lai n, kebut u ha n customer, dan pengalaman masa lalu terhadap mutu pelayanan keperawatan berdasarkan perspektif pelanggan sehingga dapat digunakan sebagai bahan masukan dalam pengembangan ilmu manajemen keperawatan yang berhubungan dengan service quality berdasarkan pendekatan konsep teori parasuraman, zeithaml dan berry pada pelayanan rawat jalan puskesmas oleh pasien jamkesmas. bahan dan metode jenis penelitian ini adalah deskriptif dengan desain survei, di mana dalam penelitian survei deskriptif penelitian diarahkan untuk mendeskripsikan atau menguraikan suatu keadaan di dalam suatu komunitas atau masyarakat tanpa melakukan inter vensi terhadap subjek penelitian (notoatmodjo, 2010). sampel pada penelitian ini adalah pelanggan unit rawat jalan puskesmas “x” pada periode tanggal 21–26 mei 2013. sampel diambil sesuai dengan kriteria inklusi yang telah ditentukan yaitu pelanggan yang minimal pendidikan sd, dewasa berumur diatas 20 tahun, dapat membaca dan menulis, bertempat tinggal di wilayah kerja puskesmas ngletih kota kediri dan merupakan pasien lama puskesmas dan telah melakukan kunjungan sebanyak tiga kali atau lebih baik kunjungan periksa maupun untuk mengurus prosedur administrasi seperti pendaftaran jamkesmas, akses, dan lain-lain. teknik sampling dalam penelitian ini adalah probability sampling tipe simple random sampling. penelitian dilakukan selama tanggal 21–26 mei 2013. variabel penelitian adalah rekomendasi dari orang lain, kebutuhan customer, pengalaman masa lalu dan mutu pelayanan keperawatan. data dikumpulkan dengan menggunakan kuesioner modifi kasi dari theory of service quality parasuraman dan dianalisis menggunakan uji regresi logistik biner dengan tingkat signifi kansi p < 0,05. hasil pada bagian ini akan disajikan hasil penelitian yang menunjukkan rekomendasi terhadap pelanggan puskesmas “x”, kebutuhan customer, pengalaman masa lalu pelanggan dan mutu pelayanan keperawatan berdasarkan perspektif pelanggan. dapat dilihat pada tabel 1 di atas, bahwa dari total responden sebanyak 46 orang (100%), 19 orang diantaranya atau sejumlah 41% menyatakan tidak pernah mendapat rekomendasi dari orang lain, baik itu tetangga, saudara maupun media massa. sedangkan 27 orang sisanya atau sejumlah 59% menyatakan pernah mendapatkan rekomendasi dari orang 304 jurnal ners vol. 8 no. 2 oktober 2013: 301–308 lain untuk berobat atau menggunakan jasa pelayanan di puskesmas. karak ter istik kebutuhan customer, sebagian besar pelanggan membutuhkan pelayanan terkait dengan aspek kemudahan akses saat menggunakan jasa pelayanan keperawatan di puskesmas “x”, yaitu sebanyak 33 responden dengan persentase sebesar 33%. aspek selanjutnya yang menjadi kebut uhan pelanggan ialah keterbukaan prosedur tindakan keperawatan yang diberikan dan pelayanan yang dapat diandalkan dan dipercaya, kedua aspek tersebut memiliki persentase yang hampir sama besarnya yaitu lebih dari 60%. sedangkan perawat yang selalu siap membantu tidak menjadi prioritas kebutuhan pelanggan saat memanfaatkan pelayanan di unit rawat jalan puskesmas “x” dan sekaligus menjadi persentase terbesar yang tidak dibutuhkan pelanggan yaitu sebesar 43%. va r iab el p e nga la m a n m a s a la lu menunjukkan persentase terbesar yaitu 54% pelanggan merasakan pengalaman yang buruk pada aspek perawat di puskesmas dapat memberikan solusi atas masalah dan kebutuhan pelanggan. pengalaman yang sama juga dirasakan oleh 24 pelanggan dengan persentase sebesar 52% pada aspek kenyamanan dan keamanan pelayanan di puskesmas. namun yang merasakan pengalaman baik terkait kenyamanan dan keamanan pelayanan ini pun cukup tinggi, yaitu sebesar 48% atau 22 pelanggan menyatakan sudah merasa nyaman dan aman terhadap pelayanan di unit rawat jalan puskesmas “x”. terdapat lima aspek mutu yang dinilai dalam penelitian, yaitu reliability, assurance, tangible, emphaty, dan responsiveness yang biasa disebut dengan rater. berdasarkan tabel hasil penelitian di atas yang memiliki tabel 1. variabel indikator peningkatan model pelayanan keperawatan pada pasien jamkesmas di puskesmas pada bulan mei 2013 (n = 46) rekomendasi dari orang lain tidak pernah mendapat rekomendasi pernah mendapat rekomendasi total ∑ % ∑ % ∑ % 1. mendapatkan rekomendasi dari orang lain untuk berobat ke puskesmas 19 41% 27 59 46 100 kebutuhan customer tidak membutuhkan membutuhkan total ∑ % ∑ % ∑ % 1. pelayanan yang dapat diandalkan dan dapat dipercaya 18 39% 28 61% 46 100% 2. akses yang mudah 13 28% 33 72% 46 100% 3. perawat yang selalu siap membantu pelanggan 20 43% 26 57% 46 100% 4. keterbukaan prosedur tindakan keperawatan 17 37% 29 63% 46 100% pengalaman masa lalu pengalaman baik pengalaman buruk total ∑ % ∑ % ∑ % 1. pelanggan merasa nyaman dan aman terhadap pelayanan puskesmas 22 48% 24 52% 46 100% 2. perawat di puskesmas bisa memberikan solusi atas masalah dan kebutuhan pelanggan 21 46% 25 54% 46 100% 305 peningkatan mutu pada pasien jamkesmas di puskesmas indonesia (nursalam, dkk.) persent a se terbesa r yait u pa d a aspek responsiveness, di mana 61% pelanggan menyatakan daya tanggap atau responsiveness petugas pelayanan masih buruk. di urutan kedua terdapat aspek tangible atau bukti langsung yang masih dinilai bur uk oleh pelanggan di unit rawat jalan puskesmas x yaitu sebesar 59% atau sebanyak 27 orang responden dari total responden 46 orang. meskipun masih lebih banyak yang menyatakan bahwa aspek assurance masih buruk namun hampir 50% pelanggan juga menilai aspek tersebut sudah baik. begitu pula terhadap aspek reliability atau kehandalan dan emphaty, di mana 21 orang dengan persentase 46% menyatakan kehandalan dan emphaty perawat di unit rawat jalan puskesmas “x” sudah cukup baik. analisis menggunakan uji statistik regresi logistik biner dengan tingkat signifi kasi p < 0.05, menunjukkan nilai signifikansi pada variabel rekomendasi dari orang lain yaitu p = 0.013 yang berarti h1 diterima atau terdapat hubungan antara rekomendasi orang lain dengan mutu pelayanan keperawatan di puskesmas “x”. untuk mengetahui seberapa besar peluang yang diberikan oleh variabel rekomendasi dari orang lain untuk dapat membentuk persepsi pelanggan terhadap mutu pelayanan keperawatan yang baik di puskesmas “x” digunakan model yang sesuai dan peluang yang terbentuk ialah sebesar 59,24%. peluang tersebut dapat diartikan bahwa pelanggan dapat memiliki persepsi mengenai mutu pelayanan yang baik di puskesmas disebabkan oleh adanya rekomendasi dari orang lain untuk menggunakan jasa pelayanan di puskesmas. nilai sig n if i k a n si pa d a va r iabel kebutuhan customer yaitu p = 0,037 yang berarti h1 diterima atau terdapat hubungan antara kebutuhan customer dengan mutu pelayanan keperawatan di puskesmas “x”. besarnya peluang variabel kebutuhan customer membentuk persepsi pelanggan terhadap mutu pelayanan keperawatan yang baik di puskesmas “x” ialah sebesar 58,32%. ni la i sig n i f i k a n si d a r i va r iab el pengalaman masa lalu customer yaitu p = 0,010 yang berarti h1 diterima atau terdapat hubungan antara pengalaman masa lalu customer dengan mutu pelayanan keperawatan di puskesmas “x”. berdasarkan model yang tabel 2 kualitas model pelayanan keperawatan pada pasien jamkesmas di puskesmas pada bulan mei 2013 (n = 46) no. mutu pelayanan keperawatan baik buruk total ∑ % ∑ % ∑ % 1. reliability 21 46% 25 54% 46 100% 2. assurance 22 48% 24 52% 46 100% 3. tangible 19 41% 27 59% 46 100% 4. emphaty 21 46% 25 54% 46 100% 5. responsiveness 18 39% 28 61% 46 100% tabel 3 hasil uji hipotesis rekomendasi dari orang lain, kebutuhan customer, dan pengalaman masa lalu dengan kualitas pelayanan keperawatan pada pasien jamkesmas di puskesmas pada bulan mei 2013 (n = 46) hubungan kualitas pelayanan keperawatan pada pasien jamkesmas p-value β koefi sien regresi (b) peluang (%) rekomendasi dari orang lain 0,013 1,696 -1,322 59,24%. kebutuhan customer 0,037 1.317 -,981 58,32% pengalaman masa lalu 0,010 1,658 -1,099 63,62%. 306 jurnal ners vol. 8 no. 2 oktober 2013: 301–308 terbent uk peluang variabel pengalaman masa lalu customer terhadap mutu pelayanan keperawatan di puskesmas “x” sebesar 63,62%. peluang tersebut dapat diartikan bahwa persepsi pelanggan mengenai mutu pelayanan keperawatan dapat terbentuk oleh pengalaman masa lalu yang dirasakan ketika menggunakan jasa pelayanan di puskesmas. variabel pengalaman masa lalu memiliki peluang paling besar dalam membentuk persepsi tersebut. pembahasan berdasarkan data penelitian yang telah dilakukan oleh peneliti didapatkan hasil bahwa rekomendasi dari orang lain be rhubu nga n de nga n mut u p elaya n a n keperawatan yang diterima di puskesmas “x”. menurut parasuraman (2001) pemilihan untuk mengonsumsi suatu jasa atau pelayanan yang bermutu memang dapat dipengaruhi oleh informasi dari mulut ke mulut yang diperoleh pelanggan sebelumnya. pernyataan parasuraman tersebut diperkuat oleh trarintya (2011), bahwa promosi merupakan salah satu faktor penentu keberhasilan suatu program pemasaran. betapapun berkualitasnya suatu produk ataupun jasa, bila konsumen belum per nah mendengar nya dan tidak yakin bahwa produk tersebut dapat berguna, maka konsumen tidak akan pernah membeli produk tersebut. salah satu alat promosi yang paling ampuh adalah dengan sistem wom (word of mouth). seperti yang dinyatakan oleh davidov (2003), ”that word of mouth is actually a u shaped relationship, where satisf ied complainers spread positive word of mouth valance, and dissatisfi ed complainersspread negative word of mouth valance”. bahwa sebenarnya hubungan dari mulut ke mulut berbentuk u, di mana apabila seseorang puas maka ia akan menyebarkan berita positif dari mulut ke mulut, tapi apabila mengeluh tidak puas maka ia akan menyebarkan berita negatif dari mulut ke mulut. pengalaman yang kurang memuaskan pada customer dapat memunculkan berbagai respons kepada perusahaan. perusahaan dapat menanggapi respons tersebut dengan berbagai cara yang dinamis. peluang meningkatnya aktivitas wom atau rekomendasi tersebut dapat memberikan pengaruh yang hebat. adanya hubungan yang signifi kan juga ditunjukkan oleh variabel kedua, kebutuhan c u sto m e r. s e b a g ia n b e s a r p el a ng g a n membutuhkan pelayanan dengan akses yang mudah dan prosedur perawatan yang terbuka. menurut supriyanto (2010) salah satu harapan customer sebagai orang yang merasakan mutu pelayanan ialah kebutuhan, di mana mereka bisa memilih provider yang bisa memenuhi kebutuhan tersebut, antara lain pemeriksaan yang cepat, mau mendengarkan keluhan dan bersikap ramah serta mau membantu. secara assurance (jaminan) pelayanan harus diberikan sesuai komitmen pemberi pelayanan atau puskesmas, sehingga pelanggan merasa yakin unt uk mengg unakan jasa tersebut. didukung dengan bentuk pelayanan fi sik seperti yang diungkapkan oleh arisutha (2005) yaitu berupa fasilitas, dan perlengkapan di dalam memberikan pelayanan, sesuai dengan kemampuan penguasaan teknologi, hal seperti ini akan diterima oleh pelanggan sebagai aspek tangible (bukti fisik) yang mempengaruhi mutu pelayanan berdasarkan perspektif mereka. martul (2004) menyatakan bahwa kualitas layanan berupa kondisi fi sik merupakan bentuk kualitas layanan nyata yang memberikan adanya apresiasi dan membentuk image positif bagi setiap individu yang dilayaninya dan menjadi suatu penilaian dalam menentukan kemampuan dari pengembang pelayanan. margaretha (2003) pun mengungkapkan ba hwa su at u orga n isa si ke r ja sa ngat memerlukan adanya kepercayaan yang diyakini sesuai dengan kenyataan bahwa organisasi tersebut mampu memberikan kualitas layanan yang dapat dijamin. mampu memberikan kepuasan dalam pelayanan yaitu setiap pegawai akan memberikan pelayanan yang cepat, tepat, mudah, lancar dan berkualitas. setiap perawat mampu menunjukkan komitmen kerja yang tinggi sesuai dengan bentuk-bentuk integritas kerja, etos kerja dan budaya kerja yang sesuai dengan aplikasi dari visi, misi suatu organisasi dalam memberikan pelayanan. 307 peningkatan mutu pada pasien jamkesmas di puskesmas indonesia (nursalam, dkk.) variabel pengalaman masa lalu memiliki peluang yang paling besar dalam membentuk persepsi pelanggan terhadap mutu pelayanan keperawatan yang baik di puskesmas “x”. lovelock (2005) mengemukakan bahwa apabila pelanggan merasakan pelayanan yang baik dan merasa puas akan memberikan banyak manfaat bagi penyedia jasa atau pelayanan. dalam jangka panjang, akan lebih menguntungkan mempertahankan pelanggan yang baik daripada terus menerus menarik dan membina pelanggan baru untuk menggantikan pelanggan yang pergi. pelanggan yang sangat puas terhadap pelayanan yang pernah dialami akan menyebarkan cerita positif dari mulut ke mulut dan malah akan menjadi iklan berjalan dan berbicara bagi suatu perusahaan, hal ini akan menurunkan biaya untuk menarik pelanggan baru. menurut azwar (2008) kepercayaan pelanggan atau pasien sangatlah penting sehingga tercipta loyalitas mereka. dengan begitu hubungan persahabatan antar pasien dan puskesmas dapat tercipta dan puskesmas tidak ditinggalkan oleh pasiennya hanya karena pengalaman buruk yang pernah dialami. va r iab el p e nga la m a n m a s a la lu memiliki peluang yang paling besar untuk membentuk persepsi pelanggan terhadap mutu pelayanan keperawatan yang baik, karena pelangganlah yang bisa merasakan baik buruknya mutu dari apa yang mereka terima selama proses pelayanan. apakah sudah sesuai dengan harapan mereka, atau justru jauh dari harapan mereka. usaha untuk menjaga pengalaman baik tersebut, penyedia layanan atau puskesmas harus tetap mempertahankan mutu yang dimiliki dan memiliki inovasi untuk mengikuti perkembangan ilmu dan teknologi yang dinamis di tengah-tengah semakin ketaatannya persaingan dalam bidang tersebut. denga n t e r penu h i nya kebut u ha n pelanggan ketika memanfaatkan pelayanan keperawatan di puskesmas, baik dari segi petugas layanan atau perawat yang tanggap, ramah dan berempati, jaminan kenyamanan dan keamanan, fasilitas fi sik dan peralatan pemeriksaan yang dapat dirasakan secara langsu ng, ser t a pet ugas yang memang berkompeten pada bidang keilmuan yang dimiliki, dan semua itu terdapat dalam ke lima aspek mutu yang disebut r ater. pelanggan akan mendapatkan pengalaman baik setelah melakukan kunjungan dan merekomendasikannya kepada orang lain, demikianlah ketiga variabel tersebut bersamasama membentuk mutu pelayanan keperawatan yang baik berdasarkan perspektif pelanggan sebagai pengguna jasa. simpulan dan saran simpulan mo d el p e n i n g k a t a n mu t u p a d a masyarakat miskin di puskesmas indonesia dengan memperbaiki aspek rekomendasi dari orang lain, kebutuhan customer, dan pengalaman masa lalu customer. ketiga indicator terebut memiliki peluang yang besar dalam membentuk persepsi pelanggan terhadap mutu pelayanan keperawatan yang baik. sebagian besar pelanggan puskesmas perawatan ngletih kota kediri mendapatkan rekomendasi untuk menggunakan pelayanan keperawatan di puskesmas, dan membutuhkan pelayanan keperawatan yang baik namun mengalami pengalaman yang buruk ketika menggunakan jasa pelayanan keperawatan di puskesmas. saran berdasarkan per nyataan pelanggan yang didapat melalui kuesioner mengenai aspek mutu, puskesmas diharapkan dapat mempertahankan dan meningkatkan mutu pelayanan keperawatan dari kelima aspek mutu yaitu, responsiveness, assurance, tangible, empathy, dan reliability. puskesmas dapat melakukan survei mutu pelayanan keperawatan berdasarkan perspektif pelanggan sebagai upaya mengetahui mutu yang sebenarnya diharapkan oleh pelanggan setiap satu tahun sekali secara rutin. lima aspek mut u yang dirasakan pelanggan merupakan bentuk nyata pelayanan keperawatan yang diberikan oleh perawat, sehingga dapat menjadi masukan bagi perawat maupu n mahasiswa keperawatan u nt u k 308 jurnal ners vol. 8 no. 2 oktober 2013: 301–308 memperbaiki dan meningkatkan kompetensi keperawatan terkait dengan daya tanggap, empati, jaminan pelayanan dan kehandalan yang dimiliki sehingga dapat memenuhi kebut uhan klien sebagai pelanggan dan menjaga kepercayaan serta loyalitas pelanggan. perlu dilakukan penelitian lebih lanjut tentang hubungan mut u pelayanan keperawatan berdasarkan perspektif penyedia layanan dengan kepuasan pelanggan. kepustakaan a r isut ha , d., 20 05. dimen si kualita s pelayanan. jakarta: penerbit gramedia pustaka. azwar, s., 2008. sikap manusia: teori dan pengukurannya. edisi 2. yogyakarta: . egc. chang, c. chen, s. lan, y., 2013. service quality, trust, and patient satisfaction in interpersonal-based medical service encounters. bmc health ser vices research. davidow, m., 2003. have you heard the word? the effect of word of mouth on perceived justice, kepuasan and repu rchase i ntent ions follow i ng komplain handling. journal of and complaining behavior.vol.16 pg. 67. pohan. i., 2006. jaminan mutu layanan kesehatan: dasar-dasar pengertian dan penerapan. jakarta: penerbit buku kedokteran: egc. lovelock, christopher.h dan wright,lauren. k., 2005. manajemen pemasaran jasa. indeks. margaretha, 2003. kualitas pelayanan: teori dan aplikasi. jakarta: penerbit mandar maju. mar t ul, shadiqqin, 2004. implementasi dimensi kualitas pelayanan konsumen. jakarta: penerbit sinar grafi ka. parasuraman, a., zeithaml, v., berry, l., 1988. servequal: a multiple-item scale for measuring consumer perception of service quality, journal of retailing. parasuraman, a. zeithaml, v., 2001. delivering quality service. new york: the free press. piligrimiene, z., buciuniene, i., 2008. different perspectives on health care quality: is the consensus possible?. journal of engineering economics issn 13922785 no 1 (56). pohan. i., 2006. jaminan mutu layanan kesehatan: dasar-dasar pengertian dan penerapan. jakarta: penerbit buku kedokteran: egc. rangkuti, freddy, 2003. konsep pengukuran ke p ua sa n. ja ka r t a: penerbit pt. gramedia pustaka utama. ret nowat i, 20 08. kualita s pela ya n a n kesehatan di puskesmas bringin kabupaten semarang (analisis tingkat ke p u a sa n m a s ya ra k a t). sk r ip si diterbitkan, universitas diponegoro, semarang. trarintya, m., 2011. pengaruh kualitas pelayanan terhadap kepuasan dan word of mouth (studi kasus pasien rawat jalan di wing amerta rsup sanglah denpasar). tesis diterbitkan, universitas udayana. issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no. 58/dikti/kep/2013 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief ferry efendi, s.kep., ns., m.sc., ph.d editor: prof. dr. ah. yusuf, s.kp., m.kes. dr. esti yunitasari, s.kep., ns., m.kep. assistant professor pei-lun hsieh dr. yulis setiya dewi, s.kep.ns.,m.ng. dr. rizki fitryasari, s. kep., ns., m. kep. dr. ilya krisnana, s.kep., ns., m.kep. retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. technical editor: masunatul ubudiyah, s.kep., ns., m.kep. rifky octavia pradipta, s.kep., ns., m.kep. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 8113287877 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 16 no. 2 october 2021. 1. anna kurniati, s.km, ma, ph.d. bppsdmk, ministry of health, indonesia 2. bayhakki, m.kep, sp.kmb, ph.d. universitas riau, indonesia 3. dianis wulan sari, s. kep., ns., mhs., ph.d. universitas airlangga, indonesia 4. erni astutik s.k.m., m.epid. universitas airlangga, indonesia 5. rista fauziningtyas, s.kep., ns., m.kep. universitas airlangga, indonesia 6. rr dian tristiana, s.kep., ns., m.kep. universitas airlangga, indonesia 7. rosnani rosnani, s. kp., m. kep., sp. mat. poltekkes kemenkes palembang 8. dr. mira triharini, s. kp., m. kep. universitas airlangga, indonesia 9. dr. muhammad miftahussurur, m.kes., sp.pd-kgeh., ph.d. universitas airlangga, indonesia 10. ni ketut armini, s. kp., m. kes. universitas airlangga, indonesia 11. qorinah estiningtyas adnani, ph.d. auckland university of technology, new zealand 12. dr. sirikanok klankhajhon, phd, rn naresuan university, phitsanulok, thailand 13. dr. yuni arief, s. kp., m. kes. universitas airlangga, indonesia 14. dr. yulis dewi, s.kep.ns., m.ng. universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no. 58/dikti/kep/2013 table of content 16. clinical profile and nursing diagnosis of the newborn in a special care nursery (scn) unit defi efendi, yeni rustina, dian sari 101-105 17. parental interactions associated with adolescent health risk behavior: premarital sexual and aggressive behavior ilya krisnana, praba diyan rachmawati, iqlima dwi kurnia, nur sayyid j rummy 106-110 18. the effect of thinking like a nurse simulation as an online clinical learning method on nursing students’ satisfaction and confidence during the covid19 pandemic dian fitria, jehan puspasari, puspita hanggit lestari 111-118 19. perspectives of pregnant women regarding iron deficiency anemia sirikanok klankhajhon, kornkarn pansuwan, kanokon klayjan, nannaphat nensat 119-127 20. the older adults experience caring for grandchildren with special needs sylvia dwi wahyuni, retno indarwati, aditya budi nugroho 128-134 21. nurses’ individual characteristics associated with five moments handwashing compliance maryana maryana, rima berti anggraini 135-141 22. the influence of web-based spiritual problem solving on the prevention of suicidal risk among university students siti khadijah, ah yusuf, hanik endang nihayati, esti yunitasari 142-147 23. teenagers’ safety smartphone use model based on health promotion theory rizki fitryasari, rr dian tristiana, ah yusuf 148-154 24. the relationship between level of knowledge and behaviors of covid-19 prevention among indonesian population weni widya shari 155-161 25. nurses’ role in taking care of gestational diabetes mellitus patients: a qualitative study tri ismu pujiyanto, indah wulaningsih 162-168 26. the effectiveness of a nurse-led team-based hypertension management among people with uncontrolled hypertension in a community hospital, thailand nongnut oba, navarat chutipanyaporn 169-176 27. empowering health cadres on nutrition education for pregnant women in industrial areas during the pandemic lasiyati yuswo yani, raras merbawani, asef wildan munfadlila 177-182 28. effects of aerobic exercise on depression and cd4 counts in people living with hiv untung sujianto, madya sulisno, richal grace zefana uly 183-187 29. challenges of online education among university students, saudi arabia lizy sonia benjamin, b. joshua steve abishek, yulis setiya dewi, priya sivaram, yoyok bekti prasetyo 188-192 30. challenges of online education among university students, saudi arabia m. hasinuddin, rusana rusana, ulva noviana, heni ekawati, nurul aini, sandeep poddar 193-197 editorial combatting pseudoscience amidst the covid-19 pandemic gading ekapuja aurizki faculty of nursing, universitas airlangga email: gading-e-a-10@fkp.unair.ac.id amid the covid-19 pandemic, it is natural for people to want to know about the causing virus, its transmission, prevention, the government’s response and other relevant information through the information channels. in the past, before science developed, people considered the plague as a manifestation of the anger of the gods. along with the times, people began to open up to science. while there are still some superstitious societies, most believe in scientific arguments. unfortunately, high expectations and enthusiasm for science are often not accompanied by a critical attitude and increased interest in reading. there is a tendency for people to cherry-pick the information. cherry-picking can distort knowledge due to bias in the selection of information sources. this can lead people to fall into pseudoscience or “bad science”—to borrow ben goldacre's term. both pseudoscience and bad science are things that sound scientific but are not or have a scientific basis but are interpreted haphazardly. during the covid-19 pandemic, much scientific-sounding information and analysis are milling about. some of the initial examples are the interpretation of the covid-19’s low case fatality rate (cfr), claims of traditional ingredients to prevent covid-19, herd immunity discourse, to the vaccines adverse effects. covid-19 was initially considered harmless with a low cfr, some even equating it with the common cold. however, instead of being similar to the common cold, covid-19 is feared to have an impact like the 1918 flu pandemic, which claimed estimated millions of lives worldwide because of its swift spread (petersen et al., 2020). in addition, when the covid-19 outbreak had not been detected in indonesia, there was a view that indonesians were immune to coronaviruses because of a diet rich in spices. some researchers even took advantage of this moment to promote their findings of ingredients that can ward off the coronavirus by increasing the immune system. however, so far, there has been no publication about the results of testing for these materials, specifically for covid-19 patients, and how significant the effects are when compared to other materials that already exist. so, the claim is only a claim. in the era of information technology, when most people have been out of superstition, worrying is not the clash between science and mystical views but between actual science and bad science or pseudoscience. in his book the death of expertise, tom nichols wrote that one could not become an expert just by reading a lot. without having the correct analytical method, ordinary people will not process information into knowledge. that is why any information circulating must be sourced from experts in the field. this makes the statement about covid-19 spreading in the community very dynamic. therefore, it is essential to keep updated with the latest information from trusted sources, as well as a crosscheck to other sources before concluding. mailto:gading-e-a-10@fkp.unair.ac.id references petersen, e., koopmans, m., go, u., hamer, d.h., petrosillo, n., castelli, f., storgaard, m., al khalili, s. and simonsen, l. 2020. comparing sars-cov-2 with sars-cov and influenza pandemics. the lancet infectious diseases. 20(9), pp.e238–e244. 201 manajemen nyeri non invasive pada ibu post partum dengan pendekatan evidence based practice (non invasive pain management in post partum mother with evidence based practice approach) nikmatur rohmah* *program studi diii keperawatan fakultas ilmu kesehatan universitas muhammadiyah jember, e-mail: r_nikmatur@yahoo.co.id abstract introduction: pain is a sensation of discomfort that most post-partum mothers complain about, in the case of prolonged pain, the risk of post-partum blues is higher. the usage of evidence based practice method gives a bigger opportunity for nurse and medical attendants to think more critically in making decisions and in performing the appropriate treatment in accordance with the patient's problem and uniqueness. this research aimed to applicate management of non-invasive pain on post partum mother through the approach of evidence based practice. method: this was a case-study, performed to client mrs. a p1-1 a0 post sectio caesarea day 1 as there is an indication of suspect cepalo pelvis disproportion secondary arrest. data were collected at maternity room, dr. soebandi regional general hospital. using interview, observation, and physical examination. data analysis was conducted through a descriptive analysis. result: through a careful nursing, it is found out that pain location and spreading that generally spotted at the patient’s back during the contraction in the uterus, occurred around the shoulders when evidence-base practice is applied. the basic principle of applying an intervention to non invasive pain based on evidence –base practice are: cutaneous stimulation and distraction, while massaging area was set on the face, while the distraction media was interaction with the baby. evaluation on evidence –based practice showed that pain is reduced to scale 2, while face and mobilitation become more relaxed. discussion: massage was intended to stimulated the production of endorphine and dinorphine that play an important roke to block the pain transmission through the descendent control system. interaction with the baby was intended to function as a distraction media to dominate the incoming impuls into the ascendant control system,which further may close the gate of the pain transmitter. both of the interventions were axpected to work synergically in reducing pain, since post-partum pain can be relieved more quickly when more than one technique are applied. thus, to reduce post-partum pain, facial massage and interaction with the baby as non –invasive treatments are of important, respectively. keyword: the management of non-invasive pain, post-partum, evidence –based practice pendahuluan n y e r i m e r u p a k a n s e n s a s i ketidaknyamanan yang sering dikeluhkan ibu post partum. nyeri post partum dapat terjadi karena berbagai macam sebab, antara lain: kontraksi uterus selama periode involusi uterus, pembengkakan payudara karena proses laktasi yang belum adekuat, perlukaan jalan lahir, dan perlukaan insisi bedah pada ibu post sectio caesarea (sc). nyeri dapat dirasakan pada berbagai macam tingkatan mulai dari nyeri ringan-sedang sampai nyeri berat. tingkatan nyeri yang dirasakan pasien post partum tergantung dari banyaknya sumber penyebab nyeri, toleransi pasien terhadap nyeri, dan faktor psikologis dan lingkungan (carpenito, 2000; potter dan perry, 2006; bobak, 2005; rohmah. n. & walid, s. 2008). nyeri berdampak sangat komplek bagi perawatan ibu post partum, antara lain: terhambatnya mobilisasi dini, terhambatnya l a k t a s i , t e r h a m b a t n y a p r o s e s b o n d i n g jurnal ners vol. 6 no. 2 oktober 2011: 201–209 202 attachment, perasaan lelah, kecemasan, kecewa karena ketidaknyamanan, gangguan pola tidur, dan bahkan bila nyeri berkepanjangan akan meningkatkan risiko post partum blues. dampak-dampak negatif ini bila tidak diatasi akan mempengaruhi proses pemulihan ibu post partum. nyeri pada ibu post partum terutama dirasakan pada hari pertama dan kedua, dimana fase adaptasi psikologis ibu masuk pada tahap taking in yaitu tahap dependent. tahap ini ibu masih membutuhkan bantuan untuk memenuhi kebutuhan sehari-hari dengan porsi terbesar yang pemenuhan kebutuhan istirahat/tidur dan nutrisi. bila nyeri yang terjadi pada fase ini tidak dapat diatasi maka akan memperpanjang fase taking in dan proses dependent-independent klien manjadi terhambat (bobak, 2005). ta n p a m e l i h a t p e n y e b a b n y a d a n berapapun tingkatannya, nyeri termasuk salah satu masalah keperawatan yang harus diatasi oleh perawat. tehnik untuk menurunkan nyeri secara non invasive saat ini telah banyak dikembangkan, namun belum ada laporan yang menjelaskan tehnik mana yang disarankan untuk digunakan pada nyeri post partum. beberapa tehnik yang dapat digunakan antara lain tehnik pernafasan berirama, tehnik distraksi, dan tehnik stimulasi kutan. masing-masing mempunyai kelebihan dan kelemahan. telaah pemilihan tehnik untuk menurunkan nyeri sampai saat ini masih cenderung tergantung secara mutlak pada sebuah rencana standar umum yang berlaku, sehingga seringkali keunikan individu menjadi terlewatkan. penggunaan metode evidence based practice lebih banyak memberi kesempatan kepada perawat untuk berpikir kritis dalam rangka mengambil keputusan dan melakukan tindakan yang tepat sesuai dengan masalah dan keunikan pasien. evidence based practice yang diterapkan pada manajemen nyeri non invasive pada ibu post partum, diharapan dapat membantu mempercepat proses pemulihan ibu pada fase puerperium. (carpenito, 2000; potter dan perry 2006; bobak 2005; bekti, 2007; rohmah. n. & walid, s. 2008). tujuan asuhan ini adalah menerapkan manajemen nyeri non invasive pada ibu post partum dengan menggunakan pendekatan evidence based practice. bahan dan metode desain penelitian ini menggunakan studi kasus yang dilakukan dengan pendekatan evidence based practice. langkah-langkah yang digunakan dalam pendekatan ini adalah identifi kasi fakta (evidence) yang diperlukan, mengkaji kebutuhan perubahan dalam layanan praktik, melihat dan mengevaluasi fakta melalui literature dan hasil penelitian terkait, memutuskan dan mendesain rencana strategis, implementasi, dan evaluasi. asuhan diberikan pada klien ny a. p1-1 a0 post sc hari ke 1 atas indikasi suspect cepalo pelvis disproporsi secondary arrest. tempat pengambilan data di ruang kandungan rsud dr. soebandi jember. waktu yang digunakan untuk memberikan asuhan adalah 4 hari. variabel yang ditelaah pada asuhan ini adalah masase pada wajah dan interaksi dengan bayi terhadap nyeri post partum. tehnik pengumpulan data melalui wawancara, observasi, dan pemeriksaan fisik. instrumen yang digunakan adalah format pengkajian (post partum), diagnosis keperawatan, perencanaan, pelaksanaan, dan evaluasi. analisa data menggunakan analisa deskriptif. strategi penelusuran artikel melalui pubmed, pubmed home, dan pmc. kata kunci dipilih berdasarkan analisis pico yang meliputi p: pain/nyeri, obstetric, surgical/bedah, acute care, i: massage, pain management, c: distraction/distraksi, mobilization/mobilisasi; o: comfort. proses penapisan artikel dilakukan melalui dua tahapan, antara lain: penapisan artikel layak baca, dan interpretasi hasil artikel. hasil evidence based data umum pasien ny. a., 24 tahun, jawa/indonesia, sma, ibu rt, islam, golongan darah o, mrs hari kedua. riwayat keperawatan meliputi keluhan utama pasien. bahu kanan terasa nyeri. riwayat penyakit sekarang (rps) kenceng-kenceng dan mulai mengeluarkan lendir dan darah mulai malam jumat, jumat pagi memeriksakan diri ke puskesmas kemudian klien mrs, klien mendapat informasi pagi manajemen nyeri non invasive pada ibu post partum (nikmatur rohmah) 203 itu pembukaan 2 cm, sabtu pagi (05.30 wib) pembukaan 4, jam 18.00 wib, pembukaan 7, sampai hari minggu jam 05.00 wib. masih pembukaan 7 cm, kemudian di rujuk ke rsud. di rsud diberikan oksitosin drip, ditunggu 2 jam, jam 07.00 wib. vt pembukaan tetap 7, kemudian disiapkan operasi sc. jam 09.00 wib, dilakukan sc lscs dengan anastesi sab. keluar dari kamar operasi jam 10.00 wib., kemudian masuk ke ruang pemulihan di ruang kandungan pukul 11.00 wib., terapi yang telah diberikan rl : d5 2 : 3, cefotaxim 3×1 gram, antrain 3×1 amp, metergin 2×1 amp (im), jam 18.00 mulai miring kanan miring kiri, fl atus mulai jam 07.00, minum sedikit-sedikit mulai jam 10.00 wib, saat ini bahu kanan terasa nyeri, dengan skala 6, rasa pegal-pegal walau tidak bergerak, perut tidak nyeri, hanya bekas operasi terasa sedikit ”nyekit” kalau dipakai bergerak, kalau diam tidak terasa nyeri. hasil pengkajian pola fungsi kesehatan menunjukkan pola nutrisi sebelum melahirkan, pasien makan 3× sehari nasi, lauk, ikan, sayuran, buah-buahan, minum ± 1500 cc/hari. saat ini tidak merasa lapar, tapi merasa haus, sudah minum pocari sweat 350 cc. pola aktivitas saat ini mika-miki tidak seberapa sakit. skala ketergantungan menunjukkan mandi 5, makan 5, toileting 5, berpakaian 4, instrumental 2. pola eleminasi menunjukkan saat ini terpasang kateter ± 200 cc/5 jam, kuning, jernih. pola konsep diri klien menyatakan sudah siap menjadi ibu, dan senang karena anaknya sudah lahir, tidak ada keinginan yang ekstrim terhadap jenis kelamin anak yang dilahirkan, klein tidak merasa perubahan bentuk tubuh setelah melahirkan adalah sesuatu yang perlu membuatnya menjadi malu, klien merencanakan merawat sendiri anaknya, dan siap menyusui bayinya. namun klien juga menyatakan bahwa belum pernah mendapat informasi dan tidak mempunyai pengalaman dalam memandikan bayi, merawat tali pusat, meneteki bayi, asi eksklusif, pernah baca majalah tetapi tidak paham. pola reproduksi dan seksual menunjukkan hubungan seksual sebelum hamil rutin setiap hari, selama hamil 3 kali dalam seminggu, setelah melahirkan klien belum tahu kapan akan memulai hubungan, ”kata orang kalau operasi baru boleh berhubungan setelah 6 bulan.” riwayat kontrasepsi dan menstruasi, menstruasi menikah 1 kali, bulan juni 2007, belum pernah menggunakan alat kontrasepsi apapun, saat ini belum tahu mau ikut kb apa ?, karena belum pernah mendapat informasi tentang kb. riwayat menstruasi pasien menarche umur 13 tahun, siklus menstruasi teratur, 28 hari, lamanya 7 hari, dismenorhoe ringan, kadang-kadang fl uor albus, tapi sedikt, tidak berbau, tidak gatal. riwayat kehamilan dan persalinan sekarang pasien periksa ke pkm rutin tiap bulan, minum frenamin mulai usia kehamilan 4 bulan sampai dengan 8 bulan, tt 2 kali usia kehamilan 1 dan 2 bulan, mualmuntah pada kehamilan 6–7 bulan, dan sering kencing pada kehamilan 8–9 bulan. riwayat persalinan sekarang telah dikerjakan lscs dengan sab, lahir bayi laki-laki as 7–8 bb 3500 garam, pb 49 cm. hasil pemeriksaan fi sik dimana meliputi keadaan umum baik, kesadaran kompos mentis, kooperatif. tensi 110/80 mmhg, nadi 84×/menit, suhu: 36,6° c, rr 20×/menit, tb 150 cm, bb 52 kg. wajah kurang rileks, konjungtiva merah muda, sklera putih, mulut dan bibir agak kering, hidung bersih, telinga bersih, tidak ada pembesaran kelenjar tiroid. dada: payudara simetris, lembek, puting susu menonjol, colostrum keluar, areola hiperpigmentasi, striae gravidarum minimal. abdomen soepel, agak cembung, luka tertutup verban, bising usus 2×/menit, samar, turgor baik, tfu 1 jari bawah pusat, kontraksi kuat, striae minimal. diatasis rectus abdominis lebar 0,5 cm, panjang 1 cm. genetalia: terpasang kateter, lokhea rubra, ± 150 cc/ 24 jam, perineum intak, tidak ada haemorroid. ektremitas: terpasang infus ditangan kanan, kekuatan otot 5, merubah posisi secara hatihati, bangun dari tidur tidak rilek, duduk tampak kaku, berjalan tidak rileks. homan sign (–), oedema, dan varises tidak ditemukan. pemeriksaan penunjang: hb: 10,8 gr%, leukosit: 14200, pcv: 32 gr. terapi: cefotaxim 3×1 gr iv, antrain 3×1 ampul iv, rl 20 tpm jurnal ners vol. 6 no. 2 oktober 2011: 201–209 204 identifi kasi kebutuhan a d a p u n k e b u t u h a n p a s i e n y a n g perlu mendapatkan pelayanan keperawatan berdasarkan evidence based yang telah dikumpulkan antara lain nyeri akut ringan yang berhubungan dengan trauma jaringan dd bahu kanan agak nyeri luka operasi nyekit kalau dipakai bergerak, risiko kekurangan volume cairan, sindrom kurang perawatan diri, kurang pengetahuan tentang asi eksklusif yang berhubungan dengan tidak ada pengalaman dan informasi, memulai penetapan adaptasi proses laktasi, persiapan progesif dalam perencanaan kb, kemungkinan infeksi, mengintegrasikan peran impian dengan peran aktual menjadi ibu, kurangnya pengetahuan tentang hubungan seksual setelah melahirkan, memulai meningkatnya kepercayaan diri dalam ketrampilan merawat bayi, memulai pencapaian peran pendampingan masa nifas, memulai pencapaian peran ayah, memulai integrasi bayi dalam keluarga, termoregulasi efektif (bayi), asupan nutrisi adekuat (bayi), menyusui efektif (bayi). prioritas kebutuhan yang harus dipenuhi adalah nyeri. beberapa dasar pertimbangan yang dipakai untuk menetapkan nyeri menjadi prioritas antara lain kenyamanan merupakan kebutuhan dasar yang fi siologis, pemenuhan yang baik tidak saja dapat mengurangi, menurunkan, atau menghilangkan nyeri, tetapi juga meningkatkan mobilisasi lebih awal, membantu klien bekerja lebih dini, memperpendek masa hospitalisasi, dan mengurangi biaya perawatan, nyeri yang tidak dapat diatasi atau dikontrol pada ibu post partum dapat menyebabkan keletihan, kecemasan dan persepsi nyeri memburuk, sehingga mobilisasi dini terhambat, laktasi terhambat, proses bonding attacmant terhambat, kecewa karena ketidaknyamanan, gangguan pola tidur, dan bahkan bila nyeri berkepanjangan akan meningkatkan risiko post partum blues (hamilton 1998: carpenito, 2000; bobak 2005; potter dan perry, 2006; rocmat, 2008). perencanaan dan dasar berpikir kritis dalam pengambilan keputusan nyeri post partum adalah nyeri yang dirasakan seperti kram menstruasi saat uterus berkontraksi setelah melahirkan (bobak, 2005). selain itu nyeri post partum juga diartikan perasaan yang tidak menyenangkan yang merupakan mekanisme pertahanan diri dari berbagai penyebab dan dapat dimanifestasikan dalam respon fi sik dan perilaku yang dirasakan ibu setelah melahirkan (rohmah dan walid, 2008). penyebab nyeri post partum antara lain afterbirth, episiotomi, laserasi perineum, pembesaran (engorgement) payudara, dan insisi bedah pada pasien post sc (bobak, 2005; rohmah, dan walid, 2008). intervensi nyeri post partum dapat dilakukan melalui kompres hangat, distraksi, imajinasi terbimbing, sentuhan terapiutik atau masase, interaksi dengan bayi (hamilton, 1998: carpenito, 2000; bobak, 2005; potter dan perry, 2006; rocmat, 2008). hasil penulusuran pustaka melalui jurnal manual maupun elektronik didapatkan tiga artikel antara lain the effects of massage therapy on pain management in the acute care setting oleh adams, white, dan beckett (2010), efektifitas distraksi visual dan pernafasan irama lambat dalam menurunkan nyeri akibat injeksi oleh rohmah (2007), dan nyeri oleh rochmat (2008). adapun penilaian layak baca masing-masing artikel dilakukan terhadap kejelasan abstrak, introduksi, metode, hasil, diskusi, dan referansi. ketiga artikel menunjukkan kebaikan dalam penulisannya. selanjutnya dilakukan interpretasi terhadap ketiga artikel, yang meliputi derajat eviden dari ketiga artikel? bagaimana penelitian itu dilakukan? apa hasilnya? apakah hasilnya valid di dalam maupun di luar kerangka penelitian?, dan konsistensi hasil penelitian. berdasarkan hasil penapisan yang dilakukan maka derajat eviden berada pada level 2b (evidence berasal dari minimal suatu studi quasi eksperimental), sedangkan hasil penelitian menunujukkan temuan yang konsisten bahwa massage dan tehnik non invasive dapat digunakan untuk memanagemen nyeri paska bedah termasuk paska bedah pada kasus obstetri. hasil penelitian ini juga memungkinkan untuk diterapkan ditempat penelitian. penjelasan dari hasil penelitian tersebut adalah sebagai berikut: adams, white, dan beckett (2010) menyimpulkan bahwa masase manajemen nyeri non invasive pada ibu post partum (nikmatur rohmah) 205 dapat menurunkan nyeri dari level rata-rata 5,18 (pada skala nyeri 0–1 vas) menjadi 2,33 dengan nilai p < 0,001. dalam penelitian ini menggunakan 65 sampel dan 26 diantaranya adalah dari unit obstetri. rochmat, 2008 menyatakan bahwa walaupun tesedia obat-obat yang efektif, namun nyeri pasca bedah tidak dapat diatasi dengan baik, sekitar 50% pasien tetap mengalami nyeri. tindakan non invasive sebaiknya terlebih dahulu dilakukan tanpa atau dengan tindakan farmakologis, karena hilangnya nyeri post partum dapat dipercepat jika menggunakan lebih dari satu tehnik (hamilton, 1998; bobak, 2005; rochmat, 2008). penelitian tentang perbedaan ekspresi nyeri pada wanita dan laki-laki menunjukkan tidak ada perbedaan, namun perempuan lebih suka mengkomunikasikan rasa sakitnya dibandingkan dengan laki-laki (rochmat, 2008). penelitian lain tentang distraksi terbukti menjadi strategi yang efektif untuk menurunkan nyeri (rochmat, 2008). hasil ini berbeda dengan penelitian rohmah (2007) yang menyatakan bahwa pernafasan irama lambat lebih efektif dibanding distraksi dalam menurunkan nyeri. teknik stimulasi transkutan dilaporkan sebanyak 50% dari pasien menyatakan nyeri menurun (rochmat, 2008). sementara doenges dan moorhouse (2001) dan bobak (2005) menyatakan bahwa tehnik stimulasi kutaneus yang digunakan untuk menurunkan nyeri post partum adalah gosokan punggung. mobilisasi dini, perubahan posisi pasien, pemasangan wash lap dingin pada wajah, dan pemijatan punggung dengan lotion yang menyegarkan dapat sangat membantu dalam menghilangkan ketidaknyamanan temporer paska operasi sc dan meningkatkan efektifitas medikasi (rochmat, 2008; bobak, 2005). melihat kajian teori dan hasil riset yang telah ditelaah maka berdasarkan evidence based yang ditemukan dapat diterapkan dua teknik manajemen nyeri non invasif yaitu masase dan interaksi dengan bayi. masase akan dilakukan pada wajah dan bahu 1 kali/hari. interaksi ibu dengan bayi akan dilakukan secepat mungkin setelah ibu siap menerima kehadiran bayi dan kondisi bayi tidak ada kontra indikasi untuk dilakukan rooming in. pelaksanaan massase alat yang diperlukan antara lain dalam melakukan massase adalah leaflet, minyak secukupnya (baby oil). persiapan pasien dan keluarga yang pertama yaitu pasien dan keluarga diberitahu tentang tindakan yang akan dikerjakan meliputi: tujuan, manfaat, kesediaan keluarga (suami) untuk terlibat aktif dalam pelaksanaan tindakan. setelah pasien dan keluarga menyetujui maka dilakukan demontrasi tahap demi tahap. kemudian keluarga pasien melakukan redemonstrasi. pelaksanaan yang dilakukan pada hari selasa tanggal 22 april 2008 pukul 09.30 wib langkah pertama yaitu meletakkan kedua ibu jari dengan posisi saling berhadapan diantara kedua alis pasien, langkah kedua melakukan masase secara perlahan kearah luar sampai di pelipis, berikan sedikit tekanan pada pelipis, lakukan sebanyak 3–5 kali, langkah ketiga yaitu menekan dengan ringan (dapat disesuaikan dengan keadaan pasien) pada tulang di pangkal hidung. tekan 3–5×, kemudian masase sepanjang os nasal kanan dan kiri sampai os zigomaticus, lakukan sebanyak 3–5 kali, langkah berikutnya memasase daerah mandibula sebanyak 3–5 kali, selanjutnya memberikan tekanan agak kuat di seputar kepala bagian atas, akhiri dengan memberikan tekanan pada kepala bagian belakang, lakukan sebanyak 3–5 kali dan langkah masase terakhir yaitu dilakukan pada punggung bagian atas yang diakhiri dengan tekanan pada bahu, lakukan sebanyak 3–5 kali. interaksi dengan bayi pelaksanaan interaksi ibu-bayi dilakukan pada hari selasa 22 april 2008 jam 10.45 wib. pertama membuat persetujuan dan persiapan ibu dan ayah untuk melakukan rawat gabung, dan keluarga setuju. kemudian kolaborasi dengan ruang perinatologi untuk rawat gabung: bayi dapat dilakukan rawat gabung. selanjutnya melakukan rawat gabung, jurnal ners vol. 6 no. 2 oktober 2011: 201–209 206 mengobservasi proses integrasi infant dalam keluarga, mengajari ibu cara meneteki yang benar. ibu mampu meneteki dengan benar, bayi menghisap kuat, dan tertidur pulas setelah menetek. evaluasi evaluasi yang dilaksanakan pada hari selasa tanggal 22 april 2008, pukul 14.00 wib terdapat hasil yaitu data subyektif pasien mengatakan ”nyeri skala 2”. sedangkan data obyektif menunjukkan wajah cukup rileks, gerakan masih hati-hati, tfu 2 jari bawah pusat, uc kuat, td 110/80 mmhg nadi 80x/ menit, rr 22×/menit, suhu 36,3° c, bu (+) 12×/menit, tersenyum saat menerima kehadiran anaknya, menerima kehadiran bayi dengan senang saat dilakukan rawat gabung, kontak mata dengan bayi, menyentuh wajah bayi, tersenyum saat bayinya menetek, payudara lembek setelah disusukan, asi kolostrum keluar, bayi dapat menghisap dengan efektif. analisis nyeri akut teratasi. planning rt dihentikan. pembahasan evidence based pada kasus yang sesuai dengan teori antara lain: posisi tubuh yang dipertahankan, gerakan hati-hati, dan ekpresi wajah tegang. sedangkan tekanan darah, nadi, pernapasan tidak mengalami perubahan, diaforesis tidak terjadi. lokasi dan luas penyebaran nyeri pada umumnya terjadi pada saat kontraksi uterus dan dirasakan di punggung, tetapi pada evidence based dirasakan pada bahu, hal ini diduga karena faktor immobilitas paska bedah. immobilitas paska bedah dapat berlangsung singkat, tetapi pada evidence based didapatkan riwayat persalinan yang lebih dari 24 jam. posisi tubuh pada saat periode pra bedah yang sedang mengalami nyeri dalam skala berat (his pembukaan) pada umumnya juga berada pada posisi yang dipertahankan (kaku), hal ini dapat berdampak pada mobilisasi pra dan paska bedah (bobak, 2005; rochmat, 2008). ibu post partum dengan riwayat persalinan lama menyebabkan nyeri yang berkepanjangan. sensasi nyeri menjadi penyebab seseorang mengurangi atau bahkan menghentikan aktifi tasnya. faktor lain yang juga meningkatkan hambatan dalam melakukan mobilisasi adalah persalinan dengan tindakan sectio caesarea. dampak lain post sectio caesarea dalam keadaan nyeri, kemudian mengurangi mobilisasi, akan menyebabkan menurunnya sirkulasi darah, dan hal ini akan menjadi pemicu bagi meningkatnya sensasi nyeri. semakin tinggi nyeri yang dirasakan pasien cenderung semakin menurunkan aktifitasnya, sehingga sirkulasi darah akan lebih menurun lagi. kondisi ini merupakan lingkaran siklikal yang satu menjadi penyebab bagi yang lain. kebutuhan perubahan yang prioritas pada evidence based adalah nyeri. nyeri yang tidak dapat diatasi atau dikontrol pada ibu post partum dapat menyebabkan keletihan, kecemasan dan persepsi nyeri memburuk, sehingga mobilisasi dini terhambat, laktasi terhambat, proses bonding attachment terhambat, kecewa karena ketidaknyamanan, gangguan pola tidur, dan bahkan bila nyeri berkepanjangan akan meningkatkan risiko post partum blues (bobak, 2005). kebutuhan yang lain meliputi kebutuhan cairan dan nutrisi, perawatan diri, persiapan menjalankan peran ibu-ayah, dan kebutuhan belajar tentang asi, laktasi, program keluarga berencana, seksual paska melahirkan, perawatan diri dan bayi. kebutuhan perubahan ini sesuai dengan konsep perawatan ibu post partum yang menekanakan pada pemulihan fi sik psikologis, meningkatkan kemampuan ibu merawat diri, dan meningkatkan kemampuan ibu merawat bayi. selain itu perawat diharapkan dapat menyiapkan alih tanggung jawab dari perawat pada keluarga, sehingga peran perawat disini bukan hanya pemberi pelayanan tetapi lebih kepada pengajar, pemberi semangat dan dukungan. intervensi nyeri non invasive yang ditetapkan adalah masase pada wajah dan bahu serta interaksi dengan bayi. masase bertujuan untuk menstimulasi produksi endhorpin dan dinorpin yang berfungsi untuk memblokade tranmisi nyeri melalui system control desenden. sedangkan interaksi dengan bayi merupakan media distraksi yang bermaksud untuk mendominasi impuls yang masuk dalam system manajemen nyeri non invasive pada ibu post partum (nikmatur rohmah) 207 control asenden sehingga dapat menutup pintu gerbang penghantar nyeri. dua intervensi ini diharapkan dapat secara sinergis menurunkan nyeri, karena hilangnya nyeri post partum dapat dipercepat jika menggunakan lebih dari satu tehnik (hamilton 1998: carpenito, 2000; bobak 2005; potter dan perry, 2006; rochmat, 2008; adams, white, dan beckett, 2010). prinsip pelaksanaan manajemen nyeri pada evidence based sesuai dengan konsep teori yaitu prinsip stimulasi kutaneus dan distraksi (carpenito, 2000; potter dan perry, 2006; adams, white, dan beckett, 2010). namun pada evidence based terdapat perbedaan pada area masase dan media distraksi. area masase dipilih pada wajah dan bahu dengan pertimbangan adanya pemetaan nyeri yaitu area 1, 2, 3, 4, dan 5. area 1 dan 2 adalah area wajah yang merupakan area yang selalu mengalami ketegangan pada saat nyeri berlangsung, dengan melakukan masase pada daerah ini diharapkan dapat menjadi rileks sehingga dapat memutuskan mata rantai siklus takut-tegang-nyeri. sedangkan area 3,4,5 adalah area yang dikeluhkan sebagai area nyeri. (hamilton, 1998; bobak, 2005; strong, et all, 2002). media distraksi yang digunakan adalah interaksi dengan bayi, media ini mempunyai banyak manfaat, selain untuk mengalihkan pusat perhatian dari nyeri media ini juga dapat dipakai untuk meningkatkan pembentukan bonding attachment. nyeri dan ketidaknyamanan pada umumnya akan selalu ada, tetapi kehadiran orang-orang yang dicintai, orang terdekat, orang kepercayaan akan membantu meminimalkan kesepian dan ketakutan, sehingga dapat mempengaruhi persepsi nyeri (carpenito, 2000). seseorang yang memfokuskan perhatiannya pada nyeri dapat mempengaruhi persepsi nyeri. perhatian yang meningkat terhadap nyeri akan meningkatkan nyeri. upaya pengalihan (distraksi) dapat menurunkan respon nyeri. interaksi dengan bayi merupakan media bonding. bonding didefi nisikan sebagai suatu ketertarikan mutual pertama antar individu, misalnya antara orangtua dan anak, saat gambar 1. patahofi siological pathway intervensi nyeri non invasive (carpenito, 2000; hamilton, 2001; dan bobak 2005; potter & perry, 2006; rocmat r. 2008) masase interaksi dengan bayi stimulasi produksi opiate endogen dalam system control desenden melepaskan serotonin, endorphin, dinorphin di dorsal medula spinalis menurunkan respon pada otak, medulla spinalis blok transmisi nyeri efek distraksi fokus perhatian pindah ke bayi impuls yang masuk didominasi oleh serabut a. betha menutup mekanisme pertahanan impuls nyeri dihambat nyeri menurun nyeri jurnal ners vol. 6 no. 2 oktober 2011: 201–209 208 pertama kali mereka bertemu. attachment terjadi pada periode kritis seperti pada kelahiran (bobak, 2005). hal ini menjelaskan suatu perasaan saling menyayangi atau loyalitas yang mengikat individu dengan individu lain yang bersifat unik, spesifi k, dan bertahan lama. proses kasih sayang dijelaskan sebagai sebagai sesuatu yang linear, dimulai saat ibu hamil, semakin menguat pada periode pasca partum, dan begitu terbentuk akan menjadi konstan dan konsisten. ikatan ini sangat penting bagi kesehatan fi sik dan mental sepanjang rentang kehidupan. simpulan dan saran simpulan evidence based pada kasus yang sesuai dengan teori antara lain posisi tubuh yang dipertahankan, gerakan hati-hati, dan ekpresi wajah tegang. sedangkan tekanan darah, nadi, pernafasan tidak mengalami perubahan, diaforesis tidak terjadi. lokasi dan luas penyebaran nyeri pada umumnya terjadi pada saat kontraksi uterus dan dirasakan di punggung, tetapi pada evidence based dirasakan pada bahu, kebutuhan perubahan yang prioritas pada evidence based adalah nyeri, intervensi nyeri non invasive yang ditetapkan berdasarkan evidence based adalah masase pada wajah dan bahu dengan pertimbangan pemetaan area nyeri serta interaksi dengan bayi, prinsip pelaksanaan manajemen nyeri pada evidence based sesuai dengan konsep teori yaitu prinsip stimulasi kutaneus dan distraksi. namun pada evidence based terdapat perbedaan pada area masase dan media distraksi. area masase dipilih pada wajah dan media distraksi yang digunakan adalah interaksi dengan bayi, evaluasi pada evidence based didapatkan bahwa nyeri dapat berkurang menjadi skala 2, wajah dan mobilisasi menjadi lebih rileks. saran perlu dilakukan penelitian lebih lanjut tentang efek interaksi ibu-bayi terhadap penurunan nyeri post partum, perlu dilakukan penelitian tentang nyeri akibat sensasi nyeri paska bedah dengan indikasi bedah umum berdasarkan pemetaan area nyeri kepustakaan adams, white, dan beckett, 2010. the effects of massage therapy on pain management in the acute care setting. international journal of therapeutic massage and bodywork., 3(1): 4–11. bobak, lowdwermilk, and jensen, 2005. maternity nursing. (fourth edition), diterjemahkan oleh: wijayarini. buku ajar keperawatan maternitas. (edisi4), jakarta: egc. bekti, y., 2007. evidence based practice. makalah disajikan dalam pelatihan nasional fasilitator klinik, fikes unmuh jember. carpenito, l.j., 2000. diagnosa keperawatan aplikasi pada praktik klinis., jakarta. egc. doengoes, m.e., dan moorhause, m.f., 2001. rencana perawatan maternal/bayi pedoman untuk perencanaan dan dokumentasi keperawatan klien. ed. 2, jakarta: egc. eny, 2006. efektivitas pemberian teknik masase efl urasi pada punggung ibu bersalin primigravida terhadap penurunan skala nyeri pada kala i, karya tulis ilmiah tidak dipubilkasikan, banyuwangi: stikes banyuwangi. hamilton, p.m., 1998. dasar-dasar kep. maternitas. ed. vi. jakarta: egc. gambar 2. pemetaan area nyeri (strong, et al., 2002) manajemen nyeri non invasive pada ibu post partum (nikmatur rohmah) 209 mansjoer, et al., 2002. kapita selekta kedokteran. ed. 3, jakarta: media ausculapius. manuaba, 2004. kepaniteraan klinik obstetri and ginekologi. jakarta: egc. potter dan perry, 2006. buku ajar fundamental keperawatan konsep, proses dan praktik. ed. 4, vol 2, jakarta: egc rochmat, r., 2008. nyeri, ratihrochmat’s. weblog. diakses pada tanggal 2 januari 2009. rohmah, n., 2007. efektivitas distraksi visual dan irama napas lambat dalam menurunkan nyeri akibat injeksi. jurnal ners. 2(1): 43–45. rohmah, n., dan walid, s., 2008. asuhan k e p e r a w a t a n d a l a m m e m e n u h i kebutuhan kenyamanan. diktat kuliah tidak dipublikasikan. sucipto, j.a., 2007. pengaruh mobilisasi dini terhadap nyeri paska bedah. skripsi tidak dipublikasikan. jember: program studi s1 keperawatan fikes unmuh jember. stolte, k.m., 2004. diagnosa keperawatan sejahtera (wellness nursing diagnosis). alih bahasa: monica ester. jakarta: egc. strong, et al., 2002. pain a textbook of therapists. philadelphia: churchill livingstone. smeltzer, s.c., dan bare, b.g., 2002. buku ajar keperawatan medikal bedah bruner & suddarth. ed. 8, vol. 3, jakarta: egc. 177 kemandirian perawatan ibu post sectio caesarea dengan pendekatan discharge planning berdasarkan teori self care orem (the independence of post sectio caesarea mother with discharge planning based on orem's self care theory) tinok ayu putri w, nursalam, eka mishbahatul mar'ah has program studi s1 ilmu keperawatan fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya 60115, e-mail: tinokayuputri@gmail.com abstract introduction: discharge planning is one of nursing intervention that aim to promote the independence of patient's self care-activities after discharge from hospital. this study was aimed to examine the effect of discharge planning on wound care independence of post sectio caesarea mother at melati room, dr. soegiri hospital, lamongan. method: design of this study was quasy experiment. the population were post sectio caesarea mother at melati room dr. soegiri hospital lamongan, since may – june 2012. the samples were taken by purposive sampling technique. fourteen responsdents matched with the inclusion criteria and divided into treatment and control groups. the datas were collected by using questionnaire and observation sheet. then datas were analyzed by using wilcoxon signed rank test and mann whitney u test with signifi cance level of α ≤ 0.05. result: the result of this study showed that post sectio caesarea mother knowledge had signifi cance level of p = 0.027 in treatment group, and in control group was p = 0.034, for post sectio caesarea patient's skill p = 0.015 in treatment group and in control group was p = 0.017. the result of mann whitney u test was p = 0.001, it means there was different in knowledge, and skill of wound care on post sectio caesarea patient between treatment and control groups. discussion: it can be concluded that there are signifi cant effect of wound care independence of post sectio caesarea patient with discharge planning approach based on orem's self care theory to improve patient's independence. hospital need to develop discharge planning procedure to meet the needs of patient with post sectio caesarea wound and decrease the number of surgical wound infection. keywords: discharge planning, wound care independence, orem's self-care theory pendahuluan sectio caesarea mer upakan jenis pembedahan dengan tujuan untuk melahirkan janin melalui suatu insisi pada dinding depan perut (laparotomi) dan dinding rahim (histerektomi) (cunningham, 2004). adanya luka pasca bedah sectio caesarea membutuhkan perawatan yang tepat (himatusujanah, 2008). perawatan luka yang tepat juga ditujukan untuk mencegah terjadinya infeksi, karena kasus terjadinya infeksi pada sectio caesarea 80 kali lebih tinggi dibandingkan dengan persalinan pervaginam (farrer, 2001). johnson (2006) melakukan penelitian mengenai infeksi luka insisi sectio caesarea dan membedakan infeksi ini menjadi 3 kategori berdasarkan waktu kejadian infeksi, infeksi pertama yaitu infeksi yang terjadi ketika pasien di rumah sakit dengan jumlah 27%, infeksi yang terjadi saat re-admission sejumlah 1%, dan kasus yang paling besar adalah setelah pasien keluar dari rumah sakit, dengan angka kejadian 71%. hal tersebut menjadi alasan sebelum pemulangan pasien harus memiliki kesiapan dan kemandirian untuk melakukan perawatan di rumah. salah satu bentuk intervensi keperawatan yang dapat dilakukan untuk mempersiapkan pasien di rumah adalah discharge planning 178 jurnal ners vol. 7 no. 2 oktober 2012: 177–185 (perencanaan pemulangan pasien) untuk mempromosikan tahap kemandirian tertinggi kepada pasien, teman-teman, dan keluarga dengan menyediakan, serta memandirikan aktivitas perawatan diri di rumah (mallet, 2004). berdasarkan studi pendahuluan yang dilakukan oleh peneliti di ruang melati rsud dr. soegiri lamongan pada bulan maret, pasien di ruangan tersebut belum mengetahui cara yang tepat melakukan perawatan post sectio caesarea ketika di r umah secara mandiri. dampak dari hal tersebut adalah 6 dari 43 orang pasien (21%) yang kontrol (7 hari pasca-bedah caesarea) kondisi luka insisi menunjukkan indikasi infeksi luka operasi (ilo). salah satu penyebab masalah ini adalah prosedur discharge planning yang tidak dibedakan antara ibu yang melahirkan secara nor mal dengan yang melahirkan secara sectio caesarea. kebutuhan antara ibu yang melahirkan secara normal dan caesar memili k i perbedaan, maka sehar usnya discharge planning yang diberikan berbeda dan disesuaikan dengan kebutuhan perawatan pasien. ancaman utama bagi wanita yang menjalani sectio caesarea berasal dar i tindakan anastesi, keadaan sepsis yang berat, serangan tromboemboli dan perlukaan pada traktus urinarius, infeksi pada luka (boba k, 2004). menu r ut boyle (2005) hal-hal yang dapat mengurangi resiko infeksi adalah pendidikan, penghilang nyeri, gizi yang cukup, perawatan luka yang baik, mengidentifikasi infeksi, mengoptimalkan kemungkinan rawat inap di rumah sakit, mengurangi stres dan meningkatkan harga diri. peran perawat sangat dibutuhkan dalam memberikan edukasi kepada pasien dengan tujuan untuk memandirikan pasien, sehingga pasien mampu untuk melakukan perawatan luka post sectio caesarea, terutama ketika pasien berada di rumah. salah satu caranya adalah melalui discharge planning yang bertujuan memberikan pelayanan terbaik untuk menjamin keberlanjutan asuhan berkualitas antara rumah sakit dan komunitas (di rumah) (discharge planning association, 2008). discharge planning ( perencanaan p e m u l a n g a n) m e r u p a k a n s a l a h s a t u bentuk intervensi keperawatan yang dapat memandirikan pasien, keluarga, serta teman terdekat klien (mallet, 2004). discharge planning dapat meningkatkan pengetahuan serta keterampilan pasien sebelum pemulangan pasien, sehingga diharapkan setelah berada di rumah pasien mampu melakukan perawatan secara mandir di rumah. kemandirian adalah tujuan dalam melakukan discharge planning. menur ut orem, manusia pada dasar nya mempunyai kemampuan dalam merawat dirinya sendiri. merawat diri sendiri (self care) adalah perilaku yang diperlukan oleh individu dan berrorientasi pada tujuan yang berfokus pada kapasitas individu yang bersangkutan untuk mengatur dirinya dan lingkungan dengan cara sedemikian rupa, sehingga ia tetap bisa hidup, menikmati kesehatan dan kesejahteraan, serta berkontribusi dalam perkembangannya sendiri (basford, 2006). bahan dan metode desain penelitian yang digunakan adalah quasy-experiment dengan rancangan penelitian pre-post test control group design. populasi pada penelitian ini adalah pasien post sectio caesarea di ruang melati rsud dr. soegiri sebanyak 15 orang. sampel yang digunakan dalam penelitian ini adalah 14 responden pasien post sectio caesarea di rsud dr. soegiri yang memenuhi kriteria inklusi yaitu, ibu post sectio caesarea dengan usia 18–35 tahun, belum pernah melahirkan secara sectio caesarea sebelumnya, memiliki kesadaran penuh sehingga tidak memiliki halanga n u nt u k belajar. penelit ia n i n i dilakukan selama 2 bulan. variabel indpenden dalam penelitian ini adalah pelaksanaan discharge planning mulai awal masuk rumah sakit, selama perawatan, dan sebelum keluar rumah sakit, sedangkan var iabel dependen adalah kemandir ian perawatan ibu post sectio caesarea. instrumen yang digunakan untuk mengukur pengetahuan tentang perawatan post sectio caesarea adalah kuesioner yang peneliti modif ikasi dari king edward memorial hospital, australia. 179 kemandirian perawatan ibu post sectio caesarea (tinok ayu putri w, dkk.) kuesioner terdiri dari 15 pertanyaan positif pada nomor 1, 2, 3, 4, 6, 7, 10, 11, 12, 14, 15 dan negatif pada nomor 5, 8, 9, 13, apabila pertanyaan dijawab secara benar bernilai 1 dan jika salah bernilai 0. instrumen untuk meng u k u r keterampilan diu k u r dengan menggunakan observasi terstruktur berupa check list yang peneliti modif ikasi dari king edward memorial hospital, australia. lembar observasi terdiri dari 10 pernyataan dengan jawaban ter t ut up, ya = 1 atau tidak = 0. data yang telah dikumpulkan kemudian diolah dan dianalisis dengan menggunakan uji statistik wilcoxon signed rank test (uji komparasi 2 sampel berpasangan) dengan derajat kemaknaan p ≤ 0,05 dan uji statistik mann whitney u test (uji komparasi 2 sampel bebas/independen) dengan derajat kemaknaan p ≤ 0,05. hasil bag ia n i n i a k a n d isaji k a n ha sil penelitian yang menunjuk kan pengar uh discharge planning dalam meningkatkan kemandirian ibu post sectio caesarea di ruang melati rsud dr. soegiri lamongan. va r iabel d i kelompok perla k u a n diketahui hasil uji statistik menggunakan wilcoxon signed rank test nilai sig (2-tailed) adalah 0,027 dan 0,015 berarti p<0,05 maka hi diterima ar tinya discharge planning tabel 1. perubahan pengetahuan responden sebelum dan setelah diberikan discharge planning pengetahuan k. perlakuan k. kontrol pre test post test pre test post test ∑ % ∑ % ∑ % ∑ % baik 3 42 7 100 2 29 4 57 cukup 2 29 0 0 1 24 3 43 kurang 2 29 0 0 4 57 0 0 total 7 100 7 100 7 100 7 100 tabel 2. tingkat pengetahuan perawatan pada ibu post sectio caesarea per parameter di ruang melati rsud dr. soegiri, lamongan no. parameter kelompok perlakuan peningkatan kelompok kontrol peningkatan pre post pre post 1. luka post sectio caesarea 1 7 6 1 4 3 2. perawatan luka post sectio caesarea 2 7 5 1 5 4 3. c a r a y a n g t e p a t d a l a m perawatan luka post sectio caesarea 3 7 4 2 4 2 median 2 7 5 1 4 3 minimum 1 7 4 1 4 2 maximum 3 7 6 2 5 4 tabel 3. perubahan keterampilan responden setelah diberikan discharge planning keterampilan k. perlakuan k. kontrol pre test post test pre test post test ∑ % ∑ % ∑ % ∑ % baik 0 0 7 100 0 0 1 14 cukup 0 0 0 0 0 0 5 72 kurang 7 100 0 0 7 100 1 14 total 7 100 7 100 7 100 7 100 180 jurnal ners vol. 7 no. 2 oktober 2012: 177–185 tabel 4. keterampilan perawatan pada ibu post sectio caesarea di ruang melati rsud dr. soegiri, lamongan no. parameter kelompok perlakuan peningkatan kelompok kontrol peningkatan pre post pre post 1. menjaga luka agar tetap kering dan bersih 0 7 7 0 6 6 2. mengkonsumsi makanan yang dapat membantu penyembuhan luka 3 7 4 0 1 1 3. menghindari hal-hal yang dapat menyebabkan infeksi serta lamanya penyembuhan pada luka 7 7 0 7 7 0 4. m i n u m a n t i b i o t i k s e s u a i dengan yang telah diresepkan oleh dokter 0 7 7 0 7 7 5. tidak melakukan aktivitas yang terlalu berat 0 7 7 0 3 3 6. melakukan latihan ringan untuk otot perut 0 7 7 0 0 0 7. mematuhi jadwal kontrol 0 7 7 1 3 2 8. kondisi luka baik saat kontrol 0 7 7 0 4 4 median 0 7 7 0 3,5 (4) 2,5 (3) minimum 0 7 0 0 0 0 maximum 7 7 7 7 7 7 tabel 5. hasil uji statistik pada variabel penelitian no. uji k. perlakuan k. kontrolz p z p 1 pengetahuan wilcoxon signed rank test –2,214 0,027 –2,120 0,034 mann-whitney u test z = –3,351 p = 0,001 2 keterampilan perawatan ibu post sectio caesarea wilcoxon signed rank test –2,428 0,015 –2,384 0,017 mann-whitney u test z = –2,400 p = 0,016 berpengaruh terhadap kemandirian perawatan ibu post sectio caesarea. hasil uji statistik menggunakan mann-whitney u test nilai sig (2-tailed) adalah p = 0,000 berarti p<0,05 sehingga h1 diterima. hal tersebut menu nju k kan bahwa terdapat perbedaan kemandirian (pengetahuan dan keterampilan) ibu post sectio caesaeea pada kelompok perlakuan yang diberikan discharge planning perawatan post sectio caesarea dan kelompok kontrol yang diberikan discharge planning sesuai prosedur tetap di ruang melati. pembahasan berdasarkan hasil penelitian, sebelum d i la k u k a n d i sch a r ge pla n n i n g u nt u k memandirikan ibu post sectio caesarea terdapat hampir 30% ibu yang memiliki pengetahuan kurang. berdasarkan karateristik umur pada kelompok perlakuan diketahui 58% responden berada pada rentang umur 27–35 tahun, dan 58% responden menempuh pendidikan terakhir di smp, 14% sd, dan 28% sma. sedangkan pada kelompok kontrol 43% responden menempuh pendidikan terakhir 181 kemandirian perawatan ibu post sectio caesarea (tinok ayu putri w, dkk.) di sd, 14% di smp, dan 43% di sma. setelah dianalisis, diketahui bahwa 1 dari 2 responden pada kelompok perlakuan yang memiliki pengetahuan kurang saat pre test menempuh pendidikan terakhir hingga sd. pada kelompok kontrol terdapat 5 responden yang memiliki pengetahuan kurang saat pre test, dan 3 di antaranya memiliki pendidikan terakhir di sd. salah satu penyebab kurangnya pengetahuan ibu mengenai kemandirian perawatan luka post sectio caesarea adalah ibu belum pernah melahirkan secara caesar sebelumnya, karena salah satu faktor yang mempengar u hi kemandir ian ibu pascabersalin adalah masa lalu ibu, apakah pernah mengalami kelahiran caesar atau tidak sebelumnya (bobak, 2004). selain itu faktor yang dapat mempengaruhi kemandirian ibu adalah faktor internal ibu, salah satunya yaitu usia dan pendidikan ibu. faktor penting lain yang sangat mempengaruhi kemandirian ibu adalah petugas kesehatan. petugas kesehatan, khususnya perawat sangat berperan penting dalam mempengaruhi perilaku perawatan mandiri ibu pasca-bersalin. perawat juga mempu nyai kewenangan dan t angg u ng jawab dalam tindakan yang berorientasi pada pelayanan melalui pemberian asuhan keperawatan kepada individu, kelompok, atau keluarga (hidayat, 2007). menur ut keterangan dari kepala ruangan di ruang melati, petugas kesehatan (perawat dan bidan) yang ada di ruangan mempunyai kewajiban untuk memberikan pendidikan kesehatan melalui discharge planning kepada ibu pascabersalin termasuk ibu post sectio caesarea. namun, selama ini discharge planning yang diberikan pada ibu post sectio caesarea tidak dibedakan dengan ibu pasca bersalin yang lainnya. sedangkan kebutuhan ibu post sectio caesarea sedikit berbeda dengan ibu yang bersalin secara normal. selain itu, discharge planning hanya dilakukan sebelum ibu keluar rumah sakit. hal ini dikarenakan adanya luka pada dinding abdomen, sehingga ibu perlu mendapatkan edukasi yang optimal untuk mempercepat penyembuhan luka serta mencegah adanya infeksi pada luka post sectio caesarea. kelompok perlakuan seluruh responden mengalami peningkatan pengetahuan dan memiliki kriteria baik setelah dilakukan intervensi. kelompok kontrol, setelah dilakukan post test 6 dari 7 responden (86%) mengalami peningkatan pengetahuan, sedangkan 1 (14%) responden mengalami penurunan pengetahuan. berdasarkan uji statistik wilcoxon signed rank test kedua kelompok (perlakuan dan kontrol) memiliki nilai p<0,05, sehingga dapat disimpulkan bahwa dengan adanya discharge planning kemandirian perawatan ibu post sectio caesarea dan discharge planning yang mer uju k pada prosedu r tetap ruang melati memiliki pengar uh terhadap pengetahuan pasien, namun tingkat peningkatan pengetahuan pada kelompok perlakuan lebih tinggi daripada kelompok kontrol, dan tidak ada penur unan nilai pengetahuan pada kelompok perlakuan. mallet (2004) menyatakan bahwa discharge planning merupakan proses mengidentifi kasi kebutuhan pasien dan perencanaannya dituliskan untuk memfasilitasi keberlanjutan suatu pelayanan kesehatan dari suatu lingkungan ke lingkungan lain. discharge planning sebaiknya dilakukan sejak pasien diterima di suatu agen pelayanan kesehatan, terk husus di r umah sakit di mana rentang waktu pasien untuk menginap semakin diperpendek. discharge planning yang efektif seharusnya mencakup pengkajian berkelanjutan untuk mendapatkan informasi yang komprehensif tentang kebutuhan pasien yang berubah-ubah, pernyataan diagnosa keperawatan, perencanaan untuk memastikan kebutuhan pasien sesuai dengan apa yang dilakukan oleh pemberi layanan kesehatan (kozier, 2004). hal-hal yang harus diketahui pasien sebelum pulang meliputi instruksi tentang penyakit yang diderita, pengobatan yang harus dijalankan, serta masalah-masalah atau komplikasi yang terjadi, informasi tertulis tentang perawatan yang harus dilakukan di rumah, pengaturan diet khusus dan bertahap yang harus dijalankan, jelaskan masalah yang mungkin timbul dan cara mengatasinya, pendidikan kesehatan yang ditujukan kepada keluarga maupu n pasien sendi r i dapat digunakan metode ceramah, demonstrasi, 182 jurnal ners vol. 7 no. 2 oktober 2012: 177–185 dan lain-lain, kemudian informasi tentang nomor telepon layanan perawatan, dokter, dan pelayanan keperawatan, serta kunjungan rumah apabila pasien memerlukan (nursalam, 2007). penelitian ini peningkatan pengetahuan terjadi pada kelompok perlakuan setelah diberikan discharge planning perawatan luka post sectio caesarea. discharge planning ini dilakukan sejak pasien masuk rumah sakit hingga saat pasien akan keluar rumah sakit. selain itu discharge planning disesuaikan dengan kebutuhan ibu post sectio caesarea, yaitu pendidikan kesehatan (educating) dan dukungan (supporting) untuk mengantisipasi apabila ibu mengalami nyeri pasca operasi, mobilisasi dini (miring kanan-kiri), latihan per napasan yang ber tujuan menur unkan d a m p a k a n a s t e s i p r e o p e r a s i y a n g mengakibatkan depresi syaraf pernapasan. selain itu disampaikan juga kepada pasien bahwa penting untuk minum dan makan makanan yang bernutrisi yang telah disiapkan oleh ahli gizi (disampaikan apabila pasien telah f latus pasca-operasi), seperti minum air putih 8 gelas setiap hari, makan makanan yang tinggi protein seperti ayam, daging, telur, kedelai, serta mengkonsumsi sayur dan buah. selain diet peneliti melakukan pemanduan atau guiding kepada pasien untuk melakukan latihan f isik, yaitu latihan ringan untuk abdomen dan punggung ( pelvic rocking dan knee rolling). pasien juga disarankan untuk melakukan aktifi tas seperti berjalan ke kamar mandi. sebelum pasien pulang, peneliti memberikan booklet kepada pasien yang berkaitan dengan luka post sectio caesarea, dan cara tepat dalam merawat luka post sectio caesarea. ha si l m a k si m al pa d a kelomp ok perlakuan lebih tinggi dari hasil maksimal pada kelompok kontrol menunjukkan secara kuantitatif terdapat peningkatan pengetahuan pada kelompok perlakuan. peningkatan besar terjadi pada responden no. 4 dan 7. responden no. 4 memiliki latar belakang pendidikan terakhir hingga sd, sedangkan pada responden no. 7 memiliki latar belakang pendidikan terak hir smp. kedua responden samasama memiliki nilai kurang pada penilaian pengetahuan saat pre test, hal ini menunjukkan ad anya penga r u h pendidi kan terhad ap pengetahuan ibu, di mana pengetahauan ibu akan mempengaruhi tingkat kemandirian dalam melakuakan perawatan luka post sectio caesarea. namun setelah dilakukan discharge planning perawatan luka post sectio caesarea, kedua responden mendapat nilai pengetahuan dengan kategori baik saat post test. dengan demikian, discharge planning perawatan luka post sectio caesarea yang dilakukan peneliti untuk meningkatkan kemandirian ibu mempengaruhi tingkat pengetahuan ibu. terjadi peningkatan yang cukup besar hampir disetiap parameter setelah dilakukan discharge planning perawatan luka post sectio caesarea berdasarkan parameter peningkatan pengetahuan mengenai kemandirian perawatan luka post sectio caesarea. adanya pengetahuan yang adekuat dapat mempersiapkan pasien secara fi sik dan psikologis untuk di transfer ke rumah atau ke suatu lingkungan. pada saat pulang, pasien harus mempunyai pengetahuan, keterampilan, dan sumber yang dibutuhkan untuk memenuhi perawatan dirinya. oleh karena itu pasien dinyatakan siap menghadapi pemulangan apabila pasien mengetahui pengobatan, tanda-tanda bahaya, aktivitas yang dilakukan, serta perawatan lanjutan di rumah. discharge planning dalam penelitian ini dilakukan sesuai dengan konsep discharge planning dalam teori, yaitu dilakukan saat pasien masuk rumah sakit, selama perawatan, dan sebelum pasien keluar r umah sakit. dalam proses discharge planning peneliti memberikan edukasi kepada pasien mengenai hal-hal yang perlu diketahui pasien untuk membanttu penyembuhan luka post sectio caesarea. edukasi yang diberikan peneliti meningkatkan pengetahuan pasien post sectio caesarea dalam melakukan perawatan luka post sectio caesarea di rumah secara tepat dan mengurangi adanya resiko infeksi. peningkatan pengetahuan responden setelah diberikan intervensi dipengaruhi oleh discharge planning perawatan luka post sectio caesarea secara mandiri yang mampu memenuhi kebutuhan ibu pasca-bersalin melalui sectio caesarea karena bantuan dengan cara guiding, supporting, dan teaching dari perawat dalam discharge 183 kemandirian perawatan ibu post sectio caesarea (tinok ayu putri w, dkk.) planning dapat menambah pengetahuan ibu yang akan mempengaruhi kemandiriannya ketika di rumah. selain itu dengan metode serta media seperti booklet juga membantu pasien dalam proses penerimaan informasi. saat dilak u kan pre test tindakan kemandirian pasien dalam perawatan post sectio caesarea, didapatkan data 100% pasien memiliki kriteria kurang. setelah dilakukan perlakuan berupa kemandirian perawatan luka pada ibu post sectio caesarea dengan pendekatan discharge planning pada kelompok perlakuan terjadi peningkatan kemandirian perawatan luka post sectio caesarea, dan seluruh responden pada kelompok perlakuan mem ili k i k r iter ia bai k. dat a ter sebut menu nju k kan secara k uantitatif bahwa tindakan kemandirian perawatan luka pada ibu post sectio caesarea meningkat setelah diberikan intervensi. terjadi peningkatan yang cukup tinggi pada 6 parameter dari 8 parameter tindakan kemandirian, yaitu pada parameter menjaga luka agar tetap kering dan bersih, minum antibiotik sesuai dengan yang telah diresepkan oleh dokter, tidak melakukan aktivitas yang terlalu berat, melakukan latihan ringan untuk otot perut, mematuhi jadwal kontrol, dan kondisi luka baik saat kontrol. ada dua faktor yang menyebabkan peningkatan pada tindakan kemandirian di kelompok perlakuan, yang pertama adalah karena saat pre test atau sebelum dilakukan intervensi, pasien dalam kondisi pro sectio caesarea atau persiapan untuk melahirkan secara caesar sehingga ada beberapa tindakan yang memang seharusnya belum dilakukan oleh pasien, seperti pada parameter pasien minum obat (antinyeri) pasca sectio caesarea sesuai dengan intruksi dokter, pasien melakukan latihan ringan (mobilisasi), pasien kontrol sesuai waktu yang dijadwalkan, dan kondisi luka post sectio caesarea saat kontrol sudah dalam keadaan baik. faktor kedua yang menyebabkan tingginya peningkatan pada kelompok perlakuan adalah karena diberikan intervensi berupa discharge planning yang disesuaikan dengan kebutuhan ibu post sectio caesarea, yaitu perawatan luka post sectio caesarea secara mandiri. discharge planning yang diterima pasien mampu meningkatkan pengetahuan pasien, dan dengan pengetahuan yang dimiliki pasien tahu dan mampu untuk melakukan perawatan sesuai dengan cara yang benar. pada kondisi post sectio caesarea ini self care requisites (self care demands) atau kebutuhan self care pasien lebih besar dibandingkan dengan self care agency-nya atau kemampuan pasien untuk melakukan perawatan mandiri, sehingga terjadi self care defi cit. pada situasi seperti inilah peran perawat sangat dibutuhakan, ada 5 helping methode yang dapat digunakan oleh perawat, yaitu melakukan atau membantu langsung (acting or doing), membimbing (guiding), pendidikan (teaching), memberi dukungan (supporting) dan menyediakan ( providing) lingkungan ya ng mendu k u ng ser t a men i ng k at k a n kemampuan pasien memenuhi self care-nya. helping methode tersebut disesuaikan dengan kondisi pasien, apakah butuh perawatan total (wholly compensatory), perawatan sebagian ( partial compensatory), serta pendidikan dan dukungan (educative supportive). pada ibu post sectio caesarea yang dipersiapkan untuk pulang (discharge planning) ibu dalam kondisi kebutuhan pendidikan dan dukungan (educative supportive), sehingga peneliti memberikan bimbingan (guiding), pendidikan (teaching), dan dukungan (supporting) melalui pendekatan discharge planning dengan tujuan agar ibu post sectio caesarea dapat mandiri melakukan perawatan di rumah. kelo m p ok ko nt r ol j u g a t e r ja d i peningkatan tindakan kemandirian, walaupun tidak setinggi peningkatan pada kelompok kontrol. adanya discharge planning pada pasien post sectio caesarea dengan metode yang merujuk pada proedur tetap rsud dr. soegiri berar ti juga mempengar uhi tindakan kemandirian ibu post sectio caesarea. terdapat perbedaan yang begitu mencolok pada kelompok perlakuan dan kelompok kontrol, salah satunya adalah kondisi luka pasien saat kontrol, pada kelompok perlakuan seluruh pasien kondisi lukanya sudah baik saat kontrol, namun pada kelompok kontrol terdapat 3 responsden, yait u responden no. 1, no. 6, dan no. 7 yang kondisi lukanya tidak baik saat kontrol. hal ini berkaitan 184 jurnal ners vol. 7 no. 2 oktober 2012: 177–185 dengan tindakan responden tersebut yang tidak melakukan perawatan secara tepat, seperti tidak mengkonsumsi makanan yang dapat mempercepat penyembuhan luka dan tidak menjaga luka agar tetap kering dan bersih. kemungkinan besar kondisi tersebut diakibatkan kurangnya pengetahuan pasien pada kelompok kontrol akan perawatan luka post sectio caesarea secara tepat dan benar. hou (2001) dalam per r y & potter (2006) kesu ksesan tindakan discharge planning menjamin pasien mampu melakukan tindakan perawatan lanjutan yang aman dan realistis setelah meninggalkan rumah sakit. berdasarkan hasil penelitian, didapatkan bahwa responden yang mendapatkan discharge planning kemandirian perawatan post sectio caesarea memiliki pengetahuan serta tindakan yang baik dalam merawat lukanya. hal ini disebabkan oleh meningkatnya pengetahuan dan keterampilan pasien dalam melakukan perawatan post sectio caesarea, sehingga kema nd i r ia n pa sien u nt u k mela k u k a n perawatan di rumah juga meningkat, selain itu didapatkan pula bahwa kondisi luka pasien saat kontrol sudah baik dan tidak ada indikasi infeksi. simpulan dan saran simpulan pengetahuan mengenai kemandirian perawatan pasien post sectio caesarea mengalami peningkatan setelah dilakukan discharge planning berdasarkan teori self care orem untuk kemandirian perawatan luka pada ibu post sectio caesarea. keterampilan dalam kemandirian perawatan pasien post sectio caesarea mengalami peningkatan setelah dilakukan discharge planning berdasarkan teori self care orem untuk kemandirian perawatan luka pada ibu post sectio caesarea. tingkat kemandirian perawatan pasien post sectio caesarea pada kelompok perlakuan lebih tinggi dibandingkan tingkat kemandirian perawatan luka post sectio caesarea pada kelompok kontrol. saran pasien post sectio caesarea diharapkan dapat secara mendiri melakukan perawatan post sectio caesarea secara tepat dan sesuai dengan petunjuk petugas kesehatan selama prosedur discharge planning, sehingga dapat mempercepat penyembuhan dan menekan resiko terjadinya infeksi. institusi rumah sakit perlu menyusun sebuah prosedur persiapan pulang pasien post sectio caesarea dalam format khusus yang membedakan format discharge planning pada ibu bersalin secara caesar dengan ibu yang melahirkan normal. perawat ruangan seharusnya memberikan intervensi discharge planning tidak hanya saat pasien akan keluar rumah sakit saja, namun sudah dimulai ketika pasien baru masuk, selama menjalani perawatan, sehingga persiapan keluar r umah sakit. penelitian selanjutnya bisa dilakukan pada analisis perilaku perawat yang berhubungan dengan pelaksanaan discharge planning yang baik dan benar. kepustakaan basford, l., et al., 2006, teori dan praktik keperawatan: pendekatan integral pada asuhan pasien, jakarta: egc. bobak, l., 2004. keperawatan maternitas, jakarta: egc. boyle, m., 2005. wounds and healing in midwifery, oxford: radclife publishing, united kingdom. cunningham, g.f., gant, f.n., leveno, j.k., gillstrap, c.l., hauth, c.j., wenstrom, d.k., 2004. obstetri williams, edisi 21. jakarta: egc. discharge planning association, 2008. discharge planning, (online), diakses di (ht t p://w w w.dischargeplan ning. org.au/index.html., diakses tanggal 15 maret 2012) farrer, helen, 2001. perawatan maternitas. edisi 2, jakarta: egc. hidayat, a.a., 2007. pengantar konsep dasar keperawatan, jakarta: salemba medika. 185 kemandirian perawatan ibu post sectio caesarea (tinok ayu putri w, dkk.) himatusujanah dan rahayuningsih, f.b., 2008. hubungan tingkat kepatuhan pelaksanaan protapperawatan luka dengan kejadian infeksi lukapost sectio caesarea (sc) di ruang mawar i rsud dr. moewardi surakarta. berita ilmu keperawatan. 1(4). 175–180, (online), (http://eprints.ums.ac.id/1129/1/4e.pdf diakses tanggal 29 maret 2012). johnson, a., young, d., reilly, j., 2006. caesarean section surgical site infection surveillance. journal of hospital infect ion.(online),(http://www.sciencedirect. com., diakses tanggal 12 maret 2012). king edward memorial hospital, 2010. following caesarean birth. media release. depa r t ment women a nd newborn health service, government of western australia, departmentof health, (online), (http://kemh.health. w a .g ov. a u / b r o c h u r e s /c o n s u m e r s / wnhs0011.pdf)., diakses tanggal 2 maret 2012). kozier, b., 2004. fundamental of nursing, seventh edition, new jersey: new jersey pearson: education inc. mallet, j., (ed), 2004. royal marsden hospital: manual of clinical nursing procedures, usa: blackwell publishers. nursalam, 2007. manajemen keperawatan aplikasi dalam praktik keperawatan profesional, edisi 2, jakarta: salemba. perry, a.g. dan potter, p.a., 2006. clinical nursing skills and technique. 6th edition, missouri: mosby inc. vol 8 no 1 april 2013.indd 88 prediktor beban merawat dan tingkat depresi caregiver dalam merawat lanjut usia dengan demensia di masyarakat (the predictors of caregiver’s burden and depression level in caring elderly people with dementia at community) yossie susanti eka putri *fakultas ilmu keperawatan universitas indonesia kampus ui depok 16424 jakarta, indonesia, e-mail: yossie_putri@yahoo.com abstrak pendahuluan: mayoritas lansia dengan dimensia di indonesia tinggal di rumah dalam perawatan anggota keluarga. keluarga sebagai caregiver lansia dengan dimensia mengalami masalah fi sik, psikologis, sosial, dan fi nansial. kebutuhan perawatan kadang menimbulkan beban dan tingkat depresi bagi caregiver. tujuan dari penelitian ini adalah mengidentifi kasi prediktor beban merawat dan tingkat depresi caregiver dalam merawat lansia dengan demensia di masyarakat. metode: penelitian ini merupakan deskriptif analitik dengan pendekatan cross sectional. populasinya adalah caregiver utama lansia dengan demensia. sampel sejumlah 183 orang. variabel independen meliputi contextual factors, stressor caregiving, dan intervening factor dari caregiver. sementara variabel dependen meliputi beban merawat dan tingkat depresi caregiver. data dikumpulkan dengan kuesioner. analisis data dilakukan dengan regresi linier. hasil: analisis statistik menunjukkan status pernikahan caregiver berhubungan dengan beban merawat. sementara, pekerjaan, pendidikan, dan hubungan keluarga caregiver dengan lansia berhubungan dengan tingkat depresi. faktor yang paling dominan berhubungan dengan beban merawat yaitu masalah memori dan perilaku, sedangkan faktor yang paling dominan berhubungan dengan tingkat depresi caregiver yaitu status kesehatan. diskusi dan kesimpulan: hasil penelitian dapat digunakan sebagai acuan dalam mengembangkan pelayanan yang sesuai dengan kebutuhan caregiver dalam memberikan perawatan pada lansia dengan dimensia di komunitas. kata kunci: beban, depresi, demensia, pengasuh abstract introduction: most older people with dementia in indonesia stay at home, cared by family members. family caregivers even experience physical, psychological, social, and fi nancial problems. care giving demands often lead to caregiver burden and depression. the objective of this study was to determine factors which contribute burden and depression experienced by the caregivers of older people with dementia. method: design was descriptive analytic with cross sectional approach. the population were caregivers living with older people with dementia. sample size were 183 respondents. the independent variables were caregiver’s contextual factors, stressor caregiving, and intervening factor. the dependent variables were the burden of care and level of caregivers’ depression. data were collected using questionnaire. data were analyzed using linier regresion. results: statistical analyses showed marital status was signifi cantly related to caregivers’ burden. while worked, education, and relationships with older people were signifi cantly related with caregivers’ depression level. memory and behavior problem, the task of caring and satisfaction of caring were related with caregivers’ burden and depression level. multivariate analyses show health status was the most factors related to caregivers’ depression level. memory and behavior problems was main factor related to caregivers’ burden of caring for older people with dementia. discussion and conclusion: 89 prediktor beban merawat dan tingkat depresi caregiver (yossie susanti eka putri) pendahuluan populasi lansia di indonesia ter us meningkat sejalan dengan meningkatnya usia harapan hidup. diperkirakan tahun 2025, populasi lansia mencapai 12,8% dari total populasi indonesia (who, 2008). saat ini jumlah lansia di indonesia 23,9 juta jiwa, di mana mayoritas tinggal di wilayah pedesaan. semakin meningkatnya populasi lansia di indonesia, sejalan dengan peningkatan prevalensi lansia dengan demensia (lloydsherlock, 2000). demensia tidak saja mempengaruhi lansia, tetapi juga caregiver atau anggota keluarga yang merawat lansia tersebut. mayoritas lansia di indonesia dirawat di rumah oleh keluarga, dalam hal ini anak ataupun yang memiliki hubungan saudara. masih terbatasnya layanan yang tersedia bagi lansia dengan demensia, serta tanggung jawab sosial budaya yang membuat kebanyakan dari para lansia tersebut dirawat oleh anak-anaknya. hal ini berdampak pada kesejahteraan keluarga lansia sebagai caregiver, karena merawat seseorang dengan demensia membutuhkan perhatian yang penuh dalam rentang waktu yang tidak dapat diperkirakan. caregiver lansia dengan demensia sering menghadapi masalah akibat perubahan yang terjadi pada lansia tersebut. kondisi ini tidak saja berdampak pada kesehatan fi sik, tetapi juga mental dan bahkan sosial ekonomi caregiver itu sendiri (shaji, et al., 2003). lebih jauh lagi juga akan berdampak terhadap hubungan antar anggota keluarga itu sendiri. beberapa hasil penelitian terdahulu menunjukkan bahwa beban caregiver dalam merawat lansia dengan demensia berhubungan dengan timbulnya kondisi depresi (gonyea, et al., 2005). selain itu, beban yang dialami caregiver juga berkaitan dengan peran yang overload dalam menghadapi per ubahan perilaku lansia demensia, serta perasaan terjebak dalam lingkaran rutinitas pekerjaan sebagai caregiver (alspaugh, et al., 1999). hasil penelitian clarck dan diamond (2010) juga menggambarkan bahwa peningkatan jumlah waktu yang dibutuhkan dalam merawat lansia demensia dengan ketergantungan merupakan faktor risiko terhadap beban caregiver yang dapat menimbulkan masalah kesehatan fi sik dan depresi. stressor caregiving akibat gangguan yang dialami lansia dan tanggung jawab merawat lansia secara langsu ng berhubungan dengan depresi. dampak psikososial yang dialami caregiver akibat merawat lansia dengan demensia perlu disiapkan lebih dini dalam m e n g h a d a pi p e r u b a h a n sit u a si y a n g dialaminya. dukungan dari tenaga kesehatan t e r ut a m a pe r awat d ala m me mbe r i k a n informasi tentang kondisi atau perubahan yang terjadi pada lansia dengan demensia sangatlah penting, sehingga risiko terjadinya depresi pun dapat diatasi. namun, untuk dapat menentukan kebutuhan apa yang diperlukan oleh caregiver, maka penting diketahui tantangan dan kendala yang dialami caregiver dalam merawat lansia demensia di masyarakat. kebutuhan caregiver dapat dipenuhi dan bentuk dukungan ataupun pelayanan yang diperlukan dapat dikembangkan. pe n el it i a n i n i b e r t uj u a n u nt u k memperoleh gambaran tentang prediktor beban merawat dan tingkat depresi caregiver dalam merawat lansia dengan demensia di masyarakat. dengan demikian, dapat diketahui kondisi yang dialami caregiver, sehingga dapat dikembangkan pelayanan yang berbasis kebutuhan caregiver dengan demensia di masyarakat. bahan dan metode penelitian ini menggunakan desain deskriptif analitik dengan pendekatan cross sectional ber t ujuan unt uk mendapatkan the results are expected to provide information about the extent of caregivers’ burden and depression which experienced in care giving, therefore the services can be designed based on the needs of the caregivers of persons with dementia in the community. keywords: burden, depression, dementia, caregiver 90 jurnal ners vol. 8 no. 1 april 2013: 88–97 gambaran hubu ngan di antara var iabel independen terhadap variabel dependen. contextual factors, stressor caregiving dan inter vening factor dihubungkan dengan beban merawat dan tingkat depresi caregiver. analisis data dilakukan dengan analisis univariat, bivariat, dan multivariat. populasi pada penelitian ini adalah keluarga yang memili k i lansia dengan demensia. sampel dalam penelitian ini adalah keluarga (caregiver utama) yang merawat lansia demensia di rumah dan lansia. alat pengumpul data menggunakan instrumen: karakteristik keluarga; beban merawat mengg u nakan k uesioner zarit caregiver burden interview dari hebert, bravo dan preville (2000); depresi yang dialami keluarga menggunakan zung self rating depression scale; status kesehatan keluarga menggunakan modifi kasi short form health survey (sf-12) dari ware, snow, kosinki & gandek (1971); kedekatan hubungan dalam keluarga menggunakan modifikasi family adaptabilit y and cohesion, evaluation scales (faces ) dari olson et al. (1985); masalah memori dan perilaku menggunakan m o d i f i k a si d a r i i n s t r u m e n t m e m o r y and behavior checklist; t ugas merawat; kepuasan merawat menggunakan modifi kasi the carer’s assessment of satisfaction index (casi ) dari andren & elmstahl (2005); dukungan sosial menggunakan modifikasi mos sosial support survey dari sherbourne & stewart (1991). hasil hasil analisis univariat menunjukkan bahwa usia caregiver rata-rata 40,78, mayoritas berjenis kelamin perempuan (78,1%), status kawin menikah (80,9%), ber pendidikan menengah (59,6%), bekerja (60,1%), hampir separuhnya berpenghasilan di bawah umr (49,7%) dan hubungan keluarga dengan lansia mayoritas sebagai orang tua (62,3%). beban merawat caregiver rata-rata 27,96 dan sebagian besar caregiver mengalami beban sedang (55,7%). tingkat depresi caregiver ratarata 17,66 dan hampir separuhnya caregiver mengalami depresi (47,0%). hasil analisis bivariat menunjukkan bahwa status kesehatan, kedekatan hubungan dan status perkawinan berhubungan secara bermakna dengan beban caregiver merawat lansia dengan demensia dengan p value <0,05. sedangkan variabel status kesehatan, pekerjaan, hubungan caregiver dengan lansia, dan pendidikan berhubungan secara bermakna dengan tingkat depresi caregiver dengan p value <0,05 (tabel 1). pada tabel 2, dapat dilihat stressor caregiving (masalah memori dan perilaku, t ugas merawat, dan kepuasan merawat) berhubungan secara bermakna dengan beban merawat dan tingkat depresi caregiver, dengan p value <0.05. intervening factor (dukungan sosial) tidak berhubungan secara bermakna dengan beban merawat dan tingkat depresi caregiver, dengan p value >0.05 (tabel 3). tabel 1. hubungan antara contextual factors dengan beban merawat dan tingkat depresi caregiver variabel beban merawat tingkat depresir p value r p value usia -0.016 0.829 0.073 0.326 lama merawat -0.071 0.340 0.058 0.439 status kesehatan -0.366 0.000 -0.528 0.000 kedekatan hubungan -0.164 0.026 -0.102 0.168 t p value t p value jenis kelamin 1.111 0.268 0.331 0.741 pekerjaan 0.749 0.455 2.141 0.034 pendapatan -1.376 0.170 -0.153 0.879 hubungan caregiver dengan lansia -0.239 0.811 -2.103 0.037 f p value f p value pendidikan 1.746 0.177 0.369 0.027 status perkawinan 3.720 0.026 0.494 0.611 91 prediktor beban merawat dan tingkat depresi caregiver (yossie susanti eka putri) hasil analisis multivariat dengan regresi linier menunjukkan bahwa faktor-faktor yang berhubungan dengan beban merawat adalah pendapatan, status kesehatan, masalah memori dan perilaku serta tugas merawat. faktor yang paling dominan berhubungan dengan beban merawat adalah masalah memori dan perilaku (tabel 4). faktor-faktor yang berhubungan dengan tingkat depresi caregiver adalah pendidikan, status kesehatan, masalah memori dan perilaku, serta tugas merawat. faktor yang paling dominan berhubungan dengan tingkat depresi caregiver adalah status kesehatan. (tabel 5). pembahasan karakteristik caregiver berdasarkan hasil penelitian, usia caregiver rata-rata 40,78 tahun yang termasuk usia dewasa di mana pada usia tersebut sudah mencapai kematangan emosional dan mempunyai kemampuan dalam pengambilan keputusan. sebagian besar caregiver berjenis kelamin perempuan (78,1%), hal ini sesuai dengan hasil penelitian riasmini (2010) yang menunjukkan bahwa mayoritas lansia dirawat oleh anak perempuannya. didukung juga oleh hasil penelitian laubunjong (2008) tentang pola caregiving pada lansia, ditemukan bahwa mayoritas lansia menginginkan dirawat oleh anak perempuannya. hubungan caregiver dengan lansia mayoritas sebagai orang tua, hal ini sesuai dengan budaya indonesia di mana budaya keluarga besar (extended family) masih berkembang, memungkinkan lansia untuk tinggal bersama keluarga (anak, menantu, cucu atau anggota keluarga lain). umumnya lansia masih mempunyai kedudukan yang cukup tabel 2. hubungan antara stressor caregiving dengan beban merawat dan tingkat depresi caregiver variabel beban merawat tingkat depresi r p value r p value masalah memori dan perilaku 0.515 0.000 0.347 0.000 tugas merawat -0.315 0.000 -0293 0.000 kepuasan merawat -0159 0.031 -0.229 0.002 tabel 3. hubungan antara intervening factor dengan beban merawat dan tingkat depresi caregiver variabel beban merawat tingkat depresir p value r p value dukungan sosial -0.082 0.269 -0.094 0.206 tabel 4. model akhir regresi linier variabel yang berhubungan dengan beban merawat variabel b beta r p value pendapatan -2.370 0.108 0.053 status kesehatan -0.413 -0.236 0.000 masalah memori dan perilaku 0.314 0.412 0.000 tugas merawat -0.383 0.110 0.001 constant 48.109 0.376 0.000 tabel 5. model akhir regresi linier variabel yang berhubungan dengan tingkat depresi caregiver variabel b beta r p value pendidikan -1.894 -0.151 0.011 status kesehatan -0.529 -0.451 0.000 masalah memori dan perilaku 0.098 0.191 0.002 tugas merawat -0.247 -0.205 0.001 constant 49.050 0.391 0.000 92 jurnal ners vol. 8 no. 1 april 2013: 88–97 tinggi sebagai orang tua yang harus dihormati dan dihargai, karena lebih banyak mempunyai pengalaman, sehingga pendapatnya masih dibutuhkan dalam pengambilan keputusan keluarga (fitriani, 2009). sebagian besar caregiver menikah dan masih bekerja, hal ini menunjukkan bahwa caregiver mempunyai tanggung jawab untuk membiayai kehidupan keluarganya termasuk lansia khususnya dalam pemenuhan kebutuhan sehari-hari dan kebutuhan akan pelayanan kesehatan bagi lansia dengan demensia. namun jika dilihat dari pendapatan caregiver hampir separuhnya berpenghasilan di bawah umr (upah minimum regional), sehingga kondisi ini dapat menimbulkan beban ganda secara fi nansial. caregiver harus menanggung biaya untuk pemenuhan kebutuhan keluarga dan juga lansia dengan ketidakmampuan yang dialami (dupuis, epp, dan smale, 2004). hubungan antara karakteristik demografi dengan beban merawat dan tingkat depresi caregiver hasil penelitian ini menunju k kan bahwa beberapa variabel dalam karakteristik demografi memiliki hubungan yang bermakna dengan beban merawat dan tingkat depresi yang dialami caregiver. ditinjau dari beban merawat, maka status perkawinan berhubungan secara bermakna dengan beban caregiver merawat lansia sedangkan untuk variabel pekerjaan, pendidikan dan hubungan dengan lansia berhubungan secara bermakna dengan tingkat depresi yang dialami caregiver. mayoritas caregiver yang merawat lansia berstatus menikah dan berjenis kelamin perempuan, sehingga mereka memiliki tanggung jawab ganda dalam hal merawat, tidak hanya untuk anak-anaknya, tetapi juga lansia yang demensia, termasuk mengurus rumah tangganya. hal ini tentu saja dapat menimbulkan beban yang sangat berat bagi caregiver karena ber usaha unt uk dapat melaksanakan tugas itu semua secara optimal. huang dkk. (2011) melaporkan bahwa secara statistik ada hubungan positif yang signifi kan antara status perkawinan dengan beban yang dialami oleh caregiver. hasil penelitian ini sejalan dengan temuan riset oleh kim dkk. (2009) yang menyatakan bahwa caregiver perempuan lebih berisiko untuk mengalami beban dalam merawat lansia dengan demensia dibandingkan caregiver laki-laki karena caregiver perempuan dituntut untuk terlibat secara total dalam merawat lansia, seperti menjaga kebersihan diri ataupun kebutuhan nutrisinya sementara caregiver laki-laki yang lebih banyak membantu dalam hal kegiatan tambahan untuk lansia tersebut. selain itu, akibat banyaknya waktu caregiver tersita untuk merawat lansia sehingga terkadang menimbulkan konfl ik dengan pasangan mereka dalam hubungan sebagai suami istri (putri, de bellis dan xiao, 2010). hasil penelitian ini juga menemukan bahwa status pekerjaan, pendidikan, serta hubungan dengan lansia memiliki hubungan bermakna dengan tingkat depresi yang dialami caregiver. walaupun penelitian ini tidak melakukan uji spesifik tingkat pendidikan dan status pekerjaan terhadap tingkat depresi caregiver. namun, dapat dipahami bahwa status pendidikan seseorang akan berpengaruh terhadap pengetahuan serta informasi yang diperolehnya. seperti yang dijelaskan oleh sansoni, vellone dan piras (2004) dalam risetnya yang menyatakan bahwa tingkat pendidi kan caregiver akan berdampak terhadap tingkat depresi yang dialaminya saat merawat lansia dengan penyakit alzheimer di mana caregiver dengan tingkat pendidikan yang tinggi akan lebih rendah insiden untuk terjadi depresi dibandingkan sebaliknya. bentuk hubungan caregiver dengan lansia pada penelitian ini mayoritas hubungan orang tua dan anak sehingga berpengaruh terhadap bagaimana bentuk interaksi di antara mereka. seperti diketahui bahwa nilai yang masih berlaku dalam masyarakat kita ialah seorang anak wajib memberikan kasih sayang kepada orang tuanya sebagaimana pernah mereka dapatkan sewaktu mereka masih kecil. hal ini menimbulkan perasaan ambivalensi bagi caregiver antara tanggung jawab harus merawat orang tua dan juga kewajibannya untuk bekerja mencari naf kah bagi keluarganya. perasaan bersalah ini akan menimbulkan terjadinya depresi pada caregiver. hasil penelitian ini selaras dengan 93 prediktor beban merawat dan tingkat depresi caregiver (yossie susanti eka putri) hasil penelitian asniar (2007) di mana caregiver mengalami stress, menangis, dan rasa bersalah akibat meninggalkan tanggung jawab untuk merawat lansia karena harus mencari naf kah untuk menghidupi keluarga. lebih lanjut hasil riset ozge dkk (2009), melaporkan bahwa 17.1% caregiver yang merawat lansia mengalami ansietas dan 14.6% mengalami depresi. hubungan antara status kesehatan keluarga dengan beban merawat dan tingkat depresi caregiver hasil penelitian menunjukkan bahwa status kesehatan berhubungan secara bermakna dengan beban dan tingkat depresi caregiver dalam merawat lansia dengan demensia. dalam hal ini kondisi kesehatan caregiver itu sendiri akan berdampak terhadap respons mereka dalam merawat lansia dengan demensia begitu juga sebaliknya bahwa status kesehatan lansia dengan demensia akan berpengaruh terhadap kondisi kesehatan caregiver karena tersitanya waktu, tenaga dan pikiran dalam merawat lansia tersebut. se p e r t i ya ng d iu ng k apk a n oleh covinsky dkk (2003) dalam penelitiannya bahwa buruknya kondisi kesehatan caregiver akan berdampak terhadap risiko terjadinya depresi pada caregiver. penelitian lebih lanjut, perlu melihat sejauh mana kondisi kesehatan caregiver akan berdampak terhadap respons beban yang dirasakannya. demikian juga dari hasil penelitian bell dkk. (2001) dalam mc conaghy (2005) yang mengungkapkan bahwa merawat lansia dengan demensia berhubungan dengan penurunan kesehatan fisik dan psikologis caregiver. faktor yang dihubungkan dengan kebosanan yang meningkatkan beban keluarga merawat lansia demensia yaitu masalah kesehatan yang dialami keluarga, dan jumlah waktu yang dihabiskan merawat lansia. depresi merupakan konsekuensi mayor dari beban caregiver dalam merawat lansia demensia. hasil penelitian menunjukkan ada hubungan positif antara beban merawat dengan gejala depresi (papastavrou, et al., 2007). walaupun penelitian ini tidak melihat beban dengan tingkat depresi namun ada beberapa hasil studi yang menunjukkan hubungan antara beban dengan tingkat depresi caregiver. hasil analisis multivariat menunjukkan bahwa status kesehatan merupakan faktor yang paling berhubungan dengan tingkat depresi caregiver. hal ini dapat dijelaskan karena sebagian besar caregiver adalah perempuan yang ber usia rata-rata di tahap dewasa pertengahan di mana mereka mempunyai peran ganda baik di rumah terhadap anak dan suami, di tempat kerja dan juga peran sebagai seorang anak yang berbakti pada orang tua dengan merawat mereka. kondisi ini menimbulkan kelelahan fi sik dan psikologis yang berpengaruh terhadap status kesehatan caregiver seperti yang dikemukakan oleh brown dkk (2007). hubungan antara hubungan dalam keluarga dengan beban merawat dan tingkat depresi caregiver hasil penelitian menunjukkan bahwa ada hubungan bermakna antara kedekatan hubungan dengan beban merawat sedangkan kedekatan hubungan dengan tingkat depresi tidak berhubungan. hasil penelitian juga menunjukkan bahwa mayoritas caregiver adalah perempuan, sehingga dapat berpengaruh terhadap kedekatan hubungan emosional dengan lansia demensia. menurut beck dan stuck, (2001), burden merupakan bagian dari situasi caregiving. peningkatan burden terjadi pada caregiver perempuan mungkin disebabkan akibat kedekatan hubungan serta keterlibatan emosional yang lebih besar. anak perempuan memberikan perawatan yang lebih termasuk perawatan personal, membantu pekerjaan r umah, menyiapkan makanan, transportasi dan mengelola keuangan. secara kultural anak perempuan mempunyai tanggung jawab yang lebih besar dalam merawat lansia dengan keterbatasan (dupuis, epp, dan smale, 2004). hubungan antara masalah memori dan perilaku dengan beban merawat dan tingkat depresi caregiver hasil penelit ia n mengga mba rka n bahwa masalah memori berhubungan secara ber ma k na dengan beban merawat d an 94 jurnal ners vol. 8 no. 1 april 2013: 88–97 tingkat depresi caregiver. stressor caregiving mencakup komponen multipel yaitu stressor objektif dan subjektif ser ta ketegangan peran seperti masalah memori dan perilaku, ke t id a k m a m pu a n d a l a m m e mb e r i k a n perawatan dan melaksanakan tugas merawat serta ketidakpuasan dalam merawat. hal ini sesuai dengan hasil penelitian bell, et al. (2001) dalam dupuis, epp, dan smale (2004) bahwa gangguan kognitif, masalah memori dan perilaku berhubungan dengan beban yang dialami caregiver dalam merawat lansia dengan demensia dan sejalan dengan hasil penelitian oleh razani dkk. (2007) yang menunjukkan ada hubungan antara gangguan kognitif yang dialami lansia dengan beban merawat dan distress psikologis yang dialami caregiver. sama halnya dengan depresi yang dialami caregiver dalam merawat lansia dengan demensia, di mana hasil penelitian whitlatch, et al. (2001), dalam majerovitz, (2007) menggambarkan ada hubungan antara interaksi negatif, masalah memori dan perilaku terhadap depresi yang dialami caregiver. hasil penelitian clarck dan diamond (2010) juga menggambarkan bahwa peningkatan jumlah waktu yang dibutuhkan dalam merawat lansia demensia dengan ketergantungan merupakan faktor risiko terhadap beban caregiver yang dapat menimbulkan masalah kesehatan fi sik dan depresi. stressor caregiving akibat gangguan yang dialami lansia dan tanggung jawab merawat lansia secara langsu ng berhubungan dengan depresi. hasil analisis multivariat menunjukkan ba hwa ma sala h memor i d a n per ila k u mer upakan faktor yang paling dominan berhubungan dengan beban caregiver dalam merawat lansia dengan demensia. caregiver yang mengalami masalah memori dan perilaku cenderung tidak mampu mengontrol diri dan emosinya dalam menghadapi per ubahan perilaku yang terjadi pada lansia dengan demensia, sehingga berdampak terhadap sikap dan perilakunya dalam merawat. menurut lee (2008), stres dan burden dalam memberikan perawatan membuat caregiver melakukan tindakan kekerasan kepada lansia yang berdampak terhadap menurunnya kualitas hidup lansia. di samping itu, faktor kontekstual seperti dukungan sosial, keterlibatan dalam memberikan perawatan dan strategi koping juga mer upakan var iabel penting yang berhubungan dengan tindakan kekerasan pada lansia. lee (2008), juga menemukan bahwa burden yang dialami caregiver dalam merawat lansia berhubungan secara signifi kan terhadap tingkat kekerasan yang dialami lansia. caregiver yang mengalami tingkat burden tinggi, lebih besar kemungkinannya untuk melakukan tindakan kekerasan kepada lansia. hubungan antara tugas merawat dengan b e b a n m e r a w a t d a n t i n g k a t d e p re s i caregiver penelitian ini menunjukkan bahwa ada hubungan bermakna antara tugas merawat dengan beban merawat dan tingkat depresi caregiver. tugas merawat orang tua dalam budaya indonesia dipandang mer upakan tanggung jawab seorang anak terhadap orang tuanya sebagai bentuk bakti, rasa sayang dan menghormati orang tua. apalagi dari hasil penelitian ini ditemukan hubungan caregiver dengan lansia mayoritas sebagai orang tua dengan sebagian besar caregiver berjenis kelamin perempuan. h o n g d a n k i m (2 0 0 8) d a l a m penelitiannya di korea bahwa mayoritas peran caregiver dilakukan oleh menantu perempuan dan beban tertinggi ditemukan pada perempuan karena sebagai caregiver utama mereka merawat lansia demensia dalam memenuhi kebutuhan sehari-hari dibandingkan caregiver laki-laki. caregiver laki-laki cenderung hanya merawat yang sifatnya dukungan instrumental seper t i memba nt u keu a nga n, membeli kebutuhan lansia dan mendampingi caregiver utama dalam merawat lansia demensia. hubungan antara kepuasan merawat dengan beban merawat dan tingkat depresi caregiver hasil penelitian menunjukkan bahwa ada hubungan bermakna antara kepuasan merawat dengan beban merawat dan tingkat depresi caregiver. kepuasan caregiver dalam merawat lansia demensia dipengaruhi oleh bagaimana 95 prediktor beban merawat dan tingkat depresi caregiver (yossie susanti eka putri) dia menerima dan menjalankan perannya sebagai caregiver dan bentuk hubungan antara anak dan orang tua. semakin banyak pengalaman positif yang dirasakan dalam merawat lansia demensia akan berdampak terhadap rendahnya beban yang dialami dan tingkat depresi yang dirasakan. sebaliknya, jika caregiver merasakan pengalaman merawat sebagai hal yang negatif maka berpengaruh terhadap kepuasannya sehingga tugas merawat dianggap sebagai suatu beban yang pada akhirnya berpengaruh pada meningkatnya tingkat depresi yang dialami. kuuppelomäki d k k. (2004) dalam risetnya menyatakan bahwa sumber kepuasan utama caregiver dalam merawat lansia adalah adanya perasaan dibutuhkan dan dicari dalam memberikan perawatan. selain itu perasaan dihargai oleh keluarga dan teman juga menjadi sumber kepuasan caregiver dalam merawat lansia. sebaliknya jika caregiver merasakan st ressor yang tinggi dalam merawat lansia demensia dan merasa tidak puas dengan kehidupannya maka cenderung tidak merasakan kepuasan dalam merawat lansia tersebut. ketidakpuasan menjadi faktor pemicu terjadinya depresi. hubungan antara dukungan sosial dengan b e b a n m e r a w a t d a n t i n g k a t d e p re s i caregiver hasil penelitian menunjukkan tidak ada hubu ngan antara du k u ngan sosial dengan beban merawat dan tingkat depresi caregiver. hasil penelitian ini tidak sejalan dengan hasil temuan riset chiou dkk. (2009) yang menyatakan bahwa beban yang dialami caregiver akan lebih tinggi jika kurangnya dukungan sosial yang diberikan. kondisi tersebut dapat dijelaskan lebih lanjut bahwa walaupun dukungan sosial tidak selalu dapat mengurangi beban merawat, akan tetapi dapat meningkatkan kesehatan psikologis caregiver (chappell dan reid, 2002, dalam majerovitz, 2007). meskipun duk ungan sosial secara langsung tidak berhubungan dengan beban merawat dan dan tingkat depresi caregiver, akan tetapi dengan memperluas jaringan sosial sebagai sistem pendukung dapat menurunkan beban merawat dan meningkatkan ketersediaan du k u ngan emosional d an pengharga an sehingga berdampak terhadap k ualit as kesehatan caregiver. konsekuensi positif dari dukungan sosial adalah perilaku peningkatan status kesehatan, kompetensi personal, koping, perasaan sejahtera, penurunan ansietas dan depresi (peterson dan brewdow, 2004). menur ut wang (2009), tidak adekuatnya dukungan sosial dan kurangnya pelatihan tentang perawatan berkontribusi terhadap perilaku kekerasan yang dilakukan caregiver kepada lansia. simpulan dan saran b e r d a s a r k a n p e m b a h a s a n h a s i l penelitian yang telah diuraikan sebelumnya, dapat ditarik kesimpulan sebagai berikut: karakteristik caregiver yaitu usia rata-rata 40.78 tahun, mayoritas berjenis kelamin p e r e m p u a n , s t a t u s k a w i n m e n i k a h , berpendidikan menengah, mayoritas bekerja, hampir separuhnya berpenghasilan di bawah umr dan hubungan caregiver dengan lansia mayoritas sebagai orang tua. terdapat hubungan bermakna antara contextual factor (stat us kawin, stat us kesehatan, dan kedekatan hubungan) dengan beban keluarga dalam merawat lansia dengan demensia. ada hubungan bermakna antara contextual factor (pendidikan, pekerjaan, hubungan caregiver dengan lansia dan status kesehatan) dengan tingkat depresi caregiver. ada hubungan bermakna antara stressor caregiving (masalah memori dan perilaku, tugas merawat dan kepuasan merawat) dengan beban merawat dan tingkat depresi caregiver. tidak ada hubungan antara intervening factor (dukungan sosial) dengan beban merawat dan tingkat depresi caregiver. fa k t o r y a n g p a l i n g d o m i n a n berhubungan dengan beban merawat yaitu masalah memori dan perilaku, sedangkan faktor yang paling dominan berhubungan dengan tingkat depresi caregiver yaitu status kesehatan. hasil penelitian ini dapat digunakan sebagai acu a n d alam mengemba ng ka n pelayanan yang sesuai dengan kebutuhan 96 jurnal ners vol. 8 no. 1 april 2013: 88–97 caregiver. caregiver perlu dipersiapkan dengan memberikan psikoedukasi tentang kondisi lansia dengan demensia dan kebutuhan perawatan lansia demensia tersebut, sehingga mereka mampu memberikan perawatan yang optimal yang pada akhirnya meningkatkan kualitas hidup lansia demensia. perlu dilakukan penelitian kualitatif untuk mengeksplorasi tingkat beban dan depresi caregiver dalam merawat lansia demensia. selanjutnya hasil penelitian tersebut ditindaklanjuti dengan melakukan penelitian yang berfokus pada pengembangan bentuk pelayanan yang sesuai dengan kebutuhan caregiver dalam merawat lansia dengan demensia di masyarakat. kepustakaan alspaugh, mel., stephens, map., townsend, a., zarit, sh., dan greene, r., 1999. longit udinal patter ns of risk for depression in dementia caregivers: objective and subjective primary stress as predictors. psychology and aging, 14, 34–43. asniar, 2007. studi fenomenologi tentang pengalaman keluarga merawat anggota keluarga paska stroke di rumah di kelurahan depok, kecamatan pancoran mas, kota depok jawa barat. tesis tidak dipublikasikan. brown, pj., bennett, k dan walker, a., 2007. care giving experiences of older husbands providing care for wives with dementia. dissertation unpublished. university of western sydney. new south wales. chiou, cj., et al., 2009. social support and caregiving circumstances as predictors of caregiver burden in taiwan. archives of gerontolog y and geriatrics 48: 419–424. clark, mc. d an diamond, pm., 2010. depression in family caregivers of elders: a theoretical model of caregiver burden, sociotropy and autonomy. research in nursing and health, 33: 20–34. clyburn, ld., et al., 2000. predicting caregiver burden and depression in alzheimer’s disease. journal of gerontolog y: social sciences, vol. 55b, no. 1: s2–s13. covinsky, ke., et al., 2003. patient and caregiver characteristics associated with depression in caregivers of patients with dementia. j gen intern med, dec 2003, vol. 18: 1006–1014. dupuis, sl., epp, t., dan smale, b., 2004. caregivers of pearson with dementia: roles, experiences, supports and coping. a literature review. murray alzheimer research and education program. university of waterloo. etters, l., goodall, d., dan harrison, be., 2008. caregiver burden among dementia patient caregiver: a review of the literature. journal of the american academy of nurse practitioners, 20: 423–428. fitriani, e., 2009. lansia dalam keluarga dan masyarakat. endafitriani. diperoleh 17 mei 2010. gonyea, jg., o‘connor, m., carruth, a., dan boyle, pa., 2005. subjective appraisal of alzheimer’s disease caregiving: the role of self-effi cacy and depressive symptoms in the experience of burden. american journal of alzheimer’s d i s e a s e a n d o t h e r d e m e n t i a s, 20: 273–280. gort, am. et al., 2007. use of the zarit scale for assessing caregiver burden and collaps in caregiving at home in dementias. international journal geriatric psychiatry, 22, 957–962. harris, gj., 2009. caregiver well-being: factor infl uencing positive outcomes in the informal caregiving process. diser tation. doctor of philosophy. depar t ment of family and child science. hong, gs. & kim, h., 2008. family caregiver burden by relationship to care recipient with dementia in korea. geriatric nursing, 29(4), 267–274. huang, ss., lee, mc., liao, yc., wang, wf., dan lai, tj., 2011. caregiver burden associated with behavioral and psychological symptoms of dementia (bpsd) in taiwanese elderly. archives of gerontology and geriatrics, 2479, 1–5. 97 prediktor beban merawat dan tingkat depresi caregiver (yossie susanti eka putri) kementerian sosial republik indonesia, 2011. penduduk lanjut usia di indonesia dan masalah kesejahteraannya. kim, md., hong sc., lee ci., kim sy., kang io., dan lee sy., 2009. caregiver burden among caregivers of koreans with dementia. gerontology, 55, 106– 113. kuuppelomaki, m., sasaki, a., yamada, k., dan asakawa, n., 2004. family carers for older relatives:sources of satisfaction and related factors in finland. international jour nal of nursing studies, 41(5), 497–505. laubunjong, et al., 2008. the pattern of caregiving to the elderly by their families in rural communities of suratthani province. abac journal, 28(2), 64–74. lee, m., 2008. caregiver stress and elder abuse among korean family caregiver of elder adult with disabilities. original article. j fame vio. 23, 702–712. lemeshow, s., holmer, dw., klar, j., dan lwanga, sk., 2002. besar sampel dalam penelitian kesehatan. (pramono, d., & kusnanto, h., penerjemah). yogyakarta: gadjah mada university press. lloyd-sherlock, p., 2000. ‘population ageing in developed and developing regions: implications for health policy’, sosial science & medicine, 51(6), 887–895. majerovitz, s.d., 2007. predictors of burden and depression among nursing home family caregivers. aging and mental health, 11(3), 323–329. mcconaghy, r., dan caltabiano, m.l., 2005. caring for a pearson with dementia: explor i ng relationships bet ween perceived burden, depression, coping and well-being. nursing and health science, 7, 81–91. morimoto, t., schreiner, as., dan asano, h., 2003. caregiver burden and health related quality of life among japanise stroke caregiver. age and aging, vol. 32, no. 2. notoatmojo, 2003. pendidikan dan perilaku kesehatan. jakarta: reneka cipta. ozge, a. et al., 2009. the caregiver burden and st roke prog nosis. journal of ne urological sciences ( turk ish), volu me 26, nu mb e r 2 , page (s) 139–152. papastavrou, et al., 2007. caring for relative with dementia: family caregiver burden. journal of advanced nursing, 58(5), 446–457. peterson, sj. dan brewdow, ts., 2004. middle range theories: application to nursing research. philadelphia: lippincott williams dan wilkins. putri, yse., debellis, a. dan xiao, l., 2010. carers’ experiences of caring for rela t i ve s with d e m e n t ia in west sumat ra, indonesia. t hesis unpublished, flinders university, south australia. razani, j. et al., 2007. predicting caregiver burden from daily functional abilities of patients with mild dementia. journal american geriatric society, 55, 1415– 1420. riasmini, m., 2011. pengalaman keluarga dan tenaga kesehatan dalam perawatan lanjut usia. risbinakes. jakarta. sahar, j., 2002. supporting family carers in caring for older people in the community in indonesia. queensland university of technology, school of nursing. centre for nursing research. disertasi. tidak dipublikasikan. sansoni, j., vellone, e. dan piras, g., 2004. anxiety and depression in communitydwelling, italian alzheimer's disease carers. international journal of nursing practice, vol. 10, pp. 93–100. wang, j., et al., 2009. caregiver burden factors contributing to psychological elder abuse behavior in long term facilities: a structural equation model approach. international psychogeriatrics, 21(2), 314–320. widnya, 2008. bunuh diri di bali perspektif bud aya d a n li ng k u nga n h idup. journal institut hindu dharma negeri. denpasar. who, 2008. health situation and trends assessment, <http://www.searo.who. i n t /e n / s e c t i o n12 43/ s e c t i o n138 2 / section1386/section1898_9436.htm>. who, 2010. depression worksheet. http:// ebookbrowse.com/search/depressionworksheets-pdf., diperoleh 15 oktober 2011. ners vol 5 no 1 april 2010_akreditasi 2013.indd 21 parameter teknis cardio-pulmonary resuscitation (cpr) dengan travelling time 20, 40 dan 60 km/jam (technical indicators of cardio-pulmonary resuscitation (cpr) with traveling time 20, 40 and 60 km/h) yogo apriyanto*, nursalam**, arie sunarno*** *instalasi gawat darurat 118 rsud dr. soetomo surabaya telp: 0315501295. email: yogo_riyan@yahoo.com ** fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya ***instalasi rawat inap bedah rsud dr. soetomo surabaya. abstract introduction: ambulances had special rule of velocity. ambulances could accelerate over 80 km/h and could break through traffi c light. during transport the patient might be got cardiac arrest. almost all of the pre hospital nurses had reported that doing cpr during transport was diffi cult. the objective of this study was to analyze the effect of traveling time 20 km/h, 40 km/h and 60 km/h on technical indicators of cpr. method: design used in this study was pre-experiment. the population were nurses in ambulances 118 of dr. soetomo hospital surabaya. a total of 14 respondents were taken as samples by purposive sampling. the independent variable was effectiveness of traveling time, while the dependent variable were technical indicators of cpr: tidal volume (tv), landmark hand position, deep of chest compression and chest compression rhythm in manekin. data were measured by observation sheet and then analyzed using chi-square test with level of signifi cance α ≤ 0.05. result: the result showed that travelling time 20 km/h and 40 km/h had a signifi cant effect on technical indicators of cpr, but not at 60 km/h. discussion: it could be concluded, the faster the travelling time, the more diffi cult to perform cpr. further study should involve the travelling time and the accuracy of cpr technical indicators to treat and safe the patients, either in traumatic or non traumatic case. keywords: travelling time, technical indicators of cpr, ambulances 118 pendahuluan ambulans gawat darurat (agd) merupakan ujung tombak pelayanan pre hospital yang berorientasi pada pelayanan load and go situation atau emergency case yang mobile. semua tindakan yang dilakukan dipengaruhi oleh faktor mekanik yang dinamis (kecepatan, lintasan dan percepatan). ambulans mempunyai hak istimewa dalam melaju, yaitu dapat melaju dengan kecepatan di atas 80 km/jam (presiden republik indonesia, 1992). dalam melakukan pertolongan (primary survey), ambulans tidak harus berhenti. menurut yoel (2007), faktor penentu utama hasil akhir kasus kedaruratan adalah waktu yang diperlukan untuk mencapai fasilitas perawatan definitif. hasil akhir yang diperoleh pada kasus trauma sangat baik apabila identifikasi, transportasi, dan perawatan definitif dapat dilakukan dalam batas waktu kritis yang disebut “golden period”. limmer (2001) dalam setiaka (2008) menyatakan bahwa seorang pasien dengan multitrauma akan membutuhkan tindakan sesegera mungkin dan transport ke fasilitas penyedia layanan kesehatan pada waktu yang bersamaan. tetapi di sisi lain, sebanyak 318 petugas ambulans di fire department of hongkong, melakukan cardio-pulmonary resusitation (cpr) selama lebih dari 30 menit setiap ada cardiac arrest selama transport dan hampir 50% perawat mengatakan sangat sulit untuk mempertahankan keseimbangan saat ambulans transport (jones, 2004). menurut setiaka (2008) dalam studinya bahwa untuk meminimalkan dampak yang merugikan pada pasien karena tidak segera ditangani, maka seharusnya saat melakukan tindakan cpr, jurnal ners vol. 5 no. 1 april 2010: 21–28 22 ambulans tetap berjalan dengan kecepatan 40 km/jam daripada harus berhenti, sehingga dengan simultan, rujukan ke rumah sakit tetap bisa dilakukan untuk penanganan yang lebih baik. respons time <10 menit (pada lebih dari 50% permintaan) dan traveling time merupakan grand design untuk meningkatkan kualitas pelayanan agd dan sebagai outcome tolak ukur adalah penurunan angka kematian kedaruratan (simovic, 2007). karjono (1991), melaporkan bahwa resusitasi selama transport hanya boleh berhenti paling lama 30 detik bila ingin mendapatkan hasil yang optimal. tim yang kompeten dan traveling time yang pendek (dengan kecepatan optimal) dapat meningkatkan penanganan kedaruratan lebih optimal dan dapat sesegera mungkin dilakukan tindakan lanjutan (definitif) pada sistem rujukan. penelitian ini mempelajari efektivitas travelling time dengan kecepatan 20 km/jam, 40 km/jam dan 60 km/jam terhadap parameter teknis cpr. faktor yang memengaruhi keberhasilan penanganan kedaruratan antara lain lokasi daerah, keadaan tenaga, penguasaan basic life support (bls) maupun advance life support (als). keberhasilan juga ditentukan oleh sarana lain seperti komunikasi, transportasi dan kecepatan penderita masuk ke dalam jaringan pelayanan gawat-darurat (karjono, 1991). data pasien yang tercatat di ruang resusitasi ird rsu dr. soetomo tahun 2007 sebanyak 69 pasien meninggal dalam keadaan death on arrival (doa). studi di swedia dan inggris periode maret 2002 sampai oktober 2003 didapatkan bahwa selama resusitasi jantung paru di atas transport dari 176 pasien dewasa, rerata pijatan jantung diberikan 64 kali/menit (52%), rerata ke dalaman pijatan 34 mm (28%), pijatan 100 kali/menit sebanyak 42% dan ventilasi diberikan rerata 11 kali/menit, dan total 61 pasien (35%) mengalami sirkulasi spontan serta 5 dari 6 pasien berhasil pulang dari rumah sakit dengan sistem neurologis yang normal. pijat jantung selama transport lebih sulit dibandingkan dengan keadaan non transport dan kompresi jantung didapatkan sebagian besar terlalu dangkal (lars, 2005). selain itu ditemukan bahwa analisis 5 menit pertama dari tiap segmen resusitasi 30 detik, menunjukkan bahwa ritme kompresi dada kurang dari 90×/menit dalam 28,1% dari segmen, ke dalaman kompresi terlalu dangkal 37,4% dari kompresi, ritme ventilasi terlalu tinggi, 60,9% tiap segmen mengandung ritme lebih dari 20×/menit. total 27 pasien (40,3%) mengalami sirkulasi spontan dan 7 (10,4%) berhasil pulang dari rumah sakit. studi di taipei city pada periode januari 2005 sampai maret 2006 tentang out of hospital cardiac arrest (ohca) dengan membandingkan efektivitas cpr manual (operator) dan mekanik (ambulans), dari 20 responden didapatkan hasil 33,40% dan 31,63% pada interval tanpa pijat jantung, pada fase pijat jantung 70% dan 30%, pada fase ventilasi 25% dan 20%, dan disimpulkan bahwa faktor penolong (operator) lebih berpengaruh sebanyak 84,7% terhadap kualitas cpr daripada pengaruh ambulans atau mekanik (wang, 2006). setiaka (2008) dalam studinya pada objek manikin di unit agd 118 pre hospital ird rsud dr. soetomo surabaya, melaporkan bahwa cpr selama transport dengan kecepatan 40 km/jam, didapatkan hasil dari tujuh responden sebagian besar (71,4%) dinyatakan baik dan sisanya (28,6%) dinyatakan cukup terhadap parameter teknis cpr (ketepatan ventilasi, ritme dan ke dalaman kompresi, serta landmark posisi tangan penolong). semakin modern tingkat kehidupan masyarakat, maka semakin tinggi tuntutan profesionalisme pelayanan yang diharapkan. agd merupakan unit pelayanan pre hospital yang menjadi garis pertama (first line) dalam pertolongan pertama kasus kedaruratan. parameter pelayanan prima agd adalah rendahnya angka kematian di tempat kejadian dan kematian selama transport atau pertolongan. respons tanggap dan kemampuan bls dan als dari tim sangat menentukan keberhasilan dari pertolongan pertama sampai sistem rujukan. selain faktor operator (teknis) di atas, faktor non teknis seperti kecepatan, percepatan dan jalan yang bergelombang juga berpengaruh terhadap kualitas pertolongan selama transport. setiaka (2008) melaporkan bahwa walaupun kecepatan ambulans dinyatakan mengganggu parameter teknis cpr (yogo a.) 23 teknis tindakan cpr, tetapi dengan kecepatan 40 km/jam belum menunjukkan hal tersebut. penanganan pre hospital merupakan penanganan berupa primary survey bukan secondary survey yaitu berupa pembebasan jalan napas (airway), bantuan dan buatan napas (breathing), dan memperbaiki keadaan hemodinamik umum (circulation). upaya untuk mencegah komplikasi akibat keterlambatan penanganan dan pemberian bantuan kehidupan lanjut diperlukan transport segera ke sistem rujukan terdekat yang kompeten. penanganan segera korban gawat darurat adalah kunci pokok keselamatan dan pencegahan komplikasi, oleh karena itu kesegeraan (respons time) dan travelling time yang pendek merupakan faktor terpenting dalam penanganan kedaruratan. kecepatan dan kesegeraan membawa ke sistem rujukan juga sangat menentukan tingkat keselamatan korban, oleh karena itu dengan hak prerogatip atau dari ambulans yang dapat melaju lebih dari 80 km/jam diharapkan dapat segera mungkin membawa korban ke sistem rujukan terdekat. berdasarkan fenomena dan masalah di atas, penelitian akan menganalisis efektivitas travelling time terhadap parameter teknis cpr dengan mengunakan manikin laerdal resuscianne skillmeter yang lengkap dengan layar monitor untuk ketepatan ventilasi, ritme dan ke dalaman kompresi, serta landmark posisi tangan penolong. bahan dan metode penelitian ini menggunakan preexperiment one-shot case study design. populasi pada penelitian ini adalah semua perawat di pelayanan pra rumah sakit ambulans 118 ird rsud dr. soetomo surabaya yang tersertifikasi ppgd sebanyak 40 orang. dengan teknik purposive sampling diperoleh sampel sebanyak 14 perawat dengan kriteria tingkat pendidikan minimal d3 keperawatan dan telah mempunyai sertifikat gels. variabel independen pada penelitian ini adalah travelling time agd dengan kecepatan 20 km/jam pada kelompok 1, 40 km/jam pada kelompok 2 dan 60 km/jam pada kelompok 3. variabel dependen yang digunakan adalah parameter teknis cpr meliputi tidal volume (tv) 450 cc, ritme kompresi 100×/menit, ke dalaman kompresi 4–5 cm dan landmark posisi tangan pada titik tumpu pijatan di tengah sternum. setiap parameter diberikan skor 2 jika sesuai dan 1 jika tidak sesuai. tindakan cpr dikatakan efektif jika skor total 8 dan tidak efektif jika skor ≤7. instrumen yang diperlukan dalam penelitian ini lembar check list dan observasi, manikin laerdal resuscianne skillmeter yang lengkap dengan layar monitor untuk menilai ketepatan ventilasi, ritme dan ke dalaman kompresi, serta landmark posisi tangan penolong dan ambulans lengkap dengan peralatan primary survey. penelitian ini dilaksanakan pada 15 desember 2008 sampai 4 januari 2009. sebelum melaksanakan penelitian, responden mendapatkan penjelasan dari peneliti mengenai tindakan teknis yang akan dilakukan berdasarkan standard operational procedure (sop) yang telah dibuat. selanjutnya responden dibagi menjadi 7 tim, 1 tim terdiri dari 2 perawat. masing-masing tim melakukan cpr dalam ambulans dengan kecepatan 20 km/jam, 40 km/jam dan 60 km/jam pada lintasan yang relatif tidak padat, tidak bergelombang dan memungkinkan tidak banyak lintasan maneuver di sepanjang jalan kertajaya galaxy mall surabaya. cpr dilakukan selama transport dengan teknis 1 perawat melakukan pijat jantung (30 kompresi) dan 1 perawat yang lain memberikan ventilasi (2 kali) dengan bag valve and mask (bvm). cpr dilakukan satu siklus (30 kompresi dan 2 kali ventilasi) untuk masingmasing segmen kecepatan (guidelines 2005 dalam materi pelatihan general emergency life support (gels, 2008). sebelum cpr pada segmen kecepatan berikutnya, peneliti memberi kode kepada driver melalui telpon untuk menghentikan ambulans sementara, pada kesempatan ini peneliti mencatat hasil rekaman data indikator teknis cpr yang terdapat pada monitor indikator manikin. monitor indikator mampu menunjukkan data parameter tv, ke dalaman kompresi dengan indikator too much (berlebih), correct (benar) dan too little (kurang), parameter ritme kompresi menunjukkan jumlah pijatan permenit dan land mark posisi tangan menunjukkan correct (benar) dan wrong position (salah). setelah jurnal ners vol. 5 no. 1 april 2010: 21–28 24 data dicatat, peneliti memberi kode kepada driver untuk menjalankan ambulans dengan segmen kecepatan berikutnya. cpr dilakukan dengan teknik yang sama pada tiap segmen kecepatan. data yang telah terkumpul kemudian dianalisis untuk mengetahui efektivitas travelling time pada masing-masing kecepatan terhadap parameter teknis cpr dan kemudian dibandingkan satu sama lain. uji statistik yang digunakan adalah chi square dengan level signifikansi α ≤ 0,05. hipotesis dalam penelitian ini adalah travelling time 60 km/jam efektif terhadap parameter teknis cpr di dalam agd 118 rsu dr. soetomo surabaya. hasil hasil penelitian dengan traveling time 20 km/jam menunjukkan tv dan titik tumpu kompresi dari 7 tim responden masing-masing 100% efektif, sedangkan terhadap ritme kompresi dan ke dalaman kompresi masingmasing sebanyak 57% efektif. tv dan titik tumpu kompresi pada kecepatan ambulans 40 km/jam masing-masing 86% efektif dan ritme kompresi dan ke dalaman kompresi masing-masing 57% efektif. pada kecepatan ambulans 60 km/jam hanya parameter titik tumpu kompresi yang menunjukkan mayoritas efektif (57%), sedangkan 86% parameter teknis ke dalaman kompresi tidak efektif, ritme kompresi 71% tidak efektif dan tv 57% tidak efektif. berdasarkan hasil uji statistik chi square, perbandingan parameter teknis cpr antara traveling time dengan kecepatan 20 km/jam dan 40 km/jam mempunyai efektivitas yang sama (tabel 1). efektivitas travelling time 20 km/jam dan 60 km/jam terhadap parameter cpr mempunyai perbedaan yang variatif (tabel 2). pembahasan parameter teknis cpr pada travelling time 20 km/jam didapatkan, tidal volum dan titik tumpu kompresi masing-masing seluruhnya (100%) efektif, selanjutnya ritme kompresi dan ke dalaman kompresi masing-masing paling banyak (57%) efektif. kecepatan yang minimal pada saat melakukan pijat jantung di atas ambulans, didapatkan kriteria teknis cpr yang baik, hal ini berarti pijat jantung cukup efektif dilakukan pada ambulans yang berjalan dengan kelajuan 20 km/jam. menurut hukum newton ii percepatan suatu benda yang diberi gaya adalah sebanding dengan besar gaya dan berbanding terbalik dengan masa benda (http:// www.e-dukasi.net), yang artinya bahwa, jika ambulans ditarik dengan gaya (kecepatan) yang lebih besar, maka percepatannya akan lebih besar pula. percepatan ini akan memengaruhi keadaan benda yang diberi percepatan, hal ini sesuai dengan hukum newton i bahwa benda akan tetap diam atau bergerak beraturan selama tidak ada gaya lain yang memengaruhi. menurut hukum newton iii bahwa setiap ada aksi pasti ada reaksi, yang artinya ketika ambulans diberikan gaya (aksi) yang besar (kelajuan yang besar), maka benda-benda yang ada di dalamnya akan memberikan reaksi gaya yang sama dengan arah yang berlawanan (http://www.e-dukasi.net). berdasar konsep di atas dapat dijelaskan bahwa, semakin cepat kelajuan suatu benda (gaya), maka semakin besar gaya reaksi yang harus diberikan, ini artinya dengan kecepatan yang tinggi akan memengaruhi stabilitas gaya (pijat jantung) yang secara teknis dapat diobservasi melalui parameter teknis cpr. tetapi di sisi lain parameter kualitas pelayanan prima ambulans adalah respons time yang pendek dan travelling time yang cepat. hal ini sesuai dengan rencana kerja besar (grand design) pelaksanaan upt blud agd dkp dki jakarta. yang dimaksud dengan grand design itu adalah acuan agar segala upaya yang dikerahkan mencapai visi jakarta sehat 2010 berhasil dicapai dengan misi utama pelayanan kesehatan gawat darurat pra rumah sakit menuju respons time <10 menit (pada lebih dari 50% permintaan), dan sebagai outcome tolok ukur angka kematian kedaruratan dan bencana menurun (simovic, 2007). selain pertimbangan di atas yoel (2007) menyatakan bahwa faktor penentu utama hasil akhir kasus kedaruratan adalah waktu yang diperlukan untuk mencapai fasilitas perawatan definitif. hasil akhir yang diperoleh pada kasus trauma sangat baik parameter teknis cpr (yogo a.) 25 apabila identifikasi, transportasi, dan perawatan definitif dapat dilakukan dalam batas waktu kritis yang disebut “golden period”. satu sisi menunjukkan bahwa kecepatan berpengaruh terhadap parameter teknis cpr, tetapi pada sisi lain juga berpengaruh terhadap kualitas penanganan kedaruratan pada sistem rujukan. ambulans mempunyai hak prerogatip dapat melaju dengan kecepatan di atas 80 km/ jam, hal ini dapat dijadikan bahan pertimbangan dan analisis lebih lanjut dalam pertolongan kedaruratan dengan menggunakan sistem transportasi ambulans (pelayanan pra rumah sakit). data hasil penelitian menunjukkan pada travelling time 40 km/jam didapatkan, parameter teknis tidal volum dan titik tumpu kompresi masing-masing mayoritas (86%) efektif, selanjutnya ritme kompresi dan ke dalaman kompresi masing-masing paling banyak (57%) efektif. analisis data dengan uji statistik chi kuadrat (χ2)/mc nemar test dengan α = 0,05, tidal volum dan titik tumpu kompresi pada kecepatan 40 km/jam didapatkan angka signifikansi 0,06 yang artinya tidak efektif, ritme kompresi dan ke dalaman kompresi didapatkan angka signifikansi 0,71 yang artinya tidak efektif. travelling time 40 km/jam cukup berpengaruh terhadap parameter teknis cpr (ritme kompresi dan ke dalaman kompresi). hal ini berbeda dengan kecepatan 20 km/jam yang efektif terhadap semua parameter cpr. tetapi dengan kecepatan 40 km/jam masih memungkinkan perawat pre-hospital dapat melakukan resusitasi jantung paru dengan efektif. selain faktor kecepatan, banyak faktor lain yang memengaruhi kualitas penanganan kasus kedaruratan di antaranya yaitu tergantung lokasi daerah (tkp), keadaan tenaga yang ada, penguasaan basic life support maupun advance life support tim. keberhasilan juga ditentukan oleh sarana lain seperti komunikasi, transportasi dan cepatnya penderita masuk ke dalam jaringan pelayanan gawat-darurat, selain itu resusitasi selama transport hanya boleh berhenti paling lama 30 detik bila ingin mendapatkan hasil yang optimal (karjono, 1991). selain faktor kecepatan, banyak faktor lain yang menentukan kualitas penanganan kasus kedaruratan (trauma atau non trauma). meskipun travelling time 40 km/jam kurang efektif terhadap parameter teknis cpr, tetapi faktor lain yang tidak kalah pentingnya adalah cepatnya korban mencapai sistem rujukan untuk mendapatkan terapi definitif atau bantuan hidup lanjutan (als), maka dengan adanya penelitian lebih lanjut tentang pengaruh travelling time terhadap kualitas penanganan tabel 1. efektivitas travelling time 20 km/jam dan 40 km/jam terhadap parameter teknis cpr tidal volume ritme kompresi ke dalaman kompresi landmark tangan 20 km/jam 40 km/jam 20 km/jam 40 km/jam 20 km/jam 40 km/jam 20 km/jam 40 km/jam mean 2 1,86 1,57 1,57 1,57 1,57 2 1,86 sd 0,00 0,38 0,53 0,53 0,53 0,53 0,00 0,38 chi square χ2 = 700 p = 0,008 χ2 = 3.57 p = 0,06 χ2 = 0,14 p = 0,71 χ2 = 0,14 p = 0,71 χ2 = 0,14 p = 0,71 χ2 = 0,14 p = 0,71 χ2 = 700 p = 0,008 χ2 = 3,57 p = 0,06 tabel 2. efektivitas travelling time 20 km/jam dan 60 km/jam terhadap parameter teknis cpr tidal volume ritme kompresi ke dalaman kompresi landmark tangan 20 km/jam 40 km/jam 20 km/jam 40 km/jam 20 km/jam 40 km/jam 20 km/jam 40 km/jam mean 2 1,43 1,57 1,29 1,57 1,14 2 1.57 sd 0,00 0,53 0,53 0,49 0,53 0,38 0,00 0,53 chi square χ2 = 700 p = 0,008 χ2 = 0,14 p = 0,71 χ2 = 0,14 p = 0,71 χ2 = 1,29 p = 0,26 χ2 = 0,14 p = 0,71 χ2 = 3,57 p = 0,06 χ2 = 700 p = 0,008 χ2 = 0,14 p = 0,71 keterangan: mean = rerata p = signifi kansi sd = standar deviasi χ2 = chi square jurnal ners vol. 5 no. 1 april 2010: 21–28 26 kedaruratan, diharapkan ditemukan standar yang baku (protap) dalam melaju selama resusitasi jantung paru. parameter teknis cpr pada travelling time 60 km/jam didapatkan, ke dalaman kompresi mayoritas (86%) tidak efektif, ritme kompresi paling banyak (71%) tidak efektif, selanjutnya parameter titik tumpu kompresi paling banyak (57%) efektif dan tidal volum paling banyak (57%) tidak efektif. analisis data dengan uji statistik chi kuadrat (χ2)/mc nemar test dengan α = 0,05, tidal volum dan titik tumpu kompresi pada kecepatan 60 km/jam didapatkan angka signifikansi p = 0,71 yang artinya tidak efektif, parameter ritme kompresi didapatkan angka signifikansi p = 0,26 dan ke dalaman kompresi didapatkan angka signifikansi 0,06 yang artinya tidak efektif. hasil analisis data dapat dijelaskan travelling time 60 km/jam tidak efektif terhadap semua parameter teknis cpr. hal ini menjadi bukti kebenaran hukum newton i dan ii yang menyatakan gaya (pijat jantung yang dilakukan) dipengaruhi oleh masa (beban tekanan) dan percepatan (kelajuan) (http:// www.e-dukasi.net). kecepatan merupakan besaran yang bergantung pada arah, sehingga termasuk besaran vektor (san, 2008). kecepatan dipengaruhi oleh jarak yang ditempuh dan waktu tempuh. kecepatan berbanding terbalik dengan waktu artinya semakin banyak waktu yang digunakan semakin kecil kecepatannya, dan berbanding lurus dengan jarak yang ditempuh. dari konsep kecepatan dan percepatan di atas dapat dijelaskan bahwa semakin cepat ambulans melaju maka semakin banyak jarak yang ditempuh, yang artinya ambulans akan cepat mencapai sistem rujukan dan korban atau pasien akan cepat mendapatkan penanganan lebih lanjut (advance life support). limmer (2001) dalam setiaka (2008) menyatakan bahwa seorang pasien dengan multitrauma akan membutuhkan tindakan sesegera mungkin dan transport ke fasilitas penyedia layanan kesehatan pada waktu yang bersamaan. meskipun kecepatan 60 km/jam kurang efektif terhadap parameter teknis cpr, tetapi disisi lain dengan respons time yang pendek dan travelling time yang cepat, pasien atau korban dapat dengan cepat mencapai tempat rujukan atau mendapat terapi definitif. oleh karena itu, travelling time 60 km/jam diharapkan dapat dijadikan acuan untuk melakukan transportasi dan acuan pada penelitian selanjutnya dengan travelling time yang lebih cepat. berdasar nilai rerata dapat dijelaskan, pada parameter ritme kompresi dan ke dalaman kompresi travelling time 20 km/jam dan 40 km/jam mempunyai efektivitas yang sama serta parameter tidal volum dan titik tumpu kompresi mempunyai efektivitas yang sama. analisis data dengan uji statistik chi kuadrat (χ2)/mc nemar test dengan α = 0,05, tidal volum dan titik tumpu kompresi pada kecepatan 20 km/jam didapatkan angka signifikansi 0,008 (0,008 < 0,05) yang artinya efektif, ritme kompresi dan ke dalaman kompresi didapatkan angka signifikansi 0,71 (0,71 > 0,05) yang artinya tidak efektif. tidal volum dan titik tumpu kompresi pada kecepatan 40 km/jam didapatkan angka signifikansi 0,06 (0,06 > 0,05) yang artinya tidak efektif, ritme kompresi dan ke dalaman kompresi didapatkan angka signifikansi 0,71 (0,71 > 0,05) yang artinya tidak efektif. hasil analisis data dapat dijelaskan travelling time 20 km/jam lebih efektif terhadap parameter teknis cpr daripada 40 km/jam. meskipun kurang efektif terhadap parameter teknis cpr, travelling time 40 km/jam lebih cepat, yang artinya kecepatan 40 km/jam akan dapat menempuh jarak lebih jauh atau waktu lebih pendek dalam penanganan kasus kedaruratan dibanding dengan kecepatan (travelling time) 20 km/jam. ambulans mempunyai hak istimewa dalam melaju, yaitu dapat melaju dengan kecepatan di atas 80 km/jam (presiden republik indonesia, 1992). berdasarkan kewenangan itu, ambulans dapat mempertimbangkan faktor kecepatan dalam melakukan transportasi ke sistem rujukan untuk mendapatkan tindakan lebih lanjut. yoel (2007) bahwa faktor penentu utama hasil akhir kasus kedaruratan adalah waktu yang diperlukan untuk mencapai fasilitas perawatan definitif. hasil akhir yang diperoleh pada kasus trauma sangat baik apabila identifikasi, transportasi, dan perawatan definitif dapat dilakukan dalam batas waktu kritis yang disebut “golden period”. parameter teknis cpr (yogo a.) 27 meskipun travelling time 40 km/jam kurang efektif terhadap parameter teknis cpr. tetapi memungkinkan pasien dengan lebih cepat mencapai sistem rujukan. berdasarkan hak khusus (prerogatip) ambulans dalam melaju, maka ambulans seharusnya dapat mencapai tempat rujukan dengan lebih cepat (travelling time lebih cepat atau pendek), karena keadaan tersebut memungkinkan korban dengan cepat akan mendapatkan perawatan definitif (als) dan intensif di rumah sakit terdekat yang kompeten. hasil nilai rerata dapat dijelaskan, pada semua parameter cpr travelling time 20 km/jam dan 60 km/jam mempunyai perbedaan efektivitas yang variatif. analisis data dengan uji statistik chi kuadrat (χ2)/mc nemar test dengan α = 0,05, tidal volum dan titik tumpu kompresi pada kecepatan 20 km/jam didapatkan angka signifikansi 0,008 (0,008 < 0,05) yang artinya efektif, ritme kompresi dan ke dalaman kompresi didapatkan angka signifikansi p = 0,71 (0,71>0,05) yang artinya tidak efektif. tidal volum dan titik tumpu kompresi pada kecepatan 60 km/jam didapatkan angka signifikansi p = 0,71 (0,71 > 0,05) yang artinya tidak efektif, parameter ritme kompresi didapatkan angka signifikansi p = 0,26 (0,26 > 0,05) dan ke dalaman kompresi didapatkan angka signifikansi 0,06 (0,06 > 0,05) yang artinya tidak efektif. travelling time 60 km/jam kurang efektif terhadap parameter teknis cpr, walaupun pada parameter titik tumpu kompresi masih cukup efektif, ini artinya transportasi dengan travelling time 60 km/jam masih dapat ditoleransi dalam melakukan rujukan atau penanganan kedaruratan. meskipun travelling time 20 km/jam dan 40 km/jam lebih menunjukkan efektivitas yang lebih baik daripada travelling time 60 km/jam, tetapi dengan mempertimbangkan faktor lain seperti medan yang memungkinkan, tenaga yang kompeten dan ”golden periode”, maka setelah bantuan hidup dasar (bls) diberikan, seharusnya pasien atau korban sesegera mungkin ditransport ke tempat rujukan terdekat yang qualified atau kompeten. peraturan di beberapa negara mungkin memperbolehkan untuk tidak mematuhi peraturan lalu lintas dalam keadaan emergensi yang sebenarnya dan dengan memperdulikan keselamatan orang lain. pengecualian dalam hal ini, mencakup aturan batas kecepatan, lampu merah atau tanda berhenti, dan peraturan lain serta sejumlah batasan larangan (http://www.desentralisasikesehatan.net/id.). memperhatikan kaidah atau norma transportasi seperti ketentuan di atas, maka diharapkan dengan adanya travelling time yang lebih pendek, maka korban dapat segera dilakukan bantuan hidup lanjutan di rumah sakit. m e n u r u t yo e l ( 2 0 0 7 ) , p e l a y a n a n kedaruratan berbeda dengan pelayanan kesehatan lain oleh karena sering harus diberikan secara langsung di tempat kejadian dalam hitungan menit bahkan detik. hasil akhirnya sangat ditentukan oleh respons, waktu, dan tempat. sistem pelayanan kedaruratan sekurang-kurangnya memiliki kemampuan: memberikan dukungan medik atau hidup dasar kasus kedaruratan di tempat kejadian (pra rumah sakit) dan menentukan fasilitas medik yang sesuai untuk lanjutan penanganan (definitive therapy), menyediakan layanan transportasi cepat dan dukungan selama transportasi kasus ke fasilitas kesehatan dan melakukan komunikasi serta koordinasi dengan fasilitas kesehatan tentang persiapan yang masih dan akan diperlukan untuk penanganan kasus kedaruratan yang ditransportasi. dari prosedur dapat dijelaskan, bahwa setelah korban dilakukan resusitasi (bantuan hidup dasar) dan stabilisasi minimal ditempat kejadian, pasien hendaknya segera dirujuk ke layanan kesehatan terdekat dengan cepat, artinya resusitasi dan stabilisasi dapat dilanjutkan di atas ambulans, kecepatan rujukan akan mempercepat survei sekunder, sehingga penyebab dan masalah yang mendasari penyakit akan segera diketahui, dan pasien akan dengan cepat mendapatkan definitif terapi. melakukan cpr selama di ambulans adalah sulit, hal ini dikarenakan faktor kinetik dan mekanik dari ambulans yang bergerak, sesulit apapun kegiatan di dalam kabin ambulans, ketika pasien mengalami henti jantung tenaga medis atau paramedik harus bisa memberikan bantuan hidup dasar atau sedikit lanjutan, hal ini sangat penting untuk jurnal ners vol. 5 no. 1 april 2010: 21–28 28 menyelamatkan jalan nafas, oksigenasi dan sirkulasi guna mempertahankan fungsi organorgan vital seperti otak dan jantung. kesulitan melakukan cpr sesuai parameter bukan menjadi penghalang untuk tidak melakukan cpr di atas ambulans atau selama transport, karena tindakan resusitasi, stabilisasi dan akselerasi (kecepatan rujukan) merupakan tindakan simultan yang harus diperhatikan untuk dapat menangani kasus kedaruratan. travelling time 60 km/jam memungkinkan klien atau korban akan lebih cepat mencapai sistem rujukan dibandingkan dengan travelling time 20 km/jam dan 40 km/jam, karena travelling time 60 km/jam masih cukup efektif terhadap parameter teknis cpr, yang artinya pasien atau korban juga akan selamat atau tertangani dengan baik dan lebih cepat mendapat terapi lebih lanjut (definitif). dengan adanya penelitian lebih lanjut tentang pengaruh travelling time terhadap kualitas penanganan kedaruratan diharapkan dapat memberikan kontribusi berupa protap (prosedur tetap) yang baku tentang kecepatan ambulans selama resusitasi. simpulan dan saran simpulan travelling time 20 km/jam memungkinkan pijatan jantung paru (cpr) yang lebih stabil daripada 40 km/jam dan 60 km/jam, sehingga lebih efektif terhadap parameter teknis cpr pada manekin laerdal resuscianne. saran peneliti selanjutnya diharapkan mampu melakukan penelitian lebih lanjut tentang ketepatan parameter teknis cpr dan kecepatan mencapai sistem rujukan (travelling time yang cepat) terhadap keberhasilan penanganan kasus kedaruratan trauma atau non trauma. kepustakaan karjono, j., 1991. cermin dunia kedokteran. surabaya: upf ilmu penyakit jantung fkua, hlm. 37–39. l a r s , w. e t a l . , 2 0 0 5 . q u a l i t y o f cardiopulmonary resuscitation during out of hospital cardiac arrest, (online), (http://jama.ama-assn.org/cgi/content/ full/293/3/299., diakses tanggal 22 oktober 2008 jam 08.00 wib). presiden, republik indonesia, 1992. lalu lintas dan angkutan jalan, (online), (http:// www.lantas.polri.go.id/vademikum/ vademikum-kapita-bab-iii.pdf., diakses tanggal 22 oktober 2008 jam 08.18 wib). simovic, v., 2007. ambulans pra rumah sakit., (online), (http://agddki.blogsome.com/, diakses tanggal 22 oktober 2008 jam 08.20 wib). rsud dr. soetomo dan fk unair, 2008. materi pelatihan gels (general emergency life support). surabaya: rsud dr soetomo dan fk unair. wang, h., et al., 2003. cardiopulmonary r e s u s c i t a t i o n d u r i n g tr a n s p o r t , (online), (http://linkinghub.elsevier. com/retrieve/pii/s0300957207000329., diakses tanggal 22 oktober 2008 jam 08.10 wib). yoel, c., 2007. pelayanan kedaruratan medik sebagai mata rantai kehidupan anak, (online), (http://www.usu.ac.id/id/fi les/ pidato/ppgb/2007/ppgb_2007_chairul_ yoel.pdf., diakses tanggal 15 november 2008 jam 11.18 wib). 2007. protap respons medis akut, (online), (http://www.desentralisasi-kesehatan. net/id/moduldm/id/tt_2/bacaan/protap_ respon_medis_akut.pdf., diakses tanggal 22 oktober 2008 jam 08.12 wib). authors index volume 17 nomor 2 october 2022 acob, joel rey u., 161 pholanun, naphaklacha, 138 afiyanti, yati, 183 pradanie, retnayu, 190 arifin, hidayat, 161 pramestirini, rizky asta, 115 asril, aulia rahma, 176 qomariah, siti nur, 110 bakar, abu, 110 qowi, nurul hikmatul, 115 bangcola, ashley, 143 rahmah, citra danurwenda, 190 debee, jennifer, 121 rahmawati, rita, 110 dewi, yulis setiya, 161 rochmawati, erna, 153 elnaeem, manal mohamed abd, 121 saun, u akbar, 153 erawati, meira, 102 setioputro, baskoro, 168 faridah, virgianti nur, 115 srisatidnaraku, boonjai, 138 fitriasari, endah, 196 sumarlan, rahmawati dimas, 168 fitryasari, rizky, 190 suratmi, 115 fouly, howieda, 121 susilaningrum, rekawati, 131 hajar, siti, 176 tehupelasury, fahrunnissa, 196 ismail, christina suhartini, 102 tisnasari, ida ayu made ari santi, 183 karsim, 115 umamity, syahfitrah, 196 lestari, trijati puspita, 115 utami, sri, 131 lombonaung, ellen, 196 wabula, la rakhmat, 196 longo, joy, 138 windari, arindiah puspa, 196 malini, hema, 201 yahya, tri, 102 mangotara, sitty aizah, 143 yanti, budi, 176 nuraini, tuti, 183 yunanto, rismawan adi, 168 pamungkas, nanda rifky tri, 115 subject index volume 17 nomor 2 october 2022 a n approach; 110 nursing education; 161 attitude; 102 nursing student; 115 nutrition; 131 b o behaviour; 110 online learning; 115 breast cancer discrimination; 183 c p cancer survivors; 183 pandemic; 161 caregiving burden; 153 perspectives; 196 caregiving preparedness; 153 post-covid-19 functional; 176 caring nursing attitudes; 161 post-covid-19 persistent symptom; 176 caring; 110 prisoner; 190 character; 110 covid-19 patients; 102 covid-19; 115; 161 d q depression; 143 quantitative research; 143 disease severity status; 176 duration mechanical ventilation; 168 e r educational program; 121 religious well-being; 143 educational program; 196 resiliency; 190 emotional regulation; 190 respiratory distress syndrome; 138 existential well-being; 143 f s family caregiver; 153 satisfaction; 115 family perspectives; 121 spiritual health; 143 family; 196 stigma; 183; 190 survival, preterm infant; 138 symptom management; 153 i t incidence; 138 traditional healing; 196 isolation room; 102 training program; 153 transcultural nursing; 196 l v low birth pregnancy; 131 vital signs; 102 m w maternal critically ill patient fracture; 196 weight infants history of illness; 131 maternal critically ill patient; 121 mechanical ventilation; 168 1 | author information pack march, 2022 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health related professions. jurnal ners is a scientific peer-reviewed nursing journal that is published biannually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the central board of the indonesian national nurses association. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which 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advanced nursing research from the asian perspective. jurnal ners publishes research related to clinical settings, community, and health policy in asia from comparative and international views. we aim to evaluated and understand the complex nursing care intervention on fundamentals of nursing, clinical nursing, community, and mental health nursing. the journal also committed to improving the high quality research by publishing analytic techniques, measures, and research methods, not an exception to systematic review papers. iii. editorial board executive editor: prof. dr. nursalam m.nurs. (hons), (scopus id: 56660628500); faculty of nursing, universitas airlangga, indonesia editor-in-chief: ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100); faculty of nursing, universitas airlangga, indonesia please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. author information pack update: march 2022 https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://suggestor.step.scopus.com/progresstracker/index.cfm?trackingid=b5f9e2c037ae75e9 https://drive.google.com/file/d/1gsa2j87z4weyeqlkf0w_bdqjkkd95q-y/view?usp=sharing https://drive.google.com/open?id=1xmj6hqvbhpeiqaubnh681o-zny94zyry javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/454') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/509') 2 | author information pack march, 2022 advisory international editorial boards: 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, bns., msc., p.hd., (scopus id: 8293647300); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172); college of nursing, university of the philippines manila, philippines 5. dr. david pickles, (scopus id: 57190150026); college of nursing & health sciences, flinders university, south australia, australia 6. dr. farhan alshammari, (scopus id: 57192298773); college of nursing, university of hail, saudi arabia 7. dr. chong mei chan, scm, bnsc, msc, phd, (scopus id: 57189591887); dept. of nursing faculty of health science, university of malaya, malaysia 8. dr. sonia reisenhofer, (scopus id: 16310818100); school of nursing and midwifery, la trobe university, australia, australia 9. assistant professor pei-lun hsieh, (scopus id: 57190748913); department of nursing, college of health, national taichung university of science and technology, taiwan editor 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100); faculty of nursing, universitas airlangga, indonesia 2. prof. dr ah yusuf, s.kp.m.kes, (scopus id: 57200914632); faculty of nursing universitas airlangga indonesia 3. yulis setiya dewi, s.kep.ns., m.ng., (scopus id: ); faculty of nursing universitas airlangga 4. dr. esti yunitasari, s. kp., m. kes., (scopus id: 57204561035); faculty of nursing, universitas airlangga, surabaya., indonesia 5. dr. rizki fitryasari, s. kep., ns., m. kep., (scopus id: 57200912279); faculty of nursing, universitas airlangga, surabaya, indonesia 6. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756); faculty of nursing, universitas airlangga, indonesia, indonesia 7. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 8. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); (web of science researcherid x1131-2019), faculty of nursing, universitas airlangga, indonesia 9. laily hidayati, s.kep., ns., m.kep., (scopus id: 57202743375); faculty of nursing, universitas airlangga, indonesia assistant editor: rifky octavia pradipta, s.kep., ns., m.kep, (scopus id : 57216705839); faculty of nursing, universitas airlangga, indonesia quality control editor: gading ekapuja aurizki, s.kep., ns., m.sc. (scopus id: 57201187775); faculty of nursing, universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 811-3287-877 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3472') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3469') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/3098') 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javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/632') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/155') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/510') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/542') https://e-journal.unair.ac.id/jners/about/editorialteambio/10603 https://e-journal.unair.ac.id/jners/about/editorialteambio/2145 https://wa.me/qr/xtgu4colhec7e1 mailto:ners@journal.unair.ac.id http://e-journal.unair.ac.id/index.php/jners 3 | author information pack march, 2022 items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on a priori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and meta-analyses will be dealt with as original articles are, as far as the editorial process is concerned. ethics in publication this journal follows the committee of publication ethics (cope) guidelines and requests authors to familarise themselves with these guidelines at: http://publicationethics.org/resources/guidelines. a few issues that authors need to pay particular attention to are set out below. it is ethically questionable to break up or segment data from a single study to create different papers for publication, a practice called salami slicinga. if the authors have legitimate reasons for reporting separately on different parts of the same study, or the same data set, they should justify that to the editor at the time of submission. equally, readers need to be aware that different aspects of the same study are being reported, thus the methods section of the submitted manuscript must clearly explain why the submitted paper is justified. double-blind peer review process the decision to publish a paper is based on an editorial assessment and peer review. initially, all papers are assessed by an editorial committee consisting of members of the editorial team. the prime purpose is to decide whether to send a paper for peer review and to give a rapid decision on those that are not. the rejection is based on the novelty or the relevancy with the scope of this journal. http://e-journal.unair.ac.id/index.php/jners http://publicationethics.org/resources/guidelines 4 | author information pack march, 2022 initial editorial assessment jurnal ners is eager to provide a rapid publication process through an initial assessment conducted by an editorial committee consisting of the editorial team members. the primary purpose is to decide whether to send the paper for peer-review or to reject it. the main point is scope, compliance with the guideline, and language. sometimes a paper will be returned to the author with a request for revisions with the purpose to help editors in deciding whether or not to send it out for review. authors may expect the decision of the initial editorial assessment from this stage of the review process within 1-2 weeks of submission. review process after passing the initial editorial assessment, the article will be sent to peer -reviewers. the peer-review process involved at least two reviewers for each manuscript selected based on their expertise. all reviewing process is done by the double-blind review, which means the authors and peer-reviewers do not know each other’s identity. the reviewers should complete the review within three weeks in each reviewing round after the review request was sent. decision-making process the decision to accept for publication is based on the peer reviewer's recommendations, based on which two acceptance recommendations are required. if there is a difference in the two reviewers’ recommendations, the editor has the right to seek the third reviewer's consideration. the final decision to publish is made by the editor-in-chief, editorial committee (national or international advisory board) by considering the advice from reviewers. review criteria each paper that the editor/s assess as suitable for peer review is allocated to two reviewers who are asked to assess the paper against one of the journal's three sets of reviewing criteria: articles submitted for review must be original works, and may not be submitted for review elsewhere whilst under review for the journal. after review, the editor-in-chief will inform the corresponding author on whether the paper has been accepted, rejected, or needs revision. categories of decision accept minor revisions (accept with revisions as advised by editors) major revisions (possible acceptance following major revision and resubmission) reject all efforts are made to provide fair and thorough reviews as speedily as possible. if an author(s) believes that a manuscript has been wrongly rejected, a detailed appeal letter that responds point-by-point to the reviewers' comments should be sent to the editor who, after having reviewed the referees' reports, will make the fina l decision. reviewed by editor-in-chief or editorial team only letter to the editor or a short comment on any topic of current interest for these types of submissions, the corresponding author will receive a fairly rapid decision on publication. language please write your text in good english (british or american or other english style usage is accepted). authors who feel their english language manuscript may require editing to eliminate possible grammatical or spelling errors and to conform to correct scientific english may wish to use the english language editing service. after receiving acceptance decision, author must send the manuscript to proofreaders that has been provide by editor through this link https://forms.gle/hdxuugycvntic4cfa . all of payment becomes author’s responsibility. production following acceptance of a manuscript; the corresponding author will receive an acknowledgement. the paper will then be edited to comply with house style, and typeset. the publisher will email a proof to the corresponding author for checking before it is published. the corresponding author is responsible for checking proofs thoroughly. by approving the proofs any editorial changes are being accepted. we also provide printed issues of jurnal ners. to purchase the printed issues, please fill this form https://goo.gl/forms/luhoutrvixqojybn2 and confirm your order to our whatsapp on +62 811-3287-877. our committee will process your order as soon as possible after your confirmation. https://forms.gle/hdxuugycvntic4cfa https://goo.gl/forms/luhoutrvixqojybn2 https://wa.me/qr/xtgu4colhec7e1 5 | author information pack march, 2022 submission of manuscripts all manuscripts, correspondence and editorial material for publication is submitted online at http://ejournal.unair.ac.id/index.php/jners simply need to "create a new account" (i.e., register) by following the online instructions, and using their own e-mail address and selected password. authors can submit manuscripts online. authors can expect an initial decision to undergo peer-review. revised submissions authors are requested to submit the revision within one month for all reviewing process i.e. rapid decision or in review stage. if not, the submission will be removed from the editorial system and needs to be submitted as a new submission. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, orcid id, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and postpublication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following:  introduction: one or two sentences on the background and purpose of the study.  method: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics).  results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals.  conclusions: should relate to the study aims and hypotheses.  keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. acknowledgment (optional) acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 6 | author information pack march, 2022 tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below:  observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/  qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq  quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/  randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/  study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/  systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/  systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 submission preparation checklist indicate that this submission is ready to be considered by this journal by checking off the following (comments to the editor can be added below). 1. as part of the submission process, authors are required to check off their submission's compliance with all of the following items. submissions may be returned to authors that do not adhere to these guidelines. 2. the author(s) haven’t suggested any personal information that may make the identity of the patient recognizable in any form of description, photograph or pedigree. when the photographs of the patient are essential and indispensable as scientific information, the author(s) must have received the consent in written form and have clearly stated such. 3. in case of experimenting on humans, the author(s) have certified that the process of the research is in accordance with the ethical standards of the helsinki declaration, as well as any domestic and foreign committees that preside over the experiment. if any doubts are raised as to whether the research proceeded in accordance with the helsinki declaration, then author(s) are required to explain it. in the case of experimenting on animals, the author(s) have certified that the author(s) had followed the necessary domestic and foreign guidelines related to experimenting on animals in a laboratory. 4. the author(s) have received consent from the author or editor of any pictures or table quoted from other journals or books. a portion or the entirety of the article must not have been published in other journals, nor must it have contributed to other journals or is still under review. 5. the author(s) undersigned hereby give the faculty of nursing universitas airlangga the rights as publisher, the right of first publication of all published material. it will be llicensed under a creative commons attribution 4.0 international license. 6. author(s) of the journal have clarified everything that may arise such as work, research expenses, consultant expenses, and intellectual property on the document in relation to the icmje form disclosure of conflicts of interest. copyright notice authors who publish with jurnal ners agree to the following terms: 1. authors transfer the copyright and grant jurnal ners the right of first publication with the work http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://mji.ui.ac.id/journal/public/journals/1/coi_disclosure.pdf http://mji.ui.ac.id/journal/public/journals/1/coi_disclosure.pdf 7 | author information pack march, 2022 simultaneously licensed under a creative commons attribution 4.0 international license that allows others to remix, adapt and build upon the work with an acknowledgment of the work's authorship and of the initial publication in jurnal ners. 2. authors are permitted to copy and redistribute the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in jurnal ners. jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your own records. your cooperation is essential and appreciated. any delay will result in a delay in publication. the form can be downloaded here. publication fee jurnal ners charges the author a publication fee amounted to idr 3.000.000 (indonesian author) and usd 200 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within a week. open access policy this journal retains copyright but provides immediate open access to its content on the principle that making research freely available to the public supports a greater global exchange of knowledge. this journal (p-issn:1858-3598; e-issn:2502-5791) is licensed under a creative commons attribution 4.0 international license. plagiarism check this journal follows the committee of publication ethics (cope) guidelines and requests authors to familarise themselves with these guidelines at: http://publicationethics.org/resources/guidelines. plagiarism is not acceptable in jurnal ners submissions. all the submitted manuscripts are checked for plagiarism before starting the review process. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): https://creativecommons.org/licenses/by/4.0/ https://drive.google.com/open?id=0b5ormcrmctnwcjrslunpyl9gueu http://issn.pdii.lipi.go.id/issn.cgi?daftar&1451966396&26&& http://issn.pdii.lipi.go.id/issn.cgi?daftar&1451966396&26&& http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ https://publicationethics.org/guidance/guidelines https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s http://creativecommons.org/licenses/by/4.0/ 8 | author information pack march, 2022 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number : 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number: 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number: 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orcid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ............................................................................................................................. ............................................................ h. funding source ............................................................................................................................................................... .......................... ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. https://orcid.org/ https://orcid.org/ https://orcid.org/ 9 | author information pack march, 2022 title page example modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : http://orcid.org/0000-0002-6669-0767 6. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/) 6. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/) 6. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): mailto:ah-yusuf@fkp.unair.ac.id http://orcid.org/0000-0002-6669-0767 mailto:hanik-e-n@fkp.unair.ac.id https://orcid.org/ mailto:krisna-e-k-2015@fkp.unair.ac.id https://orcid.org/ https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 10 | author information pack march, 2022 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, nonstandard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .......................................................................................................................... ........................................................................ ............................................................................................................................. ..................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... ................................................................................................. .............................................................. ................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ...................................................................................................................................................... ............................................ ...................................................................................... ......................................................................... ................................... results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to 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(2020) ‘the effect of range of motion exercise on blood pressure, pulse and sleep quality among hypertensive patients’, international journal of innovation, creativity and change. faculty of nursing, universitas airlangga, mulyorejo street, campus c unair, surabaya, 60115, indonesia: primrose hall publishing group, 13(6), pp. 220–234. available at: https://www.scopus.com/inward/record.uri?eid=2-s2.085087361125&partnerid=40&md5=b7318712857248d9ea896f85f82d69c9. reference to a book: de virgilio, c. & grigorian, a. 2019, ‘surgery: a case based clinical review’ in surgery: a case based clinical review, pp. 1-689. reference to a book section/chapter: harper, m.s. 2021, ‘mental health and mental health services’ in services to the aging and aged: public policies and programs, pp. 283-297. reference to a website: who (2021) who coronavirus disease (covid-19) dashboard: situation by country, territory & area. reference in conference: yuarnistira, nursalam, n., rachmawati, p.d., efendi, f., 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https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk vol 8 no 1 april 2013.indd 142 rekomendasi penurunan burnout pada perawat kontrak (recommendation in decreasing burnout on the contract nurses) dewa kadek adi surya antara*, nursalam**, ninuk dian kurniawati** *rsup sanglah denpasar, jalan diponegoro denpasar e-mail: dewakadek.antara@yahoo.com **fakultas keperawatan universitas airlangga abstrak pendahuluan: burnout merupakan masalah yang sering muncul pada bidang pelayanan pelanggan (human service). profesi keperawatan sangat rentan mengalami burnout berkaitan dengan pekerjaan yang digeluti melibatkan interaksi antar personal, serta lingkungan dalam pekerjaan. area of worklife merupakan faktor prediktor pencetus burnout, mengakibatkan timbul keinginan untuk berpindah kerja (turnover intention). tujuan penelitian ini adalah memberikan rekomendasi penurunan burnout pada perawat kontrak di rsup sanglah denpasar. metode: penelitian ini merupakan penelitian eksplanatif dengan pendekatan crossectional. populasi adalah perawat ruang kelas iii di rsup sanglah denpasar, besar sampel 81 orang perawat kontrak dengan teknik proporsional random sampling. data dikumpulkan melalui kuesioner, focus group discussion (fgd) dan dianalisis dengan partial least square (pls). hasil: hasil penelitian menunjukkan bahwa tidak terdapat pengaruh kontrol terhadap beban kerja namun terdapat pengaruh kontrol terhadap keadilan, komunitas dan penghargaan, terdapat pengaruh beban kerja terhadap kelelahan emosional, terdapat pengaruh komunitas dan penghargaan terhadap nilai namun tidak terdapat pengaruh keadilan terhadap nilai, terdapat pengaruh nilai terhadap kelelahan emosional dan penurunan prestasi pribadi namun tidak terdapat pengaruh nilai terhadap depersonalisasi, terdapat pengaruh kelelahan emosional terhadap depersonalisasi, terdapat pengaruh depersonalisasi terhadap penurunan prestasi pribadi, terdapat pengaruh kelelahan emosional dan penurunan prestasi pribadi terhadap turnover intention namun tidak terdapat pengaruh depersonalisasi terhadap turnover intention pada perawat kontrak. pembahasan: penurunan burnout dapat dilakukan dengan membentuk nilai pribadi dan menurunkan beban kerja perawat kontrak, nilai pribadi dibentuk oleh kontrol melalui dua aspek yaitu komunitas dan penghargaan, depersonalisasi memiliki pengaruh paling dominan dalam dimensi burnout yang dibentuk oleh aspek kelelahan emosional, turnover intention dapat diturunkan melalui penurunan dimensi kelelahan emosional dan meningkatkan prestasi pribadi. model penurunan burnout ini dapat diterapkan di rumah sakit lain karena memberikan gambaran tentang aspek yang mempengaruhi burnout serta mencegah munculnya turnover intention. kata kunci: burnout, area of worklife, turnover intention, perawat kontrak, rekomendasi abstract introduction: burnout is a problem that often arises in the fi eld of human service. nursing profession is very susceptible in experiencing burnout related to the served work involving interpersonal interactions, as well as work environment. area of worklife is predictor factors trigger burnout, resulting in the turnover intention. the purpose of this study was to provide recommendations in decreasing burnout on the contract nurses in the sanglah central hospital. method: this study was an explanatory research using crosssectional approach. the population consists of the nurses at the third class ward sanglah central hospital-denpasar. eighty one nurses were recruited as sample by proportional random sampling technique. data were collected through questionnaires and focus group discussion (fgd), and they were analyzed by using partial least square (pls). result: results of this study showed that control had effect on fairness, community and reward but it had no 143 rekomendasi penurunan burnout (dewa kadek adi surya antara, dkk) effect on workload, workload had signifi cant effect on emotional exhaustion, value had no effect on justice and depersonalization however it showed effect on community, reward, emotional exhaustion and decreasing personal accomplishment, emotional exhaustion had effect on depersonalization and turnover intention, depersonalization had no effect on turnover intention but it had effect on the decreasing of personal accomplishment, emotional exhaustion and decreasing personal accomplishment have effect on turnover intention of contract nurse. discussion: the decreasing of burnout can be done by forming personal values and reducing workload of the contract nurses. the personal values can be formed through controls of the two aspects: community and appreciation depersonalization has the most dominant infl uence in the burnout dimensions established by aspects of emotional exhaustion, turnover intention can be decreased by reducing the dimensions of emotional exhaustion and improving personal achievement. the decreasing burnout model can be applied in other hospitals because it provides an overview of the aspects that affect burnout and prevents the emergence of turnover intention. keywords: burnout, area of worklife, turnover intention, contract nurses, recomendation pendahuluan burnout merupakan kumpulan gejala yang muncul akibat penggunaan energi yang melebihi sumber daya seseorang sehingga m e ng a k i b a t k a n mu nc u l ny a kelel a h a n fi sik, emosional dan mental (schaufeli dan greenglass, 2001). konteks tentang burnout muncul dalam pelayanan pelanggan (human service) seper ti tenaga perawat, pekerja sosial, perusahaan jasa, bidang pendidikan dan lain-lain yang berkaitan dengan layanan yang melibatkan interaksi antar personal yang mengakibatkan mu nculnya ketiga gejala burnout (maslach dan leither, 1996). perawat sering dihadapkan pada kondisi upaya menyelamatkan pasien, mengerjakan tugas rutinitas, ruang kerja yang sumpek, jumlah pasien yang banyak, dan harus bertindak cepat dalam menangani pasien kebutuhan pasien. banyaknya jumlah pasien yang dirawat dan semakin beragamnya penyakit merupakan stresor kerja bagi perawat, stressor kerja yang tidak dapat diadaptasi dan berlangsung dalam jangka waktu yang lama dengan intensitas yang cukup tinggi inilah yang disebut dengan burnout (tawale dan novita, 2011). area pekerjaan (area of worklife) mer upakan faktor prediktor munculnya bur nout. aspek beban ker ja mem ili k i pengar uh langsung munculnya kelelahan emosional per awat ya ng berhubu nga n dengan pekerjaan (leither dan maslach, 2004). otonomi atau kewenangan perawat di dalam merawat pasien akan berpengaruh juga terhadap kemampuan perawat dalam mengambil keputusan terhadap pekerjaaannya, mengelola pekerjaan (karasek dan theorell, 1990). penghargaan mengacu kepada kekuatan reinforcement yang membentuk perilaku perawat. komunitas mencakup dukungan sosial dalam pekerjaan dan interpersonal konfl ik, keadilan muncul dari keseimbangan faktor yang mempengaruhi harapan seseorang. sedangkan nilai merupakan hasil dari kekuatan emosional kognitif untuk mencapai tujuan dari pekerjaan dan harapan. tuntutan kerja merupakan determinan penting pembentukan kelelahan emosional, munculnya kelelahan emosional mengakibatkan depersonalisasi atau munculnya sikap sinisme terhadap pekerjaan (leither dan maslach, 1999). ha si l st ud i p e nd a hu lu a n ya ng dilakukan dengan menggunakan instrumen maslach burnout inventory (mbi), menilai 3 dimensi burnout didapatkan hasil 10 orang (50%) mengalami kelelahan emosional sedang, 11 orang (55%) mengalami depersonalisasi sedang dan 11 orang (55%) mengalami penurunan prestasi ringan. data yang diambil saat studi pendahuluan tentang area of worklife dari enam aspek yang dikaji 15% merasakan beban kerja tinggi, 55% merasakan beban kerja sedang, 20% memiliki kontrol dalam pekerjaan yang rendah, 25% merasakan penghargaan ya ng d iter i ma rend a h, 5% merasa ka n komunitas kerja yang tidak kondusif, 15% 144 jurnal ners vol. 8 no. 1 april 2013: 142–152 merasakan keadilan dalam pekerjaan yang rendah dan 5% merasakan nilai pribadi yang diyakini tidak sejalan dengan nilai dalam organisasi. pe n i ng k at a n b eb e r ap a i nd i k at or pelayanan akan berdampak pada peningkatan beban kerja perawat. tingkat hunian bed (bor) di ruang rawat inap kelas iii di rsup sanglah rata-rata diatas 85%, jika dilihat dari standar nasional yaitu 60-85% maka jumlah tersebut melebihi nilai standar yang berdampak pada beban kerja yang sangat tinggi dibandingkan dengan jumlah tenaga perawat yang terbatas. jumlah tenaga keperawatan di rsup sanglah tahu n 2012 adalah 988 orang perawat, 710 (71,8%) status pegawai negeri sipil (pns) dan 36 orang (3,64%) perawat honorer dan 242 (24,49%) mer upakan tenaga kontrak (bidang keperawatan, 2012). perbandingannya perawat dengan jumlah tempat tidur di kelas iii adalah 1:1,4 dilihat dari standar 3– 4 perawat: 2 tempat tidur, dapat disimpulkan masih kurang dari standar nasional. tuntutan pekerjaan terhadap perawat untuk meningkatkan kualitas pelayanan terkadang membuat manajemen k urang memperhatikan kebutuhan dan keinginan perawat sehingga muncul rasa tidak nyaman (prahoro, 2010). ketidaknyamanan dalam bekerja yang terjadi dapat menimbulkan halhal yang berakibat buruk bagi rumah sakit dan perawat yang bersangkutan sehingga munculnya turnover di rumah sakit tersebut. data tahun 2011 menunjukkan bahwa sejumlah 53 orang dari 244 orang perawat kontrak keluar dari rsup sanglah pada tahun 2011 dengan berbagai alasan yaitu; lulus pns di instansi lain, pindah kerja ke tempat lain, meninggalkan tugas tanpa alasan, serta berhenti karena alasan sakit. studi pendahuluan yang mengkaji tentang keinginan perawat untuk keluar dari rumah sakit atau pindah unit kerja (turnover intention) menunjukkan 7 orang (35%) memiliki keinginan yang tinggi terhadap turnover dan 9 orang (45%) memiliki keinginan sedang melakukan turnover. solusi untuk mempertahankan perawat beker ja d ala m profesi d a n men i k mat i pekerjaannya tanpa menimbulkan burnout sangat diperlukan, karena burnout memiliki hubungan negatif dari respons pekerjaan dan komitmen terhadap organisasi (leither dan maslach, 2009). tujuan penelitian ini adalah menyusun rekomendasi penurunan burnout pada perawat kontrak di rsup sanglah denpasar. bahan dan metode jenis penelitian ini adalah penelitian eksplanatif, dengan pendekatan crossectional. subjek diukur tentang kondisi area of work life, burnout dan turnover intention menggunakan kuesioner area of work life scale (aws), maslach burnout inventor y (mbi) dan pertanyaan tentang turnover intention yang dimodifikasi sesuai dengan karakteristik subjek penelitian. populasi yang diteliti adalah seluruh perawat kontrak di ruang rawat inap kelas iii di rsup sanglah denpasar dengan ju m la h popu la si per awat kont r a k 101 orang. teknik pengambilan sampel dalam penelitian ini menggunakan proportional random sampling dengan besar sampel 81 orang. variabel eksogen dalam penelitian ini adalah area of work life: kontrol, beban kerja, keadilan, komunitas, penghargaan dan nilai, sedangkan variabel endogennya adalah dimensi burnout: kelelahan emosional, depersonalisasi, penurunan prestasi pribadi dan turnover intention. pengambilan data kuesioner dilakukan pada tanggal 4-30 maret 2013. analisa data dilakukan secara bertahap dengan analisis deskriptif dan dilanjutkan dengan analisis inferensial menggunakan partial least square (pls), pengujian hipotesis dilakukan dengan uji t statistik bermakna signifi kan jika nilai t statistik >1,96. lokasi penelitian dilakukan di ruang rawat inap kelas iii rsup sanglah denpasar. hasil hasil pengumpulan data tentang area of work life. nilai tertinggi jawaban yang mendominasi aspek area of worklife adalah aspek komunitas sebanyak 60 orang (74,1%) dapat diartikan bahwa rekan kerja sesama perawat kontrak di rsup sanglah memiliki 145 rekomendasi penurunan burnout (dewa kadek adi surya antara, dkk) tingkat kebersamaan yang tinggi dalam menghargai dan melaksanakan perannya masing-masing. penilaian kategori paling rendah adalah aspek kontrol (otonomi) yang dimiliki perawat kontrak yaitu tidak ada yang memiliki kontrol rendah. hal ini menunjukkan bahwa sebagian besar kontrol (otonomi) yang dimiliki perawat kontrak di rsup sanglah cukup tinggi dalam penyelesaian tugas mereka. aspek beban kerja dalam melaksanakan tugas didominasi jawaban sedang 72,8% dan hanya 2 orang (2,5%) yang mengatakan beban kerja rendah dari responden 81 perawat kontrak di rsup sanglah, sisanya merasakan beban kerja tinggi 37 orang (45,7%). hal ini menunjukkan bahwa sebagian besar beban kerja yang dimiliki perawat kontrak di rsup sanglah cukup tinggi dalam penyelesaian tugas mereka (tabel 1). jawaban ter tinggi didominasi oleh penurunan prestasi pribadi yaitu 73 orang (90,1%) artinya menunjukkan bahwa dalam menjalankan pekerjaannya perawat kontrak tidak mengalami penurunan prestasi pribadi. jawaban kategori terendah adalah kelelahan emosional sebanyak 59 orang (72,8%) sedangkan sisanya mengalami kelelahan emosional sedang 21 orang (25,6%) serta terdapat 1 orang yang mengalami kelelahan emosional tinggi. kondisi burnout perawat kontrak secara umum berada dalam kondisi rendah. dimensi kelelahan emosional menjadi aspek yang mempengaruhi dimensi burnout lainnya (tabel 2). variabel turnover intention didominasi oleh jawaban sedang yaitu sebesar 66,7%. hal ini menunjukkan bahwa sebagian besar perawat kontrak memiliki keinginan untuk pindah kerja jika mendapatkan tempat yang lebih baik dalam kategori sedang (tabel 3). pengar uh depersonalisasi terhadap penurunan prestasi pribadi memiliki nilai koefi sien jalur ( path coeffi sien) yang paling besar yait u 0.689 dibandingkan dengan pengar uh antar variabel lainnya, dengan signifi kansi t hitung 15.634. sedangkan nilai koefisien jalur yang paling rendah adalah pengaruh depersonalisasi terhadap turnover intention perawat kontrak yaitu 0.012 dan t hitung 0.141 yang berarti tidak ada pengaruh signifi kan depersonalisasi terhadap turnover intention perawat kontrak di rsup sanglah denpasar (gambar 1). tabel 1. area of work life perawat kontrak awl rendah sedang tinggi totalf % f % f % n % beban kerja 2 2,5 59 72,8 20 24,7 81 100 kontrol 44 54,3 37 45,7 81 100 keadilan 7 8,6 45 55,6 29 35,8 81 100 komunitas 3 3,7 18 22,2 60 74,1 81 100 reward 10 12,3 53 65,4 18 22,2 81 100 nilai 1 1,2 27 33,3 53 65,4 81 100 tabel 2. burnout pada perawat kontrak burnout rendah sedang tinggi totalf % f % f % n % kelelahan emosional 59 72,8 21 25,9 1 1,2 81 100 depersonalisasi 68 84,0 12 14,8 1 1,2 81 100 penurunan prestasi pribadi 73 90,1 6 7,4 2 2,5 81 100 tabel 3. turnover intention pada perawat kontrak rendah sedang tinggi total f % f % f % n % turnover int. 18 22,2 54 66,7 9 11,1 81 100 146 jurnal ners vol. 8 no. 1 april 2013: 142–152 gambar 1. analisis uji model rekomendasi penurunan burnout pada perawat kontrak di rsup sanglah tabel 4. hasil uji hipotesis penelitian rekomendasi penurunan burnout pada perawat kontrak hubungan antar variabel koefi sien path t hitung keterangan 1 control workload 0.064 0.208 tidak signifi kan 2 control fairness 0.310 5.399 signifi kan 3 control community 0.541 8.152 signifi kan 4 control reward 0.251 3.543 signifi kan 5 workload emotional exhaustion 0.419 2.538 signifi kan 6 fairness value 0.134 1.407 tidak signifi kan 7 community value 0.226 2.987 signifi kan 8 reward value 0.232 2.802 signifi kan 9 value emotional exhaustion -0.238 3.471 signifi kan 10 value depersonalization 0.080 1.160 tidak signifi kan 11 value personal accomplishment -0.214 3.470 signifi kan 12 emotional exhaustion depersonalization 0.688 16.236 signifi kan 13 depersonalization personal accomplishment 0.689 15.634 signifi kan 14 emotional exhaustion turnover intention 0.371 5.253 signifi kan 15 depersonalization turnover intention 0.012 0.141 tidak signifi kan 16 personal accomplishment turnover intention 0.268 2.767 signifi kan rek apit u la si uji h ipot e sis d apat dilihat dalam tabel 4. menunjukkan bahwa terdapat 12 hubungan antar-variabel yang memiliki pengaruh signifi kan berdasarkan nilai t hitung yang dibandingkan dengan t tabel, dikatakan signifi kan jika nilai t hitung lebih besar dari t tabel (1,96). sedangkan 4 hubungan antar-variabel menunjukkan tidak ada pengaruh signifi kan karena memiliki nilai t hitung lebih kecil dari t tabel (1,96). nilai path coeffi sien menunjukkan nilai besarnya pengaruh hubungan antar variabel, sedangkan nilai negatif (–) menunjukkan kondisi yang berlawanan. h a s i l a n a l i s i s d a t a k e m u d i a n dilanjutkan dengan kegiatan focus group 147 rekomendasi penurunan burnout (dewa kadek adi surya antara, dkk) discussion (fgd) dilakukan dua kali fgd yaitu dengan kelompok perawat kontrak serta jajaran kepala ruangan dan kaupp untuk mendapatkan isu strategis dan menghasilkan rekomendasi adalah rekomendasi untuk menyesuaikan beban kerja perawat sesuai standar. peningkatan reward, memperhatikan aspek keadilan terhadap perawat kontrak, mengurangi faktor-faktor pencetus kelelahan emosional, dan menurunkan turnover intention pada perawat kontrak. pembahasan h a si l p e n el it ia n p a d a ta b el 4, menunjukkan bahwa variabel kontrol tidak berpengaruh signifi kan terhadap beban kerja pada perawat kontrak di rsup sanglah denpasar. perbedaan hasil uji hipotesis dengan teori yang ada berhubungan juga dengan faktor-faktor yang mempengaruhi beban kerja. gillies (1994) mengatakan bahwa beban kerja tenaga keperawatan, setidaknya ada beberapa faktor yang mempengaruhi yaitu; jumlah pasien, kondisi pasien, rata-rata hari perawatan pasien, tindakan keperawatan langsung dan tidak langsung yang dibutuhkan oleh masing-masing pasien, frekuensi masingmasing tindakan keperawatan yang harus dilakukan, rata-rata waktu yang diperlukan untuk pelaksanaan masing-masing tindakan keperawatan. asumsi yang dapat diberikan berdasarkan teori dan kenyataan yang terjadi adalah dari faktor-faktor yang mempengaruhi beban kerja ada yang dapat di kontrol dan tidak bisa dikontrol, faktor yang tidak dapat dikontrol misalnya yang berkaitan dengan jumlah pasien dan tingkat ketergantungan pasien. kebijakan di rsup sanglah dengan mengeluarkan surat edaran direktur bahwa tidak boleh menolak pasien merupakan suatu hal yang tidak dapat di kendalikan oleh perawat secara individu. variabel kontrol berpengaruh signifi kan terhadap keadilan ( fairness) pada perawat kontrak di rsup sanglah denpasar. kontrol (autonomi) yang dimiliki oleh seorang perawat berperan dalam keputusan penting terhadap pekerjaan serta otonomi professional. seorang perawat yang memiliki kontrol yang tinggi terhadap pekerjaannya, memiliki hak untuk memilih, dan diberikan otonomi untuk mengatur cara kerjanya sesuai dengan kemampuannya akan merasakan keadilan dalam pekerjaannya unt u k menent ukan sikap, tidak ada ambiguitas dalam perannya (leither dan maslach, 2004). kewenangan yang diber i kan d alam peker ja an a kan memberikan rasa adil, hal ini sesuai dengan pendapat (colquitt, 2001) bahwa keadilan berkembang selama proses yang dilalui atau datang pengaruh dari luar dengan mengikuti kriteria proses yang adil meliputi: konsistensi, tidak memihak, infor masi yang akurat, keterwakilan, kontribusi dalam pekerjaan, keterbukaan dan etika. kriteria proses tersebut jika ditegakkan, maka proses akan berjalan dengan baik atau adil. suatu kondisi seperti berapa banyak seorang perawat berkontribusi terhadap rumah sakit berdasarkan autonomi yang dimiliki akan merasakan aspek keadilan berdampak pada reaksi secara lebih positif terhadap organisasi dibandingkan dengan yang merasakan ketidakadilan. proses yang adil sangat penting karena hal itu akan memuaskan orang untuk terlibat dalam organisasi (tyler, 1996). kont rol b e r p e nga r u h sig n i f i k a n terhadap komunitas pada perawat kontrak di rsup sanglah denpasar. hasil uji hipotesis tersebut sesuai dengan the demand control theory of job stress, mengemukakan besar pengaruh kontrol dalam pekerjaan. kontrol berkontribusi pula terhadap lingkungan kerja perawat, kewenangan atau otonomi yang dimiliki oleh perawat mempengaruhi bagaimana perawat kontrak tersebut berperan dalam lingkungannya karasek dan theorell (1990) dalam (leither dan maslach, 2004). variabel kontrol berpengaruh signifi kan terhadap reward pada perawat kontrak di rsup sanglah denpasar. hasil penelitian menunjukkan hal ini sesuai dengan pendapat leiter dan maslach (2009) menyatakan bahwa otonomi yang dimiliki perawat berpengaruh terhadap reward yang dirasakan. penghargaan dapat berupa keuangan, sosial dan konsisten dengan harapan seseorang, ketika seseorang merasa diabaikan karena tidak dihargai secara material dan dukungan sosial, dia akan 148 jurnal ners vol. 8 no. 1 april 2013: 142–152 kehilangan nilai-nilai dalam mencapai tujuan dari pekerjaanya. hal ini dikuatkan oleh hasil penelitian menunjukkan bahwa penurunan reward akan berpeluang munculnya kejadian burnout (siefert dan jayaratne, 1991). beban kerja berpengaruh signifikan terhadap kelelahan emosional pada perawat kontrak di rsup sanglah denpasar. beban kerja yang berlebihan merupakan salah satu penyebab timbulnya stress kerja. (garrosa et al., 2011). misalnya merawat pasien yang terlalu banyak, mengalami kesulitan dalam mempertahankan standar yang tinggi, merasa tidak mampu member i du k u ngan yang dibutuhkan teman sekerja dan menghadapi masalah keterbatasan tenaga. kelelahan emosional mer upakan inti dari sindrom burnout yang ditandai dengan terkurasnya sumber-sumber emosional di dalam diri seperti rasa kasih, empati dan perhatian, yang pada akhirnya memunculkan perasaan tidak mampu lagi memberikan pelayanan pada orang lain. hal ini didukung oleh hasil penelitian (leither dan maslach, 2009) munculnya kelelahan emosional sangat dipengaruhi secara langsung oleh faktor beban, kerja beban kerja tersebut ada yang dapat di manage dan unmanagable. keadilan tidak berpengaruh signifi kan terhadap nilai pada perawat kontrak. nilai nilai pribadi setiap individu sangat berbeda, perbedaan tujuan kerja karena perbedaan nilai hidup yang dianut. perawat yang bekerja karena ingin mendapatkan upah/gaji demi menghidupi ekonomi keluarga akan sangat berbeda motivasi/semangat dan cara kerjanya jika dibandingkan dengan orang yang bekerja hanya karena ingin mengabdikan dirinya sebagai panggilan hidup (harjana, 1994). faktor faktor yang mempengaruhi nilai pribadi seseorang bukan hanya dipengaruhi oleh aspek keadilan. aspek prinsip seseorang yang memiliki tujuan hidup tertentu menjadikan misalnya u nt u k mengembangkan kar ir/ mendapatkan ilmu meskipun dia merasakan kurang adil, namun tetap mampu diadaptasi bahwa perawat kontrak memiliki nilai pribadi bahwa dengan bekerja di rsup sanglah dia akan mencapai tujuan dalam pekerjaannya dan tidak bertentangan dengan visi dan misi rumah sakit. komunitas ber pengar uh signif ikan terhadap nilai pada perawat kontrak di rsup sanglah. hasil penelitian sesuai dengan apa yang dikemukakan oleh leiter dan maslach (2004) menyatakan bahwa value adalah sumber dari kedekatan hubungan dengan pekerjaan, nilai dan motivasi yang baik dapat dibentuk dari hubungan pekerja dengan lingkungannya, dengan kondisi lingkungan kerja yang baik, akan berkontribusi terhadap tujuan individu dan organisasi. penghargaan berpengaruh signifi kan terhadap nilai/value pada perawat kontrak di rsup sanglah. ketika seseorang merasa diabaikan karena tidak dihargai secara material dan dukungan sosial, dia akan kehilangan nilai-nilai dalam mencapai tujuan dari pekerjaanya (cordes dan dougherty, 1993) dalam (maslach & leither, 1996). hal ini didukung dengan pendapat dari leiter dan maslach (2004) value akan memberikan motivasi dan keterikatan seorang dengan t e mpat ke r ja nya , ket i k a me mb e r i k a n kontribusi terhadap tempat kerjanya dia akan menerima reward dan kesempatan untuk mengembangkan karirnya. h a si l p e n el it ia n p a d a ta b el 4, menunjukkan pengaruh yang signifi kan dari variabel nilai terhadap kelelahan emosional. nilai-nilai pribadi yang dimiliki oleh perawat kontrak cukup baik, hal ini dapat diasumsikan dari hasil uji hipotesis, terjadi penurunan kelelahan emosional ketika perawat kontrak sangat memahami tujuan dari pekerjaannya, cara untuk menjalin hubungan emosional yang baik dengan pasien, orang lain dan atasan sehingga tidak terjadi peningkatan kelelahan emosional dalam hal ini rsup sanglah mampu membentuk nilai-nilai pribadi perawat seiring dengan nilai organisasi meskipun faktor lain seperti beban kerja mempengaruhi kelelahan emosional, namun karena nilai pribadi sejalan dengan visi dan misi rumah sakit sehingga tidak terjadi kelelahan emosional yang berat pada perawat kontrak di rsup sanglah. nilai tidak ber pengar uh signif ikan terhadap depersonalisasi/cinism pada perawat kontrak. pengar uh yang tidak signif ikan dapat dilihat dari faktor yang mempengaruhi t e r ja d i nya de p e r son a l isa si, p e nel it ia n 149 rekomendasi penurunan burnout (dewa kadek adi surya antara, dkk) yang dilakukan oleh leither dan maslach (2009) menyatakan bahwa kontribusi dalam pembentukan perilaku depersonalisasi perawat dipengaruhi oleh karakteristik individu, nilai dan lingkungan, dalam penelitian ini dapat diasumsikan bahwa nilai-nilai pribadi seorang perawat bukan satu satunya yang dapat menurunkan sikap depersonalisasi, hal ini dilihat dari path coeffi sien yang memiliki nilai 0,08 kurang dari 20% sedangkan faktor lain yang dapat memicu terjadinya depersonalisasi karena karakteristik individu dan lingkungan. perilaku individu adalah sebuah fungsi dari atribut-atribut personal dan situasional yang saling berinteraksi, perspektif interaksi ini meningkatkan pemahaman terhadap sikap karyawan dan tujuan mereka dalam organisasi, karena interaksi individu dengan organisasi secara bersama-sama akan memengaruhi perilaku. variabel nilai berpengaruh signifi kan terhadap penurunan prestasi pribadi pada perawat kontrak. tingginya tingkat nilai-nilai pribadi yang dianut oleh perawat kontrak mempengaruhi kinerja perawat, kesesuaian t ujuan pr ibadi dengan organisasi akan berdampak pada tingginya kesadaran perawat dalam melaksanakan tugas. hal ini tercermin dari banyaknya situasi yang mer upakan stressor bagi perawat mampu diadaptasi dan tidak terjadi penurunan prestasi pribadi meskipun ada dalam jumlah yang sangat kecil mengalaminya. nilai-nilai pribadi yang dianut oleh perawat kontrak menjadi pegangan bahwa pelayanan terhadap pasien adalah yang utama, sehingga mampu mengatasi segala hambatan dan dengan dukungan segenap jajaran rumah sakit yang baik akan memberikan semangat dalam bekerja dan meningkatkan pencapaian prestasi pribadi. kelelahan emosional ber pengar uh signif ikan terhadap depersonalisasi pada perawat kontrak. hasil penelitian didukung oleh pendapat maslach dan schaufeli (1993). kelelahan emosional yang mengacu pada perasaan merupakan hasil dari yang emosional berlebihan dan karena kehabisan cadangan yang normal sumber daya seseorang. menurut maslach et al. (2001) kontributor utama semacam ini mengalami kelelahan kerja lebih dari satu dapat mengatasi (kelebihan beban kerja) dan harus menanggung konfl ik pribadi yang berlebihan di tempat kerja. depersonalisasi berpengaruh signifi kan terhadap penurunan prestasi pribadi pada perawat kontrak pengaruh yang signifi kan antara variabel depersonalisasi terhadap v a r i a b el p e nu r u n a n p r e s t a si p r i b a d i menunjukkan pengaruh yang searah. semakin baik tingkat pelayanan dari perawat yaitu dengan melibatkan perasaan dalam melayani pasien, semakin baik pula prestasi pribadi perawat dalam pekerjaannya. pendapat berikut yang mendukung bahwa penurunan prestasi pribadi mengacu pada penurunan perasaan kompetensi pribadi dan produktivitas di tempat kerja dan benar-benar dapat mencerminkan konsekuensi semua perasaan . komponen dari sindrom burnout ini berhubungan dengan evaluasi diri dan penilaian diri, realistis atau tidak realistis, akurat atau tidak akurat (maslach dan schaufeli, 1993). maslach (1997) menyatakan hubungan defi sit dalam prestasi pribadi terhadap efek depresi dan ketidakmampuan secara konsekuen untuk mengatasi apa yang mungkin menjadi tuntutan nor mal peker jaan. dismished personal accomplished merupakan evaluasi negatif diri dan ketidakmampuan yang diperburuk dengan tidak adanya dukungan sosial dan peluang karir yang memungkinkan seseorang untuk berkembang secara profesional. kelelahan emosional ber pengar uh signifi kan terhadap turnover intention pada perawat kontrak. pendapat yang mendukung penelitian ini yaitu penyebab keinginan ber pindah antara lain pekerja memiliki kepuasan gaji, kepuasan ker ja, sit uasi pekerjaan yang berat dan komitmen organisasi yang rendah atas pekerjaannya yang ada sekarang dan termotivasi untuk mencari pekerjaan lain, (andini, 2006). pernyataan ini juga diperkuat oleh hasil penelitian leiter dan maslach (2009) bahwa dimensi burnout: kelelahan emosional sebagai kritikal mediator terjadinya turnover. depersonalisasi tidak ber pengar uh signifi kan terhadap turnover intention pada perawat kontrak. perbedaan hasil penelitian ini dapat diakibatkan oleh beberapa hal. model 150 jurnal ners vol. 8 no. 1 april 2013: 142–152 price (2001) ada 5 kategori aspek pokok yang mendukung timbulnya intensi turnover yaitu: gaji, integrasi, instrumental komunikasi, ko mu n i k a si fo r m a l d a n s e nt r a l i s a si. be rd a sa rk a n p e m apa r a n t e or i d iat a s , dapat diasumsikan bahwa selain pengaruh depersonalisasi ada banyak faktor yang mempengaruhi kejadian turnover intention. penurunan prestasi pribadi memiliki pengar u h sig nif ikan terhadap turnover intention pada perawat kontrak. wanous (1980) menyatakan ada dua faktor yang mempengaruhi timbulnya intensi turnover, yaitu: dari faktor individu; usia lebih muda, pendidikan yang lebih tinggi, status yang belum menikah cenderung memiliki keinginan turnover yang tinggi. faktor organisasi; gaji, kesempatan pengembangan karir, kesempatan pelatihan yang dirasakan k u rang akan memiliki kecenderungan turnover yang lebih tinggi. temuan penelitian berdasarkan hasil keselur uhan uji hipotesis, maka dapat diketahui jalur kuatnya hubungan yang digambarkan model hasil penelitian ini (gambar 2). variabel kontrol mempengaruhi secara signifikan variabel keadilan, komunitas dan penghargaan, namun tingkat kontrol tinggi yang dimiliki oleh perawat kontrak tidak mempengaruhi beban kerja. beban kerja terbukti secara langsung mempengaruhi dimensi burnout; kelelahan emosional. hasil ini juga menunjuk kan bahwa var iabel komu nit as dan reward membentuk nilai-nilai pribadi yang dianut oleh perawat kontrak di rsup sanglah. nilai (value) berkontribusi terhadap dua dimensi burnout yait u kelelahan emosional dan penurunan prestasi pribadi. dimensi burnout depersonalisasi yang dibentuk oleh aspek kelelahan emosional memengaruhi secara kuat terhadap penurunan prestasi pribadi hasil gambar 2. jalur pengaruh signifi kan antar variabel keterbatasan penelitian ini adalah: pengumpulan data, penelitian hanya menggunakan data primer dari responden penelitian dengan menggunakan kuesioner area of worklife scale (aws) dan maslach burnout inventory (mbi) yang dimodifi kasi serta dengan kegiatan fgd, tidak melakukan pengukuran secara spesifi k terhadap beban kerja misalnya time motion studi sehingga unsur subjektivitas sangat berpengaruh. 151 rekomendasi penurunan burnout (dewa kadek adi surya antara, dkk) terakhir pada penelitian ini adalah faktor faktor yang mempengaruhi turnover intension secara signifi kan dari dimensi burnout adalah kelelahan emosional dan prestasi pribadi. simpulan dan saran simpulan kontrol (otonomi) yang dimiliki perawat membentuk nilai-nilai pribadi melalui dua aspek yaitu komunitas serta reward. penurunan burnout dapat dilakukan dengan membentuk nilai-nilai pribadi dan menurunkan beban kerja perawat kontrak. hasil penelitian ini menjelaskan pengar uh area of work life terhadap burnout. depersonalisasi memiliki pengaruh paling dominan terhadap penurunan prestasi pribadi dalam dimensi burnout yang dibentuk oleh aspek kelelahan emosional pada perawat kontrak. hubungan antar variabel ini menunjukkan bahwa dimensi burnout kelelahan emosional mempengaruhi depersonalisasi dan penurunan prestasi pribadi secara kuat. turnover intention dapat diturunkan melalui penurunan burnout yaitu dimensi kelelahan emosional dan peningkatan prestasi pribadi. burnout merupakan mediator variabel yang mempengaruhi turnover intention. saran model p e nu r u n a n b u r n o ut pa d a perawat dapat diterapkan pada rumah sakit pemerintah karena memberikan gambaran tentang aspek yang mempengaruhi burnout serta output negatif yang dapat dicegah. untuk menurunkan burnout dapat dilakukan dengan penurunan beban kerja tanpa mengabaikan aspek lain dalam area of worklife kontrol, keadilan, komunitas, nilai dan penghargaan pada perawat. penelitian lebih lanjut tentang burnout dapat meneliti tentang aspek beban kerja dengan lebih spesifik menggunakan beberapa formula penghitungan beban kerja serta dengan observasi time motion study. kepustakaan andini, r., 2006. analisis pengaruh kepuasan gaji, kepuasan kerja, komitmen organisasional terhadap turnover intention: studi kasus pada rumah s a k i t ro e m a n i m u h a m m a d i y a h s e m a r a n g. t h e s i s . s e m a r a n g : universitas diponegoro. bidang keperawatan, 2012. rekapitulasi tenaga. denpasar: rsup sanglah. colquitt, ja., 2001. on the dimensionality of organizational justice: a. journal of applied psychology, 86(3), 386-400. cordes, cj. dan dougherty, tw., 1993. a review and integration of research on job burnout. academy of managemen review, 18, 621–58. garrosa, e., moreno-jime, b. dan rodrı́guez, a., 2011. role stress and personal resources in nursing: a cross-sectional study of bur nout and engagement. international journal of nursing studies, 48, 479–489. gillies, 1994. nursing management: a systems approach. philadelphia: saunders (w.b.) co ltd. harjana, a., 1994. konfl ik di tempat kerja. yogyakarta: kanisius. karasek, r. dan theorell, t., 1990. stress productivity and the reconstruction of working life. new york: basic book. leither, m. dan maslach, c., 1999. six area of worklife: a model of the organizational context burnout. journal of health and human resources administration, 472–89. leither, m. dan maslach, c., 2004. area of worklife: a str uctured approach to organizational predictors of job burnout. 3, 91–134. leither, m. dan maslach, c., 2009. nurse turnover: mediating role of burnout. journal of nursing management, 17, 331–39. maslach, cj. dan leither, mp., 1996. mbi: the maslach burnout inventory. palo alto: ca: consulting psychologists press. maslach, c. dan leither, mp., 1997. the truth about burnout. san fran cisco, ca: jossey-bass. maslach, c. d a n schaufeli, w., 1993. professional burnout. new york: crc press. maslach, cj., schaufeli, wb. dan leither, mp., 2001. job burnout. in: st. fiske, dl. annual review of psychology, 397–422. 152 jurnal ners vol. 8 no. 1 april 2013: 142–152 p r a horo, a., 2010. hub u nga n anta ra komunikasi efektif dengan intensi turnover pada karyawan bank jatim. malang: fakultas psikologi universitas wisnuwardhana. p r ice, j l ., 20 01. ref le ct ion s on t he determinants of voluntary turnover. international journal of manpower, 22(7), 660–24. schaufeli dan green glass, 2001. introduction on special issue on burnout and health. psychology & health, 501–10. siefert, k. dan jayaratne, sw., 1991. job satisfaction,burnout, and turnover in health care social worker. kealth and social work, 16(3), 193–202. tawale dan novita, e., 2011. hubungan antara motivasi kerja perawat dengan kecenderungan mengalami burnout pada perawat. insan, 13(02), 74–84. tyler, tdp. dan sh., 1996. understanding why the justice of group procedures matters: a test of the psychological dynamics of the group-value model. journal of personalit y and social psychology, 70(5), 913–930. wanous, jp., 1980. organizational entry. ma: addison-wesley. vol 8 no 2 oktober 2013.indd 175 burnout syndrom mahasiswa profesi ners berdasarkan analisis faktor stressor, relational meaning dan coping strategy (burnout syndrome in nursing students based on effect of stressor, relational meaning and coping strategy) hilda mazarina devi*, nursalam*, laily hidayati* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya 60115 email: hilmazarina@yahoo.com abstrak pendahuluan: pada level program pendidikan profesi mahasiswa akan menghadapi berbagai stressor. tujuan dari penelitian ini adalah untuk menganalisis hubungan stressor personal; stressor lingkungan; relational meaning dan coping strategy terhadap burnout syndrom pada mahasiswa keperawatan yang sedang menjalani pendidikan profesi. metode: desain penelitian ini adalah studi korelasi dengan pendekatan cross-sectional. populasi adalah mahasiswa reguler program profesi ners fakultas keperawatan universitas airlangga. besar sampel ditentukan dengan simple random sampling dan 61 orang termasuk dalam kriteria inklusi. pengumpulan data menggunakan kuesioner dan dianalisis menggunakan uji regresi linier berganda dengan signifi kansi p < 0,05. hasil: hasil penelitian menunjukkan bahwa total burnout syndrom berhubungan signifi kan terhadap relational meaning (p = 0,005, β = 0,460). kelelahan emosional berhubungan signifi kan terhadap relational meaning (p = 0,001, β = 0,532) dan emotion focused coping (p = 0,035, β = 0,298). relational meaning juga memiliki hubungan signifi kan terhadap depersonalisasi (p = 0,002, β = 0,050). kemudian penurunan pencapaian prestasi diri berhubungan signifi kan terhadap stressor personal antara lain jumlah individu tinggal dalam sekamar (p = 0,016, β = 0,344), total waktu belajar setiap hari (p = 0,036, β = 0,366) dan stressor lingkungan yakni beban kerja (p = 0,039, β = -0,349). diskusi: mahasiswa disarankan untuk menyiapkan diri menghadapi pendidikan profesi dan fakultas keperawatan universitas airlangga disarankan untuk mengupayakan penguatan fungsi pembimbing akademik dalam hal role model secara preceptorship demi menghindari risiko terjadinya burnout syndrom ketika mahasiswa keperawatan menjalani pendidikan profesi. kata kunci: stressor, relational meaning, coping strategy, burnout syndrom, mahasiswa keperawatan abstract introduction: professional education program is a program in which nursing students are transformed to become professional nurses. at this level, nursing students will encounter various stressors. the purpose of this study was to analyze the relationship between stressors, relational meaning and coping strategy on burnout syndrome in nursing students who are undergoing professional education. method: this was a correlational study using cross-sectional approach. population comprised regular student of nursing profession program at the faculty of nursing, airlangga university. sample size was determined by simple random sampling and 61 persons were included in the inclusion criteria. data then analyzed using multiple linear regression test with signifi cance level of α < 0.05. results: this study found that total burnout syndrome was signifi cantly related to relational meaning (p = 0.005, β = 0.460). emotional exhaustion was signifi cantly related to relational meaning (p= 0.001, β = 0.532) and emotion focused coping (p = 0.035, β =0.298). relational meaning was also signifi cantly related to depersonalization (p = 0.002, β = 0.050). subsequently, the decline in self-achievement was signifi cantly related to personal stressors, i.e the number of room mates (p = 0.016, β = 0.344), total learning time/day (p = 0.036, β=0.366) and environmental stressors (workload) (p = 0.039, β = -0.349). discussion: it is suggested for students to prepare for professional education, and the faculty of nursing, airlangga university, should strengthen the function of academic counselors in terms of preceptorship role model in order to avoid the risk of burnout syndrome when the nursing students undergoing professional education. keywords: stressor, relational meaning, coping strategy, burnout syndrome, nursing students pendahuluan program studi s-1 keperawatan adalah suat u pendidikan yang ber t ujuan unt uk menghasilkan perawat yang profesional melalui dua tahapan pendidikan yak ni tahapan pendidikan akademik dan profesi. ketika menjalani program profesi mahasiswa keperawatan akan diberikan kesempatan untuk beradaptasi pada peran sebagai perawat profesional ( nursalam, 2011). sehingga mahasiswa akan ter papar stressor yang sama dengan perawat yang bekerja di klinik. dalam proses pembelajaran inilah mahasiswa tidak jarang mengalami st res (irawati, 176 jurnal ners vol. 8 no. 2 oktober 2013: 175–182 2012). stres yang berkelanjutan dan kronis akan menimbulkan dampak negatif yang dapat menyebabkan perubahan motivasi dan memunculkan terjadinya burnout syndrome (greenberg dalam watson, 2008). pembelajaran klinik menjadi kegiatan yang sulit bagi mahasiswa terutama dengan tekanan berbagai macam stressor personal yakni usia, jenis kelamin, ipk akademik, total waktu belajar per hari dan total waktu klinik per pekannya (baker, 2012). tuntutan membina hubungan baik dengan pasien, perawat dan pembimbing klinik ser ta teman sejawat juga menjadi stressor sosial bagi mahasiswa profesi, hal ini kemudian masih ditambah dengan adanya tekanan stressor beban kerja tugas, ujian, kompetensi (nelwati, 2013), serta adanya kesenjangan harapan antara teori yang didapatkan dalam pendidikan akademik dengan kenyataan dalam dunia klinik. terlebih apabila stressor tersebut tidak diikuti dengan adanya proses penerimaan, pembentukan persepsi dan pemilihan coping strategy yang baik dapat memicu timbulnya kelelahan kerja yang dikenal dengan burnout syndrome (mangkunegara, 2002). tiga dimensi burnout syndrome menurut maslach (2003) antara lain adalah kelelahan emosional, depersonalisasi, se r t a d i me n si p e nu r u n a n p e ncapaia n prestasi diri. hal ini sejalan dengan konsep transactional theory (lazarus & folkman, 1984). dari hasil studi pendahuluan pada 15 orang mahasiswa reguler program profesi ners fakultas keperawatan universitas airlangga pada tanggal 2–9 maret 2013 dapat diketahui bahwa pada dimensi kelelahan emosional 73,3% mahasiswa mengalami kelelahan emosional di tingkat menengah dan berat. pada dimensi depersonalisasi sebanyak 86,7% mahasiswa mengalami depersonalisasi tingkat rendah dan sekitar 13,3% di tingkat menengah. kemudian pada dimensi penurunan prestasi diri sebanyak 66,7% mengalami pada tingkat menengah hingga berat. beberapa upaya fakultas keperawatan universitas airlangga yang telah diupayakan antara lain adanya program pbp (program belajar praktik) yang telah dimulai sejak pendidikan akademik pada semester ketiga hingga keenam serta adanya pendidikan pre-klinik sebelum mahasiswa terjun dalam klinik. terdapat beberapa kategori sumber stres (stressor) yang berkontribusi dalam terjadinya stres pada mahasiswa keperawatan, antara lain stressor personal dan stressor lingkungan (lazar us & folkman, 1984). terdapat tiga bentuk relational meaning terhadap pemaknaan stres dalam diri individu yak ni persepsi bahaya (harm), ancaman (threat) dan tantangan (challange) (lazarus & folkman, 1984). terdapat dua jenis koping yang digunakan oleh seorang individu dalam menghadapi stres antara problem focused coping dan emotion focused coping (lazarus & folkman, 1984). sehingga, berdasarkan fenomena dan masalah diatas perlu dilakukan analisa hubu ngan antara su mber st res (stressor), relational meaning dan coping strategy terhadap burnout syndrome pada mahasiswa reguler program profesi ners fakultas keperawatan universitas airlangga. bahan dan metode desain pada penelitian correlational dengan pendekatan cross sectional, dengan populasi dalam penelitian adalah semua mahasiswa regular program profesi ners fakultas keperawatan universitas airlangga periode genap tahun akademik 2012/2013 (89 mahasiswa). pengambilan sample sebanyak 61 responden dengan menggunakan simple random sampling berdasarkan beberapa kriteria inklusi. penelitian dilaksanakan pada 22–26 april 2013. variabel independen penelitian antara lain stressor personal yakni data demografi (usia, jenis kelamin, ipk akademik, situasi tempat tinggal, total wakt u belajar/hari dan total waktu profesi/minggu); stressor lingkungan (beban kerja dan hubungan interpersonal); relational meaning dan coping strategy. variabel dependen penelitian antara lain burnout syndrom yang terdiri atas tiga dimensi yakni kelelahan emosional, depersonalisasi dan penur unan pencapaian prestasi diri. instrumen yang digunakan berupa kuesioner 177 burnout syndrom mahasiswa profesi ners (hilda mazarina devi, dkk.) data demografi . kuesioner stressor lingkungan (beban kerja dan hubungan interpersonal) yang dikembangkan dari uraian pengelolaan profesi program ners yang berpatokan pada pedoman pendidikan profesi fakultas keperawatan universitas airlangga 2012/2013. kuesioner asns (assassement of tress in nursing students) yang dikembangkan oleh costa & polak (2009) digunakan oleh peneliti sebagai kuesioner relational meaning. dimensi yakni kelelahan emosional, depersonalisasi dan penur unan pencapaian prestasi diri. instrumen yang digunakan berupa kuesioner data demografi . kuesioner stressor lingkungan (beban kerja dan hubungan inter personal) yang dikembangkan dari uraian pengelolaan profesi program ners yang berpatokan pada pedoman pendidikan profesi fakultas keperawatan universitas airlangga 2012/2013. kuesioner asns (assassement of stress in nursing). copi ng st ra teg y d iu k u r de nga n modifi kasi kuesioner ways of coping strategy (lazar us & folk man, 1988). kemudian bur nout syndrom dalam penelitian ini menggunakan kuesioner mbi berdasarkan teori maslach (2003). data yang diperoleh kemudian dianalisis menggunakan uji regresi linier berganda dengan derajat kemaknaan adalah p < 0,05. hasil distribusi data demografi responden pada penelitian ini didapatkan karakteristik responden menunjukkan bahwa dari 61 orang responden, mayoritas berjenis kelamin perempuan sebanyak 51 responden (83,6%) dan 10 responden (16,4%) berjenis kelamin laki-laki. mayoritas (86,9%) usia responden 22-23 tahun. sebaran gerbong atau stase pendidikan profesi yang sedang dilalui oleh responden adalah sebanyak 15 orang (24,6%) berada di stase keperawatan kritis, 13 orang (21,3%) sedang berada di stase keperawatan maternitas, 14 orang (23%) sedang berada di stase keperawatan jiwa dan sisanya sebanyak 19 orang (31,1%) berada di stase keperawatan anak. ipk akademik responden paling banyak adalah berada pada rentang 2,76–3,50 (sangat memuaskan) sebanyak 39 orang (63,9%). sebanyak 46 orang (75,4%) tinggal berpisah tabel 1. karakteristik responden penelitian burnout syndrom mahasiswa profesi ners berdasarkan analisis faktor stressor, relational meaning dan coping strategy pada mahasiswa reguler program profesi ners fakultas keperawatan unair surabaya per desember april 2013 (n = 61) no stressor personal parameter σ % 1 usia 22 21 34,4 % 23 32 52,5 % 2 jenis kelamin laki laki 10 16,4 % perempuan 51 83,6 % 3 ipk akademik 2,76–3,50 (sangat memuaskan) 39 63,9% 3,50–4,0 (dengan pujian cumlaude) 14 23,0% 4 situasi tempat tinggal bersama orang tua 15 15,6% berpisah dengan orang tua 46 75,4% 5 jumlah individu sekamar ≤ 2 35 57,4% > 2 26 42,6% 6 total waktu belajar/hari tidak belajar – 1,33 jam/hari 35 57,4% 1,34–2,66 jam/hari 19 31,1% 7 to t a l wa k t u p r o f e s i / minggu 2,67–4 jam/hari 7 11,5% 45–50 jam/minggu 31 50,8% 51–56 jam/minggu 10 16,4% 57–62 jam/minggu 8 13,1% > 63 jam/minggu 12 19,7% 178 jurnal ners vol. 8 no. 2 oktober 2013: 175–182 tabel 2. beban kerja mahasiswa reguler program profesi ners fkp unair surabaya 22–26 april 2013 (n = 61) no beban kerja kategori r s t ∑ ∑ ∑ 1 ujian 11 (18%) 45 (73,8%) 5 (8,2%) 2 tugas 23 (37,7%) 36 (59%) 2 (3,3%) 3 kompetensi klinik 6 (9,8%) 50 (82%) 5 (8,2%) 4 kesenjangan harapan 26 (42,6%) 32 (52,5%) 3 (4,9%) rerata 16 (26,2%) 41 (66,8%) 4 (6,14%) ket: r = ringan; s = sedang; t = tinggi tabel 3. hubungan interpersonal mahasiswa reguler program profesi ners fakultas keperawatan unair surabaya per maret–april 2013 (n = 61) no hubungan interpersonal kategori r s t ∑ ∑ ∑ 1 pasien 0 (0%) 53 (86,9%) 8 (13,1%) 2 pembimbing klinik: perawat ruangan dan pembimbing akademik 0 (0%) 46 (75,4%) 15 (24,6%) 3 teman satu kelompok 0 (0%) 53 (86,9%) 8 (13,1%) rerata 0 (0%) 51 (83,6%) 10,3 (16,8%) ket: r = ringan; s = sedang; t = tinggi dengan orang tua selama masa pendidikan profesi. mayor itas responden sebanyak 35 orang (57,4%) tinggal bersama ≤ 2 individu dalam sekamar. sebanyak 35 orang (67,2%) menyatakan tidak memiliki waktu belajar dan atau menyediakan rentang hingga 1,33 jam waktu untuk belajar tiap harinya. total waktu profesi yang dihabiskan mahasiswa dalam seminggu untuk melaksanakan semua kegiatan yang berhubungan dengan pendidikan profesi mayoritas adalah sebanyak 45–50 jam/minggu yakni sebanyak 31 orang (50,8%). tugas (laporan pendahuluan, laporan kasus, seminar, pkrs dan asuhan keperawatan) menjadi beban yang tinggi bagi 5 orang mahasiswa keperawatan (8,1%). ujian dan kompetensi klinik adalah beban kerja tingkat sedang yang dipilih oleh rata-rata sebanyak 41 orang (66,8%). dan beban kerja yang dianggap oleh mahasiswa keperawatan menjadi beban kerja rendah adalah kesenjangan harapan antara teori dan praktik yakni oleh sebanyak 26 orang (42,6%). rata-rata terdapat 4 orang responden (6,14%) yang menyatakan bahwa keseluruhan parameter beban kerja selama pendidikan profesi sebagai beban kerja dengan tingkat tinggi. tidak ada responden yang menyatakan memiliki kemampuan hubungan interpersonal yang rendah terhadap pasien, pembimbing klinik: perawat dan pembimbing akademik serta teman dalam satu kelompok. rata rata sebanyak 51 orang (83,6%) memiliki kemampuan tingkat sedang dan terdapat ratarata 10 orang (16,8%) responden yang memiliki kemampuan tinggi. pembahasan usia pada mahasiswa keperawatan memiliki hubungan yang tidak signifikan terhadap burnout syndrom secara keseluruhan maupun terhadap tiap dimensi dalam burnout syndrom: kelelahan emosional, depersonalisasi dan penur unan pencapaian prestasi diri. berdasarkan teori perkembangan hurlock (1980) maka responden penelitian tergolong dalam rentang usia dewasa muda (early adulthood). seseorang yang berada dalam rentang awal usia dewasa muda (usia 20– 40 tahun) memiliki perkembangan fi sik dan kondisi tubuh yang prima, berada di puncak kesehatan dan kekuatan, energi dan daya tahan. tidak terdapatnya hubungan signifi kan antara usia terhadap ketiga dimensi burnout syndrom dapat disebabkan karena mayoritas responden penelitian berada dalam rentang 179 burnout syndrom mahasiswa profesi ners (hilda mazarina devi, dkk.) usia yang sama. proses adaptasi terhadap stres akan berkembang sesuai dengan tingkat kematangan emosional (hurlock, 1980) dan tingkat kematangan emosional amat ditentukan oleh usia, sehingga secara alamiah semakin menambahnya usia mahasiswa keperawatan ma ka a ka n sema k i n bai k kemat a nga n emosional dan mampu mengembangkan adaptasi terhadap kondisi burnout syndrome. je n i s kel a m i n p a d a m a h a si s wa keperawatan tidak memiliki hubungan yang signifi kan terhadap burnout syndrom secara umum maupun terhadap tiap dimensi dalam burnout syndrom: kelelahan emosional, depersonalisasi dan penurunan pencapaian prestasi diri. mayoritas responden penelitian adalah berjenis kelamin wanita sebanyak 51 orang (83,6%). wardhani (2006) menyatakan frustasi perempuan lebih tinggi dibanding frustasi laki-laki. tidak terdapatnya hubungan secara signifi kan antara jenis kelamin dengan burnout syndrom secara umum maupun terhadap pada setiap dimensi dapat disebabkan k a r e n a d o m i n a s i j u m l a h m a h a s i s w a perempuan dibandingkan dengan jumlah mahasiswa laki-laki. mahasiswa dengan jenis kelamin perempuan yang mendominasi tugas perawat diharapkan memiliki pertahanan diri yang lebih baik dalam menghadapi bunrout syndrom. situasi tempat tinggal tidak memiliki hubungan yang signifi kan terhadap burnout syndrome secara umum maupun terhadap tiap dimensi dalam burnout syndrom (kelelahan emosional, depersonalisasi dan penurunan pencapaian prestasi diri). tidak terdapatnya hubungan signifikan antara situasi tempat tinggal terhadap burnout syndrom dapat terjadi akibat seluruh responden adalah mahasiswa yang telah menjalani 4 tahun pendidikan akademik tinggal berpisah dengan orang tua sehingga telah mampu beradaptasi dan membangun kemampuan sosial dengan baik terhadap kondisi tersebut ketika menjalani setahun pendidikan profesi setelah masa pendidikan akademik. jumlah individu sekamar memiliki hubungan signifi kan terhadap kejadian burnout syndrom : penurunan pencapaian prestasi diri, namun tidak memiliki hubungan signifi kan terhadap burnout syndrom secara umum maupun terhadap burnout syndrom dimensi kelelahan emosional dan depersonalisasi. lingk ungan yang terlalu dipenuhi oleh banyak individu ataupun terlalu sedikit dapat mempengaruhi pencapaian seorang mahasiswa dalam berprestasi. hubungan positif yang terjadi menunjukkan bahwa semakin sedikit jumlah individu sekamar maka akan semakin terjadi peningkatan terhadap pencapaian prestasi diri seorang mahasiswa. terdapat hubungan signifi kan antara jumlah individu s e k a m a r d e ng a n d i m e n si p e nu r u n a n pencapaian prestasi diri menunjukkan bahwa mahasiswa keperawatan akan memiliki kemampuan menciptakan lingkungan tempat tinggal yang kondusif dengan jumlah individu ≤ 2 orang dalam sekamar untuk menurunkan risiko terjadinya penur unan pencapaian prestasi diri. total waktu belajar/hari pada mahasiswa keperawat a n mem ili k i hubu nga n ya ng signifi kan terhadap burnout syndrome dimensi penurunan pencapaian prestasi diri, namun tidak memiliki hubungan signifi kan terhadap burnout syndrom secara umum dan terhadap burnout syndrom dimensi kelelahan emosional dan penur unan pencapaian prestasi diri. sebanyak 35 orang mahasiswa keperawatan (57,3%) tidak memiliki waktu belajar dan hanya meluangkan 1,33 jam waktu per hari untuk melaksanakan pembelajaran. perilaku belajar seorang mahasiswa memberikan pengaruh positif dan signifi kan terhadap kondisi stress yang dialami selama masa pendidikan (berli, 2012). hasil analisis data menyebutkan bahwa hubungan yang terjadi adalah hubungan positif yakni semakin meningkat waktu belajar maka akan terjadi peningkatan pula terhadap pencapaian prestasi seorang mahasiswa. terdapat hubungan signifikan antara total waktu belajar/hari terhadap penurunan pencapaian prestasi diri menunjukkan bahwa semakin banyak seorang mahasiswa melakukan perilaku belajar dengan baik maka akan menghindarkan dirinya dar ipada burnout syndrom: penu r u nan pencapaian prestasi diri sehingga perlu adanya motivasi dan dukungan agar mahasiswa meluangkan waktu belajar. 180 jurnal ners vol. 8 no. 2 oktober 2013: 175–182 total wak t u profesi /mingg u pada mahasiswa keperawatan tidak memiliki hubungan yang signifi kan terhadap burnout syndrom secara umum maupun terhadap tiap dimensi burnout syndrom (kelelahan emosional, depersonalisasi dan penurunan p e nc a p a ia n p r e s t a si d i r i). m ayor it a s mahasiswa reguler program profesi ners fakultas keperawatan universitas airlangga menyatakan bahwa menjalani kegiatan profesi selama 45–50 jam per minggu. jadwal dan peraturan pendidikan profesi mahasiswa reguler di fakultas keperawatan universitas airlangga terhadap waktu untuk kegiatan di lingkungan klinik telah terjadwal sebanyak 9 jam dalam tiap kali shift tiap harinya, sehingga apabila diakumulasi dalam 5 hari aktif maka normal jam praktik yang harus dilalui oleh seorang mahasiswa keperawatan adalah sebanyak 45 jam tiap minggu. b e r d a s a r k a n b u k u k o m p e t e n s i keperawatan medikal bedah dan kritis fkp universitas airlangga terdapat sedikitnya 14 kompetensi keperawatan dan masing-masing terdapat 4 sub kompetensi klinik yang harus dilaksanakan saat melalui gerbong kritis selama 4 minggu hal ini yang menyebabkan besarnya angka mahasiswa yang mengalami kelelahan emosional tingkat berat pada gerbong tersebut. selain itu terdapat 30 orang (49,2%) yang mengalami kelebihan waktu dalam menjalani pendidikan profesi terutama dalam menjalani praktik klinik diperkuat hingga 63 jam per minggu bahkan lebih. padahal berlebihannya waktu untuk kegiatan profesi dapat menimbulkan kejenuhan dan menjadi stressor yang amat berpengaruh sehingga secara klinis akan menimbulkan risiko munculnya burnout syndrom (baker, 2012). tidak ada hubungan antara total waktu klinik/minggu terhadap setiap dimensi burnout syndrom pada mahasiswa keperawatan dapat disebabkan karena adanya faktor lain yang berperan seperti kepribadian dan penghargaan (irawati, 2012) dan peneliti tidak melaksanakan penelitian pada kedua hal tersebut. hasil penelitian menunjukkan bahwa secara klinis mahasiswa keperawatan akan berisiko mengalami burnout syndrom apabila melalui gerbong kritis dan mengalami kondisi berlebihan dalam waktu profesi/minggu sehingga mahasiswa harus lebih menggunakan manajemen waktu dengan lebih baik. b e b a n k e r j a p a d a m a h a s i s w a keperawat a n mem ili k i hubu nga n ya ng sig nif ikan terhadap ter jadinya burnout syndrom dimensi penur unan pencapaian prestasi diri, namun tidak memiliki hubungan signifi kan terhadap burnout syndrom secara umum maupun terhadap dimensi kelelahan emosional dan depersonalisasi. rata-rata 4 orang (6,1%) responden merasakan ujian, tugas dan asuhan keperawatan, kompetensi klinik, serta kesenjangan harapan antara teori dan praktik adalah beban kerja dengan level tinggi dan sebanyak rata-rata 41 orang (66,8%) menganggap sebagai beban kerja pada level sedang beban kerja yang berlebihan menjadi salah satu faktor penyebab burnout syndom sesuai dengan penelitian irawati (2012). sebagai seorang mahasiswa sebai k nya mempersiapkan diri dalam menghadapi beban kerja yang dianggap berlebihan dengan melaksanakan manajemen waktu dengan baik, sehingga risiko terjadinya penurunan pencapaian prestasi diri dapat cegah dan mahasiswa dapat menciptakan bentuk adaptasi yang lebih baik dalam menghadapi beban kerja ketika menjalani pendidikan profesi. h u b u n g a n i n t e r p e r s o n a l p a d a mahasiswa keperawatan tidak memiliki hubungan secara signifi kan terhadap burnout syndrom secara umum maupun terhadap setiap dimensi dalam burnout syndrom (kelelahan emosional, depersonalisasi dan penurunan pencapaian prestasi diri). terdapat rata-rata 51 orang responden (83,6%) yang menyatakan memiliki kemampuan sedang dalam membangun hubungan interpersonal terhadap klien, pembimbing klinik (perawat dan pembimbing akademik) serta terhadap teman dalam satu kelompok. sebanyak ratarata 10 orang (16,8%) responden memiliki kemampu a n t i ngg i d a n t id a k terd apat responden (0%) yang menyatakan memiliki kemampuan rendah. kemampuan yang baik dalam membina hubungan interpersonal dapat menjadi salah 181 burnout syndrom mahasiswa profesi ners (hilda mazarina devi, dkk.) satu intervensi yang efektif dan sebagai koping yang efektif dari burnout (huey, 2007). relational meaning pada mahasiswa keperawat a n mem ili k i hubu nga n ya ng signifi kan terhadap burnout syndrom secara u mu m, ser t a memili k i hubu ngan yang signifi kan terhadap burnout syndrom dimensi kelelahan emosional dan depersonalisasi. sedangkan terhadap burnout syndrom dimensi penurunan pencapaian prestasi diri, relational meaning tidak memiliki hubungan signifi kan. mayoritas mahasiswa reguler mengalami pemaknaan stres yang baik terhadap setiap kondisi dalam dunia pendidikan keperawatan. terlebih pada domain pendidikan profesi sebanyak 45 orang menyatakan bahwa pendidikan profesi adalah tantangan bagi mereka. relational meaning diartikan sebagai suatu pemaknaan terhadap stres, terdiri atas tiga komponen persepsi antara lain harm (bahaya), threat (ancaman) dan challange (tantangan) (schwarzer, 2008). pemaknaan terhadap stres yang negatif akan dapat menimbulkan respons dan koping yang negatif (lazarus dalam taylor, 1991). seor a ng ma ha siswa ke per awat a n diharapkan memiliki pemak naan positif terhadap setiap tekanan dan stres yang dialami ketika menjalani pendidikan profesi, sehingga akan tercipta coping strategy yang tepat dan mengurangi risiko burnout syndrom ketika mahasiswa menjalani pendidikan profesi. coping st rateg y pada mahasiswa keperawat a n mem ili k i hubu nga n ya ng sig n if i k a n terha d ap b u r n o ut s y n d rom dimensi kelelahan emosional terutama pada penggunaan emotion focused coping (efc), namu n tidak memili k i hubu ngan yang signifi kan terhadap burnout syndrom secara umum, serta burnout syndrom pada dimensi depersonalisasi dan penurunan pencapaian prestasi diri. sebanyak 35 orang responden menggunakan efc sebagai coping strategy. pemilihan coping strategy pada seorang perawat tidak dipengaruhi oleh gender namun lebih kepada persepsi terhadap kemampuan dalam menyelesaikan masalah (lestarianita, 2007). pfc menyebabkan seorang individu akan berfokus untuk menyelesaikan masalah, sed ang kan efc menyebabkan seorang individu mengendalikan emosinya terlebih dahulu sebelum melaksanakan penyelesaian terhadap stressor yang datang. hasil penelitian menunjukkan memiliki koping yang terpusat kepada emosi akan dapat menyebabkan seorang mahasiswa akan mudah mengalami burnout syndrom terutama pada kelelahan emosional, sehingga mahasiswa harus melakukan pemilihan coping strategy secara bijaksana. simpulan dan saran simpulan berdasarkan hasil penelitian yang telah dilakukan pada mahasiswa reguler program profesi ners fakultas keperawatan universitas airlangga, maka dapat diambil kesimpulan bahwa burnout syndrom secara total memiliki hubungan signifi kan terhadap relational meaning. jumlah individu sekamar dan total waktu belajar/hari menjadi stressor personal yang memiliki hubungan signifi kan terhad ap bu r nout syndrom: penu r u nan pencapaian prestasi diri. beban kerja menjadi stressor lingkungan yang memiliki hubungan secara signifi kan terhadap terjadinya burnout syndrom: penur unan pencapaian prestasi diri. relational meaning signifi kan terhadap ter jadi nya bur nout syndrom kelelaha n emosional dan depersonalisasi. serta coping strategy : emotion focused coping adalah salah satu strategi koping yang berhubungan sig nif ikan terhadap ter jadinya burnout syndrom dimensi kelelahan emosional. saran berdasarkan simpulan yang telah d iu r ai k a n d iat a s, sela njut nya pe nel it i mengemukakan beberapa saran bagi mahasiswa keperawatan yakni untuk mempersiapkan diri dengan baik dalam menghadapi stressor pada dunia pendidikan profesi. bagi fakultas keperawatan universitas airlangga untuk menggunakan program pbp dan program prapendidikan klinik dan memperkuat peran pembimbing akademik sebagai role model dalam model pembelajaran preceptorship 182 jurnal ners vol. 8 no. 2 oktober 2013: 175–182 pada program pbp yang dilaksanakan ketika pendidikan akademik. serta bagi perawat untuk selalu dapat melakukan pemaknaan terhadap stres dengan baik dan positif serta penggunaan coping strategy dengan tepat untuk menghindari risiko terjadinya burnout syndrom sehingga tidak menurunkan kualitas layanan keperawatan. bagi peneliti selanjutnya perlu dilakukan penelitian kembali mengenai stressor personal: kepribadian, komitmen dan kepercayaan serta mengukur relational meaning revisited terhadap burnout syndrom dengan teori adaptasi dari sc. roy. kepustakaan baker, mary l, 2012. nursing student stress and demographic factors. thesis master, california state university, san marcos berli, 2012. pengaruh perilaku belajar dan kecerdasan emosional terhadap stres kuliah mahasiswa akuntansi. skripsi : universitas tarumanegara costa, al polak, c., 2009. construction and validation of an instrument for the assessement of stress among nursing students. rev esc enferm usp vol. 43, hal. 17–26 huey, s, 2007. occupational stress, social problem solving and burnout among mental health professional in hiv/ aids care. thesis. drexel university hu rlock, elizabeth, 1980. a life span approach. 5th ed. mcgraw-hill, inc. irawati, e, 2012. burnout syndrom pada mahasiswa reguler program profesi ners fakultas keperawatan universitas airlangga berdasarkan analisis faktor perilaku dan lingkungan. skripsi, universitas airlangga, surabaya lazar us, rs folkman, s., 1984. stress, appraisal and coping. new york: springer lazarus, rs & folkman s, 1988. ways of coping questionnaire. consulting psychologist, inc lazar us & taylor, 1991. emotion and adaptation. london: oxford university press lestar ianita, p, fak h r ur rozi, m., 2007. pengatasan stres pada perawat pria dan wanita. skripsi. depok : universitas gunadarma mangkunegara, a., 2002. perilaku konsumen. bandung: penerbit refi ka masclah, c jackson, s leiter, m., 2003. maslach burnout inventory manual. california: cpp. nelwati, mckenna, l plummer, v., 2013. indonesian student nurses perception of stress in clinical learning: a phenomenological study. journal of nursing education and practice, vol. 3, no. 5, 56–65 nursalam, 2011, manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 3. jakarta: penerbit salemba medika putri, rissa t., 2013. hubungan antara dukungan sosial orang tua dengan motivasi menyelesaikan. jakar ta: universitas bina nusantara schwarzer, r., 2008. stress and coping resources. theory and review. 1–28 wardhani, dk., 2006. pengaruh faktor individu, faktor organisasi, dan perbedaan jenis kelamin pada perawat terhadap burnout di rumah sakit haji surabaya. skripsi, universitas airlangga, surabaya watson, r deary, i thompson, d lig, 2008. study of stress and burnout in nursing students in hongkong: a questionnaire survey. international journal of nursing studies vol 45, 1534–1542 154 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 154-158 http://dx.doi.org/10.20473/jn.v18i2.44580 original article open access knowledge, attitudes, and practice against covid-19 in west nusa tenggara, indonesia menap menap 1 , sismulyanto sismulyanto 1 , mursaka mursaka 1 , and made mahaguna putra 2 * 1 faculty of health, universitas qamarul huda, lombok, west nusa tenggara, indonesia 2 faculty of medicine, universitas pendidikan ganesha, bali, indonesia *correspondence: made mahaguna putra. address: faculty of medicine, universitas pendidikan ganesha, bali, indonesia. email: mputra@undiksha.ac.id responsible editor: retnayu pradanie received: 3 april 2023 ○ revised: 23 june 2023 ○ accepted: 23 june 2023 abstract introduction: covid-19 spread rapidly, but little is known regarding knowledge, attitudes, and practices (kap) against covid-19 among residents from various regions in indonesia. this study aims to determine the level of knowledge, practice and attitudes related to covid-19 to provide a scientific basis for the prevention and control of this major outbreak in indonesia. methods: online survey with convenience sampling was conducted among urban and rural residents in west nusa tenggara province, and collected 523 questionnaires through online media. the instruments used in this research are demographic information, such as age, gender, educational level, marital status and area of residence (urban or rural) and knowledge, attitude and practice questionnaires. results: the results of multiple linear regression analysis showed that education level (p=0.01), gender (p=0.00) and age (p=0.03) had a significant effect on knowledge about covid-19. residential area (urban) affects practices related to covid-19 (p=0.00). furthermore, knowledge of covid-19 (p=0.00) and area of residence (urban) (p=0.00) are closely related to residents’ attitudes toward preventive measures that can control this disease. conclusions: both urban and rural residents of west nusa tenggara province displayed moderate levels of knowledge as well as the practice of covid-19 and showed the disease with a positive attitude. developing suitable education programs targeted at the general residents in west nusa tenggara province is essential to increase knowledge, attitudes, as well as practices of covid-19, especially for rustic and low-educated citizens. keywords: attitude, covid-19, knowledge, practice, residents introduction ever since the covid-19 pandemic was declared in 2020, there have been 6,730,016 confirmed cases and 160,814 deaths recorded in indonesia (as per 31 january, 2023) (chen et al., 2020). although categorized as a class b (clinical disease frequent, few deaths, high pathogenesis, and low virulence) infectious disease, its high transmission resulted in a prevention and control management level of a (inapparent infection). the virus disseminates mainly through contact with infected individuals and droplets. similarly, common symptoms include difficulty breathing, dry cough, myalgias, and fever. other less common symptoms include losing smell or taste and diarrhea. the varied symptom severity is influenced by older age and co-morbidities being risk factors for more severe disease (wiersinga et al., 2020; albahri et al., 2021). the number of confirmed cases of covid-19 in indonesia will increase every month in 2022. the transmission of covid-19 is estimated to be similar to that of previous cases of mers and sars, which mainly occur through droplets and contact with infected surfaces. to prevent the spread of the infection, it is https://creativecommons.org/licenses/by/4.0/ mailto:mputra@undiksha.ac.id https://orcid.org/0000-0003-4424-6646 https://orcid.org/0009-0002-8171-1500 https://orcid.org/0009-0000-8014-5928 https://orcid.org/0000-0001-7800-646x jurnal ners http://e-journal.unair.ac.id/jners 155 recommended to practice good cough and sneeze etiquette, wash hands regularly with soap, cook meat and eggs thoroughly, and avoid close contact with people exhibiting respiratory disease symptoms, such as coughing and sneezing (ministry of health republic indonesia, 2020). the most effective strategy presently used in containing the covid-19 pandemic is prevention methods including washing hands continually, keeping physical distance, as well as using masks (adhikari et al., 2020; lewnard and lo, 2020; gadarian, goodman and pepinsky, 2021). knowledge, attitudes, and practices toward disease are important factors in determining health decisions and health outcomes (szymonapałkowska et al., 2016). effective control of the virus's spread relies on individuals taking necessary precautions and following health protocol guidelines. the study has demonstrated that people's adherence to disease prevention measures is strongly influenced by their knowledge, attitude, and practice levels. earlier studies accomplished on the sars outbreak during 2002-2004 as well as the mers outbreak in 2012 showed that levels of stress, anxiety, panic emotions, as well as coping skills were particularly related to their knowledge and attitudes against infectious diseases. additionally, attitudes and knowledge also impact an individual's efforts to stop the disease's infection (clements, 2020; zhong et al., 2020). the trend of increasing positive cases in west nusa tenggara province continues to occur, therefore it needs to be seriously anticipated. community active participation in controlling the spread of the coronavirus (covid-19) is very important. currently, people in west nusa tenggara province are facing various challenges related to covid-19, including limited knowledge, low public attitudes, and inadequate disease control practices. despite the precarious situation, the status of community attitudes, knowledge, and practices regarding covid-19 in the province remains largely unknown, and no national data have yet been found to address this issue. therefore, this research aims to assess the level of attitudes, knowledge, as well as practices related to covid-19 among residents of west nusa tenggara province to provide a scientific basis for the prevention and control of this major outbreak. materials and methods study design and participant this is a cross-sectional analytical observational study that was conducted in june 2022 in central lombok district and mataram city in west nusa tenggara. the sample size was obtained by the rule of thumb by means of 10 times the number of questions in the questionnaire so that 310 were obtained. the sample size was increased by 20% to make it more representative so that the sample in this study was 523 respondents. convenience sampling has been used in this study in order to reach the respondents quickly. people aged 17 years or older with access to the computer and/or mobile phone were invited to participate in the study. the variables under investigation are knowledge, attitudes, and practice toward covid-19. measurement tool we designed an online questionnaire created with google forms for data collection. the questionnaire consists of two parts: 1. the demographic characteristics of age, education level, gender, marital status, occupation, as well as residence area (urban or rural), 2. kap questionnaire consists of 31 items assessing knowledge, attitudes, and behavior. the knowledge instrument contains 14 items asking about the etiology of covid-19, signs and symptoms, prevention, transmission, and risk factors. the attitude instrument consisting of six questions was used to evaluate participants' attitudes toward covid-19, their willingness to take preventive measures, isolate when infected, and their confidence in reducing the pace of the pandemic. the practice instrument contained 11 questions about the evaluation of participants' infection control during a pandemic. the questionnaires were tested for validity with the pearson product formula and were considered valid with a correlation value of ≥0.5. all knowledge and attitude questions achieved good validity. the reliability was tested with cronbach’s alpha formula and considered reliable with a coefficient ≥0.7. (syakurah and moudy, 2020; limbong, kuswinarti and sitorus, 2021). the results of validity and reliability for the kap questionnaire were knowledge (r=.601; cronbach's alpha=.809), attitude: (r= .437; cronbach's alpha= .926). behavior: (r=.623; cronbach's alpha=.826). data collection due to the pandemic and home quarantine, participants could not be contacted directly; data collection was carried out by distributing online questionnaires through several social networking platforms, such as whatsapp and telegram. the data collection process took four months in order to achieve the targeted sample size. menap, sismulyanto, mursaka, and putra (2023) 156 p-issn: 1858-3598  e-issn: 2502-5791 statistical analysis descriptive analysis is used to present demographic characteristics as well as the level and distribution of knowledge, attitudes and practices toward covid-19 consisting of frequency (n), proportion (%) and mean. binary logistic regression analysis was used to identify factors related to knowledge, attitude, and practice of covid-19. ethical statements informed consent was obtained from all participants involved in this study, which has been deemed ethically feasible by the health research ethics commission of the uniqhba faculty of health (no:015/ec/fkesuniqhba/yppqh/vii/2022). results descriptive characteristics a total of 523 questionnaires were distributed using google forms, and all participants recruited filled out the questionnaire to completion. urban residents were 294 (45.9%) and 347 (54.1%) were rural residents. of the total sample, 207 (39.6%) were males, while 316 (60.4%) were females. table 1 displays the distribution of demographic characteristics. the knowledge, attitude as well as practice of covid‑19 measures the mean scores for knowledge and behavior among participants who answered correctly were 89% and 84%, respectively. in terms of knowledge, almost all participants (98.8%) recognized the effectiveness of isolating and treating infected individuals as a strategy to reduce the spread of covid-19. regarding behavior, 57.3% of respondents believed that the virus only spreads through objects contaminated with the sarscov-2 virus and not through the air. additionally, 95.7% of respondents reported using masks when in crowded places, and 64.4% of respondents stated that they exercise regularly. in terms of attitudes, all respondents acknowledged the severity of covid-19, and 98.2% believed that people with covid-19 who self-isolate are responsible for preventing the virus's transmission. moreover, 51.8% of respondents stated that those who violate government advice in efforts to stop the virus's spread are the only ones who suffer from covid-19. finally, 96.7% of respondents believed that it is essential to follow information related to government appeals regarding efforts to prevent covid-19 in the community. the affecting factors of knowledge, attitude as well as practice on covid‑19 based on the results of the binary logistic regression test, it was found that factors related to knowledge about covid-19 were age, gender, education level, and area of residence. factors related to attitudes toward covid-19 are gender, education level, and area of residence. meanwhile, actions against covid-19 are influenced by gender and area of residence (as shown in table 2). discussions the percentage levels of sufficient knowledge and sufficient practice were 60% and 69%. this shows that the level of knowledge and practice of urban and rural residents in west nusa tenggara province is at a sufficient level. a cross-sectional study in india showed similar results (roy et al., 2020). as more and more countries experience covid-19 outbreaks and with the efforts made by who and local governments, knowledge regarding covid-19 is growing. our study found that all respondents were aware of the seriousness of this disease and were concerned about the worsening of the epidemic. most residents believe that preventive measures can prevent infection with covid-19 and think that the community should immediately report or cut contact with those around them who are positive for covid-19. the results regarding attitudes toward covid-19 are similar to those found in previous studies conducted in china (zhong et al., 2020). residents' self-protection table 1. participants' demographic characteristics demographic characteristics number of participants (%) age mean 36.65 years old gender female 316 (60.4%) male 207 (39.6%) area of residence urban 294 (45.9%) rural 347 (54.1%) education level primary school 7 (1.3%) middle school 12 (2.3%) senior high school 150 (28.7%) higher education 354 (67.7%) marital status never married 103 (19.7%) married 353 (67.5%) divorced 5 (1%) widowed 62 (11.9%) table 2. the binary logistic regression analysis result of covid-19 knowledge, attitudes, practice and its associated factors variable knowledge attitudes practice age 0.00* 0.65 0.51 gender 0.02* 0.02* 0.00* education level 0.00* 0.01* 0.80 marital status 0.09 0.15 0.33 area (urban vs rural) 0.00* 0.00* 0.00* *p < 0.05 jurnal ners http://e-journal.unair.ac.id/jners 157 awareness still needs to be strengthened, and the protective measures taken by residents still need to be improved. studies have shown that health education interventions can increase knowledge about communicable diseases and adherence to healthy living habits among both urban and rural residents (fan et al., 2021). based on this study, age, gender level of education and area (rural vs urban) affect knowledge about covid19. greater education level is positively correlated with higher knowledge levels regarding covid-19 in line with the findings of previous studies. hence, it is crucial to prioritize health education for the general public, particularly for individuals with lower education levels (abdelhafiz et al., 2020). the level of knowledge of women is higher than that of men, which is the same as the survey carried out by kumar, pinky, and nurudden (2021). the possible explanation for this finding could be the fact that 68% of the females surveyed held a bachelor's degree or higher. prior discussion has demonstrated females tend to have a higher literacy level in preventing as well as controlling infectious diseases compared to males, who are more prone to engaging in risky behavior (kumar, pinky, and nurudden, 2021; yue et al., 2021). the results of our study found that both urban and rural residents have an adequate attitude toward covid-19. it should be noted that a score of knowledge of covid-19 is associated with an optimistic attitude to take protective measures, and people living in urban areas are more likely than people in rural areas to seek medical advice if they suspect infection. this actually illustrates the importance of increasing knowledge and awareness of the covid-19 outbreak among the population, especially people who live in rural areas (geldsetzer, 2020; luo, zeng and liao, 2020). the study found that both rural and urban residents had moderate attitudes toward covid-19. however, it revealed that a higher score in covid-19 knowledge is related to a more optimistic attitude toward taking defensive efforts, and urban residents tend to follow medical recommendations when they suspect an infection. this highlights the importance of increasing knowledge and awareness of the covid-19 outbreak among the population, particularly in rural areas (geldsetzer, 2020; luo, zeng and liao, 2020). based on the multiple linear regression analysis, urban citizens had better prevention techniques, which could be attributed to their high levels of health literacy and exposure to extensive health information (zheng, zhang and xu, 2020). in contrast, rural residents generally have lower levels of education, inadequate health services, and less exposure to health information, highlighting the need for increased prevention and control measures in rural areas (abdelhafiz et al., 2020). strength and limitation of the study this study describes the knowledge, attitudes and actions of the community toward infectious diseases and the factors that influence them. the findings of this study can be used as a reference in developing promotive and preventive programs for infectious diseases. however, there are some limitations in this study. knowledge of covid-19 in respondents with a low education level cannot be described in this study because most of the respondents are at the higher education level. in this study, the involvement of the elderly was minimal, so information about knowledge, attitudes and behavior regarding covid-19 in the elderly could not be described. conclusions practice towards covid-19 is strongly influenced by gender and region (rural vs urban). urban area has sufficient practice against covid-19. this study found that attitudes toward covid-19 were generally fair between urban and rural residents. knowledge of covid-19 has been influenced by age, gender and level of education. the need to strengthen and increase the level of knowledge, attitudes and health behavior is very important to prevent infectious diseases. health education can help prepare individuals and communities to implement effective health protocols in the future and prevent rapid transmission. acknowledgment we are grateful for the master's thesis research grant that has been given by the ministry of education, culture, research and technology. conflict of interest there is no conflict of interest. references abdelhafiz, a. s. et al. (2020) ‘knowledge, perceptions, and attitude of egyptians towards the novel coronavirus disease (covid-19)’, journal of community health. springer, 45(5), pp. 881–890. doi: 10.1007/s10900-020-00827-7/tables/5. adhikari, s. p. et al. (2020) ‘epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review’, infectious diseases of poverty. infect dis poverty, 9(1). doi: 10.1186/s40249-020-00646-x. menap, sismulyanto, mursaka, and putra (2023) 158 p-issn: 1858-3598  e-issn: 2502-5791 albahri, a. h. et al. (2021) ‘knowledge, attitude, and practice regarding covid-19 among healthcare workers in primary healthcare centers in dubai: a cross-sectional survey, 2020’, frontiers in public health. front public health, 9. doi: 10.3389/fpubh.2021.617679. chen, n. et al. (2020) ‘epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study’, the lancet. elsevier, 395(10223), pp. 507–513. doi: 10.1016/s0140-6736(20)30211-7. clements, j. m. (2020) ‘knowledge and behaviors toward covid-19 among us residents during the early days of the pandemic: cross-sectional online questionnaire’, jmir public health and surveillance. jmir public health surveill, 6(2). doi: 10.2196/19161. fan, z. et al. (2021) ‘investigation of knowledge, attitude and practice of personal protection among different types of workers returning to work under covid-19 epidemic’, frontiers in public health. frontiers media sa, 9, p. 679699. doi: 10.3389/fpubh.2021.679699. gadarian, s. k., goodman, s. w. and pepinsky, t. b. (2021) ‘partisanship, health behavior, and policy attitudes in the early stages of the covid-19 pandemic’, plos one. plos one, 16(4). doi: 10.1371/journal.pone.0249596. geldsetzer, p. (2020) ‘use of rapid online surveys to assess people’s perceptions during infectious disease outbreaks: a crosssectional survey on covid-19’, j med internet res 2020;22(4):e18790 https://www.jmir.org/2020/4/e18790. journal of medical internet research, 22(4), p. e18790. doi: 10.2196/18790. ministry of health republic indonesia (2020) guidelines for the prevention and control of coronavirus disease (covid-19) 5th revision. jakarta: ministry of health, republic of indonesia.. kumar, b., pinky, s. d. and nurudden, a. m. (2021) ‘knowledge, attitudes and practices towards covid-19 guidelines among students in bangladesh’, social sciences & humanities open. elsevier, 4(1), p. 100194. doi: 10.1016/j.ssaho.2021.100194. lewnard, j. a. and lo, n. c. (2020) ‘scientific and ethical basis for social-distancing interventions against covid-19’, the lancet. infectious diseases. lancet infect dis, 20(6), pp. 631–633. doi: 10.1016/s1473-3099(20)30190-0. limbong, j., kuswinarti, k. and sitorus, t. d. r. (2021) ‘knowledge, attitude, and practices towards the covid-19 pandemic among undergraduate students’, althea medical journal. international journal of integrated health sciences (ijihs), 8(2), pp. 70–76. doi: 10.15850/amj.v8n2.2282. luo, l., zeng, x. and liao, x. (2020) ‘disease cognition, coping style and exercise behavior among the public during novel coronavirus epidemic: an online survey’, chinese journal of public health. 中 国公共卫生, 36(2), pp. 156–159. doi: 10.11847/zgggws1128079. roy, d. et al. (2020) ‘study of knowledge, attitude, anxiety & perceived mental healthcare need in indian population during covid-19 pandemic’, asian journal of psychiatry. elsevier science b.v., 51, p. 102083. doi: 10.1016/j.ajp.2020.102083. syakurah, r. a. and moudy, j. (2020) ‘pengetahuan terkait usaha pencegahan coronavirus disease (covid-19) di indonesia’, higeia (journal of public health research and development), 4(3), pp. 333–346. doi: 10.15294/higeia.v4i3.37844. szymona-pałkowska, k. et al. (2016) ‘knowledge of the disease, perceived social support, and cognitive appraisals in women with urinary incontinence’, biomed research international. biomed res int, 2016. doi: 10.1155/2016/3694792. wiersinga, w. j. et al. (2020) ‘pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (covid19): a review’, jama. american medical association, 324(8), pp. 782–793. doi: 10.1001/jama.2020.12839. yue, s. et al. (2021) ‘knowledge, attitudes and practices of covid-19 among urban and rural residents in china: a cross-sectional study’, journal of community health. springer, 46(2), pp. 286– 291. doi: 10.1007/s10900-020-00877-x/tables/5. zheng, j., zhang, y. and xu, y. (2020) ‘health literacy and demand for health education on novel coronavirus pneumonia epidemic among community residents in fujian province: an online survey during epidemic outbreak’, chinese journal of public health. 中国 公共卫生, 36(2), pp. 160–164. doi: 10.11847/zgggws1128092. zhong, b. l. et al. (2020) ‘knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey’, international journal of biological sciences. ivyspring international publisher, 16(10), pp. 1745–1752. doi: 10.7150/ijbs.45221. how to cite this article: menap, m., sismulyanto, s., mursaka, m., and putra, m. m. (2023) ‘knowledge, attitudes, and practice against covid-19 in west nusa tenggara, indonesia’, jurnal ners, 18(2), pp. 154-158. doi: http://dx.doi.org/10.20473/jn.v18i2.44580 47 mutu asuhan keperawatan berdasarkan analisis kinerja perawat dan kepuasan perawat dan pasien (quality of nursing care based on analysis of nursing performance and nurse and patient satisfaction) abdul muhith*, nursalam** * stikes majapahit mojokerto, jl. raya gayaman km. 02 mojoanyar mojokerto, e-mail: cua_muhith@yahoo.com ** fakultas keperawatan universitas airlangga abstract introduction: nurses who frequently often contact to patients and most of their time serve patients in 24 hours, have an important role in caring for the patient. patient satisfaction as quality indicator is the key success for competitiveness of service in hospital. the aim of this research was to develop nursing service quality model based on the nursing performance, nurse and patient satisfaction. method: the research method used cross sectional study, at 14 wards of gresik hospital. research factors were namely: oganization characteristic (organization culture and leadership), work factors (feedback and variety of nurses work), nurse characteristics (motivation, attitude, commitment and mental model), nursing practice, interpersonal communication, nurse and patient satisfaction. statistical analysis of study data was analyzed by partial least square (pls). results: the results of nursing performance revealed that nurse characteristic were not affected by organization culture and leadership style, nurse characteristics were affected by work factors, nurse characteristics affected nursing quality service (nursing practice, nursing professional, nurse and patient satisfaction), nurse satisfaction did not affect nursing professionals. discussion: based on the overall results of the development of nursing care model that was originally only emphasizes the process of nursing care only, should be consider the input factor of organizational characteristics, job characteristics, and characteristics of individual nurses and consider the process factors of nursing care standards and professional performance of nurses and to consider the outcome factors nurse and patient satisfaction. so in general the development model of quality of existing nursing care refers to a comprehensive system of quality. keywords: nursing service quality, determinant factors of performance, satisfaction pendahuluan perkembangan pelayanan kesehatan di indonesia telah berhasil meningkatkan pelayanan kesehatan secara lebih merata. kemajuan ilmu pengetahuan dan teknologi telah mengakibatkan golongan masyarakat yang berpendidikan dan menguasai informasi semakin bertambah, sehingga mereka dapat memilih dan menuntut untuk memperoleh pelayanan kesehatan yang berkualitas (supriyanto dan ernawaty, 2010). organisasi pelayanan kesehatan, seperti rumah sakit perlu memiliki karakter mutu pelayanan prima yang sesuai dengan harapan pasien. semakin baik penilaian pasien, maka semakin baik pula mutu pelayanan kesehatan rumah sakit tersebut (donabedian, 1980). kualitas mutu pelayanan keperawatan di rumah sakit bergantung pada keterampilan, kecepatan, kemudahan dan ketepatan dalam melakukan tindakan praktek keperawatan (supriyanto dan ratna, 2011). pelayanan keperawatan yang bermutu merupakan salah satu kebutuhan dasar yang diperlukan setiap orang. sampai saat ini para ahli dibidang kesehatan dan keperawatan berusaha meningkatkan: mutu diri, profesi, peralatan keperawatan, kemampuan manajerial keperawatan dan mutu asuhan keperawatan (potter dan perry, 2005). pada tahun 2005 direktorat pelayanan keperawatan depkes bekerja sama dengan world health organization (who) mengadakan penilaian tentang pelayanan keperawatan di jurnal ners vol. 7 no. 1 april 2012: 47–55 48 kalimatan timur, sumatra utara, jawa barat, jawa timur, dan dki menunjukkan bahwa: 70,9% perawat selama 3 tahun terakhir tidak pernah mengikuti pelatihan, 39,8% perawat masih melakukan tugas non keperawatan, 47,4% perawat tidak mempunyai uraian tugas secara tertulis, dan belum dikembangkan evaluasi kinerja perawat secara khusus. d a t a d i r u m a h s a k i t k a b u p a t e n gresik tahun 2010 menunjukkan bahwa rasio (perbandingan) jumlah perawat dan jumlah tempat tidur belum sesuai standar depkes ri artinya jumlah tenaga keperawatan masih kurang (departemen kesehatan, 2005). data indikator layanan rawat inap tahun 2008 sampai dengan tahun 2010 di rsud gresik menunjukkan bahwa pemanfaatan bed occupancy rate (bor), unit rawat inap rsud gresik sudah efi sien. begitu juga dengan data indikator layanan unit rawat inap di rumah sakit semen gresik menunjukkan kondisi bor dalam kategori standar artinya pemanfaatan tempat tidur rumah sakit dapat dikategorikan sudah efi sien. data indikator layanan unit rawat inap di rumah sakit petrokimia gresik juga sudah sesuai standar dan efi sien, walaupun pada tahun 2009 dan 2010 ada penambahan jumlah perawat dan tempat tidur. sedangkan data indikator layanan unit rawat inap di rumah sakit muhammadiyah gresik masih belum efi sien dan kategori kurang standar. kualitas layanan dan pelaksanaan asuhan keperawatan dari rumah sakit di kabupaten gresik belum memenuhi standar (100%). rumah sakit semen gresik lebih baik karena tingkat kepuasan pasien sudah memenuhi konsep pareto 80:20. tu j u a n u m u m p e n e l i t i a n a d a l a h pengembangan model mutu asuhan keperawatan berdasarkan analisis kinerja perawat dan kepuasan kerja perawat serta kepuasan pasien. bahan dan metode penelitian ini menggunakan metode penelitian survey dengan desain cross-sectional dan sifat penelitian yakni penelitian penjelasan (explanatory research). penelitian dilaksanakan pada bulan maret sampai september 2011. populasi dalam penelitian ini adalah seluruh unit rawat inap rumah sakit di kabupaten gresik yaitu rsud gresik, rumah sakit semen gresik, rumah sakit petrokimia gresik dan rumah sakit muhammadiyah gresik. sampel penelitian adalah seluruh kepala unit rawat inap, perawat dan pasien di ruang rawat inap rumah sakit di kabupaten gresik dengan kriteria inklusi: memiliki salah satu dari 3 tipe budaya (clan, market dan hirarki) dan memiliki salah satu dari 2 tipe kepemimpinan coaching dan directing. kriteria inklusi yang memenuhi syarat adalah rsud gresik dan rumah sakit semen gresik. besar sampel adalah 14 unit rawat inap. pengambilan sampel dengan simple random sampling. teknik analisis yang digunakan adalah model persamaan struktural berbasis variance atau component based, yang terkenal disebut partial least square (pls). hasil hasil pengujian hipotesis pengujian hipotesis dilakukan dengan analisis model struktural pada masing-masing jalur pengaruh langsung secara parsial dan pengaruh tidak langsung melalui variabel mediasi. pembahasan pengaruh budaya organisasi dan tipe kepemimpinan terhadap karakteristik individu perawat hasil penelitian menunjukkan bahwa tidak ada pengaruh yang signifikan budaya organisasi dan tipe kepemimpinan kepala unit rawat inap rumah sakit terhadap karakteristik individu perawat ruangan. tipe budaya organisasi ruangan didominasi oleh budaya clan 50%, budaya pasar 28,6% dan budaya hirarki 21,4%. budaya clan menurut cameron dan quinn (2006), adalah budaya yang berorientasi kolaborasi, keterikatan emosional, dan budaya yang fokus pada pemeliharaan dengan fl eksibilitas, perhatian pada staf, anggota tim dengan nilai pemicu adalah komitmen, dan pengembangan staf dan partisipasi staf tinggi, sedangkan budaya pasar menunjukkan adanya mutu asuhan keperawatan (abdul muhith) 49 orientasi bersaing dengan nilai pemicunya adalah layanan berbasis pemenuhan kebutuhan pasien. budaya hirarki adalah budaya yang berorientasi pengawasan dan pengendalian dengan nilai pemicu efi siensi dan disiplin. hasil penelitian dapat disimpulkan bahwa budaya clan yang mendominasi sudah sesuai dengan karakteristik perawat dalam hal memberi motivasi dan komitmen kerja perawat yang tinggi. budaya hirarki diperlukan pada situasi sikap dan mental model atau kemandirian kerja perawat terhadap pekerjaan lemah, karena pada budaya hirarki berorientasi pada pengawasan dan pengendalian pekerjaan bawahan. tipe kepemimpinan kepala unit rawat inap sebagian besar adalah coaching (57,8%), kemudian tabel 1. hasil pengujian hipotesis pengaruh langsung antarvariabel no hubungan antar variabel koefi sien jalur (standardize) tstatistik ket 1 budaya organisasi dan kepemimpinan kepala unit rawat inap terhadap karakteristik individu perawat 0.189 0.386 tidak signifi kan 2 umpan balik dan variasi pekerjaan terhadap karakteristik individu perawat 0.688 5.214 signifi kan 3.1 karakteristik individu perawat terhadap standar asuhan keperawatan 0.845 8.159 signifi kan 3.2 standar asuhan keperawatan terhadap standar kinerja profesional perawat 0.818 3.003 signifi kan 3.3 standar asuhan keperawatan terhadap kepuasan kerja perawat 0.833 8.450 signifi kan 3.4 standar kinerja profesional perawat terhadap kepuasan pasien 0.736 5.169 signifi kan 4 kepuasan kerja perawat terhadap standar kinerja profesional perawat 0.152 0.616 tidak signifi kan gambar 1. hasil pengujian hipotesis directing (42,9%). kepemimpinan coaching atau mentor dan fasilitator akan membangun komunikasi yang efektif antar anggota tim serta menumbuhkan adanya partisipasi yang kuat di antara anggotanya. coaching dalam budaya organisasi tercermin pada budaya clan. coaching adalah perilaku pemimpin dengan pengarahan orientasi hubungan tinggi dan orientasi tugas tinggi. kontrol pengambilan keputusan tetap pada pemimpin (cameron dan quinn, 2006). h a s i l m e n u n j u k k a n b a h w a t i p e kepemimpinan coaching cenderung baik dalam menumbuhkan motivasi dan komitmen (> 80%), seperti budaya clan namun lemah pada mental model atau kemandirian kerja dan sikap kerja jurnal ners vol. 7 no. 1 april 2012: 47–55 50 perawat (< 49%). kepemimpinan directing cenderung memberikan nilai cukup pada semua komponen karakteristik perawat (komitmen, motivasi, mental model atau kemandirian kerja dan sikap kerja perawat). studi oleh lewin, leppitt dan white dalam gillies (1989) menunjukkan bahwa kelompok menghasilkan kuantitas kerja yang lebih besar di bawah kepemimpinan directing namun kualitas kerja yang lebih baik di bawah kepemimpinan coaching. menurut gillies (1989), faktor yang menentukan gaya kepemimpinan yang terbaik untuk situasi yang ada meliputi kesulitan dan kompleksitas tugas yang diberikan: banyaknya waktu yang tersedia bagi penyelesaian tugas, ukuran kelompok, pola komunikasi dalam kelompok tersebut, latar belakang pendidikan dan pengalaman pegawai. hasil penelitian menunjukkan bahwa tidak ada pengaruh signifi kan budaya dan tipe kepemimpinan kepala unit rawat inap terhadap mutu asuhan keperawatan (standar asuhan keperawatan, standar kinerja profesional perawat, dan kepuasan perawat dan pasien) di rumah sakit kabupaten gresik. p e n g a r u h u m p a n b a l i k d a n va r i a s i pekerjaan perawat terhadap karakteristik individu perawat hasil penelitian menginformasikan bahwa ada pengaruh yang signifi kan umpan balik dan variasi pekerjaan perawat terhadap standar kinerja profesional perawat. pengaruh umpan balik dan variasi pekerjaan terhadap standar kinerja profesional perawat melalui karakteristik perawat (motivasi, komitmen, sikap dan mental model atau kemandirian kerja perawat). umpan balik dari atasan masih rendah (50% dijalankan) dan variasi pekerjaan cukup tinggi (71,4%), sehingga dapat diprediksi bila umpan balik sebagai upaya pengawasan dan pengendalian pekerjaan ditingkatkan dan menambah sedikit lagi variasi pekerjaan atau pekerjaan tidak monoton lagi, pasti akan memberikan peningkatan motivasi dan komitmen kerja serta sikap dan mental model kerja perawat dan akhirnya berpengaruh pada peningkatan standar kinerja profesional perawat peningkatan kinerja. hasil penelitian menunjukkan bahwa ada pengaruh signifikan umpan balik dan variasi pekerjaan perawat di unit rawat inap terhadap mutu asuhan keperawatan (standar asuhan keperawatan, standar kinerja profesional perawat, kepuasan kerja perawat dan kepuasan pasien) melalui karakteristik individu perawat (motivasi, sikap, komitmen dan mental model atau kemandirian kerja perawat) di rumah sakit kabupaten gresik. pengaruh karakteristik perawat terhadap mutu asuhan keperawatan hasil analisis jalur terbukti ada pengaruh signifikan karakteristik individu perawat (motivasi, sikap, komitmen, mental model atau kemandirian kerja perawat) terhadap mutu asuhan keperawatan, yakni: karakteristik individu perawat ke standar asuhan keperawatan, standar asuhan keperawatan ke standar kinerja profesional keperawatan dan kepuasan perawat, standar kinerja profesional keperawatan ke kepuasan pasien. hasil ini membuktikan bahwa hipotesis penelitian terbukti. pengaruh karakteristik perawat terhadap standar asuhan keperawatan hasil analisis jalur menunjukkan ada pengaruh signifikan karakteristik individu perawat (motivasi, sikap, komitmen dan mental model atau kemandirian kerja perawat) terhadap kepatuhan menjalankan standar asuhan keperawatan. m o t i v a s i d a n k o m i t m e n p e r a w a t pada pekerjaan dinilai tinggi, sehingga perlu dipertahankan, kalau perlu ditingkatkan secara terus-menerus. sikap pada pekerjaan dan mental model untuk dapat melakukan pekerjaan secara mandiri dan profesional masih lemah. bila mutu layanan keperawatan jauh berkonstribusi dalam memenangkan persaingan rumah sakit, kemandirian dan profesional dalam menjalankan keperawatan harus menjadi perhatian untuk setiap rumah sakit (leebov dan scott, 1994). hasil penelitian disimpulkan bahwa imbalan, pelatihan dan pengembangan, kepemimpinan dan pembagian jadwal kerja memiliki pengaruh terhadap kepuasan karyawan (nursalam, 2011). mutu asuhan keperawatan (abdul muhith) 51 pengaruh standar asuhan keperawatan terhadap standar kinerja profesional perawat mereka yang melaksanakan standar asuhan keperawatan yang lebih patuh juga akan melakukan standar kinerja profesional keperawatan (komunikasi interpersonal) yang lebih baik pada pasien. demikian pula terhadap kepuasan kerja perawat. hasil penelitian menunjukkan seperti yang dijelaskan nursalam (2008), bahwa ada pengaruh signifi kan standar asuhan keperawatan terhadap standar kinerja profesional perawat. pengaruh standar asuhan keperawatan terhadap kepuasan perawat penerapan standar asuhan keperawatan berpengaruh pada kepuasan kerja perawat. kepuasan perawat adalah salah satu indikator loyalitas perawat, sehingga perawat yang loyal akan termotivasi memberikan layanan pada pasien dengan lebih baik. kepuasan perawat pada dukungan organisasi dengan mengacu teori abraham maslow sebagian besar berada pada kebutuhan afi liasi dan perlunya adanya pengawasan dalam menjalankan pekerjaan. teori maslow analog dengan teori motivasi. hasil analisis jalur menunjukkan ada pengaruh standar asuhan keperawatan terhadap kepuasan perawat. pengaruh kinerja profesional perawat terhadap kepuasan pasien hasil analisis jalur menunjukkan bahwa ada pengaruh kepuasan pasien terhadap pelaksanaan standar kinerja profesional perawat. kepuasan pasien pada standar kinerja profesional perawat di ruang rawat inap rumah sakit adalah cukup puas, baik dalam hal caring, kolaborasi, empati, courtesy dan sincerety. kajian empiris kepuasan berada pada tingkat kepuasan cukup puas, artinya meskipun ada pengaruh, hal ini mengisyaratkan bahwa kinerja profesional perawat harus ditingkatkan, kalau rumah sakit ingin berhasil dalam memenangkan persaingan. hasil analisis jalur menunjukkan bahwa ada pengaruh kinerja profesional perawat terhadap kepuasan pasien. kepuasan pasien pada standar kinerja profesional perawat di ruang rawat inap rumah sakit adalah cukup puas, baik dalam hal caring, kolaborasi, empati, courtesy dan sincerety. kajian empiris kepuasan berada pada tingkat kepuasan cukup puas, artinya meskipun ada pengaruh, hal ini mengisyaratkan bahwa kinerja profesional perawat harus ditingkatkan, kalau rumah sakit ingin berhasil dalam memenangkan persaingan. perawat adalah mereka yang banyak terlibat langsung pada pelayanan pasien. kinerja profesional perawat yang bisa dipersepsikan oleh pasien. pernyataan ini sesuai dengan supriyanto dan ernawaty (2010), bahwa layanan kesehatan adalah jenis produk yang “credence quality” artinya walaupun pasien sering memanfaatkan, mereka tetap berada pada ketidaktahuan apa yang dinilai. kepuasan pasien pada perawat yang bisa diteliti adalah proses penyampaian layanan atau standar profesional keperawatan, dan bukan pada aspek keperawatan (standar praktik keperawatan) itu sendiri. hal ini sesuai dengan konsep mutu layanan jasa kesehatan menurut donabedian (1980). pengaruh kepuasan kerja perawat terhadap standar kinerja profesional perawat hasil penelitian menunjukkan bahwa motivasi kerja perawat adalah tinggi. hal yang sama penilaian tinggi pada komitmen kerja dan cukup pada sikap dan mental kerja perawat. pada dasarnya produktivitas kerja perawat dipengaruhi oleh berbagai faktor seperti tingkat pendidikan, latihan, motivasi kerja, etos kerja, pengalaman kerja, sikap mental, kondisi fi sik, teknologi, jaminan sosial, keselamatan dan kesejahteraan kerja, manajemen maupun kebijakan yang diterapkan, terutama pimpinan (supriyanto, 2010). sikap perawat pada asuhan keperawatan atau aktivitas pengkajian sampai evaluasi cukup. hal ini dimungkinkan karena asuhan keperawatan adalah pekerjaan sebagai wujud keterampilan perawat yang bersifat rutin, sehingga hanya cukup memberikan dorongan kerja. hasil penelitian membuktikan bahwa variasi pekerjaan ada asosiasi terhadap karakteristik perawat, khususnya sikap kerja. jurnal ners vol. 7 no. 1 april 2012: 47–55 52 hasil akhir uji jalur penelitian dari keseluruhan hasil pengujian hipotesis, maka dapat diketahui lintasan atau jalur yang signifi kan, yang menggambarkan model hasil penelitian ini. dengan memperhatikan hasil analisis jalur penelitian dapat diuraikan temuan penelitian sebagai berikut. jalur 1. dari umpan balik dan variasi pekerjaan perawat → karakteristik individu perawat → standar asuhan keperawatan → standar kinerja profesional perawat → kepuasan pasien. temuan ini memberi bukti, bahwa karakteristik pekerjaan perawat dan karakteristik individu perawat merupakan determinan penting dalam menjalankan kinerja, standar asuhan keperawatan dan standar kinerja profesional p e r a w a t u n t u k m e n u j u p e r b a i k a n a t a u peningkatan kepuasan pasien. dan temuan ini juga menunjukkan bahwa kondisi eksternal (umpan balik dan variasi pekerjaan perawat) dan internal (sikap, motivasi, komitmen dan mental model atau kemandirian kerja perawat) menjadi faktor atau variabel penentu (enablers) pada peningkatan mutu kinerja perawat. jalur 2. dari umpan balik dan variasi pekerjaan perawat → karakteristik individu perawat → standar asuhan keperawatan → kepuasan perawat. temuan ini mengindikasikan bahwa umpan balik dan variasi pekerjaan perawat dan kondisi internal perawat (sikap, motivasi, komitmen, mental model atau kemandirian kerja perawat) dapat sebagai faktor atau variabel penentu (enablers) kepuasan kerja perawat. p e n g e m b a n g a n m o d e l m u t u a s u h a n keperawatan pengembangan model mutu asuhan keperawatan mengacu pada sistem mutu dan temuan hasil analisis penelitian kinerja (empiris) dan kajian teoritis. asumsi dasar model asuhan keperawatan yang lama lebih menekankan pada penerapan asuhan keperawatan (proses asuhan keperawatan dan caring), belum secara komprehensif mempertimbangkan semua komponen sistem kinerja atau sistem mutu oleh donabedian (1980), yang meliputi komponen struktur (input), proses dan outcome. asumsi kedua evolusi paradigma mutu, yang semula didorong dari “provider driven” menjadi “customer driven). customer driven adalah salah kunci keberhasilan dalam memenangkan persaingan sdm (competitive advantage). customer driven adalah mutu layanan yang berusaha memenuhi kebutuhan dan harapan pelanggan. pengembangan mutu asuhan keperawatan berdasarkan kedua asumsi tersebut, di mulai dari kondisi outcome saat ini (kepuasan pasien dan kepuasan perawat), kemudian di analisis penyebabnya pada proses mutu (penerapan asuhan keperawatan dan kinerja profesional perawat). masalah proses mutu di analisis penyebabnya di komponen struktur. gambar 1. model akhir studi tentang pengembangan mutu asuhan keperawatan. mutu asuhan keperawatan (abdul muhith) 53 outcome kepuasan pasien dan perawat kepuasan pasien hasil penelitian menunjukkan bahwa kepuasan pasien dalam hal caring, kolaborasi, empathy, courtesy dan sincerety dikategorikan cukup puas. kepuasan pasien merupakan salah satu indikator kualitas pelayanan yang diberikan dan modal untuk mendapatkan pasien lebih banyak dan yang loyal (setia). pasien yang loyal akan menggunakan kembali pelayanan kesehatan yang sama bila mereka membutuhkan lagi. bahkan telah diketahui bahwa pasien loyal akan mengajak orang lain untuk menggunakan fasilitas pelayanan kesehatan yang sama (kaplan, 1996). kinerja profesional terkait kemampuan seorang perawat berkomunikasi, menjalin hubungan interaktif dalam menjalankan t e r a p e u t i k k e p e r a w a t a n h a r u s s e l a l u ditingkatkan. pasien lebih mudah menilai bagaimana perawat menyampaikan pelayanan dari aspek teknik keperawatan. karena itu tugas organisasi profesi keperawatan, yakni bagaimana meningkatkan kemampuan komunikasi terapeutik perawat sebagai komplemen dalam menyampaikan standar a s u h a n k e p e r a w a t a n . i n i d a p a t b e r u p a p e n d i d i k a n t a m b a h a n d i l u a r p r o f e s i perawat. pengembangan mutu untuk kinerja profesional perawat dapat dilakukan dengan memberikan pelatihan baik on atau off the training tentang komunikasi terapeutik yang benar. komunikasi keperawatan diharapkan dapat membantu pasien dalam memperbaiki dan mengendalikan emosi, sehingga membantu percepatan penyembuhan dari upaya medis. membantu pasien untuk memperjelas dan mengurangi beban perasaan dan pikiran serta dapat mengambil tindakan untuk mengubah situasi yang ada bila pasien percaya pada hal yang diperlukan, mengurangi keraguan, membantu dalam hal mengambil tindakan yang efektif dan mempertahankan kekuatan egonya, memengaruhi orang lain, lingkungan fi sik dan dirinya sendiri, komunikasi terapeutik memberikan pelayanan prima (service excellence atau tanpa cacat), sehingga dicapai kesembuhan dan kepuasan pasien, dan komunikasi yang menghasilkan kepuasan semua pihak yang terlibat (win win solution bagi dokter, perawat, pasien). on the job training dapat dilakukan dengan mengikutsertakan perawat dalam seminar tentang keperawatan, memberikan kesempatan kepada perawat untuk mengikuti pelatihan yang berhubungan dengan peningkatan kompetensi perawat. selain itu dapat juga mendatangkan trainer dari luar yang relevan. sehingga kompetensi perawat dan mental model atau kemandirian kerja perawat dapat ditingkatkan. pada off the job training yang dapat dilakukan adalah peningkatan jenjang pendidikan perawat pada strata s1. kepuasan perawat bentuk kinerja dapat berupa kecepatan, kemudahan, dan kenyamanan bagaimana perawat dalam memberikan jasa pengobatan terutama keperawatan pada waktu penyembuhan yang relatif cepat, kemudahan dalam memenuhi kebutuhan pasien dan kenyamanan yang diberikan dengan memperhatikan kebersihan, keramahan dan kelengkapan peralatan rumah sakit. hasil penelitian menunjukkan bahwa kepuasan perawat lebih dipengaruhi penerapan standar asuhan keperawatan dapat dilaksanakan dibandingkan adanya dukungan organisasi (fasilitas, gaji, promosi dan kesesuaian jenis pekerjaan). nilai yang dirasakan perawat pada penerapan standar asuhan keperawatan dalam pengkajian, diagnosis, perencanaan adalah tinggi (100% dapat dilaksanakan dengan baik), sedangkan untuk implementasi dan evaluasi belum bisa dilaksanakan 100%. dukungan organisasi dirasakan oleh perawat sampai sebatas cukup puas. hasil di atas mengindikasikan bahwa perawat masih perlu ditingkatkan kemampuan melaksanakan standar asuhan keperawatan melalui peningkatan kompetensi (knowledge and skill). demikian pula dukungan organisasi yang kondusif dan fasilitatif agar perawat dapat menerapkan standar asuhan keperawatan secara penuh. jurnal ners vol. 7 no. 1 april 2012: 47–55 54 karakteristik organisasi, pekerjaan dan individu pengembangan budaya organisasi dan tipe kepemimpinan kepala unit rawat inap sekumpulan nilai terbangun di dalam organisasi sebagai kristalisasi nilai individu, kelompok dan akhirnya menjadi nilai bersama (cameron dan quinn, 2006). dari riset yang dilakukan cameron dan quinn (2006) dapat ditentukan bahwa ada empat tipe budaya atau kepemimpinan organisasi, yaitu kepemimpinan clan, hirarki, market dan adhocracy. tipologi budaya, kepemimpinan organisasi bisnis didasarkan pada teori manajemen: effective performance, leadership dan manajemen skill, dari teori manajemen ini dimunculkan indikator (alat ukurnya) dalam enam dimensi pengukuran. hasil penelitian menginformasikan bahwa tipe budaya organisasi sebagian besar didominasi budaya clan (menekankan kolaborasi dan kerja sama tim), dan sudah mulai ada budaya orientasi pasar atau pemenuhan kebutuhan pasien. tipe kepemimpinan kepala ruangan sebagian besar di dominasi tipe coaching (kepemimpinan dengan tipe pendampingan). tipe kepemimpinan directing juga masih dijumpai pada kerja sama tim perawat. hal ini menunjukkan bahwa perawat belum terbukti melakukan kerja sama secara profesional. pengembangan karakteristik pekerjaan (umpan balik dan variasi pekerjaan perawat) saat melaksanakan fungsi dan kegiatan karyawan berhubungan dengan kepuasan dan tingkat imbalan, sehingga dapat ditambahkan faktor lain yaitu harapan mengenai imbalan, persepsi terhadap tugas, dorongan eskternal atau kepemimpinan, kebutuhan menurut maslow dan faktor pekerjaan (desain, variasi tugas, umpan balik, pengawasan, dan pengendalian). terkait faktor pekerjaan, hasil penelitian menginformasikan bahwa umpan balik pekerjaan perawat kurang dilakukan oleh pimpinan rawat inap rumah sakit dan variasi pekerjaan perawat cukup bervariasi. hasil penelitian tersebut jika dikaitkan dengan teori kopelmen (1986), faktor pekerjaan yakni umpan balik, variasi, desain pekerjaan, beban kerja, job desain berpengaruh terhadap kinerja individu melalui variabel sikap, pengetahuan, kemampuan dan motivasi, sehingga dapat disimpulkan secara umum bahwa dengan kurangnya umpan balik yang dilakukan oleh pimpinan rawat inap dapat berpengaruh terhadap kinerja individu perawat. usulan yang dapat dilakukan adalah umpan balik sebagai alat kontroling pimpinan. kepala rawat inap melakukan kontrol, pengendalian dan pengawasan, dan jangan terlalu banyak fokus pada pekerjaan atau tugas nonkeperawatan. pengembangan sikap, motivasi, komitmen dan mental model atau kemandirian kerja perawat komitmen pada pekerjaan dan motivasi kerja perawat adalah tinggi, namun dalam kemampuan menjalankan kemandirian masih cukup, maka tipe kepemimpinan ruangan dalam tipe coaching dan directing masih dirasakan perlu. namun dengan peningkatan jenjang kompetensi melalui on atau off the job education, menjadikan perawat mampu melaksanakan mutu asuhan keperawatan (able), maka tipe kepemimpinan supporting bisa dipertimbangkan. tipe kepemimpinan situasional tidak ada yang paling cocok untuk segala kondisi tujuan, dan kondisi perilaku bawahan. kenyataan hasil penelitian semua tipe kepemimpinan situasional delegating, supporting, coaching dan directing ada semua. tipe coaching dan directing yang banyak dipraktikkan oleh kepala rawat inap. untuk meningkatkan kemandirian perawat dalam menerapkan asuhan keperawatan secara independen dan profesional. on the job training diperlukan di tempat kerja untuk pengelolaan management pengetahuan (knowledge management); adanya gugus kendali mutu (gkm) sehingga hasil akhirnya adalah adanya kemandirian perawat bagus. selain itu perlu ada remunerasi perawat. saat ini remunerasi adalah bentuk yang paling efektif meningkatkan komitmen. remunerasi perawat dapat dilakukan dalam bentuk sistem imbalan dan sementara berfokus pada keperawatan tim. mutu asuhan keperawatan (abdul muhith) 55 on the job training juga dapat dilakukan dalam bentuk peningkatan hand skill pada perawat. diharapkan dapat meningkatkan komitmen dan mental model atau kemandirian kerja perawat. sikap perawat semakin dan percaya akan kemampuan yang dimilikinya. pada off job training yang perlu segera diusulkan adalah peningkatan jenjang pendidikan perawat pada strata s1. secara prinsip melakukan perbaikan proses dan input dengan on the job training atau off job training akan berdampak pada pengelolaan pengetahuan (knowledge management) dan peningkatan skill komunikasi. tentunya dalam input – proses – outcome harus ada dukungan organisasi (rumah sakit), demikian juga peran organisasi profesi perawat. simpulan dan saran simpulan model pengembangan mutu asuhan keperawatan disusun dengan prinsip berdasarkan analisis hasil uji jalur penelitian, analisis realita atau kondisi faktual analisis deskriptif, sintesis dari hasil analisis diskriptif dan jalur, kemudian dikembangkan model yang mengacu pada kebutuhan dan harapan customer (customer driven) yang mengarah pada keunggulan bersaing rumah sakit (competitive advantages). saran pengembangan model mutu asuhan keperawatan yang ada mengacu pada sistem mutu yang komprehensif. pengembangan model mutu asuhan keperawatan dapat dilaksanakan apabila dilakukan pelatihan baik on atau off the job training tentang knowledge skill dan komunikasi terapeutik. on the job training diperlukan di tempat kerja untuk pengelolaan management pengetahuan (knowledge management) yaitu dengan adanya gugus kendali mutu (gkm) sehingga hasil akhirnya adalah adanya kemandirian perawat bagus, sedangkan off the job training yang dapat dilakukan adalah peningkatan jenjang pendidikan perawat pada pendidikan strata 1 (s1) dengan harapan dapat mengubah mindset (pola pikir layanan) dalam memberikan layanan p e n d i d i k a n d a n p e l a t i h a n d i l u a r profesional dan soft skill diselenggarakan oleh kelompok profesi perawat, penerapan remunerasi bagi perawat dan adanya kebijakan rumah sakit yang mendukung kemandirian profesi perawat. kepustakaan cameron, k.s. dan quinn, r.e., 2006. diangnosis and changing organizational cultur. san fransisco: john wiley and sona, inc,. departemen kesehatan, 2005. standar tenaga keperawatan di rumah sakit, d e p a r t e m e n k e s e h a t a n r e p u b l i k indonesia. donabedian, a., 1980. aspects of medical care administration, harvad: university, press. gilles, d.a., 1989. management a systems approach, philadelphia: w. b. saunders. company. kaplan, r.s., dan norton, d.j., 1996. balanced scorecard, translating strategy into action. harvard business school press. kopelman, r.e., 1986. managing productivity in organizations. new york: mcgrawhill book company, leebov, w. dan scott, g., 1994. service quality improvement the customer satisfaction for health care, hospital publishing, inc, america. nursalam, 2011. manajemen keperawatan aplikasi dalam praktik keperawatan. jakarta: salemba raya. nursalam, 2008. proses dan dokumentasi k e p e r a w a t a n . j a k a r t a : s a l e m b a medika. potter, a.p., dan perry, g.a., 2005. fundamental keperawatan: konsep, proses dan p r a k t e k , j a k a r t a : p e n e r b i t b u k u kedokteran egc. supriyanto, s., dan ernawaty, 2010. pemasaran industri jasa kesehatan. yogjakarta: pt andi. ners vol 5 no 1 april 2010_akreditasi 2013.indd 70 training pengisian kartu menuju sehat (kms) merubah perilaku kader posyandu balita (training of growth record changes a behaviour for posyandu’s cadres) nursalam*, dinna agustina*, ni ketut alit a* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257, e-mail: nursalam_psik@yahoo.com abstract introduction: most posyandu’s cadres cannot fi ll growth record of children correctly due to lack of training. the objective of this study was to explain the effect of training about growth record fi lling to behaviour changing of posyandu cadres. method: this research used quasy experimental method. the population of this research were all posyandu cadres. sample was taken by simple random sampling then 20 respondents divided into treatment group and control group. independent variable in this research was the training for cadres fi lling growth record of children and dependent variable was the behaviour changing of posyandu’s cadres. data were taken by using the questionnaire and directly the interview to respondent then be analyzed by using wilcoxon signed ranks test and mann whitney u test, with signifi cant level α ≤ 0.05. result: the result showed that training for cadres about fi lling growth record had signifi cant effect to the cadre’s behaviour (knowledge α = 0.007, attitude α = 0.005, and action α = 0.007). but, it had no signifi cant effect on control group (knowledge α = 0.157, attitude α = 0.102, action α = 1.00). discussion: it can be concluded that training of cadre about fi lling growth record could change the posyandu’s cadres behaviour. public health centers need to conduct training which have compatible content with the standard of government health departement. further studies should involve larger respondents to obtain more accurate result. keywords: cadre, posyandu, training, behaviour, growth record, nutrition status pendahuluan perkembangan paradigma pembangunan, telah menetapkan arah kebijakan pembangunan kesehatan, yang tertuang dalam rencana pembangunan jangka menengah (rjpm) 2004–2009 bidang kesehatan, yang lebih mengutamakan pada upaya preventif, promotif, pemberdayaan keluarga dan masyarakat dalam bidang kesehatan. salah satu bentuk upaya pemberdayaan masyarakat di bidang kesehatan adalah menumbuhkembangkan posyandu. ada 5 macam kegiatan dalam posyandu balita yaitu kia, kb, imunisasi, gizi, dan penanggulangan diare. peran kader sangat penting dalam pelaksanaan posyandu sebagai tenaga preventif dan promotif bagi kesehatan balita. posyandu di indonesia telah kehilangan pamornya sejak tahun 1990-an karena merosotnya mutu kader dan pelayanannya (departemen kesehatan republik indonesia, 2006). tingkat presisi dan akurasi para kader posyandu masih rendah. hal tersebut berdasarkan penelitian di 72 posyandu di jawa barat dan jawa tengah yang menunjukkan bahwa hanya 30% kegiatan posyandu dilaksanakan dengan benar dan 90% kader membuat kesalahan dalam penimbangan dan pencatatan kms sehingga dapat disimpulkan bahwa tingkat kemampuan, presisi, dan akurasi data dalam pencatatan kms masih rendah (satoto, 2002). data dari posyandu di desa karang jeruk jatirejo mojokerto, menunjukkan bahwa ternyata dari 20 kader posyandu balita, didapatkan 15 kader masih belum mengerti cara mengisi kms yang baik dan benar. terbatasnya informasi dan pelatihan kader yang kurang menyebabkan tingkat pengetahuan kader tentang pengisian kms sangat rendah. pelatihan terakhir pada tahun 2002, yang hanya diikuti 1 orang kader per dusun sehingga sebagian kader mempunyai pengetahuan yang kurang tentang posyandu balita dan tidak mengetahui bagaimana cara training pengisian kms (nursalam) 71 pengisian kms yang baik dan benar. pengaruh pelatihan kader terhadap perubahan perilaku kader posyandu balita di desa karang jeruk jatirejo mojokerto, belum dapat dijelaskan. jumlah posyandu balita di jawa timur pada tahun 2007 sebanyak 44.442 posyandu, pada tahun 2008 jumlah posyandu menjadi 44.899. sedangkan jumlah kader di jawa timur pada tahun 2007 sebanyak 202.720 kader, pada tahun 2008 sebanyak 307.380 kader (dinas kesehatan jawa timur, 2008). kabupaten mojokerto, pada tahun 2007 sebanyak 1248 posyandu dan tidak mengalami peningkatan pada tahun 2008. jumlah kader posyandu pada tahun 2007 sebanyak 6169 kader dengan kader yang terlatih 5975 kader. pada tahun 2008 mengalami peningkatan dengan jumlah kader sebanyak 6209 dan kader yang terlatih mengalami penurunan sebanyak 5753 kader (dinas kesehatan kabupaten mojokerto, 2009). data yang diperoleh dari puskesmas karang jeruk menunjukkan dari 20 kader yang ada hanya ada 5 kader yang dapat mengisi kms dengan benar, karena ke-5 kader pernah mendapatkan pelatihan di kecamatan. apabila kader dalam melakukan pengisian kms kurang tepat maka dalam mengidentifikasi status kesehatan akan salah. data dari puskesmas didapatkan pada tahun 2008–2009 ada dua bayi yang berat badannya di bawah garis merah, jika dalam pengisian kms salah maka identifikasi status gizi balita juga akan salah. penelitian yang dilakukan oleh universitas andalas (sumatera barat), universitas hasanuddin (sulawesi selatan), dan sekolah tinggi ilmu gizi (jawa timur) pada tahun 1999 (seperti dikutip departemen kesehatan republik indonesia, 2005) menunjukkan hasil bahwa sebagian besar posyandu belum mempunyai jumlah kader yang cukup bila dibandingkan dengan sasaran dan hanya 30% kader yang terlatih serta sebagian besar belum mandiri, karena sangat tergantung dengan petugas puskesmas. penelitian sebelumnya yang dilakukan oleh satoto dkk. pada tahun 2002, menunjukkan bahwa sekitar 35% desa di indonesia masih melaksanakan posyandu sampai sekarang dan sebagian rakyat miskin masih menggunakan posyandu sebagai tempat pelayanan kesehatan. kemampuan kader dalam memberikan pelayanan kesehatan khususnya melakukan p e n c a t a t a n k m s s a n g a t m e m e n g a r u h i indentifikasi status gizi balita. apabila k e m a m p u a n k a d e r d a l a m m e m b e r i k a n pelayananan kesehatan khususnya melakukan pencatatan kms masih rendah, maka akan berdampak identifikasi status gizi balita dan memengaruhi penyuluhan yang diberikan kepada balita sesuai dengan data kms yang ada, hal ini akan mengakibatkan salah penafsiran apakah balita dalam keadaan gizi kurang atau tidak. lemahnya penguasaan dan keterampilan akan menyebabkan pelaporan yang yang tidak akurat dalam penyusunan perencanaan program kesehatan selanjutnya. (departemen kesehatan republik indonesia, 2006). kms sebagai bahan penunjang atau sarana komunikasi bagi petugas kesehatan untuk menentukan jenis tindakan yang tepat sesuai dengan kondisi kesehatan dan gizi balita, untuk mempertahankan, meningkatkan, dan memulihkan kesehatannya (departemen kesehatan republik indonesia, 2000). pentingnya pelatihan bagi kader untuk meningkatkan pengetahuan dan kemampuan kader dalam mengisi kms agar tidak terjadi kesalahan dalam pencatatan. dan gizi sesuai dengan hasil penimbangan. salah satu manfaat dengan adanya kader yang terlatih adalah posyandu akan berjalan secara teratur dan baik, agar mudah mendeteksi kemungkinan terjadinya masalah gizi buruk pada balita. jika kasus gizi buruk ini segera teratasi dan diikuti oleh penanganan yang baik oleh tenaga kesehatan, maka diharapkan kasus kekurangan gizi berat pada anak-anak balita di akan dapat terhindarkan (saprudin, 2007). berdasarkan uraian di atas peneliti tertarik untuk memberikan pelatihan kepada kader tentang pengisian kms di desa karang jeruk kecamatan jatirejo mojokerto. bahan dan metode r a n c a n g a n d a l a m p e n e l i t i a n i n i menggunakan quasy eksperiment untuk mengidentifikasi pengaruh pelatihan kader terhadap perubahan perilaku kader posyandu jurnal ners vol. 5 no. 1 april 2010: 70–78 72 balita. populasi dalam penelitian ini adalah kader posyandu balita di desa karang jeruk jatirejo mojokerto. sampel didapatkan dengan cara probability sampling dengan teknik simple random sampling. pemilihan sampel dengan cara ini merupakan jenis probabilitas yang paling sederhana. untuk mencapai sampling ini, setiap elemen diseleksi secara acak. (nursalam, 2008). variabel independen dalam penelitian ini adalah pelatihan kader posyandu balita. parameter yang diukur adalah proses dari pelatihan posyandu balita dan materi pelatihan posyandu balita yang telah dibuat oleh peneliti, sedangkan variabel dependennya adalah perilaku kader (tingkat pengetahuan, sikap, dan tindakan kader). instrumen yang digunakan dalam pengumpulan data adalah dengan kuesioner untuk mengukur pengetahuan dan sikap kader tentang posyandu. untuk menilai tingkat pengetahuan menggunakan kuesioner dengan 10 pertanyaan, kuesioner untuk sikap menggunakan 5 pertanyaan positif dan 5 pertanyaan negatif pada pertanyaan positif bila jawaban sangat setuju (ss) skor 4, (s) skor 3, (ts) skor 1, (sts) skor 0. pertanyaan negatif diberi skor (ss) skor 0, (s) skor 1, (ts) skor 3, (sts) skor 4. sedangkan instrumen yang digunakan untuk mengukur tindakan adalah dengan lembar observasi. data yang telah terkumpul dianalisis perbedaan perubahan perilaku sebelum dan sesudah diberikan intervensi dengan uji wilcoxon signed rank. selanjutnya untuk mengontrol perbedaan perilaku pada kader yang dilakukan kontrol dan perlakuan dengan uji mann whitney u test dengan tingkat kemaknaan α ≤ 0,05 apabila p ≤ α maka h1 diterima. hasil rerata pengetahuan responden pada kelompok perlakuan sebelum diberikan p e l a t i h a n a d a l a h 5 9 p o i n , n i l a i r e r a t a pengetahuan responden kelompok perlakuan sesudah diberikan pelatihan adalah 88 poin. kelompok kontrol, pada pre-test nilai rerata yang diperoleh adalah 57 poin dan pada posttest adalah 59 poin. h a s i l u j i s t a t i s t i k m e n g g u n a k a n wilcoxon signed rank test pada kelompok perlakuan adalah 0,007 yang artinya terdapat perbedaan pengetahuan yang bermakna pengetahuan perlakuan kontrol perlakuan selisih kontrol selisih post post pre post pre post mean 59 88 +29 57 59 +2 88 59 sd 12,87 11,35 16,63 14,49 11,35 14,49 p = 0,007 wilcoxon signed ranks test p = 0,157 wilcoxon signed ranks test p = 0,001 mann whitney u-test tabel 2. pengaruh pelatihan kader tentang pengisian kms terhadap sikap kader posyandu balita sikap perlakuan kontrol perlakuan selisih kontrol selisih post post pre post pre post mean 26,50 36,20 31,40 31,80 36,20 31,80 sd 4,72 2,35 4,53 4,34 4,72 4,34 p = 0,005 wilcoxon signed ranks test p = 0,102 wilcoxon signed ranks test p = 0,28 mann whitney utest keterangan: mean = rerata sd = standar deviasi p = signifi kansi tabel 1. pengaruh pelatihan kader tentang pengisian kms terhadap pengetahuan kader posyandu balita training pengisian kms (nursalam) 73 sebelum dan sesudah diberikan pelatihan pengisian kms. sedangkan pada kelompok kontrol menunjukkan hasil p=0,157, ini berarti bahwa tidak ada peningkatan pengetahuan pada kelompok kontrol apabila tidak diberi pelatihan. hasil analisis dengan menggunakan uji statistik mann whitney u test didapatkan nilai signifikasi p= 0,001 artinya ada perbedaan pengetahuan yang bermakna antara kelompok perlakuan dan kelompok kontrol setelah diberikan pelatihan tentang pengisian kms. nilai rerata sikap responden kelompok perlakuan sebelum diberikan pelatihan adalah 26,50 dan sesudah diberi pelatihan adalah 36,2. kelompok kontrol nilai rerata respondennya pada pre-test adalah 31,40 dan pada post-test 31,80. hasil uji statistik menggunakan uji statistic wilcoxon signed rank test pada kelompok perlakuan adalah 0,005 di mana artinya ada perbedaan sikap yang bermakna sebelum dan setelah diberikan pelatihan, sedangkan pada kelompok kontrol menunjukkan hasil p=0,102, sehingga p ≥ 0,05 ini menunjukkan bahwa tidak terjadi perubahan sikap pada kelompok kontrol apabila tidak diberi pelatihan. h a s i l a n a l i s i s d a t a s i k a p s e t e l a h mendapatkan pelatihan dengan uji mann whitney u test didapatkan nilai signifikasi p=0,28. nilai ini berarti bahwa tidak adanya perbedaan sikap yang bermakna kelompok perlakuan dan kelompok kontrol setelah diberikan pelatihan pengisian kms. nilai rerata tindakan responden kelompok perlakuan sebelum diberikan pelatihan adalah 15,00, kemudian sesudah diberi pelatihan nilai rerata responden menjadi 92,59. nilai rerata kelompok kontrol pada pre-test adalah 30 dan pada post-test adalah 30. hasil uji statistik menggunakan wilcoxon signed rank test pada kelompok perlakuan adalah 0,007. ini menunjukkan bahwa terjadi perubahan yang sangat signifikan sekali setelah diberikan pelatihan tentang pengisian kms. kelompok kontrol didapatkan nilai signifikasi p=1,00, sehingga p≥0,05 hasil ini menunjukkan bahwa tidak ada peningkatan tindakan pada kelompok kontrol apabila tidak diberi pelatihan. hasil analisis data dengan uji mann whitney u test didapatkan nilai signifikasi p=0,001 yang artinya ada perbedaan tindakan yang bermakna antara kelompok perlakuan dan kelompok kontrol setelah diberikan pelatihan. pembahasan pengetahuan atau kognitif merupakan domain penting untuk terbentuknya tindakan seseorang (notoadmodjo, 2007). tingkat pengetahuan dipengaruhi oleh pembelajaran dan tingkat pendidikan. pembelajaran dimaksudkan untuk memberikan pengetahuan kepada kader tentang pentingnya cara pengisian kms yang baik dan benar. perubahan dalam hal pengetahuan tentang cara pengisian kms dan hal-hal yang berhubungan dengan kegiatan posyandu, didahului oleh persepsi seseorang terhadap apa yang akan dijalani, sehingga muncul persepsi berhubungan dengan tingkat pengetahuan yang diperoleh dari informasi. informasi yang diterima bisa kurang jelas, dalam hal ini pembelajaran tentang cara pengisian kms yang baik dan benar yang tidak optimal dapat memengaruhi persepsi seseorang sehingga perubahan pengetahuan akan sulit tindakan perlakuan kontrol perlakuan selisih kontrol selisih post post pre post pre post mean 15,00 92,50 30 30 15,00 92,50 sd 31,62 12,08 36,89 36,89 431,62 12,08 p = 0,007 wilcoxon signed ranks test p = 1,00 wilcoxon signed ranks test p = 0,002 mann whitney u-test tabel 3. pengaruh pelatihan kader tentang pengisian kms terhadap tindakan kader posyandu balita keterangan: mean = rerata sd = standar devisi p = signifi kansi jurnal ners vol. 5 no. 1 april 2010: 70–78 74 didapatkan. menurut notoadmodjo (2007), pelatihan dapat meningkatkan pengetahuan, sikap, tindakan. pelatihan tidak lepas dari proses belajar karena proses belajar itu ada dalam rangka mencapai tujuan pendidikan. pengetahuan responden yang kurang sebagian besar disebabkan karena responden tidak pernah mendapatkan pelatihan dan memperoleh informasi yang baru tentang posyandu balita dan pengisian kms yang benar. suatu pelatihan yang tidak dapat meningkatkan pengetahuan responden setelah diberikan intervensi dapat dipengaruhi oleh pemberian informasi yang tidak jelas, tidak dapat diterima maksimal oleh responden. pertanyaan yang kurang sesuai dengan materi yang diberikan, pemilihan kata-kata yang tidak lugas untuk orang awam secara langsung membuat responden bingung sehingga nilai pengetahuan mereka kurang, pendidikan responden. hal ini paling penting yang harus diberikan dalam memberikan suatu pelatihan, orang yang memiliki pendidikan tinggi lebih mudah memahami dan menerima materi, menguraikan kata-kata dalam pertanyaanpertanyaan yang diberikan peneliti. hasil penelitian didapatkan bahwa sebelum pelatihan sebagian responden pengetahuannya masuk dalam kategori kurang hal ini terjadi karena sebagian besar responden hanya tamatan sd. banyaknya responden yang mempunyai pengetahuan kurang tentang posyandu balita karena rendahnya tingkat pendidikan. tingkat pendidikan memengaruhi pengetahuan seseorang, yaitu semakin tinggi pendidikan semakin tinggi juga tingkat pengetahuan yang didapat. selain itu karena faktor usia, sebagian besar responden berusia 41–50 tahun. usia berpengaruh terhadap penerimaan dan proses ingatan seseorang. semakin tua usia seseorang maka semakin lemah ingatannya. hal ini sesuai dengan teori yang dikemukakan oleh kuntjoro (2002) bahwa dalam kehidupan manusia daya ingat akan berubah sesuai dengan usia. setelah diberikan intervensi pengetahuan responden masuk dalam kategori baik meningkat menjadi (80%), hal ini disebabkan karena responden mendapatkan intervensi tentang posyandu balita dan pengisian kms. peneliti menggunakan metode ceramah, diskusi, dan demonstrasi. metode ceramah kurang mampu merangsang seseorang dalam proses belajar (zifana, 2008), karena metode ceramah hanya efektif selama 30 menit. peneliti mengkombinasikan dengan metode diskusi dan demonstrasi, dengan metode diskusi responden bisa banyak berpikir, responden bisa lebih aktif dalam proses belajar. metode demonstrasi merupakan salah satu metode pembelajaran partisipatif, di mana responden diikutsertakan secara langsung dalam proses pemberian informasi. responden secara langsung berlatih mengisi kms dan menginterprestasikan hasil dari pengisian kms tersebut. pemberian informasi dengan metode yang tidak sesuai akan mengakibatkan informasi yang kurang jelas, sehingga tujuan dari pelatihan tidak akan tercapai. setelah pemberian intervensi, responden masuk dalam kategori baik karena responden telah dapat mengingat suatu materi yang telah dipelajari sebelumnya, responden telah memahami dan menggunakan materi yang telah dipelajari pada situasi atau kondisi real (nyata). pada kelompok kontrol sebagian besar responden, pengetahuan masuk dalam kategori kurang hal ini disebabkan karena responden tidak mendapatkan suatu intervensi sama sekali, sehingga tingkat pengetahuan tidak mengalami perubahan. sehingga hasil uji statistik menggunakan mann whitney u-test yang membandingkan kelompok perlakuan dan kontrol didapatkan nilai signifikasi p = 0,001 yang artinya pelatihan tentang pengisian kms pada kader posyandu balita dapat merubah tingkat pengetahuan responden. hasil uji statistik sikap seteleh diberikan perlakuan dengan menggunakan wilcoxon signed rank test pada kelompok perlakuan didapatkan nilai lebih kecil dari standar sedangkan pada kelompok kontrol yang tidak diberi pelatihan didapatkan nilai lebih besar dari standar. hasil ini berarti bahwa adanya perbedaan yang bermakna sebelum dan sesudah diberikan pelatihan pengisian kms, yaitu terjadi peningkatan perubahan pada responden setelah diberi intervensi, sebagian besar responden masuk dalam kategori positif. nilai sikap positif dan negatif diperoleh dari menghitung nilai dari pernyataan responden training pengisian kms (nursalam) 75 berdasarkan skoring azwar (2008), kemudian dibandingkan dengan rerata data. hasil sikap positif pada seluruh responden dikarenakan faktor yang memengaruhi perubahan sikap yaitu pertama adalah pengalaman pribadi, yaitu apa yang telah dan sedang kita alami akan ikut membentuk dan memengaruhi penghayatan stimulus sosial. tanggapan akan menjadi salah satu terbentuknya sikap, untuk dapat mempunyai tanggapan dan penghayatan, seseorang harus mempunyai pengalaman yang berkaitan dengan objek psikologis, yang kedua adalah kebudayaan, kebudayaan telah menanamkan garis pengaruh sikap, karena kebudayaan yang memberikan corak pengalaman individu. hal yang memengaruhi sikap yang ketiga adalah orang lain yang dianggap penting, keempat adalah media massa. peranan media massa tidak kecil artinya, karena media massa merupakan bentuk informasi sugestif dalam dunia usaha guna memperkenalkan suatu produk baru. kemudian faktor yang kelima adalah institusi atau lembaga pendidikan dan lembaga agama. kedua lembaga ini mempunyai pengaruh dalam pembentukan sikap dikarenakan keduanya meletakkan dasar pengertian dan konsep moral dalam diri individu, dan faktor terakhir adalah faktor emosi dalam diri individu. kadang, suatu bentuk sikap merupakan pernyataan yang didasari oleh emosi, sikap demikian dapat merupakan sikap yang sementara dan segera berlalu begitu frustasi telah hilang akan tetapi dapat merupakan sikap yang lebih persisten dan bertahan lama. nilai sikap responden perlakuan setelah diberikan pelatihan mayoritas menjadi meningkat dikarenakan responden sudah bisa menangkap seluruh hal positif yang mereka dapatkan dari intervensi, setelah pengetahuan mereka cukup, emosional mereka mulai bereaksi dengan stimulus yang ada. sikap berupa keyakinan seseorang terhadap suatu objek, tidak dapat dilihat langsung, menunjukkan reaksi emosional terhadap suatu stimulus merupakan pernyataan newcomb, yang dikutip dalam notoadmodjo (2007), mengungkapkan bahwa orang akan mengubah sikap, jika ia mampu mengubah komponen kognitif dahulu, diikuti perubahan afektif. pernyataan bloom juga diperkuat oleh azwar (2009) yang menyatakan bahwa k o m p o n e n a f e k t i f ( s i k a p ) m e r u p a k a n komponen kedua setelah komponen kognitif dalam struktur sikap. penerimaan sikap terdiri dari empat tingkatan yaitu menerima, merespon, menghargai, dan bertanggung jawab (notoadmodjo, 2007). hasil penelitian didapatkan bahwa sebelum penelitian responden sebagian besar mempunyai sikap negatif dan sebagian besar pula mempunyai sikap positif. sikap negatif responden disebabkan karena pengetahuan yang kurang tentang posyandu balita dan informasi tentang pengisian kms, karena responden jarang memperoleh pelatihan. s e t e l a h d i b e r i k a n i n t e r v e n s i t e n t a n g posyandu balita dan pengisian kms, dengan menggunakan metode ceramah, diskusi, dan demonstrasi responden yang mempunyai sikap positif meningkat lebih banyak hal ini karena responden sudah bisa menangkap hal positif yang mereka dapatkan dari intervensi pelatihan tentang posyandu balita dan pengisian kms, tetapi masih ada responden yang mempunyai sikap negatif setelah penelitian, responden yang mempunyai sikap negatif ini hanya tamatan sd sehingga kemampuan mereka dalam mamahami pelatihan dan penerimaan terhadap materi masih kurang dan interprestasi mereka terhadap pernyataan sikap kurang tepat. selain itu, evaluasi perubahan sikap yang hanya sekali dilakukan pada saat post intervensi dinilai kurang. pada kelompok kontrol masih ada responden masih mempunyai sikap negatif, hal ini disebabkan karena responden tidak mendapatkan intervensi, sehingga responden masih kurang tepat dalam menginterprestasikan sikapnya. hasil uji statistik menggunakan mann whitney u-test yang membandingkan kelompok kontrol dan perlakuan post perlakuan didapatkan nilai signifikasi lebih besar dari standar ini berarti bahwa pelatihan terhadap kader posyandu balita tentang pengisian kms tidak merubah sikap kader, hal ini disebabkan karena dalam melakukan proses matching peneliti kurang tepat, selain itu data sikap terlalu mengarahkan ke responden sehingga dari awal responden sudah mempunyai sikap yang positif. jurnal ners vol. 5 no. 1 april 2010: 70–78 76 tindakan responden pada kelompok perlakuan sebelum diberikan intervensi sebagian besar masuk dalam kategori kurang, setelah diberikan pelatihan sebagian besar kader masuk dalam kategori baik yaitu responden dapat melakukan tindakan yang baik dan benar tentang pengisian kms ini dibuktikan pula dengan hasil uji statistik pada kelompok perlakuan di mana didapatkan nilai signifikasi lebih kecil dari nilai standar. hal ini disebabkan karena responden telah mendapatkan kejelasan informasi tentang pengisian kms. kelompok kontrol sebagian besar responden masuk dalam kategori kurang dalam melakukan pengisian kms dan pada post-test tidak terjadi perubahan sama sekali. hal ini disebabkan karena responden tidak mendapatkan kejelasan informasi tentang cara pengisian kms yang baik dan benar sehingga pada kelompok kontrol didapatkan nilai signifikasi lebih besar dari standar. notoadmodjo (2007) mengatakan bahwa suatu sikap belum otomatis terwujud dalam suatu tindakan (overt behavior), untuk mewujudkan sikap menjadi suatu perbuatan yang nyata diperlukan faktor pendukung atau situasi yang memungkinkan, antara lain adalah fasilitas dan faktor dukungan (support) yaitu tindakan. tingkatan tindakan terdiri dari persepsi, respons terpimpin, mekanisme, dan adopsi. tindakan dapat dikatakan berhasil jika telah melewati tingkatan keempat yaitu adopsi, karena adopsi merupakan suatu praktik atau tindakan yang sudah berkembang dengan baik, artinya tindakan itu sudah dimodifikasi tanpa mengurangi kebenaran tindakan tersebut. praktik merupakan domain perilaku yang ketiga setelah pengetahuan dan sikap (notoadmodjo, 2007), setelah mengetahui stimulus atau objek, kemudian mengadakan penilaian atau pendapat terhadap apa yang diketahui, kemudian seseorang diharapkan akan mampu melaksanakan, mempraktikkan, atau memiliki kemampuan praktik terhadap apa yang diketahui dan disikapi. pelatihan merupakan usaha untuk membantu individu, keluarga, dan masyarakat dalam meningkatkan kemampuan baik pengetahuan, sikap, maupun keterampilan (sofo, 2003). hasil penelitian tindakan responden sebelum diberikan pelatihan sebagian besar masuk dalam kategori kurang, hal ini terjadi karena pengalaman responden menjadi kader sebagian besar masih 0–5 tahun, pengalaman sangat memengaruhi pengetahuan seseorang dalam melaksanakan tindakan, karena pengalaman akan lebih mendalam dan membekas pada ingatan seseorang, dengan pengalaman yang masih kurang sehingga tindakan responden dalam pengisian kms masih kurang tepat, di samping itu responden juga jarang mendapatkan pelatihan tentang posyandu balita dan pengisian kms, setelah dilakukan intervensi tentang pengisian kms dengan menggunakan metode ceramah, diskusi dan demonstrasi, responden yang mempunyai tindakan baik dalam pengisian kms meningkat menjadi 70% dan masuk dalam kategori baik, hal ini terjadi karena metode yang digunakan peneliti dalam memberikan pelatihan sangat efektif, yaitu responden bisa langsung mempratekkan pengisian kms sehingga proses penerimaan informasi atau materi dapat diterapkan secara langsung. meskipun dalam waktu yang cukup singkat, terjadi perubahan yang cukup tinggi, dengan demikian dapat disimpulkan bahwa kader posyandu balita yang telah dilatih sangat potensial dalam merubah perilaku. kader yang telah terlatih telah melakukan motivasi dengan cukup baik, baik secara langsung (memberikan pelatihan) maupun secara tidak langsung, sehingga pelatihan dapat meningkatkan perilaku seseorang apabila diberikan dengan baik dan dengan prosedur yang benar. uji statistik menggunakan mann whitney u-test, didapatkan nilai signifikasi pada kelompok perlakuan didapatkan nilai lebih kecil dari standar yang artinya pelatihan terhadap kader posyandu balita tentang pengisian kms dapat meningkatkan tindakan kader dalam pengisian kms. pelatihan dapat dipilih untuk merubah perilaku ke arah yang lebih baik. pelatihan ini terbukti dapat merubah pengetahuan, sikap, dan tindakan responden. menurut notoatmodjo (2003) pelatihan dapat merubah pengetahuan, sikap, dan tindakan seseorang. mekanisme training pengisian kms (nursalam) 77 perubahan pengetahuan, sikap, dan tindakan setelah diberikan pelatihan dimulai dengan pemberian informasi yang tepat. tepat yang dimaksud adalah tepat sasaran dengan berbagai metode yang dipilih serta alat bantu yang digunakan. informasi yang telah diberikan tersebut diterima, dimengerti, dan dipahami, sehingga pengetahuan responden meningkat. pemberian informasi tersebut ternyata tidak hanya meningkatkan pengetahuan saja, tetapi dengan informasi tersebut dapat membangun suatu keyakinan yang positif pada diri responden. setelah pengetahuan berubah menjadi baik serta sikap yang positif, maka terciptalah suatu tindakan untuk melakukan pengisian kms dengan benar. perubahan pengetahuan, sikap, dan tindakan responden ini dipengaruhi oleh proses pemberian informasi pada saat dilakukan intervensi, jika proses pemberian intervensi itu tepat maka informasi yang didapatkan responden dapat maksimal. informasi tersebut diolah membentuk suatu pengetahuan baru, keyakinan serta kesadaran akan pentingnya pemahaman terhadap pengisian kms yang benar. metode belajar yang digunakan peneliti juga memengaruhi proses perubahan perilaku. peneliti menggunakan metode diskusi dan demonstrasi. metode diskusi membuat responden berpikir dan juga responden berpartisipasi aktif dalam proses belajar, dengan metode demonstrasi responden dapat langsung mengaplikasikan pengisian kms secara langsung. hasil akhir yang didapat adalah perubahan perilaku ke arah yang lebih baik. simpulan dan saran simpulan pelatihan tentang pengisian kms meningkatkan pengetahuan kader posyandu, merubah sikap kader menjadi positif dan meningkatkan tindakan kader posyandu dalam pengisian kms. saran peneliti memberikan saran bagi kader posyandu balita agar tetap aktif sebagai kader dan selalu menghadiri dalam setiap pelatihan yang dilakukan oleh pihak puskesmas atau institusi lainnya untuk meningkatkan pengetahuan, sikap, dan tindakan, bagi pihak puskesmas agar melaksanakan pelatihan setiap tahun dengan menggunakan metode diskusi, demonstrasi untuk meningkatkan pengetahuan dan keterampilan kader posyandu balita tentang sesuatu hal yang baru dengan cara memberikan pelatihan dan materi sesuai dengan standar departemen kesehatan dan perlu dilakukan evaluasi secara berkala. pihak puskesmas harus mengadakan perekrutan bagi kader yang lebih muda, dan perlunya penelitian lebih lanjut tentang pelatihan kader posyandu balita untuk meningkatkan pengetahuan dan keterampilan kader yang tidak hanya dalam melakukan pengisian kms saja, tetapi dalam penimbangan berat badan, cara memberikan penyuluhan kepada ibu balita. kepustakaan azwar, saefudin, 2008. sikap manusia teori dan pengukurannya. yogyakarta: pustaka belajar. departemen kesehatan republik indonesia, 1999. profi l peran serta masyarakat dalam pembangunan kesehatan. jakarta: departemen kesehatan. d e p a r t e m e n k e s e h a t a n r e p u b l i k indonesia,2006. pedoman pembinaan k e s e h a t a n b a l i t a b a g i p e t u g a s kesehatan i. jakarta: departemen kesehatan. dinas kesehatan jawa timur, 2006. buku pegangan kader posyandu. surabaya: dinas kesehatan propinsi jawa timur. sofo, fransesco, 2003. pengembangan sdm perspektif, peran. surabaya: airlangga university press. notoatmodjo, soekidjo, 2003. ilmu kesehatan masyarakat. jakarta: pt rineka cipta. jurnal ners vol. 5 no. 1 april 2010: 70–78 78 notoatmodjo, soekidjo, 2007. promosi kesehatan perilaku. jakarta: rineka cipta. nursalam, 2008. konsep dan penerapan m e t o d o l o g i p e n e l i t i a n i l m u k e p e r a w a t a n . j a k a r t a : s a l e m b a medika. satoto, 2002. evaluasi hasil penimbangan dan pencatatan kms, (online), (http// www: dinkesbonebolango.org. diakses pada tanggal 12 mei 2009, jam 15.00 wib. http://e-journal.unair.ac.id/jners 121 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 121-130 http://dx.doi.org/10.20473/jn.v17i2.34560 original article open access nurses’ perspectives of families ‘needs of the maternal critically ill cases in woman health hospital: an educational program howieda fouly1* , jennifer debeer2, and manal mohamed abd elnaeem3 1 faculty of nursing, king saud bin abdulaziz university of health science, jeddah, saudi arabia 2 king faisal specialist hospital and research centre, jeddah, saudi arabia 3 faculty of nursing, assiut university, assiut, egypt *correspondence: howieda fouly. address: faculty of nursing, assiut university, assiut, egypt. email: hoida_elfouly@yahoo.com responsible editor: retnayu pradanie received: 25 march 2022 ○ revised: 4 july 2022 ○ accepted: 19 july 2022 abstract introduction: meeting the family needs of patients in intensive care units is challenging for healthcare providers. the critical illness of one family member affects the wellbeing of other family members, causing changes in the life of the whole family. this study aimed to assess nurses' perspectives of the family needs of the critically ill maternal patient and to provide an educational program to nurses about these family needs. methods: a pre post-test design was used. the study was conducted in the obstetric intensive care unit at women's health hospital at assiut university hospital, egypt. a convenient sample of 28 was recruited from the total 35 female nurses of the women’s health hospital’s icu. results: there was a significant relationship between the sociodemographic items and family needs at p=0.00. there was also a statistically significant relationship between support needs, working hours, and years of experience at p=0.03 and p=0.01, respectively. there was a significant difference in the pre-post application of an educational program in all family needs items (p=0.00). conclusions: the educational program improved nurses' perspectives and awareness toward family needs. a regular educational program should be conducted in all intensive care units to improve the understanding and management of patients’ needs, especially in an african context. keywords: family; educational program; perspectives; maternal critically ill patient introduction the family is one of the basic units of society and has a significant influence on its members. the critical illness of one family member affects the wellbeing of other family members, causing changes in the life of the whole family. the critical illness usually occurs suddenly, and the patient's family members do not have enough time to comprehend and deal with this situation. consequently, the family members will experience many needs regarding the patient's condition, and, to meet family member's needs, critical care unit nurses must be able to identify their needs accurately (ghabeesh et al., 2014; iranmanesh et al., 2014). therefore, the patient’s family needs in icus are challenging roles for healthcare providers, particularly nurses, as families of critical patients depend on the healthcare providers to obtain data about their family member’s disorders and status of the disease progress (hashim and hussin, 2012). many critically ill patients are incapable of communicating with healthcare providers regarding icu care procedures due to the severity of their disease or condition (mitchell et al., 2009). accordingly, healthcare providers are increasingly seeking for family members to communicate with them and clarifying the care and support provided to the patient from their family (al‐ https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0001-7060-764x fouly, debee, and elnaeem (2022) 122 p-issn: 1858-3598  e-issn: 2502-5791 mutair et al., 2013). it is essential to involve the patient's family in the icu stage of care to empower the health with complete person-centered care (paul and finney, 2015). however, some studies have reflected the importance of meeting the family needs to avoid the negative effect on family satisfaction due to insistent unmet family needs (khalaila, 2013). therefore, the quality of icu care should involve the families' needs perspective regarding their patient care process outcome and evaluation of this care to improve their psychological health and safety (flaatten, 2012). obringer, hilgenberg, and booker (2012) confirmed that the least important needs of family members were those related to the aspect of support. the core responsibilities of nurses in the icus are to meet patients and their family members' needs. these priority needs of family members of icu patients differ according to sociocultural contexts (bandari et al., 2015). in saudi arabia, alsharari (2019) displayed that the family members of patients admitted to icu have higher levels of needs toward the assurance, proximity, and information aspects (alsharari, 2019). furthermore, the family members had the lowest level of needs in the comfort and support aspects. however, other needs varied according to the sociodemographic characteristics of the participants. therefore, recognizing the aspects of the family members' different needs is essential for the progress of effective communication and good collaboration toward the best care and support to icu patients and their families. in egypt, the intensive care unit is a highly stressful environment for patients' families due to the high critical and sophisticated care. nursing care is mostly directed to critically ill patients' management without significant attention to their families. due to the shortage of nurses, they lack information and training on how to meet this issue. on the other hand, meeting the patient's family needs is one of the holistic healthcare components among critically ill patients (abdel-aziz, ahmed and younis, 2017). critical care nurses are in the first line to provide the family members with their needs to accommodate stressful situations. therefore, the accurate assessment and reacting to critically ill obstetric patients' family needs is noteworthy in decreasing the negative impact of that stress, increasing family awareness about the care, and promoting trust. consequently, inadequate attention to family needs can result in inappropriate care, family hostility, and the development of confrontational relationships between family members and care providers (buckley and andrews, 2011). in egypt, the icus policies do not have specific regulations or rules regarding critically ill patients' families in care. therefore, the critical care nurses do not have a clear rule about the best practices of family engagement in their critically ill patients. thus, icu nurses' perception toward family engagement in patients' care is critical (abd el wareth and elcokany, 2019). although the women’s health hospital is the first hospital in upper egypt to include a maternal icu, the families of critical maternal cases have limited contact with their patients, and they are always seeking to meet their needs. so, the nurses need to recognize how this part is essential for both nursing care and family needs satisfaction. hence, all previous studies done in egypt focused on icus patients but not specifically toward critically ill maternity-related patients (abdel-aziz, ahmed and younis, 2017; abd el wareth and elcokany, 2019). our study aimed to assess the nurses’ perspectives toward family needs of the maternal critically ill cases and to provide an educational program about family needs of maternal icu cases at the women’s health hospital. materials and methods study design a pre-posttest design was used to determine nurses' perspectives on the needs of family members of critically ill maternal patients before and after an educational program. the study was conducted in the intensive care unit at the women’s health hospital at assiut university hospital. it is the largest teaching hospital in upper egypt and a tertiary referral center with all maternity services inclusive of a 12-bed obstetric icu for cases of severe condition related to pregnancy, delivery, and postpartum conditions such as severe postpartum hemorrhage, severe preeclampsia, eclampsia, sepsis and ruptured uterus, or any system failure depending on certain clinical criteria and laboratory markers. respondent the population included all obstetric critical care nurses at the hospital. the inclusion criteria included obstetric critical care nurses who worked in the current icu for at least six months and who nursed critically ill maternal patients. in addition, nurses who withdrew from the study whilst it was ongoing were excluded, as well as nurses with less than six months of experience and did not work with critically ill maternal patients. there was a total of 35 obstetric critical care nurses employed at the hospital during the time of the study. the total number of nurses in the icu was 35. the study jurnal ners http://e-journal.unair.ac.id/jners 123 conveniently recruited 28 nurses. five nurses were included in the pilot study and excluded from the final data collection. two nurses did not participate due to maternity leave and sick leave due to the coronavirus pandemic. instrument the tool used was the critical care family needs inventory (ccfni) which includes two parts: the first part was the sociodemographic data of participants and the second consisted of the items of the ccni (molter & js, 1995). there were forty-five (45) items related to family needs arranged in categories, namely support (items 1 to 14), proximity (items 15 to 23), proximity or closeness (items 24 to 32), assurance (items 33 to 39), and comfort (items 40 to 45). the responses are noted on a 4-point likert scale, and the scoring is coded as not important (1), slightly important (2), necessary (3), and very important (4). the original english version was translated into arabic by a qualified english to arabic translator. data collection the investigator applied the education program based on the pre-test of the nurses’ perspectives toward the family needs from may 1st to july 28th, 2020. after explaining the study aim, the investigator submitted the questionnaire to all available maternal critical care nurses in all shifts under high control of infection during covid-19. instead of regular face-to-face interviews, the investigator interviewed by cellphone and collected their answers regarding the family needs (support, information, proximity or closeness, assurance, and comfort items). this process continued for four weeks and each week the researcher interviewed approximately seven nurses in their free hours, not during work hours. once the investigator got the confirmation from the head of nurses, all icu nurses were accepted other than those on maternity and sick leave. in the fifth week, the investigator held four online sessions according to nurses' availability to attend these sessions to give them an instructional lecture presentation to clarify how are the family needs very important for triangle care, “the patient, family, and the nurses,” to improve the nursing care and patient outcomes. through the presentation, the investigator discussed the concept of the family needs and the history of this concept and the evidence of research regarding this issue. also, all items were explained to verify the importance of these concepts in a low-middle income country. after each session, the investigator submitted the online post-test questionnaire to check how the nurses perceived family needs after the lecture. the answers were submitted promptly online through the investigator's email. data analysis and ethical consideration spss 0.20 version (ibm corporation armonk, ny, and the usa) was used to analyze the data in the form of descriptive statistics (frequency and percentage, mean, and standard deviation) and analytical statistics (independent t-test) were used to analyze the data between nurses' perspectives before and after the application educational program instructions regarding family needs. the study obtained the approval of the ethics committee of women health hospital’s icu authorities, and the nursing ethical committee and research committee (no. 017 dated april 28th, 2020). the researcher also obtained informed consent from every obstetric critical care nurse after explaining the table 1 sociodemographic relationship to nurses’ perspectives of family needs support needs mean (sd) f p-value education bachelor high diploma secondary diploma 2.42(0.50) 2.80(0.70) 2.52(0.70) 0.96 0.39 working hours 2.64(0.65) 2.78 0.03* years working in icu 2.64(0.65) 3.25 0.01* information needs mean (sd) education 2.68 (0.31) 2.93 (0.44) 2.80 (0.53) 0.89 0.42 years of working 2.83(0.42) 0.59 0.82 years of working in icu 2.83(0.42) 1.00 0.48 education bachelor high diploma secondary diploma proximity mean (sd) 2.42(0.64) 2.82(0.42) 2.74(0.79) 1.325 0.284 years of working 2.69(057) 1.123 0.214 years of working in icu 2.69(057) 1.536 0.420 education bachelor high diploma secondary diploma assurance mean (sd) 2.51(0.45) 2.76(0.40) 2.67(0.45) 0.919 0.412 years of working 2.67(0.42) 0.565 0.849 years of working in icu 2.67(0.42) 0.928 0.545 education bachelor high diploma secondary diploma comfort mean (sd) 2.56(0.90) 3.16(0.67) 2.50(1.06) 2.085 0.145 years of working 2.87(0.84) 0.80 0.653 years of working in icu 2.87(0.84) 0.84 0.61 *p<0.05 fouly, debee, and elnaeem (2022) 124 p-issn: 1858-3598  e-issn: 2502-5791 study's aim the privacy and confidentiality of responses considered during data collection. finally, the participants had the right to withdraw from the study at any time without a negative impact on them. results the distribution of sociodemographic characteristics of the 28 critical care nurses reflects their ages range 22 to 42 years old, 50% of the respondents aged 22 to 26 years old, 32.1% aged 27 to 31 years old, while 17.7% were aged from 32to 42 years old. those who graduated from a high nursing diploma accounted for 53/5%, while bachelor was 28.6%, and 17.9% from secondary diploma. the work experience reflects that two-thirds have up to five years’ experience, 17.8% up to 10 years, and 17.9% up to 19 years. however, 75%, 10.7%, and 14.3% have up to six, 12, and 19-years’ experience in the critical care nursing field, respectively. the relationship between the sociodemographic items and family needs revealed a statically significant relationship between support needs and working hours and, years of icu experiences (p<0.03 and p<0.01), respectively. however, the other items of family needs did not show any significant relationship (table 1). appendix 1 shows the nurses’ perspectives toward family support needs. it reflects a significant difference before and after receiving the educational program (p=0.00). there is dramatic improvement in the support items before and after application of the educational program. the improvements occurring in very important items from the nurses' perspectives are to know the expected outcomes (32.1% to 67.9%); to have explanations of the environment (10.7% to 67.9%); to talk to the doctor every day (25.0% to 50.0%); to have visiting hours changed for special conditions (14.3% to 60.7%); to have directions as to what to do at bedside (25.0% to 64.3%); and to visit at any time (7.1% to 53.6%). however, there are three items (5, 7, 11) which showed significance (p=0.000) in the opposite direction in which the correct answers decreased instead of increased. the nurses' perspectives toward family information needs (appendix 2) reflect a significant difference (p=0.00). it showed great improvement in the information items to be very important in the following: to know about the types of staff members taking care of the patient, to know how the patient is being treated medically, to have a place to be alone while in the hospital, and to have someone to help with financial problems. before the educational program, the score was 17.9%, 21.4% and 21.4%, and after receiving of the educational program the posttest the score was 57.1%, 60.7%, and 53.6%, respectively. the proximity/closeness needs of the family needs include nine items, as shown in appendix 3. the item considered important is “to have another person with you when visiting the critical care unit,” and very important items are “to be assured it is all right to leave the hospital for a while,” “to talk to the same nurse every day,” and “to be told about other people that could help with problems.” the pretest scores were 32.1%, 10.7%, 3.6%, and 28.6% and after posttest the scores were 46.4%, 39.3%, 25.0%, and 39.3%, respectively. there was a statistically significant difference (p=0.000) except in four items (1, 3, 6, 9), but the before training test was better than after. family assurance needs include seven items and showed improvement after applying for the program regarding important and very important. the pretest score for the items “to be told about transfer plans while they are being made,” “to be told about someone to help with family problems,” “to have explanations given that are understandable,” “to have visiting hours start on time,” “to be told about chaplain services,” “to help with patient's physical care,” and “to be called at home about changes in the patient's condition” were 35.7%, 14.3%, 35.7%, 3.6%, 14.3%, 3.6% and 3.6%, respectively, while the posttest scores were 46.4%, 42.9%, 50.0%, 53.6%, 35.7%, 35.7% and 39.3%. it showed a statistically significant difference (p=0). the family comfort needs include seven items and showed improvement after applying the educational program. in these items perceived as important and very important were: “to receive information about the patient at least once a day,” “to feel that the hospital personnel care about the patient,” “to know specific facts concerning the patient's progress,” “to see the patient frequently,” “to have comfortable furniture in table 2 comparison of the total mean of family needs items before and after applying for the educational program t-test mean (sd) p value support needs (before) support needs (after) 21.31 40.86 2.64(0.65) 3.10(0.40) 0.00 information needs (before) information needs (after) 35.37 40.61 2.83(0.42) 3.29 (0.42) 0.00* proximity needs (before) proximity needs (after) 24.97 33.17 2.69(0.57) 3.02(0.48) 0.00* assurance needs (before) assurance needs (after) 33.21 38.24 2.67(0.42) 3.03(0.41) 0.00* comfort needs (before) comfort needs (after) 26.46 28.22 3.09(0.87) 3.37(0.63) 0.00* * p-value = 0 significant jurnal ners http://e-journal.unair.ac.id/jners 125 the waiting room,” and “to have a waiting room near the patients.” the scores before intervention were 35.7%, 32.1%, 32.1%, 28.6%, and 25.0%, and after intervention were 60.8%, 75.0%, 75.0%, 67.9%, and 50.0%, respectively. there was a statistically significant difference (p=0). the family needs items' total means include support, information, proximity, assurance, and comfort. all items showed a statistically significant difference after the application of the educational program (table 2). discussions half of the nurses who participated in this study were aged 22-26 years old. similarly, the egyptian study by abdel-aziz, ahmed and younis (2017) showed most nurses aged 20-30 (abdel-aziz, ahmed and younis, 2017). however, the education level and experience of work were more than our participants. the difference may be related to the variety of participant icus as the authors collected the sample from neurological and anesthesia and medical icus. our participants were younger due to the innovation establishment of the women's health icu. moreover, in the same age category, most nurses were aged up to 30 years, bachelor’s degree, and years of experience up to five years (abd el-aziz basal, 2017). there was a dramatic improvement in the nurses' perception of family support needs after applying the educational program. the most significant statements perceived by the nurses were: “to know the expected outcomes,” which changed after the training program from one-third to two-thirds; “to have explanations of the environment before going into critical care unit for first time” which changed from only 10% to more than two-thirds; “to have directions as to what to do at bedside” from one-fourth to more than two-thirds; and “to talk to the doctor every day” from one-fourth to half. correspondingly, abdel-aziz, ahmed and younis (2017) reported the important perceived support needs were “to know how the patient was being treated” and “to talk to the doctor every day.” moreover, shorofi et al. (2016) confirmed the important statement was “to have directions regarding what to do at the bedside.” the mentioned studies reported the perceived needs based on a survey that reflected nurses' primary perceived needs while our study improved the perceived needs based on the educational program (shorofi et al., 2016). regarding the family information needs, our study revealed that the nurses' perspectives showed a remarkable improvement toward family information needs with a statistically significant difference after receiving of the educational program. however, before the training program, one-fifth of nurses perceived that the statement “to know how the patient is being treated medically” is very important, while, after training, the perception changed to two-thirds of nurses acknowledged this statement as very important. the perceived information after training matches previous studies by naderi et al. (2013) and abdel-aziz, ahmed and younis (2017), which reported that getting information about a patient's state is one of the very important family’s needs (naderi et al., 2013; abdelaziz, ahmed and younis, 2017). in the same line, gundo et al. (2014) and gaeeni et al. (2015) reported that most nurses perceived the need for “knowledge about the patients' treatment” as the utmost important needs of family members (gundo et al., 2014; gaeeni et al., 2015). in the same line, scott, thomson, and shepherd (2019) confirmed regarding the importance toward icu patients' family needs, especially the need for more information and reassurance (scott, thomson and shepherd, 2019). however, the healthcare providers' perceived needs almost did not meet and, consequently, will negatively affect those families. whereas there is some evidence that procedures established on the providing of proper information in icu could effectively reduce worry and increase satisfaction. therefore, our study assessed the nurses' perspectives toward the family needs of the maternal critically ill cases and provided an educational program, as well as the family needs of maternal icu cases. the findings of the current study regarding the proximity (closeness) and assurance needs of the family showed a statistically significant difference, reflecting an improvement of the nurses’ perspectives after receiving the educational program. the important statements were: “to have another person with you when visiting the critical care unit” which changed from almost onethird to almost 50%; “to be assured it is all right to leave the hospital for a while” changed from two-fifths to half; and “to talk to the same nurse every day” changed from one-fifth to one-third. however, the very important statement was “to be told about other people that could help with problems," which changed from more than one-fourth to almost two-fifth. on the other hand, two statements stayed in the same perception level as very important and important without any change, “to have a bathroom near the waiting area” and “to be alone at any time,” respectively. however, according to nurses' perspectives, the assurance needs revealed a statistically significant difference after applying the fouly, debee, and elnaeem (2022) 126 p-issn: 1858-3598  e-issn: 2502-5791 educational program (p=0.000). these items were: “to be told about transfer plans while they are being made;” “to be told about someone to help with family problems;” “to have explanations given that are understandable;” “to have visiting hours start on time;” “to be told about chaplain services;” “to help with patient's physical care;” and “to be called at home about changes in the patient's condition,” which reflected that our study objectives achieved through the dramatic change of nurses' perspective to be more favorable toward family needs. compared to similar studies reported by gaeeni et al. (2015) and abdel-aziz, ahmed and younis (2017), it reflected similar findings of nurses’ perspectives that the important family proximity and assurance needs were focused on changes in the patient's condition, visiting hours and honest answers to questions, the transfer plans, and called at home regarding patient's condition. this similarity interpreted that the family members need to be updated regarding their patient’s conditions. the findings of comfort needs showed a statistically significant difference in all comfort items about “receiving information about the patient daily, feeling that the hospital cares about the patient, facts concerning the patient's progress, frequently seeing the patient, availability of comfortable furniture in the waiting room, and to have a waiting room near the patient”, which reflected a dramatic change after the application of the educational program. contradictory, the findings of previous studies by shorofi et al. (2016) and abdel-aziz et al. (2017) reported that the minority of nurses confirmed that “to feel accepted by the hospital staff” and “to have visiting hours changed for specific conditions” were important needs. this minor percentage was interpreted by the author by inadequate preparation or education and nurses' experience to manage the family needs in emergencies, which supports our study's objectives that the nurses need an educational program to increase their awareness regarding family needs. however, conclusively the family needs of support, information, proximity, assurance, and comfort showed a statistically significance difference after applying the educational program. correspondingly, the other literature scope studies highlighted that the highest everyday important family needs were information and assurance, followed by proximity, comfort, and support, respectively (al‐ mutair et al., 2013; scott, thomson and shepherd, 2019). in the end, the findings of the current study presented all the items of the family needs from nurses’ perspectives that family members need reliable and accurate information and availability of proximity regarding the icus' patient. also, the needs of support, assurance, and comfort from the health care providers, especially nurses, which were supported by a previous study conducted by (davidson, 2009). limitations of the research regarding the research design did not involve a control group so that the change in nurses' perspectives and awareness toward family needs was solely based on the educational program being held through the study. the covid-19 crisis appeared during the data collection and affected the number of participants from nurses and increased obstacles to collect data from other icus occupied by patients with coronavirus. conclusions the study concludes that the educational program achieved the objective of dramatically improving nurses' perspectives toward family needs. on the other side, the educational program increased nurses' awareness regarding that issue, which was not one of our objectives. the nurse’s awareness was confirmed orally when they acknowledged that our program was useful for them. in addition, the educational background and work experiences in icus were positive factors to improve nurses' perspectives within a short time. the regular educational program application in all icu types will enhance nurses' ability to understand the family needs and consider these needs to facilitate the relationship between healthcare providers and family members. also, it will help to enhance the services introduced in the icus. however, this study was done in a female icu, so the concern of family needs focused on one side. therefore, the study needs to expand to include the other nurses' perspectives who care for male patients and their family members, most of the time by males. references abd el-aziz basal, a. (2017) ‘critical care nurses&apos; knowledge, practice, obstacles and helpful measures towards palliative care for critically ill patients’, american journal of nursing science, 6(4), p. 293. doi: 10.11648/j.ajns.20170604.13. abd el wareth, m. s. and elcokany, n. m. (2019) ‘perception of intensive care unit nurses toward family engagement in patients’ care’. abdel-aziz, a. l., ahmed, s. e. and younis, g. a. (2017) ‘family needs of critically ill patients admitted to the intensive care unit, comparison of nurses and family perception’, am j nurs sci, 6(4), pp. 333–346. al‐mutair, a. s. et al. (2013) ‘family needs and involvement in the intensive care unit: a literature review’, journal of clinical nursing, 22(13–14), pp. 1805–1817. alsharari, a. f. (2019) ‘the needs of family members of patients admitted to the intensive care unit’, patient preference and adherence, 13, pp. 465–473. doi: 10.2147/ppa.s197769. bandari, r. et al. (2015) ‘information and support needs of adult family members of patients in intensive care units: an iranian perspective’, journal of research in nursing, 20(5), pp. 401–422. buckley, p. and andrews, t. (2011) ‘intensive care nurses’ knowledge jurnal ners http://e-journal.unair.ac.id/jners 127 of critical care family needs’, intensive and critical care nursing, 27(5), pp. 263–272. davidson, j. e. (2009) ‘family-centered care: meeting the needs of patients’ families and helping families adapt to critical illness’, critical care nurse, 29(3), pp. 28–34. flaatten, h. (2012) ‘the present use of quality indicators in the intensive care unit’, acta anaesthesiologica scandinavica, 56(9), pp. 1078–1083. gaeeni, m. et al. (2015) ‘informational support to family members of intensive care unit patients: the perspectives of families and nurses’, global journal of health science, 7(2), p. 8. ghabeesh, s. h. al et al. (2014) ‘exploring the self-perceived needs for family members having adult critically ill loved person: descriptive study’, health, 06(21), pp. 3005–3012. doi: 10.4236/health.2014.621338. gundo, r. et al. (2014) ‘comparison of nurses’ and families’ perception of family needs in critical care unit at referral hospitals in malawi’, open journal of nursing, 2014. hashim, f. and hussin, r. (2012) ‘family needs of patient admitted to intensive care unit in a public hospital’, procedia-social and behavioral sciences, 36, pp. 103–111. iranmanesh, s. et al. (2014) ‘patient family needs : perception of iranian intensive care nurses and families of patients admitted to icus patient family needs : perception of iranian intensive care nurses and families of patients admitted to icus’, asian journal of nursing education and research, 4(3), pp. 290–297. doi: 10.5958/2349-2996. khalaila, r. (2013) ‘patients’ family satisfaction with needs met at the medical intensive care unit’, journal of advanced nursing, 69(5), pp. 1172–1182. mitchell, m. et al. (2009) ‘positive effects of a nursing intervention on family-centered care in adult critical care’, american journal of critical care, 18(6), pp. 543–552. molter, n. and js, l. (1995) ‘critical care family needs inventory’, heart and lung. doi: 10.1037/t37619-000. naderi, m. et al. (2013) ‘health literacy among adults of isfahan, iran’, journal of health system research, 9(5), pp. 473–483. obringer, k., hilgenberg, c. and booker, k. (2012) ‘needs of adult family members of intensive care unit patients’, journal of clinical nursing, 21(11‐12), pp. 1651–1658. paul, r. g. and finney, s. j. (2015) ‘family satisfaction with care on the icu: essential lessons for all doctors’, british journal of hospital medicine, 76(9), pp. 504–509. scott, p., thomson, p. and shepherd, a. (2019) ‘families of patients in icu: a scoping review of their needs and satisfaction with care’, nursing open, 6(3), pp. 698–712. shorofi, s. a. et al. (2016) ‘psychosocial needs of families of intensive care patients: perceptions of nurses and families’, nigerian medical journal: journal of the nigeria medical association, 57(1), p. 10. how to cite this article: fouly, h., debee, j., and elnaeem, m. m. a. (2022). ‘nurses’ perspectives of families ‘needs of the maternal critically ill cases in woman health hospital: an educational program’, jurnal ners, 17(2), pp. 121–130. doi: http://dx.doi.org/10.20473/jn.v17i2.34560 fouly, debee, and elnaeem (2022) 128 p-issn: 1858-3598  e-issn: 2502-5791 appendix i. family support needs from nurses’ perspectives before and after receiving the training program family needs items (items 1 to 14) support needs not important n (%) slightly important n (%) important n (%) very important n (%) to know the expected outcomes before after 2 (7.1) 0 (0) 5 (17.9) 0 (0) 12 (42.9) 9 (32.1) 9 (32.1) 19 (67.9) p value 0.000 to have explanations of the environment before going into the critical care unit for the first time before after p value 5 (17.9) 0 (0) 15 (53.6) 0 (0) 5 (17.9) 9 (32.1) 3 (10.7) 19 (67.9) 0.000 to talk to the doctor every day before after p value 6 (21.4) 0 (0) 8 (28.6) 1 (3.6) 7 (25.0) 13 (46.4) 7 (25.0) 14 (50.0) 0.000 to have a specific person to call at the hospital when unable to visit before after p value 9 (32.1) 2 (7.1) 4 (14.3) 7 (25.0) 6 (21.4) 11 (39.3) 9 (32.1) 8 (28.6) 0.000 to have questions answered honesty before after p value 1 (3.6) 2 (7.1) 2 (7.1) 11 (39.3) 14 (50.0) 12 (42.9) 11 (39.3) 3 (10.7) 0.000 to have visiting hours changed for special conditions before after p value 13 (46.4) 0 (0) 5 (17.9) 1 (3.6) 6 (21.4) 10 (35.7) 4 (14.3) 17 (60.7) 0.000 to have talked about feelings about what happened before after p value 5 (17.9) 9 (32.1) 9 (32.1) 8 (28.6) 11 (39.3) 9 (32.1) 3 (10.7) 2 (7.1) 0.000 to have good food available in the hospital happen before after p value 3 (10.7) 0 (0) 8 (28.6) 5 (17.9) 8 (28.6) 20 (71.4) 9 (32.1) 3 (10.7) 0.000 to have directions as to what to do at the bedside before after p value 6 (21.4) 0 (0) 8 (28.6) 0 (0) 7 (25.0) 10 (35.7) 7 (25.0) 18 (64.3) 0.000 to visit at any time before after p value 14 (50.0) 1 (3.6) 8 (28.6) 2 (7.1) 4 (14.3) 10 (35.7) 2 (7.1) 15 (53.6) 0.000 to know which staff members could give what type of information time before after p value 4 (14.3) 9 (32.1) 8 (28.6) 10 (35.7) 14 (50.0) 5 (17.9) 2 (7.1) 4 (14.3) 0.000 to have friends nearby for support before after p value 9 (32.1) 2 (7.1) 10 (35.7) 4 (14.3) 5 (17.9) 14 (50.0) 4 (14.3) 8 (28.6) 0.000 to know why things were done for the patient before after p value 2 (7.1) 0 (0) 6 (21.4) 5 (17.1) 14 (50.0) 16 (57.1) 6 (21.4) 7 (25.6) 0.000 to feel there is hope before after p value 1 (3.6) 0 (0) 0 (0) 5 (17.1) 10 (35.7) 5 (17.1) 17 (60.7) 18 (64.3) 0.000 jurnal ners http://e-journal.unair.ac.id/jners 129 appendix ii family information needs from nurses’ perspectives before and after receiving the training program family needs items (items 15 to 23) information needs not important n (%) slightly important n (%) important n (%) very important n (%) to know about the types of staff members taking care of the patient before after p value 2 (7.1) 0 (0) 10 (35.7) 1 (3.6) 11 (39.3) 11 (39.3) 5 (17.9) 16 (57.1) 0.000 to know how the patient is being treated medically before after p value 2 (7.1) 0 (0) 6 (21.4) 5 (17.9) 14 (50.0) 6 (21.4) 6 (21.4) 17 (60.7) 0.000 to be assured that the best care possible is being given to the patient before after p value 1 (3.6) 0 (0) 0 (0) 2 (7.1) 11 (39.3) 11 (39.3) 16 (57.1) 15 (53.6) 0.000 to have a place to be alone while in the hospital before after p value 11 (39.3) 0 (0) 11 (39.3) 0 (0) 4 (14.3) 9 (32.1) 2 (7.1) 19 (67.9) 0.000 to know precisely what is being done for the patient before after p value 3 (10.7) 3 (10.7) 10 (35.7) 8 (28.6) 7 (25.0) 11 (39.3) 8 (28.6) 6 (21.4) 0.000 to feel accepted by the hospital staff before after p value 1 (3.6) 1 (3.6) 5 (17.9) 4 (14.3) 10 (35.7) 8 (28.6) 12 (42.9) 15 (53.6) 0.000 to have someone to help with financial problems before after p value 0 (0) 0 (0) 11 (39.3) 1 (3.6) 11 (39.3) 12 (42.9) 6 (21.4) 15 (53.6) 0.000 to have a telephone near the waiting room before after p value 6 (21.4) 0 (0) 5 (17.9) 5 (17.9) 13 (46.4) 13 (46.4) 4 (14.3) 10 (35.7) 0.000 to have a pastor visit before after p value 14 (50.0) 2 (7.1) 7 (25.0) 4 (14.3) 3 (10.7) 12 (42.9) 4 (14.3) 10 (35.7) 0.000 fouly (2022) 130 p-issn: 1858-3598  e-issn: 2502-5791 appendix iii family proximity and assurance needs from nurses’ perspectives before and after receiving the training program family needs items (items 24 to 32) proximity or closeness not important n (%) slightly important n (%) important n (%) very important n (%) to talk about the possibility of the patient's death before after p value 3 (10.7) 3 (10.7) 3 (10.7) 8 (28.6) 15 (53.6) 11 (39.3) 7 (25.0) 6 (21.4) 0.000 to have another person with you when visiting the critical care unit before after p value 10 (35.7) 0 (0) 6 (21.4) 9 (32.1) 9 (32.1) 13 (46.4) 3 (10.7) 6 (21.4) 0.000 to have someone concerned with patient health before after p value 2 (7.1) 5 (17.9) 1 (3.6) 10 (35.7) 10 (35.7) 7 (25.0) 15 (53.6) 6 (21.4) 0.000 to be assured it is all right to leave the hospital for a while before after p value 8 (28.6) 0 (0) 5 (17.9) 3 (10.7) 12 (42.9) 14 (50.0) 3 (10.7) 11 (39.3) 0.000 to talk to the same nurse every day before after p value 14 (50.0) 3 (10.7) 7 (25.0) 8 (28.6) 6 (21.4) 10 (35.7) 1 (3.6) 7 (25.0) 0.000 to feel it is all right to cry before after p value 5 (17.9) 10 (35.7) 9 (32.1) 12 (42.9) 9 (32.1) 4 (14.3) 5 (17.9) 2 (7.1) 0.000 to be told about other people that could help with problems before after p value 1 (3.6) 0 (0) 6 (21.4) 7 (25.0) 13 (46.4) 10 (35.7) 8 (28.6) 11 (39.3) 0.000 to have a bathroom near the waiting area before after p value 1 (3.6) 2 (7.1) 4 (14.3) 1 (3.6) 15 (53.6) 17 (60.7) 8 (28.6) 8 (28.6) 0.000 to be alone at any time before after p value 9 (32.1) 0 (0) 10 (35.7) 2 (7.1) 8 (28.6) 8 (28.6) 27 (96.4) 18 (64.3) 0.000 family assurance needs items (items 33 to 39) to be told about transfer plans while they are being made before after p value 7 (25.0) 6 (21.4) 6 (21.4) 5 (17.9) 10 (35.7) 13 (46.4) 5 (17.9) 4 (14.3) 0.000 to be told about someone to help with family problems before after p value 15 (53.6) 4 (14.3) 6 (21.4) 5 (17.9) 4 (14.3) 12 (42.9) 3 (10.7) 7 (25.0) 0.000 to have explanations given that is understandable before after p value 1 (3.6) 0 (0) 3 (10.7) 3 (10.7) 14 (50.0) 11 (39.3) 10 (35.7) 14 (50.0) 0.000 to have visiting hours start on time before after p value 3 (10.7) 0 (0) 10 (35.7) 1 (3.6) 14 (50.0) 12 (42.9) 1 (3.6) 15 (53.6) 0.000 to be told about chaplain services before after p value 3 (10.7) 3 (10.7) 8 (28.6) 8 (28.6) 3 (10.7) 7 (25.0) 4 (14.3) 10 (35.7) 0.000 to help with patient's physical care before after p value 6 (21.4) 0 (0) 9 (32.1) 3 (10.7) 12 (42.9) 15 (53.6) 1 (3.6) 10 (35.7) 0.000 vol 6 no 1 april 2011_akreditasi 2013.indd 1 peningkatkan perilaku pasien dalam tatalaksana diabetes melitus menggunakan model behavioral system (changing the patient’s behavior in diabetes mellitus management by application behavioral system model) nur aini*, widati fatmaningrum**, ah. yusuf*** *stikes insan unggul surabaya, jl. raya kletek no. 4 taman sidoarjo e-mail: aini_anindya@yahoo.com **fakultas kedokteran unair surabaya ***fakultas keperawatan unair surabaya abstract introduction: diabetic treatment need a very long time that make most of patient doesn’t obey. one of the methods can be used to improve patient’s compliance is nursing care model behavioral system by dorothy e. johnson with its interventions are motivation and education. the objective of this study was to analyze the differences between knowledge, attitude, practice, blood sugar fasting and 2 hours post prandial (pp) of diabetic patients. method: this experimental research using randomized control group pretest posttest design. sample used 30 persons divided into 2 groups. motivation and education are given 4 times in period of 1 month by visiting to the patient’s house. data were collected by questionnaires and observation then analyzed by wilcoxon with α < 0.05. result: results showed that after intervention, treatment group who haved good knowledge were 15 persons (100%), good attitude were 8 persons (53.3%), moderate were 7 persons (46.7%), good practice were 11 persons (73.3%), moderate were 3 persons (20%) and less was 1 person (6.7%). blood sugar fasting and 2 hours post prandial (pp) decreased were 13 persons (86.7%). analysis using wilcoxon showed that result was signifi cant. discussion: it can be concluded that motivation and education can improve knowledge, attitude, practice, decrease blood sugar fasting and 2 hours post prandial (pp). it was suggested to optimalized education and giving motivation due to improving support and awareness of patient to implement diabetes mellitus treatment. keywords: knowledge, attitude, practice, blood sugar, motivation and education pendahuluan diabetes mellitus (dm) merupakan salah satu penyakit yang prevalensinya semakin meningkat dari tahun ke tahun. world health organization (who) memprediksi kenaikan jumlah pasien diabetes di indonesia dari 8,4 juta pada tahun 2000 menjadi sekitar 21,3 juta pada tahun 2030, bahkan indonesia menempati urutan keempat di dunia sebagai jumlah penderita diabetes mellitus terbanyak setelah india, china, dan amerika (pratiwi, 2007). pengobatan diabetes memerlukan waktu yang lama (karena diabetes merupakan penyakit menahun yang akan diderita seumur hidup) dan sangat kompleks (tidak hanya membutuhkan pengobatan tetapi juga perubahan gaya hidup) sehingga seringkali pasien tidak patuh dan cenderung menjadi putus asa dengan program terapi yang lama, kompleks dan tidak menghasilkan kesembuhan. menurut asti (2006) umumnya penderita diabetes patuh berobat kepada dokter selama ia masih menderita gejala yang subjektif dan mengganggu hidup rutinnya sehari-hari, begitu ia bebas dari keluhan-keluhan tersebut maka kepatuhannya untuk berobat berkurang (pratiwi, 2007). hasil penelitian di beberapa negara, ketidakpatuhan pasien diabetes dalam berobat mencapai 40–50%. menurut laporan who pada tahun 2003, kepatuhan rata-rata pasien pada terapi jangka panjang terhadap penyakit kronis di negara maju hanya sebesar 50% jurnal ners vol. 6 no. 1 april 2011: 1–10 2 dan di negara berkembang jumlah tersebut bahkan lebih rendah. tahun 2006 jumlah penderita diabetes di indonesia mencapai 14 juta orang, dari jumlah itu baru 50% penderita yang sadar mengidap dan sekitar 30% di antaranya melakukan pengobatan secara teratur (delamater, 2009; pratiwi, 2007). h a s i l p e n g u m p u l a n d a t a a w a l yang dilakukan di rumkital dr. ramelan surabaya tanggal 15–16 april 2010 pada 15 pasien didapatkan pengetahuan baik 100%, sikap sedang 47% (7 orang) dan sikap baik 53% (8 orang), praktik kurang 6% (1 orang), praktik sedang 40% (6 orang) dan praktik baik 54% (8 orang), meskipun pengetahuan pasien sudah baik (pengetahuan baik ini mungkin disebabkan karena pasien sudah sering mendapatkan penyuluhan dari rumah sakit), namun praktik pasien yang baik hanya 54% sehingga pasien perlu dimotivasi lagi supaya lebih patuh dalam pengobatan diabetes. ketidakpatuhan pasien dalam melakukan tatalaksana diabetes akan memberikan dampak negatif yang sangat besar meliputi peningkatan biaya kesehatan dan komplikasi diabetes. komplikasi diabetes terjadi pada semua organ dalam tubuh yang dialiri pembuluh darah kecil dan besar dengan penyebab kematian 50% akibat penyakit jantung koroner dan 30% akibat gagal ginjal. diabetes juga menyebabkan kecacatan, sebanyak 30% penderita mengalami kebutaan akibat komplikasi retinopati dan 10% harus menjalani amputasi tungkai kaki, bahkan diabetes membunuh lebih banyak dibandingkan dengan hiv/aids (soegondo, 2008). tujuan utama pengobatan segala bentuk diabetes adalah untuk mencapai serta mempertahankan glukosa darah dalam keadaan normal (normoglikemi) dengan harapan dapat mencegah komplikasinya. menurut konsensus perkeni (2006), pilar penatalaksanan diabetes di antaranya meliputi terapi gizi medis/pengaturan makan, latihan jasmani, intervensi farmakologis dan edukasi. namun itu belum cukup untuk menjamin keberhasilan suatu terapi jika tidak diikuti dengan kepatuhan pasien. menurut mishali dari departemen psikologi universitas tel aviv, dari 21 studi atau penelitian dengan pemberikan intervensi yang bertujuan untuk meningkatkan kepatuhan berobat pada pasien diabetes tipe-2 ternyata tidak memberikan hasil yang signifi kan. ketidakpatuhan pasien beserta alasannya ini masih sedikit dipahami (mishali et al., 2007). begitu pula yang diungkapkan oleh tjokroprawiro (1997), walaupun pasien diabetes telah mendapatkan pengobatan oad, masih banyak pasien tersebut mengalami kegagalan. p e r a w a t m e r u p a k a n f a k t o r y a n g mempunyai peran penting dalam merubah perilaku pasien sehingga terjadi kondisi keseimbangan (equilibrium) dalam diri pasien. salah satu metode yang dapat digunakan adalah dengan model asuhan keperawatan behavioral system model dari dorothy e. johnson. teori behavioral system model memandang individu sebagai sistem perilaku yang selalu ingin mencapai keseimbangan dan stabilitas, baik di lingkungan internal atau eksternal, juga memiliki keinginan dalam mengatur dan menyesuaikan dari pengaruh yang ditimbulkannya (tommey dan alligood, 2006). intervensi yang digunakan untuk merubah perilaku pasien dalam behavioral system model yaitu regulasi eksternal, misalnya dengan cara membatasi perilaku dan menghambat respons perilaku yang tidak efektif, merubah elemen structure dengan tujuan untuk memotivasi pasien dengan cara memberikan pendidikan kesehatan dan konseling dan memenuhi kebutuhan subsistem dengan cara nurture, protect dan stimulate (tommey dan alligood, 2006). pemberian motivasi dapat memperbaiki perilaku pasien terhadap pengobatan karena dalam hal ini kita menanamkan kesadaran individu untuk mentaati pengobatan didasari adanya keinginan yang timbul dari dirinya sendiri. hal ini sesuai dengan konsep yang diciptakan oleh johnson bahwa untuk merubah perilaku seseorang dapat dilakukan dengan cara memotivasi drive menjadi action. aplikasi teori ini untuk memperbaiki perilaku pasien diabetes mellitus belum diteliti, oleh karena itu peneliti ingin mengadakan penelitian tentang perbedaan pengetahuan, sikap dan praktik pasien dalam tatalaksana dm akibat pemberian motivasi dan edukasi. upaya meningkatkan perilaku pasien diabetes melitus (nur aini) 3 bahan dan metode jenis penelitian yang digunakan adalah eksperimen dengan rancangan randomized control group pretest posttest design karena penelitian ini untuk mengetahui perbedaan pengetahuan, sikap, praktik serta gula darah puasa dan 2 jam pp pasien diabetes sebelum dan sesudah pemberian motivasi dan edukasi. populasi pada penelitian ini adalah pasien diabetes mellitus di poli diabet rumkital dr. ramelan surabaya sejumlah 40 orang pada bulan mei 2010. sampel sebanyak 13 orang untuk masing-masing kelompok perlakuan dan kontrol (menurut penghitungan rumus dari kasiulevicius et al., 2006) diperoleh melalui teknik simple random sampling. variabel intervensi dalam penelitian ini adalah pemberian motivasi dan edukasi. sedangkan variabel outputnya adalah pengetahuan, sikap dan praktik pasien dalam tatalaksana dm serta gula darah puasa dan 2 jam pp. instrumen yang digunakan dalam penelitian ini adalah kuesioner pengetahuan, sikap dan praktik serta alat pemeriksaan gula darah (pemeriksaan gula darah dilakukan di laboratorium). lama penelitian adalah 1 bulan, peneliti menggunakan batas waktu ini karena berdasarkan penelitian yang dilakukan phillippa lally dari university college london yang dipublikasikan dalam european journal of social psychology, rata-rata seseorang dapat beradaptasi dengan perilaku barunya dalam waktu 18–254 hari, sedangkan menurut dr. maxwell (ahli bedah plastik) manusia memerlukan waktu sekitar 3 minggu untuk beradapatasi terhadap perubahan (depraxis, 2010). langkah-langkah dalam pengumpulan data adalah membagi responden menjadi dua kelompok yaitu perlakuan dan kontrol, melakukan pre test pada kedua kelompok, memberikan intervensi berupa pemberian motivasi dan edukasi pada kelompok perlakuan yang dilakukan dengan cara kunjungan rumah, sebanyak 4 kali dalam waktu 1 bulan, lama kunjungan antara 30–60 menit dan melakukan post test pada kedua kelompok. data yang diperoleh kemudian diolah menggunakan wilcoxon signed rank test untuk variabel pengetahuan, sikap dan praktik. sedangkan variabel gula darah diuji dengan paired t-test. sebelum dilakukan uji t, akan dilakukan uji normalitas dengan shapiro wilk (karena sampel < 50 orang), bila tidak normal data akan diuji dengan wilcoxon signed rank test. hasil pengetahuan responden kelompok perlakuan pada saat pre test dan post test adalah baik masing-masing sebesar 15 orang (100%). pengetahuan kelompok kontrol yang terbesar pada saat pre test dan post test adalah baik masing-masing sebesar 13 orang (86,7%). hasil uji statistik pada kelompok perlakuan menunjukkan ada perbedaan signifikan pengetahuan sebelum dan sesudah intervensi sedangkan pada kelompok kontrol tidak ada perbedaan meskipun pengetahuan post test responden ada yang mengalami peningkatan. sikap responden kelompok perlakuan yang terbesar pada saat pre test adalah sedang sebesar 13 orang (86,7%). setelah pemberian intervensi berubah menjadi baik sebesar 8 orang (53,3%). sikap responden kelompok kontrol yang terbesar pada saat pre tabel 1. pengetahuan responden dalam tatalaksana dm di poli diabet rumkital dr. ramelan surabaya mei 2010 perlakuan kontrol pre post pre post mean 85,6 96,06 85,13 85,55 negative ranks 15 0,001 3 12 0,102 positive ranks ties ranks sig-2 tailed (p) jurnal ners vol. 6 no. 1 april 2011: 1–10 4 test adalah sedang sebesar 11 orang (73,3%). saat post test yang terbesar adalah sedang sebesar 10 orang (66,7%). hasil uji statistik pada kelompok perlakuan menunjukkan ada perbedaan signifi kan sikap sebelum dan sesudah intervensi, sedangkan pada kelompok kontrol tidak menunjukkan perbedaan. praktik responden kelompok perlakuan yang terbesar pada saat pre test adalah sedang sebesar 9 orang (60%). setelah pemberian intervensi berubah menjadi baik sebesar 11 orang (73,3%). praktik responden kelompok kontrol yang terbesar pada saat pre test adalah sedang sebesar 7 orang (46,7%). saat post test yang terbesar adalah baik sebesar 7 orang (46,7%). hasil uji statistik menunjukkan pada kelompok perlakuan dan kontrol ada perbedaan signifi kan praktik pre test dan post test. gula darah puasa responden kelompok perlakuan mengalami penurunan dari 224 gr/dl menjadi 156 gr/dl, demikian pula pada kelompok kontrol mengalami penurunan dari 224 gr/dl menjadi 190 gr/dl. hasil uji statistik pada kelompok perlakuan menunjukkan ada perbedaan signifi kan gula darah sebelum dan sesudah intervensi, sedangkan pada kelompok kontrol tidak ada perbedaan signifi kan meskipun gula darah post test mengalami penurunan. gula darah 2 jam pp responden kelompok perlakuan mengalami penurunan dari 239 gr/dl menjadi 226 gr/dl, sedangkan pada kelompok kontrol mengalami peningkatan dari 232 gr/dl tabel 2. sikap responden dalam tatalaksana dm di poli diabet rumkital dr. ramelan surabaya mei 2010 perlakuan kontrol pre post pre post mean 46,26 48,6 46,53 46,86 negative ranks 1 12 2 0,007 3 12 0,102 positive ranks ties ranks sig-2 tailed (p) tabel 3. praktik responden dalam tatalaksana dm di poli diabet rumkital dr. ramelan surabaya mei 2010 perlakuan kontrol pre post pre post mean 68,53 82,86 68,87 72 negative ranks 15 0,001 5 10 0,039 positive ranks ties ranks sig-2 tailed (p) tabel 4. gula darah puasa responden dalam tatalaksana dm di poli diabet rumkital dr. ramelan surabaya mei 2010 perlakuan kontrol pre post pre post mean (gr/dl) 224 156 224 190 negative ranks 13 2 0,035 4 11 0,320 positive ranks ties ranks sig-2 tailed (p) upaya meningkatkan perilaku pasien diabetes melitus (nur aini) 5 menjadi 248 gr/dl. hasil uji statistik pada kelompok perlakuan menunjukkan ada perbedaan signifikan gula darah 2 jam pp sebelum dan sesudah intervensi, sedangkan pada kelompok kontrol tidak ada perbedaan. pembahasan hasil penelitian menunjukkan bahwa ada perbedaan pengetahuan yang signifi kan pada kelompok perlakuan sebelum dan sesudah pemberian motivasi dan edukasi. peningkatan pengetahuan ini terjadi karena dalam pemberian motivasi ada materi edukasi tentang diabetes juga sehingga peningkatan pengetahuan yang terjadi adalah karena pemberian edukasi. peneliti memberikan edukasi tentang diabetes mellitus (dm) juga karena menurut dorothy e. johnson (perumus teori behavioral sytem model), dalam motivasi terkandung edukasi dan konseling. perbedaan pengetahuan juga terjadi pada kelompok kontrol, namun perbedaan ini tidak signifikan. peningkatan pengetahuan pada kelompok kontrol mungkin disebabkan karena mereka mendapatkan informasi dari sumber lain, karena pada kelompok kontrol tidak mendapatkan edukasi dari peneliti. pengetahuan responden kelompok kontrol yang baik tentang dm dan penatalaksanaannya ada 13 orang. pengetahuan yang baik ini terutama mengenai tatalaksana/pengobatan dm, penyebab peningkatan gula darah dan pantangan yang harus dihindari. bila dilihat dari hasil kuesioner, pengetahuan mereka yang masih kurang terutama mengenai gejala, penyebab penyakit, pengaturan makan, komplikasi dan setelah dikaji lebih jauh mereka juga belum memahami cara mengatur makan dan minum obat yang benar. seperti halnya kelompok kontrol, pengetahuan responden kelompok perlakuan tentang dm dan penatalaksanaannya (sebelum pemberian motivasi dan edukasi) juga sudah baik semua sebesar 15 orang. pengetahuan yang baik ini terutama mengenai tatalaksana/pengobatan dm, penyebab peningkatan gula darah dan pantangan yang harus dihindari. bila dilihat dari hasil kuesioner, pengetahuan mereka yang masih kurang terutama mengenai gejala, penyebab penyakit, pengaturan makan, komplikasi dan setelah dikaji lebih jauh ternyata beberapa responden kelompok perlakuan juga mempunyai pemahaman yang salah tentang obat diabetes dan tidak mengetahui cara mengatur makan yang benar. menurut mereka dengan banyak minum obat akan ketergantungan dan semakin memperparah penyakit. mengenai diet, mereka hanya tahu bahwa pasien dm tidak boleh makan manis, jumlah makan harus dikurangi dan banyak makan sayur, namun untuk pengaturan yang lebih detail terutama dalam hal kalori mereka tidak tahu karena penjelasan mengenai hal ini biasanya diberikan oleh ahli gizi sedangkan konsul gizi hanya diperuntukkan bagi pasien baru dan pasien yang gula darahnya tinggi. pengetahuan meningkat setelah diberikan motivasi dan edukasi tentang diabetes. edukasi yang diberikan peneliti meliputi: definisi, penyebab diabetes, gejala diabetes, komplikasi diabetes dan penatalaksanaan yang meliputi diit, olahraga dan obat. responden kelompok kontrol dan perlakuan yang pengetahuannya baik sebagian besar berjenis kelamin perempuan, lama sakit > 7 tahun, pendidikannya sltp sampai pt dan usia 60–65 tahun. jenis kelamin responden yang terbanyak memang perempuan sebesar 23 orang. berdasarkan data statistik tabel 5. gula darah 2 jam pp responden dalam tatalaksana dm di poli diabet rumkital dr. ramelan surabaya mei 2010 perlakuan kontrol pre post pre post mean (gr/dl) 239 226 232 248 negative ranks 13 2 0,047 4 11 0,280 positive ranks ties ranks sig-2 tailed (p) jurnal ners vol. 6 no. 1 april 2011: 1–10 6 penduduk jawa timur tahun 2007, jumlah penduduk perempuan di jawa timur lebih banyak daripada laki-laki. jumlah penduduk perempuan adalah 1.403.631 ribu sedangkan laki-laki 1.316.525 ribu dengan sex ratio 94, artinya dalam setiap 100 penduduk perempuan terdapat 94 penduduk laki-laki (badan pusat statistik, 2007). kelompok usia responden termasuk pada kelompok usia lanjut dini atau prasenium. jumlah ini dapat dimengerti karena proporsi jumlah penduduk khususnya yang berusia 55 tahun akan mengalami peningkatan oleh karena berhasilnya meningkatkan umur harapan hidup waktu lahir, serta meningkat dan membaiknya sosial ekonomi (departemen kesehatan ri, 1992). menurut who, kecepatan tumbuh lanjut usia (usia 60 tahun atau lebih) dua kali lipat dari 11% pada tahun 2006 menjadi 22% pada tahun 2050. pertumbuhan ini lebih cepat di negara berkembang dibanding negara maju, dalam lima dekade lebih dari 80% penduduk usia lanjut dunia hidup di negara berkembang dibanding 60% pada tahun 2005, ini menyebabkan jumlah penduduk usi lanjut lebih banyak dari anak-anak (joni, 2009). hal ini sesuai pula dengan penelitian yang dilakukan oleh pratiwi (2007) bahwa di negara berkembang orang dewasa yang berisiko terkena diabetes mellitus (dm) adalah usia 46–64 tahun. lama sakit responden terbanyak adalah > 7 tahun sebanyak 19 orang. hal ini dapat dimengerti karena dm adalah penyakit kronis. lamanya seseorang menderita penyakit dapat memberi gambaran mengenai patogenesis penyakit tersebut. salah satu faktor risiko dm adalah resistensi insulin yang dapat terjadi pada usia > 40 tahun dan dari penelitian yang dilakukan pratiwi (2007) didapatkan usia yang terbanyak terkena dm adalah > 45 tahun. r e s p o n d e n k e l o m p o k p e r l a k u a n yang berada pada usia lanjut dini atau masa prasenium dalam penelitian ini ternyata masih bisa menerima informasi dengan baik bila diberikan motivasi dan edukasi. ada dua pendapat mengenai umur yaitu: semakin tua makin bijaksana, semakin banyak informasi dan semakin banyak hal yang dikerjakan sehingga menambah pengetahuannya; tidak dapat mengajarkan kepandaian baru kepada orang yang sudah tua karena mengalami kemunduran baik fisik maupun mental (notoatmodjo, 2007). kemampuan belajar pada usia tua akan sedikit menurun tapi bukan berarti tidak bisa mempelajari hal-hal baru lagi (desmita, 2006). kemunduran kemampuan mental dan intelektual merupakan bagian dari proses penuaan organisme secara umum (desmita, 2006). hampir sebagian besar penelitian menunjukkan bahwa setelah mencapai puncak pada usia antara 45–55 tahun, kebanyakan kemampuan seseorang secara terus-menerus mengalami penurunan. hal ini juga berlaku bagi lansia. kemerosotan intelektual lansia ini pada umumnya merupakan sesuatu yang tidak dapat dihindarkan, disebabkan berbagai faktor seperti penyakit dan kecemasan atau depresi. tetapi kemampuan intelektual lansia tersebut pada dasarnya dapat dipertahankan salah satunya dengan menyediakan lingkungan yang dapat merangsang ataupun melatih keterampilan intelektual mereka. s e b a g i a n b e s a r r e s p o n d e n y a n g pendidikannya sltp sampai dengan pt ternyata pengetahuannya meningkat setelah diberikan motivasi dan edukasi. hal ini dapat dimengerti karena pendidikan memengaruhi motivasi dan proses belajar. makin tinggi pendidikan seseorang makin mudah orang tersebut untuk menerima informasi. walaupun sltp termasuk dalam kategori tingkat pendidikan rendah namun ternyata responden yang pendidikannya sltp masih bisa menerima informasi yang disampaikan. p e k e r j a a n d a n p e n d a p a t a n j u g a memengaruhi pengetahuan. masyarakat yang sibuk dengan kegiatan atau pekerjaan seharihari akan mempunyai waktu yang lebih sedikit untuk memeroleh informasi. pendapatan erat kaitannya dengan status kesehatan, umumnya makin tinggi pendapatan maka akan semakin baik status kesehatannya. penghasilan responden terbanyak adalah rp.1.031.500 s/d 2.063.000/bulan. angka ini sudah di atas umr (upah minimum regional) jawa timur tahun 2010. menurut mereka penghasilan ini sudah cukup, karena rata-rata anak mereka sudah berkeluarga dan mempunyai penghasilan upaya meningkatkan perilaku pasien diabetes melitus (nur aini) 7 sendiri sehingga penghasilan ini digunakan untuk memenuhi kebutuhan hidup responden sendiri. peningkatan pengetahuan pada kelompok perlakuan mungkin juga disebabkan oleh pemberian motivasi. dengan pemberian motivasi kita menanamkan kesadaran pada individu sehingga individu lebih menyadari pentingnya informasi yang diberikan, karena informasi akan terekam baik dalam ingatan seseorang bila informasi tersebut bermanfaat bagi dirinya. selain itu pemberian intervensi dilakukan secara pesonal (individu). saat tatap muka secara personal responden dapat menerima pesan baik verbal dan non-verbal dari peneliti melalui bahasa tubuh atau ekspresi wajah. menurut teori neuro linguistic body language, intonasi dan ekspresi berpengaruh 85% dibandingkan bahasa verbal. saat tatap muka pasien menerima seluruh pesan tubuh dengan baik sehingga kekuatan memori jauh lebih kuat. materi yang disampaikan dengan tatap muka dan diskusi akan lebih mudah dipahami responden karena materi yang diberikan berfokus pada individu. penelitian tentang keterkaitan antara motivasi dengan pengetahuan memang belum ada, namun beberapa penelitian untuk meningkatkan pengetahuan dengan cara konseling individu dan diskusi misalnya penelitian andari (2006) pada pasien menopause menunjukkan hasil yang lebih baik daripada dengan ceramah saja. proses pembentukan memori diawali dengan diterimanya berbagai rangsangan yang diterima panca indera oleh sensori memori di hipotalamus. proses pembentukan memori jangka pendek (short term memory) dimulai di hipotalamus. informasi yang diterima oleh memori jangka pendek ini masih mudah dilupakan, tetapi jika suatu objek tersebut dianggap penting dan bermakna, maka proses pemindahan memori ke jangka panjang akan dimulai (yusuf, 2003). proses pembentukan memori jangka panjang terjadi di lobus anterior pituitary. memori jangka panjang yang terbentuk di otak dapat saja hilang atau terlupakan, tetapi hal ini bisa distimulasi kembali agar bisa diingat. pemberian materi motivasi juga berfungsi sebagai stimulator untuk mengingat kembali memori jangka panjang yang pernah diperoleh. selama proses pengolahan informasi secara otomatis akan terjadi proses penyaringan informasi berdasarkan nilai kemanfaatan informasi tersebut bagi seseorang. semakin bermanfaat informasi tersebut bagi dirinya, maka informasi tersebut akan terekam dengan baik dalam ingatannya (notoatmodjo, 2007). m e n u r u t r o g e r s ( 1 9 7 4 ) d a l a m notoatmodjo (2003), dari pengalaman dan penelitian terbukti bahwa perilaku yang didasari oleh pengetahuan akan lebih langgeng daripada perilaku yang tidak didasari oleh pengetahuan, oleh karena itu pemberian materi motivasi yang salah satunya berupa materi tentang diabetes dan penatalaksanaannya dapat menjadi dasar untuk merubah perilaku. hasil penelitian menunjukkan bahwa ada perbedaan sikap yang signifikan pada kelompok perlakuan sebelum dan sesudah pemberian motivasi dan edukasi. perbedaan sikap juga terjadi pada kelompok kontrol, namun perbedaan ini tidak signifi kan. s i k a p s e b a g i a n b e s a r r e s p o n d e n kelompok perlakuan dan kontrol awalnya berada pada kategori sedang sebesar 13 orang pada kelompok perlakuan dan selebihnya pada kategori baik 2 orang. sedangkan pada kelompok kontrol, kategori sedang sebesar 11 orang dan baik 4 orang. responden kelompok kontrol yang sikapnya baik adalah mereka yang lama sakitnya > 3–5 tahun dengan pendidikan pt, hal ini mungkin disebabkan karena pendidikan mereka baik sehingga secara emosional sikap mereka juga baik. sedangkan kelompok perlakuan yang sikapnya baik adalah mereka yang lama sakitnya > 10 tahun, hal ini disebabkan karena mereka sudah bisa menerima penyakit yang dideritanya dengan lapang dada. banyak responden yang awalnya merasa putus asa dengan pengobatan yang dijalani karena tidak juga menghasilkan kesembuhan dan kedisiplinan mereka kurang ketika gula darah sudah normal, tetapi kelompok perlakuan menunjukkan peningkatan sikap setelah pemberian motivasi dan edukasi. meskipun usia responden termasuk dalam kategori usia lanjut dini tetapi sikap mereka bisa berubah dengan adanya pemberian motivasi dan edukasi. hal ini tidak sepenuhnya jurnal ners vol. 6 no. 1 april 2011: 1–10 8 sesuai dengan ciri perkembangan emosional lansia yang diungkapkan oleh hurlock (1980) bahwa lanjut usia kurang bisa menyesuaikan diri, munculnya rasa tersisih, tidak dibutuhkan lagi dan ketidakikhlasan menerima kenyataan baru seperti penyakit yang tidak kunjung sembuh. menurut sunaryo (2004), sikap tidak dibawa sejak lahir tetapi dapat dipelajari dan dibentuk berdasarkan pengalaman individu sepanjang perkembangan selama hidupnya. pembentukan sikap dipengaruhi oleh faktor eksternal (pengalaman, situasi, norma, hambatan dan pendorong) dan internal (fisiologis, psikologis, dan motif). beberapa penelitian menunjukkan bahwa sikap dipengaruhi pula oleh pendidikan. umumnya semakin tinggi pendidikan seseorang, semakin baik pula sikapnya biasanya makin tinggi pendidikan seseorang makin mudah orang tersebut untuk menerima informasi dan memahami sesuatu. pendidikan responden yang dalam penelitian ini minimal sltp, ternyata menunjukkan perubahan sikap setelah diberikan motivasi dan edukasi. pemberian motivasi dan edukasi pada kelompok perlakuan menyebabkan perubahan pada ketiga komponen sikap yaitu kognitif, afektif dan konatif. komponen kognitif adalah komponen perseptual, berkaitan dengan pengetahuan, pandangan, keyakinan. komponen ini berhubungan dengan bagaimana orang mempersepsi terhadap objek sikap. komponen afektif adalah merupakan komponen emosional, berkaitan dengan nada perasaan, senang atau tidak senang terhadap suatu objek. komponen ini menunjukkan arah sikap yaitu positif dan negatif. penilaian positif apabila mereka merasakan ada keuntungan langsung, sedangkan penilaian negatif apabila sebaliknya. k o m p o n e n k o n a t i f a d a l a h k o m p o n e n kecenderungan perilaku, berhubungan dengan kecenderungan bertindak terhadap objek sikap (azwar, 2003). a p a b i l a d i l i h a t d a r i f a k t o r y a n g memengaruhi pembentukan sikap, maka pemberian motivasi dan edukasi merupakan faktor eksternal. pemberian motivasi dan edukasi dapat mengubah sikap seseorang karena di sini kita menanamkan kesadaran pada diri individu agar mereka tidak berputus asa dan tetap melaksanakan tatalaksana dm, sehingga dalam diri responden terjadi perubahan drive menjadi set menjadi choice dan akhirnya menjadi action atau tindakan seseorang untuk melaksanakan tatalaksana dm. hal ini sesuai dengan penelitian yang dilakukan oleh yusuf (2003) tentang pengaruh motivasi terhadap perubahan sikap perawat dalam memberikan asuhan keperawatan. penelitian ini membuktikan bahwa motivasi dan edukasi bisa merubah sikap seseorang karena dengan pemberian motivasi dan edukasi kita menanamkan kesadaran pada mereka agar berbuat sesuatu dengan rasa percaya diri sendiri bahwa apa yang dilakukan itu adalah untuk mencapai tujuan tertentu dan ada keinginan dari dalam. mar’at (1998), dalam sunaryo (2004) juga mengatakan bahwa sikap yang terbentuk dalam diri seseorang adalah hasil dari proses penginderaan. hasil proses penginderaan dari melihat, mendengar dan merasakan akan melahirkan pengetahuan dan pemahaman terhadap informasi, kemudian dari proses pemahaman tersebut seseorang akan memberikan penilaian atau sikap. menurut walgito (2001), sikap tidak dibawa sejak lahir, selalu berhubungan dengan objek, dapat berlangsung lama atau sebentar, bahkan sikap mengandung faktor perasaan dan motivasi, sehingga sikap responden yang terbentuk selama penelitian ini mungkin tidak berlangsung lama, oleh karena itu pemberian motivasi dan edukasi perlu ditingkatkan lagi dan diberikan secara berkelanjutan. hasil penelitian menunjukkan bahwa ada perbedaan praktik yang signifi kan pada kelompok perlakuan sebelum dan sesudah pemberian motivasi dan edukasi. perbedaan praktik yang signifikan juga terjadi pada kelompok kontrol. praktik pada sebagian besar kelompok perlakuan dan kontrol awalnya berada pada kategori sedang sebesar 9 orang pada kelompok perlakuan, kategori baik 4 orang dan kurang 2 orang. sedangkan pada kelompok kontrol kategori sedang sebesar 7 orang, baik 5 orang dan kurang 3 orang. praktik yang kurang terutama dalam hal olahraga, minum obat dan mengatur makan. alasan responden tidak upaya meningkatkan perilaku pasien diabetes melitus (nur aini) 9 melakukan olahraga rutin adalah karena pagi mereka harus mengerjakan pekerjaan rumah sehingga tidak ada waktu untuk olahraga. alasan responden tidak meminum semua obatnya dan mengurangi dosis obat tanpa instruksi dokter karena mereka mengira dengan minum obat akan semakin memperparah penyakit. pengaturan makan sesuai dengan jumlah, jenis dan jadwal juga belum benar dan tepat karena responden memang belum mengerti tentang hal ini. selain itu, bila gula darah normal sebagian besar responden tidak disiplin atau sembrono dalam penatalaksanaan dm. sebagian besar responden kelompok kontrol yang praktiknya baik dan sedang adalah mereka yang lama sakitnya > 7 tahun, hal ini mungkin disebabkan karena mereka sudah terbiasa melakukan tatalaksana dm. sedangkan responden kelompok perlakuan yang praktiknya baik dan sedang juga lama sakitnya > 7 tahun. namun setelah diberikan motivasi dan edukasi akhirnya praktik pada kelompok perlakuan berubah menjadi lebih baik lagi. penatalaksanaan dm memang sangat kompleks dan membutuhkan kedisiplinan, oleh karena itu pemberian motivasi dan edukasi sangat penting karena bisa menjadi support bagi pasien. memang belum ada penelitian tentang pengaruh motivasi dan edukasi terhadap perubahan praktik atau perilaku pasien, tetapi hasil penelitian ini memperkuat teori dorothy e. johnson bahwa pemberian motivasi dan edukasi akan merubah drive menjadi set menjadi choice dan akhirnya menjadi action atau tindakan. jika dilihat dari teori cara memberikan motivasi, maka motivasi yang kita berikan dalam teori dorothy e. johnson ini adalah motivasi dengan identifi kasi, artinya kita menanamkan kesadaran sehingga individu berbuat sesuatu karena adanya keinginan yang timbul dari dalam dirinya sendiri (tommey dan alligood, 2006). menurut notoatmodjo (2007), perubahan perilaku terjadi melalui perubahan kognitifafektif-praktik (kap) dan perubahan perilaku yang didasari oleh kesadaran diri sendiri akan bersifat lebih langgeng. beberapa penelitian membuktikan hal itu, namun penelitian lainnya juga membuktikan bahwa proses tersebut tidak selalu seperti teori di atas (kap). hasil penelitian ini membuktikan bahwa dengan pengetahuan dan sikap yang baik, maka praktik seseorang akhirnya akan berubah menjadi baik pula. hasil penelitian menunjukkan bahwa ada perbedaan gula darah puasa dan 2 jam pp yang signifi kan pada kelompok perlakuan sebelum dan sesudah pemberian motivasi dan edukasi. perbedaan gula darah puasa juga terjadi pada kelompok kontrol, tapi perbedaan ini tidak signifikan. sedangkan pada gula darah 2 jam pp malah sebaliknya yaitu terjadi peningkatan. penurunan gula darah puasa dan 2 jam pp pada kelompok perlakuan dapat terjadi karena dengan pemberian motivasi dan edukasi akan terjadi perubahan pengetahuan, sikap dan praktik ke arah yang lebih baik sehingga praktik yang kurang dalam tatalaksana dm menjadi lebih baik lagi. keadaan ini akhirnya berdampak pula pada penurunan gula darah puasa dan 2 jam pp. simpulan dan saran simpulan pemberian motivasi dan edukasi dapat memperbaiki perilaku pasien dalam tatalaksana d i a b e t e s m e l l i t u s m e l a l u i p e n i n g k a t a n pengetahuan, sikap dan praktik. selanjutnya apabila perilaku pasien sudah baik maka gula darah akan stabil. saran r u m a h s a k i t d a l a m m e m b e r i k a n penyuluhan, hendaknya lebih mengoptimalkan jadwal yang telah ditetapkan dan membuat program penyuluhan semenarik mungkin sehingga akan lebih banyak lagi pasien yang tertarik untuk mengikuti penyuluhan. pasien juga perlu diberikan motivasi karena dengan memberikan motivasi maka kita memberikan dukungan dan menanamkan kesadaran pada pasien untuk melaksanakan tatalaksana dm. perawat adalah orang yang paling dekat dengan pasien karena waktu interaksi antara perawat dan pasien lebih lama dibandingkan dengan tenaga kesehatan lain, oleh karena itu jurnal ners vol. 6 no. 1 april 2011: 1–10 10 hendaknya mereka juga dibekali dengan materi motivasi karena pemberian motivasi terbukti bisa merubah pengetahuan, sikap maupun praktik pasien sehingga perilaku pasien dapat berubah menjadi lebih baik dan gula darahnya turun. kepustakaan andari, p.n., 2006. pengaruh konseling m e n o p a u s e t e r h a d a p t i n g k a t pengetahuan dan sikap wanita dalam m e n g h a d a p i m a s a m e n o p a u s e . skripsi tidak dipublikasikan. surabaya: universitas airlangga. asti, t., 2006. kepatuhan pasien: faktor penting dalam keberhasilan terapi. majalah infopom. 7(5), 1–3. a z w a r, s . , 2 0 0 3 . s i k a p m a n u s i a d a n pengukurannya. yogyakarta: pustaka pelajar. badan pusat statistik, 2007. data penduduk jawa timur. (online), (http://jatim. bps.go.id. diakses tanggal 25 agustus 2010). delamater, 2009. improving patient adherence, (online), (http://clinical diabetesjournals, diakses tanggal 21 desember 2009). departemen kesehatan republik indonesia, 1992. direktorat bina kesehatan keluarga, pedoman manajemen upaya kesehatan usia lanjut di puskesmas. jakarta: departemen kesehatan republik indonesia. depraxis, l., 2010. mitos kebiasaan 21 hari, (online), (http://lexdepraxis.wordpress. com., diakses tanggal 17 maret 2010). desmita, 2006. psikologi perkembangan. edisi ii. bandung: remaja rosdakarya. hurlock, elizabeth b., 1980. psikologi perkembangan suatu pendekatan sepanjang rentang kehidupan. jakarta: erlangga. joni, b., 2009. sekilas tentang geriatri (ilmu kesehatan lanjut usia), suatu upaya menuju hari tua yang sehat dan bahagia, (online), (http://miias.info, diakses tanggal 10 agustus 2010). kasiulevicius, sapoka, dan filipaviciute. 2006. sample size calculation in epidemiological studies. gerontologija. 7(4): 225–231. mar’at, s., 1998. perilaku manusia. bandung: refi ka aditama. mishali, vaknin, omer, dan heymann, 2007. conceptualization and measurement of resistance to treatment: the resistance to treatment questionnaire for people with diabetes. oxford university press. notoatmodjo, s. 2003. ilmu kesehatan masyarakat prinsip-prinsip dasar. jakarta: rineka cipta. notoamodjo, s., 2007. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta.. perkeni, 2006. konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia. pratiwi, a.d., 2007. epidemiologi, program penanggulangan dan isu mutakhir d i a b e t e s m e l l i t u s . s k r i p s i t i d a k dipublikasikan. makassar: universitas hasanuddin. soegondo, s., 2008. hidup secara mandiri dengan diabetes mellitus. jakarta: fkui. sunaryo, 2004. psikologi untuk keperawatan. jakarta: ecg. tjokroprawiro, a., 1997. surabaya diabetes update ii. pusat diabetes dan nutrisi. rsud dr. soetomo dan fk unair. tommey dan alligood, 2006. nursing theorists and their work. philadelphia usa: mosby. yusuf, a.h., 2003. pengaruh pemberian motivasi tentang keperawatan terhadap perubahan sikap perawat dalam memberikan asuhan keperawatan di rumah sakit jiwa menur surabaya. tesis tidak dipublikasikan. surabaya: program pascasarjana unair. walgito, b., 2001. psikologi sosial suatu pengantar. yogyakarta: andi ofset. 74 development of the quality of nursing care scale for hospitalised children with acute respiratory infection in indonesia dewi elizadiani suza,* busakorn punthmatharith,** ladawan prateepchaikul** *faculty of nursing, universitas sumatera utara, indonesia **faculty of nursing, prince of songkla university, thailand email: elizadiani@hotmail.com abstract introduction: acute respiratory infection in children leads to high morbidity and mortality. this is probably due to a lack of quality of care and no quality control. the quality of nursing care for hospitalized ari children (qncs-haric) instrument is expected to be a potential tool for improving the quality of nursing practice with an approach more genuinely focused on parental involvement, especially in indonesia. the purpose of this study is to develop a scale of qncs-haric in indonesia. methods: development of the qncs-haric refers to a literature review, expert panel meeting, experts’ review, and pilot study. results: four dimensions and 79 items were generated: 1) the physical needs of ari children (36 items); 2) the psychological needs of ari children and their families (26 items); 3) the socio-cultural needs of ari children and their families (10 items) and 4) the spiritual needs of ari children and their families (7 items). the validity was approved by five experts yielding a content validity index equalling .96. after performing the cvi, the qncs-haric consisted of 78 items (deleting 2 items from the dimension on the physical needs of ari children and an additional 1 item from the dimension on the physical needs of ari children). the reliability was tested with 30 pediatric nurses yielding an alpha cronbach's coefficient of the overall qncs-haric 77 items of .94 and each of the dimensions equalled .94, .87, .79, and .73, respectively. conclusion: to improve the quality of nursing care delivery, pediatric nurses need to be equipped with a quality instrument which should be psychometrically tested, sensitive, specific, accurate, objective, and feasible. key words: quality of nursing care scale, acute respiratory infection, children introduction acute respiratory infection (ari) is the leading cause in the global burden of diseases (nair et al. 2013) because of high incidence, substantial morbidity, and potential sequel, a tendency towards over-diagnosis, associated overuse and misuse of antibiotics, and its contribution to health care costs and indirect societal costs (schaad 2005). the global incidence of aris in children is estimated to be 156 million new cases per year of which 151 million episodes occur in developing countries (rudan, nair, marusic & campbell 2013). one to four million deaths occur each year among children with ari worldwide (liu et al. 2012). acute respiratory infections consist of upper and lower respiratory infections, the latter being more commonly found in developing countries (shafik et al. 2012). the main causes of ari in children are streptococcus pneumonia, haemophilus influenza, as well as the respiratory syncytial virus (nair et al. 2010). acute respiratory infection in children in indonesia is a serious problem because it leads to high morbidity and mortality. ari kills more children under five years of age than any other illness in indonesia (department of health government of indonesia 2010). lower respiratory tract infection is the most commonly found in indonesia (wee-ling 2010). pneumonia is a common cause of morbidity and mortality among children under five years old (agustina et al. 2012). the two major diseases causing child mortality from ari in indonesia are pneumonia and bronchitis (lipoeta, wattanapenpaiboon & wahlqvist 2004). acute respiratory infection was the major primary cause of death among infants and under-five-year-old children (affandi & utji 2009; yuliarti, hadinegoro, supriyatno & karuniawati 2012) and was ranked second as a cause of death amongst infants and children under five years old after diarrhea (basic health research 2007; faizal 2012). hernani, sudarti, agustina and sariasih (2009) reported that the trend of incidence rates of acute respiratory infection in children under five from 2004– 2008 decreased but was still high (2004 = 39.91%, 2005 = 27.65%, 2006 = 29.12%, 2007 = 27.71%, 2008 = 22.13%). the high incidence of morbidity and mortality of ari children in indonesia is probably due to 1) a lack of complete operational procedures for ari (hernani, sudarti, agustina & sariasih 2009) and 2) a low quality of nurse performance (barber, gertler & mailto:elizadiani@hotmail.com pengembangan skala kualitas asuhan keperawatan untuk anak (dewi elizadiani suza, dkk) 75 harimurti 2007). also, nurses not only face problems of caring for patients with tropical diseases and their families but also have had to adapt to providing care in a system which is beset with difficulties such as shortages of supplies, and inadequate resources (shields & hartati 2003). these possible reasons influence the quality of nursing care for ari children. in general, the quality of nursing care for sick children with ari in indonesia is still far from optimal. this is due to the lack of regulatory standards for education and clinical competence, the absence of proper job descriptions, and also, the training of many nurses does not necessarily match the nature of the work being undertaken (hennessy, hicks, hilan & kowanal 2006). chakraborty and frick (2002) conducted a study among private hospitals in rural west bengal, india and focused on providers’ disease management practices for acute respiratory infections among under-five children. the study reported inadequate technical quality of care for ari among the providers which was related to a lack of knowledge (technical incompetence), low levels of performance (limited potential), and inconsistency in performance (within-provider variation). indonesia’s health minister (2010) reported that, in general, quality of care is often lacking and there is no quality control and treatment options are limited. similar to the study of lesa and dixon (2007) in nigeria, they found an aberration with the clinical training given to nurses in the training institutions largely because of a lack of equipment, lack of continuous training and re-orientation on the job by some employers, lack of commitment on the part of the nurse professionals, and nurses seeing their professional training as just the necessity for registration and licensure. one possible way to reduce the morbidity and mortality of ari children and increase the quality of nursing care of ari children is to develop a scale of the quality of nursing care for hospitalized ari children (qncsharic). the scale development will be based on related concepts such as quality of nursing care, holistic care, nursing process, and holistic nursing care for ari children. the purpose of this study was to develop a scale of qncsharic in indonesia. the qncs-haric in this study was developed based on the literature review regarding concepts of quality of nursing care, holistic care, nursing care for ari children, the nursing process and holistic nursing care for acute respiratory infection children. it was norm referenced and based on an expert panel meeting. the concept of quality of nursing care was defined as the degree to which pediatric nurses provide nursing care based on holistic nursing care to meet the physical, psychological, socio-cultural, and spiritual needs of ari children and their families. method an inductive methodological design was used to develop an instrument to measure nurse perceptions of quality of nursing care for hospitalised acute respiratory infection (ari) children. development of the qncs-haric consisted of 1) determining what is to be measured, 2) generating an item pool, 3) determining the format for measurement, 4) having the initial item pool reviewed by experts, and 5) considering inclusion of validation items (devellis 1991). this research has been reviewed for ethical consideration by the faculty of nursing, prince of songkla university, thailand (certificate number: 5110430015). the sample for the expert panel meeting consisted of pediatric nurses, pediatric nurse lecturers, and pediatricians. purposive sampling was used to recruit the expert panel who met the inclusion criteria. the participants for the expert panel meeting consisted of four pediatric nurses who provide nursing care to ari children in the hospital, four pediatric nurse lecturers, and four pediatricians who provide care to ari children in the hospital. the inclusion criteria consisted of 1) pediatric nurses who have provided nursing care to ari children for at least six years, 2) pediatric nurse lecturers who have taught nursing care of ari children for at least six years, and 3) pediatricians who have provided care to ari children for at least six years. banner (2001) recommended that six years’ experience was the minimum number of years required before being an expert in the field. the sample for the expert review consisted of two pediatricians who have provided care to ari children for at least six years, one pediatric nurse who has provided nursing care to ari children for at least six jurnal ners vol. 9 no. 1 april 2014: 74–82 76 years, and two pediatric nurse lecturers who have taught nursing care of ari children for at least six years. the pilot study consisted of 30 pediatric nurses from general hospitals in western indonesia. purposive sampling was used to recruit nurses who met the inclusion criteria. the inclusion criteria included pediatric nurses who 1) have provided nursing care to ari children (aged under five) for at least one year, 2) are willing to participate in this study, and 3) can communicate in the indonesian language. results the study was based on the literature review regarding the quality of care, the quality of nursing care perspective, the quality of nursing care evaluation, the existing quality of nursing care instruments, the nursing process, holistic care, nursing care for ari children, and holistic nursing care for ari children; four dimensions and 80 items of the qncs-haric version 1 were established: 1) physical dimension of ari children (37 items), 2) psychological dimension of ari children and their families (26 items), 3) socio-cultural dimension of ari children and their families (10 items), and 4) spiritual dimension of ari children and their families (7 items). the panel of experts consisted of 12 participants from pediatric nurses (n= 4), pediatric nurse lecturers (n= 4), and pediatricians (n= 4). based on the expert panel meeting, four dimensions and 79 items of the qncs-haric were identified: 1) the physical dimension of ari children (36 items), 2) the psychological dimension of ari children and their families (26 items), 3) the socio-cultural dimension of ari children and their families (10 items), and 4) the spiritual dimension of ari children and their families (7 items). only item 14 in the physical dimension of ari children was deleted because it was redundant, (already contained within item 13). also, the researcher gave further explanation regarding holistic nursing care and gave an example because some members of the panel of experts did not understand the concepts of holistic nursing care and a nursing care plan. the content validity of the qncsharic was performed by five experts. the acceptable content validity index (cvi) of the qncs-haric was .96. two items of the qncs-haric (items 21, 22) were deleted because they were not relevant to nursing care for ari children. one item (item 34) was added by the experts because they believed that the parents should be instructed to monitor signs of respiratory distress including danger signs at home and when to bring the child to the hospital. nine items (items 1, 2, 5, 14, 30, 31, 53, 67, and 77) were modified because of a lack of clarity. sixty-seven items were retained. thus, after the experts’ review, the qncsharic consisted of four dimensions and 78 items: 1) physical dimension of ari children (35 items), 2) psychological dimension of ari children and their families (26 items), 3) sociocultural dimension of ari children and their families (10 items), and 4) spiritual dimension of ari children and their families (7 items). the back translation method was used to translate the original english version of the qncs-haric into the indonesian version (brislin, 1986). the translation process included forward translation of the development instrument, a blind backtranslation, and comparisons of the original and back-translated version. firstly, the original english version of the qncs-haric was translated into the indonesian language by three nursing experts who were natives of indonesia and fluent in both english and indonesian, and also had knowledge of the quality of nursing care with ari children, instrument development and indonesian culture. after the translation, the researcher carefully compared and checked for discrepancies among the three questionnaires from the three translators. there were no discrepancies between the three translators. secondly, the indonesian version of the qncs-haric was translated back into english by another three nursing experts native to indonesia who were fluent in both english and indonesian. after the back translation, the researcher examined, compared, and checked for discrepancies between the three questionnaires from three translators. there were no discrepancies between the three translators. thirdly, an editor who was fluent in english compared the equivalence of two english versions: the original version and the back-translated version. this method was expected to result in equivalence between the original and back translation instrument. the evaluations of semantic equivalence during the translation process indicated that the translated pengembangan skala kualitas asuhan keperawatan untuk anak (dewi elizadiani suza, dkk) 77 indonesian version of the qncs-haric demonstrated satisfactory semantic equivalence as relative to the english version of the qncsharic through the quality of translation. the original version of the qncs-haric and the back-translated english version were compared. no items were deleted or added at this stage of research. however, the editor made suggestions to change some words or delete items 1, 5, and 12. item 1: assess for signs of inadequate oxygen (e.g., cyanotic lip or fingernails, irregular breathing or restlessness, capillary refill > 2 seconds, hypoxia). the phrase “restlessness” was changed to “difficulty breathing”. item 5: assess the child’s response to activity daily intolerance. the word “daily” was deleted. item 12: administer oxygen correctly as prescribed. the phrase “prescribed” was changed to “physician order”. in addition, verb tenses were also changed for appropriateness. the pilot study was conducted with 30 pediatric nurses who had similar qualifications as the study sample from the general hospital, at western indonesia. the participants’ ages ranged from 25 to 48 years. eighteen of them (60.0%) were aged more than 40 years old (m = 40.03; sd = 7.04). all participants were female. twenty-one participants were christian (70.0%) and eight were muslim. twenty-eight participants were married (93.3%). all participants had a bachelor degree (100%). twenty-six participants (86.7%) had more than six years of nursing experience (m = 15.13; sd = 6.74). twenty-six participants (86.7%) had more than six years of working experience with acute respiratory infection children (m = 11.17; sd = 5.23). thirteen participants (43.3 %) took care of ari children at a rate of fewer than ten cases per month (m = 8.63; sd = 6.43). the results from the pilot study showed that cronbach’s alpha coefficient for overall qncs-haric (78 items) was .94. cronbach’s alpha coefficients for the physical dimension of ari children, the psychological dimension of ari children and their families, the sociocultural dimension of ari children and their families, and the spiritual dimension of ari children and their families dimensions were .94, .87, .79, and .66, respectively. since cronbach’s alpha coefficient for the spiritual of ari children and their families dimension was low (r=.66) and an item-to-total correlation of item 75 belonging to the spiritual dimension was also low (r=.155), it was deleted. after deleting that item, cronbach’s alpha coefficient for the spiritual dimension increased to .73. overall cronbach’s alpha coefficient for 77 items of the qncs-haric and the physical, psychological, socio-cultural, and spiritual dimensions were .94, .94, .87, .79, and .73, respectively. discussion many of the criteria considered in developing the qncs-haric were based on three suppositions: 1) the complex, subjective, and multi-dimensional concept of the quality of nursing care makes it difficult to define and measure (attree 1993, 1996; hogston 1995b; idvall & rooke 1998; kunaviktikul et al. 2001; norman, redfern, tomalin & oliver 1992), 2) there is a lack of definition and evaluation of the concept of quality of nursing care in children (leino-kilpi & vuorenheimo 1999; pelander 2008; suhonen & valimaki 2003), and 3) acute respiratory infection is the major cause of childhood mortality (mdgs-indonesia 2008). the components of quality of nursing care for nurses who work with ari children has not been identified in the nursing literature. thus, development of components of quality of nursing care for ari children was based on an extensive review of the literature regarding the quality of nursing care as previously mentioned, the expert panel meeting, and expert review. these four components consisted of 1) the physical dimension of ari children, 2) the psychological dimension of ari children and their families, 3) the socio-cultural dimension of ari children and their families, and 4) the spiritual dimension of ari children and their families. this study used devellis (1991) as the guideline to develop the qncs-haric. devellis’s theory of scale development described basic measurement concepts and contains sufficient practical guidance to support construction of a working scale development. there are eight steps in developing the instrument. by using devellis’s theory, the researcher was guided in the development of the qncs-haric to specify the content domain of the construct, generate an item pool that samples the domain of the qncs-haric, assess the relevance of items through expert review, consider validation items, administer items to a developmental sample, and evaluate items. jurnal ners vol. 9 no. 1 april 2014: 74–82 78 during the research process, the researcher realised that teamwork among the nurses in the expert panels, educational background of the expert reviewers, participation of pediatric nurses, and devellis’s theory of scale development were the prerequisites for the success of the scale development process of implementation. plans and strategies set up at every step always involved other parties in the unit to ensure their successful completion. to arrange a meeting among the involved parties was difficult due to limited time. but, with coordination and understanding, the overall process of scale development research was completed and conducted in an appropriate manner. the qncs-haric was developed based on the quality of nursing care, holistic care, nursing process, and holistic nursing care for ari children. the philosophy of holism emphasises a sensitive balance between art and science, analytical and intuitive skills, self-care, and the ability to care for patients using the interconnectedness of body, mind and spirit (dossey 1997). the holistic nursing care of children is a caring activity that focuses on children and families with regard to culture, beliefs and values to meet physical, emotional, mental, spiritual, social and cultural needs (tjale & bruce 2007). use of holistic nursing care is believed to help pediatric nurses provide nursing care as whole care designed to meet the needs of the whole person (dossey 1997). the results of the review of the quality of nursing care instrument using holistic nursing care as the conceptual framework showed that there is only one instrument designed for orthopedic adult patients in taiwan (lee, hsu & chang 2002). the orthopedic nursing care quality monitor tool (oncqmt) was used to evaluate the quality of nursing care and compare the quality score based on the plan of nursing care, the physical needs of the patient were attended to, the psycho-social-cultural-spiritual needs of the patient were attended to, and the achievement of nursing care objectives was evaluated. in similarities, the quality patient care scale (qualpacs) was developed by wandelt and ager (1974 as cited in chance 1997). the qualpacs is designed to measure the quality of nursing care observed by adult patients in any setting in the united states. it consists of physical, psychosocial, general activities, communication, and professional implications. the rush-medicus quality monitoring instrument (rmt-mqnc) was developed by hegyvary and haussmann (1975 as cited in chance 1997). the rush-medicus quality monitoring instrument consists of the folllowing elements: the plan of nursing care is formulated, the physical needs of the patient are attended to, the psychological, emotional, mental, social needs of the patient are attended to, the achievement of nursing care objectives is evaluated, procedures are followed for the protection of all patients and the delivery of nursing care. in contrast, the patient’s assessment of quality scale-acute care version (paqsacv) was developed by lynn, mcmillen and sidani (2007). the paqs-acv is designed to measure the quality of nursing care in acute care units, in the united states. the paqs-acv consists of individualisation, nurse character, caring, environment and responsiveness. the oncology patients’ perceptions of the quality of nursing care scale (oppqncs) was developed by radwin, alster and rubin (2003). the oppqncs is designed to measure the quality of nursing care in new england. the oppqncs consists of responsiveness, individualisation, coordination, and proficiency. when comparing the present instrument with those other instruments, there were some similarities as well as different features. the oncqmt, qualpacs and rmt-mqnc showed some similarities in terms of the physical, psychosocial, socio-cultural and spiritual needs, and the plan for nursing care. the oncqmt was useful to evaluate the quality of nursing care and assist administrators and educators to identify the strengths and weaknesses in the delivery of nursing care. the disadvantage of this instrument was that it did not give an indication of the patient outcome. the qualpacs results showed a significant improvement in the quality of nursing care with primary nursing practice. however, the fact is that the use of the qualpacs instrument in a different setting from from that for which it was originally designed could have affected the results (archibong 1999) and some difficulties are expected if it is used in other countries (sale 1996). the rmt-mqnc was designed to estimate quality for a nursing unit, but may not be suitable for measurement of differences in care received by individual patients (fox 1982). pengembangan skala kualitas asuhan keperawatan untuk anak (dewi elizadiani suza, dkk) 79 furthermore, the paqs-acv and oppqncs focus on the individualisation, nurse character, caring, environment, responsiveness, coordination and proficiency. those instruments are not designed to measure quality of nursing care based on the holistic care approach. that instrument was representative for adult patients and developed to measure the quality of nursing care from a patient’s perspectives. there is only one study focused on the evaluation of the child care quality at hospital (ccqh) instrument for hospitalised school-age children (7–11 years) developed in finland (pelander, leino-kilpi & katajisto 2009). the rush medicus nursing process quality monitoring instrument (rmi-msv) was developed by jelenik et al. (1975 as cited in chance 1997). the rmi-msv examined using patient records, patient observation, patient interviews, staff interviews, staff observation, patient environment observation, observer inference and management observation. the rmi-msv has been translated, modified and tested in several countries. a swedish version of the rmi-msv instrument was modified and tested by gotherstron, hamrin and carstensen (1994). the modified swedish version of the rmimsv has been tested within surgical, medical, and orthopedic units in a county hospital. the rmi-msv was found to be sensitive to changes and appropriate for quality assessment. the qncs-haric instrument was expected to be a potential tool for obtaining knowledge about the quality of pediatric nursing care with ari children and thereby contributing to improving quality in nursing practice with a more genuinely parental involvement approach, especially in indonesia. to improve the quality of nursing care delivery, pediatric nurses need to be equipped with a quality instrument which should be psychometrically tested, sensitive, specific, accurate, objective, and feasible. conclusion the results of this study suggest that the newly-developed 77 items of the qncsharic scale is reliable and valid. the reliability was tested with 30 pediatric nurses yielding an alpha cronbach’s coefficient for the overall 77 items of the qncs-haric of .94 and the physical, psychological, socio-cultural, and spiritual dimensions were .94, .87, .79, and .73, respectively. the qncs-haric consisted of four dimensions and 77 items which included: 1) physical dimension of ari children (35 items), 2) psychological dimension of ari children and their families (26 items), 3) socio-cultural dimension of ari children and their families (10 items), and 4) spiritual dimension of ari children and their families (6 items). there were no reported difficulties encountered during the process of collecting pilot testing data. the average time for a pediatric nurse to complete the pilot testing was approximately 45 to 60 minutes. the results of the pilot testing supported the readiness for constructing a psychometric evaluation. the use of qncs-haric to evaluate the quality of nursing care will assist administrators and educators in identifying the strengths and weakness in the delivery of nursing care for ari children. references affandi, n.b. & utji, r., 2009. lower respiratory tract infection in indonesia with special reference to harapan kita children and maternity hospital, jakarta, viewed 17 january 2010. http://www.tempo.co.id/medika/arsip/ 092002/art-4.htm agustina, r., kok, f.j., de rest, o.v., firmansyah, a., lukito, w., ferkens, e.m., bovee-oudenhoven, i.m., 2012. randomized trial of probiotics and calcium on diarrhea and respiratory tract infections in indonesian children. pediatrics, 5(129), pp. 1155–1164. archibong, u.e., 1999. evaluating the impact of primary nursing practice on the quality of nursing care: a nigerian study. journal of advanced nursing, 29(3), pp. 680–689. attree, m., 1993. an analysis of the concept quality as it relates to contemporary nursing care. international journal of nursing studies, 30(4), pp. 355–369. attree, m., 1996. towards a conceptual model of quality care. international journal of nursing studies, 33, pp. 13–28. banner, p., 2001. from novice to expert: excellence and power in clinical nursing practice. upper saddle river, nj: prentice hall. http://www.tempo.co.id/medika/arsip/092002/art-4.htm http://www.tempo.co.id/medika/arsip/092002/art-4.htm jurnal ners vol. 9 no. 1 april 2014: 74–82 80 barber, s. l., gertler, p. j. & harimurti, p., 2007. differences in access to high quality outpatient care in indonesia. health affairs, 26 (3), pp. 352–366. basic health research, 2007. indonesia demographic and health survey 2007, viewed 20 march 2010. www.itpbkkbn.org/pulin/004population/004_id hs_2007_prelim.pdf brislin, r.w., 1986. the wording and translation of research instrument. in w.j. lonner & j.w. berry (eds), field methods in cross-cultural research (pp. 137–164). beverly hills, np: sage. chakraborty, s. & frick, k., 2002. factors influencing private health providers technical quality of care for acute respiratory infections among under five in rural west bengal, india. social science & medicine, 55 (9), pp. 1579– 1587. chance, k.s., 1997. the quest for quality: an exploration of attempts to define and measure quality nursing care. image, 128(2), pp. 41–45. devellis, r.f., 1991. scale development: theory and applications. newbury park, np: sage. dossey, b.m., 1997. core curriculum for holistic nursing. gaithersburg, md: aspen. faizal, e.b., 2012. poor skills among health workers blamed for high infant mortality, viewed 10 august 2013. http://www.thejakartapost.com/news/2012/04/ 21/poor-skills-among-health-workersblamed-high-infant-mortality.html fox, r.n. 1982. measurement of quality of nursing care received by hospitalized surgical patients: conceptual and methodological sources of variation. new york, ny: buffalo. gotherstron, c., hamrin, e. & carstensen, j., 1994. testing a modified swedish version of the rush medicus nursing process quality monitoring instrument in short-term care. international journal quality health care, 6 (1), pp. 77–83. hennessy, d., hicks, c., hilan, a. & kowanal, y., 2006. the training and development needs of nurses in indonesia: paper 3 of 3. human resources for health, vol. 4, no. 10, pp. 1–14. hernani, sudarti, agustina, t. a. & sariasih, t., 2009. report on situation analysis of acute respiratory infection in children in indonesia, jakarta, viewed 9 november 2010. http://files.dcp2.org/pdf/dcp/dcp25.pd f hogston, r., 1995b. quality of nursing care: a qualitative enquiry. journal of advanced nursing, 21, pp. 116–124. idvall, e. & rooke, l., 1998. important aspects of nursing care in surgical wards as expressed by nurses. journal of clinical nursing, 7 (6), pp. 512–520. indonesian health ministry (2010). quality control, viewed 20 july 2011. http://www.time.com/time/world/article/ 0,8599,1964611,00.html kunaviktikul, w., anders, r.l., srisuphan, w., chontawan, r., nuntasupawat, r. & pumarporn, o., 2001. development of quality nursing care in thailand. journal of advanced nursing, 36 (6), pp. 776– 784. lee, l.l., hsu, n. & chang, s.c., 2007. an evaluation of quality of nursing care in orthopedic units. journal of orthopaedic nursing, 11, pp. 160–168. leinonen, t. & leino-kilpi, h., 1999. research in peri-operative nursing care. review journal of clinical nursing, 8, pp. 123– 138. lesa, r. & dixon, a., 2007. physical assessment implications for nurse educators and nursing practice. international nursing review, 54(2), pp. 166–172. lipoeta, n.l., wattanapenpaiboon, n., malik, a. & wahlqvist, m.l., 2004. the nutrition transition in west sumatra, indonesia asia. pacific journal clinical nutrition, 13 (3), pp. 312–316. liu, l., johnson, h.l., cousens, s., perin, j., scott, s., lawn, j.e. & mathers, c., 2012. global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. the lancet, 379(9832), pp. 2151–2161. lynn, m.r., mcmillen, b.j. & sidani, s., 2007. including the provider in the assessment of quality care: development and testing of the nurses assessment of quality scaleacute care version. journal of nursing care quality, 22 (4), pp. 328–336. millennium development goals of indonesia. (2008). current situation on mdg 4 and http://www.itp-bkkbn.org/pulin/004population/004_idhs_2007_prelim.pdf http://www.itp-bkkbn.org/pulin/004population/004_idhs_2007_prelim.pdf http://www.itp-bkkbn.org/pulin/004population/004_idhs_2007_prelim.pdf http://www.thejakartapost.com/news/2012/04/21/poor-skills-among-health-workers-blamed-high-infant-mortality.html http://www.thejakartapost.com/news/2012/04/21/poor-skills-among-health-workers-blamed-high-infant-mortality.html http://www.thejakartapost.com/news/2012/04/21/poor-skills-among-health-workers-blamed-high-infant-mortality.html pengembangan skala kualitas asuhan keperawatan untuk anak (dewi elizadiani suza, dkk) 81 5 in indonesia, viewed 10 april 2010. http://www.targetmdgs.org/download/m dg_report_2008_en.pdf nair, h., simoes, e.a., rudan, i., gessner, b.d., azziz-baumgartner, e., zhang, j.s. & feikin, d.r., 2013. global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analyis. the lancet, 20(381), pp. 1380–1390. norman, i.j., redfern, s.j., tomalin, d.a. & oliver, s., 1992. developing flanagan’s critical incident technique to elicit indicators of high and low quality nursing care from patients and their nurses. journal of advanced nursing, 17(5), pp. 590–600. pelander, t., 2008. the quality of paediatric nursing care – children’s perspective (doctoral dissertation), viewed 12 december 2010. https://www.doria.fi/bitstream/handle/ pelander, t., leino-kilpi, h. & katajisto, j., 2009. the quality of paediatric nursing care: developing the child care quality at hospital instrument for children. journal of advanced nursing, 65(2), pp. 443–453. radwin, l.e., alster, k. & rubin, k., 2003. the development and psychometric testing of the oncology patient’s perceptions of the quality of nursing care scale (oppqncs). oncology nursing forum, 30, pp. 283 290. rudan, i., nair, h., marusic, a. & campbell, h., 2013. reducing mortality from childhood pneumonia and diarrhoea: the leading priority is also the greatest opportunity. journal global health, 3(1), pp. 1–4. schaad, u.b., 2005. preventions of pediatric respiratory tract infections: emphasis on the role of om-85. the european respiratory review, 14(95), pp. 74–77. shafik, c.f., mohareb, e.m., yassin, a.s., amin, m.a., kholy, a.e., el-karaksy, h. & youssef, f.g., 2012. viral etiologies of lower respiratory tract infections among egyptian children under five years of age. british medical journal infectious diseases, 12(350), pp. 2–8. shields, l. & hartati, l. 2003. nursing and health care in indonesia. journal of advanced nursing, vol. 44, no. 2, pp. 209–216. suhonen, r. & valimaki, m., 2003. surveying patient satisfaction: challenging for nursing research. hong kong nursing journal, 39(2), pp. 7–14. tjale, a.a. & bruce, j., 2007. a concept analysis of holistic nursing care in paediatric nursing. curationis, 30(4), pp.45–52. wee-ling, s.s., 2010. molecular epidemiology of respiratory viruses in a pediatric cohort from indonesia (doctoral dissertation), viewed 8 april 2012. http://eprints.qut.edu.au/37309/1/ yuliarti, k., hadinegoro, s.r., supriyatno, b. & karuniawati, a., 2012. invasive pneumococcal disease among hospitalized children aged 28 days to 60 months in jakarta. southeast asian journal tropical public health, 43, 1, pp.136–144. http://www.targetmdgs.org/download/mdg_report_2008_en.pdf http://www.targetmdgs.org/download/mdg_report_2008_en.pdf http://eprints.qut.edu.au/37309/1/ yuliarti, k., hadinegoro, s.r., supriyatno, b. & karuniawati, a., 2012. invasive pneumococcal disease among hospitalized children aged 28 days to 60 months in jakarta. southeast asian journal tropical public health, 43, 1, pp.136–144. 253 a comparative study of the effects of vibration and electrical stimulation therapies on the acceleration of wound healing in diabetic ulcers yunita sari*, saryono saryono*, eman sutrisna**, hartono hartono*** * department of nursing, jenderal soedirman university, purwokerto, indonesia ** department of medical science, jenderal soedirman university, purwokerto, indonesia *** department of physics science, jenderal soedirman university, purwokerto, indonesia e-mail: yunita-tky@umin.ac.jp/sasa.yunita@gmail.com abstract introduction: diabetic ulcers accompanied by ischemia is difficult to treat. such ulcers require therapy that can improve the blood flow. previous studies have revealed that two therapies could improve blood flow and accelerate the healing of diabetic ulcers; vibration and electrical stimulation (es). however, it is unknown which of these two therapies is best at accelerating wound healing in diabetic ulcers. the purpose of this study was to compare both therapies in relation to accelerating the wound healing of diabetic ulcers. methods: this study was an experimental study involving diabetic rats. the rats were divided into two groups: vibration and es. vibration and es were applied for 10 minutes per day for 7 days. wound size, inflammation, intensity of fibroblast infiltration, area of necrosis and degree of re-epithelialisation were compared. the difference in wound size was analysed using an independent t-test, while the histological data were analysed using a mann-whitney u-test. results: on day 5 onwards, there was a thin slough in the es group which was not present in the vibration group. day 4 onwards and the wound size was significantly smaller in the vibration group than in the es group. the intensity of inflammation was significantly less, and the degree of fibroblast infiltration was significantly higher in the vibration group compared with the es group. re-epithelialisation was more advanced in the vibration group than the es group. conclusions: our study revealed that wound healing in diabetic ulcers following vibration was better than after es. we suggest that nurses should use vibration rather than es in clinical settings. keywords: complementary therapy, diabetic ulcer, electrical stimulation, vibration, wound healing introduction indonesia has the tenth highest proportion of people with diabetes mellitus (dm) in the world (shaw, sicree and zimmet, 2010). it is predicted that indonesia will become number six by 2030 (shaw, sicree and zimmet, 2010). soewondo, ferrario and tahapary (2013) revealed that the prevalence of patients with dm in indonesia had increased by 11 % over 19 years, although this figure is likely to be higher since there are many unreported cases (yusuf et al., 2016). diabetes mellitus causes many complications. patients have a risk of limb amputation at a rate that is 40 times higher than people without dm (brechow et al., 2013). after amputation, patients with dm also have a higher risk of limb re-amputation and rate of mortality (moulik, mtonga and gill, 2003; izumi et al., 2006). armstrong, wrobel and robbins (2007) showed that the prevalence of deaths due to diabetic foot ischemia was higher than that due to cancer. considering the impact of diabetic ulcers on patients, a therapy that accelerates wound healing is urgently required. wu et al., 2007 revealed that diabetic ulcers that heal with difficulty are accompanied by impaired blood flow (ischemia). the presence of ischemia impairs the wound healing process, especially the angiogenetic phase, thus a therapy that improves blood flow would be of great benefit, including the use of drugs which act as vasodilators that improve blood flow or induce angiogenesis such as prostaglandins or basic fibroblast growth factor (addison et al., 1972; lees, 1994). however, the continuous administration of these drugs causes side effects such as cramping, the vasoconstriction of blood vessels and the acceleration of osteogenesis (nagase et al., 2007). because most patients with diabetic foot ulcers also have other complications due to high blood glucose, a therapy that has minimal side effects is not invasive and is comfortable for patients is required. previous studies have shown that two complementary therapies that are safe for application to patients are vibration and electrical stimulation (es). a previous study revealed that a low vibration frequency can improve blood flow (nakagami et al., 2007), and accelerate healing of stage i pressure ulcers (arashi et al., 2010), deep tissue injury jurnal ners vol. 12 no. 2 oktober 2017: 253-260 254 (sari, et al., 2015) and diabetic ulcers (sari, sutrisna and hartono, 2016). sari et al., (2015) revealed that the reduction of hypoxia and reduction of activation of matrix metalloproteinase-2 and matrix metalloproteinase-9 are the mechanisms that are responsible for the acceleration of wound healing following vibration. studies reveal that es has been utilised for many health purposes because it can improve blood flow. humans create a type of electricity called bioelectricity. following an injury to the skin, a low current flows between the skin and underlying tissue, which is called the current of injury. this is important during the wound healing process (kim, cho and lee, 2014). the electric current which is used in es is a low current (microampere, μa). thus, the low current of es therapy reflects the bioelectric current created by the body (ud-din and bayat, 2014) . results of studies both in vitro and in vivo reveal that es improves the healing process by promoting keratinocyte migration, improving wound perfusion, stimulating collagen synthesis (kim, cho and lee, 2014), and inducing angiogenesis (liebano and machado, 2014). (liebano and machado, 2014). a previous in vitro study revealed that es could also reduce inflammation (cho et al., 2000). in results similar to the effect of vibration, previous studies have also shown that es accelerates wound healing in pressure, ischemic and diabetic ulcers (eriksson et al., 1981; goldman et al., 2003; koel and houghton, 2014). based on the above studies, both vibration and es could improve wound healing. however, up to the present, there is no study that compares the effectiveness of the two complementary therapies, therefore, which therapy is better for accelerating wound healing of diabetic ulcer is still unknown. materials and methods research design this was an experimental study utilising post-test only, using a control group design approach. electrical stimulation device (figure 1) electrical stimulation consisted of two main parts, the electrodes and power supply. the electrodes served as a distributor of electrical current to the skin and were constructed from corrosion-resistant metal that could easily be attached to the skin. the power supply provided electric current to both electrodes. the current generated was a square wave of electrical pulses whose amplitude and frequency could be varied (sari, sutrisna and hartono, 2017). the electrodes were attached to the skin as shown in figure 2. based on previous research, es was applied for 10 minutes every day for 7 days (20 hz, 320 µs, 50 µa) (sari, sutrisna and hartono, 2017). 1. electrical stimulation device figure 2. the application of es in rat skin figure 3. rat was placed on the vibrating device. the wound is at the centre of the vibrating device. a comparative study of the effects of vibration... (yunita sari et al.) 255 vibration device the vibration device which was used in this study was originally constructed by our research team (sari, sutrisna and hartono, 2016). in brief, the vibration bed consisted of 3 vibrating motors and its frequency can be varied by changing the velocity. the application of the use of vibration bed for the rat can be seen in figure 3. the rats were given an application of vibration for 10 minutes once a day for 7 days. animal this study used male wistar rats aged 12-14 weeks. the rat’s body weight was in the range of 190-220 grams. the rats had free access to food and drink. the protocol of this study was approved by the research committee ethics for an animal study, of the faculty of medicine, jenderal soedirman university (1208/kepk/iii/2017). the rats were divided into two groups, vibration-treated and electrical stimulationtreated. every day, the wounds were washed with saline in both groups prior to being covered with a film dressing. induction of rats the rats were acclimatised for 7 days before the induction of diabetes by injection of alloxan monohydrate (sigma aldrich, usa) at a dose of 90 mg/kg. blood was drawn from the tail vein 4 days after induction to assess whether the blood glucose concentration had increased. the rats were considered diabetic when their blood glucose was greater than 250 mg/dl. the rats were shaved the day prior to wounding. the rats were anesthetised with ketamile (25-30 mg/kg body weight) during the shaving and wounding procedures. the procedure of wounding was according to the previous publication (sari et al., 2015a) the diameter of each wound was 1 cm, extending to the panniculus carnosus. the wounds were cleaned with normal saline, dried with gauze then covered with a parafilm dressing. the wound was monitored daily from day 0 to 7 and recorded with a digital camera. tissue staining the rats were sacrificed on day 7 using an overdose of ketamile. the tissue samples were fixed in 10% formalin then processed and embedded into paraffin. the samples were sectioned and then stained with a hematoxylin and eosin (h&e). sections were observed using a light microscope. the inflammation and infiltration of inflammatory cells were indicated by blue staining in the h&e sections. wound size the size of the wound was measured by using imagej software from the national health institute. the wound area was determined based on the inner wound margins (ueda et al., 2010) the relative wound areas were determined as (day n area – day 0 area) / (day 0 area). (ueda et al., 2010) reepithelialisation reepithelialisation was indicated by the presence of new epithelial tissue in the epidermis layer. reepithelialisation was observed with a light microscope. the result of the study was described qualitatively. statistical analysis statistical analysis was performed by spss software, version 16. the data of the wound size was analysed by an independent ttest. the histological result was analysed by a mann-whitney u-test. the value of p < 0,05 was considered to be significant. results the result of the macroscopical findings could be seen in figure 4. on day 0, the visual appearance of the wound was similar in both groups. on day 1 to day 3, the wound base in both groups started to be filled with granulation tissue. on day 3, the wound size in the vibration group tended to be smaller table 1. intensity of inflammation and fibroblast between vibration and es group groups pmns fibroblas vibration 2* 3* electrical stimulation 3 2 values indicated median score rating scale : 0 = absent, 1= occasional, 2 = moderate, 3 = abundant, >3 = very abundant * p< 0.05 pmns = polymorphonuclear neutrophils jurnal ners vol. 12 no. 2 oktober 2017: 253-260 256 compared with the es group. on day 5, the granulation tissue in both groups was increased. however, there was a thin layer of slough in the es group, which was not present in vibration group. on day 7, the thin layer of the slough was still present in the es group. the difference of the wound size between two groups could be seen in figure 5. there was no significant difference in wound size between vibration therapy and es from day 0 to day 3. however, the wound size in the vibration group was significantly smaller than in the es group on day 4 to day 7 (p=0,011 on day 4, p=0.025 on day 5, p=0.005 on day 6, p=0.0001 on day 7). the microscopical difference between the vibration and es group in the epidermis and dermis layers can be seen in figure 6. the intensity of inflammation in both the epidermis and dermis layer in the vibration group was less compared to the inflammation in the es group. the intensity of the fibroblasts was higher in the vibration group than in the es group. the difference in the histological findings can be seen in table 1. the intensity of inflammation was significantly less in the vibration compared with the es group (p=0,034), and the fibroblast intensity was higher in the vibration compared with the es group (p=0,045). discussion this study is the first study in the literature that compares vibration and electrical stimulation in accelerating the wound healing of diabetic ulcers. in this study, we found that wounds heal better if treated with vibration therapy compared with electrical stimulation. the previous study revealed that es could reduce inflammation, improve blood flow, reduce the bacterial burden, reduce pain and edema, decrease muscle spasms, and improve tgf-β1, collagen-i, and muscle figure 4. macroscopical findings of the wounds treated with vibration (upper picture) and electrical stimulation (lower picture) (bar = 1 cm) figure 5. the comparison of the wound size between the wounds treated with vibration and electrical stimulation (* p< 0.05, **p< 0.01) a comparative study of the effects of vibration... (yunita sari et al.) 257 contraction (demir, balay and kirnap, 2004; sebastian et al., 2011; kim, cho and lee, 2014; torkaman, 2014). recent research by the author has shown that compared with the standard treatment, wounds treated with es showed a reduction in inflammation and an increase in re-epithelialisation (sari, sutrisna and hartono, 2017). a reduction in inflammation following es in diabetic ulcers might be due to the ability of es to enhance phagocytosis (cho et al., 2000). the improvement of reepithelialization might be due to the ability of es to promote keratinocyte migration (kim, cho and lee, 2014). based on previous studies, vibration could also accelerate the healing of diabetic ulcers, such as in pressure ulcers stage i, deep tissue injuries, and diabetic ulcers (arashi et al., 2010; sari, sanada, et al., 2015; sari, sutrisna and hartono, 2016). vibration therapy that can accelerate the healing of diabetic ulcer is a vibration which is applied at a low frequency. if the vibration is applied at a high frequency, it will cause tissue damage (sari, sutrisna and hartono, 2016). a high frequency of vibration might cause an excessive increase of reactive oxygen species and nitric oxide that causes the vasoconstriction of blood vessels (hughes et al., 2009). in this study, the author used a vibration of 40 hz and es with a frequency of 20 hz, pulse width of 320 hz at a current of 50 µa. these values were chosen after previous studies by the author, and other researchers found that wounds healed using those ranges of frequency and currents (torkaman, 2014; sari, sutrisna and hartono, 2017). the previous study revealed that a vibration below 50 hz could accelerate the wound healing of chronic ulcers (arashi et al., 2010; sari, et al., 2015). the author investigated a vibration frequency range and determined that a frequency of 40 hz accelerated the healing of diabetic ulcers (sari, sutrisna and hartono, 2016). in relation to es, the author also found that the frequency of 20 hz, the pulse width of 320 hz and a current of 20 μa could accelerate the healing of diabetic ulcers (sari, sutrisna and hartono, 2017). in this study, we found that wound healing in diabetic ulcers using vibration was better than using es. the wound sizes were smaller when treated with vibration and showed a greater reduction in inflammation compared with the wounds treated using es. however, the mechanism for this difference remains unknown. in this study, the vibration was experienced by the entire body, and so it is possible that blood flow might increase systemically and not only to the wound area. however, blood flow is likely to increase only in the wound area during es, since the electrodes were placed directly on the wound. in patients with dm, increased blood flow around the body is important since high blood glucose frequently causes plaque that can result in impaired blood flow. another study is needed to elucidate the mechanism as to why figure 6. the histological findings of the epidermis and dermis layer between the vibration and es groups. hematoxylin and eosyn staining in the epidermis layer (upper part) and dermis (lower part) between vibration and electrical stimulation (magnification of 400x) figure 7. re-epithelialisation between the vibration and es group. reepithelialisation was longer in the vibration group than in electrical stimulation group (arrow line indicates length of reepithelialisation, magnification of 100x) jurnal ners vol. 12 no. 2 oktober 2017: 253-260 258 the wound healed better in vibration compared with in es. in this study, all of the animals with diabetic ulcers survived during the observation of wound healing. however, es can sometimes cause skin tearing. it is, therefore, reasonable to suggest that vibration therapy is safer than es. the results of this study are very important since it is the first study that establishes that vibration accelerates wound healing in diabetic ulcers to a greater extent than es. nurses should consider using complementary therapies such as vibration to accelerate the healing of diabetic ulcers instead of using es. conclusions this study is the first study in the literature to investigate the comparison of the effect of vibration therapy and electrical stimulation therapy in accelerating the wound healing of diabetic ulcers. in this study, we revealed that wounds treated with vibration therapy healed better than by es therapy. besides, this is the first study in the literature that compares the effect of vibration therapy with electrical stimulation therapy in relation to the wound healing of diabetic ulcers. we have demonstrated that the wounds treated with vibration therapy healed better than by es therapy, and so we suggest that nurses in clinical settings use complementary vibration therapy instead of es when treating wounds. in this study, we used animals since we wanted to investigate the healing of the wounds in diabetic ulcers in deep tissue. in the future, we will compare the effects of vibration and es in human subjects. acknowledgment this study was funded by the penelitian unggulan perguruan tinggi grant from the ministry of research, technology and higher education. the researcher would like to thank wawan setiawan and genti larasati for their assistance during the animal experiments. references addison, g. m. et al. (1972) ‘prostaglandin e1 in severe’, pp. 155–156. arashi, m. et al. (2010) ‘vibration therapy accelerates healing of stage i pressure ulcers in older adult patients’, advances in skin & wound care, 23(7), pp. 321–327. doi: 10.1097/01.asw.0000383752.39220 .fb. armstrong, d. g., wrobel, j. and robbins, j. m. (2007) ‘guest editorial: are diabetes-related wounds and amputations worse than cancer?’, international wound journal, 4(4), pp. 286–287. doi: 10.1111/j.1742481x.2007.00392.x. brechow, a. et al. (2013) ‘improving major amputation rates in the multicomplex diabetic foot patient: focus on the severity of peripheral arterial disease’, therapeutic advances in endocrinology and metabolism, 4(3), pp. 83–94. doi: 10.1177/2042018813489719. v c lees, t. p. d. f. (1994) ‘a freeze-injured skin graft model for the quantitative study of basic fibroblast growth factor and other promoters of angiogenesis in wound healing’, br j plast surg, 47, pp. 349–359. cho, m. r. et al. (2000) ‘integrin-dependent human macrophage migration induced by oscillatory electrical stimulation.’, annals of biomedical engineering, 28(3), pp. 234–43. doi: 10.1114/1.263. demir, h., balay, h. and kirnap, m. (2004) ‘a comparative study of the effects of electrical stimulation and laser treatment on experimental wound healing in rats.’, journal of rehabilitation research and development, 41(2), pp. 147–54. doi: 10.1682/jrrd.2004.02.0147. eriksson, e. et al. (1981) ‘effect of electrical stimulation on human skeletal muscle.’, international journal of sports medicine, 2(1), pp. 18–22. doi: 10.1055/s-2008-1034578. goldman, r. et al. (2003) ‘electrotherapy promotes healing and microcirculation of infrapopliteal ischemic wounds: a prospective pilot study.’, advances in skin & wound care, 17(6), pp. 284–294. doi: 10.1097/00129334-20040700000010. hughes, j. m. et al. (2009) ‘increased oxidant activity mediates vascular a comparative study of the effects of vibration... (yunita sari et al.) 259 dysfunction in vibration injury.’, the journal of pharmacology and experimental therapeutics, 328(1), pp. 223–30. doi: 10.1016/s07494041(09)79206-1. izumi, y. et al. (2006) ‘risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation’, diabetes care, 29(3), pp. 566–570. doi: 10.2337/diacare.29.03.06.dc05-1992. kim, t. h., cho, h. and lee, s. m. (2014) ‘high-voltage pulsed current stimulation enhances wound healing in diabetic rats by restoring the expression of collagen, α-smooth muscle actin, and tgf-β1’, the tohoku journal of experimental medicine, 234(1), pp. 1–6. doi: 10.1620/tjem.234.1. koel, g. and houghton, p. e. (2014) ‘electrostimulation: current status, strength of evidence guidelines, and meta-analysis’, advances in wound care, 3(2), pp. 118–126. doi: 10.1089/wound.2013.0448. liebano, r. e. and machado, a. f. p. (2014) ‘vascular endothelial growth factor release following electrical stimulation in human subjects.’, advances in wound care, 3(2), pp. 98–103. doi: 10.1089/wound.2013.0427. moulik, p. k., mtonga, r. and gill, g. v. (2003) ‘amputation and mortality in new-onset diabetic foot ulcers stratified by etiology’, diabetes care, 26(2), pp. 491–494. doi: 10.2337/diacare.26.2.491. nagase, t. et al. (2007) ‘heterotopic ossification in the sacral pressure ulcer treated with basic fibroblast growth factor: coincidence or side effect?’, journal of plastic, reconstructive & aesthetic surgery, 60(3), pp. 327–329. doi: 10.1016/j.bjps.2005.11.043. nakagami, g. et al. (2007) ‘effect of vibration on skin blood flow in an in vivo microcirculatory model’, bioscience trends, 1(3), pp. 161–166. sari, y., saryono, et al. (2015) ‘modifikasi pompa asi sebagai terapi luka bertekanan negatif untuk mempercepat penyembuhan luka diabetes’, 10(1), pp. 104–111. sari, y., sanada, h., et al. (2015) ‘vibration inhibits deterioration in rat deeptissue injury through hif1-mmp axis’, wound repair and regeneration, 23(3), pp. 386–393. doi: 10.1111/wrr.12286. sari, y., sutrisna, e. and hartono (2016) ‘pengaruh frekuensi vibrasi terhadap penyembuhan luka diabetes the provision of different vibration frequency to accelerate diabetic wound healing’, jurnal keperawatan padjajaran, 4, pp. 117–126. sari, y., sutrisna, e. and hartono (2017) ‘the effect of electrical stimulation on promoting wound healing in diabetic ulcer’, in the 3rd international conference on nursing (icon) 2017. malang, indonesia. sebastian, a. et al. (2011) ‘acceleration of cutaneous healing by electrical stimulation: degenerate electrical waveform down-regulates inflammation, up-regulates angiogenesis and advances remodeling in temporal punch biopsies in a human volunteer study’, wound repair and regeneration. mosby, inc., 19(6), pp. 693–708. doi: 10.1111/j.1524-475x.2011.00736.x. shaw, j. e., sicree, r. a. and zimmet, p. z. (2010) ‘global estimates of the prevalence of diabetes for 2010 and 2030’, diabetes research and clinical practice, 87(1), pp. 4–14. doi: 10.1016/j.diabres.2009.10.007. soewondo, p., ferrario, a. and tahapary, d. (2013) ‘challenges in diabetes management in indonesia: a literature review’, globalization and health, 9(1), p. 63. doi: 10.1186/1744-8603-9-63. torkaman, g. (2014) ‘electrical stimulation of wound healing: a review of animal experimental evidence’, advances in wound care, 3(2), pp. 202–218. doi: 10.1089/wound.2012.0409. ud-din, s. and bayat, a. (2014) ‘electrical stimulation and cutaneous wound healing: a review of clinical evidence’, healthcare, 2(4), pp. 445–467. doi: jurnal ners vol. 12 no. 2 oktober 2017: 253-260 260 10.3390/healthcare2040445. ueda, k. et al. (2010) ‘a possible animal model for critical colonisation.’, journal of wound care, 19(7), pp. 295–300. wu, s. c. et al. (2007) ‘foot ulcers in the diabetic patient, prevention and treatment’, vascular health and risk management, 3(1), pp. 65–76. doi: 10.3310/hta13540. yusuf, s. et al. (2016) ‘prevalence and risk factor of diabetic foot ulcers in a regional hospital , eastern indonesia’, open journal of nursing, 6(january), pp. 1–10. doi: 10.4236/ojn.2016.61001. vol 8 no 1 april 2013.indd 41 profil antigen ns1 dengan hari sakit (los) pada anak dengan infeksi virus dengue (the relationship of ns1 antigen profi le and days of illness in children with dengue virus infection) dwiyanti puspitasari*, saraswati dewi*, aryati** *departemen ilmu kesehatan anak fakultas kedokteran universitas airlangga **departemen patologi klinik fakultas kedokteran universitas airlangga e-mail: yanti@dr.com abstrak pendahuluan: deteksi atau kuantifi kasi antigen ns1 dengue (ns1 ag) telah menjadi alat diagnostik yang spesifi k untuk infeksi virus dengue, tetapi memiliki sensitivitas variabel. penelitian sebelumnya melaporkan tingkat ns1 ag dapat dideteksi sampai dengan tanggal 7–10 hari demam, penelitian lain menyatakan bahwa sensitivitas menurun setelah empat hari demam. penelitian ini dilakukan untuk menganalisis ns1 ag profi l dan hubungannya dengan hari sakit. metode: penelitian ini merupakan studi kohort prospektif pada 39 anak dirawat di dr. soetomo surabaya bulan november 2009 sampai mei 2010. kriteria inklusi adalah demam akut kurang dari 72 jam, perdarahan setidaknya dengan uji tourniquet positif, umur antara 1–14 tahun, dan positif dengue igm/igg pada hari ke-5 demam. penelitian ini dilakukan setiap hari dengue ns1 ag tes kuantitatif sampai hari penurunan suhu badan sampai normal, dan hubungannya dengan hari penyakit dianalisis. hasil: ns1 ag positif pada 19/39 sampel. infeksi sekunder terjadi pada 14/19 kasus dan 17/20 kasus. kepositifan ns1ag lebih tinggi pada primer (6/8 kasus) dibandingkan dengan infeksi sekunder (12/31 kasus). berarti tingkat ns1 ag tertinggi pada hari ke-2, setelah itu menurun dan tidak terdeteksi pada hari ke-5 demam. ada hubungan yang signifi kan antara ns1 ag positif (p=0,037, rs=-0.9) dan tingkat (p<0,001, rs=-1) dengan hari sakit. diskusi: dengue ns1 ag positif dan tingkat yang tertinggi selama fase akut demam dan menurun setelahnya. kata kunci: dengue ns1 ag, positif, hari sakit, infeksi virus dengue, anak abstract introduction: dengue ns1 antigen (ns1 ag) detection or quantifi cation has become a specifi c diagnostic tool for dengue virus infection, but has variable sensitivity. previous research reported ns1 ag level can be detected up to the 7th–10th day of fever, others stated the sensitivity was decreased after four days of fever. we performed this research to analyze the ns1 ag profi le and its relationship with the day of illness. methods: this study was a prospective cohort study on 39 children hospitalized at dr. soetomo hospital surabaya since november 2009 to may 2010. inclusion criteria were acute fever less than 72 hours, bleeding tendency denoted at least by positive tourniquet test, age between 1–14 years, and confi rmed by positive dengue igm/igg on the 5th day of fever. we performed daily quantitative dengue ns1 ag tests until defervescence day, and its relationship with the day of illness were analyzed. results: ns1 ag was positive in 19/39 samples. secondary infection occurred in 14/19 of dengue fever and 17/20 of dengue hemorrhagic fever cases. positivity of ns1ag was higher in primary (6/8 cases) than secondary infection (12/31 cases). mean level of ns1 ag was highest on the 2nd day, decreased afterwards and undetected on the 5th day of fever. there was signifi cant relationship between ns1 ag positivity (p=0.037, rs=-0.9) and level (p<0.001, rs=-1) with the day of illness. discussions: dengue ns1 ag positivity and level were highest during the acute phase of fever and decreased afterwards. keywords: dengue ns1 ag, positivity, days of illness, dengue virus infection, child 42 jurnal ners vol. 8 no. 1 april 2013: 41–46 pendahuluan manifestasi klinis infeksi virus dengue sangat bervariasi mulai dari asimptomatis hingga demam berdarah dengue dengan sindrom renjatan yang berak hir dengan kematian (who, 1997). pada awal sakit tidak mudah membedakan infeksi vir us dengue dengan penyebab demam akut lain. deteksi trombositopenia, immunoglobulin m (igm), dan g (igg) anti dengue umumnya bar u tampak setelah demam hari ke4, yang terkadang sudah terlambat. saat ini, deteksi maupun kuantifi kasi antigen nonstruktural 1 (ag ns1) dengue yang beredar bebas di sirkulasi pada fase akut telah menjadi diagnosis spesifi k untuk virus dengue, tetapi memiliki sensitivitas yang bervariasi (alcon, 2002, libraty 2002, kumarasany, 2007). pe nel it ia n t e rd a hu lu me mpu nyai positivitas ag ns1 dengue yang berbedabeda berdasar hari sakit. ag ns1 terdeteksi pada fase akut sampai dengan hari ke-10 dari serum penderita infeksi virus dengue. kadarnya berkorelasi dengan titer infeksius virus dengue (hang, 2009). positivitas dan kadar ag ns1 tinggi pada hari ke-0 sampai ke4 demam, dan menur un setelah hari ke-5 demam (dussart, 2006). penelitian lain mendapatkan sensitivitas ag ns1 tetap tinggi (81,8%-91,9%) pada penderita infeksi virus dengue hingga hari ke-7 sakit (hu, 2011). tujuan penelitian ini dilakukan untuk menganalisis hubungan profi l ag ns1 dengan hari sakit pada anak dengan infeksi virus dengue, sehingga dapat memberikan petunjuk pada klinisi kapan sebaiknya melakukan pemeriksaan ini. bahan dan metode penelitian yang kami lakukan adalah kohor t prospektif yang bersifat analitik observasional. pengambilan sampel dilakukan di instalasi rawat jalan, rawat darurat, dan rawat inap anak rsud dr. soetomo surabaya, mulai bulan november 2009 sampai dengan mei 2010, dan telah disetujui oleh panitia etik penelitian kesehatan rsud dr. soetomo. sampel dipilih dengan cara consecutive sampling, secara statistik penghitungan besar sampel menggunakan rumus penghitungan besar sampel untuk analisis korelasi, dengan r=0,5 dari penelitian terdahulu (libraty, 2002) didapatkan besar sampel minimal (n total) adalah 29 penderita. kriteria inklusi adalah penderita demam pendek (≤72 jam), usia 12 bulan–14 tahun, terdapat tanda perdarahan, minimal uji tourniquet positip, tidak jelas terdapat fokus infeksi lain, orang tua bersedia dilibatkan dalam penelitian dan dilakukan rawat inap dengan menandatangani inform consent. penderita dengan kelainan hematologi, penyakit jantung, paru, penderita imunokompromis (hiv, sle, keganasan, gizi buruk), serta penderita dengan pengobatan asam salisilat atau aspirin, yang dapat mempengar uhi kadar serologis/ ns1 dan tampilan klinis infeksi virus dengue dieksklusi dari sampel. variabel yang kami teliti adalah kadar ag ns1 dengue serial, igm/igg anti dengue, jenis infeksi dengue (primer/sekunder) dan hari sakit. penderita diperiksa ag ns1 kuantitatif serial tiap hari mulai saat masuk rumah sakit (mrs) sampai dengan hari defervescence, m e n g g u n a k a n p l a t e l i a d e n g u e n s1 quantifi cation assay bio rad. dinyatakan positif bila ag ns1 mencapai titer 150 bru/ ml. pada penelitian dussart 2006, didapatkan sensitivitasnya 88,7% (95%ci 84–92,4%) dan spesifi sitas 100% (95% ci 84,9–100%) (dussart, 2006). konfirmasi infeksi virus deng ue dilak u kan melalui pemeriksaan antibodi anti dengue igm/igg captured elisa panbio pada hari sakit ke-5. digolongkan infeksi primer dengue bila didapatkan perbandingan titer igm/igg >1,2, dan infeksi sekunder bila rasionya <1,2. luaran yang dilihat adalah profi l ag ns1 dengue, hari sakit dan jenis infeksi virus dengue. analisis positivitas dan kadar ag ns1 dihubungkan dengan hari sakit pada anak dengan infeksi virus dengue. hari sakit diperoleh dari anamnesis, hari sakit ke-1 adalah hari pertama penderita mengalami demam, hari sakit ke-2 adalah hari kedua penderita demam, demikian seterusnya. hari defervescence adalah hari di mana suhu badan kembali normal tanpa pemberian antipiretik. diagnosis akhir penderita dengue dibuat berdasarkan kriteria who 1997, dibedakan 43 profi l antigen ns1 dengan hari sakit (los) pada anak (dwiyanti puspitasari, dkk.) menjadi demam dengue dan demam berdarah dengue (derajat i, ii, iii, iv). uji statistik yang kami gunakan adalah uji t2 sampel bebas dan korelasi spearman dengan program spss ver.15.0, dan tingkat kemaknaan (α) sebesar <0,05. hasil selama periode penelitian ini didapatkan 45 sampel yang memenuhi kriteria inklusi dan eksklusi. selanjutnya, 6 sampel tidak dianalisis oleh karena pemeriksaan serologi igm dan igg dengue sebagai konfi rmasi infeksi virus dengue hasilnya negatif. umur rerata subjek penelitian adalah 7,5 tahun, dengan rentang 1–13 tahun. perbandingan anak laki-laki dibanding perempuan 1:1,05. hasil pemeriksaan ag ns1 positif pada 19/39 sampel, meliputi demam dengue 8/18 sampel, 11/20 sampel demam berdarah dengue. positivitas ag ns1 tertinggi pada hari sakit ke-2, menur un menjelang dan bersamaan dengan defervescence. hasil uji korelasi spearman didapatkan hubungan yang bermakna antara positivitas ag ns1 dengan hari sakit (p=0,037, rs=-0,9), dengan interpretasi semakin meningkat hari sakit positivitas ag ns1 semakin menurun. rerata kadar ag ns1 juga tertinggi pada hari sakit ke 2, menurun menjelang dan bersamaan dengan defervescence. pada hari sakit ke-5 saat hari defervescence terbanyak, rerata kadar menjadi negatif. semakin meningkat hari sakit kadar ag ns1 semakin menurun (p<0,001, rs=-1). (tabel 1) i nfeksi sek u nder pad a penelit ia n ini terjadi pada 14/19 demam dengue dan 17/20 kasus demam berdarah dengue. pada infeksi primer, 6/8 sampel memiliki ag ns1 positif, sedangkan hanya 12/31 sampel infeksi sekunder memiliki ag ns1 positif. rerata (sd) kadar ag ns1 pada infeksi primer 620 (385) bru/ml, lebih tinggi daripada infeksi sekunder (252 (335) bru/ml) dengan p=0,011, 95%ci -645 sampai -91. pola rerata kadar ag ns1 serial menurut hari sakit berdasarkan jenis infeksi ditunjukkan pada grafi k 2. pembahasan p e m e r i k s a a n a g n s1 d e n g u e mempunyai positivitas beragam. penelitian kami mendapatkan positivitas ag ns1 48,7%. penelitianpenelitian terdahulu mendapatkan sensitivitas dari pemeriksaan ag ns1 menggunakan kit yang sama berkisar 37–93,4% (ku marasany, 2007; bessof, 2010; osorio, 2010). penelitian kumarasany dengan sensitivitas ag ns1 yang tinggi (93,4%) mempunyai sampel infeksi primer lebih besar (86,4%), dengan positivitas ag ns1 lebih besar (97,3%) pada infeksi primer dibandingkan infeksi sekunder (kumarasany, 2007). penelitian lain juga mendapatkan ag ns1 terdeteksi lebih banyak pada infeksi primer dibandingkan infeksi sekunder dengue (kumarasany, 2007; chuansumrit, 2008; hang, 2009). tricou di vietnam mendapatkan positivitas ag ns1 sebesar 61,6%, dengan jumlah sampel infeksi primer (26,9%) lebih sedikit dibanding sekunder (71,8%), dan positivitas lebih tinggi pada infeksi dengue primer (80,3%) dibanding sekunder (55,1%). menurut tricou, infeksi sekunder merupakan salah satu faktor yang menyebabkan ag ns1 ditemukan negatif pada sampel (tricou, 2010). pada penelitian kami positivitas ns1 ag pada infeksi dengue primer lebih tinggi, yaitu 6/8 (75%) kasus. sebagian besar (79,5%) sampel kami merupakan infeksi sekunder tabel 1. hasil pemeriksaan ag ns1 berdasarkan hari sakit hari sakit-1 (n=1) hari sakit-2 (n=6) hari sakit-3 (n=39) hari sakit-4 (n=38) hari sakit-5 (n=32) hari sakit-6 (n=6) uji spearman ag ns1 positif (jumlah) 0 4 18 12 5 1 p = 0,037 rs = -0,9 rerata kadar ag ns1 (sd) (bru/ml) 0 (0) 526,8 (411,2) 356,6 (380,8) 215,8 (336,5) 95,3 (233,4) 90,2 (220,8) p < 0,001 rs = -1 44 jurnal ners vol. 8 no. 1 april 2013: 41–46 yang mempunyai positivitas ag ns1 rendah (38,7%). rendahnya positivitas ag ns1 pada infeksi sekunder oleh karena rendahnya kadar ag ns1. rendahnya kadar ag ns1 pada infeksi sekunder diperkirakan oleh karena sejumlah besar ag ns1 berikatan dengan antibodi pada fase akut dan terjadi sequestered komplek imun (libraty, 2002; dussart, 2008; hang, 2009) serta terjadinya ikatan ag ns1 dengan sel endotel (avirutnan, 2007). dua hal tersebut menyebabkan berkurangnya ag ns1 bebas di sirkulasi dan tidak tercapainya epitop target oleh monoklonal ab pada pemeriksaan (hang, 2009). pada penelitian kami, rerata kadar ag ns1 tinggi pada awal sakit, tertinggi pada hari sakit ke-2, menurun menjelang dan bersamaan dengan defervescence. pada infeksi primer, rerata kadar ag ns1 tetap terdeteksi hingga defervescence, bila dibandingkan dengan infeksi sekunder yang reratanya mulai tidak terdeteksi pada hari ke4 demam. pada penelitian libraty, rerata kadar ag ns1 paling tinggi pada awal sakit, baik pada demam dengue maupun demam berdarah dengue, kemudian mengalami penurunan (libraty, 2002). ag ns1 terdeteksi pada fase akut hingga tujuh (kumarasany, 2007) sampai sepuluh (avirutnan, 2007) hari kemudian. chuansumrit pada penelitian infeksi virus dengue, menunjukkan penurunan positivitas dengan bertambahnya hari sakit, hari sakit ke-2 100%, hari sakit ke-3 92,3%, hari sakit-4 56,5%, hari sakit-5 56,6%, hari sakit ke-6 saat defervescence 43,1% dan hari sakit ke-7 29,8% (chuansumrit, 2008). alcon menemukan ag ns1 berada di sirkulasi dan mencapai kadar puncak antara hari sakit ke-2 dan ke-4 dan grafi k 1. positivitas ag ns1 berdasarkan hari sakit 0 10 20 30 40 50 60 70 80 1 2 3 4 5 6 persentase hari sakit grafi k 2. rerata kadar ag ns1 serial sepanjang hari sakit berdasarkan jenis infeksi 45 profi l antigen ns1 dengan hari sakit (los) pada anak (dwiyanti puspitasari, dkk.) turun pada fase konvalesen (alcon, 2002). positivitas ag ns1 tinggi pada awal sakit ini menunjukan secreted ag ns1 pada fase tersebut dan dapat digunakan sebagai petunjuk adanya infeksi vir us dengue. terjadinya penurunan kadar ag ns1 menjelang dan bersamaan dengan defervescence oleh karena virus dengue yang beredar dalam darah selama 4–5 hari fase panas hilang saat defervescence (who, 2005; avirutnam 2006). pada infeksi sekunder, rerata kadar ag ns1 menurun lebih cepat mungkin disebabkan adanya ikatan ag ns1 dengan antibodi pada fase akut (libraty. 2002; dussart, 2008; hang, 2009). rendahnya positivitas ag ns1 juga mungkin dipengaruhi oleh serotipe virus dengue. pada penelitian terdahulu disebutkan bahwa di surabaya didominasi oleh serotipe den 2 (soegijanto, 2010). menurut penelitian hang, deteksi ag ns 1 pada den 2 (55%) lebih rendah daripada deteksi terhadap den 1 (98%) serta den 3 (96%). penyebab rendahnya positivitas pada den 2 oleh karena terdapat kecenderungan banyaknya infeksi sekunder berhubungan dengan den2 (hang, 2009). hal yang sama ditemukan pada penelitian bessoff, ag ns1 positif pada den 2 (82,2%) dan den 4 (70,9%) lebih rendah daripada den 1 (92,9%) dan den 3 (86,5%), berhubungan dengan kejadian infeksi sekunder pada den 2 (88,9%), den 4 (89%) lebih tinggi daripada den 1 (53,6%) dan den 3 (59,6%) (bessof, 2010). beberapa keterbatasan penelitian ini antara lain: pada penelitian ini tidak dilakukan pemeriksaan kultur virus sebagai standar baku emas diagnostik infeksi virus dengue, dan tidak memeriksa viral load yang dapat digunakan untuk menganalisis korelasi antara positivitas dan kadar ag ns1 berdasarkan hari sakit dengan viral load. simpulan dan saran simpulan ada hubungan antara positivitas dan kadar ag ns1 dengan hari sakit. positivitas dan kadar ag ns1 tertinggi pada hari-hari awal sakit dan akan menurun dengan bertambahnya hari sakit. saran pemeriksaan ag ns1 sebagai alat bantu dignosis infeksi virus dengue sebaiknya dilakukan pada hari-hari awal demam. daftar pustaka alcon, s., talarmin, a. debruyne, m., dkk., 2002. enzyme linked immunosorbent assay specific to dengue virus type 1 nonstructural protein ns1 reveals circulation of the antigen in the blood during the acute phase of disease in patients exper iencing pr imar y or secondary infections. j clin microbiol, 40, 376–81. avirutnan, p., zhang, l., punyadee n., dkk., 2007. ns1 of dengue virus attaches to the surface of cells via interactions with heparin sulfate and chondroitin sulfate e. plos pathog. (online), (http:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc2092380/?tool=pubmed, diakses tanggal 1 maret 2012, jam 09.55 wib). bessoff, k., phoutrides, e., delorey, m., dk k., 2010. utility of commercial nonstructural protein 1 antigen capture kit as a dengue virus diagnostic tool. clin vaccine imunol., 6, 943–53. c h u a n s u m r i t a . , c h a i y a r a t a n a w, pongthanapisith v, dkk., 2008. the use of dengue nonstructural protein 1 antigen for the early diagnosis during the febrile stage in patients with dengue infection. pediatr infect dis j., 27: 43–8. dussart p., labeau b., lagathu gl, dkk., 2006. evaluation of an enzyme immunoassay for detection of dengue vir us ns1 antigen in human ser um. clin vac immunol., 13: 1185–9. dussart, p., petit, l., labeau, b., dkk., 2008. evaluation of two new commercial tests for the diagnosis of acute dengue vir us infection using ns1 antigen detection in human serum. plos negl trop dis. (online), (http://www.ncbi. nlm.nih.gov/pmc/articles/pmc2500180/ ?tool=pubmed, diakses pada 5 maret 2012, jam 08.55 wib). hang, vt., nguyet, nm., trung, dt., dkk., 2009. diagnostic accuracy of ns1 elisa and lateral fl ow rapid test for dengue 46 jurnal ners vol. 8 no. 1 april 2013: 41–46 sensitivity, specifi city and relationship to viremia and antibody response. plos negl trop dis (online),(http://www. plosntds.org/article/info%3adoi%2f10. 1371%2fjournal.pntd.0000360, diakses tanggal 3 maret 2012, jam14.00 wib). hu, d., di, b., ding, x., dkk., 2011. kinetics of non-strutural protein 1, igm and igg antibodies in dengue type 1 primary infection. virol j (online), (http://www. biomedcentral.com/content/pdf/1743422x-8-47.pdf, diakses tanggal 4 maret 2012, jam 11.23 wib). kumarasamy, v., wahab, aha., chua, sk., dkk., 2007. evaluation of commercial dengue ns1 antigen-capture elisa for laboratory diagnosis of acute dengue virus infection. j virol methods., 140: 75–9. libraty, dh., young, pr., pickering, d., dkk., 2002. high circulating levels of the dengue virus nonstructural protein ns1 early in dengue illness correlate with the development of dengue hemorrhagic fever. j infect dis., 186: 1165–8. osorio, l., ramirez, m., bonelo, a., dkk., 2010. comparison of the diagnostic accuracy of commercial ns1-based diagnostic tests for early dengue infection. virol j (online), (http://www.biomedcentral. com/content/pdf/1743-422x-7-361.pdf, diakses tanggal 3 maret 2012, jam 20.00 wib). soegijanto, s., darmowandowo, w., ginting ap., dkk., 2010. serotype and clinical performance of dengue virus infection on the year 2009. indonesian journal of tropical and infectious disease, 1: 55–9. tricou, v., vu, h., quynh, n., dkk., 2010. comparison of two dengue ns1 rapid tests for sensitivity, specificity and relationship to viraemia and antibody responses. bmc infect dis. (online), (ht t p://w w w.ncbi.nlm.nih.gov/pmc/ articles/pmc2895602/?tool=pubmed, diakses tanggal 16 februari 2012, jam 09.00 wib). who, 1997. dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd ed. geneva: world health organization. who, 2005. dengue, dengue haemorrhagic fever and dengue shock syndrome in context of the integrated management of childhood illness, (online), (http:// whqlibdoc.who.int / hq/2005/ w ho_ fch_cah_05.13_eng.pdf, diakses pada 1 maret 2012, jam 09.00 wib). p-issn: 1858-3598  e-issn: 2502-5791 183 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 183-189 http://dx.doi.org/10.20473/jn.v17i2.39448 original article open access stigma and discrimination against breast cancer survivors in indonesia: an interpretive phenomenology study ida ayu made ari santi tisnasari 1 , tuti nuraini 1 , and yati afiyanti 1 * 1 faculty of nursing universitas indonesia, depok, indonesia *correspondence: yati afiyanti. address faculty of nursing universitas indonesia, depok, indonesia. email: yatiafiyanti@yahoo.com responsible editor: rizki fitryasari received: 29 september 2022 ○ revised: 24 october 2022 ○ accepted: 28 october 2022 abstract introduction: breast cancer is the most common malignancy in women worldwide. breast cancer and its treatment have a direct impact on all aspects of a woman's life, as well as on breast cancer survivors, thereby affecting the fulfillment of her needs. the purpose of the study is to explore stigma and discrimination against breast cancer sufferers. methods: this study uses a qualitative method of interpretive phenomenology. semi-structured interviews were purposively conducted from march to june 2022 with 14 women breast cancer survivors. the process of data analysis in this study was carried out based on braun and clarke. results: the three themes identified in this study include: a short duration of survival, being labeled as a suffering person, and social discrimination. conclusions: breast cancer survivors experienced stigma regarding their cancer diagnosis. thus, highlighting the rising need of health professionals’ intervention in resolving and adapting to stigma and discrimination regarding breast cancer diagnosis in indonesia.. keywords: breast cancer; cancer survivors; discrimination; stigma introduction breast cancer is the most common malignancy in women worldwide. in women, breast cancer accounts for almost 1 in 4 cases. the number of breast cancer cases every year also always increases (lee et al., 2021). in 2020, it was estimated that the number of new cases of breast cancer in the world is 2,261,419 cases (ferlay et al., 2020). the incidence of breast cancer is the highest incidence of cancer in women in indonesia compared to the incidence of cervical cancer, ovarian cancer, and other gynecological cancers (pangribowo, 2019). the same incident occurred in bali province, as described in the study by aryana, adiputra, prayudi, permatasari, setiawan, and kuswardhani (2018), balinese women who experienced breast cancer were 1,045 samples. in the study of aryana et al. (2018), it was also explained that race or ethnicity might play an important role in the expression of certain breast cancer phenotypes. this role can be attributed to differences in genetics and lifestyle among women within each race. the incidence of breast cancer in the province of bali, indonesia, is one of the highest. based on data reported by sanglah hospital denpasar, breast cancer patient visits from august to november 2020 there were 285 cancer patient visits from 1,380 patient visits at sanglah hospital denpasar. the experience of breast cancer is an experience that greatly affects a woman's life. the results of recent studies confirm that it is very important to carry out health checks, address post-treatment concerns, and improve the well-being and quality of life of cancer survivors (runowicz et al., 2016). as in many asian and eastern background, in indonesia, the view of illness or chronic disease is often influenced the culture and beliefs of the community. https://creativecommons.org/licenses/by/4.0/ mailto:yatiafiyanti@yahoo.com https://orcid.org/0000-0001-9267-4114 https://orcid.org/0000-0003-1170-0398 https://orcid.org/0000-0001-9382-6714 tisnasari, nuraini, and afiyanti (2022) supremo, bacason, and sañosa (2022) 184 p-issn: 1858-3598  e-issn: 2502-5791 many illnesses are associated with negative views or stigma. similarly, cancer is often viewed negatively, such as a karmic retribution, a form of god’s punishment, is infectious, and so on (orujlu et al., 2022; phenwan et al., 2019). these negative perceptions of cancer developed into a stigma among many communities’ way of viewing individuals with cancer. goffman (1963) first defined stigma as an attribute that leads to being discredited by society for a negative label of the person affected. the definition has since been conceptualized into different fields, including health-related stigma. according to weiss et al. (2006), health-related stigma is a social process, characterized by exclusion, rejection, blame or devaluation resulting from experience, perception, or anticipation of negative social judgement related to a person’s health condition. the stigma that affects a woman with breast cancer can have an impact on the problem of meeting her healthcare needs. a study by amane (2021) explains that, of all types of cancer, breast cancer is the type of cancer that has the most supportive care needs. on the other hand, many existing studies investigating cancer stigma were conducted in lung cancer patients or survivors and preferred cross-sectional methods. an in-depth study of the stigma and discrimination among cancer survivors, in specific groups such as breast cancer, is, in contrast, relatively scarce. especially in the unique cultural community of indonesia, there is a knowledge gap on how the women with breast cancer were viewed or treated by their community. meanwhile, perceptions of stigma and experiences of discrimination against breast cancer survivors are very important to understand. this study was conducted to fulfil the need to explore in depth, the stigma and discrimination experienced based on direct stories from breast cancer survivors in indonesia materials and methods research design the research design used in this study is an interpretative phenomenological qualitative research design to explore stigma and discrimination against breast cancer survivors. this research design was a concept from heidegger which stated that the focus of hermeneutic inquiry was not the pure content of human subjectivity, rather, what the individual’s narratives imply about what he or she experiences daily (speziale et al., 2011). sample and sampling participants in this study were determined by selecting individuals or participants using the purposive sampling method and saturation principles. the sample in this study was selected from the women with breast cancer survivors who were indicated to have had experiences getting a stigma and social discrimination after a cancer diagnosis. the inclusion criteria for the participants were: 1) able to communicate in indonesian language, able to understand questions, and to express their experiences; 2) had been a breast cancer survivor for at least two years; and 3) had no cancer metastasis. data collection process the first and the third authors collected the data using in-depth interviews. the interviews were conducted in bahasa indonesia from march june 2022. the study was conducted at the oncology outpatient of sanglah hospital denpasar. during the interview, the women were encouraged to elaborate on their experiences of what kinds of stigma were like for them and how they responded to them. sample questions were “what is your community’s thought of the cancer diagnosis you experienced?”; “is there any stigma from your community regarding the cancer you experienced? how did you respond to them?” all interviews were tape-recorded and lasted between 60 to 80 minutes. the interview tapes were transcribed. the researcher avoided personal bias by using a bracketing technique during the interview process. in this technique, the researcher sets aside personal beliefs and knowledge, not making judgments about what is observed or heard, and remains open to the data as they are revealed (speziale et al., 2011). data analysis process the second and the first conducted the data analysis. the process of data analysis in this study was carried out based on braun and clarke, (2006) regarding the thematic approach to analysis, namely identifying, analyzing, and reporting patterns (themes) in the data. the first stage is to read and re-read the subsets of interview transcripts independently and capture exciting elements from the coding data by the first and the second author. throughout this coding process, the researchers conducted debriefing and reflexive writing simultaneously to generate themes and maintain a solid and oriented relation to the participants’ experiences. when the final themes were defined, a research report was written up. data validity the validity of the data in this study enhances the trustworthiness of the findings, and a number of means of credibility were established. due to the nature of qualitative research approach, the researcher themselves is the research instrument. as the research jurnal ners http://e-journal.unair.ac.id/jners 185 instrument, the researcher is obliged to fulfil the validity elements to gather representative data. one the elements of validity in qualitative research is researcher’s credibility (creswell, 2013). the credibility of this study is established by the researchers, who are a nurse with experience in caring for women with breast cancer and members of an indonesian cancer foundation. for these reasons, the researchers could build trust with participants by discussing the intimate details of their experiences. furthermore, to enhance data credibility, confirmation and member-checking of the themes were established with the participants. results demographic characteristics there were seventeen participant candidates that fit the inclusion requirement. of the seventeen candidates, three women expressed unwillingness to participate in the study, resulting in the final sample size of fourteen participants. the fourteen women who participated in the study ranged in age from 33 to 55 year with a mean age of 40 years. twelve women were married and two women were unmarried (single). there was variation of educational background among the participants. five participants had bachelor degree, three from senior high school, four from college with a diploma, and the others had master degree. participants were workers, housewives, and civil servants. this study resulted in three themes, namely a negative view of women with breast cancer supported by three themes, including 1) short duration of survival, 2) being labeled as a suffering person, and 3) social discrimination theme 1: short duration of survival several participants described that there are still many people who believe that someone will soon die when they are diagnosed as suffering from cancer. this affects the mentality of participants when interacting with other people because they are considered unfit to live. participant 5, 47 years old, self-employed, explained that some people believe that people who have cancer will face death. she said: "but still there are some people who believe cancer will not live long. cancer can't be cured. our mentality is affected too, right?” (p5) participant 6, a 55-year-old woman, who was a housewife, conveyed that there is still a strong stigma attached to someone with cancer, one of which is considered a family disgrace. while in truth, breast cancer survivors also want to live a decent life like other people in general. "i feel like i can't change people's views about cancer. i really hope that people are aware of cancer survivors, and start to realize how much we don't want to be privileged, no, but we just want to live a decent life. as survivors, we have the right to be accepted properly, not to be considered a family disgrace. don't be thought of as someone who is so down that she is to be pitied.” (p6) participant 7, a 50-year-old woman, who works as a housewife, explained about hearing words that someone with cancer will not last long. she affirmed: "once, there were people who saw me. i heard bad words, he said ‘cancer is scary, it doesn't live long’ and then i said ‘i'm sorry, if you look at me,’ i say various things, ‘it's better not to look at me, okay,’ i answered that. so, he kept quiet and immediately apologized." (p7) theme 2: being labeled as a suffering person several participants explained that they wanted people to stop talking about cancer patients because they did not like to be labeled as sick people. participant 8, a 49-year-old housewife, said: "i want to convey to the people around, please stop using the word sufferer. because when someone is given the word lab suffers, she will label herself suffering. ‘survivors’ or ‘patients’ is better. for example, such as patients who have finished undergoing cancer therapy. so the effect of the word sufferer as a sick person. the proof is that we can travel, we can work but why do people call me suffering like that. so, what do you feel like, it's like we were created by another group. you are a sufferer." (p8) participant 9, a 33-year-old woman, unmarried, explained that there is a stigma attached to women who have breast cancer, namely, they are considered to have bad luck. here is the participant's statement: “it seems that there is a mistake in women who have breast cancer, there seems to be a stereotype type or label minded attached that bad luck happens to women, bad behavior to women. the woman did not dare to speak up like that. to express himself sick and tisnasari, nuraini, and afiyanti (2022) supremo, bacason, and sañosa (2022) 186 p-issn: 1858-3598  e-issn: 2502-5791 when the woman is sick, maybe the work environment is not supportive, the family environment is also not supportive. so, i thought what do i need, such assistance.” (p9) theme 3: social discrimination in young unmarried women, the experience of breast cancer has a profound impact on their lives. young women in bali who experienced breast cancer and must undergo a mastectomy often get stigmatized as imperfect people; this is associated with the values that exist in balinese society, which still prioritizes appearance so that sometimes someone who has incomplete limbs, such as having one breast removed, is often the subject of discussion, especially by the general public about breast cancer. furthermore, in balinese society, there is often a fear of having a female partner who has breast cancer because it is considered that it will carry bad genes for the offspring in the family. participant 11, a woman aged 34 years, unmarried, explained that, when she had breast cancer, many friends did not want to hang out, and the opposite sex was not interested in her. she explained: “i felt like i was being shunned when i got breast cancer or like i was being left behind. i feel that many people don't want to be friends with me anymore because of my condition after therapy. i feel more like that. i am also aware that the opposite sex of men would want a perfect partner, right, while i am not perfect anymore.” (p11) participant 13, a 53-year-old woman, who was a housewife, explained that the people around her felt sorry for the participants when they had breast cancer. she stated: "yes, they feel sorry for me, right if people in the village are a bit scary to think that they have breast cancer, in the city it's normal. if you're in the village you say why you're sick like that, even though we're used to it. the proof is that we can move here and there.” (p13) participant 6, a 55-year-old woman, who was a housewife, conveyed that there is still a strong stigma attached to someone with cancer, one of which is considered a family disgrace. whereas breast cancer survivors also want to live a decent life like other people in general. "i feel like i can't change people's views about cancer. i really hope that people are aware of cancer survivors, and start to realize how much we don't want to be privileged, no, but we just want to live a decent life. as survivors, we have the right to be accepted properly, not to be considered a family disgrace. don't be thought of as someone who is so down that he is pitied.” (p6) discussions the main purpose of this study was to have a deeper understanding of the stigma and discrimination against women with breast cancer. participants explained the need to change society's stigma about cancer survivors. participants conveyed that there is still a strong stigma attached to women who have breast cancer, such as being considered not to live long, considered a person who suffers, considered a family disgrace, considered to have bad luck, and considered an imperfect woman. these findings were similar to several previous studies on cancer stigma in general (huang et al., 2020; shiri et al., 2018). in breast cancer survivors specifically, stigma impacting the self-identity, self-esteem, and body image has been proven to be a burden to the survivors' physical and emotional quality of life (amini‐tehrani et al., 2021; chu et al., 2020; fujisawa et al., 2020; yeung, lu, & mak, 2019). the first theme identified in this study gathered that individuals with breast cancer have a short duration of survival or are short-lived. similar sentiments were shown in the findings of a different study on cancer stigma (bhattacharyya et al., 2018). additionally, according to nyblade et al. (2017), breast cancer and cervical cancer in women in india are considered infectious diseases both for children and even for society at large, considered as punishment, and considered incurable, and those who suffer from it will die quickly. whereas breast cancer survivors also want to live a decent life like other people in general. in accordance with solikhah et al. (2020), in indonesia, women with breast cancer are considered to be dying. this causes women with breast cancer in indonesia to feel ashamed and afraid to reveal their identity to the surrounding environment. unfortunately, there was no accurate statistical data on breast cancer survival rate in indonesia to provide insight into the notion of breast cancer survivors being short-lived. according to world population review (2022), in its global cancer survivor rates, the survival rate of breast cancer in indonesia was 77,70%. however, the factors influencing such value were not stated jurnal ners http://e-journal.unair.ac.id/jners 187 clearly. the researchers deliberated that such finding was the result of several factors. when facing breast cancer diagnosis, patients tended to seek medical treatment at the later stage of cancer. oftentimes, patients seek traditional or folk medicine to treat their illness. this resulted in worse treatment outcomes. this was supported with the findings of solikhah (2020) that stated patients chose traditional treatment before seeking medical treatment when the symptoms worsen. additionally, the healthcare facilities in indonesia were not equally equipped to treat cancer diagnosis. furthermore, individuals with breast cancer who live in rural areas or provinces with less comprehensive healthcare facilities might find seeking proper medical treatment a challenge. thirdly, while cancer treatments were covered in national health insurance, the coverage is applicable only when cancer diagnosis is established, other costs, such as the screening phase and many miscellaneous costs, must be covered by the individuals and their families. the cost could amount to an enormous number, which discourages the women with breast cancer to seek treatment. the second theme identified was being labeled as a suffering person. the participants explained that they were uncomfortable with the use of labels such as sufferer or unlucky person when addressing them. this may impair the quality of life of the participants in this study. the reality in bali, according to the participants, is they are not allowed to participate in religious rituals anymore because they are viewed as a sick person. these labels were more prevalent in sub-culture communities or low to middle-income countries (lmic) culture as opposed to high income countries’ view of cancer. similarly, in high income countries stigma about cancer was low or confined in small communities and small percentage of cases, for example the stigma around male breast cancer survivors (midding et al., 2018; vrinten et al., 2019). the last theme identified was social discrimination. the discrimination referred to the ability to participate in social engagements or interactions. owing to the cultural beliefs, a breast cancer diagnosis may delay a woman’s marriage and hinder their interaction with family members and the community. this could negatively impact the woman’s willingness to seek treatment and support in their experience with cancer, which is directly adverse to optimal outcomes. furthermore, it can cause women with breast cancer to be isolated from their surroundings. this is consistent with the results of existing research that, in general, women with breast cancer receive negative stigma from the general public (dewan et al., 2021; jin et al., 2021). therefore, an explanation is needed for the surrounding community about breast cancer so that patients who are undergoing cancer therapy or who have completed cancer therapy are not ostracized by the surrounding community. this study highlights the importance of adding nursing interventions to overcome the stigma that occurs in the community about breast cancer (kang et al., 2020), such as carrying out educational programs about marital problems and relationships after a cancer diagnosis. this can increase general public knowledge about empathy and self-acceptance of cancer survivors so that there is no fear when having family members or partners who have breast cancer or other gynecological cancers (reese et al., 2019). while cancer stigma itself has received much attention, interventions to alleviate cancer stigma negative impact, in contrast, need further exploration (akin-odanye & husman, 2021). recent research by afiyanti et al. (2020) highlights the needs of breast cancer survivors, including explaining cancer to others and moving on with their life. the results of this study explain that breast cancer survivors have a need to explain this cancer to other people, in this case, namely the community (explaining cancer to others), and want to return to life as it should be (moving on with their life) because participants only want to return to a normal life without the bad stigma attached to her as someone who is helpless, has bad luck, disgraces her family, is close to death, or is considered an imperfect woman. the results of this study are also expected to provide an overview to nurses and other health workers regarding the needs to accommodate psychological post-cancer treatment, especially about the stigma on breast cancer survivors. in addition, the findings of this study raise the expectation of the availability of consultation on problems experienced by patients and cancer survivors, which triggers the importance of the presence of oncology specialist nurses in existing cancer care installations. furthermore, a specific program is needed such as comprehensive nursing care provided by nursing care providers to help cancer survivors meet their needs so that there is an increase in the life expectancy or survival rate of cancer survivors in. limitation of the study several researchers realize that there are limitations and shortcomings in this study. the first includes the stigma issues, which are generally sensitive and tend to be ignored, especially in eastern culture. the participants of this study might not fully to express their tisnasari, nuraini, and afiyanti (2022) supremo, bacason, and sañosa (2022) 188 p-issn: 1858-3598  e-issn: 2502-5791 feelings when discussing their experiences and preferences. the second is the small sample size, the characteristic of qualitative study, which may cause the study to be limited to a certain population, that is, in women attending the research cancer hospital. therefore, it may not represent the general population and it is difficult to establish transferability of study results. conclusions this study showed the stigma and discrimination experiences of breast cancer survivors faced. it can be concluded the breast cancer survivors received negative views from their community as a result of their cancer diagnosis. the results of this study offer insights, information, and understanding into experiences of indonesian women with breast cancer related to the various stigmas from their community. they were blamed by the community as a dying person, a sick person, and various social discriminations, which lowered their quality of life. there is an opportunity for oncology nurses in indonesia to assume the roles and responsibility to work with the breast cancer survivors in resolving the stigma they experienced and disseminating information to the society that breast cancer survivors are not what they are negatively assumed to be. acknowledgment the authors are grateful to all participants in this study. this study was supported financially by a grant from the ministry of education, culture, research and technology, republic of indonesia (no. nkb903/un2.rst/hkp.05.00/2022). funding source this work was supported by the universitas indonesia under the magistrate thesis research grant (hibah ptm) from the ministry of education, culture, research and technology, republic of indonesia (no. nkb-903/un2.rst/hkp.05.00/2022). conflict of interest the author declares that there is no conflict of interest in this study. references afiyanti, y., besral, & haryani. (2020). the quality of life of indonesian women with gynecological cancer. enfermeria clinica, 30(march 2021), 65–69. https://doi.org/10.1016/j.enfcli.2020.07.013 akin-odanye, e.o. and husman, a.j. (2021). impact of stigma and stigma-focused interventions on screening and treatment outcomes in cancer patients. ecancermedicalscience, [online] 15, p.1308. doi:10.3332/ecancer.2021.1308. amane, h. y., tessema, a. m., seid, k. a., hassen, a. m., assen, h. e., asfaw, z. a., endrie, s. m., & hussien, f. m. (2021). factors associated with unmet supportive care needs of oncology patients at dessie referral hospital, 2020. ecancermedicalscience, 15, 1– 28. https://doi.org/10.3332/ecancer.2021.1300 amini‐tehrani, m., zamanian, h., daryaafzoon, m., andikolaei, s., mohebbi, m., imani, a., tahmasbi, b., foroozanfar, s. and jalali, z. (2021). body image, internalized stigma and enacted stigma predict psychological distress in women with breast cancer: a serial mediation model. journal of advanced nursing, 77(8). doi:10.1111/jan.14881. aryana, i. s., adiputra, p. a., prayudi, p. k., permatasari, y., setiawan, h. p., & kuswardhani, r. t. (2018). histology and biologic profile of breast cancer in elderly of balinese population. journal of geriatric oncology, 5(5), s9–s10. https://doi.org/10.1016/j.jgo.2014.06.022. bhattacharyya, g.s., malhotra, h., babu, g., vora, a. and bhattacharyya, s. (2018). 1545pcancer stigma related to beliefs of patients and care providers. annals of oncology, 29(suppl_8). doi:10.1093/annonc/mdy296.006. braun, v., & clarke, v. (2006). qualitative research in psychology using thematic analysis in psychology using thematic analysis in psychology. qualitative research in psychology, 3(2), 77–101. cheng, k. k. f., wong, w. h., & koh, c. (2016). unmet needs mediate the relationship between symptoms and quality of life in breast cancer survivors. supportive care in cancer, 24(5), 2025–2033. https://doi.org/10.1007/s00520-015-2994-0 chu, q., wong, c.c.y., chen, l., shin, l.j., chen, l. and lu, q. (2020). self‐stigma and quality of life among chinese american breast cancer survivors: a serial multiple mediation model. psychooncology, 30(3), pp.392–399. doi:10.1002/pon.5590. creswell, j.w. and poth, c.n., (2013). qualitative inquiry and research design: choosing among five approaches. sage publications. dewan, m.f., lyons, k.s., song, m. and hassouneh, d. (2021). factors associated with depression in breast cancer patients in saudi arabia. cancer nursing, 45(2). doi:10.1097/ncc.0000000000000996. ferlay j, ervik m, lam f, colombet m, mery l, piñeros m, znaor a, soerjomataram i, b. f. . (2020). international agency for research on cancer 2020. global cancer observatory: cancer today., 419, 1–2. https://gco.iarc.fr/today/data/factsheets/populations/900world-fact-sheets.pdf fujisawa, d., umezawa, s., fujimori, m. and miyashita, m. (2020). prevalence and associated factors of perceived cancer-related stigma in japanese cancer survivors. japanese journal of clinical oncology, 50(11), pp.1325–1329. doi:10.1093/jjco/hyaa135. goffman, e., (1963), stigma: notes on the management of spoiled identity. prentice-hall englewood cliffs, n.j huang, z., yu, t., wu, s. and hu, a. (2020). correlates of stigma for patients with cancer: a systematic review and meta-analysis. supportive care in cancer. doi:10.1007/s00520-020-05780-8. jin, r., xie, t., zhang, l., gong, n. and zhang, j. (2021). stigma and its influencing factors among breast cancer survivors in china: a cross-sectional study. european journal of oncology nursing, 52, p.101972. doi:10.1016/j.ejon.2021.101972. kang, n.e., kim, h.y., kim, j.y. and kim, s.r. (2020). relationship between cancer stigma, social support, coping strategies and psychosocial adjustment among breast cancer survivors. journal of clinical nursing, 29(21-22), pp.4368–4378. doi:10.1111/jocn.15475. lee, j. w., lee, j., lee, m. h., lee, s. k., kim, w. s., jung, s. y., kim, z., lee, j., & youn, h. j. (2021). unmet needs and quality of life of caregivers of korean breast cancer survivors: a cross-sectional study. annals of surgical treatment and research, 101(2), 69–78. https://doi.org/10.4174/astr.2021.101.2.69. nyblade, l., stockton, m., travasso, s. et al. a qualitative exploration of cervical and breast cancer stigma in karnataka, india. bmc women's health 17, 58 (2017). https://doi.org/10.1186/s12905017-0407-x orujlu, s., hassankhani, h., rahmani, a., sanaat, z., dadashzadeh, a. and allahbakhshian, a., 2022. barriers to cancer pain management from the perspective of patients: a qualitative jurnal ners http://e-journal.unair.ac.id/jners 189 study. nursing open, 9(1), pp.541-549. doi: 10.1002/nop2.1093 pangribowo, s. (2019). beban kanker di indonesia. pusat data dan informasi kemeterian kesehatan ri, 1–16. phenwan, t., peerawong, t. and tulathamkij, k., 2019. the meaning of spirituality and spiritual well-being among thai breast cancer patients: a qualitative study. indian journal of palliative care, 25(1), p.119. doi: 10.4103/ijpc.ijpc_101_18 reese, j. b., lepore, s. j., daly, m. b., handorf, e., sorice, k. a., porter, l. s., tulsky, j. a., & beach, m. c. (2019). a brief intervention to enhance breast cancer clinicians’ communication about sexual health: feasibility, acceptability, and preliminary outcomes. psycho-oncology, 28(4), 872–879. https://doi.org/10.1002/pon.5036 runowicz, c. d., leach, c. r., henry, n. l., henry, k. s., mackey, h. t., cowens-alvarado, r. l., cannady, r. s., pratt-chapman, m. l., edge, s. b., jacobs, l. a., hurria, a., marks, l. b., lamonte, s. j., warner, e., lyman, g. h., & ganz, p. a. (2016). american cancer society/american society of clinical oncology breast cancer survivorship care guideline. journal of clinical oncology, 34(6), 611–635. https://doi.org/10.1200/jco.2015.64.3809. shiri, f.h., mohtashami, j., nasiri, m., manoochehri, h. and rohani, c. (2018). stigma and related factors in iranian people with cancer. asian pacific journal of cancer prevention: apjcp, [online] 19(8), pp.2285–2290. doi:10.22034/apjcp.2018.19.8.2285. speziale, h.s., streubert, h.j. and carpenter, d.r., (2011). qualitative research in nursing: advancing the humanistic imperative. lippincott williams & wilkins. solikhah, s. et al. (2020) ‘breast cancer stigma among indonesian women: a case study of breast cancer patients’, bmc women’s health, 20(1), pp. 1–6. doi: 10.1186/s12905-020-00983-x. weiss, m.g., ramakrishna, j. and somma, d., (2006). health-related stigma: rethinking concepts and interventions. psychology, health & medicine, 11(3), pp.277-287. doi: 10.1080/13548500600595053 yeung, n.c.y., lu, q. and mak, w.w.s. (2019). self-perceived burden mediates the relationship between self-stigma and quality of life among chinese american breast cancer survivors. supportive care in cancer, 27(9), pp.3337–3345. doi:10.1007/s00520-018-4630-2. how to cite this article: tisnasari, i., a., m.. a., s., nuraini, y., and afiyanti, t. (2022) ‘stigma and discrimination against breast cancer survivors in indonesia: an interpretive phenomenology study’, jurnal ners, 17(2), pp. 183-1829 doi: http://dx.doi.org/10.20473/jn.v17i2.39448 vol 8 no 2 oktober 2013.indd 240 pengalaman odha mendapatkan dukungan sosial dalam menjalani kehidupan sehari-hari di malang raya (the experience of plwha who get social support undergoing in daily life in malang) setyoadi* *program studi ilmu keperawatan fakultas kedokteran universitas brawijaya jl. veteran malang 65145 e-mail: setyoadi@ub.ac.id abstrak pendahuluan: hiv/aids adalah penyakit kronis yang menyebabkan berbagai permasalahan rumit sehingga membutuhkan dukungan sosial. kelompok dukungan (kelompok swadaya) dapat membantu mengidentifi kasi dan menggunakan sumber daya koping yang lebih adaptif. tujuan penelitian ini untuk mendapatkan pemahaman yang mendalam dari pengalaman orang yang hidup dengan hiv dan dukungan sosial. metode: penelitian ini menggunakan metode kualitatif fenomenologi deskriptif dengan wawancara mendalam dengan delapan peserta yang didiagnosis hiv/aids yang tinggal di malang raya. data dianalisis dengan analisis tematik oleh transkrip wawancara dan memperoleh 11 tema. hasil: hasil penelitian menunjukkan tiga tema faktor risiko infeksi hiv, yaitu: risiko sosial ekonomi, risiko perilaku, penyesuaian pertumbuhan dan perkembangan, tema yang berkaitan dengan respons diagnosis hiv/aids yaitu respons psikososial, dua tema makna spiritual dalam hidup adalah perubahan dan merancang masa depan, tema dukungan (support) berasal dari dukungan sosial, dua tema mengenai pengaruh dukungan sosial yang diterima mempengaruhi kesehatan dan perawatan kesehatan, dan tiga tema dari dukungan yang diharapkan, yaitu: perawatan kesehatan, bentuk dukungan, dan pemberdayaan. diskusi: peran perawat komunitas pada kelompok dukungan sosial dalam konteks asuhan keperawatan dan pemberdayaan ekonomi masyarakat yang hidup dengan hiv sangat perlu untuk dikembangkan. rekomendasi berdasarkan hasil penelitian ini adalah perawat kesehatan perlu membuat program kunjungan rumah dan memfasilitasi pemberian kredit modal (microfi nance) pada odha. kata kunci: odha, dukungan sosial, perawat komunitas abstract introduction: hiv/aids is a chronic disease that are different from other diseases, because of the problems caused so complex that they need social support. support groups (self help groups) can help identify and use resources more adaptive coping. the purpose of this study to gain a deep understanding of people living with hiv experience of social support. method: this study used qualitative methods of descriptive phenomenology with depth interviews with eight participants were diagnosed with hiv/aids who live in malang raya. data were analyzed with a thematic analysis of transcripts of the interviews and obtained 11 themes. result: the results showed that the three themes of hiv infection risk factors, namely: socioeconomic risk, behaviour risk, adjustment of growth and development, a theme related to the response associated with a diagnosis of hiv/aids namely psychosocial responses, the two themes of spiritual meaning in life is change and designing the future, a theme of support came from the social support, two themes concerning the effect of social support received is controlled health and health care, and the three themes of the support he expected, namely: health care, a form of support, and empowerment. discusion: it is important to develop a community nurse role of social support groups in the context of nursing care and economic empowerment of people living with hiv. the recommendation based on this study is health nurses need to make a home visit program and facilitate the provision of working capital loans (microfi nance) in plwha. keywords: plwhas, social support, community nurse pendahuluan hiv/aids telah menyebar luas di hampir seluruh bagian dunia. berdasarkan laporan who/unaids (2009), bahwa dalam dasawarsa terakhir telah terjadi penyebaran secara endemi dan peningkatan jumlah penderita hiv & aids secara tajam. data tersebut menggambarkan 33.4 juta orang mengidap hiv & aids, munculnya infeksi baru 2.7 juta orang, dan kejadian kematian berjumlah 2 juta orang. indonesia telah digolongkan menjadi nega r a de nga n t i ng k at e pide m i ya ng terkonsent rasi at au concent rated le vel epidemic (cle) karena memiliki kantongkantong epidemi dengan prevalensi lebih dari 5% pada subpopulasi berisiko terinfeksi hiv 241 pengalaman odha mendapatkan dukungan sosial (setyoadi) seperti: pekerja seks komersial, narapidana, pengguna narkoba jarum suntik, darah donor, dan ibu hamil (depkes r.i, 2009). wilayah di jawa timur yang mempunyai kontribusi tinggi meningkatnya penderita hiv & aids adalah wilayah malang raya yang terdiri dari kota malang, kabupaten malang, dan kota batu (kpan, 2009). kota malang tertinggi pertama yaitu 223 orang dibandingkan kabupaten malang dan kota batu. di kabupaten malang penderita aids yang terdeteksi kpan hanya 177 orang dan kota batu hanya 15 orang. peningkatan jumlah penderita hiv & aids tidak lepas dari sikap dan perilaku odha yang cenderung menutup diri karena adanya stigma di masyarakat (vivi, 2009). kondisi ini semakin memperburuk kesehatan d i s e b a bk a n ke t id a k m a m pu a n m e r e k a mengakses pelayanan kesehatan, sementara proses penyakit terus semakin memburuk (brown, trujilo, & macintyre, 2001). beban yang dialami oleh penderita hiv & aids sangat kompleks mulai dari fi sik disebabkan munculnya infeksi oportunistik, psikologi disebabkan karena munculnya keluhan, ketidakpastian hidup, dan takut akan kematian, dan sosial berkaitan dengan adanya stigma di masyarakat akibat persepsi yang salah terhadap penyakit hiv & aids. banyaknya stressor yang dialami oleh odha menyebabkan koping mereka tidak adaptif dan memperburuk kualitas hidup, mereka membutuhkan dukungan sosial (gay et al, 2009). dukungan sosial bisa berasal dari lingkungan keluarga atau masyarakat yang lebih luas untuk membantu meningkatkan koping yang lebih adaptif dan mengontrol kesehatannya (yadav, 2009). m e n g i n g a t b e g i t u k o m p l e k n y a permasalahan yang dihadapi odha, perlu adanya kajian untuk menggali bagaimana pengalaman dukungan sosial yang diterima termasuk sumber dukungan sosial dan bentuk du k u ngan sosial mengg u nakan konsep keperawatan komunitas dengan pendekatan studi fenomenologi deskriptif. penggalian pengalaman yang dimaksudkan dalam hal ini adalah bagaimana mereka memaknai dukungan sosial, agar dapat mempertahankan dan meningkatkan kualitas hidup. bahan dan metode tu j u a n p e n e l i t i a n i n i a d a l a h m e n g i d e n t i f i k a s i g a m b a r a n o d h a me nd apat k a n du k u nga n sosia l d a la m menjalani kehidupan sehari-hari. pendekatan fenomenologi deskriptif pada penelitian ini memungkinkan peneliti melakukan eksplorasi secara mendalam pada odh a tentang bagaimana persepsi dan pengalaman mereka mendapat dukungan sosial (streuber t & carpenter, 2003). penelitian ini dilakukan pada delapan odha yang bergabung dalam kelompok dukungan sebaya (kds) di wilayah malang raya. sampel diambil secara purposif yaitu odha yang telah dinyatakan positif hiv atau aids berdasarkan hasil pemeriksaan vct. kriteria partisipan adalah dapat berbahasa indonesia, bergabung dalam kds, tinggal di wilayah malang raya, mampu menceritakan pengalaman, dan usia dewasa lebih dari 15 tahun. wawancara indepth interview dengan menggunakan pedoman wawancara sambil mengobservasi respons verbal dan non verbal. wawancara dan observasi ini dilakukan dalam waktu 40 sampai 50 menit selama 4 minggu. hasil partisipan dalam penelitian ini berusia antara 25 tahun sampai 34 tahun dengan jenis kelamin perempuan dan laki-laki masingmasing berjumlah empat orang. empat dari delapan partisipan berstatus menikah dan tinggal bersama pasangan dan anak dalam sebuah keluarga inti, tiga orang dengan status belum menikah dengan rincian dua orang tinggal bersama kedua orang tuanya dan satu orang tinggal bersama neneknya, sedangkan satu orang dengan status janda yang tinggal bersama anak dan kedua orang tuanya. pekerjaan partisipan di bidang wiraswasta dan sebagai ibu rumah tangga (irt) masingmasing empat orang. lama terdiagnosa positif hiv mulai dari enam bulan sampai lima tahun saat proses wawancara dan pengalaman bergabung dalam kelompok dukungan sebaya (kds). lsm paramitra mulai dari satu bulan hingga satu tahun. berdasarkan hasil analisa 242 jurnal ners vol. 8 no. 2 oktober 2013: 240–252 dapat diidentifi kasi 11 tema yang terbagi dalam enam kelompok tema. tema pertama adalah faktor risiko penyebab terinfeksi hiv pada odha. faktor risiko yang teridentifi kasi tergambar dalam tiga tema, yaitu risiko sosial ekonomi, risiko perilaku, dan penyesuaian tumbuh kembang. risiko sosial ekonomi berkaitan dengan kurangnya pengetahuan akibat kurang terpapar informasi dan tuntutan kebutuhan dalam keluarga yang menyebabkan harus bekerja sebagai psk, seperti pernyataan partisipan di bawah ini: “waktu itu kan pingin berhenti (dari pekerjaan psk), pingin cari modal untuk berhenti…kebutuhan di rumah kan tinggi, untuk makan sehari-hari, biaya anak sekolah, bayar listrik…suami saya kan cuma buruh tani sehari hanya 10 ribu, mana cukup kalau saya tidak kerja” (p.4). “saya ngak tahu awalnya kok bisa sakit begini…ngak ada informasi” (p.8). risiko perilaku yang digambarkan oleh partisipan berkaitan dengan perilaku s e k s u a l d e n g a n c a r a b e r go n t a g a n t i pasangan, homoseksual, dan tidak konsisten menggunakan kondom saat berhubungan. di samping itu perilaku penggunaan jarum suntik secara bersama pada penasun. “saya dulu sering gonta ganti sama laki-laki…gonta ganti pasangan” (p. 2). “hubungan seksual sesama laki-laki” (p. 7). “kadang-kadang pelanggan itu pakai kondom, kadang-kadang juga ngak mau… ngak terasa” (p.4). “syringnya tetap digunakan bergantian… biasanya anak 7, anak 10…disimpan lagi, satu minggu masih digunakan” (p. 1). penyesuaian tumbuh kembang pada usia remaja berkaitan dengan kematangan berpikir belum sepenuhnya berkembang yang ditandai dengan partisipan tidak berpikir panjang dan perilaku ikut-ikutan menggunakan narkoba suntik sesama teman kelompok. “saya tidak berpikir kedepannya yang penting senang…waktu itu kan masih smp” (p.1). “cuma ikut-ikutan saja sama temanteman disana, di jakarta…kita sering kumpul akhirnya terus diajak pakai” (p.8). tema yang kedua adalah respons perasaan odha terhadap diagnosa hiv/aids. rentang respons perasaan odha ketika diketahui terdiagnosa positif hiv sampai menderita aids tergambar dalam satu tema yaitu respons psikososial yang ditunjukkan dengan adanya respons kehilangan, kecemasan, dan respons sosial. respons kehilangan yang ditunjukkan oleh partisipan mulai dari shock dan penolakan terhadap diagnosa, seperti pernyataan partisipan di bawah ini: “saya ngak bisa bicara mas, terus terang saya merasa shock…saya pertama ngak bisa nangis, saya ngak bisa jawab apapun… saya ngak percaya bisa seperti ini” (p. 3). respons selanjutnya adalah marah yang ditunjukkan partisipan dengan menyalahkan tuhan dan dendam pada mereka yang dianggap menulari, seperti pernyataan di bawah ini: “tuhan sudah ngak sayang sama saya, sempat marah saya sama tuhan” (p. 2). “aku mau bekerja (psk) mengumpulkan sebanyak orang lak i-lak i, biar semua terinfeksi…saya lakukan ini selama satu bulan” (p. 4). partisipan mulai melakukan penawaran dengan kembali pada masa lalu, depresi yang tunjukkan dengan kesedihan, dan diakhri dengan penerimaan dengan cara menyerahkan semua masalah pada tuhan. “nggak mungkin lah saya ngak tertular karena kondisi suami saya waktu itu kan buruk sekali…seandainya sejak awal saya tahu suami saya pengguna narkoba, mungkin saya tidak akan seperti ini” (p. 5). “saya cuma bisa menangis tiap hari… sampai satu bulan lebih” (p. 2). “saya menyadari dan membuka lebar hati saya…dan mengambil manfaat untuk semua ini…saya kembalikan semua pada tuhan karena dia yang member sakit, dia juga yang akan member kesembuhan” (p.3). respons psikologi kecemasan muncul pada partisipan sebagai respons dari proses penyakit yang dapat menjadi stresor karena 243 pengalaman odha mendapatkan dukungan sosial (setyoadi) ketidakpastian hidup yang berujung pada k hawatir akan kesakitan dan kematian yang setiap saat menghantui seperti yang ditunjukkan oleh partisipan di bawah ini: “sekarang juga takut, kadang waswas (perasaan khawatir) sakit atau kematian menghantui” (p.4). respons sosial muncul akibat dari persepsi masyarakat terhadap odha seperti perasaan terstig ma mulai dar i sorot an sampai takut dijauhkan atau dikucilkan, perasaan diskriminasi, dan perasaan diterima masyarakat sebagai bagian dar i proses keterbu kaan masyarakat dan du k u ngan terhadap odha. perasaan terstigma yang paling dirasakan adalah menutup status dan takut diusir atau dikucilkan. “tetangga ngak ada yang tahu…untuk sementara saya tutupi dulu”…masyarakat kan belum ngerti, takutnya nanti diusir atau dijauhkan” (p. 6). respons diskriminasi muncul sebagai akibat dari adanya stigma yang ditunjukkan oleh par tisipan d alam hal kesempat an kerja. sebalik nya, hasil penelitian juga menemukan respons penerimaan masyarakat terhadap odha, kondisi ini dipengaruhi oleh pemahaman tentang informasi seputar hiv/aids yang ada di masyarakat, seperti pernyataan partisipan sebagai berikut: “kalu kerja di mana pasti ditolak karena peyakitnya…ada perasaan gimana gitu kalu mau masuk ke tempat kerja untuk melamar…sudah ada perasaan menarik diri” (p. 2). “nggak ada tekanan di masyarakat, karena di wilayah x ngak tabu lagi, sekarang sudah biasa, meskipun diketahui odha masyarakat sudah biasa…informasi sudah masuk di wilayah ini, sehingga masyarakat sudah mengerti tentang hiv & aids” (p. 1). tema yang ketiga adalah makna hidup odha dalam menjalani kehidupan. makna hidup odha tergambar dalam dua tema yaitu perubahan pola spiritual dan merancang masa depan. perubahan pola spiritual diwujudkan dalam bent uk kedekatan dengan tuhan melalui sikap kepasrahan, perilaku bertobat, rajin berdo’a. “sekarang saya sudah sholat, dulu ngak pernah, sekarang sudah bisa baca qur’an baru-baru ini, dulu ngak bisa, tujuannya saya ingin berubah lebih baik” (p.6). merancang masa depan merupakan wujud dari kesadaran odha mengambil pelajaran dari pengalaman dengan cara menjaga kesehatan dan harapan masa depan keluarga. menjaga kesehatan ditunjukkan dengan cara menanamkan keyakinan tetap sehat, mengubah sikap, dan perilaku, seperti pernyataan partisipan di bawah ini: “saya ingin menunjukkan bahwa positif hiv itu bisa sehat, tidak saki-sakitan” (p.4). “merubah pola hidup kita, merubah semua…dari yang jelek-jelek saya tinggalkan, seperti minum, narkoba, seks bebas, sudah saya tinggalkan semua” (p.6). h a r a p a n m a s a d e p a n kel u a r g a merupakan harapan terhadap keberlangsungan keluarga terhadap masa depan anak bagi odha yang sudah berkeluarga dan berusaha untuk membahagiakan keluarga bagi odha ter utama yang belum menikah, seper ti pernyataan partisipan di bawah ini: “yang saya kawatirkan anak saya, kalau saya sih tertular ngak apa-apa…bagaimana nanti anak saya, sipa yang akan merawat jika saya mati…saya harus sehat untuk masa depan anak saya” (p. 5). “p i n g i n n y a m b u t g a w e m a n e h nyenengno wong tuwo ( pingin beker ja lagi menyenangkan orang tua)…orang tua perhatiannya makin tinggi” (p. 6). tema yang keempat adalah dukungan sosial yang diterima odha. identifikasi dukungan sosial odha dari hasil penelitian diperoleh gambaran tema tentang dukungan sosial yang tergambar dalam sumber dukungan dan bentuk dukungan. sumber dukungan yang diperoleh berasal dari lingkungan keluarga seperti pasangan, orang tua, dan paman. sedangkan sumber dukungan yang diperoleh dari lingkungan masyarakat berasal dari teman, tetangga, dukungan kelompok, tenaga kesehatan, dan konselor. “setiap keluar rumah saya selalu didampingi sama istri…dia memang saya minta untuk mengontrol saya, supaya jika ada 244 jurnal ners vol. 8 no. 2 oktober 2013: 240–252 teman yang mau ngajak pakai lagi sungkan ada istri…istri saya ngak paki” (p. 1). “selama di rumah sakit saya dimotivasi dan didampingi perawat kayak (seperti) saudara sendiri” (p. 3). bentuk dukungan sosial yang diterima oleh odha berdasarkan hasil studi berupa i n for masi, i nteg r it as sosial, pelayanan kesehatan, emosional, dan spiritual. dukungan informasi merupakan dukungan yang diterima partisipan dalam bentuk pendidikan kesehatan berupa perawatan dan pengobatan penyakit hiv/ & ids dan pelatihan keterampilan yang dapat dijadikan sumber penghasilan. “di dalam kds kita dikasih tahu tentang hiv/aids…membicarakan masalah penyakit… jika kekebalan tubuh kita turun kan bisa terkena berbagai penyakit…cara perawatan, cara pengobatan juga diajarkan” (p.6). “pernah ada pelatihan bikin keset untuk menambah keterampilan dan bisa dikembangkan jadi usaha” (p. 4). bentuk dukungan integritas sosial dalam bentuk penerimaan masyarakat dengan tidak memberikan tekanan sosial dan menerima dalam kelompok yang lebih luas. “meskipun sudah diketahui odha, masyarakat sudah biasa…kita bergaul dengan masyarakat seperti tidak ada apa-apa sama dengan yang lain” (p. 1). d u k u ng a n p el aya n a n ke s e h a t a n yang diterima odha dalam bentuk tempat pelaya na n kesehat a n, pengobat a n d a n laboratorium, dan pembiayaan kesehatan. “saya ke puskesmas biasanya, saya juga sering ke rumah dokter x…kalau pilek atau sariawan…jika ngambil obat saya biasanya ke rumah sakit di malang” (p.2). “mendapat pelayanan kesehatan seperti ambil obat-obatan cepat, kontrol cd4 tiap 6 bulan sekali” (p.6). “kalau berobat menggunakan kartu jamkesmas…semua teman-teman odha sudah punya jamkesmas diuruskan sama pak x, sehingga kalau berobat bisa gratis” (p. 2) dukungan emosional yang diterima oleh odha dalam bentuk pemberian motivasi saling menguatkan satu sama lain dan pemberian perasaan yang menunjukkan empati. “kalau kita berkumpul seperti saudara sendiri, ada perasaan saling mendukung, saling menguatkan satu sama lain…yang mebuat kita bisa lebih bertahan dalam hidup” (p.6). “ternyata saya ngak sendiri, masih ba n ya k te m a n ya ng lai n…sa m a sa m a merasakan penderitaan yang sama” (p. 2). dukungan spirit ual yang diteriam odha dalam bentuk nasihat untuk selalu bersyukur dan bersabar terhadap apa yang dialami saat ini. “ o r a n go r a n g t i a p k a l i d a t a n g mengatakan kamu harus bersyukur pada tuhan yang maha kuasa, saya tidak menyesali dengan apa yang telah terjadi…mereka juga memberi motivasi saya agar saya bersabar dan bertawakal dan berdo’a” (p. 3). tema yang kelima adalah pengaruh duk ungan sosial yang diterima odha. pengaruh yang sangat dirasakan oleh odha selama mendapatkan dukungan sosial adalah kesehatan terkontrol yang ditunjukkan dengan adanya kemudahan akses pelayanan, dan koping yang adaptif. “…jika kita bergabung dalam kds cara kita ngakses obat ngak dipersulit…karena mk (manajer kasus) kan sudah kenal sama dokternya dan jadinya mudah…kita langsung datang ke rumah sakit…jika ngak punya mk biasanya kita disuruh kesana-kesana binggung jadinya” (p. 1). “pelayanan kesehatan terasa mudah… kesehatan jadi terjamin…” (p. 8). koping adaptif mer upakan bentuk kesehatan mental yang banyak ditunjukkan oleh penderita penyakit kronis atau terminal t e r m a s u k y a ng d i a l a m i ole h odh a digambarkan dengan terus mencari informasi, menggali kelebihan, motivasi tumbuh, dan menghindari stresor. “dengan berkumpul dalam kds saya menegtahui terus bagaimana perkembangan diluar…setiap pertemuan saya yakin ada saja informasi yang baru yang belum saya tahu” (p. 3). “dengan berkumpul sama teman-teman, kita dapat baanyak informasi, dukungan semangat dan bisa bertahan…kita menjadi 245 pengalaman odha mendapatkan dukungan sosial (setyoadi) diri kita…kita menggali kekuatan diri…agar kita bisa menghadapi semua ini” (p. 3). “ada perasaan maju untuk ter us bertahan, semangat terus untuk hidup” (p. 8) “melamun saya hilangkan…perasaan saya ringan…karena saya yakin kesehatan juga dipengaruhi oleh pikiran kita, saya berusaha melupakan apa yang terjadi dan berfi kir kedepan” (p. 5). tema yang keenam adalah dukungan sosial yang diharapkan odha. gambaran dukungan sosial yang diharapkan partisipan dikelompokkan ke dalam tiga tema yaitu pelayanan kesehatan, bentuk dukungan, dan pemberdayaan. harapan odha terhadap dukungan pelayanan kesehatan ter utama terhadap peran perawat yang ada di puskesmas dalam bentuk kunjungan rumah, pendidikan kesehatan, dan menjaga rahasia status. “sa ya k ira pera wat perlu untuk melakukan kunjungan lapangan…harusnya mereka menyempatkan diri untuk keluar lapangan…karena tenaganya sedikit bisa dilakukan dengan cara bergiliran” (p. 3). “perawat juga harusnya ngasih tahu seperti apa alur pengobatan dan perawatan… memudahkan odha untuk mendapatkan pelayanan kesehatan” (p. 8). “menjaga rahasia…jangan samapi status diomongkan ke orang-orang…perawat kan sukanya gitu” (p. 8). bentuk dukungan yang diharapkan odha antara lain dukungan emosional, integritas sosial, dan informasi. dukungan emosional yang diharapkan oleh odha berupa menjaga rahasia status dan pemberian motivasi. “butuh kepercayaan, soale odha kan butuh kepercayaan…untuk menjaga supaya status tidak tersebar” (p. 1). “ad a d u k u nga n d u k u nga n u n t u k memberi semangat kepada teman-teman sebaya” (p. 3). dukungan informasi yang diharapkan odha seperti perawatan dan pengobatan, p e m e c a h a n m a s a l a h , d a n d i a j a r k a n keterampilan. “saya ingin mendapatkan dukungan informasi tentang perawatan dan pengobatan” (p. 5). “sesering mungkin kita kumpul untuk cari informasi gimana solusi yang terbaik” (p. 1). “pinginnya diajari jahit gitu…juga pingin belajar masak…kita bisa warung untuk menambah penghasilan” (p. 4). pemberdayaan yang diharapkan oleh odha meliputi pemberdayaan kelompok dan pemberdayaan ekonomi. pemberdayaan kelompok yang diingin kan oleh odha adalah pengembangan peran kds seperti, memajukan kds, memperluas anggota kds dengan cara menjaring teman odha yang luar, dan memperbaiki manajemen kds. “k ds lebih besar lagi atau lebih diperbesar anggotanya atau lebih banyak menjaring teman-teman” (p. 8). “manajemennya ruwet (tidak teratur), soale penguruse durung (karena pengurusnya belum) tahu tugase sehingga perlu pelatihan, sehingga kds bisa tetap berjalan” (p.6) pemberdayaan ekonomi yang diharapkan odha adalah membuat lapangan pekerjaan dengan cara pemberian modal usaha seperti yang ditunjukkan oleh delapan partisipan, berikut salah satu pernyataan partisipan: “kepinginku yo iku lo mas pemberdayaan ekonomi…kepingine ada modal usaha bisa kelompok atau sendiri” (p 6). pembahasan persepsi partisipan tentang pengalaman dukungan sosial dipengaruhi oleh pengalaman sebelum terinfeksi dan selama diagnosa. pengalaman sebelum mendapatkan dukungan berpengaruh terhadap kemampuan mereka untuk mencari dukungan sosial. pengalaman partisipan terhadap faktor risiko terjadinya infeksi sebenarnya sudah disadari dengan adanya perilaku yang tidak sehat akan menyebabkan timbulnya masalah kesehatan, tetapi belum spesifik terhadap infeksi hiv. salah satu alasannya adalah kurang terpapar informasi sehingga odha tidak tahu awalnya jika perilaku berisiko yang dilakukan dapat menyebabkan terinfeksi hiv. kurangnya paparan terhadap informasi khususnya masalah kesehatan berpengaruh terhadap sikap dan per ilak u, sehingga 246 jurnal ners vol. 8 no. 2 oktober 2013: 240–252 cenderung melakukan tindakan yang berisiko terhadap masalah kesehatan (stanhope & lancaster, 2002). tingkat pengetahuan berhubungan erat dengan kesejahteraan. kemiskinan menyebabkan individu tidak dapat bersekolah dan kesulitan dalam mengakses informasi. hasil penelitian bloom et al (2002, dalam u nicef, 2009) menggambarkan bahwa kem isk i na n pad a i nd iv idu mempu nyai risiko lebih besar untuk terinfeksi virus, karena rendahnya tingkat pendidikan dan ketidakmampuan mendapatkan informasi menurunkan kemampuan mereka melakukan usaha pencegahan. pendidikan kesehatan tentang hiv & aids mampu meningkatkan kesadaran pencegahan penularan dengan cara mengontrol diri (self management) dan keterampilan dalam mengambil keputusan (decision-making skills) (brigham et al, 2002). perilaku yang berisiko terjadinya infeksi hiv cenderung dilakukan oleh subpopulasi pekerja seksual dan pengguna narkoba jarum suntik. pekerja seksual dengan perilaku gontaganti pasangan, tidak menggunakan kondom saat berhubungan, dan mode hubungan seksual, cender ung berhubungan dengan banyak pasangan sehingga tidak terdeteksi adanya pasangan yang terinfeksi hiv sehingga dapat menular kepada pekerja seks atau sebaliknya klien terinfeksi oleh pekerja seks (depkes ri, 2003). hal ini dibuktikan hasil penelitian rachel dan robert (2010) di dua negara afrika yaitu rwanda dan tanzania menggambarkan bahwa perilaku bergantian pasangan berisiko dua kali untuk tertular hiv (or 2.39 (ci: 1.21,4.73). subpopulasi penasun banyak terjadi pada kelompok usia remaja atau dewasa awal yaitu usia 15 tahun ketas, usia muda mempunyai karakteristik ingin bebas, mencari pengalaman, ikatan emosional kuat dengan teman sebaya dan mencoba-coba hal yang baru (sudrajad, 2008). rentannya remaja terhadap penyimpangan seksual dan aids bersumber dari perubahan fisiologis serta psikologis, berkaitan dengan perkembangan organ reproduksi mereka. pada tahap ini, remaja mulai merenggang dari orang tuanya kemudian membentuk kelompok sahabat karib. perilaku remaja yang bertendensi ke arah penarikan diri, sangat mungkin terjadi tindakan irasional (rachmawati, 2000). perilaku penggunaan jar um suntik bergantian pada panasun disebabkan karena kesulitan untuk mendapatkan jarum suntik atau spuit, hal ini dikarenakan adanya pembatasan dalam pembelian jarum suntik secara bebas di apotek yang harus menggunakan resep dokter. alasan lain yang penasun menggunakan bersama jarum suntik adalah karena mahalnya narkoba jenis intravena menyebabkan mereka patungan dalam membeli dan memakai secara bersama dengan cara bergantian (who/ unaids, 2009). bersedih sebagai bentuk dari respons kehilangan status kesehatan yang ditunjukkan pertama kali oleh odha dalam bentuk shock dan tidak percaya terhadap infeksi hiv (willy, 2008; taylor, 2006). reaksi ini digambarkan oleh semua partisipan, dan berlangsung lebih pendek kurang dari satu bulan dan diakhiri tahap penerimaan dengan cara menyerahkan semua permasalahan pada tuhan. proses kehilangan yang lebih cepat dan pendek dikarenakan kehilangan yang dialami oleh partisipan termasuk yang diantisipasi dan faktor keyakinan agama turut membentuk memberikan pengaruh positif ditandai dengan berkurangnya depresi, peningkatan kualitas hidup, mengurangi ketakutan menghadapi kematian, dan tumbuh semangat untuk tetap hidup (potter & perry, 2005; djauzi, 2006). kecemasan adalah respons umum yang sering dijumpai pada penderita hiv/aids dan kadang sulit dibedakan dengan depresi, respons ini muncul dimulai saat pertama kali terdiagnosa positif hiv disebabkan oleh sesuatu yang tidak pasti dalam pikirannya dan perasaan ketakutan (taylor, 2006, stuart & laraia, 2005). perasaan ketakutan muncul disebabkan oleh gambaran odha adalah orang yang sakit-sakitan, tidak sembuhsembuh, dikucilkan atau dijauhkan dari lingkungan, dan kematian yang setiap saat bisa menjemput (burnam et al, 2003). kecemasan dapat diatasi dengan adanya dukungan sosial yang diterima dari keluarga dalam bentuk perhatian dan penerimaan, dan dukungan ini 247 pengalaman odha mendapatkan dukungan sosial (setyoadi) bisa meningkatkan semangat hidup odha (brown, trujilo, & macintyre, 2001; lee et al, 2009). perasaan terstigma dan diskriminasi merupakan masalah yang sering dihadapi oleh odha, hal ini disebabkan adanya perasaan ketakutan masyarakat untuk tertular penyakit yang dianggap berbahaya dan ter masuk penyakit akibat “kutukan tuhan “ sehingga harus dijauhi dan dikucilkan (brown, trujilo, & macintyre, 2001; lee et al, 2009). reaksi umum yang ditunjukkan oleh odha adalah dengan menutup status dan malu bergaul dengan membatasi berhubungan dengan orang lain. perasaan malu juga bisa disebabkan karena perasaan bersalah telah melanggar nilai dan norma masyarakat seperti perilaku bergonta-ganti pasangan, hubungan sejenis, dan menggunakan narkoba (link & parker, 1998 dalam brown, trujilo, & macintyre, 2001; jenifer, 2007). diskriminasi merupakan dampak dari stigma di masyarakat disebabkan pemahaman yang salah terhadap penyakit hiv & aids. diskriminasi yang dialami sering ditunjukkan oleh pember i pelayanan kesehatan dan kesempatan kerja. diskriminasi di pelayanan kesehatan disebabkan karena kurangnya pengetahuan dan praktik universal precaution (waluyo, sukmarini, & rosakawati, 2005). sedangkan diskriminasi dibidang pekerjaan disebabkan karena odha kurang produktif disebabkan karena seringnya muncul keluhan sak it ak ibat i nfeksi opor t u nisti k yang menyebabkan mereka sering tidak masuk kerja dan menimbulkan image negatif terhadap perusahaan (elliott, uthyasheva, & zack, 2009; dawn, 2009). me n d e k a t k a n d i r i p a d a tu h a n mer upakan hikmah yang dirasakan oleh penderita penyakit k ronis atau ter minal (garung, 2009). kedekatan ditunjukkan dalam bentuk praktik keagamaan dan keyakinan lai n nya denga n ha r apa n mend apat k a n kesembuhan. sikap dan perilaku ini dilakukan sebagai bentuk rasa malu dan bersalah kepada tuhan atas sikap dan perilaku yang tidak sesuai dengan ajaran agama serta adanya anggapan “penyakit kutukan” dari tuhan (pamujie, 2009). dilain pihak, keyakinan ikut membent uk stigma dengan adanya kepercayaan bahwa penyakit yang diderita adalah hukuman dari tuhan sehingga respons yang dimunculkan adalah mendekatkan diri pada tuhan dengan cara beribadah dengan keyakinan bahwa tuhan akan memberikan kesembuhan (james et al, 2009). mayoritas orang yang terdiagnosa hiv & aids cenderung untuk membuat perubahanperubahan positif di dalam perilaku kesehatan mereka segera setelah terdiagnosa (taylor, 2006). perubahan ini ditujukan untuk menjaga dan mempertahankan kesehatan, di samping itu juga perubahan terkait dengan tuntutan peran dalam keluarga untuk membesarkan dan mendampingi anak sampai dewasa. dampak hiv & aids terhadap keluarga menyebabkan terjadinya perubahan struktur dan fungsi dalam keluarga. orang tua yang terinfeksi akan mengalami kematian lebih cepat yang mengakibatkan anak menjadi yatim atau yatim piatu (unicef, 2010). perasaan khawatir terhadap keluarga muncul sebagai bent u k tangg ung jawab unt u k menjaga keberlangsungan fungsi keluarga. harapan terhadap anak ini memberikan pengaruh yang positif terhadap partisipan untuk tetap bertahan hidup demi merawat dan membesarkan anakanaknya. dukungan sosial yang berasal dari lingkungan keluarga sangat efektif diberikan pada odha, karena sesuai dengan nilai, nor ma, dan keyak inan dalam keluarga sehingga mudah untuk diberikan setiap saat (kuntjoro, 2002). di samping itu odha juga membutuhkan penerimaan dari lingkungan yang lebih luas dari masyarakat seperti teman, tetangga, tenaga kesehatan, dan kelompok dukungan untuk mengurangi depresi, isolasi sosial, kepatuhan pengobatan, dan sebagai sumber koping (edward, 2009; young, 2010). bentuk dukungan sosial yang diterima partisipan berdasarkan hasil studi berupa i n for masi, i nteg r it as sosial, pelayanan kesehatan, emosional, dan spiritual. dukungan informasi merupakan dukungan yang paling dirasakan oleh partisipan selama bergabung dalam kds, seperti informasi tentang tanda gejala hiv/aids, perilaku yang berisiko terjadinya penularan, cara perawatan dan 248 jurnal ners vol. 8 no. 2 oktober 2013: 240–252 pengobatan, kapan harus kontrol atau cek laboratorium, dan pelatihan keterampilan cara merawat anggota keluarga yang sakit atau buddys. dukungan informasi ini penting sebagai antisipasi bagi odha untuk mencegah terjadinya depresi akibat sering munculnya kelu han kesa k it an yang sili h bergant i disebabkan menurunnya sistem kekebalan tubuh (taylor, 2006). dukungan integritas kelompok dengan penerimaan pada masyarakat yang lebih luas dengan tujuan mempertahankan kontak sosial di antara anggota kelompok, tujuannya adalah membantu mendapatkan informasi yang dibutuhkan, saling bertukar pengalaman, mendengarkan dan menerima pengalaman anggota, saling memahami dan membuat jaringan sosial (garung, 2006; randall, 2003). laura (2009), melibatkan odha dalam berbagai kegiatan mampu mengurangi perasaan terstigma dan diskriminasi sehingga mampu meningkatkan hubungan jaringan social jane et al (2009), juga mengungkapkan bahwa penerimaan masyarakat terhadap odha mampu meningkatkan konsep diri yang pada akhirnya mampu meningkatkan kesehatan psikologi. d u k u ng a n p el aya n a n ke s e h a t a n sangat dirasakan manfaatnya oleh odha untuk mengontrol tanda dan gejala yang sebabkan oleh menurunnya sistem kekebalan tubuh. tanda dan gejala yang dialami oleh odha berkaitan dengan munculnya infeksi oportunistik, di samping itu juga untuk mengontrol jumlah cd4, termasuk dalam kategori dukungan instrumental. dukungan pelayanan kesehatan bisa langsung dirasakan manfaatanya oleh odha, karena sangat membantu dalam kondisi kesakitan yang dialami (jacobson 1987, dalam oxford, 1992). hasil penelitian basanti dan nomathemba (2010), menggambarkan bahwa salah satu dukungan yang dibutuhkan odha untuk menjalan i perawat an di r u mah ad alah dukungan instrumental seperti keuangan karena tidak punya penghasilan, pelayanan kesehatan seperti pengobatan keluhan infeksi dan obat arv, dan material seperti makanan, pengobatan, dan produk kebersihan. gambaran dukungan emosional yang diterima partisipan dalam bentuk pemberian motivasi yang ditunjukkan dengan cara saling mengingatkan, mendukung, dan menguatkan semangat serta empati yang ditunjukkan dengan perasaan tidak sendiri dan merasakan penderitaan yang sama bila bergabung dalam kelompok. kelly et al (2009), menggambarkan bahwa dukungan sosial mampu mengurangi ga ng g u a n psi kolog i e mosion a l st re ss dan depresi yang pada ak hir nya akan meningkatkan kualitas hidup odha. basanti dan nomathemba (2010) menambahkan bahwa dukungan sosial dapat mengurangi kesedihan dan rasa khawatir terhadap ketidakpastian kesehatan, prognosis yang buruk, dan nasib anak-anak mereka jika ditinggal mati. dukungan spiritual yang diterima odha dalam bentuk motivasi untuk dekat dengan tuhan dengan cara bersyukur dan menyerahkan semua permasalahan padanya. genrich dan brathwaite (2005, dalam james et al, 2009) menyatakan bahwa keyakinan agama membentuk sikap individu secara signifi kan hidup dengan hiv. praktik keyakinan dan kepercayaan dapat memberikan perasaan damai dan harapan, dan dapat juga membantu orang-orang untuk menyiapkan diri dan menerima kematian. orang-orang kembali kepada agama untuk mengembalikan kesadaran dan muncul sebagai orang dengan infeksi hiv. beribadah, meditasi, yakin pada tuhan, dan bentuk lain dari kegiatan agama lebih sering dilakukan oleh odha. ha si l p e nel it ia n i n i d id apat k a n gambaran tentang pengaruh dukungan sosial yang diterima partisipan dalam bentuk kontrol terhadap kesehatan yang ditunjukkan dengan koping yang adaptif dan kemudahan akses pelayanan kesehatan. kemudahan akses pelayanan kesehatan seperti pengobatan dan rujukan. partisipan yang berada di bawah binaan lsm paramitra mempunyai jaringan pelayanan kesehatan yang difasilitasi oleh manajer kasus di bawah program vct yang berada di tingkat puskesmas. setiap manajer kasus membawahi suatu wilayah untuk melakukan binaan terhadap odha dan subpopulasi berisiko. keberadaan program vct sendiri merupakan bagian dari program nasional untuk penanggulangan hiv & aids. program vct mempunyai alur rujukan 249 pengalaman odha mendapatkan dukungan sosial (setyoadi) dengan rumah sakit yang telah ditunjuk untuk melakukan penanganan penderita aids. kondisi ini yang menyebabkan partisipan mendapatkan kemudahan pelayanan kesehatan sehingga kesehatan terkontrol. koping adaptif yang dit u nju k kan par tisipan ditandai dengan pengetahuan bertambah, menjaga kesehatan, harga diri tinggi, dan motivasi tumbuh. taylor (2006), menjelaskan salah satu keterampilan koping adalah kemampuan individu untuk menggali informasi yang terkait dengan dirinya untuk melakukan kontrol personal dan mengambil manfaat dari apa yang telah dilakukan. pe nde r it a p e nya k it k ron is ce nde r u ng melakukan perubahan untuk meningkatkan kualitas hidup dan mempertahankan status kesehatannya. hasil penelitian brigham et al (2002), bahwa pengetahuan yang tinggi mampu membuat pilihan-pilihan dan kontrol terhadap lingkungan yang ditunjukkan dengan keterampilan mengelola diri (self management) dan menggunakan keterampilan tersebut untuk berlatih memilih dan mengontrol mana yang penting bagi kehidupan mereka. mempertahankan kesehatan dengan cara mewaspadai munculnya infeksi oportunistik merupakan wujud dari pemahaman terhadap dirinya yang dibekali dengan pengetahuan tentang proses penyakit hiv & aids. kewaspadaan mer upakan bentuk kontrol diri terhadap munculnya stresor fi sik akibat menurunnya fungsi imunologi. mekanisme koping yang dipakai oleh partisipan merupakan koping yang berorientasi pada penyelesaian masalah, artinya partisipan berusaha mengatasi munculnya infeksi oportunistik dengan cara mewaspadai jangan sampai muncul infeksi (taylor, 2006). tumbuhnya motivasi pada partisipan ditandai oleh bangkitnya semangat untuk tetap hidup. motivasi untuk tetap hidup ini merupakan sikap optimis untuk mendapatkan sesuatu harapan yang lebih baik, dibandingkan dengan sesuatu yang jelek. orang memiliki sikap optimis selalu dapat menemukan aspek positif dari berbagai situasi dan selalu menampakkan sisi yang lebih baik dari kehidupannya. sikap optimis yang kuat dan positif berhubungan erat dengan kesehatan psikologi (garung, 2006). motivasi atau harapan dapat meningkatkan akibat pengaruh dari dukungan sosial yang diterima dan dapat meningkatkan kualitas hidup penderita (yadav, 2009). harapan terhadap pelayanan kesehatan khususnya peran perawat dikomunitas yang diharapkan adalah adanya kunjungan rumah untuk memantau kondisi kesehatan odha, pendidikan kesehatan dengan memberikan i nfor masi tent ang alu r perawat an d an pengobatan penderita hiv & aids sehingga mud a h d ala m mend apat ka n pelaya na n kesehatan, memberikan motivasi, menjaga ra hasia tent a ng st at us sebagai odh a karena partisipan menganggap perawat suka bergunjing, dan keramahan perawat dalam member ikan pelaya na n karena adanya anggapan dari partisipan bahwa perawat ”judes”. bentuk dukungan yang diharapkan oleh odha pada dasarnya sudah pernah disampaikan pada setiap pertemuan rutin bulanan, tetapi masih menjadi harapan dikarenakan tidak semua partisipan bisa hadir pada setiap kali pertemuan karena berbagai alasan diantaranya letak sekretariat kds yang terlalu jauh sehingga menyulitkan, beberapa alasan yang disampaikan seperti; karena membutuhkan transportasi dan ongkos untuk menjangkaunya, kondisi kesehatan yang kurang baik karena pengaruh infeksi oportunistik, dan ada perasaan bosan karena yang dibicarakan sama dan tidak ada jalan keluar konkret yang bisa diberikan. di samping itu lama bergabung partisipan dalam kds sangat bervariasi mulai dari satu bulan sampai sepuluh bulan, itu artinya yang satu bulan baru pertama mengikuti pertemuan sehingga partisipan ingin mendapatkan informasi yang lebih lengkap. h a r a p a n p a r t i s i p a n t e r h a d a p pemberdayaan ada dua yaitu harapan terhadap pemberdayaan kelompok dan pemberdayaan ekonomi. pemberdayaan kelompok yang diharapkan adalah keberlangsungan kds dan perbaikan manajemen kds. partisipan berharap kds tetap ada sebagai wujud bahwa dukungan kelompok ini memberikan manfaat yang dapat dirasakan. berbagai hasil penelitian telah membuktikan bahwa dukungan kelompok 250 jurnal ners vol. 8 no. 2 oktober 2013: 240–252 member ikan pengar u h yang sig nif ikan terhadap kesehatan dan kualitas hidup odha (ludgendorf, 1998 dalam taylor, 2006). di samping itu keberadaan sekretariat kds yang belum permanen menjadi kecemasan tersendiri bagi partisipan, kondisi ini setiap saat bisa berhenti sehingga disampaikan menjadi harapan untuk tetap berdiri dan memperluas anggota dengan cara menjaring teman-teman yang lain. harapan terhadap perbaikan manajemen disampaikan oleh partisipan karena merasa tidak ada program yang jelas pada setiap pertemuan dan sifatnya spontanitas. agenda dan target pencapaian yang tidak jelas membuat partisipan mengusulkan adanya pelatihan mengelola kds bagi para pengurus supaya tahu hak dan tanggung jawab. pe m b e r d a y a a n e ko n o m i p a l i n g diharapkan oleh partisipan terutama dalam pemberian modal usaha untuk membuka lapangan pekerjaan. lapangan pekerjaan sangat diharapkan oleh semua partisipan khususnya yang sudah berkeluarga untuk memenu h i kebut u ha n kelu a rga seper t i membelikan susu anak dan kebutuhan seharihari. beban ekonomi yang dirasakan partisipan adalah biaya belanja kesehatan, karena adanya infeksi oportunistik yang setiap saat muncul silih berganti disebabkan menurunnya sistem kekebalan tubuh. di samping itu usia partisipan masuk dalam kategori usia produktif yaitu antara 25 tahun sampai 36 tahun, salah satu tugas perkembangan usia ini adalah melakukan pekerjaan. pe n ol a k a n d a l a m b e ke r ja j u g a menjadi hambatan tersendiri karena adanya stigma yang berdampak pada munculnya diskriminasi untuk mendapatkan kesempatan kerja yang sama dengan yang lain. beberapa kondisi diatas yang menyebabkan odha menginginkan adanya pemberdayaan ekonomi khususnya pemodalan usaha. salah satu cara meningkatkan pemberdayaan ekonomi untuk mengatasi kemiskinan menurut dworkin dan blankenship (2009) adalah melalui program pinjaman modal usaha (microfi nance). simpulan dan saran simpulan dukungan sosial yang diterima odha diperoleh dari lingkungan keluarga seperti pasangan, orang t ua, teman, tetangga, dukungan kelompok, dan tenaga kesehatan yang diberikan dalam bentuk dukungan infor masi, integ r itas sosial, emosional, pelayanan kesehatan, dan spiritual. dukungan sosial berpengaruh positif terhadap kontrol kesehatan odha yang ditunjukkan dengan kemudahan dalam mengakses pelayanan kesehatan dan koping yang lebih adaptif. saran dukungan sosial yang sangat diharapkan oleh odha adalah dukungan pemberdayaan ekonomi dalam bentuk pemberian modal usaha dan kegiatan perawat puskesmas untuk melakukan kunjungan rumah. kepustakaan basanti & namathemba. 2010. the experiences of people living with hiv/aids and of their direct informal caregivers in a resource-poor setting, journal of the international aids society 2010, (online), ( http://www.jiasociety.org/ content/13/1/20., diakses tanggal 21 januari 2010, jam 13.00 wib). brigham et al. 2002. psichology and aids education: reducing high-risk sexual behaviour. behavior dan social journal. washington state university. brow n, tr ujilo, d a n maci nt y re. 20 01. inter vention tor reduce hiv/aids stig ma: what ha ve we lear ned?. louisiana. the population council inc, (online), (http://www.popcouncil. org/pdfs/horizons/litrvwstigdisc.pdf., diakses tanggal 19 januari 2010, jam 16.00 wib). burnam et al. 2003. use of psychotropic medication s a mong hiv-infected patients in the united states. am j psychiatry 2003; 160: 547–554. 251 pengalaman odha mendapatkan dukungan sosial (setyoadi) dawn et al., 2009. komwaa qualitative study of the impact of hiv/aids on agricultural departemen kesehatan republik indonesia. 2003. estimasi nasional infeksi hiv pada orang de wa sa tahun 2022, (online), (http://www.pppl.depkes.go.id/ images_data/hiv-aids.pdf, diakses tanggal 20 januari 2010, jam 12.00 wib). depkes ri. 2009. hiv/aids. (online), (http:// www.pppl.depkes.go.id/images_data/ hiv-aids.pdf, diakses tanggal 20 januari 2010, jam 14.00 wib). dworkin dan blankenship. 2009. microfi nace and hiv/aids prevention: assessing its promise limitation. (online), (http:// gateway.nlm.nih.gov/meetingabstracts/ ma?f=102253707.html. diakses tanggal 16 maret 2010, jam 15.00 wib). elliott, uthyasheva & zack. 2009. hiv, d i s a b i l i t y a n d d i s c r i m i n a t i o n: making the links in international and domestic human rights law. journal of the inter national aids society, (online), (http://www.jiasociety.org/ content/12/1/29, diakses tanggal 16 juni 2010, jam 12.00 wib). garung, r. 2006. health psycology : coping and social support. belmont. thomson wadswarth. gay et al. 2009. symptom experience in hiv infected adult: a function of demographic and clinical characteristic, (online), (http://gateway.nlm.nih.gov/meetingab stracts/102253707.html, diakses tanggal 16 maret 2010, jam 14.00 wib). h o u se h old s i n s o uth e a ste r n uga n d a . international journal of environmental research and public health, (online), (w w w. m d p i . c o m / j o u r n a l / i j e r p h . diperoleh tanggal 18 juni 2010, jam 13.30 wib). james et al. 2009. religion and hiv in tanzania: infl uence of religious beliefs on hiv jane et al. 2009. stigma, identity and resistance among people living with hiv in south africa. journal of social aspects of hiv/aids vol. 6 no. 3. jenifer et al. 2007. experiences of social stigma and implications for healthcare among a diverse population of hiv positive adults. journal of urban health: bulletin of the new york academy of medicine, vol. 84, no. 6. new york. kelly et al. 2009. putting episodic disability into conte xt: a qualitative stud y e xploring fa ctors that inf luence disability experienced by adults living with hiv/aids, (online), ( http://www. jiasociety.org/content, diakses tanggal 18 juni 2010, jam 17.00 wib). kpn. 2007. strategi nasional penanggulangan hiv dan aids 2007-2010, (online), (http://www.kpn.org.id, diakses tanggal 19 januari 2010, jam 18.00 wib). laura et al. 2009. combating hiv stigma in health care setting: what work?. jour nal of the inter national aids society, (online), (http://www.jiasociety. org/content/12/i/15, diakses tanggal 24 februari 2010 jam 13.30 wib). lee et al. 2009. stigma, social support, and depression among people living with hiv in thailand, (online), ( http:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc2584319/pdf/afhs0802-0097.pdf., diakses tanggal 23 februari 2010, jam 10.00 wib). oxford, j. 1992. community psycology : theory and practice. new york: john wiley & son, inc. pamujie. 2009. aspek spiritual keagamaan sebagai salah satu terapi hiv/aids, (online), (http://mrpams212.wordpress. com/category/, diakses tanggal 18 juni 2010, jam 11.00 wib). potter & perry. 2005. fundamental of nursing. 6th. vol. 1. missouri. elsevier mosby. rachmawati. 2009. narkoba, aids, dan kita, (online), (http://www.ikonbali. org/25/11/2007/penyadaran/narkobaaids-dan-kita.html, diakses tanggal 16 juni 2010, jam 09.00 wib). randal, m.c. 2003. support group : what theay are and what they do. (online), ( h t t p: // w w w. g e n e t i c h e a l t h . c o m / resources_suppor t_groups_what_ they_are_and_what_they_do.shtml, diakses tanggal 27 febr uari 2010, jam 09.30 wib). stigma, disclosure, and t reat ment attitude, (online), (http://www.biomedcentral.com/14712458/9/75, diakses tanggal 18 juni 2010, jam 12.30 wib). 252 jurnal ners vol. 8 no. 2 oktober 2013: 240–252 stuart & laraia. 2005. principles and practice of psyciatric nursing. 8th ed. missouri. mosby inc. su d r aja d , a . 20 0 8. p r o b le m a m a s a remaja.(online), (http://akhmadsudrajat. wordpress.com/problema-masa-remaja2/, diakses tanggal 11 maret 2010, jam 08.30 wib). taylor, s.e . 20 06. he a lth p s yc olog y psycoimunology, aids, cancer, and arthritis. 6th ed. new york: mcgraw hill. unicef. 2009. children and aids : fourth stocktaking report 2009, (online), ( ht t p://w w w.u n icef.org /aid s /f i le s / b230stocktaking _06nov09_final_ lores.pdf, diakses tanggal 27 februari 2010, jam 11.00 wib). welly, v. 2008. pengalaman pasien pertama kali terdiagnosa hiv/aids : studi f e n o m e n o l o g i d a l a m p e r s p e k t i f keperawatan. tesis tidak dipublikasikan. universitas indonesia. who/unaids. 2009. aids epidemic up date 2009, (online), (http://www.unaids. org/en/k nowledgecentre/hivdata/ e pi up d a t e / e pi up d a r c h ive /2 0 0 9/ default.asp, diakses tanggal 19 januari 2010, jam 13.30 wib). 91 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 91-100 http://dx.doi.org/10.20473/jn.v18i1.42404 original article open access a systematic review of illness representations in patients with mild traumatic brain injury mulyadi mulyadi 1 * , santo imanuel tonapa 2 , heriyana amir 3 , and bih-o lee 4 1 school of nursing, faculty of medicine sam ratulangi university, manado, indonesia 2 college of nursing, kaohsiung medical university, kaohsiung, taiwan 3 graha medika institute of health and technology, kotamobagu, indonesia 4 college of nursing, kaohsiung medical university, kaohsiung, taiwan *correspondence: mulyadi mulyadi. address: school of nursing, faculty of medicine sam ratulangi university, manado, indonesia. email: mulyadi@unsrat.ac.id responsible editor: ferry efendi received: 10 january 2023 ○ revised: 17 february 2023 ○ accepted: 18 february 2023 abstract introduction: little is known about the cognitive and emotional perceptions of patients with mild traumatic brain injury, although studies showed patients experiencing difficulties in cognitive functioning and psychological impacts following their injury. this systematic review aims to identify the current literature regarding illness representation dimensions in mild traumatic brain injury and their related factors. methods: a search of electronic databases was completed using pubmed, cinahl, embase, and web of science, which were published from 2002 to april 2020. studies were assessed for quality and bias, and data were analyzed using narrative synthesis. results: the initial search yielded 155 studies, and ten were included. the results showed that patients had negative perceptions toward their mild traumatic brain injury. some dimensions of illness representation were found to have relationships to their post-concussion symptoms, post-traumatic stress disorder, and quality of life of mild traumatic brain injury patients. conclusions: the illness representations can be applied to such patients because it is able to explain symptoms and related factors that indicate their recovery process. the findings help trauma nurses to build interventions based on the dimensions of illness representations to generate appropriate perceptions after injury, and may to enhance the recovery process and outcomes. keywords: illness representations, mild traumatic brain injury, nursing, systematic review introduction mild traumatic brain injury (mtbi) constitutes one of the most challenging public health issues, with an estimated incidence of 100-350/100,000 people worldwide (cassidy et al., 2004; nguyen et al., 2016; skandsen et al., 2019). patients with mtbi frequently experience headaches, dizziness, fatigue (van der naalt et al., 2017), poor quality of life (fikriyanti et al., 2014; voormolen et al., 2019), cognitive function impairments (theadom et al., 2016), and psychological distress after receiving mtbi (cassidy et al., 2014; vikane et al., 2019). although an mtbi is not a life-threatening event, studies have emerged indicating that mtbi patients experience difficulties in cognitive functioning and psychological distress. the cognitive problems of such patients vary in terms of the associated recovery rates, with one study reporting that the majority of mtbi patients fully recovered within 90 days after the injury (karr et al., 2014). in contrast, another study found that about 39% of patients with mtbi still reported cognitive complaints as of six months after being injured (stulemeijer et al., 2007). in addition, various https://creativecommons.org/licenses/by/4.0/ mailto:mulyadi@unsrat.ac.id https://orcid.org/0000-0003-0632-3452 https://orcid.org/0000-0002-9730-1939 https://orcid.org/0000-0003-1910-6879 https://orcid.org/0000-0003-1903-8378 supremo, bacason, and sañosa (2022) 92 p-issn: 1858-3598  e-issn: 2502-5791 psychological problems, such as anxiety and depression, have also been reported as of two months after receiving an mtbi (vikane et al., 2019). furthermore, one recent study found that not all patients with mtbi reported experiencing a full recovery after the injury (nelson et al., 2019). the recovery process after an mtbi might not always be observed by a medical professional (theadom et al., 2016), as one three-month follow-up study of patients with mtbi reported that only 52% had even visited a medical practitioner regarding their injury (seabury et al., 2018). furthermore, it has been reported that most non-hospitalized mtbi patients do not experience a full recovery, with visits to outpatient clinics being common among such patients (de koning et al., 2017). evidence has showed that the recovery process after an mtbi influenced by patients' perceptions and behavioral responses to their condition (var & rajeswaran, 2012). therefore, an innovation for posthospital follow-up with respect to patient perception is definetely important, because a study showed patients with negative perceptions of injury-related symptoms, self-control, and treatment controls on discharge from the hospital were at increased risk of impaired quality of life 3 months after discharged from the hospital (tonapa et al., 2021). one of the increasingly popular models that describe patients' views and responses toward illness is leventhal's common-sense model of illness representations (csmir) (petrie et al., 2007). the csmir model has received increasing attention because it can explain how individuals view and adapt to changing consequences and health threats (rice, 2012). illness representations (irs) are a central part of the csmir, and can be assessed along different dimensions of ir. irs were originally conceived of as being comprised of five dimensions of cognitive representations, including identity, timeline, consequences, control, and causes. each dimension reflects different perceptions or internal beliefs regarding an illness (leventhal et al., 2001). moss-morris et al. (2002) used different patient populations to rebuild the dimensions of ir. two dimensions, illness coherence and emotional representations, were added as a result. the timeline dimension was divided into two subscales, timelineacute/chronic and timeline cyclical, and the control dimension was divided into personal control and treatment control (moss-morris et al., 2002). the figure 1 prisma flowchart records identified through database searching pubmed=55, cinahl=27, embase=28, web of science=45 (n = 155) s c re e n in g in c lu d e d e li g ib il it y id e n ti fi c a ti o n additional records identified through other sources (n = 0 ) records after duplicates removed (n = 111) records screened (n =22) records excluded based on title/abstract (n = 89) full-text articles assessed for eligibility (n = 10 ) full-text articles excluded, with reasons (n = 12 ) • sample age (n=2) • non mtbi populations (n = 4) • not measured illness representation dimensions (n = 6) studies included in the review (n = 10 ) records removed pubmed=15, cinahl=2, embase=9, web of science=18 (n = 44) jurnal ners http://e-journal.unair.ac.id/jners 93 concept of irs has been helpful in understanding conditions such as cardiovascular disease (french et al., 2006; nur, 2018), kidney disease (lin et al., 2013; velezvelez & bosch, 2016), and traumatic injury (lee et al., 2010). early screening and prevention innovations using interventions based on reframing illness representations in trauma patients before they transition back into society would be beneficial (lee et al., 2015; tonapa et al., 2022). relatedly, a study regarding irs in mtbi reported that a patient's increasing understanding of his or her condition was reflected in various ir dimensions (such as the timeline acute/chronic, timeline cyclic, consequences, and illness coherence dimensions) (snell et al., 2013). there have been few studies reviewing the role of irs and the various ir dimensions in mtbi patients. it is essential, however, to better understand the present evidence regarding irs in mtbi, as such evidence could potentially be useful in terms of informing future clinical interventions based on the ir dimensions. therefore, this review aims to review the current literature regarding illness representation dimensions in mild traumatic brain injury and their related factors. the research questions were: (a) what have been the ir dimensions of mtbi patient groups studied? (b) what are the irs related factors in patients with mtbi? materials and methods research design this study was a systematic review using the the preferred reporting items for systematic reviews and meta‐analyses (prisma) statement process of identification, screening, and assessment of eligibility (moher et al., 2009). search methods a systematic review (sr) was completed using electronic searches across four databases: pubmed, cinahl, embase, and web of science databases. the keywords or key terms used in these searches matched the population, intervention, comparison intervention, and outcome measures (pico) inclusion criteria, and were then combined with the boolean operator (aromataris & riitano, 2014). the search terms used in searching each database were slightly different based on the preferences of each database. relatedly, the search terms were organized into three groups of keywords that were determined based on the respective databases that the terms were used to search (table 1). the inclusion and exclusion criteria were the study: (1) concerned patients with mtbi, (2) included ir dimensions measurements, (3) included adult participants, and (4) was presented in a full-texts paper in english. search outcomes a total of 155 potentially relevant articles were initially identified in the four databases. a total of 111 of those remained after duplications were removed using endnote software. next, the titles and abstracts of those articles were read one by one for further screening, after which 22 remaining full-text articles were further assessed for eligibility. subsequently, 12 of those articles were excluded for various reasons (i.e., the age of the study subjects, the inclusion of non-mtbi populations, and no measurements conducted using a questionnaire that contained the dimensions ir). finally, ten studies were deemed eligible for inclusion in this review (figure 1). the study selection process was carried out by two of this study's authors (mm and tsi) independently, after which they reached agreement. there was no disagreement between the two authors during the selection proces. quality appraisal the joanna briggs institute (jbi) critical appraisal checklist has been used for analytical cross-sectional table 1 search terms used computerized databases group pubmed (indexed terms) cinahl (cinahl headings) embase (embase emtree) web of science search keywords group 1 ((((mild traumatic brain injury) or (mild brain injury)) or (mtbi)) or (concussion)) or (mild traumatic brain) mild traumatic brain injury or mild brain injury or concussion or mtbi 'traumatic brain injury' or 'head injury' or concussion ((((mild traumatic brain injury or mild brain injury or concussion or mtbi) ))) search keywords group 2 (((illness perceptions) or (illness representations)) or (common sense model illness representations)) or (leventhal) illness representation or illness perception or leventhal & johnson self-regulation theory or self-regulation 'illness perception' or 'illness perception questionnaire' or 'self regulation model' or 'common sense'/exp or 'common sense model' ((((illness perceptions or illness representations or common sense model illness representations or leventhal) ))) search keywords group 3 group 1 and group 2 group 1 and group 2 group 1 and group 2 group 1 and group 2 supremo, bacason, and sañosa (2022) 94 p-issn: 1858-3598  e-issn: 2502-5791 and cohort studies (the joanna briggs institute, 2017). more specifically, for a cohort study, a jbi checklist assessment regarding 11 qualities is used, while for cross-sectional research, a jbi checklist assessment regarding eight qualities is used. that approach was therefore taken initially in this study. two authors independently assessed the collected studies for methodological quality, after which they came to agreement. for each study assessed with jbi checklist, each criterion was given a score (yes = 2, no = 0, unclear =1), and these scores were then converted to a percentage. in order to ensure methodological quality among the studies ultimately reviewed, a minimum score of 70% was required for an included study (fernandez et al., 2020). this study followed these criteria, and no study was excluded based on its methodological quality (table 2 and table 3). data extraction and synthesis two authors independently extracted data from all of the included studies into excel spreadsheets. any disagreements during the data extraction process were resolved through un-blinded discussion. the authors extracted data into five main categories: (a) study information including the author(s), year of publication, and study country; (b) populations; (c) research design; (d) measurements; and (e) findings. narrative synthesis was applied to analyze and explain the findings in this study (popay et al., 2006). the process included listing data for the included studies, identifying ir dimensions, and exploring ir-related factors in patients with mtbi. results characteristics of included studies the number of participants in those studies ranged from 30 to 245. four of the studies were conducted in new zealand (jones et al., 2016; jones et al., 2019; snell et al., 2013; snell et al., 2011), two in australia (anderson & fitzgerald, 2018; sullivan et al., 2014), two in india (var & rajeswaran, 2012; war & rajeswaren, 2013), one in the usa (bahraini et al., 2018), and one in the uk (whittaker et al., 2007). five of the studies collected their data using prospective longitudinal observations (anderson & fitzgerald, 2018; jones et al., 2016; snell et al., 2013; snell et al., 2011; whittaker et al., 2007), four used a cross-sectional design (bahraini et al., 2018; sullivan et al., 2014; var & rajeswaran, 2012; war & rajeswaren, 2013), and one used a retrospective design (jones et al., 2019). two different instruments developed from the csmir were used. they were the illness perceptions questionnaire-revised (ipq-r) and the brief illness perceptions questionnaire (bipq). the ipq-r was used in six studies (anderson & fitzgerald, 2018; bahraini et al., 2018; snell et al., 2013; snell et al., 2011; sullivan et al., 2014; whittaker et al., 2007), and the bipq was used in four studies (jones et al., 2016; jones et al., 2019; var & rajeswaran, 2012; war & rajeswaren, 2013). dimensions of illness representation in mtbi seven of the ten studies used all of eight ir dimensions (anderson & fitzgerald, 2018; jones et al., table 2 critical appraisal of cohort studies authors checklist criteria for cohort studies results (%) 1 2 3 4 5 6 7 8 9 10 11 whittaker et al. 2007 y y y n n y y y y n y 16/22 (73%) snell et al. 2011 y y y y y y y y y y y 22/22 (100%) snell et al. 2013 y y y y y y y y y y y 22/22 (100%) jones et al. 2016 y y y y y y y y y u y 21/22 (95%) jones et al. 2019 y y y y y y y y u u y 20/22 (91%) anderson & fitzgerald. 2018 y y y y y y y y y u y 21/22 (95%) y = yes; n = no; u = unclear. 1.were the two groups similar and recruited from the same population? 2.were the exposures measured similarly to assign people to both exposed and unexposed groups? 3.was the exposure measured in a valid and reliable way? 4.were confounding factors identified? 5.were strategies to deal with confounding factors stated? 6.were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)? 7.were the outcomes measured in a valid and reliable way? 8.was the follow up time reported and sufficient to be long enough for outcomes to occur? 9.was follow up complete, and if not, were the reasons for loss to follow up described and explored? 10.were strategies to address incomplete follow up utilized? 11.was appropriate statistical analysis used? table 3 critical appraisal of cross-sectional studies authors checklist criteria for cross-sectional studies results (%) 1 2 3 4 5 6 7 8 var & rajeswaran. 2012 y y y y n n y y 12/16 (75%) war & rajeswaren. 2013 y y y y n n y y 12/16 (75%) sullivan et al. 2014 y y y y y u y y 15/16 (94%) bahraini et al. 2018 y y y y y y y y 16/16 (100%) y = yes; n = no; u = unclear. 1.were the criteria for inclusion in the sample clearly defined? 2.were the study subjects and the setting described in detail? 3.was the exposure measured in a valid and reliable way? 4.were objective, standard criteria used for measurement of the condition? 5.were confounding factors identified? 6.were strategies to deal with confounding factors stated? 7.were the outcomes measured in a valid and reliable way? 8.was appropriate statistical analysis used? jurnal ners http://e-journal.unair.ac.id/jners 95 2016; jones et al., 2019; snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). two studies reported using only three dimensions, namely, consequences, illness coherence and emotional representations (bahraini et al., 2018), identity, timeline (acute/chronic) and consequences (whittaker et al., 2007). one study used only two of them, namely, timeline (acute/chronic) and consequences (sullivan et al., 2014). two studies divided the measured irs scores into three groups, namely, low, medium, and high groups (var & rajeswaran, 2012; war & rajeswaren, 2013). regarding the ir dimensions, both the ipq-r and bipq measure eight dimensions. it should be noted, however that the ipq-r specifically divides the timeline dimension into two parts (acute/chronic (a/c), and cyclical), while the bipq includes two items used to assess the emotional representation dimension (namely, the concern and emotions items). identity: symptoms that the individual patient labels as being related to their injury most of the studies, consistently reported that patients with mtbi identified few symptoms that appeared to be a result of their mtbi (jones et al., 2016; snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). timeline: the progress and duration of the injury (i.e., acute, chronic, or cyclic) three studies reported that patients with mtbi were more confident that their injury would only affect them for a short time (jones et al., 2016; var & rajeswaran, 2012; war & rajeswaren, 2013). these findings, however, were in contrast to those of other studies, which found the mtbi patients perceived that the impacts of their injury would last longer/that they would table 4 study characteristics, dimensions of illness representation, and factors related to illness representations authors, year, country population research design measure findings whittaker et al. (2007), uk 73 patients with mild head injury longitudinal study ipq-r rpq symptomatic mtbi was correlated with identity and consequences. snell et al. (2011), new zealand 147 patients with mtbi prospective observational study ipq-r rpq identity, timeline, illness coherence, and emotional representations were correlated with pcs. var & rajeswaran. (2012), india 31 patients with mild to moderate tbi cross-sectional bipq rpq consequences, timeline, personal control, treatment control, concern, and emotional representations were correlated with pcs. snell et al. (2013), new zealand 147 patients with mtbi prospective observational study ipq-r rpq emotional representations, identity, and consequences were correlated with pcs. war & rajeswaren. (2013), india 30 patients with a mild to moderate tbi cross-sectional bipq rpq whoqol bref consequences, concern, personal control, and emotional representations were correlated with physical qol, and the timeline dimension was correlated with psychological qol. sullivan et al. (2014), australia 108 volunteers with diagnosis of mtbi (n = 27), minor head injury (n = 24), concussion (n = 31), no diagnosis (n = 26). cross-sectional ipq-r nsi mbias patients who were diagnosed with mtbi perceived worse undesirability, timeline, and consequence. jones et al. (2016), new zealand 245 adults with predominantly mtbi prospective longitudinal study bipq rpq greater drawing of brain damage at one month was correlated with the consequences and, timeline dimensions for recovery at six months. jones et al. (2019), new zealand 92 adults following mtbi retrospective observational study bipq rpq greater drawing of brain damage at one month was correlated with perceived greater impacts on life, including in the timeline, identity, and emotional representation dimensions at four years. bahraini et al. (2018), usa 80 patients (mtbi and ptsd, mtbi and no ptsd, non-tbi and ptsd, non tbi and no ptsd) cross-sectional ipq-r pcl-c consequences and emotional representations were correlated with ptsd symptom severity, irrespective of mtbi vs non-tbi. anderson & fitzgerald. (2018), australia 61 individuals who were admitted to hospital after mtbi prospective observational ipq-r rpq identity was correlated with whole pcs symptoms, and timeline-cyclical was correlated with late enduring pcs. abbreviations: mtbi: mild traumatic brain injury, tbi: traumatic brain injury, ptsd: post traumatic stress disorder, ipq-r: illness perception questionnaire-revised, bipq: brief illness perception questionnaire, rpq: rivermead post concussion questionnaire, nsi: neurobehavioral symptom inventory, pcl-c: ptsd checklist-civilian version, whoqol bref: who quality of life bref version, mbias: mild brain injury atypical symptoms scale supremo, bacason, and sañosa (2022) 96 p-issn: 1858-3598  e-issn: 2502-5791 take some time to recover (snell et al., 2013; sullivan et al., 2014). consequences: patient's perception of the severity or negative influence of their injury the majority of the studies reported that the investigated patients perceived that their mtbi might severely impact their lives (bahraini et al., 2018; snell et al., 2013; snell et al., 2011; sullivan et al., 2014; var & rajeswaran, 2012; war & rajeswaren, 2013; whittaker et al., 2007). only one study reported that the investigated patients believed that their mtbi would not severely and negatively influence their lives (jones et al., 2016). illness coherence: the degree to which the injury can be understood by the patient consistent findings regarding mtbi coherence were found in several of the reviewed studies, with several reporting patients with mtbi can comprehend their injury (bahraini et al., 2018; jones et al., 2016; snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). personal control: patients' beliefs about themselves that can control the injury the reviewed studies consistently reported that the investigated patients with mtbi perceived themselves as having a high level of control over their condition (jones et al., 2016; snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). treatment control: patients' expectations the medical treatments can control over the injury the findings from the earlier reviewed studies repeatedly indicated that the included patients' viewed their medical treatments as effective in controlling their injury (snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). surprisingly, however, one study reported that the investigated patients with mtbi viewed their medical treatments as in-adequate for their condition (jones et al., 2016). concern: how concerned are individuals toward their injury the investigated patients with mtbi reported being relatively worried and concerned about their injury (var & rajeswaran, 2012; war & rajeswaren, 2013). however, one of the studies conducted by jones and his colleagues (2016) found that the investigated patients were less concerned about their condition as of one month after the mtbi (jones et al., 2016). emotional representations: the amount of negative emotion that individuals showed as results of an injury patients with mtbi may show emotional responses such as anger, fear, becoming upset, and even depression. this was shown by a number of the reviewed studies, which all found that most of the investigated patients exhibited a lot of emotional responses to their injury (bahraini et al., 2018; snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). however, one of the more recent reviewed studies found that the investigated patients exhibited fewer emotional responses as of one month after their mtbi (jones et al., 2016) factors related to illness representations this review found that irs are associated with several factors in mtbi including post-concussion symptoms (pcs), post-traumatic stress disorder (ptsd), and quality of life (qol) (table 4). factors that have a relationship with irs, are statistically described with pvalue <005. many of the reviewed studies reported that irs have a relationship with pcs (anderson & fitzgerald, 2018; snell et al., 2013; snell et al., 2011; sullivan et al., 2014; var & rajeswaran, 2012; whittaker et al., 2007). one study reported a link between ptsd and irs (bahraini et al., 2018), while another reported correlation among irs and physical, psychological, and environmental aspects of qol for patients with mtbi (war & rajeswaren, 2013). discussions this review aims to review the current literature regarding illness representation dimensions in mild traumatic brain injury and their related factors. the results showed that patients had negative perceptions toward their mtbi. the results also showed that the irs are correlated with pcs, ptsd, and qol. the findings for the identity dimension were clear in those cases in which patients with mtbi experienced symptoms. the symptoms following an mtbi include early and late-onset symptoms, which the common in physical symptoms (eg, headaches), the most frequent in affective/social symptoms (eg, anxiety), and cognitive impairments (eg, difficulty in concentration) (mcallister, 2008). studies found that patients perceived fewer symptoms (identity) as a result of mtbi (jones et al., 2016; snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). in addition, these previous studies consistently showed that patients' perceptions of symptoms were positively related to the occurrence of pcs (anderson & fitzgerald, jurnal ners http://e-journal.unair.ac.id/jners 97 2018; snell et al., 2013; snell et al., 2011; whittaker et al., 2007). it was indicated among patients with mtbi, those with more beliefs or concerns regarding the illness label and their symptoms experienced more pcs and vice versa. relatedly, the identity domain itself was considered an important factor. the misattribution or labeling of symptoms could influence individuals' health-related behaviors, such as adherence (clarke et al., 2016). moreover, it was found as a significant predictor of quality of life three months after injury (tonapa et al., 2021). thus, understanding how patients perceive their symptoms after injuries is essential for developing a nursing care plan. patients may have various expectations and beliefs regarding the duration and timeline of an mtbi. some found that recently injured tbi patients relative to beliefs that their injury would end for briefly (var & rajeswaran, 2012; war & rajeswaren, 2013), with other studies finding that, as time passes, mtbi patients tend to perceive that their injury will take more time to recover (snell et al., 2013; sullivan et al., 2014). also, previous studies have noted that the expected timeline has an impact on the mtbi recovery process, psychological health, and the occurrence of pcs (snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). in other words, how patients perceive their injury duration and progress is very important, such that nurses should devote some attention to clarifying these perceptions. patients' perceptions of the extent to which an injury will impact their life are notably important, because those perceptions may affect their health-related outcomes. a number of the previous studies have found that strong perceptions regarding injury consequences are correlated with the perceived negative effect of brain damage, more symptomatic events, and the occurrence of ptsd (bahraini et al., 2018; jones et al., 2016; jones et al., 2019; snell et al., 2013; var & rajeswaran, 2012; whittaker et al., 2007). the current review further revealed that patients generally perceive their mtbis to have badly impacted their lives. therefore, taking patient perceptions of mtbi consequences into account may reduce the risk of adverse outcomes. patient's understandings of their illness are necessarily valuable because their perceptions may influence the recovery process. this review revealed that patients with mtbi can comprehend their injury (bahraini et al., 2018; jones et al., 2016; jones et al., 2019; snell et al., 2013; var & rajeswaran, 2012; whittaker et al., 2007). one of the reviewed studies reported that illness coherence is related to the experience of pcs (snell et al., 2011), findings that lower level of understanding of these conditions are correlated with the appearance of more pcs. another study reported an association between coherence and ptsd severity symptoms, finding that among veterans with mtbi, ptsd symptoms were experienced in individuals with a poorer understanding of their injury (bahraini et al., 2018). as such, providing relevant educational interventions could potentially prevent adverse outcomes. patient's control perceptions are considered an important factor driving post-injury behavioral adjustment. this review found that mtbi is generally considered to be a condition that can be controlled by patients (jones et al., 2016; snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). additionally, the current review found that if patients have inappropriate personal control, it may affect their qol (war & rajeswaren, 2013). further, concerning treatment control, the reviewed studies indicated that the majority of patients with mtbi believe that their medical treatments are sufficient for caring for their injuries (snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013). personal and treatment control are notably important because past study results imply the importance of partnerships between healthcare providers with patients and further indicate the importance of patient adherence to treatment plans (martin et al., 2005). in addition, a recent prospective study showed that patients with negative perceptions of their personal control and treatment control at hospital discharge had a higher risk of impaired quality of life three months post-discharge than those with positive perceptions (tonapa et al., 2021). hence, enculturing patients have an optimistic perception of themselves and treatment is warranted for nurses. this review found that some patients with mtbi are highly concerned about their conditions (var & rajeswaran, 2012; war & rajeswaren, 2013). however, it should be underlined that such perceptions may change as time passes because patients may gain more knowledge regarding the nature of their injuries and may in turn become less concerned with their conditions (jones et al., 2016). providing specific interventions to lead mtbi patients toward having appropriate levels of concern is among the responsibilities of nurses, especially with respect to trauma care that has physical or psychological impacts. supremo, bacason, and sañosa (2022) 98 p-issn: 1858-3598  e-issn: 2502-5791 showing negative emotions as a result of injury might contribute to behavioral changes. in the early phase after being injured, mtbi patients may show a lot of emotional responses, but as of a few months after the mtbi, their emotional responses may be reduced. in addition, nurses should be careful in taking emotional representations into account, because it was related to the occurrence of pcs (snell et al., 2013; snell et al., 2011; var & rajeswaran, 2012; war & rajeswaren, 2013) and, the perceived negative effects of brain injury (jones et al., 2016; jones et al., 2019), and may also be a determinant of qol (war & rajeswaren, 2013). for example, having more emotional responses such as anger, fear, and depression can result in patients having poorer physical and psychological health. irs are the foundation of the csmir, commonly used to determine individuals' illness-related behaviors or coping responses to mitigate health threats. the complete csmir can be used to capture patients' perceptions and, coping methods, which in turn impact their health outcomes. for example, different patterns of coping and patient perception were found related to patients' behaviors in enduring pcs symptoms (anderson & fitzgerald, 2018). also, a recent study found that indonesian adults with extremity injuries who harbored harmful ir were less focused on using adaptive coping strategies and more on using maladaptive coping strategies, and these mediations significantly explain the lower quality of life (tonapa et al., 2022). regarding the benefits of the csmir and the limited number of studies in mtbi, further studies should apply the whole model in investigating mtbi patient groups. in sum, ir dimensions, including the identity, timeline, consequences, coherence, and emotional representation dimensions, have been found to be related to factors affecting mtbi patient groups, including pcs, ptsd, and qol. patients with mtbi tend to have inappropriate perceptions of their post-injury condition that may influence their recovery process. the findings of this study demonstrate the strength of the evidence regarding the value, in clinical practice, of routinely assessing patients’ cognitive and emotional perceptions and preparing appropriate interventions to improve the recovery processes and outcomes of patients with mtbi. implication and limitations capturing the illness representation dimensions of mild traumatic brain injury patients is necessary to ascertain the needs of patients who will receive trauma nursing care. based on the findings of this review, it is important for clinical practice to regularly assess illness representations to identify what trauma interventions are needed. furthermore, it is essential to build interventions based on illness representation dimensions to ensure that patients have appropriate interpretations of their injuries, which can enhance the recovery process and health outcomes for patients with mild traumatic brain injury. for future researchers, these results can be used as a basis for further research, especially by considering the use of the entire common sense model of illness representation model by adding coping assessment. this will be useful for providing a more comprehensive basis for developing intervention studies. three of the ten studies included in this review did not include all eight of the ir dimensions. it is possible that the exclusion of several dimensions could have fundamentally affected the findings of these studies. conclusions understanding the ir dimensions of mtbi patients and their related factors can help trauma nurses ascertain the needs of patients receiving trauma nursing care. some dimensions of ir have been found to be related to factors affecting mtbi patient groups, including pcs, ptsd, and qol. it is crucial in clinical practice to address this issue by focusing on the ir dimensions, such as by conducting routine ir assessments and providing interventions to make patients more adherent to their treatment and postinjury recovery. thus, it would be beneficial to acknowledge the ir dimensions as a target for nursing interventions. the results of this study may provide critical evidence for influencing the recovery process and outcomes of patients with mtbi. acknowledgments the authors would like to express their gratitude to the school of nursing, faculty of medicine, sam ratulangi, manado and college of nursing, kaohsiung medical university, taiwan for the support to this research author contribution mm & lbo conceiving and designing the work. mm. & tsi completed data collection. mm, lbo, tsi & ah took responsibilities for analyzing and interpreting the data. mm & lbo drafted the manuscript. mm, lbo, tsi jurnal ners http://e-journal.unair.ac.id/jners 99 & ah revising the manuscript to make important changes in content. all authors have read and approved the final version for submission conflict of interest statement the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. references anderson, j. f. i., & fitzgerald, p. (2018). associations between coping style, illness perceptions and self-reported symptoms after mild traumatic brain injury in prospectively studied pre-morbidly healthy individuals. neuropsychol rehabilitation, 1-14. https://doi.org/10.1080/09602011.2018.1556706 aromataris, e., & riitano, d. (2014). systematic reviews: constructing a search strategy and searching for evidence. american journal of nursing, vol. 114( issue 5 p 49-56). https://doi.org/https://doi.org/10.1097/01.naj.0000446779.995 22.f6 bahraini, n. h., monteith, l. l., gerber, h. r., forster, j. e., hostetter, t. a., & brenner, l. a. (2018). the association between posttraumatic stress disorder and perceptions of deploymentrelated injury in veterans with and without mild traumatic brain injury. journal of head trauma rehabilitation, 33(2), e7e15. https://doi.org/10.1097/htr.0000000000000307 cassidy, j. d., cancelliere, c., carroll, l. j., cote, p., hincapie, c. a., holm, l. w., hartvigsen, j., donovan, j., nygren-de boussard, c., kristman, v. l., & borg, j. (2014). systematic review of selfreported prognosis in adults after mild traumatic brain injury: results of the international collaboration on mild traumatic brain injury prognosis. archives of physical medicine and rehabilitation, 95(3 suppl), s132-151. https://doi.org/10.1016/j.apmr.2013.08.299 cassidy, j. d., carroll, l. j., peloso, p. m., borg, j., von holst, h., holm, l., kraus, j., coronado, v. g., & injury, w. h. o. c. c. t. f. o. m. t. b. (2004). incidence, risk factors and prevention of mild traumatic brain injury: results of the who collaborating centre task force on mild traumatic brain injury. journal of rehabilitation medicine(43 suppl), 28-60. https://doi.org/10.1080/16501960410023732 clarke, a. l., yates, t., smith, a. c., & chilcot, j. (2016). patient's perceptions of chronic kidney disease and their association with psychosocial and clinical outcomes: a narrative review. clinical kidney journal, 9(3), 494-502. https://doi.org/10.1093/ckj/sfw014 de koning, m. e., scheenen, m. e., van der horn, h. j., hageman, g., roks, g., spikman, j. m., & van der naalt, j. (2017). nonhospitalized patients with mild traumatic brain injury: the forgotten minority. journal of neurotrauma, 34(1), 257-261. https://doi.org/10.1089/neu.2015.4377 fernandez, p. r., lord, h., halcomb, p. e., moxham, p. l., middleton, d. r., alananzeh, d. i., & ellwood, l. (2020). implications for covid-19: a systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. international journal of nursing studies. https://doi.org/10.1016/j.ijnurstu.2020.103637 fikriyanti, kitrungrote, l., & songwathana, p. (2014). the post concussion symptom experience and quality of life in indonesian persons with mild traumatic brain injury. songklanagarind journal of nursing, vol. 34 no.2 french, d. p., cooper, a., & weinman, j. (2006). illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis. journal of psychosomatic research, 61(6), 757-767. https://doi.org/10.1016/j.jpsychores.2006.07.029 jones, k. m., kydd, r., broadbent, e., theadom, a., barker-collo, s., edwards, h., feigin, v. l., & group, b. s. (2016). brain drawings following traumatic brain injury (tbi) and links to illness perceptions and health outcomes findings from a populationbased study. psychology & health, 31(10), 1182-1202. https://doi.org/10.1080/08870446.2016.1193178 jones, k. m., theadom, a., barker-collo, s., broadbent, e., & feigin, v. l. (2019). associations between brain drawings following mild traumatic brain injury and negative illness perceptions and postconcussion symptoms at 4 years. j health psychol, 24(10), 14481458. https://doi.org/10.1177/1359105317695430 karr, j. e., areshenkoff, c. n., & garcia-barrera, m. a. (2014). supplemental material for the neuropsychological outcomes of concussion: a systematic review of meta-analyses on the cognitive sequelae of mild traumatic brain injury. neuropsychology, vol. 28, no. 3, 321–336. https://doi.org/10.1037/neu0000037.supp lee, b. o., chaboyer, w., & wallis, m. (2010). illness representations in patients with traumatic injury: a longitudinal study. journal of clinical nursing, 19(3-4), 556-563. https://doi.org/10.1111/j.1365-2702.2009.02972.x lee, b. o., chien, c. s., hung, c. c., & chou, p. l. (2015). effects of an in-hospital nursing intervention on changing illness perceptions in patients with injury. journal of advanced nursing, 71(11), 25402550. https://doi.org/10.1111/jan.12716 leventhal, h., leventhal, e. a., & and cameron, l. (2001). representations, procedures, and affect in illness selfregulation: a perceptual-cognitive model. in: baum as, revenson ta and singer je (eds) handbook of health psychology. in (pp. 19-48 ). lawrence erlbaum associates. lin, c. c., chen, m. c., hsieh, h. f., & chang, s. c. (2013). illness representations and coping processes of taiwanese patients with early-stage chronic kidney disease. the journal of nursing research, 21(2), 120-128. https://doi.org/10.1097/jnr.0b013e3182921fb8 martin, l. r., williams, s. l., haskard, k. b., & dimatteo, m. r. (2005). the challenge of patient adherence. therapeutics and clinical risk management, 1(3) 189–199. mcallister, t. w. (2008). neurobehavioral sequelae of traumatic brain injury: evaluation and management. world psychiatry, 7:3-10. https://doi.org/10.1002/j.2051-5545.2008.tb00139.x moher, d., liberati, a., tetzlaff, j., altman, d. g., & group, p. (2009). preferred reporting items for systematic reviews and metaanalyses: the prisma statement. plos med, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097 moss-morris, r., weinman, j., petrie, k., horne, r., cameron, l., & buick, d. (2002). the revised illness perception questionnaire (ipq-r). psychology & health, 17(1), 1-16. https://doi.org/10.1080/08870440290001494 nelson, l. d., temkin, n. r., dikmen, s., barber, j., giacino, j. t., yuh, e., levin, h. s., mccrea, m. a., stein, m. b., mukherjee, p., okonkwo, d. o., diaz-arrastia, r., manley, g. t., and the, t.-t. b. i. i., adeoye, o., badjatia, n., boase, k., bodien, y., bullock, m. r., et al. (2019). recovery after mild traumatic brain injury in patients presenting to us level i trauma centers: a transforming research and clinical knowledge in traumatic brain injury (track-tbi) study. jama neurology. https://doi.org/10.1001/jamaneurol.2019.1313 nguyen, r., fiest, k. m., mcchesney, j., kwon, c. s., jette, n., frolkis, a. d., atta, c., mah, s., dhaliwal, h., reid, a., pringsheim, t., dykeman, j., & gallagher, c. (2016). the international incidence of traumatic brain injury: a systematic review and meta-analysis. canadian journal of neurological sciences, 43(6), 774-785. https://doi.org/10.1017/cjn.2016.290 nur, k. r. m. (2018). illness perception and cardiovascular health behaviour among persons with ischemic heart disease in indonesia. international journal of nursing sciences, 5(2), 174180. https://doi.org/10.1016/j.ijnss.2018.04.007 petrie, k. j., lana, a., jago, & devcich, d., a. (2007). the role of illness perceptions in patients with medical conditions. current opinion in psychiatry, 20, 163–167. https://doi.org/10.1097/yco.0b013e328014a871 popay, j., roberts, h., sowden, a., petticrew, m., arai, l., rodgers, m., britten, n., roen, k., & duffy, s. (2006). guidance on the conduct of narrative synthesis in systematic reviews. a product from the esrc methods programme. rice, v. h. (2012). handbook of stress, coping, and health: supremo, bacason, and sañosa (2022) 100 p-issn: 1858-3598  e-issn: 2502-5791 implications for nursing research, theory, and practice. sage publications. https://books.google.com.tw/books?id=tmvxbfl0lhwc seabury, s. a., gaudette, e., goldman, d. p., markowitz, a. j., brooks, j., mccrea, m. a., okonkwo, d. o., manley, g. t., investigators, t.t., adeoye, o., badjatia, n., boase, k., bodien, y., bullock, m. r., chesnut, r., corrigan, j. d., crawford, k., diaz-arrastia, r., dikmen, s., et al. (2018). assessment of follow-up care after emergency department presentation for mild traumatic brain injury and concussion: results from the track-tbi study. jama network open, 1(1), e180210. https://doi.org/10.1001/jamanetworkopen.2018.0210 skandsen, t., nilsen, t. l., einarsen, c., normann, i., mcdonagh, d., haberg, a. k., & vik, a. (2019). incidence of mild traumatic brain injury: a prospective hospital, emergency room and general practitioner-based study. frontiers neurology, 10, 638. https://doi.org/10.3389/fneur.2019.00638 snell, d. l., hay-smith, e. j., surgenor, l. j., & siegert, r. j. (2013). examination of outcome after mild traumatic brain injury: the contribution of injury beliefs and leventhal's common sense model. neuropsychology rehabilitation, 23(3), 333-362. https://doi.org/10.1080/09658211.2012.758419 snell, d. l., siegert, r. j., hay-smith, e. j., & surgenor, l. j. (2011). associations between illness perceptions, coping styles and outcome after mild traumatic brain injury: preliminary results from a cohort study. brain injury, 25(11), 1126-1138. https://doi.org/10.3109/02699052.2011.607786 stulemeijer, m., vos, p. e., bleijenberg, g., & van der werf, s. p. (2007). cognitive complaints after mild traumatic brain injury: things are not always what they seem. journal of psychosomatic research, 63(6), 637-645. https://doi.org/10.1016/j.jpsychores.2007.06.023 sullivan, k. a., edmed, s. l., & kempe, c. (2014). the effect of injury diagnosis on illness perceptions and expected postconcussion syndrome and posttraumatic stress disorder symptoms. journal of head trauma rehabilitation, 29(1), 54-64. https://doi.org/10.1097/htr.0b013e31828c708a the joanna briggs institute. (2017). the joanna briggs institute critical appraisal tools for use in jbi systematic reviews. http://joannabriggs.org/research/critical-appraisal-tools.html theadom, a., parag, v., dowell, t., mcpherson, k., starkey, n., barkercollo, s., jones, k., ameratunga, s., feigin, v. l., & group, b. r. (2016). persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in new zealand. british journal of general practice, 66(642), e16-23. https://doi.org/10.3399/bjgp16x683161 tonapa, s. i., lin, w. t., kuo, f. l., & lee, b. o. (2022). mediating effects of coping strategies on quality of life following extremity injury. nurs res, 71(3), 200-208. https://doi.org/10.1097/nnr.0000000000000581 tonapa, s. i., liu, y., mulyadi, m., & lee, b.-o. (2021). changes in selfregulation and the predictors of quality of life 3 months after extremity injury: a prospective study. clinical nursing research, 10547738211058980. https://doi.org/10.1177/10547738211058980 van der naalt, j., timmerman, m. e., de koning, m. e., van der horn, h. j., scheenen, m. e., jacobs, b., hageman, g., yilmaz, t., roks, g., & spikman, j. m. (2017). early predictors of outcome after mild traumatic brain injury (upfront): an observational cohort study. the lancet neurology, 16(7), 532-540. https://doi.org/10.1016/s1474-4422(17)30117-5 var, f. a., & rajeswaran, j. (2012). perception of illness in patients with traumatic brain injury. indian journal of psychological medicine, 34(3), 223-226. https://doi.org/10.4103/0253-7176.106014 velez-velez, e., & bosch, r. j. (2016). illness perception, coping and adherence to treatment among patients with chronic kidney disease. journal of advanced nursing, 72(4), 849-863. https://doi.org/10.1111/jan.12873 vikane, e., froyland, k., naess, h. l., assmus, j., & skouen, j. s. (2019). predictors for psychological distress 2 months after mild traumatic brain injury. frontiers in neurology, 10, 639. https://doi.org/10.3389/fneur.2019.00639 voormolen, d. c., polinder, s., von steinbuechel, n., vos, p. e., cnossen, m. c., & haagsma, j. a. (2019). the association between post-concussion symptoms and health-related quality of life in patients with mild traumatic brain injury. injury, 50(5), 1068-1074. https://doi.org/10.1016/j.injury.2018.12.002 war, f. a., & rajeswaren, j. (2013). quality of life and perception of illness in patients with traumatic brain injury. the indian journal of neurotrauma, 10(2), 115-119. https://doi.org/10.1016/j.ijnt.2013.12.004 whittaker, r., kemp, s., & house, a. (2007). illness perceptions and outcome in mild head injury: a longitudinal study. journal of neurology, neurosurgery, and psychiatry, 78(6), 644-646. https://doi.org/10.1136/jnnp.2006.101105. how to cite this article: mulyadi, m., tanapa, s. i., amir h., and lee, b. o. (2023) ‘a systematic review of illness representations in patients with mild traumatic brain injury’, jurnal ners, 18(1), pp. 91-100. doi: http://dx.doi.org/10.20473/jn.v18i1.42404 99 model self care management-holistic psychospiritual care terhadap kemandirian, glukosa darah, dan hba1c penderita diabetes melitus tipe 2 (self care management-holistic psychospiritual care on independence, glucose level, and hba1c of type 2 diabetes mellitus patient) kusnanto fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya e-mail: kusnanto_ners@yahoo.com abstract introduction: diabetes mellitus is a kind of incurable chronic disease that actually manageable. the global prevalence tends to increase due to less self management of the disease and the impact of it was health condition declines physically, psychologically, socially, and spiritually. there were so many interventions implemented but failed to give positive improvement in patient's holistic condition which is lead to complications. the purpose of this research was to improve patient independency in managing the disease and to explain changes in blood glucose and hba1c levels through self care management-holistic psychospiritual care model. method: patient newly diagnose with type 2 diabetes mellitus at public health centre kebonsari was selected with purposive sampling and divided into two groups. each group contains 25 patients. intervention group was given self care management model development with self diabetes management module. the intervention was given fi ve times in three months. before and after intervention patient was observed for blood glucose level of 2 hours before and after meal, and also hba1c level. questionnaire was given to patient. the data then analyzed using wilcoxon, mann whitney, and student-t test. result: the result of this research showed patient with type 2 diabetes have independency improvement and lower blood glucose level of 2 hours before and after meal and also decreased hba1c after intervention. discussion: self care management-holistic psychospiritual care model improves patient independency in managing their disease, lowering blood glucose and hba1c levels. keywords: self care management, independency, blood glucose level, hba1c, type 2 dm pendahuluan menurut american diabetes association (ada) tahun 2010, diabetes melitus (dm) me r upa k a n su at u kelomp ok p e nya k it metabolik dengan karakteristik hiperglikemia yang terjadi karena kelainan sekresi insulin, kerja insulin, atau kedua-duanya. seseorang dikatakan menderita dm tipe 2 jika memiliki kadar gula darah puasa > 126 mg/dl dan gula darah acak > 200 mg/dl disertai dengan keluhan klasik berupa poliuria, polidipsia, polifagia ,dan penurunan berat badan yang tidak dapat dijelaskan sebabnya (perkeni, 2011). diabetes melitus tipe 2 merupakan penyakit metabolik yang prevalensinya meningkat dari tahun ketahun. indonesia dengan jumlah penduduk yang melebihi 200.000.000 jiwa, sejak awal abad ini telah menjadi negara dengan jumlah penderita dm nomor 4 terbanyak di dunia (arifi n, 2011). penyakit dm adalah suatu penyakit kronis yang tidak bisa disembuhkan tetapi bisa dikurangi dan dikontrol kadar gula darahnya (who, 2006). laporan centers for disease and prevention (cdp) tahun 2007, bahwa prevalensi dm mencapai 4% di seluruh dunia yang diprediksi mencapai 5,4% pada tahun 2025; hal ini berarti bahwa prevalensi secara global cenderung meningkat dari tahun ke tahun. sepuluh negara yang paling banyak menderita dm yaitu india, cina, amerika serikat, indonesia, jepang, pakistan, rusia, brazil, italia, dan bangladesh. 100 jurnal ners vol. 7 no. 2 oktober 2012: 99–106 berbagai penelit ian epidem iologi m e n u nju k k a n a d a ny a ke c e n d e r u ng a n peningkatan angka insidensi dan prevalensi dm tipe 2 di berbagai penjuru dunia. who memprediksi adanya peningkatan jumlah penyandang diabetes yang cukup besar pada tahun-tahun mendatang (perkeni, 2011). who memprediksi kenaikan jumlah penyandang dm di indonesia dari 8,4 juta pada tahun 2000 menjadi sekitar 21,3 juta pada tahun 2030. international diabetes federation (idf) pada tahun 2009 juga memprediksi kenaikan jumlah penderita dm dari 7,0 juta menjadi 12,0 juta pada tahun 2030. meskipun terdapat perbedaan angka prevalensi, laporan keduanya menunjukkan adanya peningkatan jumlah penderita dm sebanyak 2–3 kali lipat pada tahun 2030. hal ini menjadikan indonesia menduduki rangking ke4 dunia setelah amerika serikat, india dan cina (perkeni, 2011). suyono (2009) mengatakan prevalensi dm tipe 2 di jawa timur untuk daerah urban adalah 1,43% dan daerah rural adalah 1,47%. dengan asumsi prevalensi tersebut dan jumlah penduduk di jawa timur pada tahun 2008 adalah 37.436.164 jiwa, maka jumlah penderita dm tipe 2 di jawa timur diperkirakan berjumlah 535.338–550.312 penderita. di jawa timur jumlah penderita dm yang dirawat adalah 5.551 penderita dan 172 di antaranya meninggal dunia. jumlah penderita dm di kota surabaya tahun 2009 sebanyak 16.365 dan tahun 2010 terdapat 15.509. puskesmas kebonsa r i mer upa ka n sala h sat u d a r i 53 puskesmas yang ada di kota surabaya dengan jumlah penderita dm yang terbanyak, jumlah penderita baru setiap tahun cenderung meningkat, tahun 2009 jumlah penderita baru 231 penderita, tahun 2010 meningkat menjadi 303 penderita, tahun 2011 (data januari sampai nopember) tercatat 261 penderita. diabetes melitus apabila tidak ditangani dengan baik akan mengakibatkan timbulnya komplikasi (who, 2006). komplikasi terkait dm merupakan penyebab mayor dari morbiditas dan mortalitas. komplikasi dm merupakan hal yang sangat penting dan berpengaruh terhadap kualitas hidup (who, 2006). kunci utama untuk menunda bahkan mencegah terjadinya komplikasi dm adalah dengan pengendalian (regulasi) gula darah. apabila penyakit terkontrol dengan baik akan menghambat atau mencegah keluhan fisik akibat komplikasi akut maupun kronis. berbagai intervensi sebagai upaya meningkatkan kualitas hidup penderita dm telah dilakukan baik berupa diabetes mellitus self care maupun diabetes self management education, namun hasilnya belum optimal dan banyak penderita dm belum menunjukkan adanya kemandirian dalam mengelola penyakitnya. hasil penelitian yang dilakukan pada 52 penderita dm tipe 2 yang berobat jalan di poli klinik penyakit dalam rsud jombang didapatkan hasil 65,4% self care kurang dan 48,1% dengan kualitas hidup kurang. hasil penelitian yang dilakukan pada 15 penderita dm tipe 2 yang dirawat di ruang pavilliun bougenville rsu dr. h. koesnadi bondowoso didapatkan hasil; 9 penderita (60%) tingkat self care behaviour dalam kategori rendah, 5 penderita (33,33%) tingkat self care behaviour dalam kategori sedang dan 1 penderita (6,67) tingkat self care behaviour dalam kategori baik. lorig dan holman (2000) menyatakan bahwa pada dasarnya penderita bertanggung jawab atas pengelolaan day-today care atas penyakitnya. oleh karena itu untuk dapat mengelola penyakitnya secara efektif, penderita harus memiliki pengetahuan, keterampilan dan keyakinan diri dalam melakukan tindakan medis tertentu seperti tes gula darah, serta pemahaman akan pengelolaan emosi (adam, 2004 dalam atak, 2007). hal utama dalam mengelola penyakit dm selalu berkenaan dengan manejemen gaya hidup di antaranya perencanaan makan, latihan jasmani, pengunaan obat hipoglikemik secara teratur, pengontrolan berat badan, pemantauan kadar glukosa darah atau urin dan yang terakhir adalah dengan pengontrolan kondisi emosi dan psikis penderita. beberapa penelitian mencatat bahwa 50 –80% penderita dm memiliki pengetahuan dan keterampilan yang kurang dalam mengelola penyakitnya (norris, 2001; palestin, 2005 dalam bondan, 2008). rendahnya pengetahuan penderita dm akan berdampak pada rendahnya self care behavior dan kemungkinan akan menyebabkan terjadinya peningkatan komplikasi penyakit b a i k a k ut m a u pu n k r o n i k d a n ju g a 101 model self care management-holistic psychospiritual care (kusnanto) menyebabkan penurunan kualitas hidup (atak, 2010). hasil optimal dari perawatan dm membutuhkan manajemen mandiri seharihari, meliputi pengontrolan makanan sesuai diet, olah raga secara teratur, dan monitoring glu kosa yang terat u r. self-management p e n d e r it a b e r g a nt u n g p a d a e d u k a si , pemberdayaan dan self monitoring mereka dalam usaha mengevaluasi hasil dari self care yang telah dilakukan. berbagai intervensi telah dilakukan namun masih terfragmentasi sehingga penderita diabetes masih sulit mengontrol kadar glukosa darah, sering terjadi komplikasi dan jumlah penderita semakin meningkat. kondisi seperti ini membutuhkan strategi baru yang terintegrasi agar penderita dapat mengelola penyakitnya secara mandiri, unt uk meningkatkan kondisi kesehatan, mencegah komplikasi, dan menur un kan prevalensi. hal ini menjadi sangat penting karena dm merupakan penyakit menahun yang akan diderita seumur hidup, sehingga a kan menjadi beban bagi pemer i nt ah, masyarakat, keluarga serta penderita dm sendiri. sa la h s at u s t r at eg i ya ng d a p at dilakukan adalah dengan memberdayakan penderita secara mandiri, untuk meningkatkan penget ahuan, memperbai k i si kap ser t a merubah perilaku. melalui pengembangan modul pengelolaan diabetes mandiri yang diaplikasikan dalam pengembangan model self care management-holistic psychospiritual care dapat memfasilitasi peningkatan pengetahuan penderita tentang dm dan pengelolaannya secara komprehensif, membentuk sikap yang utuh (total attitude), dan merubah perilaku sesuai dengan pengetahuan yang dimilikinya dalam menghadapi penyakit kronis sehingga akan berpengaruh pada perbaikan kondisi kesehatan secara optimal. selain itu modul pengelolaan dm mandiri dapat menjembatani komunikasi antara tenaga kesehatan (dokter, perawat, ahli gizi, dan lain-lain) dengan penderita dm. pe nge mb a ng a n mo d el s e lf c a r e management holistic psychospiritual care mer upakan konsep yang dikembangkan peneliti dengan bentuk intervensi keperawatan berupa pemberian modul pengelolaan dm mandiri yang komprehensif dengan penekanan pada aspek psikologis dan spiritual. strategi ini merupakan kombinasi kekuatan antara energi spiritual dan energi psikologi yang diharapkan dapat memperbaiki kondisi pikiran emosi dan perilaku penderita dm yang pada akhirnya glukosa darah dapat teregulasi dengan baik sehingga self care behaviour meningkat yang pada akhirnya penderita mampu merawat dirinya sendiri secara mandiri, dapat berperan sebaik-baiknya secara aktif di masyarakat, karena komplikasi dapat dicegah ser ta penderita dapat lebih produktif dan kualitas hidup penderita akan meningkat. bahan dan metode pe nel it ia n d ila k u k a n d ala m du a tahap, rancangan pada tahap pertama dalam penelitian ini adalah penelitian deskriptif dan tahap kedua adalah quasy experimental research dengan rancangan nonrandomized control group pretest-posttest design. pada penelitian tahap pertama dilakukan untuk mengembangkan modul pengelolaan diabetes mandiri dengan cara berfi kir deduktif-induktif. hasil pengembangan modul digunakan sebagai media penelitian tahap kedua yaitu sebagai aplikasi integrasi self care managementholistic psychospiritual care. populasi dalam penelitian ini adalah seluruh penderita dm yang berobat atau kontrol di puskesmas kebonsari surabaya dan penderita dm yang memenuhi kriteria inklusi dijadikan sampel, besar sampel pada penelitian tahap pertama adalah 15 penderita, tahap kedua adalah 50 penderita yang dibagi menjadi 2 kelompok. penghitungan besar sampel berdasarkan rumus s.k. lwanga and s lemeshow, who. geneva, (1996). variabel penelitian tahap per tama adalah pengembangan modul pengelolaan diabetes mandiri. variabel penelitian tahap kedua; variabel independennya adalah self care management menggunakan pendekatan holistic psychospiritual care (hpc) dan variable dependennya adalah kemandirian, nilai kadar glukosa darah dan h ba1c. instrumen yang digunakan pada penelitian tahap per tama adalah kuesioner dengan 102 jurnal ners vol. 7 no. 2 oktober 2012: 99–106 pertanyaan terbuka, penelitian tahap kedua adalah kuesioner dengan pertanyaan tertutup dan pemeriksaan laboratorium (sampel darah); pemeriksaan glukosa darah dengan metode heksokinase sedangkan pemeriksaan hba1c dengan menggunakan metode baku emas (gold standard) yaitu high performance liquid chromatography (hplc). data yang diperoleh dianalisis dengan menggunakan uji wilcoxon, mann whitney dan uji t. hasil h a si l p e n el it ia n t a h a p p e r t a m a oleh penelit i d ija d i k a n a cu ha n u nt u k mengembangkan modul pembelajaran diabetes mandiri, yang digunakan sebagai media pembelajaran oleh penderita pada penelitian tahap kedua. hasil uji statistik dengan menggunakan wilcoxon signed rank test dan mann whitney u test didapatkan nilai per ubahan yang tabel 1. kebutuhan belajar penderita diabetes melitus tipe 2 kebutuhan belajar frekuensi (n) persentase (%) pengertian penyakit kencing manis 11 73,3 penyebab kencing manis 13 86,6 proses terjadinya penyakit kencing manis 10 66,6 tanda dan gejala awal kencing manis 13 86,6 pengelolaan kencing manis 15 100 komplikasi kencing manis 15 100 cara memeriksa gula darah 10 66,6 makanan/diet untuk penderita kencing manis 14 93 obat untuk kencing manis 15 100 aktivitas/olah raga yang dapat dilakukan oleh penderita kencing manis 11 73,3 senam untuk penderita kencing manis 5 33,3 perawatan kaki 12 80 cara menghadapi stress 12 80 tehnik menghadapi musibah/cobaan sakit 13 86,6 paguyuban penderita kencing manis 11 73,3 tabel 2. karakteristik penderita karakteristik kelompok perlakuan kelompok pembandingfrekuensi (n) persentase (%) frekuensi (n) persentase (%) jenis kelamin laki-laki 5 20 6 24 wanita 20 80 19 76 total 25 100 25 100 usia (tahun) 40–45 3 12 2 8 46–50 2 8 4 16 51–55 9 36 7 28 56–60 7 28 8 32 61–65 4 16 4 16 total 25 100 25 100 pendidikan smp 10 40 8 32 sma 11 44 12 48 perguruan tinggi (pt) 4 16 5 20 total 25 100 25 100 103 model self care management-holistic psychospiritual care (kusnanto) karakteristik kelompok perlakuan kelompok pembandingfrekuensi (n) persentase (%) frekuensi (n) persentase (%) status perkawinan menikah 16 64 18 72 janda/duda 9 36 7 28 total 25 100 25 100 pekerjaan bekerja 6 24 6 24 tidak bekerja 19 76 19 76 total 25 100 25 100 lanjutan tabel 2 tabel 3. aspek kognitif, afektif dan psikomotor penderita aspek/kategori kelompok perlakuan kelompok pembanding sebelum sesudah sebelum sesudah σ % σ % σ % σ % kognitif: baik 3 8,3 22 88 2 8 2 8 cukup 11 50 3 12 11 44 12 48 kurang 11 41,7 0 0 12 48 11 44 σ 25 100 25 100 25 100 25 100 afektif positif 8 32 23 92 7 28 8 32 negatif 17 68 2 8 18 72 17 68 σ 25 100 25 100 25 100 25 100 psikomotor: baik 3 12 21 84 2 8 3 12 cukup 9 36 3 12 10 40 10 40 kurang 13 52 1 4 13 52 12 48 σ 25 100 25 100 25 100 25 100 tabel 4. hasil analisis statistik terkait kognitif, afektif dan psikomotor penderita aspek kelompok perlakuan kelompok pembanding sesudah sebelum sesudah sebelum sesudah kel. perlakuan kel. pembanding kognitif mean 37,65 64,14 44,00 51,44 64,14 51,44 sd 13,94 18,32 19,81 21,96 18,32 21,96 uji statistik wilcoxon signed rank test p = 0,012 wilcoxon signed rank test p = 0,046 mann whitney u test p = 0,14 afektif mean 29,79 68,43 41,70 44,05 68,43 44,05 sd 12,15 11,91 9,09 13,87 11,91 13,87 uji statistik wilcoxon signed rank test p = 0,012 wilcoxon signed rank test p = 0,34 mann whitney u test p = 0,004 psikomotor mean 56,05 83,04 65,16 51,34 83,04 51,34 sd 28,57 35,80 25,17 32,72 35,80 32,72 uji statistik wilcoxon signed rank test p = 0,027 wilcoxon signed rank test p = 0,18 mann whitney u test p = 0,048 104 jurnal ners vol. 7 no. 2 oktober 2012: 99–106 signifi kan (p < 0,05) terkait dengan aspek kognitif, afektif dan psikomotor (kap) pada kelompok perlakuan sebelum dan sudah dilakukan intervensi dengan pemberian self care management-holistic psychospiritual care melalui media modul diabetes mandiri. hal tersebut berarti tinggkat pengetahuan penderita tentang diabetes dan pengelolaanya menjadi meningkat, afektif (sikap) penderita dalam merespons penyakit yang diderita dan pengelolaannya menjadi lebih baik dan psikomotor (keterampilan) penderita dalam mengelola penyakit menjadi lebih meningkat. hasil uji paired t-test diperoleh nilai signifi cancy 0.000 (p < 0 > 0,05) untuk glukosa tabel 5. kadar glukosa darah sebelum dan sesudah perlakuan hasil one-sample kolmogorov-smirnov test variabel mean std. deviation sig. gula darah 2 jam pp sebelum 213,20 42,480 0,526 sesudah 157,86 53,289 0,193 hba1c sebelum 7,6804 0,45624 0,228 sesudah 6,8480 0,61120 0,92 tabel 6. perbedaan nilai kagar glukosa darah dan hba1c sebelum dan setelah perlakuan kelompok variabel n rerata ± s.b perbedaan rerata ± s.b ik 95% p perlakuan pair 1 gula darah 2 jam pp sebelum 25 212,00 ± 43,07 90,480 ± 37,89 106,12–74,84 0,000kadar gula darah 2 jam pp sesudah 25 121,51 ± 29,23 pair 2 hba1c sebelum 25 7,74 ± 0,37 1,42 ± 0,31 1,54–1,29 0,000hba1c sesudah 25 6,33 ± 0,18 pembanding pair 1 gula darah 2 jam pp sebelum 25 213,84 ± 45,16 19,64 ± 33,35 33,41–5,87 0,007kadar gula darah 2 jam pp sesudah 25 194,20 ± 46,82 pair 2 hba1c sebelum 25 7,54 ± 0,51 0,17 ± 0,26 0,28–0,06 0,004hba1c sesudah 25 7,37 ± 0,41 tabel 7. perbedaan nilai kadar glukosa darah dan kadar hba1c antara kelompok perlakuan dan kelompok pembanding setelah perlakuan variabel kelompok n mean std. deviation perbedaan rerata (ik 95%) p gula darah 2 jam pp sesudah perlakuan 25 121,52 29,23 72,6 (50,3–94,98) 0,000 pembanding 25 194,20 46,82 hba1c sesudah perlakuan 25 6,33 0,17 1,04 (0,86–1,22) 0,000 pembanding 25 7,37 0,41 darah 2 jam pp dan hba1c, yang berarti terdapat perbedaan rerata kadar glukosa darah 2 jam pp dan hba1c yang bermakna sebelum dan sesudah tiga bulan pemberian integrasi self care management-holistic psychospiritual care. sedangkan pada kelompok pembanding diperoleh nilai signif icancy 0,007 untuk glukosa darah 2 jam pp, 0,004 untuk hba1c. dan hasil independent-test diperoleh nilai signifi cancy 0,000 (p<0,05) untuk glukosa darah 2 jam pp dan hba1c, artinya terdapat perbedaan yang bermakna sesudah tiga bulan pemberian integrasi self care managementholistic psychospiritual care antara kelompok perlakuan dan pembanding. 105 model self care management-holistic psychospiritual care (kusnanto) pembahasan dm tipe 2 umumnya terjadi pada saat pola gaya hidup dan perilaku telah terbentuk dengan mapan. pemberdayaan penderita dm memerlukan partisipassi aktif pasien, keluarga dan masyarakat (perkeni, 2006). untuk mencapai keberhasilan perubahan perilaku, dibutuhkan informasi yang komprehensif dan upaya peningkatan motivasi. informasi yang diterima akan lebih mudah dan efektif jika informasi tersebut sesuai dengan kebutuhan. hasil penelitian yang dilakukan pada tahap pertama menunjukkan bahwa penderita dm membutuhkan informasi terkait penyakit yang diderita secara komprehensif, mulai dari kebutuhan biologis, psikologis, sosial maupun spiritual. te or i si st e m ke p e r awat a n ya ng dikembangkan oleh orem, memberikan identifi kasi di antaranya sistem supportif dan edukatif; merupakan sistem bantuan yang diberikan pada pasien yang membutuhkan du k u nga n pendidi k a n denga n ha r apa n pasien mampu melakukan perawatan secara mandiri. sistem ini dilakukan agar pasien mampu melakukan tindakan keperawatan setelah dilakukan pembelajaran. menurut parker (2001) seorang individu akan selalu menginginkan adanya keterlibatan dirinya terhadap perawatan diri, individu tersebut juga mempunyai keinginan untuk dapat merawat dirinya secara mandiri. kebutuhan seorang individu untuk terlibat dalam merawat dirinya disebut sebagai self care therapeutic demand atau self care requisites. menurut orem di dalam parker (2001) manusia membutuhkan masukan secara kontinyu untuk dirinya dan lingkungannya, sehingga dapat memenuhi kebutuhan alaminya, human agency dilatih untuk menemukan, mengembangkan, dan menyampaikan cara dan maksud dalam mengidentifi kasi kebutuhan dan memenuhi kebutuhan untuk diri sendiri dan orang lain. melalui media modul diabetes mandiri, maka penderita dm dapat mempelajarinya modul tersebut secara mandiri sehingga penderita dapat mengetahui tentang penyakit diabetes, penderita mengetahui bahwa dm adalah penyakit yang tidak berbahaya asal tidak diremehkan dan terkendali, penderita mengetahui bahwa diet dan latihan f isik (olah raga) memegang peran utama dalam pengobatan diabetes melitus, penderita dapat melaksanakan diet diabetes secara benar dengan prinsip benar 3 j yang meliputi benar jumlah, benar jenis, dan benar jadwal. dengan membaiknya pengetahuan penderita maka sikap penderita juga menjadi lebih positif dalam merespons setiap permasalahan maupun perubahan yang terjadi pada dirinya, penderita lebih mampu mengontrol diri untuk tidak melakukan hal-hal yang dapat meningkatkan kadar glukosa darah, seperti pada saat ada undangan hajatan maka penderita memilih tidak makan makanan yang berkalori dan mengandung gula (manis) tetapi penderita ha nya m i nu m ai r m i neral. per uba ha n psikomotor terkait penyediaan diet/makanan di rumah, pemilihan jenis makanan penetapan waktu makan menjadi lebih baik, penderita juga melakukan aktivitas olah raga rutin setiap hari berupa jalan kaki 15–20 menit perhari serta melakukan aktivitas rutin di posyandu lansia berupa kegiatan senam seminggu sekali selama 30 menit, dan keteraturan minum obat menjadi lebih baik. hal ini sangat penting bagi penderita karena keberhasilan dalam pengontrolan gula darah untuk penderita dm tidak tergantung pada petugas kesehatan atau orang lain, namun tergantung pada pasien itu sendiri. perubahan pada aspek kognitif, afektif, dan psikomotor penderita, berdampak pada perubahan nilai kadar glukosa darah dan kadar hba1c. terjadinya perubahan nilai kadar glukosa darah penderita karena penderita mematuhi diet yang telah dianjurkan terkait jumlah kalori yang harus dikonsumsi, jenis makanan yang harus dikonsumsi maupun jadwal makan utama dan selingan ser ta penderita melakukan aktivitas secara rutin dan teratur. sedangkan perubahan nilai kadar hba1c karena hba1c merupakan zat yang terbentuk dari reaksi antara glukosa dengan hemoglobin. hba1c yang terbentuk akan tersimpan dan tetap bertahan di dalam sel darah merah selama ± 3 bulan, sesuai masa hidup sel darah merah. jumlah hba1c yang terbentuk, tergantung kadar glukosa di dalam darah sehingga hasil pemeriksaan hba1c 106 jurnal ners vol. 7 no. 2 oktober 2012: 99–106 dapat menggambarkan rata-rata kadar glukosa darah selama ± 3 bulan. dari hasil pemeriksaan setelah 3 bulan perlakuan kadar glukosa darah lebih terkontrol, sehingga hal ini berdampak pada nilai hba1c penderita juga menjadi lebih baik yaitu berada pada batas normal (rerata < 6,5% dan ini menunjukkan bahwa kemandirian penderita dalam mengelola penyakit sangat berpengaruh terhadap kendali diabetesnya. simpulan dan saran simpulan pe nge mb a ng a n mo d el s e lf c a r e management-holistic psychospiritual care dengan media modul pengelolaan diabetes ma nd i r i efek t i f d ala m me n i ng k at k a n kognitif, afektif dan psikomotor penderita diabetes mellitus sehingga penderita dapat lebih mandiri dalam mengelola penyakitnya ter utama berkaitan dengan hal-hal yang bersifat umum dan sederhana. kemandirian penderita terbukti dari hasil tes laboratorium glukosa darah dengan metode heksokinase dan test hba1c dengan metode baku emas (gold standard ) menunjukkan hasil yang signifi kan. saran modul pengelolaan diabetes mandiri yang telah dikembangkan oleh peneliti dapat dijadikan acuan oleh penderita diabetes untuk mengelola penyakitnya secara mandiri di r umah, pengembangan model self care management-holictic psychospiritual care d a p a t d ig u n a k a n p e r awa t ko mu n it a s (puskesmas) sebagai intervensi memandirikan penderita diabetes melitus tipe 2 di masyarakat dan sebagai strategi pemberdayaan para penderita diabetes untuk meningkatkan derajat kesehat a n seca ra opt i mal, ser t a d apat digunakan sebagai complementary therapy untuk mengendalikan prevalensi komplikasi dm. kepustakaan arifi n, a.l., 2011. panduan terapi diabetes melitus tipe 2. bandung: sub-bagian endok r i nolog i d a n met abol isme bagian / upf ilmu penyakit dalam fakultas kedokteran unpad/rsup dr. hasan sadikin bandung. atak, n., gurkan, t., dan kose k., 2010. the effect of education on knowledge, self management and self efficacy with type 2 diabetes. australian journal of advanced nursing. 26(2), (online), diakses di (htt p://www. australian jour nal of advanced nursing. org., diakses tanggal 10 februari 2011). a mer ican diabetes associat ion, 2010. standards of medical care in diabetes 2010. jour nal of diabetes care. 33., (o n li ne), ( ht t p://w w w. ca re. diabetesjournals.org/., diakses tanggal 10 februari 2011). basuki, e., 1995. tehnik penyuluhan diabetes m elit u s d ala m pe n a tala k sa n a a n diabetes melitus terpadu. jakarta: fa k u lt as kedok tera n un iversit as indonesia. murti, b., 1997. prinsip dan metode riset epidemiologi. yogyakar ta: gadjah mada university press, p. 139–140. nor r is, s.l ., 20 03. s elf-m a n a ge m e n t education in type 2 diabetes. practical diabetology 22: 713. parker, m.e., 2001. nursing theorists and nursing practice. philadelphia: fa. davis company. perkeni, 2011. konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia. jakarta. pb perkeni. world health organization, 2006. defi nition, diagnosis and classifi cation of diabetes mellitus and its complications. report a who consultation. who, geneva. 164 improving the services quality of educational staff based on satisfaction and loyalty analysis of nursing students fresty africia*, stefanus supriyanto**, tiyas kusumaningrum* * faculty of nursing universitas airlangga, kampus c mulyorejo surabaya, 60115 ** faculty of public health universitas airlangga, kampus c mulyorejo surabaya, 60115 email: tiyas-k@fkp.unair.ac.id abstract introduction: educational staff services play a role in determining the quality of education. service quality is able to provide satisfaction for students. students who were satisfied with the perceived quality will develop student loyalty to the institution. the purpose of this study was to assess the effect of educational staff service quality with the satisfaction and loyalty of nursing students so that the educational institutions as service providers are able to provide the best service and survive in the midst of competition. method: the study was an explanative survey with a cross-sectional design. data collection was conducted using both quantitative (questionnaires) and qualitative (focus group discussion/fgd) methods. this study used proportional random sampling, with 110 students as samples. the variables in this research were customer expectations, perceived quality, student satisfaction and loyalty. the data was collected by a questionnaire and analyzed by linear regression, while fgd was conducted in two different groups (students and staff’s managers). result: the result of the study explains the influence of student expectations on the perceived quality of the educational staff with a p-value = 0,002. there was no influence of student expectation on student satisfaction with a p-value = 0,156. the influence of the perceived quality of the educational staff towards student satisfaction had a p-value = 0,000. the influence of student satisfaction on student loyalty had a p-value = 0,000. conclusion: the fulfilment of student expectations will have a positive impact on perceived quality. furthermore, the positively perceived quality will create student satisfaction and student loyalty towards the educational institutions. for further research, it is suggested to examine the effect of satisfaction on student complaints. keywords: customer expectation; educational staff; loyalty; perceived quality; satisfaction introduction education is a conscious and wellplanned effort to create an atmosphere of learning in the learning process so that learners can actively develop their self-potential to have spiritual strength, self-control, personality, intelligence, a noble character, and the necessary skills that they, society, the nation and the state needs (ri, 2012). educators and education staff are two professions that are closely related to the world of education, although the scope of the two is different. educators and education staff have roles and positions that are equally important in the context of education (learning). this is in accordance with law no.20, article 40, paragraph (2) 2003 where educators and education staff are obliged to create a meaningful, fun, creative, dynamic and dialogical education atmosphere and have a professional commitment to improving the quality of education. academic institutions are always expected to improve the academic services offered so as to improve the student’s performance (goga, kuyoro and goga, 2015). educational institutions need to implement appropriate management so that the educational environment can be modified as needed (khachian et al., 2013). the globalization era is a challenge for universities preparing their graduates to be able to compete in the struggles of the job market and to produce innovative and creative graduates (prasetyaningrum, 2009). under these conditions, educational institutions are finding it necessary to recognize and meet the needs of consumers in providing quality services (muzakiyah, syukri and setyaningsih, 2011). data from the quality assurance team at stikes ganesha husada kediri in 2016, in their assessment on their educators (lecturers), showed that 26% were in a very good category and 74% were in a good category. the assessment of the educational staff had never been done before. the results of the initial survey using questionnaires on october 17, 2016, showed that 4 out of 10 nursing students felt that the service personnel at stikes ganesha husada kediri are below their expectations. students, as the most important element in educational institutions, need to be heard regarding whether the service that has been given is below their expectations or not. customer satisfaction is expected to affect loyalty (rinala, yudana and natajaya, 2013). data from the new admissions team at stikes ganesha husada kediri in 2016 showed that the number of registered students had improving the services quality of educational staff based on ... (tiyas kusumaningrum, et.al.) 165 decreased by 14% from 175 to 151 students. according to tjiptono (2003), the creation of consumer satisfaction can provide several benefits such as a harmonious relationship between service owners and consumers, providing a good basis for repurchase and the creation of consumer loyalty, and forming a recommendation from word of mouth services. if there is dissatisfaction from the concerned student, it can have a bad impact in the form of demands or complaints, even lawsuits and spreading it in mass media. if this happens, it is very harmful to the reputation of the concerned college (suardana, i., 2007). the competitive situation between universities’ demands requires the institutions to pay attention to the quality in order to be able to excel in the competition (ayu, srinadi and eka, 2008). universities should take anticipatory steps to face the competition and to be responsible for exploring and improving all aspects of the owned services (ayu, srinadi and eka, 2008). quality services can be identified through customer satisfaction, especially from the students (ayu, srinadi and eka, 2008). tjiptono (2011) mentioned that quality has a close relationship with the satisfaction of the customer. quality provides a boost to the consumers to forge strong bonds with the service owners. in the long term, such ties allow the service owners to understand the expectations of consumers and their needs (tjiptono, 2011). institutions should be able to improve student satisfaction by improving the quality of the services offered, making the good quality services better and improving the weaker ones. the priority is considered to be student satisfaction in order to achieve student loyalty. this study has examined customer expectations (student), perceived quality of the supporting educational staff, student satisfaction, and student loyalty. the aim of this study was to assess the effect of educational staff service quality on the satisfaction and loyalty of the nursing students. materials and methods the research method used was an explanative survey with a cross-sectional approach. the study was conducted at stikes ganesha husada kediri on 13 th to the 31 st march 2017. the research population was all of the nursing students at stikes ganesha husada kediri, which was many as 151 students. the sampling technique used in this study was proportional random sampling, with a sample size of 110 students based on sample size formula. the data was collected by using a questionnaire. the questionnaire had been tested for validity and reliability with the pearson and cronbach alpha tests. the collected data were analysed by using linear regression. the research variables include customer expectations (student) and perceived quality, student satisfaction, and student loyalty. a focus group discussion (fgd) was conducted after the quantitative data collection was completed in two different groups; the students and the student’s services manager. the implementation of fgd for students was on a different schedule than that of the managers. this study passed the ethical test conducted on march 8 th , 2017 at the faculty of nursing universitas airlangga surabaya with no 355-kepk. results this section will present the results of the study based on student expectations, perceived service, satisfaction and the loyalty of the students along with the influence of the variables. the total respondents were 110 students with the majority being female (67%). from this number, the majority said that they were between their second and fifth year of being students. from table 1, it can be explained that the customer expectation variable fulfilled as many as 55.5% of the respondents. the perceived quality variable on technical quality, functional quality, and amenity was also quite good, with 50.9%, 51.8%, and 51.8% respectively. student satisfaction with the services provided by the majority in the category of quite satisfied was mentioned by 52.7% of the students. the loyalty variable shows that the majority of students (94.5%) are willing to recommend the school to the community and expect the continuity of relationship by 64.5%. the students who proud getting a degree in nursing school were 66.4%. table 2 indicated that as many as 36 students thought their fulfilment and the value of the services as being good, and as many as 20 students felt unfulfilled and thought that the valued services are felt fair enough. as many as 25 students thought that the assessment jurnal ners vol. 12 no. 2 oktober 2017: 164-170 166 service was felt fair enough, and as many as 29 of the students thought that their expectations were unfulfilled and judged the perceived service to be fair enough. table 3 is the result of the tabulation that indicates that as many as 48 students perceive the service as being good and feeling satisfied, as many as four students perceive the service being quite satisfied and as many as 50 students who assessed the service felt sufficiently satisfied with the service. table 4 presents the influence of the research variables. there was a significant correlation between customer expectation and perceived quality. customer expectation has no direct correlation with student satisfaction, but instead through the variable between the perceived qualities. perceived quality has a very strong correlation (β: 0,910) and is positive towards student satisfaction. student satisfaction has a strong enough correlation (β; 0,456) to student loyalty. fulfilling customer expectations will, therefore, enhance perceived quality, which will have an impact on increasing student satisfaction and increasing student loyalty to the institution. discussion the correlation of customer expectation to perceived quality of student the direct correlation of customer expectation towards the perceived quality by way of the linear regression test indicates if there was an increase in student expectations, there would be a requirement for improvement of the perceived quality of the service based on the student’s perception. this was in accordance with the concept of the american customer satisfaction index which states that there is a significant correlation between student expectation’s on the perceived quality service (fornell et al., 1996). the expectation of the customer is the consumer's belief that a product has certain desired attributes and it is the prediction of the consumer towards the possible attributes or performance of a given product (tanuwijaya, 2012). woodruff, r.b. & gardial (2002) used the term "comparison standard" against the customer's expectation; they compared between the service product used with the standard that must be received. perceived quality is an important element for consumer decision-making, and as a consequence, consumers will compare the quality according to the owned category of the product compared to the price paid (yee, c.j. & san, 2011). the quality of educational staff services is assessed based on the quality distribution of the services. according to donabedian a., 1980 in (supriyanto, 2010), there are 3 categories that are technical quality, functional quality, and amenity. technical quality in this study assessed the duties and functions of each educational staff based on ganesha husada kediri foundation decree no.01/ygh-k/xii/2013. functional quality assessed the reliability, assurance, tangible, empathy and responsiveness of the educational staff. amenity is based on the comfort and convenience in relation to the received service. a well-fulfilled expectation will encourage an assessment of the service, and judgment as well. from table 2, we saw that most of the students' expectations were fulfilled and that they gave positive feedback of the perceived service. however, there was an unfulfilled expectation that needs to be analysed by the academic manager such as the slow distribution of certificates by the academic administrative staff. fgd revealed that the slow certificate distribution was happening because the hospital does not immediately send a certificate of practice to the associated institution. the existence of the correlation of expectations on perceived quality is supported by a statement from fornell et al., (1996) which stated that customer expectation is a forecast of the company's ability to provide good quality in the future and positively relates to perceived quality. kunanusorn (2014) also supported the findings by stating that the quality of service is centred on the efforts to meet the needs, desires, and accuracy of delivery to balance with the customer expectations. trimurthy (2008) stated that quality is a fundamental decision-making factor determined by the consumers based on the consumer's actual experience of a product or service based on its measurement results, expectations, the promised services, awareness and objectivity. improving the services quality of educational staff based on ... (tiyas kusumaningrum, et.al.) 167 the correlation of customer expectation to nursing student satisfaction this study shows no direct correlation between customer expectations and student satisfaction. tse and wilton (1988) in tjiptono (2008) stated that customer satisfaction is directly proportional to customer loyalty, where customer satisfaction is determined by two main things: expectations and perceived performance. if the perceived performance exceeds expectations, then the customer will be satisfied. otherwise, the customer will not be satisfied. oliver (2013) agreed with the concept of tse and wilton by stating that the process of satisfaction begins after the consumer has obtained a standard of expectation or an example of the product or service performance. woodruff, r.b. & gardial (2002) stated that satisfaction is a gap between customer expectations and expected quality standards, where satisfaction can be felt positively or negatively based on the impression experienced by the customers. this condition occurs as a result of the interaction between service providers and customers. table 1. research variables (n = 110) no variables fulfilled unfulfilled total n % n % n % 1. customer expectation 61 55.5 49 45.5 110 100% 2. perceived quality good enough total n % n % n % a. technical quality 56 50.9 54 49.1 110 100% b. functional quality 57 51.8 53 48.2 110 100% c. amenity 57 51.8 53 48.2 110 100% 3. student satisfaction 52 47.3 58 52.7 110 100% 4. student loyalty loyal disloyal total n % n % n % a. advocate/recommendation 106 94.5 6 5.5 110 100% b. continuity of relationship 71 64.5 39 35.5 110 100% c. proud 73 66.4 37 34.6 110 100% table 2. cross-tabulation result of customer expectation, perceived quality, and student satisfaction customer expectation perceived quality total student satisfaction total good enough good enough fulfilled 36 25 61 32 29 52 unfulfilled 20 29 49 20 29 58 total 56 54 110 71 39 110 table 3. cross-tabulation result of perceived quality, student satisfaction, and student loyalty student satisfaction perceived quality total student loyalty total good enough loyal disloyal good 48 8 56 44 8 52 enough 4 50 58 27 31 58 total 52 58 110 71 39 110 table 4 statistic test of correlations of customer expectation, perceived quality, student’s satisfaction and student’s loyalty at stikes ganesha husada kediri variables p-value β customer expectation perceived quality 0,002 0,290 customer expectation student’s satisfaction 0,156 -0,065 perceived quality student’s satisfaction 0,000 0,910 student’s satisfaction student’s loyalty 0,000 0,456 jurnal ners vol. 12 no. 2 oktober 2017: 164-170 168 kotler (2007) stated that satisfaction is the level of one's satisfaction after comparing the perceived results with their expectations. conversely, if the student’s expectations are not fulfilled, then the level of student satisfaction with the institution will also decrease. the results of this study are consistent with the previous research conducted at several universities in tehran showing that student expectations do not have a significant effect on student satisfaction and the values that the students understand. the quality of service has a direct and meaningful effect on student satisfaction (kheiry, 2012). the correlation of the expected quality of the students does not directly affect the satisfaction but instead works through the intermediate variable, which is the students' perceived judgment on the educational personnel services. some of the literature does mention that customer's satisfaction or that of the patient is determined by the accepted quality examiner (strasse and davis, 1991). the correlation of perceived quality to nursing student satisfaction the correlation of perceived quality to student satisfaction within the linear regression test was indicated by an increase in the perceived quality of the students. there will, therefore, be an increase in student satisfaction at stikes ganesha husada kediri. this is in accordance with the concept of acsi (american customer satisfaction index) fornel which states that there is a significant correlation between perceived quality towards overall customer satisfaction (fornell et al., 1996). according to the results of a research study on students in singapore, it showed that service quality judged from the perspective of functional and technical quality has a positive influence on the satisfaction that impacts on wom (word of mouth) positively (teo and soutar, 2012). kheiry (2012) stated that the quality of the service perceived by students has a direct effect on student satisfaction and value. according to durianto (2004) on suprapti (2010), perceived quality is a consumer perception of the overall quality and superiority of a product or service similar to its intended purpose. positive perceived quality will drive the consumer’s decision to purchase and create loyalty towards the product. furthermore, considering that consumer perception can be forecasted, if the perceived quality is negative then the product will not be liked and will not last long in the market. conversely, if the consumer’s perceived quality is positive then the product will be liked, and so the consumer will make the decision to buy the product. the correlation of student satisfaction to the loyalty of nursing student the correlation of student satisfaction to student loyalty showed that when student satisfaction is increased, it will be followed by student loyalty at stikes ganesha husada kediri. this is in accordance with the concept of acsi (american customer satisfaction index) which states that there is significant influence between customer satisfaction and customer loyalty (fornell et al., 1996). the ultimate goal of a company that pursues consumer loyalty is the achievement of increased usage, the interest in repurchasing the same item, continuing or always using the same service product and choosing the brand of the service product in the future (kotler and keller, 2007). consumer loyalty is a manifestation and continuation of consumer satisfaction (rahadian, 2006). satisfied students will be loyal to the institution. this is in accordance with table 4 where most students are satisfied and have good loyalty towards the institution. helgesen & nesset (2007) stated that student satisfaction has the strongest correlation compared to other factors towards student loyalty and that the effect is three times greater than the image and brand image of the college towards student loyalty. satisfied and loyal customers are the chance to gain new opportunities. maintaining existing customers will generally be more profitable than turnover. as the cost to attract new customers can be five times the cost of maintaining an existing customer (kotler and keller, 2007). thus, keeping the existing customers is the same as maintaining the survival of the company. in terms of education, to maintain the loyalty of community in the nursing college is similar with maintaining the continuity of the nursing education process helps to improve the quality of nursing services to the community. improving the services quality of educational staff based on ... (tiyas kusumaningrum, et.al.) 169 conclusions the quality expectation and assessment of the educational staff is still quite good, as well as student satisfaction and loyalty. there is a positive correlation between customer expectation and perceived quality. however, customer expectation has no direct effect on student satisfaction but instead works through the perceived quality intermediary variable. this means that when assessing student satisfaction, one should simply use the assessment variable. the student's satisfaction has a very strong and positive impact on the student’s loyalty. the higher the fulfilment of the customer’s expectations, the perceived quality will result in a better judgment, and student satisfaction will increase, and ultimately affect the high loyalty of the students towards the institution. educational institutions must continuously improve the quality of their services to students as a whole in terms of the educational staff, educators (lecturers), and infrastructure facilities. further research is expected to examine the influence of student satisfaction with student complaints. references ayu, i. g., srinadi, m. and eka, p. (2008) ‘faktor-faktor penentu kepuasan mahasiswa terhadap pelayanan fakultas sebagai lembaga pendidikan’, cakrawala pendidikan, xxvii(3), pp. 217–231. fornell, c. et al. (1996) ‘the american customer satisfaction index: nature, purpose, and findings’, journal of marketing, 60(4), pp. 7–18. goga, m., kuyoro, s. and goga, n. (2015) ‘a recommender for improving the student academic performance’, procedia social and behavioral sciences. elsevier, 180, pp. 1481– 1488. doi: 10.1016/j.sbspro.2015.02.296. helgesen, ø. and nesset, e. (2007) ‘what accounts for students’ loyalty? some field study evidence’, international journal of educational management, 21(2), pp. 126–143. doi: 10.1108/09513540710729926. khachian, a. et al. (2013) ‘the role of the organizational internal environment in the establishment of change management in nursing and midwifery schools’, in procedia social and behavioral sciences. elsevier, pp. 308–316. doi: 10.1016/j.sbspro.2013.09.195. kheiry, b. (2012) ‘university intellectual image impact on satisfaction and loyalty of students (tehran selected universities)’, african journal of business management, 6(37), pp. 10205–10211. doi: 10.5897/ajbm11.434. kotler, p. and keller, k. l. (2007) marketing management. new jersey: pearson education inc. kunanusorn, a. and d. p. (2014) ‘the mediating effect of job satisfaction on student loyalty to higher institution’, european scientific journal, 1(october), pp. 449–464. muzakiyah, syukri, s. h. a. and setyaningsih, i. (2011) ‘analisis kualitas pelayanan pada bagian tata usaha berdasarkan tingkat kepuasan mahasiswa’, ilmiah teknik industri, 10(2), pp. 95–100. oliver, r. l. (2013) ‘whence consumer loyalty ?’, journal of marketing, 63(1999), pp. 33–44. prasetyaningrum, i. d. (2009) analisis pengaruh pembelajaran dan kualitas pelayanan terhadap kepuasan mahasiswa dan loyalitas mahasiswa (studi kasus pada undaris ungaran), tesis. universitas diponegoro semarang. rahadian, s. s. (2006) analisis pengaruh loyalitas pelanggan dan perilaku mencari variasi terhadap perpindahan merek. universitas diponegoro semarang. ri (2012) undang-undang republik indonesia nomor 12 tahun 2012 tentang pendidikan tinggi. rinala, i. n., yudana, i. m. and natajaya, i. n. (2013) ‘pengaruh kualitas pelayanan akademik terhadap kepuasan dan loyalitas mahasiswa pada sekolah tinggi pariwisata nusa dua bali’, ejournal pascasarjana universitas pendidikan ganesha, 4. strasse, s. and davis, r. (1991) measuring patient satisfaction for improved patient service (management series). michigan: american college of healthcare executives. jurnal ners vol. 12 no. 2 oktober 2017: 164-170 170 suardana, i., m. (2007) ‘analisis kepuasan mahasiswa terhadap pelayanan jasa pendidikan sekolah tinggi ilmu ekonomi’, jurnal valid, 4(1). suprapti (2010) analisis pengaruh brand awareness, perceived value, organizational association an perceived quality terhadap keputusan pembelian konsumen. universitas diponegoro semarang. supriyanto, s. (2010) manajemen mutu pelayanan kesehatan. surabaya: health advocacy yayasan pemberdayaan kesehatan masyarakat. tanuwijaya, a. (2012) ‘pengaruh customer perceived value terhadap customer loyalty melalui customer satisfaction pada secong royal plaza surabaya’, jurnal universitas katolik surabaya, 1(2), pp. 1–6. teo, r. and soutar, g. n. (2012) ‘word of mouth antecedents in an educational context: a singaporean study’, international journal of educational management, 26(7), pp. 678–695. doi: 10.1108/09513541211263746. tjiptono, f. (2003) total quality management. yogyakarta: andi offset. tjiptono, f. (2008) strategi pemasaran. yogyakarta: andi offset. tjiptono, f. (2011) service, quality satisfaction. yogyakarta: andi offset. trimurthy, i. g. a. (2008) analisa hubungan persepsi pasien tentang mutu pelayanan dengan minat pemanfaatan ulang palayanan rawat jalan di puskesmas pandanaran kota semarang. universitas diponegoro semarang. woodruff, r. and gardial, s. (2002) ‘exploring the phenomenon of customers’ desire value change in a business to business context’, journal of marketing, 66(4), pp. 102– 117. yee, c.j. & san, n. c. (2011) ‘consumers perceived quality, perceive value, and perceived risk towards purchase decision on automobile’, american journal of economics and business administration, 3(1), pp. 47–57. ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 127 pemberian sukrosa dan non-nutritive sucking terhadap respons nyeri dan lama tangisan neonatus pada prosedur invasif (grant of sucrose and non-nutritive sucking to pain response and the long cries of neonates to invasive procedures) kristiawati*, krisna yetti**, hening pujasari** *pascasarjana keperawatan anak fakultas ilmu keperawatan universitas indonesia, depok e-mail: tia.woespinto@gmail.com ** fakultas ilmu keperawatan, kampus universitas indonesia, depok abstract intoduction: hospitalized neonates may experience pain caused by invasive procedures. sucrose and non-nutritive sucking are non-pharmacological analgesics. the aimed of this study was to examine the effectiveness of sucrose and non-nutritive sucking administration on pain and crying duration of neonates during invasive procedures. method: the study used quasi-experimental design with post-test only control group design approach. this study used nonprobability sampling technic with consecutive sampling. the sample consisted of 45 neonates, divided into three groups, each group of 15 neonates. result: the results showed that the pain response and the crying duration were insignifi cantly different between the sucrose group and the nns, respectively p = 0.635 and p = 0.848. discussion: age was identifi ed as a confounding variable that effected pain responses. provision of sucrose and nns proven to reduce pain as non-pharmacological pain management for neonates during invasive procedures. keywords: crying duration, neonates, non-nutritive sucking, pain response, sucrose pendahuluan b a y i b a r u l a h i r ( n e o n a t u s ) p e r l u melakukan adaptasi karena perubahan yang dialami dari dalam rahim ke luar rahim. bobak et al. (1999) menyatakan bahwa kebanyakan bayi dapat menjalani penyesuaian yang dibutuhkan untuk hidup di luar rahim tanpa banyak kesulitan, tetapi kesehatannya tergantung pada perawatan yang diterimanya. bayi baru lahir cukup bulan yang dirawat di rumah sakit secara kontinu akan dilakukan evaluasi, oleh sebab itu diperlukan pungsi vena. tindakan ini merupakan prosedur invasif yang menyakitkan (taddio et al., 1998). prosedur invasif yang salah satunya adalah pungsi vena merupakan metode yang dianjurkan untuk pengambilan sampel darah pada neonatus cukup bulan. keuntungan pungsi vena adalah meningkatnya volume sampel, dan tidak terlalu nyeri dibandingkan tusukan pada tumit (gradin et al., 2002). nyeri adalah fenomena kompleks yang paling sulit dipahami neonatus (merestein dan gardner, 2002). efek nyeri dapat menimbulkan respons fi siologis dan perubahan perilaku (codipietro et al., 2008). oleh sebab itu perawat anak memiliki peran untuk pemberikan asuhan dengan memperhatikan kenyamanan neonatus dan mengurangi trauma (hockenberry dan wilson, 2007). nyeri diungkapkan secara subjektif oleh neonatus dengan tangisan. tangisan yang muncul tiba-tiba dan panjang merupakan tangisan sebagai akibat dari nyeri yang dirasakan bayi (santrock, 2001). oleh sebab itu diperlukan penanganan terhadap nyeri pada neonatus. penanganan nyeri dikelompokkan menjadi dua kategori yaitu farmakologi dan nonfarmakologi yang diperlukan untuk mengatasi respons nyeri dari prosedur invasif yang diterima oleh bayi (american academy of pediatric, 2006). namun penatalaksanaan secara nonfarmakologi sangat penting karena intervensi ini didasarkan pada pengkajian klinis perawat terhadap nyeri dan dapat dilakukan oleh staf perawat tanpa instruksi dari dokter (kashaninia et al., 2008). selain itu penatalaksanaan nonfarmakologi bersifat aman, noninvasif, tidak mahal dan merupakan fungsi jurnal ners vol. 5 no. 2 oktober 2010: 127–132 128 keperawatan yang mandiri (hockenberry dan wilson, 2009). penanganan nyeri secara nonfarmakologi dapat dilakukan dengan pemberian sukrosa (aap, 2006). hal ini didukung oleh taddio, shah dan katz (2009) yang menyatakan bahwa sukrosa adalah gula alami dengan analgesik dan efeknya menenangkan pada bayi muda. studi yang dilakukan oleh elserafy et al. (2009) menyatakan bahwa sukrosa (karena rasa manis) dan nyeri saling berhubungan melalui sistem opioid endogen tubuh yang menyediakan analgesia alami. non-nutritive sucking (nns) juga termasuk salah satu jenis penanganan nonfarmakologi yang dapat diberikan pada neonatus yang menerima prosedur invasif (aap, 2006). nns diperkirakan menghasilkan analgesia melalui stimulasi orotactile dan mekanoreseptor ketika diberikan kepada bayi. mekanisme yang mendasari kerja nns adalah teori gate control dan efeknya akan berakhir ketika mekanisme menghisap berhenti (gibbins dan stevens, 2001). hasil observasi di rsal dr. ramelan surabaya didapatkan bahwa tindakan invasif yang sering dilakukan pada neonatus adalah pungsi vena. pada setiap tindakan pungsi vena belum ada penatalaksanaan terhadap nyeri. hal ini dibuktikan dengan belum adanya standar operasional dalam penatalaksanaan nyeri. penelitian ini bertujuan untuk mengetahui efektivitas sukrosa dan nns terhadap respons nyeri dan lama tangisan neonatus yang dilakukan prosedur invasif. sehingga dapat memberikan masukan dan bahan pertimbangan bagi perawat, tim medis dan tenaga kesehatan lain dalam memberikan intervensi untuk mengatasi nyeri pada neonatus. bahan dan metode penelitian ini menggunakan quasy eksperimental design dengan pendekatan rancangan posttest only control group design. kelompok intervensi menerima perlakuan pemberian sukrosa dan nns, sedangkan kelompok kontrol mendapatkan intervensi sesuai standar di ruangan. sampel pada penelitian ini sebanyak 45 neonatus, terbagi dalam 3 kelompok. jumlah sampel untuk tiap kelompok adalah 15. teknik pengambilan sampel menggunakan cara non-probability sampling jenis consecutive sampling. kriteria inklusi adalah bayi aterm, usia 2–28 hari, apgar score lebih dari 7 pada 5 menit pertama, bayi dengan tidak asi ekslusif, bayi dengan refl eks isap baik dan dilakukan tindakan pungsi vena. alat pengumpulan data yang digunakan dalam penelitian ini adalah instrumen data karakteristik responden dan instrumen observasi respons nyeri menggunakan neonatal infant pain scale (nips). kamera digital untuk merekam respons nyeri dan lama tangisan setelah dilakukan pungsi vena. stop watch untuk mengukur lama tangisan neonatus setelah dilakukan prosedur pungsi vena. k e g i a t a n p e n e l i t i a n m e l i p u t i m e m p e r s i a p k a n s u k r o s a , n n s d a n mempersiapkan kamera untuk merekam respons nyeri dan lama tangisan. kelompok i diberikan sukrosa 24% sebanyak 2 ml pada saat 2 menit sebelum dilakukan intervensi dan memberikan nns pada kelompok ii mulai dari 2 menit sebelum dilanjutkan selama dan setelah intervensi. peneliti melakukan observasi terhadap respons nyeri pada menit pertama setelah dilakukan pungsi vena dengan menggunakan lembar observasi nips. data hasil rekaman video digunakan untuk menilai kembali respons nyeri dan lama tangisan neonatus, yang dilakukan segera setelah satu prosedur pungsi vena selesai. analisis data pada penelitian ini diolah dengan program statistik. analisis dilakukan secara univariat, bivariat dan multivariat. analisis univariat digunakan untuk menjelaskan karakteristik responden, respons nyeri dan alam tangisan. analisis bivariat menggunakan uji anova untuk melihat perbedaan antara kelompok yang diberikan sukrosa, nns dan kelompok kontrol. analisis multivariat menggunakan uji regresi linier berganda. hasil hasil penelitian menunjukkan bahwa kelompok kontrol mempunyai respons nyeri yang berbeda dengan kelompok nns dengan nilai p = 0,017, kelompok kontrol juga pemberian sukrosa dan non-nutritive sucking (kristiawati) 129 mempunyai respons nyeri yang berbeda dengan kelompok sukrosa dengan nilai p = 0,001. sedangkan pada kelompok nns dan sukrosa mempunyai pengaruh respons nyeri yang sama karena nilai p = 0,635. kelompok kontrol mempunyai pengaruh lama tangisan yang berbeda dengan kelompok nns dan sukrosa dengan nilai p = 0,001 dan p = 0,000. sedangkan pada kelompok nns dan sukrosa dengan nilai p = 0,001 dan p = 0,000. sedangkan pada kelompok nns dan sukrosa mempunyai pengaruh lama tangisan yang sama karena nilai p = 0,848. analisis multivariat menunjukkan bahwa variabel yang berpengaruh terhadap respons nyeri adalah umur dan intervensi pemberian tabel 1. hasil pengujian pembandingan berganda respons nyeri responden di rsal dr. ramelan surabaya, mei–juni 2010 (n = 45) pembandingan antarkelompok perbedaan rata-rata p value kontrol nns 1,46667 0,017 sukrosa 1,93333 0,001 nns sukrosa 0,46667 0,635 tabel 2. hasil pengujian pembandingan berganda lama tangisan responden di rsal dr. ramelan surabaya, mei-juni 2010 (n = 45) pembandingan antarkelompok perbedaan rata-rata p value kontrol nns 2,12533 0,001 sukrosa 2,42200 0,000 nns sukrosa 0,29667 0,848 tabel 3. hasil multivariat regresi linier pengaruh pemberian sukrosa dan nns terhadap respons nyeri setelah dikontrol variabel perancu di rsal dr. ramelan surabaya, mei–juni 2010 variabel r r square persamaan garis p value respons nyeri 0,600 0,359 respons nyeri = 7,843–0,159 umur 0,999 intervensi 0,000 tabel 4. hasil multivariat regresi linier pengaruh pemberian sukrosa dan nns terhadap lama tangisan setelah dikontrol variabel perancu di rsal dr. ramelan surabaya, mei–juni 2010 (n = 45) variabel r r square persamaan garis p value lama tangisan 0,552 0,305 lama tangisan = 7,337–1,211 intervensi 0,000 sukrosa dan nns. hubungan umur dan intervensi pemberian sukrosa dan nns dengan respons nyeri menunjukkan hubungan yang kuat (r = 0,600).hasil tersebut menunjukkan juga bahwa umur dan intervensi menentukan respons nyeri sebesar 35,9% sedangkan sisanya dipengaruhi oleh variabel lain. hasil multivariat terhadap lama tangisan menunjukkan bahwa variabel intervensi pemberian sukrosa dan nns yang berpengaruh terhadap lama tangisan. hubungan intervensi dengan lama tangisan menunjukkan hubungan kuat (r = 0,552). hasil menunjukkan data bahwa intervensi pemberian sukrosa dan nns menentukan lama tangisan sebesar 30,5%. jurnal ners vol. 5 no. 2 oktober 2010: 127–132 130 pembahasan respons nyeri neonatus saat dilakukan prosedur invasif yang diukur dengan skala nyeri nips antara kelompok sukrosa dan kelompok nns menunjukkan bahwa tidak berbeda signifi kan, dengan nilai p = 0,635. hasil penelitian ini berbeda dengan penelitian yang dilakukan oleh carbajal et al. (1999) terhadap 150 neonatus aterm yang dilakukan pungsi vena dengan cara random dengan membagi dalam 6 kelompok yaitu kelompok tanpa intervensi, 2 ml air sebagai plasebo, 2 ml glukosa 30%, 2 ml sukrosa 30%, 2 ml sukrosa dengan non-nutritive sucking dan non-nutritive sucking. pada penelitian carbajal menunjukkan bahwa non-nutritive sucking lebih efektif dibandingkan dengan sweet solution (p ≤ 0,001). hal ini juga didukung oleh penelitian mathai, natrajan dan rajalakshmi (2006) yang menyatakan bahwa non-nutritive sucking adalah analgesik nonfarmakologi yang lebih efektif menurunkan nyeri dibandingkan dengan sukrosa (p < 0,05). n o n n u t r i t i v e s u c k i n g m e m b a n t u neonatus untuk beradaptasi terhadap stimulus dan dapat meningkatkan pelepasan neurotransmitter yang menurunkan nyeri (gibbins dan stevens, 2001). oleh sebab itu pemberian non-nutritive sucking direkomendasikan sebagai salah satu manajemen nonfarmakologi terhadap nyeri. kegiatan menghisap selama neonatus menerima stimulus yang menimbulkan nyeri akan menurunkan perilaku distress dan memiliki efek yang menenangkan bagi neonatus (hockenberry dan wilson, 2009). hasil penelitian ini, menunjukkan bahwa pemberian sukrosa dan nns pada saat dilakukan pungsi vena tidak memiliki perbedaan bermakna. hal ini dapat dipengaruhi oleh beberapa faktor seperti pada kelompok nns ditemukan 2 neonatus yang tidak menunjukkan respons nyeri saat dilakukan pungsi vena, hal ini berkaitan dengan ambang nyeri yang dimiliki setiap individu berbeda-beda, kemampuan refl ek hisap dan perkembangan psikoseksual yaitu fase oral. sukrosa yang diberikan 2 menit sebelum tindakan efektif menurunkan respons nyeri. pemberian sukrosa membuat neonatus tenang dan efeknya masih berlanjut beberapa lama setelah prosedur selesai dilakukan. pemberian sukrosa maupun nns dapat dianggap sama-sama efektif dan dapat digunakan sebagai intervensi untuk mengatasi respons nyeri neonatus yang dilakukan tindakan yang menimbulkan nyeri. lama tangisan neonatus pada saat dilakukan prosedur invasif menunjukkan tidak berbeda antara kelompok sukrosa dan nns (p value 0,848). hasil penelitian ini didukung oleh penelitian devaera (2006), neonatus yang diberikan larutan glukosa oral 30% sebanyak 0,5 ml sebagai analgesik dua menit sebelum prosedur pengambilan darah tumit. pada penelitian tersebut ditemukan bahwa tidak terdapat perbedaan yang bermakna lama tangisan pertama dan lama tangisan total pada kelompok intervensi dengan kelompok kontrol. hal ini menunjukkan bahwa pemberian analgesik seperti sweet solution termasuk sukrosa bukanlah satu-satunya intervensi yang dapat digunakan dalam menurunkan lama tangisan neonatus yang mengalami prosedur yang menyakitkan. rasa nyeri yang dirasakan neonatus saat dilakukan prosedur invasif disampaikan melalui tangisan. menurut santrock (2001) perkembangan bahasa pada masa bayi masih sangat sederhana, sehingga bayi masih sulit mengkomunikasikan keinginannya. oleh karena itu neonatus menggunakan tangisan sebagai mekanisme yang paling penting dalam berkomunikasi dengan dunia sekitar mereka. tidak ada perbedaan lama tangisan antara kelompok sukrosa dan nns dapat disebabkan karena rasa nyeri yang disebabkan oleh pungsi vena tidak dapat ditoleransi oleh neonatus sehingga dikomunikasikan dalam bentuk tangisan. pada kelompok nns bahwa saat neonatus menangis menyebabkan nns terlepas dari mulutnya sehingga neonatus mengungkapkan rasa nyerinya secara verbal dengan menangis keras. oleh karena bila nns terlepas dari mulutnya maka efek analgesiknya juga hilang. hasil analisis menunjukkan bahwa variabel jenis kelamin dan pernah dilakukan pungsi vena bukan merupakan variabel perancu, sedangkan umur merupakan variabel yang berpengaruh terhadap respons nyeri selain intervensi yang diberikan. hasil analisis pemberian sukrosa dan non-nutritive sucking (kristiawati) 131 ini sesuai dengan teori yang dikemukakan o l e h b o w d e n , d i c k e y, d a n g r e e n b e rg (1998), bahwa tingkat perkembangan anak akan memengaruhi proses kognitif dalam mempersepsikan rasa nyeri yang dirasakan anak. tingkat perkembangan akan sejalan dengan pertambahan umur, sehingga semakin meningkat umur maka toleransi terhadap nyeri akan meningkat. hasil penelitian menunjukkan umur dan intervensi berpengaruh sebesar 35,5% sedangkan sisanya dipengaruhi oleh faktor lain. faktor lain yang dapat memengaruhi persepsi terhadap nyeri positif maupun negatif dapat disebabkan oleh jenis cidera, karakteristik genetik, temperamen, sosial dan pengaruh budaya, serta koping individu (bowden, dickey, dan greenberg, 1998). perubahan perilaku merupakan indikator umum dari respons nyeri yang dilihat pada penelitian ini, dan sangat bermanfaat dalam mengkaji nyeri pada bayi yang belum dapat mengungkapkan respons nyeri secara verbal. respons perilaku terhadap nyeri ini akan berubah dengan bertambahnya umur dan sejalan dengan tahap perkembangan anak. hasil analisis menunjukkan bahwa variabel umur, jenis kelamin dan pernah dilakukan pungsi vena bukan merupakan variabel yang berpengaruh terhadap lama tangisan. lama tangisan dipengaruhi sebesar 30,5% oleh pemberian sukrosa dan nns, sedangkan sisanya dipengaruhi oleh faktor lain. tangisan merupakan respons verbal yang dapat diukur. neonatus menyampaikan semua keinginan dan perasaannya dengan tangisan. menangis merupakan mekanisme penting dalam berkomunikasi dengan dunia sekitarnya (potter dan perry, 2005). hal yang perlu diperhatikan dalam tangisan bayi adalah penyebab dari bayi menangis. menurut suririnah (2009) dengan mempelajari dan mengerti tangisan bayi, tanpa disadari akan memahami dan mengerti keinginan dari bayi. bertambahnya umur pada bayi membuat tangisan bayi juga akan berkurang, karena bayi sudah semakin belajar dan berinteraksi dengan lingkungan. namun belum tentu membuat semakin singkat lama tangisannya. penelitian ini yang memengaruhi lama tangisan adalah pemberian sukrosa dan nns. pemberian sukrosa dan nns dapat menurunkan respons nyeri saat mendapat prosedur invasif, karena keduanya sebagai analgesik. rasa nyeri yang dirasakan neonatus ditunjukkan secara verbal melalui tangisan. oleh sebab itu untuk melihat nyeri neonatus dapat dinilai juga dari lama tangisan. tangisan yang panjang dapat diasumsikan bahwa respons nyerinya berat. simpulan dan saran simpulan rerata respons nyeri setelah diberikan sukrosa dan nns lebih rendah dibandingkan dengan kelompok kontrol. rata-rata lama tangisan setelah diberikan sukrosa dan nns lebih singkat dibandingkan kelompok kontrol. respons nyeri tidak berbeda secara bermakna antara kelompok sukrosa dan kelompok kontrol. respons nyeri antara kelompok sukrosa dan kelompok kontrol berbeda secara bermakna. respons nyeri antara kelompok sukrosa dan kelompok nns berbeda secara bermakna. lama tangisan responden antara kelompok sukrosa dan kelompok kontrol berbeda secara bermakna. lama tangisan responden antara kelompok nns dan kelompok kontrol berbeda secara bermakna. lama tangisan responden antara kelompok sukrosa dan kelompok nns tidak berbeda secara bermakna. umur responden sebagai variabel perancu memberikan pengaruh terhadap respons nyeri. umur, jenis kelamin dan pengalaman pungsi vena tidak memberikan pengaruh terhadap lama tangisan responden. saran hasil penelitian ini merekomendasikan untuk pemberian sukrosa maupun nns dalam manajemen nyeri nonfarmakologi pada neonatus yang dilakukan prosedur invasif karena terbukti dapat menurunkan respons nyeri dan lama tangisan. jurnal ners vol. 5 no. 2 oktober 2010: 127–132 132 kepustakaan american academy of pediatrics, 2006. prevention and management of pain in the neonate: up date. pediatrics 2006, 118, 2231–2241, (online),(http:// pediatrics.aappublications.org/cgi/ reprint/118/5/2231.pdf., diakses tanggal 27 maret 2009). bobak, i.m., lowdermilk, d.l., jensen, m.d., dan perry, s.e., 1999. maternity nursing. missouri: mosby. bowden, v.r., dickey, s.b., dan greenberg, c.s., 1998. children and their families: the continuum of care. pennsylvania: wb saunders company. carbajal, r., chauvet, x., couderc, s., d a n o l i v i e r m a r t i n , m . , 1 9 9 9 . randomisedtrial of analgesic effects of sucrose, glucose and pacifi ers in term neonates. bmj 1999, 319, 1393–1397, (online), (http://www.bmj.com/cgi/ content/full/319/7222/1393, diakses tanggal 12 mei 2010). codipietro, l., ceccareli, m., dan ponzone, a . , 2 0 0 8 . b r e a s t f e e d i n g o r o r a l sucrose solution in term neonates receiving heel lance: a randomized controlled trial. pediatrics 2008, 122, e716-e72,(online),(http://pediatrics. aappublications.org., diakses tanggal 5 februari 2010). devaera, y. , 2006. larutan glukosa oral sebagai analgesik pada prosedur pengambilan darah tumit bayi baru lahir: suatu uji klinis acak tersamar ganda. tesis tidak dipublikasikan. jakarta: fkui, (online), (http://www. lontar.ui.ac.id., diakses tanggal 6 juni 2010). gibbins, s., dan stevens, b., 2001. mechanisms of sucrose and non-nutritive sucking in procedural pain management in infants. pain res manage 2001, 6(1), (online), (http://www.pulsus.com diakses tanggal 18 januari 2010). gradin, m., eriksson, m., holmqvist, g., holstein, a., dan schollin, j., 2002. pain reduction at venipuncture n newborns: oral glucose compared with local anesthetic cream. pediatrics 2002, 110(1053), (online), (http://pediatrics. aappublications.org, diakses tanggal 5 februari 2010). hockenberry, m.j., dan wilson, d., 2009. essentials of pediatric nursing. (8th ed.). missouri: mosby. hockenberry, m.j., dan wilson, d., 2007. wong's nursing care of infants and children. (8th ed.). missouri: mosby. kashaninia, z., sajedi, f., rahgozar, m., dan noghabi, f.a., 2008. the effect of kangaroo care on behavioral responses to pain of an intramuscular injection in neonates. journal for specialists in pediatric nursing 2008, 13(4),(online), (http://proquest.umi.com., diakses tanggal 5 februari 2010). mathai, s., natrajan, n., dan rajalakshmi, n.r., 2006. a comparative study of non-pharmacological methods to reduce pain in neonates. indian pediatrics 2006, 43 (17), (online), (http://www. indianpediatrics.net., diakses tanggal 10 juni 2010). merenstein, g.b., dan gardner, s.l., 2002. handbook of neonatal intensive care. (5th ed.). missouri: mosby. potter, p.a., dan perry, a.g., 2005. fundamentals of nursing: concepts, process, and practice. missouri: mosby. santrock, j.w., 2001. child development. (9th ed.). new york: mcgraw-hill. suririnah, 2009. buku pintar merawat bayi 0–12 bulan. jakarta: gramedia pustaka utama. taddio, a., shah, v., dan katz, j., 2009. reduced infant response to a routine care procedure after sucrose analgesia. pediatrics 2009, 123 (3),(online),(http:// pediatrics.aappublications.org., diakses tanggal 18 januari 2010). taddio, a., ohlsson, a., einarson, t.r., stevens, b., dan koren, g., 1998. a systematic review of lidocaine-prilocaine cream (emla) in the treatment of acute pain in neonates. pediatrics 1998. 101. e1, (online), (http://pediatrics. aappublications.org., diakses tanggal 9 februari 2010). vol 6 no 1 april 2011_akreditasi 2013.indd 58 analisis faktor pemanfaatan vct pada orang risiko tinggi hiv/aids (analysis factor related to vct utilization for the high risk person of hiv/aids) purwaningsih*, misutarno**, siti nur imamah* * fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya e-mail: purwaningsih_ners@unair.ac.id ** rsu dr. soetomo surabaya abstract introduction: voluntary counseling and testing (vct) is an entry point for the provision of nursing, support and medication of people living with hiv/aids. vct is also a model for the dissemination of comprehensive information and support to change risk behavior and prevent hiv/aids infection. the purpose of this research was describe determinants of vct utilization for the high risk person of hiv/aids at puskesmas dupak based on health belief model. method: design used in this study was descriptive survey design. the population was high risk people of hiv/aids who utilize vct at puskesmas dupak surabaya in 2010. the variables were component of health belief model for the high risk people of hiv/aids who utilize vct. it consist of perceived susceptibility factor, perceived seriousness factor, perceived benefi t and barrier factor, self effi cacy, and cues to action factor. the samples were recruited with probability sampling consist of 23 respondents. data were collected by using structured questionnairs with multiple choice questions and were then analyzed using descriptive analysis. result: results showed that perceived suscebtibilty was in strong criteria (61%), perceived seriousness was in strong criteria (78%), perceived benefi t was in strong criteria (66%), perceived barrier was in enough criteria (65%), self effi cacy was in strong criteria (82%), and cues to action factor was in strong criteria (52%). discussion: component health belief model to vct utilization on high risk people of hiv/aids was in strong criteria. it is recommended to health worker at puskesmas dupak to give adequate information frequently to the high risk people of hiv/aids. keywords: vct utilization on high risk people, health belief model pendahuluan kasus human immunodefi ciency virus (hiv) dan acquired immune deficiency syndrome (aids) di indonesia sampai 30 maret 2011 telah mencapai 24.482 kasus dan sudah tersebar di 32 provinsi (direktorat jendral ppm dan pl departemen kesehatan republik indonesia, 2011). voluntary counseling and testing (vct) merupakan salah satu strategi kesehatan masyarakat yang dilakukan untuk menangani penyebaran hiv/aids (departemen kesehatan republik indonesia, 2006). vct perlu dilakukan karena merupakan pintu masuk untuk menuju ke seluruh layanan hiv/aids, dapat memberikan keuntungan bagi klien dengan hasil tes positif maupun negatif dengan fokus pemberian dukungan terapi anti retroviral (arv), dapat membantu mengurangi stigma di masyarakat, serta dapat memudahkan akses ke berbagai layanan kesehatan maupun layanan psikososial yang dibutuhkan klien (murtiastutik, 2008), akan tetapi pemanfaatan layanan vct oleh masyarakat, khususnya oleh populasi rawan masih rendah. hasil wawancara peneliti kepada 3 orang risiko tinggi pada 10 mei 2011, diketahui bahwa alasan mereka memanfaatkan vct di puskesmas dupak antara lain 67% mengatakan bahwa mereka berisiko tertular hiv/aids, 100% mengatakan adanya anjuran dari petugas kesehatan, serta 67% ingin mengetahui status hiv/aids mereka. health belief model (hbm) merupakan salah satu model yang digunakan untuk analisis faktor pemanfaatan vct (purwaningsih) 59 menjelaskan perubahan perilaku kesehatan. model ini menyebutkan bahwa perilaku kesehatan akan dipengaruhi oleh 6 faktor, meliputi persepsi kerentanan terhadap penyakit (perceived susceptibility), persepsi keseriusan terhadap ancaman kesehatan (perceived seriousness), persepsi manfaat dan hambatan terhadap perubahan perilaku kesehatan (perceived benefi t and barrier), self effi cacy, serta faktor pendorong (cues to action) (mabachi, 2008). komponen hbm terhadap pemanfaatan vct pada orang risiko tinggi hiv/aids di puskesmas dupak masih belum diketahui dengan jelas. data yang diperoleh dari laporan vct di puskesmas dupak selama tahun 2011, secara kumulatif terdapat 232 orang yang melakukan vct. komisi penanggulangan aids (kpa) dalam strategi dan rencana aksi nasional (sran) penanggulangan hiv/aids tahun 2010–2014 telah menetapkan 720 orang per tahun dalam setiap layanan vct berdasarkan ketersediaan tenaga, jumlah jam kerja dan efektivitas layanan yang akan dilakukan sehingga dalam 1 tahun hanya 32,2% orang risiko tinggi yang dapat memenuhi target kpa dalam memanfaatkan vct di puskesmas dupak. hasil wawancara peneliti dengan salah satu dokter di puskesmas dupak tanggal 10 mei 2011, diketahui bahwa wilayah kerja puskesmas dupak meliputi kelurahan dupak dan kelurahan morokrembangan dengan jumlah penduduk sekitar 79.000 jiwa termasuk di dalamnya sekitar 3.000 kepala keluarga urban, di wilayah tersebut diperkirakan terdapat 600 pekerja seks komersial (psk) yakni 250 psk di dupak dan 350 psk di tambak asri, serta diketahui sekitar 10% dari psk di wilayah tersebut telah hiv positif. hasil wawancara lanjutan yang dilakukan oleh peneliti dengan salah satu dokter di puskesmas dupak pada 11 mei 2011, diketahui bahwa sampai saat ini cakupan pemanfaatan vct di puskesmas dupak masih terbatas pada kelompok psk. dokter di puskesmas tersebut juga menyatakan sekitar 95% orang risiko tinggi lainnya di luar psk seperti pelanggan, pria risiko tinggi, serta pasangan orang risiko tinggi belum mau melakukan vct dengan berbagai alasan seperti takut dengan hasil tes yang positif, merasa tidak berisiko terhadap hiv/aids, tidak tahu dengan vct, serta perasaan takut distigma. apabila hal ini tidak segera ditindaklanjuti, dikhawatirkan akan terjadi penyebaran hiv/aids yang semakin tinggi. peningkatan prevalensi hiv/aids dikarenakan kurangnya kesadaran untuk memanfaatkan layanan vct serta kurangnya pemahaman tentang hiv/aids dan vct terutama bagi orang risiko tinggi. banyak faktor yang dapat memengaruhi orang risiko tinggi untuk memanfaatkan vct. abebe (2006), melaporkan bahwa responden (51,1%) yang memiliki persepsi kerentanan yang tinggi menyatakan niatnya untuk melakukan vct daripada mereka yang memiliki persepsi yang rendah (48,9%), responden (52,6%) dengan persepsi yang tinggi terhadap keparahan hiv/aids menyatakan niatnya untuk vct, responden yang memiliki persepsi hambatan yang tinggi menyatakan kurang kesediaannya untuk melakukan vct daripada mereka yang memiliki persepsi yang rendah, dan responden yang merasakan adanya manfaat dalam melakukan vct akan menyatakan kesediaannya untuk vct daripada mereka dengan persepsi yang rendah. hasil penelitian yang telah dilakukan oleh afridi et al. (2008), menyebutkan bahwa faktor-faktor yang memengaruhi aksesibilitas dan akseptabilitas vct pada kelompok risiko tinggi hiv antara lain 91% dari responden melaporkan bahwa mereka telah mendengar tentang hiv/aids (36% mendengar melalui media dan 33% dari teman), hampir 31% dari responden menyatakan bahwa mereka memiliki risiko tertular hiv, 46% responden mengetahui tempat di mana tes hiv (vct) dilakukan dan 85% responden mengatakan bahwa tempat itu adalah rumah sakit. apabila masalah ini tidak segera diatasi maka penyebaran hiv/ aids akan semakin meningkat. bila hal ini dibiarkan tanpa tindakan yang nyata baik dari pihak eksekutif, legislatif, yudikatif maupun masyarakat maka angka kasus hiv/aids akan semakin bertambah dan memperberat beban negara di kemudian hari. beberapa pendekatan teoritis yang digunakan dalam penelitian pencegahan hiv/ aids, antara lain: theory of reasoned action, jurnal ners vol. 6 no. 1 april 2011: 58–67 60 theory of planned behavior, information motivation behavior model, aids risk reduction model, dan health belief model. pada penelitian ini menggunakan pendekatan teori hbm. hbm merupakan teori yang digunakan sebagai upaya menjelaskan secara luas kegagalan partisipasi masyarakat dalam program pencegahan atau deteksi penyakit (maulana, 2009). hbm juga dapat digunakan untuk mengidentifi kasi beberapa faktor prioritas penting yang berdampak terhadap pengambilan keputusan secara rasional dalam situasi yang tidak menentu serta teori ini berpusat pada perilaku kesehatan individu (maulana, 2009). pendekatan teori hbm diharapkan dapat menjelaskan faktor-faktor yang memengaruhi pemanfaatan vct pada orang risiko tinggi hiv/ aids di puskesmas dupak sehingga dengan mengetahui faktor-faktor yang berhubungan dengan pemanfaatan vct, tenaga kesehatan dapat menentukan rencana dan strategi selanjutnya agar orang risiko tinggi yang memanfaatkan vct meningkat. permasalahan dalam penelitian ini adalah hbm terhadap pemanfaatan vct pada orang risiko tinggi hiv/aids di puskesmas dupak masih belum dapat dijelaskan. bahan dan metode penelitian ini menggunakan desain penelitian deskriptif survei. populasi target dalam penelitian ini adalah orang risiko tinggi hiv/aids yang telah memanfaatkan vct di puskesmas dupak selama tahun 2010 sebesar 232 orang. sedangkan populasi terjangkau dalam penelitian ini adalah orang risiko tinggi hiv/aids yang berada di wilayah yang paling banyak melakukan vct di puskesmas dupak selama tahun 2010, yaitu di kelurahan dupak sebesar 169 orang. besar sampel yang digunakan dalam penelitian ini adalah orang risiko tinggi yang telah memanfaatkan vct di puskesmas dupak selama tahun 2010 sebesar 23 orang. peneliti menggunakan teknik probability sampling. metode pemilihan sampel yang digunakan peneliti adalah metode undian. variabel dalam penelitian ini adalah variabel bebas (independent). variabel bebas yang digunakan adalah komponen health belief model terhadap pemanfaatan vct pada orang risiko tinggi yang meliputi: faktor kerentanan (perceived susceptibility) yang dirasakan, faktor keseriusan (perceived seriousness) yang dirasakan, faktor manfaat dan rintangan (perceived benefi t and barrier) yang dirasakan, faktor pendorong (cues to action), serta self effi cacy orang risiko tinggi yang memanfaatkan vct di puskesmas dupak. hal ini ditentukan oleh peneliti karena dalam penelitian ini hanya satu faktor tersebut yang akan dianalisis yang berkaitan dengan tujuan penelitian. hasil penelitian ini menunjukkan hasil bahwa dari segi tingkat kerentanan (perceived susceptibility) yang dirasakan sebagian besar responden dengan tingkat kerentanan kuat yakni sebesar 14 responden (61%). identifi kasi k e s e r i u s a n y a n g d i r a s a k a n ( p e rc e i v e d seriousness). mayoritas adalah responden dengan tingkat keseriusan kuat yakni sebesar 18 responden (78%). distribusi responden berdasarkan tingkat manfaat yang dirasakan (perceived benefi t), sebagian besar adalah responden yang merasakan tingkat manfaat kuat yakni sebesar 15 responden (66%). identifi kasi hambatan yang dirasakan (perceived barrier) mayoritas responden merasakan tingkat hambatan yang cukup yakni sebanyak 15 responden (65%). segi tingkat self effi cacy distribusi responden adalah sebagian besar responden dengan tingkat self effi cacy kuat yakni sebesar 19 responden (82%). distribusi responden berdasarkan adanya pemotivasi vct adalah 20 responden (87%) menyatakan memiliki pemotivasi vct. distribusi responden berdasarkan sumber motivasi vct yakni sebanyak 19 responden (95%) dari 20 responden menyatakan sumber motivasi vct diperoleh dari petugas kesehatan. distribusi responden berdasarkan pengalaman mendapat informasi vct yakni sebanyak 13 responden (57%) dari total keseluruhan responden menyatakan pernah mendapat informasi tentang vct sebelumnya. distribusi responden berdasarkan sumber analisis faktor pemanfaatan vct (purwaningsih) 61 informasi vct, sebanyak 13 responden (100%) dari total keseluruhan responden yang pernah mendapat informasi tentang vct sebelumnya menyatakan mendapat informasi vct dari petugas kesehatan. segi tingkat faktor pendorong sebagian besar responden merasakan memiliki faktor pendorong kuat yakni sebesar 12 responden (52%). pembahasan hasil penelitian, diketahui bahwa orang risiko tinggi yang memanfaatkan vct di puskesmas dupak merasakan kerentanan yang kuat terhadap hiv/aids yakni sebesar 61%. orang risiko tinggi lainnya yakni sebesar 39% menyatakan merasakan kerentanan yang cukup. notoatmodjo (2003), menyatakan agar seseorang bertindak untuk mengobati atau mencegah penyakitnya maka ia harus merasakan bahwa ia rentan (susceptible) terhadap penyakit tersebut. bock (2009), juga melaporkan bahwa pemanfaatan vct salah satunya dipengaruhi oleh persepsi terhadap risiko yakni individu yang memiliki persepsi bahwa dirinya berisiko terhadap hiv/aids akan mempertimbangkan untuk melakukan vct. terdapat kesesuaian antara teori dengan fakta di lapangan yakni pemanfaatan vct di puskesmas dupak oleh orang risiko tinggi salah satunya dapat dipengaruhi oleh faktor kerentanan. menurut hasil penelitian, diketahui bahwa mayoritas responden merasakan kerentanan yang kuat terhadap hiv/aids sehingga mereka memutuskan untuk memanfaatkan vct di puskesmas dupak. perilaku pencegahan terhadap hiv/ aids akan timbul jika seseorang merasa bahwa dirinya berisiko untuk terkena penyakit tersebut. kerentanan merupakan kondisi yang subjektif sehingga penerimaan individu, khususnya orang risiko tinggi terhadap kerentanan untuk terinfeksi hiv/aids dapat bervariasi. seseorang kemungkinan dapat dinyatakan memiliki kerentanan yang sangat kuat terhadap hiv/aids apabila ia memiliki keyakinan bahwa dirinya berisiko menderita hiv/aids, memiliki teman atau pasangan yang terinfeksi hiv/aids, atau memiliki riwayat perilaku yang berisiko untuk tertular hiv/aids. seseorang sebaliknya kemungkinan dapat dinyatakan memiliki kerentanan yang sangat lemah terhadap hiv/aids apabila ia tidak memiliki keyakinan bahwa dirinya berisiko menderita hiv/aids, tidak memiliki teman atau pasangan yang terinfeksi, serta tidak memiliki riwayat perilaku yang berisiko. orang risiko tinggi yang memiliki kerentanan yang sangat kuat untuk terkena hiv/aids kemungkinan akan terdorong untuk memanfaatkan vct di puskesmas dupak. mayoritas responden memiliki riwayat pekerjaan sebagai psk. sebagian besar responden yang memiliki riwayat pekerjaan sebagai psk yakni 10 responden (56%) menyatakan bahwa mereka tahu perilakunya sangat berisiko untuk terinfeksi hiv sedangkan mayoritas responden non-psk yakni sebanyak 5 orang (62,5%) menyatakan bahwa mereka tidak tahu apakah perilakunya dapat berisiko untuk terinfeksi hiv/aids. hal tersebut menunjukkan bahwa kelompok dari psk lebih merasakan kerentanan terhadap hiv/ a i d s d i b a n d i n g k a n d e n g a n k e l o m p o k non-psk atau masyarakat umum. maulana (2009), menyatakan bahwa variabel struktural yang salah satu di antaranya merupakan pengalaman yang dimiliki individu, termasuk pengalaman pekerjaan (riwayat pekerjaan) dapat memengaruhi persepsi individu terhadap kesehatannya. dengan demikian, kerentanan terhadap hiv/aids yang dirasakan orang risiko tinggi yang memanfaatkan vct di puskesmas dupak dapat dipengaruhi oleh riwayat pekerjaan yang dimiliki. individu yang memiliki riwayat pekerjaan yang jelas berisiko terinfeksi hiv/aids mungkin akan lebih mudah memotivasi dirinya untuk memanfaatkan vct di puskesmas dupak karena ia menyadari bahaya yang akan dialami sedangkan individu yang beranggapan bahwa dirinya tidak berisiko, kemungkinan tidak akan melakukan vct di puskesmas dupak. hal ini secara tidak langsung dapat memperluas penularan hiv/aids karena individu yang menganggap bahwa dirinya tidak memiliki pekerjaan yang berisiko cenderung untuk tidak melakukan vct. adanya anggapan tersebut dapat menyebabkan individu tidak menyadari jurnal ners vol. 6 no. 1 april 2011: 58–67 62 bahwa dirinya telah tertular atau dapat menulari hiv/aids. s t a t u s p e r n i k a h a n j u g a d a p a t memengaruhi persepsi seseorang terhadap kondisi rentan yang dialami. bock (2009), menyatakan rendahnya pemanfaatan vct di malawi pada umumnya terjadi di kalangan individu yang telah menikah. seseorang yang telah menikah dan telah hidup lama bersama pasangannya, akan berpikir dirinya tidak memiliki risiko terinfeksi hiv karena ia percaya terhadap pasangannya sehingga individu tersebut tidak akan memiliki inisiatif untuk melakukan vct. teori tersebut sesuai dengan fakta dari hasil penelitian yang menunjukkan bahwa sebagian besar responden dalam penelitian ini berstatus janda/duda. dengan demikian, status pernikahan orang risiko tinggi dapat memengaruhi perilaku pemanfaatan vct di puskesmas dupak. orang risiko tinggi yang berstatus janda/duda kemungkinan akan lebih terdorong untuk memanfaatkan vct di puskesmas dupak dibandingkan dengan orang risiko tinggi yang telah memiliki pasangan atau telah menikah. hasil penelitian, diketahui bahwa orang risiko tinggi yang memanfaatkan vct di puskesmas dupak merasakan keseriusan yang kuat terhadap hiv/aids yakni sebesar 78%. orang risiko tinggi lainnya yakni sebesar 13% menyatakan merasakan keseriusan yang sangat kuat. hasil penelitian juga menunjukkan bahwa 9% orang risiko tinggi merasakan keseriusan yang cukup, serta tidak ada orang risiko tinggi yang merasakan keseriusan yang lemah atau pun sangat lemah terhadap hiv/aids. tindakan individu untuk mencari pengobatan dan pencegahan penyakit akan didorong oleh keseriusan penyakit terhadap individu atau masyarakat (notoatmodjo, 2003). hal tersebut memperlihatkan bahwa terdapat kesesuaian antara teori dan fakta di lapangan yakni tindakan pencegahan terhadap penyakit tertentu, salah satunya dipengaruhi oleh adanya persepsi terhadap keseriusan suatu penyakit sehingga dalam hal ini pemanfaatan vct oleh orang risiko tinggi di puskesmas dupak salah satunya dipengaruhi oleh persepsi keseriusan orang risiko tinggi terhadap hiv/aids. persepsi keseriusan yang dirasakan terhadap hiv/aids kemungkinan juga berbeda-beda pada setiap orang risiko tinggi. hal itu karena tiap orang risiko tinggi memiliki pandangan yang subjektif terhadap keseriusan hiv/aids. salah satu variabel yang mungkin dapat memengaruhi orang risiko tinggi dalam merasakan keseriusan hiv/aids sehingga mendorong dirinya untuk memanfaatkan vct di puskesmas dupak adalah tingkat pendidikan orang risiko tinggi. faktor pengubah seperti tingkat pendidikan dipercayai mempunyai pengaruh tidak langsung terhadap perilaku dengan cara memengaruhi persepsi individu seperti persepsi terhadap keseriusan. individu dengan pendidikan tinggi, cenderung memiliki perhatian yang besar terhadap kesehatannya sehingga jika individu tersebut mengalami gangguan kesehatan maka ia akan segera mencari pelayanan kesehatan. semakin tinggi tingkat pendidikan orang risiko tinggi maka semakin besar keseriusan yang dirasakan terhadap hiv/aids sehingga dengan persepsi keseriusan yang dimiliki akan mendorong orang risiko tinggi tersebut untuk memanfaatkan vct di puskesmas dupak. sebagian besar responden dalam penelitian ini telah berpendidikan walaupun masih tergolong mempunyai tingkat pendidikan yang rendah yaitu sd/mi/sederajat. pada penelitian ini, tingkat pendidikan tidak terlalu memengaruhi tingkat keseriusan yang dirasakan responden karena sebagian besar responden merasakan keseriusan yang kuat. hal tersebut berarti bahwa selain pendidikan kemungkinan terdapat faktor lain yang dapat mempengaruhi persepsi responden terhadap keseriusannya. faktor lingkungan mungkin dapat menjadi salah satu faktor pendorong yang membuat responden merasakan keseriusan yang kuat terhadap hiv/aids sehingga dapat memotivasi dirinya untuk memanfaatkan vct di puskesmas dupak. kondisi lingkungan merupakan salah satu faktor yang dapat memengaruhi perilaku manusia secara langsung. lingkungan responden merupakan salah satu kawasan lokalisasi sehingga sangat rawan untuk terinfeksi hiv/aids. lingkungan responden yang demikian menuntut responden harus lebih memiliki perhatian yang besar analisis faktor pemanfaatan vct (purwaningsih) 63 terhadap keseriusan yang ditimbulkan oleh suatu penyakit tertentu, terutama keseriusan terhadap hiv/aids. pengetahuan atau kognitif merupakan domain yang sangat penting untuk terbentuknya tindakan seseorang (notoatmodjo, 2003). berdasarkan pengalaman dan penelitian, diperoleh bahwa perilaku yang didasari oleh pengetahuan lebih langgeng daripada perilaku yang tidak didasari pengetahuan (maulana, 2009). pengetahuan responden tentang transmisi hiv/aids dalam penelitian ini tergolong sedang sedangkan responden memiliki keseriusan yang kuat. faktor pengetahuan mempengaruhi keseriusan yang dirasakan orang risiko tinggi terhadap hiv/aids. orang risiko tinggi yang memiliki pengetahuan tinggi tentang hiv/aids akan merasakan keseriusan yang sangat kuat terhadap hiv/aids sehingga dengan keseriusan yang dirasakannya, orang risiko tinggi tersebut akan terdorong untuk melakukan vct di puskesmas dupak. menurut hasil penelitian, diketahui bahwa orang risiko tinggi yang memanfaatkan vct di puskesmas dupak merasakan manfaat yang kuat terhadap vct yakni sebesar 66%. orang risiko tinggi lainnya yakni sebesar 30% menyatakan merasakan manfaat yang cukup. hasil penelitian juga menunjukkan bahwa 4% orang risiko tinggi merasakan manfaat yang sangat kuat, serta tidak ada orang risiko tinggi yang merasakan manfaat yang lemah atau pun sangat lemah terhadap vct di puskesmas dupak. menurut rosenstock (2005), suatu tindakan akan dipengaruhi oleh keyakinan tentang efektivitas relatif dari alternatif yang tersedia yang dikenal dapat mengurangi ancaman penyakit yang dirasakan individu. perilaku kesehatan dalam hal ini pemanfaatan vct di puskesmas dupak, mungkin tergantung pada bagaimana orang risiko tinggi berpikir tentang manfaat yang akan ia peroleh untuk mengatasi masalah kesehatannya, terutama masalah yang berkaitan dengan hiv/aids sehingga dapat disimpulkan bahwa individu mungkin lebih mengutamakan keyakinan terhadap efektivitas suatu tindakan dan bukan melihat secara objektif terhadap efektivitas suatu tindakan yang diambil. keyakinan sering disebut sebagai faktor yang berkaitan dengan motivasi seseorang untuk melakukan suatu tindakan. keyakinan orang risiko tinggi tentang adanya manfaat melakukan vct di puskesmas dupak termasuk dalam kategori kuat. orang risiko tinggi telah mempercayai bahwa kesehatan dirinya mungkin terancam dalam beberapa tahun mendatang jika tidak melakukan vct. mereka juga telah mempercayai keseriusan kondisi yang terjadi bila terinfeksi hiv/aids. orang risiko tinggi yang memiliki keyakinan yang kuat tentang manfaat vct akan terdorong untuk melakukan vct di puskesmas dupak sedangkan orang risiko tinggi yang tidak percaya tentang manfaat vct mungkin cenderung untuk tidak melakukan vct di puskesmas dupak. kesadaran akan perlunya melakukan vct sudah dimiliki orang risiko tinggi yang memanfaatkan vct di puskesmas dupak. hasil penelitian juga menunjukkan terdapat beberapa responden yang masih belum memahami manfaat melakukan vct di puskesmas dupak. sepuluh responden (43%) menyatakan vct tidak akan membantu karena mereka dapat menjaga dirinya sendiri dan mereka memiliki keyakinan bahwa tidak ada alasan untuk mengetahui status hiv karena pada akhirnya tidak ada obat yang bisa menyembuhkan hiv/aids. delapan orang responden juga menyatakan vct tidak akan mengubah perilaku seksual seseorang. hal tersebut kemungkinan dapat terjadi karena kurangnya penyebarluasan informasi dan pemberian edukasi kepada orang risiko tinggi. mobilitas orang risiko tinggi seperti wps, cukup tinggi dengan berpindah-pindah lokalisasi sehingga dapat menyebabkan mereka kurang mendapatkan informasi yang benar tentang hiv/aids karena mereka mendapat informasi yang belum lengkap sehingga memungkinkan terbentuknya keyakinan yang salah. teman atau sesama orang risiko tinggi, dapat memberikan pengaruh yang cukup besar bagi individu. hal ini kemungkinan juga dapat memengaruhi terbentuknya keyakinan yang salah pada orang risiko tinggi karena individu yang mempunyai persepsi yang salah tentang vct akan meniru perilaku yang kurang baik dari individu lainnya. jurnal ners vol. 6 no. 1 april 2011: 58–67 64 orang risiko tinggi yang memanfaatkan vct di puskesmas dupak merasakan hambatan yang cukup dalam melakukan vct yakni sebesar 65%. orang risiko tinggi lainnya yakni sebesar 22% menyatakan merasakan hambatan yang kuat dalam melakukan vct di puskesmas dupak. hasil penelitian juga menunjukkan bahwa 13% orang risiko tinggi merasakan hambatan yang lemah, serta tidak ada orang risiko tinggi yang merasakan hambatan yang sangat kuat atau pun sangat lemah dalam memanfaatkan vct di puskesmas dupak. satu alasan utama individu tidak mengubah perilaku kesehatan mereka karena mereka berpikir melakukan hal tersebut akan menimbulkan kesulitan, baik kesulitan secara psikologis atau fi sik maupun sosial. menurut notoatmodjo (2003), individu akan melakukan suatu tindakan tertentu apabila merasa dirinya rentan untuk penyakit-penyakit yang dianggap serius. tindakan ini tergantung pada manfaat yang dirasakan dan rintangan-rintangan yang ditemukan dalam mengambil tindakan tertentu. pada umumnya, manfaat tindakan lebih menentukan daripada rintangan-rintangan yang mungkin ditemukan dalam mengambil suatu tindakan. individu mungkin merasakan manfaat terhadap suatu perilaku tertentu tetapi pada saat yang sama mereka juga mungkin merasakan hambatan untuk melakukan perilaku tersebut. faktor hambatan yang dirasakan dapat memengaruhi orang risiko tinggi untuk memanfaatkan vct di puskesmas dupak akan tetapi faktor hambatan yang dirasakan kemungkinan tidak terlalu besar pengaruhnya terhadap pemanfaatan vct di puskesmas dupak. hal tersebut kemungkinan disebabkan oleh adanya persepsi orang risiko tinggi terhadap adanya manfaat melakukan vct lebih besar dibandingkan dengan persepsi terhadap hambatan. penelitian ini diketahui bahwa jarak dan biaya bukan merupakan hambatan yang besar bagi orang risiko tinggi dalam memanfaatkan vct di puskesmas dupak. hal ini karena hanya sebagian kecil responden yang menyatakan bahwa tempat melakukan vct jauh, yakni 1 responden sedangkan yang menyatakan vct memerlukan biaya yang mahal hanya 7 responden. mayoritas responden (19 responden) juga menyatakan bahwa mereka percaya bahwa petugas kesehatan atau konselor akan menjaga kerahasiaan hasil tes mereka sehingga hal ini bukan menjadi penghambat orang risiko tinggi untuk memanfaatkan vct di puskesmas dupak. sebelas responden menyatakan ketakutannya untuk melakukan vct karena takut dengan hasil tes yang positif. bock (2009), melaporkan bahwa salah satu yang dapat memengaruhi pemanfaatan vct adalah ketakutan mereka terhadap kemungkinan hasil tes yang positif. pernyataan di atas menunjukkan ketakutan terhadap hasil tes yang positif kemungkinan merupakan salah satu faktor yang dapat menghambat pemanfaatan vct di puskesmas dupak. ketakutan tersebut kemungkinan merupakan ketakutan terhadap kematian, takut atas nasib mereka sendiri atau takut karena harus menghadapi masalah yang lebih rumit di kemudian hari karena mendapat hasil tes yang positif. ketakutan tersebut kemungkinan juga dapat diperburuk dengan adanya stigma atau diskriminasi yang akan diterima dari masyarakat atau pun keluarga. lima responden menyatakan bahwa ia tidak merasa berisiko terhadap hiv/aids sehingga tidak punya alasan untuk melakukan vct. adanya persepsi tidak memiliki risiko terhadap hiv/aids dapat menjadi salah satu penghambat dalam pemanfaatan vct di puskesmas dupak. hal tersebut sesuai dengan hasil penelitian yang dilakukan oleh usaid di guangxi, cina (2009) yakni salah satu hambatan dalam pemanfaatan vct adalah adanya persepsi tidak memiliki risiko tinggi terhadap hiv/aids. anggapan tersebut kemungkinan dapat dipengaruhi oleh kurangnya pengetahuan tentang cara transmisi hiv/aids. berdasarkan hasil penelitian, diketahui bahwa 9 responden menyatakan tidak setuju dan 1 orang responden menyatakan sangat tidak setuju jika berhubungan seks tanpa menggunakan kondom merupakan salah satu cara transmisi hiv/aids. lima belas responden juga menyatakan tidak setuju jika berbagi jarum suntik dengan orang lain juga dapat menyebabkan terinfeksi hiv/aids. hal tersebut menunjukkan bahwa pengetahuan secara tidak langsung dapat memengaruhi analisis faktor pemanfaatan vct (purwaningsih) 65 persepsi seseorang. orang risiko tinggi yang memiliki pengetahuan yang tinggi tentang cara transmisi hiv/aids akan menyadari bahwa suatu perilaku tertentu dapat menyebabkan ia kemungkinan berisiko untuk terkena hiv/ aids sehingga dirinya akan berinisiatif untuk memanfaatkan vct di puskesmas dupak. hambatan lain yang dirasakan oleh orang risiko tinggi yang memanfaatkan vct di puskesmas dupak adalah 16 responden menyatakan untuk mengetahui hasil tes maka mereka harus kembali lagi di lain waktu. lama waktu tunggu akan memengaruhi motivasi wps untuk mau datang ke klinik vct untuk waktu yang selanjutnya (widiyanto, 2008). waktu yang lama untuk mengetahui hasil tes kemungkinan dapat menyebabkan orang risiko tinggi menjadi kurang termotivasi untuk melakukan vct. orang risiko tinggi yang pada awalnya memiliki motivasi yang besar untuk melakukan vct di puskesmas dupak kemungkinan akan berubah pikiran jika mengetahui bahwa tindakan yang akan dilakukan dapat menyita waktu. hasil penelitian menunjukkan bahwa orang risiko tinggi yang memanfaatkan vct di puskesmas dupak memiliki self effi cacy yang kuat untuk melakukan vct yakni sebesar 82%. orang risiko tinggi lainnya yakni sebesar 9% memiliki self effi cacy sangat kuat dan 9% lainnya memiliki self effi cacy cukup. hasil penelitian juga menunjukkan bahwa tidak ada orang risiko tinggi yang memiliki self effi cacy lemah atau pun sangat lemah dalam memanfaatkan vct di puskesmas dupak. dengan demikian, diketahui bahwa orang risiko tinggi yang memanfaatkan vct di puskesmas dupak, mayoritas memiliki tingkat self effi cacy yang kuat. hal ini dapat ditunjukkan dengan beberapa pernyataan responden yakni 21 responden menyatakan akan berencana untuk melakukan vct lagi suatu saat nanti, 18 responden menyatakan dirinya berencana untuk meminta pasangan seksnya melakukan vct, serta 18 responden juga menyatakan bahwa melakukan vct merupakan keputusan pribadinya. self effi cacy adalah kepercayaan diri individu dan menjelaskan bagaimana pandangan individu terhadap kemampuannya untuk melakukan tindakan tertentu atau kepercayaan mereka sendiri dalam kemampuan mereka untuk mengambil tindakan. seseorang yang memiliki self effi cacy yang kuat kemungkinan akan mampu untuk mengambil tindakan tertentu sedangkan seseorang dengan self efficacy yang rendah kemungkinan akan mengalami hambatan untuk mengambil tindakan tertentu. self effi cacy orang risiko tinggi dapat mempengaruhi pemanfaatan vct di puskesmas dupak. orang risiko tinggi yang memiliki self effi cacy yang sangat kuat akan lebih mudah untuk memanfaatkan vct di puskesmas dupak daripada orang risiko tinggi dengan self effi cacy yang sangat lemah. self effi cacy orang risiko tinggi untuk memanfaatkan vct di puskesmas dupak, salah satunya mungkin dapat dipengaruhi oleh berapa kali ia telah melakukan vct. pada penelitian ini, diketahui sebagian besar responden telah melakukan vct lebih dari dua kali. semakin banyak pengalaman orang risiko tinggi dalam melakukan vct maka kemungkinan kepercayaan diri yang dimiliki untuk melakukan vct lagi semakin besar. hasil penelitian, diketahui orang risiko tinggi yang memanfaatkan vct di puskesmas dupak sebesar 52% menyatakan merasakan adanya faktor pendorong yang kuat. faktor pendorong yang cukup dirasakan oleh orang risiko tinggi sebesar 48%. hasil penelitian juga menunjukkan bahwa tidak ada orang risiko tinggi yang merasakan adanya faktor pendorong yang sangat kuat, lemah, atau pun sangat lemah untuk memanfaatkan vct di puskesmas dupak. hasil tersebut menunjukkan orang risiko tinggi yang memanfaatkan vct di puskesmas dupak mayoritas merasakan faktor pendorong yang kuat. mayoritas responden menyatakan mendapat dukungan dari temanteman dan keluarga untuk melakukan vct. sebagian besar responden (18 responden) juga menyatakan mereka melakukan vct atas anjuran dari petugas kesehatan/dokter. notoatmodjo (2003), menyatakan bahwa untuk mendapatkan tingkat penerimaan yang benar tentang kerentanan, kegawatan, dan keuntungan tindakan maka diperlukan isyaratisyarat yang berupa faktor-faktor eksternal. jurnal ners vol. 6 no. 1 april 2011: 58–67 66 faktor-faktor tersebut misalnya pesan-pesan dari media massa, nasihat atau anjuran kawankawan atau anggota keluarga lain dari si sakit. dorongan yang muncul secara terus-menerus dari orang-orang yang terkait kemungkinan akan mempunyai pengaruh yang besar terhadap pemanfaatan vct di puskesmas dupak yang dilakukan oleh orang risiko tinggi. beberapa di antaranya kemungkinan mempunyai pengaruh yang lebih besar dibanding dengan dorongan dari pihak lain, seperti dorongan dari teman, keluarga, dan dari petugas kesehatan. faktor pendorong yang dirasakan orang risiko tinggi yang memanfaatkan vct di puskesmas dupak belum mencapai maksimal, dalam hal ini mencapai kategori yang sangat kuat. hal ini kemungkinan dapat dipengaruhi oleh beberapa faktor, salah satunya adalah terdapat beberapa responden yang kurang mendapat dukungan dari teman dan keluarga. sembilan responden menyatakan dirinya tidak mendapat dukungan dari teman-temannya untuk melakukan vct dan 8 responden menyatakan tidak mendapatkan dukungan dari keluarga. gambar 5.16 memperlihatkan bahwa selama ini responden mendapat informasi vct dari petugas kesehatan. seluruh responden menyatakan belum pernah mendapat informasi vct dari media massa seperti majalah, radio, televisi atau koran. hambatan dalam pemanfaatan vct, salah satu di antaranya disebabkan oleh kurangnya publikasi tentang vct di masyarakat. fakta di atas menunjukkan bahwa faktor pendorong lain terhadap responden yang melakukan vct di puskesmas dupak dari selain petugas kesehatan masih lemah. padahal indikator dalam penelitian ini yang dapat menjadi faktor pendorong responden dalam melakukan vct di antaranya adalah informasi dari media massa (seperti radio, majalah, televisi), nasihat dari teman atau anggota keluarga, serta petugas kesehatan. orang risiko tinggi yang memiliki faktor pendorong yang sangat kuat mungkin akan lebih mudah bagi dirinya untuk melakukan vct di puskesmas dupak daripada orang risiko tinggi yang tidak memiliki faktor pendorong. semakin banyak motivasi dan informasi yang didapatkan oleh orang risiko tinggi tentang vct kemungkinan akan membuat orang risiko tinggi tersebut semakin terdorong untuk melakukan vct di puskesmas dupak. simpulan dan saran simpulan kerentanan untuk terinfeksi hiv/aids pada orang risiko tinggi yang memanfaatkan vct di puskesmas dupak dalam kategori kuat, keseriusan yang dirasakan (perceived seriousness) orang risiko tinggi terhadap hiv/ aids sudah kuat, persepsi terhadap manfaat vct yang dirasakan (perceived benefi t) orang risiko tinggi sudah kuat, tetapi masih terdapat beberapa orang risiko tinggi yang memiliki keyakinan yang salah tentang manfaat vct, orang risiko tinggi yang memanfaatkan vct di puskesmas dupak mengalami hambatan yang cukup, self effi cacy orang risiko tinggi yang memanfaatkan vct di puskesmas dupak sudah kuat, faktor pendorong bagi orang risiko tinggi yang memanfaatkan vct di puskesmas dupak sudah kuat. saran petugas kesehatan di puskemas dupak dalam upaya meningkatkan pemanfaatan vct dapat dengan cara memberikan penyuluhan kepada masyarakat, khususnya orang risiko tinggi tentang hiv/aids dan vct yang dapat dilakukan 1 bulan sekali di puskesmas dupak dengan sasaran pesertanya adalah pasien yang memeriksakan dirinya ke puskesmas dupak atau keluarga yang mengantar pasien saat itu atau dapat melalui pemberian media informasi seperti poster atau leafl et, pengetahuan orang risiko tinggi tentang hiv/aids dan vct masih rendah maka diharapkan orang risiko tinggi dapat secara aktif mencari informasi tentang hiv/aids dan vct. salah satunya dengan cara konsultasi langsung mengenai hiv/aids dan vct dengan petugas kesehatan yang ada di puskesmas dupak, perawat komunitas atau perawat bidang hiv/aids diharapkan dapat ikut serta dalam upaya meningkatkan pemanfaatan vct pada orang risiko tinggi dengan cara membantu petugas kesehatan di puskesmas dupak dalam memberikan penyuluhan tentang hiv/aids dan vct atau dengan melalui penyebaran informasi analisis faktor pemanfaatan vct (purwaningsih) 67 melalui poster atau leafl et, dan bagi peneliti selanjutnya diharapkan dapat meneliti lebih lanjut tentang faktor-faktor yang berhubungan dengan pemanfaatan vct pada orang risiko tinggi dengan menggunakan sampel yang lebih besar dan menggunakan instrument yang telah divalidasi sebelumnya agar dapat menganalisis lebih mendalam terhadap pemanfaatan vct. kepustakaan abebe, 2006. perception of high school s t u d e n t s t o w a rd s vo l u n t a r y h i v counseling and testing, using health belief model in butajira, snnpr. thesis, master of public health, addis ababa university. hal. 28–30, 44–56. bock, 2009. factors infl uencing the uptake of hiv voluntary counseling and testing in namibia. thesis. vrije university amsterdam. netherlands, hlm. 12–29. departemen kesehatan republik indonesia, 2006. pedoman pelayanan konseling dan testing hiv/aids secara sukarela (voluntary counselling and testing). jakarta, hlm. 6–7. departemen kesehatan republik indonesia, 2006. situasi hiv/aids di indonesia tahun 1987–2006. jakarta, hlm. 1, 3–4. komisi penanggulangan aids nasional, 2003. strategi nasional penanggulangan hiv/ aids 2003–2007. jakarta, hlm. 10. komisi penanggulangan aids nasional, 2009. strategi dan rencana aksi nasional penanggulangan hiv dan aids 2010– 2014. jakarta, hlm. 41. maulana, 2009. promosi kesehatan. jakarta: penerbit buku kedokteran egc, hlm. 52–57. murtiastutik, 2008. buku ajar infeksi menular seksual. surabaya: airlangga university press, hlm. 269–279. notoatmodjo, soekidjo, 2003. pendidikan dan perilaku kesehatan. jakarta: pt rineka cipta, hlm. 204–205. rosenstock, 2005. why people use health services. the milbank quartely, vol. 83, no. 4, hlm. 6–9. vol 9 no 1 april 2014.indd 126 keperawatan spiritualitas pada pasien skizofrenia (spirituality nursing among patients with schizophrenia) sri padma sari*, diyan yuli wijayanti* * program studi ilmu keperawatan, fakultas kedokteran universitas diponegoro e-mail: ners_45@yahoo.com abstrak pendahuluan: spiritual memiliki manfaat bagi kesembuhan dan kualitas hidup bagi pasien gangguan jiwa termasuk pasien skizofrenia. spiritual juga dapat menjadi strategi koping bagi pasien skizofrenia. penelitian ini bertujuan untuk mengeksplorasi pentingnya spiritualitas pada pasien skizofrenia. metode: design penelitian ini menggunakan pendekatan deskriptif fenomenologi. partisipan dalam penelitian ini adalah 9 partisipan, 7 partisipan adalah partisipan yang didiagnosa dengan skizofrenia dan 2 partisipan adalah pengasuh para rehabilitan. data dianalisa dengan analisis deskriptif dan melalui proses interpretasi fenomenologi hermeneutic. hasil: dua tema dihasilkan dari penelitian ini yaitu: 1) pengertian spiritual yaitu dekat dengan allah dan aktifi tas ibadah yang bertambah rutin, dan 2) manfaat dari spiritual yaitu kesembuhan dari penyakit jiwa, manajemen symptoms, perubahan perilaku, perubahan emosi dan perhatian pada masa depan. diskusi: spiritual memiliki peran yang penting bagi pasien skizofrenia termasuk dalam membantu kesembuhan dan peningkatan harapan. hasil penelitian ini diharapkan dapat memberikan gambaran tentang kebutuhan spiritual pada pasien skizofrenia sehingga perawat dapat menggunakan agama dan atau kegiatan spiritual dalam intervensi keperawatan. kata kunci: skizofrenia, spiritual, kesembuhan abstract introduction: spirituality has been reported to have benefi ts for recovery and quality of life for people with mental disorders including patients with schizophrenia. spiritual can also be a coping strategy for patients with schizophrenia. this study aims to explore the importance of spirituality among patients with schizophrenia. method: this study uses descriptive phenomenological approach. there are 9 participants in this study, 7 participants are patients who diagnosed of schizophrenia and 2 participants are the caregivers. the data were analyzed by phenomenological hermeneutic approach. results: two main themes emerge from this study are 1) the meaning of spirituality is closed with allah and the improvement of the spiritual practice and 2) the benefi ts of spirituality is recovery from the illness, symptoms management, behavioral change, emotional change and hope. discussion: spirituality has an important role for patients with schizophrenia including helping the recovery process and hope. the results of this study are expected to give an overview of the spiritual need among patients with schizophrenia so that the nurses can give religion and or spiritual activity in the nursing intervension. key words: schizophrenia, spirituality, recovery pendahuluan sk i zof ren ia dialam i oleh ba nya k orang di dunia. ada sekitar 24 juta orang yang menderita skizofrenia di seluruh dunia (world health organization [who], 2011). di indonesia sendiri, ada sekitar 1-2 % pasien skizofrenia berdasarkan badan pusat statistik pada tahun 2010 (sidakaton, 2011). skizofrenia adalah penyakit kronis berupa gangguan mental yang serius yang ditandai dengan gangguan dalam proses pemikiran yang mempengar uhi perilaku (thorson, matson, rojahn, dan dixon, 2008). berdasarkan penelitian yang dilakukan oleh domininguez et al. (2009), pasien skizofrenia mengalami gejala positif dan gejala negatif. gejala positif meliputi halusinasi, delusi, dan bicara dan perilaku yang tidak teratur. mereka juga mengalami gejala negatif, misalnya, afek datar, apatis dan penarikan social. kondisi yang demikian menyebabkan gangguan fungsi di berbagai segi. sk i zof ren ia berd a mpa k terha d ap individu yang bersangkutan. pasien dengan skizofrenia memiliki beberapa gejala yang dapat menyebabkan disfungsi sosial dan pekerjaan seperti gangguan dalam pekerjaan a t a u keg i a t a n , k u r a n g ny a hu b u n g a n i nt e r pe r son a l , p e nu r u n a n ke m a mpu a n perawatan diri dan juga kematian atau kesakitan (moller, 2009). individu yang 127 keperawatan spiritualitas pada pasien skizofrenia (sri padma sari dan diyan yuli wijayanti) menderita penyakit ini juga memiliki penyakit kedua dari reaksi lingkungan sosial dan stigma yang terkait dengan beberapa gangguan. dampak dari stigmatisasi akan menyebabkan pasien skizofrenia mengalami isolasi sosial, kurangnya kesempatan hidup seperti pekerjaan dan juga diskriminasi sosial (horrison dan gill, 2010). kesemuanya dapat mengurangi kualitas hidup dari pasien skizofrenia. a g a m a d a l a m a r t i l u a s d a p a t didef inisikan sebagai spiritualitas (yang berkait a n denga n hubu nga n t ra nseden berupa makna dari kehidupan) dan religious (perilaku tertentu, social, doktrin) (huguelet et al., 2006). akan tetapi masih jarang yang mempertimbangkan bahwa agama memiliki peran yang penting sebagai faktor yang dapat mempengaruhi outcome pasien skizofrenia. kebanyakan penelitian pada skizofrenia masih berfokus pada waham dan halusinasi agama yang menghubungkan agama dengan psikopatologi dari penyakit skizofrenia (mohr et al., 2011). spir it ualit as di konsept ualisasi kan sebagai “esensi dari orang”, dan meskipun tidak ada konsensus yang ada, banyak teori percaya bahwa spiritualitas memahami makna pribadi. selain itu, spiritualitas secara pribadi maupun komunitas didefi nisikan berdasarkan pada nilai-nilai keyakinan, pengalaman, dan praktek yang muncul dari budaya individu, keluarga dan juga komunitas keagamaan. kata agama dan atau spiritual banyak digunakan untuk merujuk pada kegiatan sehari-hari (smith dan suto, 2012). beberapa penelitian menunju k kan bahwa agama dan atau spirit ual sangat penting bagi pasien penyakit kronis, termasuk diantaranya bagi pasien skizofrenia. penelitian sebelumnya menunjuk kan bahwa agama memiliki hubungan dengan peningkatan kesejahteraan. penelitian di swiss terhadap 115 pasien dengan skizofrenia menemukan bahwa 45% dari pasien menganggap bahwa agama merupakan elemen yang paling penting dalam kehidupan mereka, dan agama dapat memberi efek positif (misalnya, harapan, makna, dan tujuan) dan juga negatif efek (misalnya, keputusasaan dan penderitaan) (huguelet et al., 2011). hal ini menyebabkan pentingnya tenaga kesehatan professional untuk menilai dan menyikapi spiritual dari pasien dengan baik (monod et al., 2011). penelitian yang dilakukan oleh shah et al. (2011) menunjukkan bahwa “religious pr a c t ice s” d a n ke p e rcaya a n p e r son al mer upakan predictor dari kualitas hidup pasien skizofrenia. penelitian menunjukkan bahwa selain manajemen farmakologis dan non farmakologis, perlunya tenaga kesehatan professional untuk meningkatkan praktek religious dan kepercayaan personal dari pasien. dengan demikian, tidaklah mengherankan bahwa banyak orang dengan penyakit mental menggunakan agama sebagai alat untuk mengatasi kondisi akibat penyakit mereka. spiritual bahkan mungkin dapat memegang peranan kunci dalam pemulihan psikologis dari gangguan mental berat seperti skizofrenia. di indonesia, mayoritas penduduknya adalah muslim (88.1%) (badan pusat statistik, 2010). sehingga islam memiliki pengaruh yang besar dalam kehidupan masyarakat dan pondok pesantren merupakan salah satu tempat untuk menempa ilmu agama islam. ada sekitar kurang lebih 27.218 pondok pesantren yang tersebar di seluruh indonesia (statistik pendidikan islam 2010). peneliti memahami bahwa agama dan atau spiritual sangat penting bagi pasien skizofrenia ter utama untuk memberikan dampak yang positif bagi kualitas hidupnya. oleh karena itu, tujuan penelitian ini adalah u nt u k mend apat ka n gamba ra n tent a ng pentingnya spiritualitas pada pasien skizofrenia yang tinggal di pondok pesantren. bahan dan metode penelitian ini merupakan penelitian deskriptif fenomenologis. dengan metode ini peneliti dapat mengerti tentang kebutuhan spiritual pada pasien skizofrenia yang tinggal di pondok pesantren. peneliti menggunakan metode giorgi sebagai panduan. partisipan dalam penelitian ini terdiri atas partisipan utama dan partisipan umum. k riteria inklusi untuk par tisipan utama adalah (1) memiliki diagnosis skizofrenia, (2) berumur 18 tahun ke atas, (3) sudah tinggal di 128 jurnal ners vol. 9 no. 1 april 2014: 126–132 ponpes selama minimal 6 bulan, (4) memiliki kesadaran yang baik, (5) dapat berkomunikasi dengan baik, (6) bersedia untuk berpartisipasi dalam penelitian. sedangkan kriteria inklusi dari partisipan utama adalah (1) tinggal di dalam ponpes, (2) peduli/ mengetahui informasi tentang kegiatan para rehabilitan, (3) bersedia untuk berpartisipasi dalam penelitian. pemilihan sampel dilakukan dengan purposive sampling, dengan jumlah partisipan sebanyak 9 orang, 7 orang partisipan utama dan 2 partisipan umum. penelitian dilakukan selama 4 bulan, juli-oktober 2013. pengumpulan data dilakukan dengan wawancara dengan panduan wawancara dan direkam dengan audio recorder. inform consent diberikan pada partisipan untuk mendapatkan persetujuan dimana partisipan mendapatkan informasi mengenai penelitian, hak untuk berpartisipasi dan juga kerahasiaan yang dijamin oleh peneliti termasuk anonymity. analisis data dilakukan berdasarkan metode giorgi sebagai panduan. metode ini memiliki 6 tahapan (oglesby, 2011) seperti mencari makna secara keseluruhan, membuat arti dari setiap unit, mentranformasikan setiap arti unit ke dalam ekspresi psikologis, membuat struktur, memvalidasi data, dan mendapatkan desk ripsi yang penting dimana peneliti menanyakan kembali makna keseluruhan pengalaman hidup mereka. hasil partisipan dalam penelitian ini sejumlah 9 partisipan, yang terdiri dari 6 perempuan dan 3 laki-laki. usia partisipan bervariasi dari usia 23 sampai 51 tahun. tingkat pendidikan rata-rata partisipan adalah sltp sejumlah 5 orang dan sisanya berpendidikan smu. lama tinggal di pondol pesantren juga bervariasi mulai dari 1 sampai 8 tahun. setelah data dianalisa, dihasilkan 2 tema utama dan 7 sub tema dalam penelitian ini. tema yang pertama adalah pengertian s pi r it u a l . te m a p e n ge r t i a n s pi r it u a l diidentifi kasi melalui subtema dekat dengan allah dan aktifi tas ibadah yang bertambah rutin. dekat dengan allah dekat dengan allah dideskripsikan dengan sejak tinggal di ponpes, partisipan merasa bertambah keimanannya, lebih dekat dengan allah dan merasakan kekhusyukan dalam melakukan kegiatan beribadah. hal ini seperti perkataan dari partisipan sebagai berikut: “…tinggal di ponpes spiritual bertambah, lebih dekat dengan allah…”(p1). “…ketenangan batin, lebih khusyuk dalam beribadah.. merasa tenang bila ikut pengajian…” (p2). aktifitas beribadah yang bertambah r utin juga diungkapkan oleh par tisipan. aktifi tas beribadah seperti sholat, mengaji dan wirid menjadi kebiasaan dalam kegiatan sehari-hari. yang bertambah rutin. di bawah ini beberapa contoh aktifi tas beribadah yang dilakukan partisipan yang menjadi lebih rutin daripada sebelum mereka tinggal di pondok pesantren. “…dulu tidak pernah sholat karena sakit, sekarang lebih teratur. yang tidak pernah sholat sunah jadi sholat sunah, sholat berjammah, mengaji, baca quran…”(p1). …mendorong kita untuk beribadah rutin: ibadah, mengaji qu’an, membaca surah-surah agar sembuh, sholat dhuha, doa nariyah… (p5). tema kedua adalah manfaat dar i spiritual. manfaat dari spiritual diidentifi kasi dari 5 subtema yaitu kesembuhan dari penyakit jiwa, manajemen symptoms, per ubahan perilaku, perubahan emosi dan perhatian pada masa depan. ke se mbu ha n d a r i pe nya k it jiwa dideskripsikan partisipan bahwa spiritual dapat membantu kesembuhan dari penyakit jiwa yait u berk u ra ng nya gejala-gejala sakit jiwa selain dengan cara minum obat. selain itu sebagai makhluk allah, mereka meminta kesembuhan kepada sang maha pencipta dengan berdoa karena mereka yakin bahwa sakitnya juga dari allah seperti yang diungkapkan oleh partisipan berikut ini: “…bisa membantu penyembuhan selain non medis karena dengan doa pikiran menjadi 129 keperawatan spiritualitas pada pasien skizofrenia (sri padma sari dan diyan yuli wijayanti) terbuka, tidak sempit, tadinya takut jadi tidak…” (p2). “…bisa sembuh karena sholawatnya banyak,… biar sembuh: control tiap bulan, kumpul dengan teman, sholawat bersama…” (p5). hal ini juga diperkuat oleh pengasuh di pondok pesantren bahwa segala penyakit itu datangnya dari allah, seperti ungkapan berikut ini: “spiritual sangat penting, kadang ilang gusti allahe, asalkan ingat pangeran, kalo ingat penyakit dari allah, kalo yang menyembuhkan juga dari allah…seperti membaca asmaul husna karena banyak teman jadi lebih mudah…” (p9). subtema selanjutnya adalah manajemen sy mptom s. pa r t isipa n menga k u d apat mengontrol symptomsnya seperti paranoid dan kecemasan yang berkurang dengan kegiatan spiritual yaitu dengan berdoa kepada allah, dzikir dan sholat seperti yang diungkapkan oleh partisipan berikut ini: “…tadinya pernah kabur, sekarang betah, semoga cepat sembuh, gak ada halusinasi, gak takut mau dibunuh orang. kalo denger bisik-bisik malah takut, biasanya malam hari. sekarang sudah tahu caranya: berdoa, istigfar yang banyak supaya tidak mengganggu lagi setannya…” (p7). “…kegiatan agama enak marai inget (allah): sholat. mumet kalo dibawa sholat jadi enak..dipaksa aja…kalo curiga dipaksa sholat aja untuk inget sehingga curiganya berkurang.”(p6). perubahan perilaku juga dilaporkan oleh partisipan sebagai manfaat dari spiritual. per ubahan perilaku tidak hanya sebagai peningkatan aktifi tas beribadah tetapi juga perbaikan akhlak dari mulai ber pakaian muslimah bagi perempuan sampai lebih mengerti sopan santun. seperti diungkapkan oleh partisipan berikut ini: “…dulu pake jeans, pake kaos pendek, kayak kurang beriman…sekarang sudah pake jilbab, pake pakaian…” (p3). hal senada juga diperkuat oleh pengasuh seperti berikut ini: “…dulu gak sopan, menjadi sopan, contone mbak…dulu kalau duduk nyuwun sewu mekangkang, ada orang tidak ada orang, alhamdulillah sekarang sudah tidak lagi.” (p8). perubahan emosi menjadi lebih tenang dirasakan oleh partisipan yang tinggal di pondok pesantren seperti contoh dari informan berikut: “…tinggal disini puas, tambah seneng… berkurang marahnya…” (p4). “…dulu emosi tidak stabil,, sekarang tidak pernah marah…” (p7). perhatian pada masa depan (hope) didesk ripsikan dengan perhatian ketika mereka meninggal dunia, dengan harapan masuk surge, seperti ungkapan salah satu partisipan berikut ini: “spiritual penting,…di rsj dulu, sholat ato tidak dibiarin…sholat sangat penting buat hidup, meski sakit tidak wajib sholat, sholat buat sangu hidup, sangu buat bekal di akhirat.” (p7). pembahasan pembahasan mencakup hasil secara umum dari penelitian. tema pertam yang teridentifi kasi dari penelitian ini adalah 1) pengertian spiritual dan 2) manfaat spiritual bagi pasien skizofrenia. selanjutnya akan dibahas secara rinci masing-masing tema yang teridentifi kasi dalam penelitian ini. pengertian spiritual yang didapatkan dalam penelitian ini yaitu dekat dengan allah dan aktifi tas ibadah yang bertambah rutin. pengertian spiritual di identifikasi dengan bertambah dekat dengan sesuatu di luar dirinya (allah), dimana seseorang merasa yakin dengan sesuatu di luar kendalinya. selain itu, spiritual juga didef inisikan dengan bertambahnya keimanan, dan kegiatan beribadah seharihari yang meningkat dan lebih khusyuk dari sebelumnya seperti sholat, dzikir dan mengaji. 130 jurnal ners vol. 9 no. 1 april 2014: 126–132 ini menunjukkan bahwa pasien skizofrenia masih merasa bahwa mereka dapat merasakan kedekatan dengan allah melalui kegiatan spiritual yang dilakukan seperti kewajiban dan ibadah yang dilaksanakan umat islam pada umumnya. hasil penelitian ini sesuai dengan penelitian sebelu m nya yang dilak u kan smith dan suto (2012), bahwa spiritualitas mer upa kan pengalaman langsu ng oleh yang bersangkutan dengan kesadaran yang lebih tinggi dalam diri seseorang, yaitu ruang internal (tuhan) dan spiritual dapat mendekatkan diri seseorang terhadap kekuatan di luar dirinya (tuhan). selain itu, beberapa partisipan juga merasakan hal yang berbedabeda seperti merasakan kedekatan dengan allah, mendapatkan ketenangan batin sampai dengan ibadah yang bertambah khusyuk. hal ini sesuai dengan pengertian dari verghese (2008) yang menggambarkan bahwa spiritual bersifat personal, yaitu pengalaman yang unik untuk setiap orang. manfaat spiritual sebagai tema kedua terdeskripsikan melalui lima sub tema yaitu kesembuhan dari penyakit jiwa, manajemen symptoms, perubahan perilaku, perubahan emosi dan perhatian pada masa depan. ke se mbu ha n d a r i pe nya k it jiwa (recovery) tergambar dari berkurangnya gejalagejala dari penyakit jiwa seperti berkurangnya gejala paranoid. hal ini sesuai dengan penelitian yang dilakukan manami, tuchman dan duarte (2010) bahwa bentuk positif dari spiritual dapat bermanfaat bagi individu dengan penyakit jiwa termasuk skizofrenia khususnya dapat mengurangi gejala dan berkontribusi dalam kualitas hidup dari segi psikologis ( psychological well being). dalam penelitian ini tergambar bahwa kesembuhan menu r ut par tisipan adalah gejala yang berkurang atau tidak ada, yang masih berfokus pada kesembuhan fi sik. hal yang tentunya berbeda dengan penelitian lain oleh slade, amering, dan oades (2008), tentang personal recovery yang berasal dari individu yang mengalami gangguan jiwa mengemukakan bahwa recovery berfokus bahwa individu merasa puas dengan kehidupannya, memiliki harapan (hope) dan memiliki kontribusi dalam kehidupan meskipun memiliki keterbatasan dikarenakan oleh kondisi penyakitnya. s e l a i n i t u , p a s i e n s k i z of r e n i a mengungkapkan bahwa spiritual dan atau agama penting bagi penderita gangguan jiwa. hal yang sesuai dengan penelitian sebelumnya yang dilakukan oleh rosmarin et al. (2013), bahwa dari 47 responden yang diteliti, mayoritas (29 responden) menyatakan bahwa agama penting bagi mereka. umumnya pasien skizofrenia mengetahui bahwa faktor yang mempengaruhi kesembuhan mereka tidak hanya dengan minum obat saja tetapi juga berkaitan dengan faktor lain seperti spiritual (dalam hal ini dengan berdoa dan membaca sholawat) dan juga sosialisasi dengan orang lain. tinggal di pondok pesantren memungkinkan pasien untuk kontak dengan pasien lain ataupun para santri. hal ini sama dengan hasil penelitian sebelumnya bahwa pengalaman spiritual membantu individu u nt u k men i ng k at k a n hubu nga n sosial (mamani, tuchman dan duarte, 2010). spiritual koping juga dilaporkan dapat menjadi koping untuk symptom management pada pasien skizofrenia seperti halusinasi dan paranoid. hal ini sesuai dengan penelitian sebelumnya oleh mohr et al. (2011), bahwa banyak pasien skizofrenia yang menggunakan agama dan atau spiritualnya sebagai alat koping. hasil penelitian ini ditemukan berdoa, istigfar dan sholat dapat mengurangi gejala yang dialami pasien skizofrenia. dalam penelitian ini kebanyakan pasien mengungkapkan adanya pengaruh spiritual dalam kehidupan mereka seperti emosi yang lebih stabil. hal ini senada dengan penelitian sebelumnya bahwa individu dengan spiritual yang tinggi memiliki rasa marah “anger” yang lebih rendah (labbe dan fobes, 2010). spiritual juga berhubungan dengan harapan dalam hidup dan harapan setelah kematian yang baik. spiritual juga dapat memunculkan harapan (hope) seperti terdapat dari hasil penelitian ini yang sesuai dengan penelitian sebelumnya oleh huguelet et al. (2007), yang meneliti hubungan antara agama dan keinginan bunuh diri pada pasien skizofrenia. hasil penelitian menunjukkan bahwa pasien yang tidak memiliki keinginan 131 keperawatan spiritualitas pada pasien skizofrenia (sri padma sari dan diyan yuli wijayanti) bunuh diri (20 pasien dari total 30 pasien), aspek agama memiliki peran yang penting sebagai alat proteksi untuk melawan penderitaan dan menekan keinginan bunuh diri serta adanya harapan di masa depan terutama menemukan kesenangan untuk hidup dalam cinta tuhan (hidup yang lebih baik setelah kematian). sela njut nya spi r it u al ya ng bai k , peningkatan aktifi tas keagamaan atau religious practices dalam kehidupan sehari-hari dapat berdampak pada pasien skizofrenia, di mana agama dan atau spiritual membuat hidup menjadi lebih bermakna dan meningkatkan kualitas hidup pasien skizofrenia. hal ini sesuai dengan hasil penelitian sebelumnya dari mohr et al. (2011). simpulan dan saran simpulan penelitian ini merefl eksikan gambaran pengalaman hidup spirit ual bagi pasien skizofrenia. ada dua tema dihasilkan dari penelitian ini yaitu: 1) pengertian spiritual yaitu dekat dengan allah dan aktifi tas ibadah yang bertambah rutin, dan 2) manfaat dari spiritual yaitu kesembuhan dari penyakit jiwa, manajemen symptoms, perubahan perilaku, perubahan emosi dan perhatian pada masa depan. penelitian ini memili k i beberapa keterbatasan seperti informan utama yang memiliki keterbatasan untuk mengungkapkan atau mengeksplorasi apa yang dialami sebagai salah satu symptoms pasien skizorenia yaitu keterbatasan bicara. meskipun peneliti juga mendapat informasi tambahan dari informan k unci akan tetapi subjek utama adalah rehabilitan unt u k mendapatkan tentang pentingnya spiritualitas bagi pasien skizofrenia. selain itu, semua responden tinggal di satu pondok pesantren, dimana setiap pondok pesantren ataupun masyarakat kemungkinan memiliki fasilitas yang berbeda-beda dalam aktifi tas keagamaan. oleh karena itu, dengan mengambil data dari beberapa rehabilitan di beberapa tempat yang berbeda seperti rumah sakit jiwa dan komunitas mungkin dapat memberikan hasil yang berbeda dan hasil yang lebih akurat. saran h a s i l d a r i p e n e l i t i a n i n i merekomendasikan bahwa perawat dan atau rumah sakit jiwa sebaiknya menyediakan fasilitas bagi peningkatan spiritual pasien skizofrenia. selain itu, perawat baik di rumah sakit ataupun komunitas perlu untuk memberikan dukungan bagi mereka untuk tetap melakukan kegiatan spiritual seperti biasa dan atau lebih meningkatkan spiritualitas mereka sebelum dirawat di rumah sakit. selain itu, perawat dapat menggunakan agama dan atau kegiatan spiritual dalam praktek keperawatan baik saat melakukan intervensi di rumah sakit maupun kegiatan pendampingan di komunitas. intervensi tidak hanya berupa p e ngajia n t et api juga p e nd a mpi nga n / pemberian dukungan untuk kegiatan spiritual bagi pasien skizofrenia. pe n t i n g n y a s p i r i t u a l i t a s d a l a m penelitian ini adalah pandangan dari pasien skizofrenia itu sendiri yang tinggal di pondok pesantren (islam). oleh karena itu, penelitian selanjutnya dapat mengeksplore pentingnya spiritualitas dari sudut pandang keluarga dan juga keluarga ataupun dengan agama yang berbeda. selain karena pasien skizofrenia memiliki keterbatasan bicara yang merupakan salah satu gejala, penelitian selanjutnya dapat menggunakan metode pengumpulan data yang berbeda seperti focus group discussion (fgd). daftar pustaka badan pusat statistik, 2010. hasil sensus penduduk 2010, (online), (http://www. bps.go.id/, diakses tanggal 23 juni 2012, jam 10.00 wib). domininguez, m. et al., 2009. are psychotic psychopathology and neurocognition orthogonal? a systematic review of their association. psychology bulletin. 135, 157-171. harrison, j., dan gill, a., 2010. the experience and consequences of people with mental health problems, the impact of stigma upon people with schizophrenia: a way forward. journal of psychiatric and mental health nursing, 17, 242–250. 132 jurnal ners vol. 9 no. 1 april 2014: 126–132 huguelet, p. et al., 2006. spirituality and religious practices among outpatients with schizophrenia and their clinicians. psychiatric services, 57(3), 366-372. huguelet, p. et al., 2007. effect of religion on suicide attempts in outpatients with schizophrenia or schizo-affective disorders compared with inpatients with non-psychotic disorders. european psychiatry, 22, 188-194. huguelet, p. et al., 2011. a randomized trial of spiritual assessment of outpatients with schizophrenia: patients’ and clinicians’ experience. psychiatric services, 62(1), 79-86. labbe, e. e., dan fobes, a., 2010. evaluating the inter play between spirit uality, p e r son al it y, a nd st re ss. ap plie d psychophysiology and biofeedback, 35, 141-146. mamani, a. g., tuchman, n., dan duarte, e. a., 2010. incorporating religion/ spi r it u a l it y i nt o tr e at me nt for serious mental illness. cognitive and behavioral practice, 17, 348–357. moh r, s. et al., 2011. spir it ualit y and religiousness as predictive factors of outcome in schizoph renia and schizo-affective disorders. psychiatry research, 186, 177–182. moller, m. d., 2009. neurobiological responses and sch izoph ren ia and psychot ic disorders. in g. w. stuart, & m. t. laraia (eds.), principles and practice of psychiatric nursing (8th ed., pp. 386422). philadelphia, pa: mosby. monod, s. et al., 2011. instruments measuring spirituality in clinical research: a systematic review. journal of general internal medicine, 26(11), 1345-1357. oglesby, r. a., 2011. the lived experience of multiple sclerosis in women of childbearing years: an existential phenomenological study, (online), (http://search.proquest.com/docview/ 1033832796?accountid=28431, diakses tanggal 10 april 2012, jam 14.00 wib. rosmarin, d. et al., 2013. religious coping among psychotic patients: relevance to suicidality and treatment outcomes. psychiatry research, 210, 182–187. shah r. et al., 2011. relationship between spirituality/religiousness and coping in patients with residual schizophrenia. quality of life research, 20(7), 105360. doi: 10.1007/s11136-010-9839-6. sidakaton, s., 2011. kpsi, untuk kita yang p e d u li s c h i z o p h r e n i a (o n l i n e), (http://www.tnol.co.id/id/community/ club/8469-kpsi-untuk-kita-yang-peduliskizofrenia.html, diakses tanggal 10 april 2012, jam 13.00 wib). slade, m., amering, m., dan oades., 2008. recovery: an international perspective. epidemiologia e psichiatria sociale, 17(2), 128-137. smith, s., dan suto, m. j., 2012. religious and/ or spiritual practices: extending spiritual freedom to people with schizophrenia. canada journal occupational therapy, 79(2), 77-85. statistik pendidikan islam., 2010. analisis d e s k r i p t i f p o n d o k p e s a n t r e n , pendidikan diniyah, dan tpq tahun pelajaran 2010-2011, (online), (http:// pendis.kemenag.go.id/file/dokumen/ databooklet03a.pdf/., diakses tanggal 11 april 2013, jam 13.00 wib). thorson, r., t, matson, j., l., rojahn, j., dan dixon, d., r., 2008. behavior problems in institutionalized people w it h i nt el le c t u a l d i s a bi l it y a nd schizophrenia spectr um disorders. journal of intellectual & developmental disability, 33, 316–322. verghese, a., 2008. spirituality and mental health. indian journal of psychiatry, 50,233–237. world health organization., 2011. mental h e alth: s chi zoph re nia, (o n l i ne), (http://www.who.int/mental_health/ management/schizophrenia/en/., diakses tanggal 10 april 2012, jam 13.00 wib). 176 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 176-182 http://dx.doi.org/10.20473/jn.v17i2.36170 original article open access the relationship between disease severity and functional status of post-covid-19 patients in banda aceh, indonesia budi yanti 1, * , aulia rahma asril 1 , and siti hajar 1 1 faculty of medicine, universitas syiah kuala, banda aceh, indonesia *correspondence: budi yanti. address faculty of nursing universitas syiah kuala, aceh, indonesia. email: byantipulmonologis@unsyiah.ac.id responsible editor: laily hidayati received: 28 may 2022 ○ revised: 27 october 2022 ○ accepted: 2 october 2022 abstract introduction: coronavirus disease-2019 known as covid-19 has spread rapidly worldwide, changing many aspects of life, including the functional status. therefore, this study aims to assess the relationship between disease severity and the functional status of covid-19 patients after recovery in banda aceh, indonesia. methods: a cross-sectional study was conducted with 109 post covid-19 patients having been cured for more than 4-8 weeks in a hospital in banda aceh, indonesia. the history of disease severity of covid-19 was collected from medical records and was divided into mild, moderate, severe, and very severe according to the who guidelines. the functional status was assessed using the post-covid-19 functional status scale (pcfs) questionnaire and divided into five categories namely no functional limitation, negligible, slight, moderate, and severe functional limitation. the relationship between the severity of covid-19 and functional status was assessed statistically using the spearman rank test. results: out of 109 selected respondents, there was one patient with mild severity, and 68, 37, and three patients have a history of moderate, severe, and very severe covid-19, respectively. those imply the functional status with no functional limitation (6%), negligible (21%), slight (4%), moderate (42%), and severe functional limitation (28%). in addition, fatigue was the most common symptom that persisted among respondents. furthermore, the statistical result showed that the history of covid-19 severity had a significant relationship with the post-covid-19 functional status (p<0.05). conclusions: this study showed that post-covid-19 cases have varying functional limitations ranging from negligible to severe. the covid-19 severity significantly correlates with the functional status post-recovery. hence, it is recommended to conduct a monitoring program to assess the post-covid-19 functional status regularly, especially in outpatient clinics of the government healthcare center, in order to enhance the research findings. keywords: disease severity; post-covid-19 functional status; post-covid-19 persistent symptom introduction according to data released by world health organization (who), there have been more than 100 million confirmed cases of covid-19 and more than two million deaths worldwide since the pandemic (hawlader et al., 2021). in indonesia, 5.667,355 confirmed cases based on the indonesian ministry of health have been recorded and 149,268 deaths as of march 3, 2022 (indonesian health ministry, 2022). according to the united nations (un) (2020), this disease continually shows conditions of uncertainty, exhaustion, and changes in the overall pattern of life, thereby having a tremendous impact on the world. it is well-known that the symptoms are highly variable and can result in a long-term disorder with persistent symptoms, regardless of age, comorbid conditions, in young adults https://creativecommons.org/licenses/by/4.0/ mailto:byantipulmonologis@unsyiah.ac.id https://orcid.org/0000-0003-2932-0764 https://orcid.org/0000-0002-1457-625x jurnal ners http://e-journal.unair.ac.id/jners 177 and without chronic disease (poudel et al., 2021). the recovering case of covid-19 is a tremendous pressure worldwide. furthermore, the primary functional side is estimated to affect physical, mental, cognitive, and public health status (united nations, 2020). this outbreak has previously been associated with a persistent disruption in lung function, muscle weakness, pain, lethargy, depression, anxiety, vocational disorders, and impaired quality of life at various levels (catherine et al., 2007; neufeld et al., 2020). the clinical spectrum of coronavirus disease 19 (covid-19), which has caused a global pandemic, varies from a moderate illness to a life-threatening condition. most covid-19 patients initially only experience minor symptoms like fever and cough, but a tiny percentage develop severe pneumonia and experience life-threatening side effects, including acute respiratory distress syndrome, multi-organ failure, and death. therefore, the world health association has made a guideline to classify the severity of covid-19 from mild, moderate, severe, and very severe (who, 2021). the prevalence of post-covid-19 symptoms varies widely, ranging from 13% 83%, in patients undergoing self-isolation by 10% 30%, while those treated in hospitals are as high as 80%. in indonesia, it was recorded that 63.5% of patients experienced persistent symptoms (callard and perego, 2021). these are often similar to the symptoms that developed during the acute phase of this virus. furthermore, the most common manifestation of post-covid-19 symptoms is fatigue, shortness of breath, cough, joint pain, and chest pain. adult survivors have limitations in activities of daily life (adls), such as walking, bathing, and wearing clothes. therefore, the disabilities in activities of daily living result in increased use of health services, such as nursing, and a higher risk of mortality (aiyegbusi et al., 2021). even though the majority of these symptoms are curable, some persist over time and profoundly influence daily living. it can develop into chronic illnesses with severe economic and public health implications. therefore, a study is required related to the severity of the disease on the daily functional ability of post-covid-19 patients in indonesia. according to the world health organization, quality of life refers to an individual's view of their position in life, which includes their culture and values in connection to goals, expectations, standards, and concerns. covid-19 is considered a significant physical and psychological disorder, which leads to deterioration in health as well as affects the quality of daily life. a simple and basic assessment is needed to monitor the progression of symptoms and their effect on the functional status of the sick patient. this is because many recovered cases require regular, easy, and measurable monitoring to categorize those patients with slow recovery or needing assistance (world health organization, 1996). therefore, klok, boon and barko (2020) compiled the post‑covid‑19 functional status scale (pcfs) which (after slight adaptation) is helpful during the pandemic. a new scale is recommended for use in patients discharged from the hospital after 4-8 weeks or six months to evaluate the functional status mohamed hussein et al., (2021). there are still limited studies assessing the functional status of people recovering from covid-19, especially in indonesia. therefore, this study aims to determine the relationship between disease severity and the functional table 1 scale assessment of post-covid-19 functional status (pcfs) scale 1. constant care yes no 1.1 do you require constant care after recovering from covid-19? 2. basic activities of daily living yes no 2.1 i can't eat alone after recovering from covid-19 2.2 i can't shower or dress myself after recovering from covid-19 2.3 i can't clean my face, brush my teeth, do my hair after recovering from covid-19 2.4 i can't walk like walking in the park, in the yard or around the house after recovering from covid-19 3. instrumental activities of daily living (iadl) yes no 3.1 i can't do activities such as washing dishes, preparing food, taking out trash, sweeping the house, watering plants after recovering from covid-19 3.2 i can't travel like using a vehicle as usual after recovering from covid-19 3.3 i can't buy daily supplies after recovering from covid-19 4. participation in usual social roles yes no 4.1 i am reducing my activity/task time at home or at work after recovering from covid-19 4.2 i need to avoid or reduce activities at home or work that i usually do after recovering from covid-19 4.3 i am not able to take care of my family such as husband or wife, children, grandchildren, and parents as usual after recovering from covid-19 4.4 since being diagnosed with covid-19 positive, have you had problems with your neighbors or at work? 4.5 i am limiting my participation in social and recreational activities such as doing hobbies, going to public places, playing games after recovering from covid-19 yanti, asril, and hajar (2022) supremo, bacason, and sañosa (2022) 178 p-issn: 1858-3598  e-issn: 2502-5791 status of recovered covid-19 patients in aceh, indonesia materials and methods study setting this research was a cross-sectional study design on confirmed covid-19 patients that have been treated in new emerging and re-emerging infectious diseases ward and respiratory intensive care unit at dr. zainoel abidin hospital, banda aceh, indonesia. respondents aged 18 to 70 years, declared cured for more than 4-8 weeks, willing for an interview met the criteria for inclusion. meanwhile, patients with probable and suspected virus cases without symptoms were excluded from this study. as many as 109 respondents were involved in this research by using a total sampling technique for one month in 2021. the research variables were the history of disease severity of covid-19 and the post0covid-19 functional status with additional information of post-covid-19 persistent symptoms. assessment of the disease severity the history of disease severity of covid-19 was divided according to the who guidelines into mild, moderate, severe, and very severe (son, lee and hwang, 2021) and provided from medical records. assessment of post-covid-19 functional status (pcfs) scale the demographic data collected include gender, age, occupation, and severity of disease. the patient's functional status was assessed using the post-covid-19 functional status scale (pcfs) questionnaire, which consisted of several questions and was divided into five grades, namely grade 0 (no functional limitations), grade 1 (negligible functional limitations), grade 2 (slight functional limitations), grade 3 (moderate functional limitation), and grade 4 (severe functional limitation), as measured by constant care needs, limitations in basic and instrumental activities of daily living, and participation in usual social role after recovering from covid-19. grade 4 shows severe functional limitation, which involves having limitations in daily activities, being unable to take care of oneself, still require treatment and has symptoms such as anxiety, fatigue, weakness muscle tone, difficulty breathing, depression, memory impairment, and cough. the pfcs questionnaire used in this study was adopted from previous study (klok, boon and barco, 2020). the original language of the questionnaire was english, which was then translated into bahasa by other independent experts. for validation, the questionnaire was tested in an outpatient clinic. completing the survey takes approximately 10 minutes. this study evaluated the questionnaire questions and gained reliability of 0.9 and the validity was lower than 0.5. the blueprint of the questionnaire is shown in table 1. statistical analysis this study uses descriptive analysis to describe the characteristics, patient’s clinical symptoms, and the post-covid-19 functional status. furthermore, the relationship between the severity covid-19 and pcfs was assessed statistically using the spearman rank test. this statistical analysis uses spss (statistical package for social sciences) for windows version 25.0 (ibm spss inc., usa). this study was approved by the health research ethics committee at the faculty of medicine, syiah kuala university/dr. zainoel abidin no. 310/ea/fk-rsudza/2021. table 2 characteristics of respondents characteristics frequency(n) percentage (%) gender male 66 61 female 43 39 age 25-44 years old 17 15.5 45-64 years old 69 63.3 65> years old 23 21.1 occupation entrepreneur 56 52 civil servant 25 24 jobless 27 25 college student 1 1 history of covid-19 severity mild 1 1 moderate 68 62 severe 37 34 very severe 3 3 post-covid-19 functional status scale no functional limitation 6 6 negligible functional limitation 23 21 slight functional limitation 4 4 moderate functional limitation 46 42 severe functional limitation 30 28 total 109 100 jurnal ners http://e-journal.unair.ac.id/jners 179 results this study collected 109 respondents, and more than half (61%) were male (n = 66) with age range of 45-64 years found to be the most (63.3%), and more than half (52%) work as self-employed (n = 56). this study revealed that the most disease severity history of covid-19 was in the moderate grade (n = 68 or 62%). the majority of respondents (46 patients or 42%) had severe degrees of pcfs and only 4% (four respondents) showed a slight functional limitation (table 2). the most common post-covid-19 persistent symptoms were fatigue (89%), muscle weakness (60%), cough (53%), and depression (43%) (figure 1). furthermore, this study shows that the disease severity of covid-19 has a significant relationship with post-covid-19 functional status with p <0.05 (table 3). the patients with moderate severity of covid-19 (n = 43) show pcfs at the moderate grade (n = 33 or 48.5%) or even more severe (n = 10 or 14.7%). discussions covid-19 patients with mild (1,1%), moderate (68,62%), severe (37,34%), and very severe (3,3%) severity were included in the study, with fatigue and persistent cough being present in 90% and 50% of the respondents, respectively. during the covid-19 pandemic, the most common complaints were mild clinical symptoms such as cough, fever, shortness of breath, musculoskeletal (lethargy and joint pain), gastrointestinal and sleep disturbances (docherty et al., 2020; wang et al., 2020). according to the course of the disease, the coronavirus (sars-cov-2) has the highest affinity for the angiotensin-converting enzyme-2 (ace-2) receptor, primarily located in the lungs. pulmonary damage occurs when the virus attacks type ii pneumocytes of the alveolar epithelium in the lungs. it can develop lung injury and sequels persistent such as scarring and pulmonary fibrosis, leading to long-term breathing problems. in addition, endothelium damage can trigger an inflammatory response in the capillaries and form microthrombi with extensive pulmonary consolidation. covid-19 changes the lungs' ability to diffuse carbon monoxide (dlco). this pathophysiology describes the extent and severity of covid-19 and manifests in symptoms (thomas, price and hull, 2021). a previous study of 355 patients with mild to severe covid-19 showed that approximately 46% of them experienced post-covid-19 symptoms in female patients, with fatigue often appearing as the primary symptom (mahmud, rahman and rassel, 2021). furthermore, a study observed patients with mild to severe disease that met who criteria and discovered that approximately 87% had persistent clinical complaints such as fatigue (53.1%), dyspnea (43.4%), joint pain (27.3%), and chest tightness (21.7%) (carf, bernabei and landi, 2020). fatigue is a disabling mental and physical exhaustion sensation and is more common in people with postcovid-19 syndrome (diem et al., 2022). another study that also supports the results is from aiyegbusi et al. (2021), which states that the most common post-covid19 clinical symptoms experienced by patients were fatigue (47%), dyspnea (32%), muscle pain (25%), pain head (18%), and cough (18%). also, an additional study conducted by qi et al. (2021) on 1171 covid-19 patients in china stated that 21.4% and 22.6% of them experienced post-covid-19 anxiety and depression, respectively taquet et al. (2021) conducted a retrospective cohort study of 236,379 covid-19 patients in the united states, of which 19.15% experienced an anxiety event within six months after infection. pant et al. (2021) reported that nearly 90% of patients had at least clinical symptoms. fever is the most common symptom, followed by cough, shortness of breath, and chest pain. therefore, impaired lung function, mental health problems, and decreased quality of life have a long-term impact on physical, mental, social, and cognitive health, leading to decreased functional status (pant et al., 2021). the virus enters the host cells, seizes control of cellular metabolism, and activates catabolic mechanisms like apoptosis and autophagy that primarily destroy cell proteins to provide amino acids for the generation of virions. this virus's tactics cause cellular damage, protein malfunction, mitochondrial energy table 3 the relationship between history of covid-19 severity and functional status of post-covid-19 history of severity functional limitation total p-value r none negligible slight moderate severe n % n % n % n % n % n % mild 0 0 1 100 0 0 0 0 0 0 1 100 0.000 0.358 moderate 4 5.9 18 25.5 3 4.4 33 48.5 10 14.7 68 100 severe 2 5.4 4 10.8 1 2.7 12 32.4 18 48.6 37 100 very severe 0 0 0 0 0 0 1 33.3 2 66.7 3 100 total 6 5.5 23 21.1 4 3.7 46 42.2 30 27.5 109 100 yanti, asril, and hajar (2022) supremo, bacason, and sañosa (2022) 180 p-issn: 1858-3598  e-issn: 2502-5791 loss, and iron leakage, which causes an increase in serum ferritin and the symptoms of weakness and fatigue (pasini et al., 2021). this mechanism links it to the two physical symptoms that are most frequently reported: fatigue and unexpected shortness of breath that impair daily activities (thomas, price and hull, 2021). the duration of treatment and psychological disturbances while suffering from this disease result in extraordinary mental and attitude disorders. in addition, these play an essential role in causing physical activity disorders. (world health organization, 2020). indeed, post-covid patients have not entirely recovered from the disease's health issues even though they recovered from the disease. in addition to the risk of lasting disruption from covid-19, many patients must contend with it daily in the community. this study assessed any persistent functional impairment in recovered covid-19 patients using the recommended pcfs questionnaire. patients had varying degrees of functional limitation ranging from no functional limitation (6%), negligible functional limitation (21%), slight functional limitation (4%), moderate functional limitation (42%), and severe functional limitation (30%) based on pcfs. sepsis survivors are likely to have similar difficulties as other survivors of severe covid-19. in addition, covid-19 can lead to many consequences due to the severe course of infection. minimized sedation, daily breathing testing, early mobility, and other evidence-based practices can improve icu outcomes. however, this practice is not implemented in icus overloaded with other covid-19-related problems that interfere with routine care. therefore, patients with severe covid-19 may experience deeper drowsiness, less respiratory effort, and limited mobility compared to other severe patients, all of which can impact day-to-day living and result in a poorer prognosis (iwashyna et al., 2010). the results were supported by a study conducted by machado et al. (2021), which stated that 1,011 people (52%) of the 1,939 respondents experienced the postcovid-19 functional status scale (pcfs) at severe degree. however, according to pant et al. (2021), 60 people (56.6%) experienced the post-covid-19 functional status scale at no functional limitation, followed by mild degree up to 29 people (27.3%) and four (1.9%) of the respondents experienced severe degree. additionally, hussein et al. (2021) stated that of 444 respondents, 280 (63.1%) experienced post-covid19 functional status scale at mild degree (mohamed hussein et al., 2021). this study showed a significant relationship between disease severity and post-covid-19 functional status (p<0.05). the main target population for the intervention of long-term recovery is patients who were more seriously unwell during their hospital stay and had more severe decreased pulmonary diffusion capabilities due to severe pneumonia and abnormal chest imaging entity. in severe covid-19 pneumonia, respiratory virus infection may cause different fibroblast activation throughout the convalescence phase and cause pathological fibroproliferation in the lung. both of these effects have a significant impact on both shortand longterm outcomes in functional status. in addition, pulmonary diffusion abnormalities and value ct imaging change were related to the severity of the disease during the acute phase (nalbandian et al., 2021). in all the studies analyzed, there was a decrease in the performance of daily activities after covid-19 figure 1 post-covid-19 persistent symptoms jurnal ners http://e-journal.unair.ac.id/jners 181 infection regardless of the rating scale used. patients that developed complications during hospitalization, such as icu admission (poudel et al., 2021), mechanical ventilation (region and maugeri, 2020), decreased consciousness (mcloughlin et al., 2020), or greater oxygen demand (curci et al., 2020), all had poorer outcomes with persistent symptoms postoperatively after covid-19. participation in a rehabilitation program is also a factor that might alter outcomes in functional status; however, activity daily living (adls) performance does not improve in all cases. various factors related to the patient's condition, such as disease severity, tend to affect functional capacity and performance of activities of daily living (pizarropennarolli et al., 2021). likewise, hussein et al. (2021) stated that only 3% of patients treated in the icu had no functional status restrictions and 97% had limited functional status where 93% had only negligible functional status limitation. this study has several limitations. the proportion of patients with comorbidities was not disclosed in this study. in addition, this study is only based on a questionnaire of clinical symptoms related to impaired lung function, not directly carried out tests, so that it may not arise from covid-19. the data for new symptoms in early covid-19 were not further stratified to establish whether the symptoms were postdischarge, exacerbated after covid-19 recovery, or persisted after covid-19. mild covid-19 symptoms did not qualify patients for enrollment. more work is required to compare the long-term results between inpatients and outpatients. conclusions most post-covid-19 cases have varying degrees of functional limitations ranging from negligible to severe according to pcfs. this study discovered that history of severe covid-19 significantly impacted the functional status after recovering from the disease. therefore, it is recommended to conduct a regular post-covid-19 monitoring program at a government clinic or be part of an outpatient program, following the patient's functional status during the 1st, 3rd, and 6th months of visit. acknowledgment we want to thank all the participants who have supported this study. funding source this investigation is unfunded. conflict of interest the author declares that there is no conflict of interest in this study. references aiyegbusi, o. l. et al. (2021) ‘symptoms , complications and management of long covid : a review’, journal of the royal society of medicine, 0(may), pp. 1–15. doi: 10.1177/01410768211032850. aliae ar mohamed hussein and mahmoud saad, hossam eldeen zayan mustafa abdelsayed, mohamed moustafa, abdel rahman ezzat (2021) ‘post‑covid‑19 functional status: relation to age, smoking, hospitalization, and previous comorbidities’, annals of thoracic medicine, 16, pp. 260–5. doi: 10.4103/atm.atm. callard, f. and perego, e. (2021) ‘social science & medicine how and why patients made long covid’, social science & medicine, 268(october 2020), p. 113426. doi: 10.1016/j.socscimed.2020.113426. carf, a., bernabei, r. and landi, f. (2020) ‘persistent symptoms in patients after acute covid-19’, jama, 324(6), p. 603. doi: 10.1136/bmj.m1985. catherine .m., t. et al. (2007) ‘one-year outcomes and health care utilization in survivors of severe acute respiratory syndrome’, archives of internal medicine, 167(12), pp. 1312–1320. available at: http://solo.bodleian.ox.ac.uk/oxvu1:lscop_ox:oxfaleph010495 829%0ahttps://jamanetwork.com/journals/jamainternalmedicin e/articlepdf/412710/ioi70065_1312_1320.pdf. curci, c. et al. (2020) ‘early rehabilitation in post-acute covid-19 patients : data from an italian covid-19 rehabilitation unit and proposal of a treatment protocol’, 56(5), pp. 633–641. doi: 10.23736/s1973-9087.20.06339-x. diem, l. et al. (2022) ‘fatigue in post-covid-19 syndrome: clinical phenomenology, comorbidities and association with initial course of covid-19’, journal of central nervous system disease, 14, p. 117957352211027. doi: 10.1177/11795735221102727. docherty, a. b. et al. (2020) ‘features of 20 133 uk patients in hospital with covid-19 using the isaric who clinical characterisation protocol : prospective observational cohort study’, 2(march), pp. 1–12. doi: 10.1136/bmj.m1985. hawlader, m. d. h. et al. (2021) ‘quality of life of covid-19 recovered patients in bangladesh’, plos one, 16(10 october), pp. 1–18. doi: 10.1371/journal.pone.0257421. indonesian health ministry (2022) the latest situation of covid-19 in indonesia. iwashyna, t. j. et al. (2010) ‘long-term cognitive impairment and functional disability among survivors of severe sepsis’, jama journal of the american medical association, 304(16), pp. 1787– 1794. doi: 10.1001/jama.2010.1553. klok fa, boon gjam, barco s, et al. (2020) ‘post covid-19 functional status scale manual version may 2020’, (2), pp. 1–16. klok fa, kruip mjha, van der meer njm, arbous ms, gommers dampj, kant km, kaptein fhj, van paassen j, stals mam, huisman mv, e. h. (2020) ‘incidence of thrombotic complications in critically ill icu patients with covid-19’, thromb res, 191, pp. 145–147. machado, f. v. c. et al. (2021) ‘construct validity of the post ‑ covid ‑ 19 functional status scale in adult subjects with covid ‑ 19’, health and quality of life outcomes, pp. 1–10. doi: 10.1186/s12955-021-01691-2. mahmud, r., rahman, m. and rassel, m. a. (2021) ‘post-covid-19 syndrome among symptomatic covid-19 patients : a prospective cohort study in a tertiary care center of bangladesh’, plos one, 16(4), p. e0249644. doi: 10.1371/journal.pone.0249644. mcloughlin, b. c. et al. (2020) ‘functional and cognitive outcomes after covid ‑ 19 delirium’, european geriatric medicine, 11(5), pp. 857– 862. doi: 10.1007/s41999-020-00353-8. nalbandian, a. et al. (2021) ‘post-acute covid-19 syndrome’, nature medicine, 27(4), pp. 601–615. doi: 10.1038/s41591-021-01283-z. neufeld, k. j. et al. (2020) ‘fatigue symptoms during the first year following ards’, chest, 158(3), pp. 999–1007. doi: 10.1016/j.chest.2020.03.059. pant, p. et al. (2021) ‘prevalence of functional limitation in covid-19 yanti, asril, and hajar (2022) supremo, bacason, and sañosa (2022) 182 p-issn: 1858-3598  e-issn: 2502-5791 recovered patients using the post covid-19 functional status scale correspondence ’:, 59(233), pp. 7–11. doi: 10.31729/jnma.5980. pasini, e. et al. (2021) ‘serum metabolic profile in patients with longcovid (pasc) syndrome: clinical implications’, frontiers in medicine, 8(july), pp. 1–8. doi: 10.3389/fmed.2021.714426. pizarro-pennarolli, c. et al. (2021) ‘assessment of activities of daily living in patients post covid-19 : a systematic review’, peerj, 9, p. e11026. doi: 10.7717/peerj.11026. poudel, a. n. et al. (2021) ‘impact of covid-19 on health-related quality of life of patients: a structured review’, plos one, 16(10 october), pp. 1–20. doi: 10.1371/journal.pone.0259164. region, p. and maugeri, c. s. (2020) ‘performance of activities of daily life in’, eur respir j, 56, p. 2002096. son, k. b., lee, t. j. and hwang, s. s. (2021) ‘disease severity classification and covid-19 outcomes, republic of korea’, bulletin of the world health organization, 99(1), pp. 62–66. doi: 10.2471/blt.20.257758. taquet, m. et al. (2021) ‘6-month neurological and psychiatric outcomes in 236 379 survivors of covid-19 : a retrospective cohort study using electronic health records’, the lancet psychiatry, 8(5), pp. 416–427. doi: 10.1016/s22150366(21)00084-5. thomas, m., price, o. j. and hull, j. h. (2021) ‘pulmonary function and covid-19’, current opinion in physiology, 21(january), pp. 29–35. doi: 10.1016/j.cophys.2021.03.005. tian, q. et al. (2021) ‘covid-19 pandemic related long-term chronic stress on the prevalence of depression and anxiety in the general population’, bmc psychiatry, 21(1), pp. 1–10. doi: 10.1186/s12888-021-03385-x. united nations (2020) un research roadmap for the covid-19 recovery. wang, d. et al. (2020) ‘clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china’, jama journal of the american medical association, 323(11), pp. 1061–1069. doi: 10.1001/jama.2020.1585. who (2021) living guidance for clinical management of covid-19, world health organization. available at: https://www.who.int/publications/i/item/who-2019-ncovclinical-2021-1. world health organization (who). (1996) ‘division of mental health. whoqol-bref: introduction, administration, scoring and generic version of the assessment: field trial version, december 1996’, p. https://apps.who.int/iris/handle/10665/63529. world health organization (who). (2020) mental health and psychosocial considerations during the covid-19 outbreak. how to cite this article: yanti, b., asril, a., r., and hajar, s. (2022) ‘the relationship between disease severity and functional status of post-covid-19 patients in banda aceh, indonesia’, jurnal ners, 17(2), pp. 176-182. doi: http://dx.doi.org/10.20473/jn.v17i2.36170 vol 9 no 1 april 2014.indd 97 kontrol diri dan efikasi diri meningkatkan kepuasan ibu menjalani proses persalinan (self control and self effi cacy increase mother’s birth labor satisfaction) agustine ramie*, yati afi yanti**, hening pujasari** * jurusan keperawatan poltekkes kemenkes banjarmasin. ** fik universitas indonesia e-mail : agustine178@gmail.com abstrak pendahuluan: kontrol diri dan efi kasi diri sangat diperlukan bagi ibu untuk meningkatkan kepuasan menjalani proses persalinan. penelitian ini bertujuan mengidentifi kasi hubungan antara kontrol diri dan efi kasi diri dengan kepuasan ibu menjalani proses persalinan di rsud ratu zalecha martapura dan rsud banjarbaru kalimantan selatan. metode: penelitian ini menggunakan rancangan analitik korelasi dengan pendekatan cross sectional. sampel sebanyak 125 ibu bersalin normal, dipilih menggunakan teknik consecutive sampling. hasil: hasil analisis uji korelasi chi square menunjukkan ada hubungan antara kontrol diri dan efi kasi diri dengan kepuasan ibu menjalani proses persalinan ( p value 0.002, α: 0.05) dan ( p value 0.000, α: 0.05). hasil analisis regresi logistik berganda didapatkan 4 variabel yang berpengaruh terhadap kepuasan ibu menjalani proses persalinan yaitu kontrol diri, efi kasi diri, penghasilan dan paritas. diskusi: variabel paling berpengaruh terhadap kepuasan ibu menjalani proses persalinan adalah penghasilan. petugas pemberi layanan persalinan perlu memberi dukungan agar ibu bersalin memandang proses persalinan sebagai pengalaman positif dan menyenangkan, sehingga ibu memiliki kepuasan dalam menjalani proses persalinan. kata kunci: efi kasi diri, kontrol diri, kepuasan ibu menjalani persalinan abstract introduction: self-control and self-effi cacy are necessary for would-be mothers to enhance their birth labor satisfaction. this research was conducted in ratu zalecha public hospital in martapura and in banjarbaru public hospital in south borneo with the aim to identify the relationship between self-control and self effi cacy on the one hand, and birth labor satisfaction on the other hand. method: cross-sectional approach with correlative analysis was applied for this research, using 125 samples chosen from normal childbirth using consecutive sampling techniques. result: the result of chi-square correlation test showed that there were some relationships between self-control as well as self-effi cacy and birth labor satisfaction (ρ value 0.002,α: 0.05) and (ρ value 0.000, α: 0.05). there were four variables resulted from double logistic analytical regression that play signifi cant roles in birth labor satisfaction, i.e., self-control, self-effi cacy, family income, and parity. discussion: the most infl uencing variable in birth labor satisfaction was family income. labor carers should provide enough support so that would-be mothers can view the process of childbirth as a positive and pleasant experience; hence, birth labor satisfaction will surely be tremendous. keywords: birth labor satisfaction, self-control, self-effi cacy pendahuluan bagi banyak perempuan, kelahiran seorang anak merupakan transisi kehidupan y a n g d i g a m b a r k a n s e b a g a i m o m e n t kemenangan, kepuasan dan penghargaan ketika mereka mendapat dukungan dari lingkungannya (nelson, 2003). pengalaman traumatis melahirkan hampir selalu dikaitkan dengan keadaan yang kurang baik seperti trauma pada bayi, tekanan psikologis seperti sakit fi sik yang dirasakan merupakan penyebab ketidak puasan ibu dengan pengalaman melahirkannya (creedy, shochet & horsfall, 2000). i b u y a n g m e r a s a p u a s d e n g a n pengalaman persalinannya akan memiliki perasaan bahagia dengan kehadiran bayinya dan akan berdampak pada kemudahan dalam menyesuaikan diri dan memulai peran menjadi ibu. sebaliknya, traumatik persalinan dapat mempenga r u h i kema mpu a n ibu d ala m mengasuh dan memberikan air susu ibu (asi) serta mengakibatkan buruknya ikatan ibu dan bayinya (simkin, 1992). penelitian goodman, mackey dan tavakoli (2004) menyimpulkan bahwa kontrol diri selama menjalani proses p e r sa l i n a n me r upa k a n fa k t or p e nt i ng 98 jurnal ners vol. 9 no. 1 april 2014: 97–103 terkait kepuasan ibu dengan pengalaman melahirkannya. menurut larkin, begley, dan devane (2009) perempuan yang telah berhasil dalam menjalani proses persalinan memiliki dampak meningkatnya harga diri dan merasakan hal itu sebagai suatu prestasi. sedangkan persalinan yang menyakitkan memiliki dampak psikologis yang menyebabkan kecemasan, depresi dan stres sehingga dapat mengganggu ikatan ibu dengan bayinya dan mengakibatkan efek psikologis jangka panjang bagi ibu maupun keluarganya. goodman, mackey dan tavakoli (2004) menyebutkan bahwa ketidakpuasan persalinan sebagai predisposisi terjadinya aborsi di kemudian hari, kurangnya hasrat dalam berhubungan seksual dengan suami atau memilih melakukan operasi caesar pada persalinan berikutnya. banyak faktor yang menyebabkan perempuan merasa puas atau tidak puas dalam proses persalinan dan kelahirannya. penelitian goodman, mackey dan tavakoli (2004) menemukan faktor kontrol diri merupakan faktor yang signif ikan dengan kepuasan persalinan dan meny u mbang sebanyak 59% dari variabel kepuasan persalinan. sedangkan efi kasi diri merupakan keyakinan individu untuk mencapai suatu kemampuan yang mempengaruhi setiap peristiwa dalam hidupnya (bandura, 1994). lowe (2010) menyebut ka n ba hwa i bu ya ng per na h melahirkan sebelumnya (multipara) memiliki efi kasi diri yang lebih tinggi dibandingkan mereka yang melahirkan untuk per tama kalinya ibu yang mampu mempertahankan kontrol diri dengan baik dapat menurunkan dampak nyeri persalinan, dan ibu yang memiliki efi kasi diri yang tinggi menunjukkan tingkat kepuasan dalam menjalani proses persalinan yang lebih baik terhadap diri sendiri, maupun terhadap perawat, bidan maupu n dok ter yang membant u proses persalinannya (christiaens & bracke, 2007). di indonesia belum ditemukan data mengenai hubungan antara kontrol diri dan efi kasi diri dengan tingkat kepuasan ibu menjalani proses persalinan, sehingga perlu untuk diteliti lebih lanjut tentang bagaimana hubungan antara kontrol diri dan efi kasi diri dengan kepuasan ibu menjalani proses persalinan. metode rancangan penelitian ini adalah analitik korelasi dengan pendekatan cross sectional. sampel 125 ibu bersalin normal, dipilih menggunakan teknik consecutive sampling. penelitian dilakukan di ruang bersalin/ nifas rsud ratu zalecha martapura dan rsud banjarbaru, kalimantan selatan. alat pengumpulan data menggunakan kuesioner. kuesioner untuk mengukur kontrol diri menggunakan labour agentry scale (las) d ar i hod net t (2002). kuesioner u nt u k mengukur ef ikasi diri ibu menggunakan childbirth self-effi cacy inventory (cbsei) dari lowe (2010), dan kuesioner unt uk mengukur kepuasan ibu menjalani proses persalinan menggunakan the women’s views of birth labour satisfaction questionnaire (womblsq) yang dikembangkan oleh smith (2001). prosedur pengambilan data dimulai dengan memilih calon responden yang sesuai dengan kriteria sampel di ruang bersalin/ nifas. analisis data univariat menguraikan variabel karakteristik demografi responden meliputi usia, tingkat pendidikan, pekerjaan, penghasilan, dan paritas, serta data katagorik kontrol diri, efikasi diri dan kepuasan ibu menjalani proses persalinan. a n a l i s a d a t a b i v a r i a t u n t u k membuktikan hipotesa penelitian apakah ada hubungan antara kontrol diri, efi kasi diri, dan karakteristik responden dengan kepuasan ibu menjalani proses persalinan. analisis data multivariat digunakan untuk mengetahui hubungan kontrol diri dan efi kasi diri dengan kepuasan ibu menjalani proses persalinan setelah dikontrol oleh variabel confounding dengan pemodelan faktor resiko. uji statistik yang digunakan adalah uji regresi logistik ganda dengan tahapan meliputi seleksi kandidat dan pemodelan multivariat. 99 kontrol diri dan efi kasi diri (agustine ramie, dkk) hasil penelitian usia responden saat persalinan sebagian besar berada pada kategori usia risiko rendah persalinan (20-35 tahun) sebanyak 85,6 %. tingkat pendidikan, sebagian besar responden berpendidikan menengah sebanyak 44,8%. karakteristik pekerjaan responden, sebagian besar tidak bekerja di luar rumah (ibu rumah tangga) yaitu sebanyak 69,6%. berdasarkan penghasilan, sebagian besar responden dengan penghasilan keluarga diatas upah minimum regional (umr) sebesar 84,4%. sedangkan berdasarkan paritas, sebanyak 56,8% sudah memiliki anak lebih dari satu (multipara). tabel 1. kontrol diri, efikasi diri dan kepuasan responden menjalani persalinan di rsud ratu zalecha martapura dan rsud banjarbaru kalimantan selatan bulan mei – juni 2013 kategori jumlah (n) persentase (%) kontrol diri baik kurang baik 69 56 55,2 44,8 efi kasi diri baik kurang baik 70 55 56 44 kepuasan responden menjalani persalinan puas kurang puas 67 58 53,6 46,4 tabel 1 menunjukkan bahwa sebagian besar responden memiliki kontrol diri yang baik misalnya dengan menyatakan kontrol diri merupakan hal yang penting, merasa r ileks, mampu meng uasai dir i, merasa berhasil menguasai diri saat melahirkan, merasa memiliki kontrol diri yang baik selama menjalani proses persalinan, yaitu sebesar 55,2%. sebanyak 56% responden memiliki efi kasi diri (keyakinan akan kemampuan diri) dalam menjalani proses persalinan dengan kategori baik. demikian juga dengan kepuasan ibu dalam menjalani proses persalinan menunjukkan bahwa sebagian besar responden merasa puas dengan proses kelahiran anak mereka yaitu sebesar 53,6 %. berdasarkan hasil analisis hubungan antara variabel kontrol diri dengan kepuasan ibu menjalani proses persalinan menunjukkan bahwa sebanyak 46 responden (66,7%) memiliki kontrol diri yang baik merasa puas dalam menjalani proses persalinan. ha si l uji st at ist i k me nu nju k k a n bahwa ada hubungan antara kontrol diri dengan kepuasan responden menjalani proses persalinan ( p value 0.002, α: 0.05). berdasarkan nilai or dapat disimpulkan bahwa responden dengan kontrol diri yang baik memiliki peluang 3,33 kali merasa puas dalam menjalani proses persalinan dibandingkan dengan responden yang memiliki kontrol diri yang kurang baik. h a si l a n a l i si s hu bu ng a n a nt a r a variabel efikasi diri dengan kepuasan ibu menjalani proses persalinan menunjukkan bahwa sebanyak 49 responden (70,0 %) yang memiliki efi kasi diri baik, merasa puas dalam menjalani proses persalinan. hasil uji statistik menunjukkan bahwa ada hubungan antara efi kasi diri dengan kepuasan ibu menjalani proses persalinan di rsud ratu zalecha martapura dan rsud banjarbaru ( p value 0.000, α: 0.05). dari hasil analisis diperoleh pula nilai or=4,79 artinya bahwa responden dengan efi kasi diri yang baik memiliki peluang 4,79 kali merasa puas dalam menjalani proses persalinan dibandingkan dengan responden yang memiliki efi kasi diri kurang baik analisis hubungan antara usia dengan kepuasan ibu menjalani proses persalinan terlihat bahwa sebanyak 58 responden (54,2 %) memiliki usia antara 20 – 35 tahun (resiko rendah persalinan) merasa puas dalam menjalani proses persalinan mereka. hasil uji statistik diperoleh p value = 0,940, maka dapat disimpulkan tidak ada hubungan antara usia dengan kepuasan responden menjalani proses persalinan. hasil analisis hubungan antara tingkat pendidikan dengan kepuasan ibu menjalani proses persalinan menunjukkan sebanyak 12 responden (48,0%) yang berpendidikan tinggi, 36 responden (64,3%) yang berpendidikan menengah, serta 19 responden (43,2%) yang berpendidikan dasar memiliki perasaan puas dalam menjalani proses persalinan mereka. 100 jurnal ners vol. 9 no. 1 april 2014: 97–103 hasil uji statistik diperoleh p value 0,090 maka dapat disimpulkan tidak ada hubungan antara tingkat pendidikan dengan kepuasan responden menjalani proses persalinan. h a si l a n a l i si s hu bu ng a n a nt a r a pekerjaan responden dengan kepuasan ibu menjalani proses persalinan menunjukkan bahwa sebanyak 19 responden (50 %) yang bekerja di luar rumah dan 48 responden yang tidak bekerja di luar rumah atau ibu rumah tangga (53,6%) memiliki perasaan puas dalam menjalani proses persalinan mereka. hasil uji statistik menunjukkan bahwa tidak ada hubungan antara pekerjaan responden dengan kepuasan mereka menjalani proses persalinan ( p value 0,735, α: 0.05). analisis hubungan antara penghasilan keluarga dengan kepuasan menjalani proses persalinan menunjukkan bahwa sebanyak 62 responden (58,5%) ya ng mem il i k i penghasilan keluarga di atas upah minimum regional (umr) dan 5 responden (26,3%) yang penghasilan keluarganya di bawah upah minimum regional (umr) memiliki kepuasan menjalani proses persalinan. hasil uji statistik menunjukkan bahwa ada hubungan antara penghasilan keluarga responden dengan kepuasan mereka dalam menjalani proses persalinan (p value 0.019, α: 0.05). berdasarkan nilai or dapat disimpulkan bahwa responden yang penghasilan keluarganya di atas upah minimum regional (umr) memiliki peluang 3,94 kali untuk merasa puas dalam menjalani proses persalinan dibandingkan dengan responden yang penghasilan keluarganya di bawah upah minimum regional. berdasarkan pemodelan multivariat d apat disi mpul kan bahwa fa k tor yang signif ikan mempengar uhi kepuasan ibu menjalani proses persalinan adalah kontrol diri, efi kasi diri, penghasilan keluarga dan jumlah anak yang dilahirkan ( par itas). berdasarkan nilai odds ratio (or) ke empat faktor, dapat disimpulkan bahwa faktor yang paling dominan berpengaruh terhadap kepuasan ibu menjalani proses persalinan adalah penghasilan keluarga. ibu yang memiliki kontrol diri kurang baik beresiko untuk kurang puas menjalani proses persalinan 2,177 (ci 95% : 0,958 – 4,947) kali lebih besar dibandingkan dengan ibu yang memiliki kontrol diri baik, setelah dikontrol oleh variabel efi kasi diri, penghasilan dan paritas. ibu yang memiliki efi kasi diri kurang baik beresiko untuk kurang puas menjalani proses persalinan 3,152 (ci 95% : 1,380–7,200) kali lebih besar dibandingkan dengan ibu yang memiliki efi kasi diri baik, setelah dikontrol tabel 2. hasil pemodelan akhir variabel utama dan variabel confounding dengan kepuasan responden menjalani proses persalinan di rsud ratu zalecha martapura dan rsud banjarbarukalimantan selatan bulan mei – juni 2013 variabel b wald pvalue or (ci 95%) kontrol diri baik 0.778 3.448 0.063 2.177 (0.9584.947) kurang baik efi kasi diri -baik 1.148 7.419 0.006 3.152 (1.380-7.200) -kurang baik penghasilan -di atas umr -di bawah umr 1.217 4.024 0.045 3.377 (1.028 -11.091) paritas -multipara 0.847 4.173 0.041 2.334 (1.035-5.262) -primipara constant -1.553 18.374 0.000 0.212 101 kontrol diri dan efi kasi diri (agustine ramie, dkk) oleh variabel kontrol diri, penghasilan dan paritas. pemodelan dengan 4 variabel independen (kontrol diri, efikasi diri, penghasilan dan paritas) mampu memprediksi kepuasan ibu menjalani proses persalinan sebesar 70,4% sedangkan sisanya yait u sebesar 29,6% dipengaruhi oleh variabel lain yang tidak diteliti dalam penelitian ini. pembahasan ad a beberapa fa k tor yang d apat mempengaruhi kepuasan ibu dalam menjalani proses persalinan yaitu pengalaman ibu mela h i rk a n sebelu m nya , kont rol d i r i, ketidaknyamanan ibu akibat nyeri persalinan, efi kasi diri, harapan ibu terhadap persalinannya. namun faktor yang paling dominan selain ketidaknyamanan nyeri persalinan adalah kontrol diri dan efi kasi diri (christiaens & bracke, 2007). penelitian lainnya tentang faktor-faktor yang berhubungan dengan kepuasan melahirkan (goodman, mackey & tavakoli, 2004) menemukan bahwa kontrol diri merupakan prediktor kepuasan yang signifi kan dari total kepuasan persalinan. kontrol diri mer upakan salah satu faktor yang berhubungan dengan kepuasan persalinan. tingginya tingkat kontrol diri berbanding lurus dengan tingginya tingkat kepuasan persalinan (simkin, 1992, dalam goodman, mackey & tavakoli, 2004). hasil penelitian menunjukkan bahwa sebagian besar responden memiliki kontrol diri yang baik dalam menjalani proses persalinan. ibu yang memiliki kontrol diri yang baik akan mampu menggunakan teknik untuk mengurangi nyeri yang telah di ajarkan maupun berdasarkan pengalaman melahirkan sebelumnya. ibu mampu menguasai diri sehingga ibu tampak lebih tenang, tidak berteriak-teriak. hal ini sesuai dengan hasil penelitian yang dilakukan oleh goodman, mackey dan tavakoli (2004) yang menyatakan bahwa variabel kontrol diri memberi kontribusi sebanya k 59% d a r i va r iabel kepuasan persalinan. a nalisis hubu ngan antara kont rol diri dengan kepuasan responden menjalani proses persalinan menu nju k kan bahwa responden yang memiliki kontrol diri yang baik memiliki perasaan puas dalam menjalani proses persalinan. hasil analisis statistik menunjukkan bahwa ada hubungan yang bermakna antara kontrol diri dengan kepuasan ibu dalam menjalani proses persalinan, dimana responden yang memiliki kontrol diri yang baik menyatakan bahwa mereka merasa tenang, rileks, tidak takut dalam menjalani proses persalinan, dapat mengikuti anjuran dan pet unjuk dari penolong persalinan, sehingga mereka memiliki pengalaman yang menyenangkan yang berdampak pada perasaan yang lebih puas dalam menjalani proses persalinan. dengan demikian hipotesis penelitian ini yang menyatakan bahwa ada hubungan antara kontrol diri dengan kepuasan ibu menjalani proses persalinan gagal ditolak, dengan didukung oleh berbagai penelitian di atas. hasil penelitian menunjukkan bahwa sebagian besar responden memiliki efi kasi diri yang baik dalam menjalani proses persalinan. ibu yang memiliki efikasi diri yang baik akan ditunjukkan dengan kemampuannya dalam beradaptasi terhadap nyeri persalinan, tampak tenang, mampu mengendalikan diri sendiri, mampu mengikuti anjuran dari penolong persalinan, mampu mengat u r pernafasan selama ada mules (kontraksi), dapat mengalihkan perhatian, dan mampu menjalani proses persalinan dengan kekuatan sendiri. lowe, perrin dan tanglakmankhong (2010) menyatakan bahwa ibu melahirkan yang memiliki efi kasi diri yang baik akan mampu melak u kan kont rol dir i secara efektif. efi kasi diri yang baik akan terlihat dari kemampuan ibu beradaptasi terhadap nyeri persalinan, ibu tampak tenang, mampu mengikuti anjuran dari penolong persalinan, dan mampu menjalani proses persalinan dengan kekuatan sendiri. sedangkan ibu yang efi kasi dirinya kurang baik akan menurunkan kemampuan dalam menyelesaikan persalinan, yang memungkinkan terjadinya persalinan dengan masalah misalnya kurangnya kekuatan mengedan, proses persalinan akan lebih lama, tidak mampu mengikuti anjuran dari penolong 102 jurnal ners vol. 9 no. 1 april 2014: 97–103 persalinan, ibu menyatakan rasa takut, ibu tampak gelisah dan kurang mampu menguasai diri, sehingga proses persalinan yang dijalani menjadi kurang baik yang mengakibatkan bertambahnya kesakitan pada ibu dan bayi yang menyebabkan pengalaman yang kurang menyenangkan sehingga ibu merasa kurang puas dengan proses persalinannya. menurut teori lawrence green (1980, dalam notoatmodjo, 2003) menyatakan bahwa penghasilan merupakan faktor pemungkin (enabling factor) ya ng mempenga r u h i p e r i l a k u s e s e o r a n g. s e s e o r a n g a k a n ber perilaku postif atau negatif terhadap pemberian layanan persalinan juga tergantung pada ketersediaan dana. bagi pasien yang berpenghasilan tinggi akan merasa mampu membayar mahal dan mudah merasa puas bila pelayanan sesuai dengan kehendaknya, tetapi yang berpenghasilan rendah bahkan yang mendapatkan keringanan bantuan (misalnya dari program jaminan persalinan), mereka akan lebih pasrah dalam menerima layanan persalinan apapun yang diberikan karena ketidakmampuan mereka dalam masalah dana. dengan demikian hipotesis penelitian ini yang menyatakan bahwa ada hubungan antara status penghasilan keluarga dengan kepuasan ibu menjalani proses persalinan gagal ditolak, didukung oleh penelitian hendriani (2006) dan penelitian goodman, mackey dan tavakoli (2004). hasil uji statistik menunjukkan bahwa ada hubungan antara paritas ( jumlah anak yang pernah dilahirkan) dengan kepuasan ibu menjalani proses persalinan. hal ini sesuai dengan penelitian waldenstorm (1999, dalam goodman, mackey & tavakoli, 2004) yang menyatakan bahwa multipara mempunyai tingkat kepuasan yang lebih tinggi dalam menjalani proses persalinan dibandingkan p r i m ip a r a . ti n g k a t ke c e m a s a n p a d a primipara lebih tinggi karena pengalaman ini memberikan perasaan bercampur baur antara senang, bahagia dan penuh harapan dengan perasaan khawatir tentang apa yang akan terjadi dalam proses persalinan (sarah, 2010). dengan demikian hipotesis penelitian ini yang menyatakan bahwa ada hubungan antara status paritas dengan kepuasan ibu menjalani proses persalinan gagal ditolak, dengan didukung oleh berbagai penelitian di atas. simpulan dan saran simpulan faktor yang mempengaruhi kepuasan responden menjalani proses persalinan adalah kontrol diri, efikasi diri, penghasilan dan paritas responden, sedangkan faktor yang dominan adalah penghasilan responden. saran kepada pemberi layanan persalinan d i ha r apk a n d apat membe r i du k u nga n sepenuhnya agar ibu bersalin memandang proses persalinan sebagai pengalaman positif dan menyenangkan ser ta membantu ibu meningkatkan kontrol diri terhadap nyeri yang dialami. institusi pelayanan persalinan perlu meningkatkan standar pelayanan persalinan menjadi lebih baik sehingga bisa memenuhi atau melampaui harapan ibu yang memiliki penghasilan keluarga diatas umr maupun yang dibawah umr. selanjut nya dapat diteliti dan dikembangkan model motivasi efikasi diri berdasarkan model the arcs (attention relevance confi dence satisfaction) yang dikembangkan oleh killer (1979, 1983) yang berdasarkan pengetahuan peneliti belum pernah dikembangkan di indonesia. kepustakaan bandura, a. (1994). self-efficacy. in v.s. ramachaudran (ed.), encyclopedia of human behavior (vol. 4, pp. 71-81). new york: academic press. ch ristiaens, w. & bracke, p.v. (2007). assessment of social psychological deter minants of satisfaction with childbirth in a cross-national perspective. bmc pregnancy and childbirth, 7:26 christiaens, w., verhaeghe, m., & bracke, p. (2010). pain acceptance and personal control in pain relief in two maternity care models: a crossnational comparison of belgium and the netherlands. bmc health services research, 10:268 103 kontrol diri dan efi kasi diri (agustine ramie, dkk) creedy, d.k., shochet, i.m., & horsfall, j. (2000). childbirth and the development of acute trauma symptoms: incidence and contributing factors. birth, 27, 104111 febriani, e. (2001). tesis analisis kepuasan pasien persalinan nor mal terhadap mutu layanan rumah sakit bersalin budi kemuliaan jakar ta. prog ram pascasarjana universitas indonesia. jakarta goodman, p., mackey, m.c., & takavoli, a.s. (2004). factors related to childbirth satisfaction. journal of advanced nursing 46 (2), 212–219 hendriani, c. (2006). tesis analisis harapan dan kepuasan pasien terhadap mutu pelayanan persalinan rumah sakit panti wilasa citar um semarang. program pascasarjana universitas diponegoro semarang. larkin, p., begley, c.m., & devane, d . (2009). women’s experiences of labour and birth: an evolutionary concept analysis. midwifery 25, e49–e59. lowe, n.k. (1993). maternal confi dence for labor: development of the childbirth self-efficacy inventory. research in nursing 6 health 16(2), 141-149. lowe, n., perrin,. a.n. tanglakmankhong.k. (2010). childbirth self-effi cacy inventory and childbirth attitudes questionnaire: psychometric properties of thai language versions. journal of advanced nursing. 2010 blackwell publishing ltd. nelson, m.a. (2003). transition to motherhood. journal of obstetric, gynecologic and neonatal nursing 32(4), 465–477. sarah,.m,. (2010). childbirth expectations and decision-making among poor, urban primiparous women. proquest dissertations and theses. sastroasmoro, s. & ismael, s. (2011). dasardasar metodologi penelitian klinis. jakarta: sagung seto smith,.p.f.l,.(2001). development of a multidimensional labour satisfaction questionnaire: dimensions, validity, and internal reliability. quality in health care 2001;10:17–22. 142 hubungan antara kategori imunodefisiensi dengan diare pada anak dengan hiv/aids (the relation between pediatric immunodefi ciency category and diarrhea in aids/hiv infected child) satrio wibowo departemen ilmu kesehatan anak fakultas kedokteran universitas brawijaya, rs. dr. saiful anwar malang, jl. jaksa agung suprapto no. 2, malang, jawa timur, 62144, e-mail: satrio_wibowo@rocketmail.com abstract introduction: diarrhea is one of the most prevalent cause of mortality and morbidity in aids/hiv infected child. severe immune suppression increase prolong and persistent diarrhea. the correlation between diarrhea and immune suppression level has not well known yet, particularly in saiful anwar hospital. the aim of this study is to determine relation between immune suppression level and prolonged or persistent diarrhea in aids/hiv infected child. method: retrospective crosssectional research were conducted on 68 medical records taken from patients who were admitted between february 2008 and august 2011. the characteristic of data taken were: age, sex, nutritional status, cd4+ counts, duration of diarrhea, other comorbid diseases beside diarrhea (pneumonia, tuberculosis, moniliasis) and the patient outcome. national guidelines clinical management of hiv/aids in children were used to diagnose hiv/aids. immune supression level was determined using cdc guidelines. immune supression level was ranked in to four categories: no immune defi cient, mild suppression, moderate suppression, and severe immunodefi cient. result: thirty six (53%) patients were male; diarrhea was found in 32 (47%) patients, acute diarhhea in 12 patients, prolonged diarrhea in 1 patient, persistent diarrhea in 19 patients. forty (40%) were severe immunodefi cient, 6% mild, 28% moderate and 40% without immunodefi ciency. discussion: statistical analysis showed that there was no correlation between immune supression level and types of diarrhea. (95% ci, p = 0.17). keywords: immune supression, diarrhea, hiv/aids pendahuluan data unaids 33 juta orang di seluruh dunia diperkirakan menderita hiv/aids dan sekitar 12% terjadi pada anak berusia kurang dari 15 tahun (unaids, 2008). di indonesia, direktorat jenderal pengendalian penyakit dan penyehatan lingkungan kementrian kesehatan republik indonesia menyebutkan bahwa secara kumulatif diperkirakan 76.000 orang terjangkit infeksi hiv/aids dan 2,9% berusia kurang dari 15 tahun. disfungsi sistem imun dan akibat klinis yang ditimbulkan oleh infeksi hiv pada anak berkembang lebih cepat dibandingkan pada dewasa (yogev, 2004; agrawal, 2008). beberapa laporan di negara berkembang seperti di india dan beberapa negara di afrika, 50–80% anak dengan hiv/aids tidak melewati usia 5 tahun (asnake, 2005; chintu, 2008; thea, 1993; unaids, 2008). diare merupakan salah satu penyebab tingginya angka morbiditas dan mortalitas pada penderita infeksi hiv/aids. insiden diare pada anak dengan infeksi hiv sekitar 50% di negara maju dan mencapai 80% di negara berkembang (chintu, 2008; thea, 1993; unaids, 2008). supresi imun diduga akan meningkatkan resiko terjadinya diare berkepanjangan atau persisten, namun demikian hingga saat ini mekanismenya belum jelas. masih sedikit penelitian mengenai hubungan antara supresi imun karena penyakit hiv/aids dengan diare di indonesia. penelitian ini bertujuan untuk mengetahui hubungan antara derajat 143 hubungan antara kategori imunodefi sensi dengan diare (satrio wibowo) supresi imun dengan terjadinya diare pada anak dengan infeksi hiv/aids. bahan dan metode penelitian dilakukan dengan metode cross sectional retrospektif. subjek penelitian adalah 68 rekam medis pasien anak yang dirawat di bagian ilmu kesehatan anak fakultas kedokteran universitas brawijayaru mah sak it umu m d r. saif ul a nwar malang dengan diagnosis hiv/aids sejak februari 2008 sampai dengan agustus 2011. diagnosis hiv/aids pada pasien-pasien tersebut ditetapkan berdasarkan pedoman tatalaksana infeksi hiv pada anak dan terapi antiretroviral di indonesia departemen kesehatan ri direktorat jenderal pengendalian penyakit dan penyehatan lingkungan. umur, jenis kelamin, status gizi, stadium hiv, jenis diare, derajat imunodefisiensi, penyakit penyerta, serta keadaan pasien keluar dicatat. stadium hiv ditentukan berdasarkan stadium klinis who untuk bayi dan anak yang terinfeksi hiv. dengan cara klasifi kasi klinis ini subjek diklasifi kasikan menjadi stadium 1 (asimptomatik), stadium 2 (ringan), stadium 3 (sedang) dan stadium 4 (berat). sedangkan derajat supresi imun ditentukan berdasarkan klasifikasi who tentang imunodefisiensi hiv menggunakan penghitungan cd4+, yang selanjutnya diklasifikasikan menjadi tidak ada imunodefi siensi, imunodefi siensi ringan, sedang dan berat. s t a t u s g i z i d it e n t u k a n d e n g a n menghitung berat badan pasien saat sakit dibandingkan berat badan ideal menurut umur. berdasarkan berat badan, status gizi digolongkan menjadi gizi baik, gizi kurang dan gizi buruk. diare didefi nisikan sebagai suatu kondisi di mana seseorang buang air besar dengan konsistensi lembek atau cair dengan frekuensi dan volume yang lebih sering (biasanya tiga kali atau lebih) dalam satu hari. jenis diare ditentukan berdasarkan lamanya diare,yaitu diare akut bila diare dialami kurang dari 7 hari, diare berkepanjangan bila berlangsung antara 7–14 hari, dan diare persisten lebih dari 14 hari (juffrie, 2009). penyakit penyer ta adalah penyakit lain yang menyertai pasien dengan infeksi hiv/aids, yang dialami oleh pasien saat masuk perawatan di rumah sakit, antara lain: tuberkulosis, pneumonia dan moniliasis. selur uh data (usia, jenis kelamin, status gizi, stadium hiv, jenis diare, derajat imunodef isiensi, penyakit penyerta serta keadaan pasien keluar) akan dikategorikan d a n d it a mpi l k a n sebagai d at a d a sa r. selanjutnya akan dilakukan crosstab antara derajat imunodefi siensi dan jenis diare. uji chi-square dan uji korelasi rank spearman digunakan untuk menguji adanya hubungan antara derajat imunodefi siensi dengan jenis diare. hasil pengujian yang menunjukkan nilai signifi kansi (p) kurang dari alpha 0,05 dianggap bermakna atau menunjukkan adanya hubungan (dahlan, 2008). hasil selama periode februari 2008 sampai agustus 2011 telah dirawat sebanyak 68 pasien hiv/aids di ruang rawat inap bangsal anak (irna iv)/lab. ilmu kesehatan anak fakultas kedokteran universitas brawijayaru mah sa k it umu m d r. saif ul a nwar malang. perbandingan antara jenis kelamin laki-laki dan perempuan hampir sama yaitu 53% dan 47%. sebanyak 42 pasien berusia kurang dari 18 bulan (61%) dan 26 pasien berusia lebih dari 18 bulan (39%). secara kumulatif, gizi kurang dan gizi buruk lebih banyak dibandingkan dengan kelompok status gizi baik dan gizi lebih yaitu 72% dan 28%. sebanyak 39 (57%) penderita hiv/aids yang dirawat pada stadium 4 dan 50% penderita secara imunologis mengalami supresi imun berat. di antara berbagai penyakit penyerta, diare masih merupakan penyakit penyerta yang paling sering (32 atau 47%), diikuti dengan moniliasis (29%), pneumonia (27%) dan tuberkulosis (19%). pada satu penderita dapat mengalami beberapa penyakit penyerta secara bersamaan. diare persisten merupakan bentuk diare yang paling banyak (19/32 atau 59%) dibandingkan diare berkepanjangan atau diare akut. sebanyak 38% pasien mengalami supresi imun berat, 6% supresi imun sedang, 144 jurnal ners vol. 7 no. 2 oktober 2012: 142–147 28% supresi imun ringan dan 38% sisanya tidak mengalami imun supresi. sebagian besar tabel 1. kategori imun berdasar pada jumlah dan persentase sel t + cd4 derajat imunodefi siensi jumlah sel t + cd4 spesifi k terkait umur dan persentase < 11 bulan (%) 12–35 bulan (%) 36–59 bulan (%) > 5 tahun (abs. count) tanpa supresi > 35 > 30 > 25 > 500 ringan 30–35 25–30 20–25 350–499 sedang 25–30 20–25 15–20 200–349 berat < 25 < 20 < 15 < 200 atau < 15% tabel 2. karakteristik dasar subjek penelitian (n = 68) karakteristik subjek penelitian jumlah (persentase) n = 68 jenis kelamin (n,%) laki-laki perempuan 36 (53%) 32 (47%) kategori umur 1–1 bulan 1–6 bulan 7–18 bulan 18–60 bulan > 5 tahun 13 (19%) 9 (13%) 20 (29%) 18 (27%) 8 (12%) status gizi gizi lebih gizi baik gizi kurang gizi buruk 4 (6%) 24 (35%) 13 (19%) 27 (40%) stadium hiv stadium 1 stadium 2 stadium 3 stadium 4 9 (13%) 10 (15%) 10 (15%) 39 (57%) penyakit penyerta* diare pneumonia moniliasis tuberculosis 32 (47%) 27 (38%) 29 (43%) 19 (28%) jenis diare diare akut diare berkepanjangan diare persisten tidak diare 12 (18%) 1 (1%) 19 (28%) 36 (53%) terapi anti retroviral mendapat terapi arv tidak mendapat terapi 28 (41%) 40 (59%) keadaan saat pulang hidup (rawat jalan) meninggal 54 (80%) 14 (20%) * satu penderita dapat mengalami beberapa penyakit penyerta penderita (80%) pulang dalam keadaan hidup dan kontrol/rawat jalan. 145 hubungan antara kategori imunodefi sensi dengan diare (satrio wibowo) a nalisis data dengan uji korelasi spearman menunjukkan tidak ada hubungan bermakna antara derajat imunodef isiensi dengan jenis diare. pembahasan limfosit t cd4+ merupakan sel sistem imun yang diserang dan dirusak oleh virus hiv (yogev, 2004; akib, 2004; miller, 2011) sehingga hitung jumlah cd4+ dianggap menggambarkan status imunologisnya dan derajat supresi imun. konsep bahwa status imunologis sangat berperan dalam menentukan kemampuan per tahanan individu unt u k melawan berbagai agen penyakit telah diterima secara luas. artinya, telah dipahami bahwa semakin rendah status imunologis atau semakin tinggi derajat supresi imun maka akan semakin tinggi resiko seorang individu mengalami sakit dan sebaliknya. terdapat hubungan yang kuat antara gambaran klinis infeksi hiv dengan derajat imunosupresi (agrawal, 2008). berbagai literatur menyebutkan bahwa diare, pneumonia, tuberkulosis, monilisasis dan malnutrisi adalah beberapa manifestasi klinis supresi imun yang paling sering (yogev, 2004; agrawal, 2008; asnake, 2005; chintu, 2008; unaids, 2008; akib, 2004; olga, 2005). diare pada hiv dapat terjadi pada semua stadium klinis, baik stadium dini maupun lanjut. pada tahap awal hiv biasanya diare ringan, intermiten dan dapat sembuh sendiri tanpa pengobatan. pada tahap lanjut, bersamaan dengan fungsi imun tubuh yang semakin menurun, diare menjadi kronik, terjadi penurunan berat badan serta malnutrisi. derajat supresi imun pada hiv selama ini dikaitkan dengan peningkatan resiko terjadinya manifestasi diare yang kronis atau persisten (yogev, 2004; miller, 2011). penelitian ini menghasilkan beberapa hal. pertama adalah diare menjadi penyakit penyerta terbanyak dalam penelitian ini (32 tabel 3. korelasi derajat imundefi siensi dengan jenis diare pada anak dengan infeksi hiv/aids derajat imunodefi siensi koefi sien korelasi (r) signifi kasi (p) kasus diare anak terkait infeksi hiv/aids -0,324 0,099 keterangan: spearman test pasien atau 47%). temuan ini sesuai dengan berbagai literatur yang menyebutkan bahwa manifestasi klinis terser ing pada anak adalah diare (yogev, 2004; agrawal, 2008; asnake,2005; chintu, 2008; miller, 2008). nilai yang beragam ditemukan dalam berbagai penelitian, berkisar antar 50–80% (yogev, 2004; asnake,2005; chintu, 2008; unaids, 2008; miller, 2011). kedua, bahwa diare persisten merupakan bentuk diare tersering (19 dari 32 pasien atau 59%) di antaranya adalah diare persisten. hasil ketiga dari penelitian ini adalah jenis diare tidak ada hubungan dengan derajat supresi imun. hal ini tidak sesuai dengan berbagai literatur terdahulu yang mendukung teori bahwa semakin tinggi derajat supresi imun, maka resiko terjadinya diare kronis atau persisten semakin tinggi. penelitian thea md, dkk menyebutkan bahwa bayi dengan infeksi hiv memiliki resiko 11 kali lipat mengalami diare dibanding bayi yang tanpa infeksi, di mana sebagian merupakan diare persisten (thea, 1993). demikian pula penelitian dari chintu yang menyatakan bahwa terdapat hubungan yang kuat antara individu dengan hiv positif dengan diare khronis dibandingkan dengan individu dengan hiv negatif (68% vs 22%, p < 0,05) (chintu, 2008). pernyataan tersebut didukung dengan teori bahwa semakin rendah jumlah sel cd4+, maka akan semakin lemah sistem kekebalan t ubuh individu sehingga infeksi oportunistik, termasuk diare, lebih sering terjadi terjadi (asnake, 2005; chintu, 2008; miller, 2008). di samping itu, saluran cerna merupakan target utama infeksi oportunistik pada anak dengan hiv/aids serta merupakan salah satu titik masuknya virus (site of infection) (miller, 2008). disebutkan bahwa penurunan jumlah cd4+ di saluran cerna lebih rendah dibandingkan dengan jumlah cd4+ di dalam darah, yang mengindikasikan supresi imun yang lebih berat terjadi di saluran cerna (miller, 2008). 146 jurnal ners vol. 7 no. 2 oktober 2012: 142–147 te rd apat beber apa kemu ng k i na n mengapa hasil penelitian ini tidak sesuai dengan penelitian-penelitian sebelumnya. pertama adalah belum diperhitungkannya faktor-faktor perancu, antara lain terapi yang sudah diberikan kepada pasien atau kepada orang tua pasien dari pasien yang masih mendapatkan asi, penyakit penyerta dan status gizi. pemberian terapi anti retroviral (arv) terbukti mampu mencegah depresi cd4+ bahkan mampu meningkatkan persentase dan jumlah absolut sel t limfosit cd4+, sekalipun peningkatannya tidak bisa setara dengan kelompok kontrol (resino, 2004). pada penelitian ini sebanyak 40 penderita (59%) telah mendapatkan terapi antiretroviral. faktor perancu lainnya adalah penyakit penyerta lain dan status gizi. seperti telah diketahui bahwa penyebab diare sangat luas, meliputi faktor-faktor infeksi maupun non infeksi. penyebab infeksi bermacam-macam, terbagi menjadi penyebab infeksi di dalam saluran cerna, maupun infeksi di luar saluran cerna. sehingga adanya faktor penyakit penyerta lain sangat mempengaruhi jenis atau durasi diare. demikian pula halnya dengan status gizi, malnutrisi akan menyebabkan atrofi villi, enteropati, dan disregulasi sistem enteral karena fungsi enzimatis yang menurun (brian, 2012). kemungkinan kedua, beberapa literatur menyebutkan bahwa kadar cd4+ dalam serum tidak selalu menggambarkan kadar cd4+ pada mukosa saluran cerna, sekalipun pada beberapa penelitian dikatakan bahwa penu r u nan kadarnya memang lebih progresif (brenchley, 2004; mehandru, 2004). ketiga, sistem imun saluran cerna memiliki karakteristik dan otonomi tersendiri yaitu ig a sekretorik (secretory iga/siga) memegang peran yang dominan dalam fungsi pertahanan saluran cerna (kaiserlian, 2005; forchielli, 2005). keempat adalah belum diperhitungkannya jenis kuman atau patogen penyebab diare, derajat virulensi dan jumlahnya. manifestasi klinis diare pada penderita hiv/aids sangat ditentukan oleh jumlah dan jenis patogennya (assefa, 2009; brink, 2002). kelima, sebaran data pada cross tabulasi dari derajat supresi imun dengan jenis diare tidak normal, di mana hal tersebut dapat mempengaruhi hasil analisa statistik penelitian. simpulan dan saran simpulan kesimpulan dari penelitian ini adalah bahwa diare masih mer upakan penyakit penyerta terbanyak pada anak dengan infeksi hiv/aids. diare persisten merupakan bentuk tersering dari diare. derajat supresi imun pada penderita hiv/aids anak tidak selalu berhubungan dengan jenis diare yang dialami. saran perlu penelitian lebih lanjut dengan desain penelitian yang lebih baik untuk meminimalkan pengaruh variabel-variabel perancu. perlu jumlah subjek penelitian yang lebih banyak untuk memperkuat validitas penelitian. kepustakaan agrawal, d., chakravarty, j., sundar, s., gupta, v., 2008. correlation between cli n ical feat u res and deg ree of immunosupression in hiv infected children. indian pediatrics, 45: 140–3. akib, a.a.p., 2004. infeksi hiv pada bayi dan anak. sari pediatri, 2: 1–14. asnake, s., amsalu, s., 2005. clinical manifestasions of hiv/aids in children i n nor t hwest et h iopia. ethiopia journal health and development, 19(1): 24–28. assefa, s., erko, b., medhin, g., assefa, z., shimelis, t., 2009. intestinal parasitic infections in relation to hiv/aids status, diarrhea and cd4-t cell count. bmc infectious disease, 9: 155. brenchley, j.m., schacker, t.w., ruff, l.e., et al., 2004. cd4+ t cell depletion during all stages of hiv disease o c c u r s p r e d o m i n a n t l y i n t h e gastrointestinal tract. journal expert of medicine, 200: 749–759. brian, c.z., thuli, p., holly, m.z., holly, f., francis, c., margaret, e.f., 2012. predictors of poor cd4 and weight recovery in hiv infected children 147 hubungan antara kategori imunodefi sensi dengan diare (satrio wibowo) initiating art in south africa. plos one, 7: 1–8. brink, a.k., mahe, c., watera, c., et al., 2002. diar rhea, cd4 counts and enteric infections in a communitybased cohort of hiv-infected adults in uganda. journal of infection, 45: 99–106. chintu, c., dupont, h.l., kaile, t., mahmoud, m., marani, s., baboo, k.s., et al., 20 08. hu ma n i m mu nodef iciency vir us – associated diar rhea and wasting in zambia: selected risk factors and clinical associations. american journal of tropical medicine and hygiene, 59: 38–41. dahlan, m.s., 2008. statistik untuk kedokteran dan kesehatan. edisi 3. jakar ta: penerbit salemba medika. forchielli, m.l., walker, w.a., 2005. the role of gut-associated lymphoid tissue and mucosal defens. british jounal of nutrition, 93: s41–s48. juffrie, m., mulyani, n.s., (ed)., 2009. modul pelatihan diare. edisi 1. jakarta: ukk gastroenterologi hepatologi idai. kaiserlian, d., cerf-bensussan, n., hosmalin, a., 2005. the mucosal immune system; from cont rol of inf lammation to protection againts infections. journal leucocytes biology, 78: 311–318. mehandru, s., poles, m.a., tenner-racz, k., et al., 2004. primary hiv-1 infection is associated with preferential depletion of cd4+ t lymphocytes from effector sites in the gastrointestinal tract. journal expert of medicine, 200: 761–770. m i l le r, t. l ., c u s h m a n , l . l ., 2 011. gast rointestinal complications of secondary immunodefi ency syndromes. dalam: willie, r., hyams, j.s., kay, m., (eds)., pediatric gastrointestinal and liver disease 4th ed. philadelphia: elsevier saunders; hlm. 447–461. olga, k., 2011. growth and development of children with hiv/aids. mhsj, 8: 16–20. resino, s., galán, i., pérez, a., león, j.a., seoane, e., gurbindo, d., et al., 2004. hiv infected children with moderate/ severe immune-suppression: changes in the immune system after highly active antiretroviral therapy. clinical expert of immunologi, 137: 570–7. thea, d.m., st. louis, m.e., atido, u., kanjinga, k., kembo, b., matondo m, et al., 1993. a prospective study of diarrhea and hiv-1 infection among 429 zairian infants. new england journal of medicine, 329 (23): 1696– 1702. unaids, 2008. aids epidemic update 2008. geneva. yogev, r., chadwick, e.g., 2004. acquired immunodefi ciency syndrome (human immunodef iciency vir us). dalam: behrman re, kliegman rm, jenson hb (ed). nelson textbook of pediatrics 17th ed. new york: elsevier; hlm. 1109– 1121. 164 analisis faktor risiko kehamilan ektopik (analysis of risk factors ectopic pregnancy) budi santoso departemen obstetri dan ginekologi fk.unair rsud. dr. soetomo surabaya, e-mail: busobg98@yahoo.com abstract introduction: ectopic pregnancy is a pregnancy with extrauterine implantation. this situation is gynecologic emergency that contributes to maternal mortality. therefore, early recognition, based on identifi cation of the causes of ectopic pregnancy risk factors, is needed. methods: the design descriptive observational. the samples were pregnant women who had ectopic pregnancy at maternity room, emergency unit, dr. soetomo hospital, surabaya, from 1 july 2008 to 1 july 2010. sampling technique was total sampling using medical records. result: patients with ectopic pregnancy were 99 individuals out of 2090 pregnant women who searched for treatment in dr. soetomo hospital. however, only 29 patients were accompanied with traceable risk factors. discussion:. most ectopic pregnancies were in the age group of 26-30 years, comprising 32 patients (32.32%), then in age groups of 31–35 years as many as 25 patients (25.25%), 18 patients in age group 21–25 years (18.18%), 17 patients in age group 36–40 years (17.17%), 4 patients in age group 41 years and more (4.04%), and the least was in age group of 16–20 years with 3 patients (3.03%). a total of 12 patients with ectopic pregnancy (41.38%) had experience of abortion and 6 patients (20.69%) each in groups of patients with ectopic pregnancy who used family planning, in those who used family planning as well as ectopic pregnancy patients with history of surgery. there were 2 patients (6.90%) of the group of patients ectopic pregnancy who had history of surgery and history of abortion. the incidence rate of ectopic pregnancy was 4.73%, mostly in the second gravidity (34.34%), whereas the nulliparous have the highest prevalence of 39.39%. acquired risk factors, i.e. history of operations was 10.34%, patients with family planning 20.69%, patients with history of abortion 41.38%, patients with history of abortion and operation 6.90% patients with family and history of abortion was 20.69%. keywords: ectopic pregnancy, ectopic pregancy risk factors, prevalence of ectopic pregnancy pendahuluan kehamilan normal, oozit yang sudah dibuahi akan melalui tuba falopii menuju ke uterus. kehamilan ektopik (ke) terjadi bila telur yang dibuahi berimplantasi dan tumbuh di luar endometrium cavum uteri (wiknjosastro, 2006). kehamilan ektopik merupakan keadaan emergensi yang menjadi penyebab kematian maternal selama kehamilan trimester pertama. sebagian besar implantasi ekstrauterin terjadi di tuba fallopii. tempat yang paling sering adalah pada ampulla (80%), kemudian berturut-turut pada pars ismika (12%), fi mbria (5%), dan pars intersisialis (0,2%), implantasi yang terjadi di ovarium (0,2%) dan di serviks (0,2%) (speroff, 2005). berbeda dengan penelitian santoso (2006) yang melakukan penelitian terhadap ke dengan pembandingan penanganan secara laparotomi vs laparoskopi, terhadap kasus ke, didapatkan 216 kasus kehamilan ektopik dalam rentang waktu mei 2004–juli 2005, dengan perincian sebagai frekuensi terbanyak lokasi terjadinya kehamilan ektopik adalah di tuba pars ampularis 61,5%, disusul dengan tuba pars istmika 11,5% dan kehamilan ovarii sebesar 3,8%, sedangkan lokasi implantasidi fi mbrie, cornu, abdominal maupun kehamilan cervical tidak didapatkan pada sampel yang diambil pada penelitian tersebut. kehamilan di luar tuba ialah kehamilan ovarium, kehamilan intraligamenter, kehamilan servikal, dan kehamilan abdominal yang analisis faktor risiko kehamilan ektopik (budi santoso) 165 bisa primer atau sekunder. beberapa faktor risiko penyebab kehamilan ektopik antara lain faktor tuba, 5–10 kali lipat pada pasien dengan riwayat salfi ngitis. perlekatan lumen tuba, kelainan anatomi tuba akibat ekspose diethyl stilbesterol-des intrauteri. riwayat operasi pada tuba falopii termasuk pasca tubektomi – pasca rekonstruksi tuba, pasca terapi konservatif pada kehamilan ektopik, kelainan zygot. faktor ovarium: migrasi eksterna, hormon eksogen kehamilan yang terjadi pada pasien dengan kontrasepsi oral yang hanya mengandung progestin (progestinonly pill) disebabkan oleh efek relaksasi otot polos progestin. faktor lain alat kontrasepsi dalam rahim (iud), merokok, usia tua, riwayat abortus berulang (condous, 2006). incident rate kehamilan ektopik di amerika serikat mengalami peningkatan lebih dari 3 kali lipat selama tahun 1970 dan 1987, dari 4,5/1000 kehamilan menjadi 16,8/1000 kehamilan. data centers for disease control and prevention, insiden rate ke di amerika serikat pada tahun 1990–1992 diperkirakan 19,7/1000 kehamilan. tahun 1997–2000 mengalami peningkatan lagi menjadi 20,7/1000 kehamilan. di logos, nigeria, 8,6% kematian ibu disebabkan oleh ke dengan case fatality rate (cfr) 3,7%. di norwegia, incidence rate ke meningkat dari 4,3/10.000 kehamilan menjadi 16/10.000 kehamilan selama periode 1970–1974 sampai 1990–1994, dan menurun menjadi 8,4/10.000 kehamilan (speroff, 2005). tujuan dari penelitian ini adalah untuk mengetahui prevalensi ke dan melakukan analisa terhadap faktor risiko kehamilan ektopik di rsud dr. soetomo surabaya. bahan dan metode jenis penelitian yang digunakan dalam penelitian ini adalah deskriptif observasional untuk mengetahui prevalensi terjadinya ke serta menganalisa faktor risiko ke dengan menggunakan data sekunder. objek penelitian adalah semua ibu hamil yang mengalami ke di ruang vk bersalin instalasi rawat darurat rsud dr. soetomo surabaya periode waktu 1 juli 2008–1 juli 2010. dengan teknik pengambilan sampel dalam penelitian ini dilakukan dengan cara total sampling. jumlah sampel penelitian penderita ke sebanyak 99 orang dari total 2090 pasien ibu hamil yang berobat atau periksa di rsud dr. soetomo. didapatkan pula sebanyak 29 pasien disertai dengan faktor risiko dari 99 pasien ke. hasil jumlah pasien ke terbanyak adalah kelompok usia 26–30 tahun yaitu sebanyak 32 pasien (32,32%), diikuti pasien dari kelompok usia 31–35 tahun sebanyak 25 pasien (25,25%). berikutnya sebanyak 18 pasien pada kelompok 21–25 tahun (18,18%), kemudian sebanyak 17 pasien pada kelompok 36–40 tahun (17,17%), didapatkan 4 pasien pada kelompok 41 tahun ke atas (4,04%) dan yang paling kecil pada kelompok usia 16–20 tahun dengan 3 pasien (3,03%). gambar 1. distribusi pasien ke di rsud dr. soetomo sejak 1 juli 2008 hingga 1 juli 2010 berdasarkan usia. jurnal ners vol. 6 no. 2 oktober 2011: 164–168 166 penelitian ini didapatkan 29 pasien, di mana pada rekam medik menunjukkan disertai faktor risiko dari 99 pasien ke. tabel 1 menunjukkan hasil bahwa ke paling banyak terjadi pada gravida kedua sebanyak 34 pasien (34,34%). sedangkan jumlah terkecil didapatkan pada ke yang terjadi di kehamilan kelima dan seterusnya sebanyak 6 pasien (6,06%). gambar 2 menunjukkan 12 pasien (41,38%) ke pernah mengalami abortus, sebanyak 6 pasien (20,69%) masing-masing pada kelompok pasien ke yang menggunakan kb, dan pada kelompok yang menggunakan kb serta adanya riwayat abortus. berikutnya didapatkan sebanyak 3 pasien (10,34%) pada kelompok pasien ke yang memiliki riwayat operasi. hanya 2 pasien (6,90%) dari kelompok pasien ke yang memiliki riwayat operasi dan riwayat abortus. pembahasan kelompok usia 26–30 tahun merupakan kelompok yang memiliki jumlah pasien paling tinggi di antara kelompok usia lainnya, sebesar 32,32%, kemudian disusul dengan kelompok usia 31–35 tahun 25,25%, setelah itu pada kelompok usia 21–25 tahun 18,18%, kelompok usia 36–40 tahun didapatkan 17,17% kelompok usia 41 ke atas memiliki persentase 4,04%. paling kecil dari kelompok usia 16–20 tahun sebesar 3,03%. pada penelitian yang dilakukan oleh bangun, di rumah sakit umum pusat haji adam malik medan tahun 2003–2008 dikatakan bahwa kelompok usia terbanyak ada pada kelompok usia 31–40 kemudian baru diikuti kelompok usia 21–30 pada urutan kedua. penelitian ini terjadi pergeseran urutan antara kelompok usia 21–30 tahun dan kelompok gambar 2. distribusi faktor risiko ke di rsud dr. soetomo sejak 1 juli 2008 hingga 1 juli 2010. gambar 3. paritas pada pasien yang mengalami ke di rsud dr. soetomo sejak 1 juli 2008 hingga 1 juli 2010. tabel 1. distribusi graviditas kehamilan ektopik graviditas jumlah persentase (%) pertama kedua ketiga keempat kelima, > kelima 32 34 16 11 6 32,32 34,34 16,16 11,11 6,06 analisis faktor risiko kehamilan ektopik (budi santoso) 167 usia 31–40 tahun. lebih spesifi knya paling banyak pada kelompok usia 26–30 tahun. hal ini sama yang dilakukan oleh tharaux dari perancis mengatakan bahwa kelompok usia terbanyak ada pada 25–29 dengan 34,8% kemudian diikuti pada kelompok usia 30–34 dengan 30,8% (tharaux, 1989), hal ini dapat dikonfi rmasikan kembali melalui penelitian ini bahwa kelompok yang paling tinggi pada kelompok usia 26–30 sejumlah 32,32%. penderita kehamilan ektopik berjumlah 99 dari 2090 wanita hamil yang pernah berobat ataupun periksa di rsud dr. soetomo surabaya. didapatkan persentase sebesar 4,73%, ini merupakan angka yang cukup tinggi, oleh karena itu diperlukan upaya pengenalan dini terhadap faktor risiko oleh para pasangan usia reproduksi dengan harapan para pasangan dan petugas kesehatan dapat melakukan upaya preventif agar frekuensi terjadinya ke dapat diperkecil. d a t a y a n g d i k u m p u l k a n h a n y a 29 pasien yang dapat ditelusuri faktor risikonya dari 99 pasien. sekitar 70 pasien lainnya tidak didapatkan data. terhitung 29 data dengan faktor risiko pasien dengan adanya riwayat abortus menjadi faktor risiko yang berjumlah paling tinggi didapatkan 41,38%, kemudian tertinggi kedua adalah pasien dengan riwayat kb dan pasien yang kb dan ada riwayat abortus 20,69%, sedangkan pasien dengan riwayat operasi 10,34%, jumlah paling rendah adalah pasien yang ada riwayat operasi dan abortus 6,90%. p a s i e n y a n g m e m i l i k i l e b i h d a r i 1 faktor risiko ke, yaitu pasien yang memiliki riwayat operasi dan pernah mempunyai riwayat abortus, pasien dengan kb dan mempunyai riwayat abortus. pasien yang memiliki riwayat operasi tuba juga pernah mengalami abortus berjumlah 2 orang, demikian juga pasien ke yang menggunakan kb dan juga mempunyai riwayat abortus berjumlah 6 orang. pemahaman dan perhatian terhadap faktor risiko sangat penting terutama pada riwayat ke, riwayat operasi tuba, riwayat expose dari diethylstilbesterol yang memiliki kemungkinan besar terhadap terjadinya ke. riwayat infeksi pada alat reproduksi, clamydia, gonorrhoeal, sterilisasi dan infertilitas memiliki kemungkinan cukup besar juga (condous, 2006). wanita dengan kebiasaan merokok memiliki peningkatan faktor risiko ke meningkat sebesar 1,6–3,5 kali dibandingkan wanita yang tidak merokok. hal ini disebabkan karena merokok menyebabkan penundaan masa ovulasi (keluarnya telur dari indung telur), gangguan pergerakan sel rambut silia di saluran tuba, dan penurunan kekebalan tubuh (tharaux, 1998), sayangnya data tersebut tidak kami dapatkan pada sampel yang kami teliti. peneliti hanya menemukan 3 faktor risiko dalam penelitian ini yaitu riwayat operasi, penggunaan kb, dan riwayat abortus. walaupun sebenarnya ada banyak faktor risiko yang menyebabkan terjadinya ke seperti merokok, riwayat operasi sebelumnya semisal salpingitis, riwayat pasien pada obat-obat diethilstilbesterol yang dapat menyebabkan terjadinya kelainan anatomi tuba, dan jenis alat kontrasepsi apa yang digunakan oleh ibu tersebut. ketidaklengkapan inilah yang menjadikan penelitian ini tidak mampu mengungkap faktor risiko yang lebih luas, walaupun sebenarnya salpingitis yang disebabkan oleh penyakit menular seksual, mempunyai konstribusi yang tidak kecil (stova, 2002; carr, 2000). ke paling banyak terjadi pada kehamilan kedua 34,34%. sedangkan terbanyak kedua terjadi pada kehamilan pertama 32,32%. kemudian ke yang terjadi pada kehamilan ketiga 16,16%, diteruskan dengan kehamilan keempat 11,11%. jumlah terkecil didapatkan pada ke yang terjadi di kehamilan kelima dan seterusnya 6,06%. penelitian di perancis dikatakan bahwa kehamilan pertama 26,3%, kehamilan kedua 25,6%, kehamilan ketiga 23,3%, kehamilan keempat dan seterusnya sebesar 24,9%. dapat dilihat bahwa pada penelitian ini mengalami pergeseran jumlah tertinggi antara kehamilan pertama dan kedua. kehamilan ketiga terdapat perbedaan yang signifi kan antara 23,2% dengan 16,16% (tharaux, 1989). p a s i e n k e p r e v a l e n s i p a l i n g tinggi pada pasien yang belum memiliki anak sebanyak 39,39%. kemudian pada pasien yang memiliki 1 anak 37,37%. jurnal ners vol. 6 no. 2 oktober 2011: 164–168 168 dua belas pasien didapatkan dari pasien yang memiliki 2 anak 12,12%. pasien ke yang memiliki 3 anak 8,08%. jumlah paling kecil didapatkan pada pasien ke yang memiliki 4 anak atau lebih 3,03%. z i g o t y a n g d i b u a h i m e n g a l a m i kesulitan melalui saluran tersebut sehingga menyebabkan implantasi zigot dan tumbuh d i d a l a m s a l u r a n t u b a . f a k t o r r i s i k o memengaruhi gangguan pada saluran tuba di antaranya seperti merokok, infeksi panggul, endometriosis, dan beberapa tindakan medis operatif yang pernah dijalani. merokok dan infeksi panggul dapat menyebabkan gangguan pergerakan sel rambut silia di saluran tuba, dan penurunan kekebalan tubuh. perubahan anatomis tuba akibat tindakan medis yang pernah dilakukan maupun dilakukan kb (adulgopar, 2009). simpulan dan saran simpulan incident rate ke adalah 4,73%, terbanyak pada graviditas kedua (34,34%) sedangkan 39,39% didapatkan pada pasien yang belum mempunyai anak. faktor risiko yang didapat, yaitu riwayat operasi 10,34%, pasien dengan kb 20,69%, pasien dengan riwayat abortus 41,38%, pasien dengan riwayat operasi juga abortus 6,90%, dan pasien dengan kb yang memiliki riwayat abortus 20,69%. saran standarisasi cara pengisian rekam medik pasien di rsud dr. soetomo agar cukup informatif sehingga mempermudah penelitianpenelitian berikutnya. dengan pengenalan faktor risiko, maka diagnosis ke dapat dibuat sedini mungkin. kepustakaan a d u l g o p a r, 2 0 0 9 . k e h a m i l a n e k t o p i k , ( o n l i n e ) , ( h t t p : / / a d u l g o p a r. f i l e s . wordpress.com/2009/12/kehamilane k t o p i k . p d f . , d i a k s e s t a n g g a l 1 0 nopember 2011, jam 19 00). bangun, r., 2009. karakteristik ibu penderita kehamilan ektopik terganggu (ket) di rumah sakit umum pusat haji adam malik medan tahun 2003–2008. skripsi tidak dipublikasikan. fakultas kesehatan masyarakat, universitas sumatera utara, medan, sumatera utara. carr, r.j., dan evans, p., 2000. ectopic pregnancy, update in maternity care, ectopic pregnancy primary care. clinical offi ce pract, 2000; 27: 169–183. coundos, g., 2006. ectopic pregnancy risk factor and diagnosis. australian family physician, sydney; vol. 35: 854–857. santoso, b., 2006. perbandingan penanganan kehamilan ektopik secara laparotomi dan laparoskopi, bahan presentasi, pertemuan ilmiah tahunan (pit) pogi, mataram. sperrof, l., glass, r.h., dan kase, n.g., 2005. clinical gynecologic endocrinology and infertility, 6 th, philadelphia, lippincott, williams and wilkins: 1149–65. stova, g.t., 2002. early pregnancy loss and ectopic pregnancy, in novak's gynecology, 13th edition. philadelphia, lippincott, williams and wilkins: 507–542. tharaux, d., dan catherine, e., 1998. risk of ectopic pregnancy and previous induced abortion. american journal of public health; 88(3): 401–405. wiknjosastro, h., 2006. ilmu kebidanan. edisi ketiga, cetakan kedelapan, yayasan bina pustaka sarwono prawiroharjo, jakarta: 323–338. vol 8 no 2 oktober 2013.indd 309 pengembangan palliative community health nursing (pchn) untuk meningkatkan kemandirian keluarga dalam merawat penderita kanker di rumah (the development of palliative community health nursing to increase family’s autonomy in caring patient with cancer at home) elida ulfi ana*, eka mishbahatul mar’ah has*, praba diyan rachmawati* prodi pendidikan ners, fakultas keperawatan, universitas airlangga jl. mulyorejo (kampus c) unair 60115 surabaya e-mail: halebib@yahoo.com abstrak pendahuluan: kanker masih menjadi penyakit dengan angka mortalitas yang tinggi. pelayanan kesehatan berkelanjutan untuk penderita kanker yang bisa bertahan hidup (cancer survivors) sangat diperlukan untuk pencegahan kekambuhan dan meningkatkan kualitas hidup penderita kanker. pchn (palliative community health nursing) merupakan paket pelayanan perawatan kesehatan masyarakat (perkesmas) paliatif yang diberikan kepada keluarga dan penderita kanker di rumah, yang berfokus pada kegiatan promotif dan preventif. tujuan dari penelitian ini adalah menjelaskan pengaruh pengembangan pchn terhadap peningkatan kemandirian keluarga dalam perawatan penderita kanker di rumah. metode: jenis penelitian adalah pra eksperimen. populasi adalah keluarga penderita kanker pascaperawatan yang tercatat di wilayah kerja puskesmas mulyorejo, kota surabaya. sampel diambil dengan teknik purposive sampling. sejumlah 7 orang memenuhi kriteria inklusi. variabel independen adalah pchn. variabel dependen adalah tingkat kemandirian keluarga, dikumpulkan dengan lembar observasi tingkat kemandirian keluarga. data kemudian dianalisis dengan wilcoxon signed rank test, α ≤ 0,05. hasil: hasil uji menunjukkan ada perbedaan tingkat kemandirian keluarga penderita kanker sebelum dan sesudah pchn (p = 0,025). diskusi: pchn dapat meningkatkan kemandirian keluarga dalam perawatan penderita kanker di rumah. pelaksanaan pchn melalui kunjungan rumah dapat memberikan dukungan informasi terkait kanker dan perawatan di rumah bagi keluarga. pchn dapat dikembangkan sebagai salah satu metode untuk meningkatkan pelayanan paliatif di masyarakat oleh perawat komunitas, dalam rangka meningkatkan kualitas hidup penderita kanker. penelitian selanjutnya, diharapkan mengembangkan pchn dengan melibatkan tim yang multidisiplin, baik dari petugas kesehatan, rohaniawan, maupun sukarelawan. kata kunci: perawatan kesehatan masyarakat, paliatif, kemandirian keluarga, kanker abstract introduction: cancer still remains a disease with high mortality rate. sustainable health services for cancer survivors are important to prevent relapse and improve patient’s quality of life. pchn (palliative community health nursing) is a packet of community health nursing services given to the family and cancer’s patient at home, focused on promotive and preventive activities. the aim of this study was to analyze the infl uence of palliative community health nursing to increase family’s autonomy in caring patient with cancer at home. method: this study was used pre-experiment design. the populations were family who lived with cancer’s patient post treatment. samples were taken by purposive sampling technique; consist of 7 people. variable independent was pchn. variable dependent were family’s autonomy in caring patient with cancer at home collected by using observation form. the data were then analyzed by using wilcoxon signed rank test, with α ≤ 0.05. results: the results had showed the differences between family’s autonomy in caring patient at home before and after pchn (p = 0.025). discussion: pchn can increase family’s autonomy in caring cancer’s patient at home. the implementation of pchn through home visit can give informational support about cancer and treatment at home to the families. pchn can be used as one of method to improve palliative services at community, in order to increase cancer’s patient quality of life. further research, should develop pchn which involve multidicipline team, such as health care provider, clergy, and health volunteer. keywords: community health nursing, palliative, familiy’s autonomy, cancer pendahuluan kan ker masi h menjadi penyebab kematian ke-6 akibat penyakit tidak menular di indonesia (depkes ri, 2006). di indonesia setiap tahunnya 100 kasus baru terjadi di antara 100.000 penduduk. sekitar 70% di antaranya ditemukan dalam keadaan stadium yang sudah lanjut (oemiati, rahajeng, dan kristanto, 2011). perkembangan ilmu pengetahuan dan teknologi dalam pelayanan kedokteran dan 310 jurnal ners vol. 8 no. 2 oktober 2013: 309–316 asuhan keperawatan bagi penderita kanker yang meliputi berbagai terapi modalitas (kemoterapi, radioterapi, pembed ahan, dan terapi kombinasi) telah terbukti dapat memperpanjang ketahanan hidup penderita dibanding 10 tahun yang lalu (society, 2009). sejalan dengan hal tersebut, maka pelayanan kesehatan berkelanjutan untuk penderita kanker yang bisa bertahan hidup (cancer survivors) sangat diperlukan untuk mencegah kekambuhan dan meningkatkan kualitas hidup penderita kanker (coward, 2006). perawatan paliatif merupakan salah satu bentuk pelayanan kesehatan berkelanjutan untuk penderita kanker. perawatan paliatif dilakukan secara terpadu untuk meningkatkan kualitas hidup dengan meringankan keluhan penderita kanker, memberikan dukungan spiritual dan psikososial mulai dari diagnosa ditegakkan sampai akhir hayat, serta dukungan pada keluarga yang merasa kehilangan (who, 2005). fokus perawatan paliatif bukan hanya pada penderita, tetapi juga keluarga. perawatan paliatif yang paripurna mencakup berbagai setting mulai rumah sakit, perawatan komunitas yang dikelola puskesmas, dan perawatan di rumah (home care) (fauzi, 2011). akan tetapi, selama ini hanya perawatan paliatif berbasis rumah sakit yang berkembang. mayor it as pender it a kan ker akan kembali tinggal bersama keluarga pasca perawatan di rumah sakit (dinkes ri, 2008). keluarga memiliki peran penting dalam perawatan kesehatan anggota keluarga, ter utama yang sedang sakit (friedman, 2010). keluarga penderita kanker diharapkan mampu secara mandiri memberikan dukungan dan perawatan yang tepat untuk membantu meningkatkan kualitas hidup penderita kanker pasca perawatan. kemandirian keluarga berorientasi pada lima fungsi keluarga dalam mengatasi masalah kesehatannya yaitu mampu mengenal masalah kesehatannya, mengambil keputusan tepat untuk mengatasi kesehatannya, melakukan tindakan keperawatan untuk anggota keluarga yang sakit, memodifi kasi lingk u ngan sehingga menu njang upaya peningkatan kesehatan, serta memanfaatkan sarana pelayanan kesehatan yang ada (depkes ri, 2006). namun, kurangnya pengetahuan me mbu at kelu a rg a b elu m me m a h a m i perawatan penderita kanker di rumah. hal tersebut berdampak pada kondisi penderita yang tidak stabil, sehingga harus kembali ke rumah sakit untuk menjalani perawatan. menu r ut k r isnana (2012), fa k tor lingkungan yang berupa fisik (sarana dan prasarana) dan non fi sik (edukasi dan informasi petugas kesehatan) merupakan faktor utama yang sangat dibut u h kan oleh keluarga dalam merawat anggota keluarga yang sakit. dukungan berupa edukasi dan informasi merupakan salah satu strategi peningkatan kemandirian keluarga dalam perawatan penderita kanker (anggraeni dan ekowati, 2010). edukasi dapat diberikan oleh perawat komunitas sebagai petugas kesehatan di puskesmas yang bertanggung jawab terhadap pelayanan tindak lanjut keperawatan di rumah (saleh, danantosa, dan kusumawardhani, 2008). sebagai bagian dari kegiatan perawatan kesehatan masyarakat (community health nursing-chn). hasil studi pendahuluan diketahui bahwa pelaksanaan chn untuk penderita kanker di wilayah kerja puskesmas mulyorejo, kota surabaya masih belum optimal. selama ini, 19 penderita kanker pasca perawatan yang tercatat hanya datang ke puskesmas untuk meminta rujukan pelayanan paliatif ke rumah sakit. perawatan di rumah dilakukan oleh perawat komunitas atas permintaan dari penderita kanker dengan kebutuhan perawatan khusus (misalnya perawatan luka, memasukkan makanan melalui ngt, dan lain-lain). sementara follow up kunjungan r u mah oleh perawat komu nit as secara rutin dan terjadwal untuk penderita pasca perawatan kanker tanpa keluhan, belum dilakukan. padahal penderita tersebut juga masih memerlu kan promosi kesehatan, seperti perilaku sehat, nutrisi, dan terapi komplementer (skinner, wallace, dan levitt, 2007). oleh karena itu, peneliti tertarik untuk mengembangkan palliative community health nursing untuk meningkatkan kemandirian keluarga dalam perawatan penderita kanker di rumah, di wilayah kerja puskesmas mulyorejo, kota surabaya. 311 pengembangan palliative community health nursing (elida ulfi ana, dkk) bahan dan metode penelitian ini merupakan jenis penelitian pra eksperimen. populasi adalah keluarga penderita kanker pasca perawatan yang tercatat di wilayah kerja puskesmas mulyorejo, kota surabaya. sampel diseleksi dari populasi dengan teknik purposive sampling, dengan kriteria inklusi: 1) keluarga adalah salah satu orang terdekat (bisa bapak, ibu, suami, istri, dan anak) yang tinggal bersama dan terlibat aktif dalam perawatan penderita kanker di rumah; 2) keluarga berstatus warga tetap di kecamatan mulyorejo, kota surabaya; dan 3) keluarga bisa membaca dan menulis. sampel dieksklusikan apabila keluarga tersebut tinggal dengan penderita kanker pasca perawatan yang tergantung secara total. sampel yang didapatkan dari kriteria tersebut sebanyak 7 orang. variabel independen dalam penelitian ini adalah palliative communit y health nursing, yang berupa paket kunjungan rumah 3x30 menit oleh perawat komunitas, berfokus pada kegiatan promotif dan preventif yang dapat dilakukan secara mandiri oleh keluarga penderita kanker di r umah. sedangkan, variabel dependen dalam penelitian ini adalah tingkat kemandirian keluarga dalam perawatan penderita kanker di rumah, yang dinilai dengan lembar obser vasi tingkat kemandirian keluarga dari depkes ri (2006). data kemudian dianalisis menggunakan uji wilcoxon signed rank test dengan α ≤ 0,05 untuk mengetahui ada tidaknya perbedaan tingkat kemandirian keluarga sebelum dan sesudah intervensi. hasil h a s i l a n a l i s i s d a t a r e s p o n d e n menunjukkan bahwa lebih dari setengah responden berjenis kelamin perempuan, yaitu sebanyak 4 orang (57%) dan berada pada kelompok usia dewasa pertangahan (30–49 tahun), sebanyak 4 orang (56%). tipe keluarga sebagian besar responden adalah keluarga besar (extended family), yaitu sebayak 5 orang (72%). sementara penderita kanker yang tinggal dengan responden pada penelitian ini juga sebagian besar berjenis kelamin perempuan, yaitu sebanyak 6 orang (86%). usia penderita kanker lebih dari setengahnya adalah kelompok usia dewasa pertengahan (30–49 tahun), sebanyak 4 orang (56%). dan kasus terbanyak adalah kanker payudara (ca mammae), sebanyak 5 orang (72%). berdasarkan tabel 1 dapat diketahui bahwa sebagian besar responden berada pada tingkat kemandirian keluarga ii sebelum pelaksanaan pchn, yaitu sebanyak 5 orang (72%). sementara, setelah intervensi diketahui sebagian besar responden berada pada tingkat kemandirian keluarga iii, yaitu sebanyak 5 orang (72%). akan tetapi, ada dua responden yang tidak mengalami peningkatan tingkat kemandirian dalam perawatan penderita kanker di rumah setelah intervensi. hasil uji wilcoxon signed rank test menunjukkan p = 0,025, yang berarti ada perbedaan yang signifi kan pada tingkat kemandirian keluarga sebelum dan sesudah pelaksanaan pchn. berdasarkan analisis hasil observasi kemandirian keluarga, diketahui bahwa sebelum pelaksanaan pchn semua responden (7 orang, 100%) sudah mampu menerima petugas kesehatan dan menerima pelayanan kesehatan sesuai dengan rencana keperawatan. sementara setelah pelaksanaan pchn, semua responden (7 orang, 100%) sudah mampu menerima petugas, menerima pelayanan kesehatan sesuai rencana keperawatan, tahu dan dapat mengungkapkan masalah tabel 1. ti n g k a t k e m a n d i r i a n k e l u a rg a sebelum dan sesudah pelaksanaan pchn nomer responden tingkat kemandirian keluarga sebelum sesudah perubahan 1 2 3 +1 2 3 4 +1 3 2 3 +1 4 2 3 +1 5 2 3 +1 6 2 2 0 7 3 3 0 wilcoxon signed rank test p = 0,025 312 jurnal ners vol. 8 no. 2 oktober 2013: 309–316 kesehatannya secara benar, dan memanfaatkan fasilitas pelayanan kesehatan sesuai anjuran. dan terdapat 1 responden (14%) yang mampu dalam semua aspek kemandirian, termasuk mampu melakukan tindakan peningkatan kesehatan (promotif) secara aktif. pembahasan be rd a s a rk a n h a si l a n al isis d at a responden diketahui bahwa lebih dari setengah keluarga yang terlibat dalam perawatan pasien kanker di rumah berjenis kelamin perempuan. hubungan antara anggota keluarga pemberi perawatan dan penderita kanker di antaranya ibu, anak kandung perempuan, dan saudara kandung perempuan. di mayoritas keluarga, peran perempuan dalam perawatan anggota keluarga yang sakit cukup besar. menurut nura (2010), dalam perawatan anak dengan kanker, anggota keluarga yang berpartisipasi aktif dan menjalin kerja sama dengan petugas kesehatan selama pengobatan dan perawatan sebagian besar adalah perempuan, yaitu ibu. perawatan penderita kanker memerlukan perhatian dari keluarga dalam jangka waktu yang relatif lama. anggota keluarga perempuan yang tinggal di rumah biasanya yang mengambil peran tersebut karena memiliki banyak waktu luang untuk memberikan perawatan kepada penderita. lebih dari setengah responden berada pada kelompok usia dewasa pertengahan (30–49 tahun). menurut stein dan book (2000), semakin dewasa usia, individu akan memiliki kematangan emosi yang lebih stabil karena pandangan yang lebih arif terhadap suatu permasalahan. individu pada kelompok usia dewasa biasanya memiliki mekanisme koping yang lebih efektif dibandingkan kelompok usia lain. kestabilan emosi diperlukan dalam perawatan penderita kanker. penyakit kanker dan perawatannya memiliki dampak yang sangat besar dalam kehidupan keluarga, baik fi sik, mental, maupun kehidupan sosial. tidak hanya penderita kanker, tetapi keluarga yang tinggal bersama dengan penderita tersebut juga mengalami stres dan depresi. anggota keluarga dengan usia dewasa pertengahan yang memiliki kematangan emosi dan pengelolaan stres yang baik, biasanya lebih kuat secara fi sik dan emosional dalam perawatan penderita kanker di rumah. hasil penelitian menunjukkan bahwa mayoritas penderita kanker adalah perempuan, pada kelompok usia dewasa pertengahan (3049 tahun), dengan kasus terbanyak adalah kanker payudara (ca mammae). hal ini sesuai dengan hasil analisis demografi pada penelitian prevalensi kanker/tumor yang dilakukan oleh oemiati (2011), bahwa odds ratio jenis kelamin pada perempuan besarnya hampir dua kali lipat dari laki-laki. perempuan lebih berisiko menderita kanker karena faktor reproduksi, seperti multiparitas, perubahan hormonal akibat menopause, dan penggunaan alat kontrasepsi hormonal dalam jangka waktu lama. menurut data rs kanker dharmais (2007), dari semua jenis kanker, kangker payudara memiliki prevalensi tertinggi, diikuti kanker serviks dan kanker paru. makin tua usia responden, maka risiko terkena penyakit tabel 2. tingkat kemandirian keluarga aspek kemandirian pre test post test f % f % menerima petugas 7 100 7 100 menerima pelayanan kesehatan sesuai rencana keperawatan 7 100 7 100 tahu dan dapat mengungkapkan masalah kesehatannya secara benar 4 58 7 100 memanfaatkan fasilitas pelayanan kesehatan sesuai anjuran 6 86 7 100 melakukan tindakan keperawatan sederhana sesuai anjuran 5 72 6 72 melakukan tindakan pencegahan secara aktif 2 28 5 72 melakukan tindakan peningkatan kesehatan (promotif) secara aktif 0 0 1 14 313 pengembangan palliative community health nursing (elida ulfi ana, dkk) tumor/kanker makin tinggi, yang mencapai puncaknya pada usia 35 sampai 44 tahun, kemudian secara perlahan risikonya akan menurun dan akan terjadi peningkatan pada usia > 65 tahun. tingkat kemandirian keluarga sebelum pelaksanaan pchn sebagian besar berada pada tingkat ii. hal ini menunjukkan bahwa seluruh keluarga telah mampu menerima kedatangan petugas kesehatan, serta menerima pelayanan saat kunjungan dengan baik. berdasarkan hasil penelitian steele dan fitch (1996), keluarga penderita kanker pasca perawatan sangat membutuhkan dukungan dari petugas kesehatan selama memberikan perawatan di rumah, sehingga keluarga dapat memberikan perawatan yang tepat dan tidak terganggu secara fi sik dan emosional. kunjungan perawat ke rumah dirasakan sebagai perhatian bagi keluarga, sehingga keluarga secara terbuka mau menerima perawat. perawatan penderita kanker yang berkelanjutan dan berlangsung dalam waktu lama membuat perawat dan kelua rga pad a u mu m nya sud ah sali ng mengenal dan memiliki hubungan yang baik. oleh karena itu, tidak ada penolakan dari keluarga terhadap kunjungan dan pelayanan yang diberikan perawat di rumah. mayoritas responden telah memanfaatkan pelayanan kesehatan, yaitu puskesmas ataupun rumah sakit untuk menjalani pengobatan kanker. begitu individu didiagnosis menderita kanker, maka saat itu pula individu tersebut mulai berhubungan dengan fasilitas pelayanan kesehatan. penatalaksanaan penderita kanker di rumah sakit dilakukan melalui kemoterapi, radioterapi, pembedahan, dan pengobatan komplementer, dengan frekuensi kunjungan berulang. untuk penderita dengan stadium lanjut, upaya yang dilakukan adalah perawatan paliatif yang difokuskan untuk mengurangi keluhan penderita, sehingga tetap bisa aktif dan kualitas hidupnya meningkat (bare, 2007). bagi penderita yang menggunakan jaminan kesehatan sosial, mereka juga terlebih dahulu harus meminta rujukan dari puskesmas. oleh karena itu, pemanfaatan fasilitas layanan kesehatan oleh penderita kanker dan keluarga sudah cukup baik. berdasarkan hasil analisis, hanya sebagia n responden saja ya ng mampu meng u ng k ap ma sala h kesehat a n ya ng di had api. menu r ut depkes r i (2007), pengetahuan keluarga yang tepat tentang kanker mempengaruhi keterampilannya dalam memberikan perawatan kepada penderita selama di rumah, untuk mencegah kekambuhan dan meningkatkan kualitas hidupnya. akan tetapi, responden hanya mengetahui bahwa salah satu anggota keluarganya tersebut menderita kanker. apabila diminta untuk menjelaskan lebih jauh tentang penanganan kanker dan cara memodifi kasi lingkungan yang tepat untuk perawatan penderita kanker di rumah, diketahui bahwa sebagian besar pemahamannya masih rendah. setelah dilak u kan pch n, tingkat kemandirian keluarga dalam perawatan kanker mengalami peningkatan, yaitu 1 keluarga yang telah mampu mencapai tingkat iv, 5 keluarga mencapai tingkat iii, dan hanya 1 keluarga yang masih berada pada tingkat ii. pada keluarga yang telah mencapai tingkat kemandirian keluarga iv, keluarga tersebut telah mampu melaksanakan tindakan keperawatan sesuai anjuran, mampu melakukan pencegahan kanker di keluarga, bahkan mampu melakukan upaya promosi kesehat an secara ak tif. responden tersebut telah berpartisipasi sebagai kader sadar kanker yang telah terbentuk di lingkungan rumah. di sisi lain, ada keluarga yang tidak mengalami peningkatan tingkat kemandirian setelah pelaksanaan pchn. hal ini dikarenakan responden berusia lanjut (> 60 tahun), sehingga kurang bisa menerima infor masi yang diberikan oleh perawat. responden mungkin memerlukan frekuensi kunjungan yang lebih banyak dan intensif dari perawat untuk meningkatkan kemandiriannya dalam perawatan penderita kanker di rumah. perawatan paliatif merupakan salah satu bentuk pelayanan kesehatan secara terpadu untuk meningkatkan kualitas hidup dengan meringankan keluhan, memberikan dukungan spiritual dan psikososial mulai diagnosa ditegakkan sampai akhir hayat (who, 2005). sedangkan communit y health nursing atau dikenal dengan perawatan kesehatan 314 jurnal ners vol. 8 no. 2 oktober 2013: 309–316 masyarakat (perkesmas) merupakan bentuk perawatan yang menekankan pada kelompok risiko tinggi di masyarakat yang ditujukan meningkatkan kemandirian mengatasi masalah kesehatan melalui peningkatan pengetahuan, keterampilan, membimbing individu, keluarga, dan kelompok masyarakat (depkes ri, 2006). pchn merupakan paket pelayanan perawatan kesehatan masyarakat yang diberikan kepada penderita dan keluarga penderita kanker di rumah yang berfokus pada kegiatan promotif dan preventif. proses pelaksanaan pchn pada penelitian ini dimulai dengan pengkajian keluarga menggunakan format pengkajian perkesmas untuk keluarga dengan kanker. pengkajian tersebut mengidentifikasi tugas keluarga dalam kesehatan yang terdiri dari kemampuan mengenal masalah kan ker, mengambil keputusan kesehatan, memberikan perawatan kepada penderita kanker di rumah, memodifi kasi lingkungan fi sik dan psikologis yang kondusif untuk peningkatan kesehatan, serta memanfaatkan fasilitas kesehatan terdekat. adapun bentuk intervensi pchn adalah upaya untuk mengatasi ketidakmampuan keluarga pada pelaksanaan tugas tersebut. pchn merupakan paket kunjungan r umah yang dilaksanakan oleh perawat komunitas terhadap penderita kanker pasca perawatan yang tinggal bersama keluarganya di rumah. melalui pchn, perawat komunitas memberikan peny uluhan tentang nutrisi pada penderita kanker, pencegahan kanker, serta motivasi untuk tetap memanfaatkan pelayanan kesehatan puskesmas dan rumah sakit untuk pengobatan dan rujukan. hal ini sesuai dengan yang dituliskan oleh friedman (1998) bahwa tujuan penyuluhan di keluarga adalah memberikan infor masi, sehingga mampu membuat keputusan-keputusan yang tepat dalam hubungan dengan kesehatan dan sakit, membantu agar ber partisipasi secara efektif dalam perawatan maupun p e nye mbu h a n , me mba nt u b e r a d apt a si terhadap realita penyakit dan pengobatannya, serta membantu agar mengalami rasa puas dengan usaha-usaha mereka sendiri yang menunjang perbaikan kesehatan. pendidikan kesehatan merupakan proses belajar dari individu, kelompok, masyarakat dari tidak tahu nilai–nilai kesehatan menjadi tahu, dari tidak mampu mengatasi masalah kesehatan menjadi mampu. pengetahuan adalah hasil tahu dan terjadi setelah orang melakukan penginderaan terhadap suatu objek tertentu. penginderaan terjadi melalui panca indra manusia yakni: penglihatan, pendengaran, penciuman, rasa dan raba. sebagian besar pengetahuan manusia diperoleh melalui mata dan telinga. pengetahuan kognitif merupakan domain yang sangat penting dalam membentuk tindakan seseorang (notoatmodjo, 2003). p e n e l i t i a n p c h n i n i m a m p u meningkatkan kemandirian keluarga dalam perawatan kanker di rumah karena penerapan pchn memandang keluarga sebagai klien. ada hubungan yang kuat antara keluarga dan status kesehatan anggotanya. keluarga berperan sangat penting bagi setiap aspek perawatan anggota keluarga secara individu anggota mulai mengenal atau mendeteksi masalah kesehatan, membuat keputusan yang tepat untuk perawatan, melakukan perawatan, menciptakan lingkungan yang sehat sampai dengan membawa ke pelayanan kesehatan. pelaksanaan pchn melalui kunjungan rumah dapat memberikan kesempatan keluarga untuk mendapatkan informasi kesehatan terkait dengan kanker dan perawatan di rumah, sehingga meningkatkan kemampuan keluarga dalam mengenal kanker. melalui pchn, keluarga semakin mampu melakukan tindakan-tindakan perawatan di rumah yang kaitannya dengan menyiapkan makanan sehat dan melaksanakan aktivitas-aktivitas untuk meningkatkan kesehatan tubuh. pada akhirnya keluarga juga mampu melakukan tindakan-tindakan pencegahan supaya tidak terjadi kanker pada anggota keluarga yang lain, dan senantiasa ke pelayanan kesehatan untuk mendapatkan pengobatan dan rujukan. simpulan dan saran simpulan pchn dapat meningkatkan kemandirian keluarga dalam perawatan penderita kanker di rumah. pelaksanaan pchn melalui kunjungan rumah dapat memberikan kesempatan kepada keluarga unt u k mendapatkan infor masi 315 pengembangan palliative community health nursing (elida ulfi ana, dkk) kesehatan terkait dengan kanker dan perawatan di rumah, sehingga meningkatkan kemampuan keluarga dalam mengenal kanker. melalui pchn, keluarga dibina dalam meningkatkan kemampuan melaksanaan tugas keluarga yaitu mengenal kanker, membuat keputusan yang tepat dalam perawatan kanker, mampu merawat kanker di r umah, menciptakan lingkungan yang sehat untuk kanker, serta memanfaatkan pelayanan kesehatan yang ada di puskesmas dan rumah sakit. saran palliative community health nursing (pch n) dapat diterapkan oleh perawat komunitas di puskesmas sebagai program pengembangan pelayanan paliatif, dalam rangka meningkatkan kualitas hidup penderita kanker pasca perawatan. keluarga penderita kan ker diharapkan melaksanakan t ugas keluarga dalam kesehatan untuk mencapai kemandirian dalam perawatan kanker di rumah. penelitian selanjutnya diharapkan mengembangkan pchn dengan melibatkan tim yang multidisiplin, baik dari tenaga kesehat a n, kelu a rga , roha n iawa n, d a n relawan. kepustakaan anggraeni, m., & ekowati, w. 2010. peran keluarga dalam memberikan dukungan terhadap pencapaian integritas diri pasien kanker payudara post radikal mastek tomi. jur nal kepera watan soedirman vol. 5 no. 2, 105–114. bare, s. 2007. brunner & suddarth’s textbook of medical surgical nursing, 10th edition. usa: mosby inc. coward, d. 2006. supporting health promotion in adults with cancer. family community health 29 (i suppl) , 52s–60s. depkes ri. 2007. kepmenkes 812/menkes/sk/ vii/2007 tentang kebijakan perawatan paliatif. depkes ri. keputusan menteri kesehatan ri nomor 279 tahun 2006 tentang perawatan kesehatan masyarakat. depkes ri. 2006. litbang depkes ri. retrieved november 3, 2010, from litbang depkes ri web site: http://www.litbang.depkes. go.id/aktual/kliping/kankerparu010306. html desen. 2008. buku ajar onkologi klinis, edisi 2. jakarta: fk-ui. dharma, k. 2011. metodologi penelitian keperawatan panduan melaksanakan dan menerapkan hasil penelitian. jakarta: cv. trans info media. dharmais, r k. 2007. statistik kanker tahun 2007. jakarta: rs kanker dharmais. dinkes jatim. 2008. kegiatan pengendalian kanker di jawa timur. ret r ieved februari 4, 2013, from dinkes jatim: http://dinkes.jatimprov.go.id/userimage/ dokumen/kegiatan%20penangg ulangan%20kanker%20di%20j awa%20timur.pdf efendi, f., & makhfudli. (2009). buku ajar keperawatan kesehatan komunitas. jakarta: pt. salemba medika. fauzi, a. 2011, agustus 06. mengembangkan pera watan paliatif di indonesia. ret r ieved febr uar i 4, 2013, f rom universitas gajah mada web site: http://ugm.ac.id/new/id/berita/2936mengembangkan-perawatan-paliatifdi-indonesia.xhtml friedman, m. 2010. buku ajar keperawatan keluarga: riset, teori dan praktik, edisi 5. jakarta: egc. nura. 2010. peran ibu bagi anak penderita kanker di rumah singgah yayasan k a s i h a n a k k a n k e r i n d o n e s i a ( y k a k d). ja k a r t a: u i n sya r i f hidayatullah jakarta. skripsi. tidak dipublikasikan. oemiati, r., rahajeng, e., & kristanto, a. 2011. prevalensi tumor/kanker dan beberapa faktor yang mempengaruhinya di indonesia. bulleting penelitian kesehatan, vol 39 no 4, 190–204. saleh, danantosa & kusumawardhani. 2008. perawatan paliatif puskesmas balongsari surabaya: upaya mendekatkan layanan rawat jalan kepada pasien kan ker stadium lanjut. indonesian journal of cancer, 1, 27–29. setiawati. 2008. penuntun praktik asuhan keperawatan keluarga. jakarta: trans info media. setiyadi. 2008. konsep dan proses perawatan keluarga. jakarta: graha ilmu. 316 jurnal ners vol. 8 no. 2 oktober 2013: 309–316 skinner, r., wallace, w., & levitt, g. 2007. long-term follow-up of children treated for cancer: why is it necessary, by whom, where, and how? arch dis child, 92, 257–260. society, a. 2009. cancer statistics 2009 presentation. retrieved january 24, 2013, from cancer web site: http:// www.cancer.org/docroot/pro/content/ pro_1_1_cancer_statistics_2009_ presentation.asp. steele, & fitch. 1996. needs of family caregivers of patients receiving home hospice care for cancer. nursing oncology forum . who. 2005. who defi nition of palliative care. retrieved februari 4, 2013, from w ho: ht t p://w w w.who.i nt /cancer/ palliative/defi nition/en/ vol 6 no 2 oktober 2011_akreditasi 2013.indd 113 model asuhan keperawatan terhadap peningkatan adaptasi kognisi dan biologis pada pasien terinveksi hiv (nursing care approch model (ncam–pakar) on the increasing of cognitif and biological adaptation responses patient with hiv infection) nursalam fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya telp/fax: (031) 5913257 e-mail: nursalam_psik@yahoo.com abstract introduction: pakar model that focused on coping strategy and social support (nurse, family and patients) lead to positive coping mechanism through the learning process. the purpose of the study was to examine the effect of pakar toward adaptive response on pwh infection. pni and nursing sciences from roy paradigm were used in this study. method: quasy-experimental pre-post-test non randomized control group design is used in this study. forty (40) pwh infections in intermediate department care for infection disease (upipi) dr. soetomo hospital in surabaya were selected and non-randomized assignment divided into 2 groups of 20, experiment and control group. in vitrotest were used to measure biological response change: cortical, cd4, ifnγ, and anti-hiv. psychological, social, and spiritual response were measured and observed by using questionnaires, in depth interview and focus group discussion. a multivariate analysis was used to evaluate the data of biological response and non-parametric test: wilcoxon and mann whitney were used to measure cognitive response. result: result showed that there were signifi cantly differences on cognitive response between pakar and standard, namely; spiritual response on be patient, social response on emotional stable, and acceptance response on anger and bargaining. in addition, biological response were signifi cantly differences between the groups with f = 0.497 and p = 0.000. the cortical and anti-hiv variables were the pattern contribution between the groups, with 77.5%. the increase the number of cd4 was found to be the dominance factor that was correlated toward the positive of cognitive response caused by pakar. discussion: pakar model that focused on coping strategy and utilizing social support lead to treat cognitive response pwh infection. the model is based on nursing science theory (roy and hall) combined with psychoneuroimmunology paradigm that is able to induce immune response modulation, especially the increase of the number of cd4. the increase of cd4 will induce ifn-γ to help macrophage in destroying hiv. keywords: nursing care approach model (pakar), cognitive adaptive responses and biological responses pendahuluan pasien hiv di indonesia menjadi masalah yang serius dan tantangan bagi tenaga kesehatan (biondi, 2001). di jawa timur terjadi suatu peningkatan kasus hiv/aids yang signifi kan. data di rsu dr. soetomo tahun 2004, pada tahun 1989–2000 tercatat 29 pasien; 2001–2002 = 80 pasien; dan 2003 – agustus 2004 = 155, dan akhir agustus 2004 adalah 85 kasus yang dirawat di upipi, 20 di antaranya meninggal dunia. keadaan tersebut akan bertambah parah jika tidak ada suatu upaya penanganan yang komprehensif dengan melibatkan beberapa pihak dan model asuhan yang lebih baik (departemen kesehatan, 2003). hal ini karena setelah pasien didiagnosis dengan hiv positif mengalami gangguan respons adaptasi (biologis, psikologis, sosial) bahkan pasien mengalami shock yang berat nursalam (2007). kondisi ini diperparah dengan stigma yang ada di masyarakat indonesia bahwa penyakit hiv jurnal ners vol. 6 no. 2 oktober 2011: 113–125 114 adalah penyakit akibat moral yang tidak baik, penyakit menular yang berbahaya, dan penyakit yang mematikan. hal dimaksud membuat pasien semakin stres (psikologis-sosialspiritual) dan merasa terisolasi yang akhirnya memperparah stres biologis, terutama pada sel imunokompeten: penurunan jumlah cd4, peningkatan kadar cortisol, penurunan kadar ifnγ, dan anti-hiv(ader, 2001). penurunan cd4 menurut (nasronudin, soewandojo, suharto. 2002) rerata 30–60 cells/μl, bahkan bisa mencapai lebih dari 180 cells/μl per tahun. berdasarkan hasil pilot study yang dilakukan peneliti pada bulan juni – juli 2004, dari 9 pasien hiv yang dirawat di upipi rsu dr. soetomo semua mengalami gangguan respons adaptif biologis, psikologis, sosial dan spiritual. kondisi yang demikian ini memerlukan penanganan yang komprehensif, khususnya dalam mengatasi stres psikososialspiritual. menurut nursalam (2007), asuhan keperawatan yang diberikan pada pasien hiv di instansi pelayanan masih belum optimal. perawat masih belum mampu memenuhi kebutuhan pasien secara holistik, khususnya dalam dukungan sosial dan strategi koping yang efektif. stres persepsi yang dialami pasien semakin bertambah. pasien yang mendapatkan asuhan keperawatan dengan menerapkan strategi koping dan dukungan sosial selama 3 bulan mengalami peningkatan cd4 rerata 12 cells/μl. asuhan keperawatan dengan pakar yang menekankan pada strategi koping dan dukungan sosial sangat diperlukan. namun sampai saat ini model asuhan keperawatan yang sesuai pada pasien hiv di indonesia dalam mempercepat respons adaptif (biologis, psikologis, sosial dan spiritual) masih belum ditemukan. stres psikososial-spiritual pasien terinfeksi hiv berlanjut akan mempercepat kejadian aids dan bahkan meningkatkan angka kematian. menurut maramis (2003) jika stres mencapai tingkat exhausted stage dapat menimbulkan kegagalan fungsi sistem imun, yang memperparah keadaan pasien. dan mempercepat kejadian aids. modulasi respons imun akan menurun secara signifi kan, seperti aktivitas apc (makrofag); th1 (cd4); ifnγ; il-2; imunoglobulin a, g, e dan antihiv. penurunan tersebut akan berdampak terhadap penurunan jumlah cd4 hingga mencapai 180 cells/μl per tahun. hal tersebut mengakibatkan pasien menjadi rentan terhadap infeksi sekunder. nursalam (2005) pasien yang mengalami penurunan aktivitas ifnγ, lebih rentan terhadap infeksi sekunder pada kulit, seperti herpes zooster dan simplek. keadaan ini sangat membahayakan kondisi pasien dan mempercepat kejadian aids serta kematian. pada umumnya penanganan pasien hiv memerlukan tindakan yang hampir sama, namun dari fakta klinis sewaktu pasien kontrol ke rumah sakit menunjukkan ada perbedaan respons imunitas (cd4). hal tersebut terbukti ada faktor lain yang memengaruhi. menurut peneliti faktor tersebut sangat berkaitan dengan peran serta keluarga dan perawat dalam menangani stres psikososial selama menjalani perawatan kurang optimal. pasien yang mengalami stres yang berkepanjangan, berdasarkan konsep psikoneuroimunologi, melalui sel astrosit pada cortical dan amigdala pada sistem limbik berefek pada hipotalamus. kemudian hipofisis akan menghasilkan crf, yaitu pada sel basofi lik. sel basofi lik tersebut akan mengekspresikan acth (adrenal cortico tropic hormone) yang akhirnya dapat memengaruhi kelenjar kortek adrenal pada sel zona fasiculata, kelenjar ini akan menghasilkan kortisol yang bersifat immunosupressive. apabila stres yang dialami pasien sangat tinggi, maka kelenjar adrenal akan menghasilkan kortisol dalam jumlah banyak sehingga dapat menekan sistem imun, yang meliputi aktivitas apc (makrofag); th-1 (cd4); dan sel plasma: ifnγ; il-2; igm – igg dan antibodi-hiv (nursalam, 2005). p e r a w a t m e r u p a k a n f a k t o r y a n g mempunyai peran penting pada pengelolaan stres khususnya dalam memfasilitasi dan mengarahkan koping pasien yang konstruktif agar pasien dapat beradaptasi dengan sakitnya dan pemberian dukungan sosial, berupa dukungan emosional, informasi, dan material (nursalam, 2005). salah satu metoda yang digunakan dalam penerapan teknologi ini adalah menerapkan model pendekatan asuhan keperawatan (pakar). pendekatan yang model asuhan keperawatan (nursalam) 115 digunakan adalah strategi koping dan dukungan sosial yang bertujuan untuk mempercepat respons adaptif pada pasien terinfeksi hiv, meliputi modulasi respons imun (nursalam, 2005) respons psikologis; dan respons sosial. dengan demikian penelitian bidang imunologi dengan 4 variabel dapat membuka nuansa baru untuk bidang ilmu keperawatan dalam mengembangkan model pendekatan asuhan keperawatan (pakar) adaptasi dari roy yang berdasar pada paradigma psikoneuroimunologi terhadap pasien terinfeksi hiv. tujuan penelitian ini adalah untuk menganalisis perbaikan respons psiko-sosiospiritual dan biologis pada pasien terinfeksi hiv dengan pakar. bahan dan metode r a n c a n g a n p e n e l i t i a n i n i a d a l a h eksperimental. jenisnya adalah quasyexperimental non-randomised pre-posttest control group design. subjek diukur respons biologis, berupa modulasi respons imun (kortisol, cd4, ifnγ dan anti-hiv) dan diberikan kuesioner serta diobservasi respons psikologis, sosial, dan spiritual sebelum dilakukan intervensi berupa penerapan pendekatan asuhan keperawatan selama 3 bulan. populasi yang diteliti adalah seluruh pasien hiv yang tinggal di kota surabaya berdasarkan data pasien yang masuk rumah sakit dan kontrol rutin di unit perawatan intermediate penyakit infeksi (upipi) rsu dr. soetomo surabaya tahun 2004. jumlah populasi pasien yang dirawat di upipi adalah 85 pasien. pasien yang terpilih akan mengisi surat pernyataan kesediaan peran serta dalam penelitian. variabel bebas (perlakuan) dalam penelitian ini adalah model pakar, sedangkan variabel tergantungnya adalah variabel respons adaptif spiritual (ronaldson, 2000): harapan yang realistis, tabah dan sabar, pandai mengambil hikmah; variabel respons adaptif sosial: emosi, cemas, interaksi sosial; variabel respons adaptif penerimaan diri: denial (penolakan), anger (marah), bargaining (tawar menawar), depression (depresi); acceptance (penerimaan); variabel respons adaptif biologis (modulasi respons imun: kortisol, cd4, ifnγ, anti-hiv. variabel kendali: status gizi (bb dan tb), faal hati (sgot, sgpt), albumin dan faal ginjal (bun, kreatinin). lokasi penelitian adalah unit perawatan intermediate penyakit infeksi (upipi) rsu dr. soetomo dan tempat tinggal pasien di wilayah kota surabaya. waktu penelitian adalah selama 1 tahun, 6 bulan mengumpulkan data dan 6 bulan adalah analisis dan penulisan hasil. hasil hasil analisis data penelitian yaitu data uji perbedaan respons kognisi (spiritual, sosial, penerimaan diri dan respons biologis). respons spiritual uji perbedaan respons spiritual antara kelompok model pakar dan standar tampak pada tabel 1. analisis hasil penelitian didasarkan pada prinsip-prinsip content analysis adalah sebagai berikut. pertanyaan: bagaimana harapan anda terhadap kesembuhan penyakit ini? "saya sebenarnya berharap sangat banyak untuk secepatnya sembuh" saya ingin segera dapat bekerja seperti semula" (tn. kn, 31 tahun). respons tabah dan sabar analisis isi (content analysis) dari hasil wawancara terstruktur yang peneliti tabel 1. uji wilcoxon signed rank test (pre-post) respons spiritual kelompok pakar dan standar respons pakar standar z hitung signifi kansi z hitung signifi kansi harapan -3,758 p = 0,000 -0,775 p = 0,439 tabah -3,848 p = 0,000 -1,941 p = 0,052 hikmah -3,368 p = 0,001 -0,812 p = 0,417 jurnal ners vol. 6 no. 2 oktober 2011: 113–125 116 digunakan untuk mengetahui respons verbal dari responden. pertanyaan: bagaimana kesabaran dan ketabahan anda terhadap sakit yang anda alami? "rasanya kesabaran saya sudah habis, setelah usaha yang saya lakukan selama ini sia-sia" saya sudah tidak tahan lagi menerima cobaan sakit ini" (ny. um, 44 tahun). setelah 3 bulan mendapatkan asuhan hasil wawancara sebagai berikut: "saya harus sabar dan tawakal sus. saya mempunyai tanggung jawab untuk mengasuh anak-anakku yang masih kecil". saya akan merasa berdosa kalau, tidak bisa mengasuh anak saya ini" (ny. um, 44 tahun). respons pandai mengambil hikmah data analisis isi (content analysis) dari hasil wawancara terhadap pertanyaan yang diajukan peneliti. pertanyaan: apakah anda berpikir bahwa dengan sakit ini ada hikmahnya dibalik semuanya? mereka selalu mengatakan penyakit ini merupakan suatu musibah dan hukuman dari tuhan yang maha esa akibat perilakunya pada masa lampau. "aku tidak tahu makna dari penyakit ini". " yang saya tahu, penyakit ini menambah derita yang saya alami" tuhan mungkin sudah tidak mau menolong saya, karena perbuatanku yang jelek pada masa lampau" (tn. ngr, 30 tahun). respons sosial uji perbedaan respons sosial antara kelompok model pakar dan standar sebelum dan sesudah intervensi ditunjukkan pada tabel 2. respons sosial aspek emosi, cemas, dan interaksi sosial semua menunjukkan perbedaan yang bermakna. data analisis isi (content analysis) dari hasil wawancara terstruktur yang peneliti gunakan untuk mengetahui respons verbal dari responden. respons emosi berikut beberapa pertanyaan yang diajukan peneliti. apakah ada orang yang paling dekat dengan anda? apa yang anda rasakan terhadap perasaan dicintai, dihargai, diperhatikan oleh keluarga atau tetangga? beberapa pasien yang dinyatakan positif sebelum mendapatkan asuhan merasa tidak diperhatikan dan dihina. hal ini dapat dilihat dari beberapa pernyataan pasien; "saat saya dinyatakan positif, banyak keluarga saya yang menjauh dan tidak memperhatikan keadaan saya lagi sus! mereka semua takut tertular" (ny. st). "orang yang dulu dekat dengan saya sekarang mulai menjauh. saya merasa tidak diperdulikan lagi" (tn bd, 30 tahun). setelah penerapan pakar selama 3 bulan hasil wawancara sebagai berikut; "sekarang ibu, istri, dan adik-adik saya selalu memberi perhatian yang lebih setelah saya dinyatakan hiv" "mereka mulai menerima kondisi saya dan memberi banyak perhatian, sepertinya tidak berkurang sedikitpun" "ibu dan adik-adik tetap bisa menerima kondisi saya sekarang apa adanya dan makin sayang saya " (tn. bd., 30 tahun). respons cemas data analisis isi pertanyaan tentang; apa yang sedang saudara cemaskan? mayoritas responden cemas terhadap kesembuhan penyakitnya. seperti yang disampaikan oleh pasien waria: "saya bingung dan khawatir dengan penyakit yang saya alami! kata orang penyakit tabel 2. uji wilcoxon signed rank test (pre-post) respons sosial kelompok pakar dan standar respons pakar standar z hitung signifi kansi z hitung signifi kansi emosi -3,756 p = 0,000 -1,228 p = 0,219 cemas -3,939 p = 0,000 -3,205 p = 0,001 interaksi sosial -3,835 p = 0,000 -1,235 p = 0,217 model asuhan keperawatan (nursalam) 117 ini tidak bisa disembuhkan ya! saya takut menularkan penyakit ini kepada orang lain, padahal saya harus tetap bekerja! belum lagi obat yang harus saya beli ya sus! (tn. bd, 30 tahun). sesudah 3 bulan mendapatkan pakar respons kecemasan pasien berkurang pada tingkat yang ringan dan ada beberapa yang sedang. "saya sekarang sudah mulai tenang sus, saya sudah mengerti tentang penyakit ini: pencegahan penularan, pengobatan, dan perawatannya. untuk masalah biaya pengobatan dari ibu, beliau juga yang membantu memecahkan masalah, tapi kan ndak bisa seterusnya sus, saya khawatir juga kalau subsidinya habis berarti saya harus beli obat sendiri mahal lho sus" (tn. sto, 26 tahun). "saya sebenarnya ingin menikah, tetapi saya khawatir anak dan istri saya nanti tertular. takut dosa lagi sus". (tn. sn) respons interaksi sosial berikut ini analisis isi (content analysis) dari hasil wawancara dari pertanyaan sebelum mendapatkan pakar; bagaimana hubungan anda dengan pasangan (suami dan istri)? apakah anda ikut berpartisipasi dalam kegiatan keluarga? adakah dukungan dari tokoh agama/tokoh masyarakat atau lsm untuk anda? jawaban dapat disimpulkan sebagai berikut. "sejak saya dinyatakan positif, saya sering dimanjakan ibu saya. saya jarang dilibatkan dalam keluarga dan biasanya saudara-saudara saya jarang mengajak bicara. selama ini yang mendukung dari luar ya cuma lsm–hiv/aids, khususnya sesama odha yang tergabung dalam perawatan di ruang pipi rsu dr. soetomo surabaya." "teman-teman sekampung dan tetangga sampai dengan sekarang tidak tahu kalau saya terkena hiv. yah kalau tahu mungkin mereka semua akan mengucilkan saya sus! (tn. sn, 22 tahun). setelah mendapatkan pakar, respons interaksi sosial sebagai berikut: "sekarang aku sudah sering diajak dan dilibatkan orang tuaku dalam kegiatan di rumah. mereka semua sudah mulai mau bicara dengan saya lagi". "sekarang aku aktif dalam kegiatan lsm (hiv) karena senang rasanya kalau bisa bertukar pikiran dengan teman-teman sesama penderita dan saling berbagi "cuma untuk kegiatan di kampung, aku masih ragu. takut kalau mereka tahu penyakitku, mereka semua akan menjauhi dan mengusir saya" (tn. sn, 22 tahun). respons penerimaan diri (psikologis) aspek respons psikologis (penerimaan) menunjukkan perbedaan yang signifi kan antara kelompok pakar dan standar. bagian ini akan disajikan hasil secara berurutan 5 respons penerimaan diri: denial, anger, bargaining, depression, dan acceptance. analisis hasil penelitian didasarkan pada prinsip-prinsip content analysis. respons denial jawaban pasien dari beberapa pertanyaan respons penolakan. pertanyaan yang diajukan pada respons ini adalah: bagaimana tanggapan b a p a k / i b u p e r t a m a m e n d e n g a r h a s i l pemeriksaan dan penyakit yang bapak/ibu tabel 3. uji wilcoxon signed rank test (pre-post) respons penerimaan diri kelompok pakar dan standar respons pakar standar z hitung signifi kansi z hitung signifi kansi denial anger bargaining depresi acceptance -3,654 -3,622 -3,221 -2,243 -2,136 p = 0,000 p = 0,000 p = 0,001 p = 0,025 p = 0,033 -3,544 -2,820 -3,831 -2,662 -2,928 p = 0,000 p = 0,005 p = 0,000 p = 0,008 p = 0,003 jurnal ners vol. 6 no. 2 oktober 2011: 113–125 118 derita? dapat disimpulkan." berdasarkan hasil dari analisis isi responden menjawab bervariasi, tetapi mayoritas responden sudah siap sehingga respons penolakan tidak berkepanjangan. "ya gimana lagi, aku sudah merasa. soalnya teman-teman sesama pengguna juga sudah positif". tetapi ada responden bernama ny. st. (25 tahun), seorang ibu muda rumah tangga yang baru mempunyai anak umur 4 tahun. suami bekerja di papua selama 3 tahun, begitu diberitahu positif hiv, ibu tadi mengalami shock dan tidak percaya. "kupikir mungkin ada kesalahan dalam pemeriksaan. masa sih aku yang kena, aku selalu setia dan tidak pernah hubungan seks dengan orang lain selain suamiku. lagian suamiku adalah orang yang khusuk dan beriman. apa ya selama di sana nakal?" "aku masih gak percaya dengan hasilnya. lha wong aku memang ada sakit livernya! tapi aku terima aja, mau diapakan lagi?" (i.s; 30 tahun). respons anger analisis isi dari pertanyaan; bagaimana tanggapan bapak/ibu bila ada orang yang membicarakan sakit anda? menurut bapak/ibu karena salah siapa anda sakit? "jangan sampe ada orang yang tahu dengan sakit saya, kecuali ibu dan bapakku." "aku sangat marah jika ada orang lain yang mengejek dan menjauhi aku jika sedang berbicara, khususnya teman-teman kampung yang tidak tahu!" "coba kalo orang tuaku gak cerai! tidak akan seperti ini! semua ini salah orang tuaku kok!" (tn. wt; 20 tahun – sma). sesudah pasien mendapatkan model pakar selama 3 bulan respons pasien sebagai berikut: "malu memang. tapi untuk apa terlalu dipikirkan yang kasih makan aku kan bukan tetangga. sakit ini karena salahku sendiri kenapa dulu berbuat seperti ini" "orang-orang sudah mau menerima aku. soalnya mereka melihat kalau badanku sekarang sudah gemuk lagi. jadi mereka tidak punya bukti untuk menuduh aku kena sakit aids. orang-orang tahunya kalo sakit aids berat badan tidak akan meningkat lagi." (jn, 30 tahun, waria). respons bargaining pertanyaan yang diajukan pada respons ini adalah: andaikata bapak/ibu sembuh apa yang hendak dilakukan atau punya niat apa? hal ini bisa dilihat dari pernyataan beberapa jawaban pasien sebelum mendapatkan intervensi: "ah aku bingung, seandainya aku hidup teratur tentu tidak akan menderita penyakit seperti ini. (ny. iis). "apa aku juga kena ya? tapi kan aku setelah menikah belum 'kumpul' dengan suamiku, soalnya waktu itu dia langsung sakit. kalau aku ciuman pernah, pas aku sariawan, dia juga. gimana ya mbak kalau aku juga positif?" (fr, perempuan, 30 tahun). berikut beberapa kutipan jawaban dari pasien yang telah mendapatkan model pakar selama 3 bulan. "kalau aku sembuh, aku gak mau pake yang gitu lagi. tapi apa aku masih bisa sembuh? obatnya apa aku bisa beli di luar? gimana kalau aku ke pengobatan alternatif saja" (tn. hr, 41 tahun). respons depression berikut ini adalah beberapa pertanyaan yang diajukan kepada pasien dalam menggali respons depresi: adakah perasaan tertekan dengan kondisi anda saat ini? bagaimana perasaan bapak/ibu bila ingat penyakit dan pengobatan yang harus dijalani? sebagian besar pasien mengalami depresi, khususnya perasaan ingin mati jika mengingat penyakit yang diderita tidak bisa disembuhkan. pernyataan ini seperti yang disampaikan ar (42 tahun, waria). "saya merasa gagal dalam hidup ini, saya tidak pernah bisa mencapai kebahagiaan"aku takut cepat mati. apalagi kalau aku pas tidak punya uang untuk beli obatnya. rasanya hidup ini semakin pendek dan hanya menunggu kematian ya sus!" sesudah dilakukan pakar selama 3 bulan respons yang ditunjukkan seperti yang disampaikan ny. mul. model asuhan keperawatan (nursalam) 119 "iya, kadang-kadang perasaan tidak berdaya, kegagalan, dan keinginan mati masih ada sus" gimana ya cara menghilangkannya, sulit sekali". "aku juga masih merasa minder dan sedih jika timbul keluhan-keluhan" respons acceptance pertanyaan: apakah bapak/ibu bisa menerima apapun kondisi anda saat ini dan yang akan datang? hal ini seperti yang disampaikan pasien ny. i.s yang pernah bekerja sebagai pegawai pabrik sony di singapura. "aku masih belum terima, suster. aku tidak pernah memakai narkoba bahkan waktu aku bekerja si singapura juga aku tidak pernah berhubungan dengan siapa pun juga. "apa yang saya usahakan selama ini sia-sia, sus. ya saya hanya akan kontrol kalau kondisi saya sudah tidak bisa saya atasi". (i.s, perempuan, 30 tahun). setelah 3 bulan mendapatkan model pakar respons yang ditunjukkan seperti yang disampaikan oleh ny. i.s; "entahlah suster, yang penting aku harus berobat dan menjaga kondisi. dengan berkunjung ke sini setiap rabu, saya merasa mendapatkan dukungan emosional dari temantaman semua. aku sudah mulai bisa menerima sus". respons nonverbal respons nonverbal yang ditunjukan selama pakar dengan individu, keluarga, dan kelompok dapat dilihat pada tabel 4. tabel 4. respons nonverbal yang menonjol selama pakar respons ekspresi/respons nonverbal spiritual pertemuan individu dan keluarga: – ekspresi yang ditunjukkan sewaktu ditanya hal-hal yang berhubungan spiritual, mereka menarik napas panjang, sering menunduk dan diam. kadang-kadang muka menghadap ke lantai untuk beberapa saat. pertemuan kelompok (peer group) – sewaktu ada sebagian mereka yang mengatakan harus tabah dan menghadapi masa depan, ekspresi yang ditunjukkan sebagian pasien adalah menunduk dengan menyangga muka, ada yang menghadapkan wajahnya ke langit-langit. sosial pertemuan individu dan keluarga – respons ekspresi yang ditunjukkan terus menunduk, menggeleng kepala, mengangguk, membuang muka dan kurang memperhatikan. jika pasien ditanya tentang apa yang dialami selama ini, pasien tampak memperhatikan. sebaliknya jika ditanya tentang hal-hal yang menyebabkan sakit, sebagian besar pasien tidak menjawab langsung, terdiam dan hanya bicara seperlunya. mereka sering bermain-main jari, lihat-lihat hp, dan menatap ke atas. pertemuan kelompok (peer group) – respons yang ditunjukkan selama diskusi mereka tampak gelisah. sebagian mereka malu bertanya sehingga hanya terdiam. penerimaan diri pertemuan individu dan keluarga – ketika ditanya tentang aspek penerimaan diri, ekspresi yang ditunjukkan mata tampak melotot dan wajah pucat. ada juga pasien yang selalu memandang peneliti setiap pembicaraan. mereka tampak ingin terus bertanya untuk meyakinkan, apakah diagnosa tidak salah. pertemuan kelompok (peer group) – mayoritas pasien aktif bertanya untuk mendapatkan keyakinan tentang sakitnya. sebagian pasien ada yang selalu mengangkat tangan, interupsi. mereka tampak ingin tukar pikiran hal-hal yang dialami dan hal-hal yang dianggap berhasil. jurnal ners vol. 6 no. 2 oktober 2011: 113–125 120 analisis data respons biologis uji perbedaan respons biologis antara k e l o m p o k m o d e l pa k a r d a n s t a n d a r pengamatan sebelum dan sesudah intervensi. hasil dari perhitungan model linier regresi pada kelompok yang mewakili pakar dan standar (dalam analisis diskriminan: fisher's linier discriminant function) ditunjukkan pada tabel 5 di mana didapatkan pola untuk menggambarkan kekuatan kortisol dan anti-hiv. pembahasan melalui penelitian ini dapat dibuktikan bahwa pengembangan model pakar yang menekankan pada strategi koping dan dukungan sosial kepada pasien terinfeksi hiv, berperan sebagai terapi kognisi untuk membangun jenis koping yang sesuai sehingga akan dapat memperbaiki respons kognisi dan biologis. model pakar digunakan untuk mempercepat respons adaptif. jika koping yang digunakan tidak efektif, maka dengan penggunaan model tersebut akan mempercepat respons adaptif. tabel 6. perbedaan model pakar dan standar perbedaan pakar standar tujuan pemenuhan respons adaptif (kognisi dan biologis) pemenuhan kebutuhan dasar pasien pengkajian fokus pada gangguan adaptasi: kognisi (spiritual, sosial, penerimaan diri) dan biologis (kortisol, cd4, ifn-γ, antihiv). sebab tidak terpenuhinya kebutuhan dasar pasien, dengan pendekatan head to toe atau ros (review of system). lebih menekankan pada aspek klinis dan sistem diagnosis keperawatan fokus pada 4 gangguan adaptasi 1. spiritual 2. sosial 3. penerimaan diri 4. imunitas respons manusia akibat tidak terpenuhi kebutuhan dasar. intervensi 1. strategi koping 2. dukungan sosial (penerapan peran caring oleh perawat, dukungan keluarga, dan dukungan sesama odha dengan menerapkan peran pendampingan 1. observasi 2. tindakan (indepeden, dependen, kolaboratif) 3. penyuluhan evaluasi respons adaptif kognisi dan imunitas keluhan subyektif, data obyektif (hasil dari ippa = inspeksi, perkusi, palpasi, auskultasi + pemeriksaan laboratorium). aplikasi di ruangan perawat dapat menerapkan perannya secara mandiri dalam memenuhi kebutuhan pasien secara holistik. perawat menjadi lebih komunikatif dan dekat dengan pasien. perawat lebih menekankan pada tugas limpah (dependen) dari dokter, sehingga perawat belum dapat memenuhi kebutuhan pasien secara holisitik. perawat kurang dekat dan komunikatif dengan pasien. tabel 5. fisher linier discriminant function kelompok asuhan pakar standar cortisol -0.231 0.001 anti-hiv 3.644 -0.683 model asuhan keperawatan (nursalam) 121 strategi koping dalam meningkatkan keadaan biologis pasien, peneliti menekankan pada penyuluhan tentang penyakit dan pengobatan (bagi yang sudah mendapatkan arv) dan infeksi sekunder, konsumsi nutrisi yang mengandung tinggi kalori, tinggi protein, multivitamin, dan anti oksidan melalui pembelajaran membuat berbagai j u s ( p e n g e m b a n g a n d a r i l a s m a d i w a t i , sukanta, nugroho, 2002), aktivitas istirahat (senam), (oka, 2005), penerapan universal precautions. strategi koping dan dukungan sosial memengaruhi proses belajar di berbagai sel otak seperti astrosit, mikroglia dan neuron sehingga produksi dan sekresi hormon berkurang. menurut roy dikutip oleh nursalam (2008) proses belajar diawali persepsi, belajar, keputusan, dan tindakan (emosi). persepsi merupakan proses informasi terhadap stimulus yang masuk, meliputi perhatian, reinforcement, dan identifikasi tanda. belajar, diartikan sebagai proses imitasi. keputusan merupakan upaya solusi dan pengambilan keputusan. emosi diartikan sebagai tindakan terhadap keputusan yang telah ditetapkan. teknik strategi koping spesifik yang diajarkan pada penelitian ini adalah dengan 3 cara, yaitu pemberdayaan potensi diri, dengan meningkatnya harga diri, berpikiran positif dan percaya diri, teknik kognisi, dapat berupa menghindar atau menghadapi secara terbuka atau kompromi dan teknik perubahan perilaku, yaitu melakukan aktivitas yang bermanfaat dalam mempercepat kesembuhan: meditasi, senam aura atau terapi alam, dan kegiatan lain yang bermanfaat. perbedaan pengaruh respons spiritual model pakar yang diberikan pada respons ini adalah strategi koping (teknik kognisi) agar pasien mempunyai harapan untuk terus hidup, pasien merasa tabah menghadapi sakitnya, dan bisa mengambil hikmah terhadap sakit yang diderita. menguatkan harapan yang realistis kepada pasien terhadap kesembuhan merupakan peran perawat yang sangat penting. perawat dapat meyakinkan kepada pasien bahwa sekecil apapun kesembuhan, akan memberikan ketenangan dan keyakinan pasien untuk berobat. sehingga diharapkan pasien menjadi lebih tabah dan sabar (nursalam, 2007). sabar dan ketabahan hati adalah kunci bagi pasien terinfeksi hiv untuk terus meningkatkan kualitas hidup. dalam hal ini unsur karakteristik seseorang dan dukungan orang terdekat (peer group) sebagai penguat untuk lebih tabah dan sabar dalam menghadapi cobaan. individu yang mempunyai kepribadian yang kuat dalam arti tidak suka mengeluh dan selalu optimis, akan tabah dalam menghadapi setiap cobaan. individu tersebut biasanya mempunyai keteguhan hati dalam menentukan kehidupannya (nursalam, 2007). lebih lanjut proto menjelaskan individu yang sering mengalami kekecewaan dan menderita lebih kuat dan tabah dalam menghadapinya. ketabahan hati sangat dianjurkan kepada pasien terinfeksi hiv. perawat dapat menguatkan diri pasien dengan memberikan contoh nyata dan atau mengutip kitab suci atau pendapat orang bijak (faugier dan hicken, 1996). sebagaimana di dalam al qur'an surat al-baqaroh ayat 286, bahwa tuhan tidak akan memberikan cobaan kepada umatnya, melebihi kemampuannya. pasien harus diyakinkan bahwa semua cobaan yang diberikan tuhan kepada dirinya pasti mengandung hikmah yang sangat penting dalam kehidupannya. sebagaimana dikutip oleh kauman dan nipan (2003) bahwa musibah (penyakit) diberikan kepada manusia oleh allah untuk menguji tingkat keimanan seseorang. barang siapa yang tetap bersabar dalam menghadapi musibah yang menimpa dirinya, niscaya ia akan memperoleh derajat yang begitu tinggi dihadapan allah swt. jika pasien sudah mulai mampu mengambil hikmah dari sakit yang diderita, maka respons psikologis: penerimaan akan bisa dipercepat. peran perawat dalam hal ini adalah mengingatkan dan mengajarkan kepada pasien untuk selalu berpikiran positif terhadap semua cobaan yang dialaminya. dibalik semua cobaan yang dialami pasien, pasti ada maksud dari sang pencipta. pasien harus difasilitasi untuk lebih mendekatkan diri kepada sang pencipta dengan jalan melakukan ibadah secara terus-menerus, sehingga pasien diharapkan memperoleh suatu ketenangan selama sakit (ronaldson, 2000). penelitian jurnal ners vol. 6 no. 2 oktober 2011: 113–125 122 ini mayoritas pasien bisa menerima sakitnya sebagai suatu pelajaran yang berharga untuk memperbaiki perilakunya yang selama ini dianggap bertentangan dengan nilai-nilai moral dan agama. "dengan sakit ini, saya menjadi lebih mengerti tentang diri saya. saya menyadari bahwa semua yang telah saya lakukan selama ini tidak benar". pernyataan pasien di atas sesuai yang dikemukakan oleh zoetmulder (2000) dalam buku manunggaling kawula gusti bahwa tuhan telah berada di dalam hati manusia, lebih tepat di bagian paling dalam dinamakan sirr. sirr berada di tengah-tengah nafsu, bawah sadar yang mendalam, kesadaran yang masih terlipat, dan disebut dengan "perawan murni". untuk itu perlu dibangkitkan sirr tersebut, agar hati pasien tergerak untuk dapat mengambil hikmah terhadap cobaan yang dialaminya. dalam al-qur'an sirr disebut sebagai tahta kesadaran. ki agen sela dalam prabowo (2004) memberikan beberapa gambaran bahwa cobaan yang diberikan tuhan kepada manusia, agar orang tersebut mencapai keluhuran atau keutamaan, menghindari sesuatu yang dinamakan tan anut mring wuruk (tidak mengikuti perintah); kumprung biasanya tidak memikirkan untuk mencapai keluhuran, karena senantiasa diliputi oleh kebingungan. suasana pikiran yang bingung, orang seperti itu tidak sempat memikirkan sesuatu yang lebih luhur yang di balik cobaan yang diberikan. semua itu terjadi karena ia tidak dapat mengikuti petuah, ajaran, petunjuk yang berguna bagi dirinya. distres spiritual berupa harapan yang terlalu berlebihan, tidak sabar dan tidak dapat mengambil hikmah dari sakitnya. dukungan informasional (keluarga berfungsi sebagai sebuah kolektor dan diseminator atau penyebar informasi tentang dunia); dan dukungan penilaian atau appraisal (keluarga bertindak sebagai sebuah bimbingan umpan balik, membimbing dan menengah pemecahan masalah dan sebagai sumber dan validator identitas anggota); dukungan instrumental ( k e l u a rg a ) m e r u p a k a n s e b u a h s u m b e r pertolongan praktis dan konkrit); dukungan emosional (keluarga sebagai sebuah tempat yang aman dan damai untuk istirahat dan pemulihan serta membantu penguasaan terhadap emosi). menurut ronaldson (2000) pasien dengan penyakit kronis yang menjalani perawatan yang lama mengalami distres spiritual yang berat. mereka sebagian besar mengalami perbaikan keadaan fi sik yang lambat. hal senada juga disampaikan oleh zoetmolder (2000) bahwa jiwa yang tidak bisa manunggal dengan gusti, mengalami keluhan-keluhan fi sik dan rentan terhadap sakit. pernyataan ini bisa disimak dari pernyataan pasien: "aku masih belum bisa mengontrol diri. saya sering marah-marah tanpa sebab. yang jadi sasaran ya anak saya dan orang tuaku (st, perempuan, 26 tahun). penelitian ini hanya variabel tabah dan sabar yang menunjukkan hubungan yang signifikan dengan peningkatan kadar cd4. artinya pasien yang tabah dan sabar dalam menghadapi sakit yang dialami akan meningkatkan kadar cd4. hasil penelitian dari nursalam (2007) menunjukkan bahwa pasien yang sabar dan menyerahkan diri terhadap sakit yang dialaminya, mengalami peningkatan kadar kortisol. ader (2001) menemukan dengan peningkatan kadar cd4 pada pasien terinfeksi hiv akan meningkatkan aktivasi ifn-γ yang akhirnya infeksi oportunistik seperti herpes simplek dan herpes zoester dapat dicegah. perbedaan pengaruh respons sosial model pakar dalam menunjang respons sosial yang adaptif adalah dengan memberikan dukungan sosial kepada pasien melalui pasien, keluarga, dan peer group odha. dukungan yang diberikan berupa dukungan emosional, dukungan informasi, dan dukungan material. nursalam (2007) menjelaskan bahwa dukungan sosial sebagai informasi atau nasihat verbal dan atau nonverbal, bantuan nyata, atau tindakan yang diberikan oleh keakraban sosial atau berupa kehadiran dan mempunyai manfaat emosional atau berpengaruh pada perilaku penerimanya. setiap anggota keluarga memiliki kebutuhan dasar fi sik, pribadi dan sosial. keluarga harus berfungsi menjadi perantara bagi tuntutan-tuntutan dan harapanharapan dari semua individu yang ada di dalamnya. menurut caplan (nursalam, 2007) model asuhan keperawatan (nursalam) 123 menerangkan bahwa keluarga memiliki delapan fungsi suportif, termasuk di antaranya dukungan. keluarga memainkan sebuah peran yang sangat penting dalam menentukan perilaku anggota keluarganya yang sakit, bersifat mendukung selama masa penyembuhan dan pemulihan. apabila dukungan semacam ini tidak ada, maka keberhasilan program penyembuhan dan pemulihan akan sangat berkurang. namun untuk penyakit hiv di mana keluarga juga mengalami kekacauan sebentar sebagai respons terhadap kekuatan stresor. pada penelitian ini pada awal pasien dinyatakan positif terinfeksi hiv, bentuk dukungan keluarga sangat bervariasi. ada keluarga yang justru menyalahkan, tetapi sebagian besar keluarga tetap memberikan semangat dan dukungan. perilaku individual sangat dipengaruhi oleh adanya tekanan sosial. adanya tekanan sosial ini dapat menimbulkan kondisi stres. respons sosial yang negatif ini muncul, karena adanya situasi yang mengancam atau menyakitkan tubuh individu tersebut, atau disebabkan oleh adanya tekanan sosial yang pada akhirnya akan berdampak pada kondisi fi sik, psikologis dan kemampuan individu untuk berinteraksi dengan lingkungan. penelitian ini hampir semua respons sosial pasien terifeksi hiv sangat labil dan mereka mengalami kecemasan yang tinggi, baik disebabkan oleh penyakit maupun oleh karena hal lain yang sifatnya dapat memperparah kondisi pasien. mayoritas pasien mempunyai perasaan dikucilkan oleh teman maupun masyarakat sehingga pasien menjadi tertutup, menyendiri, dan jarang berhubungan dengan lingkungan sekitar. menurut roy, respons sosial berhubungan dengan respons imunitas. pasien yang terganggu hubungan sosial, berupa merasa terisolasi, dikucilkan, dan tidak bisa berperan sesuai dengan statusnya menunjukkan penurunan respons imunitas berupa rentan terhadap sakit. pada hasil kajian (nursalam, 2007) pasien terinfeksi hiv waria menunjukkan adanya gangguan interaksi sosial dengan lingkungan. gangguan interaksi tersebut disebabkan penolakan masyarakat tentang statusnya yang bertentangan dengan agama dan budaya di indonesia. kondisi tersebut akan menjadikan beban moral bagi pasien (waria) di masyarakat. hal demikian berdampak terhadap penurunan kadar cd4 dan peningkatan antihiv. pada penelitian ini kelompok pasien yang mendapatkan model pakar selama 3 bulan menunjukkan respons sosial yang signifi kan, khususnya pasien yang mempunyai emosi yang stabil (perasaan dicintai, dihargai, dan diperhatikan) oleh lingkungan sekitar akan meningkatkan kadar cd4. pasien menunjukkan respons emosi yang positif, merasa dihargai, diperhatikan dan dicintai. sebagaimana yang disampaikan sy (laki-laki, 33 tahun). "selama ini orang tuaku dan adik dan kakakku tetap mendukung saya. mereka semua menginginkan saya cepat sembuh". pasien yang tidak terlalu mencemaskan k e a d a a n s a k i t n y a , b i a y a p e r a w a t a n , kesembuhan, dan hubungan dengan sesama menunjukkan peningkatan cd4 dan anti-hiv yang signifi kan. "kata teman-teman saya ini tidak sakit hiv/aids, badan saya tetap gemuk dan bb tidak turun. paling kamu tidak sakit yn). saya semakin senang dengan pujian tetangga tersebut. saya juga merasa senang dengan bisa berkumpul sesama odha setiap hari di upipi ini. saya bisa belajar banyak (jn, waria, 30 tahun). kecemasan merupakan respons gangguan afek emosi. individu yang mengalami cemas sampai pada tingkat panik, meningkatkan kerja dari jantung dan menjadi mudah kelelahan. kondisi tersebut akan memperparah respons imunitas. perbedaan pengaruh respons penerimaan diri (psikologis) respons psikologis yang digunakan dalam penelitian ini didasarkan pada konsep kubler dan ross yang meliputi lima tahapan respons, yaitu: denial – anger – bargaining – depression – acceptance (sunaryo, 2004) p e n e r a p a n pa k a r d i h a r a p k a n d a p a t mempercepat respons penerimaan. percepatan respons adaptif pada penyakit ini memengaruhi mekanisme koping dan menurunkan aktivitas hpa. penurunan aktivitas hpa berpengaruh terhadap penurunan produksi dan sekresi jurnal ners vol. 6 no. 2 oktober 2011: 113–125 124 neuromodulator disertai neurotransmitter. pada penelitian kelompok pasien yang mendapatkan model pakar menunjukan penurunan produksi kortisol yang signifi kan. tetapi secara menyeluruh antara kelompok perlakuan dan standar tidak menunjukkan perbedaan yang signifi kan. hal ini diduga karena sebagian besar pasien sudah menduga positif terinfeksi hiv, karena teman-teman kencan/sesama pengguna sudah terlebih dahulu positif hiv. a d e r ( 2 0 0 1 ) m e n j e l a s k a n b a h w a respons psikologis (stres) berhubungan dengan peningkatan kadar kortisol dan penekanan immunosupresan (cd4, sitokin, dan antibodi). pasien terinfeksi hiv yang mengalami depresi yang berat berdampak terhadap penurunan cd antara 30–60 cells/μl. pada penelitian ini respons psikologis secara keseluruhan tidak menunjukkan hubungan yang signifi kan dengan respons biologis. secara individu, respons denial berhubungan dengan peningkatan ifn-γ. hal ini diduga bahwa pasien sudah siap dengan didiagnosa yang diberitahukan tim kesehatan. menurut carpenito (2003) pasien yang sudah dipersiapkan terhadap suatu kesedihan (anticipatory grieving) mempunyai koping yang lebih konstruktif dibandingkan yang tidak dipersiapkan. keadaan demikian akhirnya tidak berdampak terhadap kondisi fi sik (biologis). hal ini bisa disimak dari pernyataan pasien laki-laki yp (28 tahun): " s a y a s u d a h t i d a k t e r l a l u k a g e t dinyatakan positif hiv, karena temanku sesama pengguna juga sudah terlebih dulu kena. stres sih iya, tapi saya bisa apa. saya masih tetap ingin konsentrasi dengan pekerjaanku sekarang sebagai tukang sablon. toh selama saya sakit tidak berpengaruh keluarga". respons anger berhubungan dengan peningkatan respons imunitas (cd4). hal ini terjadi karena respons imunitas tersebut, sering terjadi pada pasien yang mengalami respons psikologis yang agresif (seperti anger). ader (2001) menjelaskan pasien yang mengalami respons marah terhadap sakit yang berkepanjangan akan memicu penurunan ifn-γ. sehingga pasien menjadi rentan terhadap infeksi oportunistik seperti herpes simplek dan zooster. suami ny. um, juga mengalami respons anger yang berkepanjangan sehingga selama 2 minggu pasien dirawat meninggal. respons adaptif bargaining juga berhubungan dengan peningkatan cd4. sebagaimana pada respons anger, respons bargaining akan memicu seseorang untuk melakukan sesuatu yang penuh risiko. mereka akan berani menghadapi risiko dari tindakan atau keputusan yang dipilih. kondisi ini memicu terhadap peningkatan kadar ifnγ. penemuan baru model pakar pada pasien terinfeksi hiv penemuan baru yang dapat menjelaskan bagaimana mekanisme penerapan model pakar dengan menggunakan paradigma adaptasi dari roy dan psikoneuroimunologi dapat memperbaiki respons adaptif kognisi (spiritual, sosial, penerimaan diri) dan respons biologis. pakar mempunyai efek terhadap proses pembelajaran yang menghasilkan kognisi yang positif sehingga koping pasien menjadi positif. koping yang positif tersebut ditunjukkan dengan respons emosi yang positif, pandai mengambil hikmah dari sakitnya, dan berpikir rasional terhadap sakit yang dialami sebagai sesuatu yang logis. hal dimaksud mempunyai efek biologis terhadap penurunan kortisol, sehingga mampu memodulasi respons imun cd4. peningkatan kadar cd4 akan meningkatkan perannya dalam berinteraksi secara langsung pada ontogen dan fungsi cd4 dalam darah perifer. interaksi yang kedua adalah cd4 bekerja sebagai reseptor masuknya antigen ke dalam limfosit, khsusnya pada hiv melalui gp 120 yang terdapat pada permukaan hiv. peningkatan cd4 akan meningkatkan kemampuan mengenal antigen melalui sistem efektor ekstraseluler, misalnya oleh sel t sitoksik yang terdapat pada makrofag sel yang terinfeksi melalui reseptor tcr dan molekul mhc kelas ii. sinyal yang diterima dari sel terinfeksi ini menginduksi limfosit untuk memproduksi berbagai jenis limfokin, termasuk di antaranya ifn-γ yang dapat membantu makrofag menghancurkan hiv. model pakar juga mempunyai efek terhadap keseimbangan perubahan hsp70 yang mampu memproteksi apoptosis melalui jalur sitokin. model asuhan keperawatan (nursalam) 125 simpulan dan saran simpulan m o d e l pa k a r y a n g d i d a s a r k a n psikoneuroimunologi mempunyai efek terhadap perbaikan mekanisme koping pada pasien hiv melalui proses pembelajaran. perbaikan koping yang positif tersebut ditunjukkan oleh perbaikan respons kognisi distress (tidak tabah, merasa dikucilkan lingkungan, dan marah) menjadi respons yang eutress (tabah dan sabar, emosi yang positif, dan penerimaan diri). perbaikan respons kognisi tersebut meningkatkan motivasi pasien untuk tetap hidup sehingga memperbaiki respons biologis (imunitas) yang dicerminkan oleh kadar cd4. peningkatan kadar cd4 akan mencegah progresivitas hiv ke aids dan memperbaiki kualitas hidup pasien. saran model pakar berbasis paradigma p s i k o n e u r o i m u n o l o g i p a s i e n h i v direkomendasikan untuk digunakan dalam perawatan di semua instansi pelayanan kesehatan. perlu dilakukan penelitian lebih lanjut efek model pakar terhadap perubahan respons biologis, khususnya hsp 70 dan hsp lainnya yang memproteksi apoptosis dan memperbaiki imunitas melalui jalur sitokin. hasil penelitian ini semakin memperjelas peran pakar sebagai model terapi kognisi. kepustakaan ader, r., felten, d.l., dan cohen n., 2001. psychoneuroimmunology. 3rd. edn. san diago: academic pres. inc. pp. 583–612. biondi, m., 2001. effects of stress on immune functions: an overview. in psychoneuroimmunology, 3rd. ed. edited by ader r, felten dl, cohen n, volume ii, pp 189–226. carpenito, l.j., 2003. nursing diagnosis. phladelphia: mosby co. pp. 20–45. departemen kesehatan republik indonesia, 2003. pedoman nasional perawatan, dukungan dan pengobatan bagi odha. buku pedoman untuk petugas kesehatan dan petugas lainnya. jakarta: dirjen ppm & pl depkes. 11–42. departemen kesehatan republik indonesia, 2006. pelatihan klinik dasar art dan perawatan akut. panduan fasilitator. jakarta: direktorat jenderal pengendalian penyakit dan penyehatan lingkungan. faugier, j., dan hicken, i., 1996. aids and hiv. the nursing response. london: chapman and hall. pp. 87–102. kauman, f., dan nipan, 2003. kisah-kisah akhlak terpuji. yogyakarta: mitra pustaka. hlm. 120–127; 162–164. lasmadiwati, e., sukanta, p.o., nugroho, s.h.s., 2002. potensi diri dan alam untuk pengobatan hiv/aids. bogor: penebar swadaya. hlm. 22–50; 174– 182. maramis, w.f., 2003. catatan ilmu kedokteran jiwa. surabaya: airlangga university press. nasronudin, soewandojo, suharto, 2002. p e n g e t a h u a n d a n s i k a p p e t u g a s kesehatan yang bekerja di rumah sakit kota surabaya dalam merawat pasien hiv/aids. hasil penelitian tidak dipublikasikan. nursalam, 2008. konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika, hlm. 13–26. nursalam, 2007. asuhan keperawatan pasien terinfeksi hiv/aids. jakarta: salemba medika. nursalam, 2005. the effect of pakar on the increase of cd4 cell account patient with hiv infection. folia medica indonesiana. prabowo, d.p., 2004. pandangan hidup kejawen. dalam serat pepali ki ageng sela. yogyakarta: narasi. hlm. 73– 89. oka, p., 2005. potensi diri dan alam untuk pengobatan hiv/aids. bogor: penebar swadana. hlm. 111–150. ronaldson, s., 2000. spirituality. the heart o f n u r s i n g . m e l b o u r n e : a u s m e d publications. pp. 5–23. sunaryo, 2004. psikologi untuk keperawatan. jakarta: egc. hlm. 20–29. zoetmulder, p.j., 2000. terjemahan oleh dick hartoko. manunggaling kawulo gusti. jakarta: pt gramedia pustaka utama. hlm. 136–163; 213–246. p-issn: 1858-3598  e-issn: 2502-5791 161 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 161167 http://dx.doi.org/10.20473/jn.v17i2.34113 original article open access five cs as reflective learning attitude among philippines nursing students joel rey ugsang acob 1, * , yulis setiya dewi 2 , and hidayat arifin 3 1 faculty of nursing, visayas state university, visca, baybay, philippines 2 faculty of nursing, universitas airlangga, surabaya, indonesia 3 faculty of nursing, universitas padjadjaran, bandung, indonesia *correspondence: joel rey u. acob. adress faculty of nursing, visayas state university, visca, baybay, philippines. email: joel.acob@vsu.edu.ph responsible editor: ferry efendi received: 4 march 2022 ○ revised: 2 october 2022 ○ accepted: 28 october 2022 abstract introduction: philosophical viewpoints from the first-hand source regarded as the best inception of covid-19 knowledge are not widely explored. humanity’s understanding grounded on experiences becomes substantial only when stringent documentation of any events is performed carefully. covid-19 as a phenomenon and as an ongoing struggle has myriad global impacts; hence the study aims to explore the understanding of nursing students’ stances regarding the covid-19 pandemic in their daily life. methods: the study used a qualitative study design with online survey. a total of 41 nursing students were recruited through total sampling technique. the study was conducted to students in a university in the philippines. interview guidelines used open questions and were spread online. the data were subjected to thematic analysis. results: the thematic analysis revealed five organizing themes, such as communication, commitment, care, collaboration, and change. those themes were found among nursing students’ stance regarding the covid-19 phenomenon. conclusions: the communication, commitment, care, collaboration, and change as development of a crisis-induced framework from study findings satisfies the essential finding that the pandemic is likewise giving rise to a new normal. moreover, the results assist nursing students and other health-inspired domains to effectively maintain positivity amidst catastrophic climates. keywords: caring; covid-19; nursing attitudes; nursing education; pandemic introduction coronavirus disease 2019 (covid-19) is considered as pandemic that has greatly changed human life (saadat et al., 2020). countries are confronted with issues the solution to which is hardly recognized since it affects multiple categories of governance other than the health sector. strong knowledge and skills are required in the prevention of infection transmission during healthcare and the availability of personal protective equipment is among the major problems encountered which have challenged leadership (hernández, 2020). covid-19 had a major impact on the world of health and education (chaturvedi et al., 2021; france et al., 2021; kim et al., 2022; seow et al., 2022). strengthening and increasing the role of health personnel is particularly important. not only that, but students who focus on the health sector, such as nursing, also need to play a role in dealing with covid-19 (bacci et al., 2021; tausch et al., 2022). covid-19 is highly infectious and can be transmitted through close contact. infected persons can spread the virus when exposed to others through coughing, sneezing, respiratory droplets or aerosols (dewi et al., 2021; riou & althaus, 2020). the first cases of pneumonia associated with covid-19 were reported in https://creativecommons.org/licenses/by/4.0/ mailto:joel.acob@vsu.edu.ph https://orcid.org/0000-0002-3829-322x https://orcid.org/0000-0003-4407-0433 https://orcid.org/0000-0002-5647-5721 acob, dewi, and arifin (2022) supremo, bacason, and sañosa (2022) 162 p-issn: 1858-3598  e-issn: 2502-5791 wuhan, china, by the end of 2019 (huang et al., 2020). as of april 2022, there were more than 503 million cases and six million deaths globally, whereas in south-east asia there were more than 57 million cases (who, 2022). covid-19 has had many negative impacts in all sectors of life (nundy et al., 2021). the most felt impact is in the field of education, where students face a new pattern of education with a home learning system. not only that, other perceived impacts such as stress with online learning methods (acob et al., 2021; black thomas, 2022; nodine et al., 2021), as well as a decrease in the skills of nursing students have gained considerable attention (aldridge & mcquagge, 2021; park & seo, 2022). other problems provoked by the covid-19 outbreak are social stigma and discriminatory behaviors against people perceived to have contracted the virus as well as ethnic groups (unicef, 2020a; wahyuhadi et al., 2022). social isolation can be led by stigma of those who have contracted viruses where people may be very afraid to get infected. meanwhile, deaths caused by covid-19 pandemic lead to irreversible damage to the community (chakraborty & maity, 2020). the gap is that covid-19 has given fear to everyone such as of death (servidio et al., 2021). this affects all daily activities that become paralyzed (karataş & tagay, 2021). however, with the right knowledge, the spread and impact of covid-19 can be minimized. for this reason, the role of all groups, both in the community, hospitals, and education, is needed. however, very limited research is found to describe a positive side from the event of the covid-19 pandemic. this essay unfolds the contradictory angle claiming that the pandemic doesn’t only procure gloomy effects. it also exhibits and unfolds in beneficial and favorable contributions across human experience. thus, the study aim was to explore the understanding of nursing students’ stances regarding the covid-19 pandemic. materials and methods the research team and reflexivity the research process was carried out online due to the covid-19 pandemic. the researchers have immense scientific experience in the fields and interest as nursing researchers and nursing lecturer in the sphere of medical surgical nursing, nursing care, caring in nursing and resilience in nursing. study design in achieving the central study concepts, the proponents utilized a qualitative process of surveying participants’ perspectives regarding the favorable effects of covid-19 to humanity. participant selection and setting this involved online inquiry with guided questions to purposively identify level one nursing students officially enrolled for the academic year 2019-2020 with no force or coercion. students must know the covid-19 information. if the students do not know, they can leave this online survey. following the declaration of enhanced community quarantine, these 41 students recruited by total sampling technique went to their respective home places and provinces in the visayas and mindanao regions of the philippines. students were explained the purpose of the research and how they participate as well as benefits of the research to them and the nursing sphere as information for consent. when they agreed to participates they were given an approval letter and asked to give their understanding of the pandemic based on individual observations to their respective locales. three guiding questions, such as “what are the positive attributes of the phenomenon (covid-19 pandemic) to human life?” were used to extract their understanding and appreciation amidst these testing times. responses were all taken and sent through email with a return rate of 90% (74/82), five days after the guide question was released. during the research process, eight participants dropped out because of the students’ condition, such as limited access to internet connectivity and those who did not respond to the questions before the deadline. participants in this study provided informed consent. each participant's identity is protected by using a code that is only known by the researchers. in addition, the research data were kept confidential by researchers and are used only for research purposes. data collection the study was conducted from april until may 2020 in the philippines, when students and educational institutions were put on hold. during the period of limited mobility, the researcher utilized the opportunity to request ideas from young people on the positive standpoint about covid-19. before students answered the question, the researcher provided a research guideline by email which was sent to all participants. through a guided question by which participants could freely express their thoughts and which was sent through email and other electronic means, responses were treated qualitatively. students were free to ask the reviewer anything regarding the question jurnal ners http://e-journal.unair.ac.id/jners 163 data analysis the study employed the step-by-step protocol of qualitative data analysis defined as the rational framework. the analytical framework described the flow of how data were processed and later in identifying developed themes (akinyode & khan, 2018). through data logging or recording of inputs from the nursing students, anecdotes were recorded from the significant statements and then vignettes (basic themes) documented from the responses, as well as inductive coding of data, and thematic network wherein the investigator connected basic links and organized a network on the constructive impact of the pandemic to people’s lives. moreover, the procedure was established on thematic networks which aimed at familiarizing the subject of concern with clarity on how the strategy was done. the stages consisted of 1) gaining familiarity with the data; 2) generating the initial codes; 3) searching for themes; 4) reviewing the themes; 5) defining and naming the themes; and 6) producing the report (braun et al., 2006). ethical consideration this study received ethical approval from the health ethical committee, st paul university philippines with number pc-2020-05. results all participants were officially enrolled to bachelor of science in nursing program level 1 in the philippines at the time the study was conducted. they were ranged from 17-19 years old, both males (18 students) and females (64 students). they were situated to different provinces in the philippines during the survey; leyte table 1 theme distribution and participant quotes themes sub-themes quotes communication recognition q1: “people and government recognized that healthcare providers are underappreciated and taken for granted” q2: “served as basis to prepare for a more prepared system to combat future pandemics” q3: “people learned the importance of and role of health workers” bonding q4: “crisis provides families the opportunity to be together” q5: “… families are coming closer” q6: “gift of time to spend for family and bonding to each other” spiritual q7: “people are moved closer to god, faith made stronger” q8: “…rebuild relationship to god” q9: “praying for healing of the world” sacrifice q10: “sacrificing lives for others” commitment responsibility q11: “people observe proper hygiene, disciplined, responsible” q12: “helps people to be more responsible of their own health” discipline q13: “to be more disciplined in terms of caring for our own health” q14: “teaches us the importance of discipline” q15: “people observe proper hygiene, disciplined” care giving q16: “helping others to decrease the spread of disease through giving personal protective equipment” q17: “…giving to those in need” q18: “opportunity to reconnect to their family, community and self” sharing q19: “significance of helping and sharing to one another during this world crisis” q20: “sharing to most in need is practiced” compassion q21: “eye opener for humanity to unite, compassion for others” q22: “…sense of humanity and compassion” q23: “people are compassionate and generous by donating personal protective equipment, shelter” collaboration unity q24: “united as one, reminded of the importance of healthcare professionals” q25: “reuniting with families and loved ones” q26: “front liners are in unison for the safety and security of everyone” helping q27: “people develop empathy toward others and try to help as much as they can” q28: “people are helping together to fight against this disease” q29: “helping those in need and build stronger relationship with the lord” change appreciation q30: “…eye opener for everyone that our hcs is vulnerable” q31: “giving importance to health providers such as nurses, doctors, which are less appreciated before” positive environment effects q32: “lessen pollution, thus environment is slowly turning back to normal” q33: “people are more vigilant, cautious, and alert toward actions to the environment” cleanliness q34: “environment is rehabilitating such as clear blue skies, pollution free-air, and reduced pressure on resources” q35: “recognizing the importance of hygiene as they stay clean and healthy” improved healthcare q36: “front liners and health professionals showed their act of patriotism toward greater good” q37: “…improve the healthcare system” q38: “importance of the health sector and healthcare providers” q40: “people are becoming more aware of their hygiene and learning healthy practices in order to prevent catching the virus” q41: “emphasized the importance of healthcare providers” acob, dewi, and arifin (2022) supremo, bacason, and sañosa (2022) 164 p-issn: 1858-3598  e-issn: 2502-5791 province (75%), samar province (4%), bohol province (18%), and surigao province (3%). subsequently, the online open question e-poll lasted for five calendar days and transcribed using careful scrutiny of the retrieved information. keywords and basic themes or vignettes were named. the vignettes were extracted from the transcripts that directly answered the issue. in this phase, a total of 117 keywords and basic themes emerged which were further clustered into five theses. the thematic network reflected the five issues as communication, commitment, care, collaboration, and change (table 1). in table 1, it is seen that communication consists of five sub-themes, namely recognition, bonding, spiritual, and sacrifice. communication is an important basis in building positive perceptions of the covid-19 pandemic. this consists of 1) recognition of health workers, preparation and assistance from the government (quotes 1-3), 2), bonding from the family and always supporting each other (quotes 4-6), 3), spiritual communication to god (quotes 7 -9) and 4) sacrifice to help others’ lives (quote 10). the commitment theme consists of two sub-themes, namely responsibility and discipline. to build a positive commitment during the covid-19 pandemic period, responsibility is needed in maintaining cleanliness (quotes 11-12) and discipline in maintaining health, as well as knowing the importance of discipline to prevent the spread of covid-19 (quotes 13-15). the next theme is care, which consists of three subthemes, namely giving, sharing and compassion. care consists of the willingness of both the citizens and the government in paying attention to the conditions during the covid-19 pandemic and helping each other, both health workers and the community (quotes 16-18). in addition, sharing is needed during the covid-19 pandemic (quotes 19-20). compassion to others by paying attention to conditions and needs with donations or other things is very meaningful during the covid-19 pandemic conditions (quotes 21-23). the collaboration theme consists of two sub-themes, namely unity and helping. during the covid-19 pandemic, a unity attitude is needed to maintain health and hygiene by reminding each other (quotes 24-26) and helping each other with empathy, helping each other in fighting the spread of covid-19 and strengthening each other (quotes 27-29). the theme of change consists of four sub-themes, namely appreciation, positive environment effects, cleanliness, and improved healthcare. appreciation can be given in the form of knowing the conditions and needs of hcs, such as nurses, doctors and other health workers (quotes 30-31). from several opinions of the participants, it is known that the existence of covid-19 with restrictions on activities is having a positive effect on the environment, such as low levels of pollution (quotes 32-33), a clean environment such as environmental rehabilitation, and the importance of maintaining cleanliness (quotes 34-35). improved health services during the covid-19 pandemic were mostly carried out by health workers, improving the health system to monitor the spread and handling of covid-19, as well as public awareness of its spread (quotes 36-41). discussions communication is very important during the covid19 pandemic (reddy & gupta, 2020). the study found that the good communication can lead to communication between health, family, spiritual, and community workers to help each other (maloney, 2020; reddy & gupta, 2020; unicef, 2020b; wickner et al., 2020). the covid-19 pandemic has a great opportunity to provide misinformation, so it requires providing proper information to the public (m. h. nguyen et al., 2020). nursing students have an important role in disseminating correct information about covid-19 to the public and health workers (swift et al., 2020). in addition, during the lockdown period implemented by the government, communication within the family has changed (marra et al., 2020). in this case, nursing students can be the right reference information for families to provide accurate information. so, worries related to the covid-19 pandemic can be reduced. the research data show that, during the lockdown period, the spiritual relationship between the people and their gods became more intense. nursing students can play a role in increasing religiosity and spirituality to provide calm during dealing with covid-19 and reduce anxiety (ferrell et al., 2020). with good and correct communication, a strong relationship to live life with covid-19 can be built. the finding in the study showed that nursing students present commitment due to the covid-19 pandemic. the commitment shown includes compliance and discipline in washing hands to avoid contracting covod-19. nursing students can be examples of discipline in hand washing, both in their surroundings and in their families. commitment to maintain cleanliness is an important key to preventing and spreading covid-19. research conducted by several researchers states that commitment is a basic thing that must be owned by everyone (alzyood et al., 2020; singh, 2020). this aims to reduce the number of spread and jurnal ners http://e-journal.unair.ac.id/jners 165 transmission of covid-19, which can be done routinely and be disciplined to wash hands. the results showed that the presence of the covid19 pandemic can increase caring behavior, such as giving, sharing, and affection. nursing students feel the change in caring to be able to share with others during the covid-19 pandemic. research conducted by several researchers shows that the sense of caring has increased during the pandemic, which can be seen from the provision of personal protective equipment (ppe) for health workers, the general public, and food assistance for people experiencing economic impacts due to covid-19 (santos, 2020; schroeder et al., 2020; zheng, 2020). it should be noted that filipinos by nature are cheerful givers. the ability to share resources intrinsically comes out when somebody is observed to be of greater need amidst a dearth of reserves. directly, the state is empowered to move and take immense initiatives in addressing the crisis’s pressing needs. government works for and on behalf of its people who breathes more apparent. whatever be the cause or origin, the occurrence of covid-19 has emphasized to improve the mutually-affective connection between humans where a feeling to care for each other is naturally developed (fernandez et al., 2020). during the covid-19 pandemic, nursing students said that collaboration in handling the disease was needed, both in the family environment and in health workers. health workers must help and strengthen each other in overcoming the spread of covid-19 (da costa belarmino et al., 2020; wong et al., 2020). health workers as front liners must maintain health and care for covid-19 patients (l. h. nguyen et al., 2020). the government's role in collaboration with health workers is very important. so that we need policies that can help and ensure the health and welfare of health workers (the lancet, 2020). rescovid-19 and collaboration with all aspects is needed to accelerate the handling of the pandemic (bielicki et al., 2020; the lancet, 2020). this study shows the results that covid-19 will not only cause bad changes, but also changes that have a positive impact. this can be seen from all aspects of society which sees hcws as health workers who are very vulnerable to contracting covid-19, so there is a lot of appreciation from the community for providing assistance to hcws (icn, 2020). in addition, covid-19 can have a positive impact on the surrounding environment. this can be seen from the low threshold value of air pollution during the lockdown period. the results of research conducted by several studies show that pollution, temperature, and carbon-dioxide conditions on earth decreased during covid-19 (kanniah et al., 2020; le quéré et al., 2020; rume & islam, 2020). another change is shown in the hygiene awareness behavior shown by the community, such as washing hands regularly, using masks, and maintaining environmental hygiene (kim et al., 2020; knell et al., 2020). not only that, changes from the healthcare system are also the center of attention, such as improved service quality supported by adequate facilities to prevent the spread of covid-19 (chan et al., 2020). this study presents the positive insight from nursing students regarding the covid-19 pandemic in the philippines. however, the study is only located in one university. a wider sample including other countries will provide more information. conclusions during the covid-19 pandemic, there are not only negative aspects, but several things can lead to positive aspects. nursing students in the philippines show an attitude that, during the covid-19 pandemic, it can lead to integrated communication for health workers, families and the government. in addition, there is an increased commitment to mutual care and care to reduce the spread of covid-19. not only that, collaboration in all aspects, such as society, health workers and the government, has a very important role in preventing the spread of covid-19. positive changes are shown in behavior, environmental changes, and improvisation in the health service system. in this case, the government can take the positive side to continue making improvements, as well as issue policies that can maintain health stability in the community, health workers, and policies to maintain good behavior change. references acob, j. r. u., arifin, h., & dewi, y. s. (2021). depression, anxiety and stress among students amidst covid-19 pandemic: a crosssectional study in philippines. jurnal keperawatan padjadjaran, 9(2), 102-109. https://doi.org/10.24198/jkp.v9i2.1673 akinyode, b. f., & khan, t. h. (2018). step by step approach for qualitative data analysis. international journal of built environment and sustainability, 5(3), 163-174. https://doi.org/10.11113/ijbes.v5.n3.267 aldridge, m. d., & mcquagge, e. (2021). “finding my own way”: the lived experience of undergraduate nursing students learning psychomotor skills during covid-19. teaching and learning in nursing, 16(4), 347-351. https://doi.org/https://doi.org/10.1016/j.teln.2021.07.002 alzyood, m., jackson, d., aveyard, h., & brooke, j. (2020). covid‐19 reinforces the importance of handwashing. journal of clinical nursing, 29(15-16), 2760-2761. https://doi.org/10.1111/jocn.15313 bacci, j. l., odegard, p., arnold, j., & stergachis, a. (2021). strengthening pandemic preparedness through pharmacy and public health collaborations: findings from a facilitated discussion exercise. journal of the american pharmacists association, 61(3), e99-e106. acob, dewi, and arifin (2022) supremo, bacason, and sañosa (2022) 166 p-issn: 1858-3598  e-issn: 2502-5791 https://doi.org/https://doi.org/10.1016/j.japh.2020.12.024 bielicki, j. a., duval, x., gobat, n., goossens, h., koopmans, m., tacconelli, e., & van der werf, s. (2020). monitoring approaches for health-care workers during the covid-19 pandemic. the lancet infectious diseases, 20(10), e261-e267. https://doi.org/10.1016/s1473-3099(20)30458-8 black thomas, l. m. (2022). stress and depression in undergraduate students during the covid-19 pandemic: nursing students compared to undergraduate students in non-nursing majors. journal of professional nursing, 38, 89-96. https://doi.org/https://doi.org/10.1016/j.profnurs.2021.11.013 braun, v., clarke, v., braun, v., & clarke, v. (2006). applied qualitative research in psychology. applied qualitative research in psychology, 3(2), 77-101. https://doi.org/10.1057/978-1-13735913-1 chakraborty, i., & maity, p. (2020). covid-19 outbreak: migration, effects on society, global environment and prevention. science of the total environment, 728, 138882-138882. https://doi.org/10.1016/j.scitotenv.2020.138882 chan, h. f., brumpton, m., macintyre, a., arapoc, j., savage, d. a., skali, a., stadelmann, d., & torgler, b. (2020). how confidence in health care systems affects mobility and compliance during the covid-19 pandemic. plos one, 15(10), e0240644-e0240644. https://doi.org/10.1371/journal.pone.0240644 chaturvedi, k., vishwakarma, d. k., & singh, n. (2021). covid-19 and its impact on education, social life and mental health of students: a survey. children and youth services review, 121, 105866. https://doi.org/https://doi.org/10.1016/j.childyouth.2020.10586 6 da costa belarmino, rodrigues, m. e. n. g., dos anjos, s. d. j. s. b. d, & ferreira júnior, a. r. (2020). collaborative practices from health care teams to face the covid-19 pandemic. revista brasileira de enfermagem, 73(suppl 2). https://doi.org/10.1590/0034-71672020-0470 dewi, y. s., qona'ah, a., arifin, h., pradipta, r. o., rosita, r., & benjamin, l. s. (2021). bridging innovation to prevent ventilatorassociated pneumonia: a descriptive qualitative study among critical care nurses. jurnal keperawatan padjadjaran, 9(3), 232239. https://doi.org/10.24198/jkp.v9i3.1923 fernandez, r., lord, h., halcomb, e., moxham, l., middleton, r., alananzeh, i., & ellwood, l. (2020). implications for covid-19: a systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. international journal of nursing studies, 111, 103637-103637. https://doi.org/10.1016/j.ijnurstu.2020.103637 ferrell, b. r., handzo, g., picchi, t., puchalski, c., & rosa, w. e. (2020). the urgency of spiritual care: covid-19 and the critical need for whole-person palliation. journal of pain and symptom management, 60(3), e7-e11. https://doi.org/10.1016/j.jpainsymman.2020.06.034 france, k., hangorsky, u., wu, c.-w., sollecito, t. p., & stoopler, e. t. (2021). the impact of the covid-19 pandemic on online oral medicine education as viewed through increased engagement in the oral cavity: portal to health and disease. oral surgery, oral medicine, oral pathology and oral radiology, 131(3), 380-382. https://doi.org/https://doi.org/10.1016/j.oooo.2020.10.027 hernández, c. l. (2020). revista habanera de ciencias medicas. revista habanera de ciencias medicas, 2(19), 1-4. huang, c., wang, y., li, x., ren, l., zhao, j., hu, y., zhang, l., fan, g., xu, j., gu, x., cheng, z., yu, t., xia, j., wei, y., wu, w., xie, x., yin, w., li, h., liu, m., . . . cao, b. (2020). clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet, 395(10223), 497-506. https://doi.org/10.1016/s01406736(20)30183-5 icn. (2020). international nurses day: nurses deserve praise, thanks, protection amid covid-19. in. kanniah, k. d., kamarul zaman, n. a. f., kaskaoutis, d. g., & latif, m. t. (2020). covid-19's impact on the atmospheric environment in the southeast asia region. science of the total environment, 736, 139658-139658. https://doi.org/10.1016/j.scitotenv.2020.139658 karataş, z., & tagay, ö. (2021). the relationships between resilience of the adults affected by the covid pandemic in turkey and covid-19 fear, meaning in life, life satisfaction, intolerance of uncertainty and hope. personality and individual differences, 172, 110592. https://doi.org/https://doi.org/10.1016/j.paid.2020.110592 kim, s., ko, y., kim, y.-j., & jung, e. (2020). the impact of social distancing and public behavior changes on covid-19 transmission dynamics in the republic of korea. plos one, 15(9), e0238684e0238684. https://doi.org/10.1371/journal.pone.0238684 kim, y., montoya, e., doocy, s., austin, l. j. e., & whitebook, m. (2022). impacts of covid-19 on the early care and education sector in california: variations across program types. early childhood research quarterly. https://doi.org/https://doi.org/10.1016/j.ecresq.2022.03.004 knell, g., robertson, m. c., dooley, e. e., burford, k., & mendez, k. s. (2020). health behavior changes during covid-19 pandemic and subsequent “stay-at-home” orders. international journal of environmental research and public health, 17(17), 6268-6268. https://doi.org/10.3390/ijerph17176268 the lancet. (2020). covid-19: protecting health-care workers. the lancet, 395(10228), 922-922. https://doi.org/10.1016/s01406736(20)30644-9 le quéré, c., jackson, r. b., jones, m. w., smith, a. j. p., abernethy, s., andrew, r. m., de-gol, a. j., willis, d. r., shan, y., canadell, j. g., friedlingstein, p., creutzig, f., & peters, g. p. (2020). temporary reduction in daily global co2 emissions during the covid-19 forced confinement. nature climate change, 10(7), 647-653. https://doi.org/10.1038/s41558-020-0797-x maloney, k. (2020). spiritual resources during the covid-19 pandemic. in. marra, a., buonanno, p., vargas, m., iacovazzo, c., ely, e. w., & servillo, g. (2020). how covid-19 pandemic changed our communication with families: losing nonverbal cues. critical care, 24(1), 1-2. https://doi.org/10.1186/s13054-020-03035-w nguyen, l. h., drew, d. a., graham, m. s., joshi, a. d., guo, c.-g., ma, w., mehta, r. s., warner, e. t., sikavi, d. r., lo, c.-h., kwon, s., song, m., mucci, l. a., stampfer, m. j., willett, w. c., eliassen, a. h., hart, j. e., chavarro, j. e., rich-edwards, j. w., . . . zhang, f. (2020). risk of covid-19 among front-line health-care workers and the general community: a prospective cohort study. the lancet public health, 5(9), e475-e483. https://doi.org/10.1016/s2468-2667(20)30164-x nguyen, m. h., gruber, j., fuchs, j., marler, w., hunsaker, a., & hargittai, e. (2020). changes in digital communication during the covid-19 global pandemic: implications for digital inequality and future research. social media + society, 6(3), 205630512094825205630512094825. https://doi.org/10.1177/2056305120948255 nodine, p. m., arbet, j., jenkins, p. a., rosenthal, l., carrington, s., purcell, s. k., lee, s., & hoon, s. (2021). graduate nursing student stressors during the covid-19 pandemic. journal of professional nursing, 37(4), 721-728. https://doi.org/https://doi.org/10.1016/j.profnurs.2021.04.008 nundy, s., ghosh, a., mesloub, a., albaqawy, g. a., & alnaim, m. m. (2021). impact of covid-19 pandemic on socio-economic, energyenvironment and transport sector globally and sustainable development goal (sdg). journal of cleaner production, 312, 127705. https://doi.org/https://doi.org/10.1016/j.jclepro.2021.127705 park, j., & seo, m. (2022). influencing factors on nursing students’ learning flow during the covid-19 pandemic: a mixed method research. asian nursing research, 16(1), 35-44. https://doi.org/https://doi.org/10.1016/j.anr.2021.12.006 reddy, b., & gupta, a. (2020). importance of effective communication during covid-19 infodemic. journal of family medicine and primary care, 9(8), 3793-3793. https://doi.org/10.4103/jfmpc.jfmpc_719_20 riou, j., & althaus, c. l. (2020). pattern of early human-to-human transmission of wuhan 2019 novel coronavirus (2019-ncov), december 2019 to january 2020. eurosurveillance, 25(4), 1-5. https://doi.org/10.2807/1560-7917.es.2020.25.4.2000058 rume, t., & islam, s. m. d.-u. (2020). environmental effects of covid19 pandemic and potential strategies of sustainability. heliyon, 6(9), e04965-e04965. https://doi.org/10.1016/j.heliyon.2020.e04965 saadat, s., rawtani, d., & hussain, c. m. (2020). environmental perspective of covid-19. science of the total environment, 728, 138870-138870. jurnal ners http://e-journal.unair.ac.id/jners 167 https://doi.org/10.1016/j.scitotenv.2020.138870 santos, l. m. d. (2020). the relationship between the covid-19 pandemic and nursing students’ sense of belonging: the experiences and nursing education management of pre-service nursing professionals. international journal of environmental research and public health, 17(16), 5848-5848. https://doi.org/10.3390/ijerph17165848 schroeder, k., norful, a. a., travers, j., & aliyu, s. (2020). nursing perspectives on care delivery during the early stages of the covid19 pandemic: a qualitative study. international journal of nursing studies advances, 2(august), 100006-100006. https://doi.org/10.1016/j.ijnsa.2020.100006 seow, c. s., lomanto, d., & ooi, l. l. (2022). covid-19 and the impact on surgical training and education in singapore. heliyon, 8(1), e08731. https://doi.org/https://doi.org/10.1016/j.heliyon.2022.e08731 servidio, r., bartolo, m. g., palermiti, a. l., & costabile, a. (2021). fear of covid-19, depression, anxiety, and their association with internet addiction disorder in a sample of italian students. journal of affective disorders reports, 4, 100097. https://doi.org/https://doi.org/10.1016/j.jadr.2021.100097 singh, p. k. (2020). promote hand hygiene to save lives and combat covid-19. in. swift, a., banks, l., baleswaran, a., cooke, n., little, c., mcgrath, l., meechan‐rogers, r., neve, a., rees, h., tomlinson, a., & williams, g. (2020). covid‐19 and student nurses: a view from england. journal of clinical nursing, 29(17-18), 3111-3114. https://doi.org/10.1111/jocn.15298 tausch, a., e souza, r. o., viciana, c. m., cayetano, c., barbosa, j., & hennis, a. j. m. (2022). strengthening mental health responses to covid-19 in the americas: a health policy analysis and recommendations. the lancet regional health americas, 5, 100118. https://doi.org/https://doi.org/10.1016/j.lana.2021.100118 unicef. (2020a). social stigma associated with covid-19 a guide to preventing and addressing. in (pp. 1-5). unicef. (2020b). use covid-19 to build better family communication. in. wahyuhadi, j., efendi, f., al farabi, m. j., harymawan, i., ariana, a. d., arifin, h., adnani, q. e. s., & levkovich, i. (2022). association of stigma with mental health and quality of life among indonesian covid-19 survivors. plos one, 17(2), e0264218. https://doi.org/10.1371/journal.pone.0264218 who. (2022). who coronavirus (covid-19) dashboard. world health organization retrieved 20 april 2022 from https://covid19.who.int wickner, p., hartley, t., salmasian, h., sivashanker, k., rhee, c., fiumara, k., resnick, a., & mendu, m. l. (2020). communication with health care workers regarding health care–associated exposure to coronavirus 2019: a checklist to facilitate disclosure. the joint commission journal on quality and patient safety, 46(8), 477-482. https://doi.org/10.1016/j.jcjq.2020.04.012 wong, e. l.-y., yeoh, e.-k., & dong, d. (2020). covid-19: transforming healthcare will require collaboration and innovative policies. bmj, m2229-m2229. https://doi.org/10.1136/bmj.m2229 zheng, c. (2020). caring for the self and others: a reflection on everyday commoning amid the covid-19 pandemic. socioecological practice research, 2(3), 243-251. https://doi.org/10.1007/s42532-020-00062-3. how to cite this article: acob, j. r. u., dewi, y. s., and arifin, h. (2022) ‘five cs as reflective learning attitude among philippines nursing students’, jurnal ners, 17(2), pp. 161-167. doi: http://dx.doi.org/10.20473/jn.v17i2.34113 http://e-journal.unair.ac.id/jners 61 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 61-66 http://dx.doi.org/10.20473/jn.v17i1.35036 original article open access self-care differences in covid-19 pandemic situation ni putu wulan purnama sari 1,* , jintana artsanthia2 1 faculty of nursing, widya mandala surabaya catholic university, indonesia 2 faculty of nursing, saint louis college, indonesia *correspondence: ni putu wulan purnama sari. address: south kalisari street no.1 pakuwon city, surabaya city, 60112, indonesia. email: wulanpurnama@ukwms.ac.id responsible editor: ferry efendi received: 14 april 2022 ○ revised: 27 april 2022 ○ accepted: 27 april 2022 abstract introduction: coronavirus disease-2019 (covid-19) pandemic has been happening for years now and no one can guarantee when this situation will end. the best thing that we can do in this new normal era is doing different self -care activity than what we usually do before the pandemic. this study aimed to analyze self-care differences before and after pandemic situation in the general population. methods: this cross-sectional study involved 645 respondents living in five congested communities in surabaya, indonesia. sample was enrolled by means of cluster random sampling. variables on this study was self-care activities related to new normal activies among community. valid and reliable questionnaire of self-care activities was used in data collection. independent sample t test was used in data analysis. results: most respondents were female (54.6%) in their productive age (29.7 ± 11.5 y.o.), graduated (77.8%), private employee (35.5%), having no income (45.7%), and live with more than 3-5 family members at home (43.4%). before pandemic, self-care was mostly sufficient (21.8 ± 5.9). after pandemic, self-care was improved greatly but still in sufficient level (28.5 ± 4.8). there was a significant self-care difference before and after pandemic situation in the general population (p = 0.000). conclusions: self-care activities changes significantly after covid-19 pandemic situation in the general population, but it was still in unoptimal level. efforts to improve individual self-care in new normal era are needed to ensure this activity is implemented in its optimal level. keywords: covid-19; new normal; pandemic; self-care introduction the global pandemic of coronavirus disease 2019 (covid-19) is caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). the world health organization (who) declared a public health emergency of international concern on 30 january 2020 and a pandemic on 11 march 2020. since 2021, variants of the virus have emerged or become dominant in many countries with the delta, alpha, and beta variants being the most virulent (anaki & sergay, 2021). at the present many countries have confirmed the high death rate, making covid-19 one of the deadliest pandemics in history. the number of new covid19 cases and deaths has continued to high and the trend slowly decreased with over 7 million cases and over 22,000 deaths reported, a decrease from 24% to 18% (who, 2022). who has come up with a plan to increase the awareness among the people about the current pandemic. this current strategic plan outlines the health system responsive and the international community stands ready to provide all necessary things in responding to covid-19. to prevent the spread of covid-19 we need to: 1) hand hygiene, 2) avoid touching our body especially eyes, nose, or mouth, 3) social distancing, 4) stay at home if necessary, and 5) seek medical care when people get sick (who, 2021a). indonesia still have confirmed positive cases of covid-19 across all provinces in the country, and the high rate of infection was in dki jakarta ,as of 16 february, the government of indonesia reported 4 966 046 (64 718 new) confirmed cases of covid-19, 145 622 (167 new) deaths and 4 375 234 recovered cases from 510 districts https://creativecommons.org/licenses/by/4.0/ mailto:wulanpurnama@ukwms.ac.id http://orcid.org/0000-0002-8869-9607 http://orcid.org/0000-0003-2227-9017 sari and artsanthia (2022) 62 p-issn: 1858-3598  e-issn: 2502-5791 across 34 provinces (who, 2021a). for identifying cases, the real-time polymerase chain reaction assay (rtpcr) and the molecular rapid test for tuberculosis (tcm tb) methods are used (who, 2021a). the other highest case is surabaya city, east java province which ranks second, with 2,296 cases. a sharp increase in the number of cases has been confirmed in the areas of east java (surabaya is the capital city), south kalimantan, and south sulawesi (who, 2021b). the impact of such an increase had a visible impact on human activity such as changing people's lifestyles in much of the world, reduced travel, the closing down of many business activities, and an increased time at home. these major changes, as well as the associated changes in impact on the environment. covid-19 pandemic has been happening for years now and no one can guarantee when this situation will end. the best thing that we can do in this new normal era is doing different self-care activity than what we usually do before the pandemic. self-care model which firstly developed by dorothea orem in 1971 has become a famous nursing theory today. she defined self-care as individual actions to care for themselves independently with purpose of having the ability to maintain their health and well-being (orem, 1971). this theory is the basis of nursing actions in empowering their clients today, especially in community setting. in the context of pandemic, self-care has never been more important or, arguably, more challenging to prioritize as millions of people have lost their jobs, are forced to stay at home, or suddenly are caring for children whose schools have been closed (nolen, 2020). psychologically, the benefits of optimum self-care in this pandemic situation are helping us in alleviating the distress and anxiety caused by the pandemic and preventing lasting adverse psychological outcomes (wise, 2020). a study towards 1,082 people from four countries (chile, colombia, ecuador, and spain) found that self-care partially mediates the relationship between stress and well-being during covid-19 confinement in the general population (luis, 2021). in the other hand, physically, the benefits of optimum self-care in this pandemic situation are helping us in countering the spread of the deadly corona virus, maintaining our health and the health of people around us (nolen, 2020). another benefits reported in one study includes promoting healthy lifestyles and improve the quality of life in the aspect social, physical and emotional (duggan, 2020). at the present, the situation of the covid-19 pandemic occurs in every place. an important thing to protect people from infection is self-care behaviors that are composed of wearing the hygenic mask, social distancing, and handwashing looking easily but high effectiveness to protect themselves. so life must go on with the new normal protocol from who (who, 2022). the who provides several indicators to be obeyed by all countries in the world in order to adjust their normal life called 'a new normal' with covid-19, such as: 1) stopping or reducing covid-19 transmission, 2) showing the capacity of the health system in responding to covid-19, and 3) conducting a massive test to the high risk group. in order to address these three indicators, indonesian government has implemented large scale social restrictions in various area, making policies related to referal system and effort in reducing covid-19 transmission (widyamurti, 2020). considering that many provinces in indonesia have shown improved health indicators, and given the need for people to restart productive activities in a safe manner, the ministry of health of indonesia has issued guidelines for a new normal life. these guidelines are a point of reference for regional governments that implement the large-scale social restrictions (so called psbb in indonesia) to be transitioned into the new normal stage, one of which is the city government of surabaya which manages 2.97 million people living in the 2nd biggest city of indonesia. in this study, we aimed at analyzing self-care differences before and after the pandemic situation in the general population, especially among adults living in congested communities of surabaya, indonesia. this may evaluate the implementation of new normal life guidelines in congested communities of big cities in indonesia, especially in the adult population. the self-care model of orem (1971) which related to self-care activities was used as this study framework. materials and methods study design this study utilized cross-sectional design. respondent population was all adults live in congested communities of surabaya amounted to 2,119,107 people (n = 2,119,107). sample size was calculated by the formula stated in nursalam (2008) yielded minimum of sample size at 645 respondents. surabaya composes of 63 communities under the authority of respectable public health center (phc). there were five study sites enrolled by mean of cluster random sampling (7.9% cluster area), namely: district of pacar keling, pucang sewu, klampis, mulyorejo, and pakis. there were 20% of sample size enrolled by mean of simple random sampling from each study site (n = 129 from each site). the randomization process was done by making lottery. figure 1 below explains the study sites and sample selection process. instrument self-developed questionnaire of self-care activities consisted of 10 items. it assessed self-care activities related to pandemic, such as: 1) wearing mask, 2) washing jurnal ners http://e-journal.unair.ac.id/jners 63 figure 1. study sites and sample selection process hands, 3) social distancing, 4) avoiding crowd, 5) showering or changing clothes immediately after arriving home, 6) touching face, 7) using public eating utensils, 8) having meals outside, 9) exercising, and 10) observing body temperature. instrument testing procedure involved content validity assessment by three experts, and reliability analysis with a trial in the congested community in surabaya (30 adults from different site of surabaya who were not being study respondents), then reported with cronbach’s alpha coefficient of 0.81. data collection the self-care activities was assessed before and after covid-19 pandemic situation. data was collected between february-april 2021. self-care activities before the pandemic was assessed by recalling memory in the period before the pandemic, while self-care activities after the pandemic assessed self-care in the pandemic period. there were five research assistants helping the door to door data collection process in the field. as five study sites existed in this study, one assistant was responsible for 129 respondents in one study site. the roles of research assistant were helping the researcher to approach the promising respondents, to obtain informed consent, and to collect the data. data analysis there were 10 items in the self-care questionnaire. likert scale of 1 to 4 was used to differentiate individual response: 1 = never (never done it at all), 2 = sometimes (doing it 1-2 days per week), 3 = often (doing it 3-4 days per week), and 4 = always (doing it >5 days per week). self-care activities were categorized into three: less (score 10-20), sufficient (score 21-30), and optimum (score: 3140). this category was made in order to ease the data interpretation in the result section. for data analysis process, raw total score will be analyzed. descriptive statistic (mean and standard deviation or sd) and independent sample t test were used in data analysis. the software used was spss 19.0. researchers conducted the data analysis alone. ethical consideration ethical clearance was issued by the ethical committee of saint louis college (slc), bangkok, thailand, with certificate number: e.010/2564. results most respondents were female (54.6%) in their productive age (29.7 ± 11.5 y.o.), graduated (77.8%), private employee (35.5%), having no income (45.7%), and live with more than 3-5 family members at home (43.4%). table 1 presents the demography characteristic of study respondents in detail. before pandemic, self-care was mostly sufficient (mean ± sd = 21.8 ± 5.9). after pandemic, self-care was improved greatly but mostly still in sufficient level (mean ± sd = 28.5 ± 4.8). there was a significant self-care difference before and after pandemic situation in the general population (p = 0.000). table 2 below explains self-care activities related to pandemic before and after pandemic in study respondents. cluster random sampling: 7.9% cluster (5 areas) pacar keling area pucang sewu area klampis area ≥ 18 years old: n = 129 n = 645 pakis area mulyorejo area surabaya composes of 63 communities (adults: n = 2,119,107) ≥ 18 years old: n = 129 ≥ 18 years old: n = 129 ≥ 18 years old: n = 129 ≥ 18 years old: n = 129 simple random sampling: 20% from each area sari and artsanthia (2022) 64 p-issn: 1858-3598  e-issn: 2502-5791 discussions in this study, most respondents reported sufficient level of self-care before and after pandemic. based on category, this may seen as insignificant difference. but after doing statistical analysis by using the raw total score, it was found that self-care changed significantly or improved greatly after pandemic, although still in the same sufficient level. this may happen potentially due to the sufficient level of perceived self-care ability or selfcare agency in most respondents. most respondents stated that they complied with who self-care recommendations during the pandemic situation. table 1 demographic characteristics of the respondents characteristic frequency (n) percentage (%) sex male 293 45.4 female 352 54.6 age (years old / y.o.) early adulthood (17-40 y.o.) 524 81.2 midlife transition years (>40-45 y.o.) 33 5.1 middle adulthood (>45-60 y.o.) 79 12.2 late adult transition years (>60-65 y.o.) 5 0.8 late adulthood (>65-85 y.o.) 4 0.6 education being student 143 22.2 graduated 502 77.8 occupation general service staff 6 0.9 private employee 229 35.5 government employee 13 2.0 semi-government employee 2 0.3 shopkeeper 49 7.6 private business worker 55 8.5 housewife 92 14.3 student 137 21.2 retired 8 1.2 unemployed 54 8.4 income no income 295 45.7 less than minimum wage 104 16.1 minimum wage (idr 4.3 million) 39 6.1 above the minimum wage 207 32.1 family member at home 0 (live alone) 7 1.1 1-3 255 39.5 > 3-5 280 43.4 > 5-8 90 14.0 > 8-11 11 1.7 > 11 2 0.3 table 2 self-care activities before and after pandemic item before pandemic after pandemic never sometimes often always never sometimes often always n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) wearing mask 237 (36.7) 190 (29.5) 94 (14.6) 124 (19.3) 5 (0.8) 25 (3.9) 102 (15.8) 513 (79.6) washing hands 178 (27.6) 274 (42.5) 97 (15.0) 96 (14.9) 6 (0.9) 43 (6.7) 167 (25.9) 429 (66.5) social distancing 388 (60.2) 154 (23.9) 54 (8.4) 49 (7.6) 19 (2.9) 95 (14.7) 218 (33.8) 313 (48.6) avoiding crowd 230 (35.7) 230 (35.7) 99 (15.3) 86 (13.3) 50 (7.8) 153 (23.7) 193 (29.9) 249 (38.6) showering/ changing clothes immediately 90 (14.0) 272 (42.2) 131 (20.3) 152 (23.6) 15 (2.3) 89 (13.8) 167 (25.9) 374 (58.0) touching face 90 (14.0) 237 (36.7) 210 (32.6) 108 (16.7) 176 (27.3) 257 (39.8) 122 (18.9) 90 (14.0) using public eating utensils 107 (16.6) 172 (26.7) 193 (29.9) 173 (26.8) 179 (27.7) 238 (36.9) 105 (16.3) 123 (19.1) having meals outside 188 (29.1) 249 (38.6) 145 (22.5) 63 (10.5) 348 (54.0) 192 (29.8) 57 (8.8) 48 (7.5) exercising 157 (24.3) 290 (45.0) 121 (18.8) 77 (12.0) 114 (17.7) 248 (38.4) 158 (24.5) 125 (19.4) observing body temperature 391 (60.6) 133 (20.6) 58 (9.0) 63 (9.8) 65 (10.1) 144 (22.3) 155 (24.0) 281 (43.6) less self-care* 299 (46.3) 26 (4.0) sufficient self-care* 301 (46.7) 406 (63.0) optimum self-care* 45 (7.0) 213 (33.0) * this category was made in order to ease the data presentation in this section, and not for statistical analysis purposes. jurnal ners http://e-journal.unair.ac.id/jners 65 results of independent sample t test showed that there was a significant difference of self-care activities before and after covid-19 pandemic situation among adults living in congested communities of surabaya, indonesia (p = 0.000). this study result was supported by various studies. a study towards 1,508 participants in general population showed that 66-80% respondents complied with self-care recommendations, therefore the implementation of pandemic care program is recommended (galindo-vazquez, et al., 2020). before and after pandemic most respondents had sufficient level of self-care, but there was a great improvement in the raw total score after pandemic. nationally, this study findings were supported by a survey conducted in bali, indonesia, regarding the public knowledge and behavior toward covid-19 pandemic which showed that most respondents have complied with the health protocols during the pandemic (yanti, et al., 2020). in the region, this study findings were supported by a survey conducted in malaysia, regarding the public knowledge, attitudes, and practices to mitigate the outbreak of covid-19 which showed that most respondents implemented new normal health behavior, such as avoiding crowds (83.4%), washing hands (87.8%), and wearing face mask (51.2%) (azlan, et al., 2020). this study findings proved that the implementation of new normal life guidelines in congested communities of big city in indonesia, especially in adults population, cannnot reach the maximum effectiveness. this possibly happened due to the negative attitude towards the covid-19 pandemic situation. a study in north sumatra, indonesia, one month after the first cases were reported in indonesia showed that the minority of respondents had negative attitude towards the outbreak in relation to two aspects, such as: 1) having to always maintain a distance of 1.5 metres when in crowds (78.6%), and 2) unable to regularly exercise or eat nutritious food (79.1%)(sari, et al., 2021). sufficient knowledge and positive attitudes are crucial to the prevention of covid19 (lin, et al., 2020). the success of behavioral interventions and policies designed to reduce the impact of the covid-19 pandemic depends on how well individuals are informed about both the consequences of infection and the steps that should be taken to reduce the impact of the disease (green, et al., 1991). moreover, understanding the complexity of health behavior will maximize their beneficial role, eliminate maladaptive prevention patterns, and facilitate the eradication of covid-19 (anaki & sergay, 2021). in contrary, another age and gender specific study towards 1,082 respondents in four countries in europe showed that young female showed less adherence to health guidelines because they experienced greater level of stress and perceived the pandemic situation as more severe, but the older female groups were generally more involved in self-care activities and adopted more healthy daily routines; therefore genders and age ranges should be considered in determining covid-19 prevention strategies in order to improve self-care and adherence to health guidelines (bermejo-martins, et al., 2021). the higher perception of stress, the less self-care activities are adopted, and in turn the lower the beneficial effects on wellbeing because self-care partially mediates the relationship between stress and wellbeing during covid-19 confinement in the general population, and age affects this relationship also (luis, et al., 2021). in this study, most respondents were mostly young female too. stress level and perception towards covid-19 pandemic were not identified in this study, but it is potential if the sufficient self-care ability happen due to the low stress level and positive perception towards the pandemic situation. there are few study limitations we found. this study had formulate objectives in a very broad manner, so in the initial phase of the development of self-care questionnaire we had various questions at that period. the items in self-care questionnaire were developed to resistant making the result may out of date. similarly with the new normal phenomena. it has been changing along with the period of time, so we need to study about self-care after pandemic continuously to be more fitted with the current situation. conclusions self-care changes significantly after covid-19 pandemic situation in the general population, but it was still in unoptimal level. efforts to improve individual selfcare in new normal era are needed to ensure this activity is implemented in its optimal level in compliance with who recommendations. acknowledgment this study was funded and supported for publication by the institute of research and community service, widya mandala surabaya catholic university, with grant reference number: 083a/wm01.5/n/2021. conflict of interest there was no conflict of interest between authors and study funder declared regarding this study and publication. references anaki, a., & sergay, j. (2021). predicting health behavior in response to the coronavirus disease (covid-19): worldwide survey results from early march 2020. plos one, 16(1), e0244534. azlan, a. a., hamzah, m. r., sern, t. j., ayub, s. h., & mohamad, e. (2020). public knowledge, attitudes and practices towards covid19: a cross-sectional study in malaysia. plos one, 15(5), e0233668. bermejo-martins, e., luis, e. o., sarrionandia, a., martinez, m., garces, m. s., oliveros, e. y., cortes-rivera, c., belintxon, m., & fernandezberrocal, p. (2021). different responses to stress, health practices, and self-care during covid-19 lockdown: a stratified analysis. international journal of environmental reserach and public health, 18(5), 2253. sari and artsanthia (2022) 66 p-issn: 1858-3598  e-issn: 2502-5791 duggan, m. (2020). self-care and health: by all, for all: learning from covid-19. australia: mitchell institute, victoria university.fridman, i., lucas, n., henke, d., & zigler, c. k. (2020). association between public knowledge about covid-19, trust in information sources, and adherence to social distancing: a crosssectional survey. jmir public health surveillance, 6(3), e22060. galindo-vazquez, o., ramirez-orozco, m., costas-muniz, r., mendozacontreras, l. a., calderillo-ruiz, g., & meneses-garcia, a. (2020). symptoms on anxiety and depression and self-care behaviors during the covid-19 pandemic in the general population. gaceta medica de mexico, 156(4), epub 27-mayo-2021. green, l. w., & kreuter, m. w. (1991). health promotion planning: an educational and environmental approach, 2nd edition. mountain view: mayfield publishing company. lin, y., hu, z., alias, h., & wong, l. p. (2020). knowledge, attitudes, impact, and anxiety regarding covid-19 infection among the public in china. frontiers in public health, 8, 236. luis, e. o., bermejo-martins, e., martinez, m., et al. (2021). relationship between self-care activities, stress and well-being during covid19 lockdown: a cross-cultural mediation model. bmj open, 11, e048469. nolen, r. s. (2020). the importance of self-care during a pandemic. retrieved from: https://www.avma.org/javma-news/2020-0601/importance-self-care-during-pandemic nursalam. (2008). concept and application of nursing research methodology, 2nd edition (in bahasa indonesia). jakarta: salemba medika. orem, d. e. (1971). nursing: cocepts of practice. new york: mcgraw-hill. sari, d. k., amelia, r., dharmajaya, r., et al. (2021). positive correlation between general public knowledge and attitudes regarding covid19 outbreak 1 month after first cases reported in indonesia. journal of community health, 46, 182-189. widyamurti, e. (2020). gov’t formulates health protocol to prepare ‘new normal’. retrieved from: https://setkab.go.id/en/govt-formulateshealth-protocol-to-prepare-new-normal/ wise, a. (2020). why self-care is important during covid-19 – especially for health care workers. retrieved from: https://healthydebate.ca/2020/04/topic/pandemic-self-care/ world health organization (who). (2022). weekly epidemiological update on covid-19 22 march 2022. retrieved from: https://www.who.int/publications/m/item/weeklyepidemiological-update-on-covid-19---22-march-2022 world health organization (who). (2021a). advice for the public: coronavirus disease (covid-19). retrieved from: https://www.who.int/emergencies/diseases/novel-coronavirus2019/advice-for-public world health organization (who). (2021b). coronavirus disease 2019 (covid-19): situation report – 64. retrieved from: https://cdn.who.int/media/docs/defaultsource/searo/indonesia/covid19/external-situation-report-64_21july-2021.pdf?sfvrsn=e9aec4fa_5 yanti, n. p. e. d., nugraha, i. m. a. d. p., wisnawa, g. a., agustina, n. p. d., & diantari n. p. a. (2020). public knowledge about covid-19 and public behavior during the covid-19 pandemic. jurnal keperawatan jiwa, 8(4), 491-504. . how to cite this article: sari, n. p. w. p. and artsanthia, j. (2022) ‘self-care differences in covid-19 pandemic situation’, jurnal ners, 17(1), pp. 61-66. doi: http://dx.doi.org/10.20473/jn.v17i1.35036 figure1 table2 table1 table3 table anaki2021 azlan2020 bermejo2021 duggan2020 galindo2020 green1991 lin2020 luis2021 nolen2020 nursalam2008 orem1971 sari2021 widyamurti2020 wise2020 who2022 who2021a who2021b yanti2020 vol 8 no 1 april 2013.indd 98 pengalaman keluarga dalam penanganan lanjut usia di masyarakat dari aspek budaya indonesia (family experience in handling the elderly in cultural aspects of indonesia) ni made riasmini*, junaiti sahar**, yeti resnayati* *politeknik kesehatan kemenkes jakarta iii ** fakultas ilmu keperawatan, universitas indonesia e-mail: maderiasmini@yahoo.co.id abstrak pendahuluan: budaya extended family masih berkembang di indonesia yang memungkinkan lanjut usia (lansia) tinggal bersama keluarga dan umumnya lansia masih mempunyai kedudukan yang cukup tinggi sebagai orang tua yang harus dihargai dan dihormati. penelitian ini bertujuan untuk mendapatkan gambaran tentang pengalaman keluarga dalam penanganan lansia dari aspek budaya indonesia. metode: desain yang digunakan adalah fenomenologi deskriptif. partisipan adalah caregiver utama yang merawat lansia berjumlah 10 orang. data dianalisis menggunakan teknik collaizi. hasil: teridentifi kasi 4 tema yaitu: 1) alasan merawat karena tanggung jawab yaitu tugas sebagai anggota keluarga, balas budi, kepuasan, caregiver utama, kedekatan dan kasihan., 2) beban merawat yaitu beban fi sik, psikologis, sosial dan fi nansial, 3) persepsi tentang nilai budaya yaitu kedudukan dan peran lansia dalam keluarga, dan 4) dukungan dalam merawat yaitu dukungan keluarga dan masyarakat. diskusi: keluarga sebagai sistem pendukung utama bagi lansia mempunyai tanggung jawab yang besar dalam merawat lansia sesuai nilai budaya indonesia. hasil penelitian ini diharapkan dapat memberikan informasi tentang kebutuhan keluarga sebagai caregiver dalam merawat lansia sehingga dapat didesain bentuk intervensi pemberdayaan keluarga yang tepat sesuai budaya indonesia. kata kunci: caregiver, nilai budaya, beban merawat, dukungan sosial, lansia abstract introduction: extended family culture still exists in indonesia, and this makes it possible for an elderly person to live with a family. in indonesia, generally an elderly person is highly respected. this research is meant to gain a picture of an experience that a family has in taking care of an elderly person from the aspect of indonesian culture. method: the design implemented is descriptive phenomenology. the participant is the main caregiver taking care of 10 elderly people. the data is analyzed using collaizi technique. result: this research have been identifi ed 4 themes i.e. 1) the reason for doing it is to fulfi ll the tasks as a member of a family, to reciprocate, to have satisfaction, but for the main caregiver it is just because of closeness and pity, 2) the burden of caring is physical, psychological, social and fi nancial, 3) the perception about culture value is the position and role of the elderly person in the family, and 4) the support or encouragement is obtained from the family and the community. discussion: the conclusion is that a family as the main supporting system for the elderly people possesses big responsibility in caring the elderly in accordance with the value of culture in indonesia. the results of the research are expected to give information about the need of a family as the caregiver in caring the elderly so that a proper intervention form of family enforcement according to the indonesian culture can be designed. key words: caregiver, culture value, caregiver burden, social support, elderly 99 pengalaman keluarga dalam penanganan lanjut usia (ni made riasmini, dkk.) pendahuluan indonesia saat ini termasuk negara yang memasuki era penduduk berstruktur lanjut usia dengan pertambahan jumlah penduduk yang tergolong cepat di dunia dan merupakan peringkat keempat dunia setelah cina, india dan amerika (suyono, 2006). pada tahun 2020 jumlah penduduk lansia diproyeksikan akan meningkat menjadi 28,8 juta atau sebesar 11,34% dari 326,6 juta jumlah penduduk, dengan uhh yaitu 71,1 tahun. (bps, 2007). kondisi sosial dan kesehatan lansia di indonesia masih memprihatinkan. jumlah lansia terlantar sebesar 2,7 juta (15% dari jumlah total penduduk lansia), yang tidak mend apat ka n perawat a n d a r i kelu a rga dan masyarakat. dar i aspek kesehatan menunjukkan kecenderungan angka kesakitan lansia mengalami peningkatan yaitu tahun 2003 sebesar 28,48% meningkat menjadi 31,11% pada t ahu n 2007 (bps, 2009). boonyakawee (2006) menemukan sebesar 87% lansia mengalami ketidakmampuan akibat penyakit yang berdampak terhadap meningkatnya ketergantungan lansia kepada keluarga. hasil penelitian laubunjong (2008) tentang pola pemberian perawatan pada lansia, menemukan mayoritas lansia menginginkan dirawat oleh anak perempuannya. lansia mengharapkan mendapat perawatan, dicintai ser t a mend apat bant uan f i nansial d an pelayanan kesehatan yang bisa dipenuhi oleh anak mereka. d u k u nga n kelu a rga ya ng ber upa pemberian bantuan dari anak kepada orang t ua masih ber peran sangat besar pada masyarakat indonesia. jika dikaitkan dengan budaya indonesia di mana budaya extended family masih berkembang, memungkinkan lansia untuk tinggal bersama keluarga (anak, menantu, cucu atau anggota keluarga lain). liu (2009) menemukan bahwa lansia dalam masyarakat tradisional di asia masih tinggal dengan keluarga. pada masyarakat taiwan, 83% lansia tinggal dengan keluarga. di thailand dan philipina sebanyak 92% lansia tinggal dengan keluarga, 83% di cina, 82% di malaysia dan 69% di jepang. umumnya lansia masih mempunyai kedudukan yang cukup tinggi sebagai orang t ua yang har us dihor mati dan dihargai karena lebih banyak mempunyai pengalaman sehingga pendapatnya masih dibutuhkan dalam pengambilan keputusan keluarga. adanya dukungan tersebut, akan memperkuat ikatan kekeluargaan sehingga lansia merasa aman, puas dan merasa berg u na ser ta mampu menjalani kehidupan dengan baik. hasil penelitian okabayashi, et al. (2004), berdasarkan karakteristik budaya melalui komitmen anak dalam mendukung orang tua yang lanjut usia, bahwa dukungan sosial dan emosional yang diberikan anak sangat penting bagi lansia. dukungan dari anak kepada lansia dikaitkan dengan kesehatan mental lansia yang positif. k e l u a r g a s e b a g a i c a r e g i v e r mempunyai peran penting dan merupakan sumber pendukung utama bagi lansia dalam memenuhi kebutuhan fi sik, emosional dan fi nansial (ahmad, 2012). efektivitas dukungan kelu a rga mer upa k a n komponen k u nci terhadap kesejahteraan lansia. perawatan yang dilakukan keluarga sebagai caregiver terhadap lansia dikaitkan dengan stres karena gangguan fungsional dan psikologis serta penyakit kronik yang dialami lansia. menurut sales, (2003), memberikan perawatan pada lansia dengan penyakit kronis menimbulkan perasaan strain atau burden pada caregiver yang dapat mempengaruhi kualitas hidup keluarga. caregiver burden diakibatkan oleh kesulitan keluarga secara subjektif maupun objektif sehubungan dengan adanya anggota keluarga yang mengalami masalah secara berkepanjangan (magliano, 2006). b a n y a k d i a n t a r a n e g a r a n e g a r a b e r k e m b a n g b e l u m o p t i m a l mengimplementasikan program maupun kebijakan pelayanan kesehatan dan sosial untuk lansia. bahkan dukungan pelayanan yang diberikan pemerintah kepada penduduk lansia masih minimal. selain it u para lansia juga mendapatkan sedikit perhatian dibandingkan dengan kelompok usia lain maupun kelompok rawan lain seperti kelompok balita di masyarakat (suyono, 2006). di 100 jurnal ners vol. 8 no. 1 april 2013: 98–106 indonesia, kebijakan dan program pemerintah yang menangani permasalahan lansia dari berbagai departemen sudah ada, namun masih belum menjangkau esensi usaha pemberdayaan lansia yang saling terintegrasi. pemerintah kini mendorong terbentuknya pelayanan penduduk lansia berbasis masyarakat melalui program pendampingan dan perawatan sosial lansia di rumah (home care). diharapkan keluarga dan masyarakat ik ut ser ta memberikan pelayanan kepada lansia di dalam keluarga dan lingkungannya sesuai dengan budaya indonesia. pemahaman yang mendalam tentang pengalaman keluarga merawat lansia dari aspek budaya indonesia perlu digali sehingga dapat ditentukan kebutuhan keluarga serta bentuk intervensi berbasis budaya dalam pemberdayaan keluarga sehingga keluarga mampu merawat lansia secara optimal, pada akhirnya kualitas hidup lansia akan meningkat. oleh karena itu, perlu dilakukan penelitian k ualitatif dengan metode fenomenologi deskriptif. metode ini dapat menstimulasi persepsi kita terhadap pengalaman hidup dengan menekankan pada kekayaan, keluasan serta kedalaman dari pengalaman tersebut (spiegelberg, 1975 d alam st reuber t & carpenter, 2003). pe n el it i a n i n i b e r t uj u a n u nt u k memperoleh gambaran tentang pengalaman kelu a rga d ala m pena nga na n la nsia d i masyarakat dari aspek budaya indonesia. selanjutnya akan diidentifi kasi beberapa hal meliputi respons keluarga dalam merawat lansia, nilai-nilai budaya dalam merawat lansia, dan kebutuhan dukungan keluarga dan masyarakat dalam perawatan lansia bahan dan metode pendekatan yang digunakan dalam penelitian ini adalah kualitatif dengan metode fenomenologi deskriptif untuk mengekplorasi kedalaman dan kompleksitas dari pengalaman kelu a rga d ala m pena nga na n la nsia d i masyarakat berdasarkan sudut pandang dan pengalaman partisipan. partisipan penelitian ini adalah keluarga yang merawat lansia di wilayah dki jakarta dengan kriteria: 1) berusia dewasa sampai pra lansia (21-59 tahun), 2) tinggal bersama lansia (usia 60 tahun ke atas) dalam satu rumah, 3) bertanggung jawab merawat lansia (sebagai caregiver utama), 4) bersedia menjadi par tisipan. pemilihan sampel dilakukan melalui purposive sampling, dengan jumlah partisipan sebanyak 10 orang caregiver. penelitian dilakukan selama 3 bulan. peneliti melakukan pengumpulan data dengan menggunakan alat bantú berupa tape recorder untuk merekam informasi dari partisipan serta pedoman wawancara yang digunakan sebagai panduan bagi peneliti dalam mengajukan pertanyaan sesuai dengan tujuan. catatan lapangan digunakan untuk mencatat respons non verbal yang ditampilkan par tisipan ser ta sit uasi lingkungan saat wawancara berlangsung. sebelum melakukan wawancara kepada partisipan yang sebenarnya, peneliti melakukan uji coba wawancara kepada 2 keluarga yang merawat lansia dat a ya ng d i k u mpu l k a n sela m a penelitian adalah hasil wawancara mendalam dan hasil observasi berupa catatan lapangan. analisis data dalam penelitian ini yaitu analisis tema menggunakan pendekatan colaizzi (1978 dalam streubert & carpenter, 2003). hasil partisipan dalam penelitian ini yaitu 10 caregiver. usia caregiver bervariasi dari usia 33 tahun sampai 59 tahun, terdiri dari satu orang laki-laki dan sembilan orang perempuan. tingkat pendidikan juga bervariasi mulai dari sd sampai perguruan tinggi dan berasal dari suku yang berbeda yaitu sunda, jawa, betawi dan manado. setelah data dianalisis menggunakan pendekatan collaizi, ditemukan 4 tema sebagai hasil penelitian ini. tema yang per tama adalah alasan merawat dan beban merawat. tema alasan merawat diidentif ikasi melalui sub tema tanggung jawab yang digambarkan melalui kategori tugas anggota keluarga, balas budi, kepuasan, caregiver utama, kedekatan dan kasihan. tugas sebagai anggota keluarga dikemukakan tergantung dari hubungan caregiver dengan lansia. salah seorang 101 pengalaman keluarga dalam penanganan lanjut usia (ni made riasmini, dkk.) par tisipan mengatakan tangg ung jawab sebagai isteri: ”ya...sudah tanggung jawab isteri ngerawat suami yang sakit....dulu kan apa-apa bapak....sekarang tugas ibu dan harus ikhlas ngelakuin semuanya” (p3) alasan merawat karena balas budi digambarkan partisipan sebagai bentuk balas budi anak kepada orang tua: ”karena dia orang tua saya yang melahirkan ...membesarkan saya... harus dilindungin, kalau dari sekarang saya sudah ngurusin orang tua... kalau kita tua nanti... mungkin kita dibalas nanti” (p2). salah seorang par tisipan laki-laki mengatakan alasannya merawat orang tua karena tidak ada lagi yang bisa merawat orang tuanya (caregiver utama): ”karena memang di rumah ini nggak ada yang lain lagi, cuma saya yang di rumah... mau nggak mau ya saya yang merawat! ya... tanggung jawab saya sebagai anak tertua, apalagi orang tua sudah nggak bisa kerja ya..” (p8) alasan karena kedekatan dikemukakan oleh partisipan sebagai hubungan antara menantu dengan mertuanya: ”walaupun saya mantunya tapi mak sudah seperti orang tua saya sendiri, ya... harus diurus dengan baik... kalau ada apa-apa, mak sering ngeluhnya ke saya” (p7).” ada juga partisipan yang mengatakan alasan merawat karena kasihan: ”ya..alasannya kasihan.... orang udah tua kan nggak boleh disia-siain... siapa lagi kalau bukan anaknya yang dekat... gitu... yang bertanggung jawab merawat orang tua...” (p9) tema kedua adalah beban keluarga merawat lansia diidentifi kasi dari sub tema beban fi sik, psikologis, sosial dan fi nansial. sub tema beban fi sik digambarkan melalui kategori keluhan kesehatan; sub tema beban psikologis digambarkan melalui kategori sikap lansia, perubahan emosi lansia, perubahan emosi caregiver, takut dosa, khawatir dan merasa bersalah; sub tema beban sosial digambarkan melalui kategori peran ganda, kurang dukungan dari anggota keluarga dan keterbatasan aktivitas; sedangkan sub tema beban fi nansial digambarkan melalui kategori meningkatnya kebutuhan biaya. beban fi sik diidentifi kasi dari keluhan fi sik yang dialami oleh keluarga, tergambar dari partisipan berikut: “ya kadang lelah… kalau lagi lelah…biasa ntar hilang lagi” (p5). “paling kalau aku ngeluh badan sakit….minta kerokin sama mbah…. jadi gantian deh….” (p9). b e b a n p si kolog i s y a n g d ia l a m i caregiver akibat sikap lansia susah diatur, sering mengada-ada dan egois serta perubahan emosi lansia seper ti diu ngkapkan oleh partisipan berikut: “ya... tetap saya harus ngalah… walaupun orang tuanya salah menurut saya…tapi namanya orang tua kan maunya bener sendiri… kadang-kadang orang tua itu egois… susah dibilangin... tapinya sebagai anak saya tetap harus menjaga… harus merawat” (p10). “kadang mak suka ngambek… marah…. kalau menurut dia bener kita kasih tahu....……. marah… nggak mau.. gitu…kadang-kadang salah tanggap gitu… kita berbuat apa….pikiran dia kemana gitu...” (p10). per ubahan emosi caregiver dapat diidentif ikasi dari ungkapan rasa sedih, menangis bahkan sering bertengkar dengan lansia seperti yang diungkapkan oleh partisipan berikut: ”.......saya pernah nggak teguran....... saya nangis...... (mata berkaca-kaca), tapi saya tu pingin nanya gimana ya... nggak nanya... orangtua sendiri... itu saya terasa menderita... karena seringnya saya berantem…... tapi saya berpikir........... mungkin ini udah usia lanjut kali ya…. jadi saya lebih baik diem….” (p10) perasaan khawatir, rasa bersalah dan takut dosa juga diungkapkan sebagai beban psikologis bagi caregiver dalam merawat lansia: “mungkin karena saya anak laki agak susah ngertiin ibu….. saya merasa nggak bisa ngerawat ibu dengan baik….” (p8). ”tapi saya takut dosa..... namanya gimana tu orang tua saya... walaupun orang tua saya salah... ya.... saya berusaha menegur” (p10). beban sosial yang dialami caregiver akibat peran ganda selain merawat lansia juga harus bekerja mencari naf kah dan mengurus anggota keluarga lain. di samping itu karena dukungan yang kurang dari anggota keluarga lain dan keterbat asan ak tivit as karena harus merawat lansia di rumah. salah satu partisipan yang bekerja sebagai tukang pijat mengungkapkan: “kalau nggak ada saya dia 102 jurnal ners vol. 8 no. 1 april 2013: 98–106 suka bilang: ”sepi nggak ada lu… apalagi kalau ditinggal… .nyariin emaknya…. soalnya dia deket dengan saya..… padahal saya kan kerja mijit… perlu cari uang juga kan?” (p5). “kadang-kadang suka merasa capek juga sih ngerawat orangtua... ya… suka ngomong sendiri: ”saudara-saudara gue pada kemana sih”?... gitu …cuma sesekali saja sih…. nggak sering……. karena saudara nggak ada yang tinggal di sini…. mereka sudah berkeluarga dan punya kesibukan” (p8). keterbatasan aktivitas yang dialami caregiver karena harus merawat lansia di rumah tergambar dari ungkapan partisipan berikut: “paling kita nggak bisa kemanamana… kalau orang pergi, kita di rumah aja nungguin mak, padahal kan saya perlu jalan juga..…. tapi seumpama saya kemanamana mikirin ini saja… takut ada apa-apa….” (p7). beban finansial juga dirasakan oleh caregiver terutama kebutuhan biaya jika lansia sakit atau dirawat dan kebutuhan sehari-hari lansia, seperti yang diungkapkan oleh par tisipan ber ik ut: “ya…pikiran… keuangannya…..... pensiun bapak kecil… untuk belanja tiap hari, juga kontrol rutin ke rumah sakit….. kadang nggak cukup apalagi kalau bapak harus dirawat” (p3). tema ketiga adalah persepsi tentang nilai budaya yang diidentifikasi dari sub tema kedudukan lansia di keluarga dan peranan lansia dalam keluarga. sub tema kedudukan lansia di keluarga digambarkan melalui kategori dihormati dan dihargai serta dirawat; sedangkan sub tema peranan lansia digambarkan melalui kategori memiliki kelebihan, pengalaman luas dan sebagai role model. kedudukan lansia dalam keluarga sebagai orang tua yang harus dihargai dan dihor mati diu ngkapkan oleh par tisipan berikut: “ya… sama saja.... menghargai...... menghormati orang tua” (p6). ”ya... jangan suka melawan orang tua...... marah gimanapun nggak usah dilawan..... mungkin semua suku seperti itu... ada...” (p10). partisipan juga mengungkapkan bahwa lansia harus dirawat dengan baik, salah satu par tisipan mengatakan bahwa merawat orang tua merupakan suatu anugrah, seperti per nyataan berikut: “nggak tahu… dari tuhan,… ya ciptaan tuhan…. sebagai anak bisa merawat orangtua itu anugrah ya…” (p1). partisipan lain mengungkapkan bahwa agar mampu merawat orang tua dengan baik maka tugas anak melindungi orang tua, seperti ungkapan berikut: ”memang karena tugas anak gimana sih..... jangankan orangtua sendiri...... walaupun mertua harus dilindungin juga ya...” (p2) pe r a n a n l a n si a d a l a m kelu a r g a diungkapkan oleh partisipan bahwa lansia memiliki kelebihan, dan bisa dijadikan sebagai role model. “….karena saya menghargai banget orangtua…. saya lihat pelajaran dia… saya ngambil yang baiknya saja… saya bisa seperti sekarang walaupun cuma lulusan sma tapi bisa punya rumah… ya dari pendidikan ibu lah…” (p2) karena orang tua punya pengalaman l u a s , m a k a s a l a h s a t u p a r t i s i p a n mengungkapkan sering meminta pendapat orang tua jika ada masalah: “alhamdullilah… dari dulu cocok aja… aku nggak pernah dengar mbah ngomel-ngomel gitu… malah aku sering minta pendapat mbah kalau lagi ada masalah… suami saya kan jauh… jarang di rumah…” (p9) tema yang keempat adalah dukungan keluarga dan masyarakat dalam merawat lansia. tema ini dibentuk dari dua sub tema yaitu jenis dukungan dan sumber dukungan. jenis dukungan digambarkan melalui kategori dukungan afektif, dukungan penghargaan dan dukungan instr umental. sedangkan sumber dukungan digambarkan melalui kategori dukungan informal (anak, mantu, cucu, adik, kakak, keponakan, tetangga) dan dukungan formal (pelayanan rumah sakit, pelayanan puskesmas, dokter praktik, jaminan kesehatan). dukungan afektif dipenuhi dengan sering menengok lansia apalagi jika dalam kondisi tidak sehat, dengan memberikan perhatian dan lebih perduli terhadap lansia. dukungan ini bisa diperoleh dari anggota kelu a rga maupu n ma sya r a k at sek it a r, seperti ungkapan partisipan berikut: “asal 103 pengalaman keluarga dalam penanganan lanjut usia (ni made riasmini, dkk.) ditengok saja.... anak-anaknya yang harus memperhatikan orang tua….” (p3). “ya… tetangga lebih peduli ya… karena kita kan bertetangga… apalagi mereka tahu kondisi ibu yang sudah pikun…” (p8) salah satu partisipan mengungkapkan dukungan penghargaan yang dibutuhkan dalam merawat lansia, seperti ungkapan: “harusnya dengan orang tua ngerti… ngerti dalam hal keuangan ya… ngerti kalau orang tua sakit… kemana-mana telpon yang lain… sampai mantu juga harus ngerti…” (p4). dukungan instrumental juga diperlukan dalam merawat lansia antara lain terkait dengan kebutuhan dana untuk memenuhi kebutuhan sehari-hari lansia dan kebutuhan pelayanan kesehatan jika lansia sakit seperti yang diungkapkan partisipan berikut: “ya… pemikiran anak-anak untuk orang tua…. karena perlu bayar air, listrik, telepon, apalagi untuk biaya bapak control ke rumah sakit…. kan nggak cukup keuangan” (p3) sumber duk ungan yang berkaitan dengan dukungan informal dari anggota keluarga terutama dari anak kepada orangtua, diungkapkan oleh partisipan berikut: “ya… anak-anak mak merhatiin…. suka datang…. kalau setiap datang ngasih…maunya mak apa? kadang-kadang saya ingetin tu... mak maunya apa… ntar dibeliin gitu….” (p10) su mber du k u ngan for mal seper ti pelayanan rumah sakit dan jaminan kesehatan diperlukan untuk merawat lansia seperti yang diungkapkan partisipan berikut: “ya biar mak sehat… mendapat jaminan kesehatan kalau ada apa-apa. (p5) “kan biar bagaimana bapak maunya di rs… soalnya sudah cocok…..selama ini berobat kesana…. obat di rs diterusin takut berhenti... tapi kan selama berobat sembuh, ….soal makan kan…. salah makan kambuh lagi…” (p3) pembahasan peneliti telah mengidentifi kasi empat tema dari hasil penelitian ini, beberapa diantaranya memiliki sub tema dengan kategori-kategori makna tertentu. tematema tersebut teridentifikasi berdasarkan tujuan penelitian. respons keluarga merawat lansia teridentifi kasi dari dua tema yaitu: 1) alasan merawat lansia dan 2) beban merawat. nilai-nilai budaya dalam merawat tergambar dalam tema ketiga yaitu persepsi tentang nilai budaya; kebutuhan akan dukungan keluarga dan masyarakat sekitar tergambar pada tema keempat yaitu dukungan dalam merawat lansia. selanjutnya akan dibahas secara rinci masing-masing tema yang teridentifi kasi. alasan keluarga merawat lansia karena tanggung jawab yaitu tugas anggota keluarga, balas budi, kepuasan, caregiver utama, kedekatan dan rasa kasihan. bentuk tanggung jawab keluarga merawat lansia tergambar melalui nilai yang masih berlaku dalam masyarakat bahwa anak wajib memberikan kasih sayang kepada orangtuanya sebagaimana pernah mereka dapatkan sewaktu mereka masih kecil sebagai bentuk balas budi anak kepada orang tua. anak masih merasa berkewajiban dan mempunyai loyalitas menyantuni orang tua mereka yang sudah tidak dapat mengurus dirinya sendiri. ini menunjukkan bahwa sistem nilai budaya yang menjunjung tinggi pengabdian terhadap orang tua, masih ada di masyarakat indonesia. hasil penelitian ini sesuai dengan penelitian fenomenologi yang dilakukan asniar (2007), bahwa alasan merawat orang tua yang sakit karena tanggung jawab yaitu tugas sebagai anggota keluarga, balas budi dan merupakan caregiver tunggal. sahar (2002) juga menggambarkan bahwa alasan merawat karena tanggung jawab sebesar (26,8%), dan ingin memberikan perawatan lebih baik (19,5%). sedangkan hasil penelitian laubunjong (2008), ditemukan bahwa alasan menjadi caregiver bervariasi yaitu karena ingin merawat, tidak bekerja dan tidak ada anggota keluarga lain yang merawat. beban keluarga merawat lansia tergambar dari beban fisik, psikologis, sosial dan fi nansial. hal ini sesuai dengan pendapat gupta, pillai dan levy (2012) bahwa beban merawat merupakan respons multidimensi terhadap stresor fi sik, psikologis, sosial dan fi nansial yang dihubungkan dengan pengalaman pelaku rawat dalam merawat klien. hasil penelitian ini ditemukan beban fi sik berupa kelelahan akibat merawat lansia, 104 jurnal ners vol. 8 no. 1 april 2013: 98–106 di samping juga karena sambil bekerja. beban psikologis yaitu perasaan khawatir ditinggal lansia karena usianya sudah tua, takut sakit mendadak dan perasaan bersalah karena tidak mampu merawat lansia dengan baik. di samping itu, yang terbanyak ditemukan karena perubahan emosi lansia yang sering marah, dan sikap lansia yang susah diatur. kondisi tersebut ser ing menimbulkan konf lik antara keluarga dengan lansia. konf lik dalam keluarga dapat dikurangi dengan interaksi positif yaitu saling memahami perasaan masing-masing anggota keluarga sehingga meningkatkan kualitas hubungan dalam keluarga (kaakinen, gedaly-duff, coehlo & hanson, 2010). beban sosial yang dialami caregiver akibat peran ganda selain merawat lansia juga harus bekerja mencari naf kah dang mengurus anggota keluarga lain sehingga seringkali keluarga tidak mempunyai kesempatan untuk melakukan aktivitas lain. sedangkan beban fi nansial dirasakan keluarga karena keterbatasan biaya terutama jika lansia sakit. hasil penelitian ini selaras dengan hasil penelitian asniar (2007) di mana beban yang dialami caregiver dalam merawat klien stroke yaitu beban psikologis yang diidentifikasi melalui karakteristik verbal seperti stres, menangis, dan rasa bersalah karena harus meninggalkan klien untuk mencari naf kah. beban juga muncul karena perubahan emosi klien yang sering marah dan berperilaku buruk. sedangkan beban fisik dilihat dari ekspresi wajah kelelahan, ungkapan rasa lelah, jenuh dan capek. selain itu karena kesulitan caregiver merawat klien terutama membagi waktu antara merawat klien dan peran lainnya, serta beban ekonomi terkait biaya pengobatan klien. peran dan kedudukan lansia dalam keluarga dan masyarakat sangat dipengaruhi oleh pandangan kebudayaan mengenai lansia. hasil penelitian ini menunjukkan bahwa budaya extended family masih berkembang di masyarakat di mana mayoritas lansia masih tinggal bersama anak atau sanak saudara lainnya. beberapa partisipan sangat menghargai dan menghormati keberadaan lansia di keluarga sehingga lansia dirawat dengan baik, bahkan salah satu partisipan mengatakan bahwa merawat orang t ua merupakan anugerah. hal ini sesuai dengan hasil penelitian liu (2009) menemukan bahwa lansia dalam masyarakat tradisional di asia masih tinggal dengan keluarga. kondisi ini menunjukkan bahwa masyarakat asia masih menjunjung tinggi nilai-nilai budaya menghormati orang tua di mana mereka harus diperhatikan, dihargai dan dirawat di lingkungan keluarga. umumnya lansia masih mempunyai kedudukan yang cukup tinggi sebagai orang tua yang har us dihor mati dan dihargai, karena lebih banyak mempunyai pengalaman sehingga pendapatnya masih dibutuhkan dalam pengambilan keputusan keluarga. adanya dukungan tersebut, akan memperkuat ikatan kekeluargaan sehingga lansia merasa aman, puas dan merasa berg u na ser ta mampu menjalani kehidupan dengan baik. hal ini ditemukan pada partisipan kedua dan kesembilan, mengatakan bahwa orang tua mempunyai pengalaman yang lebih sehingga setiap kali akan melakukan tindakan pasti meminta pendapat orang tua dan bisa saling bertukar pikiran. karena pengalaman yang dimiliki tersebut bahkan orang tua akan tahu jika anak-anaknya mengalami kesulitan. h a s i l p e n e l i t i a n m e n u n j u k k a n bahwa mayoritas lansia dirawat oleh anak perempuannya. hal ini sesuai dengan hasil penelitian laubunjong (2008) tentang pola caregiving pada lansia, ditemukan bahwa mayoritas lansia menginginkan dirawat oleh anak perempuannya. lansia mengharapkan mendapat perawatan, dicintai serta mendapat bantuan fi nansial dan pelayanan kesehatan yang bisa dipenuhi oleh anak mereka. kebanyakan masyarakat indonesia memandang bahwa dukungan keluarga yang berupa pemberian bantuan dari anak kepada orang tua masih berperan sangat besar. jika dikaitkan dengan budaya indonesia di mana budaya extended family masih berkembang, memungkinkan lansia untuk tinggal bersama keluarga (anak, menantu, cucu atau anggota keluarga lain). keluarga merupakan sumber pendukung utama bagi lansia di masyarakat. 105 pengalaman keluarga dalam penanganan lanjut usia (ni made riasmini, dkk.) efektivitas dukungan keluarga merupakan komponen kunci terhadap kesejahteraan lansia. hasil penelitian karlikaya, et al. (2005) menggambarkan mayoritas caregiver adalah pasangan dan anak usia dewasa. pada penelitian ini, sebagian besar (70%) caregiver yang merawat lansia adalah anak perempuannya dan 20% adalah pasangan. hal ini selaras dengan hasil penelitian okabayashi, et al. (2004), berdasarkan karakteristik budaya melalui komitmen anak dalam mendukung orang tua yang lanjut usia, bahwa dukungan sosial dan emosional yang diberikan anak sangat penting bagi lansia. anak memiliki ikatan emosional yang kuat dengan orang tua sehingga dukungan yang diberikan dapat meningkatkan kesehatan mental lansia. je n i s d u k u ng a n s o sia l me nu r ut arpact (2008) yaitu: dukungan informasi, dukungan instrumental, dukungan emosional, dukungan penghargaan dan integrasi sosial. hasil penelitian ditemu kan hanya tiga jenis dukungan yang diberikan caregiver maupun masyarakat sekitar kepada lansia yait u du k u nga n emosional, du k u nga n penghargaan dan dukungan instrumental. masih kurangnya dukungan informasi baik dari keluarga dan masyarakat yang diberikan kepada lansia menunjukkan bahwa keluarga maupun masyarakat belum memahami tentang penanganan lansia sehingga tidak mampu memberikan infor masi kesehatan terkait dengan masalah kesehatan serta pola hidup sehat bagi lansia. simpulan dan saran simpulan merawat lansia di rumah merupakan bentuk tanggung jawab caregiver sebagai anak kepada orang tua. adanya keterbatasan fi sik dan psikologis yang dialami lansia juga merupakan alasan dalam merawat lansia. keluarga mempersepsikan beban dalam merawat lansia melalui karakteristik beban yaitu beban f isik, psikologis, sosial dan fi nansial. beban yang paling besar dialami keluarga yait u beban psikologis karena perubahan emosi yang dialami lansia. nilainilai budaya yang dipersepsikan keluarga dalam merawat lansia tergambar dari rasa hormat dan penghargaan yang diberikan keluarga kepada lansia. ini menunjukkan bahwa nilai budaya yang menjunjung tinggi pengabdian terhadap orang tua, masih berlaku pada masyarakat indonesia. lansia juga diyakini mempunyai kedudukan dan peranan penting dalam keluarga karena memiliki kelebihan dan pengalaman yang luas. keluarga memerlukan dukungan dari anggota keluarga maupun masyarakat sekitar dalam merawat lansia dalam memenuhi kebutuhan fisik, psikologis, sosial dan fi nansial lansia. saran memprioritaskan pelayanan kesehatan berbasis masyarakat dan mudah dijangkau mengingat kondisi lansia yang mengalami berbagai keterbatasaan. model pemberdayaan keluarga melalui self help group merupakan intervensi yang tepat untuk mengurangi beban keluarga merawat lansia. mengembangkan pendekatan berbasis budaya dalam memberikan perawatan kepada lansia di masyarakat. perlu dikembangkan kelompok pendukung sebagai support system bagi keluarga dalam merawat lansia. kepustakaan ahmad, k., 2012. informal caregiving to chronically iii older family members: caregivers’ experiences and problems. a research journal of south asian studies, 27(1), 101–120. arpact, f., 2008. a study into the quality of life of the elderly living at the rest homesin turkey. pakistan journal of sosial science, 5(1), 76–81. asniar, 2007. studi fenomenologi tentang pe n ga la m a n ke l u a r ga m e ra wa t anggota keluarga pascastroke di rumah di kelurahan depok, kecamatan pancoran mas, kota depok jawa barat. tesis tidak dipublikasikan. bad a n p usat st at ist i k , 20 07. statistik indonesia. jakarta. _____. 2009. statistik indonesia. jakarta. boonyakawee, c., 2006. the functional disability of the elderly in tambon krabi-noi m uang dist rict krabi 106 jurnal ners vol. 8 no. 1 april 2013: 98–106 province. thesis. degree of master of public health program in health system development. chulalongkorn university. creswell, jw., 1998. qualitative inquiry and research design: choosing among fi ve tra dit ion s. l ondon: sage publications. etters, l., goodall, d., & harrison, be., 2008. caregiver burden among dementia patient caregiver: a review of the literature. journal of the american academy of nurse practitioners, 20, 423–428. fitriani, e., 2009. lansia dalam keluarga dan masyarakat. endafi triani diperoleh 17 mei 2010. gort, am. et al., 2007. use of the zarit scale for assessing caregiver burden and collaps in caregiving at home in dementias. international journal geriatric psychiatry, 22, 957–962. gupta, r., pillai, vk., & levy, ef., (2012). relat ion sh ip q u al it y a nd elde r caregiver burden. journal of social intervention: theory and practice, 21 (2): 39–62. harris, gj., 2009. caregiver well-being: faktor infl uencing positive outcomes in the informal caregiving process. diser tation. doctor of philosophy. depar t ment of family and child science. kaakinen, jr., gedaly-duff,v., coehlo, dp., & hanson, smh., 2010. family health care nursing: theory, practice and research. 4th ed. philadelphia: fa. davis company. karlikaya, g. et al., 2005. caregiver burden in dementia: a study in the turkish population. the internet journal of neurology, volume 4 number 2. kozier, et al., 2004. fundamental of nursing: concept, process and practice. 7th ed. upper saddle river: pearson education, inc. laubunjong, et al., 2008. the pattern of caregiving to the elderly by their families in rural communities of suratthani province. abac journal, 28(2), 64–74. lee, m., 2008. caregiver stress and elder abuse among korean family caregiver of elder adult with disabilities. original article. j fame vio, 23, 702–712. liu, 2009. family involvement in and satisfaction with long ter m care facilities in taiwan. asian j. gerontol geriatr, 4, 30–35. magliano, l., 2008. families of people with severe mental disorder: diffi culties and resources. italy: who collaborating center for research and training in mental health. polit, df. & beck, ct., 2008. nursing research: generating and assessing evi d e n c e fo r nu r si n g p ra c t i c e. philadelphia: lippincott williams & wilkins. sahar, j., 2002. supporting family carers in caring for older people in tha community in indonesia. queensland university of technology, school of nursing. centre for nursing research. tidak dipublikasikan. sales, e., 2003. family burden and quality of life. quality of life research 12 (supp. 1.1): 33–41. streuebert, hj. & car penter, dr., 2003. q ualitative research in n ursing: advancing humanistic imperative. (3rd ed). philadelphia: lippincott. suyono, h., 2006. mengantisipasi lansia di kota besar. diunduh dari http:// w w w.ha r yono.com. pa d a t a nggal 24 september 2009. 186 tindakan error prosedur keperawatan: jenis dan faktor penyebabnya pada mahasiswa profesi ners (an action error of nursing procedures: types and cause factor ners profession student ) uswatun khasanah *program studi ilmu keperawatan fakultas kedokteran dan ilmu kesehatan uin syarif hidayatullah jakarta, jl. kertamukti pisangan ciputat tangerang selatan banten, email: uswatun@uinjkt.ac.id atau uunkeho@yahoo.com abstract introduction: an error could be danger for the safety of patients. ners students because of its lack clinical experiences are at risk to make an error in medication or procedure to the patient. the purposes of this study are to identify types and causes error events conducted by ners students. method: this is a qualitative study. the participants are 29 students for answering the open questionnaire and 5 students for in-depth interview. the instruments are open questionnaire and interview guideline. data analysis is used content analysis. result: this study revealed that the error is classifi ed into 2 types: error related to medication and nursing procedures. the natures of error are from mild to severe error. the factors of error are classifi ed into 3 categories: student factor, environment and preceptor factor. the student factors: lack of confi dence, nervous, fi rst time experience, and lack of practice. environment factor: lack of facilities, emergency condition, lack of supervision, and lack of patient safety habit in the hospital. preceptor factors: lack of guidance, unclear instruction. discussion: the students feeling when doing an error is classifi ed into 2: negative and positive feeling. negative feelings are fear, feeling guilty. positive feeling: motivated to learn. the student actions after doing an error are keep silent, inform to other students, or inform the preceptor or hospital nurses. the suggestion from this research is improving the skills lab education during academic phase and developing procedure for manage and prevent the error. keywords: error, nurse student, profession education pendahuluan kesalahan di dalam praktek keperawatan maupun kedokteran sangat membahayakan kemanan pasien (henneman, et al., 2010). khususnya di indonesia masih sedikit sekali bahkan peneliti belum pernah menemukan penelitian yang membahas tentang jenisjenis kesalahan atau error yang dilakukan oleh perawat, terlebih yang dilakukan oleh mahasiswa yang sedang praktek di klinik, baik itu rumah sakit, klinik, maupun puskesmas. rothschild et al. (2005) sangat sedikitnya publikasi terkait error yang dilakukan oleh tenaga kesehatan sering kali terkendala karena kurang baiknya dokumentasi terkait error dan membutuhkan multi pendekatan dalam pengambilan data serta membutuhkan observasi yang juga tidak mudah. perawat mempunyai posisi yang sangat strategis terhadap outcome perawatan atau pelayanan yang akan diterima pasien, sebagai contohnya adalah dalam mengidentifikasi komplikasi yang dapat saja terjadi pada pasien ( needlema n, 20 02). ma hasiswa perawat, sebagai salah satu pihak yang juga memberikan perawatan kepada pasien, tentu saja juga akan mempengar uhi kemajuan klien. koohestani dan baghcheghi (2009) s e c a r a jel a s m e n g g a m b a r k a n k a r e n a keterbatasan pengalaman klinis mahasiswa, m a k a m a h a siswa p e r awat me mpu nyai resiko melakukan error dalam memberikan pengobatan atau tindakan kepada pasien. sehingga ketika memberikan tindakan atau pengobatan kepada pasien, maka mahasiswa dapat membahayakan kondisi pasien ketika 187 tindakan error prosedur keperawatan (uswatun khasanah) dilakukan dengan tidak sempurna atau salah dalam melakukan suatu prosedur. penelitian sharif dan masoumi (2005) mahasiswa perawat tidak puas dengan kemampuan klinis mereka selama pendidikan. mahasiswa mengalami kecemasan oleh karena perasaan tidak mampu atau tidak menguasai dan karena kurangnya keterampilan dan pengetahuan dalam merawat pasien dalam berbagai seting klinis. penelitian tersebut juga menemukan bahwa kecemasan mahasiswa akan tinggi ketika di awal-awal praktek klinik. baghcheghi dan koohestani (2008) melakukan studi observasi terkait frekuensi, tipe dan penyebab kesalahan penatalaksanaan terapi intravena pada mahasiswa perawat tingkat akhir. hasil penelitian menunjukkan dari 372 observasi, maka terdapat 153 kejadian error yang terdeteksi. kejadian error yang paling sering terjadi adalah pengenceran obat (2,68%) dan ketidaktepatan kecepatan infus (11,55%). sedangkan penyebab error paling banyak adalah ketidakadekuatan pengetahuan tentang farmakologi. selain itu lymn et al. (2008) mengidentifikasi bahwa mahasiswa perawat seringkali mengalami kesulitan dalam ilmu far makologi ser ta mengkaitkannya dengan praktek klinik, hal ini senada yang disampaikan oleh king (2004). hasil evaluasi praktik klinik mahasiswa perawat di psik fkik uin syarif hidayatullah jakarta, terdapat beberapa laporan mengenai kejadian error selama dalam praktik klinik. beberapa kejadian itu di antaranya adalah salah obat, salah dalam pengenceran pengobatan, salah lokasi peny untikan ataupun tidak lengkapnya atau tidak telitinya mahasiswa dalam melakukan suatu prosedur tindakan. adapun secara pasti data kuantitatif kejadiankejadian tersebut belum ada penelitian sampai saat ini. lebih lanjut peneliti sangat kesulitan di dalam menemukan hasil-hasil penelitian terkait tindakan error yang dilakukan oleh mahasiswa baik itu di jurnal, tesis maupun disertasi khususnya di indonesia. hanya data yang sifatnya informal yang sering terdengar, yaitu ketika peneliti berbincang-bincang dengan perawat di rumah sakit. beberapa faktor resiko yang berhasil diidentifi kasi terkait kejadian error adalah kurangnya pemahaman mahasiswa dalam melakukan suatu prosedur, kurangnya cek, dan pengawasan dari pembimbing selama mahasiswa melak u kan suat u prosedu r. ketakutan mahasiswa juga dirasakan bisa sebagai faktor penyebab terjadinya error dalam pengobatan maupun tindakan. melihat berbagai hal di atas, maka penelitian ini bertujuan untuk mengetahui k a r a k ter ist i k ma ha siswa profesi ner s, mengidentifi kasi jenis-jenis tindakan error, mengidentif ikasi faktor-faktor terjadinya error, mengidentifi kasi tindakan mahasiswa ners setelah melakukan error, mengetahui saran, dan harapan untuk pencegahan kejadian error selanjutnya. hasil identifikasi ini tentunya akan sangat berguna bagi evaluasi pendidikan keperawatan baik pada tahapan akademik ataupun ketika praktik klinik, sehingga keamanan pasien dapat ditingkatkan, baik untuk pendidikan profesi di psik uin sendiri maupun secara nasional. bahan dan metode penelitian ini merupakan penelitian kualitatif. jenis penelitian ini dipilih karena peneliti ingin mengeksplorasi tentang topik penelitian ini secara lebih mendalam. metode ini akan melibatkan dalam penyelidikan yang lebih mendalam dan pemeriksaan secara menyeluruh terhadap tingkah laku suatu unit atau individu. partisipan dalam penelitian ini adalah 29 mahasiswa yang telah menyelesaikan pendidikan profesi ners program studi ilmu keperawatan fkik uin syarif hidayatullah jakarta. sedangkan instrumen penelitian adalah kuesioner berisi pertanyaan terbuka dan panduan wawancara yang akan digunakan sebagai panduan dalam wawancara mendalam yang dilakukan kepada 5 mahasiswa di antara 29 mahasiswa tersebut. tek nik peng umpulan data adalah dengan menyebarkan kuesioner yang berisi pertanyaan terbuka kepada 32 mahasiswa yang 188 jurnal ners vol. 7 no. 2 oktober 2012: 186–195 dilanjutkan kepada wawancara mendalam kepada 5 orang mahasiswa. analisa data dengan analisa konten. terkait dengan isu etik penelitian, penelitian ini telah mendapatkan persetujuan d a r i p a r t i s i p a n p e n e l i t i a n d e n g a n memperhatikan aspek-aspek di antaranya a d ala h penjela sa n ma n fa at penelit ia n, kemungkinan resiko dan ketidaknyamanan, jaminan anonimitas dan kerahasiaan, dan aspek sukarela dalam keterlibatan penelitian ini (dempsey, 2002). hasil karakteristik partisipan partisipan dalam penelitian ini adalah ma ha siswa ya ng t ela h me nyele sai k a n pendidikan profesi ners psik uin syarif hidayat ullah. sebanyak 29 mahasiswa berpartisipasi di dalam penelitian ini. adapun karakteristik mahasiswa terdapat dalam tabel 1. jenis-jenis tindakan error mahasiswa ners selama pendidikan profesi hasil penelitian menunjukkan ada 2 jenis kategori error yang diidentifi kasi oleh mahasiswa, yaitu kesalahan di dalam kegiatan yang berkaitan dengan pengobatan serta error yang berkaitan dengan prosedur suatu tindakan. sekitar 13 mahasiswa atau 44,8% mahasiswa mengidentifi kasi dirinya pernah melakukan error yang berkaitan dengan pemberian obat serta 22 mahasiswa atau sekitar 75% melakukan error yang berkaitan dengan suatu prosedur tindakan. beberapa contoh jenis error yang pernah dilakukan oleh mahasiswa yang sifatnya cukup membahayakan di antaranya yaitu mahasiswa memberikan obat heparin yang diberikan pada pasien yang salah. sedangkan heparin merupakan kontraindikasi bagi pasien tersebut karena proses pembekuan darahnya yang cukup memanjang. salah pasien juga cukup sering dialami oleh mahasiswa lain. "saya salah dalam pemberian obat yaitu salah pasien, tetapi dengan obat yang sama tetapi dengan dosis yang berbeda". c o n t o h d a r i k e s a l a h a n w a k t u disampaikan oleh mahasiswa cukup sering terjadi dan menjadi kebiasaan diruangan sebagaimana pernyataan berikut: "kalau yang saya alami untuk pemberian obat hanya salah waktu, misalnya pada saat pemberian obat harusnya jam 18.00 tetapi dipercepat pemberiannya menjadi jam 16.00, katanya sih biar dapat didokumentasikan atau perawat pekerjaannya masih banyak yang ingin dikerjakan. serta tetesan infus seperti rl, program dokter 20 tetes/menit harus tabel 1. karakteristik partisipan (n = 29) n nilai jenis kelamin – jumlah (%) laki-laki 7 (24,14) perempuan 24 (75,86) mean indek prestasi kumulatif akademik* 3,09 (± 0,26) median 3,05 nilai tertinggi 3,71 nilai terendah 2,61 missing case 3 mean indek prestasi kumulatif profesi** 3,71 (± 0,18) median 3,72 nilai tertinggi 4 nilai terendah 3,28 missing case 2 ket: * ipk akademik, **ipk profesi 189 tindakan error prosedur keperawatan (uswatun khasanah) habis 8 jam tetapi jarang tepat waktu habis cairan rl tersebut, biasanya waktu tetesan itu jamnya lebih atau kurang". "pemberian jadwal obat injeksi tidak tepat waktu karena instruksi dari pihak perawat di rs". contoh error pada tindakan prosedur adalah pasien memberikan makanan melalui ngt pada pasien tidak sadar dengan tidak dicek terlebih dahulu residunya, akan tetapi makanan dipaksa masuk, sehingga pada akhirnya makanan terdorong ke atas. hal ini sebagaimana yang disampaikan oleh mahasiswa ners, perempuan sebagai berikut: "sewaktu memberi makan via ngt, saya tidak mencek residu terlebih dahulu. saat diberi makanan ada tahanan. makanan tidak masuk sehingga tidak kuat mendorong akhirnya semua makanan terdorong ke atas. pasien dalam keadaan somnolen. cepat-cepat saya aspirasi, ternyata kateter tip kurang tersambung/ kurang pas dengan selang sehingga udara masuk. hal ini terjadi 1 kali saja selama saya praktek". tanda-tanda vital hanya ditebak dan tidak diukur, atau hanya dikira-kira saja tentang output dan input cairan adalah hal yang kadang dilakukan oleh mahasiswa ners sebagaimana pernyataan di bawah ini: "o ya, kadang waktu ttv (mengukur tanda-tanda vital) suka nebak suhu, respirasi pasien, soalnya waktu ttv pasiennya banyak, kadang cuma berdua dan harus mengukur ttv 1 lantai (1 ruangan)". "suka mengira-ngira intake dan output pasien (cairan pasien). kadang mungkin ini terbawa dari lingkungan juga, karena perawat di rs juga sering mengira-ngira dan nyuruh kita untuk dikira-kira aja". kejadian er ror berkait an dengan t i nd a ka n i nva sive ya ng pali ng ser i ng diidentifikasi mahasiswa adalah berkaitan dengan prosedur int ravena, baik unt u k m e ng a mbi l d a r a h a t a u u nt u k t e r a pi intravena. "memasang infus gagal karena infus set jatuh, tidak masuk vena ataupun bengkak". "saya pernah memasang infus salah sampai pasien pingsan 1 kali". perawatan luka juga diidentif ikasi oleh mahasiswa sering terjadi error dalam pelaksanaannya. tabel 2. distribusi frekuensi jenis-jenis error item nilai error dalam pemberian obat –n (%) 13 (44,8%) error dalam prosedur tindakan –n (%) 22 (75%) tabel 3. jenis-jenis error yang pernah terjadi error dalam pemberian obat error dalam prosedur tindakan salah waktu set luka untuk beberapa orang salah dosis infus tidak tepat obat tidak masuk semua prinsip steril kurang diperhatikan obat tidak diencerkan p e m b e r i a n m a k a n a n n g t y a n g t i d a k memperhatikan residu dosis dobel pengambilan darah arteri yang gagal tidak mendokumentasikan pengobatan sehingga duplikasi pemberian obat ttv sering hanya ditebak tanpa diperiksa salah pasien suntikan yang tidak tepat salah rute pemberian obat salah lokasi pasang kateter pada perempuan 190 jurnal ners vol. 7 no. 2 oktober 2012: 186–195 "saat perawatan luka, set steril digunakan untuk 2–3 pasien, sarung tangan tidak ganti hanya dibersihkan dengan alcohol 70% saat pergantian/perawatan luka pada pasien lain". "perawatan luka di lahan praktek ada yang menggunakan 1 set dressing luka dipakai/digunakan untuk 4–5 pasien, secara prosedur hal tersebut sebenarnya salah". (12) faktor-faktor penyebab mahasiswa ners melakukan error p e n e l i t i a n i n i m a h a s i s w a mengidentifikasi terdapat 3 faktor utama sebagai faktor penyebab terjadinya error. faktor tersebut adalah mahasiswa atau diri sendiri, lingkungan, dan pembimbing. hasil identifi kasi mahasiswa tentang faktor-faktor penyebab error ketika mahasiswa pendidikan profesi ners, dapat disimpulkan bahwa terjadinya suatu error dapat disebabkan oleh multi faktor. pertama kali melakukan suatu prosedur tindakan seringkali menjadi penyebab error, sebagaimana disampaikan oleh mahasiswa ners: "karena deg-degan waktu itu pertama kali melakukan pembersihan luka. saya tidak percaya diri (grogi), karena pengalaman pertama implementasi langsung ke pasien". "grogi karena baru pertama kali melakukan pemasangan infus dan diawasi oleh perawat ruangan". ketidakmampuan mahasiswa di dalam menata diri sebelum melakukan suatu tindakan seringkali menjadi penyebab error ataupun juga karena masih kurang terampilanya di dalam melakukan suatu prosedur. "saya merasa belum mampu melakukan suatu tindakan tetapi saya harus melakukannya". fa k tor li ng k u nga n d iident if i k a si mahasiswa menjadi penyebab error. "situasi (lingkungan) terkadang terburuburu agar pekerjaan cepat selesai (tuntutan dari lahan praktek)". "seringkali fasilitas kurang sehingga kita tetap melakukan walaupun tahu yang dilakukan itu adalah salah". tabel 4. hasil identifi kasi mahasiswa tentang faktor-faktor penyebab error mahasiswa lingkungan pembimbing kurang teliti, kurang konsentrasi keadaan emergensi pembimbing kurang membimbing tidak percaya diri, grogi, takut gagal, cemas tenaga kesehatan diruangan seringkali melepas sendiri ketika mahasiswa melakukan suatu prosedur tanpa adanya validasi lagi pembimbing hanya berrorientasi pada laporan/tugas kurang dalam melatih skills pertama kali melakukan suatu prosedur j u m l a h p a s i e n y a n g h a r u s ditangani kadang terlalu banyak tidak diawasi/dibimbing ketika melakukan suatu prosedur pertama kali praktek s a r a n a d a n p r a s a r a n y a n g kurang i n s t r u k s i k u r a n g j e l a s d a n lengkap kurang terampil kebiasaan rs yang kurang mendukung kurang pengetahuan tentang suatu prosedur p a s i e n c e m a s a t a u t i d a k percaya kurang latihan m e r a s a b e l u m s i a p u n t u k praktek 191 tindakan error prosedur keperawatan (uswatun khasanah) p e m b i m b i n g a n y a n g k u r a n g memperhatikan kebutuhan mahasiswa, "ada beberapa pembimbing ruangan yang tidak pernah membimbing mahasiswa". p e m b i m b i n g s e r i n g k a l i h a n y a berrorientasi terhadap tugas mahasiswa maupun laporan, tetapi kurang membimbing tentang teknis pelaksanaan suatu prosedur atau kurang mendampingi dan memberikan masukan ketika mahasiswa melakukan suatu prosedur. perasaan mahasiswa setelah melakukan error perasaan mahasiswa setelah melakukan error dari hasil penelitian dapat dikategorikan menjadi 2 macam perasaan, baik yang bersifat negatif maupun positif. perasaan negatif adalah takut, cemas, merasa bersalah, merasa berdosa, serta kuatir, sedangkan perasaan positif adalah merasa termotivasi untuk lebih belajar lagi, ingin lebih teliti dalam mengerjakan sesuatu lagi. perasaan yang sering dialami oleh mahasiswa adalah takut, cemas, kuatir, merasa bersalah, merasa trauma, dan juga merasa berdosa. adapun perasaan ini sebagai akibat kejadian yang dianggap oleh mahasiswa merugikan orang lain dalam hal ini terutama pasien maupu keluarganya, merasa telah melukai orang lain, takut akan komplain dari pasien, takut tidak dipercaya lagi setelah melakukan kesalahan, kuatir kondisi pasien akan memburuk setelah adanya prosedur yang salah yang telah dilakukan oleh mahasiswa, merasa terbebani karena harus bertanggung jawab atas kejadian yang terjadi. "perasaan setelah berbuat salah adalah merasa menyesal atas tindakan yang dilakukan serta merasa trauma dengan tindakan pemberian obat…". "merasa bersalah terhadap tindakan yang pernah dilakukan, cemas akan kondisi pasien yang bisa memburuk". selai n perasa a n ya ng cender u ng negatif, dari penelitian menunjukkan efek kejadian error yaitu berupa perasaan positif, di antaranya adalah menumbuhkan perasaan semangat untuk lebih teliti, keinginan untuk terus belajar. … "tetapi ingin lebih teliti lagi dalam semua tindakan". "saya merasa bersalah, namun termotivasi untuk belajar lebih giat lagi supaya tidak terulang lagi, dan akhirnya tidak terjadi kesalahan lagi". t i n d a k a n m a h a s i s w a n e r s s e t e l a h melakukan error setelah mahasiswa mengetahui bahwa ada tindakan error yang telah dilakukannya, beberapa tindakan yang dilakukan adalah dengan memberi tahu teman dan pembimbing, diam saja atau merahasiakannya, diskusi dengan teman terlebih dahulu baru kemudian memberitahu pembimbing, ataupun hanya memberi tahu teman-temannya saja. hasil wawancara dengan mahasiswa didapatkan hasil bahwa seringkali tindakan yang dilakukan setelah error tergantung pada jenis error-nya. jika sekiranya error dianggap sebagai kesalahan yang tidak terlalu membahayakan, maka seringkali mahasiswa hanya diam saja atau memberitahu temantemannya saja untuk meminta pendapat dan diskusi terkait error yang terjadi dan apa yang harus dilakukan selanjutnya. beberapa mahasiswa menyat akan bahwa jika terjadi kesalahan maka dirinya akan melaporkan ke pembimbing atau perawat jaga, terutama jika error itu sekiranya dapat membahayakan bagi diri pasien. pembimbing yang dimaksud adalah baik pembimbing akademik maupun pembimbing klinik dari rumah sakit. "saya segera melaporkan kejadian tersebut (error) pada pembimbing akademik dan menjelaskan kronologis kejadian. kemudian saya melaporkan kejadian tersebut pada pembimbing lapangan (ci) dan menjelaskan kronologis kejadian dan membuat berita acara dan kronologis secara tulis tangan dan kemudian diketik". 192 jurnal ners vol. 7 no. 2 oktober 2012: 186–195 saran dan harapan mahasiswa ners untuk pencegahan error selanjutnya terhadap kejadian-kejadian error yang per nah dilakukan oleh mahasiswa, mahasiswa memberikan beberapa harapan agar kejadian-kejadian serupa dapat terhindar atau dapat diminimalkan. adapun saransaran dari mahasiswa tersebut di antaranya a d a l a h , s t r a t eg i p e mbi mbi n g a n a t a u pengajaran klinis perlu ditingkatkan, kegiatan pada saat akademik, yaitu pada saat skills laboratorium, perlu ada tindakan atau standar untuk mencegah terjadinya error atau ketika tindakan error sudah terjadi. pembahasan hasil penelitian menunjukkan bahwa sekitar 75% mahasiswa menilai dirinya pernah melakukan error berkaitan dengan prosedur tindakan, sedangkan error berkaitan dengan pemberian obat pernah dilakukan sekitar 44,8%. adapun error dalam pemberian obat di antaranya yaitu salah waktu pemberian obat, salah dosis, salah pasien, salah rute, dan tidak mendokumentasikan pengobatan yang diberikan. adapun error dalam prosedur tindakan yang diidentifi kasi mahasiswa adalah set luka 1 untuk beberapa orang, infus tidak tepat, tanda tanda vital sering ditebak tanpa diperiksa, ataupun juga prinsip steril kurang dijaga. hasil penelitian ini senada dengan penelitian dari stetler et al. (2000) dan hume (1999) yang menunjukkan bahwa 10% sampai dengan 18% dari kecelakaan dirumah sakit yang dilaporkan adalah berkaitan dengan error dalam hal pengobatan, sedangkan mrayyan et al. (2007) mengemukakan bahwa error dalam hal pengobatan disebabkan oleh tim kesehatan yaitu: dokter, ahli farmasi, akan tetapi perawat seringkali menjadi profesi yang paling sering melakukan error dalam hal pengobatan. hasil penelitian dari baghcheghi and kooshestani (2008) yang melakukan studi observasi terkait terapi intravena, menunjukkan bahwa dari 372 observasi, terdeteksi sebanyak 153 error. kejadian error paling sering adalah pada tahap persiapan dan pemberian obat adalah pada saat mencampur obat (2,68%) dan ketidaktepatan kecepatan infus (11,55%), sedangkan penelitian kooshest ani dan baghcheghi (2009) menunjukkan bahwa 30% dari mahasiswa yang berpartisipasi dalam penelitian pernah melakukan satu kali selama masa pendidikan, dengan rata-rata error pengobatan sebanyak 1,93 kali. penelitian dar i rothschild (2006) menemukan bahwa jenis-jenis error umum yang berhasil diidentifi kasi dalam penelitiannya adalah salah dosis (17%), salah obat (15%), duplikasi obat (15%), salah rute (9%), salah pasien (8%). sedangkan jenis obat yang paling sering berkaitan dengan error adalah jenis antikoagulan, elektrolit, vasopressor, betablocker, anti aritmia, dan insulin. jenis-jenis error dalam penelitian rothschild juga selaras dengan hasil temuan dalam penelitian ini. wolf et al. (2006) mengemukakan bahwa salah satu faktor mahasiswa sering melakukan error adalah karena terbatasnya pengalama n k li n is mereka. terkad a ng mahasiswa melakukan kesalahan tanpa sengaja. dalam hal ini wolf menyarankan perawat pendidik menekankan secara serius tentang administrasi pengobatan dan mendiskusikan strategi keamanan dalam hal pengobatan pada saat diskusi kelas maupun pada saat super visi klinis. sedangkan baghcheghi and kooshestani (2008) berpendapat bahwa penyebab umum terjadinya error adalah ketid a kadek uat an penget ahuan tent ang farmakologi, hal ini menurut king et al. (2002), manias dan bullock (2002) disebabkan karena kurangnya konten tentang farmakologi di dalam kurikulum pendidikan keperawatan. penelitian dari weeks et al. (2000), hu t t o n (19 9 8) m e n u nj u k k a n b a h w a keterampilan dalam hal matematika secara signif ikan berkontribusi terhadap resiko kesala ha n d ala m hal pember ia n obat, sedangkan pada penelitian ini mahasiswa masih belum mengidentifi kasi jika kesulitan ataupun kemampuan yang rendah dalam hal matematika dasar dan kalkulasi pengobatan berkontribusi terhadap kesalahan dalam pengobatan. 193 tindakan error prosedur keperawatan (uswatun khasanah) penelitian ini mengidentifi kasi bahwa faktor yang berkontribusi terjadinya error dapat terbagi 3 yaitu faktor mahasiswa, l i ng k u nga n , d a n pe mbi mbi ng. fa k t or mahasiswa di antaranya yaitu: kurang teliti, takut atau cemas, merasa kurang terampil dan merasa belum siap untuk praktek. mahasiswa beranggapan bahwa pendidikan profesi adalah suatu pendidikan yang cukup membuat cemas. terutama pada awal pertama kali praktek atau pertama kali melakukan suatu tindakan. penelitian sharif dan masoumi (2005) menyebutkan bahwa pendidikan profesi cukup membuat stress bagi mahasiswa, terutama pada awal-awal pendidikan profesi/klinis. stres muncul adalah sebagai akibat ketakutan mahasiswa membuat kesalahan dan takut dievaluasi oleh pembimbing. oleh karena itu membangun rasa percaya diri sangat penting sebagai salah satu komponen dalam pendidikan profesi (grundy, 1993). lebih lanjut grundy mengemukakan pembanguan rasa percaya diri harus difasilitasi oleh proses selama pendidikan keperawatan, sehingga mahasiswa akan menjadi kompeten dan percaya diri. perawat pendidik mempunyai peran yang cukup penting dalam dalam pencegahan error dan juga perlu mengidentifi kasi strategi efektif dalam mencegah terjadinya error (henneman, et al., 2010). perasaan mahasiswa setelah melakukan error dalam penelitian ini teridentifikasi menjadi 2 kategori, yaitu perasaan positif dan negatif. perasaan negatif adalah takut, cemas, merasa bersalah, berdosa, dan khawatir. sedangkan perasaan positif adalah termotivasi untuk belajar lagi, ingin lebih teliti lagi dalam mengerjakan sesuatu. perasaan umum yang sering ada setelah perawat melakukan error adalah perasaan panik, putus ada, takut, merasa bersalah, malu dan lainnya. sedangkan tindakan yang dilakukan setelah melakukan error di antaranya adalah mencari seseorang yang dapat mendengarkan permasalahannya, secara formal melaporkan kejadian error, mencari pengetahuan dan informasi hal-hal yang berkaitan dengan kejadian error. terlebih carlton dan blegen (2006) mengemukakan bahwa tenaga kesehatan tidak dipersiapkan untuk menghadapi atau mengatasi dengan perasaan tidak nyaman yang disebabkan k a r e n a a d a ny a e r r o r, s e p e r t i m a lu , merasa tidak mampu, merasa ragu dengan pengetahuannya. studi dari koohestani et al. (2008) mengi ndi kasi kan bahwa 75,8% terkait error pengobatan yang dilak ukan oleh mahasiswa dilaporkan kepada instruktur. akan tetapi studi dari sanghera et al (2007) menunjukkan bahwa beberapa staf perawat hanya melaporkan sebagian error atau error yang dapat membahayakan pasiennya. hasil penelitian sanghera et al. tersebut selaras dengan hasil penelitian ini, di mana salah satu responden menyampikan bahwa jenis error yang dilaporkan seringkali error yang membahayakan pasien, sedangkan error yang dianggap ringan tidak akan disampaikan kepada yang berwenang dalam arti mahasiswa tersebut menyimpan kejadian error untuk dirinya sendiri atau hanya memberitahukan kepada teman prakteknya saja. adapun hambatan dalam melaporkan kejadian error adalah seringkali kawatir atau takut. hal ini selaras dengan penelitian kooshestani dan baghcheghi (2009) bahwa takut adalah sebagai salah satu sebab bagi ma hasiswa t id a k melaporka n kejad ia n error. administrasi juga di dalam penelitian tersebut dianggap sebagai penghalang dalam melaporkan kejadian error. ketika kejadian error terjadi, johnson dan kanitsaki (2006) merekomendasikan agar kejadian error segera dilaporkan kepada pihak yang berwenang sesegera mungkin. hal ini agar kejadian error tersebut dapat segera ditangani dan untuk mencegah error pada waktu selanjutnya. lebih lanjut koohestani dan baghcheghi (2009) berpendapat bahwa melaporkan er ror dapat meningkatkan keamanan pasien dan dapat memberikan informasi berharga untuk pencegahan error pada masa depan. simpulan dan saran simpulan jenis-jenis error yang sering terjadi dapat diklasifi kasikan menjadi 2 kategori besar, yaitu error yang berkaitan dengan pemberian 194 jurnal ners vol. 7 no. 2 oktober 2012: 186–195 obat atau administrasi obat dan error yang berkaitan dengan prosedur tindakan. jenis error yang terjadi dapat berbentuk error yang sifatnya ringan sampai dengan error berat yang dapat membahayakan keselamatan pasien. faktor penyebab error dalam penelitian ini teridentifi kasi menjadi 3 kategori, yaitu faktor mahasiswa atu diri sendiri, lingkungan, dan faktor pembimbing. faktor mahasiswa di antaranya yaitu kurang percaya diri, grogi, karena baru pertama kali melakukan suatu prosedur dan merasa kurang latihan. faktor lingkungan yaitu keadaan emergensi, tidak ada pengawasan dari rumah sakit, sarana dan prasarana yang kurang mendukung, serta kebiasaan di rumah sakit yang kurang mendukung terlaksananya patient safet y dengan baik. faktor pembimbing adalah pembi mbi ng k u ra ng membi mbi ng d a n instruksi kepada mahasiswa terkadang kurang jelas. perasaan mahasiswa ketika terjadi error dapat dibedakan menjadi 2 jenis ketegori, yaitu perasaan negatif dan perasaan positif. perasaan negaitf adalah takut, cemas, merasa bersalah, berdosa, sedangkan perasaan positif adalah termotivasi untuk lebih belajar lagi dan ingin lebih teliti dalam melakukan suatu tindakan. tindakan mahasiswa setelah melakukan error diantaranya adalah diam, memberi tahu teman dan memberi tahu pembimbing. penelitian ini hanya mengambil data dari perspektif mahasiswa terkait kejadian error, sehingga diharapkan pihak-pihak yang terlibat dalam pendidikan profesi mahasiswa perlu menjadi responden dalam penelitian selanjutnya agar mendapatkan gambaran yang jelas dan menyeluruh terkait dengan error yang terjadi pada mahasiswa. saran strategi pendidikan skills lab dapat lebih dimodifi kasi dan ditingkatkan di antaranya yaitu dengan small group teaching di mana seringkali pendidikan skills lab dilaksanakan pada mahasiswa pada kelompok besar, atau lebih dari 15 orang/group atau terkadang 1 kelas menjadi 1 kelompok besar. hal ini menjadikan pendidikan skills lab menjadi kurang efektif, mahasiswa tidak fokus ketika instruktur menjelaskan atau tidak mempunyai kesempatan untuk melakukan secara mandiri. kelompok kecil dengan maksimal 10 mahasiswa per group disarankan kepada pendidikan ketika kegiatan skills lab dilaksanakan, strategi kedua dengan pemanfaatan video untuk pendidikan skills lab. video dapat dimanfaatkan u nt u k pendidikan skills lab. keluhan dari mahasiswa a d a l a h t e r k a d a ng m a h a si s wa k u r a ng mendapatkan feedback dari tindakan prosedur yang telah dilaksanakannya. jumlah dosen yang terbatas ketika pendidikan skills lab dapat sebagai salah satu penyebabnya. pemanfaatan teknologi video dapat digunakan sebagai salah alternatif agar mahasiswa dapat mengevaluasi setiap tindakan yang telah dilakukannya. prinsip dari aplikasi teknologi video ini adalah; mahasiswa dapat merekam tindakan yang dilakukannya di skills lab dengan video, dan kemudian dapat melakukan evaluasi diri tindakan yang telah dilakukannya dengan menggunakan checklist suatu prosedur dengan memutar kembali video hasil rekaman. kepustakaan baghcheghi, n., da koohestani, n., 2008. nursing students' erors in preparation and administration of intravenous drugs. st rides in development of medical education, 5(1): 43–49. carlton, g. dan blegen, m.a., 2006. medicationrelated errors: a literature review of incidence and antecedents: annu rev nursing research, 24: 19–38. dempsey, p.a., 2002. nursing research: text and workbook. palupi widyastuti penerjemah. jakarta: egc. grundy, s.e., 1993. the confidence scale. nurse educator. 18(1): 6–9. henneman, e.a., roche, j.p., fisher, d.l., c u n n i n g h a m , h ., re i l ly, c. a ., nathanson, b.h., hen neman, p.l. 2010. eror identifi cation and recovery by student nurses using human patient simulation: opportunity to improve patient safet y. in applied nursing research. 23: 11–21. hume, m. 1999. changing hospital culture and systems reduces drug errors and 195 tindakan error prosedur keperawatan (uswatun khasanah) adverse events. the quality letter for health care leaders, 11(3): 2–9. hutton, m., 1998. nursing mathematics: the importance application. nursing standard, 13(11): 35-38. johson, m.j. dan kanitsaki, o., 2006. the ethics and practical importance of defining, distinguighing and disclosing nursing errors: a discussion paper. international journal of nursing studies, 43: 367–376. king, r.l., 2004. nurses' perceptiom of their phar machologi educational needs. journal of advanced nursing. 45(4): 392–400. koohestani, h.r. dan baghcheghi, n., 2009. barriers to the reporting of medication administration errors among nursing students. in australian journal of advance nursing, 27(1): 66–74. lymn, j.s., bath-hextall, f.b., wharrad h.j., 2008. phar macology education for nurse prescribing students – a lesson in reusable learning objects. in bmc nursing 2008, 7:2doi:10.1186/1472-69557, (online) (http://www.biomedcentral. com/1472-6955/7/2, diakses tanggal 1 maret 2011) manias, e. dan bullock, s., 2002. the educational preparation of undergraduate nursing students in pharmachology: perceptions and experiences of lecturers and students. international journal of nursing studies. 39(7): 757–769. mrayyan, m.t., shistani, k., dan faouri, i., 2007. rate, causes and reporting of medication errors in jordan: nurses's perspectives. jour nal of nursing management. 15(6): 659–670. needleman, j., buerhaus, p., mattke, s., steward, m., dan zelevinski, k., 2002. nurse-staffi ng levels and the quality of care in hospitals. new england journal of medicine, 346: 1715−1722. rothschild, j.m., hurley, a.c., landrigan, c.p., cronin, j.w., martell-waldrop, k., foskestt, c., burdick, e., czeisler, c.a., bates, d.w., 2006. recovery from medical errors: the critical care nursing safety net. journal on quality and patient safety. 32(2): 62–72. rothschild, j.m., landrigan, c.p., cronin, j.w., kaushal, r., lockley, s.w., burdock, e., et al., 2005. the critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. critical care medicine, 33: 1694−1700. sanghera, i.s., franklin, b.d., dan dhillon, s., 2007. the attitude and beliefs of healthcare professionals on the causes and reporting of medication errors in a uk intensive care unit. anesthesia, 62(1): 53–61. sharif, f. dan masoumi, s., 2005. a qualitative study of nursing student experiences of clinical practice. in bmc nursing. 4(6). stetler, c.b., morsi, d., dan burns, m., 2000. physical and emotional patient safety: a different look at nursing-sensitive outcomes. outcomes management of nursing practice, 4(4): 159–165. weeks, k., lyne, p., dan torrance, c., 2000. written dr ug dosage errors made by st udents: the threat to clinical effectiveness and the needs for a new approach. clinical effectiveness in nursing. 4(2): 20–29. wolf, z.r., hicks, r., dan serembus, j.f. 2006. characteristics of medication error made by student during the administration phase. journal of professional nursing, 22(1): 39–51. 1 respons psikologis (kecemasan dan depresi) dan respons biologis (cortisol, ifn-γ dan tnf-α) pada pasien stroke iskemik dengan pendekatan model home care holistic (psychological respons (anxiety and depression) and biological respons (cortisol, ifn-γ and tnf-α) in ischemic stroke patients by home care holistic model approach) luluk widarti*, moh. hasan mahfoed**, kuntoro***, ketut sudiana**** *poltekes kemenkes surabaya, jl. prof. dr. moestopo no. 8c surabaya e-mail: lulukwidarti@yahoo.co.id **ilmu penyakit saraf fakultas kedokteran universitas airlangga ***fakultas kesehatan masyarakat universitas airlangga ****fakultas kedokteran universitas airlangga abstract introduction: the patient with stroke often experience on psychological disorder such as anxiety and depression that lead to biologycal aspects such as on cytokin. the objective of the study was to analyse the corelation between psychological respons (anxiety and depression) and biological respons (cortisol, ifn-γ dan tnf-α) in ischemic stroke patients by home care holistic model approach. method: this study applied an experimental research with quasy experimental design. the study was conducted in the area of surabaya by selecting ischemic stroke patients after being hospitalised at ”a-seruni room, medic irna, dr. soetomo hospital”. a sample of size 40 was patients divided equally into two groups, control and treatment groups. the treatment and control groups respectively received holistic home care and home care. the depression and anxiety level were measured by using questionnaires and observation technique, while cortisol level, ifn-γ and tnf-α levels were measured by using elisa quantitative technique. the data was analyzed by using levene’s test for homogeneity of variance, t-test and correlation test. result: the statistical analysis shows there was a signifi cant difference between psychological response in control group after intervension with p = 0.000 for anxiety, and p = 0.000 for depression. for biological response, there is a signifi cant difference p = 0.007 for cortisol and p = 0.000 for tnf-α. however, there is no signifi cant difference in ifn-γ with p = 0.425. the correlation test result shows there was signifi cant correlations between anxiety and biological responses such as cortisol with r = 0.724 and p = 0.038; ifn-γ with r = 0.475 and p = 0.034; tnf-α with r = 0.592 and p = 0.006. furthermore, there was positive correlation between depression and biological responses such as cortisol with r = 0.705 and p = 0.033; ifn-γ with r = 0.454 and p = 0.044, tnf-α with r = 0.561 and p = 0.010. discussion: holistic home care could improve the psychological responses by decreasing anxiety and depression level and also could improve biological responses by decreasing cortisol, ifn-γ and tnf-α level in ischemic stroke patients. keywords: holistic home care, anxiety and depression, biological responses pendahuluan persentasi tertinggi stroke adalah stroke iskemik, yang terjadi akibat penyumbatan aliran darah. penyumbatan dapat terjadi karena timbunan lemak yang mengandung kolesterol (disebut plak) dalam pembuluh darah besar (arteri karotis) atau pembuluh darah sedang (arteri serebri) atau pembuluh darah kecil (sustrani l., et al., 2004). kasus stroke di amerika serikat 90% selamat (stroke survivor), mengalami kecacatan (de graba, 1998). stroke merupakan penyebab utama kecacatan jangka panjang. stroke juga menyebabkan biaya yang sangat tinggi baik secara medis maupun sosial. karena itu sangatlah penting memperhatikan stroke iskemik (infark) karena sebagian besar kasus stroke iskemik (infark) berhasil diselamatkan. kasus stroke jurnal ners vol. 7 no. 1 april 2012: 1–12 2 yang selamat, bisa mempunyai risiko terjadinya gangguan kognitif atau demensia. dilaporkan bahwa sepertiga dari stroke survivor menunjukkan demensia dalam waktu 3 bulan setelah stroke (prencipe, et al., 1997; ballard, et al., 2003; zhou, et al., 2005; serrano, et al., 2007). penelitian hospital based yang telah dilakukan di rs dr. sardjito yogyakarta dan rsud dr. sutomo surabaya menunjukkan bahwa angka kejadian gangguan kognitif pascastroke iskemik adalah hampir 60% (martini, dkk., 2000; martini, 2002). stroke menyebabkan kelumpuhan sebelah bagian tubuh (hemiplegia). kelumpuhan sebelah bagian tubuh kanan atau kiri, tergantung dari kerusakan otak. bila kerusakan terjadi pada bagian bawah otak besar (cerebrum), penderita sulit menggerakkan tangan dan kakinya. bila terjadi pada otak kecil (cerebellum), kemampuan untuk mengkoordinasikan gerakan tubuhnya akan berkurang. kondisi demikian membuat pasien stroke mengalami kesulitan melaksanakan kegiatan sehari-hari. pasien stroke mungkin kehilangan kemampuan indera merasakan (sensorik) yaitu rangsang sentuh atau jarak. cacat sensorik dapat mengganggu kemampuan pasien mengenal benda yang sedang dipegangnya. kehilangan kendali pada kandung kemih merupakan gejala yang biasanya muncul setelah stroke, dan seringkali menurunkan kemampuan saraf sensorik dan motorik. pasien stroke mungkin kehilangan kemampuan untuk merasakan kebutuhan kencing atau buang air besar. dampak psikologis penderita stroke adalah perubahan mental. setelah stroke memang dapat terjadi gangguan pada daya pikir, kesadaran, konsentrasi, kemampuan belajar, dan fungsi intelektual lainnya. semua hal tersebut dengan sendirinya memengaruhi kondisi psikologis penderita. marah, sedih, dan tidak berdaya seringkali menurunkan semangat hidupnya sehingga muncul dampak emosional berupa kecemasan yang lebih berbahaya. pada umumnya pasien stroke tidak mampu mandiri lagi, sebagian besar mengalami kesulitan mengendalikan emosi. penderita mudah merasa takut, gelisah, marah, dan sedih atas kekurangan fi sik dan mental yang mereka alami. keadaan tersebut berupa emosi yang kurang menyenangkan yang dialami oleh pasien stroke karena merasa khawatir berlebihan tentang kemungkinan hal buruk yang akan terjadi. hal ini didukung oleh teori spielberger, liebert, dan morris dalam (elliot, 1999); jeslid dalam hunsley (1985); gonzales, tayler, dan anton dalam guyton (1999). mereka telah mengadakan percobaan untuk mengukur kecemasan yang dialami individu selanjutnya kecemasan tersebut didefi nisikan sebagai konsep yang terdiri dari dua dimensi utama, yaitu kekhawatiran dan emosionalitas (hawari, 2008). gangguan emosional dan perubahan kepribadian tersebut bisa juga disebabkan oleh pengaruh kerusakan otak secara fi sik. penderitaan yang sangat umum pada pasien stroke adalah depresi. tanda depresi klinis antara lain: sulit tidur, kehilangan nafsu makan atau ingin makan terus, lesu, menarik diri dari pergaulan, mudah tersinggung, cepat letih, membenci diri sendiri, dan berfi kir untuk bunuh diri. depresi seperti ini dapat menghalangi penyembuhan/rehabilitasi, bahkan dapat mengarah kepada kematian akibat bunuh diri. depresi pascastroke, selayaknya ditangani seperti depresi lain yaitu dengan obat antidepresan dan konseling psikologis (sustrani, l., et al., 2004). metode penyembuhan stroke antara lain metode konvensional umumnya dengan pemberian obat yang merupakan penanganan yang paling lazim diberikan selama perawatan di rumah sakit maupun setelahnya. obat apa yang diberikan tergantung dari jenis stroke yang dialami apakah iskemik atau hemoragik. kelompok obat yang paling populer untuk menangani stroke adalah antitrombotik, trombolitik, neuroprotektif, antiansietas dan antidepresi. tindakan untuk metode operatif, ini bertujuan untuk memperbaiki pembuluh darah yang cacat sehingga diharapkan dapat meningkatkan peluang hidup pasien, dan pada gilirannya dapat menyelamatkan jiwa pasien. teknik fisioterapi dilakukan pada penderita stroke yang mengalami hambatan fisik. penanganan fisioterapi pascastroke adalah kebutuhan yang mutlak bagi pasien untuk dapat meningkatkan kemampuan gerak dan fungsinya. model home care di indonesia untuk penyembuhan pasien stroke sampai saat ini masih terfokus pada pemenuhan kebutuhan respons psikologis (kecemasan dan depresi) (luluk widarti) 3 fisik. home care yang dilaksanakan hanya berdasarkan standar pelayanan seperti di rumah sakit, dengan demikian model asuhan keperawatan home care yang diberikan pada pasien stroke iskemik belum optimal. keadaan tersebut akan bertambah parah jika tidak ada suatu upaya penanganan yang holistic dengan melibatkan beberapa pihak dan model asuhan yang lebih baik (departemen kesehatan, 2002). kelemahan metode penyembuhan stroke yang dilakukan di atas belum menyentuh aspek mental, padahal penderita stroke mengalami perubahan mental dan gangguan emosional. untuk itu ditawarkan hal baru yaitu model perawatan home care holistic dengan pendekatan bio-psiko-sosial-spiritual. asuhan biologis (fi sik) adalah pelayanan yang diberikan untuk memenuhi kebutuhan kesehatan fi sik. asuhan keperawatan psikis ditekankan pada strategi koping yang positif supaya pasien dapat memecahkan persoalan sendiri dengan menggunakan kekuatan yang ada pada dirinya. asuhan keperawatan sosial termasuk pelayanan untuk mempertahankan keseimbangan hubungan dan komunikasi dengan keluarga. asuhan keperawatan pada aspek spiritual ditekankan pada penerimaan pasien terhadap sakit yang dideritanya (ronaldson, 2000). pendekatan home care holistic tersebut diharapkan dapat memengaruhi keseimbangan mental pasien stroke. keseimbangan mental tersebut akan memengaruhi sekresi crf oleh pvn di hipotalamus. sekresi crf yang terkendali pula sekresi acth oleh hpa (hipotalamus, pituitary, adrenal), apabila model home care holistic dikategorikan mampu memperbaiki mekanisme koping pada pasien stroke iskemik melalui proses pembelajaran, maka dampak berikutnya adalah perbaikan respons psikologis berupa penurunan kecemasan dan depresi. kondisi respons psikologis berkorelasi dengan perbaikan respons biologis yang dicerminkan oleh penurunan kecemasan dan depresi pada pasien stroke iskemik. respons psikologis tersebut dapat mencegah terjadinya proses infl amasi lebih lanjut maupun perluasan infark serebri. belum ada hasil penelitian yang menguji manfaat home care holistic terhadap perbaikan respons psikologis pada pasien stroke iskemik. apabila peran home care holistic pada pasien stroke iskemik tidak diperjelas maka pemahaman tentang peran home care holistic tersebut tidak bisa dimanfaatkan bagi kepentingan penyembuhan pasien stroke iskemik maupun penanggulangan perkembangan infark serebri, sehingga kecacatan akibat stroke iskemik akan tetap besar. hal ini secara umum tentu akan memengaruhi kemampuan sumber daya manusia dan produktivitas. bahan dan metode penelitian ini menggunakan rancangan q u a s i e x p e r i m e n t a l d e n g a n b e n t u k nonrandomized pre-post test control group design (nasir, 2005). kelompok perlakuan diberi home care holistic (kp) dan kelompok kontrol diberi home care (kk). penelitian ini dimaksudkan untuk menguji adanya perbedaan tingkat kecemasan, tingkat depresi, kadar cortisol, ifn-γ dan tnf-α antara kelompok perlakuan dan kelompok kontrol. subjek diukur respons psikologis berupa kecemasan dan depresi, selanjutnya diukur respons biologis berupa kadar cortisol, ifn-γ dan tnf-α. pengukuran respons psikologis dilakukan sebelum dan setelah intervensi selama 3 bulan. pengukuran respons biologis dilakukan sebelum dan setelah intervensi. setelah itu hasil pengukuran kedua kelompok dibandingkan untuk menentukan perbedaan respons psikologis dan biologis pada pasien stroke iskemik yang mendapatkan model home care holistic dan model home care. populasi dan sampel yang dimaksud dalam penelitian ini adalah seluruh pasien stroke iskemik yang mengalami serangan pertama dan telah diijinkan pulang setelah rawat inap di ruang seruni a rsud dr. soetomo surabaya tahun 2009. jumlah populasi pasien yang dirawat mulai bulan januari sampai bulan desember adalah 683 pasien, rata-rata tiap bulan 54 pasien. kriteria inklusi dalam penelitian ini adalah pasien menyatakan bersedia menjadi responden penelitian dengan menandatangani surat persetujuan atau informed consent baik sebagai subjek penelitian maupun tindakan keperawatan, umur antara 35–65 tahun, tidak jurnal ners vol. 7 no. 1 april 2012: 1–12 4 menderita komplikasi penyakit lain, beragama islam dan bertempat tinggal di wilayah kota surabaya. variabel dalam penelitian ini yaitu home care adalah suatu pendekatan dalam asuhan keperawatan di rumah yang menekankan pada intervensi biologis (aspek fi sik), home care holistic adalah suatu pendekatan dalam asuhan keperawatan di rumah yang menekankan pada intervensi bio-psiko-sosial-spiritual, tingkat kecemasan dan tingkat depresi diukur dengan daftar pertanyaan yang sudah diuji validitas dan reabilitasnya dengan skala data interval. data kecemasan dan depresi dikumpulkan dengan menggunakan kuesioner dan wawancara, sedangkan respons bilogis menggunakan elisa quantitative technique. data di analisis dengan menggunakan analisis inferensial statistik levene’s test, t-test dan correlation. hasil terdapat dua karakteristik responden yang dijadikan objek penelitian yaitu karakteristik kelompok model home care holistic (kp) dan yang mendapatkan perawatan model home care (kk). data tentang karakteristik kelompok model home care holistic dan yang mendapatkan perawatan model home care (kk) mengenai umur, jenis kelamin, status perkawinan, tingkat pendidikan, pekerjaan, dan sosial ekonomi (tabel 1). pelaksanaan home care holistic selama 3 bulan (2× setiap minggu yaitu hari senin– kamis, dan hari selasa–jum’at) kepada kelompok perlakuan. selama intervensi kelompok perlakuan mendapatkan pemeriksaan tanda-tanda vital dan asuhan keperawatan berupa pelayanan untuk kesehatan fi sik, mengajak pasien untuk menerapkan koping yang efektif, mengajak pasien untuk berinteraksi sosial, dan mengajak pasien untuk beribadah. kegiatan dimulai jam 08.00, peneliti mengadakan kunjungan rumah ± 1,5 jam setiap pasien. kegiatan pertama adalah perkenalan atau silaturrahmi dengan pasien dan keluarga. to p i k y a n g d i b i c a r a k a n a d a l a h keluhan-keluhan yang dialami pasien. peneliti mendengarkan dan mencatat beberapa hal tabel 1. karakteristik pasien stroke iskemik yang mendapatkan perawatan model home care holistic no karakteristik jumlah persentase 1 umur 37–44 tahun 45–51 tahun 52–58 tahun 59–65 tahun 4 1 8 7 20,0 5,0 40,0 35,0 2 jenis kelamin laki-laki perempuan 11 9 55,0 45 3 status perkawinan kawin tidak kawin 20 0 100 0 4 tingkat pendidikan dasar menengah perguruan tinggi 10 6 4 50,0 30,0 20,0 5 pekerjaan tani/nelayan/swasta ibu rt pns/tni 12 4 4 60,0 20,0 20,0 6 sosial ekonomi umr – umr + 16 4 80,0 20,0 respons psikologis (kecemasan dan depresi) (luluk widarti) 5 yang penting serta memberikan justifi kasi dan penyuluhan. pertemuan selanjutnya dilaksanakan bersama dengan keluarga pasien yang digunakan untuk menggali sejauh mana peran keluarga dalam memberikan dukungan sosial kepada pasien. selanjutnya pasien menjalani program kontrol untuk mendapatkan perawatan dan terapi medik. hubungan respons psikologis (kecemasan dan depresi) dengan respons biologis (cortisol, ifn-γ dan tnf-α) pada pasien stroke iskemik yang mendapat model home care holistic pengujian korelasi dilakukan untuk mengetahui apakah respons psikologis yang terdiri dari kecemasan dan depresi berhubungan dengan respons biologis yang terdiri dari kadar cortisol, ifn-γ dan tnf-α. dua variabel dikatakan saling berkorelasi atau saling berhubungan jika nilai pearson correlation lebih dari nilai r tabel atau dapat pula dilihat dari nilai signifi kannya, jika nilai signifi kan kurang dari nilai α (0,05) maka dapat dikatakan dua variabel tersebut saling berkorelasi. uji korelasi respons kecemasan dengan kadar cortisol, ifn-γ, tnf-α uji pearson correlation menghasilkan nilai signifi kan sebesar 0,038 di mana nilai tersebut kurang dari 0,05, sehingga dapat disimpulkan bahwa kecemasan berhubungan atau berkorelasi dengan kadar cortisol. berdasarkan scatterplot, terlihat titik-titik yang ada mengikuti atau mendekati pola garis lurus, maka dapat dikatakan kecemasan berhubungan secara linear dengan kadar cortisol (tabel 2). uji pearson correlation menghasilkan nilai signifi kan sebesar 0,034 di mana nilai tersebut kurang dari 0,05, sehingga dapat disimpulkan bahwa kecemasan berhubungan atau berkorelasi dengan kadar ifn-γ. berdasarkan scatterplot, terlihat titik-titik yang ada mengikuti atau mendekati pola garis lurus, maka dapat dikatakan kecemasan berhubungan secara linear dengan kadar ifn-γ (tabel 3). tabel 4 menunjukkan bahwa uji pearson correlation menghasilkan nilai signifi kan sebesar 0,006 di mana nilai tersebut kurang dari 0,05, sehingga dapat disimpulkan bahwa kecemasan berhubungan atau berkorelasi dengan kadar tnf-α. berdasarkan scatterplot, terlihat titiktitik yang ada mengikuti atau mendekati pola garis lurus, maka dapat dikatakan kecemasan berhubungan secara linear dengan kadar tnf-α. tabel 2. uji korelasi kecemasan terhadap kadar cortisol variabel pearson correlation signifi kansi kecemasan kadar cortisol 0,467 0,038 tabel 3. uji korelasi kecemasan terhadap kadar ifn-γ variabel pearson correlation signifi kansi kecemasan kadar ifn-γ 0,475 0,034 tabel 4. uji korelasi kecemasan terhadap kadar tnf-α variabel pearson correlation signifi kansi kecemasan kadar tnf-α 0,592 0,006 tabel 5. uji korelasi depresi terhadap kadar cortisol variabel pearson correlation signifi kansi depresi kadar cortisol 0,478 0,033 uji korelasi respons depresi dengan kadar kortisol, ifn-γ, tnf-α uji pearson correlation menghasilkan nilai signifi kan sebesar 0,033 di mana nilai tersebut kurang dari 0,05, sehingga dapat disimpulkan bahwa depresi berhubungan atau berkorelasi dengan kadar cortisol. berdasarkan scatterplot, terlihat titik-titik yang ada mengikuti atau mendekati pola garis lurus, maka dapat dikatakan depresi berhubungan secara linear dengan kadar cortisol (tabel 5). jurnal ners vol. 7 no. 1 april 2012: 1–12 6 uji pearson correlation menghasilkan nilai signifi kan sebesar 0,044 di mana nilai tersebut kurang dari 0,05, sehingga dapat disimpulkan bahwa depresi berhubungan atau berkorelasi dengan kadar ifn-γ. berdasarkan scatterplot, terlihat titik-titik yang ada mengikuti atau mendekati pola garis lurus, maka dapat dikatakan depresi berhubungan secara linear dengan kadar ifn-γ. uji pearson correlation menghasilkan nilai signifi kan sebesar 0,010 di mana nilai tersebut kurang dari 0,05, sehingga dapat disimpulkan bahwa depresi berhubungan atau berkorelasi dengan kadar tnf-α. berdasarkan scatterplot, terlihat titik-titik yang ada mengikuti atau mendekati pola garis lurus, maka dapat dikatakan depresi berhubungan secara linear dengan kadar tnf-α (tabel 7). pembahasan penanganan terhadap stroke akhir ini berkembang dengan pesat mulai dari penelitian faktor risiko, patofi siologi, managemen dan obat-obatan serta penanganan pascastroke. perhatian terhadap penanganan stroke iskemik akut sampai saat ini kebanyakan diarahkan kepada neuron yang terganggu karena iskemia. masih jarang perhatian tertuju kepada lingkungan di jaringan serebral yang 6 .0 0 4 .0 0 2 .0 0 0 .0 0 -2 .0 0 -4 .0 0 -6 .0 0 0 .0 0-1 0 .0 0-2 0 .0 0-3 0 .0 0-4 0 .0 0-5 0 .0 0-6 0 .0 0 d e lta k e c e m a s a n l in e a r o b s e rv e d d e lta c o r tis o l gambar 1. uji korelasi kecemasan terhadap kadar cortisol 2 0 .0 0 1 0 .0 0 0 .0 0 -1 0 .0 0 -2 0 .0 0 -3 0 .0 0 -4 0 .0 0 0 .0 0-1 0 .0 0-2 0 .0 0-3 0 .0 0-4 0 .0 0-5 0 .0 0-6 0 .0 0 d e lta k e c e m a s a n l in e a r o b s e rv e d d e lta if n -g a m m a gambar 2. uji korelasi kecemasan terhadap kadar ifn-γ tabel 6. uji korelasi depresi terhadap kadar ifn-γ variabel pearson correlation signifi kansi depresi kadar ifn-γ 0,454 0,044 tabel 7. uji korelasi depresi terhadap kadar tnf-α variabel pearson correlation signifi kansi depresi kadar tnf-α 0,561 0,010 respons psikologis (kecemasan dan depresi) (luluk widarti) 7 2 .0 0 0 .0 0 -2 .0 0 -4 .0 0 -6 .0 0 0 .0 0-1 0 .0 0-2 0 .0 0-3 0 .0 0-4 0 .0 0-5 0 .0 0-6 0 .0 0 d e lta k e c e m a s a n l in e a r o b s e rv e d d e lta t n f -a lfa gambar 3. uji korelasi kecemasan terhadap kadar tnf-α 6 .0 0 4 .0 0 2 .0 0 0 .0 0 -2 .0 0 -4 .0 0 -6 .0 0 0 .0 0-1 0 .0 0-2 0 .0 0-3 0 .0 0-4 0 .0 0-5 0 .0 0-6 0 .0 0 d e lta d e p r e s i l in e a r o b s e rv e d d e lta c o r tis o l gambar 4. uji korelasi depresi terhadap kadar cortisol 2 0 .0 0 1 0 .0 0 0 .0 0 -1 0 .0 0 -2 0 .0 0 -3 0 .0 0 -4 0 .0 0 0 .0 0-1 0 .0 0-2 0 .0 0-3 0 .0 0-4 0 .0 0-5 0 .0 0-6 0 .0 0 d e lta d e p r e s i l in e a r o b s e rv e d d e lta if n -g a m m a gambar 5. uji korelasi depresi terhadap kadar ifn-γ 2 .0 0 0 .0 0 -2 .0 0 -4 .0 0 -6 .0 0 0 .0 0-1 0 .0 0-2 0 .0 0-3 0 .0 0-4 0 .0 0-5 0 .0 0-6 0 .0 0 d e lta d e p r e s i l in e a r o b s e rv e d d e lta t n f -a lfa gambar 6. uji korelasi depresi terhadap kadar tnf-α jurnal ners vol. 7 no. 1 april 2012: 1–12 8 mengalami iskemia, padahal pada saatnya juga akan memperberat neuron itu sendiri. beberapa tahun terakhir banyak perhatian ditujukan peran dari infl amasi setelah oklusi arterial dan reperfusi. pada stroke iskemik terjadi proses seluler dan molekuler yang mendasari transisi dari iskemia menjadi infl amasi, meliputi reaktivitas mikrovaskuler, aktivasi dan kemotaksis dari lekosit polimorfonuklear, perubahan biologi reseptor endotil, sintesis dan pelepasan sitokin, transmigrasi dan infasi dari lekosit ke jaringan otak, dan trombosis mikrovaskuler (fuerstein, 1997; yamasaki kogure, 1997). penelitian ini dilakukan untuk mengungkap peran home care holistic terhadap perubahan respons psikologis dan biologis pada pasien stroke iskemik. paradigma psikoneuroimunologi diterapkan pada penelitian ini. variabel yang diteliti adalah home care holistic. alasan pemilihan variabel tersebut karena model home care holistic adalah hal baru yang perlu diungkap perannya terhadap perbaikan respons psikologis dan biologis pada pasien stroke iskemik. variabel kecemasan dan depresi adalah respons psikologis yang sering dialami pasien stroke iskemik karena ketakutan, ketidakberdayaan dalam menghadapi hidup. variabel kortisol diteliti karena merupakan parameter biologis tingkat stres. variabel ifnγ dan tnf-α alasan pemilihan sitokin tersebut karena mampu memodulasi respons imun, mempunyai peran sitokin pro-infl amasi yang terkait dengan pasien stroke, sedangkan kaitan pro-infl amasi pada stroke dengan home care holistic belum pernah diteliti. penelitian ini kelompok perlakuan diberikan intervensi berupa pendekatan home care holistic dan kelompok kontrol diberikan intervensi berupa home care. idealnya pada kelompok kontrol tidak diberi intervensi, namun tidak etis pasien stroke tidak diberikan perawatan apapun, kemudian dimasukkan dalam sampel penelitian. home care holistic berupa pendekatan dalam asuhan keperawatan di rumah yang menekankan pada intervensi bio-psikososial-spiritual yang mempunyai peran terhadap perbaikan respons psikologis yang bisa berpengaruh terhadap respons biologis. selanjutnya respons biologis dapat memodulasi respons imun melalui sistem imun saraf otonom dan sistem endokrin pada pasien stroke iskemik (ader, 2001). melalui penelitian ini dapat dijelaskan bahwa model home care holistic dapat menurunkan respons psikologis (kecemasan, depresi) yang berdampak pada perbaikan imunitas. perbedaan kadar cortisol, ifn-γ dan tnf-α antara kelompok model home care holistic (kp) dan kelompok model home care (kk) saat pasien mengetahui bahwa menderita stroke iskemik disertai manifestasi kelumpuhan, wajah tidak simetris dan gangguan bicara, maka akan terjadi stres psikologi, sosial dan spiritual. rangsang stres berat yang dialami pasien stroke iskemik berjalan mengikuti jalur sistem sensorik menuju talamus, di talamus rangsang stres akan menuju ke korteks sensoris dan kemudian menuju ke amigdala. keadaan ini akan memengaruhi sistem imun. pengaruh respons stres pada fungsi sistem imun terjadi melalui peptida hipotalamus dan pituitary, yaitu crf (corticotropin relealising factor) dan acth (adrenocorticotropic hormone). crf merupakan subtansi utama yang menggambarkan sinyal stresor ke sistem imun, crf mengakibatkan aksis hpa menjadi aktif, berupa peningkatan acth yang akan merangsang korteks adrenalis untuk meningkatkan sekresi cortisol. pada kondisi stres kadar cortisol di darah tinggi karena semua likosit termasuk limfosit mempunyai reseptor untuk cortisol maka cortisol dapat memodulasi sistem imun (mccance, 1994; dunn, 1995; tache, 1999; otagiri, 2000) kadar cortisol yang tinggi merupakan imunosupresor (dunn, 1995). cortisol adalah hormon korteks adrenal yang digunakan sebagai indikator stres perifer (dunn, 1994). penelitian ini hasil uji beda kadar cortisol diketahui bahwa ada terdapat perbedaan yang bermakna antara kelompok yang mendapatkan home care holistic dengan home care dengan nilai signifikansi p = 0,007 (tabel 4.23). hal ini diduga pada pasien yang mendapatkan model home care holistic melalui pendekatan psikologis secara persuasif menimbulkan persepsi dan motivasi positif respons psikologis (kecemasan dan depresi) (luluk widarti) 9 tentang penyembuhan penyakit. bila proses koping yang diupayakan dengan pendekatan psikologis berhasil, maka kecemasan dan depresi menurun sehingga diikuti penurunan kadar cortisol. hal serupa juga didapatkan oleh rehatta (1999); dalono (2001); zainullah (2005); sholeh (2006). respons inflamatorik pada stroke iskemik merupakan suatu proses penting yang memengaruhi perjalanan stroke pada fase akut. unsur infl amasi berupa unsur seluler seperti neutrofi l dan unsur molekuler seperti sitokin. variabel sitokin yang diteliti pada penelitian ini adalah ifn-γ dan tnf-α. hasil penelitian pemeriksaan kadar ifn-γ diketahui bahwa ada penurunan rerata antara kelompok yang mendapatkan home care holistic dengan kelompok home care. hasil uji beda tidak menunjukkan perbedaan yang bermakna p = 0,425. hal ini diduga bahwa peran ifnγ terhadap kejadian stroke iskemik belum jelas (roit, 1993). sitokin ifnγ adalah sitokin yang berhubungan dengan infeksi virus dan mampu memodulasi respons imun. belum banyak penelitian yang menghubungkan dengan stroke (gangguan vaskuler). namun ifnγ mempunyai sifat saling menghambat dengan il-10, jadi perlu diteliti keterlibatan ifnγ pada stroke iskemik. hasil penelitian pemeriksaan kadar tnf-α diketahui bahwa ada perbedaan bermakna antara kelompok yang mendapatkan home care holistic dengan kelompok home care dengan nilai signifikansi p = 0,000. beberapa penelitian terdahulu yang terkait dengan tnf-α (suroto, 2001) mendapatkan bahwa tnf-α meningkat secara signifikan. hal ini diduga pada pasien stroke iskemik yang mengalami proses infl amasi pada jaringan otak yang mengalami iskemik pada fase akut akan mempertahankan respons inflamasi dengan jalan makrofag melepas il-1 dan meningkatkan produksi neutrofil dan monosit. tnf-α dan il-1 merupakan 2 sitokin yang berperanan penting pada respons infl amasi yang diproduksi makrofag. respons infl amasi akut dikontrol oleh sitokin antiinfl amasi (il-4, il10 dan tgfβ). kortikosteroid dikenal sebagai antiinfl amasi dan dapat mencegah produksi hampir semua mediator proinfl amasi, menurunkan mencegah aktivasi makrofag dan sintesis ifn-γ dan tnf-α. keadaan tersebut dapat menekan inflamasi dengan mencegah proliferasi dan migrasi sel. bila fase infl amasi sudah di netralisasi oleh molekul antiinfl amasi, penyembuhan jaringan dimulai dengan melibatkan berbagai sel seperti fi broblast dan makrofag, yang memproduksi kolagen yang diperlukan oleh jaringan. hubungan respons psikologis (kecemasan dan depresi) dengan respons biologis (cortisol, ifn-γ dan tnf-α) pada pasien stroke iskemik yang mendapat model home care holistic stres fi siologis maupun psikologis dapat menyebabkan perubahan biomolekuler di otak (nestler, 2000). hasil penelitian didapatkan korelasi antara respons psikologis (kecemasan dan depresi) dengan respons biologis (cortisol, ifn-γ dan tnf-α). uji korelasi yang dilakukan ialah korelasi antara kecemasan dengan cortisol diperoleh nilai signifi kansi, p = 0,038 dengan demikian terdapat hubungan bermakna (p < 0,05) antara kecemasan dengan cortisol. adapun kekuatan hubungan menunjukkan arah positif dengan koefisien korelasi r = 0,724 yang artinya korelasi kuat. uji korelasi antara kecemasan dengan ifn-γ diperoleh nilai signifikansi, p = 0,034 dengan demikian terdapat hubungan bermakna (p < 0,05) antara kecemasan dengan ifn-γ. adapun kekuatan hubungan menunjukkan arah positif dengan koefi sien korelasi r = 0,475 yang artinya korelasi sedang. uji korelasi antara kecemasan dengan tnf-α diperoleh nilai signifi kansi, p = 0,006 dengan demikian terdapat hubungan bermakna (p < 0,05) antara kecemasan dengan tnf-α. adapun kekuatan hubungan menunjukkan arah positif dengan koefi sien korelasi r = 0,592 yang artinya korelasi sedang. uji korelasi yang dilakukan ialah korelasi antara depresi dengan cortisol diperoleh nilai signifi kansi, p = 0,033 dengan demikian terdapat hubungan bermakna (p < 0,05) antara depresi dengan cortisol. adapun kekuatan hubungan menunjukkan arah positif dengan koefisien korelasi r = 0,705 yang artinya korelasi kuat. uji korelasi jurnal ners vol. 7 no. 1 april 2012: 1–12 10 antara kecemasan dengan ifn-γ diperoleh nilai signifi kansi, p = 0,044 dengan demikian terdapat hubungan bermakna (p < 0,05) antara depresi dengan ifn-γ. adapun kekuatan hubungan menunjukkan arah positif dengan koefisien korelasi r = 0,454 yang artinya korelasi sedang. uji korelasi antara depresi dengan tnf-α diperoleh nilai signifi kansi, p = 0,010 dengan demikian terdapat hubungan bermakna (p < 0,05) antara depresi dengan tnfα. adapun kekuatan hubungan menunjukkan arah positif dengan koefi sien korelasi r = 0,561 yang artinya korelasi sedang. terkait dengan stres psikologis maka neurologi menjadi aktif memproduksi dan mensekresi sitokin pro-infl amatorik (il-1β, ifnγ, tnf-α). sitokin pro-infl amatorik tersebut akan memengaruhi paraventriculer nucleus (pvn) di hipotalamus kemudian memproduksi molekuler signal berupa corticotropine releasing factors (crf). pasien yang mengalami (kecemasan dan depresi) ada hubungan dengan respons biologis. stres yang dialami pasien stroke iskemik berupa harapan yang terlalu berlebihan, tidak sabar dan tidak dapat mengambil hikmah dari sakitnya memperparah kondisi fi sik seseorang menurut ronaldson (2000). penelitian ini semua variabel psikologis (kecemasan dan depresi) menunjukan hubungan yang signifikan dengan penurunan kadar cortisol, ifn-γ, tnf-α. artinya pasien yang tabah dan sabar dalam menghadapi sakit yang dialami akan membuat ketenangan dan ketentraman hati, hal ini bisa dicerminkan dari penurunan kadar cortisol, ifn-γ, tnf-α. adapun penurunan kadar cortisol, ifn-γ, tnfα dapat mengindikasikan pasien stroke iskemik mengalami proses perbaikan karena proses infl amasi akut sudah terlewati. hal ini didukung penelitian ader dan cohen, 1975 menyimpulkan dari penelitiannya bahwa sistem imun bekerja melalui proses belajar yang diisyaratkan (learning by conditioning). hal ini merupakan landasan pemikiran baru yang menunjukkan terdapat hubungan erat antara repons psikologis dan biologis. hal serupa dikemukakan goleman (2002). hal ini juga selaras dengan konsep sehat menurut who, 1974 yaitu sehat adalah keadaan yang sempurna dari fisik, mental, sosial, tidak hanya bebas dari penyakit atau kelemahan. kesehatan fisik terwujud apabila seseorang tidak merasa sakit atau tidak adanya keluhan, kesehatan mental mencakup fi kiran yang sehat, emosional yang sehat dan spiritual yang sehat, sedangkan kesehatan sosial apabila seseorang mampu berinteraksi dengan orang lain sehingga pada akhirnya penderita bisa produktif dalam arti mempunyai kegiatan yang menghasilkan sesuatu yang menyokong secara finansial terhadap hidupnya sendiri dan keluarganya. kekurangan dan kelemahan dalam penelitian ini antara lain adalah pemeriksaan respons psikologis dan respons biologis tidak dilakukan time series melainkan pre dan post intervensi. selanjutnya variabel biologis pada pasien stroke hanya diukur dengan biomarker sakit saja tanpa diukur dengan biomarker sehat. variabel nonfisik pada pasien stroke hanya diukur dengan respons psikologis saja melainkan respons sosial dan spiritual belum diukur. simpulan dan saran simpulan m o d e l h o m e c a re h o l i s t i c y a n g menekankan pendekatan bio-psiko-sosialspiritual untuk membangun coping style yang positif, ternyata dapat memperbaiki respons psikologis berupa penurunan tingkat kecemasan dan depresi, serta dapat memperbaiki respons biologis yang dicerminkan oleh penurunan kadar kortisol, ifn-γ, dan tnf-α pada pasien stroke iskemik. respons biologis tersebut dapat mencegah terjadinya proses inflamasi lebih lanjut maupun perluasan infark serebri, sehingga kecacatan akibat stroke iskemik bisa dicegah dan penderita tetap produktif. saran tenaga medik khususnya ahli saraf, untuk penanganan pascastroke supaya tidak hanya rehabilitasi fi sik saja, walaupun sudah penuh kesibukan, sangat diharapkan agar bersenang hati berkenan memberikan pelayanan dalam aspek kesehatan mental, karena kesehatan mental berhubungan dengan kesehatan fi sik. hasil penelitian yang menguntungkan tersebut, respons psikologis (kecemasan dan depresi) (luluk widarti) 11 hendaknya dapat diimplementasikan, karena sampai saat ini tenaga kesehatan belum optimal melakukan pendekatan holistic dalam merawat pasien. perlu dilakukan penelitian lebih lanjut pengaruh model home care holistic terhadap variabel perubahan tanda gangguan neurologik, sosial, dan spiritual. hasil ini semakin memperjelas peran home care holistic sebagai model terapi bio-psiko-sosial-spiritual dalam pengobatan dan perawatan pasien stroke iskemik akut selain pendekatan farmakologik untuk mendukung proses penyembuhan pasien kepustakaan ader, r., felten, d.l., cohen, n., felten, s.y., dan carlson, s.l., 1991. central neural circuits involved in neuralimmune interactions. neurochemical links between the nervous and immune system. in. (ader, r., felten, d.l., cohen, n., eds). psychoneuroimmunology. san diego: academic press inc. pp. 3–25. buckley, m.b., 2003. lipids and stroke. br j diabetes vasc dis. pp. 170–6. de graba, t.j., 1998. the role of infl amation after acute stroke: utility of pursuing a n t i a d h e s i o n m o l e c u l e t h e r a p h y . neurology. pp. 62–8. departemen kesehatan republik indonesia. 2002. pedoman perawatan kesehatan di rumah. jakarta: direktorat keperawatan dan keteknisian dirjen yanmed. diwanto, m.a., 2009. tips mencegah stroke, hipertensi dan serangan jantung. yogyakarta: paradigma indonesia. dunn, a.j., 1995. interaction betwenn the nervous system and the immune system. implications for psycopharmacology. i n ( b l o o m f e , k u p l e r d j , e d s ) . p s y c o p h a r m a c o l o g y. t h e f o u r t h generation of progress. pp. 719–731. new york: raven press. fuerstein, g.z., wang, x., dan barone, f.c., 1997. infl amatory gene expression in cerebral approaches. canada: education program syllabus, american academy of neurology, 51st annual meeting. goleman, d., 2002. healing emotions ( p e n y e m b u h a n e m o s i ) . b a t a m : interaksara. guyton, a.c., 1999. textbook of medical physiology. philadelphia: wb saunders company. hawari, d., 2008. managemen stres, cemas dan depresi. jakarta: balai penerbit fkui jakarta. hinkle, j.l., dan guanci. 2007. acute ischemic stroke review. journal neuroscience nursing, 285–310. lauw, f.n., et al., 2000. pro-infl ammatory effects of il-10 during human endotoxemia. j immunol. pp. 2783–2789. martini, s., 2002. faktor risiko gangguan k o g n i t i f . b e r k a l a k e d o k t e r a n masyarakat, triwulan 4. otagiri, a., wakabayashi, i., dan shibasaki, t., 2000. selective corticotropinreleasing factor type 1 receptor antagonist blocks conditioned fearinduced release of noradrenalin in the hypothalamic paraventricular nucleus of rats. j. neroendokrinol. pp. 1022–1026. rehatta, n.m., 1999. pengaruh pendekatan p s i k o l o g i s p r a b e d a h t e r h a d a p toleransi nyeri dan respons ketahanan imunologik pascabedah. disertasi tidak dipublikasikan. universitas airlangga. roitt, i., brostoff, j., dan male, d., 1993. immunology. 3rd ed. st louis: mosby. roitt, i., brostoff, j., dan male, d., 1993. cytokines. in: immunology 3rd ed. mosby. ronaldson, s., 2000. spirituality. the hearth o f n u r s i n g . m e l b o u r n e : a u s m e d publication. sholeh, m., 2006. terapi salat tahajud menyembuhkan berbagai penyakit. jakarta: hikmah. suroto. 2001. peran sitokin il-1 beta, tnf alfa, il-8, il-4 dan tgf beta 1 pada stroke iskemik. disertasi tidak dipublikasikan. universitas airlangga. sustrani, l.a., alam, s., dan hadibroto, i., 2004. stroke. jakarta: pt gramedia pustaka umum. tache, y., martinez, v., million, m., dan rivier, j., 1999. corticotropin-releasing-factor and the brain-gut motor response to stress. can j gastroenterol, suppl. pp. 18a–25a. yamasaki, y., dan kogure, k., 1997. cytokines, growth factors, adhesive melecules jurnal ners vol. 7 no. 1 april 2012: 1–12 12 and inflamation after ischemia in (welch, kma., caplan, lr., reis, dj., siesjo, bk., weir, b., eds). primer on cerebrovascular disease. san diego: academic press. zainullah, a. 2005. perubahan respons psikoneuroimunologis pada pelaksana puasa ramadhan. disertasi tidak dipublikasikan. universitas airlangga. ners vol 5 no 1 april 2010_akreditasi 2013.indd 29 relaksasi afirmasi meningkatkan self efficacy pasien kanker nasofaring (relaxation affi rmation technique increases self effi cacy of patients with nasopharingeal cancer) ah. yusuf*, ira suarilah*, pandu rahmat* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257 e-mail: yusuf@fk.unair.ac.id abstract introduction: patient with nasopharynx cancer may experience emotional distres. emotional distres and anxiety may lead to decrease self-effi cacy. clients with a negative perception of the health or low self-effi cacy would become apathetic and disability in soluns problem as compensation of getting that disease. the purpose of this study was the relaxation affi rmations techniques in order to increase self-effi cacy patient with nasopharynx cancer. methode: this study used pra-experiment pre-post test design. population was taken from patient with nasopharynx cancer of ear nose and throat (ent) patient departement dr. soetomo hospital at surabaya. sample comprised of 19 respondents who selected based on inclusion criteria. independent variable was the relaxation affi rmations. dependent variable was self effi cacy of nasopharyngeal cancer patients. data were collected using the observation sheet. result: the results showed that there was a signifi cant infl uence of relaxation affi rmation in increased self-effi cacy patient with nasopharynx cancer, with p = 0.008. discussion: based on that results, it can be concluded that relaxation affi rmations help patients nasopharyngeal cancer in tht patient departement dr. soeotomo hospital at surabaya in improving self-effi cacy so that they would have ability to accept reality and belief in health pattern for optimalizing quality of life. relaxation affi rmations techniques including diaphragma breathing and affi rmation decrease sympatic nerve activity and increase positive fi rm belief in patient. keywords: relaxation affi rmations, self-effi cacy, nasopharyngeal cancer patients pendahuluan p a s i e n y a n g m e n g e t a h u i d i r i n y a mengidap kanker dapat menjadi stres dan merasa dia akan cepat mati (sukardja, 2000). hal ini dikarenakan kanker dapat menimbulkan gejolak psikis dan sosial bagi pasien karena kanker masih sangat mudah diasosiasikan dengan kematian, penderitaan, biaya mahal, pengobatan jangka panjang yang melelahkan dan akibat terapi yang tidak nyaman (deviana, 2009). kanker nasofaring sendiri merupakan kanker yang berasal dari sel epitel nasofaring yang berada di rongga belakang hidung dan di belakang langit-langit rongga mulut. letak kanker yang berdekatan dengan area kepala membuat penyebaran virus epstain barr mudah terjadi, virus ini dapat menyebar pada bagian mata, telinga, kelenjar leher, dan otak sehingga penderita kanker nasofaring sering kali mengalami emotional distres (djafar, 2009). perbedaan prognosis (angka bertahan hidup) pada pasien kanker nasofaring yaitu 76,9% untuk stadium i, 56% untuk stadium ii, 38,4% untuk stadium iii, dan hanya 16,4% untuk stadium iv (averdi, 2000). perkembangan penyakit kanker nasofaring pada umumnya relatif cepat sehingga angka harapan hidup relatif pendek kurang dari 5 tahun, kondisi seperti ini akan memengaruhi kondisi psikis seseorang, yang dapat berupa ansietas dan depresi (sudoyo, 2007). klien dengan persepsi yang negatif yang berasal dari diri sendiri, seperti kekhawatiran yang berlebihan, tekanan batin karena kehilangan sesuatu dalam dirinya menyebabkan pasien mengalami penurunan self efficacy. tingkat self efficacy yang rendah dan lingkungan yang tidak mendukung akan menjadi apatis, pasrah atau merasa tidak jurnal ners vol. 5 no. 1 april 2010: 29–37 30 mampu untuk mengatasi keadaan (alwisol, 2004). self efficacy merupakan keyakinan yang bisa memengaruhi seseorang dalam merasakan, berfikir, memotivasi dirinya dan beraksi yang dikembangkan dari teori belajar sosial oleh bandura pada tahun 1977. k e a d a a n e m o t i o n a l d i s t re s , j i k a tidak di atasi dapat berkembang menjadi gangguan psikologis (adjustment disorder) dan memperburuk kondisi fisik penderita kanker. kondisi psikologis merupakan penggerak hidup kita untuk berbuat menjadi lebih baik atau lebih buruk tergantung pada kemampuan dalam mengendalikan kondisi psikologis. gambaran reaksi psikologis pada pasien kanker nasofaring di ruang tht umumnya merasa khawatir, firasat buruk, sampai gelisah. relaksasi merupakan salah satu prosedur latihan yang bisa digunakan untuk menurunkan tingkat stres dan depresi (bernhardt, 2001). afirmasi merupakan self hypnoterapy dalam dunia lebih ringan, disebut juga sugesti diri, di mana seseorang dapat menghipnosis diri sendiri dari emosi negatif. afirmasi dapat memperkuat rasa percaya diri dan keyakinan pasien dalam mengatasi situasi dan menghasilkan sesuatu yang positif dengan cara pengulangan kalimat penegasan (afirmasi) sehingga tercipta kecenderungan seseorang untuk mengucapkan hal-hal positif yang dapat meningkatkan integritas diri dalam memaknai suatu kehidupan sehingga tercipta self efficacy yang baik (brealey, 2002). namun pengaruh relaksasi afirmasi terhadap self efficacy pasien kanker nasofaring belum dapat dijelaskan. kurang lebih 5 dari 100.000 penduduk indonesia adalah pengidap kanker nasofaring. kanker nasofaring masuk dalam kelompok lima besar tumor ganas yang sering dijumpai di indonesia, bersama-sama dengan kanker payudara, leher rahim, paru dan kulit. kanker nasofaring merupakan kanker yang paling banyak diderita masyarakat untuk jenis kanker telinga hidung tenggorokan (tht) kepala leher (kl) (tritia, 2009). berdasarkan data yang didapat peneliti di ruang tht rsud dr. soetomo surabaya pada tahun 2007 didapatkan kenaikan sebesar 63% pasien kanker nasofaring dari tahun 2006, yaitu sebanyak 194 pasien kanker nasofaring pada tahun 2006 dan 304 pasien pada tahun 2007. pada bulan oktober, november dan desember didapatkan rata-rata 25 pasien kanker nasofaring yang mayoritas menjalani kemoterapi. penderita kanker nasofaring lebih sering dijumpai pada pria dibanding pada wanita dengan rasio 2–3: 1. penyakit ini ditemukan terutama pada usia yang masih produktif yaitu usia 30–60 tahun, dengan usia terbanyak adalah 40–50 tahun (asroel, 2002). berdasarkan hasil penelitian didapatkan bahwa hampir 47% pasien kanker nasofaring di ruang rsud dr. soetomo surabaya tanggal 25 juni 2008 sampai 10 juli 2008 mempunyai self efficacy yang sedang di mana masih banyak didapatkan pasien yang belum bisa menerima akan keadaan dengan selalu menyesali kehidupan yang dialaminya sekarang, dan 6% mempunyai self efficacy yang kurang di mana pasien tidak memiliki keyakinan akan kesembuhannya, merasa untuk tidak bertanggung jawab akan kesembuhannya dengan bersikap acuh dan tidak kooperatif (eka, 2008). kondisi seperti ini jika dibiarkan akan menjadi gangguan psikologis yang lebih parah dan memengaruhi kondisi klinis pasien. pengobatan kanker merupakan stresor baru bagi penderita, kemoterapi sering menimbulkan masalah atau stres pada pasien. perasaan negatif dan informasi yang kurang dari petugas kesehatan tentang pelaksanaan, manfaat dan efek samping dari kemoterapi dapat menimbulkan kecemasan dan ketakutan pada pasien (gale, 2000). emosi yang kuat, takut, cemas, stres dapat mengurangi self efficacy (alwisol, 2004). jika tidak dapat mengatasi stresor yang dialaminya, maka pasien bisa mengalami emosi yang negatif dan menuju ke tahapan stres lebih lanjut. hal tersebut bisa memperburuk kondisi pasien, baik kondisi fisik maupun psikis. kondisi stres pasien kanker memiliki pengaruh yang signifikan pada perjalanan penyakit. stres memengaruhi motivasi untuk hidup yang membuat seluruh hormonal tubuh tidak mampu menjadi imun atau kekebalan bagi dirinya sendiri. pengaruh stres terhadap sistem imun adalah akibat pelepasan neuropeptida dan adanya reseptor neuropeptida pada limfosit b dan limfosit t. kecocokan neuropeptida dan reseptornya akan menyebabkan stres dan dapat relaksasi afi rmasi cpr (ah. yusuf) 31 memengaruhi kualitas sistem imun seseorang maka perlu meningkatkan self efficacy dan menciptakan lingkungan yang kondusif selama proses pengobatan. dengan kepercayaan kesehatan yang tinggi diharapkan klien dapat mengatasi stres dan akan berusaha mencapai kesembuhan yang diharapkan atau mengubah tingkah laku menjadi perilaku sehat sehingga stres berkurang dan self efficacy pasien akan lebih baik (alwisol, 2004). di ruang tht rsud dr. soetomo saat ini sudah dilakukan pendekatan spiritual dan pkmrs individu untuk meminimalkan reaksi psikologis pasien kanker nasofaring. pengurangan emosi negatif dan relaksasi dapat membantu seseorang untuk menurunkan stres dan depresi (bernhardt, 2001). penetralisiran emosi negatif melalui pemberian nafas ditambah dengan pemberian kalimat afirmasi yang ditanamkan dipikiran alam bawah sadar pasien dapat membentuk persepsi dan koping yang positif sehingga akan memengaruhi sistem lymbik untuk meningkatkan respon emosi yang positif, meningkatkan pertahanan diri, serta perasaan relaks (andika, 2007). relaksasi afirmasi merupakan teknik gabungan antara relaksasi dan afirmasi yang dapat menurunkan emosi negatif dengan menanamkan kalimat afirmasi ke dalam pikiran alam bawah sadar seseorang disaat merasa rileks setelah diberikan relaksasi yang prosedurnya mudah untuk dilakukan, serta tidak membutuhkan biaya, waktu, dan tenaga yang begitu besar sehingga dengan latar belakang demikian peneliti mencoba menerapkan relaksasi afirmasi sebagai satu upaya untuk meningkatkan self efficacy pasien kanker nasofaring di ruang tht rsud dr. soetomo surabaya bahan dan metode penelitian yang akan dilaksanakan merupakan penelitian pra eksperimental onegroup pre-post test design. populasi dalam penelitian ini adalah pasien kanker nasofaring di ruang tht rsud dr. soetomo surabaya pada tanggal 4–14 januari 2009 berjumlah 25 pasien dengan stadium lanjut. teknik sampling yang digunakan dalam penelitian ini adalah purposive sampling dengan penentuan kriteria sampel yang memenuhi kriteria inklusi dan eksklusi. kriteria inklusi yang dimaksud adalah: pasien kanker nasofaring dengan usia minimal 20 tahun, pasien kanker nasofaring stadium iii dan iv yang kooperatif, pasien kanker nasofaring yang menjalani kemoterapi. kriteria eksklusi yang dimaksud adalah pasien kanker nasofaring yang pulang paksa. sampelyang didapat sebanyak 19 orang. variabel bebas dalam penelitian ini adalah relaksasi afirmasi, sedangkan variabel tergantung yang digunakan yaitu self efficacy pada pasien kanker nasofaring. teknik relaksasi afirmasi merupakan teknik gabungan antara dari teknik nafas dalam dan afirmasi yang berbasis pada teori respon relaksasi benson (benson, 1975) dan teori self-affirmation steele yaitu penggunaan nafas dalam dan pengulangan kalimat positif sederhana yaitu kalimat yang dapat meningkatkan keyakinan diri dan menghindari kata “tidak” yang terangkai dalam 6 langkah yang dilakukan secara terprogram dan teratur yang bertujuan untuk meningkatkan integritas diri dan memberikan kondisi santai serta perasaan rileks (tabel 1). pelaksanaan relaksasi afirmasi dilakukan sehari sekali selama 3 hari pada masing-masing pasien. waktu pelaksanaan pada sore hari antara jam 5–7 sore dan dalam satu sesi dilakukan antara 10–15 menit. pelaksanaan dilakukan di ruang kelas 1 atau kelas 2, atau ruangan yang memungkinkan yang tidak terlalu bising. pengumpulan data pada penelitian ini menggunakan kuisioner yang didapatkan peneliti dari konsep yang sudah ada dengan sedikit modifikasi untuk menyesuaikan dengan keadaan lingkungan responden. kuesioner self efficacy dimodifikasi dari vanderbilt mental health self efficacy questionnaire yang terdiri dari 25 item pernyataan skala likert tentang efficacy expectation, yaitu persepsi diri sendiri mengenai seberapa bagus diri dapat berfungsi dalam situasi tertentu dan outcome expectations, yaitu perkiraan atau estimasi diri bahwa tingkah laku yang dilakukan diri itu akan mencapai hasil tertentu dan motivasi untuk berpartisipasi terhadap proses mencapai kesembuhan. semua item pernyataan adalah favorable dengan pertimbangan pernyataan unfavorable dapat memengaruhi kondisi jurnal ners vol. 5 no. 1 april 2010: 29–37 32 psikologis individu dan dapat meningkatkan stres. kuesioner self efficacy adalah kuesioner tertutup dan akan diisi oleh penderita kanker nasofaring. kuesioner tertutup adalah kuesioner yang disajikan dalam bentuk sedemikian rupa sehingga responden tinggal memberikan tanda centang (√) pada kolom yang sesuai (arikunto, 2007). skala likert yang dipakai yaitu sangat setuju (ss) bernilai 5, setuju (s) bernilai 4, tidak setuju (ts) bernilai 2 dan sangat tidak setuju (sts) bernilai 1. peneliti sengaja menghilangkan item yang ada di tengah, yaitu ragu-ragu karena responden cenderung memilih alternatif yang ada di tengah (karena dirasa aman dan paling gampang karena hampir tidak berpikir) (arikunto, 2007). nilai tertinggi yang didapat = 125, nilai terendah yang didapat = 25, dikategorikan dalam persentase (arikunto, 2003): tinggi = 76–100%, sedang = 56–75%, rendah = <56%. data yang terkumpul dan memenuhi syarat dikelompokkan dan ditabulasikan sesuai dengan sub variabel. datadata tersebut selanjutnya diolah dan dianalisis menggunakan uji statistik wilcoxon signed ranked test program windows spss dengan menggunakan derajat kemaknaan α < 0,05. dari analisis tersebut dilakukan pembahasan secara deskriptif dan analitik sehingga diperoleh suatu gambaran dan pengertian yang lengkap tentang hasil penelitian. hasil penelitian distribusi responden berdasarkan data demografi, sebagian besar responden berusia 51–60 tahun (37%), usia 31–40 tahun sebanyak 27%, dan berusia 41–50 tahun (26%). berdasarkan jenis kelamin yaitu sebagian besar responden adalah berjenis kelamin laki-laki (74%). seluruh responden sudah menikah dengan tingkat pendidikan sebanyak 37% tamat sd, 16% tamat sltp, dan responden yang tidak pernah mendapatkan pendidikan formal sebanyak 31%. berdasarkan pekerjaan yaitu sebagian responden bekerja sebagai petani (53%), dan wiraswasta (26%), serta sebanyak 10% responden tidak bekerja. seluruh responden sudah mendapatkan informasi dari petugas kesehatan. mayoritas tidak ada keluarga responden yang menderita kanker (89%). sebanyak 15 responden (79%) menyatakan suka merokok dan 14 responden tabel 1. langkah-langkah relaksasi afi rmasi no. langkah-langkah 1. anjurkan klien duduk dengan bahu rileks dan punggung tegak, namun tetap merasa nyaman 2. anjurkan klien untuk bernafas melalui hidung di sepanjang latihan dan menggunakan pernafasan perut. 3. anjurkan klien untuk berfokus pada pernafasannya. tarik nafas dengan lambat dan mendalam dalam hitungan empat hitungan (detik). lalu hembuskan secara perlahan dalam delapan detik. ulangi sebanyak dua atau tiga kali, lalu tarik beberapa kali pernafasan yang normal, lalu ulangi pernafasan yang dilakukan secara perlahan. 4. lakukan pernafasan secara perlahan dan mendalam dalam empat hitungan (detik), tahan selama empat detik tanpa ketegangan, lalu hembuskan nafas dalam empat hitungan. ulangi beberapa kali. 5. tutup mata apabila mungkin, lalu tarik nafas dua atau tiga kali. dalam setiap hembusan nafas, anjurkan klien untuk merasakan bahwa ia sedang melepaskan ketegangan yang ada pada dirinya serta merasakan bahwa dengan setiap hembusan nafas dia menjadi lebih segar dan lebih berenergi. 6. anjurkan klien untuk fokus pada bagian di antara pusar dan tulang dada (solar plesus) dan menyadari pernafasan yang mengalir keluar dan masuk. sambil merasakan gerakan naik-turun perut, anjurkan klien untuk mengucapkan kalimat afi rmasi yang ditentukan pasien sendiri, dengan cara kita menanyakan pasien apa yang sedang dirasakan dan ingin dilakukan serta harapan pasien kedepan misal: “semuanya baik-baik saja, saya merasa tenang” atau “saya yakin bisa menjalani cobaan ini”, “saya percaya tuhan masih menyayangi saya, saya ikhlas dan pasrah”. relaksasi afi rmasi cpr (ah. yusuf) 33 (74%) sering makan makanan instan dan penyedap rasa, makan ikan asin didapatkan pada 12 responden (63%). berdasarkan kemoterapi yang dijalankan yaitu paling banyak responden menjalani kemoterapi yang ke-ii (42%) dan kemoterapi yang ke-iii (26%), sisanya masih menjalani kemoterapi ke-i, iv, dan v. penderita stadium iv yaitu sebanyak 16 orang (84%). hasil penelitian menunjukkan sebelum diberikan perlakuan relaksasi afirmasi 7 responden (37%) mengalami self efficacy sedang, 58% baik, dan 5% kurang. setelah diberikan relaksasi afirmasi 17 responden (89%) pasien kanker nasofaring memiliki self efficacy yang tinggi dan 2 responden (11%) masih mengalami self efficacy yang sedang. berdasarkan uji statistik wilcoxon signed rank test ditemukan adanya perubahan tingkat self efficacy sebelum dan setelah dilakukan intervensi relaksasi afirmasi dengan nilai p=0,008 (tabel 2). pembahasan berdasarkan hasil penelitian diketahui bahwa dari 19 responden, pasien yang memiliki self efficacy tingkat tinggi sebanyak 11 responden (58%), 7 responden sedang (37%), dan kurang sebanyak 1 responden (5%). dari 11 responden yang mempunyai self efficacy tinggi 7 responden (64%) memiliki outcome expectation yang lebih tinggi dan 2 responden (18%) memiliki efficacy expectation yang lebih tinggi, dan 2 responden (18%) memiliki efficacy expectation dan outcome expectation yang berimbang. efficacy expectation yang tinggi yaitu percaya bahwa dirinya dapat memperoleh kesembuhan dengan usaha yang sungguh-sungguh diyakini dapat berhasil, dan outcome expectation tinggi yaitu responden termotivasi, turut berperan serta dalam proses pengobatan. responden merasa bertanggung jawab dalam proses pengobatan dan mengerti bagaimana usaha yang harus dilakukan untuk membantu mendapatkan kesembuhan. diketahui bahwa dari 7 responden yang mempunyai self efficacy sedang mempunyai outcome expectation yang rendah sebanyak 3 responden (43%), tidak berpartisipasi langsung pada perencanaan pengobatan, mereka mempercayakan rencana pengobatan kepada keluarga atau petugas kesehatan sendiri. responden pasif tidak tahu mengenai rencana pengobatan dan kurang merasa bertanggung jawab atas kesembuhannya. sebagian responden juga tidak mengatakan keluhan tentang permasalahan dalam kesehatan seperti nyeri kepala, berdenging di telinga dan mual baik kepada petugas kesehatan maupun kepada keluarga. permasalahan tersebut di atasi sendiri dengan membiarkannya begitu saja dengan beristirahat. kepercayaan seseorang akan self efficacy dapat dipengaruhi oleh empat sumber yang termasuk pengalaman pribadi, bertemu seseorang yang mengalami kejadian yang sama dengan dirinya yang berhasil sukses, pengaruh sosial oleh seseorang yang sukses dalam keadaan yang sama dan keadaan emosi seseorang (alwisol, 2004). persepsi self efficacy dapat dilihat dari persepsi diri sendiri mengenai seberapa bagus diri dapat berfungsi dalam situasi tertentu yang disebut efficacy expectation dan perkiraan diri bahwa usaha yang dilakukan akan mencapai hasil dan partisipasi dalam usaha yang dilakukan atau outcome expectation (godwin, 2004). self efficacy juga dipengaruhi oleh gender. pada umumnya dilaporkan bahwa laki-laki cenderung lebih percaya diri daripada perempuan (meece, 1991 dalam schunk, 1999). laki-laki dan perempuan juga mempunyai kecenderungan perbedaan sikap ketika mempersepsi self efficacy. perempuan lebih rendah dalam mempresepsi self efficacy mereka daripada laki-laki (schunk, 1999). self efficacy dipengaruhi oleh usia. tabel 2. tingkat self effi cacy pasien kanker nasofaring sebelum dan setelah relaksasi afi rmasi tingkat self effi cacy pre post n n baik 11 17 sedang 7 2 kurang 1 0 total 19 19 hasil uji statistik wilcoxon signed rank test p = 0,008 keterangan: p = signifi kansi n = jumlah jurnal ners vol. 5 no. 1 april 2010: 29–37 34 f a k t o r k e m a t a n g a n u s i a s a n g a t memengaruhi proses berpikir seseorang (huclock, 1998). persepsi kognitif in-efficacy disertai rendahnya tingkat intelektual individu akan membuat seseorang lebih rentan terhadap stres dan depresi. self efficacy akan meningkat ketika mengamati keberhasilan orang lain, sebaliknya self efficacy akan menurun jika mengamati orang yang gagal. sebagian responden adalah laki-laki sehingga mereka lebih baik dalam mempersepsi self efficacy mereka. ini tergambar bahwa dari 11 orang yang mempunyai self efficacy tinggi, 8 di antaranya adalah laki-laki dan 3 orang lainnya adalah perempuan. sebanyak 26% responden berusia antara 41–50 tahun. semakin cukup umur, tingkat pengetahuan dan kematangan seseorang akan lebih dalam berpikir dan bekerja, semakin banyak pula pengalaman hidup yang didapat sehingga akan berpengaruh terhadap self efficacy individu. responden yang mempunyai self efficacy kurang berusia >60 tahun yang menderita stadium iv, menjalani kemoterapi ke-1 dan menderita kanker nasofaring selama 6 bulan, hal ini dipengaruhi karena belum adanya pengalaman pribadi dan keadaan emosi yang labil karena kemoterapi merupakan hal yang baru bagi pasien. kurangnya komunikasi dan interaksi dengan model sosial membuat self efficacy individu menjadi kurang. keadaan fisik responden juga memengaruhi persepsi self efficacy, responden yang sudah menjalani kemoterapi tahap akhir tetapi kondisi fisik mereka menurun membuat self efficacy kurang. sebagian responden tidak mengerti dan binggung pada rencana pengobatan, tahapan kemoterapi serta pengobatan lanjutan setelah kemoterapi, dan prosedur dalam pengobatan masih dirasakan membingungkan bagi responden sehingga membuat kurangnya self efficacy individu. berdasarkan hasil penelitian setelah dilakukan relaksasi afirmasi terjadi perubahan tingkat self efficacy pasien kanker nasofaring. sebanyak 37% pasien kanker nasofaring yang memiliki self efficacy sedang setelah dilakukan relaksasi afirmasi berubah menjadi 11%, dan 5% pasien kanker nasofaring yang memiliki self efficacy yang kurang setelah dilakukan relaksasi afirmasi berubah menjadi 0%. secara keseluruhan pemberian relaksasi afirmasi memberikan reaksi positif terhadap peningkatan self efficacy pasien kanker nasofaring. berdasarkan data 17 responden pasien kanker nasofaring yang memiliki self efficacy tinggi sudah mengalami peningkatan efficacy expectation sebanyak 11 responden (65%) yang ditunjukkan dengan 8 responden (73%) menyatakan setuju dan 27% menyatakan setuju sekali bahwa mereka harus memiliki kepercayaan dan kemampuan untuk turut berperan serta dalam mencapai kesembuhan. peningkatan efficacy expectation pasien kanker nasofaring juga tergambar pula bahwa bukan merupakan hal yang sia-sia untuk percaya bahwa bisa mendapatkan kesembuhannya kembali, 74% pasien setuju akan hal itu. setelah dilakukan relaksasi afirmasi juga terjadi peningkatan outcome expectation pada pasien kanker nasofaring sebesar 94%, mereka percaya akan hasil yang diharapkan dengan selalu mengikuti program terapi secara aktif dan ingin selalu mengetahui perkembangan kesehatannya. sebagian besar responden setelah dilakukan relaksasi mempunyai self efficacy yang tinggi, sudah menerima dengan pasrah menderita penyakit kanker nasofaring meskipun sudah menderita sakit selama 12 bulan ataupun yang baru 5 bulan, tapi responden tetap yakin dapat memperoleh kembali kesehatannya sehingga tetap mencari pengobatan yang mereka yakini dapat membantu mendapatkan kesembuhan. responden sudah mempercayakan pengobatan kepada pihak rsud dr. soetomo. responden yang merasa harus mengetahui keadaan mereka sudah mengerti bagaimana caranya mendapatkan informasi tentang penyakit dan pengobatan terbaik kanker nasofaring. seseorang yang memiliki pandangan positif terhadap diri sendiri memiliki tingkat distres dan efek fisik terhadap stres yang lebih rendah dan kesejahteraan mental yang lebih tinggi (bonnano, recknicke dan deckel, 2005 dikutip oleh creswell, 2007). peningkatan relaksasi afi rmasi cpr (ah. yusuf) 35 integritas diri juga membantu seseorang untuk menghadapi ancaman dan peristiwa hidup yang menyakitkan dengan lebih adaptif (sherman dan cohen, 2006). p a s i e n k a n k e r n a s o f a r i n g y a n g mendapatkan intervensi relaksasi afirmasi memiliki pemahaman dan kemampuan yang relatif baik karena didukung oleh umur pasien yang sebagian besar berada pada rentang 31–60 tahun dan juga terdapat responden yang berpendidikan setingkat sd dan smp sehingga responden masih dapat menerima stimulus dan instruksi yang diberikan dengan baik. sebanyak 17 responden memiliki self efficacy yang tinggi dan masih ada 2 responden memiliki self efficacy yang sedang, hal ini dikarenakan salah satu responden sudah berusia >60 tahun dalam pemahaman dan kemampuan intervensi kurang baik. hasil uji wilcoxon signed rank test menunjukkan nilai kemaknaan p=0,008 (α ≤ 0,05) dengan demikian hipotesis diterima, yang berarti terjadi peningkatan self efficacy yang signifikan sebelum dan sesudah dilakukan relaksasi afirmasi. relaksasi afirmasi merupakan teknik gabungan antara penggunaan nafas dan pengulangan kalimat positif sederhana yang terangkai dalam 6 langkah yang dilakukan secara terprogram dan teratur yang bertujuan untuk memberikan kondisi santai dan perasaan rileks. melakukan relaksasi afirmasi seperti ini dapat memberikan perasaan rileks dan melalui afirmasi dapat memperkuat rasa percaya diri dalam mengatasi situasi dan menghasilkan sesuatu positif dengan cara pengulangan kalimat penegasan sehingga tercipta kecenderungan seseorang untuk mengucapkan hal-hal positif yang dapat meningkatkan integritas diri sehingga tercipta self efficacy yang baik (brealey, 2002). pada waktu tarik nafas panjang otototot dinding (musculus rectus abdominalis transversus, musculus abdominalis internal dan eksternal oblique) menekan iga bagian bawah ke arah belakang serta mendorong sekat diafragma ke atas dapat berakibat meningkatkan tekanan abdominal, sehingga dapat merangsang aliran darah (vaskularisasi) menjadi meningkat ke seluruh tubuh jaringan tubuh terutama organ-organ vital seperti otak, jantung (sudarsono, 1999; nurhidayah, 2005). ketika inspirasi panjang dilakukan, hal itu akan menstimulasi secara perlahan-lahan reseptor regang paru karena inflasi paru. kemudian rangsang atau sinyal dikirimkan ke medulla yang memberikan informasi tentang peningkatan aliran darah. kemudian informasi diteruskan ke batang otak, efeknya saraf parasimpatis mengalami peningkatan aktivitas dan saraf simpatis mengalami penurunan aktivitas begitu pada kemoreseptor. selanjutnya respon akut peningkatan tekanan darah dan inflasi paru ini akan menurunkan frekuensi denyut jantung dan terjadi vasodilatasi pada sejumlah pembuluh darah (rice, 2006). afirmasi merupakan pernyataan yang kuat dan positif yang sangat berpengaruh untuk memperkuat rasa percaya diri. melalui pengulangan dari beberapa kalimat penegasan (afirmasi) tertentu, maka alam bawah sadar akan dapat menerima pesan yang terkandung dalam kalimat afirmasi tersebut, dan kecenderungan untuk mengucapkan hal-hal positif mulai ditukar dengan gambar-gambar dan pemikiran yang lebih positif (brealey, 2002). seseorang dengan gambaran diri yang positif (harga diri yang tinggi dan keyakinan terhadap diri sendri yang tinggi) memiliki respon biologis terhadap stres dan tingkat distres yang rendah dan kesehatan mental yang lebih baik (taylor, 1997). perasaan ikhlas dan pasrah, kondisi lingkungan yang tenang, serta posisi yang nyaman dalam melakukan relaksasi afirmasi dapat meningkatkan keyakinan positif terhadap diri, meningkatkan integritas diri, membentuk koping dan respon emosi yang positif, meningkatkan pertahanan diri dan perasaan tenang, serta menurunkan aktivitas saraf simpatis sehingga menurunkan sekresi hormon epinefrin-norepinefrin-ketekolamin, meningkatkan vasodilatasi pembuluh darah, meningkatkan vaskularisasi yang pada akhirnya dapat menurunkan rangsangan emosional dan dapat meningkatkan self efficacy. pasien kanker nasofaring yang terlibat dalam penelitian ini sebagian besar mempunyai penurunan akan kemampuan diri dalam menghadapi penyakitnya, mereka masih jurnal ners vol. 5 no. 1 april 2010: 29–37 36 belum sepenuhnya yakin akan program terapi yang dijalani merasa sia-sia dan tidak merasa bertanggung jawab untuk perlu mengetahui perkembangan kesehatan dirinya sendiri sehingga pasien kurang dalam berperan aktif terhadap pengobatan, dengan keterlibatan mereka dalam relaksasi afirmasi membuat mereka mendapatkan peningkatan gaya berfikir yang positif dengan selalu menanamkan pada diri sendiri bahwa mereka harus menjalani hidup dengan semangat, selalu berusaha untuk memperoleh yang terbaik dan menerima dengan ikhlas cobaan yang dialami. relaksasi afirmasi juga dapat meningkatan koping pasien yang lebih adaptif yaitu dengan selalu mengutarakan permasalahan yang berhubungan dengan kesehatannya kepada tenaga kesehatan sehingga mereka bisa mendapatkan pengobatan yang tepat. relaksasi juga dapat memberikan perasaan tenang dan rasa tentram yang mereka butuhkan sehingga dalam menjalani kehidupan mereka lebih sabar dan pasrah menghadapi cobaan tanpa menghilangkan kemampuan untuk tetap berusaha akan kesehatannya. p e l a k s a n a a n r e l a k s a s i a f i r m a s i m e m b u t u h k a n p e r a s a a n y a n g t e n a n g dan nyaman sehingga dibutuhkan tingkat spiritualitas akan kepercayaan terhadap tuhan yang baik. penggunaan kalimat afirmasi “semuanya baik-baik saja, saya merasa tenang” atau “saya yakin bisa menjalani cobaan ini”, “saya percaya tuhan masih menyayangi saya, saya ikhlas dan pasrah” yang dilakukan oleh peneliti masih bisa ditingkatkan dengan penambahan do’a sesuai keyakinan pasien sehingga fase penerimaan akan kalimat afirmasi dalam alam bawah sadar bisa lebih optimal. simpulan dan saran simpulan relaksasi afirmasi membantu pasien kanker nasofaring di ruang tht rsud dr. soeotomo surabaya dalam meningkatkan self efficacy melalui pengulangan dari beberapa kalimat penegasan (afirmasi) tertentu, maka alam bawah sadar akan dapat menerima pesan yang terkandung dalam kalimat afirmasi tersebut dan kecenderungan untuk mengucapkan hal-hal positif mulai ditukar dengan gambar-gambar dan pemikiran yang lebih positif sehingga pasien kanker nasofaring mengalami peningkatan kemampuan untuk menerima kenyataan dengan ikhlas dan pasrah dan terjadi peningkatan perasaan tenang. saran bagi profesi keperawatan sebaiknya menerapkan latihan relaksasi afirmasi kepada pasien kanker nasofaring yang mengalami penurunan self efficacy karena melalui latihan ini memungkinkan pasien kanker nasofaring untuk memiliki koping yang positif dan kepercayaan akan kemampuan mereka dalam mencapai kesembuhan sehingga dalam tindakan keperawatan mereka juga dapat bertindak kooperatif. bagi institusi rumah sakit sebaiknya menyediakan ruangan khusus untuk melakukan relaksasi afirmasi karena proses pelaksanaan relaksasi membutuhkan suasana yang tenang dan nyaman. selain itu dibutuhkan sop agar perawat memiliki standart dalam melaksanakan relaksasi afirmasi yang bermanfaat untuk meningkatkan self efficacy pasien. kepada pembaca khususnya dan masyarakat pada umumnya diharapkan ikut memperhatikan penurunan self efficacy yang terjadi pada pasien kanker nasofaring dan usahausaha untuk meningkatkannya melalui relaksasi afirmasi atau kegiatan lainnya. perlu diadakan penelitian lebih lanjut mengenai pengaruh relaksasi afirmasi dan terapi doa terhadap self efficacy pasien. daftar pustaka alwisol, 2004. psikologi kepribadian edisi revisi. malang: penerbit universitas muhammadiyah malang. andika, r.n., 2007. pengaruh dukungan sosial dari teman dekat terhadap penurunan depresi pada lansia di upstw bangkalan. skripsi tidak dipublikasikan. surabaya: universitas airlangga. arikunto, suharsimi, 2007. prosedur penelitian suatu pendekatan praktek. jakarta: rinneka cipta. asroel, harry a., 2002. penatalaksaan radioterapi pada karsinoma nasofaring. (online), (http://library.usu.ac.id., relaksasi afi rmasi cpr (ah. yusuf) 37 diakses tanggal 3 oktober 2009, jam 21.00 wib) benson, h., 1975. the relaxation response. n e w yo r k : wi l l i a m m o r r o w a n d company, inc. bernhardt, s.i., 2001. combating, depression: exercise, relaxation, cleansing, and nutrition. (online), (http://www.havea-heart.com/self-help-viii.html., diakses tanggal 10 oktober 2009, jam 21.00 wib) brealey, e., 2002. seri 10 menit menghilangkan stres. batam: karisma publishing group. creswell, j.d., 2007. does self-afi rmattion, cognitive, processing or discovery of meaning explain cancer-related health benefi t of expressive writing. pspb. 33 (2), februari 2007, 238–250, (online), (http://creswel.ucla.edu., diakses tanggal 22 oktober 2009, jam 21.00 wib) deviana, yuniko, 2009. kebersamaan sebagai terapi psikososial bagi penderita kanker. (online), (http://klubkanker. multiply.com/journal., diakses tanggal 22 oktober 2009, jam 19.00 wib) djafar, rayat, 2009. ikan asin picu kanker nasofaring. (online), (http://rayatdjafar. com http://infodunia-4u.blogspot. com/2009/08/ikan-asin-picu-kanker nasofaring.html., diakses tanggal 21 oktober 2009, jam 19.00 wib) eka, n.p., 2008. hubungan self efficacy dengan respon emosional pasien kanker nasofaring stadium lanjut. skripsi tidak dipublikasikan. surabaya: universitas airlangga. godwin, jennifer, 2004. vanderbilt mental health self efficacy questionnaire, (online), (http://www.fasttrackproject. org/sanford.duke.edu/centers/child/ fasttrack/techrept/v/vmh/vmh12tech. pdf., diakses tanggal 4 desember 2009, jam 16.00 wib) nurhidayah, 2005. pengaruh pelaksanaan teknik relaksasi pernafasan terhadap penurunan tingkat kecemasan pada pasien ima. skripsi tidak dipublikasikan. surabaya: universitas airlangga. rice, l.b., 2006. relaxation training & its role in diabetes & health, (online), (http://myhealth.goy., diakses tanggal 12 oktober 2009, jam 14.00 wib) schunk, 1999. the development of academic self efficacy. (online), (http://www. e d s t . p u r d u e . e d u / m o o n / e d p s 2 3 5 / lectures/00-0119%20social%20cogn itive%20theory.htm., diakses tanggal 22 oktober 2009, jam 09.00 wib) sherman, d.k., dan cohen, g.i., 2006. the psychology of self-defense: selfaffi rmation theory, in m.p zasna (ed.) advances in experimental social psychology, vol. 38. san diego, ca: academik press. sukardja, 2000. onkologi klinik. surabaya: airlangga university press. taylor, 1997. fundamental of nursing “the art of nursing care”. philadelphia: lippicont. ners vol 5 no 1 april 2010_akreditasi 2013.indd 79 senam otak meningkatkan fungsi kognitif lansia (brain gym improves cognitive function for elderly) ah. yusuf*, retno indarwati*, arifudin dwi jayanto* * fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya telp/fax: (031) 5913257 e-mail: yusuf@fk.unair.ac.id abstract introduction: the degradation of cognitive function present early dementia in elderly. brain gym is one of the alternative implementation to improve the cognitive function of elderly. the objective of this study was to analyze the effect of brain gym to the improvement of cognitive function in elderly. method: this study used quasy experimental design. the populations were elderly in social service unit tresna werdha lamongan. the samples were recruited using purposive sampling, consist of 30 respondents, taken according to the inclusion criteria. samples then divided into 2 groups, experimental groups and control groups. the independent variable of research this study was brain gym and the dependent variable was cognitive function at elderly. data were collected by using mmse score and then analyzed using wilcoxon signed rank test and mann whitney test with level of signifi cance α ≤ 0.05. result: result showed that there is an effect of brain gym to the improvement of cognitive function in elderly (p = 0.001). the difference of cognitive function also seen between experimental groups and control groups (p = 0.001). discussion: the conclusion of this research is brain gym improve cognitive function in elderly. the simple movement of brain gym able to coordinate the brain function so the brain activity become more optimal hence the improvement of memory function, recall and concentration. keywords: brain gym, cognitive function, elderly pendahuluan proses menjadi tua disebabkan oleh faktor biologi, berlangsung secara alamiah, terus-menerus dan berkelanjutan yang dapat menyebabkan perubahan anatomis, fisiologis, biokemis pada jaringan tubuh sehingga memengaruhi fungsi, kemampuan badan dan jiwa (constantinides, 1994 dalam darmojo, 1999). lansia mengalami kemunduran sel karena proses penuaan yang berakibat kelemahan organ, kemunduran fisik dan penyakit degeneratif. kemampuan kognitif yang menurun sering dianggap sebagai masalah biasa dan merupakan hal yang wajar terjadi pada mereka yang berusia lanjut. penurunan kemampuan kognitif tersebut ditandai dengan banyak lupa merupakan salah satu gejala awal kepikunan yang terjadi pada lansia. dampak lanjut dari kemunduran fungsi kognitif umumnya akan terjadi demensia. demensia merupakan penyakit degeneratif akibat kematian sel yang meliputi kemunduran daya ingat dan proses berpikir. menurut kitchin (1994) kemampuan kognitif merupakan kemampuan mental untuk mengonstruksikan atau mampu memprediksikan suatu lingkungan, serta menciptakan suatu matriks dari berbagai pengalaman lingkungan di mana pengalaman baru dapat diintegrasikan ke dalamnya (kompas, 2004). pada beberapa lansia proses penuaan menjadi sebuah beban. lansia juga mulai kehilangan kemandirian, baik secara fisik misal keterbatasan gerak, dan secara psikologis misal kerusakan kognitif (watson, 2003). pada umumnya setelah orang memasuki lansia maka akan mengalami penurunan fungsi kognitif dan psikomotor. fungsi kognitif meliputi proses belajar, orientasi, pemahaman, pengertian dan perhatian, sehingga menyebabkan reaksi dan perilaku lansia menjadi makin lambat. berdasarkan beberapa penelitian, penurunan kognitif pada usia lanjut yang berumur kurang lebih 75 tahun terjadi penurunan fungsi kognitif jurnal ners vol. 5 no. 1 april 2010: 79–86 80 25% (silvia, 2008). brain gym (senam otak) merupakan latihan yang terangkai dari gerakan tubuh yang dinamis, yang memungkinkan keseimbangan aktivitas kedua belahan otak secara bersamaan. gerakan ini merangsang seluruh bagian otak untuk bekerja. senam otak, mengaktifkan tiga dimensi, yakni lateralitaskomunikasi, pemfokusan-pemahaman, dan pemusatan-pengaturan (dennison, 2002). dampak positif senam otak pada lansia, setelah 2 bulan pelaksanaan senam otak terjadi peningkatan fungsi memori, konsentrasi, atensi dan kewaspadaan untuk mengurangi pikun (lihardo, 2005). penelitian tentang pengaruh senam otak terhadap peningkatan fungsi kognitif belum pernah dilakukan. umur harapan hidup di indonesia tahun 2000 mencapai lebih dari 70 tahun (darmojo, 1999). jumlah usia lanjut pada tahun 2000 sebesar 7,28% dan diproyeksikan sebesar 11,34% pada tahun 2020 (bps, 1992). data usa-bureau of the census, menyatakan indonesia diperkirakan akan mengalami pertambahan warga lansia terbesar di dunia, antara tahun 1990–2025, yaitu sebesar 414% (kinsella & taeuber, 1993 dalam darmojo, 2006). menurut penelitian di inggris terhadap 10.255 orang, terdapat lansia dengan gangguan fisik seperti anthrosis atau gangguan sendi (55%), keseimbangan berdiri (50%), fungsi kognitif pada susunan saraf pusat (45%), penglihatan (35%), pendengaran (35%), kelainan jantung (20%), sesak napas (20%), serta gangguan miksi (ngompol) (10%) (sulianti, 2000). darmojo mengatakan, para lansia umumnya mengalami kemunduran mental-psikologik. hasil penelitiannya pada tahun 1997 menunjukkan, mereka yang mengalami penurunan daya ingat (kognitif) mencapai 50,3 persen, kesepian (20,4), sulit tidur (21,3), dan depresi (4,2). itu semua merupakan gejala dini kelainan mental (demensia) alzheimer. berdasarkan data di unit pelayanan sosial tresna werdha lamongan didapatkan, bahwa sampai bulan november tahun 2008 jumlah penghuni panti sebanyak 47 lansia. berdasarkan tes mmse yang dilakukan untuk mengetahui kemampuan kognitif lansia, didapatkan hasil sebanyak 30 lansia yang mengalami penurunan kognitif sampai usia 75 tahun. korteks serebral adalah daerah otak yang paling besar dipengaruhi oleh kehilangan neuron. perubahan dalam sistem neurologis dapat termasuk kehilangan dan penyusutan neuron, dengan potensial 10% kehilangan yang diketahui pada usia 80 tahun. sistem neurologis terutama otak adalah suatu faktor utama dalam penuaan yang adaptif. neuron menjadi semakin kompleks dan tumbuh seiring kita dewasa, tetapi neuron tersebut tidak dapat mengalami regenerasi. penelitian yang dilakukan dewasa ini pada otak menunjukkan bahwa walaupun neuron mengalami kematian, hubungan di antara sel yang tersisa meningkat dan mengisi kekosongan tersebut. keadaan ini mendukung kemampuan lansia untuk terus terlibat dalam tugas kognitif seperti yang dilakukannya pada beberapa tahun sebelumnya, walaupun secara perlahan. perubahan struktural yang paling terlihat terjadi pada otak itu sendiri, walaupun bagian lain dari sistem saraf pusat (ssp) juga terpengaruh. perubahan ukuran otak yang diakibatkan oleh atrofi girus dan dilatasi sulkus dan ventrikel otak (stanley, 2006). berat otak akan menurun sebanyak sekitar 10% pada penuaan antara umur 30 sampai 70 tahun (darmojo, 2006). dari banyak penelitian diterima secara luas bahwa kecepatan memproses informasi mengalami penurunan pada masa dewasa akhir. penelitian lain membuktikan bahwa orang dewasa lanjut kurang mampu mengeluarkan kembali informasi yang telah disimpan dalam ingatannya. kecepatan memproses informasi secara pelan-pelan memang akan mengalami penurunan pada masa dewasa akhir, namun faktor individual differences juga berperan dalam hal ini. denney (1986) menyatakan bahwa kebanyakan tes kemampuan mengingat dan memecahkan masalah mengukur bagaimana orang dewasa lanjut melakukan aktivitas yang abstrak atau sederhana (juliani, 2008). orang yang mengalami gangguan pada sistem transmisi (neurotransmitter) sel-sel saraf pusat otak nantinya dapat mengakibatkan gangguan mental dan perilaku (mental disorder and behaviour disorder) salah satu akibatnya adalah senam otak meningkatkan fungsi kognitif lansia (ah. yusuf) 81 melemahnya fungsi kognitif yang meliputi kemampuan memecahkan masalah, memori, perhatian dan bahasa sumber daya manusia yang bersangkutan (dadang, 2003). dari penelitian diketahui bahwa ada fungsi otak yang sedikit saja mengalami perubahan atau tidak mengalami perubahan dengan melanjutnya usia, misalnya dalam menyimpan (storage) informasi (lumbantobing, 2001). tidak hanya terdapat di indonesia, kebanyakan orang di dunia memang hidup dengan mengandalkan otak kiri. jumlah mereka ada sekitar 80 sampai 85 persen. sebagian di antaranya memang tidak didominasi otak kiri saja, tetapi campuran antara keduanya. sisanya, 15–20 persen adalah para pengguna otak kanan. penurunan kognitif ini dapat diperbaiki dengan diberikan senam otak. biasanya latihan ini yang dianjurkan empat kali seminggu, masing-masing sekitar 15–20 menit. brain gym mengoptimalkan otak belahan kanan secara garis besar bertugas mengontrol badan bagian kiri, serta berfungsi untuk intuitif, merasakan, bermusik, menari, kreatif, dan melihat keseluruhan. otak kanan juga mendorong manusia untuk bersosialisasi, komunikasi, interaksi dengan manusia lain, serta pengendalian emosi. pada otak kanan ini pula terletak kemampuan intuitif, kemampuan merasakan, memadukan, dan ekspresi tubuh. otak belahan kiri secara garis besar bertugas mengatur badan bagian kanan yang berfungsi untuk berpikir logis, rasional, menganalisis, kemampuan menulis dan membaca, berbicara, berorientasi pada waktu, dan hal-hal yang rinci. otak kiri juga merupakan pusat matematika (sapardjiman, 2003). brain gym bukanlah suatu terapi melainkan suatu metode untuk membantu mengakses potensi otak. prinsip dasarnya adalah bagaimana bergerak itu bisa menstimulasi otak. gerakan senam otak bisa membantu menyeimbangkan kedua belahan otak, mempertajam konsentrasi, meredakan ketegangan otot (relaksasi), mempertajam daya ingat. dampak senam otak tidak saja akan memperlancar aliran darah dan oksigen ke otak, tetapi juga merangsang kedua belahan otak untuk bekerja (sapardjiman, 2003). menurut sapardjiman (2003), senam otak merupakan latihan yang terangkai dari gerakan tubuh yang dinamis, yang memengaruhi keseimbangan aktivitas kedua belahan otak secara bersamaan. bahan dan metode desain penelitian yang digunakan adalah quasy-experiment pre-post test control group design. populasi di dalam penelitian ini adalah seluruh lansia yang tinggal di panti werdha sebanyak 47 lansia. sampel sebanyak 30 lansia diambil dengan purposive sampling dengan kriteria lansia berumur 60–75 tahun serta sehat fisik dan mental. variabel independen dalam penelitian ini metode senam otak (brain gym), sedangkan variabel dependen yang digunakan fungsi kognitif lansia. penelitian ini akan dilaksanakan di unit pelayanan sosial tresna werdha lamongan pada tanggal 17 desember 2008 sampai dengan 18 januari 2009. proses pengambilan dan pengumpulan data selama penelitian diperoleh dengan m e l a k u k a n o b s e r v a s i . i n s t r u m e n y a n g digunakan untuk menilai fungsi kognitif adalah mini mental state examination (mmse). setyopranoto & lamsudin (1999) dalam santi martini (2005) menyebutkan bahwa dalam tes mmse ini terdapat lima domain dari fungsi kognitif yang dinilai yaitu orientasi, registrasi, perhatian dan berhitung serta kemampuan bahasa. menurut mcdowell et al. (1996), tes mmse terdiri atas 11 item yang dibagi dalam dua bagian, bagian pertama meliputi respon verbal terhadap orientasi, memori, dan perhatian. bagian kedua meliputi membaca dan menulis serta kemampuan mencakup nama, mengikuti perintah secara verbal dan tertulis, menulis kalimat, menggambar kembali suatu poligon (tabel 1). nilai mmse 27–30 = fungsi kognitif baik, nilai mmse 22–26 = fungsi kognitif cukup, nilai mmse <21 = fungsi kognitif kurang. senam otak (brain gym) diajarkan kepada responden berdasarkan standar operasional prosedur (sop). senam otak diberikan sebanyak 4 kali dalam seminggu selama 1 bulan dengan durasi waktu tiap pertemuan jurnal ners vol. 5 no. 1 april 2010: 79–86 82 15–20 menit. senam otak dilaksanakan secara berkelompok yang beranggotakan 15 orang dengan dipimpin peneliti dan didampingi oleh pegawai panti. post-test dilakukan setelah 1 bulan untuk mengetahui perbedaan fungsi kognitif pada kelompok perlakuan. d a t a y a n g t e l a h d i p e r o l e h d i u j i menggunakan uji statistik wilcoxon signed rank test dan mann-whitney u test untuk mengetahui perbedaan pos test tingkat fungsi kognitif kelompok perlakuan dengan kelompok kontrol dengan tingkat kemaknaan α ≤ 0,05. hasil distribusi tingkat fungsi kognitif pada lansia sebelum diberi senam otak (pre test) pada kelompok perlakuan mayoritas yaitu sebanyak 12 lansia (80%) mempunyai tingkat fungsi kognitif kurang, 20% cukup dan tidak ada lansia dengan fungsi kognitif baik. hasil pre test tingkat fungsi kognitif pada kelompok kontrol juga didapatkan sebagian besar mempunyai tingkat fungsi kognitif kurang yaitu sebanyak 10 lansia (66%), 27% cukup dan 7% lansia dengan fungsi kognitif baik. tabel 1. mini mental state examination (mmse) item pertanyaan nilai (setiap jawaban benar dinilai 1) orientasi 1. sekarang ini: tahun berapa? musim apa? tanggal berapa? hari apa? bulan apa? 5 2. saat ini: kita di negara mana? kita di propinsi mana? kita di kota mana? kita di panti werda apa? kita di lantai berapa? 5 registrasi 3. sebutkan nama tiga benda, dengan selang waktu masing-masing 1 detik. kemudian penderita diminta menyebut ketiga nama benda tadi. 3 perhatian dan berhitung 4. pasien diminta untuk mengeja kata d-u-n-i-a dari belakang 5 menyebut kembali (recall) 5. pasien diminta menyebut nama tiga benda pada pertanyaan nomor 3 3 bahasa 6. tunjukkan sebuah pensil dan arloji. pasien diminta menyebut nama benda tersebut 2 7. pasien diminta mengulang kata ”anu”, ”tetapi” 1 8. pasien diminta untuk mengikuti perintah tiga langkah: letakkan kertas di tangan kananmu lipat kertas tadi menjadi setengahnya kemudian letakkan di tempat tidur. 3 9. penderita diminta membaca tulisan berikut dan kemudian mematuhinya: tutuplah mata anda 1 10. pasien diminta menulis kalimat yang dipilihnya sendiri. kalimat harus berisi subjek dan objek agar mempunyai arti. abaikan bila ada kesalahan tulis 1 11. pasien diminta menggambar kembali dua segilima berikut. benar apabila semua sisi dan sudut serta sisi segilima tergambar 1 total 30 senam otak meningkatkan fungsi kognitif lansia (ah. yusuf) 83 setelah diberikan perlakuan berupa senam otak selama 1 bulan terlihat peningkatan fungsi kognitif lansia pada kelompok perlakuan. jumlah lansia dengan fungsi kognitif cukup meningkat menjadi 60%, sebanyak 20% lansia mengalami peningkatan fungsi kognitif menjadi baik dan fungsi kognitif kurang masih tetap ada sebanyak 20%. hal yang berlawanan terlihat pada kelompok kontrol yang tidak diberikan perlakuan berupa senam otak. sebanyak 14 lansia (93%) mempunyai fungsi kognitif kurang, hanya 7% lansia dengan fungsi kognitif cukup dan tidak ada lansia dengan fungsi kognitif baik. b e r d a s a r k a n d a t a t e r s e b u t , h a s i l perhitungan uji statistik wilcoxon signed rank test menunjukkan ada pengaruh senam otak terhadap peningkatan fungsi kognitif lansia pada kelompok perlakuan. sedangkan hasil uji mann-whitney u-test menunjukkan perbedaan tingkat fungsi kognitif lansia yang melakukan senam otak dan yang tidak melakukan senam otak. (tabel 2). pembahasan lansia mengalami kemunduran sel karena proses penuaan yang berakibat kelemahan organ, kemunduran fisik, dan timbulnya penyakit degeneratif. pada umumnya setelah orang memasuki masa lansia maka ia akan mengalami penurunan fungsi kognitif dan psikomotor. kognitif adalah kemampuan pengenalan dan penafsiran seseorang terhadap lingkungan berupa perhatian, bahasa, memori, visuospasial, dan fungsi memutuskan. para ilmuwan telah melakukan penelitian dan menyimpulkan bahwa masyarakat yang mengalami penurunan fungsi kognitif harus membuat prioritas utama untuk meningkatkan kualitas hidup. memiliki jenjang pendidikan yang lebih tinggi disertai dengan berada di strata sosial yang lebih tinggi diasumsikan dapat mengurangi penurunan kognitif (ahmad, 2006). berdasarkan data demografi hasil penelitian, lansia yang mempunyai riwayat pendidikan lebih tinggi mempunyai nilai mmse yang lebih baik daripada lansia yang memiliki pendidikan lebih rendah. lansia yang memiliki nilai mmse baik dan cukup sebagian besar mempunyai riwayat pendidikan sekolah dasar (sd) atau sekolah rakyat (sr). lansia memang cenderung mengalami penurunan fungsi memori, namun lesmana ( 2 0 0 6 ) m e n g a t a k a n b a h w a p e n e l i t i a n menunjukkan perbendaharaan kata lebih baik pada orang usia 70 tahun daripada 30 tahun. batasan umur juga memengaruhi dari tingkat fungsi kognitif lansia. pada penelitian ini dari 30 responden yang didapat mayoritas berumur antara 60–67 tahun dengan kategori fungsi kognitif cukup dan kurang. menurut lesmana, (2006) pengalaman pekerjaan dahulu mempunyai dampak pada kualitas proses berpikir lansia. pada penelitian ini hampir setengah lansia mempunyai riwayat pekerjaan sebagai petani, buruh tani, koperasi dan tukang masak. mereka masuk dalam kategori fungsi kognitif kurang. sedangkan lansia yang mempunyai riwayat pekerjaan lebih baik (swasta), termasuk dalam kategori cukup. peningkatan fungsi kognitif lebih dominan terjadi pada lansia berumur 60–67 tabel 2. tingkat fungsi kognitif lansia di unit pelayanan sosial tresna werdha lamongan perlakuan kontrol perlakuan kontrol pre post pre post post post rerata 1,20 2,00 1,40 1,07 2,00 1,07 sd 0,41 0,65 0,63 0,26 0,65 0,26 p = 0,001 p = 0,025 p = 0,001 wilcoxon signed rank test wilcoxon signed rank test mann-whitney u-test keterangan: sd = standar deviasi p = signifi kansi jurnal ners vol. 5 no. 1 april 2010: 79–86 84 tahun, mempunyai riwayat pendidikan sd dan mempunyai riwayat pekerjaan swasta. rerata kenaikan skor mmse mencapai 3–5, jika dibandingkan dengan lansia berumur 67–75 tahun dan mempunyai riwayat pendidikan tidak sekolah terjadi penurunan skor mmse mencapai 1–4. otak besar jika dibelah menjadi otak kiri dan kanan dan dilihat dari atas tampak dipisahkan oleh lekukan yang dalam dan memanjang disebut fissura longitudinalis. pada dasar lekukan terdapat sekumpulan serat yang menghubungkan kedua belahan otak dan disebut dengan corpus callosum dan di juluki sebagai ”jembatan emas atau golden bridge”. senam otak dapat mencapai brain exrcise melalui gerakan crossing the midline. gerakan tubuh, kepala dan bola mata yang menyilang garis tengah tubuh dapat meningkatkan potensi otak (sidiarto, 2004). lansia mengalami penurunan berat otak berkisar sampai 10% pada usia 30–70 tahun. volume otak yang berkurang sejalan dengan penuaan memengaruhi penyusutan neuron sel-sel otak. penyusutan neuron ini akan memengaruhi kinerja dari korteks serebri. sebagian besar penyimpanan informasi dan proses berpikir terjadi di dalam korteks serebri. penyimpanan informasi merupakan proses yang disebut daya ingat (memori). penurunan kemampuan korteks serebri akan mengakibatkan gangguan sistem transmisi neurotransmitter yang dapat mengakibatkan gangguan mental dan perilaku sehingga berakibat pada penurunan fungsi kognitif. penurunan fungsi kognitif lansia dapat diberikan terapi senam otak. di dalam aplikasi metode senam otak terdapat dimensi pemusatan untuk sistem limbis (midbrain) dan otak besar (cerebral cortex) (dennison, 2008). di dalam korteks serebri terdapat area fungsional yang membagi fungsi dari masing-masing hemisfer kanan dan kiri. brain gym mengoptimalkan otak belahan kanan yang secara garis besar bertugas mengontrol badan bagian kiri, serta berfungsi untuk intuitif, merasakan, bermusik, menari, kreatif, dan melihat keseluruhan. otak kanan juga mendorong manusia untuk bersosialisasi, komunikasi, interaksi dengan manusia lain, serta pengendalian emosi. pada otak kanan ini pula terletak kemampuan intuitif, kemampuan merasakan, memadukan, dan ekspresi tubuh. otak belahan kiri secara garis besar bertugas mengatur badan bagian kanan yang berfungsi untuk berpikir logis, rasional, menganalisis, kemampuan menulis dan membaca, berbicara, berorientasi pada waktu, dan hal-hal yang rinci. otak kiri juga merupakan pusat matematika (sapardjiman, 2003). dalam pertemuan dari berbagai area interpretasi sensorik ini terutama berkembang pada sisi otak yang dominan yaitu sebelah sisi kiri pada hampir semua orang dan area ini sangat berperan pada fungsi otak yang lebih tinggi dalam bagian setiap korteks serebri, fungsi ini kita sebut ”berpikir”. untuk proses berpikir, pemahaman bahasa dan pola ingatan pada area fungsional korteks serebri terdapat di area wernicke. bila area wernicke pada hemisfer dominan seorang yang tumbuh dengan baik mengalami kerusakan, maka penderita akan kehilangan hampir seluruh fungsi berpikir, pola ingatan yang berhubungan dengan bahasa (guyton dan hall, 1997). senam otak sendiri bertujuan untuk menjaga keseimbangan kinerja antara otak kanan dan kiri tetap optimal. senam otak memberikan stimulus perbaikan pada seratserat di corpus callosum yang menyediakan banyak hubungan saraf dua arah antara area kortikal kedua hemisfer otak, termasuk hypokampus dan amygdala. gerakan senam otak mengaktifkan kembali hubungan saraf antara tubuh dan otak sehingga memudahkan aliran energi elektromagnetik ke seluruh tubuh. gerakan ini menunjang perubahan elektrik dan kimiawi yang berlangsung pada semua kejadian mental dan fisik (dennison, 2008). peranan hipokampus dalam konsolidasi s e b a g a i s i s t e m r e f e r e n s i s i l a n g , y a n g mengkaitkan aspek memori tertentu yang disimpan dibagian otak yang terpisah sehingga dapat meningkatkan kandungan asam nukleat dalam perubahan memori neuron. sinaps berpengaruh dalam mengolah informasi atau data yang diterima sehingga manusia akan menyimpan informasi dalam memorinya. penyimpanan informasi merupakan proses yang kita sebut daya ingat dan juga merupakan fungsi dari sinaps. sinaps adalah tempat hubungan senam otak meningkatkan fungsi kognitif lansia (ah. yusuf) 85 satu neuron dengan neuron berikutnya. sinaps merupakan suatu tempat yang menguntungkan untuk mengatur penghantaran perintah. sinaps juga berfungsi menghantarkan informasi dari satu neuron ke neuron yang lain dengan mudah. perbaikan fungsi sinaps dapat memengaruhi kinerja korteks serebri yang terlibat dalam proses informasi baru sebagai jalan menuju korteks untuk penyimpanan memori secara permanen. korteks serebri merupakan lapisan luar otak yang terlibat dalam proses kognisi tingkat tinggi yang dapat diikuti oleh peningkatan fungsi kognitif yang lain seperti orientasi, registrasi, perhatian dan berhitung, menyebut kembali (recall), dan bahasa. fungsi kognitif merupakan kemampuan seseorang untuk menerima, mengolah, menyimpan dan menggunakan kembali semua masukan sensorik secara baik. fungsi kognitif terdiri dari unsur memperhatikan (atensi), mengingat (memori), berkomunikasi (bahasa), bergerak (motorik) dan merencanakan/ melaksanakan keputusan (eksekutif) (gallo, 1998). gangguan kognitif adalah suatu gangguan fungsi luhur otak berupa gangguan orientasi, perhatian, konsentrasi, daya ingat dan bahasa serta fungsi intelektual (setyopranoto et al., 2000). dampak positif senam otak pada lansia, setelah 2 bulan pelaksanaan senam otak terjadi peningkatan fungsi memori (kognitif), konsentrasi (kecerdasan), atensi dan kewaspadaan untuk mengurangi pikun (lihardo, 2005). simpulan dan saran simpulan gerakan senam otak mengaktifkan kembali hubungan saraf antara tubuh dan otak sehingga memudahkan aliran energi elektromagnetik ke seluruh tubuh. senam otak dapat menjaga keseimbangan kinerja antara otak kanan dan kiri tetap optimal dengan memberikan stimulus perbaikan pada seratserat di corpus callosum dan beberapa struktur otak termasuk hipokampus dan amigdala sehingga dapat meningkatkan fungsi kognitif pada lansia. saran senam otak dapat dijadikan protap oleh pihak panti untuk menoptimalkan kembali fungsi kognitif yang cenderung menurun pada masa usia lansia. perlu penelitian lebih lanjut untuk mengetahui dampak lain senam otak misalnya terhadap stres pada lansia. kepustakaan darmojo, 2006. geriatri. jakarta: balai penerbit fkui. darmojo, 1999. geriatri. jakarta: balai penerbit fkui. dennison, p.e. dan dennison, g.e., 2008. brain gym, senam otak. jakarta: grasindo. gallo, j. j., et al., 1998. buku saku gerontologi edisi 2. jakarta: egc. guyton, a.c., 1990. fisiologi manusia dan mekanisme penyakit edisi 3. jakarta: egc. hawari, d., 2003. iq, eq, cq, dan sq kriteria sumber daya manusia (pemimpin) berkualitas. jakarta: balai penerbit fkui. lihardo, j., 2005. penurunan kognitif pada lansia, (online), (http://www.info-sehat. com/inside_level2.asp?artid=1285&s ecid=55&intid=6., diakses tanggal 20 november jam 05.15 wib). juliani, 2008. ilmu psikologi, (online), (http:// www.ilmupsikologi.com/?p=11., diakses tanggal 22 november 2008 jam 05.12 wib). sapardjiman, k., 2003. senam otak merangsang kecerdasan lansia, (online), (http://. depkes.go.id/index.php?option=article s&task=viewarticle&artid=111&itemid =3., diakses tanggal 20 november 2008 jam 05.00 wib). kompas, 2004. berita penurunan ingatan pada lansia, (online), (http://www2. kompas.com/kompas-cetak/0410/28/ ilpeng/1352062.htm., diakses tanggal 24 november 2008 jam 05.35 wib). lesmana, 2006. mengasah otak pada lansia, (online), (http://trisna19.wordpress. com/2008/04/02/mengasah-otak-padasaat-lanjut-usia/. diakses tanggal 21 november 2008 jam 06.56 wib). jurnal ners vol. 5 no. 1 april 2010: 79–86 86 lumbantobing, s.m., 2001. neurogeriatri. jakarta: penerbit fkui, hlm. 158–170. lumbantobing, s.m., 2001. kecerdasan pada usia lanjut dan dimensia. jakarta: f a k u l t a s k e d o k t e r a n u n i v e r s i t a s indonesia. setyopranoto et al., 2000. peranan stroke iskemik akut terhadap timbulnya gangguan fungsi kognitif di rsud dr. sardjito yogyakarta. berkala neuro sains 2(1), 34–227. sidiarto, l.d., 2004. rekreasi terapeutik untuk warga senior. disampaikan dalam semiloka kesehatan dan kesejahteraan sosial lansia, cimahi 21 februari 2004. stanley, m., 2006. perawatan pada lansia. jakarta: egc. watson, r., 2003. perawatan pada lansia. jakarta: egc. 56 model adaptif conservation (acm) dalam meningkatkan dukungan keluarga dan kepatuhan berobat pada pasien tb paru di wilayah kota surabaya (adaptif conservation (acm) model in increasing family support and compliance treatment in patient with pulonary tuberculosis in surabaya city region) siti nur kholifah*, minarti*, hilmi yumni* * program studi keperawatan sutopo jurusan keperawatan politeknik kesehatan kemenkes surabaya, jl. parangkusumo no. 1 surabaya, e-mail: kholifah_stp@yahoo.co.id abstract introduction: tuberculosis (tb) in indonesia is still health problem and the prevalence rate is high. discontinuing medication and lack of family support are the causalities. numbers of strategies to overcome are seemingly not succeeded. roles and responsibilities of family nursing are crucial to improve participation, motivation of individual, family and community in prevention, including pulmonary tuberculosis. unfortunately, models of pulmonary tuberculosis currently unavailable. the combination of adaptation and conservation in complementarily improving family support and compliance in medication is introduced in this study. method: this research intended to analyze adaptive conservation model (acm) in extending family support and treatment compliance. modeling steps including model analysis, expert validation, fi eld trial, implementation and recommending the output model. research subject involves 15 families who implement family assistance and supervision in medication (asm) and other 15 families with acm. result: the study revealed acm is better than asm on the case of family support and medication compliances. it supports the role of environment as infl uential factor on individual health belief, values and decision making. therefore, it is advised to apply acm in enhancing family support and compliance of pulmonary tb patients. discussion: social and family supports to acm group obtained by developing interaction through communication. family interaction necessary to improve family support to pulmonary tuberculosis patients. and social support plays as motivator to maintain compliance on medication keywords: adaptive conservation model (acm), family support, medication compliance, pulmonary tb pendahuluan penyakit tuberkulosis (tbc) adalah penyakit kronis menular yang masih tetap merupakan masalah kesehatan masyarakat di dunia termasuk indonesia (tbc indonesia. or.id, diakses tanggal 15 januari 2011). hasil riset kesehatan dasar (riskesdas) tahun 2010 menunjukkan bahwa periode prevalence tb paru 2009/2010 sebesar 725/100.000 penduduk (kementerian kesehatan republik indonesia, 2010). data dari dinas kesehatan provinsi jawa timur tahun 2009, jumlah kasus baru tb paru dengan bta positif adalah 37.000 penduduk dan terjadi trend kenaikan penemuan kasus dalam 5 tahun terakhir (dinas kesehatan provinsi jawa timur, 2010). upaya yang dilakukan pemerintah sejak tahun 1995 adalah program pemberantasan tuberkulosis paru yang telah dilaksanakan dengan strategi directly observed treatment shortcourse (dots). salah satu strategi dari upaya ini adalah promosi kesehatan dalam rangka meningkatkan perilaku hidup sehat (departemen kesehatan republik indonesia, 2002). namun hasil yang diharapkan kurang memuaskan, prevalence tb paru di indonesia masih tinggi. faktor penyebab masih tingginya prevalensi tb paru di indonesia termasuk model adaptif conservation (acm) (siti nur kholifah) 57 di jawa timur di antaranya kemiskinan, kebodohan, geografis, perilaku yang tidak sehat, lingkungan yang kurang sehat, penyakit dan akses pelayanan kesehatan terbatas (dinas kesehatan provinsi jawa timur, 2010). faktor lain yang juga menjadi penyebab adalah putus berobat dan kurangnya dukungan keluarga (pratiwi, 2008). keperawatan keluarga yang merupakan entry point dari keperawatan komunitas merupakan bagian integral dari pelayanan kesehatan mempunyai peran dan tanggung jawab untuk meningkatkan perilaku yang sehat dengan partisipasi dan motivasi individu, keluarga, dan masyarakat sebagai upaya preventif terhadap tb paru. tujuannya agar pasien dapat melakukan pemeliharaan diri sesuai kondisi yang dialaminya dan patuh untuk minum obat dengan dukungan keluarga serta masyarakat sekitar. upaya untuk mencapai tujuan keperawatan di atas, peneliti akan melakukan blended 2 (dua) model keperawatan yaitu adaptation dan conservation, kedua model tersebut mempunyai beberapa komponen yang sama dan saling melengkapi satu dengan yang lain dan diharapkan dapat diterapkan menjadi satu model keperawatan keluarga (adaptive conservation models) sebagai salah satu pedoman perawat dalam menanggulangi tb paru di masyarakat melalui peningkatan dukungan keluarga dan kepatuhan berobat. mengingat sampai saat ini belum ada model keperawatan yang diterapkan untuk penanggulangan tb paru. model adaptasi (adaptation models) dapat diterapkan pada keluarga dengan tb paru karena pasien tb paru memerlukan pengobatan dalam jangka waktu yang lama. kondisi tersebut akan menimbulkan stres psikologis karena tuntutan untuk minum obat setiap hari dan adanya berbagai efek samping dari pengobatan yang membuat rasa tidak nyaman pada pasien tb paru. kondisi tersebut membutuhkan proses adaptasi agar pasien dapat melakukan perilaku yang adaptif untuk menunjang keberhasilan proses pengobatan. s e d a n g k a n m o d e l k o n s e r v a s i (conservation models) dari mary e. levine dapat diaplikasikan pada keluarga dengan tb paru karena pasien memerlukan pemenuhan kebutuhan dasar sebagai upaya pemeliharaan yang harus dilakukan secara terus-menerus untuk mencapai kesembuhan total. selama proses pemeliharaan pasien tb paru memerlukan interaksi dengan keluarga berupa dukungan untuk menunjang perawatan yang dilakukan, sehingga dapat mencapai tujuan yang diharapkan yaitu kepatuhan pengobatan secara teratur sesuai dengan jangka waktu yang ditentukan. tujuan dari penelitian ini adalah menganalisis adaptive conservation models (acm) dalam meningkatkan dukungan keluarga dan kepatuhan berobat pada pasien tb paru di wilayah kota surabaya. bahan dan metode penelitian ini menggunakan langkahlangkah penelitian pemodelan meliputi analisis model dikembangkan dengan cara melakukan studi pendahuluan untuk mengumpulkan informasi berupa kajian pustaka, dan identifi kasi permasalahan yang terkait dengan dukungan dan kepatuhan berobat pasien tb paru. selanjutnya mengembangkan model awal, validasi ahli dan revisi, uji coba lapangan pertama, uji coba lapangan akhir untuk penetapan model akhir dan merekomendasikan model acm dalam meningkatkan dukungan keluarga dan kepatuhan berobat pasien tb paru. sedangkan subjek uji coba atau sampel untuk uji coba pada penelitian ini adalah keluarga dengan anggota keluarga yang menderita tb paru sebagai unit analisis terdiri dari 15 keluarga yang melaksanakan program pmo dan 15 keluarga yang dilakukan intervensi model acm. teknik pengumpulan data dukungan keluarga dan kepatuhan dengan menggunakan observasi, wawancara, dan kuesioner. instrumen dikembangkan sendiri oleh peneliti, berdasarkan berbagai teori yang diperoleh. kuesioner ini dilakukan uji coba dan uji validitas dan reliabilitasnya, untuk mengetahui perbedaan dukungan keluarga dan kepatuhan berobat pada pasien tb paru setelah uji coba subjek menggunakan analisis deskriptif. jurnal ners vol. 7 no. 1 april 2012: 56–63 58 hasil uji validasi ahli uji validasi ahli dilakukan setelah peneliti merancang model dengan literatur review. uji validasi ahli pertama bertujuan untuk sharing model yang telah dirancang dari beberapa ahli yang terkait dengan aplikasi model dan pemegang kebijakan yang diharapkan akan mengadopsi model yang telah dirancang. selain itu, memberikan masukan juga untuk pelaksanaan uji lapangan. beberapa rekomendasi yang dihasilkan dari uji validasi ahli i adalah adanya kesesuaian model adaptif dan conservation bila diblended dan diaplikasikan pada pasien tb paru, perlu pengukuran tingkat kecemasan dan pengukuran tingkat pengetahuan, mengkaji kebutuhan sebelum memberikan pendidikan kesehatan, pengumpulan data pada 2 (dua) kelompok yaitu kelompok dengan pmo dan kelompok dengan model acm, sebagai aplikasi model acm membentuk kelompok atau paguyuban penderita tb paru (peer group support) di satu puskesmas, melakukan konseling pada pasien yang bermasalah secara psikologis dan bila perlu bekerja sama dengan social worker. uji validasi ahli yang kedua dilakukan setelah proses penerapan acm pada pasien tb paru dan keluarga. tujuan dari uji validasi ahli yang kedua adalah memaparkan hasil uji lapangan yang telah dilaksanakan dan kelemahan serta kelebihan dari model. uji coba lapangan uji coba lapangan penerapan model acm pada 15 sampel penelitian meliputi beberapa kegiatan, yaitu memberikan pendidikan kesehatan, meningkatkan interaksi keluarga dengan komunikasi, meningkatkan partisipasi keluarga dalam perawatan, melakukan konseling, meningkatkan dukungan kelompok dan masyarakat dengan proses kelompok. memberikan pendidikan kesehatan sebelum memberikan pendidikan kesehatan, peneliti melakukan pengkajian kebutuhan informasi pada klien dan keluarga melalui wawancara. hasil pengkajian yang diperoleh hampir keseluruhan pasien tb paru dan keluarga belum mengetahui tentang pencegahan penularantb paru. bahkan ada beberapa keluarga belum mengerti bahwa tb paru dapat menular. beberapa ungkapan keluarga, “ saya tahunya tbc itu menular, tapi bagaimana penularannya saya nggak ngerti ...”. “katanya dokter di puskesmas anak saya tbc, dapat menular, tapi saya ndak tahu apa yang harus saya lakukan di rumah....”. pemberian pendidikan kesehatan yang dilakukan dapat meningkatkan pengetahuan dan keterampilan. hal ini akan berdampak pada perilaku pasien dan keluarga terhadap perawatan yang dilakukan karena pasien tb paru dan keluarga mampu mengambil keputusan secara tepat untuk melanjutkan proses pengobatan dan perawatan sesuai waktu yang telah ditentukan. hasil pengukuran pengetahuan menunjukkan bahwa dengan analisis deskriptif didapatkan ada perbedaan pengetahuan antara kelompok pmo dan kelompok acm. mayoritas (73,3%) pengetahuan pada kelompok pmo adalah kurang, sedangkan pada kelompok acm mayoritas (60%) adalah berpengetahuan baik dan tidak ada yang berpengetahuan kurang. dengan demikian penerapan acm diperlukan untuk meningkatkan pengetahuan pasien dan keluarga. meningkatkan interaksi keluarga dengan komunikasi program pmo setiap pasien tb paru mempunyai seorang pengawas menelan obat dari salah satu anggota keluarganya. kenyataan di lapangan, ternyata hanya orang yang ditunjuk sebagai pmo ini yang mengetahui bagaimana kondisi pasien, sedangkan anggota keluarga yang lain kurang peduli terhadap pasien. d a t a y a n g d i d a p a t k a n d a r i h a s i l kunjungan rumah, terdapat beberapa keluarga yang kurang terjalin komunikasi dengan baik. misalnya mengingatkan pasien minum obat dengan membentak atau marah-marah, “ .... kalau kamu tidak minum obat, awas...” “ ... mau minum obat atau mau mati.....”. ada juga anggota keluarga yang kurang peduli terhadap pasien, serta tidak tahu penyakit pasien, “ bapak saya memangnya sakit apa bu...?.”, padahal pasien sudah berobat 2 (dua) minggu. penerapan acm untuk meningkatkan model adaptif conservation (acm) (siti nur kholifah) 59 interaksi keluarga yang telah dilakukan adalah dengan mengumpulkan anggota keluarga yang tinggal serumah dan menginformasikan tentang penyakit pasien. menjelaskan perlunya dukungan keluarga terhadap kesembuhan pasien dan bagaimana cara memberikan dukungan sesuai dengan kapasitas yang dimiliki keluarga. dengan demikian setiap anggota keluarga akan berkontribusi memberikan dukungan meskipun hanya dengan pertanyaan-pertanyaan sederhana, misalnya. menanyakan kondisinya hari ini, apakah obatnya sudah diminum, kapan kontrol lagi dan sebagainya. interaksi keluarga melalui komunikasi yang dilakukan keluarga juga dapat memberikan dukungan secara emosional pada pasien tb paru yaitu meliputi perhatian, adanya kepercayaan, perhatian, mendengarkan dan didengarkan. dukungan emosional dapat meningkatkan respons adaptif pada pasien tb paru. setelah intervensi acm ungkapan yang disampaikan pasien tb paru dan keluarga, “ ....anak saya sekarang sering tanya, saya sudah makan apa belum....,”, saya ingatkan kakak saya untuk minum obat dan makan yang banyak, biar cepat sembuh....”. “ adik saya sekarang sering mengingatkan minum obat dan kalau waktunya kontrol....”. meningkatkan partisipasi keluarga dalam perawatan hasil kunjungan rumah didapatkan data keluarga kurang memperhatikan kebutuhan sehari-hari pasien tb paru, misalnya tersedianya tempat dahak, pemenuhan kebutuhan makan dan minum yang bergizi dan lingkungan rumah yang bersih. keluarga menyamakan kebutuhan pasien dengan kebutuhan anggota keluarga lainnya. data dari seluruh responden, semuanya tidak mempunyai tempat dahak tersendiri. pasien tb paru lebih banyak meludah di got atau di halaman rumah. peneliti memberikan saran kepada keluarga untuk menyediakan tempat dahak tersendiri dari wadah yang tertutup dan diisi oleh larutan desinfektan. pada pertemuan berikutnya keluarga sudah menyediakan tempat dahak tersebut. u p a y a l a i n u n t u k m e n i n g k a t k a n partisipasi keluarga selama perawatan adalah dengan memodifi kasi lingkungan yang sehat. dari 15 keluarga yang dilakukan kunjungan rumah, sebagian besar lingkungan rumahnya kurang menunjang perawatan pada pasien tb paru, baik dari segi kebersihan, kecukupan ventilasi, dan penataan perabotan. kunjungan pertama peneliti dengan melakukan observasi lingkungan rumah keluarga. kalau ada yang tidak sesuai peneliti memberikan masukan untuk modifi kasi lingkungan sesuai dengan sarana yang dimiliki oleh pasien. melakukan konseling konseling dilakukan pada pasien tb paru yang mempunyai masalah yang berkaitan dengan konsep diri. hasil kunjungan rumah pada salah satu pasien tb paru bernama sdr. g (29 th) yang berhenti bekerja karena didiagnosa tb paru. sdr. g ini tidak mau keluar rumah sejak sakit. ketika kunjungan rumah pertama kali sdr. g juga tidak mau menerima peneliti. setelah mengenalkan diri dan menjalin trust dengan keluarga, peneliti mulai melaksanakan konseling kepada pasien dan 2 (dua) orang anggota keluarga lainnya. setelah 3 (tiga) kali kunjungan, sdr. g sudah mau keluar rumah dan mencari pekerjaan lagi. data tersebut di atas menunjukkan kelebihan acm dibandingkan pmo untuk mengatasi permasalahan pasien tb paru dan keluarga. pendekatan secara menyeluruh selama konseling dilaksanakan merupakan salah satu kunci keberhasilan dalam menyelesaikan masalah. meningkatkan dukungan kelompok dan masyarakat dengan proses kelompok kegiatan yang dilakukan sebagai aplikasi acm dalam meningkatkan dukungan kelompok dan masyarakat adalah dengan membentuk paguyuban tb paru di puskesmas krembangan selatan surabaya. tujuan dari pembentukan paguyuban tb paru adalah meningkatkan dukungan kelompok dan masyarakat selama proses pengobatan dan perawatan. masingmasing anggota kelompok dapat saling memberikan support untuk melanjutkan pengobatan sampai tuntas. kegiatan pertama yang dilaksanakan di paguyuban tb paru bertemu dengan sesama penderita yang ternyata mereka bertetangga, jurnal ners vol. 7 no. 1 april 2012: 56–63 60 yang semula tidak tahu kalau tetangganya tersebut sakit menjadi tahu. kondisi ini dapat memperkuat motivasi mereka untuk bersamasama menjalankan pengobatan secara tuntas. beberapa ungkapan pasien tb paru setelah pembentukan paguyuban penderita tb paru sebagai berikut, “...ternyata tetangga saya banyak yang sakit seperti saya juga.... kemarin ndak tahu... (sambil tersenyum)...”. “ ....enak ya gini banyak temannya, ndak saya sendiri yang sakit....”. “...kalau bisa diadakan pertemuan rutin seperti ini...bisa tanya-tanya....”. setelah tahapan uji coba model, dilakukan pengambilan data dukungan keluarga dan kepatuhan berobat baik pada keluarga dengan pmo maupun keluarga dengan acm. data dukungan keluarga diperoleh dari kelompok pmo dan acm. strategi pengumpulan datanya dengan wawancara terstruktur menggunakan kuesioner. hasil yang didapatkan adalah pada kelompok pmo mayoritas dukungan informasionalnya (40%) adalah baik, dukungan instrumental mayoritas (53,3%) kurang, dukungan penilaian mayoritas (40%) cukup dan dukungan emosionalnya mayoritas (46,7%) kurang. sedangkan pada kelompok acm, dukungan informasional mayoritas (80%) baik, dukungan instrumental (60%) baik, dukungan penilaian mayoritas (60%) baik dan dukungan emosional keseluruhan (100%) baik. berdasarkan analisis deskriptif didapatkan bahwa ada perbedaan dukungan keluarga pada kelompok pmo dan acm (tabel 1). tabel 1. distribusi dukungan keluarga pasien tb paru pada kelompok pmo dan model acm di wilayah kota surabaya dukungan keluarga kelompok pmo kelompok acm baik cukup kurang baik cukup kurang informasional 6 (40%) 4 (26,7%) 5 (33,3%) 12 (80%) 2 (12,3%) 1 (6,7%) instrumental 3 (20%) 4 (26,7%) 8 (53,3%) 9 (60%) 5 (33,3%) 1 (6,7%) penilaian 4 (26,7%) 6 (40%) 5 (33,3%) 9 (60%) 4 (26,7%) 3 (20%) emosional 3 (20%) 5 (33,3%) 7 (46,7%) 15 (100) 0 (0%) 0 (0%) tabel 2. distribusi kepatuhan berobat pasien tb paru pada kelompok pmo dan acm di wilayah kota surabaya variabel mean sd min-mak kepatuhan berobat kelompok pmo kelompok acm 8,7 9,5 0,72 0,52 7 – 10 9 – 10 data kepatuhan berobat pasien tb paru diperoleh dengan metode wawancara. jumlah pertanyaan 10 buah. komponen pertanyaan kepatuhan berobat terdiri dari kepatuhan minum obat, kepatuhan untuk kontrol sesuai jadwal, kepatuhan untuk dapat mengatasi efek samping dari obat, dan kepatuhan untuk melaksanakan program pengobatan sampai selesai. data yang diperoleh pada kelompok pmo minimal menjawab 7 pernyataan kepatuhan dan maksimal menjawab seluruh (10) pernyataan kepatuhan dengan benar, tetapi pada kelompok pmo ini hanya 1 (satu) orang yang menjawab 10 pernyataan kepatuhan dengan benar. mayoritas kepatuhan untuk dapat mengatasi efek samping dari obat masih kurang. sedangkan pada kelompok acm minimal menjawab 9 pernyataan kepatuhan dan maksimal menjawab seluruh (10) pernyataan kepatuhan dengan benar. pada kelompok pmo terdapat 8 (delapan) orang yang menjawab 10 pernyataan kepatuhan dengan benar. berdasarkan analisis deskriptif, didapatkan perbedaan kepatuhan berdasarkan jumlah jawaban benar yang menyatakan kepatuhan. pembahasan hasil penelitian didapatkan bahwa dukungan keluarga dan kepatuhan berobat kelompok acm lebih baik daripada kelompok pmo. dukungan informasional dan peningkatan interaksi melalui komunikasi kelompok acm model adaptif conservation (acm) (siti nur kholifah) 61 lebih baik. pemberian pendidikan kesehatan pada keluarga dapat meningkatkan dukungan terhadap pasien tb paru. hal ini sesuai dengan friedman (1998), bahwa keluarga berfungsi sebagai kolektor dan diseminator (penyebar) informasi yang dapat menekan munculnya suatu stressor karena informasi yang diberikan dapat menyumbangkan aksi sugesti yang khusus pada individu. levine (1973) menyatakan bahwa interaksi individu dengan lingkungannya merupakan sebuah sistem terbuka, dan memberikan kemudahan jaminan integritas di semua dimensi kehidupan. peningkatan interaksi keluarga yang dilakukan merupakan dukungan sosial dari keluarga yang dapat mengembangkan koping yang positif pada pasien tb paru. roy (1991) menjelaskan bahwa salah satu proses internal seseorang sebagai sistem adaptasi adalah pada mode interdependensi yang fokusnya pada interaksi untuk saling memberi dan menerima cinta/kasih sayang, perhatian dan saling menghargai. intervensi lain yang dapat meningkatkan dukungan keluarga adalah peningkatan partisipasi keluarga dalam memenuhi kebutuhan pasien tb paru sesuai dengan teori dasar yang digunakan pada acm yaitu teori adaptasi dan conservation. friedman (2008) menyatakan bahwa keluarga mempunyai tugas dibidang kesehatan yang ketiga yaitu kemampuan keluarga merawat anggota keluarga yang sakit. keluarga juga merupakan sebuah sumber pertolongan praktis dan konkrit, di antaranya: kesehatan pasien dalam hal kebutuhan makan dan minum, istirahat, serta terhindarnya pasien dari kelelahan. dukungan kelompok dan masyarakat juga diperlukan pasien tb paru. proses kelompok yang telah dilakukan dengan pembentukan paguyuban tb paru berdasarkan teori dari levine yang menjelaskan bahwa integritas sosial dimaknai sebagai proses penyesuaian di antara unsur-unsur yang saling berbeda dalam kehidupan keluarga dan masyarakat sehingga menghasilkan pola kehidupan keluarga dan masyarakat yang memiliki keserasian fungsi. proses penyesuaian dalam mencapai integritas sosial diperlukan interaksi yang baik antaranggota keluarga dan masyarakat (levine, 1989 dalam tomey, 2006). kebersamaan dalam berbagai kegiatan, minat, dan sikap sering diberikan oleh hubungan dalam kelompok. inilah yang sering berkembang menjadi rasa persahabatan serta rasa memiliki dan dimiliki oleh kelompok (sense of belongingness). strategi intervensi lain dari acm yang dapat meningkatkan dukungan dan kepatuhan berobat adalah pemberian konseling. upaya ini dapat membangun konsep diri yang positif pada pasien tb paru. teori yang mendasari dilakukannya konseling dari teori adaptasi. roy (1991) menyatakan bahwa salah satu mode adaptasi dalam pengembangan internal seseorang adalah mode konsep diri, di mana mode konsep diri ini berhubungan dengan psikososial dengan penekanan spesifi k pada aspek psikososial dan spiritual manusia. kebutuhan dari konsep diri ini berhubungan dengan integritas psikis antara lain persepsi, aktivitas mental dan ekspresi perasaan. berdasarkan teori conservation, pemberian konseling juga dapat dijelaskan bahwa individu sebagai kepribadian yang berintegritas berusaha untuk mendapatkan pengakuan, kehormatan, martabat, harga diri, reputasi, kepercayaan, emosi yang stabil dan melakukan tindakan sesuai dengan norma dan etika (levine, 1989 dalam tomey, 2006). kepatuhan berobat pada pasien tb paru dipengaruhi oleh dukungan keluarga. hasil penelitian didapatkan bahwa dukungan keluarga pada pasien tb paru kelompok acm lebih baik dari kelompok pmo. menurut baekeland dan lundawall dalam suparyanto, 2009, dukungan keluarga dapat menjadi faktor yang dapat berpengaruh dalam menentukan keyakinan dan nilai kesehatan individu serta menentukan program pengobatan yang akan mereka terima. keluarga juga memberi dukungan dan membuat keputusan mengenai perawatan anggota keluarga yang sakit. keluarga juga dapat menjadi faktor yang sangat memengaruhi dalam menentukan keyakinan dan nilai kesehatan individu (niven, 2002 dalam syakira, 2009). dukungan sosial dari kelompok dapat meningkatkan kepatuhan pada pasien tb paru pada kelompok acm. dengan terbentuknya paguyuban tb paru, pasien mendapatkan teman baru yang senasib sehingga dapat menjadi motivator selain keluarga. sesuai jurnal ners vol. 7 no. 1 april 2012: 56–63 62 dengan pernyataan meichenbaun, (1997 dalam suparyanto, 2009) bahwa teman dapat membantu mengurangi ansietas yang disebabkan oleh penyakit tertentu, mereka dapat menghilangkan godaan pada ketidakpatuhan dan mereka seringkali dapat menjadi kelompok pendukung untuk mencapai kepatuhan. kepatuhan berobat pada kelompok acm lebih baik dapat disebabkan juga karena adanya dukungan dari profesi kesehatan yaitu tim peneliti yang turut memperhatikan kebutuhan dari pasien tb paru. hal ini sesuai dengan pernyataan meichhenbaum (1997) dalam suparyanto (2009) bahwa tenaga kesehatan merupakan faktor lain yang dapat memengaruhi perilaku kepatuhan pasien. dukungan mereka terutama berguna pada saat pasien menghadapi kenyataan bahwa perilaku sehat yang baru itu merupakan hal yang penting. begitu juga mereka dapat memengaruhi perilaku pasien dengan cara menyampaikan antusias mereka terhadap tindakan tertentu dari pasien, dan secara terusmenerus memberikan yang positif bagi pasien yang telah mampu beradaptasi dengan program pengobatannya. simpulan dan saran simpulan penelitian ini menyimpulkan bahwa dukungan keluarga kelompok acm lebih baik dari kelompok pmo. demikian juga kepatuhan berobat kelompok acm lebih baik dari kelompok pmo. sedangkan kelebihan acm adalah meningkatkan pengetahuan pasien tb paru dan keluarga, dukungan keluarga pasien tb, dukungan kelompok dan masyarakat pada pasien tb paru, dukungan perawat pada kepatuhan berobat pasien tb paru serta kepatuhan berobat pasien tb paru. saran s a r a n d a r i p e n e l i t i a n i n i a d a l a h merekomendasikan penerapan model acm dalam memberikan asuhan keperawatan pada pasien tb paru karena dapat meningkatkan pengetahuan, dukungan keluarga serta dukungan sosial. kepustakaan aisyah, 2001. hubungan persepsi, pengetahuan tb paru dan pmo dengan kepatuhan berobat pasien tb paru di puskesmas jatinegara jakarta timur, (online), (http://www.lontar.ui.ac.id., diakses pada tanggal 23 maret 2011. allender, j.a., dan spradley, b.w., 2005. community health nursing: promoting and protecting the public’s health. (6th ed). philadelphia: lippincott. barry, p.d., 1996. psychosocial nursing: care of physically ill patients and their families. philadelphia: lippincott. chomisah, elyu, 2002. faktor-faktor yang berhubungan dengan kepatuhan berobat pasien tb paru bta positif di rsup dr. moh. husein palembang tahun 1998–2000, (online), (http://www. lontar.ui.ac.id, diakses tanggal 23 maret 2011). d e p a r t e m e n k e s e h a t a n r e p u b l i k indonesia, 2002. pedoman nasional penanggulangan tuberculosis. jakarta dinas kesehatan provinsi jawa timur, 2010. laporan penanggulangan tb paru di jawa timur. tidak dipublikasikan. surabaya. erawatinisih, dkk., 2009. faktor-faktor yang memengaruhi ketidakpatuhan berobat pada pasien tuberculosis paru. hasil penelitian. tidak dipublikasikan. ervin, e.n., 2002. advanced community health nursing practice: population-focused care. new jersey: prentice-hall. friedman, m.m., 1998 family nursing: research, theory and practice. (4th ed.), california: appleton and lange. freeman, rb. 1981. community health nursing practice, (2th ed.) philadelphia: w.b. saunders. gillies, dee, a., 1994. nursing managemant a system approach. (3th ed.), usa: wb. saunders company george, jb. 2002. nursing theories: base for professional nursing. (5th ed). pearson education hanson, s.m.h., dan boyd, st., 1996. family health care nursing: theory, practice and research, philadelphia: f.a. davis company. model adaptif conservation (acm) (siti nur kholifah) 63 hutapea p., 2009. pengaruh dukungan keluarga terhadap kepatuhan minum obat anti-tuberculosis di rsud dr. syaiful anwar malang. hasil penelitian. tidak dipublikasikan. kementerian kesehatan republik indonesia, 2010. hasil riset kesehatan dasar (riskesdas) tahun 2010. jakarta. levine, m.e., 1973. introduction to clinical nursing. philadelphia: f.a. davis company. n a s r u l , e f f e n d y, 2 0 0 9 . d a s a rd a s a r keperawatan kesehatan masyarakat. jakarta; egc. parker, m.e., 2001. nursing theories and n u r s i n g p r a c t i c e . p h i l a d e l p h i a : f. a. davis company. papalia, d.e.s.w., old, r.d., feldman., 2008. human development. 9th ed. mcgrawhill co. pratiwi, a.h., 2008. hubungan antara partisipasi pengawas menelan obat (pmo), keluarga dengan sikap pasien tuberkulosis paru di wilayah kerja puskesmas banyuanyar surakarta. skripsi. tidak dipublikasikan. roy, sister, callista, 1991. the roy adaptation model, the defi nitif statement. appleton and lange a publishing division of prentice-hall. smet, b., 1994. psikologi kesehatan. jakarta: garamedia wiidiasarana indonesia. suparyanto, 2009. konsep kepatuhan. (online), (http//www.suparyanto blog.spot., diakses tanggal 18 januari 2011). syakira, 2009. konsep kepatuhan. (online), (http//www. syakira blog.spot., diakses tanggal 16 januari 2011). tomey, a.m. and alligood, m.r., 2006. nursing theorists and their work. (6th ed.). elsevier health science. vol 8 no 1 april 2013.indd 153 model caring islami terhadap peningkatan kepuasan pasien (islamic caring model on increase patient satisfaction) muh. abdurrouf*, nursalam**, purwaningsih** *fik unissula jl. raya kaligawe km.4 po. box. 1235 semarang e-mail: rouf_dmk@yahoo.com **fakultas keperawatan universitas airlangga surabaya abstrak pendahuluan: kepuasan pasien merupakan hal penting yang harus diperhatikan oleh penyedia pelayanan kesehatan, pasien yang tidak puas akan meninggalkan rumah sakit dan menjadi pelanggan pesaing sehingga dapat menyebabkan penurunan penjualan produk/jasa dan pada gilirannya dapat menurunkan laba dan bahkan kerugian, oleh karena itu rumah sakit harus memberikan pelayanan terbaik sehingga dapat meningkatkan kepuasan pasien. tujuan penelitian ini adalah menjelaskan pengaruh model caring islami terhadap peningkatan kepuasan pasien. metode: penelitian ini menggunakan desain pre-eksperimen, dengan responden sebanyak 31 pasien pada kelompok perlakuan yang diberikan caring islami dan 31 pasien kelompok kontrol yang tidak diberikan caring islami di instalasi rawat inap bedah rumah sakit islam sultan agung semarang dengan menggunakan teknik consecutive sampling, data kepuasan pasien dikumpulkan melalui kuesioner dan dianalisis dengan uji mann-whitney, adapun untuk mengetahui pengaruh caring islami terhadap kepuasan pasien dianalisis dengan uji spearman’s rho. hasil: hasil penelitian menunjukkan bahwa terdapat pengaruh secara signifi kan caring islami terhadap perceived disconfi rmation (p=0,000), terdapat pengaruh perceived disconfi rmation terhadap kepuasan pasien secara signifi kan (p=0,000), terdapat pengaruh secara signifikan caring islami terhadap kepuasan pasien pada kelompok perlakuan dengan kelompok control (p=0,001). pembahasan: kesimpulan dalam penelitian ini yaitu model caring islami dapat diterapkan di rumah sakit sehingga bisa meningkatkan perceived disconfi rmation dan kepuasan pasien, upaya yang dilakukan untuk meningkatkan kepuasan pasien perlu memperhatikan peningkatan dimensi emphaty dan responsiveness, pasien yang diberikan caring islami memiliki tingkat kepuasan lebih tinggi daripada pasien yang tidak diberikan caring islami. saran berdasarkan hasil penelitian yaitu model caring islami dapat diterapkan di rumah sakit sebagai model asuhan keperawatan sehingga bisa meningkatkan kepuasan pasien, perilaku caring islami dapat dipelajari dan ditingkatkan melalui pelatihan dan komitmen yang tinggi serta dapat diaplikasikan dengan menampilkan perilaku professional, ramah, amanah, istiqomah, sabar dan ikhlas dalam memberikan asuhan keperawatan, penelitian lebih lanjut terhadap variabel lain yang belum diteliti sesuai teori expectancy-disconfi rmation menurut wodruff dan gardial 2002 yaitu comparison standard dan satisfaction outcome. kata kunci: caring islami, perceived disconfi rmation, kepuasan pasien. abstract introduction: patient satisfaction was important aspect that must be considered by health service providers, patients who were not satisfi ed will leave the hospital and be a competitor's customers so be able caused a decrease in sales of products/services and in turn could reduce and even loss of profi t, therefore, the hospital must provided the best service so that it could increase patient satisfaction. the purpose of this study was to exams the effect of islamic caring model on increase patient satisfaction.. method: this study was used pre-experimental design, the respondents were 31 patients in the treatment group assigned islamic caring and 31 patients with a kontrol group that were not given islamic caring inpatient surgical sultan agung islamic hospital semarang by using 154 jurnal ners vol. 8 no. 1 april 2013: 153–164 consecutive sampling techniques, patient satisfaction data collected through questionnaires and analyzed with mann-whitney test, as for fi nding out the islamic caring for patient satisfaction were analyzed with spearmen's rho test. result: the results showed that there was a signifi cant infl uence of islamic caring for perceived disconfi rmation (p=0,000) there was a perceived disconfi rmation infl uence on patient satisfaction signifi cantly (p=0,000), there was a signifi cant infl uence of islamic caring for patient satisfaction in the treatment group with a kontrol group (p=0.001). discussion: discussion of this study was islamic caring model effect on the increase perceived disconfi rmation and patient satisfaction, perceived disconfi rmation effect on patient satisfaction, patient satisfaction who given islamic caring was increase, patients given islamic caring had higher satisfaction levels than patients who not given islamic caring. suggestions put forward based on the results of the study of islamic caring model could be applied in sultan agung islamic hospital as a model of nursing care, islamic caring behavior can be learned and improved through training and commitment and could be applied in providing nursing care, further studies of other variables that had not been examined in accordance expectancy-disconfi rmation theory according wodruff and gardial 2002 of comparison standard and satisfaction outcome. keywords: caring islami, perceived disconfi rmation, patient satisfaction meninggalkan per usahaan dan menjadi pelanggan pesaing, hal ini dapat menyebabkan penurunan penjualan produk/jasa dan pada gilirannya dapat menurunkan laba dan bahkan kerugian, oleh karena itu perusahaan jasa kesehatan/rumah sakit harus dapat memuaskan pelanggan/pasien (supranto, 2006). ke t id a k p u a s a n p a sie n t e r h a d a p palayanan keperawatan dapat dipengaruhi oleh beberapa faktor antara lain : product yaitu mutu tidaknya sebuah produk/jasa, price atau biaya yang harus dibayarkan oleh pasien terhadap pelayanan yang diterima, place yaitu tempat atau fasilitas yang diberikan, promotion yaitu kesesuaian antara produk/ jasa yang diterima dengan informasi yang diberikan, process atau mekanisme pelayanan dan people yaitu tenaga atau sumber daya yang memberikan pelayanan (wiyono, 2007). perawat sebagai tenaga kesehatan yang paling banyak bersama pasien dituntut untuk memberikan pelayanan terbaik berupa perilaku caring di mana caring merupakan inti dari keperawatan berupa pengetahuan, sikap dan perilaku yang dilandasi oleh nilainilai kebaikan, perhatian, kasih terhadap diri sendiri dan orang lain serta menghormati keyakinan spiritual klien bertujuan untuk melindungi, meningkatkan dan membantu orang lain dalam proses penyembuhan. perilaku caring yang diberikan perawat kepada pasien dapat meningkatkan kepuasan pendahuluan pelayanan keperawatan mer upakan suatu bentuk pelayanan profesional sebagai bagian integral dari pelayanan kesehatan yang mempunyai daya ungkit besar terhadap pembang unan bidang kesehatan (ppni, 2012), perawat mer upakan sumber daya manusia terbesar dalam pelayanan kesehatan di rumah sakit, di mana perawat bekerja selama 24 jam setiap harinya secara bergilir dan berkesinambungan untuk memberikan asuhan keperawatan yang komprehensif dan profesional dan siap membantu pasien setiap saat. perawat memiliki posisi yang vital di mana sehari-harinya perawat kontak langsung dan mempunyai waktu terbanyak dalam berinteraksi dengan klien sehingga tinggi rendahnya mutu pelayanan kesehatan di rumah sakit salah satunya ditentukan oleh tenaga keperawatan (farida, 2011), di mana mutu/kualitas pelayanan kesehatan yang diberikan akan mempengar uhi kepuasan pasien (kucukarslan dan nadkarni, 2008). l e mb a g a p e nye d ia ja s a / laya n a n dituntut untuk selalu memberikan pelayanan terbaik kepada palanggan/konsumen karena adanya persaingan yang semakin ketat. para konsumen akan mencari produk ber upa pelayanan atau jasa dari perusahaan yang dapat memberikan pelayanan yang terbaik kepadanya. pelanggan yang tidak puas akan 155 model caring islami (muh. abdurrouf, dkk) pasien (rafii, et al, 2007) apalagi dengan memasukkan nilai-nilai islam di mana nilai nilai islam bersifat rahmatan lil alamin atau kasih sayang untuk seluruh makhluk tanpa melihat ras suku, bangsa, bahasa dan agama, sehingga dengan diterapkannya caring islami akan lebih meningkatkan kepuasan pasien di rumah sakit. bahan dan metode rancangan penelitian dalam penelitian i n i mengg u na ka n praeksper i men (the static group comparison) yang bertujuan membandingkan data kepuasan pasien pada kelompok perlak uan dengan kelompok kontrol setelah diberikan tindakan caring islami. populasi dalam penelitian ini adalah seluruh pasien kelas 2 dan 3 di ruang rawat inap bedah rsi sultan agung pada bulan maret sampai dengan april 2013. sampel pada penelitian ini adalah pasien kelas 2 dan 3 di ruang rawat inap bedah rsi sultan agung, sebanyak 31 responden pada kelompok perlakuan dan 31 responden pada kelompok kontrol. kriteria inklusi: pasien dewasa, pendidikan minimal sd, dapat membaca dan menulis, pasien yang dirawat lebih dari 3 hari. kriteria eksklusinya adalah pasien yang mengalami penurunan tingkat kesadaran, tidak bersedia menjadi responden, pasien jamkesmas. variabel independen pada penelitian ini adalah caring islami dan perceive disconfi rmation. variabel dependen dan variabel dependen pada penelitian ini adalah kepuasan pasien. pengambilan sampel dalam penelitian ini menggunakan teknik consecutive sampling yaitu dengan mengambil semua responden yang memenuhi kriteria inklusi sampai terpenuhi jumlah sampel. instrumen yang digunakan untuk pengumpulan penilaian data caring islami menggunakan modif ikasi kuesioner caring behaviour inventory (cbi-24) yang telah dikembangkan oleh wu et al (2006) berdasarkan teori caring transpersonal watson. instrumen perceive disconfirmation memuat tentang penilaian pasien terhadap kinerja yang dirasakan atau yang diterima dibandingkan dengan harapan pasien. kuesioner yang digunakan merupakan modifi kasi dari teori servqual menurut parasuraman, zeithmal dan berry tahu n (1996) dan inst r u men kepuasan pasien pada caring islami meliputi: rater (reliability, assurance, tangible, emphaty, responsiveness). kuesioner mer upakan modif i kasi dar i bu k u nu rsalam t ahu n 2011. latihan penerapan caring islami oleh perawat kepada pasien dengan bimbingan atau pendampingan oleh peneliti dan tim secara bergantian dalam 3 shift selama 1 minggu. penerapan caring islami pada kelompok perlakuan mulai dari pasien masuk sampai pasien pulang, dan pada kelompok kontrol tidak diberikan caring islami mulai pasien masu k sampai pasien pulang obser vasi kepuasan pasien pada kelompok perlakuan dan kelompok kontrol setelah 3 hari perawatan atau pada saat pasien pulang dengan cara mengajukan lembar perset ujuan kepada responden apabila setuju dilanjutkan dengan pengisian kuesioner. tabel 1. perilaku caring islami perawat di irna bedah rsi sultan agung semarang no. parameter kriteria totaltinggi sedang rendah σ % σ % σ % σ % 1 profesional 23 74 8 26 0 0 31 100 2 ramah 19 61 10 32 2 7 31 100 3 amanah 19 61 9 29 3 10 31 100 4 istiqomah 19 61 9 29 3 10 31 100 5 sabar 15 48 12 39 4 13 31 100 6 ikhlas 18 58 9 29 4 13 31 100 jumlah 113 363 57 184 16 53 186 600 156 jurnal ners vol. 8 no. 1 april 2013: 153–164 tabel 2. perceived disconfi rmation pasien irna bedah rsi sultan agung semarang no. dimensi kriteria totalsangat baik baik buruk σ % σ % σ % σ % 1 reliability 10 32 19 61 2 6 31 100 2 assurance 7 23 22 71 2 6 31 100 3 tangible 7 23 22 71 2 6 31 100 4 emphaty 8 26 21 68 2 6 31 100 5 responsiveness 9 29 19 61 3 10 31 100 jumlah 41 134 103 332 11 34 155 500 tabel 3. kepuasan pasien irna bedah rsi sultan agung semarang no dimensi kelompok perlakuan kelompok kontrol totaltinggi sedang rendah tinggi sedang rendah σ % σ % σ % σ % σ % σ % σ % 1 reliability 12 39 16 51 3 10 3 10 27 87 1 3 31 100 2 assurance 10 32 18 58 3 10 1 3 28 90 2 7 31 100 3 tangible 11 35 17 55 3 10 3 10 22 71 6 19 31 100 4 emphaty 9 29 18 58 4 13 1 3 24 78 6 19 31 100 5 responsiveness 8 26 19 61 4 13 6 19 24 78 1 3 31 100 jumlah 50 161 88 283 17 56 14 45 125 404 16 51 155 500 tabel 4. uji spearman’s rho pengaruh perilaku caring islami terhadap perceived disconfi rmation pasien irna bedah rsi sultan agung semarang variabel n r p perilaku caring islami terhadap perceived disconfi rmation 31 0,626 0,000 tabel 5. uji regresi linier sederhana pengaruh perceived disconfi rmation terhadap kepuasan pasien irna bedah rsi sultan agung semarang variabel n r square r p perceived disconfi rmation terhadap kepuasan pasien 31 0,474 0,688 0,000 tabel 6. uji spearman’s rho pengaruh perilaku caring islami terhadap kepuasan pasien pasien irna bedah rsi sultan agung semarang variabel n r p caring islami terhadap kepuasan pasien 31 0,644 0,000 tabel 7. uji mann-whitney kepuasan pasien pada kelompok kontrol dan kelompok perlakuan pasien irna bedah rsi sultan agung semarang variabel n p kepuasan kelompok perlakuan dan kelompok kontrol 62 0,001 157 model caring islami (muh. abdurrouf, dkk) hasil a n a l i si s d a t a p e n el it i a n u nt u k membandingkan antara kelompok kontrol dan kelompok perlakuan yang diberikan caring islami terhadap kepuasan pasien dengan menggunakan uji statistik mann whitney karena data kepuasan pasien pada kelompok kontrol tidak berdistribusi normal dengan tingkat kemaknaan 0,05 dengan ketentuan pengaruh dikatakan bermakna bila ρ value ≤ 0,05 dan pengaruh dikatakan tidak bermakna bila ρ value ≥ 0,05. pembahasan terdapat pengaruh yang signif ikan perilaku caring islami terhadap perceived disconfi rmation pasien di rsi sultan agung semarang. caring islami yang terdiri dari professional, ramah, amanah, istiqomah, ik hlas dan sabar ber pengar uh terhadap perceived disconfi rmation yang terdiri dari reliability, assurance, tangible, emphaty, dan responsiveness. caring islami mer upakan perilaku profesional perawat dalam memberikan p el a y a n a n ke p e r a w a t a n b e r d a s a r k a n kemampuan intelektual yang diberikan kepada pasien, keluarga dan masyarakat dengan penuh perhatian, peduli, ramah, empati, santun, komunikasi terapeutik serta selalu tanggap untuk memberikan yang terbaik bagi klien berdasarkan al-quran dan assunnah. caring islami mencakup beberapa karakteristik antara lain professional, ramah, amanah, istiqomah, sabar dan ikhlas (widarti, 2010). caring islami merupakan perceived performance atau kinerja yang diterima oleh pasien dalam teori expectancy-disconfi rmation yang dikemukakan oleh woodruff dan gardial (2002) yaitu bentuk kinerja obyektif atau teknis yang diberikan oleh perawat kepada pasien berupa pelayanan keperawatan di mana pasien akan merasa lebih puas dengan kemampuan perawat untuk menyediakan apa yang mereka butuhkan. perceived disconf irmation adalah evaluasi kinerja yang dirasakan sesuai dengan perbandingan satu atau lebih standar. disconfi rmation dapat memiliki efek positif (umumnya menyiratkan hasil memuaskan), efek negatif (umumnya menyiratkan hasil yang tidak memuaskan), atau tidak berefek. kepuasan pasien ditentukan oleh dipenuhi atau tidak dipenuhi (dis/confi rmation) harapan pasien, sedangkan dipenu hi atau tidak dipenuhi (dis/confi rmation) harapan pasien ditentukan oleh perbandingan antara harapan dan pengalaman saat ini (damayanti, 2001) pengar u h caring islami terhadap p e r c e i v e d d i s c o n f i r m a t i o n d id u k u n g oleh woodr uff dan gardial (2002) dan hong (2006) yang menyat a kan bahwa perceived disconfi rmation dipengaruhi oleh perceived performance dalam hal ini caring islami, menurut hom (2000), pasien akan membandingkan antara kinerja yang mereka terima atau perceived performance dengan standar atau pengalaman mereka unt uk menilai apakah sesuai harapan atau tidak sesuai harapan, penilaian positif apabila sesuai dengan harapan dan penilaian negatif bila tidak sesuai harapan. pasien sebagian besar menilai perilaku caring islami perawat tinggi terutama pada dimensi professional, hal ini karena perawat telah mendapatkan pelatihan caring islami dan beberapa perawat ada yang per nah mengikuti pelatihan komunikasi terapeutik dan manajemen bangsal, rsi sultan agung saat ini mulai menerapkan perawatan islami dimulai pada ruang vip dan ada perwakilan perawat dari r uang lain yang dilibatkan dalam beberapa pelatihannya, pada tabel 1.3 menunjukkan bahwa pasien kecenderungan memiliki perceived disconf irmation baik ter ut ama pada dimensi assurance dan tangible. caring islami pada dimensi professional dinilai tinggi oleh pasien karena pasien menilai perawat selalu mengetahui cara memasang infus, mengetahui cara melakukan injeksi, pasien menilai perawat selalu percaya diri dan menunjukkan profesionalisme di hadapan pasien serta mampu menggunakan peralatan dengan baik, perawat selalu memberikan informasi dengan penuh keyakinan pada pasien. sehingga sebagian besar pasien menilai perilaku caring islami perawat dalam dimensi professional dalam kategori tinggi, meskipun 158 jurnal ners vol. 8 no. 1 april 2013: 153–164 pada dimensi sabar dan ikhlas ada beberapa pasien menilai buruk hal ini bisa disebabkan beban kerja perawat terkadang tinggi ketika pasien penuh sementara jumlah perawat belum sesuai dengan kebutuhan ruangan dan juga bisa diakibatkan pembagian ketenagaan pada masing-masing shift yang belum optimal, menur ut prawitasari (2009) beban kerja perawat pelaksana yang adekuat diperlukan agar perawat dapat memberikan pelayanan yang sesuai dengan standar pelayanan keperawatan dan meminimalkan terjadinya masalah keselamatan pasien. perceived disconfi rmation baik terutama pada dimensi assurance dan tangible karena pasien menilai baik atau sesuai dengan harapan pasien yaitu perawat memberi perhatian terhadap keluhan yang pasien rasakan, perawat dapat menjawab pertanyaan tentang tindakan keperawatan yang diberikan kepada pasien, perawat jujur dalam memberikan informasi tentang keadaan pasien, perawat selalu memberikan salam dan senyum ketika bertemu dengan pasien, perawat teliti dan terampil dalam melaksanakan tindakan keperawatan kepada pasien, perawat menjaga kebersihan dan kerapian ruangan yang pasien tempati, perawat selalu menjaga kerapian dan penampilannya, perawat ramah dan tampak senang dalam merawat pasien, perawat menjaga kebersihan dan kesiapan peralatan kesehatan yang digunakan, perawat tampak percaya diri dalam melakukan tindakan keperawatan, sehingga pasien memiliki perceived disconfi rmation baik pada dimensi assurance dan tangible. uji hipotesis dengan spearman rho yang menunjukkan hasil bahwa ada pengaruh yang signifi kan antara perilaku caring islami terhadap perceived disconfi rmation pasien di rsi sultan agung semarang hal ini sesuai dengan model expectancy-disconfirmation menurut woodruff dan gardial (2002). pasien yang diberikan caring islami, mereka akan membandingkan atau mengevaluasi antara pelayanan keperawatan yang diberikan berupa perilaku perawat yang professional, ramah, amanah, istiqomah, sabar dan ikhlas dengan harapan-harapan dan pengalaman sebelumnya, apabila pasien terpenuhi harapannya maka pasien akan mempunyai persepsi yang positif terhadap pelayanan keperawatan di rumah sakit (baik), apabila pelayanan yang diberikan melebihi harapannya maka pasien akan memiliki penilaian (disconfirmation) yang lebih positif (sangat baik). berdasarkan hasil penelitian tersebut didapatkan data bahwa semakin tinggi perilaku caring islami maka pasien akan memiliki disconfi rmation yang sangat baik. terdapat pengaruh yang signif ikan perceived disconfi rmation terhadap kepuasan pasien di rsi sultan agung semarang yang terdiri dari dimensi reliability, assurance, tangible, emphat y, dan responsiveness. pengaruh perceived disconfi rmation terhadap kepuasan pasien didukung oleh hong (2006) yang menyatakan bahwa ada pengar uh perceived disconfi rmation terhadap kepuasan pasien, demikian juga disampaikan oleh woodr uff et al. (2003) bahwa perceived disconfi rmation berpengaruh positif terhadap kepuasan pasien, meskipun hasil riset yang dilakukan oleh kucukarslan dan nadkarni (2008) dalam penelitian nya evaluating medicatio-related service in hospital setting using the disconfi rmation of expectation menunjukkan tidak ada pengar uh antara disconf irmation of expectation terhadap kepuasan pasien. riset yang dilakukan oleh kucukarslan dan nadkarni (2008) adalah disconfi rmation atau penilaian terhadap pelayanan medis sed a ng ka n pad a penelit ia n i n i ad ala h penilaian terhadap pelayanan keperawatan atau caring islami di mana pelayanan medis belum bisa menggambarkan pelayanan rumah sakit secara utuh karena porsinya lebih kecil dibandingkan dengan pelayanan keperawatan, pelayanan keperawatan memiliki posisi yang vital di mana perawat selalu kontak langsung dan mempunyai waktu terbanyak dalam berinteraksi dengan klien sehingga tinggi rendahnya mutu pelayanan kesehatan di rumah sakit sangat besar dipengaruhi oleh pelayanan keperawatan karena 90% pelayanan kesehatan di rumah sakit diberikan oleh perawat (damayanti, 2001) sehingga antara disconf irmation atau penilaian terhadap pelayanan medis dengan disconf irmation 159 model caring islami (muh. abdurrouf, dkk) atau penilaian terhadap pelayanan berbeda pengaruhnya terhadap kepuasan pasien. disconfi rmation merupakan kesimpulan dari evaluasi terhadap kinerja yang dirasakan dibandingkan dengan standar, apabila sesuai dengan harapan maka akan merasa puas dan apabila tidak sesuai harapan maka akan tidak puas. pasien yang dirawat di rumah sakit mempunyai bermacam harapan dan akan membandingkan atau menilai (disconfi rmation) antara apa yang diterima atau pelayanan yang diberikan dengan harapannya, apabila kenyataan yang didapatkan berupa pelayanan di rumah sakit sesuai harapan (baik) maka pasien akan puas, sebaliknya bila pengalaman selama mendapatkan pelayanan di rumah sakit tidak sesuai harapan (buruk) maka pasien akan merasa tidak puas, dan bila pelayanan yang diberikan melebihi harapan pasien (sangat baik) maka pasien akan merasa sangat puas (suryawati, 2004); (supranto, 2006) ke ce nde r u nga n pa sie n me m i l i k i perceived disconfi rmation baik pada semua dimensi terutama assurance dan tangible, dan pasien sebagian besar memiliki tingkat kepuasan sedang pada semua dimensi terutama pada dimensi responsiveness. pasien sebagian besar memiliki tingkat kepuasan sedang pada dimensi responsiveness karena perawat segera menawarkan bantuan tanpa diminta saat melihat pasien kesulitan, perawat melakukan orientasi kepada pasien saat masuk ruangan perawatan, perawat segera datang bila dipanggil (tidak memerlukan waktu menunggu yang lama) khususnya keluhan tentang penyakit, perawat bersedia membantu pasien untuk berjalan, bab, bak, ganti posisi tidur bila dibutuhkan, perawat mengikutkan pasien dan keluarga dalam perawatan, perawat membantu pasien untuk pelaksanaan foto dan pemeriksaan laboratorium di rumah sakit. hasil ini didukung oleh uji regresi linier sederhana bahwa ada pengaruh yang signifi kan perceived disconfi rmation terhadap kepuasan pasien dan menunjukkan besar hubungan bersifat kuat, hal ini sesuai dengan model a conceptual look at the infl uence of relationship structure on the disconfi rmation process in a business-to business context yang dikemukakan oleh (woodruff et al, 2003). kepuasan pasien ditentukan oleh bagaimana penilaian (disconfi rmation) pasien terhadap pelayanan keperawatan yang diberikan apabila penilaiannya buruk maka pasien akan merasa tidak puas, apabila pasien menilai pelayanan yang diberikan baik maka akan merasa puas dan apabila pasien menilai pelayanan yang diberikan oleh rumah sakit sangat baik maka pasien akan merasa sangat puas. berdasarkan hasil penelitian tersebut dapat disimpulkan bahwa semakin baik penilaian pasien terhadap pelayanan yang diberikan maka pasien akan semakin puas. terdapat pengar uh perilaku caring islami terhadap kepuasan pasien di rsi sultan agung semarang yang terdiri dari dimensi reliability, assurance, tangible, emphaty, dan responsiveness. pengar u h per ila k u caring islam i terhadap kepuasan pasien didukung oleh woodruff et al. (2003) yang menyebutkan p e r c e i v e d p e r f o r m a n c e b e r p e n g a r u h t e rh a d ap ke pu a s a n pa sie n , p e r c e i ve d performance dalam penelitian ini adalah caring islami. supriyanto dan er nawaty (2010) menyatakan bahwa kepuasan pasien dipengaruhi oleh pelayanan yang diberikan oleh rumah sakit, pelayanan yang diberikan oleh institusi pelayanan kesehatan dianggap baik apabila dalam memberikan pelayanan lebih memperhatikan kebut uhan pasien. kepuasan pasien dapat muncul dari kesan pertama terhadap pelayanan keperawatan yang diberikan, misalnya: pelayanan yang cepat, ramah dan tanggap dalam memberikan pelayanan keperawatan. menurut kucukarslan dan nadkarni (2008) bahwa ada hubungan yang positif antara kepuasan pasien dengan pelayanan medis, kepuasan adalah tingkat kepuasan seseorang setelah membandingkan kinerja atau hasil yang dirasakan dibandingkan dengan harapannya (kotler, 2008) pasien sebagian besar menilai perilaku caring islami perawat tinggi terutama pada dimensi professional, meskipun ada pasien yang menilai buruk pada dimensi sabar dan ikhlas, hal ini bisa disebabkan oleh beberapa hal antara lain pasien dengan lama perawatan yang panjang dan kondisi penyakit pasien menyebabkan pasien menilai perawat kurang 160 jurnal ners vol. 8 no. 1 april 2013: 153–164 sabar dan ikhlas, menurut thi et al. (2002) lama perawatan dan persepsi pasien tentang kondisi penyakit mempengaruhi penilaian pasien terhadap pelayanan yang diberikan. sebagian besar pasien menunjukkan tingkat kepuasan sedang pada semua dimensi terutama dimensi responsiveness. terdapat pengaruh yang signif ikan perilaku caring islami terhadap kepuasan pasien di rsi sultan agung semarang, hal ini sesuai dengan model expectancydisconf irmation menur ut woodr uff dan gardial (2002) yaitu perceived performance dalam penelitian ini berupa kinerja pelayanan keperawatan atau caring islami yang diberikan kepada pasien berpengaruh terhadap kepuasan pasien. kepuasan merupakan perasaan senang seseorang setelah mener ima pelayanan dibandingkan dengan harapannya, pasien yang diberikan caring islami akan merasa puas karena pasien mendapatkan pelayanan keperawatan oleh perawat yang memiliki karakter antara lain profesional, ramah, amanah, istiqomah, sabar dan ikhlas, sehingga pasien mendapatkan pelayanan yang sesuai dengan harapannya atau bahkan melebihi harapan pasien. berdasarkan hasil penelitian tersebut dapat disimpulkan bahwa semakin tinggi perilaku caring islami perawat maka pasien akan menunjukkan kepuasan yang meningkat. ha si l p e nel it ia n pa d a t ab el 1.8 menunjukkan ada perbedaan yang signifi kan rata-rata tingkat kepuasan pasien pada kelompok perlakuan yang diberikan caring islami dan kelompok kontrol yang tidak diberikan caring islami, caring islami terdiri dari profesional, ramah, amanah, istiqomah sabar dan ikhlas, pasien yang diberikan caring islami akan memiliki tingkat kepuasan lebih tinggi daripada yang tidak diberikan caring islami kelompok perlakuan memiliki kepuasan tinggi lebih besar daripada kelompok kontrol pada semua dimensi reliability, assurance, tangible, emphat y, dan responsiveness, namun pasien yang memiliki kepuasan rendah pada dimensi reliability, assurance, dan responsiveness pada kelompok perlakuan lebih banyak daripada kelompok kontrol, hal ini bisa disebabkan karena pada kelompok kontrol yang memiliki tingkat pendidikan rendah lebih banyak sehingga t unt utan terhadap pelayanan keperawatan lebih sedikit, menurut hekkert (2009) pendidikan pasien berpengaruh terhadap kepuasan pasien, pasien yang berpendidikan lebih tinggi lebih banyak yang menyatakan tidak puas dibandingkan pasien yang berpendidikan rendah karena pasien dengan tingkat pendidikan rendah lebih sedikit tuntutan daripada pasien dengan pendidikan yang lebih tinggi, pada kelompok kontrol pasien usia tua lebih banyak daripada kelompok perlakuan sehingga pasien akan cenderung puas, menurut thi, briancon, empereur dan guillemin (2002) pasien yang berumur lebih tua akan lebih merasa puas dibandingkan dengan pasien yang berumur lebih muda. dimensi reliabilit y pada kelompok perlakuan mempunyai tingkat kepuasan tinggi lebih banyak daripada kelompok kontrol yaitu perawat menangani pasien tepat waktu saat melakukan kegiatan non medis seperti, memandikan, makan, ganti balut, perawat melakukan tindakan sesuai dengan waktunya, perawat mampu menangani masalah perawatan pasien dengan tepat dan professional, perawat memberitahukan cara perawatan, cara minum obat secara lengkap, perawat berusaha agar pasien merasa puas selama dirawat di rumah sakit, sehingga pasien memiliki tingkat kepuasan tinggi pada kelompok perlakuan untuk dimensi reliability. dimensi assurance pada kelompok perlakuan menunjukkan tingkat kepuasan tinggi lebih banyak daripada kelompok kontrol yaitu perawat mampu menjawab dengan jelas per tanyaan pasien terkait tindakan keperawatan, perawat memberikan dukungan/motivasi kepada pasien agar cepat sembuh dan berobat dengan baik, perawat memberikan ketenangan ketika pasien cemas atau ketak utan, perawat dapat menjadi penghubung antara pasien dengan dokter maupun rumah sakit, perawat bertanggung jawab dan jujur atas tindakannya serta menjaga kerahasiaan tentang penyakit pasien, perawat mengingatkan dan membantu untuk beribadah sesuai dengan kemampuan pasien, sehingga 161 model caring islami (muh. abdurrouf, dkk) pasien menunjukkan tingkat kepuasan tinggi pada kelompok perlakuan untuk dimensi assurance. dimensi tangible pada kelompok perlakuan menunjukkan tingkat kepuasan tinggi lebih banyak daripada kelompok kontrol yaitu pasien menilai perawat rapi, bersih, dan berpenampilan baik, perawat selalu memberi salam dan senyum saat bertemu dengan pasien, perawat kelihatan senang dan ramah saat merawat pasien, perawat selalu bersikap halus dan menerima jika ada sikap negatif dari pasien, perawat tampak percaya diri di hadapan pasien saat melakukan tindakan (terlihat tenang), sehingga pasien memiliki tingkat kepuasan tinggi pada kelompok perlakuan untuk dimensi tangible. dimensi emphaty menunjukkan pasien pada kelompok perlakuan memiliki tingkat kepuasan tinggi lebih banyak daripada kelompok kontrol yaitu perawat mendengarkan keluhan, perasaan, dan masukan pasien dengan penuh perhatian, perawat sering menengok pasien tanpa diminta, minimal untuk menanyakan keadaan dan perasaan pasien, perawat memberikan informasi jelas dan lengkap tentang segala tindakan yang akan dilakukan kepada pasien, perawat memberikan kesempatan kepada pasien untuk berinteraksi dengan pasien lain sesuai keadaan dan kemampuan pasien, perawat mendukung upaya kegiatan dan kreativitas pasien sesuai dengan keadaan dan kemampuan pasien, perawat dalam memberikan pelayanan kepada pasien penuh perhatian, sehingga pasien pada kelompok perlakuan menunjukkan tingkat kepuasan tinggi pada dimensi emphaty. dimensi responsiveness pada kelompok perlakuan menunjukkan tingkat kepuasan tinggi lebih banyak daripada kelompok kontrol yaitu perawat segera menawarkan bantuan tanpa diminta saat melihat pasien kesulitan, perawat melak u kan orientasi kepada pasien saat masuk ruangan perawatan, perawat segera datang bila dipanggil (tidak memerlukan waktu menunggu yang lama) khususnya keluhan tentang penyakit pasien, perawat bersedia membantu pasien untuk berjalan, bab, bak, ganti posisi tidur bila dibutuhkan, perawat mengikutkan pasien dan keluarga dalam perawatan, perawat membantu pasien untuk pelaksanaan foto dan pemeriksaan laboratorium di rumah sakit ini. tingkat kepuasan sedang lebih tinggi pada kelompok kontrol daripada kelompok perlakuan, sehingga pada kelompok perlakuan menunjukkan tingkat kepuasan tinggi untuk dimensi responsiveness. ada perbedaan rata-rata secara signifi kan tingkat kepuasan pasien yang diberikan caring islami dan yang tidak diberikan caring islami, hal ini sesuai dengan woodruff et al. (2003) bahwa perceived performance atau kinerja yang diterima dalam hal ini adalah caring islami berpengaruh terhadap kepuasan pasien, hal senada juga disampaikan oleh sutriyanti (2009) bahwa perilaku caring oleh perawat dalam memberikan pelayanan keperawatan berpengaruh terhadap kepuasan pasien dan keluarga, kinerja yang diterima oleh pasien akan dibandingkan dengan harapan atau pengalaman pasien apabila sesuai harapan maka akan merasa puas dan apabila tidak sesuai harapan maka akan merasa tidak puas. pasien yang diberikan caring islami akan cenderung memiliki kepuasan lebih tinggi dibandingkan dengan yang tidak mendapatkan caring islami, pasien yang diberikan caring islami akan menilai baik pada lima dimensi yaitu reliability, assurance, tangible, emphaty dan responsiveness, dan berdasarkan hasil uji mann-whitney menunjukkan ada perbedaan rata-rata secara signifi kan tingkat kepuasan pasien yang diberikan caring islami dan yang tidak diberikan caring islami. simpulan dan saran simpulan penerapan caring islami oleh perawat di rsi sultan agung berpengaruh terhadap peningkatan perceived disconfi rmation dan kepuasan pasien. perceived disconfi rmation atau penilaian pasien di rsi sultan agung terhadap pelayanan keperawatan berpengaruh terhadap kepuasan pasien. pasien di rsi sultan agung yang diberikan caring islami memiliki tingkat kepuasan lebih tinggi daripada pasien yang tidak diberikan caring islami. 162 jurnal ners vol. 8 no. 1 april 2013: 153–164 saran model caring islami dapat diaplikasikan di r u mah sa k it sebagai model asu han keperawatan dalam memberikan pelayanan keperawatan dengan memberikan pelatihan kepada semua perawat secara ber tahap dan berkesinambungan. perawat di rumah sakit pada dimensi sabar dan ikhlas serta meni ngkatkan responsiveness perawat, manajer keperawatan dapat menghitung kembali kebutuhan tenaga perawat dengan rumus gilies atau depkes dan memenuhi jumlah perawat, mengatur penjadwalan secara efektif sesuai tingkat ketergantungan pasien, mengadakan pelatihan soft skill, melakukan supervisi dan bimbingan kepada perawat. perilaku caring islami dapat dipelajari oleh perawat dan ditingkatkan melalui pelatihan soft skill dan hard skill serta komitmen yang tinggi dalam memberikan asuhan keperawatan sehingga dapat meningkatkan kepuasan pasien dan pada penelitian lebih lanjut terhadap variabel-variabel yang belum diteliti sesuai teori expectancy-disconfirmation menurut wodruff dan gardial (2002) yaitu comparison standard dan satisfaction outcome. kepustakaan aritonang, 2005. kepuasan pelanggan, pengukuran penganalisis dengan spss, jakarta: gramedia pustaka utama. ayubi, 2008. hubungan kepuasan pasien dengan minat kunjungan ulang di puskesmas wisma jaya bekasi, makara kesehatan, 12, 42–46. basford , l., 20 06. teori dan pra k tik keperawatan pendekatan integral pada asuhan pasien, jakarta: egc. bassett, c., 2004. nursing care from teory to practice, london: whurr publishers. blais, hayes, kozier dan erb., 2007. praktek keperawatan profesional konsep dan perspektif, 4th edition, jakarta: egc. dahlan, 2010. besar sampel dan cara pengambilan sampel dalam penelitian kedokteran dan kesehatan, edisi 3, jakarta: salemba medika damayanti, n., 2001. kontribusi kinerja perawat dan harapan pasien dalam dimensi non tek nik k epera watan terhadap kepuasan pasien rawat inap kasus kronis. disertasi program doktor tidak dipublikasikan. surabaya depkes. 2008. pedoman mutu pelayanan keperawatan klinik di sarana kesehatan. jakarta: depkes ri. dossey, keegan, gezzetta, 2005. holistic nursing: a handbook for practice. 4th edition, london: jones and bartlett publishers. dwidayanti, 2007. caring kunci sukses pera wat/ners mengamalk an ilmu. semarang: penerbit hasani. fadilah, h., 2006. asuhan keperawatan islami makalah disajikan pada seminar alquran, sains kedokteran dan fiqih keperawatan. jakarta. maret 2006. farida, 2011. effective leadership and work motivation in the aplication of nursing therapeutic communication, journal ners, 6(1), 31–41. hek ker t, cihangir, berg & kool, 2009. ' p a t i e n t s a t i s f a c t i o n r e v i s i t e d : a multilevel approach. social science & medicine. 69, 68–75, (online), (http:// www.sciencedirect.com/science/article/ pii/s0277953609002470 diakses tanggal 3 januari 2013. jam 12.00) hong, 2005. an integrative model of consumer satisfaction in the context of e-services. international journal of consumer studies. 30(2), 137–149, (online), (http:/ onlinelibrary.wiley.com/doi/10.1111/j.14706431.2005.00458.x / diakses tanggal 11 februari 2013. jam 14.00 wib). hom, 2000. customer satisfaction model. rp group proceedings. 100-108, (online), (http://www.eric.ed.gov/ericwebportal/ search/detailmini.jsp. diakses tanggal 10 februari 2013 jam 15.00 wib) jevon, p., 2010. care of the dying and decresed patient, a practical guide for nurses, oxford usa: wiley-blackwell. kotler, p., 2008. manajemen pemasaran. 13rd edition, jakarta: penerbit erlangga. kozier, b., 2010. buku ajar fundamental keperawatan, konsep, proses dan praktik. 7th edition. jakarta: salemba medika. kucukarslan dan nadkarni, 2008. evaluating medicatio-related service in hospital setting using the disconfi rmation of expectation, research in social and 163 model caring islami (muh. abdurrouf, dkk) administrative farmacy. 4, 12–22, (online), (http://www.sciencedirect.com/ science/ar ticle/pii /s1551741107000022 diakses tanggal 20 desember 2012. jam 15.00 wib). lea et al., 1998. 'caring in nursing: a multi variate análisis'. journal of advanced nursing, 28, 662-671, (online), (http:// on l i nel ibr a r y.w i ley.com /doi /10.10 46/. diakses tanggal 19 desember 2012. jam 13.00 wib). leininger, m., 2002. transcultural nursing concepts, theories, research and practice, 3rd edition, usa: mcgrawhill companies. mpinga dan chastonay, 2011. satisfaction of patients: a right to health. health policy. 100, 144–150, (online), (http:// www.sciencedirect.com/science/article/ pii/s0168851010003283. diakses tanggal 14 desember 2012 jam 11.00 wib). muninjaya, 2011. manajemen mutu pelayanan kesehatan, jakarta: egc. muslim, r., 2011. keperawatan islami, makalah disajikan dalam seminar keperawatan semarang maret 2011. notoatmojo, 2005. metodologi penelitian kesehatan, jakarta: penerbit rineka cipta. nursalam, 2011a. konsep dan penerapan m e t o d o l o g i p e n e l i t i a n i l m u keperawatan pedoman skripsi, tesis dan instrumen penelitian keperawatan. edisi 2. jakarta: salemba medika. nursalam, 2011b. manajemen keperawatan aplikasi dalam praktek keperawatan profesional, 3rd ed it ion, ja ka r t a: salemba medika. pot ter dan per r y, 2009a. fundamental of nursing, 7th edition, singapore: elsevier. pot ter dan per r y, 2007b. fundamental keperawatan, 7th edition, jakar ta: salemba medika. prawitasari, 2009. hubungan beban kerja perawat pelaksana dengan keselamatan pa sie n d i ru m a h s a k it hu sa d a jakarta, tesis, jakarta : fik-ui, tidak dipublikasikan. raf ii, hajinezad, haghani, 2007. 'nurse caring in iran and ist relationship with patient satisfaction', american journal of advanced nursing. 26(2), 18–30, (online), (http://www.ajan.com. au/vol26/26-2_rafi i.pdf . diakses tanggal 16 desember 2012 jam 13.00 wib) r a v i c h a n d r a n , m a n i , k u m a r , prabhakaran,2010. 'infl uence of service quality on customer satisfaction', international journal of business and management, 5, 117–124 , (online), (http://ccsenet.org/journal/index.php/ijbm/ article/view/5158, diakses pada tanggal 9 januari 2013 jam 10.00 wib). ronaldson, 2000. spiritualit y the heart o f n u r si n g, au s t r a l i a : au s m e d publication. soleh, 2000. pengar uh sholat tahajud t e r h a d a p pe n i n g k a t a n re s p o n s ketahanan tubuh, surabaya: disertasi pps unair. sudalhar, 2012. keperawatan islami, tuban: duta ilmu indonesia. supranto. 2006. pengukuran tingkat kepuasan pelanggan untuk menaikkan panguasa pasar, 3rd edition, jakarta: rineka cipta. supriyanto, 2007. metodologi riset, surabaya: program administrasi & kebijakan kesehatan. fkm-unair. supriyanto & ernawaty, 2010. ‘pemasaran industri jasa kesehatan, yogyakarta: andi. s u r y a w a t i , 2 0 0 4. ' k e p u a s a n pa s i e n rumah sakit (tinjauan teoritis dan penerapannya pada penelitian)' jmpk, 7 (4), (i-lib.ug m .a c.id /jur nal/d etail. php?dataid=8613 diakses tanggal 6 februari 2013 jam 09.00 wib). sut r iya nt i, 20 09. penga r uh pelat iha n caring terhadap kepuasan pasien dan keluarga, jakarta: fik ui. tidak dipublikasikan. taylo r, li l l i s , l emon e , ly n n , 2011. fundamental of nursing the art and science of nursing care, 7th edition, lippincott: william & wilkins. tehrani, fieldman, camacho dan balkrishna, 2011. patient satisfaction with outpatient medical care in united state. heath outcomes research in medicine, 2, 4, (online), (http://www.sciencedirect.com/ science/ar ticle/pii /s1877131911000395 diakses tanggal 14 desember 2012 jam 09.00 wib) 164 jurnal ners vol. 8 no. 1 april 2013: 153–164 t h i, br ia ncon , empe reu r, g u il lem i n , 2002. factors determining inpatient satisfaction with care, social science & medicine 54, 493-504, (online), (http:// www.sciencedirect.com/science/article/ pii/s0277953601000454, diakses tanggal 4 januari 2013 jam 13.00 wib) tjiptono dan gregorius, 2005a. service, quality & satisfaction, yogyakarta: andi. tjiptono dan gregorius, 2008b. pemasaran strategik, 2nd edition, yogyakarta: penerbit andi. tomey, 2006. nursing teorists and their work, 7th edition, philadelphia usa: mosby elsevier. watson, j., 2008. nursing the philosophy and science of caring, new york: the university press of colorado. watson, j., 2009. assessing and measuring caring in nursing and health science, 2nd edit ion, new york: spr i nger publishing company. widarti, 2010. implementasi nilai islam dalam pelayanan kesehatan, disampaikan dalam seminar nasional fkik uin syarif hidayatullah, jakarta, 16 agustus 2010 wijono, d., 2007. evaluasi program kesehatan dan rumah sakit, surabaya: cv duta prima airlangga. wood r uff, broyles d an golicie, 2003. a conceptual look at the infl uence of relationship st r uct u re on the disconfi rmation process in a businessto busi ness context', jour nal of customer satisfaction, dissatisfaction & complaining behaviour, 4, 103-109, (online), (http://lilt.ilstu.edu/staylor/csdcb/ ar ticles/ volume16/golicic diakses 15 desember 2012 jam 10.00 wib) woodr uff dan gardial, 2002. practicalpeople oriented perspective, canada: mcgraw-hill publiser company. xiao dan harber, 2008. the effect of perceived health status on patient satisfaction', value in health. 11, 2, (online), (http:// www.sciencedirect.com/science/article/ pii/s1098301510605499 . diakses tanggal 15 desember 2012 jam 13.00 wib) yosep, 2010. spirit & softskill of nursing enterpreneur, 1st edition, bandung: refi ka aditama. vol 8 no 2 oktober 2013.indd 183 indikator pemenuhan kebutuhan nutrisi oleh pasien rawat inap rumah sakit tentara dr. soepraoen malang (inpatients nutritional requirements indicator at army hospital dr. soepraoen malang) kumboyono*, vina* * psik-fk universitas brawijaya jl. veteran malang 65145 e-mail: kumbo_yono05@yahoo.com abstrak pendahuluan: penerimaan pasien terhadap diet sangat mempengaruhi pemenuhan kebutuhan nutrisi pasien selama masa rawat inap. penerimaan terhadap diet yang diberikan rumah sakit dapat dilihat dari jumlah sisa makanan, sedangkan faktor-faktor yang mempengaruhinya adalah makanan tambahan, cita rasa makanan, tingkat adaptasi lingkungan rumah sakit sehingga mempengaruhi motivasi untuk makan. tujuan penelitian untuk mengetahui faktor-faktor yang berhubungan dengan penerimaan diet makanan biasa oleh pasien di ruang rawat inap kelas iii rumah sakit tentara dr. soepraoen malang. metode: desain penelitian yang digunakan deskriptif analitik dengan pendekatan cross-sectional. sampel dipilih secara purposive sampling pada 51 responden. analisis data menggunakan chi-square dengan derajat kemaknaan 95%. hasil: hasil penelitian menunjukkan terdapat hubungan yang signifi kan antara makanan tambahan dengan sisa makanan (pv = 0,018). terdapat hubungan yang signifi kan antara cita rasa dengan sisa makanan (pv = 0,032). terdapat hubungan yang signifi kan antara tingkat adaptasi dengan sisa makanan (pv = 0,026). diskusi: disimpulkan bahwa makanan tambahan, cita rasa makanan, dan tingkat adaptasi berhubungan dengan penerimaan pasien rawat inap terhadap diet. disarankan agar perawat lebih memperhatikan faktor-faktor tersebut dalam memenuhi kebutuhan nutrisi pasien rawat inap di rumah sakit. kata kunci: diet makanan biasa, makanan tambahan, cita rasa makanan, tingkat adaptasi, sisa makanan abstract introduction: patient acceptance to diet infl uences patient intake during the hospitalization. patient acceptance on meals provided by the hospital can be seen from the left over. whilst factors which infl uences patient motivation to fi nish their meals including addtional food, taste, and adaptation level to the hospital, the aim of this research was to identify factors that related to patient acceptance on meals provided by the hospital in class three ward dr. soepraoen hospital, malang. method: descriptive analitic was used as research design with cross-sectional approach. as many as 51 samples were chosen with purposive sampling. data was analyzed with chi square with 95%signifi cance. results: the results showed a signifi cant relation between additional food and the leftover (p-value = 0,018). there is signifi cant relation on the taste and the leftover (p-value = 0.032) and adaptation level and leftover (p-value = 0.026). discussion: it can be concluded that additional food, taste, and adaptation level to the hospital have signifi cant relation with hospitalized patient acceptance on their diet. it is suggested that nurse pay more attention on these factors to fulfi ll patient nutrition needs during hospitalization. keywords: diet, additional food, taste, adaptation level, leftover pendahuluan berdasar visi indonesia sehat 2025 diharapkan masyarakat indonesia memiliki kemampuan menjangkau pelayanan kesehatan yang bermutu dan juga memperoleh jaminan kesehatan. pelayanan kesehatan bermutu yang dimaksud adalah pelayanan yang dapat memenu hi kebut u han masyarakat ser ta diselenggarakan sesuai dengan standar dan etika profesi (depkes ri, 2009). salah satu usaha untuk mencapainya adalah memperbaiki sistem dan manajemen pelayanan di rumah sakit sebagai salah sat u penyelenggara pelayanan kesehatan masyarakat. rumah sakit merupakan salah satu tempat umum yang memberikan pelayanan kesehat a n masya ra kat ya ng kompleks, sehingga banyak sekali pelayanan kesehatan yang berkaitan dan saling bekerja dalam satu tim kesehatan mulai dari pelayanan medis, pelayanan keperawatan, pelayanan gizi, dan pelayanan rehabilitasi (evawati, 2008). salah satu pelayanan di rumah sakit yang memegang peranan penting adalah pelayanan gizi di rumah sakit (pgrs). hal ini mer upakan bagian integral dari pelayanan kesehatan paripurna di rumah sakit dengan beberapa kegiatan, antara lain 184 jurnal ners vol. 8 no. 2 oktober 2013: 183–189 pelayanan gizi rawat inap. pelayanan gizi rawat inap adalah, serangkaian kegiatan yang dilakukan untuk memenuhi kebutuhan gizi pasien melalui makanan sesuai penyakit yang dideritanya. adapun pelayanan gizi rawat inap yang paling umum yaitu penyelenggaraan makanan bagi pasien yang dirawat (almatsier, 2010). penyelenggaraan makanan di rumah sakit dilaksanakan dengan tujuan untuk menyediakan makanan yang kualitasnya baik, jumlah sesuai kebutuhan serta pelayanan yang layak dan memadai bagi pasien yang membutuhkan (depkes, 2007). mutu pelayanan gizi yang baik akan mempengaruhi indikator mutu pelayanan rumah sakit. semakin baik kualitas pelayanan gizi rumah sakit semakin tinggi tingkat kesembuhan pasien, semakin pendek lama rawat inap dan semakin kecil biaya perawatan rumah sakit (depkes, 2007). keberhasilan suatu pelayanan gizi antara lain dikaitkan dengan daya terima pasien terhadap diet yang disajikan, sehingga merupakan salah satu cara penentuan dari evaluasi yang sederhana dan dapat dipakai sebagai indikator keberhasilan pelayanan gizi (susetyowati, 2010). penerimaan diet oleh pasien rumah sakit dapat dilihat dari jumlah sisa makanan di rumah sakit. adapun faktor-faktor yang mempengaruhinya adalah makanan tambahan di luar diet rumah sakit, cita rasa makanan yang kurang enak, tingkat adaptasi terhadap lingkungan rumah sakit yang berbeda dengan lingkungan rumah sehingga mempengaruhi motivasi untuk makan (soegianto, 2008). makanan tambahan biasanya dibawa oleh keluarga pasien di luar dari diet yang diberikan rumah sakit karena alasan makanan tersebut adalah makanan kesukaan pasien (proverawati, 2010). diet dari rumah sakit dibuat rendah/ pantang garam jadi makanan yang disajikan terasa hambar, sehingga makanan terasa kurang enak, dan porsi yang disajikan terlalu banyak bagi pasien sehingga tidak mampu menghabiskan porsi diet yang diberikan. daya terima pasien yang rendah akan berdampak bur uk bagi status gizi dan kesembuhan pasien selain itu daya terima pasien terhadap makanan juga dipengar uhi oleh keadaan fi sik/klinis pasien itu sendiri. sehingga risiko kurang gizi akan muncul secara klinis pada periode rawat inap di rumah sakit berkaitan dengan penyakit yang mendasarinya. perawat merupakan penghubung utama antara pasien dengan anggota tim kesehatan lainnya, karena adanya kontak yang terusmenerus dengan pasien. peran perawat adalah melakukan pemesanan makanan atau diet ke dapur sesuai preskripsi diet yang sudah ditetapkan. perawat mengamati pasien sewaktu makan, melaporkan tentang penerimaan pasien terhadap diet yang diberikan, apakah habis dimakan atau tidak, kemungkinan adanya masalah dengan defekasi atau hal-hal lain yang berkaitan dengan makanan atau diet yang diberikan. perawat bertanggung jawab dalam pemberian makanan peroral, enteral, maupun parenteral, dan memberi laporan secara lisan atau tertulis tentang kemungkinan akibat yang kurang baik karena pemberian makanan tersebut. serta memberi penjelasan secara garis besar kepada pasien dan keluarganya tentang makanan atau diet yang diberikan (almatsier, 2010). rumah sakit tentara dr. soepraoen di kota malang adalah rumah sakit tipe b dengan kapasitas 316 tempat tidur yang terbagi dalam beberapa kelas perawatan dengan jumlah pasien perhari rata-rata 109 pasien. macam-,macam diet makanan yang diberikan kepada pasien tergantung dari jenis penyakitnya dengan kalori standar diet makanan biasa yang diberikan 2080 kalori. penyebab sisa makanan di r umah sakit merupakan masalah yang sangat kompleks dan saling berkaitan dan hal ini akan bervariasi dan berbeda-beda ditiap daerah karena terkait dengan kebiasaan dan perilaku yang berbedabeda juga. dari uraian dan fenomena diatas peneliti ingin mengetahui faktor-faktor yang berhubungan dengan penerimaan diet makanan oleh pasien rawat inap di rumah sakit tentara dr. soepraoen malang. tujuan umum penelitian ini adalah untuk mengetahui faktor-faktor yang berhubungan dengan penerimaan diet makanan biasa yang disajikan pada pasien rawat inap kelas iii di rumah sakit tentara dr. soepraoen malang. manfaat penelitian ini adalah memberikan 185 indikator pemenuhan kebutuhan nutrisi oleh pasien rawat inap (kumboyono, dkk.) informasi dan pemahaman kepada masyarakat tentang faktor-faktor apa saja terkait pengaruh penerimaan makanan pada pasien rawat inap di rumah sakit serta bagi rumah sakit dapat memperbaiki pelayanan asuhan keperawatan pada pasien rawat inapnya. bahan dan metode pe nel it ia n me ngg u na k a n metode deskriptif analitik dengan pendekatan cross sectional. variabel penelitian dilakukan satu kali pengukuran dalam kurun waktu yang sama pada pasien rawat inap kelas iii yang mendapatkan makanan biasa. populasi dalam penelitian ini adalah semua pasien di r uang rawat inap yang mendapatkan makanan biasa yang dirawat di ruang rawat inap kelas iii rumah sakit tentara dr. soepraoen malang yang berjumlah 51 orang. pengambilan sampel penelitian ini dilakukan dengan metode non probability sampling, dengan pengambilan sampel menggunakan teknik purposive sampling. kriteria inklusi: pasien pria dan wanita usia 17–59 tahun yang rawat inap minimal tiga hari di kelas iii, kesadaran compos mentis, diet biasa (2080 kalori). kriteria eksklusi: pasien dengan keluhan menelan, sakit gigi sariawan dan mual/muntah. dat a yang di k u mpul kan meliputi makanan tambahan, cita rasa makanan, tingkat adaptasi terhadap lingkungan rumah sakit dan data sisa makanan. data dianalisis menggunakan chi-suqare dengan tingkat kemaknaan 95%. hasil dari hasil penelitian diketahui bahwa sebagian besar responden berjenis kelamin laki-laki yaitu sebanyak 29 orang (56,86) dan berada pada kisaran umur 45–59 tahun yaitu sebanyak 31 orang (60,78%). adapun masa lama rawat inap pasien mayoritas 3–5 hari yaitu sebanyak 41 orang (80%). tabel 2 menjelaskan bahwa dari 51 responden penelitian, mayoritas responden mengkonsumsi makanan tambahan dari luar rumah sakit yakni sebanyak 43 orang (84%). sebagian besar (61%) responden memberikan penilaian cukup terhadap cita rasa makanan. selama rawat inap mayoritas responden tidak bisa beradaptasi dengan lingkungan rumah sakit yakni sebanyak 31 orang (61%). berdasarkan tabel 3 diketahui dari 51 responden penelitian, mayoritas responden (67%) memiliki sisa makanan karbohidrat dalam jumlah sedikit. sebagian besar (63%) responden memiliki sisa makanan lauk hewani dalam jumlah sedikit. mayoritas (53%) responden mempunyai sisa makanan lauk nabati tergolong banyak. mayoritas (59%) responden mempunyai sisa makanan sayuran tergolong banyak. sebagian besar (63%) responden memiliki sisa makanan buah tergolong sedikit. analisis bivariat dilakukan unt uk mengetahui hubungan antara variabel bebas dengan variabel terikat dianalisis dengan menggunakan uji chi-square. tabel 4 di atas menunjukkan nilai p (0.018) < dari α (0,05), sehingga h0 ditolak. hal ini berarti pada selang kepercayaan 95% diketahui bahwa terdapat hubungan yang signifi kan antara makanan tambahan dengan penerimaan diet makanan biasa. pasien yang tidak mendapatkan makanan tambahan cender ung hanya menyisakan sedikit sisa makanan, baik berupa karbohidrat, lauk hewani, lauk nabati, sayuran dan buahbuahan. tabel 1. karakteristik sampel berdasarkan jenis kelamin, usia, lama rawat inap karakteristik f % jenis kelamin laki-laki perempuan 29 22 57 43 usia 17–25 tahun 25–35 tahun 35–45 tahun 45–59 tahun 2 8 10 31 3 16 20 61 lama rawat inap 3–5 hari 5–10 hari > 10 hari 41 9 1 80 18 2 186 jurnal ners vol. 8 no. 2 oktober 2013: 183–189 lebih kecil daripada α (0,05) sehingga h0 ditolak. diinterpretasikan dari uji tersebut bahwa terdapat hubungan yang signifikan antara kemampuan pasien dalam beradaptasi dengan penerimaan diet makanan biasa. pasien yang tidak bisa beradaptasi cenderung menyisakan diet makanan dalam jumlah yang banyak baik dari unsur karbohidrat, lauk hewani, lauk nabati, sayuran dan buahbuahan. pembahasan berdasarkan hasil penelitian sebagian besar responden yaitu sebanyak 43 orang (84%) mendapatkan makanan tambahan dari luar rumah sakit, dan sebanyak 8 orang (16%) tidak mendapatkan makanan tabel 2. distribusi responden berdasarkan variabel yang berhubungan dengan penerimaan diet variabel n % makanan tambahan responden ada makanan tambahan 43 84 tidak ada makanan tambahan 8 16 cita rasa makanan menurut responden baik 8 16 cukup 31 61 buruk 12 23 t i n g k a t a d a p t a s i t e r h a d a p lingkungan rumah sakit dapat beradaptasi 20 39 tidak dapat beradaptasi 31 61 tabel 3. distribusi responden berdasarkan penerimaan diet jumlah sisa makanan karbohidrat n % banyak 17 33 sedikit 34 67 lauk hewani banyak 19 37 sedikit 32 63 lauk nabati banyak 27 53 sedikit 24 47 jumlah sisa makanan sayuran n % banyak 30 59 sedikit 21 41 buah-buhan banyak 19 37 sedikit 32 63 tabel di atas menunjukkan nilai p (0.032) < α (0,05), sehingga h0 ditolak. pada 95% selang kepercayaan, disimpulkan adanya hubungan yang signifikan antara cita rasa dengan penerimaan diet makanan biasa. pasien yang memiliki cita rasa yang baik terhadap diet, cenderung hanya menyisakan sedikit sisa makanan dari golongan unsur karbohidrat, lauk hewani, lauk nabati, sayuran maupun buah-buahan. hasil uji chi-square pad a selang kepercayaan 95%, diperoleh nilai p (0,026) tabel 4. hubungan makanan tambahan dengan sisa makanan makanan tambahan sisa makanan total x2 sig. sedikit banyak n % n % n % ada 19 37 24 47 43 84 5,63 0,018tidak ada 8 16 0 0 8 16 total 27 53 24 47 51 100 tabel 5. hubungan cita rasa makanan dengan sisa makanan cita rasa makanan sisa makanan total x2 sig. sedikit banyak n % n % n % baik 7 15 1 1 8 16 7,73 0,032 cukup 17 33 14 28 31 61 kurang 3 5 9 18 12 23 total 27 53 24 47 51 100 tabel 6. hubungan tingkat adaptasi dengan sisa makanan tingkat adaptasi sisa makanan total x2 sig. sedikit banyak n % n % n % bisa beradaptasi 17 33 3 6 20 39 6,28 0,026tidak bisa beradaptasi 10 20 21 41 31 61 total 27 53 24 47 51 100 187 indikator pemenuhan kebutuhan nutrisi oleh pasien rawat inap (kumboyono, dkk.) tambahan. berdasarkan hasil analisis statistik menggunakan uji chi-square terdapat hubungan yang signifi kan antara makanan tambahan dengan sisa makanan pada pasien dengan nilai p < 0,05. pasien yang tidak mendapatkan makanan tambahan cenderung menyisakan sedikit sisa makanan. sedangkan pasien yang mendapatkan makanan tambahan cenderung menyisakan banyak makanan. pasien rawat inap selain mengkonsumsi makanan dari rumah sakit juga mengkonsumsi makanan dari luar rumah sakit, sehingga menimbulkan terjadinya banyak sisa makanan pada pasien rawat inap (sumiyati, 2008). pasien seringkali mengeluh nafsu makan berkurang ketika disajikan makanan dari rumah sakit (kozier et al., 2009). sebagai dampaknya kerabat/ keluarga sering membawa makanan kesukaan pasien dari rumah atau membeli makanan kesukaan pasien dari luar, sehingga pasien sudah merasa kenyang dengan konsumsi makanan di luar diet tersebut (evawati, 2008). akibatnya makanan yang di sajikan dari rumah sakit banyak tersisa untuk dibuang. adapun makanan tambahan yang paling banyak dikonsumsi oleh 48 responden adalah makanan ringan seperti roti, kue kering, kue tradisional dan buah-buahan serta beberapa menu makanan pokok seperti pecel, ayam goreng lalapan, sop ayam, ikan panggang dan lain-lain yang sesuai dengan selera pasien masing-masing. makanan tambahan didapat dari kemauan pasien sendiri maupun dibawakan oleh keluarga sebagai buah tangan pada saat mengunjungi pasien. dalam hal ini mungkin keluarga memerlukan sedikit bimbingan mengenai diet k husus yang dibutuhkan klien sehingga bila membawa makanan tetap mematuhi aturan diet pasien dengan memperhatikan jumlah kalori dan tanpa kontra indikasi (budiningsari, 2011). berdasarkan hasil penelitian terdapat hubungan yang signifikan antara cita rasa dengan sisa makanan dengan nilai p < 0,05. semakin baik cita rasa yang dirasakan oleh pasien, cenderung menyisakan sedikit sisa makanan. menurut sumiyati (2008) rasa enak pada jenis makanan yang sama akan berbeda pada setiap orang karena pengalaman yang berbeda tergantung dari kesenangan atau selera seseorang. rasa makanan ditimbulkan oleh terjadinya berbagai indera dalam tubuh manusia, terutama indera penglihatan, indera penciuman, indera pengecap dan makanan yang memiliki rasa yang tinggi adalah makanan yang menarik, menyebarkan bau yang sedap dan memberikan rasa yang lezat. adapun yang mempengaruhi rasa makanan adalah suhu makanan, bumbu masak dan bahan penyedap, tekstur makanan, dan aroma makanan. perbedaan suhu akan menyebabkan perbedaan rasa yang timbul. makanan yang terlalu panas atau terlalu dingin akan meng urangi sensitivitas saraf pengecap t e r h a d a p r a s a . s u h u m a k a n a n j u g a mempengaruhi daya terima seseorang terhadap makanan yang disajikan sesuai dengan cuaca/ lingkungan. bumbu adalah bahan yang ditambahkan pada makanan dengan maksud tujuan untuk mendapatkan rasa makanan yang enak dan rasa yang tepat setiap kali masak serta dapat membangkitkan selera karena memberikan rasa makanan yang khas. tekstur makanan adalah hal yang berkaitan dengan struktur makanan yang dirasakan di mulut. tekstur meliputi rasa renyah, keempukan dan kekerasan makanan yang dirasakan oleh indera pengecap. aroma yang disebarkan oleh makanan merupakan daya tarik yang sangat kuat dan mampu merangsang indera penciuman sehingga membangkitkan selera serta dapat menentukan kelezatan makanan tersebut. berdasarkan hasil penelitian sebagian besar responden yaitu sebanyak 31 orang (61%) tidak bisa beradaptasi, dan sebanyak 20 orang (39%) yang bisa beradaptasi. berdasarkan hasil analisis statistik menggunakan uji chisquare terdapat hubungan yang signifikan antara tingkat adaptasi dengan sisa makanan pada pasien p < 0,05. pasien yang tidak bisa beradaptasi dengan lingkungan rumah sakit cenderung banyak dalam hal sisa makanan. sedangkan pasien yang mampu beradaptasi dengan lingkungan cenderung menyisakan sedikit sisa makanan. 188 jurnal ners vol. 8 no. 2 oktober 2013: 183–189 menata r uangan pasien senyaman mungkin akan meningkatkan nafsu makan pasien misalnya membuat ruangan bebas dari bau obat dan bau-bauan lain yang mengganggu nafsu makan pasien (budiningsari, 2011). li ng k u nga n r u ma h sa k it ya ng sa ngat berbeda dengan lingkungan r umah akan berdampak pada peningkatan tingkat stress pasien, sehingga nafsu makan pasien akan berkurang atau hilang. berikan lingkungan yang rapi, bersih yang bebas dari hal-hal yang tidak enak dipandang dan aroma yang tidak menyenangkan. balutan kotor, pispot yang telah digunakan, set irigasi yang tidak tertutup atau bahkan alat makanan yang telah kotor dapat mempengaruhi selera makan pasien secara negative (kozier et al., 2009). ketidaknyamanan lingkungan fisik tanpa sadar atau disadari akan menyebabkan stress pada pasien, bentuk ketidaknyamanan lingkungan fi sik di rumah sakit dapat berupa kebersihan ruang yang tidak terjaga, suhu ruang yang terlalu panas, kebisingan yang mengganggu, penerangan yang terlalu terang atau intensitas penerangan yang rendah bila dibiarkan berlanjut ter us mener us dikhawatirkan akan berpengaruh negatif pada kualitas kesehatan pasien (an-nafi , 2009). be rd a s a rk a n d a r i h a si l a n al isis dengan menggunakan uji statistik diperoleh hasil bahwa ada hubungan antara makanan tambahan dengan sisa makanan karbohidrat, lauk hewani, lauk nabati, sayuran, dan buah di mana pasien yang tidak mendapatkan makanan tambahan cenderung sisa makanan sedikit. hal ini dikarenakan pasien yang tidak mendapatkan asupan makanan tambahan hanya mengandalkan asupan dari diet yang diberikan rumah sakit, sedangkan pasien yang mendapatkan makanan tambahan dari luar menyisakan sisa makanan yang banyak karena bentuk makanan tambahan dari luar yang dikonsumsi juga kaya akan karbohidrat, lauk hewani, lauk nabati, sayuran dan buah. dari hasil penelitian dapat disimpulkan ada hubungan antara cita rasa dengan sisa makanan karbohidrat, lauk hewani, lauk nabati, sayuran, dan buah pada pasien. di mana pasien yang memiliki cita rasa yang baik cenderung hanya menyisakan sedikit makanan, sehingga pasien cocok dan menyukai dengan jenis makanan yang disajikan oleh rumah sakit baik itu dari tingkat kematangan dan teksturnya. sebagian besar pasien tidak menyukai dengan jenis makanan lauk nabati yang disajikan oleh rumah sakit seperti tahu atau tempe, hal ini dikarenakan menu lauk nabati yang disajikan tidak sesuai dengan selera pasien. hal ini sesuai dengan penelitian ariefuddin, et al. (2009) di rsud gunung jati cirebon menunjukkan bahwa persentase ketidakpuasan pasien yang terbesar ditemui pada sisa lauk nabati, kemungkinan bukan disebabkan oleh rasa makanan akibat tidak ada perbedaan menu setiap kelas perawatan, melainkan disebabkan frekuensi pengulangan variasi lauk nabati sama yang terlalu sering dalam waktu berdekatan seperti tahu dan tempe. berdasarkan dari hasil analisis dengan menggunakan uji statistik diperoleh hasil bahwa ada hubungan antara tingkat adaptasi dengan sisa makanan karbohidrat, lauk hewani, lauk nabati, sayuran dan buah pada pasien. pasien yang bisa beradaptasi cenderung hanya menyisakan sedikit makanan. menurut an-nafi (2009) mengatakan untuk mendukung kondisi psikologis pasien perlu diciptakan lingkungan yang menyehatkan, nyaman. secara psikologis lingkungan memberikan dukungan positif bagi proses penyembuhan. faktor psikologis dapat membantu pemulihan kesehatan penderita yang sedang dalam masa perawatan di rumah sakit. faktor tersebut dapat dibentuk melalui suasana ruang pada fi sik bangunan rumah sakit yang bersangkutan. kehadiran sebuah suasana tertentu diharapkan dapat mereduksi faktor stress atau tekanan mental yang dialami oleh penderita yang sedang menjalani proses pemulihan kesehatan. suasana ter tent u dalam lingkungan fisik rumah sakit dapat menambah faktor stress penderita, sehingga dapat menghambat atau menggagalkan proses pemulihan kesehatannya. sehingga dapat dilihat bahwa faktor lingkungan mempunyai peranan terbesar dalam proses penyembuhan, oleh sebab itu perlu mendapatkan perhatian yang cukup besar pada sebuah fasilitas layanan rumah sakit (proverawati, 201). 189 indikator pemenuhan kebutuhan nutrisi oleh pasien rawat inap (kumboyono, dkk.) simpulan dan saran simpulan hasil penelitian menunjukkan sebagian besar responden yang menjalani rawat inap mendapatkan makanan tambahan di luar diet yang diberikan. sebagian besar responden memberikan penilaian cukup pada cita rasa makanan yang diberikan. mayoritas pasien tidak bisa beradaptasi dengan lingkungan rumah sakit. berdasarkan hasil penelitian dapat diketahui faktor-faktor yang berhubungan dengan penerimaan diet makanan biasa di ruang rawat inap rumah sakit tentara dr. soepraoen malang adalah adanya makanan tambahan, cita rasa dan tingkat adaptasi. saran perawat sebagai anggota tim asuhan gizi rumah sakit hendaknya memberikan penjelasan dalam pemberian makanan pada pasien harus memperhatikan faktor-faktor yang mempengaruhi penerimaan diet yaitu ada tidaknya makanan tambahan, cita rasa makanan, tingkat adaptasi pasien terhadap lingkungan rumah sakit. untuk penelitian selanjutnya disarankan pengambilan variabel penelitian lebih luas lagi tentang faktorfaktor yang mempengaruhi penerimaan diet dan dalam perhitungan sisa makanan dapat digunakan metode visual yang terbaru. daftar pustaka almatsier, s., 2010. penuntun diet. jakarta: pt gramedia pustaka utama. an-nafi , fa., 2009. pengaruh kenyamanan lingkungan fisik ruang rawat inap kelas iii terhadap kepuasan pasien di rsui kustati surakarta. tugas akhir tidak dipublikasikan. universitas sebelas maret. ariefuddin, kuntjoro, dan prawiningdyah, 2009. analisis sisa makanan lunak r umah sakit pada penyelenggaraan makanan dengan sistem outsourcing di rsud gunung jati cirebon. jurnal gizi klinik indonesia, 5 (3): 133–42. depkes r, 2007. pedoman penyelenggaraan m a k a na n rumah s a k it. ja k a r t a: direktorat jenderal bina pelayanan medik. departemen kesehatan. depkes ri, 2009. departemen kesehatan ri, (online), (www.depkes.go.id/downloads /.../rpjpk%202005_2025.pdf, diakses 24 april 2011, jam 14.00 wib). evawati, d., 2008. efektivitas penyuluhan gizi terhadap tingkat pengetahuan pasien post operasi di ruang flamboyan rsu usd gambiran kediri. wahana, vol 51 no 2, november 2008, (online), (ht t p://ju r nal.pdii.lipi.go.id /ad min / jurnal/512085459.pdf, diakses 1 mei 2011, jam 13.00). kozier, et al., 2009. buku ajar praktik keperawatan klinis. edisi 5. jakarta: penerbit egc. budiningsari, d. dkk., 2011. menu pilihan diet nasi yang disajikan berpengaruh terhadap tingkat kepuasan pasien vip di rumah sakit umum daerah provinsi sulawesi tenggara. jurnal gizi klinik indonesia, vol. 7, no. 3, maret 2011 hal 112–120, (online), (http://i-lib.ugm.ac.id/jurnal/download. php?dataid=11220, diakses tanggal 20 oktober 2011, jam 15.00 wib). proverawati, dkk., 2010. ilmu gizi untuk keperawatan dan gizi kesehatan. edisi pertama. yogyakarta: nuha medika. soegianto, b., 2008. pelayanan gizi rumah sakit, (online), (www.f k.uwks.ac.id/ elib/ arsip/departemen/ilmu%20gizi/ advokasi, diakses 28 april 2011, jam 20.00 wib). sumiyati, 2008. analisa sisa makanan, (online), (http://digilib .unimus. ac.id /f iles /disk1/21/jtptunimus_ gdl_s1_ 20 0 8 _ s u m iy a t ig 01019 -2b a b2 , p d f , diakses 28 mei 2011, jam 16.00 wib). susetyowati, dkk., 2010. status gizi awal berdasarkan patient generated subjective global assessment berhubungan dengan asupan zat gizi dan perubahan berat badan pada penderita kanker rawat inap di rsup dr. mohammad hoesin palembang. jurnal gizi klinik indonesia, vol.7(2): 80–84, (online), (http://digilib. unnes.ac.id /gsdl// collect/ archiver / hash oidf/82f1e1ed, diakses tanggal 3 mei 2011, jam 18.00 wib). vol 8 no 1 april 2013.indd 47 meningkatkan respons psikososial-spiritual pada pasien diabetes melitus tipe 2 melalui aplikasi modul self care management (promoting psycho-social-spiritual response in patients with type 2 diabetes mellitus through aplication on self care management modul) kusnanto* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax. (031) 5913257 e-mail: kusnanto_ners@yahoo.com abstrak pendahuluan: dm adalah suatu penyakit kronis yang tidak bisa disembuhkan tetapi bisa dikontrol kadar gula darahnya, prevalensi secara global cenderung meningkat hal ini disebabkan ketidakmampuan penderita dalam mengelola penyakitnya secara mandiri dan berdampak pada kondisi kesehatan yang semakin memburuk. upaya untuk meningkatkan kualitas hidup penderita dm telah dilakukan namun hasilnya belum optimal penderita dm masih banyak yang belum menunjukkan adanya kemandirian dalam mengelola penyakitnya. karena itu untuk dapat mengelola penyakitnya secara efektif, penderita harus memiliki pengetahuan, keterampilan dan keyakinan diri dalam melakukan tindakan medis tertentu. self-management penderita bergantung pada edukasi, pemberdayaan dan self monitoring mereka dalam usaha mengevaluasi hasil dari self care yang telah dilakukan. tujuan penelitian ini adalah menjelaskan terjadinya perbaikan kondisi psikologis, sosial dan spiritual melalui aplikasi modul self care management. perbaikan pada kondisi psikologis, sosial dan spiritual diharapkan akan memperbaiki kondisi gula darah dan hba1c penderita dm. metode: pasien yang baru didiagnosis dm tipe 2 di puskesmas kebonsari diseleksi dengan purposive sampling dan dibagi menjadi dua kelompok, masing-masing kelompok berjumlah 25 penderita. kelompok perlakuan diberikan modul self care management. sebelum dan sesudah pemberian modul penderita diberikan kuesioner. data dianalisis dengan uji t, mcnemar dan chisquare. hasil: hasil penelitian menunjukkan bahwa koping penderita lebih konstruktif, hubungan interpersonal meningkat dan penderita lebih bertawakal dalam menghadapi penyakit yang sedang diderita. pembahasan: modul self care management dapat memperbaiki kondisi psikologis, sosial dan spiritual penderita dm tipe 2 di masyarakat. kata kunci: modul self care management, respons psycho, social dan spiritual, dm tipe 2 abstract introduction: diabetes mellitus was a kind of incurable chronic disease that actually manageable. the global prevalence tends to increase due to less self management of the disease and the impact of it was severe health condition. there were so many interventions implemented but failed to give optimal improvement in patient’s condition and there are so many dm patients have insuffi cient ability to manage their own disease. patients need to have knowledge, skills, and self confi dent to be able to manage their disease. patient’s self-management depends on patient’s education, empowerment, and self monitoring in evaluating their self-care management. the purpose of this research was promoting patient’s psychological, social, and spiritual conditions through self care management. improvement in psychological, social, and spiritual conditions in patients with dm will lead to better level of blood glucose and hba1c. method: patient newly diagnose with type 2 dm at puskesmas kebonsari was selected with purposive sampling and divided into two groups. each group contains 25 patients. intervention group was given self diabetes management module. before 48 jurnal ners vol. 8 no. 1 april 2013: 47–55 and after intervention patient was given questionnaire. the data then analyzed using student-t test, mcnemar and chi-square. result: the result of this research showed patient have constructive coping, increase interpersonal relation. patients also have better acceptance about the disease and involve in its management. discussion: self care management module promotes psychological, social, and spiritual conditions in patients with type 2 dm. keywords: self care management module, psychological, social and spiritual, type 2 dm berlebihan, hidup santai dan kurang gerak badan), faktor demografi (jumlah penduduk meningkat, urbanisasi, penduduk berumur diatas 40 tahun meningkat), dan berkurangnya penyakit infeksi dan kurang gizi. upaya untuk meningkatkan kualitas hidup penderita dm telah dilakukan baik berupa diabetes mellitus self care (guthrie & guthrie, 2002) maupun diabetes self management education (fun nel, 2010), masih banyak penderita dm yang belum mandiri dalam mengelola penyakitnya. lorig dan holman (2000) menyatakan bahwa pada dasarnya penderita bertanggung jawab atas pengelolaan day-to-day care atas penyakitnya. penderita har us memiliki pengetahuan, keterampilan dan keyakinan diri dalam melakukan tindakan medis tertentu seperti tes gula darah, serta pemahaman akan pengelolaan emosi untuk dapat mengelola penyakitnya secara efektif (atak, 2007). hal utama dalam mengelola penyakit dm selalu berkenaan dengan manajemen gaya hidup antara lain pe re nca na a n ma k a n , lat i ha n ja sma n i, pengunaan obat hipoglikemik secara teratur, pengontrolan berat badan, pemantauan kadar glukosa darah atau urin serta pengontrolan kondisi emosi dan psikis penderita (anderson, 1999). self management penderita bergantung pad a edu kasi, pemberd aya a n d a n self monitoring mereka dalam usaha mengevaluasi hasil dari self care yang telah dilakukan (pasavic, 1980). memberdayakan penderita seca ra ma nd i r i sa ngat pent i ng, u nt u k meningkatkan pengetahuan, memperbaiki sikap ser ta meng ubah per ilak u. modul self care management dapat memfasilitasi p e n i n g k a t a n p e n g e t a h u a n p e n d e r i t a tentang dm dan pengelolaannya secara pendahuluan diabetes mellitus (dm) merupakan suatu kelompok penyakit metabolik dengan karakteristik hiperglikemia yang terjadi karena kelai na n sek resi i nsuli n, ker ja insulin atau kedua-duanya (ada, 2012). penelitian epidemiologi menunjukkan adanya kecenderungan peningkatan angka insidensi dan prevalensi dm tipe 2 di berbagai penjuru dunia. who memprediksi adanya peningkatan ju mlah pender ita diabetes yang cu k up besar pada tahun-tahun mendatang. who memprediksi kenaikan jumlah penyandang dm di indonesia dari 8,4 juta pada tahun 2000 menjadi sekitar 21,3 juta pada tahun 2030 dan komposisinya lebih banyak pada usia muda dan usia yang produktif (who, 2012). international diabetes federation (idf) pada tahun 2009, memprediksi kenaikan jumlah penyandang dm dari 7,0 juta pada tahun 2009 menjadi 12,0 juta pada tahun 2030. laporan keduanya menunjukkan adanya peningkatan jumlah penyandang dm sebanyak 2–3 kali lipat pada tahun 2030 (perkeni, 2011). kasus dm yang terbanyak dijumpai adalah dm tipe 2, yang umumnya mempunyai latar belakang kelainan berupa resistensi insulin. kasus dm tipe 1 yang mempunyai latar belakang kelainan berupa kurangnya insulin secara absolut akibat proses autoimun tidak begitu banyak ditemukan di indonesia (waspadji, 2009). menyatakan bahwa suyono (2009) 90% dari semua populasi diabetes adalah dm tipe 2, bahkan dalam kur un waktu 1 atau 2 dekade yang akan datang kekerapan dm tipe 2 di indonesia akan meningkat dengan drastis, yang disebabkan oleh fak tor ket u r u nan (geneti k, fak tor kegemukan/ obesitas (perubahan gaya hidup dari tradisional ke gaya hidup barat, makan 49 meningkatkan respons psikososial-spiritual pada pasien diabetes melitus (kusnanto) komprehensif, membentuk sikap yang utuh (total attitude), dan merubah perilaku sesuai dengan pengetahuan yang dimilikinya dalam menghadapi penyakit kronis sehingga akan berpengaruh pada perbaikan kondisi kesehatan secara optimal. pengaruh pemberian modul self care management terhadap perbaikan aspek psikososial dan spiritual penderita dm sampai saat ini masih belum jelas. bahan dan metode i n s t r u m e n p e n e l i t i a n d e n g a n menggunakan kuesioner pertanyaan tertutup yang terdiri atas kondisi psikologis (koping), kondisi sosial (hubungan interpersonal) dan kondisi spiritual (bertawakal). kuesioner pengukuran kondisi psikologis (koping) b e r fo k u s e m o s i : i n d i v i d u b e r u s a h a mengurangi reaksi emosi negatif (menghindar, melepaskan emosi, rileks, menyalahkan diri sendiri). kuesioner pengukuran kondisi sosial (hubungan inter personal) mengacu pada dimensi sosial yang dikembangkan oleh who (who qol) berfokus masalah: individu dapat memecahkan masalah, mencari informasi, melakukan tindakan langsung, mengubah pola pikir dan motivasi, membuat rencana baru. kuesioner pengukuran kondisi spiritual berfokus religi atau spiritual: mengatasi masalah dengan tindakan ritual, berdoa, sembahyang, dzikir, meditasi dan relaksasi. u j i v a l i d i t a s d a n r e l i a b i l i t a s menunjukkan ketiga kuesioner tersebut valid dan reliable. uji validitas kuesioner perilaku koping dengan rumus korelasi product moment didapatkan nilai r di atas 0,658>0,228 (p<0,05) dan uji reliabilitas dengan uji alpha, didapatkan hasil cronbach’s alpha 0.929 jauh diatas nilai 0,80 (p<0,05). uji validitas kuesioner kondisi sosial menunjukkan nilai r diatas 0,658>0,228 (p<0,05) dan hasil cronbach’s alpha 0.960 jauh diatas nilai 0.80 (p<0,05). uji validitas kuesioner kondisi spiritual (tawakal) didapatkan nilai r diatas 0,658>0,228 (p<0,05) dan hasil cronbach’s alpha 0,975 jauh diatas nilai 0.80 (p<0,05). pe nel it ia n i n i me r upa k a n qua s y experiment, menggunakan non randomized controlled group pretest-posttest design. besar sampel dihitung dengan adequacy of sample size for health research (rumus s.k. lwanga and s lemeshow dalam who genewa, 1996) kemudian dibagi secara acak pada kelompok perlakuan dan kontrol masingmasing 28 orang. semua sampel dilakukan pre test, meliputi pengukuran kondisi psikologis (perilaku koping), kondisi sosial (hubungan interpersonal) dan kondisi spiritual (tawakal). kelompok perla k u a n d iber i k a n modul self care management untuk dipelajari dan diaplikasikan, sedangkan kelompok pembanding tidak berikan perlakuan apa-apa. setelah 3 bulan dilakukan evaluasi (post test). analisis data menggunakan uji t berpasangan, yang dimulai dari uji normalitas (distribusi data) dengan one-sample kolmogorov-smirnov test dan paired t-test. hasil pa d a s a at keg iat a n p e nel it ia n berlangsung, terdapat 8 penderita yang dikeluarkan dari penelitian, yait u pada kelompok perlakuan ada 3 penderita yang dikeluarkan karena tidak dapat mengikuti kegiatan secara penuh dan 1 penderita mengundurkan diri tanpa alasan. sedangkan pada kelompok pembanding terdapat 5 penderita yang dikeluarkan dari penelitian karena 2 pender it a pindah r u mah dan 1 pender ita meng u ndu rkan dir i karena kondisi kesehatan menurun dan 2 penderita mengundurkan diri dengan alasan ingin segera mendapatkan pengobatan. dengan demikian total sampel yang ada adalah 50 penderita yang dapat dilakukan pemeriksaan post test. hasil uji mcnemar unt uk kondisi psikologis (koping) pada kelompok perlakuan menunjuk kan bahwa angka signif ikansi tidak bisa dihitung karena salah satu variabel bernilai konstan. pada kelompok pembanding ha sil uji m cne m a r d id apat k a n a ng k a signifi kansi 1,000 (p>0,05) yang berarti tidak ada perbedaan yang bermakna antara koping pretest dan posttest. hubungan interpersonal pada kelompok perlakuan antara sebelum dan sesudah tiga bulan pemberian modul self 50 jurnal ners vol. 8 no. 1 april 2013: 47–55 care management berbeda secara bermakna yang ditunjukkan oleh hasil uji mcnemar p=0,000, pada kelompok pembanding angka signifi kansi adalah 0.250 (p>0,05), maka dapat disimpulkan bahwa hubungan interpersonal tidak berbeda secara bermakna antara pre test dan post test. angka signifi kansi uji mcnemar kondisi spiritual (tawakal) pada kelompok perlakuan tidak dapat dihitung karena salah satu variabel bernilai konstan, sedangkan pada kelompok pembanding didapatkan nilai 1,000 (p>0,05) yang berarti kondisi spiritual (tawakal) antara pretest dan post-test tidak berbeda secara bermakna. pengaruh pemberian modul self care management dapat dilihat berdasarkan hasil uji chi square yang membandingkan nilai posttest antara kelompok perlakuan dan pembanding. perbandingan kondisi psikologis (koping) antara kelompok perlakuan dan pembanding didapatkan nilai signifi kansi 0,000 (p<0,05), berarti terdapat perbedaan yang bermakna (tabel 1). nilai post test kondisi sosial (hubungan interpersonal) antara kelompok perlakuan dan pembanding juga menunjukkan perbedaan yang signifi kan yaitu 0,000 (p<0,05) (tabel 2). kondisi spiritual (tawakal) pada saat post-test antara kelompok perlakuan dan pembanding menunjukkan perbedaan yang signifi kan yaitu 0,000 (p<0,05) (tabel 3). pembahasan diag nosis sebagai pender it a dm merupakan suatu kondisi yang menimbulkan teka na n st res ya ng cu k up besa r pad a penderita dm yang bersangkutan. terkena dm kadang membuat seseorang menjadi cemas, panik, takut hingga merasa marah. seseorang yang mengalami stres/ketegangan psikologik memerlukan kemampuan pribadi maupun dukungan dari lingkungan agar dapat mengurangi stres, cara yang digunakan oleh individu untuk mengurangi stres itulah yang disebut dengan koping (rasmun, 2004). tabel 1. kondisi psikologis (koping) sesudah perlakuan pada kelompok perlakuan dan pembanding variabel kelompok total pperlakuan pembanding perilaku koping sesudah perlakuan destruktif 2 24 26 0.000konstruktif 23 1 24 total 25 25 50 tabel 2. kondisi sosial (hubungan interpersonal) sesudah perlakuan pada kelompok perlakuan dan pembanding variabel kelompok total pperlakuan pembanding hubungan interpersonal sesudah perlakuan kurang 1 21 22 0.000baik 24 4 28 total 25 25 50 tabel 3. kondisi spiritual (tawakal) sesudah perlakuan pada kelompok perlakuan dan pembanding variabel kelompok total pperlakuan pembanding tawakal sesudah perlakuan kurang 2 21 23 0.000baik 23 4 27 total 25 25 50 51 meningkatkan respons psikososial-spiritual pada pasien diabetes melitus (kusnanto) pemberian modul self care management u nt u k mema nd i r i ka n pender it a d ala m mengembangkan koping yang konstruktif. hasil penelitian menunjukkan bahwa pada kelompok perlakuan sebelum dilakukan diberikan modul self care management semua responden dalam kategori koping yang destruktif dan setelah diberikan perlakuan hanya ada 2 penderita dari 25 penderita yang dalam kategori koping yang destruktif. dengan hasil tersebut setelah dilakukan uji mcnemar kelompok perlakuan, menunjukkan angka signifi cancy tidak bisa dihitung karena salah satu variable nilainya konstan, yaitu dari 25 penderita hanya ada 2 penderita yang masih memiliki koping yang destruktif sedangkan 23 penderita telah memiliki koping yang konstr uktif. hasil uji chi-square, menunjukkan nilai signifi cancy-nya adalah 0.000. karena nilai p<0,05, berarti terdapat perbedaan yang bermakna, perilaku koping sebelum dan sesudah tiga bulan pemberian modul self care management. koping adalah proses yang dilalui oleh individu dalam menyelesaikan situasi stresfull. koping tersebut adalah merupakan respons individu terhadap situasi yang mengancam dirinya baik fi sik maupun psikologik. koping diartikan sebagai usaha perubahan kognitif dan perilaku secara konstan untuk menyelesaikan stres yang dihadapi. pada saat seseorang mangalami stres ada yang menghadapinya dengan berdiam diri, ada pula yang bersikap memberontak menurut tandra (2007), ada tiga fase emosi yang umum dialami oleh mereka yang baru mendapat informasi bahwa dirinya menderita dm (1) reaksi penolakan; tidak bisa menerima kenyataan bahwa dirinya mengidap dm atau menyalahkan hasil laboratorium, (2) reaksi marah; marah kepada orang di sekitarnya, kadang timbul rasa bersalah karena marah kepada istri atau suami atau anak, dan semuanya ini tidak akan memberikan hasil pengobatan dm yang baik, dan (3) reaksi depresi; d i kat a ka n ba hwa ora ng ya ng menderita dm akan mengalami reaksi depresi 3–4 kali lebih banyak daripada orang biasa. penderita umumnya merasa tidak bebas lagi untuk berteman, makan sesuka hati, memilih aktivitas yang disenangi, merasa terus diawasi dan lain sebagainya. ketiga reaksi di atas bisa berlangsung hanya sebentar, tetapi ada pula orang yang mengalaminya dalam waktu lama sebelum akhirnya menerima kondisinya. masalah yang dihadapi oleh penderita dm bukanlah bagaimana ia sampai terkena dm atau tipe dm apa yang dia derita, melainkan bagaimana ia dapat mengubah gaya hidup untuk memiliki kehidupan yang sehat dan lebih aktif. penderita dm dituntut untuk melakukan perubahan gaya hidup, baik yang meliputi pengaturan pola makan, tuntutan untuk aktif berolah raga, pengontrolan kadar gula darah, bahkan pada kondisi tertentu menuntut adanya konsistensi dalam peny untikan insulin. kondisi ini tentunya menimbulkan rasa tidak nyaman, terganggu hingga malu dan marah akan kondisinya (tandra, 2008). stres pada penderita dm tidak hanya berasal dari respons terhadap penyakit yang dihadapinya, namun penderita dm juga harus berhadapan dengan stres kehidupan sehari-hari. oleh sebab itu, amat penting bagi penderita dm untuk dapat melakukan pengelolaan stress. pada penelitian ini melalui modul dm mandiri penderita diajari mengelola stres yang efektif dan mengembangkan koping yang konstruktif. koping yang efektif akan menghasilkan adaptasi (keliat, 1999). menurut rasmun (2004) koping yang efektif menghasilkan adaptasi yang menetap dan merupakan kebiasaan baru dan perbaikan dari situasi yang lama, sedangkan koping yang tidak efektif berakhir dengan maladaptif yaitu perilaku yang menyimpang dari keinginan yang normatif dan dapat merugikan diri sendiri maupun orang lain atau lingkungan (keliat, 2004). implementasi yang dilakukan untuk memperbai k i kondisi sosial (hubu ngan interpersonal) pada penelitian ini adalah dengan membentuk peer group support atau membentuk kelompok paguyuban penderita diabet di puskesmas kebonsari. paguyuban (gameinschaft) menurut horton dan hunt (1993) merupakan bagian dari bentuk kelompok, 52 jurnal ners vol. 8 no. 1 april 2013: 47–55 ferdinan tonnies mengembangkan istilah ini yang secara umum dapat diterjemahkan sebagai komunitas (community). mo d u l s e l f c a r e m a n a g e m e n t memfasilitasi penderita untuk bergabung dalam sebuah kelompok penderita diabetes. menu r ut ost alo (20 07) keg iat a n peer group support dapat berlangsung aktif apabila dilakukan dengan langkah-langkah; (1) checking in, (2) presentasi masalah, (3) klarifi kasi masalah, (4) berbagi usulan, (5) perencanaan tindakan, dan (6) checking out. semua informasi tentang pelaksanaan peer group support dijelaskan dalam modul tersebut. hasil penelitian pada kelompok perlakuan menunjukkan bahwa sebelum diberi modul semua penderita mengalami hubungan interpersonal yang kurang dan setelah diberi perlakuan 24 penderita dari 25 penderita mengalami hubungan inter personal yang baik. hasil uji mcnemar kelompok perlakuan, nilai signifi cancy adalah 0,000. karena nilai p<0.05, maka dapat diambil kesimpulan bahwa hubungan interpersonal antara sebelum dan sesudah tiga bulan diberi modul self care management berbeda secara ber mak na. hasil uji chi-square juga menunjukkan nilai signifi cancy-nya adalah 0,000. karena nilai p<0,05, berarti terdapat perbedaan yang bermakna, hubungan interpersonal sebelum dan diberi modul self care management. menurut robert weiss (1974) dalam peplau (1992), individu yang bergabung dengan suat u kelompok berkesempatan untuk mendapatkan hal-hal penting seperti kasih saying, interaksi sosial, harga diri, rasa persat uan yang d apat diand al kan dan bimbingan ser ta kesempatan unt uk mengasuh. me nu r ut g a i l (2010) i nt e r ve n si peer group dapat menur un kan depresi, meningkatkan aspek psikososial meliputi kualitas hidup dan self effi cacy. keberhasilan dari peer group support berkaitan dengan adanya rasa kebersamaan dan berbagi pengalaman hidup dengan sesama penderita diabetes (heisler, 2010). hasil penelitian menunjukkan bahwa hubungan antara penderita satu dengan penderita yang lain lebih baik dan penderita tidak banyak menyendiri, hubungan penderita dengan orang lain (tetangga) dan saudara meningkat, penderita lebih terbuka dalam mengungkapkan permasalahan yang dihadapi khususnya berkaitan dengan penyakit yang sedang dialaminya, kegiatan keagamaan dan kegiatan sosial lebih meningkat, serta rasa persaudaraan di antara penderita diabetes lebih meningkat. dalam paradigma keperawatan sudah jelas bahwa profesi perawat memandang klien sebagai makhluk bio-psiko-sosio-kultural dan spiritual yang berespons secara holistik dan unik terhadap perubahan kesehatan atau pada keadaan krisis dan asuhan keperawatan ditujukan untuk memenuhi kebutuhan manusia secara holistik (yani, 2000). watson (1988) dalam george (1990) mendefi nisikan caring lebih dari sebuah exisestensial philosophy, ia memandang sebagai dasar spiritual, baginya caring adalah ideal moral dari keperawatan. ma nusia a ka n ek sistensi bila d i mensi spiritualnya meningkat ditunjukkan dengan penerimaan diri, tingkat kesadaran diri yang tinggi, kekuatan dari dalam diri, intuitif. menurut hutchison (1998) manusia digambarkan dari tiga dimensi yaitu (1) fi sik atau biologis dimensi yang berkaitan dengan dunia di sekitar kita melalui lima indera kita. (2) dimensi psikososial yang berkaitan dengan diri sendiri dan orang lain, melibatkan emosi, moral, akal. (3) rohani yang melebihi dimensi fi sik dan dimensi psikososial dan memiliki kemampuan untuk berhubungan dengan yang lebih tinggi. i m ple m e nt a si m o d u l s e lf c a r e management memfasilitasi untuk kebutuhan spiritual penderita dm, hal ini didasarkan pada perkembangan konsep psikoterapi dan terapi religius yang saat ini sedang berkembang. dalam penelitian ini psikoterapi ditekankan pada aspek psychocare, dengan psychocare dimaksudkan untuk memberikan motivasi, semangat dan dorongan agar penderita diabetes tidak merasa putus asa dan diberi keyakinan serta percaya diri (self confidence) bahwa ia mampu mengatasi stressor yang sedang dihadapinya. sedangkan dalam aplikasi terapi religius lebih ditekankan pada aspek spiritual care, dengan memberikan rambu-rambu bimbingan spiritual untuk meningkatkan 53 meningkatkan respons psikososial-spiritual pada pasien diabetes melitus (kusnanto) keyakinan tentang makna sakit yang sedang diderita dan melakukan spiritual emotional freedom technique (seft). kebutuhan spiritual adalah kebutuhan untuk mempertahankan atau mengembalikan keyakinan dan memenuhi kewajiban agama, serta kebutuhan untuk mendapatkan maaf atau pengampunan, mencintai, menjalin hubungan penuh rasa percaya dengan tuhan (yani, 2000). menurut dorsey (1996), do’a termasuk kepasrahan atau penyerahan diri terhadap tuhan, merupakan faktor yang penting dalam perjalanan penyakit. ia melakukan meta analisis terhadap berbagai kasus dan penelitian kuantitatif untuk membuktikan pendapatnya tersebut. serupa dengan pendapat ini, pada abad ke-10, pakar kedokteran ibnu sina (980–1037) juga telah mengatakan pentingnya pikiran atau daya kejiwaan seseorang dalam setiap penyakit. pada penelitian ini melalui modul pengelolaan diabetes mandiri bimbingan spiritual diarahkan pada mengembangkan sikap yang baik pada saat sakit. sebelum pemberian perlakuan, semua penderita pada kelompok perlakuan kurang tawakal dalam menghadapi sakitnya dan setelah perlakuan menunjukkan 23 penderita tingkat tawakalnya membaik dan hanya 2 penderita yang masih menunjukkan kurang tawakal. banyak orang yang datang mencari penyembuhan kepada para dokter atau para imam, namun, setiap orang sebenar nya memiliki potensi unt uk menyembuhkan diri sendiri. penerapan konsep berserah diri dalam awal langkah teknik terapi juga telah dibakukan dalam memulihkan seseorang. penerapan konsep tawakal tidak berarti/ menghapuskan usaha pengobatan melalui teknologi kedokteran. pada umumnya imam berbagai agama dan kepercayaan masih menganjurkan untuk mengikuti pemanfaatan teknologi kedokteran, baik untuk diagnosis maupun untuk pengobatan. nabi muhammad saw, misalnya dengan jelas menyatakan keharusan untuk mencari pengobatan ketika seseorang menderita penyakit, tawakal harus disertai dengan ikhtiar agar berhasil mencapai tujuan. pada modul penelitian ini penderita juga dibantu melakukan seft. seft (spiritual emotional freedom technique) mer upakan salah satu varian dari satu cabang ilmu baru yang dinamai energy psychology. seft adalah kombinasi kekuatan antara spiritual power dengan energy psychology. energy psychology adalah seperangkat prinsip dan teknik memanfaatkan system energy tubuh untuk memperbaiki kondisi pikiran emosi dan perilaku. seft bekerja dengan prinsip yang kurang lebih sama dengan akupunt ur dan akupresur, ketiganya berusaha merangsang titik-titik kunci di sepanjang 12 jalur energy (energy meridian) tubuh yang sangat berpengaruh pada kesehatan kita. perbedaannya seft menggunakan cara yang lebih aman, lebih mudah, lebih cepat dan lebih sederhana. ada empat hal yang harus diperhatikan agar seft yang dilakukan efektif, empat hal tersebut merupakan kunci keberhasil seft, yaitu khusyu’. ikhlas, pasrah dan syukur. simpulan dan saran simpulan mo d u l s e lf c a r e m a n a g e m e n t merupakan media yang dapat digunakan oleh penderita dm dalam mengelola penyakitnya secara mandiri untuk memperbaiki kondisi psikologis sehingga koping menjadi lebih konstr uktif, memperbaiki kondisi sosial sehingga hubungan interpersonal meningkat dan memperbaiki kondisi spiritual, sehingga penderita lebih bertawakal, dapat menerima keadaan nya dan selalu ber upaya unt u k melakukan perawatan dan pengobatan yang optimal demi mencapai kesembuhan. saran penderita dm di komunitas dapat menggunakan modul self care management sebagai acuhan untuk mengelola penyakitnya secara mandiri di rumah, perawat komunitas (puskesmas) dapat menjadikan modul self care management sebagai media intervensi memandirikan penderita diabetes melitus tipe 2 di masyarakat, dan modul self care management dapat dijadikan sebagai strategi pemberdayaan para diabetisi untuk 54 jurnal ners vol. 8 no. 1 april 2013: 47–55 meningkatkan derajat kesehatan secara optimal sehingga penderita dm bermanfaat bagi masyarakat luas. kepustakaan atak n., gurkan t., kose k., 2010. the effect of education on knowledge, self management and self efficacy with type 2 diabetes. australian journal of advanced nursing. vol. 26. (2) (online), (http://australian journal of advanced nursing. org; tanggal 10 febr uari 2011). amelie, n., 2010. the role of peer patients in ch ronic disease management. american college of physician. (online) (http://www.annal.org. tanggal akses 14 februari 2011 pukul 11.12). american diabetes association (ada), 2012. standards of medical care in diabetes 2012. journal of diabetes care. 35(1) (online), (ht t p://care. diabetesjour nals.org /tanggal akses 18 april 2012). american diabetes association (ada), 2012. diagnosis and classifi cation of diabetes mellitus. journal of diabetes care, 35(1), (online) (ht t p://care. diabetesjournals.org/ diakses tanggal 18 april 2012). a n d e r s o n , r ., 2 0 0 0. t h e d i a b e t e s empowerment scale: a measure of psychosocial self-efficacy. diabetes care, 23(6) 739–743. atak n., gurkan t., kose k., 2010. the effect of education on knowledge, self management and self efficacy with type 2 diabetes. australian journal of advanced nursing. 26(2) (http:// australian journal of advanced nursing. org/diakses tanggal 10 februari 2011). baranowski, cheryl ip., guy s parcel, 1997. how individual, environment, and health beha vior interact, social cognitive theory in text book health behavior and health education. editor: karen glanz, frances ml, barbara k rimerl 2nd edition. san francisco: jossey bass inc. publishes. basuki, e., 1995. teknik penyuluhan diabetes mellitus dalam penatala k sanaan diabetes mellitus terpadu. jakarta: fa k u lt as kedok tera n un iversit as indonesia. benjamin, gc., et al., 2008. diabetes self management education, establishing a community-based dsme program for adults with type 2 diabetes to improve glicemic control, an actiont guide. atlanta: centers for disease control and prevention. clerah, mg., 2008. stress, coping, and s piritual wellbeing of a sample of nurses. school of psycholog y. universitas of kwazulu-natal. dahlan, m,s., 2011. statistik untuk kedokteran dan kesehatan. jakar ta: penerbit salemba medika. daniel, ww., 1983. biostatistics: a foundation for analysis in the health science. canada: john wiley 5 sons inc., dods r f., 1996. diabetes mellitus, in: clinical chemistry: theory, analysis, correlation, eds, kaplan l.a, pesce a.j, 3rd edition. usa: mosby inc. dorsey, l., 1996. healing words; katakata yang menyembuhkan. jakarta: pt gramedia utama. dr ivsholm, t., et al., 2001. increasing prevalence of diabetes mellitus and inpaired glucose tolerance among 60year-old danes. diabetic medicine, 18, 126–132. fishbein, m. and ajzen, i., 1975. beliefs, attitude, intention and behavior: an introduction to theory and research, philippines: addison-wesley publishing company, inc. fryback, et al., 2001. spirituality and people with potentially fatal diagnoses. nursing forum journal. 34(1). funnel m., et al., 2010. national standards for diabetes self management education. diabetes care. 33(1), 89–96. gail, f., 2010. the effect of a. web-based intervention on psychososial weelbeing among adults aged 60 and older with diabetes, (online), (http:// tde.sagepub.com., diakses tanggal 17 maret 2011). george, julia b., 1990. nursing theories:the base for professional nursing practice. 3rd ed. new jersey: prentice-hall, inc. 55 meningkatkan respons psikososial-spiritual pada pasien diabetes melitus (kusnanto) keliat ba., 1999. penatalaksanaan stres. jakarta. penerbit buku kedokteran egc. ostalo, p., 2007. peer support group, (online), (http://www.dadalos.org., diakses tanggal 28 desember 2010). perk u mpula n endok r i nolog i i ndonesia ( p e r k e n i ) , 2 011. k o n s e n s u s pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia. jakarta: pb perkeni. rasmun, 2004. stres, koping dan adaptasi: teori dan pohon masalah keperawatan. jakarta. cv sagung seto. tandra, h., 2008. segala sesuatu yang harus diketahui tentang diabetes. jakarta: pt gramedia pustaka utama. suyono, s., 2009 ‘kecenderungan peningkatan jumlah penyandang diabetes’, dalam soegondo et al (eds), penatalaksanaan diabetes melitus terpadu (ed 7 ), jakarta: fkui. waspadji, s., 2009 ‘diabetes melit us: mekanisme dasar dan pengelolaannya ya ng rasional’, d alam soegondo et al (eds), penatalaksanaan diabetes melitus terpadu (ed 7 ), jakar t a: fkui. world health organization, 2006. defi nition, diagnosis and classifi cation of diabetes mellitus and its complications. report a who consultation. geneva: who. world health organization, 2012. health topics: diabetes, (online), (http:// www.who.int/topics/diabetes_mellitus, diakses tanggal 26 februari 2012). yani, a., 2000. buku ajar: aspek spiritual dalam keperawatan, jakarta: widya medika. vol 8 no 2 oktober 2013.indd 190 pengembangan model self regulated learning in studying nursing (srlsn) untuk peningkatan kompetensi belajar mahasiswa (development of self regulated learning model in studying nursing (srlsn) to improve student learning competence) pepin nahariani*, nursalam, mira triharini, ririn probowati *stikes pemkab jombang jl. dr. soetomo 75–77 jombang, kode pos 68155 jawa timur email: pepin.nahariani@gmail.com abstrak pendahuluan: mahasiswa baru di perguruan tinggi perlu menyesuaikan diri dengan proses pembelajaran dengan cara lebih mandiri, tidak bergantung pada para dosen, dan regulasi diri dalam belajar. tujuan dari penelitian ini adalah untuk mengembangkan model srlsn terhadap peningkatan pencapaian kompetensi di kalangan mahasiswa sarjana ilmu keperawatan semester 4 di stikes pemkab jombang. metode: desain yang digunakan adalah explanatory dan quasi eksperimen pre-post test dengan kelompok kontrol. populasi dalam penelitian ini adalah 71 mahasiswa ilmu keperawatan semester 4 tahun akademik 2012–2013. sampel yang digunakan 60 siswa dengan simple random sampling. data dikumpulkan dengan menggunakan fgd, observasi dan kuesioner, kemudian dianalisis dengan menggunakan hasil regresi. hasil: hasil srlsn menunjukkan bahwa korelasi antara fase persiapan dan fase pelaksanaan sebesar 0,976, korelasi antara fase pelaksanaan dan fase refl eksi diri memiliki sebesar 0,374, hubungan antara fase persiapan dan fase refl eksi diri sebesar 0,576. terdapat perbedaan yang signifi kan antara kelompok perlakuan dan kontrol pada aspek pencapaian kompetensi kognitif, kompetensi afektif, dan kompetensi psikomotor. diskusi: model srlsn secara sistematis dibentuk oleh persiapan, pelaksanaan dan fase refl eksi diri. penerapan model srlsn akan meningkatkan pembelajaran siswa secara kognitif, afektif, dan psikomotor dalam pencapaian kompetensi. kompetensi psikomotor mempunyai nilai signifi kansi yang lebih besar dari kompetensi lainnya. model srlsn sebaiknya diberlakukan secara umum untuk semua proses pembelajaran terutama dalam mahasiswa keperawatan. kata kunci: srlsn, fase persiapan, fase pelaksanaan dan fase refl eksi diri, pencapaian kompetensi belajar siswa keperawatan abstract introduction: new students at the college have to adjust to the learning process in a way more independent, not dependent on the lecturer, and self-regulation in learning. the purpose of this study is to develop a model of competence srlsn to increased achievement among undergraduate students in the fourth semester of nursing stikes pemkab jombang. methods: the design used is explanatory and quasi-experimental pre-post test with control group. the population in this study were 71 nursing students of 4th semester of the academic year 2012–2013. the sample used 60 students with simple random sampling. data was collected using focus group discussions, observation and questionnaires, then analyzed using regression results. results: the results showed that the correlation between srlsn preparation phase and implementation phase of 0.976, the correlation between the phase and the implementation phase has a self-refl ection of 0.374, the relationship between the phase of preparation and refl ection phase of 0.576. there are signifi cant differences between treatment and control groups on aspects of cognitive competence achievement, competence affective, and psychomotor competencies. discussion: srlsn models are systematically formed by the preparation, implementation and refl ection phase. the application of the model srlsn will enhance student learning in the cognitive, affective, and psychomotor in achieving competence. psychomotor competency has a value greater signifi cance than other competencies . srlsn models should be generalized to all learning processes, especially in nursing students . keywords: srlsn, the preparation phase, the implementation phase and the phase of self-refl ection, achievement of learning competencies of nursing students pendahuluan mahasiswa ba r u ya ng memasu k i perg u r u a n t i ngg i d it u nt ut ber a d apt a si dalam belajar. mahasiswa diharapkan dapat lebih mandiri dan tidak bergantung pada pengajar dan dapat mengerjakan tugas-tugas perkuliahan. hal ini memerlukan pengaturan diri mahasiswa (deasyanti, 2007). namun, pada kenyataannya masih banyak mahasiswa mengalami kesulitan dalam memenuhi belajar sehingga menyebabkan terjadinya cara belajar instant dan dalam jangka panjang proses pembelajaran menjadi kurang bermakna. per masalahan tersebut diatas salah satu 191 pengembangan model self regulated learning in studying nursing (pepin nahariani, dkk.) masih juga memiliki motivasi yang kurang, yang ditunjukkan oleh kurangnya persiapan penguasaan materi yang akan disampaikan dalam pembelajaran, mahasiswa lebih memilih kegiatan lain daripada proses belajar dan softskill mahasiswa yang kurang. p rog r a m st ud i s1 ke p e r awat a n stikes pemkab jombang telah melaksanakan penyelesaian bagi mahasiswa yang memiliki nilai ipk kurang dengan motivasi yang rendah melalui pemanggilan mahasiswa kepada bagian dosen kemahasiswaan, pemantapan kuliah oleh dosen pjmk. namun program studi s1 keperawatan stik es pemkab jombang belum ada pengembangan perilaku pembelajaran mahasiswa sehingga diperlukan melalui pendekatan model self regulated learning in the studying of nursing. menurut yulinawati (2007, hal 65) ada beberapa faktor yang mempengaruhi keberhasilan mahasiswa untuk mencapai prestasi, yait u intelegensi, kepribadian, lingkungan kampus dan lingkungan rumah dan pengat u ran dir i mahasiswa dalam belajar. zimmer man dan mar tinez pons (2002) menyebutkan bahwa individu yang memiliki sr l dan meyakini bahwa ia mampu mengatasi bahan-bahan akademik akan memiliki kesuksesan dan prestasi belajar yang tinggi dibanding individu yang tidak percaya pada kemampuan dirinya. usaha individu untuk mencapai tujuan belajar dengan mengaktif kan dan mempertahankan pikiran, emosi dan perilaku disebut srl. penerapan model srlsn dalam meningkatkan prestasi belajar mahasiswa merupakan masalah yang secara umum dialami mahasiswa di indonesia. berbagai hasil penelitian menggambarkan pentingnya keterampilan srl yang dimiliki oleh mahasiswa karena korelasinya dengan usaha belajar yang efektif dan ef isien. selanjutnya akan diperoleh kepuasan akademik yang lebih tinggi (desyanti, 2007). pengaruh positif lain dari srl adalah membentuk karakter yang memiliki motivasi untuk belajar sepanjang hayat (life long learning) dan juga menjadi mandiri dalam berbagai konteks kehidupan lainnya. upaya untuk perbaikan pencapaian kompetensi mahasiswa keperawatan dalam faktor yang mempengaruhi adalah mahasiswa k u rang memili k i keterampilan tent ang bagaimana caranya belajar (how to learn) yang mencakup pemahaman tentang kemampuan berpikir, proses berpikir dan motivasi diri untuk mencapai tujuan belajar. kemampuan tersebut dalam istilah psikologi pendidikan disebut dengan self regulated learning yang selanjutnya disebut srl. penerapan model self regulated learning dalam pendidikan keperawatan dikenal dengan model self regulated learning in studying of nursing yang selanjutnya dikenal dengan srlsn. peran perawat menduduki prioritas pertama dalam kategori tenaga kesehatan pasien d a n 80% perawat member i ka n pelayanan langsung kepada pasien (nasrin, 2012). dalam hal ini peran pendidikan penting sekali memperhatikan srlsn mahasiswa perawat. mahasiswa perawat memerlukan srlsn sepanjang waktu untuk membantu orang lain dan pasien di masa depannya (nasrin, 2012). profesi perawat dituntut untuk memberikan pelayanan keperawatan yang bermutu, memiliki landasan ilmu pengetahuan dan keterampilan yang kuat, disertai sikap dan tingkah laku yang profesional dan berpegang kepada etika keperawatan (pribadi, 2009). hasil tr y out uji kompetensi ners indonesia tahun 2012 didapatkan bahwa dari seluruh peserta 358 yang melibatkan 90 instansi se-indonesia, nilai rerata tertinggi 63.9 dan terendah 21. berdasarkan nilai hasil uji kompetensi tahun 2012 oleh majelis tenaga kesehatan propinsi (mtkp) wilayah propinsi jawa timur, didapatkan angka pencapaian kategori lulus mencapai 95%. terdapat 5% lulusan perawat yang memerlukan pembinaan secara lanjut. permasalahan ditunjukkan hampir ditemukan rata-rata pada aspek kognitif dan psikomotor mahasiswa. namun pada aspek sikap dan nilai etika keperawatan sudah menunjukkan hasil pencapaian secara umum memuaskan. berd a sa rk a n st ud i pend a hu lu a n , didapatkan 57% mahasiswa kurang persiapan penguasaan materi yang akan dipelajari, 65% mahasiswa tidak memiliki tujuan jelas dalam belajar dan daya analisis dalam evaluasi belajar yang kurang. selain itu, 54% mahasiswa 192 jurnal ners vol. 8 no. 2 oktober 2013: 190–201 masa pendidikan sehingga dapat menciptakan tenaga perawat profesional, maka dilakukan dengan model srlsn. mahasiswa diharapkan dapat meningkatkan motivasi dalam kebutuhan u nt u k ber prestasi dalam pembelajaran, memiliki afiliasi belajar yang tinggi serta memiliki kekuatan dalam manajemen belajar. srl merupakan strategi pembelajaran yang spesifi k yang berfungsi untuk merekam dan menyimpulkan bahan pelajaran yang penting dan bukan merupakan rencana di luar proses pembelajarannya, di mana mahasiswa mampu mengatur diri terhadap cara belajar akademik mereka sendiri (zimmerman, 2002). seorang pengajar berperan dalam membantu mahasiswa u nt u k sr l ya ng mel iput i me mba nt u mahasiswa dalam menemukan tujuan, strategi pembelajaran, persiapan evaluasi, membangun keyakinan diri, self effi cacy mahasiswa dalam belajar. bahan dan metode penelitian menggunakan dua desain yaitu eksplanatip dan quasy eksperimen. desain eksplanatip dilakukan terlebih dahulu untuk menemukan penjelasan tentang suatu kejadian atau gejala terjadi. hasil akhirnya adalah gambaran mengenai hubungan sebab akibat antara subvariabel self regulated learning in studying nursing (srlsn). desain quasy experiment pre dan post test control group digunakan untuk melihat perbedaan hasil antara kelompok perlakuan dan kontrol. populasi dalam penelitian ini adalah seluruh mahasiswa prodi s1 keperawatan stikes pemkab jombang semester 4 tahun ajaran 2012– 2013 berjumlah 71 mahasiswa. berdasarkan teknik simple random sampling diperoleh besar sampel sebanyak 20 responden. variabel independen penelitian ini adalah intervensi penerapan model srlsn dengan pemberian modul. variabel dependen yang diukur meliputi pencapaian kompetensi mahasiswa pada aspek kognitif, afektif dan psikomotor. inst r umen yang dig u nakan u nt u k meng uk ur sr lsn ini adalah k uisioner yang dibuat berdasarkan konsep srl oleh zimmerman (2002). kuesioner terdiri dari 45 per t anyaan dengan k uesioner skala likert dengan pilihan jawaban tidak pernah mela k u ka n, ja ra ng, sa ngat ser i ng d a n selalu. instrumen untuk fase persiapan, fase pelaksanaan dan fase refl eksi diri masingmasing terdiri dari 15 pertanyaan. total skor dikategorikan menjadi baik (nilai 45–60 atau 75–100%), cukup (nilai 30–44 atau 50-74%), dan kurang (nilai 0–29 atau 0–49%). instrumen lain yang digunakan adalah untuk 3 ranah penilaian yaitu kognitif, afektif dan psikomotor. pertanyaan ranah kognitif bertujuan untuk menilai kemampuan kognitif mahasiswa terhadap mater i yang telah disampaikan dalam satu kompetensi dasar. hasil penilaian dikategorikan menjadi baik (nilai 76–100), cukup (nilai 66–75), dan kurang (nilai 0–65). pertanyaan ranah afektif bertujuan untuk menilai softskill mahasiswa yang terjadi selama proses pembelajaran berlangsung dalam satu kompetensi dasar. penilaian ranah psikomotor untuk menilai kemampuan mahasiswa diutamakan skill lab yang telah dilakukan mahasiswa dalam satu kompetensi dasar. penelitian dilaksanakan di stikes pemkab jombang prodi s1 keperawatan selama bulan 13 maret–25 april 2013. pengumpulan data dilakukan setelah peneliti mendapatkan surat laik etik dari lembaga penelitian dan pengabdian masyarakat universitas airlangga. tahap pelaksanaan penelitian ini dibagi menjadi tiga. tahap pertama, peneliti melakukan pengambilan data dengan menilai data dari karakteristik responden. kemudian dilakukan pengukuran variabel srlsn dan uji model srl untuk mendapatkan isu strategis yang akan didiskusikan melalui kegiatan focus groups discussion (fgd). fgd merupakan langkah penetapan solusi sebagai dasar untuk menyusun rekomendasi dalam pengembangan model srlsn. fgd dilaksanakan di stikes pemkab jombang sebanyak 3 kali dengan kelompok yang berbeda, yaitu fgd kelompok mahasiswa, fgd kelompok dosen, dan fgd kelompok pengambil kebijakan. tahap kedua yaitu tahap pelaksanaan pengembangan model srlsn. pada tahap ini disusun berdasarkan hasil fgd dan 193 pengembangan model self regulated learning in studying nursing (pepin nahariani, dkk.) didiskusikan bersama empat pakar yaitu dari pakar kurikulum keperawatan, pakar pendidikan dan pakar psikologi. tahap ketiga adalah tahap penerapan model srlsn. pada tahap ini memerlukan waktu 2 minggu dalam satu kompetensi dasar dan dibagi menjadi enam kali tatap muka. terdapat 2 kelompok, yaitu kelompok perlakuan dan kelompok kontrol yang tidak mendapat slrsn. hasil tabel 1 menunjuk kan bahwa jenis ke l a m i n m a h a s i s w a p a d a ke l o m p o k perlakuan dan kelompok kontrol adalah sama. keseluruhan responden berusia 19–21 tahun. nilai rerata ipk pada kelompok perlakuan adalah sebagian besar dengan nilai 2–2,74 dan ipk kelompok kontrol sebagian besar 2,75–3,4. status pendidikan orang tua pada kelompok perlakuan sebagian besar adalah sma. kelompok kontrol hampir setengahnya memiliki pendidikan sd dan pt. status pekerjaan orang tua pada kelompok perlakuan adalah setengahnya petani dan kelompok kontrol setengahnya memiliki pekerjaan swasta. status penghasilan orang tua pada kelompok perlakuan dan pada kelompok kontrol sama yaitu setengahnya memiliki penghasilan rp750.000 –1.500.000. jarak tempat tinggal dengan kampus yang ditempuh pada kelompok perlakuan dan kontrol sama yaitu setengahnya memiliki jarak rumah dengan kampus lebih dari 10 meter. tempat tinggal responden pada kelompok perlakuan dan kontrol sama yaitu sebagian besar tinggal bersama orang tua. fa se p e r siapa n t e rd i r i d a r i du a subvariabel yaitu analisis tugas dan motivasi diri. tabel 2 menunjukkan bahwa pada analisis tugas fase persiapan kurang optimal. sebagian tabel 1. distribusi karakteristik responden no karakteristik kategori kelompok perlakuan kelompok kontrol f (%) f (%) 1 jenis kelamin laki-laki 50 50 perempuan 50 50 2 umur responden 16–18 tahun 0 0 19–21 tahun 100 100 3 rentang ipk lebih dari 3,5 10 0 2,75–3,45 30 60 2–2,745 60 40 4 status pendidikan orang tua tidak sekolah 0 0 sd/sederajad 0 40 smp 30 0 sma 60 20 pt 10 40 5 status pekerjaan orang tua tidak bekerja 10 0 pns 30 20 swasta 50 50 petani 10 10 wiraswasta 0 20 6 status penghasilan orang tua kurang dari rp750.000 20 10 rp750.000–1.500.000 50 50 lebih dari rp1.500.000 30 40 7 jarak tempuh kurang dari 5 m 40 20 5–10 meter 10 20 lebih dari 10 m 50 60 8 jenis tempat tinggal rumah orang tua 80 70 asrama/kos 20 30 total 100 100 194 jurnal ners vol. 8 no. 2 oktober 2013: 190–201 besar mahasiswa tidak melakukan dan jarang melakukan rencana strategi pembelajaran dan penetapan tujuan pembelajaran. pada subvariabel motivasi diri, sebagian besar mahasiswa tidak melakukan dan jarang melakukan orientasi tujuan pembelajaran, kriteria harapan pembelajaran dan tidak melakukan dan jarang memiliki self effi cacy belajar. fase pelaksanaan terdiri dari dua sub variabel yaitu self control dan self observation. tabel 3 memperlihatkan bahwa pada subvariabel self control fase pelaksanaan sebagian besar mahasiswa tidak melakukan dan jarang melakukan imagery pembelajaran, sebagian besar tidak melakukan dan jarang melakukan self instruction, sebagian besar mahasiswa tidak melakukan dan jarang melakukan strategi tugas. pada subvariabel self observation, sebagian besar mahasiswa tidak melakukan dan jarang melakukan self experiment. sebaliknya, sebagian besar mahasiswa sudah sangat sering dan selalu melakukan self recording. fase refl eksi diri pada model srlsn ini meliputi dua subvariabel, yaitu: self judment dan self reaction. tabel 4 menunjukkan bahwa pada self judgment fase refl eksi diri mahasiswa kurang optimal, hal ini dapat dilihat sebagian besar mahasiswa tidak melakukan dan jarang melakukan self evaluation pembelajaran dan sebagian besar mahasiswa tidak melakukan dan jarang melakukan self attribution. pada subvariabel self reaction, mahasiswa tidak tabel 2. fase persiapan pada model srlsn no fase persiapan srlsn kategori tdk melakukan jarang sangat sering selalu total f (%) f (%) f (%) f (%) f (%) analisis tugas 1 penetapan tujuan 47 45 7 2 100 2 rencana strategi 52 42 5 2 100 motivasi diri 3 orientasi tujuan pembelajaran 22 38 18 22 100 4 kriteria harapan pembelajaran 10 52 28 10 100 5 self effi cacy mahasiswa 7 45 25 28 100 total 27 43 17 13 100 tabel 3. fase pelaksanaan pada model srlsn no fase pelaksanaan srlsn kategori tdk melakukan jarang sangat sering selalu total f (%) f (%) f (%) f (%) f (%) self control 1 imagery 8 52 23 17 100 2 self instruction 15 50 25 10 100 3 strategi tugas 40 22 0 38 100 4 focus 2 40 32 27 100 self observation 5 self experiment 25 50 15 10 100 6 self recording 5 42 20 33 100 total 16 43 19 22 100 195 pengembangan model self regulated learning in studying nursing (pepin nahariani, dkk.) melakukan dan jarang melakukan sikap adaptive dalam pembelajaran. sebaliknya, mahasiswa sebagian besar sudah sangat sering dan selalu puas pada pembelajaran. berdasarkan tabel 5, tabulasi silang hubungan antara kedua fase yait u fase persiapan dan fase pelaksanaan memiliki nilai keduanya sebagian besar memiliki nilai cukup dan sebagian kecil memiliki nilai baik dan sebagian kecil memiliki nilai kurang. berdasarkan hasil uji jalur menunjukkan bahwa terdapat hubungan fase persiapan terhadap fase pelaksanaan pada model srlsn mahasiswa. berdasarkan tabel 6 tabulasi silang hubungan antara kedua fase yait u fase pelaksanaan dengan fase refl eksi diri memiliki nilai keduanya hampir setengahnya memiliki nilai cukup, memiliki nilai keduanya sebagian kecil baik dan memiliki nilai keduanya sebagian kecil kurang. berdasarkan hasil uji jalur menunjukkan bahwa terdapat hubungan fase pelaksanaan dengan fase refl eksi diri pada model srlsn. berdasarkan tabel 7 tabulasi silang hubungan antara kedua fase yaitu fase refl eksi diri dengan fase persiapan memiliki nilai keduanya yaitu setengahnya memiliki nilai cukup, memiliki nilai keduanya sebagian kecil baik dan memiliki nilai keduanya sebagian kecil kurang. berdasarkan hasil uji jalur menunjukkan bahwa terdapat hubungan fase persiapan dengan fase refl eksi diri pada model srlsn ta b e l 8 m e n u n j u k k a n b a h w a berdasarkan uji statistik wilcoxon sign tabel 4. fase refl eksi diri pada model srlsn no fase refl eksi diri srlsn kategori tdk melakukan jarang sangat sering selalu total f (%) f (%) f (%) f (%) f (%) self judgment 1 self evaluation 20 48 23 8 100 2 causal attribution 15 45 28 12 100 self reaction 3 adaptive 12 53 20 15 100 4 satisfaction 2 15 30 53 100 total 12 40 20 22 100 tabel 5. hasil tabulasi silang hubungan fase persiapan dengan fase pelaksanaan pada model srlsn fase persiapan fase pelaksanaan kurang cukup baik total kurang 3,3 5 0 8,3 cukup 5 66,7 10 81,7 baik 0 5 5 10 total 8,3 76,7 15 100 hasil uji jalur = t-statistik = 2,971, path coef = 0,976 tabel 6. hasil tabulasi silang hubungan fase pelaksanaan dengan fase refl eksi diri pada model srlsn fase pelaksanaan fase refl eksi diri total kurang cukup baik kurang 3,3 5 0 8,3 cukup 8,3 48,3 20 76,7 baik 0 5 10 15 total 11,7 58,3 30 100 hasil uji t-statistik = 2,969, path coef = 0,374 jalur tabel 7 hasil tabulasi silang hubungan fase persiapan dengan fase refl eksi diri pada model srlsn fase refl eksi diri fase persiapan totalkurang cukup baik kurang 3,3 8,3 0 11,7 cukup 5 50 3,3 58,3 baik 0 23,3 6,7 30 total 8,3 81,7 10 100 hasil uji jalurt-statistik = 3,073, path coef = 0,576 196 jurnal ners vol. 8 no. 2 oktober 2013: 190–201 rank test ada perbedaan yang nyata pada kemampuan kognitif, afektif, dan psikomotor mahasiswa jika diberikan perlakuan srlsn. pada kelompok kontrol didapatkan hasil tidak ada perubahan yang signifi kan sebelum dan sesudah test pada kemampuan afektif mahasiswa. lebih dari setengah mahasiswa memiliki pencapaian di ranah psikomotor pada uji statistik ada perbedaan nyata pada kemampuan psikomotor mahasiswa sebelum dan sesudah perlakuan srlsn. kelompok kontrol menunjukkan perbedaan kemampuan psikomotor antara sebelum dan sesudah test, namun perbedaan ini relatif lebih kecil dibandingkan dengan kelompok perlakuan. pembahasan fase persiapan merupakan fase pertama dari ketiga fase yang ada dalam self regulated learning (srl) di mana mahasiswa dituntut untuk menyiapkan materi sebelum proses pembelajaran. fase persiapan ini penting tabel 8. hasil pencapaian kompetensi mahasiswa pada ranah kognitif, afektif, dan psikomotor sebelum dan sesudah penerapan srlsn no pencapaian kompetensi kelompok perlakuan kelompok kontrol selisih p value pretest posttest pretest posttest 1 ranah kognitif baik 10 60 0 10 0,043 cukup 10 30 20 30 kurang 80 10 80 60 mean 54,10 70,70 68,7 73,8 sd 15,3 7,58 11,4 5,37 uji wilcoxon sign rank test p value = 0.007 p value = 0.05 2 ranah afektif baik 20 100 20 30 0,077 cukup 50 0 60 70 kurang 30 0 20 0 mean 73,8 77,7 73,7 72,9 sd 7,64 5,07 4,19 4,7 uji wilcoxon sign rank test p value = 0.006 p value = 0.083 3 ranah psikomotor terampil 10 60 20 30 0.013 cukup terampil 70 40 70 70 kurang terampil 20 0 10 0 mean sd 3,22 0,76 4,14 0,26 3,56 0,72 3,98 0,56 uji wilcoxon sign rank test p value = 0.005 p value = 0.018 dalam siklus pembelajaran sr l karena dengan fase ini, mahasiswa akan menyiapkan rencana tindakan yang akan dilaksanakan, mengenal jadwal perkuliahan, mendapatkan pilihan terbaik tindakan dan mengembangkan kesu ksesan sebuah kar ir (zim mer man, 2012). pembelajaran yang efektif dimulai perencanaan mahasiswa memasuki ruang kelas. fasilitator yang baik akan merencanakan tujuan pembelajaran yang mer ujuk pada kompetensi k husus yang ingin dicapai. selain itu, mahasiswa juga dituntut untuk menemukan cara terbaik membagi topik-topik dan keterampilan untuk memudahkan dalam memahaminya. (ormrod, 2012). nursalam & effendi (2008) menyebutkan bahwa dalam teori herzberg teori motivasi dua faktor menyebutkan pula bahwa terdapat dua faktor yang mendasari seseorang dalam bekerja, yait u faktor pemeliharaan dan faktor pemotivasi. faktor pemeliharaan adalah meliputi dissatisffi ers, hygiene factor, 197 pengembangan model self regulated learning in studying nursing (pepin nahariani, dkk.) job context dan factor eksternal. faktor pemotivasi meliputi satifi er, motivators, job contect dan instrinsic factor. mahasiswa belum memiliki motivasi akan berdampak pada hasil pelaksanaan tugas sehingga dalam mempersiapkan perkuliahan kurang optimal pula. pe r m a s a l a h a n f a k t o r e k s t e r n a l yang mempengar u hi mahasiswa dalam mempersiapkan pembelajaran, hal ini sejalan denga n liter at u r pendekat a n psi kolog i pend id i k a n ya ng menyebut k a n ba hwa perkembangan self regulated learning tidak hanya berkembang dengan sendirinya namun diperlukan lingkungan yang kondusif untuk memenuhinya (woods, 2011). mahasiswa dalam menetapkan t ujuan pembelajaran masih belum optimal, hal ini dikarenakan selain faktor motivasi juga dipengar uhi oleh komitmen mahasiswa dan dosen dalam persiapan pembelajaran. peningkatan prestasi mahasiswa di kelas, tidak hanya diperlukan strategi, tujuan dan self effi cacy yang baik, namun juga diperlukan performa mahasiswa yang baik di kelas. standard dan tujuan yang telah ditetapkan oleh seorang mahasiswa sendiri yang selanjutkan melakukan kegiatan monitor diri dan proses evaluasi proses kognitif dan konsekuensi yang ditetapkan sendiri, semua merupakan aspek pengaturan diri (self regulation). mahasiswa yang memiliki prestasi tinggi akan memiliki penilaian metacognisi dan self control yang lebih baik daripada mahasiswa yang memiliki prestasi rendah (zimmerman, 2012). pada penelitian ini, mahasiswa masih memiliki self control dan self observation rendah. hal ini dikarenakan mahasiswa sebag ia n b e s a r b elu m me nge n a l d a n menerapkan self regulated learning dengan baik. hal ini dibuktikan dalam hasil fgd sebagian mahasiswa menyebutkan bahwa mereka tidak memiliki pengendalian diri dan instruksi diri yang jelas. salah satu penyebabnya mereka tidak memiliki persiapan pembelajaran yang baik sebelum perkuliahan. salah satu cara untuk melaksanakan adalah minimal mahasiswa mencari bantuan teman, menilai kekuatan pribadi dalam menyusun strategi pembelajaran dan mengevaluasi tujuan pembelajaran. mahasiswa yang sukses mengatur diri dalam proses belajar adalah mereka yang berusaha untuk memfokuskan perhatian mereka pada pembelajaran yang sedang berlangsung dan menghilangkan dari pikiran yang mengganggu (schunk, 2001). fase ref leksi diri merupakan fase di mana mahasiswa menetapkan suatu standar evaluasi diri, mampu menetapkan penyebab atribut suatu kejadian/masalah pada proses pembelajaran yang berlangsung. mahasiswa pada akhirnya mampu melakukan pertahanan diri dan koping adaptasi untuk menetapkan strategi pembelajaran yang lebih efektif bagi di r i nya sendi r i. mahasiswa yang memiliki prestasi tinggi lebih cenderung mem ili k i at r ibu si d i r i d ala m st r ateg i pelaksanaan srlsn yang lebih baik sehingga menimbulkan kepuasan belajar dan respons adaptif dalam mencapai tujuan pembelajaran daripada mahasiswa yang berprestasi rendah (zimmerman, 2012). pada refl eksi diri ini, mahasiswa masih memiliki self judgment dan self reaction rendah. hal ini dikarenakan mahasiswa sebag ia n b e s a r b elu m me nge n a l d a n menerapkan self regulated learning dengan baik. hal ini dibuktikan dalam hasil fgd sebagian mahasiswa menyebutkan bahwa mereka tidak memiliki evaluasi diri dan hasil tindak lanjut pembelajaran yang baik. salah satu penyebab mereka menyatakan bahwa fase persiapan dan pelaksanaan sebelumnya yang tidak berhasil pula sehingga mempengaruhi hasil evaluasi diri mahasiswa. mahasiswa kurang dapat memanajemen wakt u belajar dengan baik dan strategi kontrak pembelajaran yang kurang efektif dalam feedback evaluasi yang secara ideal harus lebih dari satu. hal ini sesuai dengan penelitian sebelumnya yang menyebutkan bahwa dalam sebuah evaluasi penerapan srlsn, harus dilaksanakan feedback lebih dari satu kali (zimmerman, 2012). walaupun ketidakpuasan hasil belajar akan timbul di fase refl eksi diri srl, hal ini dapat dicegah dengan keyakinan seseorang dapat sukses dan dengan menggunakan perubahan strategi pencapaian tujuan pembelajaran (schunk, 2010). 198 jurnal ners vol. 8 no. 2 oktober 2013: 190–201 s e l f e f f i c a c y m a h a s i s w a a k a n mempengaruhi dalam aktivitas belajar, tujuan dan usaha serta persistensi mahasiswa dalam aktivitas di kelas, dengan demikian self effi cacy akan mempengaruhi pembelajaran dan prestasi akademik mahasiswa. mahasiswa yang memiliki self effi cacy yang tinggi cenderung lebih banyak belajar dan berprestasi daripada mahasiswa yang memiliki self effi cacy rendah. penerimaan self effi cacy membantu mengubah perbedaan kejadian sehingga menjadi perilaku koping yang dipengaruhi oleh reaksi stress psikologi, gambaran perilaku self regulated learning (bandura, 1982). konsep self regulated learning bahwa fase persiapan memiliki peran yang penting dalam keberhasilan proses pembelajaran selanjutnya. peningkatan fase persiapan sebagai bahan dasar untuk mencetak prestasi belajar yang lebih baik lagi di kelas (bandura, 1982). persepsi mahasiswa mengenai persiapan belajar yang tidak dianggap penting akan berdampak pada hasil pembelajaran. penelitian sebelumnya didapatkan bahwa pencapaian tujuan pembelajaran dipengaruhi oleh persepsi mahasiswa dalam proses belajar (anthoby, 2012). pencapaian sebuah kompetensi dapat diraih dengan mencoba meniru orang yang dapat melakukan dengan baik dan dengan mengadopsi prosedur pemecahan masalah yang dihadapi dalam belajar dari fasilitator yang baik dilakukan. pada fase pelaksanaan ini, memerlukan sebuah strategi dalam pengendalian diri dalam proses pelaksanaan belajar, meliputi instruksi diri, focus, imagery dan strategi penyelesaian tugas. pada tahap pelaksanaan ini jika dilaksanakan secara konsisten dan efektif akan menghasilkan kemampuan keahlian tertentu. (ormrod, 2012). di dalam fase ref leksi diri, terdapat kemampuan evaluasi diri, atribusi diri, memiliki sikap puas dan mampu beradaptasi. evaluasi diri lebih cenderung dipengaruhi oleh performa teman lain yang memiliki standard tertentu dan tingkat penilaian sebelumnya. atribusi diri dipengaruhi oleh latar belakang keyakinan seseorang mengenai kesuksesan dan kegagalan. hal ini penting untuk meraih sebuah kesuksesan belajar (schunk, 2004). adaptasi yang dialami bagi mahasiswa yang sering mengalami kegagalan adalah sikap defensif dalam pembelajaran, seperti sikap menghindari tugas, ketidakpahaman materi yang diterima dan sikap apatis. (or mrod, 2012). pada penelitian sebelumnya juga disebutkan bahwa fase persiapan srlsn akan mempengaruhi fase ref leksi diri. disebutkan pula bahwa dengan memiliki metakognisi yang baik akan meningkatkan evaluasi diri mahasiswa yang didasarkan pada hasil pencapaian kompetensi mahasiswa (zimmerman 2002). self evaluation pada srl mengarah pada upaya untuk membandingkan informasi yang diperolehnya melalui self monitoring dengan standar atau tujuan yang telah ditetapkan pada fase persiapan. selain self evaluation, pada fase refl eksi diri ini juga memiliki kegiatan self reaction. self reaction yang terus-menerus dilakukan akan mempengaruhi fase persiapan belajar mahasiswa dan seringkali berdampak pada fase pelaksanaan yang ditampilkan di masa mendatang terhadap tujuan yang ditetapkan (susanto, 2006). proses self regulated learning akan menyesuaikan informasi di dalam tubuh selama waktu yang lama. dalam setiap harinya, individu akan melakukan pengaturan diri dengan mengomunikasikan diri untuk menginformasikan kebutuhan kerja anggota tubuh, proses pemikiran ini akan berlangsung secara teratur sehingga menghasilkan sebuah perilaku yang mengantarkan pada kemampuan psi komotor ( beth, 2003). pad a proses pencapaian suatu tujuan kegiatan, kognitif sangat penting peranannya dalam keputusan diri secara rasional. kemampuan kognitif dalam waktu yang cepat akan melakukan sebuah proses pengolahan persepsi, identifi kasi dan simbolisasi di dalam informasi tubuh tergantung dari rangsangan baik dari dalam maupun luar. hal ini berarti bahwa di dalam proses transformasi penyelesaian masalah, secara sadar akan terjadi proses pengaturan diri meliputi biopsikososial. aspirasi yang dimiliki mahasiswa menurut bukan ingin menguasai materi secara mendalam, melainkan sekedar asal lulus kompetensi semata. oleh karenanya mahasiswa lebih memusatkan 199 pengembangan model self regulated learning in studying nursing (pepin nahariani, dkk.) perhatiannya untuk benar-benar memahami dan juga memikirkan cara menerapkannya (syah, 2007). srlsn merupakan proses kegiatan met akog nisi dan motivasi di r i. proses belajar merupakan rencana strategi dengan pendekatan aktivitas dan tugas, di mana metakognisi di sini berperan dalam menilai kebutuhan belajar dengan menilai kelemahan dan kekuatan belajar dan beradaptasi terhadap proses pembelajaran selanjutnya. hal ini sesuai dengan hasil penelitian pada perubahan pember ian perlak uan sr lsn terhadap peningkatan kognitif bahwa terdapat nilai signifi kan yang kuat pada kelompok perlakuan daripada kelompok kontrol dalam peningkatan proses berpikir mahasiswa dalam pengaturan belajar. pada kelompok perlakuan memiliki nilai signifi kan daripada kelompok kontrol, hal ini dikarenakan di dalam proses srl, fasilitator/dosen membangun motivasi diri mahasiswa dan memberikan pengetahuan kepada mahasiswa secara sistematis fase persiapan, pelaksanaan dan refl eksi diri. pada keberhasilan pengembangan ranah kognitif tidak hanya akan membuahkan kemampuan kecakapan kognitif saja, namun juga akan menghasilkan kecakapan ranah afek t if. seca ra pema hama n mend alam terhadap arti penting materi dalam pencapaian kognitif, mahasiswa juga akan meningkatkan kemampuan ranah afektif (syah, 2007). dampak lain dari kompetensi afektif ini, mahasiswa memiliki sikap mental dan sosial yang lebih tegas dan lugas. kondisi psikologis ini srlsn berfungsi untuk mengatur emosi belajar (emotional regulation) agar tidak menghasilkan respons yang kontra produktif. peran srlsn dalam afektif juga berperan dalam meningkatkan performa mahasiswa di kelas, self effi cacy yang tinggi. selain meningkatkan self eff icacy pribadi, dan membangun self effi cacy kolektif yang dapat meningkatkan suasana akademik di kelas dan membangun strategi-strategi pembelajaran kerja kelompok yang efektif dalam pembelajaran (cooperative learning). pemecahan masalah yang di atur diri sendiri (self reg ulated problem solving) dapat melibatkan komponen pembelajaran yang diatur oleh dirinya sendiri, hal ini mahasiswa dapat melakukan pelatihan mediasi teman sebaya ( peer mediation) di mana mahasiswa dapat saling membantu memecahkan masalah inter personal antar mahasiswa (or mrot, 2009). penilaian afektif lebih menekankan area softskill pembelajaran dengan evaluasi sikap. bloom menunjukkan kompetensi ranah afektif dapat dijelaskan melalui pengenalan, me re spon s, r a sa me ng ha rgai se sa ma , pengorganisasian dan pengalaman. hoge (2003) menyampaikan bahwa pendidikan berkarakter adalah suatu usaha yang didasari dan terencana untuk mempengaruhi berkembangnya sikap yang diinginkan (nursalam & effendi, 2008). pengaruh srlsn pada kelompok perlakuan memberikan perbaikan kemampuan afektif mahasiswa yang memiliki uji signifi kan pada sebelum dan sesudah perlakuan. penyelesaian analisa t ugas pada fase per tama dapat meningkatkan performance mahasiswa untuk meningkatkan kompetensi baik secara kognitif dan afektif. keberhasilan pengembangan ranah kognitif juga akan berdampak positif terhadap perkembangan ranah psikomotor. kecakapan psikomotor ialah segala kegiatan yang konkret dan mudah diamati baik kuantitasnya maupun kualitasnya, karena sifat yang terbuka. namun, di samping kecakapan psikomotor itu tidak terlepas dari kecakapan kognitif yang juga terikat pada kecakapan afektif. jadi kecakapan psikomotor mahasiswa merupakan manifestasi wawasan pengetahuan dan kesadaran serta sikap mentalnya (syah, 2007). ericson dalam zimmer man (2002) menyebutkan bahwa seseorang yang memiliki keahlian dalam bidang tertentu maka akan menghasilkan skill/keterampilan praktik lapangan. dalam hal ini, tujuan dari model penerapan srlsn adalah untuk memantapkan t uj u a n p e m b el aja r a n d a n m e m b a n t u mahasiswa untuk mencapai suatu kompetensi pembelajaran yang diinginkan. penerapan model srlsn pada kelompok perlakuan untuk kompetensi psikomotor menunjukkan nilai yang signifikan daripada kelompok kontrol. hal ini dikarenakan di dalam proses pembelajaran, mahasiswa dikenalkan dan 200 jurnal ners vol. 8 no. 2 oktober 2013: 190–201 sekaligus menerapkan konsep model srlsn mulai fase persiapan, pelaksanaan dan refl eksi diri dan menghasilkan nilai keterampilan skill yang lebih baik daripada kelompok kontrol.. strategi srl secara tepat dapat meningkatkan performance dengan mengembangkan kognitif, mengontrol afektif dan mengarahkan pada motorik. (santoso, 2006). gagne (1976) dalam nursalam (2008) menyebutkan bahwa kondisi yang mempelajari keterampilan memerlukan petunjuk dari pengajar yang menciptakan pengalaman praktik agar mahasiswa tau apa yang akan dilakukan, tahu bagaimana melakukan dan latihan keterampilan serta tercapainya hasil belajar. hal ini sejalan bahwa dengan usaha yang optimal dari srl yang memiliki siklus yang saling berkaitan antara fase persiapan akan meningkatkan performance mahasiswa di kelas dan akan berdampak dalam pencapaian kompetensi aspek psikomotor). simpulan dan saran simpulan pengembangan model srlsn pada pembelajaran dibentuk dari fase persiapan, fase pelaksanaan dan fase refl eksi diri di mana fase persiapan sangat menentukan keberhasilan fase pelaksanaan dan fase ref leksi diri. penerapan model srlsn dapat meningkatkan pencapaian kompetensi pembelajaran mata kuliah keperawatan khususnya pada aspek kognitif, afektif dan psikomotor. pencapaian kompetensi afektif lebih menunjukkan nilai yang paling signifi kan dari ranah kognitif dan psikomotor. hal ini dikarenakan afektif lebih mudah dibangun melalui srlsn daripada ranah yang lain. saran srlsn secara umum bisa diterapkan pada pendidikan keperawatan khususnya pada pendidikan strata satu dalam meningkatkan pencapaian kompetensi mahasiswa pada aspek kognitif, afektif dan psikomotor. evaluasi pada setiap ranah hendaknya dilakukan lebih satu kali. pihak instansi pendidikan keperawatan diharapkan dapat menerapkan srlsn ini u nt u k pen i ng kat an kompetensi belajar mahasiswa. penelitian selanjutnya hendaknya mengkaji lebih lanjut fase persiapan srlsn dengan mempertimbangkan faktor ekstrinsik yang mempengaruhi proses pembelajaran seperti kepuasan sarana prasarana, metode pembelajaran, dukungan keluarga dan aspek psikososial mahasiswa. kepustakaan anthoby, a.r. & friends, 2012. achievement goal structure and self-regulated learning: relationship and changes in medical school. academic medicine, vol 87, no. 107. bandura, a., 1982. self effi cacy mechanism in human agency. america psichologist. vol. 37 no. 2. stanford university usa. hal 122–147. beth t. stalvey and cynthia owsley, 2003. the development and eff icacy of a theory-based educational curriculum to promote self regulation among high risk older driver. health promotion practice, (online), (http://www.sagepub. com, diakses pada tanggal 21 maret 2013, jam 12.00 wib). deasyanti. & ar meini, r.a., 2007. self regulation learning pada mahasiswa fakultas ilmu pendidikan universitas negeri ja k a r ta . per spek t if i l mu pendidikan-vol 16, hal 1–12. desyanti, a.a., 2007. self regulated learning p a d a m a h a si s wa fa k u lt a s i l mu pendidikan universitas negeri jakarta. penelitian. di publikasikan dalam jurnal perspektif ilmu pendidikan vol. 16 th. viii oktober 2007. .nicol, d. j., 2006. formative assessment and self regulated learning: a model and seven principles of good feedback practice. glasgow: studies in higher education. nasrin, k.e.l. & stomberg., margareta,i., wa r ren , 2012. nu rsing s t ud ents motivation toward their studies-a survey study. sweden: bmc nursing 2008, 7: 6. nu rsalam, 2008. standard kompetensi perawat. disampaikan dalam seminar nasional, tidak dipublikasikan. 201 pengembangan model self regulated learning in studying nursing (pepin nahariani, dkk.) nursalam. & effendi, f., 2008. pendidikan d a l a m k e p e r a w a t a n . s a l e m b a , jakarta. ormrod, j.e., 2002. psikologi pendidikan. surabaya: erlangga. pribadi, 2009. the relationship between f lexible and self regulated learning in open and distance university. the international review of research in open and distance learning. research article. vol. 13 no. 2. pintrich, p.r., 2004. a conceptual framework for assessing motivation and selfregulated learning in college students. educational psychology review, vol 16, no. 4, december 2004. hal 385–407, (online), (http://www.spinger.science. com, diakses pada tanggal 15 maret, jam 17.00) schunk, d.h., 2001. self regulated learning: the educational legacy of paul r. pintrich. educational psichologist, 40. hal 84–94, (online), (http://www.tandf. co.uk/journals/, diakses pada tanggal 13 maret 2013, jam 09.00 wib). su s a nt o, h., 20 0 6. me nge mb a ng k a n kemampuan self reg ulation unt u k meningkatkan keberhasilan akademik siswa. jurnal pendidikan penabur no 07/th. v/desember 2006. syah, m., 2003. psikologi belajar. jakarta: pt rajagrafi ndo persada. woods, nicole, n., mylopoulus., maria., brydges., ryan., 2011. informal selfregulated learning on a surgical in context. adv in health sci educ. springer sci-business media b.v. yulinawarti, i. & hartati, d.r.s, 2007. self regulated learning mahasiswa fast tract. fakultas psikologi universitas diponegoro. zimmerman, b.j., 2002. becoming a self regulation learner: an overview. theor y into practice. volume 41, nu r mb e r 2 . s p r i n g. col lege of education. the ohio state university. zimmerman, b.j., timthy, j., cleary., 2004. self regulation empowerment program : a school based program to enhance self regulated and self motivated cycles of student learning. cit y univercity of new york. psychology in the schools. vol. 41 (5). published online in wiley inter scieence, (online), (http://www.interscience.wiley.com, diakses pada tanggal 12 maret 2013, jam 17.00 wib). zim mer man, b.j., kitsantas, a., 2012. comparing self regulateory processes among novice, non expert, and expert volleyball players : a microanalytic stud y. t he g rad uate school and university center the university of new york. journal of applied psychology, 14: 91–105 zim mer man b. j., maria, k.d., 2011. d i f fe r e nc e s i n sel f reg u l at or y processes among student studying science : a microanalytic investigation. cit y universit y of new york, the graduate school and university center cit y universit y of new york. the international journal of educational and psychological assessment. vol. 5 vol 6 no 1 april 2011_akreditasi 2013.indd 11 formula penghitungan tenaga keperawatan modifikasi fte dengan model asuhan keperawatan profesional tim (fte modifi cation of nursing staff calculating formula with team profesional nursing care model) erlin kurnia*, nyoman anita damayanti**, nursalam*** *stikes rs baptis kediri jl. mayjend. panjaitan no.3b kediri 64102 e-mail: egan.erlin@gmail.com ** fakultas kesehatan masyarakat universitas airlangga *** fakultas keperawatan universitas airlangga abstract introduction: a variety of formulas that can be done to count the needs of nursing staff in inpatient rooms include ministry of health republic of indonesia method, gillies, nina formulation, douglas, and full time equivalent (fte). the purpose of this study was to recommend the formula for calculating nurse staff needs in implementation of team nursing model of care delivery. method: the design used in this study was a time and motion study. data was collected by observations and questionnaires. the population was the nurses who work at kediri baptist hospital inpatient wards. the observation and questionnaires to the resource persons utilized as a data collection method. two inpatient wards were the taken as simulation places, there were ward a and ward b. ward a was taken as simulation place based on fte method and ward b was taken as simulation place based on ministry of health republic of indonesia method. based on the calculation according to the ministry of health republic of indonesia method obtained the required number of nursing staff as many as 17 people in ward a and 23 in ward b. meanwhile, according to fte count obtained the number of nursing staff as many as 20 people in ward a and 33 in ward b. result: the simulation results obtained an increase in performance of duties and job satisfaction of nurses in inpatient wards that were simulated using the fte method. discussion: the inpatient ward that is simulated using the ministry of health republic of indonesia method obtained an increase in performance of duties but a decrease in job satisfactions. it can be concluded that the fte method is more appropriate to use than ministry of health republic of indonesia. keywords: formula, nurse staff needs, team nursing models of care delivery pendahuluan pelayanan keperawatan merupakan bagian dari pelayanan kesehatan di rumah sakit sehingga mutu pelayanan kesehatan juga ditentukan oleh mutu pelayanan keperawatan. pelayanan keperawatan terutama diperuntukkan bagi pemenuhan kebutuhan dasar manusia ( k u n t o r o , 2 0 1 0 ) . k u a l i t a s p e l a y a n a n keperawatan di ruang rawat inap juga dapat dipengaruhi oleh model asuhan keperawatan profesional (makp) yang diberlakukan. makp memiliki empat komponen utama yang perlu diperhatikan yaitu: kebutuhan pasien, demografi populasi pasien, jumlah perawat, rasio perawat dengan berbagai peran dan tingkat tanggung jawab. makp yang ada saat ini antara lain tim, primer, modular dan manajemen kasus. jumlah perawat sesuai rasio yang sesuai dengan mempertimbangkan tingkat tanggung jawab sesuai makp yang digunakan memerlukan metode penghitungan kebutuhan yang perlu disesuaikan dengan kebutuhan. formula penghitungan kebutuhan tenaga yang jurnal ners vol. 6 no. 1 april 2011: 11–20 12 ada antara lain metode departemen kesehatan republik indonesia, gillies, formulasi nina, douglas, dan full time equivalent (fte). tujuan penelitian ini adalah untuk mengusulkan formula penghitungan tenaga keperawatan dalam pelaksanaan makp tim di rumah sakit baptis kediri (rsbk). bahan dan metode metode penelitian yang digunakan dalam penelitian ini adalah penelitian survei analitik dengan pendekatan time and motion study. jenis penelitian adalah action research, yaitu memberikan intervensi berupa simulasi penyesuaian jumlah tenaga keperawatan sesuai hasil penghitungan berdasarkan departemen kesehatan republik indonesia dan fte. simulasi tersebut dilakukan untuk mengevaluasi apakah jika jumlah tenaga dipenuhi akan terjadi perubahan mutu pelaksanaan tugas dan kepuasan perawat. penelitian ini dilakukan melalui dua tahap. tahap i untuk menghitung tenaga keperawatan menggunakan pedoman cara penghitungan dari departemen kesehatan republik indonesia dan full time equivalent (fte). tahap ii yaitu melakukan simulasi untuk dapat mengusulkan formula penghitungan tenaga keperawatan untuk pelaksanaan makp tim di ruang rawat inap dewasa rsbk. penelitian ini dilakukan di ruang rawat inap dewasa yaitu instalasi rawat inap gedung utama lantai iii kelas iiia (gu iii kelas iiia) dan instalasi rawat inap gedung paviliun lantai iii kelas iiib (gp iii kelas iiib) rumah sakit baptis kediri. penelitian ini dilakukan mulai bulan maret–juli 2011. tahap i dilakukan pada bulan maret–juni 2011, tahap ii dilakukan pada bulan juli 2011. populasi dalam penelitian ini adalah perawat di ruang rawat inap dewasa rsbk yang digunakan sebagai ruang simulasi yaitu ruang gu iii kelas iiia dan gp iii kelas iiib. sampel penelitian dari perawat diambil dengan teknik purposive sampling, dikategorikan sesuai tingkat tanggung jawab perawat dalam pelaksanaan makp tim di ruang gu iii kelas iiia dan gp iii kelas iiib. jumlah sampel dalam penelitian ini sebanyak 3 yang diklasifi kasikan berdasarkan tingkat tanggung jawab perawat. tingkat tanggung jawab perawat tersebut adalah kepala ruang, ketua tim dan anggota tim (staf perawat). instrumen yang digunakan dalam penelitian ini adalah lembar observasi untuk mengetahui kegiatan perawat pada setiap shift dinas. kuesioner untuk mengetahui pelaksanaan tugas dan kepuasan perawat sebelum dan sesudah simulasi. kemudian data akan ditabulasi dan dianalisis menggunakan uji statistik paired t-test untuk mengetahui apakah ada perbedaan tugas yang dilakukan perawat dan kepuasan kerja perawat sebelum dan sesudah simulasi. hasil penghitungan tenaga keperawatan yang dilakukan berdasarkan pedoman cara penghitungan kebutuhan tenaga keperawatan dari departemen kesehatan republik indonesia yang dilakukan di instalasi rawat inap ruang a dan ruang b dilakukan dengan berdasarkan data tentang rerata jumlah pasien per hari dengan berbagai tingkat ketergantungan, rerata jam perawatan pasien perhari sesuai tingkat ketergantungan sesuai pedoman. d e p a r t e m e n k e s e h a t a n r e p u b l i k indonesia, jam kerja efektif perawat per hari sesuai pedoman departemen kesehatan republik indonesia yaitu sebanyak 7 jam, jumlah hari libur/cuti perawat dalam setahun, yaitu 78 hari (meliputi 52 hari minggu dalam setahun +12 hari cuti dalam setahun +14 hari libur nasional dalam setahun), serta jumlah perawat yang dibutuhkan untuk melakukan kegiatan non keperawatan sesuai pedoman departemen kesehatan republik indonesia (25% dari jumlah perawat). tabel 1. rekapitulasi jumlah kebutuhan te n a g a m e n u r u t d e p a r t e m e n kesehatan republik indonesia dan fte di instalasi rawat inap ruang a dan ruang b rsbk no komposisi ruang a ruang b 1 kepala ruang 1 1 2 perawat 13 18 3 pos 3 4 jumlah 17 23 formula penghitungan tenaga keperawatan modifi kasi (erlin kurnia, dkk) 13 berdasarkan tabel 1 dapat dipelajari bahwa berdasarkan penghitungan departemen k e s e h a t a n r e p u b l i k i n d o n e s i a j u m l a h p e r a w a t y a n g d i b u t u h k a n d i r u a n g a sebanyak 17 orang dan di ruang b adalah 23 orang. metode fte merupakan metode yang mendasarkan bahwa seorang perawat penuh waktu bekerja selama 52 minggu/tahun, 40 jam/minggu. berdasarkan asumsi tersebut dapat dihitung jam potensial seorang perawat adalah 2080 jam/tahun. namun, beberapa jam potensial tersebut digunakan untuk libur, sakit, melanjutkan pendidikan, dan sebagainya sehingga waktu yang dimiliki kurang dari 2080 jam. waktu produktif dari seorang perawat penuh waktu diasumsikan sebesar 85% sehingga menghasilkan 1768 jam/tahun. untuk menghitung jumlah tenaga keperawatan dilakukan dengan membagi total jam perawatan yang diperlukan perawat untuk memberikan perawatan pada pasien di satu ruang dibagi dengan 1768 jam. penghitungan tenaga keperawatan yang dilakukan berdasarkan metode fte yang dilakukan di instalasi rawat inap ruang a dan ruang b dilakukan dengan berdasarkan data berikut ini. a. jam perawatan per 24 jam b. hari perawatan pasien berdasarkan perkalian kedua data tersebut dapat dihitung beban kerja unit rawat inap. setelah diketahui beban kerja unit maka akan dibagi dengan 1768 jam sehingga akan diketahui jumlah tenaga yang diperlukan. penghitungan metode fte jumlah perawat yang dibutuhkan di ruang a sebanyak 20 orang dan di ruang b adalah 33 orang. upaya penentuan formula penghitungan tenaga keperawatan yang sesuai dilakukan melalui simulasi yaitu menempatkan sejumlah perawat sesuai jumlah hasil penghitungan untuk bekerja di instalasi rawat inap ruang a dan ruang b. simulasi tersebut dilaksanakan pada tanggal 11–16 juli 2011. instalasi rawat inap ruang a disimulasikan dengan metode fte sedangkan instalasi rawat inap ruang b disimulasikan metode departemen kesehatan republik indonesia. hal yang dievaluasi adalah pelaksanaan tugas sesuai tanggung jawab perawat seperti kepala ruang, ketua tim dan anggota tim serta kepuasan kerja perawat. kedua hal itu diukur pada saat sebelum dan sesudah simulasi, kemudian dibandingkan hasilnya. jumlah tenaga keperawatan yang ada di instalasi rawat inap ruang a sebelum simulasi sebanyak 17 orang (terdiri dari 13 perawat dan 4 pos). saat simulasi jumlah tenaga menjadi 20 orang (terdiri dari 18 perawat dan 2 pos). rerata jumlah pasien sebelum simulasi adalah tabel 3. tugas kepala ruang di instalasi rawat inap ruang a dan b rsbk sebelum dan sesudah simulasi no. tugas ruang a ruang b rerata rerata sebelum sesudah sebelum sesudah 1. perencanaan 3,9 3,8 3,8 3,9 2. pengorganisasian 3,8 4 4 4 3. pengarahan 3,3 4 4 4 4. pengawasan 4 4 4 4 5. evaluasi 3,5 3,5 3,5 4 rerata 3,7 4 3,9 3,9 uji paired t-test p = 0,115 p = 1 tabel 2. rekapitulasi jumlah kebutuhan tenaga menurut fte di instalasi rawat inap ruang a dan ruang b rsbk no komponen ruang a ruang b 1 kepala ruang 1 1 2 perawat 17 29 3 pos 2 3 jumlah 20 33 jurnal ners vol. 6 no. 1 april 2011: 11–20 14 16, sedangkan saat simulasi meningkat menjadi 25 pasien. jumlah tenaga keperawatan yang ada di instalasi rawat inap ruang b sebelum simulasi sebanyak 24 orang (terdiri dari 17 perawat dan 7 pos). saat simulasi jumlah tenaga menjadi 23 orang (terdiri dari 19 perawat dan 4 pos). rerata jumlah pasien sebelum simulasi adalah 28, sedangkan saat simulasi sebanyak 19 pasien. berikut ini disajikan data tentang hasil rekapitulasi tugas yang dilaksanakan oleh kepala ruang, ketua tim dan anggota tim sesuai dengan uraian tugas masing-masing perawat di instalasi rawat inap ruang b dan instalasi rawat inap ruang a sebelum dan sesudah simulasi. kepala ruang dalam pelaksanaan tugasnya sesudah simulasi di ruang a terdapat peningkatan pelaksanaan tugas dibandingkan sebelum simulasi yaitu dari 3,7 menjadi 4. perubahan terjadi pada semua aspek tugas kecuali aspek pengawasan yang sudah memiliki nilai optimal pada saat sebelum simulasi, namun, di ruang b didapatkan tidak ada perubahan. tugas kepala ruang mulai dari perencanaan sampai evaluasi didapatkan rerata yang sama antara sebelum dan sesudah simulasi. sebagian besar tugas yang dilaksanakan kepala ruang sudah mencapai nilai optimal. ketua tim dalam pelaksanaan tugasnya sebelum dan sesudah simulasi di ruang a tidak terjadi perubahan karena pelaksanaan tugas ketua tim sebelum simulasi sudah mencapai nilai maksimal. sedangkan di ruang b didapatkan peningkatan rerata yaitu dari 3,4 menjadi 3,8. hasil uji statistik didapatkan perubahan yang signifikan. perubahan yang terjadi pada ketua tim ruang b meliputi tugas untuk mengkaji catatan perkembangan, tabel 4. tugas ketua tim di instalasi rawat inap ruang a dan b rsbk sebelum dan sesudah p no tugas ruang a ruang b rerata rerata sebelum sesudah sebelum sesudah 1 pengkajian 4 4 3,7 3,7 2 catatan perkembangan 4 4 3,7 4 3 koordinasi rencana keperawatan 4 4 3,7 3,7 4 pembimbingan anggota tim 4 4 3,3 4 5 evaluasi respons klien 4 4 3 3,7 6 penilaian kemajuan kondisi klien 4 4 3,3 3,7 rerata 4 4 3,4 3,8 uji paired t-test p = 1 p = 0,042 tabel 5. tugas anggota tim di instalasi rawat inap ruang a dan instalasi rawat inap ruang b rsbk sebelum dan sesudah simulasi no tugas ruang a ruang b rerata rerata sebelum sesudah sebelum sesudah 1 memberi asuhan keperawatan 3, 4 3,9 3,9 3,8 2 kerja sama 3,6 3,8 4 3,9 3 pelaporan tindakan keperawatan 3,5 3,6 4 3,8 4 menerima bimbingan dari ketua tim 3 2,5 3,2 3,1 rerata 3,4 3,6 3,5 3,8 uji paired t-test p = 0,022 p = 0,118 formula penghitungan tenaga keperawatan modifi kasi (erlin kurnia, dkk) 15 tabel 6. kepuasan kerja kepala ruang di instalasi rawat inap ruang a dan instalasi rawat inap ruang b rsbk sebelum dan sesudah simulasi no. kepuasan ruang a ruang b rerata rerata sebelum sesudah sebelum sesudah 1. kebutuhan fi siologis 4 4 4 4 2. kebutuhan aman nyaman 3,2 3,2 3,6 3,6 3. kebutuhan dicintai mencintai 4 4 3,4 3,4 4. kebutuhan penghargaan dan pengakuan 4 4 4 4 rerata kepuasan 3,7 3,7 3,6 3,6 uji statistik paired t-test p = 1 p = 1 tabel 7. kepuasan kerja ketua tim di instalasi rawat inap ruang a dan instalasi rawat inap ruang b rsbk sebelum dan sesudah simulasi no. kepuasan ruang a ruang b rerata rerata sebelum sesudah sebelum sesudah 1. kebutuhan fi siologis 2 2,5 3,3 3,3 2. kebutuhan aman nyaman 3,8 4,2 3,1 2,9 3. kebutuhan dicintai mencintai 4,1 4,5 4 4 4. kebutuhan penghargaan dan pengakuan 4 4,5 4,7 4 rerata kepuasan 3,7 4,2 3,7 3,6 uji statistik paired t-test p = 0,001 p = 0,266 tabel 8. kepuasan kerja anggota tim di instalasi rawat inap ruang a dan instalasi rawat inap ruang b rsbk sebelum dan sesudah simulasi no. kepuasan ruang a ruang b rerata rerata sebelum sesudah sebelum sesudah 1. kebutuhan fi siologis 3,1 3,4 3,2 3,1 2. kebutuhan aman nyaman 2,9 3,1 3,0 3,1 3. kebutuhan dicintai mencintai 3,7 3,8 3,9 3,6 4. kebutuhan penghargaan dan pengakuan 3,6 3,6 3,8 3,7 rerata kepuasan 3,3 4,3 3,5 3,4 uji statistik paired t-test p = 0,308 p = 0,103 p e m b i m b i n g a n a n g g o t a t i m , e v a l u a s i r e s p o n k l i e n , d a n p e n i l a i a n k e m a j u a n kondisi klien. sedangkan nilai tugas yang tetap sama yaitu pengkajian dan koordinasi rencana keperawatan. anggota tim dalam pelaksanaan tugasnya sebelum dan sesudah simulasi di ruang a dan ruang b terjadi peningkatan rerata. jika dilihat dari hasil uji statistik, didapatkan adanya perubahan pelaksanaan tugas yang signifi kan di ruang a tetapi di ruang b perubahan yang ada tidak signifi kan. semua aspek tugas anggota tim di ruang a mengalami peningkatan. sedangkan di ruang b dari semua aspek tugas anggota tim mengalami peningkatan rerata ada satu aspek yang reratanya tetap yaitu memberi asuhan keperawatan. kepuasan kepala ruang sebelum dan sesudah simulasi di ruang a dan ruang b tidak didapatkan perubahan pada semua aspek jurnal ners vol. 6 no. 1 april 2011: 11–20 16 penilaian kepuasan mulai dari aspek kebutuhan fisiologis sampai kebutuhan penghargaan dan pengakuan kepuasan ketua tim sebelum dan sesudah simulasi di ruang a didapatkan peningkatan kepuasan tetapi di ruang b ada penurunan rerata kepuasan. jika dilihat berdasarkan uji statistik maka perubahan yang terjadi di ruang a merupakan perubahan yang signifi kan. hal tersebut terjadi akibat semua aspek kepuasan pada ketua tim di ruang a mengalami peningkatan rerata. dua dari empat aspek kepuasan yang diteliti pada ketua tim di ruang b yaitu kebutuhan aman nyaman dan kebutuhan penghargaan pengakuan mengalami penurunan rerata, sedangkan dua aspek yang lain yaitu kebutuhan fi siologis dan kebutuhan dicintai mencintai tetap nilainya. rerata kepuasan anggota tim di ruang a mengalami peningkatan tetapi di ruang b mengalami penurunan. tiga dari empat aspek kepuasan yang dinilai di ruang a meningkat reratanya setelah simulasi yaitu kebutuhan fi siologis, aman nyaman dan dicintai mencintai. hanya satu aspek saja yaitu kebutuhan penghargaan dan pengakuan yang mengalami nilai tetap. kepuasan anggota tim di ruang b, tiga dari empat aspek kepuasan yang dinilai menurun reratanya setelah simulasi, hanya satu aspek saja yaitu kebutuhan aman nyaman yang mengalami peningkatan rerata meskipun hanya 0,1 poin. tugas yang dilaksanakan oleh kepala ruang, ketua tim dan anggota tim di ruang a dan ruang b adalah baik karena terjadi peningkatan pada saat sesudah simulasi. pada saat simulasi terjadi peningkatan jumlah pasien di ruang a dari rerata per hari 16 pasien menjadi 25 pasien, sedangkan di ruang b terjadi penurunan dari rerata 28 pasien menjadi 19 pasien. meskipun dengan peningkatan jumlah pasien lebih dari 50% tetapi perawat ruang a dapat bekerja lebih baik. kepuasan kerja perawat di ruang a mengalami peningkatan pada saat sesudah simulasi tetapi di ruang b justru terjadi penurunan kepuasan kerja. ruang a sebagai ruang simulasi metode fte setelah simulasi didapatkan peningkatan tugas yang dilakukan perawat dan peningkatan kepuasan kerja meskipun terjadi penambahan jumlah pasien lebih dari 50% dibanding sebelumnya. ruang b sebagai tempat simulasi metode departemen kesehatan republik indonesia didapatkan peningkatan tugas yang dilakukan perawat tetapi terjadi penurunan kepuasan kerja perawat. pada saat simulasi di ruang b terjadi penurunan jumlah pasien mencapai 25% dibanding sebelumnya. pembahasan pasien yang dirawat inap di instalasi rawat inap mempunyai tingkat ketergantungan yang berbeda. departemen kesehatan republik indonesia membagi tingkat ketergantungan pasien menjadi 4 yaitu pasien dengan tingkat ketergantungan minimal, sedang, agak berat, dan maksimal. tiap tingkat ketergantungan tersebut mempunyai kriteria yang didasarkan pada penggunaan alat bantu pemenuhan kebutuhan dan frekuensi observasi yang diperlukan (departemen kesehatan republik indonesia, 2005). tingkat ketergantungan memengaruhi kebutuhan akan perawatan dari perawat. klasifi kasi tingkat ketergantungan menurut departemen kesehatan republik indonesia adalah ketergantungan maksimal (jam perawatan 6,16 jam/hari), ketergantungan agak berat (4,15 jam/hari), ketergantungan sedang (3,08 jam/hari) atau ketergantungan minimal tabel 9. perbandingan perubahan tugas dan kepuasan kerja perawat sebelum dan sesudah simulasi di instalasi rawat inap ruang a dan instalasi rawat inap ruang b rsbk no. ruang jabatan tugas kepuasan kerja 1. ruang a kepala ruang meningkat (p = 0,115) tetap (p = 1) ketua tim tetap (p = 1) meningkat (p = 0,042) anggota tim meningkat (p = 0,022) meningkat (p = 0,118) 2. ruang b kepala ruang tetap (p = 1) tetap (p = 1) ketua tim meningkat (p = 0,001) menurun (p = 0,266) anggota tim meningkat (p = 0,308) menurun (p = 0,103) formula penghitungan tenaga keperawatan modifi kasi (erlin kurnia, dkk) 17 (2 jam/hari). metode departemen kesehatan republik indonesia hanya menghitung waktu perawatan langsung yang diberikan kepada pasien. setelah mengetahui jam perawatan total maarus ditka akan dibagi dengan 7 jam (jam efektif perawat) sehingga diketahui jumlah tenaga yang diperlukan. jumlah ini masih perlu ditambah dengan faktor koreksi yaitu loss day dan non-nursing jobs. loss day adalah jumlah perawat yang dibutuhkan untuk mengganti waktu hari libur. non-nursing jobs menurut pedoman departemen kesehatan republik indonesia dijelaskan sebagai jumlah tenaga keperawatan yang mengerjakan tugastugas non keperawatan. non-nursing jobs ini diperkirakan 25% dari jam pelayanan keperawatan (departemen kesehatan republik indonesia, 2005). metode fte juga mempertimbangkan hari rawat inap dan klasifikasi tingkat ketergantungan karena klasifikasi tersebut memengaruhi jumlah jam perawatan yang diperlukan. namun, tidak semua waktu tersebut digunakan sepenuhnya oleh seorang perawat untuk bekerja. ada waktu yang dihabiskan untuk libur, sakit, melanjutkan pendidikan dan sebagainya. oleh sebab itu waktu produktif seorang perawat dalam satu tahun sebesar 85% yaitu 1768 jam/tahun (hendrich, et al., 2008). jumlah perawat sesuai metode fte dihitung dengan mengalikan jam perawatan per 24 jam dengan hari rawat inap. jam perawatan pasien per 24 jam merupakan penjumlahan semua waktu yang digunakan perawat untuk melakukan perawatan baik perawatan langsung maupun tidak langsung. simulasi di ruang rawat inap dilakukan dengan menempatkan sejumlah tenaga keperawatan sesuai jumlah hasil penghitungan dua metode. evaluasi dilakukan dengan mengukur tugas yang dilaksanakan perawat dan kepuasan kerja baik dari kepala ruang, ketua tim dan anggota tim. tugas yang dilakukan oleh perawat di ruang simulasi metode fte (ruang a) dapat dipelajari bahwa terjadi peningkatan terutama pada kepala ruang dan anggota tim, sedangkan pada ketua tim tetap. pada saat simulasi di ruang tersebut mengalami perubahan jumlah tenaga dari 17 menjadi 20 orang, dan terjadi peningkatan rerata jumlah pasien dari 16 menjadi 25 pasien per hari. peningkatan tugas perawat tersebut dapat terjadi karena jumlah tenaga yang ada dapat diatur sesuai kebutuhan makp tim yang dijalankan. ruang a terbagi menjadi dua tim. pada saat simulasi setiap tim bisa terdiri dari 2 orang, sebelumnya seringkali hanya terdiri dari satu orang perawat per tim. berdasarkan observasi, kepala ruang bersama ketua tim lebih dapat mengatur pembagian tugas pemberian asuhan keperawatan pada sekelompok pasien sesuai tanggung jawabnya. anggota tim lebih dapat fokus melakukan perawatan pada kelompok pasien yang menjadi tanggung jawab mereka. kepuasan kerja ketua tim dan anggota tim di kedua ruang rawat inap mengalami perubahan, sedangkan kepuasan kerja kepala ruang tetap. perubahan kepuasan kerja ketua tim dan anggota tim di instalasi rawat inap ruang a merupakan perubahan positif yaitu kepuasan sesudah simulasi menjadi lebih tinggi dibanding sebelumnya. hal tersebut dapat terjadi akibat perubahan jumlah tenaga yang dinas. total jumlah perawat yang dinas mengalami penambahan 3 orang. berdasarkan uji statistik perubahan kepuasan kerja pada ketua tim menunjukkan hasil yang signifi kan. semua aspek kepuasan yang diteliti mengalami peningkatan. kebutuhan fisiologis yaitu waktu untuk makan dan minum, kebutuhan aman nyaman meliputi jumlah perawat yang dinas dan rotasi dinasnya, kebutuhan dicintai mencintai yaitu kebutuhan akan komunikasi antar perawat, dengan dokter dan tim kesehatan lain, kebutuhan penghargaan dan pengakuan yaitu interaksi dengan pasien mengalami peningkatan. jumlah tenaga yang ditempatkan di ruang a setiap shift dapat memberikan waktu bagi perawat untuk melakukan tugasnya memberi asuhan keperawatan pada pasien, menjaga komunikasi dan interaksi yang lebih baik baik bagi pasien, sesama perawat, kepada dokter maupun tim kesehatan lain. hasil kuesioner tugas yang dilakukan oleh perawat di ruang simulasi metode departemen kesehatan republik indonesia (ruang b) dapat dipelajari bahwa terjadi peningkatan terutama pada ketua tim dan anggota tim, sedangkan pada kepala ruang tetap. hal tersebut dapat jurnal ners vol. 6 no. 1 april 2011: 11–20 18 terjadi karena ada penurunan rerata jumlah pasien dari 28 menjadi 19 per hari. jumlah pasien yang lebih sedikit dibanding jumlah perawat yang relatif tetap akan menyebabkan ketua tim menjadi lebih mudah melakukan asuhan keperawatan maupun melakukan koordinasi antar anggota tim yang lain. begitu pula anggota tim merasakan beban kerja lebih berkurang karena ada penurunan jumlah pasien yang menjadi tanggung jawabnya. berdasarkan wawancara dan observasi, kepala ruang menghabiskan waktu lebih banyak untuk melakukan asuhan keperawatan pada pasien dibandingkan melakukan tugas mereka sebagai kepala ruang. ketua tim diberi tanggung jawab melakukan asuhan keperawatan langsung pada pasien dengan jumlah sebanyak jumlah pasien yang diberikan untuk anggota tim. kondisi tersebut menyebabkan ketua tim kurang dapat melakukan semua tugas yang seharusnya menjadi tugas ketua tim. kepuasan kerja ketua tim dan anggota tim di kedua ruang rawat inap mengalami perubahan, sedangkan kepuasan kerja kepala ruang tetap. perubahan kepuasan kerja ketua tim dan anggota tim di ruang a merupakan perubahan positif yaitu kepuasan sesudah simulasi menjadi lebih tinggi dibanding sebelumnya. hal tersebut dapat terjadi akibat perubahan jumlah tenaga yang dinas. perubahan jumlah tenaga tersebut mengakibatkan kepala ruang lebih mampu mengatur penjadwalan dan pengaturan tugas setiap shift sesuai pedoman dalam pelaksanaan makp tim. berdasarkan uji statistik perubahan kepuasan kerja pada ketua tim menunjukkan hasil yang signifi kan. semua aspek kepuasan yang diteliti mengalami peningkatan. jumlah tenaga yang ditempatkan di ruang a setiap shift dapat memberikan waktu bagi perawat untuk melakukan tugasnya memberi asuhan keperawatan pada pasien, menjaga komunikasi dan interaksi yang lebih baik baik bagi pasien, sesama perawat, kepada dokter maupun tim kesehatan lain. perubahan kepuasan kerja pada ketua tim dan anggota tim di instalasi rawat inap ruang b adalah negatif yaitu kepuasan sesudah simulasi menjadi lebih rendah dibanding sebelumnya. hal tersebut dapat terjadi akibat perubahan jumlah dan komposisi tenaga keperawatan yang dinas. aspek kepuasan yang menurun pada sesudah simulasi adalah aspek kebutuhan aman nyaman dan kebutuhan penghargaan dan pengakuan. hal tersebut menandakan perubahan jumlah perawat yang ditempatkan di ruang b menyebabkan penurunan kepuasan perawat pada aspek jumlah perawat yang dinas setiap shift juga memengaruhi interaksi mereka dengan pasien. evaluasi kuesioner tugas yang dilakukan perawat di kedua ruang rawat inap dapat dipelajari bahwa sebagian besar perawat baik kepala ruang, ketua tim maupun anggota tim mengalami peningkatan tugas setelah simulasi dari sebelum simulasi. sebagian kecil memiliki rerata yang tetap antara sebelum dan sesudah simulasi. apabila dicermati dari hasil uji statistik, terjadi peningkatan rerata tugas secara signifi kan yang dilakukan oleh anggota tim di ruang a. anggota tim merupakan perawat yang memiliki paling banyak waktu untuk memberikan asuhan keperawatan langsung pada sekelompok pasien yang menjadi tanggung jawabnya. hasil kuesioner kepuasan kerja pada kepala ruang di kedua ruang rawat inap tidak mengalami perubahan. kepuasan kerja ketua tim dan anggota tim di ruang a mengalami peningkatan tetapi di ruang b justru mengalami penurunan jika dibandingkan dengan hasil sebelum simulasi. p e r b e d a a n h a s i l p e n g h i t u n g a n berdasarkan pedoman departemen kesehatan republik indonesia dan fte dapat disebabkan antara lain pada penentuan jam perawatan pasien. bila pada pedoman departemen kesehatan republik indonesia yang diperhitungkan hanya perawatan langsung (direct care) sedangkan pada metode fte jam perawatan merupakan semua waktu yang digunakan perawat untuk memberikan perawatan kepada pasien. semua waktu tersebut berarti tidak hanya waktu untuk perawatan langsung (direct care) tapi juga waktu perawatan tidak langsung (non-direct care). selain itu pada pedoman departemen kesehatan republik indonesia, jam efektif perawat dihitung 7 jam sedangkan pada metode fte yang dipertimbangkan hanya waktu produktif perawat yaitu waktu yang diperlukan untuk melakukan asuhan keperawatan pada pasien. bila jam efektif perawat ini lebih formula penghitungan tenaga keperawatan modifi kasi (erlin kurnia, dkk) 19 banyak padahal waktu yang diperlukan untuk melakukan perawatan adalah sama maka akan didapatkan hasil yang berbeda dalam jumlah perawat. kedua aspek tersebut yang dapat memengaruhi perbedaan hasil penghitungan berdasarkan pedoman departemen kesehatan republik indonesia dan fte. hasil perhitungan departemen kesehatan republik indonesia lebih sedikit jumlah perawat yang diperlukan daripada metode fte. h a s i l p e n i l a i a n k e d u a m e t o d e penghitungan kebutuhan tenaga keperawatan tersebut dapat disimpulkan bahwa penghitungan berdasarkan departemen kesehatan republik indonesia dapat menyebabkan peningkatan pelaksanaan tugas perawat pada kondisi penurunan rerata jumlah pasien, sedangkan p e n g h i t u n g a n b e r d a s a r k a n f t e d a p a t menyebabkan peningkatan pelaksanaan tugas perawat meskipun rerata jumlah pasien meningkat lebih banyak. metode departemen kesehatan republik indonesia dapat menurunkan kepuasan kerja perawat sedangkan metode fte dapat meningkatkan kepuasan kerja perawat. hasil observasi dan wawancara yang peneliti lakukan di ruang a dapat dipelajari bahwa dengan perubahan jumlah tenaga yang disimulasikan, perawat dapat lebih mengatur pemberian asuhan keperawatan setiap perawat yang dinas setiap shiftnya. perawat juga dapat memberikan waktu dan meningkatkan kualitas asuhan keperawatan yang diberikan pada pasien. jumlah perawat yang ditempatkan masih mencukupi meskipun terjadi peningkatan jumlah pasien dari rerata 16 menjadi 25 orang. jumlah tersebut juga masih bisa diterima pada kondisi ada beberapa perawat yang tidak dinas karena melanjutkan pendidikan. observasi terhadap tindakan keperawatan langsung yang dilakukan perawat kepada pasien, didapatkan bahwa perawat lebih mempunyai waktu untuk berinteraksi lebih baik dengan pasien, melaksanakan tindakan sesuai prosedur operasional yang ditetapkan rumah sakit. hasil kuesioner pelaksanaan tugas menunjukkan tugas perawat meningkat pada saat sesudah simulasi. peningkatan tersebut dapat dikaitkan dengan penurunan rerata jumlah pasien dari 28 menjadi 19 orang. jumlah pasien yang menurun sedangkan jumlah perawat relatif tetap menyebabkan perawat tetap dapat memberikan asuhan keperawatan yang baik bagi setiap pasien. namun, dari wawancara perawat mengatakan bahwa jumlah perawat yang dinas saat simulasi memang masih cukup tetapi pada kondisi yang biasa terjadi dengan rerata 28–30 pasien maka jumlah yang ada saat simulasi tidak akan mencukupi. berdasarkan fakta tersebut dapat disimpulkan bahwa metode fte lebih sesuai dengan kebutuhan ruang rawat inap. metode fte dapat dimodifi kasi dengan menyesuaikan waktu libur dan cuti setiap karyawan. modifi kasi fte dilakukan pada persentase waktu produktif yang semula adalah 85% menjadi 92%. simpulan dan saran simpulan tugas perawat yang dilakukan oleh kepala ruang dan anggota tim di ruang simulasi metode fte meningkat, sedangkan tugas ketua tim tetap karena nilai sebelum simulasi sudah optimal. tugas perawat yang dilakukan oleh ketua tim dan anggota tim di ruang simulasi metode departemen kesehatan republik indonesia meningkat, sedangkan tugas kepala ruang tetap karena nilai sebelum simulasi sudah optimal. kepuasan kerja ketua tim dan anggota tim di ruang simulasi metode fte terjadi peningkatan rerata kepuasan sesudah simulasi, sedangkan kepuasan kepala ruang tetap. kepuasan kerja ketua tim dan anggota tim di ruang simulasi metode departemen kesehatan republik indonesia mengalami penurunan rerata kepuasan sesudah simulasi, sedangkan kepala ruang rerata kepuasannya tetap, formula penghitungan kebutuhan tenaga keperawatan yang diusulkan untuk pelaksanaan makp tim di rumah sakit baptis kediri adalah metode fte. formula fte dapat dimodifi kasi pada persentase waktu produktif yaitu menjadi 92%. saran rumah sakit baptis kediri dapat menggunakan metode modifi kasi fte sebagai jurnal ners vol. 6 no. 1 april 2011: 11–20 20 metode penghitungan kebutuhan tenaga keperawatan dalam pelaksanaan makp tim. hal ini sangat diperlukan supaya makp tim yang merupakan model asuhan keperawatan professional minimal yang seharusnya dilakukan di ruang rawat inap, dapat dijalankan secara optimal. kepustakaan delaune dan ladner, 2002. fundamentals of nursing: standards & practice. united states of america: delmar, a division of thomson learning, inc. departemen kesehatan republik indonesia, 2005. standar tenaga keperawatan di rumah sakit. jakarta: direktorat keperawatan dan keteknisan medik, direktorat jenderal pelayanan medik. g i l l i e s . 1 9 9 4 . n u r s i n g m a n a g e m e n t . philadelphia: wb saunders company. hendrich. et al., chow. marilyn, skierczynski. boguslaw a, dan lu. zhenqiang. 2008. a 36-hospital time and motion study: how do medical-surgical nurses spend their time?. the permanente journal, 12(3). kuntoro agus. 2010. buku ajar manajemen k e p e r a w a t a n . yo g y a k a r t a : n u h a medika, hlm. 110–147. neisner dan raymond, 2002. nurse staffi ng and care delivery models: a review of the evidence. oakland: kaiser permanente institute for health policy. nursalam. 2007. manajemen keperawatan aplikasi dalam praktik keperawatan profesional. jakarta: salemba medika. parker, marilyn e. 2005. nursing theories and nursing practice: 2nd ed. philadelphia: f.a. davis company. spetz, joanne. 2008. nurse satisfaction and the implementation of minimum nurse staffi ng regulations. policy, politics & nursing practice, 20(10). w h i t e h e a d , d i a n e k , we i s s , s a l l y a , tappen, ruth m. 2010. essentials of nursing leadership and management. philadelphia: f.a. davis company. http://e-journal.unair.ac.id/jners 61 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 61-69 http://dx.doi.org/10.20473/jn.v18i2.42714 original article open access effects of the tailored intervention program in lowering blood glucose levels and diabetes distress among patients with diabetes in indonesia: a randomized controlled trial satriya pranata 1 * , shu-fang vivienne wu 2 , tsae-jyy tiffany wang 2 , shu-yuan liang 2 , difran nobel bistara 3 , yeu-hui chuang 4 , and kuo-cheng lu 5,6 1 faculty of nursing and health sciences, universitas muhammadiyah semarang, semarang, indonesia 2 school of nursing, national taipei university of nursing and health sciences, taipei, taiwan 3 faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia 4 school of nursing, college of nursing, taipei medical university, taipei, taiwan 5 5department of medical research, taipei tzu chi hospital, buddhist tzu chi medical foundation, taipei, taiwan 6 school of medicine, fu-jen catholic university, taipei, taiwan *correspondence: satriya pranata. address: faculty of nursing and health sciences, universitas muhammadiyah semarang, semarang, indonesia. email: satriya.pranata@unimus.ac.id responsible editor: laily hidayati received: 19 january 2023 ○ revised: 31 march 2023 ○ accepted: 31 march 2023 abstract introduction: blood glucose levels and diabetes distress are the foremost factors contributing to diabetes treatment outcomes and managements. no tailored intervention program was implemented for patients with diabetes in indonesia. this study aimed to investigate the effectiveness of a tailored intervention program in lowering blood glucose levels and diabetes distress among patients with diabetes patients in indonesia. methods: a randomized controlled trial (rct) with pre-test and post-tests was applied. a total of 163 people with diabetes were collected for both intervention (n=80) and control (n=83) groups: a diabetes-tailored intervention program was attempted in the intervention group. descriptive statistics, analysis of variant (anova) and inferential statistics were used to analyze the data (significance level <0.05).. results: the mean blood glucose levels and diabetes distress before and after in the intervention group were 255.19 mg/dl, and 245.60 mg/dl (p-value >0.05); 2.46 and 2.01 (p-value <0.01). while the control group's mean of blood glucose levels and diabetes distress before and after the intervention was were 227.81 mg/dl, and 245.94 mg/dl (p value <0.05); and 2.37 (p-value >0.05). conclusions: the diabetes-tailored intervention program is effective on decreasing blood glucose levels and diabetes distress, and showed a significant result to diabetes distress. keywords: blood glucose, diabetes, diabetes distress, personalized introduction diabetes is considered a major global health problem that causes diabetes distress (hu et al., 2020; jeong & reifsnider, 2018; young et al., 2020). diabetes distress happens because of unstable blood glucose levels and medication needed for a long time (young et al., 2020). blood glucose levels and diabetes distress are the most important factors contributing to treatment outcomes and management of diabetes (hu et al., 2020). diabetes distress releases the excessed glucocorticoid hormone that impairs glucose production in the liver and reduces https://creativecommons.org/licenses/by/4.0/ mailto:satriya.pranata@unimus.ac.id https://orcid.org/0000-0002-2026-8931 https://orcid.org/0000-0003-1248-4738 https://orcid.org/0000-0002-8714-5530 https://orcid.org/0000-0002-4155-9236 https://orcid.org/0000-0002-7995-5509 https://orcid.org/0000-0003-2559-7184 https://orcid.org/0000-0002-7062-8560 pranata, wu, wang, liang, bistara, chuang, and lu (2023) 62 p-issn: 1858-3598  e-issn: 2502-5791 the cell’s sensitivity to insulin which causes hyperglycemia (farm et al., 2017). the prevalence of distress was high among patients with diabetes (batais et al., 2021). simultaneous increases in blood glucose levels due to diabetes distress have also been reported (dekkers & hertroijs, 2018; pranata et al., 2022). moreover, the routine interventions implemented by health professionals for glycemic control and distress management in several countries are health education (suciana & arifianto, 2019). health education alone is not enough, we need to understand health-seeking behaviors based on patient culturally (seligman et al., 2018; widayanti, 2018). moreover, support from various groups, especially families and health professionals, is needed (pranata et al., 2021). however, health professionals' health education and support in the hospital for patients with diabetes did not meet the patient's personal needs (cimo & dewa, 2019; kolb, 2021). health education and support should be tailored to patients' requirements (social-cognitive factors, intention, and behaviour) (pranata et al., 2022). every patient has the obligation and right to participate in individual and group healthcare planning and implementation. additionally, patient-centred education and support increase satisfaction and is crucial for efficient patient education (sassen, 2018). four thousand years ago, a collection of sacred indian literature, a tailored intervention, was first addressed (dekkers & hertroijs, 2018). its goal was to customize treatment through education and support to each person to establish a balance between body, mind, and spirit. at the time, it was known as ayurvedic medicine. today, tailored intervention aims to improve patients' health outcomes and care experience by taking their unique requirements and preferences into consideration while creating a treatment plan (dekkers & hertroijs, 2018; hertroijs et al., 2018). such an approach might be a personalized strategy based on patient phenotyping. according to this method, patients' biopsychosocial characteristics are used to distinguish subgroups of patients with comparable care requirements, capacities, and preferences so that customized treatment plans can be constructed (dekkers & hertroijs, 2018; pranata et al., 2022). the increasing rates of morbidity and death now seen in the diabetes community may be reduced by modifying program delivery for education and support programs customized to that population (cimo et al., 2020). patient preferences, cultural sensitivity, patient center, and support reference to tailored intervention (hertroijs et al., 2018; mayor, 2017). all components of tailored intervention are allowing clients' requirements to direct diabetes education, adapting instruction to match individual needs, and supporting and empowering clients to self-manage (cimo & dewa, 2019). there is a lot of opportunity for personalized care in tailored intervention to be implemented in indonesia as an innovation in enhancing health services for diabetic patients (pranata et al., 2021). a tailored intervention plan for managing diabetes may help patients control their condition, provide tools to manage it more successfully, and lower blood glucose levels and diabetes distress simultaneously. thus, this study's objective was to assess how effective a tailored intervention program is for diabetic patients. the evaluation focused on lowering blood glucose levels and diabetes distress. materials and methods. design of the study a randomized controlled trial (rct) with two groups for the pre-and post-test design was used to examine a repeated measure with a single-blind for a tailored intervention program. the study was carried out from january 7 to april 7, 2021. population and sample of the study laboratory testing of blood glucose levels, as well as a doctor's diagnosis, were used to diagnose the diabetes population in this study. the laboratory data were assessed by the medical records. people with diabetes who visited and registered at primary healthcare in sumbawa city, west nusa tenggara, indonesia, were included as study samples. respondents were recruited from patient list data that had been recorded at the hospital and further randomized using the abab pattern. group a is included in the intervention and group b is included in the control. the level of significance or alpha (α) = 0.05, population effect size (es) = 0.5, and power (1-β) = 0.80 were used to calculate the sample size for the study (kim, 2016). the calculations showed that a sample size of 126 people (64 in each group) was necessary. to account for the possibility that a person would withdraw, the researcher increased the number of participants by 30%. consequently, 168 volunteers were required for this investigation (84 per group). simple randomization by computerized random numbers were used in this study. after randomization by researchers, each respondent received a different inform concern from one another. the intervention group received informed concerns about the implementation of tailed care and the control jurnal ners http://e-journal.unair.ac.id/jners 63 group received traditional health education informed concerns. the study included respondents older than 20 at the time of recruitment, identified as the indonesian citizen, willing to participate, had a mobile device, and lived with the family. twenty years is a mature age in which a person can make their own decisions (icenogle, 2019). if patients reside with their families, the researcher will find it easier to contact them afterwards or to call them to remind them to follow the study protocol. the study excluded those have a history of or a diagnosis of ischemic heart disease, transient ischemic attack (tia), peripheral vascular disease, or persistent mental health concerns. medical condition is used as a criterion to reduce the risk of dropout. standard care standard care from the hospital includes routine blood sugar monitoring, blood pressure assessments, and monthly health counselling for each group (suciana & arifianto, 2019). the standard care services provided to diabetic patients typically concentrate on five key areas: diet, medications, physical activity, health education, and routine blood sugar monitoring (sujana, 2019). although many other media are used to provide health advice, a leaflet or booklet was primarily utilized in standard care (srikartika et al., 2019). advice on how to alter one's diet, use drugs like insulin or oral medications, and notice clinical signs of blood sugar swings are frequently included in leaflets and booklets (nanda et al., 2018; srikartika et al., 2019). participants who received standard care are blinded to the allocation. it avoids those elements that have potentially influenced the outcomes from allocations. participants were also blinded as to their group assignment to avoid their expectations for that treatment. tailored intervention program the tailored intervention program strategies for diabetes were divided into seven steps: 1. brief deducting teaching; 2. assessment for self-management level; 3. brainstorming through a support group for sharing patient's difficulty on glycaemic target and specific target behaviour; 4. making a list of patients' needs and then ranking the priorities; 5. setting a goal and writing action; 6. follow-up; and 7. report of goals attempt. figure 1 the recruitment process for the randomized controlled trial analysed (n = 80) lost to follow-up (n = 2) discontinued intervention (n = 3) allocated to intervention group (n = 86) received allocated intervention (n = 85) did not receive allocated intervention (n = 1) lost to follow-up (n = 2) discontinued intervention (n = 1) allocated to control group (n = 86) received allocated intervention (n = 86) did not receive allocated intervention (n = 0) analysed (n = 83) follow-up randomized 172 assessed for eligibility of patients with diabetes in both primary health care (n = 524) excluded not meeting inclusion criteria (n =160) declined to participate (n =119) rarely check their health condition at health facilities (data/laboratory test incomplete) (n = 73) enrolment allocation pranata, wu, wang, liang, bistara, chuang, and lu (2023) 64 p-issn: 1858-3598  e-issn: 2502-5791 as presenters, brief deducting teaching activities were carried out by health professionals (nurse, physician and dietitian). previously, health professionals had been briefed in detail to ensure that they delivered topics according to patient needs and research needs. the researchers also assessed the material they conveyed to the respondents. health professionals explained about 1) treatment options for high or low blood sugar levels; 2) proper nutritional treatment based on culturally sensitive dietary information; 3) how to combine daily physical activity and exercise; 4) a condition in which patients are required to consume drug or insulin medication; 5) teach patients for blood glucose self-monitoring test; 6) acute comorbidity prevention, detection, and treatment; 7) chronic comorbidity prevention, detection, and treatment; 8) goal-setting and achievement-based health promotion; and 9) integration of psychological adjustment for daily living and problem-solving advice. after the brief deductive teaching has been transferred, the respondent was assessed on his level of self-management. the level of self-management will determine the small group of each respondent. respondents with a good level of self-management are grouped with good levels in small groups, moderate levels are grouped with moderate levels in small groups and so on. when they are in small groups, respondents exchange information with each other through the support group. in support groups, respondents learn from each other from the experience of group members to maintain glucose control. after they exchanged information, each respondent then made personal targets according to their respective abilities along with how long it would take them to reach these targets. the explanation in the support group is adjusted to the respondent's preferred language. the tailored care and support group target from the small group was evaluated twice a month for three months. research assistants were employed to deliver the support group and brainstorming after a brief deducting teaching. two research assistants were selected from each primary health facilities where the study was conducted because they had a better understanding of the patients and conditions in the local area. the research assistant's qualifications were a bachelor's degree level and a working period of more than five years. before the assistant carried out the planned intervention, the research assistant was trained. this process was to ensure that they have the same understanding of each other about the study process and intervention. blinding each respondent received a different inform concern from one another. the intervention group acknowledged that they received the implementation of tailed care and the control group received traditional health education. it has been confirmed that there was no communication between participants in the intervention and the control group. the area of sumbawa island is quite large, with a less population, therefore, the distance between respondents was quite far and minimized the probability of them doing interaction. further, applying a blinding process to the trial was important since it can be reduced perceptions of the impact of the treatment on the mental or physical responses among participants. instruments blood glucose level and diabetes distress were measured twice: at m1 (baseline, before the intervention) and m2 (3 months after the intervention). the laboratory test of blood glucose levels and the diabetes distress scale were used to collect the data. blood glucose levels blood glucose level was measured after the patient's blood sample is collected by the research assistant and further laboratory equipment analysis of the blood sample. laboratory test was used to evaluate the participants' blood glucose levels in this study. diabetes distress scale (dds) dds was developed by william h. polonsky from the problem areas in diabetes (paid) instrument and has since become well-established and widely recommended for assessing the level of distress in patients with diabetes (farm et al., 2017; polonsky et al., 2005). however, the dds has a more precise and crossculturally consistent factor structure (polonsky et al., 2005). the dds consists of 17 items that measure patients' feelings in four general domains. first, the interpersonal distress domain (3 items) reflects the psychological emotions and feelings of patients with diabetes during their interaction with families, friends, or people around them. second, the physician distress domain (4 items) portrays the distress patients with diabetes experience during interaction with their physician. the third domain, regimen distress (5 items), describes the distress felt by patients with diabetes because of the need to adhere to a therapy management plan. the last is the emotional burden domain (5 items), which describes the distress related to the personal emotions of the patients suffering from jurnal ners http://e-journal.unair.ac.id/jners 65 type 2 diabetes, including fear of the possibility of diabetes-related complications (farm et al., 2017; polonsky et al., 2005). the factor analysis of dds instrument revealed a correlation among the four factors ranging from 0.40 to 0.67. the factor loadings of selected items from the four factors ranged from 0.41 to 0.98. the internal consistency for the four domains ranged from 0.78 to 0.83 (farm et al., 2017). the dds17 bahasa indonesia provides an initial psychometric validation study, factor structure, and internal consistency for assessing the distress of indonesian type 2 diabetes outpatients (farm et al., 2017). diabetes distress data assessed by research assistants. the two research assistants did not know which was the intervention group and which was the control group. they only know that group one received tailored care interventions while the other group received traditional health education. demographic and disease characteristics the demographic characteristics included the patient's age, time since the diagnosis of diabetes, sex, religion, educational level, marital status, occupation, and smoking status. process of participant recruitment the current study was approved by indonesia centre for health resources and services research and development (registry number: ina-kfqzkg). figure 1 shows the recruitment process for this study. data analysis ibm spss statistics for windows v. 20.0 (ibm corporation, armonk, ny, usa) was used for archiving and statistically analyzing. the statistical methods included descriptive statistics (frequency distributions, percentages, means, and standard deviations), anova and also inferential statistics (independent sample ttests and paired t-tests) with significance level of 0.05. ethical considerations to protect the human rights of the study participants, the current study was approved by the institutional review board no. 235/ea/kepk-bub-2020. participants were invited to participate in the study after the researchers gave them an overview of it and completed an informed consent form. participants in the study were all chosen voluntarily. for the creation of the questionnaire and data analysis, their information was coded anonymously. the participants were given the researcher’s phone numbers and were told they may leave the research at any time without any consequences. after the study was completed, the control group also received tailored care interventions from a team of research assistants. results baseline respondent characteristics there were no significant differences between the two groups on sex, religion, education level, marital status, complication and smoking status in the intervention and control groups. this indicates that in terms of respondent characteristics for both groups were similar. the majority of respondents in this study were 78.75% female in the intervention group and 79.14% in the control group. education level was 66.25% primary school in the intervention group and 63.86% in the control group, 98.75% married in the intervention group and 98.79% in the control group, 98.75% without complication in the intervention group and 97.59% in table 1 respondents characteristics variables intervention control n= 163 (%) significance n=80 (%) n=83 (%) sex male female 17 63 21.25% 78.75% 17 66 20.48% 79.52% 34 (20.86%) 129 (79.14%) 0.905* education level illiteracy primary school junior high school senior high school college 1 53 7 11 8 1.25% 66.25% 8.75% 13.75% 10% 2 53 5 13 10 2.4% 63.86% 6.03% 15.66% 12.05% 3 (1.84%) 106 (65.03%) 12 (7.36%) 24 (14.73%) 18 (11.04) 0.726 * marital status single married 0 79 0% 98.75% 1 82 1.21% 98.79% 1 (0.61%) 161 (98.78%) 0.179 * complication none hypertension 79 1 98.75% 1.25% 81 2 97.59% 2.41% 160 (98.16%) 3 (1.84%) 0.585 * smoking smoking no smoking 8 72 10% 90% 6 77 7.23% 92.77% 14 (8.59%) 149 (91.41%) 0.531* pranata, wu, wang, liang, bistara, chuang, and lu (2023) 66 p-issn: 1858-3598  e-issn: 2502-5791 the control group, 90% smoking in the intervention group and 92.77% in the control group (table 1). in table 2, there were no observable changes in age or the amount of time since diabetes diagnosis between the intervention and control groups. this indicates that in terms of participant characteristics, both groups shared similarities. moreover, the mean age of respondents in this study was 55.53 years in the intervention group and 57.61 years in the control group. in addition, the mean of the diagnosis of diabetes in the intervention group was 3.3 years, while the control group was 3.8 years. description and comparison of the outcome indicators for the two groups in the pre-test and post-test before the intervention, there were no appreciable variations in blood glucose levels and diabetes distress between the intervention and control groups (table 3) by anova tested. this indicates that before the intervention, the participant characteristics of both groups were comparable. the mean blood glucose levels before the intervention group received a tailored intervention program was 255.19 mg/dl, then decreased to 245.60 mg/dl. furthermore, the diabetes distress scale from 2.46 (moderate) and then decreased to 2.01 (moderate). on the other hand, the mean blood glucose levels before the control group received traditional health education intervention program was 227.81 mg/dl, then increased to 245.94 mg/dl, and the diabetes distress scale from 2.40 (moderate) then decreased to 2.37 (moderate). blood glucose levels and diabetes distress between groups before the intervention did not significantly change but did differ significantly after the intervention, according to independent t-test analysis in (table 4). therefore, it is required to conduct additional tests using the paired t-test to compare the effectiveness of traditional health education before and after the intervention with a tailored intervention program. the paired t-test analysis (table 5) showed that the intervention and control group's blood glucose levels decreased before and after treatment. still, the decrease in blood glucose levels was bigger in the intervention group compared to the control group. both groups were not statistically significant, with a p-value >0.05. however, the diabetes distress scale in the intervention group significantly decreased, namely 0.441, with a p-value <0.05. while in the control group, the decrease was only 0.036 with a p-value > 0.05. discussions both groups for blood glucose tested were not statistically significant with p-value 0.984. however, the blood glucose levels of participants in the intervention group who received a tailored intervention program were better than the control group who received traditional health education. based on the study, traditional diabetes education models did not translate table 3 description of the outcome indicators for the two groups variables baseline p-value follow-up (3-month) p-value intervention control intervention control blood glucose pre-test = 0.134 * post-test= 0.984 * mean 255.19 227.81 245.60 245.94 median 253.50 205 218 237 sd 109.867 121.905 116.650 105.207 min-max 76-512 72-594 84-595 91-595 95% ci 230.74-279.64 201.19-254.43 219.64-271.56 222.97-268.91 diabetes distress pre-test = 0.638 * post-test= 0.000 * mean 2.46 2.40 2.01 2.37 median 2.40 2.40 1.90 2.50 sd 0.743 0.716 0.585 0.607 min-max 1-5 1-4 1-4 1-4 95% ci 2.29-2.62 2.25-2.56 1.88-2.15 2.23-2.50 *=anova test table 2 participant characteristics variables intervention control p-value mean sd minmax ci 95% mean sd min-max ci 95% age 55.53 9.237 37-76 53.47-57.58 57.61 9.243 33-79 55.60-.63 0.151* time since the diagnosis of diabetes in year 3.345 2.4770 1-11 2.794-3.896 3.837 3.3057 1-15 3.116-559 0.285* * =anova test jurnal ners http://e-journal.unair.ac.id/jners 67 appropriately and did not meet patients’ needs. the tailored care intervention program was better and more successful to improve the diabetes self-management through blood glucose indicator. participants in the studies perceived themselves as becoming more informed about their disease and diabetes complications through tailored care intervention program. this encourages them to keep their blood glucose levels stable within normal limits. evidenced by the blood glucose data in the intervention group which decreased compared to the control group. intervention based on the participant’s preferred language and incorporated culturally sensitive dietary information by the same cultural group was the key in the tailored care intervention program (navodia et al., 2019). ideal members of each small group no more than ten members (pranata et al., 2022). education programs that do not support behaviour change are potentially ineffective and inaccurate (choi et al., 2017). on the other hand, intervention based on the participant's preferred language and incorporating culturally sensitive dietary information and the same cultural group through tailored intervention program potentially influence participants’ engagement in behavioural changes, uptake adherence and further decrease the blood sugar level among respondents (navodia et al., 2019). from our study, after 3 months of implementation of the tailored care intervention program, respondents became more active in seeking information from health professionals and regularly monitoring blood sugar in health facilities. with regular monitoring, respondents know more about their condition so they are able to make the best preventive choices towards the risk of complications in the future. diabetes forces people to manage their diet and sometimes need medication for glycemic control. in the long course of treatment therapy, patients with diabetes might suffer from diabetes distress. to avoid these situations, some efford is required. our study proved that tailored intervention program is better at reducing diabetes distress in the diabetes population compared to traditional health education. diabetes distress in the intervention group before receiving the tailored intervention program was 2.46 (moderate), then decreased to 2.01 (moderate) with a p-value of 0.000. meanwhile, in the control group who received traditional health education, the diabetes distress score was 2.40 (moderate), decreased to 2.37 (moderate), and was not statistically significant. our data related to another study by lutes et al. (2018) was that tailored integrated intervention among uncontrolled type 2 diabetes patients has a good impact on reducing the level of diabetes distress (lutes et al., 2018). diabetes distress comprises several domains, such as emotional distress, distress with health professionals, medication and interpersonal distress (farm et al., 2017). the decrease in diabetes distress shown by participants in this study is closely related to good communication between patients and health workers. in the tailored intervention program, professional staff is faced with conditions to place the expected intervention outcome by the profile of each patient (cummings et al., 2019; lake et al., 2020; navodia et al., 2019). in addition, patient preferences are a determinant in the choice of medication. in the tailored intervention program, participants feel more valued for their opinions, which impacts a sense of responsibility for what they choose in medication (hertroijs et al., 2018; tinetti et al., 2016). awareness of healthy behaviour that began to emerge among each respondent made them start doing selfmanagement voluntarily without coercion from anyone. this condition makes each diabetic patient feel much more empowered, further affecting the reduction in diabetes distress. limitations the single-blind design may appear to be biased in that participants may exaggerate the data they provide. in addition, blood glucose examination in this study was limited to the pre-test at the beginning of the test and the post-test after three months. blood glucose examination was not able to accurately show blood glucose results in the previous three months but only at the time of examination. bias results can happen if we just used blood glucose tested in this case. we suggest table 4 comparison of blood glucose levels and diabetes distress in both groups (independent t-test) variable significance (p) blood glucose levels pre-test post-test diabetes distress pre-test post-test 0.807 0.356 0.688 0.000 table 5 comparison of blood glucose levels and diabetes distress for the two groups (paired t-test) variables mean difference sd p-value blood glucose pair 1 pre-post pair 2 pre-post 9.588 -18.133 140.597 110.646 0.544 0.139 diabetes distress pair 1 pre-post pair 2 pre-post 0.441 0.036 0.688 0.284 0.000 0.250 pranata, wu, wang, liang, bistara, chuang, and lu (2023) 68 p-issn: 1858-3598  e-issn: 2502-5791 that the hba1c examination be carried out in future studies in order to observe the respondents' average blood glucose levels for the last three months. conclusions both the experimental and control groups' mean blood glucose levels were not statistically significant. conversely, diabetes distress in the intervention group statistically decreased compared to the control group. this approach can be an important concern for improving the quality of services by health professionals, particularly nurses for diabetes distress prevented. longer follow-up studies are required to see if there are any benefits over the course of the disease. in the future, more than 3 months of follow-up research will be needed. acknowledgment we would like to express our gratitude to the respondent and any parties who support this study. funding source there is no funding has been granted for this study. conflict of interest the authors affirm no conflict of interest in this study. references batais, m. a., alfraiji, a. f., alyahya, a. a., aloofi, o. a., almashouq, m. k., alshehri, k. s., almizel, a. m., alotaibi, m. t. & alosaimi, f. d. (2021). assessing the prevalence of diabetes distress and determining its psychosocial predictors among saudi adults with type 2 diabetes : a cross-sectional study. frontiers in psychology, 12(759454), 1–12. https://doi.org/10.3389/fpsyg.2021.759454 choi, t. s. t., walker, k. z. & palermo, c. (2017). culturally tailored diabetes education for chinese patients: a qualitative case study. journal of transcultural nursing, 28(3), 315–323. https://doi.org/10.1177/1043659616677641 cimo, a. & dewa, c. s. (2019). tailoring diabetes education to meet the needs of adults with type 2 diabetes and mental illness: client and health-care provider perspectives from an exploratory pilot study. canadian journal of diabetes, 43(6), 421-428.e3. https://doi.org/10.1016/j.jcjd.2018.09.008 cimo, a., loong, d. & dewa, c. s. (2020). exploring the outcomes of a pilot education program tailored for adults with type 2 diabetes and mental illness in a community mental health care setting. canadian journal of diabetes, 44(6), 461-472.e1. https://doi.org/10.1016/j.jcjd.2020.06.015 cummings, d. m., lutes, l. d., littlewood, k., solar, c., carraway, m., kirian, k., patil, s., adams, a., ciszewski, s., edwards, s., gatlin, p. & hambidge, b. (2019). randomized trial of a tailored cognitive behavioral intervention in type 2 diabetes with comorbid depressive and/or regimen-related distress symptoms: 12-month outcomes from. diabetes care, 42(5), 841–848. https://doi.org/10.2337/dc18-1841 dekkers, t. & hertroijs, d. f. l. (2018). tailored healthcare: two perspectives on the development and use of patient profiles. advances in therapy, 35(9), 1453–1459. https://doi.org/10.1007/s12325-018-0765-2 farm, b. a. s., perwitasari, d. a., thobari, j. a., cao, q., krabbe, p. f. m. & postma, m. j. (2017). translation, revision, and validation of the diabetes distress scale for indonesian type 2 diabetic outpatients with various types of complications. value in health regional issues, 12, 63–73. https://doi.org/10.1016/j.vhri.2017.03.010 hertroijs, d. f.l., brouwers, m. c. g. j., elissen, a. m. j., hiligsmann, m., schaper, n. c. & ruwaard, d. (2018). patients’ preferences for diabetes care: a discrete choice experiment. international journal of integrated care, 18(s2), 283. https://doi.org/10.5334/ijic.s2283 hertroijs, dorijn f.l., elissen, a. m. j., brouwers, m. c. g. j., schaper, n. c. & ruwaard, d. (2018). relevant patient characteristics for guiding tailored integrated diabetes primary care: a systematic review. primary health care research and development, 19(5), 424–447. https://doi.org/10.1017/s146342361800004x hu, y., li, l. & zhang, j. (2020). diabetes distress in young adults with type 2 diabetes : a cross-sectional survey in china. journal of diabetes research, 2020, 6–8. icenogle, g. (2019). adolescents’ cognitive capacity reaches adult levels prior to their psychosocial maturity: evidence for a “maturity gap” in a multinational, cross-sectional sample. physiology & behavior, 176(3), 139–148. https://doi.org/10.1037/lhb0000315.adolescents jeong, m. & reifsnider, e. (2018). associations of diabetesrelated distress and depressive symptoms with glycemic control in korean americans with type 2 diabetes. the diabetes educator, 44(6). https://doi.org/10.1177/0145721718807443 kim, h.-y. (2016). statistical notes for clinical researchers: sample size calculation 1. comparison of two independent sample means. restorative dentistry & endodontics, 41(1), 74–78. https://doi.org/10.5395/rde.2016.41.1.74 kolb, l. (2021). an effective model of diabetes care and education: the adces7 self-care behaviorstm. science of diabetes selfmanagement and care, 47(1), 30–53. https://doi.org/10.1177/0145721720978154 lake, a. j., hateley-browne, j. l., rees, g. & speight, j. (2020). effect of a tailored leaflet to promote diabetic retinopathy screening among young adults with type 2 diabetes: a randomised controlled trial. bmc ophthalmology, 20(1), 1–13. https://doi.org/10.1186/s12886-020-1311-y lutes, l. d., cummings, d. m., littlewood, k., solar, c., carraway, m., kirian, k., patil, s., adams, a., ciszewski, s. & hambidge, b. (2018). comrade: a randomized trial of an individually tailored integrated care intervention for uncontrolled type 2 diabetes with depression and/or distress in the rural southeastern us. in contemporary clinical trials (vol. 70, pp. 8–14). https://doi.org/10.1016/j.cct.2018.04.007 mayor, s. (2017). individualising treatment and care of patients with diabetes. prescriber, 28(4), 23–25. https://doi.org/10.1002/psb.1557 nanda, o. d., wiryanto, b. & triyono, e. a. (2018). hubungan kepatuhan minum obat anti diabetik dengan regulasi kadar gula darah pada pasien perempuan diabetes mellitus. amerta nutrition, 2(4), 340. https://doi.org/10.20473/amnt.v2i4.2018.340-348 navodia, n., wahoush, o., tang, t., yost, j., ibrahim, s. & sherifali, d. (2019). culturally tailored self-management interventions for south asians with type 2 diabetes: a systematic review. canadian journal of diabetes, 43(6), 445–452. https://doi.org/10.1016/j.jcjd.2019.04.010 polonsky, w. h., fisher, l., earles, j., dudl, r. j., lees, j., mullan, j. & jackson, r. a. (2005). assessing psychosocial distress in diabetes: development of the diabetes distress scale. diabetes care, 28(3), 626–631. https://doi.org/10.2337/diacare.28.3.626 pranata, s., vivienne wu, s. f., tiffany wang, t. j., liang, s. y., chuang, y. h., lu, k. c. & khoiriyah, k. (2022). discovering elements and developing strategies to implement the tailored care education for patients with diabetes through a systematic review. nurse jurnal ners http://e-journal.unair.ac.id/jners 69 media journal of nursing, 12(1), 75–87. https://doi.org/10.14710/nmjn.v12i1.44336 pranata, s., wu, s. v., alizargar, j., liu, j., liang, s. & lu, y. (2021). precision health care elements , definitions and strategies for patients with diabetes : a literature review. 1–14. pranata satriya, wu shu-fang vivienne, chu chun-hua & nugroho khristophorus heri. (2021). precision health care strategies for older adults with diabetes in indonesia: a delphi consensus study. medical journal of indonesia, 30(3), 221–227. https://doi.org/10.13181/mji.oa.215525 sassen, b. (2018). nursing: health education and improving patient self-management. https://doi.org/10.1007/978-3-319-51769-8 seligman, h. k., smith, m., rosenmoss, s., marshall, m. b. & waxman, e. (2018). comprehensive diabetes self-management support from food banks: a randomized controlled trial. american journal of public health, 108(9), 1227–1234. https://doi.org/10.2105/ajph.2018.304528 srikartika, v. m., akbar, m. r. & lingga, h. n. (2019). evaluasi intervensi media booklet terhadap tingkat pengetahuan dan kepatuhan pasien diabetes melitus tipe 2 di puskesmas banjarbaru selatan. jurnal publikasi kesehatan masyarakat indonesia, 6(1), 27–35. suciana, f. & arifianto, d. (2019). penatalaksanaan 5 pilar pengendalian dm terhadap kualitas hidup pasien dm tipe 2. jurnal ilmiah permas: jurnal ilmiah stikes kendal, 9(4), 311–318. sujana, t. (2019). peran puskesmas dalam identifikasi dini penyakit diabetes program studi ilmu gizi fakultas kedokteran dan ilmu kesehatan penyakit diabetes melitus ( dm ) rentang waktu menahun atau kronik yang ditandai dengan meningkatnya glukosa darah didalam tubuh atau. 19(2), 111–123. tinetti, m. e., esterson, j., ferris, r., posner, p. & blaum, c. s. (2016). patient priority-directed decision making and care for older adults with multiple chronic conditions. clinics in geriatric medicine, 32(2), 261–275. https://doi.org/10.1016/j.cger.2016.01.012 widayanti, a. w. (2018). understanding health-seeking behaviours of people in indonesia; and developing, piloting, and evaluating a culturally appropriate intervention for people with diabetes. june. https://ourarchive.otago.ac.nz/handle/10523/8965 young, b. m. o. e. e., okafor, c. b. n. c. i. & ugwueze, c. v. (2020). diabetes distress and associated factors in patients with diabetes mellitus in south east nigeria. dubai diabetes endocrinol journal, 26(31), 31–37. https://doi.org/10.1159/000508706. how to cite this article: pranata, s., wu, s. f. v., wang, t. j. t., liang, s. y., bistara, d. n., chuang, y. h., and lu, k. c. (2023) ‘effects of the tailored intervention program in lowering blood glucose levels and diabetes distress among patients with diabetes in indonesia: a randomized controlled trial’, jurnal ners, 18(1), pp. 61-69. doi: http://dx.doi.org/10.20473/jn.v18i1.42714 54 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 54-60 http://dx.doi.org/10.20473/jn.v18i1.37721 original article open access health literacy and post-vaccination covid-19 prevention behavior in the community: a crosssectional study in indonesia yofita refvinda desfiani 1 , jon hafan sutawardana 1 * , and nur widayati 1 1 faculty of nursing, universitas jember, jember, indonesia *correspondence: jon hafan sutawardana. address: faculty of nursing, universitas jember, jember, indonesia. email: hafan@unej.ac.id responsible editor: retnayu pradanie received: 22 july 2022 ○ revised: 3 march 2023 ○ accepted: 18 march 2023 abstract introduction: the government has made vaccination as the primary strategy to control the covid-19 pandemic. however, the public still needs to implement covid-19 prevention behavior even though they have been vaccinated. this study aimed to determine the correlation between health literacy and post-vaccination covid-19 prevention behavior of the community in the work area of the patrang public health center, jember regency, indonesia. methods: a cross-sectional design was performed in the public health center in jember regency indonesia, in may 2022. the sample in this study was 435 people selected by purposive sampling with the inclusion criteria of those aged >17 years old and receiving a total primary vaccination dose. the data were collected using the health literacy survey coronavirus disease questionnaire 22 (hls-covid-q22) and the covid-19 prevention behavior questionnaire. the data were analyzed by using spearman test with a significance level of α<0.05. results: the results showed that the most of health literacies were inadequate (n=188, 43.2%), and the postvaccination covid-19 prevention behavior was in the moderate category (n=186, 42.7%). there was a moderate correlation between health literacy and post-vaccination covid-19 prevention behavior (p < 0.001; r = 0.513). conclusions: the higher the health literacy, the better the post-vaccination covid-19 prevention behavior. the nurse was important in providing health education about covid-19 by paying attention to community health literacy ability. improving health literacy is an important strategy to enhance covid-19 prevention behavior and reduce coronavirus transmission. keywords: covid-19 prevention behavior; health literacy; post-vaccination introduction vaccines are the primary strategy for controlling the pandemic that is effective in overcoming infections of severe acute respiratory syndrome coronavirus 2 (sars cov-2) and cases of coronavirus disease 2019 (covid-19) (haas et al., 2021; world health organization, 2021). however, covid-19 prevention behavior, despite vaccination, still needs to be done because covid-19 infection with symptoms or without symptoms can still occur (bahl et al., 2021; jain, iyengar and ish, 2021). people who have been fully vaccinated but are infected with sars cov-2 are called "breakthrough infections" (centers for disease control and prevention, 2021). individuals loosen covid-19 preventive behavior after vaccination, it can be seen that fewer people are wearing masks in public area after vaccination. this behavior can increase the potential risk of infection in a new wave of virus variants and would possibly provide loopholes for causing virus transmission (zhang et al., 2021; satuan tugas penanganan covid-19, 2022). health promotion and preventive measures still need to be implemented to stop the pandemic (yuan et al., 2021). however, there are still global gaps in the https://creativecommons.org/licenses/by/4.0/ mailto:hafan@unej.ac.id https://orcid.org/0000-0001-8866-6242 https://orcid.org/0000-0002-5059-6821 https://orcid.org/0000-0003-2257-3128 jurnal ners http://e-journal.unair.ac.id/jners 55 availability and accessibility of various preventive and public health protection measures that can prevent the virus's spread and future global pandemics (taggart et al., 2022). sometimes information is subjected to contradictory opinions and experts’ views. too much information made it hard to distinguish between correct and incorrect information, allowing for the introduction of misconceptions and wrong beliefs, often under cover of almost scientific language (silva and santos, 2021). even if fully vaccinated, precautions such as keeping a distance of at least 1 meter from other people, wearing a mask, avoiding poorly ventilated places, washing hands frequently, staying home if unwell and testing for covid-19, staying informed about covid-19 must be still implemented (world health organization, 2020). but a loosening of the behavior of covid-19 prevention has happened globally. based on research in israel, preventive behavior was reported to show a decrease in the rate of wearing masks (21.1%) and implementing social distancing (47.3%) in people who had been vaccinated (rahamim-cohen et al., 2021). facts related to the application of preventive behavior in data as of january 30, 2022, in indonesia show that 88.89% of people adhere to wearing masks and 85.61% adhere to keeping their distance. however, individuals actually weaken the behavior prevention of covid-19 after vaccination (zhang et al., 2021). one of the factors that can influence covid-19 prevention behavior is the level of health literacy (sánchez-arenas et al., 2021). health literacy is defined as an ability that requires knowledge, motivation, and individual competence to seek or access information, understand its meaning, and assess health information to make decisions so that they can adequately apply information into actions in daily life. this health information relates to healthcare, disease prevention, and health promotion to maintain and improve a better quality of life (okan et al., 2019). good health literacy levels are associated with better attitudes as a key to prevention strategies against covid-19 and its spread leading to better health outcomes (silva and santos, 2021). health literacy during the pandemic is essential to find or access information about covid-19, transmission, preventive behavior that needs to be done, understand what it means, and assess the information so that decisions can be made to apply knowledge to behavioral compliance (sørensen et al., 2012; do et al., 2020; hong et al., 2021). good health literacy allows individuals to gain knowledge about covid-19, seek relevant facts about infection transmission and prevention behavior, and find the necessary information and apply it in daily life (do et al., 2020). increasing health literacy becomes very important at the individual and community level to deal with pandemic situations that require immediate and rapid action (abdel-latif, 2020). accordingly, this study aimed to determine the relationship between health literacy and post-vaccination covid-19 prevention behavior. materials and methods research design this study used a descriptive correlation with a crosssectional approach to determine the correlation between health literacy and post-vaccination covid-19 prevention behavior. respondents the sample was 435 people in the work area of the patrang public health center which covers a geographical area consisting of the sub-districts of patrang, gebang and jember lor in may 2022. the sample was collected by purposive sampling in order to get the complete address of the respondent, as there were no clear data about the address of the respondents from public health center. minimum total sample based on the lemeshow formula n = [z21−α × (p) × (1 − p)]/d2, assuming the proportion of the covid-19 vaccination coverage rate as 50% with a precision level of 0.05 (nursalam, 2020). the inclusion criteria were aged >17 years old and receiving 2 or 3 doses of covid-19 vaccine. the exclusion criteria were healthcare workers, because the health workers are likely to have good health literacy, and people with mental and cognitive disorders validated by the mini-mental state examination (mmse) for the respondents >65 years old. the mmse is used in respondents >65 to determine the presence of dementia, and are suspected of experiencing cognitive problems related to aging beyond normal memory problems. respondents with mental and cognitive disorders such as mental disorders, mental retardation were immediately excluded from the study. during the research the mmse test was conducted on 37 respondents with the interpretation that all respondents had normal cognitive status. instruments this research used the self-report data collection techniques by filling out a questionnaire. the questionnaires used were the respondent's characteristics (age, gender, marital status, education level, occupation, income level, history of comorbidities, and sources of information about covid-19), health desfiani, sutawardana, and widayati (2023) supremo, bacason, and sañosa (2022) 56 p-issn: 1858-3598  e-issn: 2502-5791 literacy survey coronavirus disease questionnaire 22 (hls-covid-q22) and covid-19 preventive behavior questionnaire. this questionnaire is specifically used to analyze health literacy during the covid-19 infodemic. health literacy is measured by the hls-covid-22q designed by okan et al. (2020). this questionnaire has been translated into the indonesian language by utami et al. (2021) with the results of the validity test having a correlation coefficient of 0.412–0.690 (r > 0.300) and cronbach's alpha reliability test showing α = 0.921. this questionnaire consists of 22 questions that are used to assess the difficulty or ease felt by respondents when accessing (6 questions), understanding (6 questions), considering (5 questions), and applying (5 questions) the health information about covid-19. the assessment in this questionnaire uses a likert scale of 1-4 with a score of 1 (very difficult) to 4 (very easy). this questionnaire used an interval scale with a minimum score of 22 and a maximum score of 88 which obtained by adding up the answer scores for each question item (okan et al., 2020; utami et al., 2021). according to okan et al. (2020), the final assessment of this questionnaire can also be presented as an index or category of health literacy. the presentation of the data is by using the average cut-off values which the average value was 2.5 (inadequate health literacy), >2.5–<3 (problematic health literacy), and 3 (sufficient health literacy). post-vaccination covid-19 prevention behavior was measured by a questionnaire consisting of seven favorable and unfavorable questions based on the guidelines of the ministry of health of the republic of indonesia. the questionnaire includes wash hands with soap or use hand sanitizer after handling objects in public places, take a shower and change clothes after coming home from traveling, wear a mask in public places, keep a distance of at least 1 meter, keep distance from elderly, don’t attend large gatherings and don’t use public facilities or go to public places. this questionnaire has been tested for validity and reliability by yanti et al. (2020); with the results of the validity test having a correlation coefficient 0.187-1 (r > 0.1409) and the cronbach alpha reliability test α = 0.770. assessment in this questionnaire used a likert scale with 0-3 for favorable questions with the score of 0 (never), 1 (rarely), 2 (almost always), and 3 (always) and vice versa for unfavorable questions. the calculation for the prevention behavior had a total score 0-7 (low protocol adherence), 8-14 (moderate protocol adherence), and 15-21 (high protocol adherence). the data were collected using a door-to-door technique where more than one respondent can be taken from each house according to the inclusion and exclusion criteria. the data collection was assisted by two enumerators. enumerators were selected from undergraduate students of faculty of nursing, universitas jember who were first given the training to equate perceptions and understanding about study, questionnaire and the data collection process used in this study. search for the respondents’ addresses was assisted by the head of the community association in the research area. respondents were recruited from accessible communities and according to established inclusion and exclusion criteria. table 1 demographic characteristics of respondents (n=104) variable n % age (years) 18-25 57 13.1 26-35 85 19.6 36-45 110 25.3 46-55 92 21.1 56-65 54 12.4 >65 37 8.5 gender male 100 23 female 335 77 marital status married 365 83.9 unmarried 45 10.3 widowed 25 5.8 educational level elementary and lower 171 39.3 junior high school 56 12.9 senior high school 176 40.5 collage 32 7.3 occupation unemployed 23 5.3 student 10 2.3 entrepreneur/trader 103 23.7 farmer 10 2.3 civil servant 7 1.6 retired 12 2.7 private employees 53 12.2 laborer/driver/housekeeper 24 5.5 housewife 193 44.4 income level <rp2.400.000,371 85.3 ≥rp2.400.000,64 14.7 history of comorbidities have comorbidities 60 13.8 hypertension 36 8.3 diabetes 6 1.4 asthma 13 3.0 tuberculosis 2 0.5 liver disease 1 0.2 heart disease 1 0.2 cancer 1 0.2 have no comorbidities 375 86.2 most used sources of information about covid-19 television 163 37.5 internet (website/online magazine/etc.) 53 12.2 newspaper/magazine 1 0.2 radio 1 0.2 social media (instagram/twitter/facebook/etc.) 82 18.9 message apps (whatsapp/line/telegram/etc.) 11 2.5 health workers 32 7.4 family or friends 92 21.1 jurnal ners http://e-journal.unair.ac.id/jners 57 data analysis data analysis in this study used univariate and bivariate analysis using spss version 27. the results of the univariate analysis of health literacy and postvaccination covid-19 prevention behavior will be presented in frequency and percentage, while the bivariate analysis was carried out using the spearman non-parametric correlation to determine the correlation between health literacy and post-vaccination covid-19 prevention behavior. ethical consideration this research was approved by the health research ethics committee of the faculty of nursing, universitas jember with a certificate no. 063/un25.1.14/kepk/2022. during the research the respondents and researchers continued to use masks and wash their hands with the handrub/hand sanitizer provided by the researchers before data collection was carried out and have agreed to informed consent as evidence of involvement in this study. results characteristic of the respondents the results of the study which consisted of 435 respondents showed that the most age of respondents was 36-45 years (n=110, 25.3%), the most gender was female (n=335, 77%), and the majority of respondents were married (n= 365, 83.9%). based on education level, most of the respondents were senior high school students (n=176, 40.5%) and most of the respondents in this study were housewives (n=193, 44.4%). based on the income level it was at most less than idr 2,400,000 (n = 371, 85.3%). most of the respondents in this study did not have comorbidities (n = 375, 86.2%). the most frequently used source of information about covid-19 by respondents was television (n=163, 37.5%). the details are shown in table 1. health literacy table 2 shows that the health literacy in respondents' results were 155 (35.6%) in the sufficient health literacy, 92 (21.2%) in the problematic health literacy, and 188 (43.2 %) in the inadequate health literacy. based on this research, the highest result is shown in the inadequate health literacy. based on the indicators of health literacy, the highest and the lowest are present in table 3. the highest score of the average value per item of the indicators of health literacy ability is the ability to understand the health information (mean=2.67) and the lowest score is the ability to appraise the health information (mean=2.37). post-vaccination covid-19 prevention behavior table 4 shows that the highest level of community adherence was moderate protocol adherence 186 (42.7%) followed by high protocol adherence (41.4%) with a slight difference (1.3%). as seen in table 5, the best post-vaccination covid-19 prevention behavior is wearing masks when in public places (mean=2.37). in contrast, the worst post-vaccination covid-19 prevention behavior is shown in the behavior of keeping a distance from the elderly (mean=0.83). the correlation between health literacy and postvaccination covid-19 prevention behavior this research shows a moderate positive correlation between health literacy and post-vaccination covid-19 table 2 health literacy in respondents (n=435) health literacy f % inadequate health literacy 188 43.2 problematic health literacy 92 21.2 sufficient health literacy 155 35.6 table 3 indicator of health literacy in respondents (n=435) indicator mean (sd) median (min-max) access 2.61 (±1.085) 3 (1-4) understand 2.67 (±1.020) 3 (1-4) appraise 2.37 (±0.999) 2 (1-4) apply 2.40 (±1.010) 2 (1-4) table 4 post-vaccination covid-19 prevention behavior in respondents (n=435) post-vaccination covid-19 preventive behavior f % low protocol adherence 69 15.9 moderate protocol adherence 186 42.7 high protocol adherence 180 41.4 table 4 post-vaccination covid-19 prevention behavior in respondents (n=435) question mean (sd) median (min-max) i wash my hands with soap or use hand sanitizer after handling objects in public places 2.2 (0.976) 3 (0-3) i take a shower and change clothes after coming home from traveling 1.69 (0.935) 2 (0-3) i wear a mask in public places (markets, terminals, prayer places, etc.) 2.37 (0.831) 3 (0-3) i keep a distance of at least 1 meter from other people when outside the house 1.22 (0.952) 1 (0-3) i keep my distance from elderly 0.83 (0.872) 1 (0-3) i attended an event that gathered many people 2.16 (0.831) 2 (0-3) i use public facilities or go to public places (public transportation, malls, markets, tourist attractions) 2.31 (0.896) 3 (0-3) desfiani, sutawardana, and widayati (2023) supremo, bacason, and sañosa (2022) 58 p-issn: 1858-3598  e-issn: 2502-5791 prevention behavior with a significance value <0.001 and a coefficient correlation r=0.513. discussions the pandemic has been going on since january 2020. even though the majority of people have received the covid-19 vaccine, confirmed cases of covid-19 are still significant showing an increase in the third wave of the new variant of the coronavirus. this study revealed that there is a positive correlation with moderate of relationship between health literacy and postvaccination covid-19 prevention behavior. this means that the higher the level of health literacy, the higher the community's adherence to prevention of covid-19 behavior. study about health literacy and covid-19 prevention behavior found that health literacy was significantly related to covid-19 awareness and covid19 prevention behavior (gautam et al., 2021). health literacy during the pandemic is very necessary to find or access information about covid-19, transmission, preventive behavior that needs to be done, understand what it means, appraise, or interpret the information correctly so that they can make decisions and apply information in the form of behavior adherence in everyday life (sørensen et al., 2012; okan et al., 2019; do et al., 2020; bin naeem and kamel boulos, 2021; hong et al., 2021). the better health literacy indicates the possibility for individuals to gain knowledge about covid-19, seek relevant facts about infection transmission and prevention behavior using, and find the necessary information (do et al., 2020). therefore, better attitudes are expected as a key to prevention strategies against covid-19 and its spread leading to better health outcomes (silva and santos, 2021) based on this study, most respondents had inadequate health literacy, but had already performed moderate to high protocol adherence of covid-19 prevention. the best prevention behavior shown in this study is wearing a mask when in a public place although the easing of the use of masks has been announced (mean=2.37). wearing masks has been practiced for health and cultural reasons so that the use of masks on covid-19 prevention behavior does not cause conflicts that arise if people are forced to change cultural norms. in addition, the majority of the community also has a habit of wearing masks to overcome air pollution (nguyen et al., 2020). health literacy so far remains a concept that is underestimated as a public health problem in the context of the covid-19 pandemic, although health information about covid-19 has dominated most of the sources of information and communication (paakkari and okan, 2020; sentell, vamos and okan, 2020. the respondents in this study had received two or three doses of covid-19 vaccine, but still had inadequate health literacy. the respondents’ ability to appraise the health information had the lowest average score (mean per item=2.37). assessing and interpreting health information demands more excellent cognitive skills and resources. in addition, too much and complicated information in various media such as the internet or smartphone applications also increases the difficulty in processing those large amounts of information (svendsen et al., 2020). health literacy is an important competency that must be developed during the current pandemic (luengo-oroz et al., 2020). too many sources of information and inaccurate information (hoax) related to covid-19 caused the spread of fear and panic among the public much faster than the virus (abdel-latif, 2020). health literacy is needed because it has the potential to make individuals understand the reasons for the recommendations and the impact or results of implementing covid-19 preventive behavior. improved health literacy will reduce health expenditure costs and ease the tremendous burden on the healthcare system (shaukat, asghar and naveed, 2021). health literacy limited to individuals, populations, and systems can cause adverse effects for some and even entire communities. when people are not competent to assess health information critically, health information providers cannot ensure the means to protect valid and useful information against the many sources that spread invalid information (hoax information). this can cause panic, and interfere with the effectiveness of information distribution and health interventions in the community (okan et al., 2020). the results of this research have implications for the importance of providing health education or counseling, especially regarding covid-19, by paying attention to the health literacy ability of the community. nurses as educators can play a role in increasing health literacy, one of which is by providing health education or counseling, especially related to covid-19 as a form of new normal for society to continue to carry out healthy living behaviors not only to prevent covid-19 but other infectious diseases. in addition, a strategy that can be done is to improve the quality of health information and training to improve information search skills about covid-19. jurnal ners http://e-journal.unair.ac.id/jners 59 limitation of the study the limitation in this study is that the sampling technique used purposive sampling which can limit the generalization of the findings. furthermore, selfreported technique could be biased for filling the questionnaire conclusions the majority of respondents to this study had inadequate health literacy. they already understand the information but have low ability to assess valid information. post-vaccination covid-19 prevention behavior in respondents showed moderate adherence to health protocols as indicated by adherence to wearing masks in public places. thus, this study reveals that there is a moderate positive correlation between health literacy and post-vaccination covid-19 prevention behavior. this means that the higher the health literacy, the better the post-vaccination covid19 prevention behavior. based on the results of this study, it is necessary to improve community health literacy. further research is expected to be able to develop a model of increasing community health literacy that can be applied effectively. acknowledgment the authors would like to thank the respondents who have participated in this study. in addition, the author would also like to thank the community leaders who have helped researchers in finding research respondents. the same gratitude goes to the faculty of nursing, universitas jember for all the technical and bureaucratic assistance. funding source no sponsors were involved in this study. research funding used private funds. conflict of interest there is no conflict of interest references abdel-latif, m. m. m. (2020) ‘the enigma of health literacy and covid19 pandemic’, public health, 185(1), pp. 95–96. doi: 10.1016/j.puhe.2020.06.030. bahl, a. et al. (2021) ‘vaccination reduces need for emergency care in breakthrough covid-19 infections: a multicenter cohort study’, the lancet regional health americas, 4(2021), pp. 1–9. doi: 10.1016/j.lana.2021.100065. centers for disease control and prevention (cdc) (2021) interim public health recommendations for fully vaccinated people, cdc. do, b. n. et al. (2020) ‘health literacy, ehealth literacy, adherence to infection prevention and control procedures, lifestyle changes, and suspected covid-19 symptoms among health care workers during lockdown: online survey’, journal of medical internet research, 22(11), pp. 1–18. doi: 10.2196/22894. gautam, v. et al. (2021) ‘health literacy, preventive covid 19 behaviour and adherence to chronic disease treatment during lockdown among patients registered at primary health facility in urban jodhpur, rajasthan’, diabetes and metabolic syndrome: clinical research and reviews, 15(1), pp. 205–211. doi: 10.1016/j.dsx.2020.12.023. haas, e. j. et al. (2021) ‘impact and effectiveness of mrna bnt162b2 vaccine against sars-cov-2 infections and covid-19 cases, hospitalisations, and deaths following a nationwide vaccination campaign in israel: an observational study using national surveillance data’, the lancet, 397(10287), pp. 1819–1829. doi: 10.1016/s0140-6736(21)00947-8. hong, k. j. et al. (2021) ‘effect of e-health literacy on covid-19 infection-preventive behaviors of undergraduate students majoring in healthcare’, healthcare (switzerland), 9(5), pp. 1–10. doi: 10.3390/healthcare9050573. jain, v. k., iyengar, k. p. and ish, p. (2021) ‘elucidating causes of covid19 infection and related deaths after vaccination’, diabetes and metabolic syndrome: clinical research and reviews, 15(5), pp. 1– 6. doi: 10.1016/j.dsx.2021.102212. luengo-oroz, m. et al. (2020) ‘artificial intelligence cooperation to support the global response to covid-19’, nature machine intelligence, 2(6), pp. 295–297. doi: 10.1038/s42256-020-0184-3. bin naeem, s. and kamel boulos, m. n. (2021) ‘covid-19 misinformation online and health literacy: a brief overview’, international journal of environmental research and public health. multidisciplinary digital publishing institute, pp. 1–8. doi: 10.3390/ijerph18158091. nguyen, n. p. t. et al. (2020) ‘preventive behavior of vietnamese people in response to the covid-19 pandemic’, plos one, 15(9), pp. 1–11. doi: 10.1371/journal.pone.0238830. nursalam (2020) metodologi penelitian ilmu keperawatan. kelima. jakarta: salemba medika. okan, o. et al. (2019) international handbook of health literacy: research, practice and policy across the lifespan, policy press. bristol. okan, o. et al. (2020) ‘coronavirus-related health literacy: a crosssectional study in adults during the covid-19 infodemic in germany’, international journal of environmental research and public health, 17(15), pp. 1–20. doi: 10.3390/ijerph17155503. rahamim-cohen, d. et al. (2021) ‘survey of behaviour attitudes towards preventive measures following covid-19 vaccination’, medrxiv, 7(8), pp. 1–8. doi: 10.1101/2021.04.12.21255304. sánchez-arenas, r. et al. (2021) ‘factors associated with covid-19 preventive health behaviors among the general public in mexico city and the state of mexico’, plos one, 16(7), pp. 1–18. doi: 10.1371/journal.pone.0254435. satuan tugas penanganan covid-19 (2022) monitoring kepatuhan protokol kesehatan tingkat nasional (update per 30 januari 2022), satuan tugas penanganan covid-19. sentell, t., vamos, s. and okan, o. (2020) ‘interdisciplinary perspectives on health literacy research around the world: more important than ever in a time of covid-19’, international journal of environmental research and public health, 17(9), pp. 1–13. doi: 10.3390/ijerph17093010. shaukat, r., asghar, a. and naveed, m. a. (2021) ‘impact of health literacy on fear of covid-19, protective behavior, and conspiracy beliefs: university students’ perspective’, library philosophy and practice, 2021(4620), pp. 1–14. silva, m. j. and santos, p. (2021) ‘the impact of health literacy on knowledge and attitudes towards preventive strategies against covid-19: a cross-sectional study’, international journal of environmental research and public health, 18(10), pp. 1–12. doi: 10.3390/ijerph18105421. sørensen, k. et al. (2012) ‘health literacy and public health: a systematic review and integration of definitions and models’, bmc public health, 12(1), pp. 1–13. doi: 10.1186/1471-2458-12-80. svendsen, m. t. et al. (2020) ‘associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among danish adults’, bmc public health, 20(1), pp. 1–12. doi: 10.1186/s12889-02008498-8. desfiani, sutawardana, and widayati (2023) supremo, bacason, and sañosa (2022) 60 p-issn: 1858-3598  e-issn: 2502-5791 taggart, l. et al. (2022) ‘preventing, mitigating, and managing future pandemics for people with an intellectual and developmental disability learnings from covid-19: a scoping review’, journal of policy and practice in intellectual disabilities, 19(1), pp. 4–34. doi: 10.1111/jppi.12408. utami, m. s. s. et al. (2021) ‘skala literasi kesehatan terkait covid-19 pada mahasiswa (22 item)’, draft journal article. world health organization (2020) ‘coronavirus disease (covid-19): vaccines’, organization, world health, p. 1. world health organization (who) (2021) coronavirus disease (covid19): vaccines, who. yanti, n. p. e. d. et al. (2020) ‘gambaran pengetahuan masyarakat tentang covid-19 masyarakat di masa pandemi covid-19’, jurnal keperawatan jiwa, 8(4), pp. 491–504. doi: 10.26714/jkj.8.4.2020.491-504. yuan, y. et al. (2021) ‘changes in mental health and preventive behaviors before and after covid-19 vaccination: a propensity score matching (psm) study’, vaccines, 9(9), pp. 1–11. doi: 10.3390/vaccines9091044. zhang, n. et al. (2021) ‘weakening personal protective behavior by chinese university students after covid-19 vaccination’, building and environment, 206(2021), pp. 1–9. doi: 10.1016/j.buildenv.2021.108367. how to cite this article: desfiani, y. r., sutawardana, j. h., and widayati, n. (2023) ‘health literacy and post-vaccination covid-19 prevention behavior in the community: a cross-sectional study in indonesia’, jurnal ners, 18(1), pp. 54-60. doi: http://dx.doi.org/10.20473/jn.v18i1.37721 ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 133 intervensi keperawatan melalui pendampingan meningkatkan perilaku pemberian makan pada anak usia 6–24 bulan pada keluarga inti dan besar (nursing intervention through family pathnership increases behavior in practice of feeding pattern on infant of age 6–24 months for nuclear and extended family) a. aziz alimul hidayat* *program studi ilmu keperawatan, fakultas ilmu kesehatan universitas muhammadiyah surabaya, jalan sutorejo no. 59, surabaya 60113 email: azizhidayat@yahoo.com abstract introduction: nursing intervention is nursing action with a supportive and educative approach done by nurses cooperating with families in overcoming the problems of nursing family. the aim of the research was to explain the effect of nursing intervention through family pathnership toward behavior in practice of feeding pattern on infant of age 6–24 months for nuclear and extended family, including the breastfeeding ( asi), pasi, soft food, family food, snacks, and way of feeding. method: the design of the research was experimental. the sample of the research was ninety six (96) samples, which was chosen with simple random sampling.the sample was then divided into two parts of family in kenjeran district and bulak surabaya, namely nuclear family and extended family. the variables measured were breastfeeding, pasi, soft food, family food, and a way of feeding through interviewing and observation. the data analysis used was mann whitney u. result: result showed that effect of nursing interventions on the style of feeding containing of giving pasi (p = 0.003), soft food (p = 0.005), family food (p = 0.00), snacks (p = 0.034), and way of feeding (p = 0.00). those effects can be shown with the increasing of frequency and way of feeding before and after intervention. discussion: the conclusion is nursing intervention through the supportive and educative approach as the form of actions on families with problems on the pattern of feeding has the infl uence on the practice of feeding pattern. the increasing of feeding frequency shows the cognitive and behavioral change on the practice of feeding pattern which can possibly improve the status of infants nutrient. keywords: nursing intervention, practice of feeding pattern, and type of family pendahuluan kebutuhan nutrisi dengan gizi seimbang pada anak sangat ditentukan oleh kualitas makanan dan gizi yang dikonsumsi pada anak. sementara kualitas makanan dan gizi sangat tergantung pada pola asuh makan yang diterapkan oleh keluarga, yang bukan hanya kesadaran akan komposisi makan yang sehat saja, tetapi kesadaran dalam menyangkut kebiasaan. penerapan pola asuh makan yang salah dapat berdampak pada gangguan tumbuh kembang anak sekaligus anak sangat rentan terhadap berbagai penyakit. berdasarkan data departemen kesehatan republik indonesia (2005) kurang lebih 6,7 juta anak balita atau 27,3% anak balita indonesia menderita gizi kurang dan 1,5 juta di antaranya anak mengalami gizi buruk yang diakibatkan pola asuh ibu dalam pemberian asi dan mp asi yang salah. pola asuh sebagai penyebab tidak langsung dari masalah gizi memiliki peran yang cukup besar khususnya dalam penanganan gizi jangka panjang (engle, dkk., 1997). upaya yang dilakukan oleh pemerintah dalam mengatasi masalah gizi dengan berbagai cara mulai program jaringan pengaman sosial, asuransi kesehatan bagi orang miskin, pengobatan gratis di rumah sakit dan puskesmas bagi gizi buruk, pemberian makan tambahan berupa mp asi dan suplementasi gizi, seperti vitamin a, fe dan lain-lain. upaya tersebut jurnal ners vol. 5 no. 2 oktober 2010: 133–137 134 hampir dilakukan untuk mengatasi penyebab langsung dari masalah gizi. upaya-upaya tersebut yang bersifat kuratif tidak akan memiliki arti kalau tidak ada upaya preventif, sebagaimana program pemberian makan tambahan hanya akan berakhir sampai waktu tertentu, kemudian berbagai penyuluhan yang dilakukan saat ini baik melalui posyandu m a u p u n p u s k e s m a s m a s i h s e d i k i t n y a masyarakat yang menyadari pentingnya perubahan perilaku, namun penyebab tidak langsung seperti penerapan pola asuh makan belum banyak dilakukan oleh pemerintah walaupun secara tidak sadar juga memiliki peran jangka panjang (bumbungan, 2003). intervensi keperawatan sebagai bagian dari upaya perawat dalam melakukan perubahan pola asuh makan dengan menekankan pada perubahan perilaku dengan pendekatan suportif edukatif serta menekankan pada pentingnya keyakinan keluarga dan faktor persepsi kognitif sebagai motivasi utama dalam penerapan pola asuh makan melalui strategi modifi kasi gaya hidup (friedman, 1995). berdasarkan hal tersebut tulisan ini bertujuan menguraikan tentang pengaruh intervensi keperawatan melalui pendampingan keluarga terhadap praktik pola asuh makan (frekuensi pemberian asi, pasi, makanan lumat, makanan selingan, makanan keluarga dan cara pemberian) anak usia 6–24 bulan pada keluarga inti dan keluarga besar. bahan dan metode rancangan penelitian yang digunakan adalah experimental. subjek diukur praktik pola asuh makan melalui wawancara dan observasi sebelum dan sesudah dilakukan intervensi. intervensi keperawatan yang diberikan berupa pendampingan. intervenís dilakukan satu kali kurang lebih 60–120 menit dan pendampingan dilakukan satu kali setiap minggu selama satu bulan. selanjutnya hasil pengukuran awal (pre-test) dibandingkan dengan hasil pengukuran akhir (posttest). populasi yang diteliti adalah ibu yang memiliki anak balita usia 6–24 bulan yang tinggal di wilayah pantai kenjeran. besar sampel penelitian minimal yang diperlukan adalah 96 responden (ibu yang memiliki anak balita usia 6–24 bulan), dengan teknik pengambilan sampel simple random sampling. variabel dalam penelitian ini terdiri atas variabel bebas (intervensi keperawatan, variabel tergantung (praktik pola asuh makan). analisis data yang digunakan adalah uji mannwhitney u. hasil pemberian asi di keluarga inti dengan frekuensi > 4×/hari terjadi kenaikan dari 6,7% menjadi 11,7% setelah dilakukan intervensi. hal tersebut tidak terjadi pada keluarga besar. pada pasi terjadi penurunan pada keluarga inti yang tidak pernah memberian pasi dari 56,7% berkurang menjadi 43,3%, hal tersebut juga tanpak pada keluarga besar dari 38,9% menjadi 25%. pada pemberian makanan lumat terjadi kenaikan pada masing-masing keluarga. pemberian makanan lumat 3×/hari pada keluarga inti terdapat kenaikan dari 0% menjadi 33,3% dan pada keluarga besar dari 7,1% menjadi 85,7%. kemudian pada pemberian makanan keluarga pada kedua jenis keluarga adalah sebagai berikut: frekuensi pemberian paling banyak pada keluarga inti sebelum intervensi adalah lebih dari 3% sebesar 66,7%, dan sesudah intervsi sebesar 52,4%. pada keluarga besar sebelum intervensi paling banyak adalah >3×/hari sebesar 52,2% tetapi setelah intervensi yang paling besar adalah pada frekuensi 3×/hari sebesar 87%. pemberian makanan selingan pada kedua jenis keluarga adalah sebagai berikut: pada keluarga inti 40% tidak pernah memberikan makanan selingan sebelum intervensi, namun setelah intervensi berkurang menjadi 25% dan sebesar 31,7% pemberian makanan selingan dilakukan sebanyak 1×/hari. pada keluarga besar sebelum intervensi dalam pemberian makanan selingan paling banyak sejumlah 1×/ hari sebesar 58,3% dan sesudah intervensi yang paling banyak pada frekuensi 2×/hari sebesar 38,9%. cara pemberian makan pada kedua jenis keluarga adalah sebagai berikut: pada keluarga inti sebelum intervensi sebagian besar cara pemberiannya cukup sebanyak 71,7%, dan tidak ada cara baik dalam pemberian makan, namun setelah intervensi sebesar intervensi keperawatan melalui pendampingan (a. aziz alimul hidayat) 135 21,7% keluarga menerapkan cara yang baik dalam pemberian makan anak kemudian pada keluarga besar sebelum intervensi sebagian besar adalah cara cukup dalam pemberian makan sebesar 66,7%, dan setelah 47,2% dari 13,9% (tabel 1). pembahasan hasil analisis statistik menunjukkan hanya pemberian asi dalam praktik pola asuh makan anak tidak ada perbedaan antara jenis keluarga inti dan keluarga besar sebagaimana dalam tabel 1. tidak adanya perbedaan jenis keluarga dalam pemberian asi kemungkinan disebabkan juga karena sampel yang dipilih usia 6–24 bulan, di mana produksi asi menurun, padahal untuk menghasilkan produksi asi cukup adalah ditentukan oleh permulaan proses menyusui yakni ketika setelah melahirkan. sebagaimana karakteristik masingmasing jenis keluarga menurut friedman peranan dari keluarga inti yang terdiri atas ayah sebagai pencari nafkah, dan ibu tidak bekerja memiliki waktu yang cukup untuk proses perawatan anak dalam hal ini pola asuh makan, selain itu waktu yang cukup. namun tidak semua ibu sebagai ibu rumah tangga sehingga peran jenis keluarga inti tidak ada bedanya dengan jenis keluarga lain. demikian halnya keluarga besar banyaknya anggota keluarga sangat menentukan peran ibu dalam praktik pola asuh khususnya dalam pemberian asi. hal ini dapat dipengaruhi saat proses awal menyusui yang mana anggota keluarga (nenek) memiliki peranan yang cukup besar dalam proses pembelajaran menyusui dengan segala keyakinan dan pengalaman terkadang juga menghambat proses pemahaman akan pentingya menyusui setelah usia 6–24 bulan, yang kemungkinan anggapan produksi asi sebelum usia tersebut masih dianggap kurang sehingga pada usia 6–24 bulan akibatnya ibu tidak mampu menyusui (widyatuti, 2001; depkes ri, 2004). hal tersebut sangat berbeda pada jenis, frekuensi dan cara pemberian makanan yang lain seperti pemberian pasi, makanan lumat, makanan keluarga, makanan selingan dan cara pemberian. pada praktik pola asuh lain (pemberian pasi, makanan lumat, makanan selingan, makanan keluarga dan cara pemberian makan). perbedaan ini sangat terkait adanya intervensi yang diberikan penyuluhan disertai pendampingan pada kedua jenis keluarga adalah sangat dibutuhkan, adanya perbedaan sebagai bukti bahwa jenis keluarga baik keluarga inti maupun keluarga besar adalah ada perbedaan dalam penerapan pola asuh, kemungkinan halnya sangat terkait adanya peranan anggota keluarga lain dalam proses penyediaan dan pemberian pasi, makanan selingan, makanan lumat, makanan keluarga dan cara pemberian makan. penyuluhan saja yang diberikan pada kedua jenis keluarga tidak cukup untuk meningkatkan praktik pola asuh. karena penyuluhan lebih diutamakan pada aspek kognitif, walaupun juga ada aspek psikomotor yang ditingkatkan dalam memahami praktik a s u h n a m u n p r a k t i k p o l a a s u h m a k a n membutuhkan beberapa latihan dan kebiasaan dalam pelaksanaan sehari-hari. sesuai dengan kelemahan cara penyuluhan, responden kurang mendapatkan kesempatan mengingat karena besarnya sasaran (kusumawati dan mutalazimah, 2004). te o r i h o s l a n d t e n t a n g s t i m u l u s – organisme-respons menunjukkan kurangya stimulus yang diterima responden dan kualitas stimulus yang rendah dalam menyebabkan perubahan sikap tidak seperti yang diharapkan. demikian juga hurlock menyatakan perubahan sikap dan keterampilan melalui meniru dan mengidentifi kasi pada yang telah dicontohkan. penyuluhan disertai pendampingan dengan kegiatan kunjungan rumah, diberikan konseling terhadap praktik pola asuh makan, kemudian dilakkan follow up atas kemajuan dan kendala selama praktik pola asuh ternyata cukup memberikan arti dalam pelaksanaan praktik pola asuh makan (notoatmodjo, 2005). teori perkembangan keluarga bahwa siklus kehidupan keluarga sangat tergantung pada asumsi bahwa dalam keluarga terdapat saling ketergantungan yang tinggi antara anngota keluarga. struktur kelompok keluarga dapat berubah karena anggota keluarga berinteraksi satu sama lain dalam berbagai persoalan yang terjadi dalam kelompok atau jurnal ners vol. 5 no. 2 oktober 2010: 133–137 136 tabel 1. praktik pola asuh makan (frekuensi pemberian asi, pemberian pasi, makanan lumat, makanan keluarga, makanan selingan, dan cara pemberian) pada nuclear dan extendeed family sebelum dan sesudah intervensi keperawatan variabel (asi) nuclear family extendeed family pre post pre post n % n % n % n % frekuensi pemberian asi tidak pernah 1×/hari 2×/hari 3×/hari >4×/hari 9 0 0 47 4 15,0 0,0 0,0 78,3 6,7 9 0 0 44 7 15,0 0,0 0,0 73,3 11,7 14 2 1 1 18 38,9 5,6 2,8 2,8 0,0 14 2 1 1 18 38,9 5,6 2,8 2,8 50,0 mann-whitney u pre: p = 0,477 post: p = 0,637 pemberian pasi tidak pernah 1×/hari 2×/hari >3×/hari 3×/hari 34 8 9 9 0 56,7 13,3 15,0 15,0 0,0 26 12 9 9 4 43,3 20,0 15,0 15,0 6,7 14 4 9 9 0 38,9 11,1 25,0 25,0 0,0 9 5 2 10 10 25,0 13,9 5,6 27,8 27,8 mann-whitney u pre p = 0,063 post: p = 0,003 makanan lumat tidak pernah 1×/hari 2×/hari >3×/hari 3×/hari 0 0 10 8 0 0,0 0,0 55,6 44,4 0,0 0 0 7 5 6 0,0 0,0 38,9 27,8 33,3 0 1 6 6 1 0,0 7,1 42,9 42,9 7,1 0 0 0 2 12 0,0 0,0 0,0 14,3 85,7 mann-whitney u pre p = 0,837 post: p = 0,005 makanan keluarga tidak pernah 1×/hari 2×/hari >3×/hari 3×/hari 6 0 8 28 0 14,3 0,0 19,0 66,7 0,0 2 4 6 22 8 4,8 9,5 14,3 52,4 19,0 0 2 4 12 5 0,0 8,7 17,4 52,2 21,7 0 1 0 2 20 0,0 4,3 0,0 8,7 87,0 mann-whitney u pre p = p = 0,070 post: p = 0,000 makanan selingan tidak pernah 1×/hari 3×/hari >3×/hari 2×/hari 24 12 12 12 0 40,0 20,0 20,0 20,0 0,0 15 19 12 12 2 25,0 31,7 20,0 20,0 3,3 9 21 1 1 4 25,0 58,3 2,8 2,8 11,1 6 11 4 1 14 16,7 30,6 11,1 2,8 38,9 mann-whitney u pre p = 0,962 post: p = 0,034 cara pemberian kurang cukup baik 17 43 0 28,3 71,7 0,0 14 33 13 23,3 55,0 21,7 7 24 5 19,4 66,7 13,9 0 19 17 0,0 52,8 47,2 mann-whitney u pre p = 0,067 post: p = 0,000 keluarga. hal tersebut juga sangat terkait dari jenis keluarga yang dilihat dari jumlah dan komposisi anggota keluarga dalam hal ini keluarga inti dan keluarga besar. dalam siklus kehidupan keluarga keluarga yang memiliki anak usia 6–24 bulan masuk dalam katagori keluarga tahap kedua (keluarga sedang mengasuh anak) dan tahapan ini sering dijumpai pada keluarga inti (khairuddin, 2002; foster dan anderson, 2005). intervensi keperawatan melalui pendampingan (a. aziz alimul hidayat) 137 simpulan dan saran simpulan i n t e r v e n s i k e p e r a w a t a n m e l a l u i pendampingan keluarga cukup efektif dalam meningkatkan praktik pola asuh makan anak usia 6–24 bulan (frekuensi pemberian pasi, makanan lumat, makanan keluarga, makanan selingan dan cara dalam pemberiannya), kecuali pemberian asi, hal ini karena produksi asi sudah mulai menurun sering dengan meningkatnya kebutuhan gizi anak, dan kesesuaian waktu mulainya intervensi. jenis keluarga (nuclear dan extended family) memiliki pengaruh dalam perubahan praktik pola asuh makan. hal tersebut sebagai akibat peran anggota keluarga. pengaruh tersebut tidak ditemukan dalam praktik pemberian asi, kondisi tersebut dapat disebabkan karena riwayat pemberian asi sejak dini. saran i n t e r v e n s i k e p e r a w a t a n m e l a l u i pendampingan dapat digunakan sebagai cara alternatif dalam mengatasi permasalahan gizi yang disebabkan karena praktik pola asuh makan di instansi pelayanan kesehatan khususnya puskesmas. adanya kecenderungan perubahan keluarga dari keluarga besar ke inti diperlukan peningkatan pemahaman dan perilaku khususnya dalam praktik pola asuh makan anak, melalui program pendampingan kecenderungan tersebut diharapkan tidak menimbulkan efek dari praktik pola asuh makan sehingga diperlukan kerja sama melalui program kemitraan dengan lembaga sosial atau lainnya. kepustakaan barness, l. a . dan curran, j.s., 2000. nutrisi. dalam behrnman, dkk., penyunting. nelson textbook of pediatrics edisi 16, philadelpia: saunders. bumbungan, a., 2003. hubungan pola asuh dan penyakit infeksi dengan kejadian kep sedang atau berat di wilayah kerja puskesmas passo propinsi maluku, laporan tesis, (online), (http://adln. lib.unair.ac.id, diakses tanggal 5 januari 2008). departemen kesehatan republik indonesia, 2 0 0 5 . r e n c a n a a k s i n a s i o n a l pencegahan dan penanggulangan gizi buruk tahun 2005–2009, jakarta: depkes ri. departemen kesehatan republik indonesia, 2004. buku kesehatan ibu dan anak, jakarta, depkes ri-jica. engle, p.l, menon, p., haddad, l., 1997. care in nutrition concept and measurement, i n t e r n a t i o n a l f o r p o l i c y r e s e a r c h institute. foster, g.m. dan anderson, b.g., 2005. alih bahasa antopologi kesehatan, jakarta: ui press. friedman, m.m., 1995. family nursing; theory and practice, california: appleton & lange. hidayat, a.a.a., dan uliyah, m., 2007. analisis pertumbuhan dan perkembangan anak balita keluarga nelayan kenjeran, laporan penelitian. surabaya: lppm universitas muhammadiyah. hidajah, a.c., 1999. upaya ibu rumah tangga dalam mempertahankan status gizi balita di masa crisis moneter, laporan penelitian, (online), (http://adln.lib. unair.ac.id., diakses tanggal 5 januari 2008). kusumawati, y dan mutalazimah, 2004. hubungan pendidikan dan pengetahuan gizo dengan berat badan bayi lahir di rsud dr. moerwardi surakarta. infokes, 8 (1). khairuddin, 2002. sosiologi keluarga, yogyakarta: liberty. notoatmodjo, s., 2005. konsep perilaku kesehatan; dalam promosi kesehatan teori dan aplikasi, jakarta: rineka cipta. wulandari, e., 2007. pola asuh gizi pada balita kep (umur 6–24 bulan): studi kasus pada masyarakat etnis madura dan jawa di kelurahan sidodadi simokerto surabaya, laporan tesis, (online), (http://adln.lib.unair.ac., diakses tanggal 5 januari 2008). widyatuti, 2001. meningkatkan status gizi balita melalui asuhan keperawatan keluarga, jki, 5 (2). 115 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 115-120 http://dx.doi.org/10.20473/jn.v17i2.34567 original article open access the effect of online learning on student satisfaction in nursing education during the covid-19 pandemic nurul hikmatul qowi1,* , suratmi suratmi1 , virgianti nur faridah1 , trijati puspita lestari1 , rizky asta pramestirini1 , nanda rifky tri pamungkas1 , and karsim karsim1 1 faculty of health science, universitas muhammadiyah lamongan, lamongan, indonesia *correspondence: nurul hikmatul qowi. address: faculty of health science, universitas muhammadiyah lamongan, indonesia. email: nurul_hikmatul_qowi@umla.ac.id responsible editor: laily hidayati received: 25 march 2022 ○ revised: 08 august 2022 ○ accepted: 29 august 2022 abstract introduction: online learning is a global trend in higher education in the era of the covid-19 pandemic. online learning becomes one of the approaches available to most students and educators, as opposed to face-to-face learning. the aim of this research is to find out the correlation of online learning and satisfaction among nursing students during the covid-19 pandemic. methods: this study was a cross-sectional approach involving 177 second-year nursing students randomly selected resulting in 121 students. students filled out an online learning questionnaire consisting of 14 items and a satisfaction questionnaire consisting of 21 items from google forms. data were analysed using logistic regression with level of significance (p=0.000). results: the online learning indicator that had the highest average value was relevance (3.12), while the highest average value of student satisfaction indicator was content (3.05). logistic regression showed that the online learning indicator that greatly affected student satisfaction was attractiveness. fair attractiveness for online learning increased satisfaction by 7.516 times compared to poor attractiveness (p = 0.000) and good attractiveness for online learning increased satisfaction by 55.538 times compared to poor attractiveness (p = 0.000). conclusions: student satisfaction depends heavily on student attractiveness to the online learning process. lecturers can increase the attractiveness of students toward online learning, whether through the utilized media, learning methods, or the technology of delivering lecture materials. keywords: covid-19; nursing student; online learning; satisfaction introduction the coronavirus disease (covid-19) pandemic is disrupting education around the world and has led to a shift from face-to-face learning to online learning. online learning is a very important new learning domain (ghadrdoost et al., 2021) and is becoming a global trend in higher education in the era of the covid-19 pandemic. online learning is one of the best approaches compared to traditional or mixed learning (eltaybani et al., 2021); however, it must be refined and developed to replace or complement traditional education (chakraborty et al., 2021). online learning is expected to be a way for students to achieve learning outcomes. nursing students, as professional graduates, are expected to take quick professional decisions that should be based on scientific concepts (das et al., 2021). in fact, a previous study has shown that students are unable to learn well in online teaching compared to classroom teaching (khobragade et al., 2021). every educational institution desires to explore innovative online learning strategies with the aim of increasing satisfaction and engagement in learning. this is in accordance with circular number three and four of 2020 of the indonesian ministry of education and https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0001-5362-0180 https://orcid.org/0000-0002-7346-918x https://orcid.org/0000-0002-2415-822x https://orcid.org/0000-0002-4448-3783 https://orcid.org/0000-0003-2109-7780 https://orcid.org/0000-0002-9100-5485 https://orcid.org/0000-0002-6929-3812 qowi, suratmi, faridah, lestari, pramestirini, pamungkas, karsim (2022) 116 p-issn: 1858-3598  e-issn: 2502-5791 culture concerning the prevention of the covid-19 and the implementation of education policies in the emergency period of the spread of the covid-19. the indonesian ministry of education and culture noted that 94.73% universities in indonesia conducted online learning which involved face-to-face interactions through online learning media such as webex, zoom, or webinars (20.11%) and non-face-to-face interactions with social media (34.70%) (aji et al., 2020). in fact, various problems arose in the implementation of online learning. a survey by unicef found that 66% of students from different levels of education in 34 provinces showed that they were uncomfortable studying at home during the covid-19 pandemic. another evaluation by directorate general of higher education of indonesian ministry of education and culture (dikti) showed that only 51% of lecturers and students had effective internet access to do online learning. assessments on online learning have shown that as many as 92% of participants were hindered during the learning process. factors related to the effectiveness of online learning or distance learning include satisfaction, learning process, self-efficacy, use of technology, skills and experience, resources, interaction between educators and learners, and learning environments (hardware infrastructure, software, and networking) (eltaybani & abdelhalim, 2021). online learning using interactive videos is most often used during learning. however, the process of interaction between lecturers and students is very rare. communication is only carried out one way by the lecturer, so that the learning outcome is not achieved optimally. the findings of previous studies have suggested that high levels of interactivity in online education environments lead to greater levels of student satisfaction (khobragade et al., 2021). the satisfaction of students toward the course can be influenced by many factors, including teaching characteristics and student experience (lengetti et al., 2021). online learning satisfaction will mediate the relationship between learning flow and learning outcomes during the covid-19 pandemic (eltaybani et al., 2021). online learning provides easy access, is not limited by time and place, and can be used for more varied learning. however, in its implementation, not all students follow the learning well, for example, not listening to lecture materials, not being active during the lecture process, and so on. this learning process will affect student satisfaction. student satisfaction and the factors that influence it during online learning have not been explained. the aim of this research was to find out the correlation between online learning and study satisfaction among nursing students during the covid19 pandemic. materials and methods this study was cross-sectional and conducted at one private university in lamongan city from february to march 2021. samples were taken with proportional random sampling. students who met the inclusion criteria were willing to be research respondents and were second level nursing students in 2021 having experience following offline learning for 1 year, and online learning for 1 year. these students have undergone a phase of change from offline to online learning, so researchers get a clearer picture of student satisfaction variables than students who only get online learning. the sample was calculated based on the number of students who met the inclusion criteria and obtained 121 students. researchers wrote the names of the students of each class, then drew lots until the number reached the proportion of the previously calculated classes a, b, and c. students received an email invitation to an online self-assigned questionnaire. this research has been declared ethically based on no. 115/ec/kepk-s2/02/2021 by the ethical committee medical research, university of muhammadiyah lamongan. demographic data consisting of age and gender were entered in the first part of the form. in the second part, questionnaires to measure online learning (14 items) and satisfaction (21 items) were adopted from the prasetya and harjanto (2020). the terms of the table 1 descriptive statistics of the online learning and students’ satisfaction scale subscale number of items mean ±sd minimum maximum online learning relevance 2 3.12±0.43 2 4 attractiveness 3 2.64±0.55 1 4 effectivity 3 2.39±0.57 1 4 efficiency 2 2.62±0.62 1 4 productivity 4 2.88±0.47 1.25 4 student satisfaction content 3 3.05±0.43 2.33 4 accuracy 3 2.91±0.51 1.33 4 form 4 2.82±0.36 1.25 4 easy to use 8 2.69±0.39 1.55 4 consistency 3 2.94±0.31 2 4 qowi, suratmi, faridah, lestari, pramestirini, pamungkas, karsim (2022) jurnal ners http://e-journal.unair.ac.id/jners 117 questionnaire assessment utilized the likert scale: 4=strongly agree, 3=agree, 2=disagree, 1=strongly disagree. online learning variable data were analyzed using a total score on each indicator, which included indicators of relevance, attractiveness, effectiveness, efficiency, and productivity. each indicator was categorized into poor, fair, and good. the student satisfaction questionnaire was also declared valid on all items with r > 0.3494. the satisfaction questionnaire was also found to have high reliability (cronbach’s alpha 0.758). descriptive analysis of satisfaction variable used total score on each indicator, which included indicators of content, accuracy, form, ease of use, and consistency. each indicator was categorized into poor, fair, and good. in inferential analysis, the total scores of all indicators are categorized into two, satisfied and dissatisfied. all items on the online learning questionnaire had an r value > 0.349 and thus it was declared valid. the online learning questionnaire was found to have high reliability (cronbach’s alpha 0.758). the data were analyzed using several stages. univariate analysis uses mean values and standard deviations to find out the indicators of the two most dominant variables. after that, the data were analyzed using chi square, to filter out some indicators that had no correlation with learning satisfaction. several indicators that had a correlation were then subject to multivariate tests, including logistic regression, to find out the indicators that have the most influence on learning satisfaction. results univariate analysis of the 121 respondents, 79% were female, while 54% were students of 20-21 years of age, with the rest were 18-19 years old. table 1 shows that of the five online learning indicators, the indicator of relevance had the highest average value (3.05±0.43). relevance means the implementation of online learning has learning conformity and is related to the science and needs of the student environment. the indicator that had the lowest average was effectivity (2.39±0.57). online learning is considered poor on the indicator of effectivity; the interpretation is that the learning can only be understood and kept in mind by students for a short time. satisfaction with the content indicator means that syllabuses, materials, assignment announcements, and assessments were in accordance with the needs of students. bivariate analysis the chi square test was utilized to select the variables that were to be included in multivariate analysis. table 2 shows that the variables of relevance (p = 0.000), attractiveness (p = 0.000), affectivity (p = 0.130), efficiency (p = 0.010), and productivity (p = 0.005) met the requirements for a logistic regression test (p < 0.250). multivariate analysis a logistic regression test was performed on the five online learning indicators to find out the ones that most affect the satisfaction variable. logistic regression was used the enter method. indicators with p>0.1 were gradually removed from the largest value. in the first model, the relevance indicator was removed from the model to make the model fit. then the indicators of productivity, efficiency, and effectiveness were removed gradually based on the largest p value. the results of the logistic regression test showed that only the attractiveness indicator could fit into the model. the or interpretation in table 3 shows that fair attractiveness for online learning increased satisfaction by 7.516 times compared to poor attractiveness (p = 0.000). good attractiveness for online learning increased satisfaction by 55.538 times compared to poor attractiveness (p = 0.000). the model also shows that the variation in satisfaction can be explained by the attractiveness table 3 regression logistic analysis of predictor of students’ satisfaction subscale b(se) or 95% ci of or significance attractiveness poor 0.000 fair 2.017(0.450) 7.516 3.11218.155 0.000 good 4.017(1.075) 55.538 6.752456.807 0.000 table 2 chi-square analysis the online learning and students’ satisfaction online learning satisfaction ∑ p dissatisfied satisfied relevance 0.000 poor 4 0 4 fair 62 30 92 good 2 23 25 attractiveness 0.000 poor 19 1 20 fair 36 14 50 good 13 38 51 effectivity 0.130 poor 10 6 16 fair 32 17 49 good 26 30 56 efficiency 0.012 poor 11 1 12 fair 25 16 41 good 32 36 68 productivity 0.005 poor 9 1 10 fair 19 7 26 good 40 45 85 qowi, suratmi, faridah, lestari, pramestirini, pamungkas, karsim (2022) 118 p-issn: 1858-3598  e-issn: 2502-5791 indicator, by 38.3%. the accuracy of the satisfaction model above is 76.9%. discussions the relevance of online learning is the aspect of online learning that is considered the best by students. high relevance shows that online learning is in accordance with the science and needs of students. the learning material must be delivered in a clear, wellorganized, and easily accessible manner to the student, wherever the student may be (kuo, 2010). the learning process is carried out with a focus on learning achievement and periodic evaluations in the learning process to maintain good quality learning even through online learning (not face-to-face). self-evaluation and peer evaluation can be a way to receive student feedback as well as a reflection of learning success (ghaljeh et al., 2021). in addition, learning evaluation can also be done by conducting final exams or student skill exams both individually and in groups (chan et al., 2021). the online learning process must be able to achieve learning outcomes. the material submitted must be organized in accordance with the existing curriculum and a clear evaluation process, so that the implementation of online learning does not reduce the quality of graduates. the productivity indicator also had a high mean value compared to the other indicators. this means that online learning is considered good in productivity and able to encourage students for a more active role than offline learning. previous research explains that increasing the active participation of students can be done using collaborative learning methods and case approaches because there will be interaction between facilitators and between students (khan et al., 2017). an active learning environment with a high level of interactivity between students and their environment (peers, instructors, and content) not only motivates students, but also improves overall learning achievement and satisfaction (croxton, 2014). good interaction between lecturers and students during learning can also increase satisfaction (eltaybani et al., 2021). lack of communication between students and lecturers, as well as low motivation, can be obstacles to online learning. good interaction between lecturers and students during the learning process will increase student participation in the learning process from beginning to end, so that learning materials can be delivered properly. the content indicator had the highest average value for the satisfaction variable. content has significance in the learning materials and during the learning process. learning is carried out in accordance with the syllabus that has been composed. in learning about nursing, students are trained to develop critical thinking to solve problems of patients and take decisions for nursing interventions in the middle of collaborative learning (nasirzadeh et al., 2021). the abilities of facilitators and rapid response when students have learning difficulties can also affect student satisfaction (qowi et al., 2016). interaction with students, preparation of learning resources, and passion for teaching are significant factors with online learning. the utilized learning methods are also one of the triggers of a good learning process. the online learning process has a good impact for faculty to develop lecturers' skills and self-efficacy in online learning (li et al., 2021). the suitability of the material with the syllabus is very helpful for students to find learning materials during online learning (culproche et al., 2021). the use of varied learning methods and media can also make it easier for students to receive the material delivered. learning media based on online simulation can facilitate the accessibility of learning materials, as well as increase the knowledge and skills of nursing students (kim & park, 2021) and increase student involvement during lectures (chan et al., 2021). collaborative learning can be implemented through powerpoint presentation activities, short videos, quizzes, and provision of feedback in each assignment (joseph et al., 2021). regression test results showed that the attractiveness indicator most affected student satisfaction in online learning. students will be satisfied during courses that are perceived as interesting. based on previous studies, online learning has a good relationship with student satisfaction levels (baherimoghadam et al., 2021). the learning process can be made to be more interesting with multimedia technology, including mobile technology, in order that learners can more actively participate in the educational process. the online learning process is also more effective when the syllabus is structured clearly, with usage of audio-visual media such as videos, images, posters, and so on (turrise et al., 2020). learning media that create interest, as well as collaborative learning methods, can reduce student frustration (khobragade et al., 2021). an interesting and fun learning process will increase students' interest in participating in online learning. students will be excited because the learning process is not monotonous. a fun learning process will make students attracted to listen to every process in learning. students of generation z who are often exposed to technology can qowi, suratmi, faridah, lestari, pramestirini, pamungkas, karsim (2022) jurnal ners http://e-journal.unair.ac.id/jners 119 easily adapt to changes related to technology (baghchegh 2021). usage of mobile technology during the learning process is also the choice of students in following the learning process. the usage of mobile technology in learning (applications about diseases, physical examinations, drugs, video and audio in medical simulations, and various games), can facilitate the learning process in health students (huwaidi et al., 2021). online learning provides a challenge for lecturers to update the latest technology in learning. lecturers must understand varied learning media such as using puzzles, quizzes, animated videos that students prefer compared to listening to courses. online learning is facilitated through several common platforms such as zoom meetings, google meet, edmodo, google classroom, and applications developed by universities, which can be a fun learning medium for students. whatsapp application is the online learning platform that students are most interested in. microsoft teams, zoom, and google classroom also provide technology features as an online learning medium (eltaybani et al., 2021). research related to learning media and learning methods that can attract students to follow the learning process can be conducted in the future (almaiah et al., 2020). however, inadequate lecturer skills during the online learning process, time constraints, and inadequate infrastructure can be obstacles during online learning (khobragade et al., 2021). an obstacle that often occurs is internal constraints. technology and media, including the internet, have a broad role in education and health education (huwaidi et al., 2021). the constraints of unstable internet networks are experienced by facilitators and learners. learning methods and mediaare utilized to increase student interest in following learning. however, there are several matters that need to be considered in order that students can achieve competency standards in the online learning process, such as readiness in technology, material readiness, and positive attitude during online learning (chakraborty et al., 2021). barriers to the implementation of online learning, such as changes in management problems, technical problems with online learning systems, and financial problems, must also be minimized so that the learning process runs optimally (hunt, 2018). the institutions also must provide facilities that support online learning. the obstacles that occur during online learning will reduce motivation, both for lecturers and students, in carrying out online learning itself. the limitation of this study is that the research is carried out with a sample from one institution only, so it cannot be generalized in all nursing educational institutions. conclusions based on the results of this study, it was revealed that attractiveness is a very important factor in online learning. attractive learning can increase students' active participation during the learning process, and in the long term can have a positive impact on learning outcomes. various efforts to increase student interest in learning are by modifying learning media, learning methods, and improving the skills of lecturers in conducting online learning. future research can be carried out related to the media and methods used during online learning and their correlation with student motivation and satisfaction. references aji, w., dewi, f., kristen, u., & wacana, s. (2020). dampak covid-19 terhadap implementasi pembelajaran daring. jurnal ilmu pendidikan, 2(1), 55–61. almaiah, m. a., al-khasawneh, a., & althunibat, a. (2020). exploring the critical challenges and factors influencing the e-learning system usage during covid-19 pandemic. education and information technologies. baherimoghadam, t., hamedani, s., naseri, n., & marzban, n. (2021). the effect of learning style and general self-efficacy on satisfaction of e-learning in dental students. bmc medical education, 5, 1–7. chakraborty, m., reddy, y. a. k., ghoshal, j. a., & amudharaj, d. (2021). towards e ‐ learning conducted during descriptive study. journal of education and health promotion |. https://doi.org/10.4103/jehp.jehp chan, s. l., lin, c. c., chau, p. h., takemura, n., & fung, j. t. c. (2021). evaluating online learning engagement of nursing students. nurse education today, 104(april), 104985. https://doi.org/10.1016/j.nedt.2021.104985 croxton, r. a. (2014). the role of interactivity in student satisfaction and persistence in online learning (vol. 10, issue 2, pp. 314–325). culp-roche, a., hardin-fanning, f., tartavoulle, t., hampton, d., hensley, a., wilson, j. l., & thaxton, a. (2021). nurse education today perception of online teacher self-efficacy: a multi-state study of nursing faculty pivoting courses during covid 19 ☆ , ☆☆. nurse education today, 106(june), 105064. https://doi.org/10.1016/j.nedt.2021.105064 das, s., das, a., rai, p., & kumar, n. (2021). case ‐ based learning: modern teaching tool meant for present curriculum: a behavioral analysis from faculties ’ perspective. journal of education and health promotion. https://doi.org/10.4103/jehp.jehp eltaybani, s., & abdelhalim, g. e. (2021). nursing students ’ and educators ’ experience with e ‐ learning during a pandemic: an online survey. february, 2021, 1–11. https://doi.org/10.1111/nuf.12634 eltaybani, s., abdelhalim, g. e., & abdelgawad, m. e. (2021). nursing students’ and educators’ experience with e-learning during a pandemic: an online survey. in nursing forum, february (pp. 1– 11). https://doi.org/10.1111/nuf.12634 ghadrdoost, b., sadeghipour, p., amin, a., & bakhshandeh, h. (2021). validity and reliability of a virtual education satisfaction questionnaire from the perspective of cardiology residents during the covid ‐ 19 pandemic. journal of education and health promotion |. https://doi.org/10.4103/jehp.jehp ghaljeh, m., rezaee, n., & arbabisarjou, a. (2021). department of psychiatry. journal of education and health promotion. https://doi.org/10.4103/jehp.jehp hunt, r. (2018). is medical education ready for generation z ? journal qowi, suratmi, faridah, lestari, pramestirini, pamungkas, karsim (2022) 120 p-issn: 1858-3598  e-issn: 2502-5791 of graduate medical education, 378–381. huwaidi, f., bayu, a., nandiyanto, d., & muhammad, n. (2021). indonesian journal of educational research and technology the urgency of online learning media during the covid19 pandemic at the vocational school in indonesia. indonesian journal of educational research and technology, 1(2), 35–40. joseph, m. a., roach, e. j., natarajan, j., karkada, s., rose, a., & cayaban, r. (2021). flipped classroom improves omani nursing students performance and satisfaction in anatomy and physiology. bmc nursing. khan, a., egbue, o., palkie, b., & madden, j. (2017). active learning: engaging students to maximize learning in an online course. the electronic journal of e-learning, 15(2), 107–115. khobragade, s. y., htoo, h., & soe, k. (2021). virtual learning during the covid ‐ 19 pandemic: what are the barriers and how to overcome them ? journal of education and health promotion. https://doi.org/10.4103/jehp.jehp kim, s. h., & park, s. (2021). influence of learning flow and distance elearning satisfaction on learning outcomes and the moderated mediation effect of social-evaluative anxiety in nursing college students during the covid-19 pandemic: a cross-sectional study. nurse education in practice, 56(january), 103197. https://doi.org/10.1016/j.nepr.2021.103197 kuo, y. (2010). digitalcommons @ usu interaction , internet selfefficacy , and self-regulated learning as predictors of student satisfaction in distance education courses. https://doi.org/10.26076/157a-7cf6 lengetti, e., cantrell, m. a., dellacroce, n., diewald, l., mensinger, j. l., & shenkman, r. (2021). learning environment and evidence among professionals and students satisfaction (leaps), experienced during the covid-19 pandemic. teaching and learning in nursing, 16(4), 342–346. https://doi.org/10.1016/j.teln.2021.07.004 li, w., gillies, r., he, m., wu, c., liu, s., gong, z., & sun, h. (2021). barriers and facilitators to online medical and nursing education during the covid ‐ 19 pandemic: perspectives from international students from low ‐ and middle ‐ income countries and their teaching staff. human resources for health, 1–14. https://doi.org/10.1186/s12960-021-00609-9 nasirzadeh, m., kaveh, f., sayadi, a. r., & asadpour, m. (2021). effect of educational intervention on preventive behaviors of brucellosis among health volunteers in rafsanjan city: application of health belief model. jurnal ilmu pendidikan, 1–7. https://doi.org/10.4103/jehp.jehp nayereh baghcheghi, h. r. k. (2021). the relationship between the and educational achievements in health ‐ care professional students. journal of education and health promotion. https://doi.org/10.4103/jehp.jehp prasetya, t. a., & harjanto, c. t. (2020). pengaruh mutu pembelajaran online dan tingkat kepuasan mahasiswa terhadap hasil belajar saat pandemi covid19. jurnal pendidikan teknologi dan kejuruan, 17(2), 188–197. https://doi.org/10.23887/jptkundiksha.v17i2.25286 qowi, n. h., lestari, t. p., & sholikhah, s. (2016). virtual algorithm simulation ( vas ) based on problem : injec. https://doi.org/10.24990/injec.v4i2.270 turrise, s. l., thompson, c. e., & hepler, m. (2020). virtual simulation: comparing critical thinking and satisfaction in rn-bsn students. in clinical simulation in nursing (pp. 1–5). https://doi.org/10.1016/j.ecns.2020.03.004 how to cite this article: qowi, n. h., suratmi, s., faridah, v. n., lestari, t. p., pramestirini, r. a., pamungkas, n. r, t., and karsim, k. (2022) ‘the effect of online learning on student satisfaction in nursing education during the covid-19 pandemic’, jurnal ners, 17(2), pp. 115-120. doi: http://dx.doi.org/10.20473/jn.v17i2.34567 table1 table2n table2 table3 aji almaiah baherimoghadam chakraborty chan croxton culp das eltaybani eltaybanietall ghadrdoost ghaljeh hunt huwaidi joseph khan khobragade kim kuo lengetti ligillies nasirzadeh nayereh prasetya qowi turrise 107 home care holistic terhadap perubahan kecemasan dan depresi pada pasien stroke iskemik (home care holistic on the change of anxiety and depression for the patient with stroke ischemic) luluk widarti,* krisnawati* *politeknik kesehatan kemenkes surabaya, e-mail: lulukwidarti@yahoo.co.id abstract introduction: stroke is the main cause of long-term disability. it was reported that one third out of stroke survivors showed dementia in three months after stroke. stroke patients need medication and palliative caring so that home-care is highly recommended. in indonesia, home-care nursing for ischemic stroke has not yet been optimally applied in caring patient with stroke. the objective of the study was to examine the effect of home care holistic nursing on the change of anxiety and depression for the patient with stroke ischemic. method: an experimental research with quasy experimental specifi cally nonrandomized pre-post test control group design was applied in this study. the study was conducted in surabaya by selecting ischemic stroke patients after being hospitalized at "aseruni was, medic irna, dr. soetomo hospital". a sample of size 40 patients was divided equally into two groups, control and treatment groups. the treatment and control groups respectively received holistic home care and home care. the depression and anxiety level were measured by using questionnaires technique. the data were analyzed by using levene's test for homogeneity of variance, and t-test. result: the result showed that there were signifi cantly different between both groups for psychological response such as anxiety with p-value = 0.000, depression with p = 0.000. discussion: it was concluded that holistic home care could improve the psychological responses by decreasing anxiety and depression level in ischemic stroke patients. it is recommended to make standard operational procedure of holistic home care that can be implemented by all health personnel who take care ischemic stroke patients. keywords: holistic home care, anxiety and depression, stroke pendahuluan stroke terjadi akibat adanya gangguan aliran darah ke otak. ketika aliran darah ke otak terganggu, maka oksigen dan nutrisi tidak dapat dikirim ke otak. kondisi ini akan mengakibatkan ker usakan sel otak mati. persentasi tertinggi stroke adalah stroke iskemik, yang terjadi akibat penyumbatan aliran darah. penyumbatan dapat terjadi karena timbunan lemak yang mengandung kolesterol (disebut plak) dalam pembuluh darah besar (arteri karotis) atau pembuluh darah sedang (arteri serebri) atau pembuluh darah kecil. stroke merupakan penyebab utama kecacatan jangka panjang. di amerika serikat, 90% kasus stroke yang selamat (stroke survivor), mengalami kecacatan. stroke juga menyebabkan biaya yang sangat tinggi baik secara medis maupun sosial. karena itu sangatlah penting memperhatikan stroke iskemik (infark) karena sebagian besar kasus stroke iskemik (infark) berhasil diselamatkan. kasus stroke yang selamat, bisa mempunyai resiko terjadinya gangguan kognitif atau demensia. dilaporkan bahwa sepertiga dari stroke sur vivor menunju k kan demensia dalam waktu 3 bulan setelah stroke. demikian pula penelitian hospital based yang telah dilakukan di rs dr. sardjito yogyakarta dan rsud dr. soetomo surabaya menunjukkan bahwa angka kejadian gangguan kognitif pasca-stroke iskemik adalah hampir 60%. 108 jurnal ners vol. 7 no. 2 oktober 2012: 107–115 st roke menyebabkan kelu mpu han s e b el a h b a g i a n t u b u h (h e m i p l e g i a). kelumpuhan sebelah bagian tubuh kanan atau kiri, tergantung dari kerusakan otak. bila kerusakan terjadi pada bagian bawah otak besar (cerebrum), penderita sulit menggerakan tangan dan kakinya. bila terjadi pada otak kecil (cerebellum), kema mpu a n u nt u k mengkoordinasikan gerakan tubuhnya akan berkurang. kondisi demikian membuat pasien stroke mengalami kesulitan melaksanakan kegiatan sehari-hari. pasien stroke mungkin kehilangan kemampuan indera merasakan (sensor i k) yait u ra ngsa ng sent u h at au jarak. cacat sensorik dapat mengganggu kemampuan pasien mengenal benda yang sedang dipegangnya. kehilangan kendali pada kandung kemih merupakan gejala yang biasanya muncul setelah stroke, dan seringkali menurunkan kemampuan saraf sensorik dan motorik. pasien stroke mungkin kehilangan kemampuan untuk merasakan kebutuhan kencing atau buang air besar. dampak psikologis penderita stroke adalah perubahan mental. setelah stroke memang dapat terjadi gangguan pada daya pikir, kesadaran, konsentrasi, kemampuan belajar, dan fungsi intelektual lainnya. semua hal tersebut dengan sendirinya memengaruhi kondisi psikologis penderita. marah, sedih, dan tidak berdaya seringkali menurunkan semangat hidupnya sehingga muncul dampak emosional ber upa kecemasan yang lebih berbahaya. pada umumnya pasien stroke tidak mampu mandiri lagi, sebagian besar mengalami kesulitan mengendalikan emosi. penderita mudah merasa takut, gelisah, marah, dan sedih atas kekurangan fi sik dan mental yang mereka alami. keadaan tersebut berupa emosi yang kurang menyenangkan yang dialami oleh pasien stroke karena merasa khawatir berlebihan tentang kemungkinan hal buruk yang akan terjadi. hal ini didukung oleh teori jeslid dalam hunsley (1985); gonzales, tayler, dan anton dalam forstermann. boissel dan harmut (1998) mereka telah mengadakan percobaan untuk mengukur kecemasan yang dialami individu selanjutnya kecemasan ter sebut d idef i n isi ka n sebagai konsep yang terdiri dari dua dimensi utama, yaitu kekhawatiran dan emosionalitas. gangguan emosional dan perubahan kepribadian tersebut bisa juga disebabkan oleh pengaruh kerusakan otak secara fisik. penderitaan yang sangat umum pada pasien stroke adalah depresi. tanda depresi klinis antara lain: sulit tidur, kehilangan nafsu makan atau ingin makan terus, lesu, menarik diri dari pergaulan, mudah tersinggung, cepat letih, membenci diri sendiri, dan berfi kir untuk bunuh diri. depresi seperti ini dapat menghalangi penyembuhan/ rehabilitasi, bahkan dapat mengarah kepada kematian akibat bunuh diri. depresi pascastroke, selayaknya ditangani seperti depresi lain yaitu dengan obat antidepresan dan konseling psikologis. metode penyembuhan stroke antara lain metode konvensional umumnya dengan pemberian obat yang merupakan penanganan yang paling lazim diberikan selama perawatan di rumah sakit maupun setelahnya. obat apa yang diberikan tergantung dari jenis stroke yang dialami apakah iskemik atau hemoragik. kelompok obat yang paling populer untuk menangani stroke adalah antitrombotik, trombolitik, neuroprotektif, antiansietas dan antidepresi. untuk metode operatif, tindakan ini bertujuan untuk memperbaiki pembuluh darah yang cacat. dengan begitu diharapkan dapat meningkatkan peluang hidup pasien, dan pada gilirannya dapat menyelamatkan jiwa pasien. teknik fi sioterapi dilakukan pada penderita stroke yang mengalami hambatan fisik. penanganan fisioterapi pasca stroke adalah kebutuhan yang mutlak bagi pasien untuk dapat meningkatkan kemampuan gerak dan fungsinya. model home care di indonesia untuk penyembuhan pasien stroke sampai saat ini masih terfokus pada pemenuhan kebutuhan fi sik. home care yang dilaksanakan hanya berdasarkan standar pelayanan seperti di rumah sakit, dengan demikian model asuhan keperawatan home care yang diberikan pada pasien stroke iskemik belum optimal. keadaan tersebut akan bertambah parah jika tidak ada suatu upaya penanganan yang holistic dengan melibatkan beberapa pihak dan model asuhan yang lebih baik (depkes, 2002). 109 home care holistic terhadap perubahan kecemasan (luluk widarti) kelemahan metode penyembuhan stroke yang dilakukan di atas belum menyentuh aspek mental, padahal penderita stroke mengalami perubahan mental dan gangguan emosional. untuk itu ditawarkan hal baru yaitu model perawatan home care holistic dengan pendekatan bio-psiko-sosial-spiritual. asuhan biologis (fisik) adalah pelayanan yang diberikan untuk memenuhi kebutuhan kesehatan fi sik. asuhan keperawatan psikis ditekankan pada strategi koping yang positif supaya pasien dapat memecahkan persoalan sendiri dengan menggunakan kekuatan yang ada pada dirinya. asuhan keperawatan sosial termasuk pelayanan untuk mempertahankan keseimbangan hubungan dan komunikasi dengan keluarga. asuhan keperawatan pada aspek spiritual ditekankan pada penerimaan pasien terhadap sakit yang dideritanya. pendekatan home care holistic tersebut diharapkan dapat memengaruhi keseimbangan mental pasien stroke. keseimbangan mental tersebut akan mempengaruhi sekresi crf oleh pvn di hipotalamus. dengan terkendalinya sekresi crf akan terkendali pula sekresi acth oleh hpa (hipotalamus, pituitary, adrenal), apabila model home care holistic dikategorikan mampu memperbaiki mekanisme koping pada pasien stroke iskemik melalui proses pembelajaran, maka dampak berikutnya adalah perbaikan respons psikologis berupa penurunan kecemasan dan depresi. kondisi respons psikologis berkorelasi dengan perbaikan respons biologis yang dicerminkan oleh penurunan kecemasan dan depresi pada pasien stroke iskemik. respons psikologis tersebut dapat mencegah terjadinya proses infl amasi lebih lanjut maupun perluasan infark serebri. sampai saat ini belu m ada hasil penelitian yang menguji manfaat home care holistic terhadap perbaikan respons psikologis pada pasien stroke iskemik. apabila peran home care holistic pada pasien st roke iskemik tidak diperjelas maka pemahaman tentang peran home care holistic tersebut tidak bisa dimanfaatkan bagi kepentingan penyembuhan pasien stroke iskemik maupun penanggulangan perkembangan infark serebri, sehingga kecacatan akibat stroke iskemik akan tetap besar. hal ini secara umum tentu akan memengaruhi kemampuan sumber daya manusia dan produktivitas. penelitian ini bertujuan menganalisis perbedaan kecemasan dan depresi sebelum dan sesudah intervensi antara kelompok model home care holistic dan kelompok model home care. bahan dan metode jenis penelitian ini mengg unakan rancangan quasy-experimental dengan bentuk nonrandomized pre-post test control group design. kelompok perlakuan diberi home care holistic (kp) dan kelompok kontrol diberi home care (kk). penelitian ini dimaksudkan untuk menguji adanya perbedaan tingkat kecemasan dan tingkat depresi antara kelompok perlakuan dan kelompok kontrol. subjek diukur respons psikologis berupa tingkat kecemasan dan tingkat depresi. peng u k u ran dilak u kan sebelu m dan setelah inter vensi selama 3 bulan. pengukuran respons psikologis dilakukan sebelum dan setelah intervensi. setelah itu hasil pengukuran kedua kelompok dibandingkan untuk menentukan perbedaan respons psikologis pada pasien stroke iskemik yang mendapatkan model home care holistic dan model home care. populasi dan sampel yang dimaksud dalam penelitian ini adalah seluruh pasien stroke iskemik yang mengalami serangan pertama dan telah diijinkan pulang setelah rawat inap di ruang ser u ni a rsu d dr. soetomo surabaya tahun 2009. jumlah populasi pasien yang dirawat mulai bulan januari sampai bulan desember adalah 683 pasien, rata-rata tiap bulan 54 pasien. kriteria inklusi dalam penelitian ini adalah pasien menyatakan bersedia menjadi responden penelitian dengan menandatangani surat persetujuan atau informed consent baik sebagai subjek penelitian maupun tindakan keperawatan, umur antara 35–65 tahun, tidak menderita komplikasi penyakit lain, beragama islam dan bertempat tinggal di wilayah kota surabaya, sedangkan kriteria eksklusi dalam penelitian ini terdapat penyakit lain yang mengganggu pengukuran, misalnya, sirosis hepatis, hepatitis, dekompensasi kordis. 110 jurnal ners vol. 7 no. 2 oktober 2012: 107–115 variabel penelitian yaitu home care adalah suat u pendekatan dalam asuhan keperawatan di rumah yang menekankan pada intervensi biologis (aspek fi sik), home care holistic adalah suatu pendekatan dalam asuhan keperawatan di rumah yang menekankan pada intervensi bio-psiko-sosial-spiritual, tingkat kecemasan dan tingkat depresi diukur dengan daftar pertanyaan yang sudah diuji validitas dan reabilitasnya dengan skala data interval. data dikumpulkan dengan menggunakan k uesioner dan wawancara kemudian di oleh dengan menggunakan analisis statistik levene's test dan t-test. hasil penelitian dilaksanakan di wilayah kota surabaya pada pasien stroke iskemik yang pulang setelah rawat inap di ruang seruni a irna medik rsud dr. soetomo surabaya. waktu penelitian selama 3 bulan (februari sampai dengan mei 2010). pelaksanaan model home care holistic dilakukan oleh peneliti dan pelaksanaan model home care dilakukan oleh tim sebanyak 5 orang perawat dengan latar pendidikan ners yang telah mendapatkan pelatihan tentang home care pada pasien stroke iskemik selama 1 minggu. besar sampel yang ditetapkan adalah 20 pasien untuk masing-masing kelompok. kelompok 1 (perlakuan 20 orang) adalah kelompok pasien yang mendapatkan model home care holistic dan kelompok 2 (kontrol 20 orang) adalah kelompok yang mendapatkan model home care. besarnya sampel sudah didasarkan pada perhitungan statistik. kelompok perlakuan mendapatkan intervensi model home care holistic berupa pendekatan dalam asuhan keperawatan di rumah yang menekankan pada intervensi biopsiko-sosial-spiritual. kegiatan penerapan model home care holistic meliputi; intervensi biologis (fi sik); intervensi psikologis; intervensi sosial; dan intervensi spiritual. p e l a k s a n a a n k e g i a t a n a s u h a n keperawatan home care holistic dilaksanakan oleh peneliti dengan jalan kunjungan rumah setiap responden secara individu 2 kali dalam seminggu (hari senin-kamis, dan hari selasa-jum'at) selama 3 bulan. di samping itu sewaktu-waktu pasien bisa langsung menghubungi peneliti melalui telepon ataupun telepon selular. kelomp ok kont r ol me nd a p at k a n intervensi model home care berupa pendekatan dalam asuhan keperawatan di rumah yang menekankan pada intervensi biologis (aspek fi sik). kegiatan penerapan model home care meliputi memberikan obat sesuai dengan anjuran dokter yang merawat, memenuhi kebutuhan nutrisi, memenuhi kebutuhan cairan dan elektrolit, memenuhi kebutuhan eliminasi, memenuhi kebutuhan aktivitas dan istirahat atau tidur, memenuhi kebutuhan integritas kulit (kebersihan dan kenyamanan fi sik), dan mengobservasi tanda-tanda vital. p e l a k s a n a a n k e g i a t a n a s u h a n keperawatan home care dilakukan oleh tim dengan rincian 5 perawat dengan jalan kunjungan rumah setiap responden secara individu, 2 kali dalam seminggu (hari seninkamis, dan hari selasa-jum'at) selama 3 bulan. di samping itu sewaktu-waktu pasien bisa langsung menghubungi tim perawat melalui telepon ataupun telepon selular. penelitian ini ada dua karakteristik responden yang dijadikan obyek penelitian yaitu karakteristik kelompok model home care holistic (kp) dan yang mendapatkan perawatan model home care (k k). data tentang karakteristik kelompok model home care holistic dan yang mendapatkan perawatan model home care (kk). data pelaksanaan home care holistic selama intervensi kelompok perlakuan mendapatkan pemeriksaan tanda-tanda vital dan asuhan keperawatan berupa pelayanan untuk kesehatan fi sik, mengajak pasien untuk menerapkan koping yang efektif, mengajak pasien untuk berinteraksi sosial, dan mengajak pasien untuk beribadah. kegiatan dimulai jam 08.00, peneliti mengadakan kunjungan rumah ± 1,5 jam setiap pasien. kegiatan pertama adalah perkenalan/ silaturrahmi dengan pasien dan keluarga. topik yang dibicarakan adalah keluhan-keluhan yang dialami pasien. peneliti mendengarkan dan mencatat beberapa hal yang penting serta memberikan justif ikasi dan penyuluhan. 111 home care holistic terhadap perubahan kecemasan (luluk widarti) pertemuan selanjutnya dilaksanakan bersama dengan keluarga pasien yang digunakan untuk menggali sejauh mana peran keluarga dalam memberikan dukungan sosial kepada pasien. selanjutnya pasien menjalani program kontrol untuk mendapatkan perawatan dan terapi medik. pe ng a r u h ke c e m a s a n r e s p ond e n sebelum intervensi lebih tinggi dibandingkan dengan pengar uh kecemasan responden setelah intervensi untuk kelompok home care holistic (kp). untuk menguji apakah pengaruh kecemasan sebelum dan setelah intervensi untuk kelompok home care holistic (kp) memiliki pola yang sama atau berbeda tiap responsdennya maka dilakukan pengujian t. paired sample test menghasil kan nilai signifi kan sebesar 0,000 di mana nilai tersebut kurang dari 0,05, dengan demikian h0 ditolak dan disimpulkan bahwa ada perbedaan kecemasan sebelum dan setelah intervensi untuk kelompok home care holistic (kp). kecemasan pada kelompok home care holistic (kp) sebelum intervensi, dilihat dari nilai mean = 76,65 yang artinya tingkat kecemasan berat, setelah intervensi nilai mean = 40,35 yang artinya tingkat kecemasan ringan. pengaruh depresi sebelum dan setelah i nter vensi u nt u k kelompok home care holistic (kp) memiliki pola yang berbeda tiap sk o r k ec em as an k el o m p o k p er la ku an gambar 1. grafi k perbedaan kecemasan antara sebelum dan sesudah intervensi pada kelompok model home care holistic (kp) gambar 2. grafi k perbedaan depresi antara sebelum dan setelah intervensi untuk kelompok home care holistic (kp) 112 jurnal ners vol. 7 no. 2 oktober 2012: 107–115 responsdennya, dapat dilihat bahwa pengaruh depresi responden sebelum intervensi lebih tinggi dibandingkan dengan pengaruh depresi responden setelah intervensi untuk kelompok home care holistic (kp). paired sample test menghasilkan nilai signifi kan sebesar 0,000 di mana nilai tersebut kurang dari 0,05, dengan demikian h0 ditolak dan disimpulkan bahwa ada perbedaan depresi sebelum dan setelah intervensi untuk kelompok home care holistic (kp). depresi pada kelompok home care holistic (kp) sebelum intervensi, dilihat dari nilai mean = 90 yang artinya tingkat depresi berat, setelah intervensi nilai mean = 55,65 yang artinya tingkat depresi ringan. pembahasan kecemasan dapat diekspresikan secara langsung melalui perubahan biologis dan perilaku serta secara tidak langsung melalui timbulnya gejala atau mekanisme koping untuk melawan kecemasan. intensitas perubahan perilaku akan meningkat sejalan dengan peningkatan tingkat cemas. gejala kecemasan antara lain didapati adanya sifat-sifat yang kompulsif dari pasien neurosa cemas. pada penelitian ini pasien menunjukkan sering gelisah dan gugup sewaktu diajak berbicara. kecemasan yang muncul pada pasien dengan stroke iskemik antara lain cemas tentang kesembuhan penyakitnya, cemas akan biaya pengobatan dan kecemasan akan masa depannya. penelitian ini setelah pasien diberikan model home ca re holist ic mengala m i penurunan kecemasan. berdasarkan hasil uji beda diperoleh signifi kansi sebesar 0,000 yang artinya ada perbedaan kondisi kecemasan pada pasien stroke iskemik kelompok model home care holistic dengan kelompok model home care setelah intervensi. penerapan model home care holistic selalu menekankan pada pendekatan bio-psiko-sosial-spiritual. perawatan biologis diberikan terapi somatik neurologis terhadap stroke-nya yang meneruskan terapi dari dokter yang merawat juga memenuhi kebutuhan nutrisi, cairan dan elektrolit, eliminasi, aktivitas dan istirahat/ tidur, integritas kulit dan mengobservasi tanda-tanda vital. pendekatan psikologis diberikan suportif dan kognitif pada saat kondisi mental emosional pasien dalam keadaan stabil agar pasien dapat menerima kenyataan dan mengembalikan rasa percaya diri. pendekatan implementasi psikologis yang diberikan berupa memfasilitasi teknik koping yang konstruktif dengan jalan mengajak pasien untuk menemukan makna dari penyakit, menggali potensi diri pasien, mengajak pasien untuk mengidentifi kasi cara yang biasa digunakan untuk mengatasi kesal, marah atau sesuatu yang tidak menyenangkan, memfasilitasi pandangan yang positif tentang konsep diri dan memotivasi untuk melakukan aktifi tas. pendekatan sosial diberikan dalam menunjang respons sosial yang adaptif kepada pasien dan keluarga. dukungan tabel 1. hasil paired sample test pada data pengaruh kecemasan sebelum dan setelah intervensi untuk kelompok home care holistic (kp) ukuran statistik uji t rerata sd nilai stat. sign. sebelum intervensi 76,65 12,466 11,950 0,000 setelah intervensi 40,35 8,375 tabel 2. hasil paired sample test pada data pengaruh depresi sebelum dan setelah intervensi untuk kelompok home care holistic (kp) ukuran statistik uji t rerata sd nilai stat. sign. sebelum intervensi 90 17,526 12,188 0,000 setelah intervensi 55,65 12,347 113 home care holistic terhadap perubahan kecemasan (luluk widarti) yang diberikan berupa dukungan emosional, dukungan informasi, dan dukungan materiil. model ini dikembangkan dari konsep pearlin dan aneshensel. pendekatan sosial agar pasien tidak rendah diri dan banyak bergaul guna menghindari keterasingan dengan jalan melakukan teknik komunikasi terapeutik, terbuka, eksplorasi dan klarifi kasi, mendorong p a sie n u nt u k m e r e d a k a n ke t eg a ng a n emosinya membantu pasien untuk menerima pikiran dan perasaannya, membantu pasien u nt u k me ngek s pr e si k a n p e r a s a a n nya , mengajak pasien untuk berpartisipasi dalam pengambilan keputusan yang berkenaan dengan perawatannya, menyakinkan kepada pasien bahwa dia adalah tetap sebagai individu yang berguna bagi keluarga dan masyarakat, mengajak keluarga untuk memberi dukungan sosial, memfasilitasi hubungan interpersonal yang memuaskan. dukungan sosial sebagai informasi atau nasehat verbal dan non verbal, bantuan nyata atau tindakan yang diberikan oleh keakraban sosial atau berupa kehadiran dan mempunyai manfaat emosional atau berpengaruh pada perilaku penerimanya. keluarga memiliki fungsi suportif. keluarga memainkan sebuah peran yang sangat penting dalam menentukan perilaku anggota keluarganya yang sakit, bersifat mendukung selama masa penyembuhan dan pemulihan (schneck, 1998). apabila dukungan semacam ini tidak ada maka keberhasilan program penyembuhan dan pemulihan akan sangat berkurang. respons sosial ini dapat bersifat adaptif yang ditunjukkan dengan adanya perilaku yang responsif sedangkan respons sosial yang bersifat mal adaptif mengarah kekhawatiran yang berlebihan sehingga menimbulkan kecemasan, kalau keadaan ini berlangsung terus-menerus akan menimbulkan depresi (stuart dan laraia, 2000). pendekatan spiritual diberikan dengan menekankan bahwa apa yang dialaminya itu sebagai ujian atau cobaan keimanan oleh karenanya pasien diberi semangat untuk tidak berputus asa dalam berupaya memulihkan kesehatannya disertai dengan sholat, doa dan dzikir. dzikir secara psikologis akan menciptakan perasaan damai, tenang dan suasana emosi diliputi oleh emosi-emosi positif. dzikir jika dilakukan dengan penuh konsentrasi akan memunculkan gelombang alpha, yaitu gelombang otak yang timbul jika kondisi tubuh rileks. efek lain dari meditasi d zik ir adalah menimbul kan per ubahan kesadaran seseorang, dari kesadaran normal menuju kesadaran lain yang sering disebut sebagai altered states of consciousness (asc). menurut ludwig dalam suryabrata (2000) perubahan-perubahan yang terjadi ketika individu berada dalam kondisi asc antara lain adanya perubahan pikiran, perubahan perasaan tentang waktu, perubahan kontrol diri, persepsi, body image, dan perasaan/ pengalaman yang sulit untuk diceritakan. zat endorphine ini bisa distimulasi dengan latihan meditasi dzikir melalui konsentrasi yang mendalam pada kalimat-kalimat dzikir sehingga beberapa individu setelah melakukan dzikir merasakan keadaan psikologisnya sangat tenang dan damai. dzikir dapat juga dikatakan sebagai strategi koping untuk menghadapi berbagai kesulitan yang dihadapi manusia. dengan berdzikir individu akan memperoleh kekuatan, harapan, optimisme dan semangat bar u untuk memecahkan masalahnya, mengatasi kesulitan-kesulitan, dan menghadapinya dengan positif (hawari, 2008). dzikir akan membantu individu di dalam menghadapi kesulitan-kesulitan hidupnya, karena dengan dzikir individu melakukan penyerahan diri secara total kepada tuhan. kemudian akan menimbulkan harapan baru (new hopefulness) dan optimisme (new optimism) dengan keyakinan bahwa tuhan akan memberikan pertolongan-nya. penelit ia n i n i d id apat ka n ba hwa pasien stroke iskemik mengalami depresi yang berat dan berkepanjangan. stigmatisasi sosial akan memperparah perasaan depresi dan harga diri yang rendah (stuart & laraia, 2000). depresi yang berkepanjangan akan berdampak pada keadaan fi sik. depresi adalah kesedihan yang berkepanjangan yang ditandai dengan putus asa untuk melakukan kegiatan apapun. distres spiritual berupa harapan yang terlalu berlebihan, tidak sabar dan tidak dapat mengambil hikmah dari sakitnya, memper parah kondisi sakitnya. menur ut 114 jurnal ners vol. 7 no. 2 oktober 2012: 107–115 ronaldson (2000) pasien dengan penyakit terminal yang menjalani perawatan lama mengalami distres spiritual yang berat. depresi pasca st roke dikarenakan gangguan pada fungsi alat gerak, pada mental emosionalnya, alam perasaannya tidak stabil, terkadang marah-marah, murung dan sedih atau sebaliknya merasa gembira dan bersemangat. gangguan mental emosional tersebut sangat tidak wajar (hawari, 2008). pada penelitian ini setelah pasien diberikan model home care holistic mengalami perubahan depresi, karena pasien sudah tidak merasa rendah diri, banyak bergaul dan pasien bersemangat untuk tidak berputus asa dalam memulihkan kesehatannya disertai dengan sholat, doa dan dzikir. setelah pasien diberikan model home care holistic, pasien mengalami penurunan depresi. hasil uji beda diperoleh signifi kansi sebesar 0,000 yang artinya ada perbedaan kondisi depresi pada pasien stroke iskemik kelompok model home care holistic dengan kelompok model home care setelah intervensi. pada kelompok pasien yang mendapatkan model perawatan home care, terapi yang diberikan hanya terapi somatik (fi sik) saja sehingga dapat menimbulkan ketegangan secara psikologis (depkes, 2002). saat individu mengalami ketegangan psikologis, dirinya akan menganggap situasi yang membuat dirinya tertekan sebagai suatu ancaman sehingga akan menyebabkan dirinya merasa cemas, sedangkan apabila situasi yang membuatnya cemas terjadi berulang kali maka akan terjadi depresi. sebagaimana disampaikan caplan (2009). jika seseorang merasakan penyakit yang diderita merupakan penyakit kronis dan sulit penyembuhannya, maka pasien sering merasa gagal dalam hidupnya akibatnya mereka menjadi sedih, sensitif dan mudah marah setiap menghadapi masalah. stigmatisasi sosial akan memperparah perasaan depresi dan harga diri yang rendah (stuart & laraia, 2000). depresi yang berkepanjangan akan berdampak pada keadaan fi sik (proto, 1990). penelitian ini kelompok pasien yang mendapatkan model perawatan home care holistic menunjukkan penurunan respons depresi. hal ini dikarenakan terapi yang diberikan bukan hanya terapi somatik (fi sik) saja melainkan dengan pendekatan holistic yaitu bio-psiko-sosial-spiritual. penggunaan model tersebut akan mempercepat respons adaptif. menurut roy dikutip oleh nursalam (2008) menjelaskan bahwa tujuan asuhan keperawatan adalah mempercepat respons adaptif 4 komponen (yang meliputi adaptasi fi sik, psikologis, sosial, dan spiritual). model home care holistic diterapkan pada pasien untuk menunjang respons fi sik yang adaptif a d ala h denga n member i k a n du k u nga n terapi somatik maupun f isioterapi untuk menghilangkan keluhan-keluhan somatik (fi sik). respons psikologis yang adaptif pada pasien yang mengalami kecemasan dan atau depresi yaitu diberikan terapi kejiwaan/ psikologik ber upa psiko terapi supor tif, terapi ini dimaksudkan untuk memberikan motivasi, semangat dan dorongan agar pasien yang bersangkutan tidak merasa putus asa dan diberi keyakinan serta percaya diri bahwa ia mampu mengatasi masalah yang sedang dihadapinya dan psiko terapi kognitif dengan terapi ini dimaksudkan untuk memulihkan fungsi kognitif pasien, yaitu kemampuan untuk berfi kir secara rasional konsentrasi dan daya ingat (hawari, 2008). simpulan dan saran simpulan model h om e ca re h oli st ic ya ng menekankan pendekatan bio-psiko-sosialspiritual untuk membangun coping style yang positif, ternyata dapat memperbaiki respons psikologis yang dicerminkan oleh penurunan kecemasan dan depresi pada pasien stroke iskemik. respons psikologis tersebut dapat mencegah terjadinya proses infl amasi lebih lanjut maupun perluasan infark serebri, sehingga kecacatan akibat stroke iskemik bisa dicegah dan penderita tetap produktif. saran m o d e l h o m e c a r e h o l i s t i c direkomendasikan untuk dapat digunakan dalam asuhan keperawatan pada berbagai kasus penyakit kronis dalam memperbaiki perubahan respons psikososial dan imunitas. 115 home care holistic terhadap perubahan kecemasan (luluk widarti) perlu dukungan pembuat kebijakan d i bid a ng pelaya na n kesehat a n d ala m menerapkan model home care holistic, hal ini bisa ditetapkan oleh pimpinan instansi pelayanan dalam membuat sop (standar operasional prosedur) untuk dilaksanakan oleh semua tenaga kesehatan. kepustakaan caplan, l.r., 2009. caplan's stroke: a clinical approach. forth edition. philadelphia: elsevier inc. depkes, r.i., 2002. pedoman perawatan kesehatan di rumah. jakarta: direktorat keperawatan dan keteknisian dirjen yanmed. diwanto, m.a., 2009. tips mencegah stroke, hipertensi dan serangan jantung. yogyakarta: paradigma indonesia. hawari, d., 2001. stres, depresi dan kecemasan, sebab akibat serta penanggulangannya. al-qur'an, ilmu kedokteran jiwa dan kesehatan jiwa, dana bhakti yasa, cetakan x. hlm. 43–87. hawari, d., 2008. managemen stres, cemas dan depresi. jakarta: balai penerbit fkui jakarta. hinkle, j.l., dan guanci. 2007. acute ischemic stroke review. journal neuroscience nursing. hlm. 285–310. lumanthobing, s.m., 2007. stroke bencana peredaran darah di otak. jakarta: balai penerbit fakultas kedokteran universitar indonesia. nursalam, 2008. proses dan dokumentasi ke p e ra wa ta n. ja k a r t a : sa le mb a medika. nursalam, 2005. efek pak ar terhadap respons kognisi dan biologis pada pasien terinfeksi hiv. disertasi tidak dipublikasikan. surabaya: universitas airlangga. proto, l., 1990. self healing. how to use your mind to heal your body. great britain: angus and robertson. ronaldson, s., 2000. spirituality. the hearth of nursing. melbou r ne: au smed publication. pp. 5–23. sch neck, m.j., 1998. acute stroke: an aggresive approach to intervention and prevention. hospital medicine. pp. 11–28. st u a r t, g.w. d a n la raia , m.t., 20 0 0. psychiatric nursing. st. louis: mosby. suryabrata, s., 2000. psikologi kepribadian. jakarta: raja grafi ndo persada. sustrani, l.a., alam, s., dan hadibroto, i., 2004. stroke. jakarta: pt gramedia pustaka umum. 169 stres dapat mengganggu proses spermatogenesis pada mencit (stress can undermine the process of spermatogenesis in mice) yuni sufyanti arief fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya, e-mail: yuni_psik@yahoo.com abstract introduction: this study aimed to determine the effect of stress on the process of spermatogenesis and testosterone levels of mice (mus musculus) male. method: this was an experimental study using a completely randomized design. the variables examined were the number of spermatogenic cells (spermatogonia, spermatocytes, and spermatids oval) and testoseron levels. data analysis using oneway analysis of variance (anova), test a small real difference (lsd) 5%, and the kruskal wallis test. this study used 36 mice (mus musculus) male age 2 months with 20–40 gram body weight divided into 4 groups. the control group (subcutaneous injection of 0.1 ml physiological saline), subcutaneous epinephrine injection group 0.001 mg/20 g bw, subcutaneous epinephrine injection group 0.005 mg/20 g bw, the subcutaneous injection of epinephrine 0.01 mg/20 bb gr. result: the results show that the analysis of spermatogenic cells (spermatogonia, spermatocytes, and spermatids oval), that repeated exposure to epinephrine with different doses showed that there was a signifi cant decrease. the average decline in a row in the treated group (p1, p2, p3) compared with the control group (k0) for spermatogonia was 28.8%, 42.4%, 45.5%, to spermatocytes was 13.7%, 37.4%, 38.9% and for oval spermatids was 33.3%, 44.2%, 50.4% having followed by lsd 5% found that there were signifi cant differences for almost all groups except the pair p2–p3 groups for the number of spermatogonia, spermatocytes, and partner groups p1–p2 and p2–p3. as for the blood serum levels of testosterone hormone mice showed no signifi cant decrease. discussion: administration of high doses of epinephrine (as stressor) can lead to bottlenecks in the process of spermatogenesis as indicated by decreased number of spermatogenic cells but not cause a decrease in testosterone levels. key words: epinephrine, spermatogonia, spermatocytes, spermatids, testosterone pendahuluan stres, dapat dialami individu dalam kehidupan sehari-hari. stres didefinisikan sebagai respons nonspesifi k dari organisme atau sebagai respons tubuh terhadap stimulus baik eksternal maupun internal yang dikenal fi ght or fl ight response. stimuli yang dapat menimbulkan respons tubuh disebut stresor (ganong, 2001). stresor baik fisik, kimia, maupun psikologis dapat mengaktifkan sistem saraf simpatis dan respons adrenal. aktivasi sistem saraf simpatis oleh stresor menyebabkan pelepasan neurotransmiter norepinefrin (ne) lokal pada ujung saraf simpatis postganglionik, sedang aktivasi stresor pada medula adrenal merangsang lepasnya epinefrin (e) ke dalam sirkulasi. epinefrin mempunyai sifat yang unik yaitu menstimulasi sejumlah ne, di mana ne yang dilepaskan akan diduplikasi dan dikuatkan oleh e yang mencapai tempat yang sama melalui sirkulasi (ganong, 2001; cunningham, 2002). selain meningkatkan kadar e, ne dan dopamin, stresor juga dapat meningkatkan kadar kortikosteroid. perbedaan jenis stresor menimbulkan respons endokrin yang berbeda pada berbagai intensitas yang berbeda. variasi respons spesies terhadap stresor dapat dipengaruhi oleh berbagai faktor yaitu: usia, jenis kelamin, dan kondisi spesies tersebut. di samping itu variasi respons juga dapat dipengaruhi oleh waktu terjadinya stressor tersebut, baik akut maupun kronik. peningkatan kadar e dan ne dapat meningkatkan pulsasi hipotalamus. peningkatan pulsasi ini dapat merangsang lepasnya jurnal ners vol. 6 no. 2 oktober 2011: 169–174 170 gonadotropin releasing hormone (gnrh) dari hipotalamus ke sistem portal menuju ke hipofisis anterior. adanya peningkatan gnrh akan merangsang lepasnya 2 macam gonadotropin dari hipofisis anterior yaitu follicle stimulating hormone (fsh) dan luteinizing hormone (lh), di mana lh lebih sensitif terhadap perubahan gnrh (guyton, 2000). secara normal gnrh disekresi dalam pulsasi yang episodik. hal ini penting bagi sekresi normal fsh dan lh (ganong, 2001). pada berbagai penelitian dapat ditunjukkan bahwa perubahan sekresi fsh dan lh dipengaruhi oleh pengeluaran gnrh secara pulsatil dengan frekuensi dan amplitudo dalam batas kritis. akan tetapi bila amplitudo dan frekuensi pulsasi gnrh ditingkatkan secara berlebihan dapat menurunkan dan menghentikan sekresi dari gonadotropin. hal ini telah dibuktikan dengan penelitian pada kera yang diberi gnrh 1 mikrogram per menit untuk 6 menit setiap jamnya (1 pulsasi per jam) menghasilkan konsentrasi di dalam darah portal kurang lebih sama dengan puncak konsentrasi di dalam darah portal manusia ± 2mg/ml. kenaikan frekuensi pulsasi gnrh menjadi 2 dan 5 pulsasi perjam dapat menghentikan sekresi gonadotropin. peningkatan pulsasi gnrh akan merangsang penekanan konsentrasi lh dan fsh. peningkatan ini akan memicu terjadinya pengaturan yang tertekan (down regulation) sehingga dapat memicu terjadinya proses internalisasi yang berarti hilangnya reseptor dari membran dan berkurangnya fungsi secara biologis. di samping itu bila gnrh diberikan dengan infus tetap maka reseptor gnrh dalam hipofi sis ditekan dan sekresi lh turun ke nol tetapi bila gnrh diberi secara episodik maka sekresi lh dirangsang (ganong, 2001). proses spermatogenesis dikendalikan oleh suatu poros hipotalamus, hipofi sis dan testis (ganong 2001). gonadotropin releasing hormone dilepaskan oleh ujung-ujung saraf dari hipotalamus yang berdekatan dengan jala kapiler utama dari sistem portal hipofi sis. melalui pembuluh portal yang panjang hormon tersebut sampai pada sasarannya yaitu hipofi sis anterior. jadi hormon utama yang mengatur fungsi testis adalah hormon gonadotropin yang dihasilkan oleh bagian anterior dari kelenjar hipofi sis. hilangnya hormon gonadotropin ini mempunyai dampak pada berhentinya proses spermatogenesis, atropi testis dan tenunan testis menjadi lunak. folicle stimulating hormone (fsh) memegang peranan penting di dalam mengatur fungsi testis. terhadap sel sertoli, adenilsiklase dirangsang hormon gonadotropin ini sehingga sintesis siklik amp (camp) dari atp meningkat. selanjutnya camp merangsang protein kinase dan proses fosforilasi protein pengikat androgen (abp). satu hormon yang juga tidak kalah penting peranannya di dalam mengatur fungsi testis adalah luteinizing hormone (lh). oleh karena organ sasarannya adalah sel-sel interstitial dari testis maka lh seringkali disebut sebagai interstitial cell stimulating hormone (icsh). aktivitas adenilsiklase dan meningkatnya kadar siklik amp dirangsang dengan adanya lh, setelah hormon ini mengadakan ikatan dengan reseptor pada dinding sel leydig. di bawah pengaruh lh sel leydig kemudian mensintesis testosteron. testosteron dan fsh bekerja secara sinergis untuk mendorong perubahan spermatosit primer menjadi spermatosit sekunder kemudian memasuki meiosis menghasilkan spermatid dan diikuti oleh proses spermiogenesis. dengan demikian dapat dikatakan bahwa spermatogenesis dikendalikan oleh interaksi antara hormon testosteron, fsh dan lh. adanya gangguan pada interaksi hormon testosteron, fsh dan lh akan menyebabkan gangguan pada proses spermatogenesis. terganggunya proses spermatogenesis merupakan salah satu penyebab terjadinya infertilitas. s e j a u h i n i b e l u m a d a p e n e l i t i a n yang secara jelas melaporkan apakah stres yang dalam penelitian ini menggunakan pemberian epinefrin akan mengganggu proses spermatogenesis. berdasarkan fenomena tersebut penelitian ini bertujuan untuk mengetahui sejauh mana pengaruh stres dapat mengganggu proses spermatogenesis. stres dapat mengganggu proses spermatogenesis (yuni sufyanti arief) 171 bahan dan metode penelitian ini termasuk penelitian eksperimen yang dilakukan di laboratorium. rancangan yang dipergunakan dalam penelitian ini adalah rancangan acak lengkap (ral). penelitian ini dilakukan pada mencit jantan dengan 9 kali ulangan. data yang dianalisis adalah jumlah sel spermatogenik dan kadar testosteron untuk setiap kelompok perlakuan. data disajikan dalam bentuk histogram (diagram batang) dan tabel. untuk mengetahui adanya pengaruh yang bermakna atau tidaknya perbedaan semua perlakuan dilakukan data dianalisis dengan menggunakan one-way analysis of variance (anova) satu arah pada taraf signifi kansi p < 0,05. jika dari hasil analisis varians didapatkan adanya pengaruh perlakuan (dengan nilai p < 0,05) terhadap jumlah sel spermatogenik, dan kadar hormon testosteron, dilanjutkan dengan uji lsd (bnt = beda nyata terkecil) untuk mengetahui bermakna tidaknya beda antar pasangan perlakuan. pada data dengan distribusi yang tidak normal digunakan uji kruskal wallis untuk mengetahui adanya pengaruh yang bermakna atau tidaknya perbedaan antar kelompok. pembahasan hasil penelitian tentang pengaruh stres (pemberian epinefrin) berulang pada jumlah sel spermatogonium, spermatosit, dan spermatid oval, menunjukkan adanya perbedaan penurunan yang nyata. uji anova pada keempat kelompok didapatkan perbedaan yang signifi kan, hal ini menunjukkan bahwa semakin tinggi dosis epinefrin yang diberikan semakin menurun jumlah sel spermatogeniknya (spermatogonium, spermatosit, dan spermatid oval). tubulus seminiferus merupakan bagian utama penyusun testis selain jaringan ikat dan pembuluh darah testis. di dalam tubulus ini diproduksi spermatozoa sebagai hasil pembelahan dari sel-sel epitel germinalis yang berurutan, membentuk sel-sel baru yang arah perkembangan selnya menuju ke lumen tubulus seminiferus. kemudian akan terbentuk spermatozoa yang bergerak bebas pada lumen tabel 1. analisis jumlah spermatogonium untuk kelompok kontrol, kelompok perlakuan yang diberi injeksi subkutan epinefrin dosis 0,001 mg/20 gram bb, dosis 0,005 mg/20 gram bb dan dosis 0,01 mg/20 gram bb. kelompok rata-rata ± sd nilai minimum nilai maksimum anova ko (kontrol) 50,02 ± 6,91 41,60 63,80 f= 37,403 p = 0,000* p1 35,62 ± 4,36 30,40 42,00 p2 28,91 ± 5,16 24,20 39,80 p3 27,24 ± 3,18 22,40 33,00 keterangan: *signifi kan pada α 0,05 tabel 2. analisis jumlah spermatosit untuk kelompok kontrol, kelompok perlakuan yang diberi injeksi subkutan epinefrin dosis 0,001 mg/20 gr bb, dosis 0,005 mg/20 gr bb dan dosis 0,01 mg/20 gr bb kelompok rata-rata ± sd nilai minimum nilai maksimum anova ko (kontrol) 58,82 ± 7,05 48,00 73,60 f = 29,663 p = 0,000 p1 50,76 ± 5,85 42,40 61,80 p2 36,84 ± 6,19 28,80 47,40 p3 35,89 ± 5,33 29,80 44,80 keterangan: *signifi kan pada α = 0,05 hasil jurnal ners vol. 6 no. 2 oktober 2011: 169–174 172 tersebut dan berlangsung secara normal jika tidak ada gangguan. pemberian obat atau zat yang bersifat toksik yang dapat memengaruhi proses spermatogenesis tersebut maka akan terjadi g a n g g u a n p a d a s a a t p e m b e l a h a n a t a u perkembangan dari sel epitel germinalis sampai menjadi spermatozoa. terganggunya proses spermatogenesis secara histologis dapat dilihat dari jumlah dan ukuran sel-sel spermatogenik penyusun tubulus seminiferus yang berkurang dan berubah, terputusnya perkembangan sel pada salah satu tahapan dan terjadinya pelepasan sel-sel germinalis. proses diferensiasi sel spermatogonia terjadi sangat kompleks di dalam tubulus seminiferus. tubulus dikelilingi oleh jaringan interstitial khususnya sel leydig yang merupakan sumber testosteron beserta fsh merupakan hormon pengatur proses spermatogenesis. dengan kata lain bahwa untuk berlangsungnya proses spermatogenesis yang normal diperlukan adanya hormon lh dan fsh. hormon lh bekerja secara langsung pada sel leydig untuk menghasilkan hormon testosteron, sedangkan hormon yang langsung bekerja pada epitel tubulus seminiferus adalah testosteron dan fsh. hormon fsh diperlukan pada saat permulaan proses spermatogenesis yang disebut spermatositogenesis di mana pada fase ini spermatogonia akan berkembang menjadi spermatosit dan diakhiri dengan terbentuknya spermatid. sementara itu, sel sertoli yang merupakan sel target dari hormon testosteron akan didorong untuk menghasilkan abp. ganong (2001) menyatakan bahwa fungsi utama sel sertoli yang dipengaruhi oleh testosteron antara lain adalah mendorong sintesis abp, sintesis inhibin, sintesis glikoprotein dan metabolisme energi untuk menghasilkan asam laktat yang merupakan salah satu sumber energi utama sel-sel spermatogenik. jika terjadi gangguan pada sel sertoli yang merupakan sel pendukung dan pemberi nutrisi bagi sel-sel spermatogenik akan mengakibatkan terjadinya hambatan perkembangan sel spermatogenik dalam tubulus seminiferus. penurunan jumlah sel spermatogenik di sebabkan karena penambahan kadar epinefrin dari luar akibat injeksi dari luar epinefrin dapat meningkatkan pulsasi hipotalamus yang dapat merangsang lepasnya gnrh dari hipotalamus ke sistem portal menuju ke hipofi sis anterior. menurut guyton (2000) katekolaminergik bekerja dengan meningkatkan frekuensi rangsangan dan amplitude gnrh. peningkatan pulsasi gnrh ini akan mengakibatkan penurunan sekresi gonadotropin (lh dan fsh), berdasarkan penjelasan tersebut menunjukkan bahwa pemberian stres fi sik berupa suntikan subkutan dan stres kimiawi berupa injeksi epinefrin berulang dapat menurunkan kadar fsh sehingga tidak mampu bekerja sama dengan testosteron untuk menstimulasi sel sertoli untuk membentuk protein khusus, yaitu abp yang berguna untuk mengangkut dan mengkonsentrasikan testosteron guna proses spermatogenesis tersebut. penurunan kadar fsh disebabkan karena katekolamin (epinefrin) yang dihasilkan oleh stimulasi akibat stressor fi sik dapat mengaktifkan sistem saraf simpatis untuk melepaskan neurotransmitter norepinefrin lokal pada ujung saraf simpatis postganglionik, sedangkan stressor pada medula merangsang pelepasan epinefrin ke sirkulasi (antony, 1995). dengan demikian peningkatan kadar tabel 3. analisis jumlah spermatid oval untuk kelompok kontrol, kelompok perlakuan yang diberi injeksi subkutan epinefrin dosis 0,001 mg/20 gram bb, dosis 0,005 mg/20 gram bb dan dosis 0,01 mg/20 gram bb. kelompok rata-rata ± sd nilai minimum nilai maksimum anova ko(kontrol) 114,07 ± 16,75 93,40 145,20 f = 21,98 p = 0,000 p1 76,04 ± 15,85 43,80 102,20 p2 63,69 ± 20,57 37,60 90,20 p3 56,56 ± 10,95 33,20 73,00 keterangan: *signifi kan pada α = 0,05 stres dapat mengganggu proses spermatogenesis (yuni sufyanti arief) 173 e ini dapat meningkatkan pulsasi hipotalamus dan selanjutnya akan memengaruhi pulsasi dari gnrh. peningkatan pulsasi gnrh ini akan merangsang penekanan konsentrasi lh dan fsh. guyton (2000) menyebutkan bahwa pemberian e menimbulkan efek mirip stimulasi saraf adrenergik. pemberian e dapat menimbulkan gejala seperti perasaan takut, khawatir, gelisah, tegang, nyeri, kepala berdenyut, tremor, rasa lemah, pusing, pucat, sukar bernapas dan palpitasi. pemberian e juga akan menyebabkan vasokonstriksi dari pembuluh darah sistemik, sebagai akibatnya suplay darah menuju testis akan menurun dan pada akhirnya fungsi testis akan terganggu sehingga proses spermatogenesis juga akan terganggu. penurunan jumlah sel spermatogenik akibat pemberian e. dengan demikian poros hipotalamus-hipofisis-testis terpengaruh oleh pemberian e di dalam mensekresi hormon yang dihasilkannya terutama hormon gonadotropin. selain itu penurunan jumlah sel spermatogenik dimungkinkan juga disebabkan karena pemberian e akan menyebabkan vasokonstriksi dari pembuluh darah sehingga suplai darah ke testis akan menurun yang menyebabkan fungsi testis terganggu dan pada akhirnya proses spermatogenesis akan terganggu. b e r d a s a r k a n h a s i l u j i b n t didapatkan data bahwa penurunan jumlah sel spermatogonium dan spermatosit tidak menunjukkan perbedaan yang nyata pada pasangan kelompok yang diberi e dosis 0,005 mg/20 gram bb dan dosis 0,01 mg/ 20 gram bb (p2–p3), dan penurunan jumlah sel spermatid oval juga tidak menunjukkan penurunan yang nyata pada pasangan kelompok yang diberi e dosis 0,001 mg/20 gram bb dan dosis 0,005 mg/20 gram bb (p1–p2) dan pasangan kelompok yang diberi e dosis 0,005 mg/ 20 gram bb dan dosis 0,01 mg/20 gram bb (p2–p3). hal ini berarti bahwa pemberian e dosis 0,005 mg/20 gram bb merupakan dosis maksimal yang menyebabkan penurunan jumlah spermatogonium, spermatosit dan spermatid oval. menurut guyton (2000) bahwa pemberian e harus diberikan pada dosis terapi yang tepat. pemberian dosis yang berlebihan akan menyebabkan efek stimulasi saraf adrenergik yang berlebihan. arif (1999) menyebutkan bahwa dosis terapi maksimal e yang dapat diberikan pada hewan coba adalah 0,001 mg/20 gram bb. sehingga pemberian e dosis 0,005 mg/20 gram bb sudah merupakan dosis yang maksimal yang dapat menyebabkan penurunan jumlah sel spermatogenik. simpulan dan saran simpulan hasil penelitian tentang stres (pemberian epinefrin) terhadap jumlah spermatogonium, spermatosit primer, spermatid oval, dan kadar hormon testosteron dapat disimpulkan bahwa stres dalam hal ini pemberian epinefrin menurunkan jumlah sel spermatogenik (spermatogonium, spermatosit, dan spermatid oval), dengan penurunan masing-masing kelompok perlakuan (p1, p2, p3) dibandingkan dengan kontrol(k0) untuk spermatogonium adalah 28,8%, 42,4%, 45,5%, untuk spermatosit adalah 13,7%, 37,4%, 38,9% dan untuk spermatid oval adalah 33,3%, 44,2%, 50,4%. saran h a s i l p e n e l i t i a n i n i m e m b e r i k a n informasi pada pelayanan kesehatan bahwa stres yang berkepanjangan dapat menganggu kesehatan reproduksi sehingga meningkatkan kejadian infertilitas. peneliti memberikan saran agar dilakukan penelitian serupa untuk jangka waktu yang lama yang disertai dengan pengukuran kadar kortisol maupun fsh dan lh yang berguna untuk melihat pengaruh lebih lanjut terhadap fertilitasnya. kepustakaan antony, 1995. endocrinology of the male reproductive sistem, (online), (http// www.endotext.org/male/male2/male1. htm., diakses tanggal 5 agustus 2006). arief, m., triyanti kuspuji, savitri rakhmi, wardhani wahyu ika, setiowulan luiwik, 1999. kapita selekta kedokteran. jakarta: media aesculapius. jurnal ners vol. 6 no. 2 oktober 2011: 169–174 174 cunningham, g., 2002. textbook of veterinay physiology, 3rd edition. wb. souinders company. philadhelpia pp: 356–357. ganong, w.f., 2001. review of medical physiology, 20th ed. appleton and large, stanford, connectut, pp 545–567. guyton, a.c., 2000. texbook of medical physiology, 10th ed. west washington aquare: wb saunder company, pp: 1284–1298. ismudiono, 1999. fisiologi reproduksi pada ternak. edisi 2, surabaya: fakultas k e d o k t e r a n h e w a n u n i v e r s i t a s airlangga, hlm 70–79. johnson, h., m., j. everitt, 2000. essential reproduction. fifth edition, blackwell science ltd, 53–68, 102–103. kusumawati, d., 2003. bahan ajar tentang hewan coba. surabaya: fakultas k e d o k t e r a n h e w a n u n i v e r s i t a s airlangga, hlm. 11–2, 22, 67, 87. prato, f.s., choleris, e., thomas, a.w., moran, g.r., 2001. behavioural stress responses of mice may be sensitive to weak, ambient elf magnetic fi elds on the order of 0.1 ut. bioelectromagnetics society, 23rd annual meeting, 11–14 june, st. paul, mn, sugiyono, wibowo eri, 2001. statistik penelitian dan aplikasinya dengan spss 10.0 for windows, bandung: alfabeta. ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 171 perubahan perilaku dan fungsi kognitif dengan terapi perilaku kognitif pada penderita napza (the changes of behaviors and cognitive functions by cognitive behavioural therapy in the drug abusers) herni susanti fakultas ilmu keperawatan universitas indonesia, kampus baru ui depok 16424, email: herni-s@ui.ac.id abstract introduction: this study was aimed to fi nd out the effect of cbt on the behaviors i.e. depressive, agressive and antisocial behaviors as well as cognitive functions of patients who were treated in rehabilitation unit at a drug addiction hospital (rumah sakit ketergantungan obat) in jakarta. method: the research design was quasi experimental pre-post test without control group by providing intervention: cbt for 6 sessions (10–12 times intervention). the population was all patients in the rehabilitation unit with a nursing diagnosis: low self esteem and/or inffective coping strategies. there were 23 participants who involved in this investigation. the data was analized by using dependent and independent sample t, and anova tests. result: the results showed that p value for depressive bahaviours, agressive behaviurs, antisocial behaviors, and cognitive functions were 0.914; 0.001; 0.039; 0.003 respectively. the outcomes indicated that there was signifi cant impact of cbt on agressive behaviors, antisocial behaviors, and cognitive functions (α = 0.05, p value < 0.05), but not on depressive behaviors (α = 0.05, p value > 0.05). discussion: it is argued that depressive symptoms might not be apparent for the users in rehabilitative phase. the fi ndings also showed that there was signifi cant relation between antisocial behaviors and the length of drug usage. this affi rms exsiting concepts in that long drug usage brings about serious damage in the users' behaviors and cognitive functions. it is recommended, therefore, to include cbt as an important intervention for clients with drug abuse problems who are cared in rehabilitation center. keywords: drugs abuse, behaviors, cognitive functions pendahuluan penyalahgunaan napza (narkotika, alkohol, psikotropika dan zat adiktif lainnya) saat ini sudah menjadi masalah nasional. hal ini terjadi karena semakin meningkatnya anggota masyarakat yang menyalahgunakan napza. jenis napza yang banyak digunakan adalah heroin yaitu jenis opiat semi sintetik (putaw), dilanjutkan cannabis, amfetamin, dan alkohol. berdasarkan penelitian yang dilakukan badan narkotika nasional (bnn) dan universitas indonesia ditemukan bahwa angka penyalahguna napza meningkat dari 3,2 juta jiwa pada tahun 2003 menjadi 3,6 juta jiwa pada tahun 2008 (bnn, 2009). beberapa penelitian menunjukkan bahwa penyalahgunaan napza, membawa dampak buruk terhadap perilaku dan fungsi kognitif para penggunanya (bergen, et al., 2003; dulin, hill, dan ellingson, 2006; thomas dan rockwood, 2001). dampak terhadap perilaku meliputi munculnya perilaku depresif (isolasi diri dari lingkungan, kurangnya kegiatan perawatan diri), perilaku agresif dan perilaku antisosial (mengganggu ketertiban). dampak terhadap fungsi kognitif terutama munculnya pikiran-pikiran negatif seperti percaya dirinya menjadi orang tidak berguna, bersalah, tidak berdaya dan tidak dapat dipercaya. selain itu, para penyalahguna napza umumnya juga memiliki pemikiran yang menolak dirinya sedang memiliki masalah (denial) atau menganggap remeh masalah yang sedang dihadapinya (minimisasi). apabila jurnal ners vol. 5 no. 2 oktober 2010: 171–180 172 dampak-dampak ini tidak ditangani dengan serius, muncul masalah yang lebih kompleks seperti bunuh diri, kekerasan dalam keluarga, kriminalitas, dan pelecehan seksual. terapi perilaku kognitif (tpk) adalah salah satu terapi spesialis keperawatan jiwa yang dapat diberikan pada semua klien penyalahguna napza (stuart, 2009). terapi perilaku kognitif merupakan sebuah proses perlakuan yang memungkinkan individu untuk mengoreksi kepercayaan diri yang salah yang dapat menimbulkan perasaan dan tingkah laku negatif. tpk juga berlandaskan konsep bahwa manusia berpikir memengaruhi bagaimana manusia bertingkah laku, serta apa yang dilakukan oleh klien akan memengaruhi pikirannya. berdasarkan hal ini, tpk dianggap sangat sesuai untuk mengatasai masalah perilaku dan kognitif yang muncul akibat penyalahgunaan napza seperti yang telah diuraikan. hasil studi literatur yang dilakukan peneliti menunjukkan bahwa studi tentang tpk pada penyalahguna napza baru dilakukan di luar indonesia (barrowclough, 2002; kadden, 2002; ouimette, 1997; castelanos dan conrod, 2006). tpk saat ini sedang dikembangkan di keilmuan keperawatan jiwa fik-ui, dan hanya dilakukan untuk klien gangguan jiwa (sasmita, 2007; fauziah; 2009; susanti dan wardani, 2009). berdasarkan hal tersebut, peneliti tertarik untuk melakukan penelitian yang bertujuan untuk mengetahui sejauh mana pengaruh tpk terhadap perilaku (depresif, agresif dan antisosial) serta fungsi kognitif klien penyalahguna napza di jakarta, khususnya yang sedang mendapatkan perawatan di rumah sakit ketergantungan obat (rsko) jakarta. hasil penelitian ini diharapkan menjadi pedoman pelaksanaan tpk dalam memberikan asuhan keperawatan pada klien dengan masalah penyalahgunaan napza untuk semua perawat di unit rehabilitasi napza. selain itu, hasil ini juga dapat dijadikan bahan pertimbangan untuk menyusun program berskala nasional dalam penanggulangan masalah penyalahgunaan napza yang melibatkan tenaga kesehatan profesional. bahan dan metode penelitian ini menggunakan desain quasi experimental pre-post test without control group dengan intervensi tpk. alasan tanpa kontrol karena jumlah pasien yang termasuk kriteria inklusi terbatas. populasi target pada penelitian ini adalah seluruh pasien yang sedang menjalani perawatan di ruang rehabilitasi rsko jakarta, yang memiliki diagnosa keperawatan gangguan konsep diri: harga diri rendah dan/atau koping individu tidak efektif. sampelnya adalah total sampling yang memenuhi kriteria inklusi, yaitu dewasa, pendidikan minimal sd, kondisi emosi stabil, dan bersedia terlibat dalam penelitian (tidak mengganggu program kegiatan lain di ruangan). sampel pada penelitian ini adalah 34 klien, namun hanya 23 yang berhasil mengikuti program tpk sampai selesai. penelitian dilakukan di ruang rehabilitasi rsko jakarta. penelitian dilaksanakan mulai dari awal bulan oktober 2010 sampai dengan mei 2011. pengumpulan data dan pemberian terapi dilaksanakan mulai tanggal 15 nopember 2010 sampai 15 april 2011. kegiatan pengumpulan data dan pemberian terapi dilaksanakan dengan melibatkan perawat yang bertugas di ruang rehabilitasi rsko jakarta untuk pemberian terapi generalis (terapi ini yang merupakan syarat diberikannya terapi spesialis: tpk). selanjutnya klien diberikan tpk oleh terapis yang terdiri dari peneliti dan perawat rsko yang telah mengikuti pelatihan tpk. sebagai tambahan informasi, sebelum proses pemberian terapi dilakukan pelatihan kepada perawat rsko untuk penyamaan persepsi dan intervensi. satu responden rata-rata yang dibutuhkan dari mulai pre-test, pemberian tindakan generalis, pemberian tpk, dan post-test adalah 6 sampai 12 kali pertemuan (satu hari pre-test sekaligus terapi generalis, 4–10 hari tpk dari sesi i–v dengan rerata 1–2 kali untuk setiap sesi, dan satu hari untuk post-test). waktu yang bervariasi ini sangat ditentukan oleh kondisi responden dan terapis, mengingat dari kelima sesi tpk ada yang dapat dilakukan satu sesi dalam satu hari, namun ada pula kondisi yang perubahan perilaku dan fungsi kognitif dengan terapi perilaku kognitif (herni susanti) 173 mengharuskan dilakukan satu sesi dalam dua hari (misalnya jika perkembangan klien tidak signifi kan dan sesi perlu diulang). alat pengumpul data terdiri dari tiga instrumen. instrumen a merupakan instrumen untuk mendapatkan gambaran karakteristik responden antara lain terdiri dari: usia, jenis kelamin, pendidikan, pekerjaan, status perkawinan, jenis napza dan lama menggunakan napza. bentuk pertanyaan dalam pertanyaan tertutup, dan peneliti memberi angka pada kotak yang tersedia, sesuai dengan pilihan yang dipilih oleh responden. jumlah pertanyaan ada 7 pertanyaan. instrumen b merupakan instrumen yang dipakai untuk mengukur tentang perilaku klien penyalahguna napza, terdiri dari instrumen b1 (depression scale menurut center for epidemiological studies depressed mood scale (ces-d) dari radloff (1977) dalam applied psicological measurement volume 1 no. 3, 2008, instrumen b2 (aggressive scale (chamberlain, 2009) dan instrument b3 (anti sosial scale (halaby, 2007). jumlah pertanyaan intrumen b1 adalah 20 pertanyaan, instrumen b2 29 pertanyaan, dan instrumen b3 sebanyak 26 pertanyaan. perlu disampaikan di sini bahwa rentang nilai untuk semua instrumen perilaku 0–100, di mana semakin tinggi nilai berarti semakin berkurang perilaku maladaptif yang dimaksud. penilaian seperti ini terjadi karena bentuk pertanyaanpertanyaan yang ada dalam instrument bersifat negatif. kuesioner c untuk mengukur fungsi kognitif responden. kuesioner ini berjumlah 20 pertanyaan yang dikembangkan oleh peneliti sendiri berdasarkan studi literatur ekstensif terkait karakteristik penyalahguna napza (fountaine, 2009; stuart, 2009; townsend, 2009). pelaksanaan tpk dilakukan berdasarkan panduan modul tpk untuk klien penyalahguna napza yang dikembangkan sendiri oleh peneliti berdasarkan bahan modul tpk sebelumnya (fauziah, 2009; sasmita, 2007). uji coba instrumen dilakukan di unit rehabilitasi napza rumah sakit marzoeki mahdi bogor pada 13 klien. rencana awal klien yang akan diujikan 15 orang, namun karena ada dua klien yang sudah pulang maka jumlah berkurang. uji reabilitas menunjukkan nilai α crombach berturut-turut: kuesioner b1 = 0,568; kuesioner b2 = 0,846; kuesioner b3 = 0,865; kuesioner c = 0,746. dikatakan reliabel jika nilai α crombach ≥ 0,6. oleh karena itu kuesioner b, b2, b3 dan c bisa dikatakan reliabel kaena mempunyai nilai α crombach ≥ 0,6. uji validitas pada semua instrumen menunjukkan adanya beberapa pertanyaan yang tidak valid (nilai r rata-rata lebih kecil dari r tabel = 0,553). berdasarkan hasil di atas, peneliti meninjau kembali instrumen tersebut dan menemukan bahwa ada beberapa pernyataan yang kurang dipahami tata bahasanya. selanjutnya dilakukan perbaikan berdasarkan diskusi dengan perawat yang sudah sangat berpengalaman di ruang rehabilitasi napza, sebelum akhirnya didistribusikan kepada calon responden. proses pemberian tpk dimulai dengan meminta kesediaan responden yang memenuhi kriteria inklusi menjawab pertanyaan pre-test. kemudian responden diberikan terapi generalis oleh peneliti maupun perawat ruangan. responden diberikan terapi spesialis (tpk) apabila indikasinya kuat yaitu setelah diberikan terapi generalis. pada beberapa klien setelah dilakukan terapi generalis, indikasi tpk tidak adekuat (tidak ada lagi masalah dalam fungsi kognitif terkait penyalahgunaan napza) maka klien tersebut gagal dijadikan responden. sebagai tambahan informasi, kondisi drop out juga terjadi karena klien diharuskan pulang (ada 9 klien yang terhenti menjadi responden karena kondisi tersebut). selanjutnya dilakukan post-test setelah responden selesai diberikan tpk. hasil usia responden dari 23 orang terbanyak berada pada usia antara 20–40 tahun (87%); jenis kelamin terbanyak adalah laki-laki yaitu sebanyak 19 orang (82,6%). pendidikan responden terbanyak berasal dari sma yaitu 11 orang (47,8%). sebagian besar responden tidak bekerja yaitu sebanyak 9 orang (39,1%). status perkawinan terbanyak adalah tidak menikah yaitu 18 orang (78,3%). mayoritas lama responden menyalahgunakan napza adalah 6–10 tahun yaitu sebanyak 13 orang jurnal ners vol. 5 no. 2 oktober 2010: 171–180 174 dan paling sedikit adalah lebih dari 20 tahun yaitu sebanyak 3 orang. adapun tentang jenis napza yang digunakan, semua responden lebih dari satu jenis, yaitu gabungan 3–4 zat yaitu opiat, ganja, kokain dan alkohol. hasil analisis untuk variabel perilaku agresif sebelum mengikuti tpk, didapatkan rerata sebesar 60,74 yang diyakini bahwa rerata perilaku depresif responden berada pada rentang antara 42 sampai 74, dengan standard deviasi 6,716. rerata perilaku agresif sebelum dilakukan tpk adalah 55,57 dengan rentang antara 34–73 dan standar deviasi 9,885. rerata perilaku antisosial sebelum dilakukan tpk adalah 68,22 dengan nilai minimal 45 dan nilai maksimal 84 dengan standar deviasi 10,651. sedangkan nilai fungsi kognitif sebelum dilakukan tpk adalah 32,26 dengan nilai minimum 19 dan nilai maksimum 43 dengan standar deviasi 6,362. hasil analisis untuk variabel perilaku agresif setelah mengikuti tpk, didapatkan rerata sebesar 60,87 yang diyakini bahwa rerata perilaku agresif responden berada pada rentang antara 53 sampai 70, dengan standard deviasi 4.985. rerata perilaku agresif setelah dilakukan tpk adalah 66,00 dengan rentang antara 52–87 dan standar deviasi 9.487. rerata perilaku antisosial setelah dilakukan tpk adalah 76,61 dengan nilai minimal 59 dan nilai maksimal 95 dengan standar deviasi 9,694. sedangkan nilai fungsi kognitif setelah dilakukan tpk adalah 36,17 dengan nilai minimum 25 dan nilai maksimum 46 dengan standar deviasi 4,386. analisis bivariat dilakukan dengan menggunakan uji statistik dependent sample ttest (paires t test) untuk mengetahui perubahan nilai perilaku depresif, perilaku agresif, perilaku antisosial, dan fungsi kognitif sebelum dan sesudah diberikan tpk. hubungan antara usia dengan perubahan nilai perilaku depresif, perilaku agresif, perilaku antisosial, dan fungsi kognitif digunakan analisis uji regresi linier sederhana. sedangkan untuk mengetahui hubungan antara jenis kelamin dan status perkawinan dengan perubahan nilai perilaku depresif, perilaku agresif, perilaku antisosial, dan fungsi kognitif digunakan uji independent sample t-test. untuk pendidikan, pekerjaan, lama menyalahgunakan napza dengan perubahan nilai perilaku depresif, perilaku agresif, perilaku antisosial, dan fungsi kognitif digunakan uji anova. pengaruh tpk terhadap nilai perilaku depresif, perilaku agresif, perilaku antisosial, dan fungsi kognitif menunjukkan bahwa hanya perilaku depresif yang tidak mengalami perubahan yang signifi kan antara sebelum dan sesudah pemberian tpk dengan nilai p value sebesar 0,914 (p value > 0,05). sedangkan untuk variabel yang lain (perilaku agresif, perilaku antisosial dan fungsi kognitif) menunjukkan adanya perubahan positif yang signifi kan antara sebelum dan sesudah perlakukan tpk dengan p value < 0,05. analisa terhadap hubungan setiap komponen karakteristik dengan perubahan perilaku depresif, agresif, antisosial serta fungsi kognitif menunjukkan tidak adanya korelasi bermakna, kecuali antara lama penggunaan napza dengan perubahan perilaku antisosial. rerata nilai perilaku antisosial pada mereka yang menyalahgunakan napza selama 1–5 tahun adalah 75,00 dengan standar deviasi 2,828. pada responden yang menyalahgunakan napza selama 6–10 tahun rata-rata nilai perilaku antisosialnya adalah 69,50 dengan standar deviasi 7,489. responden dengan penyalahgunaan n a p z a s e l a m a 1 0 – 1 5 t a h u n r a t a r a t a memiliki nilai perilaku antisosial 66,33 dengan standar deviasi 5,508. responden yang menyalahgunakan napza selama 15–20 tahun rata-rata nilai perilaku antisosialnya adalah 84,40 dengan standar deviasi 9,788. sedangkan yang menyalahgunakan napza selama lebih dari 20 tahun mempunyai rata-rata nilai perilaku antisosialnya 65,00 dengan standar deviasi 9,788. hasil uji statistik didapatkan p value = 0,014 (p value < 0,05) yang berarti ada hubungan bermakna antara perubahan perilaku antisosial dengan lama menyalahgunakan napza. pembahasan hasil penelitian menunjukkan bahwa karakteristik klien penyalahguna napza yang perubahan perilaku dan fungsi kognitif dengan terapi perilaku kognitif (herni susanti) 175 dirawat di ruang rehabilitasi rsko jakarta memiliki kesamaan dengan studi sejenis tentang karakteristik penyalahguna napza di unit rehabilitasi di kota deli serdang, sumatera utara (saragih, 2009). meskipun terdapat perbedaan signifikan pada kedua penelitian tersebut, terutama terkait jumlah sampel (pada penelitian saragih menggunakan 169 responden, dan penelitian ini hanya 23 responden), secara umum karakteristik klien penyalahguna napza di beberapa kota besar di indonesia telah tergambarkan. karakteristik yang dimaksud antara lain usia klien yang kebanyakan berada pada masa produktif (20–40 tahun), jenis kelamin yang mayoritas laki-laki, status perkawinan yang kebanyakan tidak menikah dan jenis pekerjaan responden yang rata-rata tidak bekerja. pendapat bahwa karakteristik yang telah disebutkan di atas bukan merupakan hal baru. sebagai contoh, badan narkotika nasional (2009) menyebutkan bahwa kebanyakan pengguna napza di indonesia adalah laki-laki dan berusia produktif. namun demikian, studi ini menegaskan kondisi klien yang menjalani perawatan di unit rehabilitasi napza yang ada di indonesia, khususnya yang berbasis rumah sakit. data ini menjadi informasi yang penting terutama bagi pemberi kebijakan untuk merancang kegiatan dan fasilitas yang mendukung program rehabilitasi sesuai karakteristik hasil-hasil studi ilmiah. te r k a i t d e n g a n l a m a p e m a k a i a n napza, terlihat dari hasil penelitian ini bahwa kebanyakan responden telah menggunakan napza lebih dari lima tahun. hasil ini berbeda dengan penelitian saragih (2009) yang menunjukkan bahwa mayoritas responden menggunakan napza kurang dari lima tahun. menurut pendapat peneliti, lamanya masa penggunaan zat ini disebabkan banyaknya responden yang telah menggunakan pelayanan rehabilitasi napza di rsko lebih dari satu kali. dengan kata lain, kondisi relaps dikalangan responden sangat tinggi. selain itu, data lain menunjukkan bahwa semua responden tidak ada yang menggunakan zat hanya 1 (satu) jenis saja. banyak responden yang menyatakan bahwa mereka telah mulai menggunakan satu jenis napza tertentu sejak lama (umumnya ganja), kemudian menggunakan zat lainnya, dan pada akhirnya baru berminat menjalankan program rehabilitasi. kondisi tersebut di atas menimbulkan sebuah pertanyaan besar yaitu bagaimana memberikan pelayanan rehabilitasi yang dapat menjamin menurunkan tingkat relaps para pengguna napza? meskipun kejadian relaps dapat pula terjadi karena faktor eksternal (lingkungan klien paska perawatan rehabilitasi), namun hasil penelitian ini dapat memicu semua tenaga profesional yang terlibat dalam program rehabilitasi napza untuk mengoptimalkan upaya pencegahan terjadinya kekambuhan. seringkali kekambuhan terjadi karena klien tabel 1. pengaruh tpk terhadap nilai perilaku depresif, perilaku agresif, perilaku antisosial, dan fungsi kognitif variabel n mean sd p value perilaku depresif sebelum sesudah perilaku agresif sebelum sesudah perilaku antisosial sebelum sesudah fungsi kognitif sebelum sesudah 23 23 23 23 23 23 23 23 60,74 60,87 55,57 66,00 68,22 76,61 32,26 36,17 6,716 4,985 9,885 9,487 10,651 9,694 ,362 4,386 0,914 0,001 0,039 0,003 jurnal ners vol. 5 no. 2 oktober 2010: 171–180 176 tidak mendapatkan bekal yang cukup selama masa rawat akibat intervensi yang diberikan terputus, tidak sistematis, dan tidak berorientasi pada persiapan pulang. di bidang keperawatan jiwa, penanganan klien di unit rehabilitasi secara lebih terstruktur, efisien dan sesuai dengan standar profesi menjadi tantangan setiap perawat yang bekerja di area ini, salah satu pendekatan yang dapat diterapkan adalah adanya kesinambungan pemberian terapi generalis dan spesialis (seperti tpk dalam penelitian ini) yang dapat menjamin keberlangsungan intervensi keperawatan pada klien secara terstruktur dalam mempersiapkan klien pulang. penelitian ini juga menunjukkan adanya perubahan yang bermakna dalam perilaku dan fungsi kognitif responden sebelum dan sesudah pemberian intervensi tpk. namun demikian, khusus untuk perilaku depresif perubahan yang terjadi tidak signifi kan. menurut peneliti, hal ini kemungkinan terjadi karena kondisi depresi pada responden memang sudah tidak muncul lagi secara dominan. dengan kata lain, perilaku depresif ini memang muncul secara jelas di fase akut, dan kurang terlihat ketika individu sudah berada di fase rehabilitasi. kondisi ini juga didukung oleh pengamatan peneliti terhadap responden yang menjadi klien di ruang rehabilitasi rsko yang tidak lagi menunjukkan karakteristik khas individu dengan depresi, seperti nafsu makan menurun, sering menangis, sering merasa sedih dan merasa sendiri. fenomena tersebut di atas kurang sejalan dengan penelitian yang dilakukan castelanos dan conrod (2006) serta pernyataan fountaine (2009) yang mengindikasikan bahwa perilaku depresif merupakan tampilan yang umum terjadi di kalangan individu yang menggunakan napza. bahkan castelanos dan conrod mampu membuktikan intervensi singkat dengan menggunakan pendekatan perilaku kognitif mampu merubah kondisi depresi cukup signifi kan (n = 423). menurut peneliti, perbedaan tersebut terjadi dipengaruhi oleh jumlah sampel pada penelitian ini yang sedikit, sehingga sulit untuk menarik kesimpulan yang lebih luas untuk memberikan gambaran tentang pengaruh tpk pada pengguna napza. ditambah lagi dengan kondisi semua responden penelitian ini yang memang sudah berada di ruang rehabilitasi, sehingga kondisi emosi relatif stabil (meskipun ada yang belum stabil umumnya mereka adalah klien yang baru dipindah dari ruang akut, dan klien seperti ini tidak diperkenankan mengikuti penelitian). fountaine pun dalam tulisannya tidak mengungkapkan secara spesifi k bahwa kondisi depresi tersebut berlaku untuk semua individu pengguna napza dan untuk semua situasi. dengan kata lain, perlu disampaikan di sini bahwa pemahaman tentang adanya perilaku depresif di kalangan penyalahguna napza perlu ditinjau ada di fase mana individu tersebut berada: akut atau rehabilitatif. di fase akut, perilaku depresif sangat mungkin muncul dominan, namun di fase rehabititasi kondisi depresi sudah menurun (meskipun muncul, biasanya karena ada stressor baru yang signifi kan). variabel penelitian dependen lainnya yaitu perilaku agresif, perilaku antisosial dan fungsi kognitif terlihat dari hasil penelitian ini adanya perubahan yang signifi kan. meskipun, beberapa hasil ini memang sudah dapat diprediksi, namun penelitian ini sekali lagi memperkuat hasil studi tentang intervensi perilaku yang sudah puluhan tahun silam dilakukan oleh banyak peneliti (krasnager, 1979). hasil ini juga menegaskan pernyataan bahwa penanganan pada klien dengan masalah kesehatan jiwa (napza) yang intensif dan profesional mampu memberikan dampak yang sangat positif terhadap klien. terlepas adanya beberapa kekurangan dari pemberian tpk pada penelitian ini, hasil yang konstruktif ini diharapkan menjadi pemicu bagi semua tenaga kesehatan jiwa untuk memberikan kontribusi yang maksimal dalam merawat klien di unit rehabilitasi. pemberian tpk yang dilakukan secara bertahap dari mulai proses membina hubungan saling percaya, identifi kasi masalah, proses perubahan distorsi kognitif, proses perubahan perilaku negatif dan pembekalan pencegahan kekambuhan merupakan rangkaian penting bagi setiap individu untuk menolong dirinya keluar dari masalah yang sedang dialaminya: harga diri rendah dan koping tidak efektif. perubahan perilaku dan fungsi kognitif dengan terapi perilaku kognitif (herni susanti) 177 sepanjang proses tersebut klien diajak oleh terapis merubah perilaku agresif (misalnya meledak-ledak, mudah marah, mudah emosi), merubah perilaku antisosial (misalnya tidak taat tata tertib, bersikap tidak sopan, berbuat keributan), dan merubah pikiran negatif (misalnya denial, proyeksi, minimisasi). terakhir klien diminta komitmennya untuk melakukan perubahan-perubahan yang positif dalam rangka mencegah kekambuhan. selama proses ini pula, klien selalu difasilitasi untuk mengungkapkan perasaan, serta kendala yang dihadapi dalam menjalani proses ini. seringkali waktu yang dihabiskan bersama terapis sekitar 45 menit-1 jam setiap sesinya terasa kurang. uraian ini tampak jelaslah bahwa kemajuan klien merupakan hasil dari sebuah proses panjang namun terstruktur dan berorientasi pada kebutuhan klien, dan pada akhirnya melalui pembuktian ilmiah klien menunjukkan perubahan yang positif dari proses pemberian tpk. terapi perilaku kognitif sendiri adalah suatu bentuk psikoterapi jangka pendek, yang menjadi dasar bagaimana seseorang berfi kir dan bertingkah laku positif dalam setiap interaksi (stuart, 2009). hasil uji statistik terhadap hubungan karakteristik dengan perubahan perilaku dan fungsi kognitif klien penyalahguna napza menunjukkan bahwa ada hubungan yang bermakna antara lama pemakaian napza dengan perubahan perilaku antisosial. hal ini memperkuat pernyataan bahwa dampak nyata yang muncul akibat penggunaan napza dalam jangka waktu lama mengakibatkan kerusakan seseorang dalam bertindak sesuai norma yang berlaku (fountaine, 2009). perilaku antisosial yang dimaksud termaksud mengganggu ketenangan, melakukan seks bebas, dan terlibat dalam perkelahian/perdebatan. hasil analisa bivariat untuk melihat hubungan setiap komponen karakteristik dengan kondisi perilaku dan fungsi kognitif sebagian besar tidak ada yang menunjukkan hubungan yang bermakna (hanya ada satu nilai hubungan yang bermakna yaitu hubungan antara lama pemakaian napza dengan perilaku antisosial). menurut peneliti, hal ini terjadi mengingat jumlah responden yang sedikit yaitu hanya 23 dengan distribusi yang sangat tidak merata (standar deviasi besar). jumlah yang sedikit ini memang sulit dihindari oleh peneliti, mengingat beberapa usaha sudah dilakukan untuk mendapatkan jumlah responden yang lebih besar. salah satu upaya yang dilakukan adalah memperpanjang masa intenvensi, yang awalnya intervensi dilaksanakan dalam waktu tiga bulan, namun memanjang sampai lima bulan (karena sampai bulan ketiga jumlah klien yang menjadi responden masih hitungan belasan, dan itupun di antaranya ada yang drop out karena harus pulang). dengan demikian, untuk selanjutnya apabila dilaksanakan penelitian sejenis, rencana waktu intervensi dan juga kontrak/komitmen klien menjadi responden merupakan hal yang sangat perlu diperhatikan. penelitian ini memiliki beberapa keterbatasan di antaranya jumlah sampel yang sedikit, yaitu hanya 23 responden. hal ini disebabkan karena jumlah klien di ruang rehabilitasi rsko yang memenuhi kriteria inklusi pada saat periode penelitian sedikit. jumlah klien yang dirawat saat dilakukan penelitian memang mencapai 10–20 orang setiap harinya, namun umumnya hanya sepertiganya yang dapat dijadikan responden karena beberapa keterbatasan: kondisi klien yang belum stabil (baru masuk ruang rehabilitasi), terikat jadwal kegiatan ruangan yang ketat, dan menolak menjadi responden. kondisi ini diperburuk dengan banyaknya jumlah responden yang drop out (9 responden) karena harus pulang ditengah-tengah proses pemberian tpk. sebagai solusi dari masalah ini peneliti akhirnya memperpanjang waktu penelitian, yaitu dari tiga bulan menjadi lima bulan. berdasarkan keterbatasan ini, hasil penelitian hanya dapat digerelisir apabila dilakukan penelitian serupa dengan jumlah sampel yang lebih banyak. keterbatasan waktu bagi pemberi terapi dan klien dalam melaksanakan tpk juga merupakan kendala. pemberi terapis adalah peneliti dan perawat yang bertugas di ruang rehabilitasi rsko jakarta. dari empat orang yang layak memberikan tpk, hanya 1 (satu) terapis yang memang sehari-hari waktu kerjanya berada di rsko. selebihnya adalah mahasiswa spesialis keperawatan jiwa, jurnal ners vol. 5 no. 2 oktober 2010: 171–180 178 mahasiswa profesi ners, dan staf pengajar. berdasar kondisi tersebut, pelaksanaan tpk diberikan setelah terapis menyelesaikan kegiatan utama mereka, dan memulai sesi mereka di sore hari (sekitar jam 16.00 wib). seringkali, pemberian tpk yang dimulai sore hari tidak dapat optimal karena setelah jam 18.00 wib klien telah memiliki kegiatan wajib yang terjadwal. sebagai solusi, terapis harus datang memberikan tpk hampir setiap hari kepada klien yang berbeda (terutama pada saat kondisi klien yang banyak/menumpuk). walaupun kondisi ini tidak berlangsung terus-menerus selama lima bulan intervensi, mengingat ada beberapa waktu, pemberian terapi tidak berjalan lancar karena tidak adanya klien yang layak menjadi responden (waktu jeda tanpa pemberian tpk). kekurangan lain adalah penelitian ini ditujukan untuk klien-klien pengguna semua zat (bukan salah satu zat yang khas). memang diawal, peneliti bermaksud memfokuskan responden penelitian ini pada penyalahguna napza jenis heroin (putau) mengingat gejala, dan respons klien dapat sangat bervariasi sesuai jenis zat yang digunakan. namun demikian, sejalan dengan proses, peneliti memutuskan untuk tidak hanya berfokus pada peyalahguna heroin saja. alasan utamanya adalah demi menjaring responden yang lebih banyak. kedepannya, penelitian yang berfokus pada responden dengan satu jenis zat tertentu tetap menjadi agenda yang penting. simpulan dan saran simpulan tpk merubah secara bermakna perilaku agresif (meningkatkan perilaku nonagresif) pada klien yang sedang dirawat di unit rehabilitasi napza, tpk merubah secara bermakna perilaku antisosial (meningkatkan perilaku non-antisosial) pada klien yang sedang dirawat di unit rehabilitasi napza, tpk meningkatkan secara bermakna fungsi kognitif pada klien yang sedang dirawat di unit rehabilitasi napza, tpk tidak merubah perilaku depresif pada klien yang sedang dirawat di unit rehabilitasi napza, ada hubungan bermakna antara lama pemakaian napza dengan perubahan perilaku dan fungsi kognitif klien yang sedang dirawat di unit rehabilitasi napza. tidak ada hubungan karakteristik (umur, jenis kelamin, status pernikahan, jenis pekerjaan, dan tingkat pendidikan) dengan kondisi perilaku dan fungsi kognitif pada klien yang sedang dirawat di unit rehabilitasi napza saran pihak pendidikan tinggi keperawatan hendaknya menggunakan evidence based d a l a m m e n g e m b a n g k a n t e k n i k a s u h a n keperawatan jiwa dalam penerapan terapi perilaku kognitif bagi klien penyalahguna napza, dan hendaknya mengembangkan modul tpk bagi klien penyalahguna napza, departemen kesehatan ri menetapkan suatu kebijakan untuk implementasi tpk pada klien penyalahguna napza, organisasi profesi menetapkan tpk sebagai salah satu kompetensi dari perawat spesialis keperawatan jiwa, pihak rumah sakit menetapkan tpk sebagai salah satu program dalam meningkatkan kualitas asuhan keperawatan jiwa, khususnya untuk klien penyalahguna napza yang dirawat di unit rehabilitasi dan pihak rumah sakit memberikan kesempatan kepada perawat kesehatan jiwa untuk mengembangkan diri melalui pendidikan formal keperawatan sampai jenjang spesialis, perawat spesialis keperawatan jiwa hendaknya menjadikan tpk sebagai salah satu terapi keperawatan dalam mengatasi masalah harga diri rendah dan koping individu tidak efektif. perlunya dilakukan replikasi pada rumah sakit lain yang memiliki program rehabilitasi napza di seluruh indonesia sehingga diketahui keefektifan penggunaan tpk dalam menangani klien penyalahguna napza dan kesempurnaan modul, perlu dilakukan penyempurnaan pelaksanaan tpk untuk menjadikan tpk sebagai salah satu model pelayanan keperawatan. hasil penelitian berguna sebagai data dasar bagi penelitian selanjutnya dalam mengubah perilaku dan fungsi kognitif maladaptif klien penyalahguna napza. perubahan perilaku dan fungsi kognitif dengan terapi perilaku kognitif (herni susanti) 179 kepustakaan barrowclough, 2002. randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. american jurnal psychiatry, 158, 1706–1713. bergen, h.a., martin, g., richardson, allison, as., dan roeger, s., 2004. sexual abuse, anti sosial behaviour and subtance use: gender diffrences in young community adolecents. australian and new zealand journal of psychiatry, 38: 34–41. b a d a n n a r k o t i k a n a s i o n a l , 2 0 0 9 . penyalahgunaan dan ketergantungan napza. (online) (http://www.bnn. go.id), diakses tanggal 30 mei 2010 dari pukul 17.00 wib) castelanos, n. dan conrod, p., 2006. brief interventions targeting personality risk factors for adolesecent substance misuse reduce depression,panic and risk-taking behaviours. journal of alcohol & drug education, 15, 645–658. chamberlain, j.m., 2009. disentangling aggressiveness and assertiveness within the mmpi-2 psy-5 aggressiveness scale. tesis, michigan: kent state university dulin, p.l., hill, r.d., dan ellingson, k., 2006. relationships among religious factors, sosial support and alcohol abuse in a western u.s. college student sample. journal of alcohol & drug education, 50 (1), 5–14. fauziah, 2009. pengaruh terapi perilaku kognitif (tpk) pada pasien skizoprenia dengan perilaku kekerasan di rumah sakit marzoeki mahdi bogor. tesis tidak dipublikasikan, depok: universitas indonesia. fontaine, k.l., 2009. mental health nursing. (sixth edition). new jersey: pearson prentice-hall. halaby, s.g., 2009. psychometric validation of the cognitive appraisal of risky events antisocial/prosocial (care-a/p) scale, (online), (http://proquest.umi.com., diakses tanggal 25 oktober 2010, jam 15.00). krasnagen. n.a., 1979. research monograph 25 series. behavioural analysis & treatment of substance abuse. national institute on drug abuse us departement of health education and welfare. kadden, r.m., 2002. cognitive-behavior therapy for substance dependence: coping skill training, (online), (http:// w w w. b h r m . o r g / g u i d e l i n e s / c b tkadden.pdf, diakses tanggal februari 2010, jam 14.00). ouimette, p.c., finney, j.w., dan moos, r.h., 1997. twelve-step and cognitivebehavioral treatment for substance abuse: a comparison of treatment effectiveness. journal of consulting and clinical psychology, 65, 230–240. radloff, l.s., 1977. the ces-d scale: a selfreport depression scale for research in the general population, (online), (http://www. apm.sagepub.com., diakses tanggal 25 oktober 2010, jam 17.00). saragih, n., 2009. karakteristik penyalahguna n a r k o t i k , p s i k o t ro p i k a , d a n z a t adiktif (napza) di sibolangit center r e h a b i l i t a t i o n f o r d r u g a d d i c t kabupaten deli serdang tahun 2004– 2007. skripsi tidak dipublikasikan, medan: universitas sumatera utara. s a r t i k a , d . , 2 0 1 0 . p e n g a r u h r e l a p s e p re v e n t a t i o n tr a i n i n g t e rh a d a p kekambuhan dan kepatuhan klien ketergantungan heroin yang menjalani program terapi rumatan metadon di dki jakarta. tesis tidak dipublikasikan, depok: universitas indonesia. sasmita, h., 2007. efektivitas cognitive behaviour therapy pada klien dengan harga diri rendah di rumah sakit marzoeki mahdi bogor. tesis tidak dipublikasikan, depok: universitas indonesia. shives, 2005. basic concepts of psychiatric – m e n t a l h e a l t h n u r s i n g ( 4 t h e d ) . philadelphia: lippincott. stuart, g.w., 2009. principles and practice of psychiatric nursing. (8th edition). st louis: mosby. susanti, h. & yulia, i.y., 2009. pengaruh terapi perilaku kognitif terhadap persepsi, sikap, dan perilaku pasien jurnal ners vol. 5 no. 2 oktober 2010: 171–180 180 skizofrenia terkait pengobatan di rs marzoeki mahdi. laporan riset hibah a2, tidak dipublikasikan, depok: universitas indonesia. thomas, v.s., dan rockwood, k.j., 2001. alcohol abuse, cognitive impairment, and mortality among older people. journal of the american geriatrics society, 49(4), 415–420. townsend, m.c., 2009. psychiatric mental health nursing. (6th ed). philadelphia: f.a. davis company. 36 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 36-41 http://dx.doi.org/10.20473/jn.v17i1.31216 original article open access relationship between stress, anxiety, and depression with suicidal ideation in adolescents heni dwi windarwati 1,* , retno lestari 1 , satrio agung wicaksono 2, mira wahyu kusumawati 1 , niken asih laras ati 3 , shofi khaqul ilmy 4 , ari dwi sulaksono 1 , desi susanti 5 1 department of mental health nursing, faculty of medicine, universitas brawijaya, indonesia 2 faculty of computer science universitas brawijaya, indonesia 3 saintek medika nusantara, jombang, indonesia 4 faculty of medicine, universitas pendidikan ganesha, indonesia 5 school of nursing, faculty of medicine, universitas brawijaya, indonesia *correspondence: heni dwi windarwati. address: veteran malang street 65145, east java, indonesia. email: henipsik.fk@ub.ac.id responsible editor: ilya krisnana and ferry efendi received: 11 august 2021 ○ revised: 20 april 2022 ○ accepted: 20 april 2022 abstract introduction: suicide is a significant mental health problem in adolescents worldwide that requires comprehensive treatment. this study examined the relationship between stress, anxiety, and depression with suicidal ideation among indonesian adolescents. methods: this cross-sectional study examined 869 high school adolescents. suicide ideation was a dependent variable, while stress, anxiety, and depression were independent variables in this study. the instrument used to measure stress, anxiety, and depression is the depression anxiety stress scale (dass-21), while the idea of suicide was measured using the scale for suicide ideation (ssi) instrument. data were analyzed with spearman statistical test to examine the association between variables. results: the results showed that teenagers who had suicidal ideation were 23.7% of respondents, while 12.4% had a high intention of suicidal ideation. a total of 44.4%, 72.7%, and 71.4% of teens experienced stress, anxiety, and depression in the mild to very severe categories, respectively. there was a significant relationship between suicidal ideation with stress levels (p-value < 0.001; r value = 0.267), anxiety (p-value < 0.001; r value = 0.237), and level of depression (p-value < 0.001; r value = 0.233) in adolescents. conclusions: the study's findings revealed that stress, anxiety, and depression significantly affect suicide ideation in adolescents. therefore, to prevent increased suicide ideation in adolescents, mental and psychological health support measures must be given to deal with stress, anxiety, and depression. keywords: adolescents; anxiety; depression; stress; suicidal ideation introduction mental health problems in adolescents have become a worldwide concern. in the last few decades, research on mental health problems in adolescents has been carried out (bruha et al., 2018), such as in the united states (mojtabai and olfson, 2020), uk (fink et al., 2015), italy (frigerio et al., 2009), australia (allen and mckenzie, 2015), korea (roh et al., 2016), china (wang, zhang and zhang, 2020), and malaysia (ahmad et al., 2015). mental health problems in adolescents are very complex, consisting of bullying, gaming or internet addiction, emotional disorders (anxiety, depression, frustration, anger), and suicide-self harm (who, 2019a). in 2015, suicide became the 20th most common cause of death globally. data from who (2019) report that around 800,000 people die from committing suicide each year, accounting for 1.5% of all deaths and the second leading cause of death at 15-29 years (who, 2019b). in north america, suicide is the 10th most common cause of death (fazel and runeson, 2020). in recent years in indonesia, the phenomenon of suicide has been increasingly worrisome. the who estimates that the suicide rate in indonesia could reach 3.4% of 100,000 https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0001-8944-2515 https://orcid.org/0000-0003-4568-9596 https://orcid.org/0000-0002-7262-1178 https://orcid.org/0000-0002-6006-2313 https://orcid.org/0000-0002-0797-3863 https://orcid.org/0000-0002-9058-5430 jurnal ners http://e-journal.unair.ac.id/jners 37 people if it does not receive serious attention from various parties (who, 2018). meanwhile, data in east java province in 2018 showed that as many as 549 suicide cases occurred in east java (badan pusat statistik, 2019) suicide is an action to end life intentionally and is carried out consciously (wuryaningsih et al., 2018). suicide consists of various terms, such as self-injury, suicide ideas, suicide plans, and completed suicide. suicidal ideation is the thought of death caused by oneself. suicidal ideation can be passive when there are only thoughts of suicide without the intention to act or can be expressed directly, verbally, or not shown at all (stuart, 2016). suicidal ideation was found prevalent in adolescents (strandheim et al., 2014). someone who has the idea of suicide experiences social isolation, low selfesteem, and lack of trust with others, tends to think negatively, is inflexible, and feels powerless over his life (austin andkunyk, 2019). suicidal ideation is positively and significantly related to the occurrence of suicide attempts (ziaaddini, navadeh and saeedi, 2009). so, it is crucial to look at factors related to suicidal ideation. among adolescents, the prevalence of suicide attempts, suicide ideation, and self-harm reaches 6%, 18% 13.5%, respectively, where suicide behavior is influenced by internal and external factors such as low individual coping, misuse of smartphones, nutrition imbalance, bad lifestyle, low interaction in family, bullying, and social problems (lim et al., 2019; rohmana, estelina and iskandar, 2020; ati, paraswati and windarwati, 2021). however, the risk of suicide is also related to attitude toward problems and personality aspects (sharif et al., 2014), namely hostility, impulsivity, depression, and despair, while anti-social symptoms and depression often appear at a young age (stuart, 2016). research related to suicidal ideation among university students in tehran showed that depression, anxiety, and daily stress were positively associated with suicidal ideation (izadinia et al., 2010). stress is an intrinsic and extrinsic stimulus that causes a biological response and compensatory response to the stimulus (stewart et al., 2019). stress can cause various actions on the body, ranging from homeostasis changes to life-threatening effects (stewart et al., 2019). exposure to focus is at the core of the theory of suicide, and stress is associated with suicidal ideation, especially in adults and adolescents (yaribeygi et al., 2017). anxiety is a normal human emotion, which involves behavior, affective, and cognitive responses when facing the perception of danger. anxiety is considered excessive or pathological when it causes significant distress or distraction. anxiety often co-exists with depression (craske and stein, 2016). depression is a common mental disorder characterized by constant sadness and a lack of interest or pleasure in previously beneficial or enjoyable activities (who, 2019). depression is associated with substantial current and future morbidity and increases the risk of suicide (thapar et al., 2012). based on the importance of the risk factors for suicidal ideation in adolescents and the limited research conducted on this topic, especially in indonesia, the present study aimed to examine the relationship between stress, anxiety, depression, and associated factors with the emergence of suicidal ideation in adolescents. the study's results are expected to be a catalyst in providing healthcare for adolescents with suicidal ideation in indonesia. materials and methods study design a cross-sectional survey design was employed in this study. respondent the population and sample were all adolescents aged between 15-16 years from five high schools in east java province, indonesia. the total sampling method was employed to select respondents from five high schools in this study, with sample size of 869 adolescents. the inclusion criteria in this study were 1) high school firstgrade adolescents aged 15-16 years, 2) willing to take part in the study, and 3) completing the questionnaire. instrument data were gathered using a questionnaire to determine the respondents' demographic data, suicide ideation, stress, anxiety, and depression. stress, anxiety, and depression were measured using the depression anxiety stress scale (dass-21), validated, and translated into the respondents' national language (indonesian language). dass-21 is a well-established instrument for measuring depression, anxiety, and stress symptoms in clinical and non-clinical samples (lovibond and lovibond, 1995). the instrument consists of 21 questions with an answer rating scale of 0 (never), 1 (sometimes), 2 (often), and 3 (always). the score on dass-21 will be multiplied by two to calculate the final score. the cut-off score for depression was 0-9 (normal), 10-13 (mild), 14-20 (moderate), 21-27 (high), and > 28 (very high). the cut-off points for anxiety were 0-7 (normal), 8-9 (mild), 10-14 (moderate), 15-19 (high), and > 20 (very high). the cut-off points for stress were 0-14 (normal), 15-18 (mild), 19-25 (moderate), 26-33 (high), and > 34 (very high) (lovibond and lovibond, 1995; brumby et al., 2011). the dass-21 indonesian version questionnaire has passed the validity and reliability test (cronbach's alpha > 0.7). furthermore, suicide ideation was measured using the scale for suicide ideation (ssi) instrument, validated, and translated into the respondents’ national language (indonesian language). the ssi instrument is an ideal tool in the psychological and clinical investigation of suicidal ideation and differentiates individuals based on their level of suicidal ideation (beck, kovacs and windarwati, lestari, wicaksono, kusumawati, ati, ilmy, sulaksono, and susanti (2022) 38 p-issn: 1858-3598  e-issn: 2502-5791 weissman, 1979). the cut-off points for suicide ideation were 0 (did not have suicide ideation), 1 (low/minimal suicide ideation), and >1 (high suicide ideation). the ssi indonesian version questionnaire has passed the validity and reliability test (cronbach’s alpha > 0.7). data analysis the data analyses conducted were univariate and bivariate. descriptive analysis as frequency and percentage were used for categorical variables. spearman rank analysis was used to see the correlation between the two variables. suicide ideation was a dependent variable, while stress, anxiety, and depression were independent variables in this study. correlation analysis was said to be significantly related if the p-value<0.05. data analysis was performed using statistical package for social sciences (spss) version 16. ethical consideration this study was approved by the health research ethics committee of the health polytechnic of the ministry of health malang with an ethical approval certificate ("ethical approval") reg. number. 335 / kepk-polkesma / 2019. before participating in the research, participants were given an explanation related to the research to be conducted. for ethical reasons, informed consent was sent to the participants. participants who agreed to participate in this research signed the informed consent. the participation of respondents in this study was voluntary. this study followed ethical research principles, which include beneficence, justice, and respecting human dignity. results mostly, adolescents in this study did not have suicidal ideation (76.3%). however, as many as 23.7% of adolescents had the intention of suicide ideation, while 12.4% of respondents had high suicide ideation. most participants did not experience stress (55.6%) or depression (28.5%). in the anxiety variable, it can be seen that the majority of adolescents’ experience anxiety in the very high category (36.1%), and as many as 27.3% of adolescents did not have anxiety. in conclusion, 44.4%, 72.7%, and 71.5% of adolescents experienced minimal to very high stress, anxiety, and depression, respectively (table 1). table 2 shows as many as 413 (47.5%) of adolescents who did not intend suicide ideation also did not experience stress. in contrast, 3% of students had a high intention of suicide ideation and very high-stress levels. the bivariate analysis results in table 2 concluded a significant relationship between stress levels with suicidal ideation in adolescents, as indicated by the pvalue of < 0.001. in addition, the correlation coefficient of 0.267 indicated a positive direction between variables. based on table 2, the analysis concluded a significant relationship between the level of anxiety with suicidal ideation in adolescents, as indicated by the value of pvalue < 0.001. furthermore, the correlation coefficient of 0.237 indicates a positive relationship between variables. in terms of depression, it showed a significant relationship between the level of depression with suicidal ideation in adolescents, as indicated by the value of pvalue < 0.001. the correlation coefficient of 0.233 shows a positive relationship between variables. this study concluded that stress, anxiety, and depression have a significant and positive relationship with suicide ideation in adolescents. this showed that the lower the stress, anxiety, and depression level, the suicidal ideation in adolescents was also getting lower, and vice versa. discussions the present study investigates the relationship between stress, anxiety, and depression with the emergence of suicidal ideation in adolescents. based on the findings, this study indicated that stress, anxiety, and depression had a significant and positive relationship with suicide ideation in adolescents. the results of this study were in line with research conducted by izadinia et al. (2010), which showed that stress, anxiety, and depression correlate positively and significantly with thoughts of suicide. in addition, other studies also indicated that stress, depression, and anxiety were the major risk factors for suicidal behavior (nguyen et al., 2013; lew et al., 2019). the idea of adolescent suicide arises because, at this stage, the emotional development that occurs is still unstable (asante et al., 2017). the percentage of suicide ideas, suicide plans, and attempted suicides have a high table 1 characteristics of research respondents (n = 869) characteristics n % sex female 426 49.0 male 443 51.0 suicidal ideation high 108 12.4 low 98 11.3 none 663 76.3 stress very high 65 7.5 high 96 11.0 moderate 131 15.1 mild 94 10.8 normal/none 483 55.6 anxiety very high 314 36.1 high 104 12.0 moderate 119 13.7 mild 95 10.9 normal/none 237 27.3 depression very high 190 21.9 high 112 12.9 moderate 205 23.6 mild 114 13.1 normal/none 248 28.5 jurnal ners http://e-journal.unair.ac.id/jners 39 rate at 17 years and 18 years and above (asante et al., 2017). the percentage of suicide risk rates are high at ages 15 until 18 years, and this age range is a stage of late adolescence (yeomans and christensen, 2017), where, in this study, the age of the respondents was between 15-16 years. the previous research stated that stress occurs a lot in adolescence, accompanied by depression and anxiety (duarte et al., 2019). youth is a period that often elicits stressful conditions because, during this time, puberty hits as the peak of growth and development, both physically and mentally (miller and prinstein, 2019). stress can occur due to pressure on unwanted thoughts such as the burden or problems inside the family environment (windarwati et al., 2020). stress also happens to those who suppress their feelings and refrain from openly expressing emotions (kim, bassett and voisin, 2019). emotional status in adolescence is still changing between behavior that shows maturity with childish acts. academic stress factors can play an essential role in determining adolescent mental health (waghachavare et al., 2013). about 26% of high school students in the study had high levels of educational stress. stress is a significant risk factor causing depression (asante et al., 2017). stress is related to anxiety and depression and is a significant risk factor for teen suicidal ideation. this study suggested that the lower the stress level, the lower the suicide idea, and vice versa. various work stressors and related life stressors, such as stressful events, loss, unemployment, and other environmental stressors, link to suicidal ideation (ibrahim, amit and suen, 2014). this study showed that stress was positively related to suicidal ideation. the problem is how to adapt to stress without experiencing distress because distress can trigger psychological effects such as anxiety and depression. interaction of various aspects of stress can complicate optimal stress management and generate suicidal ideation (ibrahim, amit and suen, 2014). the lower the anxiety indicated, the lower the suicidal ideation in adolescents. adolescents who experience anxiety tend to have a higher level of vigilance and concern about something that has not yet happened. adolescents who experience anxiety can affect daily activities related to weakness and powerlessness (craske et al., 2017). adolescence is a period where individuals are worried about their future and face various pressures from family, school environment, and peers. this situation makes adolescents feel anxious, with emotions that are still unstable, and difficulty in solving difficult problems can make teens have ideas for suicide or selfinjury as a way out of anxiety experienced. people with anxiety were more likely to have suicidal ideation, attempted suicide, and completed suicide than those who did not experience anxiety (malik et al., 2014). there was a significant relationship between the level of depression with suicidal ideation in adolescents. the lower the depression level indicated, the lower the suicide idea. depression in adolescents occurs due to overflowing emotions and immaturity in making decisions and continuing the physiological development process. the high incidence of depression is caused by the increased responsibility they have to bear, both responsibility to parents, teachers, and those closest to them. there are various physical, social, emotional, and academic challenges in adolescents. this stage is also the peak age of onset of many mental health disorders (ibrahim, amit table 2 spearman rank correlation analysis of stress, anxiety, and depression with suicidal ideation suicidal ideation pvalue r high low none total n % n % n % n % stress very high 26 3.0 4 0.5 35 4.0 65 7.5 <0.001 0.267 high 16 1.8 14 1.6 66 7.6 96 11 moderate 25 2.9 26 3.0 80 9.2 131 15.1 mild 15 1.7 10 1.2 69 7.9 94 10.8 normal 26 3.0 44 5.1 413 47.5 483 55.6 total 108 12.4 98 11.3 663 76.3 869 100 suicidal ideation pvalue r high low none total n % n % n % n % anxiety very high 69 7.9 42 4.8 203 23.4 314 36.1 <0.001 0.237 high 17 2.0 12 1.4 75 8.6 104 12.0 moderate 5 0.6 12 1.4 102 11.7 119 13.7 mild 7 0.8 14 1.6 74 8.5 95 10.9 normal 10 1.2 18 2.1 209 24.1 237 27.3 total 108 12.4 98 11.3 663 76.3 869 100 suicidal ideation pvalue r high low none total n % n % n % n % depression very high 49 5.6 25 2.9 116 13.3 190 21.9 <0.001 0.233 high 14 1.6 18 2.1 80 9.2 112 12.9 moderate 27 3.1 21 2.4 157 18.1 205 23.6 mild 6 0.7 14 1.6 94 10.8 114 13.1 normal 12 1.4 20 2.3 216 24.9 248 28.5 total 108 12.4 98 11.3 663 76.3 869 100 windarwati, lestari, wicaksono, kusumawati, ati, ilmy, sulaksono, and susanti (2022) 40 p-issn: 1858-3598  e-issn: 2502-5791 and suen, 2014). furthermore, psychological conditions of students generally cause depression in adolescents, relationship problems with friends (boy/girlfriend), academic problems at school, relationship problems with parents and family, relationship problems with classmates, financial issues, relationship problems with teachers, and physical health problems (magklara et al., 2015). lack of parental supervision, alcohol abuse, and smoking are also significant risk factors for teenage depression (asante et al., 2017). suicidal ideation in late teens is caused by depression (asante et al., 2017). depression is a significant cause of suicide in adolescents (towsend, 2018). depression is associated with feelings of individual despair, helplessness, and lack of social support and skills to overcome difficulties and a stressful life (ibrahim, amit and suen, 2014). depression can also be a response to the loss of parents, relatives, friends, or the end of a relationship with a lover (towsend, 2018). early adolescence is the initial stage of puberty, the regulation system itself is still immature, so it tends to exhibit unstable emotions (curtis, 2015). the frontal lobe, which is part of the brain to regulate reasoning and decision-making, begins to develop during early adolescence. consequently, adolescents tend to act impulsively and think uncritically (unicef, 2011). in the late adolescence stage, emotions that are not yet sufficiently stable and a self-regulation system that is still developing gives this age stage an emotional status that is ever-changing between behavior that shows maturity and acting like children (curtis, 2015). more complex problems in late adolescence lead to a higher prevalence of depression and a higher risk of suicide at this age. however, physical development and growth will continue at this stage, including the frontal lobe, which is part of the brain that governs reasoning and decisionmaking. frontal lobes that experience further development cause late adolescents to tend to have the power of reasoning and the ability to make their own decisions well (curtis, 2015). therefore, coping mechanisms must be strengthened at this age. anxiety and depression are related to the idea of suicide and selfinjury. adolescents with suicidal ideation and self-injury tendencies have higher depression, anxiety, and stress levels. the use of a cross-sectional survey design in the present study is not without limitations. for instance, it cannot determine the causal relationship among variables. however, this study was conducted in a population with a large enough number and the same respondents (10th grade) characteristics, so the results are expected to reduce possible bias. furthermore, this study can also add to the literature on risk factors for suicide in adolescents in indonesia, which is still very limited. conclusions this present study indicated that stress levels, anxiety, and depression correlated positively and significantly with suicidal ideation in adolescents. stress, anxiety, and depression comprise a condition that is closely related to adolescent activities and is close to teenage life. therefore, nurses have to provide mental health education in the form of counselling, psychoeducation, and screening to adolescents, teachers, and parents of students who are healthy and at-risk of mental health problems. at the same time, students who experience mental health problems that can cause suicide ideas should be given psychotherapy in the form of cognitive-behavioral therapy to overcome their problems. mental health service providers have to pay great attention to adolescents regarding psychological issues due to emotional burdens experienced by adolescents either at school, at home, or in the environment that can cause mental health problems, especially stress, anxiety, and depression in adolescents. schools need to develop a school mental health unit to promote and prevent stress in adolescents through early detection, mental health therapy, and psychosocial support. lastly, further research is needed to identify the causal relationship between stress, anxiety, depression with suicide ideation in indonesia. it is hoped that a decrease in adolescent suicide ideation has implications for decreasing the incidence of suicide in adolescents. references ahmad, n. a. et al. (2015) 'trends and factors associated with mental health problems among children and adolescents in malaysia', international journal of culture and mental health, 8(2), pp. 125– 136. doi: 10.1080/17542863.2014.907326. allen, k. a. and mckenzie, v. l. (2015) 'adolescent mental health in an australian context and future interventions', international journal of mental health, 44(1), pp. 80–93. doi: 10.1080/00207411.2015.1009780. asante, k. o. et al. (2017) 'the prevalence and correlates of suicidal behaviours (ideation, plan and attempt) among adolescents in senior high schools in ghana', ssm population health, 3(may), pp. 427–434. doi: 10.1016/j.ssmph.2017.05.005. ati, n. a. l., paraswati, m. d. and windarwati, h. d. (2021) 'what are the risk factors and protective factors of suicidal behavior in adolescents? a systematic review', journal of child and adolescent psychiatric nursing, 34(7), pp. 7–18. doi: 10.1111/jcap.12295. austin, w & kunyk, d. (2019) psychiatric and mental health nursing for canadian practice. cina: wolters kluwer. badan pusat statistik (2019) banyaknya desa/kelurahan menurut keberadaan korban bunuh diri, lokasi berkumpul anak jalanan, gelandangan, dan pekerja seks komersial (psk), 2018. jawa timur. beck, a. t., kovacs, m. and weissman, a. (1979) 'assessment of suicidal intention: the scale for suicide ideation.', journal of consulting and clinical psychology, 47(2), pp. 343–352. doi: 10.1037//0022006x.47.2.343. bruha, l. et al. (2018) 'global child and adolescent mental health: challenges and advances', london journal of primary care, 10(4), pp. 108–109. doi: 10.1080/17571472.2018.1484332. brumby, s. et al. (2011) 'reducing psychological distress and obesity in australian farmers by promoting physical activity', bmc public health, 11(1), p. 362. doi: 10.1186/1471-2458-11-362. craske, m. g. et al. (2017) 'anxiety disorders', nature reviews disease primers, 3. doi: 10.1038/nrdp.2017.24. craske, m. g. and stein, m. b. (2016) 'anxiety', the lancet, 388(10063), pp. 3048–3059. doi: 10.1016/s0140-6736(16)30381-6. curtis, a. c. (2015) 'defining the adolescent', journal of adolescent and family health, 7(2). available at: https://scholar.utc.edu/jafh/vol7/iss2/2 . jurnal ners http://e-journal.unair.ac.id/jners 41 duarte, t. a. et al. (2019) 'self-harm as a predisposition for suicide attempts: a study of adolescents' deliberate self-harm, suicidal ideation, and suicide attempts', psychiatry research, 287. doi: 10.1016/j.psychres.2019.112553. fazel, s. and runeson, b. (2020) 'suicide', new england journal of medicine, 382(3), pp. 266–274. doi: 10.1056/nejmra1902944. fink, e. et al. (2015) 'mental health difficulties in early adolescence: a comparison of two cross-sectional studies in england from 2009 to 2014', journal of adolescent health, 56(5), pp. 502–507. doi: 10.1016/j.jadohealth.2015.01.023. frigerio, a. et al. (2009) 'prevalence and correlates of mental disorders among adolescents in italy: the prisma study', european child and adolescent psychiatry, 18(4), pp. 217–226. doi: 10.1007/s00787008-0720-x. ibrahim, n., amit, n. and suen, m. w. y. (2014) 'psychological factors as predictors of suicidal ideation among adolescents in malaysia', plos one, 9(10). doi: 10.1371/journal.pone.0110670. izadinia, n. et al. (2010) 'a study of relationship between suicidal ideas, depression, anxiety, resiliency, daily stresses and mental health among tehran university students', procedia social and behavioral sciences, 5, pp. 1615–1619. doi: 10.1016/j.sbspro.2010.07.335. kim, d. h., bassett, s. m. and voisin, d. r. (2019) 'family stress and youth mental health problems: self-efficacy and future orientation mediation', american journal of orthopsychiatry, 89(2), 125. doi: https://doi.org/10.1037/ort0000371. lew, b. et al. (2019) 'associations between depression, anxiety, stress, hopelessness, subjective well-being, coping styles and suicide in chinese university students', plos one, 14(7), pp. 1–10. doi: 10.1371/journal.pone.0217372. lim, k. s. et al. (2019) 'global lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-injury in children and adolescents between 1989 and 2018: a metaanalysis', international journal of environmental research and public health, 16(22). doi: 10.3390/ijerph16224581. lovibond, p. and lovibond, s. (1995) manual for the depression anxiety stress scales. 2nd edn. sydney: psychology foundation. magklara, k. et al. (2015) 'depression in late adolescence: a crosssectional study in senior high schools in greece', bmc psychiatry, 15(1). doi: 10.1186/s12888-015-0584-9. malik, s. et al. (2014) 'the association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis', systematic reviews. doi: 10.1186/2046-4053-3-18. miller, a. b. and prinstein, m. j. (2019) 'adolescent suicide as a failure of acute stress-response systems', annual review of clinical psychology, 15(1), pp. 425–450. doi: 10.1146/annurev-clinpsy050718-095625. mojtabai, r. and olfson, m. (2020) 'national trends in mental health care for us adolescents', jama psychiatry, 77(7), pp. 703–714. doi: 10.1001/jamapsychiatry.2020.0279. nguyen, d. t. et al. (2013) 'depression, anxiety, and suicidal ideation among vietnamese secondary school students and proposed solutions: a cross-sectional study', bmc public health, 13(1). doi: 10.1186/1471-2458-13-1195. roh, s. et al. (2016) 'mental health services and r&d in south korea', international journal of mental health systems, 10(1), pp. 1–10. doi: 10.1186/s13033-016-0077-3. rohmana, d. y., estelina, k. and iskandar, i. (2020) 'the bullying phenomenon and handling efforts in reducing cases of bullying: a systematic review', jurnal ners, 15(2). doi: http://dx.doi.org/10.20473/jn.v15i2.20479 this. sharif, f. et al. (2014)' comparison of personality traits, coping styles, and psychiatric disorders in adult suicidal and non-suicidal individuals', international journal of community based nursing and midwifery, 2(3), pp. 148–156. stewart, j. g. et al. (2019) 'life stress and suicide in adolescents', journal of abnormal child psychology, 47(10), pp. 1707–1722. doi: 10.1007/s10802-019-00534-5. strandheim, a. et al. (2014) 'risk factors for suicidal thoughts in adolescence-a prospective cohort study: the young-hunt study', bmj open, 4(8). doi: 10.1136/bmjopen-2014-005867. stuart, g. . (2016) prinsip dan praktik keperawatan jiwa stuart (terjemahan) jilid 1 & 2. singapore: elsevier. thapar, a. et al. (2012) 'depression in adolescence', lancet, 379(9820), pp. 1056–1067. doi: 10.1016/s0140-6736(11)60871-4. towsend, m. c. (2018) psychiatric mental health nursing: concepts of care in evidence-based practice. philadelphia: f. a. davis company. unicef (2011) adolescence an age of opportunity. waghachavare, v. b. et al. (2013) 'a study of stress among students of professional colleges from an urban area in india', sultan qaboos university medical journal, 13(august), pp. 429–436. wang, c., zhang, p. and zhang, n. (2020) 'adolescent mental health in china requires more attention', the lancet public health, 5(12), p. e637. doi: 10.1016/s2468-2667(20)30094-3. who (2018) suicide rate estimates, crude estimates by country, global health observatory data repository. available at: https://apps.who.int/gho/data/node.main.mhsuicide (accessed: 23 april 2020). who (2019a) adolescent mental health, fact sheets. available at: https://www.who.int/news-room/fact-sheets/detail/adolescentmental-health (accessed: 28 august 2020). who (2019b) fact sheets : suicide. available at: http://www.who.int/en/news-room/fact-sheets/detail/suicide (accessed: 20 august 2020). who (world health organization) (2019) depression, health topics. available at: https://www.who.int/healthtopics/depression#tab=tab_1 (accessed: 17 october 2020). windarwati, h. d. et al. (2020) 'the relationship between family harmony with stress , anxiety , and depression in adolescents', jurnal ners, 15(3). doi: http://dx.doi.org/10.20473/jn.v15i2.21495. wuryaningsih, e. w. et al. (2018) keperawatan kesehatan jiwa. jember: percetakaan & penerbitan universitas jember. yaribeygi, h. et al. (2017) 'the impact of stress on body function: a review', excli journal, 16, pp. 1057–1072. doi: 10.17179/excli2017480. yeomans, c. and christensen, h. (2017) youth mental health report youth survey 2012-16. ziaaddini, h., navadeh, s. and saeedi, a. (2009) 'prevalence of suicide ideation, attempts and the associated factors among a sample of iranian population in south part of the country: a population based study', iranian journal of psychiatry, 4(3), pp. 92–96. . how to cite this article: windarwati. h. n., lestari, r., wicaksono, s. a., kusumawati, m. w., ati, , n. a. l., ilmy, s. k., sulaksono, a. d., susanti, d. (2022) ‘relationship between stress, anxiety, and depression with suicidal ideation in adolescents’, jurnal ners, 17(1), pp. 36–41. doi: http://dx.doi.org/10.20473/jn.v17i1.31216 table1 table2 ahmad2015 allen2015 asante2017 ati2021 austin2019 bps2019 beck1979 bruha2018 brumby2011 craske2017 craske2016 curtis2015 duarte2019 fazel2020 fink2015 frigerio2009 ibrahim2014 izadinia2010 kim2019 lew2019 lim2019 lovibond1995 magklara2015 malik2014 miller2019 mojtabai2020 nguyen2013 roh2016 rohmana2020 sharif2014 stewart2019 strandheim2014 stuart2016 thapar2012 towsend2018 unicef2011 waghachavare2013 wang2020 who2018 who2019a who2019b who2019 windarwati2020 wuryaningsih2018 yaribeygi2017 yeomans2017 ziaaddini2009 148 penilaian kualitas hidup anak penderita kanker (assessment of quality of life in cancer children) mira irmawati,* irwanto,* andy cahyadi* *departemen ilmu kesehatan anak rsud dr. soetomo universitas airlangga jl. mayjen prof. dr. moestopo 6–8 surabaya e-mail: miracle_m1r4@yahoo.com abstract introduction: the survival rate of cancer children has increased over the past decade. the assessment of quality of life in childhood cancer survivors is required for understanding children's psychosocial functioning, perception of illness and its effect on daily life. the objective of this study was to assess the quality of life of cancer children. method: this study was a cross sectional study done to both parents and cancer children 5–18 years old in january-february 2012. subject and their parents were given the pedsql 3.0 cancer module that was translated in to indonesia language. cronbach's alpha and pair-t tests were used for analysis. result: forty-four cancer children participated, mean age 6.4 years old, 30 (56.6%) were female, 24 (45.3%) suffered from leukemia. no signifi cant gender differences were found for all subscales. all subscales showed satisfactory reliability (cronbach's alpha = 0.615–0.929). the scores from children-report was higher than parents-report for treatment anxiety, cognitive problem and total scale (p<0.05), the overall scores of 61–81. the subscale procedure anxiety, worry, and pain-hurt had low-scores for both children and parent. disscussion: pedsql 3.0 cancer module is an objective instrument for measuring quality of life in cancer children and their family. keywords: cancer children, quality of live, pedsql 3.0 cancer module pendahuluan survei epidemiologi mencatat ada 131 dari setiap 100.000 anak terancam jiwanya karena penyakit kanker. di indonesia, diperkirakan setiap tahun ada 4100 kasus baru kanker pada anak (tuheteru, 2009). angka harapan hidup 5 tahun untuk semua jenis kanker, secara umum meningkat dari 55,7% (1974–1976) menjadi 77,1% (1992–1997). meskipun terjadi kemajuan pesat dalam hal pengobatan dan tatalaksana suportif, kanker masih merupakan penyebab utama kematian yang kedua pada anak-anak usia di bawah 15 tahun (setelah kecelakaan) di amerika. tercatat 1.340 anak meninggal akibat kanker pada tahun 2012 (american cancer society, 2011). pengelola an kan ker t id a k diu k u r berdasarkan kesehatan anak secara f isik saja, tetapi juga dengan tercapainya kualitas hidup yang baik secara spiritual dan psikososial. anak-anak yang menderita kanker bisa mengalami cacat fi sik, gangguan mental, dan gangguan fungsi sosial sebagai akibat dari keganasan kanker dan efek samping pengobatan (susanto, et al., 2009). banyak anak yang menderita kanker bisa menikmati hidup normal, tetapi status kesehatannya buruk serta didapatkan gangguan kognitif dan emosi. (pickard, m. 2004; yaris, et al.,, 2001). penilaian kualitas hidup anak penderita kanker diperlukan agar dapat menggambarkan k ualit as hidup anak pender it a kan ker. instrumen untuk menilai kualitas hidup anak penderita kanker yang tersedia saat ini adalah pedsql 3.0 cancer module. (varni, et al., 2002). tujuan penelitian ini adalah untuk mengetahui kualitas hidup anak penderita kanker di rsud dr. soetomo surabaya, sehingga dapat dipantau kualitas hidupnya secara berkesinambungan dan anak-anak tersebut memperoleh kesempatan unt uk tumbuh dan berkembang secara optimal. 149 penilaian kualitas hidup anak penderita kanker (mira irmawati, dkk.) bahan dan metode penelitian ini merupakan penelitian cross sectional. selama januari sampai dengan februari 2012 di rsud dr. soetomo surabaya untuk mengetahui kualitas hidup anak-anak penderita kanker dan orang tuanya masing-masing menggunakan pedsql 3.0 cancer module. k riteria inklusi adalah semua anak usia 5–18 tahun yang didiagnosis kanker. sedangkan subyek yang mengalami penurunan kesadaran tidak diikutkan dalam p e nga mbi la n sa mp el. pe ngelomp ok a n diagnosis kanker dibagi menjadi 3 yaitu: leukemia, limfoma, dan solid tumor, yang termasuk dalam solid tumor antara lain wilm's tumor, neuroblastoma, dan retinoblastoma. pedsql 3.0 cancer module diterjemahkan dalam bahasa indonesia oleh peneliti. peneliti mendampingi selama pengisian for mulir dilakukan, dan hanya memberikan komentar apabila ada pertanyaan dari subyek atau orangt ua mengenai pet unjuk pengisian. terdapat delapan sub-skala penilaian dalam pedsql 3.0 cancer module ini yaitu nyeri dan sakit, mual, kecemasan prosedural, kecemasan pengobatan, khawatir, masalah kognitif, penampilan fi sik yang dirasakan, serta komunikasi. deskripsi skor sesuai subskala dalam pedsql 3.0 cancer module; nilai kuisioner 0 = skor 100, nilai kuisioner 1 = skor 75, nilai kuisioner 2 = skor 50, nilai kuisioner 3 = skor 25, nilai kuisioner 4 = skor 0. semakin tinggi skor (mendekati 100), semakin baik kualitas hidupnya. data yang diperoleh dianalisis mengg unakan uji cronbach's alpha. nilai ≥ 0,70 dianggap diterima untuk perbandingan antara kelompok. hasil sejumlah 44 subjek masuk dalam penelitian ini. diagnosis kanker dikelompokkan menjadi 3 yaitu leukemia, limfoma, dan solid tumor. 19 43% 6 14% 19 43% 5 7 th 8 12 th 13 18 th 6 14% 19 43% 5–7 th 8–12 th 13–18 th 19 43% gambar 2. distribusi umur. 24 55% 20 45% laki-laki perempuan 20 45% 24 55% laki-laki perempuan gambar 1. distribusi jenis kelamin. 150 jurnal ners vol. 7 no. 2 oktober 2012: 148–152 pembahasan selama periode penelitian januari sampai dengan februari 2012 didapatkan 44 subyek berusia 5–18 tahun beserta orang tuanya. dua puluh empat (54,4%) subjek lakilaki dan 20 (45,5%) perempuan. tidak ada perbedaan yang bermakna antara anak lakilaki dan perempuan. hal ini sama dengan penelitian sebelumnya yang dilakukan oleh sitaresmi, et al., (2008) di indonesia, demikian pula yaris, et al., (2001), dengan menggunakan instrumen yang berbeda yaitu health utility index (hui-2). tetapi landolt, et al., (2006) tabel 1. skor masing-masing sub-skala dengan pedsql 3.0 cancer module mean cronbach's alpha children report 1. pain and hurt 68.7500 0.792 2. nausea 79.3182 0.758 3. procedural anxiety 64.2045 0.855 4. treatment anxiety 81.8182 0.865 5. worry 61.9318 0.763 6. cognitive problems 73.5227 0.716 7. perceived physical appearance 77.8409 0.714 8. communication 65.9091 0.727 parent report 1. pain and hurt 67.3295 0.886 2. nausea 75.4545 0.817 3. procedural anxiety 62.5000 0.873 4. treatment anxiety 75.1894 0.818 5. worry 55.4924 0.818 6. cognitive problems 67.1591 0.717 7. perceived physical appearance 79.1667 0.743 8. communication 68.5606 0.722 menyatakan bahwa anak perempuan lebih banyak mengalami masalah emosional. pada penelitian kami didapatkan anak penderita kanker usia 5–7 tahun sebanyak 19 (43,2%) subyek, 8–12 tahun 19 (43,2%) subjek, 13–18 tahun 6 (13,6%) subyek. penelitian sebelumnya menyatakan bahwa anak-anak penderita kanker yang usianya lebih muda memiliki angka penilaian kualitas hidup yang lebih rendah dalam sub-skala kecemasan prosedural, kecemasan pengobatan, subskala komunikasi (sitaresmi, et al., 2008). sedangkan penelitian yang dilakukan oleh 34 77% 6 14% 4 9% leukemia lymphoma solid tumor 6 14%4 9% 34 77% leukimia lymphoma solid tumor gambar 3. distribusi jenis penyakit 151 penilaian kualitas hidup anak penderita kanker (mira irmawati, dkk.) yaris, et al., (2001) mendapatkan kesimpulan bahwa tidak terdapat perbedaan bermakna untuk usia pada pengukuran kualitas hidup anak penderita kanker. jenis kan ker pada penelitian ini, dikelompokkan menjadi 3 yaitu leukemia, limfoma, dan solid tumor. jumlah subjek penderita leukemia adalah 34 (77,3%), limfoma 4 (9,1%), dan solid tumor 6 (13,6%). jenis kanker yang terbanyak adalah leukemia. sedangkan pek, (2010) menemukan hal yang sama yaitu kanker pada anak yang terbanyak (satu sepertiga kasus) adalah leukemia. selama 3 tahun (2003–2005) didapatkan 237 penderita leukemia bar u yang berobat di rsud dr. soetomo surabaya (divisi hematologionkologi, 2005). h a si l p e n el it ia n k u a l it a s h id u p didapatkan bahwa laporan anak lebih tinggi dari laporan orang tua untuk sub-skala kecemasan pengobatan, masalah kognitif, dan skala total. skor keseluruhan berkisar antara 61–81. sub-skala kecemasan prosedur, khawatir, dan sakit-nyeri, skornya rendah baik pada laporan anak-anak maupun orangtuanya. hasil ini sesuai dengan penelitian sitaresmi, et al., (2008). anak penderita kanker termasuk dalam kategori anak dengan kondisi kesehatan kronik. peran pelayanan kesehatan terhadap anak dengan kondisi kesehatan kronik bukan untuk menyembuhkan tetapi untuk perawatan. tujuan perawatan adalah mengurangi dampak dari kondisi kesehatan kronik, mencegah disf ungsi, dan mengoptimalkan t umbuh kembang anak baik dalam perkembangan fi sik, kognitif maupun psikososial. dampak jangka panjang kondisi kesehatan kronik selain pada penderita sendiri juga berpengaruh terhadap orang tuanya. dampak pada anak tercermin pada perkembangan psikososial, keterlibatannya dengan teman sebaya, dan penampilan di sekolah. sedangkan dampak terhadap keluarganya, antara lain terhadap status psikososial orang tuanya, aktivitas dan penampilan di tempat kerja, status ekonomi keluarga, struktur dan peran langsung dari keluarga, keterlibatan masyarakat disekitarnya, dan status psikososial, serta penampilan di sekolah dari saudara kandungnya. masalah tumbuh kembang pada anak dengan kondisi k ronik tergant ung pada pandangan anak terhadap organ tubuhnya, penyakitnya, pengobatan yang diterimanya, dan pandangan terhadap kematian. peran tenaga kesehatan profesional disini dapat dilakukan dengan cara mengetahui dan menghargai kekuatan yang ada di dalam keluarga, meningkatkan rasa percaya diri dan kemampuan merawat anaknya, memberi kesempatan pada keluarga untuk membantu anak mereka berhubungan dengan pelayanan kesehatan (soetjiningsih, 2005). simpulan dan saran simpulan ke b e r h a si l a n p e n gelol a a n a n a k penderita kanker tidak hanya diukur dari anak sehat secara fi sik, tetapi juga dengan tercapainya kualitas hidup yang baik secara spiritual dan psiko-sosial. penilaian kualitas hidup pada anak pendeita kanker memerlukan instrumen yang khusus. pedsql 3.0 cancer module merupakan instrumen yang obyektif untuk menilai kualitas hidup anak penderita kanker dan keluarganya. saran perlu dilakukan penelitian lebih lanjut tentang kualitas hidup anak penderita kanker dengan populasi sampel yang lebih besar. kepustakaan divisi hematologi onkologi anak. 2005. laporan kunjungan pasien poli rawat jalan khusus hematologi-onkologi anak rsud dr. soetomo surabaya. tidak dipublikasikan. american cancer society, 2011. cancer in children. (online), diakses di (www. cancer.org, diakses tanggal 16 juni 2012, jam 23.00 wib). landolt, m.a., et al., 2006. health-related quality of life in children with newly diagnosed cancer: a one year follow-up study. health and qual life outcomes, 4, 63. 152 jurnal ners vol. 7 no. 2 oktober 2012: 148–152 pek, h.j., 2010. health-related quality of life in children with cancer undergoing treatment: a fi rst look at the singapore experience. ann acad med singapore, 39: 43–48. pickard, a.s., 2004. a structured review of studies on health-related quality of life and economic evaluation in pediat r ic acute ly mphoblastic leukemia. natl cancer inst monogr; 33: 102–125. sitaresmi, m.n., et al., 2008. health-related quality of life assessment in indonesian childhood acute lymphoblastic leukemi. health and qual life outcomes; 6: 1–8. susanto, i.y., et al., 2009. assessment of healthrelated quality of life in children with cancer using pedsqltm (a preliminary study. paediatr indones; 49: 330–6. sutjiningsih, 2005. tumbuh kembang anak dengan kondisi kesehatan kronik. dala m: na rend r a , m b., su la r yo ts., dkk, editor. buku ajar tumbuh kembang anak dan remaja, edisi kedua. jakarta: cv. sagung seto, hlm. 61–70. tehuteru, e.s., 2009. mewaspadai gejala kanker pada anak. ikatan dokter anak indonesia, (online), (http://www.idai. or.id/kesehatananak/artikel.asp, diakses tanggal 18 juni 2012, jam 21.00 wib) yaris, n., et al., 2001. assessment of quality of life in pediatric cancer patients at diagnosis and during therapy. turk j cancer, 31(4): 139–149. varni, j.w., et al., 2002. the pedsql™ in pediatric cancer reliability and validity of the pediatric quality of life inventory™ generic core scales, multidimensional fatigue scale, and cancer module. cancer, 4(7): 2090–2106. vol 9 no 1 april 2014.indd 104 produksi asi ibu post seksio sesarea dengan pijat oketani dan oksitosin (breastmilk production of mother with post caesarean section given oketani and oxitocyn massage) machmudah*, nikmatul khayati* *fakultas ilmu keperawatan dan kesehatan universitas muhammadiyah semarang jl. kedungmundu raya no. 18 semarang e-mail : ummu_aulya@yahoo.com abstrak pendahuluan: pijat oketani dan oksitosin merupakan salah satu metode breast care yang tidak menimbulkan rasa nyeri. pijat oketani dapat menstimulus kekuatan otot pectoralis untuk meningkatkan produksi asi dan membuat payudara menjadi lebih lembut dan elastis sehingga meumudahkan bayi untuk mengisap asi. pijat oketani juga akan memberikan rasa lega dan nyaman secara keseluruhan pada responden, meningkatkan kualitas asi, mencegah putting lecet dan mastitis serta dapat memperbaiki/mengurangi masalah laktasi yang disebabkan oleh putting yang rata (fl at nipple), putting yang masuk kedalam (inverted). metode: jenis penelitian ini adalah quasi eksperimen dengan rancangan yang digunakan adalah post test only design with control group. hasil: penelitian menunjukkan bahwa ada beda frekuensi menyusu, frekuensi bab, frekuensi bak pada responden yang dilakukan pijat oketani dan oksitosin. diskusi: salah satu penilaian produksi asi adalah dengan menilai frekuensi bak bayi dan volume urine. bayi yang normal akan bak sebanyak 6-8 kali sehari, warna urine kuning jernih dengan volume urine antara 30-50 mg sehari. hasil penelitian ini sesuai dengan penelitian yang dilakukan oleh budiarti (2009) dan mardianingsih (2010) yang menyebutkan bahwa produksi asi dapat dinilai dari frekuensi miksi bayi yaitu sebanyak 6-8 kali sehari kata kunci: pijat oketani, pijat oksitosin, produksi asi abstract introduction: oketani massage and oxytocin is one of the breast care methods that do not cause pain. massage can stimulate oketani pectoralis muscle strength to increase milk production and make the breasts become more soft and elastic so meumudahkan baby to suck milk. massage oketani will also provide a sense of relief and an overall comfortable on respondents, improving the quality of breast milk, to prevent mastitis and nipple blisters and can fi x / reduce lactation problems caused by putting a fl at (fl at nipples), nipples that enter into (inverted). method: this research was a quasi experimental with post test only design. result: the results showed that there are different breastfeeding frequency, frequency of bowel, bladder frequency of respondents who do massage and oxytocin oketani. discussion: one milk production assessment is to assess the frequency and volume of urine bladder baby. normal babies will urinate 6-8 times a day, with a clear yellow color of urine is urine volume between 30-50 mg daily. this result is consistent with research conducted by budiarti (2009) and mardianingsih (2010) which states that the milk production can be judged from the frequency of micturition babies as many as 6-8 times a day key words: oketani massage, oxytocin massage, milk production pendahuluan a ngka kematian bayi (a k b) di indonesia, masih cukup tinggi dibandingkan dengan negara-negara di asia tenggara yaitu 34/1000 kelahiran hidup, masih cukup tinggi dibandingkan malaysia (16/1000) dan singapura (2/1000) kelahiran hidup. (sdki, 2007). angka tersebut juga masih jauh dari target mdgs yaitu 24 per 1000 kelahiran hidup pada tahun 2015 (bps, 2008). pe n ye b a b k e m a t i a n b a y i y a n g terbanyak adalah masalah diare dan masalah pemberian minum (31,4%) dan pneumonia (23,8%) (riskesdas, 2007). tingginya angka kematian bayi ini dapat ditanggulangi jika bayi mendapat asupan nutrisi dan zat gizi yang mencukupi, yaitu melalui pemberian air susu ibu (asi). data unicef menyatakan bahwa 30.000 kematian bayi yang ada di indonesia dan 10 juta kematian anak balita di dunia setiap tahunnya bisa dicegah melalui pemberian asi secara eksklusif selama enam bulan sejak tanggal kelahirannya, tanpa harus memberikan makanan dan minuman tambahan kepada bayi. (roesli, 2008). 105 produksi asi ibu post seksio sesarea (machmudah dan nikmatul khayati) berd a sa rk a n d at a su sena s 2010, baru 33,6% atau sekitar sepertiga bayi yang mendapatkan asi eksklusif mulai lahir hingga berusia enam bulan, cakupan yang dinilai masih sangat rendah. data dari dinas kesehatan kota semarang menunjukkan bahwa cakupan pemberian asi eksklusif masih dibawah target dinas kesehatan provinsi jawa tengah yaitu sebesar 65%. pada tahun 2009 sebesar 24,53%, pada tahun 2010 sebesar 25,10% dan pada tahun 2011 sebesar 24,19%. pemberian asi eksklusif dipengaruhi oleh beberapa faktor antara lain asi tidak segera keluar pada hari per tama paska melahirkan, ibu merasa asi keluar sedikit, kesulitan bayi dalam menghisap, keadaan putting susu ibu dan pengaruh promosi susu pengganti asi (siregar, 2004). kondisi dilapangan menu nju k kan bahwa keberhasilan menyusui secara dini juga dipengaruhi oleh kondisi ibu dan bayi. ibu paska seksio sesarea membutuhkan waktu pemulihan akibat efek anestesi dan adanya rasa nyeri akibat luka seksio. kebijakan beberapa rumah sakit yang tidak menerapkan rawat gabung (rooming in) dengan alas an ibu masih membutuhkan pengawasan, masih lemah dan tidak bisa merawat bayinya, akan mengakibatkan proses menyusu akan mengalami penundaan. proses menyusu yang tertunda akan menyebabkan ibu berhenti menyusui. penelitian yang dilakukan oleh chertok & shoham-vardi (2008) menunjukkan bahwa ibu yang melahirkan seksio sesarea beresiko tiga kali lebih besar untuk berhenti menyusui pada bulan pertama postpartum k a re n a t id a k d i la k u k a n nya i m d d a n keterlambat an dalam member i kan asi dibandingkan ibu yang melahirkan normal. proses menyusui yang tertunda dapat diatasi dengan memerah atau memompa asi selama 10-20 menit sampai bayi dapat menyusu. tindakan tersebut dapat membantu memaksimalkan reseptor prolaktin dan mengurangi efek samping karena tidak adanya proses menyusui (evariny, 2008). upaya unt uk merangsang hor mon prolaktin dan oksitosin selain dengan memerah asi juga dapat dilakukan dengan melakukan perawatan payudara (breast care), pemijatan pada payudara serta pijat oksitosin. penelitian yang dilakukan oleh desmawati (2009) tentang efektifi tas kombinasi areolla massage dengan rolling massage terhadap pengeluaran asi secara dini pada ibu postpartum di puskesmas pamulang dan cikupa banten menunjukkan bahwa ibu-ibu yang diberikan intervensi tersebut mempunyai peluang 5,146 kali untuk terjadinya pengeluaran asi kurang dari 12 jam postpartum. penelitian mardiyaningsih (2010) menunjukkan bahwa kombinasi tehnik marmet dengan pijat oksitosin dapat meningkatkan produksi asi pada ibu post seksio sesarea. metode penelitian tahapan penelitian diawali dengan penyusunan proposal kemudian dilanjutkan dengan pengajuan ijin penelitian. st udi pendahuluan dilakukan di rumah sakit yang akan dijadikan sebagai lokasi penelitian. pengajuan ijin penelitian kepada direktur rumah sakit dan diteruskan ke kepala ruang postpartum. identif ikasi responden yang akan dijadikan sebagai kelompok intervensi dan kelompok kontrol. pada pada kelompok intervensi dilakukan pijat oketani dan oksitosin, kemudian penilaian produksi asi dengan melakukan pengukuran pada frekukuensi bak, frekuensi bab dan peningkatan berat badan pada hari ke 1,2,3 dan ke tujuh. jenis penelitian ini adalah quasi eksperimen dengan rancangan yang digunakan adalah post test only design with control group, yaitu suatu pengukuran hanya dilakukan pada saat terakhir penelitian (sugiyono, 2001). pada rancangan penelitian ini, intervensi hanya dilakukan pada kelompok intervensi yaitu pemberian pijat oketani dan oksitosin pada ibu post seksio sesarea hari pertama sampai hari ketiga, sedangkan pada kelompok kontrol tidak dilakukan intervensi. a n a l i s i s u n i v a r i a t u n t u k mendeskripsikan karakteristik responden dan variabel terikat dengan menggunakan distribusi frekuensi. analisis bivariat untuk mendeskripsikan parameter produksi asi pada 106 jurnal ners vol. 9 no. 1 april 2014: 104–110 kelompok intervensi dan kelompok kontrol. uji yang digunakan adalah uji independent sample t test. hasil penelitian tabel 1. karakteristik responden berdasarkan umur dan paritas pada ibu post seksio sesarea di rs wilayah kota semarang variabel dipijat tidak dipijat p umur 16 16 0,960 paritas 16 16 0,151 pendidikan 16 16 0,135 dari tabel 1 di atas dapat dijelaskan bahwa tidak ada beda antara umur, paritas dan pendidikan responden dengan pijat oketani dan oksitosin pada ibu post seksio sesarea di rumah sakit wilayah kota semarang. tabel 2 menjelaskan frekuensi menyusu pada responden yang dilakukan pijat oketani dan oksitosin paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 2 kali dalam sehari, paling tinggi 12 kali menyusu dalam sehari, rata-rata menyusu dalam sehari 7 kali dengan standar deviasi 3,845. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 2 kali dalam sehari, paling tinggi 6 kali menyusu dalam sehari, rata-rata menyusu dalam sehari 4 kali dengan standar deviasi 1,34. dari hasil uji analisis menunjukkan bahwa ada beda frekuensi menyusu pada kelompok intervensi dan kelompok kontrol dengan p-value 0,004 (α=0,05). frekuensi bab pada responden yang dilakukan pijat oketani dan oksitosin paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 1 kali dalam sehari, paling tinggi 4 kali bab dalam sehari, rata-rata bab dalam sehari 2 kali dengan standar deviasi 1,063. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 0 kali dalam sehari, paling tinggi 2 kali bab dalam sehari, rata-rata bab dalam sehari 1 kali dengan standar deviasi 0,443. dari hasil uji analisis menunjukkan bahwa ada beda frekuensi bab pada kelompok intervensi dan kelompok kontrol sebelum dilakukan pijat oketani dan oksitosin dengan p-value 0,005 (α=0,05). tabel 2. komparasi pengaruh pijat oketani dan oksitosin terhadap parameter produksi asi pada ibu post seksio sesarea di rs wilayah kota semarang tahun 2013 variabel dipijat tidak dipijat p min max mean sd min max mean st d f. menyusu1 2 12 7,12 3,845 2 6 3,94 1,340 0,004 f.bab1 1 4 1,94 1,063 0 2 1,06 0,443 0,005 f.bak1 1 6 3,94 1,611 3 6 5 0,816 0,025 berat badan1 2400 3800 3025 329,85 2400 4200 3137 545,44 0,486 f. menyusu2 5 12 8,25 2,955 4 7 5,88 0,885 0,004 f.bab2 1 5 2,13 1,258 1 3 1,94 0,680 0,604 f.bak2 2 10 5,44 2,337 5 6 5,44 0,512 1,00 berat badan2 2400 3800 3041 337,35 2400 4200 3090 540,13 0,762 f. menyusu3 4 12 9 3,077 4 7 5,56 0,719 0,000 f.bab3 1 8 3,12 1,784 1 3 1,87 0,719 0,014 f.bak3 4 12 7 2,280 5 6 5,56 0,512 0,020 berat badan3 2400 3740 2980 354,54 2400 4400 3084 559,98 0,536 f. menyusu7 6 12 9,75 2,817 6 8 6,81 0,911 0,000 f.bab7 1 6 3,25 1,612 1 2 1,56 0,512 0,000 f.bak7 6 12 8,50 2,129 6 7 6,06 0,250 0,000 berat badan7 2560 3990 3110 396,75 2600 4500 3221 523,12 0,501 107 produksi asi ibu post seksio sesarea (machmudah dan nikmatul khayati) dari tabel 2 dapat dijelaskan bahwa f rek uen si ba k pa d a responden ya ng dilakukan pijat oketani dan oksitosin paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 1 kali dalam sehari, paling tinggi 6 kali bak dalam sehari, rata-rata bak dalam sehari 4 kali dengan standar deviasi 1,611. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin frekuensi bak paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 3 kali dalam sehari, paling tinggi 6 kali bak dalam sehari, rata-rata bak dalam sehari 5 kali dengan standar deviasi 0,816. dari hasil uji analisis menunjukkan bahwa ada beda frekuensi bak pada kelompok intervensi dan kelompok kontrol sebelum dilakukan pijat oketani dan oksitosin dengan p-value 0,025 (α=0,05). dari tabel 2 dapat dijelaskan bahwa berat badan bayi pada responden yang dilakukan pijat oketani dan oksitosin paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 2400 gram, paling tinggi 3800 gram, rata-rata 3025 gram dengan standar deviasi 329,85. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin berat badan bayi paling rendah sebelum dilakukan pijat oketani dan oksitosin adalah 2400 gram, paling tinggi 4200 gram, rata-rata 3137 gram dengan standar deviasi 545,436. dari hasil uji analisis menunjukkan bahwa tidak ada beda berat badan bayi pada kelompok intervensi dan kelompok kontrol sebelum dilakukan pijat oketani dan oksitosin dengan p-value 0,486 (α=0,05). dari tabel 2 dapat dijelaskan bahwa frekuensi menyusu pada responden yang dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin pada hari ketujuh adalah 6 kali dalam sehari, paling tinggi 12 kali menyusu dalam sehari, rata-rata menyusu dalam sehari 10 kali dengan standar deviasi 2,817. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin pada hari ke tujuh adalah 6 kali dalam sehari, paling tinggi 8 kali menyusu dalam sehari, rata-rata menyusu dalam sehari 7 kali dengan standar deviasi 2,817. dari hasil uji analisis menunjukkan bahwa ada beda frekuensi menyusu setelah dilakukan pijat oketani dan oksitosin dengan p-value 0,000 (α=0,05). dari tabel 2 dapat dijelaskan bahwa f rek uen si ba b pa d a responden ya ng dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin pada hari ke tujuh adalah 1 kali dalam sehari, paling tinggi 6 kali bab dalam sehari, rata-rata bab dalam sehari 3 kali dengan standar deviasi 1,612. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin adalah 1 kali dalam sehari, paling tinggi 2 kali bab dalam sehari, rata-rata bab dalam sehari 1 kali dengan standar deviasi 0,512. dari hasil uji analisis menunjukkan bahwa ada beda frekuensi bab setelah dilakukan pijat oketani dan oksitosin dengan p-value 0,000 (α=0,05). dari tabel 2 dapat dijelaskan bahwa frekuensi bak pada responden yang dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin adalah 6 kali dalam sehari, paling tinggi 12 kali bak dalam sehari, rata-rata menyusu dalam sehari 8 kali dengan standar deviasi 2,129. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin frekuensi bak paling rendah setelah dilakukan pijat oketani dan oksitosin adalah 6 kali dalam sehari, paling tinggi 7 kali bak dalam sehari, rata-rata bak dalam sehari 6 kali dengan standar deviasi 0,250. dari hasil uji analisis menunjukkan bahwa ada beda frekuensi bak setelah dilakukan pijat oketani dan oksitosin dengan p-value 0,000 (α=0,05). dari tabel 2 dapat dijelaskan bahwa berat badan bayi pada responden yang dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin pada hari ke tujuh adalah 2560 gram, paling tinggi 3990 gram, rata-rata 3110 gram dengan standar deviasi 396,75. sedangkan pada responden yang tidak dilakukan pijat oketani dan oksitosin berat badan bayi paling rendah setelah dilakukan pijat oketani dan oksitosin adalah 2600 gram, paling tinggi 4500 gram, rata-rata 3221 gram dengan standar deviasi 523,12. dari hasil uji analisis menunjukkan 108 jurnal ners vol. 9 no. 1 april 2014: 104–110 bahwa tidak ada beda berat badan bayi pada kelompok intervensi dan kelompok kontrol setelah dilakukan pijat oketani dan oksitosin dengan p-value 0,501 (α=0,05). pembahasan pijat oketani dan oksitosin merupakan salah satu metode breast care yang tidak menimbulkan rasa nyeri. dari 16 responden yang diberi inter vensi pijat oketani dan oksitosin semuanya berespon positif terhadap pemijatan yang diberikan. pijat oketani dapat menstimulus kekuatan otot pectoralis untuk meningkatkan produksi asi dan membuat payudara menjadi lebih lembut dan elastis sehingga meumudahkan bayi untuk mengisap asi. pijat oketani juga akan memberikan rasa lega dan nyaman secara keseluruhan pada responden, meningkatkan kualitas asi, mencegah putting lecet dan mastitis serta dapat memperbaiki/mengurangi masalah laktasi yang disebabkan oleh putting yang rata (fl at nipple), putting yang masuk kedalam (inverted). (tasnim & kabir, 2009). hasil penelitian menunjukkan bahwa ada peningkatan frekuensi menyusu pada responden setelah dilak u kan inter vensi yaitu 12 kali sehari. hasil analisis statistik menunjukkan bahwa ada beda frekuensi menyusu setelah dilakukan pijat oketani dan oksitosin dengan p-value 0,000 (α=0,05). penelitian gartner (2005) menjelaskan bahwa untuk menjaga produksi asi agar tetap tinggi dapat dengan membiasakan menyusui setiap dua-tiga jam. ibu postpartum biasanya menyusui bayinya sebanyak delapan kali sehari untuk mempertahankan produksi asi. hal ini sesuai dengan hasil penelitian ini yaitu frekuensi menyusu bayi sebanyak 12 kali dalam 24 jam atau rata-rata 10 kali dalam 24 jam. re sponde n d ala m pe nel it ia n i n i diberi intervensi pijat oketani dan oksitosin masing-masing selama 15 menit dengan frekuensi dua kali sehari selama tiga hari berturut-turut (6 kali pemijatan). kabir & tasnim (2009) menjelaskan bahwa pijat oketani dapat meningkatkan kemampuan bayi dalam mengisap (neonate suck). sehingga semakin kuat bayi mengisap, semakin sering bayi menyusu dan semakin meningkat juga produksi asi. frekuensi dilakukan pijat oksitosin juga dapat mempengaruhi produksi asi. hockenberry (2002) menyebutkan bahwa pijat oksitosin lebih efektif apabila dilakukan dua kali sehari yaitu tiap pagi dan sore hari. penelitian yang dilakukan oleh biancuzzo (2003) menyatakan bahwa pijat oksitosin dan breast care yang dilakukan sehari dua kali dapat mempengaruhi produksi asi pada ibu post partum. penelitian yang sama juga dilakukan oleh sholichah (2011) menyatakan bahwa perawatan payudara yang sering dapat memperlancar keluaran produksi asi. hasil penelitian menunjukkan bahwa f rek uen si ba b pa d a responden ya ng dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin pada hari ke tujuh adalah 1 kali dalam sehari, paling tinggi 6 kali bab dalam sehari, rata-rata bab dalam sehari 3 kali dengan standar deviasi 1,612. dari hasil uji analisis menunjukkan bahwa ada beda frekuensi bab pada kelompok intervensi dan kelompok kontrol sebelum dilakukan pijat oketani dan oksitosin dengan p-value 0,005 (α=0,05). frekuensi bab pada bayi baru lahir akan lebih sering sekitar 6-8 kali sehari. bayi yang mendapat asi akan berbeda dengan susu formula. asi sangat mudah dicerna maka bayi akan lebih sering bab. hasil penelitian menunjukkan bahwa ada peningkatan frekuensi bak bayi pada responden setelah dilak u kan inter vensi yaitu 12 kali sehari. hasil analisis statistik menunjukkan bahwa ada beda frekuensi bak bayi setelah dilakukan pijat oketani dan oksitosin dengan p-value 0,000 (α=0,05). bobak, 2005 menjelaskan bahwa salah satu penilaian produksi asi adalah dengan menilai frekuensi bak bayi dan volume urine. bayi yang normal akan bak sebanyak 6-8 kali sehari, warna urine kuning jernih dengan volume urine antara 30-50 mg sehari. hasil penelitian ini sesuai dengan penelitian yang dilakukan oleh budiarti (2009) dan mardianingsih (2010) yang menyebutkan bahwa produksi asi dapat dinilai dari frekuensi bak bayi yaitu sebanyak 6–8 kali 109 produksi asi ibu post seksio sesarea (machmudah dan nikmatul khayati) sehari. penelitian yang dilakukan desmawati (2008) menunjukkan bahwa ada perbedaan yang bermakna antara waktu pengeluaran asi ibu postpartum antara kelompok yang diberi intervensi areola massage dan rolling massage dengan kelompok yang tidak diberi intervensi dengan or 5,714 (95% ci : 1,560–20,929). berat badan bayi pada responden yang dilakukan pijat oketani dan oksitosin paling rendah setelah dilakukan pijat oketani dan oksitosin pada hari ke tujuh adalah 2560 gram, paling tinggi 3990 gram, rata-rata 3110 gram dengan standar deviasi 396,75. dari hasil uji analisis menunjukkan bahwa tidak ada beda berat badan bayi pada kelompok intervensi dan kelompok kontrol setelah dilakukan pijat oketani dan oksitosin dengan p-value 0,501 (α=0,05). hasil penelitian kurniatika (2013) menunjukkan bahwa ada peningkatan berat badan bayi setelah diberi asi selama satu bulan. secara teori, beberapa hari setelah lahir berat badan bayi akan turun lima hingga sepuluh persen dari berat badan bayi saat lahir. hal ini normal terjadi karena bayi kehilangan cairan saat dilahirkan dan asupan asi pada hari-hari pertama belum maksimal. karena itulah, berat badan bayi tidak dapat segera kembali seperti saat dilahirkan, atau naik dengan cepat. berat badan bayi akan meningkat dalam 14 hari, seiring dengan kemahirannya menyusu dan mendapatkan asi (ibu dan balita, 2013). hasil penelitian ini tidak menunjukkan penurunan berat badan yang ekstrem pada bayi baru lahir. pengukuran berat badan pada hari ke tujuh menunjukkan rata-rata penurunan berat badan bayi sebanyak 100 gram dibandingkan dengan berat lahir bayi. yuniati (2010) dalam penelitiannya yang berjudul peningkatan berat badan bayi baru lahir dengan seksio sesarea yang diberikan kombinasi asi dengan susu formula mengandung probiotik dan nonprobiotik, menunjukkan bahwa tidak ada beda peningkatan berat badan bayi sejak lahir sampai usia 4 minggu yang mendapat kombinasi asi dan susu formula mengandung probiotik dan tidak mengandung probiotik dengan nilai p=0,258. ada beberapa faktor yang mempengaruhi tidak meningkatnya berat badan bayi baru lahir antara lain infeksi, adanya kelainan bawaan pada kerongkongan atau lambung bayi yang menyebabkan bayi sering muntah sehingga tidak mendapat asi yang mencukupi untuk pertumbuhannya, atau bayi sensitif terhadap makanan yang dimakan ibu yang dihantarkan melalui asi (ibu dan balita, 2013). simpulan dan saran simpulan ada beda antara frekuensi menyusu, frekuensi bab, frekuensi bak pada responden setelah dilakukan pijat oketani dan oksitosin pada hari ke tujuh dengan, namun tidak ada beda berat badan bayi setelah dilakukan pijat oketani dan oksitosin. saran i nst it usi pend id i ka n perlu u nt u k mengenalkan metode oketani sebagai salah satu upaya untuk meningkatkan produksi asi pada ibu post seksio sesarea. untuk mendukung upaya ini pihak rumah sakit juga harus menerapkan kebijakan rawat gabung sehingga memudahkan ibu dalam menyusui bayinya. perlu dilakukan penelitian lanjutan tentang bagaimana pengaruh pijat oketani dan oksitosin terhadap kualitas produksi asi (komposisi asi) dan bagaimana pijat oksitosin mempengaruhi produksi hormone oksitosin pada ibu. kepustakaan bobak i.m., lowdermilk, d.l., & jensen, m.d., perry, s.e. (2005). buku ajar keperawatan maternitas. edisi 4. alih bahasa: maria & peter. jakarta: egc. depkes ri. (2007). pelatihan konseling menyusui. jakarta : depkes ri desmawati. (2008). efektif itas kombinasi areolla ma ssage dengan rolling massage terhadap pengeluaran asi secara dini pada ibu postpartum di puskesmas pamulang dan cikupa banten. tesis. depok : fik ui (tidak dipublikasikan). evariany, a. (2007). agar asi lancar diawal masa menyusui. diunduh dari http:// 110 jurnal ners vol. 9 no. 1 april 2014: 104–110 www.hypno-birthing.web.id/? diunduh tanggal 10 februari 2013 foda,. et al (2004). composition of milk obtained from unmassaged versus massaged breasts of lactating mothers. journal of pediatric gastroenterology and nutrition 38:484–487 ibu dan balita. (2013). memantau pertumbuhan melalui berat badan bayi. diunduh dar i ht t p://w w w.ibudanbalita.com / pojokcerdas/memantau-pertumbuhanmelalui-berat-badan-bayi, tanggal 09 november 2013. jeongsug., hye young., sukhee & myeong soo. (2012). effects of oketani breast massage on breast pain, the breast milk ph of mothers and the sucking speed of neonates. journal of korean j women health nurs , vol 18 no 2, 149-158 kabir & tasnim. (2009). oketani lactation management : a new method to augment breast milk. journal of bangladesh college of physicians and surgeon, vol. 27,no 3 lowdermilk, d.l., perry, s.e., & bobak, i.m. (2000). maternity women’s health care. 7th ed. st. louis: mosby.inc mardiyaningsih, eko. (2010). efektif itas kombinasi tehnik marmet dan pijat oksitosin terhadap produksi asi pada ibu post seksio sesarea di rumah sakit jawa tengah. tesis. depok : fik ui (tidak dipublikasikan m ay., k . a & m a h l m e i s t e r. (2 0 0 0). comprehensive maternity nursing : nursing process and child-bearing family 2nd edition. j.b. lippincott : philadelphia mck i n ney. em ily., slone., & mu r ray. sharon., smith. (1998). foundation of maternal – newborn nursing. 2nd edition. philadelphia: w.b. saunders company469 olds, s.b., london, m.l., & ladewig, p.a.w. (2000). maternal – newborn nursing a family and communitybased approach. 6th ed. new jersey: prentice hall health pilliteri. (2003). maternal and child health nursing. care of childbearing and childrearing family. 3rd edition. lippincott pudjiadi. (2005). ilmu gizi klinis pada anak. edisi 4. jakarta. fk ui roesli, u. (2005). mengenal asi eksklusif. jakarta : trubus agriwidya sugiyono. (2001). statistik untuk penelitian. bandung : cv. alfabeta yuniati t.(2010). peningkatan berat badan bayi baru lahir dengan seksio sesarea yang diberikan kombinasi asi dengan susu formula mengandung probiotik dan nonprobiotik. diu ndu h d a r i http://saripediatri.idai.or.id/abstrak. asp?q=850, tanggal 09 november 2013. wong , d.l., perry, s.e., & hockenberry, m.j.(2002). maternal child nursing care. (2nd ed). st. louis : mosby vol 9 no 1 april 2014.indd 133 ethnonursing penggunaan terapi komplementer pada suku using banyuwangi (ethnonursing for utilizing complementary therapy at using tribes in banyuwangi) hanny rasny*, tantut susanto*, erti ikhtiarini dewi* * program studi ilmu keperawatan universitas jember jl. kalimantan 37 jember e-mail: hannyrasni@yahoo.co.id abstrak pendahuluan: suku using di banyuwangi sampai saat ini masih mempertahankan tradisi pemanfaatan sumber daya alam sekitar sebagai pengobatan atau perawatan tradisional. penelitian ini dilaksanakan untuk memperoleh gambaran arti dan makna pengalaman suku using menggunakan terapi komplementer dalam praktik penyembuhan pengobatan tradisional. metode: metode kualitatif fenomenologi dengan model ethnonursing digunakan sebagai acuan dalam pelaksanaan penelitian ini. sejumlah 13 responden diperoleh dengan teknik purposive sampling dari 3 komunitas suku using di kecamatan glagah, rogojampi, dan banyuwangi kota. data didapatkan dengan melakukan wawancara mendalam pada responden dan juga observasi lapangan, serta pengamatan saat wawancara. analisa dilaksanakan dengan memilah dan memilih kata atau kalimat yang memiliki arti dan makna sesuai tujuan dengan dikelompokkan menjadi tema-subtema dan kategori. hasil: hasil yang didapatkan adalah suku using memiliki karakteristik keeratan sosial, apresiasi seni, melakukan aktifi tas sehari-hari di sungai, mengkonsumsi makanan dari sumber pangan hewani dan nabati, kurang dekat dengan pelayanan kesehatan, faktor mitos merupakan faktor yang kental dalam perilaku kesehatan dan perilaku pemeliharaan fi sik, perilaku penanganan masalah kesehatan fi sik dan psikis pada suku using adalah dengan penggunaan herbal dan pergi ke dukun. kesimpulan dan diskusi: perilaku penggunaan tanaman herbal secara umum berkesesuaian dengan ilmu kesehatan modern sebagai terapi komplementer, tetapi pada saat ini hampir pudar karena cenderung jarang dilakukan, sehingga perlu adanya penguatan perilaku positif yang telah dimiliki masyarakat, sebagai upaya peningkatan status kesehatan masyarakat. kata kunci: ethnonursing, terapi komplementer, suku using abstract introduction: using tribe in banyuwangi untill today still using natural resources as a traditional treatment or care. this study was purposed to gain value and meaning of using tribe experience for utilizing complementary therapies in traditional healing practice. method: phenomenology study with qualitative methods based on ethnonursing models was used for this research. there were 13 respondents gathered by purposive sampling from three districs: glagah, rogojampi and banyuwangi kota. the data were obtained by conducting in-depth interviews on respondents and fi eld observations as well as observations while interview. the analysis carried out by sorting and selecting a word or phrase that has value and meaning to the goal related with subthemes grouped into themes and categories. result: the results had showed that using tribe’s characteristic were social cohesion, appreciate arts, performing daily activities on the river, consume foods of animal and vegetable, not too close with health service, the myth factor was a strong factor in health and physical maintenance’s behavior, the the use of herbs and shaman to treat health problems. conclusion and discussion: the use of herbs is suitable with modern health science as a complementary therapy, but this point almost faded because it tends to rarely performed. so, the using tribe need positive reinforcement from nurses, as an effort to improve their health status. key words: ethnonursing, complementary nursing, using tribe pendahuluan p r a k t i k ke percaya a n ma sya r a k at t r a d isional me nya k i n i su at u pe nya k it disebabkan oleh sistem naturalistik dan sistem personalistik (foster & anderson, 2002). masyarakat suku using masih meyakini penyebab penyakit dengan sistem tersebut. suku using secara personalistik meyakini penyakit disebabkan oleh sesuatu yang berada di luar si sakit seperti gangguan gaib dari orang lain (guna-guna), jin, makhluk halus, dan lain-lain. secara naturalistik, suku tersebut mempercayai bahwa penyakit disebabkan oleh faktor alamiah, seperti cuaca ataupun gangguan keseimbangan tubuh. 134 jurnal ners vol. 9 no. 1 april 2014: 133–137 nilai-nilai budaya yang masih dianut suku using dalam pencarian pengobatan atau terapi memiliki keunikan dan karakter yang berbeda dari daerah lain di jawa timur. terapi alter natif yang dilak u kan su k u using didasarkan pada alam sekitar, dengan penggunaan sumber hayati dan hewani, melalui suatu perantara pemimpin atau dukun dengan menggunakan sarana upacara tradisional. sistem medis tradisional dalam kenyataannya masih tetap hidup, meskipun praktik-praktik biomedik kesehatan makin berkembang pesat dengan munculnya pusat-pusat pelayanan kesehatan, baik yang dikelola swasta ataupun pemerintah (leininger, 2002). keperawatan sebagai bagian dar i sistem medis modern dapat mengidentifi kasi keberagaman suku using dalam memandang penyakit dan mencari pertolongan melalui penggunaan terapi alternatif melalui kajian ethnonursing (omeri & mcfarland, 2008). st udi ethnonursing dalam pengg u naan terapi alternatif oleh suku using saat ini mulai dikembangkan sebagai bagian dari terapi komplementer keperawatan. studi ethnonursing dalam terapi komplementer mencoba memahami dan membantu kelompok budaya berbeda dan anggota-anggotanya terhadap kebutuhan asuhan keperawatan dan kesehatan (giger & davidhizar, 2004). penelitian ini bertujuan untuk mencari tahu memperoleh gambaran ar ti dan mak na pengalaman su k u using mengg u nakan t e r a p i ko m pl e m e n t e r d a l a m p r a k t i k penyembuhan pengobatan tradisional, dengan mengidentifikasi karakteristik masyarakat using, faktor-faktor yang terkait dengan perilaku kesehatan, perilaku pemeliharaan kesehatan dan perilaku penanganan masalah kesehatan terkait pengobatan tradisional. metode penelitian ini menggunakan metode penelitian kualitatif. pendekatan ethnonursing dapat digunakan untuk mengenali hubungan dan mengidentifi kasi serta mengembangkan pola-pola yang terkait dengan arti atau makna dari fenomena budaya yang diteliti. jumlah responden dalam penelitian ini 13 orang, yang dipilih berdasarkan kriteria: 1) sebagai tokoh masyarakat yang memiliki pengalaman m e n d a p a t k a n p e l a y a n a n p e n g o b a t a n t radisional; dan 2) pember i pelayanan tradisional atau dukun dan masyarakat awam yang memili k i pengalaman mengakses pelayanan pengobatan tradisional. responden b e r a sal d a r i ke ca m at a n ba ny uwa ng i kota, glagah, dan rogojampi. wawancara dilaksanakan di r u mah masing-masing respoden dan dukun yang digunakan oleh masyarakat awam untuk mengakses pelayanan pengobatan tradisional. alat pengumpulan data yang digunakan adalah pedoman wawancara, catatan lapangan (field notes), dan mobile phone dengan aplikasi perekam, serta tape recorder adapun alat perekam yang digunakan dibawa oleh pengumpul data. hasil su k u usi ng me m i l i k i b eb e r a p a karakteristik, yaitu 1) memberikan apresiasi tinggi terhadap kesenian terutama musik; 2) memiliki hubungan sosial yang erat dengan melakukan interaksi sosial yang intens; 3) mengkonsumsi berbagai olahan dari berbagai sumber pangan: tanaman dan hewan (seperti kelor, boboan, pakis, tokek, jangk r ik); 4) memiliki perilaku konsumtif (seper ti kebiasaan mengumpulkan uang satu tahun dan dihabiskan beberapa hari saat perayaan idul fitri); 5) melakukan kegiatan seharihari tidak jauh dari sungai seperti: buang air, mandi, cuci baju, mususi (mencuci beras); dan 6) cenderung berjarak dengan pelayanan kesehatan modern. pa d a fa k t or p e r i la k u ke seh at a n diketahui bahwa faktor mitos merupakan faktor yang paling mempengaruhi suku using. selain faktor tersebut, faktor keeratan sosial (keluarga) merupakan salah satu penentu untuk pilihan perilaku kesehatan, faktor persepsi masyarakat mengenai jenis penyakit tertentu tidak dapat ditangani di pelayanan kesehatan modern dan sebaliknya, dan persepsi bahwa pelayanan kesehatan tradisional dan moder n saling melengkapi. faktor jarak pelayanan kesehatan modern yang masih cukup jauh (sulit dijangkau) atau sulit untuk 135 ethnonursing penggunaan terapi komplementer (hanny rasny, dkk.) mengakses tenaga kesehatan karena jumlah yang terbatas merupakan faktor yang masih ada, tetapi cenderung sudah berubah lebih baik. faktor tindakan pelayanan kesehatan moder n ya ng asi ng at au menya k it ka n (seperti disuntik) menjadi satu pemberat untuk memilih pelayanan kesehatan modern dan faktor perbandingan biaya pelayanan kesehatan modern terbilang mahal (khususnya pada masa lampau sebelum jamkesmas). sedangkan pelayanan kesehatan tradisional tidak menentukan tarif. faktor pendidikan juga turut sebagai penentu pilihan perilaku kesehatan tetapi terkait dengan siapa yang sakit (misalnya, anak atau orangtua yang tidak dapat memutuskan pilihan oleh diri sendiri dan keputusan pilihan merupakan rembukan sosial) menjadikan faktor pendidikan ada di urutan selanjutnya. gambaran per ilak u pemeliharaan kesehatan, diketahui adanya perilaku perawatan (upaya untuk tetap sehat atau bertambah sehat) dan perilaku pencegahan. perilaku perawatan tubuh terbagi dalam perawatan tubuh bagian luar dan dalam. perawatan tubuh bagian luar, sebagai berikut: 1) perempuan (atau laki-laki) melakukan wuwung keramas dengan menggunakan merang padi untuk mendapatkan rambut yang bersih, tidak bau (cender ung masa lampau); 2) perempuan melakukan lulur badan dengan menggunakan mangini lulur untuk mendapatkan tubuh yang cantik dan halus (cenderung masa lampau, 27 berinteraksi dengan sungai dalam adl,apresiasi tinggi pada kesenian, keeratan sosial, suka makan olahan berbagai sumber pangan nabati dan hewani, konsumtif dan berjarak dengan pelayanan kesehatan modern faktor internal: mitos persepsi sejarah alam ikatan sosial pendidikan faktor ekternal: jarak pelayanan jenis pelayanan biaya pelayanan: tarif perilaku perawatan: a.tubuh bagian dalam b. tubuh bagian luar perilaku pencegahan perilaku penanganan masalah kesehatan fisik bagian luar perilaku penanganan masalah kesehatan fisik bagian dalam perilaku penanganan masalah kesehatan psikis model: sunrise of java (using banyuwangi) gambar 1. model sunrise of java (using tribes, banyuwangi) pada saat ini lulur dengan membeli bahan lulur kemasan). sementara tubuh bagian dalam, sebagai berikut: 1) melaksanakan pantangan makan (misalnya, pada keluarga tertentu yang diturunkan pesan dari orang tua untuk berpantang makan-makanan tertentu (seperti terong), maka tidak berani untuk melanggar walaupun laki-laki); 2) perilaku konsumsi nutrisi: makan ikan laut, makan berbagai jenis sayuran: sayur kelor, pakis, klentang, boboan, makan berbagai jenis rujak: janganan, kecut/ cemplung, pasrah, ramonan, montor, iris/letok (khusus: rujak mengkudu untuk meningkatkan nafsu makan); 3) perilaku minum jamu, seperti pada perempuan bermaksud untuk menghilangkan bau badan, pada laki-laki bermaksud untuk memelihara vitalitas tubuh, nama jamu: jamu kuat; dan 4) perilaku khusus, pada saat tertentu (tidak rutin) pada laki-laki dengan bermaksud menjaga vitalitas maka memakan langsung (dalam keadaan mentah) atau olahan, seperti empedu kambing, bayi mencit, janin rusa. g a mb a r a n p e r i la k u p e n a ng a n a n masalah kesehatan diketahui bahwa ada perilaku penanganan masalah kesehatan fi sik dan perilaku penanganan masalah kesehatan psikis. perilaku penanganan masalah kesehatan fi sik terbagi menjadi: 1) penanganan masalah kesehatan bagian tubuh luar (misalnya, luka disembuhkan dengan menendang kepong (kotoran kuda/sapi) atau getah daun yodium); 2) penanganan masalah kesehatan f isik 136 jurnal ners vol. 9 no. 1 april 2014: 133–137 pada tubuh bagian dalam (misalnya, batuk diobati dengan jeruk jawa dibakar diberi njet, diperas dan diminum atau jeruk nipis dibakar dan airnya diminum; diare diobati dengan pucuk daun jambu klutuk/sawo manila dan diminum; panas diobati dengan mengoleskan bawang putih ke pusar atau diminumkan air dari dukun kepada anak yang panas; sakit kuning diobati dengan pisang mas ditambah 7 ekor pediculus capitis; dan lain-lain). sedangkan, 1) perilaku penanganan masalah kesehatan psikis, antara lain: 1) kesurupan, diobati dengan mengoleskan bawang putih di pusar atau minum air pemberian dukun; 2) stres akibat tekanan hidup sehari-hari disarankan untuk melakukan midang (melihatlihat ke jalan raya); dan 3) ditenung, disihir, disantet, dicekek disarankan untuk mencari dukun yang dapat mengembalikan kiriman. pembahasan “jika anda berharap untuk membantu satu komunitas untuk mencapai kesehatan, anda harus belajar untuk berpikir seperti orangorang yang berada di komunitas tersebut. sebelum menanyakan sekelompok orang untuk mengasumsikan kebiasaan kesehatan yang baru, adalah bijak untuk menyadari kebiasaan yang ada, bagaimana kebiasaan tersebut berhubungan satu dengan yang lain, apa fungsinya dari yang mereka lakukan, apa makna bagi mereka melakukan hal tersebut” (andrews dan boyle, 1995; rasni, 2008). sehat adalah keadaan lengkap dari sehat jasmani, rohani, dan sosial, ser ta tidak hanya mengenai bebas dari penyakit atau kecacatan, tetapi juga dapat bekerja secara produktif (who, 1975). sehat pada masyarakat terkait dengan adanya status sehat pada individu-individu di wilayah, adanya perilaku-ketrampilan yang mengupayakan sehat dan adanya lingkungan fi sik serta sosial (termasuk sistem-struktur masyarakat) yang bergerak untuk mengupayakan sehat. sehat pada masyarakat tidak akan pernah terwujud jika hanya dari tenaga kesehatan profesional yang mengupayakan hal tersebut, tanpa ada kesertaan atau kemandirian dari masyarakat, dan adanya persepsi nilai-indikator sehat pada masyarakat yang sesuai dengan indikator yang digunakan dalam menentukan status sehat pada masyarakat. keperawatan sebagai bagian dar i sistem medis modern dapat mengidentifi kasi ke b e r a g a m a n m a s y a r a k a t t r a d i sio n a l dalam memandang penyakit dan mencari per tolongan melalui pengg unaan terapi alternatif dapat diidentifi kasi melalui kajian ethnonursing (omeri & mcfarland, 2008). studi ethnonursing dalam terapi komplementer mencoba memahami dan membantu kelompok budaya berbeda dan anggota-anggotanya dengan kebutuhan asuhan keperawatan dan kesehatan (giger & davidhizar, 2004). caracara memfasilitasi suatu budaya masyarakat dalam penggunaan terapi alter natif atau komplemeter dalam asuhan keperawatan perlu ditekankan pada tindakan keperawatan terkait dengan transcultural nursing model (leininger, 1978; dalam omeri & mc.farland, 2008), yaitu: cultural preservation, cultural care accomodation, dan cultural care repattering. cultural preservation mencoba membantu budaya tertentu untuk memper tahankan nilai care yang berhubungan, sehingga sehat. cultural accommodation membantu budaya tertentu untuk bernegosiasi untuk manfaat dan sehat yang memuaskan bersama tim kesehatan. cultural repattering membantu budaya tertentu untuk berubah, memodifi kai gaya hidup mereka untuk kesehatan yang memuaskan daripada sebelumnya. gambaran mengenai pengalaman suku using dalam pemeliharaan atau penanganan masalah kesehatan yang didapatkan dari hasil analisa data penelitian tersebut, menunjukkan bahwa banyak perilaku yang sesuai dan dapat digunakan dalam adaptasi perilaku kesehatan modern. seperti pengobatan herbal pada saat ini banyak dianjurkan oleh pengobatan kesehatan modern dikarenakan adanya obatobat herbal yang minim efek samping, contoh adanya pelayanan kesehatan modern dengan mengadopsi dari cara tradisional adalah pemijatan. pelayanan pemijatan (khusunya pada bayi-anak) saat ini berkembang menjadi satu jasa pelayanan di r umah sakit atau klinik kesehatan modern, atau pengenalanpengenalan oleh tenaga kesehatan kepada 137 ethnonursing penggunaan terapi komplementer (hanny rasny, dkk.) keluarga-keluarga saat ini untuk menggunakan obat-obat herbal sebagai tindakan awal dalam penanganan masalah kesehatan, seper ti meminum jer uk nipis untuk menangani batuk, meminum jamu kunyit, temulawak, beras kencur, atau mengkonsumsi bawang putih. interaksi sosial yang erat pada suku using merupakan salah satu potensi yang menjadi sistem pendukung untuk keberdayaan masyarakat yang dapat menjadi landasan untuk terwujudnya masyarakat sehat dengan tentunya individu-individu yang ada pada masyarakat akan memiliki status sehat. “culturally congruent (nursing) care is defi ned as ‘those cognitively based assistive, supportive, facilitative or enabling acts or decisions that are tailor-made to fi t with individual, group or institutional cultural values, beliefs and lifeways in order to provide or support meaningful, benefi cial and satisfying health care or well-being services” (george, 2008) hasil penelitian ini merupakan awal dari upaya untuk mengenal suku using dan berharap untuk lebih lanjut dapat mengenal dan mendokumentasikan potensi-potensi suku using, yang kemudian dapat bersama mewujudkan kesehatan masyarakat, bahkan mengadopsi potensi suku using untuk dapat terus dilakukan. simpulan dan saran simpulan suku using memiliki karakteristik: interaksi sosial yang erat, memberikan apresiasi tinggi pada kesenian, menyukai makanan olahan dari sumber hewani dan nabati, memiliki perilaku konsumtif, tetapi juga masyarakat yang ber jarak dengan pelayanan kesehatan, dan kegiatan seharihari masih banyak dilakukan di sungai. suku using memiliki mitos, persepsi, pengalaman sejarah, keadaan alam, keterikatan sosial, tingkat pendidikan, jarak dengan pelayanan, jenis pelayanan kesehatan dan tarif pelayanan menjadi penentu untuk pilihan pelayanan kesehatan. suku using memiliki perilaku perawatan kesehatan, perilaku pencegahan masalah kesehatan dan perilaku penanganan masalah kesehatan secara fisik dan psikis yang sudah lama ada pada masyarakat yang cenderung mulai memudar. secara umum, pengalaman suku using dalam perilaku kesehat a n ba nya k ya ng berkesesu aia n dengan ilmu kesehatan modern dan perlu adanya penguatan potensi dari yang pernah dimiliki masyarakat, sehingga tidak hilang dari masyarakat dan justru dapat digunakan sebagai penyelesaian masalah yang ada pada saat ini. saran peran dari berbagai pihak, pemerintah kabupaten, akademisi, tokoh masyarakat, profesi kesehatan dan keterlibatan aktif masyarakat diperlu kan u nt u k membuat kegiatan-kegiatan sosial kemasyarakatan yang mengikutsertakan masyarakat secara aktif dari pengenalan masalah yang ada sampai dengan penyelesaian masalah yang ada dengan menggunakan potensi-potensi yang dimiliki menjadi suatu keadaan yang dibutuhkan pada suku using saat ini. kepustakaan foster & anderson. (1999). antropologi kesehatan. ui press: jakarta. giger & davidhizar. (2001). transcultural nursing: assessment and intervention 2nd ed. st louis: mosby a times miror company. george & julia ( 2008). nursing theories: the base for professional nursing practice. fifth edition. prentice hall: new jersey. leininger & mcfarland. (2002). transcultural nursing concepts, theories, research, and practice. 3rd ed. the mcgraw-hill companies, inc: us of america. omeri & mcfarland. (2008). advances in competar y transcultural nursing second edition. content management: sydney. rasni. (2008). laporan aplikasi keperawatan komunitas ii. fik-ui. depok jawa barat. 49 development of transactional communication model for midwife and postpartum mother on exclusive breastfeeding rekawati susilaningrum, sri utami, susilorini school of midwifery soetomo health polytechnic ministry of health surabaya prodi midwifery soetomo surabaya surabaya polytechnic ministry of health email: srekawati@yahoo.com abstract introduction. exclusive breastfeeding has become a major issue in surabaya because the number of exclusive breastfeeding coverage are less than 80% which is below the national target. the purpose of this study was to develop a transactional communication model based on management between midwife and postpartum mother on exclusive breastfeeding. method. the design used in this study was cross-sectional with 175 postpartum mothers in public health center surabaya as the samples that recruited by purposive sampling. questionnaires were used as instrument and data were analyzed by using descriptive statistical test and partial least square (pls). result. the result showed that predisposing factors and enabling factors were able to improve the practice of exclusive breastfeeding directly or indirectly by transactional communication with t-table (>1.96). however, reinforcing factors could not directly improve the practice of exclusive breastfeeding. this study indicates that practice of exclusive breastfeeding could be improved with transactional communication based on human interaction theory. discussion and conclusion. the implementation of transactional communication between midwife and mother would be able to optimize the predisposing factors, enabling factors, and reinforcing factors on the practice of exclusive breastfeeding. keywords: transactional communication, practice of exclusive breast feeding. __________________________________________________________________________________________ introduction the indonesian health law number 36, 2009 in article 128 explains that every baby is deserved to get exclusive breastfeeding from birth to six months, except on medical indications. as part of the government's commitment to increase breastfeeding rates, indonesia has set up indonesian government regulation number 33 of 2012 about exclusive breastfeeding. the regulation makes it possible to create an environment in which empowers women to exclusively breastfeed for the first six months and continue breastfeeding for two years or more. but this effort has not fully implemented by health worker and society. the most reasoning used are not enough breast milk, sick baby, mother’s condition and various other reasons. in the end, the best solution is infant formula milk. the regulation of rooming in at the hospital, maternity clinics, and private midwives can not be implemented properly because of the limited space. thus the mother and the baby is treated separately and might inhibit exclusive breastfeeding. based on data from riskesdas on 2013 and ministry of health, exclusive breastfeeding coverage could not reach the indonesian government target by 80%. those caused by the high number of pre-lacteal feeding, working mother, and infant formula milk. pre-lacteal feeding at the age of 0-5 months is an indicator of exclusive breastfeeding failure. the percentage of prelacteal feeding at 0-5 months is 44.7%. while the percentage of exclusive breastfeeding based on surabaya city health profile in 2012 was 60.52%, then increase slightly in 2013 become 62.67% and 64.33% in 2014. for the east java province, the percentage of exclusive breastfeeding was 64.08% in 2012 and 68.48% in 2013. although there was an increasing number, those indicate that the exclusive breastfeeding coverage, both in surabaya and east java still on the below of government’s target. based on afifah’s research in 2007, there were 11 out of 12 subjects failed to provide exclusive breastfeeding because most of them had given pre-lacteal feeding and there was only one subject who had been success giving exclusive breastfeeding until the baby was older than four months. the predisposing factors of the failure of exclusive breastfeeding are the lack of knowledge about exclusive breastfeeding and their beliefs about pre-lacteal feeding, hence encourage low motivation to provide exclusive breastfeeding. the enabling factors are a lack of counseling jurnal ners vol. 12 no. 1 april 2017: 49-59 50 or guidance about exclusive breastfeeding and unavailability of the rooming-in facility in clinical settings. the reinforcing factors are the lack of direction from midwife about breastfeeding and the strong influence of the mother (grandmother) for infants care in nonexclusive breastfeeding (afifah 2007). one effort to improve the coverage of exclusive breastfeeding is their transactional communication between health worker and mother by adopting the behavior theory of lawrence green. the purpose of this research is to develop a model of transactional communication between midwife and patient on exclusive breastfeeding by postpartum mothers at health center in surabaya. methods this study design was a cross-sectional (observatory). samples were postpartum mother treated at health centers in surabaya city. the sample size was determined by rule of the thumb formula. in this study, the number of the parameter was 37, so the samples were 175 respondents taken by multistage random sampling technique. there was 11 health center chosen by proportional random sampling. respondent were determined by purposive sampling. data analysis techniques used inferential analysis techniques to test the empirical model and the hypothesis proposed by the researcher. inferential analysis using structural equation modeling (sem) was based on variance, called partial least square (pls). the research location was at the health centers in surabaya which provided normal childbirth service. there was 21 health centers hospitalization. result according to table 1, good knowledge, positive attitude, intermediate education, low socio-economic and support tradition were the dominant number of predisposing factors. among enabling factor (table 2), good worker behavior, support infrastructure, and positive attitudes revealed the highest percentage. among reinforcing factors namely good and positive public figure and understand legislation (table 3). the highest percentage of good seci 1 and good seci 2 was found within transactional communication factor (table 4). figure 1. model of transactional communication between midwife and patient based on knowledge management on exclusive breastfeeding provision by postpartum mother development of transactional communication model (rekawati susiloningrum, et.al.) 51 table 1. distribution respondent based on variable of factor predisposing no. predisposingfactor frequency percentage dimension category 1 knowledge low 49 28.0 moderate 41 23.4 good 85 48.6 2 attitude negative 20 11.4 positive 155 88.6 3 education basic 66 37.7 intermediatte 87 49.7 high 22 12.6 4 socio-economic low 86 49.1 moderate 61 34.9 high 28 16.0 5 tradition does not support 32 18.3 support 143 81.7 table 2. distribution of respondent based on enabling factor at puskesmas, surabaya, 2016 no. enabling factor frequency percentage dimension category 1 worker behavior less 23 13.1 good 152 86.9 2 infrastructure does not support 58 33.1 support 117 66.9 3 the attitude of worker negative 19 10.9 positive 156 89.1 table 3. distribution of respondents based on reinforcing factor at puskesmas, surabaya, 2016 no. reinforcing factor frequency percentage dimension category 1. public figure behavior less 78 44.6 moderate 0 0 good 97 55.4 2. legislation missunderstand 63 36.0 understand 112 64.0 3. public figure attitude negative 33 18.9 positive 142 81.1 table 4. distribution of respondent based on transactional communication factor no. transactional communications frequency percentage dimension category 1. seci 1 less 28 16.0 moderate 60 34.3 good 87 49.7 2. seci 2 less 30 17.1 moderate 58 33.1 good 87 49.7 jurnal ners vol. 12 no. 1 april 2017: 49-59 52 figure 2. result of outer model with loading factor value using partial least square (pls) the calculation shows predisposing factor variables, which were education, knowledge, attitude, socio-economic, and tradition, showed five dimensions had a loading factor value over 0.5 and t value was greater at 1.96. among those five dimensions, which the greatest loading value was the attitude. therefore, the attitudes, including the most influential dimension on the predisposing factor. the enabling factor variable, which consists of worker behavior, infrastructure, and worker attitude showed three dimensions had loading factor value over 0.5 and t value was greater than it at 1.96. among those dimensions, the worker attitude was the highest at 0.9170. therefore, the worker attitude was the most influential dimension on enabling factor. moreover, reinforcing factors, such as public figure attitude, public figure behavior, and legislation, showed loading factor value at 0.5 and t was higher than the former at 1.96. among them attitude of public figure was the highest at 0.8417. so, public figure attitude was the most influential dimension on reinforcing factor. transactional communication variable shows that the dimensions of the first and second seci had loading factor value over 0.5 and the greater value was t at 1.96. the greatest loading factor value was seci 1 at 0.9231. thus, the seci 1 was the most influential dimension of transactional communication. in breastfeeding variable, the number of dimensions was only one. so the value of loading factor for variable breastfeeding was 1. all variable constructs showed all variables had ave value over 0.5. so that, the entire latent variables had good validity. results of cross loading for education, knowledge, attitudes, socio-economic, and tradition had a greater value on predisposing factor than other variables. thus, the dimensions of a predisposing factor were different with another dimension. cross loading value of worker behavioral dimension, infrastructure and worker attitude were bigger than other development of transactional communication model (rekawati susiloningrum, et.al.) 53 variables. so, the dimension of enabling factor was different with another dimension. cross loading which was public figure attitude, public figure behavior, and legislation were higher than another variable. therefore, the dimension of the reinforcing factor was different with another dimension. cross loading value for seci 1 and seci 2 was greater than other variables. so, the dimension of transactional communications was different dimension with another dimension. the test results indicate that the constructs (variables) had a composite reliability value over 0.7. so it is reliable. inner model testing stage (structural model stage) this structural model phase aims to determine whether there is influence between variables or not. the test is carried out by using t-test.variable will have influence if t value is greater than t table. t table was at 1.96. likewise, if the relationship among variables are negative, t value is smaller than t table. the calculation result can be seen in figure 3. figure 3. result of inner model test (structural model stage) table 5. path coefficient value and the t-test among variable relationship between variables path coefficients t statistics information predisposing factor  communication transactional 0.3660 4.5837 ho rejected enabling factor  communication transactional 0.2740 3.0040 ho rejected reinforcing factor  communication transactional 0.1553 2.0144 ho rejected predisposing factor  breastfeeding 0.2534 2.8172 ho rejected enabling factor  breastfeeding 0.2444 2.2818 ho rejected reinforcing factor  breastfeeding 0.0119 0.1505 ho accepted transactional communications  breastfeeding 0.3981 4.3971 ho rejected jurnal ners vol. 12 no. 1 april 2017: 49-59 54 based on table 5, coefficient estimation of predisposing factors, reinforcing factors, and enabling factors for transactional communication had a positive value. it means the more improvement of those factors will increase the transactional communication. while the coefficient estimation of predisposing factors, reinforcing factors, and enabling factors for breastfeeding also had positive value, means that breastfeeding will be enhanced if those factors are increased. the positive value also seen on the coefficient estimate for transactional communication on breastfeeding, it means that transactional communication will lead to enhancement of breastfeeding. t-test aimed to observe whether there was a direct influence or not. based on t test on table 5, it showed that predisposing factors, enabling factors, and reinforcing factors had to influence to transactional communication. while the factors which had influenced to breastfeeding were predisposing factors, enabling factors, and transactional communication. reinforcing factors did not had influence the breastfeeding behavior. testing goodness of fit test on the structural model was conducted with looking at the value of rsquare which is a test for the goodness-fit model. testing of the model can be seen through r-square value on equality among latent variables. the value r2 explains that how large exogenous (independent/free) in the model can explain the endogenous variables (dependent / dependent). r square shows that predisposing factor, enabling factor, reinforcing factor influenced communication transactional which was at 0.4610 or 46.10%. meanwhile, the influence of predisposing factor, enabling factor, reinforcing factor and communication transactional on breastfeeding was at 0.6069 or 60.69%. in addition, the r-square model is also evaluated with the value of q-square. the value of the q-square can be calculated with: q2= 1 (1 -0.4610) (1 -0.6069) = 0.788. based on the result, it can be seen that the q-square value was at 0.788. because the value q2 > 0, it can be concluded that the variables of a predisposing factor, enabling factor, reinforcing factor to the transactional communication had a good prediction of the breastfeeding. the result of the ave average was 0.7569 while the average of r2was 0.5340 so that the goodness of fit index (gof) value was 0.6358. this value was good or great category. according to tenenhau (2004), the value of gof small = 0.1, gof medium = 0.25 and gof great = 0.38. table 6 indicates that the indirect relationship which was greater than the direct relationship was indirect relationship reinforcing factor against breastfeeding. however, other relationships in its direct influence were greater than its indirect influence, the namely direct relationship between predisposing factor and breastfeeding, and also enabling factor and breastfeeding. focus group discussion (fgd) fgd conducted to get feedback from the coordinator of the health center, midwife, and postpartum mother at a health center in surabaya about the strategic issues. the results and recommendation of fgd described in table 7. table 6. indirect relation and its comparison to direct influence indirect relationships originally coefficient indirectcoefficient direct coefficient predisposing factorbreastfeeding predisposing factortransactional communicationsbreastfeeding 0.3660x0.3981=0.1457 0.2534 enabling factorbreastfeeding enabling factortransactional communicationsbreastfeeding 0.2740x0.3981=0.1091 0.2444 reinforcing factorbreastfeeding reinforcing factortransactional communicationsbreastfeeding 0.1553x0.3981=0.0618 0.0119 development of transactional communication model (rekawati susiloningrum, et.al.) 55 table 7. the result and recommendation of fgd no theme recommendation 1. the lack of commitment in providing exclusive breastfeeding her baby  personal counseling on exclusive breastfeeding had to be given from commencing pregnant to childbirth.  improving maternal commitment to keep providing her breast milk by emphasizing on disadvantages of no giving exclusive breastfeeding and the benefits of breastfeeding, especially for health and child development. 2. the lack of parent in-law (grandmother of the baby) support  socialization to grandmother about exclusive breastfeeding  involving grandmothers in implementation of exclusive breastfeeding counseling  class formation for grandmother that is focused on the material of exclusive breastfeeding and newborn care table 8. development of transactional communication model between midwife and postpartum mother structure standard development low practice/ behavior of mother in exclusive breastfeeding 1. breastmilk is given from newborn to 6 months, and it continues to breastfeed until the child is 2 years old. 2. personal counseling to a mother with transactional communication approach starting from pregnancy to childbirth. 1. personal counseling on exclusive breastfeeding with transactional communication approach. 2. increasing commitment to exclusive breastfeeding mother to her baby 3. improving knowledge of grandmother about exclusive breastfeeding 4. transactional communication is not only for mother but also for grandmother. grandmother formation focuses on exclusive breastfeeding discussion the predisposing factor can improve transactional communication. predisposing factor consists of education, knowledge, attitude, socioeconomic and tradition. good knowledge, good education background, positive attitude of mother who support exclusive breastfeeding, proper learning, and positive tradition/culture that supports exclusive breastfeeding are factors that help health professional (midwife) to perform transactional communication based on knowledge management. only a few mothers who still believe that breastfeeding will deform the breast and mothers are not allowed to eat certain food like egg, fish, chicken, and meat during breastfeeding. those indicate only a few mothers had poor knowledge and attitude about breastfeeding. transactional communication can be delivered by socialization, counseling, and guidance on breastfeeding, information, and education about the benefit of breastfeeding, mother nutrition during lactation, and the negative consequences of infant formula. this communication can be done to the mother since the pregnancy until the period of exclusive breastfeeding. this is in accordance with government regulation no. 33 of 2012 about exclusive breastfeeding (indonesia n.d.). the enabling factor can improve transactional communication. enabling factor consists of worker behavior, infrastructure, worker attitude, and communication media. in health care settings, personal communication occurs between health worker and client. in this study, interpersonal communication carried out between midwife and pregnant or postpartum. interpersonal communication is effective communication between health worker and client. the most important media in interpersonal communication is language, both spoken and writing (notoatmodjo 2007). there are still some health centers not supporting to facilitate exclusive breastfeeding such as breastmilk storage because of limited jurnal ners vol. 12 no. 1 april 2017: 49-59 56 funds. the condition is not a significant problem because the mother usually returns 24 hours postpartum. on the other hand, midwives have been providing information to mothers about the importance of exclusive breastfeeding as well as the attitude of health worker who supports exclusive breastfeeding. it needs a commitment from all health workers, especially midwives to the success of exclusive breastfeeding. it has been stated in the regulations about breastfeeding, organizers of health care facilities are required to provide information and education about exclusive breastfeeding to mother and family member since her pregnancy. the reinforcing factors also have an influence on transactional communication. reinforcing factor consist of public figure attitude, public figure behavior, and regulation. the reinforcing factor is an amplifier for someone to change behavior such as public figure, law, regulation, and decree. lawrence green, 1984 in notoatmodjo (2007) stated that health promotion is any combination of health education and interventions related to economic, political, and organizations designed to ease behavioral and environmental changes for health. the attitude and behavior of public figures who support exclusive breastfeeding make easier the implementation of transactional communication based on knowledge management. the public figure will be easier to affect the surrounding community. their attitude and behavior are role model for society. this condition makes easier the midwife to socialize public about the importance of exclusive breastfeeding. figure support will improve community empowerment in health. a predisposing factor which consists of knowledge, attitude, socioeconomic and tradition affects on improvement the exclusive breastfeeding. according to the theory of lawrence green in notoatmodjo (2007) states that a person's behavior or public about health is determined by the knowledge, attitude, belief and tradition of the person or people concerned. knowledge is an essential aspect to determine a person's behavior to realize and decide their behavior. knowledge is one of the predisposing factors to behavior. mother’s knowledge about breastfeeding is one of the important factors in the success of breastfeeding. research in bangkok, thailand on 221 mothers using questionnaires gave good result but the behavior of providing exclusive breastfeeding was low because there were other influential factor, namely: (1) the mother was busy as career woman; (2) the influence of other people / families who care for babies; (3) the absence of exclusive breastfeeding during antenatal; and (4) the provision of infant formula after childbirth in the hospital or health facility (li et al. 2003). the most contributing socioeconomic variable was a mother with incomes below the minimum wage and not providing exclusive breastfeeding. purnamawati research (2003), there is a relationship between socio-economic and breastfeeding. the result also explains the low socioeconomic will have more chance (4.6 times) to breastfeed than mothers with high socio-economic. however, yefrida cited by (purnamawati 2003) said there was no relationship between socioeconomic and breastfeeding practice. socio-economic status of the family can affect a family's ability to produce or purchase the food. a mother from a low-income family is mostly less educated and access to health information is more limited than the mother with a high-income family so that their understanding of exclusive breastfeeding is low (suyatno 2000). the habit has two aspects, namely knowledge and practice. in fact, the practice is influenced by knowledge. if the traditional knowledge still exists, the practice will be still running. therefore, the socialization does not only include activities providing new knowledge to the mother. what is more important is to convince the mother that the wrong habit can harm the baby's nutritional and health status (maas n.d.). enabling factor affects to breastfeeding. enabling factor consists of worker behavior, infrastructure, and worker attitude. the important role of health workers is to protect, promote, and support breastfeeding seen by their involvement in the social aspect. as an individual who has an important role in infant nutrition and health care, health worker have a unique position to influence the organization and function of mother’s health services, in before, during, and after pregnancy and childbirth. knowledge, attitudes, and behavior development of transactional communication model (rekawati susiloningrum, et.al.) 57 of health workers in providing health services is crucial for breastfeeding. breastfeeding implementation by postpartum mother, health workers can provide a positive influence by demonstrating attitude to the mother and her family so that they see pregnancy, childbirth, and breastfeeding as an enjoyable experience gained in a friendly and supportive environment (perinasia 1994). place of birth can also give effect to the provision of exclusive breastfeeding in infants because it is the starting point for mothers to choose whether to continue providing exclusive breastfeeding or give a formula given by health workers and non-health prior to her breastmilk come out. the result of fgd has been agreed with the control of pregnant women to the health center, they will be given personal counseling on exclusive breastfeeding preparation and all aspects associated with exclusive breastfeeding. it is held with starting at trimester and continuing until after giving birth. inadequate infrastructure such as breastfeeding corner, leaflet, and breastfeeding kit are obstacles for a counselor. it is same as a previous study showing that a breastfeeding counselor with good facilities and equipment has a tendency to have good performance when compared with a breastfeeding counselor that is not supported by complete facilities and equipment (amirudin 2008). there is no influence of reinforcing factor to breastfeeding. reinforcing factor consist of public figure attitude, public figure behavior and regulation. regulation or policy is a series of concept and principle guide to conduct a certain work. the policy is a guideline for action likely to get the desired result. a policy is a written rule that a formal decision of the organization which are binding and regulates behavior to create a new value system in society. if the policy at health center supports exclusive breastfeeding program, breastfeeding will be easier for six months during implementation. but if there is no policy, despite the knowledge and attitudes of health workers has been good to practice exclusive breastfeeding, it will still be an obstacle. fgd concluded that health center does not provide or does not impose any infant formula with no excuse. the health center has imposed the rule that the child's birth will do the imd and followed by exclusive breastfeeding and continued breastfeeding until the child is two years old. there is no effect of this regulation in improving exclusive breastfeeding behavior caused by a misunderstanding of client or mother. or it could be due to the client merely know about the rules of exclusive breastfeeding. but do not understand the content of the regulation. therefore, the rule which supports a policy should be socialized for client and society. transactional communication improves the mother’s behavior to implement exclusive breastfeeding. transactional communication model emphasizes sending and receiving messages that continue over time in an episode of communication. communication is a cooperative process, in which the sender and receiver of the message, the midwife and mother/patient, have a responsibility to the impact and effectiveness of communication (komala 2009). transactional communication assumes that we are continually sending and receiving messages, dealing with verbal and non-verbal elements. in other words, communicant conducts on the negotiation process about the meaning of communication. transactional communication has been done by the midwife with mother since the pregnancy, giving birth and post-partum. personal communication aims to improve the knowledge, attitude, and practice of mother in breastfeeding (rohim 2007). breastfeeding counseling is an effective way to enhance exclusive breastfeeding (qureshi et al. 2011). the availability of breastfeeding counselor in a facility of health services is expected to provide information about the benefit, the way to breastfeeding well, and problem-solving in breastfeeding. mother gets completely and intensively breastfeeding counseling or get counseling at least 5 visits which are more likely to provide exclusive breastfeeding until six months (nankunda et al. 2010). transactional communications model between midwife and patient is based on knowledge management. it used analysis of measurement model and structural model and then compared with the initial model. the result of the structural model is described on figure 4. exclusive breastfeeding behavior can jurnal ners vol. 12 no. 1 april 2017: 49-59 58 be improved by improving the quality of transactional communication. it also needs to consider predisposing factors, enabling factors and reinforcing factors. the effective transactional communication between midwife and mothers will be able to optimize the behavior of exclusive breastfeeding. figure 4. research finding of transactional communication model between midwife and postpartum in providing exclusive breastfeeding conclusion predisposing factor, enabling factor, the reinforcing factor can improve the process of transactional communication and improve the behavior of mother to give exclusive breastfeeding. transactional communication between the midwife and the client can improve the behavior of mother in exclusive breastfeeding. reinforcing factor can improve the transactional communication between midwife and client, but can not increase directly to the mother's behavior in exclusive breastfeeding. reinforcing factor will be able to improve the behavior of mother in exclusive breastfeeding if there has been an effective communication between the midwife and client. transactional communication between the midwife and client has an important role to improve mother’s behavior in increasing exclusive breastfeeding provision. it needs further studies related to mother’s behavior in exclusive breastfeeding by testing a model of transactional communication between midwife and client in health improvement, both of mother and baby's health. the midwife needs to improve transactional communication between midwife and client. references afifah, d.n., 2007. faktor yang berperan dalam kegagalan praktik pemberian asi eksklusif (studi kualitatif di kecamatan tembalang, kota semarang. universitas diponegoro semarang. available at: http://core.ac.uk/download/pdf/11702480 .pdf. amirudin, 2008. pengaruh motivasi terhadap kinerja konselor asi eksklusif di kabupaten aceh barat propinsi naggroe aceh darussalam. universitas sumatera utara medan. indonesia, p.r., pemberian air susu ibu eksklusif, indonesia. enabling factors 1. infrastucture 2. worker behaviour 3. worker attitude predisposing factors 1. knowledge 2. behaviour 3. tradition/belief 4. education background 5. socio-economic background transactional communication health worker --- mother breasfeeding provision 1. imd 2. exclusive breastfeedin g reinforcing factors 1. public figure behaviour 2. public figure attitude 3. regulation development of transactional communication model (rekawati susiloningrum, et.al.) 59 komala, l., 2009. ilmu komunikasi: perspektif, proses, dan konteks, bandung: widya padjajaran. li, l., zhang, m. & binns, c.w., 2003. chinese mothers’ knowledge and attitudes about breastfeeding in perth, western australia. breastfeeding review : professional publication of the nursing mothers’ association of australia, 11(3), pp.13–9. available at: http://www.ncbi.nlm.nih.gov/pubmed/14 768309 [accessed may 30, 2017]. maas, l.t., kesehatan ibu dan anak : persepsi budaya dan dampak kesehatannya. available at: http://library.usu.ac.id/download/fkm/fk m linda2.pdf [accessed may 30, 2017]. nankunda, j. et al., 2010. &quot;she would sit with me&quot;: mothers’ experiences of individual peer support for exclusive breastfeeding in uganda. international breastfeeding journal, 5(1), p.16. available at: http://www.ncbi.nlm.nih.gov/pubmed/20 977715 [accessed may 30, 2017]. notoatmodjo, 2007. promosi kesehatan dan ilmu perilaku, jakarta: rineka cipta. perinasia, 1994. melindungi, meningkatkan, dan mendukung menyusui: peran khusus pada pelayanan kesehatan ibu hamil dan menyusui pernyataan., jakarta. purnamawati, s., 2003. faktor-faktor yang berhubungan dengan pola pemberian asi pada bay1 usia empat bulan (analisis data susenas 2001) | purnamawati | media penelitian dan pengembangan kesehatan. media litbang kesehatan, xiii(3), pp.29–37. available at: http://ejournal.litbang.depkes.go.id/index .php/mpk/article/view/1055/578 [accessed may 30, 2017]. qureshi, a.m. et al., 2011. using community volunteers to promote exclusive breastfeeding in sokoto state, nigeria. the pan african medical journal, 10, p.8. available at: http://www.ncbi.nlm.nih.gov/pubmed/22 187590 [accessed may 30, 2017]. rohim, s., 2007. teori komunikasi: perspektif, ragam dan aplikasi, jakarta: rineka cipta. suyatno, 2000. pengaruh pemberian makanan pendamping asi (mp-asi) tradisional terhadap kejadian ispa, diare, dan status gizi bayi pada 4 (empat) bulan pertama kehidupannya. universitas gajah mada yogyakarta. available at: https://core.ac.uk/download/pdf/1171680 0.pdf. vol 6 no 1 april 2011_akreditasi 2013.indd 68 perubahan keluhan seksual (fisik dan psikologis) pada perempuan pascaterapi kanker serviks setelah intervensi keperawatan (the changes of physical and psychological sexual complains in women with post treatment cervical cancer after sexual nursing intervention) afi yanti*, andrijono*, gayatri** * departemen keperawatan maternitas dan anak, fakultas keperawatan, universitas indonesia e-mail: lupinavalon@hotmail.com ** departemen obstetri dan ginekologi, fakultas kedokteran, universitas indonesia *** departemen keperawatan dasar, fakultas keperawatan, universitas indonesia abstract introduction: despite increasing awareness related to sexual health for cervical cancer survivors, health care providers are passive in addressing their sexual issues. the objectives were to develop and investigate the effect of a sexual nursing intervention packet to mitigate sexual dysfunction among cervical cancer survivors. method: a sample of 104 survivors were participated consecutively based on required inclusive criteria in this quasi-experimental study. the sexual nursing intervention packet focused on the physical, psychological, and care of relational aspects of sexual health elements. the packet consisted of 6 weekly 2-hour sessions. results: the participants reported poor sexual satisfaction and sexual function. there were no statistically signifi cant differences in sexual interest, sexual arousal, orgasm, and vaginal lubrication improvement following the intervention, although all the variables in the intervention group were improved clinically. the sexual nursing intervention packet was effective in increasing sexual satisfaction and decreasing dispareunia among cervical cancer survivors. discussion: this study suggests that the quality of life in cervical cancer survivors could be improved with the sexual nursing intervention packet provided as part of supportive group care. this program may be more effective if delivered earlier and for a longer period. implications for practice: the sexual nursing intervention packet offers an opportunity to facilitate small-group dynamics that lay the ground for further contacts leading to earlier recognition of sexual problems and active involvement for sexual health improvement for cervical cancer survivors and nurses. it could be utilized for survivor education or support groups to increase sexual satisfaction following cancer treatment. keywords: sexual dyfunction, cervical cancer, sexual education-counselling pendahuluan keberhasilan memanfaatkan kemajuan ilmu dan teknologi biomedik dalam pelayanan kedokteran dan asuhan keperawatan penderita kanker dengan berbagai modalitas terapi (kemoterapi, radioterapi, pembedahan, dan terapi kombinasi) telah terbukti dapat memperpanjang masa bebas kanker dan survival/ketahanan hidup penderita dibanding 10 tahun yang lalu (wenzel, et al., 2005; burns, 2007). akibatnya, fenomena cancer survivorship menjadi meningkat. dibanding dengan kanker ginekologi lainnya (kanker endometrium, ovarium, dan vagina), kanker serviks merupakan pemicu utama munculnya fenomena cancer suvivorship. gangguan seksualitas pada penderita kanker serviks akibat efek terapi kanker serviks dapat menyebabkan disfungsi seksual yang memengaruhi kualitas hidup perempuan. banyak studi melaporkan bahwa para survival kanker serviks mengalami berbagai permasalahan seksualitas yang memberikan dampak buruk pada kualitas hidup perubahan keluhan seksual fisik dan psikologis (afi yanti) 69 mereka (klee dan machin, 2000; wenzel, et al., 2005; burns, 2007). terapi kanker serviks terbukti dapat menimbulkan berbagai permasalahan jangka panjang terhadap aspek seksualitas baik pada para cancer survivorship maupun pada pasangannya. pasangan survival cancer mengalami berbagai dampak buruk akibat terapi kanker, mulai dari masalah umum sampai yang spesifi k. secara umum, dampak buruk yang muncul antara lain adalah kelelahan, sementara secara khusus dapat mengalami berbagai ketidaknyamanan akibat munculnya gejala menopause dini, ketidakberfungsian reproduksi/infertilitas, serta disfungsi seksual akibat kerusakan ovarium dan saluran senggama (vagina), yaitu memendeknya ukuran vagina, menurunnya elastisitas vagina, dan berkurangnya lubrikasi vagina. sementara secara psikologis, dampak buruk terapi kanker adalah timbulnya gangguan kepuasan seksual, gangguan intimasi dengan pasangan, kurang percaya diri, gangguan gambaran diri dan berkurangnya rasa feminimitas sebagai perempuan (schultz dan van de wiel, 2003; brotto, 2008; wilmoth, 2006). model intervensi keperawatan seksual merupakan upaya meningkatkan kualitas hidup perempuan pascaterapi kanker. di luar negeri banyak dikembangkan model intervensi tersebut untuk mempromosikan kesehatan seksual para penderita kanker ginekologi. sebagai contoh, di amerika serikat, sejak tahun 1996, booth dan mcguire telah mempelajari pengaruh pelayanan konseling oleh para perawat terhadap para pasien kanker. filosofi tentang ‘keperawatan baru’ yang dilekatkan pada perawat spesialis telah menjelaskan peran perawat spesialis onkologi dan ginekologi dalam memenuhi berbagai kebutuhan psikoseksual para pasien. selanjutnya, studi yang dilakukan oleh maughan dan clarke (2001) mempelajari intervensi konseling yang diberikan para perawat spesialis telah membuktikan bahwa intervensi konseling yang dilakukan para perawat spesialis tersebut terbukti memberikan pengaruh yang positif terhadap pengembalian fungsi seksual yang sehat di antara para penderita, walaupun secara statistik tidak bermakna. pelayanan keperawatan di indonesia belum memiliki standar pelayanan untuk mempromosikan kesehatan seksual para penderita kanker serviks. berbagai intervensi terapetik melalui edukasi dan konseling untuk mempromosikan peningkatan kualitas hidup berhubungan dengan kesehatan seksual dan merupakan bagian dari tujuan pelayanan keperawatan belum optimal dilaksanakan oleh para perawat onkologi di indonesia. kurangnya pengetahuan, perilaku, dan sikap untuk memberikan edukasi dan konseling tentang kesehatan seksual dan perilaku budaya malu mendiskusikan masalah yang berkaitan dengan aspek seksual merupakan beberapa hambatan utama tidak terlaksananya pelayanan rehabilitas seksual yang seharusnya diberikan para perawat. bahan dan metode penelitian ini mengujicobakan efektivitas paket intervensi keperawatan seksual pada perempuan pascakemoradiasi kanker serviks dan bertujuan membuktikan efektivitas paket intervensi keperawatan seksual dalam mengatasi keluhan disfungsi seksual pada perempuan pascakemoradiasi kanker serviks. rancangan penelitian ini adalah quasy eksperiment dengan rancang bangun pre-post test only with control group design. sampel pada penelitian adalah perempuan yang sedang melakukan kunjungan pertama kali setelah menyelesaikan terapi kanker di rumah sakit rscm unit radioterapi rscm dan poliklinik departemen obstetrik dan ginekologi, rscm dalam periode desember 2010 sampai april 2011. kriteria inklusi responden adalah para responden yang masih aktif secara seksual, memiliki pasangan dan bersedia mengikuti penelitian dan dimintai kesediaannya untuk sukarela berpartisipasi. sampel dikumpulkan dan dipilah (proses randomisasi) menjadi dua kelompok yaitu kelompok intervensi dan kelompok non intervensi pada saat para calon responden melakukan non intervensi pertama kali setelah selesai menjalani terapi sinar. f o r m a t i n f o r m a s i p e r s o n a l y a n g dikembangkan oleh peneliti untuk memperoleh data karakteristik demografi responden. indeks fungsi seksual perempuan/ (fsfi) dari meston jurnal ners vol. 6 no. 1 april 2011: 68–75 70 (2000) dan kuesioner sexual satisfaction scale dari meston (2005) digunakan untuk mengukur variabel-variabel dalam penelitian ini. data yang diperoleh dianalisis dengan menggunakan uji statistik wilcoxon signed test dan mann whitney u-test dengan derajat kemaknaan α < 0,05. hasil sebanyak 104 subjek yang memenuhi kriteria inklusi dilakukan proses randomisasi berdasarkan waktu pengambilan sampel, hasil randomisasi diperoleh sebanyak 53 subjek penelitian kemudian dimasukkan ke dalam kelompok intervensi dan 51 subjek lainnya dimasukkan ke dalam kelompok non intervensi. hasil analisis menemukan rerata umur responden adalah di atas 40 tahun dalam arti berada dalam periode reproduksi lanjut. umur rerata suami lebih tua sekitar 9 tahun dari umur rerata istri. umur termuda istri adalah 32 tahun dan umur tertua adalah 55 tahun. sementara umur suami, termuda di atas 36 tahun dan umur tertua adalah 61 tahun. rerata jumlah anak responden adalah 3 orang. lama menikah rerata lebih 20 tahun. mayoritas istri memiliki tingkat pendidikan lebih rendah daripada suami baik pada kelompok intervensi maupun pada kelompok non intervensi. penelitian ini menemukan 48% istri berpendidikan lulus sekolah dasar dan sementara itu hanya 26% untuk suami. ditemukan pula sebanyak 54% istri berpendidikan lulus smp dan sma, sedangkan untuk suami presentase yang ditemukan adalah sebanyak 70%. pekerjaan istri, sebanyak 80% sebagai ibu rumah tangga sedangkan pekerjaan suami, baik pada kelompok intervensi maupun pada kelompok non intervensi, 53% bekerja sebagai buruh dengan penghasilan yang tidak menentu. penelitian ini juga memberi informasi bahwa baik pada pada kelompok intervensi maupun pada kelompok non intervensi, ditemukan sebesar 64% para istri memperoleh dukungan fi sik, psikologis, dan sosial dari para suami. selanjutnya, tentang pengetahuan para istri terkait hubungan seksual pascaterapi kanker, ditemukan 90% para istri pada kelompok intervensi dan 88,7% pada kelompok non intervensi memiliki pengetahuan yang kurang tentang hubungan seksual pascaterapi kanker sebelum dilakukan intervensi. hasil analisis statistik menunjukkan nilai rerata keluhan fi sik seksual yang dibedakan lubrikasi vagina dan disparenia dan nilai rerata keluhan psikologis seksual yang dibedakan atas minat dan gairah seksual, kepuasan hubungan seksual, kedekatan emosional, keterbukaan komunikasi, kepedulian hubungan dengan pasangan, dan kepercayaan diri mengalami perbaikan yang lebih besar pada kelompok intervensi jika dibandingkan dengan kelompok non intervensi. perbedaan yang bermakna secara statistik untuk variabel keluhan fi sik seksual hanya ditemukan pada variabel dispareunia (p = 0,000 < p = 0,05), sedangkan untuk variabel lubrikasi vagina secara statistik tidak menunjukkan perbedaan bermakna (p = 0,078 – 0,752 > p = 0,05). sebaliknya, untuk seluruh variabel keluhan psikologis seksual, semuanya menunjukkan perbedaan yang bermakna (p = 0,000 < p = 0,05). hal ini mengindikasikan bahwa paket intervensi keperawatan seksual cukup efektif memperbaiki k e l u h a n p s i k o l o g i s s e k s u a l d i b a n d i n g memperbaiki keluhan fi sik seksual. pembahasan salah satu fungsi area yang masih menjadi fokus utama dalam penyelidikan tentang kualitas hidup pasca-kanker servik adalah area fungsi seksual. seksualitas merupakan bagian yang penting dari kualitas hidup keseharian penderita kanker servik, baik sebelum, selama, dan setelah pascaterapi kanker (gender, 1992; hughes, 2009). masalah-masalah seksual yang banyak dialami penderita kanker ketika didiagnosis dan setelah memperoleh terapi kanker antara lain disfungsi ereksi, menurunnya libido dan kekeringan pada daerah vagina (hughes, 2009). berbagai masalah yang berkaitan tentang seksualitas dapat memengaruhi gairah hidup, gambaran diri dan hubungan intimasi dengan pasangan, stabilitasi hubungan, dan berakhirnya kapasitas reproduksi diimplikasikan sebagai perubahan keluhan seksual fisik dan psikologis (afi yanti) 71 efek negatif yang langsung berpengaruh terhadap fungsi seksual setelah mengalami kanker dan terapinya. penelitian ini memberikan informasi atau data tentang permasalahan seksualitas para responden, yaitu para perempuan yang mengalami kanker servik dan telah dilakukan kemoradiasi dalam satu tahun pertama pascaterapi kanker serviks. secara umum, para responden pada penelitian ini, baik pada kelompok intervensi maupun pada kelompok non-intervensi, mengalami permasalahan tabel 1. gambaran perubahan rerata keluhan fi sik seksual dan keluhan psikologis seksual pada kelompok intervensi dan kelompok non-intervensi variabel intervensi % kenaikan n non intervensi % kenaikan n p rerata sd p rerata sd p lubrikasi 56,60 25,49 pre-test 3,61 1,28 0,009** 12,38 3,67 1,37 0,516** 5,17 post-test 4,12 0,88 3,87 1,16 0,078* disparenia 92,45 39,22 pre-test 3,39 0,31 0,000** 26,62 3,42 0,28 0,075** 5,26 post-test 4,62 0,70 3,61 0,17 0,000* minat 24,53 23,53 pre-test 3,79 1,19 0,844** 2,32 3,98 1,19 0,995** 1,49 post-test 3,88 1,04 4,04 0,89 0,489* gairah 30,18 31,37 pre-test 3,99 1,19 0,797** 1,48 4,22 1,19 0,77** 1,17 post-test 4,05 1,01 4,27 0,89 0,299* orgasme 47,17 29,41 pre-test 3,50 1,77 0,252** 10,49 3,61 1,81 0,494** 5,74 post-test 3,91 0,98 3,83 1,46 0,752* kepuasan hubungan 92,45 25,29 pre-test 3,66 0,41 0,000** 20,09 3,77 0,38 0,057** 3,58 pos-test 4,58 0,34 3,91 0,28 0,000* kedekatan emosi 98,11 43,14 pre-test 3,26 0,42 0,000** 10,68 3,26 0,45 0,045** 3,55 post-test 3,65 0,43 3,38 0,89 0,000* komunikasi 98,11 54,90 pre-test 3,65 0,43 0,000** 17,79 3,71 0,44 0,053** 3,89 post-test 4,44 0,37 3,86 0,30 0,000* kepedulian hubungan 39,22 pre-test 3,11 0,76 0,78 0,205** 6,19 post-test 4,16 1,35 0,54 0,000* kepercayaan diri 29,41 pre-test 3,65 0,62 0,63 0,552** 4,47 post-test 4,94 1,08 0,35 0,000* jurnal ners vol. 6 no. 1 april 2011: 68–75 72 seksual yaitu penurunan minat atau bahwa sudah tidak memiliki minat untuk melakukan kembali aktivitas seksual dengan para pasangan mereka. studi-studi sebelumnya melaporkan hal yang sama bahwa pascaterapi kanker serviks, kebanyakan perempuan mengalami penurunan hasrat atau minat untuk kembali melakukan hubungan seksual (jensen, et al. 2003; ganz et al. 2003; hunges, 2009). mengalami nyeri saat berhubungan seksual (dispareunia) juga dialami oleh para responden dalam penelitian ini, baik pada kelompok intervensi maupun pada kelompok non intervensi. kondisi ini menyebabkan terjadi penurunan frekuensi melakukan hubungan seksual. permasalahan dispareunia yang berakibat menurunkan frekuensi hubungan seksual pada para perempuan pascaterapi kanker serviks juga dilaporkan pada studistudi lainnya (bergmark, et al., 2005; flay dan matthews, 1995, wilmoth, 2006). penelitian ini, secara statistik dilaporkan bahwa ada perbedaan bermakna antara kelompok intervensi dan kelompok non intervensi berhubungan dengan perbaikan disparenia, kepuasan hubungan seksual, kedekatan emosional, kepedulian hubungan dengan pasangan, kemunikasi, dan kepercayaan diri, namun, tidak ada perbedaan yang bermakna atau signifikan antara kelompok intervensi dan kelompok non-intervensi berhubungan dengan perbaikan minat, gairah, lubrikasi, dan orgasme. setelah dilakukan intervensi keperawatan seksual, terjadi perbaikan minat, gairah seksual, lubrikasi vagina, serta orgasme seksual pada kelompok intervensi sedikit lebih baik dibandingkan kelompok non-intervensi. oleh karena itu, hipotesis peningkatan rerata minat, gairah seksual, lubrikasi vagina, serta orgasme tidak terbukti bermakna, namun, jika dilihat secara peningkatan nilai rerata minat, gairah seksual, lubrikasi vagina, dan orgasme pada kelompok intervensi sedikit lebih baik dibanding pada kelompok non intervensi. hal ini karena perbaikan minat hubungan seksual, gairah seksual dan perbaikan lubrikasi vagina serta orgasme membutuhkan waktu yang lebih lama (lebih dari 6 minggu) karena aspekaspek tersebut merupakan isu emosional yang perbaikannya membutuhkan waktu yang tidak sedikit berkaitan dengan perubahan perilaku individu terhadap kondisi seksualitasnya saat ini (derzko c, elliott s, dan lam w, 2007). permasalahan tersebut sama dialami oleh para survivor kanker payudara seperti yang dilaporkan oleh jun, et al. (2011) yang memberikan program sexual reframing juga tidak menunjukkan perbedaan bermakna antara kelompok intervensi dan non intervensi dalam perbaikan pada minat hubungan seksual dan lubrikasi vagina pascaterapi kanker selama 6 minggu diberikan program tersebut. hasil temuan penelitian ini dan hasil penelitian oleh jun, et al (2011) berbeda dengan yang dilaporkan oleh brotto et al. (2008) seorang yang memotori penggunaan intervensi psiko-pendidikan singkat untuk memperbaiki gangguan gairah seksual pada 22 perempuan dengan kanker serviks atau endometrium yang menjalani histerektomi. hasil studinya menemukan terdapat efek positif pada hasrat seksual, rangsangan, orgasme dan kepuasan seksual dalam kelompok intervensi kecil ini. berbeda dengan brotto, et al. (2008), schroder et al. (2005) memotori pemakaian seperangkat vakum klitoris pada 13 perempuan pascaradioterapi yang mengalami masalah gairah seksual atau disfungsi orgasme. bila dibandingkan dengan penilaian awal, ke-13 perempuan yang menyelesaikan pembelajaran selama 3 bulan, seluruhnya melaporkan peningkatan hasrat seksual, gairah, lubrikasi vagina, orgasme, kepuasan seksual dan dispareunia yang berkurang. adanya perbedaan hasil penelitian ini dengan dua studi sebelumnya, dapat disebabkan perbedaan karakteristik dan budaya para responden juga mempengaruhi keberhasilan intervensi yang dilakukan. kelompok intervensi pada penelitian ini terjadi peningkatan kepuasan hubungan seksual dan perbaikan disparenia yang signifikan dibanding dengan kelompok non intervensi terjadi karena pada kelompok intervensi telah diberikan penjelasan dan pemahaman tentang pentingnya melakukan hubungan seksual untuk mempercepat pemulihan kesehatan seksual mereka. selanjutnya, booklet yang dibagikan pada kelompok intervensi berisi tentang berbagai teknik mengurangi dispareunia. pada saat dilakukan pemberian edukasiperubahan keluhan seksual fisik dan psikologis (afi yanti) 73 konseling, para responden memperoleh bimbingan langsung dan kebanyakan mereka mempraktikkan teknik-teknik tersebut, di antaranya mereka melakukan variasi posisi dan mempraktikkan latihan kegel untuk mengurangi diaparenia dan meningkatkan lubrikasi vagina mereka seperti yang terdapat pada booklet. alhasil, dilihat dari nilai posttest, nampak terjadi penurunan dispareunia dan peningkatan kepuasan hubungan seksual pada kelompok intervensi. latihan menstimulasi sendiri/self-stimulation termasuk latihan kegel dan latihan berbagai posisi dalam melakukan hubungan seksual terbukti dapat membantu mengatasi dispareunia pada perempuan yang mengalami disfungsi seksual (wilmoth dan spinelli, 2000) dan intervensi edukasikonseling terbukti sebagai strategi intervensi promosi terbaik meningkatkan kualitas hidup perempuan penderita kanker (juraskova, et al., 2005). penelitian ini juga melaporkan bahwa pada kelompok intervensi terjadi peningkatan rerata kepercayaan diri pascaterapi kanker serviks setelah diberikan edukasi – konseling dibandingkan dengan kelompok intervensi. hal ini sesuai dengan hasil yang ditemukan oleh robinson (1999) melaporkan dari studi mereka bahwa kelompok intervensi yang memperoleh konseling kesehatan seksual memiliki kepercayaan diri kembali pascaterapi kanker dan memiliki cara-cara lainnya untuk mengatasi masalah seksual yang dialaminya pascaterapi kanker. selanjutnya, studi yang dilakukan oleh maughan dan clarke (2001) mempelajari intervensi konseling yang diberikan para perawat spesialis telah membuktikan bahwa intervensi konseling yang dilakukan para perawat spesialis tersebut terbukti memberikan pengaruh yang positif terhadap pengembalian fungsi seksual yang sehat di antara para penderita, walaupun secara statistik tidak bermakna. penelitian ini memiliki keterbatasan antara lain studi ini hanya melibatkan para perempuan dari satu rumah sakit, sehingga generalisasi hasil studi ini belum representatif mengungkap permasalahan seksualitas yang dialami para perempuan pascaterapi kanker di indonesia. jumlah sampel yang kecil dan isu seksual yang masih taboo untuk dibicarakan secara terbuka menyebabkan penelitian ini masih sulit untuk mampu laksana secara skala besar. selain itu, bahan pembelajaran untuk pemberian edukasi-konseling masih membutuhkan penyempurnaan sehingga diharapkan pada penelitian selanjutnya, bahan pembelajaran yang digunakan menjadi lebih sempurna. simpulan dan saran simpulan intervensi keperawatan seksual terbukti efektif memperbaiki fungsi seksual dan kepuasan seksual perempuan pascaterapi kanker serviks yang dievaluasi selama kurun waktu 6 minggu. itervensi keperawatan berupa edukasi dan konseling dapat menurunkan dispareunia, meningkatkan kepercayaan diri, dan frekuensi hubungan seksual pascaterapi kanker serviks. saran perawat perlu memberikan edukasi konseling seksual untuk mengatasi keluhankeluhan tersebut mengingat komplikasi yang dapat terjadi pascakemoradiasi kanker. oleh karena itu, penerapan kebijakan lokal untuk pelayanan di rumah sakit-rumah sakit perawatan kanker, mengupayakan latihan-latihan yang diajarkan pada paket ini dalam upaya meningkatkan kualitas hidup para survivor dianjurkan dilakukan secara berkesinambungan oleh perawat kepada para kliennya. selain itu, pengembangan program promosi kesehatan dengan pelatihan untuk para perawat agar memiliki pengetahuan dalam memberikan edukasi dan konseling seksualitas dan terlatih perlu dilakukan sehingga para perawat dapat melakukan pengkajian dan intervensi terhadap permasalahan seksual para kliennya. paket intervensi ini diusulkan dapat dilaksanakan oleh para perawat di rumah sakit dengan bekerja sama membentuk suatu team kolaborasi dengan tenaga kesehatan lainnya. jurnal ners vol. 6 no. 1 april 2011: 68–75 74 kepustakaan bergmark, k., avall-lundqvist, e., dickman p.w., henningsohn, l., dan steineck, g., 2005. patient-rating of distressful symptoms after treatment for early cervical cancer. acta obstet gynecol scand, 81, 443–450. b o o t h , k . , b e a v e r, k . , k i t c h e n e r, h . , o’neill, j., dan farrell, c., 2005. women’s experiences of information, psychological distress and worry after treatment for gynaecological cancer. patient education and counselling, 56, 225–232. brotto, l.a., heiman, j.r., goff, b, et al., 2008. a psychoeducational intervention for sexual dysfunction in women with gynecologic cancer. arch sex behav. 10, 91–96. burns, m., costello, j., ryan-woolley, b., dan davidson, s., 2007. assessing the impact of late treatment effects in cervical cancer: an exploratory study of women’s sexuality. european journal of cancer care, 16, 364–372. departemen kesehatan, 2008. profi l kesehatan r e p ro d u k s i i n d o n e s i a . j a k a r t a : departemen kesehatan. derzko, c., elliott, s., dan lam, w., 2007. management of sexual dysfunction in postmenopausal breast cancer patients taking adjuvant aromatase inhibitor therapy. curr oncol. 14 (suppl 1): s20ys40. ganz, p.a., rowland, j.h., desmond, k., meyerowitz, b.e., dan wyatt, g.e., 1998. life after breast cancer: understanding women’s health-related quality of life and sexual functioning. journal of clinical oncology, 16, 501–514. greenwald, h.p., dan mccorkle, r., 2007. remedies life change among invasive cervical cancer survivor. urology nursing, 27(1), 47–53. hunges, m.k., 2009. sexuality and cancer: the fi nal frontier for nurses. oncology nursing forum, 36(5), 241–246. jensen, p.t., groenvold, m., klee, m.c., thranov, i., petersen, m.a., dan machin, d., 2003. early stage cervical carcinoma, radical hysterectomy and sexual function. cancer, 100(1), 97–106. jun, e.y., et al., 2011. the effect of a sexual life reframing program on marital intimacy, body image, and sexual function among breast cancer survivors. cancer nursing, 34(2), 142–149. juraskova, i., butow, p., robertson, r., sharpe, l., mcleod, c., dan hacker, n., 2003 post-treatment sexual adjustment following cervical and endometrial cancer: a qualitative insight. psychooncology, 12. 267–297. kaplan, h.s., 1992. a neglected issue: the sexual side effects of current treatment for breast cancer. journal of sex and marital therapy, 18, 3–19. klee, m., thranov, i., dan machin, d., 2000. life after radiotherapy: the psychological and social effects experienced by women treated for advanced stages of cervical cancer. gynaecol oncol, 76, 5–13. maughan, k., dan clarke, c., 2001. the effect of a clinical nurse specialist in gynaecology oncology on quality of life and sexuality. journal of clinical nursing, 10(2), 221–229. maughan, k., heyman, b., dan matthews, m., 2002. in the shadow of risk: how men cope with a partner’s gynaecological cancer. international journal of nursing studies, 39, 27–34. monga, u., 2005. sexuality in cancer patients. archives of physical medicine and rehabilitation, 9, 417–442. robinson, j.w., faris, p.d., scott, b., 1999. psychoeducational group increases vaginal dilation for younger women and reduces sexual fears for women of all ages with gynecological carcinoma treated with radiotherapy. int j radiat oncol biol phys, 44, 497–506. schroder, m.a., mell, l.k., hurteau, j.a., et al., 2005. clitoral therapy device for treatment of sexual dysfunction in irradiated cervical cancer patients. int j radiat oncol biol phys, 61, 1078– 1086. turns, d., 2001. psychosocial issues: pelvic exenterative surgery. journal surg oncology, 76, 224–236. wenzel, l., dealba, i., habbal, r., et al., 2005. quality of life in long-term cancer survivors. gynecologic oncol, 97, 310–317. perubahan keluhan seksual fisik dan psikologis (afi yanti) 75 wilmoth, m.c., dan spinelli, a., 2000. sexual implications of gynaecologic cancer treatments. journal of obstetric, gynaecologic and neonatal nursing, 29 (4), 413–423. wilmoth, m.c., 2006. life after cancer: what does sexuality have to do with it? oncology nursing forum, 33(5), 905–910. world health organization (who), 2006. c o m p re h e n s i v e c e r v i c a l c a n c e r kelompok non non intervensi: a guide to essential practice. geneva. vol 8 no 2 oktober 2013.indd 253 efektivitas supportive educative terhadap peningkatan self regulation, self efficacy, dan self care agency dalam kontrol glikemik penderita diabetes mellitus tipe 2 (the effectiveness of supportive educative in increasing self regulation, self effi cacy, and self care agency to control glichemic index in patient with type ii diabetes) darmansyah af*, nursalam**, suharto*** *politeknik kesehatan kementrian kesehatan kalimantan timur **fakultas keperawatan universitas airlangga surabaya ***fakultas kedokteran universitas airlangga surabaya e-mail: darmansyah_af@ymail.com abstrak pendahuluan: diabetes melitus (dm) tipe ii merupakan penyakit kronis yang memerlukan perawatan dalam jangka waktu lama. model supportive educative menfasilitasi peningkatan self care agency melalui self regulation dan self effi cacy. penelitian ini bertujuan untuk menilai peningkatan kemampuan perawatan mandiri (self care agency) dan kontrol gula darah (hba1c) pada penderita dm tipe 2 yang menjalani perawatan di poliklinik endokrin penyakit dalam, rumah sakit pemerintah samarinda, kalimantan timur. metode: jenis penelitian adalah quasy experimental dengan desain pre post with control group design. sampel adalah 76 orang penderita dm tipe 2 yang diperoleh dengan teknik consecutive sampling, yang dibagi menjadi kelompok perlakuan (38 orang) dan kontrol (38 orang). data dikumpulkan dengan kuesioner dan tes hba1c. data dianalisis dengan paired t-test, independent t-test dengan α ≤ 0.05, serta pls (partial least square). hasil: hasil analisis menunjukkan bahwa model supportive educative berpengaruh positif dan signifi kan terhadap self regulation (0,651) dan self effi cacy (0,548), self regulation terhadap self care agency (0,592), self effi cacy terhadap self care agency (0,094), dan self care agency terhadap hba1c (0,130). kesimpulan dan diskusi: penelitian ini menunjukkan supportive educative keperawatan dapat meningkatkan self care agency penderita dm tipe 2 dan hba1c melalui peningkatan self regulation. model supportive educative dapat diterapkan pada pelayanan kesehatan di indonesia dalam memandirikan penderita dengan dm tipe 2 dan penderita dengan penyakit kronis lainnya. kata kunci: model supportive educative, self regulation, self effi cacy, self care agency, hba1c abstract introduction: type 2 diabetes mellitus (dm) is a chronic disease that requires long-term treatment. supportive educative model facilitates self care agency improvement through self regulation and self effi cacy. this study was aimed the impact of supportive educative model on the improvement of self care regulation and self effi cacy on an increased of self care agency as well as hba1c. method: the research method used was quasy experimental with pre-post control group design. this study was conducted with a sample size of 76 patients with diabetes mellitus type 2 who were selected through consecutive sampling, they were divided into treatment group of 38 subjects and control of group 38 subjects. data were collected by questionnaire and hba1c test. analysis of the data used paired t-test, independent t test and partial least square (pls). result: result showed that supportive educative model affect on self regulation on dietary control and diet, physical exercise, medication, blood sugar control and foot care (p = <0.05), self effi cacy (p = 0,05), self care agency (p = <0,05). test result of the correlation among the variables using partial least square (pls) suggest supportive educative model and the obtained value of self regulation is (0,561), self effi cacy is (0,548) self regulation to self care agency (0,592), self effi cacy to self regulation (0,162), self regulation to self care agency (0,094), and self care agency to hba1c (0,130). discussion and conclusion: novelty in this study indicated that supportive educative is able to improve self care agency patient and hba1c through increasing self regulation. it is recommended that model of supportive educative could be applied in health service in indonesia in regard to be independency patient with type 2 dm and other chronical disease. keywords: supportive educative model, self regulation, self effi cacy, self care agency, hba1c pendahuluan penyakit diabetes mellitus (dm) yang ditandai dengan meningkatnya kadar gula darah hingga mancapai 126 mg/l tergolong jenis penyakit yang cenderung menakutkan yang dapat menimbulkan kematian. terdapat 2 jenis penyakit diabetes mellitus yaitu dm tipe 1 dan dm tipe 2. perbedaan tipe jenis penyakit memerlukan perlakuan pengobatan yang berbeda pula. penyalit dm tipe 1 lebih 254 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 g a n g g u a n y a n g t e r j a d i p a d a kemampuan self effi cacy dan self care agency diakibatkan rendahnya self regulation pada penderita dm tipe 2. paddison et al (2010), menyat akan bahwa u nt u k memperk uat keberhasilan penanganan penyakit dm tipe 2 terkait dengan manajemen emosional akibat penyakit dm tipe 2. pengelolaan emosi pada penderita dm tipe 2 salah satunya dapat dilakukan pendidikan. pendidikan yang diberikan kepada para penderita dm tipe 2 dapat menurunkan (hba1c < 7%) sebesar 27,1%, meningkatkan self efficacy sebesar 62,0% dan meningkatkan self care behavior sebesar 30% (nyunt et al, 2010). hasil ini diperkuat penelitian oleh keeratiyutawong et al (2005) yang menunjukkan supportive educative berhubungan signifikan dengan self eff icay. mcnamara et al (2010) juga mengemukakan intervensi pendidikan sangat membantu dalam menghindari komplikasi pada penderita dm tipe 2. karter (2008), memberikan kesimpulan bahwa penderita dm tipe 2 perlu mendapatkan pendidikan tentang riwayat penyakit diabetes, sehingga mereka dapat melakukan perawatan secara mandiri. atak (2007), menyatakan bahwa edukasi meningkatkan pengetahuan, self efficacy, perilaku, dan keterampilan penderita dm tipe 2 dalam melakukan perawatan mandiri. program supportive educative dapat dilakukan melalui pengajaran (teaching), bimbingan (guiding), dan memberikan lingk ungan yang memu ngkin kan klien u nt u k aktif berpartisipasi melakukan self care ( providing environment). supportive educative, nursing system (orem study group, 2004) adalah suatu metode edukasi yang menggunakan berbagai metode seperti teaching, guiding, supporting, dan providing environ ment yang akan berkonstribusi penting dalam self care agency dalam meningkatkan kemampuan penderita dm mengont rol penyakit. atak (2007) menyatakan bahwa edukasi meningkatkan pengetahuan, self eff icacy, perilaku dan keterampilan pender ita diabetes dalam melakukan perawatan mandiri. pender it a dm t ipe 2 mengalam i berbagai keterbatasan dalam pengelolaan memerlukan tahapan pengobatan secara klinis, sementara penyakit dm tipe 2 lebih mengutamakan manajemen emosional pada penderita karena adanya penyakit tersebut (paddison et al, 2010). khusus untuk kasus penyakit dm tipe 2 international diabetes federation ((2010) memperkirakan jumlah penderita dm tipe 2 mencapai 350 juta orang pada tahu 2025 dengan peningkatan jumlah penderita mencapai 3% tiap tahun atau sekitar 7 juta orang. peningkatan jumlah penderita dm tipe 2 dilaporkan lebih dari separuh terjadi di wilayah asia terutama india, cina, pakistan dan indonesia. pada tahun 2010 indonesia berada diurutan keempat (perkeni, 2011) yang menu nju k k a n ba hwa t i ng k at keja d ia n yang tergolong mempr ihatin kan. hasil riset kesehatan dasar (depkes ri, 2008), menunjukkan prevalensi penderita dm tipe 2 di indonesia mencapai 5,7%, berarti sekitar 12 juta orang indonesia saat ini menderita dm tipe 2. berdasarkan penelitian papadopoulos (2007) dikemukakan bahwa penderita dm tipe 2 selalu diikuti oleh kondisi hipertensi (76,9%), hiperlipidemia (42,5%), angiopati (15,8%), retinopati (11,1%), dan neuropati (8,5%). penelitian lain oleh wing et al (2001), memberikan kesimpulan bahwa dm tipe 2 disebabkan oleh obesitas, diet yang tidak sehat, kurang aktivitas fi sik, urbanisasi dan industrialisasi. nyunt et al (2010) dalam penelitian lain mengemukakan terdapat hubungan antara self care exercise dengan kontrol gula darah or = 2,22; (95% ci; 1.21–4.07). selain itu hasil juga menunjukkan skor self effi cacy pada penderita dm tipe 2 sebesar 13,9% rendah (skor 18–62), di mana kondisi ini menunjukkan bahwa penderita dm tipe 2 memiliki self effi cacy yang rendah. nyunt et al (2010) mengemukakan pula skor self care diet sebesar 81.2% kategori rendah, self care latihan fi sik sebesar 84.2% dengan kategori rendah. sementara itu penelitian yang dilakukan oleh keeratiyutawong et al (2005), memperoleh hasil bahwa body mass index (bmi) berhubungan dengan self effi cay p < 0,01. 255 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) emosi, keyakinan kemampuan diri, gangguan pengaturan makanan dan diet, gangguan aktivitas fi sik, kontrol gula darah, pengobatan dan perawatan kaki. keterbatasan yang dialami penderita dm tipe 2 diperlukan sebuah program pendidikan untuk kemandirian penderita dalam upaya meningkatkan self care agency. pentingnya perawatan bagi penderita dm tipe 2 terhadap pemenuhan kebutuhan sehari-hari memberi ruang bagi profesi perawat untuk memberikan asuhan keperawatan terhadap penderita dm tipe 2. peran perawat tidak saja memberikan pelayanan medis, melainkan dapat memberikan pelayanan pendidikan terhadap individu, keluarga, dan masyarakat (song, 2008). leventhal (1980), menyatakan bahwa self regulation model pada penyakit ada dua proses regulasi yang berjalan secara paralel yang aktif yaitu kognisi, interprestasi objektif, dan subjektif dari ancaman kesehatan dan emosi. berdasarkan salah satu model dari self regulatory yang terkait dengan ancaman kesehatan yaitu common sense model, adanya stimulus kesehatan seperti informasi kesehatan tentang penyakit tertentu akan memunculkan respons emosional bagi penderita dan kahirnya akan meningkatkan kesadaran (awareness) akan penyakit tersebut (cameron, 2003). penelitian ini dimaksudkan unt uk mengetahui pengaruh dari supportive educative pada penderita dm tipe 2 untuk meningkatkan self regulation dan self effi cacy dan self care agency yang berkaitan dengan pengaturan pola makan, latihan fi sik, kontrol gula darah, ketaatan pengobatan dan perawatan kaki. peningkatan yang terjadi pada kemampuan self regulation, self efficacy dan self care agency diharapkan akan dapat menurunkan indeks hba1c. bahan dan metode j e n i s p e n e l i t i a n a d a l a h q u a s y experimental dengan desain pre post with control group design. sampel adalah 76 orang penderita dm tipe 2 yang menjalani perawatan di poliklinik endokrin penyakit dalam, rumah sakit pemerintah samarinda, kalimantan timur, yang diperoleh dengan teknik consecutive sampling, yang dibagi menjadi kelompok perlakuan (38 orang) dan kontrol (38 orang). data dikumpulkan dengan kuesioner dan tes hba1c. data dianalisis dengan paired t-test, independent t-test dengan α ≤ 0,05, serta pls (partial least square). hasil dari hasil evaluasi self regulation (y1) terbukti bahwa dari kelima indikator terdapat tiga indikator yang memiliki nilai faktor lebih besar dari 0,5 dan t-statistik > 1,96. hasil tersebut menunjukkan ketiga indikator tersebut merupakan indikator yang valid dalam merefl eksikan variabel self regulation, sedangkan dua indikator yang tidak valid sebagai pengukur variabel self regulation yakni latihan fi sik dengan faktor loading 0,561 dengan t-statistik 7,362 dan pengobatan dengan faktor loading 0,480 dengan t-statistik 5,491. hasil pengujian membuktikan indikator perawatan kaki merupakan indikator konstruk terkuat dari variabel self regulation dengan faktor loading 0,754 dengan t statistik 20,147 dibandingkan dengan indikator lain dari self regulation. hasil pengukuran variabel self effi cacy (y2) terbukti dari kelima indikator terdapat empat indikator yang memiliki nilai faktor mendekati atau lebih besar dari 0,5 dan tstatistik > 1,96. hasil ini menunjukkan keempat indikator tersebut merupakan indikator yang valid dalam meref leksikan variabel self effi cacy. hasil pengujian membuktikan latihan fi sik merupakan indikator konstruk terkuat dalam merefl eksikan variabel self effi cacy pada penderita dm tipe 2 dengan faktor loading 0,862 dengan t-statistik 37,511. hasil pengukuran variabel self care agency (y4) terbukti dari kelima indikator yakni pengaturan pola makan dan diet, latihan fisik, pengobatan, kontrol gula darah, dan perawatan kaki merefl eksikan variabel self care agency dengan nilai faktor lebih dari 0,5 dan t-statistik > 1,96, sedangkan tiga indikator yang tidak valid sebagai pengukur variabel self care agency yakni latihan fi sik, pengobatan, dan kontrol gula darah. hasil 256 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 pengujian membuktikan indikator perawatan kaki merupakan indikator konstruk terkuat dari self care agency dengan faktor loading 0,914 dengan t-statistik 46,491 dibanding dengan indikator lain dari self care agency. berdasarkan tabel 2 tentang nilai composite reliability dan nilai r square dapat dijelaskan bahwa nilai composite reliability pada tabel menunjukkan nilai yang lebih besar dari 0,70. hasil tersebut menunjukkan bahwa pengukuran untuk setiap variabel sudah konsisten dan hasil uji untuk measurement model struktural yaitu uji convergent validity, discriminant validity dan composite reliability telah menunjukkan hasil yang baik. dalam analisis dengan partial least square (pls) uji kesesuaian model didasarkan pada nilai r square. diketahui nilai r square untuk variabel self regulation adalah sebesar 0,566. hal ini berarti keragaman data pada variabel self regulation dapat dijelaskan oleh variabel supportive educative dan self effi cacy sebesar 56,6%. variabel self effi cacy r square sebesar 0,300 hal ini berarti keragaman data pada variabel self effi cacy dapat dijelaskan oleh variabel supportive educative sebesar 30%. unt u k var iabel self care agency dihasilkan nilai r square sebesar 0,417 yang berarti keragaman data untuk variabel self care agency dapat dijelaskan oleh variabel self effi cacy dan self regulation sebesar 41,7%. dan yang terakhir nilai r square untuk variabel hba1c dihasilkan nilai 0,017 yang artinya keragaman ukuran hba1c penderita dm tipe 2 dapat dijelaskan oleh besarnya self care agency yang dimiliki penderita sebesar 1,7%, maka dapat disimpulkan model struktural yang disusun sudah sesuai dengan keadaan sebenarnya yang terdapat di lapangan. tabel 3 menunjukkan bahwa model s u p p o r t i v e e d u c a t i v e ( x1) t e r b u k t i ber penga r u h sig n if i k a n terha d ap s elf regulation (y1) (γ = 0,651; t = 13,069). model supportive educative (x1) ber pangar uh signifi kan terhadap self effi cacy (y2) (γ = 0,548; t = 15,059). tabel 1. hasil faktor loading setiap indikator pada variabel penelitian variabel indikator faktor loading t-statistik model suppotive educative (x1) 1,000 self regulation (y1) pengaturan pola makan dan diet 0,699 18,746 latihan fi sik -0,561 7,362 pengobatan 0,480 5,491 kontrol gula darah 0,743 11,313 perawatan kaki 0,754 20,147 self effi cacy (y2) pengaturan pola makan dan diet 0,544 5,948 latihan fi sik 0,862 37,511 pengobatan 0,693 10,951 kontrol gula darah 0,393 6,105 perawatan kaki 0,498 5,052 self care agency (y3) pengaturan pola makan dan diet 0,794 16,933 latihan fi sik 0,051 0,420 pengobatan 0,090 0,744 kontrol gula darah 0,073 0,541 perawatan kaki 0,914 46,491 hba1c (y4) 1,000 tabel 2. nilai composite reliability dan nilai r square variabel composite reliability r-square supportive educative 1,000 self regulation 0,792 0,566 self effi cacy 0,761 0,300 self care agency 0,861 0,417 hba1c 1,000 0,017 257 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) s elf ef f ica c y ( y2) b e r p e nga r u h signifi kan terhadap self regulation (y1) (γ = 0,162; t = 2,440). self regulation (y1) terbukti berpengaruh signifi kan terhadap self care agency (y3) (γ = 0,592; t = 14,429). self effi cacy (y2) terbukti berpengaruh signifi kan terhadap self care agency (y3) (γ = 0,094; t = 2,162). self care agency (y3) terbukti berpengaruh signifi kan terhadap nilai hba1c (y4) sebesar (β = –0,130; t = 2,251). pengaruh tidak langsung self effi cacy (y2) terhadap self care agency (y3) yang melalui self regulation. hasil estimasi pengaruh langsung self effi cacy terhadap self care agency disimpulkan telah memilki pengaruh yang signifi kan, sementara hasil pengaruh tidak langsung antara self care effi cacy terhadap self care agency yang melalui self regulation adalah 0,592 × 0,162 = 0,094. besarnya pengaruh tidak langsung self effi cacy terhadap self care agency sebesar 0,097 lebih besar dibandingkan pengaruh langsungnya yang sebesar 0,094. hasil perbandingan menyimpulkan bahwa self regulation yang baik memperkuat hubungan self effi cacy dengan self care agency, sehingga self regulation sebagai memediasi hubungan antara self effi cacy terhadap self care agency. pembahasan tujuan penelitian ini adalah untuk menilai peningkatan kemampuan perawatan diri (self care agency) penderita diabetes mellitus (dm) tipe 2 setelah mendapatkan model supportive-educative keperawatan berbasis self care, self regulation, dan self efficacy. model supportive-educative pada asuhan keperawatan penderita dm tipe 2 adalah pendekatan asuhan keperawatan yang menekankan pada peningkatan kemampuan penderita untuk dapat melaksanakan dan meningkatkan kemampuan perawatan diri (self care agency). kemandirian tersebut dapat dicapai jika penderita dm tipe 2 mempunyai self regulation dan self effi cacy dalam perawatan diri (self care), dan dengan demikian kondisi glycemic control dapat di capai dengan menilai kadar hba1c sebagai standarisasi untuk menetapkan penderita dm tipe 2 terkontrol atau tidak terkontrol. peran perawat adalah memberikan keterampilan kepada penderita dm tipe 2, menguatkan faktor psikologis dengan cara meningkatkan k e m a m p u a n k o g n i t i f b a i k d e n g a n membangkitkan motivasi penderita diabetes mellitus tipe 2 maupun menstimulasi self effi cacy penderita bahwa penderita memiliki kemampuan, dan sumber daya, karena pada dasarnya self-care merupakan perilaku yang dapat dipelajari, dan setiap individu memiliki potensi untuk belajar dan berkembang. penyakit dm tipe 2 akan menyebabkan penderita mengalami self care deficit atau ketergantungan pada orang lain. perawat berperan sebagai pendidik bagi penderita dm tipe 2 untuk mempertahankan kemampuan optimalnya dalam mencapai sejahtera. kondisi self care defi cit pada penderita dm tipe 2 antara lain dalam pengaturan pola makan dan diet, latihan fi sik, ketaatan pada program tabel 3. hasil pengujian hipotesis pengaruh langsung antar variabel no. hubungan antar variabel koefi sien jalur (standarize) t-statistik keterangan 1 model supportive educative terhadap self regulation 0,651 13,069 signifi kan 2 model supportive educative terhadap self effi cacy 0,548 15,059 signifi kan 3 self effi cacy terhadap self regulation 0,162 2,440 signifi kan 4 self regulation terhadap self care agency 0,592 14,429 signifi kan 5 self effi cacy terhadap self care agency 0,094 2,162 signifi kan 6 self care agency terhadap hba1c -0,130 2,251 signifi kan 258 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 pengobatan, kontrol gula darah dan perawatan kaki. hasil analisis menunjukkan bahwa pemberian supportive educative berpengaruh sig n if i k a n t e rh a d ap p e n i ng k at a n self regulation penderita dm tipe 2 (tabel 3). hal ini dapat disebabkan oleh karena penderita mendapatkan program supportive educative yang dalam program supportive educative terdapat sesi tentang teaching (pengajaran) tentang penyakit dm tipe 2. adanya teaching terhadap pender ita dapat menyebabkan pengetahuan penderita tentang penyakit dm tipe 2 dapat meningkat sehingga adanya peningkatan pemahaman penderita tentang dm tipe 2 dapat menyebabkan peningkatan self regulation penderita khususnya pada aspek penilaian tentang regulasi dalam pengaturan pola makan. pengetahuan yang meningkat pada penderita dm tipe 2 dapat menyebabkan penderita memiliki penilaian yang positif terhadap upaya kesembuhan penyakit yang dider it a sehingga self reg ulation pada penderita dm tipe 2 khususnya pada aspek penilaian meningkat. upaya mekanisme perubahan penilaian positif dapat melibatkan aspek emosi bagi penderita sehingga penderita merasa penyakit dm tipe 2 merupakan sebuah ancaman kesehatan bagi penderita. adanya respons emosi yang berupa ancaman dapat menyebabkan penderita dm tipe 2 berupaya meningkatkan self regulation tentang penyakit dm tipe 2. pengenalan penyakit khususnya pada penyakit dm tipe 2 tidak terlepas dari kondisi kognitif yang dimiliki oleh penderita. adanya kognitif yang cukup tentang penyakit dm tipe 2 lebih memungkinkan untuk terjadinya regulasi mandiri bagi penderita dm tipe 2. proses kognitif yang dimiliki oleh penderita dm tipe 2 dapat melalui beberapa proses seperti indentifikasi penyakit dm tipe 2, tanda gejala, penyebab penyakit dm tipe 2 dan cara pencegahan penyakit dm tipe 2. pada program supportive educative khususnya pada aspek teaching penderita mendapatkan materi tentang penyakit dm tipe 2, tanda gejala, penyebab penyakit dm tipe 2 dan cara pencegahan penyakit dm tipe 2 sehingga penderita mengalami proses dalam kognitif penderita. peningkatan pengetahuan bagi penderita tentang penyakit dm tipe 2 mengalami proses inter pretasi (penafsiran masalah) karena penderita dm tipe 2 mendapatkan teaching pada program supportive educative sehingga pender it a memili k i kemampuan dalam menafsirkan masalah khususnya tentang penyakit dm tipe 2. adanya kemampuan penderita dalam menafsirkan masalah dapat menyebabkan penderita dm tipe 2 membuat sebuah koping (mekanisme per tahanan) terhadap penyakit dm tipe 2. mekanisme koping dapat berupa keinginan penderita untuk menyembuhkan penyakitnya. adanya mekanisme pertahanan dapat menyebabkan penderita melakukan upaya penilaian terhadap ancaman yang menjadi penyebab penyakit dm tipe 2. adanya upaya penilaian yang menyebabkan terjadinya peningkatan self regulation pada penderita dm tipe 2. hasil penelitian ini sesuai dengan pendapat jane ogden (2007) yang mengatakan bahwa individu memilki penilaian terhadap penyakit salah sat u nya dengan metode pengenalan sakit. baumeiter (2005) self regulation memandang individu sebagai agen yang aktif dan pengambil keputusan karena merupakan aspek penting dari adaptasi/koping manusia terhadap kehidupan. self regulation muncul ketika seseorang memotivasi dan memandu tindakan mereka secara proaktif sesuai dengan harapan yang mereka miliki. menurut uno (2007) motivasi dapat diartikan sebagai dorongan inter nal dan ek st e r n al d ala m d i r i se se or a ng ya ng diindikasikan dengan: 1) adanya hasrat dan minat untuk melakukan kegiatan, 2) adanya dorongan dan kebutuhan untuk melakukan kegiatan, 3) adanya harapan dan cita-cita, 4) penghargaan dan penghormatan atas diri, 5) adanya lingkungan yang baik, dan 6) adanya kegiatan yang menarik. hasil penelitian didukung oleh teori dari proses perubahan self regulation menurut ogden (2004) yang menyebutkan bahwa model self regulation mengacu pada proses pemecahan masalah. model menggambarkan pemecahan masalah dalam tiga tahap yaitu: 259 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) 1) interpretasi (penafsiran permasalahan), 2) koping (mengelola masalah untuk mencapai stat us keseimbangan), dan 3) penilaian (mengkaji seberapa sukses tahap koping yang diterapkan). dalam model self regulation terdapat proses interpretasi masalah, koping, dan appraisal atau penilaian keberhasilan koping. teori dari leventhal (1980) menyatakan bahwa self regulation model pada penyakit ada dua proses regulasi yang berjalan secara paralel yang aktif yaitu kognisi, interprestasi objektif dan subjektif dari ancaman kesehatan dan emosi. model regulasi diri dari perilaku sakit menggambarkan pemecahan masalah dalam tiga tahap yaitu (1) interpretasi (penafsiran permasalahan), (2) koping (mengelola masalah u nt u k mencapai st at us keseimbangan), (3) penilaian (mengkaji seberapa sukses t ahap koping yang diterapkan). model regulasi leventhal (self regulation model) menekankan pada aspek pengenalan sakit (illnees cognition) dan penilaian pengenalan sakit. pengenalan penyakit merupakan hal yang penting dalam upaya penguatan regulasi pada penderita dm tipe 2. pengenalan sakit (illness cognition) sebagai “keyakinan implisit penderita tentang sakit.” pengenalan sakit memberi penderita framework atau skema unt u k menangani dan memahami sakit mereka, dan memberitahu mereka apa yang harus dicari jika mereka menjadi sakit. dari lima parameter pada self regulation terdapat perbedaan bermakna yaitu pada aspek (1) pengaturan pola makan dan diet, (2) kontrol gula darah, (3) keteraturan obat dan (4) perawatan kaki sedangkan pada aspek latihan fi sik tidak terdapat perbedaan signifi kan. pemberian supportive educative pada variabel self regulation lebih berdampak pada pengaturan pola makan dan diet (δ1-3 = –0,74) dibanding dengan indikator lain seperti latihan fi sik, pengobatan, kontrol gula darah dan perawatan kaki (tabel 3). s u p p o r t i v e e d u c a t i v e l e b i h mempengaruhi pada indikator pola makan dan diet dapat disebabkan oleh persepsi yang terbangun dalam masyarakat di mana penyakit dm tipe 2 merupakan penyakit yang disebabkan oleh kesalahan pengaturan pola makan dan diet sehingga penderita cenderung ber upaya meningkatkan pengaturan diri khususnya pada aspek pola makan dan diet dibanding dengan aspek lain seperti latihan fi sik, pengobatan, perawatan kaki dan kontrol gula darah. hal ini didukung oleh situasi dan kondisi penderita yang dimungkinkan pemahaman tentang penyakit dm tipe 2 relatif rendah yang ditunjukkan dengan sebagian besar penderita dm tipe 2 memiliki pendidikan rendah (sd) sehingga lebih dimungkinkan pemahaman tentang penyakit relatif rendah dan pemahaman tentang penyakit cenderung diperoleh dari opini yang berkembang dalam masyarakat. kondisi pemahaman penderita yang rendah dapat menyebabkan adanya informasi bagi penderita melalui teaching dapat signifi kan meningkatkan pengetahuan penderita khususnya tentang penyakit dm tipe 2. peningkatan rata-rata pengaturan pola makan dan diet lebih tinggi dibanding dengan peningkatan latihan fi sik, pengobatan, kontrol gula darah dan perawatan kaki. keadaan ini dapat disebabkan oleh jauhnya jangkauan rumah sakit dari tempat tinggal penderita sehingga penderita tidak memiliki regulasi dalam mencapai tujuan yaitu melakukan pengobatan dan kontrol gula darah. keadaan ini dapat dilihat dari jangkauan tempuh penderita yang jauh dan kondisi geografis yang tidak terdapat sarana transportasi untuk datang ke rumah sakit. rendahnya peningkatan perawatan kaki dapat disebabkan oleh persepsi yang dibangun oleh penderita di mana perawatan dan pengobatan lebih cenderung dilakukan oleh tenaga medis dan perawat sehingga penderita kurang memiliki keyakinan akan upaya perawatan kaki dan pengobatan. hal ini yang menyebabkan indikator perawatan kaki dan pengobatan lebih rendah dibanding dengan regulasi pengaturan pola makan dan diet. rend ah nya reg ulasi lati han f isi k dibanding dengan pengaturan pola makan dan diet dapat disebabkan oleh faktor umur dan jenis kelamin sebagian besar penderita wanita 260 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 yang tidak memungkinkan untuk melakukan latihan fi sik, sehingga pada aspek regulasi latihan fi sik lebih rendah. pada penelitian ini didapatkan bahwa supportive educative lebih berdampak pada pengaturan pola makan dan diet. keadaan ini dapat disebabkan oleh rendahnya tingkat pendidikan subjek penelitian sehingga adanya supportive educative lebih berdampak pada pengaturan pola makan dan diet karena adanya interpretasi subjek tentang penyebab penyakit dm tipe 2 adalah pengaturan pola makan dan diet. adanya pengetahuan setelah mendapatkan supportive educative memberikan dorongan kepada subjek penelitian untuk mengatur pola makan dan diet sehingga nilai rata-rata subjek meningkat tertinggi pada aspek pengaturan pola makan dan diet. koping dapat terjadi melalui perubahan kognitif dan perilaku secara konstan dalam upaya untuk mengatasi tuntutan internal dan atau eksternal khusus yang melelahkan atau melebihi sumber individu. pada penelitian ini koping lebih terjadi pada aspek yang lebih memungkinkan yaitu pengaturan pola makan dan diet. pengaturan pola makan dan diet lebih diyakini bagi subjek penelitian untuk mengembalikan kondisi kesehatan seperti sebelum menderita dm tipe 2. hasil penelitian ini sesuai dengan penelitian gagliardino and etchegoyen (2001) bahwa program pendidikan signifi kan memengaruhi kecepatan gula darah dari 10.6 ± 3.5 vs 8.7 ± 3.0 mmol/l; tekanan darah sistolik dari rata-rata 149,6 ± vs 142,9 ± 18,8 mmhg; kolesterol 6.1 ± 1.1 vs 5.4 ± 1.0 mmol/l. dalam kurun waktu selama 12 bulan terjadi penurunan pemanfaatan obat diabetic, hipertensi dan hiperlipidemia 62%. hasil penelitian ini sesuai dengan pendapat baumeister & vohs (2007) self regulation lebih menekankan pada aspek penilaian. penilaian yang diyakini oleh subjek penelitian cenderung pada aspek diet. selfregulation adalah kapasitas atau kemampuan seseorang untuk mengubah perilakunya. hasil penelitian ini sesuai dengan teori levent hal yang menyebutkan bahwa interpretasi dapat dilakukan melalui dua cara atau penyaluran yaitu persepsi gejala. individu kemudian termotivasi untuk kembali ke keadaan normalnya “bebas masalah”. masalah dapat diberi arti dengan mengakses pengetahuan sakit individual. representasi kognitif dari masalah memberi arti masalah dan membuat individu dapat mengembangkan dan mempertimbangkan strategi penanganan yang tepat. berdasarkan hasil penelitian dan telaah penelitian terdahulu dan teori yang mendu k u ng d apat d isi mpul ka n ba hwa penilaian pengenalan sakit memberikan arahan bagaimana urgensinya penyakit dm tipe 2. penilaian subjek terhadap penyakit dm tipe 2 memberikan arahan secara subjektif terhadap ancaman dari penyakit yang diderita. pada penelitian ini sebagian besar subjek memiliki pendidikan relatif rendah (sd) sehingga hal ini yang menyebabkan terjadinya keadaan yang sebagian besar subjek mengalami kejadian komplikasi karena subjek penelitian tidak merasakan adanya ancaman akibat penyakit dm tipe 2. penguatan self regulation menekankan pada tiga komponen model (interpretasi, koping dan penilaian) yang saling berkaitan untuk mempertahankan keseimbangan sehingga keadaan sehat individu terganggu (terkena sakit) maka model ini menjelaskan bahwa individu termotivasi untuk kembali ke keadaan sehat. pada penelitian ini kondisi yang terjadi adalah sebagian besar tingkat pendidikan relatif rend ah sehi ngga di mu ng k i n kan interpretasi, koping dan penilaian terhadap penyakit dm tipe 2 relatif rendah. para ahli menggolongkan dua strategi coping yang biasanya digunakan oleh individu, yaitu: problem-solving focused coping, di mana individu secara aktif mencari penyelesaian dari masalah untuk menghilangkan kondisi atau situasi yang menimbulkan stres; dan emotion focused coping, di mana individu melibatkan usaha-usaha untuk mengatur emosinya dalam rangka menyesuaikan diri dengan dampak yang akan ditimbulkan oleh suatu kondisi atau situasi yang penuh tekanan. adapun tahapan dalam koping adalah sebagai berikut: 1) penilaian primer. masalah kesehatan selalu dievaluasi awalnya sebagai ancaman atau sebagai stres negatif. dua dasar 261 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) penilaian primer ini adalah persepsi kerentanan terhadap ancaman dan persepsi keparahan dari ancaman. menurut model transaksional dari st res dan koping, penilaian risiko pribadi dan keparahan ancaman berupaya untuk mengatasi stressor. penilaian dari keparahan tinggi dan kerentanan juga dapat mendorong perilaku menghindar-melarikan diri. 2) penilaian sekunder. penilaian sekunder ad ala h ketet apa n seseora ng mengat asi sumber daya dan pilihan. 3) upaya-upaya koping. upaya-upaya koping dapat dilihat dari dua dimensi yaitu manajemen masalah dan regulasi emosional. upaya strategi dapat melalui mencari dukungan sosial dan perasaan terbuka (membeberkan masalah-masalah) serta menghindari dan penolakan. 4) hasil koping. hasil koping merupakan adaptasi seseorang terhadap stressor, menyusul penilaian dan situasi (penilaian primer) dan sumberdaya (penilaian sekunder) dan dipengaruhi oleh upaya koping. hasil penelitian memberikan kesimpulan bahwa supportive educative yang diberikan cenderung lebih berdampak pada indikator self regulation pengaturan pola makan dan diet. self regulation pola makan dan diet lebih memungkinkan bagi penderita karena adanya peningkatan pengetahuan subjek tentang makanan yang harus dibatasi sehingga subjek lebih cenderung memiliki keyakinan akan kondisi penyakit terkait dengan pola makan dan diet. h a s i l p e n e l i t i a n m e n u n j u k k a n bahwa supportive educative signif ikan mempengaruhi self efficacy penderita dm tipe 2. keadaan ini dapat disebabkan oleh program supportive educative yang diberikan kepada penderita dm tipe 2 salah satunya adalah guiding, dalam guiding terdapat diskusi dan alternative pemecahan masalah khususnya pemecahan masalah penyakit dm tipe 2. adanya diskusi pemecahan masalah dapat menyebabkan terjadinya kepercayaan pada penderita akan alternatif pemecahan masalah yang ada dapat memberikan solusi terhadap penyakit yang diderita, sehingga supportive educative yang diberikan kepada penderita dapat meningkatkan self effi cacy penderita dm tipe 2. hasil penelitian sesuai dengan penelitian bakken et al (2010) yang melakukan penelitian tentang dampak pendidikan terhadap self efficacy diperoleh hasil bahwa intervensi pendidikan yang dapat meningkatkan self effi cacy. penelitian nyunt et al. (2010) yang melakukan penelitian tentang self-effi cacy, self care dan kontrol gula darah diperoleh hasil bahwa pemberian pendidikan dapat meningkatkan self effi cacy 62% dan self-care behavior 30%. hasil penelitian sesuai dengan pendapat funnel (2010) di dalam proses diabetes self manegent education (dsme) terdapat suatu proses untuk memberikan dukungan informasi yang diperlukan oleh penderita dalam membuat keputusan yang tepat dalam perawatan dirinya, memungkinkan adanya kerja sama atau kolaborasi aktif antara penderita dan petugas kesehatan dalam memecah kan masalah ( problem solving). bakken et al (2010) tentang self effi cacy penderita dm tipe 2 memberikan kesimpulan bahwa upaya dalam peningkatan self efficacy diperlukan upaya yang terus menerus terhadap penderita diperlukan sebuah model pendidikan yang spesifi k yang dapat meningkatkan afektif penderita sehingga penderita mampu mempercayai dari edukasi yang telah diberikan. dari lima parameter pada self effi cacy kesemuanya terdapat perbedaan bermakna pada aspek (1) keteraturan obat, (2) kontrol gula darah, (3) perawatan kaki (4) pengaturan pola makan dan (5) latihan fi sik. pemberian supportive educative pada variabel self effi cacy lebih berdampak pada latihan fi sik (δ1–2 = –1,50) dibanding dengan indikator lain seperti pengaturan pola makan, pengobatan, perawatan kaki dan kontrol gula darah. pada penelitian ini adanya supportive educative khususnya pada aspek guiding yang di dalam program terdapat diskusi alternatif pemecahan masalah lebih berdampak terhadap indikator self effi cacy pada aspek latihan fi sik. keadaan ini dapat disebabkan oleh adanya kepercayaan subjek penelitian dari kondisi penyakit dm tipe 2 yang dapat dicegah melalui latihan fisik sehingga adanya supportive educative yang diberikan kepada subjek penelitian lebih diyakini pada aspek latihan 262 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 fisik untuk terjadinya pemulihan penyakit dm tipe 2. peningkatan self effi cacy pada aspek latihan fi sik lebih tinggi dibanding dengan aspek lain dapat disebabkan oleh adanya guiding pada program supportive educative yang memberikan fasilitas terhadap penderita untuk pemecahan masalah dari masalah yang diderita sehingga solusi yang lebih dipercaya dan dapat dilakukan oleh penderita adalah latihan fi sik. hal yang memberikan kepercayaan akan latihan fisik antara lain karena untuk pengaturan diet dan pola makan dipercaya lebih sulit karena menu yang disajikan oleh keluarga tidak selalu sesuai dengan menu untuk penderita dm tipe 2 sehingga penderita akan mengikuti menu makanan yang ada di keluarga. self eff icacy skor pengobatan lebih rendah dibanding dengan latihan f isik dapat disebabkan oleh kondisi jangkauan pelayanan rumah sakit yang relatif jauh dari tempat tinggal sehingga penderita percaya kalau pengobatan akan cenderung lebih sulit dilakukan karena pelayanan kesehatan jauh dari rumah. selain itu situasi usia responden yang sebagian mengalami komplikasi lebih dimungkinkan untuk pergi ke pelayanan kesehatan memerlukan bantuan orang lain. self effi cacy skor kontrol gula darah lebih rendah dibanding dengan latihan fi sik dapat disebabkan oleh pelayanan kesehatan (rumah sakit) yang jauh dengan penderita dan untuk kontrol gula darah memerlukan alat dan keahlian, sehingga penderita mempercayai hal tersebut lebih sulit dilakukan dibanding dengan latihan fi sik. hasil penelitian ini sesuai dengan penelitian nyunt et al. (2010) tentang kontrol gula darah diperoleh hasil bahwa penderita dm tipe 2 yang memiliki skor self effi cacy 72–90 cenderung aktif melakukan kontrol gula darah di mana penderita yang memiliki skor self-effi cacy 72–90 berisiko untuk melakukan kontrol gula darah sebesar 5,65 (95% ci; 2,56– 12,48). keadaan ini dapat disebabkan oleh penderita yang memiliki skor self-efficacy tinggi cenderung mengatur pola hidupnya sehingga penderita aktif dalam mengontrol gula darah. hasil penelitian bakken et al. (2010) tentang self efficacy penderita dm tipe 2 memberikan kesimpulan bahwa upaya dalam peningkatan self efficacy diperlukan upaya yang terus menerus terhadap penderita dm tipe 2, diperlukan sebuah model pendidikan yang spesifik yang dapat meningkatkan efektivitas penderita sehingga penderita mampu mempercayai dari edukasi yang telah diberikan. hasil penelitian sesuai dengan teori bandura (1997) yang mengatakan bahwa self-effi cacy sebagai suatu kepercayaan diri seseorang tentang kemampuannya dalam melakukan aktivitas ter tentu yang akan berpengaruh terhadap kehidupannya. self effi cacy akan menentukan bagaimana seseorang merasa, berpikir, dan memotivasi dirinya. self effi cacy mempengaruhi pengelolaan hambatan dalam bertindak, sehingga semakin tinggi effi cacy akan menurunkan persepsi adanya hambatan untuk melakukan tindakan. self effi cacy seseorang bersumber dari 4 faktor, yaitu, performance accomplishment, vicarious experience, verbal persuasion, d a n e m osion al a ro u sal. pe r for m a n ce accomplishment merupakan suatu pengalaman atau prestasi yang per nah dicapai oleh individu tersebut di masa lalu. faktor ini adalah pembentuk self effi cacy yang paling kuat. prestasi yang baik pada masa lalu yang pernah dialami oleh subjek akan membuat peni ng kat an pad a ekspek t ansi ef i kasi, sedangkan pengalaman kegagalan akan menurunkan efi kasi individu. vicarious e xperience mer upa ka n pengalaman yang diperoleh dar i orang lain, dan menir u perilaku mereka untuk mendapatkan seperti apa yang orang lain peroleh. self-efficacy akan meningkat jika mengamati keberhasilan yang telah dicapai oleh orang lain, sedangkan sebaliknya selfeff icacy akan menur un apabila individu me nga m at i se se or a ng ya ng me m i l i k i kemampuan setara dengan dirinya mengalami kegagalan. pengaruh yang diberikan faktor ini terhadap self-effi cacy adalah berdasarkan kemiripan orang yang diamati dengan diri pengamat itu sendiri. semakin orang yang diamati memiliki kemiripan dengan dirinya, 263 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) maka semakin besar potensial self-effi cacy yang akan disumbangkan oleh faktor ini. verbal persuasion merupakan persuasi yang dilakukan orang lain secara verbal maupun oleh diri sendiri (self talk) yang dapat mempengaruhi bagaimana seseorang bertindak atau berperilaku. individu mendapat pengar uh atau sugesti bahwa ia mampu mengatasi masalah-masalah yang akan dihadapi. seseorang yang senantiasa diberikan keyakinan dan dorongan untuk sukses, maka akan menunjukkan perilaku untuk mencapai kesuksesan tersebut, begitu pun sebaliknya. faktor ini sifatnya dapat berasal dari luar atau dalam diri individu sendiri, namun yang membedakan dengan vicarious experience adalah pada faktor subjek mendapatkan feedback langsung dari pihak lain, sedangkan pada vicarious experience subjek sendiri lah yang secara aktif mengamati pihak lain tanpa intervensi dari pihak yang diamati. besar pengaruh yang dapat diberikan oleh pemberi persuasi adalah rasa percaya kepada pemberi persuasi serta kriteria kerealistisan tentang apa yang dipersuasikan. selain itu, subjek dapat memberikan persuasi kepada dirinya sendiri dengan semacam self talk kepada dirinya sendiri. e m o t i o n a l a r o u s a l m e r u p a k a n pembangkitan emosi positif sehingga individu mempunyai kepercayaan diri untuk melakukan suatu tindakan tertentu. kondisi emosional (mood) juga mempengaruhi pengambilan keputusan seseorang terkait self-effi cacy-nya. keadaan emosi yang menyertai individu ketika dirinya sedang melakukan suatu kegiatan akan mempengaruhi self-effi cacy seseorang pada bidang tersebut. emosi yang dimaksudkan adalah emosi yang kuat seperti takut, stres, cemas dan gembira. emosi-emosi tersebut dapat meningkatkan ataupun menurunkan self-effi cacy seseorang. berdasarkan hasil penelitian terdahulu dan teori pendukung dapat disimpulkan hasil penelitian bahwa supportive educative khususnya pada aspek guiding memberikan solusi pemecahan masalah bagi penderita sehingga penderita lebih memiliki kepercayaan terhadap upaya penanganan penyakit dm tipe 2. hasil penelitian memberikan kesimpulan bahwa pemberian supportive educative lebih meningkatkan self effi cacy pada aspek latihan fi sik dibanding aspek lain yang disebabkan pada program supportive educative terdapat guiding yang memberikan solusi pemecahan masalah terhadap penyakit dm tipe 2. berdasarkan hasil penelitian diperoleh hasil bahwa supportive educative signifi kan meningkatkan self care pender it a dm (tabel 5.5) keadaan ini dapat disebabkan oleh pada program supportive educative meliputi environment yang memberikan cara penanganan penyakit dm tipe 2 sehingga penderita mengetahui cara memberikan perawatan penyakit dm tipe 2. adanya keterampilan penderita dalam melakukan praktek perawatan menyebabkan penderita melakukan perawatan sendiri di rumah dalam upaya mencoba/mempraktikkan ilmu yang telah diperoleh melalui program supportive educative. adanya keterampilan yang diberikan selama program supportive educative melalui environment menumbuhkan keterampilan bagi penderita dm tipe 2 sehingga penderita dm tipe 2 memahami dan melakukan apa yang diperoleh dari program supportive educative. adanya keterampilan tentang cara perawatan diri melalui supportive educative menumbuhkan pembelajaran, pengetahuan, motivasi dan skill bagi penderita dm tipe 2. ad a nya pembelaja r a n, penget a hu a n dan motivasi ser ta keterampilan dapat menyebabkan penderita melakukan upaya perawatan mandiri di rumah. s elf ca re ya ng d apat d ila k u k a n oleh pender ita antara lain kemampuan penderita dalam mengelola pola makan dan diet, mengelola latihan fi sik, mengatur pengobatan, kontrol gula darah dan perawatan kaki. adanya supportive educative dapat menumbuhkan penderita dapat mengatur diet yang terkait dengan penyakit dm tipe 2, selain itu penderita dapat melakukan latihan fi sik di rumah dan kontrol gula darah secara teratur. kemampuan penderita dalam merawat diri dapat menyebakan penderita terhindar dari kondisi kejadian komplikasi. self care pada penderita dm tipe 2 perlu mendapat 264 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 perhatian khusus baik dari keluarga maupun dari lingkungan keluarga yang mendukung terciptanya kemampuan penderita. hasil penelitian ini sesuai dengan pendapat taylor & renpenning (2011) yang menyatakan bahwa interaksi antara perawat dengan klien akan dapat terjadi jika klien mengalami self care deficit, sehingga self care agency perlu ditingkatkan oleh individu karena pelaksanaan self care membutuhkan pembelajaran, pengetahuan, motivasi dan skill (taylor & renpenning, 2011). alligood & tomey (2006) yang menyebutkan bahwa self care agency adalah kemampuan atau kekuatan yang dimiliki oleh seorang individu untuk mengidentifikasi, menetapkan, mengambil keputusan dan melaksanakan self care. pemberian supportive educative pada variabel self care agency lebih berdampak pada perawatan kaki (δ1-2 = -1,82) dibanding dengan indikator lain seperti pengaturan pola makan, latihan fi sik, pengobatan dan kontrol gula darah. keadaan ini dapat disebabkan oleh a d a nya prog r a m supportive ed ucative khususnya pada aspek environment yang memberikan keterampilan penderita dalam upaya perawatan mandiri yang meliputi perawatan pola makan dan diet, latihan fisik, kontrol gula darah, pengobatan dan perawatan kaki. adanya supportive educative, environment menyebabkan penderita lebih mudah menerima kemandirian perawatan kaki. kemudahan kemandirian perawatan kaki dapat disebabkan oleh adanya keterampilan yang dimiliki oleh penderita dm tipe 2 selama program supportive educative sehingga penderita mampu melakukan perawatan mandiri di rumah. kemudahan perawatan mandiri di rumah dapat ditunjukkan oleh ratarata nilai lebih tinggi pada indikator perawatan kaki. kemandirian perawatan yang dapat dimungkinkan bagi subjek penelitian adalah melakukan perawatan kaki secara mandiri. self care pengaturan diet dan pola makan lebih rendah disbanding dengan perawatan kaki dapat disebabkan oleh sulitnya mengat ur makanan yang disajikan oleh anggota keluarga sehingga penderita lebih cenderung memiliki pola makan yang sama dengan anggota keluarga lain. keadaan ini yang menyebabkan penderita lebih sulit dalam perawatan mandiri dalam pengaturan pola makan dan diet. self care pengobatan dan kontrol gula darah lebih rendah dibanding dengan perawatan kaki dapat disebabkan oleh mahalnya kontrol gula darah dan pengobatan penderita dm tipe 2, sehingga penderita dm tipe 2 lebih cenderung memilih perawatan kaki secara mandiri karena alasan ekonomi. h a si l p e n el it i a n s e s u a i d e ng a n penelitian allen et al (2008) menyebutkan bahwa pemberian konseling meningkatkan frekuesi penderita dalam mengontrol gula darah, meningkatkan aktivitas fi sik. penelitian gagliardino and etchegoyen (2001) program p e nd id i k a n sig n i f i k a n me mp e nga r u h i kecepatan gula darah dari 10.6 ± 3.5 vs 8.7 ± 3.0 mmol/l. hasil penelitian sesuai dengan pendapat kar ter (2008) member ikan kesimpulan bahwa penderita diabetes perlu mendapatkan pendidikan tentang riwayat penyakit diabetes sehingga mereka dapat melakukan perawatan secara mandiri. pendapat likitratchharoen (2000) yang menyebutkan bahwa self-care untuk penderita dm tipe 2 perlu perhatian khusus untuk aktivitas yang harus penderita lakukan seperti; pengaturan pola makan (dietary kontrol), latihan fisik (exercise), manajemen stress (management stress), pengobatan (medication) dan personal hygiene. hasil penelitian sesuai dengan teori orem’s yang menyatakan bahwa terdapat tiga macam kebutuhan self care yaitu universal, developmental, dan health diviation. kebutuhan self care universal adalah kebutuhan dasar setiap manusia yaitu kebutuhan akan: udara, makanan, air, eliminasi, keseimbangan aktivitas dan istirahat, keseimbangan untuk menyendiri dan berinteraksi sosial, bebas dari ancaman, dan pengembangan pribadi dalam kelompok sesuai dengan kemampuan masingmasing individu. self care developmental dikaitkan pada kebutuhan yang muncul karena perkembangan akibat penyakit. kebutuhan health deviation adalah kebutuhan self care yang muncul karena seseorang mengalami sakit, misal kebutuhan untuk mendapatkan 265 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) bantuan kesehatan, memperoleh informasi kesehatan, dan kebutuhan akan kemampuan beradaptasi dengan keadaan sakit. pember ia n pend id i ka n kesehat a n me r upa k a n ca r a u nt u k me n i ng k at k a n kemampuan dasar self care agency. booklet asuhan keperawatan penderita dm tipe 2 yang digunakan dalam penelitian ini memuat materi tentang pemahaman penyakit diabetes secara umum, self care, dan diet. pemberian materi tersebut akan meningkatkan pengetahuan dan kemampuan penderita dm tipe 2 untuk mengenali masalah yang akan maupun sedang dialami. self care agency adalah kemampuan atau kekuatan yang dimiliki oleh seorang individu untuk mengidentifi kasi, menetapkan, mengambil keputusan dan melaksanakan self care (alligood & tomey 2006); (taylor & renpenning, 2011). interaksi antara perawat dengan klien akan dapat terjadi jika klien mengalami self care defi cit, di sinilah self care agency perlu ditingkatkan oleh individu karena pelaksanaan self care membutuhkan pembelajaran, pengetahuan, motivasi dan skill (taylor & renpenning, 2011). berdasarkan hasil penelitian terdahulu dan teori pendukung dapat disimpulkan bahwa pada penelitian ini adanya supportive educative lebih berdampak pada indikator self care pada aspek perawatan kaki. keadaan ini dapat disebabkan oleh adanya supportive educative lebih dimungkinkan bagi subjek penelitian untuk melakukan perawatan kaki secara mandiri di rumah dibanding dengan perawatan pola makan dan diet, pengobatan, kontrol gula darah dan latihan fi sik. hasil penelitian menunjukkan bahwa supportive educative signifi kan menurunkan h ba1c. keadaan ini dapat disebabkan adanya program supportive educative yang meliputi teaching, guiding dan environment me n i ng k at k a n p e nget a hu a n p e nde r it a tent ang penya k it dm t ipe 2 sehi ngga penderita memiliki keyakinan, kepercayaan dan kemandirian perawatan dalam upaya pengendalian penyakit dm tipe 2 ke arah yang lebih baik yang dapat dilihat dari adanya peningkatan skor self regulation, self effi cacy dan self care penderita dm tipe 2 setelah mendapatkan supportive educative. program supportive educative salah sat u nya meliputi environment di mana penderita mendapatkan keterampilan tentang perawatan diri penyakit dm tipe 2. adanya keterampilan perawatan diri penderita dapat menyebabkan penderita dm tipe 2 memiliki keterampilan dalam melakukan perawatan diri antara lain perawatan pola makan dan diet, perawatan mandiri latihan fi sik, perawatan mandiri pengobatan, perawatan mandiri kontrol gula darah dan perawatan kaki mandiri. adanya keterampilan menyebabkan penderita dapat melakukan perawatan mandiri di rumah. hal ini dapat dilihat dari rata-rata skor pada masing-masing self care agency mengalami peningkatan . hasil penelitian ini sesuai dengan penelitian gao et al. (2013) hasil penelitian menunjukkan bahwa self care signifikan secara langsung berdampak terhadap glycemic control (β = −0.21, p = .007). osborn et al. (2010) yang melakukan penelitian tentang kontrol gula darah diperoleh hasil bahwa keyakinan penderita akan berkaitan dengan kontrol gula darah a1c p ≤ 0.01. bains et al. (2011) yang melakukan peneletian tentang self care behavior terhadap kontrol gula darah diperoleh hasil bahwa pengetahuan tentang diabetes signif ikan berkaitan dengan kontrol gula darah. penelitian nyunt et al. (2010) yang melakukan penelitian tentang selfeffi cacy, self-care dan kontrol gula darah diperoleh hasil bahwa pemberian pendidikan dapat menurunkan gula darah (hba1c ≤ 7%) sebesar 27,1%. zhou et al (2013) yang melakukan peneletian tentang self care terhadap kontrol gula darah diperoleh hasil bahwa pengetahuan pender it a mer upa k a n fa k tor pred i k t if terjadinya self care penderita p ≤ 0.01 dan usia merupakan faktor prediktif terjadinya self care penderita p = 0.002. hasil penelitian ini sesuai dengan pend apat mayber r y & osbor n (2012) member i kan kesi mpulan bahwa u nt u k meningkatkan kontrol gula darah pada penderita dm tipe 2 diperlukan upaya peningkatan 266 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 keyakinan dan kepercayaan akan kemampuan kesembuhan penyakit sehingga penderita memiliki perilaku dalam mendukung terjadi penurunan a1c pada penderita dm tipe 2. keadaan ini memberikan gambaran bahwa penderita yang memiliki keterampilan dalam perawatan mandiri menyebabkan penderita tidak mengalami defi cit self care, sehi ngga pender it a mampu melak u kan perawat a n ma ndi r i di r u ma h. ad a nya kemampuan perawatan diri pada penderita menyebabkan penderita mampu melakukan upaya pengendalian penyakit dm tipe 2 sehingga keadaan ini yang menyebabkan terjadinya penur unan kadar hba1c bagi penderita. glukosa darah pada saat puasa dan pada dua jam sesudah makan menggambarkan keadaan gula darah pada suatu saat atau pada hari itu saja. hba1c (glycosylated hemoglobin) adalah protein yang dibentuk atas reaksi antara glukosa dengan hemoglobin dalam sel darah merah. semakin tinggi hba1c berarti semakin tinggi kadar glukosa darah, yang berlangsung selama usia sel darah merah, yaitu sekitar 3 bulan. jadi, hba1c adalah gambaran tentang gula darah penderita dm tipe 2 selama 2–3 bulan terakhir (tandra, 2009). jalur model pemberian supportive educative dapat melalui self regulation, self efficacy dan self care sehingga akan menur unkan hba1c. keadaan ini dapat disebabkan oleh pemberian program supportive educative terdapat aspek teaching, guiding dan environment sehingga akan berdampak pada peningkatan kognitif penderita. selain peningkatan kognitif pemberian guiding dapat meningkatkan afektif penderita dm tipe 2 dan adanya environment pada program supportive educative dapat menyebabkan penderita dm tipe 2 memiliki keterampilan dalam kemandirian perawatan diri seperti pengaturan diet dan pola makan, latihan fi sik, pengobatan, kontrol gula darah dan perawatan kaki. adanya peningkatan pengetahuan akibat teaching dapat menyebabkan penderita mampu melakukan identifi kasi permasalahan sehingga membuat sebuah koping dalam upaya penanganan penderita sehingga penderita dm tipe 2 mampu meningkatkan self regulation k hususnya pad a aspek reg ulasi d alam pengaturan pola makan dan diet. adanya peningkatan afektif penderita d apat me nyebabk a n pe nget a hu a n d a n kepercayaan diri dalam upaya pengendalian penyakit dm tipe 2. adanya peningkatan afektif dapat menyebabkan penderita memiliki motivasi untuk menyembuhkan penyakitnya. adanya motivasi ini yang menyebabkan terjadinya peningkatan self effi cacy penderita. adanya peningkatan keterampilan dalam kemandirian perawatan diri menyebabkan penderita dm tipe 2 mampu melakukan upaya perawatan di rumah, sehingga akan mengurangi akan kebutuhan perawatan (self defi cit). supportive educative yang diberikan dapat berdampak terhadap peningkatan self regulation melalui penilaian sehingga menyebabkan adanya motivasi. adanya motivasi menyebabkan penderita melakukan perawat an mandir i. adanya perawat an mandiri yang dilakukan oleh penderita dapat menyebabkan terjadinya penurunan hba1c. hasil penelitian ini sesuai dengan penelitian gao et al (2013) yang melakukan penelitian tentang hba1c diperoleh hasil bahwa self eff icacy (β = 0.32, p < .001), dukungan keluarga sosial support (β = 0.17, p = .009) berdampak secara langsung terhadap self care penderita. zhou et al. (2013) yang melakukan penelitian tentang self care terhadap kontrol gula darah diperoleh hasil bahwa rendahnya pengetahuan tentang diabetes dan rendahnya keterampilan tentang self care merupakan faktor yang menyebabkan penderita tidak mengontrol gula darah. hasil penelitian ini sesuai dengan pendapat gao et al. (2013) yang melakukan penelitian tent ang h ba1c member ikan kesimpulan bahwa komunikasi dengan petugas pemberi pelayanan, dukungan sosial dan peningkatan self effi cacy penderita signifi kan terhadap pembentukan perilaku perawatan diri penderita dm tipe 2, dan perilaku perawatan diri signifi kan berdampak langsung terhadap hba1c. zhou et al. (2013) memberikan kesimpulan bahwa keterampilan self care 267 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) allen,n.a., fain,j.a., braun,b. & chipkin, s.r . 20 0 9. c o nt i nu ou s g lu c o s e monitoringcounseling improves physical activity behaviors of individuals with type 2 diabetes: a randomized clinical trial, asian nursing research; 3 (3): 139–146 a mer ican diabetes association. 2003. physycal activity/exercise and diabetes mellitus (position statement), diabetes care, 26 (suppl.1) 73–77 a mer ican diabetes association. 2003. preventive foot care in people with diabetes. (position statement), diabetes care, 26 (suppl.1) 78–79 american association of diabetes educators. 2005. cqi: a step-by-step g uide for quality improvement in diabetes e d u c a t i o n . c h i c a g o , a m e r i c a n association of diabetes educators. (4) american diabetes association. 2008. clinical practice recommendation. diabetes care 2008; 31 (suppl i) a mer ican diabetes association. 2009. standars of medical care in diabetes. diabetes care; jan 2009; academic research library pg. s13 a mer ican diabetes associat ion. 2010. standars of medical care in diabetes 2010. journal of diabetes, vol. 23. suplement 1 januari 2010 11–61 american diabetes assosiation. 2010. standar of medical care in diabetes 2010, journal of diabetes care, vol. 33, supplement anselmo. i.m., nery. m., and parisi. c.r. 2010. the effectiveness of education practice in diabetic foot: a view from brazil. http://.dms journal.com/content/2/1/45 atak, n., gurkan, t., kose, k. 2007. the effect of education on knowledge, self ma nagement behav iors a nd self efficacy of patiens with type 2 diabetes. australian journal of advanced nursing. vol. 26 number 2 bains, s.s., and egede, l.e. 2011. associations between health literacy, diabetes knowledge, self-care behaviors, and glycemic control in a low income population with ty pe 2 diabetes, di a be t e s t e c h n o l o g y & therapeutics, volume 13, number 3, 2011 merupakan faktor yang dapat memperbaiki status kesehatan penderita dm tipe 2. simpulan dan saran simpulan penerapan model supportive educative dalam asuhan keperawatan pada penderita dm tipe 2 meningkatkan kemampuan perawatan diri (self care agency) melalui aktivitas self regulation terlebih dahulu, mulai dari interpretasi yang positif, koping yang sesuai, dan penilaian. peningkatan kemampuan perawatan diri (sca) terutama pada aspek pengaturan pola makan dan diet, pengobatan dan perawatan kaki dapat menurunkan kadar hba1c. peningkatan sca yang baik, maka memperbaiki regulasi tubuh pada kontrol glikemik pada batas normal. supportive educative juga dapat meningkatkan perawatan diri melalui jalur self effi cacy yang berproses kognitif, motivasi, afektif, dan selektif meskipun tidak sekuat pada aktivitas jalur self regulation. saran model supportive educative dapat diterapkan pada institusi pelayanan kesehatan dengan mengembangkan sistem pelayanan secara terintegrasi dan menyediakan sarana untuk center of supportive educative sebagai upaya peningkatan pengendalian diri dan kemandirian penderita dm tipe 2 dalam merawat dirinya. model ini juga dapat diterapkan pada kasus penyakit kronis lain yang memerlukan perawatan mirip dengan penderita dm misalnya penderita dengan gagal ginjal, post stroke, dan tbc. penelitian lebih lanjut tentang mekanisme peningkatan hba1c dengan peningkatan kemandirian penderita. kepustakaan allen, n.a., fain, j.a., braun, b., and ch ipk i n, s.r. 20 08. cont i nuou s g l u c o s e m o n it o r i n g c o u n s el i n g improves physical activity behaviors of individuals with type 2 diabetes: a randomized clinical trial, diabetes res clin pract, 2008 june; 80 (3): 371–379. doi:10.1016/j.diabres.2008.01.006. 268 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 baker, l. k., & denyes, m. j. 2008. predictors of self-care in adolescents with cystic fibrosis: a test of orem’s theories of self-care defi cit. journal of pediatric nursing, 23 (1) bakken, l.l., byars-winston, a., gundermann, d,m., ward, e, c., slattery, a., king, a., scott, d., and taylor, r.e. 2010. effects of an educational intervention on female biomedical scientists’ research self-effi cacy, adv health sci educ theory pract. 2010 may; 15 (2): 167–183. doi:10.1007/s10459-009-91902. bandura a. 1997. self efficacy toward a unifying theory of behaviour change, psychology review, vol. 84. p. 191–215 bandura, a. (1989) human agency in social cognitif theory, america psychologist, vol. 44, p. 1175–1184 baumeister, r.f., gailliot m., de wall, c.n., oaten m. 2006. self regulation and personality: how interventions increase regulatory success, and how depletion moderates the effects of traits on behavior. journal of personality 74: 6, december 2006 baumeister, r.f., and vohs, k.d. 2007. self regulation, ego depletion, and motivation. social and personality compass 1 (2007): 10.1114. 1751– 9004.2007.00001.8ul browning, k., wewers, m.e., ferketich, a., otterson, g., reynolds, n. 2009. the self regulation model of illness applied to smoking behavior in lung cancer. cancer nursing, 32 (4), e15–e25. callaghan, d. 2006. basic conditioning factors inf luences on adolescents healthy behaviors, self effi cacy, and self care. issues in comprehensive pediatric nursing, 29. doi: 10.1080/0146086060 1087156 cameron, l.d., & leventhal, h. 2003. the self regulation of health and illness behavior. london and new york: routledge. davies, m.j., heller, s., skin ner, t.c., campbell, m.j., carey, m.e., cradock, s., dallosso, h.m., daly, h., doherty, y., eaton, s., fox, c., oliver, l., rantell, k., ray man, g., k hunti, k., and vascularmedicine. 2007. effectiveness of the diabetes education and self management for ongoing and newly diagnosed (desmond) programme for people with newly diagnosed type 2diabetes: cluster randomised controlled trial, bmj | online first | bmj.com page 1 of 11 depkes ri. 2008. petunjuk teknis pengukuran faktor risiko diabetes melitus, jakarta: ditjen pp dan pl. depkes ri. 2008. hasil riset kesehatan dasar (r iskesdas), direktorat jenderal pengendalian penyakit dan penyehatan lingkungan depkes ri. departemen kesehatanes ri. 2008. pedoman teknis penemuan dan tatalaksana penyakit diabetes militus, cetakan ke2, direktorat pengendalian penyakit tidak menular, dirjen p2pl depkes ri. jakarta. delamater, alan m. 2006. clinical use of he m oglobi n a1c to im p rove diabetes management. (online). crop managemen doi:10.2337/diacalin.24.1.6 clinical diabetes januari 2006 vol. 24 no. 1 6–8. de rider d.t.d., de wit. j.b.f. 2006. self reg u lat ion i n he a lt h beh av ior: concepts, theories, and central issues. self regulation in health behavior c. 2006 john wiley wiley & sons ltd edgar, k.a., & skinner, t.c. 2003. illness representation and coping as predictors of emotional well-being in adolescents with t y pe 1 diabetes. journal of pediatric psychology, 485–493 gagliardino, j.j., and etchegoyen, g. 2001. a model educational program for people with type 2 diabetes, a cooperative latin american implementation study (pednid-la), diabetes care, vol. 24, number 6, juni 2001. gao, j., wang, j., zheng, p., haardörfer, r., kegler, m.c., zhu, y., and fu, h. 2013. effects of self-care, self-effi cacy, social support on glycemic control in adults with type 2 diabetes, bmc family practice 2013, 14:66 glanz, k., rimer & lewis, f.m. 2008. health behaviour and health education theory. reaseach and practice. san fransisco; wiley & sons inter national diabetes federation. 2010. 269 efektivitas supportive educative terhadap peningkatan self regulation (darmansyah af., dkk.) diabetes atlas, fifth edition. http/www. idf.org /diabetesatlas/5e/the-globalburden. (sitasi 21 mei 2012 karter, a.j., stevens, m.r., gregg, e.w., brown, a.f., tseng, c.w., marrero, d.g., duru, k., gary, t.l., piette, j.d., waitzfelder, b., herman, w.h., beckles, g.l., safford, m.m., and ettner, s.l. 2008. educational disparities in rates of smoking among diabetic adults: the translating research into action for diabetes st udy, am j public health. 2008; 98: 365–370. doi:10.2105/ ajph.2005.083501 keeratiy utawong p., hanuchar un kul s., boonchauy w., phumleng b., muangkae w. (2005) effectiveness of a supportiveeducative program on diabetic control, perceived self-care effi cacy, and body mass index in persons with type 2 diabetes mellitus. thai j nurs res 2005; 9 (1): 1–12 ku ntoro. (2010) metode sampling dan penentuan sampel. edisi revisi. surabaya. pustaka melati kuntoro. 2011. dasar filosofi s metodologi penelitian. edisi revisi. surabaya. pustaka melati leventhal, h., brissete l. 2003. the commensense model of self-regulation of health and illness, in: cameroon ld. leventhal h, editors. the self regulation of health and illnes behaviour. london: routledge likitracharoen, s. 2000. meta-analysis of educative suppor tive inter vention resea rch for d iabet ic pat ients i n thailand., universit y of mahidol, thailand limruangrong, p., sinsuksai, n., rathinthon, a., bor iboon h i r u nsa r n, d. 2011. effectiveness of a self-reg ulation program on diet control, exercise and two-hour postprandial blood glucose levels in thais with gestational diabetes mellitus. pcifi c rim int j nurs res 2011 ; 15 (3) 173–187 lipowsk i. 1979. physical ill ness, t he individual and the coping processes. psychiar. med. 1: 91–102 mayberry, l.s & osborn, c.y. 2012. family support, medication adherence, and glycemic control among adults with type 2 diabetes, diabetes care, volume 35, june 2012 mcnamara, r., robling, m., hood, k., bennert, k., channon, s., cohen, d., crowne, e., hambly, h., hawthorne, k., longo, m., lowes, l., playle, r., rollnick, s., gregory, j.w. 2010. development and evaluation of a psychosocial intervention for children and teenagers experiencing diabetes (depicted). bmc health services research 2010, 10:36, http://www. biomedcentral.com/1472-6963/10/36al, mersal, f.a., mahday, n.e., mers, n.a. 2012. efficiency of web-based education versus counseling on diabetic patients’ outcomes. life sei j 2012; 9 (3): 912– 926. (isn: 1097-8135) nursalam. 2003. konsep dan penerapan m e t o d o l o g i p e n e l i t i a n i l m u ke p e ra wa ta n. ja k a r t a : sa le mb a medika nyunt s.w., howteerakul n., suwannapong n., rajatanun t. 2010. self effi cacy, self-care behaviors and glycemic cont rol a mong ty pe 2 diabetes patients attending two private clinics in yangoon, myanmar. faculty of public health, mahidol university, bangkok, vol 41 no. 4 july 2010 ogden, j. 2004. healt psychology: a textbook 3rd edition. new york, ny 10121-2289. usa ogden, j. 2007. health psychology 4th ed. open university: england orem study group. 2004. working papers: the orem study group of the 8 th world congress s-cdnt, sept. 29–oct, 3, 2004, institute for nursing diagnostic and practice research. clopenburg, germany. paddison. c.a.m., alpass. f.m., stephens. c.v. 2010. using the common sense model of illness self-regulation to understand diabetes-related distress: the importance of being able to’make sense’ of diabetes. new zeiland journal of psychology vol. 39, no. 1, 2010 papadopoulos, a.a., kontodimopoulos, n, frydas, a.,ikonomakis, e., and niakas, d. 2007. predictors of health-related quality of life in type ii diabetic patients in greece, bmc public health (2007). 270 jurnal ners vol. 8 no. 2 oktober 2013: 253–270 7: 186 ht t p://w w w.biomedcent ral. com/1471-2458/7/186 perkni. 2011. konsensus pengelolaan dan pencegahan diabetes mellitus tipe 2 di indonesia. jakarta. pb perkeni resnick, barbara. 2008. middle range theory for nursing second edition. chapter 10. theory of self-effi cacy. springer publishing company, llc. new york, ny 10036. rsud a.w. syahranie. 2011. profi l rsud. a.w. syahranie samarinda : laporan rekam medik penderita diabetes salsali, m. 2005. evaluat i ng teach i ng effectiveness in nursing education: an iranian perspective, bmc medical education 2005. smeltzer, s.c., bare, bg., br u n ner & sudarth’s. 2004. textbook of medical surgical nursing 10th edition. volume 2. philadelphia: lippincot & wilkins shi, q., ostwald, s.k., & wang, s. 2010. improving glycemic cont rol self ef f ica cy a nd glyc e m ic c ont rol behavior in chinese patients with type 2 diabetes mellitus: randomized control trial. j. clini. nurs; 19, 398–404. song, m.k., and lipman, t.h. 2008. concept analysis: self-monitoring in type 2 diabetes mellitus, international journal of nursing studies 45, 1700–1710. suyono, slamet., dkk. 2007. penatalksanaan diabetes mellitus terpadu: sebagai panduan penatalaksanaan diabetes mellitus bago dokter dan educator. jakarta: balai penerbit fkui tandra, h. 2009. segala sesuatu yang harus diketahui tentang diabetes, jakarta: pt gramedia pustaka utama taylor, s.g., renpenning, k. 2011. self care science, nursing theory, and evidencebased practice. springer publishing company, llc. new york, ny 10036 teixeira, c,r,s., zanetti, m.l., pereira m.c,a. 2009. nursing diagnoses in people with diabetes mellitus according to orem’s theory of self-care, acta paul enferm, 2009; 22 (4): 385–91. tjokroprawiro. a. 2011. hidup sehat dan bahagian bersama diabetes, edisi revisi ke-3. jakar ta. penerbit pt gramedia pustakan utama tom mey, a.m., alligood, m.r. 2006. nursing theorists and their work. six edition. st. louis missouri: mosby uno, h.b. (2007). teori motivasi dan pengukurannya: analisis di bidang pendidikan. jakarta: bumi aksara wilson, f.l., mood, d.w., risk j., and kershaw, t. 2003. evaluation of education materials using orem’s selfcare defi cit theory, nursing science quarterly, 16: 1, january 2003 world health organization. 2006. defi nition, diagnosis and clasifi cation of diabetus mellitus and its complications. report a who consultation. who, geneva world health organization. 2009. standarts of medical care in diabetes. diabetes care: jan 2009; 32, 1; academic research library pg. s13 world health organization. 2011. causes of death 2008: data sources and methods, department of health statistics and informatics, world health organization, geneva, april 2011 zhou, y., liao, l., sun, m., and he, g. 2013. self-care practices of chinese individuals with diabetes, experimental and therapeutic medicine, 5: 1137–1142, 2013 144 http://e-journal.unair.ac.id/jners © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 144-152 http://dx.doi.org/10.20473/jn.v17i2.36187 original reseacrh open access correlation of spiritual health and depression among young adults in a state university in southern philippines sitty aizah mangotara1 and ashley bangcola1* 1faculty mindanao state university-main, college of health sciences, marawi city, 9700 lanao del sur, philippines *correspondence: ashley bangcola. address: faculty mindanao state university-main, college of health sciences, marawi city, 9700 lanao del sur, philippines. email: ashley.bangcola@msumain.edu.ph responsible editor: risky fitryasari received: 7 june 2022 ○ revised: 21 september 2022 ○ accepted: 21 september 2022 abstract introduction: depression is a leading cause of disability in the philippines. according to data from the world health organization, the overall prevalence of depression in the philippines is 3.3 percent, implying that over 3.3 million filipinos are suffering from symptoms of depression. depression thus affects a majority of filipinos. meanwhile, previous studies have shown a link between spirituality and mental health. methods: the overall objective of this study is to assess the respondents' demographic characteristics, their spiritual health, their level of depression and to find a significant relationship, if any, among the variables. results: the data indicated that respondents' average religious well-being score was 55.28, indicating a favorable sense of one's relationship with god. the existential well-being score had a mean of 44.56, indicating a moderate level of life fulfillment and meaning. furthermore, the total score for all depressed symptoms was 23.32, indicating that people who took part in the survey during the pandemic suffered moderate to severe depression. correlation analysis found a negative correlation between spiritual health and the level of depression (r=-0.458, p=0.001) which means that as respondents' spiritual health grows, their level of depression lowers. conclusion: the study concluded that spiritual health, as expressed through existential well-being and religious well being, is a separate component that lends explanatory power to mental well-being prediction. the study advises heads of health sectors in various institutions to intensify their fight against depression. additional research is also strongly encouraged. keywords: depression; existential well-being; mental health; quantitative research; religious well-being; spiritual health introduction although the philippines consistently ranks in the top five of a global optimism index, the national center for mental health (ncmh) has discovered a significant increase in monthly depression hotline calls, with numbers rising from 80 prior to the lockdown to around 400 (who, 2020). according to the world health organization (2020), young adults aged 15 to 29 are the most vulnerable to depression. mental health-related deaths are the second leading cause of death in this age group. depression is the most widely recognized mental health disorder affecting over 264 million people of all ages worldwide (reddy, 2010). furthermore, depression is the leading cause of disability worldwide and a significant contributor to the overall global disease burden (who, 2020). these figures demonstrate the need for more action in this area. depression is also a significant contributor to disability in low-income countries such as the philippines (flores et al., 2018). because depression is most prevalent in people between the ages of 15 and 25, it is likely that the difficulties associated with depression and its https://creativecommons.org/licenses/by/4.0/ mailto:ashley.bangcola@msumain.edu.ph https://orcid.org/0000-0002-0925-8599 https://orcid.org/0000-0002-8228-9930 jurnal ners http://e-journal.unair.ac.id/jners 145 consequences are significantly severe in the young adult filipino population (hedden et al., 2015; statistics canada, health statistics division, 2014). most filipino young adults may not feel comfortable revealing their psychological condition for fear of isolation or discrimination since there are many who dismiss depression. some people might label a person suffering from depression as unreligious or having a sporadic amount of spirituality, which may be seen negatively since filipinos are known to be religiously minded (bonelli et al., 2012). many psychologists are fascinated by the connection between mental health and spirituality and numerous studies have shown that spiritual health has a substantial influence on mental health (akbari & hossaini, 2018). according to their findings, spiritual intelligence fosters the development of emotional intelligence and helps individuals achieve better emotional intelligence and, as a consequence, live a happier life with excellent physical, mental, and spiritual health and no stress (sahebalzamani et al., 2013). given the relevance of spiritual health as a connected structure associated with mental health and the necessity of emotion regulation, there has been a paucity of research undertaken in the philippines related to determining the relationship between spiritual health and depression. there has been no research completed in the study's target area and especially among young people aged 18 to 25. thus, the purpose of this research was to examine the relationship between spiritual wellbeing and depression among undergraduate students enrolled for the academic year 2020 2021 to promote awareness among them about their spiritual and mental well-being. this may also be used as a reference for future and further study on the subject. materials and methods design of the study this study assessed the respondents' demographic characteristics, their spiritual health as measured by the spiritual well-being scale (swbs), and their level of depression as measured by the beck depression inventory (bdi). a quantitative approach using cross-sectional descriptive-correlation design was used to carry out a study on a sample of 200 undergraduate students aged 18-25 years old. the cross-sectional methodology was selected because it allowed for the simultaneous gathering of quantitative data on many variables (bushnik, 2020), in this instance, young adults' spiritual health and depressive symptoms. additionally, a descriptive-correlational study approach was employed to ascertain the magnitude of the association between young adults' spiritual health and depressive symptoms. this type of research design seeks and interprets relationships between and among a collection of information. this form of study identifies trends and patterns in data, but does not go so far as to establish the reasons of observed patterns. this form of observational study is devoid of causal relationships. only the data, relationships, and distributions of variables were examined. rather than manipulating variables, they are recognized and investigated in their natural state (creswell, 2008). sample and setting in this research, the eligibility of the participants were based on the following criteria: (1) they must be young adults between the ages of 18 and 25; (2) they must be officially enrolled at mindanao state university, main campus during the second semester of academic year 2020-2021; and (3) they must have agreed to participate in the study. convenience sampling was used to narrow down the sample. a total of two hundred and forty-eight (248) students responded to the survey questionnaires that were sent to their intuitional email addresses. after using purposive sampling, forty-eight (48) questionnaires were excluded from the sample because of insufficient information on age, gender, or any of the responses to survey questionnaire items, resulting in a final sample of 200 respondents.. instrument data were gathered from the students using selfreported questionnaires. the questionnaires were divided into three sections: the first section was authordeveloped and focused on the respondents’ demographic profile and which included items such as age, sex, college/department, year level, religion, and ethnicity. the second section consisted of scales to measure spiritual health and, lastly, the third section consisted of scales to measure self-reported depressive symptoms experienced by the students. to measure the spiritual health of the respondents, the spiritual well-being scale (swbs) developed by poulotizan and ellison in 1982 was utilized. the swbs provides an overall measure of the perceived spiritual quality of life, as understood in two senses religious well-being and existential well-being. religious wellbeing items include the term "god" and assess how one sees and reports the well-being of one's spiritual life in connection to god. items measuring existential wellmangotara and bangcola (2022) 146 p-issn: 1858-3598  e-issn: 2502-5791 being include basic remarks about life direction and happiness, as well as measures of how well an individual sees and assesses his or her adjustment to self, community, and environment (paloutzian et al., 2021). to measure the level of depression, the long form of the beck depression inventory (bdi) developed by aaron t. beck (1961) was used. the bdi is a 21-item self-report rating inventory that assesses depression-related attitudes and symptoms (cotton et al., 2006). items 1 to 13 assess symptoms that are psychological in nature, while items 14 to 21 assess more physical symptoms. each item in the bdi has four possible responses. each response is assigned a score ranging from 0 to 3, indicating the severity of the symptom. the total score may vary from 0 to 63. the highest possible score that can be obtained by the respondent is 63 and the lowest possible score is 0. no depression is indicated by a score of 5 to 9, mild to moderate depression by a score of 10 to 18, moderate to severe depression by a score of 19 to 29, and severe depression by a score of 30 to 63. because it is lower than average scores for normal people, a score of less than 5 may suggest denial of depression (cotton et al., 2006). validity and reliability of the instrument in terms of reliability, the rwbs, ewbs, and swbs are all very reliable. test-retest reliability coefficients for the rwbs are 0.96, 0.99, 0.96, and 0.88 across four investigations with testing intervals of 1-10 weeks. the coefficients for the ewbs are 0.86, 0.98, 0.98, and 0.73 while the coefficients for total swbs are 0.93, 0.99, 0.99, and 0.82. internal consistency, as measured by the coefficient alpha, also demonstrates a high degree of dependability. internal consistency coefficients varied from 0.82 to 0.94 (rwb), 0.78 to 0.86 (ewb), and 0.89 to 0.94 (swb) among seven samples (malinakova et al., 2017). the bdi test is well-known and has been validated in terms of content, concurrent, and construct validity. the bdi has a high concurrent validity rating; a 0.77 correlation rating was calculated when compared with inventory and psychiatric ratings. the bdi has also shown high construct validity with the medical symptoms it measures. beck’s study reported a coefficient alpha rating of 0.92 for outpatients and 0.93 for college student samples. the bdi-ii had a positive correlation with the hamilton depression with rating scale, r=0.71, had a one-week test-retest reliability of r=0.93 and an internal consistency α= 0.91 (wang & gorenstein, 2013). data collection the survey questionnaire was administered by the researcher using google forms, created and hosted by google. an informed consent form, which had all the pertinent information about the study, was included in the questionnaire. the respondents were provided assurances that their responses and their identities would remain confidential. when the total number of responses was attained, the google form link was closed two weeks after the surveys were sent out through email. the responses to the surveys were collected over the course of two weeks. two hundred and forty-eight students replied to the survey; however, only 200 completed questionnaires were found to be suitable for analysis. data analysis the data were analyzed using the statistical package for the social sciences (spss) software package version 28.0. a descriptive analysis of the data and the assessment of the response rates were carried out on the basis of the frequencies of the replies. first, the respondents' profiles, spiritual health, and depression symptoms were computed using frequencies and percentages to characterize the respondents. secondly, the pearson's r correlation coefficient was utilized to assess whether there is a link between respondents' spiritual health and the depression symptoms they have experienced. to undertake an in-depth statistical analysis of the data, the following statistical approaches were used: frequency count and percent. frequency distributions can show either the number of observations falling into each range or the percentage of observations falling into each range. this was used to determine the profile variable as well as the number of respondents who share the same level of spirituality and depression symptoms. table 1 socio-demographic characteristic of the respondents character number percentage gender male female 39 161 19.5 81 age 19 20 21 22 23 24 25 12 22 81 44 16 3 6 6 19 40.50 22 8 1.50 3 religion catholic islam others 19 170 11 9 85 6 jurnal ners http://e-journal.unair.ac.id/jners 147 ethical consideration to adhere to ethical standards while conducting research, all respondents were required to sign an informed permission form that was linked to the questionnaire. while it is customary to get written agreement, silverman (2009) asserts that excessively structured methods of obtaining consent should be avoided in favor of developing relationships characterized by a continuous ethical care for participants. consent was regarded adequate in this research when the completed questionnaire was returned via email. throughout the course of this research study, research ethics were primarily observed and upheld. the research ethics committee of mindanao state university's college of health sciences checked, verified, and approved the questionnaire tools used in this study before data collection began. results respondents characteristics the findings of the respondents' socio-demographic characteristics are shown in the following figures. it contains information such as age, gender, and religion. the tables were sorted according to their frequency, and the totals were calculated according to the percentage on which the conclusion and interpretation were based. as shown in table 1, the students' ages varied from 19 to 25, with a median age of 22, which means that half of the student population was younger than 22 years old. nearly half of the students who replied to the survey (40.5%) were 21 years old, followed by students aged 22 years old (22%), 20 years old (19%), 23 years old (8%), 19 years old (6%), 25 years old (3%), and 24 years old (1.5%). the data suggest that females made up an overwhelming majority of the respondents (80.5%), with just 19.5 percent of male respondents. in terms of religion, table 1 reveals that islam represents an overwhelming majority of respondents' religion, accounting for 85 percent of all respondents' religions. catholicism accounts for 9.5 percent of all respondents' religions and the remaining 5.5 percent are classified as belonging to other types of religion, with eleven respondents falling into this category respondents’ spiritual health spiritual health is used in this research to refer to young adults' overall spiritual well-being, which covers both their religious and existential well-being. the spiritual well-being scale (swbs) assesses spiritual health by separating it into two related but independent dimensions: religious and existential wellbeing. religious well-being (rwb) is a vertical dimension that emphasizes one's connection with god, while existential well-being (ewb) is a horizontal dimension that emphasizes a feeling of life purpose and fulfillment (paloutzian et al., 2021). in the context of the vertical component of spiritual health, which focuses on one's connection with a higher being or god, the data demonstrate that, for the negatively phased statements, the majority of respondents not only disagree, but strongly disagree with item 1, “i do not find much satisfaction in private prayer with god” at 79 percent. this is also true for item 5, "i believe god is impersonal and not interested in my daily situations," with 78 percent strongly disagreeing, and item 9, "i do not get much personal strength and support from my god" at 71 percent. item 13, "i do not have a personally satisfying relationship with god," yields a similar result, with 71 percent strongly disagreeing. this is congruent with the responses to positively framed statements such as item 3, "i believe that god loves and cares about me," with the majority of respondents with 90.5 percent of the respondents strongly agreeing. sixty percent of respondents strongly agree with the statement "i have a personal meaningful relationship with god" in item number seven. a total of 82 percent strongly agree with the statement in item 11, "i believe that god is concerned about my problems," and a total of 69.5 percent strongly agree with the statement in item 15, "my relationship with god helps me not to feel lonely." finally, the majority of respondents strongly agreed with the statements "i feel most fulfilled when i am in close communication with god " (76%) and "my relation with god contributes to my sense of well-being" (72.5%) on items seventeen and nineteen, respectively. when viewed in the context of the horizontal dimension of spiritual health, which focuses on one's relationship with oneself and others, the results show that, for the negatively-worded statements item 2, "i do not know who i am, where i came from, or where i’m going;" item 6, “i feel unsettled about my future;" and table 2 respondents’ extent of spiritual health dimensions mean score sd interpretation religious well-being (rwb) 55.28 6.72 positive view of one’s relationship with god existential well-being 44.56 7.24 moderate level of life satisfaction and purpose total score spiritual well-being 99.84 12.07 moderate spiritual well-being mangotara and bangcola (2022) 148 p-issn: 1858-3598  e-issn: 2502-5791 item 12, "i do not enjoy about life;" as well as item 16, "i feel that life is full of conflict and unhappiness," the respondents’ responses were almost evenly distributed in the agreement-disagreement continuum, which means that they had different opinions about the statements. on the other hand, the respondents' responses to the positively-worded statements, such as in item 4, "i feel that life is a positive experience;" item 8, "i feel very fulfilled and satisfied with life;" item 10, "i have sense of well-being about the direction of my life;" and item 14, "i feel good about my future," revealed that they had differing opinions about them, though their responses were pulled toward the agreement end of a continuum ranging from agreement to disagreement. according to the findings, young individuals who were college students had a more optimistic attitude on life, despite the hardships and adversities that they were experiencing at the time. in line with this, the majority of respondents strongly agreed on item 20, “i believe there is some real purpose for my life," with 78 percent of the total number of respondents strongly agreeing. spiritual health refers to the component of an individual's well-being that organizes his or her values, relationships, and hence the meaning and purpose of their existence (seidl, 1993). the spiritual well-being scale (swbs) was used to assess the respondents' spiritual health. the swbs is a composite index of perceived spiritual quality of life in two dimensions: religious well-being and existential well-being and has three basic scores: religious well-being, existential well-being, and overall spiritual well-being. religious well-being items include the term "god" and assess how one sees and reports the well-being of one's spiritual life in connection to god. the religious well-being score is a reflection of an individual's perspective on their connection with god. a score between 10 and 20 indicates an inadequate connection with god. a score between 21 to 49 indicates a moderate level of religious well-being. a score between 50 and 60 indicates a favorable assessment of one's connection with god (paloutzian et al., 2021). the existential well-being scale includes basic remarks about life direction and happiness, as well as measures of how well an individual sees and assesses his or her adjustment to self, community, and environment. a score between 10 and 20 indicates a low level of contentment with one's life and a likely lack of clarity about one's life purpose, a score between 21 to 49 indicates a moderate degree of life fulfillment and meaning and a score of 50–60 indicates a high degree of life satisfaction and a strong feeling of purpose (paloutzian et al., 2021). in terms of overall spiritual well-being, a score between 20 and 40 indicates a poor feeling of total spiritual well-being, a score between 41 to 99 indicates a modest feeling of spiritual well-being and a score between 100 and 120 indicates a high level of spiritual well-being (paloutzian et al., 2021). the religious well-being scale (rwbs) and the existential well-being scale (ewbs) both have a maximum score of 60. as a result, the maximum possible score on the full scale spiritual well-being (swbs) is 120. the findings in table 2 indicate that the mean score on the rwbs for the participants was 55.28 with a standard deviation of 6.72, corresponding to a positive view of one’s relationship with god. the mean score on the ewbs was 44.56, with a standard deviation of 7.24, suggesting a moderate level of life satisfaction and purpose. the mean score for the full scale swbs was 99.84, with a standard deviation of 12.07, suggesting an overall moderate spiritual well-being. the overall score obtained by the respondents in the spiritual well-being scale (swbs) indicate that muslim college students in their early adulthood had an overall moderate or average level of spiritual well-being, with a mean of 99.84 in the current study. respondents’ symptoms of depression depression appears in a variety of forms and to varying degrees and includes feelings of sadness, pessimism, past failure, guilt, punishment, self-dislike, self-criticism, suicidal thoughts or wishes, crying, agitation, loss of interest, indecisiveness, worthlessness, loss of energy, changes in sleeping pattern, irritability, changes in appetite, concentration difficulty, and tiredness or fatigue. this study examined the most commonly reported symptoms of depression among young people studying at one institution in the philippines. most of the respondents "feel sad much of the time" at 66.5 percent, 10 percent were “sad all the time” while another 8.5 percent felt “so sad or unhappy that i cannot stand it.” on the other hand, only 15 percent reported not feeling sad. based on the aggregated data, the respondents felt “a little” sadness with mean of 1.12 (sd=.76) in the past two weeks prior to the collection of data. nearly half of the respondents did not exhibit pessimism when they said they were not discouraged about their future (49%), but more than a quarter said they were more discouraged than they used to be (33.5%), and a significant number said they did not jurnal ners http://e-journal.unair.ac.id/jners 149 expect things to work out for them (11%), and some even said they were hopeless about their future (6.5%). according to aggregated data, the respondents reported feeling “a little” pessimistic in the two weeks before data collection, with a mean of .75 (sd=.89). with a mean of 1.17 (sd=.97), the respondents reported feeling "a little" bit like a failure in the past; 32.5 percent of the respondents confirmed this by saying they perceive a lot of failures when they look back on their lives, 27 percent said they failed more than they should have, and a very significant 8.5 percent reported that they felt like a complete failure as a person. the respondents reported experiencing "a little" decrease of enjoyment (pleasure) on a mean of 1.02 (sd=.92). this is confirmed by 33.5 percent of respondents who claimed that they no longer enjoy things as much as they used to and 24.5 percent who reported receiving very little pleasure from the things they used to like, while others reported receiving no pleasure at all (6.5%). only 35.5 percent of those who answered the survey said they were experiencing as much enjoyment from their favorite activity as they had in the past. with a mean of 1.21 (sd=.70), the respondents reported feeling a little level of guilt on average among all respondents. the majority of those who answered the survey felt guilty about a variety of things they had done or should have done (64.5%). in addition, another 19.5 percent of people feel somewhat guilty most of the time, and six percent feel very guilty all of the time. in fact, just 10 percent of the respondents do not feel particularly guilty or remorse for the things they might have done. regarding punishment sentiments, respondents reported experiencing a little punishment, with a mean of 1.22 (sd=1.0) per respondent. similar to the results of guilty feelings, the vast majority of respondents felt sentiments of being punished in varying degrees, which was consistent with the findings regarding guilty feelings: 39.5 percent believe they will be punished for actual or imagined wrongs they have committed, 19 percent believe they will be punished in the future, and 15 percent believe they are now suffering the consequences of their actions by being punished. collectively, the respondents reported disliking themselves a little with a mean of 1.00 (sd=.81): 45 percent of the respondents answered "i have lost confidence in myself,” 22.5 percent stated that they were disappointed in themselves and 3.5 percent stated that they disliked themselves only 29 percent felt the same about themselves as ever. the percentage of respondents who showed a little self-criticism was measured with a mean of 1.20 (sd=1.02). those who answered "i criticize myself for all of my faults" was 29.5 percent, closely followed by the percentage of respondents who said "i am more critical of myself than i used to be," which was 29.0 percent. "i don't criticize or blame myself more than usual," said 27.5 percent of those polled, while the remaining 14.0 percent stated that "i blame myself for everything bad that happens." on average, the respondents have only a passing thought (a little) about suicide, with a mean of .42 (sd=.65). although the majority of respondents (64.5%) do not have suicidal thoughts, a significant number do have suicidal ideation to varying degrees; 31.5 percent of people have considered suicide but have no plans to do so, 1.5 percent said they wanted to kill themselves, and 2.5 percent said they would kill themselves if they had the chance. the prevalence of crying among respondents was about evenly divided among the four response options, with a mean of 1.50 (sd=1.15) equating to ‘a little.’ with 27.5 percent indicating that they no longer cry as much as they once did. twenty-five percent of respondents table 3 respondents’ level of depression scale dimension mean score sd interpretation 1. sadness 1.12 0.76 2. pessimism 0.75 0.89 3. past failure 1.17 0.97 4. loss of pleasure 1.02 0.92 5. guilty feelings 1.21 0.70 6. punishment feelings 1.22 1.00 7. self-dislike 1.00 0.81 8. self-criticalness 1.30 1.02 9. suicidal thoughts or wishes 0.42 0.65 10. crying 1.50 1.15 11. agitation 1.21 1.03 12. loss of interest 1.19 0.92 13. indecisiveness 1.20 0.99 14. worthlessness 0.83 0.94 15. loss of energy 1.28 0.86 16. changes in sleeping pattern 1.42 0.86 17. irritability 1.01 0.94 18. changes in appetite 1.32 0.98 19. concentration difficulty 1.42 0.96 20. tiredness or fatigue 1.40 0.96 21. changes of interest in sex 0.28 0.67 total score 23.32 .90 moderate to severe depression scoring: 05-09 no depression 10-18 mild to moderate depression 19-29 moderate ro severe depression 30-63 severe depression mangotara and bangcola (2022) 150 p-issn: 1858-3598  e-issn: 2502-5791 stated that they cry more than they used to, 26.0 percent stated that they cry at insignificant things, while another 26.0 percent stated that they are incapable of crying even when they feel like it. in terms of agitation, 36.5 percent said "i feel more restless or wound up than usual,” 29 percent said "i don't feel any more restless or wound up than usual," 18.5 percent said "i am so restless or agitated, it's hard to stay still," and 16 percent said "i am so restless or agitated, i have to keep moving or doing something." for loss of interest, 45 percent of respondents stated that they were less interested in other people or things than they were previously, 23.5 percent stated that they had not lost interest in other people or activities, 20 percent stated that they had lost their interest in other people or things, and 11.5 percent stated that it was difficult to become interested in anything. in the category of indecisiveness, 42 percent responded "i find it more difficult to make decisions than usual," 26.5 percent responded "i make decisions about as well as i have in the past," 16.5 percent responded "i have much greater difficulty in making decisions than i used to," and 15 percent responded "i have difficulty making any decisions." in the category of worthlessness, 50 percent responded "i do not feel i am worthless," 24 percent responded "i feel more worthless when compared to others," 21.5 percent responded "i don't consider myself as worthwhile and useful as i used to" and 4.5 percent responded "i feel utterly worthless." when asked about energy loss, 53.5 percent said they had "less energy than i used to have," 19.5 percent said they “do not have enough energy to do too much,” 15 percent said they had "as much energy as i always had," and 12 percent said they “do not have enough energy to complete any work.” this loss of energy, which can leave a student feeling exhausted most of the time, if not all of the time, can hamper their ability to carry out their daily activities. with regard to sleep pattern changes, 48 percent said they slept slightly more/less than usual, 27 percent said they slept a lot more/less than usual, 13.5 percent said they slept most of the day/wake up 1-2 hours early and can't get back to sleep, and 11.5 percent said they had not noticed any change in their sleep pattern. sleep disturbances are experienced by up to 90 percent of those who suffer from clinical depression. in irritability, 42 percent responded "i am more irritable than usual,” 33 percent responded "i am more irritable than usual," 14.5 percent responded "i am considerably more irritable than usual," 10 percent responded "i am constantly irritable," and 0.5 percent did not respond. in terms of appetite changes, 40.5 percent responded that their appetite was slightly greater or less than usual, 22% responded that their appetite was significantly greater or less than before, 21.5 percent responded they had not noticed any change in their appetite, and 16 percent responded that they had no appetite at all or craved food constantly. in terms of concentration difficulty, 35 percent responded "i can't concentrate as well as usual," 34 percent responded "it's difficult to keep my mind on anything for an extended period of time," 18 percent responded "i can concentrate as well as ever," and 13 percent responded "i find i can't concentrate on anything." depression is characterized by difficulty with concentration and decision-making. individuals suffering from depression may understand this in themselves, or others may notice their inability to think properly. when it came to tiredness or fatigue, 50.5 percent said they get more tired or fatigued more easily than usual, 23 percent said they were too tired or fatigued to do a lot of the things they used to do, 14.5 percent said they were too tired or fatigued to do most of the things they used to do, and 12 percent said they were no more tired or fatigued than usual. as indicated in table 3, the total score for all depressive symptoms was 23.32, indicating that the level of depression experienced by those who participated in the survey during the pandemic was between "moderate to severe depression," with a standard deviation of 0.90. in this study, crying (m=1.50, sd=1.15) was shown to be the most common symptom of depression, followed by changes in sleeping patterns and concentration difficulty, both of which had mean scores of 1.42 and standard deviations of 0.86 and 0.96, respectively. another symptom that many experience is tiredness or fatigue (m=140, sd =0.96). for the remaining depressive symptoms, mean scores ranged from 1.30 to 0.28, with standard deviations ranging from 1.15 to.67. it is worth mentioning that the mean score for suicidal thoughts or wishes is 0.42 (sd=0.65). although relatively small, this result is quite concerning because suicidal ideation can develop into successful suicide if not immediately addressed. additionally, young adults who are depressed and having moderate to severe symptoms are more prone to ponder suicide. jurnal ners http://e-journal.unair.ac.id/jners 151 respondents’ spiritual health table 4 shows the data required to test the null hypothesis which states that spiritual health is significantly correlated with the level of depression experienced by young adults aged 18-25 years old who were also college students. with a pearson's correlation coefficient of -0.458 and a p-value of 0.001, both of which are less than the 0.01 alpha threshold of significance, it can be concluded that spiritual health is moderately correlated with the respondents' level of depression. correlation is statistically significant at the 0.01 level (2-tailed). the negative correlation between these two variables implies an inverse link, which means that as respondents' spiritual health grows, their level of depression lowers. inversely, it could also suggest that as respondents' spiritual health falls, their level of depression increases. the findings suggest that a lack of spiritual health has a detrimental effect on respondents' levels of depression. discussion oss the results in this study were analogous to the findings of menodza et al. (2020), who discovered that 53 percent of university students suffer from depression. crying was shown to be the most prevalent depressive symptom, followed by changes in sleeping habits and attention difficulties. tiredness or weariness is another symptom that many respondents encounter. furthermore, the total score for all depressed symptoms was 23.32, indicating that people who took part in the survey during the pandemic suffered moderate to severe depression. finally, the data show that spiritual health is inversely connected to the level of depression experienced by young adults between the ages of 18 and 25, who are also college students. at the 0.01 level, the association is statistically significant. the inverse relationship between these two variables is implied by the negative correlation between these two variables, which signifies that as respondents' spiritual health improves, their level of depression decreases. on the other hand, it is possible that, when respondents' spiritual health declines, their depression level rises. according to the findings, a lack of spiritual well-being has a negative impact on respondents' degrees of depression. in the current study, young adults who were predominantly muslim college students and had a higher level of spiritual participation, beliefs, and religiosity were more likely to have a higher level of spiritual, existential, and religious well-being. previous research has found a significant positive correlation between spiritual well-being and spiritual involvement and beliefs (musa, 2015; rubin et al., 2009) and religiosity (musa, 2015; musa & pevalin, 2012; williamson & sandage, 2009) in various arab muslim and western samples. according to the findings in this study, meranao muslim college students use religious and spiritual beliefs and practices as coping techniques to create a feeling of calm, comfort, and spiritual wellbeing. other research has suggested that religious and spiritual beliefs and practices influence an individual's well-being by promoting meaning, purpose, connectedness, and hope (koenig, 2008), encouraging transcendental experiences (nelson, 2009), and promoting religious meaning and forgiveness (koenig, 2008). the findings in table 4 are consistent with findings in the study conducted by doolittle and farrell (2004) which discovered that high spirituality scores on items in the domain of intrinsic beliefs, such as belief in a higher power (p<. 01), the importance of prayer (religious wellbeing) (p<. 0001), and finding meaning in times of adversity (existential well-being) (p<. 05), were associated inversely with depression. the study concluded that appropriate encouragement of a patient's spirituality may be a helpful adjunct to treating depression. the findings are also consistent with those of another study which showed that a high level of spiritual well-being (swb) is associated with a low level of stress and depression. the current study's findings are also consistent with neuman's theory, which holds that the independent variable, spiritual well-being, can influence or explain the dependent variable, psychological wellbeing (depression), because, according to neuman's theory, the spirituality variable pervades all other system variables and can increase the effectiveness of the flexible line of defense by protecting against stressors. the spirit guides the mind, and the mind guides the body, whether consciously or unconsciously. using spirituality as a source of energy may generate optimism and help a person heal from a psychological disease (neuman, 1989). the implication that can be drawn from the findings is that young adults should engage in activities that promote spiritual health, such as religious seminars and self-reflective programs that assist them in discovering their purpose of existence, faith, and self-love. these activities can contribute to a young adult's spiritual health and hence serve as a preventative measure against depression. in general, the findings suggest that an approach for lowering distress and suicide ideation among college students may entail exploring processes mangotara and bangcola (2022) 152 p-issn: 1858-3598  e-issn: 2502-5791 that build a sense of meaning in life for those who do not identify with organized religion. conclusion spirituality is a notion that defies easy categorization, classification, or measurement, yet it has an impact on our social, emotional, psychological, and intellectual life. the evidence linking spirituality and religious expression to many elements of mental health, and in particular, various symptoms of depression, has been evaluated in this study. the evidence is mixed; some forms of spirituality can be beneficial in certain situations. these are usually spiritual expressions that promote personal empowerment, affirm and welcome diversity, and emphasize the value of emotions like hope, forgiveness, and purpose. other components of spirituality appear to have little influence on mental health or, in certain situations, can lead to emotions of guilt, humiliation, or powerlessness, all of which can be detrimental to one's mental health. in general, however, the data appear to support a cautious optimism about the role spirituality can play in establishing and maintaining excellent mental health. in conclusion, the high mean levels of spiritual involvement and beliefs, religiosity, spiritual well-being, religious well-being, and existential well-being demonstrate the importance of religion and spirituality in the lives of young adults, with implications for practice, education, and research. references akbari, m., & hossaini, s. m. (2018). the relationship of spiritual health with quality of life, mental health, and burnout: the mediating role of emotional regulation. iranian journal of psychiatry, 13(1), 22–31. beck, a.t., erbaugh, j., mendelson, m., mock, j., & ward, c. h. (1961) an inventory for measuring depression. archives of general psychiatry 4, 561571.doi:10.1001/archpsyc.1961.01710120031004 bonelli, r., dew, r. e., koenig, h. g., rosmarin, d. h., & vasegh, s. (2012). religious and spiritual factors in depression: review and integration of the research. depression research and treatment, 2012, 962860. https://doi.org/10.1155/2012/962860 bushnik, t., tjepkema, m., & martel, l. (2020). socioeconomic disparities in life and health expectancy among the household population in canada. health rep. doi:10.25318/82-003202000100001-eng cotton, s., puchalski, c. m., sherman, s. n., mrus, j. m., peterman, a. h., feinberg, j., pargament, justice, a. c., leonard, a. c., & tsevat, j. (2006). spirituality and religion in patients with hiv/aids. journal of general internal medicine, 21 s5–s13. doi:10.1111/j.1525-1497.2006.00642.x creswell, j. w. (2008). educational research: planning, conducting, and evaluating quantitative and qualitative research. upper saddle river, nj: pearson education, inc. doolittle, b., & farrell, m. (2004). the association between spirituality and depression in an urban clinic. primary care companion to the journal of clinical psychiatry. flores, j. l., hernandez, m. a., leyva, e. w., cacciata, m., tuazon, j., & evangelista, l. (2018). prevalence and correlates of depression, anxiety, and distress among filipinos from lowincome communities in the philippines. the philippine journal of nursing, 88(2), 8–13. hedden, s.l., kennet, j., lipari, r., medley, g., & tice, p. (2015). behavioral health trends in the united states: results from the 2014 national survey on drug use and health. center for behavioral health statistics and quality. 35(2), 13-17. doi:10.1080/00635986.2011.617372 koenig, h. g. (2008). concerns about measuring “spirituality” in research. journal of nervous and mental disease, 196, 349355. doi:10.1097/nmd.0b013e31816ff796 koenig, h. g., george, l. k., & titus, p. (2004). religion, spirituality, and health in medically ill hospitalized older patients. journal of the american geriatrics society, 52(4), 554–562. https://doi.org/10.1111/j.1532-5415.2004.52161.x koenig h. g. (2012). religion, spirituality, and health: the research and clinical implications. isrn psychiatry, 2012, 278730. https://doi.org/10.5402/2012/278730 malinakova, k., kopcakova, j., kolarcik, p., geckova, a. m., solcova, i. p., husek, v., kracmarova, l. k., dubovska, e., kalman, m., puzova, z., van dijk, j. p., & tavel, p. (2017). the spiritual wellbeing scale: psychometric evaluation of the shortened version in czech adolescents. journal of religion and health, 56(2), 697–705. https://doi.org/10.1007/s10943-016-0318-4 mendoza, m. (2020). what you need to know about depression and the country’s mental health state musa, a. (2015). spiritual beliefs and practices, religiosity, and spiritual well-being among jordanian arab muslim university. european scientific journal . 17 (1), 34-49. 39. nelson, j. m. (2009). psychology, religion, and spirituality. in j. m. nelson (ed.), psychology, religion, and spirituality (pp. 311– 345). new york, ny: springer. neuman, b. (1989). the neuman systems model (2nd ed.). norwalk, ct: appleton and lange. paloutzian r.f., agilkaya-sahin, bruce, kvande, malinakova, marques. musa et al. (2021) the spiritual well-being scale (swbs): cross-cultural assessment across 5 continents,10 languages, and 300 studies. in: ai a.l., wink p., paloutzian r.f., harris k.a. reddy m. s. (2010). depression: the disorder and the burden. indian journal of psychological medicine, 32(1), 1–2. https://doi.org/10.4103/0253-7176.70510 rubin, d., dodd, m., desai, n., pollock, b., & graham-pole, j. (2009). spirituality in well and ill adolescents and their parents: the use of two assessment scales. pediatric nursing, 35(1), 3742. sahebalzamani m, farahani h, abasi r, talebi m. (2013).the relationship between spiritual intelligence with psychological well-being and purpose in life of nurses. iran j nurs midwifery res. 2013 jan;18(1):38-41. pmid: 23983726; pmcid: pmc3748553. wang, y. p., & gorenstein, c. (2013). psychometric properties of the beck depression inventory-ii: a comprehensive review. revista brasileira de psiquiatria, 35(4), 416–431. https://doi.org/10.1590/1516-4446-2012-1048. williamson, i. t., & sandage, s. j. (2009). longitudinal analyses of religious and spiritual development among seminary students. undefined, 12(8), 787–801. https://doi.org/10.1080/13674670902956604 world health organization. (2020). doh and who promote holistic mental health wellness in light of world suicide prevention day. how to cite this article: mangotara, s. a. and bangcola, a. (2022) ‘correlation of spiritual health and depression among young adults in a state university in southern philippines’, jurnal ners, 17(2), p.143-152 http://dx.doi.org/10.20473/jn.v17i2.36187 https://doi.org/10.1155/2012/962860 https://doi.org/10.1111/j.1532-5415.2004.52161.x https://doi.org/10.5402/2012/278730 https://doi.org/10.1007/s10943-016-0318-4 https://doi.org/10.1590/1516-4446-2012-1048 http://e-journal.unair.ac.id/jners 25 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 25-30 http://dx.doi.org/10.20473/jn.v18i2.40942 original article open access effect of isometric handgrip exercise on blood pressure and comfort among hypertensive patients veralia veralia 1 , hema malini 1 * , and reni prima gusty 1 1 faculty of nursing, universitas andalas, andalas, indonesia *correspondence: hema malini. address: faculty of nursing, universitas andalas, andalas, indonesia. email: hemamalini@nrs.unand.ac.id responsible editor: ferry efendi received: 25 november 2022 ○ revised: 12 march 2023 ○ accepted: 12 march 2023 abstract introduction: hypertension patients with uncontrolled blood pressure will experience some physical complaints. controlled blood pressure will reduce physical complaints and improve comfort. physical activity can help in making blood pressure controlled. however, due to limited time and access, many hypertensive patients rarely do some exercise. this study aimed to investigate the isometric handgrip exercise's effect on blood pressure and comfort of hypertension patients. methods: the research design is a quasi-experimental pre and post-test with the control group. the population was hypertension patients who were members of the chronic program disease, had hypertension pre and grade 1, and no further complication or physical impairment. the sample used unpaired numerical analytical formulas, obtained by 25 patients for each group. the intervention of an isometric handgrip was conducted for ten days. in one day, there is one session with 4x3 minutes. results: the results showed a significant relationship between isometric handgrip exercise with a decrease in blood pressure and increased patient comfort. conclusions: isometric handgrip exercise can be an alternative activity for patients that influences helping to maintain stable blood pressure and reduce the physical discomfort. keywords: physical activity, hypertension, blood pressure, comfort introduction hypertension has a significant effect on public health (manimala, 2015). it is already a significant healthcare burden worldwide (jørgensen et al., 2018). hypertension is the third primary cause of death globally (who, 2021). world health organization (who data showed that around 972 million (26.4%) worldwide suffer from hypertension, which is expected to reach 29.2% by 2025 (who, 2021). the prevalence of hypertension in indonesia has increased by 34.1% compared to the prevalence in 2013 by 25.8%. north sumatra is ranked third in hypertension cases in indonesia, with 32,944 cases (ministry of health ri, 2018). uncontrolled high blood pressure can result in longterm and potentially fatal complications such as coronary artery disease, heart failure, stroke, and kidney failure. in addition, patients will experience cognitive decline and overall poor quality of life (who, 2021). patients with uncontrolled hypertension have symptoms such as dizziness, headache, anxiety, difficulty sleeping, shortness of breath, buzzing ears, fatigue, nosebleeds, and sunken eyes (makruf, 2019). symptoms of hypertension cause discomfort; research shows that most hypertension sufferers, 75.2%, experience discomfort (insana, 2018). discomfort among people with hypertension requires a proper management. management in https://creativecommons.org/licenses/by/4.0/ mailto:hemamalini@nrs.unand.ac.id https://orcid.org/0000-0001-5733-6590 https://orcid.org/0000-0002-3224-5657 https://orcid.org/0000-0001-8937-6239 veralia, malini, and gusty (2023) 26 p-issn: 1858-3598  e-issn: 2502-5791 overcoming hypertension can use pharmacological and non-pharmacological therapies. physical activity is one of the alternatives to non-pharmacological therapies developed to lower blood pressure (carlson et al., 2014). physical activity increases the blood flow which promotes comfort (naldi et al., 2022). in indonesian public health centers, there was an existing chronic disease program called prolanis. hypertensive patients received medication and an educational program with physical activity included. however, many patients still lack physical activity because they are busy with work or have no time. physical activity is challenging due to limited time and access to sports activities provided. european and united states of america (usa) treatment guidelines recommend physical activity through isometric handgrip exercise therapy (okamoto et al., 2020). isometric handgrips exercises are simple physical exercises that do not require many facilities or rooms. moreover, it does not take much time and is not affected by the weather because it can be done indoors (owen et al., 2010). isometric handgrip exercises reduce blood pressure in hypertension by about seven mmhg for systolic and five mmhg for diastolic (farah et al., 2017), prevent muscle atrophy, build muscle volume, improve joint stability, and reduce edema (rahmawati et al., 2018). physical activities such as ergonomic stretching reduce the pain score in musculoskeletal disorders so that it will achieve a state of comfort (andari, 2019). increased physical activity will help increase the secretion of endorphin hormones to create comfort (naldi et al., 2022). therefore, researchers are interested in researching physical activity using isometric handgrip exercises to reduce pressure and improve comfort. the purpose of this study was to investigate the effect of isometric handgrip exercises on blood pressure and comfort in hypertension patients in healthcare centers. materials and methods. design the research design used was quasi-experimental quantitative research with control group. a repeated measure design for blood pressure variables and a pretest and post-test design for comfort variables were used. population and sample the population in this study was 523 hypertensive patients who underwent treatment at the local public health center. determining samples by randomized sampling is a method of selecting samples. there were 25 subjects in the intervention group and 25 in the control group. the inclusion criteria in this study were: stage one and two uncontrolled hypertension patients who consume antihypertensive drugs with a single dose (amlodipine or captopril); experienced symptoms of discomfort; attended the chronic disease program (prolanis) for at least the last three months. the exclusion criteria were hypertension patients who experience disorders in the upper extremities, such as arthritis; patients who experience further complications. intervention the intervention in this study used a handgrip device with the brand “speeds." the isometric handgrip exercise (ihe) was conducted in one session for ten days routine without stopping with a frequency of 4 x 3 minutes on both hands alternately (mcgowan et al., 2017) before the subject performed the ihe, the researcher did some simple training to the patients to obtain each subject's grip ability. the day before the intervention began, researchers measured blood pressure using a digital sphygmomanometer and comfort with the general comfort questionnaire (gcq). furthermore, the researchers asked the subjects to do ihe at 09.00 am every day until the tenth day. researchers visited the subject's home on the sixth, eighth and tenth days to measure the subject's blood pressure at 9:00 am. on the tenth day, the researchers also re-measured the subjects' comfort (post-test) with the gcq questionnaire again. during the research process, from the first to the tenth day, researchers communicated via telephone to ensure that the subjects took antihypertensive drugs and conducted isometric handgrip exercises. instruments comfort measurement was measured by the general comfort questionnaire (gcq). this research is adapted from the gcq, which is adapted to the concept of comfort consisting of relief, ease, and transcendence. there were 48 questions with a response format of a four-point likert scale. there were three questions jurnal ners http://e-journal.unair.ac.id/jners 27 about relief; five about ease, questions, and four about transcendents. the 12 questions consist of seven positive questions and five negative questions. likert scores range from 1 (strongly disagree) to 4 (strongly agree) (kolcaba, 2003). meanwhile, researchers also documented the discomfort complaints reported by the patients at the first day and which are symptoms of the presence of discomfort the subject feels. these complaints of discomfort were obtained using an observation sheet containing complaints of discomfort: headaches, stiffness, difficulty sleeping, sunken eyes, and fatigue. data analysis univariate analysis in the study used frequency distribution for characteristics using computer spss version 2.3 software. bivariate analysis of this study related to the mean blood pressure of systole and diastole using the repeated measure anova test, comfort measurements using wilcoxon analysis tests, and comfort differences between the two groups using the mann-whitney test. ethical clearance this research has received recommendations and ethical clearance from the ethics commission of hangtuah university pekanbaru. it has obtained permission from the sihepeng health center. this research has gone through an ethical review procedure and was declared feasible to be carried out and is valid from july-september 2022 with number: 515/kepk/stikes-htp/vii/2022. results the intervention group conducted ihe with one session per day on both hands alternately with a total duration of three minutes for ten days and continued to take antihypertensive drugs. the number of samples was 50, with 25 in the intervention group and 25 in the control group using randomized sampling techniques. the control group was not given ihe treatment and continued to take anti-hypertension drugs. characteristics of respondents table 1 shows the characteristics of respondents in both the intervention and control groups. most respondents were the early elderly (46-55 years), female, taking the anti-hypertension drug amlodipine, have grade 1 hypertension, and have different levels of education and different types of work. average value of blood pressure pretest and day 6, 8, 10 intervention group and control group systole blood pressure based on figure 1, it was found that there was a decrease in the average blood pressure of systole in both groups. the intervention group averaged systole blood pressure at the pre-period was 154 mmhg, on the sixth day 145 mmhg, day to day 142 mmhg, and on day ten 140 mmhg. the control group averaged systole blood pressure at pre-time of 152 mmhg on day six, 149 mmhg, day to day 148 mmhg, and day ten 148 mmhg. the mean results show that the intervention group's average systole blood pressure is significant. table 1 frequency distribution of subject characteristics (n=50) no subject characteristics group intervention control group f % f % 1. age age 36 – 45 years age 46 – 55 years 14 11 56 44 7 18 28 72 2. gender man woman 8 17 32 68 8 17 32 68 3. occupation farmer self-employed private civil servants housewives 3 2 5 6 9 12 8 20 24 36 4 1 5 3 12 16 4 20 12 48 4. education level junior high school diploma bachelor 6 11 2 6 24 44 8 24 6 14 2 3 24 56 8 12 5. types of drugs amlodipine captopril 21 4 84 16 23 2 92 8 6. grade hypertension grade 1 grade 2 24 1 96 4 25 0 100 0 figure 1 average blood pressure of systole pretest and day 6, 8, 10 intervention group and control group veralia, malini, and gusty (2023) 28 p-issn: 1858-3598  e-issn: 2502-5791 diastole blood pressure based on figure 2, there was an average decrease in diastole blood pressure in both groups. the intervention group averaged diastole blood pressure at pre was 95 mmhg, 88 mmhg on the sixth day, 86 mmhg on the eighth day, and 85 mmhg on the tenth day. the control group averaged systole blood pressure at 95 mmhg pre, 92 mmhg on the sixth day, 92 mmhg on day eight, and 91 mmhg on the tenth day. based on the mean results, it shows that the average blood pressure of diastole is significant in the intervention group. differences in preand post-comfort in intervention groups and control groups based on table 2, it was found that for pre, in both groups there was no difference in comfort, as indicated by the value of p = 0.159. however, ten days after monitoring, the difference in comfort between the two groups was shown with a p-value = 0.000. there was an increase in comfort in the intervention group after conducting ihe for ten days. effect of isometric handgrip exercise on the comfort of hypertensive patients table 3 shows the effect of isometric handgrip exercise on the comfort of hypertensive patients with a p-value = 0.000. the increase in comfort in the intervention group was experienced in 20 subjects, three subjects did not experience a change in comfort in the intervention group and in two subjects there was a decrease in comfort. discussions this study aims to mitigate the effect of isometric handgrip exercise (ihe) on blood pressure and comfort in patients with hypertension at the public health center. the results showed a change in the average blood pressure value in the intervention group given ihe for ten days. a significant decrease in blood pressure was seen in the intervention group compared to the control group. ihe lowers blood pressure through physiological pathways such as changes in the autonomic nervous system, vascular function, and heart rate. in the ihe procedure, the handgrip mechanism shows that a grip works in three ways: balancing the autonomic nervous system, including blood pressure, repairing damage, and encouraging blood vessels to dilate, which allows more accessible blood flow. this exercise can lower blood pressure if the individual can perform training regularly (pratiwi, 2020). furthermore, the shear stress mechanism happened when ihe is carried out. the shear stress mechanism is the friction of blood with the endothelium, which will trigger a longitudinal force. the shear stress mechanism causes the release of nitrite oxide (no)-endothelium as derivatives produced by endothelial cells that are vasodilators of blood vessels. nitrite oxide is a crucial mediator of endothelial cells, which are the inside of the lumen of blood vessels throughout the body and have an essential role as a link between blood circulation and smooth muscle cells in blood vessels (mcgowan et al., 2017). figure 2 average diastole pretest blood pressure and days 6, 8, and 10 intervention groups and control groups table 2 differences in pre and post-comfort in intervention groups and control groups comforts group n mean rank sum of rank z ρ-value pre intervention 25 28.34 708.50 -1.409 0.159 control 25 22.66 566.50 total 50 post intervention 25 34.26 856.50 -4.292 0.000 control 25 16.74 418.50 total 50 table 3 effect of isometric handgrip exercise on hypertension patient comfort n mean rank number of positive ratings z ρ-value pre-test and posttest group intervent ions decreased comfort 2 1.50 3.00 -4.031 0.000 increased comfort 20 12.50 250.00 no change 3 total 25 jurnal ners http://e-journal.unair.ac.id/jners 29 this study showed a decrease in the average systolic and diastolic blood pressure in the intervention group, where a decrease in blood pressure values led to a decrease in hypertension grade (from hypertension grade 1 to pre-hypertension) (joint national committee 8, 2014). meanwhile, in the control group, there was also a decrease in blood pressure, but it did not significantly show a change in hypertension grades. this is in line with study from susiladewi (2017) which showed the same results, that there was a significant difference also occurred in the average post-test results of the control group who only consumed hypertension drugs and the treatment group that carried out ihe. hormonally, isometric exercise will increase the secretion of the hormone b-endorphin in the body as an effect of exercise or physical activity as a natural analgesic that can provide a sense of relaxation to the body. physical activity is one way to meet the needs of a sense of comfort. increased physical activity will help increase the secretion of endorphine hormones. physical activity will stimulate the pituitary gland to release endorphin hormones so that there is an increase in endorphin levels in the blood. this hormone can function as a natural sedative produced by the brain that channels a sense of comfort (naldi et al., 2022). providing physical activity in the form of ihe meets the needs of comfort for people with hypertension. kolcaba's comfort theory is used to explain the discomfort felt due to the symptoms of hypertension (relief) and then help solve it so that the client feels free from problems and is at peace, namely a decrease in blood pressure and the presence of comfort felt (kolcaba., 2003). the gcq questionnaire is a comfort questionnaire with the kolcaba comfort theory approach, where three aspects of comfort, namely relief, ease, and transcendence, are measured. the results showed significant changes in all aspects of comfort. in this study, on day 10 researchers asked the subjects about the benefits after doing ihe, and they said that they would continue to do ihe because of the benefits that had been felt. the comfort felt by the subject is due to the absence of complaints of discomfort due to the symptoms of hypertension. according to research based on kolcaba's theory, the type of comfort that the subject feels ihe gives has entered into the transcendence type of comfort. this study also found a change in respondents' complaints before and after getting the ihe. before getting ihe, the most common complaints felt were fatigue, headaches and stiffness, but after being given an ihe then the complaints felt were just headaches. this is because there are still patients who experience sleep deprivation, which affects complaints during the measurement day. research conducted by andari (2019) on the effect of physical activity in the form of ergonomic gymnastics stretching on the pain score of musculoskeletal disorders (msds), shows the results of decreasing msds pain scores so that the benefits that can be felt directly are the achievement of a condition of comfort. in this study, the ihe which was carried out for ten days was part of the physical activity of the results of this study and obtained a value of p = 0.000, which means that there is an influence of ihe administration on the comfort of hypertensive patients. even though this study has proven that ihe has an impact on blood pressure and comfort of hypertension patients, there is some limitation. the limitations in this study are dietary arrangements and stress levels in hypertensive patients that can affect blood pressure and discomfort have not been fully noticed by researchers. conclusions this study has proven that isometric handgrip exercise (ihe) conducted regularly once a day significantly influences hypertensive patients' blood pressure and physical comfort. in addition, ihe also influences reducing physical complaints felt by patients. isometric handgrip exercise influences controlling blood pressure in patients with hypertension. the implication of this study is that ihe can become an independent modality therapy for hypertensive patients in lowering blood pressure and increasing comfort. this exercise also can be considered an integrative therapy modality for hypertensive patients in the public health centers. acknowledgment the researchers thank all the respondents and nurses in sihepeng public health centers and all the persons who facilitated this study. funding source there is no funding has been granted for this study. conflict of interest there is no conflict of interest to declare from this study. veralia, malini, and gusty (2023) 30 p-issn: 1858-3598  e-issn: 2502-5791 references ahmed, y. r., hala, ;, hanfy, m., wafaa, ;, kamal, m., & fouad, m. m. (2685). the effect of isometric hand grip on blood pressure in post menopausal hypertension. in cairo univ (vol. 87, issue 5). www.medicaljournalofcairouniversity.net andari, f, n. (2019). pengaruh pelatihan peregangan senam ergonomis terhadap penurunan skor nyeri muskuloskeletal disorders (msds) pada perkerja pembuat kaleng alumunium. 19–26. carlson, d. j., dieberg, g., hess, n. c., millar, p. j., & smart, n. a. (2014). isometric exercise training for blood pressure management: a systematic review and meta-analysis. mayo clinic proceedings, 89(3), 327–334. https://doi.org/https://doi.org/10.1016/j.mayocp.2013.10.030 dahlan, s. (2013). statistik untuk kedokteran dan kesehatan. jakarta farah, b. q., germano-soares, a. h., rodrigues, s. l. c., santos, c. x., barbosa, s. s., vianna, l. c., cornelissen, v. a., & ritti-dias, r. m. (2017). acute and chronic effects of isometric handgrip exercise on cardiovascular variables in hypertensive patients: a systematic review. sports, 5(3), 1–10. https://doi.org/10.3390/sports5030055 insana, m. (2018). gangguan rasa nyaman pada pasien hipertensi. jurnal keperawatan suaka insan (jksi), 3(vol 3 no 2 (2018): jurnal keperawatan suaka insan (jksi)), 2. armstrong, c. (2014) ‘jnc 8 guidelines for the management of hypertension in adults’, american family physician, 90(7), pp. 503–504. available at: https://www.aafp.org/pubs/afp/issues/2014/1001/p503.html jørgensen, m. g., ryg, j., danielsen, m. b., madeleine, p., & andersen, s. (2018). twenty weeks of isometric handgrip home training to lower blood pressure in hypertensive older adults: a study protocol for a randomized controlled trial. trials, 19(1), 1–7. https://doi.org/10.1186/s13063-018-2441-x kolcaba, k., kolcaba, k. (2003). comfort theory and practice. in aorn journal (vol. 78, issue 5, pp. 868–869). https://doi.org/10.1016/s0001-2092(06)60651-0 makruf, a. (2019). bekam dan self help group terhadap tekanan darah dan kecemasan pada pasien hipertensi rawat jalan (studi di puskesmas soromandi kabupaten bima). manimala, j. (2015). efficacy of isometric hand grip training to lower resting blood pressure : a systematic review and meta analysis. american college of sports medicine, 14(7), 1–20. mcgowan, c. l., proctor, d. n., swaine, i., brook, r. d., jackson, e. a., & levy, p. d. (2017). isometric handgrip as an adjunct for blood pressure control: a primer for clinicians. current hypertension reports, 19(6), 51. https://doi.org/10.1007/s11906-017-0748-8 ministry of health ri. (2018). hasil utama laporan riskesdas 2018. jakarta naldi, f., juwita, l., & silvia, s. (2022). pengaruh latihan isometrik untuk menurunkan tekanan darah pada penderita hipertensi. real in nursing journal, 5(1), 8–17. okamoto, t., hashimoto, y., & kobayashi, r. (2020). isometric handgrip training reduces blood pressure and wave reflections in east asian, non-medicated, middle-aged and older adults: a randomized control trial. aging clinical and experimental research, 32(8), 1485–1491. https://doi.org/10.1007/s40520019-01330-3 owen, a., wiles, j., & swaine, i. (2010). effect of isometric exercise on resting blood pressure: a meta-analysis. journal of human hypertension, 24(12), 796–800. https://doi.org/10.1038/jhh.2010.13 pratiwi, a. (2020). isometri chandgrip exercise pada pasien hipertensi: literature review. proceeding seminar nasional keperawatan. http://www.conference.unsri.ac.id/index.php/snk/article/view/ 1733 rahmawati, e., dewi, a., & sari, n. k. (2018). perbandingan isometric handgrip exercise dan jalan kaki terhadap tekanan darah sistolik dan tekanan darah diastolik pada pasien hipertensi. jurnal …, vi(1), 12–23. http://jurnal.stikesnotokusumo.ac.id/index.php/jkn/article/view/66 susiladewi, i. a. m. v., widyanthari, d. m., adnyana, i. m. o. (2017). pengaruh latihan isometrik terhadap tekanan darah pasien hipertensi. community of publishing in nursing, 5 (3)(2303–1298), 153–160. sugiyono. (2018). metode penelitian kuantitatif. alfabeta. sopiyudin, d. (2018). langkah-langkah membuat proposal penelitian bidang kedokteran dan kesehatan. jakarta. sagung seto. who (2021) hypertension. available at: https://www.who.int/newsroom/fact-sheets/detail/hypertension. how to cite this article: veralia, v., malini, h., and gusty r. p. (2023) ‘effect of isometric handgrip exercise on blood pressure and comfort among hypertensive patients’, jurnal ners, 18(1), pp. 25-30. doi: http://dx.doi.org/10.20473/jn.v18i1.40942 74 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 74-82 http://dx.doi.org/10.20473/jn.v17i1.35055 original article open access factors associated with the implementation of covid-19 health protocols among indonesian older adults living in rural areas: a crosssectional study nurul maurida 1,* , prestasianita putri 1 , wike rosalini 1 1 faculty of nursing, universitas dr. soebandi jember, indonesia *correspondence: nurul maurida. address: dr. soebandi street, no.99, jember, east java 68111, indonesia. email: nurul@stikesdrsoebandi.ac.id responsible editor: gading ekapuja aurizki received: 16 april 2022 ○ revised: 28 april 2022 ○ accepted: 28 april 2022 abstract introduction: implementing health protocols became a challenge for older adults living in rural area. this study aimed to analyze the factors influencing implementation of covid-19 health protocols among elderly in rural areas based on the theory of planned behavior (tpb). methods: this study used an explanatory survey with cross-sectional approach. the sample consisted of 100 older adults who resided in rural areas. data were collected using the tpb questionnaire and covid -19 health protocol questionnaire, both have 21 items. the data were analyzed using bivariate and multivariate analysis. bivariate analysis used pearson correlation, chi-square test, and fisher’s exact test. multivariate analysis used multiple linear regression with a level of significance = 0.05. the independent variables were attitude toward behavior, subjective norm and perceived behavioral control while the dependent variable was the implementation of covid-19 health protocols. results: gender (p < 0.001), age (p < 0.001), employment status (p < 0.001), attitude toward behavior (p < 0.001), subjective norm (p < 0.001) and perceived behavioral control (p < 0.001) were significantly associated with the implementation of covid-19 health protocols, while education level (p = 1.000) was not significantly associated with the implementation. the r-square shows 0.610 which indicates that tpb model can predict 61% of implementation of covid-19 health protocols. conclusions: the most dominant factor in increasing the implementation of the covid-19 health protocol is attitude toward behavior. nurse need to provide education to elderly and their family to increase the implementation of covid19 health protocols as prevention of transmission of covid-19. keywords: attitude; covid-19; elderly; perceived behavioral control; subjective norm; theory of planned behavior introduction coronavirus disease (covid-19) is an infectious disease that has been affecting many countries globally since late-2019. indonesia reported its first positive covid-19 case on march 2, 2020 (melia, triana and prasetyo, 2020). this disease can infect humans of all ages, including the elderly. the elderly population is a priority population in preventing the transmission of covid-19 (géa et al., 2022). the covid-19 patients aged 60 years and over have a higher mortality compared to younger patients (karadavut and altintop, 2022). elderly with comorbidities such as heart disease, diabetes mellitus, hypertension, chronic kidney failure and chronic lung disease have a greater risk of being infected with covid-19 compared to the same population without comorbidities (tobing and wulandari, 2021; ventura, molinelli and barranco, 2021). implementing health protocols is one of the factors to prevent the transmission of covid-19. in indonesia, and many countries, the protocols consist of wearing a mask, avoiding crowds, keeping a distance and implementing clean and healthy lifestyles (ministry of health, 2020). the protocols need to be implemented by all population groups including the elderly regardless of the residence, both rural and urban. in rural areas, people tend to have https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-6310-9850 https://orcid.org/0000-0002-3728-9018 https://orcid.org/0000-0003-3815-4673 jurnal ners http://e-journal.unair.ac.id/jners 75 more difficult access to health services and receiving information (murdiyanto, 2020), especially information about covid-19 (cahyawati, lestarini and saniathi, 2021). consequently, people living in rural areas will be more likely to have different perceptions and beliefs about the pandemic situation compared to those living urban areas, which results in the low compliance to health protocols (benu, febriyanti and tahu, 2022). by january 2022, the number of confirmed positive cases for covid-19 globally was more than 200 million and five million people have died (murri et al., 2022). in indonesia, confirmed covid-19 patients in august 2021 were 426,1759 people and until march 2022 were 5,939,082 people (zakiah and pujiati, 2022) . the number of confirmed cases of covid-19 in east java is 399,989. the highest case of death occurred in patients aged >60 years. the case fatality rate (cfr) in patients aged 60 years and over was 12.06% (rubina et al., 2022). the data show that the elderly need more protection in preventing the transmission of the disease. the elderly as a vulnerable group have a higher mortality rate. this shows that the elderly need to protect themselves. changes that occur among elderly cause them to be less disciplined in implementing covid-19 health protocols (kristamuliana, renteng and datu, 2021). information that is less than optimal for the elderly in rural areas also makes negative perceptions of the elderly in implementing of covid-19 health protocols (nur, 2021). a good perception can reduce the risk of the elderly from transmission of covid-19 because prevention efforts by implementing the covid-19 health protocol are done in a disciplined manner (prihati et al. 2020). the indonesian government has socialized the implementation of covid-19 health protocols. there has been a lot of research on the implementation of the covid-19 health protocol in the indonesian people. the majority have the same conclusion: the implementation of the covid-19 health protocol was in a low category (daoust, 2020). a research explains factors influencing implementation of the covid-19 health protocol are economic problems, indifferent attitude, vulnerability to the covid-19 virus and distrust of the government with many inconsistent policies (sari, 2021). other research explains the factors are the community reaction towards pandemic situation, the perception of the effectiveness of self-quarantine, concern about self vulnerability, gender, educational status, marital status, health status and age. people who are married, have a good education background, and a younger age demonstrated a higher level in implementing the covid-19 health protocol than people who are older (riyadi and larasaty, 2021). this is in accordance with the results of the study which explained that the majority of the elderly in rural areas had the implementation of the covid-19 health protocol in the low category (daoust, 2020). however, studies that identified the factors associated with the implementation of the covid-19 health protocol, especially for the elderly in rural areas, are still limited. the implementation of the covid-19 health protocol is a behavior to prevent the transmission of covid-19. ogilvie et al. (2016) explain that behavior is formed by perceptions and beliefs. one theory that explains the behavior is the theory of planned behavior (tpb). tpb explains that behavior is influenced by attitudes toward behavior, subjective norms, and perceived behavioral control. implementing the covid-19 health protocol is a form of behavior that needs to be developed. tpb has analyzed a lot of behavior and has been successful in changing behavior from negative to positive. a research explains that tpb is able to improve the behavior of early detection for cervical cancer in women (maurida, sukartini and indarwati, 2019), the background for changes in cataract surgery decisions (wikamorys and rochmach, 2017), and improve care adherence in diabetes mellitus clients (lestarina, 2018). however, there is no research that uses tpb as a theoretical basis in analyzing the implementation of the covid-19 health protocol for the elderly in rural areas. based on this description, this study aimed to analyse the factors that are associated with the implementation of the covid-19 health protocols among elderly in rural areas based on the theory of planned behavior. materials and methods study design this study used analytical observational with crosssectional approach. the study was conducted in august 2021 in one of the rural areas in east java province, indonesia. the independent variables were attitudes toward behavior, subjective norms, and perceived behavioral control. the dependent variable was the implementation of covid-19 health protocols. respondents the population of this study was the elderly aged 60 years and over. the total population in the study site was 7,949 people selected using quota sampling. after calculating the slovin’s formula with a confidence level of 0.1, it was determined that the sample size was 100 respondents. the study only included the elderly who were able to do activity daily living independently. the study excluded the elderly who had psychological problems or dementia. instruments the instruments were questionnaires to assess the demographic data, tpb and covid-19 health protocol. the tpb questionnaire was self-developed based on the tpb concept, consisting of attitudes toward behavior (6 questions), subjective norms (6 questions) and perceived behavioral control (9 questions) (table 1). the tpb questionnaire used closed questions with a 4-item likert maurida, putri, and rosalini (2022) 76 p-issn: 1858-3598  e-issn: 2502-5791 scale. favorable questions, i.e., number 1-9, 11, 12, 14-16, 19, and 21, were scored using the following: 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree. meanwhile, unfavorable questions, i.e., number 10, 13, 17, 18, and 20, have a different likert scale (4 = strongly disagree, 3 = disagree, 2 = agree, and 1 = strongly agree). the categorization of the data results is divided to good category and poor category with the distribution based on the mean. a value less than the mean is included in poor category and a value more than the mean included in good category. the covid-19 health protocol questionnaire was adapted from the covid-19 prevention and control guidelines issued by the ministry of health of the republic of indonesia, 5th revision (ministry of health, 2020). the questionnaire assessed the implementation of table 1 21-item theory of planned behaviour questionnaire component item statement attitude toward behavior 1 for me, wearing a mask, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle are very good things 2 for me, efforts to prevent the spread of covid-19 by implementing a health protocol is a very good thing 3 for me, maintaining health is a very good thing 4 wearing a mask, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle really help to prevent me from transmission of covid-19 5 wearing masks, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle are one of the efforts to prevent covidd-19 6 wearing a mask, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle make me confident about my health status subjective norm 7 my family thinks that wearing masks, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle are needed to prevent the transmission of covidd-19 8 my peers think that wearing masks, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle are needed to prevent the transmission of covid-19 9 health workers in my area think that wearing masks, avoiding crowds, washing hands with soap and practicing a clean and healthy lifestyle are needed to prevent the transmission of covid-19 10 i really don't care what my family has to say and i won't follow their advice 11 i really care what my peers say and i will follow their advice 12 i really care what my healthcare provider has to say and i will follow their advice perceived behavioral control 13 i object to wearing a mask, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle 14 i feel comfortable if i wear a mask, stay away from crowds, wash my hands with soap and practice a clean and healthy lifestyle 15 i find it easy to wear a mask, stay away from crowds, wash my hands with soap and practice a clean and healthy lifestyle 16 i have time to wear a mask when i leave the house, stay away from crowds, wash my hands with soap and practice a clean and healthy lifestyle 17 i don't have a mask so i don't wear a mask 18 i have to go outside with a lot of people so i can't stay away from the crowd 19 i have confidence that wearing a mask when leaving the house, avoiding crowds, washing hands with soap and practicing a clean and healthy lifestyle can prevent me from catching covid-19 20 wearing a mask when leaving the house, staying away from crowds, washing hands with soap and practicing a clean and healthy lifestyle costs a lot of money 21 i show my concern for my health by wearing a mask when leaving the house, staying away from crowds, washing my hands with soap and practicing a clean and healthy lifestyle table 2 bivariate correlation between gender, age, profession and education on implementation of covid-19 health protocols (n = 100) variable implementation of covid-19 health protocols total n (%) p-value good n (%) poor n (%) gender women 48 (71.6%) 19 (28.4%) 67 (67.0%) <0.001† men 3 (0.09%) 30 (0.91%) 33 (33.0%) age 60-70 years old 36 (46.2%) 49 (62.8%) 78 (78.0%) <0.001† 70-80 years old 12 (100.0%) 0 (0.0%) 12 (12.0%) >80 years old 10 (100.0%) 0 (0.0%) 10 (10.0%) employment status self-employed 0 (0.0%) 16 (100.0%) 16 (16.0%) <0.001† retired public officer 23 (100.0%) 0 (0.0%) 23 (23.0%) unemployed 28 (45.9%) 33 (54.1%) 61 (61.0%) educational level uneducated 28 (50.9%) 27 (49.1%) 55 (55.0%) 1.000‡ elementary school 6 (60.0%) 4 (40.0%) 10 (10.0%) junior high school 5 (35.7%) 9 (64.3%) 14 (14.0%) senior high school 5 (35.7%) 9 (64.3%) 14 (14.0%) bachelor degree 7(100.0%) 0(0.0%) 7 (7.0%) † chi-square test; ‡ fisher’s exact test jurnal ners http://e-journal.unair.ac.id/jners 77 wearing a mask, avoiding crowds, keeping social distance and implementing clean and healthy lifestyles in 21 items of closed questions with the answer choices on a 4-item likert scale (1 = never, 2 = sometimes, 3 = often, 4 = always) (ministry of health, 2020). the categorization of the data results is divided to good category and poor category with the distribution based on the mean. a value less than the mean is included in poor category and a value more than the mean included in good category. all research instruments were considered valid and reliable. the validity was measured using pearson correlation product moment and the reliability test was cronbach’s alpha. the validity and reliability tests were delivered to 25 respondents who were not the study respondents. the results of the validity test showed that all items had a significance level of < 0.05 and r-count > 0.396. the reliability test showed all questionnaires had cronbach’s alpha > 0.65; the tpb questionnaire (cronbach’s alpha = 0.874) and the covid-19 health protocol questionnaire (cronbach’s alpha = 0. 958). data collection data collection was carried out by enumerators who have shared perceptions with the investigators so that there was no interference by the investigators during the data collection process to reduce bias. the data collection procedures were conducted through several steps. first, the enumerators contacted the respondent and explained about the research. second, the enumerators provided an explanation of the study protocol to the respondents, especially about the study purpose, benefits and that the participation was voluntary. third, the enumerators asked the respondents about their willingness to participate in the study and to sign an informed consent. fourth, the enumerators delivered the questionnaires to the respondents. the enumerators provided explanation regarding the questionnaires if the respondent did not understand its meaning. data analysis coding was carried out after the questionnaires were filled out by the respondents. the coded data were processed using spss 20 software. the data were analyzed using bivariate analysis and multivariate analysis. bivariate analysis used pearson correlation, chisquare test and fisher’s exact test. chi-square and fisher’s exact tests were used to analyze the correlation between demographic data (gender, age, employment status and educational level) on the implementation of covid-19 health protocols. pearson correlation was used to analyze the correlation among tpb variables on the health protocol implementation. a multivariate analysis, multiple linear regression with significance value 0.05, was used to identify how the tpb variables can be predictors of the implementation of the covid-19 health protocols. ethical consideration this research received ethical approval from the health research ethics committee of dr. soebandi university (no. 200/uds/vii/2021). results the demographic characteristic showed that the majority of respondents were women (67.0%) and most of them showed a good category on implementation of covid-19 health protocols (71.6%). the majority of the elderly aged 60-70 years old (78.0%) and most of them showed a poor compliance to covid-19 health protocols (62.8%). most respondents were unemployed (61.0%) and most of them had a poor compliance on covid-19 health protocols (54.1%). the majority of respondents were uneducated (55.0%) and most of them have a good covid-19 health protocol implementation (71.6%). the bivariate analysis between demographic characteristics on the health protocol implementation showed that gender (p < 0.001), age (p < 0.001) and employment status (p < 0.001) were associated with the covid-19 health protocol compliance, while educational level was not associated with the compliance (p = 1.000) (table 2). the attitude toward behavior had maximum score of 24, mean = 19.80 and sd = 2.13. this means that there are respondents who get maximum score for this variable. the subjective norm had a maximum score of 22, mean = 18.50 and sd = 1.35. the perceived behavioral control had maximum score of 36, mean = 29.02 and sd = 2.23 which means that the respondents were in the range “agree” and “disagree.” the implementation of covid-19 health protocol had maximum score 81, mean = 62.80 and sd = 14.3 which means that the respondents were in the range of “always” and “often.” the bivariate analysis among tpb constructs showed that attitude toward behavior (r = 0.751 and p < 0.001), subjective norm (r = 0.726 and p < 0.001) and perceived behavioral control (r= 0.523 and p < 0.001) has association on the implementation of covid19 health protocols. the relationship between attitudes toward behavior and the implementation of covid-19 health protocols was very strong correlation (r > 0.75). the relationship between subjective norms, perceived behavioral control and the covid-19 health protocol implementation was in strong category (r = 0.50-0.75). the regression equation formed through this study is ‘implementation of the covid-19 health protocol among elderly in rural areas = -60.864 + 3.552 attitudes + 3.820 subjective norms – 0.620 perceived behavioral control’ (table 3). the results of multiple linear regression showed that the variable attitude toward behavior (t = 4365; p < 0.001) and subjective norm (t = 3.298; p < 0.001) had a partial influence on the implementation of the covid-19 health maurida, putri, and rosalini (2022) 78 p-issn: 1858-3598  e-issn: 2502-5791 protocol. perceived behavioral control (t = -1,000; p = 0.320) had no partial effect on the implementation of the covid-19 health protocol. this explains that, if the attitude toward behavior and subjective norm have high value so the implementation of covid-19 health protocols become higher. otherwise, if the perceived behavioral control has high value so the implementation of covid-19 is lower. the dominant factor that has the most influence on the implementation of the covid-19 health protocol is attitude toward behavior because it has a standard coefficient beta value of 0.530, which is greater than the other variables (table 4). the model summary showed that the r-square was 0.610, which indicates that the strength of the relationship between the independent variables on the dependent variable was 61%, while the remaining 39% is explained by other factors. the f-test result showed that the p-value < 0.001 with f-value was 50.052 greater than the f-table (f-table = 2.70). this means that there is a simultaneous influence between attitudes toward behavior, subjective norms and perceived behavioral control on the implementation of covid-19 health protocols among elderly in rural areas (table 5). discussions demographic characteristic on the implementation of covid-19 health protocols there was association between gender, age and employment status on implementation of covid-19 health protocols. the majority of women respondents showed implementation pf the covid-19 health protocol in good category, while the majority of male elderly respondents did not. this is in line with the results of research that women's compliance in implementing the covid-19 health protocol is better than that of men (riyadi and larasaty, 2021). elderly women in rural areas have a better concern for health than elderly men in rural areas. this is also related to the dominant role in maintaining health in the family. women have a role to protect the whole family, from regulating diet, maintaining cleanliness and modifying the home environment. some respondents in elderly category (6070 years old) have good category and others have poor category on implementation of covid-19 health protocols. all respondent 70-80 years old and more than 80 years old have good category. this is in accordance with research which showed that the people who are more mature will have opportunity to perform the expected behavior (ringroad, daya and tamantirto, 2016). the older have more life experience and will more care about their health. in addition, families with the elderly in rural areas will pay more attention to their family members in improving their health. families are more protective in regulating the lifestyle of the elderly with old age. all retired respondents have good category in implementation of covid-19 health protocols. this is contrary to research which showed that employment status was not related to implementation of the covid19 health protocol (niruri et al., 2021). all the elderly who have their own business need cooperation with other people so that the health protocol becomes difficult to table 3 sd, minimum and maximum value, mean and bivariate analysis among theory of planned behavior variable (n = 100) variable sd minmax mean pearson correlation attitude toward behavior subjective norm perceived behavioral control covid-19 health protocol attitude toward behavior 2.13 17-24 19.80 na 0.807* 0.727* 0.751* subjective norm 1.35 15-22 18.50 0.807* na 0.646* 0.726* perceived behavioral control 2.23 23-36 29.02 0.727* 0.646* na 0.523* covid-19 health protocol 14.3 35-81 62.80 0.751* 0.726* 0.523* na *p < 0.001 table 4 multiple linear regression (n = 100) model† unstandardized coefficients standardized coefficients t‡ p-value b std error beta (constant) -60.864 14.157 -4.299 <0.001* attitude toward behavior 3.552 0.814 0.530 4.365 <0.001* subjective norm 3.820 1.158 0.360 3.298 0.001* perceived behavioral control -0.620 0.620 -0.94 -1.000 0.320 † dependent variable: implementation of covid-19 health protocols; ‡ t-table (df 98) 1.644; * p < 0.05 table 5 model summary model r r square f p-value 1 0.781 0.610 50.052 <0.001* jurnal ners http://e-journal.unair.ac.id/jners 79 implement. occupational activities, such as farm laborers and gardeners, need interaction with others as well. the results of this study explain that there is no relationship between education level on implementation of the covid-19 health protocols. this is contrary to research which showed that educational level was related to implementation of the covid-19 health protocol (riyadi and larasaty, 2021). educational level does not fully influence individual knowledge in shaping attitudes. the majority of respondents do not have education, but the village government continues to make efforts to increase the knowledge of residents, including the elderly, about the covid-19 health protocol. attitude toward behavior on the implementation of covid-19 health protocols there was an influence of attitude toward behavior and subjective norm on the implementation of covid-19 health protocols among elderly in rural areas. the perceived behavioral control has no influence on the implementation of the covid-19 health protocol among elderly in rural areas. attitudes are formed from beliefs about behavior and the consequences. the elderly who have belief that implementing the covid-19 health protocol during a pandemic can prevent them from transmission of covid-19 will have a good attitude. a good attitude causes the expected behavior to be formed, that is the implementation of the covid-19 health protocols including wearing a mask, avoiding crowds, keeping a distance and implementing clean and healthy lifestyles. this is in accordance with the results of a study which concluded that a positive attitude could affect the use of masks during covid-19 (pan and liu, 2022). the belief in doing something for the elderly in rural areas is based on the sociodemographic characteristics of the individual and the socio-cultural impact from their interactions in the community (watson and austin, 2021). the beliefs of the elderly in rural areas are formed from the information received by the elderly. knowledge is a basic factor in the formation of beliefs (simanjorang et al., 2022). the village government provides intensive information to the community, including the elderly, about the implementation of the covid-19 health protocols as an effort to prevent the transmission of covid-19. information on preventing the transmission of covid-19 through the implementation of health protocols has been comprehensive in rural areas through health education by health workers through billboards or posters. a study explains that billboards and banners are media types that are considered effective for informing the prevention of covid-19 in rural areas (badri, 2020). this also shows that health workers in rural areas have optimal performance in improving health services, especially for the elderly (he and tang, 2021). the government give more attention to activities to prevent the transmission of covid-19. the government moves all its units to the lowest unit, that is village. this requires the village government, including stakeholders, to apply all policies that have been set by the central government, including in socializing the implementation of the covid-19 health protocol and collaboration between sectors and across sectors. this activity has an impact on increasing public knowledge, especially among the elderly in rural areas. subjective norm on the implementation of covid-19 health protocols subjective norms affect the implementation of the covid-19 health protocol among elderly in rural areas. subjective norms are formed by an individual's perception of the beliefs of the closest people. in rural areas, the family is the closest person for the elderly. they tend to follow the directions given by the family compared to other. families provide support in caring for the elderly, one of which is doing activities that prevent the elderly from transmission of covid-19. this is in accordance with the results of the study which concluded that the family has a role in healthcare for the elderly who live with their family (zulfitri, sabrian and herlina, 2019). therefore, the family belief about preventing the transmission of covid-19 by implementing a health protocol makes the elderly have the same belief as their families (nugraha, 2020). families need to increase their knowledge in caring for elderly. the increased family knowledge has had an impact on change in their belief and formed good subjective norm for elderly (badriah et al., 2021). functional aspects of family support include the type or nature of family support and can be classified into four domains: instrumental support, emotional support, informational support and social integration. in rural areas, elderly are individuals who need protection and supervision from the family, so they can do anything to keep the elderly still health (yuan et al., 2011). subjective norms are also influenced by peers and health workers. behavior change in the elderly is influenced by peer support. elderly tend to do something if they get support from their peers (raue et al., 2015). a good relationship between nurses and the elderly is well-established. this will have an impact on improving the quality of therapeutics so as to achieve successful implementation carried out by nurses (happ and raderstorf, 2019). the elderly are a vulnerable group. families in rural areas believe that the elderly are individuals who have more life experience so they are wiser than others. therefore, families with the elderly in rural areas will strive to maintain the health of the elderly, especially keeping the elderly from being infected with covid-19. maurida, putri, and rosalini (2022) 80 p-issn: 1858-3598  e-issn: 2502-5791 perceived behavioral control on the implementation of covid-19 health protocols there is a relationship between perceived behavioral control and implementation of the covid-19 health protocol in the elderly in rural areas. this is in line with other studies which explain that perceptions of behavioral control affect behavior (sin and rochelle, 2022).perceived behavioral control is formed from the individual's perception of support or obstacles. the influence formed by subjective attitudes and norms still needs to be strengthened with the support of the social environment to improve the implementation of the covid-19 health protocol for the elderly in rural areas. impact of perceived behavioral control actually depends on the factors determining behavior, such as access to information, access to health services, self-efficacy, availability of materials, financial and time (zhang et al., 2021). a sense of togetherness and cooperation is still entrenched in people in rural areas, including the elderly in east java (windarwati et al., 2020). this is an inhibiting factor in the elderly, limiting interaction with other people (utomo et al., 2019). changes that occur in the elderly because the aging process makes the elderly unable to make decisions on their own without assistance (chen, dai and xia, 2022). perceived behavioral control is individual perceptions of assessing barriers to behavior. the perception is about self-efficacy, self-awareness, time availability, access, infrastructure and individual financial conditions in implementing the covid-19 health protocol. some of the elderly in rural areas still work to meet their daily needs. its makes the elderly difficult to implement the covid-19 health protocol, especially in the aspect of staying away from crowds. the work that is mostly done by the elderly in rural areas is as farm laborers or garden workers. this makes the elderly do work in groups. the majority of the educational background of the elderly in rural areas did not attend school. its causes the elderly to have low self-efficacy and self-awareness about their vulnerability to contracting covid-19 and their belief in implementing the covid-19 health protocol is still low. however, efforts to increase knowledge carried out by the village government by emphasizing policies that compel and bind the community to implement of covid-19 health protocols have caused the elderly in rural areas to be able to override perceived barriers and implement covid-19 health protocols. effect of attitude toward behavior, subjective norm and perceived behavioral control on implementation of covid-19 health protocols attitude toward behavior, subjective norm and perceived behavioral control had simultaneous effect on implementation of covid-19 health protocols among elderly in rural areas. across a range of health behaviors, interventions to change attitudes, norms, or perceived behavioral control effectively changed behavior or behavioral intentions (watson and austin, 2021). attitudes toward behavior, subjective norms, and perceived behavioral control have a strong relationship in conducting analyses to change behavior in individuals. the elderly in rural areas are a minority group and tend to have homogeneous characteristics and uphold the local culture. good knowledge is the background for the formation of beliefs in implementing behavior. however, the existing belief needs to get support from family, health workers, and peers in terms of availability of time, infrastructure, and the financial condition of the elderly. limitations there are some limitations of this research. the number of respondents is as many as 100 older persons. this can be improved to describe the real condition. characteristic demographics were not included in the multivariate analysis because the scale was categorical and not a dichotomous table. in the process of collecting data, the information provided by the respondent through questionnaires sometimes does not show the actual opinion of respondents, this happens because sometimes there are differences of opinion, assumptions and different understanding of each respondent, as well as other factors such as honesty factor in filling respondents' opinions in the questionnaire. respondents have different educational backgrounds. this will have an impact on the respondent's level of knowledge in determining attitudes that was not identified in this research. the pandemic situation at the time of the study showed an increasing fluctuation in transmission. the situation at the time of the study could affect the results of similar studies. conclusion tpb construct and demographic characteristic such as gender, age and employment status have influence on the implementation of the covid-19 health protocols among elderly in rural areas. the most dominant factor in increasing the implementation of the covid-19 health protocol is attitude toward behavior. based on the research above, it is necessary to improve attitudes, subjective norms and perceived behavioral control among elderly in rural areas to improve the implementation of the covid-19 health protocol by increasing perceptions and beliefs of the elderly in implementing the covid-19 health protocols, which will be in line with increasing knowledge of the elderly. this can be done use counseling methods or health education by involving the elderly group. health workers need to work together with stakeholders in rural areas, including culture figure or religious leaders, to increase the perceptions and belief of the elderly in implementing the covid-19 health protocol. besides that, there is a need for jurnal ners http://e-journal.unair.ac.id/jners 81 family involvement to make good family support in preventing the transmission of covid-19 in the elderly in rural areas. recommendation for further research is to use knowledge variables in identifying factors that influence the implementation of the acovid-19 protocol. acknowledgment we would like to say thank you to university of dr. soebandi jember for the opportunity to conduct this research. we also say thank you to the enumerators, village government, regional health workers, kader and respondent who have worked well together in this research. funding source we would like to say thank you to the directorate of research and community service dr. soebandi university for funding this study. references badri, m. (2020) ‘perancangan media luar ruang untuk kampanye pencegahan covid-19 di komunitas perdesaan’, menara riau, 14(2), pp. 68–77. badriah, s. et al. (2021) ‘sundanese culture-sensitive family nursing model improves behavior in controlling blood sugar in elderly patients with diabetes’, enfermeria clinica. elsevier españa, s.l.u., 31, pp. s361–s365. doi: 10.1016/j.enfcli.2020.09.027. benu, y. m., febriyanti, e. and tahu, s. k. (2022) ‘perbedaan tingkat pengetahuan masyarakat pedesaan dan perkotaan tentang 5 m sebagai pencegahan penularan coronavirus disease-19’, chmk nursing scientific journal, 6, pp. 18–33. cahyawati, p. n., lestarini, a. and saniathi, n. k. e. (2021) ‘konsultasi online dan pendampingan masyarakat dalam rangka pencegahan penularan covid-19’, buletin udayana mengabdi, 20(24), pp. 123– 128. chen, t., dai, m. and xia, s. (2022) ‘perceived facilitators and barriers to intentions of receiving the covid-19 vaccines among elderly chinese adults’, vaccine. elsevier ltd, 40(1), pp. 100–106. doi: 10.1016/j.vaccine.2021.11.039. daoust, j. f. (2020) ‘elderly people and responses to covid-19 in 27 countries’, plos one, 15(7), pp. 1–13. doi: 10.1371/journal.pone.0235590. géa, l. p. et al. (2022) ‘public perceptions of psychiatric, justiceinvolved, and elderly populations during the covid-19 pandemic’, journal of psychiatric research, 146(february 2021), pp. 67–76. doi: 10.1016/j.jpsychires.2021.12.019. happ, m. b. and raderstorf, t. (2019) ‘engaging nurses in gerontechnology and innovation in acute care for the elderly’, geriatric nursing. elsevier inc., 40(5), pp. 533–535. doi: 10.1016/j.gerinurse.2019.08.013. he, a. j. and tang, v. f. y. (2021) ‘integration of health services for the elderly in asia: a scoping review of hong kong, singapore, malaysia, indonesia’, health policy. elsevier ireland ltd, 125(3), pp. 351–362. doi: 10.1016/j.healthpol.2020.12.020. health ministry of indonesia (2020) pedoman pencegahan dan pengendalian coronavirus disease (covid-19), kementrian kesehatan ri. doi: 10.33654/math.v4i0.299. karadavut, s. and altintop, i. (2022) ‘long-term cardiovascular adverse events in very elderly covid-19 patients’, archives of gerontology and geriatrics. elsevier b.v., 100(january), p. 104628. doi: 10.1016/j.archger.2022.104628. kristamuliana, k., renteng, s. and datu, r. j. (2021) ‘pengalaman lansia menerapkan protokol kesehatan di masa pandemi covid-19: studi kualitatif di bplu senja cerah manado’, media publikasi promosi kesehatan indonesia, 4(3), pp. 406–412. lestarina, n. n. w. (2018) ‘theory of planned behavior sebagai upaya peningkatan kepatuhan pada klien diabetes melitus’, media kesehatan masyarakat indonesia, 14(2), p. 201. doi: 10.30597/mkmi.v14i2.3987. maurida, n., sukartini, t. and indarwati, r. (2019) pengembangan model perilaku deteksi dini kanker serviks pada perempuan di kabupaten jember. surabaya: program studi magister keperawatan universitas airlangga. melia, s., triana, h. and prasetyo, y. a. (2020) ‘edukasi kesehatan lansia dan adaptasi kebiasaan baru melalui media live streaming youtube’, seminar nasional semnas lppm universitas muhammadiyah purwokerto, pp. 150–153. murdiyanto, e. (2020) sosiologi perdesaan pengantar untuk memahami masyarakat desa (edisi revisi). universitas pembangunan nasional ‘veteran’: lembaga penelitian dan pengabdian kepada masyarakat, yogyakarta press. murri, r. et al. (2022) ‘a real-time integrated framework to support clinical decision making for covid-19 patients’, computer methods and programs in biomedicine. elsevier b.v., 217, p. 106655. doi: 10.1016/j.cmpb.2022.106655. niruri, r. et al. (2021) ‘perilaku masyarakat dalam pelaksanaan protokol kesehatan sebagai upaya pencegahan covid-19 di punggawan , banjarsari surakarta’, journal farmasi indonesia, 18(1), pp. 75–81. nugraha, s. (2020) ‘prediktor faktor lingkungan sosial untuk kualitas hidup lansia di wilayah rural dan urban’, jurnal untuk masyarakat sehat (jukmas), 4(1), pp. 81–89. doi: 10.52643/jukmas.v4i1.803. nur, r. a. (2021) gambaran pengetahuan dan praktik protokol covid-19 pada lansia di kabupaten takalar. program studi ilmu keperawatan fakultas keperawatan universitas hasanudin. ogilvie, g. s. et al. (2016) ‘correlates of women ’ s intentions to be screened for human papillomavirus for cervical cancer screening with an extended interval’, bmc public health. bmc public health, pp. 1–8. doi: 10.1186/s12889-016-2865-8. pan, j. y. and liu, d. (2022) ‘mask-wearing intentions on airplanes during covid-19 – application of theory of planned behavior model’, transport policy. elsevier ltd, 119(january), pp. 32–44. doi: 10.1016/j.tranpol.2022.01.023. prihati, d. r., maulidita and supriyanti, e. (2020) ‘analisis pengetahuan dan perilaku masyarakat di kelurahan baru, kotawaringin barat tentang penyakit covid-19’, jurnal edudikara, 2(2), pp. 3–5. raue, p. j. et al. (2015) ‘peer to peer behavioral activation for elderly depressed senior center clients’, the american journal of geriatric psychiatry. elsevier inc, 23(3), p. s165. doi: 10.1016/j.jagp.2014.12.172. ringroad, j., daya, b. and tamantirto, n. (2016) ‘usia berpengaruh dominan terhadap perilaku perawatan luka perineum pada ibu nifas di rsud sleman postpartum women hospital sleman’, pp. 95–101. riyadi, r. and larasaty, p. (2021) ‘faktor yang berpengaruh terhadap kepatuhan masyarakat pada protokol kesehatan dalam mencegah penyebaran covid-19’, seminar nasional official statistics, 2020(1), pp. 45–54. doi: 10.34123/semnasoffstat.v2020i1.431. rubina, m. et al. (2022) ‘factors associated with differential covid-19 mortality rates in the sear nations: a narrative review’, ijid regions. elsevier ltd, 3(january), pp. 54–67. doi: 10.1016/j.ijregi.2022.02.010. sari, r. k. (2021) ‘identifikasi penyebab ketidakpatuhan warga terhadap penerapan protokol kesehatan 3m di masa pandemi covid-19’, jurnal akrab juara, 6(1), pp. 84–94. simanjorang, c. et al. (2022) ‘the determinants of sars-cov-2 vaccine hesitancy in a rural area of an indonesia-philippines border island: a mixed-method study’, enfermería clínica (english edition). elsevier espa\u00f1a, s.l.u. doi: 10.1016/j.enfcle.2022.03.002. sin, c. s. and rochelle, t. l. (2022) ‘using the theory of planned behaviour to explain hand hygiene among nurses in hong kong during covid-19’, journal of hospital infection. the healthcare infection society, (xxxx). doi: 10.1016/j.jhin.2022.01.018. tobing, c. p. r. l. and wulandari, i. s. m. (2021) ‘tingkat kecemasan bagi lansia yang memiliki penyakit penyerta ditengah situasi pandemik covid-19 di kecamatan parongpong, bandung barat’, community of publishing in nursing (coping), p-issn 2303-1298, eissn 2715-1980, 8(april 2021), pp. 124–132. utomo, a. et al. (2019) ‘social engagement and the elderly in rural indonesia’, social science and medicine. elsevier, 229(december 2017), pp. 22–31. doi: 10.1016/j.socscimed.2018.05.009. ventura, f., molinelli, a. and barranco, r. (2021) ‘journal of forensic and legal medicine covid-19-related deaths in residential care homes for elderly : the situation in italy’, journal of forensic and legal medicine. elsevier ltd, 80(march), p. 102179. doi: 10.1016/j.jflm.2021.102179. watson, c. e. and austin, r. a. (2021) ‘differences in rural and urban drivers’ attitudes and beliefs about seat belts’, accident analysis and prevention. elsevier ltd, 151(august 2020), p. 105976. doi: 10.1016/j.aap.2021.105976. wikamorys, d. a. and rochmach, t. n. (2017) ‘aplikasi theory of planned behavior dalam membangkitkan niat pasien untuk maurida, putri, and rosalini (2022) 82 p-issn: 1858-3598  e-issn: 2502-5791 melakukan operasi katarak’, administrasi kesehatan indonesia, 5, pp. 6–18. windarwati, h. d. et al. (2020) ‘in the middle of the covid-19 outbreak: early practical guidelines for psychosocial aspects of covid-19 in east java, indonesia’, psychiatry research. elsevier ireland ltd, 293(april), p. 113395. doi: 10.1016/j.psychres.2020.113395. yuan, s. c. et al. (2011) ‘how family support affects physical activity (pa) among middle-aged and elderly people before and after they suffer from chronic diseases’, archives of gerontology and geriatrics. elsevier ireland ltd, 53(3), pp. 274–277. doi: 10.1016/j.archger.2010.11.029. zakiah, r. and pujiati, p. (2022) ‘gambaran rumah sakit umum dan khusus covid-19 di provinsi jawa timur tahun 2022’, isjmhs, 01(06), pp. 202–207. zhang, l. et al. (2021) ‘utilizing the theory of planned behavior to predict willingness to pay for urban heat island effect mitigation’, building and environment. elsevier ltd, 204(july), p. 108136. doi: 10.1016/j.buildenv.2021.108136. zulfitri, r., sabrian, f. and herlina (2019) ‘sociodemographic characteristics and psychosocial wellbeing of elderly with chronic illnesses who live with family at home’, enfermeria clinica. elsevier españa, s.l., 29, pp. 34–37. doi: 10.1016/j.enfcli.2018.11.014 how to cite this article: maurida, n., putri, p., rosalina, w. (2022) ‘factors associated with the implementation of covid-19 health protocols among indonesian older adults living in rural areas: a cross-sectional study’, jurnal ners, 17(1), pp. 74-82. doi: http://dx.doi.org/10.20473/jn.v17i1.35055 table1 table2 table3 table4 table5 support badri2020 badriah2021 benu2022 cahyawati2021 chen2022 daoust2020 géa2022 happ2019 he2021 health2020 karadavut2022 kristamuliana2021 lestarina2018 maurida2019 melia2020 murri2022 niruri2021 nugraha2020 nur2021 ogilvie2016 pan2022 prihati2020 raue2015 ringroad2016 riyadi2021 rubina2022 sari2021 simanjorang2022 sin2022 tobing2021 utomo2019 ventura2021 watson2021 wikamorys2017 windarwati2020 yuan2011 zakiah2022 zhang2021 zulfitri2019 192 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 192-199 http://dx.doi.org/10.20473/jn.v18i2.46310 original article open access how to live longer: lived experience of older adults in thailand kittisak kumpeera 1 * , laddawan daengthern 2 , somsak thojampa 3 , and kunchayarat udkhammee 4 1 faculty of nursing, naresuan university, phitsanulok, thailand 2 faculty of nursing, panyapiwat institute of management, bangkok, thailand 3 faculty of nursing, naresuan university, phitsanulok, thailand 4 phrae hospital, phrae, thailand *correspondence: kittisak kumpeera. address: faculty of nursing, naresuan university, phitsanulok, thailand. email: kittisakk@nu.ac.th responsible editor: ferry efendi received: 12 june 2023 ○ revised: 28 june 2023 ○ accepted: 28 june 2023 abstract introduction: thai population data across the country have revealed an increase in the number of older adults aged over 80 years. the data indicate that individuals exhibit good self-care practices in terms of lifestyle, effective emotional coping, and strong social support, which contributes to their ability to live longer than the average life expectancy. the primary objective of this study was to explore the experiences of older people regarding self -care practices aimed at surpassing the average life expectancy of thai individuals. methods: this phenomenological descriptive qualitative research utilized a purposive sampling method to select ten participants who were aged 80 years and above and residing in five villages. the inclu sion criteria required individuals to be able to communicate in the thai language and express their agreement to participate in the research project. in-depth interviews utilizing open-ended questionnaires were conducted to explore the perspectives of older people on self-care practices that contribute to longevity among this population. data were analyzed thematically using descriptive phenomenological analysis. results: this study identified four themes related to longevity in older adults as follows: fo od type choices, exercise as part of daily life, reduction of stress exposure, and dealing with illness . conclusions: the findings of the study can serve as guidelines for managing the healthcare system at the sub district level. this can be achieved through a project that focuses on developing self-care practices to promote longevity among older adults in a community. successful management of the health system can contribute to the sustainability of healthcare management at the sub -district level. keywords: food type choices, exercise as part of daily life, reduction of stress exposure, dealing with illness, life long introduction nowadays, advanced medical knowledge and modern technology are factors that effectively contribute to increasing the longevity of the population. therefore, it is important to promote health among older adults, enabling them to remain self-reliant for as long as possible. this includes promoting physical and mental well-being, teaching them how to utilize technology for independent living, fostering happiness in their solitary lives, and facilitating communication with other community members (chanburee et al., 2020). the worldwide life expectancy for men is 68.9 years, while, for women, it averages at 73.9 years (world data, 2021). in terms of neighboring countries with direct national borders with thailand, including myanmar, cambodia, laos, and malaysia, the life expectancy for men is 62.5, 66.8, https://creativecommons.org/licenses/by/4.0/ mailto:kittisakk@nu.ac.th https://orcid.org/0000-0001-7417-6314 https://orcid.org/0000-0002-2797-8979 jurnal ners http://e-journal.unair.ac.id/jners 193 66.2, and 72.7 years, respectively. for women, the figures are 69, 72.3, 70.1, and 77.4 years, respectively (world data, 2021). the life expectancy for thai people is approximately 71.8 years for men and 78.6 years for women. on average, individuals aged 60 can expect to live an additional 20.1 years for men and 23.4 years for women. for those aged 65, the expected additional years of life are about 16.4 for men and 19.3 for women (institute for population and social research, mahidol university, 2016). consequently, when comparing with the thai population, it becomes evident that the life expectancy of thai people is higher than that of three-quarters of neighboring countries for men and higher than that of all countries for women. in 2017, the national statistical office conducted a survey on the thai population nationwide and discovered that the number of individuals aged 60 years and above was 10,225,322, accounting for 15.45 percent of the population by age (national statistical office thailand, 2017). the northern region had the highest number of older adults, with 2,093,071 individuals, representing 20.47 percent of the population by age, surpassing all other regions (national statistical office thailand, 2017). the top five provinces with the highest proportion of older people are chai nat, phrae, uttaradit, phichit, and sing buri provinces (national statistical office thailand, 2014). in nong muang khai district, phrae province, the population is 17,803, consisting of 8,376 men and 9,427 women. within tamnak tham subdistrict, nong muang khai district, the population is 3,336, and the number of older adults is 845 (25.52 percent of th e population), with 350 men and 495 women (tamnak tham subdistrict development project report, 2017). these figures indicate that tamnak tham subdistrict has an older population of over 20 percent, classifying it as an aging society (pho-yen, 2019). in addition, various factors contribute to increased life expectancy in different countries, among them lifestyle, traditions, culture, genetics, education, the quality of public health, and medical services available (piensriwatchara, 2010). a study conducted on 100year-old japanese individuals identified nine factors associated with longevity: maintaining good chewing ability, consuming protein-rich foods, engaging in regular exercise, maintaining normal vision, getting sufficient sleep, waking up early, avoiding any history of injury, abstaining from alcohol consumption, and not smoking tobacco. when combined with positive perception and psychosocial conditions, these factors contribute to a valuable life for older adults (siriwanarangsan, 2014). four main factors are associated with enabling older adults to be healthy and strong, live life in society, and have a long life: firstly, food is a big issue in our daily lives, eating foods that are natural and have no toxins will help in longevity (chernoff, 2001). secondly, the exercise factor is the body's movement which helps relax muscles, prevents joint stiffness, and stimulates the circulatory system so appropriate exercise will help longevity (piercy et al., 2018). thirdly, the stress reduction factor is an important factor related to physical and emotional well-being. older adults who are aged 80 years old and above who spend time close to nature, enjoy growing vegetables, livin g together as a large family, and eating with family regularly has a positive effect on mental health and reduces stress (krajangchom et al., 2014). fourthly and very important, the healing factor is that when older adults are having health problems they should seek medical consultation, self-practice by following their doctor's advice, take their prescription medication, follow up on time to see a doctor, and have access to public health services easily. these factors allow an older adult with diseases to be able to reduce suffering (hao et al., 2020). these are the main factors that influence older people's longevity. therefore, it is crucial to establish a community health promotion system that encourages individuals to adopt healthy behaviors and self-care practices. this can lead to increased longevity and improved quality of life as individuals transition into older adulthood. health promotion is an essential role for nurses, encompassing various aspects: 1) physical health promotion focuses on adequate hydration, consumption of all five food groups, engaging in aerobic exercise for 15-30 minutes or more, practicing deep breathing exercises, and ensuring 6-8 hours of sleep per day. 2) mental health promotion aims to enhance psychological well-being by fostering a positive mindset, emotional stability, maintaining a bright mood, practicing mindfulness, and developing stress management techniques such as optimism and positive thinking. 3) social health promotion involves encouraging individuals to actively participate in creating suitable physical and social environments that support their well-being, both physically and mentally., and 4) intellectual or spiritual health promotion can be achieved by adhering to religious and cultural principles that promote well-being, as well as reducing and avoiding risky behaviors that could negatively impact kumpeera, daengthern, thojampa, and udkhammee (2023) 194 p-issn: 1858-3598  e-issn: 2502-5791 health (pattarateeranon et al., 2021). the researcher is interested in studying the care of older adults, focusing on their lifestyle, self-care practices, and social support, as these factors contribute to increased longevity and the potential to surpass the average life expectancy. nurses can utilize this information to provide appropriate health promotion strategies for individuals transitioning into older adulthood, ultimately enhancing their quality of life and life expectancy. the primary objective of this study was to explore the experiences of older people regarding self-care practices aimed at surpassing the average life expectancy of thai individuals. materials and methods study design this qualitative research with descriptive phenomenology (wojnar & swanson, 2007) and by indepth interview method. the participants were older males and females living in phrae province aged 80 years old and above who were not suffering from serious illnesses such as paralysis, were independent, being fully conscious, can communicate by speaking, reading, and writing in thai, and willing to participate in this research. the researcher selected 1-2 older adults who fulfilled the inclusion criteria in five villages from tamnak tham subdistrict, nong muang district, phrae province. the total participants in this research was 10 older people. instrument the instruments in this study consisted of general information forms, semi-structured interview guidelines, a voice recorder, and field notes. the interview used open questions and consisted of 10 questions that aim to explore the factors that contribute to longevity in older people. the questions were based on kiatisevi’s (2013) conceptual framework of the main factors that contribute to the health and longevity. the instrument has been verified for content validity by three experts including two geriatric nursing instructors and a geriatric doctor. the created open ended questionnaire was examined for content coverage, checked for language clarity, and improved according to suggestions from experts. after that, an experiment was conducted with 10 similar older adults who were used in the study to test their understanding of the meaning and clarity of the language. questions were revised before applying to the actual in-depth interview. data collection the in-depth interview process in the study lasted 60–90 minutes for each participant and ended when the data were saturated. the researcher used field notes and observation methods in a notebook according to the structured interview form, documented the atmosphere, facial expressions, behavior, and non-verbal responses of participants during the interview process and a voice recorder was used for the whole duration of the interview. after all the interviews were completed, the researcher made an appointment with the participants for the next meeting for data validation. in addition, the researcher applied epoche or bracketing by ignoring all personal assumptions related to the phenomenon under study when digging research data, putting aside his personal knowledge, understanding, and trying fully to position himself as a participant and see things from the participant's perspective. data analysis statistical analyses for this study were conducted the data were analyzed using descriptive phenomenological analysis by wojnar and swanson (2007), which consists of four steps. first, bracketing involves field recording and conducting a critical review from the perspective of an experienced person in the subject matter. second, the analysis involves seven steps (colaizzi): transcribing, extracting important text, determining the meaning of the text, grouping the meaning of the text, collecting duplicate findings, annotating, coding the information, and linking issues. a triangular review is conducted to confirm their reliability and consistency. third, intuiting is the researchers' insight, which is enhanced by a substantial amount of information obtained through attentive listening. in-depth critiques are used to foster mutual understanding. finally, describing involves presenting the findings to everyone and writing about the experience for a wider audience. ethical consideration this study has been approved by the human ethics committee naresuan university coa no.355 / 2019, irb no. 0105/62, dated 7 august 2019 7 august 2020. results participants in this study were two males and eight females; there were five people aged between 80-84 years old, three people aged between 85-90 years old, and two people aged above 90 years old; most of them jurnal ners http://e-journal.unair.ac.id/jners 195 were educated at primary school level, most of them do not work, and have an income from subsistence allowance (government), most of them do not have enough income to spend so must rely on children, all of them have chronic diseases that require continuous medication such as dyslipidemia, hypertension, and diabetes mellitus. all of them do not engage in alcohol drinking and smoking. findings from this study revealed four essential themes from the interviews as follows: theme 1: food type choices from the interview, the older adults had cooking styles that focus on preparing their food by mainly boiling, currying, and steaming. they avoid cooking with frying, stir-frying, grilling, and broiling. if they bought food that was cooked by grilling or broiling, they will cook them again by boiling it. the ingredients used for cooking were mostly vegetables that are grown by themselves without the use of pesticides, chemical fertilizers, or other toxins, such as lettuce, morning glory, chinese broccoli, horse tamarind, ivy gourd, acacia, sponge gourd, eggplant, long beans, pumpkin, etc. they also eat fish, eggs, and local fruits such as bananas, papaya, and ripe mangoes. they avoid ingredients such as meat, coconut milk, and monosodium glutamate (msg). some desserts are eaten infrequently such as banana in coconut milk, pumpkin in coconut milk, green beans in syrup, etc. their eating pattern is eating all three meals a day. most of the older adults’ eating patterns in the past up to the present day are eating vegetable curries such as lettuce curry, jackfruit curry, and mixed vegetable curry. in addition, chili paste with fresh or boiled vegetables is a menu that everyone likes to eat the most. chili paste is an easy menu with herbal ingredients such as chilies, garlic, onions, basil leaves, lemon, or tamarind. most of them like to eat fruit in the evening. some elderly will increase protein by adding one boiled egg or drinking one cup of fresh milk after a meal. most of them will drink one cup of water immediately after waking up in the morning before washing their face, brushing their teeth, or showering, which makes defecation easier and feels comfortable. as p1 (female, 82 years old) said, “i have eaten three meals for a long time. i focus on eating vegetables, eating fish, and not buying cooked food. most of the time i cook at home by boiling, steaming, not deep frying or stir-frying.” in a similar manner, p2 (female, 90 years old) said, “i eat one egg every day, i only eat egg whites, i do not eat egg yolk. since childhood, i have regularly eaten chili paste, boiled vegetables, and vegetable curry with fish, if have bananas, eat another one banana (nam wa bananas). i cook at home, focus on boiling and steaming, do not use msg at all, for dessert such as banana or pumpkin in coconut milk sometimes.” in a similar manner, p9 (male, 92 years old) said, “since i was 40 years old, i have practiced by focusing on boiled vegetables and chili paste in the evening. after i wake up in the morning without having to brush my teeth to drink one cup of water. i feel that it will be easy to defecate, i feel comfortable.” in a similar manner, p10 (female, 91 years old) said, “today, we must try to control which diet is good and which is not good. i will choose what to eat and eat three full meals, focusing on eating a lot of vegetables. to help with bowel movement. i eat desserts occasionally like banana or pumpkin in coconut milk.” theme 2: exercise as part of daily life the older adults in tamnak tham subdistrict exercise regularly, consistently, and done together in the older adults’ school. wherein the tamnak tham subdistrict administration organization has the policy to carry out training activities to promote knowledge and exercise for the older adults such as retro dance and kongka dance. the older adults exercised with kongka dance every wednesday, for approximately 10 15 minutes. exercising at home by themselves was an uncertain practice, which depends on their convenience and the situation of each person. if they exercised at home, it would take about 20-30 minutes including walking, swinging arms, dancing, weaving bamboo baskets, pulling out the grass in the garden, planting vegetables, and gardening. the feeling an older adult mostly agreed with was that, after exercise, the body will be able to move better, and sweating will feel comfortable. most of the older adults were interested in exercising together at the older adults’ school very much because it enabled them to meet with the people in the village where by they can socialize with each other. as p3 (female, 80 years old) said, “i exercised at home by swinging my arms for 20-30 minutes and every wednesday by doing a kongka dance with three songs. i think exercise makes me sweat and makes the body comfortable.” in a similar manner, p5 (male, 86 years old) said, “some days, i pull the grass in the garden at home which is like exercising. some days, i walk for about 2030 minutes. every wednesday, when i come to the kumpeera, daengthern, thojampa, and udkhammee (2023) 196 p-issn: 1858-3598  e-issn: 2502-5791 elderly school, i can do kongka dance with three songs. after exercising i can sweat, it makes me feel comfortable.” in a similar manner, p7 (male, 83 years old) said, “i will weave bamboo baskets in my free time. every wednesday when i go to the elderly school, i do kongka dance with three songs which allow my body to move, have good mobility, and feel comfortable because i sweat.” theme 3: reduction of stress exposure from the interview, it was found that the stress reduction of the older people consisted of letting things go, resting, waiting for stress or other issues to pass, and go-to stress relief activities by themselves such as reading books, reading dharma books, watching television, singing, or dancing alone. in addition, when stress occurs, they will go out to meet with trusted neighbors or will go to school for older adults every wednesday to talk with other people to relieve stress. the kongka dance also helps relieve stress and participating in various product creation activities such as basking weaving helps to enjoy the activities and make them forget the stress that occurs. as p1 (female, 82 years old) said, “i'm not stressed often but sometimes i think about my disease. if stress occurs, i will relax by reading the book. some days, i just rest and relax, i do not think about anything, or i go to the elderly school to meet with friends and talk to each other.” in a similar manner, p5 (male, 86 years old) said, “i sometimes think about my children, i am worried about money is not enough, since i have income only from subsistence allowance (government). but it’s ok, i just sleep and relax, let it go. every wednesday i go to the elderly school to meet and talk with other elderly and will forget about stress.” in a similar manner, p10 (female, 91 years old) said , “i will read dharma books. sometimes let the uncomfortable things pass by themselves without doing anything.” theme 4: dealing with illness when the older people in tamnak tham subdistrict have little illnesses such as headaches, stomachaches, or muscle pain, they will take care of themselves by buying and using medication by themselves. if the symptoms do not improve, they will go for treatment in the hospital. those older adults who have chronic diseases, regularly take medication, and even sometimes forget to take medication but there was appropriate management. they regularly visit a doctor for an appointment to follow up on symptoms. as p1 (female, 82 years old) said, “i go to the doctor. the doctor makes an appointment whenever i go to the hospital. taking medicine as the doctor said can't be absent.” in a similar manner, p4 (female, 85 years old) said, “i don't have any diseases, no diabetes mellitus, hypertension, or dyslipidemia at all. therefore, i do not need to see a doctor. whenever i have a little pain in the body just take paracetamol” in a similar manner, p6 (female, 85 years old) said, “if i am ill but not serious, i take care of myself first. if it is not better, i will go to see the doctor. " in a similar manner, p9 (female, 92 years old) said, “i often forget to take the medicine. therefore, i have prepared the medicine before meals so i will not forget to take it; after eating i will take my medicine immediately. i always go to see the doctor for an appointment.” discussions the self-care experiences of older people aged 80 and over begin with a crucial factor of food type choices, which plays a vital role in promoting growth and strength. older adults predominantly consume foods derived from nature, with a focus on vegetables containing non-toxic substances, as well as fish, eggs, and milk. when it comes to cooking, they primarily utilize homegrown vegetables, avoiding the use of pesticides, chemical fertilizers, and other toxins. commonly used vegetables include lettuce, morning glory, chinese broccoli, eggplant, long beans, and pumpkin. these ingredients are safe, devoid of chemicals, and abundant in protein and vitamins. protein, as a significant nutrient, aids in repairing the body's wear and tear, while the vitamins present in vegetables contribute to strengthening the immune system (plodpluang et al., 2017). in addition, most older people prefer boiling as the cooking method over frying, grilling, or stir-frying. this choice is made because frying or grilling can result in pollution from incomplete combustion, leading to the formation of polycyclic aromatic hydrocarbons (pahs). prolonged exposure to pahs during cooking can have adverse health effects, including an increased risk of cancer (chaiklieng et al., 2021). according to studies conducted by krajangchom and champawan (2014) and supma and sakdiworaphong (2014), older adults aged 80 and above traditionally adopt a simple lifestyle jurnal ners http://e-journal.unair.ac.id/jners 197 when it comes to their eating habits. they prioritize easily accessible vegetables, often found in dishes like mixed vegetable curry or chili paste with boiled vegetables. these specific menus are highly favored by the elderly as they offer a low-fat diet that has been passed down through generations. food plays a significant role in their daily lives and contributes to their longevity. similarly, japanese individuals who live longer tend to avoid high-fat foods and instead focus on obtaining protein from fish, while maintaining a diet rich in fruits and vegetables. they adhere to consuming three balanced meals in moderation. the food they consume should be fresh, clean, non-toxic, and free from chemical processes. these dietary choices are believed to contribute to a longer life (chernoff, 2001; piensriwatchara, 2010; bootsri1 et al., 2017). in addition, older adults are aware of the importance of exercise. they incorporate physical activity into their daily lives through various activities like weaving bamboo baskets, tending to the garden by pulling out grass, and planting vegetables. furthermore, they regularly engage in exercise at home, which includes activities such as walking, swinging their arms, or dancing for about 20-30 minutes per day, 2-3 times per week. older adults are recommended to participate in a minimum of 150 to 300 minutes per week of moderate exercise, or 75 to 150 minutes per week of vigorous activity, or a combination of both intensities. moderate physical activities include walking, weightlifting, and lowerintensity exercises, while vigorous exercises encompass activities like running, cycling, and swimming. research has found that surpassing the recommended amount of exercise can contribute to a longer life span. (piercy et al., 2018) moreover, the tamnak tham subdistrict administration organization has developed a system of care for older people since 2010. this system is called the "older adult school" and it encompasses concrete development and actions such as promoting exercise, providing knowledge about healthcare, and organizing various activities for the participants' well-being. there is a coordination mechanism between the subdistrict older adult club, the subdistrict administration organization, the primary healthcare center, and the village headman. they work together to promote exercise by organizing retro dance sessions once a month and kongka dance sessions that last 10 to 15 minutes every wednesday at the school (tamnak tham subdistrict development project report, 2017). this system enables older individuals to engage in regular exercise that harmonizes with their lifestyle. according to kassis et al. (2023), longevity in humans can be attributed to genetics by only 20–30 percent, while the remaining 70–80 percent is influenced by the environment. physical activity has age-appropriate effects that lead to improvements in body structure and muscle function among older adults. additionally, exercise promotes muscle and bone mass, increases bone density, and, when performed moderately and consistently, it enhances immunity, reduces illness rates, and decreases body inflammation (kassis et al., 2023). furthermore, aerobic exercises, such as dancing accompanied by music and involving multiple participants, have been shown to increase cognitive performance, stimulate memory, enhance attention, and facilitate cognitive learning (klimova et al., 2020). in the context of older individuals, the accumulation of stress throughout life contributes to a weakened immune system and the development of chronic diseases (renzaho et al., 2014). furthermore, stress can have an impact on colonic motility and the composition of intestinal microbes, leading to a reduction in lactobacillus levels and an increase in the adhesion of pathogenic bacteria (conlon et al., 2014). therefore, stress management is crucial to mitigate the detrimental effects of stress and promote the overall physical and mental well-being of older adults. given that older people have experienced stress throughout their lives, it becomes especially important to minimize stress exposure in this population (kassis et al., 2023). the reduction of stress exposure for older adults consists of conversations with friends, dancing in older adults’ school every wednesday, letting things go, reading dhamma books as well as exercising. according to supma and sakdiworaphong (2014), the importance of positive emotions, stress avoidance, and engaging in enjoyable activities for older adults is related to longevity. regular participation in community events and cultivating a positive attitude, self-esteem, and adaptability are key factors in maintaining a positive mental state. for those who don't participate in community activities, finding relaxation at home through activities like watching tv or reading is suggested. positive emotions and mental well-being not only benefit their psychological health but also have a positive impact on their physical health. effectively managing illnesses is crucial for older individuals to achieve a long life. this involves dealing with chronic diseases that require ongoing medication, such as dyslipidemia, hypertension, and diabetes mellitus. when older people experience mild illness, they typically prioritize self-care. however, if symptoms kumpeera, daengthern, thojampa, and udkhammee (2023) 198 p-issn: 1858-3598  e-issn: 2502-5791 persist without improvement, they go to a hospital for examination and treatment by healthcare professionals. additionally, they can take care of themselves by consistently adhering to medication for chronic diseases, regularly monitoring their bodies for any abnormal symptoms, and scheduling regular checkups with their doctors for continuous follow-up. according to han et al. (2022), self-management significantly enhances the quality of life and longevity of older individuals with chronic diseases. this includes self-monitoring of symptoms, adherence to medication plans, regular professional follow-ups, and the development and adherence to a lifestyle aimed at maintaining their overall health. in addition, all older adults who participated in the interview do not smoke or drink alcohol. older adults who do not smoke or drink alcohol can have a longer life as they avoid the harmful chemicals found in tobacco and alcohol. smoking and drinking alcohol contribute to a decline in the energy production process and cause severe damage to brain cells. smoking accelerates the aging process by increasing the number of free radicals in th e body. additionally, smoking raises the risk of emphysema, lung cancer, hypertension, and heart disease. on the other hand, alcohol consumption increases the chances of developing cirrhosis and liver cancer (piensriwatchara, 2010). furthermore, accessing public health services is crucial for older adults. when facing health problems, they consult a doctor promptly, follow the doctor's instructions, take prescribed medications, and regularly visit the doctor to monitor chronic diseases. by doing so, they can effectively control and reduce the impact of chronic diseases. in terms of life expectancy, women experience an increase of 6 percent and 8 percent at ages 65 and 85, respectively, due to adequate access to healthcare. in comparison, men generally experience even greater increases in life expectancy, with a rise of 10 percent and 14 percent at the same age ranges (hao et al., 2020). the results of this study were based on a one-sided perspective of older adults. it is important to acknowledge that the longevity of older individuals is influenced by various environmental factors. this limitation highlights the need for further studies to explore the viewpoints of individuals involved in the development of care systems for older adults, including community leaders, healthcare professionals, village health volunteers, and families of older people. exceeding the average life expectancy is a frequent occurrence; however, attaining a lengthy and healthy life necessitates careful planning prior to reaching old age. the findings of this study can serve as guidelines for managing the healthcare system at the sub-district level. this can be accomplished through a project that emphasizes the development of self-care practices aimed at promoting longevity among older adults within the community. successful management of the healthcare system can contribute to the sustainability of healthcare services at the sub-district level. conclusions the research findings indicate that food, exercise, reduction of stress exposure, and dealing with illness are key factors contributing to the long lives of older adults in phrae province, thailand. consequently, it is crucial for the families and healthcare providers of older adults to support them in adopting healthy eating habits, engaging in regular exercise, volunteering in activities that benefit the community, practicing meditation for mental calmness, effectively managing illnesses, and ensuring swift access to healthcare services. therefore, those responsible for the wellbeing of older individuals including family members, government agencies, and healthcare professionals, should promote these factors to enhance the older adults' quality of life and longevity. family members should encourage older adults to embrace healthy eating, engage in suitable exercise, actively participate in community activities, and receive appropriate medical care. acknowledgment the researcher would like to thank the older adults in tamnak tham subdistrict for being the sample group. thank you to all the experts who checked, corrected, and provided useful suggestions for our research instrument. lastly, we would like to thank the thai health promotion foundation for supporting this research. references bootsri, w., & lohapiboonkul, n. (2017) ‘health behaviors of the longevity elderlyin pathumsub-district, mueang district, ubon ratchathani province’, journal of health science boromarajonani college of nursing sunpasitthiprasong, 1(2), 86 – 98. https://he01.tcithaijo.org/index.php/bcnsp/article/view/193303 /134666 conlon, m., & bird, a. (2014) ‘the impact of diet and lifestyle on gut microbiota and human health’, nutrients, 7(1), 17 – 44. https://doi:10.3390/nu7010017 chaiklieng, s., & dacherngkhao, t. (2021) ‘health risk assessment on exposure to polycyclic aromatic hydrocarbon (pahs) of workers in different positions of restaurants: a case study in kitchens of golf clubs and tourist dams’, thai j toxicol, 36(1), 54 – 73. https://li01.tcithaijo.org/index.php/thaijtoxicol/article/view/248528/170600 chanburee, s., & thanomsat, k. (2020) ‘holistic health care for elders jurnal ners http://e-journal.unair.ac.id/jners 199 in community based on the concept of active aging’, the 12th npru national academic conference, 1090 – 1097. https://publication.npru.ac.th/jspui/handle/123456789/930 chernoff, r. (2001) ‘nutrition and health prom otion in older adults’, j gerontol a biol sci med sci, 56(spec no 2), 47 – 53. https://doi : 10.1093/gerona/56.suppl_2.47. hao, l., xu, x., dupre, m.e., guo, a., zhang, x., qiu, l., gu, d. (2020) ‘adequate access to healthcare and added life expectancy among older adults in china’, bmc geriatrics, 20(1), 129 – 143. https://doi:10.1186/s12877-020-01524-9 han, t.c., lin, h.s., & chen, c.m. (2022) ‘association between chronic disease self-management, health status, and quality of life in older taiwanese adults with chronic illnesses’, healthcare, 10(4), 609 – 622. https://doi.org/10.3390/healthcare10040609 institute for population and social research mahidol university. (2016) ‘mahidol population gazette’, year 25 january 2016. https://i psr.mahidol.ac.th/en/population-of-thailand-2016-vol25-january-2016/ kassis, a., fichot, m.c., horcajada, m.n., horstman, a.m.h., duncan, p., bergonzelli, g., preitner, n., zimmermann, d., bosco, n., vidal, k., & donato, c.l. (2023) ‘nutritional and lifestyle management of the aging journey: a narrative review’, front. nutr, 9(1087505), 1 – 19. https://doi: 10.3389/fnut.2022.1087505 krajangchom, s., & champawan, s. (2014) ‘food consum ption for longevity of tai yuan elderly in mae chaem district, chiang mai province’, journal of community development and life quality, 2(2), 161 – 170. https://so02.tcithaijo.org/index.php/jcdlq/article/view/133581/100136 klimova. b., & dostalova, r. (2020) ‘the impact of physical activities on cognitive performance among healthy older individuals’, brain sci, 10(6), 1 – 14.https://doi:10.3390/brainsci10060377 national statistical office thailand. (2014) ‘the survey of the elderly population in thailand of 2014’, bangkok: national statistical office thailand. http://www.nso.go.th/sites/2014en/home national statistical office thailand. (2017) ‘the survey of the elderly population in thailand of 2017’, bangkok: national statistical office thailand. http://www.nso.go.th/sites/2014en/home pattarateeranon, p., sriyoha1, n., sreeprasarn1, p., & saowanee1, r. (2021) ‘role of community nurses in health promotion and prevention of coronavirus 2019 pandemic in 8 community responsible area, ramathibodi hospital’, thai journal of health education, 44(1), 1 – 11. https://he01.tcithaijo.org/index.php/muhed/article/view/24955 1/168940 piensriwatchara, e. (2010) ‘the secrets of centenarians’, thailand journal of dental public health, 15(1), 9 – 16. https://he02.tcithaijo.org/index.php/thdphjo/article/view/178702/126969 piensriwatchara, e., & poramatthakon, a. (2010) ‘walking for health: model of promoting physical activity in the community for thai elderly’, thailand journal of health promotion and environment, 33(4), 82 – 89. piercy, k. l., troiano, r. p., ballard, r. m., carlson, s. a., fulton, j. e., galuska, d. a., olson, r. d. (2018) ‘the physical activity guidelines for americans’, jama, 320(19), 2020 – 2028. https://doi:10.1001/jama.2018.14854 pho-yen, k. (2019) ‘aging society: opportunities for the future sustainable business’, journal of management science review, 1(1), 201 – 209. https://so03.tcithaijo.org/index.php/msaru/article/view/248389/167224 plodpluang, u., srijan, a., & kaewpraphan, s. (2017) ‘a study of lifestyle of active aging: narrative study’, princess of naradhiwas university journal of humanities and social sciences, 4(1), 91 – 104. https://so05.tcithaijo.org/index.php/pnuhuso/article/view/74972/60511 renzaho, a.m.n., houng, b., oldroyd, j., nicholson, j. m., d’esposito, f., & oldenburg, b. (2014) ‘stressful life events and the onset of chronic diseases among australian adults: findings from a longitudinal survey’, european journal of public health, 24(1), 57–62. https://doi:10.1093/eurpub/ckt007 siriwanarangsan, p. (2014) ‘the secret of elixir. in: piansriwatchara, e. (eds) the secret to 100 years of longevity and a happy life (2nd ed., pp. 90-114)’, office of the veterans affairs printing organization, https://eh.anamai.moph.go.th/th/elderlymanual/downl oad/?did=201580&id=64016&reload= supma, n., & sakdiworaphong, ch. (2014) ‘lifestyle patterns of long lived elderly in donkha community thatako district, nakhonsawan province’, journal of social sciences and humanities, 40(2), 108 – 120. https://so04.tcithaijo.org/index.php/socku/article/view/79681/63594 tamnak tham subdistrict development project report. (2017) ‘copy documents tamnak tham subdistrict development project: funded by thai health promotion foundation’, bangkok. world data. (2021) ‘life expectancy’, https://www.worlddata.info/life-expectancy.php wojnar, d.m., & swanson, k.m. (2007) ‘phenomenology: an exploration’, journal of holistic nursing, 25(3), 172 – 180. https://doi.org/10.1177/0898010106295172. how to cite this article: kumpeera, k., daengthern, l., thojampa, a., and udkhammaee, k. (2023) ‘how to live longer: lived experience of older adults in thailand’, jurnal ners, 18(2), pp. 192-199. doi: http://dx.doi.org/10.20473/jn.v18i2.46310 vol 8 no 2 oktober 2013.indd 317 intervensi (stimulasi memori) meningkatkan fungsi kognitif lansia (memory stimulation) intervention increase elderly cognitive function kushariyadi* darungan, kec. tanggul, kab. jember, kode pos 68155 jawa timur email: kushariadi@gmail.com blog: kushariadi.blogspot.com abstrak pendahuluan: lansia secara fi siologis mengalami penurunan reversible pada fungsi kognitif (memori) disebabkan proses penuaan dan perubahan degeneratif progresif. stimulasi memori tidak dikembangkan untuk remaja dan dewasa, namun penggunaan terhadap peningkatan memori lansia perlu penjelasan. penelitian ini bertujuan meningkatkan memori lansia dengan promosi perawatan daya ingat. metodologi: jenis penelitian ini eksperimen semu dengan two group pre-post treatment design. besar sampel kelompok perlakuan dan kontrol 30 lansia, diambil dengan teknik simple random sampling. penelitian bertempat di panti werdha mojopahit mojokerto pada april 2013. instrumen menggunakan modul promosi perawatan daya ingat dan kuesioner fungsi kognitif. data yang terkumpul diuji dengan wilcoxon sign rank test (α < 0,05) dan mann whitney test (α < 0,05). hasil: hasil penelitian menunjukkan ada perbedaan tingkat kemampuan orientasi ( p < 0,003), tidak ada perbedaan tingkat kemampuan registrasi (p < 1,000), ada perbedaan tingkat kemampuan perhatian dan kalkulasi (p < 0,039), ada perbedaan tingkat kemampuan mengingat kembali ( p < 0,046), ada perbedaan tingkat kemampuan bahasa (ρ < 0,035), ada perbedaan fungsi kognitif (memori) ( p < 0,001), ada perbedaan fungsi kognitif (memori) kelompok perlakuan dan kontrol ( p < 0,002). diskusi: promosi perawatan daya ingat menggunakan teori hubungan terapeutik perawat-pasien dan teori konsekuensi fungsional secara signifi kan meningkatkan memori lansia. penggunaan promosi perawatan daya ingat pada lansia memerlukan kerja sama dan partisipasi aktif semua pihak. kata kunci: stimulasi memori, fungsi kognitif, lansia abstract introduction: physiologically elderly experience irreversible decline in cognitive function due to the aging process and progressive degenerative changes. memory care promotion can be used in adolescents and adults, however, its use in elderly still need explanation. the research was aimed to improve the memory of elderly using memory care promotion. method: type of research was quasy-experimental, two group pre-post treatment design. sample size were 30 respondents. taken using simple random sampling technique. the research took place in nursing homes mojopahit mojokerto in april 2013. the instruments used were memory care promotion module and cognitive function questionairre. wilcoxon signed rank test and mann whitney test were used to analyze the data with a signifi cance level of α < 0.05. result: the result showed there were differences in orientation levels (p < 0.003), no difference in registration levels (p < 1.000), differences in attention and calculation levels (p < 0.039), differences in recall levels (p < 0.046), differences in language levels (p < 0.035), differences in the cognitive function (p < 0.001), and differences in the cognitive function between treatment group and the control group (p < 0.002). discussion: memory care promotion using the theory of therapeutic nurse-patient relationship and functional consequences theory can signifi cantly improve elderly memory. the use of memory care promotion needs the cooperation and active participation of all parties. keywords: memory care promotion, cognitive function (memory), elderly pendahuluan lanjut usia secara fisiologis terjadi penurunan fungsi kognitif (memori) yang bersifat ireversibel. kondisi ini disebabkan oleh proses penuaan dan perubahan degeneratif yang mungkin progresif (gething et al., 2004; lovell, 2006). promosi perawatan daya ingat (stimulasi memori) dapat digunakan pada remaja dan dewasa (calero & navarro, 2007; miller, 2009). namun promosi perawatan daya ingat (stimulasi memori) terhadap peningkatan fungsi kognitif (memori) lansia masih perlu penjelasan. permasalahan mengenai perubahan terkait usia pada proses penuaan yang dapat menurunkan fungsi kognitif (memori) pada lansia perlu diprioritaskan, karena pada lansia yang semakin bertambah usianya diharapkan fungsi daya ingatnya dapat terpelihara dengan baik sehingga fungsi dan kualitas hidup lansia sebagai individu kompleks, unik dapat berfungsi dan sejahtera. 318 jurnal ners vol. 8 no. 2 oktober 2013: 317–329 di a mer i ka i nsiden pad a la nsia yang mengalami penurunan fungsi kognitif (memori) berjumlah 47 lansia berusia 50–67 tahun (lesch, 2003). di italia insiden lansia yang mengalami penurunan memori terdapat 20 lansia berusia 60–70 tahun (cavallini et al., 2003). di netherlands insiden pada lansia yang mengalami penurunan memori berjumlah 93 lansia dengan usia 65 tahun (ekkers et al., 2011). di norwaygia insiden pada lansia yang mengalami penurunan memori terdapat 27% dengan diagnosis gangguan memori subjektif dan sebanyak 19 lansia berusia rerata 60,9 tahun (braekhus et al., 2011). di hongkong insiden pada lansia yang mengalami penurunan memori berjumlah 20 lansia berusia 80 tahun (lim, et al., 2012). namun saat ini masih belum ada penelitian mengenai peningkatan daya ingat pada lansia. data bulan maret 2013 di panti werdha mojopahit mojokerto berjumlah 43 lansia terdiri dari 9 lansia laki-laki dan 34 lansia perempuan dengan usia antara 58–91 tahun. penurunan fungsi kognitif (memori) lansia jika tidak dilakukan tindakan akan berakibat terjadi penurunan ingatan pada lansia (abraham & shanley, 1997; miller, 2009). hal ini sesuai dengan teori kemunduran yang menyatakan dengan bertambahnya usia, daya ingat akan mengalami penurunan. perubahan neuron dan sinaps otak sebagai pembentukan ingatan juga mengalami penurunan seiring bertambahnya usia (solso et al., 2008; wade & travis, 2008). akibat lainnya yaitu informasi yang tidak cepat dipindahkan ke ingatan jangka pendek akan menghilang (hartley, 2006; solso et al., 2008; wade & travis, 2008). beberapa penelitian terhadap peningkatan memori lansia misalnya penelitian cavallini et al (2003) bertujuan mencari keefektifan antara strategi mnemonic dengan strategi pelatihan pada usia muda dan lansia dan mengevalusi kemampuan lansia unt uk meningkatkan kinerja. penelitian calero dan navarro (2007) bertujuan menganalisa adanya plastisitas pada lansia berisiko terjadi kerusakan kognitif dan mengeksplorasi hubungan plastisitas kognitif dan hasil yang diperoleh dari program pelatihan memori. penelitian ekkers et al (2011) bertujuan mengkaji keefektifan intervensi perilaku kognitif untuk menangani depresi dan ruminasi lansia. penelitian lesch (2003) bertujuan menilai keefektifan beberapa kondisi pelatihan yang berbeda untuk meningkatkan pemahaman dan memori lansia. penelitian engvig et al (2010) bertujuan memeriksa efek jangka pendek dari program pelatihan memori intensif pada kognisi dan struktur otak pada paruh baya dan lansia. penelitian lim et al (2012) ber t ujuan member i kan prog ram stimulasi perhatian dan ingatan, strategi dasar gabungan dan imajinasi. penelitian engvig et al (2012) bertujuan mengetahui volume dan efek hipocampus terkait perubahan kinerja memori saat mengikuti pelatihan. penelitian carretti et al (2011) bertujuan mengevaluasi kontribusi metakognitif dan motivasi terhadap keefektifan strategi pelatihan memori lansia. penelitian bottiroli et al (2008) bertujuan mengukur efektifi tas jangka panjang dari dua strategi mnemonic dengan tehnik lokus dan pelatihan strategis. penelitian mcdaniel dan bugg (2012) bertujuan meningkatkan manfaat pelatihan memori menggunakan salah satu pendekatan seperti strategi pengambilan pelatihan, strategi memori prospektif, dan strategi untuk belajar dan mengingat nama. permasalahan yang ingin diangkat peneliti dalam penelitian ini bertujuan menganalisis perbedaan fungsi kognitif (memori) lansia sebelum dan sesudah dilakukan promosi perawatan daya ingat (stimulasi memori). solusi untuk meningkatkan fungsi kognitif (memori) lansia dengan memberikan intervensi keperawatan untuk mencapai hasil kesehatan dan peningkatan kualitas hidup lansia misalnya promosi perawatan daya ingat (stimulasi memori) dengan mengaplikasikan gabungan model teori hubungan terapeutik per awat-pa sien d a n teor i konsek uensi fungsional. perawat meningkatkan kesehatan lansia dengan member i harapan u nt u k dilibatkan dalam aktivitas yang membantu perkembangan kebugaran kognitif. manfaat t e h n i k p e n i n g k a t a n f u n g s i ko g n i t i f (memori) terhadap lansia secara signifi kan mempengaruhi hasil terhadap kesehatan dan status mental (hoyer & verhaeghen, 2006; miller, 2009; peplau, 1992). 319 promosi perawatan daya ingat (stimulasi memori) (kushariyadi) bahan dan metode jenis penelitian quasy exsperiment menggunakan two group pre-post treatment design bertujuan membandingkan kelompok perlakuan yang diberi intervensi dengan kelompok kontrol yang tidak diberi intervensi. sampel lansia di panti werdha mojopahit mojokerto pada maret 2013 sebanyak 30 responden dengan kriteria inklusi: 1) usia 6080 tahun; 2) dapat dilakukan pengukuran status fungsi kognitif (memori); 3) memiliki tingkat status fungsi kognitif (memori) ringan sampai sedang; 4) bisa berkomunikasi dengan lancar; 5) bersedia menjadi responden. tehnik pengambilan sampel menggunakan simple random sampling. sampel kemudian dibagi menjadi kelompok perlakuan dan kelompok kontrol berdasarkan matching usia. instrumen untuk promosi perawatan daya ingat (stimulasi memori) menggunakan modul promosi perawatan daya ingat (stimulasi memori) diadaptasi dari fogler & stern (1994). modul dikembangkan dan dimodifi kasi ke dalam 3 fase hubungan interpersonal perawatpasien (orientasi, kerja, resolusi) memiliki 16 item panduan yang diklasifi kasikan menjadi 3 tahapan daya ingat (ingatan sensori, ingatan jangka pendek atau primer, ingatan jangka panjang atau sekunder). instrumen fungsi kognitif menggunakan diadaptasi dan dimodifi kasi dari folstein, et al. (1975). instrumen tersebut memiliki 11 item pertanyaan atau perintah mengenai: orientasi, registrasi, perhatian, kalkulasi, mengingat kembali dan bahasa. total skor dikategorikan menjadi gangguan kognitif ringan (nilai 21–30), gangguan kognitif sedang (nilai 11–20), gangguan kognitif berat (nilai < 10). pada pelaksanaannya responden dibagi menjadi kelompok perlakuan dan kontrol masing-masing sebanyak 15 lansia. masingmasing kelompok diberikan pre-test fungsi kognitif hari ke-1. kelompok perlakuan diberi intervensi keperawatan promosi perawatan daya ingat 2 kali seminggu selama 2 minggu sekitar 15 menit, sedangkan kelompok kontrol tidak diberi intervensi. teknik promosi perawatan daya ingat meliputi: fase orientasi (salam terapeutik, e v a l u a s i p e r t e m u a n , ko n t r a k t o p i k , waktu, tempat), fase kerja: ingatan sensori (menggunakan isyarat indera penglihatan, mengamati dengan aktif, mengenali nama benda yang dilihat), ingatan jangka pendek (menentukan waktu dan tempat, menghitung angka, menggambar, mengikuti perintah, menggabung huruf, mengatur kata yang cocok, menggabung kalimat dan mengulangginya, menggabung nama dan kata), ingatan jangka panjang (bercerita dan menginggatnya), fase resolusi (evaluasi, tindak lanjut, kontrak akan datang mengenai topik, waktu, tempat). melak ukan post-test kognitif hari terakhir minggu ke-2 menggunakan pada kedua kelompok. hasil pre-test dan post-test dicatat dan disimpan untuk diolah dan dianalisis. kelompok kontrol akan diberi perlakuan yang sama yaitu intervensi keperawatan promosi perawatan daya ingat setelah penelitian selesai untuk memenuhi aspek justice. analisis data menggunakan wilcoxon siqned rank test dan mann whitney test dengan tingkat kemaknaan α < 0,05. hasil sebagian besar usia responden kelompok perlakuan 60–65 tahun, 71–75 tahun, 76–80 tahun, sedangkan kelompok kontrol berusia 76–80 tahun. pada jenis kelamin menunjukkan sebagian besar responden kelompok perlakuan maupun kelompok kontrol adalah perempuan. pada pendidikan terak hir menunjuk kan sebagian besar responden kelompok perlakuan maupun kelompok kontrol adalah tidak tamat sekolah dasar. pada agama menunjukkan sebagian besar responden kelompok perlakuan maupun kelompok kontrol beragama islam. berdasarkan tabel 1 dapat diketahui bahwa ada perbedaan tingkat kemampuan orientasi lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori) dengan p = 0,003. namun, nilai signifi kansi kelompok kontrol p = 0,377 maka tidak ada perbedaan tingkat kemampuan orientasi lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). pada tingkat kemampuan registrasi kelompok perlakuan dan kontrol didapatkan 320 jurnal ners vol. 8 no. 2 oktober 2013: 317–329 tabel 1. perbedaan tingkat kemampuan kelompok perlakuan dan kontrol di panti werdha mojopahit, mojokerto no tingkat kemampuan perlakuan kontrol pretest postest pretest postest 1 orientasi median (min-max) 5 (3–8) 7 (2–9) 3 (0–8) 4 (0–8) mean ± sd 5,13 ± 1,76 6,33 ± 2,19 3,60 ± 2,29 3,86 ± 2,16 wilcoxon p = 0,003 p = 0,377 2 registrasi median (min-max) 3 (3–3) 3 (3–3) 3 (3–3) 3 (3–3) mean ± sd 3,00 ± 0,00 3,00 ± 0,00 3,00 ± 0,00 3,00 ± 0,00 wilcoxon p = 1,000 p = 1,000 3 perhatian dan kalkulasi median (min-max) 5 (0–5) 5 (0–5) 5 (0–5) 5 (0–5) mean ± sd 3,93 ± 1,66 4,46 ± 1,45 3,93 ± 1,66 3,66 ± 2,02 wilcoxon p = 0,039 p = 0,102 4 mengingat kembali median (min-max) 3 (2–3) 3 (3–3) 3 (1–3) 3 (2–3) mean ± sd 2,73 ± 0,45 3,00 ± 0,00 2,66 ± 0,61 2,73 ± 0,45 wilcoxon p = 0,046 p = 0,317 5 bahasa median (min-max) 8 (7–9) 8 (7–9) 8 (4–9) 8 (5–9) mean ± sd 7,73 ± 0,59 8,20 ± 0,77 7,46 ± 1,24 7,53 ± 0,99 wilcoxon p = 0,035 p = 0,564 tabel 2. perbedaan status fungsi kognitif (memori) kelompok perlakuan dan kontrol di panti werdha mojopahit, mojokerto, 2013 fungsi kognitif (memori) perlakuan kontrol sebelum median (min-max) mean ± sd 23 (16–27) 22,53 ± 3,31 21 (14–27) 20,66 ± 4,02 sesudah median (min-max) mean ± sd 26 (18–29) 25,00 ± 3,38 22 (16–27) 20,80 ± 3,76 wilcoxon p = 0,001 p = 0,642 mann whitney p = 0,002 nilai signifikan p = 1,000 maka tidak ada perbedaan tingkat kemampuan registrasi lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). hasil uji wilcoxon signed rank test kelompok perlakuan didapatkan nilai signifikan p = 0,039 maka ada perbedaan tingkat kemampuan perhatian dan kalkulasi lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). kelompok kontrol didapatkan nilai signifi kan p = 0,102 maka tidak ada perbedaan tingkat kemampuan perhatian dan kalkulasi lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). perbedaan tingkat kemampuan mengingat kembali lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori) terjadi pada kelompok perlakuan ( p = 0,046), sedangkan pada kelompok kontrol (p= 0,317) yang berarti tidak ada perbedaan tingkat kemampuan mengingat kembali. tingkat kemampuan bahasa pada lansia dalam kelompok perlakuan mengalami peningkatan setelah diberikan intervensi promosi perawatan daya ingat ( p = 0,035) dan tidak ada perbedaan tingkat kemampuan bahasa lansia pada kelompok kontrol ( p = 0,564). hasil uji wilcoxon signed rank test kelompok perlakuan didapatkan nilai signifi kan p = 0,001 maka ada perbedaan status fungsi kognitif (memori) lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi 321 promosi perawatan daya ingat (stimulasi memori) (kushariyadi) memori). kelompok kont rol didapatkan nilai signifikan p = 0,642 maka tidak ada perbedaan status fungsi kognitif (memori) lansia yang bermakna antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). hasil uji mann whitney antara post kelompok perlakuan dan post kelompok kontrol menunjukkan p = 0,002 maka ada perbedaan status fungsi kognitif (memori) lansia antara kelompok perlakuan dan kontrol. pembahasan terdapat perbedaan signifikan pada tingkat kemampuan orientasi lansia antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). perbedaan tampak pada hasil nilai rerata t i ng kat kema mpu a n or ient asi sebelu m diberikan perlakuan sebesar 5,13 dengan simpangan baku ±1,76. perbedaan juga terlihat saat lansia kurang bisa menjawab pertanyaan mengenai tanggal, bulan, tahun, kelurahan, dan kecamatan. namun, sesudah diberikan perlakuan nilai rerata tingkat kemampuan orientasi meningkat menjadi 6,33 dengan simpangan baku ±2,19. perbedaan juga terlihat saat lansia sebagian besar dapat menjawab pertanyaan mengenai jam, hari, tahun, alamat, kecamatan, kabupaten, dan propinsi. terdapat peningkatan selisih nilai rerata antara data pre-test dan post-test pada kelompok perlakuan sebesar 1,20 dan pada kelompok kontrol selisih nilai rerata antara data pre-test dan post-test juga meningkat sebesar 0,26. secara keseluruhan berarti pemberian promosi perawatan daya ingat (stimulasi memor i) ber pengar u h terhadap tingkat ke m a mpu a n or ie nt a si la n sia . hal i n i d isebabka n k a rena kema mpu a n la nsia menerima pembelajaran promosi perawatan daya ingat dan melatihnya di dalam aktivitas kegiatan hidup harian seperti menentukan waktu ( jam, hari, tanggal, bulan, tahun) dan menentukan tempat (alamat, desa atau kelurahan, kecamatan, kabupaten atau kota, propinsi). penelitian calero dan navarro (2007) menunjukkan pemberian pelatihan berfokus pada kemampuan strategi dalam memori verbal seperti orientasi, efektif terhadap lansia. penelitian cavallini et.al, (2003) menyebutkan lansia menunjukkan kemampuan strategi meningkatkan memori verbal seperti orientasi terkait tempat, waktu dan orang. lansia memungkinkan untuk menempatkan kemampuan strateginya ke dalam aktivitas kegiatan hidup harian. orientasi ter masuk dalam memori jangka pendek atau primer. memori jangka pendek mencakup memori verbal dengan menilai memor i bar u tentang or ientasi dan menilai kemampuan strategi individu mempelajar i hal bar u. or ientasi lansia terhadap orang, waktu dan tempat merupakan informasi sangat penting. proses pertukaran informasi mengenai orang, waktu dan tempat dalam aktivitas kegiatan hidup harian secara verbal terlihat melalui penggunaan kata yang digunakan individu untuk berbicara (lumbantobing, 2012; videbeck, 2008). data dalam ingatan primer tidak lagi berupa kesan sensori harfi ah, bentuk akuistik, visual, fi tur sensorik, tetapi berubah bentuk menjadi penyandian yang diidentifi kasi dan dinamai seperti bentuk kata, lalu dimasukkan ke ingatan sekunder. jika data tersebut tidak dimasukkan maka akan menghilang (solso et al., 2008; wade & travis, 2008). hal ini sesuai ingatan primer atau ingatan kerja merupakan ingatan baru atau komponen ingatan berfokus pada daya individu mengingat, menyimpan, secara aktif memikirkan, mengelola sejumlah informasi atau materi atau peristiwa harian yang baru terjadi dan terbatas serta mengambil materi setelah beberapa menit sampai hari (bah r udin, 2011; lu mbantobing, 2012; ormrod, 2009). kemampuan strategi peningkatan fungsi kognitif (memori) lansia di panti mojopahit mojokerto terhadap orientasi tempat, waktu dan orang melalui proses pembelajaran dengan promosi perawatan daya ingat dan diterapkan di dalam aktivitas kegiatan hidup harian. pembelajaran orientasi meliputi menentukan waktu ( jam, hari, tanggal, bulan, tahun) 322 jurnal ners vol. 8 no. 2 oktober 2013: 317–329 dan menentukan tempat (alamat, desa atau kelurahan, kecamatan, kabupaten atau kota, propinsi). tidak terdapat perbedaan signifikan pada tingkat kemampuan registrasi lansia antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). tampak pada hasil nilai rerata tingkat kemampuan registrasi sebelum dan sesudah diberikan perlakuan adalah sama tinggi yaitu 3,00 dengan simpangan baku ± 0,00. terlihat juga saat lansia dapat menjawab pertanyaan mengenai mengulangi 3 nama benda yaitu buku, pensil, dan penghapus. tidak terdapat selisih nilai rerata antara data pre-test dan post-test pada kelompok perlakuan dan kelompok kontrol. hal ini berarti pemberian promosi perawatan daya ingat (stimulasi memori) tidak berpengaruh terhadap tingkat kemampuan registrasi lansia. hal ini disebabkan karena pengetahuan umum lansia terhadap nama benda atau kata. lansia terus-menerus melatih mengulang informasi seperti bentuk verbal misalnya nama benda secara sengaja dan sadar mengingat objek. s e s u a i p e n g e t a h u a n d e k l a r a t i f merupakan pengetahuan terkait karakteristik sesuatu pada saat ini, sebelumnya, dan setelahnya, yang mencakup pengetahuan dunia secara umum dan ingatan tentang pengalaman hidup spesif ik. pengetahuan deklaratif melibatkan pengetahuan bahwa sesuatu adalah benar. sebagian besar pengetahuan deklaratif adalah pengetahuan eksplisit yaitu pengetahuan disadari dan dijelaskan secara verbal (ormrod, 2009; wade & travis, 2008). i n d iv id u m e n g u l a n g i i n fo r m a si (registrasi) yang telah disampaikan tanpa dibantu objek untuk diingat melalui cara eksplisit yaitu secara sengaja, sadar mengingat objek. individu berlatih secara efektif, kreatif dan konst r uktif akan lebih baik dalam kemampuan registrasi misalnya menyebut nama benda yang dipelajari (ginsberg, 2008; walgito, 2004). memori eksplisit merupakan registrasi atau pengulangan kembali informasi (peristiwa atau objek) secara sadar melalui: 1) recall yaitu mengulangi kembali, mereproduksi informasi yang tersimpan di memori; 2) recognition yaitu mengenali informasi yang diobservasi, dibaca dan didengar sebelumnya. misalnya membandingkan informasi yang disajikan secara verbal dengan informasi yang tersimpan di memori lansia. informasi yang disimpan di memori dikode dalam berbagai bentuk seperti bentuk verbal misalnya dalam bentuk nama atau kata aktual yang semuanya dikode secara verbal maupun secara pembayangan (imagery) (lumbantobing, 2012; ormrod, 2009; wade & travis, 2008). pengulangan (rehearsal) atau registrasi merupakan proses kognitif dimana informasi diulang terus-menerus secara mental atau verbal dengan cukup cepat sebagai cara mempelajari dan mengingat. pengulangan p e m a nt ap a n (m a i n te n a n c e re h e a r sa l ) merupakan pengulangan secara cepat sejumlah kecil informasi agar tetap berada di memori kerja. menyimpan informasi di memori kerja selama individu bersedia terus berbicara pada diri sendiri dapat membantu mempertahankan informasi di memori kerja sampai waktu yang tak terbatas. jika individu sering mengulang fakta pada diri sendiri, akhirnya fakta dapat tersimpan (ormrod, 2009; wade & travis, 2008). sesuai dengan komunikasi terapeutik mer upakan tehnik komunikasi berfokus pada individu, perawat dan proses interaktif menghasilkan hubungan perawat-pasien, merupakan faktor pendukung lansia dalam p e ng u la nga n at au r eg ist r a si mel iput i mendengarkan secara aktif yaitu proses aktif menerima informasi dan mengkaji reaksi individu terhadap pesan yang diterima (parker & smith, 2010; smeltzer, 2001). lansia di panti werdha mojopahit mojokerto diharapkan secara teratur, efektif, kreatif dan terus-menerus melatih kemampuan registrasi atau mengulang informasi yang didapat, agar lansia menjadi tetap produktif. hal ini sesuai tujuan komunikasi terapeutik antara lain memotivasi dan mengembangkan pribadi pasien ke arah konst r uktif dan adaptif. terdapat perbedaan signifi kan (p = 0,039) tingkat kemampuan perhatian dan kalkulasi lansia antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi 323 promosi perawatan daya ingat (stimulasi memori) (kushariyadi) memori). perbedaan tampak pada hasil nilai rerata tingkat kemampuan perhatian dan kalkulasi sebelum diberikan perlakuan sebesar 3,93 dengan simpangan baku ±1,66. perbedaan juga terlihat saat lansia kurang bisa menjawab pertanyaan mengenai pengurangan angka 500–100. namun sesudah diberikan perlakuan nilai rerata tingkat kemampuan perhatian dan kalkulasi meningkat menjadi 4,46 dengan simpangan baku ± 1,45. perbedaan juga terlihat saat lansia sebagian besar dapat menjawab pertanyaan mengenai pengurangan angka 500–100, 400–100, 300–100, 200–100, dan 100–100. terdapat peningkatan selisih nilai rerata antara data pre-test dan posttest pada kelompok perlakuan sebesar 0,53 sedangkan pada kelompok kontrol selisih nilai rerata antara data pre-test dan post-test menurun sebesar 0,27. secara keseluruhan berarti pemberian promosi perawatan daya ingat (stimulasi memori) berpengaruh terhadap tingkat kemampuan perhatian dan kalkulasi lansia. hal ini disebabkan karena lansia memperhatikan secara seksama saat menerima stimulus dari luar berupa pertanyaan yang diajukan perawat, sehingga strategi yang digunakan lebih efektif untuk menjawab pertanyaan tersebut. penelitian calero dan navarro (2007) menunjukkan pelatihan memori terhadap perhatian dan kalkulasi pada lansia dipengaruhi kecepat an pem rosesan dan keefek tifan strategi untuk meningkatkan lansia dalam belajar mengingat angka, urutan angka, dan menghitung mundur. kecepatan pemrosesan dapat mengkompensasi defi sit akibat pengaruh usia, pendidikan dan kemampuan verbal. kemampuan seperti menyelesaikan masalah, proses ber pikir, perhatian dan kalkulasi termasuk fungsi berpikir yang lebih tinggi. kemampuan pembelajaran, kecepatan pemrosesan dan keefektifan strategi seseorang menjadi selektif karena motivasi, pemahaman, dan pengenalan terhadap isi materi. seseorang menggunakan pendekatan tertentu (strategi) untuk mengingat sesuatu dan belajar dalam hal perhatian dan kalkulasi (maas et al., 2011; ormrod, 2009). atensi (perhatian) yaitu memfokuskan kecepatan pemrosesan mental pada stimuli tertentu. sesuatu yang diperhatikan individu secara mental dipindahkan ke memori kerja. memberikan perhatian berarti mengarahkan pikiran pada sesuatu yang perlu dipelajari dan diingat, misalnya mengingat angka dan menghitung mundur. pada pemrosesan i n for ma si, memor i mel ibat k a n proses penyandian, penyimpanan, dan pemanggilan kembali (ormrod, 2009; wade & travis, 2008). terdapat perbedaan signifi kan (p = 0,046) tingkat kemampuan mengingat kembali lansia antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). perbedaan tampak pada hasil nilai rerata tingkat kemampuan mengingat kembali sebelu m d iber i ka n perla k u a n sebesar 2,73 dengan simpangan baku ±0,45. perbedaan juga terlihat saat lansia kurang bisa menjawab pertanyaan mengenai mengulang nama penghapus. namun sesudah diberikan perlakuan nilai rerata tingkat kemampuan mengingat kembali meningkat menjadi 3,00 dengan simpangan baku ±0,00. perbedaan juga terlihat saat lansia sebagian besar dapat menjawab pertanyaan mengenai mengulang nama buku, pensil, dan penghapus. terdapat peningkatan selisih nilai rerata antara data pretest dan post-test pada kelompok perlakuan sebesar 0,27 sedangkan pada kelompok kontrol selisih nilai rerata antara data pre-test dan post-test juga meningkat sebesar 0,07. secara keseluruhan berarti pemberian promosi perawatan daya ingat (stimulasi memori) berpengaruh terhadap tingkat kemampuan mengingat kembali lansia. hal ini disebabkan k a re n a la n sia me ng u a sai ke m a mpu a n mengenal nama benda dan menjadi suatu kebiasaan dalam hidup keseharian sehingga memudahkan lansia untuk mengingatnya kembali secara spontan. sesuai dengan memori atau pengetahuan prosedural merupakan memori mengenai cara melaksanakan tindakan atau keterampilan. memor i prosedu ral mer upakan memor i implisit, karena begitu suatu kemampuan atau kebiasaan dikuasai oleh seseorang, kemampuan atau kebiasaan tersebut tidak lagi memerlukan pemrosesan secara sadar. individu belajar bagaimana melakukan banyak hal. individu 324 jurnal ners vol. 8 no. 2 oktober 2013: 317–329 dapat melakukan hal tersebut dengan baik, dengan cara mengadaptasi perilakunya sendiri dengan kondisi yang berubah. pengetahuan prosedural mencakup informasi bagaimana memberikan respons di sit uasi berbeda (ormrod, 2009; wade & travis, 2008). pemanggilan atau mengingat kembali (retrieval ) mer upakan proses mengingat kembali infor masi yang telah disimpan sebelumnya di memori. individu mengingat kembali informasi dengan cara implisit yaitu secara otomatis tidak disadari perkataan m el u n c u r t e r u c a p, b e r k a it a n d e n g a n keterampilan. individu berlatih secara efektif, kreatif dan konstruktif akan lebih baik dalam kemampuan mengingat kembali informasi (kumpulan kata dan nama) yang dipelajari sehingga saat berbicara perkataan tersebut keluar secara otomatis (ginsberg, 2008; ormrod, 2009; walgito, 2004). pembelajaran implisit merupakan proses pembelajaran terjadi saat individu memperoleh pengetahuan atau perilaku mengenai sesuatu, namun tidak menyadari cara memperoleh dan tidak mampu menjelaskan dengan baik bagaimana mempelajari pengetahuan tersebut (ormrod, 2009; wade & travis, 2008). memori implisit atau pengetahuan implisit merupakan informasi pengetahuan masa lalu mempengaruhi pikiran dan tindakan sekalipun tidak ber usaha mengingatnya seca r a sa d a r. m isal nya mengg u na k a n pancingan ( priming), individu dimint a mendengarkan lalu menguji apakah informasi tersebut mempengar uhi kinerja individu (lumbantobing, 2012; ormrod, 2009; wade & travis, 2008). fa k t o r p e n d u k u n g l a i n y a i t u lingkungan yang menstimulasi dan kesehatan kardiovaskular berefek positif pada aspek fungsi kognitif (memori) lansia dalam registrasi dan mengingat kembali. demontrasi efektif, kreatif dan konstruktif lansia menunjukkan bahwa kreativitas, produktivitas pada semua tingkatan usia berdampak positif pada kemampuan registrasi dan mengingat kembali. kiner ja efektif dan k reatif dibut uh kan integritas seluruh sistem memori meliputi pengenalan, retensi, penyimpanan informasi, registrasi dan mengingat kembali informasi yang disimpan (lumbantobing, 2012; smeltzer, 2001). hal i n i terk ait f u ngsi ek sek ut if yang lebih tinggi meliputi kemampuan merencanakan, beradaptasi, menyelesaikan masalah, digabung dengan aspek perilaku sosial dan kepribadian misalnya inisiatif, kreatif, konstruktif, produktif, motivasi dan inhibisi (ginsberg, 2008). sesuai model peplau yang bersifat psikodinamis bahwa keperawatan sebagai proses interpersonal terapeutik bertujuan mengembangkan personal ke arah pribadi dan kehidupan sosial yang kreatif, konstruktif dan produktif. interaksi nonverbal sebagai sebuah faktor, model utama komunikasi terapeutik sebagai interaksi verbal (basford & slevin, 2006; potter & perry, 2009). lansia dikonsepkan sebagai individu dinamis yang mempengaruhi dan dipengaruhi lingk ungan ser ta orang lain, mendapat dukungan sumber daya dan faktor lingkungan. lansia yang tidak bergantung pada orang lain memiliki hubungan interpersonal yang mempengar uhi kesehatan kebut uhan nya (basford & slevin, 2006; miller, 2009). keperawatan adalah proses terapeutik dan interpersonal berpartisipasi membentuk si s t e m a s u h a n ke s e h a t a n m e mb a n t u individu mengembangkan interaksi perawatpasien. keperawatan sebagai proses terapi interpersonal merupakan alat pendidikan, kekuatan dalam berkembang meningkatkan kepribadian kreatif, konstruktif, produktif, personal dan komunitas (alligood & tomey, 2006; videbeck, 2011). hal ini sesuai t ujuan komunikasi t e r a p e u t i k y a i t u m e m o t i v a s i d a n mengembangkan pribadi pasien kearah kreatif, konstruktif, produktif dan adaptif. perawat juga mempromosikan dan meningkatkan pengalaman individu mencapai keadaan sehat yaitu kehidupan kreatif, konstruktif dan produktif. perawat memberikan dukungan kesehatan dan bimbingan pada masalah pasien sehingga pemecahan masalah mudah dilakukan (basford & slevin, 2006; videbeck, 2011). tehnik komunikasi terapeutik berfokus pada individu, perawat dan proses interaktif 325 promosi perawatan daya ingat (stimulasi memori) (kushariyadi) menghasilkan hubungan perawat-pasien, merupakan faktor pendukung lansia dalam mengingat kembali informasi dengan cara meng u ng kapka n kembali yait u pa sien meng ulang apa yang diyak ini perawat mengenai pendapat yang diungkapkan (parker & smith, 2010; smeltzer, 2001). faktor pendukung lain yang membuat lansia mampu dalam hal tingkat kemampuan registrasi dan mengingat kembali yait u lansia mengikuti kegiatan secara aktif yang diadakan panti mojopahit mojokerto meliputi senam pagi, bimbingan agama, pemeriksaan kesehatan berkala, berkebun, lomba, dan pendampingan. terdapat perbedaan signifi kan tingkat kemampuan bahasa lansia antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). perbedaan tampak pada hasil nilai rerata tingkat kemampuan bahasa sebelu m diber i kan perlakuan sebesar 7,73 dengan simpangan baku ±0,59. perbedaan juga terlihat saat lansia kurang bisa menjawab pertanyaan mengenai bercerita kegiatan sehari-hari secara berurutan. namun sesudah diberikan perlakuan nilai rerata tingkat kemampuan bahasa meningkat menjadi 8,20 dengan simpangan baku ±0,77. perbedaan juga terlihat saat lansia sebagian besar dapat menjawab pertanyaan mengenai memperlihatkan dan menamai kunci dan uang, mengulangi kata “tak ada jika, dan, atau tetapi”, mengikuti perintah tiga langkah “angkat telapak tangan”, “lalu jari menggenggam”, “lalu membuka”, mengikuti perintah tarik napas lewat hidung dan keluarkan lewat mulut”, dan menyalin gambar kotak. terdapat peningkatan selisih nilai rerata antara data pre-test dan posttest pada kelompok perlakuan sebesar 0,47 sedangkan pada kelompok kontrol selisih nilai rerata antara data pre-test dan post-test juga meningkat sebesar 0,07. secara keseluruhan berarti pemberian promosi perawatan daya ingat (stimulasi memori) berpengaruh terhadap tingkat kemampuan bahasa lansia. hal ini disebabkan karena lansia menggunakan bahasa dalam keseharian aktivitas kegiatan hidupnya, misalnya berkomunikasi, berpikir dan berperilaku. penelitian cavallini et.,al. (2003) menu nju k kan memor i ker ja meningkat saat lansia menyelesaikan tugas dari segi bahasa menggunakan kumpulan daftar kata, penamaan dan mengikuti perintah. hal ini dipengaruhi kemampuan lansia dalam mengevaluasi kembali tugas dari segi bahasa menggunakan strategi belajar terkait cara berpikir dan melakukan tindakan pada situasi berbeda misalnya dalam aktivitas kegiatan hidup harian. penelitian bot tirolli et.,al, (2008) menunjukkan pelatihan memori diberikan ke dalam aktivitas kegiatan hidup harian. strategi pelatihan yang dipelajari dalam aktivitas kegiatan hidup harian meningkatkan memori kerja lansia dan memelihara efek latihan jangka panjang. lansia menjalani pelatihan memori menunjukkan pengetahuan memori lebih besar dan sedikit keluhan. pe n el it i a n e ng v ig e t .a l , (2010) menunjukkan efek jangka panjang pelatihan memori terkait cara meningkatkan memori kerja ke dalam fungsi aktivitas kegiatan hidup harian yang berfungsi sebagai mekanisme dalam melindungi kerusakan fungsi kognitif (memori). penelitian menunjukkan pelatihan memori meningkatkan memori kerja. sesuai teor i hubu ngan terapeutik memandang bahasa mempengaruhi pemikiran, berpikir mempengaruhi tindakan, berpikir dan ber tindak mempengar uhi perasaan. sehingga bahasa adalah model utama dalam mempengaruhi pikiran dan perasaan (basford & slevin, 2006; potter & perry, 2009). meskipun lansia di panti mojopahit mojoker to memiliki riwayat pendidikan formal tidak tamat sekolah dasar, akan tetapi hal tersebut tidak menyurutkan lansia dalam melatih kemampuan strategi keterampilan b el aj a r y a i t u d e n g a n m e n i n g k a t k a n kemampuan strategi keterampilan pelatihan dan pembelajaran melalui pendidikan informal dengan cara melaksanakan aktifi tas kegiatan hidup harian terkait bahasa. h a si l n i l a i t i ng k at ke m a m pu a n bahasa menunjuk kan per ubahan berar ti terhadap peningkatan memori (maas et al., 2011). penelitian matthews et al (1999) memperlihatkan kelompok lansia banyak 326 jurnal ners vol. 8 no. 2 oktober 2013: 317–329 yang mempertahankan fungsi intelektualnya. pendidikan formal melindungi lansia dari penurunan fungsi kognitif (memori) terkait penuaan, walaupun pendidikan yang dijalani lansia berlangsung selama beberapa tahun sebelumnya. penelitian zhu et al (1998) menunjukkan pendidikan formal membantu pada fungsi kognitif (memori) lansia. selain itu lansia mampu memperbaiki penampilan intelektualnya melalui pendidikan informal dengan latihan dan pengalaman melakukan berbagai tugas dalam aktivitas kegiatan hidup harian. penelitian calero dan navarro (2007) menunjukkan tingkat pendidikan ( jumlah tahun di sekolah) dan kemampuan bahasa dapat memprediksi peningkatan daya ingat setelah pelatihan memori. penelitian lim et al (2012) dalam kriteria inklusi menggunakan responden lansia dengan tingkat pendidikan berkisar dari tidak sekolah sampai 4 tahun sekolah dasar. sebagaimana peran perawat pada hubungan terapeutik perawat-pasien sebagai pendidik (teacher) bahwa perawat berupaya membe r i k a n pe ny u lu ha n , pe nd id i k a n , pelatihan, bimbingan pada pasien atau keluarga mengatasi masalah kesehatan, dibimbing ke arah pertumbuhan dan perkembangan kepribadian. perawat membantu pasien belajar secara formal maupun informal. perawat membangk itkan minat pasien terhadap sesuatu yang harus diketahui pasien dan cara menghadapi informasi tersebut (alligood & tomey, 2006; basford & slevin, 2006; videbeck, 2011). hal ini sesuai kompetensi f u ngsi kognitif (memori) lansia yaitu kemampuan melakukan aktivitas kegiatan harian terusme ne r u s, me r upa k a n ha sil pe ne r apa n proses kognitif berulang di berbagai situasi. kecerdasan terkristalisasi digunakan jika strategi penyelesaian tugas yang dilakukan memerlu kan penget ahuan yang per nah dipelajari selama kehidupan lansia. kecerdasan cairan digunakan saat strategi penyelesaian tugas yang dilakukan tidak berhubungan denga n pengala ma n at au penget a hu a n sebelumnya (maas et al., 2011). bahasa dalam komunikasi terapeutik dig u nakan mengidentif i kasi objek dan konsep yang didisk usikan. ur utan dan makna terbentuk dengan menyusun perkataan menjadi frase dan kalimat yang dapat dipahami oleh pembicara dan pendengar. penggunaan bahasa di dalam hubungan terapeutik, perawat mendorong pasien bercerita mengenai kegiatan aktivitasnya. melalui cara ini, perawat memahami konteks kehidupan pasien dan dapat membantu permasalahannya (potter & perry, 2009; videbeck, 2011). terdapat perbedaan signifi kan status fungsi kognitif (memori) lansia antara sebelum dan sesudah pemberian promosi perawatan daya ingat (stimulasi memori). perbedaan tampak pada hasil nilai rerata status fungsi kognitif (memori) lansia sebelum diberikan perlakuan sebesar 22,53 dengan simpangan bak u ±3,31. namun sesudah diberikan perlakuan nilai rerata status fungsi kognitif (memori) lansia meningkat menjadi 25,00 dengan simpangan baku ±3,38. terdapat peningkatan selisih nilai rerata antara data pretest dan post-test pada kelompok perlakuan sebesar 2,47 dan pada kelompok kontrol selisih nilai rerata antara data pre-test dan post-test juga meningkat sebesar 0,14. hasil uji mann whitney menunjukkan terdapat perbedaan status fungsi kognitif (memori) lansia antara kelompok perlakuan dan kelompok kontrol ( p = 0,002). secara keselur uhan berar ti pemberian promosi perawatan daya ingat (stimulasi memori) berpengaruh terhadap status fungsi kognitif (memori) lansia. hal ini disebabkan karena lansia nampak aktif berpartisipasi mengikuti pelatihan promosi perawatan daya ingat. penelitian bot tirolli et al (2008) menunjukkan pengetahuan memori kerja lansia meningkat secara efektif di usia tua melalui peran aktif lansia mengikuti pelatihan memori. penelitian mengenai efek beberapa jenis pelatihan memori meningkatkan fungsi memori di usia tua dan mengurangi keluhan masalah memori. penelitian cavalli ni et al (2003) menyebutkan pelatihan memori terbukti lebih bermanfaat bagi semua kelompok usia 327 promosi perawatan daya ingat (stimulasi memori) (kushariyadi) termasuk lansia. efektivitas program pelatihan memori lansia dipengaruhi oleh hubungan inter personal dan keak tifan par tisipasi lansia yang secara signifi kan meningkatkan memori. penelitian calero dan navarro (2007) menunjukkan hubungan interpersonal yang beragam dan keaktifan dapat meningkatkan memori lansia. hal ini dibuktikan dengan subjek yang memiliki skor tinggi mini mental state exam menunjukkan peningkatan fungsi kognitif (memori) setelah pelatihan. pengembangan pelatihan memori sangat membantu memulihkan penuruan kemampuan fungsi kognitif (memori). pe n el it i a n e k ke r s e t a l (2011) membuktikan pelatihan memori pada lansia sangat membantu, dan penilaian menggunakan mini mental state exam yang mempunyai skor tinggi secara signifi kan mempengaruhi memori kerja lansia. ke m a m p u a n b el aja r, m e n e r i m a keterampilan dan infor masi bar u pada lansia dipengaruhi keaktifan berpartisipasi di pengalaman menerima informasi. proses kemampuan belajar lansia akan mudah bila perawat: 1) memberikan tehnik meningkatkan daya ingat untuk memperkuat mengingat data; 2) menggunakan intelegensi tiap saat; 3) menghubungkan informasi baru dengan yang sudah dikenal; 4) memaksimalkan penggunaan alat indera; 5) menggunakan penerangan yang tidak menyilaukan; 6) menyediakan suasana tenang dan nyaman; 7) menentukan sasaran jangka pendek dengan input dari kelompok pembelajaran; 8) mengatur periode mengajar singkat (smeltzer, 2001; miller, 2009). b e r d a s a k a n t e o r i pe pl a u y a it u teori kolaborasi hubungan perawat-pasien membent uk dorongan kek uatan melalui hubungan interpersonal yang efektif dalam membantu pemenuhan kebutuhan pasien. hubungan perawat-pasien adalah proses dinamis meliputi usaha kolaborasi perawatpasien mengatasi masalah, meningkatkan kesehatan dan kemampuan adaptasi (parker & smith, 2010; potter & perry, 2009) lansia dalam meningkatkan daya ingat. hal ini sesuai inti asuhan keperawatan yaitu hubungan pelayanan yang terbentuk a n t a r a p e r aw a tp a sie n m e n g g u n a k a n komunikasi terapeutik. perilaku merupakan komunikasi dan komunikasi mempengaruhi per ilak u, sehingga komu nikasi penting bag i hubu nga n i nter personal perawatpasien. perawat menggunakan komunikasi mengekspresikan kepedulian pada pasien dengan cara mendorong pengajaran dan pembelajaran interpersonal (potter & perry, 2009; videbeck, 2011). promosi perawatan daya ingat (stimulasi memori) merupakan tindakan keperawatan m e n i n g k a t k a n ke t e r a m p i l a n m e m o r i menggunakan proses interaksi interpersonal atau hubungan terapeutik perawat-pasien melalui fase orientasi, kerja dan resolusi, bertujuan: 1) meningkatkan keterampilan daya ingat lansia; 2) meningkatkan kesejahteraan lansia sehingga tercapai kesehatan optimal, fungsi dan kualitas hidup. selama tahapan fase tersebut pasien menyelesaikan tugas dan hubungan berubah, yang membantu proses penyembuhan (parker & smith, 2010; peplau, 1992). simpulan dan saran simpulan terdapat pengaruh promosi perawatan daya ingat (stimulasi memori) terhadap status fungsi kognitif (memori) lansia. terdapat perbedaan status fungsi kognitif (memori) lansia kelompok perlakuan dan kelompok kontrol setelah diberikan promosi perawatan daya ingat (stimulasi memori). saran p r o m o s i p e r aw a t a n d ay a i n g a t (stimulasi memori) dapat digunakan untuk meningkatkan f ungsi kognitif (memori) lansia di panti werdha mojopahit mojokerto. untuk meningkatkan fungsi kognitif (memori) lansia perlu kerjasama dan partisipasi aktif dari semua pihak panti werdha mojopahit mojokerto agar didapatkan hasil kesehatan lansia yang optimal. 328 jurnal ners vol. 8 no. 2 oktober 2013: 317–329 kepustakaan abraham, c & shanley, e 1997, psikologi sosial untuk perawat, jakarta: egc. alligood, mr & tomey, am 2006, nursing theorists and their work, 7th ed, mosby, st. louis missouri. bahrudin, m 2011, pemeriksaan klinis di bidang penyakit syaraf, umm pres, malang. umm press. bottiroli, s, cavallini, e & vecchi, t 2008, long-term effects of memory training in the elderly: a longitudinal study. archives of gerontology and geriatrics 47 (2008) 277–289. diakses 17 desember 2012, <http:www.sciencedirect.com>. braek hus, a, ulstein, i, wyller, tb & enge d a l, k 2011, t he me mor y clinic-outpatient assessment when dementia is suspected. tidsskr. nor. laegeforen. 131, 2254–2257. diakses 2 november 2012, <www.ncbi.nlm.nih.gov/ pubmed/22085955>. calero, md & navarro, e 2007, cognitive plasticity as a modulating variable on the effects of memory training in elderly persons. archives of clinical neuropsychology 22 (2007) 63–72. diakses 17 desember 2012, <http:www. sciencedirect.com>. carretti, b, borella, e, zavagnin, m & beni, rd 2011, impact of metacognition and motivation on the eff icacy of strategic memory training in older adults: analysis of specifi c, transfer and maintenance effects. archives of gerontology and geriatrics 52 (2011) 192–197. diakses 17 desember 2012, <http:www.sciencedirect.com>. cavallini, e, pagnin, a & vecchi, t 2003, aging and ever yday memor y: the benefi cial effect of memory training. arch. gerontol. geriatr. 37 (2003) 241257. diakses 17 desember 2012, <www. elsevier.com/locate/archger. http:www. sciencedirect.com>. ekkers, w, korrelboom, k, huijbrechts, i, smits, n, cuijpers, p & gaag, mvd 2011, competitive memory training for treating depression and rumination in depressed older adults: a randomized controlled trial. behavior research and therapy 49 (2011) 588–596. elsevier. diakses 17 desember 2012, <http:www. sciencedirect.com>. engvig, a, fjell, am, westlye, lt, moberget, t, sundseth, o, larsen, va & walhovd, kb 2010, effects of memory training on cortical thickness in the elderly. neuroimage 52 (2010) 1667–1676. diakses 17 desember 2012, <http:www. science direct.com>. engvig, a. fjell, am, westlye, lt, skaane, nv, sundseth, o & walhovd, k b 2012, hippocampal sub field volumes correlate with memory training benefi t in subjective memory impairment. ne u roim age 61 (2012) 188 –194. diakses 17 desember 2012, <http:www. sciencedirect.com>. erviyanti, ad 2007, peningkatan daya ingat dengan metode belajar hafalan system asosiasi: penelitian true eksperimen d alam bid a ng kesehat a n ment al sekolah di sdn keputran 3 surabaya. tesis. universitas airlangga. surabaya. diakses 28 januari 2013, <http://adln. com/. library@lib.unair.ac.id>. gething, l, fethney, j, mckee, k, persson, lo, goff, m & church-ward, m 2004, validation of the reactions to ageing questionnaire: assessing similarities a cross several countries. journal of gerontological nursing. 30 (9), 47–54. d ia k se s 5 nop e mb e r 2012 , <w w w. conceptwiki.org/.../concept:f2db3afe-7ebb11df-9387-001517>. ginsberg, l 2008, lecture notes: neurology, jakarta: penerbit erlangga. hartley, a 2006, changing role of the speed of processing construct in the cognitive psychology of human aging. in j.e. birren & k.w. schaie (eds.), handbook of the psychology of aging (6th ed., pp. 183-207). san diego: academic press. diakses 2 nopember 2012, <https://tspace. library.utoronto.ca/.../burton_christine_ m_201111_ph>. hoyer, wj & verhaeghen, p 2006, memory aging. in j.e. birren & k.w. scaie (eds). handsbook of the psycology of aging (6th ed., pp. 209–232) san diego: academic press. diakses 2 nopember 2012, <w w w.scribd.com /doc/6239681/ memory-aging-chapter-102505>. 329 promosi perawatan daya ingat (stimulasi memori) (kushariyadi) lesch, mf 2003, comprehension and memory for warning symbols: age-related differences and impact of training. journal of safety research 34 (2003) 495–505. diakses 17 desember 2012, <http:www.sciencedirect.com>. lim, mhx, liu, kpy, cheung, gsf, kuo, mcc, li, k r & tong, cy 2012, effectiveness of a multifaceted cognitive training programme for people with mild cognitive impairment: a onegroup preand posttest design. hong kong journal of occupational therapy (2012) 22, 3–8. diakses 17 desember 2012, <http:www.sciencedirect.com>. lovell, m 2006, caring for the elderly: changing perceptions and attitudes. journal of vascular nursing. 24(1), 22-26. diakses 7 nopember 2012, <www. scienced i rect.com /science/a r t icle/pii / s1062030305001688>. lumbantobing, sm 2012, neurologi klinik pemeriksaan fisik dan mental, jakarta: balai penerbit fkui. maas, ml, komalasar i, r, lusyana, a & yuningsih, y 2011, asuhan keperawatan geriatric: diagnosis nanda, kriteria hasil noc & intervensi nic, jakarta: egc. matthews., cauley., yaffe & zmuda 1999, estrogen replacement therapy and cognitive decline in older community women. journal of the american geriatrics society, 47 (5), 518–523. mcdaniel, ma & bugg, jm 2012, memory training interventions: what has been forgotten?. journal of applied research in memory and cognition 1 (2012) 45– 50. diakses 17 desember 2012, <http: www.sciencedirect.com>. miller, ca 2009, nursing for wellness in older adults, 5th edition ed, philadelphia: lippincott williams & wilkins. ormrod, je 2009, psikologi pendidikan. me m b a n t u si s w a tu m b u h d a n berkembang, ed. 6, jilid 1, jakarta: penerbit erlangga. parker, me & smith, mc 2010, nursing theories & nursing practice, 3rd. ed, philadelphia: davis company. peplau, he 1992, interpersonal relations: a theoretical framework for application in nursing practice. nursing science quarterly, 5 (1), 13–18. diakses 7 nopember 2012, <nsq.sage pub.com / content/5/1/13.abstract>. smeltzer, sc 2001, buku ajar keperawatan medical bedah brunner & suddarth, ed.8, jakarta: egc. solso, rl, maclin, oh & maclin, mk 2008, psikologi kognitif, ed. 8, jakarta: penerbit erlangga. videbeck, sl 2011, psychiatric-mental health nursing, 5th ed, philadelphia: lippincott williams & wilkins. wade, c & travis, c 2008, psikologi, jilid 2, ed. 9, jakarta: penerbit erlangga. walgito, b 2004, pengantar psikologi umum, ed.4, yogyakarta: penerbit andi. zhu., viitanen., guo., winblad & fratiglioni 1998, blood pressu re reduction, cardiovascular disease and cognitive decline in the mini-mental state examination in community population of normal very old people: a three year follow-up, journal of clinical epidemiology. 51 (5), 385–391 http://e-journal.unair.ac.id/jners 19 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 19-24 http://dx.doi.org/10.20473/jn.v17i1.34150 original article open access the association between self-control and satisfaction in life among filipino older adults laarni a. caorong 1,* 1 mindanao state university, philippines *correspondence: laarni a. caorong. address: main campus, marawi city, 9700 lanao del sur, philippines, email: laarni.caorong@msumain.edu.ph responsible editor: rizki fitryasari received: 7 march 2022 ○ revised: 10 april 2022 ○ accepted: 12 april 2022 abstract introduction: self-control has been associated with a host of positive life outcomes. this correlational study was aimed at determining the link between self-control and life satisfaction among the older population. methods: this study used a quantitative correlational design. ninety-six (96) older adult residents of iligan city and lanao del norte, mindanao philippines, who met the inclusion criteria were recruited. this quantitative study made use of two standardized instruments namely the brief self-control scale (bscs) and the satisfaction with life scale (swls). the association was assessed using pearson correlation statistics. results: there is a significant relationship between the older adults’ self-control and their life satisfaction. the computed r value is 0.248 (p < 0.05). evidently, there is a positive relationship between self-control and life satisfaction. this current study has provided evidence to support the assumption that exercising self-control leads to life satisfaction. conclusions: as a significant positive relationship between the older adults’ self-control exercise and their life satisfaction was proven, this means that effective exercise of self-control positively leads to better life outcomes such as satisfaction in life. linking self-control exercise with life satisfaction offers an innovative way for us to know why some people may feel more satisfied with life than others. keywords: elderly; filipino; life satisfaction; older adults; self-control introduction the concept of attaining life satisfaction has always been an aspiration to most human beings. while selfcontrol is attributed to a host of positive outcomes, it is still interesting to know the link between self-control and the satisfaction with life. the essence of self-control in attaining important life outcomes is widely recognized. high self-control, according to several authors, positively predicts a person’s well-being, life satisfaction and positive affect. high self-control here means the ability of a person to regulate his thoughts, feelings and behaviors (de ridder et al., 2012; hofmann et al., 2014). several authors have pointed out that self-control is a powerful determinant of success across the life span (de ridder et al., 2012). the practice of self-control is associated with positive outcomes such as better interpersonal relationships, good physical health and better intellectual performance (finkel and campbell, 2001; schmeichel, vohs and baumeister, 2018). in this study, self-control is defined as the self's capacity to override or change one's inner responses, as well as to interrupt undesired behavioral tendencies and to refrain from acting on them (tangney, boone and baumeister, 2018). exercising high self-control is a pertinent aspect of a person’s behavior for a person to have a successful and healthy life (de ridder et al., 2012; tangney, boone and baumeister, 2018). it was found that behaviors such as minimized aggression, reduced criminality improved relationships, less abuse of alcohol, smoking and other prohibited substances and high self-esteem and improved interpersonal skills were all related to the practice of high self-control (finkel and campbell, 2001; sayette and griffin, 2004). moreover, hofmann et al. (2014) stated that self-control is a person’s ability to override one’s inner response and to interrupt undesirable behavioral inclinations or impulses. additionally, greater self-control is also positively attributed to psychological adjustments and negatively predicts psychopathology (tangney, boone and https://creativecommons.org/licenses/by/4.0/ mailto:laarni.caorong@msumain.edu.ph https://orcid.org/ 0000-0002-1987-4854 caorong (2022) 20 p-issn: 1858-3598  e-issn: 2502-5791 baumeister, 2018). it was also found that the more selfcontrol a person exhibits, the fewer are the experience of symptoms and stress while having a better mental health (boals, vandellen and banks, 2011). this finding was corroborated with the outcome of the study that there is a link between self-control and higher quality and satisfying relationships (bogg and roberts, 2004; jensencampbell and malcolm, 2007). moreover, several researchers have perceived selfcontrol as a key aspect in personal conscientiousness, which is subsequently linked to longevity, physical health and other relevant health behaviors (friedman et al., 1993; bogg and roberts, 2004; goodwin and friedman, 2006). succinctly, self-control practice is an allencompassing important human quality trait essential for attaining a good life, thus its practice results in many positive life outcomes. the aging population is rapidly growing worldwide, and attention must be given to the older sector of the society. there are certain conditions associated with aging such as decline in economic resources, decrease in cognitive ability, failing health and weakening social support (deary et al., 2009). the various changes that take place in old age suggest that aging might be linked to a decline of the older adults’ well-being. an important measure of subjective well-being is life satisfaction. life satisfaction is established as an essential indicator of wellness in general. it is also seen as a necessary gauge of positive functioning (gilman, 2009). numerous people and several researchers find getting old linked to a decline in happiness in older people. this is attributed to the physical, social and psychological changes that they experience in old age which clearly exhibit that the experiences that older people go through impact their satisfaction with life. the theory of self-control in old age has an assumption that the exercise of self-control is linked to life satisfaction (caorong, 2019). the aim of this study is to know and determine if the exercise of self-control is associated with life satisfaction. determining the association between self-control and life satisfaction will help confirm the assumption of the theory of self-control in old age which states that the exercise of self-control among older adults leads to life satisfaction. the result of this study will give a better perspective on the concept of life satisfaction in late life and will provide and enhance the viewpoint on the link between life satisfaction and self-control. materials and methods study design this study utilized a quantitative correlational research design to determine the relationship between the self-control of older people and their life satisfaction. respondent the target participants were 60 years old and older adults from iligan city and lanao del norte, the philippines. target population (n=96) was calculated based on correlation sample size calculator [α=0.05, ß=0.50, r=0.2]. participants were purposively chosen to answer the research instruments. inclusion criteria included: being a male or female, sixty years old and above, and those older adults demonstrating normal cognitive and mental functioning. cognitive functioning was assessed utilizing the short portable mini-mental status questionnaire or spmsq by pfeiffer (1975). participants who committed two or less errors were asked to join the study. however, those who committed three or more errors using the (spmsq) indicating cognitive impairment were not included. instrument the brief self-control scale (bscs) is a standardized instrument which measures self-control. it is comprised of statements which are measured on a scale ranging from 1 to 5 where 1 indicates ‘not at all like me’ and 5 indicates ‘very much like me’ (tangney, boone and baumeister, 2018). the scale consists of a total of thirteen items with an internal consistency estimate (alpha) of 0.83 and 0.85 in two study samples. the test-retest reliability estimate was 0.87 (three-week interval). selfcontrol as defined by tangney is the self's capacity to override or change one's inner responses, as well as to interrupt undesired behavioral tendencies and to refrain from acting on them (tangney, boone and baumeister, 2018). the satisfaction with life scale (swls) is another standardized instrument used in this study which measures the life satisfaction element of subjective wellbeing. life satisfaction judgments represent the cognitive component of subjective well-being, or the experience commonly referred to as happiness (diener et al., 1985, 1999). the swls is likert in type where a seven-point response category is used for the 5-item statements comprising the scale. the lowest score is five while the highest possible score that can be obtained is 35. score interpretation included the following: 5-9 (extreme dissatisfaction with life); 10-14 (dissatisfied with life); 1519 (slightly dissatisfied with life); 20 (neutral); 21-25 (slightly satisfied with life); 26-30 (satisfied with life) and 31-35 (extremely satisfied with life). the scale has a high internal consistency with a coefficient alpha of 0.79 to 0.89. additionally, in a month interval, the test-retest correlation scores were 0.84 and 0.80. data collection the researcher collected data by distributing a standardized research instrument for the participants to answer. the instrument comprised the brief self-control scale developed by tangney, baumeister and boone (2018) and the satisfaction with life scale (swls) by jurnal ners http://e-journal.unair.ac.id/jners 21 diener et al. (1985). the survey took about 10 to 15 minutes to complete. the survey was conducted where older adults congregated in groups or individually at their homes or work area. qualified research assistants were employed to help in the qualitative data collection. they were at least high school graduates and able to communicate and document written information from the research participants. they were initially required to undergo a training that was personally conducted by the researcher herself before the data collection process. the research assistants were also asked to sign a confidentiality agreement form. the administration of the research questionnaires was carried out by the researcher herself and the investigator’s research assistants. the researcher hired three research assistants who helped in the data gathering process. the data collection was completed within four weeks. the participants’ concerns and questions were addressed during the data collection process. the participants were also asked to indicate their agreement to participate in the research study by asking them to sign a consent form before giving them the questionnaire or allowing them to start answering the questions. only those who were keen and willing to be included in the study were involved. the study respondents were invited voluntarily by giving them a letter of invitation indicating the aims and purpose of the study. they were also informed of their right to refuse and it was highlighted to them that participation was voluntary. the participants were asked to sign an informed consent indicating their voluntary participation. data analysis the data gathered were tabulated and transferred to the statistical package for the social sciences for analysis (file version 1.0.0-51). data analysis of the sample characteristics was utilized as descriptive statistics to determine the sample characteristics. the correlation of the two main variables (self-control and life satisfaction) was determined using pearson’s correlation coefficient. correlation coefficients vary from -1 to +1, where 0 indicates no relationship, -1 indicates a perfectly negative linear relationship, and +1 indicates a perfectly positive linear relationship. for a positive coefficient, as one variable increases, the other also increases. for negative coefficients, as one variable increases, the other variable decreases (pallant, 2020). cohen’s standard (cohen, 2013) was used to evaluate the coefficient to assess the strength of the relationship between self-control and life satisfaction. coefficients between 0.10 and 0.29 represent a small relationship; coefficients between 0.30 and 0.49 represent a medium relationship and coefficients 0.50 and above represent a large relationship. an alpha of 0.05 was used for analysis. ethical consideration data collection started after approval from the cebu normal university-research ethics committee (cnurec) with cnu rec code 335/2019-06 caorong. the study participants were purposively selected to join the study. they were screened following certain inclusion criteria such as the following: older adults aged sixty years old and above, cognitively, physically and psychologically well, and female or male residents of iligan city and lanao del norte. each of the participants was given a copy of the informed consent duly approved by the cebu normal university-ethics review committee (cnu-rec). table 1 profile of the participants (n = 96) variable n % age 60-69 years old 60 62.50 70-79 years old 31 32.29 80 years old and above 5 5.20 marital status married 51 53.12 widow 37 38.54 single 3 3.12 separated 5 5.20 religion roman catholic 82 85.41 islam 9 9.37 others 5 5.20 educational attainment no formal education 18 18.75 elementary level 30 31.25 elementary graduate 7 7.29 high school level 12 12.50 high school graduate 8 8.33 college level 7 7.29 college graduate 10 10.41 postgraduate level 4 4.16 employment status unemployed 53 55.20 employed 43 44.7 monthly income (in php) 5,000 and below 76 79.16 5,000-9,999 7 7.29 10,000-14,999 7 7.29 15,000-19,999 2 2.08 20,000-24,999 1 1.11 25,000-29,999 1 1.11 30,000 and above 2 2.08 table 2 descriptive statistics for the older adults’ level of self-control (n = 96) self-control categories n % very low (13-26) 0 0 low (27-39) 27 28.01 moderate (40-52) 55 57.30 high (53-65) 14 14.60 note: categories arbitrarily made by the researcher (cutoff scoring was determined through averaging from perfect score into quintiles); perfect score is 65. caorong (2022) 22 p-issn: 1858-3598  e-issn: 2502-5791 results this section of the study presents the results and findings of this current study. to test the hypothesis that older adults’ self-control is associated with life satisfaction, correlation statistics was performed. the presentation starts with descriptive statistics describing the characteristics of the respondents in terms of age, gender, religion, educational attainment, income and occupation. the older adults’ self-control scores and their level of life satisfaction are also presented in this section of the study as well as the correlation between the two. table 1 indicates that the majority of the respondents who participated in the current study are young older adults, most are female roman catholics, and the majority of them still remain married in late life. additionally, a great number of study participants did not reach college and more than half of them were unemployed. it can also be noted from the findings that the majority of the older participants have a monthly income of less than five thousand pesos. results as shown in table 2 revealed that, generally, the respondents have moderate self-control (m=44.10, sd= 6.72) using the brief self-control scale. this result is shown in the above figure, indicating that more than half of the older people involved in the study have moderate self-control. yet it cannot be discounted from the figure above that there are fairly a number of study participants who have low level of self-control while participants of the study with high self-control are lesser in number. it is established from the results above that the older adult participants are satisfied with life. the data show that, generally, the participants agree to the first three indicators listed in the scale while slightly agreeing to the other two indicators. table 4 shows the correlation between the two main variables of the current study, which are self-control and life satisfaction. using pearson correlation statistics, the computed r value signifies that there is a positive relationship between the older adults’ self-control and their life satisfaction. it means that a significant positive relationship between the identified variables exist. this suggests that the higher the self-control, the more satisfied the older adult is. although pearson's correlation between the self-control of the older adult respondents and their life satisfaction is significant at the 0.5 significance level, the magnitude is relatively small. this may be due to the sample size (n=96), hence an indication that further study must involve a much larger sample. discussions the aim of this current study was to determine the link between self-control and life satisfaction among the older people to validate a proposition of the theory of self-control in old age which states that the exercise of self-control leads to life satisfaction. in this study, it was hypothesized that older adults who have high selfcontrol have better life satisfaction. findings of this present study reveal that the majority of the older adult participants have moderate level of selfcontrol while are also satisfied with life. the result of the study coincides with several modern empirical studies indicating the relevance of self-control in achieving important life outcomes. good self-control as being able to give up immediate desires and focus on long-term table 3 descriptive statistics for the older adults’ life satisfaction (n = 96) indicators mean standard deviation descriptive rating i am satisfied with my life 5.50 1.472 satisfied the conditions of my life are excellent 5.44 1.609 satisfied in most ways my life is close to my ideal 5.34 1.368 satisfied so far i have gotten the important things i want in life 5.15 1.402 slightly satisfied if i could live my life over, i would change almost nothing 5.07 1.643 slightly satisfied overall mean 5.30 satisfied scaling: 1.00-1.85 = strongly disagree/ extremely dissatisfied; 1.86-2.71 = disagree/ dissatisfied; 2.72-3.57 = slightly disagree; 3.58-4.43 = neither agree nor disagree/ neutral; 4.44-5.29 = slightly agree/ slightly satisfied; 5.30-6.15 = agree/ satisfied; 6.16-7.00 = strongly agree/ extremely satisfied categorization of scaling was determined through averaging from perfect score resulting to seven classified ranges. *perfect score is 7 in each item table 4 correlation between the older adults’ self-control and their life satisfaction life-satisfaction self-control pearson correlation 0.248* sig. (2-tailed) 0.015 n 96 * correlation is significant at the 0.05 level (2-tailed). jurnal ners http://e-journal.unair.ac.id/jners 23 goals, positively predicts life satisfaction as was concluded by hofmann et al. (2014) in their study. the present findings reveal that the majority of the older adult participants of the study are satisfied with life. this result is arguably plausible as was concluded by a study of mercier, peladeau and tempier (1998) to older people determining their satisfaction with life. it was found in their study that, with aging, older people’s psychological state remains stable or even increases even with some inevitable aging changes being experienced. moreover, the satisfaction with life does not necessarily change in late life. as was established by carstensen, isaacowitz and charles (1999). the result of this study is also in consonance with the findings of a recent study conducted by ng, tey and asadullah (2017) among china’s eldest people where the majority of the older adults who participated in their study considered their satisfaction with life as very good. furthermore, as exercising self-control has been associated with many positive outcomes, including life satisfaction, the result of the current study positively linking self-control to life satisfaction is not at all unforeseen. this is corroborated by numerous studies claiming that high self-control positively predicts not only a person’s life satisfaction but also their well-being (hofmann et al., 2014). moreover, in a study conducted by dou et al. (2016) to chinese employees, self-control was also found to be positively related to both job and life satisfaction. this provides evidence of the positive association between self-control and life satisfaction. additionally, it was also concluded in a study that high trait self-control positively predicts happiness (cheung et al., 2014). this current study has a similar finding, that there is an apparent positive association of self-control with life satisfaction. the higher self-control the more satisfied are the older adults. understanding the link between self-control and life satisfaction has potential applications across a broad range of human behaviors. linking self-control exercise to life satisfaction offers an innovative way to make people know why some may feel satisfied and why some do not. conclusions this current study has provided evidence to support the proposition claiming that exercising self-control leads to life satisfaction. the significant positive relationship between the older adults’ self-control exercise and their life satisfaction means that effective exercise of self-control positively leads to better life outcomes such as satisfaction in life. linking self-control exercise to life satisfaction offers an innovative way for people to know why some people are satisfied with life and others are not. findings of this research underscore the positive relationship of self-control and life satisfaction among older adults. it is recommended that further research be conducted using other variables such as quality of life to enhance the exploration concerning the relationship of self-control to the subjective well-being of the older people. references boals, a., vandellen, m. r. and banks, j. b. (2011) ‘the relationship between self-control and health: the mediating effect of avoidant coping’, psychology & health. taylor & francis, 26(8), pp. 1049–1062. bogg, t. and roberts, b. w. (2004) ‘conscientiousness and healthrelated behaviors: a meta-analysis of the leading behavioral contributors to mortality.’, psychological bulletin. american psychological association, 130(6), p. 887. carstensen, l. l., isaacowitz, d. m. and charles, s. t. (1999) ‘taking time seriously: a theory of socioemotional selectivity.’, american psychologist. american psychological association, 54(3), p. 165. cheung, t. t. l. et al. (2014) ‘why are people with high self-control happier? the effect of trait self-control on happiness as mediated by regulatory focus’, frontiers in psychology. frontiers, 5, p. 722. cohen, j. (2013) statistical power analysis for the behavioral sciences. routledge. deary, i. j. et al. (2009) ‘age-associated cognitive decline’, british medical bulletin. oxford university press, 92(1), pp. 135–152. de ridder, d. t. d. et al. (2012) ‘taking stock of self-control: a metaanalysis of how trait self-control relates to a wide range of behaviors’, personality and social psychology review. sage publications sage ca: los angeles, ca, 16(1), pp. 76–99. diener, e. et al. (1999) ‘subjective well-being: three decades of progress.’, psychological bulletin. american psychological association, 125(2), p. 276. diener, e. d. et al. (1985) ‘the satisfaction with life scale’, journal of personality assessment. taylor & francis, 49(1), pp. 71–75. dou, k. et al. (2016) ‘the relationship between self-control, job satisfaction and life satisfaction in chinese employees: a preliminary study’, work. ios press, 55(4), pp. 797–803. finkel, e. j. and campbell, w. k. (2001) ‘self-control and accommodation in close relationships: an interdependence analysis.’, journal of personality and social psychology. american psychological association, 81(2), p. 263. friedman, h. s. et al. (1993) ‘does childhood personality predict longevity?’, journal of personality and social psychology. american psychological association, 65(1), p. 176. gilman, r. (2009) ‘shannon m. suldo, e. scott huebner, allison a. friedrich’, handbook of positive psychology in schools. routledge, p. 27. goodwin, r. d. and friedman, h. s. (2006) ‘health status and the fivefactor personality traits in a nationally representative sample’, journal of health psychology. sage publications sage ca: thousand oaks, ca, 11(5), pp. 643–654. hofmann, w. et al. (2014) ‘yes, but are they happy? effects of trait self‐ control on affective well‐being and life satisfaction’, journal of personality. wiley online library, 82(4), pp. 265–277. jensen-campbell, l. a. and malcolm, k. t. (2007) ‘the importance of conscientiousness in adolescent interpersonal relationships’, personality and social psychology bulletin. sage publications sage ca: thousand oaks, ca, 33(3), pp. 368–383. laarni, c. (2019) theory of self-control in old-age. cebu normal university, philippines. mercier, c., peladeau, n. and tempier, r. (1998) ‘age, gender and quality of life’, community mental health journal. springer, 34(5), pp. 487– 500. ng, s. t., tey, n. p. and asadullah, m. n. (2017) ‘what matters for life satisfaction among the oldest-old? evidence from china’, plos one. public library of science san francisco, ca usa, 12(2), p. e0171799. pallant, j. (2020) spss survival manual: a step by step guide to data analysis using ibm spss. routledge. pfeiffer, e. (1975) ‘a short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients’, journal of the american geriatrics society. wiley online library, 23(10), pp. 433– 441. sayette, m. a. and griffin, k. m. (2004) ‘self-regulatory failure and addiction’, handbook of self-regulation: research, theory, and applications, 3, pp. 571–590. schmeichel, b. j., vohs, k. d. and baumeister, r. f. (2018) ‘intellectual performance and ego depletion: role of the self in logical reasoning and other information processing’, in self-regulation and selfcontrol. routledge, pp. 310–339. caorong (2022) 24 p-issn: 1858-3598  e-issn: 2502-5791 tangney, j. p., boone, a. l. and baumeister, r. f. (2018) ‘high selfcontrol predicts good adjustment, less pathology, better grades, and interpersonal success’, in self-regulation and self-control. routledge, pp. 173–212. how to cite this article: caorong, l. a. (2022) ‘the link between self-control and satisfaction in life among older adults’, jurnal ners, 17(1), pp. 19–24. doi: http://dx.doi.org/10.20473/jn.v17i1.34150 table1 table2 table3 table4 boals2011 bogg2004 carstensen1999 cheung2014 cohen2013 deary2009 deridder2012 diener1999 diener1985 dou2016 finkel2001 friedman1993 gilman2009 goodwin2006 hofmann2014 jensen2007 l2019 mercier1998 ng2017 pallant2020 pfeiffer1975 sayette2004 schmeichel2018 tangney2018 196 peningkatan coping keluarga dalam merawat pasien gangguan jiwa melalui terapi spiritual direction, obedience, dan acceptance (doa) (the improvement of family coping in taking care of patient mental disorder with spiritual therapy; direction, obedience and acceptance (doa)) ah. yusuf*, suhartono taat putra**, yusti probowati*** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya, e-mail: yusuf_fkp_unair@yahoo.co.id ** fakultas kedokteran universitas airlangga *** fakultas psikologi universitas surabaya abstract introduction: mental disorder remains a stigma in society, even until now. a family who have a member with mental disorder, will experience continues objective and subjective burden, experience serious stress for a lifetime, which may cause ineffective coping. method: design used in this study was experimental (pre post test control group design). the population was every family of patient with mental disorder in menur mental hospital along the year of 2010, has been taking care there twice, in minimum, lived in surabaya. the samples were chosen by allocation simple random. samples were 13 persons in each treatment and control group. the intervention was given in 60–120 minute in 8 times meeting with average interval about 1 week. data analysis was done using paired t-test and independent t-test. result: results in this study showed that there was signifi cant change in total of family coping (p = 0.040), maintaining family integration, cooperation and an optimistic defi nition of the stuation (p = 0.009), maintaining social support, self esteem, and psychological stability (p = 0.230), understanding the medical situations through communication with other parents and concultation with medical staff (p = 0.025). discussion: the provision of family therapy with spiritual approach (doa) can increase family coping in taking care of patient with mental disorder. keywords: family coping, spiritualtherapy doa, mental disorder pendahuluan gangguan jiwa adalah suatu keadaan di mana seseorang mengalami kehilangan kemampuan untuk mengadakan relasi dan limitasi dalam hubungannya dengan orang lain, waktu, tempat, dan lingkungan (maramis, 1998). pasien tidak mampu menjalin hubungan, membatasi hubungan dengan dirinya sendiri, orang lain dan lingkungan. pasien menjadi berperilaku menarik diri, agresif, mencederai orang lain atau merusak lingkungan. keluarga dengan salah satu anggota keluarga mengalami gangguan jiwa dapat menimbulkan konfl ik yang tinggi, menjadi beban obyektif dan subyektif, saling menyalahkan, keterlibatan dalam permusuhan antar anggota keluarga (pharoah, 2010; fitryasari, 2009).berbagai dampak negatif yang dihadapi keluarga menyebabkan stres keluarga tinggi, koping keluarga tidak efektif, dan menimbulkan kegagalan keluarga dalam merawat pasien gangguan jiwa di rumah (hamid, 2009; keliat, 2006; mccubbin, 1991). seseorang yang mengalami stres berat akan mencari kenyamanan dan kekuatan dari tuhan. proses pemilihan pendekatan spiritual terdiri atas tiga tahapan yaitu mengidentifi kasi faktor yang berkontribusi terhadap stresor, mengeksplorasi sumber dan strategi spiritual, serta hidup dengan pilihannya (ahmadi, 2006; chiu, 2005). inti dari semua nilai spiritualitas manusia adalah doa, karena doa mengandung komponen direction, obedience, dan acceptance (hartanto, 2010; sentanu, 2010; putra, 2011), tetapi sejauh ini model spiritual yang paling tepat sesuai karakteristik 197 peningkatan coping keluarga (ah. yusuf, dkk) masyarakat indonesia untuk mengubah koping keluarga dalam merawat pasien gangguan jiwa di rumah belum ditemukan. keliat (1996) mengidentifi kasi faktor penyebab kekambuhan adalah pengetahuan, si k a p, d a n t i nd a k a n kelu a rg a d a la m merawat pasien gangguan jiwa. keluarga perlu mempunyai sikap menerima pasien, memberikan respons positif, menghargai pasien sebagai anggota keluarga dan menumbuhkan sikap tanggung jawab kepada pasien, sehingga keseimbangan hidup dalam keluarga dapat terjadi (hamid, 2009; mohr, 2006; keliat, 1996). berbagai intervensi keluarga telah dikembangkan sejak tahun 1945. bowen mengembangkan model psikodinamik, virinia satir dengan eksperiensial, jacobson dengan model kognitif behavior, jay haley dengan strategic dinamic model (pharoah, 2010; mohr, 2006; gladding, 2002), tetapi hasilnya belum memuaskan. dossey (2005) mengembangkan paradigma holistik dalam keperawatan, bahwa body-mind-spirit adalah sesuatu yang saling ketergantungan, saling memperkuat satu sama lain, keberadaannya sangat diperlukan dalam proses penyembuhan (healing). paradigma ini memberikan sugesti secara alamiah bahwa proses penyembuhan mer upakan proses spiritual yang mencerminkan totalitas manusia. totalitas spiritual manusia tampak pada domain spiritual, ber upa; mister y, love, suffering, hope, forgiveness, peace and peacemaking, grace, and prayer (hamid, 2009; tanyi, 2006; chiu, 2005; dossey, 2005; sullivan, 2004; bown, 1993). koping adalah cara individu dalam menyelesaikan masalah, menyesuaikan diri dengan keinginan, dan merupakan respons terhadap situasi yang mengancam. keluarga dengan salah satu anggota keluarga mengalami gangguan jiwa, akan merasakan beban objektif dan subjektif secara terus-menerus, menjadi stressor yang berat bagi keluarga, sehingga koping tidak efektif. koping keluarga dalam penelitian dibentuk dengan memperbaiki model keyakinan dalam kesehatan, melalui perbaikan persepsi keluarga tentang tanda dan gejala gangguan jiwa, tingkat keparahan, kemungkinan bisa disembuhkan, dan hasil yang telah diperoleh dari pengobatan yang dilakukan. dengan demikian, keyakinan d a n ke percaya a n menja d i lebi h k u at , persepsi keluarga lebih positif, pola interaksi dalam keluarga berkembang lebih baik dan terbentuklah dukungan keluarga terhadap salah satu anggota keluarga yang mengalami gangguan jiwa, sehingga koping keluarga menjadi lebih efektif, keluarga dapat menerima keadaan salah satu anggota keluarga yang mengalami gangguan jiwa dengan apa adanya, dan memperlakukan pasien dengan lebih baik. bahan dan metode penel it ia n i n i d i r a nca ng denga n penelitian eksper imental ( pre-post test control group design) dengan tujuan untuk membuktikan pengaruh pemberian terapi kelu a rga denga n pendek at a n spi r it u al direction, obedience, acceptance (doa) terhadap peningkatan koping keluarga dalam merawat pasien gangguan jiwa. populasi dalam penelitian ini adalah selur uh keluarga pasien yang salah satu anggota keluarganya dirawat di rumah sakit jiwa menur surabaya pada tahun 2010. kriteria: alamat di surabaya, tinggal serumah dengan pasien, memberikan asuhan langsung kepada pasien (care giver), pasien telah didiagnosis gangguan jiwa minimal 1 tahun, pernah dirawat di rumah sakit jiwa minimal 2 kali. besar sampel ditentukan dengan rumus hypothesis testing for two population means (two-side test) dari sample size determination in health studies who soft ware. hasil penelitian sebelumnya tentang pola koping ibu yang salah satu anggota keluarganya menderita cerebral palsy (mccubbin, 1991) diperoleh nilai σ = 8.0, μ1 = 13.7, μ2 = 24,0. jika dalam penelitian ini menggunakan α = 5% dan β = 10%, maka setelah dimasukkan software diperoleh besar sampel 13. dengan demikian, besar sampel dalam penelitian ini adalah 13 orang, untuk setiap kelompok. variabel independen dalam penelitian ini adalah terapi keluarga dengan pendekatan spiritual direction, obedience, dan acceptance 198 jurnal ners vol. 7 no. 2 oktober 2012: 196–202 (doa). variabel dependen dalam penelitian ini adalah koping keluarga dalam merawat pasien gangguan jiwa, meliputi kemampuan memelihara integritas keluarga, kerja sama, dan memandang sit uasi dengan positif, kemampuan memeliharan dukungan sosial, harga diri, dan stabilitas psikologis, serta kema mpu a n mema ha m i sit u asi med is, komunikasi dengan orang lain, dan konsultasi dengan petugas kesehatan (mccubbin, 1991). pengumpulan data diawali dengan mengajukan ijin peneltian kepada direktur ru m a h sa k it jiwa me nu r su r a baya . intervensi keperawatan dilakukan di rumah keluarga pasien, dengan memberikan terapi keluarga dengan pendekatan spiritual doa, terdiri dari fase direction, obedience, dan acceptance sesuai panduan dalam satuan acara kegiatan (sak) yang telah direncanakan. fase, direction u nt u k mengembangkan kepercayaan kesehatan (health belief ) keluarga terhadap gangguan jiwa, obedience untuk mengembangkan keyakinan keluarga bahwa pasien dapat dilatih hidup lebih mandiri sesuai kemampuan, sehingga keluarga dapat mengembangkan pola interaksi antar anggota keluarga dan memberikan dukungan keluarga dengan baik. fase acceptance dilakukan untuk mengembangkan sikap bisa menerima apapun yang terjadi akibat gangguan jiwa dengan pendekatan nilai spiritual agama islam (sabar, ikhlas, syukur), sehingga keluarga dapat mengambil hikmah atas segala kejadian yang dialami keluarga. untuk kegiatan ini diberikan beberapa motivasi melalui penerapan nilai spr it ual agama islam dan bu k u modul penelitian. intervensi keperawatan ini dilakukan selama dua bulan, kemudian diukur kembali koping keluarga dalam merawat pasien gangguan jiwa setelah mendapat intervensi keperawatan dengan pos test. pengumpulan data keselur uhan dilaksanakan selama 8 kali pertemuan. pertemuan pertama untuk menjelaskan maksud, t ujuan penelitian, dan pre test, minggu ke 2 dan 3 untuk fase direction, minggu 4 dan 5 fase obedience, minggu 6 dan 7 fase acceptance, minggu 8 untuk terminasi dan post test. hasil tabel 1. hasil pengaruh terapi keluarga degan pendekatan spiritual doa terhadap koping keluarga dalam merawat pasien skizofrenia no. variabel uji perlakuan kontrol independent t-test 1 memelihara integritas keluarga, kerja sama, dan memandang situasi dengan positif pre test (x ± sd) 60,53 ± 7,25 (x ± sd) 57,38 ± 7,68 t = 1,076 p = 0,293 post test (x ± sd) 63,69 ± 5,25 (x ± sd) 57,00 ± 6,67 t = 2,842 p = 0,009 paired t test t = -2,473 p = 0,029 t = 0,672 p = 0,515 2 memelihara dukungan sosial, harga diri, dan stabilitas psikologis pre test (x ± sd) 52,76 ± 13,27 (x ± sd) 50,30 ± 12,93 t = 0,479 p = 0,636 post test (x ± sd) 56,00 ± 9,82 (x ± sd) 50,69 ± 12,30 t = 1,215 p = 0,230 paired t test t = -1,819 p = 0,094 t = -0,672 p = 0,514 ∆ pre post 3,24 0,39 p = 0,140 3 memahami situasi medis, komunikasi dengan orang lain, konsultasi dengan petugas kesehatan pre test (x ± sd) 23,84 ± 6,86 (x ± sd) 23,00 ± 5,24 t = 0,353 p = 0,727 post test (x ± sd) 27,07 ± 4,60 (x ± sd) 22,84 ± 4,41 t = 2,391 p = 0,025 paired t test t = -3,228 p = 0,007 t = 0,257 p = 0,801 199 peningkatan coping keluarga (ah. yusuf, dkk) no. variabel uji perlakuan kontrol independent t-test 4 koping total pre test (x ± sd) 137,15 ± 24,65 (x ± sd) 130,69 ± 22,03 t = 0,705 p = 0,488 post test (x ± sd) 146,92 ± 17,69 (x ± sd) 130,53 ± 20,73 t = 2,167 p = 0,040 paired t test t = -2,829 p = 0,015 t = 0,176 p = 0,864 pembahasan terdapat perbedaan signifi kan (p=0,040) total koping keluarga dalam merawat pasien gangguan jiwa antara sebelum dan sesudah diberikan terapi keluarga dengan pendekatan spiritual direction, obedience, acceptance (doa). perbedaan utama tampak pada kemampuan keluarga dalam memelihara integ r itas, kerja sama dan memandang situasi yang dilami dengan positif (p=0,029). kemampuan keluarga dalam memahami situasi medis, komunikasi dengan orang lain, dan konsultasi dengan petugas kesehatan juga mengalami perubahan signifi kan (p=0,007). tidak ada perubahan signifi kan pada aspek kemampuan keluarga dalam memberikan dukungan sosial, harga diri, dan stabilitas psi kologis bagi pasien ga ngg u a n jiwa (p=0,094), tetapi terdapat peningkatan selisih rerata pada kelompok perlakuan sebesar 3,24 dan pada kelompok kontrol juga meningkat sebesar 0,39. jadi sebenar nya terdapat perbedaan antara sebelum dan sesudah intervensi, tetapi perbedaan ini tidak bermakna secara statistik. hasil penelitian ini sejalan dengan teori bahwa koping adalah cara individu untuk beradaptasi terhadap masalah, merupakan sebuah proses perubahan kognitif dan perilaku secara konstan dalam upaya mengatasi tuntutan internal dan atau eksternal yang melelahkan (stuart, 1998). mekanisme koping adalah cara yang dilakukan individu dalam menyelesaikan masalah, menyesuaikan diri dengan perubahan, serta respons terhadap situasi yang mengancam (keliat, 2009; hamid, 1999; stuart, 1998). perbedaan kemampuan keluarga dalam memelihara integritas, kerja sama dan memandang situasi dengan positif lanjutan tabel 1. adalah merupakan adanya perubahan kognitif dari responden, meskipun belum diikuti perubahan konsisten pada aspek perilaku pemberian dukungan sosial, harga diri, dan stabilitas psikologis pasien. keluarga menganggap pasien tidak mempunyai cukup waktu dan tenaga dalam bekerja (makan tapi tidak mau bekerja), tidak dapat terlibat dalam aktifi tas sosial dengan teman sebayanya. kenyataan ini menyebabkan keluarga kurang termotivasi untuk melibatkan pasien dalam berbagai aktivitas harian di rumah, keluarga lebih memilih membiarkan pasien melakukan aktifitas yang disukai, asal tidak marah atau tersinggung. keluarga memberi kebebasan pasien untuk memilih kegiatan yang dilakukan setiap hari, tetapi tidak memberi stimulasi, dukungan harga diri, dan stabilitas psikologis kepada pasien. intervensi yang diberikan dalam terapi keluarga untuk mengatasi masalah ini adalah memfokuskan diskusi pada peningkatan harga diri dan stabilitas psikologis pasien. filosofi yang digunakan adalah falsafah dalam keperawatan jiwa (hamid, 1999; stuart, 1995), bahwa, setiap individu memiliki harkat dan martabat, sehingga setiap individu perlu dihargai, yang kedua tujuan individu meliputi tumbuh, sehat, otonomi dan aktualisasi diri, yang ketiga setiap individu mempunyai potensi untuk berubah, yang keempat manusia adalah mahluk holistik, berinteraksi dan bereaksi dengan lingkungan sebagai manusia yang utuh, yang kelima setiap orang memiliki kebut u ha n d a sa r sa ma , ya ng kee na m semua perilaku individu adalah bermakna, yang ketujuh perilaku individu meliputi persepsi, pikiran, perasaan, dan tindakan, yang kedelapan individu memiliki kapasitas koping yang bervariasi, dipengaruhi oleh 200 jurnal ners vol. 7 no. 2 oktober 2012: 196–202 kondisi genetik, lingkungan, kondisi stres, dan sumber yang tersedia, yang kesembilan sakit dapat menumbuhkan dan mengembangkan psikologis bagi individu, yang kesepuluh setiap orang mempunyai hak mendapatkan pelayanan kesehatan yang sama, yang kesebelas kesehatan mental adalah komponen kritikal dan penting dari pelayanan kesehatan komprehensif, yang ke duabelas individu mempunyai hak untuk berpartisipasi dalam pembuatan keputusan untuk kesehatan fi sik dan mentalnya, yang ketigabelas t ujuan keperawat an adalah meningkatkan kesejahteraan, memaksimalkan f u ngsi (mem i n i mal ka n kecacat a n at au ket id a k ma mpu a n) d a n men i ng k at k a n aktialisasi diri, yang keempatbelas hubungan interpersonal dapat menghasilkan perubahan dan pertumbuhan pada individu. diskusi mendalam tentang falsafah keperawatan jiwa ini diharapkan dapat meningkatkan peran keluarga dalam memberikan dukungan harga diri dan stabilitas psikologis pasien, sehingga koping keluarga dalam merawat pasien gangguan jiwa (skizofrenia) di rumah dapat lebih baik. koping keluarga dalam merawat pasien gangguan jiwa adalah merupakan kemampuan adaptasi keluarga dalam menghadapi stressor berat dan lama (kronis) akibat salah satu anggota keluarga mengalami gangg uan jiwa. mccubbin (2001) mengidentif ikasi instrumen yang dapat digunakan mengukur koping keluarga dalam mengatasi stressor kronis adalah dengan coping health inventory for parents (chip), meliputi, kemampuan memelihara integritas keluarga, kerja sama, dan memandang sit uasi dengan positif, kemampuan keluarga memelihara dukungan sosial, harga diri, dan stabilitas psikologis, kemampuan keluarga memahami situasi medis, komunikasi dengan orang lain, dan konsultasi dengan petugas kesehatan. mccubbin (2001) mengembangkan instrumen evaluasi diri berbentuk check list: coping health inventory for parents (chip) tentang perilaku spesifi k dalam menghadapi stres kronis yang dialami keluarga. struktur kuesioner chip didasarkan pada perilaku penting dari keluarga dalam berespons terhadap stress (mccubbin, 1991), termasuk hubu nga n i nter personal a nt a r a nggot a keluarga dan masyarakat, termasuk hubungan emosional, harga diri, dan jejaring social. teori stress keluarga di mana mengandung persepsi keluarga dalam mengelola keadaan stress yang lama, teori psikologi koping individu di mana difokuskan pada kondisi psikologis aktif dan pasif dalam mengelola peningkatan emosi dan kecemasan, dan peran keluarga dalam memberikan pelayanan atau bantuan terhadap pasien, ter masu k komu ni kasi keluarga dengan team petugas kesehatan dan orang lain yang mempunyai masalah sama. semua item ini digunakan untuk memprediksi dan mendiskripsikan bagaimana keluarga beradaptasi terhadap situasi stress kronis, yang dalam beberapa keadaan disebut coping behavior. lipowski membagi coping menjadi coping style dan coping strategy. coping style adalah mekanisme adaptasi individu meliputi aspek psikologis, kognitif, dan persepsi. coping strategy merupakan koping yang dilakukan secara sadar dan terarah dalam mengatasi rasa sakit atau menghadapi stressor. dua strategi koping yang biasa digunakan individu dalam mengatasi permasalahan adalah problem-solving focused coping, di mana individu secara aktif mencari penyelesaian dari masalah untuk menghilangkan kondisi atau situasi yang menimbulkan stres, dan emotion-focused coping di mana individu melibatkan berbagai upaya untuk mengatur emosinya dalam rangka menyesuaikan diri dengan dampak yang akan ditimbulkan oleh kondisi atau situasi yang penuh tekanan. seseorang cenderung menggunakan problemsolving focused coping dalam menghadapi masalah yang menurutnya bisa dikontrol seperti masalah yang berhubungan dengan sekolah atau pekerjaan, seseorang cenderung menggunakan strategi emotion-focused coping ketika dihadapkan pada masalah yang sulit dikontrol seperti masalah yang berhubungan dengan penyakit yang tergolong berat dan kronis seperti kanker, aids dan gangguan jiwa. menurut mccubbin (2001), ketika salah satu anggota keluarga mengalami penyakit kronis, kecacatan, termasuk gangguan jiwa, 201 peningkatan coping keluarga (ah. yusuf, dkk) keluarga har us member ikan perawatan dalam waktu yang panjang, dan harus tetap mendukung agar pasien dapat menjalankan kegiatan rutin harian. harapan seluruh anggota keluarga diperlukan unt uk bisa melihat dampak keluarga dalam memberikan bantuan adaptasi pasien. oleh karena itu, pengukuran koping keluarga dalam penelitian ini diukur melalui tiga sub variabel yang dikembangkan ol e h m c c u b b i n , y a i t u , k e m a m p u a n memelihara integritas keluarga, kerja sama, dan memandang sit uasi dengan positif, kemampuan keluarga memelihara dukungan sosial, harga diri, dan stabilitas psikologis, dan kemampuan keluarga memahami situasi medis, komunikasi dengan orang lain, dan konsultasi dengan petugas kesehatan. simpulan dan saran simpulan koping keluarga mengalami perubahan pada aspek memelihara integritas keluarga, kerjasama, memandang situasi dengan positif, dan memahami situasi medis, komunikasi dengan orang lain, serta konsultasi dengan petugas kesehatan. tidak terdapat perbedaan pada aspek memelihara dukungan sosial, harga diri dan stabilitas psikologis, meskipun demikian terdapat perbedaan selisih nilai rerata antara kelompok perlakuan dan kelompok kontrol. saran harga diri keluarga yang salah satu anggota keluarganya mengalami gangguan jiwa perlu ditingkatkan agar st abilit as psikologis pasien dapat berkembang baik dalam keluarga. kepustakaan ahmadi, f., 2006. culture, religion and spirituality in coping. sweden: uppsala university library. bown, j. dan williams, s., 1993. spirituality in nursing: a review of the literatur. journal of advances in health and nursing care, 2(4): 41–66. chiu l., mor row, marina, ganesan, s., dan clark, n., 2005. spirituality and treatment choices by south and east asian women serious mental illnes, (o n li ne), ht t p://t ps.sage pub.com., diakses tgl 6 november 2009. dossey, a.m., keegan, l., guzzetta, c.e., 2005. holistic nursing a handbook for practice, fourth edition. massachusetts: jones and bartlet publisher inc. fitryasari, p.k.r., nihayati, h.e., yusuf, a., 2009. pengalaman keluarga selama mera wat anggota keluarga yang mengalami gangguan jiwa di ruang jiwa c rsu dr. soetomo surabaya. laporan hasil penelitian fkp unair, t id a k di publi kasi ka n. su rabaya: universitas airlangga. gladding, s.t., 2002. family therapy; hystory, theory, and practice (3rd edition). london: perason education inc. hamid, a.y., 1999. aspek spiritual dalam keperawatan. jakarta: widya medika. hartanto, i., 2010. 4 kekuatan mahadahsyat; ikhlas, sabar, syukur, do'a, syura yogjakarta: media utama. keliat, b.a., nancy, p., windarwati, h.d., 2009. pengelolaan consultation liaison mental health nursing (clmhn) pada pelayanan umum, makalah disajikan dalam seminar dan workshop. malang. maramis, 2006. mengurangi resiko gangguan jiwa, (online), (http://www.suarakaryaon l i ne.c om /news.ht m l.id=157830, diakses tanggal 25 oktober 2009). maramis, w.f., 1998. catatan ilmu kedokteran jiwa. surabaya: airlangga university press. mccubbin, h.i. dan thompson, a.i., 1991. family assessment inventories for research and practice, madison: university of wisconsin. moh r, w.k., 2006. psychiatric mental health nursing. (6th ed.), philadhelpia: lippincott williams wilkins. ph a r o a h , f., m a r i , j., r at hb o n e , j., wong, w., 2010, family intervention for schizophrenia (review), the cocrane collaboration, wiley publishers. p ut ra , s.t., 2011. psik on uroimunologi ke d ok te ra n, e d isi 2 , su r abaya: airlangga university press. 202 jurnal ners vol. 7 no. 2 oktober 2012: 196–202 sentanu, e., 2010, quantum ikhlas; teknologi aktivasi kekuatan hati, the power of positive feeling. jakarta: pt. elex media komputindo. stuart, g.w. dan sundeen, s.j., 1995. principles and practice of psychiatric nursing, st. louise: mosby year book. sullivan, n. dan walton, j., 2004. men of prayer: spi r it ualit y of men with prostate cancer: a grounded theory stud, journal of holistic nursing. 133– 151, (online), (http://jhn.sagepub.com, diakses tgl 6 november 2010). tanyi, r.a., 2006. spirituality and family nursing; spiritual assessment and inter ventions for family. journal compilation; blackwall publishing ltd. 40 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 40-46 http://dx.doi.org/10.20473/jn.v18i1.43704 original article open access determinant factors of anemia in pregnancy based on health belief model: a correlational study mira triharini 1 * , eka mishbahatul mar’ah has 1 , and gita nofita 1 1 faculty of nursing, universitas airlangga, surabaya, indonesia *correspondence: mira triharini. address: faculty of nursing, universitas airlangga, surabaya, indonesia. email: mirat@fkp.unair.ac.id responsible editor: retnayu pradanie received: 26 february 2023 ○ revised: 29 february 2023 ○ accepted: 29 february 2023 abstract introduction: pregnancy anemia is still a big problem worldwide. health behavior can be influenced by perceptions of the importance of disease prevention. the theory of the health belief model can study the relationship between prevention efforts and perceptions. the purpose was to analyze the relationship between perceived susceptibility, perceived severity, perceived benefit, perceived barrier, self-efficacy and cues to action with anemia prevention behaviors. methods: this study used a correlational design cross-sectional approach. the total samples were 104 pregnant women selected using purposive sampling. the independent variables in this study were perceived susceptibility, perceived severity, perceived benefit, perceived barrier, self-efficacy, and cues to action. the dependent variable in this study was anemia prevention behaviors. data were collected at one obstetrical polyclinic in hospital and also home visits were conducted to respondents who did not come to the hospital. the instrument used questionnaires on perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, cues to action and anemia prevention behaviors. results: perceived susceptibility (p=0.023 r=0.223), and cues to action (p=0.037 r=0.204) had a significant relationship with anemia prevention behaviors., while there was no relation between perceived severity (p= 0.839), perceived benefit (p= 0.986), perceived barrier (p= 0.585), and self-efficacy (p=0.399) with anemia prevention behaviors. conclusions: health workers can increase the susceptibility and cues to action of pregnant women through health education about anemia prevention. keywords: anemia, health promotion, health belief model, maternal health, maternity nursing introduction anemia persists as a health problem for pregnant women around the world (hasan et al., 2022). anemia not only results in the death of the mother but also the fetus; therefore, a serious concern by all relevant parties is needed (daru et al., 2018). various efforts to prevent anemia in pregnant women have been carried out. the indonesian government has pursued a prevention program by providing 90 iron supplements to pregnant women, but the incidence of anemia in pregnant women is still high (ministry of health ri, 2016). the many causes of pregnancy anemia in women are due to differences in socioeconomic conditions, lifestyles, or health-seeking behaviors that come from various diverse cultures (lin et al., 2018). it is estimated that 40% of pregnant women worldwide suffer from anemia. the incidence of anemia pregnant women in southeast asia is as many as 48.7% or around 202 million people (who, 2016). this is also in line with pregnant women who experience anemia in https://creativecommons.org/licenses/by/4.0/ mailto:mira-t@fkp.unair.ac.id mailto:mira-t@fkp.unair.ac.id https://orcid.org/0000-0001-7872-6256 https://orcid.org/0000-0002-1786-285x https://orcid.org/0009-0006-7814-9480 jurnal ners http://e-journal.unair.ac.id/jners 41 indonesia; in 2013 there were 37.1% of pregnant women experienced anemia, and this increased in 2018 to 48.9%. there are still 70-80% of pregnant women in indonesia who experience anemia during pregnancy (kemenkes ri, 2018). the incidence of anemia in pregnant women in south kalimantan province is based on data from the south kalimantan provincial health office (2016) as many as 21,141 people (27.43%) (rizani & yuliastuti, 2020). according to patient registration data at bontang hospital from november 2018 to september 2019, there were 1127 pregnant women patients, with hb levels <8gr/dl in 27 (2.3%) cases, hb levels 8-8.9 gr/dl in 69 (6.1%) cases, hb10-10.9gr/dl in 253 (22.4%) cases, hb>11gr/dl in 611 (54.2%) cases. from the above data it can be seen that pregnant women with low hb levels or anemia totaled 349 (30.8%) cases (rsud bontang, 2019). a pregnant woman's belief in her body condition affects her behavior in maintaining health. an individual will take precautions when one is considered susceptible to conditions that have serious consequences (bazargani et al., 2022). many factors influence the behavior of pregnant women in preventing anemia, one of the examples is the perception that anemia is naturally experienced by women during pregnancy (klankhajhon et al., 2021), as well as dietary restrictions during pregnancy which affect the dieting behavior of pregnant women (mariana et al., 2018). the perception and behavior of pregnant women in preventing anemia can be seen from the theory of the health belief model. at present, the factors related to the behavior of pregnant women in preventing anemia have not been resolved. providing health information to pregnant women or those preparing for pregnancy is very important so that the women will understand more about anemia as well as nutritional benefits during pregnancy to prevent anemia (triharini et al., 2018a). the health belief model theory as a nursing theory can be used as a basic theory to assist patients’ behavior to improve their health status. the advantage of the health belief model theory is to describe individual beliefs about carrying out healthy living behaviors. the healthy behavior is in the form of preventive behavior and the use of health facilities (becker et al., 1977). this study aims to analyze the relationship between perceived susceptibility, perceived severity, perceived benefit, perceived barrier, self-efficacy, and cues to action with anemia prevention behaviors. materials and methods research design this study applied a descriptive correlational design with cross-sectional approach. the population of the study consisted of pregnant women that visited during the period from june to december 2020 at the obstetric polyclinic at bontang hospital, east kalimantan, indonesia. research subject this study used purposive sampling, namely a sampling technique by selecting samples from the population according to the objectives or problems in research (nursalam, 2016). sample size was based on slovin’s formula (sugiyono, 2015). the sample that met the criteria was 104 people. drop out calculation was plus 10% of the total sample, w here the drop out criterion is mothers who cannot complete filling out all the research questionnaires given. the inclusion criteria used were the following: pregnant women with the ability to read and write, and able to communicate well and pregnant women in the 1-3 trimesters that received iron supplements. the exclusion criteria used were pregnant women who were in a state of sickness (experiencing mental disorders, complications of imminent abortion, preeclampsia, ectopic pregnancy, hyperemesis gravidarum, antepartum hemorrhage, placenta previa, complications of endocrine disease. the mothers who left the study during the research process were used as a dropout criterion. instruments the instruments for collecting this data were in the form of a behavior questionnaire to prevent anemia in pregnant women by rahmawaty (2019) which had its validity and reliability tested and a questionnaire that the researchers compiled themselves based on the opinions of experts and the conceptual framework of the health belief model theory. the questionnaires used included the perceived susceptibility (4 items of confidentiality), perceived severity (5 items of statement), perceived benefits (7 items of statements), perceived barriers (5 items of statements), self-efficacy (3 items of statements), cues to action (6 items of statements) and anemia prevention behaviors (11 items) that researchers have tested for validity and reliability. the results of the validity test results were all declared valid, with the value of r count > from the value of r table, namely the lowest r count value of 0.502; this value was more than the r table value of 0.444. reliability test results obtained cronbach’s alpha value = triharini, has, and nofita (2023) supremo, bacason, and sañosa (2022) 42 p-issn: 1858-3598  e-issn: 2502-5791 0.927 which means the questionnaire used is very reliable. data collection before conducting the research, researchers conducted preliminary research to determine the incidence of anemia in pregnant women and to find out the problems experienced by clients. the research was carried out at the same time as the outpatient polyclinic service. because of the current covid pandemic, pregnant women cannot come every month for antenatal care, so researchers make visits to homes whose areas can be reached by researchers. previously the researchers conducted health checks and conducted rapid tests / pcr to ensure researchers were in good health. the data obtained from the hospital's medical record were managed by the researcher to determine which respondents were included in the inclusion and exclusion criteria. collecting data from respondents at the obstetrical polyclinic at taman husada bontang hospital was in accordance with the control schedule, assistance in filling out the questionnaires assisted by obstetrical poly workers (officers in obstetrical polyclinics also follow the applicable health protocols), who have received information on the placement of attention with researchers. researchers conducted home visits to respondents who did not come to the hospital to check themselves. before visiting the house, the researcher contacted the respondent via whatsapp, and via telephone to ask for permission. at the time of data collection, the researcher followed the applicable health protocol. the researcher provided an explanation, information, advantage or benefit and then asked for approval through informed consent, ensuring that the respondent understood the contents of the questions by supporting the respondent. this provides opportunity for respondents to ask questions if anything is unclear. during data collection, researchers did not experience unexpected events such as changes in the respondent's health status, for example increased blood pressure/dizziness/anxiety and so on. data analysis data analysis used univariate analysis and bivariate analysis. univariate analysis was carried out on each variable from the research results. in general, this analysis produces the distribution and proportion of each variable, so that the variation of each variable in this study is known about the features of the respondents. this analysis is used to see the relationship of more than two independent variables and the dependent variable. statistical test to see the relationship between the independent and dependent variables used spearmen's rho correlation; is the data distribution is not normal with a significance level of α ≤ 0.05, the research hypothesis is accepted, if the significance level is α ≥ 0.05, then the research hypothesis is rejected. ethical consideration this research has received an ethical certificate from the ethics commission (kepk) of airlangga university, faculty of nursing with no. 2144-kepk, approval date 13 january 2021 and expiration date 13 january 2022. at the beginning of this study, participants fulfilled informed consent and demographic data. the researchers kept the data of each participant secret by using a code. results most of the respondents were in the age of 20-29 years (46.2%). almost 48 (46%) of respondents had graduated from high school/ equivalent. in addition, as many as 63 respondents (65%) had a family income below the regional minimum wage, and 52 (50%) respondents worked as housewives. the highest number of children was two children with 47 (45.2%) table 1 demographic characteristics of respondents (n=104) category n % age < 20 years 20 – 29 30 – 39 ≥ 40 5 48 37 14 4.8 46.2 35.6 13.5 education elementary school middle school high school undergraduate 9 13 48 34 8.6 12.5 46 32.6 income (rupiah) < 3.100.000 >3.100.000 63 41 60.5 39.4 occupation farmer entrepreneur house wife civil servant non permanent staff 4 11 52 29 8 3.8 10.5 50 27.8 7.6 number of children 1 2 3 >3 23 47 26 8 22.1 45.2 25.0 7.6 pregnancy interval 1 year 2 years ≥ 3 years 26 73 5 25 70.2 4.8 number of pregnancies 1 2 >2 0 23 81 0 22.1 77.8 total 104 100 jurnal ners http://e-journal.unair.ac.id/jners 43 respondents, the highest pregnancy interval was two years, with 73 (70.2%) respondents. in addition, as many as 81 respondents (77.8%) had more than two pregnancies (table 1). based on table 2, it can be seen that there is a relationship between perceived susceptibility (p=0.023 r=0.223), and cues to action (p=0.037 r=0.204) with anemia prevention behaviors. while there was no relation between perceived severity (p= 0.839), perceived benefit (p= 0.986), perceived barrier (p= 0.585), and self-efficacy (p=0.399) with anemia prevention behaviors. in the perceived susceptibility variable, the highest number is found in respondents with high perceived susceptibility and having sufficient anemia prevention behaviors, namely 72 respondents (69.3%). in the perceived severity variable, the highest number is found in respondents with high perceived severity and having sufficient anemia prevention behaviors, namely 49 respondents (47.1%). in the perceived benefits variable, the highest number is found in respondents with high perceived benefits and having sufficient anemia prevention behaviors, namely 52 respondents (50%). in the perceived barriers variable, the highest number is found in respondents with high perceived barriers and having sufficient anemia prevention behaviors, namely 52 respondents (47.1%). in the self-efficacy variable, the highest number is found in respondents with high selfefficacy and having sufficient anemia prevention behaviors, namely 49 respondents (50%). in the cues to action variable, the highest number is found in respondents with high cues to action and having sufficient anemia prevention behaviors, namely 75 respondents (72.1%). discussions most pregnant mothers feel vulnerable and have sufficient behavior in preventing anemia and some already have cues to action when considered vulnerable to a condition which has serious consequences. perceived susceptibility is a personal risk perceived by individuals, which in this case is related to perceptions of health conditions (lennon, 2016). perceived susceptibility includes a person's acceptance and sensitivity to their health conditions. the main findings of this research show that perceived susceptibility and cues to action had a significant relationship with pregnant mothers’ behavior in preventing anemia. respondents with high susceptibility factors tend to have sufficient preventive behavior. however, based on the results of the study, some respondents also fell into a moderate level of perceived susceptibility but had good behavior. in addition, due to the factor of ignorance, the mother was still willing to take preventive behaviors following recommendations from health workers. some mothers also had a high perceived susceptibility but had poor preventive behavior. perceived severity of illness or health conditions can be considered a threat; therefore, the individual is willing to take preventive action, follow the screening, and control the existing illness (glanz et al., 2002). triharini et al. (2018b) revealed that maternal education can be an obstacle to maternal compliance in consuming nutritional needs during pregnancy. respondents with high perceived severity tend to have sufficient behavior. from a demographic point of view, some respondents already had high levels of education, but low family income made some of the mothers unable to carry out good behavior and fell into table 2 the relationship between the hbm factors and the behavior of pregnant women in preventing anemia (n=104) variable category the behavior of pregnant women in preventing anemia good sufficient poor spearman rho test n % n % n % p r perceived susceptibility high 2 1,9 72 69,2 6 5,8 0.023 0.223 moderate 1 1,0 12 11,5 6 5,8 low 0 0,0 4 3,8 1 1,0 perceived severity high 1 1.0 49 47.1 6 5.8 0.839 0.020 moderate 1 1.0 31 29.8 5 4.8 low 1 1.0 8 7.7 2 1.9 perceived benefits high 1 1.0 52 50.0 6 5.8 0.986 0.002 moderate 1 1.0 23 22.1 6 5.8 low 1 1.0 13 12.5 1 1.0 perceived barriers high 1 1.0 49 47.1 6 5.8 0.585 0.054 moderate 2 1.9 35 33.7 5 4.8 low 0 0.0 4 3.8 2 1.9 self-efficacy high 2 1.9 52 50.0 6 5.8 0.399 0.084 moderate 1 1.0 28 26.9 6 5.8 low 0 0.0 8 7.7 1 1.0 cues to action high 2 1.9 75 72.1 7 6.7 0.037 0.204 moderate 1 1.0 13 12.5 6 5.8 low 0 0.0 0 0.0 0 0.0 triharini, has, and nofita (2023) supremo, bacason, and sañosa (2022) 44 p-issn: 1858-3598  e-issn: 2502-5791 sufficient behavior in maintaining their health. some respondents had low perceived severity and poor behavior, this was due to low educational factors which led to a lack of understanding regarding the severity of health conditions if mothers are suffering anemia. some respondents also regarded that pregnancy anemia normally occurred in pregnant women, which meant the severity of anemia did not become a condition that increased maternal awareness. the perceived severity of the mother related to anemia during pregnancy did not have an impact on pregnant women to increase their awareness status regarding health condition and the fetus. this was in line with research conducted by amir and djokosujono (2019) through a literature review study that found the perceived severity is not related to individual behavior in preventing anemia. this means the higher the severity felt by the mother, the less preventive behavior will be carried out. the high perceived severity does not change the behavior of the mother in preventing anemia in pregnancy; therefore, it does not increase the awareness of the mother to make preventive efforts. likewise, if the mother has a low perceived severity, it is not an indication that the mother does not make preventive efforts. pregnant women with a high perceived benefit will have good anemia prevention behavior. pregnant women that carry out anemia prevention depend on their belief in the impact of anemia and the success of its prevention efforts. efforts to prevent anemia can be done by having a balanced diet, treating infectious diseases that can increase the risk of anemia, and being willing to take iron supplements (parulian et al., 2016). mothers’ belief in the benefits of preventing anemia can occur by having support from family, social support (groups of pregnant women), and health workers (triharini, et al., 2018b). efforts to prevent anemia during pregnancy were dominated by moderate to high perceived benefits with the mother's behavior in the sufficient category. pregnant women understood and felt the impact of anemia; therefore, some women increased their willingness and preventive efforts. although the perceived benefits of the respondents were high, it did not always lead to good behavior in preventing pregnancy anemia. on the other hand, if the perceived benefits of the respondent low, it did not mean that the respondent would have poor anemia prevention. this can be caused by low family income which was below the minimum regional wage. even though the pregnant women already understood the benefits of this anemia prevention behavior, they were unable to prepare a balanced diet (khoramabadi et al., 2015). this is in line with research conducted by diddana et al. (2018) which states that the perceived benefit does not affect the behavior of pregnant women in preventing pregnancy anemia. whether the benefit exists or nonexistent, it does not affect the mother's behavior in preventing anemia. according to glanz et al. (2002), the perceived barriers are anything that hinders an individual from making certain behavior changes. the hbm theory, explains that everything that hinders can be seen in terms of costs, benefits, unsatisfactory and pleasant health services, and support from family and others. based on the results of the study, the perceived barriers of the mothers were due to the lack of understanding about the benefits of iron supplements, nausea felt when consuming iron supplements, and occupied with activities which led to the absence of doing anc examination, as well as the factor of income and support from the husband (family member). however, some of these barriers could be overcome by mothers so that they were able to carry out preventive efforts in a sufficient way. respondents with high perceived barrier perceptions were dominated by those who had sufficient anemia prevention behavior, not too good and not too poor. the respondents did not understand the benefits of preventive behavior, for example, the consumption of iron supplements regularly and anc checks. barriers can also occur due to demographic factors such as inadequate family income which causes respondents to be unable to prevent pregnancy anemia, by consuming balanced nutrition during pregnancy. some respondents also had a good level of education and high income but did not have sufficient behavior for various reasons, such as not consuming the iron supplements because of the taste. however, it is not in line with the research conducted by triharini et al., (2018b) who suggest that the perceived barrier by pregnant women has a significant correlation with the behavior of pregnant women in preventing pregnancy anemia). according to the social cognitive theory (bandura, 2010), a sense of personal control facilitates changes in health behavior. according to the theory, the higher the belief in one's self-efficacy, the better the health behavior is shown. on the contrary, the lower the confidence in one's own self-efficacy, the change in health behavior would be lower. therefore, family support is very important for pregnant women to increase confidence (mardhiah & marlina, 2019). in an explanation of the results of a study, prevention of jurnal ners http://e-journal.unair.ac.id/jners 45 anemia by providing iron supplements to mothers who were at high risk of suffering from anemia includes individuals from families with low socioeconomic conditions (abdulsalam & daniel, 2016). the absence of a significant relationship in this study was due to the number of respondents who believed in anemia prevention was dominated by the sufficient category, not all the respondents had good pregnancy anemia prevention behavior, and on the other hand, not all respondents with low self-efficacy had poor anemia prevention behavior. this was probably because the pregnant women did not feel confident enough about their own preventive behaviors such as buying and consuming healthy food, obeying the consumption of iron supplements, and carrying out routine anc examinations. the low level of education also had an impact. some respondents did not understand the benefits of consuming iron supplements. the lowincome factor also caused uncertainty for nutritional intake during pregnancy. belief in self-efficacy did not affect the mother's behavior in preventing pregnancy anemia. this is not in line with research conducted by cal et al. (2020), which states that self-belief has a direct and significant relationship with the behavior of pregnant women in preventing anemia. cues to action is the perception of an individual's willingness to take preventive action through information from the media, health workers, or families who are also influenced by individual sociodemographic aspects (darmawati et al., 2020). cues to action can be obtained from educational information provided by health workers either directly or through printed, electronic, or social media information. in addition, the information provided by the family can also increase the mother's willingness to increase prevention efforts against anemia (heru et al., 2012). respondents with high cues to action tend to have sufficient behavior. the reason was due to the majority of respondents had been provided with information from health workers. the existence of increasingly sophisticated technology has made accessing information easier from electronic media and mass media. another explanation is that most of the mothers were multigravidas. even so, some respondents had high cues to action but poor behavior caused by demographic factors, namely low education and lack of support from their families/ husbands. the results of this study were in line with research conducted by salama (2018), which states that the higher the cues to action for a pregnant woman, the higher the preventive behavior that the mother does. perceived susceptibility has a relationship with maternal behavior in preventing anemia during pregnancy, because mothers who feel high susceptibility to a hazard will make better prevention efforts, especially in behavior to prevent anemia in pregnancy. perceived severity is not related to maternal behavior in preventing anemia during pregnancy. mothers feel that anemia during pregnancy is a natural thing for mothers to experience and does not have a serious effect on their health. many or at least the perceived benefits by the mother during pregnancy are not related to the behavior of pregnant women in preventing anemia. perceived barriers are also not related to the behavior of pregnant women in preventing anemia. the higher the perceived barriers, the worse the behavior of pregnant women in preventing anemia during pregnancy. the level of cues to action in a mother is not related to her behavior in preventing anemia during pregnancy. cues to action in pregnant women has a relationship with the mother's behavior in preventing anemia during pregnancy, meaning that the higher the desire to act, the better the behavior of pregnant women in preventing anemia. this can happen because pregnant women can easily get information from the media, as well as health workers. consistent health counseling provided by health workers concerning pregnancy anemia leads to sufficient behavior and willingness to act. cues to action have a significant relationship with the behavior of pregnant women in preventing pregnancy anemia. the higher the respondent's cues to action, the better the anemia prevention behavior is carried out. conversely, the lower cues to action, then the lower the anemia prevention behavior of pregnant women (darmawati et al., 2020). it is expected to conduct further research by providing interventions, especially about anemia in pregnancy to improve maternal behavior in preventing anemia during pregnancy, which is based on the health belief model. the limitation in this study is purposive sampling means the finding cannot be generalized and the self-reported questionnaire has several limitations to measure behavior. conclusions perceived susceptibility and cues to action have a relationship with maternal behavior in preventing anemia during pregnancy. developments in health education should consistently be carried out to increase public awareness concerning good behavior in maintaining health. providing health education is important regarding the compliance with routine anc triharini, has, and nofita (2023) supremo, bacason, and sañosa (2022) 46 p-issn: 1858-3598  e-issn: 2502-5791 check-ups, the benefits of iron supplements, and balanced nutrition for pregnant women during pregnancy. it is also important to provide a correct understanding regarding anemia and the impact of pregnancy anemia on mothers, in turn encouraging pregnant women to behave better in maintaining their health, especially in preventing pregnancy anemia from occurring. the education provided also should consider the mother's socioeconomic and demographic characteristics. it is important to carry out further research by providing interventions to audio-visual behavior groups, especially providing education about anemia in pregnancy to increase perceived susceptibility and cues to action, which is based on the health belief model. references abdulsalam, m., & daniel, a. (2016). diagnosis, pengobatan dan pencegahan anemia defisiensi besi. sari pediatri, 4(2), 74. https://doi.org/10.14238/sp4.2.2002.74-7 amir, n., & djokosujono, k. (2019). faktor-faktor yang berhubungan dengan konsumsi tablet tambah darah (ttd) pada remaja putri di indonesia: literatur review. jurnal kedokteran dan kesehatan, 15(2), 119. https://doi.org/10.24853/jkk.15.2.119-129 bandura, a. (2010). self‐efficacy. the corsini encyclopedia of psychology, 1–3. bazargani, z., sarikhani, f., darenjani, s. k., amirkhani, m., harsini, p. a., & khani jeihooni, a. (2022). effect of educational intervention based on health belief model on promoting preventive behaviours of urinary tract infections in mothers with children under 6-years of age. bmc women’s health, 22(1), 1–8. https://doi.org/10.1186/s12905-022-01981-x becker, m.h., haefner, d.p. and maiman, l. a. (1977). the health belief model in the prediction of dietary compliance: a field experiment. journal of health and social behaviour, 18, 348–66. darmawati, d., siregar, t. n., kamil, h., & tahlil, t. (2020). barriers to health workers in iron deficiency anemia prevention among indonesian pregnant women. anemia, 2020. https://doi.org/10.1155/2020/8597174 daru, j., zamora, j., fernández-félix, b. m., vogel, j., oladapo, o. t., morisaki, n., tunçalp, ö., torloni, m. r., mittal, s., jayaratne, k., lumbiganon, p., togoobaatar, g., thangaratinam, s., & khan, k. s. (2018). risk of maternal mortality in women with severe anaemia during pregnancy and post partum: a multilevel analysis. the lancet global health, 6(5), e548–e554. https://doi.org/10.1016/s2214-109x(18)30078-0 diddana, t. z., kelkay, g. n., dola, a. n., & sadore, a. a. (2018). effect of nutrition education based on health belief model on nutritional knowledge and dietary practice of pregnant women in dessie town, northeast ethiopia: a cluster randomized control trial. journal of nutrition and metabolism, 2018. https://doi.org/10.1155/2018/6731815 glanz, k., rimer, b. k., & viswanath, k. (2002). health behavior and health education theory, research, and practice (4th editio). jossey-bass a wiley imprint san francisco. hasan, m. m., soares magalhaes, r. j., garnett, s. p., fatima, y., tariqujjaman, m., pervin, s., ahmed, s., & mamun, a. a. (2022). anaemia in women of reproductive age in low-and middle-income countries: progress towards the 2025 global nutrition target. bulletin of the world health organization, 100(3), 196–204. https://doi.org/10.2471/blt.20.280180 heru, r., hasanbasri, m., & hakimi, m. (2012). counseling for pregnant women at midwife practice and community health center at bantul district. jurnal kebijakan kesehatan indonesia, 01(3), 168– 172. kemenkes ri. (2018). laporan nasional riskesdas 2018. kementrian kesehatan ri, 1–582. khoramabadi, m., dolatian, m., hajian, s., zamanian, m., taheripanah, r., sheikhan, z., mahmoodi, z., & seyedi-moghadam, a. (2015). effects of education based on health belief model on dietary behaviors of iranian pregnant women. global journal of health science, 8(2), 230–239. https://doi.org/10.5539/gjhs.v8n2p230 klankhajhon, s., pansuwan, k., klayjan, k., & nensat, n. (2021). perspectives of pregnant women regarding iron deficiency anemia. jurnal ners, 16(2), 119–127. https://doi.org/10.20473/jn.v16i2.27418 lennon, s. l. (2016). risk perception in pregnancy: a concept analysis. journal of advanced nursing, 72(9), 2016–2029. https://doi.org/10.1111/jan.13007 lin, l., wei, y., zhu, w., wang, c., su, r., feng, h., & yang, h. (2018). prevalence, risk factors and associated adverse pregnancy outcomes of anaemia in chinese pregnant women: a multicentre retrospective study. bmc pregnancy and childbirth, 18(1), 1–8. https://doi.org/10.1186/s12884-018-1739-8 mardhiah, a., & marlina, m. (2019). faktor-faktor yang mempengaruhi kepatuhan mengkonsumsi tablet fe pada ibu hamil. window of health : jurnal kesehatan, 2(3), 266–276. https://doi.org/10.33368/woh.v0i0.182 mariana, d., wulandari, d., & padila, p. (2018). hubungan pola makan dengan kejadian anemia pada ibu hamil di wilayah kerja puskesmas. jurnal keperawatan silampari, 1(2), 108–122. https://doi.org/10.31539/jks.v1i2.83 ministry of health ri. (2016). profil kesehatan indonesia. kementerian kesehatan republik indonesia. nursalam, n. (2016). metodologi penelitian ilmu keperawatan pendekatan praktis. salemba medika. parulian, i., roosleyn, t., tinggi, s., kesehatan, i., & widya, j. i. (2016). strategi dalam penanggulangan pencegahan anemia pada kehamilan. jurnal ilmiah widya, 3(3), 1–9. rahmawaty. (2019). analisis faktor perilaku pencegahan anemia pada ibu hamil dengan pendekatan teori lawrence w. green. 2019. rizani, a., & yuliastuti, e. (2020). determinan anemia dalam kehamilan di wilayah kerja puskesmas sungai tabuk i kabupaten banjar tahun 2019. jurnal skala kesehatan, 11(2), 56–66. https://doi.org/10.31964/jsk.v11i2.240 rsud bontang. (2019). data register pasien rsud bontang. salama, a. m. (2018). utilizing health belief model to enhance the preventive behavior againts iron-deficiency anemia among pregnant women. iosr journal of nursing and health science, 7(2), 59–69. https://doi.org/10.9790/1959-0704015969 sugiyono. (2015). teknik pengumpulan data. in teknik pengumpulan data, pp, 1689–1699. triharini, m., armini, n. k. a., & nastiti, a. a. (2018). effect of educational intervention on family support for pregnant women in preventing anemia. belitung nursing journal, 4(3), 304–311. triharini, m., nursalam, sulistyono, a., adriani, m., armini, n. k. a., & nastiti, a. a. (2018). adherence to iron supplementation amongst pregnant mothers in surabaya, indonesia: perceived benefits, barriers and family support. international journal of nursing sciences, 5(3), 243–248. https://doi.org/10.1016/j.ijnss.2018.07.002 who. (2016). "strategies to prevent anaemia: recommendations from an expert group consultation‟, strategies to prevent anaemia: recommendations from an expert group consultation. how to cite this article: triharini, m., has, e. m. m., and nofita, g. (2023) ‘determinant factors of anemia in pregnancy based on health belief model: a correlational study’, jurnal ners, 18(1), pp. 40-46. doi: http://dx.doi.org/10.20473/jn.v18i1.43704 ners vol 5 no 1 april 2010_akreditasi 2013.indd 87 stimulasi kutaneus slow-stroke back massage menurunkan intensitas nyeri osteoartritis pada lansia (cutaneus stimulation: slow-stroke back massage reduces the intensity of osteoartritis pain of elderly) mira trihartini*, mardliyah**, setho hadisuyatmana* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257. e-mail: rara_raditya@yahoo.co.id ** rsud dr. moch. soewandi surabaya abstract introduction: osteoarthritis disease is the result of both mechanical and biological process which lead come to unstable degradation and synthesis of condrozyte cartilage and extracellular matrix. the risk factor of this instability is aging process. the aging process stimulates osteophytes formation and degradation of cartilage, and emerged pain as primary clinical symptom. one of the non pharmacological ways to cope this pain is by applying cutaneus stimulation through slow-stroke back massage method. the objective of this study was to analyze the effect of applying cutaneus stimulation with slow-stroke back massage method to osteoarthritis’s pain intensity. method: pre experimental design with one group pre test-post test approach was used in this study. the subject of this study were elderly above 50 years old living in panti werdha hargo dedali surabaya, 15 participants were involved using purpose sampling technique. this study started on january 29th until february 6th, 2010. data were collected by interview and observation and analyzed by wilcoxcon signed rank test α = 0.05, p value <α. result: the resul showed that the message intervention was signifi cantly affect the elder’s level of osteoarthritis pain in panti werdha hargo dedali surabaya (p = 0.003). discussion: it can be concluded that gives stimulation cutaneus: slow-stroke back massage reduce osteoathritis pain intensity. slow-stroke back massage increase level of endorphin, so that pain reduction and individual pain perception will decrease. keywords: slow-stroke back massage, pain intensity, osteoarthritis, elderly pendahuluan perkembangan jumlah penduduk lanjut usia (lansia) di indonesia mengalami peningkatan dari tahun ke tahun. berdasarkan data biro pusat statistik tahun 2009 menunjukkan peningkatan usia harapan hidup (uhh) dari 64,5 tahun menjadi 70,5 tahun tersebut menjadi 23,9 juta jiwa (irwanasir, 2009). peningkatan jumlah lansia yang tinggi berpotensi menimbulkan berbagai macam permasalahan baik dari aspek sosial, ekonomi, budaya, maupun kesehatan (nugroho, 2000). data depkes ri 2008 menunjukkan bahwa salah satu penyakit degeneratif yang sering dikeluhkan oleh lansia adalah penyakit sendi (52,3%) terutama osteoathritis (peradangan pada sendi atau tulang) (puskom, 2008). keluhan utama yang paling sering terjadi pada osteoathritis adalah nyeri pada persendian, yang membuat penderita sering kali takut untuk bergerak sehingga mengganggu aktivitas sehari-hari dan menurunkan produktivitas. penanganan nyeri sendi yang dapat dilakukan di antaranya dengan menggunakan terapi farmakologi dan atau terapi non farmakologi (grainger dan cicuttino, 2004). stimulasi kutaneus, distraksi, relaksasi, imajinasi terbimbing dan hipnosis adalah contoh intervensi non farmakologis yang sering digunakan dalam keperawatan untuk mengelola nyeri. pada osteoartritis, umumnya pengelolaan nyeri dilakukan dengan stimulasi kutaneus seperti terapi panas/dingin, latihan/aktivitas fisik dan distraksi (reeves, 1999; koopman, 1997). masase dan sentuhan, merupakan teknik integrasi sensori yang memengaruhi aktivitas sistem saraf otonom (meek, 1993 jurnal ners vol. 5 no. 1 april 2010: 87–92 88 dalam potter dan perry, 2005). salah satu terapi modalitas fisik yaitu slow stroke back massage. terapi tersebut sudah mulai dikembangkan di indonesia pada kasus low back pain sejak tahun 2005 dan menunjukkan angka keberhasilan mencapai 30% dalam menurunan intensitas nyeri (sumartini, 2008). beberapa penelitian juga telah mengidentifikasi manfaat dari slow-stroke back massage antara lain penurunan secara bermakna pada intensitas nyeri dan kecemasan serta perubahan positif pada denyut jantung dan tekanan darah, yang mengindikasikan relaksasi pada pasien lansia dengan stroke (mok, et al., 2004), di samping itu penggunaan terapi non farmakologis ini tidak mempunyai efek samping berarti dan mudah dalam pengaplikasiannya. namun sampai dengan saat ini belum ada penelitian tentang pengaruh stimulasi kutaneus: slow stroke back massage terhadap intensitas nyeri osteoathritis. i n s i d e n o s t e o a r t r i t i s m e n y e r a n g pada usia di atas 35 tahun dan meningkat pada kelompok wanita yang berusia di atas 50 tahun (reeves, 1999). prevalensi nyeri yang disebabkan osteoathritis di indonesia sebesar 36% (handoyo, 2009). berdasarkan hasil studi pendahuluan di panti wreda hargo dedali pada tanggal 20 oktober 2009 didapatkan jumlah lansia di panti wreda adalah 36 orang dan 67% lansia mengeluh nyeri pada punggung. hasil pemeriksaan rontgen lumbal terhadap responden tersebut sebanyak 75% di antaranya menunjukkan spondylosis lumbal dan osteoathritis acetabuli. penanganan sistem nyeri medial (yang memproses aspek emosional dari nyeri seperti ketakutan dan stres) sangat penting pada pasien osteoathritis dibandingkan sistem lateral yang memproses sensasi fisik seperti intensitas, durasi, dan lokasi nyeri, selama episode nyeri. nyeri pada osteoathritis terjadi sebagai akibat spasme otot atau tekanan pada saraf di daerah sendi yang terganggu dan pertumbuhan tulang yang berlebihan sehingga merangsang akar saraf sewaktu keluar dari tulang vertebra (price, 2005). kondisi tersebut mengakibatkan pasien sering kali takut untuk bergerak sehingga mengganggu aktivitas sehari-hari dan dapat menurunkan produktivitas yang akan berdampak terhadap penurunan kualitas hidup, sedang pada masa tua diharapkan menjadi tua sejahtera, sehat, produktif sehingga kualitas kesehatan lansia meningkat. oleh karena itu manajemen sistem nyeri sebaiknya dijadikan target baru baik untuk intervensi farmakologi maupun non farmakologi (kulkarni et al., 2007). salah satu teknik masase punggung yang dapat digunakan adalah dengan usapan yang perlahan (slow-stroke back massage). penggunaan lotion diharapkan memberikan sensasi hangat dan mengakibatkan vasodilatasi lokal (kenworthy, 2002). vasodilatasi akan meningkatkan peredaran darah pada area yang diusap sehingga aktivitas sel meningkat dan akan mengurangi rasa sakit (kusyati, 2006; stevens, 1999). sensasi hangat juga dapat meningkatkan rasa nyaman (reeves, 1999). nilai terapeutik yang lain dari masase punggung termasuk mengurangi ketegangan otot dan meningkatkan relaksasi fisik dan psikologis (kusyati, 2006). berdasarkan masalah tersebut perlu dilakukan penelitian untuk mengetahui pengaruh stimulasi kutaneus: slow-stroke back massage terhadap intensitas nyeri osteoartritis pada lansia di panti werdha hargo dedali. bahan dan metode penelitian ini menggunakan rancangan penelitian metode pra eksperimental dalam satu kelompok (one group pretest-posttesti). sebelum memberikan perlakuan berupa stimulasi kutanius: slow-stroke back massage terhadap lansia yang mengalami nyeri osteoathritis, langkah awal yang dilakukan adalah mengidentifikasi lansia yang mengalami nyeri punggung dan memastikan nyeri tersebut disebabkan osteoathritis dengan pemeriksaan radiologis. setelah mengidentifikasi satu kelompok lansia yang mengalami nyeri karena osteoathritis diobservasi terlebih dahulu, kemudian menentukan intensitas skala nyeri, setelah menentukan tingkat intensitas skala nyeri kemudian satu kelompok lansia yang mengalami nyeri osteoathritis diberi perlakuan yaitu stimulasi kutanius: slow-stroke back massage. setelah pemberian stimulasi kutanius: slow-stroke back massage yang mengalami stimulasi kutaneus menurunkan nyery artritis (mira t.) 89 nyeri osteoathritis diukur kembali tingkat intensitas nyeri dan kemudian dibandingkan apakah ada penurunan intensitas nyeri sebelum diberikan perlakuan dan sesudah diberikan perlakuan. populasi dalam penelitian ini adalah semua lansia yang mengeluh nyeri punggung di panti werdha hargo dedali berjumlah 24 orang, dengan besar sampel adalah 15 orang yang ditentukan berdasarkan kriteria inklusi. kriteria inklusi pada penelitian ini adalah lansia perempuan yang berusia >50 tahun, lansia dengan osteoartritis primer sesuai dengan catatan medik panti, lansia yang mengalami nyeri di punggung, tidak sedang menggunakan analgesic, tidak memiliki kontraindikasi untuk pijatan punggung seperti fraktur tulang rusuk atau vertebra, luka bakar, adanya daerah kemerahan pada kulit, atau luka terbuka pada punggung, kesadaran compos mentis dan mampu berkomunikasi dengan baik, kooperatif, dan bersedia menjadi subjek penelitian variabel independen dalam penelitian ini adalah pemberian stimulus kutaneus: slow-stroke back massage di mana dengan memberikan pijatan secara perlahan dan berirama dengan kecepatan 30 kali pijatan selama 10 menit pada kulit punggung dari bokong ke bahu dan sekitar bawah leher dengan acuan standar operasional prosedur (sop) sedangkan variabel dependen adalah intensitas nyeri osteoarthritis. instrumen intensitas nyeri berupa lembar observasi dengan menggunakan skala bourbonais untuk mengukur skala nyeri sesuai tingkat nyeri yaitu 0 tidak nyeri (tidak nyeri), 1–3 (nyeri ringan yaitu secara objektif pasien dapat berkomunikasi dengan baik), 4–6 (nyeri sedang yaitu secara objektif pasien mendesis, menyeringai, dapat menunjukkan lokasi nyeri dan mendiskripsikannya, serta dapat mengikuti perintah dengan baik), 7–9 (nyeri berat yaitu secara objektif pasien terkadang tidak dapat mengikuti perintah tapi masih respon terhadap tindakan, dapat menunjukkan lokasi nyeri, tidak dapat mendiskripsikannya, tidak dapat di atasi dengan alih posisi serta nafas panjang maupun distraksi, 10 (nyeri sangat berat yaitu pasien tidak mampu lagi berkomunikasi, mengikuti perintah, mengejan tanpa bisa dikendalikan, menarik-narik, memukul benda sekitar, tidak respon terhadap tindakan serta tidak dapat menunjukkan lokasi nyeri). data kemudian di tabulasi dan dianalisis dengan menggunakan uji wilcoxon signed rank test dengan tingkat kemaknaan α ≤ 0,05. hasil pengukuran intensitas nyeri sebelum p e r l a k u a n s l o w s t ro k e b a c k m a s s a g e menunjukkan bahwa seluruh responden mengeluh nyeri pada tingkat sedang karena tipe osteoathritis adalah nyeri sedang. setelah responden penelitian diberikan stimulasi kutaneus: slow-stroke back massage pada akhir masa perlakuan responden penelitian diobservasi tingkat nyerinya menggunakan skala bourbonais. terdapat penurunan frekuensi pada intensitas nyeri sedang sehingga hanya 40%, sedangkan responden yang menyatakan nyerinya meningkat sampai dengan 60%. penurunan nyeri yang berbeda-beda dipengaruhi oleh kadar endorphin pada seseorang yang berbeda-beda. s a a t p re t e s t s e l u r u h r e s p o n d e n mengalami nyeri pada tingkat sedang, dan setelah di berikan stimulasi kutaneus: slowstroke back massage tingkat nyeri 9 responden mengalami penurunan menjadi tingkat ringan dan 6 orang responden dengan intensitas nyeri tetap. hasil tersebut dilakukan uji statistik wilcoxon signed rank test dengan α = 0,05 didapatkan p = 0,003, maka dapat disimpulkan bahwa pemberian stimulasi kutaneus: slowstroke back massage mempunyai pengaruh terhadap intensitas nyeri osteoathritis pada lansia di panti werdha hargo dedali surabaya (tabel 1). jurnal ners vol. 5 no. 1 april 2010: 87–92 90 pembahasan penyakit osteoartritis terjadi kerusakan fokal tulang rawan sendi yang progresif dan pembentukan tulang rawan baru pada dasar lesi tulang rawan sendi dan tepi sendi (osteofit) (wyman, 1999). sebelum dilakukan pemberian stimulasi kutaneus: slow-stroke back massage pada nyeri osteoartritis peneliti melakukan observasi intensitas nyeri berdasarkan skala bourbonais dan didapatkan hasil seluruh responden mengalami nyeri sedang dengan nilai skala nyeri yang berbeda-beda. selanjutnya, bagian-bagian tonjolan-tonjolan tulang ini atau kartilago yang remuk masuk ke dalam cairan sinovial dan akhirnya menyebabkan timbulnya persepsi nyeri (reeves, 1999). persepsi yang dirasakan responden adalah nyeri sedang hal tersebut dikarenakan tipe nyeri osteoartritis termasuk nyeri kronis di mana klien sudah pernah merasakan nyeri sebelumnya dan berlangsung lebih dari 6 bulan. skala nyeri yang dipersepsikan oleh responden berbeda-beda meskipun stimulus diberikan dalam intensitas sama. perbedaan persepsi tersebut disebabkan oleh kadar endorphin, individu satu dengan lainnya berbeda dan nyeri merupakan pengalaman yang bersifat pribadi, serta dipengaruhi oleh faktor usia, dan pengalaman nyeri. refleksi perubahan kimia dari kartilago artikuler seiring dengan usia menyebabkan perubahan dalam fungsi kondrosit dan peningkatan perubahan pada komposisi tulang rawan sendi. adanya pengalaman nyeri sebelumnya membantu individu untuk dapat melakukan tindakan pada saat nyeri berikutnya. pemberian stimulasi kutaneus: slowstroke back massage selama 10 menit pada responden penelitian memperlihatkan hasil m a y o r i t a s 8 0 % r e s p o n d e n m e n g a l a m i penurunan skala nyeri, di mana 20% tetap dalam kategori sedang dan 60% terjadi perubahan kategori skala yaitu dari kategori sedang menjadi kategori ringan. penurunan nilai intensitas nyeri setiap individu berbedabeda walaupun stimulus yang menyebabkan nyeri dan perlakuan yang diberikan sama karena nyeri bersifat individu (mahon, 1994 dalam potter dan perry, 2005) sehingga respons yang terjadi setelah perlakuan tidak dapat disamakan dengan orang lain. perbedaan nyeri yang adekuat atau tidak di masa lalu akan memengaruhi reaksi individu terhadap nyeri (potter dan perry, 2005). jadi jika nyerinya teratasi dengan cepat dan adekuat, individu mungkin lebih sedikit ketakutan terhadap nyeri di masa mendatang dan dapat mentoleransi nyeri dengan lebih baik. namun jika individu pernah mengalami nyeri tanpa pernah sembuh maka ansietas dan bahkan rasa takut dapat muncul yang dapat menguatkan persepsi terhadap nyeri. akibatnya dengan tindakan tertentu untuk mengurangi nyeri kadang sulit berhasil, intensitas nyeri yang dirasakan cenderung tetap (tidak terjadi penurunan). faktor-faktor yang meningkatkan kesadaran terhadap stimulus (misalnya ansietas dan gangguan tidur) meningkatkan persepsi nyeri. ansietas yang relevan atau berhubungan dengan nyeri dapat meningkatkan persepsi pasien tentang nyeri. pemberian stimulasi kutaneus: slow-stroke back massage pada responden penelitian sedang mengalami cemas atau gangguan tidur, dapat memengaruhi intensitas nyeri sehingga nyeri yang dirasakan cenderung tetap. gaya koping juga dapat memengaruhi kemampuan individu dalam mengatasi nyeri karena nyeri dapat menyebabkan seseorang merasa kehilangan kontrol terhadap lingkungan atau hasil akhir dari peristiwa-peristiwa yang terjadi. klien sering kali menemukan berbagai cara untuk mengembangkan koping terhadap efek fisik tabel 1. data jumlah responden berdasarkan intensitas nyeri sebelum dan setelah dilakukan pemberian stimulasi kutaneus: slow-stroke back massage intensitas nyeri pre-test intensitas nyeri post-test ringan sedang berat ringan sedang berat jumlah responden 0 15 0 9 6 0 wilcoxon signed rank test signifi kansi (p) = 0,003 keterangan: p = signifi kansi stimulasi kutaneus menurunkan nyery artritis (mira t.) 91 dan psikologis dari nyeri seperti berkomunikasi dengan keluarga pendukung, melakukan latihan atau menyanyi. gaya koping yang tidak adekuat dapat mengakibatkan kemampuannya mengatasi nyeri berkurang sehingga persepsi nyeri yang dirasakan cenderung tetap. hasil uji statistik wilcoxon signed rank test menunjukkan bahwa pemberian stimulasi kutaneus: slow-stroke back massage memiliki pengaruh terhadap intensitas nyeri osteoartritis pada lansia. pemberian stimulasi kutaneus: slow-stroke back massage terhadap responden penelitian didapatkan mayoritas responden mengalami penurunan intensitas nyeri sebanyak 2 nilai, yaitu pada tingkat nyeri sedang menjadi nyeri ringan. mekanisme penurunan nyeri ini dapat dijelaskan dengan teori gate control, yaitu intensitas nyeri diturunkan dengan memblok transmisi nyeri pada gerbang (gate), dan teori endorphin, yaitu menurunnya intensitas nyeri dipengaruhi oleh meningkatnya kadar endorphin dalam tubuh (guyton dan hall, 1999) sehingga persepsi nyeri individu menurun. setelah dilakukan stimulasi kutaneus: slow-stroke back massage, maka serabut saraf a beta yang banyak terdapat di kulit akan terangsang sehingga pintu gerbang tertutup dan stimulus nyeri tidak diteruskan ke otak. di samping itu, endorphin juga dilepaskan sehingga kadarnya meningkat. kedua hal tersebut menyebabkan terjadinya penurunan intensitas dan nilai skala nyeri yang dirasakan oleh subjek penelitian. dengan demikian pemberian stimulasi kutaneus: slowstroke back massage dapat dijadikan sebagai alternatif pilihan untuk menurunkan intensitas nyeri osteoartritis pada lansia secara non farmakologis yang relatif tidak menimbulkan efek samping. simpulan dan saran simpulan nyeri osteoarthritis pada lansia di panti werdha hargo dedali surabaya sebelum dilakukan simulasi kutaneus: slow-stroke back massage seluruhnya mengalami nyeri sedang dengan skala nyeri yang berbedabeda dipengaruhi oleh pengalaman masa lalu terhadap nyeri, faktor usia serta belum pernah dilakukannya terapi atau simulasi kutaneus: slow-stroke back massage dalam menurunkan intensitas nyeri osteoarthritis. setelah dilakukan simulasi kutaneus: slowstroke back massage lansia di panti werdha hargo dedali surabaya mayoritas mengalami penurunan nyeri osteoarthritis dengan skala yang berbeda-beda dan terjadinya penurunan tersebut disebabkan reaksi individu terhadap toleransi nyeri, rasa takut dengan nyeri sebelumnya serta peningkatan kadar endorphin sehingga akan terjadi reduksi nyeri dan persepsi nyeri individu menurun. saran simulasi kutaneus: slow-stroke back massage sebagai salah satu intervensi non farmakologis oleh petugas kesehatan (ibu wiwik) dalam menurunkan intensitas nyeri osteoarthritis pada lansia di panti werdha hargo dedali surabaya dan pada penelitian selanjutnya dapat melakukan penelitian intervensi non farmakologis simulasi kutaneus: slow-stroke back massage dengan alat ukur teori comfort dalam menurunkan intensitas nyeri osteoarthritis pada lansia. kepustakaan grainger, r dan cicuttini, f.m., 2004. medical management of osteoathritis of the knee and hip joints, (online), (http//: www.mja.com.au/public/issues.html., diakses tanggal 16 november 2009, jam 12.00 wib). guyton, arthur c. dan hall je., 1999. buku ajar fisiologi kedokteran, edisi 10. jakarta: egc. irwanasir, r., 2009. kondisi dan permasalahan penduduk lansia, (online), (http:// www. komnaslansia.or.id., diakses tanggal 18 oktober 2009, jam 10.00 wib). kulkarni, b. et al., 2007. arthritic pain is processed in brain areas concern with emotions and fear, (online), (http:// www interscience.com/journal/artritis, diakses tanggal 29 oktober 2009. jam 14.00 wib). kusyati, e., 2006. keterampilan dan prosedur laboratorium keperawatan dasar. jakarta: egc. jurnal ners vol. 5 no. 1 april 2010: 87–92 92 mok, e., et al., 2004. the effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients, (online), (http://www.sciencedirect.com/science. diakses 29 oktober 2009. jam 14.30 wib). nugroho, w., 2000. keperawatan gerontik. jakarta: egc potter, p. dan perry, a.g., 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktik. edisi 4 volume 2. jakarta: egc. price, s.a., 2005. patofi siologi: konsep klinik dan proses-proses penyakit. jakarta: egc. puskom, 2008. jumlah penduduk lanjut usia meningkat, (online), (http:// www. lansia.com. diakses pada tanggal 15 oktober 2009 jam 14.00 wib). reeves, c.j., et al., 1999. medical surgical nursing. usa: mcgraw-hill companies inc. s u m a r t i n i , 2 0 0 8 . p e n g a r u h s t i m u l a s i kutaneus slow stroke back massage. (online), (http://www. interscience/ journal/arthritis.com. diakses tanggal 15 november 2009, jam 10.00 wib). wyman, j.f., 1999. geriatric nursing. usa: wb saunders company. 126 kejadian ventilator associated pneumonia (vap) pada klien dengan ventilasi mekanik menggunakan indikator clinical pulmonary infection score (cpis) (the incident of ventilator associated pneumonia (vap) to patient with mechanical ventilation using clinical pulmonary infection score (cpis) indicators) dally rahman*, emil huriani*, ema julita** * program studi ilmu keperawatan fakultas kedokteran universitas andalas, kampus universitas andalas limau manis padang e-mail: dally_rahman@yahoo.co.id **rumah sakit dr m djamil padang abstract introduction: ventilator associated pneumonia (vap) is defi ned as nosocomial pneumonia that occurs 48 hours after using mechanical ventilation. the incident of vap in dr. m. djamil padang hospital was still high when compared to other hospitals that reached only 9%. nursing intervention that can be used to avoid vap is endotracheal secretions suctioning. however, the results of the intervention has not been evaluated by using standardized measuring tool. the purpose of this study was to determine the description of signs differences of vap on fi rst and third day to clients with mechanical ventilation who were performed endotracheal secretions suctioning in icu dr. m. djamil hospital padang 2011. method: the type of this study was a descriptive analytic. the samples were 15 who had a mechanical ventilation during minimal 3 days. respondents were derived by accidental sampling by using simplifi ed version of cpis as a measuring tool. the statistic test is paired t-test. result: the result of this study showed that there was a signifi cant difference of the signs of vap on the fi rst and the third day with p=0,048 (< 0.05). discussion: there were signifi cant difference on symptom of vap in mechanically ventilated patient in day 1 and day 3. simplifi ed version of cpis was sensitive in early determining vap. simplifi ed version of cpis are expected to be included in standard procedures of patient management and assessment intervention of endotracheal secretions suctioning. keywords: ventilator associated pneumonia, endotracheal secretions suctioning, simplifi ed version of cpis pendahuluan ventilasi mekanik adalah alat bantu pernafasan bertekanan negatif atau positif yang dapat mempertahankan ventilasi dan pemberian oksigen dalam waktu yang lama (brunner dan suddart, 1996). sejalan dengan penggunaan ventilasi mekanik juga dilakukan intubasi. intubasi adalah teknik melakukan laringoskopi dan memasukkan endotracheal tube (ett) melalui mulut atau melalui hidung (elliott, aitken dan chaboyer, 2007). terpasangnya ett akan menjadi jalan masuk bakteri secara langsung menuju saluran nafas bagian bawah. hal ini akan mengakibatkan adanya bahaya antara saluran nafas bagian atas dan trakea, yaitu terbukanya saluran nafas bagian atas dan tersedianya jalan masuk bakteri secara langsung. karena terbukanya saluran nafas bagian atas akan terjadi penurunan kemampuan tubuh untuk menyaring dan menghangatkan udara. selain itu, refl ek batuk sering ditekan atau dikurangi dengan adanya pemasangan ett, dan gangguan pada pertahanan silia mukosa saluran nafas karena adanya cidera pada mukosa pada saat intubasi dilakukan, sehingga akan menjadi tempat bakteri untuk berkolonisasi pada trakea. keadaan ini akan mengakibatkan peningkatan produksi dan sekresi sekret (agustyn, 2007). sekret dalam saluran nafas akan tergenang dan menjadi media untuk pertumbuhan bakteri (agustyn, 2007), sehingga pengisapan sekret endotrakheal merupakan intervensi yang kejadian ventilator associated pneumonia (vap) (dally rahman) 127 sering dibutuhkan pada pasien yang sedang diintubasi (elliott, aitken, dan chaboyer, 2007). pengisapan sekret endotrakheal dibutuhkan untuk mengeluarkan sekret dan menjaga kepatenan jalan nafas. sedangkan, frekuensinya tergantung pada kesehatan klien (kozier, 1995). selanjutnya, teknik suction yang aseptik saat melakukan pengisapan pada ett penting untuk mencegah kontaminasi di saluran nafas (agustyn, 2007). vap didefi nisikan sebagai pneumonia yang terjadi 48 jam atau lebih setelah ventilator mekanik diberikan. vap merupakan bentuk infeksi nosokomial yang paling sering ditemui di unit perawatan intensif (upi), khususnya pada pasien yang menggunakan ventilator mekanik (wiryana, 2007). diagnosa vap secara klinis ditegakkan berdasarkan adanya demam (> 38,3° c), leukositosis (> 10.000 mm3), sekret trakea bernanah dan adanya infi ltrat yang baru atau menetap dari radiologi. definisi tersebut mempunyai sensitivitas yang tinggi namun spesifi sitasnya rendah (joseph, sistla, dutta, badhe dan parija, 2010). diagnosa vap dengan spesifi sitas yang tinggi dapat dilakukan dengan menghitung clinical pulmonary infection score (cpis) yang mengkombinasikan data klinis, laboratorium, perbandingan tekanan oksigen dengan fraksi oksigen (pao2/fio2) dan foto toraks (luna, 2003). penelitian tentang perbandingan cpis dan kriteria klinik dalam mendiagnosis vap pada pasien icu yang komplek menunjukkan, 40 orang pasien yang dirawat di icu dengan umur rata-rata adalah 14,8–59,6 tahun. lama hari rawat di icu antara 14,5–19,2 hari dengan rata-rata durasi penggunaan ventilator mekanik 12,3–13,6 hari. sensitivitas menunjukkan 35,3% dan 78,3% pada hari pertama dan ketiga dari hari rawat masing-masing pasien. spesifi sitas menunjukkan 95,7% dan 81,3% pada hari pertama dan hari ketiga dari hari rawat masing-masing pasien (tan, banzon, ayuyao dan guia, 2007). vap merupakan komplikasi di sebanyak 28% dari pasien yang menerima ventilasi mekanik. kejadiannya meningkat seiring dengan peningkatan durasi penggunaan ventilasi mekanik. estimasi insiden adalah sebesar 3% per hari selama 5 hari pertama, 2% per hari selama 6–10 hari, dan 1% per hari setelah 10 hari (amanullah dan posner, 2010). insiden vap pada pasien yang mendapat ventilasi mekanik sekitar 22,8%, dan pasien yang mendapat ventilasi mekanik menyumbang sebanyak 86% dari kasus infeksi nosokomial. selanjutnya risiko terjadinya pneumonia meningkat 3–10 kali lipat pada pasien yang mendapat ventilasi mekanik (agustyn, 2007). vap mempunyai banyak risiko, akan tetapi, banyak intervensi keperawatan yang dapat menurunkan insiden vap. tindakan yang dapat dilakukan untuk mencegah vap di antaranya cuci tangan dan pemakaian sarung tangan sebelum dan sesudah melakukan tindakan, dekontaminasi oral, intervensi farmakologis oral, stress ulcer prophilaxis, pengisapan sekret endotrakheal, perubahan posisi klien, posisi semi-fowler, pengisapan sekret orofaring dan pemeliharaan sirkuit ventilator (agustyn, 2007). peninjauan sistematis dan meta-analisis oleh melsen (2009) dikutip dari amanullah dan posner (2010) tidak menemukan bukti kematian disebabkan vap pada pasien dengan trauma atau sindrom gangguan pernapasan akut. pemusatan data pada 17.347 pasien menunjukkan bahwa di antara pasien trauma, risiko relatif diperkirakan adalah 1,09, dan di antara pasien dengan sindrom gangguan pernapasan akut, risiko relatif adalah 0,86. melsen (2009) dikutip dari amanullah dan posner (2010) menemukan bukti untuk kematian yang terjadi antara subkelompok pasien lain, tetapi risiko ini tidak dapat dihitung karena heterogenitas dalam hasil studi. hasil juga terkait dengan waktu terjadinya vap. awal-onset pneumonia terjadi dalam 4 hari pertama rawat inap, sedangkan akhir-onset vap terjadi 5 hari atau lebih setelah masuk. akhir-onset pneumonia biasanya dikaitkan dengan organisme multi drugs resistance (mdr). m e s k i p u n b e l u m a d a p e n e l i t i a n mengenai jumlah kejadian vap di indonesia, namun berdasarkan kepustakaan luar negeri diperoleh data bahwa kejadian vap cukup tinggi, bervariasi antara 9–27% dan angka kematiannya bisa melebihi 50%. faktor-faktor jurnal ners vol. 6 no. 2 oktober 2011: 126–135 128 risiko yang berhubungan dengan vap seperti usia, jenis kelamin, trauma, penyakit paru obstruktif kronik (ppok) dan lama pemakaian ventilasi telah banyak diteliti. sebagian besar faktor risiko tersebut merupakan predisposisi kolonisasi mikroorganisme patogen saluran cerna maupun aspirasi (wiryana, 2007). saanin (2006) dikutip dari yuldanita (2009) mengemukakan bahwa insiden vap di rumah sakit dr. m. djamil padang pada klien yang menggunakan ventilasi mekanik dan intubasi adalah 15–59%. tingginya angka infeksi nosokomial ini tidak terlepas dari peranan tenaga kesehatan terutama tenaga keperawatan sebagai tenaga mayoritas di rumah sakit ini. data laporan surveilans pencegahan dan pengendalian infeksi rumah sakit (ppirs) dr. m. djamil padang (2010), insiden vap yang terjadi di icu rs dr. m. djamil padang pada klien yang menggunakan ventilasi mekanik dan intubasi adalah 15,52%. data ini masih menggambarkan tingginya angka vap di rumah sakit ini. hasil penelitian tentang hubungan pengetahuan dan sikap perawat dengan tindakan pencegahan vap di unit perawatan intensif rs dr. m. djamil padang didapat kesimpulan sebanyak 60% perawat di unit perawatan intensif rs dr. m. djamil padang memiliki tingkat pengetahuan tinggi tentang tindakan pencegahan vap, sebanyak 72% perawat memiliki sikap positif tentang tindakan pencegahan vap dan sebanyak 60% perawat melakukan tindakan yang baik dalam pencegahan vap. hal ini menggambarkan bahwa ruang perawatan intensif rs dr. m. djamil padang sudah melakukan tindakan pencegahan vap dengan cukup baik (yuldanita, 2009). hasil survei awal peneliti menunjukkan bahwa pengisapan sekret endotrakheal pada pasien yang terpasang ventilasi mekanik telah dilakukan sesuai dengan standar operasional prosedur (sop) icu rs dr. m. djamil padang. akan tetapi, untuk menilai kemajuan pasien selama tindakan keperawatan belum dilakukan dengan menggunakan alat ukur terstandar cpis. cpis dapat mengidentifi kasi vap secara dini (luna, 2003). pembuatan diagnosa vap secara dini sangat penting untuk menurunkan biaya, angka kesakitan dan kematian serta lamanya tinggal dirumah sakit (agustyn, 2007). selain itu, cpis dapat digunakan sebagai alat yang sensitif untuk mendefenisikan waktu yang tepat untuk memulai terapi vap (luna dkk, 2006). dengan demikian terapi antibiotik dapat diberikan dengan tepat dalam menurunkan angka kematian. pemberian antibiotik yang tidak tepat dapat meningkatkan biaya, menimbulkan risiko reaksi obat yang merugikan dan resistennya flora normal terhadap antibiotik tersebut (gillespie, 2009). bahan dan metode jenis penelitian ini adalah penelitian deskriptif analitik dengan sampel adalah 15 orang pasien yang dirawat di ruangan icu rs dr. m. djamil padang yang menggunakan ventilator mekanik. teknik pengambilan sampel dalam penelitian ini adalah accidental sampling, dengan kriteria inklusi sampel adalah pasien dengan ventilasi mekanik minimal 72 jam dengan berbagai indikasi dengan skor cpis awal < 5. kriteria eksklusi sampel adalah klien dengan ventilasi mekanik karena copd, infeksi dan tuberkulosis paru. pengambilan data dilakukan selama 2,5 bulan. instrumen pengumpulan data yang digunakan berupa lembar observasi berbentuk check list yang digunakan untuk melihat tandatanda vap yang mengacu pada simplified version of cpis (suhu, jumlah leukosit, sekresi trakea, oksigenasi dan foto toraks) (luna, 2003). suhu tubuh klien diukur setiap 3 jam sekali dalam rentang waktu 12 jam dan diambil nilai tertinggi. jumlah leukosit diketahui melalui pemeriksaan darah satu kali dalam satu hari. oksigenasi dinilai dengan membagi hasil analisa gas darah (agd) yaitu pao2 dengan konsentrasi/fio2 yang diberikan seperti yang tertera pada ventilator mekanik dan data yang diambil adalah nilai terendah dari hasil tersebut minimal satu kali atau sesuai dengan frekuensi pemeriksaan analisa gas darah arteri. sekresi trakea dinilai selama 4 jam dan jumlah sekresi dihitung dengan mengukur tinggi kejadian ventilator associated pneumonia (vap) (dally rahman) 129 cairan sekresi dari dasar tabung penampung ke permukaan. foto toraks hari i dilakukan pada semua pasien yang masuk ke icu. foto toraks hari iii dinilai jika ada indikasi foto toraks pada pasien sesuai standar operasional prosedur icu rs dr. m. djamil padang. jika pada hari iii tidak ada indikasi foto toraks, maka skor diberikan nilai 0. observasi hari iii dilakukan pada pasien antara 48–72 jam intubasi. analisa data dilakukan secara bertahap dimulai dengan analisa univariat untuk menggambarkan distribusi dari masing-masing indikator pada simplified version of cpis. selanjutnya, analisa bivariat dilakukan dengan menggunakan uji t berpasangan dengan tingkat kemaknaan p < 0,05 yang dilakukan dengan komputerisasi. hasil responden sebanyak 15 orang yang telah terkumpul datanya terdapat sebanyak 9 orang (60%) berumur 20–40 tahun, sebanyak 3 orang berusia 40–60 tahun dan sebanyak 3 orang berusia lebih dari 60 tahun. selanjutnya, sebanyak 9 orang (60%) berjenis kelamin lakilaki. diagnosa medis pasien menunjukkan sebanyak 6 orang (40%) memiliki diagnosa medis post laparatomy karena berbagai sebab, sebanyak 4 orang (26,4%) memiliki diagnosa medis post kraniotomi karena berbagai sebab dan 5 orang yang lainnya juga merupakan pasien post operasi. jumlah responden yang memiliki total skor simplifi ed version of cpis hari i adalah 1 sebanyak 1 orang (6,7%), skor cpis 2 sebanyak 3 orang (20%), skor cpis 3 sebanyak 8 orang (53,3%), dan skor cpis adalah 4 sebanyak 3 orang (20%). pada hari ke-3, jumlah responden yang memiliki total skor cpis adalah 0 sebanyak 2 orang (20%), skor cpis adalah 1 sebanyak 5 orang (33,3%), skor cpis 2 sebanyak 5 orang (33,3%), dan skor cpis adalah 5 sebanyak 3 orang (20%) (grafi k 1). adapun distribusi frekuensi responden berdasarkan tanda-tanda vap pada hari i dan hari 3 dapat dilihat pada tabel 1. terdapat penurunan rata-rata total skor simplifi ed version of cpis hari i dari 2,87 menjadi 2,00 pada hari iii yaitu sebesar 0,867. di samping itu diketahui pula penurunan total skor simplifi ed version of cpis terbesar adalah 3 dan peningkatan terbesar adalah 2. selanjutnya berdasarkan uji statistik dengan menggunakan uji t-berpasangan diperoleh nilai kemaknaan p = 0,048. hal ini berarti secara statistik pada tingkat kemaknaan p < 0,05 terdapat perbedaan rata-rata yang bermakna antara total skor simplifi ed version of cpis hari i dan hari iii. pembahasan hari i sebanyak 14 orang mengalami demam, yaitu sebanyak 11 orang (73,3%) memiliki suhu 38,5–38,9° c, sedangkan grafi k 1. perbandingan frekuensi total skor cpis hari 1 dan hari 3 pada responden dengan ventilasi mekanik yang dilakukan penghisapan sekret endotrakeal. 0 1 3 8 3 2 5 5 0 0 3 0 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 total skor cpis f re k u e n s i hari 1 hari 3 jurnal ners vol. 6 no. 2 oktober 2011: 126–135 130 tabel 1. distribusi frekuensi responden berdasarkan tanda-tanda vap hari 1 dan hari 3 no. tanda-tanda vap hari 1 hari 3 frekuensi persentase frekuensi persentase 1. suhu (° c) skor 0 (36,5–38,4) 1 6,7 6 40 skor 1 (38,5–38,9) 11 73,3 8 53,3 skor 2 (≥ 39 atau ≤ 36) 3 20 1 6,7 total 15 orang 100 15 orang 100 2. leukosit/mm3 skor 0 (4000–11000) 2 13,3 5 33,3 skor 1 (< 4000 atau > 11000) 13 86,7 10 66,7 total 15 orang 100 15 orang 100 3. sekresi trakea skor 0 (sedikit) 8 53,3 10 66,7 skor 1 (sedang) 7 46,7 3 20 skor 2 (sedang + bernanah) 0 0 2 13,3 skor 2 (banyak) 0 0 0 0 total 15 orang 100 15 orang 100 4. oksigenasi pao2/fio2 skor 0 (> 240 atau ards) 12 80 15 100 skor 2 (≤ 240 dan tidak ards) 3 20 0 0 total 15 orang 100 15 orang 100 5. foto toraks skor 0 (tidak ada infi ltrat) 15 100 12 80 skor 1 (bercak atau infi ltrat difus) 0 0 3 20 skor 2 (infi ltrat terlokalisir) 0 0 0 0 total 15 orang 100 15 orang 100 3 o r a n g ( 2 0 % ) m e m i l i k i s u h u d i a t a s 39° c. marik (2000) menjelaskan dalam hasil penelitiannya sebagian besar demam yang timbul di icu bukan karena infeksi melainkan disebabkan oleh proses infl amasi dari cidera jaringan. demam dengan sebab yang tidak pasti biasanya digambarkan oleh suhu yang tidak lebih dari 38,9° c. oleh karena itu, jika peningkatan suhu di atas ambang batas ini harus dipertimbangkan pasien memiliki penyebab demam oleh infeksi. di samping itu, demam juga dapat disebabkan oleh proses transfusi darah. demam ini biasanya dimulai 30 menit sampai 2 jam setelah transfusi darah dan dapat berlangsung sampai 2 jam atau 24 jam setelah transfusi. hari i sebanyak 13 orang (86,7%) responden memiliki jumlah leukosit yang meningkat di atas 11.000/mm3. mekanisme patofisiologi penting yang menyebabkan tingginya jumlah leukosit adalah respons s u m s u m t u l a n g y a n g n o r m a l t e r h a d a p rangsangan eksternal dan gangguan sumsum tulang primer. leukositosis dapat terjadi sebagai respons terhadap rangsangan eksternal seperti infeksi, infl amasi, obat-obatan, trauma, keganasan, keracunan, olahraga dan gangguan kejiwaan. selain itu, leukositosis dapat juga terjadi sebagai akibat dari leukimia akut, leukimia kronis dan gangguan mieloproliferatif (asadollahi, 2011). kejadian ventilator associated pneumonia (vap) (dally rahman) 131 sekret juga menyumbang skor simplifi ed version of cpis pada hari i. dari 15 orang r e s p o n d e n , s e b a n y a k 7 o r a n g ( 4 6 , 7 % ) responden telah memiliki sekret sedang. agustyn (2007) mengemukakan terpasangnya ett akan menjadi jalan masuk bakteri secara langsung menuju saluran nafas bagian bawah. hal ini akan mengakibatkan adanya bahaya antara saluran nafas bagian atas dan trakea, yaitu terbukanya saluran nafas bagian atas dan tersedianya jalan masuk bakteri secara langsung. karena terbukanya saluran nafas bagian atas akan terjadi penurunan kemampuan tubuh untuk menyaring dan menghangatkan udara. selain itu, refl ek batuk sering ditekan atau dikurangi dengan adanya pemasangan ett, dan gangguan pada pertahanan silia mukosa saluran nafas karena adanya cidera pada mukosa pada saat intubasi dilakukan. dengan demikian, akan menjadi tempat bakteri untuk berkolonisasi pada trakea dan akan mengakibatkan peningkatan produksi dan sekresi sekret. h a s i l p e n g u k u r a n o k s i g e n a s i menunjukkan sebanyak 3 orang (20%) responden memiliki nilai oksigenasi yang < 240. hal ini berkaitan dengan indikasi penggunaan ventilasi mekanik yaitu apnea atau risiko untuk tidak bisa bernafas, kegagalan pernafasan akut (biasanya digambarkan dengan ph ≤ 7,25 dengan paco2 ≥ 50 mmhg), hipoksia berat dan kelumpuhan otot pernafasan (lewis, 2009). selanjutnya tidak ada responden yang memiliki infi ltrat pada foto toraks. hari iii diintubasi dari 15 orang responden terdapat 12 orang (80%) yang tidak mengalami vap, sedangkan 3 orang (20%) lainnya mengalami vap. pada hari iii, responden memiliki total skor simplifi ed version of cpis yang bervariasi. nilai yang didapatkan ada yang menurun, meningkat dan sama dibandingkan dengan hari i. vap merupakan komplikasi di sebanyak 28% dari pasien yang menerima ventilasi mekanik. kejadiannya meningkat seiring dengan peningkatan durasi penggunaan ventilasi mekanik. estimasi insiden adalah sebesar 3% per hari selama 5 hari pertama, 2% per hari selama 6–10 hari, dan 1% per hari setelah 10 hari (amanullah dan posner, 2010). analisa peneliti terjadinya vap pada 3 orang (20%) responden dipengaruhi oleh faktor umur. semua responden yang mendapat vap berumur di atas 60 tahun. joseph (2010) mengemukakan bahwa salah satu faktor risiko vap yang berasal dari pasien adalah faktor umur. pasien yang berada pada umur ≥ 60 tahun akan semakin tinggi berisiko vap. hasil konsensus american thoracic society (1995) menyatakan usia lanjut sangat rentan dengan peningkatan risiko vap, terutama karena peningkatan komorbiditas pada usia lanjut. di samping itu semakin meningkatnya usia akan terjadi penurunan dari kekebalan tubuh. sebanyak 3 orang (20%) responden yang mengalami vap, 2 orang (13,3%) mempunyai diagnosa medis cidera kepala. dunham dan chirichella (2011) menjelaskan angka kejadian vap yang diakibatkan oleh cidera traumatis berkisar dari kurang dari 20% sampai 40–60%. tingkat vap dengan cidera otak traumatis yang substensial adalah 32–45%, dikarenakan risiko aspirasi paru setelah trauma. vap mungkin akan menjadi masalah yang akan berlanjut bagi lembaga yang mengelola pasien cidera otak parah. nilai skor simplifi ed version of cpis yang banyak meningkat yaitu pada foto toraks. hari i semua responden (100%) tidak memiliki infi ltrat, sedangkan pada hari iii terdapat 3 orang (20%) responden memiliki infi ltrat yang difus. infi ltrat yang berada di dalam paru merupakan substansi yang masuk ke dalam paru. infi ltrat tampak sebagai area yang lebih terang pada foto toraks dan menunjukkan daerah yang tidak terisi udara. salah satu penyakit paru yang dapat menyebabkan infi ltrat adalah pneumonia yang menyebabkan paru-paru meradang dan terisi cairan. foto toraks merupakan pemeriksaan penunjang utama untuk menegakkan diagnosis pneumonia dengan menemukan gambaran radiologis berupa infiltrat (perhimpunan dokter paru indonesia, 2003). agustyn (2007) menambahkan diagnosis vap paling sering didasarkan pada adanya infiltrat baru atau progresif pada foto toraks. nilai oksigenasi hari iii merupakan nilai yang paling banyak mengalami penurunan. hasil pengukuran menunjukkan terjadi penurunan skor simplifi ed version of cpis dari jurnal ners vol. 6 no. 2 oktober 2011: 126–135 132 semua responden (100%). jika dibandingkan dengan hari i terjadi kenaikkan dari nilai oksigenasi pada 3 orang (20%) responden. hal ini menggambarkan bahwa terjadi kemajuan pada pasien terhadap tindakan pengisapan sekret endotrakheal yang dilakukan oleh perawat di samping penggunaan ventilator dengan pengaturan yang sesuai. hal ini sesuai dengan kesimpulan penelitian luna (2003) yang mengemukakan bahwa rasio pao2/fio2 jauh lebih akurat dan cepat mengukur respons pasien terhadap terapi. nilai rasio pao2/fio2 akan meningkat secara cepat pada pasien yang mendapat terapi yang adekuat. hasil pengukuran simplified version of cpis hari iii menunjukkan sebanyak 9 orang masih mengalami demam. sebanyak 8 orang (53,3%) memiliki suhu 38,5–38,9° c, sedangkan 1 orang (6,7%) memiliki suhu di atas 39° c. jika dibandingkan dengan hari i sebanyak 7 orang mengalami penurunan suhu. disamping itu, 10 orang (66,7%) responden memiliki jumlah leukosit di atas 11.000/mm3. jika dibandingkan dengan hari i sebanyak 3 orang mengalami penurunan jumlah leukosit. dunham dan chirichella (2011) mengemukakan bahwa respons infl amasi yang terjadi setelah 48 jam trauma menunjukkan risiko untuk munculnya vap. sekret pada hari iii menunjukkan sebanyak 3 orang (20%) memiliki sekret yang sedang dan 2 orang (13,3%) memilki sekret sedang dan purulen. jika dibandingkan dengan hari i terdapat penurunan jumlah sekret pada 5 orang (33,3%) responden. penelitian ini menemukan adanya vap hari iii pada 3 orang (20%) responden. tanda-tanda vap yang muncul pada 3 orang responden tersebut adalah demam, leukositosis, sekret yang meningkat dan disertai dengan purulen pada 2 orang responden. di samping itu, pada foto toraks didapatkan adanya infi ltrat. hal ini menunjukkan simplified version of cpis sensitif digunakan pada hari iii. tan dkk. (2007) dalam hasil penelitian mereka tentang perbandingan cpis dan kriteria klinik dalam mendiagnosis vap pada pasien icu yang komplek menunjukkan, 40 orang pasien yang dirawat di icu dengan umur rerata adalah 14,8–59,6 tahun. lama hari rawat di icu antara 14,5–19,2 hari dengan rerata durasi penggunaan ventilator mekanik 12,3–13,6 hari. sensitivitas cpis menunjukkan 35,3% dan 78,3% pada hari pertama dan ketiga dari hari rawat masingmasing pasien. spesifi sitas cpis menunjukkan 95,7% dan 81,3% pada hari pertama dan hari ketiga dari hari rawat masing-masing pasien. luna (2003) menambahkan pengukuran skor cpis dapat menentukan perjalanan klinis resolusi vap dengan indentifi kasi yang paling baik dilakukan pada hari iii. penelitian ini juga menemukan dari 3 orang (20%) responden yang mengalami vap, sebanyak 2 orang (13,3%) mengalami penurunan suhu. selanjutnya tidak terjadi perubahan jumlah leukosit dan oksigenasi pada semua responden. akan tetapi, semua responden mengalami peningkatan jumlah sekret. dengan demikian tanda vap yang benar-benar terlihat pada responden adalah peningkatan jumlah sekret. sejalan dengan itu, setelah dikonfi rmasi dengan menggunakan foto toraks semua responden memiliki infi ltrat. hasil penelitian ini juga sesuai dengan penelitian yang dilakukan nurniti (2002) tentang efektivitas penghisapan sekret endotrakheal terhadap pencegahan risiko pneumonia pada klien dengan ventilasi mekanik di ruang icu rs adi husada undaan surabaya yang mendapatkan kesimpulan penelitian ada pengaruh antara sebelum dan sesudah perlakuan pengisapan sekret endotrakeal terhadap risiko pneumonia pada klien dengan ventilator mekanik secara signifikan yaitu hasil uji statistik t-test p = 0,001 di bawah nilai probabilitas 0,05. p e n g i s a p a n s e k r e t e n d o t r a k h e a l merupakan salah satu prosedur yang paling umum dilakukan pada pasien dengan saluran ett. pengisapan sekret endotrakheal adalah komponen dari terapi kebersihan bronkial dan ventilasi mekanik yang melibatkan aspirasi secara mekanik sekresi paru pada ett untuk mencegah obstruksi (american association for respiratory care, 2010). pengisapan sekret endotrakeal merupakan tindakan yang sangat penting pada pasien dengan ett untuk menghilangkan sekret dari jalan nafas dan memelihara permeabilitas jalan nafas (lorente, 2005). kejadian ventilator associated pneumonia (vap) (dally rahman) 133 kozier (1995) mengatakan pengisapan s e k r e t e n d o t r a k h e a l d i b u t u h k a n u n t u k mengeluarkan sekret dan menjaga kepatenan jalan nafas. sedangkan, frekuensinya tergantung pada kesehatan klien. agustyn (2007) menjelaskan pengisapan sekret endotrakheal akan menurunkan jumlah sekret dan kolonisasi bakteri dalam saluran nafas, sehingga dapat mencegah terjadinya vap. a u g u s t y n ( 2 0 0 7 ) m e n g e m u k a k a n pencegahan vap dapat dilakukan dengan melakukan tindakan mencuci tangan, memakai sarung tangan, dekontaminasi oral, intervensi farmakologis oral, dan stress ulcer prophylaxis. di samping itu, pengisapan sekret endotrakheal, perubahan posisi klien, posisi semifowler, dan pemeliharaan sirkuit ventilator juga dapat mencegah terjadinya vap. hal ini dapat menurunkan total skor dari simplifi ed version of cpis. gillepspie (2009) menjelaskan faktor risiko dari vap terdiri dari faktor intervensi dan faktor pasien. faktor intervensi yang dapat menyebabkan berisiko vap adalah intubasi endotrakheal, peningkatan durasi penggunaan ventilasi mekanik, lama tinggal di rumah sakit, pemakaian alat yang memerlukan tindakan invasif (seperti: ett, kateter, alat ukur tekanan vena sentral), penggunaan antibiotik sebelumnya (penggunaan sembarangan antibiotik), transfusi sel darah merah (efek imunomodulator), posisi terlentang, tindakan pembedahan dan obat-obatan. penelitian ini menemukan 3 orang (20%) responden yang mengalami vap pada hari iii. hal ini menunjukkan bahwa vap dapat diketahui secara dini (early onset) dengan menggunakan simplified version of cpis. cpis dapat mengidentifikasi vap secara dini. strategi untuk mempersingkat durasi terapi dapat dilakukan dengan menentukan perjalanan klinis resolusi vap. hal ini dapat dilakukan dengan mengukur skor cpis yang paling baik dilakukan pada hari iii (luna, 2003). pembuatan diagnosa vap secara dini sangat penting untuk menurunkan biaya, angka kesakitan dan kematian serta lamanya tinggal di rumah sakit (agustyn, 2007). selain itu, cpis dapat digunakan sebagai alat yang sensitif untuk mendefenisikan waktu yang tepat untuk memulai terapi vap (luna, 2006). dengan demikian terapi antibiotik dapat diberikan dengan tepat dalam menurunkan angka kematian. pemberian antibiotik yang tidak tepat dapat meningkatkan biaya, menimbulkan risiko reaksi obat yang merugikan dan resistennya flora normal terhadap antibiotik tersebut (gillespie, 2009). kollef (1995) dalam penelitian mereka menemukan risiko kematian di rumah sakit meningkat pada pasien dengan late-onset vap, karena kuman patogen yang berisiko tinggi. mereka juga menemukan bahwa terjadinya pneumonia nasokomial karena kuman patogen yang berisiko tinggi merupakan prediktor terbaik kematian di rumah sakit di antara pasien dengan late-onset vap. simplified version of cpis secara statistik terbukti dapat mengidentifi kasi vap secara dini (early onset). di samping itu, dapat menentukan perjalanan klinis resolusi vap dan menentukan waktu yang tepat untuk memulai terapi. namun demikian, american thoracic society sampai saat ini masih menyarankan untuk menggunakan complete version of cpis, walaupun simplifi ed version of cpis telah mampu untuk mendeteksi vap. perbedaan antara keduanya adalah pada pemeriksaan kultur. penelitian ini turut menyumbang saran perlu dipikirkan kembali efektivitas pemeriksaan kultur rutin pada hari iii intubasi. simpulan dan saran simpulan terdapat penurunan skor cpis dari hari i ke hari iii pada pasien yang terpasang ventilator mekanik di icu rumah sakit dr. m. djamil padang dari 2,87 menjadi 2,00. terdapat perbedaan yang bermakna antara tanda-tanda vap pada klien dengan ventilasi mekanik yang dilakukan pengisapan sekret endotrakheal hari i dan hari iii. saran simplifi ed version of cpis dimasukkan ke dalam protap pengelolaan pasien yang menggunakan ventilasi mekanik dan penilaian tindakan pengisapan sekret endotrakeal agar dapat dilakukan secara rutin oleh perawat. bagi jurnal ners vol. 6 no. 2 oktober 2011: 126–135 134 peneliti selanjutnya diharapkan melakukan penelitian membandingkan penggunaan cpis dan simplifi ed version of cpis dalam menilai tanda-tanda vap hari i dan hari iii pada klien dengan ventilasi mekanik yang dilakukan pengisapan sekret endotrakheal. kepustakaan amanullah, s., dan posner, d.h., 2010. ventilator-associated pneumonia, (online), (http://emedecine.medscape. com., diakses tanggal 15 maret 201, jam 19.48 wib). american association for respiratory care, 2010. endotracheal suctioning of mechanically ventilated patients with artifi cial airways 2010, (online),(http:// rcjournal.com/cpgs/pdf., diakses tanggal 22 maret 2011, jam 21.05 wib). american thoracic society, 1995. hospitala c q u i re d p n e u m o n i a i n a d u l t s : diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies a consensus statement, (online), (http://thoracic. org/statements/resources/archive/hosp115.pdf., diakses tanggal 02 juni 2011, jam 21.04 wib). asadollahi, k., hastings, i.m., beeching, n.j., gill, g.v., asadollahi, p., 2011. leukocytosis as an alarming sign for mortality in patients hospitalized in general wards., (online), (http:// ijms.sums.ac.ir/files/pdffiles/09-dr_ %20asadollahi.pdf., diakses tanggal 15 juli 2011, jam 06.44 wib). agustyn, b., 2007. ventilator-associated pneumonia risk factors and preventions, (online), (http://aacn.org/wd/cetests/ media/c0742.pdf, diakses tanggal 15 maret 2011 jam 22.45 wib). brunner dan suddart, 1997. buku ajar keperawatan medikal bedah. jakarta: penerbit buku kedokteran: egc, hlm. 543–567. dunham, c.m., chirichella, t.j., 2011. a t t e n u a t e d h y p o c h o l e s t e ro l e m i a following severe trauma signals risk for late ventilator-associated pneumonia, ventilator dependency, and death: a retrospective study of consecutive patients. (online), (http:// lipidworld.com., diakses tanggal 18 juli 2011, jam 00.06 wib). elliot, d., aitken, lm., chaboyer, w., 2007. critical care nursing. elsevier australia: mosby, hlm. 73–89. gillespie, r., 2009. prevention and management of ventilator-associated pneumonia – the care bundle approach, (online), (http://ajol.info/index.php., diakses tanggal 15 maret 2011, jam 22.11 wib). joseph, et al., 2010. ventilator-associated p n e u m o n i a : a r e v i e w , ( o n l i n e ) , ( h t t p : / / x a . y i m g . c o m / k q / g r o u p s / 1 6 2 9 8 3 2 3 / 2 1 1 9 3 0 9 9 6 4 / n a m e / r e v i e w + n av, + e j i m + 2 0 1 0 . p d f . , diakses tanggal 04 april 2011, jam 21.51 wib). kollef, m.h., silver, p., murphy, d.m., trovillion, e., 1995. the effect of lateonset: ventilator-associated pneumonia in determining patient mortality, (online), (http://chestjournal.chestpubs. org/content/108/6/1655. diakses tanggal 05 juli 2011, jam 12.01 wib). kozier, b., et al., 1995. fundamental of nursing concepts, process, and practiced. united states: addison-wesley publishing company, hlm. 508–522. lewis, 2007. medical surgical nursing assessment and management of clinical problems. usa: mosby, hlm.1751– 1768. lorente, et al., 2005. ventilator-associated pneumonia using a closed versus an open tracheal suction system. (online), (http://portalsaudebrasil.com/ artigosuti/resp366, diakses tanggal 30 maret 2011 jam 20.32 wib). luna, et al., 2006. appropriateness and delay to initiate therapy in ventilatorassociated pneumonia. (online), (http:// erj.ersjournals.com/content271158.full. pdf, diakses tanggal 27 april 2011 jam 21.43 wib). luna, cm., et al., 2003. resolution of ventilatorassociated pneumonia: prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome. (online), (http:// medscape.com/viewarticle/450885, diakses tanggal 01 mei 2011 jam 00.24 wib). kejadian ventilator associated pneumonia (vap) (dally rahman) 135 marik, p.e., 2000. fever in the icu. (online), (http://chestjournal. chestpubs.org/ content/117/3/855.full, diakses tanggal 05 juli 2011 jam 11.50 wib). nurniti, n., 2002. efektivitas penghisapan s e k r e t e n d o t r a k h e a l t e r h a d a p pencegahan risiko pneumonia pada klien dengan ventilator mekanik di ruang icu rs adi husada undaan surabaya. skripsi: tidak dipublikasikan. surabaya: universitas airlangga. pencegahan dan pengendalian infeksi rumah sakit (ppirs) dr. m. djamil padang, 2010. laporan surveilans ppirs dr. m. djamil padang 2010. tidak dipublikasikan. perhimpunan dokter paru indonesia, 2003. p n e u m o n i a k o m u n i t i . ( o n l i n e ) , ( h t t p : / / k l i k p d p i . c o m / k o n s e n s u s / konsensuspneumoniakom/pnkomuniti. pdf, diakses tanggal 02 januari 2011 jam 21.53 wib). tan, j.c., banzon, a.g., ayuyao, f., guia t.d., 2007. comparison of cpis (clinical pulmonary infection score and clinical criteria in the diagnosis of ventilatorassociated pneumonia in icu complex patiens. (online), (http://phc.gov. ph/about-phc/journals/pdf/tan.pdf, diakses tanggal 20 maret 2011 jam 23.14 wib). wiryana, m., 2007. ventilator associated pneumonia. (online), (http://ejournal. unud.ac.id/abstrak/ventilator%20associ ated%20pneumonia.pdf, diakses tanggal 06 januari 2011 jam 21.21 wib). yuldanita, 2009. hubungan pengetahuan dan sikap perawat dengan tindakan pencegahan ventilator associated pneumonia (vap) di unit perawatan intensif rs dr. m. djamil padang tahun 2009. skripsi tidak dipublikasikan. padang: universitas andalas. vol 8 no 2 oktober 2013.indd 202 penurunan insiden infeksi nosokomial pasien pasca sectio caesarea di rumah sakit melalui pelatihan asuhan keperawatan berbasis knowledge management (nursing care knowledge management based training decrease nosocomial infection inciden in post sectio cesarea patients) ahsan*, nursalam**, nyoman anita damayanti*** *psik fk universitas brawijaya, **fakultas ilmu keperawatan, universitas airlangga ***fakultas kesehatan masyarakat, universitas airlangga e-mail: ahsanfkub@yahoo.com abstrak introduksi: model asuhan keperawatan berbasis pada knowledge management dapat menurunkan insiden infeksi nosokomial melalui performa perawat dalam pencegahan infeksi. asuhan keperawatan berbasis manajemen knowledge dibangun atas identifi kasi pengetahuan yang merupakan aktor yang diperlukan dan performa pencegahan atas infeksi nosokomial post sectio cesaria. komponen infeksi nosokomial terdiri atas hasil kultur dari luka. metode: penelitian ini menggunakan studi observasional dengan desain quasi eksperimental. populasi penelitian ini yaitu seluruh perawat yang bekerja di ruang obstetri dan sejumlah pasien yang dirawat di rumah sakit a dan b post sc. responden perawat adalah seluruh perawat yang memenuhi kriteria sampel, sedangkan responden pasien ditetapkan berdasar simple random sampling dan didapatkan 15 pasien. data dikumpulkan melalui lembar observasi dan pemeriksaan hasil kultur luka. hasil data dianalisis menggunakan uji t bebas dengan α = 0,05. hasil: terdapat perbedaan yang signifi kan insiden infeksi nosokomial pada pasien post sc di rumah sakit antara sebelum dan sesudah pelatihan berbasis knowledge management (tvalue = 2,316 dan p = 0,028). diskusi: dapat disimpulkan bahwa pelatihan berbasis knowledge management dapat menurunkan insiden infeksi nosokomial pada pasien post sc. kata kunci: infeksi nosokomial, asuhan keperawatan, knowledge management, seksio sesaria abstract introduction: model of nursing care based on knowledge management can reduce the incidence of nosocomial infections through the performance of nurses in the prevention of infection. nursing care based on knowledge management is established from identifi cation knowledge which is required, prevention performance of nosocomial infections post caesarean section. nosocomial infections component consists of wound culture result. method: this study was an observational study with a quasy experimental design. the population were all of nursing staff who working in obstetrics installation and a number of patients who is treated in hospitals a and b post sectio caesarea. sample is comparised a total population all the nursing staff who worked in obstetrics installation according to criteria of the sample, and most of patients were taken care by nursing staff post caesarean section which is taken by random sampling 15 patients. data was collected through observation sheets and examination of the wound culture. data analysis which is used the t test. result: the result was showed that there was signifi cant difference in the incidence of nosocomial infection in patients with post sesctio caesarea in hospital before and after nursing care training based on knowledge management (tvalue = 2.316 and p = 0.028 < α = 0.05 level), and the incidence of nosocomial infection was lower after training than before training . discussion: it can be concluded that training knowledge management based on nursing care effectives to reduce incidence of nosocomial infections in patients after sectio caesarea keywords: nosocomial infections, nursing care, knowledge management, sectio caesarea pendahuluan infeksi nosokomial merupakan salah satu indikator kualitas pelayanan kesehatan di mata masyarakat yang menjadi penentu citra institusi pelayanan kesehatan. hal ini karena infeksi nosokomial merupakan penyebab utama tingginnya angka kesakitan (morbidity) dan angka kematian (mortality) di rumah sakit. infeksi nosokomial adalah infeksi yang terjadi di rumah sakit dan terjadi pada pasien yang masuk rumah sakit lebih dari 72 jam sedang mengalami proses keperawatan, disebabkan adanya transmisi mikroba patogen yang bersumber dari lingkungan rumah sakit dan perangkatnya. 203 penurunan insiden infeksi nosokomial pasien pasca sectio caesarea (ahsan, dkk.) sebaiknya didasarkan atas adanya keluhan nyeri pada daerah luka, warna kemerahan, adanya pembengkaan daerah luka, adanya nanah pada luka, serta hasil pemeriksaan bakteriologis berupa sediaan hapusan dengan pewar naan gram dan pembiakan kuman untuk mengetahui penyebab jenis bakteri dan menentukan pengobatannya (graham,2003). rumah sakit merupakan salah satu mata rantai di dalam pemberian pelayanan kesehatan serta suatu organisasi dengan sistem terbu ka dan selalu ber interaksi dengan lingkungannya untuk mencapai suatu keseimbangan yang dinamis. rumah sakit mempunyai fungsi utama melayani masyarakat yang membutuhkan pelayanan kesehatan serta sebagai tempat penelitian. pencegahan infeksi nosokomial telah menjadi isu global dalam pelayanan kesehatan. menur ut nursalam (2008) indikator infeksi nosokomial meliputi adanya mikroorganisme pada jaringan atau cairan tubuh disertai gejala klinis baik lokal maupun sistemik. infeksi nosokomial merupakan masalah penting di seluruh dunia dan terus meningkat setiap tahunnya (alvarado, 2000). berbagai upaya telah dilakukan tenaga keperawatan untuk mencegahnya salah satunya dengan penerapan universal precaution (perlindungan diri). angka kejadian infeksi nosokomial yang tinggi di negara amireka serikat terjadi 20 ribu kematian setiap tahunnya akibat infeksi nosokomial. di seluruh dunia 10% pada pasien rawat inap di rumah sakit mengalami infeksi yang baru dirawat atau sebesar 1,4 juta infeksi setiap tahunnya. di indonesia penelitian yang dilakukan dki jakarta pada tahun 1994 menunjukkan bahwa 9,8% pasien yang dirawat inap mendapatkan infeksi baru selama dirawat. di yogyakarta kejadian infeksi nosokomial rata-rata 4,26%, untuk lama perawatan 4,43– 11,2 hari, dengan rata-rata keseluruhan 6,7 hari (nursalam, 2011). hasil survei awal oleh peneliti yang dilakukan pada tanggal 3 mei 2012 tentang kejadian infeksi nosokomial pasca sectio caesarea di ruang bersalin dan nifas rsud b diperoleh sebanyak 124 pasien (12,7%) pasien yang dirawat pasca sectio caesarea mengalamai infeksi pada tahun 2010 dan menurut world health organization, infeksi nosokomial mer upakan masalah global dan menimbulkan lebih dari 1,4 juta pasien yang dirawat di rumah sakit di seluruh dunia. infeksi nosokomial dapat terjadi di setiap tempat pada rumah sakit. menurut tim pengendali infeksi nosokomial rsup dr. m. jamil padang pada tahun 1996 tercatat angka prevalensi infeksi nosokomial 9,1% dan pada tahun 2002 kejadian infeksi nosokomial 10,6 % dan pada tahun 2011 menjadi 10,8%. angka tersebut di atas prevalensi rata-rata rumah sakit pemerintah di indonesia yaitu 6,6%. infeksi nosokomial yang terjadi di r umah sakit dipengar uhi faktor ekternal seperti tim kesehatan yaitu perawat, dokter, termasuk perilaku perawat dalam perawatan luka pascaoperasi dan pencegahan infeksi, lingkungan rumah sakit, makanan, udara, benda dan alat-alat yang tidak steril, dan faktor internal meliputi fl ora normal dan keadaan pasien itu sendiri. infeksi nosokomial disebabkan oleh bakter i patogen seper ti staphylococcus aureus yang merupakan bakteri gram positif, pseudomonas aereginosa, escheriachia coli, klebsella pneumonia yang merupakan bakteri gram negative. menurut who salah satu kejadian infeksi nosokomial terbanyak adalah infeksi luka pascaoperasi dan penyebab kedua terbanyak infeksi saluran kemih. infeksi luka pasca operasi adalah penyebab utama morbiditas dan mortalitas serta peningkatan biaya rumah sakit. selain itu, infeksi luka operasi dapat memacu pemberian antibiotika tambahan untuk penanganan infeksi tersebut yang dapat meningkatkan risiko terjadinya resistensi ba k ter i. lu ka operasi d apat menurunkan kualitas hidup. pasien dengan infeksi pada daerah operasi akan menjalani perawatan dua kali lebih lama di rumah sakit dari pada pasien yang tidak mengalami infeksi, dengan biaya dua kali lipat lebih besar (wilson, 2004). r isi ko ter jadi nya setelah pembed aha n dipengaruhi beberapa faktor antara lain: jenis pembedahan, umur pasien, kondisi pasien, kompetensi perawat dalam perawatan pra dan pasca pembedahan serta perawatan luka. oleh karena itu diagnosis dini infeksi nosokomial 204 jurnal ners vol. 8 no. 2 oktober 2013: 202–210 sebanyak 156 pasien (13,8%) pada tahun 2011. hal ini mengalami peningkatan dari tahun sebelumnya. hal ini lebih tinggi dari standar nasional dan internasional yang ditetapkan depkes dan who pada tahun 2000. hasil survey tentang besar dan waktu munculnya infeksi luka pasca sectio caesarea di ruang nifas rsud b tahun 2011diperoleh dari 43 pasien menunjukkan kejadian infeksi pada hari ke-3 sebanyak 3 pasien (7,0%), kejadian infeksi hari ke-6 sebanyak 9 pasien (20,9%) dan kejadian infeksi hari ke-9 sebanyak 7 pasien (16,3%) dan kejadian terbesar pada hari ke-6 pascaoperasi (20,9%). kejadian terbesar terjadi pada hari ke-6 pascaoperasi. hal ini merupakan alasan pentingnya keuntungan pencegahan infeksi nosokomial pasca sectio caesarea. berdasar hasil data di atas didapakan ba hwa masi h ad a nya kejad ia n i n fek si nosokomial yang ter us meningkat tiap tahunnya, maka perlu dilakukan penelitian t e nt a ng keja d ia n i n fek si nosokom ial. diharapkan dengan ditemukannya penyebab kejadian infeksi nosokomial, maka semakin tahun akan semakin menurun dan bahkan tidak terjadi. tuju a n a k h i r d a r i penelit ia n i n i adalah mencari perbedaan kejadian infeksi nosokomial yang terjadi pada pasien pasca section sesarea sebelum dan sesudah pelatihan asuhan keperawatan berbasis knowledge management. bahan dan metode penelitian ini merupakan penelitian quasy eksperimental dengan pendekatan observasional. sampel penelitian terdiri dari 2 kelompok, yaitu kelompok kontrol dan kelompok perlakuan. penelitian ini dilakukan di intalasi ruang perawatan kebidanan yaitu di ruang bersalin, nifas dan poli kandungan (ruang brawijaya) rsud a sebagai kelompok kontrol, ruang dahlia dan bougenvil rsud b sebagai kelompok perlakuan. penelitian tahap pertama dilakukan tanggal 24 januari 2013 sampai dengan tanggal 26 februari 2013 dan tanggal 16 maret sampai 15 april 2013. tahap 2 dilakukan perlakuan pelatihan dilaksanakan pada tanggal 14 juni sampai 20 juli 2013 dan pemeriksaan infeksi nosokomial dengan lembar observasi serta pemeriksaan swab kultur luka operasi dilaksanakan pada tanggal 14–20 juli 2013. populasi penelitian ini semua tenaga keperawat an yang beker ja di i nst alasi kebidanan dan sejumlah pasien yang dirawat di rumah sakit a dan b pasca sectio caesarea. besar sampel terdiri total populasi yaitu semua tenaga keperawatan yang bekerja di instalasi kebidanan sesuai kriteria sampel, dan sebagian pasien yang diasuh tenaga keperawatan pasca sectio caesarea yang diambil secara random sampling. pengambilan data tahap 1 dilakukan di dua rumah sakit sebelum diberi perlakuan tentang kejadian infeksi nosokomial dengan uji kultur. pengumpulan data ini digunakan untuk mengetahui hasil uji kultur sebelum diberi pelatihan apakan berbeda atau tidak. setelah tahap 1 lalu pada kelompok rumah sakit b dilakukan pelatihan asuhan keperawatan tentang pencegahan infeksi nosokomial dan kelompok rs a tidak dilakukan pelatihan, kemudian diambil dat a kembali u nt u k mengetahui perbedaan hasil pencegahan infeksi nosokomial antara yang diberi pelatihan dengan yang tidak diberi pelatihan. inst r umen yang dig u nakan u nt u k mengumpulkan data adalah lembar observasi dan hasil uji kuktur untuk menilai keadaan luka apakah terjadi infeksi atau tidak. analisis data yang digunakan adalah uji independent t-test sampel dengan taraf signif ikansi α = 0,05. hasil o b s e r v a s i p e l a k s a n a a n a s u h a n keperawatan dilakukan dengan mengamati langsung aktivitas tenaga keperawatan dalam melaksankan asuhan keperawatan berbasis knowledge management dalam pencegahan infeksi nosokomial pada pasien dengan menggunakan lembar observasi, hasil disajikan dalam tabel 1. ta b e l 1 m e n u n j u k k a n b a h w a pelaksanaan pencegahan infeksi nosokomial dalam asuhan keperawatan pasca sectio 205 penurunan insiden infeksi nosokomial pasien pasca sectio caesarea (ahsan, dkk.) saesarea, menunjukan kecenderungan ke arah positif pada kategori baik dalam komponen mencuci tangan dengan benar sebelum dan sesudah melakukan asuhan, menyiapkan alat perawatan secara steril, mencegah penularan melalui percikan ludah, melakukan teknik pembalutan luka dengan benar. kecenderungan ke arah positif pada kategori sangat baik dalam komponen melakukan perawatan luka secara steril dan teknik pembalutan luka dengan benar. sebaliknya kecendrungan ke arah negatif pada kategori cukup dalam kompenen menyiapkan alat secara steril serta kategori kurang pada komponen menyiapkan alat secara steril, mencegah penularan melalui percikan ludah. hasil uji t sebelum dan sesudah pelatihan menunjukkan hasil yang signifi kan antara pelaksanaan asuhan keperawatan dalam pencegahan infeksi nosokomial terhadap kinerja tenaga keperawatan dengan hasil mean sebelum pelatihan antara 3,90 s/d 4,80–5 dan delta t antara -2,449 -11,000 dengan p 0,01 s/d 0,005. observasi kejadian infeksi nosokomial dilak u kan dengan mengamati langsu ng keadaan luka pasien pasca sectio caesarea yang dilakukan tenaga keperawatan dalam memberikan asuhan pada pasien dengan me ng g u n a k a n le mba r obse r va si, d a n pemeriksaan kultur luka yang hasil disajikan dalam tabel 1. tabel 2 menunjuk kan bahwa hasil pemeriksaan kultur didapatkan hasil positif sebanyak 26 pasien (56,6%), dinyatakan terindikasi infeksi, didapatkan gram negatif (acinetobacter baumannii) sebanyak 19,5% (9 orang) dan gram positif (stapylococcus aureus) sebanyak 15,2% (7 orang), keadaan ini menunjukkan kecenderungan ke arah negatif terjadinya infeksi nosokomial dan har us mendapatkan perhatian tenaga keperawatan, karena sectio saesarea yang direncanakan dengan baik (elective) adalah operasi bersih yang seharusnya harus dibebaskan dari infeksi nosokomial. sebaliknya kecenderungan ke arah positif tidak didapatkan infeksi dengan hasil kult ur negatif sebanyak 20 orang (43,4%). hasil observasi keadaan luka pasca sectio caesarea setelah pelatihan pada kelompok perlakuan dan kelompok kontrol (y2) dengan mengamati langsung keadaan luka pasien pasca sectio caesarea yang dilakukan tenaga keperawatan yang telah diberikan pelatihan pada kelompok perlakukan dan tidak diberikan perlakuan pada kelompok control dalam memberikan asuhan pada pasien dengan menggunakan lembar observasi, dan pemeriksaan cultur luka yang hasil disajikan dalam tabel 3. tabel 1. pelaksanaan pencegahan infeksi dalam asuhan keperawatan di rumah sakit a dan b, juli 2013 no indikator kategori (%) jumlahsangat baik baik cukup kurang tidak baik 1 mencuci tangan dengan benar sebelum, sesudah melakukan asuhan 8 (17,4%) 33 (73,9%) 4 (8,7%) 0 (0%) 0 (0%) 46 (100%) 2 menyiapkan alat perawatan secara steril 8 (17,4%) 29 (63,%) 8 (17,4%) 1 (2,2%) 0 (0%) 46 (100%) 3 mencegah penularan melalui percikan ludah 2 (4,3%) 39 (84,8%) 4 (8,7%) 1 (2,2%) 0 (0%) 46 (100%) 4 melakukan perawatan luka secara steril 9 (19,6%) 33 (71,7%) 4 (8,7%) 0 (0%) 0 (0%) 46 (100%) 5 melakukan teknik pembalutan luka dengan benar 9 (19,6%) 33 (71,7%) 4 (8,7%) 0 (0%) 0 (0%) 46 (100%) 206 jurnal ners vol. 8 no. 2 oktober 2013: 202–210 tabel 2. hasil pemeriksaan kultur keadaan luka pasca sectio caesaria di rumah sakit a dan b, bulan juli 2013 (sebelum pelatihan) no hasil test kultur luka jenis kuman sebelum pelatihan infeksi tidak infeksi 1 gram negative a. acinetobacter baumannii 9 (19,0%) 20 (43,4%)b. pseudomanas stutzeri 3(6,5%) c. salmonella aizona 2(4,3%) d. seratia liquifaciens 2(4,3%) e. stapylococcus aureaus 7(15,2%) f. staphylo coccus koag negative 3(6,3%) 2 gram positif a. stapylococcus aureaus 7(15,2%) b. staphylo coccus koag negative 3(6,3%) jumlah 26 (56,52%) 20 (43,4%) tabel 3. hasil pemeriksaan kultur keadaan luka pasca sectio caesaria pada kelompok kontrol dan perlakuan bulan juli 2013 setelah pemberian pelatihan no. hasil kultur kelompok perlakuan kelompok kontrol sebelum pelatihan sesudah pelatihan sebelum pelatihan sesudah pelatihan 1 positif 7 (46,6%) 4 (26,6%) 10 (66,6%) 10(66,6%) 2 negatif 8 (53,3%) 11 (73,3%) 5(33,3%) 5(33,3%) tabel 3 menunjuk kan bahwa hasil ada perbedaan kejadian infeksi sebelum dan sesudah pelatihan dengan kecendrungan ke arah positif, tetapi dari persentase kejadian infeksi semakin menurun sebelum pelatihan kejadian infeksi 46,6%, sebaliknya sesudah pelatihan kejadian infeksi 26,6%. hasil uji t perbedaan kejadian infeksi nosocomial pada kelompok perlakuan dan dan kelompok kontrol sesudah pemberian pelatihan diperoleh t value = 2,316 dan p = 0,028 < 0,05. hal ini dapat disimpulkan bahwa ada perbedaan bermakna kejadian infeksi nokocomial pada pasien pasca section cesarea di rumah sakit sebelum dan sesudah pemberian pelatihan asuhan keperawatan berbasis knowledge management. pembahasan hasil penelitian tingkat kemampuan responden dalam pelaksanaan pencegahan infeksi nosokomial rata-rata dalam kategori sering atau baik pada komponen mencuci tangan dengan benar sebelum dan sesudah melakukan asuhan, mencegah penularan melalui percikan ludah atau menggunakan masker, melakukan perawatan luka secara steril, melakukan teknik pembalutan luka dengan benar. kategori sangat baik atau selalu pada komponen melakukan perawatan luka secara steril, melakukan teknik pembalutan luka dengan benar. sebalik nya kategori cukup atau kadang-kadang pada komponen menyiapkan alat secara steril. hasil uji t test sebelum dan sesudah pelatihan menunjukkan hasil yang signifi kan antara pelaksanaan asuhan keperawatan dalam pencegahan infeksi nosokomial terhadap kinerja tenaga keperawatan dengan hasil mean sebelum pelatihan antara 3,90 s/d 4,80–5 dan delta t antara –2,449 s/d –11,000 dengan p 0,01 s/d 0,005. 207 penurunan insiden infeksi nosokomial pasien pasca sectio caesarea (ahsan, dkk.) hasil penelitian tingkat kemampuan responden dalam melakukan cuci tangan dengan benar rata-rata dalam kategori sangat baik atau selalu dalam komponen melakukan cuci tangan sesuai spo. kategori baik atau sering pada komponen mencuci tangan setiap merawat pasien sebelum dan sesudah melakukan asuhan. sebalik nya kategori cu k up pada komponen mencuci tangan setiap merawat pasien sebelum dan sesudah melakukan asuhan. trasmisi penyakit dapat diminimalisasi dengan menjaga kebersihan tangan, tetapi kenyataannya, hal ini sulit dilakukan karena banyak alasan seper ti peralatan kurang, alergi produk pencuci tangan, kurangnya pengetahuan mengenai pentingnya hal ini, waktu mencuci tangan yang lama, kurang kesadaran dan budaya menjaga kebersihan. selain itu penggunaan sarung tangan sangat dianjurkan bila akan melakukan tindakan atau pemeriksaan pada pasien dengan penyakit infeksi. menurut nursalam (2011), hal yang perlu diingat adalah memakai sarung tangan ketika akan mengambil atau menyentuh darah, cairan tubuh, atau keringat, tinja urine, membran mukosa dan bahan yang kita anggap telah terkontaminasi, segera mencuci tangan setelah melepas sarung tangan. hasil penelitian tingkat kemampuan responden dalam pelaksanaan mencegah penularan dengan menyiapkan alat perawatan secara steril rata-rata dalam kategori sering atau baik pada komponen satu set alat steril dalam perawatan luka dan menggunakan alat sesuai standar atau satu pasie satu alat disposible. menurut simonsen (1999) menyimpulkan lebih dari 50% suntikan yang dilakukan di negara berkembang tidak aman (contonya jarum, tabung dan keduanya yang dipakai berulang-ulang) dan banyak suntikan tidak penting (misal penyuntikan antibiotika). pengamatan di lapangan infeksi nosokomial pada luka operasi disebabkan penggunaan alat perawatan luka yang tidak steril terutama satu alat untuk beberapa pasien. hal ini akan menyebabkan penularan pada satu pasien ke pasien yang lain, keterbatasan alat dan jumlah tenaga, jumlah tenaga yang tidak sebanding dengan jumlah pasien yang dirawat, cara kerja yang tergesa-gesa karena beban kerja yang melebihi kemampuan tenaga keperawatan. hasil penelitian tingkat kemampuan responden dalam pelaksanaan mencegah penularan melalui percikan ludah dengan menggunakan masker baik pada komponen menggunakan masker ketika melakukan perawatan luka dan menggunakan masker dengan benar. menur ut nursalam (2011) pengg unaan masker dapat menu r un kan 90 % penularan melalu udara, debu yang mengandung kuman. penggunaan masker yang baik pada waktu merawat luka dapat mencegah penularan kuman melalui udara. percikan ludah dapat menyebakan penularan infeksi pneumonia terutama pada pasienpasien yang menggunakan ventilator, tindakan tracheostomy, intubasi, pemasangan ngt, terapi inhalasi. kuman penyebab infeksi ini paling sering berasal dari gram negative seperti klebsiella dan pseudomonas. organisme ini sering berada di mulut, hidung, kerongkongan dan perut. keberadaan organisme ini dapat menyebabkan infeksi karena adanya aspirasi oleh organisme ke tractus respiratorius bagian bawah. sedangkan dari klompok virus penyebab pneumonia adalah cytomegalovirus, infl uenzavirus, adenovirus, parainfl unza virus, enterovirus, dan coronavirus. hasil penelitian tingkat kemampuan responden dalam pelaksanaan mencegah penularan dengan melakukan perawatan luka secara steril rata-rata dalam kategori baik atau sering pada komponen tindakan aseptic dan anti septic, perawatan luka sesuai spo yang benar. sebaliknya sebagian dalam kategori sangat baik atau sering pada komponen yang sama. sebaliknya sebagian kecil dalam kategori cukup atau kadang pada komponen yang sama. menurut achpr, (1994) teknik aseptic dan anti septic harus diterapkan tenaga perawatan pada saat merawat luka dengan menjaga sterilitas alat, tangan perawat, luka serta setiap benda yang bersentuhan dengan luka operasi. perawatan luka secara steril dapat menurunkan kejadian infeksi nosokomial. pembersihan luka dapat digunakan cairan fi siologis (norma salin 0,9%) dengan teknik mekanik yang tidak menimbulkan cedera, 208 jurnal ners vol. 8 no. 2 oktober 2013: 202–210 dengan cara yang lembut sehingga tidak menimbulkan perlukaan atau cedera yang dapat menjadi pintu masuk kuman. hasil penelitian tingkat kemampuan responden dalam pelaksanaan mencegah penu la r a n melalu i t ek n i k pembalut a n l u k a d e n g a n b e n a r r a t a r a t a d a l a m kategori baik atau sering pada komponen mela k u k a n tek n i k pembebat a n sesu ai indikasi, melakukan pembebatan dengan menyerap drainase, menjaga kebersihan. pembalutan yang tepat dapat mempercepat penyembu han lu ka, pember ian balut an yang tidak sesuai karakteristik luka dapat mengganggu penyembuhan luka balutan juga harus dapat menyerap drainase untuk mencegah terkumpulnya eksudat yang dapat memungkinkan pertumbuhan bakteri dan maserasi di sekeliling luka akibat eksudat luka (potter & perry, 2005). hasil a nalisis jalu r terbu k t i ad a hubungan pelaksanaan pencegahan infeksi nosokomial dengan kinerja perawat dalam pencegahan infeksi meliputi subvariabel (melakukan cuci tangan, upaya desinfeksi dan sterilisasi, upaya tindakan isolasi dan pencegahan transmisi melalui penggunaan masker, melakukan perawatan luka secara steril, melakukan teknik pembalutan) terhadap kejadian infeksi nosokomial yakni: keadan luka bersih, keluhan nyeri dan panas, keadaan luka bengkak, keadaan luka kemerahan, keadaan luka bernanah, dinyatakan infeksi oleh dokter yang merawat, hasil pemeriksaan laboratorium, hasil kultur luka (gram positif dan gram negatif). hasil penelitian hamatussujana et al (2010) menunjukkan 1) tingkat kepatuhan pelaksanaan prosedur tetap baik, perawat dan bidan yang memiliki tingkat kepatuhan pelaksanaan prosedu r tetap k u rang, 2) responden (pasien) pasca sectio caesaria, terdapat kejadian infeksi sebesar 3) responden (pasien) paska sectio caesaria, sebagian besar mengalami infeksi pada hari ke–7 pasca sectio caesaria dan yang paling kecil responden mengalami infeksi pada hari ke–3 pasca sectio caesaria. 4) ada hubungan yang bermakna (signifikan) antara kepatuhan pelaksanaan protap perawatan luka dengan kejadian infeksi luka pasca sectio caesaria. menurut nursalam (2011), indikator keselamatan pasien (patient safety) yang tinggi, alur komunikasi yang kurang tepat, penggunaan sarana kurang tepat dan lain sebagainya. indikator keselamatan pasien meliputi adanya mutu pelayanan meliputi usaha menurunkan angka kejadian tidak diharapkan (ktd), yang sering terjadi selama perawatan di rumah sakit disebabkan faktor beban kerja dari waktu ke waktu, area standar pelayanan klinik tidak memenuhi standar yang diharapkan, tingginya variasi antar rumah sakit dan antar pemberi pelayanan, ketidak sepadanan antar unit pelayanan kesehatan. indikator keselamatan pasien menurut joint comition international (jci), (2012), meliputi angka kejadian dekubitus, kesalahan pemberian obat oleh perawat, pasien jatuh ( patient fall), cedera a k ibat rest raint, infeksi nosokomial, phlebitis yang akan mengakibatkan mutu pelayanan asuhan, lama perawatan, biaya yang bertambah serta kepuasan pasien menurun (nursalam, 2011). menurut alvarado (2000), berbagai upaya yang dilakukan tenaga kesehatan untuk mencegah terjadinya infeksi nosokomial salah satunya universal precaution (perlindungan diri). angka kejadian infeksi nosokomial di seluruh dunia di ruang rawat inap (10%) dari total pasien yang dirawat di rumah sakit, di dki jakarta (2004) sebanyak (9,8%), di rs yogjakarta, 1999 (12,6%). berdasarkan p e n e l i t i a n y a n g t e l a h d i l a k s a n a k a n penggunaan antibiotika, penyakit penyerta, tidak didapatkan data pada dokumen rekaman med i k , keber si ha n r u a nga n, per alat a n perawatan, lama pasien dirawat, dan kepadatan pengunjung. dari ketujuh variabel ini yang berpengaruh terjadinya infeksi nosokomial adalah lama perawatan dan perawatan luka karena p < 0,05. hubungan pelaksanaan pencegahan infeksi nosokomial dengan kinerja perawat dalam pencegahan infeksi nosokomial sangat signifikan karena perawat harus menjaga kebersihan, keseterilan alat yang digunakan dalam pemberian asuhan, serta menjaga jangan 209 penurunan insiden infeksi nosokomial pasien pasca sectio caesarea (ahsan, dkk.) sampai menimbulkan kecelakaan, cedera pada pasien serta melindungi pasien dari bahaya infeksi, penurunan daya tahan tubuh serta komplikasi lain yang membahayakan kesehatan (nursalam, 2011). mutu pelayanan keperawatan dapat meningkatkan, mencegah penyebarluasan infeksi nosokomial perlu diadakan pelatihan bagi tenaga kerja di lingkungan rumah sakit, semua tenaga yang terlibat dalam pelayanan dari cleaning service sampai orang-orang yang terlibat dalam asuhan serta perbaikan pencegahan infeksi nosokomial, untuk peneliti selanjutnya perlu parameter pemeriksaan kultur pada beberapa aspek pada kasus infeksi nosokomial. berdasarkan hasil penelitian didapatkan hasil test kultur luka pasca sectio caesaria sebagian besar hasil test dinyatakan positif baik dari kuman gram negatif maupun positif. hasil uji t test menunjukan terdapat hubungan yang sig nif ikan kinerja perawat dalam pelaksanaan asuhan keperawatan berbasis knowledge management terhadap kejadian infeksi nosokomial dengan β = 1,274 dan p = 0,028. hasil analisis jalu r menu nju k kan ada hubungan positif antara pelaksanaan pengetahuan tentang asuhan keperawatan infeksi nosokomial terhadap pelaksanaan pencegahan infeksi nosokomial. jadi ada pengaruh pelaksanaan knowledge management terha d ap kejad ia n i n fek si nosokom ial. pengaruh pelaksanaan knowledge management terha d ap keja d ia n i n fek si nosokom ial mempunyai nilai dengan tingkat signifi kan. pelaksanaan knowledge management (x2) mampu menjelaskan pelaksanaan knowledge management sebesar 28%, sisanya ditentukan oleh faktor lain. hasil analisis dengan menggunakan uji t-test didapatkan nilai tvalue = 2,316 dan p = 0,028 < α = 0,05. hal ini dapat disimpulkan bahwa ada perbedaan bermakna kejadian infeksi nokocomial pada pasien pasca section sesarea di rumah sakit sebelum dan sesudah pemberian pelatihan asuhan keperawatan berbasis knowledge management. nilai t value didapatkan nilai posutit yang berarti dengan pemberian pelatihan kejadian infeksi semakin kecil. hal ini dapat dilihat pada hasil pelatrihan bahwa pada kelompok perlakuan kejadian infeksi lebih kecil dari pada kelompok kontrol. pelatihan dan observasi dilaksanakan selama 1 bulan dengan dimulai dari pelatihan dan bimbingan pelaksanaan k nowledge management dalam asuhan keperawatan pasien pasca sectio caesaria. kegiatan ini dilakukan selama 2 jam dengan metoda mempelajari modul, diskusi tanya jawab dilanjutkan bimbingan asuhan pada pasien kelolaan masing-masing selama 6 hari. bimbingan dilakukan oleh peneliti dibantu kepala ruangan dan wakil kepala ruangan cempaka pada setiap siklus dinas. untuk dinas pagi dilakukan oleh peneliti dibantu kepala ruangan dan wakil kepala ruangan dan untuk dinas sore dibantu kepala jaga atau ketua tim, pelatihan dan bimbingan berkaitan dengan proses pelaksanaan knowledge management asuhan keperawatan yang meliputi pengkajian pasien, diagnosa keperawatan, perencanaan a s u h a n k e p e r a w a t a n , i m p l e m e n t a s i asuhan keperawatan, dan evaluasi asuhan keperawatan. simpulan dan saran simpulan ada perbedaan positif yang signifi kan kejadian inf kesi nosokomial pada pasien pasca sectio saesarea di rumah sakit sebelum dan sesudah pelatihan asuhan keperawatan berbasis knowledge management. saran model asuhan keperawatan berbasis knowledge management dapat dikembangkan dan mempunyai kontribusi positif dalam menurunkan kejadian infeksi nosokomial di rumah sakit pemerintah, 2) rumah sakit perlu melakukan pengembangan model asuhan keperawatan berbasis knowledge management dan meningkatkan pengetahuan perawat dan bidan dengan memberikan pelatihan dan bimbingan serta pendidikan tentang pentingnya menjaga sterilitas dan pencegahan infeksi nosokomial. 210 jurnal ners vol. 8 no. 2 oktober 2013: 202–210 kepustakaan achpr.1994. african commition of human right relation, standar praktik luka operasi, infeksi nosokomial. alvarado, l. 2000. tahap-tahap dalam evalua si .te r jema ha n e d isi ke -2 , jakarta. graham. 2003. specif iying a knowledge management system, journal. hammatussujana, et al. 2010. hubungan ti ng k at ke pat u h a n pela k sa n a a n protap oleh prawat, skripsi, universitas muhammadiyah surakarta nursalam. 2008. proses dan dokumentasi ke p e ra wa ta n, ja k a r t a : sa le mb a medika pot t e r & pe r r y. 20 05. fu n d a m e n t a l keperawatan,jakarta: penerbit buku kedokteran egc. wilson. 2004. local government in the united kingdom, london: macmillan. vol 8 no 1 april 2013.indd 107 penilaian risiko jatuh lanjut usia (lansia) menggunakan pendekatan hendrich falls scale dan morse falls scale (elderly fall risk assessment (elderly) scale using hendrich falls fall and morse scale) vivi armany dessy*, harmayetty**, ika yuni widyawati** *mahasiswa program studi ilmu keperawatan, fakultas keperawatan universitas airlangga **staf pengajar fakultas keperawatan universitas airlangga, e-mail: vie_armany@yahoo.com abstrak pendahuluan: insiden jatuh pada lansia menjadi masalah serius bagi pasien rawat inap yang dengan keterbatasan aktivitas. saat ini telah tersedia instrument untuk mengukur risiko jatuh untuk pasien lanjut usia. tujuan dari penelitian ini adalah untuk menguji perbedaan risiko jatuh pasien lanjut usia dengan menggunakan instrument hendrich false scale (hfs) dan morse false scale (mfs). metode: desain penelitian yang dipergunakan dalam penelitian ini adalah penelitian komparatif longitudinal. populasi dalam penelitian ini adalah pasien usia lanjut di ruang perawatan d2 dan d3 rumah sakit adi husada. terdapat 20 responden lansia yang diperoleh dengan menggunakan teknik purposive sampling. variabel penelitian ini adalah nilai risiko jatuh dengan penggunaan instrument hfs dan mfs. data dianalisis dengan menggunakan wilcoxon signed rank test dengan nilai signifi kansi α≤0,05. hasil: hasil penelitian menunjukkan bahwa instrumen hfs yang dibandingkan dengan mfs di hari pertama memiliki sensitivitas yang sama yaitu 100%, pada hari kedua: 80%, hari ketiga: 31,3%, hari keempat: 20%. perbandingan spesivisitas hfs dari mfs pada hari pertama yaitu 64%: 100%. hasil analisis statistic pada kedua skala penilaian menunjukkan bahwa ada perbedaan nilai pada hari pertama p=0,180; hari kedua p=0,58; ketiga dan hari keempat p=0,001. instrumen mfs lebih sensitif untuk mendeteksi pasien usia lanjut dengan risiko jatuh. diskusi: kesimpulan dari hasil instrument ini mfs adalah lebih sensitif dibandingkan hfs untuk menilai lansia dengan risiko jatuh karena item-item penilaian yang lebih rinci. disarankan bahwa pasien lansia dengan risiko jatuh perlu menilai dengan menggunakan mfs. kata kunci: lansia, pasien jatuh, hendrich false scale (hfs), morse false scale (mfs) abstract introduction: incidence of falls in elderly become a serious problem for patients hospitalised with limited activity. there was now the patients instruments to measure risk of fall for elderly patients. the aimed of the study was to examine the differences of risk fall to the elderly by using instrument hendrich falls scale (hfs) and morse falls scale (mfs). methods: a comparative-longitudinal design was used in this study. the population were elderly patients in the treatment room d2 and d3 adi husada’s hospital. there were 20 elderlys as a respondents which taken by using purposive sampling technique. dependent variable was the value of measuring the risk of falling and independent variable was the instrument of hfs and mfs. data were analyzed by using wilcoxon signed rank test with signifi cance level α≤0.05. result: the results showed that hfs’s instrument compared with mfs in the fi rst day are equally sensitive on the presented 100%, second day: 80%, third day: 31.3%, fourth day: 20%. hfs specifi city of mfs on fi rst day compared only 64% than mfs was 100%. the statistical results tests on the both scale of assessment indicated that there were differences the value on fi rst day p=0.180, second day p=0.58, third and fourth day p=0.001. discussion: the use of mfs was more sensitive than hsf for detection of elderly patients with falling risk. the conclution of this results mfs’s instrument was more sensitive to assess elderly with risk 108 jurnal ners vol. 8 no. 1 april 2013: 107–117 of fall because mfs,s points more detailed assessment. it is recommended that elderly patients with falling risk need to assess by using mfs. further research to focus on the risk of fall assessment using hfs and mfs categories. keywords: elderly, patient falls, hendrich falls scale, morse falls scale pendahuluan faktor risiko jatuh di r umah sakit memiliki kesamaan faktor risiko yang di jumpai di panti jompo dan di masyarakat, misalnya gangguan keseimbangan atau gaya berjalan, mobilitas berubah, riwayat jatuh, bertambahnya usia, gangguan kemampuan berpikir, depresi, pusing/vertigo, hipotensi or tost at i k , ga ngg u a n pengli hat a n d a n penggunaan obat penenang (hitcho, et al., 2004). kejadian jatuh di amerika serikat pada tahun 2002, terjadi pada orang berusia lebih dari 65 tahun (rubenstein, 2006). tujuan memahami risiko jatuh, pencegahan dan perlindungan adalah untuk meningkatkan klinis dan kepuasan perawatan. metode a nt isipasi lai n ya ng d ig u na ka n u nt u k memprediksi kondisi jatuh dilakukan dengan menggunakan penilaian risiko jatuh. skala hendrich fall scale (hfs) dan morse falls scale (mfs) merupakan bentuk assessment untuk antisipasi risiko jatuh di rumah sakit pada pasien. st udi yang dila k u kan di belgia, diperoleh data usia rerata populasi lansia yang mengalami jatuh antara 69–85 tahun, terjadi di rumah sakit (coussement, et al., 2008). tahun 2002 di rumah sakit yahudi, sebanyak 183 pasien lansia mengalami jatuh. sebanyak 30% orang mengalami cidera ringan, 4–6% berakibat cidera serius, terkait patah tulang, hematoma subdural, perdarahan yang berlebih dan bahkan kematian pasca-kejadian jatuh (hitcho, et al., 2004) tahun 2007–2009 di panti wreda kediri, data pasien lansia jatuh sebanyak 16 orang (60%) yang diakibatkan oleh adanya kelemahan otot ekstremitas bawah (kristi, dkk., 2009). survei pendahuluan yang dilakukan di rumah sakit adi husada undaan wetan surabaya sebagai tempat penelitian diperoleh data pasien seperti terlihat pada tabel 1. kejadian jatuh di rumah sakit adi husada beberapa disebabkan karena pasien memaksakan diri untuk melakukan aktivitas tanpa meminta bantuan petugas, kelemahan dan pasien tidak menghiraukan himbauan dari petugas ruangan. alat penilaian r isiko jat uh unt u k mengurangi tingkat kejadian jatuh di rumah sakit terdapat 38 alat uji, namun hanya 34 alat uji yang terstandarisasi. mfs dan hfs termasuk alat penilaian yang memenuhi kriteria dan dirancang untuk membantu menargetkan pasien yang berisiko jatuh ter ut ama pad a usia >65 t ahu n (scot t, et al., 2006). pengkajian jatuh pada pasien di rumah sakit dinilai dengan menggunakan instrumen hendrich fall scale dan morse fall scale. fokus penilaian jatuh pada hfs ditentukan dengan 7 item instrumen yang telah ditetapkan dengan menilai kondisi pasien dan memberikan skor sesuai dengan keadaan saat dilakukan observasi (stalhandske, et al., 2004). skala mfs dinilai secara menyeluruh dan berkala, diidentifikasi dari tingkatan jatuh skor >45 risiko tinggi, skor 25–44 risiko sedang, skor 0–24 risiko ringan dan mewakili 6 fak tor yang berkont r ibusi sig nif ikan terhadap kemungkinan pasien jatuh (morse dan tylko, 1989 dalam morse, 2009). skala pengukuran jatuh mfs dan hfs merupakan instrumen yang relatif mudah digunakan dan tabel 1. insiden jatuh di rumah sakit adi husada undaan wetan surabaya tahun usia insiden jatuh 2009 2010 2011 71 tahun 60 tahun 77 tahun 67 tahun 81 tahun 75 tahun 70 tahun 62 tahun 1 orang 1 orang 1 orang 1 orang 1 orang 1 orang 1 orang 1 orang 109 penilaian risiko jatuh lanjut usia (lansia) (vivi armany dessy, dkk.) telah terbukti dapat diandalkan dan berlaku di berbagai pengaturan kesehatan (unit medis dan bedah akut, perawatan jangka panjang, rumah sakit rehabilitasi) (gray-miceli, 2007). metode h fs terbag i at as fa k tor risiko jatuh karena gangguan eliminasi, kebingungan /disorientasi, riwayat jatuh, depresi, pusing/vertigo, non-adaptative dan kelemahan. metode hfs dipergunakan untuk pencegahan primer jatuh dan merupakan bagian integral dalam penilaian pasca-jatuh untuk pencegahan sekunder jatuh (gray-miceli, 2007). strategi pencegahan jatuh dengan metode mfs dirancang dengan menciptakan lingkungan yang bebas dari bahaya, yaitu mengorientasikan pasien terhadap lingkungan dan pemberian instruksi yang jelas tentang bagaimana menggunakan alat bantu jalan (morse, 2009). penelitian ini bertujuan untuk menganalisis efektivitas penilaian risiko jatuh pada lanjut usia (lansia) dengan pendekatan hendrich falls scale dan morse falls scale di ruang perawatan rumah sakit adi husada undaan surabaya. bahan dan metode penelitian ini menggunakan desain non eksperimen yaitu desain komparatif l o n g i t u d i n a l . r a n c a n g a n p e n e l i t i a n longitudinal, yaitu pengamatan tidak hanya dilakukan satu kali sesuai dengan waktu yang ditentukan oleh peneliti, difokuskan pada hari rawat pasien dengan pengamatan selama 4 hari yaitu hari ke-1, ke-2, ke-3 dan ke-4. populasi dalam penelitian ini adalah semua lansia yang memenuhi kriteria inklusi yang dirawat di rumah sakit adi husada undaan surabaya. sampel pada penelitian ini lansia yang dirawat di ruang perawatan d2 dan d3, rumah sakit adi husada undaan yang memenuhi k riteria inklusi sebagai berikut: lansia dengan tingkat ketergantungan parsial; berusia >60 tahun; minimal hari ke-2 rawat inap dan pasien tidak dengan diagnosis penyakit kronis. adapun kriteria eksklusi pada penelitian ini yaitu lansia yang menderita penyakit patologis (kanker). penelitian ini menggunakan teknik non probability sampling dengan jenis pengambilan sampel purposive sampling. variabel dependen dalam penelitian ini adalah nilai pengukuran risiko jatuh dan variabel independen adalah kuesioner hfs (tabel 2) dan mfs (tabel 3). penilaian pada instrument hfs diperoleh nilai minimum 0 dan nilai maksimum 25. nilai instrumen hfs untuk skoring risiko jatuh pada pasien di modifi kasi oleh peneliti dengan tabel 2. instrumen penilaian hendrich falls scale (hendrich, bender & nyhuis, 2003) faktor risiko skala skor riwayat jatuh sebelumnya gangguan eliminasi (inkontinensia, nokturia, frekuensi eliminasi) binggung/disorientasi depresi vertigo/pusing gangguan mobilisasi/keterbatasan gerak dan kelemahan tidak mampu mengambil keputusan ya tidak ya tidak ya tidak ya tidak ya tidak ya tidak ya tidak 7 0 3 0 3 0 4 0 3 0 2 0 3 0 110 jurnal ners vol. 8 no. 1 april 2013: 107–117 menggunakan perhitungan rumus persentil, untuk menyamakan kriteria hfs dan mfs menjadi tiga tingkatan tanpa mengubah item instrumen yang terdapat pada hfs. peneliti hanya memodifi kasi tingkatan kategori skor dan peneliti tetap mempertahankan skor risiko rendah jatuh 0–5, sisa dari skor total hfs 25 dengan rentang nilai 6 sampai 25 di bagi menjadi 4 dengan rataan hitung. persentil adalah ukuran yang membagi sekelompok nilai menjadi 100 bagian yang sama (supranto, 2000). mfs diidentifikasi dari tingkatan jatuh skor >45 risiko tinggi, skor 25–44 risiko sedang, skor 0–24 risiko ringan. hasil hasil penelitian perbedaan penilaian risiko jat uh lanjut usia (lansia) dengan pendekatan hfs dan mfs memiliki perbedaan yang signifi kan, terlihat dari persentase dari uji spesifi sitas dan sensitivitas kedua instrumen. hasi dari uji statistik dengan menggunakan wilcoxon signed rank test didapatkan hasil pada hari ke-1 p=0,180 hari ke-2 didapatkan p=0,58, hari ke-3 dan ke-4 didapatkan p=0,01 di mana α yang ditetapkan ≤0,05, berarti ada perbedaan yang signifi kan antara instrumen hfs dan mfs. data pasien yang berisiko jatuh berdasarkan diagnosis medis yang diukur dengan menggunakan instrumen hfs dan mfs dapat dilihat pada tabel 4 dan 5. pembahasan penilaian risiko jat uh lansia pada hari pertama dengan skala hfs dan mfs berdasarkan hasil observasi, diperoleh data penilaian risiko jatuh hari ke-1 dengan hfs responden yang termasuk dalam risiko jatuh tinggi sebanyak 65%, sedangkan penilaian dengan mfs responden yang berisiko tinggi sebanyak 45% dari 20 orang jumlah responden. risiko jatuh pada pasien bervariasi, beberapa yang mempengaruhi yaitu jenis kelamin, usia dan diagnosis penyakit. hasil observasi penilaian risiko jatuh pada lansia berdasarkan jenis kelamin dengan skala hfs dan mfs diperoleh data, perempuan lebih berisiko jatuh dibandingkan laki-laki. pada penelitian ini perbandingan penilaian dengan menggunakan hfs atau m fs menu nju k k a n perempu a n 2 –2,25 kali berisiko tinggi jatuh pada hari ke-1 perawatan dibandingkan laki-laki. pada hari ke4 penilaian menunjuk kan perempuan tetap berisiko tinggi jatuh dibandingkan laki-laki (tabel 4 dan 5). hasil penelitian ini tabel 3. instrumen penilaian dengan menggunakan morse fall scale (morse, 2009) faktor risiko skala skor riwayat jatuh pernah tidak pernah pernah: 25 tidak pernah: 0 diagnosis penyerta ada tidak ada ada: 15 tidak ada: 0 alat bantu untuk berpindah 1. perabotan (kursi, meja, dll) 2. walker 3. tidak ada/bed/kursiroda, perawat perabotan: 30 walker:15 tidak ada/bed/kursi roda, perawat:0 penggunaan obat iv atau heparin 1. menggunakan 2. tidak menggunakan menggunakan: 20 tidak:0 cara berjalan atau berpindah 1. tidak mampu 2. lemah 3. normal, bedrest, immobilisasi tidak mampu: 20 lemah: 10 normal, bedrest, immobilisasi: 0 keadaan mental status 1. mudah lupa 2. orientasi baik mudah lupa: 15 orientasi baik: 0 111 penilaian risiko jatuh lanjut usia (lansia) (vivi armany dessy, dkk.) menunjukkan bahwa perempuan lebih berisiko tinggi jatuh dibandingkan laki. menur ut pendapat peneliti hal ini dapat disebabkan karena pada perempuan lansia disertai pula dengan penurunan fungsi hormonal yang turut berperan dalam kekuatan tulang yaitu estrogen. lansia dengan jenis kelamin laki-laki juga berisiko tinggi jatuh disebabkan karena lansia laki-laki lebih cenderung melakukan aktivitas sendiri tanpa meminta bantuan. data hasil obser vasi menunjuk kan bahwa dengan menggunakan instrumen hfs maupun mfs dapat diidentifikasi bahwa yang berisiko tinggi jatuh adalah lansia yang berusia 60 –74 tahun. hal ini sesuai dengan hasil penelitian yang dilakukan oleh coussement, et al. (2007) dan rubenstein, et al. (2002) lansia yang berisiko jatuh terutama berusia lebih dari 65 tahun dan beberapa diantaranya mengalami cidera ringan hingga cidera berat akibat jatuh. hal ini berkaitan dengan semakin bertambahnya usia maka terjadi penurunan pada seluruh fungsi tubuh, oleh sebab itu baik pada instrumen hfs dan mfs faktor usia merupakan salah satu faktor yang dipertimbangkan dalam menentukan keadaan dan skor untuk mengetahui derajat risiko pasien mengalami jatuh. penilaian risiko jat uh pada lansia dengan instrumen hfs dan mfs ini dilakukan pada lansia dengan beragam diagnosis medis. diagnosis penyakit pada lansia mempengaruhi perubahan nilai risiko jatuh pada hari ke1 sampai dengan hari ke-4 penilaian.dapat dilihat pada tabel 6 dan 7 hasil penilaian risiko jatuh pada lansia dengan diagnosis medis yang berbeda menunjukkan pula variasi hasil penilaian. hasil penilaian pun mengalami tabel 4. hasil penilaian derajat risiko jatuh dengan hfs dan mfs berdasarkan jenis kelamin laki-laki padahari ke-1 s/d ke-4 di ruang perawatan d2 dan d3 rumah sakit adi husada undaan surabaya no. nilai derajat hfs mfs hari ke-1 hari ke-2 hari ke-3 hari ke-4 hari ke-1 hari ke-2 hari ke-3 hari ke-4 1 rendah 22,2% (2 org) 55,6% (5 org) 55,6% (5 org) 55,6% (5 org) 11,1% (1 org) 11,1% (1 org) 0% (0 org) 11,1% (1 org) 2 sedang 33,3% (3 org) 0% (0 org) 33,3% (3 org) 44,4% (4 org) 55,6% (5 org) 44,4% (4 org) 22,2% (2org) 11,1% (1 org) 3 tinggi 44,4% (4 org) 44,4% (4 org) 11,1% (1 org) 0% (0 org) 33,3% (3 org) 44,4% (4 org) 77,8% (7 org) 77,8% (7 org) total 100% (9 org) 100% (9 org) 100% (9 org) 100% (9 org) 100% (9 org) 100% (9 org) 100% (9 org) 100% (9 org) tabel 5. hasil penilaian derajat risiko jatuh dengan hfs dan mfs berdasarkan jenis kelamin perempuan pada hari ke-1 s/d ke-4 di ruang perawatan d2 dan d3 rumah sakit adi husada undaan surabaya no. nilai derajat hfs mfs hari ke-1 hari ke-2 hari ke-3 hari ke-4 hari ke-1 hari ke-2 hari ke-3 hari ke-4 1 rendah 9,1% (1 org) 9,1% (1 org) 36,4% (4 org) 45,5% (5 org) 9,1% (1 org) 9,1% (1 org) 9,1% (1 org) 9,1% (1 org) 2 sedang 9,1% (1 org) 36,4% (4 org) 27,3% (3 org) 36,4% (4 org) 36,4% (4 org) 18,2% (2 org) 9,1% (1 org) 18,2% (2 org) 3 tinggi 81,8% (9 org) 54,5% (6 org) 36,4% (4 org) 18,2% (2 org) 54,5% (6 org) 72,7% (8org) 81,8% (9 org) 72,7% (8 org) total 100% (11 org) 100% (11 org) 100% (11 org) 100% (11 org) 100% (11 org) 100% (11 org) 100% (11 org) 100% (11 org) 112 jurnal ners vol. 8 no. 1 april 2013: 107–117 gambar 1. hasil penilaian derajat risiko jatuh dengan hfs dan mfs pada hari ke-1 s/d ke-4 di ruang perawatan d2 dan d3 rumah sakit adi husada undaan surabaya tabel 6. penilaian risiko jatuh dengan instrumen hfs berdasarkan diagnosis medis di ruang perawatan d2 dan d3 rumah sakit adi husada undaan surabaya no. nilai dx hfs hari ke-1 hari ke-2 hari ke-3 hari ke-4 r s t r s t r s t r s t 1 2 3 4 5 6 7 8 9 parkinson hnp fr. patella vertigo febris bph hipertensi dyspepsia fr. collum femur 1 2 1 1 2 1 1 2 2 1 3 3 1 3 2 1 1 1 1 1 1 2 1 2 3 1 1 2 3 2 1 1 1 1 1 1 1 2 2 1 1 2 3 2 1 1 1 1 1 2 1 1 1 1 tabel 7. penilaian risiko jatuh dengan instrumen mfs berdasarkan diagnosis medis di ruang perawatan d2 dan d3 rumah sakit adi husada undaan surabaya no. nilai dx mfs hari -1 hari-2 hari-3 hari-4 r s t r s t r s t r s t 1 2 3 4 5 6 7 8 9 parkinson hnp fr. patella vertigo febris bph hipertensi dyspepsia fr. collum femur 1 1 1 2 2 2 1 1 1 2 1 1 2 2 1 1 2 2 1 1 1 1 2 1 2 2 3 1 1 2 1 1 2 2 1 3 3 3 1 1 1 1 1 1 2 2 2 2 3 3 113 penilaian risiko jatuh lanjut usia (lansia) (vivi armany dessy, dkk.) per ubahan pada setiap hari pengukuran. menurut analisis peneliti hal ini dipengaruhi karena adanya beberapa item pertanyaan yang berbeda pada kedua instrumen tersebut (tabel 2 dan 3). berdasarkan hasil analisis statistik diperoleh pula hasil bahwa skala mfs untuk mengenali semua diagnosis responden lebih sensitif, sedangkan untuk spesifi sitas keduanya memiliki kemampuan yang sama. hal ini dibuktikan dengan hasil uji sensitivitas hfs terhadap mfs untuk mengenali risiko jatuh dari hari rawat ke-1 sampai dengan hari ke-4 hfs mengalami penurunan, sedangkan spesifi sitas hfs terhadap mfs untuk mengenali risiko jatuh didapatkan dari hari rawat ke-1 sampai dengan ke-4 mengalami peningkatan. menurut hendrich (2007) efektivitas dan efi siensi hfs dalam mengidentifi kasi pasien berisiko jatuh selama ini terbukti pada pasien di bidang: acute care, long-term care-assisted living centers, ambulatory care settings, short-term stays, rehabilitation centers, homecare. perbedaan hasil kepekaan instrumen hfs dalam menilai risiko jatuh pasien sub akut pada penelitian sebelumnya dengan penelitian ini dapat disebabkan karena adanya modif ikasi skor yang dilakukan peneliti dengan pertimbangan untuk memudahkan dalam pengolahan data dan uji perbandingan. hasil penelitian ini menunjukkan bahwa instrumen mfs lebih peka dibandingkan dengan instrumen hfs dalam mengenali risiko jatuh responden dengan berbagai diagnosis penyakit. hal ini ditunjukkan dengan adanya hasil penilaian bahwa instrumen mfs mampu mengenali risiko jatuh pasien pada semua kategori diagnosis dan setiap harinya mengalami peningkatan kategori risiko. rerata responden penelitian ini berusia >60 tahun dengan diagnosis medis yang masuk dalam kategori penyakit akut atau sub akut yang dapat menimbulkan berbagai masalah yang meningkatkan risiko jatuh. pada bahasan selanjutnya peneliti memaparkan hasil penilaian risiko jatuh dengan menggunakan instrumen hfs dan mfs tersebut pada setiap diagnosis medis yang dialami responden. pada responden dengan parkinson dinilai berisiko tinggi jatuh pada hari ke-1 dan ke-2 karena dengan penggunaan instrumen hfs dapat diidentifi kasi bahwa responden memiliki riwayat jatuh, mengalami gangguan eliminasi, keterbatasan gerak, pusing dan binggung. penilaian dengan skala mfs pada responden yang terdiagnosis parkinson dinilai berisiko tinggi, karena responden memiliki diagnosis penyerta dan adanya penggunaan terapi infus. menurut peneliti hal ini dapat disebabkan karena adanya suatu kondisi diminished propriocepcy yang disebabkan karena bed rest atau istirahat yang cukup lama, di mana menurut morse (2009) hal ini dapat meningkatkan vulnerabilitas dari individu yang memiliki riwayat jatuh, menerima terapi intra vena, mengalami kerusakan status mental atau membutuhkan bantuan untuk berjalan (assisted device). gambar 2. spesivisitas dan sensitivitas penilaian risiko jatuh hfs terhadap mfs pada hari ke-1 s.d ke-4 di ruang perawatan d2 dan d3 rumah sakit adi husada undaan surabaya 114 jurnal ners vol. 8 no. 1 april 2013: 107–117 r e s p o n d e n y a n g d e n g a n h n p menunjukkan hasil penilaian yang relatif konstan pada hari ke-1, hari ke-3 sampai dengan hari ke-4 baik dengan menggunakan instrumen hfs maupun mfs. hal ini dapat terjadi karena sejak awal perawatan responden tersebut meskipun mengalami keterbatasan gerak namu n selu r u h kebut u han dasar dibantu oleh keluarga dan perawat ruangan. berdasarkan instrumen hfs pada hari ke-2 nilai risiko jatuh meningkat menjadi risiko sedang karena item gangguan eliminasi dialami oleh responden yang bersangkutan. responden akan menjalani tindakan operasi yang mengharuskan persiapan pengosongan isi colon dengan pemberian obat pencahar sehingga mengalami gangguan frekuensi bab. pada responden dengan diagnosis fracture patella dengan mengg u nakan instrumen hfs risiko jatuh dari hari ke-1 sampai dengan hari ke-4 mengalami penurunan yaitu dari risiko tinggi menjadi risiko rendah. hal ini disebabkan karena adanya perubahan keluhan (gangguan frekuensi bab dan pusing) sesuai dengan item pertanyaan pada instrumen hfs. hal sebaliknya terjadi dengan penilaian menggunakan instrumen mfs. peningkatan nilai dari risiko sedang menjadi risiko tinggi terjadi pada hari ke-1 sampai dengan hari ke-4. hal ini terjadi karena adanya perubahan kondisi responden (yang merupakan kategori penilaian dalam mfs) yaitu adanya penggunaan infus (pascaoperasi) dan alat bantu. penggunaan infus, adanya kondisi paska operasi serta penggunaan alat bantu kruk untuk berjalan meningkatkan risiko jatuh. pe n i l a i a n r i s i k o j a t u h d e n g a n m e n g g u n a k a n i n s t r u m e n h f s p a d a responden yang dengan diagnosis vertigo diperoleh hasil bahwa pada hari ke-1 dan ke-2 berisiko tinggi, yang menurun pada hari ke-3 sampai dengan hari ke-4. penilaian dengan menggunakan instrumen mfs menunjukkan bahwa dari hari ke-1 sampai dengan hari ke4 responden berisiko tinggi jatuh. menurut morse (2009) masalah keseimbangan (balance problem) seperti vertigo, pusing dan postural hypotension merupakan hasil dari disfungsi sistem kontrol keseimbangan dan vestibular apparatus yang meningkatkan risiko jatuh. disequilibrium ditimbulkan dari berbagai macam penyakit, seperti parkinson, alzeimer, peripheral neurophat y yang disebabkan oleh anemia, alkoholik dan diabetes. pasien umumnya mengalami ketidakseimbangan tubuh dan tendensi untuk jatuh dan kadang me me rlu k a n ba nt u a n u nt u k b e r jala n. oleh sebab itu diperlukan instrumen yang sensitif dalam mengenali risiko pasien untuk mengalami jat u h agar dapat dilak u kan tindakan pencegahan. terdapat perbedaan hasil penilaian hfs dan mfs pada kondisi ini disebabkan karena aspek pengkajian pada kedua instrumen memiliki perbedaan. pada responden dengan diagnosis febris, hasil penilaian risiko jatuh dengan instrumen hfs pada hari ke-1 bervariasi (2 orang responden berisiko tinggi dan 1 orang berisiko sedang) dan mengalami penur unan risiko pada hari ke-2 sampai ke-4 penilaian. penilaian risiko jatuh dengan instrumen mfs pada lansia dengan diagnosis febris penilaian hari ke-1 sampai dengan hari ke-4 berubah-ubah pada setiap responden namun perubahan nilai terjadi hanya pada risiko sedang menjadi tinggi atau sebaliknya. penurunan metabolisme tubuh menyebabkan temperatur tubuh menurun (hipotermia) secara fi siologis (nugroho, 2009; stockslager dan schaeffer, 2008). pada pasien febris terjadi peningkatan suhu tubuh yang disebabkan karena proses peningkatan metabolisme tubuh karena penyakit yang dialami. temperatur tubuh diatur oleh hipothalamus, oleh sebab itu kondisi febris dapat disebabkan karena abnormalitas pada sistem termoregulator atau adanya pengaturan ulang suhu tubuh sebagai dampak dari berbagai kondisi yang mendahului (price dan wilson, 2006). kondisi febrisini dapat menyertai berbagai macam kelainan dan juga dapat menimbulkan gejala lain seperti peningkatan nadi dan laju pernapasan; dehidrasi ringan hingga berat; hilang nafsu makan; dan kelemahan, keletihan dan nyeri ringan pada otot akibat katabolisme protein (mims, 2001). beberapa gangguan akibat demam inilah yang terukur saat penilaian risiko jat uh baik dengan mengg unakan instrumen hfs maupun mfs. hasil penilaian 115 penilaian risiko jatuh lanjut usia (lansia) (vivi armany dessy, dkk.) risiko jatuh dengan instrumen hfs maupun mfs menunjukkan perbedaan karena terdapat perbedaan kondisi dan derajat penyakit. pada penilaian dengan instrumen hfs dijumpai adanya penurunan risiko jatuh pada hari ke-2 sampai dengan ke-4 dapat disebabkan karena responden sudah mulai berespons terhadap pengobatan yang diberikan sehingga kondisi febris mulai menurun dan dampak febris yang teridentifikasi dengan instrumen hfs pun berubah. lansia dengan diagnosis bph pada penelitian ini sebanyak 3 orang. hasil penilaian risiko jatuh dengan instrumen hfs menunjukkan bahwa risiko jatuh pada hari ke-1 bervariasi, dua orang responden berisiko rendah dan satu orang berisiko sedang. pada hari ke-2 sampai hari ke-4 semua responden pada kategori risiko jatuh rendah. penurunan nilai risiko jatuh tersebut terjadi karena pada item pengkajian gangguan eliminasi, pusing dan keterbatasan gerak berkurang. hendrich, bender dan nyhuis (2003) menyebutkan bahwa inst r u men h fs ini menjadi kan gangguan eliminasi sebagai salah satu aspek yang dinilai. pasien dengan bph terutama lansia akan mengalami gangguan eliminasi urin yang ditunjukkan dengan adanya gejala iritatif dan obstruktif. gangguan eliminasi urin yang dialami oleh responden dengan bph inilah yang membuat pada hari ke-1 penilaian menunjukkan ada yang berisiko sedang. hal ini terjadi karena pada responden tersebut selain gangguan eliminasi urin yang dialami responden tersebut juga mengalami gangguan eliminasi alvi sebagai dampak pemberian obat pencahar untuk persiapan operasi yang menambah frekuensi bab, pusing (karena responden harus berulang kali bangkit dari tempat tidur untuk bab) dan mengalami kelemahan karena lelah. hasil penilaian risiko jatuh dengan instrumen mfs menunjukkan variasi risiko jatuh pada hari ke-1 dan ke-2, satu orang responden berisiko rendah dan dua orang berisiko sedang. pada hari ke3 sampai hari ke-4 penilaian, risiko jatuh meningkat meskipun ada 1 orang responden pada hari ke-4 mengalami penurunan risiko. hal ini disebabkan karena dengan instrumen mfs dapat teridentifi kasi aspek cara berjalan, penggunaan alat bantu dan pemberian obat iv (infus), di mana aspek tersebut tidak ada dalam instrumen hfs. menurut peneliti penggunaan infus dapat mempengaruhi mobilisasi dan responden yang mengalami peningkatan risiko juga disebabkan karena responden tersebut lebih memilih melakukan aktivitas sendiri tanpa bantuan perawat. penelit ia n i n i responden denga n diagnosis hiper tensi sebanyak 3 orang. penilaian risiko jatuh dengan instrumen hfs bervariasi, pada hari ke-1 diperoleh hasil 2 orang berisiko sedang dan 1 orang berisiko tinggi jatuh. pada hari ke-2 sampai dengan hari ke-4 semua responden mengalami penurunan risiko jatuh, meskipun pada hari ke-4 dijumpai pula peningkatan risiko. pada penilaian risiko jatuh dengan instrumen mfs diperoleh hasil yaitu hari ke-1:2 orang responden berisiko sedang dan 1 orang berisiko tinggi jatuh. pada hari ke-2 sampai hari ke-4 terjadi pula peningkatan risiko jatuh. pada lansia terjadi proses degeneratif pada seluruh sistem tubuh (price dan wilson, 2006). salah satunya yaitu gangguan pada sistem kardiovaskuler yang berupa elastisitas dinding aorta menurun; ukuran jantung agak mengecil; katup jantung menebal dan menjadi kaku; kemampuan jantung memompa darah menurun (hal ini menyebabkan menurunnya kontraksi dan volumenya); kehilangan elastisitas pembuluh darah; penur unan efektivitas pembuluh darah perifer untuk oksigenisasi; perubahan posisi yang dapat menyebabkan tekanan darah menurun dan atau pusing mendadak; ser ta peningkatan tekanan darah akibat peningkatan resistensi pembuluh darah perifer (nugroho, 2009; stockslager dan schaeffer, 2008). adanya berbagai masalah pada sistem kardiovaskuler tersebut maka memperberat kondisi responden lansia yang dengan hipertensi. menurut peneliti dengan risiko komplikasi yang dialami pasien lansia dengan hipertensi, maka diperlukan suatu instrumen yang sensitif mengenali kemungkinan pasien tersebut untuk jatuh. instrumen hfs dan mfs dalam penilaian risiko jatuh memang memiliki perbedaan dalam berbagai aspek yang dinilai, namun dengan melihat adanya perbedaan nilai risiko jatuh yang teridentifi kasi dengan kedua 116 jurnal ners vol. 8 no. 1 april 2013: 107–117 instrumen tersebut maka menurut peneliti kedua instrumen tersebut belum cukup sensitif dalam mengenali masalah pada responden lansia dengan hipertensi. hasil penelitian menunjukkan responden dengan diagnosis dyspepsia sebanyak 3 orang. hasil penilaian risiko jatuh dengan instrumen hfs pada hari ke-1 menunjukkan bahwa semua responden berisiko tinggi jatuh, sedangkan pada hari ke-2 sampai dengan ke-4 penilaian terjadi penurunan risiko jatuh. hasil penilaian risiko jatuh dengan instrumen mfs menunjukkan bahwa pada hari ke-1 terdapat variasi nilai risiko jatuh (2 orang berisiko tinggi dan 1 orang berisiko sedang. pada hari ke-2 sampai dengan ke-4 risiko jatuh relatif meningkat. pada lansia masalah pencernaan yang umum dihadapi antara lain kesehatan gigi yang buruk dan gizi yang buruk; penurunan fungsi indera pengecap (hilangnya sensitivitas saraf pengecap di lidah terhadap rasa manis, asin, asam dan pahit); pelebaran esophagus; penurunan elastisitas mukosa; penurunan rasa lapar; peristaltik lemah dan biasanya timbul konstipasi; serta daya absorbsi yang melemah (nugroho, 2009; stockslager dan schaeffer, 2008). menurut peneliti kondisi dyspepsia yang dialami oleh responden (lansia) serta penurunan fungsi pada sistem pencernaan tersebut yang membuat rerata risiko jatuh yang dialami responden baik penilaian yang menggunakan instrumen hfs maupun mfs berada pada kategori risiko tinggi jatuh. pe n i l a i a n r i s i k o j a t u h d e n g a n menggunakan instrumen hfs pada responden dengan diagnosis fracture collum femur menunjukkan penurunan dari hari ke-1 sampai dengan hari ke-4. penurunan nilai risiko jatuh terjadi karena adanya penurunan keluhan yang dialami responden. pada penggunaan instrumen mfs ditemukan hasil yang berbeda dimana responden mengalami peningkatan risiko jatuh. menurut pudjiastuti dan utomo (2002) penuaan dan gangguan gerak pada la n sia d apat me nyebabk a n pe r uba ha n fungsional otot, yaitu terjadinya penurunan kekuatan dan kontraksi otot, elastisitas dan f leksibilitas otot, kecepatan waktu reaksi dan rileksasi, kinerja fungsional. penurunan fungsi dan kekuatan otot akan mengakibatkan penurunan kemampuan mempertahankan keseimbangan tubuh, hambatan dalam gerak duduk ke berdiri, peningkatan risiko jatuh, penur unan kekuatan otot dasar panggul, perubahan postur (pudjiastuti dan utomo, 2002). hal ini diperkuat dengan adanya penggunaan obat intra vena (iv) pada hari ke-2 sampai dengan ke-4 yang berdampak pada penambahan skor penilaian. simpulan dan saran simpulan simpulan dari penelitian ini sebagai be r i k ut t e rd apat p e rbe d a a n p e n i laia n sensitivitas hfs dan mfs dalam penilaian risiko jatuh pada lansia dari hari rawat ke-1 sampai hari ke-4; skor instrumen mfs lebih efektif untuk menilai risiko jatuh dibandingkan dengan skor pada instr umen hfs; hasil penilaian menunjukkan instrumen mfs lebih sensitif mengenali risiko jatuh dibandingkan dengan hfs, sedangkan untuk spesivisitas keduanya memiliki kemampuan yang sama, namun sensitivitas dan spesivisitas untuk salah satu diagnosis medis masih memerlukan analisis lebih lanjut. saran peneliti menyarankan agar dilakukan penelitian lebih lanjut tentang penilaian risiko jatuh pada lansia dengan diagnosis medis vertigo dan fracture collum femur menggunakan skala hfs tanpa mengubah dua kategori kriteria yang ada. kepustakaan coussement, j., depaepe, l., schwendimann, r., denhaerynck, k., dejaeger,e. & milisen, k., 2008. interventions for preventing falls in acute and chronic-care hospitals: a systematic review and meta-analysis, journal of american geriatric society, 56(1), 29–36. gray-miceli, d., 2007 fall risk assessment for older adults: thehendrichiifallris kmodel, (online), (http://consultgerirn. org/uploads/file/trythis/try_this_8.pdf, 117 penilaian risiko jatuh lanjut usia (lansia) (vivi armany dessy, dkk.) diakses dari tanggal 13 november 2011, pukul 16.59 wib). hendrich, al, bender, ps. dan nyhuis, a. 2003. validation of the hendrich ii fall risk model: a large concurrent case/ control study of hospitalized patients, applied nursing research. 16(1), 10–15. hendrich, al., 2007. better resources for better care, american journal of nursing. 107(11), 50–58. hitcho, eb., krauss, mj., birge, s., dunagan, wc., fischer, i., johnson, s., nast, pa., costantinou, e. & fraser, vj., 2004. characteristics and circumstances of falls in a hospital setting, society of general internal medicine. 19(7), 732–739 kristi, m., nursalam, indarwati, r., 2009. berg balance test (bbt) dan time up and go test (tugt) sebagai indikator prediksi jatuh pada lansia. skripsi t id a k d ipubl i k a si k a n . su r abaya: universitas airlangga. mims, ca., 2001. the pathogenesis of infectious disease. 4th ed. jakarta: salemba medika. morse, jm., 2009. preventing patient falls establishing a fall inter vention program, 2nd ed., new york: springer publishing company. nugroho, 2009, keperawatan gerontik, jakarta: egc. price, sa. dan wilson, 2006. patofi siologi konsep klinis proses-proses penyakit edisi 6. jakarta: egc. pudjiastuti, s. dan utomo, b., 2002, fisioterapi pada lansia, jakarta: egc. rubenstein, ss., 2006. pre venting falls among older adults in the united states: literature update 2005, (online), (http:// www.iprc.unc.edu/pages/cdc_bulletins/ falls_feb08.pdf, diakses dari tanggal 7 nopember 2011, pukul 19.21 wib). scott, v., lord, s., donaldson, m. dan khan, k., systematic review of fall risk assessment tolls, (online), (http://www. americangeriatrics.org/education/falls. shml, diakses dar tanggal 13 november 2011, pukul 06.30 wib). stalhandske, e., mills, p., quigley, p., neily, j. & bagian, jp., 2004. the veterans affairs healthcare administration’s (vha’s) national falls collaborative andprevention programs, (online), (htt ps://www.google.co.id /, diakses tanggal 2 desember 2011, pukul 21.30 wib). stockslager, j. dan schaeffer, l., 2008. buku saku asuhan keperawatan geriatrik edisi 2, alih bahasa: nike budhi subekti, jakarta: egc. supranto, j., 2000, statistik teori dan aplikasi, jakarta: penerbit erlangga. 64 peningkatan perkembangan multiple intelligences anak usia prasekolah melalui stimulasi alat permainan edukatif (the increasing of preschool multiple intelligences by educative playing instrument stimulation) yuni sufyanti arief*, ilya krisnana*, heny ferdiana*, praba diyan rachmawati* *fakultas keperawatan universitas airlangga, jl. mulyorejo kampus c unair, e-mail: yuni_psik@yahoo.com abstract introduction: multiple intelligences can be incresed by playing stimulation with educative playing instrument. educative playing is the activity that uses educate ways and instrument. educative playing very important to increase speech development, cognitive, socialisation with the environment and also increse the streght and skill of child’s body. method: design used in this study was quasy experiment design. the population was preschool children 4–5 years old in working area of mojo public health centre of surabaya. the sample was preschool children 4–5 years old that spesifi c in inclution criteria of this study. data were analyzed by wilcoxon signed rank test to compare the ordinal data pre and post intervention and mann withney u-test that compare between intervention group and control group with level of signifi cance of α ≤ 0.05. result: the result of speech development that analyzed by wilcoxon signed rank test showed that controlled group had p = 0.157 and intervention group had p = 0.005 and the result of mann whitney test was p = 0.03. the result of kinesthetic development by wilcoxon signed rank test showed that controlled group has p = 0.317 and intervention group has p = 0.005, and analyzed by mann whitney test in kinesthetic development showed the result of p = 0.02. discussion: educative playing instrument (picture cards, play dough, origami and meronce) increased speech and fi ne motoric development of preschool children 4–5 years old in mojo indah kindergarten of surabaya. educative playing instrument is the activity that makes the playing function optimally in child development and this activity can increase the child development such as physical, speech, cognitive and social adaptation. keywords: educative playing instrument, preschool, speech development, kinesthetic development pendahuluan teori multiple intelligences howart gardner telah menetapkan sembilan kecerdasan yaitu kecerdasan verbal linguistik, logikamatematika, visual spasial, gerak kinestetik, musikal, intrapersonal, interpersonal, naturalis, dan eksistensial. sembilan kecerdasan dapat distimulasi apabila seseorang melakukan kegiatan langsung yang memungkinkan mereka memanfaatkan setiap kecerdasan. pada anakanak, kegiatan langsung harus mereka sukai dan memungkinkan mereka terlibat aktif di dalamnya. multiple intellegences anak, dapat diamati melalui permainan dan alat bermain yang digunakannya. bentuk-bentuk permainan edukatif memberi banyak peluang pada pemainan untuk membuat berbagai karya dari tingkat yang paling sederhana sampai yang paling lengkap merupakan stimulan yang sangat berharga dalam upaya mengasah multiple intelligences pada anak (musfi roh, 2008). banyak referensi menyebutkan bahwa di dunia ini sekitar 10–15% anak berbakat dalam pengertian memiliki kecerdasan atau kelebihan yang luar biasa termasuk dalam bersikap, kreativitas, bahasa dan motoriknya (wibisonodops, 2007). bermain dengan alat permainan edukatif seperti bermain kartu gambar, membentuk benda dari adonan kue, meronce dan melipat kertas jarang dilakukan ape bermain kartu bergambar dapat menambah kosakata anak, bermain adonan kue, melipat kertas dan meronce dapat melatih motorik halus anak serta melatih koordinasi mata-tangan saat membentuk tepung, peningkatan perkembangan multiple intelligences anak (yuni sufyanti arief) 65 melipat atau menjumput benda untuk dironce bermanfaat untuk merangsang pertumbuhan otak yang lebih maksimal dan dapat merangsang kerja otak anak mengingat di usia ini merupakan masa pertumbuhan otak yang sangat pesat. upaya untuk meningkatkan kecerdasan dapat dilakukan stimulasi bermain dengan alat permainan edukatif. permainan edukatif adalah suatu kegiatan yang sangat menyenangkan dan dapat merupakan cara atau alat pendidikan yang bersifat mendidik. permainan edukatif merupakan sebuah bentuk kegiatan mendidik yang dilakukan dengan menggunakan cara atau alat yang bersifat mendidik pula. permainan edukatif bermanfaat untuk meningkatkan kemampuan berbahasa, berpikir, serta bergaul dengan lingkungannya dan juga permainan edukatif juga bermanfaat untuk menguatkan dan menerampilkan anggota badan si anak, mengembangkan kepribadian, mendekatkan hubungan antara pengasuh dengan anak didik, serta menyalurkan kegiatan anak. alat bermain adalah segala macam sarana yang bisa merangsang aktivitas yang membuat anak senang. alat permainan edukatif merupakan alat bermain yang bisa meningkatkan fungsi menghibur dan fungsi mendidik (munandar, 2004). setiap alat permainan edukatif dapat difungsikan secara multiguna. masing-masing alat memiliki kekhususan, dalam artian mengembangkan aspek perkembangan tertentu pada anak, tidak jarang pada satu alat permainan edukatif dapat meningkatkan lebih dari satu aspek perkembangan (tedjasaputra, 2005). peneliti tertarik untuk meneliti sejauh mana pengaruh alat permainan edukatif terhadap perkembangan multiple intelligences anak pra sekolah usia 4–5 tahun di di wilayah kerja puskesmas mojo surabaya. bahan dan metode tipe desain yang digunakan dalam penelitian ini adalah quasy eksperiment. rancangan ini berupaya untuk mengungkapkan sebab akibat dengan cara melibatkan kelompok kontrol di samping kelompok eksperimental. populasi terjangkau dalam penelitian ini adalah anak usia 4–5 tahun (kelompok a) di wilayah kerja puskesmas mojo surabaya. sampel dalam penelitian ini diambil berdasarkan jumlah anak prasekolah usia 4–5 tahun di wilayah kerja puskesmas mojo surabaya yang memenuhi kriteria inklusi penelitian ini yaitu orang tua yang bersedia anaknya menjadi responden, anak sehat fi sik dan mental, sedangkan kriteria eksklusi pada penelitian ini adalah anak prasekolah usia 4–5 tahun yang tidak kooperatif: menolak bermain, meninggalkan permainan sebelum selesai, anak yang merupakan siswa tidak tetap (titipan). pengumpulan data pada penelitian ini menggunakan 2 lembar observasi untuk mengetahui perkembangan kecerdasan bahasa dan kecerdasan kinestatik anak prasekolah usia 4–5 tahun, ditambah lembar kuesioner yang diberikan kepada orang tua respoden. pengumpulan data untuk obsevasi perkembangan kecerdasan bahasa dan kecerdasan kinestatik berasal dari standar pedoman penilain tk departemen pendidikan nasional 2006. teknik pemberian skor mampu tanpa bantuan 2, mampu dengan bantuan 1, tidak mampu 0. skala data ordinal untuk perkembangan kecerdasan bahasa dan kinestatik yang dianalisa menggunakan uji statistik wilcoxon sign rank test dan dengan derajat kemaknaan p < 0,05. uji untuk mengetahui perbedaan antara perkembangan kecerdasan bahasa dan perkembangan kecerdasan kinestatik antara kelompok perlakuan dan kelompok kontrol dengan menggunakan mann whitney test (uji komparasi 2 sampel bebas/independen). jika hasil analisis penelitian didapatkan nilai p < 0,05 maka h0 ditolak dan h1 diterima, artinya ada pengaruh perkembangan kecerdasan bahasa dan kecerdasan kinestatik antara kelompok perlakuan dan kelompok kontrol. hasil hasil uji statistik menggunakan wilcoxon signed rank test nilai sig (2-tailed) adalah p = 0,005 berarti α < 0,05 maka h1 diterima artinya ape berpengaruh terhadap perkembangan multiple intelligences: perkembangan bahasa pada kelompok perlakuan. kelompok kontrol menunjukkan hasil uji statistik menggunakan wilcoxon signed rank test nilai sig (2-tailed) adalah p = 0,157 berarti α > 0,05 maka jurnal ners vol. 7 no. 1 april 2012: 64–70 66 h1 ditolak artinya ape tidak berpengaruh terhadap perkembangan multiple intelligences: perkembangan bahasa pada kelompok kontrol. hasil uji statistik menggunakan mann whitney test nilai sig (2-tailed) adalah p = 0,03 yang menunjukkan bahwa terdapat perbedaan perkembangan multiple intelligences: bahasa antara kelompok perlakuan dan kelompok kontrol (tabel 1). hasil uji statistik menggunakan wilcoxon signed rank test nilai sig (2-tailed) adalah p = 0,005 berarti α < 0,05 maka h1 diterima artinya ape berpengaruh terhadap perkembangan multiple intelligences: perkembangan kinestatik pada kelompok perlakuan. kelompok kontrol didapatkan hasil uji statistik menggunakan wilcoxon signed rank test nilai sig (2-tailed) adalah p = 0,317 berarti α > 0,05 maka h1 ditolak artinya ape tidak berpengaruh terhadap perkembangan multiple intelligences: perkembangan kinestatik pada kelompok kontrol (tabel 2). hasil uji statistik menggunakan mann whitney test nilai sig (2-tailed) adalah p = 0,02 yang menunjukkan bahwa terdapat perbedaan perkembangan multiple intelligences: kinestatik tabel 1. perkembangan multiple intelligences: perkembangan bahasa kelompok perlakuan dan kontrol sebelum dan sesudah kelompok perlakuan kelompok kontrol pre-test post-test pre-test post-test mean : 9,80 sd : 3,99 mean : 15,10 sd : 4,23 mean : 10,80 sd : 2,974 mean : 11,00 sd :3,091 wilcoxon (2-tailed) p = 0,005 wilcoxon (2-tailed) : p = 0,157 mean : 13,05 sd : 4,174 mann whitney (2-tailed) : p = 0,03 tabel 2. perkembangan multiple intelligences: perkembangan kinestatik kelompok perlakuan dan kontrol sebelum dan sesudah pemberian alat permainan edukatif pada anak usia prasekolah usia 4–5 tahun kelompok perlakuan kelompok kontrol pre-test post-test pre-test post-test mean : 9,90 sd : 1,91 mean : 14,80 sd : 3,65 mean : 10,8 sd : 3,16 mean : 10,9 sd : 3,14 wilcoxon (2-tailed) p = 0,005 wilcoxon (2-tailed) : p = 0,317 mean : 13,05 sd : 4,174 mann whitney (2-tailed) : p = 0,03 antara kelompok perlakuan dan kelompok kontrol. pembahasan perkembangan bahasa dan kinestatik (motorik halus) pada kelompok perlakuan dan kelompok kontrol anak prasekolah sebelum diberikan ape berdasarkan analisis data sebagian besar dalam kategori tidak optimal. perkembangan bahasa dan motorik halus anak mempunyai intensitas atau tingkat yang berbedabeda sesuai stimulus yang diberikan sebelumnya. berdasarkan distribusi riwayat play group sebagian besar anak tidak mengikuti play group. pendidikan usia dini atau yang dikenal play group banyak memberikan peluang stimulasi untuk tumbuh kembang anak. masa usia dini merupakan periode emas (golden age) bagi perkembangan anak untuk memperoleh proses pendidikan. periode ini adalah tahun-tahun berharga bagi seorang anak untuk mengenali berbagai macam fakta di lingkungannya sebagai stimulan terhadap perkembangan kepribadian, psikomotor, kognitif maupun sosialnya. berdasarkan hasil penelitian, sekitar peningkatan perkembangan multiple intelligences anak (yuni sufyanti arief) 67 50% kapabilitas kecerdasan orang dewasa telah terjadi ketika anak berumur 4 tahun, 80% telah terjadi ketika berumur 8 tahun, dan mencapai titik kulminasi ketika anak berumur sekitar 18 tahun. hal ini berarti bahwa perkembangan yang terjadi dalam kurun waktu 4 tahun pertama sama besarnya dengan perkembangan yang terjadi pada kurun waktu 14 tahun berikutnya. sehingga periode emas ini merupakan periode kritis bagi anak, di mana perkembangan yang diperoleh pada periode ini sangat berpengaruh terhadap perkembangan periode berikutnya hingga masa dewasa. sementara masa emas ini hanya datang sekali, sehingga apabila terlewat berarti habislah peluangnya. untuk itu pendidikan untuk usia dini dalam bentuk pemberian rangsanganrangsangan (stimulasi) dari lingkungan terdekat sangat diperlukan untuk mengoptimalkan kemampuan anak (direktorat paud, 2004). analisis data tentang pengaruh ape terhadap perkembangan multiple intelligences: perkembangan bahasa kelompok perlakuan dapat diketahui bahwa ada perubahan yang signifikan pada perkembangan multiple intelligences: bahasa setelah diberikan perlakuan ape kartu bergambar. hal ini ditunjukkan dari distribusi responden setelah diberikan perlakuan ape dengan persentase terbanyak perkembangan multiple intelligences: bahasa optimal. dengan uji wilcoxon signed rank test untuk perkembangan multiple intelligences: bahasa menunjukkan ada pengaruh ape terhadap perkembangan multiple intelligences: bahasa anak prasekolah usia 4–5 tahun pada kelompok perlakuan. meskipun masih ada 2 orang anak dari 10 anak yang memiliki perkembangan bahasanya meningkat tetapi tidak optimal yaitu anak “h” dan anak “sl”. selama observasi yang dilakukan saat penelitian anak “h” memiliki keterlambatan motorik halus dan bahasa hal ini bisa dikarenakan pola asuh orang tua yang terlalu over protektif pada anak, sedangkan pada anak “sl” bisa dikarenakan pola asuh yang terlalu dimanja. alat permainan edukatif (ape) adalah permainan yang dapat memberikan fungsi permainan secara optimal dan perkembangan anak di mana melalui permainan ini anak akan selalu dapat mengembangkan kemampuan fi siknya, bahasa, kemampuan kognitifnya dan adaptasi sosialnya (hidayat, 2005). setiap alat permainan edukatif dapat difungsikan s e c a r a m u l t i g u n a . s e k a l i p u n m a s i n g masing alat memiliki kekhususan, dalam artian mengembangkan aspek perkembangan tertentu pada anak, tidak jarang satu alatpun dapat meningkatkan lebih dari satu aspek perkembangan (tedjasaputra, 2005). ketika memasuki taman kanak-kanak, atau usia 4 tahun, anak dapat memberikan sejumlah informasi dan menggunakan berbagai bentuk pertanyaan dengan menggunakan kata “apa“, “mengapa“, “kapan“, “di mana , dan “siapa“. mereka juga dapat berargumentasi dan dapat tertawa oleh penggunaan kata-kata yang keliru. anak usia 4 tahun mempunyai selera humor yang relatif baik, senang terhadap rima atau persajakan, teka-teki, lelucon sederhana, dan gurauan lisan. mereka juga dapat menikmati cerita yang di bicarakan kepada mereka, khususnya ketika mereka dapat melihat ke ilustrasi gambar yang menyertai cerita tersebut (sheridan, 1999 dikutip dalam musfi roh, 2008). usia 5 tahun pertama adalah usia yang sangat menentukan bagi seorang anak. usia ini biasa disebut dengan golden age atau usia emas dikarenakan pada usia itu aspek kognitif, fi sik, motorik, dan psikososial seorang anak berkembang secara pesat. untuk itu diperlukan stimulasi-stimulasi yang mampu mengoptimalkan seluruh aspek tersebut agar seorang anak kelak juga mampu menjadi pribadi yang matang sehingga kelak mampu menjadi pribadi yang matang, bertanggung jawab, mampu menghadapi segala permasalahan dalam hidupnya. salah satu cara mengoptimalkan kemampuan kognitif, fisik, motorik, dan psikososial seorang anak adalah dengan stimulasi, salah satu alat ataupun sarana menstimulasinya adalah dengan mainan ataupun permainan. perkembangan kinestatik pada kelompok perlakuan anak prasekolah setelah diberikan ape, berdasarkan analisis data tentang pengaruh ape terhadap perkembangan multiple intelligences: perkembangan kinestatik kelompok perlakuan dapat diketahui bahwa ada perubahan yang signifikan pada perkembangan multiple intelligences: kinestatik setelah diberikan perlakuan alat ape. hal ini ditunjukkan jurnal ners vol. 7 no. 1 april 2012: 64–70 68 dari distribusi responden setelah diberikan perlakuan ape dengan persentase terbanyak perkembangan multiple intelligences: kinestatik optimal. hasil uji wilcoxon signed rank test untuk perkembangan multiple intelligences: kinestatik menunjukkan ada pengaruh ape terhadap perkembangan multiple intelligences: kinestatik anak prasekolah usia 4–5 tahun pada kelompok perlakuan. sheriden (1999) mengatakan bahwa keterampilan motorik anak usia 4–5 tahun meningkat pesat melalui kegiatan bermain balokbalok kreativitas, aktivitas yang membutuhkan keterampilan sederhana, menguntai manikmanik, melakukan aktivitas yang berulangulang. perkembangan dan kemampuan motorik halus anak dapat dipacu dengan menyediakan k e s e m p a t a n y a n g l u a s k e p a d a m e r e k a untuk mencoba, menyediakan perangkatperangkat yang memadai dan dibutuhkan serta memberikan bantuan yang dibutuhkan. bukti menunjukkan bahwa pengalaman-pengalaman anak dan antisipasi kultural amat kondusif bagi perkembangan keterampilan motorik halus ini (musfi roh, 2008). alat permainan edukatif memiliki kebermanfaatan bagi anak bila dapat mengembangkan kecerdasan yang ada pada anak. hal ini tentunya akan terwujud apabila orang dewasa yang ada di sekitar anak termasuk tenaga pendidik dan orang tua memberikan arahan atau stimulasi yang baik kepada anak saat bermain dengan alat permainannya. alat permainan edukatif yang sesuai tujuannya yaitu untuk mengembangkan kecerdasan dan potensi dalam diri anak barulah dikatakan alat permainan yang efektif. pada perkembangan motorik halus dimulai dengan memiliki kemampuan menggoyangkan jari, menggambar dua bagian tubuh, memilih garis yang lebih panjang, dan menggambar orang, melepas objek dengan jari lurus, mampu menjepit benda, melambaikan tangan, menggunakan tangannya untuk bermain menempatkan objek ke dalam wadah, makan sendiri, membuat coretan di atas kertas (hidayat, 2005). keterampilan motorik halus (fine motor skills) adalah aktivitas-aktivitas yang memerlukan pemakaian otot-otot kecil pada tangan. aktivitas ini termasuk memegang benda kecil seperti manik-manik, butiran kalung, menjumput sedotan, memegang pencil dengan benar, menggunting, mengikat tali sepatu, mengancing, dan menarik ritsleting. sangat gampang melihat betapa pentingnya keterampilan motorik halus pada setiap area kehidupan anak. hampir sepanjang hari di sekolah, anak menggunakan keterampilan motorik halusnya. misalnya di kelas taman kanak-kanak. anak banyak mengerjakan hal seperti menggunting gambar dari majalah lalu menempelkannya di kertas. mewarnai dan menulis nama mereka. anak sering membuat kalung dari tali dan butiran manik. saat istirahat makan, mereka membuka bekalnya dan makan dengan menggunakan sendok. saat bermain di lapangan, kadang mereka harus mengikat tali sepatu yang lepas, mengancing baju, dll. keterampilan motorik halus sangatlah penting dalam kehidupan mereka dan dapat secara langsung memengaruhi rasa percaya diri anak dan kesuksesan di sekolah. stimulasi dengan bermain melipat kertas, bermain adonan kue atau play dough dan meronce dapat meningkatkan perkembangan m o t o r i k h a l u s p a d a a n a k p r a s e k o l a h 4–5 tahun. melipat kertas ini butuh kesabaran dan kehalusan diri. melipat kertas, terlebih sampai membuat sebuah karya, takkan berhasil atau maksimal hasilnya jika dilakukan secara tergesa-gesa, tak bisa tenang dan tak memiliki kehalusan diri. bermain adonan kue atau play dough. permainan ini sangat membantu mengasah kreativitas anak. selain ketelitian dan kesabaran serta jiwa seni bisa didapat anak lewat permainan ini, meronce bisa melatih konsentrasi selain melatih ketajaman koordinasi mata dan tangannya sehingga dapat merangsang kerja otak anak. keterlambatan perkembangan motorik halus anak pada usia perkembangan, biasanya akan memengaruhinya pada saat ia besar. termasuk, pada saat memasuki usia sekolah. misalnya, belum mampu memenuhi kebutuhannya sendiri atau memegang pensil dengan sempurna. efeknya akan memengaruhi p e r f o r m a d a n k e m a n d i r i a n n y a d a l a m melakukan sejumlah aktivitas yang seharusnya bisa dilakukan dengan mudah. sebaiknya memberikan stimulus yang tepat sejak dini. dalam perkembangannya, anak membutuhkan stimulus, sesuai dengan usianya. banyak anakpeningkatan perkembangan multiple intelligences anak (yuni sufyanti arief) 69 anak yang akhirnya diidentifi kasikan mengalami keterlambatan dalam perkembangan motorik halusnya. hal itu akan tampak semakin jelas seiring pertambahan usianya. analisis data tentang pengaruh ape terhadap perkembangan multiple intelligences: perkembangan bahasa dan kinestatik (motorik halus) kelompok kontrol dapat diketahui bahwa tidak ada perubahan yang signifi kan pada perkembangan multiple intelligences: bahasa dan kinestatik. hal ini ditunjukkan dari distribusi responden dengan persentase terbanyak perkembangan multiple intelligences: bahasa dan kinestatik (motorik halus) tidak optimal. hasil uji wilcoxon signed rank test untuk perkembangan multiple intelligences: bahasa dan kinestatik menunjukkan tidak ada pengaruh ape terhadap perkembangan multiple intelligences: kinestatik anak prasekolah usia 4–5 tahun pada kelompok kontrol. gustiana dari lembaga psikologi terapan ui menjelaskan bahwa banyak faktor yang dapat menyebabkan anak tidak dapat mencapai perkembangan optimal, di antaranya: kurangnya kesempatan untuk melakukan eksplorasi terhadap lingkungan sejak bayi, pola asuh orang tua yang cenderung overprotektif dan kurang konsisten dalam memberikan rangsangan belajar, tidak membiasakan anak untuk mengerjakan aktivitas sendiri sehingga anak terbiasa selalu dibantu untuk memenuhi kebutuhannya (admin, 2008). perkembangan bahasa dan kinestatik (motorik halus) pada anak dapat ditingkatkan dengan sebaiknya orang tua tidak memberikan kritikan ketika mendapati perkembangan bahasa dan motorik halus yang belum optimal karena hal ini akan menimbulkan perasaan kurang nyaman dan cemas pada anak untuk mengulang kembali kegiatan yang dilakukan, latih anak untuk mengembangkan keterampilannya tersebut. misalnya, meningkatkan frekuensi permainan yang merangsang koordinasi motorik halus seperti melipat kertas, bermain adonan kue, melipat kertas, dan lain-lain. berikan dukungan yang positif setiap kali anak menunjukkan hasil karyanya karena akan memperkuat keinginan anak untuk melakukan kegiatan dengan baik. simpulan dan saran simpulan kemampuan bahasa pada anak prasekolah usia 4–5 tahun di tk mojo indah surabaya meningkat setelah diberikan perlakuan dengan ape (kartu bergambar, bermain adonan kue, melipat kertas dan meronce) dan kemampuan motorik halus pada anak prasekolah usia 4–5 tahun di tk mojo indah surabaya meningkat setelah diberikan perlakuan dengan ape (kartu bergambar, bermain adonan kue, melipat kertas dan meronce). saran orang tua dan perawat diharapkan dapat menggunakan ape (kartu bergambar, bermain adonan kue, melipat kertas dan meronce) sebagai alternatif alat permainan untuk menunjang perkembangan anak, khususnya perkembangan bahasa dan motorik halus anak prasekolah usia 4–5 tahun, institusi pendidikan prasekolah diharapkan dapat menyediakan permainan kartu bergambar, bermain adonan kue, melipat kertas dan meronce sebagai variasi jenis permainan di taman kanak-kanak dan lebih mengoptimalkan ape untuk menstimulasi tumbuh kembang anak dengan optimal, para guru diharapkan mengikuti pelatihan lebih dalam mengenai berbagai macam permainan edukatif, kegunaan, dan cara-cara memainkan sehingga lebih berkompeten dalam mengajarkan kepada anak, dan pada penelitian selanjutnya diharapkan dapat mengembangkan variabel lain tentang pengaruh ape terhadap perkembangan multiple intelligences yang lain seperti perkembangan naturalis, eksistensial, musikal, dan lain-lain pada anak khususnya usia prasekolah, mengingat pada usia ini perkembangan anak sangat pesat. kepustakaan anonim, 2008. rangsangan perkembangan anak, (online), (http://sebastian. wordpress.com., diakses tanggal 3 november, jam 16.55). arikunto, suharsimi, 2002. prosedur penelitian suatu pendekatan praktek. jakarta: rineka cipta. jurnal ners vol. 7 no. 1 april 2012: 64–70 70 arimurti, 2007. tanda-tanda siap masuk tk, (online), (http://click.egroup.com., diakses tanggal 3 november 2008, jam 16.35) chatarina, istiya, 2008. media belajar untuk meningkatkan multiple intelligence anak, (online), (http://www.e-psikologi. com., tanggal 4 november 2008, jam 15.45). departemen pendidikan nasional, 2006. pedoman penilaian di taman kanakkanak. jakarta: departemen pendidikan nasional. h i d a y a t , a . a . , 2 0 0 5 . p e n g a n t a r i l m u keperawatan anak 1. jakarta: salemba medika. hurlock, elizabet, b., 1997. perkembangan anak jilid 1. jakarta: erlangga. irawati, m., 2006. menggali kecerdasan jamak melalui bermain, (online), (http://www. indomedia.com., diakses tanggal 4 november 2008, jam 16.00). jasmine, grace., 2008. cerdas dan kreatif melalui bermain. yogyakarta: locus. munandar, 2008. pentingnya kreativitas dan aktivitas bagi anak usia dini, ( o n l i n e ) , ( h t t p : / / a g u s t r i a n s y a h . wordpress.com/a, diakses tanggal 28 oktober 2008, jam 16.00). musfi roh, tadkiroatun, 2008. cerdas melalui bermain. jakarta: grasindo. prasetyo, dwi, 2007. membedah psikologi bermain anak. yogyakarta: penerbit think. p o t t e r, p a t r i c i a , a . , 2 0 0 5 . b u k u a j a r fundamental keperawatan; konsep, proses, dan praktik ed. 4. jakarta: egc. santrock, john, w., 2002. life span development jilid 1. jakarta: erlangga. semiawan, conny, r., 2004. belajar dan pembelajaran dalam taraf usia dini. jakarta: prenhallindo septeni, garda, 2008. bermain dan berkreasi dengan limbah kayu, (online), (http:// edutoys.multiplay.com., diakses tanggal 28 oktober 2008. jam 16.30). soetjiningsih, 1995. tumbuh kembang anak. jakarta: egc. subair, agus, 2008. mengenal dunia bermain anak. yogyakarta: banyu media. sudono, anggani, 2000. sumber belajar dan alat permainan untuk pendidikan usia dini. jakarta: grasindo sugianto, mayke, 1995. bermain, mainan dan permainan. jakarta: departemen pendidikan dan kebudayaan. supartini, yuni, 2004. buku ajar konsep dasar keperawatan anak. jakarta: egc. surya, sutan, 2007. melejitkan multiple intelegence anak sejak dini. yogyakarta: andi ofset. tangyong, agus f., dkk., 1994. pengembangan anak usia taman kanak-kanak. jakarta: grasindo. tedjasaputra, mayke, s., 2005. bermain, mainan dan permainan untuk pendidikan usia dini. jakarta: grasindo. ners vol 5 no 1 april 2010_akreditasi 2013.indd 38 cooperative play memengaruhi interaksi sosial anak dengan gejala kepribadian introvert (cooperative play affects social interaction of children who have introvert personality) ira rahmawati*, ah. yusuf**, ilya krisnana** *rumah sakit mitra keluarga jl. satelit indah ii darmo satelit telp./fax (031) 7345333. e-mail: ira_cantik@yahoo.com ** fakultas keperawatan universitas airlangga surabaya abstract introduction: one of school age children may developing task is learning to interact with their peer groups. the introvert have problem with their social interaction. one ways that can increase the social skill is play activities with social situation. so social play activities: cooperative play can be one of alternative solution to increase social interaction of children with introvert symptom. this study was aimed to explain effect of social play activities: cooperative play on social interaction of children with introvert symptom. method: quasy experiment design was used in this study. the population was school aged children with introvert symptom in sdn kendangsari iii/278 surabaya. total sample was 23 respondents consist of 12 respondents as treatment group and 11 respondents as controlled group. the independent variable was social play activities: cooperative play. the dependent was social interaction of children with introvert symptom. the data was analyzed by wilcoxon signed rank test and mann whitney u test with level signifi cance of α ≤ 0.005. result: result showed that social play activities: cooperative play had signifi cant effect on social interaction of children with introvert symptom (increased). wilcoxon signed rank test showed treatment group had p = 0.002 and controlled group had p = 1.00. mann whitney u test showed p = 0.002. discussion: it concluded that social play activities: cooperative play can be one way to change social interaction of children with introvert symptom. further studies should involve larger respondents and better measurement tools to obtain more accurate results. keywords: introvert, social interaction, social skill, cooperative play pendahuluan pertemanan adalah langkah awal menyusun pondasi sosialisasi melalui interaksi sosial pada anak (waldrop, 2007). salah satu faktor yang memengaruhi interaksi sosial pada anak adalah karakter kepribadian (santrock, 2000). carl jung membagi karakter kepribadian berdasarkan orientasi minat atau sikap menjadi dua, yaitu introvert dan ekstrovert (suryabrata, 2003). menurut carl jung, individu introvert cenderung diam, pemalu dan merasa tidak nyaman di situasi sosial (wilson, dkk, 1996 dalam rich, 2003). mereka mengalami penarikan dan penghindaran sosial (burger, 2000 dalam rich, 2003). tak jarang mereka ada yang menjadi agresif, bandel, pembangkang, atau bahkan menjadi seorang yang pemurung, menarik diri dari interaksi sosial (introvert), tentunya hal ini tergantung kepada kecenderungan pribadi tiap individu (ramdhani, 2002). semakin matang orang introvert akan menyadari kalau keadaan ketertutupan itu kurang nyaman (savitri, 2008). namun anak introvert pada akhirnya bisa juga membuka diri (share) terbuka kepada orang lain. semua itu tergantung pada pengalaman yang dialami anak (savitri, 2008). pengalaman bermain dapat menjadi sarana untuk perkembangan sosial anak, terutama jenis bermain sosial (supendi dan nurhidayat, 2007). anak di perkotaan lebih mengenal play station, nintendo atau permainan lainnya yang berhubungan dengan teknologi (supendi dan nurhidayat, 2007). anak berkepribadian introvert atau ekstrovert baru bisa diketahui saat mereka masuk bangku cooperative play dan interaksi sosial anak (ira rahmawati) 39 sekolah. anak ekstrovert, sepulang sekolah akan spontan menceritakan kegiatannya di sekolah. sebaliknya anak-anak introvert akan diam saja (savitri, 2008). pada anak sekolah tepatnya usia 9 tahun, anak memasuki “usia gang” atau usia berkelompok (pillitteri, 1999). sebagian besar kegiatan mereka lakukan dengan kelompok mereka (pillitteri, 1999). menjadi pribadi sosial merupakan salah satu tugas perkembangan yang utama pada periode ini (hurlock, 2005). berdasarkan pengamatan peneliti, sudah ada aktivitas bermain sosial di sdn kendangsari iii/278 surabaya, tetapi jenis permainan yang sering dimainkan adalah jenis permainan sosial level rendah seperti parallel dan associative play. jenis aktivitas bermain sosial level tinggi seperti cooperative play jarang digunakan. permainan tersebut hanya dilakukan seminggu sekali saat pelajaran olah raga (seperti sepak bola dan voli). sehingga keadaan tersebut belum dapat menjawab masalah interaksi sosial anak sekolah dengan gejala kepribadian introvert. survei yang dilakukan peneliti di sdn kendangsari iii/278 surabaya menggunakan kuisioner yang diadaptasi dari personality test kepribadian introvert yayasan dharma graha berbahasa indonesia (disusun oleh psikiater dr. h. yul iskandar ph.d.). hasil tes tersebut menunjukkan anak sekolah dengan gejala kepribadian introvert sebesar 62,5%. sesuai dengan interpretasi ciri sifat introvert dalam personality test (iskandar, 2005), anak introvert dengan tingkat introvert rendah tidak mengalami masalah interaksi sosial sedangkan anak tingkat introvert sangat tinggi, tinggi dan rata-rata dapat mengalami masalah interaksi sosial. anak dengan masalah interaksi sosial cenderung mempunyai konsep diri negatif. konsep diri negatif dapat memberikan dampak buruk pada tumbuh kembang anak terutama aspek psikologis dan sosial (tim familia, 2006). konsep diri negatif yang terus berlangsung akan menyebabkan harga diri rendah kronis (hdrk). hdrk merupakan salah satu penyebab terbesar gangguan jiwa depresi (sarason dan sarason, 2002). sebaliknya, pada anak introvert yang tidak mengalami masalah interaksi sosial cenderung terbentuk konsep diri positif. konsep diri positif tidak hanya akan memberi efek positif pada aspek psikologis dan sosial anak saja. namun juga berpengaruh pada prestasi akademik anak di sekolah (tim familia, 2006). komponen utama pola kepribadian ada dua yaitu konsep diri dan sifat. namun konsep diri lebih sebagai inti pola kepribadian yang memengaruhi berbagai bentuk sifat (sabri, 2001). pada seorang dengan kepribadian introvert, kemungkinan pertama penyebab permasalahan interaksi sosial yaitu mereka mempunyai self concept yang mengambarkan diri mereka eksklusif dibandingkan orang lain (fenn, 2002). kemungkinan kedua adalah karena seorang dengan kepribadian introvert kurang percaya diri (nussbaum, 2002 dalam rich, 2003). anak di perkotaan lebih mengenal play station, nintendo atau permainan lain yang berhubungan dengan teknologi (supendi dan nurhidayat, 2007). permainan tersebut lebih mengarah pada permainan level sosial rendah atau individualis. kondisi permainan tersebut bukanlah konsep permainan yang dapat meningkatkan interaksi sosial anak introvert. sehingga dengan keadaan seperti itu, anak introvert akan tetap mengalami masalah interaksi sosial dan berdampak buruk pada keterampilan sosial anak. beberapa fakta menunjukkan anak dengan keterampilan sosial rendah umumnya tidak disukai, dikucilkan atau diabaikan (familia, 2006). salah satu intervensi dalam asuhan keperawatan anak adalah aktivitas bermain s o s i a l s e s u a i t u m b u h k e m b a n g a n a k . keterampilan yang berhubungan dengan basic life skill, seperti keterampilan berkomunikasi, bersosialisasi, bekerja sama dan negosiasi dalam tim dapat dipelajari melalui proses bermain sosial (supendi, 2007). menurut hasil penelitian, terdapat pengaruh yang signifikan dari terapi bermain sosial terhadap peningkatan kemampuan dan keterampilan sosial anak (chusairi, 2006). bermain sosial adalah permainan yang melibatkan interaksi sosial dengan kelompok (santrock, 2000). pada interaksi sosial terdapat proses imitasi, identifikasi, sugesti, dan simpati (walgito, jurnal ners vol. 5 no. 1 april 2010: 38–48 40 2003). proses tersebut akan meningkatkan keterampilan sosial anak. peningkatan keterampilan sosial akan meningkatkan interaksi sosial anak. berdasarkan uraian tersebut, aktivitas bermain sosial: cooperative play dapat digunakan sebagai alternatif solusi untuk meningkatkan interaksi sosial anak dengan gejala kepribadian introvert. bahan dan metode desain penelitian yang digunakan adalah quasy experiment. populasi target dalam penelitian ini anak dengan gejala kepribadian introvert sedangkan populasi terjangkau anak sekolah dengan gejala kepribadian introvert di sdn kendangsari iii/278 surabaya. responden sebanyak 23 anak sekolah didapat berdasarkan kriteria inklusi sebagai berikut: anak sekolah di sdn kendangsari iii surabaya kelas 5 (usia 9, 10 dan 11), anak dengan gejala kepribadian introvert tingkat rata-rata, tinggi dan sangat tinggi serta anak sekolah sehat mental dan fisik. kriteria eksklusi yang digunakan meliputi: anak sekolah tidak bersedia diteliti, anak sekolah tidak kooperatif dan anak sekolah tidak masuk pada saat penelitian. variabel independen yang digunakan dalam penelitian ini adalah aktivitas bermain sosial: cooperative play dan variabel dependen yang digunakan dalam penelitian ini yaitu interaksi sosial pada anak dengan gejala kepribadian introvert. pengumpulan data dilakukan dengan menggunakan kuesioner dan observasi terhadap kelompok perlakuan dan kontrol untuk mengukur interaksi sosial sebelum dan setelah perlakuan. indikator dari interaksi sosial yang akan digunakan pengembangan dari kompleks interaksi sosial menurut gillis mattson dan raymond g. romanczyk yang terdiri dari kontak sosial dan kemampuan komunikasi. kemampuan komunikasi terdiri dari kemampuan komunikasi verbal dan nonverbal. kuesioner yang digunakan untuk mengukur kontak sosial menggunakan jenis pertanyaan kuesioner tertutup dan diisi oleh anak sebagai responden (subjek penelitian). pengukuran kemampuan komunikasi baik verbal maupun nonverbal menggunakan metode observasi. pengumpulan data observasi verbal dikembangkan dari taks keliat dan akemat (2005) meliputi beberapa aspek. aspek tersebut adalah perkenalan; bertanya (jelas, ringkas, relevan dan spontan); menjawab (jelas, ringkas, relevan dan spontan); menyampaikan topik tertentu (jelas, ringkas, relevan dan spontan); memberi pendapat (jelas, ringkas, relevan dan spontan); dan kemampuan bekerja sama: bertanya dan meminta (jelas, ringkas, relevan dan spontan), menjawab dan memberi (jelas, ringkas, relevan dan spontan). sedangkan kemampuan komunikasi nonverbal dikembangkan saluran komunikasi non verbal menurut baron dan byrne (2004). komunikasi non verbal tersebut akan diukur melalui kesesuaian ekspresi wajah, kontak mata dan bahasa tubuh (kesesuaian bahasa tubuh dan jarak personal sosial). kuesioner dan observasi yang akan dilakukan saat jam pelajaran berlangsung dengan ijin dari guru pengajar sebagai jam pembelajaran khusus. observasi dilakukan saat permainan puzzle dengan potongan puzzle tersebar acak untuk menilai kemampuan komunikasi verbal kerja sama dan komunikasi nonverbal responden. penelitian ini dilaksanakan pada tanggal 3 sampai 7 juni 2008 dilanjutkan 16 sampai 21 juni 2008 di sdn kendangsari iii/278 surabaya. data yang terkumpul dianalisis untuk mengetahui perbedaan interaksi sosial anak sebelum dan sesudah diberikan aktivitas bermain sosial: cooperative play dengan uji statistik willcoxon sign rank test dan mann whitney u test untuk mengetahui perbedaan antara kelompok perlakuan dan control dengan tingkat kemaknaan α ≤ 0,05. hasil pada kelompok perlakuan sebelum diberikan aktivitas bermain sosial: cooperative play, diperoleh data interaksi sosial dengan kriteria kurang baik sebanyak 50%, interaksi sosial cukup sebanyak 41,7% dan interaksi sosial baik sebanyak 8,3%. setelah diberikan perlakuan, hampir setengah anggota kelompok perlakuan mempunyai kriteria baik (41,7%), cukup sebanyak 41,7% dan kurang baik sebanyak 16,7%. cooperative play dan interaksi sosial anak (ira rahmawati) 41 pada kelompok kontrol, sebelum diberikan aktivitas bermain sosial: cooperative play, diperoleh data interaksi sosial dengan kriteria kurang baik sebanyak 36,4%, interaksi sosial cukup sebanyak 36,4% dan interaksi sosial tidak baik sebanyak 27,3%. adapun setelah diberikan perlakuan, didapatkan hasil kriteria interaksi sosial sama seperti sebelum perlakuan. berdasarkan hasil tersebut didapatkan perbedaan yang signifikan pada kelompok perlakuan antara sebelum dan sesudah diberikan aktivitas bermain sosial: cooperative play. sedangkan pada kelompok kontrol sebagian besar berada pada ties yang berarti hasil interaksi sosial antara sebelum dan sesudah perlakuan tidak mengalami perubahan. hasil uji statistik wilcoxon signed rank test kelompok kontrol menunjukkan derajat kemaknaan 1,000 yang berarti tidak ada perbedaan yang signifikan antara hasil interaksi sosial sebelum dan sesudah perlakuan. hasil uji statistik mann whitney u test p = 0,002 yang berarti bahwa ada perbedaan yang signifikan antara kelompok perlakuan dan kelompok kontrol. sehingga dari hasil uji statistik tersebut dapat disimpulkan bahwa ada pengaruh aktivitas bermain sosial: cooperative play terhadap interaksi anak dengan gejala kepribadian introvert (tabel 1). pembahasan sebagian besar responden mempunyai derajat kepribadian introvert rata-rata. interaksi sosial responden sebelum dilakukan aktivitas bermain sosial: cooperative play mengalami masalah. keadaan ini dibuktikan oleh setengah dari responden kelompok perlakuan mempunyai kriteria interaksi sosial kurang baik. sedangkan pada kelompok kontrol terdapat hampir setengah mempunyai kriteria interaksi sosial kurang baik dan sebagian kecil mempunyai kriteria interaksi sosial tidak baik. interaksi sosial yang kurang dapat dilihat dari hasil skor kuesioner kontak sosial dan observasi komunikasi. pada hasil tabulasi kuesioner kontak sosial, baik kelompok perlakuan maupun kontrol sebagian besar mendapat skor rendah di bagian kontak sosial primer, kontak sosial sekunder, subjek tempat bertukar pikiran, fungsi responden sebagai tempat berkeluh kesah bagi orang lain, tingkat kebutuhan akan orang lain, tingkat kebutuhan orang lain terhadap dirinya dan jenis kegiatan di luar rumah serta tempat bermain. sedangkan berdasarkan hasil tabulasi observasi komunikasi, baik kelompok perlakuan maupun kontrol sebagian besar mendapat skor rendah komunikasi verbal di bagian bertanya, memberi pendapat, kemampuan bekerja sama (bertanya dan meminta; menjawab dan memberi); dan komunikasi nonverbal di bagian kontak mata serta bahasa tubuh. introvert merupakan salah satu tipe kepribadian. komponen utama pola kepribadian ada dua yaitu konsep diri (self concept) dan sifat (trait). namun konsep diri lebih sebagai inti pola kepribadian yang memengaruhi berbagai bentuk sifat (sabri, 2001). menurut c.g. jung introvert menunjukkan bahwa individu yang memiliki minat ke dalam dirinya sendiri; pikiran, perasaan dan cita-citanya sendiri yang menjadi sumber, minat dan nilai-nilainya (sabri, 2001). menurut ahli psikologi, pola kepribadian terdiri dari dua bagian yaitu the self concept (konsep diri) sebagai pusat bentuk kepribadian dan trait (sifat) sebagai roda atau kemudi kepribadian yang berhubungan erat dan dipengaruhi oleh the self concept (sabri, 2001). ada tiga dimensi yang tergabung dalam sifat introvert yaitu: kecenderungan atau suka akan perenungan atau pemikiran, sebagai lawan terhadap kecenderungan bertindak, lebih cenderung untuk menyendiri daripada turut aktif di tengah kumpulan orang atau masyarakat dan kecenderungan untuk mencari atau membayangkan kesukaran dalam hidupnya (sabri, 2001). hasil interpretasi tes personaliti versi dharma graha didapatkan anak introvert yang mempunyai masalah interaksi adalah anak dengan derajat introvert sangat tinggi, tinggi dan rata-rata (iskandar, 2003). pada anak derajat introvert sangat tinggi mempunyai sifat kaku, pemalu, pendiam, keras kepala, tidak ada kepercayaan diri, sulit diterima orang banyak dan tidak mampu berkomunikasi dengan orang lain. adapun anak derajat introvert tinggi mempunyai sifat kurang percaya diri sehingga tidak percaya pada orang lain dan tidak mau bergaul. anak derajat introvert ratajurnal ners vol. 5 no. 1 april 2010: 38–48 42 rata mempunyai sifat pendiam, tidak percaya diri, sulit diajak bekerja sama dan cenderung pemilih dalam mencari teman atau sahabat (iskandar, 2003). pola kepribadian tersebut terbentuk disebabkan mereka mempunyai self concept yang menggambarkan diri mereka eksklusif dibandingkan orang lain (fenn, 2002). serta dapat juga disebabkan seorang dengan kepribadian introvert kurang percaya diri (nussbaum, 2002 dalam rich, 2003). berdasarkan uraian di atas, anak dengan gejala kepribadian introvert mempunyai masalah dengan interaksi sosial disebabkan oleh pola kepribadian mereka baik itu konsep diri maupun sifat. kemungkinan pertama, anak dengan gejala kepribadian introvert mempunyai rasa percaya diri rendah. rasa percaya diri rendah akan berpengaruh pada sifat pribadi tingkah laku anak seperti tidak percaya pada orang lain dan tak mau bergaul. sifat anak yang tidak percaya pada orang lain menyebabkan anak jarang bertukar pikiran (sharing) dan dijadikan tempat bertukar pikiran. sedangkan sifat tidak mau bergaul menyebabkan anak mempunyai kontak sosial baik primer maupun sekunder rendah. keadaan tersebut akan menyebabkan menurunnya jenis kegiatan anak di luar rumah, menyempitnya jangkauan tempat bermain dan menurunnya tingkat kebutuhan orang lain terhadap anak. kepercayaan diri yang rendah juga dapat menyebabkan menurunnya kemampuan komunikasi verbal maupun non verbal. kemungkinan kedua, anak introvert menggambarkan diri mereka eksklusif dibandingkan orang lain. penggambaran diri tersebut akan menyebabkan tingkat kebutuhan anak akan orang lain berkurang. pola kepribadian tidak hanya dipengaruhi oleh unsur pembentuknya saja tapi juga oleh beberapa faktor yang memengaruhi perkembangan kepribadian itu sendiri. hasil penelitian menunjukkan baik kelompok perlakuan maupun kontrol sebagian besar berusia 10 tahun dan sebagian kecil 9 dan 11 tahun. berdasarkan tabulasi hasil interaksi sosial anak usia 10 dan 11 tahun mempunyai skor interaksi sosial lebih besar daripada anak usia 9 tahun. seiring bertambah usia, anak banyak belajar dan mengembangkan emosi melalui pengalaman dalam berinteraksi dengan orang lain di sekelilingnya (daengsari, 2000). kemampuan anak mengatur emosi dan perilaku akan menambah keterampilan sosial anak sehingga anak dapat menjalin interaksi secara efektif (fajar, 2007). selain itu usia anak yang semakin bertambah diikuti oleh perkembangan fungsi organ tertentu dari tubuh dan interaksi sosial yang dialami (geibreil, 2008). semakin bertambah usia maka semakin bertambah juga pengalaman yang berarti juga meningkatnya keterampilan sosial. anak dengan keterampilan sosial yang baik akan mempunyai interaksi sosial yang baik juga. sehingga semakin bertambah usia semakin baik perkembangan interaksi sosialnya. setengah dari responden pada kelompok perlakuan berjenis kelamin lelaki, sedangkan pada kelompok kontrol sebagian besar berjenis kelamin lelaki. berdasarkan tabulasi hasil interaksi sosial, anak lelaki mempunyai skor interaksi sosial lebih besar daripada anak perempuan. anak lelaki cenderung mempunyai hubungan teman sebaya yang lebih luas daripada anak perempuan. ia lebih suka tabel 1. interaksi sosial anak dengan gejala kepribadian introvert di sdn kendangsari iii/278 surabaya pada tanggal 3 sampai 21 juni 2008 kelompok perlakuan kelompok kontrol negative ranks 0 1 positive ranks 12 2 ties 0 8 total 12 11 wilcoxon singed ranks test signifi kansi (p) = 0,002 wilcoxon singed ranks test signifi kansi (p) = 1,00 mann whitney u-test signifi kansi (p) = 0,002 cooperative play dan interaksi sosial anak (ira rahmawati) 43 bermain berkelompok daripada hanya dengan satu atau dua anak. sebaliknya, hubungan sosial anak perempuan lebih intensif dalam arti bahwa ia lebih sering bermain dengan satu atau dua orang daripada dengan seluruh kelompok (hurlock, 2004). pada permainan berkelompok, interaksi akan lebih luas dan beragam. sehingga pada anak lelaki, mereka akan mempunyai kesempatan belajar mengenal pola interaksi yang lebih baik daripada anak perempuan. oleh karena itu, anak lelaki akan mempunyai interaksi sosial yang lebih baik dibandingkan dengan anak perempuan. sebagian besar responden kelompok perlakuan dan kontrol adalah anak sulung dan sebagian kecil anak tunggal serta bungsu. berdasarkan tabulasi hasil interaksi sosial, anak sulung mempunyai skor interaksi sosial lebih rendah daripada anak bungsu dan tunggal. anak yang lahir pertama dan terakhir dalam keluarga besar sering menjadi egosentrik karena mereka merupakan pusat perhatian dari seluruh anggota keluarga. semakin kecil keluarga, semakin egosentrik si anak. anak tunggal cenderung menjadi lebih egosentrik daripada anak dari keluarga besar. anak yang egosentrik terikat pada dirinya dalam arti bahwa perhatian mereka terutama berpusat kepada diri mereka sendiri (hurlock, 2005). anak sulung mempunyai karakteristik kurang berani, kurang agresif, sering tidak bahagia karena adanya perasaan kurang aman yang timbul dari berkurangnya perhatian orang tua dengan kelahiran adiknya (hurlock, 2004). anak sulung juga sering mengkritik orang lain dan tidak kooperatif (adler dalam alwisol, 2004). anak bungsu mengalami hubungan sosial yang baik di luar rumah dan biasanya populer tetapi jarang menjadi pemimpin karena kurangnya kemauan memikul tanggung jawab (hurlock, 2004). anak tunggal mempunyai karakteristik masak secara sosial (hurlock, 2004). urutan kelahiran mempunyai peranan penting dalam membentuk kepribadian seseorang. baik anak tunggal, bungsu maupun sulung sama cenderung egosentrik. tetapi dengan berkembangnya berbagai kecakapan dan kemampuan berkomunikasi, egosentrisme seharusnya berkurang. namun berdasarkan pengalaman hidupnya, anak sulung yang mempunyai karakteristik sifat kurang bagus (sering mengkritik dan tidak kooperatif) akan mengakibatkan pandangan kelompok sosial terhadap mereka tidak menguntungkan baik dari orang dewasa maupun teman sebaya. keadaan ini berdampak pada penyesuaian pribadi dan sosial yang buruk. sehingga interaksi sosial mereka lebih rendah daripada interaksi sosial anak tunggal dan anak bungsu. responden kelompok perlakuan dan kontrol sebagian besar tinggal di perkampungan dan sebagian kecil tinggal di perumahan. berdasarkan tabulasi hasil interaksi sosial, anak yang tinggal di perumahan mempunyai skor interaksi sosial lebih rendah daripada anak yang tinggal di perkampungan. lingkungan kehidupan yang serba individu, biasanya terjadi pada perumahan. hal ini tidak baik bagi anak. ia menjadi tidak bisa bergaul, suka memilihmilih teman, tidak suka melakukan kegiatan yang berbau sosial dan senang menyendiri (kasandra dalam pernamasari, 2006). lingkungan merupakan faktor yang sangat menentukan tercapai atau tidaknya potensi bawaan. lingkungan yang cukup baik akan memungkinkan tercapainya potensi bawaan, sedangkan yang kurang baik mungkin dapat menghambat. lingkungan perumahan kurang kondusif untuk sosialisasi anak. hal ini dikarenakan lingkungan perumahan lebih sedikit menyediakan kesempatan untuk anak berinteraksi dengan teman sebayanya sehingga anak menjadi individualis. oleh sebab itu, interaksi sosial anak yang tinggal di perkampungan lebih baik daripada interaksi sosial anak yang tinggal di perumahan. kelompok kontrol maupun perlakuan sebagian besar mempunyai derajat introvert rata-rata dan sisanya derajat introvert tinggi. berdasarkan tabulasi hasil interaksi sosial, anak dengan kepribadian introvert derajat tinggi mempunyai kriteria interaksi sosial kurang baik dan tidak baik. sedangkan anak dengan derajat kepribadian introvert rata-rata sebagian besar mempunyai kriteria interaksi sosial cukup dan kurang baik serta sisanya tidak baik. adapun anak derajat introvert tinggi mempunyai sifat kurang percaya diri sehingga tidak mudah percaya pada orang lain jurnal ners vol. 5 no. 1 april 2010: 38–48 44 dan tidak mau bergaul. sedangkan anak derajat introvert rata-rata mempunyai sifat pendiam, tidak percaya diri, sulit diajak bekerja sama dan cenderung pemilih dalam mencari teman atau sahabat (iskandar, 2003). berdasarkan uraian tentang sifat anak introvert di atas, maka dapat dikatakan semakin tinggi derajat introvert anak maka makin rendah kriteria interaksi sosialnya. berdasarkan distribusi karakteristik responden tingkat pendidikan, setengah dari orang tua kelompok perlakuan mempunyai tingkat pendidikan sma dan kelompok kontrol hampir setengah memiliki tingkat pendidikan sma. anak dengan pendidikan orang tua sma dan perguruan tinggi mempunyai interaksi sosial yang lebih besar dibandingkan anak dengan orang tua berpendidikan smp dan sd. taraf pendidikan orang tua akan memengaruhi kemampuan orang tua dalam membimbing anak, dengan pendidikan yang baik kemampuan orang tua membimbing anak semakin baik (dariyo, 2004). dengan pendidikan yang baik maka orang tua dapat menerima segala informasi dari luar terutama tentang cara pengasuhan anak yang baik, bagaimana menjaga kesehatan anak dan bagaimana memberikan pendidikan pada anak (soetjiningsih, 2002). semakin tinggi tingkat pendidikan seseorang semakin mudah orang tersebut menerima informasi baik dari orang lain maupun dari media massa sehingga semakin banyak pula pengetahuan yang didapat. semakin tinggi pengetahuan orang tua maka akan semakin banyak hal yang akan diajarkan pada anak seperti cara bersosialisasi yang baik. sehingga anak dengan orang tua berpendidikan tinggi akan mempunyai kemampuan interaksi sosial yang tinggi juga. jenis pekerjaan orang tua kelompok perlakuan dan kelompok control setengah dari ibu mempunyai jenis pekerjaan sebagai ibu rumah tangga atau tidak bekerja. anak yang dibesarkan oleh ibu bekerja mempunyai skor interaksi sosial yang lebih rendah dibandingkan dengan anak yang ibunya tidak bekerja. orang tua berperan besar dalam membentuk kepribadian anak, salah satu caranya yaitu dengan memberikan stimulasi melalui berbagai corak komunikasi antara orang tua dengan anak. pada kenyataannya yang sering berfungsi sebagai orang tua adalah ibu. (gunarsa dan gunarsa, 2000). adapun studi mengenai pengalaman awal anak telah memperlihatkan bahwa pengalaman dan ingatan tentang sesuatu, walaupun samar, sangat berpengaruh karena pengalaman meninggalkan kesan yang tidak terhapuskan pada konsep diri anak (hurlock, 2005). harga diri (konsep diri) sangat berpengaruh pada interaksi sosial anak (petranto, 2006). ibu rumah tangga yang tidak mempunyai pekerjaan maka akan mempunyai banyak waktu luang untuk berinteraksi dengan anaknya. oleh karena itu anak akan mendapat lebih banyak perhatian dan pendidikan dari orang tuanya. perasaan diperhatikan dan pengalaman belajar lebih banyak dari orang tua akan menyebabkan anak tumbuh dengan konsep diri yang baik. anak yang tidak dibekali aturan sosial namun memiliki rasa percaya diri yang kuat, bisa dianggap aneh oleh lingkungannya. misalnya ia dianggap tidak sopan karena tidak tahu bagaimana cara meminjam barang yang semestinya pada orang lain. sementara anak pemalu yang tidak dibekali aturan sosial, bisa jadi akan merasa minder jika berhadapan dengan lingkungan yang belum dikenalnya. sehingga akan berdampak buruk pada interaksi sosial anak. jenis pekerjaan orang tua kelompok perlakuan dan kelompok kontrol sebagian besar ayah mempunyai jenis pekerjaan swasta. berdasarkan tabulasi, hasil interaksi sosial anak dengan orang tua yang mempunyai pekerjaan lebih besar skor interaksi sosialnya. pendapatan keluarga yang memadai akan menunjang tumbuh kembang anak karena orang tua dapat menyediakan semua kebutuhan anak baik yang primer maupun yang sekunder (soetjiningsih, 2002). ayah sebagai tulang punggung keluarga mempunyai peran besar terhadap pendapatan keluarga. adapun anak yang kebutuhannya terpenuhi akan menunjang tumbuh kembang anak. jadi ayah yang berpenghasilan mampu memenuhi kebutuhan keluarga. sehingga tumbuh kembang anak akan berjalan optimal. salah satunya adalah perkembangan keterampilan sosial anak. tumbuh kembang yang baik akan berdampak positif pada interaksi sosial anak. cooperative play dan interaksi sosial anak (ira rahmawati) 45 setelah diberikan aktivitas bermain sosial: cooperative play pada kelompok perlakuan didapatkan peningkatan interaksi sosial. hurlock menyebutkan bahwa salah satu jenis permainan yang mampu memotivasi perkembangan emosi dan sosial anak adalah permainan yang bernuansa sosial (hartini, 2000). keterampilan yang berhubungan dengan basic life skill, seperti keterampilan berkomunikasi, bersosialisasi, penghargaan, dan bekerja sama dalam tim juga dapat dipelajari melalui proses bermain sosial (supendi dan nurhidayat, 2007). lewat bermain, fisik anak akan terlatih, kemampuan kognitif dan kemampuan berinteraksi dengan orang lain akan berkembang (tasmin, 2002). aktivitas bermain sosial: cooperative play merupakan jenis permainan yang bernuansa sosial. permainan ini dapat mengajarkan anak keterampilan yang dibutuhkan saat berinteraksi dengan orang lain. dengan bertambahnya keterampilan tersebut maka akan meningkatkan kemampuan anak untuk berinteraksi sosial. berdasarkan hasil tabulasi hasil interaksi sosial, menunjukkan peningkatan interaksi sosial anak lebih besar pada kemampuan komunikasi dibandingkan dengan kontak sosial. terjadinya suatu kontak sosial tidaklah semata-mata tergantung dari tindakan, tetapi juga tanggapan terhadap tindakan tersebut (dwiumami, 2008). kemampuan kontak sosial bukanlah kemampuan yang bisa didapat dalam waktu singkat. selain itu kontak sosial tidak tergantung dari tindakan saja, tetapi juga tanggapan terhadap tindakan tersebut. jika usaha kontak hanya dilakukan pada satu sisi saja, tetapi tidak ada usaha dari sisi lawan kontak maka kontak sosial tidak akan terjadi. pada kelompok perlakuan masih ada responden yang tetap memiliki kriteria interaksi sosial kurang baik. terdapat 2 anak yang tidak mengalami peningkatan yaitu responden no. 4 dan 6. berdasarkan data karakteristik responden didapatkan pada responden no. 4 berusia sembilan tahun, lelaki, introvert rata-rata, anak sulung, tinggal di perkampungan, pendidikan ayah perguruan tinggi, ibu sma, dan pekerjaan ayah swasta serta ibu wirausaha. beberapa bentuk belajar hanya mungkin setelah tercapai tingkat kematangan tertentu (horton dan hunt, 2006). pada usia sepuluh tahun anak mulai menyukai peraturan dan siap untuk berkompetisi dalam permainan (pillitteri, 1999). saat berumur 10 atau 11 tahun kebanyakan anak mulai belajar permainan olah raga (santrock, 2000). anak mempunyai pertumbuhan dan perkembangan yang unik di setiap tahapan usianya. meskipun saat usia sembilan tahun merupakan usia berkelompok (gang) tapi mereka belum menyukai peraturan. padahal permainan sosial: cooperative play merupakan permainan yang mementingkan peraturan sebagai analogi bahwa di masyarakat ada aturan untuk setiap tindakan. sehingga peningkatan interaksi sosial anak sembilan tahun lebih rendah daripada anak berusia sepuluh tahun. responden no. 6 berusia 11 tahun, introvert rata-rata, anak tunggal, tinggal di perumahan, pendidikan ayah perguruan tinggi, ibu sma, dan pekerjaan ayah tni/polisi serta ibu swasta. keluarga merupakan basis pertama dan utama dalam berbagai rangkaian proses interaksi sosial yang dialami individu selama hidupnya. kebutuhan psikologis dan sosiologis anak yang dialami anak di dalam keluarga kemudian menjadi dasar untuk pergaulannya dengan masyarakat sosial yang lebih luas (geibreil, 2008). terdapat banyak bukti bahwa sikap dan reaksi emosional orang tua, konteks budaya dari lingkungan tempat anak dibesarkan dan faktor lain dalam pengalaman total anak penting sekali dalam menentukan pola kepribadian. peran yang dipelajari anak di rumah memengaruhi konsep dirinya (hurlock, 2005). hasil riset dan para psikologi banyak yang menyatakan bahwa peran ayah juga penting dalam pertumbuhan seorang anak. ikatan emosional antara ayah dan anak, ditentukan salah satunya oleh interaksi antara ayah dan anak itu sendiri (eramuslim, 2004). petranto, 2006 menyatakan bahwa orang tua mendidik anak berdasarkan pola asuh tertentu (demokratis, otoriter, permisif dan penelantar). pola asuh orang tua ini sangat memengaruhi bagaimana kelak anak berperilaku, bentuk-bentuk kepribadian anak secara keseluruhan (petranto, 2006). anak yang terbiasa mendapat pendidikan yang sangat otoriter biasanya mengembangkan jurnal ners vol. 5 no. 1 april 2010: 38–48 46 kekakuan dalam pola penyesuaian mereka yang karakteristik atau sindrom kepribadian otoriter. mereka bersikap menahan diri, sangat terkendali, introvert tertutup, konservatif, dan konvensional. akibat ciri-ciri itu, mereka tidak toleran terhadap perubahan, ketidakteraturan dan hal yang tidak jelas. mereka cenderung patuh terhadap tokoh yang berkuasa, tetapi agresif terhadap semua yang lebih lemah dari mereka. secara lazim, mereka merasa cemas, mudah merasa khawatir, selalu ragu, merasa tidak aman, menganut moral yang kaku dan diganggu perasaan ketidakmampuan dan inferioritas. karakteristik tersebut mewarnai seluruh penyesuaian mereka dalam hidup (hurlock, 2005). adapun orang tua yang mempunyai pekerjaan tni/polisi cenderung menerapkan pola asuh diktator. pola asuh tersebut akan berpengaruh kepada kepribadian anak. karena pola asuh diktator tidak memberikan kebebasan pada anak untuk mengeluarkan pendapat. sehingga anak akan mempunyai interaksi sosial kurang baik, seperti dalam komunikasi verbal saat mengungkapkan pendapat. berdasarkan hasil tabulasi kuesioner kontak sosial, sebagian besar kelompok perlakuan mendapat skor rendah di bagian kontak sosial sekunder, subjek tempat bertukar pikiran (sharing), fungsi responden sebagai tempat berkeluh kesah bagi orang lain, tingkat kebutuhan akan orang lain. sedangkan berdasarkan hasil tabulasi obervasi komunikasi, sebagian besar kelompok perlakuan mendapat skor rendah di bagian bertanya dan memberi pendapat. suatu kontak dapat bersifat primer atau sekunder. kontak sekunder memerlukan suatu perantara seperti alat telepon, telegraf, radio. efektivitas dan hambatan komunikasi antar personal menekankan pada keterbukaan (openness), empati (empathy) suportif (supportive), saling mengerti (equality) dan kejujuran (possitiveness) (noegroho dan istiyanto, 2000). bertanya membutuhkan proses berpikir, kontemplasi, dan kreasi (jon, 2007). sedangkan berpendapat membutuhkan kemampuan berpikir kritis. kemampuan ini merupakan integrasi beberapa bagian pengembangan kemampuan, seperti pengamatan (observasi), analisis, penalaran, penilaian, pengambilan keputusan, dan persuasi (setiono, 2007). sikap mental juga perlu disiapkan untuk memberi dan menerima kritik serta sanggahan (rachman dan savitri, 2008). beberapa kemampuan interaksi sosial memang tidak mudah untuk didapat. pertama, kontak sekunder sulit mengalami peningkatan karena memerlukan perantara yang belum tentu tersedia bagi responden. kedua, kontak sosial yang berhubungan dengan bertukar pikiran (sharing) sulit mengalami peningkatan karena ada hambatan dalam komunikasi antar personal. anak dituntut untuk mempunyai keterbukaan (openess), empati (empathy) suportif (supportive), saling mengerti (equality) dan kejujuran (possitiveness) dengan pasangan komunikasinya. ketiga, kemampuan dalam bertanya dan berpendapat tidak hanya dipengaruhi oleh kemampuan sosial namun masih membutuhkan kemampuan yang lain juga. sehingga perubahan pada kemampuan sosial juga membutuhkan perubahan pada kemampuan yang lain untuk mengubah kemampuan bertanya dan berpendapat. aktivitas bermain sosial: cooperative play adalah permainan yang melibatkan interaksi sosial dalam kelompok di mana d a p a t d i t e m u i i d e n t i t a s k e l o m p o k d a n kegiatan yang terorganisir (santrock, 2000). piaget mengemukakan bahwa kesempatan menurunkan ego anak dapat terjadi saat anak berdiskusi bersama karena mereka harus menerima kenyataan bahwa tidak semua orang mempunyai pandangan yang sama dengannya dalam situasi tertentu (heningger, 1999). permainan ini menggambarkan pentingnya koordinasi suatu kelompok dalam memecahkan masalah. setiap kelompok dituntut untuk memecahkan masalahnya, tetapi tetap sportif menaati aturan yang ada. permainan ini berfungsi sebagai analogi bahwa dalam kehidupan bermasyarakat pun selalu ada aturan dan norma yang mengatur setiap tindakan (supendi dan nurhidayat, 2007). aktivitas bermain sosial: cooperative play merupakan permainan yang melibatkan interaksi sosial dengan kelompok (peers). pada interaksi sosial terdapat proses imitasi, identifikasi, sugesti, dan simpati. diharapkan cooperative play dan interaksi sosial anak (ira rahmawati) 47 saat mengikuti terapi bermain tersebut anak akan mengalami proses tersebut dengan teman sepermainannya sehingga terjadi respon mengenal pola interaksi sosial berhubungan dengan orang lain yang akan meningkatkan keterampilan sosial anak. melalui proses belajar (pengalaman) berupa fisik yang kemudian berkembang menjadi psikis akan menjadikan proses kesadaran menjadi ketidaksadaran yang mengubah pola kepribadian. perubahan yang terjadi pada pola kepribadian adalah konsep diri (harga diri) meningkat serta perubahan sifat kualitatif dan atau kuantitatif. kondisi tersebut terefleksi dengan sikap percaya diri dan suka bergaul dengan banyak orang. sehingga keadaan tersebut akan meningkatkan interaksi sosial yang terdiri dari komunikasi maupun kontak sosial. simpulan dan saran simpulan aktivitas bermain sosial: cooperative play mampu meningkatkan interaksi sosial anak dengan gejala kepribadian introvert. saran saran yang dapat diberikan antara lain bagi perawat terutama perawat anak agar lebih kreatif dan inovatif dalam menstimulasi tumbuh kembang anak melalui permainan, seperti aktivitas bermain sosial: cooperative play, melibatkan keluarga terutama orang tua sebagai support system dan pendorong yang efektif dalam tugas tumbuh kembang anak, mengembangkan penelitian lebih lanjut mengenai stimulasi tumbuh kembang anak untuk membantu anak dengan masalah sosialisasi. bagi anak dengan gejala kepribadian introvert agar tetap melanjutkan aktivitas bermain sosial, seperti cooperative play baik di rumah maupun di sekolah. bagi orang tua, hendaknya dapat menjadi role model interaksi sosial yang baik untuk anak, menyediakan waktu luang untuk berinteraksi dengan anak dan memberikan kesempatan anak untuk bersosialisasi. bagi sekolah, hendaknya dapat menyediakan sarana dan prasarana untuk dapat membantu tumbuh kembang anak seperti aktivitas bermain sosial: cooperative play. sebagai orang kedua yang penting pengaruhnya setelah orang tua, guru dapat menjadi role model interaksi sosial yang baik serta menyediakan alat, media maupun metode stimulasi anak dalam proses tumbuh kembang terutama keterampilan sosial. daftar pustaka alwisol, 2004. psikologi kepribadian. malang: umm press, hlm. 73, 106–110. chusairi, a., 2006. efektivitas terapi bermain sosial untuk meningkatkan kemampuan dan keterampilan sosial anak dengan autism. http://fulltext.lib.unair.ac.id. tanggal 16 mei 2008. jam 09.00 wib. daengsari, d., 2000. perkembangan emosi, (online), http://www.tabloid-nikita. com., diakses tanggal 28 juli 2008. jam 16.00 wib). dariyo, 2004. psikologi perkembangan remaja. bogor: ghalia indonesia, hlm. 109. dwiumami, n., 2008. proses sosial dan interaksi sosial, (online), (http;// kuliahkomunikasi.wordpress.com., diakses tanggal 28 juli 2008, jam 16.00 wib). eramuslin, 2004. kiat memperkuat hubungan ayah dan anak, (online), (http://info. balitacerdas.com., diakses tanggal 28 juli 2008, jam 16.00 wib). fajar, 2007. keterampilan sosial pada anak menengah akhir. (online), (http://f4jar. multiply.com/journal/item/191., diakses tanggal 28 juli 2008, jam 16.00 wib). fenn, n., 2002. so your child is an introvert, (online), (http://www.selfgrowth.com., diakses tanggal 2 oktober 2007, jam 20.00 wib). geibreil, 2008. membentuk kepribadian melalui interaksi sosial, (online), (http://geibreil.wordpress.com., diakses tanggal 28 juli 2008, jam 16.00 wib). gunarasa dan gunarsa, 2000. psikologi praktis: anak, remaja dan keluarga. jakarta: bpk gunung mulia. hartini, n., 2000. peran pola permainan sosial dalam meningkatkan kecerdasan emosi anak. (online), (http://fulltext. lib.unair.ac.id., diakss tanggal 17 juli 2008., jam 10.00 wib). jurnal ners vol. 5 no. 1 april 2010: 38–48 48 henninger, m., 1999. theaching young children: an introduction. new jersey: prentice, hlm. 121–122. hurton dan hunt, 2006. sosiologi jilid i ed. 6. jakarta: erlangga, hlm. 102–103. hurlock, e, 2005. perkembangan anak ed. 5 jilid i. jakarta: erlangga. hurlock, e., 2005. perkembangan anak ed. 5 jilid ii. jakarta: erlangga. iskandar, y., 2003. tes personaliti. jakarta: yayasan graha group. jon, 2007. bertanya cermin kecerdasan anak. (online), (http://www.kompas.com., diakses tanggal 28 juli 2008, jam 16.00 wib). noegroho dan istiyanto, 2000. komunikasi antar personal. (online), (http://www. sbektiistiyanto.wordpress.com., diakses tanggal 28 juli 2008, jam 16.00 wib). pernamasari, 2006. neighbour, friend o r f o e ? . ( o n l i n e ) , ( h t t p : / / w w w. i n s p i r e d k i d s m a g a z i n e . c o m / artikelfamilylife.php?artikelid=85., diakses tanggal 28 juli 2008, jam 16.00 wib). petranto, i., 2006. rasa percaya diri anak adalah pantulan pola asuh orang tuanya. (online), (http://dwpptrijenewa. isuisse.com., diakses tanggal 24 mei, jam 16.00 wib). pillitteri, a., 1999. child health nursing care of the child and family. philladelphia: lippincott. rachman dan savitri, 2008. berpikir kritis. (online), (http://www.experd.com., diakses tanggal 28 juli 2008, jam 16.00 wib). ramdhani, a., 2002. problema pubertas dipondok pesantren. (online), (http:// digilib.itb.ac.id., diakses tanggal 2 juni 2008, jam 09.00 wib). rich, s., 2003. degree of active helping: an interaction between extraversion and self-esteem. (online), (http://web.sbu. edu/psychology.htm., diakses tanggal 3 oktober 2007, jam 10.00 wib). sabri, m., 2001. pengantar psikologi umum dan perkembangan bahan kuliah dan diskusi mahasiswa. jakarta: pedoman ilmu jaya. santrock, j., 2000. children. usa: mcgrawhill. savitri, i., 2008. anak-anak introvert, bermasalahkah?. (online), (http://www. republika.co.id., diakses tanggal 3 juni 2008, jam 10.00 wib). setiono, 2007. berpikir kritis. (online), (http://agustinussetiono.wordpress. com., diakses tanggal 26 juli 2008, jam 16.00 wib). soetjiningsih, 2002. tumbuh kembang anak. jakarta: egc. supendi, p. dan nurhidayat, 2007. fun game 50 permainan menyenangkan di indoor dan outdoor. jakarta: penebar plus. suryabrata, s., 2003. psikologi kepribadian. jakarta: raja grafi ndo persada. tasmin, m., 2002. bermain lebih penting daripada bermain?. (online), (http:// www.e-psikologi.com., diakses tanggal 26 juli 2008, jam 16.00 wib). tim familia, 2006. konsep diri positif, menentukan prestasi anak. yogyakarta: kanisus. waldrop, s., 2007. choosing friends an experience in social development. (online), (http://preschoolerstoday. com/resources/articles/friends.htm., diakses tanggal 2 oktober 2007., jam 20.00 wib). walgito, b., 2003. psikologi sosial (suatu pengantar). yogyakarta: andi. 13 peningkatan self-care agency pasien dengan stroke iskemik setelah penerapan self-care regulation model (the improvement of the self-care agency for patients with ischemic stroke after applying self–care regulation model in nursing care) av. sri suhardingsih*, moh. hasan mahfoed**, rahmat hargono***, nursalam**** *rsal dr. ramelan surabaya, jl. gadung no. 1 surabaya, 60244 e-mail: aves0705@yahoo.co.id **ilmu penyakit saraf fakultas kedokteran universitas airlangga ***fakultas kesehatan masyarakat universitas airlangga ****fakultas keperawatan universitas airlangga abstract introduction: the patiens with ischemic stroke caused a dependence in a need of self-care for the aspect of physically, psychologically, socially and spiritually. nursing care approach will encourage patiens to became independence in self-care. the purpose of this research was to examine the improvement of the self care agency of the patients with ischemic stroke after aplying a nursing care of self care regulation model. method: an experimental research with quasy experimental design was applied in the study. the study was conducted in the area of surabaya by selecting 40 patients of ischemic stroke being hospitalized in stroke unit irna medik rsud dr. soetomo surabaya and selected by consecutive sampling. sample of 40 patients were divided equally into two groups, namely treatment and control groups. the selection of sample was matching based on age and sex. independent variable in the study were self-care regulation: interpretation coping and appraisal. while dependent variable was self-care agency of the patients with ishemic stroke. data was analysed by wilcoxon signed rank, mann-whitey test and modeling by sem pls. result: the result showed that there were signifi cant differences on the increase of self care agency between the groups. the group model that aplying a nursing care of self-care regulation gained the value of r2 = 0.857 and the standart nursing care gained the value of r2 = 0.614, so it could be inferred that the best model was self care regulation model, with the differentiation r2 = 0.243. discussion: it was concluded that the nursing care of self care regulation model could self-care agency up to 24.3% than the standard of nursing care. it is recomended that self-care regulation model can be used as a standard of nursing care in health care institutions both in hospitals and in clinics. keywords: the nursing care of self-care regulation model, self-care agency, self-care defi cit, ischemic stroke pendahuluan stroke secara nyata menjadi penyebab kematian dan kecacatan di seluruh dunia. stroke juga merupakan penyebab utama kecacatan jangka panjang, dan memiliki dampak emosional dan sosial-ekonomi besar pada pasien, keluarga, dan layanan kesehatan. pada tahun 2020, stroke bersama dengan penyakit arteri koroner, diperkirakan akan menjadi penyebab utama hilangnya tahun-tahun kehidupan sehat (stein, et al., 2009). penyakit stroke pada umumnya hanya menyerang kaum lanjut usia (lansia) namun seiring dengan berjalannya waktu, kini ada kecenderungan bahwa stroke mengancam usia produktif bahkan di bawah usia 45 tahun. data dari who monitoring trends and determinant in cardiovascular disease (monica) stroke project menunjukkan insiden dari stroke terbanyak pada orang berusia 35–64 tahun (stein, et al., 2009). stroke terjadi akibat adanya gangguan suplai darah ke otak. ketika aliran darah ke otak terganggu, maka oksigen dan nutrisi tidak dapat dikirim ke otak. kondisi ini akan mengakibatkan kerusakan sel jurnal ners vol. 7 no. 1 april 2012: 13–23 14 otak mati (diwanto, 2009). presentasi tertinggi stroke adalah stroke iskemik, yang terjadi akibat penyumbatan aliran darah. penyumbatan dapat terjadi karena timbunan lemak yang mengandung kolesterol (disebut plak) dalam pembuluh darah besar (arteri karotis) atau pembuluh darah sedang (arteri serebri) atau pembuluh darah kecil (sustrani, et al., 2004). stroke akan berdampak terhadap menurunnya tingkat produktivitas serta dapat mengakibatkan terganggunya sosial ekonomi keluarga. dampak yang ditimbulkan dari penyakit stroke pada setiap pasien berbeda-beda tergantung dari bagian otak yang terkena injuri, keparahan injuri, dan status kesehatan seseorang, namun secara umum dampak tersebut dapat dikelompokkan menjadi empat yaitu dampak fi sik atau biologis, dampak psikologis, dampak sosial dan spiritual. dampak penyakit stroke tersebut menyebabkan pasien mengalami selfcare defi cit atau ketergantungan kepada orang lain dan membutuhkan bantuan keperawatan secara berkesinambungan agar secara bertahap pasien dan keluarga dapat melakukan perawatan diri (self-care) secara mandiri. perawat berperan penting dalam semua fase perawatan pada pasien stroke, peran perawat tersebut terlihat melalui intervensi asuhan keperawatan yang dilakukan oleh perawat (summers, et al., 2009). self-care regulation model merupakan gabungan teori self-care model dan self regulation model yaitu pengembangan kemampuan perawatan diri (self-care agency) pasien dengan kemampuan meregulasi diri (self regulation) melalui peningkatan kemampuan pasien mengenal penyakitnya (illness cognition) agar pasien mampu mengembangkan koping yang konstruktif. koping yang konstruktif tersebut juga harus difasilitasi oleh perawat agar memaksimalkan potensi pasien dan keyakinan keberhasilan diri (self effi cacy) pasien untuk melakukan regulasi diri yang positif (self regulation). model self-care regulation ini berdasarkan pemikiran bahwa self-care yang dilakukan oleh pasien secara mandiri melalui proses regulasi diri (self regulation) yang baik akan membantu pasien mampu mengelola penyakitnya. pengetahuan dan keterampilan mengelola penyakitnya diperoleh melalui proses regulasi perawatan diri (self-care regulation). self-care regulation memposisikan pasien sebagai observant dan membuat penilaian berdasarkan observasi yang dilakukan sendiri oleh pasien. proses observasi, penilaian dan reaksi yang dihasilkan oleh pasien bergantung pada kerja sama yang harmonis antara perawat, pasien dan koping yang dimiliki pasien. proses yang melibatkan self-care regulation model ini merupakan proses yang berkesinambungan dan timbal balik hingga pasien mampu melakukan self care regulation secara mandiri dan terarah. pada kondisi inilah, penderita stroke dapat diberdayakan untuk menunjang proses kesembuhannya. bahan dan metode rancangan penelitian yang digunakan adalah quasy experimental research. jumlah sampel sebanyak 40 pasien stroke iskemik trombotik yang menjalani perawatan (rawat inap) di unit stroke seruni, seruni a dan seruni b irna medik rsud dr. soetomo surabaya, yang dipilih secara non probability sampling (consecutive sampling) menjadi subjek penelitian ini, selanjutnya dibagi menjadi dua kelompok subjek perlakuan 20 orang dan kelompok kontrol 20 orang. pemilihan sampel dilakukan berpasangan (matching) yaitu sampel yang dijadikan kelompok perlakuan dan kelompok kontrol dipilih dengan matching umur dan jenis kelamin. kriteria inklusi penelitian ini adalah pasien stroke iskemik trombotik yang dalam keadaan sadar (compos mentis), bersedia menjadi responden, umur 40–70 tahun, pendidikan minimal smp, berdomisili di surabaya. semua pasien diberikan asuhan keperawatan pasien stroke iskemik. kelompok kontrol menggunakan model asuhan keperawatan standar, sedangkan untuk kelompok perlakuan mengunakan asuhan keperawatan self-care regulation model berdasarkan modul yang sudah disusun. pengukuran self-care regulation (interpretasi sakit, koping dan penilaian) dan kemampuan perawatan diri (self-care agency) pasien stroke iskemik dilakukan pada waktu pasien dirawat di rumah sakit yaitu sebelum diberikan intervensi (pre-test) dan sesudah 3 bulan keluar dari rumah sakit (post-test). analisis yang digunakan dalam peningkatan self-care agency pasien (av. sri suhardingsih) 15 penelitian ini adalah dengan menggunakan uji statistik wilcoxon signed rank untuk mengetahui perbedaan pre–post intervensi pada kedua kelompok dan uji statistik mann whitney untuk mengetahui perbedaan kelompok kontrol dan perlakuan setelah dilakukan intervensi (postpost) dan untuk menganalisis hubungan antar variabel menggunakan analisis partial least square (pls). hasil data uji pengaruh asuhan keperawatan selfcare regulation model (interpretasi sakit, koping, penilaian) dengan kemampuan perawatan diri (self-care agency) a n a l i s i s d a t a p e n g a r u h a s u h a n keperawatan self-care regulation model (interpretasi sakit, koping, penilaian) terhadap peningkatan kemampuan perawatan diri atau self-care agency dilakukan dari data hasil post test kedua kelompok. hal ini untuk mengetahui lebih baik mana model asuhan keperawatan self-care regulation dengan model asuhan keperawatan standar dalam meningkatkan kemampuan perawatan diri (self-care agency) pasien stroke iskemik. teknik analisis yang digunakan adalah model persamaan struktural (structural equation modeling sem) berbasis variance atau component based sem, yang terkenal disebut partial least square (pls). data analisis jalur hubungan interpretasi sakit, koping, penilaian dengan kemampuan perawatan diri (self-care agency) model dari hasil post-test kelompok perlakuan self-care regulation model yang ditemukan dari penelitian ini adalah jalur hubungan untuk peningkatan kemampuan perawatan diri (self-care agency), pasien harus memiliki interpretasi yang benar tentang penyakitkan, sehingga pasien akan mengembangkan strategi koping dengan mengoptimalkan potensi diri, mengoptimalkan peran lingkungan dan usaha yang bersifat religius dalam mengatasi masalahnya dan melakukan penilaian atau mengevaluasi keberhasilan strategi koping yang telah dilakukan untuk mengatasi masalah yang dihadapi, dengan membandingkan kondisi kesehatannya sebelum dengan sesudah sakit stroke, sehingga akhirnya pasien menetapkan atau mengambil keputusan bertindak untuk memenuhi kebutuhan self-care dan model penelitian setelah dilakukan reduksi (dibuang dari model penelitian) model setelah dilakukan reduksi (gambar 1). hasil uji outer weight menunjukkan semua indikator memiliki nilai loading faktor > 0,5 dan nilai composite reliability > 0,6. oleh karena itu, indikator-indikator tersebut dinyatakan valid dan reliabel untuk mengukur variabel latennya yang digunakan dalam penelitian ini. ganbar 1. model jalur hubungan interpretasi sakit, koping, penilaian dengan kemampuan perawatan diri (self-care agency). jurnal ners vol. 7 no. 1 april 2012: 13–23 16 pembahasan p e n i n g k a t a n k e m a m p u a n s e l f c a r e regulation dalam hal interpretasi sakit pasien stroke iskemik pasien stroke iskemik yang mendapatkan asuhan keperawatan self-care regulation model mengalami peningkatan kemampuan self-care regulation dalam hal interpretasi sakit, lebih baik dibandingkan dengan pasien stroke iskemik yang mendapatkan asuhan keperawatan standar, interpretasi tersebut meliputi aspek gejala dan tanda penyakit stroke, hubungan gejala dan penyakit stroke.waktu yang dibutuhkan untuk penyembuhan penyakit stroke, konsekuensi dari penyakit stroke, kontrol atau penyembuhan penyakit stroke, respons emosi akibat penyakit stroke, sebab penyakit stroke. peningkatan interpretasi pasien stroke iskemik yaitu didapatkan hasil bahwa semua variabel interpretasi sakit terdapat perbedaan peningkatan yang signifi kan (α < 0,05) antara kelompok responden yang mendapatkan asuhan keperawatan self-care regulation model (kelompok perlakuan) dengan kelompok yang mendapatkan asuhan keperawatan standar (kelompok control). jika dilihat dari perbedaan mean ranknya dapat disimpulkan bahwa interpretasi sakit pada kelompok perlakuan atau pasien yang mendapatkan asuhan keperawatan self-care regulation model lebih baik daripada kelompok kontrol atau pasien yang mendapatkan asuhan keperawatan standar. variabel interpretasi paling dominan memengaruhi aspek psikologis dari komponen kemampuan perawatan diri (selfcare agency). leventhal (1997) menyebutkan bahwa sakit atau gejala sakit berhubungan dengan bagaimana individu dengan cara yang sama menghadapi masalah lain di antaranya adalah interpretasi. individu dapat dikonfrontasikan dengan masalah sakit potensial melalui dua cara atau penyaluran: persepsi gejala (“saya merasakan sakit dan kelemahan pada tangan kiri saya”) atau pesan sosial (“dokter saya telah mendiagnosa sakit ini sebagai stroke”). saat individu telah menerima informasi tentang kemungkinan sakit melalui saluran ini, menurut teori penyelesaian masalah, individu kemudian termotivasi untuk kembali ke keadaan normalnya “bebas masalah”. ini juga melibatkan defi nisi lain dari masalah. menurut leventhal, masalah tabel 1. hasil outer loading setiap indikator pada variabel penelitian dari hasil post-test kelompok intervensi pada pasien di rsud dr. soetomo tahun 2011 variabel indikator outer loading tstatistic interprs gejala 0.403 3.541 p'sembuh 0.895 114.867 r-emosi 0.906 28.138 sebab 0.802 19.668 koping b'pikir + 0.684 17.105 ds-emosi 0.847 29.162 ds-inst 0.844 44.854 knt diri 0.826 18.822 ko aktif 0.940 78.436 ky spirit 0.799 21.742 p'nerima 0.891 37.575 p'renc 0.879 75.542 reint + 0.772 22.038 p'nilai fisik 0.684 14.767 psikologis 0.847 36.088 sosial 0.844 90.154 spiritual 0.826 40.889 self ca fisik 0.784 17.391 psikologis 0.931 82.211 sosial 0.772 22.338 spiritual 0.801 25.200 peningkatan self-care agency pasien (av. sri suhardingsih) 17 dapat diberi arti dengan mengakses pengetahuan sakit individual. oleh karena itu, gejala dan pesan sosial dapat memberi kontribusi pada pengembangan pengetahuan sakit, yang akan dikonstruksi menurut dimensi-dimensi berikut: identitas, sebab, konsekuensi, batasan waktu, penyembuhan atau kontrol. representasi kognitif dari masalah ini akan memberi arti masalah dan membuat individu dapat mengembangkan dan mempertimbangkan strategi penanganan yang tepat. identifikasi masalah sakit juga akan menghasilkan perubahan pada keadaan emosional. misalnya, merasakan gejala sakit dan menerima pesan sosial bahwa sakit ini dapat dihubungkan ke penyakit jantung koroner, akan menghasilkan kegelisahan. oleh karena itu, setiap strategi penanganan harus dihubungkan ke pengetahuan sakit dan keadaan emosional dari individu. ogden (2007) berpendapat bahwa diperlukan suatu upaya bagaimana mengukur penilaian sehat dan penilaian sakit yang dialami oleh individu, salah satunya dengan metode pengetahuan sakit. pemberian self-care regulation model akan memperbaiki pengetahuan orang sakit, seperti yang disampaikan leventhal (2003) masalah dapat diberi arti dengan mengakses pengetahuan sakit individual. oleh karena itu, gejala dan pesan sosial dapat memberi kontribusi pada pengembangan pengetahuan sakit, yang akan dikonstruksi menurut dimensi-dimensi identitas, sebab, konsekuensi, batasan waktu, penyembuhan atau kontrol. representasi kognitif dari masalah ini akan memberi arti masalah dan membuat individu dapat mengembangkan dan mempertimbangkan strategi penanganan yang tepat. lau (1995) meneliti makna dari “sakit” itu sendiri dan menemukan bahwa jawaban pasien menggambarkan dimensi yang mereka gunakan untuk mengkonseptualisasikan kesakitan itu sendiri yaitu merasa tidak normal, gejala khusus, sakit khusus, konsekuensi penyakit, batas waktu dan tidak sehat. adanya interpretasi yang baik terhadap penyakit yang dideritanya akan menghasilkan motivasi yang kuat untuk bisa sembuh. hal ini sesuai dengan pendapat uno (2007) bahwa motivasi menjadi suatu kekuatan, tenaga atau daya, atau suatu keadaan yang kompleks dan kesiapsediaan dalam diri individu untuk bergerak ke arah tujuan tertentu, baik disadari maupun tidak disadari. s e l f c a re re g u l a t i o n m o d e l a k a n meningkatkan pengetahuan pasien tentang penyakit diderita, sehingga akan menyadari tentang apa yang sedang diderita dan dengan kesadaran tersebut akan menimbulkan motivasi untuk melakukan berbagai upaya sehingga mempercepat penyembuhan penyakit. p e n i n g k a t a n k e m a m p u a n s e l f c a r e regulation dalam hal strategi koping pasien stroke iskemik strategi koping merupakan salah satu aspek dari self regulation, strategi koping dalam penelitian ini meliputi optimalisasi potensi diri (koping aktif, perencanaan, kontrol diri, penerimaan, dan berpikir positif optimalisasi peran lingkungan (dukungan sosial yang bersifat instrument dan dukungan sosial yang bersifat emosional), dan usaha yang bersifat religious (reinterpretasi positif, dan keyakinan spiritual). hasil penelitian menunjukkan bahwa ada perbedaan peningkatan strategi koping yang signifi kan pada semua variabel strategi koping pasien stroke iskemik kelompok yang mendapat asuhan keperawatan self-care regulation model (kelompok perlakuan) dengan kelompok yang mendapat asuhan keperawtan standar (kelompok control) (α < 0,05). apabila dilihat dari mean rank masing-masing variabel strategi koping didapat bahwa mean rank pada kelompok perlakuan lebih tinggi daripada kelompok kontrol. hal ini juga menujukkan bahwa pada kelompok perlakukan atau pasien yang mendapatkan asuhan keperawatan selfcare regulation model memiliki strategi koping yang lebih baik daripada kelompok kontrol atau pasien yang mendapatkan asuhan keperawatan standar. variabel strategi koping paling dominan memengaruhi aspek psikologis dari komponen kemampuan perawatan diri (self-care agency). menurut lazarus dan rekan yang dikutip ogden (2007), koping didefi nisikan sebagai proses penanganan stressor-stressor yang telah dipertimbangkan sebagai beban atau berlebihannya sumber daya seseorang dan sebagai usaha untuk menangani tuntutantuntutan lingkungan dan internal. dalam konteks jurnal ners vol. 7 no. 1 april 2012: 13–23 18 stress, koping juga merefleksikan cara-cara di mana individu berinteraksi dengan stressor dalam usaha untuk kembali ke beberapa jenis fungsi normal. ini bisa termasuk mengkoreksi atau mengangkat masalah, atau bisa termasuk mengubah cara seseorang berpikir tentang masalah atau belajar untuk toleransi dan menerimanya. lazarus dan folkman (1987) menekankan sifat dinamis dari koping yang melibatkan penaksiran dan penaksiran ulang, evaluasi dan re-evaluasi. saat dihadapkan dengan masalah penyakit, individu mengembangkan strategi koping sebagai usaha untuk kembali ke keadaan normalitas yang sehat. menurut smet (1998) koping dipengaruhi oleh beberapa faktor, antara lain usia dalam rentang usia tertentu, individu mempunyai tugas perkembangan yang berbeda, sehingga memengaruhi cara berpikir dan kemampuan untuk beradaptasi dengan situasi disekelilingnya. jenis kelamin secara teoretis pria dan wanita mempunyai cara yang berbeda dalam menghadapi suatu masalah. wanita lebih memperlihatkan reaksi emosional dibandingkan dengan pria. harga diri memengaruhi individu dalam menilai dirinya sendiri dan memengaruhi perilaku dalam mengatasi ancaman atau peristiwa. penggunaan strategi koping yang paling penting adalah harga diri. harga diri dimiliki individu sebagai sikap, gagasan dan kemampuan dalam mengatasi masalah. pendidikan, individu yang mempunyai pendidikan lebih tinggi akan lebih tinggi pula perkembangan kognitifnya, sehingga akan mempunyai penilaian yang lebih realitis dan koping mereka akan lebih aktif dibandingkan mereka yang mempunyai pendidikan lebih rendah. hasil penelitian ini juga sesuai dengan pendapat lazarus (1985), koping adalah perubahan kognitif dan perilaku secara konstan dalam upaya untuk mengatasi tuntutan internal dan atau eksternal khusus yang melelahkan atau melebihi sumber individu. mekanisme koping terbentuk melalui proses belajar dan mengingat, yang dimulai sejak awal timbulnya stressor dan saat mulai disadari dampak stressor tersebut. kemampuan belajar ini tergantung pada kondisi eksternal dan internal, sehingga yang berperan bukan hanya bagaimana lingkungan membentuk stressor tetapi juga kondisi temperamen individu, persepsi, serta kognisi terhadap stressor tersebut. efektivitas koping memiliki kedudukan sangat penting dalam ketahanan tubuh dan daya penolakan tubuh terhadap gangguan maupun serangan penyakit (fi sik maupun psikis). jadi, ketika terdapat stressor yang lebih berat (dan bukan yang biasa diadaptasi), individu secara otomatis melakukan mekanisme koping, yang sekaligus memicu perubahan neurohormonal. kondisi neurohormonal yang terbentuk akhirnya menyebabkan individu mengembangkan dua hal baru yaitu perubahan perilaku dan perubahan jaringan organ. lipowski (1970) membagi koping menjadi copingstyle dan coping strategy. coping style adalah mekanisme adaptasi individu yang meliputi aspek psikologis, kognitif, dan persepsi. coping strategy merupakan koping yang dilakukan secara sadar dan terarah dalam mengatasi rasa sakit atau menghadapi stressor. apabila koping dilakukan secara efektif, stressor tidak lagi menimbulkan tekanan secara psikis, penyakit, atau rasa sakit, melainkan berubah menjadi stimulus yang memacu prestasi serta kondisi fi sik dan mental yang baik. pemberian perlakuan asuhan keperawatan self-care regulation model akan memperbaiki dan meningkatkan strategi koping dari pasien stroke iskemik yaitu memiliki strategi koping keaktifan diri, perencanaan yang baik, berpikir positif, termasuk mengkoreksi, mengubah cara seseorang berpikir tentang penyakitnya, belajar untuk toleransi dan menerima kenyataan bahwa ia sakit stroke, tetapi tetap memiliki keyakinan yang baik bahwa pasien akan mampu mengatasi masalah penyakitnya sehingga dengan sakit stroke bukan lagi stressor yang menimbulkan tekanan secara psikis dan rasa sakit, tetapi merupakan stimulus yang memacu individu berkembang menjadi lebih baik, maka hal ini akan lebih mempercepat penyembuhan dari penyakit yang diderita. p e n i n g k a t a n k e m a m p u a n s e l f c a r e regulation dalam hal penilaian pasien stroke iskemik p e n i l a i a n s e s e o r a n g t e r h a d a p keberhasilannya mengatasi masalah yang dihadapi merupakan aspek yang penting dalam self regulation, dampak dari penyakit stroke peningkatan self-care agency pasien (av. sri suhardingsih) 19 menyebabkan pasien mengalami masalah baik aspek fi sik atau biologis, psikologis, sosial dan spiritual, penilaian dalam penelitian ini meliputi penilaian fi sik, psikologis, sosial, dan spiritual. ada perbedaan peningkatan penilaian yang signifi kan pada 3 variabel penilaian (psikologis, sosial dan spiritual) pasien stroke iskemik kelompok yang mendapat asuhan keperawatan self-care regulation model (kelompok perlakuan) dengan kelompok yang mendapat asuhan keperawatan standar (kelompok kontrol) (α < 0,05). sedangkan untuk penilaian fi sik tidak ada perbedaan peningkatan penilaian pasien stroke iskemik kelompok yang mendapat asuhan keperawatan self-care regulation model (kelompok perlakuan) dengan kelompok yang mendapat asuhan keperawatan standar (kelompok kontrol) (α < 0,081), hal ini karena pada asuhan keperawatan standar intervensi keperawatan lebih terfokus pada aspek fi sik, sehingga pasien kelompok kontrol juga memiliki penilaian yang sama dengan kelompok perlakum, namun apabila dilihat dari mean rank masing-masing variabel penilaian didapat bahwa semua mean rank pada kelompok perlakuan lebih tinggi daripada kelompok kontrol. hal ini juga menunjukkan bahwa pada kelompok perlakukan atau pasien yang mendapatkan asuhan keperawatan selfcare regulation model memiliki penilaian yang lebih baik daripada kelompok kontrol atau pasien yang mendapatkan asuhan keperawatan standar. variabel penilaian paling dominan memengaruhi aspek psikologis dari komponen kemampuan perawatan diri (self-care agency). karen glanz (2008) berpendapat bahwa penilaian primer adalah penilaian seseorang tentang suatu peristiwa yang signifi kan sebagai stres, positif, terkendali, menantang, jinak, atau tidak relevan. sakit stroke adalah stressor bagi individu. ketika berhadapan dengan stressor, individu akan mengevaluasi potensi ancaman atau bahaya dari penyakit stroke (penilaian primer), serta kemampuannya untuk mengubah situasi dan mengelola reaksi emosional negatif terhadap penyakit stroke (penilaian sekunder). upaya koping aktual, ditujukan untuk pengelolaan atau manajemen masalah penyakit stroke dan regulasi emosional, di mana hasil dari strategi koping yang telah dilakukan akan dievaluasi oleh pasien berhasil tidak mengatasi masalah yang aspek fi sik, psikologis sosial dan spiritual yang dihadapi pasien stroke. penilaian utama lainnya melibatkan relevansi motivasional dan fokus sebab dari penyakit stroke. menerima diri sebagai individu yang bertanggung jawab atas terjadinya penyakit stroke mungkin lebih cenderung menumbuhkan rasa bersalah dan depresi, daripada kecemasan (smith, et al., 1993), namun, aspek yang paling penting dari penilaian penyebab penyakit adalah pasien akan menghindari hal-hal yang menyebabkan sakit stroke, termasuk merubah perilaku yang tidak sehat yang dapat menimbulkan serangan stroke yang kedua. penilaian sekunder adalah ketetapan atau keputusan seseorang untuk mengatasi masalah berdasarkan sumber daya yang dimiliki dan alternatif yang dapat dipilih (cohen, 1984). berbeda dengan penilaian utama yang berfokus pada fi tur dari situasi stres, penilaian sekunder apa yang bisa dilakukan terhadap situasi. penilaian sekunder dianggap kemampuan untuk mengubah situasi dan kemampuan yang dirasakan untuk mengelola reaksi emosi seseorang menghadapi ancaman penyakit stroke dan ekspektasi-ekspektasi tentang efektivitas sumber daya koping seseorang misalnya, keyakinan keberhasilan diri atau self effi cacy (glanz, 2008). secara harafi ah, self memiliki makna diri atau identitas individu sedangkan effi cacy adalah kekuatan untuk menghasilkan efek. sinonim dari effi cacy meliputi efektivitas, kesadaran dan produktivitas. kombinasi dari makna tersebut menunjukkan kesadaran akan kemampuan seseorang menjadi efektif dan mengendalikan tindakan. atribut yang berada di dalam self efficacy meliputi kognitif dan afektif serta pengendalian diri. keyakinan tentang kemampuan seseorang untuk melakukan perilaku yang diperlukan untuk menggunakan kendali (self effi cacy) memainkan peran sentral dalam kinerja berbagai perilaku kesehatan. bandura (1997) menyatakan bahwa peran self effi cacy dalam fungsi tubuh manusia sangatlah besar yaitu mempertahankan dan meningkatkan tingkat motivasi seseorang, keadaan afektif dan tindakan berdasarkan tujuan yang ingin dicapai. dengan alasan ini, bagaimana seseorang berperilaku dapat jurnal ners vol. 7 no. 1 april 2012: 13–23 20 diprediksi melalui keyakinan yang dipegang dan menentukan pengetahuan serta keterampilan yang dimiliki oleh individu. hal ini berhubungan dengan keyakinan diri, kepercayaan diri bahwa mereka bisa mencapai tujuan yang mereka inginkan. konsekuensinya, pencapaian individu pada umumnya lebih baik diprediksi dengan keyakinan diri dibandingkan dengan pencapaian sebelumnya, pengetahuan atau keterampilan yang dimiliki. tentunya, sebesar apapun keyakinan diri yang dimiliki tidak akan dapat menghasilkan kesuksesan jika tidak didampingi oleh keterampilan dan pengetahuan yang memadai. bandura (1989) menyatakan bahwa perilaku manusia dipengaruhi oleh pikiran dan tujuan individu dipengaruhi oleh kemampuan pencapaian diri. individu dengan self effi cacy yang tinggi cenderung untuk menentukan tujuan yang lebih tinggi, komitmen terhadap tantangan yang lebih sulit dan berusaha keras mencapai tujuan yang diinginkan. self effi cacy tidak berhubungan dengan keterampilan khusus yang dimiliki seseorang tetapi lebih kepada penilaian dari apa yang bisa individu lakukan dengan keterampilan khusus tersebut. konsep self effi cacy memiliki implikasi terhadap praktik keperawatan. kunci untuk meningkatkan self effi cacy adalah membantu pasien untuk belajar perilaku melalui model atau belajar untuk memodifi kasi perilaku yang maladaptif melalui pengubahan penguatan (ziegler, 2005). perilaku pada umumnya dipelajari melalui pembelajaran observasional dan diajarkan melalui pemodelan (bandura, 1997). sebagai contoh, individu diberitahu untuk mematuhi langkah-langkah dalam injeksi subkutan, tetapi demonstrasi diperlukan untuk menunjukkan tindakan nyata dari keterampilan tersebut. modifi kasi perilaku melibatkan perubahan kepercayaan pasien terhadap kekuatan dari self effi cacy. intervensi dilakukan sebagai cara untuk memfasilitasi perubahan perilaku ini. penilaian keberhasilan stategi koping yang telah dilakukan secara fi sik dapat dinilai oleh pasien dengan membandingkan kemampuan fi sik pasien sebelum dan sesudah sakit stroke. penilaian psikologis dapat dinilai pasien bagaimana pasien merasa memiliki mental dan emosional yang kuat untuk menjalani hidup dengan berbagai keterbatasan yang adalah setelah sakit stroke. oleh karena itu diperlukan penguatan faktor psikologis dengan cara meningkatkan kemampuan kognitif baik dengan membangkitkan motivasi pasien maupun menstimulasi self efficacy pasien bahwa pasien memiliki kemampuan, sumber daya serta pasien harus diyakinkan bahwa apa yang pasien inginkan akan tercapai. perawat harus mampu menumbuhkan motivasi pasien agar pasien stroke tetap memiliki tujuan hidup, memiliki harapan akan masa depannya, dan diyakinkan bahwa dia memiliki kemampuan (self effi cacy) untuk mencapai tujuan hidupnya yang baru (karena sakit stroke). penilaian sosial dapat dinilai oleh pasien sejauh mana pasien merasa mendapat dukungan dari lingkungan baik dukungan instrumental maupun dukungan emosional. sedangkan penilaian spiritual dapat dinilai oleh pasien bagaimana pasien telah melakukan usaha yang bersifat religius seperti reinterpretasi positif yaitu menafsirkan kembali situasi yang dihadapi dengan cara yang positif. pasien dibantu untuk melihat kembali tujuan hidupnya dan merevisinya bila perlu, disesuaikan dengan kondisinya pasien saat ini. keyakinan pasien bahwa selalu saja ada alternatif lain dalam setiap situasi akan membantu pasien merasa ketidakberdayaannya bukan untuk selamanya masih ada alternatif lain yang bisa dipilih untuk masa depannya. dengan menggali pilihan tersebut bersama perawat dalam keluarga akan membantu membuka realitas sebagai dasar untuk membuat keputusan selanjutnya. keyakinan spiritual pasien, bagaimana sikap individu menenangkan dan menyelesaikan masalah secara keagamaan. menemukan makna dari penyakit. penyakit merupakan satu pengalaman manusia kebanyakan orang menganggap penyakit serius sebagai titik balik kehidupan mereka baik spiritual maupun fisiologis, terkadang orang menemukan kepuasan dalam kepercayaan mereka bahwa pasien mungkin mempunyai makna atau berguna bagi orang lain, seperti keluarga dapat berkumpul akibat ada yang sakit stroke, meskipun menyakitkan namun dengan cara sangat berarti, sehingga pasien dapat menemukan hikmah dari sakitnya. dengan peningkatan kemampuan penilaian fi sik, psikologis, sosial, dan spiritual peningkatan self-care agency pasien (av. sri suhardingsih) 21 pasien stroke iskemik akan keberhasilan strategi koping yang digunakan untuk mengatasi masalah yang dihadapi, maka pasien akan mampu menetapkan atau membuat keputusan untuk melakukan tindakan untuk mengatasi masalah yang ada karena dengan penilaian yang positif maka pasien akan dapat menerima realita atau kenyataan bahwa ia sakit stroke, namun pasien tidak putus asa, tetap optimis menghadapi masa depan karena pasien punya kemampuan, tetap tabah dan sabar serta dapat mengambil hikmah dari sakit stroke yang diderita. hal ini akan mempercepat kesembuhan pasien dan meningkatkan kemampuan perawatan diri (selfcare agency) pasien stroke iskemik. peningkatan kemampuan perawatan diri/ self-care agency pasien stroke iskemik tu j u a n a k h i r p e m b e r i a n a s u h a n keperawatan self-care regulation model adalah kemandirian pasien stroke iskemik dalam memenuhi kebutuhan perawatan diri atau selfcare baik self-care fi sik, self-care psikologis selfcare sosial dan self-care spiritual. kemandirian tersebut dapat dicapai kalau pasien stroke mempunyai kemampuan dalam perawatan diri (self-care agency). asuhan keperawatan self-care regulation model adalah pendekatan asuhan keperawatan yang menekankan pada peningkatan kemampuan pasien untuk dapat melaksanakan self regulation. dari hasil penelitian menunjukkan bahwa ada perbedaan peningkatan kemampuan perawatan diri atau self-care agency yang signifi kan pada seluruh variabel (p < 0,05). antara kelompok responden yang mendapatkan asuhan keperawatan selfcare regulation model (kelompok perlakuan) dengan kelompok yang mendapatkan asuhan keperawatan standar (kelompok kontrol). jika dilihat dari perbedaan mean rank nya dapat disimpulkan bahwa kemampuan perawatan diri atau self-care agency pada kelompok perlakuan atau pasien yang mendapatkan asuhan keperawatan self-care regulation model lebih baik daripada kelompok kontrol atau pasien yang mendapatkan asuhan keperawatan standar. orem de (2001) menyatakan bahwa self-care adalah penampilan dari aktivitas individu dalam melakukan perawatan diri sendiri untuk mempertahankan kehidupan, kesehatan dan kesejahteraannya. self-care yang dilakukan secara efektif dan menyeluruh dapat membantu menjaga integritas struktur dan fungsi tubuh serta berkontribusi dalam perkembangan individu. seorang individu dalam melakukan selfcare harus mempunyai kemampuan dalam perawatan diri yang disebut sebagai self-care agency. individu yang terlibat dalam self-care memiliki tuntutan kemampuan bertindak, yaitu kekuatan untuk bertindak secara mandiri untuk mengendalikan faktor yang memengaruhi fungsi diri dan perkembangan mereka (orem, 2001). tindakan ini memerlukan pengetahuan, pengambilan keputusan dan tindakan untuk berubah. hal ini sesuai dengan hasil penelitian ini, yaitu walaupun pada penlaian fisik kedua kelompok tidak ada perbedaan, tetapi pada kemampuan self-care fi sik antara kedua kelompok ada perbedaan yang signifi kan (p < 0,05) pada kemampuan perawatan diri atau self-care agency aspek fi sik pada kelompok perlakuan atau pasien yang mendapatkan asuhan keperawatan self-care regulation model lebih baik daripada kelompok control atau pasien yang mendapatkan asuhan keperawatan standar. hal ini dapat dijelaskan bahwa untuk dapat bertindak dibutuhkan keterampilan, keyakinan akan keberhasilan diri atau self effi cacy, semangat dan motivasi yang tinggi untuk selalu berusaha mencapai tujuan yang diinginkan. maka peran perawat adalah memberikan keterampilan kepada pasien stroke, menguatkan faktor psikologis dengan cara meningkatkan kemampuan kognitif baik dengan membangkitkan motivasi pasien maupun menstimulasi self effi cacy pasien bahwa pasien memiliki kemampuan, dan sumber daya, karena pada dasarnya self-care merupakan perilaku yang dapat dipelajari, dan setiap individu memiliki potensi untuk belajar dan berkembang. penyakit stroke adalah stressor bagi individu, maka individu yang tadinya normal atau sehat kemudian diganggu oleh penyakit stroke iskemik, maka individu akan termotivasi untuk mengembalikan keseimbangan kembali ke normalitas, melalui proses self regulation, yang dari penelitian ini telah membuktikan bahwa pemberian asuhan keperawatan self-care regulation dapat meningkatkan kemampuan perawatan diri atau self-care agency lebih baik jurnal ners vol. 7 no. 1 april 2012: 13–23 22 daripada dengan pemberian asuhan keperawatan standar. penemuan baru penemuan baru yang diperoleh dalam penelitian ini adalah jalur hubungan yang menjelaskan bagaimana asuhan keperawatan self-care regulation model dapat meningkatkan kemampuan perawatan diri (self-care agency) dengan mengaktifkan self-care regulation melalui peningkatan interpretasi sakit pasien, pengembangan strategi koping pasien dan mengembangkan kognitif yang positif sehingga pasien juga memiliki kemampuan penilaian yang positif terhadap upaya koping yang telah dilaksanakan, dapat menerima realitas yang ada, tabah, sabar dan dapat mengambil hikmah dari peristiwa yang dialami sehingga selalu optimis akan mencapai tujuan yang diinginkan. hal ini akan meningkatkan kemampuan perawatan diri (self-care agency), seperti yang ditunjukkan dari hasil uji model bahwa dengan asuhan keperawatan self-care regulation mampu meningkatkan kemampuan perawatan diri (self-care agency) sebesar 0,243% atau 24,3% dibandingkan dengan asuhan keperawatan standar. tersusun modul asuhan keperawatan self-care regulation model pada pasien stroke iskemik yang dapat digunakan sebagai pedoman perawat dalam memberikan asuhan keperawatan profesional. gambar 2. jalur hubungan antarvariabel yang memengaruhi peningkatan kemampuan perawatan diri (self care agecy) keterangan: x 1 = interprestasi x 2 = koping x 3 = penilaian y = self-care agency x 1.1 = kemampuan mengidentifi kasi gejala penyakit x 1.5 = kontrol x 1.6 = emosional x 1.7 = penyebab penyakit x 2.1 = koping aktif x 2.2 = perencanaan x 2.3 = kontrol diri x 2.4 = penerimaan x 2.5 = berfi kir positif x 2.6 = dukungan sosial yang bersifat instrumental x 2.7 = dukungan sosial yang bersifat emosional x 2.8 = reinterprestasi positif x 2.9 = keyakinan spiritual x 3.1 = fisik x 3.2 = psikologi x 3.3 = sosial x 3.4 = spiritual y 1 = self-care fisik y 2 = self-care psikologi y 3 = self-care sosial y 4 = self-care spiritual peningkatan self-care agency pasien (av. sri suhardingsih) 23 hasil uji model struktural menunjukkan bahwa indikator hubungan gejala dengan penyakit, indikator waktu dan indikator konsekuensi tidak berpengaruh secara signifi kan terhadap variabel interpretasi sakit sehingga model hubungan yang ditemukan (gambar 3). simpulan dan saran simpulan pemberian asuhan keperawatan self-care regulation model pada pasien stroke iskemik meningkatkan interpretasi pasien tentang penyakitnya dan strategi koping yang positif serta penilaian pasien akan keberhasilan koping yang digunakan dapat menurunkan therapeutic selfcare demands dan meningkatkan kemampuan perawatan diri (self-care agency). saran modul asuhan keperawatan self-care regulation model yang digunakan sebagai pedoman di dalam memberikan asuhan keperawatan pada pasien stroke iskemik ini, menuntut perubahan peran pasien yang tadinya pasif, menjadi lebih aktif, lebih berinisyatif dan bertanggung jawab terhadap kesehatannya sendiri, oleh karena itu sejak awal perawatan, pasien dilibatkan dalam setiap kegiatan perawatan yang dilakukan oleh perawat. kepustakaan bandura, a., 1997. self effi cacy: toward a unifying theory of behavior change, psychological review, 84: 191–215. jane, ogden., 2007. health psychology 4th ed. open university: england karen, glanz, dan barbara, k.r., 2008. health behavior and health education, theory, research, and practice, fourth edition. yossey-bass. inc: san francisco. lau, r., 1995. cognitive representations of health and illness, in d. gochman (ed.), handbook of health behavior research, vol. i. new york: plenum. lazarus, r.s. dan cohen, f., 1973. active coping processes, coping dispositions, and recovery from surgery, psychosomatic medicine, 35, 375–89. l e v e n t h a l , h . d a n b r i s s e t t e , i . , 2 0 0 3 . the common-sense model of selfregulation of health and illness. in: cameron l,d., leventhal h., editors. the self-regulation of health and illness behaviour. london: routledge. lipowski, 1970. physical illness, the individual and the coping processes. psychiar. med, 1, 91–102. orem, d.e., 2001. nursing concept of practice. st louis: cv mosby company. stein, j., harvey, r.l., macko r.f., winstein, c.j., zorowitz, r.d., 2009. stroke recovery and rehabilitation. usa: demosmedpub. summers, et al., 2009. comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientifi c statement from the american heart association stroke, 40: 2911– 2944. sustrani, l., a.s. alam, dan i. hadibroto., 2004. stroke. jakarta: pt gramedia pustaka umum. u n o , h . b . , 2 0 0 7 . te o r i m o t i v a s i d a n pengukurannya: analisis di bidang pendidikan. jakarta: bumi aksara. ziegler, s.m., 2005. theory-directed nursing practice (2nd ed.). new york: springer. jurnal ners vol. 12 no. 2 oktober 2017: 158-163 158 development of a supervision model based on experiential learning for the implementation of patient safety goals at a teaching hospital in surabaya ita maulidiawati*, nursalam nursalam**, hanik endang nihayati** * universitas airlangga hospital, kampus c mulyorejo surabaya, 60115 ** faculty of nursing, universitas airlangga email: itamaulidiawati@gmail.com abstract introduction: one of the demands of clients who access health services is patient safety. the hospital is required to maintain and upgrade the patient's safety goals. nurses as health care providers are at risk of making error and mistakes during their duty which may cause harm to the patient. the purpose of this study was to develop a model of supervision based on experiential learning in the implementation of patient safety goals. method: this research used explanatory survey. the sample was from nurses who were working at a ward unair hospital, one hundred respondents were selected by using stratified random sampling technique. the variables in this research were organizational characteristics, individual characteristics, work characteristics, supervision based on experiential learning and the implementation of patient safety goals. data collection was through the survey using questionnaires. the data were analyzed using partial least square (pls). result: there were a significant effect of organizational characteristics, individual characteristics and work characteristic on the supervision based on experiential learning. this result indicated that the improvement of organizational, individual and work characteristics also improved the implementation of supervision based on experiential learning. supervision based on experiential learning affects the implementation of patient safety goals. conclusion: supervision based on experiential learning uses four stages: concrete experience, reflective observation, abstract conceptualization and active experimentation. supervision affects the implementation of patient safety goals by nurses in the hospital. keywords: experiential learning, patient safety goals, supervision introduction patient safety is a global issue as the community of health-care users is expecting a safe and convenient services. improving quality and patient safety is a concern for all health care facilities, especially hospitals. the world health organization (who, 2007) issued a policy on the nine life saving patient safety solution as a system designed to prevent or reduce patient injury and improve patient safety. some institutes report incidents of patient safety due to errors that could have been prevented through the implementation of patient safety. the data from patient safety committee of hospital in indonesia september 2006-2011 based on incident type revealed 249 reports of adverse events and 283 reports of near miss events. factors contributing to the occurrence of patient safety incidents include individual characteristic factors, the characteristic of work, the physical environment, the interaction between the system and human, organizational and social environment, management, and external environment (lucian, of, & so, 2010). according to the study from sumarni (2013), the most dominant directive function in patient safety implementation is supervision. mckimm (2010) stated that supervision can basically improve patient safety and quality of care. therefore, supervision is required to improve the hospital staff performance in patient safety. harmatiwi (2017) in her study found that the disobedience of supervisors on the protocol of supervision was quite high (60%) and the majority of supervisors do with indirect supervision. there are several factors related to the implementation of nurse unit manager’s (num’s) supervision. zulfikar (2015) in his research reported that leadership style and work experience have a relationship with nursing supervision. the results of sulastri’s study (2002) showed that the characteristics of the organization have a significant relationship with the ability of supervision. clinical supervision can improve the quality of nursing services, reduce errors, improve efficiency, improve staff performance, development of supervision model... (ita maulidiawati, et.,al) 159 and reduce burnout rates (cruz, carvalho, & sousa, 2014). suyanto (2009) also explained that a nursing supervisor in carrying out his/her daily duties should have the ability to provide guidance and clear instructions, so that, it can be understood by nurses. clinical supervision is a facilitative process of professional development, contributing to the quality of practice, promoting the safety of care and protection of clients in clinical complex situations. in the supervision process, it is essential that clinical supervisors use appropriate clinical supervision strategies in order to facilitate the development of the supervisee (pires, reis, pereira, & rocha, 2016). nurses will comprehend more easily when supported to directly implement the right patient safety goals. experiential learning emphasizes a holistic learning model in the learning process. in the reflective observation phase, the learner closely observes the actions performed by others, then reflects the results obtained, hence facilitating ease of understanding. giving direct examples can encourage the nurse to perform patient safety according to the required standards. the aim of this study was analyzing the effect of organizational characteristics on supervision, analyzing the effect of individual characteristics on supervision, analyzing the effect of work characteristics on supervision, and analyzing the effect of supervision on the implementation of patient safety goals. materials and methods the population in this study was nurses who work in the inpatient ward of the teaching hospital. they were 112 nurses. the number of sample in this research were determined using a rule of thumb formula. there was 20 variable in this study, so the number of a sample was 100 nurses. the sampling technique in this study using stratified random sampling, it is a sampling method in which the population is first divided into strata, then a simple random sample is taken from each stratum so that it can reach a representative sample. the grouping of strata used in this study is based on the length of work in the hospital. the strata were divided into, less than 1 year, 1-3 years, and more than 3 years. the study was conducted in the inpatient ward of teaching hospital in surabaya from march april 2017. the variables in this research are, organizational characteristic, individual characteristic, work characteristic, supervision based experiential learning and the implementation of patient safety goals. organizational characteristic consists of two sub-variables, they are reward system and leadership. individual characteristics consist of two sub-variables, namely capability and motivation. the work characteristic of this study is job design and work schedule. in the variable of supervision, the four experiential learning stages are observed in the implementation of supervision. the four stages consist of concrete experience, reflective observation, abstract conceptualization, and active experimentation. the patient safety implementation variables consist of sub-variables, identifying patient correctly, improving effective communication, improving the safety of high-alert medications, ensuring safe surgery, reducing the risk of healthcare-associated infections, and reducing the risk of a patient from falls. the data were collected by using questionnaire made by the researcher. the test of validity and reliability of the questionnaire were done, and the question which was not valid have been removed from it. the data analysis used partial least square (pls). results most of the nurses stated that reward system was in moderate category (79%, n=100), and leadership also in moderate category (73%). these two indicators were included in organizational characteristics. individual characteristics consist of capability and motivation. this study found that capability in moderate category (62%), and motivation also in moderate category (72%). for the work characteristic, most of the nurses that job design was in moderate level (70%). jurnal ners vol. 12 no. 2 oktober 2017: 158-163 160 table 1. the result of analysis no variable path coefficients t statistic p-value conclusion 1 the influence of organizational characteristics to supervision based experiential learssning 0.215 2.568 0.005 significant 2 the influence of individual characteristics to supervision based experiential learning 0.242 2.829 0.011 significant 3 the influence of work characteristics to supervision based experiential learning 0.263 2.974 0.003 significant 4 the influence of supervision model based experiential learning to implementation of patient safety goals 0.560 8.043 0.000 significant picture 1. outer loading factor results analysis using partial least square (pls) the model in this study determined that the indicator is valid if the value of outer loading is more than 0.4 (vinzi et al in sofyani, 2010). invalid indicator includes work schedule on work characteristics variable (x3.1). the other indicators were declared valid, it were reward system, leadership, capability, motivation, job design, supervision, and implementation of patient safety included: identifying patient correctly, improving effective communication, improving the safety of highalert medications, ensuring safe surgery, reducing the risk of health care-associated infections, and reducing the risk of patient harm resulting from falls. the analysis of hypothesis testing used pls, and the results as in table 1. the result of the analysis shows that there was significant affect of organizational characteristics, individual characteristics and work characteristic to the supervision based on experiential learning with the p-value were 0.005, 0.011 and 0.003. supervision based on experiential learning also had affected the implementation of patient safety goals with the p-value 0.000. that patient safety goals consist of identifying patient correctly, improving effective communication, improving the safety of high-alert medications, ensuring safe surgery, reducing the risk of health careassociated infections, and reducing the risk of patient harm resulting from falls. development of supervision model... (ita maulidiawati, et.,al) 161 discussion the influence of organizational characteristics on supervision based on experiential learning organizational characteristics consist of rewards systems and leadership. in this study, organizational characteristics contributed to the implementation of supervision based on experiential learning by the num. the rewards is defined as a stimulus to improve nurse's performance in providing nursing care. giving reward is a statement that explains what hospital wants to give to the staff in the long term to develop and implement policies, practices and reward system process that support the achievement of goals and needs (brown, 2001 in nursalam 2016). in this study, nurse’s perceptions about the hospital's reward system were mostly in quite satisfaction level. the organization or employer should reward the staff by award presentation, advancement or promotion (mangkunegara, 2005). this study, that most of the nurses had perceived moderately about the reward system. the result of this study was consistent with mandagi (2015) that stated the reward system had affected to the nurse's performance, and the reward could become the effective motivator to the nurses work. the definition of leadership is the activity or art that affects others to work together based on the ability of the person to guide others in achieving the organizational goals. leadership is one of the most important in the management function, especially in directing and controlling functions. melo (2015) in his study stated that a num who apply all of the management roles can improve the nurse's satisfaction in supervision done by num. the influence of individual characteristics on supervision based on experiential learning the indicators that contribute to individual characteristics include capability and motivation. this characteristic influence on supervision based experiential learning is done by the num the higher capability and motivation caused the better supervision by num.a person's motivation is very influential on the performance that can be achieved in his job because the support will make the person doing the thing for achieving their goals (suyanto, 2009). motivation level of nurses in this study is found to be in a moderate category. the numis motivated to conduct supervision based on experiential learning in order to achieve the task and management functions and vice versa. many aspects can be assessed from the variables of capability, including cognitive, affective, and psychomotor abilities. this study also found that motivation level influences the ability to supervision implementation done by the num. this is consistent with the study conducted by wahyuningsih (2015), which states that the ability to work has a significant positive influence on the nurse’s performance, and also for the num. the influence of supervision model based on experiential learning in the implementation of patient safety goal the result of this study stated that supervision model based experiential learning was significantly affected the implementation of patient safety goals. in this supervision, the supervisor observed implementation of patient safety goals done by nurses based on responsibility, accountability and authority aspects. each aspect followed by experiential learning process consists of concrete experience, reflective observation, abstract conceptualization, and active experimentation. supervision can influence nurse’s performance on implementation of patient safety goals. this is in accordance with the previous study by hastuti (2014), which reported a significant relationship between nurse’s perception about supervision with nurse’s performance. this is also consistent with the study conducted by amsrud et al (2015), which revealed that clinical supervision definitely influences the development of important skills for patient safety care, brunero et al (2010) also asserted that clinical supervision promotes professional accountability, skill, and knowledge development. clinical supervision was more positive evaluation where the sessions running for over one hour and took place on at least a once a month (edwards, hannigan, & fothergill, 2005). previous research, show there was a relationship between the num conducting jurnal ners vol. 12 no. 2 oktober 2017: 158-163 162 supervision of the nurse in the implementation of patient safety, the nurse will be able to implement patient safety well if they are given optimal supervision by num (ernawati et al, 2014). conclusions the supervision model based on experiential learning was affected by the reward system, leadership, capability, motivation, and job design. supervision based on experiential learning improved the implementation of patient safety goals by nurses included identifying patient correctly, improving effective communication, improving the safety of highalert medications, ensuring safe surgery, reducing the risk of healthcare-associated infections, and reducing the risk of patient harm resulting from falls. this supervision model is expected to be applied in hospitals to improve performance in the implementation of patient safety goals and prevent the error incident of patient safety. references amsrud, k.e., lyberg, a., & severinsson, e. (2015). the influence of clinical supervision and its potential for enhancing patient safety-undergraduate nursing students’ views, journal of nursing education and practice, 5(6) brunero, s., & parbury, j.s. (2010). the effectiveness of clinical supervision in nursing: an evidenced-based literature review. australian journal of advanced nursing, 25(3), 86-94 cruz, s., carvalho, a. l., & sousa, p. (2014). clinical supervision : priority strategy to a better health clinical supervision : priority strategy to a better health. procedia social and behavioral sciences, 112(february), 97–101. https://doi.org/ 10.1016/j.sbspro.2014.01.1143 edwards, d., hannigan, b., & fothergill, a. (2005). factors influencing the effectiveness of clinical supervision, (august). https://doi.org/10.1111/j.13652850.2005.00851.x ernawati, e, asih t.r., wiyanto, s. (2014). penerapan hand hygiene perawat di ruang rawat inap rumah sakit. jurnal kedokteran brawijaya, 28 (1), 89-94 harmatiwi, dd, sumaryani, s., rosa, em. (2017).evaluasi pelaksanaan supervisi keperawatan di rumah sakit umum daerah panembahan senopati bantul. jurnal medicoeticolegal dan manajemen rumah sakit. 6 (1). doi: 10.18196/jmmr.6126. hastuti, a.t. (2014). hubungan persepsi perawat pelaksana tentang kemampuan supervisi kepala ruang dengan kinerja perawat di instalasi rawat inap rumah umum daerah kota semarang. fikkes jurnal keperawatan, 7(2), 118-129 lucian, l., of, p., & so, m. (2010). error in medicine. mangkunegara. (2005). kinerja sdm. cetakan1. bandung: pt refikaaditama mckimm, j., & rebecca, v. (2010). clinical teaching made easy: mentoring. british journal of hospital medicine, 71(2), 106 melo, r. c. c. p. (2015) ‘leadership and nurses ’ satisfaction with supervision’, 4(4), pp. 57–63. doi: 10.5430/jha. v4n4p57. moon, j.a. (2004). a handbook of reflectiveand experiential learning, theory and practice. newyork: routledge falmer taylor & francis group nursalam. (2016). manajemen keperawatan aplikasi dalam praktik keperawatan profesional, edisi 5. jakarta: penerbit salemba medika sofyani, h. (2010). modul praktik partial least square (pls). universitas muhammadiyah yogyakarta sulastri, t. (2002). faktor-faktor yang berhubungan dengan kemampuan supervisi yang dipersepsikan oleh perawat manajer di rsud pasar rebo jakarta. (tesis, universitas indonesia) sumarni, t. (2013). hubungan pelaksanaan fungsi pengarahan kepala ruangan dengan penerapan patient safety di rawat inap rsud padang panjang. universitas andalas development of supervision model... (ita maulidiawati, et.,al) 163 suyanto.(2009). mengenal kepemimpinan dan manajemen keperawatan di rumah sakit. jogjakarta: mitra cendekia pires, r., reis, m., pereira, f., & rocha, i. (2016). most relevant clinical supervision strategies in nursing practice. wahyuningsih, r.t. (2015). pengaruh kemampuan kerja, kompensasi dan motivasi terhadap kinerja perawat di instalasi rawat inap rumah sakit daerah balung kabupaten jember. universitas jember who. nine life saving patient safety solution (2007). retrieved from http://www.who.int zulfikar. (2015). faktor-faktor yang mempengaruhi supervisi kepala ruang di rumah sakit umum daerah dr. zainoel abidin banda aceh. universitas syiah kuala 153 peran prosedur endoskopik dalam mendiagnosis gangguan pencernaan pada anak (the role of endoscopic procedure in diagnosing gastrointestinal disorder in children) alpha fardah athiyyah,* andy darma,* reza ranuh,* subijanto* *rumah sakit umum dr. soetomo surabaya, jl. mayjend prof moestopo 6-8 surabaya 60286 email: alpha_achmadi@yahoo.co.id abstract introduction: gastrointestinal endoscopy in children requires more than the technical expertise needed to pass an endoscope through a smaller digestive tract lumen. children require more careful attention to patient preparation and sedation compared with adults. the incidence of various disease varies through childhood and differs from the adult. aim of this study is to elucidate profi le esophagoduodenoscopic dan colonoscopic procedures in diagnosing gastrointestinal tract disorder in children in soetomo hospital, including role of nursing team role these procedures. method: this study is a descriptive study which is done in gastroenterlology division soetomo hospital in october 2009–march 2012 for patients undergoing esophagoduodenoskopy and colonoscopy. age, sex, indication, preparation, sedation, results, complication data were collected. data from pathological examination were also collected. data analysis were done descriptively such as mean, median and percentage, and presented in tables. result: there were 114 patients undergo esophagoduodenoscopy procedure and 7 patients undergo colonoscopy procedures. the most indication for esophagoduodenoscopy was recurrent abdominal pain (71.1%) and for colonoscopy was chronic diarrhea (42.8%). nill by mouth for 6 hours is preparation for esophagoduodenoscopy and for colonoscopy needs bowel preparation a day before. bowel preparation is using biphosphate sodium phosphate oral and enema. most of all sedation was done by anasthesiologist. nursing team role were start from preparation, relaxing patient, and monitoring during and after procedure. chronic gastroduodenitis was found on 110 (96.4%) cases, 15 cases of it accompanied nodularity. seventy cases (64.9%) from 114 cases of biopsy result were helicobacter pylore positive, and 21 cases of it has barret's esophagus. colonoscopy procedure results 5 (71.4%) cases were colitis, and 3 of them are amoebic colitis. discussion: diagnosis of sructural and histological abnormalities could be establish with endoscopic procedure. this is an important role in diagnosing gastrointestinal disorder in children and nursing team have important role in it. keywords: endoscopy, esophagoduodenoscopy, colonoscopy, nursing, children, gastrointestinal yang kecil memungkinkan untuk melakukan pemeriksaan endoskopi pada anak (manfredi, 2010). departemen ilmu kesehatan anak rsud dr. soetomo mulai secara intensif melakukan pemeriksaan endoskopi sejak tahun 2010. pemeriksaan esofagodudodenoskopi dan kolonoskopi masih relatif baru dilakukan karena pemeriksaan ini termasuk pemeriksaan cukup invasif dan relatif mahal. masih diperlukan pemberian edukasi pada pasien maupun pada dokter anak yang melakukan r ujukan pada konsultan gastroenterologi pendahuluan pemeriksaan endoskopi gastrointestinal memungkinkan untuk melihat bagian dalam traktus gastrointestinal. pemeriksaan ini dapat menggunakan alat endoskopi yang kaku (rigid) maupun yang fl eksibel. endoskopi yang fl eksibel ada sejak sekitar tahun 1960-an dan ditandai sebagai lahirnya endoskopi modern. dengan adanya endoskopi f leksibel ini menungkinkan untuk mendapatkan gambaran lebih jauh dibandingkan dengan yang kaku. pada tahun 1970-an diameter alat endoskopi 154 jurnal ners vol. 7 no. 2 oktober 2012: 153–160 anak agar tidak ragu lagi dalam mengerjakan pemeriksaan esophagodudodenoskopi maupun kolonoskopi. indikasi esophagoduodenoskopi adalah untuk diagnostik, skrining beberapa penyakit dan untuk terapi. esophagoduodenoskopi diagnostik adalah prosedur endoskopi yang paling sering dilakukan. beberapa kondisi yang merupakan indikasi untuk dilakukan esophagoduodenoskopi adalah nyeri perut ber ulang, hematemesis melena, ter telan benda asi ng, ter mi nu m bahan korosif, dysphagia, dan lain sebagainya. terapeutik e s o p h a g o d u o d e n o s k o p i y a n g p a l i n g sering dilakukan adalah pemasangan tube percutaneus endoskopic gastrostomi (peg). perdarahan gastrointestinal bagian bawah adalah indikasi terbanyak untuk dilakukan kolonoskopi. indikasi yang lain adalah diare, skirining untuk infl ammatory bowel disease. salah satu tindakan terapeutik yang bisa dilakukan dengan kolonskopi adalah polipektomi (pittman, ns, 1997). pemeriksaan endoskopi pada anak memerlu kan keahlian tersendir i karena anak adalah bukan miniatur orang dewasa. saluran gastrointestinal anak lebih kecil, dan dibutuhkan perhatian lebih pada persiapan dan sedasi yang dilakukan. insiden beberapa kelainan gastrointestinal pada anak berbeda dibandingkan dewasa, selain itu indikasi dilakukannya endoskopi dan kolonoskopi juga berbeda (benaroch, 1994). penelitian ini bertujuan untuk memberikan gambaran peran pemeriksaan esophagoduodenoskopi dan kolonoskopi di rsud dr. soetomo dalam diagnosis penyakit gastrointestinal pada anak, termasuk peran tim keperawatan dalam mempersiapkan pemeriksaan tersebut. bahan dan metode penelitian ini merupakan penelitian d e sk r ipt i f ya ng d i l a k u k a n d i d iv i si gastroenterologi rsud dr. soetomo surabaya. subyek penelitian ini adalah semua pasien anak yang menjalani pemeriksaan endoskopi dan kolonoskopi di unit endoskopi rsud dr. soetomo mulai oktober 2009 sampai dengan maret 2012. pemeriksaan esophagoduodenoskopi dan kolonoskopi memerlukan persiapan sebelum pemeriksaan esophagoduodenoskopi, pasien setidaknya puasa dalam 6 jam. sedangkan untuk pemeriksaan kolonoskopi diperlukan persiapan untuk membersihkan usus agar tidak didapatkan kotoran saat pemeriksaan dilakukan. pasien sebaiknya masuk rumah sakit sehari sebelumnya. data yang diambil adalah umur, jenis kelamin, indikasi dilakukan pemeriksaan esophagoduodenoskopi dan kolonoskopi, persiapan pemeriksaan esophagoduodenoskopi dan kolonoskopi, sedasi yang diberikan, hasil pemeriksaan esophagoduodenoskopi dan kolonoskopi, dan komplikasi yang t e r ja d i . h a m pi r s e t i a p p e m e r i k s a a n esophagoduodenoskopi dan kolonoskopi dilakukan biopsi. data hasil pemeriksaan patologi anatomi sediaan biopsinya juga dii k utkan dalam analisa. a nalisa dat a dilakukan dengan analisa deskriptif seperti mean, median, dan prosentase serta disajikan dalam bentuk tabel. hasil per iode penelit ia n mulai denga n oktober 2009 sampai dengan maret 2012 didapatkan 121 pasien dilakukan pemeriksaan esophagoduodenoskopi dan kolonoskopi. 114 p a s i e n d i l a k u k a n p e m e r i k s a a n esophagoduodenoskopi, dan 7 pasien dilakukan pemeriksaan kolonoskopi. pemeriksaan yang dilakukan adalah sebatas diagnostik, belum melakukan endoskopi terapeutik. usia pasien yang dilakukan pemeriksaan endoskopi dan kolonoskopi sebagian besar di atas 5 tahun. salah satu penyebabnya adalah karena keterbatasan alat yang bisa digunakan u nt u k bay i. kelu ha n terba nya k u nt u k dilakukan pemeriksaan endoskopi adalah nyeri perut berulang sedangkan keluhan pada pemeriksaan kolonoskopi adalah diare kronis, hematoschezia dan melena. pemeriksaan endoskopi memerlukan persiapan yang tidak terlalu rumit. pasien perlu puasa terlebih dahulu setidaknya 6 jam dan tidak diperlukan persiapan khusus yang lain. pemeriksaan kolonoskopi pasien perlu 155 peran prosedur endoskopik (alpha fardah athiyyah, dkk.) diberikan obat untuk membersihkan usus agar pada saat pemeriksaan kolonoskopi dilakukan terminal illeum, caecum, colon, sigmoid, dan rectum dapat terlihat dengan baik. pembersihan usus sangat penting untuk dilakukan. tim keperawatan mematikan bahwa obat untuk enema dan oral diberikan tepat waktu dan dosis agar pemeriksaan kolonoskopi keesokan harinya dapat berjalan dengan baik. persiapa n kolonoskopi d ila k u ka n 1 hari sebelum jadwal pemeriksan. pasien rawat inap sehari sebelumnya untuk persiapan pembersihan usus. divisi gastroenterologi ilmu kesehatan anak rsud dr. soetomo masih belum pernah melakukan kolonoskopi untuk anak kurang dari 2 tahun, karena masih belum tersedia alat kolonoskopi yang kecil. tabel 1. karakteristik dasar penelitian karakteristik dasar jumlah (persentase) n = 121 umur kurang 5 tahun lebih 5 tahun 32 (26,4%) 89 (73,5%) jenis kelamin laki-laki perempuan 55 (45,4%) 66 (54,5%) endoskopi kolonoskopi 114 (94,2%) 7 (5,8%) indikasi esophagoduodenoskopi nyeri perut berulang muntah hematemesis – melena dispepsia terminum air aki kolonoskopi diare kronis hematoschezia melena 81 (71,1%) 10 (8,8%) 12 (10,5%) 10 (8,8%) 1 (0,9%) 3 (42,8%) 2 (28,6%) 2 (28,6%) tabel 2. persiapan endoskopi dan kolonoskopi pemeriksaan persiapan endoskopi puasa 6 jam kolonoskopi sodium biphosphate sodium phosphate (fl eet®) oral– > 5 tahun: 2–3 sdm dilarutkan dalam 1 gelas air, minum banyak setelahnya– < 5 tahun: 1–2 sdm dilarutkan dalam 1 gelas air, minum banyak setelahnya enema sodium biphosphate sodium phosphate (fl eet®)– > 2 th: 60 ml enema setara denfan setengah dosis dewasa tanda bahwa persiapan untuk perbersihan usus ini berhasil adalah apabila buang air besar penderita berwarna putih jernih. pemberian sodium biphosphate sodium phosphate tidak dilakukan apabila pasien mempunyai kelainan ginjal, dan sebaiknya pasien tidak mengalami dehidrasi dan pernah mengalami kelainan elektrolit selama 1 minggu terakhir. penelitian ini pasien yang menjalani pemeriksaan endoskopi dan kolonoskopi tidak ada kelainan ginjal. selain persiapan secara medis, pasien dan keluarga juga diberikan penjelasan yang baik mengenai prosedur yang akan dilakukan baik untuk endoskopi dan kolonoskopi. pasien rawat inap penjelasan diberikan oleh perawat r uangan dan unt uk pasien yang datang 156 jurnal ners vol. 7 no. 2 oktober 2012: 153–160 untuk endoskopi saja penjelasan dilakukan oleh perawat di r uang endoskopi. untuk pemeriksaan endoskopi, dijelaskan pada pasien dan keluarga bahwa sebelum tindakan, pasien akan diberikan obat agar pasien tidur dan tidak merasakan sesuatu saat tindakan dilakukan. hal ini ditujukan agar pasien tenang, tidak cemas dan tidak berontak saat masuk ke ruang tindakan baik untuk endoskopi maupun kolonoskopi. sedasi yang diberikan terkadang tidak membuat pasien tidur dalam, sehingga pasien terkadang dalam kondisi setengah sadar. hal ini dimaksudkan agar pasien lebih cepat sadar dan pulih kembali. setelah tindakan selesai dilakukan, pasien dapat pulang pada sore harinya apabila pasien dalam kondisi sadar baik, sudah bisa makan dan minum baik, tidak muntah, tidak diare, dan dalam kondisi umum baik. sedasi yang diberikan pada pasien saat akan dilakukan endoskopi dan kolonoskopi sebagian besar dilak u kan oleh sejawat departemen anestesiologi dan reanimasi rsud dr. soetomo surabaya. sebagian besar pemeriksaan endoskopi dilakukan dengan bantuan sejawat anestesiologi. untuk pasien yang dilakukan endoskopi dan pasien sudah cukup besar, maka pemeriksaan endoskopi bisa dilakukan dengan memberikan sedasi midazolam 0,1 mg/kg berat badan. untuk pemer i k sa a n kolonoskopi, k a m i t id a k pernah melakukan tanpa bantuan sejawat anestesiologi karena waktu yang diperlukan untuk pemeriksaan lebih lama dan diperlukan persiapan seandainya terjadi komplikasi pada pemeriksaan kolonoskopi. hasil pemeriksaa endoskopi dari 114 pasien menunjukkan bahwa sebagian besar hasilnya adalah gastroduodenitis k ronis dengan berbagai variasinya. apabila kita lihat pada indikasi dilakukannya endoskopi, 12 pasien dilakukan endoskopi dengan indikasi perdarahan, satu pasien menunjukkan adanya varises esophagus, dan yang lainnya dengan gastritis erosiva. beberapa pasien dengan hasil gastritis erosiva tidak menimbulkan perdarahan. satu pasien dengan terminum air aki menunjukkan hasil erosi dan infl amasi luas daerah antrum disertai dengan perdarahan, dan didapatkan kerusakan struktur lambung. hasil pemeriksaan kolonoskopi sebagian besar adalah kolitis. pasien dengan hasil kolitis yang disertai ulkus adalah pasien dengan kecurigaan infeksi amuba berat. hasil pemeriksaan patologi anatomi pada sediaan biopsi pemeriksaan endoskopi menunjukkan beberapa hal yang menarik. terdapat 74 (64,9%) kasus dengan infeksi helicobacter pylori dari 114 kasus yang diperiksa, dan 21 (28,4%) di antaranya telah mengalami metaplasia pada sel-sel epitel esophagus (barret's esophagus). selain itu tabel 3. hasil pemeriksaan endoskopi dan kolonoskopi pemeriksaan hasil endoskopi (114 kasus) gastroduodenitis kronis gastroduodenitis kronis dengan gastroduodenal refl uks gastroduodenitis kronis dengan noduler hiperplasia gastritis erosiva gastroduodenitis kronis dengan ulkus gastroduodenitis kronis dengan esophagitis gastroduodenitis kronis dengan gastroesophageal refl uks varises esophagus erosi dan inflamasi luas di derah antrum disertai perdarahan normal 47 (41,2%) 17 (14,9%) 15 (13,2%) 20 (17,5%) 6 (5,3%) 2 (1,8%) 3 (2,6%) 1 (0,9%) 1 (0,9%) 2 (1,8%) kolonoskopi (7 kasus) kolitis disertai ulkus kolitis polip rekti hemoroid interna 3 (42,8%) 2 (28,6%) 1 (14,3%) 1 (14,3%) 157 peran prosedur endoskopik (alpha fardah athiyyah, dkk.) didapatkan juga 12 kasus dengan eosinophilia pada pemeriksan sediaan biopsi endoskopi dan 1 kasus eosinophilia pada pemeriksaan sediaan biopsi kolonoskopi. selama per iode penelit ia n, t id a k ditemukan komplikasi baik pada pemeriksaan esophagoduodenoskopi maupun kolonoskopi. kompli kasi ya ng d apat ti mbul ad alah perforasi saluran cerna, perdarahan hebat, infeksi, dan sebagainya. keluhan yang timbul adalah nyeri telan ringan setelah pemeriksaan esophagoduodenoskopi yang cepat menghilang. setelah pemeriksaan kolonoskopi keluhan yang timbul adalah rasa tidak nyaman di perut, tetapi keluhan ini juga cepat hilang. pembahasan pemeriksaan esophagoduodenoskopi d a n kolonoskopi masi h belu m ba nya k dilakukan. selama 3 tahun terakhir terjadi peningkatan drastis jumlah pemeriksaan esophadoduodenoskopi dan kolonoskopi. hal ini tidak lepas dari banyaknya rujukan dari para dokter spesialis anak dan dokter umum. angka ini apabila dibandingkan dengan negara lain tentulah msih sangat kecil. penelitian di inggris menunjukkan dalam waktu 20 tahun terdapat 1372 pemeriksaan esophagoduodenoskopi dan kolonoskopi pada anak kurang dari 1 tahun (volonaki et al., 2012), sedangkan di singapore, pada tahun 1990 didapatkan 200 pemeriksaan endoskopi pada anak (sh quak, 1990), di korea dilaporkan 1040 endoskopi pada anak selama kurun waktu 5 tahun (jae hong park, 2010). meskipun jumlah pemeriksaan yang dilakukan di rsud dr. soetomo masih sedikit, tapi dari waktu ke waktu jumlah pasien yang memerlukan pemeriksaan esophagoduodenoskopi dan kolonoskopi semakin meningkat. indikasi untuk dilakukan pemeriksaan esophagoduodenoskopi pada penelitian ini sebagian besar adalah nyeri perut berulang, berikutnya adalah perdarahan saluran cerna atas, diikuti dengan dispepsia. ada satu kasus dengan terminum air aki. nyeri perut berulang dalam penelitian ini sebagian besar nyeri perut di daerah epigastrial. menurut napsghan (north american pediatric societ y of gastroenterolog y hepatolog y and nutrition), indikasi untuk dilakukan pemeriksaan esophagoduodenoskopi adalah disfagia, odinofagia, nyeri perut yang sangat menganggu dan ditandai dengan tanda-tanda penyakit organik, penyakit gastroesophageal refl uks kronis dan termasuk untuk skrining adanya barret's esophagus, terminum bahan korosif, anemia yang tidak dapat dijelaskan, dan sebagainya (dr umm, 2000, poddar, 2007, asge, 2008). dengan pemeriksaan esophagoduodenoskopi, pada esophagus dapat melihat adanya esophagitis yang ditandai dengan granularitas pada mukosa, juga dapat pula dilihat adanya robekan pada mukosa (mallory weiss) akibat muntah yang sering. tabel 4. hasil pemeriksaan patologi anatomi biopsi endoskopi dan kolonoskopi pemeriksaan hasil patologi anatomi endoskopi – gastritis kronis dan duodenitis kronis – gastritis kronis, duodenitis kronis dengan eosiniphilia – gastritis kronis, duodenitis kronis dengan helicobacter pylori – gastritis kronis, duodenitis kronis, barret's esophagus dan infeksi helicobacter pylori – barret's esophagitis – ulkus peptikum disertai infeksi helicobacter pylori – hipersplenisme – perdarahan stroma dan gastritis kronis superfi sial – normal 24 (21%) 12 (10,5%) 52 (45,6%) 21 (18,4%) 1 (0,9%) 1 (0,9%) 1 (0,9%) 1 (0,9%) 1 (0,9%) kolonoskopi – kolitis kronis non spesifi k – kolitis kronik dengan erosi – kolitis kronis dengan bentukan polip – kolitis kronis dengan eosinophilia 2 (28,6%) 3 (42,6%) 1 (14,3%) 1 (14,3%) 158 jurnal ners vol. 7 no. 2 oktober 2012: 153–160 pada gaster dapat ditemukan adanya gastritis, adanya ulkus, infeksi helicobacter pylori dapat pula dilihat dengan adanya perubahan noduler pada mukosa gaster terutama pada daerah antrum. endoskopi dan biopsi merupakan pemeriksaan yang sangat berguna dalam melakukan diagnosis dan tatalaksana penyakit infl ammatory bowel disease yaitu ulcerative colitis dan penyakit crohn (wyllie, r, 1993). peran perawat sangat diperlukan dalam hal ini. di rsud dr. soetomo belum ada tim keperawatan khusus untuk pemeriksaan esophagoduodenoskopi dan kolonoskopi, akan tetapi tindakan keperawatan tetap dilakukan. tindakan keperawatan dimulai dari sebelum pelaksanaan, pada saat pelaksanaan dan setelah selesai pelaksanaan. sebelum pelaksanaan lebih difokuskan pada edukasi pada pasien dan orang tua, persiapan untuk tindakan termasuk di dalamnya agar pasien merasa nyaman, dan merencanakan tindakan keperawatan selanjutnya. pada saat pelaksanaan, melakukan monitoring pasien dan menjamin keamanan pasien serta saat selesai pemeriksaan masih tetap melakukan monitoring pada pasien sampai pasien dapat rawat jalan (chuang e, 2001). heard l menyatakan bahwa persiapan endoskopi pada anak dapat dilakukan dengan baik dengan melihat penggolongan kelompok umur, pada bayi sampai usia 1 tahun sangat tergantung pada orang tua dan juga pada kelompok anak usia 1–3 tahun masih belum bisa dilepas dari orang tua. pada kelompok ini sebaiknya orang tua diikutkan pada proses awal sampai dengan sedasi. sedangkan usia 3 tahun keatas sudah bisa mulai menyatakan pendapat, dan pada remaja biasanya sudah mandiri (heard, l, 2008). persiapan terpenting pada pemeriksaan kolonoskopi adalah pembersi han usus. pe mb e r si h a n u s u s s e b a g a i p e r sia p a n k o l o n o s k o p i m e n g g u n a k a n s o d i u m biphosphate sodiu m phospate (f leet®) oral dan enema. sampai saat ini belum ada keseragaman dalam pemakaian obat untuk pembersihan usus. yang paling ser ing digunakan adalah peg (polyethylene glicol) baik yang dengan elektrolit maupun yang tanpa elektrolit, sedangkan untuk sodium biphosphate sodium phospate (fl eet®) enema mendapatkan approval fda amerika serikat untuk penggunaan pada anak di atas 2 tahun. efek samping pemberian obat-obatan ini adalah ketidakseimbangan elektrolit, kembung, mual dan sebagainya. peg lebih sering digunakan karena merupakan obat yang paling aman (hunter a, 2010). sayang sekali peg ini belum tersedia di surabaya. rekomendasi dari ispgan (israeli society pediatric of gastroenterology and nutrition) menyatakan bahwa untuk anak yang kurang dari 6 tahun, pembersihan usus yang paling aman adalah peg, sedangkan sodium biphosphate sodium phospate (fl eet®) bisa digunakan pada anak usia > 6 tahun (turner d, 2010). endoskopi saluran cerna bagian atas dengan biopsi merupakan standar baku emas diagnosis h. pylori (wong, 2003, guarner j, 2010) penelitian ini mendapatkan bahwa didapatkan 64,9% dari endoskopi yang dilakukan terdapat infeksi helicobacter pylori. angka ini merupakan angka yang sangat besar. bahkan 28,4% di antaranya telah mengalami per ubahan ke arah metaplasia (barret's esophagus). kori dalam penelitiannya pada tahun 2003, mendapatkan 201 penderita anak yang dibiopsi didapatkan 17% menunjukkan abnormalitas saluran cerna yaitu metaplasia saluran cerna yang dapat dikaitkan dengan adanya infeksi h. pylori (krogfelt, 2005). pittman ns dalam tulisannya menyatakan bahwa infeksi helicobacter pylori didapatkan sekitar 15% dari penderita yang dilakukan pemeriksaan esophagoduodenoskpi dan biopsi (pittman, ns, 1997). didapatkan 3 pasien dengan kecurigaan infeksi amoeba berat, dan ternyata pada saat pemeriksaan kolonoskopi didapatkan hasil kolitis disertai dengan ulkus. hal ini sesuai dengan stanley sl, pada infeksi amoeba berat, pemeriksaan kolonoskopi menunjukkan adanya ulkus baik noduler maupun irreguler (stanley, sl, 2001). pemeriksaan kolonoskopi memberikan kepastian kelainan struktur kolon pada anak dengan infeksi ataupun indikasi lain. pemeriksaan kolonoskopi dapat terlihat adanya kolitis, adanya ulkus, polip dan lain sebagainya. pemeriksaan histopatologi dapat memberikan petunjuk untuk diagnosa (wyllie, r, 1993). 159 peran prosedur endoskopik (alpha fardah athiyyah, dkk.) satu pasien dengan terminum air aki dan dilakukan pemeriksaan endoskopi dengan hasil erosi dan infl amasi luas di daerah antrum disertai perdarahan. pemeriksaan endoskopi sebaiknya dilakukan dalam 24 jam pertama setelah kejadian karena akan menentukan tindakan selanjutnya dan dapat memperkirakan prognosa selanjutnya (keh, 2006). p e m e r i k s a a n e n d o s k o p i b a i k esophagoduodenoskopi maupun kolonoskopi dapat memberikan kepastian diagnosa pada beberapa penyakit gastrointestinal, akan tetapi pemeriksaan endoskopi ini mempunyai kelemahan yaitu pemeriksaan ini termasuk pemer i k sa a n i nva sif d a n memerlu k a n koordinasi banyak orang serta memerlukan ruangan yang sebaiknya dengan peralatan monitoring lengkap. akan tetapi karena peran pemeriksaan endoskopi ini cukup penting, sebaiknya pemeriksaan ini dipertimbangkan dalam mendiagnosa penyakit gastrointestinal pada anak. simpulan dan saran simpulan pemeriksaan esophagoduodenoskopi dan kolonoskopi mempunyai peran penting dalam manajemen penyakit gastrointestinal pada anak yaitu pada penegakan diagnosis kelainan str uktur dan histologi. perawat mempunyai peran besar dalam persiapan pra pelaksanaan, saat pelaksanaan dan pasca pelaksanaan. saran pemeriksaan esophagoduodenoskopi dan kolonoskopi akan membantu penegakan diagnosis. pemeriksaan ini relatif aman dengan efek samping minimal, sehingga tidak perlu ragu untuk menyarankan pemeriksaan tersebut. pelatihan khusus perawat dalam persiapan penderita (pre dan pasca tindakan) akan sangat membantu kelancaran pemeriksaan dan meningkatkan kepuasan akan pelayanan. kepustakaan asge standard of practice committee, 2008. modifi cations in endoscopic practice for pediatric patients. gastrointest endosc, 67(1): 1–9. benaroch, l.m., rudolph, c.d., 1994. pediatric endoscopy. semin gastrointest dis, 5(1): 32–46. chuang, e., zimmerman, a., neiswender, k.m., liacouras, c.a., 2001. sedation in pediatric endoscopy. gastrointest endosc clin n am, 11(4): 569–84, v-vi. drumm, b.s., koletzko, g., oderda., 2000. helicobacter pylori infection in children: a consensus statement. j pediatr gastroenterol nutr, 30: 207–213. guarner, j., kalach, n., elitsur, y., koletzko, s., 2010. helicobacter pylori diagnostic tests in children: review of the literature from 1999 to 2009. eur j pediatr, 169(1): 15–25. heard, l., 2008. taking care of the little things: preparation of the pediatric endoscopy patient. gastroenterol nurs, 31(2): 108– 12. hu nter, a., ma mula , p., 2010. bowel preparation for pediatric colonoscopy procedures. j pediatr gastroenterol nutr, 51(3): 254–61. jae hong park., 2010. role of colonoscopy in the diagnosis and treatment of pediatric lower gastrointestinal disorders. korean j pediatr, 53(9): 824–829. keh, s.m., onyekwelu, n., 2006. corrosive injury to upper gastrointestinal tract. world j gastroenterol, 12(32): 5223–8. krogfelt, k.a., lehours, p., megraud, f., 2005. diagnosis of helicobacter pylori infection. helicobacter, 10(suppl): 5–13. manf redi, m.a., lightdale, j.r., 2010. endoscopy. in bishop wp ed. pediatric practice gastroenterology. new york: mc graw hill, 126–41. p i t t m a n , n . s . , b a r n a r d , j. , 19 9 7. gastrointestinal endoscopic procedures in children. pediatric annals, 26(4): 218–24. 160 jurnal ners vol. 7 no. 2 oktober 2012: 153–160 poddar, u., yaccha, s., 2007. helicobacter pylori in children: an indian perspective. indian pediatr, 44: 761–70. quak, s.h., lam, s.k., low, p.s., 1990. upper gastrointestinal endoscopy in children. singapore med j, 31: 123–6. stanley, s.l., read, s.l., 2001. entamoeba histolytica: parasite-host interactions. am j physiol gastrointest liver physiol, 280: 1049–54. turner, d., levine, a., weiss, b., et al., 2010. evidence-based recommendations for bowel cleansing before colonoscopy in children: a report from a national working group. endoscopy, 42: 1063– 70. volonaki, e., sebire, n.j., borelli, o., et al., 2012. gastrointestinal endoscopy and mucosal biopsy in the first year of life: indications and outcome. j pediatr gastroenterol nutr doi: 10.1097/ mpg.0b013e3182478f83 (publish ahead of print) wong, r.m., ota, s., bamba, h., itoyama, s., et al., 2003. accuracy of endoscopic diagnosis of helicobacter pylori in patients with hemorrhagic peptic ulcers. dig endoscopy, 15: 25–9. wyllie, r., kay, m.h., 1993. gastrointestinal endoscopy in infants and children. pediatr rev, 14: 352–9. ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 138 penurunan kecemasan ibu menjelang seksio sesaria dengan model "sayang bunda" (the decrease of anxiety in secsio sesaria mother with "sayang bunda" model) dhiana setyorini*, moch. bahrudin* *jurusan keperawatan poltekkes kemenkes surabaya, jalan prof. dr. moestopo no. 8c surabaya e-mail: selalu.mesra@yahoo.co.id abstract introduction: mother with secsio sesaria will fi nd an problem, both a physical and psychological problems. a psychological problem that often happen in mother with secsio sesaria is an anxiety problem. the aimed of this study was to know the effectiveness of "sayang bunda" in reducing the anxiety of seccio caesaria mother. method: quasy experimental pretest-postest with contol group design was used in this study. the population in this study was mother with electif sectio sesaria who pregnant examinated in darmo hospital, william both hospital, suwandi hospital, bunda hospital and darus syifa' hospital of surabaya. total sample was 60 people divided into 30 of intervention group and 30 of control. the samples was taken by quota sampling. the effectiveness of "sayang bunda" to decrease anxiety was analyzed by using t test (independent samples t-test). result: the results of homogeneity test found that between control and intervention groups were homogeneous (p ≥ 0.05). the results of this study indicate that there were signifi cant differences on anxiety between control and intervention group (p = 0.00), the control group had an average higher anxiety than the intervention group after getting "sayang bunda". similarly to the level of anxiety, anxiety levels decreased after getting "sayang bunda" (p = 0.018). discussion: "sayang bunda" effective for reducing anxiety in women with secsio sesaria. the implication of this study is health education with "sayang bunda" can be applied to mothers with planned elective cesarean section at the time of antenatal education. keywords: anxiety, " sayang bunda", secsio sesaria pendahuluan persalinan adalah suatu peristiwa alami dan penting dalam kehidupan seorang wanita, namun peristiwa persalinan bukan hanya merupakan pengalaman yang menyenangkan. persalinan merupakan suatu ancaman yang dapat mengantarkan mereka pada kecacatan dan kematian. setiap menit seorang ibu meninggal karena penyebab yang berkaitan dengan kehamilan dan persalinan. ia biasanya berusia muda (kurang dari 21 tahun), sudah menjadi ibu dan hidup di negara berkembang. (sherris, 1999). selain ibu yang meninggal saat persalinan, diperkirakan ada 100 wanita yang selamat saat persalinan tapi mengalami kesakitan, cacat atau kelainan fisik akibat komplikasi kehamilan. s e c a r a k e s e l u r u h a n d i p e r k i r a k a n bahwa setiap tahunnya 585.000 wanita meninggal akibat kehamilan dan persalinan: 99% dari kematian tersebut terjadi di negara berkembang. wanita di afrika barat dan timur menghadapi risiko kematian ibu paling tinggi; demikian pula wanita di beberapa negara asia berisiko tinggi (sherris, 1999). sebagian besar (60–80%) kematian ibu disebabkan oleh perdarahan saat melahirkan, persalinan macet, sepsis, tekanan darah tinggi pada kehamilan, dan komplikasi dari aborsi yang tidak aman. komplikasi kehamilan dan persalinan atau yang menyebabkan kematian pada ibu tidak bisa diperkirakan sebelumnya, dan sering terjadi beberapa jam atau hari setelah persalinan (sherris, 1999). penyebab tersebut penurunan kecemasan ibu menjelang seksio sesaria (dhiana setyorini) 139 akan menyebabkan persalinan yang seharusnya berjalan alami menjadi terhambat dan harus dilakukan tindakan bedah kebidanan dengan seksio sesaria. tindakan ini ada yang sudah direncanakan sebelumnya (elektif) namun ada pula yang tidak ada perencanaan sebelumnya (emergensi). abad ke-20 cara kelahiran dengan seksio sesaria hampir di seluruh dunia mengalami peningkatan. di amerika serikat, dari 4,5 per seratus kelahiran pada tahun 1965 menjadi 23,5 per seratus kelahiran pada tahun 1991 (phillips, 1966). di negara inggris, scotland, sweden, sekitar 10% menjadi 12% (old, london dan ladewig, 2000). indikasi seksio sesaria ditunjukkan oleh survei yang dilakukan di amerika bahwa dari 123.837 kelahiran, sebesar 33,4% karena distosia, 23,1% karena bekas seksio sesaria, 18,8% karena letak sungsang, 13,2% karena gawat janin, dan 11,2% karena indikasi lain (martius, 1997). peningkatan jumlah kasus seksio sesaria dapat dilihat dari survei yang dilakukan oleh wiknjosastro dan basalamah (1993) pada 64 rumah sakit di jakarta yang didapatkan angka berkisar antara 35,7–55,3% dari 17.665 kelahiran. sementara di rsud dr. soetomo menunjukkan adanya peningkatan kelahiran dengan seksio sesaria, dari 452 kasus pada tahun 2000 menjadi 545 kasus pada tahun 2004 dengan indikasi yang bervariasi (rsud dr. soetomo surabaya, 2005). sebagian besar persalinan seksio sesaria dilakukan dengan indikasi medis, namun ada pula indikasi nonmedis walaupun jumlahnya tidak terlalu banyak. data di rsud m. soewandhie didapatkan data bahwa terjadi peningkatan jumlah kelahiran dengan seksio sesaria. tahun 2006 jumlah persalinan dengan tindakan seksio sesaria sebesar 225 kasus tahun 2007 sebesar 234 kasus, tahun 2008 sebesar 260 kasus dan tahun 2009 sebesar 332 kasus. perawat perlu untuk menerapkan perannya sebagai advokat dalam membantu klien dan keluarga memutuskan tindakan yang terbaik bagi diri mereka dalam proses persalinannya. selain itu, adanya peningkatan kejadian persalinan dengan cara seksio sesaria tentunya harus dibarengi dengan peningkatan kemampuan profesional perawat maternitas sehingga mampu mengatasi konsekuensi munculnya berbagai permasalahan yang cukup kompleks baik dari aspek fisik, psikologis maupun sosio ekonomik. permasalahan pada aspek fisik dapat dilihat melalui kejadian morbiditas maternal dan perinatal. sekitar 25–50% kelahiran secara seksio sesaria mengalami komplikasi seperti aspirasi, embolisme pulmonal, infeksi luka, luka terbuka (dehisence), tromboplebitis, perdarahan, infeksi saluran kemih, perlukaan vesika urinaria dan usus, dan komplikasi yang berhubungan dengan anestesi (perry dan hess, 1998). selain dari aspek fi sik, permasalahan psikologis dapat terjadi pada ibu yang akan menjalani seksio sesaria maupun sesudahnya. permasalahan p s i k o l o g i s y a n g s e r i n g t e r j a d i a d a l a h kecemasan. tingkat kecemasan yang dirasakan ibu menjelang seksio sesaria berhubungan erat dengan pengetahuan yang kurang dan status sosial ekonomi yang rendah. tingkat kecemasan pada ibu hamil menjelang seksio sesaria merupakan hal yang sangat penting, karena kecemasan yang berlangsung terus-menerus dapat menimbulkan gangguan-gangguan yang dapat mempersulit k e h a m i l a n m a u p u n p r o s e s p e r s a l i n a n sendiri. kecemasan yang berlangsung terusmenerus tanpa adanya suatu tindakan akan mengkibatkan peningkatan kecemasan ke level yang lebih parah dan meningkatkan risiko cedera serta komplikasi post partum (taylor, 1997). dalam kondisi distress atau cemas akan mengakibatkan peningkatan kadar kortisol, yang disertai dengan kadar neutrofi l mengalami penurunan sehingga menurunkan daya tahan tubuh seseorang. dengan turunnya daya tahan tubuh menjelang tindakan seksio sesaria akan menyebabkan terjadinya berbagai komplikasi setelah pembedahan, yang akan memperpanjang lama hari perawatan pasien di rumah sakit dan hubungan ibu dengan bayi akan terhambat. komplikasi setelah seksio sesaria ini dapat dicegah bila daya tahan tubuh ibu sebelum menjalani pembedahan cukup tinggi. salah satu cara yang dapat dilakukan oleh seorang perawat untuk meningkatkan daya tahan ibu sebelum menjalani seksio sesaria adalah dengan mengurangi kecemasan ibu. jurnal ners vol. 5 no. 2 oktober 2010: 138–146 140 kecemasan ibu akan berkurang bila ibu sudah mengerti tentang perngertian seksio sesaria, alasan atau indikasi dilakukan seksio sesaria, persiapan seksio sesaria, prosedur seksio sesaria, komplikasi dan risiko seksio sesaria, dan perawatan setelah seksio sesaria. untuk mengerti tentang semua ini ibu perlu diberi suatu bentuk pendidikan kesehatan, karena dengan diberikan pendidikan kesehatan ini akan meningkatkan pengetahuan ibu dan ibu siap untuk menjalani seksio sesaria. peningkatan pengetahuan ibu ini dapat diperoleh dengan pendidikan kesehatan sebelum dilakukan pembedahan. hal ini penting karena pendidikan kesehatan pre operasi berhubungan erat dengan antisipasi terhadap rasa cemas, takut, nyeri dan tingkat ketergantungan klien. pemberian pendidikan kesehatan pre operasi juga dapat meningkatkan rasa aman, percaya diri, partisipasi dalam perawatan diri dan meminimalkan komplikasi dan membantu dalam mengambil keputusan yang positif. (perry dan potter, 1997; notoatmodjo, 2003). penelitian tentang pentingnya pendidikan kesehatan pada pre operasi seksio sesaria yang dilakukan oleh milne, hundley, dan graham (1999) tentang alasan seorang wanita memutuskan melahirkan dengan seksio sesaria, terhadap 166 responden didapatkan hasil bahwa 94 orang (58%) puas dengan informasi yang diterima selama kehamilan tentang pendidikan kesehatan yang terkait dengan seksio sesaria. 47 orang (29%) tidak puas terhadap informasi yang diterima sedangkan 21 orang (13%) tidak dapat memberikan jawaban. mereka yang merasa puas, kemudian memutuskan untuk dilakukan seksio sesaria pada dirinya. melihat pentingnya pendidikan kesehatan sebelum operasi seksio sesaria ini, maka perlu diberikan pendidikan kesehatan pada ibu yang akan menjalani seksio sesaria dengan berbagai metode dan media. berbagai macam metode dan media dapat digunakan untuk memberikan pendidikan kesehatan pada ibu menjelang seksio sesaria. metode yang dapat digunakan dalam memberikan pendidikan kesehatan ini adalah metode pendidikan perorangan atau kelompok dengan cara: ceramah, tanya jawab, diskusi, demonstrasi, simulasi dan curah pendapat. sedangkan media yang dapat digunakan antara lain: booklet, pamfl et, leafl et, fi lm dan alat peraga lainnya. (notoatmodjo, 2003; sumijatun, 2006). peningkatan jumlah ibu yang harus menjalani seksio sesaria dan banyaknya komplikasi yang terjadi setelah tindakan seksio sesaria, baik itu seksio sesaria yang elektif, terlebih lagi seksio sesaria yang emergensi maka diperlukan suatu bentuk pendidikan kesehatan untuk ibu hamil yang akan menjalani seksio sesaria. selama ini masih banyak rumah sakit yang belum memberikan pendidikan kesehatan untuk mengurangi kecemasan pada ibu yang akan menjalani seksio sesaria, terutama pendidikan kesehatan yang bersifat formal dan terstruktur. sehingga diperlukan suatu bentuk media pendidikan kesehatan untuk menurunkan kecemasan ibu yang akan menjalani seksio sesaria. peneliti membuat suatu bentuk paket pendidikan kesehatan untuk menurunkan kecemasan ibu yang akan menjalani seksio sesaria yaitu "sayang bunda" dalam bentuk booklet. "sayang bunda" ini dibuat sendiri oleh peneliti berdasarkan beberapa teori yang telah peneliti pelajari. bahan dan metode penelitian ini merupakan penelitian quasy experiment, penelitian dilakukan dengan mengkaji kecemasan ibu sebelum (pre-test) dan sesudah (post-test) diberikan " sayang bunda" dengan menggunakan kelompok kontrol, desain penelitian ini disebut desain pretest-posttest with kontrol group (budiharto, 1999). kesimpulannya penelitian ini menggunakan design non randomised quasy experimental pretest-posttest with control group. populasi dalam penelitian ini adalah ibu dengan seksio sesaria elektif yang periksa di poli hamil rumah sakit yang ada di surabaya. sedangkan sampelnya adalah ibu dengan seksio sesaria elektif dan hamil trimester ke-3 di klinik hamil rs darmo, rs william booth, rs suwandi, rs bunda dan rs darus syifa' surabaya, yang memenuhi kriteria inklusi. penurunan kecemasan ibu menjelang seksio sesaria (dhiana setyorini) 141 penelitian ini menggunakan tiga jenis instrumen yang terdiri dari kuesioner data demografi terdiri dari empat pertanyaan yang harus diisi oleh responden yaitu umur, pendidikan terakhir, pekerjaan dan paritas serta instrumen yang digunakan dalam pengumpulan data tingkat kecemasan ibu dengan seksio sesaria adalah close-ended questionaire, alat ukur ini disusun sendiri oleh peneliti dengan memodifikasi pada instrumen pengkajian kecemasan dari zsas dan zung dan dari " hamilton anxiety rating scale (hars)" (hawari, 2001). lembar observasi merupakan alat pengumpul data yang berisi tentang data objektif kecemasan ibu dengan seksio sesaria. alat ukur ini berisi tentang perubahan fi siologis yang terjadi pada ibu yang mengalami kecemasan. cara menilainya dengan cara pengukuran dan observasi. pengolahan dan analisis data yang digunakan adalah analisis univariat dilakukan dengan menganalisis distribusi frekuensi dari karakteristik responden dan frekuensi tingkat kecemasan responden, analisis bivariat yaitu uji homogenitas untuk mengetahui homogenitas responden digunakan uji chi square dan uji perbedaan kedua kelompok dengan menggunakan rumus t-test. hasil karakteristik ibu melahirkan dalam penelitian ini meliputi umur, pendidikan, pekerjaan dan paritas. jumlah ibu yang berusia sebagian besar berusia kurang dari 30 tahun pada kelompok kontrol ada 17 ibu (56,7%), sedangkan pada kelompok intervensi jumlah ibu yang berusia kurang dari 30 tahun ada 16 ibu (53,3%). hasil uji statistik didapatkan nilai p-value antara kedua kelompok tersebut adalah 0,29. jadi dilihat dari umur responden kedua kelompok tersebut homogen. analisis tingkat pendidikan ibu pada kelompok kontrol 27 ibu (90%) berpendidikan menengah ke atas, demikian juga untuk kelompok intervensi 26 ibu (86,7%) berpendidikan menengah ke atas. hasil uji statistik didapatkan nilai p-value antara kedua kelompok tersebut adalah 1,00. jadi dilihat dari tingkat pendidikan responden kedua kelompok tersebut homogen. ibu pada kelompok kontrol sebagian besar bekerja yaitu 21 ibu (70%), sedangkan pada kelompok intervensi yang tidak bekerja sejumlah 16 ibu (53,3%) dan yang bekerja 14 ibu (46,7%). selain itu hasil uji statistik didapatkan nilai p-value antara kedua kelompok tersebut adalah 0,81. jadi dilihat dari pekerjaan responden kedua kelompok tersebut homogen. sebagian besar responden dalam penelitian ini adalah ibu yang sedang hamil pertama yaitu sebanyak 19 ibu (63,3%) pada kelompok kontrol, sedangkan pada kelompok intervensi sebanyak 18 ibu (60%), kehamilan kedua pada kelompok kontrol 6 ibu (20%) pada kelompok intervensi 9 ibu (30%). kehamilan ketiga pada kelompok kontrol 2 ibu (6,7%) pada kelompok intervensi 3 ibu (10%), pada kelompok intervensi tidak ada. dari hasil uji statistik didapatkan nilai p-value antara kedua kelompok tersebut adalah 0,56. jadi dilihat dari paritas responden kedua kelompok tersebut homogen. distribusi tingkat kecemasan ibu melahirkan dengan seksio sesaria berdasarkan karakteristiknya didapatkan hasil p value > 0,05 (umur, pendidikan, pekerjaan, paritas). ini menunjukkan bahwa tidak ada hubungan antara karakteristik responden dengan tingkat kecemasan yang dialami. rerata nilai kecemasan pengukuran pre pada kelompok kontrol adalah 26,57 dengan standar deviasi 4,967, sedangkan pada kelompok intervensi didapat rerata nilai kecemasan pengukuran pre 29,63 dengan strandar deviasi 3,449. hasil uji statistik didapatkan nilai b p-value = 0,007. jadi ada perbedaan yang bermakna antara nilai kecemasan pengukuran pre pada kelompok kontrol dengan kelompok intervensi, rerata kecemasan kelompok intervensi lebih tinggi dari pada kelompok kontrol nilai kecemasan pengukuran post pada kelompok kontrol 32,43 dengan standar deviasi 5,144. sedangkan pada kelompok intervensi rerata nilai kecemasan pada pengukuran post adalah 26,80 dengan standar deviasi 2,657. hasil uji statistik didapatkan nilai p-value = 0,000. jadi ada perbedaan yang bermakna antara kecemasan kelompok intervensi lebih rendah daripada kelompok kontrol. jurnal ners vol. 5 no. 2 oktober 2010: 138–146 142 tabel 1. distribusi responden kelompok kontrol dan kelompok intervensi menurut karakteristik karakteristik p-value umur ≤ 30 tahun ≥ 31 tahun 0,29 pendidikan sltp ≥ smu 1,00 pekerjaan tidak bekerja bekerja 0,81 kehamilan ke 1, 2, lebih dari 3 0,56 tabel 2. distribusi tingkat kecemasan responden berdasarkan karakteristiknya no karakteristik p-value 1. umur 0,662 2. pendidikan sltp ≥ smu 0,183 3. pekerjaan • tidak bekerja • bekerja 0,842 4. kehamilan ke (1, 2, 3 atau lebih dari 3) 0,908 tabel 3. kecemasan pada ibu melahirkan dengan seksio sesaria sebelum dan setelah mendapatkan paket "ibu" pada kelompok kontrol dan kelompok intervensi kelompok kecemasan pre post mean sd mean sd kontrol 26,57 4,967 32,43 5,144 intervensi 29,63 3,449 26,80 2,657 perbedaan kontrol dan intervensi -3,06 1,518 5,63 2,486 p value 0,007 0,000 tabel 4. distribusi frekuensi tingkat kecemasan ibu melahirkan dengan seksio sesaria di rs darmo, rs william booth, rs suwandi, rs bunda dan rs darus syifa' surabaya tahun 2010 kecemasan kelompok intervensi kontrol pre post pre post f % f % f % f % cemas ringan 2 6,7 4 13,3 11 35,7 3 6,6 cemas sedang 27 90 26 86,7 18 60 22 73,3 cemas berat 1 3,3 0 0 1 3,3 6 20 jumlah 30 100 30 100 30 100 30 100 p value 0,081 penurunan kecemasan ibu menjelang seksio sesaria (dhiana setyorini) 143 pengukuran pre berdasarkan distribusi frekuensi tingkat kecemasan ibu melahirkan dengan seksio sesaria jumlah responden kelompok intervensi terbanyak mengalami kecemasan sedang yaitu 27 orang (90%), yang mengalami kecemasan berat hanya 1 orang (3,3%) dan yang mengalami cemas ringan hanya 2 orang (6,7%). pengukuran post jumlah responden kelompok intervensi terbanyak mengalami kecemasan sedang yaitu 26 orang (90%), pada responden dengan kecemasan berat tidak ada (0%) dan responden dengan kecemasan ringan meningkat menjadi 4 orang (13,3%). pada kelompok kontrol pengukuran pre jumlah responden terbanyak mengalami kecemasan sedang yaitu 18 orang (60%), yang mengalami kecemasan berat hanya 1 orang (3,3%) dan yang cemas ringan 11 orang (36,7%). pengukuran post jumlah responden terbanyak mengalami kecemasan sedang yaitu 22 orang (73,3%), pada responden dengan kecemasan ringan turun menjadi 2 orang (67%). hasil uji statistik didapatkan nilai p-value = 0,018. jadi ada perbedaan yang bermakna antara jumlah responden pada masing-masing tingkat kecemasan pada pengukuran pre dan pengukuran post baik pada kelompok intervensi maupun control. pembahasan rerata nilai kecemasan pada kedua kelompok juga mempunyai perbedaan yang bermakna. hal ini dapat terjadi karena banyak hal lain yang dapat memengaruhi kecemasan pada ibu yang akan melahirkan dengan seksio sesaria. kecemasan akan lebih tinggi dirasakan pada ibu yang berusia kurang dari 30 tahun, hal lain dipengaruhi oleh kematangan emosi. pada ibu yang berusia lebih dari 30 tahun emosinya lebih stabil sehingga kecemasannya akan semakin rendah. hal ini didukung hasil penelitian yang dilakukan oleh maemonah (2002) tentang faktor yang memengaruhi kecemasan pada klien dengan pembedahan. disamping itu ibu yang berusia kurang dari 30 tahun, kebanyakan menjalani persalinan yang pertama sehingga pengalaman persalinan masih kurang dan anak yang akan dilahirkan adalah anak yang sangat diharapkan. namun demikian kecemasan pada ibu dengan usia lebih dari 30 tahun dan merupakan persalinan pertama kecemasannya jauh lebih tinggi. faktor pekerjaan dapat pula berpengaruh terhadap kecemasan, pada ibu yang bekerja kecemasannya akan lebih rendah karena pada ibu yang bekerja lebih banyak kesempatan untuk mengekspresikan kecemasan yang dirasakan. teknik distraksi dengan menceritakan kecemasan yang dirasakan akan membantu ibu mengurangi kecemasan yang dirasakan. pendidikan seseorang juga berpengaruh terhadap kecemasan yang dirasakan, seseorang yang mempunyai tingkat pendidikan yang tinggi akan mempunyai pengetahuan yang tinggi pula. pengetahuan yang cukup tentang pembedahan akan membuat seseorang memiliki koping yang bagus sehingga kecemasan yang dirasakan tidak terlalu tinggi. hal ini sesuai dengan teori dari direktorat kesehatan jiwa departemen kesehatan republik indonesia (1994) tentang faktor-faktor yang memengaruhi kecemasan bahwa individu yang tingkat pengetahuannya lebih tinggi akan mempunyai koping yang adaptif terhadap kecemasan. pendapat ini didukung pula oleh penelitian yang dilakukan oleh maemonah (2002) tentang faktor yang memengaruhi kecemasan pada klien dengan pembedahan, dikatakan bahwa klien yang pengetahuannya baik mempunyai kecemasan lebih rendah dibanding klien dengan pengetahuan kurang baik. penelitian ini semua karakteristik responden tidak berpengaruh terhadap kecemasan yang dialami responden, baik itu faktor usia, pendidikan, pekerjaan, maupun paritas. sehingga dapat disimpulkan bahwa perubahan kecemasan yang terjadi pada responden adalah akibat dari pemberian " sayang bunda". kelompok yang tidak mendapatkan pendidikan kesehatan berupa "sayang bunda" saat pengukuran pre didapatkan jumlah ibu melahirkan dengan seksio sesaria yang mengalami kecemasan ringan 11 orang, cemas sedang 18 orang dan cemas berat 1 orang, namun pada pengukuran kedua jumlah ibu melahirkan dengan seksio sesaria yang mengalami kecemasan berat meningkat menjadi 6 orang, cemas sedang juga meningkat jurnal ners vol. 5 no. 2 oktober 2010: 138–146 144 menjadi 22 orang sedang cemas ringan menurun menjadi 2 orang. penurunan jumlah ibu melahirkan dengan seksio sesaria yang mengalami kecemasan ringan ini karena ibu menjadi cemas sedang dan cemas berat. hal ini terjadi karena pada kelompok ini ibu tidak mendapatkan " sayang bunda", sehingga kecemasan ibu saat pengukuran meningkat. demikian pula dengan peningkatan jumlah ibu yang mengalami kecemasan berat dan kecemasan sedang. rerata nilai kecemasan pada pengukuran pre dan post juga mengalami peningkatan yang bermakna. hasil uji statistik didapatkan nilai p value = 0,000 maka dapat disimpulkan ada perbedaan yang bermakna antara nilai kecemasan pada pengukuran pre dengan pengukuran post, rerata kecemasan pengukuran post lebih tinggi daripada pengukuran pre. jadi tingkat kecemasan kelompok kontrol meningkat secara bermakna pada saat akan dilakukan tindakan seksio sesaria. k e l o m p o k y a n g m e n d a p a t k a n pendidikan kesehatan berupa "sayang bunda" saat pengukuran pre didapatkan jumlah ibu melahirkan dengan seksio sesaria yang mengalami kecemasan ringan 2 orang, cemas sedang 27 orang dan cemas berat 1 orang, sedangkan pada pengukuran kedua jumlah ibu melahirkan dengan seksio sesaria yang mengalami kecemasan berat tidak ada, cemas sedang berkurang menjadi 26 orang sedang cemas ringan meningkat menjadi 4 orang. ibu melahirkan dengan seksio sesaria yang mengalami cemas sedang dan cemas berat jumlahnya berkurang menjadi cemas ringan karena pada ibu ini telah mendapatkan pendidikan kesehatan berupa "sayang b u n d a " , y a n g m a m p u m e n i n g k a t k a n pengetahuan ibu sehingga kecemasan ibu menurun. rerata nilai kecemasan pada pengukuran pre dan post juga mengalami penurunan yang bermakna. hasil uji statistik didapatkan nilai p value = 0,000 maka dapat disimpulkan ada perbedaan yang bermakna antara nilai kecemasan pada pengukuran pre dengan pengukuran post, rerata kecemasan pengukuran post lebih rendah daripada pengukuran pre. jadi tingkat kecemasan kelompok intervensi menurun secara bermakna pada saat akan dilakukan tindakan seksio sesaria. peningkatan kecemasan ibu melahirkan dengan seksio sesaria pada kelompok kontrol ini disebabkan oleh ketakutan dan ketidaktahuan ibu tentang pembedahan. pendapat dari hamilton (1995) menyatakan bahwa salah satu penyebab dari kecemasan pada persalinan adalah ketidaktahuan tentang proses persalinan dan cerita yang menakutkan tentang kehamilan dan persalinan. hal ini juga sesuai dengan penelitian yang dilakukan mubaidah (2002) bahwa ada hubungan bermakna antara tindakan pembedahan dengan kecemasan yang dialami klien. semakin dekat waktu pelaksanaan pembedahan akan meningkatkan kecemasan pada klien yang pembedahannya direncanakan. terutama pada klien yang tidak tahu tentang pembedahan yang akan dijalani. hasil penelitian yang mendukung pengaruh pendidikan kesehatan terhadap p e n i n g k a t a n p e n g e t a h u a n a d a l a h h a s i l penelitian dari setyowati (2004) tentang pengaruh pendidikan kesehatan perawatan ibu nifas (pk-pin) terhadap kemampuan merawat diri dan kepuasan ibu post partum di rs panti rapih yogyakarta. (p-value = 0,000). penelitian jatipuro (1998) tentang pengaruh pendidikan kesehatan dengan leafl et terdapat peningkatan pengetahuan secara bermakna (p value = 0,000). "sayang bunda" adalah salah satu bentuk pendidikan kesehatan yang diberikan pada ibu dengan seksio sesaria yang bertujuan untuk meningkatkan pengetahuan ibu tentang persalinan dengan seksio sesaria, diajarkan oleh perawat atau bidan yang sudah terlatih, sehingga dengan meningkatnya pengetahuan ibu maka kecemasan ibu pun akan menurun. pendidikan kesehatan berupa "sayang bunda" ini diberikan pada ibu yang akan menjalani seksio sesaria untuk menurunkan kecemasan ibu. karena berdasarkan pada konsep atau teori psikoneuroimunologi (pni), melalui poros hipotalamus hipofi sis adrenal, bahwa kecemasan pada klien yang akan menjalani seksio sesaria akan berpengaruh pada hipotalamus, kemudian hipotalamus akan memengaruhi hipofi se sehingga hipofi se akan mengekspresikan acth yang akhirnya penurunan kecemasan ibu menjelang seksio sesaria (dhiana setyorini) 145 akan memengaruhi kelenjar adrenal. kelenjar adrenal akan menghasilkan kortisol yang akan menekan sistem imun, semakin tinggi kecemasan seseorang maka semakin banyak kortisol yang diproduksi dan akan semakin rendah daya tahan tubuhnya. adanya penekan pada sistem imun inilah yang akan berdampak pada penghambatan proses penyembuhan. sehingga memerlukan waktu perawatan yang lebih lama dan bahkan akan mempercepat terjadinya komplikasi-komplikasi sekunder setelah pembedahan (putra dan nursalam 2005). respons kecemasan pada klien sebelum dilakukan pembedahan merupakan peningkatan kecemasan paling tinggi pada klien, hal ini disebabkan klien tidak mengerti alasan mengapa harus dioperasi dan klien memerlukan penjelasan lebih lanjut. kecemasan yang berlebihan dapat berdampak buruk pada klien di mana klien dapat memperlihatkan sikap bermusuhan, respons terhadap lingkungan menurun bahkan tidak ada sama sekali sehingga sulit diajak kerja sama dengan perawat dalam mempersiapkan tindakan yang akan dilakukan, berbeda dengan klien yang menerima informasi yang benar sebelum tindakan pembedahan dan efek sampingnya. pada klien yang sudah menerima informasi lebih dulu sebelum dilakukan tindakan pembedahan akan memperlihatkan sikap kerja sama dan lebih dapat melakukan perawatan sendiri (keliat 1998). hasil penelitian yang berhubungan d e n g a n m a n f a a t d i b e r i k a n p e n d i d i k a n kesehatan terhadap peningkatan pengetahuan setelah diberikan pendidikan kesehatan adalah penelitian yang dilakukan oleh halimatussakdiyah (2005) tentang efektivitas pemberian paket pendidikan kesehatan pre operasi seksio sesaria terhadap invulsio uterus di banda aceh (p-value = 0,000) dan penelitian dari wijayanti (2004) tentang efektivitas paket "senyum" terhadap tingkat kecemasan ibu primigravida dalam menghadapi persalinan (p-value = 0,008). simpulan dan saran simpulan pendidikan kesehatan pada ibu dengan seksio sesaria berupa "sayang bunda" dapat menurunkan kecemasan ibu sebelum menjalani seksio sesaria. bila ibu tidak cemas atau sedikit mengalami kecemasan sebelum seksio sesaria maka komplikasi yang dialami setelah seksio sesaria pun dapat diminimalkan. saran saran yang dapat peneliti berikan adalah pemberian paket "ibu terbukti efektif untuk menurunkan kecemasan pada ibu dengan seksio sesaria, sehingga bagi institusi pelayanan kesehatan terutama di bagian maternitas diharapkan menggunakan " sayang bunda" sebagai salah satu standar operasional prosedur pada ibu yang akan menjalani seksio sesaria, dan pendidikan kesehatan berupa "sayang bunda" ini dapat dijadikan bahan pelatihan bagi perawat atau bidan yang bertugas di bagian maternitas dalam memberikan asuhan keperawatan pada ibu dengan seksio sesaria. kepustakaan budiharjo, e., 1999. metodologi penelitian. jakarta: bagian ilmu kesehatan gigi masyarakat dan pencegahan, fkg-ui direktorat kesehatan jiwa depkes ri., 1994. perawatan pasien yang merupakan kasus-kasus psykiatri. jakarta. sakdiyah, 2005. efektivitas pemberian pendidikan kesehatan pre operasi sc terhadap involusi uteri. tesis tidak dipublikasikan. h a m i l t o n , p. m . , 1 9 9 5 . d a s a r d a s a r keperawatan maternitas. jakarta: egc. hawari, d., 2001. manajemen stres, cemas, dan depresi. jakarta: fakultas kedokteran universitas indonesia. j a t i p u r o , 1 9 9 8 . p e n g a r u h p e n d i d i k a n kesehatan dengan leaflet terhadap peningkatan pengetahuan. tesis. tidak dipublikasikan. jurnal ners vol. 5 no. 2 oktober 2010: 138–146 146 keliat, b., 1998. hubungan terapeutik perawatan dan pasien. jakarta: egc. maemonah, s., 2002. faktor-faktor yang memengaruhi kecemasan pada klien dengan pembedahan. tesis, tidak dipublikasikan. martius, g., 1997. bedah kebidanan martius, 12th ed. jakarta: egc. milne, j., hundley,.v., dan graham, w.j., 1999. an investigation of women's involvement in the decision and deliver by cesarian section. british journal of obstetric and gynaecology. mubaidah, s., 2002. studi tentang respons kecemasan klien operasi terhadap tindakan keperawatan di rsud pare. tidak dipublikasikan. notoatmodjo, s., 2003. metodologi penelitian kesehatan, jakarta: rineka cipta. old, london, dan ladewig, 2000. maternalnewborn nursing care: the nurse, the family, and the community, 4th ed. california: addison-wesly. phillips, c.e., 1996. family centered maternity and newborn care 4th ed. philadelphia: mosby. putra, s.t., 2005. psikoneuroimunologi kedokteran. surabaya: gramik fk unair-rsu dr. soetomo. sherris, j., 1999. sectio caesaria, (online), (http:/www.outlook.co.id., diakses tanggal 23 januari 2006). taylor, s., 1997. fundamental of nursing, the art and science of nursing care. 3rd ed. philadelphia: lippincot. wiknjosastro, h., 1992. ilmu kebidanan, jakarta: yayasan bina pustaka sarwono. wijayanti, l.a., 2004. efektiitas paket " s e n y u m " t e r h a d a p t i n g k a t kecemasan ibu primigravida dalam menghadapi persalinan, tesis tidak dipublikasikan. perry dan potter, 1997. clinical nursing skill an tehnigue: basic, intermediate, and advance. st louis: the cv mosby company. setyowati, t.t., 2004. pengaruh pendidikan kesehatan perawatan ibu nifas (pkpin) terhadap kemampuan merawat diri dan kepuasan ibu postpartum di rs panti rapih yogyakarta. tesis, tidak dipublikasikan. sumijatun, sulistyawati, payapo, t., maruhawa, j., dan sumartini, m., 2006. konsep dasar keperawatan maternitas. jakarta: egc wijayanti, l.a., 2004. efektivitas paket " s e n y u m " t e r h a d a p t i n g k a t kecemasan ibu primigavida dalam menghadapi persalinan. tesis, tidak dipublikasikan. vol 8 no 1 april 2013.indd 56 fungsi kemandirian pasien stroke dengan metode latihan “gait” (independence functions of stroke patients with "gait" exercise) marlina*, elly nurachmah** *staf pengajar program studi ilmu keperawatan, fakultas kedokteran universitas syiah kuala banda aceh. kode pos: 23111. e-mail: linanajwan@yahoo.co.id telp/hp: 08126914547 ** fakultas keperawatan universitas indonesia abstrak pendahuluan: stroke adalah penyakit pembuluh darah cerebro yang memiliki manifestasi klinis berdasarkan lokasi dan lesi rusak. gangguan aliran oksigen ke otak hasil manifestasi klinis disebut hemipharese atau kekurangan beberapa bagian ekstremitas yang ditunjukkan oleh defi siensi otot. pengaruh program latihan diperlukan dalam rangka untuk memulihkan kemampuan perawatan diri yang ditunjukkan oleh peningkatan kekuatan ekstremitas. tujuan dari penelitian ini adalah untuk menganalisis pengaruh latihan gait untuk perbaikan fungsi perawatan diri pasien di rumah sakit umum singli di kabupaten pidie nanggroe aceh darussalam. metode: sebuah eksperimen semu dengan design group pretest-postest digunakan dalam penelitian ini. tiga puluh empat pasien dipilih dengan menggunakan non probability sampling (berturut-turut teknigue sampling) sebagai sampel penelitian. empat belas hari dari program latihan kiprah diberikan kepada pasien. evaluasi terhadap hasil dari program ini dilakukan setelah empat belas hari dengan mengukur functional self perawatan mata pelajaran. hasil: analisis statistik menunjukkan bahwa rata-rata perawatan patiens functional self stroke secara signifi kan setelah pengobatan (p=0,000). ada hubungan antara pasien usia dan perawatan functional self (p=0,000) dan tidak ada hubungan antara seks dan perawatan diri fungsional (p=0,148). ada juga ada hubungan antara faktor risiko perawatan functional self (p=0,13). pembahasan: penelitian ini merekomendasikan penggunaan latihan untuk meningkatkan kiprah functional self perawatan pasien stroke dalam rangka meningkatkan kemampuan mereka untuk melakukan aktivitas hidup sehari-hari. kata kunci: latihan gait, fungsional self care, pasien stroke abstract introduction: stroke is a cerebro vascular disease which has clinical manifestation based on the location and the damaged lesion. the disorder of oxygen fl ow to the brain results clinical manifestation called hemipharese or the defi ciency of some parts of extremities which is indicated by the muscle defi ciency. effect of exercise gait program in needed in order to recover the strength functional self care of which is indicated by the improve strength extremitas. the aimed of this study was to analyze the effect of exercise gait to the improvement of functionalself care of the patients at sigli general hospital in kabupaten pidie nanggroe aceh darussalam. methods: a quasi experimental with pretest-postest group design was used in this study. thirty four patients were selected by using non probability sampling (consecutive sampling tehnigue) as the sample of the study. fourteen days of exercise gait program were given to the patient. an evaluation to the result of the program was conducted after fourteen days by measuring functional self care of the subjects. result: the statistical analysis showed that the average of the stroke patiensfunctional self care is signifi cantly after the treatment (p=0.000). there was a relationship between patients age and the functionalself care (p=0.000) and there was no relationship between sex and the functional self care (p=0.148). there was also no relationship between risk factor the functional self care (p=0.13). discussion: 57 fungsi kemandirian pasien stroke (marlina) this study recommended the use of exercise gait to improve functional self care of stroke patients in order to improve their ability to do daily living activities. keywords: exercise gait, functional self care, stroke patients angka kejadian stroke sebesar 63,52 per 100.000 penduduk pada kelompok usia di atas 65 tahun. secara kasar, terdapat dua orang mengalami serangan stroke setiap harinya di indonesia. berdasarkan hasil survey awal di badan pelayanan kesehatan rumah sakit umum (bpk rsu) sigli kabupaten pidie nanggroe aceh darussalam jumlah pasien yang dirawat dengan stroke dari bulan januari sampai dengan bulan desember 2007 mencapai 223 pasien stroke dan 126 dari kasus tersebut adalah pasien stroke iskemia dan 97 orang merupakan stroke hemoragik. penel it ia n chefez , et al. (20 01) menyimpulkan bahwa proses pemulihan pada pasien stroke tergantung dari usia pasien, faktor serangan, stroke berulang dan status sosial. demikian pula besarnya defi sit yang pertama kali menentukan ramalan keadaan stroke. pemulihan pasien stroke tidak saja dipengaruhi oleh dukungan psikososial dan lingkungan serta tempat dan bentuk latihan fi sioterapi, pemulihan juga dipengaruhi oleh motivasi pasien untuk menjadi mandiri dalam perawatan diri sendiri. pada fase pemulihan perawat harus segera melakukan latihan gait sebagai salah satu cara untuk mencegah kecacatan fi sik. latihan gait yang dilakukan secara baik akan berdampak pada fungsi kemandirian pasien dan mempunyai hasil perbaikan fungsional, sehingga akan meningkatkan kemampuan aktivitas sehari-hari pasien. namun demikian belum banyak penelitian tentang pengaruh latihan gait terhadap fungsi kemandirian beraktivitas pasien dengan stroke. berdasarkan uraian yang telah dikemukakan pada latar belakang penelitian, maka permasalahan penelitian adalah: pengaruh latihan gait terhadap fungsi kemandirian pasien dengan stroke di badan pelayanan kesehatan rumah sakit umum sigli kabupaten pidie nanggroe aceh darussalam. pendahuluan stroke adalah kerusakan fungsi saraf akibat kelainan vascular yang berlangsung lebih dari 24 jam atau kehilangan fungsi otak yang diakibatkan oleh berhentinya suplai darah ke bagian otak. sehingga mengakibatkan penghentian suplai darah ke otak, kehilangan sementara atau permanen gerakan, berpikir, memori, bicara atau sensasi (black, 2005). stroke merupakan penyakit perdarahan otak yang timbul secara mendadak dan dapat mengakibatkan terganggunya fungsi otak. kejadian st roke yang lebih berat mengakibatkan kematian sebagian sel-sel otak sehingga dapat menyebabkan kelumpuhan sebelah anggota gerak. stroke juga merupakan yang datang dan dapat terjadi pada siapa pun secara mendadak dan tiba-tiba. secara teor i di kat akan bila seseorang per nah mengalami stroke serangan yang pertama, maka berisiko untuk mengalami serangan stroke kedua bahkan stroke selanjutnya, bila penatalaksanaan stroke pertama tidak maksimal (hickey, 2005). st roke mer upa kan masalah saraf kesehatan utama di dunia, meskipun upaya pencegahan telah menimbulkan penurunan pada insiden dalam beberapa tahun terakhir, stroke merupakan peringkat ketiga penyebab kematian, dengan prevalensi mortalitas 18% sampai 37% untuk stroke serangan pertama dan sebesar 62% untuk stroke ber ulang. terdapat kira–kira 2 juta orang bertahan hidup dari stroke yang mempunyai beberapa kecacatan, dari angka ini, 40% memerlukan bantuan dalam aktivitas kehidupan sehari-hari (smeltzer & bare, 2004). menurut ketua harian yayasan stroke indonesia (yastroki), sejauh ini stroke masih merupakan penyebab kematian pertama di rumah sakit di indonesia dan sebagai penyebab kecacatan terbanyak pada kelompok usia dewasa. data dasar rumah sakit mencatat 58 jurnal ners vol. 8 no. 1 april 2013: 56–63 pe n el it i a n i n i b e r t uj u a n u nt u k mengetahui pengaruh latihan gait terhadap fungsi kemandirian pasien dengan stroke di badan pelayanan kesehatan rumah sakit umum sigli kabupaten pidie nanggroe aceh darussalam (bpk rsu sigli kabupaten pidie nad). bahan dan metode penelitian ini menggunakan quasi eksperiment dengan desain pretest-postest group design. sumber data adalah data primer yang didapat dari hasil pengisian format pengkajian dan nilai kemandirian berdasarkan skala bartel indeks. jumlah sampel 34 responden (pasien stroke iskemia). pengambilan sampel secara non probability sampling, dengan jenis consecutive sampling, yait u mengambil selu r u h sampel yang memenuhi kriteria inklusi dan eksklusi selama penelitian berlangsung. pasien bersedia ikut dalam penelitian ini dan menandatangani informed consent, tingkat kesadaran compos mentis dengan kontak yang adekuat dan pasien mengalami hemiparese. instrumen yang digunakan dalam penelitian ini adalah format pengkajian, format observasi dan pelaksanaan latihan gait dan format evaluasi bartel indeks. pada penelitian ini, peneliti melakukan 3 tahapan pelaksanaan penelitian yang meliputi: 1) tahap persiapan (administrasi), di mana pada tahapan ini peneliti meminta persetujuan pembimbing untuk melakukan penelitian di ruang rawat inap saraf bpk rsu sigli kabupaten pidie di nanggroe aceh dar ussalam dan mengajukan surat izin melakukan penelitian dari universitas indonesia ditujukan kepada direktur bpk rsu sigli kabupaten pidie di nanggroe aceh darussalam; 2) tahap pelaksanaan (pengkajian dan observasi), pada tahapan ini peneliti dibantu oleh kolektor data dari perawat dengan dasar pendidikan d3 keperawatan dan untuk menyamakan persepsi latihan gait yang akan diberikan pada pasien stroke, peneliti melatih 3 (tiga) orang kolektor data tersebut. pada tahapan ini, peneliti memastikan bahwa responden adalah pasien terdiagnosis stroke iskemia; mencocokkan pasien sesuai dengan kriteria yang masuk dalam penelitian ini; menyampaikan tujuan penelitian kepada pasien sebagai responden; memberikan formulir informed consent dan meminta tanda tangan bila bersedia mengikuti penelitian; mencatat data responden sesuai tujuan penelitian. kegiatan dilanjutkan dengan menilai fungsi kemandir ian pasien sebelum dilak u kan latihan gait oleh peneliti dan kolektor data. kolektor data mengobservasi pasien, selama 2×24 jam untuk melihat kestabilan tanda vital (tekanan darah, nadi, pernapasan dan suhu); menilai status neurologi (tingkat kesadaran dan kekuatan otot). jika terjadi perubahan tekanan darah lebih dari 20 mmhg, latihan gait tidak dilakukan kemudian peneliti dan kolektor data melakukan observasi ulang; dan 3) tahap pelaksanaan (intervensi), di mana peneliti bersama kolektor data menyiapkan pelaksanaan latihan gait, melakukan intervensi latihan gait selama empat belas hari dan menilai fungsi kemandirian pasien sesudah dilakukan latihan gait. semua data yang telah dikumpulkan kemudian dilakukan pengolahan data dan dianalisis secara statistik dengan menggunakan analisis statistik univariat dan bivariat yaitu dengan menggunakan independent sample test ( pooled t-test), paired t-test, pearson colleration dan uji anova one waytest. pada penelitian ini menggunakan derajat kemaknaan 95% atau alpha 0,05 (hastono, 2007). hasil penelitian ini dilaksanakan di bpk rsu sigli kabupaten pidie nad dimulai tanggal 24 maret sampai dengan 26 mei 2008. karakteristik responden berdasarkan usia menunjukkan bahwa rerata usia responden adalah 58 tahun dengan standar deviasi 5,29 tahun, umur tertua adalah 65 tahun dan umur termuda adalah 45 tahun. distribusi frekuensi responden berdasarkan jenis kelamin adalah perempuan sebanyak 18 orang (52,9%) dan laki-laki sebanyak 16 orang (47,1%); sedangkan berdasarkan faktor risiko diperoleh data bahwa responden dengan faktor risiko hipertensi sebanyak 25 orang (73,5%), sisanya penyakit 59 fungsi kemandirian pasien stroke (marlina) jantung 5 orang (14,7%) dan diabetes melitus 4 orang (11,8%). dist r ibusi responden berdasarkan nilai fungsi kemandirian dapat dilihat pada tabel 3, sedangkan hasil analisis nilai fungsi kemandirian sebelum dan sesudah intervensi dapat dilihat pada tabel 4. hasil analisis statistik menunjukkan bahwa rerata selisih nilai kemandirian pasien setelah diberikan intervensi adalah 6,26 dengan standar deviasi 3,36. hasil uji statistik didapatkan p=0,000 (α=0,05) dengan demikian dapat disimpulkan bahwa ada pengaruh yang bermakna latihan gait terhadap peningkatan kemandirian pasien dengan stroke di bpk rsu sigli kabupaten pidie nad. hasil analisis lain dengan menggunakan pearson correlation menunjuk kan nilai kolerasi -0,388 artinya ada hubungan antara umur dengan peningkatan kemandir ian semakin tua usia pasien semakin rendah nilai kemandirian dan hasil uji statistik didapatkan p=0,023 (α=0,05) dengan demikian dapat disimpulkan bahwa terdapat hubungan yang bermakna antara umur dengan peningkatan kemandirian. hasil analisis rerata peningkatan kemandirian pasien stroke yang telah mendapat intervensi pada jenis kelamin laki-laki yaitu 5,38 dengan standar deviasi 3,32 sedangkan rata-rata peningkatan kemandirian pasien stroke yang telah mendapatkan intervensi pada jenis kelamin perempuan yaitu 7,05 dengan standar deviasi 3,28 dan hasil uji statistik didapatkan p=0,148 (α=0,05) dengan demikian dapat disimpulkan bahwa tidak terdapat pengaruh yang bermakna antara rerata nilai kemandirian pasien stroke dengan jenis kelamin. hasil analisis pada rerata peningkatan kemandirian pasien stroke yang telah mendapat intervensi yang paling banyak adalah dengan faktor risiko hipertensi yaitu 6,88 dengan standar deviasi 3,42 dan hasil uji statistik didapatkan p=0,13 (α=0,05) dengan demikian dapat disimpulkan bahwa tidak ada pengaruh yang bermakna antara rata-rata nilai kemandirian pasien stroke dengan faktor risiko penyakit. tabel 1. distribusi responden berdasarkan usia pasien stroke variabel mean median sd min-max 95% ci umur 58 60 5,29 45,00–65,00 56,89–60,58 tabel 2. distribusi frekuensi responden berdasarkan jenis kelamin pasien stroke variabel frekuensi persentase (%) jenis kelamin laki-laki perempuan 16 18 47,1 52,9 tabel 3. distribusi frekuensi responden berdasarkan faktor risiko pasien stroke variabel frekuensi persentase (%) faktor risiko hipertensi diabetes melitus penyakit jantung 25 4 5 73,5 11,8 14,7 tabel 4. distribusi responden berdasarkan fungsi kemandirian sebelum dan sesudah intervensi no. variabel mean sd min-max 95% ci 1 sebelum intervensi 1,02 1,68 0,00–9,00 0,44–1,62 2 sesudah intervensi 7,29 3,54 2,00–15,00 6,06–8,53 60 jurnal ners vol. 8 no. 1 april 2013: 56–63 pembahasan hasil analisis statistik menunjukkan bahwa nilai kemandir ian pasien st roke meningkat sesudah dilakukan latihan. hal ini pun menunjukkan bahwa intervensi yang telah diberikan dapat diterima oleh pasien stroke di bpk rsu sigli kabupaten pidie naggroe aceh darussalam sehingga pasien dapat meningkatkan nilai kemandiriannya. hasil penelitian yang dilakukan oleh chefez, et al. (2001) mengemukakan bahwa latihan gait merupakan intervensi yang sangat berpengaruh terhadap fungsi kemandirian pasien. hal ini terjadi karena dengan latihan ini pasien dapat mengembalikan kemampuan untuk duduk, berdiri. latihan berjalan bisa melatih distribusi berat badan pada kedua tungkai, sekaligus melatih keseimbangan dalam berbagai posisi. pada pasien stroke sebagian besar akan mengalami kecacatan, terutama pada kelompok usia diatas 45 tahun (black, 2005). manifestasi klinis biasanya terjadi kelumpuhan yang mendadak pada salah satu sisi tubuh, hal tersebut diakibatkan oleh lesi (pembuluh darah yang tersumbat) yang secara khusus dapat mengenai sisi kontra lateral dari tubuh. derajat kelainan akibat lesi berbeda satu pasien dengan pasien lainnya, tergantung dari lokasi dan luas lesi yang akan tampak pada disfungsi motorik. komplek nya pe r ma sala ha n ya ng muncul pada pasien stroke, sehingga perlu penanganan yang segera, tepat, teliti dan penuh kesabaran dan melibatkan kerja sama antar disiplin ilmu seperti dokter, physiotherapist, speech therapist, occupational therapist juga termasuk keterlibatan keluarga pasien (warlow, 2001). penanganan yang cepat, tepat dan adekuat diharapkan akan mempercepat penyembuhan serta dapat memperkecil risiko kecacatan fi sik dan komplikasi lainnya yang akan timbul. per masalahan yang sering ditemui dapat berupa kelemahan pada anggota gerak yang berakibat berkurangnya kemampuan fungsional motorik, namun dengan latihan gait berupa latihan mobilisasi dini/preambulasi, s i t t i n g b a l a n c e , s t a n d i n g b a l a n c e , memakai kruk, walker dan tongkat maka diharapkan pasien dapat meningkatkan nilai kemandiriannya serta dapat meningkatkan kemampuan fungsional motorik (hickey, 2003; smeltzer & bare, 2004) pelaksanaan latihan gait pada pasien stroke secara intens, terarah dan teratur, maka dapat memengaruhi kemampuan motorik pasien untuk meningkatkan kemandirian. setelah latihan ini dilakukan maka pasien dapat melakukan aktivitas sehari-hari sehingga pasien pulang tidak lagi ketergantungan pada perawat maupun keluarga ataupun orang lain. hasil penelitian ini menunjukkan bahwa intervensi yang telah diberikan pada pasien stroke disertai dengan latihan gait berpengaruh terhadap peningkatan kemandirian. dengan demikian dapat disimpulkan bahwa terdapat pengaruh latihan gait terhadap peningkatan kemandirian pasien dengan stroke di bpk rsu sigli kabupaten pidie nad. hal ini terjadi karena intervensi yang diberikan sesuai dengan landasan teori dan latihan diberikan dengan intensitas yang teratur dan tepat. rentang umur pasien stroke 45– 65 tahun sebagai responden dalam penelitian ini sebanyak 34 orang. hal ini sesuai dengan perkiraan depkes bahwa mayoritas angka kejadian stroke terjadi pada usia diatas 40 tahun, demikian pula menurut lumban tobing (2004) yang mengatakan angka kejadian stroke meningkat seiring dengan bertambahnya usia seseorang. menurut who (2004) dalam suhardi (2005) pasien stroke lanjut usia sangat terbatas dalam upaya pemulihan fungsional, hal ini disebabkan keadaan mental dan adaptasi, selain tabel 5. analisis peningkatan kemandirian sebelum dan sesudah intervensi variabel mean sd p nilai kemandirian sebelum dan sesudah intervensi 6,26 3,36 0,000 61 fungsi kemandirian pasien stroke (marlina) itu pemulihan pasien stroke akan lebih cepat terjadi pada usia muda dibandingkan usia lanjut yang mengalami defi sit lebih berat namun tidak semua pasien stroke mempunyai manifestasi klinis yang sama tergantung dari lokasi dan luasnya lesi yang terkena. pada pasien lanjut usia kelenturan otot-otot sudah berkurang dibandingkan pada usia muda, usia lanjut sulit beradaptasi pada saat latihan, kadang-kadang juga kurang kooperatif. selain itu pasien usia lanjut sudah kurang memperhatikan penampilan diri, sehingga bila hendak dilakukan suatu t i nd a k a n h a r u s d i la k u k a n hu bu ng a n interpersonal yang intens. h a si l p e n el it i a n s m it h (2 0 01), menjelaskan bahwa pemulihan pada pasien stroke lanjut usia sangat terbatas, hal ini berhubungan dengan keadaan mental dan adaptasi. biasanya pemulihan pada pasien stroke usia muda lebih cepat karena usia muda lebih cepat beradaptasi. penelitian smith memiliki hasil yang sama dengan penelitian di bpk rsu sigli kabupaten pidie nad semakin tua umur seseorang yang terkena stroke maka semakin sulit pasien untuk beradaptasi terhadap latihan. hasil penelitian ini menunjukkan bahwa terdapat hubungan yang bermakna antara umur dengan peningkatan kemandirian pasien dan dapat disimpulkan bahwa semakin tua usia pasien stroke maka semakin rendah nilai kemandiriannya. hasil penelitian ini pun menunjukkan bahwa ada pengaruh umur terhadap peningkatan kemandirian pasien dengan stroke di bpk rsu sigli kabupaten pidie nad. hasil penelitian yang dilakukan pada bulan maret sampai dengan bulan mei 2008 di bpk rsu sigli kabupaten pidie nanggroe aceh dar ussalam menu nju k kan bahwa kejadian stroke pada jenis kelamin perempuan lebih tinggi dibandingkan jenis kelamin lakilaki. angka kejadian stroke pada kelompok perempuan ini meningkat karena pada kelompok perempuan terdapat responden yang memiliki riwayat beberapa penyakit seperti hipertensi, diabetes melitus dan penyakit jantung yang sebenarnya dapat dicegah dengan olah raga teratur (black, 2005). penelitian chefez et al. (2001) yang mengatakan bahwa risiko jenis kelamin lakilaki berpengaruh terhadap kejadian stroke. hal ini dilihat dari gaya hidup laki-laki yang banyak merokok, minum alkohol, sehingga dapat merusak pembuluh darah. pada penelitian ini yang menunjukkan bahwa angka kejadian stroke lebih tinggi pada perempuan menurut peneliti lebih disebabkan karena perempuan biasanya lebih banyak mengerjakan pekerjaan rumah tangga dan jarang melakukan perilaku gaya hidup seperti merokok dan minum alkohol, sehingga meskipun angka kejadian tinggi namun pada perempuan memiliki kemampuan dalam peningkatan kemandirian yang lebih baik. berdasarkan hasil analisis statistik dapat disimpulkan bahwa hasil penelitian ini menunjukkan bahwa tidak terdapat pengaruh yang bermakna antara jenis kelamin dengan peningkatan nilai kemandirian pada pasien stroke. hasil penelitian ini menunju k kan bahwa tidak ada pengaruh yang bermakna antara faktor risiko terjadinya stroke dengan peningkatan nilai kemandirian. pada penelitian ini responden yang paling tinggi peningkatan nilai kemandirian adalah responden yang dengan faktor risiko hipertensi. faktor risiko terjadinya stroke dibagi menjadi dua bagian, yaitu faktor risiko yang dapat dikontrol dan faktor risiko yang tidak dapat dikontrol. faktor risiko yang tidak dapat dikontrol adalah umur, jenis kelamin dan ras atau etnik; sedangkan faktor risiko yang dapat dikontrol adalah hipertensi, diabetes melitus, penyakit jantung dan hiperlipidemia serta pola hidup seperti perokok, peminum alkohol serta kegemukan (smeltzer & bare, 2004). menurut hasil penelitian misbach & ali (2002) menyebutkan bahwa faktor risiko stroke turut berperan serta dalam proses pemulihan, karena faktor risiko yang tidak terkontrol akan menyebabkan komplikasi sehingga dapat menghambat program rehabilitasi. faktor risiko utama stroke dapat berupa hipertensi dan penyakit jant u ng yang akan dapat menimbulkan komplikasi seperti pembesaran jantung kiri, infark miocard dan insufi siensi ginjal keadaan tersebut akan menyebabkan kemampuan pasien stroke untuk berlatih berkurang dan menghambat pemulihan. 62 jurnal ners vol. 8 no. 1 april 2013: 56–63 ba nya k ca r a u nt u k meng h i nd a r i terjadinya serangan stroke, salah satunya denga n ca ra men i ng kat ka n kebuga ra n jasmani, mengendalikan faktor risiko stroke dan menghindari konsumsi lemak ser ta merokok yang berlebihan, karena seseorang yang memiliki kebugaran jasmani yang baik relatif kecil terkena stroke dan terjaga kebugaran jantung dan paru-paru serta dapat mempertahankan kelenturan otot dan berat badan yang seimbang. hasil penelitian ini menunju k kan bahwa tidak terdapat pengar uh latihan terhadap peningkatan kemandirian. hal ini dapat terlihat bahwa rerata responden dengan riwayat hipertensi memiliki nilai kemandirian lebih tinggi dibandingkan dengan responden yang memiliki riwayat diabetes melitus dan penyakit jantung. faktor risiko hipertensi lebih toleran terhadap latihan dibandingkan penyakit jantung yang harus lebih banyak istirahat untuk mencegah komplikasi. simpulan dan saran simpulan simpulan dari penelitian ini yaitu penelitian ini telah mengidentifi kasi beberapa karakteristik dari 34 responden yang meliputi usia responden berada antara 45–65 tahun, jenis kelamin terbanyak pada penelitian ini adalah: 1) kelompok jenis kelamin perempuan dan faktor risiko terbanyak pada penelitian ini adalah faktor risiko hipertensi; 2) rerata nilai kemandirian pasien stroke berbeda yang berarti bermakna antara nilai kemandirian sebelum diberikan intervensi dengan nilai kemandirian sesudah diberikan intervensi yang artinya bahwa latihan gait dapat meningkatkan nilai kemandirian pada pasien stroke; 3) terdapat pengaruh antara usia dengan peningkatan nilai kemandirian pasien stroke sebelum dan sesudah latihan yang berarti semakin tinggi usia pasien stroke maka semakin rendah nilai kemandirian; 4) tidak terdapat pengar uh antara jenis kelamin dengan peningkatan nilai kemandirian pasien stroke sebelum dan sesudah dilakukan latihan gait; dan 5) tidak terdapat pengaruh antara faktor risiko dengan peningkatan nilai kemandirian pada pasien stroke sebelum dan sesudah dilakukan latihan gait. saran peneliti menyarankan kepada pihak r u mah sa k it at au pengelola pelayanan kesehatan: 1) perlu mengadakan pelatihan tenaga keperawatan dan 2) menjelaskan discharge planning yang berkaitan dengan latihan gait pada pasien stroke. kepustakaan black, jm., 2005. medical surgical nursing, clinikal management for positive outcome 7th, philadelphia: mosby inc., hal. 2093–2097. chefez, ba., dickstein, r., laufer, y. & marcovitz, e., 2001. journal of rehabilitationresearch& development, (online), (http://www.rehab.research. va.gov/jou r/01/38/1/pdf /laufer.pdf., diakses pada tanggal 2 januari 2008, jam 09.00 wib). dochterman, jm. and bulechek, gm., 2004. nursing intervention classif ication (nic) 4th edition. philadelphia: mosby inc. gleadle, j., 2007. anamnesis dan pemeriksaan fi sik. air langga. surabaya. hastono, sp., 2007. analisis data kesehatan, jakarta: fakultas kesehatan masyarakat universitas indonesia. hickey and hock, 2003. stroke and other cerebrovascular disease, dalam hickey, j.. 2003. the clinical practice of neurological and neurosurgical nursing, 5th edition. philadelphia: lippincott williams and wilkins. hickey, jv., 2003. the clinical practice of neurological and neurosurgical nursing, 5th edition. philadelphia: lippincott williams and wilkins. lumbantobing, sm., 2004. neurologi klinik pemeriksaan fisik dan mental, jakarta: balai penerbit fk m un iver sit a s indonesia. misbach, j., 2003. stroke: aspek diagnostik, patofi siologi dan manajemen. jakarta: balai penerbit fakultas kedokteran universitas indonesia. 63 fungsi kemandirian pasien stroke (marlina) moorhead, s., jhonson, m. and maas, m., 2004. nursing outcomes classifi cation (noc) 4th edition. philadelphia: mosby inc. smith, hauser and easton, 2001. disease of central nervous system, dalam braunwald et al. (eds). harrisons principles of internal medicine, 15th edition. new york: mcg raw-hill companies inc. smeltzer, sc. and bare, bc., 2004. medical s u r g i c a l n u r s i n g, 7 t h e d i t i o n , philadelphia: mosby inc. suhardi, 2005. profil insan paska stroke, (online), 2. (http://www.yastroki.or.id/ read. php?id=86 diakses pada tanggal 22 januari 2008, jam 10.00 wib). warlow, ms., 2001. a practical guide to management, 2nd edition. london: blackwell science ltd. oxford. http://e-journal.unair.ac.id/jners 131 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 131-144 http://dx.doi.org/10.20473/jn.v18i2.44630 original article open access exploring children’s condition of adolescent mothers in east kalimantan indonesia: an ethnography study tri wahyuni 1,2 * and somporn rungreangkulkij 2 1 faculty of nursing, universitas muhammadiyah of east kalimantan, samarinda indonesia 2 faculty of nursing, khon kaen university, muang, thailand *correspondence: tri wahyuni. address: faculty of nursing, universitas muhammadiyah of east kalimantan, samarinda indonesia. email: tw879@umkt.ac.id responsible editor: rizki fitryasari received: 4 april 2023○ revised: 20 june 2023 ○ accepted: 20 june 2023 abstract introduction: children born to adolescent mothers tend to experience problems in health, growth, and development, also social problems. these problems persist and worsen due to various factors such as a pandemic, deteriorating economic conditions, and people’s readiness to become parents. it is associated with the unpreparedness of adolescent mothers to face the dual roles carried out as mothers and adolescents themselves. the study aims to explore and describe children’s condition of adolescent mothers during their motherhood in the community. methods: this is an ethnography study which involves adolescent mothers in two public health centers in samarinda, east kalimantan. twenty participants aged between 13 to 19 years old, and who had children were gained by purposive sampling. data were collected using in-depth interviews, observation, and field notes to explore behaviors, beliefs, values, and perceptions of adolescent mothers about children’s health status. data saturation was accomplished and analyzed with content analysis. results: the result revealed 3 themes about children’s conditions of adolescent mothers in the community which involve: 1) children’s health status, 2) children’s breastfeeding status, and 3) children’s immunization status. conclusions: many of their children have health problems at birth related to health problems during pregnancy. the low coverage of exclusive breastfeeding and basic immunization is caused by low support from families, inconsistent cultural beliefs, incomplete information, and the conditions of the covid-19 pandemic. being stigmatized as adolescent mothers caused them to lack regular check-ups on their children. keywords: children’s health status, adolescent mothers, qualitative, breastfeeding, basic immunization introduction poor maternal and child health (mnch) is considered a global public health burden (sobhy et al., 2019). in 2019, an estimated 5.2 million children under five years died from mostly preventable or treatable causes, while children aged 1 to 11 months accounted for 1.5 million (world health organization, 2020). in indonesia, the estimated number of deaths of children under the age of 5 in 2021 is 22.17 per 1000 live births (un igme, 2023). the causes of their death include respiratory infection, diarrheal disease, measles, malaria, malnutrition, and newborn condition (world health organization, 2023). in line with prior study, the vital development of a child starts after conception until two years of age (bradley et al., 2022), while other scholars have stated neurodevelopmental outcomes suggest a slightly broader window extending to three years (cusick and georgieff, 2016; erny, prasetyo and soekanto, 2022). https://creativecommons.org/licenses/by/4.0/ mailto:tw879@umkt.ac.id https://orcid.org/0000-0002-8513-2322 https://orcid.org/0000-0001-9307-9237 supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 132 in the middle of 2019, adolescent population was 17.2% and the population of adolescent females was 8.3% (worldometer, 2019). indonesia ranked fourth in adolescent birth rate in southeast asia region (world bank, 2020), and 1 in 9 girls married before they were 18 years old (bps, bappenas and unicef, 2020). this condition occurs in almost all provinces in indonesia. east kalimantan is province that is a red zone for adolescent marriage, that means prevalence of child marriage is higher than in the national case, with prevalence of adolescent marriage 31.13% (bps, 2016). adolescent mothers are a vulnerable group compared to adult mothers, and become major global health and social problems (oyeyemi et al., 2019). this is because their physical and mental conditions are not ready to undergo pregnancy, childbirth, and become a mother, increasing the risk for medical, psychological, developmental, and social problems (pinzon and jones, 2012). getting pregnant at an adolescent age is a stigma, making them isolated and not doing antenatal care (sriyasak, åkerlind and akhavan, 2013; govender, naidoo and taylor, 2020). this is the beginning of child health problems because children's health is determined from the prenatal period (pem, 2015; schwarzenberg and georgieff, 2018). likewise, when children of adolescent mothers experience illness or have to monitor their growth and development, adolescent mothers tend not to bring their children to health facilities because they are often treated impolitely and verbally abused (sriyasak, åkerlind and akhavan, 2013; govender, naidoo and taylor, 2020). children's physical and mental health will determine how they become adults in the future. this condition is influenced by the readiness of adolescents to be the parents, included their health during pregnancy. even though there have been government regulations regarding welfare, education, and health insurance for citizens in indonesia (minister of law and human rights, 2008; 2020; yusriadi, 2019), adolescent mothers and their children are all a problem. according to prior study, they are relatively untouched by the government and come from disadvantaged groups (gurung et al., 2020). the unregistered marital status (sirri marriage) is also an obstacle for adolescent mothers because they feel insecure, embarrassed, and afraid of meeting new people, thus neglecting their child's health needs (oyeyemi et al., 2019). in addition, children born from sirri marriages have constraint to access welfare insurance from the government, children do not get their full rights, and there are inheritance problems, and population administrative problems (ministry of women’s empowerment and child protection, 2015). children are born with a readiness to learn anything around them. to be able to learn well, they need good nutrition, even when they are still in the womb (erny, prasetyo and soekanto, 2022; likhar and patil, 2022; nahak, fouk and esperanca, 2022). children who have a good start will become healthier adults which results in better social, economic, physical, and cognition status (pem, 2015). the effects of failure to provide adequate essential nutrition during the first 1000 days of life can result in increased expenses later in life in the form of medical care, psychiatric and psychological care, remedial education, lost wages, and behavior management (schwarzenberg and georgieff, 2018). fulfillment of adequate nutritional needs makes them live better lives for their families and communities and promotes the country's gross national happiness (pem, 2015). however, mistakes in providing nutrition to children will make children experience digestive disorders, be prone to allergies and experience growth and development disorders. many pregnant adolescents experience chronic energy deficiency and anemia in indonesia caused by a lack of energy in the long term, closely related to knowledge of nutritious food, age, employment status, and previous poor nutritional status (wiyono et al., 2020). at the research site there are still some beliefs and cultures that endanger children's health, which are believed by adolescent mothers and their families, such as giving young coconuts that are still clear to make the baby's digestive system good. they believe that breastfeeding for two years is good for babies, but babies must also be immediately given complementary foods in the form of young coconut, a mixture of bananas and soft rice so that the child's nutritional needs are met and can grow healthy. in line with previous study in rural indonesia, mothers in indonesia understand the importance of breastfeeding for their children, but still provide complementary food from the start because they believe that giving food to babies faster is better, and there is the influence of other mothers in their environment who also provide complementary food earlier (anggraeni et al., 2022). the babies require just breast milk for the first six months of life (likhar and patil, 2022), because breast milk contains nutrients, growth factors, and cells important for brain development that formula does not (schwarzenberg and georgieff, 2018). exclusive breastfeeding, adequate complementary feeding, stimulation, a safe environment, and care are necessary to ensure optimal physical, mental, social, and cognitive development and to prevent adverse impacts on shortterm survival and long-term health and development (pem, 2015), and also play a crucial role in wahyuni and rungreangkulkij(2023) jurnal ners 133 p-issn: 1858-3598  e-issn: 2502-5791 neurodevelopment (schwarzenberg and georgieff, 2018). the unpreparedness of adolescents to become mothers affects their response in meeting the nutritional needs of their children (govender, naidoo and taylor, 2020). lack of knowledge and information about infant and child care, makes them less likely to have the courage to make decisions about their child's health (sriyasak, åkerlind and akhavan, 2013). adolescent mothers will follow the advice and suggestions of their parents (erfina et al., 2019). the problem is that not all suggestions from parents are health-wise, but based on experience, culture, and beliefs that have been passed down from their ancestors. one of the beliefs that they carry from their origins is refusing to immunize children, because they believe it will make children sick, and, according to them, this condition has proven that their children are healthy without immunizations, in line with prior study that parents rejected to immunize their child for health consent due to being contrary to belief and religion, and mistrust of the government (syiroj, pardosi and heywood, 2019). the study aimed to explore and describe children’s condition of adolescent mothers during their motherhood using an ethnography approach. although in previous studies there has been research on the condition of children, information about the condition of children of teenage mothers is very limited, so this research needs to be carried out, so that they get specific support from family, government and other related parties. materials and methods design this is qualitative research using postmodern philosophy, that emphasizes there is no absolute truth and knowledge is relative (dickens and fontana, 2015) with an ethnographic approach that focuses on the way of life, different factors, and conditions related to the occurrence of each phenomenon which depends on the context of child health condition of adolescent mothers. following sardar and loon (1998), it explored child health’s condition among adolescent mothers group, including personal relationship within the group, preconception, and their ethnicity. this approach was considered an appropriate method because the study aims to explore and describe children’s condition of adolescent mothers in their life span. after all, culture is a complex whole that includes knowledge, belief, art, morals, law, customs, and other capabilities and habits acquired by man as a member of society (sardar and loon, 1998). this research provides valuable information about the health conditions of adolescent mothers' children based on their culture. setting a total of 42 participants attended the four focus groups. the dhb group included the deputy district chief, the chief executive of subdistrict administrative organization. population the population in this study was adolescent mothers aged between 13 and 19 years old, who had children. the sample was adolescent mothers who had children under 5 years of age as inclusion criteria. purposive sampling was used to recruit participants from the work area of the samarinda municipality health office. the researcher was accompanied by cadres to visit the participants, after obtaining permission from the head village, the researcher met the head to of the neighborhood association to inform him if he was going to visit his residents, by showing a research permit from the public health center. recruitment of participants ceased when the data obtained saturation, that means the researcher began to hear the same answer again and again, resulting in 20 participants. data collection this study used three ways of data collection methods: observation, in-depth interview, and field note. the observation was carried out as a grand tour, which was carried out before the in-depth interviews were conducted, such as when adolescent mothers interact with their children such as feeding, breastfeeding, bathing, playing, and stimulating. researchers also observed how adolescent mothers and their children interacted with their husband, family, healthcare provider, and people around them. field notes from observations were written. after observing the environment where the participants live, the researcher conducted in-depth interviews using semistructured questions formulated by researchers, as the interview guide served only as the stimulating or triggering of questions. trigger questions have been consulted with the experts (advisors), and proven relevant to the research aims. during the in-depthinterviews, the questions flowed following the conversation between the key informant and the researcher. the questions focused to explore and understand their child health status at birth and nowadays, how they breastfeed, and their child’s basic immunization status. the first author conducted all interviews, and all were interviewed individually in supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 134 bahasa (indonesian language). the trigger questions are mentioned in table 1. the study was conducted from march 2, 2021 to december 2021 and comprised of participant observation (march 15, 2021 to august 31, 2021), and in-depth interviews from 26 april to 15 december, 2021. eleven of the participants were informed the study aims and the study designs, nine of the 20 participants were aged less than 18 years old (45%), seven of the nine participants lived with their parent from whom the researcher asked permission, and two of the participants lived with the guardians, and researcher telephoned the participant’s parent to ask permission. the in-depth interviews lasted about 45 – 60 minutes for each key informant, and were conducted at places as per the participants’ preference, such as their houses or a room at public health center. types of question used for interview were general question, specific question and other questions which were related to the research questions. in order to obtain an adequate information suiting the research question, sometimes the researcher carried out in-depth-interviews to the same key informant up to 2 to 3 times depending on the needs and the adequacy of information needed until the data reached saturation, first time by face-to-face, the second and the third by using a video call, due to increasing covid-19 cases. observations and field notes were used to complete the data from in-depth interviews, and stopped when the data were saturated. data analysis in this study, the researcher followed the analysis data process of ethnography study, according to gerrish and lacey (2010) in seven steps: 1) bringing order to the data and organizing the material with transcripts of data case-by-case from field notes of participant observation, and the recording of in-depth interviews; 2) reading and re-reading about the data, 3) coding the data; 4) summarizing and reducing the codes to larger data; 5) searching for patterns and regularities in the data, sorting and recognizing themes; 6) uncovering variations in the data and revealing those cases that do not fit with the rest of the data, and accounting for them; 7) engaging with, and integrating, the related literature. this all consisted of themes, sub-themes, data supported from participant observation, in-depth interview, and the literature related to those themes and sub-themes the first researcher conducted initial data analysis, and this was discussed with another researcher (advisor, who has expertise in qualitative research in mental health and women health), enabling interaction and understanding to allow themes and categories to emerge. all findings were cross-checked to enhance the table 1 list of questions for participants in in-depth interview no list of questions 1 could you tell me about your child’s condition after birth? how was his or her health condition? 2 how is her/his current health condition?? 3 do you give her/him breastmilk? how many months did you give her/him breastfeeding only, without any complementary food? 4 could you tell me why you gave him/her complementary food earlier? 5 what do you think about the immunization for babies? table 2 descriptive summary of participants and their children participant age (years) number of children child’s age (month) child’s sex birth weight (gram) birth complications health status now exclusive breastfeeding basic immunization (as their age) 1 19 2 4 girl 1600 lbw, asphyxia malnutrition, allergic no incomplete 4 girl 1750 lbw, asphyxia malnutrition no incomplete 2 19 2 32 boy 2600 none stunting yes complete 11 girl 2800 none health yes complete 3 16 1 4 girl 2250 lbw allergic no incomplete 4 19 1 20 girl 3000 none health no complete 5 17 1 15 boy 2500 asphyxia allergic lw no incomplete 6 19 1 6 boy 2300 lbw lw no complete 7 18 1 5 girl 2650 none health no complete 8 17 1 9 boy 2700 none health no complete 9 17 1 6 girl 2800 none health no incomplete 10 16 1 6 boy 2550 none health yes complete 11 19 1 14 boy 3200 none health yes complete 12 17 1 16 girl 2100 lbw, postmature malnutrition no incomplete 13 19 1 12 girl 1900 lbw malnutrition no complete 14 18 1 7 girl 2650 none health no complete 15 18 1 22 girl 2900 none allergic no complete 16 17 1 7 girl 2500 none health no incomplete 17 17 1 6 boy 1900 lbw, asphyxia asthma lw no incomplete 18 17 1 24 girl 2550 none health no incomplete 19 18 1 9 boy 2700 none allergic no incomplete 20 18 1 14 girl 2650 none health no incomplete wahyuni and rungreangkulkij(2023) jurnal ners 135 p-issn: 1858-3598  e-issn: 2502-5791 quality of reporting. to follow up, the categories and themes were resulted after the coding. data were analyzed used latent content analysis, which connects text with aspect. trustworthiness refers to “truth value” of the study findings or how accurately the investigator interpreted the participants’ experiences (jeanfreau and jack, 2010). according to guba and lincoln (2017), there are four criteria to measure trustworthiness of qualitative research: credibility, dependability, transferability, and confirmability. several ways can be used to achieve credibility; the researcher spend sufficient time in the research field to get information and real data, building trust and a good relationship with participants in the research site, doing persistent observation, and carrying out a triangulation process. transferability was achieved through detailed descriptions of findings and comparing them with relevant research and concepts surrounding adolescent mothers’ child condition. dependability and confirmability were enhanced by detailed discussions between researchers during analysis to reach agreement. during data collection, the participants could choose to withdraw without further prejudice. the researcher ensured that all participants remained anonymous. in addition, the researcher verified that the participants' privacy and confidentiality were protected. the researcher did not use a specific name and relied on a code instead. the researcher also kept all documents from informants securely. results there were 22 children from 20 adolescent mothers in this study. the mean age of the children was 11 months, ranging from 4 to 32 months. two of them were twins, another two were siblings, and 18 children were single. eight out of 22 children from adolescent mothers had health problems at birth, namely lbw and respiratory syndrome such as asphyxia; no child had a congenital defect. twenty-one children were born at 37 weeks of gestational age, and one child was born at 42 weeks of gestational age. the descriptive summary of adolescent mothers and their children is shown at table 2. to determine the themes, latent content analysis was carried out as shown in table 2. the result revealed three themes about children’s conditions of adolescent mothers in the community which involve: 1) children’s health status, 2) children’s breastfeeding status, and 3) children’s immunization status as shown in figure 1. theme 1. child health condition the theme child health condition summarizes the result of how the condition of the child is related with health problems at birth and child health problems now. the health condition of the baby at birth is influenced by the condition of the adolescent mother's pregnancy. most adolescent mothers get pregnant before marriage. they don't go to health facilities for antenatal care because they tried to hide their pregnancy from parents and community member. they did pregnancy checks after they had complications, or after the cadre knew and reported it to the healthcare provider, and then an examination was carried out if both parents allowed it. there are several cultures and beliefs associated with the health condition of children in general. particularly for adolescent mothers, the stigma of being pregnant is synonymous with the moral problem that they got pregnant before marriage, making them reluctant to have an examination. apart from that, their disobedience in consuming iron tablets, because of the belief that iron tablets will make the baby bigger, makes pregnant women the target of "kuyang" ghosts, and consuming iron tablets is a prayer so that pregnant women become sick, due to taking medicine. table 3 example of content analysis to explore child’s conditions of adolescent mothers meaning unit condense meaning unit code subcategories categories theme i've read about the importance of exclusive breastfeeding for my baby, the midwife also explained the importance of exclusive breastfeeding for my child's immunity, but the traditional birth attendance (dukun bayi) who care for me and my baby said that the first breast milk had to be thrown away because it was stale, and young coconut was good for helping the baby poop the first time. my mother-in law told me to obey the traditional birth attendants, as she has a lot of experience in caring for newborn. she used to take care of me when i was born 19 years ago according to our culture and our beliefs. she is confused about whether to exclusively breastfeed her baby or follow the advice of mother-in-law and traditional birth attendants who have experience caring for postpartum mothers and their babies for decades according to their culture lack support in exclusive breastfeed from family’s culture and community members culture that is not supportive for exclusive breastfeeding failure in breastfeeding breastfeeding history supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 136 categories 1: child health problem at birth eight out of 22 babies experienced health problems during delivery. six babies were born with low birth weight, even though they were of sufficient gestational age. in addition to low birth weight, twins also experienced asphyxia. fourteen babies were born in good health, having a birth weight of more than 2500 grams. the child health problems were occurred because of the child and mother’s condition. culture and beliefs also influence this problem, such as an adolescent mother is stigmatized, unmarried pregnancy is a stigma that inhibits them to getting antenatal care. changes in their health during pregnancy which endangered themselves and their babies were not detected early. some adolescent mothers revealed their babies were born small compared with others babies. one adolescent mother reported why her babies were born with small weight, as follows: “when i was pregnant my mother forbade me to eat a lot because my stomach is very big, and i have never done a pregnancy check because i am ashamed, i am not married.” (p1, 19 years old) another participant expressed why her baby’s weight low at birth as: “my son was small when born, only 1.9 kg, even though the gestational age was appropriate, the hcp said i had severe blood deficiency, because i don't want to take red pills (iron tablets) for fear of big babies and too young to get pregnant.” (p17, 17 years old) figure 1 themes, categories, and subcategories of the descriptive results wahyuni and rungreangkulkij(2023) jurnal ners 137 p-issn: 1858-3598  e-issn: 2502-5791 there is a belief in the culture of east kalimantan that the participants believe that iron tablets that smell fishy will make them the target of the "kuyang" ghost (a ghost who is believed to suck the mother's blood before giving birth). regarding the respiratory problems experienced by babies at birth, a participant expressed as follows: “the hcp said that my gestational age was too old, so i had to try to be labor by induced, it was very painful and the baby didn't cry right away when he was born and he needs to care in neonate intensive care unit.” (p12, 17 years old) categories 2: current child health condition eleven out of 22 children were aged under 1 year, and the rest aged between 1 to under 3 years. half of the number of children experienced health problems such as malnutrition, susceptibility to allergies, asthma, and stunting. lack of knowledge about good nutrition for child development, poor parents' economic conditions, history of illness during pregnancy, and the conditions of the covid-19 pandemic contribute to problems in children's health. this condition is also influenced by the parents of adolescent mothers. apart from that, there are beliefs and cultures that prevail in society such as restrictions on high protein foods such as fish and eggs as causes of ulcers, nutritious food is prioritized for husbands as the main breadwinner, while children and wives only get leftovers from their food. grandparents believe that small babies don't matter as long as they stay active, so that adolescent mothers don't feel worried about their child's condition. several participants mentioned the current health condition of their children, who are less healthy and get sick more easily than their peers. one reported that her child was diagnosed with stunting, and that made her feel sad and guilty, for not being able to properly care for her child: “the cadre said that my son was stunted, malnourished... maybe because i was pregnant again when he was only 1 year old, and i was very drunk (hyperemesis gravidarum) until i was treated for lack of fluids, and he was not well cared for.” (p2, 19 years old) in this study, among the babies who had low birth weight, currently all children have problems with underweight or malnutrition. feeding too early does not make children well, but they have digestive problems, such as being prone to diarrhea and allergies. three children of adolescent mothers experienced malnutrition, but the children were quite healthy, and had no other complaints. they have provided food like adult food for their children, but not chili so it is not spicy. for the babies, they provided porridge made from mashed bananas with rice, or biscuits for babies with formula milk, as one expressed: the midwife said that my child was malnourished, i thought it was normal, she never sick, active. she was born with low weigh, and my mother had given her porridge and formula milk since her aged 2 days. (p13, 19 years old) two other children suffered from malnutrition and allergies. they suspect the cause is their baby was born with a low birth weight, so they get sick easily, as one expressed: “my child has diarrhea easily, i think the milk is not suitable, but when i change the milk, he is still diarrhea, is it because the water is not good for him, i don't know.” (p19, 18 years old) theme 2. history of breastfeeding breast milk is the best food for babies because it contains nutrients and igg immune substances needed for the baby’s growth and development. in islam, perfecting breastfeeding is explained in the koran, surah al baqarah verse 233, which recommends breastfeeding for two years. exclusive breastfeeding is a struggle for parents, especially for mothers. exclusive breastfeeding is very possible for babies, with strong support from partners, families, health workers and cadres. however, there are some cultural and wrong beliefs about breast milk and breastfeeding. the culture of throwing away colostrum is still practiced by some participants because it is considered stale breast milk which makes babies have stomachache. in addition, there is a belief that if the shape of the nipple is split, then the mother may not breastfeed, because the breast milk will mix with blood, and this will make the child disobedient to the mother, or make them die. categories 1: exclusive breastfeeding there were three teenage mothers who exclusively breastfed their babies. one mother had two children, both of whom were exclusively breastfed. the reason for exclusive breastfeeding is because of the strong support from their parents, while their husbands just follow the advice of their parents-in-law or their parents, and as form of adolescent mother's commitment to provide the best life for her child, because she feels the sadness of being separated from her mother because she is pregnant without being married. the success of breastfeeding in teenage mothers is influenced by family support, commitment from the supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 138 adolescent mother, and the adolescent mother’s knowledge about exclusive breastfeeding. religious knowledge and good general knowledge of parents about breastfeeding are strong reasons for teenage mothers to exclusively breastfeed their children. the reason of exclusive breastfeed was as follows: “i breastfeed exclusively for my children; my father explained that breastfeeding is regulated in the koran, meaning it is very important and good, even though i sometimes feel tired and feel that breast milk is not enough, but my mother always supports me and prepares good food for breastfeeding mothers.” (p2, 19 years old) one single adolescent mother revealed that the reason for exclusive breastfeeding was because she wanted to prove to her parents that she was trying hard to provide the best food for her baby: “i promise myself to give the best for my child, including exclusive breastfeeding, because i have failed to be a good child, i don't want to fail as a mother.” (p10, 16 years old) another participant committed to give her son exclusive breastfeeding because she is a midwifery academy student, who understands the benefits of breastfeeding for her child's health, and because of the support from family members, because he is the first grandchild for their extended family: “i learned about the benefits of breastfeeding for mothers and babies at university, and want to implement it for my son, as well as support from the family, because my son is the first grandson in our extended family.” (p11, 19 years old) categories 2: failure of exclusive breastfeeding participants and their families agreed on the importance of breastfeeding for babies. but in their culture, newborn must clean their tongue, mouth and digestive system by being fed with young coconuts. they also believe that colostrum is stale breast milk, and should not be given. the cause of the failure in exclusive breastfeeding is due to several factors such as the physical health status of the mother, the condition of the mother's breasts such as sinking or cracked nipples, maternal mental health, incorrect information about breastfeeding in adolescent mothers, and also impact of knowledge about covid-19. one participant expressed her health condition after birth as: “i didn't breastfeed from the start because i was treated in the icu because of a seizure before giving birth.” (p1, 19 years old) several participants stated that the condition of their breasts was the reason for not breastfeeding their babies perfectly, as follows: “my nipples are inverted, and my daughter can't suck the nipple and keeps crying. finally, my mother gave formula milk to my baby according to my mother-inlaw's advice.” (p3, 16 years old) other participants explained the reasons why they stopped breastfeeding their babies: “i used to breastfeed, but my nipples were blistered and bleeding, and painful, and my baby kept crying because she was hungry, my mother finally gave formula milk to calm him down.” (p18, 17 years old) another cause of babies not getting exclusive breastfeeding is the existence of cultures and beliefs that are not in accordance with the knowledge that is believed by the family. the assumption that when breast milk comes out for the first time (colostrum) it is considered stale milk, which must be thrown away to avoid stomach pain for the baby, is expressed as follows: “my mother and my aunty said that the first breast milk was stale, the yellowish color and the fishy smell indicate that the first breast milk is stale so it had to be thrown away because it could cause the baby to be bloated and have stomach pains, and give my baby honey.” (p8, 17 years old) erroneous beliefs about the shape of the nipples are also the reason why babies are given formula milk early on, as follows: “my mother forbade me to breastfeed because my nipples were split, and bleeding when sucked. she said, it is not good, because breast milk is mixed with blood causing stomachache, and cause infant death, like our neighbor’s children.” (p6, 18 years old, married) postpartum maternal mental health conditions are also the cause of exclusive breastfeeding, as expressed by one of the participants: “my child was born prematurely, and when he was born, i was stressed and didn't want to touch him, don’t want to breastfeed… i used to hate him. i feel angry because of him i was scolded by my parents and was expelled from school. my parents don't want to talk to me, they hate me for his presence.” (p17, 17 years old) the covid-19 outbreak which increased sharply, and the unclear management at that time, made all kinds of complaints related to coughing and fever associated with covid-19 disease. this condition forces mothers wahyuni and rungreangkulkij(2023) jurnal ners 139 p-issn: 1858-3598  e-issn: 2502-5791 who are still breastfeeding their babies to self-isolate. this causes the breastfeeding process to be forced to stop for fear of infecting the baby: “my baby was 4 months old. i had a cough, fever, and lost my sense of smell. my mother-in-law and husband told me to stop breastfeeding, afraid that if i caught covid-19 it would pass it on to my baby. i ended up living in the back room, and my son was in the care of inlaws and given bottled milk.” (p19, 18 years old) theme 3. basic immunization history basic immunization in infants is important to maintain their health against various diseases caused by bacteria and viruses. in indonesia, basic immunization is provided free of charge to all indonesian children, either through services at the hospital, private practice of a medical doctor or midwife, community health center, or at the integrated service unit (posyandu). the completeness of immunization is that a child's immunization schedule is maintained according to the child's age, and it validated with a child's health card record. the success of parents in getting complete basic immunization is influenced by several factors. parents' knowledge about the benefits of immunization, family support, healthcare provider support, and support from cadres also determines children get basic immunizations. in this study, children who received incomplete basic immunizations were caused by their grandfathers refusing to vaccinate their grandchildren, because they believed that the vaccine would cause problems for their grandchildren, rising cases of covid19, health workers who were infected with covid-19, empty vaccines due to delays in delivery from the center, parents who are sick, or children who are sick, making immunizations impossible to give, and preventing children from getting complete basic immunizations. categories 1: complete basic immunization completeness of basic immunization in infants was influenced by knowledge, attitudes, and family support. the support of the grandfathers to bring their grandchild to get immunized was due to their good knowledge and education, as well as their belief about their grandsons as the successors of their ancestor's name, as one stated: “my father-in-law provides the best facilities for my child, including immunization at a pediatrician, because he is the first grandson, from the first son, who is predicted to carry on the great name of their ancestors.” (p11, 19 years old) during the covid-19 pandemic, many health workers are infected with covid-19, they had to isolate, so the public health center was closed. some parents had to take their child to a pediatrician, to get immunization because immunization is important for their child, as stated: “i took my child for immunization to a private pediatrician practice because the public health center was closed, many health workers were infected with covid-19, even though we had to pay, we were fine, my husband said immunization was important for our child. so, it must be immunized when the time comes.” (p7, 18 years old) categories 2: incomplete basic immunization all mothers who have babies and monitor the growth and development of children at posyandu or community health centers, explained the importance of immunization for a child's immunity. however, there are some parents who don't carry out immunizations because they don't comply with their beliefs, sick children, effect of immunization, empty vaccines, and health workers infected with covid-19 causing health facilities to close. one participant explained why she did not take her children to be immunized: “my father forbade me to carry out immunizations for my children, according to him, in our tribe it is useless, and will actually make children sick, because children are given diseases.” (p1, 19 years old) another participant did not bring their child for immunization because at the time of the immunization schedule their child was sick, as disclosed as follows: “my daughter lacked two immunizations because at the time of immunization, she was sick, and it was recommended by the midwife to postpone it until he recovered first, but at the appointed time, he had diarrhea, until the time was up, and had to be immunized with another type.” (p19, 18 years old) several immunizations have an impact on babies such as fever and children becoming fussy and having difficulties sleeping, such as the bcg and dpt vaccines. this causes concern for parents to take their children to be immunized: “there was one immunization that my child didn't get, because i was afraid, she would have a fever and be cranky, she had just recovered from an illness.” (p16, 17 years old) supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 140 the covid-19 pandemic has also become a problem in vaccine distribution from the central government to the regions. to prevent the spread of the virus, the government was making efforts to impose restrictions on community activities. this has had an impact on the distribution of goods to regions including vaccines, resulting in empty vaccine stocks at health facilities. this condition was expressed by a participant as follows: “i want my child to be fully immunized, but according to cadre information, immunizations have been suspended for an indefinite period because vaccine stocks were empty.” (p15, 18 years old) discussions the results of the study show how adolescent mothers live their lives in caring for their children. most of them tend to be quiet, and make their parents the main support, including in caring for their children. their husbands also rely on their parents as teachers in caring for their children. half of the total children experienced health problems at birth such as low birth weight and asphyxia. similar with previous studies, the children of adolescent mothers were born with low body weight, respiratory problems, and lower apgar scores compared to adult mothers (gurung et al., 2020; jae´n-sa´nchez et al., 2020; world health organization, 2020). this condition shows that being a mother in their teens affects the health of their children, so we must support the maturity to become parents to reduce the risk of health problems in children. some adolescent mothers and their parents said that it was normal for their babies to be small because they had small offspring, and it was not because they were pregnant in their teens. lack of knowledge about the effects of adolescent pregnancy, not only on adolescent mothers, but also on their parents must be stopped, so that cases of adolescent pregnancy can be reduced. eleven out of 22 children of adolescent mother experienced health problems, most of them suffered from malnutrition, underweight, prone to allergies, asthma, and stunting, as in previous studies (salmon et al., 2018). two of these children were born under normal conditions, without health problems, but due to parental limitations of knowledge and no experience in child care, it made them experience obstacles in caring for children, in line with previous studies (david, dyk and ashipala, 2017; mangeli et al., 2018). information about child’s health that is not comprehensive makes them confused to act, in line with prior study, and fulfill basic physical needs related with stunting (surani and susilowati, 2020). health problems in children in the first 1000 days of life are a big problem, because this is a critical period. fulfillment of adequate nutritional is needed to encourage normal brain development (cusick and georgieff, 2016). this obstacle was caused by their process of becoming mothers, mostly due to getting pregnant before marriage, which is considered as a mistake in social institutions (govender, naidoo and taylor, 2020). chronic energy deficiency commonly found in pregnant women in indonesia has an effect on the growth and development of the fetus in the womb (wiyono et al., 2020). this condition is related to unhealthy eating habits in school-age children and adolescents, such as eliminating breakfast, and eating not according to the body's needs for fear of becoming fat. and when they get pregnant, it will have an impact on themselves and their baby, because their bodies are not yet ready for pregnancy. the child health’s condition of adolescent mothers is influenced by adolescent mother’s health status during pregnancy (schwarzenberg and georgieff, 2018; nahak, fouk and esperanca, 2022). health problems during pregnancy affect the health of the fetus at birth, and also the current condition of the child. for the children born with these health problems, their mothers experience complications during pregnancy such as hypertension, pre-eclampsia, anemia, and chronic energy deficiency. the anemia experienced by pregnant adolescent mothers is often ignored, due to a lack of knowledge about the benefits of iron tablet supplements for their pregnancy (klankhajhon et al., 2021). this is in line with previous study that there is a wrong belief that taking iron tablets during pregnancy will make the baby bigger (wahyuni and setyowati, 2010),. this is in accordance with research conducted by pinho-pompeu et al. (2017) who confirmed anemia iron deficiency as a predisposing factor for preterm birth. the results of this study are in line with previous research, where adolescent mothers are at high risk of experiencing health problems such as gestational hypertension, mild to severe preeclampsia, intrauterine infection, post-term pregnancy, and eclampsia (riyana et al., 2015). in indonesia, anemia is common in school-age children and adolescents. this is due to the selection of foods that are low in good nutrition, and anemia is not considered an important problem, because they feel that the effect is not severe. this bad habit is also passed down in giving food to their children, the important thing is that their children want to eat it; it doesn't matter about the nutritional content. chronic energy deficiency in pregnant women in indonesia caused by a lack of energy in the long term is closely related to knowledge of nutritious food, age, employment status, wahyuni and rungreangkulkij(2023) jurnal ners 141 p-issn: 1858-3598  e-issn: 2502-5791 and previous poor nutritional status (wiyono et al., 2020). the principle of "what is important to eat" by ignoring nutritional content is still a problem in the community where this research was carried out. society's stigma towards adolescents, and unfriendly treatment of health workers, makes them isolated themselves from society, and causes them not to do enough antenatal care (sriyasak, åkerlind and akhavan, 2013; govender, naidoo and taylor, 2020). their appearance in society as pregnant before marriage, and having children at a young age is considered a disgrace to the family and society, and makes society ostracize them (smithbattle, 2013; kumar et al., 2018) in line with study in texas, adolescent mothers experiencing stigmatization leads to negative outcome including depression, social isolation, lowered self-esteem and poorer academic performance (wiemann et al., 2005). even though adolescent pregnancy before marriage is a violation of social norms, nevertheless, we have to support them, so that they can go through difficult conditions and be able to raise their children well. supporting them does not mean justifying their wrongdoing, but saving the next generation. exclusive breastfeeding was a challenge for mothers, including for adolescent mothers. in this study, only 3 out of 20 adolescent mothers gave exclusive breastfeeding. in line with previous studies, most of mothers do not provide exclusive breastfeeding to their babies, because they believe that giving complementary food to the babies earlier is better (lailatussu’da et al., 2018; anggraeni et al., 2022). the failure of exclusive breastfeeding is due to the belief that breastfeeding for four months does not cause problems for the baby (nahak, fouk and esperanca, 2022). the belief that colostrum is considered as stale milk is a cause of failure of exclusive breastfeeding. in addition, the culture of giving young coconut to newborns as an effort to cleanse the baby's digestive system is a challenge in itself to be stopped by health workers as an effort to support the success of exclusive breastfeeding and reduce infant mortality rate. the hereditary belief and culture of providing complementary food to babies from an early age is a sign of respect by mothers for their parents, even though some of them already know about exclusive breastfeeding (anggraeni et al., 2022). the success of exclusive breastfeeding is influenced by many factors, such as the support of spouses, families, health workers, and cadres. family support is the biggest factor in the success of exclusive breastfeeding, compared to husband support in bantul, jogjakarta, indonesia (lailatussu’da et al., 2018). some children easily get diarrhea and are allergic to food or snacks. in line with prior study, children born to adolescent mothers had lower z-scores for height-forage, weight-for-age, and higher prevalence of stunting, than children born to adult mothers, the strongest link being through women’s weight, education, socioeconomic status and complementary feeding practices (nguyen et al., 2020). it also increased the risk for infant mortality (yurdakul, 2018), respiratory distress, and low apgar score (jae´n-sa´nchez et al., 2020). allergies in children are associated with immunity, where in infants immunity can be obtained from exclusive breastfeeding, immunization and adequate nutrition. in this study, children often experience diarrhea and allergies, do not get exclusive breastfeeding, and immunizations are incomplete. in line with prior study, in infants who were nonexclusively breastfed, the odds of having an illness with fever in the last two weeks among infants who were exclusively breastfed decreased by 66%, and exclusively breastfed infants had lower odds of having an illness with a cough and having diarrhea compared to nonexclusively breastfed infants (mulatu et al., 2021). misunderstandings about the benefits of colostrum and inappropriate breastfeeding practices must be corrected through the interaction of religious leaders and health workers to avoid repeated misunderstandings. for teenage mothers and their families who are muslim, it is necessary to understand the meaning of surah al baqarah verse 233 concerning improving breastfeeding. community members have a tendency to follow the advice of ustad or priests because they are considered as pious scholars. basic immunization in infants is important to maintain their health against various diseases caused by bacteria and viruses. immunization has been proven in the past two centuries to help reduce the incidence of diseases such as polio, smallpox and measles in children worldwide (unicef, 2020). providing incomplete basic immunization to children was influenced by the beliefs and culture of their parents or grandparents (syiroj, pardosi and heywood, 2019). there are several immunizations that have an impact on infants such as fever and the child becomes fussy and has difficulty sleeping, such as the bcg and dpt vaccines. this causes concern for parents to take their children to be immunized. in this study, 10 babies of adolescent mothers did not receive complete immunizations, for various reasons such as worries that babies would get sick when immunized, wrong information about immunizations, not having means of transportation, and the covid-19 pandemic which caused health workers to supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 142 become infected with the virus, and the temporary elimination of immunizations from the health office at the phc. similar study showed the factors of parents refused vaccines related to religious belief (anderson, 2017), personal beliefs, safety concern, and lack of information from healthcare providers (mckee and bohannon, 2018; syiroj, pardosi and heywood, 2019). in order for babies to get complete basic immunization, it is necessary to increase knowledge among teenage mothers, as well as their parents, as the closest support system. in addition, trained cadres, as an extension of the health workers, can explain to them in their language that is easy to understand, so that babies get their right to get complete immunization for their body's immunity. the covid-19 pandemic has also caused a decrease in basic immunization coverage in indonesia. this is due to several factors, such as the closing of the posyandu or phc because health workers are infected with covid19, limited personal protective equipment for health workers, and parents' fear of taking their children to public facilities for fear of contracting covid-19 (ministry of health of indonesia and unicef, 2020). adolescent mothers worried about the effects of immunization. their lack of knowledge is detrimental to their children because basic immunizations which are important for the child's immune system are missed. erroneous beliefs about the benefits of immunization need to be straightened out through the intensive participation of health workers and community leaders, through activities that incorporate local cultural wisdom, so that they can change without feeling forced. limitations there are limitations in this current study that need to be stated. firstly, the study was undertaken at a single location. however, this area had the highest number of adolescent mothers; secondly, there is a higher case of stunting in the province, and so may not represent the children’s health problems of adolescent mothers in indonesia generally. secondly, care provided may differ across settings so there may be other experiences elsewhere. with a qualitative design, new insights are provided into adolescent mothers' experiences of parenting and thereby contribute to understanding the problems they face and their needs for support. implications as an archipelagic country, indonesia has thousands of different tribes and cultures, has a different culture in caring for pregnancy, childbirth and raising children. this study found some cultures and myths against the health system. a special approach is needed for them to optimize care for adolescent pregnant women, adolescent mothers and their children. nurses in indonesia have an opportunity to improve public health by using a family-centered maternity care model to support adolescent mothers achieve their motherhood. in indonesian culture, the family is the health center for family members. in addition, there is a wider need to influence society's more accepting views of adolescent mothers. the development of interventional care for adolescent mothers must include the involvement of the extended family. further studies are needed to explore the maternal role of adolescent mothers from different cultures globally, and also investigate the effectiveness of nursing interventions to enhance the development of adolescent mothers’ roles. conclusion the growth and development of children in early life is influenced by the health conditions of the mother during pregnancy, including nutrition and antenatal care during pregnancy, childbirth, and care during early life. exclusive breastfeeding and appropriate complementary food after exclusive breastfeeding, complete basic immunization, good growth and development stimulation, child-friendly environment, and caring for children in a harmonious family with good economic status will promote children’s health status from adolescent mothers. some cultures and beliefs that are not in harmony with the health of mothers and babies, but can be harmonized by involving community leaders and religious leaders as their role models. funding the author received funding from asean gms khon kaen university and universitas muhammadiyah kalimantan timur. conflict of interest the authors declared they have no conflicting interest. ethical statement this research obtained approved from the international review boards of khon kaen university with id he642011 date 1 march 2021. all participants were provided informed consent and anonymity. for participants below 18 years old, authors sought approval from the parents and guardians. wahyuni and rungreangkulkij(2023) jurnal ners 143 p-issn: 1858-3598  e-issn: 2502-5791 acknowledgments the authors would like to express thanks to asean gms for providing a scholarship to study at khon kaen university thailand, universitas muhammadiyah kalimantan timur to all support during study. we also grateful for all participants who shared their experiences with the authors references anderson, v. l. (2017) ‘promoting childhood immunizations’, the journal for nurse practitioners, 11(1), pp. 1–10. doi: 10.1016/j.nurpra.2014.10.016. anggraeni, m. d. et al. (2022) ‘understanding early complementary food practice in rural indonesia: a qualitative study’, british journal of midwifery, 30(7), pp. 384–394. doi: 10.12968/bjom.2022.30.7.384. bps (2016) ‘perkawinan usia anak di indonesia 2013 dan 2015’. bps, bappenas and unicef (2020) ‘pencegahan perkawinan anak’. bradley, k. l., shachmut, k., viswanathan, s., griffin, b., & vielehr, d. adebiyi, b. o. et al. (2022) ‘enablers and barriers to effective parenting within the first 1000 days: an exploratory study of south african parents and primary caregivers in low socio‑economic communities’, bmc public health, 22(279), pp. 1–13. doi: 10.1186/s12889-022-13179-9. cusick, s. e. and georgieff, m. k. (2016) ‘the role of nutrition in brain development: the golden opportunity of the ‘ first 1000 days’, j. pediatr, 175(august), pp. 16–21. doi: 10.1016/j.jpeds.2016.05.013.the. david, s. a., dyk, a. van and ashipala, d. o. (2017) ‘experiences of young adolescent mothers regarding adolescent motherhood in oshana region’, journal of nursing education and practice, 7(12), p. 39. doi: 10.5430/jnep.v7n12p39. denzin norman, lincoln ys. (2017) ‘the sage handbook of qualitative research. 5th ed. los angeles’, ca: sage publications dickens, d. r. and fontana, a. (eds.) (2015) ‘postmodernism and social inquiry’, london: routledge taylor & fracis group. erfina, e. et al. (2019) ‘adolescent mothers’ experiences of the transition to motherhood: an integrative review’, international journal of nursing sciences, 6(2), pp. 221–228. doi: 10.1016/j.ijnss.2019.03.013. erny, prasetyo, o. and soekanto, a. (2022) ‘the impact of using gadgets at early age on the brain development of infants and children (literature review article)’, jurnal ilmiah kedokteran wijaya kusuma, 11(2), pp. 183–191. available at: https://journal.uwks.ac.id/index.php/jikw/article/view/2225. gerrish, k. and lacey, a. (eds.) (2010) ‘the research process in nursing, 6th edition’, wiley-blackwell. govender, d., naidoo, s. and taylor, m. (2020) ‘i have to provide for another life emotionally, physically and financially’: understanding pregnancy, motherhood and the future aspirations of adolescent mothers in kwazulu-natal south, africa’, bmc pregnancy and childbirth, 20(1), pp. 1–21. doi: 10.1186/s12884020-03319-7. gurung, r. et al. (2020) ‘the burden of adolescent motherhood and health consequences in nepal’, bmc pregnancy and childbirth, 20, pp. 1–7. doi: https://doi.org/10.1186/s12884-020-03013-8 (2020). jae´n-sa´nchez, n. et al. (2020) ‘adolescent motherhood in mozambique . consequences for pregnant women and newborns’, plos one, pp. 1–12. doi: 10.1371/journal.pone.0233985. jeanfreau, s. g. and jack, l. (2010) ‘appraising qualitative research in health education: guidelines for public health educators’, society for public health education, 11(5), pp. 612–617. doi: 10.1177/1524839910363537. klankhajhon, s. et al. (2021) ‘perspectives of pregnant women regarding iron deficiency anemia’, jurnal ners, 16(2), pp. 119– 127. doi: 10.20473/jn.v16i2.27418. kumar, m. et al. (2018) ‘adolescent pregnancy and challenges in kenyan context: perspectives from multiple community stakeholders’, global social welfare, 5(1), pp. 11–27. doi: 10.1016/j.physbeh.2017.03.040. lailatussu’da, m. et al. (2018) ‘family support as a factor influencing the provision of exclusive breastfeeding among adolescent mothers in bantul, yogyakarta’, kesmas, 12(3), pp. 114–119. doi: 10.21109/kesmas.v12i3.1692. likhar, a. and patil, m. s. (2022) ‘importance of maternal nutrition in the first 1,000 days of life and its effects on child development : a narrative review’, cureus, 14(10), pp. 8–13. doi: 10.7759/cureus.30083. mangeli, m. et al. (2018) ‘exploring the experiences of iranian adolescent mothers about the maternal role: a qualitative study,’, electronic physician, 10(5), pp. 6812–6820. doi: 10.19082/6812. mckee, c. and bohannon, k. (2018) ‘exploring the reasons behind parental refusal of vaccines’, journal of pediatric pharmacology and therapeutics, 21(2), pp. 104–109. doi: 10.5863/1551-677621.2.104. minister of law and human rights (2008) ‘government regulation of the republic of indonesia no. 47 of 2008 concerning compulsory education’, indonesia. available at: http://www.desarrollosocialyfamilia.gob.cl/storage/docs/inform e_de_desarrollo_social_2020.pdf%0ahttp://revistas.ucm.es/ind ex.php/cuts/article/view/44540/44554. minister of law and human rights (2020) ‘regulation of the president of the republic of indonesia number 64 of 2020 concerning health insurance. indonesia’. ministry of health of indonesia and unicef (2020) ‘imunisasi rutin pada anak selama pandemi covid-19 di indonesia : persepsi orang tua dan pengasuh agustus 2020’, pp. 1–16. available at: https://www.unicef.org/indonesia/reports/rapid-assessmentimmunization-services-indonesia]%0aimunisasi. ministry of women’s empowerment and child protection (2015) ‘sirri marriage and its impact in west java province’. bandung. available at: https://www.kemenpppa.go.id/lib/uploads/list/34529-laporanriset-perkawinan-sirri-dan-dampaknya.pdf. mulatu, t. et al. (2021) ‘exclusive breastfeeding lowers the odds of childhood diarrhea and other medical conditions: evidence from the 2016 ethiopian demographic and health survey’, italian journal of pediatrics, 47(1), pp. 1–6. doi: 10.1186/s13052-02101115-3. nahak, m. p. m., fouk, m. f. w. a. and esperanca, m. j. (2022) ‘nutrition awareness: family practices in indonesian borderland’, jurnal kesehatan masyarakat, 18(1), pp. 147–155. doi: https://doi.org/10.15294/ kemas.v15i2.14349. nguyen, p. et al. (2020) ‘why are adolescent mothers more likely to have stunted and underweight children than adult mothers? path analysis using data from 30.000 bangladeshi mothers, 19662014’, nutritional epidemiology, 2020, p. 1463. oyeyemi, a. l. et al. (2019) ‘association between adolescent motherhood and maternal and child health indices in maiduguri, nigeria: a community-based cross-sectional study’, bmj open, 9(3), pp. 1–9. doi: 10.1136/bmjopen-2018-024017. pem, d. (2015) ‘factors affecting early childhood growth and development : golden 1000’, journal of advanced practice in nursing, 1(1). doi: 10.4172/2573-0347.1000101. pinho-pompeu, m. et al. (2017) ‘anemia in pregnant adolescents: impact of treatment on perinatal outcomes’, journal of maternalfetal and neonatal medicine, 30(10), pp. 1158–1162. doi: 10.1080/14767058.2016.1205032. pinzon, j. l. and jones, v. (2012) ‘care of adolescent parents and their children’, american academy of pediatrics, 130(6). doi: 10.1542/peds.2012-2879. riyana, h. et al. (2015) ‘outcome and risk of obstetric complication in teenage pregnancy in tertiary center hospital in indonesia’, in aspire conference proceedings. jakarta. doi: 10.18502/kme.v1i1.539. salmon, d. a. et al. (2018) ‘disparities in preschool immunization coverage associated with maternal age’, human vaccine, 5(8), pp. 557–561. sardar, z. and loon, b. van (1998) ‘introducing cultural studies’, icon books uk. schwarzenberg, s. j. and georgieff, m. k. (2018) ‘advocacy for improving nutrition in the first 1000 days to support childhood supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 144 development and adult health: policy statement’, pediatrics, 141(2). doi: e20173716. smithbattle, l. i. (2013) ‘stigmatization of teen mothers’, mcn. the american journal of maternal child nursing, 38(august), pp. 235– 241. sobhy, s. et al. (2019) ‘maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and metaanalysis’, the lancet, 393(10184), pp. 1973–1982. doi: 10.1016/s0140-6736(18)32386-9. sriyasak, a., åkerlind, i. and akhavan, s. (2013) ‘childrearing among thai first-time teenage mothers’, the journal of perinatal education, 22(4), pp. 201–211. doi: 10.1891/1058-1243.22.4.201. surani, e. and susilowati, e. (2020) ‘the relationship between fulfilment of basic needs with the incidence of stunting in toddlers’, jurnal ners, 15(1), pp. 26–30. doi: http://dx.doi.org/10.20473/jn.v15i1.17286. syiroj, a. t. r., pardosi, j. f. and heywood, a. e. (2019) ‘exploring parents’ reasons for incomplete childhood immunisation in indonesia’, vaccine, 37(43), pp. 6486–6493. doi: 10.1016/j.vaccine.2019.08.081. un igme (2023) ‘un inter-agency group for child mortality estimation’, available at: https://childmortality.org/data/indonesia. unicef (2020) ‘immunization’, available at: https://www.unicef.org/immunization. wahyuni, t. and setyowati (2010) ‘compliance of pregnant women in consuming iron tablets influenced by kutai culture: study grounded theory’, universitas of indonesia. wiemann, c. m. et al. (2005) ‘are pregnant adolescents stigmatized by pregnancy?’, journal of adolescent health, 36(4), pp. 352.e1352.e7. doi: 10.1016/j.jadohealth.2004.06.006. wiyono, s. et al. (2020) ‘study causes of chronic energy deficiency of pregnant in the rural areas’, international journal of community medicine and public health, 7(2), p. 443. doi: 10.18203/23946040.ijcmph20200412. world bank (2020) ‘adolescent fertility rate (birth per 1,000 women ages 15-19) – bangladesh’, p. 2018. world health organization (2020) ‘children : improving survival and well-being’, fact sheet. available at: https://www.who.int/newsroom/fact-sheets/detail/children-reducing-mortality. world health organization (2023) ‘child health’, available at: https://www.who.int/health-topics/child-health#tab=tab_1. worldometer (2019) ‘indonesian populasi pyramid 2019’. yurdakul, m. (2018) ‘perceived social support in pregnant adolescents in mersin area in turkey’, pakistan journal medical science, 34(1), pp. 115–120. yusriadi (2019) ‘public health services : a case study on bpjs in indonesia’, public administration journal, 9 (2), pp. 85–91. doi: 10.31289/jap.v9i2.2279.. how to cite this article: wahyuni, t. and rungreangkulkij, s. (2023) ‘exploring children’s condition of adolescent mothers in east kalimantan indonesia: an ethnography study’, jurnal ners, 18(2), pp. 131-144. doi: http://dx.doi.org/10.20473/jn.v18i2.44630 175 pendekatan modelling keperawatan anak terhadap pengetahuan, kemampuan praktik dan percaya diri ibu dalam menstimulasi tumbuh kembang bayi 0–6 bulan (pediatric nursing modelling approach on mother's knowledge, practice ability and maternal confi dence of infant growth and development) ariyanti saleh program studi magister ilmu keperawatan fakultas kedokteran universitas hasanuddin jalan perintis kemerdekaan km 10, kampus unhas tamalanrea makassar e-mail: yantie_nersuh@yahoo.com abstract introduction: the fi rst fi ve years of age of a child is a critical time that will affect the child growth development process. any untreated disorders may impair the process that subsequently infl uences quality of life of the child in the future. therefore, it is imperative for a mother to optimize the growth development process. this study aimed to identify the effectiveness of health education with modelling approach on mother's knowledge, practice ability and maternal confi dence of infant (0-6 months) growth and development. method: a quasy eksperimental pre-post with control group design was used. the intervention given was health education with modelling approach related to lactation management and infant growth development stimulation. the research was conducted in maros regency wiht 81 samples (41 in the treatment group and 40 in the control group). result: the wilcoxon test reveals that there was a signifi cant difference between treatment and control group, accordingly, knowledge (p = 0.00, p = 0.01), practice ability (p = 0.00, p = 0,006) and maternal confi dence (p = 0.03, p = 0.03). in addition, from mann whitney test, between the two group, the data obtained are: knowledge (p = 0,950), practice ability (p = 0.00) and maternal confi dence (p = 0,061). discussion: health education with modelling approach conducting by nurse was effective in increasing knowledge, practice ability, maternal confi dence breastfeeding and baby stimulation, which was in turn can optimize baby growth and development. that is why, community health nurses role should be increase by making community health nursing program as one of primary public health centre program. keywords: health education, modelling approach, mother, maternal confi dence. pendahuluan periode penting dalam tumbuh kembang adalah pada usia di bawah lima tahun (balita). menurut minick (1991), soetjiningsih (1995) dan departemen kesehatan (2001), masa balita merupakan masa kritis dari tumbuh kembang, karena merupakan hal mendasar yang akan memengaruhi dan menentukan tumbuh kembang selanjutnya. oleh sebab itu, tumbuh kembang pada masa balita harus optimal. k u a l i t a s t u m b u h k e m b a n g a n a k dipengaruhi oleh faktor genetik yang merupakan potensi dasarnya dan faktor lingkungan yang diterimanya. faktor lingkungan inilah yang menentukan apakah potensi yang sudah ada akan berkembang secara optimal. faktor lingkungan dapat dimulai sejak dalam kandungan, pada saat persalinan dan setelah lahir. orang tua terutama ibu merupakan lingkungan terdekat yang dapat berperan terhadap tumbuh kembang anak, untuk mengoptimalkan potensi bawaan, seorang anak membutuhkan pengasuhan (asuh), kasih sayang (asah) dan stimulasi (asih) secara optimal (soetjiningsih, 1995; dan departemen kesehatan 2001). peningkatan kesehatan dan pendidikan dasar anak serta pengurangan angka kemiskinan dan kelaparan merupakan tujuan pertama d a n k e d u a d a r i p e n c a p a i a n m i l l e n i u m development goals yang dicanangkan pbb (who, 2001). sedangkan menurut grantham, jurnal ners vol. 6 no. 2 oktober 2011: 175–186 176 et al. (2006), banyak balita di negara berkembang yang terpapar oleh berbagai risiko secara bersamaan meliputi kemiskinan, malnutrisi, status kesehatan yang buruk dan kurangnya stimulasi lingkungan. hal ini juga didukung oleh data dari departemen kesehatan (2001) bahwa di indonesia, terdapat sekitar 10 persen balita dari seluruh populasi penduduk yang harus mendapatkan perhatian memadai dari berbagai pihak. oleh karena itu, diperlukan upaya peningkatan pengetahuan orang tua khususnya ibu, dalam meningkatkan daya hidup anak, kesehatan anak, gizi dan stimulasi kognitif, yang merupakan upaya penting dalam mengoptimalkan tumbuh kembang anak. faktor lain yang juga dapat berpengaruh pada tumbuh kembang bayi adalah pemenuhan kebutuhan gizi bayi 0–6 bulan. pemberian asi bukan hanya semata memenuhi kebutuhan fisik biologis tetapi juga berdampak pada aspek pemberian kasih sayang, rasa aman serta akan meningkatkan ikatan ibu dan anak yang merupakan hal penting dalam optimalisasi tumbuh kembang anak. stimulasi merupakan salah satu faktor lingkungan yang juga berpengaruh pada tumbuh kembang anak. stimulasi merupakan cikal bakal proses pembelajaran anak yang harus dimulai sejak awal kehidupan. anak yang mendapat stimulasi yang terarah dan teratur akan lebih cepat berkembang dibandingkan dengan anak yang kurang atau tidak mendapat stimulasi. berbagai penelitian yang mendukung hal ini telah banyak dilakukan. penelitian oleh field (1986) dan kuperus (1993) mengatakan bahwa stimulasi di lingkungan keluarga, dapat meningkatkan pertumbuhan bayi dan bagi anak dengan risiko biologis tinggi akan mampu mengejar ketinggalan di bidang kognitifnya. orang tua khususnya ibu, merupakan lingkungan yang pertama dan utama bagi seorang bayi. peran seorang ibu sangat penting, terutama sebagai agen kesehatan bagi anak dan keluarga dalam upaya memenuhi kebutuhan asah, asuh, asih pada bayi. oleh karena itu, setiap ibu yang memiliki bayi memerlukan pengetahuan, keterampilan yang benar serta memiliki kepercayaan diri yang tinggi tentang hal tersebut. perawat sebagai salah satu profesi kesehatan memiliki tanggung jawab untuk mempromosikan kesehatan keluarga dan anak, menyediakan layanan pada klien yang meliputi dukungan, pendidikan kesehatan dan pelayanan keperawatan yang dapat berkontribusi dalam meningkatkan pengetahuan, sikap dan keterampilan ibu dalam merawat bayinya (mercer, 2006). mercer (2006) juga mengemukakan bahwa keperawatan adalah profesi yang dinamis dengan tiga fokus utama yaitu promosi kesehatan, mencegah kesakitan dan menyediakan layanan keperawatan bagi yang memerlukan untuk mendapatkan kesehatan yang optimal serta penelitian untuk memperkaya dasar pengetahuan bagi pelayanan keperawatan. teori keperawatan maternal role attainment (mra) dapat digunakan sebagai kerangka konseptual penelitian dalam meningkatkan peran ibu dan percaya diri ibu dalam merawat bayi (russell, 2006; meighan, 2006). berdasarkan hal tersebut, maka penelitian ini menjadikan teori keperawatan sebagai dasar pemikiran. teori keperawatan mra merupakan salah satu dari teori middle range yang dikembangkan oleh ramona t. mercer, yang berfokus pada ibu dalam mengembangkan perannya sebagai seorang ibu agar lebih percaya diri dalam melakukan perawatan anak-anaknya, melalui upaya pemberian pendidikan kesehatan oleh perawat (mercer, 2006; mercer dan walker, 2006). beberapa asumsi yang mendasari teori ini adalah karakteristik ibu, percaya diri ibu, status kesehatan bayi dan hasil akhir berupa status tumbuh kembang bayi (mercer, 2006). hasil pengamatan di lapangan masih banyak ditemukan praktik pengasuhan bayi yang kurang kaya akan upaya stimulasi. untuk itu diperlukan pendidikan kesehatan yang dapat merubah perilaku ibu melalui pengetahuan, sikap, kemampuan, dan kepercayaan diri yang tinggi dalam merawat bayi khususnya dalam menstimulasi tumbuh kembang bayi. beberapa studi menunjukkan bahwa pendidikan kesehatan memberikan dampak yang positif terhadap peningkatan pengetahuan dan kemampuan praktik dalam merawat bayi (butz et al., 2005; piwoz et al., 2005; harisawati, 2008). salah satu pendekatan teori belajar yang digunakan dalam pendidikan kesehatan adalah pendekatan modelling keperawatan anak (ariyanti saleh) 177 teori belajar sosial yang dikembangkan oleh albert bandura. modelling merupakan konsep dasar dari teori belajar sosial yang fokus akhirnya adalah mewujudkan kemampuan diri seseorang melalui upaya peningkatan atensi, retensi, reproduksi dan motivasi selama proses belajar berlangsung (hall dan lindzey, 1985). melalui pendidikan kesehatan dengan pendekatan modelling inilah, diharapkan dapat meningkatkan kemampuan dan kompetensi ibu dalam merawat bayi terutama dalam menstimulasi tumbuh kembang bayi. kabupaten maros memiliki tingkat pertumbuhan kesehatan yang cukup rendah, khususnya yang terkait dengan kepedulian orang tua (ibu) terhadap perawatan kesehatan dan tumbuh kembang bayi, hal ini dapat dilihat dari data kunjungan bayi sebesar 65,8% dari 90% target yang ingin dicapai oleh pemerintah, demikian juga dengan cakupan deteksi dini tumbuh kembang bayi dan balita sebesar 13,37% dari 70% target yang ingin dicapai pemerintah (dinas kesehatan sulsel, 2008). beberapa penelitian tentang upaya penyelesaian masalah gizi dan tumbuh kembang anak telah banyak dilakukan, baik di tingkat propinsi sulawesi selatan maupun di tingkat kabupaten maros, namun yang terkait dengan upaya penanganan masalah gizi dan tumbang melalui pendidikan kesehatan pada ibu belum banyak ditemukan. studi ini dilakukan untuk mengidentifi kasi efektivitas pemberian pendidikan kesehatan dengan pendekatan modelling pada para ibu terhadap pengetahuan, kemampuan praktik dan kepercayaan diri ibu dalam menstimulasi tumbuh kembang bayi 0–6 bulan. bahan dan metode penelitian ini telah dilaksanakan di wilayah kerja puskesmas barandasi kecamatan lau dan puskesmas hasanuddin kecamatan mandai kabupaten maros, dilaksanakan mulai bulan juli 2009 sampai dengan bulan september 2010. keseluruhan sampel berjumlah 81 orang ibu terdiri dari 41 orang kelompok intervensi dan 40 orang kelompok kontrol sesuai dengan kriteria penelitian. instrumen penelitian yang digunakan dalam penelitian ini adalah kuesioner dan lembar observasi. peneliti memperoleh identitas responden, pre-test untuk menilai pengetahuan, sikap, kemampuan praktik dan percaya diri ibu. pendidikan kesehatan yang digunakan adalah pendidikan kesehatan dengan pendekatan modeling yang memfokuskan praktik dalam aktivitasnya. pendidikan kesehatan diberikan dalam 3 tahap yaitu: pendidikan kesehatan 1 pada trimester 3 kehamilan, pendidikan kesehatan 2 pada minggu pertama post partum dan pendidikan kesehatan 3 ketika bayi berusia 3 bulan. pendidikan kesehatan dengan pendekatan modelling ini dilakukan melalui beberapa fase yaitu fase peningkatan atensi, retensi, reproduksi dan motivasi. metode yang digunakan dalam pendidikan kesehatan adalah demonstrasi, redemonstrasi dan simulasi, sedangkan alat bantu pendidikan kesehatan yang digunakan adalah leafl et, lembar balik dan pantom. metode dalam penelitian ini adalah quasy eksperiment pre-post with control group design. perlakuannya (intervensi) berupa pemberian pendidikan kesehatan dengan pendekatan modelling. desain quasy eksperiment ini dilakukan untuk menilai dampak pendidikan kesehatan pendekatan modelling tentang manajemen laktasi dan stimulasi tumbuh kembang bayi, pada ibu yang telah mendapat tablet zat gizi mikro pada trimester 2 kehamilan. hasil hasil penelitian ini menunjukkan berdasarkan uji wilcoxon membuktikan ada perbedaan yang bermakna pada kelompok perlakuan dan kontrol, secara berurutan yaitu pengetahuan (p = 0,00, p = 0,01), kemampuan praktik (p = 0,00, p = 0,006). kepercayaan diri (p = 0,03, p = 0,03). uji mann whitney antara kedua kelompok didapat data, pengetahuan p = 0,950, kepercayaan diri p = 0,061 dan kemampuan praktik p = 0,00. kepercayaan diri (p = 0,03, p = 0,03). uji mann whitney antara kedua kelompok didapat data, pengetahuan p = 0,950, kepercayaan diri p = 0,061 dan kemampuan praktik p = 0,00. jurnal ners vol. 6 no. 2 oktober 2011: 175–186 178 tabel 1. perbedaan pengetahuan ibu sebelum dan setelah intervensi antara kelompok perlakuan dengan kelompok kontrol. kelompok pengetahuan ibu p*sebelum setelah perubahan median median median perlakuan (n = 41) 31,87 29,67 40,88 0,000 kontrol (n = 40) 50,36 52,61 41,12 0,001 p** 0,000 0,000 0,950 keterangan: *uji wilcoxon **uji mann whitney tabel 2. perubahan pengetahuan ibu antara kelompok perlakuan dengan kelompok kontrol kelompok pengetahuan ibu total pmeningkat tetap/menurun n % n % n % perlakuan (n = 41) kontrol (n = 40) 31 30 75,6 75,0 10 10 24,4 25,0 41 40 100 100 0,949 keterangan: rr: 1,5 (0,9–2,4) tabel 3. perbedaan kemampuan ibu menstimulasi tumbuh kembang antara kelompok perlakuan dengan kelompok kontrol kelompok kemampuan stimulasi p*sebelum setelah perubahan median median median perlakuan (n = 41) 37,27 43,05 47,77 0,000 kontrol (n = 40) 44,82 38,90 34,06 0,006 p** 0,145 0,424 0,001 keterangan: *uji wilcoxon **uji mann whitney tabel 4. perubahan kemampuan ibu menstimulasi tumbuh kembang antara kelompok perlakuan dengan kelompok kontrol. kelompok kemampuan stimulasi total pmeningkat tetap/menurun n % n % n % perlakuan kontrol 19 5 46 12,5 22 35 53,70 87,5 41 40 100 100 0,01 keterangan: rr: 1,5 (0,9–2,4) pendekatan modelling keperawatan anak (ariyanti saleh) 179 tabel 5. perbedaan kepercayaan diri ibu sebelum dan setelah intervensi antara kelompok perlakuan dan kelompok kontrol. kelompok kepercayaan diri ibu p*sebelum setelah perubahan median median median perlakuan (n = 41) 39,46 47,32 36,80 0,003 kontrol (n = 40) 42,58 34,52 45,30 0,152 p** 0,550 0,014 0,061 keterangan: *uji wilcoxon **uji mann whitney tabel 6. perubahan kepercayaan diri ibu antara kelompok perlakuan dan kontrol kelompok kepercayaan diri ibu total pmeningkat tetap/menurun n % n % n % perlakuan kontrol 25 16 61 40 16 24 39 60 41 40 100 100 0,059 keterangan: rr: 1,5 (0,9–2,4) pembahasan hasil uji homogenitas responden berdasarkan usia ibu, usia suami, pekerjaan suami dan pendapatan keluarga, hasil penelitian menunjukkan bahwa antara kelompok perlakuan dan kelompok kontrol telah memiliki kesetaraan atau homogenitas. hasil uji homogenitas antara kelompok perlakuan dan kelompok kontrol pada rerata usia ibu didapat nilai p = 0,78, rerata usia suami didapat nilai p = 0,49, pekerjaan suami didapat nilai p = 0,26 dan pendapatan keluarga didapat nilai p = 0,19. hasil uji homogenitas berdasarkan pendidikan ibu didapat nilai p = 0,005, pendidikan suami didapat nilai p = 0,01 dan jumlah anggota keluarga didapat nilai p = 0,01, hasil analisis statistik ini menunjukkan bahwa pendidikan ibu, pendidikan suami dan jumlah anggota keluarga pada kelompok perlakuan tidak setara atau tidak homogen dengan kelompok kontrol. tingkat pendidikan (ibu dan suami) pada kelompok perlakuan, masing-masing rerata tingkat pendidikan masih berada pada tingkat pendidikan yang rendah yaitu sebanyak 87,8% (36 orang) pada ibu dan 73,2% (30 orang) pada suami, dibandingkan rerata tingkat pendidikan pada kelompok kontrol yaitu pendidikan yang rendah pada ibu sebanyak 65% (26 orang) dan pada suami sebanyak 42,5% (17 orang). hasil penelitian menunjukkan tidak terdapat perbedaan untuk jenis pekerjaan suami antara kelompok perlakuan dan kelompok kontrol, sebagian besar pekerjaan suami adalah wiraswasta. keluarga yang memiliki pendapatan kurang dari 1 juta pada kelompok perlakuan sebanyak 78% (32 orang), sedangkan pada kelompok kontrol sebanyak 65% (26 orang). hal ini menunjukkan bahwa status ekonomi pada kelompok kontrol masih lebih tinggi dibandingkan pada kelompok perlakuan. diperoleh informasi bahwa pada kelompok perlakuan, keluarga yang memiliki jumlah anggota keluarga yang banyak (> 4) yaitu sebanyak 61% (25 orang), sedangkan pada kelompok kontrol keluarga yang memiliki jumlah anggota lebih dari 4 orang hanya 32,5% (13 orang). penelitian ini merupakan penelitian intervensi. intervensi yang dilakukan pada kelompok perlakuan adalah dengan pendidikan kesehatan. tujuan pendidikan kesehatan adalah untuk mengubah perilaku ibu ke arah positif yang dilaksanakan secara terencana melalui proses belajar. perubahan perilaku mencakup tiga ranah perilaku, yaitu pengetahuan, sikap dan kemampuan praktik. proses belajar yang jurnal ners vol. 6 no. 2 oktober 2011: 175–186 180 digunakan dalam pendidikan kesehatan pada penelitian ini adalah berdasar pada teori belajar sosial oleh bandura dengan konsep intinya adalah modelling, yang mengedepankan pelaksanaan praktik pada pelaksanaan pendidikan kesehatannya. perubahan perilaku yang dimaksud dalam proses belajar modelling adalah perubahan efi kasi diri dan perubahan kompetensi (kemampuan) ibu yang dapat digambarkan melalui kepercayaan diri ibu. pendidikan kesehatan dalam penelitian ini dilaksanakan sebanyak 3 kali, yaitu pendidikan kesehatan i dengan menggunakan modul tentang manajemen laktasi (pemberian asi) yang diberikan pada pada akhir trimester iii kehamilan. pendidikan kesehatan ii dengan menggunakan modul tentang stimulasi tumbuh kembang 1 (bayi 0–3 bulan) yang diberikan pada minggu pertama post partum dan pendidikan kesehatan iii dengan menggunakan modul tentang stimulasi tumbuh kembang 2 (bayi 3–6 bulan) yang diberikan ketika usia bayi 3 bulan. proses belajar modelling ini memiliki 4 fase yaitu atensi, retensi, reproduksi dan motivasi, yang sebagian besar fase-fase tersebut merupakan proses internal dari subjek belajar dalam menjalani pembelajaran sosial (hall dan lindzey, 1993; bandura, 1977; bastabel, 2002). pelaksanaan pemberian pendidikan kesehatan, dimulai dengan fase pertama yaitu petugas lapangan meningkatkan perhatian (atensi) para ibu. petugas memulainya dengan membina hubungan saling percaya, menanyakan kebutuhan ibu tentang informasi yang terkait dengan perawatan bayi, khususnya tentang cara pemberian asi dan stimulasi tumbuh kembang dan mengkaji hambatan ibu dalam merawat anak sebelumnya. menurut bandura (1977; bastabel, 2002), fase perhatian merupakan fase awal atau suatu kondisi yang diperlukan agar pembelajaran terjadi. model peran yang menarik, mampu membina hubungan saling percaya dan berkompetensi tinggi, akan lebih diamati oleh subjek belajar. sebagai upaya meningkatkan atensi ibu ketika memulai pendidikan kesehatan dan selama pendidikan kesehatan berlangsung serta peningkatan retensi ibu terhadap materi pendidikan kesehatan, maka digunakanlah berbagai metode belajar antara lain, demonstrasi, redemontrasi dan simulasi. selain itu, digunakan berbagai media belajar berupa leafl et, lembar balik dengan gambar dan warna yang menarik serta pantom boneka bayi saat demonstrasi keterampilan. metode belajar dan alat bantu yang digunakan didasarkan pada prinsip bahwa pengetahuan yang ada pada setiap manusia itu diterima atau ditangkap oleh panca indra, semakin banyak indra yang digunakan untuk menerima sesuatu, maka akan semakin jelas pengertian yang diperoleh. sesuatu yang menimbulkan perhatian, akan memberikan pengertian baru baginya dan merupakan pendorong untuk melakukannya (notoatmojo, 2007b). pemberian leafl et ketika petugas sudah tidak ada, memberikan pengalaman tersendiri bagi para ibu dan mendukung proses retensi terhadap materi dan teknik-teknik pemberian asi dan stimulasi. e v a l u a s i m e n g g a m b a r k a n b a h w a pendidikan kesehatan dengan metode belajar dan media belajar yang digunakan dalam penelitian ini, dapat meningkatkan atensi ibu dan retensi ibu dalam mengingat kembali materi pendidikan kesehatan, hal ini dapat dilihat dari hasil penelitian. hasil penelitian seperti yang terlihat pada tabel 2 menunjukkan bahwa pada kelompok perlakuan mengalami ranking positif (peningkatan urutan) dengan nilai median pengetahuan ibu sebelum intervensi adalah 31,87 dan setelah intervensi 29,67 serta nilai median perubahan sebesar 40,88. hasil uji wilcoxon didapatkan nilai p = 0,000, artinya ini terdapat perbedaan pengetahuan ibu pada kelompok perlakuan setelah pemberian pendidikan kesehatan dengan pendekatan modelling. pada kelompok kontrol nilai median sebelum intervensi 50,36, setelah intervensi 52,61 dan nilai median perubahan 41,12, dengan menggunakan uji wilcoxon didapatkan nilai p = 0,001, ini berarti bahwa pada kelompok kontrol juga mengalami perbedaan pengetahuan, namun dari nilai median terlihat bahwa pada kelompok kontrol ini mengalami penurunan urutan. hasil uji mann whitney terhadap kedua kelompok setelah intervensi menunjukkan nilai p = 0,000, artinya ada perbedaan pengetahuan ibu antara kelompok perlakuan dan kelompok kontrol setelah pendekatan modelling keperawatan anak (ariyanti saleh) 181 dilakukan intervensi. berdasarkan kategorisasi perubahan pengetahuan pada tabel 3 terlihat, terjadi peningkatan pengetahuan pada kedua kelompok sebanyak 75% dengan nilai p = 0,949, hal ini menunjukkan bahwa tidak terjadi perbedaan perubahan pengetahuan dari kedua kelompok. hasil penelitian menggambarkan bahwa pendidikan kesehatan dengan pendekatan modelling dapat meningkatkan pengetahuan ibu pada kelompok perlakuan. pada kelompok kontrol, meskipun tidak diberikan pendidikan kesehatan secara langsung oleh petugas dari tim peneliti, tetapi para ibu juga mengalami peningkatan pengetahuan. hal ini dapat disebabkan oleh tingkat pendidikan ibu tinggi dan informasi yang sebelumnya telah diperoleh ibu melalui informasi yang diberikan petugas kesehatan misalnya dari bidan dan perawat puskesmas. hal ini didukung pula oleh penelitian pendahuluan di wilayah kerja kecamatan mandai terhadap 30 sampel ibu menunjukkan bahwa para ibu sebanyak 53,3% memperoleh informasi mengenai pertumbuhan dan perkembangan bayi berasal dari media massa, 30% dari puskesmas dan 16,7% dari keluarga. hasil penelitian ini sesuai dengan penelitian yang dilakukan oleh sharma dan nagar (2006) bahwa pendidikan kesehatan pada ibu akan meningkatkan pengetahuan ibu terhadap perawatan anak dan akan mengurangi kesalahan ibu atau caregiver dalam merawat dan akan meningkatkan tumbuh kembang yang positif. selanjutnya hasil penelitian ini juga sejalan dengan laporan hasil studi piwoz (2005), yang menunjukkan bahwa pemberian pendidikan kesehatan dan konseling, memiliki relevansi dengan peningkatan pengetahuan dan praktik pemberian asi. tingkat pengetahuan seseorang yang semakin tinggi akan berdampak pada perkembangan ke arah yang lebih baik sehingga ibu yang berpengetahuan baik akan lebih objektif dan terbuka wawasannya dalam mengambil suatu keputusan atau tindakan yang diaplikasikan dengan perbuatan atau perilaku yang positif, terutama dalam hal memberikan stimulasi pertumbuhan dan perkembangan anaknya. staton (1978) dalam notoatmojo (2007a), menyebutkan pengetahuan atau k n o w l e d g e a d a l a h i n d i v i d u y a n g t a h u apa yang akan dilakukan dan bagaimana melakukannya. sehubungan dengan itu pengetahuan merupakan salah satu aspek perilaku yang menunjukkan kemampuan seseorang untuk mengerti dan menggunakan kemampuan (dengan pikiran) segala sesuatu yang telah dipelajarinya. pengetahuan atau kognitif merupakan domain yang sangat penting untuk terbentuknya tindakan seseorang (overt behaviour). departemen kesehatan (2001) melaporkan bahwa ketidaktahuan ibu hamil tentang dampak anemia terhadap kesehatan diri, kehamilan dan janinnya, menyebabkan kepedulian dan kemauannya untuk mencegah dan menanggulanginya kurang/tidak ada. demikian pula tentang tidak diketahuinya manfaat stimulasi sebagai upaya untuk mencegah terjadinya kegagalan tumbuh kembang, menyebabkan mereka tidak tertarik dan enggan untuk melakukan stimulasi pada anaknya. tahap berikut dari pendidikan kesehatan dengan pendekatan modelling adalah tahap reproduksi, yaitu terjadinya pengaktifan kembali hal-hal yang telah dicamkan sebelumnya. pada tahap ini terjadi proses mengingat kembali dan mempraktikkan kembali keterampilan yang telah disampaikan pada saat pendidikan kesehatan. menurut rogers (1974) dalam notoatmojo (2007a) pada proses perubahan perilaku apabila didasari oleh pengetahuan, kesadaran dan sikap yang positif maka perilaku tersebut akan bersifat langgeng (long lasting), begitu pula pada penelitian ini para ibu yang telah memilki pengetahuan yang baik dan sikap yang positif dari hasil penelitian terlihat memiliki kemampuan yang meningkat. h a s i l p e n e l i t i a n p a d a t a b e l 4 memperlihatkan bahwa pada kelompok perlakuan, nilai median sebelum intervensi 37,27, setelah intervensi nilai median 43,05 dan nilai median perubahan 47,77, berdasarkan uji wilcoxon didapatkan nilai p = 0,000. hal ini berarti terdapat perbedaan kemampuan ibu menstimulasi tumbuh kembang pada kelompok perlakuan sebelum dan setelah intervensi. jurnal ners vol. 6 no. 2 oktober 2011: 175–186 182 pada kelompok kontrol nilai median sebelum intervensi 44,82, setelah intervensi 38,90 dan nilai median perubahan 34,06, dengan menggunakan uji wilcoxon didapatkan nilai p = 0,006, hal ini berarti terjadi pula perbedaan kemampuan ibu menstimulasi tumbuh kembang pada kelompok kontrol. berdasarkan uji mann whitney, diperoleh hasil tidak bermakna p = 0,424, artinya tidak ada perbedaan kemampuan menstimulasi tumbuh kembang antara kelompok perlakuan dan kelompok kontrol setelah dilakukan intervensi. meskipun terjadi perubahan pengetahuan ke arah rangking negatif setelah intervensi pada kelompok perlakuan, namun jika dilihat dari data berdasarkan kategorisasi seperti yang terlihat pada tabel 5, bahwa terjadi perubahan peningkatan kemampuan dari ibu setelah intervensi pendidikan kesehatan sebanyak 46% ibu pada kelompok perlakuan, sedangkan kelompok kontrol hanya sebesar 12,5% ibu yang mengalami peningkatan kemampuan. hal ini sesuai dengan konsep yang menjelaskan bahwa pendidikan kesehatan pada klien telah menunjukkan potensinya untuk meningkatkan kepuasan, memperbaiki kualitas hidup, memastikan kelangsungan perawatan, secara efektif mengurangi insiden komplikasi penyakit, memasyarakat masalah kepatuhan terhadap rencana pemberian perawatan kesehatan dan menurunkan ansietas dan memaksimalkan kemandirian dalam melakukan aktivitas yang terkait kesehatan yang salah satunya adalah melakukan stimulasi perkembangan pada bayi (bastabel, 2002). hasil penelitian yang dilakukan oleh pulley and stepans (2002) berupa intervensi pendidikan kesehatan tentang smoking hygiene. smoking hygiene, diajarkan dengan menggunakan pamphlet and reinforcement tiap kunjungan, menunjukkan hasil yang tidak berbeda terhadap penanganan dan kejadian penyakit pernafasan di antara kelompok intervensi dan kelompok kontrol. praktik pengasuhan yang dijalankan ibu dipandang sebagai peubah yang berpengaruh terhadap pertumbuhan anak. esensi kualitas p e n g a s u h a n a n a k a d a l a h p r a k t i k y a n g dijalankan ibu terhadap anaknya terkait pengasuhan makanan anak, perawatan dasar, higiene-perorangan-kesehatan lingkungan dan keamanan anak (bahar, 2002). h a s i l p e n e l i t i a n t e r l i h a t b a h w a kemampuan praktik menstimulasi dari kedua kelompok tidak menunjukkan perbedaan, yang artinya ibu yang pengetahuannya setelah pendidikan kesehatan lebih meningkat tetapi dari kemampuan tidak berbeda, namun dari pengalaman dan penelitian ternyata bahwa kemampuan seseorang tidak harus didasari oleh pengetahuan atau sikap saja. meskipun dikatakan juga bahwa perilaku yang didasari oleh pengetahuan akan lebih langgeng daripada yang tidak didasari oleh pengetahuan. hal ini juga terkait dengan budaya yang tidak menjadikan tindakan stimulasi bayi menjadi sebuah keharusan bagi ibu atau keluarga dalam melaksanakan perawatan bayi. hal penting dari perilaku kesehatan adalah pembentukan atau perubahan perilaku yang merupakan tujuan dari suatu pendidikan kesehatan. perubahan perilaku yang menetap dalam penelitian ini sesuai dengan konsep modelling adalah dikaitkan dengan kemampuan ibu dalam melakukan reproduksi kembali keterampilan pemberian asi dan stimulasi bayi secara terus-menerus. walaupun disadari bahwa perubahan perilaku membutuhkan waktu yang lama dalam pencapaiannya. dalam upaya melihat kesinambungan kemampuan ibu, maka pada penelitian ini dilakukan evaluasi proses sesaat setelah pendidikan kesehatan dan evaluasi hasil pada 2 kali kegiatan. meskipun dari hasil penelitian terlihat peningkatan kemampuan ibu pada 2 kali evaluasi, namun peneliti merasakan perlunya kegiatan evaluasi dan supervisi yang berkesinambungan untuk melihat kemampuan dalam mempertahankan perilakunya seperti memberikan asi dan menstimulasi bayi. seperti dilaporkan oleh robert et al (2007) bahwa evaluasi dari implementasi yang dilaksanakan dibandingkan dengan implementasi yang direncanakan penting dilakukan untuk pengembangan implementasi program pendidikan kesehatan selanjutnya. pencapaian peran menjadi ibu yang merupakan konsep inti dalam teori mra, kemampuan ibu merupakan hal yang penting. pada konsep kedua dari teori keperawatan mra pendekatan modelling keperawatan anak (ariyanti saleh) 183 menjelaskan bahwa role strain-role confl ict (konfl ik peran) didefi nisikan sebagai konfl ik dan kesulitan yang dirasakan oleh wanita dalam penyesuaiannya terhadap tugas peran ibu, dipengaruhi oleh kemampuannya dalam berinteraksi dengan bayinya. selanjutnya infant temperament yang dikaitkan dengan kesulitan bayi dalam mengirimkan berbagai isyarat, juga dipengaruhi oleh ketidakmampuan dan keputusasaan ibu dalam merawat bayi (mercer, 2006). menurut mercer dan walker (2006), dalam konsep keperawatan mra upaya yang dilakukan dalam meningkatkan percaya diri dan efi kasi diri ibu adalah dengan cara memberikan pendidikan kesehatan. dengan pendidikan kesehatan yang diberikan pada ibu maka pertumbuhan dan perkembangan bayi diharapkan akan menjadi lebih meningkat. selanjutnya mercer dan walker (2006) mengatakan bahwa kepercayaan diri ibu merupakan variabel penting dalam adaptasi menjadi ibu dan peran maternal. maternal role identity dalam teori mra melibatkan komponen afektif dan perilaku. komponen afektif dikaitkan dengan perasaan subjektif ibu tentang kemampuan merawat bayi. berdasarkan hasil penelitian seperti terlihat pada tabel 5 menunjukkan bahwa pada kelompok perlakuan, nilai median sebelum intervensi 39,46, setelah intervensi 47,32, dan nilai median perubahan 36,80, dengan menggunakan uji wilcoxon didapatkan nilai p = 0,003. hal ini berarti terjadi perbedaan kepercayaan diri ibu setelah intervensi pada kelompok perlakuan. pada kelompok kontrol nilai median sebelum intervensi 42,58, setelah intervensi 34,52 dan nilai median perubahan 45,30 pada uji wilcoxon didapatkan nilai p = 0,152, artinya tidak ada perbedaan kepercayaan diri ibu pada kelompok kontrol. uji mann whitney menunjukkan hasil yang bermakna p = 0,014, hal ini berarti ada perbedaan kepercayan diri antara kelompok perlakuan dan kelompok kontrol setelah dilakukan intervensi. setelah intervensi terlihat, berdasarkan kategorisasi terhadap kepercayaan diri ibu, pada kelompok perlakuan menunjukkan bahwa ibu yang mengalami perubahan peningkatan kepercayaan diri sebanyak 61% ibu, bila dibandingkan dengan kelompok kontrol yang perubahannya cenderung berkebalikan yaitu kepercayaan diri ibu tetap/menurun sebanyak 60% dengan nilai p = 0,059. hasil ini menunjukkan bahwa terjadi peningkatan k e p e r c a y a a n d i r i i b u p a d a k e l o m p o k perlakuan. hal ini sesuai dengan teori yang dikemukakan oleh monk (2002) bahwa tingkat pengetahuan seseorang mempunyai pengaruh dalam pembentukan kepercayaan dirinya. semakin tinggi tingkat pengetahuan seseorang, berarti semakin banyak yang telah dipelajari individu sehingga dapat lebih mengenal diri baik kekurangan maupun kelebihannya sehingga mampu menentukan sendiri standar keberhasilannya. semakin dewasa umur seseorang maka semakin banyak pengalaman dan informasi yang diperoleh sehingga dapat membangun konsep diri yang baik yang mampu menumbuhkan kepercayaan diri dalam melakukan sesuatu. seperti yang diungkapkan russell (2006) bahwa kepercayaan diri maternal adalah sebuah komponen peran maternal, diartikan sebagai persepsi ibu terhadap kemampuannya dalam merawat dan memahami anak-anaknya. kepercayaan diri maternal adalah persepsi ibu akan kemampuannya merawat bayi, mengenali dan merespons perilaku bayi, dan merasa puas menjalankan perannya sebagai ibu. kepercayaan diri merupakan refleksi kompetensi ibu, kemampuan maternal yang dipengaruhi oleh beberapa variabel, selain pengetahuan dan perolehan keterampilan, juga termasuk variabel psikososial maternal dan karakteristik ibu, serta dukungan sosial, sedangkan hal lain yang memengaruhi adalah karakteristik dan sifat bayi. penelitian ini sesuai dengan hasil penelitian russell (2006) yang menyebutkan bahwa kepercayaan diri ibu berhubungan secara signifi kan dengan dukungan keluarga, selain itu kondisi depresi ibu dan temperamen bayi, juga dipengaruhi tingkat pengetahuan dan pendidikan ibu. semakin dewasa umur seseorang maka semakin banyak pengalaman dan informasi yang diperoleh sehingga dapat membangun konsep diri yang baik yang mampu menumbuhkan kepercayaan jurnal ners vol. 6 no. 2 oktober 2011: 175–186 184 diri dalam melakukan sesuatu. di samping itu, pengalaman dan dukungan sosial juga merupakan faktor yang sangat berpengaruh terhadap kepercayaan diri ibu dalam merawat bayi. dengan kepercayaan diri yang tinggi ibu akan lebih optimal dalam mengasuh anak-anaknya. zahr (1993) melaporkan adanya hubungan bermakna antara perilaku maternal dengan berat badan bayi, bahwa ibu dengan bayi yang berat badan lebih besar akan membuat ibu tersebut lebih percaya diri dalam merawat bayinya. ibu dengan bayi yang mengalami status kesehatan yang rendah memiliki kepercayaan diri yang lebih rendah. porter dan hsu (2003) melaporkan bahwa ibu yang memiliki beberapa anak lebih percaya diri dibandingkan dengan ibu yang baru pertama kali mempunyai anak. selanjutnya dilaporkan bahwa karakteristik maternal pengetahuan tentang tumbuh kembang anak, demografi maternal (usia, pendapatan keluarga, pekerjaan), paritas, status kesehatan bayi dan dukungan keluarga memengaruhi kepercayaan diri ibu, walaupun bermakna namun korelasinya relatif rendah. intervensi pendidikan kesehatan pada ibu telah meningkatkan percaya diri ibu. hasil ini menunjukkan bahwa teori mra dapat menjadi panduan bagi perawat atau petugas kesehatan dalam membantu pencapaian peran ibu. pada teori ini dikemukakan bagaimana proses pencapaian peran ibu dan proses akan menjadi seorang ibu dengan memberikan bantuan terhadap klien dengan memberikan pendidikan kesehatan dan dukungan serta memfasilitasi interaksi antara ibu dan bayi sedini mungkin. penelitian ini juga sesuai dengan penelitian goto et al. (2010) yang menunjukkan pentingnya program parenting support yang salah satu kegiatannya adalah pendidikan kesehatan dalam membantu ibu jepang dan vietnam untuk meningkatkan self-effi cacy yang merupakan tahap lanjut dari percaya diri. menurut blyth r et al. (2002), self-effi cacy ibu menyusui merupakan predictor signifi cant untuk durasi dan tingkat menyusui. integrasi strategi atau upaya peningkatan self-efficacy dapat meningkatkan kualitas pelayanan kesehatan yang diberikan oleh tenaga kesehatan dan dapat meningkatkan kepercayaan diri ibu baru dalam menyusui dan untuk tetap menyusui meski mengalami kesulitan. simpulan dan saran simpulan pendidikan kesehatan dengan pendekatan modelling yang dilakukan perawat efektif dalam meningkatkan pengetahuan, kemampuan praktik, kepercayaan diri ibu dalam pemberian asi dan menstimulasi bayi. saran pelaksanaan pendidikan kesehatan di masyarakat, sebaiknya dilakukan dengan pendekatan modelling disertai modul karena terbukti dapat meningkatkan pengetahuan, kemampuan praktik dan kepercayaan diri ibu yang memang sangat dibutuhkan dalam perawatan bayi sehingga bayi dapat tumbuh dan kembang lebih optimal. oleh sebab itu, pemberdayaan perawatan kesehatan masyarakat perlu ditingkatkan dengan menjadikan program perawatan kesehatan masyarakat sebagai salah satu program wajib puskesmas. kepustakaan bahar, b., 2002. pengaruh pengasuhan t e r h a d a p p e r t u m b u h a n a n a k : pengamatan longitudinal pada anak etnis bugis usia 0–12 bulan di barru, sulawesi selatan. disertasi yang tidak diterbitkan. surabaya: program pascasarjana unair. bandura, a., 1986. social foundations of thought and action. englewood cliffs. nj: prentice-hall. bandura, a., 1997. self-effi cacy: the exercise of control. new york: w.h. freeman. bastabel, s.b., 2002. perawat sebagai pendidik: prinsip-prinsip pengajaran dan pembelajaran. terjemahan oleh wulandari, g. dan widyanto, g. jakarta: egc. blyht, r., et al., 2002. effect of maternal confi dence on breastfeeding duration: an application of breastfeeding selfeffi cacy theory. birth, 29(4), 278–284. butz, a., et al., 2005. rural children with asthma: impact of a parent and child pendekatan modelling keperawatan anak (ariyanti saleh) 185 asthma education program. j asthma, 42(10), 813–821. departemen kesehatan republik indonesia, 2001. survei kesehatan rumah tangga (skrt). jakarta: badan penelitian dan pengembangan kesehatan. departemen kesehatan. departemen kesehatan republik indonesia, 2005a. pedoman pelaksanaan stimulasi, deteksi dan intervensi dini tumbuh kembang anak di tingkat pelayanan kesehatan dasar. jakarta: direktorat gizi masyarakat. departemen kesehatan. departemen kesehatan republik indonesia, 2005b. manajemen laktasi: pedoman bagi bidan dan tenaga kesehatan di puskesmas. jakarta: direktorat gizi masyarakat. departemen kesehatan. departemen kesehatan republik indonesia, 2006b. pedoman kegiatan perawat kesehatan masyarakat di puskesmas. j a k a r t a : d i r e k t o r a t k e p e r a w a t a n dan keteknisian medis. departemen kesehatan. dinas kesehatan sulawesi selatan, 2008. cakupan pelayanan minimal bidang kesehatan dalam angka propinsi sulawesi selatan tahun 2003–2007 (online).(http://datinkessulsel.files. wordpress.com/2008/10/spm-kesehatansulsel-2003-2007-dalam-angka.pdf, diakses 25 februari 2010). goto, a., et al., 2010. assosiations of psychocial factors with maternal confi dence among japanese and vietnamese mothers. j child fam stud, 19, 118–127. grantham-mcgregor, et al., 2007. the international child development steering group, child development in developing countries: developmental potential in the fi rst 5 years for children in developing countries. lancet, 369 (9555), 60–70. f i e l d , t. m . , 1 9 8 6 . ta c t i l e / k i n e s t h e t i c stimulation effects on preterm neonates. the american academy of pediatrics journal, 77, 654–658. hall, c.s., dan lindzey, g., 1985. introduction the theories of personality. new york: jhon wiley & sons, hlm. 553–570. hall, c.s., dan lindzey, g., 1993. teori-teori sifat dan behavioristik. yogyakarta: kanisius. harisawati, rr., h., 2008. konseling gizi pada ibu hamil untuk perubahan perilaku makan dan status gizi selama kehamilan di rsb pertiwi makassar. tesis yang tidak diterbitkan. makassar: program pascasarjana unhas. kuperus, n.w., baerts, w., smrkovsky, m., sauer, p.j., 1993. effects of biological and social factors on the cognitive development of very low birth weight children. the american academy of pediatrics journal, 92, 658–659. meighan, m., 2006. maternal role attainment – becoming a mother. in m.alligood and a.tomey (ed.). nursing theorists and their work. missouri: mosby inc. mercer, t.r., 2006. maternal role attainment– becoming a mother. in m. alligood and a.tomey (ed.) nursing theorists and their work. missouri: mosby inc. mercer, t.r., dan walker, l.o., 2006. a review of nursing intervention to foster becoming a mother. awhonn. jognn. 35(5). minick, m.j.a., brasel, dan pedro, r., 1991. nutrition and cell growth, nutrition and development. canada: john wiley and sons inc. monk, f.j., knoers, a.m.p., haditono, s.r., 2002. psikologi perkembangan pengantar dalam berbagai bagiannya. yogyakarta: gajah mada university press. notoatmodjo, s., 2007b. promosi kesehatan masyarakat dan ilmu perilaku. jakarta: pt rineka cipta. piwoz, e.g., et al., 2005. an education and counseling program for preventing b r e a s t f e e d i n g a s s o c i a t e d h i v transmission in zimbabwe: design and impact on maternal knowledge and behaviour. the journal of nutrition, 135, 950–955. porter, c., dan hsu, h., 2003. first-time mothers' perceptions of effi cacy during the transition to motherhood: links to infant temperament. journal of family psychology, 17(1), 54–64. pulley, k.r., dan stepans, m.b.f., 2002. smoking hygiene: an educational intervention to reduce respiratory symptoms in breastfeeding infants jurnal ners vol. 6 no. 2 oktober 2011: 175–186 186 exposed to tobacco. the journal of perinatal education, 11(3), 28–37. robert, cr., 2007. implementation examined in a health center-delivered, educational intervention that improved infant growth in trujillo peru successes and challenges. oxford journals, 22(3), 318–331. russell, k., 2006. maternal confidence of first-time mothers during their child's infancy, (online), (http:// www.conferenceprogram.com/snrs/ graduateposters/g140_russell.pdf., diakses 25 mei 2010). sarma, s., nagar, s., 2006. impact of educational intervention on knowledge of mothers regarding chilcare and nutrition in himachal pradesh. journal social science, 12(2), 139–142. soetjiningsih, 1995. tumbuh kembang anak. jakarta: egc. world health organization (who), 2001. guiding principles for complementary feeding of the breastfed child. global consultation on complementary feeding: geneva. zahr, l.k., 1993. the confi dence of latino mothers in the care of their low birth weight infants. research in nursing and health, 16, 335–342. vol 9 no 1 april 2014.indd 138 kondisi ekonomi dan budaya keluarga dengan status gizi balita (family’s economic level and culture correlate with nutritional status of children under five years) abdul muhith*, nursalam**, lutfi ana wulandari* *stikes majapahit mojokerto jl raya jabon gayaman km.02 mojokerto ** fakultas keperawatan, universitas airlangga e-mail: cua_muhith@yahoo.co.id abstrak pendahuluan: nutrisi adalah bagian penting dari kehidupan manusia. perbedaan budaya dan tingkat ekonomi berdampak pada perbedaan kebiasaan makan keluarga. tingkat ekonomi yang baik membuat keluarga memiliki kesempatan yang lebih besar untuk memenuhi kebutuhan nutrisi balita. perbedaan budaya berdampak pada perbedaan pemilihan bahan, cara pengolahan, dan penyajian makanan. tujuan dari penelitian ini adalah untuk menjelaskan hubungan tingkat ekonomi dan budaya dengan status nutrisi balita. metode: desain penelitian observasional analitik dengan pendekatan cross sectional. populasi adalah ibu dan balitanya (usia 1-5 tahun) di desa jatigono kunir, kabupaten lumajang. sampel sejumlah 184 orang diambil dengan teknik cluster sampling. variabel independen adalah tingkat ekonomi dan budaya keluarga. variabel dependen adalah status nutrisi balita. data dikumpulkan dengan kuesioner dan lembar observasi. data yang terkumpul kemudian dianalisis dengan spearman rho test α<0.05. hasil: hasil penelitian menunjukkan bahwa 140 (76.1%) responden memiliki tingkat ekonomi bawah, 105 (57.1%) responden memiliki budaya yang negatif tentang nutrisi balita, dan 89 (48%) responden berada pada status nutrisi yang baik. analisis dengan spearman rho test menunjukkan ada hubungan antara tingkat ekonomi (p=0.000) dan budaya (p=0.019) dengan status nutrisi balita. diskusi: kondisi ekonomi dan budaya berhubungan dengan status nutrisi balita. perawat dapat menyusun strategi pendidikan kesehatan dan konseling gizi pada keluarga, sehingga status nutrisi balita berada pada rentang yang normal. kata kunci: tingkat ekonomi, budaya keluarga, status nutrisi, balita abstract introduction: nutrition is an important thing for human life. variety in family’s economic level and culture have effect on family’s eating habit. family with higher economic status have big opportunity to met under fi ve year’s nutrition. cultural diversity on each family has an impact on the difference of raw food selection, processing methods, and presentation of food. the purpose of this study was to determine the correlation between family’s economic level and culture with nutritional status of children under fi ve year. method: research design was observational analytic with cross sectional approach. the population were mother and their children under fi ve years at desa jatigono kunir, kabupaten lumajang. sampel were 184 respondents, taken by using cluster sampling. independent variables were family’s economic level and culture. dependent variable was nutritional status of children under fi ve years. data were collected by using questionnaire and observational sheet. then, data were analyzed by using spearman rho test with α<0.05. result: the results showed that 140 (76.1%) respondents have low economic level, 105 (57.1%) respondents have negative culture in children’s nutrition, and 89 (48%) respondents have good nutritional status. the result of spearman-rho test showed that family’s economic level (p=0.000) and culture (0.019) have correlated with nutritional status of children under fi ve years. discussion: it can be concluded that family’s economic level and culture have correlated with nutritional status of children under fi ve years. nurses should develop health education and counseling to improve family’s knowledge about nutrition, so children will have good nutritional status. keywords: economic level, family’s culture, nutritional status, children under fi ve years pendahuluan tujuan utama pembangunan nasional adalah peningkatan kualitas sumber daya manusia (sdm) yang dilak ukan secara berkelanjutan. salah satu faktor penentu utama kualitas sumber daya manusia adalah gizi (depkes ri, 2004). krisis ekonomi di indonesia pada pertengahan 1997 telah berpengaruh negatif terhadap kondisi perekonomian secara menyeluruh, khususnya terhadap kesejahteraan penduduk. kondisi ini menyebabkan sebagian masyarakat tidak mampu mengakses pangan dan pada akhirnya berpengaruh terhadap keadaan gizi, terutama balita, serta ibu hamil dan ibu menyusui (yessy, 2012). di negara berkembang, kesakitan dan kematian pada 139 kondisi ekonomi dan budaya keluarga (abdul muhith, dkk.) balita banyak dipengaruhi oleh keadaan gizi (supariasa, 2012). oleh karena itu, status gizi balita perlu dipertahankan dalam kondisi baik dengan cara memberikan makanan bergizi seimbang yang sangat penting untuk pertumbuhan (paath, 2004). kualitas gizi di indonesia sangat memprihatinkan. gizi merupakan bagian penting dari kehidupan manusia yang tak dapat dilepaskan dari faktor sosial budaya, serta lingkungan di mana masyarakat bertempat tinggal. kebudayaan ber pengar uh pada pola makan dan gizi masyarakat (erna, 2005). menurut riset kesehatan dasar (2007) di indonesia diketahui bahwa prevalensi balita dengan gizi buruk 5.4%, gizi kurang 13.0%, gizi baik 77.2%, dan gizi lebih 4.3%. sementara itu, di jawa timur tercatat prevalensi balita dengan gizi buruk 4.8%, gizi kurang 12.6%, gizi baik 78%, dan gizi lebih 4.5%. menurut data pemantauan status gizi (psg) balita berdasarkan bb/u pada 2010 di kabupaten lumajang, dari 70.749 balita yang ditimbang didapatkan balita dengan gizi buruk 1.32%, gizi kurang 13.15%, gizi baik 83.63%, dan gizi lebih 1.90% (yessy, 2012). berdasarkan data register pencatatan bulan timbang desa/kelurahan jatigono, kecamatan kunir, kabupaten lumajang (2012) diketahui ada 329 balita, yang berasal dari keluarga gakin sebanyak 74 orang dan non gakin 255 orang. dari data tersebut, yang berstatus gizi kurang sebanyak 2 balita, gizi baik 291 balita, dan gizi lebih 36 balita. faktor yang mempengar uhi stat us gizi balita antara lain, kurangnya persediaan pa nga n d a n k u r a ng bai k nya k u al it a s lingkungan (almitsier, 2010). adapun faktor lain yang mempengar uhi adalah kondisi ekonomi dan budaya keluarga, seperti pola asuh keluarga (depkes ri, 2004). kondisi ekonomi keluarga dapat diukur dari variabel pendapatan keluarga, tingkat pendidikan, dan pekerjaan (notoatmodjo, 2005). indonesia memiliki keanekaragaman budaya dengan latar belakang suku dan tata kehidupan sosial budaya yang berbeda. perbedaan budaya berdampak pada perbedaan pemilihan bahan, cara pengolahan, dan penyajian makanan. para ahli sosiologi dan ahli gizi menyatakan bahwa faktor budaya sangat berperan terhadap proses terjadinya kebiasaan makanan dan bentuk makanan itu sendiri, sehingga tidak jarang menimbulkan berbagai masalah gizi apabila tidak diperhatikan baik. masalah gizi pada balita akan berdampak serius terhadap kualitas generasi mendatang (almatsier, 2010). upaya p e n a ng g u la nga n m a s a la h gizi telah dilakukan pemerintah melalui pemberdayaan keluarga u nt u k menjaga ketahanan pangan di tingkat rumah tangga, peningkatan upaya pelayanan gizi terpadu, dan pengembangan sistem r ujukan dari tingkat pos pelayanan terpadu (posyandu), puskesmas, dan rumah sakit, peningkatan komunikasi informasi dan edukasi di bidang pangan dan gizi masyarakat, serta intervensi langsung kepada sasaran melalui pemberian makanan tambahan (pmt), distribusi vitamin a dosis tinggi, tablet, dan sirup besi, serta kapsul minyak beriodium (almatsier s, 2010). akan tetapi, hasilnya masih kurang signifi kan terhadap penurunan masalah gizi di indonesia. oleh karena itu, perlu adanya strategi baru untuk mendukung upaya-upaya yang sudah dilakukan tersebut. penelitian ini bertujuan untuk menganalisis hubungan tingkat ekonomi dan budaya keluarga dengan status gizi balita. bahan dan metode d e s a i n p e n e l i t i a n i n i a d a l a h observasional analitik dengan pendekatan cross sectional. populasi adalah semua ibu dan balitanya (usia 1-5 tahun) yang tercatat di posyandu balita, desa jatigono, kecamatan kunir, kabupaten lumajang, yaitu sebanyak 340 responden. sa mpel seba nya k 184 responden diambil dengan teknik cluster sampling. variabel independen adalah tingkat ekonomi dan budaya keluarga. sedangkan, variabel dependen adalah status nutrisi balita. data tingkat ekonomi dan budaya keluarga dikumpulkan dengan kuesioner dan data status nutrisi balita dikumpulkan dengan lembar observasi. data yang terkumpul kemudian dianalisis dengan spearman rho test dengan α<0.05. 140 jurnal ners vol. 9 no. 1 april 2014: 138–142 hasil berdasarkan hasil pengolahan data diketahui bahwa sebagian besar responden dengan berada pada tingkat ekonomi bawah, yait u sebanyak 140 (76,1%) responden, memiliki budaya negatif tentang gizi pada balita sebanyak 105 (57,1%) responden, dan sebagian besar responden memiliki status gizi yang baik, yaitu sebanyak 89 (48%) responden. berdasarkan tabel 1, diketahui bahwa ada hubungan yang signifi kan antara tingkat ekonomi keluarga dan status gizi balita. sementara tabel 2 menunjukkan bahwa ada hubungan yang signifikan antara budaya keluarga dan status gizi balita. pembahasan tabel 1 menunjukkan bahwa sebagian besar responden berada pada tingkat ekonomi bawah. tingkat ekonomi adalah kedudukan atau posisi seseorang dalam masyarakat. tingkat ekonomi membentuk gaya hidup keluarga. pendapatan keluarga yang memadai akan menunjang tumbuh kembang anak tabel 1. hasil uji spearman rho test hubungan tingkat ekonomi keluarga dan status gizi balita tingkat ekonomi status gizi balita total lebih baik sedang kurang f % f % f % f % f % bawah 4 2,1 72 39,1 62 33,7 2 1,1 140 76,1 menengah 18 9,8 16 8,7 9 4,9 0 0 43 23,4 atas 0 0 1 0,5 0 0 0 0 1 0,5 total 22 11,9 89 48,4 71 38,6 2 1,1 184 100 spearman rho test p=0.000 tabel 2. hasil uji spearman rho test hubungan budaya keluarga dan status gizi balita budaya keluarga status gizi balita total lebih baik sedang kurang f % f % f % f % f % positif 9 4,9 37 20,1 33 17,9 0 0 79 42,9 negatif 13 7 52 28,3 38 20,7 2 1,1 105 57,1 total 22 11,9 89 48,4 71 38,6 2 1,1 184 100 spearman rho test p=0.0190 karena orang tua dapat memenuhi semua kebutuhan, baik primer maupun sekunder (soetjiningsih, 2005). menurut friedman (2004), faktor yang mempengaruhi tingkat ekonomi individu, antara lain pendidikan, pekerjaan, keadaan ekonomi, latar belakang budaya dan pendapatan. pekerjaan merupakan sarana untuk memperoleh uang dalam rangka memenu hi kebut u han hidup, ter masu k pelayanan kesehat an yang dii ngi n kan. sebagian besar responden bekerja sebagai buruh dan tidak bekerja (ibu rumah tangga), dengan penghasilan rata-rata keluarga per bulan rp.1.000.000,00. oleh karena itu, sebagian besar responden memiliki tingkat ekonomi bawah. tabel 2 menunjukkan bahwa sebagian besar responden memiliki budaya negatif tentang gizi balita. kebudayaan adalah peradaban yang mengandung pengertian luas, meliputi pemahaman dan perasaan suatu bangsa yang kompleks, pengetahuan, kepercayaan, seni, moral, hukum, adat istiadat (kebiasaan), dan pembawaan lainnya yang diperoleh dari anggota masyarakat (taylor, 2009). faktor yang mempengaruhi perubahan sosial budaya, 141 kondisi ekonomi dan budaya keluarga (abdul muhith, dkk.) antara lain: kontak dengan kebudayaan lain, sistem pendidikan formal yang maju, toleransi, sistem stratifi kasi terbuka, penduduk yang heterogen, ketidakpuasan masyarakat terhadap berbagai bidang kehidupan, orientasi ke masa depan, dan pandangan bahwa manusia harus senantiasa ber usaha untuk memperbaiki hidupnya (damayanti, 2012). berdasarkan hasil pengola ha n k uesioner penelit ia n diketahui bahwa sebagian besar responden tidak memiliki jadwal makan tetap untuk balita dalam keluarga, setiap habis makan tidak selalu ada makan pendamping seperti buah, dan keluarga tidak segera membawa ke rumah sakit saat balita mengalami sakit. sebagian besar responden memiliki balitas dengan status gizi baik. status gizi adalah ekspresi dari keadaan keseimbangan d ala m be nt u k va r iabel t e r t e nt u , at au perwujudan dari nutriture dalam bentuk variabel tertentu (supariasa, 2012). status gizi balita merupakan hal penting yang harus diketahui oleh setiap orang tua. perlunya perhatian lebih dalam tumbuh kembang di usia balita didasarkan fakta bahwa kurang gizi yang terjadi pada masa emas ini, bersifat irreversible (tidak dapat pulih). status gizi pada balita dapat diketahui dngan cara mencocok kan umur anak (dalam bulan) dengan berat badan standar tabel who-nchs. apabila berat badannya kurang, maka status gizinya kurang (khomsan, 2009). faktorfaktor yang mempengaruhi keadaan gizi balita, antara lain: 1) faktor eksternal (meliputi, status ekonomi, pendidikan, pekerjaan, dan budaya); 2) faktor internal (meliputi: usia, kondisi fi sik, dan infeksi) (nurdiana, 2012). status gizi baik pada balita disebabkan karena kebutuhan gizi pada balita sudah cukup. kebutuhan gizi seseorang adalah jumlah yang diperkirakan cukup untuk memelihara kesehatan. asupan zat gizi dan pengeluarannya harus seimbang, sehingga diperoleh status gizi baik. hasil penelitian menunjuk kan ada hubungan yang signifikan antara tingkat ekonomi keluarga dan status gizi balita. salah satu faktor yang mempengaruhi status gizi balita adalah tingkat ekonomi keluarga. tingkat ekonomi, terutama jika yang dalam keluarga hidup di bawah garis kemiskinan (keluarga prasejahtera), berguna unt uk pemastian apakah keluarga berkemampuan membeli dan memilih makanan yang bernilai gizi tinggi untuk anaknya. ekonomi juga selalu menjadi faktor penentu dalam proses pertumbuhan anak. keluarga dengan ekonomi cukup dapat memenuhi kebutuhan nutrisi pada anaknya (nurdiana, 2012). status gizi berkaitan erat dengan kondisi ekonomi. apabila keluarga memiliki tingkat ekonomi menegah ke atas, maka status gizi balita diharapkan semakin baik. berdasarkan hasil penelitian juga diketahui bahwa ada hubungan yang signifi kan antara budaya keluarga dan stat us gizi balita. budaya adalah suatu ciri khas, akan mempengaruhi tingkah laku dan kebiasaan. culture universal adalah unsur kebudayaan yang bersifat universal, ada di dalam semua kebudayaan di dunia, seperti pengetahuan bahasa dan khasanah dasar, cara pergaulan sosial, adat-istiadat, serta penilaian umum. tanpa disadari, kebudayaan memberikan garis pengar uh sikap terhadap berbagai masalah. kebudayaan memberi pengalaman individu-individu yang menjadi anggota kelompok masyarakat asuhannya. hanya kepercayaan individu yang telah mapan dan kuatlah yang dapat memudarkan dominasi kebudayaan dalam pembent u kan si kap individual (friedman, 2004). setiap kelompok masyarakat, bagaimanapun sederhananya, memiliki sistem klasifikasi makanan yang didefi nisikan secara budaya. setiap kebudayaan memiliki pengetahuan tentang bahan makanan yang dimakan, bagaimana makanan tersebut ditanam atau diolah, bagaimana mendapatkan makanan, bagaimana makanan tersebut dipersiapkan, dihidangkan, dan dimakan. makanan bukan saja sumber gizi, lebih dari itu makanan memainkan beberapa peranan dalam berbagai aspek kehidupan. simpulan dan saran simpulan ada hubungan antara tingkat ekonomi dan budaya keluarga dengan status gizi balita. 142 jurnal ners vol. 9 no. 1 april 2014: 138–142 saran pe t u g a s k e s e h a t a n s e h a r u s n y a melakukan penyuluhan tentang gizi balita d ala m r a ng k a p e n i ng k at a n ke seh at a n k hususnya dalam hal status gizi balita. masyarakat harusnya lebih terbuka dalam mencari tambahan informasi tentang gizi. kepustakaan khomsan. 2009. pangan dan gizi untuk kesehatan. jakarta: pt. rajagrafi ndo. arikunto. 2010. prosedur penelitian suatu pendekatan praktek. jakarta: rinneka cipta almitsier. 2010. gizi kesehatan masyarakat . jakarta: salemba medika arisman. 2010. gizi dalam daur ulang kehidupan. jakarta: egc budiarto. 2006. masalah ekstradisi dan ja mina n perlind unga n ata s ha khak asasi manusia, jakarta: ghalia indonesia cahyaningsih. 2011. pertumbuhan dan perkembangan anak dan remaja. jakarta: trans info media efendi dan makhfudi. 2009. keperawatan kesehatan komunitas teori dan praktik dalam keperawatan. jakarta: salemba medika taylor. 2009. psikologi sosial. jakar ta: kencana predana media. friedman. 2004. keperawatan keluarga teori dan praktik. edisi 3. jakarta: egc hidayat. 2010. metode penelitian kebidanan dan tek nik analisis data. jakar ta: salemba medika notoatmodjo. 2010. metodologi penelitian kesehatan. jakarta: pt. rinneka cipta. kartini. 2006. psikologi umum . bandung : mandar maju notoatmodjo.2005. promosi kesehatan teori dan aplikasi. jakar ta: pt. rineka cipta notoatmodjo. 2010. metodologi penelitian kesehatan. jakarta: pt. rineka cipta nursalam. 2008. konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika pudjiadi. 2006. variasi makanan balita. jakarta: egc setiadi. 2007. konsep & penulisan riset keperawatan. yogyakarta: graha ilmu soetjiningsih. 2005. tumbuh kembang anak. jakarta: egc sugiyono. 2007. statistika untuk penelitian. bandung: alfabeta suprajit no. 2004. asuhan kepera watan keluarga. jakarta: egc supariasa. 2012. penilaian status gizi. jakarta: egc tarwoto dan wartonah. 2010. kebutuhan dasar manusia dan proses keperawatan. jakarta: salemba medika vol 6 no 1 april 2011_akreditasi 2013.indd 21 strategi peningkatan mutu pelayanan keperawatan berdasarkan analisis posisi perilaku caring perawat dengan jendela pelanggan (nursing care improvement strategy based on nurses caring behavior position analysis with customer window) widiharti*, sunaryo**, purwaningsih*** * stikes insan unggul surabaya, jl. raya kletek no. 4 taman sidoarjo e-mail: ibundae_naufal@yahoo.com ** fakultas kedokteran universitas airlangga *** fakultas keperawatan universitas airlangga abstract introduction: in this era of globalization and free market, demand from the society for adequate health care is increasing and encouraging hospitals to provide the best services. better services require continuous and perfect planning in service quality improvement. the goal of this study was to fi nd the development strategy to improve the quality of nursing care based on analysis of nurses caring behaviors position using customer window. method: this study used 30 samples to assess input, proses and output. research site was in bhakti rahayu hospital surabaya for 1 month. research instrument was questionnaire. research data was used to determine optimum strategy of operational research approach using a simple dynamic program. result: the result showed that the optimum strategy throught the line of affordable cuost – good fasilities – suffi cient caring behavior – suffi cient administrative – suffi cient infrastructure – reliable human resources had the greates value of 70. discussion: it can be cancluded that not all ideal line have a high value. keywords: strategy, caring behavior, quality of service pendahuluan era globalisasi dan pasar bebas tuntutan masyarakat terhadap pelayanan kesehatan yang mamadai semakin meningkat dan memacu rumah sakit (rs) untuk memberikan layanan terbaik agar tidak di marginalkan oleh masyarakat. persaingan di bidang perumahsakitan semakin tajam, bukan hanya dalam jumlah, tapi juga agresifitas rumah sakit pesaing yang menerapkan strategi secara kreatif dan efektif dengan maksud menciptakan keunggulan kompetitif agar bertahan dalam persaingan. dalam kondisi persaingan yang ketat hal utama yang perlu diprioritaskan oleh rumah sakit adalah bagimana strategi p e n i n g k a t a n m u t u p e l a y a n a n t e r h a d a p pelanggan. pelayanan yang diberikan agar lebih baik perlu adanya perencanaan strategi yang baik dalam meningkatkan mutu palayanan yang berkesinambungan dan paripurna. jaminan mutu layanan kesehatan atau quality assurance in healthcare merupakan salah satu pendekatan atau upaya yang sangat penting serta mendasar dalam memberikan layanan kesehatan kepada pasien. harapan pelanggan dari waktu ke waktu berkembang, seiring dengan semakin banyaknya informasi yang diterima pelanggan serta semakin berkembangnya pengalaman pelanggan, semua ini akan berpengaruh terhadap tingkat kepuasan yang dirasakan pelanggan. mutu layanan kesehatan sangat di pengaruhi oleh banyak faktor salah satunya adalah perilaku petugas kesehatan, kadang mutu layanan kesehatan yang diselenggarakan oleh manusia tanpa di sadari dapat berubah menjadi kurang bermutu karena faktor emosi petugas. penilaian mutu pelayanan ada delapan dimensi yaitu: kompetensi teknik (technical competence), akses terhadap pelayanan (access to service), efektivitas (effectiveness), efi siensi (effi ciency), kontinuitas (continuity), jurnal ners vol. 6 no. 1 april 2011: 21–30 22 keamanan (safety), hubungan antar manusia (interpersonal relations), dan kenyamanan (amenities). mutu pelayanan sebuah rumah sakit (rs) mempunyai angka-angka standar yang dibandingkan dengan standar nasional. jika tidak mempunyai standar nasional maka menggunakan standar pihak manajemen rs (muninjaya, 2004). tim mutu rs bhakti rahayu menyepakati bahwa standar mutu kepuasan pasien terhadap pelayanan keperawatan adalah 90–100%. namun hasil evaluasi 2 (dua) tahun terakhir menunjukkan rata-rata tingkat kepuasan baik mencapai 50%. perbandingan standar nilai yang telah ditetapkan rata-rata pencapaian nilai mutu pelayanan masih kurang baik, hal ini di duga karena sdm yang turn over tinggi sehingga perlu beradaptasi lagi dengan lingkungan rs yang dapat menyebabkan perilaku caring perawat dan keterampilan perawat masih kurang. keperawatan sebagai profesi dan perawat sebagai tenaga profesional yang bertanggung jawab meningkatkan kesehatan dengan kompetensi dan kewenangan yang dimiliki sehingga mutu pelayanan keperawatan dapat dicapai dan ditingkatkan. perilaku caring perawat merupakan salah satu faktor yang memengaruhi pelayanan keperawatan (wijayana, 2008), karena dalam caring mencakup hubungan antar manusia yang dapat memengaruhi mutu pelayanan. perilaku caring sebagai bentuk dasar dari praktik keperawatan yang membantu klien untuk pulih dari sakitnya (potter dan perry, 2009). menurut tommey dan alligood (2006), caring adalah teknik perawatan dalam keterkaitan nilai dengan perasaan seseorang terhadap commitment dan tanggung jawab. teori swanson berguna dalam memberikan petunjuk bagaimana membangun strategi caring yang berguna dan efektif (perry dan poter, 2009). strategi dihubungkan dengan pilihan s u a t u k e g i a t a n y a n g d i m a k s u d u n t u k mencapai tujuan yang ditentukan dalam situasi tertentu (wijono, 1999). manajemen strategi adalah suatu proses yang digunakan oleh manajer dan karyawan untuk merumuskan dan mengimplementasikan strategi dalam penyediaan customer value untuk mewujudkan visi organisasi. manajemen strategi merupakan suatu proses. manajemen strategi mencakup dua proses utama yaitu perumusan strategi dan pengimplementasian strategi (mulyadi, 2005). perumusan strategi eksternal yang ada di rs bhakti rahayu sejak tahun 2000 sampai dengan saat ini menggunakan market development strategy yang bertujuan untuk memperbesar pangsa pasar ke berbagai daerah, untuk mencapai rencana strategi yang dilakukan oleh rs bhakti rahayu dengan cara home care, bakti sosial, layanan antar jemput dan poli pengobatan. hasil yang telah dicapai dengan strategi eksternal sudah berhasil. hal ini dibuktikan dengan terdapatnya balai pengobatan, banyaknya pasien rujukan dari daerah dan meningkatnya jumlah pasien. untuk mempertahankan pencapaian strategi eksternal perlu diimbangi dengan strategi internal. perumusan strategi internal yang sudah dilakukan oleh rs yaitu sosialisasi visi, misi rs dan pemahaman profesi. visi rs bhakti rahayu “we care and we serve” untuk mencapai visi rs. oleh karena itu untuk meningkatkan dan mencapai visi rs perlu tabel 1. hasil penilaian tim mutu tingkat kepuasan pasien terhadap pelayanan keperawatan tahun 2009 dan 2010 di rs bhakti rahayu surabaya. no tahun komponen mutu yang dinilai hasil penilaian kepuasan baik nilai standar rs bhakti rahayu (%) 1 2009 tingkat kepuasan pasien terhadap pelayanan keperawatan 53% 90–100 2 2010 tingkat kepuasan pasien terhadap pelayanan keperawatan 50% 90–100 strategi peningkatan mutu pelayanan keperawatan (widiharti) 23 penyusunan strategi dalam peningkatan mutu pelayanan keperawatan yang lebih difokuskan pada perilaku caring perawat. analisis posisi perilaku caring perawat dengan menggunakan jendela pelanggan (customer window). menurut lynne miller franco et al., jendela pelanggan adalah alat untuk mendapatkan feedback dari pasien tentang pelayanan yang mereka dapatkan. alat ini berbeda dengan survei, di mana survei ini menanyakan pada pasien tentang produk atau kinerja pelayanan berdasarkan ide-ide pembuat survei tentang apa yang diinginkan dan dibutuhkan pasien, sedangkan jendela pelanggan menyampaikan pertanyaan dalam istilah yang amat luas, memberi kesempatan pada pasien untuk mengutarakan apa yang mereka butuhkan, harapkan, sukai dan yang tidak mereka sukai (wijono, 1999). hal ini yang mendasari untuk melakukan peningkatan mutu pelayanan keperawatan berdasarkan perilaku caring perawat di rs bhakti rahayu surabaya. masalah dalam penelitian ini adalah tingkat kepuasan pasien yang baik di rs bhakti rahayu surabaya terhadap mutu pelayanan keperawatan yaitu sebesar 50%. perumusan strategi eksternal yang digunakan; market development strategy sudah berhasil, untuk mempertahankan perlu diimbangi dengan pengembangan internal untuk meningkatkan mutu pelayanan keperawatan berdasarkan hasil analisis perilaku caring perawat. mengembangkan strategi peningkatan mutu pelayanan keperawatan berdasarkan analisis posisi perilaku caring perawat dengan menggunakan jendela pelanggan (customer window) di rs bhakti rahayu surabaya. bahan dan metode j e n i s p e n e l i t i a n y a n g d i g u n a k a n adalah penelitian dengan model pendekatan operasional research system analysis (orsa). riset operasional ialah riset dengan penerapan metode ilmiah melalui suatu sistem secara terpadu untuk memecahkan permasalahan yang timbul dalam kegiatan operasional suatu sistem organisasi agar diperoleh pemecahan yang optimal (supranto j, 2006). pada penelitian ini menggunakan program dinamik sederhana, sehingga dapat dilakukan terhadap proses berlangsungnya suatu kegiatan yang dilakukan oleh organisasi/ rumah sakit untuk mencapai hasil atau output yang paling baik dengan menggunakan input yang dalam praktiknya serba terbatas dalam serba keterbatasan itulah yang dicapai suatu pemecahan yang optimum. besar sampel pada penelitian ini adalah 30 responden, semua pasien post operasi sc yang menjalani perawatan di ruang rawat inap lantai 2 rumah sakit bhakti rahayu dan telah mendapatkan pelayanan keperawatan. sampel ditentukan kriteria inklusi, yaitu pasien yang telah mendapatkan pelayanan keperawatan di ruangan sebelum krs (keluar rumah sakit), pasien tanpa disertai penyakit lain. variabel intervensi pada penelitian ini adalah peningkatan mutu pelayanan dengan melihat posisi perilaku caring perawat dengan jendela pelanggan dan pengembangan strategi peningkatan mutu pelayanan sedangkan variabel output dalam penelitian ini adalah mutu pelayanan keperawatan dan perilaku caring perawat. instrumen yang digunakan dalam penelitian ini adalah kuesioner perilaku caring perawat dengan menggunakan modifikasi care profesional scale dan caring demention inventory dengan menggunakan rating scale, tingkat kepuasan pasien, input, proses dan output. data tersebut kemudian ditabulasi dan dianalisis dengan menggunakan jendela pelanggan untuk perilaku caring perawat, sedangkan untuk penentuan pengembangan strategi menggunakan riset operasional dengan menggunakan program dinamik. cara pengghitungan pada program dinamik mengunakan pertambahan tidak menggunakan perkalian karena jumlah responden kurang dari 100 sehingga tidak bisa menggunakan probabilitas. hasil secara keseluruhan posisi perilaku caring perawat sebagian besar pada bravo 57,4%, bagian kecil pada don’t worry be jurnal ners vol. 6 no. 1 april 2011: 21–30 24 happy yaitu 3,1%. 5.2. hasil penilaian mutu didapatkan nilai bor pada bulan april 55,6% sedangkan pada bulan mei terjadi penurunan bor menjadi 54,7%. hal ini belum bisa dikatakan bahwa pengelolaan rs masih belum optimal karena hanya 2 bulan saja, bor lebih baik dinilai dalam 1 tahun sehingga bisa dikatakan efi siensinya rs. nilai los pada bulan april 4,5 hari sedangkan pada bulan mei terjadi penurunan los menjadi 4,2. hal ini sudah bisa dikatakan bahwa pelayanan perawatan di rs bhakti rahayu lantai 2 sudah baik. tingkat kepuasan responden sebagian besar baik yaitu 22 responden (73,3%). hal ini menunjukkan bahwa nilai mutu dari pandangan pelanggan sudah baik. hasil penilaian dari segi pasien mulai dari tahap input (sdm, sarana prasarana, administrasi), proses (perilaku caring, fasilitas, biaya) dan output (tingkat kepuasan pasien). penilaian ini dari kuesioner yang menggunakan skala rating dari kurang (0–3) cukup (4– 6) dan baik (7–10) setelah data diperoleh didistribusikan ke masing-masing tahapan dan kriteria (kurang, cukup, baik). penilaian menggunakan skor akan mengurangi perbedaan persepsi. persepsi satu pasien yang mengatakan cukup dengan persepsi pasien yang lain tentu berbeda meskipun sama-sama cukup dengan menggunakan skor maka maksud cukup akan menjadi lebih pasti dan akan mengurangi perbedaan persepsi selain itu pasien dapat menilai sesuai dengan kriterianya. dari hasil distribusi masing-masing tahap dapat dirinci sebagai berikut: pada tahap input nilai sdm menunjukkan pasien yang mengatakan sdm di rs bhakti rahayu yang mengatakan kurang tidak ada, cukup 20 pasien, baik 10 pasien. nilai sarana prasarana yang mengatakan kurang 4 pasien, cukup 19 pasien dan baik 7 pasien. nilai untuk administrasi yang mengatakan kurang 1 pasien, cukup 10 pasien, baik 19 pasien. pada tahap proses nilai perilaku caring yang mengatakan kurang 1 pasien, cukup 21 pasien dan baik 8 pasien. nilai fasilitas pada tahap proses tidak yang menilai kurang cukup 14 pasien dan baik 16 pasien, sedangkan nilai biaya tidak ada yang menilai kurang, cukup 10 pasien dan baik 20 pasien. dari hasil gambar 2 sebagian besar memiliki nilai cukup yaitu mulai tahap input, proses dan output. hal ini menunjukkan bahwa mulai dari input, proses dan output perlu perhatian dari manajer rumah sakit. pembahasan hasil penelitian dengan menggunakan kuisioner penilaian dan harapan pasien dengan menggunakan jendela pelanggan dari 26 komponen item pertanyaan dari kuisioner gabungan teori cdi dengan cps untuk perilaku caring perawat yang ada pada posisi attention yaitu: membantu klien dalam adl (mandi, bak, bab, pindah posisi, makan, minum dan berjalan). hal ini menunjukkan apa yang telah pelanggan menginginkannya attention bravo don’t worry be happy cut or communicate pelanggan tidak menginginkannya penilaian p el an gg an t id ak m em pe ro le h 26,3% 57,4% 3,1% 13,2% h ar ap an p el an gg an m em pe ro le h gambar 1. analisis perilaku caring perawat berdasarkan jendela pelanggan strategi peningkatan mutu pelayanan keperawatan (widiharti) 25 didapatkan pasien dengan harapannya tidak sesuai. pemenuhan adl pada ruang rawat inap lantai 2 dilakukan oleh perawat terutama pada pasien pascaoperasi sectio caesaria akan tetapi tidak dapat dilakukan dengan optimal oleh perawat karena jumlah perawat tiap shift 3 orang dengan rata-rata jumlah pasien 30 orang sehingga perawat dalam melakukan a b c sdm sarana prasarana administrasi perilaku caring fasilitas biaya kepuasan pasien 10 4 19 7 0 20 211 1 10 19 8 101 0 14 19 16 0 8 22 gambar 2. distribusi input, proses, dan output pengembangan strategi peningkatan mutu pelayanan keperawatan yang sesuai rs bhakti rahayu surabaya keterangan: a : kurang b : cukup c : baik input : sdm, sarana prasarana, administrasi proses: perilaku caring, fasilitas, biaya output: kepuasan pasien jurnal ners vol. 6 no. 1 april 2011: 21–30 26 a sdm sarana prasarana administrasi perilaku caring fasilitas biaya kepuasan pasien k a b c 2 1 1 3 3 1 4 6 9 2 15 4 0 10 15 0 0 0 7 1 0 0 0 0 0 0 0 4 0 4 0 14 4 0 0 1 1 16 4 3 0 4 0 9 12 0 4 0 0 0 5 9 0 6 25 37 53 67 42 38 29 b c keterangan: a : kurang b : cukup c : baik → : jalur ideal : jalur optimum gambar 3. pengembangan strategi dengan program dinamik strategi peningkatan mutu pelayanan keperawatan (widiharti) 27 adl membuat prioritas yaitu pasien yang pascaoprasi sectio caesaria dengan kriteria: belum fl atus, masih terpasang infus dan belum melakukan mobilisasi duduk dan jalan. p e r i l a k u c a r i n g p e r a w a t m a s i h membutuhkan perhatian dengan baik sehingga mutu pelayanan lebih dapat di tingkatkan lagi. upaya yang sudah dilakukan rumah sakit bhakti rahayu oleh hrd dan pelayanan medik yaitu membuat program peningkatan kualitas sdm dengan mengadakan seminar sehari misalnya seminar tentang penanganan kegawatdaruratan dan sudah terencana minimal 6 bulan sekali. masalah yang ada di ruang rawat inap lantai 2 dari hasil penelitian ini penilaian perilaku caring perawat dari kuisioner penilaian perilaku caring yang menggunakan rating (kurang, cukup dan baik) menunjukkan pada nilai cukup sebanyak 21 pasien. komponen yang ada pada perilaku caring yang membutuhkan perhatian pada pemenuhan activity daily living (adl) di mana setiap pasien berharap untuk mendapatkan bantuan pelayanan dalam hal makan, mandi dan mobilisasi. sebagian besar pasien dirawat inap lantai 2 pasien post partum dengan sc yang membutuhkan bantuan dalam pemenuhan adl nya selama pasien belum mampu untuk melakukan sendiri. penelitian yang dilakukan witri, tuti, dan anastasi (2006) membuktikan bahwa perawat mengetahui komponen kebutuhan dasar manusia. namun demikian dalam pemenuhannya selama ini perawat hanya b e r p i k i r k o n d i s i p a s i e n d a r i a p a y a n g dilihat saja. pelayanan keperawatan yang diberikan kepada pasien menimbulkan adanya interaksi antara perawat dan pasien. kozier et al. (2004) mengatakan bahwa hubungan perawat-pasien menjadi inti dalam pemberian asuhan keperawatan, karena keberhasilan penyembuhan dan meningkatkan kesehatan pasien sangat dipengaruhi oleh hubungan perawat-pasien. oleh karena metode pemberian asuhan keperawatan harus memfasilitasi efektifnya hubungan tersebut. konsep yang mendasar hubungan perawat-pasien adalah hubungan saling percaya, empati, caring, otonomi dan mutualisme. pelaksanaannya harus tetap memperhatikan kualitas hubungan antara perawat-pasien yaitu rasa percaya, empati dan caring. to m m e y d a n a l l i g o o d ( 2 0 0 6 ) mempelajari tentang klien dan profesi layanan dalam usahanya untuk membuat teori tentang caring dalam praktik keperawatan. caring adalah teknik perawatan dalam keterkaitan nilai dengan perasaan seseorang terhadap commitment dan tanggung jawab. menurut linberg (1990), caring tidak hanya sekedar memberikan tindakan keperawatan seperti menyiapkan tempat tidur ataupun memberikan perawatan secara rutin. caring yang sebenarnya adalah sikap dasar pengasuhan, membantu memelihara orang lain. linberg (1990) juga menyatakan bahwa untuk merawat orang lain dibutuhkan suatu perasaan yang mendalam untuk menumbuhkan aktualisasi dirinya. pada umumnya bor diambil dalam kurun waktu satu tahun sebagai target dari standar nilai departemen kesehatan. hal ini dikarenakan untuk mengantisipasi ketidakseimbangan faktor lingkungan yang berbeda setiap bulannya yang memengaruhi banyaknya jumlah pasien yang dirawat perbulan, salah satu faktor lingkungan seperti perubahan cuaca atau musim. suatu pengelolaan rumah sakit dikatakan efektif jika rumah sakit mendapat keuntungan suatu rumah sakit. tetapi nilai bor mempunyai standar nilai yang dapat mengatakan efi siensi pengelolaan rumah sakit sudah efi sien yaitu jika pengelolaan rumah sakit menggunakan sumber daya sekecilkecilnya yaitu yang dimaksud dengan sumber daya disini dapat berupa jumlah tempat tidur maupun jumlah tenaga medis. jadi suatu rumah sakit yang efektif belum berarti rumah sakit tersebut sudah dikelola efi sien, dan begitu juga juga sebaliknya. persentasi bor 60–85% per tahun merupakan standar nilai dari departemen kesehatan republik indonesia, apabila rata rata tingkat penggunaan tempat tidur di bawah 60% berarti tempat tidur yang tersedia di rumah sakit sebelum dapat dimanfaatkan sebagaimana mestinya dan apabila lebih dari 85% maka hal itu akan mengakibatkan tempat tidur yang seharusnya bisa digunakan untuk kejadian luar biasa akan terisi penuh sehingga rumah sakit tidak akan mampu menampung pasien jurnal ners vol. 6 no. 1 april 2011: 21–30 28 yang akan dirawat dengan kejadian luar biasa tersebut. selain itu juga untuk menghindari ketidakadaannya waktu untuk pembersihan kamar pasien yang dirawat karena hampir semua tempat tidur per harinya lebih dari 85% sehingga dapat menyebabkan terjadinya peningkatan infeksi nasokomial. l o s m e n u r u t h u f f m a n ( 1 9 9 4 ) adalah “the average hospitalization stay of inpatient discharged during the period under consideration”. los menurut departemen kesehatan republik indonesia (2005) adalah rata-rata lama rawat seorang pasien. indikator ini di samping memberikan gambaran tingkat efi siensi, juga dapat memberikan gambaran mutu pelayanan, apabila diterapkan pada diagnosis tertentu dapat dijadikan hal yang perlu pengamatan yang lebih lanjut. secara umum nilai los yang ideal antara 6–9 hari (departemen kesehatan, 2005). rata-rata hari rawat pasien post partum 4,2 hari. hal ini disebabkan karena mayoritas pasien datang untuk menjalani operasi sc sehingga masa perawatan relatif pendek. penilaian bor dan los yang ada di rs bhakti rahayu tidak dilakukan secara rutin tiap tahunnya sehingga tidak diketahui tingkat efektif dan efi siensinya. selain itu indikator mutu yang lainnya seperti penilaian infeksi nasokomial, kejadiaan dekubitus dan pasien jatuh belum terdokumen. t i n g k a t k e p u a s a n p a s i e n y a n g mengatakan kepuasan baik sebanyak 22 responden, dan yang kepuasan cukup sebanyak 8 orang dan tidak ada responden yang tidak mengatakan tidak puas. hal ini sangatlah mungkin terjadi, karena terdapat berbagai faktor yang dapat memengaruhi kepuasan mereka. maka untuk itu sangatlah penting bagi sebuah rumah sakit untuk menganalisa tingkat kepuasan pasien mereka. mengukur tingkat kepuasan pasien dapat digunakan sebagai alat untuk evaluasi kualitas pelayanan, evaluasi terhap konsultasi intervensi dan hubungan antara perilaku sehat dan sakit, membuat keputusan administrasi, evaluasi efek perubahan organisasi pelayanan, administrasi staf, fungsi pemasaran, formasi etik profesional. kepuasan pasien dalam menilai mutu atau pelayanan yang baik, dan merupakan pengukuran penting yang mendasar bagi mutu pelayanan. hal ini memberikan informasi terhadap suksesnya pemberi pelayanan bermutu dengan nilai dan harapan pasien yang mempunyai wewenang diri sendiri untuk menetapkan standar mutu pelayanan yang dikehendaki. rsu bhakti rahayu telah memberikan pelayanan yang cukup berkualitas sehingga sebagian besar dari pasien mengatakan puas terhadap pelayanan yang mereka berikan. pihak rs perlu mengevaluasi lagi karena masih ada sebagian kecil pasien yang merasa kurang tingkat kepuasannya terhadap pelayanan yang mereka berikan.hasil perhitungan pendekatan program dinamik untuk mendapatkan kepuasan yang baik dengan melalui tahap-tahap yang ada (input, proses dan output). pada penelitian ini tidak menggunakan nilai probabilitas hal ini dikarenakan jumlah responden yang sedikit sedangkan untuk menggunakan nilai probobalitas minimal jumlah responden 100. maka pada penelitian menggunakan penjumlahan tidak menggunakan perkalian. metode operasional riset pada penelitian ini menggunakan pendekatan program dinamik yang sederhana untuk menentukan jalur kemungkinan yang dapat digunakan dalam menentukan strategi melalui program dinamik akan didapatkan 36 jalur alternatif tetapi pada penelitian manajer mengharapkan pada tingkat kepuasan baik sehingga jalur yang diperhitungkan pada jalur yang melalui tingkat kepuasan baik saja. pada jalur ideal yang seharusnya untuk mendapat tingkat kepuasan baik melalui biaya baik – fasilitas baik – perilaku caring baik – administrasi baik – sarana prasarana baik – sdm baik. namun dalam penelitian ini nilai jalur ideal hanya 48 sedangkan pada jalur optimum yang melalui biaya baik – fasilitas baik – perilaku caring cukup – administrasi cukup – sarana prasarana cukup – sdm baik memiliki nilai yang paling besar yaitu 70. hal ini menunjukkan bahwa untuk mendapatkan kepuasan yang baik tidak harus semua tahapan baik. sesuai dengan penelitian yang dilakukan morison dan hariadi s (1990) tentang penggunaan program dinamik pada evaluasi pelayanan balai pengobatan di puskesmas kotamadya surabaya hasil strategi peningkatan mutu pelayanan keperawatan (widiharti) 29 penelitiannya membuktikan bahwa tidak semua proses diagnosis baik – ketepatan diagnosis baik – ketepatan terapi baik – ketepatan penerimaan obat baik – kepatuhan minum obat baik dapat meningkat kesembuhan yang baik pula. pada penelitian ini bahwa dengan biaya baik – fasilitas yang baik dengan perilaku caring cukup dapat meningkatkan kepuasan pasien. di mana kepuasan pasien sangat tergantung pada persepsi pasien itu sendiri. persepsi pasien sulit kita ketahui karena persepsi masing-masing individu berbeda, bisa saja pasien puas terhadap mutu pelayanan yang diterimanya akan tetapi tidak puas akan sikap provider atau bahkan tidak puas dengan fasilitas fi siknya. sebagian besar pasien merasa puas pada perilaku caring cukup, fasilitas cukup dan biaya cukup, hal ini disebabkan karakteristik responden ditinjau dari status pekerjaannya responden banyak yang menjadi ibu rumah tangga sehingga dengan pemberian perilaku caring yang cukup dan fasilitas kamar yang diasumsikan cukup oleh pasien (6 tt, kipas angin dan kamar mandi di dalam ruangan) dengan biaya yang relatif lebih murah karena di rs bhakti rahayu surabaya pembiayaan operasinya menggunakan sistem paket. hal ini sesuai dengan penelitian rachmadi (2008) bahwa pelayanan sarana penunjang, administrasi rumah sakit tidak berpengaruh secara signifi kan terhadap kepuasan pasien. penelitian ini tidak sesuai dengan pendapat subanegara (2003) pelayanan dan produk unggulan dalam organisasi perusahan jasa dipengaruhi oleh beberapa faktor yaitu keadaan internal organisasi berupa keadaan sumber daya manusia, sarana prasarana, sistem dan pembiayaan. tetapi tidak sesuai dengan penelitian yang dilakukan pada penelitian yang dilakukan arief, yuni s dkk bahwa perilaku caring perawat tingkat sedang dapat membentuk kepuasan yang baik sebesar 67,7%. perilaku caring perawat yang baik dapat membentuk kepuasan yang baik pula. strategi yang digunakan dan sesuai dengan rs bhakti rahayu surabaya pada level fungsional yaitu meningkatkan fungsi dari masing-masing tugas. rencana strategi yang dapat dilakukan oleh tim manajer dilihat dari hasil perhitungan program dinamik adalah mempertahankan dan meningkatkan perilaku caring perawat, untuk mendukung hal itu perlu adanya peningkatan kualitas dan kuantitas, selain perilaku caring manajer meningkatkan fasilitas atau sarana-prasana. oleh karena itu untuk mendapatkan peningkatan kepuasan yang lebih optimal maka diperlukan peningkatan perilaku caring perawat yang ada dalam posisi attention tetapi juga perlu memperhatikan kualitas maupun kuantitas dari perawat yang ada diruangan untuk mencapai jalur ideal. pada saat ini di ruang rawat inap lantai 2 dalam setiap shifnya terdapat 2–3 orang perawat sedangkan rata-rata jumlah pasien perhari 25–30 pasien dilihat dari rasio jumlah perawat dan pasien sangat tidak sesuai. pada dasarnya manajemen strategi adalah suatu upaya manajemen dan karyawan untuk membangun masa depan organisasi (mulyadi, 2005). membangun masa depan organisasi diperlukan perencanaan dan perubahan secara baik dan tidak mengharapkan hasil yang instan karena dengan hasil yang terlalu cepat maka pemberi pelayanan bisa merasa cepat bosan dan dapat melakukan penolakan. mencapai jalur ideal perlu adanya strategi dan perubahan. dalam membuat perubahan harus memperhatikan hal-hal sebagai berikut perubahan harus terencana, orang yang terlibat dalam perubahan ikut diajak dalam pembuat perencanaan dan perubahan tidak boleh terlalu tercepat. perencanaan strategi dan perubahan yang terstruktur dan berkesinambungan akan menghasilkan hasil yang baik sesuai dengan kriteria yang kita tentukan. simpulan dan saran simpulan posisi perilaku caring perawat dengan menggunakan jendela pelanggan sebagian besar ada pada bravo. mutu pelayanan di rs bhakti rahayu surabaya ruang rawat inap lantai 2 yaitu bor 54,7% dan tingkat kepuasan pasien sebagian besar dengan tingkat kepuasan baik. pengembangan strategi yang sesuai dengan ruang rawat inap lantai 2 rs bhakti rahayu surabaya dengan menggunakan metode riset operasinal pendekatan program dinamik pada jurnal ners vol. 6 no. 1 april 2011: 21–30 30 jalur optimal yaitu biaya baik – fasilitas baik – perilaku caring cukup – administrasi cukup – sarana prasarana cukup – sdm baik memiliki nilai yang paling besar yaitu 70. strategi yang perlu ada yaitu peningkatan kualitas perilaku caring perawat dan kualitas perawat untuk tetap meningkatkan mutu pelayanan keperawatan. saran perawat ruangan rawat inap lantai 2 rs bhakti rahayu surabaya dapat meningkatkan perilaku caring perawat dengan mengadakan pelatihan caring perawat misalnya bekerja sama dengan fakultas keperawatan universitas airlangga, beserta biaya yang dibutuhkan kepada human resorce development (hrd) untuk menunjang visi, misi, dan mutu pelayanan rs bhakti rahayu. program latihan minimal 6 bulan sekali secara bergantian dan berkesinambugan. perilaku caring perawat dalam pemenuhan adl masih perlu perhatian, hal ini bisa disebabkan karena jumlah rasio perawat dan pasien tidak seimbang. perilaku caring perawat dapat terlaksana dengan baik sehingga tidak hanya kualitasnya saja, maka koordinator ruang rawat inap lantai 2 rs bhakti rahayu surabaya juga meningkatkan kuantitas perawatnya dengan mengajukan telaah staf tentang permasalahan yang ada di ruangan terutama ketenagaan kepada pimpinan rs dalam hal ini hrd. penambahan jumlah tenaga dengan tenaga kontrak atau honorer untuk meningkatkan kualitas pelayanan k e p e r a w a t a n d a n m e n d u k u n g p r o g r a m peningkatan mutu yang sudah ada. selain itu juga perlu diperhatikan dan ditingkatkan lagi sistem pelayanan yang lainnya seperti administrasi, pemeliharaan fasilitas. perlu dilakukan penelitian yang sama namun dengan jumlah sampel yang lebih besar dan menggunakan pendekatan program dinamik yang sesuai sehingga dapat menentukan strategi yang tepat dalam meningkatkan mutu pelayanan. kepustakaan gasperzs, v., 2002. total quality management. jakarta. pt gramedia pustaka utama. george, julia b., 1995. nursing theories: the base for professional nursing practice, 4th edition. haris, m., 2004. analisis harapan mahasiswa terhadap penyelenggaraan pembelajaran sebagai dasar pengembangan strategi pembelajaran di politeknik kesehatan surabaya program studi kebidanan b a n g k a l a n . j u r n a l a d m i n i s t r a s i kebijakan kesehatan, 2(2), 108–116. kozier, b., 2004. fundamentals of nursing: concepts, process, and practice. new jersey: pearson. linberg, j.b., 1990. introduction to nursing con'cepr, issues and opportunities. philedelphia: j.b lippincott. mulyadi, 2005. sistem manajemen strategik berbasis balance scorecard. yogyakarta: upp amp ykpn. muninjaya, a, a., gde, 2004. manajemen kesehatan. edisi 2. jakarta: egc. parasuraman, a., zeithmal, v., dan berry, ll., 1990. delivering quality service: balancing customer perceptions and expectations. new york. potter, p.a., dan perry, a .g., 2009. fundamental of nursing; concept, proses and practice. st. louis: mosby. w i j a y a n a , m . , 2 0 0 8 . m e m b a n g u n pribadi perawat, (online), (http:// www.52.11.148.220/ppko/file/memba ngun%20pribadi%caring%20perawat, diakses tanggal 10 januari 2011, jam 22.00 wib). wijono, djoko, 1999. manajemen mutu pelayanan kesehatan, teori, strategi dan aplikasi. surabaya: airlangga university press. wijono, djoko, 1997. manajemen mutu pelayanan kesehatan, vol. 1 surabaya: airlangga university press. witri, tuti, dan anastasi, 2006. majalah keperawatan. nursing journal of padjajaran university 7(12). vol 9 no 1 april 2014.indd 143 self management intervention sebagai upaya peningkatan kepatuhan pada penderita dm (self management intervention increasing compliance in patient with dm) siti nur kholifah* program studi d iii keperawatan kampus sutopo jurusan keperawatan politeknik kesehatan kementerian kesehatan surabaya jl. parangkusuma no.1 surabaya e-mail : kholifah_stp@yahoo.co.id abstrak pendahuluan: diabetes mellitus (dm) merupakan penyakit degeneratif yang sering ditemukan di masyarakat. diabetes disebabkan oleh kebiasaan yang tidak sehat seperti makan berlebihan, kurang olahraga, dan stres. tujuan dari penelitian ini adalah untuk mengidentifi kasi self management sebagai salah satu intervensi yang dapat meningkatkan kepatuhan perawatan pada penderita dm. metode: penelitian ini menggunakan berdesain quasy experiments non randomized pretest-posttest. jumlah responden adalah 20 keluarga yang tinggal dengan penderita dm tipe 2. variabel independen dalam penelitian ini adalah self management intervention dan variabel dependennya adalah kepatuhan penderita dm. data dikumpulkan dengan cara wawancara, food recall, dan observasi perubahan perilaku. data kemudian dianalisis mengunakan paired t-test dengan α≤0.05. hasil: hasil penelitian menunjukkan ada peningkatan kepatuhan diet diabetes, di mana sebelum intervensi hanya ada 3 (15 %) responden yang patuh pada diet dan setelah intervensi meningkat menjadi 19 (95 %) responden dengan p = 0.000. kepatuhan pengobatan juga meningkat dari sebelum intervensi hanya 6 (30 %) responden yang patuh dan setelah intervensi seluruh responden (100%) patuh minum obat, dengan p=0.000. kepatuhan olah raga juga mengalami peningkatan, dari hanya 2 (10%) responden yang patuh sebelum intervensi, menjadi 19 (95%) responden setelah intervensi, dengan p=0.000. diskusi: self management intervention dapat meningkatkan pengetahuan, pengembangan ketrampilan pemecahan masalah, dan meningkatkan self-effi cacy penderita. self management dilakukan setelah penderita dm memahami penyakit dan menyadari pentingnya perawatan diri. perawat komunitas diharapkan dapat menerapkan strategi intervensi keperawatan self management agar kepatuhan penderita diabetes dalam perawatan di rumah dapat ditingkatkan. kata kunci: self management, kepatuhan, penderita dm tipe 2 abstract introduction: diabetes mellitus (dm) was a degenerative disease which often found in the community. diabetes was caused by unhealthy habits, such as overeating, lack of exercise, and stress. the purpose of this study was to identify self management as one of the interventions that can improve treatment compliance in patients with diabetes. method: this study was used quasy experiments non randomized pretest-posttest design. samples were 20 families who lived with type 2 diabetes patient. variable independent was self management intervention and variable dependent was patient complience. data were collected by using interview, food recall, and observation on behavioral change. data then analyzed by using paired t-test with α≤0.05. results: the results had showed that before intervention only 3 (15 %) respondents who obey diabetes diet, then increase to 19 (95 %) respondents after intervention with p value=0.000. patient’s medication compliance also increased, from 6 (30 % ) respondents before intervention to 20 (100%) respondents after intervention, with p value= 0.000. patient compliance on exercise also increase from 2 (10%) respondents before intervention, become 19 (95%) respondents after intervention, with p value=0.000. discussion: self management intervention could improve patient’s knowledge, problem-solving skills, and self-effi cacy. self management should be done after the patient had understand their disease and realized the importance of self-care. community health nurses were expected to implement self management as one of nursing intervention, so that patient compliance on their treatment can be increased. key words: self management intervention, compliance, patient dm type 2 144 jurnal ners vol. 9 no. 1 april 2014: 143–150 pendahuluan diabetes mellitus (dm) merupakan penyakit metabolik yang berlangsung kronik, di mana penderitanya tidak dapat memproduksi insulin dalam jumlah yang cukup atau tubuh tidak mampu menggunakan insulin secara efektif, sehingga terjadi kelebihan glukosa dalam darah (brunner & suddart, 2000; arora, 2007). penyebab dm antara lain gaya hidup yang tidak sehat seperti kebiasaan makan berlebih, kurang olahraga, dan stres (depkes ri, 2005). be rd a sa rk a n d at a w ho (20 0 0), indonesia menempati urutan ke-4 terbesar unt u k prevalensi penderita dm setelah india, cina, dan amerika serikat. prevalensi penderita dm di indonesia adalah 8,6% dari total penduduk. sekitar 3,2 juta meninggal dunia karena komplikasi penyakit tersebut. komplikasi dapat mengenai seluruh organ yang penting pada tubuh, seperti mata menjadi buta, penyakit jantung, penyakit ginjal, dan risiko amputasi karena luka yang membusuk. komplikasi yang terjadi akan berdampak pada penurunan kemampuan fi sik, psikologis, dan sosial ekonomi bagi penderita dan keluarganya (arisman & suyono, 2000). up ay a p e n a n g g u l a n g a n dm d i m a sya r a k at sud a h d i la k u k a n melalu i pencegahan primer dan sekunder untuk mengurangi risiko komplikasi, kematian, dan mengurangi biaya pengobatan. pencegahan primer merupakan tindakan pencegahan dm pada individu yang berisiko melalui modifi kasi gaya hidup, di antaranya pola makan sesuai, aktivitas fi sik, dan penurunan berat badan dengan program edukasi yang berkelanjutan. sedangkan pencegahan sekunder merupakan tindakan pencegahan terjadinya komplikasi akut maupun jangka panjang. programnya meliputi pemeriksaan, pengobatan tekanan darah, perawatan kaki diabetes, pemeriksaan mata secara rutin, pemeriksaan protein dalam urin, serta program untuk menurunkan atau menghentikan kebiasaan merokok (depkes ri, 2005). perawatan dm dapat berhasil dengan bai k apabila dilak u kan secara terat u r. kepat uhan unt uk melakukan perawatan secara teratur ini membutuhkan kedisiplinan diri. oleh karena itu, pengaturan diri sendiri (self management) merupakan salah satu cara untuk mencapai kedisiplinan diri dalam melakukan perawatan. berdasarkan pendapat beberapa ahli, self management merupakan suatu upaya pengaturan diri untuk mencapai suatu tujuan. self management bertujuan agar individu mampu mengobservasi kebutuhan diri tanpa bergantung pada lingkungan. self management ini banyak digunakan sebagai salah satu intervensi untuk penyakit kronis di antaranya dm (sarkar, fisher & schillinger, 2006). s e l f m a n a g e m e n t m e r u p a k a n bagian dari ilmu perilaku psikologi yang dikemukakan pertama kali oleh bandura pada 1970. menurut bandura, self management merupakan motivasi manusia yang tidak hanya berdasarkan penghargaan dari luar, tetapi juga karena observasi kebutuhan dari dalam diri, penghargaan dan hukuman dari tindakan untuk mencapai tujuan tertentu (takoshian, 1997). yukl (1994) mengungkapkan bahwa self management merupakan proses pendelegasian dan pemberdayaan dalam pemberian tanggung jawab serta pengambilan keputusan untuk mencapai suatu tujuan. beberapa hasil penelitian terdahulu me njela sk a n ba hwa se lf m a n a ge m e n t dapat digunakan sebagai intervensi untuk men i ng kat ka n keberha sila n per awat a n penderita penyakit kronis, seperti dm tipe 2, asma, dan artritis. intervensi self management dapat mengefektif kan pelaksanaan program pengobatan. penderita dapat menyadari pent i ng nya menjala n i pengobat a n d a n perawatan untuk kesembuhan. contohnya, penderita dm harus patuh dengan diet, minum obat, olahraga, dan pemantauan kadar gula darah. pemantauan keberhasilan intervensi self management pada penderita dm dilakukan dengan mengevaluasi kadar gula darah, berat badan, kadar lemak dalam darah, dan imt (indeks massa tubuh) (newman dkk, 2004; coleman, 2005). oleh karena itu, penelitian ini bertujuan mengidentifi kasi self management sebagai salah satu intervensi yang dapat meningkatkan kepatuhan perawatan pada penderita dm. 145 self management intervention (siti nur kholifah) bahan dan metode pe n el it i a n i n i b e r d e s a i n q u a s y experiment non randomized pretest posttest. jumlah responden adalah 20 keluarga yang tinggal dengan penderita dm tipe 2. penelitian ini dirancang dengan memberikan perlakuan berupa self management intervention. sebelum dan sesudah diberi perlakuan, dilakukan pretest dan posttest dengan menilai tingkat kepatuhan responden terhadap perawatan dm. variabel independen penelitian ini adalah self management intervention dan variabel dependennya adalah kepatuhan penderita dm. data dikumpulkan dengan cara wawancara, food recall, dan observasi peubahan perilaku. untuk mengetahui perbedaan kepatuhan sebelum dan sesudah dilakukan uji paired t test dengan α≤0.05. self management intervention dalam penelitian ini dilakukan dengan langkahla ng k a h t i nd a k a n sebagai ber i k ut: 1) member ikan pendidikan dan pelatihan kepa d a kelu a rga , denga n menjelaska n tentang pengertian dari tindakan yang akan dilakukan, manfaatnya dan mempraktikkan prosedu r t i nd a k a n nya; 2) member i k a n motivasi sekaligus mengkaji komitmen dari keluarga untuk melakukan tindakan yang telah diajarkan; 3) melakukan perawatan langsung (direct care), tahap ini dilakukan untuk terapi modalitas perawatan luka; 4) mengadakan follow up secara berkala dengan sistem pencatatan dan pelaporan untuk semua tindakan yang dilaksanakan oleh keluarga menggunakan lembar pemantauan kegiatan harian dan food recall; 5) proses penyadaran diri (setelah pemantauan dilakukan selama satu bulan dan keluarga telah mampu melakukan perawatan secara teratur, maka keluarga dianjurkan untuk membuat jadwal sendiri untuk perawatan dirinya); dan 6) memberikan penguatan pada saat keluarga sudah mencapai kondisi penyadaran diri untuk membentuk kepercayaan diri dan meyakinkan perilaku keluarga. hasil tabel 1 menunjukkan bahwa sebelum dilakukan intervensi hanya ada 3 (15%) responden yang patuh menjalankan diet dm, tetapi sesudah intervensi meningkat menjadi 19 (95%) responden yang patuh. satu keluarga yang belum patuh sebenarnya sudah mengerti tentang diet dm, tetapi tidak mau mematuhi diet dm karena merasa sudah tidak ada keluhan. hasil uji statistik didapatkan p=0.000, yang berarti ada perbedaan yang bermakna antara kepatuhan diet dm sebelum dan sesudah pelaksanaan self management intervention. intervensi pertama dilakukan dengan pendidikan dan pelatihan pada keluarga. data yang didapatkan adalah keluarga belum mengerti tentang pengaturan makan untuk penderita dm tipe 2. keluarga kemudian diajarkan materi tentang pengertian diet, manfaat, prinsip pelaksanaan, cara menghitung kebutuhan kalori, dan cara membuat menu sesuai dengan kalori yang dibutuhkan dalam waktu 24 jam. waktu yang diperlukan untuk intervensi berbeda-beda untuk tiap keluarga. akan tetapi, rata-rata dibutuhkan waktu minimal 3 bulan untuk mencapai tujuan agar keluarga mampu menjalankan diet secara teratur. media yang digunakan adalah buku penduan diet dm. pendidikan dan pelatihan dilanjutkan dengan memberikan motivasi sekaligus mengkaji komitmen keluarga untuk melakukan diet dm. langkah berikutnya adalah memantau kepatuhan diet dm dengan food recall. setelah keluarga menjalankan diet dm, keluarga diajarkan untuk membuat tabel 1. data kepatuhan diet dm sebelum dan sesudah dilaksanakan self management intervention kepatuhan diet patuh tidak patuh jumlah sebelum 3 (15%) 17 (85%) 20 sesudah 19 (95%) 1 (5%) 20 paired t-test (2-tailed) p= 0.000 146 jurnal ners vol. 9 no. 1 april 2014: 143–150 catatan harian sendiri tentang makanan dan minuman yang dikonsumsi agar keluarga mampu mengevaluasi secara mandiri diet dm yang telah dilaksanakan. apabila keluarga sudah mampu menjalankan diet dm secara benar, keluarga diberikan reinforcement untuk menguatkan perubahan perilaku yang sudah dilakukan. tabel 2 menjelaskan bahwa hanya ada 6 (30%) responden yang patuh minum obat sebelum dilakukan intervensi, tetapi sesudah inter vensi selu r u h responden (100%) patuh untuk minum obat. hasil uji statistik didapatkan p=0.000, yang berarti ada perbedaan yang bermakna antara kepatuhan minum obat sebelum dan sesudah pelaksanaan self management intervention. penerapan self management intervention untuk meningkatkan kepatuhan minum obat dilaksanakan dengan memberikan pendidikan kesehatan. materi pendidikan kesehatan yang diberikan adalah mengenai jenis obat yang biasa diberikan kepada penderita dm, khasiat dari masing-masing jenis obat, dosis obat, dan dampak apabila tidak minum obat secara teratur. setelah keluarga memahami informasi yang diberikan, perawat membuatkan jadwal minu m obat pada tiap keluarga sesuai dengan jenis obat dan dosisnya. setiap kali pasien selesai minum obat, keluarga harus memberikan tanda (vb) pada jadwal yang tersedia. perawat melakukan follow up dengan melihat jadwal dan membandingkan dengan tabel 2. data kepatuhan minum obat sebelum dan sesudah dilaksanakan self management intervention kepatuhan minum obat patuh tidak patuh jumlah sebelum 6 (30%) 14 (70%) 20 sesudah 20 (100%) 0 20 paired t-test (2-tailed) p= 0.000 tabel 3. data kepatuhan olahraga sebelum dan sesudah dilaksanakan self management intervention kepatuhan olahraga patuh tidak patuh jumlah sebelum 2 (10%) 18 (80%) 20 sesudah 19 (95%) 1 (5%) 20 paired t-test (2-tailed) p= 0.000 berkurangnya jumlah obat yang tersedia. setelah pemantauan selama satu bulan, perawat memberikan penguatan karena keluarga telah teratur minum obat dengan cara menyadarkan perubahan dari gejala yang dirasakan dan pemeriksaan kadar gula darah. tabel 3 menjelaskan bahwa responden yang patuh berolahraga sebelum dilakukan intervensi hanya 2 (10%) responden dan sesudah intervensi terdapat 19 (95%) responden. hasil uji statistik didapatkan p=0.000, yang berarti ada perbedaan yang bermakna kepatuhan olahraga sebelum dan sesudah pelaksanaan self management intervention. p e l a k s a n a a n s e l f m a n a g e m e n t intervention untuk meningkatkan kepatuhan berolah raga dilakukan dengan memberikan pendidikan kesehatan tentang manfaat olahraga bagi penderita diabetes, jenis olahraga yang dapat dilakukan, dan urutan gerakan olahraga yang dianjurkan. kemudian perawat membuat jadwal untuk senam secara bersama-sama pada 20 keluarga yang dilakukan intervensi. senam dilaksanakan 2 kali per minggu selama 2 bulan dengan bantuan instruktur. selama 2 bulan tersebut, dilakukan evaluasi kemampuan penderita dm dalam melakukan senam. setelah dua bulan, semua penderita dm diminta untuk membuat jadwal sendiri untuk melakukan senam. penderita dm lebih memilih untuk senam di rumahnya sendiri dengan jadwal disesuaikan dengan kesibukannya masingmasing. perawat melakukan follow up kegiatan 147 self management intervention (siti nur kholifah) olahraga sesuai dengan jadwal yang dibuat. perawat memberikan reinforcement setiap melakukan follow up care. perawat juga menyadarkan bagaimana perubahan kebugaran jasmani setelah melakukan olahraga secara r utin. penyadaran ini akan menguatkan keluarga untuk terus melanjutkan olahraga secara rutin. waktu yang dibutuhkan keluarga untuk mampu melakukan olahraga sendiri di rumah adalah 2-3 bulan. hasilnya, 3 keluarga melakukan olahraga 1 kali dalam seminggu dengan waktu 30 menit-1 jam, 12 keluarga 2-3 kali seminggu dengan waktu 30 menit-1 jam, dan 4 keluarga melakukan olahraga setiap hari dengan durasi waktu 30 menit-1 jam. sementara ada 1 keluarga yang melakukan olahraga tidak secara rutin, karena alasan kesibukan. pembahasan keberhasilan peningkatan kepatuhan penderita dm dalam melaksanakan diet dan minum obat di keluarga karena self management intervention dapat digunakan sebagai upaya untuk meningkatkan pengetahuan, proses pengembangan ket rampilan pemecahan masalah penderita, dan meningkatkan selfeffi cacy dalam situasi kehidupan nyata yang penting bagi penderita. pendekatan ini juga mencakup perubahan sistem yang berfokus pada lingkungan perawatan primer. keluarga dan petugas kesehatan dapat mendukung pender it a dalam pengelolaan dir i (self management). upaya dapat dilakukan dengan penataan interaksi antara penderita, keluarga, dan petugas kesehatan dalam mengidentifi kasi masalah, membuat perubahan lingkungan yang menghilangkan hambatan pengelolaan diri, serta memberikan pendidikan secara individu, maupun melalui sumber daya manajemen diri masyarakat yang tersedia (newman s., steed l. & mulligan k., 2005). berdasarkan penelitian meta analisis dari glazier, bajcar, kennie dan wilson (2006), self management untuk perawatan dm terdiri dari monitoring glukosa darah, pengaturan diet, olahraga, minum obat, dan memanfaatkan pelayanan kesehatan pada saat membutuhkannya. self management dilakukan setelah penderita dm memahami penyakitnya, mengerti komplikasi yang terjadi dan menyadari pentingnya perawatan diri. self management menjadi suatu intervensi karena dianggap lebih efektif. dikarenakan pemantauan perawatan terdapat pada diri penderita dm sendiri tidak tergantung pada anggota keluarga serta petugas kesehatan yang ada. tahapan proses pelaksanaan intervensi self management adalah pertama, memberikan pendidikan dan pelatihan kepada penderita, keluarga, dan masyarakat tentang perawatan penyakit dm, komplikasi yang timbul akibat perawatan yang tidak teratur, ketrampilan mengenali tanda dan gejala, ketrampilan mengukur gula darah dan reduksi urin. pengetahuan yang dimiliki oleh masyarakat dan keluarga sangat berpengaruh terhadap perilaku yang ditunjukkan. pemberian materi disesuaikan dengan tingkat pendidikan masyarakat. teori yang mendasari memberikan pendidikan ini adalah bahwa meningkatkan pengetahuan penderita tentang penyakit yang menyebabkan perubahan perilaku akan meningkatkan hasil klinis. sebuah teori yang mendasari pemberian pendidikan pada self management adalah selfef f ica c y. s elfef f ica c y mer upa k a n suatu keyakinan penderita sesuai dengan kemampuannya sendiri unt uk mencapai suat u per ilak u ter tent u at au mencapai pengurangan gejala sehingga hasil klinis me mbai k . d u k u nga n m a n aje me n d i r i memperluas peran profesional perawatan kesehatan dalam memberikan informasi untuk membantu penderita membangun kepercayaan dan membuat pilihan yang mengarah pada peningkatan manajemen diri dan hasil yang lebih baik. pendidikan penderita biasanya diberikan oleh ahli kesehatan (newman, mulligan & steed, 2004). schamall (1994) dalam lueckenotte (2000) mengkategorikan 6 (enam) informasi umum yang dibutuhkan, yaitu pengetahuan keluarga tentang kondisi fi sik penderita dm, peningkatan ketrampilan koping, perset ujuan dengan keluarga, komunikasi yang efektif dengan penderita dm, memanfaatkan pelayanan yang ada di masyarakat dan perencanaan perawatan 148 jurnal ners vol. 9 no. 1 april 2014: 143–150 pada penderita dm dalam jangka waktu yang panjang. pengetahuan keluarga tentang kondisi fi sik diberikan karena keluarga perlu mengetahui tentang tanda dan gejala penyakit dm, pengobatan yang dilakukan, penurunan kemampuan fungsional dan implikasi pada keluarga. kedua, memberikan motivasi kepada keluarga dan masyarakat bahwa perawatan secara rutin pada penderita dm penting dilakukan untuk menghindari komplikasi. berdasarkan beberapa teori, arti motivasi a d a l a h a l a s a n ya ng me nd a s a r i s e bu a h perbuatan yang dilakukan oleh seorang individu. seseorang memiliki motivasi tinggi berarti orang tersebut memiliki alasan yang kuat untuk mencapai apa yang diinginkannya. tujuan yang mendasari motivasi ditentukan sendiri oleh penderita dm. penderita dm akan tergerak untuk melakukan perawatan secara rutin karena keinginannya untuk hidup sehat. motivasi intrinsik inilah yang yang perlu dibangun pada penderita dm. selain itu, motivasi ekstrinsik yang juga penting adalah dari keluarga. keluarga merupakan orang terdekat dengan penderita dm mempunyai kesempatan yang besar untuk senantiasa memberikan dorongan agar penderita dm mau melaksanakan perawatan. berdasarkan beberapa penelitian, sumber dukungan dari keluarga sangat penting untuk kesejahteraan fisik dan psikososial. penderita dm akan memperoleh keunt ungan dari dukungan keluarga seperti kesehatan fi sik, kepuasaan diri, kesejahteraan emosional dan penyesuaian. dukungan keluarga juga melindungi penderita dm dari dampak stres yang merugikan karena perawatan dalam jangka waktu yang lama (rose, 1997 dalam riasmini, 2002; jang dkk, 2002 dalam miller, 2004). dorongan yang dapat diberikan keluarga di antaranya adalah dengan memberikan fasilitas yang dibutuhkan penderita dm untuk perawatan sehari-hari. k e t i g a , m e n g g u n a k a n m e t o d e perawatan langsu ng (direct care) pada keluarga dan masyarakat dalam jangka waktu tertentu dengan melibatkan partisipasi mereka dan memberdayakan potensi yang ada. perawatan langsung dimaksudkan juga untuk memberikan contoh secara langsung dan melatih keluarga tentang perawatan penderita dm. keluarga merupakan komponen utama sebagai pendukung dalam pemberian perawatan kepada usia lanjut di rumah (jang dkk, 2002 dalam miller, 2004). keluarga didefi nisikan sebagai dua atau lebih individu yang hidup dalam satu rumah tangga karena adanya hubungan darah, perkawinan atau adopsi. anggota keluarga saling berinteraksi satu dengan yang lain, mempunyai peranan masing-masing, dan menciptakan ser ta mempertahankan suatu budaya (bailon & maglaya, 1987). helvie (1998), menyatakan bahwa tujuan dari pemberdayaan keluarga adalah meningkatkan potensi keluarga dalam bidang kesehatan agar mampu meningkatkan kualitas hidup yang lebih baik bagi seluruh keluarga melalui kegiatan swadaya. tahapan pemberdayaan terdiri dari tahap penyadaran dan pembentukan perilaku menuju perilaku sa d a r d a n pedu li, t a hap t r a n sfor ma si kemampuan berupa wawasan pengetahuan dan kecakapan dan tahap peningkatan kemampuan pengetahuan dan keterampilan, sehingga terbent uklah inisiatif ser ta kemampuan inovatif untuk mengantarkan pada kemandirian keluarga dalam melaksanakan perawatan dm. keempat, mengad a kan follow up secara berkala dengan sistem pencatatan dan pelaporan. kelima, proses penyadaran diri. keluarga dianjurkan untuk membuat jadwal sendiri untuk perawatan dirinya dengan dibantu perawat. misalnya mengatur dietnya, jadwal olahraga dan minum obat secara teratur. untuk memantau pelaksanaan jadwal tersebut, keluarga diberikan suatu buku untuk mencatat setiap tindakan yang dilakukan dan dampak yang dirasakannya. setiap keluhan yang dirasakan oleh klien dan upaya yang telah dilakukan dicatat dalam buku tersebut. dengan metode ini diharapkan keluarga menyadar i apapu n yang telah dilakukannya ternyata membawa dampak bagi kondisi kesehatannya. apabila keluarga atau masyarakat sudah sadar dengan dampak dan manfaat yang dirasakan dari setiap tindakan yang dilakukan, maka mereka akan dapat mengatur diri mereka sendiri untuk melakukan perawatan diri secara teratur. 149 self management intervention (siti nur kholifah) pada saat keluarga sudah mencapai kondisi penyadaran diri, perawat dapat memberikan penguatan untuk membentuk kepercayaan diri dan meyakinkan perilaku keluarga yang telah terbentuk tersebut. berdasarkan tabel 1 dan 3, ada 1 (satu) keluarga yang sama tidak patuh untuk menjalankan diet dan olahraga. keluarga tersebut merasa dengan minum obat secara teratur sudah tidak ada keluhan. keluarga mengatakan dahulu pada saat pertama kali didignosa dm sudah melakukan diet, tetapi penyakitnya tidak sembuh-sembuh. kesibukan dalam mengurus rumah tangga juga alasan keluarga tidak melakukan olahraga. hal ini dapat dijelaskan bahwa hambatan dalam kebe rha sila n self m a n age me nt a d ala h kondisi kronis yang sering terjadi sebagai komorbiditas. penderita dengan penyakit kronis sering merasa jengkel, putus asa dan depresi, hal ini yang menjadi penghalang keefektifan self management. rendahnya self-efficacy mer upakan potensi hambatan lain untuk pelaksanaan intervensi ini. untuk mengatasi hambatan tersebut, berdasarkan beberapa hasil penelitian, kunci dari strategi pelaksanaan intervensi self management di masyarakat adalah 1) modif ikasi budaya masyarakat setempat dan mengidentif i kasi budaya masyarakat baik yang dapat menguatkan maupun yang melemahkan tercapainya tujuan intervensi; 2) mengajarkan masyarakat sebagai pendidik; 3) berorientasi juga pada perilaku masyarakat tentang pengobatan; 4) intensitas intervensi >10 kali kontak dalam waktu lebih dari 6 bulan (glazier, bajcar, kennie dan wilson, 2006). p e l a k s a n a a n s e l f m a n a g e m e n t memerlukan dukungan dari berbagai pihak terutama orang-orang yang ada di sekitar penderita dm. dukungan dapat berasal dari pelayanan kesehatan yang ada, petugas kesehatan, anggota keluarga atau orang yang paling berpengaruh serta masyarakat sekitar. semua komponen tersebut berkontribusi terhadap pembentukan kesadaran diri untuk melakukan perawatan secara teratur, sehingga penderita dm dapat memelihara stat us kesehatannya secara mandiri. kesimpulan dan saran simpulan ada peningkatan kepatuhan penderita dm tipe 2 d alam mela k sa na ka n d iet dm, minum obat, dan olahraga setelah dilakukan self management intervention. self management merupakan salah satu bentuk intervensi keperawatan yang bertujuan untuk membentuk kesadaran diri, sehingga penderita penya k it dm pat u h d alam mela k u kan perawatan secara teratur. saran pe r awat komu n it a s d i h a r apk a n dapat menerapkan strategi intervensi self management agar kepatuhan penderita dm dalam melakukan perawatan sehari-hari dapat meningkat. penelitian lebih lanjut perlu dilakukan untuk mengetahui efektifi tas intervensi self management pada penderita dm di wilayah jawa timur. kepustakaan a risman & suyono. 2000. pencegahan diabetes mellitus. jakarta: hipokrates. arora. 2007. press diabetes. jakarta: bhuana ilmu populer. bailon & maglaya. 1987. family health nursing: the process, philippiness: up. college of nursing diliman, quezon city. brunner & suddarth. 2000. medical surgical n u r si n g. (9 t h e d). ph i l a d el p h i a : lippincott depkes ri, 2005, diabetes mellitus di indonesia, http://www.depkes.go.id diperoleh tanggal 1 oktober 2006. glazier, bajcar, kennie dan wilson. 2006. a systematic review of intervention to improve diabetes care in sicially disadvantaged populations. proquest medical library. 29 (7). 1675-1688. helvie. 1998. advanced practice nursing in the community. new delhi india: sage publication inc. jones. 2003. self management and self direction in the success of native literacy learners, http://www.proquest.umi.com diperoleh tanggal 4 desember 2006 150 jurnal ners vol. 9 no. 1 april 2014: 143–150 miller. 2004. nursing for wellness in older adults: theory and practice. (4th ed.), philadelphia : lippincott. newman, steed, & mulligan. 2004. self management intervention for chronic illness. http://www.ncbi.nlm.nih.gov/ pubmed/15500899 diperoleh tanggal 3 september 2013. ta kosh ia n. 1997. self management in organization, http://www.proquest. umi.com diperoleh tanggal 4 desember 2006 yukl. 1994. leadership in organization. new jersey: prentice-hall inc. lueckenotte. 2000. gerontologic nursing. (2th ed.). st. louis: mosby. watkins, edward, & gastrell. 2003. community health nursing: framework for practice. (2nd ed.), london: bailliere tindall. 116 voluntary counseling and testing (vct) hiv – aids pada tahanan di rumah tahanan negara kelas i surabaya (voluntary counseling and testing (vct) to prisoner in class i prison of surabaya) abdul muhith*, linda prasetyaning*, nursalam** * stikes majapahit mojokerto, jl. raya gayaman km. 02 mojoanyar mojokerto, e-mail: cua_muhith@yahoo.com ** fakultas keperawatan universitas airlangga abstract introduction: vct is one of the efforts of the prison to minimize the risk of hiv/aids on injecting drug user prisoners. but there are still obstacles in the implementation of this program in prison. the purpose of this study was to evaluate the vct in class i surabaya prison. method: this study used qualitative and quantitative method. samples to evaluate the vct program among offi cer, clinical offi cers who carry out vct and ngos as well as four idu prisoners selected using purposive sampling. samples to describe prisoner's characteristic and risk factor of hiv/aids from behavior aspect were 60 prisoners. data were collected by fi lling out the questionnaire and in depth interview. result: the results were analyzed by qualitative descriptive narrative. the results of this study was a major behavioral factors that lead to the incidence of hiv/aids on injecting drug user prisoners, unsafe sexual behavior and tattooing. discussion: as for the evaluation of vct was not performed well. in terms of input, the human resources sector and source of funds and independent laboratory facilities were deemed less. on process aspects, the sector of pre-and post-test counseling and support programs was still not optimal. in the aspect of output, an indicator to measure the success of vct, patient satisfaction questionnaire coverage and effort to vct client was still not implemented. it is necessary to enhance the implementation of vct and to realize a program especially for drug user prisoners to prevent and control the transmission of hiv/aids such as harm reduction program. keywords: hiv/aids, vct, injecting drugs, prisoners pendahuluan pelaksanaan voluntary counseling and testing (vct) di rumah tahanan (rutan) kelas i surabaya rutin dilakukan setiap tiga bulan sekali. pelaksanaan vct merupakan kerjasama antara dinas kesehatan kabupaten sidoar jo dan ru mah sak it di wilayah surabaya dan sidoarjo. meskipun pelaksanaan sudah rutin, tetapi cakupan program masih rendah. hal ini dikarenakan prinsip sukarela (voluntary) dari program vct itu sendiri sehingga memungkin kan warga binaan pemasyarakatan (w bp) menolak unt u k dilakukan vct. misalnya pada pelaksanaan vct bulan desember tahun 2011, wbp yang beresiko terkena hiv (pemakai napza suntik) tidak semua ikut ber par tisipasi. rendahnya cakupan program dibandingkan dengan standar kemenkumham, kendala yang dihadapi dalam pelaksanaan program vct d an apa kah dibut u h kan prog ram selain program vct untuk mencegah dan menanggulangi hiv/aids bagi wbp napza suntik merupakan hal yang melatarbelakangi dilakukannya penelitian ini. oleh karenanya penting dilakukan evaluasi terhadap program vct untuk menggambarkan pelaksanaan dalam program vct sehingga dapat menjadi rekomendasi untuk pihak rutan dalam upaya pencegahan dan penanggulangan hiv/aids terutama bagi wbp napza suntik di rutan klas i surabaya. bahan dan metode jenis penelitian ini termasuk penelitian dengan pendekatan kualitatif dan kuantitatif. evaluasi program vct pada aspek input, 117 voluntary counseling and testing (vct) hiv – aids (abdul muhith, dkk.) proses dan output, dilakukan penelitian kualitatif di mana data diperoleh melalui telaah data dan indepth interview. deskripsi dist r ibusi karak ter isti k sosiodemog raf i dan aspek perilaku, dilakukan penelitian kuantitatif. data distribusi karakteristik sosiodemografi dan aspek perilaku diperoleh melalui pengisian kuisioner tanpa diadakan perlakuan. rancang bangun penelitian ini ter masuk dalam desain cross sectional. penelitian ini dilakukan di wilayah rutan klas i surabaya, jawa timur. penelitian dilaksanakan selama 3 bulan. populasi dalam penelitian dibagi menjadi dua yaitu untuk mengevaluasi program vct ( penelitian kualitatif ), populasi dalam penelitian ini adalah petugas rutan, petugas klinik rutan, tenaga magang lsm dan wbp dan untuk mendisk ripsikan distribusi karakteristik sosiodemografi dan aspek perilaku (penelitian kuantitatif ), populasi dalam penelitian ini adalah semua wbp napza suntik di rutan klas i surabaya. sampel dalam penelitian dibagi menjadi dua yait u unt uk mengevaluasi program vct (penelitian kualitatif ), sampel dalam penelitian ini adalah petugas rutan 1 orang, petugas klinik rutan 1 orang, tenaga magang lsm 1 orang dan wbp 4 orang dengan total responden adalah 7 orang dan untuk distribusi karakteristik sosiodemograf i dan aspek perilaku (penelitian kuantitatif), akan dipilih 60 wbp napza suntik secara purposive. kriteria inklusi dalam pengambilan sampel adalah wbp yang terjerat uu psikotropika dan menggunakan napza suntik serta wbp yang telah mengikuti program vct di rutan. sampel didapatkan melalui purposive sampling u nt u k mengevaluasi prog ram vct ( penelitian k ualit atif ) dan u nt u k mendiskripsikan karakteristik sosiodemografi dan aspek perilaku (penelitian kuantitatif). hasil hasil dalam penelitian ini adalah karakteristik wbp sebagian besar berusia produ k t if, ber jen is kela m i n la k i-la k i, berpendidikan tinggi, telah berada di rumah tahanan negara klas i surabaya lebih dari 3 bulan, tidak dalam ikatan pernikahan dan ditangkap sebagai pemakai napza suntik. faktor resiko perilaku, penelitian ini membagi perilaku menjadi 3 aspek yaitu pengetahuan, sikap dan perilaku. pengetahuan mayoritas wbp tentang hiv/aids, cara penularan dan pencegahannya masih kurang walaupun sikap mayoritas wbp cenderung per misif terhadap pender ita hiv/aids dan program-program terkait pencegahan dan penanggulangan hiv/aids di rutan. perilaku beresiko wbp adalah penggunaan napza suntik dan hubungan seks tidak aman. sedangkan perilaku pembuatan tato dan tindik tidak ditemukan. hasil evaluasi pelaksanaan program vct pada aspek input sudah cukup baik. faktor resiko sudah terpetakan dengan jelas dan kebijakan atau spo pelaksanaan vct sudah ada. sarana-prasarana sudah ada namun perlu dibangun laboratorium untuk program vct. sumber daya manusia masih kurang terutama tenaga konselor di mana konselor masih belum dapat menjalankan tugasnya sebagaimana mestinya. sumber dana dirasa masih kurang untuk pelaksanaan program vct. pelaksanaan program vct pada aspek proses masih dirasa kurang optimal. kegiatan konseling pra-testing belum dilaksanakan sesuai spo yang ditetapkan menteri kesehatan. formulir informed consent sudah ada. proses testing hiv sudah sesuai dengan spo menteri kesehatan. kegiatan konseling pasca-testing sudah dilakukan namun hanya pada wbp yang positif hiv. layanan dukungan yang telah berjalan antara lain peer education, kie (penyuluhan), abstensia napza, pitc (provider-initiated testing and counselling). pela k sa na a n prog ra m vct pad a aspek output masih dirasa kurang. indikator keberhasilan dan ketercapaian program masih belum ada begitu pula dengan kegiatan monitoring evaluasi dan kendali mutu program vct yang masih belum dilaksanakan. angket kepuasan pasien belum ada. peningkatan ca k upa n prog ra m masi h belu m d apat dilaksanakan terkait pembatasan k uota laboratorium yang ditunjuk bekerjasama dengan rumah tahanan negara klas i surabaya. 118 jurnal ners vol. 7 no. 2 oktober 2012: 116–120 pembahasan pelaksanaan program vct pada aspek input masih kurang. faktor resiko kejadian hiv/aids di dalam rutan yang dominan adalah tindakan hubungan seks tidak aman (8%), pembuatan tato (3%) dan pemakaian napza suntik (2%). penelitian ini sesuai dengan penelitian yang menyebutkan bahwa penjara bukan hanya tempat aman bagi praktikpraktik homoseksual, tetapi juga tempat aman untuk konsumsi dan peredaran narkoba serta penularan virus hiv/aids melalui penggunaan jarum suntik. penggunaan narkotika suntik di penjara dengan saling menukar alat suntik merupakan medium penularan hiv. penelitian ya ng d ila k u ka n ju rgens menu nju k ka n bahwa sebagian besar narapidana yang hidup dengan hiv/aids terinfeksi di luar penjara sebelum menjalani masa hukuman. namun dalam perkembangannya, maraknya penggunaan narkotika suntik di penjara justru meningkatkan resiko penularan hiv di penjara. dalam banyak kesempatan, menurut jurgens 15–20 orang memakai jarum suntik yang sama. tingginya penularan hiv di penjara ditambah dengan kurangnya akses pencegahan. kebijakan atau spo pelaksanaan vct sudah ada. spo program vct di rutan klas i surabaya masih terbatas pada alur pelaksanaan vct tanpa melihat aspek lain yang telah di atur dalam keputusan menteri kesehatan no. 1507/menkes/sk/x/2005 tentang pelayanan konseling dan testing hiv sukarela. berdasarkan kmk tersebut klinik vct terintegrasi harus memenuhi beberapa kriteria seperti sarana, sdm dan prosedur kerja demi optimalnya pelaksanaan program. tolok ukur keberhasilan program terletak pada pelaksanaan program sesuai kebijakan yang ditetapkan. kebijakan meliputi prosedur, target dan tujuan dilakukannya suat u prog ram. kebijakan pelaksanaan program vct di rutan secara khusus dapat dilihat pada keputusan menteri hukum dan hak asasi manusia no: m.hh.01.ph.02.05 tahun 2010 tentang rencana aksi nasional penanggulangan human immunodefi ciency virus–acquired immune defi ciency syndrome dan penyalahgunaan narkotika, psikotropika dan bahan adiktif berbahaya lainnya pada unit pelaksana teknis pemasyarakatan tahun 2010–2014 yang menjelaskan mengenai tujuan, kebijakan pelaksanaan, sasaran, kegiatan pokok dan keluaran dalam program vct di rutan. sarana-prasarana sudah memadai namun perlu dibangun laboratorium untuk program voluntary counseling and testing (vct). menurut djaelani (2009) keterbatasan sarana dan hal-hal di atas akan menjadi penghambat dalam pelaksanaan penanggulangan hiv/aids di rutan. karena mau tidak mau pencegahan dan penanggulan hiv/aids harus didukung dengan fasilitas dan sarana yang memadai. juga perlu dii ngat ka n kembali ba hwa pencegahan dan penanggulangan hiv/aids memerlukan tes hiv, perawatan kesehatan dasar dan program terapi serta pengalihan dari ketergantungan dari narkoba. sumber daya manusia masih kurang terutama tenaga konselor di mana konselor masih belum dapat menjalankan tugasnya sebagaimana mestinya. penelitian ini sesuai dengan penelitian napitupulu yang menyebutkan keberadaan petugas kesehatan yang masih belum terpenuhi secara proposional dan professional, dana perawatan kesehatan yang dianggarkan masih kurang proposional, persediaan obat-obatan serta persediaan sarana maupun prasarana masih sangat terbatas akan menghambat pemenuhan kebut uhan pelaksanaan hak pelayanan kesehatan narapidana. sumber dana dirasa masih kurang untuk pelaksanaan program vct. penelitian ini sesuai dengan penelitian kementrian hukum dan hak asasi manusia yang menyebutkan bahwa kekurangan dalam pendanaan, jumlah tenaga kesehatan, dan prasarana dasar; terutama bila dibandingkan dengan jumlah penghuni, merupakan hal yang paling kerap dikemukakan oleh petugas rutan. minimnya anggaran untuk beberapa uji laboratorium tambahan guna pemeriksaan hiv juga menjadi kendala di beberapa rutan. pelaksanaan program vct pada aspek proses masih kurang optimal. kegiatan konseling pra-testing belum dilaksanakan sesuai spo yang ditetapkan menteri kesehatan. hasil penelitian ini sesuai dengan penelitian dayaningsih (2009) yang menyebutkan faktorfaktor yang mempengar uhi pelaksanaan vct adalah pengetahuan konselor, kualitas 119 voluntary counseling and testing (vct) hiv – aids (abdul muhith, dkk.) konselor, faktor pendukung, pelaksanaan tahapan vct, hambatan pelaksanaan vct. faktor dari konselor antara lain: ketenagaan konselor kurang, konsulan tidak tepat waktu, subjektivitas konselor. formulir informed consent sudah ada. proses testing hiv sudah sesuai dengan spo menteri kesehatan. lapas/rutan harus senantiasa menyediakan layanan tes hiv berbasis kesukarelaan dengan memberikan informed consent kepada mereka yang menjalani tes dan akses konseling pre dan paska-tes. kegiatan konseling pascatesting sudah dilak u kan namu n hanya pada wbp yang positif hiv. layanan tes dan konseling berhubungan dengan akses perawatan, pengobatan, dan dukungan bagi mereka yang kedapatan hasil tes positif. tes dan konseling layaknya menjadi bagian dari program hiv/aids komprehensif yang turut menyertakan akses pencegahan. layanan dukungan yang telah berjalan antara lain peer education, kie (penyuluhan), abstensia napza, pitc (provider-initiated testing and counselling). untuk mengantisipasi dan mencegah penularan infeksi hiv, jangka pendek: meningkatkan penyuluhan tentang cara penularan dan pencegahan infeksi hiv, pelatihan kepada kepala dan petugas lapas, diusahakan penyediaan kondom di lapas, disediakan ruangan khusus di lapas untuk melakukan hubungan seks narapidana yang memiliki istri yang syah dan berkumpul dengan anaknya, disediakan disinfektan untuk mensterilkan jarum, perlu dibuat lapas khusus napza, dipersiapkan program harm reduction, perlu dianggarkan dana operasional rs tutan, perlu dibuat rs khusus untuk narapidana hiv positif di rutan. pela k sa na a n prog r a m vct pa d a aspek out put masi h k u rang. i ndi kator keberhasilan dan ketercapaian program masih belum ada. indikator keberhasilan program penangg ulangan h i v/a i ds bagi w bp adalah sebagai berikut per ubahan warga binaan yang dijangkau program perubahan perilaku, persentase warga binaan yang mengikuti vct, persentase warga binaan yang mengikuti ptrm, persentase warga binaan yang mengikuti program perawatan dukungan dan pengobatan. target keberhasilan program vct menurut kpa bagi wbp adalah 80% dari keseluruhan wbp dan penasun dapat mengaksesnya tahun 2011. jika dilihat dari target inipun, indikator keberhasilan program vct di rutan klas i surabaya masih di bawah target. angket kepuasan pasien belum ada. menur ut tjiptono dalam ar manita (2008) pelanggan akan menggunakan indera penglihatan untuk menilai, sebagian besar kesimpulan terhadap kualitas pelayanan disimpulkan oleh pelanggan berdasarkan apa yang terlihat oleh mata mereka. selain itu, kepuasan pasien juga dapat dilihat dari kinerja yang ditunjukkan oleh para petugas seperti bersikap ramah, sopan, dan cepat tanggap serta berempati terhadap mereka. peningkatan cakupan program masih belum dapat dilaksanakan terkait pembatasan kuota laboratorium yang ditunjuk bekerja sama denga n ru ma h ta ha na n nega ra klas i surabaya. cakupan adalah jumlah populasi kunci yang dijangkau kegiatan penyelenggaraan program efektif dalam kurun waktu tertentu. cakupan program vct adalah 720 klien per tahun. karakteristik wbp sebagian besar berusia produktif (100%), berjenis kelamin laki-laki (63%), berpendidikan tinggi (83%), telah berada di rumah tahanan negara klas i surabaya lebih dari 3 bulan (87%), tidak dalam ikatan pernikahan (42%) dan ditangkap sebagai pemakai napza suntik (92%). hasil penelitian ini sesuai dengan penelitian yang menyebutkan bahwa mayoritas wbp di rutan sebagian besar berusia produktif, berjenis kelamin laki-laki, berpendidikan tinggi, telah berada di rutan lebih dari 3 bulan, tidak dalam ikatan pernikahan, dan ditangkap sebagai pemakai napza. faktor resiko wbp menurut aspek perilaku dijelaskan berdasarkan knowledge, attitude dan practice sebagai berikut adalah dari segi pengetahuan mayoritas (53%) wbp di rutan klas i surabaya tentang hiv/aids, cara penularan dan pencegahannya masih kurang, sikap mayoritas (55%) wbp di rutan klas i surabaya setuju terhadap penderita hiv/aids dan program-program terkait pencegahan dan penanggulangan hiv/aids di rutan, dan tindakan wbp beresiko terinfeksi hiv/aids di rutan klas i surabaya adalah 120 jurnal ners vol. 7 no. 2 oktober 2012: 116–120 hubungan seks tidak aman (8%), pembuatan tato (3%) dan penggunaan napza suntik (2%). sedangkan tindakan pembuatan tindik tidak ditemukan. simpulan dan saran simpulan pelaksanaan program vct sudah cukup baik namun masih belum optimal dalam pelaksanaannya, mulai dari aspek input, proses maupun output. saran diperlukan komitmen dan kerja sama dari berbagai pihak untuk dapat mewujudkan opt i malisasi prog ra m pencega ha n d a n penangg ulangan hi v/a ids yang lebih komprehensif terutama bagi wbp napza suntik seper ti program harm reduction. diperlukan peran petugas kesehatan, dokter dan perawat dalam penerapan vct secara komprehensif dalam upaya menurunkan angka kesakitan, kematian dan yang lebih penting menunukan terjadinya penularan sesama narapidana. kepustakaan armanita, r.y., 2008. gambaran manajemen program konseling dan tes sukarela hiv/aids rumah sakit ketergantungan o b a t ( r s ko ). s k r i p s i t i d a k dipublikasikan. jakarta: universitas indonesia. azwar, azrul, 1996. menjaga mutu pelayanan kesehatan, jakar ta: pustaka sinar harapan. dayaningsih, diana, 2009. studi fenomenologi pelaksanaan hiv voluntary counseling and testing (vct) di rsup dr. kariadi semarang. skripsi tidak dipublikasikan, semarang: universitas diponegoro. djaelani, arry, 2009. penanganan khusus terhadap narapidana penderita hiv/ aids di lembaga pemasyarakatan dan rumah tahanan negara di indonesia. skripsi tidak dipublikasikan. jakarta: universitas indonesia. http://e-journal.unair.ac.id/jners | 207 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i1.4686 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research life writing therapy decreases depression in late adolescence zulaikah nur istiqomah, erna erawati and suyanta suyanta nursing department of health polytechnic kemenkes, semarang, indonesia abstract introduction: late adolescence (16-18 years old) usually experiences a crucial period in life which makes teenagers vulnerable to mood disorders such as depression. one of the interventions that can decrease depression is writing a memoir, biography, diary, and life writing. writing can disclose the feeling and help mind care. the objective of this study was to investigate the influence of life writing therapy to decrease depression in late adolescence. methods: this study used pretest-post-test control group design with 40 people as samples, divided into intervention and control groups. before and after the treatment, both groups were measured using the scale of the phq-9a to see the depression in late adolescence of high school students. results: life writing therapy shows differences in mean between intervention group and control group with a p-value of 0.000 (α <0.05). conclusion: the life writing therapy has an effect in reducing depression in students. it facilitates subjects to evaluate, analyze, and reassess past, current and future events so that subjects can get an understanding, develop a solution and self-motivation, accept the existing situation, learn from what is experienced, focus thoughts on positive things, and assess positive things from an event. article history received: june 16, 2017 accepted: january 04, 2019 keywords depression, adolescence; life writing therapy contact zulaikah nur istiqomah  zulaikahnuristiqomah@gmail.com  nursing department of health polytechnic kemenkes, semarang , indonesia cite this as: istiqomah, z, n., erawati, e., & suyanta, s. (2018). life writing therapy decreases depression in late adolescence. jurnal ners, 13(2), 207-212. doi:http://dx.doi.org/10.20473/jn.v13i2.4686 introduction the term adolescence comes from latin word adolescere (noun, adolescentia which means teenager) which means “to grow” or “to grow into adulthood”. the term adolescence, as used nowadays, has a broader meaning including mental, emotional, social and physical maturity (hurlock, 2002). the term adolescence, once a synonym for puberty, is now more emphasized stating the psychosocial changes that accompany puberty. however, the acceleration of somatic growth which is part of physical changes at puberty is called adolescent growth spurt (soetjiningsih, 2010). adolescence is a transition period between childhood and adulthood followed by biological, cognitive, and socioemotional changes (santrock, 2014). adolescence has a broad meaning including mental, emotional, social, and physical maturations (signs of secondary sex, maturation of reproduction, a way of thinking is more abstract, logical, and idealistic, emotionally more labile, and the relationship with peers become more intimate). adolescence is divided into two stages, early and late adolescences. early adolescence usually lasts roughly from 13-16 years old, while late adolescence starts from 16 or 17 years old to 18-years-old. during the late adolescence, teenagers commonly spend their times studying at high school. in addition, they experience a crucial time in life because they live in transition period between adolescence and adulthood. when teenagers are in the last year of high school, their parents usually consider that they are almost an adult and about to enter higher education or receive specific job training. being student also makes them aware of the responsibilities they had never thought before (hurlock, 2002). awareness of new formal status, either at home or at school, has encouraged most of teenagers to behave in a more mature way. however, looking at the juvenile psychological mental status, it is not stable yet. in addition, some of them assume that this responsibility is a huge burden. pressure from parents, schools, and environment can make https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ z. n. istiqomah et al. 208 | pissn: 1858-3598  eissn: 2502-5791 teenagers feel frustrated or stressed because of the lack of gain in self-fulfillment (soetjiningsih, 2010). inability to deal with stressors or pressures has led teenagers to the risk of disorders moods such as depression to behave detrimental both for themselves and others. most of the depressions in adolescents are undiagnosed. psychological developments commonly found in adolescence include emotional disorder, excessive introspection, and high sensitivity. as a result, the symptoms of depression are considered as part of the change in adolescent development. in fact, depression is a normal response phenomenon to negative life experiences, such as loss of family, valuables or social status. depression can be seen as a continuum that moves from normal depression to clinical depression (murti, 2012). caron in aditomo (2004) mentions the normal symptoms of depression such as feelings of not getting excited, feeling of hopeless, etc. that usually do not last long or minor depression. coping with these symptoms, a new perspective that is more mature will appear; thus, normal depression could be seen as an adaptive experience. depression becomes maladaptive and abnormal when appear in high intensity and settle or major depressive disorder. depression in teenagers is basically a disorder that affects affective regulation. in particular, this disorder appears to cause problems by initiating, maintaining, or modifying the quality, intensity, or affective response time. the key aspects of this disorder, especially the sedentary low mood and anhedonia typical of depressive episodes, can be conceptualized as changes in affective regulation. both the intensity and duration of the affective stage appear abnormal in depression as showing changes in the regulatory affective process (forbes, silk, & dahl, 2009). bps kota magelang (2015) states that the population of adolescents at the age of 15-19 are 10.759 teenagers and the numbers of student who study at high school in magelang are about 4,716 students. lentera jiwa (2015) in one of their articles mention the results of a survey conducted in 50% of schools in magelang ranging from early childhood through high school in june 2014. the survey shows a comparison of the number of children and adolescents who had problems in magelang, i.e. mental-emotional disorders. longitudinal research conducted by sihvola et al. (2016) on 1854 respondents indicates that minor depression is more common in adolescents than major depression with a ratio of 12%: 2.5%. this percentage indicates the importance of research to assess effective method in reducing depression in adolescents. some types of interventions have been studied for its effectiveness in reducing depression. one of the therapies that can be done is cognitive behavior therapy that drives to think of realistic and positive about themselves, environment and future whether in dialogues or writing. life writing is one of cognitive therapies by writing the stories, memoirs, biographies, diaries (progoff in pranoto, 2015). research conducted by pennebaker about emotional writing has also proven that writing can help heal the effects of trauma (pranoto, 2015). in addition, writing will stimulate the brain to organize his thoughts, pour emotions and feelings, and help solve problems. writing a diary or life writing therapy is the treatment to write the easiest thing to do. domar in rais & hidayati (2009) states that writing is a step to express emotions and feelings and help care for the mind. the effect of writing in alleviating depression has also been investigated by qonitatin (2011). in these studies, there is a significant influence on students who have mild depression. through expressive writing therapy, emotional experiences as catharsis or emotional release their lower levels of mild depression. the objective of this study is to examine the effect of life writing therapy in decreasing depression in late adolescence. materials and methods this study was a quasi-experiment research with the pretest-posttest control group design method. the research was conducted in a high school in magelang from january to february 2017. the population of this study was 146 students of the 12th grade who experienced depression based on the preliminary study conducted by researchers. the samples were selected using the purposive sampling technique based on inclusion criteria, i.e. the subjects were the 12th grade student at the age of 16-18 with depression scores between 10-27 (mild depression to severe depression using phq-9a), able to write, and had never been exposed to depression-related therapy. there were 40 samples who were divided into two groups, intervention and control groups consisting of 20 students for each. the groups were divided using simple random sampling with statistic application where samples have the same opportunity. the data collection tool uses a modified phq-9a scale measuring tool for teens (patient health questionnaire-9 adolescence), i.e. a tool to measure the scale of depression in adolescents with likert scale 0-3 consisting of 9 questions, each of which represents an indicator of depression for approximately 2 weeks last. this questionnaire has been tested for validity and reliability. the validity test showed that the question items were valid with a correlation value between 0.434 0.826 at the 95% significance level. the value of reliability in this questionnaire was 0.822; thus, the questionnaire was reliable or trusted. the ethical considerations were met, as the participants signed an informed consent form. after obtaining approval from all respondents, it was subjected to an initial reassessment or pretest as a baseline to strengthen screening data in both the intervention and control groups. the intervention jurnal ners http://e-journal.unair.ac.id/jners | 209 was carried out for 4 weeks with a total of 8 meetings containing 3 sessions of writing with a different topic for approximately 45-60 minutes simultaneously at each meeting. respondents were given workbooks related to interventions consisting of several commands for life writing therapy that could be written every day and done at home. posttest was conducted after the follow-up during the last week of intervention. the media used in this study were workbook, observation sheet, and evaluation sheet. this research study received ethical clearance approval from the ethics committee of the research and community service units of the health polytechnic kemenkes semarang no. 1475 in 6th february 2017. results the respondents were 40 students of the 12th grade divided into two groups: the intervention and the control groups. during the research, there were no respondents who dropped out and all of them were included in the analysis. most respondents were at age of 17, 60% in the intervention group and 75% in the control group. based on the sex, most respondents were female, 50% in the intervention group and 65% in the control group. 77.5% respondents were science class and 22.5% respondents were social class (table 1). table 2 shows that the average pre-test score in the intervention group is 8,9 and post-test score is 4.8,and the difference between pre-test and post-test score are 4.10 (table 2). meanwhile, the control group shows the average pre-test score of 8.55 and average post-test score of 8.40; thus, the difference between pre-test and post-test is 0.15 (table 2). table 2 shows the comparison between the average, decrease in depression pre-test and posttest scores in the intervention group and the control group of 0.000 (p-value <0.05). it means that there is a very significant influence of life writing therapy to decrease depression in adolescents (table 2). discussion the research results show that most respondents from a total of 40 students were at age of 17, or 67.5%. another study which had the same thing was a study conducted by harijanto, handayani, & asmika (2008). it reported that the prevalence of the depression among the high school students based on the age was found at the age of 17. there are a lot of factors that can influence it as revealed by el kelly in bahiyatun (2011). at the age of 16 to 18, teenagers are commonly spend their times studying at high school. in addition, they will experience a crucial transition period between adolescence and adulthood. during this period, the status of the individual is not clear and there are doubts about the roles that must be performed. they are not expected to be childish anymore, but also not expected to behave like adults. the results also show that that the number of female students was higher than male students, 57.5% women and 42.5% males. what makes it different is because girls tend to keep their depressed moods and strengthen them, female selfimage, especially in a more negative body image than males, females find more discrimination than males, and puberty occurs earlier in females (santrock, 2014). darmayanti (2008) concludes that there were differences in depression between adolescent girls and boys. adolescent girls have depressive tendencies compared to adolescent boys. the research results also show that the mean pre-test score in depression of the intervention group was 8.90, and the control group was 8.55. the ranges of depression levels based on the set score are 0-4 not depressed/normal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 severe depression, 20-27 very severe depression. seeing these results, it can be said that both groups experienced an average level of mild depression. the results of this study are consistent with the results of research conducted by safitri (2013) and harijanto (2008) who reported that the level of depression experienced by adolescents at most was mild depression. ardjana (2010) suggests that a person can be said to experience mild depression if he/she shows at least two of the main symptoms. in addition, there should be no severe symptoms, and the duration of the entire episode is about two weeks. the main symptoms felt are the atmospheres of feeling depressed throughout the day and losing interest and passion in almost all activities, fatigue and decreased activity. the research results show that there is the influence of life writing therapy to decrease depression in adolescents. this hypothesis is proven by statistical tests using independent t-test results showing p-value of 0.000 (p-value <0.05). it means that the average decrease in depression pre-test and post-test scores in the intervention group is larger than in the control group. therefore, it can be concluded that there is a very significant effect on the depression score between the group with life table 1. characteristics of respondents (n=40) variable intervention control total f % f % f % age 16 0 0 1 5 1 2.5 17 12 60 15 75 27 67.5 18 8 40 4 20 12 30.0 sex boys 10 50 7 35 17 42.5 girls 10 50 13 65 23 57.5 class science 19 95 12 60 31 77.5 social 1 5 8 40 9 22.5 z. n. istiqomah et al. 210 | pissn: 1858-3598  eissn: 2502-5791 writing therapy than the group without this treatment. the measurements before taking the life writing therapy show that a mean decrease in depression score of the pre-test in the intervention group is 8.90 and the control group is 8.55. it means that both groups had a quite similar mean of depression score. the intervention of life writing therapy is not performed immediately after the measurements pretest are limited due to the time of respondents. the intervention of life writing therapy took 4 weeks and 8 meetings. post-test was conducted on the last day of therapy and showed that a mean of depression score in the intervention group was 4.8 or at the level of the normal depression; while in the control group was 8.40 or at the level of mild depression. therefore, both groups showed equally decreased mean of depression score. since this study was included in the social studies, it is very difficult for researchers to control the daily activities of the subject and other variables that could affect the decrease in depression score either the intervention group or the control group, and it is one of the weaknesses in this study. in addition, the research results show that the mean of depression score in the pre-test of the intervention group decreased by 4.10; while, in the control group, it decreased by 0.15. it suggests that the decrease in the intervention group was higher than in the control group. furthermore, the results show that there was a change in the level of depression for the intervention group in which the mild depression in the pre-test changed into normal depression in the post-test. whereas, there was no difference in the control group between the depression levels in the pre-test and post-test scores. the results also show that the respondents stated that writing was fairly effective means to vent feelings, understand the situation of themselves and were able to identify a problem that was happening. the results of this research are consistent with the results of research conducted by susilowati and hasanat (2011) which reported that there is a significant decrease in emotional experience after implementing life writing therapy for depression in the first year students. furthermore, a study by indah, afiatin, & astuti (2011) shows that there is significant emotional experience to reduce depression among women of violence victims. however, these results are against the results of research suggested by murti and hamidah (2012) finding that there is no significant effect of expressive writing on decreasing depression in adolescents in vocational high schools. they found that the control group also experienced a decrease in depression scores caused by giving treatment of writing daily activities. seligman in maulida (2012) states that depression is an emotion that comes amid helplessness and failure of individuals, and when an individual attempting to gain unrealized power. one thing that can be done to let the emotions go is by writing. qonitatin (2011) reports that expressive writing therapy of emotional experience has a significant impact as a catharsis or emotional release in lowering the level of mild depression. hawkins in indah (2011) also mentions that the model of therapy-oriented catharsis, as is done in the intervention group with life writing or writing life, has the power to dramatically and automatically change the personality or alter the regulatory process accompanying personality changes. this model holds that a cathartic experience is achieved, and then there is an automatic process that transforms a person becomes better. writing can integrate thoughts and feelings about experiences that are experienced so that they can see or analyze what really happened to themselves. therefore, one can understand the existing problems and develop problem-solving strategies (firdaus, 2015). the process of writing therapy conducted in this research is to tell about their past, current, and future lives which are not only painful but also fun. pennebaker in hernowo (2016) suggests that the thoughts and feelings associated with the trauma force individuals to unite the many facets of the complex events that a person can digest complex thoughts into a unity that is more easily understood. writing unpleasant emotional experience may also increase positive emotions temporarily. some topics that can be written in life writing therapy are about themselves, like who i am, the body, personal or family problems and their relationship with themselves, relationships with friends, loss of someone, change management, and mind building (bolton, 2011). besides, the topic is not only related to past experience but also the situations faced in the future and dreams (susanti, 2013). murti (2012) states that the use positive words will lead positive cognitive at the end of the therapy; while the use of negative words in moderation (no more or less) storyline is clear and well-organized. furthermore, the emerging outlook and positive expectations after writing therapy can help reduce depression. therefore, life writing therapy can be table 2. differences in depression scores of pre and post life writing therapy groups mean sd p-value ci 95% pre-test post-test intervention (n=20) 8.9 4.8 4.10 (3.46) 0.000 3.95 (2.0-5.9) control (n=20) 8.55 8.40 0.15 (2.50) jurnal ners http://e-journal.unair.ac.id/jners | 211 used as one of the interventions to help decrease depression. researchers realized that there are still a lot of shortcomings of this study that make this research is far from perfect. there are some limitations in this analysis. first, it is a social experiment research so that there are internal and external factors that cannot be controlled during the study. second, the distance between pretest and intervention as well as the distance in each meeting to write the course made the respondents experienced a different atmosphere at each meeting and influenced the internal validity of the study. since there was no expert assistance in conducting the therapy, there was bias or manipulation during the research. during the meeting, therapy was conducted by taking over a counselling guidance class (60 minutes) and the time spent to write was 45 minutes. it was insufficient to devote about their lives, feelings and thoughts completely, although their writing in the second session could be continued at home. the writing therapy performed on a scheduled basis at certain times had the respondent should write about their lives on the condition whether they were interested or not. this study can be one of effective therapies applied to the risk groups so that it can prevent depression in adolescents. this therapy can be done by anyone and anywhere since it is easy to apply. besides, it can also be a learning material for nursing care especially in adolescent mental health and can be used as evidence for further research related to adolescent mental health by developing writing therapy both for individual or group of individuals. conclusion life writing therapy is proved to influence on decreasing depression in adolescents. it occurs because life writing therapy facilitates the subject to evaluate, analyze and reassess past, current, and future events so that the subjects get an understanding, develop a solution, have selfmotivated, accept the existing situation, learn from what is experienced, focus thoughts on positive things, and assess the positive things of an event. it is recommended that the next researchers who wants to conduct similar research should examine the internal and external factors that can influence depression in adolescents. furthermore, the intervention was suggested to be carried out on the same day as the pre-test and intervention was not carried out by the researchers themselves to increase the accuracy of the results of the study. in addition, there is a need for additional time in writing therapy so that respondents can devote more about their feelings. acknowledgement we would like to express our great gratitude to dra. turhastuti, m. pd, as a counselling guidance teacher for her assistance in study implementation and angga sugiarto, s.st, m. kes for his assistance with statistical measurement and analysis. references aditomo, a., & retnowati, s. (2004). perfeksionisme, harga diri, dan kecenderungan depresi pada remaja akhir. jurnal psikologi, (1), 1–14. ardjana, i. g. a. e. (2010). depresi pada remaja. in soetjiningsih (ed.), tumbuh kembang remaja dan permasalahannya (pertama, hal. 219–232). jakarta: sagung seto. bahiyatun. (2011). buku ajar bidan : psikologi ibu dan anak. (m. ester & d. widiarti, ed.). jakarta: egc. bolton, g. (2011). writing routes: a resource handbook of therapeutic writing. (g. bolton, ed.). london: jessica kingsley publishers. https://doi.org/10.1108/09641861211286348 darmayanti, n. (2008). meta-analisis : gender dan depresi pada remaja. jurnal psikologi, 35(2), 164–180. retrieved from http://jurnal.psikologi.ugm.ac.id/index.php/fpsi/ article/view/58 firdaus, u. d. (2015). terapi menulis ekspresif sebagai upaya menurunkan depresi pada remaja perempuan dengan orang tua bercerai (skripsi). yogyakarta : fakultas ilmu sosial dan humaniora, universitas islam negeri sunan kalijaga. forbes, e. e., silk, j. s., & dahl, r. e. (2009). neurobiological processes in depressive disorders: links with adolescent brain development. in n. b. allen & l. b. sheeber (ed.), adolescent emotional development and the emergence of depressive disorders (hal. 116–134). new york: cambridge university press. https://doi.org/10.1017/cbo9780511551963.0 07 harijanto, handayani, n., & asmika. (2008). prevalensi depresi dan gambaran stressor psikososial pada remaja sekolah menengah umum di wilayah kotamadya malang. jurnal kedokteran brawijaya, vol 24(no 1 (2008)), pp.15-21. retrieved from http://jkb.ub.ac.id/index.php/jkb/article/view/3 48 hernowo (ed.). (2016). quantum writing : cara cepat nan bermanfaat untuk merangsang munculnya potensi menulis. bandung: kaifa pt mizan pustaka. hurlock, e. b. (2002). psikologi perkembangan: suatu pendekatan sepanjang rentang kehidupan. (ridwan max sijabat, ed.), erlangga (kelima). jakarta: erlangga. indah, v. p., afiatin, t., & astuti, y. d. (2011). menulis pengalaman emosional untuk menurunkan depresi pada perempuan korban kekerasan. jurnal intervensi psikologi, 3(2), 149–168. kota magelang dalam angka 2015. (2015). magelang: bps kota magelang. maulida, a. (2012). gambaran tingkat depresi pada z. n. istiqomah et al. 212 | pissn: 1858-3598  eissn: 2502-5791 mahasiswa program sarjana yang melakukan konseling di badan konseling mahasiswa universitas indonesia (skripsi). jakarta: fakultas ilmu keperawatan universitas indonesia. murti, r. d., & hamidah. (2012). pengaruh expressive writing terhadap penurunan depresi pada remaja smk di surabaya. jurnal psikologis klinis dan kesehatan mental, 1(2), 94–100. pangestuti, r. d., purwono, & heri, a. (2015). promosi masalah kesehatan jiwa anak dan remaja untuk guru di kota magelang. lentera jiwa media komunikasi rsjs, 16. retrieved from https://rsjsoerojo.co.id/wpcontent/uploads/2014/07/lj-32-edt1.pdf accessed on 29/11/2016 14:41 pranoto, n. (2015). writing for therapy (pertama). jakarta: yayasan pustaka obor indonesia. qonitatin, n., widyawati, s., & asih, g. y. (2011). pengaruh katarsis dalam menulis ekspresif sebagai intervensi depresi ringan pada mahasiswa. jurnal psikologi undip, 9(1), 21–32. rais, s., & hidayati, n. (2009). asyiknya menulis buku harian. bandung: lawang ilmu. safitri, y., & hidayati, e. (2013). hubungan antara pola asuh orang tua dengan tingkat depresi remaja di smk 10 november semarang. jurnal keperawatan jiwa, 1(1), 11–17. santrock, j. w. (2014). adolescence. mc-graw hill (15th ed.). new york: mcgraw-hill education. sarwono, j. (2006). metode penelitian kuantitatif dan kualitati (pertama). yogyakarta: graha ilmu. sihvola, e., keski-rahkonen, a., dick, d. m., pulkkinen, l., rose, r. j., marttunen, m., & kaprio, j. (2016). minor depression in adolescence: phenomenology and clinical correlates. journal of affective disorders, 97(1–3), 211–218. https://doi.org/10.1016/j.jad.2006.06.019 soetjiningsih. (2010). pertumbuhan somatik pada remaja. in soetjiningsih (ed.), tumbuh kembang remaja dan permasalahannya (pertama, hal. 1– 4). jakarta: sagung seto. susanti, r. (2013). pengaruh expressive writing therapy terhadap penurunan tingkat kecemasan berbicara di muka umum pada mahasiswa. jurnal psikologi, 9(2), 191–129. susilowati, t. g., & hasanat, n. u. (2011). pengaruh terapi menulis pengalaman emosional terhadap penurunan depresi pada mahasiswa tahun pertama. jurnal psikologi, 38(1), 92–107. vol 8 no 1 april 2013.indd 1 kadar oksitosin dan bendungan asi pada ibu primipara dengan postpartum blues (oxytocin level and breast engorgement in primipara mother with postpartum blues) ika larasati sugeng stikes artha bodhi iswara, jl. pumpungan iii/29 surabaya e-mail: larasati_23@yahoo.com abstrak pendahuluan: postpartum adalah momen bahagia bagi wanita, tapi dapat menjadi menakutkan untuk beberapa wanita. postpartum blues membuat wanita menghindari bayi mereka, sedangkan proses laktasi perlu dilakukan dalam periode postpartum awal. tujuan dari penelitian ini adalah menganalisis tingkat oksitosin dan kejadian pembengkakan payudara pada ibu primipara dengan postpartum blues di bangsal obstetri dan ginekologi rumah sakit dr. m soewandhie surabaya. metode: penelitian ini menggunakan desain cross sectional. populasi adalah primipara dan sampel sebanyak 41 primipara dipilih secara random sampling sesuai dengan kriteria inklusi. variabel independen adalah postpartum blues, variabel dependen adalah pembengkakan payudara dan tingkat oksitosin. instrumen yang digunakan adalah kennerly dan gath postpartum scale dan six-point engorgement scale. data dianalisis dengan spearman test dan mann whitney test menggunakan α<0,05. hasil: hasil penelitian menunjukkan bahwa perubahan tingkat oksitosin pada postpartum blues p=0,002 dan kejadian pembengkakan payudara meningkat pada ibu dengan postpartum blues p=0,000. diskusi: ada perbedaan tingkat oksitosin antara ibu postpartum blues dan ibu tidak postpartum blues. kejadian pembengkakan payudara juga lebih meningkat pada ibu postpartum blues dibandingkan dengan ibu tidak postpartum blues. rumah sakit dr m. soewandie surabaya perlu mengatur standar dalam pelayanan untuk mengurangi stres selama proses persalinan dan mengelola situasi ruang nifas agar lebih nyaman. kata kunci: ibu primipara, postpartum blues, tingkat oksitosin dan pembengkakan payudara abstract introduction: postpartum is a great moment for most the woman, but for some of them is a frightening moment. postpartum blues makes woman avoiding their baby. whereas lactation process needs to be done in early postpartum period. the aim of this study is analyzing the oxytocin level and breast engorgement incident in primipara mother with postpartum blues in obtetry & gynecology department of dr. m soewandhie hospital of surabaya. method: this study was used cross sectional design. population were primiparas and samples were 41 primiparas choosen by random sampling according to inclusion criteria. the independent variable was postpartum blues, dependent variables were breast engorgement and oxytocin level. the instruments used were kennerly & gath postpartum scale, and six-point engorgement scale. data were analyzed with spearman test and mann whitney test using α<0,05. result: the result shown that the oxytocin level change comparing the postpartum blues in p=0,002 and increasing breast engorgement incident comparing to postpartum blues in p=0,000. discussion: there was difference of oxytocin level between postpartum blues mother and not postpartum blues mother and increasing of breast engorgement incident to postpartum blues mother comparing to not postpartum blues mother. dr. m. soewandie hospital of surabaya needs to arrange a standard in service of treating laboring mother in case of reducing stress during delivery process and manage ward situation comfortly. keywords: primipara mother, postpartum blues, oxytocin level and breast engorgement 2 jurnal ners vol. 8 no. 1 april 2013: 1–8 pendahuluan persalinan mer upakan proses yang sangat menggembirakan bagi kebanyakan wanita. hal tersebut juga akan menjadi sa ngat mena k ut ka n bagi sebagia n ibu yang lain, terutama ibu dengan kehamilan pertama (primipara). persalinan dan semua hal yang akan berlangsung di dalamnya seringkali dipersepsikan sebagai pengalaman menyeramkan, yang dapat menyebabkan postpartum blues bagi ibu. masa postpartum merupakan masa yang paling rentan pada seorang ibu, banyak gangguan afektif yang dimungkinkan dapat terjadi, seperti depresi puerperal dan postpartum blues (cury et al., 2009; adewuya, 2005; gale & harlow, 2003). postpartum blues (disebut juga maternity blues) merupakan fenomena yang sering muncul pada beberapa hari pertama hingga beberapa hari pada minggu pertama postpartum, dan karakternya didapati sebagai mood swing, kelemahan, insomnia, mudah menangis, malas melakukan sesuatu, berpikir negatif, dan susah berkonsentrasi (kennerly dan gath, 1978). postpartum blues merupakan hal yang sangat berpengaruh terhadap fase penting setelah persali nan yang membut u h kan kelembutan ibu, dalam menjalin bonding attachment antara ibu dengan bayi (leonardou dan gonidakins, 2008). keadaan ini akan mempengaruhi keberhasilan program skin-toskin breast feeding yang sebaiknya dilakukan segera setelah persalinan (foster et al., 1997 dalam woods et al., 2003). asi terbaik yang dibutuhkan bayi adalah asi yang keluar segera setelah persalinan. asi mengandung kolostrum yang dalamnya merupakan nutrisi yang sangat dibutuhkan bayi dan akan menjadi antibodi esensial yang didapatkan bayi dari ibunya sebelum t ubuhnya memproduksi antibodi sendiri. kolostrum dalam asi akan memberikan dampak positif bila diberikan pada bayi, pada sistem imunitas tubuhnya. bayi yang mendapatkan kolostr um dan mendapatkan asi eksklusif menjadi bayi yang tidak mudah sakit, bila dibandingkan dengan bayi yang tidak mendapatkan kolostrum, atau yang tidak mendapatkan asi ekslusif, atau keduanya. penelitian ruis et al., (1981) dalam chatterton et al., (2000) didapatkan gambaran korelasi positif antara oksitosin dan volume asi pada periode postpartum, yaitu berfungsi dalam breast emptying pada manusia, yang bermanfaat dalam peningkatan produksi asi (hasil pengeluaran asi). m a nch i n i e t a l., (20 07 ) d a l a m p e n el it ia n nya m e n e mu k a n p r e v a le n si postpartum blues di negara berkembang sek it a r 5 –25% . hage n (1999) d a la m penelitiannya menyebutkan bahwa angka prevalensi depresi postpartum terjadi sekitar 13% lebih banyak daripada yang tidak mengalami depresi postpartum. kumar (1994) mendeskripsikan prevalensi postpartum blues pada ibu ditemukan sekitar 13– 43% yang merupakan severe blues dan lebih mencapai 76% ibu postpartum yang mengalami perasaan mudah menangis. chandra dan colleagues (2002) dalam kathleen (2010) menyebutkan bahwa 43% ibu postpartum yang mengalami postpartum blues pada minggu per tama menunjukkan pemikiran menolak bayinya, 36% bersikap menolak pada bayinya, dan 34% menunjukkan pemikiran dan penolakan bayi mereka sekaligus. setyowati (2007) m e nye bu t k a n b a hw a a n g k a ke ja d i a n postpartum blues dalam penelitiannya adalah sebanyak 29,03% multipara, dan 25,81% primipara. studi awal menunjukkan bahwa di rsu dr. soewandhie ibu primipara yang mengalami postpartum blues adalah sebanyak 45%. postpartum blues merupakan ancaman utama bagi ibu postpartum dan bayi (beck dan driscoll, 2006) yang mana dapat membuat ibu jatuh pada keadaan depresi, yang kemudian akan semakin diperparah dengan keadaan ibu yang memutuskan untuk bunuh diri agar terhindar dari bayi mereka. postpartum blues secara langsung dapat mempengaruhi siklus hormonal tubuh, terutama bagi ibu postpartum. roy (2009) dalam masters (2011) tentang teori adaptasi roy bahwa fungsi subsistem kognator-regulator dan stabilizer-inovator adalah mempertahankan proses kehidupan secara terintegrasi. proses ini dimanifestasikan dalam bentuk perilaku individu dan kelompok, perilaku sendiri merupakan bentuk dari adaptif 3 kadar oksitosin dan bendungan asi pada ibu primipara (ika larasati sugeng) maupun inadaptif respons. stimulus yang berupa keadaan postpartum blues membuat subsistem kognator dalam tubuh ibu mulai bekerja, sehingga muncul ketidakadekuatan sek resi oksitosin, kadar oksitosin yang disekresi tubuh menjadi lebih sedikit sehingga milk-ejection refl ect tidak terjadi. bendungan asi dapat terjadi pada payudara ibu dalam keadaan seperti ini. sekresi oksitosin yang terganggu, menyebabkan asi yang mampu dikeluarkan payudara menurun, sehingga bayi juga kurang mendapatkan asupan nutrisi yang adekuat, yang berdasarkan penelitian telah menunjukkan fakta peningkatan angka kesakitan bayi. sejauh ini berbagai penelitian telah dilakukan berkaitan dengan postpartum blues, namun belum diteliti hubungan antara postpartum blues dengan kadar oksitosin dalam darah serta hubungannya dengan kejadian bendungan asi pada payudara ibu. apabila diketahui hubungan antara postpartum blues dengan bendungan asi dan kadar oksitosin, maka perawat dapat melakukan peran sebagai educator dan advocate untuk memberikan health education pada ibu postpartum agar tidak jatuh pada keadaan postpartum blues. bahan dan metode penelitian ini merupakan penelitian cross sectional yaitu penelitian analitik yang bertujuan mengetahui hubungan antar variabel, di mana variabel independen dan variabel dependen diidentifikasi pada satu satuan waktu. peneliti melakukan penelitian pada ibu postpartum primipara hari ke-3 sampai ke-6 postpartum, baik yang mengalami postpartum blue s maupu n ya ng t id a k mengala m i postpartum blues. populasi dalam penelitian ini adalah ibu postpartum primipara di rsu dr. m. soewandhie surabaya dalam kurun waktu mulai juli 2012. sampel dalam penelitian ini diambil berdasarkan kriteria inklusi dan ekslusi. besarnya sampel adalah 41 orang. penelitian ini menggunakan teknik pengambilan sampel secara random sampling. hasil ada perbedaan rata-rata kadar oksitosin ibu primipara postpartum blues adalah 38,40 pg/ml yaitu sebanyak 22 orang, sedangkan kadar oksitosin ibu primipara yang tidak mengalami postpartum blues adalah 99,11 pg/ml yaitu sebanyak 19 orang. hasil tersebut dapat disimpulkan bahwa ada perbedaan yang signifi kan antara kadar oksitosin ibu primipara yang mengalami postpartum blues dan kadar oksitosin ibu primipara yang tidak mengalami postpartum blues dengan p<0,05 yaitu p=0,000. jumlah ibu primipara yang mengalami postpartum blues adalah 54,75%, dengan kadar oksitosin dibawah kadar oksitosin rata-rata. sebanyak 45,23% ibu postpartum primipara yang menjadi responsden tidak mengalami postpartum blues. ibu postpartum primipara yang mengalami postpartum blues dan bendungan asi adalah 40,48%, yang mengalami postpartum blues dan tidak bendungan asi adalah 14,28%. ibu postpartum primipara yang tidak mengalami postpartum blues dan mengalami bendungan asi adalah 2,38%, sedangkan yang tidak mengala m i post pa rt um blue s maupu n bendungan asi adalah 42,85% h a s i l u j i s t a t i s t i k s p e a r m a n menunjukkan adanya hubungan kejadian bendungan asi dengan postpartum blues pada ibu primipara sebanyak 84%, dengan p=0,000. hal ini memberikan kesimpulan bahwa ada korelasi antara kejadian bendungan asi dengan postpartum blues pada ibu primipara. pembahasan i bu p r i m ip a r a y a ng m e ng a l a m i postpartum blues dan mengalami peningkatan kadar oksitosin dibawah rata-rata adalah sebanyak 23 orang, yaitu 54,76%. sekresi oksitosin dipengaruhi beberapa hal, yaitu stimulus sensori dan stimulus emosional (sala et al., 2005), sesuai dengan hasil penelitian bahwa ibu pr i mipara yang mengalami postpartum blues juga mengalami kenaikan kadar oksitosin yang jauh di bawah rata-rata ibu primipara pada minggu pertama postpartum. i bu pr i m ipa r a ya ng t id a k mengala m i 4 jurnal ners vol. 8 no. 1 april 2013: 1–8 postpartum blues, mengalami peningkatan kadar oksitosin yang signifi kan dibandingkan dengan ibu pr imipara yang mengalami postpartum blues. hal ini disebabkan oleh terhambatnya produksi oksitosin pada hipofi sis posterior ibu akibat adanya stresor psikologis yaitu kekhawatiran terhadap maladaptasi ibu terhadap keberadaan bayinya. ref lek ‘milk ejection’ sebagaimana disebutkan dalam prime et al. (2009) banyak dipengaruhi oleh stresor yang dialami ibu primipara, hal ini menyebabkan adanya hambatan dalam sekresi oksitosin oleh hipofi sis posterior. seba nya k 46,35% ibu pr i m ipa r a t id a k m e n g a l a m i p o s t p a r t u m b l u e s. data hasil penelitian dan keterangan ibu primipara tersebut, menunjukkan dukungan keluarga, ter utama suami dan orang tua sangat membantu dalam mereduksi stres pascapersalinan. salah seorang ibu primipara dengan postpartum blues menyatakan bahwa bantuan orang tuanya dalam mengasuh anak memang sangat diperlukan, dalam rangka adaptasi ibu primipara terhadap peran dan tanggung jawab barunya. stres pascapersalinan dapat berupa ketakutan untuk tidak dapat merawat bayi dengan baik, ketakutan untuk tidak sanggup memenuhi kebutuhan bayi mengingat komunikasi antara ibu dengan bayi hanya melalui tangisan dan sentuhan. ibu postpartum primipara memiliki risiko mengalami postpartum blues 54% lebih tinggi dibandingkan dengan ibu postpartum multipara (setyowati, 2006). ibu postpartum mengalami beberapa macam respons sebagai upaya penyesuaian diri terhadap “anggota baru” dalam keluarga (r icci dan kyle, 2009). i bu pr imipara membutuhkan dukungan lebih besar terhadap pola perubahan peran menjadi seorang ibu dengan keadaan bar u yang sebelum nya belum pernah dialami. kehadiran bayi yang merupakan suatu kebahagiaan juga dianggap sebagai suatu tuntutan bagi ibu untuk dapat merawat dan memenuhi kebutuhan bayi tersebut. pengalaman melahirkan dan merawat bayi juga mempengaruhi keadaan psikologis ibu primipara, beberapa ibu primipara telah mendengar pengalaman dan keterampilan merawat bayi dari orang di sekitarnya, namun hal tersebut masih belum dapat mereduksi stres dan kekhawatiran terhadap ketidakmampuan menjalankan peran baru. kadar oksitosin meningkat akibat adanya efek dari dukungan sosial pada respons stres dan merupakan m e k a n i s m e biolog i s y a n g m e n d a s a r i mekanisme protektif terhadap stres dengan adanya efek sosial yang berinteraksi secara positif (heinrich et al., 2003). ibu primipara yang mendapatkan dukungan penuh baik dari suami maupun dari orang di sekitarnya yang lain, untuk mengembalikan kepercayaan diri yang hilang timbul akibat kekhawatiran terhadap ketidakmampuan menjalankan peran baru. ibu primipara yang tidak mengalami postpartum blues menurut konsep adaptasi roy, mampu beradaptasi dalam menghadapi dan menjalankan peran baru. kemampuan menghadapi dan menjalan kan tanggung jawab terhadap peran baru ini dipengaruhi kuat oleh adanya dukungan dari orang-orang yang berada di sekitar ibu tersebut. hal ini diperkuat oleh keterangan yang disebutkan oleh ibu primipara, bahwa kehadiran orang tua, keluarga lain dan suami memberikan ketenangan dalam merawat bayi mereka. ibu primipara yang didampingi orang tua dan suami memiliki kadar oksitosin di atas rata-rata. hal ini dikarenakan dengan adanya lingkungan yang mendukung, maka ibu primipara merasa lebih tenang dan kecemasan yang berlebihan terhadap ketidakmampuan melaksanakan peran baru lebih tereduksi. kecemasan, perasaan bersalah dan distress menu r ut konsep sistem adapt asi roy, merupakan respons-respons yang terjadi pada keadaan fi sik maupun emosional seseorang (daniels, 2004). ibu postpartum primipara pada golongan ini menyatakan bahwa mereka tidak mengerti cara menyusui yang benar, atau bayi tidak mampu menyusu pada ibunya. kadar oksitosin juga dipengar u hi oleh stimulus terhadap payudara ibu primipara. bayi yang mampu menghisap secara adekuat, dengan cara menyusu yang benar, memicu sekresi hormon oksitosin yang dihasilkan oleh hipofi sis posterior juga menjadi adekuat dalam menjalan kan peran sebagai milk 5 kadar oksitosin dan bendungan asi pada ibu primipara (ika larasati sugeng) ejection ref lect. kadar oksitosin pada ibu primipara yang tidak didampingi orang tua dan atau suami, serta yang tidak mengerti atau memahami cara menyusui bayi adalah di bawah rata-rata. peningkatan angka risiko mengalami bendungan asi pada ibu primipara dengan postpartum blues sebanyak 79% dibanding dengan ibu primipara yang tidak mengalami postpartum blues. pada penelitian ini, ibu primipara dengan postpartum blues mengalami bendungan asi adalah 40,48%, yaitu sebanyak 17 ora ng. bendu nga n asi mer upa ka n komplikasi yang umum terjadi pada masa awal postpartum, dan biasanya muncul antara hari ke-2 sampai ke-5 postpartum (kee et al., 1989). ibu primipara yang menjadi responden mengeluhkan adanya pembengkakan pada payudara atau asi tidak keluar atau hanya keluar sedikit. milk ejection mer upakan indikator utama dalam menentukan status kadar oksitosin (milk let down), saat bayi menyusu dengan benar dan sesuai maka asi akan memancar dengan adekuat. bendungan payudara diimplikasikan oleh ketidakmampuan pengeluaran air susu. kejadian ini umumnya disebabkan oleh penundaan waktu menyusui atau stres emosional (neifert, 2009). kejadian bendungan asi atau asi tidak memancar dengan adekuat meskipun payudara tampak dan terasa penuh, hal yang harus diperhatikan adalah keadaan psikologis ibu primipara. ibu yang mengalami stres baik itu secara psikologis maupun f isik, akan mensekresi kortisol, sehingga produksi oksitosin sebagai hormon yang mempengaruhi pengeluaran asi terganggu. kadar oksitosin relatif lebih rendah dari yang dibutuhkan, maka terjadi ketidakadekuatan pengosongan payudara, sehingga asi yang tidak dapat dipancarkan semakin banyak dan keadaan bendungan asi itu semakin berat. kejadian bendu ngan asi tidak dit angani sedini mungkin, maka dapat terjadi mastitis dan kerusakan jaringan. roy mendefi nisikan manusia sebagai suatu sistem yang adaptif, tempat berkumpul dan berinteraksi semua bagian fungsi menjadi kesat uan u nt u k mencapai suat u t ujuan (daniels, 2004). manusia merupakan makhluk biopsikososial yang selalu berinteraksi terhadap perubahan yang terjadi baik dalam lingkungan internal maupun eksternal. ibu primipara yang mengalami postpartum blues menyatakan bahwa adanya peran dan tanggung jawab baru bagi mereka menyebabkan keadaan psikologis mereka terganggu. ibu primipara dengan tingkat pendidikan lebih tinggi mengalami gejala postpartum blues lebih jelas tampak pada kehidupan sehari-hari, dibandingkan dengan ibu yg tidak mengalami postpartum blues. ibu primipara yang dulunya/ saat ini bekerja merasa keadaan postpartum dan peran serta tanggungjawab baru yang dihadapi saat ini merupakan sumber stres sehingga ibu mudah merasa ingin menangis, mudah marah, dan sering merasa terabaikan. ibu primipara dengan postpartum blues tetapi tidak mengalami bendungan asi sebanyak 14,28%. hal ini disebabkan tingginya tingkat pendidikan ibu dan keinginan ibu mencari informasi melalui buku, internet dan tenaga kesehatan di sekitarnya, sehingga meskipun ibu tidak ingin terlalu sering kontak dengan bayi, namun ibu melakukan breast-pumping. proses breast pumping ini membuat pengosongan asi pada payudara tetap terjadi dan bayi tetap bisa mendapatkan asi, sekalipun tidak terjadi atau minim terjadi kontak fi sik antara ibu dan bayi. ibu primipara yang tidak mengalami postpartum blues dan tidak mengalami bendungan asi sebanyak 43,90%. hal ini sesuai dengan konsep refl ek ‘milk ejection’ sebagaimana disebutkan dalam prime et al. (2009) banyak dipengaruhi oleh stresor yang dialami ibu primipara, hal ini menyebabkan adanya hambatan dalam sekresi oksitosin oleh hipofi sis posterior. oksitosin yang dihasilkan secara adekuat pada ibu primipara merupakan pa r a meter ter ja d i nya bendu nga n asi. oksitosin yang tidak dihasilkan secara adekuat, menyebabkan milk ejection refl ect tidak akan terjadi secara optimal. pengosongan duktus pada payudara menjadi terhambat, sehingga terjadi pembengkakan akibat asi yang terus mener us diproduksi, namun tidak dapat dipancarkan. keadaan ini akan mengakibatkan terdesa k nya nosiseptor pad a pay ud a ra dan terjadi ker usakan jaringan sehingga 6 jurnal ners vol. 8 no. 1 april 2013: 1–8 menimbulkan rasa nyeri. ibu postpartum primipara mengakui bahwa semakin keras payudara maka rasa nyeri semakin meningkat, hal ini membuat ibu semakin menghindari perawatan payudara maupun proses laktasi. keadaan tersebut membuat payudara akan semakin penuh dan membengkak. ibu primipara yang tidak mengalami post partum blues d a n mem ili k i kad a r oksitosin di bawah rata-rata adalah sebanyak 12 responden (28,57%). proses lak t asi terdapat dua refl ek yang berperan, yaitu refl ek prolaktin dan refl ek aliran yang timbul akibat perangsangan puting susu akibat isapan bayi, dan menghasilkan sekresi oksitosin. oksitosin mer upakan hor mon yang menghasilkan respons “milk let down” atau “milk ejection” pada saat puting susu dihisap oleh bayi, bahkan kadang dapat dihasilkan hanya dengan melihat, mencium aroma bayi, dan mendengar suara bayi (leng et al., 2005). isapan bayi yang benar akan menstimulasi tersekresinya oksitosin dalam jumlah yang adekuat. bayi yang tidak mampu menghisap dengan benar, atau jika bayi tidak mau menyusu pada ibu karena adanya intervensi pemberian susu formula dengan botol, maka oksitosin tidak tersekresi. hormon oksitosin yang tidak tersekresi dengan cukup, namun prolaktin tetap tersekresi, maka produksi asi tetap baik dan lancar tetapi tidak mampu memancarkan asi, sehingga terjadi bendungan asi. keadaan bendungan asi akan semakin membuat ibu menjauh dari bayi, karena ketakutan akan efek nyeri yang ditimbulkan. i bu primipara yang menjadi responden menyatakan bahwa bendungan asi yang dirasakan adalah perasaan ingin sendiri, terkait dengan rasa sakit pada payudaranya, sehingga ibu takut untuk menyusui anak. upaya pengeluaran asi dapat dikeluarkan dengan cara breast pumping atau breast massage, dengan demikian maka bendungan asi akan dapat terhindari. ibu primipara dengan bendungan asi menyatakan bahwa nyeri yang dirasakan pada payudara mereka menyebabkan adanya perasaan enggan menyusui bayi, sehingga keadaan bendungan asi menjadi semakin berat. nyeri yang dirasakan oleh ibu juga menurut ibu primipara membuat mereka semakin menghindari untuk menyentuh payudara, sekalipun untuk breast massage atau breast pumping. ibu yang tidak melakukan kedua solusi di atas, berisiko mengalami bendungan asi dan pada keadaan yang lebih parah akan terjadi infeksi (reeder, 2003). simpulan dan saran simpulan kadar oksitosin pada ibu primipara dengan postpartum blues lebih rendah dibanding kadar oksitosin ibu postpartum primipara yang tidak mengalami postpartum blues. ibu primipara dengan postpartum blues mempunyai kecenderungan untuk mengalami bendungan asi. saran ibu post par t um primipara dengan postpartum blues sebaiknya mencari bantuan tenaga kesehatan untuk dapat mereduksi keadaan stres psikologis postpartum agar proses lak t asi tidak tergangg u dengan adanya ketidakadekuatan kadar hor mon oksitosin. perawat, bidan dan dokter perlu melakukan interaksi dengan ibu primipara, untuk memberikan motivasi dan komunikasi terapeutik untuk mereduksi kecemasan dan stres yang dialami ibu. selanjutnya, perlu adanya penelitian korelasi antar hormon stres, prolaktin, dan oksitosin dalam menentukan kuatitas asi, sehingga diketahui dengan jelas bagaimana melakukan penatalaksanaan kepada ibu yang mengalami postpartum blues. kepustakaan adewuya, ao., 2005. the maternity blues in western nigerian women: prevalence and risk factors, american journal of obstetric and gynecology, 193, number 4, pp 1522–1555. alexander, ll., larosa, jh., bader, h., garfield, s., alexander, wj., 2007. new dimensions in women’s health (4th ed.), ma, jones & bartlett publishers, sudbury. 7 kadar oksitosin dan bendungan asi pada ibu primipara (ika larasati sugeng) beck, ct. and driscoll, 2006. postpartum mood and anxiety disorder, a clinician’s guide, jones and bartlett publishers, sudbury. butts, jb. and rich, karen, 2011. philosophi and theories for advance nursing practice, jb publishers, sudbury. cadwell, karin and maffei, ct., 2006. breastfeeding a-z: terminology and telephone triage, ma. jones dan bartlett publishers, sudbury. casper, regina, c., 2008. women’s health: hormones, emotions, dan behavior, cambridge university press. chiver ton, chuck, 2007. the effect of postpartum adjusment on childbearing attitudes, doctoral dissertation, proquest information and learning company, umi, no. 3278400. cury, af., menezes, pr., tedesco, jja., k a h a l le , s., zu g a i b, m., 20 0 9. mater n it y blues: prevalence a nd risk factors, the spanish journal of psychology, volume 11, number 2, pp. 593–599. daniels, rick, 2004. nursing fundamentals: caring and clinical decision making, n e w yo r k , t h o m s o n d e l m a r learning. edmonds, k., 2011. dewhurst’s textbook of obstetrics and gynaecology, wileyblackwell, london. fewtrell ms, lucas p, collier s, singhal a, ahluwalia js, lucas a., 2001. a randomize trial comparing efficacy of a novel manual breast pump with a standard electric breast pump in mothers who delivered pre-term infants, pediatrics, 107(6), 1291–1297. fink, george, 2000. enciclopedia of stress, academic press, florida. g a le a nd h a rlow, 20 03. po s t p a r t u m m o o d d i s o r d e r s: a r e v i e w of c l i n i c a l a n d e p i d e m i o l o g i c a l factors, journal of psychosomatics obstetrics and gynecolog y, 24(4), 257–266. ganschow, pamela, 2004. breast health and common breast problems: a practical approach, versa press, philadelphia. har t, susan, 2008. brain, attachment, p e r s o n a li t y: a n i n t ro d u c t i o n t o neuroaffective development, karnac books ltd, london. heffner, linda j. and schust, danny j., 2006. at a glance: sistem reproduksi. jakarta: erlangga medical services. heinrich, m., baumgartner, t, kirschbaum, c, ehlert, u., 2003. social support and oxy tocin interact to suppress cortisol and subjective responses to psychosocial stress, biopsychiatry, 54, 1389–1398. kammerer m., taylor a., glover v., 2006. the hpa axis and perinatal depression: a hypothesis, archive of women’s mental health vol. 9, pp 187–196, austria, springer-verlag. kathleen a. kendall-tacket, 2010. depression in new mothers: causes, consequences, and treatment alternatives, 2nd edition, new york: the hawton press. kumar r., 1994. postnatal mental illness: a transcultural perspective, social psychiatry epidemiology, 29, 250 – 264. kulshi, jk., hartmann pe., martin jd., smith m., 1978. éffect of bromocriptine mesylate on the composition of the mam mar y secretion in non-breast feeding women, obstet gynaecol, 52, 38–42. lauwers, judith and swisher, anna, 2011. cou n seling the n u rsing mothe r: a lactation consultation, ma. jones and bartlett , sudbury: publishers. leonardou and gonidakis, 2008. maternity blues and post-par t um depression f indings f rom g reece, europeans psychiatric review, in non-breast feeding women. lemeshow s., hosmer jr, david w., klar j., lwnga sk., 1990. adequacy of sample size in helath studies, john willey and sons, new york. leng, gareth., ludwig, m., doughlas, a., 2012. handbook of neuroendocrinology: neural control of the posterior pituitary gland (neurohypopyisis). chapter 6, p. 139, london: elsevier academic press. leng, gareth, caquineau, celine, sabatier, nancy, 2005. “regulation of oxytocin secretion”, journal of vitamins and 8 jurnal ners vol. 8 no. 1 april 2013: 1–8 hormones, volume 71, page 27–58, elsevier academic press, london. leveno, kenneth, j., cunningham, fg., gant, fg., 2003. williams manual of obstetry. usa: mcgraw-hill. manchini, f., carlson, c., albers, l., 2007. use of the post par t um depression screening scale in a collaborative obstetric practice. j midwifery womens health. 52, 429–434, london: elsevier science. masters, kathleen, 2011. nursing theories: a f r a m e w o r k f o r p r o f e s s i o n a l practice, jones and bartlett publisher, massachusetts. manuaba, i bagus gede, 1998. ilmu kebidanan, penyakit kandungan dan keluarga berencana untuk pendidikan bidan. jakarta: egc. munhall, patricia l., 2012. nursing research: massachusetts: a qualitative perspective, fi fth ed, jones and bartlett learning. nasir, abdul and muhith, abdul, 2005. dasardasar keperawatan jiwa: pengantar dan teori. jakarta: salemba medika. neifert, marianne, 2009. great expectations: guide to breastfeeding, everything a nursing mother needs to know. new york: sterling publishing co., inc. orshan, sa., 2008. maternity, newborn, and women's health nursing: comprehensive care accros the life span, lippincott and wilkins, philladelphia. pfaf, donald, w., 2002. hormone, brain and behavior, vol. 5. usa: elsevier science. ricci, susan s. and kyle, ter r y, 2009. maternit y and pediat ric nursing. philadelphia: lippincott williams and wilkins. riordan, jan and wambach, karen. 2005. breastfeeding and human lactation. canada: jones and bartlett publishers, inc. roy, sr. c., 2009. the roy adaptation model: the defi nitive statement. appleton and lange: norwalk, ct. semium, yustinus. 2006. kesehatan mental 2. yogyakarta: kanisius. simkin, penny and ancheta, ruth, 2011. the labor progress handbook: early inter ventions to prevent an treat dystocia. london: whilley-blackwell. sitzman, kathleen and ichelberger, lw., 2011. understanding the work of nurse theorist: a great beginning. sudburry. jb publishers. white, lois, duncan, gena, and baumle, wendy, 2011. fou n d a me ntals of maternal and pediatric nursing, 3rd edition. canada: delmar cengage learning. wight, n.e., 2001. management of common breastfeeding issues. breastfeeding, part 2. woods a., dykes, f., bramwell, r., 2003. an intervention study using a breastfeeding positioning and attachment tool, elsevier science ltd, p. 134–142. ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 181 proses berduka dan beban yang dialami keluarga dalam merawat anak dengan autisme (the grieving process experienced family and charges in treating children with autism) rizki fitryasari patra koesoemo divisi keperawatan jiwa fakultas keperawatan universitas airlangga surabaya e-mail: risqiv@yahoo.com.sg abstract introduction: children with autism will be a stressor to their family. this research aims to describe about family grieving process and family burden when taking care of their children with autism at special needs school bangun bangsa, surabaya. method: this research used descriptive phenomenology design with indepth interview method. the participant of this research was six member of a family who plays role as the main caregiver for autism child. this study employs the purposive sampling method. the data is gathered through interviews and fi eld notes that is then analyzed with the collaizi technique. this research generated three themes. result: the results illustrate families display the grieving process as a cycle. they feel a deep, permanent and long period of grief through in to fi ve stages of grief: denial, anger, depression, bargaining and acceptance. the grieving is come from the caregiver and the autism child. large amounts of grief cause families in grief for a long period and this causes family burden. there are six family burden, psychological burden, physical burden, fi nancial burden, social burden, time burden and thought burden. conclusion: finding of the research would hopefully be benefi cial to professional health staff, especially psychiatric nurses to complete their ability in minimizing various negative impacts that the family may suffer from while taking care their autism children with autism through nursing care plans designs development, researches about family empowerment in burden managements and also a research to improve the family psycho-education therapy and a specifi c supportive group therapy modules for family with autism children. keywords: autism; family; grieving process; family burden pendahuluan peningkatan jumlah penderita autisme terjadi di kota surabaya yang memiliki angka pertumbuhan penduduk sebesar 2,06% per tahun. angka kelahiran anak di kota surabaya pada tahun 2005 menurut badan pusat statistik kotamadya surabaya sebanyak 65.235 jiwa, sehingga jumlah anak dengan autisme diperkirakan akan meningkat sebanyak 435 anak setiap tahunnya. penelitian ini dilaksanakan di sekolah kebutuhan khusus (skk) bangun bangsa surabaya. studi awal didapatkan bahwa orang tua yang merawat anak autisme sering tidak dapat memberikan dukungan secara optimal akibat stressor yang tinggi, tetapi tidak sedikit yang berhasil mengatasi stressor tersebut sehingga anak autisme dapat berkembang dengan lebih baik (skk bangun bangsa, 2009). dampak yang dirasakan keluarga dengan anak autisme yaitu munculnya beban baik secara psikologis, sosial, fi nansial, pekerjaan dan waktu yang akan memengaruhi perilaku keluarga dalam mendampingi dan merawat anak dengan autisme bahkan untuk tetap dapat mempertahankan dan melanjutkan kehidupan keluarga. keluarga membutuhkan penguatan dukungan keluarga, kemampuan untuk mengelola stres terkait dengan keberadaan anak autisme dan kebutuhan perawatannya. keluarga membutuhkan bantuan tenaga kesehatan profesional yang salah satunya adalah perawat, khususnya perawat jiwa. anggota keluarga yang mengalami autisme akan menjadi stressor bagi setiap anggota keluarga karena keluarga merupakan suatu jurnal ners vol. 5 no. 2 oktober 2010: 181–190 182 sistem. keluarga merasa malu memiliki anak yang berbeda dengan anak yang seusianya saat berkumpul dengan keluarga besar atau teman kerja bahkan keluarga harus menghadapi situasi di mana keluarga tidak diikutsertakan dalam kegiatan masyarakat yang melibatkan seluruh anggota keluarga karena memiliki anak dengan autisme. peran perawat jiwa yaitu memberdayakan keluarga yang memiliki anak dengan disability atau anak dengan kondisi kronis dengan cara membantu orang tua untuk memilih strategi koping yang tepat, mengajarkan komunikasi yang efektif di dalam keluarga, melatih keluarga dalam menggunakan strategi dan kemampuan manajemen konfl ik (serr, et al., dan dyches, 2005). kenyataan yang dijumpai di beberapa tempat pelayanan terapi untuk autisme maupun sekolah dengan kebutuhan khusus, peran perawat dalam memberdayakan kemampuan keluarga masih perlu ditingkatkan karena perawat lebih berfokus pada pelaksanaan terapi bagi anak dengan autisme (bappenkar rsu dr. soetomo, 2009). p e n e l i t i a n i n i b e r t u j u a n u n t u k mengidentifi kasi proses berduka dan beban yang dialami keluarga selama merawat anak dengan autisme. gambaran proses berduka dan beban yang dialami keluarga dapat menghasilkan pengetahuan dasar yang akan berguna dalam mengembangkan suatu pendekatan kesehatan dan keperawatan jiwa yang lebih tepat untuk meningkatkan kemampuan keluarga dalam beradaptasi selama menghadapi stressor dalam merawat anak dengan autisme. peneliti ingin mengetahui proses berduka dan beban keluarga selama mendampingi dan merawat anak dengan autisme yang bersekolah di skk bangun bangsa surabaya melalui penelitian. bahan dan metode penelitian ini menggunakan desain kualitatif dengan pendekatan fenomenologi deskriptif untuk menggambarkan pengalaman keluarga selama merawat anak dengan autisme di sekolah kebutuhan khusus bangun bangsa surabaya. sampel dalam penelitian ini sebanyak enam partisipan yang diperoleh dengan menggunakan teknik purposive sampling yaitu metode pemilihan sampel yang sesuai dengan tujuan penelitian. seluruh partisipan penelitian mengalami fenomena yang diteliti memenuhi karakteristik yang diinginkan peneliti, yaitu: keluarga yang merawat anak dengan autistik disorder/classic autism; keluarga yang bertanggung jawab dalam pengasuhan dan pemenuhan kebutuhan sehari-hari anak dengan autisme atau yang berperan dalam pengambilkeputusan terhadap anak autisme; berusia minimal 20 tahun; mampu berkomunikasi dengan baik dengan menggunakan bahasa indonesia atau bahasa daerah (bahasa jawa) yang dimengerti oleh partisipan dan peneliti serta 5) sehat fi sik dan mental saat dilakukan wawancara. saturasi dicapai pada partisipan keenam setelah dirasa informasi yang disampaikan oleh partisipan sudah tidak memberikan tambahan informasi baru. metode yang digunakan dalam penelitian ini yaitu wawancara mendalam (indepth interview) dan catatan lapangan. alat pengumpulan data dalam penelitian ini adalah media player (mp4), pedoman wawancara, catatan lapangan dan diri peneliti sendiri. hasil peneliti mengidentifi kasi 3 tema sebagai hasil penelitian. proses pemunculan tema-tema tersebut diuraikan berdasar tujuan penelitian. proses berduka yang dialami keluarga selama merawat anak dengan autisme tema 1: tahapan berduka tahapan berduka yang dialami keluarga selama merawat anak dengan autism terdiri dari lima tahap, yaitu menyangkal, marah, menawar, depresi dan menerima. menyangkal dibagi menjadi dua kategori, yaitu tidak percaya dan syok. perasaan tidak percaya diungkapkan petikan transkrip berikut ini: " ...tak baca terus lho lho anakku kok kayak gini separah ini gitu ya.... aku ini nggak percaya" (p1). sementara perasaan syok dialami partisipan sebagai perasaan tidak menyadari seperti diillustrasikan berikut ini: "aduh nduk (nak) proses berduka dan beban yang dialami keluarga (rizki fitryasari patra koesoemo) 183 kamu itu kok wudho (telanjang) di sini (dikelas)…. mau ditaruh di mana muka ini…." (p3) tahapan kedua dari berduka yaitu marah terdiri dari dua kategori, yaitu sedih dan kecewa. perasaan sedih dirasakan partisipan seperti uraian berikut ini: "wess sampe rumah mbak, jungkel (nangis sejadi jadinya) aja mbak..." (p1) "saya ya ndak bisa apa-apa saya nangis ya.. wes gak karuan waktu itu...." (p5) rasa kecewa dialami saat menyadari anaknya mengalami autisme, kecewa terhadap sikap pemberi pelayanan kesehatan, maupun kecewa terhadap keluarga tergambar pada kondisi yang disampaikan partisipan di bawah ini: "yaa.... rasanya tu kayak.... (diam sebentar raut muka menjadi muram) apa ya... apa yang.. apa apa kata dokter, katanya itu apa yaa, apa yang saya impikan... angan angan saya, anak saya nanti, orang tua kan pengennya anaknya menjadi begini.... ya tahapan-tahapannya tho mbak, ternyata seperti itu... ya kayaknya hilang sudah (semuanya) saya itu (gitu mikirnya)" (p1) "wes aku cari dokter lain, soale itukan orangnya ndak enak.. omongnya kasar.. wes tho saya ndak mau kembali situ (ke dokter tersebut) lagi." (p2) tahapan ketiga yaitu menawar yang meliputi dua kategori, yaitu khawatir dan b e r h a r a p . p e r a s a a n k h a w a t i r t e r h a d a p kemampuan keluarga merawat anak autisme dialami oleh dua orang partisipan yang menyatakan: "...apa bisaa gitu ya (merawat anak dengan autisme)...." (p1) " y a s e m p e t y a , a p a s a n g g u p g i t u a k u membesarkan anakku yang autis ini..." (p4) s e m e n t a r a a d a p a r t i s i p a n m a s i h mempunyai perasaan berharap terhadap kemampuan anak seperti digambarkan pernyataan berikut ini: "sampai saya itu ya allah anakku kalau sampai bisa manggil mama aku mau potong kambing aku.." (p1) "... kadang ya (saya mikir)..... pasti a bisa normal..." (p5) tahapan keempat berduka adalah depresi dan dikelompokkan menjadi dua kategori, yaitu secara fi sik dan secara psikologis. depresi secara fisik disampaikan partisipan dalam ungkapan berikut ini: " ..... badan tambah kurus ....apa ya makan itu rasane gak ada rasane.... saya itu mikir, apa salah saya ya?" (p5) sebagian besar partisipan mengeluhkan depresi secara psikologis yang dialami, seperti berikut ini: "aku yo wes...aku nelongso (menderita) aja buk...iyo tho.. pokoke wes ndak ada, ndak ada yang ngerti dikasih tahu itu (bahwa k autis).. ndak ada yang ngerti, malah mereka itu menyalahkan, katanya aku itu kalau ndidik itu salah, dibentaki aja, jangan dilarang-larang, kalau main ya biar aja main, gitu..." (p2) menerima digambarkan dalam empat kategori yaitu bersyukur, memahami, senang dan adaptasi. rasa syukur terhadap keadaan anak yang mengalami kemajuan, seperti pernyataan partisipan berikut ini: "lha tapi ya alhamdulillah o itu, saya ke dokter itu ya nggak rutin lho, obatnya yang ee.... ya supplemen yang sekian juta yang harus ditebus gitu ya saya nggak njangkau, tapi kok perkembangan o ini bisa ngomong bisa keluar, ya kebanyakan anak autis kan verbalnya keluarkan itu enggak sejelas ini, kan pelat pelat (cedal) gitu mbak... tapi o ini jelas kalimatnya, sampai huruf huruf nya itu jelas gitu ya" (p1) sebagian partisipan pada akhirnya memiliki perasaan memahami terhadap kehadiran dan keadaan anak dengan autisme dalam keluarga dan tergambar dalam ilustrasi yang disampaikan berikut ini: "mungkin yaa... setiap anak autis itu kan beda beda ya, 100 anak autis ya 100 macamnya ini, o saja sama adiknya juga tidak sama ya, yang adiknya sulit, yang o begini (tidak sulit)" (p1) "tapi ya gimana kan ini ya memangnya anak saya... ya harus dirawat, wes pasrah aja ya, ya dirawat ya diobatkan.... wes diterima ya (tersenyum dan mata mulai berkaca-kaca)....." (p6) jurnal ners vol. 5 no. 2 oktober 2010: 181–190 184 perasaan senang karena adanya perilaku anak autisme yang membuat partisipan bisa lepas dari rutinitas merawat untuk sesaat dialami partisipan dua, seperti digambarkan dalam pernyataan berikut ini: "kalo mandi itu lama, kungkum (berendam) ae, terus ya berhenti sendiri, kadang tak biarkan, kalo k mandi tambah enak aku bisa masak, bisa tak tinggal (mengerjakan) lainnya (tertawa)" (p2) kategori adaptasi terhadap lingkungan dan kehidupan yang dijalani bersama anak autismediillustrasikan dalam petikan transkrip partisipan berikut ini: "kalau saya sudah biasa mbak...... mungkin kalau orang lain yang melihat, (misalnya) keluarga saya (yang) jauh main kesini ngelihat saya itu sepertinya..., (lalu berkata) yang sabar ya.., lha ini sudah menumpuk sabarnya (tertawa) ini kalau habis kulakan (beli) lagi ini, belum sampai habis kulakan saya (sambil tertawa ringan), yaa saya anggap ini sudah biasa ya.. (tersenyum)" (p1) "dulu yaaa....kadang ada orang ngomong apaaaa gitu, sakit hati ya... sekarang ndak ya... (saya) cuek hehhe (tertawa kecil)" (p6) tema 2: penyebab berduka partisipan yang telah melalui tahapan menerima pada proses berduka dapat merasakan kembali perasaan berduka, saat ditemui adanya penyebab berduka. penyebab berduka berasal dari dua sumber, yaitu caregiver dan anak yang mengalami autisme. penyebab berduka yang berasal dari caregiver, yaitu akumulasi perasaan caregiver seperti yang tergambar dalam transkrip berikut ini: "...sabarnya kita menghadapi anak normal sama anak seperti ini itu beda, kalau anak normal itu, eh ndak boleh kamu begini begini itu langsung ngerti, kalau anak begini ini ngomong sepuluh kali mbak, wooo masih nggak direken (diperdulikan)" (p1) "yaa...... gimana yaa....(diam sesaat).... ya rasane macem-macem ya, banyaknya ya jengkel ya gak menentu wes pokoke...." (p2) penyebab berduka yang lain berasal dari anak dengan autisme meliputi resistensi anak, respons anak yang lambat, perilaku anak yang berlebihan, perilaku sulit konsentrasi pada anak dan perilaku anak yang tidak dapat dimengerti. resistensi anak ditemukan pada partisipan dalam pernyataan berikut ini: "ya itu kadang tu ya anak-anak ini kalau bikin masalah ..tidak bisa dikasih tau" (p1) partisipan juga menyatakan tentang respons anak yang lambat, berikut ini: "kan kadang pagi itu (anak autis) suka bikin susah, gak bisa cepat" (p2) p e r i l a k u a n a k y a n g b e r l e b i h a n diceritakan oleh dua orang partisipan seperti dalam transkrip berikut ini: "nakalnya amit-amit, wes klesetan (gulingguling dilantai) wes.. terus suka ngambil jemuran kok... pokoke ada baju warnae pink, gak tau itu punyae siapa gak peduli wes ganti di jemuran itu tadi, pulang ganti baju wes pokoke..." (p2) " .... lha masa ke rumahnya orang itu ya... tingkah lakunya itu lho ya, tidak bisa diam, masuk masuk ke dalam rumah langsung" (p5) partisipan juga menyatakan perilaku anak yang sulit konsentrasi sebagai berikut: " .. lha susah kalau suruh nulis suruh apa, nggarap pr itu matane gak karuhan, lihat tv, lihat lihat... (memeragakan nengok kanan nengok kiri)...wes susah pokoke (menggelengkan kepala 2 kali)" (p2) perilaku anak yang tidak bisa dimengerti diilustrasikan oleh beberapa partisipan seperti yang disampaikan oleh partisipan empat dan enam berikut ini: "dia sendiri.... kadang anak kayak gini kan ndak tau karep e (keinginannya) apa, dikasih ini .... keliru, dikasih ini..... emoh (tidak mau), tapi nguamuk (marah sekali), lha terus karepe (inginnya) apa kita kan ya ndak ngerti" (p4) " .....kadang-kadang kayak ndak mau diem gitu lho... kadang itu ada apa ini dicari gitu... dia keliling kayak muter muter gitu, sampai sekarang ya masih gitu muter terus di rumah" (p6) beban yang dirasakan keluarga selama merawat anak dengan autisme tema 3: beban sebagai dampak proses berduka berbagai macam beban dirasakan oleh partisipan yang merupakan akibat lanjut yang proses berduka dan beban yang dialami keluarga (rizki fitryasari patra koesoemo) 185 dialami partisipan setelah melalui tahapan berduka. beban yang teridentifi kasi meliputi beban psikologis, beban pikiran, beban fi sik, beban finansial, beban sosial, dan beban waktu. beban psikologis yang dirasakan oleh partisipan terbagi menjadi perasaan jengkel, marah, malu, menderita, takut, khawatir, dan berat/sulit. perasaan jengkel terhadap hal-hal yang ditemui selama merawat anak autisme yang tidak dapat diungkapkan oleh partisipan berikut ini: "yaa...... gimana yaa....(diam sesaat).... ya rasane macem-macem ya, banyaknya ya jengkel ya gak menentu wes pokoke, wes susah pokoke" (p2) perasaan marah terhadap perilaku anak autisme diungkapkan oleh partisipan dalam pernyataan berikut ini: "tidak bisa dikasih tau ya saya ceples (di pukul di bagian paha menggunakan telapak tangan terbuka) ya, tetep kalau dia buat kesalahan yaaa saya marahin, sama saja seperti ibu-ibu yang lain, kita tidak mungkin ya... jadi wonder womennya anak-anak ini (tertawa kecil), yaa gitu itu kalau seterusnya gemes (tidak bisa menahan diri) ya saya cubit" (p1) "dikasih ini, dia ndak mau, aku emosi, woo aku ngamuk marah dulu... marah beneran... kalau aku wes ndak sabaran itu, wes biru-biru tok wes (bekas dicubit)" (p4) partisipan menceritakan perasaan malu terhadap orang lain yang dirasakan seperti tergambarkan dalam situasi yang diceritakan oleh partisipan dua dan lima berikut ini: " ya kalau orangnya itu tau seperti apa anak autis, kalau gak ngerti kan kok rasanya anak saya ini apa ndak pernah diajari sopan santun gitu yaa kan ya malu juga ya rasanya jadi orang tua.... kadang itu pernah ya... dimeja makan itu ada makanan apa gitu langsung ambil.... gitu kan saja jadi sungkan yaa.... iya sungkan ..." (p5) perasaan menderita karena sikap orang lain yang tidak mau mengerti keadaan anak autisme diungkapkan dua partisipan penelitian dalam kutipan transkrip partisipan dua dan tiga berikut ini: "aku yo wes.... aku nelongso (menderita) aja buk... iyo tho.. pokoke wes ndak ada, ndak ada yang ngerti, malah mereka itu menyalahkan, katanya aku itu kalau ndidik itu salah" (p2) p a r t i s i p a n m e n y a t a k a n m e m i l i k i perasaan takut bila hamil dan melahirkan anak yang kedua kalinya serta perasaan takut terhadap penurunan kemampuan anak autisme di jelaskan dalam pernyataan berikut: "aku wes sampai takut kalau sampai hamil lagi (memegang perut)..... nanti jangan-jangan anakku autis lagi sumbing pisan...(mendesah dan menggelang kepala)" (p2) perasaan khawatir terhadap masa depan anak autisme diungkapkan berikut ini: "w ini kan perlu pendamping, pendampingnya itu entah besok siapa, ya selama bapak masih hidup, walaupun jauh, saya harapkan meski sampai saya meninggal gitu, saya harapkan semua masih tetep (kakak membantu adik yang autis" (p3) perasaan berat/sulit dalam menjaga anak autisme, digambarkan dalam petikan transkrip berikut ini: " ngerawatnya (anak autis) itu sangat... sensitif sekali.... ya anak begini (autis) ya bukan w saja itu ekstra.. apa yang dilakukan (pemilihan makanan) itu betul-betul harus (dijaga)" (p3) jenis beban yang lain yaitu beban pikiran yang dialami partisipan penelitian dan bersumber pada dua kategori, yaitu caregiver dan anak autis. sumber yang berasal dari pikiran caregiver akibat kejenuhan selama merawat tergambar dalam pernyataan partisipan satu dan dua berikut ini: " n a m a n y a p i k i r a n i t u j e n u h i t u j u g a ada..."(p1) beban pikiran yang bersumber dari anak dengan autisme digambarkan seperti berikut ini: "... pikiran ini kok gak bisa lepas ya dari a, kalau udah naruh a di sekolah, kan saya pulang, sebenarnya ya kan saya ya gak sama a ya.... ya rasanya bebas ya... tapi ya ndak bisa, hehe (tertawa) namanya anak ya... digendong 9 bulan diperut..... ya kepikiran, apa nanti pas disekolah gimana-gimana...." (p5) beban fi sik juga merupakan jenis beban yang teridentifi kasi sebagai hasil penelitian dalam bentuk kelelahan fi sik selama merawat jurnal ners vol. 5 no. 2 oktober 2010: 181–190 186 anak autisme seperti digambarkan berikut ini: "ya kadang saya itu ya capek yaa... capek itu pasti ya mbak, bayangkan satu hari penuh merawat 2 anak autis" (p1) partisipan juga menyebutkan beban fi nansial dalam kategori penggunaan uang, pengobatan, nutrisi dan sekolah. penggunaan uang untuk memenuhi permintaan anak autisme menjadi beban bagi keluarga karena karakteristik anak autisme yang tidak dapat dikendalikan apabila memiliki keinginan untuk membeli sesuatu. sehingga keluarga harus menyediakan alokasi keuangan khusus untuk memenuhi permintaan anak, seperti yang diceritakan oleh partisipan berikut ini: "setiap harinya kalau ada sari roti lewat, mama roti, mama es krim, semua diminta buk, pokok wes gitu ya... setiap ketemu es diminta es... pokoke duit itu harus ada dikantong ini, wes habis banyak duit buat jajan itu tok" (p2) mahalnya biaya pengobatan dapat digambarkan melalui pernyataan berikut ini: "wes abis-abisan pokoknya, buat ngobati k ae bangkrut buk.. untuk beli obat, suplemen, ke dokter ya terapine... ya gitu buk...." (p2) besarnya biaya untuk mencukupi kebutuhan nutrisi disampaikan oleh partisipan dua berikut ini: "buat makanan ya jajane gak karuhan juga.... ya susunya itu buk, sekaleng wes berapa itu 150 lebih... sebulan paling nggak 6–7 kaleng..... berapa itu buat susu tok....." (p2) partisipan juga menyatakan mahalnya biaya sekolah sebagai beban fi nansial dalam petikan berikut ini: "sekarang katakan berapa (biayanya), sama bayaran anak sekolah (sd biasa) sudah lain" (p3) jenis beban yang lain yaitu beban sosial dan dapat dijelaskan dalam dua kategori yaitu membatasi sosialisasi caregiver dan membatasi sosialisasi anak dengan autisme. partisipan menggambarkan bagaimana mereka membatasi sosialisasi diri dengan lingkungan seperti dalam illustrasi berikut ini: "cuma ya kalau main ke rumahnya saudara itu ya saya batesi, saya tidak mungkin main ke rumah mereka anak saya dibiarkan, tetep silaturohmi tapi tidak lama, jadi ya sebentar aja, sekadar nongol gitu saja" (p1) partisipan membatasi sosialisasi anak autisme dengan lingkungan seperti dalam uraian di bawah ini: "sejak itu ya saya kurung dia di rumah ya.... lha kalau tidak dikunci rumah itu dia bisa mbuka pintu sendiri terus kalau keluar kan nanti bikin saya itu gak enak yaa....." (p5) beban waktu merupakan jenis beban yang juga dialami oleh partisipan dan dijabarkan dalam dua kategori, yaitu kategori mengorbankan waktu pribadi dan kategori kebebasan pribadi. mengorbankan waktu pribadi untuk mendampingi anak autisme diungkapkan berikut ini: "emm.... yaaa sekarang aku wes rasane hidup ini gak ada buat diri sendiri ya..... ndak ada, papae k kalau dateng malam itu aku sudah tinggal capeknya, tak tinggal tidur buk...." (p2) pembahasan tema 1: tahapan berduka perasaan berduka yang ditemukan dalam penelitian ini merupakan perasaan berduka sepanjang kehidupan. hal tersebut sejalan dengan penelitian yang dilakukan oleh blaska (1998), tentang "model siklus berduka" dan serupa dengan pendapat mallow dan bechtel (1999, dalam collins, 2008) yang menjelaskan perasaan berduka yang dialami keluarga dengan anak autisme merupakan bentuk dari "berduka kronis". hasil penelitian ini menunjukkan, keluarga akan merasa berduka sesaat setelah mengetahui bahwa anaknya mengalami autisme dan akan terus berlangsung selama keluarga mendampingi anak dalam setiap tahapan tumbuh kembangnya. partisipan akan mengalami tahapan berduka dan mencapai suatu tahap menerima kenyataan bahwa ia memiliki anak dengan autisme. partisipan belum mengakhiri perasaan berduka yang dialami. perasaan berduka tersebut akan kembali dirasakan saat keluarga menghadapi keadaan yang menimbulkan perasaan berduka itu kembali. seperti yang disampaikan oleh blaska (1998) bahwa berduka merupakan satu siklus yang terus berputar, suatu saat keluarga proses berduka dan beban yang dialami keluarga (rizki fitryasari patra koesoemo) 187 merasa berduka, sesaat kemudian merasa menerima, namun tiba-tiba merasa berduka kembali. mallow dan bechtel (1999, dalam collins, 2008) menggunakan kata "berduka kronis" untuk menggambarkan perasaan berduka mendalam yang menetap, selalu berulang, setiap saat semakin bertambah dan terjadi sepanjang kehidupan keluarga. tahapan berduka yang teridentifi kasi dalam penelitian ini sama dengan tahapan proses kehilangan yang dikembangkan oleh kubbler-ross (2005), yaitu terdiri dari lima tahap, yaitu menyangkal, marah, menawar, depresi dan menerima. tidak ada partisipan yang mengalami lima tahapan berduka secara lengkap. pada partisipan dua dan partisipan enam yang tidak mengalami tahapan tawarmenawar. hal ini identik dengan proses kehilangan yang ditemukan oleh bolwby dan parkes (1970, dalam collins, 2008) yang menyatakan proses kehilangan dalam empat tahapan, yaitu syok dan mati rasa, hasrat mencari penyelesaian, disorientasi dan disorganisasi serta reorganisasi dan resolusi. hasil penelitian ini tahap tawar-menawar tidak muncul karena pada tahap hasrat mencari penyelesaian, keluarga merasakan kegelisahan, kemarahan, rasa bersalah dan kebingungan secara bersamaan. keluarga berusaha mencari tahu bagaimana dan mengapa peristiwa yang menimbulkan perasaan berduka tersebut dapat terjadi. disaat yang sama keluarga berusaha untuk membantah kenyataan bahwa peristiwa tersebut tidak terjadi. hal tersebut dialami oleh partisipan dua dan enam. partisipan dua berusaha mencari informasi tentang keadaan anaknya ke petugas kesehatan, namun keluarga mengalami kekecewaan yang mendalam terhadap cara petugas kesehatan saat menyampaikan informasi, sehingga keluarga marah dan menyalahkan petugas kesehatan. partisipan enam berulang kali membantah kenyataan bahwa anaknya mengalami autisme dengan mengatakan bahwa anaknya sebenarnya mampu berkomunikasi. sikap partisipan enam tersebut mengakibatkan konfl ik dalam diri yang terus menyiksa dan pada akhirnya marah dan menyalahkan diri sendiri. keluarga cenderung menyalahkan diri, marah kepada orang lain, lingkungan bahkan tuhan. hal tersebut menyebabkan kehancuran perasaan yang semakin dalam dan keluarga mengalami fase disorientasi dan disorganisasi atau masuk ke tahap depresi tanpa melalui tahap menawar. kesamaan tahap akhir proses berduka menurut kubbler-ross (2005), bowlby dan parkes (1970, dalam collins, 2008) dan temuan dalam penelitian ini, di mana tahap akhir perasaan berduka adalah tahap menerima. tahap ini ditandai dengan kembalinya energi yang telah hilang selama proses berduka, peningkatan kemampuan mengambil keputusan dan tumbuhnya kepercayaan diri dan merencanakan cara untuk menyelesaikan masalah. tema 2: penyebab berduka penelitian ini menemukan bahwa perasaan berduka yang dialami oleh keluarga tidak berhenti pada tahap menerima, karena perasaan berduka kembali terjadi berulangkali saat keluarga menemui beberapa penyebab berduka. penyebab perasaan berduka bersumber dari diri caregiver dan bersumber dari keadaan anak autisme itu sendiri. hal ini sejalan dengan pendapat blaska (1998) yang menyebutkan adanya sejumlah kejadian yang mengiringi keluarga selama mendampingi proses tumbuh kembang anak dengan kecacatan, termasuk di dalamnya anak autisme yang menyebabkan kembalinya perasaan berduka. eakes (1995, dalam collins, 2008) dalam struktur "berduka kronis" yang dikembangkannya menguatkan hasil penelitian ini dengan menjelaskan bahwa peristiwa penyebab yang membawa keluarga kembali mengalami perasaan berduka berasal dari lingkungan, situasi dan kondisi yang berbeda dengan yang dialami keluarga. blaska tidak secara jelas memaparkan bentuk-bentuk kejadian yang dapat memicu kembalinya perasaan berduka tersebut, sementara eakes (1995, dalam collins, 2008) dengan lebih jelas mendefi nisikan penyebab kembalinya perasaan berduka. contoh, keluarga akan merasa sedih saat melihat anak yang seusia dengan anggota keluarga yang mengalami autisme telah mampu berbicara dengan lancar dan mampu menyatakan keinginannya, sementara anaknya masih belum mampu berkomunikasi. pendapat eakes tentang jurnal ners vol. 5 no. 2 oktober 2010: 181–190 188 kejadian penyebab tidak ditemukan secara langsung dalam penelitian ini, tetapi merupakan gabungan dari dua sumber, yaitu keadaan anak autisme seperti lambat dalam berespons, berperilaku berlebihan serta berperilaku yang tidak mudah dimengerti akan menjadi hal yang menyakitkan saat keluarga melihat anak yang tumbuh dan berkembang secara normal. seorang partisipan penelitian pernah menyampaikan bahwa ada perasaan jengkel sekaligus sedih saat melihat anak yang seusia dengan anaknya yang mengalami autisme dapat melakukan berbagai hal yang belum dimiliki oleh anaknya. hal tersebut sedikit demi sedikit akan memengaruhi perasaan keluarga sampai terjadi suatu akumulasi berlebihan dan menyebabkan keluarga merasakan kembali perasaan berduka yang mendalam. tema 3: beban sebagai dampak proses berduka proses berduka yang terus berlanjut akan berkembang menjadi beban yang dialami keluarga. temuan penelitian tersebut didukung oleh fontain (2008) yang mendefi nisikan bahwa beban keluarga merupakan tingkat pengalaman distress keluarga sebagai dampak keberadaan anggota keluarga terhadap keluarganya. dalam konteks penelitian ini, keberadaan anak dengan autisme menyebabkan keluarga mengalami tahapan berduka dan apabila keluarga tidak mampu menyeimbangkan kemampuan untuk menghadapi perasaan berduka tersebut akan menimbulkan dampak tertentu yang digambarkan dalam berbagai beban yang dihasilkan. jenis beban yang teridentifi kasi dalam penelitian ini meliputi beban psikologis, beban pikiran, beban fi sik, beban fi nansial, beban sosial dan beban waktu. berbagai macam beban tersebut memiliki karakteristik yang serupa dengan jenis beban yang dialami keluarga dengan anggota keluarga mengalami gangguan jiwa menurut who (2008). who membagi beban menjadi dua jenis, yaitu beban subjektif dan beban objektif. beban subjektif merupakan beban yang berhubungan dengan reaksi psikologis anggota keluarga, seperti perasaan kehilangan, sedih, cemas, malu, stres dan frustasi. sementara beban objektif meliputi gangguan hubungan antaranggota keluarga, keterbatasan hubungan sosial dan aktivitas kerja, kesulitan fi nansial dan dampak negatif terhadap kesehatan fi sik anggota keluarga. beban psikologis dinyatakan dalam bentuk perasaan jengkel, marah, malu, menderita, takut, khawatir dan berat/sulit selama merawat anak dengan autisme dan hal tersebut identik dengan beban subjektif menurut who (1998). berbagai macam perasaan tersebut timbul silih berganti dan berulang-ulang berdasarkan penyebab yang dialami oleh keluarga dan dipengaruhi oleh karakteristik partisipan, seperti jenis kelamin dan tingkat keparahan autisme yang dialami oleh anak. suatu saat keluarga akan mampu mengatasinya, namun disaat yang berbeda keluarga merasa tidak mampu untuk melaluinya, dan hal tersebut akan memengaruhi kualitas hidup keluarga sebagai caregiver. gray (2003) juga memperkuat hasil penelitian ini dan menyatakan bahwa 35 keluarga yang merawat anak autisme lebih dari sepuluh tahun mengalami tekanan emosi yang terus-menerus seperti depresi, kecemasan dan kemarahan. beban fi sik, beban fi nansial, beban sosial dan beban waktu memiliki karakteristik yang serupa dengan jenis beban objektif menurut who (2008). beban fisik yang dialami keluarga sedikit berbeda dengan pendapat who (2008) yang menemukan adanya dampak negatif kesehatan fisik anggota keluarga sebagai bagian dari beban objektif. beban fi sik keluarga selama merawat anak autisme dalam penelitian ini belum menimbulkan gangguan fi sik yang nyata, tetapi hanya berbentuk pada kelelahan fi sik, sementara pada keluarga dengan gangguan jiwa menurut who (2008) telah memberikan dampak yang negatif terhadap kesehatan fi sik keluarga. penelitian ini juga menemukan, bahwa karakteristik partisipan yang sebagian besar adalah seorang ibu yang cenderung mengambil alih seluruh tugas perawatan anak sehingga sering merasakan beban psikologis yang berlebihan dan lebih mudah merasa lelah saat merawat anak autisme. gray (2003) memperkuat hasil analisis ini dalam pernyataannya bahwa keluarga akan merasakan masalah kesehatan secara fisik sebagai dampak stres yang terus berkelanjutan proses berduka dan beban yang dialami keluarga (rizki fitryasari patra koesoemo) 189 atau merupakan kumulatif beban psikologis yang selalu berulang. beban fi nansial yang ditemukan dalam penelitian ini, seperti penggunaan uang untuk kebutuhan anak autisme, pembiayaan pengobatan dan terapi rutin anak autisme, pengeluaran untuk pemenuhan nutrisi khusus anak autisme serta pembiayaan sekolah khusus untuk anak autisme juga menggambarkan kemiripan dengan kesulitan finansial yang dirasakan sebagai beban objektif pada keluarga yang merawat anggota keluarga dengan gangguan jiwa menurut who (2008). keluarga merasa kesulitan untuk memenuhi kebutuhan fi nansial selama perawatan karena membutuhkan biaya yang tidak sedikit dan berlangsung terusmenerus sepanjang kehidupan anak. perbedaan dalam hal penggunaan fi nansial untuk anak autisme dan anggota keluarga yang memiliki gangguan jiwa, yaitu pada anak autisme terdapat kebutuhan untuk pemenuhan kebutuhan nutrisi khusus dan pemenuhan kebutuhan pendidikan di sekolah khusus. sosial yang ditemukan dalam penelitian ini berupa pembatasan aktivitas sosialisasi pada caregiver dan anak autisme sama dengan pembatasan hubungan sosial pada beban objektif keluarga yang merawat pasien gangguan jiwa. keluarga akan membatasi interaksi diri dengan lingkungan saat bersama dengan keluarga yang mengalami gangguan maupun anak yang mengalami autisme akibat adanya ketakutan dan kekhawatiran bahwa anak menampilkan perilaku yang kurang baik dan menyebabkan keluarga merasa malu saat berada di tempat umum. beban sosial tersebut dirasakan keluarga sebagai bentuk ketidakbebasan untuk bersosialisasi dengan lingkungan sekitar. penelitian ini juga diidentifikasi adanya beban waktu, di mana keluarga harus mengorbankan waktu pribadi dan kebebasan pribadi selama merawat anak dengan autisme. beban waktu ini identik dengan beban objektif keluarga yang merawat anggota keluarga dengan gangguan jiwa menurut who (2008), yaitu adanya pembatasan aktivitas kerja karena keluarga harus menyediakan waktu untuk merawat anggota keluarga yang mengalami gangguan jiwa. kondisi anggota keluarga yang mengalami gangguan jiwa maupun anak yang mengalami autisme membutuhkan perhatian yang intensif dan berkesinambungan, terkait dengan perawatan, proses pengobatan dan pemenuhan kebutuhan sehari-hari. keluarga sebagai caregiver harus menyediakan waktu, bahkan mengorbankan waktu untuk kepentingan pribadi selama merawat anak yang mengalami autisme. penelitian ini menemukan satu beban yang belum masuk ke dalam kategori beban subjektif maupun beban objektif berdasarkan who (2008), yaitu beban pikiran. beban pikiran yang dirasakan partisipan berasal dari caregiver seperti pikiran jenuh dan bosan selama merawat anak autisme serta beban pikiran yang berasal dari anak autisme, di mana partisipan tidak dapat berhenti memikirkan keadaan anak autisme. beban pikiran dapat digolongkan ke dalam beban subjektif. simpulan dan saran simpulan pengalaman keluarga merawat anak dengan autisme merupakan pengalaman yang luar biasa berat dan tidak mudah untuk dilalui. keluarga mengalami proses berduka yang mendalam, menetap dan berkepanjangan serta berulang-ulang sejak keluarga mengetahui bahwa salah satu anggota keluarganya mengalami autisme. keluarga akan melalui lima tahapan berduka, yaitu menyangkal, marah, menawar, depresi dan menerima. penelitian ini menegaskan tahapan menawar akan dialami oleh keluarga apabila setelah melewati tahap marah keluarga menampilkan perasaan dan pemikiran yang menyeimbangkan perasaan berduka tersebut, di mana keluarga menyatakan perasaan khawatir sekaligus berharap terhadap kemampuan keluarga untuk menghadapi kehidupan mendatang selama merawat anak dengan autisme. tahapan berduka akan diakhiri dengan tahap menerima, di mana keluarga dapat memahami keadaan anak autisme dan mampu melanjutkan kehidupan bersama anak autisme. perasaan berduka kembali terjadi secara fluktuatif dan berulang meskipun keluarga telah mencapai tahap menerima, yaitu saat keluarga menemui suatu keadaan yang jurnal ners vol. 5 no. 2 oktober 2010: 181–190 190 menyebabkan timbulnya kembali perasaan berduka. penyebab dapat berasal dari caregiver maupun dari anak autis itu sendiri. perasaan berduka yang muncul kembali ditampilkan dalam berbagai bentuk beban subjektif dan objektif, yang dirasakan keluarga secara psikologis, pikiran, fisik, finansial, sosial dan waktu. penelitian ini menemukan beban pikiran sebagai tambahan dari beban subjektif berdasarkan pengelompokan beban yang telah ada. setiap keluarga akan mengalami dampak berduka dalam berbagai tingkatan sesuai dengan jenis, karakteristik dan kemampuan adaptasi keluarga. saran p e n e l i t i a n i n i d i h a r a p k a n d a p a t dimanfaatkan oleh tenaga kesehatan profesional, khususnya perawat jiwa untuk melengkapi k e m a m p u a n n y a d a l a m m e m i n i m a l k a n berbagai dampak yang dirasakan keluarga selama merawat anak dengan autisme melalui pengembangan desain asuhan keperawatan jiwa anak dalam konteks keluarga, penelitian lanjut disarankan terkait pemberdayaan keluarga dalam pengelolaan beban selama merawat anak dengan autisme serta penelitian untuk menyempurnakan modul terapi psikoedukasi keluarga dan terapi kelompok suportif yang spesifi k untuk keluarga dengan anak autisme. kepustakaan blaska, jk., 1998. cyclical grieving: reoccuring emotions experienced by paretnts who have children with disabilities, (online), (http://proquest. umi.com/pqdweb., diakses tanggal 10 juni 2009). dunn, m.e. dan burbine, t., 2001. moderators of stress in parents of children with autism. community mental health journal, 37, 39–51. hulme, 1999. family empowerment: a nursing intervention with suggested outcomes for family of children with chronic heath condition, journal of family nursing, 5(1), 33–50. hastings, r.p., 2003. brief report: behavioral adjustment of siblings of children with autism. journal of autism and developmental disorders, 33 (1), 99–104. rodrigues, 2007. financial burden in families with children with special health care needs. journal pediatric psychology; 32: 417–426. novak, j.m., 2006. coping strategies used by parents of children with autism. journal of the american academy of nursing practitioners 19 (2007). 251. http://e-journal.unair.ac.id/jners 47 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 47-53 http://dx.doi.org/10.20473/jn.v18i1. 41229 original article open access resilience after stroke and its correlation with functional independence heltty heltty 1 * , and zahalim zahalim 1 1 faculty of health science, universitas mandala waluya, kendari, indonesia *correspondence: heltty heltty. address: faculty of health science, universitas mandala waluya, kendari, indonesia. email: helttyheltty75@gmail.com responsible editor: yulis setiya dewi received: 5 desember 2022 ○ revised: 29 february 2023 ○ accepted: 29 february 2023 abstract introduction: resilience involves the ability to adapt to the conditions of disability experienced by post-stroke patients. the purpose of this study was to investigate the resilience of post-stroke patients and determine the relationship with the patient's functional ability. methods: this research was a cross-sectional study that included 122 post-stroke patient respondents who had undergone a stroke recovery phase for 5 8 weeks. selection of the sample used simple random sampling method. univariate analysis was used to describe the characteristics of each respondent. bivariate analysis was carried out to determine the relationship between resilience and functional abilities of respondents, especially functional abilities related to activities of daily living. results: the results of this study found that there was a significant relationship between resilience and functional ability of the respondents (p = 0.000; 95% ci). conclusions: respondents with a high level of resilience can make better use of their abilities so that they can increase their functional independence abilities. thus, it can achieve a better quality of life improvement. keywords: activities of daily living, functional independence, resilience, stroke introduction stroke is responsible for an estimated 5.5 million deaths worldwide (méndez-gallardo et al., 2020). based on the results of basic health research / riset kesehatan dasar (riskesdas) in 2018, stroke begins to occur at the age of 15 years and the highest prevalence is at the age of 75 years and over (kementerian kesehatan republik indonesia, 2019). based on the age group numbers, the highest incidence of stroke occurred in the age group of 55-64 years (33.3%) and the lowest occurred in the group aged 15-24 years (kementerian kesehatan republik indonesia, 2019). stroke causes severe longterm disability (hollist et al., 2021). disability is one of the sequelae of stroke that affects the patient's quality of life (chen & tung, 2021) and affects activities of daily living (tiwari et al., 2021; wassenius et al., 2022). approximately 3/4 of stroke patients experienced paralysis and experienced severe disability rates of up to 40% or more (li et al., 2020). post-stroke dysfunction, which includes disturbances in movement, language, and cognition, affects the patient's activities of daily living (adl) (li et al., 2020). stroke sequelae also have negative effects on patients' self-care abilities and social participation (lv et al., 2021). the inability to carry out activities is not only related to physical, cognitive, or emotional disturbances, but also to the ability to adapt (wassenius et al., 2022). resilience involves the ability to adapt to stressful events that can affect the impact of major health crises and reduce the damage caused by stress (chen & tung, 2021). adaptation to stroke sequelae requires balancing all aspects of life including physical and psychological. the results showed that resilience was protective against the limitations of activities of daily living (adl) https://creativecommons.org/licenses/by/4.0/ mailto:helttyheltty75@gmail.com https://orcid.org/0000-0003-1580-3327 https://orcid.org/0009-0001-6359-6804 heltty and zahalim (2023) supremo, bacason, and sañosa (2022) supremo, bacason, and sañosa (2022) 48 p-issn: 1858-3598  e-issn: 2502-5791 and modifies the relationship between the emergence of new chronic conditions and the occurrence of subsequent disabilities. this shows that individuals who had a higher level of resilience experience a lower level of disability (chen & tung, 2021). resilience involves a dynamic development process that enables individuals to bounce back from adversity (chen & tung, 2021). in post-stroke patients, less adaptive psychological factors have been shown to be negatively related to participation over time, while resilience has been shown to act as an independent predictor of quality of life and physical independence (norvang et al., 2022). for this reason, resilience is a factor that needs to be considered in optimizing the functional abilities of patients after stroke, including their ability to care for themselves. so far, various efforts have been made to increase the participation of post-stroke patients in care, but have not examined or measured patient responsibility in achieving increased functional abilities independently. however, it has not been studied in more depth to what degree the patient's resilience has an effect on improving the functional independence status of poststroke patients. previous research found that resilience had a significant effect on adl ability in two weeks up to the first three months after stroke, but after three months there was no significant effect on changes in adl ability in post-stroke patients, thus recommending the need to link resilience with the psychosocial aspects of post-stroke patients (norvang et al., 2022). in this study, respondents were selected by considering the psychosocial aspects of patients, such as those who have a passion for rehabilitation, enthusiasm for carrying out daily activities according to their abilities, including positive thinking and drawing closer to god. resilience also includes a deeper understanding of the relationship between intrapersonal, interpersonal, and socio-ecological constructs because it has been highlighted as important for understanding the neurophysiological and neuropsychological mechanisms of resilience in post-stroke patients. interventions carried out to increase the patient's functional independence require active participation from the patient. this requires patient resilience. a person who is resilient is considered to have comprehensive psychological resources needed to overcome adverse events, including self-confidence, personal competence, and interpersonal interactions (chen & tung, 2021). for this reason, this study aims to investigate the resilience of post-stroke patients and determine its relationship with the patient's functional abilities. materials and methods study design this research was a correlation study using a crosssectional approach. this research was conducted from february to july 2022 at the badan layanan umum daerah (blud) rehabilitation unit of bahteramas hospital and kendari city public hospital, southeast sulawesi, indonesia. sample as many as 122 respondents to this study were taken based on simple random sampling technique. respondents experienced a stroke recovery phase for 58 weeks. this is based on the results of previous studies that the post-stroke recovery process achieves the most significant improvement in the first week to two months after an acute stroke (grefkes & fink, 2020; heltty, 2022). after three months, the recovery related to motor becomes less significant (grefkes & fink, 2020). respondents aged 35-65 years, in stable condition, not experiencing cognitive impairment, able to communicate, were actively encouraged to carry out daily activities independently according to their abilities, to do exercises in the rehabilitation unit regularly, carry out diet management such as managing food that can increase blood pressure; they were also encouraged to do stress management by thinking positively and worshiping. to ensure it, the researcher asked respondents about their daily activities and how to deal with problems, then the researcher validated the respondent's answer with the family living with the respondent instrument the instruments used in this were the brief study resilience scale and the barthel index instrument. the brief resilience scale (brs) is an instrument used to measure a patient's ability to solve the problems they face (norvang et al., 2022). the instrument reflects the toughness of the patient while dealing with his illness. this instrument consists of six question items, using a likert scale with an assessment score of 1 (totally disagree) to 5 (strongly agree) (norvang et al., 2022; smith, 2008). all items in the brs start with and revolve around 'self' or belief in one's ability to bounce back (such as the question item: “i tend to get back on my feet quickly after hard times”) (ye e al., 2022). the brs scores are divided into three categories, namely 1.002.99 (low resilience), 3.00-4.30 (normal resilience), 4.315.00 (high resilience). brs had good internal jurnal ners http://e-journal.unair.ac.id/jners 49 consistency, with an alpha coefficient / cronbach's alpha value of 0.71. this result was consistent with the alpha value (range from 0.71 to 0.85) (fung, 2020). this instrument had also demonstrated an adequate reliability value (alpha 0.83) (rodríguez-rey et al., 2016). the barthel index (bi) is used to measure the patient's functional ability, especially the ability to perform daily activities. bi has demonstrated high internal consistency and inter-rater reliability, good validity, and adequate response among samples from various populations, such as stroke patients and neurorehabilitation patients (yi et al., 2020). the results showed that the barthel index is a reliable measure, with adequate internal consistency and is valid for measuring patient functional independence (cronbach's alpha = 0.942) (dos santos barros et al., 2022). the bi score was the cumulative score of all (10) question items, with a maximum score of 10 indicating independence, and a minimum score of 0 indicating total dependence. the bi rating hierarchy can assist in understanding the sequence of loss of adl ability in patients and provides useful information for observing and identifying potential functional disorders that occur in patients. for example, inability to perform the easiest adls (such as transfers) indicates severe functional dependence of the patient, whereas inability to perform only the most difficult adls (such as bathing) indicates a patient's mild functional dependence (yi et al., 2020). bi scores are divided into five categories, namely 0-20 (total dependent), 25-40 (severe dependent), 45-60 (moderate dependent), 65-80 (mild dependent), and 85100 (independent) (li et al., 2020). data collection data collection was carried out from february to july 2022. respondent resilience data were collected through a survey conducted by researchers and research assistants. respondents were given an explanation of each question item contained in the questionnaire. data on the respondent's ability to carry out daily activities were measured by the research assistant. data analysis descriptive data analysis and chi-square were used in this study. descriptive data analysis was carried out to analyze the respondent's demographic and clinical data. testing the relationship between resilience and functional independence used the pearson chi-square test. all data were analyzed using spss version 25 where the significance level was p<0.05. data collection this research has received ethical approval from the ethical commission of the university of mandala waluya kendari (number of ethical letter: 422/umw/ii/2022). all respondents were given an explanation about the research before signing the informed consent. ethical consideration this research has received an ethical certificate from the ethics commission (kepk) of airlangga university, faculty of nursing with no. 2144-kepk, approval date 13 january 2021 and expiration date 13 january 2022. at the beginning of this study, participants fulfilled informed consent and demographic data. the researchers kept the data of each participant secret by using a code. results the characteristics of the respondents can be seen in table 1, that the average age of the respondents was 53 years (with an age range of 35-65 years). there were more female respondents than male respondents. last education most graduated from high school (45.1%). most respondents experienced hemiparesis on the left side of the body (61.5%). most of the respondents were married (55.7%). all respondents had a comorbidity, the table 1 characteristics of respondents (n=122) characteristics of respondents n % gender woman man 67 55 54.9 45.1 last education college high school middle/elementary school 38 55 29 31.1 45.1 23.8 type of hemiparesis hemiparesis on the left side of the body hemiparesis on the right side of the body 75 47 61.5 38.5 marital status marry widow/widower/not married 68 54 55.7 44.3 comorbid hypertension hypertension + diabetes hypertension + diabetes + hypercholesterolemia 50 43 29 41 35.2 23.8 stroke severity low moderate 35 87 28.7 71.3 m±sd age 53.20±10.46 heltty and zahalim (2023) supremo, bacason, and sañosa (2022) supremo, bacason, and sañosa (2022) 50 p-issn: 1858-3598  e-issn: 2502-5791 most experienced being hypertension. the degree of severity of stroke that was most experienced by respondents was moderate (71.3%). table 2 shows that more respondents experienced normal resilience (77.0%) than high resilience, which was only 10.7%. in addition, in table 2 it can be seen that more respondents experienced a moderate dependent (65.6%) in carrying out their daily activities than those who experienced severe dependent which was only 16.4%. in this study, there were no respondents who were in the total dependent and independent categories. table 3 shows that resilience has a significant relationship with the independence of respondents in carrying out their daily activities (p value = 0.000). the results of the correlation test analysis also show that the relationship between resilience and the level of independence of the respondents has a strong relationship and a positive pattern, meaning that the better the level of one's resilience, the higher the level of independence. discussions based on the results of this study, 79.8% of respondents in the normal category of resilience experienced a moderate dependent. stroke patients and even mild stroke patients experience adl dependence (wurzinger et al., 2021). research proves that most adl recovery usually occurs within the first six weeks after a stroke (wurzinger et al., 2021). respondents in this study had been undergoing stroke treatment for eight weeks so they had shown an increase in adl independence, although the increase in functional ability that was achieved was mostly in the moderate dependent category. this is in line with the results of other studies where there was an increase in basic adl independence during the first three months after stroke (norvang et al., 2022). although norvang et al. (2022) stated that resilience is not related to functional improvement in stroke patients, other studies have found that high resilience can increase functional independence by 55% in postoperative hip fracture patients (tan et al., 2021). in this study, respondents were actively motivated to carry out daily activities independently according to their abilities, encouraged to do regular exercises in the rehabilitation unit, make dietary adjustments, carry out stress management by thinking positively and worshiping as these can improve respondent resilience capacity. in this study, it was also found that there were more respondents who were in the moderate dependent category (65.6%) compared to the severe dependent category (16.4%). the achievement of functional abilities of respondents in the category of mild dependent was only 18.0%. this can be associated with the presence of comorbidities experienced by respondents thereby limiting the respondent's ability to achieve optimal functional abilities. patients with more comorbidities have poorer functional outcomes after stroke (simić-panić et al., 2018). stroke patients with diabetes mellitus achieve poorer functional recovery and longer recovery after stroke, thus prolonging rehabilitation treatment (simić-panić et al., 2018). stroke recovery is a long-term process in which resilience has been shown to be a very important factor in the stroke recovery process (han et al., 2021). to achieve this recovery, effort and a process of adaptation of the patient to the conditions of the disability that they experience are needed. resilient individuals are able to successfully adapt to adversity and maintain mental health (han et al., 2021). resilience is a way to help relieve stress and emotional pressure so that it can influence the response of stroke patients to rehabilitation and achieve better long-term functional achievement results. the high level of resilience ability of the respondents in this study can also be associated table 2 frequency distribution of resilience and independence of post-stroke patients in carrying out daily activities variable frequency (f) percentage (%) post-stroke patient resilience low resilience 15 12.3 normal resilience 94 77.0 high resilience 13 10.7 patient independence in performing daily activities total dependent 0 0 severe dependent 20 16.4 moderate dependent 80 65.6 mild dependent 22 18.0 independent 0 0 table 3 the relationship between resilience and independence in carrying out daily activities in post-stroke patients resilience patient independence in performing daily activities total p value r total dependent (n=0) n (%) severe dependent (n=20) n (%) moderate dependent (n=80) n (%) mild dependent (n=22) n (%) independent (n=0) n (%) (n= 122) low resilience 0 10 (66.7) 3 (20.0) 2 (13.3) 0 15 0.000 0.676 normal resilience 0 9 (9.6) 75 (79.8) 10 (10.6) 0 94 high resilience 0 1 (7.7) 2 (15.4) 10 (76.9) 0 13 jurnal ners http://e-journal.unair.ac.id/jners 51 with age, where the respondents have an average age of 53 years with an age range of 35-65 years. this is in line with other studies which prove that the older the patient is, the better the resilience and healthcare outcomes achieved (chen & tung, 2021). the results of this study indicate that there was a strong relationship between resilience and increased patient independence in performing adls. this relates to the patient's adaptability to the conditions they experienced. post-stroke patients who can adapt to the conditions they experience are associated with more positive emotions, which are generally related to mental health and better quality of life (matérne at al., 2022). stroke not only damages the sufferer's physical health, but also affects his mental health (zhao et al., 2021). resilience is closely related to positive emotions that contribute to positive mental health and act as a buffer against negative psychological stress and psychological distress (matérne et al., 2022). a low level of resistance is associated with a greater susceptibility to pathological reactions that occur in stroke patients. in contrast, patients with high levels of resilience can make better use of their abilities to adaptively cope with and adapt to negative life events (zhao et al., 2021). based on a longitudinal developmental perspective, the effect of resilience on mental health status has a chain effect: mental health status appears to affect resilience, then resilience in turn influences mental health status (wu et al., 2020). through sufficient resilience, individuals have the ability to overcome the negative effects of stress and face challenging life changes (chen & tung, 2021). this can explain that poststroke patients who have good resilience have a better level of independence in performing adls. independence can be achieved through a process of training, including rehabilitation. stroke patients undergoing rehabilitation are required to be active participants in their treatment, and are motivated to participate actively (yoshida et al., 2021). the active participation of the patient can improve the patient's functional ability (heltty, 2022). active participation can be achieved by cultivating enthusiasm within the patient to carry out activities (heltty, 2021). this enthusiasm is part of resilience. even so, in this study there were 9.6% of normal resilience respondents who were severe dependent. this is related to the lack of support system received by respondents, where, based on marital status, it can be seen that some respondents have the status of a widower, widow, and are not married. even though many of them have married status, there are still respondents who do not get social support from their families. this can be due to the age of the respondent's partner who has also entered the elderly stage and the fatigue experienced by the respondent's partner so that it is not optimal in providing physical, psychological, and emotional support to the respondent. lack of social support is considered a risk factor for impaired resilience (lima et al., 2020). resilience as an interactive and multifactorial process involving individuals and the environment, including the family. continuity of care at home can affect an individual's capacity to deal with the disease. this continuity includes family functions and acceptance, financial resources, education level, spiritual beliefs, service availability, and health information (lima et al., 2020). support for post-stroke patients is very important for rehabilitation, increasing individual resilience, and preventing mental disorders such as post-stroke depression. the support provided by the family includes emotional support which includes trust, empathy, affection, love, listening, information support, availability of facilities and information. there was evidence that emotional support is an important factor in health recovery (lima et al., 2020). in addition to emotional support, post-stroke patients also need informational support. the results of the study show that resilience was also correlated with the availability of information (han et al., 2021). the family as a source of support for patients also contributes in providing information to patients. information will help patients to better understand the conditions they were experiencing so that they can perform better resilience. research proves that a greater level of resilience will be associated with better cognitive and emotional outcomes (gyawali et al., 2020). when individuals think they are unable to control what happens in a situation, then their adaptive skills become limited and often ineffective, leading to powerlessness. conversely, when individuals believe that life events and outcomes can be managed, they will make active efforts to overcome adverse situations, opening possibilities for moving forward and achieving resilience. by becoming resilient, individuals gain the strength to adapt, resist stress, and potentially thrive in the face of adversity (chen & tung, 2021). the findings from this study have several practical implications for the care of post-stroke patients. in optimizing patient resilience in an effort to improve the functional abilities of post-stroke patients, nurses need to improve providing information to patients and their families. information can be conveyed through leaflet media. patients and families are also always motivated and confident in their ability to achieve better functional heltty and zahalim (2023) supremo, bacason, and sañosa (2022) supremo, bacason, and sañosa (2022) 52 p-issn: 1858-3598  e-issn: 2502-5791 abilities. these efforts are aimed at increasing patient resilience and can be included in nursing care interventions. however, this study also had limitations, where the results cannot be generalized to the general population, considering that this research was conducted in kendari, southeast sulawesi, which only covered a small portion of the ethnic groups in indonesia. in addition, the resilience measurement instrument used in this study has not explored in depth the indicators of life principles or cultural values as things that increase resilience. conclusions this study proves that resilience was related to the independence of post-stroke patients in performing adls. the achievement of resilience is inseparable from the patient's ability to understand the importance of doing exercises during rehabilitation. this is also inseparable from family support in providing information, infrastructure, financial, emotional for the healing of patients. future research needs to add aspects that need to be assessed in patient resilience such as related to norms and customs because these aspects effect on increasing patient resilience. the higher the patient's resilience level, the greater the patient's level of independence to improve the patient's quality of life. conclusions the authors thank all those who have helped so that this research can be carried out. conclusions all authors declared no conflict of interest. references chen, c.p., tung, h.h. (2021). resilience and daily activity among patients after stroke. aging medicine and healthcare. https://doi.org/10.33879/amh.2021.0301 dos santos barros, v., bassi-dibai, d., guedes, c.l.r., morais, d.n., coutinho, s.m., simões, g., mendes, l.p., da cunha leal, p., dibaifilho, a.v. (2022). barthel index is a valid and reliable tool to measure the functional independence of cancer patients in palliative care. bmc palliative care. 21:124. https://doi.org/10.1186/s12904-022-01017-z fung, s.f. (2020). validity of the brief resilience scale and brief resilient coping scale in a chinese sample. international journal of environmental research and public health, 17(4), 1265. https://doi.org/10.3390/ijerph17041265 gyawali, p., chow, w.z., hinwood, m., kluge, m., english, c., ong, l.k., nilsson, m., walker, f.r. (2020). opposing associations of stress and resilience with functional outcomes in stroke survivors in the chronic phase of stroke: a cross-sectional study. frontiers in neurology, 11:230. https://doi.org/10.3389/fneur.2020.00230 grefkes, c., fink, g.r. (2020). recovery from stroke: current concepts and future perspectives. neurological research and practice. 2, 17. https://doi.org/10.1186/s42466-020-00060-6 han, z.t., zhang, h.m., wang, y.m., zhu, s.s., wang, d.y. (2021). uncertainty in illness and coping styles: moderating and mediating effects of resilience in stroke patients. world journal of clinical cases. 9(30). https://doi.org/10.12998/wjcc.v9.i30.8999 heltty, h., sitorus, r., martha, e., nusdwinuringtyas, n. (2021) experience of the patient's success in facing post-stroke urinary incontinence: the patient's perspective. frontiers of nursing. 2021, 8:291-301. https://doi.org/10.2478/fon-2021-0030 heltty, h. (2022). patient, family, and peer engagement in nursing care as an effort to improve the functional independence of poststroke urinary incontinence patients: a cross-sectional study. cureus. 14(7); e26649. https://doi.org/10.7759/cureus.26649 hollist, m., morgan, l., cabatbat, r., au, k., kirmani, m.f., kirmani, b.f. (2021). acute stroke management: overview and recent updates. aging and disease, 12(4), 1000–1009. https://doi.org/10.14336/ad.2021.0311 kementerian kesehatan republik indonesia. (2019). hasil utama riskesdas 2018. jakarta: kementerian kesehatan republik indonesia li, q.x., zhao, x.j., wang, y. et al. (2020). value of the barthel scale in prognostic prediction for patients with cerebral infarction. bmc cardiovascular disorder, 20(14). https://doi.org/10.1186/s12872019-01306-1 lima, r.j., silva, c.r.r., costa, t.f., madruga, k.m.a., pimenta, c.j.l., costa, k.n.f.m. (2020). resilience, functional capacity and social support of people with stroke sequelae. revista eletronica de enfermagem. 22:59542. https://doi.org/10.5216/ree.v22.59542. lv, y., sun, q., li, j., zhang, w., he, y., zhou, y. (2021). disability status and its influencing factors among stroke patients in northeast china: a 3-year follow-up study. neuropsychiatric disease and treatment, 17, 2567–2573. https://doi.org/10.2147/ndt.s320785 matérne, m., simpson, g., jarl, g., appelros, p., arvidsson-lindvall, m. (2022). contribution of participation and resilience to quality of life among persons living with stroke in sweden: a qualitative study, international journal of qualitative studies on health and well-being, 17:1, 2119676, https://doi.org/10.1080/17482631.2022.2119676 méndez-gallardo, j.j., méndez, b., cano-nigenda, v., faringtonterrero, e.y. d., castellanos-pedroza, e., merino, j.g., arauz, a. (2020). update on the management of acute stroke. a practical clinical guide. revista mexicana de neurociencia. 21(4):163-177. https://doi.org/10.24875/rmn.20000041 norvang, o.p., dahl, a.e., thingstad, p., askim, t. (2022). resilience and its association with activities of daily living 3 months after stroke. frontiers in neurology, 13, 881621. https://doi.org/10.3389/fneur.2022.881621 rodríguez-rey, r., alonso-tapia, j., hernansaiz-garrido, h. (2016). reliability and validity of the brief resilience scale (brs) spanish version. psychological assessment, 28(5), e101–e110. https://doi.org/10.1037/pas0000191 simić-panić, d., bošković, k., milićević, m., rabi žikić, t., cvjetković bošnjak, m., tomašević-todorović, s., & jovićević, m. (2018). the impact of comorbidity on rehabilitation outcome after ischemic stroke. acta clinica croatica, 57(1), 5–15. https://doi.org/10.20471/acc.2018.57.01.01 smith, b.w., (2008). the brief resilience scale (brs). edinstruments. https://edinstruments.com/instruments/brief-resilience-scalebrs tan, c.y.f., fang, a.h.s., koh, e.y.l., low, l.l. (2021). the effect of psychological resilience on functional outcomes in post-operative hip fracture patients in a singapore community hospital. proceedings of singapore healthcare, 30(1):28-35. https://doi.org/10.1177/2010105820948531 tiwari, s., joshi, a., rai, n., satpathy, p. (2021). impact of stroke on quality of life of stroke survivors and their caregivers: a qualitative study from india. journal of neurosciences in rural practice, 12:680–688. https://doi.org/10.1055/s-0041-1735323 https://doi.org/10.33879/amh.2021.0301 https://doi.org/10.1186/s12904-022-01017-z https://doi.org/10.3390/ijerph17041265 https://doi.org/10.1186/s42466-020-00060-6 https://doi.org/10.12998/wjcc.v9.i30.8999 https://doi.org/10.2478/fon-2021-0030 https://doi.org/10.7759/cureus.26649 https://doi.org/10.14336/ad.2021.0311 https://doi.org/10.1186/s12872-019-01306-1 https://doi.org/10.1186/s12872-019-01306-1 https://doi.org/10.5216/ree.v22.59542 https://doi.org/10.2147/ndt.s320785 https://doi.org/10.1080/17482631.2022.2119676 https://doi.org/10.24875/rmn.20000041 https://doi.org/10.3389/fneur.2022.881621 https://doi.org/10.1037/pas0000191 https://doi.org/10.20471/acc.2018.57.01.01 https://edinstruments.com/instruments/brief-resilience-scale-brs https://edinstruments.com/instruments/brief-resilience-scale-brs https://doi.org/10.1177/2010105820948531 https://doi.org/10.1055/s-0041-1735323 jurnal ners http://e-journal.unair.ac.id/jners 53 wassenius, c., claesson, l., blomstrand, c., jood, k., carlsson, g. (2022). integrating consequences of stroke into everyday life – experiences from a long-term perspective. scandinavian journal of occupational therapy. 29(2):126-138, https://doi.org/10.1080/11038128.2020.1857433 wu, y., sang, z., zhang, x-c., margraf, j. (2020). the relationship between resilience and mental health in chinese college students: a longitudinal cross-lagged analysis. frontiers in psychology. 11:108. https://doi.org/10.3389/fpsyg.2020.00108 wurzinger, h., abzhandadze, t., rafsten, l., sunnerhagen, k.s. (2021). dependency in activities of daily living during the first year after stroke. frontiers in neurology, 12, 736684. https://doi.org/10.3389/fneur.2021.736684 ye, y-c., wu, c-h., huang, t-y., yang, c-t. (2022). the difference between the connor–davidson resilience scale and the brief resilience scale when assessing resilience: confirmatory factor analysis and predictive effects. global mental health, 1–8. https://doi.org/10.1017/gmh.2022.38 yi, y., ding, l, wen, h., wu, j., makimoto, k. and liao x (200) is barthel index suitable for assessing activities of daily living in patients with dementia? frontiers in psychiatry, 11:282. https://doi.org/10.3389/fpsyt.2020.00282 yoshida, t., otaka, y., osu, r., kumagai, m., kitamura, s., yaeda, j. (2021). motivation for rehabilitation in patients with subacute stroke: a qualitative study. frontiers in rehabilitation sciences. 2:664758. https://doi.org/10.3389/fresc.2021.664758 zhao l, yang f, sznajder kk, zou c, jia y and yang x (2021). resilience as the mediating factor in the relationship between sleep disturbance and post-stroke depression of stroke patients in china: a structural equation modeling analysis. frontiers in psychiatry, 12:625002. https://doi.org/10.3389/fpsyt.2021.625002 how to cite this article: heltty, h. and zahalim, z. (2023) ‘resilience after stroke and its correlation with functional independence’, jurnal ners, 18(1), pp. 47-53. doi: http://dx.doi.org/10.20473/jn.v18i1.41229 https://doi.org/10.3389/fpsyg.2020.00108 https://doi.org/10.3389/fneur.2021.736684 https://doi.org/10.1017/gmh.2022.38 https://doi.org/10.3389/fresc.2021.664758 vol 6 no 1 april 2011_akreditasi 2013.indd 76 pengalaman seksualitas ibu hamil di puskesmas pondok aren tangerang (sexuality experience in pregnant woman at pondok aren tangerang health center) vike dwi hapsari*, sari sudarmiati* *program studi ilmu keperawatan fakultas kedokteran universitas diponegoro semarang e-mail: vike_sari@yahoo.co.id abstract introduction: pregnancy is an important event in women life. various physical and psychological changes may affect pregnant women, particularly on sexuality. along with the growing size of uterus in pregnant women, it can lead to discomfort and diffi culty for sexual intercourse. the aimed of this tudy was to understand sexuality experience among pregnant women. method: this was qualitative research with phenomenological approach. five participants involved in this study using purposive sampling. data was collected with an indepth interview and then was analyzed with colaizzi’s. this research was emerged six themes. the meaning of sexuality, changes of sexuality, cause of sexuality changes in intimate relationship, the reason for doing intercourse, partner caring, and myth about sexuallity in pregnan women. result: the results showed pregnant women have difefrence sexuality experience from the step trimester. discussion: this research concludes that a nurse needs to give information to women and their family especially her husband regarding sexuality changes in pregnant women. keywords: sexuallity, pregnant women pendahuluan kehamilan merupakan salah satu peristiwa yang penting dalam kehidupan perempuan. proses yang diawali dari konsepsi hingga pengeluaran bayi dari dalam rahim membawa perubahan-perubahan yang menuntut adanya adaptasi dari ibu hamil dan orang-orang terdekatnya. berbagai perubahan fi sik dan psikis dapat memengaruhi kehidupan seorang ibu hamil, khususnya mengenai seksualitasnya. seiring dengan membesarnya ukuran uterus pada ibu hamil dapat mengakibatkan ketidaknyamanan dan kesulitan dalam melakukan hubungan seks (pangkala, 2001). ibu hamil mungkin merasa lekas lelah, pusing, mual, muntah atau nyeri pada payudara sehingga libidonya menurun. masalah dari perubahan fi sik yang sering menggangu ibu hamil saat berhubungan seksual adalah kesulitan untuk berbaring telentang pada saat hamil tua. begitu pula dengan psikis ibu hamil yang berubah karena pengaruh dari kehamilannya. faktor lain yang turut memengaruhi ketidaknyamanan ibu hamil untuk melakukan hubungan seksual adalah faktor psikologi. beberapa ibu hamil memang mengalami variasi yang sangat berbeda dalam keinginan seksual. faktor emosi merupakan faktor yang paling berpengaruh dalam perubahan ini (de judicibus dan mccabe, 2002). bagi sebagian ibu hamil, kehamilan justru meningkatkan dorongan seksual, tetapi bagi sebagian lain tidak berpengaruh. sementara bagi ibu hamil yang lain, kehamilan justru menekan atau menurunkan dorongan seksual (alfiben, wiknjosastro, dan elvira, 2000). perbedaan pengaruh terhadap dorongan seksual ini ditentukan oleh sejauh mana perubahan fi sik dan psikis yang terjadi selama kehamilan berpengaruh terhadap kesehatan dan fungsi seksual ibu hamil tersebut. biasanya perbedaan dorongan seksual ini berdasarkan kehamilan pada berbagai trimester. tiap-tiap trimester ibu hamil mempunyai gairah seksual yang berbedabeda (pangkahila, 2001). pengalaman seksualitas ibu hamil (vike dwi hapsari) 77 pada trimester pertama gairah seksual ibu hamil umumnya menurun karena mengalami morning sickness, muntah, mual dan kelelahan, sehingga akan memengaruhi semangat, hasrat dan libido mereka untuk berhubungan seksual (bobak, lowdermilk, dan jensen, 2005). memasuki trimester kedua, umumnya libido timbul kembali, hal ini disebabkan tubuh telah dapat menerima dan terbiasa dengan kondisi kehamilan, sehingga ibu hamil dapat menikmati aktivitas dengan lebih leluasa daripada trimester pertama. berbeda pada trimester ketiga, libido dapat turun kembali. data yang diperoleh di puskesmas pondok aren tangerang dari sebanyak 100 orang ibu hamil, 60% merupakan ibu hamil anak pertama. hasil wawancara kepala puskesmas didapatkan pasangan muda yang suaminya kerja dari pagi hingga malam yang menjadikan ibu hamil datang untuk memeriksakan kehamilannya seorang diri. ibu hamil juga banyak yang menanyakan tentang masalah hubungan seksualitas pada masa kehamilannya karena mereka tidak memiliki waktu untuk mendiskusikan masalah ini pada pasangannya masing-masing. survei awal yang dilakukan peneliti dan dapat disimpulkan hasil yang memprihatinkan bahwa sekitar 50% ibu hamil tidak menemukan kebahagiaan saat berhubungan intim. umumnya ibu hamil khawatir bahwa hubungan seksual selama kehamilan dapat melukai bayinya dan orgasme bisa menyebabkan keguguran. data memaparkan banyaknya pengalaman hubungan seksualitas yang berbeda-beda dari ibu hamil dari tiap-tiap trimester di puskesmas tersebut, karena dengan banyaknya perubahan fi sik dan psikis yang terjadi pada ibu hamil. fenomena tersebut merupakan suatu hal yang sangat menarik bagi peneliti karena walaupun sedang hamil dan mengalami perubahan fisik dan psikis ibu hamil tetap terpenuhi hubungan seksualitas. dampak secara fi sik bila pasangaan tidak melakukan hubungan seksual akan mengalami perubahan fisik seperti lemah, lesu, tidak bersemangat dalam pekerjaan dan tidak bergairah secara psikis, pasangan dapat mengalami stress, membawa dampak negatif pada rumah tangganya seperti perselingkuhan karena merasa istri tidak dapat melayani suaminya atau sebaliknya. peneliti ingin mengetahui lebih lanjut tentang pengalaman seksualitas ibu hamil dari persepsi ibu hamil tentang seksualitas, persepsi ibu hamil mengenai cara mengungkapkan kasih sayang, cinta, dan perhatian, persepsi pasangan mengenai hubungan seks selama kehamilan, persepsi ibu hamil mengenai posisi melakukan hubungan seks selama kehamilan, dan faktorfaktor yang memengaruhi pasangan khususnya ibu hamil dalam melakukan hubungan seks selama kehamilan. bahan dan metode desain dalam penelitian ini adalah penelitian kualitatif dengan pendekatan fenomenologi. pengambilan sampel dilakukan secara purposive sampling. partisipan dalam penelitian ini berjumlah 5 responden, yaitu satu ibu hamil trimester pertama, dua orang ibu hamil trimester dua, dan dua orang ibu hamil trimester tiga yang memeriksakan kehamilannya di puskesmas pondok aren tangerang. prosedur pengumpulan data menggunakan in-depth interview dilengkapi dengan catatan lapangan. analisa data menggunakan metode colaizzi’s. hasil penelitian ini menghasilkan enam (6) tema. masing-masing tema dibentuk dari kategori dan kata kunci yang didapat dari pernyataan partisipan, yaitu: arti seksualitas, perubahan seksualitas, penyebab perubahan hasrat dalam melakukan hubungan seksual, suami lebih perhatian kepada istri saat hamil, alasan istri melakukan hubungan seksual saat hamil, dan mitos atau kepercayaan tentang hubungan seksual saat hamil dari suku jawa. tema pertama yaitu arti seksualitas, seksualitas diartikan sebagai hubungan fi sik dan hubungan psikis. pada katagori pertama yaitu hubungan fi sik, seluruh partisipan menyatakan bahwa hubungan seksualitas adalah hubungan suami istri, hubungan badan, hubungan yang dimulai dari berciuman sampai memasukan alat kelamin. berikut pernyataan partisipan: "hubungan badan antara saya dan suami" (p2) jurnal ners vol. 6 no. 1 april 2011: 76–84 78 tabel 1. proses pembentukan tema no. kata kunci kategori sub tema tema 1 hubungan suami istri hubungan fi sik arti seksualitas2 hubungan badan 3 hubungan yang dimulai dari berciuman hingga memasukkan alat kelamin 4 pembuktian cinta, kasih sayang hubungan psikis 5 seminggu 4–7 kali frekuensi sebelum hamil perubahan frekuensi hubungan seksual perubahan seksualitas 6 awal kehamilan tidak melakukan hubungan seks sama sekali frekuensi saat hamil trimester ke-1 7 peningkatan frekuensi di trimester kedua dibandingkan dengan trimester pertama frekuensi saat hamil trimester ke-2 8 trimester kedua lancar 9 absen mulai trimester ke-3 frekuensi saat hamil trimester ke-3 10 trimester ke-3, satu kali dalam seminggu 11 menurunnya di awal kehamilan penurunan hasrat diawal kehamilan perubahan hasrat istri dalam melakukan hubungan seksual 12 trimester ke-2 meningkat peningkatan hasrat pada kehamilan lanjut 13 tuanya kehamilan makin menurun penurunan hasrat diakhir kehamilan 14 hasrat suami meningkat peningkatan hasrat suami pada saat istri hamil perubahan hasrat suami dalam melakukan hubungan seksual 15 posisi miring jenis-jenis posisi saat berhubungan seksual perubahan posisi dalam melakukan hubungan seksual 16 istri di atas dan dipangku suami 17 membelakangi suami 18 mual pada saat hubungan seks perubahan fi sik penyebab perubahan hasrat dalam melakukan hubungan seksual 19 pinggang pegal dan sakit 20 tidak nyaman karena perut tertekan 21 sesak nafas pada trimester ke-3 pengalaman seksualitas ibu hamil (vike dwi hapsari) 79 "hubungan yang dimulai dari ketertarikan lalu berdekatan berpelukan, berciuman sampai memasukan alat kelamin" (p3) kategori kedua yaitu hubungan psikis. tiga dari lima informan juga mengatakan bahwa hubungan seksualitas adalah pembuktian cinta dan kasih saying. berikut pernyataan partisipan: "setelah hubungan seks kita sudah dapat membuktikan rasa cinta dan kasih sayang seberapa besarnya" (p3) tema yang kedua adalah perubahan seksualitas, perubahan seksualitas terdiri dari empat subtema yaitu yang pertama perubahan frekuensi hubungan seksual, terdapat perubahan frekuensi hubungan seksual sebelum dan setelah kehamilan. sebelum hamil, seluruh partisipan menyatakan melakukan hubungan seksual 4 hingga 7 kali dalam seminggu. setelah hamil, terdapat penurunan frekuensi. empat partisipan menyatakan tidak melakukan hubungan seksual sama sekali pada awal kehamilan. empat partisipan menyatakan lancar melakukan hubungan seksual pada trimester ke2. sedangkan pada trimester ke-3, 2 partisipan menyatakan absen melakukan hubungan seksual. berikut pernyataan partisipan: "… bila tidak hamil sih setiap hari mba, 7 kali dalam seminggu" (p1) "… 2 hari sekali seminggu 4–5 kali…" (p2) “ pas pertama-tama saya hamil tidak hubungan seks tuh mba" (p4) "… lancar mba, trimester ke-2 ini" (p4) "… sudah absen pas masuk trimester ke-3 ini untuk melakukan hubungan seksual" (p1) hasrat istri melakukan hubungan seksual selama kehamilan mengalami perubahan. menurun di awal kehamilan, meningkat di kehamilan lanjut serta penurunan kembali di kehamilan akhir (trimester iii). berikut pernyataan partisipan: " …hasrat tuh bener-bener menurun pas awal kehamilan… " (p2) "kalau masalah hasrat atau kepengen yaitu mba, pas pertengahan trimester ke-2" (p5) "… hamil tua gini mba, hasrat atau kepengen melakukan hubungan seksualnya menurun." (p1) no. kata kunci kategori sub tema tema 22 perhatian suami bertambah bentuk perhatian suami lebih perhatian kepada istri saat hamil 23 jarang mengambil lembur 24 tiap malam cium-cium perut istri 25 memuji istri saat hamil tambah cantik dan menarik 26 melarang istri bepergian terlalu jauh 27 melarang istri bekerja terlalu capek 28 takut suami marah ketakutan istri alasan istri melakukan hubungan seksual saat hamil 29 takut suami selingkuh 30 takut suami mengira istri tidak mau melayani 31 hamil tidak boleh melakukan hubungan seks sama sekali alasan tidak melakukan hubungan seksual saat hamil mitos atau kepercayaan tentang hubungan seksual saat hamil dari suku jawa 32 nanti bayinya kenapa-kenapa bila melakukan hubungan seks 33 bayi bisa keguguran lanjutan tabel 1. jurnal ners vol. 6 no. 1 april 2011: 76–84 80 seluruh partisipan menyatakan hasrat suami semakin meningkat saat istri sedang hamil. suami sering istri mengajak untuk melakukan hubungan seks setiap hari, merayu, dan membujuk istri untuk mau melakukan hubungan seks. berikut pernyataan partisipan: "suami … hasratnya meningkat deh mba, rayurayu saya terus." (p2) "meningkat mba… kalau kepengen tiap ada kesempatan pasti mau hubungan terus." (p3) seluruh partisipan menyatakan posisi dalam melakukan hubungan seksual saat hamil berubah. sebelum hamil, rata-rata pasangan melakukan posisi konvensional/misionaris. setelah hamil, terdapat perubahan posisi menjadi miring, membelakangi ataupun didepan suami. berikut pernyataan partisipan: "saya tuh lebih nyaman miring mba." (p1) "biasanya kalau hamil gini saya diatas suami mba." (p1) "waah kalau saya posisi dipangku suami." (p5) "kalau membelakangi suami juga biasanya saya coba mba." (p2) tema yang ketiga adalah penyebab perubahan hasrat dalam melakukan hubungan seksual, perubahan hasrat disebabkan perubahan fisik dan psikologis. seluruh partisipan menyatakan perubahan hasrat hubungan seksual disebabkan oleh perubahan fi sik yang dialami oleh ibu hamil seperti, pinggang terasa sakit, perut tertekan ataupun sesak nafas. terdapat satu partisipan yang menyatakan hasrat hubungan seksual dipengaruhi alasan psikologis. partisipan menyatakan merasa mual saat hendak melakukan hubungan seksual. berikut pernyataan partisipan: "mual rasanya mba kalau mau berhubungan sama suami…nggak tahu kenapa." (p3) "tidak kuatnya dipinggang mba sakit, pegel macem-macem lah." (p5) "… perutnya tertekan…" (p1). "sesak nafas…" (p5) tema keempat yaitu suami lebih perhatian kepada istri saat hamil, seluruh partisipan menyatakan bahwa suami lebih memberikan perhatian kepada mereka. perhatian yang diberikan seperti memanjakan istri, mengantar istri kemana saja, lebih sering menemani istri di rumah, lebih mengkhawatirkan kesehatan istri, serta memberikan pujian kepada istri. berikut pernyataan partisipan: "… perhatian banget mba, kalau saya sedang hamil makanan apa yang saya mau dibeliin.. suami jadi khawatir banget mba." (p1) "…tiap jam hubungi saya… mengantar saya kemana saja." (p2) "… tidak pernah ambil lembur lagi …" (p2) " …kata suami, saya tambah seksi… tambah cantik." (p1) te m a k e l i m a a d a l a h a l a s a n i s t r i melakukan hubungan seksual saat hamil seluruh partisipan menyatakan takut suami marah ataupun selingkuh bila menolak melakukan hubungan seksual saat hamil. selain itu, partisipan juga takut tidak dapat melakukan tugas sebagai istri dengan baik. berikut pernyataan partisipan: "suami marah mba… saya takut kalau dia marah gara-gara saya tidak mau melayani dia." (p5) "takut kalau saya tidak melaksanakan tugas menjadi istri yang baik yaitu melayani suami." (p3) "saya takut suami selingkuh…" (p4) te m a k e e n a m a d a l a h m i t o s a t a u kepercayaan tentang hubungan seksual saat hamil dari suku jawa. seluruh partisipan menyatakan bahwa terdapat kepercayaan bahwa hubungan seksual saat kehamilan dapat mengakibatkan keguguran. berikut pernyataan partisipan: "kalau hubungan seks nanti bayinya bisa keguguran mba." (p1) pembahasan tema pertama yaitu arti seksualitas, seluruh informan menjawab hubungan seksualitas dilakukan oleh suami istri. arti hubungan seksualitas yang mereka maksudkan adalah hubungan yang wajib harus dilakukan oleh pasangan suami istri yang sudah menikah untuk memperoleh keturunan. oruc, et al., (2003) menyatakan hubungan seksualitas diartikan sebagai sebuah indentitas masing-masing individu untuk membina pengalaman seksualitas ibu hamil (vike dwi hapsari) 81 rasa kepercayaan kepada pasangannya masingmasing. tiga partisipan mengatakan persepsi seksualitas adalah hubungan badan yang menggunakan badan atau anggota tubuh untuk mencapai suatu kepuasaan yang dirasakan para pasangan. andrew (1998) mengatakan bahwa hubungan seksualitas adalah hubungan badan. dua partisipan menyatakan seksualitas adalah hubungan yang dimulai dari berciuman sampai memasukan alat kelamin. kelly (2001) dan winkosastro menyatakan bahwa siklus respon seksual wanita dimulai dari fase gairah, terangsang, hingga fase resolusi. sedangkan partisipan lain mengartikan seksualitas adalah cara pembuktian seberapa besar rasa cinta dan kasing sayang terdapat suaminya. hubungan seksualitas bertujuan untuk membangun suatu kepercayaan, nilai, minat, daya tarik dan tingkah laku kepada pasangannya (pangkahila, 2001). te m a k e d u a t e n t a n g p e r u b a h a n seksualitas, selama kehamilan ibu hamil merasakan perubahan dengan hubungan seksnya yang meliputi: perubahan frekuensi seksualitas selama masa kehamilan, perubahan hasrat atau keinginan untuk berhubungan seks, perubahan posisi selama hamil yang dirasakan berhubungan dengan hubungan seks saat hamil yang dapat membawa dampak pada perubahan hubungan seks saat hamil. hasil penelitian ini menunjukkan terdapat variasi frekuensi hubungan seksual ibu hamil selama masa kehamilan. mayoritas ibu hamil dalam penelitian ini menyatakan bahwa penurunan frekuensi hubungan seksual semenjak awal kehamilan, meningkat pada pertengahan dan turun kembali bahkan semakin menurun dengan tuanya masa kehamilan. hal tersebut bisa disebabkan karena kehamilan merupakan masa transisi dalam siklus kehidupan di mana terjadi perubahan baik secara fi sik dan psikis yang harus diadaptasikan oleh ibu hamil. brelin dan lucas (2003), menguatkan kondisi tersebut dengan menyatakan bahwa kehamilan merupakan suatu kondisi yang bisa menimbulkan perubahan dalam kehidupan seksual suami istri. perubahan hasrat atau keinginan dalam berhubungan seks saat hamil sangat mengalami perubahan didukung dengan pernyataan tiga informan, mengatakan hasrat menurun, dan tidak ada keinginan untuk melakukan hubungan seks pada saat awal kehamilan. pada trimester pertama atau awal-awal kehamilan gairah seks memang menurun karena kondisi yang lemah dari ibu seperti mual-muntah, nafsu makan yang menurun akan membuat ibu hamil lemah dan keinginan seksualnya menurun (de judicibus dan mccabe, 2002). masuk ke trimester ke-2 ibu hamil mengalami peningkatan keinginan yang dinyatakan empat informan mengatakan mengalami peningkatan keinginan pada trimester ke-2. memasuki trimester ke-2, umumnya libido yang sempat menurun atau bahkan hilang pada trimester ke-1 muncul kembali, hal ini disebabkan tubuh ibu hamil telah dapat menerima dan terbiasa dalam kondisi kehamilan, sehingga ibu dapat menikmati aktivitas seksualnya dengan lebih leluasa (eisenberg, murkof, dan halloway, 2009). pada kehamilan tua atau trimester ke-3, dua informan menyatakan hasrat atau hubungan seks menurun. libido turun kembali pada trimester ke-3 dikarenakan adanya faktor fi siologis yang sangat terlihat. yaitu kehamilan yang sudah membesar, serta adanya peningkatan cairan tubuh, akibatnya cairan vagina juga bertambah, sehingga kontak seksual menjadi kurang memuaskan. hasrat atau keinginan istri yang berubahubah pada tiap trimester, ternyata tidak sebanding dengan hasrat atau keinginan suami pada saat istri hamil. semua informan menjawab bahwa hasrat suami bertambah dilihat dari suami sering mengajak, merayu istri untuk melakukan hubungan intim setiap hari. hasrat suami untuk melakukan hubungan intim tidak mengalami perubahan ketika istri hamil. para suami merasa lebih bergairah melihat istri yang sedang hamil sehingga motivasi dan hasrat untuk hubungan intim meningkat (pangkahila, 2001). berdasarkan pernyataan yang dituturkan diatas tentang perubahan hasrat, penelitian ini menunjukkan adanya variasi hasrat atau gairah ibu hamil dalam melakukan hubungan seksual selama masa kehamilan. hasil penelitian ini menunjukkan bahwa mayoritas ibu hamil mengalami penurunan hasrat melakukan hubungan seksual selama masa kehamilan. keadaan ini menggambarkan bahwa perubahan jurnal ners vol. 6 no. 1 april 2011: 76–84 82 diri selama masa kehamilan berdampak besar terhadap keinginan ibu hamil untuk melakukan hubungan seksual dengan pasangan. kondisi hamil, posisi sangat berpengaruh dalam melakukan hubungan intim. didapat dua pernyataan informan yang mengatakan posisi miring kesamping atau menyamping. posisi yang dimaksudkan informan adalah posisi yang memberikan peluang untuk melakukan penetrasi yang dangkal. suami dapat melakukan penetrasi dari belakang yang tidak menyebabkan tekanan pada perut (kelly, 2001). hasil penelitian ini menunjukkan bahwa seiring peningkatan usia kehamilan ibu hamil memilih untuk merubah posisi hubungan seksual menjadi miring, ataupun berada di atas. posisi “ man on top “ yang sering kali digunakan sebelum masa kehamilan, pada masa kehamilan mengalami penurunan. posisi miring dan posisi ibu hamil di atas memberikan lebih banyak keuntungan bagi ibu hamil. ibu hamil akan merasakan lebih nyaman dalam melakukan hubungan seksual karena perut yang sudah membesar akan terbebas dari penekanan. selain itu dengan posisi membelakangi suami ibu hamil akan mampu untuk mengatur kenyamanannya sendiri. tema ketiga adalah penyebab perubahan hasrat dalam melakukan hubungan seksual. keluhan-keluhan fisik yang dirasakan ibu hamil sangat memegang peranan penting dalam melakukan hubungan seks. dua pernyataan informan mengatakan mual saat mau memulai hubungan seks. dua informan yang masih dalam tahap awal kehamilan memang masih risiko mendapatkan serangan mual yang terjadi pada waktu tertentu. pada waktu yang tidak tenang atau masih ada keluhan mual tidak bisa ibu hamil dipaksakan untuk melakukan hubungan seks (bobak dan jensen, 2005). hasil penelitian menunjukan beberapa kondisi yang bisa menurunkan hubungan seksual ibu hamil. kondisi tersebut di antaranya mual muntah, pinggang terasa sakit sampai perut tertekan dan merasakan sesak nafas. hasil penelitian ini sejalan dengan studi literatur yang menyatakan bahwa terdapat berbagai faktor yang menyebabkan timbulnya penurunan hasrat seksual pada ibu hamil di antaranya faktor biomedis. faktor biomedis berupa kondisi fi sik ibu hamil yang kurang optimal seperti mual, muntah, pusing pada trimester pertama serta perubahan ukuran perut dan meningkatnya kelelahan di akhir trimester ke-3. tema keempat yaitu perhatian suami kepada istri saat hamil. saat istri hamil kepedulian suami menjadi peran yang sangat penting, istri hamil yang mengalami banyak perubahan menjadi sangat sensitif. lima informan menyatakan bahwa perhatian suami terhadap istri hamil bertambah dilihat dari seringnya memanjakan istri, menuruti semua keinginan istri, menghubungi istri setiap waktu dan mengantar istri kemana saja. pernyataan informan tersebut dapat disimpulkan bahwa suami ibu hamil tersebut sangat memperhatikan kondisi istri, kewajiban suami harus peduli pada istri apalagi istri yang sedang hamil karena efek bila keinginan istri dan perhatian suami yang kurang dapat berefek samping pada janin yang dikandungnya. kepedulian suami, perhatian suami merupakan salah satu ekspresi kasih sayang yang penting selama kehamilan. hasil penelitian ini menunjukkan bahwa perhatian tersebut ditunjukkan suami dalam bentuk peduli kondisi istri, pemenuhan nutrisi, memanjakan istri, sentuhan mesra suami. berbagai bentuk perhatian tersebut sering dipilih suami untuk mengekspresikan seksualitasnya karena sering kali ibu hamil merasa tidak nyaman dalam melakukan hubungan seksualitasnya. ketakutan suami pada istri hamil, kekhawatiran suami akan terjadi apa-apa pada istri saat suami tidak bersamanya. semua informan mengatakan suami melarang istri berpergian terlalu jauh tanpa didampinginya. maksud dari pernyataan semua informan ini adalah suami tidak mau istri yang sedang hamil berpergian sendiri karena sangat bahaya. suami melarang istri yang sedang hamil adalah tindakan yang wajar karena suami tidak ingin istrinya yang sedang hamil terancam jiwanya. diperkuat juga dengan pernyataan dua informan yang takut bila istri terjatuh dan tiga pernyataan yang melarang istri beres-beres rumah yang akan menyebabkan istri kecapekan. kecemasan suami saat istri hamil akan mengalami perasaan yang bercampur aduk ketakutan dan kepedulian suami, pemikiran tentang tanggung jawab akan membuat suami cemas bila terjadi musibah pengalaman seksualitas ibu hamil (vike dwi hapsari) 83 yang mengancam istri dan calon anaknya (bitzer dan alder, 2000). hasil penelitian tersebut menjawab ketakutan suami akan kondisi istri pada saat hamil sangat besar. sangat bervarian perubahan yang diperlihatkan suami dari mulai melarang istri pergi terlalu jauh tanpa didampinginya, takut istri terjatuh dari tangga, dan tidak ingin istri kecapean dalam mengurus rumah tangga. tema kelima yaitu alasan istri melakukan hubungan seksual saat hamil. kondisi psikis seorang ibu hamil memang tidak menentu. hal ini disebabkan adanya ketakutan yang dialami ibu hamil, yaitu ketakutan seorang istri yang sedang hamil pada sangat wajar. dilihat dari penelitian ini didapat semua informan mengatakan takut bila suami akan marah bila istri tidak mau melayaninya diperkuat dengan tiga informan yang mengatakannya, takut suami menyangka istri sengaja mencari alasan pada saat hamil untuk tidak melayani suami diperkuat dari dua pernyataannya, dan terakhir ketakutan istri suami akan melirik wanita lain saat istri tidak bisa melayaninya atau selingkuh yang diperkuat dari dua pernyataan informan. pernyataan informan di atas membawa hasil penelitian ini pada perubahan psikis, emosi ibu hamil masih dalam rentang yang berubah-ubah. ibu hamil seharusnya selalu berpikir positif karena bila berpikir negatif akan membahayakan kondisi janin yang ada didalam kandungannya. dari lima informan yang bervarian didapat data ibu hamil pada tiap-tiap trimester mengalami kecemasaan dan kemarahan yang tidak didasari alasan yang jelas. te m a k e e n a m a d a l a h m i t o s a t a u kepercayaan tentang hubungan seksual saat hamil. hasil mitos atau kepercayaan berdasarkan wawancara ke-5 informan berbeda dengan literatur yang didapat peneliti. literatur yang didapat bahwa mitos atau kepercayaan suku jawa berhubungan seksual saat hamil harus sering dilakukan, sedangkan informan menjawab tidak boleh dilakukan. mitos atau kepercayaan informan tersebut tidak dilakukan karena dilihat dari beberapa pernyataan, bahwa walaupun mitos atau kepercayaan mereka melarang untuk berhubungan seksual tapi mereka tetap melakukannya. simpulan dan saran simpulan persepsi seksualitas ibu hamil di puskesmas pondok aren tanggerang sudah cukup baik. hal ini didapat dari data semua informan mengatakan bahwa hubungan seksualitas adalah hubungan yang dilakukan suami istri, hubungan badan yang menggunakan badan atau anggota tubuh untuk mencapai suatu kepuasaan yang dirasakan para pasangan. perubahan hubungan seks saat hamil meliputi perubahan frekuensi hubungan seks saat hamil, perubahan hasrat keinginan ibu hamil hingga hasrat suami, dan sampai keluhan fi sik yang dirasakan ibu hamil yang berdampak pada hubungan seksnya. pada trimester pertama atau awal-awal kehamilan umumnya tidak melakukan hubungan seks karena libido menurun, tubuh belum dapat beradaptasi dengan perubahan fi sik yang dirasakan. pada trimester ke-2, umumnya frekuensi hubungan seks naik kembali karena libido mulai muncul kembali, tubuh sudah dapat beradaptasi dengan perubahan yang dialaminya. dan pada trimester ke-3 umumnya turun kembali karena ibu hamil sudah merasakan kelelahan pada perut yang sudah membesar. posisi hubungan seks dipengaruhi oleh tuanya usia kehamilan, bila usia tua umumnya ibu hamil lebih memilih posisi di atas suami agar dapat mengontrol kedalaman penetrasi. keluhan fisik sangat berpengaruh dalam melakukan hubungan seksnya seperti mual pada saat hubungan seks, pinggang terasa pegal dan sakit, tidak nyaman karena perut tertekan dan menjadi sesak nafas. perhatian suami pada saat istri hamil ditunjukkan dalam bentuk peduli kondisi istri, pemenuhan nutrisi, memanjakan istri, sentuhan mesra suami. perubahan yang diperlihatkan suami dari mulai melarang istri pergi terlalu jauh tanpa didampinginya, takut istri terjatuh dari tangga, dan tidak ingin istri kecapean dalam mengurus rumah tangga. mitos atau kepercayaan para informan yang bervarian dan sangat membawa anggapan bahwa ibu hamil di puskesmas pondok aren tanggerang masih menjujung tinggi nilai leluhur dari suku jawa. ibu hamil yang jurnal ners vol. 6 no. 1 april 2011: 76–84 84 mempercayai bahwa bila sedang hamil tidak boleh melakukan hubungan karena akan terjadi hal yang dapat membahayakan bayi. saran belum banyak penelitian di indonesia tentang aspek seksualitas terutama di masa kehamilan, sehingga perlu dikembangkan penelitian lebih lanjut. seksualitas dari sisi suami belum tergali banyak dalam penelitian ini, sehingga implikasi penelitian selanjutnya agar mengeksplorasi lebih jauh tentang pengalaman seksualitas suami saat istri hamil. diharapkan penelitian yang terus dikembangkan akan meningkatkan khasanah keilmuan keperawatan. daftar pustaka alfi ben, wiknjosastro, dan elvira, s.d., 2000. efektivitas peningkatan dukungan suami dalam menurunkan terjadinya depresip postpartum. majalah obstetri ginekologi indonesia. bitzer, j., dan alder, j., 2000. sexuality during pregnancy and the postpartum period. journal of sex education and therapy. bobak, lowdermilk, dan jensen, 2005. keperawatan maternitas. jakarta: egc. de judicibus, m.a., dan mccabe, m.p., 2002. psychological factors and sexuality of pregnant and postpartum women. the journal of sex research. eisenberg, a., murkoff, h.e., dan halloway, s.e., 2009. kehamilan apa yang anda hadapi bulan perbulan. edisi ke-4. jakarta: egc. 2009. fogel, c.i., dan lauver, d., 2000. sexual health promotion. philadelphia: saunders. kelly, g.f., 2001. sexuality today the human perspective. new york: the dushkin publishing group inc. holloway, immy, dan stephanic, 2004. qualitative research for nurses. united kingdom: blackwell science. harvey, h., wenzel, a., dan sprecher, s., 2004. the handbook of sexuality in closerelationship. now. jersey: law rence eribaum associates, inc publisher. lestari, s., dan anganthi, n., 2008. pola komunikasi seksualitas pada pasangan suami istri. journal ilmiah psikologis indigeneous. pangkahila, w., 2001. seks yang indah. jakarta: penerbit buku kompas. saifudin, a.b., 2002. diagnosa kehamilan, buku panduan praktis pelayanan kesehatan maternal dan neonatal. jakarta: yayasan bina pustaka. stoppard, m., 2008. buku pintar kehamilan dan persalinan modern. yogyakarta: kdt. sukri, s.s., dan sofwan, r., 2001. perempuan dan seksualitas dalam tradisi jawa. yogyakarta: gama media. walsh, i.p., 2001. midwifery community based care during the childbearing. london: wb sauders company. wiknjosatro, h., et al., 2002. ilmu kebidanan. jakarta: yayasan bina pustaka sarwono prawiroharjo. authors index volume 16 nomor 2 october 2021 abishek, b. joshua steve, 188 noviana, ulva, 193 aini, nurul, 193 nugroho, aditya budi, 128 anggraini, rima berti, 135 oba, nongnut, 169 benjamin, lizy sonia, 188 pansuwan, kornkarn, 119 chutipanyaporn, navarat, 169 poddar, sandeep, 193 dewi, yulis setiya, 188 prasetyo, yoyok bekti, 188 efendi,defi, 101 pujiyanto, tri ismu, 162 ekawati, heni, 193 puspasari, jehan, 111 fitria, dian, 111 rachmawati, praba diyan, 105 fitryasari, rizki, 148 rummy, nur sayyid j, 105 hasinuddin, m, 193 rusana, rusana, 193 indarwati, retno, 128 rustina,yeni, 101 khadijah, siti, 142 sari, dian, 101 klankhajhon,sirikanok, 119 shari, weni widya, 155 klayjan, kanokon, 119 sivaram, priya, 188 krisnana, ilya, 106 sujianto, untung, 183 kurnia, iqlima dwi, 105 tristiana, rr dian, 142, 148 lestari, puspita hanggit, 111 wahyuni, sylvia dwi, 128 maryana, maryana, 135 wulaningsih, indah, 162 merbawani, raras, 177 yani, lasiyati yuswo, 177 munfadlila, asef wildan, 177 yunitasari, esti, 142 nensat, nannaphat, 119 yusuf, ah, 142, 148 nihayati, hanik endang, 142 subject index volume 16 nomor 2 october 2021 a h addiction; 148 handwashing compliance; 135 adolescent; 106 health risk; 106 aerobic exercise; 183 hiv; 183 hypertension; 169 b behaviour; 177 i iron deficiency anemia; 119 c caring; 128, 162, 193 k cd4 count; 183 knowledge; 155, 177 child; 193 college students; 142 n commitment; 148 newborns; 101 covid 19 pandemic; 188 nurse; 169 covid-19; 111, 155 nurses’ role experience; 162 nursing diagnosis; 101 d nursing implementation; 135 depression; 183 nursing student; 111 nursing; 188 e nutrition education; 177 e-learning; 188 experience; 128 o older adults; 128 f online clinical learning; 111 five moments; 135 online education; 188 g p gestational diabetes mellitus; 162 pandemic; 193 grandchildren with special needs; 128 parent; 193 parent-child relation; 106 t patients; 162 team management; 169 pregnant women; 119 teenagers; 148 prevention behavior; 155 teenagers’ thinking; 148 psychosocial; 193 thailand; 169 s u safety smartphone’s use; 148 university students; 188 sexual behavior; 106 special care nursery; 101 spiritual problem solving web-based; 142 suicide risk prevention; 142 1 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 author information pack update: march 5, 2020 please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing 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to systematic review papers. policy concerns of this journal are as follows: fundamentals of nursing, management in nursing, medical-surgical nursing, critical care nursing, emergency and trauma nursing, oncology nursing, community health nursing, occupational health nursing, mental health nursing, holistic nursing, geriatric nursing, family nursing, maternity nursing, women's health nursing, pediatric nursing, education in nursing, nursing policies, legal nursing, advanced practice nursing, and nursing informatics https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing https://drive.google.com/file/d/0b5ormcrmctnwq0dix2dictffdlk/view?usp=sharing 2 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam m.nurs. (hons), (scopus id: 56660628500; h-index: 4); faculty of nursing, universitas airlangga, indonesia international advisory board reviewers 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740; h-index: 13); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200; h-index: 10); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, (scopus id: 8293647300; h-index: 12); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172; h-index: 2); college of nursing, university of the philippines manila, philippines 5. dr. nicola cornally, (scopus id: 36982904800; h-index: 13); school of nursing and midwifery, university college cork, ireland 6. dr. david pickles, (scopus id: 57190150026; h-index: 5); college of nursing & health sciences, flinders university, south australia, australia 7. dr. farhan alshammari, (scopus id: 57192298773; h-index: 3); college of nursing, university of hail, saudi arabia 8. dr. patricia leahy-warren, (scopus id: 55954181800; h-index: 11); school of nursing and midwifery, university college cork, ireland 9. dr. wendy abigail, (scopus id: 24467540600; h-index: 3); school of nursing and midwifery, flinders university, australia 10. dr. chong mei chan, (scopus id: 57189591887; h-index: 2); dept. of nursing faculty of health science, university of malaya, malaysia 11. dr. sonia reisenhofer, (scopus id: 16310818100; h-index: 4); school of nursing and midwifery, la trobe university, australia, australia editor: 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100; h-index: 3); faculty of nursing, universitas airlangga, indonesia 2. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756; h-index: 1); faculty of nursing, universitas airlangga, indonesia, indonesia 3. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 4. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); faculty of nursing, universitas airlangga, indonesia 5. laily hidayati, s.kep., ns., m.kep., (scopus id: 57202743375); faculty of nursing, universitas airlangga, indonesia 3 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 assistant editor: 1. hidayat arifin, s. kep., ns., (scopus id: 57211333166); faculty of nursing, universitas airlangga, indonesia 2. masunatul ubudiyah, faculty of nursing, universitas airlangga, indonesia 3. dluha maf'ula, faculty of nursing,. universitas airlangga, indonesia 4. rifky octavia pradipta, s.kep., ns, faculty of nursing, universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., (scopus id: 57201187775); faculty of nursing, universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, 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systematic reviews systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on mailto:secretariat_jurnalners@fkp.unair.ac.id http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 4 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 apriori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and meta-analyses will be dealt with as original articles are, as far as the editorial process is concerned. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should 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characteristics). • results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals. • conclusions: should relate to the study aims and hypotheses. • keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. acknowledgment (optional). 5 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below: • observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reporting guidelines/strobe/ • qualitative studies coreq consolidated criteria for reporting qualitative research, 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http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 6 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and post publication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: ………………………………………………………………………………………………….. f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. 7 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 title page example modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): mailto:ah-yusuf@fkp.unair.ac.id http://orcid.org/0000-0002-6669-0767 mailto:hanik-e-n@fkp.unair.ac.id mailto:krisna-e-k-2015@fkp.unair.ac.id https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 8 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 9 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: 𝐇′ = − ∑𝑠 (𝑃𝑖)(log2 𝑃𝑖) ....................................................................................................................... (1) 𝑖=1 remarks: .............................................................................................................................................. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old age groups (years) type of care <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 10 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. https://www.mendeley.com/guides/harvard-citation-guide http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf 11 | a u t h o r i n f o r m a t i o n p a c k m a r c h 5 , 2 0 2 0 vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author, • hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language. • have read the final version of the manuscript and responsible for what is said in it. • have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website. • hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below. • acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk 33 determinant factors of vasectomy method selection esti yunitasari, retnayu pradanie, hardiansyah hardiansyah faculty of nursing universitas airlanggakampus c, mulyorejo, surabaya, telp/fax: (031) 5913754, email: esti-y@fkp.unair.ac.id abstract introduction: the level of male participation in family planning by choosing vasectomy in east lampung region pekalongan health centres is still low, although the success rate of vasectomy as a family planning method is very high. this study aims to explain the factors related to men’s choice of vasectomy in the pekalongan health center east lampung. methods: this study used an analytical study design with a cross-sectional approach. samples were 117 men of reproductive age gathered using purposive sampling. the independent variables were knowledge, attitudes, parity, age, availability of health resources and infrastructure, health education, attitude and behaviour of health care workers and family support. the dependent variable was the men’s participation in vasectomy as a family planning method. data were retrieved using questionnaires and statistically analysed using the chi-square test. results: factors affecting the selection of vasectomy as a family planning method amongst men of reproductive age were attitude (p=0.020), parity (p=0.022), age (p=0.021), the availability of health resources and health infrastructure (p=0.018), and family support (p=0.011). however, the knowledge, health education, and the attitudes and behaviour of health workers did not affect the selection of vasectomy as a family planning method. conclusiom: public health centres are expected to build family planning services, especially for vasectomies, through, for example, the provision of vasectomy facilities which can reach the community and the establishment of cadres for male birth control. keywords: family planing; vasectomy; lawrence green __________________________________________________________________________________________ introduction population problems in indonesia include a large population with a relatively high rate of population growth. the indonesian population and family planning agency (bkkbn) has a role in increasing the use of contraception (badan kependudukan dan keluarga berencana indonesia (bkkbn) 2016). some family planning institutions are oriented towards contraceptive use in women rather than in men, but the results of contraceptive method surveys in various countries show that 50% of couples use condoms and vasectomies as contraceptives (anderson & baird 2002). some women cannot use contraception due to their health condition, so many men take over to use contraception to prevent unintended pregnancies (amory 2016). male participation is one of the indicators of success for a contraception program in creating a small family with qualities. the participation of the male/husband could be direct or indirect. direct participation is using a contraception method such as a condom, vasectomy, coitus interruptus, or the periodic abstention method (bkkbn 2005). in indonesia, the achievement of family planning goals for participants with long-term contraception methods (vasectomy, tubectomy, implant and intra uterine device (iud)) in 2015 is very high, exceeding the target that has been set at 103.9% (bkkbn 2016). males who actively followed the contraception program and preferred to choose a vasectomy were 148,560 persons in total (11.9%), and there were 1,099,380 other persons (89.1%) using a condom as contraception (bkkbn 2015). data from bkkbn (2014) in lampung province show that 86 persons have chosen a vasectomy from a total of 47,268 males who joined the active contraception program, while the number of males who used a condom as contraception reached 20,068. based on these data, it was revealed that the east lampung regency had the lowest number of males using vasectomy – three persons out of 10 members who were eligible for vasectomy contraception. pekalongan has the highest number of men of reproductive age in the east lampung regency, but the presentation of vasectomy contraceptive participation was only 2.3% of the total number of men using contraceptives. the majority of those were located in sidodadi, part of a community health centre at pekalongan (pekalongan, 2015). vasectomy is one effective method of contraception, as seen from the high success rate, that it is safe and has no longmailto:esti-y@fkp.unair.ac.id jurnal ners vol. 12 no. 1 april 2017: 33-40 34 term side effects (chang et al. 2015). the cost for vasectomy is relatively cheap and affordable, and, additionally, many men are eligible to use vasectomy. however, men still prefer to use other contraceptive methods such as condoms (bkkbn, 2015). men who use condoms argue that condoms are simpler and require no action from medical staff, are available in stores, pharmacies, leave them free to choose, and do not interfere with sexual intercourse. but, in fact, condoms can not be used in the long term, there is still a risk of leakage, discomfort during sex, and they can reduce the sensitivity of the penis (tejo, 2009). factors related to the use of vasectomy are still not known. based on that phenomenon this study aims to determine the factors related to the selection of vasectomy as a contraceptive method amongst men of reproductive age in pekalongan east lampung. method this study was an analytical study with a cross sectional design. the population in this study were men of reproductive age who actively use contraception in puskesmas pekalongan east lampung regency. samples were 117 respondents selected using a purposive sampling technique, often called judgment sampling. the independent variables in this study were the knowledge, attitudes, number of children, age, availability of health resources and infrastructure, health education, attitude and behaviour of health care workers, and family support. the dependent variable was the selection of vasectomy. the research instrument used questionnaires that were composed based on the theory dependant on the study variables. the questionnaire’s validity and reliability were tested first before they were used for data collection. data obtained were then processed using a descriptive analysis and chisquare data analysis with 95% significance (α≤0.05). this study has been through the ethical clearance test at the faculty of nursing universitas airlangga with a serial number 287-kepk. results the number of men who chose vasectomy as a method of contraception in this study was lower when compared with the number of men who chose another male contraceptive method. the correlation between knowledge and vasectomy selection amongst the men is described in table 1. the majority of respondents had a sufficient level of knowledge. the chi-square analysis test demonstrated that there was no correlation between knowledge and vasectomy selection. the attitude of the respondents either in the vasectomy and non-vasectomy group were mostly in a positive category. respondents who participated as vasectomy acceptors had a positive attitude; it was higher than in the nonvasectomy group. non-vasectomy respondents had a negative attitude. this means that there was a correlation between attitude and vasectomy selection as shown by the statistical test (table 2). the number of children was usually a factor that could be a consideration in choosing the contraceptive method. most respondents had more than three children (69.2%). this statement was supported by the chi-square statistical test which was obtained showing that there was a correlation between the number of children and vasectomy selection (p=0.022) (table 3). table 1 the correlation of knowledge and vasectomy selection using a chi-square test participation in contraception total % non vasectomy % vasectomy % knowledge good 15 12.8% 10 8.5% 25 21.4% sufficient 36 30.8% 37 31.6% 73 62.4% low 10 8.5% 9 7.7% 19 16.2% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.652 determinant factors of vasectomy (esti yunitasari, et. al.) 35 table 2 the correlation of attitude and vasectomy selection using a chi-square test participation in contraception total % non vasectomy % vasectomy % attitude negative 37 31.6% 21 17.9% 58 49.6% positive 24 20.5% 35 29.9% 59 50.4% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.020 table 3 the correlation between the number of children with vasectomy selection participation in contraception total % non vasectomy % vasectomy % parity 2 children 25 21.4% 11 9.4% 36 30.8% more than 3 36 30.8% 45 38.5% 81 69.2% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.022 table 4 the correlation of age with vasectomy selection participation in contraception total % non vasectomy % vasectomy % age less than 30 15 12.8% 4 3.4% 19 16.2% more than 30 46 39.3% 52 44.4% 98 83.8% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.021 table 5 the correlation of health resources and infrastructure availability with vasectomy selection participation in contraception total % non vasectomy % vasectomy % health resource and infrastructure negative 35 29.9% 19 16.2% 54 46.2% positive 26 22.2% 37 31.6% 63 53.8% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.018 table 6 the correlation of health education with vasectomy selection participation in contraception total % non vasectomy % vasectomy % health education never 47 40.2% 36 30.8% 83 70.9% ever 14 12.0% 20 17.1% 34 29.1% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.188 jurnal ners vol. 12 no. 1 april 2017: 33-40 36 table 7 the correlation of attitude and behaviour of health workers with vasectomy selection participation in contraception total % non vasectomy % vasectomy % attitude and behaviour negative 18 15.4% 9 7.7% 27 23.1% positive 43 36.8% 47 40.2% 90 76.9% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.133 table 8 the correlation of family support with vasectomy selection participation in contraception total % non vasectomy % vasectomy % family support negative 35 29.9% 18 15.4% 53 45.3% positive 26 22.2% 38 32.5% 64 54.7% total 61 52.1% 56 47.9% 117 100% statistical test chi-square p=0.011 the most common age of respondents who participated in choosing a vasectomy as contraceptive method was more than 30 years old (44.4%), while in the non-vasectomy group the number of respondents who were older than 30 totalled 39.3%. the results of the correlation analysis using the chisquaresquare statistical test revealed the significant value of p=0.021, which means that there was a relationship between age and vasectomy selection (table 4). the availability of health resources and infrastructure both in the vasectomy and nonvasectomy group were in a positive category (53.8%). respondents who participated in the vasectomy group had positive health resources and infrastructure (31.6%), while in the nonvasectomy group the percentage was only 22.2%. the results of the chi-square test obtained the significant value of p 0.018, which means there was a relationship between health resources and infrastructure, and vasectomy selection (table 5). based on table 6, the majority of respondents (70.9%) never received health education about contraception, especially vasectomy. however, the number of respondents in the vasectomy group who did totalled 47.9%. this indicates that health education did not have a significant effect on the selection of contraceptive method as shown by a statistical test using chi-square which had p=0.188. the majority of health workers already had a positive attitude and behaviour (76.9%). however, this fact was not the dominant factor affecting the decision of the respondents to choose a particular contraceptive method. it can be seen from the results of a statistical test using chi-square that there was no correlation between attitude and behaviour of health workers with vasectomy selection with p=0.133 (table 7). the last factor considered in this study in correlation with vasectomy selection method was family support. table 8 showed that 35 (29.9%) respondents mentioned that they had negative family support in choosing a contraceptive method, in the non-vasectomy group, while 38 (32.5%) respondents in the vasectomy group had positive family support. this number indicated that respondents who had selected vasectomy as their contraception had higher positive family support than those in the non-vasectomy group. by using a chisquare test, the p-value was 0.011, meaning that family support was a contributory factor in respondents choosing to participate in a vasectomy or not. determinant factors of vasectomy (esti yunitasari, et. al.) 37 discussion the knowledge level of respondents about vasectomy was at an insufficient level. this might be due to the level of education of many respondents who had junior and senior high school levels of education. the vasectomy method is usually used by men who have a good level of education (wespes 2014). the results of a study in taiwan showed that men who chose vasectomy had a high education (68,5% had graduate degrees) (chang et al. 2015). according to mubarak (2007) the higher level of education could mean the information is more easily transferred and received, and ultimately the more knowledge could be gained. conversely, if the level of education is low, it will hinder the development of one's attitude to receiving information and newly introduced values. however, the number of non-vasectomy respondents was higher than respondents who participate actively by using vasectomy and there were still some respondents who had good knowledge but did not participate in vasectomy. this means that the level of knowledge does not guarantee a person will commit an act or demonstrate a type of behavioural health. skinner (1938) in notoatmodjo (2012) stated that behaviour is a person's reaction to a stimulus from the outside, but in responding, it depends on the characteristics or other factors of the person concerned. this means that even though the stimulus is the same for some people, the response of each person is different. this can also be caused by misunderstandings and negative rumours about vasectomy that causes a person to be reluctant to choose a vasectomy (bunce, a., guest, g., searing, h., frajzyngier, v., riwa, p., kanama, j.,achwal 2007). there were respondents who had a low level of knowledge who participated actively in vasectomy. this can occur as a result of a persuasive family planning program from the government, so that whoever participates in using a vasectomy will be given money, so even though respondents have less knowledge, they still participate in a vasectomy program. from the analysis, there was no correlation between knowledge and the selection of vasectomy. this means that a good knowledge of vasectomy does not affect a man’s decision to choose a vasectomy. the results of this study are supported by other studies which suggest that income, knowledge, age and attitude of public figures does not affect the use of vasectomy contraception (muklison 2015). the results of the study in the distribution frequency of attitudes towards vasectomy selections showed that more respondents had a positive attitude than a negative one. a positive attitude towards vasectomy is determined by respondents' votes for vasectomy themselves. a positive attitude arises from positive beliefs. the total number of respondents who had a positive attitude mostly used vasectomy rather than nonvasectomy, but those who had a negative attitude mostly did not participate in using vasectomy. attitude is a reaction or response which was still closed from one to a stimulus or object (notoatmodjo 2012). according to allport in notoatmodjo (2012) components that are built into attitude are: 1) faith (belief), ideas and concepts, to an object; 2) the emotional life or evaluation of an object; 3) the tendency to act. thus, a person's belief or conviction about an object affect the action to be performed. the analysis of attitude in relation to vasectomy selections showed that there were respondents who had a positive attitude but did not use vasectomy, as well as respondents who had a negative attitude but participated actively in vasectomy. this happens as a result of the government's program on vasectomy in east lampung. there are two kinds of community participation methods according to notoadmojo (2012): participation by coercive means to force the public to contribute to the program (through legislation, regulations or verbal commands), then, secondly, participation by persuasion and education. positive trust will form a positive attitude. furthermore, a positive attitude develops a person's tendency to act positively as well. if someone has negative beliefs or a negative concept, it will form a negative attitude then create a difficulty to act positively. on the other hand, the number of children could be one of the factors that affected men’s decisions to participate in vasectomy selection. in indonesia, the number of children is often related to economic status. jurnal ners vol. 12 no. 1 april 2017: 33-40 38 most respondents worked as farmers and had a low income per month. pratiwi in her research (2011) mentioned that family income was an indicator of economic factors, and affects the number of children born to a family. respondents who have more than three living children have a tendency to more actively participate in vasectomy than respondents who have two children. this is because vasectomy is more effective than other types of contraceptive method for men so that respondents prefer to choose vasectomy to terminating a pregnancy. the effectiveness of vasectomy is in the range between 99.6%– 99.8%; it is very safe and has no long term side effects, only once it is applied, it is effective in the long term, and cost efficient (saifuddin et al. 2010). there was a correlation between the number of children and vasectomy selection. this means that respondents who had more than three children had more of a tendency to participate in the selection of vasectomy, than those who had two children. the results of this study are supported by arsila’s research (2014) which stated that there is a relationship between the number of children and the decision to use birth control. in another study, couples with a low number of living children had a tendency to use contraceptive methods with low effectiveness, while couples with many living children had a tendency to use high effectiveness contraceptive methods (purwoko 2000). this is supported by the research results that the increasing use of vasectomy is due to the increasing number of children and increasing age (sharma et al. 2013). the other factor that had a correlation with the selection of a vasectomy was age. there were respondents who had two children and used vasectomy; this is probably due to the age of the respondents. according to manuaba (2009), the age of 35 or more is the time for terminating reproduction. this statement is also concordant with the age range of the vasectomy group for this research. participants who are 30 years old or more tend to use the long-term effectiveness of contraception. the frequency distribution of health resources and infrastructure availability showed that more respondents positively assess health infrastructure. this indicates that most respondents have easy access to a vasectomy. but from the questionnaire, analysis showed that more respondents answered that there is no place to get a vasectomy around their home, as well as a few respondents who get explanation about vasectomy. the availability of health resources and health infrastructure affects the tendency to participate in vasectomy. it was common that the respondents did not participate in vasectomy due to the unavailability of resources and infrastructure. healthcare is one of the parameters for determining the health status of the community (tangkilisan et al. 2015); also, ariyanti (2016) in her study said that the availability (quantity and distribution) of health resources contributes towards achieving family planning programs. lawrence green (1991) in nursalam (2013) also stated that one of the factors that influences health behaviour is the availability of health resources and infrastructure. so, the quality of access to family planning services is one important element in achieving reproductive health services (saifuddin 2010). another fact obtained through this study is that the majority of respondents did not ever receive health education about contraception or vasectomy. this is because the majority of respondents worked as farmers, with most of their time spent on agricultural land when health centre services were open so that most respondents could not get health counseling. respondents who had no health education about vasectomy showed a lack of information about vasectomy, which causes the respondents to tend to avoid vasectomy. however, based on the result, a high level of knowledge about birth control and vasectomy after getting health education does not guarantee a person will participate actively in vasectomy. the expected outcome of health promotion is a change in health behaviours, or behaviour to maintain and improve health levels (notoatmodjo 2012). although many respondents said that they never got health education, the majority agreed that health workers already had a positive attitude and behaviour. the attitudes and behaviours response of the health workers was reflected in the questionnaire in which most respondents said that health workers are kind to explain vasectomy. attitudes and behaviour of health workers affects whether determinant factors of vasectomy (esti yunitasari, et. al.) 39 the client follows the advice given by health workers (notoatmodjo 2003). but, the statistical result showed something different. it showed that health care attitude and behaviour had no correlation with vasectomy selection. this might indicate that the most important things to come out of the performance of a health care provider are real action, how to stimulate awareness of health among the community, not just exhibiting a kind attitude and behaviour. the last factor obtained as a factor that affects a man’s decision to use vasectomy was family support. based on the answers to the questionnaire, respondents agreed that planning the number of children was part of the family’s emotional support. men who still had minimal support from the family cited informational support. lack of information support was given by the families because they lacked knowledge and there were many respondents from a low social economic level. according to putri et al. (2016) family support was affected by a family's ability to cover what they need. the family fulfillment capabilities related to income level or a family’s socioeconomic level, where families from a higher socio-economic level give better family support. family support, according to friedman (2010), is an attitude, a family perception towards other members, with information, appraisal, instrumental and emotional support. these types of support are what categorise family support received by respondents. this study found that respondents who get good support from families participate more actively in vasectomy. if the respondent does not get the support and consent from his wife, vasectomy is not done. family support is indicated by a form of interpersonal relationship which includes attitudes, actions, and acceptance of family members so that the family members feel comfort (friedman 2010). the results of this study are supported by previous studies conducted by widoyo (2010) and muklison (2015) where there is a significant correlation between family support (wife) and vasectomy selection. limitations of this study are that most of the respondents are people who participate in government programs. the program is a mass vasectomy program that aims to launch the vasectomy program in the east lampung regency. conclusion attitude, the number of children, age, health resources and infrastructure availability and family support are factors that affect men’s decisions to select vasectomy, while knowledge, health education, attitude and behaviour of health workers are not factors for someone to participate in vasectomy. nurses are expected to arrange interventions to increase men’s interest and motivation to participate in vasectomy actively. the intervention also needs to be complemented with affordable facilities and active cadres engagement. references amory, j.k., 2016. male contraception. fertility and sterility, 106(6), pp.1303– 1309. available at: http://linkinghub.elsevier.com/retrieve/pii /s0015028216627449 [accessed october 13, 2016]. anderson, r.a. & baird, d.t., 2002. male contraception. endocrine reviews, 23(6), pp.735–762. available at: https://oup.silverchaircdn.com/oup/backfile/content_public/jo urnal/edrv/23/6/10.1210_er.20020002/3/edrv0735.pdf?expires=14975123 14&signature=owvyjlwhfq011scxy ugv8qkxx8jtatm4z3uizxddol12j y8afniog9dqq6rhprctd7i3pbyakv z079hrvx7ua8rdvvci2efevlcngi0tevymxkx [accessed september 11, 2016]. badan kependudukan dan keluarga berencana indonesia (bkkbn), 2016. laporan kinerja bkkbn tahun 2015, jakarta: badan kependudukan dan keluarga berencana indonesia (bkkbn). available at: https://www.bkkbn.go.id/pocontent/uploads/lakip_bkkbn_2016_ 1.pdf [accessed september 27, 2016]. bunce, a., guest, g., searing, h., frajzyngier, v., riwa, p., kanama, j., achwal, i., 2007. factors affecting vasectomy acceptability in tanzania. international family planning perspectives, 13(1). jurnal ners vol. 12 no. 1 april 2017: 33-40 40 available at: https://www.guttmacher.org/sites/default/ files/pdfs/pubs/journals/3301307.pdf [accessed october 18, 2016]. chang, y.-h. et al., 2015. economic fluctuation affects vasectomy utilization: a?single-institution study. urological science, 26(3), pp.214–217. available at: http://linkinghub.elsevier.com/retrieve/pii /s1879522615002298 [accessed october 15, 2016]. friedman, m.m., 2010. buku ajar keperawatan keluarga : riset, teori dan praktek. jakarta: egc. manuaba, i.a.c., 2010. ilmu kebidanan, penyakit kandungandan kb: untuk pendidikan bidan. jakarta: egc. mubarak, w., 2007. buku ajar keperawatan komunitas. jakarta: cv. sagung seto. muklison, a.p., 2015. faktor-faktor yang mempengaruhi masyarakat dalam menggunakan kontrasepsi vasektomi di kabupaten tulungagung. swara bhumi, 1, 51–57. notoatmodjo, s., 2003. promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta. notoatmodjo, s., 2012. promosi kesehatan dan perilaku kesehatan (1st ed.). jakarta: rineka cipta. nursalam, 2013. metodologi penelitian ilmu keperawatan: pendekatan praktis (3rd ed.). jakarta: salemba medika. pekalongan, p., 2015. laporan profil puskesmass pekalongan. lampung timur. pratiwi, n., 2011. pengaruh faktor sosial, ekonomi, dan demografi terhadap jumlah anak yang pernah dilahirkan hidup di kecamatan pesantren kota kediri. surabaya. purwoko, h., 2000. perbandingan penerimaan antara akseptor vasektomi dan akseptor sterilisasi tuba. undip. putri, m.a., 2016. psycoeducative family therapy mempengaruhi pengetahuan, dukungan keluarga dan stigma kusta. jurnal ners, 11, 88–98. saifuddin, a.b., 2010. buku panduan praktik pelayanan kontrasepsi. jakarta: yayasan bina pustaka sarwono prawirohardjo. sharma, v. et al., 2013. vasectomy demographics and postvasectomy desire for future children: results from a contemporary national survey. fertility and sterility, 99(7), pp.1880–1885. available at: http://www.sciencedirect.com/science/art icle/pii/s0015028213003233 [accessed november 11, 2016]. wespes, e., 2014. vasectomy in male contraception and its reversal. european urology supplements, 13, pp.68–72. available at: http://ac.elscdn.com/s1569905614000190/1-s2.0s1569905614000190main.pdf?_tid=657ae40e-54cc-11e78c1200000aab0f6c&acdnat=1497862431_6b3 31f8ad75e07aa780646f18b0f2184 [accessed october 19, 2016]. tangkilisan, m., 2015. peran sarana pelayanan kesehatan terhadap kejadian malaria di kecamatan silian raya kabupaten minahasa tenggara. universitas sam ratulangi. tedjo, l., 2009. faktor-faktor yang mempengaruhi pemilihan kontrasepsi yang digunakan pada keluarga miskin. universitas diponogoro. widoyo, r., 2010. faktor yang mempengaruhi pemilihan vasektomi sebagai metode kb pria di kecamatan luhak nan duo kabupaten pasaman barat tahun 2010. universitas andalas. 70 http://e-journal.unair.ac.id/jners © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 70-77 http://dx.doi.org/10.20473/jn.v18i2.43770 original article open access gabra6 and slc6a4 genotypes are correlated with the fasting blood glucose and physical fitness in the seemingly healthy young adults viskasari p. kalajanti 1 , mariana wahjudi2 , kusuma e. purwantari 1 , visuddho 1 , peppy nawangsasi 3 , rury t. oktariza 4 , krisnawan a. pradana 1 , dzanuar rahmawan 5 , and bambang e. suwito 6 1 faculty of medicine, universitas airlangga, surabaya, indonesia 2 faculty of techbiology, university of surabaya, surabaya, indonesia 3 faculty of medicine, university of hang tuah, surabaya, indonesia 4 faculty of medicine, university of muhammadiyah palembang, palembang, indonesia 5 institut ilmu kesehatan bhakti wiyata, kediri, indonesia 6 faculty of medicine, university of nahdlatul ulama surabaya, surabaya, indonesia *correspondence: viskasari p. kalajanti. address: faculty of medicine, universitas airlangga, surabaya, indonesia. email: viskasari-p-k@fk.unair.ac.id responsible editor: laily hidayati received: 28 february 2023 ○ revised: 29 march 2023 ○ accepted: 29 march 2023 abstract introduction: we examined environmental and genetic factors potentially correlated with the blood glucose and physical fitness in kediri, east java, indonesia to elucidate the predominant cardiovascular disease risk. methods: this was a cross-sectional study on 68 adults aged 18-22 years. direct interview was conducted to get socio-economy, daily diets (rice/ r, snacks and sweets/ ss, veggies and fruits/ vf), daily activity (locomotors and nonlocomotors) data. peripheral blood-gabra6 and slc6a4 polymorphisms, fasting blood glucose (fbg), blood pressure, 3 fitness parameters (1 min push-up, 3 minutes step up, pulse rate after 3 minutes step-up) were measured by 2 independent and pre-trained medical doctors. kruskal-wallis, chi-square, and eta-coefficient tests were used to seek differences between genotypes and correlation strength between variables, respectively (significant if p<0.05). results: both gene’s genotypes showed significant correlations with the fbg (p=0.042, p=0.013, respectively); gabra6 polymorphism significantly correlated with su (p=0.033). there was a significant difference in the fbg between 2 vf subgroups (p=0.02). strongest association was found between fbg and slc6a4 (η=0.3); pr and gabra6 (η=0.168), pu and slc6a4 (η=0.38); su and locomotors (η=0.237). conclusions: in these seemingly healthy young adults, daily diets and the genotypes of both genes have a good association with the fbg and physical fitness levels. keywords: diabetes mellitus, fitness, gaba, health risk, serotonin introduction pre-diabetes and hypertension would increase risk to develop metabolic disease including type 2 diabetes mellitus characterized by relative decreased insulin secretion and insulin resistance that constituting for approximately more than 90% of all diabetes cases (qiu et al., 2015; hadi alijanvand et al., 2020; kalanjati et al., 2021).the prevalence of t2dm and pre-diabetes have been increased worldwide, and reported to widely associate with an increase prevalence of cardiovascular diseases (cvd) including hypertension (chia et al., 2020). the prevalence of diabetes for all age groups was https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-7005-0025 https://orcid.org/0000-0002-5861-2566 https://orcid.org/0000-0001-7416-6714 https://orcid.org/0000-0002-6780-6207 https://orcid.org/0000-0001-5817-6859 https://orcid.org/0000-0002-1087-1200 https://orcid.org/0000-0002-9124-665x https://orcid.org/0000-0002-4678-5208 jurnal ners http://e-journal.unair.ac.id/jners 71 approximately 2.8% in 2000 and will be around 4.4% in 2030 globally (hakola, 2015; hamasaki, 2016; ncd risk factor collaboration (ncd-risc), 2016). this could become a national burden, and is warranted for early detection and prevention. management of pre-diabetes and pre-hypertension including changes in lifestyle and monitoring glycaemia also sodium intake to lower the risk of developing diabetes and cvd in the later life (hamasaki 2016; kamal et al 2020; mathur et al. 2021). physical activity was reported to correlate with the levels of blood glucose (osailan et al., 2021). blood glucose also determines the health and physical fitness that normal levels would be allowing individuals to carry out daily activity without excessive fatigue. amongst many factors determining the levels of physical fitness i.e. muscular strength, endurance, and flexibility as needed to perform sit-up and push up exercises (hakola, 2015). it was reported that physical fitness can be used to assess university student’s study performance (sookhanaphibarn and choensawat, 2015). physical activity and low-carbohydrate diets improve glycemic control and decrease the risk of cvd and mortality rate in pre-diabetes patients with hypertension. moderate to high-intensity exercise is recommended in controlling the glycemic levels and increasing the insulin sensitivity, however in certain cases walking for at least 30 minutes a day has been reported to reduce the t2dm risk by approximately 50% (hakola 2015; hamasaki 2016; kam et al 2020). on the other hand, sedentary time was reported to have a close association with higher risk of diabetes and cvd incidence and mortality rate in adults (biswas et al 2015). on the other hand, the genotypes of slc6a4 (serotonin transporter gene, solute carrier family 6 member 4), which code serotonin transporters have been reported to associate with body mass index (bmi) and situation awareness performance in healthy young adults in colombia (gonzález-giraldo et al., 2018). serotonin uptake affects the mood and behavior through its work at the limbic system and hypothalamus (dunn et al., 2012; gonzález-giraldo et al., 2018). this neurotransmission accounted for appetite, autonomic signals to regulate the blood pressure, emotion and higher cortical functions related to the hypothalamus, limbic system and the prefrontal cortex (qin et al., 2018; simpson et al., 2008). in these area, gamma-amino butyric acid (gaba) has been observed to play major role as the predominant inhibitory neurotransmitter, and closely related with the stress response, specifically in obese persons (arias et al., 2012; lynch et al., 2015; rosmond et al., 2002). gabra6 (gamma amino-butyric acid type a receptor subunit alpha-6) gene polymorphism has been reported to correlate strongly with mood, anxiety and motor response; this gene encodes the gaba-a alpha-6 subunit protein receptors (han et al., 2008; garcía-martín et al., 2018). although both neurotransmissions have been shown to relate with feeding behavior, stress response and lipid deposition, their impact on the blood glucose and other determinants of cvds have yet widely explored and thus examined in the current study. the result of this study would provide evidence on the association of genetic and non-genetic determinants with the physical performance and risk factors to develop cvds in later life. materials and methods. this study was carried out in accordance with the declaration of helsinki. all participants in this study signed written informed consents and this study has been granted by the health ethical committee (no. 226/ec/kepk/fkua/2020). we conducted an observational analytic study with a cross-sectional design to analyze the daily diets and activity, biomarkers and the genotypes of gabra6 and slc6a4 with the physical fitness of 68 consented participants aged 18-22 years old javanese ethnicity males and females conducted in march-april 2020. all measurements were done in duplicate by 2 independent-pre trained medical doctors for minimizing any potential observer bias. we have done a preliminary study to ensure standard protocols can be applied thoroughly during the observation. we include participants with the current healthy condition and able, also willing to follow all protocols in this study. we exclude ones who have a history of any metabolic diseases i.e. type-2 diabetes mellitus, dyslipidemia and any cardiovascular diseases. we also exclude those with history of any major known table 1 frequency of slc6a4 and gabra6 polymorphisms gene genotype n frequency allele n frequency p chi-square test slc6a4 s/s l/s l/l 51 14 3 0.75 0.21 0.04 s l 116 20 0.85 0.15 2.19 (p>0.05) gabra6 t/t t/nt nt/nt 32 34 2 0.47 0.5 0.03 t nt 98 38 0.72 0.28 3.97 (>0.05) kalajanti, wahjudi, purwantari, visuddho, nawangsasi, et al (2023) 72 p-issn: 1858-3598  e-issn: 2502-5791 diseases i.e. any type of neoplasms, major injury and autoimmune diseases. information from each participant i.e. daily diet including approximate rice consumption (rice) in a day (100 grams, 200 grams, ≥300 grams), vegetables and fruit (veggies-fruits) inclusion in daily diet (yes or no), daily sweets and snacks (snacks-sweets) consumption (yes or no); nonlocomotors activity was measured from daily gadget usage (less than 30 minutes, 30 to 120 minutes, 120 to 240 minutes and more than 240 minutes); data of daily walking time/ locomotor (less than 45 minutes, 45 to 120 minutes, more than 120 minutes), age, family monthly income were also collected via direct interview (biswas et al., 2015; castro, macedo-de la concha and pantoja-meléndez 2017; castro-diehl et al., 2014). the age of each participant was confirmed from the data in the citizen card. blood pressure was measured in participants in sitting position prior to other tests, after 5 minutes of rest at the time of survey, using digital sphygmomanometer (hem-7121, china) after checking for the device accuracy by comparing with the measurement through a mercury sphygmomanometer. the prehypertension blood pressure was defined by 120 mmhg<sbp<139 mmhg and/ or 80 mmhg<dbp<89 mmhg. hypertension blood pressure was defined by sbp≥140 mmhg and/ or dbp≥90 or if the patient was under antihypertensive drugs (hadi alijanvand et al., 2020). the fasting blood glucose (fbg) was analyzed using the easy-touch machine (taiwan) by applying peripheral blood from the fingertip, after a 12-hour overnight fast. the fbg levels 70-100 mg/dl was classified as normal, >100-125 mg/dl was classified as pre-diabetes (chia et al., 2020; hadi alijanvand et al., 2020). the cardiovascular fitness were evaluated from the numbers of 1 minute push-up and 3 minutes step-up (pu and su, respectively) were counted with resting intervals of 60 minutes, and the pulse rate after su (pr) was measured subsequently (sookhanaphibarn and choensawat 2015). all parameters were measured by 2 medical doctors trained prior to the current study for standardized procedures. the average from two closest measurements of each variable were used. the isolated dna was obtained from 68 participants (from a peripheral blood-swab). the dna was extracted using the dna extraction kit (instagene matrix, biorad, usa). the spectroscopy was done to quantify the dna concentration (fluostar omega, bmg labtech, germany). the primer pair of slc6a4 was 5′-tcc tcc gct ttg gcg cct ctt cc-3′ and 5′-tgg ggg ttg cag ggg aga tcc tg-3′ (gonzález-giraldo et al., 2018; gonzález-giraldo et al., 2018). the primer pair of gabaa receptor subunit α6 (gabra6) was 5’-gga ggc acc agt aaa ata gac cag-3’) and 5’-aat act gaa caa tgg aag aca aaa-3’ (garcía-martín et al., 2018; rosmond et al., 2002; uhart et al., 2004). the pcr was done using 2x go taggreen master mix pcr (promega) on a thermocycler (tc-5000, techne, uk) in 20 µl of total reaction volume, contained 20 ng genomic dna as template. the pcr reaction was set as follows: predenaturation at 95◦c for 5 minutes, followed byreaction cycles of denaturation step at 94◦c for 30 seconds, and elongation at 72◦c for 40 seconds, and ended with postelongation at 72◦c for 10 minutes. for gabra6 analysis, the next step was digestion of pcr product using alwni restriction enzyme (neb) according to the neb product manual (han et al., 2008; lynch et al., 2015). the digestion fragment size was determined after separation on agarose gel. the electrophoresis was done using 12% agarose gel containing ethidium bromide, and then were visualized on the uv box (biodocanalyze, swiss). the approximate restriction table 2 characteristics of the socioeconomic, environmental and health parameters of all participants (n=68) no. variables n (%) 1 gender male 32 (47.1) female 36 (52.9) 2 age (years) 18 1 (1.5) 19 10 (14.7) 20 16 (23.5) 21 29 (42.6) 22 12 (17.6) 3 family monthly income (idr) < 2 millions 3 (4.4) 2-5 millions 46 (67.6) >5-10 millions 15 (22.1) >10 millions 4 (5.9) 4 non-genetic determinants a daily walking time (locomotors activity) <45 minutes 47 (69.1) 45-120 minutes 15 (22.1) >120 minutes 6 (8.8) b daily use of gadget time (nonlocomotors) <30 minutes 2 (2.9) 30-120 minutes 24 (35.3) 120-240 minutes 20 (29.4) >240 minutes 22 (32.4) c daily rice intake (grams) <100 24 (35.3) 100-200 29 (42.6) 200-300 15 (22.1) >300 0 (0) d daily snacks and sweets intake yes 47 (69.1) no 21 (30.9) e daily veggies and fruits intake yes 16 (23.5) no 52 (76.5) 5 blood pressure normal 48 (70.6) pre-hypertension 17 (25) hypertension 3 (4.4) 6 fasting blood glucose (mg/dl) normal 64 (94.1) pre-diabetes 4 (5.9) diabetes 0 (0) jurnal ners http://e-journal.unair.ac.id/jners 73 fragment length of gabra6 t-allele was 423 base pairs and the non-t allele were 257 and 166 base pairs; whilst the slc6a4 l-allele was 512 base pairs and sallele was 469 base pairs. fasting sub-sample for the pcr was used (±10% of population) to confirm the genotype of each polymorphism. the distribution of individual genotype and frequency of the participants and control subjects were analyzed using hardy-weinberg equilibrium calculator. kolmogorov-smirnov tests was used for normality test. differences in the blood pressure, fbg and physical fitness between slc6a4 genotypes, gabra6 genotypes, daily diets and activity subgroups were assessed using kruskal-wallis and chi-square tests. differences in genotype frequencies were assessed using the chi-square test. pearson’s’ chi-square correlation was used to measure the significance of correlation of the slc6a4 genotypes; gabra6 genotypes; daily diets and activity subgroups with the blood pressure, whilst eta-coefficient test was used to assessed the degree of association of the slc6a4 genotypes; gabra6 genotypes; daily diets and activity subgroups with the fbg and physical fitness parameters. a two-tailed p<0.05 was considered statistically significant (ibm spss statistical package version 17.0, usa). results there were 32 (47.1%) males and 36 (52.9%) females participating in this study. approximately the mean age was 20.7±0.99 years with predominant family monthly income was between 2-5 million idr (46%). daily activity of non-locomotors and locomotors mostly consisted of less than 45 minutes of walking (47%) and more than 30 minutes of using gadgets (97.1%; n=66). whereas the daily diets consisted of more than 300 grams of rice was found in 22.1% of all participants; 69.1% had snacks and sweets whilst 76.5% had not veggies and fruits in their daily routine (table 2). we observed 3 polymorphism of slc6a4 gene i.e. l/l, l/s, s/s; and 3 polymorphism of gabra6 gene i.e. (t/t, t/nt, nt/nt) (figure 1a-b). the distribution of l and s alleles of slc6a4 and of t and nt alleles of gabra6 followed the hardy-weinberg equilibrium. the frequency of l and s allele of slc6a4 was 0.15% and 0.85%, with p>0.05, respectively; whilst the frequency of t and nt allele of gabra6 was 0.72% and 0.28%, with table 3 differences in the blood pressure, fbg and physical fitness amongst slc6a4 genotypes, gabra6 genotypes, daily diets and activities subgroups groups blood pressure fbg (mg/dl) physical fitness pulse rate after 3 minute step-up count of 1 minute push-up count of 3 minute step-up p kruskalwallis p chisquare p kruskalwallis p chisquare p kruskalwallis p chisquare p kruskalwallis p chisquare p kruskalwallis p chisquare slc6a4 .996 .967 .381 .042* .592 .211 .708 .335 .594 .947 gabra6 .755 .877 .525 .013* .280 .702 .461 .956 .523 .033* locomotors .224 .266 .074 .271 .678 .902 .388 .59 .105 .051 nonlocomotors .716 .900 .431 .451 .816 .491 .753 .935 .906 .888 rice .706 .664 .200 .582 .777 .289 .795 .728 .373 .511 snackssweets .802 .473 .099 .738 .729 .393 .609 .506 .627 .635 vegies-fruits .084 .215 .016* .493 .954 .048* .648 .501 .582 .741 *p<0.05 (significant) figure 1 a-b. a representative gel of slc6a4 showed 2 distinctive alleles i.e., l-allele (~512 base pairs) and s-allele (~469 base pairs); whilst gabra6 showed 2 distinctive bands i.e., t-allele (~423 base pairs) and non-t/ c-allele (~257 base pairs). a. slc6a4 ~512 bp ~469 bp b. gabra6 ~423 bp ~257 bp kalajanti, wahjudi, purwantari, visuddho, nawangsasi, et al (2023) 74 p-issn: 1858-3598  e-issn: 2502-5791 p>0.05, respectively. the frequency of slc6a4 l/l, l/s and s/s was 0.04%, 0.21% and 0.75%, respectively; whilst gabra6 t/t, t/nt and nt/nt was 0.47%, 0.5% and 0.03%, respectively (table 1). the fasting blood glucose (fbg) was found normal in 94.1% participants, whilst 5.9% was pre-diabetes with fbg levels was ≥100 mg/dl. the blood pressure was categorized normal-tension in 70.6%, pre-hypertension in 25% and hypertension with systole/ diastole pressure was ≥140/90 mmhg in 4.4%. we found no significant differences either on the blood pressure, fbg, physical fitness [pr, pu, su], between 3 groups of slc6a4 polymorphisms (p=0.996, p=0.381, [p=0.592, p=0.708, p=0.594]), and between 3 groups of gabra6 polymorphisms (p=0.775, p=0.525, [p=0.28, p=0.461, p=523]), respectively. we found no significant differences either on the blood pressure, fbg or 3 physical fitness parameters [pr, pu, su] amongst: (1) 3 groups with different quantity of daily rice intake (p=0.706, p=0.2, [p=0.78, p=0.8, p=0.63]); (2) 2 groups of snacks and sweets daily intake (p=0.802, p=0.099, [p=0.73, p=0.61, p=0.58]); (3) 3 groups of locomotors daily activity time (p=0.224, p=0.074, [p=0.68, p=0.39, p=0.11]); and (4) 4 groups of non-locomotors daily activity time (p=0.716, p=0.431, [p=0.82, p=0.75, p=0.91]), respectively. although there were no significant differences on the blood pressure (p=0.08), or on the physical fitness [pr (p=0.95), pu (p=0.65), su (p=0.58)]; the fbg between those who include and exclude veggies and fruits from their daily diets was significantly different (p=0.02) (table 3). we found no significant correlations between slc6a4 polymorphism either with the blood pressure (p=0.97), or with the physical fitness [pr (p=0.21), pu (p=0.34), su (p=0.95)]; however significant correlation was found with fbg (p=0.042). we found no significant correlations between gabra6 polymorphism either with the blood pressure (p=0.88), or with 2 physical fitness parameters [pr (p=0.702), pu (p=0.96)]; however significant correlation was found with the su (p=0.033) and with the fbg (p=0.013). we found significant correlations between diastole and nonlocomotors activity daily (p=0.005); and between the pr and daily intake of veggies and fruits (p=0.048). however no other significant correlations were observed either between the daily diets and the blood pressure, fbg or physical fitness; or between the daily activity time and these 3 cardiovascular risk factors (table 3). the highest eta-coefficient in the fbg was shown with the slc6a4 genotypes (η=0.3); whilst in the physical fitness parameters [pr, pu, su] was with the gabra6 genotypes, with the slc6a4 genotypes and with the daily locomotors activity (η=0.168, η=0.38, η=0.237, respectively) (table 4). discussions we found that the participants of this study were university students of the same race, and came from the low to middle class of family income. we also found that several of these seemingly healthy young adults suffered from the pre-diabetes and/ or prehypertension. socioeconomic factors play a significant role to determine the utilization of healthcare and education, including cardiovascular-related preventive care (mulyanto et al., 2019; nadasya et al., 2021; ncd risk factor collaboration (ncd-risc) 2016). castro-diehl et al., (2014) reported variations in the correlations of income-wealth index and education with the cortisol levels (castro et al., 2017). in african americans race, this association tended to be strongest; it was reported that the income-wealth index showed contrast levels with the urinary stress hormones i.e. levels of cortisol, table 4. association analysis of association degree between the blood pressure, fbg and 3 physical fitness parameters either with the slc6a4 and gabra6 genotypes or with the daily diets and activities dependent variables independent variables p pearson’s chi-square test etavalue (η2) bp slc6a4 genotypes .967 gabra6 genotypes .877 rice .644 snacks_sweets .473 vegies_fruits .215 locomotors .266 non-locomotors .900 [fbg] slc6a4 genotypes .300 (.09) gabra6 genotypes .141 rice .191 snacks_sweets .203 vegies_fruits .274 locomotors .234 non-locomotors .175 pr slc6a4 genotypes .159 gabra6 genotypes .168 (.03) rice .069 snacks_sweets .064 vegies_fruits .016 locomotors .103 non-locomotors .151 pu slc6a4 genotypes .380 (.14) gabra6 genotypes .036 rice .158 snacks_sweets .132 vegies_fruits .002 locomotors .037 non-locomotors .100 su slc6a4 genotypes .109 gabra6 genotypes .134 rice .173 snacks_sweets .070 vegies_fruits .063 locomotors .237 (.06) non-locomotors .103 jurnal ners http://e-journal.unair.ac.id/jners 75 epinephrine, norepinephrine and dopamine; lower stress level was found amongst higher income-wealth group (castro et al., 2017). in our study, the genotypes of both genes showed significant correlations with the fasting blood glucose, although stronger association was shown with the slc6a4 compared to the gabra6 genotypes. we also found that slc6a4 and gabra6 polymorphism had significant correlation with physical fitness. stress response has been reported to be associated with the polymorphism of serotonin transporter gene’s polymorphism, the slc6a4. slc6a4 plays a vital role in the reuptake of serotonin in the synaptic cleft, where this neurotransmitter can be found abundance both in the brain area controlling appetite and mood, also in the intestine where the digestion process actively occurs (garcía-martín et al., 2018; gonzález-giraldo et al., 2018). mental status and motor response during various stressor induction have also been reported to correlate with the gabra6 genotypes (braat and kooy 2015; lynch et al., 2015). gabra6 is responsible for the expression of gaba-a alpha-6 receptors; this gene is located on chromosome 5q31.1-q35 (rosmond et al., 2002). by acting through this receptor, gaba (gammaamino butyric acid) might affect the hormonal control of cortisol by reducing the secretion of corticotropin releasing hormone, which in turn increases the secretion of cortisol by the adrenal cortex. gaba is the predominant inhibitory neurotransmitter in the adult mammalian brain (kalanjati et al., 2017; miller et al., 2017; qin et al., 2018). several natural diets component i.e. lithium, taurine, vitamin b6, vitamin b12 and folic acid from fermented milk products and/ or sprouts brown rice, barley and beans could raise the activity of gaba-ergic system. gene alteration in gaba-a receptors have been shown to associate widely with the neurodevelopmental disorders due to the predominant inhibition modality in adult mammalian brain (kalanjati et al., 2017; rosmond et al., 2002; uhart et al., 2004). gabra6 polymorphism correlates with abdominal obesity and cortisol secretion that leads to hypercortisolism. environmental determinants including stress produce modulation on the gaba-hypothalamicpituitary-adrenal systems in the individuals with genetic vulnerability. polymorphism of gabra6 alleles also associated with specific psychoneurological traits i.e. neuroticism, motor reflex reponse and mood disorders in women (chiriboga et al., 2008; han et al., 2008; lynch et al., 2015). arias et al., (2012) reported that neuroticism as shown as harm avoidance traits connected to the anxiety, self-consciousness, vulnerability and depression in persons with homozygous t allele in t1512c polymorphism were slightly higher than those with c allele carriers (hadi alijanvand et al., 2020). garcía-martín et al. (2018) reported that when certain dose of ethanol were induced, the polymorphism of gabra6 rs4454083 t/c amongst these individuals were related to motor times, whilst the c/c genotype showed both basal and peak ethanol concentration-faster motor times; this was proposed to be the result of certain subunit expression levels and distribution in human’s brain region (garcíamartín et al., 2018; rosmond et al., 2002; simpson et al., 2008). qiu et al., (2015) reported that hypertension withor without pre-diabetes increased the chance to suffer from cvds and t2dm when compared to those with normal blood pressure and blood glucose (qiu et al., 2015). however, weak associations were observed between blood pressure and genetics and non-genetic factors in the current study. no significant differences of the blood pressure of all participants were observed between different groups of either genetic or nongenetic determinants. although, we observed significant differences on the fbgs between participants who included and excluded the veggies and fruits in their daily diets. we also found significant correlation between a parameter of physical fitness and the daily intake of veggies and fruits. healthy eating by consuming the right type and quantity of food from 5 different food groups can ensure the proportional energy produced and prevent the excess calories that may lead to overweight and obesity. mathur et al., (2021) reported that motor activity was amongst determinants of non-communicable diseases (ncd) risk factors in 1531 adolescents aged 15-17 years old in india. they observed that insufficient levels of physical activity was found in approximately 6.2% of overweight and 1.8% obese adolescents. a study by chiriboga et al., (2008) reported that men gained 0.3 kg whilst women lost 0.2 kg over the 1-year study period. they also observed that greater leisure-time physical activity was amongst predictors for lower body weight at the baseline in both groups. lower percentage of caloric intake and greater occupational physical activity were reported to correlate with lower body weight in men whilst increased total calorie intake and leisure-time in women were counted for the longitudinal predictors of 1-year weight gain. the study reported that children with overweight and obesity would likely suffer from similar conditions in their future life and increase the risk kalajanti, wahjudi, purwantari, visuddho, nawangsasi, et al (2023) 76 p-issn: 1858-3598  e-issn: 2502-5791 of suffering from chronic diseases such as metabolic syndrome and cvds. strength and limitation a novel aspect of this study is the investigation of both genetic and non-genetic factors as potential determinants correlated to the cardiovascular diseases risks and neuromuscular fitness. however, due to relatively limited and homogenous sample numbers with a cross-sectional type of study, the metabolism dynamic could not be captured thoroughly; extrapolation of results to other groups must be done in discretion. conclusions genetic polymorphism of slc6a4 and gabra6 along with the daily diets show significant correlations with the fasting blood glucose and the physical fitness levels in these seemingly healthy young adults. acknowledgment we would like to thank university of surabaya, indonesia and universitas airlangga, indonesia for the support funding source this study was funded by faculty of medicine, universitas airlangga, indonesia. conflict of interest the authors have declared no conflicts of interest. references arias, b. et al. (2012) ‘the role of genetic variability in the slc6a4, bdnf and gabra6 genes in anxiety-related traits.’, acta psychiatrica scandinavica, 125(3), pp. 194–202. doi: 10.1111/j.1600-0447.2011.01764.x. biswas, a. et al. (2015) ‘sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis’, annals of internal medicine, 162(2), pp. 123–32. doi: 10.7326/m14-1651. braat, s. and kooy, r. f. (2015) ‘the gabaa receptor as a therapeutic target for neurodevelopmental disorders’, neuron, 86(5), pp. 1119–30. doi: 10.1016/j.neuron.2015.03.042. castro-diehl, c. et al. (2014) ‘associations of socioeconomic and psychosocial factors with urinary measures of cortisol and catecholamines in the multi-ethnic study of atherosclerosis (mesa).’, psychoneuroendocrinology, 41, pp. 132–41. doi: 10.1016/j.psyneuen.2013.12.013. castro, a. m., macedo-de la concha, l. e. and pantoja-meléndez, c. a. (2017) ‘low-grade inflammation and its relation to obesity and chronic degenerative diseases’, revista médica del hospital general de méxico, 80(2), pp. 101–105. doi: 10.1016/j.hgmx.2016.06.011. chia, y.-c. et al. (2020) ‘target blood pressure and control status in asia’, journal of clinical hypertension (greenwich, conn.), 22(3), pp. 344–350. doi: 10.1111/jch.13714. chiriboga, d. e. et al. (2008) ‘gender differences in predictors of body weight and body weight change in healthy adults.’, obesity (silver spring, md.), 16(1), pp. 137–45. doi: 10.1038/oby.2007.38. dunn, j. p. et al. (2012) ‘relationship of dopamine type 2 receptor binding potential with fasting neuroendocrine hormones and insulin sensitivity in human obesity.’, diabetes care, 35(5), pp. 1105–11. doi: 10.2337/dc11-2250. garcía-martín, e. et al. (2018) ‘missense gamma-aminobutyric acid receptor polymorphisms are associated with reaction time, motor time, and ethanol effects in vivo’, frontiers in cellular neuroscience, 12, p. 10. doi: 10.3389/fncel.2018.00010. gonzález-giraldo, y. et al. (2018) ‘situation awareness performance in healthy young adults is associated with a serotonin transporter gene polymorphism’, psychological reports, 121(5), pp. 877–891. doi: 10.1177/0033294117740136. gonzález-giraldo, y., trujillo, m. l. and forero, d. a. (2018) ‘two dopaminergic genes, drd4 and slc6a3 , are associated with body mass index in a colombian sample of young adults’, archives of physiology and biochemistry, 124(4), pp. 330–334. doi: 10.1080/13813455.2017.1401643. hadi alijanvand, m. et al. (2020) ‘prevalence and predictors of prediabetes and its coexistence with high blood pressure in firstdegree relatives of patients with type 2 diabetes: a 9-year cohort study.’, journal of research in medical sciences : the official journal of isfahan university of medical sciences, 25, p. 31. doi: 10.4103/jrms.jrms_472_18. hakola, l. (2015) cardiorespiratory fitness and physical activity in older adults, publications of the university of eastern finland. finland: faculty of health sciences, university of eastern. hamasaki, h. (2016) ‘daily physical activity and type 2 diabetes: a review’, world journal of diabetes, 7(12), pp. 243–51. doi: 10.4239/wjd.v7.i12.243. han, d. h. et al. (2008) ‘craving for alcohol and food during treatment for alcohol dependence: modulation by t allele of 1519t>c gaba a α6’, alcoholism: clinical and experimental research, 32(9), pp. 1593–1599. doi: 10.1111/j.1530-0277.2008.00734.x. kalanjati, v. p. et al. (2017) ‘gabaa receptor expression and white matter disruption in intrauterine growth restricted piglets.’, international journal of developmental neuroscience : the official journal of the international society for developmental neuroscience, 59, pp. 1–9. doi: 10.1016/j.ijdevneu.2017.02.004. kalanjati, v. p. et al. (2021) ‘cardiovascular disease risk factors and anthropometry features among seemingly healthy young adults’, international journal of public health science (ijphs), 10(1), p. 77. doi: 10.11591/ijphs.v10i1.20554. kamal, r. h., wigati, k. w. and lefi, a. (2020) ‘the similar changes of glucose levels before and after moderate intensity exercise acutely in the morning and evening’, majalah biomorfologi, 30(2), p. 39. doi: 10.20473/mbiom.v30i2.2020.39-44. lynch, m., manly, j. t. and cicchetti, d. (2015) ‘a multilevel prediction of physiological response to challenge: interactions among child maltreatment, neighborhood crime, endothelial nitric oxide synthase gene (enos), and gaba(a) receptor subunit alpha-6 gene (gabra6).’, development and psychopathology, 27(4 pt 2), pp. 1471–87. doi: 10.1017/s0954579415000887. mathur, p. et al. (2021) ‘baseline risk factor prevalence among adolescents aged 15-17 years old: findings from national noncommunicable disease monitoring survey (nnms) of india.’, bmj open, 11(6), p. e044066. doi: 10.1136/bmjopen-2020-044066. miller, s. m. et al. (2017) ‘developmental changes in expression of gabaa receptor subunits α1, α2, and α3 in the pig brain’, developmental neuroscience, 39(5), pp. 375–385. doi: 10.1159/000468926. mulyanto, j., kringos, d. s. and kunst, a. e. (2019) ‘socioeconomic inequalities in healthcare utilization in indonesia: a comprehensive survey-based overview’, bmj open, 9(7), p. e026164. doi: 10.1136/bmjopen-2018-026164. nadasya, o. c. et al. (2021) ‘the profile of coronary heart disease patients in dr. soetomo general academic hospital, surabaya, jurnal ners http://e-journal.unair.ac.id/jners 77 indonesia’, majalah biomorfologi, 31(1), p. 6. doi: 10.20473/mbiom.v31i1.2021.6-10. ncd risk factor collaboration (ncd-risc) (2016) ‘worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants.’, lancet (london, england), 387(10027), pp. 1513–1530. doi: 10.1016/s0140-6736(16)006188. osailan, a. m. et al. (2021) ‘the association between cardiorespiratory fitness and reported physical activity with sleep quality in apparently healthy adults: a cross-sectional study.’, international journal of environmental research and public health, 18(8). doi: 10.3390/ijerph18084263. qin, c., li, j. and tang, k. (2018) ‘the paraventricular nucleus of the hypothalamus: development, function, and human diseases.’, endocrinology, 159(9), pp. 3458–3472. doi: 10.1210/en.201800453. qiu, m. et al. (2015) ‘effects of prediabetes mellitus alone or plus hypertension on subsequent occurrence of cardiovascular disease and diabetes mellitus: longitudinal study’, hypertension (dallas, tex. : 1979), 65(3), pp. 525–30. doi: 10.1161/hypertensionaha.114.04632. rosmond, r., bouchard, c. and björntorp, p. (2002) ‘allelic variants in the gaba(a)alpha6 receptor subunit gene (gabra6) is associated with abdominal obesity and cortisol secretion.’, international journal of obesity and related metabolic disorders : journal of the international association for the study of obesity, 26(7), pp. 938–41. doi: 10.1038/sj.ijo.0802022. simpson, k. a., martin, n. m. and bloom, s. r. (2008) ‘hypothalamic regulation of appetite’, expert review of endocrinology & metabolism, 3(5), pp. 577–592. doi: 10.1586/17446651.3.5.577. sookhanaphibarn, t. and choensawat, w. (2015) ‘standardized test system of health-related physical fitness for thai college students’, procedia manufacturing, 3, pp. 1527–1534. doi: 10.1016/j.promfg.2015.07.411. uhart, m. et al. (2004) ‘gabra6 gene polymorphism and an attenuated stress response.’, molecular psychiatry, 9(11), pp. 998–1006. doi: 10.1038/sj.mp.4001535. how to cite this article: kalajanti, v. p., wahjudi, m., purwantari, k. e., visuddho, v., nawangsasi, p., oktariza, r. t., pradana, k. a., rahmawan, d., and suwito, b. e. (2023) ‘gabra6 and slc6a4 genotypes are correlated with the fasting blood glucose and physical fitness in the seemingly healthy young adults’, jurnal ners, 18(1), pp. 70-77. doi: http://dx.doi.org/10.20473/jn.v18i1.43770 ners vol 5 no 1 april 2010_akreditasi 2013.indd 93 analisis faktor penyebab pelaksanaan pendokumentasian asuhan keperawatan berdasarkan balanced scorecard (analyzed factors that leads to the balanced scorecard nursing care documentation at rumah sakit jiwa menur surabaya) yuli anggraini*, purwaningsih**, eka misbahatul** * rumah sakit jiwa menur, jl. menur 120 surabaya telp./fax 031-5021635/5021636. e-mail: nersyulianggraini@yahoo.co.id **fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya abstract introduction: nursing documentation is an important aspect of nursing practice so that should be assessed comprehensively. the objective of the study was to analyze the causing factor of nursing care documentation at rumah sakit jiwa menur surabaya through balanced scorecard. method: this research was an analytical descriptive conducted out on january 2010 at rumah sakit jiwa menur surabaya that measured nursing care documentation through four perspectives of balanced scorecard by distributing quisioner to 55 nurses and 69 customers (patient families) using inclusion criteria, and holding personal interview to 3 structural offi cial, 2 functional offi cial, and 6 ward supervisors. data of nurse education, percentage of trained nurse was gained by checklist. data were analyzed using content analysis to fi nd the causing factor of nursing documentation within balanced scorecard. result: the result showed that fi nancial, internal business processes, and learning and growth perspectives had causal relationship with nursing care documentation at rumah sakit jiwa menur surabaya, but customer perspective didn’t have direct causal relationship with it. discussion: it can be concluded that impractical nursing documentation form especially in dimension of time on assessment, implementation, and evaluation, and comprehension on assessment, absence of physical nursing standards, limited knowledge on nursing documentation evoked by absence of inhouse training about nursing documentation, ineffective supervision and audit were factors which affecting nursing documentation at rumah sakit jiwa menur surabaya. the researcher recommended that the hospital manager should modifi cate the nursing documentation form using nic & noc of nanda and computerized system, compose physical nursing standards, carry out advanced nursing education and inhouse training about nursing care documentation, improve supervision program, and nursing documentation audit. keywords: balanced scorecard, causing factor, nursing care documentation pendahuluan dokumentasi yang baik mencerminkan tidak hanya kualitas perawatan tetapi juga membuktikan pertanggunggugatan setiap anggota tim perawatan dalam memberikan perawatan (potter dan perry, 2005). menurut hariyati (2009), masalah yang sering muncul dan dihadapi di indonesia dalam pelaksanaan asuhan keperawatan adalah banyak perawat yang belum melakukan pelayanan keperawatan sesuai standar asuhan keperawatan. pelaksanaan asuhan keperawatan juga tidak disertai pendokumentasian yang lengkap. observasi yang dilakukan peneliti selama satu minggu menggunakan instrumen studi dokumentasi departemen kesehatan republik indonesia, sejak tanggal 28 oktober sampai 3 november 2009 di ruang rawat inap, dari sepuluh berkas rekam medis pasien, didapatkan hasil bahwa pelaksanaan pendokumentasian asuhan keperawatan di rumah sakit jiwa menur masih belum optimal, di mana bagian yang paling tidak sesuai dengan standar, yaitu hanya dilakukan kurang dari sama dengan lima puluh lima persen adalah diagnosis keperawatan (100%), tindakan keperawatan (100%), dan evaluasi jurnal ners vol. 5 no. 1 april 2010: 93–106 94 (80%). hal ini menunjukkan bahwa kualitas pendokumentasian asuhan keperawatan di rumah sakit jiwa menur masih rendah. p e n d o k u m e n t a s i a n y a n g a k u r a t merupakan salah satu pertahanan diri terbaik terhadap tuntutan yang berkaitan dengan asuhan keperawatan (potter dan perry, 2005). menurut iyer (2005) dokumentasi yang tidak memenuhi aspek hukum teknik pencatatan bisa menimbulkan tuntutan yang merugikan perawat maupun rumah sakit yang bersangkutan. seorang wanita texas berusia 84 tahun menderita serangkaian stroke dan harus masuk ke fasilitas perawatan jangka panjang. ia menderita penyakit vaskular pada tungkainya, yang memerlukan pemantauan ketat, namun sepuluh bulan kemudian tungkainya diamputasi di bawah lutut, dan setelah menderita infark miokard mayor ia meninggal. pemalsuan rekam medik terdeteksi ketika ditemukan prosedur medis ditulis beberapa kali bahkan ketika pasien tidak berada di rumah perawatan. perawat yang dulu merawatnya bersaksi bahwa rumah perawatan tersebut kekurangan tenaga, dan mereka menyebutkan contohcontoh pengabaian pasien. juri memberikan ganti rugi pada penggugat sebesar $721.000 untuk mengganti kerusakan dan $10 juta sebagai pengganti hukuman (laska, 1998). tahun 1997 di massachusetts terdapat gugatan karena pemberian haldol yang berlebihan akibat perilaku pasien menyerang setelah sadar dari anestesi. karena perawat tidak mempertanyakan instruksi yang ditulisnya, maka pasien akhirnya meninggal dan rumah sakit mengganti rugi sebesar $ 1.050.000. tingkat pendidikan dan kesadaran akan hukum masyarakat indonesia yang makin tinggi akan memungkinkan sering terjadi tuntutan hukum bagi rumah sakit dan tenaga perawat jika pendokumentasian asuhan keperawatan tidak berkualitas (trisnawati, 2006). rumah sakit jiwa menur merawat pasien-pasien gangguan jiwa, yang menurut iyer (2005) pasien tersebut mungkin mengalami resiko cedera akibat perilaku bunuh diri atau kekerasan, melakukan penolakan terhadap pengobatan, dan melarikan diri. untuk itu diperlukan pendokumentasian asuhan keperawatan yang tepat, lengkap, dan akurat baik dalam pengkajian, diagnosis, perencanaan, tindakan keperawatan, maupun evaluasi guna mencegah terjadi masalah hukum. konsep balanced scorecard pada dasarnya adalah suatu konsep pengukuran kinerja yang berusaha menerjemahkan strategi organisasi ke dalam serangkaian aktivitas yang terencana yang dapat diukur secara kontinyu. balanced scorecard akan membantu perusahaan untuk melakukan pengukuran kinerja secara lebih komprehensif dan akurat (ciptani, 2000). berdasarkan penelitian yang dilakukan oleh yong (2008) balanced scorecard memiliki tingkat reliabilitas dan validitas yang tinggi sehingga relevan digunakan untuk mengukur kinerja organisasi keperawatan rumah sakit di korea. castaneda-mendez et al. (1998) dalam zelman (2003) menyatakan bahwa untuk menghubungkan praktik, hasil, kualitas, nilai, dan biaya-biaya, organisasi kesehatan harus menggunakan balanced scorecard. menurut weber (2001) dalam zelman (2003) balanced scorecard bisa dijadikan alat untuk mengukur performa keperawatan. untuk itu peneliti mencoba menganalisis masalah pelaksanaan pendokumentasian asuhan keperawatan di rumah sakit jiwa menur dengan menggunakan balanced scorecard. penelitian ini akan melakukan pengukuran pada empat perspektif balanced scorecard yaitu keuangan, pelanggan, proses bisnis internal, dan pembelajaran dan pertumbuhan sehingga hasil pengukuran yang komprehensif ini bisa dianalisis untuk menemukan faktor penyebab pelaksanaan pendokumentasian asuhan keperawatan yang tidak sesuai standar departemen kesehatan republik indonesia, untuk kemudian bisa disusun rekomendasi upaya peningkatan dokumentasi asuhan keperawatan di rumah sakit jiwa menur surabaya. bahan dan metode penelitian ini merupakan penelitian deskriptik analitik yaitu penelitian non hipotetis yang menyelidiki dan melukiskan keadaan subjek dan objek penelitian pada saat sekarang berdasarkan fakta-fakta yang tampak dan bagaimana adanya, di instalasi rawat analisis faktor penyebab pelaksanaan pendokumentasian asuhan (yuli anggraini) 95 inap rumah sakit jiwa menur surabaya di mana pelaksanaan pendokumentasian asuhan keperawatan sebagai unit analisis, dengan melakukan pengumpulan dan analisis terhadap data primer maupun sekunder pada keempat perspektif balanced scorecard yang meliputi: keuangan, pelanggan, proses bisnis internal, dan pembelajaran dan pertumbuhan. populasi perawat dalam penelitian ini adalah jumlah perawat yang berdinas di instalasi rawat inap rumah sakit jiwa menur, yaitu 64 orang. populasi pelanggan (keluarga pasien) adalah jumlah rata-rata per bulan pasien yang dirawat inap di ruang wijaya kusuma tiga bulan terakhir (september sampai nopember 2009) yaitu 84 pasien, sedangkan populasi manajemen adalah 21 pejabat struktural, 12 pejabat fungsional, dan 6 kepala ruang rawat inap yang ada di rsj menur. sampel penelitian ini adalah keluarga pasien sejumlah 69, dan perawat sejumlah 55 orang perawat. sampel perawat diambil berdasarkan kriteria inklusi yaitu perawat bersedia diteliti, perawat pelaksana di instalasi rawat inap rumah sakit jiwa menur, sementara kriteria inklusi untuk sampel keluarga pasien adalah keluarga pasien bersedia diteliti keluarga pasien selalu mendampingi pasien di ruang rawat inap. sampel manajemen adalah pejabat struktural dan fungsional yang berkaitan langsung dengan pelaksanaan pendokumentasian asuhan keperawatan, yaitu kepala bidang perawatan, kepala seksi rekam medik, kepala sub bagian penyusunan program dan anggaran, kepala bagian pendidikan dan pelatihan, ketua tim asuhan komite keperawatan, dan semua kepala ruang rawat inap di rumah sakit jiwa menur surabaya di mana pengambilan sampel perawat dengan menggunakan proportional random sampling. variabel yang diukur dalam penelitian ini adalah perspektif keuangan yang meliputi biaya kertas, lama waktu pendokumentasian asuhan keperawatan, ketersediaan biaya pendidikan dan pelatihan pendokumentasian asuhan keperawatan. variabel yang diukur kedua adalah perspektif pelanggan di mana meliputi kemanfaatan dokumentasi keperawatan bagi pelanggan (pasien dan keluarga), kepuasan pelanggan. variabel ketiga adalah perspektif proses bisnis internal, meliputi ketersediaan standar asuhan keperawatan (sak) baik jiwa maupun fisik ketersediaan format dokumentasi keperawatan dan petunjuk teknis pengisiannya kemudahan pengisian format dokumentasi keperawatan, komitmen manajemen, dan variabel yang diukur keempat yaitu perspektif pembelajaran dan pertumbuhan, meliputi: pendidikan perawat, pengetahuan perawat tentang dokumentasi, persentase perawat yang mengikuti diklat pendokumentasian asuhan keperawatan, kepuasan kerja perawat, motivasi perawat dalam pengisian dokumentasi keperawatan, penilaian dan harapan perawat terhadap format dokumentasi keperawatan, audit dokumentasi keperawatan. i n s t r u m e n y a n g d i g u n a k a n p a d a penelitian ini adalah wawancara, kuesioner dan lembar observasi pada responden yang diteliti dengan menggunakan balanced scorecard. hasil aspek yang diukur dalam balanced scorecard terdiri dari empat, yaitu perspektif keuangan, perspektif pelanggan, perspektif proses bisnis internal, serta perspektif pembelajaran dan kebutuhan. aspek yang pertama adalah perspektif keuangan, di mana meliputi biaya kertas m e n u n j u k k a n h a s i l b a h w a s u d a h a d a pembiayaan yang diprogramkan, yaitu anggaran kertas format dokumentasi asuhan keperawatan tercukupi karena biaya yang dikeluarkan untuk dokumentasi asuhan keperawatan hanya 90,9% anggaran. segi perspektif keuangan kedua adalah lama waktu pendokumentasian menunjukkan hasil bahwa pengkajian paling banyak selama 10 menit yaitu 24 orang (43,6%). sedangkan analisis data/diagnosis paling banyak selama 5 menit yaitu 28 orang (50,9%). perencanaan paling banyak adalah 5 menit yaitu 27 orang (49,1%). pendokumentasian tindakan keperawatan memerlukan waktu terbanyak adalah 10 menit yaitu 25 orang (45,5%), untuk evaluasi menunjukkan waktu pendokumentasian evaluasi paling banyak adalah 5 menit yaitu 29 orang (52,7%), yang terakhir adalah catatan perkembangan (tindakan jurnal ners vol. 5 no. 1 april 2010: 93–106 96 dan evaluasi) yaitu satu pasien (tindakan dan evaluasi) paling banyak dibutuhkan waktu 20 menit. tidak seperti pengkajian, analisis data, dan perencanaan, pendokumentasian catatan perkembangan (tindakan dan evaluasi) harus dilakukan setiap hari. jika satu perawat mendokumentasikan empat pasien maka dibutuhkan waktu 80 menit hanya untuk menulis tindakan dan evaluasi. dan catatan lainnya (laporan perpindahan pasien, pemberian obat, kurva, resume keperawatan) paling banyak adalah 5 menit yaitu 22 orang (40%). total waktu pendokumentasian asuhan keperawatan satu pasien paling banyak adalah 41–50 menit yaitu 20 orang (36,4%). perspektif keuangan yang ketiga adalah ketersediaan biaya pendidikan dan pelatihan pendokumentasian asuhan keperawatan. tahun 2010 anggaran pengembangan tenaga keperawatan dapat sebesar 40,3% dari anggaran pengembangan tenaga kesehatan. anggaran tersebut direncanakan untuk mengadakan pelatihan kesehatan kerja, infeksi nosokomial, outbound, dan seminar serta pelatihan keperawatan di luar rumah sakit. jadi pada tahun 2010 tidak dianggarkan pelatihan pendokumentasian asuhan keperawatan. a s p e k k e d u a d a l a m b a l a n c e d scorecard adalah perspektif pelanggan, di mana terdiri dari 2 hal, yang pertama adalah kemanfaatan dokumentasi keperawatan b a g i p e l a n g g a n ( p a s i e n d a n k e l u a rg a ) menunjukkan hasil bahwa semua pelanggan mengatakan pendokumentasian diperlukan dan hampir semuanya merasakan manfaat pendokumentasian asuhan keperawatan. begitu juga hasil analisis isi berdasarkan kuesioner terstruktur, sebagian besar responden (pasien) memerlukan dokumentasi keperawatan karena untuk mengetahui perkembangan pasien setiap hari. perspektif pelanggan yang kedua adalah kepuasan pelanggan di mana menunjukkan hasil bahwa proporsi terbanyak responden keluarga pasien yang dirawat di ruang wijaya kusuma kepuasannya berdasarkan dimensi tanggung jawab dan empati adalah tinggi. perspektif proses bisnis internal, yang merupakan aspek ketiga dalam balance scorecard meliputi ketersediaan standar asuhan keperawatan (sak) baik jiwa maupun fisik, ketersediaan format dokumentasi keperawatan dan petunjuk teknis pengisiannya, kemudahan pengisian format dokumentasi keperawatan, dan komitmen manajemen. h a s i l w a w a n c a r a d e n g a n k e p a l a ruang puri anggrek, puri mitra, flamboyan, wijaya kusuma, gelatik, dan kenari tentang ketersediaan standar asuhan keperawatan diperoleh informasi bahwa semua ruangan tersebut memiliki standar asuhan keperawatan jiwa, namun belum memiliki standar asuhan keperawatan fisik, masing-masing ruangan mempunyai satu bendel buku sak jiwa, dari enam ruangan ada dua ruangan yang meletakkan standar asuhan tersebut di tempat yang tidak mudah dijangkau. sedangkan menurut ketua tim asuhan keperawatan komite keperawatan, saat ini standar asuhan keperawatan fisik masih dalam penyusunan. ketersediaan format dokumentasi keperawatan dan petunjuk teknis pengisiannya menunjukkan hasil bahwa berdasarkan wawancara dengan kepala ruang puri anggrek, puri mitra, flamboyan, wijaya kusuma, gelatik, dan kenari, didapatkan data sebagai berikut di semua ruangan tersedia format asuhan keperawatan yang baku, jumlah format tercukupi setiap hari, format yang paling sering dipakai adalah format catatan perkembangan, namun di ruangan tidak pernah kehabisan, di semua ruangan tersedia petunjuk teknis pengisian format dokumentasi asuhan keperawatan yang dibendel menjadi satu dengan standar asuhan keperawatan jiwa, ada dua ruangan yang meletakkan petunjuk teknis tersebut di tempat yang tidak mudah dijangkau. sedangkan mengenai kemudahan pengisian format dokumentasi keperawatan menunjukkan bahwa proporsi terbanyak responden perawat di instalasi rawat inap rumah sakit jiwa menur surabaya menilai kemudahan pengisian format dokumentasi asuhan keperawatan baik. k o m i t m e n m a n a j e m e n d i n i l a i berdasarkan wawancara terhadap kepala seksi rekam medik, kepala bidang perawatan, kepala diklat, dan kepala ruangan rawat inap didapatkan informasi bahwa sagian rekam medik menyediakan lembar format dokumentasi asuhan keperawatan sesuai analisis faktor penyebab pelaksanaan pendokumentasian asuhan (yuli anggraini) 97 kebutuhan sehingga saat ini jumlah format tercukupi, hasil pendokumentasian asuhan keperawatan disimpan dalam status pasien yang disusun rapi di almari khusus, hasil pendokumentasian asuhan keperawatan saat ini tidak digunakan sebagai pertimbangan penilaian dp3 sebagai penilaian pegawai negeri sipil (pns), tetapi sudah digunakan dalam penilaian kinerja untuk pembagian jasa pelayanan, supervisi pendokumentasian asuhan keperawatan dilakukan oleh kepala ruangan berupa “standar penilaian dokumentasi asuhan keperawatan pada lembar implementasi”, yang setiap bulan dilaporkan kepada kepala sub bidang asuhan dan mutu keperawatan. namun menurut kepala ruangan supervisi tersebut kurang optimal karena banyaknya tugas kepala ruangan. hal ini dibuktikan bahwa dari data yang didapatkan di bidang perawatan, sejak bulan agustus 2009 sampai dengan desember 2009, dari 6 ruangan ada 2 ruangan yang tidak mengumpulkan laporan “standar penilaian dokumentasi asuhan keperawatan pada lembar implementasi” secara lengkap, dan tahun 2010 tidak ada program pelatihan pendokumentasian asuhan keperawatan. aspek terakhir dalam balace scorecard yang diukur adalah perspektif pembelajaran dan pertumbuhan, di mana perspektif ini meliputi pendidikan perawat, pengetahuan perawat, persentase perawat yang mengikuti diklat pendokumentasian asuhan keperawatan, kepuasan perawat, motivasi perawat dalam p e n g i s i a n d o k u m e n t a s i k e p e r a w a t a n , penilaian dan harapan perawat terhadap format dokumentasi keperawatan, dan audit dokumentasi keperawatan. tingkat pendidikan perawat terbanyak di instalasi rawat inap rumah sakit jiwa menur terbanyak adalah diii keperawatan sejumlah 49 orang (76,6%). peneliti mendapatkan informasi bahwa saat ini ada 4 perawat rawat inap yang tengah menjalani pendidikan diii keperawatan dan 5 orang perawat sedang menempuh pendidikan s1 keperawatan. 70,9% reaponden perawat di instalasi rawat inap rumah sakit jiwa menur surabaya memiliki pengetahuan kurang baik. data bagian pendidikan dan pelatihan rumah sakit jiwa menur diperoleh informasi bahwa sejak tahun 2005 tidak pernah dilakukan pendidikan dan pelatihan pendokumentasian asuhan keperawatan. namun pada tanggal 20 sampai 21 september 2006 diselenggarakan pelatihan clinical educator, yang di dalamnya ada materi pengkajian asuhan keperawatan jiwa, yang diikuti 50 perawat (78,1%). pada tanggal 13 sampai 15 oktober 2009 dilakukan pelatihan mpkp (model praktik keperawatan profesional) yang diikuti 43 perawat rawat inap (67,1%). sebanyak 50 perawat (78,1%) sudah mengikuti pendidikan dan pelatihan bls (basic life support). k e p u a s a n p e r a w a t m e n u n j u k k a n bahwa dari 55 responden di instalasi rawat inap rumah sakit jiwa menur surabaya mayoritas kepuasannya adalah sedang yaitu 33 responden (60%), sedangkan motivasi perawat dalam pengisian format dokumentasi asuhan keperawatan di rumah sakit jiwa menur surabaya mayoritas tinggi yaitu 38 responden (69,1%). hasil penelitian penilaian perawat t e r h a d a p f o r m a t d o k u m e n t a s i a s u h a n keperawatan berdasarkan kepraktisan, jumlah lembar format, dan tanggapan terhadap format menunjukkan bahwa sebagian banyak perawat yaitu 33 responden (60%) tidak setuju format dokumentasi cukup praktis, 38 responden (69,1%) menilai jumlah lembar format dokumentasi asuhan keperawatan banyak, dan mayoritas responden (69,1%) menilai format dokumentasi asuhan keperawatan perlu direvisi. a u d i t d o k u m e n t a s i k e p e r a w a t a n menunjukkan bahwa berdasarkan wawancara dengan ketua tim asuhan keperawatan komite keperawatan pada tahun 2008 pernah dilakukan audit dokumentasi. namun hasilnya tidak terdokumentasi dengan baik. pembahasan ditinjau dari perspektif keuangan jelas bahwa format yang digunakan saat ini kurang efisien karena biaya kertas cukup tinggi. status rumah sakit jiwa menur sebagai badan layanan umum daerah mengharuskannya mengatur keuangan sedemikian rupa agar mampu mandiri. meskipun saat ini jumlah jurnal ners vol. 5 no. 1 april 2010: 93–106 98 kertas terpenuhi dengan anggaran yang cukup akan lebih baik jika biaya tersebut ditekan untuk menambah pendapatan. hal ini sejalan dengan kaplan dan norton (2000) yang mengemukakan perlunya perusahaan meningkatkan kinerja biaya dan produktivitas dengan salah satu caranya adalah mengurangi biaya operasi termasuk biaya administratif. menurut iyer, (2005) kebutuhan untuk menghemat biaya mengharuskan perawat untuk memeriksa ulang praktik rutin yang dilakukannya, seperti pendokumentasian guna mengembangkan metode pencatatan yang lebih efisien. maka manajemen rumah sakit dalam hal ini bidang perawatan bekerja sama dengan tim asuhan komite keperawatan dan seksi rekam medik sebaiknya menelaah kembali berbagai model format dan sistem pendokumentasian, dan memilih yang paling sesuai dengan rumah sakit jiwa menur. hasil penelitian menunjukkan bahwa waktu yang dibutuhkan dalam pengkajian paling banyak 10 menit. menurut doenges (2007) salah satu tujuan dokumentasi asuhan keperawatan adalah untuk memfasilitasi pemberian perawatan yang berkualitas. untuk itu perlu dilakukan pengkajian yang sesuai standar yaitu pengumpulan data harus lengkap, akurat, sistematis, menggunakan format, dan valid. untuk memenuhi unsur tersebut maka waktu yang dibutuhkan cukup lama. waktu analisis data/diagnosis paling b a n y a k s e l a m a 5 m e n i t k a r e n a u n t u k memenuhi standar dokumentasi, analisis data difokuskan pada prioritas masalah dengan menuliskan tanda/gejala berupa data subjektif dan objektif, kemungkinan penyebab, dan masalah keperawatan. maka masing-masing pasien berbeda, sehingga harus ditulis secara naratif, dan membutuhkan waktu yang cukup untuk merumuskannya. sedangkan waktu yang dibutuhkan untuk perencanaan paling banyak adalah 5 menit. perawat di rumah sakit jiwa menur tidak perlu menuliskan perencanaan tindakan keperawatan karena sudah disediakan format perencanaan yang merupakan 7 masalah utama yaitu halusinasi, perilaku kekerasan, menarik diri, harga diri rendah, waham, ketidakmampuan keluarga merawat pasien, dan kurangnya pengetahuan keluarga. menurut peneliti perlu dipikirkan jika ada masalah keperawatan yang tidak ada dalam ketujuh perencanaan yang ada dimungkinkan terjadi keadaan di mana perawat mencari-cari perencanaan yang secocok mungkin dengan masalah yang ditemukan meskipun data kurang mendukung atau mencoba menulis sendiri sesuai kemampuannya. hal ini tentu akan menyebabkan pendokumentasian tidak sesuai standar. oleh karena itu format perencanaan yang telah dicetak tersebut perlu ditelaah kembali apakah lebih baik menggunakan kode perencanaan sesuai nic dan noc. pendokumentasian tindakan keperawatan memerlukan waktu terbanyak adalah 10 menit sedangkan untuk evaluasi paling banyak adalah 5 menit. untuk mendokumentasikan catatan perkembangan (tindakan dan evaluasi) paling banyak dibutuhkan waktu 20 menit. menurut standar dokumentasi implementasi atau tindakan keperawatan harus dilaksanakan sesuai rencana keperawatan, mengamati keadaan biopsiko-sosio-spiritual pasien, menjelaskan setiap tindakan kepada pasien/keluarga, dan mencatat semua tindakan yang dilakukan. menurut standar evaluasi perawat melakukan pengkajian ulang yang diarahkan pada tercapainya tujuan atau tidak, menetapkan prioritas dan tujuan serta melakukan pendekatan keperawatan lebih lanjut secara tepat dan akurat, menetapkan tindakan keperawatan baru dengan cepat dan tepat. untuk itu waktu yang dibutuhkan cukup lama berdasarkan penelitian, perawat banyak menulis rutinitas sehari-hari namun tindakan dan evaluasi yang sesuai diagnosis keperawatan terlupakan. m e n u r u t p e n e l i t i a n w a k t u y a n g digunakan untuk mendokumentasikan catatan lainnya paling banyak adalah 5 menit. menurut standar dokumentasi implementasi semua tindakan yang dilakukan harus dicatat. catatan lainnya, yang harus dilakukan setiap hari pada semua pasien adalah pencatatan pemberian obat dan kurva tanda-tanda vital, sedangkan laporan perpindahan pasien dan resume keperawatan hanya dilakukan pada saat memindahkan pasien ke ruangan lain dan saat pasien pulang. dengan adanya format pemberian obat dan format kurva tanda-tanda vital memudahkan perawat dalam dokumentasi tindakan rutin. format analisis faktor penyebab pelaksanaan pendokumentasian asuhan (yuli anggraini) 99 perpindahan pasien dan resume yang tersedia juga memudahkan karena yang ditulis tidak terlalu banyak. jadi waktu mendokumentasikan catatan lainnya tidak terlalu menyita waktu harian perawat. sesuai hasil penelitian satu perawat pada pagi hari di ruang wijaya kusuma melakukan pendokumentasian asuhan keperawatan selama 120 menit, setiap perawat mendokumentasikan 27 lembar setiap paginya. menurut gillies dalam departemen kesehatan republik indonesia (1997) waktu efektif pelayanan keperawatan di ruang nonbedah/non-icu adalah 4 jam. ini berarti waktu perawat hampir separuhnya tersita untuk kegiatan dokumentasi yang sesuai dengan mcdaniel (1997) dalam iyer (2005) yang mengemukakan bahwa sebuah perkiraan menunjukkan bahwa perawat menghabiskan 40% waktunya untuk melakukan pekerjaan tertulis. kelebihan waktu untuk dokumentasi lebih baik digunakan untuk aktivitas perawatan pasien yang lain. waktu pendokumentasian yang lama memungkinkan perawat harus mengurangi waktu bersama pasien, sehingga kondisi pasien tidak terevaluasi secara maksimal sementara di ruang jiwa menurut iyer (2005) pasien mungkin mengalami resiko cedera akibat perilaku bunuh diri atau kekerasan, melakukan penolakan terhadap pengobatan, dan melarikan diri. pasien jiwa kondisinya sangat fluktuatif sehingga harus dilakukan pengawasan ketat. h a s i l p e n e l i t i a n p e r s p e k t i f pelanggan semua responden mengatakan pendokumentasian diperlukan. sedangkan analisis isi berdasarkan kuesioner terstruktur, jawaban dari pertanyaan terbuka alasan perlu dilakukan dokumentasi terbanyak adalah supaya mengetahui perkembangan kondisi pasien, yang diungkapkan hampir separuh responden. sesuai hasil penelitian hanya 1 responden mengatakan tidak merasakan manfaat pendokumentasian asuhan keperawatan. adapun alasan tidak merasakan manfaat pendokumentasian karena perawat tidak menjelaskan perkembangan pasien, menurut notoatmojo (2007) dalam erfan (2009) usia memengaruhi daya tangkap dan pola pikir seseorang. semakin bertambah usia akan semakin berkembang pula daya tangkap dan pola pikirnya, sehingga pengetahuan yang diperolehnya semakin membaik. selain itu pengetahuan juga dipengaruhi oleh tingkat pendidikan. pendidikan memengaruhi proses belajar, makin tinggi pendidikan seseorang makin mudah orang tersebut untuk menerima informasi. semakin banyak informasi yang masuk semakin banyak pula pengetahuan yang didapat tentang kesehatan. pengalaman juga menjadi sumber pengetahuan di mana seseorang memperoleh kebenaran pengetahuan dengan cara mengulang kembali pengetahuan yang diperoleh dalam memecahkan masalah yang dihadapi pada masa lalu. proporsi terbanyak responden berusia >40 tahun sehingga pengalamannya lebih banyak, dan ditunjang dengan pendidikan dengan proporsi terbanyak smp dan sma, responden memiliki pengetahuan cukup dalam dokumentasi keperawatan secara umum. perawat harus mendokumentasikan asuhan keperawatan dengan baik sehingga bisa memenuhi harapan pelanggan akan jaminan mutu, di mana menurut nursalam (2008) pencatatan data klien yang lengkap dan akurat, akan memberi kemudahan bagi perawat dalam membantu menyelesaikan masalah pasien dan untuk mengetahui sejauh mana masalah pasien dapat teratasi dan seberapa jauh masalah baru dapat diidentifikasi dan dimonitor melalui catatan yang akurat. hal ini akan meningkatkan mutu pelayanan keperawatan. tingkat kepuasan pelanggan berdasarkan d i m e n s i t a n g g u n g j a w a b d a n e m p a t i menunjukkan tingkat kepuasan tinggi di mana proporsi terbanyak adalah laki-laki dengan proporsi pekerjaan terbanyak adalah swasta dan wiraswasta. menurut sugiarto (1999) dalam purwanto (2007) tingkat kepuasan antar individu satu dengan individu lain berbeda. hal ini terjadi karena adanya pengaruh dari faktor jabatan, umur, kedudukan sosial, tingkat ekonomi, pendidikan, jenis kelamin, sikap mental dan kepribadian. sesuai hasil kuesioner semua pelanggan merasa puas terhadap pelayanan perawat di instalasi rumah sakit jiwa menur. menurut kaplan dan norton (2000) ukuran kepuasan pelanggan memberikan umpan balik mengenai seberapa baik perusahaan melaksanakan bisnis. kepuasan pelanggan di rumah sakit jiwa menur jurnal ners vol. 5 no. 1 april 2010: 93–106 100 memang tinggi, namun kepuasan tersebut tidak berkenaan langsung dengan pendokumentasian asuhan keperawatan. sebagaimana disebutkan di atas tingkat ekonomi memengaruhi tingkat kepuasan. hampir semua pasien yang dirawat di ruang wijaya kusuma menggunakan jamkesmas dan jamkesda, dengan kata lain tingkat ekonominya relatif rendah, sehingga standar kepuasannya relatif tidak tinggi. menurut guruprapti (2007) tidak ada hubungan yang signifikan antara kinerja perawat yang mengacu pada proses pendokumentasian asuhan keperawatan dengan kepuasan pasien. hal ini bisa dijelaskan bahwa keluarga pasien di rumah sakit jiwa menur lebih berfokus pada hasil akhir bagaimana kebutuhan pasien dilayani dengan cepat dan tepat, dan pasien cepat sembuh, tidak dipengaruhi oleh pelaksanaan pendokumentasian asuhan keperawatan. penelitian menunjukkan bahwa pada tahun 2010 anggaran pengembangan tenaga keperawatan cukup besar, namun pada tahun ini tidak ada prioritas untuk pendidikan dan pelatihan pendokumentasian asuhan keperawatan. pendidikan dan pelatihan pendokumentasian asuhan keperawatan perlu untuk diprioritaskan. hal ini dikarenakan menurut nursalam (2008) dokumentasi sangat penting ditinjau dari berbagai aspek baik hukum, jaminan mutu, komunikasi, keuangan, pendidikan, penelitian, dan akreditasi. pengetahuan perawat proporsi terbanyak adalah kurang baik. hal ini bisa dijelaskan karena sejak tahun 2005 perawat tidak pernah mengikuti pelatihan pendokumentasian asuhan keperawatan, sehingga perawat sangat mungkin lupa akan hal-hal yang berkaitan langsung dengan pendokumentasian asuhan keperawatan. hal ini dibuktikan bahwa jawaban yang tidak tepat pada kuesioner terutama yang mengenai pengertian dan metode dokumentasi keperawatan. penelitian yang dilakukan azis, (2005) ada pengaruh yang bermakna, pelatihan terhadap peningkatan pengetahuan, sikap dan motivasi perawat dalam pendokumentasian asuhan keperawatan. tahun 2006 sudah dilakukan pelatihan clinical educator yang mengandung materi pengkajian asuhan keperawatan jiwa, namun tidak bisa dibuktikan apakah pengetahuan, sikap, dan motivasi perawat dalam pendokumentasian asuhan keperawatan meningkat dengan pelatihan tersebut, karena belum dilakukan penelitian. p e l a t i h a n p e n d o k u m e n t a s i a n a s u h a n keperawatan akan dibahas lebih spesifik tujuan, manfaat, fungsi, standar, metode, prinsipprinsip dokumentasi keperawatan, dan hal-hal lain yang terkait dengan dokumentasi. d o k u m e n t a s i k e p e r a w a t a n y a n g baik merupakan bukti asuhan keperawatan yang baik sesuai nursalam (2008) bahwa dokumentasi merupakan bukti kualitas asuhan keperawatan. hasil penelitian menunjukkan secara keseluruhan proporsi terbanyak adalah responden dengan masa kerja 1–5 tahun dan 6–10 tahun. menurut robbins (2000) dalam trisnawati (2006) ada hubungan antara senioritas dan produktivitas. jika kondisinya sama maka orang yang lama berada pada suatu pekerjaan akan produktif daripada mereka yang senoritasnya lebih rendah. perawat di rumah sakit jiwa menur memiliki masa kerja paling banyak 1–5 tahun, sehingga mungkin produktivitasnya masih belum setinggi yang lebih senior. maka dengan dilakukan pelatihan pendokumentasian asuhan keperawatan diharapkan kinerjanya dalam pendokumentasian lebih baik. p e n e l i t i a n y a n g t e l a h d i l a k u k a n mendapatkan data bahwa semua ruangan di instalasi rawat inap rumah sakit jiwa menur surabaya memiliki standar asuhan keperawatan jiwa, namun belum memiliki standar asuhan keperawatan fisik, di mana saat ini standar asuhan keperawatan fisik masih dalam penyusunan. di semua ruangan tersedia format asuhan keperawatan yang baku dengan jumlah tercukupi setiap hari. format yang paling sering dipakai adalah format catatan perkembangan, namun di ruangan tidak pernah kehabisan. dengan tersedianya standar asuhan keperawatan jiwa di semua ruangan, format asuhan keperawatan dengan jumlah tercukupi, dan petunjuk teknis pengisian format asuhan keperawatan memudahkan perawat melakukan pendokumentasian asuhan keperawatan yang seragam. menurut tim departemen kesehatan republik indonesia (1994) salah analisis faktor penyebab pelaksanaan pendokumentasian asuhan (yuli anggraini) 101 satu tujuan standar asuhan keperawatan adalah untuk melakukan pengukuran yang minimal sama bagi asuhan keperawatan di manapun dilakukan. sementara berkenaan dengan standar asuhan keperawatan fisik yang masih dalam tahap penyusunan, menyebabkan pelaksanaan dokumentasi yang berkenaan dengan masalah fisik tidak terdokumentasi dengan baik, terutama pada diagnosis dan perencanaan, dengan tidak adanya standar asuhan keperawatan fisik, tindakan yang dilakukan tidak bisa seragam, tergantung pemikiran masing-masing perawat berdasarkan pengetahuan dan pengalamannya masingmasing. hal ini bisa menyebabkan mutu asuhan keperawatan tidak terjaga. secara umum menurut hasil penelitian format asuhan keperawatan mudah pengisiannya. namun pada dimensi waktu hampir separuh responden mengatakan kesulitan pada aspek waktu pengkajian dan aspek waktu analisis data, sementara hampir semua responden kesulitan pada aspek waktu penulisan tindakan, dan lebih dari separuh responden kesulitan pada aspek waktu evaluasi. sedangkan pada aspek pemahaman, hampir separuh responden merasa sulit pada pengkajian dan proporsi terbanyak kesulitan dalam memahami analisis data. menurut carpenito (1995) dalam ali (2005) bahwa format dokumentasi masih banyak ragamnya sehingga perawat merasa rumit dan banyak memakan waktu, maka diperlukan sistem dokumentasi yang efisien, komprehensif, dapat mengkomunikasikan lebih banyak data dalam waktu yang lebih sedikit dan sesuai standar yang berlaku. hal ini menjadi tantangan bagi tim asuhan keperawatan komite keperawatan untuk memodifikasi format asuhan keperawatan yang ada menjadi lebih mudah pengisiannya yang lebih menghemat waktu dan sistem pendokumentasian yang lebih praktis. m a n a j e m e n r u m a h s a k i t s u d a h m e m i l i k i k o m i t m e n y a n g b a i k u n t u k mendukung pelaksanaan pendokumentasian asuhan keperawatan. bagian rekam medik menyediakan lembar format dokumentasi asuhan keperawatan sesuai kebutuhan dan hasil pendokumentasian asuhan keperawatan disimpan dalam status pasien yang disusun rapi di almari khusus. menurut potter dan perry (2005), dokumentasi berfungsi penting sebagai komunikasi staf, pengkajian, edukasi, tagihan finansial, dokumentasi legal, riset, audit dan pemantauan. dengan penyimpanan yang rapi, maka semua fungsi dokumentasi tersebut bisa terpenuhi. jadi meskipun pasien sudah pulang, data pasien yang tersimpan masih bisa bermanfaat untuk berbagai kepentingan. h a s i l p e n d o k u m e n t a s i a n a s u h a n keperawatan saat ini tidak digunakan sebagai pertimbangan penilaian dp3 sebagai penilaian pegawai negeri sipil (pns), tetapi sudah digunakan dalam penilaian kinerja untuk pembagian jasa pelayanan. hal ini merupakan hal yang baik, karena bisa meningkatkan motivasi perawat, sesuai dengan teori keadilan yang didasarkan pada asumsi bahwa faktor utama dalam motivasi pekerjaan adalah evaluasi individu atau keadilan dari penghargaan yang diterima. individu akan termotivasi kalau mereka mengalami kepuasan dan mereka terima dari upaya dalam proposi dan dengan usaha yang mereka kerjakan (nursalam, 2009). supervisi pendokumentasian asuhan keperawatan dilakukan oleh kepala ruangan yang setiap bulan dilaporkan kepada kepala sub bidang asuhan dan mutu keperawatan. namun dari data yang didapatkan di bidang perawatan, sejak bulan agustus 2009 sampai dengan desember 2009, dari 6 ruangan ada 2 ruangan yang tidak mengumpulkan laporan “standar penilaian dokumentasi asuhan keperawatan pada lembar implementasi” secara lengkap. supervisi menurut kron dan gray (1987) dalam lusianah (2008) yaitu tindakan membimbing, mengarahkan, mengobservasi, mengevaluasi secara terusmenerus setiap karyawan dengan sabar, adil serta bijaksana sehingga setiap karyawan dapat memberikan proses keperawatan dengan baik, terampil, aman, cepat dan tepat secara komprehensif sesuai dengan karakteristik personal karyawan. kepala ruangan sebagai manajer lapis pertama bertanggung jawab dalam pelaksanaan pemberian asuhan keperawatan utama di unit ruang rawat yang dipimpinnya. peran dan fungsi kepala ruangan sangat strategis dalam jurnal ners vol. 5 no. 1 april 2010: 93–106 102 meningkatkan mutu asuhan keperawatan melalui peningkatan kualitas dokumentasi proses keperawatan di ruangan. dalam melaksanakan supervisinya kepala ruangan mengkoordinasikan sistem kerjanya itu antara lain dengan cara membimbing, memberikan contoh (role model), mengarahkan dan menilai atau mengevaluasi. melalui kegiatan bimbingan yang dilakukan supervisor diharapkan dapat memperbaiki dan memberi masukan atas kekurangan yang dilakukan perawat ketika sedang menjalankan tugasnya (kron dan gray, 1987 dalam lusianah, 2008). efektivitas supervisi yang dilakukan oleh supervisor akan meningkat bila ada contoh langsung (role model) yang konsisten dalam melaksanakan tugas yang akan dicapai. kegiatan pengarahan yang dilakukan dalam supervisi berfokus pada tindakan fisik dan proses interpersonal perawat pelaksana dalam mencapai tujuan keperawatan. supervisor memberikan arahan sesuai kebutuhan perawat dan mendorong motivasi perawat dalam melaksanakan pekerjaannya sesuai perencanaan yang telah disusun. pengarahan yang diberikan oleh kepala ruangan dapat meningkatkan kualitas asuhan keperawatan kepada pasien (gillies, 1999 dalam lusianah, 2008). selain itu kegiatan bimbingan yang diberikan oleh supervisor keperawatan sangat diperlukan agar ada perubahan perilaku mencakup perubahan mental (kognitif), emosional dan aktivitas fisik. hasil kerja yang dicapai oleh perawat dalam melakukan asuhan keperawatan dan mendokumentasikannya perlu dinilai oleh supervisor. penilaian atas hasil kerja perawat tersebut perlu dilaksanakan terusmenerus untuk melihat aspek positif dan negatif yang ditemui pada pelaksanaan kerja perawat untuk kemudian dilakukan pembimbingan, pengarahan yang sesuai dengan karakter personal perawat tersebut. oleh karena itu proses penilaian ini membutuhkan berbagai keterampilan antara lain pengetahuan tentang standar asuhan keperawatan, respon normal yang muncul pada pasien, dan kemampuan memantau keefektifan intervensi keperawatan (craven dan himle, 2000 dalam lusianah, 2008). supervisi pendokumentasian asuhan keperawatan di rumah sakit jiwa menur menurut kepala ruangan masih kurang optimal karena banyaknya tugas kepala ruangan. hal ini bisa dipahami, karena selain sebagai manajer ruangan, kepala ruangan merupakan pejabat fungsional yang harus melakukan koordinasi dengan manajemen dalam rapatrapat, dan juga menjadi clinical educator bagi mahasiswa yang jumlahnya cukup banyak dari berbagai institusi keperawatan, yang sekaligus menjadi penguji mahasiswa dalam ujian praktik keperawatan jiwa. meskipun demikian supervisi seharusnya dilakukan dengan sebaikbaiknya untuk menjamin pendokumentasian asuhan keperawatan yang berkualitas sebagai salah satu upaya meningkatkan mutu pelayanan keperawatan. hasil penelitian menunjukkan bahwa tingkat pendidikan perawat terbanyak di instalasi rawat inap rumah sakit jiwa menur adalah diii keperawatan. azwar (1996) dalam (hapsara, 2006; lusianah, 2008) mengungkapkan bahwa pendidikan yang baik dapat meningkatkan ketrampilan dan profesionalisme tenaga perawat sehingga lebih percaya diri dalam melaksanakan tugasnya. dalam hal ini tingkat pendidikan perawat di rumah sakit jiwa menur cukup baik karena mayoritas diii keperawatan sehingga diharapkan bisa dihasilkan pendokumentasian asuhan keperawatan yang baik, karena materi dokumentasi asuhan keperawatan telah didapatkan selama mengenyam pendidikan diii keperawatan. namun adanya tuntutan akan profesionalisme seyogianya manajemen memfasilitasi peningkatan pendidikan ke jenjang sarjana keperawatan. kepuasan kerja perawat di instalasi rawat inap rumah sakit jiwa menur surabaya mayoritas adalah sedang. berdasarkan kelompok umur, diketahui bahwa responden terbanyak pada usia relatif muda yaitu 21–30 tahun sehingga kepuasannya sedang karena menurut robbin (2000) dalam trisnawati (2006) sebuah studi menunjukkan hubungan yang berbentuk “u” yang artinya pada usia muda kepuasan karyawan tinggi, kemudian menurun seiring dengan makin bertambahnya usia karyawan. analisis faktor penyebab pelaksanaan pendokumentasian asuhan (yuli anggraini) 103 sedangkan motivasi perawat dalam p e n g i s i a n f o r m a t d o k u m e n t a s i a s u h a n keperawatan di rumah sakit jiwa menur surabaya proporsi yang terbanyak adalah tinggi. dari hasil penelitian dapat diketahui bahwa proporsi terbanyak adalah responden dengan status pns. menurut herzberg dalam masithoh (1998) status kepegawaian merupakan salah satu faktor ekstrinsik atau sumber ketidakpuasan yang memengaruhi motivasi. maka dengan kondisi perawat yang sebagian besar sudah berstatus pns (pegawai negeri sipil) tingkat motivasinya baik dalam pelaksanaan pendokumentasian asuhan keperawatan. kaplan dan norton (1996) dalam yuwono (2003) mengatakan bahwa pekerja yang puas merupakan prakondisi bagi meningkatnya produktivitas, daya tanggap, mutu, dan layanan pelanggan. sedangkan perspektif motivasi, pemberdayaan, dan keselarasan penting untuk menjamin adanya proses yang berkeseimbangan terhadap upaya pemberian motivasi dan inisiatif yang sebesarbesarnya bagi pegawai. perawat rumah sakit jiwa menur paling banyak memiliki tingkat kepuasan sedang dan motivasinya dalam pengisian format dokumentasi asuhan keperawatan adalah tinggi. ini berarti pada kedua aspek tersebut tidak menjadi penyebab pelaksanaan pendokumentasian asuhan keperawatan yang rendah di rumah sakit jiwa menur. bahkan kepuasan kerja dan motivasi perawat yang baik merupakan modal untuk meningkatkan pelayanan keperawatan. dengan demikian manajemen harus menjaga kondisi yang sudah kondusif dengan prinsip memotivasi pegawai dengan cara yang dikemukakan mangkunegara (2005), yaitu memberikan kesempatan ikut berpartisipasi dalam menentukan tujuan yang akan dicapai oleh pemimpin, mengkomunikasikan segala sesuatu yang berhubungan dengan usaha pencapaian tugas, mengakui bahwa bawahan (pegawai) mempunyai andil di dalam usaha pencapaian tujuan, memberikan otoritas atau wewenang kepada pegawai bawahan untuk sewaktu-waktu dapat mengambil keputusan terhadap pekerjaan yang dilakukannya, dan memberikan perhatian terhadap apa yang diinginkan pegawai bawahan. menurut kaplan dan norton (1996) dalam yuwono (2003) proses pembelajaran memerlukan dukungan motivasi yang besar dan pemberdayaan pegawai berupa delegasi wewenang yang memadai untuk mengambil keputusan diiringi upaya penyesuaian yang terus-menerus sejalan dengan tujuan organisasi. maka perlu diukur penilaian dan harapan perawat terhadap format dokumentasi asuhan keperawatan sehingga bisa disusun format yang sesuai standar tetapi memenuhi harapan perawat, dengan demikian bisa meningkatkan motivasi perawat dalam pendokumentasian asuhan keperawatan. proporsi terbanyak perawat tidak setuju bahwa format dokumentasi asuhan keperawatan cukup praktis, jumlah lembar format banyak, dan lebih dari separuh perawat menilai format dokumentasi perlu direvisi. perawat berharap agar format dibuat lebih simpel atau praktis, pengkajian disederhanakan, format tindakan direvisi biar tidak banyak menulis, kalau bisa mencontreng, dan dibuat format yang lebih spesifik pada kondisi pasien dan obat yang diminum. hal ini merupakan masukan bagi manajemen agar melakukan modifikasi format dokumentasi asuhan keperawatan sehingga menjadi lebih sederhana, tidak memakan banyak waktu, tetapi sesuai standar dokumentasi. ta h u n 2 0 0 8 p e r n a h d i l a k u k a n audit dokumentasi. namun hasilnya tidak terdokumentasi dengan baik. saat itu audit dokumentasi dilakukan dalam rangka persiapan iso 9001: 2000. sejak bulan agustus tahun 2009 audit dokumentasi asuhan keperawatan dilakukan oleh kepala ruangan dan dilaporkan setiap bulan kepada kepala sub bidang asuhan keperawatan dan mutu. data yang dilaporkan tersebut menunjukkan bahwa dari semua pasien yang dirawat pendokumentasiannya sesuai dengan standar penilaian yang meliputi jumlah diagnosa keperawatan, implementasi sesuai diagnosa keperawatan, evaluasi sesuai dengan implementasi, tanda tangan dan nama terang, identitas pasien, tanggal dan jam tindakan, serta tulisan mudah dibaca. padahal pada tanggal 28 oktober sampai dengan 3 nopember 2009, pada saat peneliti mengumpulkan data awal, didapatkan pendokumentasian asuhan keperawatan tidak sesuai dengan standar jurnal ners vol. 5 no. 1 april 2010: 93–106 104 departemen kesehatan republik indonesia, terutama pada aspek diagnosis keperawatan, tindakan, dan evaluasi. hal ini mungkin bisa terjadi karena banyaknya tugas kepala ruangan sehingga pelaksanaan dokumentasi asuhan keperawatan belum optimal. a u d i t d o k u m e n t a s i k e p e r a w a t a n dilakukan untuk menjamin quality control. menurut peneliti, saat ini yang dilakukan oleh kepala ruangan di rumah sakit jiwa menur bukanlah audit, tetapi supervisi, karena menurut martoyo (2000) dalam nursalam (2008) audit adalah prosedur di mana ahli memeriksa catatan-catatan akunting untuk melindungi dari kelalaian dan kesalahan, dan untuk menjamin bahwa catatan tersebut sesuai dengan prinsip-prinsip akunting. seharusnya audit dilakukan oleh ahli, dalam hal ini adalah tim khusus, misalnya tim asuhan keperawatan komite keperawatan yang melakukan audit dokumentasi asuhan keperawatan secara terjadwal, sehingga hasil yang didapatkan lebih objektif untuk menjamin mutu dokumentasi asuhan keperawatan. simpulan dan saran simpulan hasil penelitian menunjukkan bahwa terdapat empat faktor pelaksanaan dokumentasi yang diukur dalam balanced scorecard meliputi: perspektif keuangan, pelanggan, proses bisnis internal, pembelajaran dan kebutuhan. perspektif keuangan bisa disimpulkan bahwa pelaksanaan pendokumentasian asuhan keperawatan di rumah sakit jiwa menur surabaya tidak sesuai standar, yang disebabkan oleh hal-hal berikut waktu yang lama untuk pendokumentasian tindakan dan evaluasi karena format yang kurang memudahkan, format perencanaan yang masih terbatas hanya 7 masalah keperawatan yang dicetak, dan tidak adanya prioritas untuk pelatihan pendokumentasian asuhan keperawatan dalam anggaran pengembangan tenaga keperawatan sejak tahun 2005, meskipun jumlahnya cukup besar. perspektif pelanggan dapat disimpulkan bahwa pelaksanaan pendokumentasian asuhan keperawatan di rumah sakit jiwa menur surabaya tidak berkaitan langsung dengan kepuasan pelanggan, namun pengetahuan pelanggan akan perlunya dokumentasi dan manfaatnya menuntut perawat untuk melakukan pendokumentasian asuhan keperawatan dengan efisien untuk memuaskan pelanggan. p e r s p e k t i f p r o s e s b i s n i s i n t e r n a l dapat disimpulkan bahwa pelaksanaan pendokumentasian asuhan keperawatan di rumah sakit jiwa menur surabaya tidak sesuai standar disebabkan oleh hal-hal berikut rumah sakit jiwa menur surabaya belum mempunyai standar asuhan keperawatan fisik, dan masih ada dua ruangan yang tidak meletakkan petunjuk teknis pendokumentasian asuhan keperawatan jiwa di tempat yang terjangkau sehingga bisa menyulitkan perawat saat memerlukannya, format yang kurang memudahkan terutama pada dimensi waktu pengkajian, tindakan, dan evaluasi. supervisi dilakukan kurang optimal oleh kepala ruangan, yang diakibatkan banyaknya tugas kepala ruangan. perspektif pembelajaran dan pertumbuhan b i s a d i s i m p u l k a n b a h w a p e l a k s a n a a n pendokumentasian asuhan keperawatan di rumah sakit jiwa menur surabaya tidak sesuai standar yang digambarkan hal-hal berikut disebabkan oleh pengetahuan perawat tentang pendokumentasian asuhan keperawatan kurang baik karena sejak tahun 2005 perawat tidak memperoleh pelatihan pendokumentasian asuhan keperawatan, tidak terkait dengan kepuasan kerja dan motivasi perawat, karena kepuasan kerja sedang dan motivasinya tinggi, format dokumentasi yang tidak cukup praktis dan jumlah lembar format yang banyak, sehingga perlu direvisi, dan disebabkan sistem audit yang belum terlaksana dengan baik. saran tim asuhan keperawatan, komite keperawatan bersama bidang perawatan dan bagian rekam medik rumah sakit jiwa menur surabaya untuk menelaah kembali berbagai model format dan sistem pendokumentasian, dan memilih yang paling sesuai dengan rumah sakit jiwa menur, misalnya menggunakan dokumentasi komputer mengingat di semua ruangan sudah tersedia komputer yang online analisis faktor penyebab pelaksanaan pendokumentasian asuhan (yuli anggraini) 105 antara yang satu dengan lainnya, memodifikasi format perencanaan menggunakan nic dan noc, sebaiknya bidang perawatan dan bagian pendidikan dan pelatihan rumah sakit jiwa menur surabaya untuk meningkatkan kualitas sumber daya manusia perawat di rumah sakit jiwa menur. bidang perawatan rumah sakit jiwa menur surabaya untuk mengoptimalkan pendokumentasian asuhan keperawatan melalui pemberdayaan kepala ruangan yaitu dengan cara melakukan supervisi agar perawat memiliki budaya menulis yang sesuai standar dokumentasi departemen kesehatan republik indonesia. bidang perawatan rumah sakit jiwa menur surabaya sebaiknya untuk mengatur pelaksanaan pendokumentasian asuhan keperawatan dengan menata sistem audit dokumentasi keperawatan secara terjadwal yang dilakukan oleh tim khusus yang disahkan oleh bidang perawatan. b a g i p e r a w a t r u m a h s a k i t j i w a menur surabaya diharapkan agar perawat membudayakan pendokumentasian asuhan keperawatan sesuai standar. kepustakaan ali, l., 2005. hubungan pengetahuan dan motivasi perawat dengan pelaksanaan pendokumentasian asuhan keperawatan di rsu dr. h. chasan boesoierie ternate. skripsi tidak dipublikasikan. surabaya: universitas airlangga. a z i s , a . , 2 0 0 5 . p e n g a r u h p e l a t i h a n pendokumentasian asuhan keperawatan terhadap motivasi dan kinerja perawat di rumah sakit umum daerah undata palu, (online), (http://www.scribd.com/ doc, diakses tanggal 25 nopember 2009, jam 15.30 wib). carpenito, l.j., 1999. rencana asuhan dan dokumentasi keperawatan, diagnosa keperawatan dan masalah kolaboratif edisi 2. jakarta: egc. ciptani, m.k., 2000. balanced scorecard sebagai pengukuran kinerja masa depan: suatu pengantar. jurnal akuntansi dan keuangan, 2(1), 21–35. doenges dkk., 2007. rencana asuhan keperawatan psikiatri edisi 3. jakarta: egc. erfan, 2009. pengetahuan dan faktor-faktor yang memepengaruhi, (online),(http:// www.orbetterhealth.wordpress.com., diakses tanggal 27 januari 2010, jam 20.00 wib). hariyati, r.t., 2009. perlukah ada sistem i n f o r m a s i m a n a j e m e n a s u h a n keperawatan, (online), (http://www. fkep.unpad.ac.id., diakses tanggal 11 oktober 2009, jam 20.00 wib). iyer, pw., dan camp, nn., 2005. dokumentasi keprawatan suatu pendekatan proses keperawatan. edisi 3. jakarta: egc. kaplan, rs., dan norton, dp., 2000. balanced scorecard: menerapkan strategi menjadi aksi. terjemahan. jakarta: erlangga. lusianah, 2008. hubungan motivasi dan supervisi dengan kualitas dokumentasi proses keperawatan di instalasi rawat inap rumah sakit marinir cilandak, (online), (http://www.digilib.ui.ac.id., diakses tanggal 25 nopember 2009, jam 15.00 wib). mangkunegara, aaap., 2005. manajemen sumber daya manusia perusahaan. bandung: pt remaja rosdakarya. masithoh, n., 1998. pengaruh unsur-unsur motivasi kerja terhadap prestasi kerja karyawan operasional pada perusahaan sepatu yang go public di jawa timur. surabaya: program pascasarjana ilmu manajemen universitas airlangga. nursalam, 2008. proses dan dokumentasi keperawatan: konsep dan praktik. edisi 2. jakarta: salemba medika. nursalam, 2009. manajemen perawatan: aplikasi dalam praktik keperawatan profesional. edisi 2. jakarta: salemba medika. potter dan perry, 2005. buku ajar fundamental keperawatan. edisi iv volume 1. jakarta: egc. purwanto, s., 2007. kepuasan pasien terhadap pelayanan rumah sakit, (online), (http://www.klinis.wordpress.com, diakses tanggal 28 januari 2010, jam 19.00 wib). jurnal ners vol. 5 no. 1 april 2010: 93–106 106 ti m d e p a r t e m e n k e s e h a t a n r e p u b l i k indonesia, 1994. standar asuhan keperawatan. jakarta: dirjen yanmed direktorat rsu dan pendidikan. ti m d e p a r t e m e n k e s e h a t a n r e p u b l i k indonesia, 2005. instrumen evaluasi standar asuhan keperawatan. jakarta: dirjen yanmed direktorat pelayanan keperawatan. trisnawati, h., 2006. upaya peningkatan kualitas pelayanan keperawatan b e r d a s a r k a n a n a l i s i s f o r m a t dokumentasi asuhan keperawatan: studi di ruang instalasi rawat inap rsud dr. soetomo surabaya. surabaya: program pascasarjana universitas airlangga. yong, h, et al., 2008. balanced scorecard for performance measurement of a nursing organization in a korean hospital, (online), (http://www.ncbi.nlm.nih. gov., diakses tanggal 2 januari 2010, jam 12.00 wib). yuwono, s dkk., 2003. petunjuk praktis penyusunan balanced scorecard, menuju organisasi yang berfokus pada strategi. jakarta: pt gramedia pustaka utama. zelman, wn., et al., 2003. use of the balanced scorecard in health care, (online), (http://www.adhb.govt., diakses tanggal 2 januari, jam 12.10 wib). 71 pengembangan model peningkatan kinerja tenaga keperawatan dalam penerapan manajemen terpadu balita sakit (mtbs) di surabaya (the development of nursing job performance model in the implementation of integrated management of childhood illness (imci) in surabaya) rekawati susilaningrum*, chriswardani suryawati**, septo pawelas arso** *poltekkes kemenkes surabaya, jl. mayjend. prof. moestopo 8a surabaya, e-mail: yahoo.reka.co.id ** fakultas kesehatan masyarakat universitas diponegoro abstract introduction: mtbs is a comprehensive approaches for child illnes and one of the way to reduce an infant and under fi ve years morbidity and mortality rateas well as appropriately to apply in public health center. in fact, mtbs has not been implemented as procedure guidance. the objective of the study was to examie the implementation of mtbs viewed from van meter and van horn model as basic measurement and the goal of policy, the sources of policy, a communication among organisation and the implementation of mtbs. method: the study was qualitative design. data were collected by in depth interview. six nurse and midwife were recruited as a sample by purposive sampling. informant triangulation were head of phc and head of deputy health services. analysis was by means of content analysis.result showed that the written and indicator of basic measurement and goal policy was not available yet. sources of policy, namely health. result: for the health workers was suffi cient and they have a good competency to carry out mtbs and have workload focus on three types. fasilities was no room, form was diffi cult to provide, instruments and medication was suffi cient available, but there was no specifi c funding. communication was carried out only on the training program by mtbs fascilitator. characteristic of beaurocracy structure (sop) consists of preparation, implementation, reporting and recording.there was no specifi c preparation, it only an introduction dessimination was done. the implementation was not as modul and the form of mtbs was not used anymore. the implementation of mtbs lack support from public health center and health care district of surabaya. healh worker unmotivated to implement mtbs. discussion: the implementation of mtbs lack support from health worker, public health center and health care district of surabaya.it is recomended that health care district &public health center cooperatively should have commitment to assess the implementation of mtbs in surabaya. keywords: development integrated management of childhood illness, public health center, nursing (nurse and midwife) pendahuluan data riset kesehatan dasar (riskesdas) tahun 2007, ada beberapa penyakit utama yang menjadi penyebab kematian bayi dan balita. pada kelompok bayi (0–11 bulan), dua penyakit terbanyak yang menyebabkan kematian adalah diare sebesar 31,4% dan pneumonia 24%, sedangkan untuk balita, kematian akibat diare sebesar 25,2%, pneumonia 15,5%, demam berdarah dengue (dbd) 6,8% dan campak 5,8% (departemen kesehatan b, 2008). penyakit-penyakit tersebut umumnya terjadi bersamaan dan sebenarnya bisa ditangani di pelayanan tingkat puskesmas apabila anak yang sakit terdeteksi sejak awal. oleh karena itu who dan unicef mengembangkan suatu strategi atau pendekatan yang dinamakan manajemen terpadu balita sakit (selanjutnya disingkat mtbs) atau integrated management of childhood illness (imci). indonesia telah mengadopsi pendekatan manajemn terpadu balita sakita (mtbs) sejak tahun 1996 jurnal ners vol. 7 no. 1 april 2012: 71–80 72 dan implementasinya dimulai tahun 1997 (departemen kesehatan, 2008). mtbs merupakan salah satu solusi mengurangi angka kematian dan kesakitan bayi dan balita serta sangat sesuai diterapkan di puskesmas. sebagian besar balita sakit yang dibawa berobat ke puskesmas, jarang mempunyai keluhan tunggal. menurut data who, tiga dari empat balita sakit seringkali memiliki beberapa keluhan lain yang menyertai dan sedikitnya menderita 1 dari 5 penyakit tersering pada balita yang dapat diakomodir oleh mtbs. tenaga kesehatan yang melaksanakan mtbs harus mengikuti pelatihan terlebih dahulu agar dapat mengenali secara dini dan cepat semua gejala anak sakit, sehingga dapat menentukan apakah anak sakit ringan, berat dan perlu dirujuk. jika penyakitnya tidak parah, petugas dapat memberikan pengobatan atau tindakan sesuai pedoman mtbs. penggunaan mtbs belum berjalan secara efektif, dalam pelaksanaannya. kondisi dialami oleh sebagian besar puskesmas di indonesia, karena berbagai kendala antara lain terbatasnya jumlah tenaga yang dilatih mtbs, perpindahan tenaga, kurang lengkapnya sarana dan prasarana pendukung. seluruh propinsi di indonesia, puskesmas yang telah melaksanakan mtbs hingga akhir 2009 sebesar 51,59%. kriteria melaksanakan bila dalam menangani balita sakit minimal 60% dari jumlah kunjungan balita sakit menggunakan modul mtbs (departemen kesehatan c, 2009). pelaksanaan di propinsi jawa timur, mtbs di setiap puskesmas juga belum sesuai dengan yang diharapkan. menurut laporan penerapan mtbs di kabupaten atau kota wilayah propinsi jawa timur (2009), dari 933 puskesmas di jawa timur, yang telah melaksanakan mtbs sekitar 74,4% (692 puskesmas) di antara jumlah puskesmas tersebut, hanya 0,7% puskesmas yang telah menangani balitanya dengan mtbs di atas 60% dari seluruh balita yang berkunjung. jika dibandingkan dengan data nasional, maka persentase puskesmas yang menerapkan mtbs di jawa timur masih memprihatinkan. data dari sub-bagian penyusunan program dinas kesehatan kota surabaya (2009), ada kenaikan persentase rata-rata balita sakit yang ditangani dengan mtbs pada tahun 2009 jika dibandingkan tahun 2008. pada tahun 2009 persentasinya sekitar 30,4% dari seluruh balita sakit yang berkunjung ke puskesmas, sedangkan pada tahun 2008 hanya sekitar 11,2%. kenaikan persentasi ini tidak selalu karena meningkatnya jumlah pelayanan pada balita dengan mtbs. ada beberapa puskesmas yang mengalami penurunan persentasi balita yang ditangani dengan mtbs, bahkan ada puskesmas yang tidak menggunakan mtbs lagi di samping itu, sebagian besar puskesmas menerapkan mtbs belum sesuai dengan harapan pemerintah, meskipun sebagian besar puskesmas telah ada petugas mtbs. merujuk model kebijakan implementasi dari van meter dan van horn, ada 6 faktor yang saling berkaitan dan berpengaruh terhadap implementasi kebijakan yaitu ukuran-ukuran dasar dan tujuan kebijakan, sumber-sumber kebijakan, komunikasi antarorganisasi dan kegiatan-kegiatan pelaksanaan, karakteristik badan-badan pelaksana, kondisi-kondisi ekonomi, sosial dan politik serta kecenderungan pelaksana. faktor-faktor tersebut bekerja secara simultan dan berinteraksi satu sama lain untuk membantu dan menghambat implementasi kebijakan (budi, 2008). tujuan penelitian ini adalah untuk mengembangkan model kinerja tenaga keperawatan dalam implementasi mtbs di puskesmas wilayah dinas kesehatan kota surabaya ditinjau dari ukuran dasar dan tujuan kebijakan, sumber kebijakan, komunikasi antarorganisasi dan kegiatan pelaksanaan, karakteristik badan pelaksana, lingkungan ekonomi, sosial dan politik serta kecenderungan pelaksana. bahan dan metode jenis penelitian yang digunakan adalah penelitian kualitatif yaitu salah satu metode penelitian yang bertujuan untuk mendapatkan pemahaman tentang kenyataan melalui proses berpikir induktif (morse, 1995). berdasarkan pendekatan waktu pengumpulan data dilakukan secara cross sectional yang dilakukan sekaligus pada satu kali pengamatan (point time approach) (sugiyono, 2008). pengembangan model peningkatan kinerja tenaga keperawatan (rekawati susilaningrum) 73 pengumpulan data dilakukan dengan cara wawancara mendalam (indepth interview) yaitu proses memperoleh keterangan untuk tujuan penelitian dengan cara tanya jawab sambil bertatap muka antara pewawancara dan informan, dengan menggunakan pedoman wawancara (basrowi, 2002). informan pada penelitian ini dibedakan menjadi 2 kelompok yaitu informan inti yang merupakan petugas pelaksana mtbs dalam hal ini bidan atau perawat di puskesmas yang telah mengikuti pelatihan mtbs dan informan triangulasi yaitu kepala puskesmas dan kepala sie kesehatan ibu dan anak (kia) dinas kesehatan kota (dkk) surabaya. dalam penelitian kualitatif, populasi diistilahkan situasi sosial yang terdiri dari 3 elemen yaitu tempat, pelaku dan aktivitas yang berinteraksi secara sinergis (sugiyono, 2008). populasi pada penelitian ini adalah petugas yang telah dilatih mtbs yang berada di puskesmas wilayah dinas kesehatan kota (dkk) surabaya. sampel pada penelitian kualitatif disebut subjek. subjek pada penelitian ini adalah perawat atau bidan pelaksana mtbs yang berasal dari 6 puskesmas yang terdiri dari dua puskesmas yang cakupan mtbs di bawah 25%, dua puskesmas yang cakupan mtbs sekitar 50%, dua puskesmas yang telah melaksanakan mtbs di atas 75%. adapun kriteria inklusi dari penelitian ini adalah bidan atau perawat yang bertugas di puskesmas kota surabaya yang telah dilatih mtbs dan sebagai penanggung jawab mtbs, tidak sedang cuti, ijin atau tugas belajar serta bersedia menjadi informan. teknik pengambilan sampel atau subjek pada penelitian secara purposive sampling yaitu teknik pengambilan sampel dengan pertimbangan tertentu yang dibuat oleh peneliti berdasarkan ciri atau sifat-sifat populasi yang telah diketahui (nursalam, 2007). variabel yang diteliti adalah faktorfaktor yang memengaruhi implementasi berdasarkan teori van meter dan van horn yaitu variabel pertama ukuran dan tujuan kebijakan yaitu pernyataan semacam surat edaran yang menyatakan maksud dilaksanakannya mtbs. dalam bentuk aturan pelaksanaan dan indikator keberhasilan yang berupa target jumlah balita yang ditangani dengan mtbs, variabel yang kedua yaitu sumber kebijakan di mana ketersediaan sumber-sumber daya yang digunakan untuk melaksanakan mtbs, terdiri dari petugas dan fasilitas, variabel ketiga adalah komunikasi yaitu penyampaian informasi tentang apa dan bagaimana penerapan mtbs, kapan dan mengapa harus dilaksanakan, yang dilakukan oleh penanggung jawab program mtbs di dkk atau atasan lainnya, variabel keempat yaitu karakteristik badan pelaksana di mana merupakan karakteristik, norma atau hubungan yang terjadi berulang-ulang di puskesmas dalam bentuk prosedur kerja atau standard operating procedure (sop), variabel kelima adalah kondisi ekonomi, sosial dan politik yaitu lingkungan yang dapat mendukung pelaksanaan mtbs dalam hal ini kelompok pembuat kebijakan maupun masyarakat yang gambar 1. model pengembangan kinerja tenaga keperawatan pada implementasi mtbs (diadaptasi dari teori van meter dan van horn (1975) jurnal ners vol. 7 no. 1 april 2012: 71–80 74 memanfaatkan pelayanan puskesmas, dan variabel keenam merupakan kecenderungan pelaksana adalah kecenderungan sikap petugas mtbs yang bisa menghambat atau mendukung pelaksanaan mtbs di puskesmas. peneliti menggunakan alat bantu untuk memperoleh data yang diperlukan berupa pedoman wawancara yang diperlukan untuk menggali informasi tentang tujuan kebijakan, komunikasi, sumber daya, sikap dan prosedur kerja, tape recorder untuk merekam semua informasi yang diberikan oleh informan. dalam menjaga validitas data maka dilakukan teknik triangulasi yaitu pengumpulan data dari berbagai sumber atau informan yang berbeda (lincoln, 2009). adapun informan triangulasi adalah kepala puskesmas berjumlah 6 orang dan sie kia atau penanggung jawab mtbs dkk surabaya adalah 1 orang. data yang diperoleh dengan wawancara mendalam, dilakukan sampai tuntas sehingga datanya jenuh. selanjutnya data diolah dengan analisis isi (content analysis) yaitu analisis berdasarkan topik dengan cara memilah-milah melalui tahapan (lincoln, 2009) penyederhanaan, reduksi data (data reduction) yaitu merangkum, memilih hal-hal yang pokok, fokus pada halhal yang penting, dicari tema dan polanya. data yang telah direduksi akan memberikan gambaran yang lebih jelas, penyajian data (data display), dalam bentuk uraian singkat (bentuk naratif), matriks dan hubungan antarkategori, penarikan kesimpulan, verifikasi simpulan (conclusion drawing). jika data yang diperoleh valid dan konsisten, maka kesimpulan yang diperoleh akan kredibel. hasil data diambil di 6 puskesmas di surabaya yang telah ada petugas mtbs yaitu puskesmas 1, puskesmas 2, puskesmas 3, puskesmas 4, puskesmas 5, puskesmas 6. setiap puskesmas, petugas mtbs rata-rata 2–3 orang yang terdiri dari dokter dan perawat atau bidan. jumlah kunjungan bayi dan balita sakit, paling sedikit di puskesmas 1 dengan jumlah 3235 balita, yang paling banyak di puskesmas 2 yaitu 87043 balita (dinas kesehatan kota surabaya, 2009). jika dirata-rata dalam satu hari, jumlah kunjungan sekitar 13 balita untuk pkm 1 dan 33 balita untuk pkm 2. jika mtbs dilaksanakan, di pkm 1 waktu yang dibutuhkan jauh lebih sedikit jika dibandingkan di pkm 2, karena setiap pasien memerlukan waktu sekitar 10 menit. ukuran dasar dan tujuan kebijakan hasil wawancara menunjukkan bahwa selama ini pedoman untuk melaksanakan mtbs, berdasarkan modul dan bagan mtbs. pedoman selain modul seperti surat edaran dari dkk yang berisi tentang aturan pelaksanaan mtbs atau indikator keberhasilan yang bisa dijadikan pijakan atau dasar untuk melaksanakan mtbs belum ada. sebagian informan mengatakan ada kesepakatan bahwa balita yang diperiksa dokter berarti sudah di mtbs. beberapa kepala puskesmas mengatakan bahwa sebaiknya ada target atau indikator agar petugas merasa ada pressurenya. menurutnya, petugas puskesmas akan mendahulukan program yang ada targetnya sebagaimana komentar berikut ini “...perlu target saya kira. selama ini mtbs tidak ada pressure dan batasannya tidak jelas. kita akan mendahulukan program yang ada pressurenya. targetnya berapa misalkan 100 harus bisa dicapai berapa lama..itu untuk mtbs ndak ada.... “: saya kira perlu untuk memberikan motivasi. dari dkk memang tidak ada target, terkesan tenang-tenang saja, tidak seperti program lain yang dikejar-kejar. jadi saya agak kendor... kepala bidang pelayanan kesehatan selaku informan triangulasi mengatakan bahwa sejauh ini dkk belum membuat suatu aturan pelaksanaan mtbs dan tidak menetapkan target, karena memaklumi kondisi puskesmas yang banyak target standar pelayanan minimal (spm). kalau memang perlu target seharusnya pemerintah pusat yang menetapkannya, karena pemerintah yang mengadakan pelatihan mtbs, namun bukan berarti dkk mengabaikan program mtbs. setiap kali ada pertemuan kepala puskesmas atau pertemuan bidan atau perawat selalu diingatkan agar tidak lupa melaksanakan mtbs. pengembangan model peningkatan kinerja tenaga keperawatan (rekawati susilaningrum) 75 sumber kebijakan sebagian petugas mengatakan untuk jumlah tenaga mtbs saat ini sudah cukup meskipun ditambah tidak jaminan untuk dilaksanakan karena ruangan tidak ada, banyak pasien dan berbagai tugas yang harus diselesaikan. beberapa kepala puskesmas juga mengatakan tidak perlu ada penambahan petugas mtbs karena pelayanan sudah dilakukan oleh dokter. berikut komentarnya. “...saya kira sudah cukup, toh yang menangani pasien sudah dokternya.. “...dua petugas yang dilatih saya kira cukup. karena semua pasien sudah ditangani dokter. intinya kan sama dengan kita kuliah, cuma dibuat modul. kalo perlu dirujuk ya dirujuk.. s e g i k o m p e t e n s i , s e m u a p e t u g a s m e n g a t a k a n s e b e n a r n y a m a m p u u n t u k melaksanakan. menurut mereka mtbs cukup mudah, tetapi memerlukan waktu yang lama dan ketenangan pasien, sedangkan beban kerja, semua petugas mengatakan bahwa beban kerja yang harus dilaksanakan lebih dari 3 jenis kegiatan. beban kerja ini berupa tugas pokok dan fungsi (tupoksi) serta tugas tambahan lain. kegiatan-kegiatan tersebut sudah menyita waktu sehingga kesempatan melaksanakan mtbs tidak ada. kepala puskesmas juga mengakui bahwa petugas mtbs mempunyai tugas rangkap sebagaimana komentar berikut. “..kalau beban kerja di puskesmas.. jika dihitung dengan rumus harusnya pegawainya kurang ya, tapi memang bebannya tumpang tindih dari dulu seperti itu, sehingga sulit kalau harus pegang mtbs saja..tk6 komunikasi semua petugas mengatakan kalau penyampaian informasi tentang pelaksanaan mtbs dilakukan saat pelatihan oleh tim fasilitator kepada peserta pelatihan. tim fasilitator juga menyampaikan tujuan dan latar belakang dilaksanakannya mtbs yaitu untuk memberikan pelayanan yang terintegrasi kepada bayi dan balita sakit. setelah pelatihan dan kembali ke puskesmas, petugas diharapkan melaksanakan deseminasi kepada staf dan karyawan puskesmas. ada kepala puskesmas yang menyarankan kalau ada program baru dari pemerintah hendaknya dilihat dulu dilapangan apakah bisa diaplikasikan. petugas mengatakan bahwa setelah pelatihan terkesan dibiarkan saja tidak ada kelanjutannya. evaluasi paska pelatihan hampir tidak pernah dilakukan. pada tahun 2010 pernah dievaluasi yaitu mengerjakan test dengan cara mengisi formulir mtbs dengan suatu simulasi. menurut kepala bidang pelayanan k e s e h a t a n , e v a l u a s i t e l a h d i l a k u k a n pascapelatihan dan refresh (penyegaran). memang dalam pelaksanaannya evaluasi dan supervisi tidak khusus untuk mtbs tetapi bersamaan dengan program lain dan rutin dilaksanakan setiap tahun. penyegaran sudah dimulai setahun terakhir. karakteristik badan pelaksana (struktur birokrasi, sop) s e b a g i a n b e s a r p e t u g a s m t b s mengatakan melakukan diseminasi informasi mtbs kepada seluruh petugas puskesmas dalam suatu pertemuan rutin yang dihadiri kepala puskesmas dan staf. diseminasi dilakukan cukup sekali pascapelatihan saat ada minilokakarya atau pertemuan rutin puskesmas. persiapan logistik dan formulir mtbs, hampir seluruh petugas mengatakan tidak ada persiapan khusus, sedangkan untuk penyesuaian alur pelayanan, semua petugas mengatakan tidak ada perubahan alur pelayanan meskipun dulu menerapkan mtbs. sebagian besar petugas mengatakan dalam pelaksanaan mtbs langkah-langkah dalam formulir mtbs dipersingkat agar tidak memakan waktu, namun sebagian lain mengatakan tidak perlu direvisi atau dipersingkat nanti malah tidak sesuai. seluruh petugas juga mengatakan bahwa sekarang tidak melaksanakan mtbs, karena tidak ada formulir, ruangan belum ada dan banyak kegiatan yang harus dilaksanakan. seluruh petugas mengatakan bahwa pencatatan pada formulir mtbs tidak dilakukan lagi, baik yang bermasalah dengan formulir maupun yang tidak. meskipun terpaksa diisi, jurnal ners vol. 7 no. 1 april 2012: 71–80 76 dilakukan setelah pasien sepi dan seingatnya dan terkadang hanya klasifi kasinya saja yang ditulis. apalagi sebagian kepala puskesmas mengatakan kalau pencatatan pada formulir mtbs sulit dilaksanakan karena waktu yang cukup lama. berikut komentarnya: “..dengan tanpa menulis di form mtbs saja waktu pelayanan kita terbatas apalagi dengan mengisi mtbs. kita sebenarnya sudah melaksanakan langkah mtbs hanya tidak dicatat di form. pelaksanaan mtbs tidak masalah tapi pencatatannya yang sulit karena terkendala waktu dan banyaknya pasien..tk5 “..gimana ya, masalahnya semua balita sudah ditangani dokter sehingga pola pikirnya sdh paham.. sebagaimana dengan pencatatan, pelaporan yang digunakan juga tidak memerlukan perubahan. dengan demikian semua pencatatan dan pelaporan yang digunakan tidak mengalami perubahan. lingkungan politik, sosial dan ekonomi lingkungan politik, sosial dan ekonomi adalah lingkungan yang dapat mendukung pelaksanaan mtbs yaitu pembuat kebijakan m a u p u n k e l o m p o k m a s y a r a k a t y a n g memanfaatkan pelayanan puskesmas dan merupakan faktor eksternal puskesmas. sebagian besar petugas mengatakan bahwa sejauh ini belum ada keterlibatan dan perhatian dari pihak luar seperti tokoh masyarakat, dan media karena kenyataannya mtbs belum dilaksanakan. beberapa petugas mengatakan dulu pernah memberitahu pasien saat akan dilayani dengan mtbs dan pasien mau dan senang karena merasa diperhatikan. namun sekarang tidak lagi, karena jika anaknya rewel atau antrian panjang, ibu minta anaknya dilayani dengan cepat. kepala puskesmas juga mengatakan bahwa mtbs hanya bisa dijalankan sesuai kondisi puskesmas, belum ada upaya untuk melibatkan pihak luar agar mtbs bisa berjalan dengan baik. ada beberapa kepala p u s k e s m a s y a n g m e n g a t a k a n b a h w a sebenarnya mtbs ditujukan untuk tenaga perawat dan bidan, sehingga lebih sesuai diterapkan di daerah yang tenaga dokternya terbatas. dkk juga belum memberikan perhatian lebih terhadap mtbs, karena mengutamakan program yang ditentukan standar pelayanan minimalnya (spm), sebagaimana pernyataan berikut: “..bukan bermaksud mengabaikan program mtbs, kalau memang ada keharusan untuk dilaksanakan, pemerintah pusat seharusnya juga memfasilitasi, misalnya dengan menentukan target atau indikator. setelah tidak ada pelatihan, pemerintah terkesan diam.. kecenderungan (sikap) pelaksana beberapa petugas yang mengatakan mtbs cukup bagus untuk diterapkan di puskesmas, tetapi untuk melaksanakannya sulit. namun sebagian informan mengatakan terlalu rumit, perlu waktu lama dan tidak cocok jika diterapkan dikota. sebagian besar petugas mengatakan pelaksanaannya belum sesuai dengan prosedur. form mtbs diisi setelah pasien sepi dan seingatnya saja karena waktu pelaksanaannya lebih lama sehingga kurang efektif. petugas tidak yakin jika mtbs dapat membantu menurunkan angka kesakitan dan kematian bayi. sebagian besar mengatakan semua tergantung pola hidup pasien itu sendiri. berbagai pernyataan yang disampaikan oleh petugas mtbs maupun informan triangulasi dapat dijelaskan bahwa ada keterkaitan antara keenam faktor tersebut. tidak jelasnya ukuran dasar dan tujuan kebijakan mempunyai dampak tidak langsung terhadap kecenderungan sikap petugas yang terwujud belum dilaksanakannya mtbs. sumber-sumber kebijakan yang kurang memadai memengaruhi komunikasi dan pelaksanaan mtbs. pada sisi yang lain kecenderungan para pelaksana dapat dipengaruhi secara langsung tersedianya sumber-sumber. kecenderungan petugas yang enggan melaksanakan mtbs dipengaruhi oleh sumber-sumber daya yang kurang memadai. jika sumber-sumber tersedia, para pelaksana akan melaksanakan kebijakan dengan senang hati, sebaliknya jika tidak cukup tersedia sumbersumber maka dukungan dan ketaatan terhadap program akan menurun. pengembangan model peningkatan kinerja tenaga keperawatan (rekawati susilaningrum) 77 pembahasan ukuran dasar dan tujuan kebijakan mtbs memang tidak dimasukkan dalam target spm, namun digunakan sebagai langkah kegiatan untuk memenuhi target spm (departemen kesehatan e, 2004), karena bukan target, maka pelaksanaannya kurang mendapat perhatian. kondisi ini terjadi di lapangan, petugas lebih mengutamakan program yang ada target dan pressure karena jika tidak terpenuhi akan mendapatkan surat peringatan. adanya ukuran dasar dan standar kebijakan sebenarnya dapat membantu untuk mengevaluasi dan membuat langkah selanjutnya, apakah mtbs dibiarkan saja atau bisa dijalankan dengan beberapa revisi. selama ini telah begitu banyak biaya yang dikeluarkan untuk pelaksanaan mtbs, diantaranya dengan pelatihan mtbs kepada tenaga puskesmas diseluruh indonesia. oleh karena itu diperlukan komitmen pejabat atau pengelola program mtbs. sumber kebijakan penambahan petugas, sulit terwujud saat ini. petugas yang telah dilatih, diharapkan menjadi tutor bagi petugas lainnya yang belum dilatih mtbs. kenyataan di lapangan, petugas yang telah dilatih memang menginformasikan tentang mtbs kepada petugas lainnya tetapi sifatnya pengenalan dan hanya sekali disosialisasikan. anggapan bahwa semua anak yang ditangani oleh dokter berarti telah melaksanakan mtbs, perlu ditelaah apakah semua dokter sudah mengikuti pola pikir secara komprehensif sebagaimana pada mtbs. saat ini belum semua dokter puskesmas mengikuti pelatihan mtbs. menurut teori edward, jumlah staf (petugas mtbs) tidak selalu mempunyai efek positif bagi implementasi kebijakan. hal ini berarti bahwa jumlah staf yang banyak tidak secara otomatis mendorong implementasi yang berhasil. namun kekurangan staf juga dapat menimbulkan persoalan pelik yang menyangkut implementasi kebijakan yang efektif (budi, 2008). kompetensi yang telah dimiliki petugas seharusnya diterapkan saat melayani pasien agar tidak lupa dan semakin terampil. pelayanan dapat dilakukan secara bertahap sesuai jumlah kunjungan pasien (departemen kesehatan d, 2008). semua petugas mengatakan belum ada ruangan tersendiri untuk melaksanakan mtbs. sebagian besar mengatakan ruang tersendiri perlu karena pelayanan pada anak berbeda dengan dewasa. anak perlu ketenangan dan merasa nyaman sehingga memperlancar pelayanan. pengadaan alat dan obat-obatan untuk pelaksanaan mtbs, tidak masalah karena sama dengan yang digunakan untuk pelayanan seharihari dan jumlahnya cukup. namun pengadaan formulir yang menjadikan kendala. sebagian petugas mengatakan kalau saat ini formulir tidak ada. berkaitan dengan pendanaan, semua kepala puskesmas mengatakan tidak ada anggaran khusus atau insentif untuk pelaksanaan mtbs, demikian juga program lain. menurut kepala bidang pelayanan kesehatan (ka. bid. yankes), bahwa kebijakan pemerintah kota, anggaran kesehatan diutamakan untuk meningkatkan kesehatan masyarakat. fasilitas seperti ruangan tersendiri memang diperlukan namun bisa bersamaan dengan pelayanan anak lainnya. pelaksanaan mtbs memang tidak memerlukan dana atau biaya yang besar. peralatan dan obat yang diperlukan tidak ada yang khusus karena sudah tersedia cukup. penyediaan fasilitas yang layak untuk mendukung suatu implementasi yang efektif memang tidak mudah. namun jika para pembuat kebijakan tidak memperhatikan masalah sumber-sumber daya tersebut, kemungkinan kecil mtbs bisa berjalan dengan baik. fasilitas fi sik merupakan sumber penting dalam implementasi. seorang pimpinan mungkin mempunyai staf yang memadai, tetapi tanpa ada fasilitas besar kemungkinan implementasi tidak akan berhasil (budi, 2008). komunikasi komunikasi tentang implementasi mtbs ini seharusnya tidak hanya memberikan informasi tentang cara menggunakan bagan dan mengisi formulir saja, namun ukuran dasar dan tujuan kebijakan juga perlu diinformasikan. selama ukuran dasar dan tujuan kebijakan jurnal ners vol. 7 no. 1 april 2012: 71–80 78 belum dirumuskan dengan jelas, pelaksanaan mtbs tidak akan berjalan dengan baik. selain itu, seharusnya komunikasi dilakukan secara konsisten dan berkesinambungan. menurut teori van mater dan van horn, implementasi yang berhasil seringkali membutuhkan mekanisme-mekanisme dan prosedur lembaga. hal ini sebenarnya akan mendorong kemungkinan yang lebih besar bagi atasan untuk mendukung pelaksana melakukan kebijakan berdasar ukuran dasar dan tujuan kebijakan secara konsisten (terry, 2008). karakteristik badan pelaksana (struktur birokrasi, sop) diseminasi mtbs seharusnya dilakukan kepada semua petugas puskesmas karena ada keterkaitan peran dan tanggung jawab antar petugas di puskesmas bila perlu dihadiri oleh supervisor dari dinas kesehatan kabupaten atau kota. demikian juga dengan persiapan logistik agar tidak mengganggu kelancaran pelaksanaan mtbs. sesuai dengan pedoman pelaksanaan mtbs di puskesmas, seharusnya petugas mempersiapkan logistik dan formulir serta melakukan pengecekan apakah di puskesmasnya masih tersedia peralatan dan obat yang dibutuhkan agar pelaksanaan mtbs tidak terhambat (departemen kesehatan, 2008). salah satu konsekuensi penerapan mtbs adalah waktu pelayanan menjadi lebih lama. guna mengurangi waktu tunggu, perlu dilakukan penyesuaian alur pelayanan, untuk memperlancar pelayanan. penyesuaian alur pelayanan balita sakit harus disepakati oleh seluruh petugas kesehatan yang ada di puskesmas saat diseminasi informasi (mtbs, 2008). penyesuaian alur ini yang belum pernah disosialisasikan kepada petugas puskesmas lainnya. memang memerlukan suatu persiapan khusus jika mtbs dilaksanakan. pelaksanaan mtbs memerlukan keterlibatan semua petugas. sebenarnya dengan mtbs, memudahkan petugas untuk mendeteksi dan menjaring secara dini penyakit-penyakit yang sering menyebabkan kematian pada bayi dan balita di antaranya pneumonia, diare dan gangguan gizi. namun saat ini yang diutamakan oleh puskesmas adalah pelayanan pasien sehingga pasien puas. dkk mempunyai kebijakan secara bertahap yaitu setiap puskesmas diharapkan mendapatkan sertifi kasi iso 9001–2008 tentang standar mutu pelayanan kesehatan. penelitian yang dilakukan djoko mardijanto dan mubasysyir hasanbasri di pekalongan tahun 2005 juga menyebutkan bahwa pelaksanaan mtbs tergantung pada petugas yang sudah pernah dilatih dan tidak bertambah baik selama periode tiga tahun. lingkungan politik, sosial dan ekonomi saat ini puskesmas masih memfokuskan program unggulan masing-masing karena mempunyai karakter yang berbeda antara satu dengan lainnya. perbedaan ini yang dikelola oleh puskesmas untuk menjadi suatu program unggulan. situasi ini didukung dengan pendapat bahwa mtbs untuk perawat dan bidan, jelas akan sulit untuk menerapkan mtbs di surabaya. sebagai pengguna pelayanan, masyarakat akan paham jika dilayani dengan waktu agak lama, yang penting ada informasi lebih dahulu, yang perlu dicermati dari lingkungan politik, sosial dan ekonomi ini adalah selama ini pemerintah mengadakan pelatihan mtbs difokuskan hanya kepada petugas di puskesmas. sementara puskesmas bukan satu-satunya fasilitas pelayanan kesehatan dasar, ada fasilitas pelayanan dasar milik perorangan atau swasta yang juga melayani kesehatan anak yang petugasnya mungkin belum pernah ikut pelatihan mtbs. kecenderungan (sikap) pelaksana pernyataan-pernyataan petugas yang telah disampaikan pada hasil dapat diartikan cenderung kurang mendukung pelaksanaan mtbs. menurut teori g. edwards, pelaksana yang memiliki kecenderungan sikap yang baik, akan dapat menjalankan kebijakan dengan baik. demikian sebaliknya, jika pelaksana bersikap negatif atau menolak maka implementasi kebijakan akan menghadapi kendala yang serius (dwiyanto, 2009). penelitian yang dilakukan nocholas d. walter (2009) di tanzania menunjukkan kepatuhan petugas yang rendah terhadap langkah pengembangan model peningkatan kinerja tenaga keperawatan (rekawati susilaningrum) 79 tindakan mtbs. sedangkan penelitian yang dilakukan christiane horwood, dkk. (2009) di afrika selatan menunjukkan bahwa mtbs merupakan metode yang efektif memperoleh keterampilan, tetapi lebih banyak waktu untuk penerapannya sehingga diperlukan solusi inovatif keterampilan yang diperoleh petugas tetap memadai dan terpelihara. simpulan dan saran simpulan ukuran dasar dan tujuan kebijakan berupa aturan pelaksanaan dan indikator keberhasilan saat ini belum ada rumusan t e r t u l i s . s u m b e r k e b i j a k a n b e r u p a ketersediaan sumber daya, dikelompokkan menjadi 2 yaitu petugas dan fasilitas. petugas meliputi jumlah tenaga, kompetensi dan beban kerja. jumlah petugas mtbs yang ada saat ini dianggap cukup, namun jika mtbs dilaksanakan pada semua balita, petugas harus ditambah. fasilitas meliputi ruangan, peralatan, obat-obatan dan formulir semua puskesmas belum memiliki ruangan tersendiri, tetapi kepala puskesmas belum ada rencana untuk menyediakannya. komunikasi antar organisasi dan kegiatan pelaksanaan dilakukan oleh fasilitator pada saat pelatihan dan sesekali oleh petugas kia saat ada pertemuan. karakteristik badan pelaksana, dalam bentuk prosedur kerja (sop), yang meliputi; persiapan, pelaksanaan, pencatatan dan pelaporan mtbs. pencatatan dan pelaporan hasil pelayanan mtbs selama ini yang dilakukan adalah mencatat jumlah balita sakit yang dilayani dokter, tanpa menggunakan formulir mtbs. ada kesepakatan bahwa balita sakit yang diperiksa dokter, sudah dianggap melaksanakan mtbs. lingkungan politik, sosial dan ekonomi. kepala puskesmas mendukung sebisanya sesuai kondisi puskesmas dan belum menjalin kerja sama dengan pihak lain karena mtbs belum dijalankan. k e c e n d e r u n g a n p e l a k s a n a d a l a m implementasi mtbs berupa kecenderungan sikap petugas yang bisa menghambat pelaksanaan mtbs di puskesmas. saran bagi dkk dan puskesmas sebaiknya bersama-sama dengan dkk mengkaji ulang penerapan mtbs apakah perlu diterapkan di puskesmas kota surabaya. mengusulkan ke dkk untuk menentukan indikator keberhasilan mtbs agar mendapatkan perhatian dari petugas, ada komitmen untuk memenuhi fasilitas yang diperlukan oleh puskesmas sesuai kebutuhannya, evaluasi dan supervisi dari dkk yang berkesinambungan terhadap programprogram puskesmas serta ada tindak lanjutnya dan dkk memodifi kasi formulir mtbs yang meringankan petugas dan hemat waktu. saat ini formulir yang baru memang sudah lebih ringkas dan dibukukan, tapi justru terkesan pemborosan karena 1 anak diberikan 1 buku untuk 60 kunjungan. bagi peneliti lain ada penelitian lain tentang efektivitas mtbs yaitu dengan membandingkan balita yang dilayani berdasar mtbs dengan balita yang dilayani dengan cara konvensional sebelum ada mtbs. kepustakaan budi, w., 2008. kebijakan publik, teori dan proses. yogyakarta: medpress. christiane horwood, et al., 2009. the training exprience and implementing imci in south afrika. bulletin of the world health organization, (online), (http:// www.biomedcentral.com) departemen kesehatan, 2008a. manajemen te r p a d u b a l i t a s a k i t m o d u l 1 (pengantar). jakarta: depkes, who dan usaid. departemen kesehatan, 2008b. laporan hasil riset kesehatan dasar (riskesdas) i n d o n e s i a ta h u n 2 0 0 7 ; j a k a r t a : badan penelitian dan pengembangan kesehatan. departemen kesehatan, 2009c. materi pada pertemuan nasional program kesehatan anak, manajemen terpadu balita sakit. jakarta: direktorat bina kesehatan anak. jurnal ners vol. 7 no. 1 april 2012: 71–80 80 departemen kesehatan, 2008d. pedoman penerapan mtbs di puskesmas (mtbs modul 7). jakarta: depkes ri, who dan usaid. departemen kesehatan, 2004e. keputusan menteri kesehatan tentang petunjuk teknis standar pelayanan minimal bidang kesehatan di kabupaten/kota. jakarta. dwiyanto, i., 2009. kebijakan publik berbasis dynamic policy analisys. yogyakarta: gava media. terry george, r., 2008. prinsip-prinsip manajemen. jakarta: pt bumi aksara. dinas kesehatan kota surabaya, 2009. laporan tahunan dinas kesehatan kota surabaya. surabaya: dinas kesehatan kota surabaya. mardiyanto, d., hasanbasri, m., 2008. evaluasi manajemen terpadu balita sakit di pekalongan (evaluation of integrated management of childhood illness program in pekalongan district of central java). jmpk ugm, 08. morse janice, mfp a., 1995. qualitative research methods for health profesionals. second edition. london: sage publications. nursalam, 2007. konsep dan penerapan metodologi penelitian llmu keperawatan. jakarta: salemba medika. dinas kesehatan kota surabaya, 2009. profi l kesehatan tahun 2009. surabaya: dinas kesehatan kota surabaya. subarsono, 2009. analisis kebijakan publik konsep, teori dan aplikasi. yogyakarta: pustaka pelajar. sugiyono, 2008. metode penelitian kuantitatif k u a l i t a t i f d a n r & d ; b a n d u n g : alfabeta. s. lincoln, nkdy., 2009. handbook of qualitative research edisi bahasa indonesia. jakarta: pustaka pelajar. nicholas d. walter, et al., 2009. why fi rst-level health workers fail to follow guidelines for managing severe disease in children in the coast region, (online), (http:// www. proquest. com/pqdweb). http://e-journal.unair.ac.id/jners 31 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 1, april 2022, p. 31-35 http://dx.doi.org/10.20473/jn.v17i1.34233 original article open access knowledge and attitudes toward covid-19 vaccination among student nurses from saudi arabia romeo mostoles jr. 1,* , richard maestrado1 , joyce buta1 , hamdan mohammad albaqawi1 , evalynne rondilla1 , salman alsaqri1 , sandro villareal 1 1 college of nursing, university of hail, hail, saudi arabia *correspondence: romeo mostoles jr. address: college of nursing, university of hail, hail, saudi arabia, email: r.mostoles@uoh.edu.sa responsible editor: retnayu pradanie received: 10 march 2022 ○ revised: 12 april 2022 ○ accepted: 13 april 2022 abstract introduction: insights into the knowledge and attitudes of students can be achieved by analyzing their general understanding and prevention of the coronavirus. therefore, it is imperative to identify attributes that influence the development of healthy behaviors among students. this study aimed to determine the dynamics of knowledge and attitudes of student nurses concerning the covid-19 vaccine. methods: this descriptive-cross sectional study involved 250 student nurses from the university of hail, nursing college, selected by convenience sampling. the data were collected between august and september 2021 using questionnaires. the data were analysed using a t-test, one-way anova, and pearson’s correlation test with a significance level of 0.05. results: the study results showed that participants have good knowledge (mean = 3.09; sd = 0.88) and attitudes (mean = 8.62; sd = 1.83). gender (except for knowledge), marital status, and age were not relevant as explanatory factors of knowledge and attitude. there was a significant difference in both knowledge (f = 2.233; p < 0.005) and attitude (f = 3.918; p < 0.004) associated with the course year. there was no significant relationship between knowledge and attitude (r = -0.013; p-value = 0.834). conclusions: this information is critical for educators as they design techniques to help students put their knowledge into practice. in this way, educators may help health students develop skills and encourage students to become accountable health professionals who can support current societal healthcare demands. keywords: covid-19; demographics; intention; student nurses; vaccine introduction the most effective preventive measure to reduce the pandemic is predicted to be the coronavirus disease-2019 (covid-19) vaccination (szmyd et al., 2021), and efforts have been made to produce the vaccines, especially in developing countries (albaqawi et al., 2021). vaccination has had a 67% acceptance rate, despite the considerable demographic and geographic differences in vaccination uptake (malik et al., 2020) due to safety concerns. it is important to note that the success of a vaccination program is determined by the vaccination uptake by the public, healthcare workers (kassianos et al., 2018), and students (e.g., nursing students), who are critical advocates of vaccination. in addition, the campus environments of student nurses are often congested with intense movement and restricted space, i.e., environments that are considered high-risk during the covid-19 pandemic. therefore, nursing students also benefit from vaccination. conversely, vaccination is a critical intervention with the potential to significantly limit the occurrence and spreading of this deadly infectious illness (jiang et al., 2021). sarscov-2 vaccines became available at the end of 2020, and healthcare workers (hcws) were among the first to be vaccinated in many countries (szmyd et al., 2021). nursing students, in turn, cover inevitable shortfalls in the healthcare sector and also need vaccination as they have played a key role in the current response to the pandemic whenever possible (fontenot et https://creativecommons.org/licenses/by/4.0/ mailto:r.mostoles@uoh.edu.sa https://orcid.org/0000-0001-7151-3151 https://orcid.org/0000-0002-6702-3835 https://orcid.org/0000-0002-7811-7992 https://orcid.org/0000-0001-9749-9669 https://orcid.org/0000-0002-5748-7003 https://orcid.org/0000-0003-2969-4416 https://orcid.org/0000-0002-4318-0561 mostoles, maestrado, buta, albaqawi, rondilla, alsaqri, and villareal (2022) 32 p-issn: 1858-3598  e-issn: 2502-5791 al., 2021). however, university students’ desire to become immunized to covid-19 varies greatly (jiang et al., 2021), which could be the result of a lack of awareness that leads to the non-intention of being vaccinated. indeed, safety issues and unfortunate events have been reported throughout the implementation of vaccination programs, damaging public opinion and influencing vaccination intentions (grady and mazzei, 2021). the resistance to covid-19 immunization may increase the danger of pathogen transmission to the patients of healthcare workers while simultaneously reducing the chance of encouraging patients to get vaccinated (biswas et al., 2021). indeed, this can due to the safety of the vaccine, its efficacy, and potential side effects. accordingly, vaccination has been explored in the literature; however scarcely concerning the dynamics of knowledge, attitudes, and practices associated with covid-19 among student nurses as advocate partners of the healthcare professionals. the negative views and skepticism toward covid-19 vaccines are key obstacles to expanding global vaccination coverage (paul et al., 2021). nursing students are partners in supporting the vaccination programs for covid-19. thus, it is critical to understand the knowledge, attitudes, and practices of student nurses, helping them develop mitigation solutions for the current scenario. most studies on the preventive behavior of nursing students during the covid19 pandemic have shown a high level of commitment to preventive measures (sun et al., 2020). moreover, vaccination acceptance rates among nursing students have been reported as satisfactory (jiang et al., 2021). it is significant, therefore, that deeper insights into existing students’ knowledge and attitudes be achieved by analyzing their general understanding and prevention of the coronavirus. hence, it is imperative to assist in the identification of attributes that influence the students in the development of healthy behaviors. this study aimed to determine the dynamics of knowledge and attitudes of student nurses toward the covid-19 vaccine. to the best of our knowledge, this is the first study that explores the knowledge and attitudes of student nurses from the hail region, kingdom of saudi arabia. materials and methods study design this study used the descriptive-cross sectional approach to determine the dynamics of knowledge and attitudes among student nurses concerning the covid19 vaccine. respondent this study involved the active participation of 250 student nurses from the university of hail, nursing college. a non-probability sampling, specifically convenience sampling, was used. all full-time students were invited to participate in the study, and those who did not provide consent were excluded. the researchers used convenience sampling, which means that all students were invited to participate in the study instrument the questionnaire comprised two parts. the first part consisted of the demographic characteristics, which include gender, marital status, age, and course year. the second part was adapted from islam et al. (2021) and had 11 items categorized as knowledge (five items) and attitudes (six items). the knowledge items asked about the general knowledge about the covid-19 vaccine (e.g. “do you know about the covid-19 vaccine?”; “do you know about the effectiveness of the covid-19 vaccine?”) and had three possible responses (i.e., “yes,” “no” or “don’t know”). the “yes” response was assigned a score of 1, while the “no/don’t know” responses were scored 0. the total score ranged from 0 to 5 and was calculated by adding the raw scores of the five items, with the highest score indicating increased level of knowledge of covid19 vaccines. the attitude section consisted of six items (e.g., “the newly discovered covid-19 vaccines are wise”; “the covid vaccines are essential for us”) that can be answered through a three-point likert scale ranging from 0 to 2, where 0 = disagree, 1 = undecided, and 2 = agree. the total score was determined by adding the raw scores of the six items, which ranged from 0 to 12, with a higher overall score suggesting more favorable attitudes toward the covid-19 vaccination. the questionnaire was subjected to content validation by three panel experts of the hail region, saudi arabia. these three experts unanimously agreed on the validity of the questionnaire. the questionnaire was subsequently tested with 15 student nurses who were no longer part of the sample. reliability results were high (0.86 for knowledge and 0.89 for attitudes). table 1 demographic characteristics of the participants (n = 250) demographic characteristics n % age 20-22 118 47.2 23-25 101 40.4 26-28 20 8 29 years old and above 11 4.4 gender male 124 49.6 female 126 50.4 marital status single 246 98.4 married 4 1.6 year level level 5 50 20 level 6 50 20 level 7 50 20 level 8 40 16 internship 60 24 jurnal ners http://e-journal.unair.ac.id/jners 33 data collection the researchers invited the students to participate through classroom announcements. the students were instructed as to what the study entails, extent of their participation, and their rights as participants, before deciding whether or not to participate in the study. informed consent forms were distributed to the willing participants thereafter. data were collected between august and september 2021. data analysis the spss v.22 was used to analyze the data. the demographic data were described using frequency and percentage values. a t-test was used to identify differences between gender and marital status for knowledge and attitude, while a one-way anova was employed to determine differences between age and course year. pearson’s r was used to determine the relationship between knowledge and attitudes. the significance level of 0.05 was considered for the statistical analyses. ethical consideration the institutional review board of the university of hail has approved this protocol (h-2021-067). in the conduct of human study, the researchers followed the ethical guidelines outlined in the world medical association declaration of helsinki. all participants signed a written informed consent form. results the participants were generally young, with 47.2% aged between 20 and 22 years. gender was nearly equally distributed with males comprising 49.6% of the participants and females 50.4% (table 1). only 1.6% of the students were married, and most belonged to an internship program (24%). the knowledge of the student nurses was good (3.09 out of 5), and they had a good attitude (8.62 out of 12) toward the covid-19 vaccine (table 2). there was a significant difference in knowledge (t = -2.678; p < 0.008) between the genders of the nursing students, such that female students had better knowledge (3.23 ± 0.843) than their male colleagues (2.94 ± 0.895). however, there were no differences in attitude between genders (t = 1.287; p > 0.199). in addition, neither knowledge (t= 0.783; p > 0.434) nor attitude (t = 0.686; p > 0.494) differed regarding the marital status of the participants. furthermore, there was no significant difference in the knowledge (f = 3.673; p > 0.703) or attitude (f = 2.623; p > 0.071) of the nursing students associated with their age. there was a significant difference in both knowledge (f = 2.233; p < 0.005) and attitude (f = 3.918; p < 0.004) associated with the course year (table 2). there was no significant relationship between knowledge and attitude (r = -0.013; p-value = 0.834). discussions this study aimed to determine the knowledge and attitudes of student nurses toward the covid-19 vaccine. the knowledge of the student nurses recorded in this study was good, which can be credited to their ongoing study and their active participation in disseminating preventive information. the results of this study are similar to that of an earlier study where the mean knowledge score was 2.83 out of 5 (islam et al., 2021), also showing the good attitude of the student nurses toward covid-19 vaccination. a positive attitude is a key to containing the outbreak and increasing willingness to receive the covid-19 vaccine. this shows the students’ willingness to be vaccinated and promote vaccination within their community or among their clients. overall, these good results concerning the knowledge and attitudes of the student nurses show the professional foundation and basic awareness of the necessity, effectiveness, and safety of the covid-19 vaccine. one table 2 differences between demographic characteristics and knowledge and attitudes of the nursing students toward covid-19 vaccine demographic characteristics knowledge attitude mean std. deviation t pvalue mean std. deviation t pvalue age 20-22 3.00 0.901 3.673 0.073 8.93 1.884 2.623 0.071 23-25 3.06 0.863 8.33 1.866 26-28 3.70 0.732 8.10 1.252 29 years old and above 3.09 0.700 8.90 1.300 gender male 2.94 0.895 -2.678 0.008* 8.77 1.928 1.287 0.199 female 3.23 0.843 8.47 1.728 marital status single 3.09 0.884 0.783 0.434 8.63 1.839 0.686 0.494 married 2.75 0.500 2.66 0.456 year level level 5 3.03 0.920 2.233 0.005* 7.93 1.550 3.918 0.004* level 6 3.00 0.890 9.33 1.660 level 7 3.40 0.672 9.10 1.450 level 8 3.09 0.641 8.90 1.300 internship 3.32 0.701 9.90 0.850 * < 0.05 mostoles, maestrado, buta, albaqawi, rondilla, alsaqri, and villareal (2022) 34 p-issn: 1858-3598  e-issn: 2502-5791 good example to strengthen their knowledge and attitudes is for the students to be given an opportunity to disseminate the value of having the vaccine to their clients or patients during their community and hospital practice. there was a considerable disparity in knowledge between the genders, where females had greater scores than males. previous research shows that females have a higher notion of self-education and self-control (cornwell, mustard and van parys, 2013), and, thus, performed better than male students. such result is comparable to an earlier study (pasay-an et al., 2021), and shows that male students need to be more educated regarding the covid-19 vaccine to perform their task in promoting the vaccination program. it is vital to emphasize, however, the importance of considering educational needs while developing educational initiatives, regardless of demographic considerations (pasay-an et al., 2021). this will help the student nurses better grasp their roles in promoting the covid-19 vaccine. for example, nurse educators can encourage their student nurses to volunteer, either giving vaccine or doing health education in the vaccination area. marital status was not associated with the knowledge and attitudes toward the covid-19 vaccine. al-hanawi et al. (2020) also reported that the marital status of participants was not significantly associated with knowledge and attitudes. while the result is not significant, there still needs a continuous effort to include all students (regardless of marital status) in the ongoing improvement plan for vaccine information dissemination. for example, offering and giving them an educational session and educational outreach materials to raise their public understanding on the value of vaccine to combat the disease. meanwhile, there were also no significant differences in the knowledge and attitude among the nursing students of different ages. however, age was previously reported as an indicator of knowledge and attitudes toward the covid-19 vaccine (al-hanawi et al., 2020; pasay-an, magwilang and pangket, 2020). a significant difference in knowledge and attitude was recorded regarding the course year, which agrees with the findings of kumar, pinky and nurudden (2021) and indicates that students needed an educational program created for their specific needs. apparently, knowledge and attitudes are not related to one another, which agrees (pasay-an et al., 2021) and disagrees (al-hanawi et al., 2020) with previous findings. this study found no significant connections between knowledge and attitudes concerning covid-19, which implies that information does not necessarily convert into attitudes and/or behaviors, and that behaviors do not transcend into attitudes. one possible explanation is that student nurses have only recently learned about the vaccination and are currently making it work in their perspectives. in contrast, erfani et al. (2020) discovered that increased knowledge of covid-19 was associated with positive attitudes and excellent practices, suggesting that good knowledge leads to positive attitudes and good practices. in context, in developing the policy, the policy makers should consider that individual knowledge and attitudes are utilized to appraise events and their potential, as well as their repercussions. despite the fact that this study was conducted in a local context and the results are not generalizable, the findings are nevertheless relevant in the global arena. international policy makers, for example, can use the data from this study to plan certain initiatives based on the similar features found in this study. furthermore, the data in this study can be utilized to evaluate and compare to data from other countries in reducing the gap on this topic. policy implication this research has substantial policy implications. with the findings, policy makers in a university institution can adjust the instructional intervention to the vaccine's information drive. moreover, this study contributes to the identification of relevant communication networks for the target demographic as part of the preventative program strategy. as a result, school or university officials can focus their efforts on programs geared at minimizing the spread of misinformation and conspiracy theories about the covid-19 vaccine. furthermore, the university has the ability to take unprecedented efforts and respond quickly in establishing tight control and preventative measures against covid-19 to safeguard student safety. strengths and weakness of the study this study targeting the knowledge and attitudes toward covid-19 vaccination among the student nurses provides a useful tool for gauging vaccine acceptability. in addition, it provides the policy makers with relevant recommendations. however, it has substantial limitations. for example, the study was conducted in one setting and the use of non-probability sampling means it may not be possible to generalize. also, the non-inclusion of practice of students in the study can be more explored as the researchers failed to do so. conclusions student nurses have a good knowledge and attitude toward the covid-19 vaccine, and female students are more knowledgeable. knowledge and attitude did not differ significantly between gender (except for knowledge), marital status, and ages. lastly, a significant difference in knowledge and attitude was recorded for course year. this information is critical for educators as they design techniques to help students put their jurnal ners http://e-journal.unair.ac.id/jners 35 knowledge into practice. indeed, in this way educators may help health students develop skills and encourage them to become accountable health professionals who can support current societal healthcare demands. references al-hanawi, m. k. et al. (2020) ‘knowledge, attitude and practice toward covid-19 among the public in the kingdom of saudi arabia: a cross-sectional study’, frontiers in public health. frontiers, 8, p. 217. albaqawi, h. m. et al. (2021) ‘risk assessment and management among frontline nurses in the context of the covid-19 virus in the northern region of the kingdom of saudi arabia’, applied nursing research. elsevier, 58, p. 151410. biswas, n. et al. (2021) ‘the nature and extent of covid-19 vaccination hesitancy in healthcare workers’, journal of community health. springer, 46(6), pp. 1244–1251. cornwell, c., mustard, d. b. and van parys, j. (2013) ‘noncognitive skills and the gender disparities in test scores and teacher assessments: evidence from primary school’, journal of human resources. university of wisconsin press, 48(1), pp. 236–264. erfani, a. et al. (2020) ‘knowledge, attitude and practice toward the novel coronavirus (covid-19) outbreak: a population-based survey in iran’, bull world health organ, 30(10.2471), pp. 10–2471. fontenot, h. b. et al. (2021) ‘undergraduate nursing students’ covid19 vaccine intentions: a national survey’, plos one. public library of science san francisco, ca usa, 16(12), p. e0261669. grady, d. and mazzei, p. (2021) ‘doctorʼs death after covid vaccine is being investigated’, health. islam, m. et al. (2021) ‘knowledge, attitudes and perceptions towards covid-19 vaccinations: a cross-sectional community survey in bangladesh’, bmc public health. springer, 21(1), pp. 1–11. jiang, n. et al. (2021) ‘nursing students’ attitudes, knowledge and willingness of to receive the coronavirus disease vaccine: a crosssectional study’, nurse education in practice. elsevier, 55, p. 103148. kassianos, g. et al. (2018) ‘motors of influenza vaccination uptake and vaccination advocacy in healthcare workers: a comparative study in six european countries’, vaccine. elsevier, 36(44), pp. 6546– 6552. kumar, b., pinky, s. d. and nurudden, a. m. (2021) ‘knowledge, attitudes and practices towards covid-19 guidelines among students in bangladesh’, social sciences & humanities open. elsevier, 4(1), p. 100194. malik, a. a. et al. (2020) ‘determinants of covid-19 vaccine acceptance in the us’, eclinicalmedicine. elsevier, 26, p. 100495. pasay-an, e. et al. (2021) ‘knowledge, attitudes, and practices regarding covid-19 among medical and allied health students in the kingdom of saudi arabia’, journal of nursing and midwifery sciences. medknow publications, 8(2), p. 114. pasay-an, e., magwilang, j. o. g. and pangket, p. p. (2020) ‘knowledge, attitudes, and practices of adolescents regarding sexuality and reproductive issues in the cordillera administrative region of the philippines’, makara journal of health research, 24(3), p. 3. sun, y. et al. (2020) ‘disease prevention knowledge, anxiety, and professional identity during covid-19 pandemic in nursing students in zhengzhou, china’, journal of korean academy of nursing. korean society of nursing science, 50(4), pp. 533–540. szmyd, b. et al. (2021) ‘attitude and behaviors towards sars-cov-2 vaccination among healthcare workers: a cross-sectional study from poland’, vaccines. multidisciplinary digital publishing institute, 9(3), p. 218. how to cite this article: jr, r. m., maestrado, r., buta, j., albaqawi, h. m., rondilla, e., alsaqri, s., villareal, s. (2022) ‘knowledge and attitudes toward covid-19 vaccination among student nurses from saudi arabia’, jurnal ners, 17(1), pp. 31-35. doi: http://dx.doi.org/10.20473/jn.v17i1.34233 table1 table3 table2 alhanawi2020 albaqawi2021 biswas2021 cornwell2013 erfani2020 fontenot2021 grady2021 islam2021 jiang2021 kassianos2018 kumar2021 malik2020 pasay2021 pasay2020 sun2020 szmyd2021 119 factors related to open defecation behavior among schoolage children in west lombok makhfudli, praba diyan rachmawati, saskiyanti ari andini faculty of nursing, universitas airlangga, kampus c mulyorejo surabaya, 60115 email: saskiyaandini@gmail.com abstract introduction: open defecation behavior is one cause of poor sanitation, which can lead to various diseases. open defecation behavior related with cultural factors that become a habit in the daily life in a society which was then followed by their children. this study aimed to analyze factors related to the parental behavior of open defecation in school-age children based on the theory of transcultural nursing in marce, sedau community health center area, west lombok indonesia. methods: this was a descriptive research design with cross-sectional approach. samples were taken by simple random sampling technique and obtained 95 parents of children aged 7-12 years. independent variables were education level, economy level, cultural values and lifestyle, social and family values, religiosity, technology. the dependent variable was open defecation behavior of the parents in school age children. this research was analyzed using spearman rho test with significance level α = 0.05. results: education level (p = 0.000; r = 0.390), economy level (p = 0.003; r = 0.298), cultural values and lifestyle (p = 0.000; r = 0.555), social and family (p = 0.000; r = 0.444), religiosity (p = 0.000; r = 0.300), technology (p = 0 .000; r = 0354) has a significant relationship with the parents about the open defecation behavior in school age children. conclusion: the intervention was needed on the factors that influence the open defecation behavior by nurses participating directly to communities to increase public awareness about the importance of healthy defecate in a closet to avoid the disease. keywords: parent’s behavior, open defecation, school-age children, transcultural nursing theory introduction the behavior of open defecation is one cause of poor sanitation. it can cause various diseases, and it is an example of unhealthy behaviors (mukherjee 2011). open defecation behavior is closely connected with a cultural factor which is a habit in daily life (qudsiyah wa; pujiati, rs; ningrum 2015). initial data retrieval conducted by the researcher showed a lot of people who do open defecation behavior has become a habit for the majority of people. they usually do defecation in the river, so their children follow this habit. children are more likely to imitate the same model which can be reached by them, seeing other children or people around them (latifah 2012). based on the united nations international children's emergency fund (unicef) data in 2015, indonesia is the second country with open defecation behavior in the world. according to the join monitoring program (jmp) of who / unicef 2015, approximately 51 million indonesian have still been doing open defecation behavior. based health research in 2013 (riskesdas) west nusa tenggara is the second province that has the largest number defecation in indonesia. (dinas kesehatan kabupaten lombok barat 2012), there was 52.48% of people have already used family latrines as places to defecate (bab), 27.21% still used the river and the surrounding environment as a place to defecate. open defecation behavior affects sanitation issues such as diarrhea, as shown by the data of the west lombok department of health 2014, the incidence of diarrhea at puskesmas sedau west lombok was extremely high with 1036 inhabitants. the interview data conducted by ahmad hazrul watoni on 29 september 2016 in children aged 7-12 years who live in merca, selat village, where it was on of puskesmas sedau area, showed that there were 11 out of 20 people have defecation habit in the river even though 7 out of 11 children had latrines in their house, while the remaining has already used toilet. those 11 people were from parents whose education in junior high school. according to research results, (qudsiyah wa; pujiati, rs; ningrum 2015) explain that quality of latrine does not affect a person to defecate in latrines, this is caused by their habit that they are more comfortable to defecate in the river. infrastructure is an enforcing factor for behavioral change, but the most dominating factor is the habit. theory of transcultural nursing with sunrise model of (leininger 2002) consists of mailto:saskiyaandini@gmail.com jurnal ners vol. 12 no. 1 april 2017: 119-125 120 seven factors influencing the belief and practice of the individual or cultural group. it affects specific and universal nursing practice to health and welfare of the individual or cultural group (leininger 2002) so that it can be used as a template to observe the factors relating to the behavior of open defecation. various problems from these conditions will relate to the behavior of open defecation in children.therefore researcher is interested in doing research on "analysis of factors related to open defecation behavior based on theory of transcultural nursing at children in merca, selat village, west lombok". method this research design uses descriptive with cross sectional approach. the population in the study were all parents with school-aged children (7-12 years) in merce, selat village, sedau community health center area. in this study, the researcher used simple random sampling technique and obtained a sample of 95 respondents. independent variables in this research are parent education, cultural values and lifestyle, social and family value, religiosity, and technology, while the dependent variable is open defecation behavior in school age children. data collection using questionnaire and implemented for three weeks in december 2016. analysis of data used to determine the relationship factors associated with open defecation behavior is to use spearman rho test. results over half of respondents graduated from secondary education. it means education pursued by respondents were still lacking. education has a significant relationship with open defecation behavior in children (table 1). based on table 2, the majority of respondents had a low economy status which was below the minimum wage of lombok barat (<1,500,000), these results indicate a significant relationship between economic status and open defecation behavior of schoolaged children. table 1. the relationship between parent’s education and parent’s behavior about open defecation to school age children open defecation behavior education did not attend school elementary school junior high school senior high school college total ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % do not do 0 0 1 1.1 19 20 18 18.9 6 6.3 44 46. 3 do 4 4.2 10 10.5 31 32.6 5 5.3 1 1.1 51 53. 7 total 4 4.2 11 11.6 50 52.6 23 24.2 7 7.4 95 100 p = 0.000, r = 0.390 table 2. the relationship between economic background and open defecation behavior in school age children economic behavior open defecation ≤1500000 ≥1500000 total σ % σ % σ % do not do 22 23.2 22 2 3.2 44 46.3 do 40 42.1 1 1 11.5 51 53.7 total 62 6 5.3 33 3 4.7 95 100 p = 0.003 , r = 0.298 factors related to open defecation behavior (makhfudli et.al.) 121 table 3. the relationship between cultural value and lifestyle and open defecation behavior in school age children cultural value and lifestyle open defecation behavior negative positive total σ % σ % σ % do not do 11 11.5 33 34.8 44 46.3 do 41 43.2 1 0 10.5 51 53.7 total 52 54.7 43 45.3 95 100 p = 0.00, r = 0.555 table 4. the relationship between social and family value with open defecation behavior in school age children social and family value open defecation behavior negative positive total σ % σ % σ % do not do 9 9.5 35 36.8 44 46.3 do 33 34.7 18 19 51 53.7 total 42 44.2 53 55.8 95 100 p = 0.00, r = 0.444 table 5. distribution of respondents by cultural value and lifestyle of parents associated with open defecation behavior in school age children open defecation behavior religiosity good moderate less total ∑ % ∑ % ∑% ∑ % do not do 44 46.3 0 0 0 0 44 46.3 do 51 53.7 0 0 0 0 51 53.7 total 95 100 0 0 0 0 95 100 p = 0.000, r = 0.300 table 6 the relationship between technological factors and open defecation behavior of school age children open defecation behavior technology good moderate less total ∑ % ∑ % ∑% ∑ % do not do 34 35.8 8 8.5 22.1 44 46.3 do 23 24.2 14 14.7 14 14.7 51 53.7 total 57 60 22 23.2 1616.8 95 100 p = 0.000, r = 0.354 according to the table 3, more than half of the respondents had negative cultural value and lifestyle. the relationship level between cultural value and lifestyle and open defecation behavior high was. this shows that the habit of open defecation was still very high. the relationship level between social and cultural value and parent’s behavior was moderate (table 4), this indicates that the value of social and family supported hygienic and healthy behavior, especially open defecation was still very good. jurnal ners vol. 12 no. 1 april 2017: 119-125 122 according to table 5, the majority of respondents had a good value to religiosity and level of religiosity with the behavior of open defecation was moderate. this shows that the people believe in their religion teach to maintain good hygiene. the majority of respondents had a good technology. the relationship level of technology with the behavior of open defecation was moderate (table 6). this shows that the technology available has been good to support the behavior of the positive open defecation. discussion based on the data showed that the majority education of respondents was junior high school. this indicates that respondents were less educated. therefore, there is correlation proved by the test spearman rho between education and the parental behavior of open defecation. education is an important thing, high education is expected to make a person always to carry out the things that are important to themselves and those around them (mahyudin, 2013). according to the theory of leininger's transcultural nursing (2002) states that a healthy behavior is shaped by a variety factors that work together. the higher education, the wiser that person is understanding everything around them because they usually look for scientific evidence and rational mind. it makes easier to adapt culturally as well as their health condition. formal education of mother is the impact of mother’s knowledge which low education leads to be less education and vice versa. knowledge is an important domain for the person's actions (kharismawati 2014). respondents who studied high school and college also had the negative open defecation is caused by lack of knowledge and information in the use of a healthy toilet.the society’s knowledge was high but still behave open defecation although already have their own latrines as defecating. it indicates that public’s knowledge about healthy latrine is still lacking (widowati 2015) and the participation of the family in the use of latrines is still lacking (tarin, 2008). also, well-educated parents usually have many activities outside, so they will leave their children (syaltut 2016)(syaltut 2016) so that the children is handed over to grandmother or neighbor. thus, children are rarely given the knowledge of the proper place and manner of defecation to keep hygiene. education is an important factor for people to behave maintaining the health of family, but it will be useless if it is not accompanied by awareness and willingness to make changes and improvements in the family environment, as well as respondents with high education, such as graduated from high school and college,they do not build their own latrines for house because their house is close to the river without a septic tank. the most respondents were less economic, which was under minimum wage of west lombok (<1,500,000). respondents who earned below minimum wage had negative open defecation behavior, so the spearman rho indicates the relationship between the economic and parental behavior of open defecation children. the level of the relationship was a moderate level category. family income determines the availability of good family health. a balance family income will affect in maintaining the cleanliness and provision of a health facility. so people with low income cannot afford good health facility because they are difficult in providing it (ministry of health, 2006). theory of transcultural nursing (leininger 2002) explains that someone will take advantage of material resources owned to pay its pain to get well soon. widowati (2015) found that income is a factor associated with health program, which means people with sufficient income will defecate in latrines while others with low income mostly do open defecation in greater number than high income. statistically, there is a significant relationship between income and open defecation behavior. a respondent with low income was likely to have 9500 times risk more than respondents with high income. however, there were respondents with a good economy doing open defecation behavior.this is caused by several factors encouraging them to do open defecation, which was people living near the river were more at risk to defecate in the open area (mukherjee 2011). another study mentioned that the distance between home and the river affects 132 times not to build latrine (salah, 2002). another factor that could reduce the factors related to open defecation behavior (makhfudli et.al.) 123 influence of technology is culture open defecation in the community because they felt defecation be more convenient and practical, open defecation as community identity and inheritance generation of the ancestor so that it becomes a habit (murwati 2012). low economy status strongly supports the behavior of open defecation because people will set a priority on another need which is more fundamental than building their own latrines especially if the distance from the house to the river near. moreover, limited of land-owner makes difficult to build latrines so awareness for has a healthy family latrine will be less. most respondents had the negative value of cultural and lifestyle, among them, there were people with negative behavior of open defecation. there was a significant relationship between the test spearman rho between cultural value and lifestyle and the parental behavior of open defecation children. the level of a relationship was high. based on research (qudsiyah wa; pujiati, rs; ningrum 2015), the behavior of open defecation is closely connected with the cultural factor that becomes a habit in daily life, they feel more comfortable if defecate in the river while facility and infrastructure are enforcing factor to change behavior, but the most dominating factor is the habit. the tribe characteristics can be described by the tradition and culture which is formed in settlement and their local wisdom. it can be seen from the traditional settlement of sasak tribe, in limbungan, east lombok, who maintain their traditional house from any changes. the pattern of spatial development of the sasak tribe in limbungan is based on cosmology value-oriented with the belief system and tradition of culture-based society resulting in special space. custom regulations about the settlement of indigenous limbungan that if you want to build a permanent house, you should build outside the area neighborhood of custom, it is forbidden to alter and damage the residential custom, location, natural materials of the building, all of this should be in accordance with the custom rules, especially it is not allowed to build bathroom/toilet in custom residential neighborhood that washing activities carried out in the river (sabrina, r., antariksa, a., & prayitno 2010). attitude and behavior of people who does not maintain environmental health have an impact on their next-generation behavioral patterns. cultural elements learned in the early stages of the process of socialization are a habit formed since childhood. it will affect the habit of a person as an adult (koentjaraningrat 2004). community with high cultural value will follow their tradition of the past and feel comfortable when they are in situation and condition where the present and the future can be predicted or have a secure while community with low cultural value will remain comfortable even if they are in a situation that is uncertain in the present and future, therefore they are not too oriented to regulation and better prepared to face the changes (imelda 2002). based on transcultural nursing theory leininger (2002), the value of culture is defined and determined by the adherents of culture considered as good or bad. one of the factors that determine the health condition of the community is the people's health behavior itself, where several factors influence the process of formation of this behavior. its factor socio-cultural factor, if these factor has been embedded and internalized in the life and activity of the community the tendency to change behavior been formed is difficult to do (imelda 2002). the value of the negative culture associated with a parental behavior of open defecation would be inherited by their children and will continue to inherit if the parents do not change a value of culture to be positive because children will imitate whatever is done by family environment.a custom which has been learned from childhood by family is a difficult thing to be changed because people prefer their lives as usual and trying to keep things comfortable so that the relationship between culture and parental behavior of open defecation to children were high. most respondents have good social value and family. it indicates there was the relationship between social value and family and parental behavior of open defecation to children. the level of the relationship was moderate. transcultural nursing by leininger (2002), social &family aims to be a support system for member and to improve health and jurnal ners vol. 12 no. 1 april 2017: 119-125 124 the adaptation process. social and family supports the family's ability to provide time, attention, and support to meet the physical, mental, and social. there are three dimensions of family support such as emotional support, material support, informative support. social and family factor have an important role in the medical management not only for children but also for the adult who can affect behavior. there were 18 people who have positive social value and family doing open defecation. low parental supervision can cause this behavior. low family care causes parents had a negative characteristic in determining the way to care children (syaltut 2016). parental care of children affects the care for children and forms of a family also affects parental attention to children. according to feiring and lewis (1984) in friedman (2010), there is strong evidence that large family and small family qualitatively describe the experiences of development. children who come from small family receive more attention than children from large family so that it becomes a factor supporting the behavior to do open defecation by children negative social and family factors are they rarely teach defecation in latrines since childhood. it means that family social factors still bound by habit, custom, and belief of the family, causing the children’s behavior to follow the custom in a family. a family is the closest neighborhood where children can imitate whatever the family does.not only does negative social and family factor encourage someone to do open defecation but also the society with positive value still do conduct open defecation because of parental attention that can be caused by large family and defecation habit. the majority of respondents had good religiosity on the behavior of open defection.there is a relationship based on the test spearman rho between religiosity and parental behavior of open defecation children. the level of relationship's category was moderate. religion is a symbol which makes people very realistic. religion gives strong motivation to put the truth above others, even its life. religion causes the person to have humility and opening (leininger, 2002). religiosity is a core of human life. high religiosity is described by their belief in the existence of god as manifested in the process of studying knowledge and behavior by its religion. the behavior of obeying what is ordered and disobeying what is forbidden by the religion will make human closer to god, the sense that prayers are being said is always granted, a sense of calm, and so on. so that, the daily activity of individual truly reflects the teaching of religion (purnamasari 2014). in this study, all respondents had a good rate of religiosity, but some of them were a negative behavior of open defecation by 51 respondents (53.7%). people who did proper defecation is caused by the religiosity because it led to the observance of obligations as religious people and always maintain personal hygiene but still had to defecate in private place. it is affected by a habit of family and community in the understanding of open defecation inappropriate. mostly, respondents owned good technology, but among them, there still had the negative value of behavior open defecation. it showed that there was correlation byspearman rho between technology and parental behavior of open defecation to children with a moderate level category. according to the theory of transcultural nursing by leininger (2002), technology is a factor that influences individual behavior based on culture. health technology is the infrastructure that allows individual to choose or get a bid to solve health care problem. utilization of health technology is influenced by the attitude of health worker, the needs, and public interest (giger 2013). technology refers to all forms of technology used for creating, saving, modifying, and using information. there were respondents who had good technology but did the behavior of open defecation, it means that the influence of technology on the behavior of open defecation could also be less influence if there were other factors explained on qualitative research (mukherjee 2011), people living near the river are likely to defecate in the open area. another study mentions that the distance between home and the river affects 132 times not to use latrine (salah, 2002). another factor that could reduce the technology's role was culture. the culture of open defecation in the open area makes people think that it is easier and simple, this defecation habit is community identity and inheritance generation of the ancestor so that it becomes a habit (murwati 2012). factors related to open defecation behavior (makhfudli et.al.) 125 the technology referred to in this research is health education about open defecation or a healthy family latrine and latrine ownership that meets the health requirements of the respondents. respondents had had latrine but there were still many people who have not qualified healthcare equipped with septic tanks or have toilets and the lack of information about the benefits to defecate in latrines for health so that respondents still went to the river. conclusion parental education background factor, economic background, cultural value and lifestyle, social value and family, religiosity and technology is related to open defecation behavior in school-aged children. further research is expected to provide the intervention of the factors that influence open defecation behavior to children, especially on factors such as cultural value and lifestyle of parents, social and family value. references dinas kesehatan kabupaten lombok barat, 2012. profil kesehatan kabupaten lombok barat tahun 2012, lombok barat: dinas kesehatan kabupaten lombok barat. friedman, 2010. buku ajar keperawatan keluarga : riset, teori dan praktek, jakarta: egc. giger, j. dan d., 2013. transcultural nursing: assesmentand intervention, canada: mosby. imelda, s., 2002. faktor sosial budaya yang mempengaruhi perilaku kesehatan masyarakat menuju paradigma sehat di kota padang. universitas indonesia. kharismawati, e., 2014. analisis faktor pemberian asi eksklusif pada bayi berdasarkan teori perilaku who di wilayah puskesmas mulyorejo surabaya. universitas airlangga. koentjaraningrat, 2004. manusia dan kebudayaan di indonesia, jakarta: djambatan. latifah, f., 2012. hubungan karakteristik anak usia sekolah dengan kejadian bullying di sekolah dasar x di bogor. universitas indonesia. leininger, m., 2002. culture care theory: a major contribution to advance transcultural nursing knowledge and practices. journal of transcultural nursing, 13(3), pp.189–192. available at: http://journals.sagepub.com/doi/10.1177/ 10459602013003005 [accessed may 27, 2017]. mukherjee, n., 2011. factors associated with achieving and sustaining open defecation free communities learning from east java, water and sanitation program., washington, dc. murwati, m., 2012. faktor host dan lingkungan yang mempengaruhi perilaku buang air besar sembarangan/(open defecation). undip. purnamasari, s., 2014. religiusitas pada remaja ditinjau dari minat terhadap musik islami, pop dan music metal. universitas muhammadiyah surakarta. qudsiyah wa; pujiati, rs; ningrum, p., 2015. faktor-faktor yang berhubungan dengan tingginya angka open defecation di kabupaten jember. universitas jember. available at: http://repository.unej.ac.id/bitstream/hand le/123456789/61805/wahyu afiatul qudsyah92110101101_1.pdf?sequence=1 [accessed december 16, 2016]. sabrina, r., antariksa, a., & prayitno, g., 2010. sabrina, r., antariksa, a., & prayitno, g. (2010). pelestarian pola permukiman tradisional suku sasak dusun limbungan kabupaten lombok timur. syaltut, m., 2016. analisis faktor pemberian mp-asi dini pada bayi usia 0-6 bulan berdasarkan teori transcultural nursing di puskesmas proppo pamekasan. universitas airlangga. widowati, n.., 2015. hubungan karakteristik pemilik rumah dengan perilaku buang air besar sembarangan di wilayah kerja puskesmas sambungmacan ii kabupaten sragen. universitas muhammadiyah, surakarta. http://e-journal.unair.ac.id/jners 159 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 159-168 http://dx.doi.org/10.20473/jn.v18i2.45127 original article open access a simple awareness for women about (sawa) stages of labor on women's childbirth experience using the childbirth roadmap tool: a quasi-experimental study howieda fouly 1 * , mervat gaber zaghloul 2 , intisar alshiekh 3 , and ayat masoud 4,5 1 faculty of nursing, assiut university, assiut, egypt 2 faculty of nursing, port said university, port said, egypt 3 department of nursing, university of jeddah, jeddah, saudi arabia 4 faculty of nursing, fayoum university, fayoum, saudi arabia 5 college of applied medical sciences, jouf university, sakaka, saudi arabia *correspondence: howieda fouly. address: faculty of nursing, assiut university. email: hoida.elfouly2@aun.edu.eg responsible editor: retnayu pradanie received: 1 may 2023 ○ revised: 24 june 2023 ○ accepted: 24 june 2023 abstract introduction: lack of knowledge about the childbirth process may lead to stress during labor. however, research confirmed that women’s knowledge regarding childbirth progress can increase their comfort and satisfaction during labor. this study aimed to assess the effectiveness of the simple awareness for women about (sawa) labor stages program on their childbirth experience using the childbirth roadmap tool. methods: a pretest and posttest technique was employed and conducted at the labor department, woman health hospital, affiliated with assiut university, egypt. based on the eligibility criteria, a convenience sampling method was used to recruit all parturient women admitted between december 2019 and february 2020. the sample consisted of 172 participants and the data were analyzed with chi-square and t-test using spss version 25. results: a statistically significant difference was observed in the baseline information regarding the stages of childbirth after the sawa program implementation at p< 0.001. there was a significant relationship between the mode of delivery and the participant's satisfaction with the study tool at p<0.001. conclusions: this study highlighted the benefits of using a simple, attractively illustrated instrument, the childbirth roadmap, for achieving the meaning of support and women’s satisfaction through the sawa program during labor stages. keywords: effectiveness, simple awareness, women, stages of labor, childbirth roadmap experience introduction women and families consider pregnancy and childbirth as unique events. therefore, they hold different expectations during childbearing based on their knowledge, experiences, beliefs, cultures, and social and family backgrounds. in light of these differences, care should be modified and systematized to meet their needs by understanding and respecting their attitudes (iravani et al., 2015). women's knowledge regarding the process of childbirth can increase their comfort and satisfaction during labor. various methods including reading, watching videos, attending childbirth classes, and discussing with caregivers, doulas, family, and friends may provide women with comfort. this information enables women to experience a safe and satisfying journey of childbirth https://creativecommons.org/licenses/by/4.0/ mailto:hoida.elfouly2@aun.edu.eg https://orcid.org/0000-0001-7060-764x https://orcid.org/0009-0008-5916-3126 supremo, bacason, and sañosa (2022) jurnal ners 160 p-issn: 1858-3598  e-issn: 2502-5791 (churchill, 2012). this, in turn, has a long-term impact on women as well as their families (maimburg et al., 2016). on the other hand, extra medical involvements and with low knowledge of childbirth positions among women (zileni et al., 2017) and recumbent positions have been adopted by many obstetricians (solnes miltenburg et al., 2018) through the childbirth process (mselle & eustace, 2020). however, previous research confirmed that free positioning and being in an upright position can also increase women’s comfort (gizzo et al., 2014) during the first stage of labor and enhances speed of normal childbirth, reduce medical mediations, and meets the mother’s physiological and mental demands. moreover, research evidence has proven that free positioning during childbirth can distract concentration and increase a woman’s sense of control and sequency, lower consuming of epidural analgesia (hodnett et al., 2013) and alleviate labor pain and anxiety (gau et al., 2011). therefore, the childbirth roadmap highlights the effect of a variety of methods such as birth-ball massage and breathing management during uterine contraction. the birth ball helps the relaxing of pelvic muscles, especially the levator ani muscles and pelvic ligaments (gallo et al., 2014) and helps women to actively participate in the childbirth process (gau et al., 2011). hence, concerning the association between high-quality maternity care and infant health, the women freely changing uncomfortable positions and holding stability and coordination increases her self-confidence and consequently enriches high-quality maternity care and infant health. moreover, previous studies have confirmed a strong relationship between positive experiences during childbearing and a sense of safety and satisfaction. in addition to other vital factors, "a safe environment and emotional strength" lead to improved childbirth satisfaction (aune et al., 2015; karlström et al., 2015). furthermore, labor contentment has been linked with caregivers' support, healthcare providers' communication skills, and the staff's understanding of women's needs (ahmad et al., 2012). however, both mothers' and midwives' perceptions regarding the content of childbearing information are important in the development of an effective childbirth education program for pregnant women (malata & chirwa, 2011). therefore, the proper preparation, in terms of support with information related to each stage of childbirth, may be reflective of the whole fear-inducing lack of understanding and familiarity with women with the birthing process. hence, educating women about the labor procedure as well as offering them information about each stage and the progress of delivery would enrich their childbirth satisfaction. in addition, providing a simple birth illustration, such as a story, may be an excellent choice to enhance women's labor contentment (howarth et al., 2019). some years ago, penny simkin developed a visual model to guide women through the labor progress using an illustrated image of a roadmap. the model shows the key childbirth landmarks, appropriate actions, and comfort measures during its progression (see figure 1). the roadmap represents three pathways. the main brick road denotes normal labor and demonstrates supportive actions, positions, and comfort techniques for its progress. the turns and spirals in the brick road indicate that normal labor does not progress in a straight line. the care provider can utilize it as a tool to conduct organized discussions of normal labor progress, providing a clear and effective way to impart knowledge related to normal labor (churchill, 2012). women's active participation in the childbirth process include such as decision-making, accessibility of information, awareness of the care provided, and support during childbirth and delivery (fair & morrison, 2012). recently, a comparative multi-country study conducted in three arab countries, including egypt, confirmed that women's experiences and satisfaction with labor were linked to women’s feelings of control regarding the facility's routine work, rather than awareness and knowledge related to childbirth stages (kabakian-khasholian et al., 2017). the world health organization has suggested intrapartum care as affecting the childbirth experience positively (who, 2016). in addition, women who receive continuous support from hospital professionals during labor, such as nurses, tend to have better birth outcomes such as lower rates of emergency cesarean section and instrument deliveries, and higher satisfaction with the childbirth experience (hodnett et al., 2013; stark et al., 2016; wang et al., 2021). our study considered a pioneer study in egypt to use the childbirth roadmap as a simple tool for guiding women during the progress of childbirth accompanied by the healthcare provider throughout, in the form of the arabic acronym simple awareness for women about ("sawa") which refers to being together. this study aimed to assess the effectiveness of the sawa program of the stages of birth using a childbirth roadmap. the study aimed to assess women's knowledge about the stages of labor after the implementation of sawa and to determine the effect of fouly, zaghloul, alshiekh, and masoud (2023) http://e-journal.unair.ac.id/jners 161 using a childbirth roadmap on women's satisfaction and labor outcomes. materials and methods study design a quasi-experimental pretest-posttest method was employed to examine parturient women's knowledge about the first stage of labor to the fourth before and after using the childbirth roadmap as a guiding awareness tool, and their satisfaction, respectively. this study was conducted at the labor department of the woman health hospital, affiliated with assiut university, egypt. study sample this study employed convenience sampling to recruit all the parturient women admitted to the hospital between december 2019 and february 2020. the sampling technique was based on the eligibility criteria and the convenience of the participants. then the recruitment used a simple randomization method by using an envelope containing two folded papers with two letters a for participation and b for no participation. the sample consisted of 172 participants selected according to the eligibility criteria. the sample size was calculated using the g power program using the following data: effect size 0.3, α error prop 0.05, one tail, power (1-β err prop) 97% using the difference between two independent means (matched paired). the sample size was supposed to be 166 but increased to 172 participants to increase the power. participant criteria the study enrolled all pregnant women when they were in the first stage of labor (early latent phase), in which the cervix is 0-3 cm dilated, contractions occurred every 10-20 min, lasting for 15-30 seconds, and mild intensity pain and healthy pregnancy without medical diseases. those in the first stage (active phase: cervix, 47 cm) experienced contractions every 2-3 min continuing for 50-60 sec, and moderate and high-risk pregnancies related to chronic diseases were excluded from the research. instruments the current study used two questionnaires, the first questionnaire was developed based on the available literature (begley et al., 2014; carquillat et al., 2017). the questionnaire consisted of six sections: the first section included seven questions: age, residence, education, occupation, husband's occupation, and figure 1. roadmap of labor (simkin, 2014) supremo, bacason, and sañosa (2022) jurnal ners 162 p-issn: 1858-3598  e-issn: 2502-5791 education. the second section comprised of four questions about obstetric history. third section comprised six items on childbirth physiology information. the fourth section included 22 questions regarding normal labor and women's actions during each stage of labor. the fifth section comprised six items related to women's perception and the satisfaction with childbirth roadmap as a childbirth facilitation tool. the sixth and final section included four questions regarding labor outcomes. the second questionnaire is the childbirth roadmap is a visual tool created by churchill, (2012) to guide women during their childbirth journey. the roadmap includes three pathways, namely, the normal labor path, the detour for back pain, and the epidural highway. in our study, only the normal childbirth pathway was employed because of the inclusion criteria. the demonstration shows childbearing as a journey that begins with early labor and ends with delivery. the childbirth roadmap includes three tracks: a winding yellow brick road with twists, turns, and devoid of fixed timelines; a diversion for back pain, which is a longer, irregular road that eventually rejoins the yellow brick road; and the epidural highway, which represents the choice to have an epidural for pain relief. each pathway ends joyfully with the infant's birth. this demonstration includes illustrations of a variety of comfort measures that can be used as labor progresses. the roadmap employs the road symbol to define each stage of labor (figure 1). validity and reliability the questionnaire validity was tested through face, content, and experts performed convergent validity of the questionnaire in the disciplines of obstetrics and gynecology nursing and medical fields. in addition, its reliability was assessed using cronbach's alpha which was found to be 0.80, indicating the scale's high level of internal consistency for our study's sample. the questionnaire was tested on 17 parturients using arabic language to conduct data collections. the translated questionnaire was reviewed by five experts in obstetrics and gynecology from nursing and medical school. the jury confirmed the applicability of the translated version. the researcher conducted a pilot study to examine its feasibility, applicability, acceptability, and consistency. the author omitted the last open-ended question because the participants didn’t answer. intervention intervention was conducted by the researcher, who holds a phd in obstetric and gynecologic nursing. the first part was initiated by explaining the study's objective to obtain informed consent from the participants. a patient questionnaire was used to collect data regarding demographic characteristics and knowledge level of procedures performed during labor and determined the needs related to each stage through the pretest. the second part, which is the posttest, used the interactive tool, "the childbirth roadmap,” which was an amusing way to educate expectant mothers about what to anticipate during labor. during the use of the childbirth roadmap, the researcher applied the steps involved guided by the map while making certain modifications according to the hospital's facilities. step 1: if the cervical dilation was 1-2 cm and the contractions were every 5 min, the researcher encouraged walking, eating, drinking, resting, and relaxing by lying down. furthermore, the researcher taught breathing techniques, if needed, and, if table 1. demographic characteristics of the participants demographic characteristics n (%) mean (sd) age (in years): 18-24 25-30 31-36 37-42 120 (69.8) 38 (22.1) 0.0 (0.00) 14 (8.1) 23.60 (5.93) education level: illiterate read and write (without finishing formal school) primary school prep school secondary school university 2 (1.2) 53 (30.8) 13 (7.6) 22 (12.8) 33 (19.2) 49 (28.4) residence: rural urban semi-urban 86 (50.0) 41 (23.8) 45 (26.2) occupation: housewife employee 147 (85.5) 25 (14.5) obstetric profile gravidity: primigravida gravida 2-4 gravida >5 130 (75.5) 40 (23.2) 2 (1.3) 1.41 (0.82) parity: para 1-2 para 3-4 39 (22.7) 3 (2.3) 0.34 (0.71) abortion none 1 abortion 162 (94.2) 10 (5.8) 0.05 (0.23) living children: none 1 child 2 children 3 children 130 (76.6) 28 (16.3) 12 (7.0) 2 (1.2) neonatal deaths: no yes 160 (93.0) 12 (7.0) fouly, zaghloul, alshiekh, and masoud (2023) http://e-journal.unair.ac.id/jners 163 membranes were intact, women were encouraged to participate in the care. in case of women feeling thirsty, the researcher offered fluids or ice chips and withholding of food and fluids to prevent aspiration in the event of an unexpected cesarean section. step 2: at 3-5 cm, with contractions 4 min apart, lasting for 1 minute, the researcher used non-pharmacologic techniques of pain control measures, education was provided between uterine contractions, and the woman was encouraged to use the comfort measures, e.g., use of the focal point, visual imagery, breathing, and application of relaxing massage). in addition, the 3rs were followed to maintain reinforcement of relaxation, with a regular rhythm, using relax. step 3: at 5-8 cm, with contractions occurring consistently 3-4 minutes apart, the pain tends to increase by 7 cm. the researcher allowed the patient to make informed decisions regarding pain control. in the table 2. previous information of participants regarding childbirth circumstances for the total sample (n=172) childbirth circumstances yes no mean (sd) n (%) n (%) previous information regarding childbirth 133 77.3 39 22.7 1.22 (0.41) source information: mother relative doctor books and magazine internet 51 30 23 13 16 38.3 22.5 17.2 1.7 12.3 0.71 (1.30) the adequacy of information to release anxiety 23 13.4 149 86.6 1.86 (0.34) the desire to know more about the childbirth process 168 97.7 4 2.3 1.02 (0.15) reasons for receiving childbirth information: none need information urgently to differentiate between normal and abnormal to decrease anxiety for reassurance this is my right (2 & 4 choices) (3 & 4 choices) (3 & 6 choices) 7 6 21 41 83 2 9* 7* 3* 4.1 3.5 12.3 23.8 48.5 1.2 2.8 4.1 1.7 5.14 (7.60) the appropriate time to get childbirth information: first trimester second trimester last trimester during labor 2 1 66 103 1.2 0.6 38.4 59.9 note: * the participants responded with multiple answers, thus, the total percentage is 119 rather than 100. table 3. participants' information regarding the current childbirth process for the total sample before and after using the childbirth roadmap (n=172) current childbirth before using the roadmap after using the roadmap yes n (%) no n (%) yes n (%) no n (%) p-value general information regarding normal labor childbirth start time 34 (19.8) 138 (80.2) 136 (78.1) 36 (21.9) <0.001 warning signs of labor 34 (19.8) 138 (80.2) 134 (77.9) 38 (22.1) 0.001 differentiate between true and false labor 6 (3.5) 166 (96.5) 114 (66.3) 58 (33.7) 0.001 stages of labor 35 (10.8) 137 (79.7) 135 (78.5) 37 (21.5) <0.001 action of medications taken during labor 40 (23.3) 132 (76.7) 160 (93.0) 12 (7.0) <0.001 1st stage criteria of the first stage of labor 10 (5.9) 162 (94.2) 123 (76.7) 49 (23.3) 0.001 labor starts 7 (4.1) 165 (95.9) 160 (93.0) 12 (0.7) <0.001 normal duration of the 2nd stage of labor 90 (52.3) 82 (47.7) 151 (87.8) 21 (12.2) 0.001 physiology and location of the pain 107 (62.2) 65 (37.8) 130 (75.6) 42 (24.4) 0.001 cervix and its dilatation 46 (26.7) 126 (73.3) 144 (83.7) 28 (16.3) 0.001 how should one move in this stage 110 (64.0) 62 (36.0) 124 (72.1) 48 (27.9) 0.001 how should one breathe 139 (80.8) 33 (19.2) 150 (87.2) 22 (12.8) 0.001 2nd stage criteria of the 2nd stage of labor 48 (27.9) 124 (72.1) 142 (27.9) 124 (72.1) 0.272 duration of the 2nd stage 63 (36.6) 109 (63.4) 151 (78.8) 21 (12.2) 0.001 cervical changes in the 2nd stage 81 (47.1) 91 (52.9) 128 (74.4) 44 (25.6) <0.001 physiology and location of pain in this stage 24 (14.0) 148 (86.0) 104 (60.5) 68 (39.5) 0.002 reaction in this stage toward bearing down 32 (18.6) 140 (81.4) 110 (64.0) 62 (36.0) 0.002 right position that should be taken 34 (19.8) 138 (80.2) 166 (96.5) 6 (3.5) <0.001 3rd stage criteria of this stage of labor 45 (26.2) 127 (73.8) 135 (78.5) 37 (21.5) 0.001 physiological changes of this stage 71 (41.3) 101 (58.7) 172 (100) 0 (0) <0.001 the normal duration of the 3rd stage 46 (26.7) 126 (73.3) 109 (63.4) 63 (36.6) 0.021 reaction during the 3rd stage 132 (76.7) 40 (23.3) 172 (100) 0 (0) <0.001 right position during the 3rd stage 46 (26.7) 126 (73.3) 165 (96.0) 7 (4.0) <0.001 information on the 4th stage of labor 110 (64.0) 62 (36.0) 124 (72.1) 48 (27.9) 0.001 supremo, bacason, and sañosa (2022) jurnal ners 164 p-issn: 1858-3598  e-issn: 2502-5791 case of normal labor, the woman was staying hydrated, resting, and leaning forward. if there was a detour "back" labor, the woman leant on the birth ball or on the bed. the ball was replaced with a pillow and moved from side to side with bending the knees while counter pressure was applied using the double hip squeeze method, thus reaching the take the toll road get the pain relief. during this stage, the researcher observed the labor team during the administration of intravenous fluids and urinary catheter as well as frequent recordings of blood pressure, in addition to pitocin which was administered frequently according to physician order. step 4: at 8-10 cm, with contractions 2-3 minutes apart. the researcher guided the woman to explain how she is feeling such as cold or hot, and instructed the woman to get sleep and waits if she can. step 5: at 10 cm also called the "second wind," the researcher advised the woman to push with the urge, while using upright positions such as squatting, hands, and knees. the phd researcher continued in providing positive reinforcement and reassurance to both the women and their support persons to implement these techniques. finally, the patient satisfaction part of the questionnaire was completed. post-labor, mothers were requested to express their satisfaction on a 5-point likert scale (strongly satisfied, satisfied, neutral, dissatisfied, and strongly dissatisfied) after they were provided with moment by moment information regarding their condition during the childbirth process. the whole time that researcher spent with the woman during labor ranged between 2-5 hours based on the progress of labor. ethical considerations informed consent was obtained from all participants before data collection and all the participants could read and write except two were illiterate and the author got the agreement from their husbands after an explanation of the study's purpose for them too. the ethical committee of the faculty of medicine and nursing faculty at assiut university approved the research proposal (no. 245/ 2019). the informed consent included written consent and verbal consent from 172 participants who had limited literacy. statistical analysis the data were managed and analyzed using the statistical package for the social sciences version 20. the findings were expressed using frequencies and percentages. inferential statistics, such as a chi-square test, were conducted to find the association between nominal (categorical) variables. in addition, the pearson correlation coefficients were used to evaluate the direction of the relationship (positive or negative) between two or more quantitative or numerical variables. p-values were statistically significant at 0.05. results the socio-demographic characteristics of the participants in table 1 show that over 69.8% of the participants belonged to the 18–24-year age group, with a mean of 23.60 (sd=+5.93). for education level, 4% had received a university level of education and around 30.8% could read and write without finishing formal school. in all, 50% of the participants lived in rural areas, table 4. the relationship between the participants’ satisfaction regarding their childbirth information before and after using the childbirth roadmap current childbirth information strongly satisfied satisfied neutral dissatisfied strongly dissatisfied normal labor before n (%) after n (%) p-value 6 (3.5) 77 (44.8) 0.001 58 (33.7) 82 (47.7) 0.002 64 (37.2) 12 (7.0) 0.010 44 (25.6) 1 (0.5) <0.001 0 (0) 1st stage of labor before n (%) after n (%) p-value 12 (0.7) 50 (29.1) 0.012 23 (13.4) 69 (40.1) 0.001 52 (30.2) 22 (13.0) 0.013 80 (46.5) 30 (17.4) 0.024 5 (2.9) 1 (0.5) 0.010 2nd stage of labor before n (%) after n (%) p-value 18 (10.5) 53 (30.8) 0.002 24 (14.0) 61 (35.5) 0.002 122 (70.9) 49 (28.5) 0.010 5 (2.9) 3 (1.7) 0.032 3 (1.7) 2 (1.2) 0.41 3rd stage of labor before n (%) after n (%) p-value 17 60 (34.9) 0.004 28 112 (65.1) 0.001 101 (91.3) 0 (0) <0.001 16 (8.7) 0 (0) <0.001 10 0 (0) <0.001 4th stage of labor before n (%) after n (%) p-value 7 (4.1) 26 (15.1) 0.002 18 (10.5) 86 (50.0) 0.001 109 (63.4) 49 (28.5) 0.053 30 (17.4) 10 (5.8) 0.050 8 (4.6) 1 (0.5) 0.002 fouly, zaghloul, alshiekh, and masoud (2023) http://e-journal.unair.ac.id/jners 165 and the majority of women were housewives, 85.5%. regarding the participants' obstetric profiles, 75.5% were primigravida, and 22% had parity at least once. only 5.8 % had a history of abortion. the majority of them had no history of neonatal deaths. table 2 indicates that more than 77.3% of the participants had previous information regarding childbirth, and nearly 38.3% and 22.5% received it from their mothers and relatives, respectively. a minority of the participants, 13.4%, reported that their previous information was adequate to release anxiety. although the most significant proportion of participants, 97.7%, desired more information about childbirth for many reasons, the most common ones included decreasing anxiety (48.5%), followed by the ability to differentiate between normal and abnormal labor progress. moreover, nearly 59.9% believed that the appropriate time to receive childbirth information was during labor, while 38.4% thought it was necessary in the last trimester of pregnancy. the participants' childbirth information regarding the 1st, 2nd, 3rd, and 4th stages gained through the childbirth roadmap (table 3) indicated that the majority's baseline information was significantly increased (p<0.001), excluding one item regarding the 2nd stage ("criteria of 2nd stage of labor"). although using the roadmap increased their knowledge, the differences reported were not statistically significant (p=0.272). table 4 displays a statistically significant relationship between women's satisfaction regarding labor information before and after using the childbirth roadmap (p<0.001). almost all the participants (92.5%) were either strongly satisfied or satisfied with their information regarding the 1st, 2nd, 3rd, and 4th stages of labor (66.3%, 69.2%, 100%, and 65.1%, respectively). it was found to increase after the implementation of the childbirth roadmap. table 5a shows a significant relationship between the mode of delivery and the participants’ satisfaction with the childbirth roadmap tool, whereby the majority of them (134; 77.0%) who delivered normally were either satisfied or strongly satisfied with the tool (p=0.04). table 5b reveals no statistically significant relationship between the duration of the second stage of labor and the participants’ satisfaction with the childbirth roadmap (p=0.63). however, most satisfied and strongly satisfied participants reported the least contentment with the second stage of labor. table 5c displays a statistically significant relationship (p=0.03) between the neonatal conditions reported using the apgar score, at 1 and 5 minutes immediately after the delivery, and the participants’ satisfaction with the tool. the majority of them (90.1%) who were satisfied with the roadmap for their neonatal outcomes reported good conditions by the apgar scores. table 6 shows a statistically significant relationship between the participants' satisfaction and their recommendation of using the childbirth roadmap as a guidance tool (p<0.001). the vast majority of the participants were satisfied either strongly (97.0%) or to some extent (96.5%) and recommended using a childbirth roadmap as a guidance tool. discussions this study aimed to assess the improvements in women's knowledge, satisfaction, and experience of childbirth using a simple awareness program about stages of birth (sawa) by employing a childbirth roadmap tool. our study found that the women's knowledge about the labor stages improved dramatically, and both satisfaction with the childbearing outcomes and the roadmap increased significantly. these findings may indicate the way of providing the information integrated with an attractive illustration, the "childbirth roadmap," and its simple delivery by the healthcare providers, and the study's researchers. table 5a. the association between the participant's satisfaction with the childbirth roadmap and the mode of delivery delivery mode pvalue normal assisted how would you evaluate this labor map strongly satisfied satisfied neutral unsatisfied strongly unsatisfied 17 39 74 4 0 4 3 30 1 0 0.04* total 134 38 note: *p-value <0.05 table 5c. association between the neonatal outcomes assessed using the apgar score and the participants' satisfaction with the childbirth roadmap what is the apgar score? pvalue severely depressed (0-3) moderate depressed (4-6) good /normal (7-10) how would you evaluate this labor roadmap strongly satisfied satisfied neutral unsatisfied strongly unsatisfied 1 1 1 1 0 1 0 8 1 0 19 41 95 3 0 0.03* total of 172 4 10 158 100% note: *p-value <0.05 supremo, bacason, and sañosa (2022) jurnal ners 166 p-issn: 1858-3598  e-issn: 2502-5791 the improvement of knowledge and satisfaction due to the use of a newly illustrated tool in the form of brief stories related to each labor stage provided women with an excellent example of self-guidance. similarly, the studies conducted by howarth et al. (2019), and howarth and swain (2019) regarding the low-cost, and self-paced educational programs and relation to birth satisfaction in new mothers as these studies reflected that skill-based childbirth preparation increases childbirth self-efficacy for first-time mothers, in which the user of an educational program imparted knowledge through birth stories and was a form of a role model for the participants, thus having a direct influence on their childbirth satisfaction. consequently, women's knowledge improvement may have long-standing wellbeing for both themselves and their families (maimburg et al., 2016). the integration of information with the continuous support of healthcare providers (study researchers) was crucial. similarly, previous studies (hodnett et al., 2013; iravani et al., 2015; stark et al., 2016) reported that the presence of healthcare providers in the labor room was an essential element in parturient women's requirements during childbirth because it decreased their anxiety levels. the world health organization recommends that laboring women be accompanied by trusted care providers, such as doulas, midwives, or family members (who, 2016). the participants in this study expressed a need for receiving information regarding the labor stages which was evidenced by the significant difference between their knowledge before and after using the sawa program. likewise, malata and chirwa (2011) and iravani et al. (2015) reported that participants required information and were interested in the information received from healthcare providers during childbirth. our findings reported a significant relationship between the mode of delivery and the participant satisfaction with the childbirth roadmap tool; the majority of those who underwent normal delivery were strongly satisfied with it. an unpredicted surgical intervention or instrumental delivery was experienced negatively by women (martin et al., 2017). therefore, previous studies reported lower satisfaction with induced labor and cesarean section (howarth & swain, 2019; martin et al., 2017). normal childbirth without complications is the most expected by women; however, when the childbirth outcomes end with an unpredicted sequence, lower satisfaction may be experienced due to other factors associated with the cesarean method (carquillat et al., 2017; hutton and hall, 2014). regarding the duration of labor, our findings revealed that the majority of the participants who were either satisfied or strongly satisfied with the childbirth roadmap tool reported the second stage as having the least duration, with no statistically significant association between its duration and satisfaction with the childbirth roadmap. there is a partially, convenience with studies by khresheh (2010); wang et al. (2021), who reported a significantly shorter duration among primiparous women with the support of both a family member and hospital professional staff. the partial congruence in our study referred that the majority of women's satisfaction with the least duration of the second stage of labor. however, the inconsistency may be because our study did not measure the complete duration of labor. nevertheless, in our study, the researcher guided the parturient step-by-step during the first stage and the outcomes of the second stage were based on what the women followed during the initial stage-besides, a comparison between primiparous and multiparous participants was not performed as most of them in the present study were primiparous. table 5b. the association between the duration of the second stage of labor and the participants' satisfaction with the childbirth roadmap duration of the second stage of labor how would you evaluate this labor roadmap strongly satisfied satisfied neutral unsatisfied strongly unsatisfied p-value .10 min .15 min .20 min .25-30 min >30 min 0.63 119 69.2 22 12.8 22 12.8 9 5.2 0 total 172 100% note: *p-value <0.05 table 6. the association between the participants’ satisfaction and the recommendation of using the childbirth roadmap as a guidance tool recommendation of childbirth roadmap as a guidance tool satisfaction with the childbirth roadmap p-value strongly satisfied satisfied neutral unsatisfied strongly recommend recommend somewhat recommend not recommend 13 6 1 1 12 28 2 0 45 48 11 0 3 1 0 1 0.001* total 21 42 104 5 172 note: *p-value <0.001 fouly, zaghloul, alshiekh, and masoud (2023) http://e-journal.unair.ac.id/jners 167 moreover, previous study by kashanian et al. (2010) demonstrated a shorter duration of the first and second stages of labor; however, the third stage among women did not receive continuous support. this study calculated the duration of all the stages, while ours focused only on the second stage. the study's strengths and limitations: this is a pioneering study to test the childbirth roadmap tool in egypt. the sample size is representative of the total cohort over the period of time. however, the application of road mapping needs further training for the childbirth team to be implemented in the future. conclusion this study highlighted the benefits of using a simple, attractively illustrated tool, the "childbirth roadmap," to achieve the meaning of support through the sawa program during the stages of labor. the findings revealed a statistically significant difference between the pre/post knowledge of women regarding each stage. in addition, a statistically significant association was found between the application of the sawa program and women's satisfaction with the tool. this study applied a new program, sawa, using newly illustrated guidance material that can be employed in the labor wards of hospitals and other private facilities to guide the parturient woman through her journey of childbirth. furthermore, our research encourages using the childbirth roadmap in the initial phase of the last trimester during antenatal visits or classes, to familiarize pregnant women with it. moreover, it could be used by nursing students during their clinical training in the antenatal and labor wards to increase mothers' awareness regarding their labor process and progress. this study recommends to use the childbirth roadmap to facilitate the birth journey for women during labor and increase the active support role by the midwife and maternity nurse to apply holistic care during childbirth. references ahmad, i., nawaz, a., khan, s., khan, h., rashid, m. a., & khan, m. h. (2012) ‘predictors of patient satisfaction’, gomal journal of medical sciences, 9(2). https://doaj.org/article/3d2ef33da0444137ad6961de8c75f450 aune, i., marit torvik, h., selboe, s.-t., skogås, a.-k., persen, j., & dahlberg, u. (2015) ‘promoting a normal birth and a positive birth experience norwegian women’s perspectives’, midwifery, 31(7), 721–727. https://doi.org/10.1016/j.midw.2015.03.016 begley, c. m., gross, m. m., dencker, a., benstoem, c., berg, m., & devane, d. (2014) ‘outcome measures in studies on the use of oxytocin for the treatment of delay in labour: a systematic review’, midwifery, 30(9), 975–982. https://doi.org/10.1016/j.midw.2014.06.005 carquillat, p., vendittelli, f., perneger, t., & guittier, m.-j. (2017) ‘development of a questionnaire for assessing the childbirth experience (qace)’, bmc pregnancy childbirth, 17(1), 279. https://doi.org/10.1186/s12884-017-1462-x churchill, r. (2012) ‘the labor progress handbook: early interventions to prevent and treat dystocia, third edition’, j. midwifery womens. health, 57(4), 426–427. https://doi.org/10.1111/j.15422011.2012.00192_3.x fair, c. d., & morrison, t. e. (2012) ‘the relationship between prenatal control, expectations, experienced control, and birth satisfaction among primiparous women’, midwifery, 28(1), 39–44. https://doi.org/10.1016/j.midw.2010.10.013 gallo, r. b. s., santana, l. s., marcolin, a. c., & quintana, s. m. (2014) ‘swiss ball to relieve pain of primiparous in active labor’, rev. dor, 15(4). https://doi.org/10.5935/1806-0013.20140054 gau, m.-l., chang, c.-y., tian, s.-h., & lin, k.-c. (2011) ‘effects of birth ball exercise on pain and self-efficacy during childbirth: a randomised controlled trial in taiwan’, midwifery, 27(6), e293300. https://doi.org/10.1016/j.midw.2011.02.004 gizzo, s., di gangi, s., noventa, m., bacile, v., zambon, a., & nardelli, g. b. (2014) ‘women’s choice of positions during labour: return to the past or a modern way to give birth? a cohort study in italy’, biomed res. int., 2014, 638093. https://doi.org/10.1155/2014/638093 hodnett, e. d., gates, s., hofmeyr, g. j., & sakala, c. (2013) ‘continuous support for women during childbirth’, the cochrane database of systematic reviews, 7(7), cd003766. https://doi.org/10.1002/14651858.cd003766.pub5 howarth, a. m., & swain, n. r. (2019) ‘skills-based childbirth preparation increases childbirth self-efficacy for first time mothers’, midwifery, 70, 100–105. https://doi.org/10.1016/j.midw.2018.12.017 howarth a, a. m., swain b abstract a corresponding author, n. r., & swain, nicola. (2019) ‘low-cost, self-paced, educational programmes increase birth satisfaction in first-time mothers’, new zealand college of midwives journal • issue, 55. hutton, e. k., & hall, w. (2014) ‘psychoeducation for pregnant women with fear of childbirth increases rates of spontaneous vaginal delivery, reduces caesarean rates and improves delivery experience’, evid. based. nurs., 17(4), 105. https://doi.org/10.1136/eb-2013-101284 iravani, m., zarean, e., janghorbani, m., & bahrami, m. (2015) ‘women’s needs and expectations during normal labor and delivery’, j. educ. health promot., 4, 6. https://doi.org/10.4103/2277-9531.151885 kabakian-khasholian, t., bashour, h., el-nemer, a., kharouf, m., sheikha, s., el lakany, n., barakat, r., elsheikh, o., nameh, n., chahine, r., & portela, a. (2017) ‘women’s satisfaction and perception of control in childbirth in three arab countries’, reprod. health matters, 25(sup1), 16–26. https://doi.org/10.1080/09688080.2017.1381533 karlström, a., nystedt, a., & hildingsson, i. (2015) ‘the meaning of a very positive birth experience: focus groups discussions with women’, bmc pregnancy childbirth, 15(1), 251. https://doi.org/10.1186/s12884-015-0683-0 kashanian, m., javadi, f., & haghighi, m. m. (2010) ‘effect of continuous support during labor on duration of labor and rate of cesarean delivery’, int. j. gynaecol. obstet., 109(3), 198–200. https://doi.org/10.1016/j.ijgo.2009.11.028 khresheh, r. (2010) ‘support in the first stage of labour from a female relative: the first step in improving the quality of maternity services’, midwifery, 26(6), e21-4. https://doi.org/10.1016/j.midw.2008.11.003 maimburg, r. d., væth, m., & dahlen, h. (2016) 'women’s experience of childbirth a five year follow-up of the randomised controlled trial “ready for child trial.”, women birth, 29(5), 450–454. https://doi.org/10.1016/j.wombi.2016.02.003 malata, a., & chirwa, e. (2011) ‘childbirth information needs for first time malawian mothers who attended antenatal clinics’, malawi med. j., 23(2), 43–47. https://doi.org/10.4314/mmj.v23i2.70747 martin, c. r., hollins martin, c., & redshaw, m. (2017)’, the birth satisfaction scale-revised indicator (bss-ri). bmc pregnancy childbirth, 17(1), 277. https://doi.org/10.1186/s12884-017-14595 mselle, l. t., & eustace, l. (2020) ‘why do women assume a supine position when giving birth? the perceptions and experiences of supremo, bacason, and sañosa (2022) jurnal ners 168 p-issn: 1858-3598  e-issn: 2502-5791 postnatal mothers and nurse-midwives in tanzania’, bmc pregnancy childbirth, 20(1), 36. https://doi.org/10.1186/s12884020-2726-4 solnes miltenburg, a., kiritta, r. f., meguid, t., & sundby, j. (2018) ‘quality of care during childbirth in tanzania: identification of areas that need improvement’, reprod. health, 15(1). https://doi.org/10.1186/s12978-018-0463-1 stark, m. a., remynse, m., & zwelling, e. (2016) ‘importance of the birth environment to support physiologic birth’, j. obstet. gynecol. neonatal nurs., 45(2), 285–294. https://doi.org/10.1016/j.jogn.2015.12.008 wang, x., abdelhamid, m., & sanders, g. l. (2021a) ‘exploring the effects of psychological ownership, gaming motivations, and primary/secondary control on online game addiction’, decision support systems, 144 (january 2021), 113512. https://doi.org/10.1016/j.dss.2021.113512 wang, x., abdelhamid, m., & sanders, g. l. (2021b) ‘exploring the effects of psychological ownership, gaming motivations, and primary/secondary control on online game addiction’, decision support systems, 144, 113512. https://doi.org/10.1016/j.dss.2021.113512 who. (2016) ‘who recommendations intrapartum care for a positive childbirth experience transforming care of women and babies for improved health and well-being executive summary 1–8. 1–8’. zileni, b. d., glover, p., jones, m., teoh, k.-k., zileni, c. w., & muller, a. (2017) ‘malawi women’s knowledge and use of labour and birthing positions: a cross-sectional descriptive survey’, women birth, 30(1), e1–e8. https://doi.org/10.1016/j.wombi.2016.06.003 how to cite this article: fouly, h., zaghloul, m. g., alshiekh, i., and masoud, a. (2023) ‘a simple awareness for women about (sawa) stages of labor on women's childbirth experience using the childbirth roadmap tool: a quasi-experimental study’, jurnal ners, 18(2), pp. 159-168. doi: http://dx.doi.org/10.20473/jn.v18i2.45127 124 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 124-130 http://dx.doi.org/10.20473/jn.v18i2.44667 original article open access the effectiveness of modified conventional cpr training among north borneo university hospital healthcare providers nazrin ahmad 1 , walton wider 2 * , fairrul kadir 2 , aizuddin hidrus 2 , and hamidah hassan 3 1 nursing services department, hospital universiti malaysia sabah, sabah, malaysia 2 faculty medicine health science, universiti malaysia sabah, malaysia 3 department of nursing, universiti tunku abdul rahman, selangor, malaysia *correspondence: walton wider. address: faculty medicine health science, universiti malaysia sabah, malaysia. email: walton.wider@newinti.edu.my responsible editor: ferry efendi received: 4 april 2023 ○ revised: 9 june 2023 ○ accepted: 17 june 2023 abstract introduction: numerous studies reported that healthcare providers are not as effective in rendering high-quality cpr over time, despite receiving basic life support (bls) or advanced cardiac life support (acls) training. thus, to overcome the issue and develop a more feasible implementation of cpr training model, this study aims to identify the effectiveness of a modified conventional training (mt-cpr) method. methods: this was an experimental study conducted to 72 healthcare providers in a teaching hospital in north borneo. subjects underwent mt-cpr and data were collected using a validated questionnaire and skills assessment checklist adopted from aha (2020). data then was analysed using friedman, wilcoxon and mcnemar test aided with ibm’s statistical package for the social science (spss) statistic software. results: this study reported that mt-cpr significantly improved the knowledge and skills on cpr (p-value: <0.001). however, the training module significantly incapable to retain the knowledge and skills as early as 3 months post initial mt-cpr (p-value: <0.001). there was a statistically significant difference between the mcq test scores (precourse, post-course, and post 3 months-course) with ꭓ2 (2) = 36.2 (2), p-value = <0.001. there is an association between post-course overall results and post 3 month overall results using mcnemar test (p-value < 0.002). conclusions: overall, this study indicated that modified cpr training (mt-cpr) were able to develop and improve the cpr knowledge and skill. the adaptation of conventional cpr training method seen effective as it has the capability for better engagement between trainer and participants. keywords: cardiopulmonary resuscitation, cardiac arrest, experimental, healthcare providers, modified conventional training method introduction cardiopulmonary resuscitation (cpr) refers to a chain of survival to be performed on a victim or patients who experience cardiac arrest, respiratory arrest and airway obstruction (chen et al., 2017). it comprises of the combination of effective ventilation and manual chest compression to a person known to be pulseless and having abnormal breathing and gasping. the cpr course educates the participants to identify the signs of cardiac arrest, provide a high-quality of chest compression as well as operate the automated external defibrillator (aed) (mersha et al., 2020). adequate knowledge and skills on cpr is fundamental for healthcare providers (hcp) who work in a healthcare setting. without proper and prompt action to cardiac arrest victims, it may lead to severe implications and https://creativecommons.org/licenses/by/4.0/ mailto:walton.wider@newinti.edu.my https://orcid.org/0000-0002-2518-6468 https://orcid.org/0000-0002-0369-4082 https://orcid.org/0000-0002-5945-714x https://orcid.org/0000-0002-1524-541x https://orcid.org/0000-0001-5040-1732 jurnal ners http://e-journal.unair.ac.id/jners 125 could cause death. therefore, early recognition of cardiac arrest events followed by effective cpr is important for a better outcome. cardiopulmonary resuscitation (cpr) is the only procedure recommended by international and local resuscitation protocols to be performed on cardiac arrest victims (kleinman et al., 2018). the outcome of cardiopulmonary resuscitation depends on the competence of the first responder who initiated the procedure (silverplats et al., 2022). the parameters used to evaluate cpr quality are chest compression rate and depth (aha, 2020). despite receiving basic life support (bls) or advanced cardiac life support (acls) training, several studies have demonstrated that nurses, as the dominant healthcare providers, become less effective at providing high-quality cpr over time (silverplats et al., 2022). during cpr skills and knowledge evaluations, nurses frequently cannot perform adequate compression depth and rate in accordance with guidelines (du plessis et al., 2022). nurses are the closest healthcare provider to the hospitalized individual and, therefore, they are usually the primary rescuer to initiate cpr for patients who develop cardiac arrest. unfortunately, it was reported that nurses were poor in the recognition of the impending deterioration of patient condition due to cardiac problems which leads to sudden cardiac arrest (sca) (chaudhary et al., 2023), identification of abnormal cardiac arrest rhythms (aljohani, 2022) and immediate action in the event of sca (varughese and silva, 2019). these weaknesses form the essential reason for providing an adequate and structured model of cpr training for nurses. periodic and structured cpr training has improved the cpr competencies among nurses (nu et al., 2023). however, there is still a need to attend the refresher course as the guideline will routinely be modified (aha, 2020). refresher cpr courses have long been used to maintain the skills of healthcare professionals. to determine the competency of participants and the efficacy of each new training model, however, multiple versions of the mode and content of cpr training have been implemented. the conventional method of cpr training is unquestionably the most effective method of instruction (sand et al., 2021). it was defined as a physically attended and face-to-face course that requires multiple sets of equipment for training. this model typically takes one to two days to complete, depending on whether the participants are novices or merely seeking a refresher course. despite the fact that numerous health institutions have begun incorporating artificial intelligence into cpr training, both models were deemed equally effective in terms of competency outcomes (ali et al., 2021). however, not all institutions were found capable of developing training software or subscribing to the existing cpr training application. this study aims to identify the effectiveness of a modified traditional training method for better knowledge and skill sustainability in tertiary health facilities to address the issue and develop a more practical model for cpr training implementation. most victims of sudden cardiac arrest die due to poor prognosis and poor cpr performance by first responders or bystanders (alnutaifi, 2021). poor performance is defined as a delay in initiating cpr and insufficient chest compression depth and rate (masood et al., 2020). poor cpr outcome is often a result of rescuers' reluctance and apprehension in performing cpr (chien et al., 2020). the majority of health institutions in malaysia continue to implement cpr training using the conventional approach (ali et al., 2021b). even though they use similar american heart association (aha) and national committee of resuscitation team (ncort) guidelines, each institution has been found to implement training differently. due to the diverse clinical backgrounds and work experience of hospital participants, cpr training in hospitals necessitates different pedagogical principles and instructional strategies (ali et al., 2021a). in comparison to those who work in a tertiary hospital, those who work in a district area will encounter fewer cardiac arrest cases. lack of proper training would, inevitably, make acquiring and maintaining cpr skills difficult. to organize effective cpr training, however, it is essential to have access to knowledgeable trainers and useful equipment (elmali and balkan kiyici, 2022). therefore, limited resources necessitate some modifications to the conventional method of cpr instruction. in this study, the conventional method of training has been adapted to fit the needs of health institutions dealing with a similar issue. in malaysia, cpr training programs adhere to the simplified and essential portion of adult bls, which includes early recognition of sca and activation of the emergency response system, early cpr with an emphasis on hands-on techniques, and rapid defibrillation (aha, 2020; ncort, 2020). some institutions cannot use the standard certification training model for large-scale cpr training due to training costs, the lack of expert trainers (ali et al., 2021b), and time constraints (rabanales-sotos et al., 2022). for busy tertiary health institutions to be feasible, cost-effective, and time-friendly, it is necessary to develop a modified conventional training method. as ahmad, wider, kadir, hidrus, and hassan (2023) 126 p-issn: 1858-3598  e-issn: 2502-5791 the number of health providers increases, numerous health institutions seek to increase the proportion of cpr-trained health providers (chien et al., 2020). numerous studies have indicated that theoretical cpr training is ineffective for developing practical skills (onan et al., 2019). according to some sources, a modified cpr training model, such as instructor-led instruction and video-assisted education emphasizing hands-on training, could effectively maintain trained participants (alnutaifi, 2021). in addition, receiving direct instruction from the instructor may result in a higher level of competency for cpr training that is both sustainable and effective (masood et al., 2020). materials and methods study design this was a quasi-experimental study aimed to identify the effectiveness of a modified traditional training method for better knowledge and skill sustainability in tertiary health facilities so as to address the issue and develop a more practical model for cpr training implementation. it was conducted in may 2022 until september 2022 (4 months) in the clinical simulation unit of a teaching hospital in northern borneo. it consists of the traditional method, modified module and the dependent variable which measures the competency level of healthcare providers focused on cognitive knowledge and hands-on skills. hands-on skills are defined as the ability to recognize and perform immediate cpr emphasizing on hand placement, depth, and rate. sample the study population consisted of medical officers, nurses, assistant medical officers, and nursing assistants from a teaching hospital in north borneo. the site study was selected as it was the first teaching hospital in north borneo of malaysia that required an effective method of cpr training for the staff. the sample population selection was chosen based on the usual composition of a resus team in local clinical setting. the inclusion criteria were 1) healthcare providers in university malaysia sabah, 2) not pregnant, 3) underwent formal cpr training for less than five (5) years and the exclusion criteria were vice versa. intervention in the first phase of the study, the subjects participated in a modified bls training course; in the second phase, three months later, they were evaluated for their knowledge and skill retention. pregnant subjects who refused to participate in this study were excluded from the analysis. all the potential participants who met the inclusion criteria read the consent form. the author answered the questions from the participants related to the study before they decided to take a part. the author described the study purpose, the significance of the study, and the expected time of completing the study questionnaires for all participants. in addition, participant's rights, including voluntary participation, the right to withdraw from the study at any time, and confidentially of the participants were assured. study instrument this was a partial validated instrument called modified conventional cpr training (mt-cpr). it consists of theoretical and practical session, preand post-test for mcq and post-test only for the practical part. the theoretical and practical content was based on the american heart association (2020) guideline for healthcare providers. mt-cpr was purposely designed to be implemented in eight (8) hours total and potentially can be reduced depending on the number of participants. to reduce the theoretical session time consumed, a lecture handbook was given two weeks prior the course being implemented. knowledge measurement in phases one and two, subjects were required to answer the 50 mcq questionnaires related to cpr knowledge. a scoring key was designed where each correct answer was awarded 1 mark and the wrong answer 0. thus, the item maximum score was 50 and the minimum was 0. consequently, the participants were required to get >43 scores to be considered as pass. since health workers should have sufficient knowledge in this very critical area, knowledge scores of above 43 or 86% were considered “adequate” knowledge, scores table 1. distribution of sample based on demographic data (n=33) respondents (n) respondents (%) age group 20-30 22 66.7 30-40 11 33.3 gender male 4 12.1 female 29 87.9 designation doctor 4 12.1 nurse (rn) 22 66.7 assistant medical officer (amo) 5 15.2 assistant nurse (an) 2 6.1 year of experience < 1 year 2 6.1 1 2 years 7 21.2 2 3 years 4 12.2 3 4 years 15 45.5 > 5 years 5 15.2 n = numbers, % = percentage jurnal ners http://e-journal.unair.ac.id/jners 127 35 42 or 70 84% were considered “moderate” knowledge, and scores of below 34 or < 68% were considered as “poor” knowledge. skills measurement the practical skills were evaluated using four parameters: rate, depth, pause duration between compression and ventilation techniques. the aha (2020) skills assessment checklist was utilized to evaluate the practical skills which consisted of assessment (recognition sign of sca and activation of ert and high-quality chest compression (rate 100-120 cpm, depth at least 5cm, minimize interruptions, avoid excessive ventilation, complete chest recoil, opening the airway using head tilt chin lift). the skills assessment was done by the certified trainer among medical officers and assistant medical officers. the participants were considered passed or failed based on the expert judgment with the emphasis on the correct sequence of looking for danger, checking for response, calling for help and performing high quality chest compression data collection prior to data collection, participants were briefed and given the opportunity to enquire about the implementation of the study. ethical consideration was taken from medical research ethics committee of ums [approval code: jketika 1/22(14)]. collected data were checked for their completeness before the analysis process took place data analysis the results of the participants’ theory test and performance on the practical skills test were entered into a data collection form as numeric values. data collection forms were reviewed and transferred to an excel spreadsheet. statistical package for the social sciences (spss version 25) was utilized to analyze the data. results the majority of respondents were in the age of 2030 years old (66.7%) followed by 33.3% of the 30-40 age group. the mean age for the study participants was 28 of 33 respondents, where 29 (87.9%) were females and four (4) (12.1%) were males. this study reveals that 22 (66.7%) respondents were nurses, followed by five (5) assistant medical officers (15.2%), four (4) doctors (12.1%) and two (2) assistant nurses (6.1%). based on work experience, this study demonstrates that the maximum year of experience is of 34 years (15,45.5%), followed by 1-2 years’ experience (7, 21.2%), more than five (5) years 5, (15.2%), 2-3 years (4, 12.2%) and less than 1 year (2, 6.1%). table 2 represents that pre-course indicated most of the respondents as having moderate knowledge (23, 76%), followed by adequate knowledge (5, 16.7%) and poor knowledge (2, 6.7%). after undergoing the mtcpr, the distribution of knowledge reported to be positive was 17 (56.7%) having adequate knowledge, 10 (33.3%) with moderate knowledge and three (3) (10%) with poor knowledge. unfortunately, the level of knowledge deteriorated three months after training, which revealed 14 (46.7%) as having moderate knowledge, six (6) (20%) having adequate knowledge and 10 (33.3%) with poor knowledge. based on table 3, there was a statistically significant difference between the mcq test scores (pre-course, post-course, and three months post-course) with ꭓ2(2) = 36.2, p <0.001. for the post-hoc test to determine where the differences among these three scores were, the wilcoxon signed-rank test was performed on the different combinations of the three score groups (table 4). from the post hoc test, the median change of score for preand post-course significantly differed from zero table 2. distribution of participants based on the level of knowledge level of knowledge score (maximum=50) respondents pre-course post-course post-3 months n % n % n % adequate knowledge >43 or >86% 5 16.7 17 56.7 6 20 moderate knowledge 35 42 or 70 84% 23 76.7 10 33.3 14 46.7 poor knowledge <34 or < 68% 2 6.7 3 10 10 33.3 table 3. comparison of mcq test result (pre-, post-, 3 months postcourse) median (iqr) ꭓ2 (df) p-value mcq test score 32.6 (2) <0.001 pre-course 38.0 (5) post-course 43.0 (5) three months post-course 39.5 (7) note: friedman test was performed, and p-value obtained was significant. table 4. comparison of mcq test result (prevs post-course, pre vs post-3 months, postvs post-3 months) comparisons median difference z pvalue prevs post-course -5 -4.185a <0.001 prevs post-3 months -1.5 -0.189a 0.850 postvs post-3 months 3.5 -4.501b <0.001 note: wilcoxon signed-rank test was performed. abased on negative ranks. bbased on positive ranks. ahmad, wider, kadir, hidrus, and hassan (2023) 128 p-issn: 1858-3598  e-issn: 2502-5791 (p < 0.001), which indicates that the score was significantly increased after the course. however, there was no significant difference between preand three months post-course (p = 0.850), which indicates that the score between preand three months post-course were almost the same. there was a significant difference between postand three months post-course (p <0.001) indicating that the score was significantly decreased three months after the course compared to the postcourse score. table 5 displays the association between the postcourse practical skills and the practical skills of participants after three months, as analysed by mcnemar test. a total of 28 participants passed the post-course skills station, while 0 participants failed. after three months, 18 participants passed the practical skills again, while 10 failed. the p-value obtained from the test was 0.002, indicating a statistically significant association between the two variables. table 6 displays the association between the postcourse overall results and the post-3 months overall results of participants, as analyzed by mcnemar test. a total of 27 participants passed the post-course overall results, while one (1) participant failed. after three months, six (6) participants passed the overall results, while 22 failed. a mcnemar test was performed to determine if there was a significant association between post-course overall results and the post-3-months overall results. the p-value obtained from the test was < 0.001, indicating a statistically significant association between the two variables. discussions the mt-cpr model was created by an emergency department expert with the primary goal of educating and ensuring that healthcare providers acquire adequate cpr knowledge and skills. this model was created in response to current hospital operations, taking into account the availability of expert trainers, equipment, budget, and time constraints. the study found a significant difference between the pre-, post-, and post-3-month mcq knowledge assessment courses. the preliminary results of the pre-course show that the majority of the subjects had a low level of knowledge before undergoing the mt-cpr. however, the level of knowledge drops dramatically after three months. ahn et al. (2016) reported that cpr knowledge and skill deteriorate as early as three months without practice. this result was similar to practical skills performance wherein it deteriorates as early as three months post initial training. following mt-cpr, the subjects’ cpr practical skills were deemed adequate. however, the mcq assessment result showed a similar pattern of deterioration in practical skills after three months. the assessor (after three months) commented that most of the subjects were unsure and found it difficult to recall the drscab sequence (danger, respond, shout for help, compression, airway, breathing), and that the rate of chest compression was irregular and could be less than 100 compressions per minute. there is no doubt that modified and simplified traditional cpr training is highly recommended to improve trainee knowledge and skills (alnutaifi, 2021). however, there is no guarantee that the participants would use the traditional training method on a regular basis due to several constraints such as time, course availability, and the fee to attend this type of training approach. because cpr certification courses are in high demand, most government public health institutions are focusing on this aspect. some critical clinical departments, such as emergency and anesthesia, may have key performance indicators (kpis) that must be met in order to organize cpr training on an annual basis. however, due to the workload, the availability of expert trainers, and the lack of equipment, the kpi were difficult to meet. nonetheless, lack of cpr practice due to lack of sca cases leads to poor hands-on performance by the hcp. nonetheless, the recent covid-19 pandemic, which prohibits any physical contact, and the strict rules requiring the use of proper ppe, has exacerbated the implementation of traditional physical training approaches (castillo et al., 2022). aside from modifying the traditional training approach for improved and sustained competency, the study recommends simplifying the sequence of cpr training to only include the core components such as look for danger, check for response, call for help, and hands-on chest compression. table 5. comparison of post-course and post-3 months practical skills variables post-3 months practical skills p-value pass fail post-course practical skills pass 18 10 0.002 fail 0 0 table 6. comparison of post-course and three months post-course overall results variables 3 months post course overall results p-value pass fail post-course overall results pass 6 21 < 0.001 fail 0 1 jurnal ners http://e-journal.unair.ac.id/jners 129 it is well-known that a simple and straightforward training module can have a positive impact on overall training results, implementation, and retention of cpr competency (grief et al., 2021). this training model could also be used by the community for training purposes. international resuscitation guidelines recommended optimizing the use of technology in cpr training as alternatives to the traditional training approach (lim et al., 2022). with the current covid-19 pandemic situation and other barriers mentioned earlier, numerous studies have been conducted to determine the efficacy of this technology-based training. in europe, smartphones were widely used as primary tools in technology-based cpr training to increase the survival rate during out-of-hospital cardiac arrest (ohca). cpr training can also be done in hybrid mode, which is a combination of technology and traditional training methods. the theory portion of the hybrid training model will be delivered via web-based learning, instructional video, mobile apps, and computer programs. vr and ar systems can be used to supplement physical practice. nonetheless, the incorporation of technology in an appropriate device not only aids in training, but is also beneficial when confronted with a cardiac arrest event (dong et al., 2020). the advantages of incorporating the traditional method into a technology-based approach may empower the user to do self-directed learning and reduce reliance on instructor availability. this advanced approach is also cost-effective because it does not necessitate additional trainers or equipment, depending on the technology-based training module used (rabanales-sotos et al., 2022). aside from that, this alternative approach to supplementing current standardized and modified cpr training can help healthcare providers and communities overcome time constraints. limitation a larger sample size is recommended for better and more consistent results. the sample size in this study, however, was small. as a result, it does not represent all healthcare providers in the study setting. larger sample sizes should be considered in future studies to provide more consistent and generalizable results. this will help to ensure that the findings apply to a larger population of healthcare providers and communities. conclusions overall, this study found that modified cpr training (mt-cpr) was effective in developing and improving cpr knowledge and skills. the adaptation of traditional cpr training method is seen as effective because it allows for greater engagement between trainer and participants. numerous studies reported that competency could deteriorate as early as three months. therefore, it is recommended to retrain hcp in monthly basis using the mt-cpr or other simplified training approach. organizing eight hours of mt-cpr is feasible in this study setting as it has a potential to be organized for a few sessions on weekly basis. thus, more hcp will be able to refresh their competency. however, the implementation of mt-cpr on monthly basis still depends on a few factors such as the availability of expert trainer, equipment, workload, and budget. the retention of competency after initial training is still debatable. as a result, it is advised to supplement current training methods with technology-based training methods. for better psychomotor and cognitive outcomes, important elements such as instructor guidance, real-time feedback, interaction between trainer and participants, hands-on practice and assessment, and an interesting method of training implementation are still required. on top of that, the mt-cpr could be implemented in hybrid mode to minimize the weakness of traditional training methods such as the availability of expert trainer and cost issue. therefore, it is critical to organize regular simplified and easier implementation of training in order to maintain competency for both healthcare providers and the community. references aha. (2020) ‘cpr & ecc guidelines | american heart association cpr & first aid’, retrieved from https://cpr.heart.org/en/resuscitation-science/cpr-and-eccguidelines ahn, c., cho, y., oh, j., song, y., lim, t. h., kang, h., & lee, j. (2016) ‘evaluation of smartphone applications for cardiopulmonary resuscitation training in south korea’ biomed research international, 2016. https://doi.org/10.1155/2016/6418710 ali, d. m., hisam, b., shaukat, n., baig, n., eng, m., ong, h., epstein, j. l., goralnick, e., kivela, p. d., mcnally, b., & razzak, j. (2021a). cardiopulmonary resuscitation ( cpr ) training strategies in the times of covid19 : a systematic literature review comparing different training methodologies. december. https://doi.org/10.1186/s13049-021-00869-3 ali, d. m., hisam, b., shaukat, n., baig, n., eng, m., ong, h., epstein, j. l., goralnick, e., kivela, p. d., mcnally, b., & razzak, j. (2021b) ‘cardiopulmonary resuscitation ( cpr ) training strategies in the times of covid19 : a systematic literature review comparing different training methodologies’, 1–16. https://doi.org/https://doi.org/10.1186/s13049-021-00869-3 aljohani, m. s. (2022) ‘competency in ecg interpretation and arrhythmias management among critical care nurses in saudi arabia : a cross sectional study’. ahmad, wider, kadir, hidrus, and hassan (2023) 130 p-issn: 1858-3598  e-issn: 2502-5791 alnutaifi, n. (2021) ‘knowledge and skills of cardiopulmonary resuscitation among critical care nurses in kuwaiti hospitals’, american journal of nursing research, 9(2), 64–70. https://doi.org/10.12691/ajnr-9-2-4 castillo, j., gonzález-marrón, a., llongueras, a., camós, l., montané, m., & rodríguez-higueras, e. (2022) ‘competencies in basic life support after a course with or without rescue ventilation: historical cohort study’, healthcare, 10(12), 1–6. https://doi.org/10.3390/healthcare10122564 chaudhary, g. p., sah, k., malla, j., das, n., chaudhary, s., chaudhary, i., & pandey, j. (2023) ‘knowledge regarding basic life support among health care workers of the hospital of nepal 2023’. chen, m., wang, y., li, x., hou, l., wang, y., liu, j., & han, f. (2017) ‘public knowledge and attitudes towards bystander cardiopulmonary resuscitation in china 2017’, https://doi.org/10.1155/2017/3250485 chien, c., fang, s., tsai, l., tsai, s., chen, c., seak, j., weng, y., lin, c., chien, w., huang, c., lin, c., chaou, c., liu, p., tseng, h., & chen, j. (2020) ‘traditional versus blended cpr training program : a randomized controlled non-inferiority study’, scientific reports, 1–9. https://doi.org/10.1038/s41598-020-67193-1 dong, x., zhang, l., myklebust, h., birkenes, t. s., & zheng, z. j. (2020) ‘effect of a real-time feedback smartphone application (tcprlink) on the quality of telephone-assisted cpr performed by trained laypeople in china: a manikin-based randomised controlled study’, bmj open, 10(10), 1–10. https://doi.org/10.1136/bmjopen-2020-038813 du plessis, n., lamacraft, g., & joubert, g. (2022) ‘training, knowledge, experience and perceptions regarding cardiopulmonary resuscitation of doctors at an academic hospital in central south africa’, african journal of emergency medicine, 12(4), 344-351. greif, r., lockey, a., breckwoldt, j., carmona, f., conaghan, p., kuzovlev, a., pflanzl-knizacek, l., sari, f., shammet, s., scapigliati, a., turner, n., yeung, j., & monsieurs, k. g. (2021) ‘european resuscitation council guidelines 2021: education for resuscitation’, resuscitation, 161, 388–407. https://doi.org/10.1016/j.resuscitation.2021.02.016 elmali, ş., & balkan kiyici, f. (2022) ‘technology-based professional development program: experiences of science teachers’, journal of educational technology and online learning, may. https://doi.org/10.31681/jetol.1081367 kleinman, m. e., goldberger, z. d., rea, t., swor, r. a., bobrow, b. j., brennan, e. e., ... & travers, a. h. (2018) ‘2017 american heart association focused update on adult basic life support and cardiopulmonary resuscitation quality: an update to the american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care’, circulation, 137(1), e7-e13. https://doi.org/10.1161/cir.0000000000000539 lim, x. m. a., liao, w. a., wang, w., & seah, b. (2022) ‘the effectiveness of technology-based cardiopulmonary resuscitation training on the skills and knowledge of adolescents: systematic review and meta-analysis’, journal of medical internet research, 24(12). https://doi.org/10.2196/36423 masood, a., dastgir, n., akram, z., hanif, a., iqtidar, t., & syed, s. (2020) ‘awareness, knowledge and critical resuscitation skills among health care professionals of a tertiary health care facility’, international journal of cardiac science and research, 108. mersha, a. t., haile, a., gebre, k., tawuye, h. y., & endalew, n. s. (2020) ‘factors associated with knowledge and attitude towards adult cardiopulmonary resuscitation among healthcare professionals at the university of gondar comprehensive specialized hospital , northwest ethiopia : an institutionalbased crosssectional st’, 1–11. https://doi.org/10.1136/bmjopen2020-037416 ncort. (2020) ‘guidelines for resuscitation training’. nu, m., htay, n., math, y. b., kyaw, h. h., dubey, k. k., begum, s., ibrahim, k., poornima, v. v., thein, a. w., winn, a. k., vui, c. s., gupta, r., venkatesan, p., & zaw, k. (2023) ‘effectiveness of basic life-support programme and public cardiopulmonary resuscitation ( cpr ) training event among medical students : a pilot quasi-experimental study’, 15(1), 59–71. https://doi.org/10.21315/eimj2023.15.1.5 onan, a., turan, s., elcin, m., erbil, b., & bulut, ş. ç. (2019) ‘the effectiveness of traditional basic life support training and alternative technology-enhanced methods in high schools’, hong kong journal of emergency medicine, 26(1), 44–52. https://doi.org/10.1177/1024907918782239 rabanales-sotos, j., guisado-requena, i. m., leiton-espinoza, z. e., guerrero-agenjo, c. m., lópez-torres-hidalgo, j., martín-conty, j. l., martín-rodriguez, f., lópez-tendero, j., & lópez-gonzález, a. (2022) ‘development and validation of a novel ultra-compact and cost-effective device for basic hands-on cpr training: a randomized, sham-controlled, blinded trial’, international journal of environmental research and public health, 19(22), 1–10. https://doi.org/10.3390/ijerph192215228 sand, k., guldal, a. u., myklebust, t. a., hoff, d. a. l., juvkam, p. c., & hole, t. (2021) ‘cardiopulmonary resuscitation retention training for hospital nurses by a self-learner skill station or the traditional instructor led course: a randomised controlled trial’, resuscitation plus, 7, 100157. https://doi.org/10.1016/j.resplu.2021.100157 silverplats, j., strömsöe, a., äng, b., & södersved källestedt, m. l. (2022) ‘attitudes towards cardiopulmonary resuscitation situations and associations with potential influencing factors—a survey among in-hospital healthcare professionals’, plos one, 17(7), e0271686. https://doi.org/10.1371/journal.pone.0271686 varughese, s., & silva, b. d. (2019) ‘knowledge and perspective on cpr among staff nurses knowledge and perspective on cpr among staff nurses’, february 2018, 3–6. https://doi.org/10.9790/19590701071214 how to cite this article: ahmad, n., wider, w., kadir, f., hidrus, a., and hassan, h. (2023) ‘the effectiveness of modified conventional cpr training among north borneo university hospital healthcare providers’, jurnal ners, 18(2), pp. 124-130. doi: http://dx.doi.org/10.20473/jn.v18i2.44667 78 http://e-journal.unair.ac.id/jners © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 78-90 http://dx.doi.org/10.20473/jn.v18i2.38960 original article open access the experience of nurses in providing holistic nursing care for covid-19 patients at banyuwangi hospital atik pramesti wilujeng 1 , akhmad yanuar fahmi pamungkas 1 , dwiky rizal mahardika 1 , and essy sonontiko 1 1 sekolah tinggi ilmu kesehatan banyuwangi, banyuwangi, indonesia *correspondence: atik pramesti wilujeng. address: sekolah tinggi ilmu kesehatan banyuwangi, banyuwangi, indonesia. email: atikpramesti@stikesbanyuwangi.ac.id responsible editor: yulis setiya dewi received: 5 october 2022 ○ revised: 27 march 2023 ○ accepted: 29 march 2023 abstract introduction: covid-19 is a new virus that was discovered at the end of december 2019 and has marked a global pandemic around the world. not only has a high-risk infection, nurses as health workers who have the most contact with covid-19 patients are also at risk of experiencing physical and emotional stress. anxiety and nurses' fear about the risk of contracting the covid-19 virus can lead to unprofessional attitudes and behavior of nurses in providing holistic nursing care to the patients. this study aimed to explore the experience of nurses in providing holistic nursing care to covid-19 patients. methods: this research used phenomenological qualitative research. data collection was done by in-depth interview. the participants in this study were 7 nurses who served in the isolation room of blambangan hospital, banyuwangi. purposive sampling method was used to select participants according to the inclusion criteria. descriptions of nurses' experiences were analyzed using the colaizzi approach. results: the study result revealed 6 themes; changes in the emotional status of nurses while caring for covid -19, social stigma against covid-19 nurses, support during caring for covid-19 patients, expectations during caring for covid-19, challenges during caring for covid-19 patients, and fulfillment holistic nursing care for covid-19 patients. conclusions: the nurses’ experience in treating covid-19 patients showed that when caring for patients, they have to go through ups and downs. this research was expected to improve nursing services, prepare nurses to adapt to the growing pandemic, and as a reference for further research related to the experience of nurses in treating covid19 patients. keywords: covid-19, holistic nursing care, nurse experience introduction at the beginning of 2020, the world was shocked by the presence of a new virus, namely a new type of coronavirus (sars-cov-2), the disease is called coronavirus disease 2019 (covid-19). this virus was first reported to have originated from wuhan, china by the end of december 2019. on february 12, 2020, who named the disease coronavirus 2019 (covid-19) which is the seventh type known in man. sars-cov-2 is classified in the beta coronavirus genus. coronaviruses are defined as family viruses that are transmitted between humans and animals (zoonosis) and can cause mild to severe symptoms. as happened in the past, there are two types of coronaviruses that have been identified to cause pathological effects in humans, these include severe acute respiratory syndrome (sars-cov) and middle east respiratory syndrome (merscov) (moudy & syakurah, 2020). the results of a preliminary study conducted on october 24, 2021 on five nurses using the interview method at the blambangan hospital, https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-8899-7452 https://orcid.org/0000-0001-7698-2520 jurnal ners http://e-journal.unair.ac.id/jners 79 banyuwangi, showed four people stated that they had confirmed covid-19. when they found out they were very shocked, worried that it would get worse, they were also afraid of infecting their family members, and they felt burdened with the stigma of friends and the surrounding community. meanwhile the other person said he had never been confirmed as having covid-19. according to world covid-19 data as of october 26, 2021, there were 243,857,028 confirmed cases of covid-19, including 4,953,246 deaths, reported. meanwhile, in indonesia from january 3, 2020, to october 26, 2021, there have been 4,241,090 confirmed cases of covid-19 with 143,270 deaths reported. as the front line in dealing with the covid-19 pandemic, nurses are one of the professions that are at very high risk of contracting covid-19. the international council of nurses (icn) stated that as many as 90,000 health workers have been infected with covid-19 and more than 260 nurses have died (icn, 2021). the death rate of health workers due to infection with the covid-19 virus in indonesia is the highest among countries in southeast asia (pusparisa, 2020). meanwhile, the results of a study of 4679 doctors and 348 hospital nurses during the covid-19 pandemic showed 15.9% psychological distress, 16.0% anxiety symptoms and 34.6% depression symptoms (liu, z. et al., 2020). the results of the study stated that covid-19 caused a psychosocial impact of anxiety on nurses, namely 154 respondents (34.00%) experienced mild anxiety, 16 respondents (3.53%) experienced moderate anxiety and two respondents (0.44%) experienced severe anxiety (cui et al., 2021). nursing personnel are one of the healthcare workers who interact with patients the most often compared to other components of health workers (romadhoni & widowati, 2017). medical personnel such as nurses are in the top position in the types of work that are most often exposed to diseases and infections such as the risk of facing an exposure to covid-19 (tiasari, 2020). the high risk, according to ehrlich, mckenney, and elkbuli (2021), is caused by the length of interaction with patients and the large number of patients causing an increase in the number of viruses around them; these factors are exacerbated by the lack of the personal protective equipment (ppe) and lack of knowledge related to the use of the ppe. during the covid-19 pandemic nurses sacrificed themselves to actively participate in services against the pandemic. facing this situation results in higher stress levels experienced by nurses, so they are at the risk of experiencing a burnout (sun et al., 2020). the fear of contracting covid-19 is a trigger for psychological problems, anxiety, and depression, which is very detrimental to health workers and can have an adverse effect on the quality of care. they must overcome the anxiety so that they can treat patients according to the established care process (wang et al., 2020). the phenomena of anxiety, depression, workload, and worrying about being infected by patients make nurses not optimal in providing holistic nursing care to covid-19 patients. in this case, nurses in particular have an important role in the readiness to handle covid-19 patients (li et al., 2020). one way to improve the quality of nursing services is supported by the development of nursing theories, namely by applying the caring theory by swanson. the experience of nurses can be seen in aspects of knowledge, motivation, and psychological conditions. efforts should be made to reduce the distribution and role of nurses in providing nursing care. these aspects can be influenced by the caring behavior of nurses such as the center of attention on people, respect for self-esteem and humanity, presence, empathy, nurse motivation to be able to care more for clients and be able to take actions according to client needs (dwiyanti et al., 2015). in general, discussions related to nursing care for covid-19 patients are still in the form of quantitative research that focuses more on disease prevalence (hui et al., 2020), clinical characteristics, diagnosis, and treatment (huang & zhao, 2020). the holistic approach of nursing includes interventions that focus on the patient's response that heal the whole person and promote balance; therapy includes biological, psychological, social, and spiritual therefore, researchers are interested in exploring the experience of nurses in providing holistic nursing care to covid-19 patients at the banyuwangi hospital. materials and methods. research design this research used a qualitative design with a phenomenological approach. this design was chosen so that participants' experiences can be explored to be more revealed so that the picture of nurses' experiences in caring for covid-19 patients can be depicted in a real way. the research method with a phenomenological approach is to explore perceptions, life experiences and understanding the essence of an individual's life. this method is appropriate to use to explore the phenomenon of nurses in treating covid-19 patients because each nurse has their own perception of their life experiences according to their views on themselves. wilujeng, pamungkas, mahardika, and sonontiko (2023) 80 p-issn: 1858-3598  e-issn: 2502-5791 with this method, it was hoped that various themes can be generated about the experience of nurses in treating covid-19 patients. participant this research was conducted in banyuwangi hospital from november 2021 until january 2022. the number of participants in qualitative research should be based on information needs. therefore, the principle in sampling is data saturation, namely sampling to a point of saturation where no new information is obtained and redundancy is achieved (polit, 2018). the population in this study was 32 nurses at the blambangan hospital, banyuwangi who had treated covid-19 patients. the criteria for participants were willing to be a participant and nurses who have experience working to treat covid-19 patients for more than five months. the sampling technique used in this study used a purposive sampling technique. this resulted in seven participants. research instrument the tools used in the study as data collection instruments were demographic data questionnaires, interview guides, field notes, and voice recorders. researchers conducted in-depth interviews to explore or explore in depth the experiences of nurses in treating covid-19 patients. researchers used questionnaires using participant demographic data which included initials, age of participants, gender of participants, and length of work. in addition, the researcher also used an interview guide during the data collection process. the interview guide contains questions based on swanson’s caring theory and consists of: physiological attitude toward others (in general) and to the patient being treated (specifically); show a caring attitude, and provide motivation to recover from covid-19; patients informed understanding of the clinical condition (in general) and the situation and client (in specific; nurses seek in-depth information regarding information and disease history; message conveyed to client; fully present, providing support, comfort, and monitoring to covid-19 patients; therapeutic actions; perform nursing actions according to established ethics and procedures, demonstrate professional skills, and protect patient rights; validate every action that has been taken, provide information to improve the health of patients and families of covid-19 patients. holistic care includes biological, psychological, social, spiritual. interview guides are made based on theoretical foundations that are relevant to the problems to be explored in the research. the interview guide is in-depth, begins with open-ended questions, and is not rigid. questions can develop according to the ongoing process during the interview without leaving the theoretical foundation that has been established. the interview guide was made to make it easier for researchers so that the interviews were directed and in accordance with the research objectives. in addition, interview guides were used to remind researchers of the main issues discussed. the questions asked were related to the experience of nurses in treating covid-19 patients. the interview guide has been tested for content validity by an expert. the purpose of this step is to assess the relevance of each item to the desired measure. the interview guides were: 1. tell us about your current experience carrying out patient assessments for covid-19 2. how do you prepare when doing assessment to the patient? 3. how do you build good therapeutic communication to a covid-19 patient? 4. how often do you take the time to communicate with covid-19 patients? 5. how do you motivate patients to survive the conditions they suffer from covid-19? 6. do you help covid-19 patients in carrying out their prayers? 7. what are the problems when using ppe when treating covid-19 patients? field notes are used by researchers to collect field note data, which comprise a written record of what is heard, seen, experienced, thoughts in the context of collecting data and reflecting on data in qualitative research in the form of documentation of non-verbal table. 1 the theme extraction theme 1: changes in the emotional status of nurses while caring for covid-19 patients sub-theme: 1. feeling sad when the patients die 2. feeling happy caring for patients until they recover 3. feeling of fear and stress theme 2: social stigma against covid-19 nurses sub-theme: 1. avoided and shunned by colleagues 2. expelled and ostracized by society theme 3: support while treating covid-19 patients sub-theme: 1. support from hospital management 2. support from family 3. support from the government 4. support from colleagues theme 4: hope while treating covid-19 patients sub-theme: 1. hope the pandemic ends 2. expectations of nurses’ welfare 3. hope for the welfare od society theme 5: social stigma against covid-19 nurses sub-theme: 1. difficulty acting and using ppe 2. dealing with uncooperative patients and families 3. difficulty performing actions with less amount of energy theme 6: fulfillment of holistic nursing care for covid19 patients sub-theme: 1. meeting the biological needs of covid-19 patients 2. meeting the psychological needs of covid-19 patients 3. meeting the social needs of covid-19 patients 4. meeting the spiritual needs of covid-19 patients jurnal ners http://e-journal.unair.ac.id/jners 81 responses during the interview process. the researcher also used a voice recorder to record conversations during the interview, then the results of the interview were typed in the form of a transcript. data collection data collection in this study used an in-depth interview method with a duration of 30-60 minutes. data collection was done through direct interviews. this research used in-depth interview guide to be submitted to participants. the in-depth interview method used an interview guide that contains questions to be asked to participants. this could make it easier for researchers to conduct interviews, collect information, data, and then depend on improvisation when at the research location. the researcher gave freedom to the participants to express their experiences with the questions asked during the interview process so that the data obtained naturally matched the experiences of the participants. participants in the study amounted to seven nurses who met the research criteria, namely being willing to be participants, having experience working caring for covid-19 patients > 5 months, not experiencing communication disorders. data analysis the descriptive colaizzi method was used to analyze the obtained data. this method consists of seven steps, as follows: (1) collecting the participants’ descriptions; (2) understanding the depth of the meanings; (3) extracting the important sentences; (4) conceptualizing important themes;(5) categorizing the concepts and topics; (6) constructing comprehensive descriptions of the issues examined; and (7) validating the data following the four criteria set out by lincoln and guba: known as credibility, dependability, confirmability, and transferability. ethical consideration this research has gone through an ethical test conducted at the health research ethics commission of the banyuwangi institute of health science permission to research, number 041/01/kepk-stikesbwi/ii/2022. all participants signed informed consent. the authors promise that there will be no academic misconduct such as plagiarism, data fabrication, falsification, and repeated publication. results the data obtained showed that generally there were six participants aged 27-36 years (90%) and one person aged 49 years (10%), the gender of the overall participants was one woman (10%) and six men (90%); the participant's position as deputy head of the room was one person (10%): due to a shortage of personnel in the covid-19 isolation room at banyuwangi hospital, the deputy head of the room participated in treating covid-19 patients. pj shift was as many as one person (50%) and implementing nurses as many as five people (40%), generally the length of work of participants is 1824 months as many as seven people (100%), generally the length of working hours/ day of participants is 7-10 hours as many as seven people (100%), and the training that has been attended by all participants is the use of ppe and the relocation of bodies as many as seven people (100%), while for the btcls training there are four people, and for the icu/iccu training there are three people. the demographic data of the participants is shown in detail in the form of a frequency distribution table. result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. the results of this study were analyzed according to the colaizzi method and found six themes, namely: (1) changes in the emotional status of nurses while caring for covid-19 patients; (2) social stigma against covid19 nurses; (3) support while caring for covid-19 patients; (4) expectations while treating covid-19 patients; (5) challenges while treating covid-19; (6) fulfillment of holistic nursing care for covid-19 patients. these themes will be discussed in detail to interpret the experience of nurses in caring for covid19 patients. theme 1: changes in the emotional status of nurses while caring for covid-19 patients changes in the emotional status of nurses while treating covid-19 are feelings experienced by nurses when they are happy about something, angry with someone, or afraid of something while caring for a covid-19 patient. this is illustrated by the sub-themes, namely: 1) feelings of sadness when the patient dies; 2) feelings of happiness in caring for patients until they recover; 3) feelings of fear and stress. each sub-theme will be explained as follows: feeling sad when patient dies the nurse's sadness when she saw the patient, she was caring for died. this statement corresponds to the following expressions: wilujeng, pamungkas, mahardika, and sonontiko (2023) 82 p-issn: 1858-3598  e-issn: 2502-5791 “of course, there are feelings of sadness and happiness. for the sad feeling is when many of the patients we care must die. when the number of covid is high, every day i see patients who die. so, we as nurses feel sad when we see it.” (p1) “we feel sad for failing to treat patients.” (p4) “sometimes we also feel sad when a patient who dies is not accompanied by his family, so we have to carry out the relocation of the corpse.” (p6) “sad moment when the patient goes home not accompanied by his family, especially the patient who died. and the handling of the corpse is quite complicated, such as having to use a coffin, the corpse can't be outside for too long, it can't be family. this makes for an unspeakable experience.” (p7) feelings of happiness that they can take care of patients until they recover the happiest thing for nurses is when they see patients being treated can recover from covid-19 and can reunite with their families; it is a happiness that exceeds anything for nurses. this statement corresponds to the following expressions: “the happy experience is that many patients recover, the patients we take home recover, the patients who come with shortness of breath recover, of course we are happy.” (p1) “very grateful when the patient recovers. because what i do with other friends and doctors is not in vain, everyone works in unison and helps each other.” (p2) “when a patient recovered, we were very proud and moved to tears, the patient said goodbye by waving.” (p4) “then the other happy person is when the patient we have treated is declared negative, it is a special happiness that cannot be expressed in anything.” (p6) feelings of fear and stress fear and stress while treating covid-19 patients are experienced by nurses who must serve patients, because nurses are the front-line troops in handling the fight against covid-19. this statement corresponds to the following expressions: "of course, personally, i am afraid, afraid of transmitting the covid virus to the family at home. even though we are afraid, we still carry out our obligations as health workers." (p1) "feeling stressed because we can't see the outside world. it's just being locked up in an isolation room; the trials of life at this time sometimes we can think for ourselves, if later we will be more stressed. sometimes we try to strengthen ourselves while praying so that god will continue to be given health." (p6) "at the beginning of the covid case, i was afraid because many died. and many nurses abroad and at home are also infected. so i feel afraid that later i will be infected with the virus, from there many doubts arise in me." (p7) theme 2: social stigma against covid-19 nurses social stigma against covid-19 nurses is a negative view between a person, a group of people who share characteristics of nurses working in covid-19 treatment rooms. the current covid-19 pandemic is causing fear for some people. feelings of fear can make a person stay alert but when the feeling of fear becomes excessive about covid-19, it causes the emergence of social stigma against the person or place associated with the disease. this is illustrated by the sub-themes, namely: 1) being avoided and shunned by peers, and 2) being expelled and ostracized by the community. avoided and shunned by colleagues while treating covid-19 patients, nurses are shunned by colleagues on duty from other treatment rooms. when you pass or meet a covid-19 nurse, there are colleagues from other rooms who fix masks and even run away and stay away. this statement corresponds to the following expressions: “other nurses avoided, they said you were taking care of covid, bro. indirectly, it offends them, they don't know our sacrifice while in the covid isolation room." (p3) "i have been shunned by colleagues. when i came with my friends to another room, they suddenly drifted away. one time when i am delivering food for the patient's diet, the door of the room was closed, and i was not allowed to enter the room. i had to give the patient's diet from outside. so, i was thought to be carrying the virus, and i felt a little offended when i was treated that way." (p4) expelled and ostracized by society nurses were evicted from their homes and even the families and children of nurses who treated covid-19 patients were ostracized from their environment. this statement corresponds to the following expressions: jurnal ners http://e-journal.unair.ac.id/jners 83 "after finishing work from the hospital, there are some of us who stay at boarding house and the owner says just move from here, so they rent a house and gather in one house." (p1) "my neighbor once asked, 'are you a covid nurse?' i said yes ma'am. so please don't stay here, poor people, instead of getting infected with the virus by you, you should go." (p5) theme 3: support while treating covid-19 patients support while caring for covid-19 patients is encouragement, motivation given by a group of people who are close to the social environment of nurses while caring for covid-19 patients. support in the form of caring, respect and love. this is reflected in the subthemes, namely: 1) support from hospital management, 2) support from family, 3) support from the government, and 4) support from colleagues. support from hospital management hospital management support is such as providing facilities for covid-19 nurses while on duty, namely housing for nurses, food and vitamins, providing attention and support and inquiring about the condition of nurses while on duty caring for covid-19 patients. this statement corresponds to the following expressions: “the management team always supports us, for example they always provide additional supplements and vitamins for the health workers here, the hospital director also makes phone calls and video calls with nurses and talks and laughs together, it makes us happy and feel cared for.” (p1) "they always support us, ‘keep fighting ya’, they always send the support by wa group. then they ask, ‘how are you? are you still healthy? don’t forget to take care of your health according to the protocol…" (p3) "a lot of support is facilities for patients. for the nurses themselves, almost 50% of us get help. we are grateful because we get two days off, so we have time to rest, there are also supplements for our health." (p6) support from family support from family is an effort given by the family and motivation from parents, husband/wife, and children if nurses treat covid-19 patients. this statement corresponds to the following expressions: "support from my husband, i have been married for 10 months ago, my husband supports me by going to the hospital. sometimes he also leaves food for me". (p4) "parents are very supportive. when i feel very tired after coming home from work, a phone call with my parents has become an encouragement, i think support from parents is very important." (p1) "support from family, when i go home from work, my parents call and encourage us." (p6) support from the government support from the government is an award in the form of incentives to health workers who treat covid-19 patients. support from the government is urgently needed by health workers, especially nurses who oversee treating covid-19 patients. this statement corresponds to the following expression: “we get incentives from the government and from the ministry of health. so that is one form of reward for the nurses' struggle while treating covid.” (p1) support from colleagues support from colleagues is the motivation given by friends who are on duty while treating covid-19, a form of attention, enthusiasm and providing support while treating covid-19 patients. this statement corresponds to the following expressions: "as a friend, we always support each other. if one of us is tired, we always say, ‘we must be patient and strengthen each other’." (p3) “from our colleagues we support each other. because we also experience the same suffering, happy and sad together.” (p6) theme 4: expectations while treating covid-19 patients hope while treating covid-19 patients is a wish that bears fruit and will be obtained from an incident while treating such patients. expectations of nurses while caring for covid-19 patients based on sub-themes are: 1) hope for the end of the pandemic, 2) hope for the welfare of nurses, 3) hope for the community. hope the pandemic ends that the pandemic will end soon is a nurse's wish and dream to be free from covid-19. this statement corresponds to the following expressions: "i hope this pandemic will pass quickly." (p3) "i hope that covid will end quickly, hopefully there won't be more patients." (p5) "hopefully this covid will pass quickly, so that our country will recover again as before." (p6) wilujeng, pamungkas, mahardika, and sonontiko (2023) 84 p-issn: 1858-3598  e-issn: 2502-5791 expectations for the welfare of nurses as a profession, nurses should get welfare in accordance with expectations. expectations for the welfare of nurses while caring for covid-19 patients are in accordance with the following expressions: "the hope is that the nurse's salary is not below the minimum wage, and they are given properly, because nursing is a profession that deserves to be rewarded with a decent salary." (p1) "hopefully the incentives will be disbursed quickly." (p3) "after this pandemic, all nurses were not underestimated, no one thought we were lying about this disease, no one said we killed their citizens, all the nurses who take care of them are healthy…" (p7) hope for society the nurse's hope for the community is the desire while caring for covid-19 patients, namely with the covid-19 pandemic, the community adheres to the health protocols recommended by the government and breaks the chain of transmission of covid-19, hoping to keep themselves healthy in order to avoid covid-19 . this statement corresponds to the following expressions: "i hope that the society is aware that they will continue to comply with the health protocols." (p5) “...especially for the elderly, i mean families who have elderly, take care of them because the elderly are more vulnerable than young children, especially those with small children…" (p7) theme 5: challenges while treating covid-19 patients challenges while treating covid-19 patients are things or activities that aim to inspire nurses' abilities while caring for covid-19 patients. various kinds of challenges faced by nurses while caring for covid-19 were based on sub-themes, namely: 1) difficulty acting and using ppe, 2) dealing with uncooperative patients and families, 3) difficulty taking action with a lack of personnel, and 4) the challenge of rotating the corpses of covid victims and the challenge of ridding the corpse of covid-19. difficulty acting and using ppe while on duty and using ppe for hours, nurses find it difficult to act on covid-19 patients. the use of complete ppe is a challenge for nurses when dealing with covid-19 patients, according to the following expressions: "there are many difficulties, especially the limitations for treating covid, it's because we use ppe like astronauts, it's automatically hard to wear boots, use goggles, use face shields, use hazmat, already wear surgical masks, wear n-95 masks, sometimes when you do this, it becomes condensed from steam. the vapor of breath condenses onto his glasses, onto his goggles so he can't see." (p1) "the difficulties are mostly related to the use of ppe, it is what makes us congested, sometimes we have to be careful to control our breath, that's all." (p3) "from the beginning of the pandemic, it was difficult for us to wear ppe because it was hot, stuffy and heavy, especially when we were about to perform actions such as installing an iv, we had difficulty because our glasses were foggy, making it difficult to find the vein." (p5) dealing with uncooperative patients and families the challenges nurses face while caring for covid-19 patients when dealing with uncooperative patients and their families. nurses are also often scolded by patients and their families while treating covid-19, according to the following expressions: "the patients don’t want to be given an iv, they don't want to take medicine, ask their family but the family is not allowed in, that's also an obstacle when treating patients in the covid room." (p1) "the problem is, in patient’s family, they don't know our position, how to deal with what's inside, while at that time we are short on power, lack of medical personnel, there are many patients with various levels, that's how it is; sometimes they just judging us, they said that we don't pay attention to the patients, they said we don't feed them, they said we have all kinds of things, it's hard to explain to their families how we are here." (p3) difficulty performing actions with less amount of energy the number of covid-19 patients that continues to increase makes medical personnel, especially nurses, have difficulty when providing care; the number of personnel is not proportional to the number of patients, thus making services less than optimal, and making nurses overwhelmed with inappropriate workloads, according to the following expressions: “there are so many difficulties when treating this covid patient, the nurse has to feed the patient if the patient is elderly, change the cloth too, automatically it will take 15 minutes to stay in the room the fastest, while the patient who wants to do the procedure is there 20 people and only three nurses on duty; automatically jurnal ners http://e-journal.unair.ac.id/jners 85 going to other patients will take a long time, the patient will be noisy even though due to limitations in things such as moving, because the weight that the ppe wears takes a long time, then overheating like that is the real obstacle.” (p1) “yes, for example the patient is already in serious condition, so sometimes we have a lot of our patients, for example, it's not that busy when the nurses are there, sometimes they are tired.” (p6) theme 6: fulfillment of holistic nursing care for covid19 patients as a nurse, the fulfillment of holistic care given to covid-19 patients is very important. in addition to requiring emergency treatment and pharmacological therapy, of course nurses in the room must also pay attention to the holistic needs of patients including biological, psychological, social, and spiritual so that patients achieve their well-being. this has been stated in the sub-themes, namely: 1). meeting the biological needs of covid-19 patients, 2). fulfillment of the psychology of covid-19 patients, 3). social fulfillment of covid-19 patients, 4). fulfilling the spiritual needs of covid-19 patients. meeting the biological needs of covid-19 patients in meeting the needs of nutrition, adl, and personal hygiene, patients with total care cannot do it alone and must be assisted by nurses in the room. this is certainly a separate experience for nurses in providing nursing care to covid-19 patients with total care in the isolation room. the experience has been expressed by the nurses as follows: “…for the biological needs of the patient, such as adl, nutrition, eating drinking, defecating or urinating, we are all helping the patient.” (p1) “on average, all the patients here are total care. so, the activity of eating and drinking, if the patients want to defecate, we change their diaper, bathe all of us and we will do it alternately, so it will take a while.” (p2) “we have to feed the patient one by one patiently, then we have to take turn too.” (p3) meeting the psychological needs of covid-19 patients it is natural for covid-19 patients to experience psychological stress. with the environmental conditions in the isolation room that is not accompanied by family and like being locked up in an aquarium, it can trigger excessive anxiety and worry. the nurses’ statements correspond to the following expressions: “…. we usually entertain them. singing together is one of our ways to entertain and not to stress or worry the patient.” (p2) “sometimes we give motivation in the form of entertainment and jokes to patients so as to reduce the stress they feel, such as singing and dancing to strong patients or patients who are still conscious.” (p4) “maybe there is a television in the room or we play music.” (p6) meeting the social needs of covid-19 patients support for the social conditions needed by covid-19 patients in isolation rooms is very important. being able to meet with family and get attention and support from nurses when carrying out nursing actions can have a positive impact on covid-19 patients. the experience of meeting the social needs of patients given by nurses can be seen from the expressions stated by nurses as follows: "so we provide cellphones for video calls with their families. so we also ensure that patients can communicate with their families, so they don't stress them out." (p4) “for patients whose vital signs are still good, we will facilitate cellphones so that patients can still communicate via video calls, but for patients who are critical and have shortness of breath, we cannot provide cellphone facilities because it will hinder the patient.” (p5) “in the past, before the delta variant, patients were allowed to operate cell phones, but at that time there were so many delta patients, we were worried, and we restricted them from using cell phones. for communication tools with family using cellphones belonging to the covid room. to update the condition that we will convey to the patient's family.” (p6) fulfilling the spiritual needs of covid-19 patients the need for worship for each patient is very important to continue to be carried out so that patients can still get peace and feel good with god almighty. this is in accordance with the following expressions: "for worship, for muslims, we will provide clean water for ablution so that some patients can perform their prayers properly. so, it is still well-facilitated, so that the spirituality is carried out." (p2) “we sometimes talk about tayammum for patients who are muslim because most of them pray here in bed so we teach them how to worship or pray in bed.” (p4) wilujeng, pamungkas, mahardika, and sonontiko (2023) 86 p-issn: 1858-3598  e-issn: 2502-5791 “for the muslim patient, we play videos of murottal, so they can get their spiritual needs.” (p5) discussions this this study focuses on the experience of nurses in treating covid-19 patients. participants were selected according to the inclusion criteria of the study and worked in the covid-19 ward. based on the results of this study, the researchers identified six themes and 20 sub themes related to the nurses’ experience in treating covid-19 patients at the blambangan hospital, banyuwangi. changes in the emotional status of nurses while caring for covid-19 patients emotional status is a feeling or reaction to something. emotions can be shown when feeling happy, angry, or afraid of something. while caring for covid-19 patients, nurses experience changes in emotional status. the covid-19 pandemic has an impact on the mental health of nurses around the world in the form of burnout, anxiety, depression, and fear of societal stigma and discrimination (icn, 2020). the importance of the position of nurses in handling the covid-19 pandemic and projections that the pandemic will continue into the second half of 2021 (vaishnav, dalal, & javed, 2020); nurses' mental health factors need to be a concern. based on this picture, the struggle of nurses in dealing with the virus while maintaining their mental health condition is not over. the results showed that changes in emotional status experienced by nurses while caring for covid-19 patients resulted in sub-themes, namely feeling sad when a patient being treated died, feeling happy when a covid-19 patient was declared cured, feeling afraid and stressed when caring for a covid-19 patient. the experience of nurses while caring for covid-19 patients causes sadness when a covid-19 patient dies. according to the assumption of researchers that loss can cause feelings of sadness or grief. this is in line with research by galehdar et al. (2020) and karimi et al. (2021) which states that the death of patients, especially young ones, provides a painful experience, as well as the strict funeral protocols that limit the patient's family from farewell and proper burial processions. an extraordinary experience while treating covid19 patients is that nurses feel happy when patients who have been tested positive for covid-19 can recover. according to the researcher's assumption, the feeling of happiness experienced by nurses is gratitude for having succeeded in providing support, enthusiasm and service to covid-19 patients while undergoing treatment. this is in line with the research conducted by yona and nursasi (2008) regarding the treatment of infectious patients that the extraordinary experience while treating patients is that nurses feel happy when patients who have been declared positive for avian influenza can recover. nurses experience feeling afraid and stressed when caring for covid-19 patients. according to the researchers' assumptions, at the beginning of the pandemic nurses were afraid of new diseases, difficult to predict and the number of patients who continued to grow. uncertain treatment procedures cause fear for nurses who must learn many new things related to procedures for treating patients with covid-19. nurses also experience stress while caring for covid-19 patients; the stress experienced arises because of situations that make nurses feel afraid. this is in line with research conducted by liu, y.e. et al. (2020) which states that the lack of experience and information about covid-19 and having to treat infected patients makes nurses feel afraid of contracting. caring for covid-19 patients is the duty of nurses as the frontline profession, but it becomes a stressor for nurses so that psychological problems arise for nurses. social stigma against covid-19 nurses stigma is a negative belief from an individual or group about something. stigma is formed because of construction by society and culture in certain contexts and has a significant impact on individuals and society. stigma can take the form of social rejection, gossip, physical abuse, and denial of service. the results showed that the social stigma of covid-19 nurses resulted in sub-themes, namely being avoided, and shunned by peers, expelled, and ostracized by the community. the experience of nurses in caring for covid-19 patients at the beginning of the pandemic was being avoided and shunned by colleagues when they passed each other and met in the hospital environment. according to the researcher's assumption, nurses from other units avoid and stay away when meeting with covid-19 nurses because they are afraid of being infected and infected if they come into direct contact with covid-19 nurses. the experience of nurses caring for covid-19 patients is of being expelled and ostracized from society. the refusal was made by the community because they were worried and afraid that the nurses in charge of caring for covid-19 patients would carry the virus and infect the surrounding environment. this is in line with research conducted by agung (2020) which states that the negative stigma of the covid-19 disease jurnal ners http://e-journal.unair.ac.id/jners 87 makes people tend to commit acts that violate norms. socially, stigma has an impact on nurses and their presence is denied when they are known to be on duty as a covid-19 nurse. the results of a survey conducted by the faculty of nursing at the university of indonesia also stated that nurses received unpleasant treatment from the community for treating covid-19 patients or serving in covid-19 referral hospitals. the community refused because they were worried about contracting the covid-19 virus (raisa, 2020). support while treating covid-19 patients support is a form of caring, existence, respect and love given to someone. as social beings, you will need support from those closest to you. nurses need great support from various parties while on duty to treat covid-19 patients. the results of the study produced sub-themes, namely support from hospital management, support from family, support from the government, and support from colleagues. support from hospital management, family, government and colleagues is in line with research conducted by liu, q. et al (2020) which states that nurses need great support to minimize the stress experienced and to change the stage of psychological change into energy renewal nurses need support from social, support from fellow nurses, the community and the government (zhang et al., 2020). based on the results of the study, the support provided by the hospital management is in the form of material and immaterial support. while on duty to care for covid-19 patients, the hospital provides facilities in the form of places to stay, eat and drink and all the needs of nurses. the hospital management paid attention to the covid-19 nurses at the banyuwangi hospital by communicating via video calls, asking about the condition of the nurses and their health. the support from the hospital management makes nurses more enthusiastic and feel cared for. support from family is the most important thing for nurses while on duty caring for covid-19 patients. the results showed that all participants stated that support from their families, both parents and husbands, was needed to stay motivated and not stressed while caring for covid-19 patients. according to the researcher's assumption, family support is needed because while on duty nurses are dealing directly with covid-19 patients whose transmission risk is very high, but because of the demands of the task as the frontline nurses, they must do it professionally. therefore, family support, both parents and husbands, is important so that it can increase enthusiasm and immunity while carrying out duties. government support for covid-19 nurses is also very much needed. the support provided by the government is in the form of awards, namely incentives for nurses who treat covid-19 patients. based on the results of interviews that nurses receive incentives from the government as a reward for covid-19 nurses, the incentives received by nurses are often delayed. according to the researcher's assumption, awards in the form of incentives from the government are needed by nurses, because incentives are used for daily needs and needs after nurses are on duty; the government should distribute incentives regularly every month so that nurses who treat covid-19 patients are more enthusiastic and enthusiastic in carrying out their duties. support from colleagues is very much needed by nurses while on duty to handle covid-19 patients. colleagues are closest, in the same fate, and share the same responsibility while on duty, so that the support of colleagues becomes an encouragement and reinforcement while on duty in the covid-19 patient care room. according to the researcher's assumption, support from fellow nurses will be needed to minimize the stress experienced by nurses. good support from various parties can increase a good emotional response in nurses, so that it can increase endorphins. with the increase in endorphins, nurses will automatically increase immunity (icn, 2021) so that nurses remain in good health and do not contract covid-19, even though nurses are in close contact with patients who have covid-19. expectations while treating covid-19 patients the results of the study with the theme of nurses' expectations while caring for covid-19 patients produced sub-themes, namely hope for the end of the pandemic, hope for the welfare of nurses, and hope for the community. the nurse in charge of treating covid-19 patients hopes that the pandemic will end soon. in this study, six out of seven participants expressed that they wished the pandemic would pass quickly and covid-19 patients would recover quickly. this is in line with the research conducted by sukiman, waluyo , and irawati (2021) who revealed that nurses hoped that the pandemic would end soon and patients would recover soon so they could gather with their families. expectations for the welfare of nurses while handling covid-19 patients were expressed by nurses during interviews. welfare in question is welfare that is wilujeng, pamungkas, mahardika, and sonontiko (2023) 88 p-issn: 1858-3598  e-issn: 2502-5791 financial in nature, then family welfare such as additional food, donations, then extra sufficient holidays, adequate rest, lodging facilities, vitamins, and moral support. this is in line with research conducted by sun et al. (2020) which states that hospitals must have a reward and welfare system to support and motivate nurses. another study was also conducted by yona and nursasi (2008) regarding phenomenological analysis of the experience of nurses in providing nursing care to patients with avian influenza, which stated that external factors that support respondents to carry out their obligations as nurses are support from the institution where they work, such as there are rewards in the form of money, transportation, additional food and vitamins that are sufficient to support the stamina of nurses as long as they treat patients. the nurse's hope for the community is to implement health protocols, while maintaining health to avoid covid-19. based on the results of research through interviews, it shows that nurses' expectations of the community are to carry out the rules that have been made by the government, namely maintaining distance when interacting with other people, reducing mobility, staying away from crowds, washing hands with running water or using hand sanitizers and using masks when leaving the house. according to the assumptions of the researchers, nurses hope that everyone is aware that, by implementing health protocols, we can reduce the number of cases of the spread of covid-19 which is increasing day by day. challenges while treating covid-19 patients during their duty to care for covid-19 patients, nurses experienced obstacles and challenges identified through four sub-themes, namely difficulties in taking action and using ppe, dealing with uncooperative patients and families, difficulties in taking action with a lack of manpower, and the challenge of rotating the bodies of covid-19 patients. based on the results of the study, all participants revealed that when handling covid-19 patients experienced difficulties, namely difficulties and limitations of movement when doing infusions, ngt insertion, difficulty acting because eye protection (goggles) were cloudy, and five of seven participants experienced shortness of breath when using ppe. this constraint is since ppe complicates the procedure. this is in line with research conducted by prasetyo eko (2015) on a simulation exercise for health workers wearing ppe in hospitals in the uk who reported that they found the use of ppe uncomfortable, and even basic tasks took longer than usual when wearing it. according to the researcher's assumptions, nurses who treat covid-19 patients also experience physical changes that occur due to the use of complete ppe. physical changes found in this study were physical complaints and physical limitations. physical changes are in the form of physical complaints that are felt in the form of fatigue and discomfort, while physical changes are in the form of physical limitations, namely limited field of view and limitations in movement. another challenge that nurses face when dealing with covid-19 patients is dealing with uncooperative patients and families. this is based on the results of interviews with participants who revealed that often the patient's family calls the nurse to ask the patient's condition, scolds the nurse because the family wants the patient to be prioritized while other patients must be followed up. this is in line with the research conducted by sukiman et al. (2021) that the negative response from patients and families did not accept the conditions and treatments carried out for covid-19 patients. according to the researcher's assumptions, the negative response from the patient's family is a sense of concern for the condition of the patient being treated and isolated in the hospital. the patient's family does not directly see the patient's condition and does not know how the treatment is carried out on the patient; the patient's family only receives information from the patient. difficulty taking action with a lack of manpower is a challenge experienced by nurses when dealing with covid-19 patients. the results of another study revealed that nurses who handled covid-19 patients had difficulties due to the large workload, but the number of patients was not balanced with the number of nurses. this is in line with research conducted by shen et al. (2020) that nurses caring for covid-19 patients have a greater workload than in caring for non-covid-19 patients, and nurses experience fatigue, sleeplessness, and decreased appetite. according to the researcher's assumptions, the high workload of nurses caring for covid-19 patients has a long impact on acting against other patients. in addition, nurses also experience fatigue when caring for patients because the number of patients is large but not proportional to the number of nurses. for this reason, it is better to arrange working hours and shifts for nurses so that fatigue in nurses caring for covid-19 can be reduced. nurses experience challenges when moving the bodies of covid-19 patients. fulfillment of holistic nursing care for covid-19 patients jurnal ners http://e-journal.unair.ac.id/jners 89 the results of interviews with all participants said that meeting the needs of patients holistically including biological, psychological, social, spiritual, nurses at the banyuwangi hospital as much as possible help meet the needs of patients. considering that many covid-19 patients in the isolation room are patients with total care, the treatment that must be given must be maximal. this happens when carrying out actions such as providing food and nutrition to patients and wiping the corpses of covid-19 patients. meanwhile, the results of research on meeting the psychological needs of patients revealed that nurses who treated covid-19 patients at the banyuwangi hospital provided optimal psychological support to patients by providing entertainment such as playing and singing together, listening to music or murottal to patients, and providing entertainment and motivation to the patient at the time of action. this is done because covid-19 patients generally experience psychological changes. the findings are consistent that people tend to feel anxious and insecure when their environment changes. in the case of an epidemic infectious disease, when the cause or progression of the disease and the outcome are unclear, rumors develop and a closed attitude occurs (ren et al., 2020). another study conducted by shaban et al. (2020) also stated the same thing where patients who were positively infected with covid-19 felt shocked and anxious when they were first diagnosed. according to the researcher's assumption, by entertaining patients, listening to music, listening to lectures or murottal, and inviting patients to play and sing, patients in the isolation room will tend to be happy and not stressed with their illness. therefore, having nurses who apply a caring attitude to patients can reduce stressors for covid-19 patients in the isolation room. the results of the research on meeting the social needs of patients revealed that the palliative care provided by the health team to patients by involving families could help the healing process of patients who were treated in isolation rooms. families can provide support through video calls, provide pictures, or letters of motivation from the family provided by the palliative care team. this is proven to support the progress of the patient's condition. this is supported by research conducted by brooke and clark (2020) explaining that innovative approaches involving family members in inpatient care during the covid-19 pandemic can lead to long-term progress, not setbacks. this has become the standard of family-centered care that has recently been achieved by the community and health services. in this study, the strategy to support family presence during physical distance relies heavily on electronic media such as smartphones and existing patient or family computers, stable internet access, and technological literacy. based on the theory described above, the researcher assumes that the family support provided to covid-19 patients during the current pandemic has a positive impact on the progress of the patient's condition during the treatment period. family support is considered influential in reducing the anxiety felt by patients due to treatment. the results of the study of fulfilling the spiritual needs of covid-19 patients revealed that nurses in the isolation room of the banyuwangi hospital had provided the spiritual needs of covid-19 patients well, provided spiritual fulfillment by showing feelings such as (praying (giving closeness to clients), supporting healing relationships (relationships from family, friends or friends), and support of religious rituals. moral support and prayers from family, friends, and health workers are important factors for the recovery of patients who are confirmed positive for covid-19 (rosyanti & hadi, 2020). the results of these efforts will provide positive thinking for the patient to be patient and surrender to god for the test given. forms of spiritual support during the covid-19 pandemic are carried out by: increasing friendship, reading scriptures, reducing news exposure from the media, taking time to worship, and taking time to get closer to god (ratnaningsih & nisak, 2022). according to the researcher's assumption, fulfilled spiritual needs can improve coping to face difficult or challenging situations. in a pandemic like this, spiritual life will be a very important part of coping. a good spiritual life will build a spiritually strong community in the face of difficult times during the covid-19 pandemic. conclusions this study provides an in-depth understanding of nurses' experiences in treating covid-19 patients which are illustrated in six themes and 20 sub-themes. in this study the nurses stated that, during caring for covid-19 patients, they feel ups and downs. the experience of nurses who were initially afraid to treat covid-19 patients are now accustomed and comfortable because they get new experiences and new knowledge related to handling covid-19 patients, although they experienced various challenges and most nurses had difficulty taking action using complete ppe. nurses also hope that incentives from the government will be immediately wilujeng, pamungkas, mahardika, and sonontiko (2023) 90 p-issn: 1858-3598  e-issn: 2502-5791 issued, and covid-19 will soon disappear from the face of the earth. it is very important for covid-19 patients to fulfill the needs of patients holistically. not only focusing on pharmacological treatment, complementary medicine with holistic therapy is also very helpful for improving patient well-being and accelerating the recovery of covid-19 patients. conflict of interest the authors have declared no conflicts of interest. references agung, i. m. (2020) ‘memahami pandemi covid-19 dalam perspektif psikologi sosial’, psikobuletin:buletin ilmiah psikologi, 1(2), p. 68. doi: 10.24014/pib.v1i2.9616. brooke, j. and clark, m. (2020) ‘older people’s early experience of household isolation and social distancing during covid-19’, journal of clinical nursing, 29(21–22), pp. 4387–4402. doi: 10.1111/jocn.15485. cui, s. et al. (2021) ‘impact of covid-19 on anxiety, stress, and coping styles in nurses in emergency departments and fever clinics: a cross-sectional survey’, risk management and healthcare policy, 14, pp. 585–594. doi: 10.2147/rmhp.s289782. dwiyanti, m. et al. (2015) keperawatan holistik, repository.akperykyjogja.ac.id. ehrlich, h., mckenney, m. and elkbuli, a. (2021) ‘the impact of covid19 pandemic on conducting emergency medicine clinical research’, american journal of emergency medicine, pp. 783–784. doi: 10.1016/j.ajem.2020.09.001. galehdar, n. et al. (2020) ‘exploring nurses’ perception about the care needs of patients with covid-19: a qualitative study’, bmc nursing, 19(1), pp. 1–8. doi: 10.1186/s12912-020-00516-9. huang, y. and zhao, n. (2020) ‘since january 2020 elsevier has created a covid-19 resource centre with free information in english and mandarin on the novel coronavirus covid19 . the covid-19 resource centre is hosted on elsevier connect , the company ’ s public news and information’, esliver psychiatry researchpsychiatry research, 288(january), pp. 2–3. hui, d. s. et al. (2020) ‘the continuing 2019-ncov epidemic threat of novel coronaviruses to global health — the latest 2019 novel coronavirus outbreak in wuhan, china’, psychiatry research, 14(4)(january), p. 293. icn (2020) ‘protecting nurses from covid-19 a top priority: a survey of icn’s national nursing associations’, icn, (september), pp. 1–9. icn (2021) ‘international council of nurses covid-19 update’, (january), p. 4. karimi, z. et al. (2021) ‘a phenomenological study of the lived experience of nurses caring for patients with covid-19 in korea’, journal of korean academy of nursing, 51(5), pp. 561–572. doi: 10.4040/jkan.21112. li, t. et al. (2020) ‘mask or no mask for covid-19: a public health and market study’, plos one, 15(8 august), pp. 1–17. doi: 10.1371/journal.pone.0237691. liu, q. et al. (2020) ‘the experiences of health-care providers during the covid-19 crisis in china: a qualitative study’, the lancet global health, 8(6), pp. e790–e798. doi: 10.1016/s2214109x(20)30204-7. liu, y. e. et al. (2020) ‘experiences of front-line nurses combating coronavirus disease-2019 in china: a qualitative analysis’, public health nursing, 37(5), pp. 757–763. doi: 10.1111/phn.12768. liu, z. et al. (2020) ‘mental health status of doctor and nurse during covid-19 epidemic in china’. moudy, j. and syakurah, r. a. (2020) ‘pengetahuan terkait usaha pencegahan coronavirus disease (covid-19) di indonesia’, higeia journal of public health research and development, 4(3), pp. 333– 346. prasetyo eko (2015) ‘pengaruh pengetahuan, sikap, dan ketersediaan alat pelindung diri (apd) terhadap kepatuhan dalam menggunakan apd di unit coating pt. pura barutama kudus’, jurnal keperawatan dan kesehatan masyarakat. ratnaningsih, t. and nisak, k. (2022) ‘pelaksanaan dukungan spiritual perawat pada pasien covid-19 di ruang hcu rsud bangil’, 5(1), pp. 78–87. ren, l. l. et al. (2020) ‘identification of a novel coronavirus causing severe pneumonia in human: a descriptive study’, chinese medical journal, 133(9), pp. 1015–1024. doi: 10.1097/cm9.0000000000000722. romadhoni, s. and widowati, e. (2017) ‘penerapan kewaspadaan standar sebagai upaya pencegahan bahaya biologi pada tenaga keperawatan’, higeia (journal of public health research and development), 1(4), pp. 14–24. rosyanti, l. and hadi, i. (2020) ‘dampak psikologis dalam memberikan perawatan dan layanan kesehatan pasien covid-19 pada tenaga profesional kesehatan’, health information : jurnal penelitian, 12(1), pp. 107–130. doi: 10.36990/hijp.vi.191. shaban, r. z. et al. (2020) ‘sars-cov-2 infection and covid-19: the lived experience and perceptions of patients in isolation and care in an australian healthcare setting’, american journal of infection control, 48(12), pp. 1445–1450. doi: 10.1016/j.ajic.2020.08.032. shen x et al. (2020) ‘psychological stress of icu nurses in the time of covid-19.critical care[revista en internet] 2020 [acceso 09 de junio del 2020]; 24(1): 200.’, critical care, pp. 2–4. sukiman, o., waluyo, a. and irawati, d. (2021) ‘studi fenomenologi: pengalaman perawat dalam menangani pasien dengan covid-19 di rumah sakit di jakarta tahun 2020’, jurnal penelitian kesehatan suara forikes, 12(2), pp. 141–147. sun, n. et al. (2020) ‘a qualitative study on the psychological experience of caregivers of covid-19 patients’, (january). vaishnav, m., dalal, p. k. and javed, a. (2020) ‘when will the pandemic end?’, indian journal of psychiatry, 62(9), pp. s330–s334. doi: 10.4103/psychiatry.indianjpsychiatry_1030_20. wang, d. et al. (2020) ‘clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china’, jama journal of the american medical association, 323(11), pp. 1061–1069. doi: 10.1001/jama.2020.1585. yona, s. and nursasi, a. y. (2008) ‘analisis fenomenologi tantang pengalaman perawat dalam memberikan asuhan keperawatan pada pasien dengan avian influenza’, jurnal keperawatan indonesia, 12(1), pp. 1–6. doi: 10.7454/jki.v12i1.192. zhang, y. et al. (2020) ‘the psychological change process of frontline nurses caring for patients with covid-19 during its outbreak’, issues in mental health nursing, 41(6), pp. 525–530. doi: 10.1080/01612840.2020.1752865. how to cite this article: wilujeng, a. p., pamungkas, a. y. f., mahardika, d. r., and sonontiko, e. (2023) ‘the experience of nurses in providing holistic nursing care for covid-19 patients at banyuwangi hospital’, jurnal ners, 18(1), pp. 78-90. doi: http://dx.doi.org/10.20473/jn.v18i1.38960 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 vol 8 no 1 april 2013.indd 118 perilaku keluarga dalam memelihara status hb pasien gagal ginjal kronik melalui manajemen diet fe dengan pendekatan family centered care (family behavior in maintenance status hb chronic renal failure patients through family centered care approach of diet fe management) anggia fajar hardianti*, ika yuni widyawati**, herdina mariyanti** *mahasiswa program studi ilmu keperawatan, fakultas keperawatan universitas airlangga ** staf pengajar fakultas keperawatan universitas airlangga e-mail: anggia.fardianti@gmail.com abstrak pendahuluan: agen erythropoietic sebagai praktik standar untuk pengobatan anemia, memiliki fungsi untuk meningkatkan nilai hemoglobin (hb) sampai 12 g/dl pada pasien dengan gagal ginjal kronis (ggk) yang menerima pengobatan dialisis. penggunaan erythropoietin mempertahankan kadar besi/fe dalam tubuh. keluarga yang bertugas merawat harus memiliki pengetahuan, sikap, dan perilaku dalam mempertahankan kadar hb pasien dengan memberikan dukungan kepada pasien untuk mematuhi diet fe. tujuan dari penelitian ini adalah untuk mengetahui pengaruh perawatan berpusat pada keluarga dalam pengelolaan diet fe terhadap perilaku keluarga dalam pemeliharaan kadar hb pasien crf di bangsal hemodialisis, rumah sakit gambiran, kota kediri. metode: penelitian ini menggunakan desain pra eksperimental. jumlah sampel adalah 10 responden, yang sesuai dengan kriteria inklusi. variabel independen adalah pengetahuan, sikap, dan psikomotor keluarga dalam pemeliharaan kadar hb pada pasien crf. variabel dependen adalah manajemen diet fe dengan pendekatan perawatan berpusat pada keluarga. data dikumpulkan dengan menggunakan kuesioner terstruktur dan observasi kunjungan rumah. data dianalisis dengan menggunakan wilcoxon sign rank test dengan taraf signifi kansi α≤0,05. hasil: hasil penelitian menunjukkan bahwa manajemen diet fe dengan pendekatan perawatan berpusat pada keluarga didapatkan pengetahuan keluarga (p=0,011), sikap keluarga (p=0,005) dan psikomotor keluarga (p = 0,005) dalam pemeliharaan kadar hb pasien crf. diskusi: pengetahuan, sikap, dan psikomotor keluarga dipengaruhi oleh pengalaman selama perawatan pasien, keterjangkauan untuk mengakses informasi dan keputusan pasien sendiri. kekuatan dan kelemahan dalam keluarga untuk perencanaan pelayanan yang lebih baik dapat diperoleh melalui diskusi dengan peneliti, pasien dan anggota keluarga. hal ini dapat disimpulkan bahwa manajemen diet fe dengan pendekatan perawatan berpusat pada keluarga mempengaruhi perilaku keluarga. penelitian lebih lanjut harus melibatkan responden yang lebih besar dan alat-alat pengukuran yang lebih baik untuk mendapatkan hasil yang lebih akurat. kata kunci: fe diet manajemen, perawatan berpusat keluarga, hb pasien crf, hemodialisis abstract introduction: erythropoietic agent as standard practice for anemia treatment, which has a function to increase the value of hemoglobin (hb) to 12 g/dl in patients with chronic renal failure (crf), who receiving dialysis treatment. the use of erythropoietin has to keep of the iron/fe amount in the body. family who have a duty of care should have knowledge, attitude, and behavior to maintain patient’s hb by giving support to the patient to obey the fe diet. the aimed of this study was to investigate the effect of family centered care approach in management fe diet toward family’s behaviour in maintenance hb level of crf patients in hemodialysis ward, gambiran hospital, kediri. method: this study was used a pre experimental design. total sample were 10 respondents, who met to inclusion criteria. the independent variables were knowledge, attitude, and psychomotor of family 119 perilaku keluarga dalam memelihara status hb pasien gagal ginjal (anggia fajar hardianti, dkk) in maintenance of hb level in crf’s patients. the dependent variable was fe diet management with family centered care approach. data was collected by using a structured questionnaire and home visit observation. result: data was analyzed by using wilcoxon sign rank test with signifi cance level α≤0.05. results showed that fe diet management with family centered care approach took effect to family’s knowledge (p=0.011), family’s attitude (p=0.005) and family’s psychomotor (p=0.005) in maintenance hb level of crf patients. discussion: family’s knowledge, attitude, and psychomotor were effected by experiences during the care of a patient, not affordable to access information and patient’s own decision. the strengths and weaknesses in the family to got a better plan of care can be made by discuss and sharing among researcher, patient and his family. it can be concluded that fe diet management with family centered care approach took effect to family’s behaviour. further studies should involve larger respondents and better measurement tools to obtain more accurate results. keywords: fe diet management, family centered care, hb of crf patients, hemodialysis darah untuk pasien jamkesmas, jamkesda, serta umum. pemberian edukasi diet hanya dilakukan sekali pada awal masuk ruang hemodialisis, sehingga informasi yang diterima oleh pasien dan keluarga minimal. permasalahan anemia pada pasien gagal ginjal kronik sangat membutuhkan partisipasi keluarga dalam mengatur dan memotivasi pasien untuk dapat memelihara status hb tetap normal. keterbatasan informasi dan pengetahuan keluarga tentang manajemen diet fe pada pasien gagal ginjal kronik dapat berpengaruh pada kondisi dan kualitas hidup pasien. salah satu upaya yang dapat dilakukan perawat adalah dengan memberikan edukasi tentang manajemen diet fe atau zat besi. family centered care merupakan pendekatan kolaboratif antara tenaga kesehatan, pasien dan keluarga yang terbukti meningkatkan kualitas perawatan kesehatan dan cost effective (blaycock, 2002). penelitian menunjukkan bahwa keterlibatan keluarga dapat mempercepat pemulihan klien dan menur unkan risiko kematian, mengurangi ketergantungan pada pelayanan kesehatan, mengurangi tingkat rehospitalisasi, kekambuhan, meningkatkan kepatuhan pengobatan dan fungsi interpersonal klien, ser ta hubungan dengan keluarga (sellwood, 2001). pemberian manajemen diet fe dengan pendekatan family centered care terhadap perilaku (pengetahuan, sikap, dan tindakan) keluarga dalam memelihara status hb pasien gagal ginjal kronik yang menjalani hemodialisis dan terapi epo sampai saat ini belum dibuktikan. pendahuluan anemia terjadi di awal perkembangan penyakit ginjal dan memburuk seiring dengan penur unan f ungsi ginjal ( neeta, 2009). penatalaksanaan anemia untuk meningkatkan nilai hemoglobin (hb) menjadi 12 g/dl pada pasien dengan gagal ginjal yang mendapat terapi dialisis, memiliki hubungan dengan peningkatan kualitas hidup pasien (moreno, 2000). the indonesian diatrans kidney foundation (2009) menyatakan berbagai penatalaksanaan telah dilak u kan unt u k mempertahankan nilai hb pasien gagal ginjal kronik pada level normal, salah satunya adalah dengan memberikan hormon erythropoietin. e s c h b a c h (2 0 0 5 ) m e n y e b u t k a n pemberian epo menyebabkan penurunan feritin serum sebesar 39% setelah pemakaian epo selama 6 bulan lebih. ferritin serum akan semakin menur un jumlah nya jika tidak ada asupan zat besi dari luar tubuh, sehingga diperlukan pemenuhan zat besi untuk tubuh yaitu dengan memberikan suplemen zat besi, baik secara oral maupun intravena (goodnough, 2000). data pendahuluan yang diambil dari unit hemodialisis rumah sakit gambiran kediri pada maret 2012, dari 32 pasien yang mendapatkan epo hanya 3 pasien yang memiliki kadar hb ≥11 g/dl dan 7 pasien dengan saturasi transferin ≤20%. upaya manajemen anemia yang telah dilak u kan di unit hemodialisis rsu d gambiran kediri selama ini adalah pemberian terapi epo dan injeksi fe secara gratis dan berkala untuk pasien askes dan tranfusi 120 jurnal ners vol. 8 no. 1 april 2013: 118–125 penget a hu a n ya ng terbat as ya ng dimiliki keluarga dalam menyediakan dan menyelek si berbagai su mber ma ka na n sehat untuk pasien, dapat menimbulkan kejenuhan pada pasien, nafsu makan pasien menjadi menurun dan pada akhirnya akan memperburuk kondisi pasien. hasil wawancara tanggal 30 maret 2012 dengan 10 pasien hemodialisis di rsud gambiran kediri juga didapatkan bahwa mereka dan keluarga hanya mampu menyebutkan 3 jenis makanan yang mengandung zat besi tinggi, yaitu daging, telur dan ikan. hasil wawancara lanjutan tanggal 31 maret 2012 pada pasien dengan menggunakan pertanyaan yang diadopsi dari parmenter (1999) diketahui bahwa keluarga kesulitan dalam mengatur jenis makanan, sehingga sering terjadi kebosanan pada pasien terhadap menu makanan yang disediakan oleh keluarga. keluarga akhirnya menyerahkan sepenuhnya diet makanan kepada pasien sendiri. berdasarkan uraian di atas, penulis ter tarik unt uk mengetahui sejauh mana pengar uh pemberian manajemen diet fe dengan pendekatan family centered care terhadap perilaku keluarga dalam memelihara status hb pasien gagal ginjal kronik yang menjalani hemodialisis dan terapi epo. bahan dan metode desain penelitian yang digunakan adalah pre-experiment dengan rancangan penelitian one group pre test-post test design atau non randomised one group pre test design. populasi pada penelitian ini adalah keluarga pasien gagal ginjal kronik. pengambilan sampel dilakukan dengan menggunakan teknik purposive sampling, dan diperoleh sampel sebanyak 10 orang responden sesuai dengan kriteria inklusi dan eksklusi. penelitian ini dilaksanakan di unit hemodialisis rsud gambiran kediri selama 1 mei–2 juni 2012. variabel independen dalam penelitian i ni adalah manajemen diet fe dengan pendekatan family centered care. sementara, variabel dependennya adalah adalah perilaku (pengetahuan, sikap, dan tindakan) keluarga pasien gagal ginjal kronik yang menjalani hemodialisis dan epo. pada penelitian ini responden akan diukur aspek pengetahuan, sikap, dan tindakan baik sebelum maupun sesudah diberikan inter vensi. inter vensi manajemen diet fe dengan pendekatan family centered care dilakukan sebanyak 2 kali pertemuan, masing-masing kurang lebih 45 menit. post test pengetahuan dan sikap dilakukan pada akhir pertemuan kedua, sedangkan observasi tindakan dilakukan 7 hari setelah pertemuan kedua. responden diberikan booklet sebagai media health education dan sebagai tempat menulis perencanaan makan keluarga dan pasien. analisis statistik diperoleh dengan perangkat komputer menggunakan uji statistik wilcoxon signed ranks test dengan derajat kemaknaan p<0,05 dan uji statistik mann whitney test dengan derajat kemaknaan p<0,05. tabel 1 pengetahuan, sikap, dan tindakan keluarga dalam memelihara status hb pasien gagal ginjal kronis yang menjalani terapi hemodialisis dan epo, sebelum dan sesudah mendapatkan manajemen diet fe dengan pendekatan family centered care di ruang hemodialisis rsud gambiran kediri tanggal 1 mei–2 juni 2012 komponen sebelum sesudahjumlah % jumlah % pengetahuan kurang baik 9 90 1 10 baik 1 10 9 90 sikap negatif 10 100 6 60 positif 0 0 4 40 tindakan kurang 10 100 4 40 cukup 0 0 6 60 baik 0 0 0 0 121 perilaku keluarga dalam memelihara status hb pasien gagal ginjal (anggia fajar hardianti, dkk) hasil pada tabel 1 dapat dilihat nilai variabel pengetahuan, sikap, dan tindakan baik sebelum maupun sesudah diberikan intervensi. hasil penelitian menunjukkan terdapat perubahan pengetahuan, sikap dan tindakan dalam pemeliharaan status hb pasien gagal ginjal kronik yang menjalani terapi hd dan epo sebelum dan sesudah diberikan manajemen diet fe dengan pendekatan family centered care. sedangkan, hasil uji statistik dengan wilcoxon signed rank test dapat dilihat pada tabel 2. pembahasan pe n g e t a h u a n kel u a r g a s e b el u m diberikan perlakuan menunjukkan bahwa 9 orang memiliki pengetahuan kurang baik. mayoritas responden menjawab salah pada item pernyataan mengenai informasi jenis makanan dan cara penyajian makanan yang memiliki nilai gizi tinggi fe untuk pasien gagal ginjal kronik (ggk). pengetahuan tentang gizi mempunyai peranan penting di dalam menentukan jenis makanan yang tepat, sehingga dapat tercapai keadaan dan status gizi yang baik. pengetahuan dipengaruhi oleh beberapa faktor, antara lain pendidikan, keterjangkauan akses informasi/media, sosial budaya dan ekonomi, lingkungan, pengalaman, dan usia (notoatmodjo, 2007). perbedaan pengetahuan responden mengenai pemeliharaan status hb pada pasien dapat disebabkan: pengalaman keluarga yang didapat saat merawat pasien; keingintahuan keluarga dalam mencari infor masi; dan hubungan keluarga yang baik dengan pasien memberikan dampak pada pengetahuan keluarga untuk lebih mengenal kondisi pasien dan memberikan dukungan kepada pasien. seseorang yang memiliki banyak pengalaman, berba nd i ng lu r us denga n pen i ng k at a n pengetahuan. pengalaman yang dimaksud adalah pengalaman yang bisa membuat hidup seseorang bisa menjadi lebih baik (suriasumantri, 2001). hal ini juga sejalan dengan penelitian kurniawati (2010), tentang pengalaman keluarga dalam merawat pasien stroke (penyakit kronik) memberikan dampak positif, salah sat unya dapat menambah pengetahuan keluarga mengenai perawatan rehabilitatif penyakit stroke. perilaku konsumsi makan dipengaruhi pula oleh wawasan atau cara pandang seseorang terhadap masalah gizi. wawasan ini berkaitan erat dengan pengetahuan dan beberapa sikap mental, baik berasal dari proses sosialisasi dalam tabel 2. skor dan analisis statistik perilaku keluarga dalam memelihara status hb pasien gagal ginjal kronis yang menjalani terapi hemodialisis dan epo, sebelum dan sesudah mendapatkan manajemen diet fe dengan pendekatan family centered care di ruang hemodialisis rsud gambiran kediri tanggal 1 mei-2 juni 2012 no pengetahuan sikap tindakanpre post selisih pre post selisih pre post selisih 1 22 23 1 25 26 1 8 11 3 2 21 24 3 22 26 4 6 14 8 3 19 22 3 17 22 5 8 10 2 4 22 23 1 24 26 2 7 11 4 5 18 23 5 24 28 4 7 13 6 6 21 24 3 22 24 2 7 12 5 7 23 24 1 21 24 3 8 10 2 8 21 24 3 23 28 5 6 7 1 9 14 23 9 10 22 12 5 10 5 10 17 23 6 22 26 4 7 11 4 mean 19.80 22.70 3.50 21.00 25.20 4.20 6.90 10.90 4.00 sd 2.781 1.829 2.550 4.447 2.150 13.048 0.994 1.912 2.108 analisis statistik wilcoxon signed rank test p=0,011 wilcoxon signed rank test p=0,005 mann whitney u test p=0,005 122 jurnal ners vol. 8 no. 1 april 2013: 118–125 sistem sosial keluarga maupun melalui proses pendidikan. hasil penelitian menunjukkan tingkat pengetahuan responden setelah diberikan perla k u a n ma najemen d iet fe denga n pendekatan family centered care adalah 9 orang yang memiliki kategori baik dan hanya 1 orang yang masuk dalam kategori kurang baik, sehingga dapat diartikan bahwa terdapat peningkatan pengetahuan pada responden. anggota keluarga akan lebih mudah menerima suatu informasi, jika informasi tersebut didukung oleh anggota keluarga lainnya (friedman, 2003). keluarga sebagai sumber dari perawatan kesehatan merupakan target pemberdayaan kesehatan keluarga memiliki kekuatan dan kemampuan serta kapasitas untuk menjadi lebih kompeten dan optimal (dunst, 1996). intervensi dengan pendekatan family centered care yait u komu nikasi antara pasien, keluarga yang dilakukan dalam 2 kali pertemuan dengan cara ceramah, sharing, dan diskusi serta review materi dapat memberikan sebuah gambaran d an wawasan u nt u k melakukan intervensi ataupun pencegahan dengan benar dan sesuai kondisi pasien. hal ini sesuai dengan yang dikemukakan roger (1974) dalam efendi & makhfudli (2009) bahwa dengan adanya pengkondisian pembelajaran akan terjadi perubahan perilaku seseorang dimulai dengan per ubahan pada tingkat pengetahuan yaitu timbul pemahaman dan kesadaran (awareness). notoadmodjo (2007) juga menyebutkan bahwa tingkat pengetahuan seseorang juga dipengar uhi oleh faktor eksternal seperti ketersediaan informasi, sarana prasarana, dukungan keluarga, dan proses pembelajaran. booklet yang diberikan kepada responden juga dapat membantu responden untuk mengingat kembali materi yang disampaikan saat di rumah. selisih perubahan tingkat pengetahuan diet bervariasi antara 1 hingga 9. selisih nilai terbanyak untuk variabel pengetahuan ini adalah 9. responden yang memiliki selisih terbanyak ini dikarenakan: responden baru merawat pasien kurang lebih 4 bulan, sehingga responden memiliki keinginan kuat untuk menggali informasi mengenai kondisi pasien; dan responden mencari informasi dari luar seperti internet, serta bertanya kepada sesama keluarga yang menemani pasien menjalani hemodialisis. selisih nilai paling sedikit yaitu 1, kemungkinan dikarenakan pada saat penelitian: responden telah memiliki pengalaman sebelumnya, sehingga untuk menerima infor masi kembali, responden lebih selektif; dan responden mengatakan telah mendapatkan konsultasi gizi sebelumnya oleh ahli gizi rumah sakit, sehingga untuk me ne r i m a i n for m a si ba r u d ip e rlu k a n kepercayaan dan sikap terbuka dari responden untuk dapat menerima informasi lain. sikap keluarga sebelum diberikan perlakuan menunjukkan bahwa 10 responden memiliki sikap negatif. mayoritas responden atau keluarga lebih memilih sikap raguragu pada kuesioner yang diberikan yaitu dalam konteks pemilihan jenis makanan yang dapat memelihara status hb pasien dan cara menyajikan makanan yang benar agar kandungan fe terserap secara optimal ke dalam tubuh. beberapa faktor yang mempengaruhi sikap seseorang adalah pengalaman pribadi, pengaruh orang lain yang dianggap penting, pengaruh kebudayaan, media massa, lembaga pendidikan atau agama, dan faktor emosional (azwar, 2002). tingkat pengetahuan gizi seseorang ber pengar u h terhadap si kap dalam pemilihan, ser ta penyelenggaraan makanan yang selanjutnya akan berpengaruh terhadap gizi seseorang (depkes ri, 1994). sikap yang ditunjukkan oleh keluarga pasien ggk kemu ngkinan dipengar uhi oleh, kurangnya pengetahuan dan rendahnya k e t e r l i b a t a n k e l u a r g a d a l a m p r o s e s perencanaan pengobatan. hal ini terlihat dari pre test pengetahuan yang mayoritas responden masuk dalam kategori kurang baik, yang bermakna kurang pengetahuan. rendahnya keterlibatan keluarga dalam proses perencanaan pengobatan juga didukung penelitian yang dilakukan oleh tryssennar (2002) bahwa keluarga yang jarang terlibat dalam perencanaan pengobatan sehingga mereka kurang mengerti dan kesulitan dalam mengambil sikap mengenai penatalaksanaan pengobatan pasien. 123 perilaku keluarga dalam memelihara status hb pasien gagal ginjal (anggia fajar hardianti, dkk) hasil penelitian menunjukkan bahwa sikap keluarga mengalami peningkatan yaitu sebanyak 6 orang setelah dilakukan intervensi dengan pendekatan family centered care. keluarga sebagai bagian yang penting bagi pasien memberikan pengaruh yang besar bagi perawatan pasien (departemen of human ser vices, 2000), begit u juga sebalik nya integritas keluarga juga akan terpengaruh oleh kondisi pasien dalam menentukan sikap dan tindakan (friedman, 2003). hal ini sejalan dengan hasil yang diperoleh mitchel (2009) tentang penggunaan family centered care yang melibatkan keluarga dalam memenuhi kebutuhan dasar pasien dapat meningkatkan rasa hormat, kolaborasi dan dukungan di antara pasien dan keluarga. adanya booklet juga membantu responden dalam memahami materi yang dapat pula mempengaruhi sikap responden. hasil penelitian juga menunjukkan bahwa selisih nilai terbanyak antara pre test dan post test adalah sebanyak 12. perubahan sikap yang terjadi pada responden dapat disebabkan: keterbu kaan infor masi dan komu nikasi diantara pasien, keluarga dan peneliti dalam proses diskusi dan sharing meningkatkan pemahaman responden terhadap kondisi yang dialami pasien. pendekatan family centered care memberikan kesempatan menggali hambatan dan peluang dalam melaksanakan diet pasien, membangun kekuatan dari klien dan keluarga dalam mendorong kemitraan di antara mereka (friedman, 2003); pemberian informasi kepada responden diterima dengan baik sehingga terjadi mekanisme perubahan sikap atau afektif yang dimulai dari proses menerima, menanggapi, menghargai dan yang terakhir bertanggung jawab (notoatmodjo, 2 0 03). a d a n y a k e m a u a n r e s p o n d e n membuka peluang untuk terjadi perubahan sikap seseorang terutama jika perubahan it u menyangkut masalah kesehatan dan keluarganya. hal ini sesuai dengan yang dikemukakan ahmadi (1991) bahwa sikap seseorang dipengaruhi oleh dua hal yaitu faktor internal yang berupa daya pilih seseorang untuk memilih atau menolak pengaruh yang datang dari luar dan faktor eksternal yang dapat berupa interaksi antar manusia. empat (4) orang responden yang tetap memiliki sikap negatif dapat disebabkan keluarga belum dapat menerima atau menolak pengaruh yang datang dari luar. keluarga masih tetap bertahan dengan pengalaman yang sudah dijalaninya selama ini. berbagai pengalaman terdahulu sangat memengaruhi bagai ma na seseora ng mempersepsi ka n dunianya sekarang (walgito, 1994). seseorang menginter pretasi pengalaman bar u dan memperoleh pengetahuan bar u berdasar realitas yang telah terbent u k di dalam pikiran sebelumnya. hal ini menunjukkan bahwa keyakinan atau pengetahuan yang sudah dimiliki seseorang akan menyaring atau mengubah informasi baru yang diterima seseorang tersebut (abruscato, 1999). tindakan yang dimiliki pasien pada obser vasi sebelum diber ikan perlak uan menunjukkan bahwa 100% masih dalam k at egor i k u r a ng. kelu a rga cende r u ng menuruti apa yang diinginkan pasien tanpa melihat kondisi pasien dan makanan yang harus dihindari pasien. menurut notoatmodjo (2003), penerimaan perilaku baru atau adopsi perilaku melalui proses yang didasari oleh pengetahuan, kesadaran, dan sikap yang positif akan membentuk perilaku yang bersifat langgeng dan apabila tanpa didasari kesadaran maka tidak akan berlangsung lama. perilaku yang berupa tindakan nyata dipengaruhi oleh beberapa faktor antara lain pengetahuan, sikap, keinginan, kehendak, keperluan, emosi, motivasi, reaksi, dan persepsi (notoatmodjo, 2003). k e l u a r g a p a s i e n g g k d a l a m mendukung diet pasien dalam memelihara status hb pasien kemungkinan dipengaruhi juga oleh: kemauan dan kondisi pasien itu sendiri dalam memutuskan perawatan untuk kesehatannya; dan keterbatasan pengetahuan d a n si kap tent a ng alter nat if d a n ca ra pengolahan makanan. perilaku responden yang terlihat dari observasi tindakan setelah diberikan perlakuan manajemen diet fe dengan pendekatan family centered care menunjukkan bahwa terdapat pengaruh yang signifi kan terhadap tindakan responden atau keluarga yait u 6 orang meningkat menjadi kategori cukup. 124 jurnal ners vol. 8 no. 1 april 2013: 118–125 keluarga dapat menjadi model, pemberi dukungan, akses terhadap persediaan makan dan aktivitas fi sik lainnya yang mempengaruhi perilaku keluarga (gruber, 2009). niven tahun 2002 juga menjelaskan bahwa pasangan hidup merupakan donatur terbesar dalam dukungan sosial. perencanaan makan yang ditulis dalam booklet membantu keluarga dan pasien untuk mengelola dietnya dengan benar dan juga mengalami peningkatan keanekaragaman makanan yang dipilih. pasien dan keluarga mengetahui bahan makanan yang dapat memelihara st at us h b dan menyeleksi makanan yang disukai oleh pasien, sehingga pasien memiliki nafsu makan yang tinggi dalam dietnya. hal ini juga diperkuat dengan penelitian oleh g r uber (2009) tent ang keterlibatan keluarga dalam perawatan anggota keluarga yang mengalami obesitas bahwa perubahan perilaku makan yang positif akan tertanam lebih lama jika intervensi ditujukan untuk keluarga daripada hanya memfokuskan pada perubahan sikap dan kebiasaan individu saja. selisih nilai terbanyak untuk variabel ti nd a kan ad alah 8 yang di mili k i oleh responden dengan karakteristik tidak bekerja dan memiliki hubungan sebagai orang tua dari pasien. selisih yang cukup banyak antara pre dan post test ini kemungkinan disebabkan oleh: responden sebagai keluarga pasien tidak memiliki pekerjaan di luar rumah sehingga memiliki waktu yang banyak untuk menyediakan menu makan yang beragam setiap harinya: dan responden sebagai orang tua pasien merupakan model dan pemberi dukungan utama dalam perawatan pasien khususnya terhadap anak. perilaku kesehatan ora ng t ua membi mbi ng perkembanga n praktek kesehatan pada anak, dan anak dapat mempengaruhi perilaku yang sama dari orang tua dan saudara kandung (gruber, 2009). responden sebanyak 4 orang yang tetap dalam kategori kurang kemungkinan dikarenakan: pada saat penelitian, kondisi pasien mengalami penurunan sehingga nafsu makan menurun dan keluarga lebih memilih untuk menuruti kemauan pasien dalam dietnya dan tidak melakukan perencanaan makan; sikap pasien dalam memutuskan perawatan yang akan dijalaninya mempengaruhi tindakan keluarga dalam menyediakan perawatan sesuai dengan yang diinginkan pasien terkait hubungan emosional keluarga dengan pasien. pasien berhak membuat keputusan dan memilih penatalaksanaan sesuai dengan kondisi dan kebutuhannya sendiri (international alliance of patient’s organization, 2006) sedangkan keluarga memiliki peran untuk memfasilitasi, m e n g a ko m o d a s i , m e n g i n g a t k a n , d a n memotivasi pasien dalam melakukan selfmanagement task (rosland, 2009); dan adanya anggapan bahwa pengaturan makan tinggi fe diperuntukkan atau digunakan ketika nilai hb menurun dan timbul gangguan atau keluhan yang dirasakan pasien. simpulan dan saran simpulan manajemen diet fe dengan pendekatan family centered care berpengaruh terhadap pengetahuan, sikap, dan tindakan keluarga d alam pemeli ha ra an st at us h b pasien gagal ginjal kronik yang menjalani terapi hemodialisis dan epo. saran perawat r uangan perlu melibatkan keluarga dalam pemberian health education kepada pasien, sehingga intervensi kesehatan yang diberikan mendapat dukungan dari keluarga dan berjalan lebih optimal. penelitian lebih lanjut perlu dilakukan untuk mengetahui pengar u h du k u ngan keluarga terhadap perilaku penderita dalam melakukan diet fe dalam upaya pemeliharaan status hb dengan besar sampel yang lebih besar dan menggunakan kelompok kontrol. perlu juga penelitian yang serupa dengan melakukan observasi secara langsung dan terus menerus mengenai kepatuhan dalam melaksanakan diet gagal ginjal kronik. kepustakaan abr uscato, j., 1999. teaching children science: a discovery approach. allyn and bacon publishers, boston. 125 perilaku keluarga dalam memelihara status hb pasien gagal ginjal (anggia fajar hardianti, dkk) ahmadi, a., 1991. psikologi sosial. jakarta: melton putra. azwar, s., 2002. sikap manusia: teori dan pelaksanaannya. edisi 2. jogjakarta: pustaka pelajar. depkes, ri., 1994. bina gizi masyarakat. jakarta: direktorat jenderal bina gizi kesehatan masyarakat. d u n st , cj. a nd tr ivet t e, cm., 1996. ‘empowering, effective helpgiving practices and family-centered care’, paediatric nursing, 22(4), 334–337. efendi, f. dan makhfudli, 2009. keperawatan kesehatan komunitas: teori dan praktik dalam keperawatan, salemba medika, jakarta. eschbach j.w., 2005. ‘iron requirements in erythropoietin therapy’, best practice res clinic haematol, 18(2), 347–61. friedman, m.m., 2003. family nursing research theory and practice 5th ed, stamford: appieton and lange. gaugler, j.e., 2005. family involvement in residential long-ter m care: a synthesis and critical review. aging mental health. 9(2), 105. goodnough, l.t., 2000. erythropoietin, iron, and erythropoiesis, blood, 96(3), 823– 833. gruber kj, haldeman la. using the family to combat childhood and adult obe sity. prev chronic dis 2009. vol. 6, no. 3, hal.: a106. http://www.cdc.gov/pcd/ issues/2009/jul/08_0191.htm. accessed 23 maret 2012 i n t e r n a t i o n a l a l l i a n c e o f pa t i e n t s' o r g a n i z a t i o n s ( i a p o) , 2 0 0 6 . d e cla ra t i o n o n pa t ie n tce n t re d healthcare. kurniawati, p., 2010. pengalaman keluarga merawat penderita stroke di wilayah pesisir kota semarang. skripsi, sarjana. program st udi ilmu keperawatan fa k u lt as kedok tera n un iversit as diponegoro mitchel, m., 2008. ‘possitive effectof nursing intervention on family centered care in adult critical care’. american journal of critical care. 18(6). moreno f., sanz-guajardo d., lopez-gomez j m, et al., 2000, ‘increasing the hematocrit has a benefi cial effect on quality of life and is safe in selected hemodialysis patients’. j am soc nephrol, 11, 335–342. neeta, b.o., 2008. ‘anemia in patients with chronic kidney disease n.j’. diabetes spectrum, 21(1), 12–19. notoadmodjo, s., 2003. prinsip-prinsip dasar ilmu kesehatan masyarakat, rineka cipta, jakarta. notoatmodjo s., 2007. promosi kesehatan ilmu dan seni, rineka cipta, jakarta parmenter, k., wrdle, j., 1999. ‘development of a general nutrition k nowledge questionnaire for adults’. european journal of clinical nutrition, 53, 298– 308. robinson, be., 2006.‘epidemiology of chronic kidney disease and anemia’. journal of the american medical directors association, 7, s3–s6. rosland, am., 2009. sharing the care: the role of family in chronic illnes, californaia health care foundation. rully, m.a.r., enday sukandar, rubin gondodiputro, rachmat permana, 2005, ‘kenaikan kadar hemoglobin setelah pemberian epoeitin alfa (hemapo) selama 12 minggu, pada penderita gagal ginjal yang menjalani hemodialisis’, cermin dunia kedokteran, 147. sellwood, w., barrowclough, c., tarrier, n., quinn, j., mainwaring, l., 2001, ‘needs-based cognitive-behavioral family inter vention for carers of patients suffering from schizophrenia: 12-month follow-up’, acta psychiatrica scandinavica, 104, 346–355. tryssenaar, j., and tremblay, m., 2002, ‘aging with a serious mental disability in rural northern ontario: family members experiences’, psychiatric rehabilitation journal, 25(3), 255–264. walgito, b., 1994. pengantar psikologi umum, edisi revisi, yogyakarta: andi offset. who, 2011. health education. diakses tanggal 27 desember 2011, http://www.who.int/ topics/health_education/en/ vol 8 no 2 oktober 2013.indd 211 studi komparatif sikap ners dan dokter spesialis terhadap kolaborasi perawat-dokter di rumah sakit (comparative study of registered nurse and specialist’s attitude toward nurse-physician collaboration in hospital) setiawan* *fakultas keperawatan, universitas sumatera utara email: setia-06@hotmail.com abstrak pendahuluan: hubungan antara perawat dan dokter di rumah sakit telah berlangsung sejak lama. hubungan ini terus menjalani perubahan ke arah hubungan yang lebih profesional demi menjadi mutu pelayanan kesehatan di rumah sakit. tujuan penelitian ini adalah untuk mengidentifi kasi sikap ners dan dokter spesialis terhadap kolaborasi perawat-dokter di rumah sakit. metode: desain penelitian yang digunakan adalah deskriptif komparatif. jumlah responden yang mengikuti penelitian ini adalah 87 orang (44 ners dan 43 dokter spesialis). data dianalisis dengan menggunakan statistik sederhana (frekuensi, mean) untuk menguraikan data demografi dan juga independent t-test untuk melihat perbedaan sikap antara ners dan dokter spesialis terhadap kolaborasi perawat-dokter. hasil: hasil penelitian ini menemukan bahwa ners mempunyai sikap yang sangat positif dan dokter spesialis mempunyai sikap yang positif terhadap kolaborasi perawat-dokter. berdasarkan uji independent t-test, ners mempunyai sikap yang secara signifi kan lebih positif terhadap kolaborasi perawat-dokter di rumah sakit dibanding dokter spesialis. diskusi: disarankan agar ners dan dokter spesialis dapat membuat suatu model kolaborasi yang digunakan di rumah sakit dalam rangka menjamin pemberian pelayanan kesehatan yang bermutu di rumah sakit. kata kunci: ners, dokter spesialis, kolaborasi perawat-dokter abstract introduction: relationships between nurse and physician in hospital in indonesia have been established for a long time. this relationship keeps continue toward more professional in order to enhance quality of healthcare. the purpose of this study was to identify attitude of registered nurse and specialist toward nurse-physician collaboration in hospital. methods: descriptive comparative design was employed in this study. number of respondents recruited was 87 which composed of 44 registered nurses and 43 specialists). data was collected by using jefferson scale of attitudes toward nurse-physician collaboration. gathered data was analyzed by simple statistics (frequency and mean) to describe demographical data and by independent t-test to determine the attitude difference between registered nurses and specialist toward nursephysician collaboration. results: results of this study showed that registered nurses and specialist have positive attitude toward nurse-physician collaboration at h. adam malik general hospital. based on independent t-test, this study found that registered nurses signifi cantly has more positive attitude toward nurse-physician collaboration in hospital compare to specialist. discussion: it is recommended that registered nurses and specialist at h. adam malik general hospital should develop a collaboration model in hospital to ensure quality hospital-based health service keywords: registered nurse, specialist, nurse-physician collaboration pendahuluan hubungan antara perawat dan dokter di rumah sakit telah berlangsung sejak lama. hubungan ini tentunya ditandai dengan perkembangan ke arah hubungan yang lebih profesional. dahulu, dokter umumnya tidak memperlihatkan kolaborasi dalam pekerjaan mereka, t api lebih menu nju kan bahwa perawat dibutuhkan untuk membantu dokter dalam bekerja. di lain pihak, perawat lebih mencari hubungan kolaborasi dengan dokter. hubungan ini pun pada saat ini sebagian masih berlangsung. namun dengan perkembangan ilmu pengetahuan dan berubahnya sistem pelayanan kesehatan, di mana pelayanan kesehatan semakin kompleks dan tuntutan masyarakat yang semakin tinggi akan pelayanan yang ber mut u, hubungan perawat dan dokter mengalami perubahan yang signifi kan. arah profesi keperawatan juga telah berubah dengan munculnya teori keperawatan (watson, 1979) 212 jurnal ners vol. 8 no. 2 oktober 2013: 211–216 yang menekankan kemandirian pekerjaan perawat dan tidak tergantung dengan profesi lain. kemandirian profesi keperawatan ini juga harus dilengkapi dengan kolaborasi dengan profesi lain. oleh karena itu, sebagai profesi yang mandiri, perawat dan dokter haruslah dapat saling berkolaborasi dengan tujuan mulia memberikan pelayanan bermutu bagi pasien. kolaborasi perawat-dokter yang baik akan memberikan dampak yang positif baik bagi pasien sebagai penerima pelayanan kesehatan dan juga baik perawat dan dokter sebagai pember i pelayanan. dar i segi pasien, kolaborasi perawat dan dokter yang terjalin dengan baik akan berpengaruh pada angka kematian yang lebih rendah dan juga angka pasien kembali dirawat di icu yang semakin turun (larson, 1999). kolaborasi perawat-dokter juga mempunyai pengaruh yang signifi kan terhadap menurunkan hari perawatan dan biaya perawatan di rumah sakit (baggs et al, 1999). bagi perawat dan dokter, kolaborasi yang baik dapat menciptakan suasana dan lingkungan kerja yang harmonis dan dalam jangka panjang akan memberikan kepuasan kerja (fagin, 1992). dalam konteks di indonesia, kolaborasi perawat-dokter masih menuju ke arah yang ideal. masih ada dokter yang beranggapan perawat sebagai pembantu dokter di rumah sakit dan sebaliknya mulai tumbuh kesadaran para perawat akan terwujudnya kolaborasi yang ideal antara perawat dan dokter di rumah sakit. hal ini dipengaruhi oleh semakin tingginya pendidikan perawat yaitu ners bahkan sudah ada perawat yang mendapat gelar spesialis keperawatan. oleh karena itu, redefi nisi kolaborasi perawat-dokter di rumah sakit menjadi poin penting dalam rangka peningkatan mutu pelayanan kesehatan di rumah sakit. berdasarkan pengalaman dan observasi hubungan antara ners dan dokter spesialis di rumah sakit didapatkan bahwa kolaborasi antara ners dan dokter spesialis sudah mulai mengalami perkembangan yang cukup baik. namun karena keberadaan ners belum cukup lama dibandingkan dengan dokter spesialis, maka kolaborasi ners dan dokter spesialis masih belum optimal. selain itu masih belum adanya model kolaborasi ners dan dokter yang baku yang merupakan hasil kontribusi kedua profesi yang memungkinkan kondisi ideal bagi berlangsungnya kolaborasi ners-dokter yang ideal. padahal, banyak penelitian menunjukan bahwa kolaborasi ners-dokter yang baik mempunyai dampak positif bagi pelayanan kesehatan, juga bagi perkembangan kedua profesi. oleh karena itu, penelitian tentang sikap ners dan dokter spesialis terhadap kolaborasi perawat-dokter sangat penting untuk memberikan deskripsi terkini dan sesuai konteks di indonesia mengenai bagaimana kolaborasi telah dan sedang berjalan selama ini. tujuan umum penelitian ini adalah untuk mengidentifi kasi sikap ners dan dokter spesialis terhadap kolabarasi perawat-dokter di rumah sakit. sedangkan tujuan khusus penelitian ini adalah mengetahui sikap ners tentang kolaborasi perawat dokter di rumah sakit, mengetahui sikap dokter spesialis tentang kolaborasi perawat dokter di rumah sakit, dan membandingkan sikap ners dan dokter spesialis terhadap kolaborasi perawat dokter di rumah sakit. bahan dan metode desain penelitian yang digunakan adalah deskriptif komparatif yang bertujuan untuk mengindentifi kasi dan membandingkan sikap ners dan dokter spesialis terhadap kolaborasi perawat-dokter di rumah sakit. populasi dalam penelitian adalah seluruh dokter spesialis dan ners yang bekerja di instalasi rindu b dan instalasi kardiovaskuler rsup h. adam malik medan yang berjumlah 451 orang (291 dokter spesialis dan 160 ners). jumlah sampel yang digunakan adalah 87 orang (43 dokter spesialis dan 44 ners). sebelum pengambilan data dilakukan, peneliti telah mendapatkan izin penelitian dari direktur rsup h. adam malik medan. izin penelitian ini diajukan melalui dekan fakultas keperawatan universitas sumatera utara. kemudian, setelah izin penelitian didapatkan d ar i di rek t u r rsu p h. ad am mali k, penelitian atau asisten peneliti memberikan penjelasan kepada calon responden tentang 213 studi komparatif sikap ners dan dokter spesialis (setiawan) penelitian yang akan dilakukan. penjelasan ini mencakup latar belakang penelitian dilakukan, pentingnya penelitian dilakukan, hasil yang didapat dari penelitian ini, dan kontribusi penelitian ini terhadap kolaborasi perawat-dokter serta kontribusi terhadap ilmu administrasi keperawatan. sebelum mengisi kuesioner, calon responden juga akan dijelaskan tentang sifat penelitian yang sukarela dimana responden bisa menolak ikut penelitian atau bisa menarik diri dari proses penelitian. juga disampaikan sifat penelitian yang rahasia dan anonomitas (nama responden tidak dapat diidentifi kasi atau dirahasiakan). responden juga mendapat penjelasan bahwa semua informasi yang diperoleh dari penelitian ini akan ditangani dengan hati-hati dan dijaga kerahasiaannya. selain itu, responden dijelaskan juga bahwa tidak ada risiko bagi mereka terkait dengan partisipasi mereka dalam penelitian ini. setelah semua penjelasan di atas diberikan kepada responden maka responden tersebut diminta untuk menandatangi informed consent yang telah disediakan. pe n el it i a n i n i m e n g g u n a k a n 2 instrumen sebagai alat pengumpul data yaitu skala sikap terhadap kolaborasi perawatdokter jefferson, yang terdiri 3 pertanyaan karakteristik responden dan 15 pertanyaan tentang kolaborasi perawat dokter. instrumen ini sudah banyak dipakai oleh peneliti di luar negeri dan mempunyai reliabilitas dan validitas yang baik. peneliti telah mendapatkan izin dari mohammadreza hojat, ph.d yang merupakan pemegang copyright instrumen ini untuk menggunakannya dalam penelitian ini. sebelum kuesioner penelitian diberikan kepada calon responden, peneliti melakukan pilot study dengan memberikan kuesioner kepada 5 orang ners dan dokter spesialis dalam rangka untuk melakukan tes reliabilitas dan melakukan perbaikan redaksi kalimat dalam kuesioner yang masih meragukan bagi responden. data yang diperoleh disajikan dengan menggunakan statistik deskriptif yaitu dalam bentuk distribusi frekuensi, persentase, mean, dan standar deviasi. untuk membandingkan sikap ners dan dokter spesialis digunakan independen t-test untuk membandingkan dua kelompok responden tersebut. hasil penelitian karakteristik responden re sponde n d ala m pe nel it ia n i n i berjumlah 87 orang dengan komposisi 44 ners dan 43 dokter spesialis. dari 44 ners, mayoritas (98%) adalah perempuan dan hanya 2% laki-laki. umur rerata ners yang menjadi responden adalah 37,8 tahun dengan umur terendah 24 tahun dan umur tertinggi adalah 49 tahun. sedangkan untuk dokter spesialis, dari jumlah keseluruhan 43 orang, mayoritas (74%) adalah laki-laki dan sisanya 26% adalah perempuan. umur rerata dokter spesialis yang ikut dalam penelitian adalah 45,2 tahun dengan umur terendah 28 tahun dan tertinggi 68 tahun. dat a ka ra k ter ist i k responden i n i menunjukan perbedaan yang cukup kontras dalam hal jenis kelamin di mana ners didominasi oleh perempuan dan dokter spesialis lebih banyak oleh laki-laki. ari segi umur juga terlihat perbedaan bahwa ners masih berada di umur di bawah 50 tahun sedangkan dokter spesialis di bawah 68 tahun yang bisa menunjukkan kematangan seseorang dalam profesinya. ringkasan karakteristik responden dapat dilihat pada tabel 1. sikap ners terhadap kolaborasi perawatdokter secara umum, ners dalam penelitian mempunyai sikap yang sangat positif terhadap kolaborasi perawat dokter. skor mean total untuk kuesioner kolaborasi adalah 56,09. angka ini menunjukkan sikap yang sangat positif di mana rentang normal untuk mean total adalah 15–65. sedangkan jika dilihat dari 4 faktor kolaborasi, skor mean ners sangat tinggi untuk semua faktor kolaborasi, yaitu 26,53 untuk faktor kolaborasi 1 (shared education dan teamwork) yang mempunyai rentang normal 7–28; 11,55 untuk faktor kolaborasi 2 (caring versus curing) yang mempunyai rentang normal 3–12; 11.33 untuk faktor kolaborasi 3 214 jurnal ners vol. 8 no. 2 oktober 2013: 211–216 (nurses’ autonomy) yang mempunyai rentang normal 3–12; dan 6.68 untuk faktor kolaborasi 4 (physicians’ dominance) yang mempunyai rentang normal 2–8. ringkasan skor mean sikap ners terhadap kolaborasi perawat-dokter dapat dilihat pada tabel 2. sikap dokter spesialis terhadap kolaborasi perawat-dokter secara umum, dokter spesialis dalam penelitian mempunyai sikap yang positif terhadap kolaborasi perawat dokter. skor mean total u nt u k k uesioner kolaborasi adalah 51,04. angka ini menunjukkan sikap yang positif di mana rentang normal untuk mean total adalah 15–65. sedangkan jika dilihat dari 4 faktor kolaborasi, skor mean dokter spesialis cukup tinggi untuk 3 faktor kolaborasi, yaitu 24.67 untuk faktor kolaborasi 1 (shared education dan teamwork) yang mempunyai rentang normal 7–28; 10.77 untuk faktor kolaborasi 2 (caring versus curing) yang mempunyai rentang normal 3–12; 11.01 untuk faktor kolaborasi 3 (nurses’ autonomy) yang mempunyai rentang normal 3–12; dan skor sedang (4,95) untuk faktor kolaborasi 4 ( physicians’ dominance) yang mempunyai rentang normal 2–8. ringkasan skor mean sikap dokter spesialis terhadap kolaborasi perawat-dokter dapat dilihat pada tabel 3. perbandingan sikap ners dan dokter spesialis terhadap kolaborasi perawatdokter hasil uji statistik menunjukan bahwa skor mean total ners (56,09) mencerminkan sikap yang secara signifikan lebih positif dibanding dengan dokter spesialis (51.4) terhadap kolaborasi perawat-dokter ( p = 0.00). sedangkan jika dilihat dari 4 faktor kolaborasi, skor mean ners untuk faktor 1, 2, dan 4 (shared education dan teamwork; caring versus curing; dan physicians’ dominance) mencer min kan si kap yang secara signifi kan lebih positif dibandingkan dengan dokter spesialis. sedangkan untuk faktor 3, yaitu nurses’ autonomy baik ners dan dokter spesialis mempunyai sikap yang setara terhadap kolaborasi perawat-dokter. ringkasan perbandingan sikap ners dan dokter spesialis terhadap kolaborasi perawat-dokter dapat dilihat pada tabel 4. pembahasan penelitian ini menemukan bahwa ners mempunyai sikap yang sangat positif terhadap kolaborasi perawat-dokter, sedangkan dokter spesialis mempunyai sikap yang cuk up positif. hal ini menunjukkan bahwa profesi keperawatan yang saat ini sedang berkembang dan keinginan untuk menciptakan kemitraan dengan dokter memperlihatkan kemauan perawat untuk lebih melakukan kolaborasi dibandingkan dengan dokter spesialis yang memang sudah cukup matang dan telah lebih tabel 1. karakteristik demografi responden (n = 87) karakteristik demografi ners (n = 44) dokter spesialis (n = 43) jenis kelamin laki-laki perempuan 1 (2%) 43 (98%) 32 (74%) 11 (26%) umur mean minimum maksimum 37,8 24 49 45,2 28 68 tabel 2. skor mean sikap ners terhadap kolaborasi perawat-dokter mean total scores range (15–65) f-1 f-2 f-3 f-4 shared education and team work range (7–28) caring vs. curing range (3–12) nurses’ autonomy range (3–12) physicians dominance range (2–8) ners 56.09 26.53 11.55 11.33 6.68 215 studi komparatif sikap ners dan dokter spesialis (setiawan) dulu dan lama berkembang masih dengan jenjang pendidikan yang lebih tinggi. dalam studi ini ditemukan bahwa terdapat perbedaan sikap ners dan dokter spesialis terhadap kolaborasi perawat-dokter. skor mean total menunjukkan bahwa ners mempunyai sikap yang secara signifi kan lebih positif dibandingkan dengan dokter spesialis. dari hasil analisis 4 faktor kolaborasi, 3 faktor (shared education dan teamwork; caring versus curing; dan physicians’ dominance) menunjukkan perbedaan sikap yang signif ikan antara ners dan dokter spesialis dan satu faktor (nurses’ autonomy) menunjukan sikap yang sama. temuan ini menunjukan bahwa kolaborasi antara ners dan dokter spesialis masih berada dalam tahap kolaborasi tradisional, masih belum beranjak ke bentuk kolaborasi modern (hubungan kolegial) (schmalenber & kramer, 2009) di mana kolaborasi masih dilihat sebagai wewenang ut ama dok ter dibandi ngkan perawat. perbedaan ini dapat juga terkait dengan perbedaan jenis kelamin antara ners yang mayoritas perempuan dengan dokter spesialis yang mayoritas laki-laki. selain itu, perbedaan juga dapat terkait dengan usia dan generasi yang berbeda sehingga menimbulkan persepsi dan harapan yang berbeda pula. hasil penelitian ini sejalan dengan penelitian yang dilakukan oleh thomson (2007) yang meneliti kolaborasi perawat dokter di unit medical bedah dan menemukan bahwa secara keseluruhan (skor mean total) perawat mempunyai sikap yang lebih positif dibandingkan dengan dokter. namun untuk tiga faktor kolaborasi pertama, perawat dan dokter sama-sama memiliki sikap yang sama dan untuk faktor ketiga, perawat dan dokter mempunyai posisi yang netral. hal ini cukup berbeda dengan hasil penelitian ini yang menemukan hanya faktor ketiga di mana ners dan dokter spesialis yang mempunyai sikap yang sama. perbedaan ini mungkin sekali terkait dengan jenjang pendidikan yang berbeda di mana ners masih dalam jenjang s1 dan dokter spesialis yang setara dengan s2. perbedaan ini tentunya berpengaruh pada pengetahuan, keterampilan, dan tanggung jawab di rumah sakit. walaupun demikian, penelitian ini menunjukan bahwa dokter spesialis telah memperlihatkan sikap yang cukup positif terhadap kolaborasi perawat dok ter. denga n dem i k ia n, d i ha r apka n tabel 4. perbandingan sikap ners dan dokter spesialis terhadap kolaborasi perawat-dokter mean total scores range (15–65) f-1 f-2 f-3 f-4 shared education and team work range (7–28) caring vs. curing range (3–12) nurses’ autonomy range (3–12) physicians’ dominance range(2–8) ners 56.09 26.53 11.55 11.33 6.68 dokter spesialis 51.4 (.000)* 24.67 (.000)* 10.77 (.000)* 11.01 (0.15) 4.95 (0.00)* tabel 3. skor mean sikap dokter spesialis terhadap kolaborasi perawat-dokter mean total scores range (15–65) f-1 f-2 f-3 f-4 shared education and team work range (7–28) caring vs. curing range (3–12) nurses’autonomy range (3–12) physicians' dominance range (2–8) dokter spesialis 51.4 24.67 10.77 11.01 4.95 216 jurnal ners vol. 8 no. 2 oktober 2013: 211–216 sikap yang positif ini dapat meningkatkan kualitas kolaborasi perawat dokter dan bisa menghasilkan outcome yang positif bagi pasien di rumah sakit. simpulan dan saran simpulan hasil penelitian ini menunjukan ners mempunyai sikap yang sangat positif dan dokter spesialis mempunyai sikap yang positif terhadap kolaborasi perawat-dokter di rumah sakit. namun, jika dibandingkan antara sikap ners dan dokter spesialis, terdapat perbedaan sikap antara ners dan dokter spesialis terhadap kolaborasi perawat-dokter di rumah sakit. sedangkan dari 4 faktor kolaborasi, hanya 1 faktor yang menunjukkan bahwa ners dan dokter spesialis sikap yang sama, dan berbeda untuk ketiga faktor lainnya. saran berdasarkan hasil penelitian bahwa ners dan dokter spesialis mempunyai sikap yang positif terhadap kolaborasi perawat-dokter di rumah sakit, namun masih ada perbedaan sikap, maka peneliti menyarankan agar ners dan dokter spesialis dapat bekerja sama dalam menyusun protap atau model kolaborasi yang dapat digunakan sebagai panduan dalam berkolaborasi di rumah sakit. dengan model yang dibuat bersama, diharapkan akan tercipta sikap yang sama terhadap kolaborasi perawatdokter di rumah sakit. daftar pustaka baggs jg, schmitt mh, mushlin ai, et al. 1999. association bet ween nursephysician collaboration and patient outcomes in three intensive care units. crit care med, 27 (9): 1991–1998. fagin, c. 1992; collaboration between nurses and physicians: no longer a choice. academic medicine, 67 (5), 295–303. larson e. 1999. the impact of physician-nurse interaction on patient care. holistic nurs pract.; 3 (2): 38–46. schmalenber, c & kramer, m. 2009. nursephysician relationships in hospitals: 20 000 nurses tell their story. critical care nurse, 12 (1), 74–83. t ho m s o n , s. 20 07. nu r s e phy sic i a n collaboration: a comparison of attitude of nurses and physician in medical surgical patient care settings. medsurg nursing, 16 (2), 87–104). watson, j. 1979. nursing: the philosophy and science of caring. boston: little, brown and company. 136 pencegahan iritasi mukosa hidung pada pasien yang mendapatkan oksigen nasal (prevention of nasal mucosal irritation in patients obtain nasal oxygen) ninuk dian kurniawati*, abu bakar* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fak: 031-5913257 e-mail: ndian.k@gmail.com abstract introduction: the provision of oxygen therapy is traditionally use a humidifi er to moisten the oxygen and prevent irritation of the nasal mucosa. recent research proves that the use of a maximum of 4 lpm nasal oxygen without using a humidifi er (non humidifi er) up to 8 hours does not cause irritation of the nasal mucosa and prevent colonization of bacteria in the humidifi er. the purpose of this study was to determine the effectiveness of nasal oxygen administration using a non-humidifi er more than 8 hours in the prevention of irritation of the nasal mucosa. method: this study employed an analytic survey with cross-sectional study design. as many as 20 patients at inpatient wards of port health center hospital surabaya were recruited as sample by means of consecutive sampling. inclusion criteria was patients must not suffer from upper respiratory tract infection and do not suffer from impaired immunity. independent variables were oxygen fl ow and long of oxygen therapy. dependent variable was irritation of the nasal mucosa. data were analyzed with descriptive statistics and tested with spearman rho correlation test. result: the results showed that the use of oxygen up to 140 hours with 4 lpm had no effect on the nasal mucosa such as signs of irritation and complaints of discomfort in the nose area. discussion: it can be concluded that the use of non-humidifi er for a maximum of 140 hours with fl ow maximum of 4 lpm is effective in preventing irritation of the nasal mucosa. further research on the effectiveness of non humidifi ers in the elderly population and children under fi ve years of age is needed. keywords: non-humidifi er, nasal canule, fl ow, irritation of the nasal mucosa. pendahuluan terapi oksigen merupakan pemberian oksigen dengan konsentrasi yang lebih tinggi dari yang ditemukan dalam atmosfi r lingkungan (smeltzer dan bare, 2008). p e m b e r i a n o k s i g e n y a n g b e r a s a l d a r i sumbernya tidak dapat digunakan langsung oleh pasien karena dibutuhkan alat penurun aliran dan humidifier (smeltzer dan bare, 2008). humidifi er merupakan suatu alat untuk melembabkan oksigen sebelum diterima oleh pasien (pavlovic, 2000). penggunaan humidifi er penting pada terapi oksigen, tetapi hasil penelitian nafi sah (2007) menemukan bahwa pemakaian humidifi er selama lebih dari 24 jam sudah mulai ditumbuhi bakteri. bakar (2009) menemukan pemakaian humidifier 12 jam sudah ditumbuhi bakteri. kondisi tersebut sangat berisiko terjadinya infeksi pada pasien, tetapi perry dan potter (2006) menyebutkan bahwa terapi oksigen yang menggunakan nasal kanul dengan kecepatan aliran oksigen kurang dari 4 lpm tidak perlu memakai humidifi er. terapi oksigen yang tidak memakai humidifi er diistilahkan dengan non humidifi er. hilton (2004) menyebutkan bahwa pemberian non humidifi er tidak boleh lebih dari 4 jam. namun penelitian nakamura, mori, takizawa, dan kawakami (1996) menunjukkan bahwa pemakaian non humidifi er selama 8 jam tidak merusak mukosa hidung. terapi oksigen nasal kanul dengan non-humidifier di salah satu rumah sakit swasta di surabaya ditemukan di setiap pencegahan iritasi mukosa hidung (ninuk dian kurniawati) 137 ruang perawatan. pemakaian non-humidifi er ditemukan hampir disetiap ruang perawatan sekitar 25% pasien. lama penggunaan oksigen rata-rata selama 1–14 hari. penggunaan nonhumidifier di ruang perawatan, selama ini tidak ditemukan adanya dokumentasi khusus atau yang dilaporkan berkaitan efek samping. penggunaan non-humidifi er perlu dicermati, karena sesuai teori penggunaan non-humidifi er untuk terapi oksigen dapat dilakukan bila kurang dari 5 lpm (kenji, 2004). keadaan ini secara teori masih memungkinkan tubuh untuk mengkompensasi. kondisi ini menjadi alasan perawat untuk mengadakan penelitian guna mengetahui kemampuan tubuh untuk mengetahui kemampuan tubuh pasien untuk mengkompensasi terhadap terapi oksigen dengan non-humidifi er. pemberian oksigen dengan non-humidifi er ditakutkan menyebabkan iritasi mukosa hidung. perawat yang harus selalu melakukan p e l a y a n a n p r o f e s i o n a l d a n p e n e l i t i a n . pendekatan yang digunakan yaitu teori keperawatan dari maslow untuk memenuhi kebutuhan dasar pasien salah satunya oksigen dan dipadu dengan teori keperawatan yang diungkapkan oleh kolcaba tentang kewajiban perawat untuk memenuhi kebutuhan rasa nyaman, maka peneliti melakukan penelitian tentang penggunaan non humidifi er yang aman (lebih dari 8 jam). bahan dan metode desain penelitian yang digunakan dalam penelitian ini yaitu survei analitik dengan rancangan studi cross-sectional. populasi pada penelitian ini yaitu pasien yang memakai oksigen nasal lebih dari 8 jam di ruang perawatan rumah sakit port health center flow oksigen 0 0 0 0 2 4 6 8 10 12 14 2 lpm 3 lpm 4 lpm tidak iritasi iritasi jumlah responden gambar 1. flow pemakaian o2 dengan keadaan mukosa hidung pada pemakaian oksigen nasal non humidifi er. lama pemakaian 0 1 2 3 4 5 6 7 8 9 10 24 jam 48 jam 72 jam 96 jam 120 jam 144 jam tidak iritasi iritasijumlah responden gambar 2. lama pemakaian o2 dengan keadaan mukosa hidung pada pemakaian oksigen nasal non humidifi er jurnal ners vol. 6 no. 2 oktober 2011: 136–140 138 surabaya dengan besar sampel 20 orang. sampel diambil satu bulan, dengan teknik consecutive sampling, dengan kriteria inklusi tidak menderita penyakit infeksi saluran nafas atas dan tidak menderita penyakit imunitas/ penurunan imunitas, dengan diidentifi kasi dari diagnosa medis pasien. variabel independen dalam penelitian ini yaitu lama terapi oksigen dan fl ow terapi oksigen. instrumen yang digunakan untuk mengukur adalah lembar observasi di mana lama dihitung dari awal mendapat terapi oksigen sampai terapi dilepas atau dirubah dengan terapi oksigen masker, dengan satuan jam. flow dilihat rata-rata pemberian oksigen selama memakai nasal pada pasien tersebut dengan satuan liter per menit. variabel dependennya adalah iritasi mukosa hidung, dengan instrumen yang digunakan adalah lembar observasi yang mengacu pada standar yaitu perubahan warna dan struktur pada mukosa hidung yang tidak sesuai dengan normal dan semua keluhan yang berhubungan dengan perasaan pada daerah hidungnya akibat pajanan oksigen non-humidifi er. data yang diperoleh dianalisis dengan menggunakan uji statistik spearman rho dengan derajat kemaknaan α ≤ 0,05. hasil hasil pengambilan data tentang pengaruh pemberian oksigen non-humidifi er dengan fl ow kurang dari 5 liter per menit (lpm) terhadap pencegahan iritasi mukosa hidung didapatkan hasil yang ditampilkan pada gambar 1 dimana menunjukkan bahwa pemberian fl ow oksigen pada responden terbanyak adalah 3 lpm (14 responden). pemberian fl ow oksigen sampai dengan 4 lpm tidak mengakibatkan efek negatif pada mukosa hidung yaitu tidak adanya tanda iritasi pada daerah mukosa hidung. h a s i l p e n g a m b i l a n d a t a t e n t a n g pengaruh lama pemberian oksigen nasal dengan menggunakan non humidifi er lebih dari 8 jam terhadap pencegahan iritasi mukosa hidung didapatkan data yang ditampilkan pada gambar 2 di mana menunjukkan bahwa lama pemakaian oksigen nasal terbanyak 72 jam (9 responden). pemakaian oksigen nasal nonhumidifi er terlama sampai 140 jam, kondisi ini tidak berpengaruh terhadap keadaan mukosa hidung (tidak ada tanda iritasi mukosa hidung). pembahasan terapi oksigen tanpa memakai humidifi er diistilahkan dengan non-humidifier. hasil penelitian ini menunjukkan bahwa pada responden dengan pemakaian oksigen dengan fl ow rata-rata 3 lpm tidak ditemukan adanya efek yang berarti pada mukosa hidung maupun keluhan tidak nyaman pada daerah hidung responden. hasil yang sama terlihat pada responden yang mendapat terapi oksigen 4 lpm. hampir pada semua reponden ditemukan mukosa hidung lembab dan bersih, hanya dua responden yang mukosanya kering (responden no. 1 dan 5), hal ini berkaitan dengan usia responden. dua responden berusia lansia dan balita. responden pertama berusia 71 tahun di mana pada usia ini fungsi mukosa hidung maupun siliaris hidung dapat menurun sehingga terlihat kering. usia responden kelima adalah 3 tahun di mana usia ini maturitas fungsi hidung masih belum optimal sehingga saat mendapat terapi oksigen mukosa hidung dapat kering. hasil pemeriksaan pada mukosa hidung kedua responden yang ditemukan kering tersebut, tidak mengakibatkan keluhan, jadi kondisi tersebut secara teori normal, sesuai dengan yang diutarakan smeltzer and bare (2008) bahwa fungsi organ dapat bekerja optimal dipengaruhi oleh usia. hasil ini membuktikan bahwa pemakaian non-humidifi er dengan fl ow meter kurang dari 4 lpm atau dengan nasal kanul, aman digunakan pasien. pernyataan ini memperkuat pendapat potter dan perry (2006) yang menyebutkan bahwa terapi oksigen menggunakan nasal kanul dengan kecepatan aliran oksigen kurang dari 4 lpm tidak perlu memakai humidifi er. hasil penelitian ini juga memperkuat penelitian dari kenji (2004). kenji melakukan penelitian dengan demonstrasi matematika dan menemukan bahwa pemakaian oksigen 4–5 lpm tidak membutuhkan humidifi er karena aliran oksigen 4–5 lpm dengan menggunakan alat nasal kanul atau masker pencegahan iritasi mukosa hidung (ninuk dian kurniawati) 139 sederhana, masih dipengaruhi oleh udara ruangan. kelembapan udara ruangan masih mencukupi untuk membantu kelembapan terapi oksigen yang diberikan. hasil penelitian ini sesuai dengan hipotesis yang diharapkan peneliti. hasil ini juga telah membuktikan beberapa teori sebelumnya bahwa pemakaian terapi oksigen dengan nasal, fl ow yang diberikan kurang dari 5 lpm pemakaian humidifi er kurang diperlukan. dilihat dari karakteristik alat tetapi oksigen di rumah sakit phc surabaya, hampir sama dengan rumah sakit lainnya khususnya rumah sakit yang berada di surabaya. keadaan ini dapat dijadikan acuan terapi oksigen di surabaya. penelitian ini juga mengukur lama pemberian oksigen terhadap keluhan dan keadaan mukosa hidung. hasil penelitian menunjukkan bahwa pada pemakaian oksigen non-humidifier rata-rata 54,8 jam tidak ditemukan tanda-tanda iritasi mukosa hidung maupun keluhan tidak nyaman pada daerah hidung. hasil penelitian ini menunjukkan bahwa lama pemberian terapi oksigen dengan non-humidifi er tidak berpengaruh pada kondisi mukosa hidung. keadaan ini juga ditunjang dari hasil salah satu responden yang mendapat terapi oksigen dengan fl ow 4 lpm dalam waktu 140 jam (5 hari lebih 8 jam) tidak ditemukan tanda-tanda iritasi mukosa hidung maupun keluhan tidak nyaman pada daerah hidung. hasil penelitian ini memperkuat hasil penelitian sebelumnya yang dilakukan nakamura, mori, takizawa, dan kawakami (1996) bahwa pemakaian non-humidifi er selama 8 jam tidak merusak mukosa hidung. sebaliknya, hasil penelitian ini membantah penelitian hilton (2004) yang menemukan bahwa pemberian non-humidifi er tidak boleh lebih dari 4 jam. lama pemakaian oksigen dengan non humidifi er hasil penelitian ini telah memperkuat hasil penelitian sebelumnya. bila dilihat dari karakteristik responden, secara umum responden di rumah sakit phc mempunyai karakteristik yang sama dengan rumah sakit lainnya, khususnya di daerah surabaya. kondisi ini dapat menjadikan hasil ini sebagai acuan untuk terapi oksigen di seluruh rumah sakit khususnya di surabaya. keterbatasan yang didapat peneliti di antaranya, penelitian ini dikerjakan dalam waktu yang terbatas sehingga memengaruhi besar sampel yang berhasil direkrut. alat ukur yang digunakan dalam penelitian ini terbatas pada observasi sederhana dalam memeriksa tanda-tanda iritasi mukosa hidung, tidak dilakukan pemeriksaan swab mukosa hidung yang lebih akurat untuk memeriksa iritasi mukosa. pasien yang diikutkan dalam penelitian ini terbatas jumlahnya dan usianya kurang homogen sehingga memengaruhi hasil penelitian. simpulan dan saran simpulan pemberian oksigen nasal dengan nonhumidifi er dapat mencegah terjadinya iritasi mukosa hidung. pemakaian non-humidifi er digunakan selama 140 jam dengan fl ow oksigen kurang dari 5 lpm. saran hasil penelitian ini telah memperkuat hasil penelitian sebelumnya, sehingga dapat menjadi salah satu dasar intervensi dalam teori keperawatan, khususnya penyusunan protap terapi oksigen nasal kanul dengan non-humidifi er. hasil penelitian ini juga dapat dijadikan dasar sebagai penelitian selanjutnya yang berkaitan dengan terapi oksigen nasal. kepustakaan bakar, a., 2009. perbedaan pertumbuhan b a k t e r i d i h u m i d i f i e r d a n n o n humidifi er pada pasien yang mendapat terapi oksigen. journal ners, 3 (2). hlm 99–104. hilton, p.a., 2004. breathing dalam hilton, p.a. fundamental nursing skills. philadelphia: whurr publishers, hlm 14. kenji, m., 2004. is it necessary to humidify inhaled low-flow oxygen or lowconcentration oxygen?. journal of the japanese respiratory society. 42(2), (online), (http://www.ncbi.nlm.nih.gov/ pubmed/6234589.htm., diakses tanggal 14 november 2008, jam 11.47 wib. jurnal ners vol. 6 no. 2 oktober 2011: 136–140 140 nafi sah, s., 2007. pengaruh lama penggantian air humidifi er lebih dari 24 jam terhadap pertumbuhan bakteri pada terapi oksigen system low flow low concentration di ruang rawat inap interna rsud dr. soebandi jember. skripsi tidak dipublikasikan. surabaya: universitas airlangga, hlm 41–49. nakamura, s., mori, y., takizawa, j., kawakami, m., 1996. effect of ondemand inhalation of dry oxygen on nasal mucociliary clearance. nihon kyobu shikkan gakkai zasshi. 34(11), (online), (http://www.ncbi.nlm.nih.gov/ pubmed/8976072.htm, diakses tanggal 30 juni 2009, jam 11.24 wib. pavlovic, 2000. inhalation therapyproducts for humidification and nebulisation, (online), (http://www.tycohealth-ece. com., di tanggal 23 november 2008, jam 12.10 wib. perry, a.g., dan potter, p.a., 2006. clinical nursing skills techniques. vol 2, 6th ed. australia: elsevier-mosby. smeltzer, s.c., dan bare, b.g., 2008. brunner & suddart's text book of medical surgical nursing. volume 1, ed 11th. philladelpia: lippincott. 74 the adaptation model of caregiver in treating family members with schizophrenia in kediri east java byba melda suhita*, chatarina u.w**, hari basuki**, ah yusuf** *institute of health science stikes surya mitra husada, manila street, number 37, sumberece, tosaren, pesantren, kediri, east java, 64133 **airlangga university email: bybamelda@yahoo.co.id abstract introduction: schizophrenia is a severe mental disorder that is characterized by impaired reality (hallucinations and delusions), inability to communicate, affect unnatural or blunt, cognitive disorders (not capable of abstract thinking) and had difficulty doing daily activities. normally, the family is most affected by the presence of people with schiz ophrenia in their families. the purpose of this study was to develop an adaptation model of the caregiver in caring for family members with schizophrenia in kediri. methods: this study used cross-sectional design with nature explanatory research. data were collected using a questionnaire on 135 respondents in nine health centers in the city of kediri region. the sampling technique used simple random sampling. for data analysis and test, the feasibility used a test model of sem with amos program 19. results: the results showed self esteem caregiver (-0.25 <0.05), community resources (0.24 <0.05), self-efficacy (0.22> 0.05) , caregiver coping effort (12:17 <0.05), and the perception of caregiver about the family situation at this time (0:19 <0.05), which means that adaptation of caregiver in treating patients with schizophrenia is influenced by the characteristics of the family, namely community resources, self-efficacy, caregiver coping effort, self-esteem and perception of family caregiver to the conditions experienced at this time. perception of caregiver about the condition of today's families is affected by stress, which appears on a caregiver stress due to stressor for caring for people with schizophrenia, especially the aggressive behavior of schizophrenics. discussion: adaptation of caregiver was highly influential in the care of people with schizophrenia because in this case becomes one of the important points to be able to sustain the process of treatment and prevent relapse of schizophrenics. keywords: schizophrenia, caregiver, adaptation introduction mental disorder is a condition in which the process of physiological or mental poorly functioning properly so interfere with the functioning of daily life. this disorder is often also referred to as a psychiatric disorder or mental disorders, and the general public is sometimes referred to as a nervous breakdown. mental disorders experienced by a person can have a variety of symptoms, both obvious and only when they exist in his mind. starting from the avoidance behavior of the environment, do not want to touch or talk to other people and would not eat until the raging with no apparent reason. starting from the silent ones to the speaking ones is not clear. some can talk to and others are not attentive to her surroundings. from the above condition makes the client must be hospitalized to recover her mental condition (hawari 2009). most people with mental disorders have schizophrenia. schizophrenia is a severe mental disorder that is characterized by impaired reality (hallucinations and delusions), inability to communicate, affect unnatural or blunt, cognitive disorders (not capable of abstract thinking) and had difficulty doing daily activities (keliat 2006). schizophrenia is a brain disease that leads to persistent and serious psychotic behavior, concrete thinking, and difficulty in information processing, interpersonal relationships, and solve the problem (stuart 2013)). schizophrenia is a form of psychotic disorders (severe mental illness) which is relatively frequent. the lifetime prevalence of nearly 1%, the incidence annually about 10-15 per 100,000 and schizophrenia is a syndrome with a variety of presentations and one variable, the disease course is long term, and often suffer relapses (davies 2009). schizophrenia is the most severe functional psychosis, and pose the greatest personality disorganization; the patient has no reality. the incidence of schizophrenia was 0.1 per million in the world regardless of their socio-cultural status (varcarolis 2000). 2009 based on data from 33 psychiatric hospitals in indonesia noted that patients with severe mental disorders reached 2.5 million people (alert online 2010). based on data from 2013 riskesdas known that the average people with mailto:bybamelda@yahoo.co.id jurnal ners vol. 12 no. 1 april 2017: 74-80 75 severe mental disorders in all provinces in indonesia was 1.7 per million, with the highest prevalence was in di yogyakarta and aceh which is 2.7 per million and for the province of east java 2.2 per million, and based calculation riskesdas 2013 in the province of east java possible economic losses arising from severe mental disorders is based on the loss of productivity of patients and their families who become caregiver is as much as 22.5 billion (riskesdas, 2013). kediri city health department in 2012 said the number of people with mental disorders in health centers increased. according to the city health office kediri, the increasing rates of up to 15 percent of people with mental disorders in the clinic kediri. as the research findings, data on the number of people who experience mental disorders has increased approximately 15 percent. the latest data from kediri city health department in 2013 showed the number of people with schizophrenia in the town of kediri reached 200 people, spread over nine health centers in the city of kediri. kediri city health department in 2012 said the number of people with mental disorders in health centers increased. according to the city health office kediri, the increasing rates of up to 15 percent of people with mental disorders in the clinic kediri. as the research findings, data on the number of people who experience mental disorders has increased approximately 15 percent. the latest data from kediri city health department in 2013 showed the number of people with schizophrenia in the town of kediri reached 200 people, spread over nine health centers in the city of kediri. from the preliminary study, researchers found that the city of kediri has nine health centers covering three districts. of the nine health centers in kediri have no mental health program in integrated health post (posyandu). mental health programs that exist now only to the rehabilitation process in the form of regular checks for the treatment of patients with schizophrenia, but there is no special program for families in their participation in the care of people with schizophrenia after the return from the mental hospital. results of interviews with 9 public health centers (puskesmas) officers who are responsible for the reporting of mental health in health centers kediri city, all stated that they had been doing duty in checking the administration of antipsychotic drugs in patients with schizophrenia in the city of kediri, while for families attendant health centers only provide health education about schizophrenia and drugs must be taken by the patient. public health centers puskesmas officers had never been taught to families how to prevent the family could have done relapse of schizophrenic patients using behavior therapy and the implementation strategy in patients with schizophrenia as the primary caregiver of schizophrenics. the result of research interviews with seven families of schizophrenics in the town of kediri, all stated that they frequently experience anxiety and confusion in caring for a family member who has schizophrenia, especially if the schizophrenic patients had a relapse. in addition to a recurrence of the problem for the family, the financial condition of the family also becomes impaired because of family financial income also decreased due to caregiver who cares for family members of schizophrenics confusion devote time to work for a living by caring for their family members who suffer from schizophrenia. another problem that arises from the family is confusion families how to care for and how to adapt to families with a schizophrenic who had been suffering from schizophrenia especially the decades and repeatedly experienced a relapse. people with schizophrenia handling process (ods) in length, ranging from hospitalization, administration of drugs, to social support, families, and communities, became a multi-factor for ods recovery process. suppose a patient is already getting the drug properly, the process of recovery in the hospital running good, but if the house is not supported by the family and the environment, it could be the patient will relapse. not given the role at home, then the negative stigma of society will make the ods recur; therefore the recovery process of this disease takes many years. as a result of the healing process is long, it takes perseverance and patience of families. during this time, many families go into the pit of despair, which ultimately makes ods stocks. government data, in indonesia there are approximately 18 thousand ods stocks. many families that include members of the family who ods to a mental hospital, clinic, foundation treatment of the adaptation model of care giver (byba melda suhita at.al) 76 mental illness, brought to the shaman, a special boarding school madman, or poorhouse (taufik, 2014). one with mental disorder schizophrenia causes suffering not only for the individual sufferer but also for people who are closest. normally the family is most affected by the presence of people with schizophrenia in their families. in addition to the high cost of care, patients also require more attention and support from the community, especially families, in the treatment of mental disorder schizophrenia one of which requires a relatively long time, when patients discontinued treatment will have a relapse (arif 2008). once clients go home, the client should perform follow-up care at public health centers pukesmas in its territory who have mental health programs, and the role of the family is needed in the healing process in the client's home (yosep 2009). methods this study uses survey research methods, the research implemented by taking a sample from a population and using questionnaires as the main data collection instrument. the design of this study uses cross-sectional design with the nature of the research studies explanation (explanatory research), based on the perception of respondents, which explains the causal relationships between variables based on the answers of respondents through hypothesis testing. independent variables consist of family characteristics, stressors, and community resources. intervening variables consist of caregiver perceptions of family members who suffer from schizophrenia, stress on the caregiver, self-efficacy, adversity quotient, caregiver coping effort and caregiver about perception of their current family situation. the dependent variable is the adaptation caregiver in caring for family members with schizophrenia. the research was conducted on a sample of location research that month from february to june 2015 in the area of kediri (includes 9 public health centers puskesmas kediri). the population in this study is all the families who have family members with schizophrenia post treatment of the hospital or psychiatric hospital in kediri. the sample in this study is a caregiver who are family members of patients schizophrenia kediri to have the inclusion criteria for the care giver include: caregiver lived one house with patients schizophrenia, a "care giver" major, willing to become respondents, domiciled in the city of kediri, while the family inclusion criteria include: the condition of the family structure is still intact, in one family only one who suffers from schizophrenia. for patients, inclusion criteria include: the schizophrenic ever been treated/be a mental patient / post-discharge. the samples are taken by the formula rule of thumb. the parameters used in this study amounted to 27 parameters, so the formula rule of thumb obtained sample number: 27 x 5 = 135 respondents. sampling was simple random. analytic analysis done using sem test is by amos program 19. results the results showed the majority of patients aged between 26-45 years, with 79 respondents (58.5%). most of the patients were male, i.e. 88 respondents (65.2). almost half of the patient's status was a child, namely 47 respondents (34.3%). for the caregiver, the results showed that most of the caregivers aged between 46-65 years are 65 respondents (48.1%). most of the caregivers are female, i.e. 92 respondents (68.1%). almost half of the care giver's status is the patient's mother, 49 respondents (36.3%) and educated past high school level, i.e. 58 respondents (43.0%). almost all the caregiver has knowledge of the treatment of schizophrenia in the poor category, ie 109 respondents (80.7%). for most of the economic status of the caregiver is the category high (> umk), i.e. 83 respondents (61.5%). caregiver portion has some family members of more than four people, namely 69 respondents (51.1%). caregiver most have high self-esteem, that is 83 respondents (61.5% ) . c a r e g i v e r m o s t h a v e f a m i l y m e m b e r s w h o h a v e schizophrenia for more than ten years, namely 58 respondents (43.0%). for the stigma, some caregiver gets a stigma from the society in negative categories, namely 79 respondents (58.5%). the average score of aggressive behavior (48.04) is higher than the score of behavioral withdraw (43.98), it can be concluded that the behavior of patients with jurnal ners vol. 12 no. 1 april 2017: 74-80 77 schizophrenia in this study tended to behave in extreme aggression. the partial caregiver has a perception in the negative categories, namely 78 respondents (57.8%). the negative perception here is the interpretation caregiver includes feelings and images in caring for family members who have schizophrenia. fraction caregiver has a lower stress level category, namely 52 respondents (38.5%). low stress or light means the state experienced caregiver as a result of environmental changes that threaten, challenge when caring for family members with schizophrenia in conditions of low or mild. the most caregiver gets enough social support categories, namely 77 respondents (57.0%). the most caregiver has a collective efficacy in positive categories, namely 72 respondents (53.3%). collective efficacy positive means that the ability of perception of family members and the public on the effectiveness of the relationship between tasks, skills, and role in caring for family members with schizophrenia to produce change towards a positive showing for the caregiver or schizophrenic. most of the caregiver has a social network in enough categories, namely, 86 respondents (63.7%). social network means enough communication and cooperation obtained caregiver and family while caring for a family member suffering from schizophrenia enough. it is obtained from the local community as well as from health workers in health centers. almost all the caregivers have access to new contact and information in enough categories, namely 125 respondents (92.6%). for most self-efficacy caregiver has a negative self-efficacy, which is 72 respondents (53.3%) and almost all the caregiver has adversity quotient in the category campers, i.e., 124 respondents (91.9%). adversity quotient campers’ category means the caregiver feel quite satisfied or feel safe with what was achieved at this time in the care of family members who have schizophrenia. no effort or progress further to find other ways of caring for family members who have schizophrenia. the partial caregiver has a perception in the negative category, which is 69 respondents (51.1%). for coping mechanisms, some caregiver has a coping effort in the category of problemfocused coping, i.e. 76 respondents (56.3%) and partial caregiver own adaptation in the negative categories, namely 70 respondents (51.9%). adaptability caregiver (caregiver coping effort) negative means caregiver figure 1. adaptation model of caregiver in treating schizophrenic kediri cannot adjust themselves well in business and shape their behavior to overcome barriers or problems that arise when caring for family members with schizophrenia. discussion families of people with schizophrenia feel the stigma and discrimination surrounding environment. conditions of their schizophrenic in the family will cause various problems, not only the patients themselves but also family particularly caregiver who treats the schizophrenic. one problem that arises is selfesteem disorder in caregiver. impaired selfesteem or self-worth are disturbed, e.g., low self-esteem. this condition appears one reason is the emergence of stigma on people who think that schizophrenia is a disgrace in the family. it raises the shame of the caregiver, which could eventually create the perception of schizophrenia caregiver becomes less good. awards and public acceptance of large families affect self-esteem, one caregiver that is part of the family because the family is the first place to interact in someone's life. one of the signs of disorder such example is the self-esteem of the care giver's unwillingness to interact with others. (warner r 2007) states that the family's reaction arising the adaptation model of care giver (byba melda suhita at.al) 78 from mental disorder suffered by their family members is to not talk to anyone about the mental disorder for years, sometimes even on their close friends. ironically, the family is open and discusses the matter is getting abuse from the public. family responds to these abuses by withdrawing socially, avoiding friends or even moving to a new residence. although there is a tendency of family members to reject stigma, concealment and withdrawal are based on shame will bring them into social isolation. the healing process in patients with mental disorders should be done holistically and involve family members. without it, as well as common illnesses, mental disorders can recur. family coping very important to participate in the healing process for the family is a major supporter in treating patients. therefore, nursing care that focuses on the family not only restore the patient but aims to develop and enhance the ability of families to cope with mental health problems in the family (syaifullah, 2005). the family is the unit closest to the patient and is the "primary caregivers" for patients. families must have an adaptive coping in overcoming or dealing with people with schizophrenia to determine how or the necessary care of patients at home. the success of the nurses at the hospital will be useless if it is not passed in the house which then lead to patients should be treated back (relapse). the role of the family since the beginning of hospital care will increase the ability of families caring for patients at home so that the possibility of recurrence can be prevented. the quality of life a caregiver associated with the female gender is lower than in men (awadilla, 2005). data from this study showed that most sex of patients was male and caregivers were mostly women. the condition also can be a stressor itself for caregiver, especially woman as caregiver will usually involve feelings or emotions when the action or make a decision. there is a reciprocal relationship between the behavior of people with schizophrenia are disruptive to the emergence of a negative response to family members caring. the behavior of the sufferer can cause high emotion in the family, and then this condition will lead to negative behavior and lead to psychological stress both for patients and for the family, and psychological stress which appears in the patient can trigger or trigger a relapse. comments and criticism from family members with high emotional expressions cause the emergence of more thoughts and unusual behavior of the patient and the thoughts and unusual behavior that will trigger an increase in comments and criticisms of the family. in addition it is depression, anxiety; self-confidence is low and less than optimal adaptability accompanied by a lack of adequate information about schizophrenia to be associated with high expression of emotions in the family.expression of high emotion of the family is one of the significant stressors for people with schizophrenia. stress that elicits emotional expressions of caregiver will affect the way caregiver in providing care for people with schizophrenia. the more stress caregiver can make the treatment process can not be the maximum, because the caregiver stress can also lead to physical and emotional complaints to the caregiver for example illness, so the ability to provide care to decrease. the condition of self-efficacy caregiver when treating people with schizophrenia may also be influenced by community resources. the community itself can be divided resources form the two are psychologically in the form of collective efficacy, social and psychological support and none namely social contact and access to new contacts and information. social caregiver support received in the form of support from the social community for example, from the neighbors, social contact with people, another family as well as with health care. besides access to search information about schizophrenia and collective efficacy of the public and health workers around are also influential. patients with schizophrenia and families need information about social situations that support recovery, the resources they can use to improve the quality of life and information about the management of the crisis. patients with schizophrenia and families also need social support from the wider community (wfmh, 2009; temes 2011). the results showed 65 respondents have a negative self-efficacy and the adversity quotient on stage campers. self-efficacy caregiver formed as a process of adaptation and learning that are in the situation they face when caring for family members who suffer from schizophrenia. the longer caregiver care jurnal ners vol. 12 no. 1 april 2017: 74-80 79 for family members who suffer from schizophrenia, the higher self-efficacy owned caregiver in carrying out their duties, but did not rule out the possibility that self-efficacy which is owned by the caregiver actually tends to decrease or remain as it has entered the stage of stagnant or in conditions of adversity quotient on stage campers, where the caregiver was already satisfied with what was achieved or was resigned to her condition during this time. it could be a family experiencing saturation in schizophrenia their care at home, should always control all activities of sufferers, have to face difficulties in the costs of care and treatment of patients in a long time. the research found empirically that the adaptation caregiver the ability caregiver to adjust in treating patients with schizophrenia is influenced by community resources, selfefficacy, perceptions of caregiver about the condition of the family in caring for people with schizophrenia, coping effort (coping mechanism) and self-esteem or price self. community resources in this regard include collective efficacy is the belief of society and the family in the care of people with schizophrenia, social support, namely the support obtained by the family of the surrounding community, a social network that is communication and cooperation that can be obtained and carried out by the family as they care for family members schizophrenic and access to new contact that is the ability of families in an effort to find resources to learn about schizophrenia and treatment processes families suffering from schizophrenia. care giver's perception about the state of today's families is affected by stress, which appears on a caregiver stress due to stressor for caring for people with schizophrenia, especially the aggressive behavior of people with schizophrenia. theories about the adaptation of the family in the care of people with schizophrenia did not exist before. the theory that there had existed only said about the adaptation of the family in general in the face of problems or difficulties in the family, one of them when there are family members who experience pain conditions. previous theories, in general, is the theory abcx hills (rice, 2000) which states that an event (a) interact with family members, will create a crisis (b) and bring up interpretation of the family about the incident (c). what distinguishes the theory of the results of the development of the model here is the adaptation of the family in caring for people with schizophrenia are not only influenced by stress and perceptions of the family but is also influenced by the self-esteem of the caregiver, community resources, caregiver coping effort (coping mechanism) and the perception of caregiver of family conditions experienced at this time. conclusion adaptation of caregiver is the ability to provide welfare care in people with schizophrenia. this is influenced by community resources, self-efficacy, caregiver perception about the family condition in caring for schizophrenia, coping mechanism, and selfesteem or self-esteem. community resources are the beliefs of people and families in the care of people with schizophrenia, a social support obtained by families from the surrounding communities, social networks of communication and cooperation that can be obtained and carried out by families, and access for families to find resources that support the care of patients with schizophrenia. the care giver's perception of family circumstances is currently influenced by stress, which is apparent in the stress of caregiver because of the stressors to treat people with schizophrenia, mainly due to the aggressive behavior of schizophrenics. the model required criteria and parameters of mental health and rehabilitation of standardized, measurable and easy-toimplement mental rehabilitation of schizophrenic patients upon return from hospitalization, enabling maximum families to assist schizophrenic healer recovery, and preventing recurrence, one of which is the establishment of integrated health services. in addition to providing training for public health centers about rehabilitation therapy for people with schizophrenia especially the holder of the mental health program at puskesmas. references arif, 2008. skizofrenia : memahami dinamika keluarga pasien., bandung: refika aditama. davies, j., 2009. mental health & psychiatric nursing a caring approach, boston: the adaptation model of care giver (byba melda suhita at.al) 80 jones & bartlett learning. hawari, d., 2009. pendekatan holistik pada gangguan jiwa edisi 2, jakarta: fkui. keliat, b.a., 2006. proses keperawatan jiwa edisi 2, jakarta: egc. stuart, g.w., 2013. psychiatric of nursing edisi 9, mosby: usa elsevier. varcarolis, e., 2000. psychiatric nursing clinical guide : assesment tools & diagnosis, philadelphia: w.b saunders company. warner r, b., 2007. community attitudes towards mental disorder in thornicroft, g., szmukler g (eds) textbook of community psychiatry 1stedition, new york: oxford university press, inc. yosep, 2009. keperawatan jiwa edisi revisi, bandung: refika aditama. murwani, anita, setyowati,sri . (2010). asuhan keperawatan keluarga; konsep dan aplikasi kasus.yogyakarta: mitra cendikia press rice, v. h. (2000). handbook of stress, coping and health : implications for nursing, theory and practice. sage publication. stoltz, paul g (2006).,adversity quotient. turning obtacles to opportunities. john wiley & sons inc temes r., (2011) ., getting your life back together when you have schizophrenia. oakland : new harbinger publications inc world health organization (2010).user empowerment in mental health. copenhagen. world health organization regional office for europe.diunduhdariwww.euro.who.int/pur equest tanggal 12 agustus 2013 ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 147 pengalaman masa pubertas remaja studi fenomenologi di purwokerto (the puberty experience of adolescent fenomenology study in purwokerto) endang triyanto fakultas kedokteran dan ilmu-ilmu kesehatan, jalan medika purwokerto universitas jenderal soedirman purwokerto e-mail: endangtriyanto@yahoo.com abstract introduction: puberty as a period of transition from childhood to adulthood and the most diffi cult stages in human growth and development. teenagers undergo during puberty will experience many physical and psychological changes that are very fast. the purpose was to explore experience of adolescents during their puberty. method: phenomenological method was used for data analysis. participants are adolescents who are undergoing puberty in purwokerto by purposive sampling. data was collected by open ended depth interviews. result: researchers found four themes: changes in puberty, adolescent psychological problems, the perceived role of family and family behaviors that adolescents are expected to undergo during puberty. adolescent girls experience menarche at age 12, while teenage boys have wet dreams at the age of 14 years. discussion: changes in the form of adolescent psychosexual fascination with the opposite sex and appearance. adolescent social change seen with increasing activity with friends and peers. researchers suggest the formation of peer counselor adolescents, clinical consultation and promotion of adolescent family development tasks. keywords: puberty period, adolescent experience pendahuluan world health organization (who) tahun 2005 memperkirakan jumlah populasi remaja di dunia meningkat tajam, bahkan mencapai sekitar setengah dari total penduduk dunia, dan sekitar 990 juta ada di negara berkembang. berdasarkan data survei demografi kesehatan indonesia tahun 2007, tercatat jumlah remaja di indonesia mencapai 30 persen dari total penduduk 231 juta atau sekitar 69 juta, tersebar paling banyak di yogyakarta dan jawa tengah. purwokerto merupakan kota yang memiliki kelompok remaja tercatat per april 2009 sejumlah 34 persen dari total penduduk (dinas kependudukan dan pencatatan sipil banyumas, 2009). salah satu fase pertama dalam kehidupan remaja adalah masa pubertas. remaja pubertas didefi nisikan sebagai masa peralihan dari masa anak-anak ke masa dewasa. anak remaja selama menjalani masa pubertas akan mengalami banyak perubahan fisik dan psikologis yang sifatnya sangat cepat. pada anak laki-laki, perubahan seks primer masa pubertas ditandai dengan mimpi basah, sedangkan perubahan sekunder berupa suara mulai berubah, tumbuh rambut di daerah ketiak, kumis, jenggot, alat kelamin. sementara perubahan seks primer anak perempuan ditandai dengan menstruasi pertama kali ( menarche) dan biasanya diikuti dengan perubahan organ seksual sekunder yaitu memiliki payudara dan pinggul yang membesar (soetjiningsih, 2004). perubahan fi sik yang dialami remaja selama masa pubertas memberikan dampak bagi perubahan psikologis dan sosial. perubahan psikologis juga diakibatkan oleh peningkatan hormon gonadotropin (guyton, 2006). bentuk perubahan yang menyertai pubertas meliputi kognitif, moral, emosi, sosial sebagai bentuk perkembangan diri remaja (hurlock, 1999). k e l u a r g a d i t u n t u t a g a r m a m p u melaksanakan tugas perkembangan keluarga sesuai friedman (2003) yaitu memberikan kebebasan yang bertanggung jawab, membina komunikasi terbuka orang tua dengan anak, jurnal ners vol. 5 no. 2 oktober 2010: 147–153 148 m e m b e r i k a n d u k u n g a n , m e m b e r i s u r i tauladan kepada remaja. keempat tugas perkembangan keluarga merupakan tugas perkembangan keluarga yang berkaitan erat dengan kebutuhan anak remaja selama menjalani masa pubertas. kenyataan di lapangan masih banyak keluarga yang belum mampu sepenuhnya untuk melaksanakan tugas perkembangan keluarga terhadap anak remaja yang menjalani masa pubertas. data yang ada di masyarakat menunjukkan bahwa informasi tentang perubahan yang terjadi pada masa pubertas yang diperoleh remaja masih sangat kurang. menurut hanifah (2000), sejumlah 78 persen anak remaja mengatakan bahwa tidak ada penjelasan yang disampaikan orang tuanya tentang tanda-tanda pubertas. apabila keluarga tidak memenuhi kebutuhan remaja yang menjalani masa pubertas, sementara remaja tersebut mengalami tahap-tahap tersulit dalam tumbuh kembangnya, maka dapat berpotensi terjadi kegagalan tumbuh kembang remaja dan menimbulkan masalah kesehatan remaja, seperti kebingungan akibat perubahan yang terjadi pada dirinya, gangguan body image, menarik diri, perilaku seks bebas, tindak kekerasan remaja, gangguan identitas seksual dan depresi. bahan dan metode penelitian ini menggunakan metode kualitatif fenomenologi yang mempelajari setiap masalah dengan menempatkannya pada situasi alamiah dan memberikan makna atau menginterpretasikan suatu fenomena berdasarkan hal-hal yang berarti bagi manusia. peneliti memilih pendekatan fenomenologi tentang pengalaman remaja selama menjalani masa pubertas. partisipan penelitian ini adalah remaja yang sedang menjalani masa pubertas menggunakan cara purposive sampling. kriteria inklusi penelitian ini adalah remaja laki-laki yang berusia 13–16 tahun dan telah mengalami mimpi basah, remaja perempuan yang berusia 12–16 tahun dan telah mengalami menstruasi, bersedia menjadi partisipan, pengetahuan yang memadai, remaja tinggal bersama keluarga dan mampu menceritakan pengalaman dengan baik. penelitian dilakukan di kota purwokerto, khususnya di kelurahan mersi, pamijen, baturaden dan bobosan. waktu penelitian yang digunakan adalah selama empat bulan yaitu maret sampai juni 2010. pengumpulan data dilakukan dengan wawancara mendalam melalui strategi open ended interview. instrumen utama penelitian ini adalah peneliti. alat bantu pengumpulan data berupa pedoman wawancara, fi eld notes dan alat mp3. tahapan analisis data menggunakan metode colaizzi 1978 dalam steubert dan carpenter, 2003) tentang pengalaman remaja dalam mendapatkan tugas perkembangan keluarga selama menjalani masa pubertas. hasil dan pembahasan peneliti menemukan empat tema, yaitu perubahan pubertas, masalah psikologis remaja, peran keluarga yang dirasakan dan perilaku keluarga yang diharapkan remaja selama menjalani masa pubertas. tema-tema tersebut akan dijelaskan secara rinci dalam uraian di bawah ini. ternyata semua remaja perempuan mengalami menarche pada usia 12 tahun, sedangkan remaja laki-laki mengalami mimpi basah pada usia 14 tahun. remaja perempuan lebih awal mengalami tanda seks primer pubertas dibanding laki-laki. hal ini dikaitkan dengan kenyataan bahwa proses fi siologis pada remaja laki-laki, testis yang terletak di skrotum baru mengalami kematangan saat usia 14 tahun. semua organ reproduksi remaja perempuan tumbuh pesat dalam tingkat kecepatan yang berbeda pada anak usia 11 atau 12 tahun. semua remaja tidak mengalami pubertas terlalu dini dan pubertas terlambat. remaja mengalami masa pubertas dalam rentang usia normal (guyton, 2006). perubahan fisik sebagai ciri seks sekunder yang terlihat dari luar terjadi selama pubertas adalah perubahan yang menyertai ciri seks primer (sarlito, 2009). perempuan tampak pertumbuhan payudara, tumbuh bulu-bulu halus di sekitar ketiak dan vagina, pinggul melebar; keringat bertambah banyak, kulit mulai berminyak, pantat bertambah lebih besar dan pertumbuhan tinggi badan yang pesat. sedangkan pada pria terjadi pertambahan tinggi badan yang cepat, tumbuh pengalaman masa pubertas remaja studi fenomenologi (endang triyanto) 149 jakun, tumbuh rambut-rambut di ketiak, sekitar muka dan sekitar kemaluan, penis dan buah zakar membesar, suara menjadi besar; keringat bertambah banyak, kulit dan rambut mulai berminyak (guyton, 2006). hasil penelitian ini menunjukkan perubahan fi sik yang dialami remaja selama menjalani masa pubertas berupa tinggi badan yang cepat, perubahan suara, tumbuh jakun dan rambut di ketiak dan sekitar muka pada remaja laki-laki. remaja perempuan terlihat payudara dan pinggul membesar. remaja laki-laki dan perempuan juga mengalami keringat yang berlebihan dan jerawat di wajah. kulit berminyak tampak ketika wawancara. wong (2003) menyatakan bahwa remaja selama menjalani masa pubertas terjadi peningkatan dorongan seksual sebagai akibat dari perubahan hormonal yaitu gonadotrofi k yang diproduksi oleh kelenjar hypothalamus. sedangkan freud dalam hurlock, 2004 berpendapat bahwa remaja mengalami perkembangan psikoseksual yaitu ketertarikan dengan lawan jenis. ketertarikan dengan lawan jenis merupakan wujud dari adanya peningkatan dorongan seksual. perubahan psikoseksual yang diungkap remaja dikategorikan menjadi dua yaitu ketertarikan dengan lawan jenis dan perubahan penampilan. tujuh remaja menyatakan ketertarikan dengan lawan jenis dengan melihat dari adanya perubahan fisik. perubahan fisik remaja perempuan yang menarik bagi laki-laki adalah adanya pertumbuhan payudara. payudara yang indah terlihat menarik bagi laki-laki yang melihatnya. begitu juga pinggul dan pantat yang besar dapat menjadi daya tarik tersendiri bagi laki-laki ketika melihatnya sesuai dengan penelitian hanifah (2000) bahwa remaja laki-laki menyatakan tertarik dengan remaja perempuan dengan melihat dari bentuk payudara dan pinggul yang besar. mighwar (2006) menyimpulkan bahwa masa pubertas disebut sebagai masa social hunger (kehausan sosial) yang ditandai dengan adanya keinginan untuk bergaul dan diterima di lingkungan kelompok sebayanya. setelah anak memasuki masa remaja akan mengalami perubahan sosial dengan memperbanyak teman dan aktivitas dengan teman-teman sebayanya, bahkan remaja akan lebih dekat dengan teman dibanding orang tuanya. hasil wawancara yang dilakukan dengan remaja, ditemukan data bahwa perubahan sosial yang dialami sesuai dengan hasil penelitian tersebut yaitu terjadi peningkatan jumlah teman, aktivitas bermain dengan teman sebaya dan kedekatan dengan teman. pada usia remaja awal masih memiliki ciri-ciri masa kanak-kanak terutama berupa kecenderungan cara berpikir yang masih egosentrisme piaget dalam agustiani, 2006. egosentrisme adalah ketidakmampuan melihat suatu hal dari sudut pandang orang lain. elkind dalam agustiani, 2006 mengungkapkan salah satu bentuk cara berpikir egosentrisme yang dikenal dengan istilah personal fabel. personal fabel ini biasanya berisi keyakinan bahwa diri seseorang adalah unik dan memiliki karakteristik khusus yang hebat, diyakini benar adanya tanpa menyadari sudut pandang orang lain dan fakta sebenarnya. menurut pengalaman remaja selama masa pubertas mengalami perubahan sikap yaitu sikap menentang. sikap menentang diungkapkan oleh dua remaja laki-laki. bentuk penolakan yang mereka lakukan adalah jika diperintah untuk melakukan yang berkaitan dengan masa depan, misalnya belajar. mereka biasanya juga akan menolak, apabila diperintah untuk menggunakan helm ketika hendak naik sepeda motor. remaja akan lebih mudah mengikuti hal-hal yang menyenangkan menurut pemikiran mereka. kondisi emosi remaja pubertas sangat mudah berubah. menurut hall dalam santrock, 2003 menyatakan bahwa remaja yang sedang menjalani masa pubertas mengalami badai dan topan dalam kehidupan perasaan dan emosinya. keadaan semacam ini sering disebut sebagai strom and stress (santrock, 2003). remaja yang sedang menjalani masa pubertas pada umumnya mengalami keadaan yang menggejolak dan sensitif. keadaan yang penuh gejolak dan sensitif sering diwujudkan dalam bentuk mudah marah dan terangsang emosinya. sebanyak enam remaja mengungkapkan perubahan emosi berupa mudah marah. perubahan emosi ini dihubungkan dengan adanya perubahan hormonal yang meningkat jurnal ners vol. 5 no. 2 oktober 2010: 147–153 150 pada remaja yang sedang menjalani pubertas. dampak perubahan hormonal yang terjadi pada remaja selama menjalani masa pubertas adalah perubahan emosional dengan ciri puncak emosi yang labil (sarlito, 2009; glasper dan richardson, 2006). penelitian hanifah (2000) menyimpulkan bahwa perasaan saat pertama kali mengalami mimpi basah dan menstruasi adalah dapat berupa bingung, cemas, takut dan tidak siap menerima tanda awal pubertas. hanifah (2000) menambahkan bahwa respons tidak siap saat menerima tanda awal pubertas dapat berupa malas, heran dan kaget. perasaan terhadap perubahan yang diungkapkan remaja dalam penelitian ini berupa perasaan senang, malas, kaget, bingung, cemas dan takut. remaja laki-laki dan perempuan selama masa pubertas biasanya tumbuh jerawat di beberapa bagian tubuh terutama wajah sebagai akibat peningkatan hormonal. sebagian remaja merasa putus asa dan minder dengan munculnya jerawat. efek lain dari peningkatan hormonal adalah produksi keringat yang meningkat pesat sebagai hasil aktivitas kelenjar keringat yang lebih produktif (guyton, 2006). penelitian reasoner (2004) menghasilkan data sebanyak 72 persen remaja menunjukkan adanya gangguan body image setelah memasuki sekolah menengah pertama akibat tumbuhnya jerawat. hasil wawancara yang dilakukan peneliti, ditemukan data bahwa remaja selama menjalani masa pubertas merasakan adanya pola perilaku keluarga yang berbeda-beda tiap remaja. ada yang merasa didukung, ada juga yang mendapatkan sikap negatif dari keluarga. dukungan keluarga yang dirasakan remaja selama menjalani masa pubertas dengan cara memahami, menasehati, mengijinkan, memenuhi kebutuhan dan mengajarkan. sikap negatif keluarga yang dirasakan remaja adalah perhatian keluarga yang kurang, tidak menjelaskan, mengekang dan tidak memberikan hak anak untuk berpendapat. keluarga menegakkan aturan yang dirasakan remaja adalah mengarahkan, mengingatkan, role model dan paksaan. dukungan keluarga berupa memahami, menasehati dan mengijinkan dapat dimasukkan ke dalam dukungan emosional keluarga. sedangkan kategori memenuhi kebutuhan merupakan dukungan material keluarga. kategori mengajarkan dapat dianggap sebagai dukungan informasional keluarga. pernyataan peneliti tersebut sesuai dengan pernyataan friedman (2003) yang menjelaskan bahwa dukungan keluarga terdiri dari dukungan emosional, material dan informasional. keluarga masih belum memberikan dukungan i n f o r m a s i o n a l y a n g d i k a i t k a n d e n g a n pemikiran bahwa diskusi seksualitas kepada anak merupakan hal yang tabu. pendekatan kepada orang tua dengan melibatkan tokoh agama perlu dilakukan agar dapat merubah pola pikir bahwa diskusi seksualitas adalah hal yang tabu menjadi suatu hal yang wajar untuk dibicarakan. seringkali kekhawatiran keluarga berlebihan, sehingga remaja banyak yang di kekang dan tidak diberi kesempatan bergaul dengan teman-temannya. sikap ini dirasakan oleh remaja dalam penelitian ini. remaja menyatakan bahwa mereka merasa sama sekali tidak boleh main, tidak diberi kelonggaran dan perlakuan orang tua sangat ketat. banyak keluarga yang menunjukkan sikap tersebut kepada anak remaja sebagai wujud perlindungan terhadap anaknya, namun dipandang remaja sebagai pengekangan. kemampuan interpersonal remaja diperoleh dengan menjalin hubungan dengan orang lain. ketika remaja menjalin hubungan dengan orang lain, maka remaja tersebut dapat belajar tentang cara berinteraksi sosial dan cara berkomunikasi dengan orang lain. sikap pengekangan ini akan memengaruhi perkembangan psikologis pada remaja (friedman, 2003; evita, 2009). setiap orang tua menginginkan anaknya berperilaku yang baik sesuai norma yang berlaku di keluarga maupun masyarakat. oleh karena itu, salah satu tanggung jawab keluarga terhadap anaknya adalah membentuk perilaku anak. cara yang dilakukan keluarga berbeda-beda. remaja mengungkapkan bahwa terdapat empat cara yang dilakukan keluarga dalam menegakkan aturan yaitu dengan mengarahkan, mengingatkan, memberi contoh dan sebagian yang lain dengan paksaan. orang tua yang menggunakan cara mengarahkan, pengalaman masa pubertas remaja studi fenomenologi (endang triyanto) 151 mengingatkan dan memberi contoh merupakan cara demokratis yang memungkinkan remaja untuk menerimanya dan menjalankan aturan dengan sepenuh hati. setiap remaja selama menjalani masa pubertas mempunyai kebutuhan yang berbeda-beda. keluarga bertanggung jawab dalam bentuk tugas perkembangan terhadap anak remaja selama masa pubertas. tugas perkembangan keluarga pada anak remaja menurut friedman (2003) adalah memberikan kebebasan bertanggung jawab sebagai hak otonomi; membina komunikasi yang terbuka antara orang tua dengan anak; memberikan dukungan keluarga; dan memberi suri tauladan penanaman nilai positif keluarga. harapan remaja terkait keluarga terhadap dirinya selama menjalani masa pubertas, terungkap berbagai macam kebutuhan yang terdiri dari bentuk dukungan, pola komunikasi, kebebasan dan cara membentuk perilaku remaja. dukungan keluarga yang diharapkan remaja selama menjalani masa pubertas yaitu ingin diperhatikan, keinginan agar orang tua dapat berperan sebagai sahabat, m e m b e r i k a n k a s i h s a y a n g , d i p a h a m i , diberitahu dan dicukupi kebutuhannya. cara komunikasi yang dimaksudkan remaja adalah tidak ada pertengkaran yang berarti remaja menginginkan orang tua untuk dapat berbicara secara lembut kepada anak bukan dengan membentak-bentak. cara berbicara yang lembut akan membuat kenyamanan bagi si remaja, bahkan mereka akan lebih terbuka pada orang tua kalau kebutuhan ini dipenuhi keluarga. hal ini sesuai dengan penelitian ramanda (2003) yang menyatakan bahwa ketika anak kabur dari rumah, mereka mau kembali apabila orang tua menunjukkan sikap yang lembut. perhatian orang tua, kasih sayang dan pengertian orang tua dalam menghadapi sikap remaja akan membantu remaja mencapai kematangan emosi yang stabil. di masa krisis ini, orang tua harus bisa menciptakan situasi yang kondusif bagi pertumbuhan remaja seperti memberi rasa aman, menciptakan suasana yang harmonis dan ceria di rumah dan menjalin hubungan mesra dengan remaja dengan berperan sebagai sahabat. semua faktor ini sangat menentukan keberhasilan remaja mengarungi masa-masa sulit dan krisis selama menjalani masa pubertas. situasi yang kondusif diperlukan untuk membentuk perilaku anak. menurut agustiani (2006) keluarga harus menciptakan kondisi yang menunjang untuk pembentukan kepribadian anak remaja agar mengikuti berbagai aturan keluarga. kondisi tersebut dapat dicapai dengan adanya kedekatan anak dengan orang tua, perhatian keluarga dan suri tauladan penanaman nilai positif. dalam rangka pembentukan perilaku, remaja berharap agar keluarga menggunakan cara diarahkan, dikontrol dan diberi contoh. pernyataan peneliti ini didukung oleh hurlock (2004) yang menyatakan bahwa bimbingan orang yang lebih tua sangat dibutuhkan oleh remaja sebagai acuan remaja dalam berperilaku. kemandirian seorang remaja diperkuat melalui proses sosialisasi yang terjadi antara remaja dan teman sebaya. hurlock (2004) menjelaskan bahwa melalui hubungan dengan teman sebaya, remaja belajar berpikir secara mandiri, mengambil keputusan sendiri, menerima atau menolak pandangan dan nilai yang berasal dari keluarga serta mempelajari pola perilaku yang diterima kelompoknya. kesempatan bermain dengan teman akan meningkatkan kemampuan komunikasi interpersonal remaja. studi yang dilakukan stuart (2002) menunjukkan bahwa remaja yang diberikan kesempatan bergaul dengan temannya secara bertanggung jawab lebih mampu berkomunikasi dengan baik dibanding remaja yang dikekang. remaja mengungkapkan ingin diijinkan untuk bermain dengan teman sebayanya. keluarga dituntut untuk memenuhi kebutuhan sosial remaja yang menjalani masa pubertas yaitu memberikan kebebasan untuk bergaul dengan teman sebayanya. sikap orang tua yang tidak lagi menganggap remaja sebagai anak kecil tapi memberikan kebebasan untuk bergaul menumbuhkan perasaan mandiri bagi remaja. selain itu, apabila keluarga mengijinkan anak remajanya untuk bergaul, mereka akan mendapatkan pengalaman caracara berkomunikasi dengan temannya. selama proses pergaulan terjadi pembelajaran bagi remaja untuk berkomunikasi. apabila tidak terpenuhi, maka dapat terjadi gangguan pada proses komunikasi interpersonal remaja. jurnal ners vol. 5 no. 2 oktober 2010: 147–153 152 selain kebutuhan yang telah dijelaskan di atas, remaja yang sedang menjalani masa pubertas mempunyai kebutuhan yang berkaitan dengan perubahan fisik mereka, seperti pembalut, kosmetik, baju dan alat komunikasi berupa handphone (erwin, 2002). kebutuhan remaja ini terungkap dari pernyataan-pernyataan remaja saat diwawancarai. beragam kebutuhan remaja tersebut, mutlak harus diberikan orang tua terutama pembalut wanita. hal ini dilakukan agar tidak terjadi masalah kesehatan bagi remaja yang sedang menjalani masa pubertas tersebut. apabila pembalut tidak dipenuhi oleh orang tuanya, maka dimungkinkan dapat terjadi penyakit organ reproduksi wanita. simpulan dan saran simpulan respons perubahan yang dialami remaja selama menjalani masa pubertas yaitu perubahan fi sik mulai dari tinggi badan, payudara, pinggul, jakun, tumbuh rambut di beberapa bagian tubuh dan adanya perubahan suara. perubahan psikoseksual yang terungkap adalah ketertarikan dengan lawan jenis dan perubahan penampilan. terdapat keinginan peningkatan jumlah teman, peningkatan aktivitas bermain dengan teman sebaya dan kedekatan dengan teman. perubahan sikap yang dialami adalah sikap menentang, sedangkan perubahan emosi dalam bentuk mudah marah. pola perilaku keluarga terhadap remaja selama menjalani masa pubertas berupa dukungan yaitu memahami, menasehati, mengijinkan, memenuhi kebutuhan dan mengajarkan. sebagian partisipan masih merasakan pola perilaku keluarga yang diberikan kurang yaitu perhatian keluarga kurang, tidak menjelaskan, mengekang dan tidak memberikan hak untuk berpendapat. keluarga menegakkan aturan dengan cara mengarahkan, mengingatkan, role model dan paksaan. perilaku keluarga yang diharapkan remaja terdiri dari bentuk dukungan, pola komunikasi, kebebasan dan cara membentuk perilaku remaja. saran puskesmas perlu membina program kelompok kesehatan remaja. perawat komunitas dapat berperan langsung dengan membentuk peer conselor dan klinik konsultasi remaja di masyarakat. strategi intervensi promosi kesehatan melalui program kampanye remaja sehat pubertas dengan optimalisasi tugas perkembangan keluarga. penelitian lanjutan yang perlu dilakukan adalah faktor faktor yang memengaruhi keluarga dalam melaksanakan tugas perkembangan keluarga pada anak remaja yang sedang menjalani masa pubertas. kepustakaan agustiani, a., 2006. karakteristik dan permasalahan remaja yang menjalani masa pubertas, (online), (http:// episentrum.com., diakses tanggal 28 februari 2010). d i n a s k e p e n d u d u k a n d a n p e n c a t a t a n sipil banyumas, 2009. data dinas kependudukan dan pencatatan sipil banyumas tahun 2009, (online), (http:// www.banyumaskab.go.id., diakses tanggal 27 februari 2010). evita, p., 2009. karakteristik pubertas remaja, (online), (http://kbi.gemari. o r. i d . , d i a k s e s d a r i p a d a t a n g g a l 26 februari 2010. friedman, marilyn, 2003. keperawatan keluarga: teori dan praktik. edisi iii. jakarta: egc. guyton,a.c., 2006. buku ajar fisiologi kedokteran. edisi 7. jakarta: egc. hanifah, l., 2000. faktor yang mendasari hubungan seks pra nikah remaja: studi kualitatif di pkbi yogyakarta 2000. tesis tidak dipublikasikan, jakarta: fakultas kesehatan masyarakat universitas indonesia. hurlock, elizabeth b., 1991. developmental psychology: a life span approach. (5th ed). london: mcgraw-hill inc. mighwar, muhammad, 2006. psikologi remaja. bandung: pustaka setia. pengalaman masa pubertas remaja studi fenomenologi (endang triyanto) 153 reasoner, s., 2004. social puberty, (online), (http://www.who.int., diakses dari/ child-adolescent-health pada tanggal 25 februari 2010. santrock, john w., 2003. adolesence: p e r k e m b a n g a n r e m a j a . j a k a r t a : erlangga. sarlito, 2009. perubahan fisik remaja, (online), (http://www.epsikologi.com., diakses tanggal 10 juni 2010. jam 16.35 wib). soetjiningsih, ranuh, suraatmaja, rusmil, pangkahila, fadlyana, dkk., 2004. buku ajar tumbuh kembang remaja dan permasalahannya. jakarta: sagung seto. streubert, h.j. dan carpenter, d.r., 2003. qualitative research in nursing. advancing the humanistic imperative. third edition. philadelphia: lippincott williams and wilkins. wong, algreen, arnow, et al., 2003. nursing care of infants and children, 8th edition. canada: mosby elsevier. vol 8 no 2 oktober 2013.indd 330 peningkatan kinerja pendokumentasian asuhan keperawatan berbasis knowledge management "seci's model" (improving performance of nursing documentation based on knowledge management through seci concept model’s r. arief santoso*, widodo j. pudjirahardjo** *dinas kesehatan sumenep, jalan dr. soetomo sumenep, 69416 **fakultas kesehatan masyarakat universitas airlangga e-mail: arief_snts35@yahoo.com abstrak pendahuluan: pendokumentasian asuhan keperawatan, terutama diagnosa keperawatan di rsi kalianget tahun 2011 rerata masih rendah. penelitian ini bertujuan meningkatkan kinerja pendokumentasian asuhan keperawatan berbasis knowledge management melalui konsep seci's model di rsi garam kalianget kabupaten sumenep. metode: desain penelitian ini adalah action research yang dilakukan dari bulan oktober 2012–juli 2013. populasi dan sampel dalam penelitian adalah perawat berjumlah 29 orang. analisis data menggunakan uji paired t test dengan tingkat signifi kasi 95%. hasil: didapatkan knowledge p = 0,0001 yang berarti ada perbedaan knowledge yang signifi kan antara sebelum dan sesudah intervensi, perbandingan kinerja pendokumentasian askep diperoleh nilai p = 0,004 yang berarti ada perbedaan kinerja yang signifi kan antara sebelum dan sesudah intervensi. perbandingan kinerja komunikasi efektif sbar diperoleh nilai p = 0,001 yang berarti ada perbedaan kinerja yang signifi kan antara sebelum dan sesudah intervensi. diskusi: knowledge management melalui seci's model mempunyai peranan penting dalam meningkatkan kinerja pendokumentasian askep dan komunikasi efektif sbar. kata kunci: knowledge management, seci's model, kinerja, pendokumentasian askep, komunikasi efektif sbar abstract introduction: documentation of nursing care in kalianget rsi in 2011 was totaled average 58,1% and in 2012 achieve was still low. according the lowest component was nursing diagnosis. this research aims to improve the performance of nursing care documentation based on knowledge management through the seci model’s concept in garam kalianget rsi sumenep district. method: design of this research was action research. population and sample in the research of knowledge, motivation and work responsibility were all nurses total ed 29 people. the dependent variable were knowledge, performance, motivation, work responsibility, and performance after intervention knowledge management (km) and as independent variable in this research was knowledge, performance, and intervention research knowledge management in documentation nursing care. data were collected by using questionnaires and checklists. result: the results after the seci model’s intervention and using paired t test with a 95% confi dence level of knowledge obtained p = 0.0001 which means that there was a signifi cant knowledge difference between before and after intervention, compariosn of performance documenting of nursing care obtained value ρ = 0.004, which means there was a difference signifi cant performance between before and after intervention. comparison of sbar effective communication performance values obtained ρ = 0.001, which means there was a signifi cant performance difference between before and after intervention. discussion: knowledge management through seci model’s has important role in improving performance documentation of nursing care and sbar effective communication. it is recommended to do in forum sharing nurse’s experience or informant in practical communication in periodic, recording, documentation, and keep document well and doing supervision continously especially form nursing care and sbar effective communication. keywords: knowledge management, seci model’s, performance, documentation nursing care, sbar effective communication pendahuluan pelayanan keperawatan merupakan salah satu faktor yang menentukan baik buruknya mutu pelayanan dan citra rumah sakit. mutu pelayanan keperawatan harus dipertahankan dan ditingkatkan seoptimal mungkin. upaya peningkatan mutu pelayanan, pemberian asuhan keperawatan harus didasarkan pada standar asuhan keperawatan (sak) sebagai pedoman dan tolak ukur. sak harus diterapkan pada seluruh tatanan pelayanan keperawatan oleh tenaga keperawatan yang ada di rumah sakit sehingga pelayanan dan asuhan keperawatan (askep) dapat dipertanggungjawabkan (pandawa, 2006). 331 peningkatan kinerja pendokumentasian asuhan keperawatan (r. arief santoso, dkk) pelayanan keperawatan yang diberikan perawat ditulis dalam bentuk dokumentasi yang disebut sebagai dokumentasi asuhan keperawatan dan merupakan salah satu alat pembuktian atas perbuatan perawat selama menjalankan tugas pelayanan keperawatan serta menjadikan hal yang penting sebagai alat bukti tanggung jawab dan tanggung gugat dari perawat dalam menjalankan tugasnya. pelayanan asuhan keperawatan yang optimal akan terus menjadi tuntutan organisasi pelayanan kesehatan (nursalam, 2008). undang-undang no. 36 tahun 2009 merupakan wujud rambu atas hak dan kewajiban tenaga kesehatan termasuk para perawat dalam menjalankan tugas pelayanan. dokumentasi asuhan keperawatan merupakan salah satu unsur penilaian kinerja perawat (depkes ri, 2001) dan rsi garam kalianget memasang standar untuk pendokumentasian asuhan keperawatan sebesar 100%. hasil penelitian diyanto (2007) menunjukkan penatalaksanaan pengisian dokumentasi asuhan keperawatan proporsi terbesar dalam kategori kurang (48%), yang selanjutnya diikuti sedang (35%) dan baik (17%). hasil penelitian lain oleh pandawa (2006) menyimpulkan tingkat pengetahuan dan sikap merupakan determinan kinerja perawat dalam pendokumentasian asuhan keperawatan. dokumentasi asuhan keperawatan berkembang seiring dengan perkembangan industri perumah sakitan. saat ini setiap pelaksanaan tindakan di rumah sakit mengarah pada patient safety. salah satu alat komunikasi efektif adalah menggunakan alat monitoring yang memastikan sebuah pendokumentasian mengarah kepada patient safety. alat yang digunakan adalah metode sbar (situation, background, assesment, recomendation). sbar dijadikan syarat utama dalam sistem akreditasi rumah sakit, dari tahun 2012 dan selanjutnya (nursalam, 2011). rsi garam kalianget kabupaten sumenep merupakan rumah sakit tipe d dengan kapasitas 50 tempat tidur. jumlah perawat sebanyak 35 orang, perawatan menggunakan metode asuhan keperawatan tim dengan mekanisme timbang terima antar shift langsung setiap tim jaga dengan waktu 30 menit sebelum jam jaga usai dengan cara baik melalui langsung pasien per pasien maupun melalui buku laporan jaga. pelaksanaan asuhan keperawatan sesuai dengan kasus dan masalah yang dihadapi oleh pasien serta intervensi yang dibuat dalam perencanaan tindakan keperawatan, namun masih banyak dokumen asuhan keperawatan yang isinya belum lengkap. dalam pelaksanaan pendokumentasian asuhan keperawatan masih belum menggunakan sbar dan melihat kinerja pendokumentasian asuhan keperawatan menggunakan instrumen a departemen kesehatan ri (rsi garam, 2011). pendokumentasian asuhan keperawatan di rsi kalianget tahun 2011 total rata-rata mencapai 58,1% dan menurut komponennya terendah adalah diagnosa keperawatan yang mencapai 42,4%. pencapaian pendokumentasian asuhan keperawatan di rsi garam kalianget tahun 2012 tetap rendah, hanya mencapai 38,9% dan menurut komponen terendah pada diagnosa keperawatan yang mencapai 31,5%, saat ini telah terjadi pergeseran paradigma di mana peran manusia menjadi sentral dibandingkan dengan peran teknologi maupun keuangan. aset yang paling berharga dalam manusia adalah pengetahuan. perawat membutuhkan pengetahuan untuk meningkatkan kemampuan mereka untuk memperbaiki hasil kerja dan pelayanan mereka, dengan menyediakan kualitas pelayanan untuk klien atau konsumen. pengetahuan merupakan nutrisi yang sangat penting yang dibutuhkan organisasi untuk berkembang. di dalam organisasi, karyawan mungkin bisa datang dan pergi begitu saja, tetapi pengetahuan tidak seperti itu, pengetahuan tidak dapat hilang ataupun mati dari sebuah organisasi (yunika, 2011) pengetahuan dari organisasi dapat menjadikan organisasi tersebut memahami tujuan keberadaannya. organisasi yang sukses, adalah organisasi yang secara konsisten menciptakan pengetahuan baru dan menyebarkannya secara menyeluruh di dalam organisasinya, dan secara cepat mengadaptasinya ke dalam teknologi dan produk serta layanan mereka. akhir ini banyak organisasi yang telah menjadikan manajemen pengetahuan (knowledge management) sebagai salah satu strategi untuk menciptakan nilai, meningkatkan efektivitas dan produktivitas organisasi, serta keunggulan kompetitif organisasi. mereka 332 jurnal ners vol. 8 no. 2 oktober 2013: 330–341 mulai menerapkan manajemen pengetahuan dalam rangka peningkatan kinerja usaha dan daya tahan organisasi mereka (kosasih, 2006). penerapan knowledge management dalam pendokumentasian asuhan keperawatan menjadi solusi dalam meningkatkan kinerja pendokumentasian asuhan keperawatan untuk menyelesaikan masalah dalam penelitian ini yaitu rendahnya pendokumentasian asuhan keperawatan di rsi garam kalianget tahun 2011 yang mencapai 58,1% dan tahun 2012 mencapai 38,9%. tujuan penelitian ini adalah upaya meningkatkan kinerja pendokumentasian asuhan keperawatan berbasis knowledge management melalui konsep seci model’s di rsi garam kalianget. bahan dan metode metode penelitian ini adalah action research. dalam penelitian ini peneliti melakukan analisis knowledge, kinerja, motivasi, dan beban kerja perawat tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar sebagai tahap pra intervensi seci. pada tahap intervensi seci melakukan analisis hasil intervensi kegiatan knowledge management (km) pada tahap socialization, externalization, combination, dan internalization. kemudian menganalisis knowledge, kinerja tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar, dan melihat perbandingan antara sebelum dan setelah intervensi sebagai tahap post intervensi seci. populasi dalam penelitian dibagi menjadi dua bagian, yaitu populasi untuk knowledge, motivasi dan beban kerja adalah sebanyak 29 orang dan sampelnya adalah seluruh perawat yang bekerja di rsi garam kalianget yang berjumlah 29 orang. sedangkan populasi untuk kinerja pendokumentasian asuhan keperawatan dan komunikasi efektif adalah rekam medik yang dibagi menjadi 2 bagian yaitu sebelum intervensi dan sesudah intervensi seci's model. populasi sebelum intervensi didapatkan 242 rekam medik. sedangkan setelah intervensi didapatkan 237 rekam medik. teknik pengambilan sampel tentang kinerja pendokumentasian asuhan keperawatan dan komunikasi efektif yaitu dengan cara mengambil 30% dari populasi. didapatkan bulan maret 2013 yaitu 73 rekam medik, mei 2013 didapatkan sebanyak 71 rekam medik yang selanjutnya diproporsionalkan menurut ruangan. teknik pengambilan sampel kinerja pendokumentasian asuhan keperawatan dan komunikasi sbar adalah teknik simple random sampling. penelitian ini dibagi menjadi 3 tahap pelaksanaan yaitu tahap sebelum intervensi, pelaksanaan intervensi dan setelah intervensi. aktivitas pada tahap sebelum intervensi yaitu melakukan analisis knowledge, kinerja, motivasi dan beban kerja perawat dalam pendokumentasian asuhan keperawatan dan komunikasi efektif sbar. hasil dari analisis dijadikan bahan fgd yang bertujuan untuk menyusun metode intervensi melalui pembahasan tentang hasil analisis knowledge, kinerja, motivasi dan beban kerja perawat dalam pendokumentasian asuhan keperawatan dan komunikasi efektif sbar. kegiatan fgd menghasilkan asessment yang nantinya dijadikan bekal untuk menjadi skenario yang akan dilakukan dalam melaksanakan intervensi. tahap kedua yaitu pelaksanaan intervensi km berdasarkan seci model yaitu antara lain yaitu 1) socialization, 2) externalization, 3) combination, dan 4) internalization. dengan rincian aktivitas sesuai dengan komponen dari seci model. tahap setelah intervensi adalah menganalisis knowledge, kinerja, perawat dalam pendokumentasian asuhan keperawatan dan komunikasi efektif sbar dan membandingkan antara sebelum dan sesudah intervensi seci. setelah itu menyusun rancangan upaya meningkatkan kinerja pendokumentasian asuhan keperawatan dengan konsep knowledge management melalui seci model’s. variabel dependen dalam penelitian ini adalah knowledge, kinerja, motivasi, beban kerja, dan kinerja setelah intervensi pelaksanaan kegiatan knowledge management dalam pendokumentasian asuhan keperawatan dan komunikasi efektif sbar melalui seci model’s. variabel independen dalam penelitian ini adalah knowledge, kinerja dan intervensi pelaksanaan kegiatan knowledge management dalam pendokumentasian asuhan keperawatan 333 peningkatan kinerja pendokumentasian asuhan keperawatan (r. arief santoso, dkk) dan komunikasi efektif sbar melalui seci model’s. peneliti menggunakan instrumen pengumpulan data berupa kuesioner yang disebarkan pada responden. instrumen pertama adalah kuesioner untuk menganalisis knowledge, motivasi, beban kerja dan penilaian dari setiap tahapan seci dalam pendokumentasian asuhan keperawatan. instrumen kedua adalah checklist untuk menganalisis kinerja pendokumentasian asuhan keperawatan yang diukur menggunakan s-bar tools. penelitian ini dilakukan di rsi garam kalianget kabupaten sumenep. variabel penelitian dapat diketahui perbandingan knowledge dan kinerja pendokumentasian asuhan keperawatan sebelum dan setelah intervensi, yang menggunakan uji statistik paired samples test melalui komputer dengan tingkat kemaknaan 5% yaitu p 0,05. hasil knowledge perawat tentang pendokumentasian askep dan komunikasi efektif sbar di rsi garam kalianget hampir setengahnya adalah cukup (44,8%). pendokumentasian askep di rsi garam kalianget sudah dilakukan dan pencapaian tertinggi adalah pada perencanaan keperawatan yang mencapai 76,0% dan terendah pada aspek tindakan keperawatan. setelah mengukur knowledge dan kinerja, sebagai bekal untuk melakukan intervensi seci juga menganalisis motivasi perawat akan pendokumentasian askep dan beban kerja dari perawat di rsi garam kalianget. motivasi perawat dalam pendokumentasian asuhan keperawatan dan komunikasi efektif sbar di rsi garam kalianget tahun 2013 sebagian besar baik yaitu 18 perawat (62,1%) seperti yang ditunjukkan pada tabel 3. beban kerja perawat dalam melaksanakan tugas setiap jam kerja dibagi menjadi beban tugas pokok, tambahan, lain dan keseluruhan dapat dilihat pada tabel 4. beban kerja tugas pokok perawat seperti pasang infus, melakukan pendokumentasian asuhan keperawatan, seperti yang ditunjukkan tabel 5.16 yang menunjukkan beban kerja tugas pokok perawat di rsi garam kalianget tahun 2013 hampir seluruhnya kurang yaitu 28 perawat (96,6%). tugas tambahan perawat yaitu tugas yang diberikan di luar sebagai perawat. beban kerja tugas tambahan perawat di rsi garam kalianget tahun 2013 sama dengan beban kerja tugas pokok yang ditunjukkan pada tabel 4 yaitu hampir seluruhnya kurang yaitu 28 perawat (96,6%). tugas lain perawat seperti mengikuti rapat, makan dan istirahat. dari tabel 4 tabel 1. k n o w l e d g e p e r a w a t t e n t a n g p e n d o k u m e n t a s i a n a s k e p d a n komunikasi efektif sbar sebelum intervensi seci model's di rsi garam kalianget no knowledge perawat jumlah % 1 kurang 5 17,2 2 cukup 13 44,8 3 baik 11 37,9 total 29 100,0 tabel 2. kinerja pendokumentasian askep sebelum intervensi seci model’s di rsi garam kalianget no aspek yang dinilai % kategori 1 pengkajian 72,9 cukup 2 diagnosis 68,5 cukup 3 perencanaan 76,0 baik 4 tindakan 49,0 kurang 5 evaluasi 70,5 cukup 6 catatan 61,5 cukup tabel 3. m o t i v a s i p e r a w a t d a l a m p e n d o k u m e n t a s i a n a s k e p d a n komunikasi efektif sbar di rsi garam kalianget no kategori motivasi jumlah % 1 kurang 1 3,4 2 cukup 10 34,5 3 baik 18 62,1 total 29 100,0 334 jurnal ners vol. 8 no. 2 oktober 2013: 330–341 keputusan oleh direktur rsi garam kalianget. c. dilakukan berbagi pengalaman antar perawat dan dengan nara sumber dalam komunikasi praktis (communities of practice) dilakukan dalam forum diskusi yang dihadiri oleh para perawat kecuali yang 5 perawat karena berjaga di ruangan. nara sumber memberikan pengalaman tentang pelaksanaan k o m u n i k a s i s b a r , m u l a i d a r i hambatan, pentingnya sampai dengan hal yang bisa membuat sukses dalam pelaksanaan komunikasi efektif sbar. dilakukan mulai jam 09.00–12.00 wib juga dilakukan sesi tanya jawab. 2) externalization tahap ini dilakukan intervensi yaitu: a. proses notulensi dilakukan oleh perawat yang masuk dalam tim yang bertugas mencatat semua kegiatan yang disampaikan dan beberapa pertanyaan dan jawaban dalam kegiatan berbagi pengalaman di komunikasi praktis (communities of practice). b. hasil notulensi dijadikan konsep dan prosedur pendokumentasian asuhan keperawatan. hasil notulensi disusun diperbanyak dan dijadikan konsep oleh tim dalam rangka persiapan menyusun prosedur yang nantinya dilakukan dalam forum komunikasi. tim juga mendapatkan beberapa literatur yang diberikan oleh nara sumber. 3) combination tahap ini dilakukan intervensi yaitu: a. dilakukan forum diskusi dalam rangka penyusunan spo pendokumentasian a s u h a n k e p e r a w a t a n . ti g a h a r i s e t e l a h p e l a k s a n a a n k e g i a t a n tabel 4. distribusi beban kerja perawat berdasarkan tugas pokok, tambahan, lain dan total di rsi garam kalianget no beban kerja kategori total kurang normal berlebih jml % jml % jml % jml % 1 tugas pokok 28 96,6 1 3,4 0 0 29 100 2 tugas tambahan 28 96,6 1 3,4 0 0 29 100 3 tugas lain 20 69,0 5 17,2 4 13,8 29 100 4 tugas total 19 65,5 9 31,0 1 3,4 29 100 menunjukkan bahwa beban kerja tugas lain di rsi garam kalianget 2013 sebagian besar adalah kurang yaitu 20 perawat (69,0%) yang berarti perawat masih minim melakukan tugas lain dan kebanyakan terpaku pada tugas di ruangan masing-masing sebagai perawat. beban kerja tugas perawat bila di jumlahkan mulai dari tugas pokok, tambahan dan lain di rsi garam kalianget didapatkan sebagian besar juga kurang seperti ditunjukkan pada tabel 4 yang menggambarkan 19 perawat (65,5%) mempunyai kategori beban kerja total kurang. tahap pelaksanaan intervensi seci model’s dibagi menjadi 4 tahap yaitu socialization, externalization, combination dan internalization. berikut hasil intervensi: pelaksanaan intervensi seci model’s dilaksanakan sesuai dengan tahapan: 1) socialization tahap ini melakukan intervensi yaitu: a. dilakukan identifikasi dokumen spo pendokumentasian askep dan komunikasi sbar. spo pendokumentasian askep dan komunikasi efektif sbar belum disusun hanya dimasukkan dalam sak di bagian keperawatan rsi garam kalianget. b. di bentuk tim knowledge management. tim knowledge management di rsi garam kalianget yang bertujuan sebagai pelaksana dalam proses knowledge management. tim dibentuk terdiri dari ketua dan anggota. ketua langsung adalah kabid. keperawatan dan anggotanya adalah para kepala ruangan yang bertanggung jawab akan perawat di masing-masing ruangan. namun pelaksanaannya belum maksimal karena belum disahkan lewat surat 335 peningkatan kinerja pendokumentasian asuhan keperawatan (r. arief santoso, dkk) berbagi pengalaman di komunikasi praktis (communities of practice) tim knowledge management rsi garam kalianget mengadakan forum diskusi yang bertujuan menyusun spo pendokumentasian asuhan keperawatan dan komunikasi efektif sbar. yang dilakukan dari jam 09.00–12.00 wib. hasil dari forum diskusi tersebut dapat dilihat pada lampiran. b. d i l a k u k a n d e s i m i n a s i d a n pendistribusian spo pendokumentasian a s u h a n k e p e r a w a t a n . s p o y a n g telah disusun di desiminasikan dan didistribusikan kepada seluruh perawat di ruangan serta di tempelkan di masing-masing ruangan oleh tim knowledge management rsi garam kalianget. 4) internalization tahap ini dilakukan intervensi yaitu: a. dilakukan percobaan penggunaan s o p. d u a h a r i s e t e l a h s e l u r u h perawat mengerti tentang adanya spo pendokumentasian asuhan keperawatan dan komunikasi efektif sbar oleh tim knowledge management rsi garam kalianget mengumumkan bahwa spo yang telah disusun mulai dilakukan percobaan selama 1 bulan. b. dilakukan monitoring and evaluation yang hasilnya didapatkan pelaksanaan spo tidak semuanya dilaksanakan s e c a r a p e n u h . k a r e n a p e r a w a t menganggap ini hal baru sehingga mereka belum terbiasa serta belum disediakannya format yang mudah untuk mengaplikasikannya. selain pelaksanaan intervensi juga dilakukan penilaian oleh perawat tentang pelaksanaan intervensi komponen seci model’s dapat dilihat sebagai berikut: mean komposit didapat dari penjumlahan total keseluruhan penilaian dibagi dengan jumlah pertanyaannya sesuai dengan komponen yang diukur. selanjutnya ditentukan standar yaitu sangat baik bila mean komposit lebih atau sama dengan 3, baik bila mean komposit 2–2, 9 dan kurang bila mean komposit kurang dari 1–1, 9. seperti yang ditunjukkan pada tabel 5 menggambarkan bahwa hasil intervensi seci model’s di rsi garam kalianget kategori sangat baik pada tahapan internalization yang mencapai mean komposit 3,01. setelah intervensi seci intervensi seci model’s memberikan dampak peningkatan knowledge perawat tentang pendokumentasian asuhan keperawatan dan komunikasi efektif, nampak dalam tabel 6, semula knowledge perawat dengan kategori baik sebesar 37,9% meningkat menjadi 72,4%. sedangkan kategori knowledge kurang menurun sebesar 6,9%. berdasarkan hasil uji paired t-test diperoleh nilai p = 0,0002 (p < α). perbandingan kinerja sebelum dan setelah pelaksanaan intervensi seci model’s pendokumentasian asuhan keperawatan dan komunikasi sbar juga dilihat mulai dari pengkajian, diagnosis, perencanaan, tindakan, evaluasi, dan catatatan keperawatan dapat dilihat pada tabel 7. peningkatan pencapaian setelah intervensi seci model’s juga terdapat pada kinerja pendokumentasian askep di rsi garam kalianget di mana seluruhnya mengalami peningkatan terutama pada tindakan keperawatan yaitu sebesar 20,7%. berdasarkan hasil uji paired t-test yang mengukur perbandingan kinerja sebelum dan setelah intervensi tentang pendokumentasian askep dan komunikasi sbar diperoleh nilai p = 0,004 (p < α). pelaksanaan komunikasi efektif sbar di rsi garam kalianget baru dilaksanakan setelah intervensi seci model’s sehingga kinerja belum mencapai baik, namun dari semua komponen terjadi peningkatan terutama pada assesment yang meningkat sebesar 39,4%, dapat dilihat pada tabel 8. tabel 5. distribusi hasil intervensi seci model’s di rsi garam kalianget no seci model’s mean komposit kategori 1 socialization 2,64 baik 2 externalization 2,76 baik 3 combination 2,59 baik 4 internalization 3,01 sangat baik 336 jurnal ners vol. 8 no. 2 oktober 2013: 330–341 tabel 6. perbandingan knowledge perawat tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar sebelum dan setelah intervensi seci model’s di rsi garam kalianget no. kategori knowledge sebelum setelah keterangan jumlah % jumlah % 1 kurang 5 17.2 3 10.3 menurun 6,9% 2 cukup 13 44.8 5 17.2 menurun 27,6% 3 baik 11 37.9 21 72.4 meningkat 34,5% tabel 7. perbandingan kinerja pendokumentasian askep sebelum dan setelah pelaksanaan intervensi seci model’s di rsi garam kalianget no aspek yang dinilai pencapaian keterangan sebelum (%) setelah (%) 1 pengkajian keperawatan 72,9 82,7 meningkat 9,8% 2 diagnosis keperawatan 68,5 78,4 meningkat 9,9% 3 perencanaan keperawatan 76,0 83,8 meningkat 7,8% 4 tindakan keperawatan 49,0 69,7 meningkat 20,7% 5 evaluasi keperawatan 70,5 76,8 meningkat 6,3% 6 catatan keperawatan 61,5 71,3 meningkat 9,8% tabel 8. perbandingan kinerja komunikasi efektif sbar sebelum dan setelah pelaksanaan intervensi seci model’s di rsi garam kalianget no komponen sbar pencapaian keterangan sebelum (%) setelah (%) 1 situation 0,0 39,2 meningkat 39,2 2 background 0,0 38,0 meningkat 38,0 3 assessment 0,0 39,4 meningkat 39,4 4 recomendation 0,0 28,2 meningkat 28,2 berdasarkan hasil uji paired samples test yang mengukur perbandingan kinerja sebelum dan setelah intervensi tentang komunikasi sbar diperoleh nilai p = 0,001 (p < α). ini berarti pada interval kepercayaan 95%, ada perbedaan kinerja yang signifi kan antara sebelum dan sesudah intervensi. pembahasan knowledge perawat saat ini tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar di rsi garam kalianget didapatkan hampir setengahnya (44,8%) mempunyai kategori cukup. setiap perawat memiliki 6 tingkatan pengetahuan, pada penelitian hanya mengukur 3 tingkatan yaitu tahu (know), memahami (comprehension), dan aplikasi (application). dari tingkatan tahu (know), perawat di rsi garam kalianget sebagian besar sudah tahu tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar mulai dari tujuan dari pengkajian awal, standar pengkajian askep, komponen diagnosa keperawatan, kepanjangan pes, dan kepanjangan sbar. namun ada bagian yang perawat pencapaian tahu masih rendah sehingga hal itu yang membuat pengetahuan perawat tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar dengan kategori cukup. dari data penelitian yang menunjukkan bahwa perawat sebagian besar tidak tahu tentang langkah, faktor yang mempengaruhi dan fungsi dokumentasi keperawatan sehingga hal tersebut bisa 337 peningkatan kinerja pendokumentasian asuhan keperawatan (r. arief santoso, dkk) dikatakan menyebabkan pengetahuan perawat di rsi garam kalianget cukup. padahal diketahui bahwa pendokumentasian asuhan keperawatan dan komunikasi efektif sbar harus diketahui oleh semua perawat, termasuk langkah pertama, fungsi dan faktor yang mempengaruhi pendokumentasian asuhan keperawatan, karena tahu diartikan sebagai mengingat suatu materi yang telah dipelajari sebelumnya termasuk dalam pengetahuan tingkat ini adalah mengingat kembali (recall) terhadap suatu spesifi k terhadap seluruh bahan yang dipelajari atau rangsangan yang telah diterima. oleh sebab itu tingkatan tahu ini adalah merupakan tingkatan pengetahuan yang paling rendah (notoatmodjo, 2005). tingkatan knowledge selanjutnya adalah memahami (comprehension), hasil penelitian menunjukkan bahwa sebagian besar sudah paham tentang pendokumentasian asuhan keperawatan dan komunikasi namun ada sebagian yang belum paham. yang belum dipahami oleh perawat di rsi garam kalianget yaitu perawat belum paham tentang prioritas pengkajian, perawat belum paham tentang perawatan keselamatan pasien dan pemahaman tentang situation, background dan assessment perawat tidak memahami tentang pendokumentasian asuhan keperawatan dan komunikasi sbar berarti belum mampu menjelaskan secara benar tentang apa yang diketahui pada hal ini tentang prioritas pengkajian, keselamatan pasien dan komunikasi efektif sbar sehingga pencapaian kinerja pengkajian keperawatan hanya mencapai 72,9% dan pencapaian kinerja komunikasi efektif sbar belum dilaksanakan. memahami diartikan sebagai suatu kemampuan menjelaskan secara benar tentang objek yang diketahui dan dapat menginterpretasikan materi secara benar (notoatmodjo, 2005). tingkatan selanjutnya adalah aplikasi (application), hasil penelitian menunjukkan bahwa sebagian besar sudah bisa mengaplikasikan konsep pendokumentasian asuhan keperawatan. namun sama hal dengan tingkatan tahu dan memahami, perawat di rsi garam kalianget belum bisa mengaplikasikan tentang pengkajian berdasarkan ana dan hampir seluruhnya belum bisa mengaplikasikan tentang pelaksanaan keselamatan pasien dari aspek komunikasi efektif sbar. hal itu berhubungan dengan pelaksanaan komunikasi efektif sbar belum dimasukkan ke dalam kebijakan rsi garam kalianget, sehingga pengetahuan yang di dapat oleh perawat tidak bisa diaplikasikan karena dari tahu dan paham perawat akan bisa mengaplikasikan suatu konsep yang perawat pelajari. aplikasi diartikan sebagai kemampuan untuk menggunakan materi yang telah dipelajari pada situasi dan kondisi riil atau sebenarnya (notoatmodjo, 2005). proses keperawatan merupakan bagian integral dari praktik keperawatan yang membutuhkan pertimbangan yang matang dalam pengambilan keputusan. pengambilan keputusan ini harus dilandaskan pada pengetahuan dan penerapan ilmu pengetahuan serta prinsip biologis, psikologis, sosial, dan spiritual. langkah dan tahapan pada proses keperawatan meliputi pengkajian, diagnosis keperawatan, perencanaan, implementasi tindakan keperawatan, dan evaluasi (diyanto, 2007). kinerja pendokumentasian asuhan keperawatan dan komunikasi efektif sbar dilihat berdasarkan pencapaian dalam instrumen a dan instrumen penilaian pelaksanaan komunikasi efektif sbar. hasil penelitian menunjukkan bahwa sebagian besar penilaian hasil kinerja pendokumentasian asuhan keperawatan di rsi garam kalianget adalah cukup dan yang baik adalah perencanaan keperawatan yang mencapai 76% serta tindakan keperawatan kurang yang mencapai 49%. sedangkan komunikasi efektif sbar di rsi garam kalianget belum dilaksanakan sehingga pencapaian kinerja mulai dari komponen situation, background, assessment dan recomendation masih 0%. pencapaian kinerja pendokumentasian asuhan keperawatan yang rata-rata sudah cukup disebabkan karena semua item penilaian sudah dilaksanakan. sedangkan pencapaian dari unsur tindakan keperawatan yang kurang disebabkan perawat tidak melakukan sama sekali observasi respons pasien terhadap tindakan keperawatan. selanjutnya yang jarang dilakukan adalah merevisi tindakan berdasarkan hasil evaluasi. secara normatif perawat dalam melakukan pendokumentasian asuhan keperawatan melakukan observasi respons pasien terhadap tindakan karena bertujuan sebagai evaluasi apakah tindakan 338 jurnal ners vol. 8 no. 2 oktober 2013: 330–341 tersebut berhasil apa tidak. hal tersebut akan berdampak pada perawat di rsi garam kalianget dalam melakukan revisi tindakan keperawatan berdasarkan hasil evaluasi yang menurut hasil penelitian menunjukkan jarang dilakukan. tindakan keperawatan merupakan langkah keempat dalam tahap proses keperawatan dengan melaksanakan berbagai strategi keperawatan yang telah direncanakan dalam rencana tindakan keperawatan (tsai, wu, lin, & hsia, 2006). kinerja komunikasi efektif sbar belum ada pencapaian disebabkan karena pelaksanaan komu ni kasi efek tif sba r belum dimasukkan ke dalam kebijakan rsi garam kalianget. sbar merupakan suatu mekanisme yang mudah untuk di ingat dalam kerangka percakapan, terutama yang kritis, membutuhkan perhatian dan tindakan segera dari seorang dokter. hal ini memungkinkan untuk mengklarifikasi informasi apa dan bagaimana yang har us dikomunikasikan antara anggota tim, dapat juga membantu untuk mengembangkan kerja sama tim dan meningkatkan budaya keselamatan pasien (cpsi, 2010). kinerja pendokumentasian askep dan komunikasi efektif sbar juga mempunyai hubungan dengan pengetahuan perawat yang sebagian besar mempunyai kategori cukup. pengetahuan perawat tentang rekam medis yang meliputi aspek hukum rekam medis dan tata cara pengisian dokumentasi asuhan keperawatan pada rekam medis memiliki hubungan dengan kelengkapan pengisian dokumentasi asuhan keperawatan pada rekam medis (ryco, 2012). hasil penelitian menunjukkan knowledge perawat tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar post intervensi seci model’s di rsi garam kalianget tahun 2013 sebagian besar baik yaitu 21 perawat (72,4%). perubahan knowledge perawat yang sebagian besar baik disebabkan karena perawat sudah mulai tahu tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar. dapat dilihat pada tingkatan tahu yang sebagian besar perawat tahu terutama tentang standar pengkajian asuhan keperawatan diikuti sudah mengetahui tentang kepanjangan sbar. dari sebagian besar sudah mengetahui maka perawat akan memahami tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar hal itu sesuai dengan hasil penelitian yang menunjukkan bahwa sebagian besar juga sudah memahami tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar, ditunjukkan tertinggi perawat sudah memahami kriteria standar pelaksanaan dan komponen sbar hampir juga dipahami. setelah tahu dan memahami perawat bisa mengaplikasikan sesuai dengan hasil penelitian yang menunjukkan sebagian besar perawat sudah bisa mengaplikasikan tentang pendokumentasian asuhan keperawatan dan komunikasi efektif sbar, mulai dari menyusun diagnosa keperawatan, kegiatan pendokumentasian askep, cara pendokumentasian askep, komunikasi keselamatan pasien, dan komponen komunikasi efektif sbar. perubahan mulai dari tahu, paham dan aplikasi didapatkan setelah adanya proses intervensi seci model’s karena sesuai dengan tujuan knowledge management yaitu menjaga agar isi dari pengetahuan yang dibawa tetap up to date dan sesuai dengan perubahan kondisi, sehingga menerapkan pengetahuan pada lokasi yang tepat, menerapkan pengetahuan disesuaikan dengan bentuk yang terbaik, menyesuaikan penerapan pengetahuan yang dimiliki dengan pengetahuan pada saat dibutuhkan (setiarso, harjanto, & subagyo, 2009). kinerja pendokumentasian askep post intervensi seci model’s di rsi garam kalianget pencapaian tertinggi adalah pada perencanaan keperawatan yang mencapai 83,8% dan terendah pada aspek tindakan keperawatan, dan pelaksanaan komunikasi efektif sbar di rsi garam kalianget baru dilaksanakan setelah intervensi seci model’s yang membuat pencapaian kinerja mulai dari komponen situation, background, assessment dan recomendation masih di bawah 50% yang berarti masih kurang. kinerja pendokumentasian asuhan keperawatan dan komunikasi efektif sbar setelah intervensi seci model’s terjadi peningkatan hal itu disebabkan karena pengetahuan perawat meningkat di mana hasil penelitian menunjukkan pengetahuan perawat sebagian besar baik yaitu 21 perawat (72,4%). pengetahuan perawat yang baik 339 peningkatan kinerja pendokumentasian asuhan keperawatan (r. arief santoso, dkk) dapat menunjang kepada kinerja individu terutama dalam hal pendokumentasian asuhan keperawatan dan komunikasi efektif sbar. pengetahuan tersebut didapatkan dari pelaksanaan intervensi seci sehingga membuat perawat bisa tahu, paham dan bisa mengaplikasikan. sesuai dengan penelitian yang dilakukan oleh ardika (2012) yang menunjukkan bahwa ada hubungan antara pengetahuan perawat dengan kelengkapan pendokumentasian asuhan keperawatan. menurut kapolmen yang dikutip oleh ilyas (2002), ada empat determinan utama dalam produktivitas organisasi termasuk didalamnya adalah prestasi kerja. faktor determinan tersebut adalah lingkungan, karakteristik organisasi, karakteristik kerja dan karakteristik individu. karakteristik kerja dan karakteristik organisasi akan memengaruhi karakteristik individu seperti imbalan, penetapan tujuan akan meningkatkan motivasi kerja, sedangkan prosedur seleksi tenaga kerja serta latihan dan program pengembangan akan meningkatkan pengetahuan, keterampilan dan kemampuan dari individu. selanjutnya variabel karakteristik kerja yang meliputi penilaian pekerjaan akan meningkatkan motivasi individu untuk mencapai prestasi kerja yang tinggi. selain pengetahuan, faktor motivasi juga mempengaruhi di mana sebagian besar perawat di rsigk mempunyai motivasi yang baik sehingga walaupun hal baru dalam pendokumentasian asuhan keperawatan terutama komunikasi efektif sbar baru diterapkan sudah mempunyai peningkatan pencapaiannya. hal tersebut sesuai dengan pendapat stoner yang dikutip oleh diyanto, (2007), mengemukakan bahwa prestasi individu di samping dipengaruhi oleh motivasi dan pengetahuan juga dipengaruhi oleh faktor persepsi peran yaitu pemahaman individu tentang perilaku apa yang diperlukan untuk mencapai prestasi individu. kemampuan (ability) menunjukkan kemampuan seseorang untuk melakukan pekerjaan dan tugas. sedangkan menurut (notoatmodjo, 2005), ada teori yang mengemukakan tentang beberapa faktor yang memengaruhi kinerja yang disingkat menjadi achieve yang artinya ability (kemampuan pembawaan), capacity (kemampuan yang dapat dikembangkan), help (bantuan untuk terwujudnya kinerja), incentive (insentif material maupun non material), environment (lingkungan tempat kerja karyawan), validity (pedoman atau petunjuk dan uraian kerja), dan evaluation (adanya umpan balik hasil kerja). intervensi seci model’s memberikan dampak peningkatan knowledge perawat tentang pendokumentasian asuhan keperawatan dan komunikasi efektif, nampak bahwa yang semula knowledge perawat dengan kategori baik sebesar 37,9% meningkat menjadi 72,4%. sedangkan kategori knowledge kurang menurun sebesar 6,9%. peningkatan knowledge perawat setelah intervensi seci disebabkan karena salah satu faktor yang mempengaruhi knowledge yaitu adanya fasilitas yaitu forum berbagi pengalaman dalam komunikasi praktis (communities practice) di mana perawat menilai baik pelaksanaan kegiatan tersebut. karena melalui fasilitas berbagi pengalaman dapat meningkatkan tingkatan knowledge perawat. selain itu tingkat pendidikan perawat juga memengaruhi. menurut notoatmodjo (2003), pengetahuan seseorang dapat dipengaruhi oleh beberapa faktor, yaitu: pengalaman, pendidikan, dan fasilitas. pengalaman dapat diperoleh dari pengalaman sendiri maupun pengalaman orang lain. pengalaman yang diperoleh dapat memperluas pengetahuan seseorang. tingkat pendidikan; secara umum, orang yang berpendidikan lebih tinggi akan memiliki pengetahuan yang lebih luas daripada orang yang berpendidikan lebih rendah. fasilitas sebagai sumber informasi yang dapat mempengaruhi pengetahuan seseorang adalah majalah, radio, koran, televisi, buku. peningkatan pencapaian setelah intervensi seci model’s juga terdapat pada kinerja pendokumentasian askep di rsi garam kalianget di mana seluruhnya mengalami peningkatan terutama pada tindakan keperawatan yaitu sebesar 20,7%. pelaksanaan komunikasi efektif sbar di rsi garam kalianget baru dilaksanakan setelah intervensi seci model’s sehingga kinerja belum mencapai baik, namun dari semua komponen terjadi peningkatan terutama pada assesment yang meningkat sebesar 39,4%. perbedaan kinerja yang signifi kan baik kinerja pendokumentasian asuhan keperawatan dan komunikasi efektif sbar di rsi garam kalianget juga tidak lepas dari peningkatan 340 jurnal ners vol. 8 no. 2 oktober 2013: 330–341 knowledge perawat yang menggambarkan bahwa yang semula knowledge perawat dengan kategori baik sebesar 37,9% meningkat menjadi 72,4%. sedangkan kategori knowledge kurang menurun sebesar 6,9%. pengetahuan dapat memengaruhi kinerja karena lewat pengetahuan individu dapat meningkatkan kinerja. dengan meningkatnya pengetahuan maka kemampuannya juga akan meningkat dan akhirnya motivasinya juga akan meningkat. hal tersebut yang menyebabkan peningkatan kinerja pendokumentasian askep dan komunikasi efektif sbar. selain itu perawat mempunyai motivasi karena form isian yang ringkas dan mudah serta 62,1% perawat menilai spo pendokumentasian asuhan keperawatan dan komunikasi efektif sbar mudah dijalankan serta perawat juga menilai sistematika spo pendokumentasian asuhan keperawatan dan komunikasi efektif sbar jelas. menurut davies yang dikutip oleh (anshori, 2005), juga mengatakan bahwa faktor yang memengaruhi pencapaian kinerja adalah faktor kemampuan (ability) dan faktor motivasi (motivation). simpulan dan saran simpulan k n o w l e d g e p e r a w a t t e n t a n g pendok u mentasian asu han keperawatan dan komunikasi efektif sbar mengalami peningkatan setelah pelaksanaan intervensi seci di rsi garam kalianget. perbandingan kinerja pendokumentasian asuhan keperawatan sebelum dan setelah pelaksanaan intervensi seci di rsi garam kalianget yaitu semua komponen mengalami peningkatan terutama pada tindakan keperawatan. sedangkan komunikasi efektif sbar semua komponen t e r j a d i p e n i n g k a t a n t e r u t a m a p a d a assesment. saran perlu d ila k u ka n for u m berbag i pengalaman baik antar perawat atau dengan nara sumber dalam komunikasi praktis secara berkala. setiap forum berbagi pengalaman perlu d ila k u k a n not u len si ya ng bai k. perlu dilak ukan pendok umentasian dan penyimpanan dokumen secara baik mulai dari hasil notulensi sampai dengan konsep yang dikumpulkan. perlu dilakukan supervisi terus menerus terutama pada kelengkapan pengisian format asuhan keperawatan dan komunikasi efektif sbar. perlu pemberian reward dan punishment bagi perawat yang mengisi format asuhan keperawatan dan komunikasi efektif sbar secara lengkap dan bagi yang tidak mengisi secara lengkap. perlu meningkatkan pencapaian kinerja pendokumentasian askep dan komu ni kasi efek tif sba r melalui evaluasi dan monitoring secara berkala. perlu membuat form askep yang ringkas dan jelas dan didukung dengan prosedur yang jelas. perlu dilakukan penelitian lebih lanjut dengan kajian lain tentang pendokumentasian asuhan keperawatan. kepustakaan anshori, 2005. analisis keunggulan bersaing m e l a l u i pe n e r a p a n k n ow l e d g e management dan knowledge-based strategy di surabaya palza hotel. manajemen perhotelan vol. 1, no. 2 september, 39–53. a rsanti, a.t., 2009. hubu ngan a nt ara penetapan tujuan, self-efficacy dan kinerja. jurnal bisnis dan ekonomi (jbe), september vol. 16, no. 2 issn: 1412–3126, 97–110. cpsi, 2010. using sbar for communicate falls risk and management interprofessional rehabilitation teams. toronto: canadian patient safety institute. depkes, r i., 2001. konsep dan proses keperawatan. jakarta: depkes ri. diyanto, y., 2007. analisis faktor-faktor pelaksanaan dokumentasi asuhan keperawatan di rumah sakit umum daerah tugurejo semarang. semarang: tesis program pasca sarjana universitas diponegoro. ilyas, y., 2002. kinerja (teori penilaian dan kinerja). depok: pusat kajian ilmu kesehatan fk m universitas indonesia. kos a si h , 20 07. pe nga r u h k nowle d ge m a n a g e m e n t t e r h a d a p k i n e r j a karyawan studi kasus departement front office surabaya plaza hotel. manajemen perhotelan vol. 3, no. 2, september, 80–88. 341 peningkatan kinerja pendokumentasian asuhan keperawatan (r. arief santoso, dkk) nursalam, & effendi, f., 2008. pendidikan dalam keperawatan. jakarta: salemba medika. nursalam, 2011. manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 3. jakarta: salemba medika. nursalam, 2011. proses dan dokumentasi keperawatan: konsep dan praktek edisi 2. jakarta: salemba medika. notoatmodjo, 2005. metodologi penelitian kesehatan. jakarta: rineka cipta. pandawa, r., 2006. determinan perawat pelaksana dalam pendokumentasian asuhan keperawatan di ruang rawat inap rsud dr. h, chasan boesoirie ternate. jakarta: program pascasarjana fakultas ilmu keperawatan universitas indonesia. rsi garam, kalianget, 2011. laporan d a n evalua si peningk ata n m ut u keperawatan periode juli – september 2011. kalianget sumenep: rsi garam kalianget. ryco, g.a., 2012. hubu nga n a nt a r a pengetahuan perawat tentang rekam medis dengan kelengkapan pengisian catatan keperawatan. jurnal penelitian media medika muda, 1–12. setiarso, b., harjanto, n., & subagyo, h. (2009). penerapan knowledge management pada organisasi. yogyakarta: graha ilmu. setiarso, b., harjanto, n., triyono, & subagyo, h., 20 09. penera pan knowledge m a n a g e m e n t p a d a o r g a n i s a s i . yogyakarta: graha ilmu. tsai, t.h., wu, h. j., lin, m.l., & hsia, l. t., 2006. a framework for designing nu rsi ng k nowledge management system. interdiciplinar y jour nal of infor mat ion , kn owledge, a n d management vol 1. yunika, d.l, 2011. pendekatan knowledge management dalam upaya mencapai competitive advantage. majalah ilmiah informatika vol 2 januari, 41–56. 24 tingkat kepatuhan pasien gagal ginjal kronik dalam pembatasan cairan pada terapi hemodialisa (the compliance chronic renal failure patient on restrictions liquids in hemodialysis therapy) endang sri p ningsih*, agus rachmadi*, hammad* *politeknik kemenkes banjarmasin jl hm cokrokusumo no 3 a kelurahan sei besar banjarbaru kalimantan selatan 70714 e-mail: endangsrinings@yahoo.co.id abstract introduction: nonadherence is a rampant problem among patients undergoing dialysis and can impact multiple aspects of patient care, including medications, and treatment regimens as well as dietary and fl uid restriction. the purpose of this descriptive correlative research, on hemodyalysa patient with chronic renal failure was to know the infl uencing factors of compliance patient to fl uid restriction. method: this study used descriptive correlative design, data was analysed by using distibution frequency and chi square for analysys relation between variable. result: the result revealed there were nor signifi cant statistic difference at p > 0.05 between age, gender, education level, frequency of hemodyalysa and health education from nurse to compliance patient to fl uid restriction (p = 0.647; p = 0.717; p = 0.345; p = 0.774; p = 0.273). discussion: level of patient adherence to therapy not infl uenced by demographi factor but by the quality of interaction health workers and other factors. this study recommended for further analysis of the factors that infl uence the level of compliance of the patient as psychological factors (belieft , motivation), socio-economic, and social support. keywords: compliance, hemodyalysa, chronic renal failure pendahuluan ginjal mempunyai peran yang sangat penting dalam menjaga kesehatan tubuh secara menyeluruh karena ginjal adalah salah satu organ vital dalam tubuh. bila ginjal tidak bekerja sebagai mana mestinya, maka akan timbul masalah yang berkaitan dengan penyakit gagal ginjal kronik (ggk). bila seseorang mengalami penyakit ginjal kronik sampai pada stadium lima, atau dikenal dengan gagal ginjal terminal, di mana laju fi ltrasi glomerolus < 15 ml/ menit, ginjal telah tidak mampu lagi menjalani seluruh fungsinya dengan baik. hingga saat ini terapi yang dibutuhkan untuk mengatasi gagal ginjal terminal tersebut di antaranya dialisis dan transplantasi ginjal (cahayaningsih, 2008). menurut suhardjono di indonesia, berdasarkan pusat data dan informasi perhimpunan rumah sakit seluruh indonesia (pdpersi, 2000) penderita ggk diperkirakan sekitar 50 orang per satu juta penduduk. angka ini tidak mencerminkan keadaan yang sebenarnya. di indonesia saat ini tercatat sekitar 70 ribu penderita ggk memerlukan cuci darah. data perhimpunan nefrologi indonesia (pernefri) menyebutkan, jumlah pasien yang dirawat di rumah sakit dengan perawatan dialisis (cuci darah) sekarang ini berkisar antara 4.000 sampai 5.000 orang setiap tahun. data statistik rumah sakit tahun 2003 menyebutkan jumlah pasien rawat inap dan rawat jalan sekitar 49.203 orang yang sebagian besar memerlukan hemodialisis (pdpersi, 2006). pasien yang sering menjalani hemodialisa memiliki banyak masalah, termasuk retensi garam dan air, retensi fosfat, hiperparatiroidisme s e k u n d e r, h i p e r t e n s i , a n e m i a k r o n i s , hiperlipidemia, dan penyakit jantung. untuk mengatasi semua masalah ini, pasien mungkin memerlukan pembatasan cairan, pengikat fosfat, vitamin d persiapan, agen calcimimetic, obat antihipertensi, agen hipoglikemik, eritropoetin, suplemen zat besi, dan berbagai obat lain (kemmerer, 2007). tingkat kepatuhan pasien gagal ginjal kronik (endang sri p ningsih) 25 pengelolaan masalah kesehatan pada pasien yang menjalani hemodialisa cukup rumit dan sangat dipengaruhi oleh gaya hidup pasien. ketidakpatuhan merupakan masalah yang sering dialami oleh pasien hemodialisis dan dapat berdampak terhadap berbagai aspek perawatan pasien, termasuk obat-obatan, dan rejimen pengobatan serta pembatasan makanan dan cairan. secara keseluruhan, telah diperkirakan bahwa sekitar 50% dari pasien hemodialisa tidak mematuhi setidaknya bagian dari rejimen dialisis mereka (kutner, 2001 dalam kemmerer 2007). pasien yang menjalani hemodialisa mengalami berbagai masalah yang timbul akibat tidak berfungsinya ginjal. kelemahan fi sik yang dirasakan seperti mual, muntah, nyeri, lemah otot, oedema adalah sebagian dari manisfestasi klinik dari pasien yang menjalani hemodialisis (stuart dan sundeen, 1998). oleh karena itu pasien yang menjalani hemodialisis harus menjaga berat badan idealnya agar tidak terjadi kelebihan cairan dan mengakibatkan oedema. berat badan ideal dan manajemen cairan bila dialisis pasien adekuat, maka pasien harus dapat mencapai berat badan ideal tanpa gejalagejala, tidak ada tanda-tanda oedema dan pertambahan berat badannya masih rasional. berat badan ideal adalah berat badan kering di mana kondisi pasien normotensif, tidak mengalami oedema atau dehidrasi. berat badan ideal ini adalah berat badan yang harus dicapai pasien di akhir dialisis. berat badan di bawah berat badan ideal akan muncul gejala dehidrasi dan atau deplesi volume misalnya hipotensi, kram, hipotensi postural atau pusing. berat badan dia atas berat badan ideal akan muncul tanda dan gejala kelebihan cairan misalnya hipertensi, oedema, sesak nafas. tanda-tanda ini harusnya tidak muncul bila berat badan pasien hanya naik satu sampai dua kilogram di atas berat badan idealnya. dengan berat badan ideal bila pasien mengalami akumulasi cairan 1–2 kg selama periode intradialistik, pasien tidak akan mengalami kelebihan cairan yang berlebihan (cahayaningsih, 2008). hasil studi pendahuluan yang dilakukan peneliti di ruang hemodialisa rsud ratu zaleha martapura pada 2 tahun terakhir. pada tahun 2009 jumlah pasien yang menjalani terapi hemodialisa sebanyak 465 orang, sedangkan pada tahun 2010 sebanyak 562 orang. data tersebut dapat disimpulkan bahwa semakin meningkatnya pasien yang mengalami penyakit ginjal yaitu sebanyak 20,86%. observasi yang peneliti lakukan terhadap 10 orang pasien yang menjalani terapi hemodialisa, didapatkan 7 di antaranya mengalami peningkatan berat badan > 3 kg dan mengatakan belum dapat membatasi masukan cairan setelah mendapatkan terapi hemodialisa. tujuan umum penelitian ini untuk mengetahui faktor-faktor yang memengaruhi tingkat kepatuhan dalam pembatasan cairan pada pasien ggk yang menjalani terapi hemodialisa di rsud ratu zaleha martapura. bahan dan metode penelitian ini menggunakan desain penelitian deskriptif korelatif yang bertujuan untuk mendeskripsikan faktor-faktor yang memengaruhi tingkat kepatuhan dalam pembatasan cairan pada pasien ggk yang menjalani terapi hemodialisa di rsud ratu zaleha martapura tahun 2011. populasi dalam penelitian ini adalah seluruh pasien yang menjalani terapi hemodialisa di rsud ratu zalecha martapura. pada bulan mei dan juni tahun 2011. metode sampling yang digunakan pada penelitian ini adalah sampling jenuh yaitu teknik penentuan sampel dengan cara pengambilan semua anggota populasi (total sampling) yang dilakukan terhadap pasien yang akan menjalani terapi hemodialisa di rsud ratu zalecha martapura sebanyak 39 orang. instrumen yang digunakan dalam penelitian ini adalah berupa kuesioner yang dibuat oleh peneliti, memuat pertanyaan yang mengacu pada faktor-faktor yang memengaruhi tingkat kepatuhan yaitu usia, jenis kelamin, tingkat pendidikan, frekuensi terapi hemodialisa, dan pendidikan kesehatan oleh perawat. penelitian ini menggunakan analisis data univariat dan bivariat. analisis univariat dilakukan untuk menggambarkan masingmasing variabel dengan menggunakan distribusi frekuensi. analisis terhadap tingkat kepatuhan dalam pembatasan cairan dilakukan dengan jurnal ners vol. 7 no. 1 april 2012: 24–30 26 menggabungkan nilai kuesioner dengan observasi fi sik (berat badan, oedema, sesak nafas dan bunyi paru). analisis bivariat dilakukan untuk melihat hubungan korelasi antara variabel dependen dan variabel independen serta untuk menguji hipotesa penelitian. analisis bivariat yang digunakan adalah uji chi square dengan derajat kepercayaan α = 0,05. hasil hasil analisis korelasi hubungan antara umur dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,647 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara kedua variabel tersebut (tabel 1). hasil analisis korelasi hubungan antara jenis kelamin dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,717 dengan nilai α = 0,05. hasil tersebut dapat disimpulkan bahwa tidak ada pengaruh yang signifi kan antara jenis kelamin dengan tingkat kepatuhan (tabel 2). hasil analisis korelasi hubungan antara tingkat pendidikan dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,345 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara tingkat pendidikan dengan tingkat kepatuhan pasien ggk dalam pembatasan cairan (tabel 3). hasil analisis korelasi hubungan antara frekuensi menjalani terapi hemodialisa dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,774 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara frekuensi terapi dengan tingkat kepatuhan pasien ggk dalam pembatasan cairan (tabel 4). hasil analisis korelasi hubungan antara pendidikan kesehatan dari perawat tentang pembatasan cairan dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,273 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara pendidikan kesehatan yang dilakukan oleh perawat dengan tingkat kepatuhan pasien ggk dalam pembatasan cairan (tabel 5). pembahasan hasil penelitian ini didapatkan bahwa sebagian besar responden berusia antara 40 sampai 60 tahun sebesar 16 orang (41,02%). tabel 1. tingkat kepatuhan dalam pembatasan cairan pada pasien ggk yang menjalani terapi hemodialisa berdasarkan umur umur tingkat kepatuhan pkurang cukup baik total n % n % n % n % < 40 2 15,4 10 76,9 1 7,7 13 100 0,647 40–60 2 12,5 11 68,8 3 18,8 16 100 > 60 3 30 5 50 2 20 10 100 total 7 17,9 26 66,7 6 15,4 39 100 tabel 2. tingkat kepatuhan dalam pembatasan cairan pada pasien ggk yang menjalani terapi hemodialisa berdasarkan jenis kelamin jenis kelamin tingkat kepatuhan pkurang cukup baik total n % n % n % n % perempuan 2 12,5 11 68,8 3 18,8 16 100 0,717 laki-laki 5 21,7 15 65,2 3 13 23 100 total 7 17,9 26 66,7 6 15,4 39 100 tingkat kepatuhan pasien gagal ginjal kronik (endang sri p ningsih) 27 guyton (2006) mengatakan seiring bertambahnya usia juga akan diikuti oleh penurunan fungsi ginjal. hal tersebut terjadi terutama karena pada usia lebih dari 40 tahun akan terjadi proses hilangnya beberapa nefron. perkiraan penurunan fungsi ginjal berdasarkan pertambahan umur tiap dekade adalah sekitar 10 ml/menit/1,73 m2. berdasarkan perkiraan tersebut, jika telah mencapai usia dekade keempat, dapat diperkirakan telah terjadi kerusakan ringan, yaitu dengan nilai gfr 60–89 ml/menit/1,73 m2, di mana artinya sama dengan telah terjadi penurunan fungsi ginjal sekitar 10% dari kemampuan ginjal. semakin meningkatnya usia, dan ditambah dengan penyakit kronis seperti tekanan darah tinggi (hipertensi) atau diabetes, ginjal cenderung akan menjadi rusak dan tidak dapat dipulihkan kembali. penelitian terhadap 39 responden ggk yang menjalani terapi hemodialisa bulan juni 58,97% berjenis kelamin laki-laki. hal ini sesuai dengan hasil penelitian oleh umri (2011) di rsud dr. pringadi medan meyatakan bahwa proporsi penderita ggk tertinggi pada jenis kelamin laki-laki (54,7%). perkembangan penyakit ginjal pada wanita lebih lambat disebabkan oleh pola makan, perbedaan struktur ginjal, respons hemodinamik terhadap stres dan hormon seks. beberapa studi menyatakan bahwa hormon seks wanita seperti estradiol berperan menghambat progresitas penyakit ginjal (silbiger dan neugarten, 2008). penelitian terhadap 39 responden ggk ini yang menjalani terapi hemodialisa bulan juni memiliki tingkat pendidikan yang rendah yaitu 18 responden (46,16%). tingkat pendidikan tabel 3. tingkat kepatuhan dalam pembatasan cairan pada pasien ggk yang menjalani terapi hemodialisa berdasarkan tingkat pendidikan tingkat pendidikan tingkat kepatuhan pkurang cukup baik total n % n % n % n % rendah 2 11,1 13 72,2 3 16,7 18 100 0,345 menengah 1 9,1 8 72,7 2 18,2 11 100 tinggi 4 40 5 50 1 10 10 100 total 7 17,9 26 66,7 6 15,4 39 100 tabel 4. tingkat kepatuhan dalam pembatasan cairan pada pasien ggk yang menjalani terapi hemodialisa berdasarkan frekuensi terapi hemodialisa frekwensi terapi tingkat kepatuhan pkurang cukup baik total n % n % n % n % 1×/minggu 0 0 1 100 0 0 1 100 0,774 2–3×/minggu 7 18,4 25 65,8 6 15,8 38 100 total 7 17,9 26 66,7 6 6 39 100 tabel 5. tingkat kepatuhan dalam pembatasan cairan pada pasien ggk yang menjalani terapi hemodialisa berdasarkan pendidikan kesehatan dari perawat tentang pembatasan cairan penjelasan perawat tingkat kepatuhan pkurang cukup baik total n % n % n % n % tidak 0 0 3 60 2 40 5 100 0,273 ya 7 20,6 22 64,7 5 14,7 34 100 total 7 17,9 25 64,1 7 17,9 39 100 jurnal ners vol. 7 no. 1 april 2012: 24–30 28 akan berkontribusi terhadap domain kognitif seseorang. domain kognitif penting dalam membentuk tindakan seseorang termasuk dalam perilaku kesehatan. status pengetahuan seseorang tentang penyakit ggk akan memengaruhi perilakunya dalam memilih dan memutuskan pola hidup yang sehat dan memutuskan terhadap terapi. hasil penelitian didapatkan bahwa frekuensi terapi hemodialisa terbanyak adalah pada 2–3 kali/minggu yaitu 38 orang (97,50%). awal menjalani terapi hemodialisa tentunya memerlukan adaptasi bagi pasien ggk, pada kondisi ini dibutuhkan penyesuaian diri yang lama terhadap penerimaan tindakan hemodialisa. begitu juga halnya dengan frekuensi atau dosis hemodialisa tentunya akan memengaruhi tingkat kepatuhan pasien dalam menjalani terapi hemodialisa. faktor terapi seharusnya dapat memberikan kontribusi yang positif dalam meningkatkan kepatuhan pasien. durasi, frekuensi terapi, dan efek samping pengobatan mungkin akan memengaruhi keyakinan pasien tentang efektivitas terapi tersebut (jin, et al., 2008). hasil penelitian ini diketahui bahwa pasien ggk yang menjalani terapi hemodialisa sebagian besar yaitu 34 orang (87,2%) telah mendapatkan penjelasan tentang pembatasan cairan oleh perawat. hal ini telah membuktikan bahwa para perawat di ruang hemodialisa rsud ratu zalecha martapura sudah optimal dalam menjalankan peran edukatornya. niven (2002) menyatakan bahwa kualitas interaksi antara profesional kesehatan dengan pasien merupakan bagian yang penting dalam memengaruhi tingkat kepatuhan. hasil penelitian yang didapat ternyata kebanyakan responden cukup patuh terhadap pembatasan cairan yaitu sebesar 66,6%. hal ini terlihat dari kebanyakan responden sudah mendapatkan penjelasan dari perawat kesehatan (87,2%). tingginya tingkat kepatuhan tersebut disebabkan oleh tingginya keyakinan terhadap keberhasilan terapi pembatasan cairan dalam mengatasi masalahnya. banyak faktor yang memengaruhi tingkat kepatuhan pasien terhadap terapi di anataranya yaitu faktor demographic (usia, gender, ethnic tingkat pendidikan, dll), faktor psikologik (kepercayaan, motivasi, hubungan dengan perawat) dan faktor terapi (jin, et al., 2008). hasil uji statitistik tentang hubungan antara umur dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,647 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara kedua variabel tersebut. hal ini dapat disebabkan bahwa faktor umum bukan merupakan faktor dominan yang memengaruhi tingkat kepatuhan pada pasien hemodialisa, seperti halnya penelitian yang dilakukan oleh hernitati (2010) di rsud arifi n achmad pekanbaru, bahwa usia tidak memiliki pengaruh yang signifi kan terhadap tingkat kepatuhan dalam mengurangi asupan pasien ggk. hasil uji statistik tentang hubungan antara jenis kelamin dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,717 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifikan antara jenis kelamin dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa. hal ini sesuai dengan pernyataan jing jin, et al. (2008) bahwa beberapa penelitian membuktikan bahwa tidak ada hubungan antara jenis kelamin dengan tingkat kepatuhan pasien. tidak adanya pengaruh pada kedua variabel tersebut dapat disebabkan oleh banyaknya faktor-faktor internal pasien yang lain dan dapat memengaruhi tingkat kepatuhan seperti pengetahuan, perilaku, motivasi, kepercayaan, persepsi dan harapan (kammerer, et al., 2007). hasil analisis statistik tentang tingkat pendidikan terhadap tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,345 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara tingkat pendidikan dengan tingkat kepatuhan pasien ggk dalam pembatasan cairan. kammerer, et al. (2007) menyatakan bahwa banyak bukti menunjukkan bahwa tingkat pendidikan pasien memainkan peran dalam kepatuhan, tetapi pemahaman pasien tentang instruksi pengobatan jauh lebih penting daripada tingkat pendidikan pasien. penelitian telah menunjukkan bahwa peningkatan pengetahuan tingkat kepatuhan pasien gagal ginjal kronik (endang sri p ningsih) 29 tidak selalu meningkatkan kepatuhan pasien untuk pengobatan yang diresepkan, yang paling penting, pasien harus memiliki sumber daya dan motivasi untuk mematuhi protokol pengobatan. hasil analisis korelasi hubungan antara frekuensi menjalani terapi hemodialisa dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,774 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara frekuensi terapi dengan tingkat kepatuhan pasien ggk dalam pembatasan cairan. tingkat kepatuhan akan menurun bersamaan dengan penambahan dosis terapi, seperti halnya sebuah meta analisis menemukan bahwa ada perbedaan yang signifi kan dalam tingkat kepatuhan antara pasien yang memakai obat antihipertensi sekali sehari dan dua kali sehari (92,1% dan 88,9%) dari hasil tersebut dinyatakan terjadi penurunan tingkat kepatuhan seiring dengan penambahan frekuensi dosis obat (iskedjian, et al., 2002). hasil analisis korelasi hubungan antara pendidikan kesehatan dari perawat tentang pembatasan cairan dengan tingkat kepatuhan pasien ggk yang menjalani terapi hemodialisa didapatkan nilai p = 0,273 dengan nilai α = 0,05, dari hasil tersebut dapat disimpulkan tidak ada pengaruh yang signifi kan antara pendidikan kesehatan yang dilakukan oleh perawat dengan tingkat kepatuhan pasien gagal ggk dalam pembatasan cairan. hasil penelitian ini tidak sesuai dengan penelitian yang dilakukan oleh hernitati (2010) di rsud arifin achmad pekanbaru, bahwa keterlibatan tenaga kesehatan memiliki pengaruh yang signifi kan terhadap tingkat kepatuhan dalam mengurangi asupan pasien ggk. tidak adanya pengaruh pendidikan kesehatan oleh perawat terhadap tingkat kepatuhan pasien ini dapat disebabkan karena pada variabel pendidikan kesehatan ini hanya menggali tentang ada tidaknya pendidikan kesehatan oleh perawat tanpa adanya penggalian tentang pengetahuan atau pemahaman pasien ggk tentang terapi pembatasan cairan serta tidak menilai interaksi antara perawat dialisis dengan pasien. krueger, et al. (2005) menyatakan bahwa salah satu faktor penting dalam memengaruhi tingkat kepatuhan adalah interaksi atau hubungan antara petugas dianalisis dengan pasien. simpulan dan saran simpulan tidak ada pengaruh antara faktor demografi pasien (umur, jenis kelamin, tingkat pendidikan), frekwensi terapi dan pendidikan kesehatan oleh perawat dengan tingkat kepatuhan pasien ggk dalam pembatasan cairan. saran penelitian ini merekomendasikan untuk menganalisis lebih lanjut terhadap faktor yang memengaruhi tingkat kepatuhan yaitu faktor psikologi pasien (kepercayaan, motivasi), sosial ekonomi, dan dukungan sosial. kepustakaan cahayaningsih, n., 2009. hemodialisis (cuci darah) panduan praktis gagal ginjal. yogyakarta: mirta cendika press . guyton, a.c. and hall j.e., 2006. textbook o f m e d i c a l p h y s i o l o g y . 11 t h e d . philadelphia: elsevier inc. h e r n i t a t i . 2 0 1 0 . f a k t o r f a k t o r y a n g m e m e n g a r u h i k e p a t u h a n p a s i e n dalam mengurangi asupan cairan pada penderita gagal ginjal kronik yang menjalani hemodialisa. jurnal keperawatan profesional indonesia, 2(2), 37–49. iskedjian, m., einarson, t.r., mackeigan, l. d., et al., 2002. relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis. clin ther.;24:302–16.[pubmed]. (online), (http://www.ncbi.nlm.nih.gov/pubmed., diakses tanggal 9 september 2011, jam 14.00 wita). jin, j., edward, g.s., sen vho., and chuen li, s., 2008. factors affecting therapeutic compliance: a review from the patient’s perspective. (online), (http://www. ncbi.nlm.nih.gov/pmc. diakses tanggal 9 september 2011, jam 09.00 wita). kammerer, j., garry, g., hartigan, m., et al., 2007. adherence in patients jurnal ners vol. 7 no. 1 april 2012: 24–30 30 on dialysis: strategies for success. nephrology nursing journal. (online), (http://fi ndarticles.com., diakses tanggal 9 september 2011, jam 09.00 wita). krueger, k.p., berger, b.a., dan felkey, b., 2005 medication adherence and persistence: a comprehensive review. advances in therapy, 22(4), 313–356. niven, n., 2002. psikologi kesehatan. edisi kedua. jakarta: egc. silbiger, s. dan neugarten, j., 2008. gender and human chronic renal disease, (online), (http://www.bat.uoi.gr., diakses tanggal 8 september 2011, jam 14.00 wita). umri, m., 2011. karakteristik penderita gagal ginjal kronik yang dirawat inap di rsu dr. pringadi medan tahun 2010, (online), (http//:wwwrepository.usu. ac.id, diakses tanggal 8 september 2011, jam 13.00). pusat data dan informasi, 2000. pengobatan gagal ginjal kronik, betapa mahalnya. (online), (http://www.pdpersi.co.id, diakses. tanggal 9 september 2011, pukul 10.00 wita). pdpersi. 2006. pasien cuci darah di indonesia capai 5.000 orang/tahun. (online), (http://www.pdpersi.co.id, diakses tanggal 9 september 2011, jam 10.00 wita). vol 8 no 2 oktober 2013.indd 271 model peningkatan kinerja perawat unit gawat darurat (ugd) berdasarkan asosiasi karakteristik individu, karakteristik organisasi dan karakteristik pekerjaan (model of emergency department nurse performance improvement based on association of individual characteristic, organization characteristic and job characteristic) maria margaretha bogar*, nursalam**, yulis setiya dewi** *rsud dr. t. c. hillers maumere, jln. wirklau maumere flores nusa tenggara timur **fakultas keperawatan universitas airlangga surabaya e-mail: margarethbogar@yahoo.co.id abstrak pendahuluan: asuhan keperawatan merupakan bagian integral dari pelayanan kesehatan dan memiliki peran penting dalam manajemen pasien dengan kondisi darurat. tujuan dari penelitian ini adalah mengembangkan model peningkatan kinerja perawat berdasarkan asosiasi karakteristik individu, karakteristik organisasi, dan karakteristik pekerjaan di unit gawat darurat rsud dr t.c. hillers maumere. metode: jenis penelitian adalah survei eksplanatif dengan pendekatan cross sectional selama juli-agustus 2012. responden dalam penelitian ini adalah 22 orang perawat dan 44 pasien yang didapatkan dengan teknik purposive sampling. data dianalisis dengan partial least square test dan nilai t signifi kan > 1,64 (alpha 10%). hasil: hasil penelitian menunjukkan bahwa karakteristik individu berpengaruh terhadap kinerja perawat (t = 7,59), karakteristik organisasi berpengaruh terhadap kinerja perawat (t = 2,03) dan karakteristik pekerjaan tidak berpengaruh terhadap kinerja perawat (t= 0,88). kinerja perawat berpengaruh terhadap kepuasan pasien (t = 6,54), tetapi kepuasan perawat tidak memiliki pengaruh terhadap kinerja perawat (t = 1,31), dan kepuasan perawat tidak menimbulkan dampak yang baik pada kepuasan pasien (t = 0,94). diskusi: karakteristik individu yang memengaruhi kinerja perawat dalam asuhan keperawatan adalah kemampuan dan keterampilan, pengalaman, usia, jenis kelamin, sikap dan motivasi. karakteristik organisasi yang mempengaruhi kinerja perawat adalah imbalan, sementara karakteristik pekerjaan yang meliputi desain pekerjaan dan umpan balik tidak mempengaruhi kinerja perawat dalam asuhan keperawatan. kinerja perawat dipengaruhi kepuasan pasien, tetapi kepuasan perawat tidak mempengaruhi kepuasan pasien dan kinerja perawat. kata kunci: kinerja keperawatan, karakteristik individu, karakteristik organisasi, karakteristik pekerjaan abstract introduction: nursing care is integral part of health care and having important role in management of patient with emergency condition. the purpose of this research was to develop nurse performance improvement model based on individual, organization and job characteristics association in emergency department of rsud dr tc hillers maumere. method: this was an explanative survey by cross sectional approach held on july -august 2012. respondents in this study were 22 nurses and 44 patients were obtained by purposive sampling technique. data were analyzed by partial least square test and signifi cant t value > 1.64 (alpha 10%). result: results showed that individual characteristic had effect on nurse performance (t = 7.59), organization characteristic had effect on nurse performance (t = 2 .03) a n d jo b c h a r a c t e r i s t i c d i d n’t h a v e e f f e c t o n n u r s e p e r f o r m a n c e (t = 0 . 8 8). n u r s e performance had ef fect on patient satisfaction (t = 6.54) but nurse satisfaction didn’t ha ve ef fect on nurse perfor mance (t = 1.31), and nurse satisfaction didn’t ha ve ef fect either on patient satisfaction (t = 0.94). discussion: this research concluded that individual characteristics which infl uence nurse performance in nursing care were ability and skill, experience, age, sex, attitude and motivation. organization characteristic that infl uence nurse performance was reward while job characteristic that include job design and feedback didn’t infl uence nurse performance in nursing care. nurse performance infl uenced patient satisfaction but nurse satisfaction didn’t infl uence patient satisfaction and nurse performance. keywords: nursing performance, individual characteristic, organization characteristic, job characteristic pendahuluan pelayanan keperawatan mer upakan bagian integral dari pelayanan kesehatan memegang peranan dalam penanggulangan pasien dengan kondisi gawat darurat. perawat merupakan tenaga kesehatan yang pertama kali berhadapan dengan pasien sangat menentukan keberhasilan dalam penanganan pasien selanjutnya (depkes, 2006). pasien sebagai pengguna jasa pelayanan keperawatan mempunyai keinginan dan harapan akan pelayanan yang ber mut u. upaya u nt u k 272 jurnal ners vol. 8 no. 2 oktober 2013: 271– 282 memenuhi keinginan dan harapan akan pelayanan kesehatan yang lebih baik, tenaga keperawatan mempunyai peranan penting dengan menunjukkan kinerja yang baik sebagai wujud dari kualitas pelayanan (nursalam, 2011). rumah sakit umum daerah (rsud) dr. t. c. hillers maumere merupakan rumah sakit rujukan untuk masyarakat flores dan lembata. oleh karena itu rumah sakit selalu ingin memperbaiki mutu pelayanan terutama pelayanan gawat darurat sebagai pintu masuk ke rumah sakit. berdasarkan hasil observasi oleh peneliti, pelaksanaan asuhan keperawatan pada unit gawat darurat rsud dr. t.c. hillers maumere hanya berkisar sekitar 50% saja yang lengkap dan sampai saat ini masih ada keluhan pengguna jasa pelayanan tentang pelayanan yang diberikan oleh perawat antara lain penanganan terlambat, perawat kurang ramah, lamanya waktu tunggu untuk mendapat pelayanan. keluhan ini kadang langsung diungkapkan di tempat pelayanan keperawatan maupun melalui media masa atau call center rumah sakit. hasil survei pengaduan masyarakat yang diselenggarakan oleh rsud dr. t. c. hillers maumere melalui pemerintah kabupaten sikka bekerja sama dengan kementerian pendayagunaan aparatur negara dan support for good governance gesellschaft für technische zusammenarbeit (sfgg-gtz) pada tanggal 15–30 juni 2009 tentang pelayanan kesehatan di rsud dr. t.c. hillers maumere dengan jumlah responden 3308 orang didapatkan pendapat bahwa dokter & perawat di ugd judes/tidak ramah sebesar 63,5%, dokter & perawat di ugd lamban dalam menangani pasien sebesar 68,5%, petugas yang menerima pasien di ugd kurang sebesar 64,2% (laporan tim survei kepuasan pelanggan rsud dr. t.c. hillers, 2009). hal ini menunjukkan kinerja perawat dalam memberikan asuhan keperawatan masih belum optimal. kinerja atau prestasi kerja seseorang dipengaruhi oleh variabel individu, variabel psikologis, variabel organisasi (gibson, 1987) atau dipengaruhi oleh karakteristik individu, karakteristik organisasi dan karakteristik pekerjaan (kopelman, 1985) namun hingga saat ini belum dilakukan penelitian terhadap variabel tersebut untuk mengukur kinerja perawat. pelaksanaan evaluasi terhadap kinerja perawat di indonesia mencakup penilaian dp3 (daftar penilaian prestasi pegawai) dan penilaian jabatan fungsional perawat dan angka kreditnya. penilaian ini baru mengukur kuantitas kegiatan, belum menggambarkan penilaian terhadap mutu asuhan keperawatan (arwani & supriyatno, 2006). globalisasi memberikan dampak yang sangat besar dalam pelayanan kesehatan sehingga perawat harus dapat bersaing secara profesional. perawat di indonesia, jumlahnya paling banyak bila dibandingkan dengan tenaga kesehatan lainnya, sehingga perannya menjadi penentu dalam meningkatkan mutu pelayanan baik di puskesmas maupun di rumah sakit. tenaga keperawatan mempunyai kontribusi besar dalam mencapai kinerja puskesmas dan rumah sakit. oleh karena itu mutu tenaga perawat perlu ditingkatkan profesionalismenya secara berkesinambungan (kemenkes, 2012). p r o g r a m p r i o r i t a s p e l a y a n a n keperawatan antara lain pengembangan sistem pemberian pelayanan keperawatan profesional, pengembangan manajemen kinerja klinik bagi perawat dan bidan, penguatan emergency nursing terkait dengan bencana dan pengembangan jenjang karir perawat rumah sakit (kemenkes, 2012). untuk itu diperlukan tenaga perawat yang profesional yang dapat memberikan pelayanan keperawatan yang efektif, efi sien dan bermutu dengan kinerja yang baik. di indonesia, sebagian besar atau 80% perawat yang bekerja di rumah sakit berpendidikan diploma iii, diploma iv 0,5%, sarjana strata satu keperawatan 1%, ners 11%. sedangkan perawat yang berpendidikan sekolah perawat kesehatan (spk) sebanyak 7% (kemenkes, 2012). unit gawat darurat (ugd) rsud dr. t.c. hillers maumere mempunyai tenaga perawat dan bidan sebanyak 24 orang dengan spesifi kasi pendidikan spk sebanyak 4 orang, program pendidikan bidan (p2b) 2 orang dan pendidikan diploma iii keperawatan sebanyak 18 orang. rata-rata kunjungan pasien per hari ke unit gawat darurat sebanyak 60 orang (laporan tahunan 273 model peningkatan kinerja perawat unit gawat darurat (maria margaretha bogar, dkk.) rsud dr. t.c. hillers, 2011). ditinjau dari aspek ketenagaan dengan jumlah pasien maka jumlah perawat di ugd masih kurang sehingga akan memengaruhi kinerja perawat achi r yani (2007) mengat akan bahwa perawat yang bekerja lembur terus-menerus atau bekerja tanpa dukungan yang memadai cenderung untuk banyak tidak masuk kerja dan kondisi kesehatan yang buruk. pe nel it ia n ya ng d i la k u k a n oleh ade nasution (2009) di rumah sakit umum dr. pirngadi medan dengan judul pengaruh k a r a k t e r ist i k i nd iv idu d a n psi kolog is terhadap kinerja perawat dalam kelengkapan rekam medis di ruang rawat inap rumah sakit dengan jenis penelitian explanatory m e n u n j u k k a n h a s i l b a h w a v a r i a b e l pengetahuan dan motivasi ber pengar uh signifi kan terhadap kinerja perawat dalam kelengkapan rekam medis, sedangkan variabel umur, jenis kelamin, lama kerja dan sikap tidak berpengaruh. menurut gibson (1987), bahwa terdapat variabel yang memengaruhi kinerja yaitu, variabel individu, psikologis dan organisasi, di mana variabel individu adalah variabel yang paling menentukan. kopel ma n (1985) menyebut ka n ba hwa faktor yang mempengaruhi kinerja adalah: karakteristik individu, karakteristik organisasi dan karakteristik pekerjaan juga dipengaruhi oleh faktor lingkungan. unit gawat dar urat rsud dr. t.c. h i l le r s m a u m e r e s a n g a t d i h a r a pk a n memberikan pelayanan medis dan keperawatan yang bermutu sesuai standar pelayanan untuk mencapai tujuan dengan cara yang cepat, tepat dan cermat, karena karakteristik pasien yang dirawat adalah pasien yang tiba-tiba berada dalam keadaan gawat atau akan menjadi gawat atau terancam nyawanya atau anggota badannya akan menjadi cacat bila tidak mendapat pertolongan secepatnya. oleh karena itu perawat dalam bekerja hendaknya menggunakan nilai-nilai keperawatan yang mendasari sikap dan perilaku (arwani & supriyatno, 2006). pelayanan keperawatan yang diberikan perawat mempunyai ar ti penting dalam menent u ka n bai k bu r u k nya pelaya na n kesehatan yang diberikan, karena mereka adalah ujung tombak dalam pemberian pelayanan keperawat an di r uang ugd sehingga perawat dituntut untuk memiliki kinerja yang baik dan akan berpengaruh pada kepuasan pasien dan kepuasan kerja perawat. untuk meningkatkan atau mempertahankan kinerja perawat perlu dianalisis terlebih dahulu faktor-faktor dominan yang ber pengaruh terhadap kinerja. seh i ngga t uju a n u mu m d a r ipad a penelitian adalah mengembangkan model peningkatan kinerja perawat unit gawat darurat berdasarkan asosiasi karakteristik individu, karakteristik organisasi dan karakteristik pekerjaan. bahan dan metode penelitian ini menggunakan metode penelitian sur vey dengan desain cross sectional dan sifat penelitian yakni penelitian penjelasan (explanatory research). penelitian dilaksanakan pada bulan juli 2012agustus 2012. populasi dalam penelitian ini adalah seluruh perawat, pasien dan keluarga pasien pada unit gawat darurat rumah sakit umum daerah dr. t. c. hillers maumere. sampel penelitian adalah unit gawat darurat rumah sakit umum daerah dr. t. c. hillers maumere dengan responden adalah perawat pelaksana pada unit gawat darurat serta pasien yang dirawat atau keluarga pasien pada unit gawat darurat rsud dr. t.c. hillers dengan kriteria inklusi untuk perawat adalah perawat yang bertugas pada unit gawat darurat, pengalaman kerja > 1 tahun; sedangkan kriteria inklusi untuk pasien dan keluarga pasien adalah pasien dengan lama perawatan lebih dari 2 jam. keluarga pasien yang merawat pasien tidak sadar atau pasien anak (0–15 tahun). besar sampel perawat sebanyak 22 orang sedangkan besar sampel pasien sebanyak 44 orang. teknik pengambilan sampel yang dilakukan untuk perawat adalah total populasi sedangkan teknik pengambilan sampel pada pasien menggunakan purposive sampling. teknik analisis yang digunakan adalah model persamaan struktural berbasis besar sampel perawat sebanyak 22 orang sedangkan besar sampel pasien sebanyak 44 orang. teknik 274 jurnal ners vol. 8 no. 2 oktober 2013: 271– 282 pengambilan sampel yang dilakukan untuk perawat adalah total populasi sedangkan teknik pengambilan sampel pada pasien menggunakan purposive sampling. teknik analisis yang dig u nakan adalah model persamaan struktural berbasis variance atau component based, yang terkenal partial least square (pls). hasil hasil analisis multivariat dengan partial least square (pls) dilakukan dalam dua tahap. tahap pertama adalah melakukan pengujian measurement model. tahap ini pada hakikatnya adalah menguji validitas dan reliabilitas dari masing-masing indikator apakah merupakan bagian dari konstrak atau variabel penelitian. pembacaan validitas dan reliabilitas konstrak adalah dari nilai faktor loading. indikator dikatakan valid dan reliabel apabila mempunyai nilai faktor loading lebih besar atau sama dengan 0,5 atau mempunyai nilai t > 1,64. tahap kedua adalah melakukan pengujian structural model yang bertujuan untuk mengetahui ada tidaknya pengaruh antar variabel. pengujian dilakukan dengan menggunakan uji t. berdasarkan hasil uji validitas konstrak, didapatkan bahwa indikator pembent uk karakteristik individu yang kuat (nilai faktor loading > 0,5) meliputi kemampuan dan keterampilan, lama kerja, pengalaman, dan umur. sedangkan indikator jenis kelamin, sikap, dan motivasi mempunyai kekuatan pengaruh yang lemah terhadap karakteristik individu pekerjaan organisasi gambar 1. uji measurement model tabel 1. analisis uji validitas konstrak konstrak indikator coefi sien path uji-t terhadap kinerja keterangan karakteristik individu kemampuan & ketrampilan 0,78 16,64 signifi kan lama kerja ugd 0,83 15,45 signifi kan pengalaman 0,50 6,76 signifi kan umur 0,53 4,52 signifi kan jenis kelamin 0,39 6,74 signifi kan sikap 0,27 2,38 signifi kan motivasi -0,38 1,97 signifi kan karakteristik organisasi kepemimpinan 0,31 1,50 tidak signifi kan imbalan 0,99 16,46 signifi kan karakteristik pekerjaan desain pekerjaan 0,51 2,35 signifi kan umpan balik 0,90 4,23 signifi kan 275 model peningkatan kinerja perawat unit gawat darurat (maria margaretha bogar, dkk.) individu. terdapat 2 indikator karakteristik organisasi, namun yang mempunyai nilai faktor loading yang kuat hanya indikator imbalan. indikator desain pekerjaan dan umpan balik sama-sama mempunyai pengaruh yang kuat terhadap karakteristik pekerjaan. setiap indikator pada karakteristik individu, organisasi, dan pekerjaan dihubungkan dengan kinerja menggunakan uji t, dan didapatkan hasil yang signifi kan, kecuali pada indikator kepemimpinan dalam karakteristik organisasi. hasil uji struktural model yang bertujuan untuk mengetahui hubungan antar variabel didapatkan bahwa karakteristik individu dan karakteristik organisasi mempunyai pengaruh yang signifi kan terhadap kinerja perawat. namun, karakteristik pekerjaan tidak menunjukkan pengaruh yang signifi kan terhadap kinerja perawat. kinerja perawat mempunyai pengaruh yang signifi kan terhadap kepuasan pasien, tetapi kepuasan perawat tidak mempunyai pengaruh yang signifi kan terhadap kinerja dan kepuasan pasien. pembahasan karakteristik individu terdiri dari kemampuan dan keterampilan, pengalaman, umur, jenis kelamin, sikap dan motivasi. hasil penelitian pada tabel 2 menunjukkan bahwa karakteristik individu berpengaruh secara signifi kan terhadap kinerja perawat dalam asuhan keperawatan. kemampuan yaitu sifat bawaan lahir atau dipelajari yang memungkinkan seseorang menyelesaikan p eke r ja a n nya at au ke m a mpu a n ya it u sifat bawaan lahir atau dipelajari yang memungkinkan seseorang melakukan sesuatu yang bersifat mental atau fi sik (gibson, 1987). menurut robbins (2001) dalam ardana, mujiati dan sriathi (2009) kemampuan adalah suatu kapasitas yang dimiliki seorang individu untuk mengerjakan berbagai tugas suatu pekerjaan. individu organisasi pekerjaan gambar 2. uji struktural model tabel 2 hasil uji hipotesis penelitian model peningkatan kinerja perawat berdasarkan asosiasi karakteristik individu, karaktersitik organisasi dan karakteristik pekerjaan di unit gawat darurat rsud dr. t.c. hillers maumere juli – agustus 2012 hubungan antar variabel coefi sien path uji-t (t standar 1,64) keterangan karakteristik individu terhadap kinerja 0,56 7,59 signifi kan karakteristik organisasi terhadap kinerja 0,22 2,03 signifi kan karakteristik pekerjaan terhadap kinerja 0,05 0,88 tidak signifi kan kinerja terhadap kepuasan pasien 0,25 6,54 signifi kan puas perawat terhadap kinerja 0,02 1,31 tidak signifi kan puas perawat terhadap kepuasan pasien -0,07 0,94 tidak signifi kan 276 jurnal ners vol. 8 no. 2 oktober 2013: 271– 282 sedangkan keterampilan adalah kecakapan yang berhubungan dengan tugas yang dimiliki dan dipergunakan oleh seseorang pada waktu yang tepat (gibson, 1986). instalasi rawat darurat adalah suatu tempat/ unit di rumah sakit yang memiliki tim kerja dengan kemampuan khusus dan peralatan yang memberikan pelayanan pasien gawat darurat dan merupakan bagian dari rangkaian upaya penanggulangan pasien gawat darurat yang terorganisir (depkes, 2004). berdasarkan data perawat yang bertugas di unit gawat darurat yang telah mengikuti pelatihan penanganan-penanganan gawat darurat hanya sebanyak 3 orang sehingga kemampuan dan keterampilan perawat untuk melaksanakan asuhan keperawatan gawat darurat masih kurang sehingga perlu pelatihan penanganan penderita gawat darurat bagi perawat yang bertugas di unit gawat darurat karena tidak semua perawat mempunyai pengalaman menangani pasien gawat darurat. keterampilan merupakan salah satu faktor yang mempengaruhi produktivitas kerja. pada aspek tertentu apabila pegawai semakin terampil, maka akan lebih mampu bekerja serta menggunakan fasilitas kerja dengan baik. kemampuan intelektual berperan besar dalam pekerjaan yang rumit, kemampuan fi sik hanya menguras kapabilitas fisik. kinerja pegawai dapat ditingkatkan apabila terdapat kesesuaian yang cukup signifikan antara kemampuan dengan jabatannya. demikian sebaliknya, apabila terdapat kesenjangan antara keduanya maka kinerja akan rendah dan cenderung pegawai tersebut akan gagal (sedar mayanti, 2009). oleh karena it u perawat yang bertugas di unit gawat darurat perlu dibekali dengan pengetahuan khusus untuk penanganan pasien gawat dar urat. pengetahuan tersebut dapat diperoleh melalui pendidikan formal d iv keperawatan gawat darurat atau melalui pendidikan non formal seperti pelatihan penanganan pasien gawat darurat (ppgd) sehingga dapat meningkatkan kemampuan dan keterampilan perawat unit gawat darurat. meningkatnya kemampuan dan keterampilan perawat akan berpengaruh terhadap peningkatan kinerja perawat dalam asuhan keperawatan. pe nd apat siag ia n (20 0 4) ba hwa pengalaman kerja menunjukkan berapa lama agar supaya pegawai bekerja dengan baik. swasto (1995) yang dikutip oleh tarigan (2007) mengungkapkan bahwa pengalaman kerja meliputi banyaknya jenis pekerjaan atau jabatan yang pernah diduduki oleh seseorang dan lamanya bekerja pada masing-masing pekerjaan atau jabatan tersebut. semakin banyak aktivitas yang dilakukan dan semakin lama waktunya, maka pemahaman pegawai tersebut akan semakin meningkat terhadap prinsip, nilai-nilai dan tujuan yang dianut organisasi. nimsar (1989) yang dikutip oleh tarigan (2007) menyatakan pengalaman kerja merupakan salah satu faktor individu yang berhubungan dengan perilaku dan persepsi individu, misalnya seseorang yang telah bekerja 15 tahun lebih lama, akan memandang situasi sungguh berbeda dengan yang sedikit pengalaman. hal ini sesuai dengan hasil penelitian bahwa sebagian besar perawat dengan lama bekerja di unit gawat darurat berkisar 1–5 tahun sehingga pengalaman untuk melaksanakan asuhan keperawatan unit gawat darurat masih kurang meskipun mempunyai pengalaman merawat pasien gawat di ruangan lain seperti rawat inap karena asuhan keperawatan di ruangan lain berbeda dengan asuhan keperawatan pasien unit gawat darurat. umur berkaitan erat dengan tingkat kedewasa a n at au mat u r it as ka r yawa n. kedewasaan adalah tingkat kedewasaan tek nis dalam melaksanakan t ugas-t ugas maupun kedewasaan psikologis. umumnya kinerja personil meningkat sejalan dengan peningkatan usia dan pekerja. semakin lanjut usia seseorang semakin meningkat pula kedewasaan teknisnya, demikian pula psikologis serta menunjukkan kematangan jiwa. usia yang semakin meningkat akan meningkat pula kebijaksanaan kemampuan seseorang dalam mengambil keput usan, berpikir rasional, mengendalikan emosi, dan bertoleransi terhadap pandangan orang lain, sehingga berpengaruh terhadap peningkatan motivasinya (siagian, 2004),. teori tersebut mungkin bermakna untuk pekerjaan lain tetapi tidak bermakna untuk 277 model peningkatan kinerja perawat unit gawat darurat (maria margaretha bogar, dkk.) kinerja perawat dalam asuhan keperawatan karena asuhan keperawatan merupakan tugas pokok dari seseorang yang berprofesi sebagai seorang perawat. oleh karena itu setiap orang sejak berprofesi sebagai seorang perawat dalam memberikan pelayanan keperawatan harus menggunakan proses keperawatan sebagai standar praktek keperawatan. shye dalam illyas (1999) mengemukakan bahwa tidak ada perbedaan produktivitas kerja antara perawat wanita dan perawat pria. walaupun demikian jenis kelamin perlu diperhatikan proporsinya untuk unit gawat darurat karena sebagian besar tenaga kesehatan berjenis kelamin wanita dan sebagian kecil berjenis kelamin pria. setiap profesi perawat tidak membedakan jenis kelamin, dalam memberikan pelayanan keperawatan kepada pasien selalu mengg unakan pendekatan proses keperawatan sehingga diasumsikan bahwa bukan perbedaan jenis kelamin itu sendiri yang menyebabkan perbedaan kinerja, tetapi berbagai faktor berkaitan dengan jenis kelamin misalnya kehamilan karena dilihat dari usia sebagian besar perawat perempuan unit gawat darurat rsud dr. t.c. hillers maumere termasuk kategori usia reproduksi, belum tersedianya tenaga transportasi pasien dari unit gawat darurat ke ruangan dan kondisi pasien yang dihadapi seperti amuk sehingga membutuhkan tenaga perawat laki-laki lebih banyak dibandingkan perawat perempuan untuk unit gawat darurat. sikap (attitude) adalah kesiapsiagaan mental, yang dipelajari dan diorganisasi melalu i pe ngala ma n , d a n mempu nyai pengaruh tertentu atas cara tanggap seseorang terhadap orang lain, objek dan situasi yang berhubungan dengannya (gibson, 1986). sedangkan menurut notoatmodjo (2010) sikap adalah respons tertutup sesorang terhadap stimulus atau objek tertentu, yang sudah melibatkan faktor pendapat dan emosi yang bersangkutan (senang-tidak senang, setujutidak setuju, baik-tidak baik, dan sebagainya menur ut gibson (1986) komponen yang menentukan sikap adalah afeksi, kognisi dan perilaku dan selanjutnya sikap menentukan afek, kognisi dan perilaku. hasil penelitian didapatkan sebagian besar perawat dengan sikap baik tetapi kinerja kurang dalam asu han keperawat an karena komponen perilaku dari suatu sikap berhubungan dengan kecenderungan seseorang untuk bertindak terhadap seseorang atau sesuatu dengan cara yang ramah, hangat, agresif, bermusuhan, apat is at au denga n sesu at u ca ra lai n. sikap merupakan faktor penentu perilaku, karena sikap berhubungan dengan persepsi, kepribadian dan motivasi. belum ada reward dan punishment yang jelas dalam pelaksanaan asuhan keperawatan sehingga berpengaruh terhadap sikap dan motivasi perawat yang tercermin dalam perilaku perawat untuk melaksanakan asuhan keperawatan. reward dan punishment yang jelas akan meningkatkan sikap dan motivasi perawat sehingga akan berpengaruh terhadap peningkatan kinerja perawat dalam asuhan keperawatan. ma slow (1943) d ala m ha sibu a n (2008), dengan teorinya yang terkenal adalah hierarki kebut uhan, mengatakan bahwa individu mempunyai lima kebutuhan yang tersusun dalam suatu hierarki dan berawal dari yang paling dasar. kelima kebutuhan individu tersebut adalah kebutuhan fi siologis ( physiological needs), kebutuhan rasa aman (safet y needs), kebutuhan sosial (social needs), kebutuhan penghargaan atau prestasi (esteem needs) dan kebutuhan aktualisasi diri (self actualization). setiap orang mempunyai kebutuhan yang berbeda-beda sehingga untuk memulai dan mengarahkan perilaku sebagai wujud dari motivasi pun berbeda-beda. menurut maslow, individu akan termotivasi untuk memenuhi kebutuhan apa saja yang paling kuat baginya pada suatu saat tertentu. kuatnya suatu kebutuhan tergantung pada situasi yang sedang berjalan dan pengalaman individu. dikatakan bahwa timbulnya perilaku seseorang pada saat tertentu ditentukan oleh kebutuhan yang memiliki kekuatan yang tinggi maka penting bagi setiap manager untuk memiliki pengertian tentang kebutuhan-kebutuhan yang dirasakan penting bagi bawahan. hasil penelitian menunjukkan bahwa karakteristik organisasi berpengaruh signifi kan terhad ap k i ner ja asu ha n keperawat a n. karakteristik organisasi dalam penelitian ini adalah kepemimpinan dan imbalan, namun 278 jurnal ners vol. 8 no. 2 oktober 2013: 271– 282 pada waktu uji structural model penelitian ke p e m i mpi n a n t id a k t e r m a su k d ala m uji tersebut karena pada tahap pengujian measurement model untuk menguji validitas dan reliabilitas konstrak dari masing-masing indikator ter nyata kepemimpinan bukan merupakan bagian dari konstrak dan tidak signifi kan (tabel 1). kepemimpinan adalah suatu upaya penggunaan jenis pengaruh bukan paksaan (concoersive) untuk memotivasi orang-orang mencapai tujuan tertentu. kepemimpinan adalah upaya memengaruhi kegiatan pengikut melalui proses komunikasi untuk mencapai t ujuan ter tent u gibson (1986). seorang pem i mpi n d i ha r apk a n d apat ber per a n sebagai pemberi arah (direction setter), agen perubahan, pembicara (spokesperson) dan pembina (coach) (ardana et.al, 2009). kepemimpinan pada penelitian ini bukan bagian dari konstrak disebabkan penerapan p e r a n ke p e m i mpi n a n t id a k m a k si m a l karena keterbatasan waktu dengan berbagai tugas lainnya sehingga pemimpin kurang memberikan motivasi dan pengarahan untuk memperbaiki atau meningkatkan prestasi kerja untuk mencapai tujuan organisasi. imbalan mer upakan konstrak dari karakteristik organisasi dalam penelitian ini. pendapat siagian (2004) bahwa imbalan erat kaitannya dengan prestasi kerja seorang karyawan. imbalan merupakan salah satu faktor eksternal yang mempengaruhi motivasi seseorang, di samping faktor ekster nal lainnya, seperti jenis dan sifat pekerjaan, kelompok kerja di mana seseorang bergabung dalam organisasi tempat bekerja dan situasi lingkungan pada umumnya. masalah imbalan merupakan masalah yang sering dialami rumah sakit terutama dalam hal pembagian jasa. setiap karyawan merasa bekerja maksimal untuk mencapai tujuan organisasi. oleh karena itu perlu remunerasi yang adil sesuai dengan beban kerja dan prestasi kerja masing-masing karyawan. dengan demikian maka setiap karyawan termotivasi untuk meningkatkan prestasi kerja. h a s i l p e n el i t i a n p a d a t a b el 2 me nu nju k k a n k a r a k t e r ist i k p eke r ja a n tidak ber pengar u h sig nif i kan terhadap kinerja perawat dalam asuhan keperawatan. karakteristik dalam penelitian terdiri dari desain pekerjaan dan umpan balik. gibson (1987) ber pendapat salah satu faktor yang cukup berpengaruh cukup signifi kan terhadap terwujudnya efektivitas dan kesehatan suatu organisasi adalah desain pekerjaan. pekerjaan yang didesain dengan baik akan dapat meningkatkan motivasi, produktivitas dan kepuasan kerja. desain pekerjaan menguraikan cakupan, kedalaman, dan t ujuan dar i setiap peker jaan yang membedakan antara pekerjaan yang satu dengan pekerjaan lainnya. tujuan pekerjaan dilaksanakan melalui analisis kerja, di mana para manajer menguraikan pekerjaan sesuai dengan aktivitas yang dituntut agar membuah kan hasil. perawat unit gawat darurat telah mempunyai pembagian tugas yang jelas namun dalam pelaksanaan sistem pekerjaan kurang didesain dengan baik karena keterbatasan tenaga sehingga hampir semua pekerjaan dilaksanakan oleh perawat. pekerjaan perawat yang merupakan tugas pokok dalam pelayanan keperawatan adalah memberikan asuhan keperawatan menggunakan pendekatan proses keperawatan dengan mengacu pada standar praktek keperawatan. apabila dalam pelaksanaan pelayanan keperawatan kepada pasien semua pekerjaan dibebankan pada perawat maka sebagian pekerjaan perawat akan menyimpang dari tugas pokok perawat sehingga akan berpengaruh terhadap kinerja dalam asuhan keperawatan. desain pekerjaan perlu disesuaikan dengan latar belakang pendidikan dan profesi yang dimiliki sesorang sehingga akan berdampak pada kinerja kerja yang dihasilkan. umpan balik yaitu suatu kondisi di mana seorang pegawai dapat menerima informasi mengenai seberapa efektif ia melaksanakan pekerjaan nya atau sampai sejauh mana pegawai memperoleh infor masi tentang pekerjaanya. mathis dan jackson (2001) dikutip oleh tarigan (2007) mengungkapkan bahwa umpan balik ( feedback) merupakan informasi yang diterima tenaga kerja mengenai baik atau buruknya pekerjaan yang telah mereka lakukan. 279 model peningkatan kinerja perawat unit gawat darurat (maria margaretha bogar, dkk.) pel a k s a n a a n u m p a n b a l i k y a ng diberikan kepada perawat di unit gawat d a r u r at sela m a i n i b elu m me nca k up pelaksanaan asuhan keperawatan sehingga perawat belu m mengetahui k iner janya. super visi terhadap pelaksanaan asuhan keperawatan perlu dilakukan setiap bulan sehingga perawat dapat mengetahui efektivitas kinerja asuhan keperawatan yang telah dilaksanakan dan sumbangannya terhadap tingkat pengetahuannya akan pekerjaan. adanya supervisi akan menjadikan perawat menget ahui sejau h mana k i ner ja yang telah dilakukan dan mendorongnya untuk meningkatkan kinerjanya. h a s i l p e n el i t i a n p a d a t a b el 2 menunjukkan pengaruh signifikan kinerja terhadap kepuasan pasien. kinerja karyawan (prestasi kerja) adalah hasil kerja secara kualitas dan kuantitas yang dicapai oleh seseorang karyawan dalam melaksanakan tugasnya sesuai dengan tanggung jawab yang diberikan kepadanya (mangkunegara, 2010). kepuasan pasien adalah tingkat kepuasan terhadap kualitas pelayanan yang diterimanya sesuai atau melebihi standar. kepuasan merupakan perasaan senang seseorang yang berasal dari perbandingan antar kesenangan terhadap aktivitas dan suatu produk dan harapannya (nursalam, 2008). kepuasan pasien menjadi bagian integral dan menyeluruh dari kegiatan jaminan mutu layanan kesehatan. pengukuran tingkat kepuasan pasien harus menjadi kegiatan yang tidak dapat dipisahkan dari pengukuran mutu layanan kesehatan (imbalo, 2007). evaluasi kinerja merupakan sarana untuk memperbaiki mereka yang tidak melakukan tugasnya dengan baik di dalam organisasi. ba nya k orga n isasi ber usa ha mencapai sasaran suatu kedudukan yang terbaik dan terpercaya dalam bidangnya. dalam menilai kualitas pelayanan keperawatan kepada pasien digunakan standar asuhan keperawatan yang merupakan pedoman bagi perawat dalam melakukan asuhan keperawatan. unit gawat darurat (ugd) adalah unit pelayanan rumah sakit yang memberikan pelayanan per tama pada pasien dengan ancaman kematian dan kecacatan secara terpadu dengan melibatkan berbagai multi disiplin. pelayanan keperawat an gawat darurat meliputi pelayanan keperawatan yang ditujukan kepada pasien gawat darurat yaitu pasien yang tiba-tiba berada dalam keadaan gawat atau akan menjadi gawat dan terancam nyawanya/anggota badannya (akan menjadi cacat) bila tidak mendapat pertolongan secara tepat dan tepat. hasil penelitian menunjukkan kinerja perawat k urang tetapi kepuasan pasien baik. hal ini disebabkan karena rsud dr. t.c.hillers maumere mer upakan r umah sakit dengan dokter ahli paling lengkap dan merupakan rumah sakit rujukan sedaratan flores dan lembata. pasien yang berkunjung paling banyak adalah pasien jamkesmas sehingga tuntutan akan pelayanan tidak begitu tinggi. dalam melaksanakan asuhan keperawatan, perawat lebih memprioritaskan tindakan dibanding aspek lainnya sehingga ketika pasien datang dan segera dilakukan tindakan maka pasien akan merasa puas. h a si l p e n el it i a n p a d a ta b el 2 menunjukkan tidak ada pengaruh signifi kan kepuasan perawat dengan kinerja perawat dalam asuhan keperawatan. salah sat u masalah yang sering diperdebatkan dan berlawanan dalam penelitian kepuasan kerja yaitu hubungan dengan prestasi kerja. terdapat tiga pandangan yang diajukan: (1) kepuasan menimbulkan prestasi; (2) prestasi menimbulkan kepuasan; (3) adanya unsur imbalan tetapi tidak ada hubungan yang k uat. kepuasan men i mbul kan prest asi dan prestasi menimbulkan kepuasan tidak mendapat dukungan kuat dari riset. tinjauan ulang dari 20 penelitian yang menyangkut hubungan antara prestasi kerja dan kepuasan menunjukkan tidak ada hubungan yang erat antara kedua variabel ini. bukti-bukti ini agak meyakinkan karena seorang yang merasa puas tidak perlu harus seorang yang berprestasi tinggi. usaha manajerial untuk membuat setiap orang puas tidak akan menghasilkan produktivitas yang tinggi. demikian juga asumsi bahwa karyawan yang menunjukkan prestasi tinggi cenderung merasa puas, tidak di dukung dengan bukti yang dapat diandalkan (gibson, 1986). 280 jurnal ners vol. 8 no. 2 oktober 2013: 271– 282 cormick dan ilgen (1980) menyatakan kepuasan kerja merupakan sikap seseorang terhadap pekerjaanya. dengan kata lain, kepuasan kerja merupakan respons afektif seseorang terhadap pekerjaan. pandangan tentang kepuasaan ker ja adalah bahwa individu menghitung sejauh mana pekerjaan itu menghasilkan hasil bernilai. kenyataan menunjuk kan bahwa orang mau bekerja bukan hanya mencari dan mendapatkan upah saja (unsur ekonomis), akan tetapi dengan bekerja dia mengharapkan akan mendapatkan kepuasan kerja (anoraga, 2006). pendapat tersebut diatas menunjukkan ba hwa se se or a ng ya ng b eke r ja a k a n mempunyai kepuasan kerja karena pekerjaan itu bernilai bagi dirinya. kepuasan kerja tidak berpengaruh kepada prestasi kerja karena prestasi kerja dipengar uhi oleh berbagai macam faktor seperti karakteristik individu dan karakteristik organisasi. h a s i l p e n el i t i a n p a d a t a b el 2 menunjukkan tidak ada pengaruh signifi kan antara kepuasaan perawat terhadap kepuasan pasien. kepuasan adalah suatu perasaan menyenangkan merupakan hasil dari persepsi i ndividu d ala m rang ka menyelesai kan tugas atau memenuhi kebutuhannya untuk memperoleh nilai-nilai kerja yang penting bagi dirinya (wijono, 2010). sedangkan kotler (20 04) d ala m nu rsala m (2011) mengat akan kepuasan adalah perasaan senang atau kecewa seseorang yang muncul setelah membandingkan antar persepsi atau kesannya terhadap kinerja atau hasil suatu produk dan harapan-harapannya. kepuasan adalah perasaan senang seseorang yang berasal dari perbandingan antar kesenangan terhadap aktivitas dan suatu produk dengan harapannya. ke pu a sa n ke r ja a d ala h ke a d a a n emosional yang menyenangkan atau sikap umum terhadap perbedaan penghargaan yang diterima dan yang seharusnya diterima serta terhadap faktor faktor pekerjaan, penyesuaian diri dan hubungan sosial individu di luar kerja (gito, 1997). sedangkan menurut cue dan ginarkis (1990) menyatakan bahwa kepuasan kerja adalah hal penting dalam teori dan praktek karena mempengaruhi kapasitas kerja agar menghasilkan kinerja yang efi sien dan dapat memenuhi pekerjaan dengan sukses. ke pu a sa n pa sien a d ala h t i ng k at kepu asan terhad ap k u alit as pelaya nan yang diter imanya sesuai atau melebihi standar. perawat dalam memberikan asuhan keperawatan tidak terlepas dari sikap dan perilaku dalam berkomunikasi dengan pasien yang dapat memengaruhi kepuasan pasien, meskipun sarana dan prasarana pelayanan sering dijadikan ukuran mutu oleh pelanggan namun ukuran utama penilaian tetap sikap dan perilaku pelayanan yang ditampilkan oleh petugas. kepu asa n perawat d a n kepu asa n pasien mempunyai suatu kesamaan dalam konsep kepuasan. namun dalam memberikan pernyataan kepuasan berbeda antara perawat dan pasien. perawat sebagai pemberi jasa pelayanan atau pemberi asuhan keperawatan kepada pasien sedangkan pasien adalah penerima jasa pelayanan keperawatan. kepuasan pasien adalah kepuasan terhadap pelayanan yang diberikan oleh perawat, sedang kepuasan perawat adalah kepuasan terhadap pekerjaan yang dilakukan yaitu sebagai pemberi asuhan keperawatan, sehingga tidak ada hubungan antara kepuasan perawat dengan kepuasan pasien. hasil penelitian juga membu k tikan besar nya koefisien estimate dari kepuasan perawat terhadap kepuasan pasien adalah bertanda negatif artinya apabila semakin ditingkatkan kepuasan perawat maka semakin kecil kepuasan pasien. dan sebaliknya semakin rendah kepuasan perawat maka semakin tinggi kepuasan pasien. model peningkatan kinerja perawat d a l a m a s u h a n ke p e r aw a t a n d i s u s u n berdasarkan kajian teoritis, analisis multivariat dengan partial least square (pls) dan analisis kondisi faktual deskriptif dan inferensial. maka model yang mengacu pada kebutuhan dan harapan perawat yang mengarah pada kemampuan dan keunggulan bersaing rumah sakit (competitive advantages). secara umum rekomendasi model peningkatan kinerja perawat dalam asuhan keperawatan sebagai berikut: 281 model peningkatan kinerja perawat unit gawat darurat (maria margaretha bogar, dkk.) kinerja perawat dipengar uhi oleh karakteristik individu dan karakteristik organisasi. karakteristik individu terdiri dari kemampuan dan keterampilan, pengalaman, umur, jenis kelamin, sikap dan motivasi, sedangkan karakteristik organisasi adalah imbalan, sehingga upaya untuk meningkatkan kinerja perawat dalam asuhan keperawatan s eb a i k nya me mp e r t i mb a ng k a n fa k t or kemampuan dan keterampilan, pengalaman, umur, jenis kelamin, sikap dan motivasi serta imbalan. kinerja perawat juga dapat ditingkatkan melalui pendidikan dan pelatihan penanganan pasien gawat darurat untuk perawat yang bertugas di unit gawat darurat, pengalaman perlu diper timbangkan dengan lamanya bekerja di unit gawat darurat, jenis kelamin perlu diperhitungkan proporsinya antara tenaga perawat laki-laki dan perempuan, sebaiknya tenaga perawat laki-laki lebih banyak dari tenaga perawat perempuan. sikap dan motivasi perawat untuk meningkatkan kinerja perlu didukung dengan reward dan punishment yang jelas serta remunerasi sesuai dengan pekerjaan atau profesi yang dimiliki; adanya kebijakan rumah sakit yang mendukung kemandirian profesi perawat dalam melaksanakan asuhan keperawatan serta adanya supervisi yang berkelanjutan yang dilakukan oleh manager keperawatan, tim kendali mutu rumah sakit dan komite keperawatan ser ta selalu ada follow up, sosialisasi dan review untuk persamaan persepsi perawat dalam pelaksanaan asuhan keperawatan yang dilakukan oleh pihak rumah sakit. simpulan dan saran simpulan model peningkatan kinerja perawat unit gawat darurat disusun dengan prinsip berdasarkan analisis hasil uji jalur penelitian, analisis realita atau kondisi faktual analisis deskriptif, sintesis dari hasil analisis diskriptif dan jalur, kemudian dikembangkan model yang mengacu pada kebutuhan dan harapan pemberi jasa pelayanan (perawat) ser ta harapan pengguna jasa pelayanan (pasien) yang mengarah pada keunggulan bersaing rumah sakit (competitive advantages). saran pengembangan model peningkatan kinerja perawat dapat dilakukan oleh institusi dengan merencanakan pendidikan dan pelatihan penanganan pasien gawat darurat bagi perawat yang bertugas di unit gawat; memberikan reward dan punishment yang jelas; melakukan remunerasi serta melakukan supervisi setiap bulan untuk mengevaluasi dan menilai pelaksanaan asuhan keperawatan. p e r a w a t d a p a t m e n i n g k a t k a n pengetahuan dalam melaksanakan asuhan ke pe r awat a n d apat d i la k u k a n de nga n membaca literatur yang terbar u tentang asuhan keperawatan atau mengikuti seminar tentang asuhan keperawatan; membangkitkan kembali motivasi untuk melaksanakan asuhan keperawatan karena merupakan standar dari profesi keperawatan. penelitian lebih lanjut dapat dilakukan denga n mengg u na k a n semu a va r iabel karakteristik individu, karakteristik organisasi, karakteristik psikologis dan karakteristik peker jaan yang mempengar u hi k iner ja perawat dalam asuhan keperawatan dan dapat dilakukan pada perawat unit lain atau pun pada tenaga non keperawatan lingkup rumah sakit. kepustakaan anoraga, p. 2006. psikologi kerja. jakarta : rineka cipta ardana, k., mujiati n., sriathi a. 2009. perilaku keorganisasian, edisi 2. yokyakarta: graha ilmu, hal. 9–164 arwani & supriyatno h. 2006. manajemen bangsal. jakarta: egc, hal. 124–129 depkes ri. 2006. pedoman pelayanan gawat daruratdi rumah sakit. jakarta : dirjen yanmed, hal. 1–22 gibson j. 1986. organizations behavior structure processes. fifth edition. plano texas : business publications, inc., hal. 51–215 gibson j. 1987. organisasi, perilaku, struktur, proces. jakarta: erlangga. halaman 49198 282 jurnal ners vol. 8 no. 2 oktober 2013: 271– 282 hasibuan, m. 2008. organisasi & motivasi, dasar peningkatan produktivitas, edisi revisi. jakarta: bumi aksara, hal. 92– 126 ilyas, y. 1999. kinerja. teori, penialian dan penelitian. depok: fakultas kesehatan masyarakat, universitas indonesia imbalo. 2007. jaminan mutu la yanan kesehatan. jakarta: egc, hal. 143– 156 kemenkes ri. 2011. standar pelayanan keperawatan gawat darurat di rumah sakit. jakar ta: dirjen bina upaya kesehatan, hal. 1–18 kemenkes ri. 2012. perawat mendominasi tenaga kesehatan. jakarta: dirjen bina upaya kesehatan kopelman, r .1985. managing productivity in organization, a practical people oriented perspective. singapore : mc.graw hill mangkunegara, a. 2010. evaluasi kinerja sdm. bandung: refi ka aditama, hal. 9–29 nasution, a. 2009. pengaruh karakteristik individu dan psikologis terhadap kinerja perawat dalam kelengkapan rekam medis di ruang rawat inap rumah sakit umum dr. pirngadi m e d a n. te sis mag ist e r. me d a n: universitas sumatera utara notoat modjo, s. 2010. ilm u pe rila k u kesehatan. jakarta: rineka cipta, hal. 72–82 nursalam. 2008. konsep dan penerapan m e t o d o l o g i p e n e l i t i a n i l m u keperawatan .jakarta: salemba medika, hal. 77–185 nursalam. 2011. manajemen keperawatan. aplikasi dalam praktek keperawatan profesional, edisi 3. jakarta: salemba medika, hal. 287–339 robbins, s.& coulter, m. (2004). manajemen. edisi bahasa indonesia. jakarta: pt. indeks rumah sakit umum dr. t. c. hillers maumere. 2009. laporan tim survei kepuasan pelanggan rsud dr. t.c.hillers rumah sakit umum dr. t. c. hillers maumere. 2011. laporan tahunan rsud dr. t. c. hillers sedarmayanti. 2009. sumber daya manusia dan produktivitas kerja. bandung: mandar maju, hal. 21–78 siagia n, s. 20 04. teori motiva si dan aplikasinya. jakarta: bina aksara tarigan, a. 2007. pengaruh karakteristik individu, pekerjaan dan organiasi terhadap kinerjka pegawai pada badan kepegawaian negara kantor regional ii (bk n-k a nr eg iii) band ung, tesis magister. surabaya: universitas airlangga wijono, s. 2010. psikologi indust ri & organisasi: dalam suatu bidang gerak psikologi sumber daya manusia. jakarta: kencana, hal. 59–106 vol 8 no 1 april 2013.indd 64 pengembangan tindakan pencegahan infeksi nosokomial oleh perawat di rumah sakit berbasis health belief model (development of nosocomial infection prevention measured by nurses at hospital based on health belief model) djaafar nurseha* * poltekkes manado jurusan keperawatan e-mail: nur_dj@ymail.com abstrak pendahuluan: infeksi nosokomial didefi nisikan sebagai infeksi yang berkembang selama tinggal di rumah sakit. semua pasien memiliki risiko 20% terkena infeksi nosokomial baik dari petugas kesehatan maupun pengunjung. tujuan dari penelitian ini adalah untuk menguji sikap perawat dalam upaya untuk mencegah infeksi nosokomial di rumah sakit didasarkan pada teori health belief model. metode: penelitian ini adalah deskriptif analitik dengan pendekatan studi cross sectional. total responden adalah 80 orang yang cocok dengan kriteria. pengumpulan data dilakukan dengan observasi langsung, wawancara dan kuesioner. variabel independen adalah health belief model terdiri dari variabel kerentanan, keseriusan, manfaat dan penghalang. variabel dependen adalah tindakan perawat untuk mencegah infeksi nosokomial. data dianalisis dengan menggunakan uji korelasi product moment. hasil: hasil penelitian menunjukkan bahwa variabel kerentanan, keparahan infeksi dan manfaat berkorelasi dengan pencegahan infeksi nosokomial (nilai p = 0,000 <0,05). sedangkan variabel penghalang tidak memiliki korelasi dengan pencegahan infeksi nosokomial (nilai p = 0,201> 0,05). diskusi: variabel health belief model yang dapat digunakan sebagai penentu pencegahan infeksi nosokomial adalah kerentanan, keseriusan dan manfaat. penelitian selanjutnya diharapkan akan dilakukan di beberapa rumah sakit untuk melihat faktor-faktor lain seperti manajemen rumah sakit, sarana dan prasarana, dan kebijakan yang dapat mempengaruhi pelaksanaan pencegahan dan pengendalian infeksi nosokomial. kata kunci: health belief model, infeksi nosokomial dan tindakan keperawatan. abstract introduction. nosocomial infections are defi ned as infection that develop during hospital stay of a patient. all patients have 20% risk of getting nosocomial infection from both health care providers and visitors. the objective of the research was to examine nurse attitude in effort to prevent nosocomial infection at hospital based on health believe model. method: this was a descriptive analytic with a cross sectional study approach. the total respondents were 80 people matched to the criteria. data was collected by direct observations, interview and questionairs. independent variable was health belief model consist of susceptibility, seriousness, benefi ts and barrier variables. dependent variable was nurse’s practice to prevent nosocomial infection. data then analyzed using correlations product moment test. result: the results showed that, susceptibility variable, severity of infection variable and benefi t variable have correlation with nosocomial infection prevention (p value=0,000<0,05). while barrier variable did not have correlation with nosocomial infection prevention (p value=0,201>0,05). discussion: variables of health belief model that can be used as determinants of nosocomial infection prevention were susceptibility, seriousness and benefi ts. future studies are expected to be done in some hospitals to look at other factors such as hospital management, facilities and infrastructure, and policies that may affect the implementation of prevention and control of nosocomial infections. keywords: health belief model, nosocomial infection and nursing practice 65 pengembangan tindakan pencegahan infeksi nosokomial (djaafar nurseha) pendahuluan rumah sakit sebagai salah satu sarana kesehatan yang member ikan pelayanan kesehatan kepada masyarakat, memiliki peran yang sangat penting dalam meningkatkan derajat kesehat a n masya ra kat, denga n melaksanakan upaya kesehatan yang berhasil guna dan berdaya guna terhadap pelayanan masyarakat, oleh karena itu rumah sakit dituntut untuk dapat memberikan pelayanan yang bermutu sesuai dengan standar yang telah ditentukan (anonim, 2007). mutu pelayanan rumah sakit dapat diukur dengan salah satu indikator angka kejadian infeksi nosokomial (nnis, 1991). infeksi nosokomial adalah infeksi yang timbul di r umah sakit, di mana pasien tersebut sebelumnya tidak menderita infeksi dan tidak dalam masa inkubasi infeksi tersebut (karyadi, 2005). infeksi nosokomial merupakan salah satu penyebab utama dari meningkatnya angka morbiditas dan mortalitas, yang dapat menghambat proses penyembuhan sehingga mengakibatkan masalah baru dalam bidang kesehatan, antara lain meningkatnya hari rawat dan bertambahnya biaya perawatan serta pengobatan pasien di rumah sakit (who, 2005). masyarakat yang menerima pelayanan kesehatan, tenaga kesehatan dan pengunjung di rumah sakit dihadapkan pada risiko terjadinya infeksi atau infeksi nosokomial, sekitar 20% disebabkan karena perawatan atau datang berkunjung ke rumah sakit. m e n u r u t t i m pe n c e g a h a n d a n pengend alia n i n fek si d i ru ma h sa k it (ppirs, 2007), beberapa faktor yang sering menimbulkan terjadinya infeksi nosokomial antara lain; peningkatan jumlah pasien yang dirawat di rumah sakit, kontak langsung antara petugas yang terkontaminasi kuman dengan pasien, penggunaan peralatan kedokteran yang telah terkontaminasi k u man, dan kondisi pasien yang lemah akibat penyakit yang sedang dialaminya. hasil penelitian menunjukkan 32% infeksi nosokomial dapat dicegah (anonim, 2007). angka kejadian infeksi nosokomial di beberapa negara berkisar antara 3,3–9,2% , angka infeksi nosokomial terus meningkat mencapai 9% (variasi 3–21% ) atau lebih dari 1,4 juta pasien rawat inap di rumah sakit seluruh dunia (al varado,2007). di negara berkembang didapatkan angka kejadian infeksi nosokomial berupa angka prevalensi sebesar 12,7% di malaysia, dan di taiwan sebesar 13,8% serta nigeria sebesar 17,5% (djoyosugito, 2007). hasil survey point prevalensi dari 11 rumah sakit di dki jakarta yang dilakukan oleh perhimpunan pengendalian infeksi indonesia (perdalin) dan rumah sakit penyakit infeksi prof. dr. sulianti soroso jakarta pada tahun 2003 didapatkan angka infeksi nosokomial untuk ilo (infeksi luka operasi) 18,9%, isk (infeksi saluran kemih) 15,1%, iadp (infeksi aliran darah primer) 26,4%, pneumonia 24,5% dan infeksi saluran napas lain 15,1%, serta infeksi lain 32,1%. hasil penelitian menunjukkan 90 – 95% infeksi nosokomial dipengaruhi oleh perilaku tenaga kesehatan. dengan demikian untuk mencapai keberhasilan program pencegahan dan pengendalian infeksi, dituntut pengetahuan dan sikap tenaga kesehatan untuk segera melakukan pencegahan dan pengendalian infeksi nosokomial (anonim, 2007). rumah sakit prof.dr.r.d.kandou merupakan rumah sakit milik pemerintah type b, dengan kapasitas tempat tidur sebanyak 701 tempat tidur, dan berfungsi sebagai rumah sakit rujukan dan rumah sakit pendidikan. jumlah tenaga sebanyak 1839 orang, yang terdiri dari dokter spesialis 182 orang, dokter umum 23 orang, dokter residen 208 orang, dokter gigi 4 orang, perawat dan bidan 815 orang dan non perawatan 637 orang (profi l blu rsup prof. dr. r.d. kandou tahun, 2011). ruang kekritisan (icu, cvcu, nicu, picu, imc penyakit dalam dan imc neuro), mempunyai jumlah tenaga keperawatan sebanyak 80 orang, dengan volume kegiatan sebagai berikut; rata-rata penggunaan tempat tidur atau bed occupancy rate 81,914%; rata-rata lamanya dirawat atau average length of stay 5 hari; frekuensi pemakaian tempat tidur atau bed turn over 19 kali; interval pemakaian tempat tidur atau turn 66 jurnal ners vol. 8 no. 1 april 2013: 64–71 over internal 3 hari. sampai saat ini angka kejadian infeksi nosokomial belum ada, tetapi angka kematian lebih dari 48 jam setelah dirawat/1000 penderita keluar yaitu “net death rate” (ndr), menunjukkan angka 180,6/1000 penderita keluar pada tahun 2011. data ini termasuk di atas rata-rata angka nasional yaitu kurang dari 25/1000 penderita keluar, dapat dipakai sebagai indikator di dalam penilaian mutu pelayanan suatu rumah sakit. peningkatan angka net death rate (ndr) memberi gambaran meningkatnya angka kejadian infeksi nosokomial (nnis,1991). angka kematian umum tiap 1000 penderita keluar, atau groos death rate menunjukkan angka 337/1000 penderita keluar, di mana hal ini menunjukkan diatas rata-rata angka nasional yakni kurang dari 45/1000 penderita (anonim, 1993). salah satu cara untuk mengatasi cara tersebut yaitu dengan memahami perilaku yang berhubungan dengan pencegahan infeksi. studi pendahuluan menunjukkan bahwa rumah sakit telah menjalankan program pencegahan infeksi nosokomial, dengan adanya kebijakan tertulis berupa standar operasional prosedur di setiap ruangan perawatan, dapat diasumsikan bahwa semua pihak yang terlibat dalam kegiatan rumah sakit mengetahui pencegahan infeksi nosokomial, tetapi sejauh mana para petugas kesehatan khususnya perawat mempraktikkan tentang apa yang diketahuinya dan bagaimana hal tersebut diaplikasikan dalam tindakan nyata, perlu dilakukan penelitian. unt u k memper mud a h mema ha m i hubungan sikap dengan tindakan pencegahan infeksi, maka penelitian ini akan menggunakan pendekatan “health belief model“ (hbm). berdasarkan latar belakang tersebut diatas dirumuskan masalah penelitian ialah sebagai berikut: bagaimana hubungan health belief model perawat dengan tindakan pencegahan infeksi nosokomial di ruang kekritisan blu rsup prof.dr.r.d. kandou manado. bahan dan metode desain penelitian dipergunakan ialah penelitian cross-sectional (potong lintang) yait u penelitian yang dilaksanakan dan mengikuti keadaan pada saat sekarang. penelitian dilaksanakan selama 3 bulan, mulai bulan juni 2012 sampai dengan september 2012, di ruang kekritisan (icu, cvcu, nicu, picu, imc penyakit dalam dan imc neuro), blu rsup prof.dr.r.d.kandou manado. populasi dalam penelitian ini yaitu seluruh perawat, berjumlah 80 orang yang bekerja di ruangan keperawatan kekritisan di blu rsup prof. r.d. kandou manado, yang memenuhi kriteria 80 orang, adapun kriteria inklusi sebagai berikut: perawat yang melaksanakan kontak langsung/bersentuhan dengan pasien, pengalaman kerja 6 bulan, pendidikan minimal spk. variabel independen adalah health belief model perawat yang terdiri atas kerentanan, keseriusan, manfaat, hambatan. variabel dependen adalah tindakan pencegahan infeksi nosokomial yaitu upaya perawat untuk menghindari terjadinya infeksi nosokomial meliputi kebersihan tangan, penggunaan sarung tangan, praktek aseptik antiseptik pengg unaan alat pengering tangan dan dekontaminasi. kuesioner untuk mengukur health belief model perawat terdiri dari variabel kerentanan 6 butir soal, keseriusan 14 butir soal, manfaat 10 butir soal, dan hambatan 10 butir soal. setiap pertanyaan yang dijawab diberi bobot 4 untuk jawaban sangat setuju (ss), bobot 3 untuk jawaban setuju (s), bobot 2 untuk jawaban tidak setuju (ts) dan bobot 1 untuk jawaban sangat tidak setuju (sts). masing-masing variabel memiliki nilai tertinggi dan terendah, kemudian dengan metode cut off dibagi dalam 2 kategori yaitu “mendukung” dan “kurang” dengan jarak setiap kelas diperoleh dari nilai tertinggi ditambah nilai terendah kemudian dibagi 2. dikatakan “mendukung” jika skor ≥ jarak antar-kelas dan “kurang” jika skor < jarak antar-kelas. selanjutnya kategori “mendukung” diberi bobot 2, dan “kurang” diberi bobot 1. kuesioner untuk mengukur tindakan pencegahan infeksi nosokomial terdiri dari 16 butir soal. setiap pertanyaan yang dijawab diberi bobot 3 untuk jawaban melakukan dengan tepat dan sempurna, bobot 2 untuk 67 pengembangan tindakan pencegahan infeksi nosokomial (djaafar nurseha) jawaban melakukan tidak tepat dan tidak sempurna, dan bobot 1 untuk jawaban tidak melakukan. jadi diperoleh nilai tertinggi 48 dan terendah 16. dengan menggunakan metode cut off, tingkat tindakan dibagi dalam 2 kategori yaitu “mempraktikkan”, dan “kurang” dengan jarak setiap kelas, yaitu 48+16/2=32. dikatakan “mempraktikkan” jika memperoleh nilai ≥32 dan “kurang” dengan nilai <32. selanjutnya kategori “mempraktikkan” diberi bobot 2, dan “kurang” diberi bobot 1. pengambilan data diawali dengan melaksanakan observasi langsung terhadap t i nd a ka n 80 responden tent a ng upaya pencegahan infeksi nosokomial yang mengacu pada standar operasional prosedur sesuai kriteria unjuk kerja kompetensi perawat dalam melaksanakan tindakan pencegahan infeksi nosokomial selama 3 minggu. setelah tahap observasi selesai dilanjutkan dengan pengambilan data menggunakan kuesioner, dengan metode wawancara, untuk mengungkap health belief model para perawat tentang tindakan keperawatan serta hubungannya dengan upaya pencegahan dan pengendalian infeksi nosokomial. uji statistik dilakukan dengan memakai metode korelasi product – moment. hasil karakteristik responden berdasarkan jenis kelamin di ruangan kekritisan blu prof. dr. r.d. kandou agustus 2012 sebagian besar responden berjenis kelamin perempuan sebanyak 61 responden (76%), sedangkan yang berjenis kelamin laki-laki sebanyak 19 responden (24%). sebagian besar responden ber pendidikan terak hir d3 sebanyak 43 orang (54%), selanjutnya diikuti oleh yang berpendidikan s1 sebanyak 31 orang (39%), kemudian spk 5 orang (6%) dan terakhir d4 1 orang (1%). dat a health belief model u nt u k variabel kerentanan, keseriusan dan manfaat menu nju k kan bahwa semua responden terdistribusi pada kategori sikap mendukung 80 orang (100%). sedangkan untuk variabel hambatan menunjuk kan bahwa sebagian besar responden terdistribusi pada kategori sikap kurang mendukung sebanyak 62 orang (77%), sedangkan yang terdistribusi pada kategori sikap mendukung sebanyak 18 orang (23%). distribusi responden berdasarkan tindakan menunjukkan bahwa sebagian besar responden terdistribusi pada kategori tindakan mempraktikkan sebanyak 48 orang (60%), sedangkan yang terdistribusi pada kategori tindakan kurang mempraktikkan sebanyak 32 orang (40%). a nal isis d at a d ila k u k a n de nga n mengg u nakan metode korelasi product moment atau disebut juga pearson correlation didapatkan bahwa ada hubungan antara kerentanan dengan tindakan pencegahan infeksi nosokomial, ada hubungan antara keseriusan dengan tindakan pencegahan infeksi nosokomial, ada hubungan antara manfaat melakukan tindakan dengan tindakan pencegahan infeksi nosokomial, dan tidak ada hubungan antara hambatan melaksanakan tindakan dengan tindakan pencegahan infeksi nosokomial. hasil tersebut dapat dilihat pada tabel 1. pembahasan h e a l t h b e l i e f m o d e l p e r a w a t merupakan gambaran perilaku perawat dalam melaksanakan tindakan pencegahan infeksi nosokomial yang terdiri dari 4 ranah (domain) yaitu: kerentanan, keseriusan, manfaat dan hambatan. tingkat pendidikan menunjukkan profesionalitas dan kinerja melaksanakan tindakan pencegahan infeksi nosokomial, sehingga semakin tinggi tingkat pendidikan semakin tinggi tingkat profesionalitas dan kinerja. kerentanan mer upakan pandangan seseorang tentang kerentanan atau mudahnya seseorang terkena suatu penyakit (risiko menjadi sakit). teori lewin (1954) mengatakan suatu tindakan pencegahan terhadap suatu penyakit akan timbul bila seseorang telah merasakan bahwa ia rentan terhadap penyakit tersebut. pada penelitian ini kerentanan dihubungkan dengan persepsi perawat tentang lamanya sakit yang dialami pasien, penyakitpenyakit endemik infeksi nosokomial, dan proses transmisi kuman di rumah sakit. 68 jurnal ners vol. 8 no. 1 april 2013: 64–71 hasil penelitian ini menunjukkan bahwa ada hubungan antara variabel kerentanan dengan variabel tindakan pencegahan infeksi nosokomial. variabel kerentanan berkorelasi dengan variabel tindakan (r=1,000) yang artinya, semakin rentan (mudah menular suatu penyakit) infeksi nosokomial, akan semakin baik tindakan perawat dalam program pencegahan infeksi nosokomial. hubungan korelasi antara variabel kerentanan dengan variabel tindakan menunjukkan hubungan sangat kuat. infeksi nosokomial dapat terjadi di setiap tempat di rumah sakit. rumah sakit sebagai suatu sarana kesehatan yang memberikan pelayanan kesehatan kepada masyarakat, berupaya untuk dapat memberikan pelayanan yang bermutu dan profesional yang didukung dengan sumber daya manusia yang kompeten (anonim, 2007). pengamatan yang sistematis, aktif dan terus menerus terhadap timbulnya dan menyebarnya penyakit pada populasi serta terhadap keadaan yang menyebabkan meningkatnya risiko terjadi penyebaran penyakit, merupakan bagian penting dalam proses pengendalian penyakit infeksi (widodo, 1997). menurut robert (1992) pengendalian infeksi nosokomial har us diprioritaskan kepada penderita dan untuk memutuskan mata rantai infeksi, prioritaskan pada tenaga perawat dengan jalan mengubah perilaku. perasaan akan seriusnya penyakit atau keganasan penyakit, didefinisikan sebagai perasaan perawat tentang seriusnya penyakit infeksi nosokomial yang menyerang para penderita, termasuk gejala, prognosis dan kemungkinan konsekuensi sosial. faktor ini menghubungkan dengan konsekuensi yang terbawa karena sifat penyakit infeksi nosokomial. tindakan pencegahan penyakit akan terdorong oleh seriusnya penyakit tersebut terhadap orang atau masyarakat. hasil penelitian ini menunjukkan bahwa ada hubungan antara keseriusan dengan tindakan pencegahan infeksi nosokomial. var iabel keser iusan berkorelasi dengan variabel tindakan (r = 1,000) yang artinya, semakin ganas (severe) penyakit infeksi nosokomial, akan semakin baik tindakan perawat dalam mencegah infeksi nosokomial semakin baik. hubungan korelasi antara variabel keseriusan penyakit dengan variabel tindakan menunjukkan hubungan sangat kuat. menu r ut asumsi peneliti hal ini dapat terjadi pada suatu rumah sakit dengan pengawasan yang cukup baik, ancaman yang terlihat tentang gejala penyakit akan dirasakan lebih serius oleh perawat oleh sebab itu tindakan pencegahan dilakukan lebih baik (notoatmojo, 2007). hubungan interaksi antara pasien dengan perawat akan memberi dampak pada penilaian mutu pelayanan rumah sakit. rumah sakit mempunyai kewajiban serta tanggung jawab moral untuk memenuhi kebutuhan pasien yang dirawat (aditama, 2003). tabel 1. hasil analisis korelasi product moment variabel penelitian jenis nilai tindakan keterangan kerentanan person correlation sig. (1-tailed) n 1,000 0,000 80 p < 0,05 keseriusan person correlation sig. (1-tailed) n 1,000 0,000 80 p < 0,05 manfaat person correlation sig. (1-tailed) n 1,000 0,000 80 p < 0,05 hambatan person correlation sig. (1-tailed) n 0,95 0,201 80 p > 0,05 69 pengembangan tindakan pencegahan infeksi nosokomial (djaafar nurseha) suatu keyakinan perawat bahwa dengan beberapa tindakan akan dapat mencegah para penderita terkena infeksi nosokomial. hal ini juga menggambarkan sebagai suatu kepercayaan yang menyatakan bahwa pola-pola tingkah laku tertentu akan dapat mengurangi risiko seseorang terkena penyakit. hasil penelitian ini menunjukkan bahwa ada hubungan antara manfaat melaksanakan tindakan dengan tindakan pencegahan infeksi nosokomial. variabel manfaat berkorelasi dengan variabel tindakan (r=1,000) yang artinya, semakin baik mendapatkan manfaat dalam penanganan infeksi nosokomial, akan makin baik tindakan para perawat. hubungan korelasi antara variabel manfaat dengan variabel tindakan menunjukkan hubungan sangat kuat. s a l a h s a t u f a k t o r y a n g d a p a t mempengaruhi tindakan seseorang untuk mempertahankan pelayanan yang profesional ialah meningkatkan manfaat tindakan dan mengurangi kelemahan dalam melaksanakan pelayanan keperawatan (aditama, 2003). hambatan untuk bertindak didefi nisikan sebagai a nt isipasi subjek t if seseor a ng sehu bu nga n de nga n h a mbat a n d a la m melakukan tindakan tertentu. mengantisipasi kesulitan-kesulitan dalam pencegah infeksi nosokmial. hasil penelitian ini menunjukkan bahwa tidak ada hubungan antara variabel hambatan dengan tindakan pencegahan infeksi nosokomial. variabel hambatan tidak berkorelasi dengan variabel tindakan (r=0,95). hal ini dapat memberikan gambaran akan semakin rendah pelayanan kepada pasien, dan semakin tidak berkualitas manajemen pemberian asuhan keperawatan, yang pada akhirnya memberikan dampak pada mutu pelayanan rumah sakit. faktor sarana dan prasarana yang berhubungan dengan pencegahan infeksi nosokomial yang tersedia belum memadai di ruangan kekritisan blu rsup prof. dr. r.d. kandou. ketersediaan sarana dan prasarana bagi perawat termasuk fasilitas pelaya na n kesehat a n pa d a ha k i kat nya mendukung atau memungkinkan terwujudnya perilaku kesehatan (notoatmojo, 2007). hasil penelitian lindawaty (2007) tentang faktor yang berhubungan dengan persepsi perawat pelaksana tentang upaya pencegahan infeksi nosokomial di ruang rawat inap rumah sakit per tamina jakar ta, menunjuk kan bahwa variabel sarana merupakan variabel yang paling berhubungan dengan upaya pencegahan infeksi nosokomial. melihat hasil korelasi antara variabel health belief model yang terdiri dari dari variabel kerentanan, variabel keseriusan, variabel manfaat dan variabel hambatan terhad ap t i nd a ka n pencega ha n i n fek si nosokomial menu nju k kan bahwa, yang mempunyai hubungan korelasi yang cukup kuat ditunjukkan oleh variabel keseriusan, variabel kerentanan dan variabel manfaat, oleh sebab itu variabel tersebut dapat dipakai sebagai faktor penentu variabel tindakan. variabel hambatan menunjukkan korelasi tidak ada hubungan, artinya variabel tersebut tidak dapat dipakai sebagai faktor penentu untuk tindakan pencegahan infeksi nosokomial. secara teoritis, health belief model seseorang akan sangat erat sekali hubungannya dengan perilak unya dan dapat menjadi faktor penentu perilaku. pada penelitian ini menunjukkan bahwa health belief tenaga keperawatan dihubungkan dengan model perawat yang berhubungan dengan pasien, d ala m a k t iv it a s seh a r i-h a r i me m i l i k i keterikatan personal dan sosial, sehingga health belief model tepat digunakan sebagai faktor penentu tindakan pencegahan infeksi nosokomial. simpulan dan saran simpulan variabel health belief model yang berhubungan dengan tindakan pencegahan infeksi nosokomial pada perawat adalah kerentanan, keseriusan dan manfaat. variabel hambatan tidak menunjukkan korelasi yang signif ikan dengan tindakan pencegahan sehingga tidak dapat digunakan sebagai faktor penentu tindakan pencegahan infeksi nosokomial. 70 jurnal ners vol. 8 no. 1 april 2013: 64–71 saran institusi pelayanan hendaknya membuat program uji kemampuan kerja perawat, mengaktif kan program surveilans infeksi nosokomial setiap unit dengan menempatkan p e r awa t y a ng k hu s u s d id id i k u nt u k pengendalian infeksi nosokomial sebagai perawat purna waktu dan bukan perawat yang berada di samping tempat pasien (non bed side nurse), perlu adanya program percontohan untuk model pencegahan infeksi nosokomial di rumah sakit. penelitian selanjutnya diharapkan dapat dilakukan di beberapa rumah sakit dengan melihat faktor-faktor lain misalnya manajemen rumah sakit, sarana dan prasarana, dan kebijakan yang dapat mempengaruhi pela k sa na a n prog ra m pencega ha n d a n pengendalian infeksi nosokomial. daftar pustaka a h madi, h a., 2007. psikologi sosial, pembentukan dan perubahan sikap. jakarta: pt. rineke cipta. a r i k u nt o, su ha r si m i, 1997. p ro se d u r penelitian suatu pendekatan praktik. jakarta: rineka cipta. azwar, s., 2003. sikap manusia teori dan pengukurannya. edisi ii. pustaka. yogyakarta: pelajar. anonimous, 2007a. infeksi nosokomial, (online), (www.yanmedik-depkes.net. akses november 2009). anonimous, 2007b. pedoman pencegahan dan pengendalian infeksi di rumah sakit dan fasilitas pelayanan kesehatan lainya. jakarta. anonimous, 2007c. pedoman manajerial pencegahan dan pengendalian infekasi di rumah sakit dan fasilitas pelayanan kesehatan lainnya. jakarta. anonimous, 2007d. dasar-dasar penyakit infeksi. jakarta . d a r m a d i , 2 0 0 8 . in fe k s i no s o k o m i a l problematik a dan pengendalian. penerbit salemba medika. jakarta. djoyosugito, 1990. infeksi luka operasi n o s o k o m i a l . d e s e r t a s i t i d a k dipublikasikan. universitas indonesia. _ _ _ _ _ , 20 07. in fe k si lu k a o p e ra si nosokomial, penentuan faktor risiko, kuman penyebab an cara surveilans, journal infection control. faturochman, 2006. pengantar psikologi sosial, yogyakarta: penerbit pustaka book publishing. gama, h., 2006. nosocomial infection, detection and preventive. bandung: universitas pajajaran press. h ic m r , 2 0 0 8. pe n e r a p a n p r o g r a m pe nge n d a lia n in fe k si d i ru m a h s a k i t , ( o n l i n e ), ( h t t p:// w w w. perawatentepreneur.wordpress.com) harjono, 1998. upaya pengendalian infeksi nosokomial di bagian ilmu kesehatan anak fkui/rscm, maj. kedokt. 48. hudak, cm. 1996. keperawatan kritis pendek atan holistik , volu me i i. jakarta: egc. k a r ya d i, 20 05. pe nge nd a l ia n i n fek si nosokomial sebagai upaya jaminan mu t u d a n pe n g h e m a t a n bi ay a , organisasi dan cara pelaksanaan. simposium pengen d alia n infe k si nosokomial rumah sakit pertamina, jakarta. mar tono, n., 2007. infeksi nosokomialsuperbakteri rumah sakit di indonesia “undercover case" (online), (http:// www.nurmartono.blospot.com.dalam www.inna-ppni.co.id. diakses tanggal nopember 2009). maramis, w., 2007 . ilmu perilaku dalam pelayanan kesehatan. jakarta mehtar, 1992. hospital infection control setting up a cost effective program. new york: oxford university press. inc. marcill, mm., 1993. handwashing practices among occupational therapy. the american journal of occupational therapy. n n is ( nat ional nosocom ial i nfect ion surveillance system), 1991, nosokomial infe cton ra te s for inte rh ospital comparison, limitations and possible solution. infection control and hospital epidemiology, 12. notoatmojo, s., 1997. promosi keseatan dan ilmu perilaku. jakarta: rineke cipta. 71 pengembangan tindakan pencegahan infeksi nosokomial (djaafar nurseha) nursalam, 2003. konsep dan penerapan m e t o d o l o g i p e n e l i t i a n i l m u . keperawatan pedoman skripsi, tesis dan instrumen penelitian keperawatan. jakarta: salemba medika. nursalam, 2007. asuhan keperawatan pada pasien. jakarta: salemba medika. notoatmodjo, s, 2005. metodologi penelitian kesehatan. jakarta: rineka cipta. pot t e r, pat r icia a., 20 05. bu k u aja r fundamental keperawatan: konsep, proses dan praktik edisi 4. jakarta: egc. slamet, 1993. analisis kuantitatif untuk data sosial. solo: debora publisher. sugiyono, 1999. statistik untuk penelitian. bandung: cv alpabeta. 161 parameter rujukan ibu bersalin (paramater on maternal delivery referral process) zubaidah*, mohammad hakimi**, abdul wahab** * akademi keperawatan intan, martapura, kabupaten banjar kalimantan selatan ** fakultas kedokteran universitas gadjah mada e-mail: zubaidah@yahoo.com abstract introduction: the rate of maternal mortality in indonesia according to 2002–2003 indonesian demographic and health survey (idhs) was 307 per 100,000 live births. the direct causes of maternal deaths, among others, are prolonged labor, hemorrhage, infection, and preeclampsia. referral system includes referring responsibility to better facilitated healthcare sites to obtain more adequate services. however, maternal referral process in banjar district still faces some problems such as referral health providers with inadequate skills of handling emergency cases, insuffi cient means of transportation, and no referral letter or partograph. usually, when referred, the pregnant woman is only accompanied by her family so that she is brought to the referral site without being equipped with infusion. the objective of the study was to evaluate the parameter of maternal delivery referral in ratu zalekha martapura district hospital. method: this study used observational study with a cross-sectional study design using quantitative and qualitative approaches. samples were 107 delivering women referred to hospitals selected with non probability sampling. data were analyzed with chi-square (χ2) and logistic regression test. result: quality maternal referral process resulted in healthy women 78.8%. post delivery women's health was greater in quality maternal referral process (rp = 2.1; 95% ci = 1.28–3.52). normal delivery had an opportunity towards post delivery women's health (rp = 1.6; 95% ci = 1.13–2.20). in addition, time needed to reach the referral sites and referral birth attendants were signifi cantly associated with maternal referral process (p = 0.002 and p = 0.002). meanwhile, women's condition when referred was insignifi cant statistically. discussion: quality maternal referral process could likely improve post delivery women's health. normal delivery affected the women's health condition. keywords: quality of referral process, delivering women, maternal morbidity pendahuluan angka kematian ibu (aki) indonesia berdasarkan survei demografi dan kesehatan indonesia (sdki) 2002–2003 sebesar 307 per 100.000 kelahiran hidup. aki indonesia tahun 1997 adalah 334 per 100.000 kelahiran hidup. angka ini menurun bila dibandingkan dengan hasil sdki 1994 yaitu sebesar 390 per 100.000 kelahiran hidup. indonesia bertekad tahun 2010 aki indonesia menjadi 125 per 100.000 kelahiran hidup. resiko kematian ibu karena melahirkan di indonesia adalah 1 dar i 65 wanita, sedangkan thailand 1 dari 1.100 wanita mengalami resiko kematian maternal. malaysia pada tahun 2005 mempunyai aki sebesar 41 per 100.000 kelahiran hidup, thailand 44 per 100.000 kelahiran hidup, dan srilanka 92 per 100.000 kelahiran hidup. indonesia berkom it men sesu ai denga n dek la rasi millenium development goals (mdgs), untuk menurunkan aki menjadi 2/3 dari keadaan tahun 2000, yaitu menjadi 102 per 100.000 kelahiran hidup. pe n e l i t i a n c h o wd h u r y (2 0 0 7 ) , m e nye b u t k a n b a hw a t e r d a p a t e m p a t komplikasi penyebab langsung kematian ibu, yang tertinggi adalah partus lama sebanyak 1270 (24,5%), perdarahan 601 (11,6%), infeksi 485 (9,3%) dan kejang 166 (3,2%). menurut 162 jurnal ners vol. 7 no. 2 oktober 2012: 161–169 depkes (2006), penyebab kematian maternal di indonesia adalah perdarahan (42%), eklampsia (13%), komplikasi abortus (11%), infeksi (10%) dan persalinan lama (9%). sistem rujukan maternal dapat berjalan, dibutuhkan penyusunan strategi r ujukan sesuai dengan sistem kesehatan yang berlaku dengan kondisi masyarakat setempat. rujukan ke rumah sakit dilaksanakan karena adanya komplikasi obstet ri seper ti perdarahan, persalinan macet dan hipertensi. jumlah kematian yang terjadi pada ibu dir ujuk karena jarak tempat tinggal ke rumah sakit > 5 km (30%). sedangkan jumlah ibu yang dirujuk kemudian dilakukan persalinan sectio caesarea sebanyak (50,9%), yang dilakukan laparatomi (4,8%), dan yang mendapatkan tranfusi darah secara darurat (44%). penelitian macintyre dan hotchkiss (1999), mengatakan bahwa masalah dalam proses rujukan meliputi mutu pelayanan yang kurang baik, ketersediaan tenaga terampil yang rendah, tidak cukupnya suplai obatobatan, peralatan medis untuk diagnosa, dan peralatan komunikasi serta transportasi yang kurang memadai. bahan dan metode p e n e l i t i a n i n i m e n g g u n a k a n observasional analitik, rancangan potong lintang (cross sectional), metode kuantitatif dan kualitatif. variabel terikat morbiditas ibu, variabel bebas proses rujukan ibu bersalin. variabel luar kondisi ibu saat dirujuk, waktu tempuh ke fasilitas r ujukan, kompetensi tenaga kesehatan pendamping rujukan dan cara persalinan. lokasi rsud ratu zalecha ma r t apu ra kabupaten ba nja r propi nsi kalimantan selatan. waktu penelitian selama 3 bulan yaitu dari juni 2008 sampai dengan agustus 2008. populasi semua ibu yang melahirkan di rsud ratu zalekha martapura. sampel ibu bersalin yang dirujuk dengan alasan obstetri. kriteria inklusi ibu bersalin yang dirujuk alasan obstetri. kriteria eksklusi ibu bersalin kehamilan kembar, ibu bersalin dengan infeksi non intrauterine seperti malaria, hepatitis, tipes dan penyakit infeksi lainnya. pe n g a m bi l a n s a m p el p u r p o s i v e sampling. besar sampel 107 orang. sumber dat a pr imer mengisi k uisioner dengan wawancara responden, indepth interview 2 bidan pengirim, 2 bidan rumah sakit. data sekunder buku registrasi ruangan bersalin. analisis rasio prevalensi (rp) dan confi dence interval 95% melihat prevalensi morbiditas ibu terhadap proses rujukan ibu bersalin. analisis hubungan antara variabel bebas dan variabel terikat serta variabel luar juga dilakukan analisis hubungan antara variabel luar dan variabel bebas. hasil rujukan ibu bersalin terbanyak alasan partus lama, ketuban pecah dini dan anemia. alasan yang paling sedikit perdarahan dan nyeri perut hebat. hal ini artinya bahwa ibu bersalin yang dirujuk disebabkan bayi tidak mau keluar setelah lebih delapan jam (partus lama) dikarenakan kontraksi rahim ya ng le m a h seh i ngga me mba h aya k a n tabel 1. distribusi parameter ibu bersalin dirujuk ke rsud ratu zalekha di kota martapura (n = 107) komplikasi persalinan frekuensi % 1. perdarahan 3 2,8 2. pre/eklampsi 5 4,7 3. infeksi 6 5,6 4. ketuban pecah dini 23 21,5 5. partus lama 42 39,5 6. hipertensi 8 7,5 7. anemia 9 8,4 8. nyeri perut hebat 3 2,8 9. serotinus (hamil > 42 minggu) 8 7,5 163 parameter rujukan ibu bersalin (zubaidah, dkk.) tabel 2. karakteristik ibu responden penelitian (n = 107) variabel frekuensi % umur ibu < 20 tahun 7 6,5 20–35 tahun 88 82,2 > 35 tahun 12 11,2 tingkat pendidikan sd/sederajat kebawah 32 31,8 sltp/sederajat 41 29,9 slta keatas 34 38,3 pekerjaan ibu tidak bekerja 91 85,1 bekerja 16 14,9 tabel 3. prinsip dalam proses rujukan ibu bersalin (n = 107) variabel frekuensi % stabilisasi stabil 99 92,5 tidak stabil 8 7,5 ketersediaan transportasi tersedia 92 86,0 tidak tersedia 15 14,0 pendampingan oleh nakes didampingi 102 95,3 tidak didampingi 5 4,7 disertai surat rujukan ada 102 95,3 tidak ada 5 4,7 proses rujukan ibu bersalin berkualitas 80 74,8 tidak berkualitas 27 25,2 kondisi ibu bersalin saat dirujuk sadar 101 94,4 tidak sadar 6 5,6 waktu tempuh ke fasilitas rujukan mudah diakses 97 90,7 sulit diakses 10 9,3 kompetensi tenaga kesehatan pendamping rujukan terlatih 95 88,8 tidak terlatih 12 11,2 institusi yang merujuk polindes 41 28,3 pustu 29 27,1 puskesmas 18 16,8 klinik swasta 19 17,8 keadaan janin serta keselamatan ibu. tingkat pendidikan ibu mayoritas adalah sltp, hal ini akan mempengaruhi pengetahuan ibu tentang kehamilan dan resiko yang terjadi selama kehamilan dan selama persalinan. ibu tidak bekerja artinya ibu tidak mempunyai penghasilan, ibu tidak mempunyai biaya untuk memeriksakan kehamilannya secara rutin, tidak terpantaunya resiko yang terjadi pada saat kehamilan dan persalinan. proses rujukan sesuai dengan prinsip dasar rujukan sehingga ibu mendapatkan penanganan yang optimal 164 jurnal ners vol. 7 no. 2 oktober 2012: 161–169 di fasilitas pelayanan rujukan, pertolongan persalinan dilakukan persalinan normal atau pervaginam, sehingga dapat menjadikan ibu sehat pasca-persalinanan. penderita tidak dilakukan stabilisasi karena ibu kondisinya baik dan jarak dari rumah ke rumah sakit dekat. tersedianya transportasi maksudnya saat ibu dirujuk tidak perlu lagi menunggu mencari kendaraan. tidak tersedianya transportasi pada proses rujukan ibu bersalin bahwa untuk merujuk ibu harus menunggu mencari kendaraan, ini akan memperlambat sampai ke fasilitas rujukan sehingga memperburuk kondisi ibu. selama proses rujukan ibu didamping oleh tenaga kesehatan. ibu bersalin tidak didampingi dengan alasan kondisi ibu baik, jarak dari rumah ke fasilitas rujukan dekat. rujukan ibu bersalin tidak disertai surat dengan alasan bidannya mengantar sendiri dan dekat dengan fasilitas rujukan. variabel proses rujukan ibu bersalin menunjukkan bahwa rujukan ibu bersalin di rsud ratu zalekha di kota martapura berkualitas. kondisi ibu bersalin saat dirujuk menunjukkan bahwa selama proses rujukan ibu dalam keadaan sadar sampai ibu di rumah sakit, berarti bahwa ibu mengetahui kejadian tentang keadaan dirinya selama diperjalanan menuju kefasilitas rujukan. dilihat waktu tempuh ke fasilitas rujukan menunjukkan waktu untuk mengakses ke rsud ratu zalekha adalah kurang dari satu jam. hal ini berarti tempat rujukan mudah dijangkau, kemungkinan ibu dapat diselamatkan. waktu tempuh lebih dari satu jam sampai ke fasilitas rujukan berasal dari tempat yang jauh jarak tempuhnya walaupun masih dalam wilayah kabupaten banjar, kabupaten hulu sungai tengah, hulu sungai selatan yang waktu tempuh mencapai empat sampai lima jam. tenaga kesehatan pendamping rujukan menunjukkan banyak tenaga kesehatan pendamping sudah terlatih. tenaga kesehatan yang tidak terlatih antara lain perawat, dokter dan masih ada bidan yang belum terlatih. pertolongan persalinan pada ibu bersalin yang dirujuk dengan alasan obstetri bila proses rujukannya sesuai dengan prinsip dasar rujukan sehingga ibu cepat mendapatkan pertolongan yang optimal, maka ibu bersalin dapat menjalani persalinan secara normal dan tidak perlu dilakukan persalinan caesar. institusi yang merujuk ibu bersalin yang terbanyak adalah rujukan yang berasal dari polindes selanjutnya dari pustu, dan rujukan tidak berkualitas terbanyak kiriman dari polindes, selanjutnya dari pustu dan puskesmas serta klinik swasta yang sedikit. variabel yang mempunyai hubungan bermakna secara statistik dengan morbiditas ibu adalah variabel proses rujukan ibu bersalin dan cara persalinan. prevalensi ibu sehat pada tabel 4. analisis chi square proses rujukan ibu bersalin, kondisi ibu, waktu tempuh, kompetensi tenaga kesehatan pendamping dengan morbiditas ibu variabel morbiditas ibu hasil sehat sakit χ2 p rp ci 95%n (%) n (%) proses rujukan ibu bersalin berkualitas 63 (78,8) 17 (21,2) 16,2 0,000* 2,1 1,28–3,52 tidak berkualitas 10 (37,0) 17 (63,0) kondisi ibu saat dirujuk sadar 70 (69,3) 31 (30,7) 0,9 0,379** 1,4 0,61–3,11 tidak sadar 3 (50,0) 3 (50,0) waktu tempuh ke fasilitas rujukan mudah diakses 68 (70,1) 29 (29,9) 1,6 0,283** 1,4 0,74–2,64 sulit diakses 5 (50,0) 5 (50,0) kompetensi nakes pendamping rujukan terlatih 67 (70,5) 28 (29,5) 2,1 0,190** 1,4 0,78–2,52 tidak terlatih 6 (50,0) 6 (50,0) keterangan: *signifi kan (p < 0,05), **analisis fi sher exact test 165 parameter rujukan ibu bersalin (zubaidah, dkk.) proses rujukan ibu bersalin yang berkualitas sebanyak 63(78,8%), sedangkan prevalensi ibu sehat pada proses rujukan yang tidak berkualitas sebanyak 10 (37,0%). secara statistik proses r ujukan ibu bersalin mempunyai hubungan yang bermakna dengan morbiditas ibu dengan p = 0,000 dan (rp = 2,1; 95% ci = 1,28–3,52). hal ini berarti prevalensi ibu sehat pada proses rujukan ibu bersalin berkualitas 2,1 kali lebih besar dibandingkan prevalensi ibu sehat pada proses rujukan ibu bersalin tidak berkualitas. variabel luar yang mempunyai hubungan bermakna dengan morbiditas ibu adalah cara persalinan dengan nilai p = 0,000 dan (rp = 1,6; 95% ci = 1,13–2,20). hal ini berarti prevalensi ibu sehat pada persalinan normal 1,5 kali lebih besar dibandingkan prevalensi ibu sehat pada persalinan caesar. sedangkan variabel kondisi ibu saat dir ujuk, waktu tempuh ke fasilitas rujukan dan kompetensi tenaga kesehatan pendamping rujukan secara praktis mempunyai hubungan secara bermakna terhadap morbiditas ibu. tab el 5 me mp e rl i h at k a n ba hwa var iabel luar yang berhubungan secara bermakna dengan proses rujukan ibu bersalin adalah variabel waktu tempuh ke fasilitas rujukan dan kompetensi nakes pendamping rujukan. waktu tempuh ke fasilitas rujukan berhubungan secara bermakna dengan proses rujukan ibu bersalin dengan p = 0,002 yang berarti bahwa waktu tempuh ke fasilitas rujukan dapat menjadikan proses rujukan ibu bersalin berkualitas. hubungan yang bermakna terhadap proses rujukan ibu bersalin juga ditunjukkan oleh variabel kompetensi tenaga kesehatan pendamping rujukan dengan p = 0,002, yang berarti kompetensi nakes pendamping dapat menjadikan proses rujukan ibu bersalin berkualitas. sedangkan variabel kondisi ibu saat dirujuk dan cara persalinan secara statistik tidak menunjukkan hubungan bermakna tetapi secara praktis menunjukkan hubungan yang bermakna. model 1 dibuat untuk melihat hubungan antara variabel bebas proses rujukan ibu bersalin terhadap variabel terikat morbiditas ibu. hasil analisis menunjuk kan adanya hubungan yang ber mak na antara kedua variabel tersebut dengan r p = 2,1 dan ci = 95% (1,28–3,52). hal ini menunjukkan prevalensi morbiditas ibu sehat pada rujukan berkualitas 2,1 kali lebih besar dari pada rujukan tidak berkualitas. jika dilihat dari nilai r2 pada model 1 diperkirakan proses rujukan berkualitas memberikan kontribusi sebesar 2,9% menjadikan ibu sehat pasca persalinan sedangkan 97,1% karena faktor lain. selanjut nya pada model 2 dibuat untuk melihat hubungan proses r ujukan tabel 5. analisis chi square tabulasi silang kondisi ibu, waktu tempuh, kompetensi tenaga kesehatan pendamping, cara persalinan dengan proses rujukan ibu bersalin variabel proses rujukan ibu bersalin hasil berkualitas tidak berkualitas χ2 pn (%) n (%) kondisi ibu saat dirujuk sadar 77 (76,2) 24 (23,8) 2,6 0,167+ tidak sadar 3 (50,0) 3 (50,0) waktu tempuh ke fasilitas rujukan mudah diakses 77 (79,4) 20 (20,6) 11,7 0,002*+ sulit diakses 3 (30,0) 7 (70,0) kompetensi nakes pendamping rujukan terlatih 76 (80,0) 19 (20,0) 12,3 0,002*+ tidak terlatih 4 (33,3) 8 (66,7) cara persalinan persalinan normal 47 (70,2) 20 (29,8) 2,0 0,155 persalinan caesar 33 (82,5) 7 (17,5) keterangan: *signifi kan (p < 0,05), + fi sher exact test 166 jurnal ners vol. 7 no. 2 oktober 2012: 161–169 ibu bersalin dengan morbiditas ibu dengan mempertimbangkan variabel cara persalinan dengan alasan cara persalinan mempunyai hubungan yang bermakna dengan morbiditas ibu pada analisis bivariabel. hasil analisis menunjukkan bahwa adanya hubungan yang bermakna antara proses rujukan ibu bersalin terhadap morbiditas ibu dengan rp = 2,2 dan ci 95% (1,33–3,46). cara persalinan mempunyai hubungan bermakna dengan morbiditas ibu rp = 1,6 dan ci 95% (1,18–2,16). setelah memasukkan variabel cara persalinan tidak terdapat perubahan rp yang berarti tetapi cara persalinan mempunyai kontribusi pada proses rujukan ibu bersalin sebesar 2,2%. dilihat dari nilai r2 pada model 2 diperkirakan proses rujukan ibu bersalin dan cara persalinan memberikan kontribusi sebesar 5,1% pada morbiditas ibu sehat pasca persalinan 94,9% karena faktor lain. sedangkan waktu tempuh ke fasilitas rujukan dan kompetensi tidak memberi kontribusi pada morbiditas ibu. model terakhir memasukkan variabel cara persalinan bersama-sama dengan dua variabel lain, yaitu variabel waktu tempuh ke fasilitas rujukan dan kompetensi nakes pengirim r ujukan, dengan alasan karena mempunyai hubungan ber makna dengan proses rujukan ibu bersalin. variabel waktu tempuh ke fasilitas rujukan dan kompetensi tabel 6. analisis model binomial regresi antara morbiditas ibu dengan proses rujukan ibu bersalin, waktu tempuh, kompetensi tenaga kesehatan pendamping dan cara persalinan variabel model 1 model 2 model 3 rp (95% ci) rp (95% ci) rp (95% ci) proses rujukan ibu bersalin berkualitas 2,1 (1,28–3,52) 2,2 (1,33–3,46) 2,2 (1,32–3,55) tidak berkualitas 1 1 1 waktu tempuh ke fasilitas rujukan mudah diakses 1,2 (0,66–2,28) sulit diakses 1 kompetensi nakes pengirim rujukan terlatih 0,9 (0,83–0,98) tidak terlatih 1 cara persalinan persalinan normal 1,6 (1,18–2,16) 1,6 (1,20–2,18) persalinan sesar 1 1 deviance 118,35 104,26 102,72 r2 0,029 0,051 0,051 n 107 107 107 nakes pengirim rujukan yang mempunyai hubungan bermakna dengan proses rujukan ibu bersalin pada analisis bivariabel. hasil analisis menunjuk kan variabel yang mempunyai hubungan dengan morbiditas ibu adalah proses rujukan ibu bersalin dengan rp = 2,2 dan ci = 95% (1,32–3,55), dan variabel cara persalinan mempunyai hubungan bermakna dengan rp = 1,6 dan ci = 95% (1,20–2,18) sedangkan variabel lainnya tidak mempunyai hubungan yang bermakna secara statistik. prediksi morbiditas ibu sehat pada model 3 variabel memberikan kontribusi sebesar 5,1% di sebabkan proses rujukan ibu bersalin dan cara persalinan sedangkan 94,9% disebabkan oleh faktor lain. analisis dari ketiga model di atas, dapat diketahui bahwa model yang baik adalah model 2. model 2 dipilih dengan alasan variabel mempunyai hubungan ber makna dengan morbiditas ibu sehat, adanya perubahan rp pada proses rujukan ibu bersalin terhadap morbiditas ibu dari 2,1 menjadi 2,2. variabel cara persalinan memberikan per ubahan deviance secara bermakna sebesar 2,2% terhadap morbiditas ibu. secara statistik dan secara praktis ada hubungan bermakna pada model 2, sehingga model 2 lebih baik. melihat dari model 2 bahwa prevalensi ibu sehat pada proses rujukan ibu bersalin berkualitas 2,2 kali 167 parameter rujukan ibu bersalin (zubaidah, dkk.) lebih besar dibandingkan proses prevalensi ibu sehat pada proses rujukan ibu bersalin tidak berkualitas. proses rujukan ibu bersalin berkualitas dan persalinan normal memberikan kontribusi sebesar 5,1% pada ibu sehat pasca persalinan sedangkan 94,9% disebabkan oleh faktor lainnya. pembahasan proses r uju kan ibu bersalin yang berk ualitas mempunyai hubungan yang bermakna dengan ibu sehat. hasil uji variat menunjukkan bahwa prevalensi ibu sehat pada proses rujukan ibu bersalin berkualitas lebih besar dibandingkan prevalensi ibu sehat pada proses rujukan tidak berkualitas. penelitian ini menunjukkan bahwa proses rujukan ibu bersalin yang berkualitas akan membuat ibu menjadi sehat pada pasca bersalin. proses rujukan ibu bersalin dikatakan berkualitas, karena telah sesuai dengan prinsip dasar merujuk secara umum berdasarkan buku acuan palayanan maternal dan neonatal. empat hal yang mendasari dalam proses rujukan yang harus terpenuhi adalah stabilitasi penderita, ketersediaan transportasi, pendampingan oleh tenaga kesehatan dan disertainya surat rujukan. hasil penelitian ini menunju k kan bahwa institusi yang merujuk telah melakukan stabilisasi penderita dengan memberikan infus atau obat-obatan. tersedianya transportasi atau kendaraan untuk membawa ibu ke fasilitas rujukan dengan tidak menunggu proses ijin atau hal-hal yang akan memperlambat proses rujukan. selama proses rujukan ibu didampingi oleh tenaga kesehatan, hal ini menunjukkan ibu bersalin dalam pengawasan selama dalam perjalanan. disertainya surat rujukan pada proses r ujukan, untuk mempercepat ibu bersalin mendapatkan pertolongan segera oleh tenaga kesehatan di fasilitas rujukan. variabel luar yang mempengaruhi morbiditas ibu adalah variabel cara persalinan. persalinan normal dapat mempengaruhi morbiditas ibu menjadi setelah pasca persalinan dibandingkan persalinan caesar. persalinan normal akan mengurangi akibat yang terjadi pada persalinan caesar seperti infeksi karena adanya luka, komplikasi karena anestesi, ibu tidak dapat beraktifi tas segera setelah melahirkan. hasil penelitian ini hampir sama dengan hasil penelitian choudhry (2005) kualitas pelayanan kesehatan dapat memberikan kepuasan pada klien bila kilen akan menjadi sehat. klien tidak puas bila dapat menyebabkan kematian atau komplikasi bila penanganan tidak berkualitas. ruminjo (2003) mengatakan bahwa pelayanan persalinan berkualitas tinggi apabila mempunyai akses yang baik. pengetahuan, sikap dan keterampilan petugas merupakan hal yang penting. ketersediaan obatobat a n d a n kebija k a n p elaya n a n persalinan merupakan hal yang mendukung di dalam pelayanan kesehatan. kualitas pelayanan dipengaruhi oleh beberapa faktor antara lain, struktur, proses dan hasil. adapun yang termasuk dalam kategori struktur adalah bangunan fi sik, fasilitas pelayanan termasuk perlengkapan dan peralatan, bentuk organisasi, struktur pemerintahan, struktur organisasi dan kualifi kasi, serta biaya kesehatan. sedangkan yang termasuk dalam kategori proses adalah diagnosis, pengobatan, pembedahan dan konsultasi, rujukan, serta koordinasi yang berkesinambu ngan. kualit as pelayanan rujukan meliputi juga adanya obat-obatan, ketersediaan transportasi. variabel waktu tempuh ke fasilitas r ujukan dan tenaga kesehatan pengirim rujukan mempunyai hubungan yang bermakna secara praktis dan secara statistik. hal ini menunjukkan bahwa waktu tempuh ke fasilitas rujukan dan nakes pengirim rujukan dapat mempengaruhi proses rujukan ibu bersalin, terlihat pada tabel 5. waktu tempuh yang singkat yaitu kurang dari 60 menit sampai ke rumah sakit akan menurunkan morbiditas ibu pasca persalinan, karena ibu segera mendapat pertolongan yang optimal di tempat rujukan, hal ini membuat ibu menjadi sehat. tenaga kesehatan yang terlatih merupakan hal yang penting dalam proses r ujukan, karena tenaga kesehatan yang terlatih dapat menangani kegawadaruratan obstetri sesuai prosedur yang telah ditetapkan, sehingga selama diperjalanan ibu dapat diawasi dan ditangani secara darurat. tenaga kesehatan yang terlatih dapat melakukan pertolongan 168 jurnal ners vol. 7 no. 2 oktober 2012: 161–169 kegawadaruratan maternal, sehingga kondisi ibu sampai kefasilitas rujukan tetap dalam keadaan baik dan ibu bersalin mendapat pertolongan secara optimal. hasil penelitian macintyre dan hotchkiss (1999) menyebutkan bahwa transpor tasi mempengaruhi rujukan karena waktu tempuh menuju rumah sakit mempengaruhi kualitas rujukan. faktor lain yang mempengaruhi rujukan meliputi faktor masyarakat yang berkaitan dengan sistem kesehatan (community factors health system) adalah meliputi jarak ke fasilitas, ketersediaan fasilitas, biaya transportasi, biaya konsultasi dan medis serta asuransi, kualitas pelayanan dan keterlibatan masyarakat. faktor masyarakat lainnya (other community factors), antara lain ketersediaan transportasi, kendaraan/bahan bakar, norma dan sikap masyarakat serta musim. hamlin (2004) menganggap bahwa keterlambatan ibu bersalin untuk mencapai fasilitas pelayanan r uju kan dapat disebabkan fak tor jarak antara tempat tinggal dengan lokasi rujukan. pelayanan rujukan ibu bersalin berkualitas tinggi apabila mempunyai akses yang baik atau mudah diakses. ibu bersalin dirujuk didampingi oleh bidan, disertai partograph, tersedianya transportasi dan kondisi umumnya baik mengurangi morbiditas ibu. pasien dengan komplikasi obstetri yang tinggal di wilayah terpencil akan mengalami kesulitan mengakses tempat rujukan bila rumah sakit tempat pelayanan kegawadaruratan berada di kota, bila jarak tempuh lebih dari 1 jam. hasil analisis bivariabel hubungan antara variabel kondisi ibu bersalin saat dirujuk, waktu tempuh kefasilitas rujukan, kompetensi nakes pendamping r uju kan dan cara persalinan dengan proses rujukan ibu bersalin, menunjukkan bahwa terdapat hubungan yang bermakna antara variabel wakt u tempuh ke fasilitas r ujukan dan kompetensi nakes pendamping r uju kan dengan proses rujukan ibu bersalin. kondisi ibu bersalin saat dirujuk dan cara persalinan tidak mempunyai hubungan yang signifi kan dengan proses rujukan ibu bersalin. walaupun tidak mempu nyai hubu ngan sig nif i kan secara statistik, tetapi kondisi ibu secara biologis akan mempengaruhi kesehatan ibu pascasalin. kondisi ibu pada saat dirujuk dalam keadaan tidak sadar ini akan beresiko ibu akan terjadinya kematian. waktu tempuh ke fasilitas rujukan dan kompetensi nakes pendamping rujukan pada proses rujukan ibu bersalin berkualitas lebih besar. hasil penelitian ronsmans et al. (2001) menunjukkan bahwa strategi penempatan bidan di desa, dapat menyelamatkan dari kematian pasien dengan komplikasi obstetri.(8) sedangkan jahn et al. (1998) mengungkapkan jarak antara r umah ibu hamil ke tempat pelayanan mer upakan faktor determinan yang sangat penting dalam pemanfaatan pelayanan rujukan obstetri. hasil penelitiannya menemu ka n sek it a r 58% pema n fa at a n perawatan obstetri bertempat tinggal dalam radius 10 k ilometer dar i r u mah sak it. pentingnya penolong persalinan yang terampil dalam menolong persalinan untuk mengurangi kematian ibu dan neonatal dan morbiditas ibu. tenaga kesehatan terampil dapat dibuktikan dengan sertifi kasi tentang pelatihan kalakarya dalam menangani komplikasi obstetri dan emergensi neonatus. pelayanan primer seharusnya mampu memberikan pelayanan obstetri esensial komprehensif ( pon ek) ( depkes. r i, 2006). untuk meningkatkan kualitas petugas kesehat a n perlu d ila k u k a n pember ia n pelatihan asuhan persalinan normal (apn), keterampilan komunikasi interpesonal dan konseling (kip/k), pelatihan life saving skill (lss) dan pelatihan manajemen pelayanan obstetri dan neonatal emergensi komperhensif bagi tim ponek di rumah sakit yang terdiri dari bidan, perawat, dan dokter dalam rangka meningkatkan dan mengembangkan dengan sistem targetted performance contract. hasil wawancara mendalam proses rujukan ibu bersalin dikatakan berkualitas karena pada pelaksanaan proses rujukan ibu bersalin dengan komplikasi obstetri bidan selalu melakukan stabilisasi penderita yaitu dengan pemberian cairan infus intravena dan obat-obatan. transportasi yang diperlukan untuk membawa ibu ke rumah sakit rujukan diperoleh dengan cepat karena alat transportasi yang sering dipakai adalah kendaraan umum atau mobil pribadi. selama proses rujukan ibu 169 parameter rujukan ibu bersalin (zubaidah, dkk.) bersalin penderita selalu didampingi oleh nakes dan bidan sudah mendapatkan pelatihan. pada saat merujuk selalu disertai surat rujukan yang menjelaskan tentang riwayat kesehatan ibu. proses rujukan ibu bersalin dalam penelitian ini merupakan rujukan ibu bersalin yang berkualitas karena memenuhi empat hal yang harus dilakukan sesuai protap proses rujukan ibu bersalin dengan komplikasi obstetri. simpulan dan saran simpulan ibu bersalin yang dirujuk yang terbanyak adalah dengan parameter partus lama, ketuban pecah dini dan anemia. sedangkan ibu bersalin yang dirujuk dengan alasan perdarahan dan nyeri perut hebat sedikit. prevalensi ibu sehat lebih besar pada proses rujukan ibu bersalin yang berkualitas dibandingkan prevalensi ibu sehat pada proses rujukan ibu bersalin yang tidak berkualitas. faktor luar yang mempengaruhi proses rujukan ibu bersalin adalah waktu tempuh ke fasilitas rujukan dan kompetensi tenaga keseahatan pendamping rujukan. saran perlu terus diupayakan peningkatan pengetahuan tenaga kesehatan (bidan, dokter, perawat) tentang prinsip dasar dalam merujuk ibu bersalin meliputi stabilisasi penderita, pendampingan, surat rujukan, dan tata cara ketersediaan transportasi, serta penanganan kegawadaruratan maternal dan neonatal. untuk daerah dengan akses pelayanan rujukan yang sulit diusulkan untuk mempersiapan kesiagaan warga masyarakat dalam ketersediaan sarana transportasi untuk secepatnya membawa ibu bersalin ke rumah sakit sehingga memudahkan akses terhadap fasilitas rujukan. di samping it u p uskesmas perlu mela k u ka n ker ja sama dengan perangkat desa, menjelaskan pentingnya membentuk kesiapan masyarakat dalam memberikan perhatian pada keluarga yang mempunyai ibu hamil. keikutsertaan masyarakat dalam menyelamatkan jiwa ibu bersalin. kepustakaan chowdhur y, r.i., islam, m.a., gulshan, j., chakraborty, n., 2007. delivery complication and healthcare seeking behavior: the bangladesh demographic health survey, 1999–2000, health soc care community, 15(3): 254–264. departemen kesehatan republik indonesia, 20 06. pe d om a n si ste m ruju k a n maternal dan neonatal. jakarta. hamlin, c., 2004. preventing fistula: transport's role in empowering communities for health in ethiopia. jahn, a., kowalewski, m., kimatta, s.s., 1998. obstetric care in southern tanzania: does it reach those in need?. trop med int health, 3(ii): 926–932. macintyre, k. dan hotchkiss., 1999. rd refe r r a l re v i sit e d : c o m mu n it y financing schemes and emergency transport in rural africa. soc sci med, 49: 1473–1487. ronsman, c., endang, a., gunawan, s., zazri, a., mcdermot, j., koblinsky, m., marshall, t., 2001. evaluation of comprehensive home-based midwifery programme in south kalimantan, indonesia. trop med int health, 6(10): 799–810. ruminjo, j., cordero, c., beattie, k.j., wegner, m.n., 2003. quality of care in labor and delivery: a paradox in the dominican republic; commentary, obstet gynecol, 82: 115–119. 126 bullying behaviour of adolescents based on gender, gang and family kadek ayu erika, dian atma pertiwi, tuti seniwati school of nursing, hasanuddin university, makassar, indonesia email: kadek20_uh@yahoo.com abstract introduction: bullying is a social problem which is characterised by aggressive violent behaviour done continuously and has an adverse impact on victims and its subject and happens at school. this study aims to find out the description of knowledge and adolescents’ behaviour with regard to bullying based on their age, gang and family. methods: this study used an analytic descriptive design with some samples – 246 adolescents from grade 1, 2, and 3 of senior high school which used stratified random sampling. instruments of this study were a knowledge questioner and a modified version of the bullying prevalence questionnaire in guttman and likert scale. data analysis used cross tabulation. result: data show that adolescents have a good knowledge (93.9%) of bullying and less (6.1%). bullying subjects were 93.9% and victims 94.7%. forms of verbal bullying indicated the subjects (93.1%) and victims (92.3%). the majority of bullying subjects were males (94.1%), and the majority of victims were women (96.3%). numbers of bullying subjects do not have a gang (94.5%), while those with a gang as victims (95.2%). there were five adolescents who live in stepfamilies who became subjects and victims of bullying. conclusion: the majority of adolescents have good knowledge about bullying, the vast majority of cases of bullying were verbal bullying with subjects and victims of bullying occurring in all classes. the majority of bullying subjects do not have a gang, and the majority of victims have a gang. almost all adolescents with different family types become subjects and victims of bullying. therefore, an intensive educational and spiritual effort needs to be made to change the behaviour of adolescents so that they are adolescents with good character. keywords: bullying, gender, gang, family. ____________________________________________________________________________________________________ introduction bullying behaviour is a social problem that is part of the violent behaviour done aggressively with discrete hurt either physically, verbally, psychologically, through an intermediary and without an intermediary, violating the rights, the power difference between perpetrator and victim and which is repeatedly performed (lai, ye, & chang, 2008). in recent years, the phenomenon of bullying has become a source of concern all over the world and it is constantly increasing and significantly mainly occurring in children and adolescents, especially at school age (lai et al., 2008). the world health organization (2012) reported that the health behaviour of schoolage children in europe ranges from 2% to 27% of girls becoming victims of bullying, and 5% to 32% of boys. according to statistics on bullying, the data also demonstrates that 70.6% of students in the united states (us) have watched bullying in their schools and more than 30% of students reported experiencing bullying (bullying statistic, 2015). moreover, according to data from the national center for education (nce) (2007), approximately 3.2 million youth aged 12–18 have reported experiencing some form of bullying, and more than 160,000 children missed school every day because of trauma as a result of the terror received in school (santoyosep, 2013). according to cokokinarto et al. (2013), cases of bullying that occur in indonesia, including in the order of 2 ads highest in the world after japan, followed by canada and the us. this is also supported by the number of reports from the public to the indonesian child protection commission (kpai) against bullying cases from 2011 to august 2014; there were 369 complaints which are about 25% of the total complaints in the field of education which has as many as 1480 cases (setyawan, 2014). the results of the study of the national consortium characters in the school development firmansyah (2014), showed that almost all schools in indonesia experienced bullying. based on this, the study stated that indonesia was categorised as an emergency for bullying in schools. according to edwards (2006) in usman (2013), bullying is most common in high school because adolescence has a high level of egocentrism. based on a survey conducted on 40 students of class xii in one secondary school (high school) in the city of semarang, 32.5% of students had been a subject, victim, or witness of bullying; 27.5% had been a witness only, 10% were victims and bullying behavior of adolescents based on gender, gang, and family (kadek ayu erika et.al.) 127 witnesses; 7.5% were subjects or witnesses; and 25% were the subject of bullying alone (sugiariyanti, 2009). according to soedjatmiko, nurhamzah, maureen, & wiguna) (2013), most victims of bullying will experience a negative impact in the form of barriers to actualising themselves, mental disorders and psychosocial disorders. this is because students feel they are in a state of distress, danger or insecurity and comfortable, have a sense of worthlessness, difficulty concentrating, find it difficult to socialise within their environment, have poor self-esteem, depression which affects academic performance and can even lead to suicide (sejiwa, 2008). one of the effects of bullying is a decrease in the level of achievement in school. this is evidenced by the results of research by dwipayanti & indrawati (2014), that the higher the bullying experienced by victims of bullying, the lower the academic achievement. research on students 'knowledge about bullying’, especially in the area of makassar south sulawesi has not been done, while the students' knowledge is very influential in bullying behavior before further action. some studies say that to solve a case of bullying, the intervention must be carried out with the perpetrators and the victims. effectiveness depends on the participants' knowledge, empathy, and adherence to the intervention (chatters, 2012). based on interviews with three students of sma negeri 1 tanete rilau, it was found that violence is very common, especially during student orientation periods (mos) occurring between seniors and juniors. also, the coordinator of counseling (bk) said that violence has occurred from year to year and the data recorded that several students had been threatened with expulsion from school. this study aims to describe the knowledge and behaviour of adolescents’ bullying based on gender, gang and family. methods the study design is descriptive analysis with cross tabulation between the variables gender, having a gang and type of family with adolescent bullying behaviour. research was conducted at sman 1 tanete rilau, district tanete rilau, barru, south sulawesi in october–november 2015. the population in this study were all adolescents in the 1 st , 2 nd , and 3 rd grade of senior high school (sma negeri 1 tanete rilau). in the 2015–2016 school year, there were 638 adolescents, with a sample of 246 adolescents selected by using a stratified random sampling technique. the samples for each class were obtained by selecting students who have an odd number on their student identification in each class. the inclusion criteria were teens at a research site for the study with a signed informed consent sheet. the variable in this study concerning the knowledge of adolescents about bullying included definitions, characteristics, causes, impacts and forms of bullying consisting of verbal bullying, physical, psychosocial/mental, and cyberbullying; variable bullying behaviour can be identified as subjects and victims of bullying, obtained from respondents through a modified version of the bullying prevalence questionnaire (physical, verbal, psychological/ mental and cyber), gender variable, gang variable, and family variable in terms of the biological family (living with parents and siblings), stepfamilies and non-biological families. the instrument used in this study was to test the validity and reliability of knowledge about bullying including a questionnaire with the value of cronbach's alpha equalling 0.959 and a corrected item-total correlation > r table (0.361), with 12 questions using the guttman scale; the bullying prevalence questionnaire was modified by researchers with the value of cronbach's alpha equalling 0.921 and corrected item-total correlation> r table (0.361), with 32 questions containing subjects and, for victims of bullying, using a likert scale; and biodata respondents. the data were processed and analysed descriptively and presented in a frequency distribution table. furthermore, bullying behavior was analysed in cross tabulation with the variables gender, gang and family type. results the frequency distribution based on the characteristics of the respondent can be seen in table 1, based on the knowledge and behaviour of bullying in table 2, and forms of bullying in table 3. table 1 shows that most respondents were female adolescents (65.4%), in grade 3, totalling 87 (35.4%), and only 63 respondents jurnal ners vol. 12 no. 1 april 2017: 126-132 128 had a gang. the majority of respondents lived with a biological family, namely 203 adolescents (82.5%). table 2 shows that the majority of the 246 respondents had a good knowledge of bullying – 231 adolescents (93.9%). while the number of bullying subjects was 231 adolescents (93.9%) and 233 adolescents (94.7%) as victims of bullying. table 3 shows that of the 231 bullying subjects, as many as 74% (171 adolescents) did the physical bullying, 93.1% (215 adolescents) did the verbal bullying, 73.6% (170 adolescents) did the bullying psychosocially/ mentally, and 24, 7% (57 adolescents) did cyber bullying. from the 231 respondents who became bullying subjects, there were some adolescents who became actors in more than one form of bullying. of the 233 victims of bullying, as many as 83.7% (195 adolescents) were victims of physical bullying, 92.3% (215 adolescents) were victims of verbal bullying, 67.4% (157 adolescents) were victims of bullying psychosocially/mentally, and 28.3% (66 respondents) became victims of cyber bullying. cross tabulation results of subjects and victims of bullying based on gender are shown in table 4, having a gang in table 5, and the type of family in table 6. table 4 shows that table 1. frequency distribution of respondents by gender, class, gang and family type (n= 246) n % gender male female 85 161 34,6 65,4 grade i ii iii 81 78 87 32,9 31,7 35,4 having gang yes no 63 183 25,6 74,4 family type biological family step family non-biological family 203 5 38 82,5 2 15,4 table 2. frequency distribution of respondents by knowledge and bullying behaviour (n = 246) knowledge n % good not good 231 15 93,9 6,1 behaviour doing bullying not doing bullying 231 15 93,9 6,1 victims of bullying not victims of bullying 233 13 94,7 5,3 table 3 frequency distribution of respondents by forms of bullying form of bullying subjects victims % % subjects of physical 74 83,7 non-subjects of physical 26 16,3 subjects of verbal 93,1 92,3 non-subjects of verbal 6,9 7,7 subjects of psychosocial/ mental 73,6 67,4 non-subjects of psychosocial 26,4 32,6 subjects of cyber bullying 24,7 28,3 nonsubjects of cyber bullying 75,3 71,7 jurnal ners vol. 12 no. 1 april 2017: 126-132 129 the distribution of bullying behaviour by gender of 85 male adolescents showed 80 bullying subjects (94.1%) and victims amounting to 78 adolescents (91.8%). while the teenage girls’ category of bullying subjects showed 151 (93.8%) and the category for victims included 155 (96.3%) of 161 girls. table 5 shows the distribution of bullying behaviour by gangs amongst 63 adolescents who have a gang, with categories of bullying subjects numbering 58 (92.1%) and the victims numbering 60 adolescents (95.2%). amongst the 183 adolescents who did not have a gang, numbers of bullying subjects as well as victims were respectively 173 adolescents. (94.5%). table 6 shows that the distribution of bullying behaviour by family of 203 adolescents who live with their biological families, included 188 bullying subjects (92.6%) and 191 victims (94.1%). there were five adolescents who lived with stepfamilies, showing that all adolescents (100%) became bullying subjects or victims of bullying, while 38 adolescents lived with no biological family, and all of these adolescents (100%) became bullying subjects and 37 adolescents were victims (97.4%). discussion data shows most adolescents have good knowledge about bullying. this is in line with research by fajrin (2013) which shows a high percentage in terms of student knowledge about bullying at smk pgri semarang. knowledge of bullying is very closely related to the information that has been obtained by respondents from various sources. one source of information that is important for this knowledge is the mass media. also, information can be derived from a teacher through the learning process. based on notoatmodjo (2010), people who have more resources will have a broad knowledge. adolescent knowledge is based on indicators of knowledge about the definition of bullying, the characteristics of bullying, forms of bullying, bullying causes and effects of bullying. the results of the evaluation questionnaire on each question showed that more than half of the respondents answered wrongly the question about the forms of bullying. this could have been caused by information obtained by adolescents that bullying is confined in general to a form of violence. however, adolescents’ information about forms of bullying is still lacking. bullying is a problem that occurs among children and adolescents and continues to receive attention from researchers. based on the results of the categorisation of subject scores of subjects and victims of bullying it is known that as many as eight adolescents very often become bullying subjects, often (14 adolescents) and sometimes become subjects (80 adolescents). while very often the victim table 4. frequency distribution of subjects and victims of bullying by sex (n=246) sex subjects non subjects victims non victims % % % % male 94,1 5,9 91,8 8,2 female 93,8 6,2 96,3 3,7 table 5.frequency distribution of subjects and victims of bullying according to gang group (n=246) gang group subjects not subjects victims non-victims % % % % having gang 92,1 7,9 95,2 4,8 non-having gang 94,5 5,5 94,5 5,5 table 6. frequency distribution of subjects and victims of bullying by family type (n=246) family type subjects not subjects victims non-victims % % % % biological family 92,6 7,4 94,1 5,9 step family 100 0 100 0 non-biological family 100 0 97,4 2,6 jurnal ners vol. 12 no. 1 april 2017: 126-132 130 of bullying as much as 7 adolescents, often (20 adolescents) and 81 adolescents sometimes become victims of bullying. thus, it shows that adolescents sometimes become subjects and victims of bullying. this is according to research conducted by usman (2013) which indicates that the student encounters moderate bullying behaviour . but keep in mind also the subjects and victims of bullying in the category very often will have an impact on their adolescent psychology. this is supported by research kpai (2013) which recorded 181 cases of bullying that led to a death. one of them is the case of a child aged 13 years in bekasi who committed suicide in 2005 triggered by a sense of inferiority and frustration because he was often derided as a son of a chicken porridge seller by his school friends (sari, 2015). results of identification about forms of bullying found that the highest form of bullying is verbal bullying. this was according to research conducted by olweus (1994) and kshirsagar (2007) in nurhamzah et al. (2013) which said that the form of bullying which most often occurs in schools is verbal bullying. the results of our analysis showed that of 96.5% (223 adolescents who became subjects as well as victims of bullying among other things as much as 87.1% experienced the physical form (149 adolescents), verbal 91.6% (197 adolescents), psychosocial/mental 70,6% (120 adolescents) and cyber bullying 64.9% (37 adolescents). this incident caused by a history of being bullied and to respond with violence also against his friend. in accordance with the theory of harris & petrie (2003) the subjects of bullying who also became victims of bullying were adolescents who were bullied, and later also found ways to do the bullying to others as an expression of pleasure, revenge or a wish to be praised. bullies in adolescent males made up a higher percentage than girls. this is in line with the results of research by aluede & oyaziwo (2006) and research by magfirah & rachmawati (2009) which showed that adolescents were more often subjects as well as victims of bullying. the reason why adolescent males tend to be more aggressive psychologically is related to their need to show physical strength and adolescent males are also often exposed to games that have violent elements (cerni obrdalj & rumboldt, 2008). as the victims of bullying, adolescent girls make up a higher percentage than adolescent males. this is consistent with the theory of the green et al. (2010) and research by nurhamzah et al. (2013) which said that women were more likely to be bullied than men. in a gang takes compactness starting of attraction which encouraged him to continue to be a member of the group and met intense and behave in line with the group members are commonly referred to conformity (leviani, 2008). research conducted by nation et al. (2008) amongst 4386 middle school students and high school students from 151 middle and 92 high schools in italy and the usa found an association between bullying behaviour and peer pressure to be accepted into a group. this study shows different results, with adolescents who do not have a gang making up a higher percentage of bullying subjects, while adolescents with a gang have a higher percentage as the victims of bullying. it can be influenced by several factors, among others, personal factors such as personality, attitudes, genetic predisposition and situational factors in the form of provocation, frustration, and drugs according to anderson and bushman (2002) in usman (2008). in addition, a study reveals that high school students are no longer dependent on the pressures or decisions of their peers to do bullying behaviour, because, at such a time, high school students are able to think objectively about what to do and have increasing values of morality themselves (eisenberg & aalsma, 2005). several studies have shown that families, especially parents, play an important role in children who commit acts of bullying. rigby (2005) in a study of middle school students (200 students) and high school students (200 students) in adelaide in south australia revealed that bullying behaviour is caused by a lack of support from parents to children to do so and also found that students who did the bullying behaviour come from families with broken homes. the results showed that the respondents who were living with stepfamilies and not biological families all became bullying subjects, even though biological families also showed a high percentage. for the victims of bullying, all the adolescents who lived with stepfamilies became victims of bullying. according to wiyani (2012), bullying subjects are usually the children of authoritarian parents, with jurnal ners vol. 12 no. 1 april 2017: 126-132 131 violent behaviour, or those who are too permissive towards the aggressive behaviour of children. thus, this study showed that although the respondents live with their biological parents, if they have parents who are authoritarian and often do violent behaviour this will form a distinct personality with respondents who lived with stepfamilies or not the biological parents who are educated without showing violence, so bullying behaviour does not occur. apart from the family, the cause of bullying could come from the environment, especially the school environment. the school environment can be seen as a community ecosystem that connects between context and individual identity in a balanced manner so that a small change both in attitudes and behaviour at school can affect the behaviour of adolescents. conclusion the majority of adolescents have good knowledge about bullying, but most adolescents do not know the forms of bullying. forms of bullying in adolescents are mostly verbal bullying with subjects and victims of bullying occurring in all classes. the majority of bullying subjects do not have a gang, and the majority of victims have a group. almost all adolescents with different family types become adolescents and victims of bullying. the importance of an intensive educational and spiritual effort should be recognised to change the behaviour of adolescents to help them become adolescents with good character and conduct regular monitoring of the students and impose sanctions so that their awareness is raised to always behave well towards their peers. reference aluede & oyaziwo. (2006). teachers’ opinions of school counseling programs in nigerian secondary schools, 33, 42. bullying statistic. (2015). bullying statistics, the ultimate guide ! |nobullying|. cerni obrdalj & rumboldt, m. (2008). bullying among school children in postwar bosnia and herzegovina: crosssectional study. croatian medical journal, 49(4), 528–535. chatters, s. j. (2012). impact of bullying prevention training on the knowledge, attitude, and behavior of pre-education majors (future trainers). proquest llc. university of south florida. cokokinarto, k., suwasono, a. a., salamoon, d. k., petra, u. k. & cokokinarto, k. (2013). perancangan film pendek mengenai "bully ”. dwipayanti & indrawati, k. r. (2014). hubungan antara tindakan bullying dengan prestasi belajar anak korban bullying pada tingkat sekolah dasar ida ayu surya. jurnal psikologi udayana, 1(2), 251–260. eisenberg, m. e. & aalsma, m. c. (2005). bullying and peer victimization: position paper of the society for adolescent medicine. journal of adolescent health, 36(1), 88–91. fajrin, a. n. (2013). hubungan antara tingkat pengetahuan dengan perilaku bullying pada remaja di smk pgri semarang. universitas muhammadiyah semarang. firmansyah, t. (2014). aduan bullying tertinggi. green, r., collingwood, a. & ross, a. (2010). characteristics of bullying victims in schools. religion, 117. https://doi.org/892d harris, s. & petrie, g. f. (2003). bullying: the bullies, the victims, the bystanders. texax: scarecrow press. lai, s.-l., ye, r. & chang, k.-p. (2008). bullying in middle schools: an asianpacific regional study. asia pacific education review, 9(4), 503–515. https://doi.org/10.1007/bf03025666 leviani. (2008). konformitas dan bullying pada siswa. jurnal psikologi, 6(1), 1. magfirah, u. & rachmawati, m. a. (2009). fakultas psikologi dan ilmu sosial budaya universitas islam indonesia. nation, m., vieno, a., perkins, d. d. & santinello, m. (2008). bullying in school and adolescent sense of empowerment: an analysis of relationships with parents, friends, and teachers. journal of community & applied social psychology, 18(3), 211–232. https://doi.org/10.1002/casp.921 notoatmodjo. (2010). metodologi penelitian kesehatan. jakarta: rineka cipta. nurhamzah, w., maureen, a. & wiguna, t. (2013). gambaran bullying dan hubungannya dengan masalah emosi dan perilaku pada anak sekolah dasar, jurnal ners vol. 12 no. 1 april 2017: 126-132 132 15(3), 174–180. santoyosep. (2013). bullying di sekolah , cara pencegahan dan penanganannya. sari, t. d. (2015). aksi bullying di kalangan siswa sekolah menengah atas wilayah surakarta tahun 2014/2015. universitas sebelas maret. sejiwa, y. s. (2008). bullying: mengatasi kekerasan di sekolah dan lingkungan sekitar anak. jakarta: gratisindo. setyawan, d. (2014). kpai : kasus bullying dan pendidikan karakter, komisi perlindungan anak indonesia (kpai). soedjatmiko, s., nurhamzah, w., maureen, a. & wiguna, t. (2013). gambaran bullying dan hubungannya dengan masalah emosi dan perilaku pada anak sekolah dasar. sari pediatri, 15(3), 174. https://doi.org/10.14238/sp15.3.2013.174 -80 sugiariyanti. (2009). perilaku bullying pada anak dan remaja. jurnal ilmiah psikologi, 1, 101–108. usman, i. (2008). perilaku bullying ditinjau dari peran kelompok teman sebaya dan iklim sekolah pada siswa sma di kota gorontalo. fakultas ilmu pendidikan universitas negeri gorontalo. usman, i. (2013). kepribadian, komunikasi, kelompok teman sebaya, iklim sekolah dan perilaku. jurnal humanitas, 10(1), 50–60. wiyani, n. a. (2012). save our children from school bullying. yogyakarta: ar ruzz media. world health organization (who). (2012). health behavior in school aged children (hbsc) study:international report from the 2009–2010 survey. ners vol 5 no 1 april 2010_akreditasi 2013.indd 49 madu temulawak meningkatkan berat badan anak usia toddler (curcuma and honey increases body weight of toddler) renny f*, yuni sufyanti a*, nk alit* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fax: (031) 5913257. e-mail: yazt_ien87@yahoo.com abstract introduction: toddler may have poor appetite and picky eater stage. it will infl uence the children food intake and thereby they loss weight. as a result they may get a growth and developmental disorder. curcuma honey can increase appetite and infl uence body weight. the purpose of this study was to analyze the infl uence of giving curcuma honey in increasing body weight in toddler. method: quasy experimental design was used in this study. sample was 10 toddlers and divided into two groups. independent variable was the giving of curcuma honey and dependent variable was the increase of body weight in toddler (1–3 years). data were collected by appetite and bodyweight observation and analyzed using paired t-test and independent t-test with signifi cance level of α ≤ 0.05. result: result showed that the giving of curcuma honey had a signifi cant effect to increase toddler’s body weight (p = 0.001). discussion: it can be concluded that curcuma honey could increase body weight of toddler by increasing the toddler’s appetite. honey contains high level of glucose and fructose that can help digestion proccess and curcuma contains curcuminoid and asiri oil that help the work of the bile and pancreas, that made the increasing in apetite and fi nally the increasing in body weight. keywords: curcuma honey, toddler, increasing of body weight pendahuluan p e r t u m b u h a n d a n p e r k e m b a n g a n anak mulai melambat pada usia toddler. pertumbuhan tubuh dan otak pada tahun kedua lebih lambat daripada umur sebelumnya (nelson, 1999). usia toddler disebut juga usia food jag, yaitu anak hanya mau makan makanan yang disukai sehingga terkesan terlalu pilih-pilih dan sulit makan. keadaan sulit makan yang berkepanjangan akan memengaruhi proses tumbuh kembang anak, salah satunya adalah penurunan berat badan dan hal ini dapat membuat anak menjadi kurang gizi. di masyarakat, sering kita mendengar pengobatan secara tradisional untuk mengatasi kurang nafsu makan, salah satunya dengan memberikan temulawak atau dalam bahasa latin dikenal dengan nama curcuma xanthorriza robx. rahmat dan setianingrum (2003) membuktikan dalam penelitiannya bahwa temulawak dapat meningkatkan nafsu makan pada penderita anorexia primer karena temulawak mengandung curcumin yang mampu memperbaiki kelainan pada empedu, sehingga proses penyerapan makanan di dalam usus lebih baik. madu merupakan zat manis alami yang dihasilkan lebah dengan bahan baku nektar bunga, sumber energi dan bahan yang diubah menjadi lemak dan glikogen (darmawan, 2003). para ilmuwan amerika menyatakan bahwa madu, royal jelly, serbuk sari dan propolis dapat mengobati berbagai penyakit. penelitian widodo (2007) membuktikan bahwa madu dapat meningkatkan nafsu makan pada balita yang menderita kurang energi protein. widodo mengungkapkan bahwa di dalam madu mengandung kadar glukosa dan fruktosa yang tinggi sehingga mampu memperbaiki proses penyerapan makanan. peningkatan nafsu makan akan meningkatkan asupan nutrisi yang ditandai dengan peningkatan berat badan anak sesuai dengan usia maupun tinggi badan. namun pengaruh pengobatan secara tradisional yaitu dengan campuran madu temulawak untuk meningkatkan berat badan pada anak usia toddler belum dapat dijelaskan. jurnal ners vol. 5 no. 1 april 2010: 49–54 50 indonesia, penurunan nafsu makan dialami oleh sekitar 25% pada usia balita (judarwanto, 2004). penurunan nafsu makan ini akan berdampak pada penurunan asupan makanan dan dapat berakibat pada penurunan berat badan. gizi kurang merupakan salah satu masalah gizi utama pada balita di indonesia. gizi buruk merupakan bentuk terparah dari proses terjadinya kekurangan gizi menahun. dari data koalisi untuk indonesia sehat, dari tahun 2000–2007 dilaporkan balita dengan gizi kurang berjumlah dari 1.348.181 menjadi 1.528.676 atau mengalami peningkatan sebesar 13,4%. dinas kesehatan surabaya melaporkan pada tahun 2007 terdapat 312.000 anak dan di tahun 2008 terdapat 515.000 anak yang mengalami gizi kurang. menurut dinas kesehatan nganjuk jumlah balita gizi kurang 515 balita pada tahun 2007 dan 408 balita di tahun 2008 di kecamatan nganjuk. data pada bulan maret 2009 tercatat 407 balita gizi kurang di kecamatan nganjuk. desa kramat mencatat 20 anak usia toddler yang mengalami gizi kurang pada bulan maret dan 18 anak usia toddler yang mengalami gizi kurang pada bulan april. meskipun angka ini menurun, masih diperlukan berbagi upaya untuk menangani masalah gizi kurang pada balita khususnya anak usia toddler. gangguan nafsu makan umumnya dialami anak-anak usia 1–3 tahun atau usia prasekolah. pada usia ini anak menjadi sulit makan karena pertumbuhan fisiknya melambat dibandingkan usia 0–12 bulan. menurut nelson (1999), pertumbuhan tubuh dan otak pada anak yang berusia 2–5 tahun lebih lambat daripada umur sebelumnya, dengan penurunan yang seimbang pada kebutuhan nutrisi dan nafsu makan. penambahan berat badan anak usia toddler rata-rata 2 kg setiap tahun. menurut khomsan (2002), beberapa penyebab anak sulit makan antara lain terlalu lama memperkenalkan makanan pada anak usia toddler, sugesti terhadap jenis makanan tertentu sebagai pencetus alergi, kontrol berlebihan dari orang tua sehingga anak cenderung menolak bila terlalu diawasi, menu kurang variatif, terlalu banyak minum susu atau makan makanan camilan dan infeksi atau sakit yang diderita sehingga anak kehilangan nafsu makannya. tanda-tanda anak sulit makan dapat bermacammacam seperti makan dengan porsi sedikit, menunjukkan sikap enggan bahkan menolak ketika waktu makan tiba, memuntahkan atau menyembur-nyemburkan makanan yang sudah masuk di mulut anak, makan berlama-lama dan memainkan makanan, sama sekali tidak mau memasukkan makanan ke dalam mulut, menumpahkan makanan dan menepis suapan dari orang tua, hanya mau makan makanan cair atau lumat, menyukai jenis makanan tertentu dan cepat merasa bosan dengan makanan yang disajikan (judarwanto, 2004). masalah sulit makan pada anak usia toddler dapat menjadi masalah yang serius karena pada usia ini anak membutuhkan lebih banyak energi dan gizi untuk pertumbuhannya. foster dan anderson yang dikutip dari limananti dan triratnawati (2003) menunjukkan bahwa masalah kekurangan gizi yang berawal dari kurang nafsu makan terutama pada anak-anak setelah disapih menyebabkan anak kekurangan protein-kalori yang dapat menyebabkan kerusakan otak secara permanen, karena pada usia ini merupakan usia golden periode di mana jika terjadi kerusakan otak sifatnya irreversible (sulit untuk pulih kembali). peningkatan berat badan dipengaruhi oleh konsumsi makanan. konsumsi makanan pada anak dapat ditingkatkan dengan meningkatkan nafsu makan. salah satu alternatifnya adalah dengan menggunakan ramuan tradisional, yaitu pemberian madu temulawak. kandungan kimia temulawak yang mampu meningkatkan nafsu makan antara lain curcuminoid dan minyak asiri (xanthorrhizol, germacon dan lain-lain). menurut winarto (2003) dan astroamidjojo (2001) yang dikutip dari agustina (2006) minyak asiri dan kurkumin berperan meningkatkan kerja organ pencernaan, merangsang dinding empedu, mengeluarkan cairan empedu dan merangsang keluarnya getah pankreas yang mengandung enzim amilase, lipase dan protease untuk meningkatkan pencernaan bahan makanan karbohidrat, lemak dan protein. efek tersebut mengakibatkan adanya peningkatan konsumsi makanan oleh karena meningkatnya penyerapan zat-zat makanan. adanya peningkatan penyerapan makanan oleh tubuh, maka kebutuhan protein, karbohidrat dan madu temulawak meningkatkan berat badan anak (renny f.) 51 lain sebagainya untuk perkembangan sel-sel tubuh dan pembentukan enzim maupun hormon akan terpenuhi (rahmat dan setianingrum, 2003). menurut winarno (1982) yang dikutip dalam artikel penelitian tentang kandungan madu (2009), kadar glukosa (dekstrosa) dan fruktosa (levulosa) yang tinggi pada madu mudah diserap oleh usus bersama zat-zat organik yang lain, sehingga dapat bertindak sebagai stimulus dan memperbaiki nafsu makan. pemberian madu temulawak sebagai suplemen nafsu makan diharapkan mampu meningkatkan berat badan pada anak usia toddler. bahan dan metode rancangan yang digunakan dalam penelitian ini adalah eksperimen semu (quasyexperiment) yaitu kelompok eksperimental diberi perlakuan sedangkan kelompok kontrol tidak. pada kedua kelompok perlakuan diawali dengan pre test, dan setelah pemberian perlakuan diadakan pengukuran kembali (posttest). populasi yang digunakan adalah anak usia toddler di desa kramat kecamatan nganjuk. jumlah populasi anak usia toddler pada akhir bulan mei di desa kramat kecamatan nganjuk adalah 25 dan yang mengalami kurang gizi sebesar 18. kriteria inklusi dalam penelitian ini yaitu anak yang mengalami malnutrisi sedang dengan kriteria berat badan sesuai tinggi badan menurut standarisasi nchs, dirawat/ diasuh oleh orang tua, tidak mendapatkam makanan tambahan dari puskesmas, merupakan cakupan desa kramat kecamatan nganjuk, keluarga toddler mempunyai penghasilan yang cukup (>rp500.000,00/bulan). teknik pengambilan sampel pada penelitian ini dengan menggunakan purposive sampling yaitu suatu teknik penetapan sampel di antara populasi yang sesuai dengan yang dikehendaki, besar sampel yang digunakan adalah 10 anak sampel yang didapatkan tersebut kemudian dibagi menjadi 2 kelompok, yaitu kelompok perlakuan dan kelompok kontrol. penelitian ini dilaksanakan pada bulan juni 2009. variabel independen dalam penelitian ini adalah pemberian madu temulawak di mana dalam penelitian ini akan diberikan dengan melarutkan 1 sendok makan madu temulawak dalam 1/2 gelas (± 125 cc) air hangat, teh, atau susu diminum setiap pagi dan sore, sedangkan variabel dependen adalah peningkatan berat badan anak usia toddler di mana pengukurannya dengan menggunakan instrumen timbangan berat badan dacin dengan tingkat ketelitian 0,1, pengukur tinggi badan (infantometer untuk anak usia 1–2 tahun dan stadiometer untuk anak usia 2–3 tahun) dan format nchs. data yang didapatkan kemudian ditabulasi dan dianalisis dengan menggunakan uji statistik paired t-test dan independent t-test dengan tingkat kemaknaan α ≤ 0,05. hasil hasil penelitian pada saat pre-test rerata berat badan kelompok perlakuan 9900 gram. pada post-test seluruh berat badan responden naik dengan rerata berat badan 10220 gram. dari data berat pre dan post test pada kelompok perlakuan, kenaikan rerata berat badan yaitu 320 gram. pada kelompok kontrol pada pre-test rerata berat badan 9380 gram dan pada post test beberapa responden mengalami kenaikan berat badan dengan rerata 9420 gram. rerata kenaikan berat badan dari pra dan pasca yaitu 40 gram. hasil uji statistik paired t-test, pada k e l o m p o k p e r l a k u a n d i d a p a t k a n h a s i l p = 0,001 yang berarti bahwa adanya pengaruh yang signifikan berat badan sebelum dan sesudah diberikan madu temulawak. dari hasil uji statistik independent t-test pada post test didapatkan nilai probabilitas 0,006 berarti ada perbedaan yang signifikan berat badan anak antara yang diberi madu temulawak dengan anak yang tidak mendapat madu temulawak. pembahasan hasil penelitian ini menunjukkan bahwa kelompok perlakuan korelasinya sangat kuat dibandingkan kelompok kontrol, keadaan ini menunjukkan bahwa masukan nutrisi pada kelompok perlakuan lebih baik daripada kelompok kontrol. hasil tersebut diperkuat jurnal ners vol. 5 no. 1 april 2010: 49–54 52 dengan hasil uji statistik independent t-test yang menunjukkan bahwa ada perbedaan rata-rata berat badan antara yang diberi madu temulawak dan yang tidak diberi madu temulawak. nafsu makan adalah keadaan yang mendorong seseorang untuk memuaskan keinginannya dalam hal makan (limananti, 2003). menurut judarwanto (2004) anak usia 1 tahun mulai menunjukkan keinginankeinginan dalam hal makan. ada kalanya anak menyukai satu jenis makanan saja dan menolak makanan lainnya. usia 2 tahun anak mempunyai pola makan yang tidak menentu dan mulai susah makan atau pilih-pilih makanan. u s i a 3 t a h u n a n a k s e r i n g t i d a k menghabiskan porsi makannya. keadaan seperti ini yang apabila terus dibiarkan mengakibatkan terjadinya penurunan berat badan dan dapat membuat anak menjadi kurang gizi. menurut wong (2003) usia toddler mengalami peningkatan berat badan 2–3 kg per tahun atau sekitar 160–250 gram per bulan. gizi kurang merupakan keadaan tidak sehat (patologis) yang timbul karena asupan makanan yang masuk ke dalam tubuh tidak sesuai dengan kebutuhan (krisno, 2001 dalam wulandari, 2008). faktor-faktor yang memengaruhi gizi kurang adalah penyakit infeksi baik infeksi akut maupun kronis yang terjadi pada saluran pencernaan, penyakit metabolik yang merupakan penyakit herediter, kelainan anatomi dan fisiologi pada saluran pencernaan, kebiasaan memakan makanan yang berupa penelanan berulang atau kronis dari bahan bukan nutrient (picca), dan keadaan psikologi (krisno, 2002 dalam wulandari, 2008). selain itu, foster dan anderson yang dikutip dari limananti dan triratnawati (2003) menunjukkan bahwa masalah kekurangan gizi yang berawal dari kurang nafsu makan terutama pada anak-anak setelah disapih yang menyebabkan anak kekurangan kalori protein. anak usia 1–3 tahun merupakan konsumen pasif, yaitu makanan yang dimakan anak tergantung pada apa yang disediakan ibu. pada usia ini anak sangat rentan terhadap penyakit infeksi dan gizi. sehingga jumlah, jenis dan jadwal pemberian makanan pada anak harus terpenuhi. adapun pendapatan keluarga yang memadai akan menunjang tumbuh kembang anak karena orang tua dapat menyediakan semua kebutuhan anak (krisno, 2002 dalam wulandari, 2008). asupan makanan yang diberikan harus seimbang baik dalam jumlah, jenis, maupun jadwal pemberian makanan. jika hal tersebut tidak sesuai maka akan mengganggu asupan gizi yang masuk ke tubuh, dan apabila ini berlangsung terus-menerus dalam jangka waktu yang lama, maka batita akan mengalami kekurangan gizi seperti yang terjadi pada responden pada penelitian ini. menurut rostita (2007) madu memiliki kadar fruktosa dan glukosa yang tinggi sehingga mudah diabsorbsi oleh usus halus bersama zat-zat organik lainnya dan merangsang pencernaan bekerja lebih baik serta meningkatkan penyerapan makanan. penyerapan makanan yang baik dapat memicu nafsu makan. sedangkan temulawak mengandung kurkuminoid dan minyak asiri yang membantu kinerja empedu dan pankreas. adanya peningkatan kerja dari empedu dan pankreas akan meningkatkan proses pencernaan makanan. kombinasi dari madu dan temulawak akan meningkatkan khasiat keduanya dalam meningkatkan nafsu makan. perilaku seseorang dipengaruhi oleh beberapa faktor, menurut teori lawrence green (1980) faktor-faktor tersebut di antaranya adalah faktor predisposisi (predisposising factor) yang mencakup pengetahuan, sikap, kepercayaan tradisi, norma sosial, dan bentuk tabel 1. data berat badan anak kelompok perlakuan dan kontrol pre dan post perlakuan responden perlakuan kontrol pre (g) post (g) pre (g) post (g) rerata 9900 10220 9380 9420 paired t-test p = 0,001 p = 0,178 independent t-test post (p = 0,006) keterangan: p = signifi kansi madu temulawak meningkatkan berat badan anak (renny f.) 53 lainnya yang terdapat dalam diri individu dan masyarakat. faktor pendukungnya (enabling factor) adalah tersedianya sarana pelayanan kesehatan dan kemudahan untuk mencapainya dan faktor pendorong (reinforcing factor) perubahan perilaku adalah sikap dan perilaku petugas kesehatan (notoatmodjo, 2007). menurut allport (1954) dalam notoatmodjo (2007) sikap mempunyai tiga komponen pokok yaitu kepercayaan (keyakinan), ide dan konsep terhadap suatu objek dan kecenderungan untuk bertindak. hasil penelitian yang dilakukan di desa kramat, terdapat pengaruh pemberian madu temulawak terhadap peningkatan berat badan pada anak usia toddler khususnya yang mengalami gizi kurang. peningkatan berat badan ini dipengaruhi oleh adanya peningkatan nafsu makan yang memengaruhi asupan makanan. madu mengandung kadar fruktosa dan glukosa yang cukup tinggi sehingga madu dapat langsung diserap tanpa harus merubahnya menjadi bentuk gula yang lebih sederhana. kadar glukosa dalam madu akan mempercepat kerja insulin dalam menyimpan glukosa dalam sel dan menurunkan glukosa dalam darah. hal ini akan mempercepat penurunan kadar insulin dalam tubuh. fruktosa yang tinggi tidak memerlukan bantuan insulin untuk menyimpan dalam sel-sel tubuh. penurunan bahkan ketiadaan insulin ini memengaruhi hipotalamus ventromedial melalui aktivasi npy/agrp yang merupakan pusat pengendalian nafsu makan. curcuminoid dan minyak asiri yang terdapat dalam temulawak dapat meningkatkan nafsu makan dengan membantu memperlancar produksi cairan empedu dan sekresi pankreas yang menstimulus hipotalamus ventromedial. hal ini terbukti dari data analisis isi (content analize) di mana semua orang tua responden y a n g m e n d a p a t k a n m a d u t e m u l a w a k menyatakan terdapat peningkatan nafsu makan meskipun terkadang masih terdapat gejala tidak nafsu makan. seperti pada responden a2 terkadang masih suka menyemburkan makanan, responden a2 yang masih suka makan berlama-lama dan responden a5 yang tetap tidak menyukai variasi makanan. peningkatan nafsu makan ini meningkatkan asupan makanan sehingga kebutuhan tubuh akan energi dan protein tercukupi. protein dan energi yang tercukupi dapat memenuhi kebutuhan pertumbuhan sel-sel tubuh sehingga terjadi peningkatan berat badan. peningkatan berat badan pada kelompok perlakuan sebagian besar telah mencapai normal yaitu 160–250 gram per bulan, akan tetapi masih belum mencapai persentil 25 menurut berat badan sesuai tinggi badan, hal ini mungkin karena adanya keterbatasan waktu penelitian dan kurangnya kepahaman ibu terhadap pemenuhan gizi dan modifikasi makanan pada anak usia toddler. kelompok kontrol didapatkan hasil tidak adanya peningkatan berat badan dan juga tidak terdapatnya peningkatan nafsu makan. meskipun pada kelompok kontrol telah diberikan pendidikan gizi, dari hasil analisis isi wawancara orang tua responden didapatkan tidak adanya peningkatan nafsu makan. sebagian besar menyatakan porsi makan anak tetap dan gejala tidak nafsu makan masih ada, seperti pada responden b1 masih sering memuntahkan makanan, menutup rapat mulutnya saat akan makan, responden b3 yang masih menolak makanan, dan responden b5 yang masih pilih-pilih makanan. hasil ini berbeda dengan kelompok perlakuan yang mempunyai hasil yang positif terhadap peningkatan nafsu makan. pemberian pendidikan gizi tidak cukup memberikan pengaruh yang cukup besar untuk merubah perilaku ibu dalam hal pemberian makanan kepada anak usia toddler. pendidikan gizi hanya bersifat informasi, tidak memberikan pengalaman langsung sehingga menyebabkan kemampuan pengambilan keputusan untuk b e r s i k a p p o s i t i f t i d a k m e n j a m i n a k a n diterapkan. selain itu, tidak adanya motif dan kepercayaan tentang gizi serta tingkat pemahaman dan kepatuhan yang berbeda memengaruhi perubahan perilaku. simpulan dan saran simpulan pemberian madu temulawak yang diberikan secara rutin setiap hari dua kali dan setiap kali minum satu sendok makan dapat meningkatkan berat badan anak usia toddler. jurnal ners vol. 5 no. 1 april 2010: 49–54 54 saran peneliti memberikan saran agar: madu temulawak diberikan pada anak yang mengalami penurunan nafsu makan. saat nafsu makan anak membaik, pemberian madu temulawak dapat dihentikan. orang tua sebaiknya lebih banyak memvariasikan makanan makanan agar anak tidak cepat bosan terhadap menu yang disajikan. orang tua sebaiknya tidak memberikan banyak kudapan menjelang waktu makan kepada anaknya agar anak lebih banyak makan makanan yang bergizi. orang tua sebaiknya lebih dini mengenalkan sayuran dan buah-buahan kepada anaknya agar anak-anak terbiasa mengkonsumsi makanan empat sehat lima sempurna sehingga nutrisi anak tercukupi. perlu dilakukan penelitian lebih lanjut tentang pengaruh pemberian madu temulawak terhadap peningkatan berat badan anak selain usia toddler, misalnya pada usia sekolah. kepustakaan anonim, 2008. penelitian tentang kandungan madu, (online), (http://www.enformasi. com/madusehat’s weblog.htm., diakses tanggal 27 mei 2009, jam 09.34 wib). darmawan, wawan, 2003. madu, obat dan suplemen. bali: pak oles centre. judarwanto, w., 2004. mengatasi kesulitan makan pada anak. jakarta: egc. limananti, dkk., 2003. ramuan jamu cekok sebagai penyembuhan kurang nafsu makan pada anak: suatu kajian etnomedisi, (online), (http://www.ojs. lib.unair.ac.id. ,diakses tanggal: 21 april 2009, jam 09.55 wib). nelson, 1999. ilmu kesehatan anak edisi 15 vol. 1. jakarta: egc. notoatmodjo, s. 2007. promosi kesehatan & ilmu perilaku. jakarta: rineka cipta. rahmat, santosa dan setianingrum, s.w., 2003. pengaruh ekstrak temulawak (curcuma xanthorriza roxb) untuk meningkatkan nafsu makan pada penderita anoreksia primer. (online), (http://www.litbang. depkes.go.id/risbinkes.com, diakses tanggal: 28 mei 2008, jam 06.24 wib). rostita, 2007. berkat madu: sehat, cantik, dan penuh vitalitas. bandung: qanita. wong, d.l., 2003. pedoman klinis keperawatan pediatrik. jakarta: egc. wulandari, t., 2008. pengaruh pemberian pati garut terhadap peningkatan berat badan anak balita usia prasekolah. skripsi tidak dipublikasikan. surabaya: universitas airlangga. 121 model pengembangan pemenuhan kebutuhan gizi anak prasekolah berbasis health promotion model (the development of nutrition demand enquiry model for preschool-aged children based on health promotion model) eka mishbahatul mar'ah has*, florentina sustini**, ni ketut alit armini* * fakultas keperawatan, universitas airlangga, kampus c mulyorejo surabaya telp/fax: (031) 5913257, email: ns.eka.m@gmail.com ** fakultas kedokteran, universitas airlangga, kampus a surabaya abstract introduction: preschool-aged children are not able to manage their nutrition independently. they need help, especially from their mother. mother's behavior has effect on preschool's nutritional status. the aim of this study was to develop nutrition demand enquiry model for preschool-aged children based on health promotion model. method: design used in this research was an observational analytic with cross sectional approach that was conducted in karangturi village, gresik, east java. the population was mothers of preschool aged children listed on integrated health post for underfi ves (posyandu balita) along april–may 2012. simple random sampling was used to take the sample. sample size was 90 respondents. the independent variables were personal factors (age, motivation, and ethnicity), perceived benefi t, perceived barrier, perceived self-effi cacy, and commitment. the dependent variable was mother's behavior on nutrition of preschool children. data were collected using questionnaire and food recall 24 hour. data were analyzed using pls (partial least square) regression. result: the result showed that 1) personal factors had correlation with perceived benefi t, perceived barrier, and perceived self-effi cacy; 2) perceived benefi t and perceived barrier had correlation with commitment; 3) commitment had no correlation with mother's behavior on nutrition. perceived benefi t and perceived barrier had direct correlation with mother's behavior on nutrition. discussion: it can be concluded that mother's perceived benefi t and perceived barrier was correlated with mother's behavior on nutrition. nurses are key health care professionals responsible for increasing health education activities about how to manage nutrition of preschool age children. so, mother should have good behavior on preschool age children's nutrition. keywords: mother's behavior on nutrition, preschool aged children, health promotion model pendahuluan malnutrisi masih menjadi masalah gizi utama anak di indonesia (nasution, 2004). anak prasekolah beresiko mengalami malnutrisi karena kebutuhan energi proteinnya yang tinggi u nt u k proses t u mbu h dan berkembang (verma dan prinja, 2008). selain itu, anak juga mulai mengenal makanan jajanan yang tidak sesuai kecukupan gizi, sehingga anak hanya kenyang tapi asupan gizinya kurang (uripi, 2004). a n a k pr a sekola h b elu m m a mpu memenuhi kebutuhan gizi secara mandiri, sehingga masih tergantung pada orang dewasa yang ada di lingkungan sosial terdekatnya, yait u kelu a rga (g regor y, pa xton, d a n brozovic, 2010). pada mayoritas keluarga, ibu berperan penting dalam pemilihan bahan makanan bergizi, serta menu seimbang sesuai kebutuhan dan selera keluarga, sehingga pemenuhan kebutuhan gizi anak prasekolah tergantung pada perilaku ibu (popularita, 2010). per ila k u ibu d alam pemenu han kebutuhan gizi berpengaruh terhadap status gizi anak prasekolah (budiarti, wahjurini, dan suryawati, 2011). berdasarkan hasil studi pendahuluan selama maret 2012, diketahui sekitar 9,79% 122 jurnal ners vol. 7 no. 2 oktober 2012: 121–130 (19 orang dari 194 orang) anak prasekolah di kelurahan karangturi, kecamatan gresik, menderita malnutrisi. hasil wawancara terhadap 10 orang ibu dengan anak prasekolah di wilayah tersebut, diketahui 70% ibu tidak menyiapkan sendiri makanan untuk anaknya (beli di warung). sebagian besar ibu tersebut juga memiliki komitmen yang kurang untuk berperilaku memenuhi kebutuhan gizi anak prasekolah sesuai angka kecukupan gizinya. mereka beranggapan bahwa yang terpenting anak mau makan, baru kemudian memikirkan gizi anak. h a si l wawa nc a r a d e ng a n bid a n desa menunjukkan upaya penanggulangan malnut r isi yang telah dilak u kan masih bersifat pemulihan, yaitu pemberian makanan tambahan bagi penderita gizi buruk selama 90 hari. sementara pengembangan perilaku ibu dalam pemenuhan kebutuhan gizi anak prasekolah belum pernah dilakukan, sehingga diperlukan upaya peningkatan perilaku ibu di kelurahan karangturi, kecamatan gresik dengan pendekatan health promotion model (hpm). namun, sampai saat ini perilaku ibu dalam pemenuhan kebutuhan gizi anak prasekolah dengan pendekatan hpm belum pernah dievaluasi. menurut unicef (2006), prevalensi anak prasekolah yang menderita malnutrisi sangat tinggi di asia tenggara, termasuk indonesia (smith dan haddad, 2000). hasil riskesdas 2010, menunjukkan persentase masalah gizi buruk menurut indeks massa tubuh (imt) pada anak prasekolah di indonesia masih cukup tinggi jika dibandingkan dengan target mdgs, yaitu 4,5% (target mdgs 3,6%). selain itu, masih ditemukan 7% anak mengalami gizi kurang, dan 12,1% anak mengalami gizi lebih. pada 2010, propinsi jawa timur memiliki prevalensi gizi buruk terbesar di indonesia, yaitu lebih dari 14.720 kasus. berdasarkan laporan profi l kesehatan kabupaten gresik tahun 2010, diketahui dari 95.521 balita (usia 0–5 tahun) yang ada, jumlah balita ditimbang 80.416 (84,19%), di mana 1,83% status gizinya kurang dan 0,25% gizi buruk. kecamatan gresik sebagai wilayah dengan jumlah penduduk tertinggi di kabupaten gresik (88.995 orang), rentan terhadap masalah gizi. di kecamatan gresik, salah satu wilayah dengan masalah malnutrisi yang ter us meningkat adalah kelurahan karangturi. januari 13 kasus, februari 14 kasus, dan maret 19 kasus. mal nut r isi d ipenga r u h i la ngsu ng oleh asupan gizi dan penyakit dan secara tidak langsung dipengaruhi oleh pola asuh, ketersediaan pangan, faktor sosial-ekonomi, budaya, dan politik. malnutrisi mencerminkan asupan gizi yang tidak seimbang antara intake dan kebutuhan (rachman dan ariani, 2008). jika tidak segera ditangani, malnutrisi dapat menyebabkan kegagalan pertumbuhan fi sik dan perkembangan kecerdasan, menurunkan produktifi tas, menurunkan daya tahan tubuh, dan meningkatkan kesakitan, serta kematian (who, 2005). salah satu strategi untuk menurunkan prevalensi malnutrisi pada anak prasekolah adalah dengan pemberdayaan keluarga, terutama ibu. ibu merupakan anggota keluarga yang memiliki peran penting dalam membantu anak prasekolah memenuhi kebutuhan gizinya (syafi q, 2008). sebagai salah satu upaya untuk mengevaluasi perilaku ibu dalam pemenuhan kebut u han gizi anak prasekolah dapat diidentifikasi dengan hpm. dalam hpm, perilaku kesehatan individu dapat timbul dan dipertahankan karena adanya komitmen untuk berperilaku, bukan karena takut akan ancaman suatu penyakit. komitmen individu dipengaruhi oleh behavior specifi c cognition and affect ( perceived benef it, perceived barrier, perceived self effi cacy, dan situational inf luences). sementara behavior specif ic cognition and affect dipengaruhi oleh perilaku individu terdahulu dan faktor personal (usia, motivasi, dan suku) (pender, murdaugh, & parsons, 2002). bahan dan metode metode penelitian yang digunakan adalah observasional analitik dengan pendekatan cross sectional. penelitian ini dilaksanakan di kelurahan karangturi, kecamatan gresik, selama 30 mei–12 juni 2012. populasi adalah ibu dengan anak prasekolah yang ditimbang di posyandu 123 model pengembangan pemenuhan kebutuhan gizi (eka mishbahatul mar'ah has, dkk.) balita selama april–mei 2012, di kelurahan karangturi, kecamatan gresik sebanyak 165 orang. tek nik pengambilan sampel menggunakan simple random sampling, dengan besar sampel 90 orang yang diseleksi berdasarkan kriteria inklusi. kriteria inklusi meliputi: 1) warga tetap kelurahan karangturi; 2) tinggal sat u r umah dengan anak; 3) mengasuh anak secara mandiri; dan 4) bisa membaca dan menulis. sementara kriteria eksklusinya yaitu ibu dengan anak prasekolah yang menderita penyakit kronis (seperti tb) dan penyakit kecacingan. variabel penelitian, meliputi faktor personal (usia, motivasi, dan suku), perceived benefit, perceived barrier, perceived selfeffi cacy, komitmen, dan perilaku ibu dalam pemenuhan kebutuhan gizi anak prasekolah. data dikumpulkan dengan kuesioner dan food recall 24 hours. kuesioner telah diuji validitas dan reliabilitas dengan uji cronbach alpha. data yang terkumpul kemudian dianalisis dengan pls regression. hasil hasil penelitian menunjukkan, tabel 1, pada indikator usia, diketahui proporsi terbanyak adalah responden yang berusia 21–40 tahun dengan perceived benefi t positif, sebanyak 49 (54,5%) orang. pada indikator motivasi, proporsi terbanyak adalah responden dengan motivasi kuat dan perceived benefi t positif, yaitu 37 (41,1%) orang. dan pada indikator suku, secara keseluruhan proporsi terbanyak adalah responden yang berasal dari suku jawa dengan perceived benefi t positif, yaitu 39 (43,4%) orang. tabel 2, menunjukkan pada indikator usia secara keseluruhan proporsi terbanyak adalah responden berusia 21–40 tahun dan mempersepsikan adanya hambatan (perceived barrier) dalam memenuhi kebutuhan gizi anak prasekolah, yaitu 50 (55,6%) orang. pada indikator motivasi, paling banyak responden memiliki motivasi yang lemah dan mempersepsikan adanya hambatan, yaitu sebanyak 31 (34,4%) orang. pada indikator suku, proporsi terbanyak adalah responden yang berasal dari suku jawa dan mempersepsikan adanya hambatan, yaitu sebanyak 42 (46,7%) orang. tabel 3, menunjukkan pada indikator usia, proporsi terbanyak adalah responden yang berusia 21–40 tahun dengan perceived self-effi cacy kuat, yaitu sebanyak 61 (67,8%) orang. pada indikator motivasi, proporsi tabel 1. tabulasi silang faktor personal dan perceived benefi t responden di kelurahan karangturi, kecamatan gresik, juni 2012 faktor personal perceived benefi t totalpositif negatif f % f % f % usia ≤ 20 0 0 1 1,1 1 1,1 21–40 49 54,5 37 41,1 86 95,6 ≥ 41 2 2,2 1 1,1 3 3,3 total 51 56,7 39 43,3 90 100 motivasi kuat 37 41,1 16 17,8 53 58,9 lemah 14 15,6 23 25,4 37 41,4 total 51 56,7 39 43,3 90 100 suku jawa 39 43,4 29 32,2 68 75,6 non-jawa 12 13,3 10 11,1 22 24,4 total 51 56,7 39 43,3 90 100 path-coef = 0,363; t-statistik = 3,577 124 jurnal ners vol. 7 no. 2 oktober 2012: 121–130 tabel 2. tabulasi silang faktor personal dan perceived barrier responden di kelurahan karangturi, kecamatan gresik, juni 2012 faktor personal perceived barrier totalada tidak ada f % f % f % usia ≤ 20 1 1,1 0 0 1 1,1 21–40 50 55,6 36 40,0 86 95,6 ≥ 41 3 3,3 0 0 3 3,3 total 54 60 36 40 90 100 motivasi kuat 23 25,6 30 33,3 53 58,9 lemah 31 34,4 6 6,7 37 41,1 total 54 60 36 40 90 100 suku jawa 42 46,7 26 28,9 68 75,6 non-jawa 12 13,3 10 11,1 22 24,4 total 54 60 36 40 90 100 path-coef = -0,543; t-statistic = 7,323 tabel 3. tabulasi silang faktor personal dan perceived self-effi cacy responden di kelurahan karangturi, kecamatan gresik, juni 2012 faktor personal perceived self-effi cacy totalkuat lemah f % f % f % usia ≤ 20 0 0 1 1,1 1 1,1 21–40 61 67,8 25 27,8 86 95,6 ≥ 41 2 2,2 1 1,1 3 3,3 total 63 70 27 30 90 100 motivasi kuat 40 44,5 13 14,5 53 58,9 lemah 23 25,5 14 15,5 37 41,1 total 63 70 27 30 90 100 suku jawa 48 53,3 20 22,3 68 75,6 non-jawa 15 16,7 7 7,7 22 24,4 total 63 70 27 30 90 100 path-coef = 0,402; t-statistik = 3,823 tabel 4. tabulasi silang perceived benefi t dan komitmen responden di kelurahan karangturi, kecamatan gresik, juni 2012 perceived benefi t komitmen totalkuat lemah f % f % f % positif 32 35,6 19 21,1 51 56,7 negatif 14 15,5 25 27,8 39 43,3 total 46 51,1 44 48,9 90 100 path-coef = 0,205; t-statistik = 2,246 125 model pengembangan pemenuhan kebutuhan gizi (eka mishbahatul mar'ah has, dkk.) tabel 5. tabulasi silang perceived barrier dan komitmen responden di kelurahan karangturi, kecamatan gresik, juni 2012 perceived barrier komitmen total kuat lemah f % f % f % ada 20 22,2 34 37,8 54 60 tidak ada 26 28,9 10 11,1 36 40 total 46 51,1 44 48,9 90 100 path-coef = -0,456; t-statistik = 3,944 tabel 6. tabulasi silang perceived self-effi cacy dan komitmen responden di kelurahan karangturi, kecamatan gresik, juni 2012 perceived self-effi cacy komitmen total kuat lemah f % f % f % kuat 33 36,7 30 33,3 63 70 lemah 13 14,4 14 15,6 27 30 total 46 51,1 44 48,9 90 100 path-coef = 0,115; t-statistik = 1,399 tabel 7. tabulasi silang komitmen dan perilaku pemenuhan kebutuhan gizi responden di kelurahan karangturi, kecamatan gresik, juni 2012 komitmen perilaku gizi total baik tidak baik f % f % f % kuat 20 22,2 26 28,9 46 51,1 lemah 24 26,7 20 22,2 44 48,9 total 44 48,9 46 51,1 90 100 path-coef = 0,112; t-statistik = 1,407 gambar 1. hasil uji model 126 jurnal ners vol. 7 no. 2 oktober 2012: 121–130 responden yang terbanyak adalah dengan motivasi kuat dan perceived self-effi cacy yang kuat pula, yaitu 40 (44,5%) orang. sedangkan pada indikator suku, dapat diketahui bahwa secara keseluruhan proporsi terbanyak adalah responden yang berasal dari suku jawa dengan perceived self-effi cacy kuat, yaitu sebanyak 48 (53,3%) orang. pada tabel 4, tampak bahwa secara keselu r u han proporsi terbanyak adalah responden dengan perceived benefi t positif dan komitmen yang kuat dalam pemenuhan kebut u han gizi anak prasekolah, yait u sebanyak 32 (35,6%) orang. sebaliknya, responden dengan perceived benefi t negatif, paling banyak memiliki komitmen yang lemah, yaitu sebanyak 25 (27,8%) orang. ta b e l 5, m e n u n j u k k a n s e c a r a keseluruhan proporsi yang terbanyak adalah responden yang mempersepsikan adanya hambatan ( perceived barrier) dan memiliki komitmen lemah dalam pemenuhan kebutuhan gizi anak prasekolah, yaitu sebanyak 34 (37,8%) orang. sedangkan responden dengan perceived barrier negatif, paling banyak memiliki komitmen yang kuat, yaitu sebanyak 26 (28,9%) orang. tabel 6, menunjukkan bahwa secara keseluruhan proporsi responden terbanyak me m i l i k i pe rceive d selfef f ica c y d a n komitmen yang kuat, yaitu sebanyak 33 (36,7%) responsden. responden dengan perceived self-effi cacy lemah, paling banyak juga memiliki komitmen yang kuat dalam pemenuhan kebutuhan gizi anak prasekolah, yaitu sebanyak 14 (15,6%) orang. ta b el 7, me nu nju k k a n prop or si terbanyak adalah responden dengan komitmen kuat, tetapi memiliki perilaku pemenuhan kebutuhan gizi anak prasekolah yang tidak baik, yaitu sebanyak 26 (28,9%) orang. sebaliknya, responden dengan komitmen lemah, paling banyak memiliki perilaku pemenuhan kebutuhan gizi yang baik, yaitu sebanyak 24 (26,7%) orang. berdasarkan hasil analisis uji model dengan menggunakan partial least square (pls) regression pada gambar 1, diketahui m o t iv a si m e r u p a k a n i n d i k a t o r y a n g paling menyusun variabel faktor personal, dibandingkan dengan usia dan suku. faktor p e r son al b e rhubu nga n p osit if de nga n perceived benefi t ( path coef 0,354; t-statistik 3,577) dan perceived self-effi cacy ( path-coef 0,402; t-statistik 3,824) ibu dalam memenuhi kebutuhan gizi anak prasekolah. sedangkan, hubungan faktor personal dengan perceived barrier adalah negatif ( path-coef – 0,543; t-statistik 7,323). s e l a nj u t n y a , p e r c e i v e d b e n e f i t berhubungan positif dengan komitmen ( pathcoef 0,203; t-statistik 2,246). perceived barrier berhubungan negatif dengan komitmen ( pathcoef –0,456; t-statistik 3,944). sementara perceived self-efficacy tidak berhubungan dengan komitmen ( path-coef 0,115; t-statistik 1,399). komitmen tidak berhubungan dengan perilaku ibu dalam pemenuhan kebutuhan gizi anak prasekolah ( path-coef 0,112; t-statistik 1,407). akan tetapi, diketahui perceived benefi t secara langsung berhubungan positif dengan perilaku ibu dalam pemenuhan kebutuhan gizi anak prasekolah ( path-coef 0,196; t-statistik 2,249). demikian pula dengan perceived barrier, yang juga memiliki hubungan positif dengan perilak u ibu dalam pemenuhan kebutuhan gizi anak prasekolah ( path-coef 0,196; t-statistik 2,249). pembahasan hasil uji pls regression menujukkan bahwa ada hubungan yang signifi kan antara karakteristik personal dengan perceived benefi t ibu dalam pemenuhan kebutuhan gizi anak prasekolah. hasil uji juga menunjukkan bahwa indikator yang paling menyusun faktor personal adalah motivasi intrinsik. hal ini menujukkan bahwa motivasi yang kuat akan berdampak pada perceived benef it yang positif. health promotion model ( h pm ) menjelaskan, persepsi individu terhadap manfaat suatu perilaku kesehatan dipengaruhi oleh karakteristik personalnya (tomey dan alligood, 2006). karakteristik personal didefinisikan sebagai karakteristik umum individu yang diprediksi telah diperoleh individu secara turun-temurun dan dibentuk oleh lingk u ngan sek it ar nya (galloway, 2003). karakteristik personal dibagi atas 127 model pengembangan pemenuhan kebutuhan gizi (eka mishbahatul mar'ah has, dkk.) karakteristik biologis, psikologis, dan sosial (pender, murdaugh, dan parsons, 2002). dalam penelitian ini karakteristik biologis diwakili oleh usia, karakteristik psikologis diwakili oleh motivasi intrinsik, dan karakteristik sosial diwakili oleh suku. hasil pengujian menunjukkan bahwa koefisien hubungan bertanda positif, yang dapat diartikan semakin kuat motivasi ibu, maka secara langsung akan membentuk perceived benef it yang semakin positif dalam memenu hi kebut u han gizi anak prasekolah sesuai dengan kecukupan gizinya. berdasarkan hal tersebut, diperlukan upaya untuk mempertahankan motivasi ibu dalam pemenuhan kebutuhan gizi anak prasekolah, sehingga kemanfaatan yang dipersepsikan ibu semakin positif. salah satu upaya yang dapat dilakukan adalah memberikan reinforcement melalui pendidikan kesehatan, baik oleh kader posyandu balita maupun bidan desa. kader bisa memanfaatkan meja 4 posyandu balita, yang memang digunakan untuk memberikan pendidikan kesehatan kepada ibu sesuai dengan hasil penilaian antropometri anak prasekolah. hasil uji pls regression menunjukkan bahwa ada hubungan yang signifi kan antara karakteristik personal dengan perceived barrier ibu dalam pemenuhan kebutuhan gizi anak prasekolah. hpm menjelaskan, perceived barrier dipersepsikan sebagai hambatan untuk melakukan sesuatu (tomey dan alligood, 2006). hambatan yang dipersepsikan oleh individu dipengaruhi oleh pengalaman masa lalu dan karakteristik personal yang diperoleh secara turun-temurun (galloway, 2003). hasil pengujian menunjukkan bahwa koefi sien hubungan bertanda negatif, yang dapat diartikan semakin kuat motivasi ibu, maka secara langsung akan membentuk perceived barrier yang semakin rendah dalam memenuhi kebutuhan gizi anak prasekolah sesuai dengan kecukupan gizinya. motivasi kuat membuat individu mempersepsikan hambatan sebagai tantangan, bukan kelemahan (ilyas, 1999). ibu dengan motivasi kuat mempersepsikan hambatan yang lebih rendah karena merasa hal ini merupakan tantangan yang harus dihadapi untuk menjaga kesehatan anak prasekolah. hasil analisis kuesioner menunjukkan hambatan yang dirasakan ibu dalam memenuhi kebutuhan anak adalah menu makanan yang kurang bervariasi. hal ini membuat anak lebih menyukai makanan yang dibeli di warung. selain itu, ibu juga merasa terhambat oleh terbatasnya waktu karena bekerja. berdasarkan hal tersebut di atas, diperlukan pemberian informasi mengenai menu makanan bergizi yang dapat disediakan dalam waktu singkat melalui forum pendidikan kesehatan atau diskusi kelompok sebaya. hpm menjelaskan bahwa perceived self-effi cacy merupakan penilaian kemampuan personal untuk mengatur dan melakukan suatu perilaku kesehatan tertentu (pender, 2011). perceived self-effi cacy juga diartikan sebagai kepercayaan diri untuk dapat melakukan peran kesehatan dengan baik (bandura, 2004). faktor yang mempengaruhi perceived selfeffi cacy antara lain, karakteristik personal dan pengalaman masa lalu (pender, murdaugh, & parsons, 2002). hasil uji pls regression menunjukkan bahwa ada hubungan yang signifi kan antara karakteristik personal dengan perceived self-effi cacy ibu dalam pemenuhan kebutuhan gizi anak prasekolah. hasil pengujian menunjukkan bahwa koefisien hubungan bertanda positif, yang dapat diartikan semakin kuat motivasi ibu, maka secara langsung akan membentuk perceived self-efficacy yang semakin kuat dalam memenu hi kebut u han gizi anak pr a sekola h se su ai de nga n ke cu k upa n gizinya. berdasarkan hasil analisis jawaban responden, hal yang paling banyak dirasa ibu mampu dilakukan adalah memilih bahan makanan yang dikonsumsi anak setiap hari. sementara hal yang tidak diyakini ibu mampu dilakukan adalah menyediakan makanan bergizi setiap kali anak makan dalam sehari. berdasarkan hal tersebut di atas, ibu perlu diberikan pelatihan tentang cara memilih bahan makanan yang baik, cara pengolahan yang tidak menghilangkan kandungan zat gizi, serta penyajian yang menarik untuk anak prasekolah. komitmen dalam hpm didefi nisikan sebagai intensi/niat untuk melakukan perilaku 128 jurnal ners vol. 7 no. 2 oktober 2012: 121–130 kesehatan tertentu, termasuk identifikasi strategi untuk dapat melakukannya dengan baik (pender, murdaugh, dan parsons, 2002). individu memiliki komitmen untuk melakukan perilaku di mana mereka telah memikirkan nilai personal yang menguntungkan (tomey dan alligood, 2006). hal ini sesuai dengan hasil uji pls regression diketahui bahwa perceived benef it berhubu ngan dengan komitmen ibu dalam memenuhi kebutuhan gizi anak prasekolah. hasil pengujian menunjukkan bahwa koefi sien hubungan bertanda positif. dengan demikian dapat disimpulkan bahwa sema k i n posit if persepsi ibu terhad ap kemanfaatan memenuhi kebutuhan gizi anak sesuai standar kecukupan gizi, maka akan semakin kuat komitmennya untuk melakukan hal tersebut. salah satu upaya yang dapat dilakukan adalah pemberian edukasi mengenai makanan bergizi sesuai kebutuhan anak usia prasekolah. hasil uji dengan pls reg ression diketahui bahwa perceived benefit secara langsung mempengaruhi perilaku ibu dalam memenuhi kebutuhan gizi anak prasekolah. hasil pengujian menunjukkan bahwa koefi sien hubu ngan ber tanda positif, yang dapat diartikan semakin positif perceived benefi t ibu, maka secara langsung akan meningkatkan perilaku dalam memenuhi kebutuhan gizi anak prasekolah sesuai dengan kecukupan gizinya. menurut pender (2011), persepsi yang positif berhubungan dengan pelaksanaan perilaku yang semakin meningkat. hal inilah yang memungkinkan ibu dengan persepsi keunt ungan yang lebih positif terhadap manfaat memenuhi kebutuhan gizi anak prasekolah, akan lebih memiliki perilaku yang baik dalam hal tersebut. menur ut pender (2011), komitmen dapat diartikan sebagai intensi/niat/keinginan yang dalam diri individu untuk melakukan pe r ila k u ke sehat a n t e r t e nt u. pe r se psi yang rendah terhadap hambatan dalam berperilaku pemenuhan gizi sesuai kebutuhan meningkatkan komitmen untuk berperilaku kesehatan tersebut, dan begitu pula sebaliknya (walker, et al, 2006). hal ini sesuai dengan hasil uji pls regression yang menunjukkan bahwa perceived barrier berhubungan dengan komitmen. hasil pengujian menunjukkan bahwa koefi sien hubungan bertanda negatif. sema k i n ibu memper se psi k a n a d a nya hambatan dalam memenuhi kebutuhan gizi anak sesuai standar kecukupan gizi, maka komitmennya akan semakin lemah untuk melakukan hal tersebut. h a si l a n a l i si s k u e sio n e r, d a p a t disimpulkan bahwa responden juga sudah berupaya untuk meminimalkan hambatan dalam memenu hi kebut u han gizi anak prasekolah. akan tetapi, responden masih me ngelu h k a n k u r a ng nya ke m a mpu a n dalam pemilihan menu makanan, sehingga responden takut anak mengalami kebosanan. selai n it u , ibu juga mempe r se psi k a n kurangnya kemampuan dalam pengelolaan waktu, sehingga waktu yang disediakan ibu untuk memperhatikan kebutuhan gizi anak cenderung terbatas. berdasarkan hal tersebut, perlu upaya meningkatkan kemampuan mengat asi hambat a n d alam memenu h i kebutuhan gizi anak, sehingga perceived barrier yang dirasakan ibu semakin rendah. salah satu upaya yang dapat dilakukan adalah membentuk diskusi kelompok sebaya sebagai media bertukar informasi dan pengalaman ibu dalam memenuhi kebutuhan gizi anak prasekolah. hasil uji dengan pls reg ression diketahui bahwa perceived barrier secara langsung mempengaruhi perilaku ibu dalam memenuhi kebutuhan gizi anak prasekolah di kelurahan karangturi, kecamatan gresik. hasil pengujian menunjukkan bahwa koefi sien hubungan bertanda positif, yang dapat diartikan semakin ibu mempersepsikan adanya hambatan dalam memenuhi kebut uhan gizi anak, maka secara langsung akan meningkatkan perilaku dalam memenuhi kebutuhan gizi anak prasekolah sesuai dengan kecukupan gizinya. hal ini bertentangan dengan pendapat pender (2011), persepsi hambatan berhubungan dengan pelaksanaan perilaku yang semakin menurun. hal inilah dimungkinkan karena ibu dengan persepsi hambatan positif akan cenderung mencari informasi dan melakukan upaya-upaya alternatif yang lebih kreatif untuk memenuhi kebutuhan gizi anak. semakin ibu mempersepsikan adanya hambat an 129 model pengembangan pemenuhan kebutuhan gizi (eka mishbahatul mar'ah has, dkk.) dalam memenuhi kebutuhan gizi anak, maka anak semakin baik perilakunya dalam hal tersebut. hasil pengujian dengan pls regression menunjukkan bahwa perceived self-effi cacy tidak berhubungan dengan komitmen. individu dengan keyakinan diri yang kuat selalu merasa mampu melaksanakan tugas yang diberikan dengan baik. akan tetapi, keyakinan diri yang tinggi tidak diikuti oleh tingginya komitmen jika tidak ada kontrol dari orang lain yang dianggap penting oleh individu (misalnya suami, orang tua, petugas kesehatan, dan lainlain). hasil uji dengan pls reg ression menunjukkan bahwa tidak ada pengaruh perceived self-eff icacy terhadap perilaku responden dalam memenuhi kebutuhan gizi anak prasekolah. hasil ini ber tentangan dengan pendapat pender yang memprediksi tingkat kepercayaan diri (self-effi cacy) yang tinggi akan membawa nilai-nilai positif dalam diri individu, dan perilaku akan dimunculkan (tomey dan alligood, 2006). menu r ut masithah, soekirman, dan martianto (2005), salah satu peran penting ibu adalah pengaturan makan anggota keluarga, terutama anak-anak yang belum bisa memenuhi kebutuhannya sendiri. hal ini yang kemudian membentuk persepsi kuat dalam diri ibu, bahwa seorang ibu yang baik adalah ibu yang mampu memenuhi kebutuhan makan anak. dalam penelitian ini, responden adalah ibu, sehingga sesuai jika responden memiliki perceived self-effi cacy yang kuat dalam pemenuhan kebutuhan gizi anak prasekolah. akan tetapi, keyakinan diri ini tidak serta-merta membuat ibu berperilaku kesehatan tersebut. niat berperilaku (komitmen) masih merupakan suatu keinginan atau rencana (pender, murdaugh, dan parsons, 2002). hasil pengujian dengan pls regression juga menunjukkan komitmen tidak berpengaruh terhadap perilaku gizi responden. komitmen yang kuat unt uk ber perilaku kesehatan tertentu belum tentu berakhir pada perilaku kesehatan yang diharapkan, jika ada perilaku lain yang ter nyata lebih menarik untuk dilakukan (pender, 2011). hasil analisis kuesioner menunjuk kan bahwa terdapat beberapa ibu yang lebih menyukai membeli makanan di warung dari pada menyiapkan sendiri makanan untuk anak usia prasekolah. berdasarkan hal tersebut, ibu dengan anak prasekolah perlu diberikan informasi mengenai cara memilih makanan dan jajanan sehat yang dijual di warung. simpulan dan saran simpulan model pengembangan pemenu han kebutuhan gizi anak prasekolah berdasarkan health promotion model dapat disusun dengan mempertimbangkan faktor personal (terutama motivasi intrinsik), perceived benefit, dan perceived barrier yang dirasakan oleh ibu. saran pe r i la k u ibu d a la m p e me nu h a n kebut u han gizi anak prasekolah dapat ditingkatkan dengan memperbaiki persepsi, serta meningkatkan pengetahuan. upaya yang dapat dilakukan antara lain pengoptimalan meja 4 di posyandu balita untuk memberikan pendidikan kesehatan tentang kebutuhan gizi sesuai dengan status gizi anak yang tercantum di kartu menuju sehat (kms)-nya, pendidikan kesehatan dengan subtopik defi nisi makanan bergizi, manfaat makanan bergizi, dan menu makanan bergizi yang dapat disiapkan dalam waktu singkat, pelatihan cara memilih bahan makanan yang sehat, mengolah bahan makanan yang tidak menghilangkan zat gizinya, serta penyajian makanan yang menarik untuk anak usia prasekolah, pembentukan kelompok diskusi sebaya atau pusat konsultasi gizi yang dapat membantu ibu mencari strategi alternatif untuk mengurangi hambatan dalam pemenuhan kebutuhan gizi anak prasekolah. riset selanjutnya diharapkan meneliti variabel lain dalam hpm yang belum diteliti dalam penelitian ini, sehingga kesesuaian model untuk menggambarkan perilaku ibu dalam pemenuhan kebutuhan gizi anak prasekolah lebih dapat diketahui. 130 jurnal ners vol. 7 no. 2 oktober 2012: 121–130 kepustakaan baumeister, r. dan vohs, k., 2011. handbook of self regulation second editions; research, theory, and application. new york: the guilford press. brown, j., baumann, b., smith, c., dan etheridge, s., 1997. self-regulation, extroversion, and substance abuse among college students. the research society of alcoholisme. san francisco, calinornia. budiarti, t., wahjurini, p., dan suryawati, f., 2011. hubungan antara asupan gizi dengan tumbuh kembang anak usia 5–6 tahun. jurnal penelitian kesehatan suara forikes, 44–50. galloway, r., 2003. health promotion: causes, beliefs, and masurements. clinical medicine and research, 249–258. gregory, j., paxton, s., & brozovic, a., 2010. maternal feeding practice, child eating behavior and body mass index in preschool-aged children: a prospective analysis. international journal of behavioral nutrition and physical activity, 1–10. ilyas, 1999. kinerja: teori, penilaian, dan penelitian. depok: badan penerbit fkm, ui. kanfer, f. dan gaelick, l., 1986. selfmanagement methods. in f. kanfer, & a. goldstein, helping people change; a textbook of methods, 3rd edition (pp. 283–345). new york: pergamon press. masithah, t., soekirman, dan martianto, d., 2005. hubungan pola asuh makan dan kesehatan dengan status gizi anak batita di desa mulya harja. media gizi dan keluarga, 29–39. nasution, e., 2004, januari 14. usu digital library, (online), (http://www..library. usu.ac.id., diakses tanggal 6 januari 2012). pender, n., murdaugh, c., dan parsons, m., 2002. health promotion in nursing practice. new jersey: prentice-hall. popularita, l.d., 2010. hubungan pengetahuan, sikap, tindakan, dan pola asuh ibu dengan status gizi balita usia 1–5 tahun. skripsi tidak dipublikasikan. surabaya: universitas airlangga. r a ch m a n , p. d a n a r ia n i, m., 20 08. penganekaragaman konsumsi pangan di indonesia: permasalahan dan implikasi untuk kebijakan program. analisis kebijakan pertanian, 140–154. r ipollone, j., 2010. health promotion theory: a critique with focus on use in adolescents. virginia: university of virginia. smith, l. dan haddad, l., 2000. explaining child's malnutrition in developing countries: a cross country analysis. washington, dc: international food policy research institute. syafi q, a., 2008. tinjauan atas kesehatan dan gizi anak usia dini. jakarta: mercy corp. tomey, a. dan alligood, m., 2006. nursing theorist and their work. new york: mosby inc. uripi, v., 2004. menu sehat untuk balita. jakarta: puspa swara anggota ikapi. verma, r. dan prinja, s., 2008. assessment of nutritional status and dietary intake of pre-school children in an urban pocket. the internet journal of epidemiology. walker, s., pullen, c., hertzog, m., broekner, l., dan hageman, p., 2006. determinants of older rural women's activity and eating. western journal of nursing research, 449–474. who., 2005. maka every mother and child count. geneva: who. vol 9 no 1 april 2014.indd 151 makna seksualitas pada remaja etnis jawa di sma wilayah surabaya utara (the meaning of sexuality for javaneese adolecent at senior high school, north surabaya) hilmi yumni*, siti nur kholifah*, asnani* program studi d iii keperawatan kampus sutopo jurusan keperawatan politeknik kesehatan kementerian kesehatan surabaya jl. parangkusuma no.1 surabaya e-mail: kholifah_stp@yahoo.co.id abstrak pendahuluan: salah satu masalah kesehatan reproduksi remaja yang dihadapi negara-negara berkembang adalah masalah seksualitas. permasalahan seksualitas bersifat multi faktor. salah satunya faktor budaya, di mana hambatan budaya berpengaruh pada sosialisasi kesehatan reproduksi dan pendidikan seksual pada remaja. selama ini pembicaraan tentang seksualitas di kalangan remaja masih dianggap tabu. metode: penelitian merupakan studi kualitatif. jumlah informan sebanyak 10 siswa remaja, 1 tokoh masyarakat, 2 orang tua remaja, dan 2 orang guru. data diperoleh dari hasil wawancara mendalam (indepth interview). teknik analisis data yang digunakan adalah model analisis interaktif yaitu reduksi data, penyajian data, dan penarikan kesimpulan. hasil: penelitian ini menghasilkan temuan-temuan tentang: 1) persepsi mengenai seksualitas sebagai hubungan intim atau aktifi tas fi sik yang didorong oleh hasrat dengan lawan jenis, persepsi tentang pergaulan remaja berkaitan dengan seksualitas dipandang sebagai sesuatu yang sangat memprihatinkan karena di luar norma dan adat istiadat, informasi tentang seksualitas lebih banyak diperoleh dari lingkungan sekolah dalam hal ini teman sebaya, media, lingkungan rumah, dalam hal ini masyarakat sekitar rumah dan hampir tidak ada yang mendapat informasi dari orang tua, dan norma-nilai-budaya masih diyakini remaja sebagai kendali diri dalam kegiatan yang berkaitan dengan seksualitas seperti pacaran; 2) perilaku remaja berkaitan dengan seksualitas yaitu perilaku seksual remaja ketika berpacaran masih normatif yang dipengaruhi oleh budaya timur, tidak ditemukan adanya informan yang melakukan hubungan seksual sebelum ada ikatan perkawinan; 3) psikoseksual remaja, dipengaruhi oleh hubungan sosial remaja di lingkungan rumah, termasuk kedekatan dengan orang tua, norma, nilai yang ditanamkan pada remaja ketika di rumah. diskusi: berdasarkan hasil penelitian dapat diberikan saran salah satunya bahwa diperlukan pembicaraan terbuka mengenai informasi seks dan seksualitas kepada remaja. kata kunci: persepsi, perilaku, seksualitas, remaja abstract introduction: one of reproductive health issues on adolescent in developing countries was sexuality. issues of sexuality was multifactor, such as cultural factors. cultural barriers affect the socialization of reproductive health and sexual education in adolescents, because it was considered taboo to talk about it. method: this study was a qualitative study. the number of informants as many as 10 adolescent students, one community leader, 2 parent of adolescents, 2 teachers. the data shown is obtained from in-depth interviews. data were then analyzed by using interactive analysis model, including data reduction, data display, and conclusion. result: the result had shown that 1) perceptions of sexuality was understood as sexual intercourse or physical activity that was driven by the desire to the opposite sex, perceptions about adolescent promiscuity with regard to sexuality was seen as something that very concern because beyond norms and customs, many sexuality information was obtained from school environment such as peers, media, environment (in this case was people around the house) and none got information from the parents, and the norms-values -culture were believed as self-control in activities related to sexuality such as relationship; 2) adolecent’s behavior related to sexuality was associated with relationship and still done normatively, infl uenced by eastern culture, there was no informant who had sexual intercourse before marriage; 3) psychosexual of adolescent, were affected by social relationships in their environment at home, including closeness to parents, norms, values learned at home. discussion: based on the research results can be given suggestions that one of them needed to talk openly about sex and sexuality information to youth. key words: perception, behavior, sexuality, adolescent 152 jurnal ners vol. 9 no. 1 april 2014: 151–157 pendahuluan salah satu masalah kesehatan reproduksi r e m aja ya ng d i h a d a pi neg a r a neg a r a berkembang adalah masalah seksualitas. di indonesia, masalah seksualitas remaja antara lain pengetahuan yang tidak lengkap dan tidak tepat tentang masalah seksualitas, kurangnya bimbingan untuk bersikap positif dalam hal yang berkaitan dengan seksualitas, penyalahgunaan narkotika dan zat aditif yang mengarah kepada penularan hiv/aids melalui jarum suntik dan melalui hubungan seks bebas, penyalahgunaan seksualitas, kehamilan remaja, dan kehamilan pranikah (depkes, 2002). lembar fakta yang diterbitkan oleh pkbi, united nation population fund ascosiation (unfpa) dan bkkbn menyebutkan bahwa setiap tahun terdapat sekitar 15 juta remaja berusia 15-19 tahun melahirkan, sekitar 2,3 juta kasus aborsi juga terjadi di indonesia di mana 20% nya dilakukan oleh remaja. fakta lain menunjukkan bahwa sekitar 15% remaja usia 10-24 tahun yang jumlahnya mencapai 52 juta telah melakukan hubungan seksual di luar nikah (bagoes, 2004). k e s e h a t a n r e p r o d u k s i r e m a j a merupakan masalah kompleks tersendiri. beberapa fenomena yang tergambar secara kuantitatif seper ti dalam uraian di atas sepertinya remaja sangat ter pojok dalam masalah seksualitas, padahal permasalahan seksualitas bersifat multifaktor. salah satunya adalah faktor budaya, di mana hambatan budaya berpengaruh pada sosialisasi kesehatan reproduksi dan pendidikan seksual pada remaja karena membicarakannya dianggap tabu (widiantoro, 2001). apabila dikaitkan dengan psikologi perkemba nga n remaja , sei r i ng denga n pertumbuhan primer dan sekunder pada remaja ke arah kematangan yang sempurna, menimbulkan hasrat dan dorongan untuk menyalurkan keinginan seksualnya. hal tersebut mer upa ka n su at u ya ng waja r karena secara alamiah dorongan seksual ini memang harus terjadi untuk menyalurkan kasih sayang antara dua insan, sebagai fungsi pengembangbiakan dan mempertahankan keturunan (hurlock, 1990). permasalahannya adalah remaja menyalurkan dorongan seksual tersebut dengan cara yang tidak bertanggung jawab, k a re na sebag ia n be sa r remaja mendapatkan pemahaman yang salah tentang seksualitas (sarwono, 2006). me n u r u t fr e u d d a l a m hu rlo c k (1990), pada masa remaja terjadi proses perkembangan meliputi perubahan-perubahan yang berhubungan dengan perkembangan psikoseksual. jika tahap-tahap psikoseksual dilalui dengan sukses, maka akan didapatkan kepr ibadian yang sehat. bila dikaitkan dengan teori freud, maka pada masa remaja berada pada fase genital, di mana fase tersebut merupakan fase di mana remaja mengembangkan minat seksual yang kuat pada lawan jenis. penelitian ini ingin mengeksplorasi makna seksualitas pada remaja etnis jawa melalui kajian persepsi remaja tentang seksualitas, perilaku remaja berkaitan dengan seksualitas dan tahapan psikoseksual menurut freud dari pandangan remaja itu sendiri, orang tua, guru, dan tokoh masyarakat. bahan dan metode penelitian ini menggunakan pendekatan kualitatif agar dapat menangkap fenomena yang ada di lapangan. kemudian dikaji lebih mendalam berkaitan dengan makna seksualitas remaja. informasi yang diperoleh di lapangan disusun ke dalam teks yang menekankan pada masalah proses dan makna. informasi at au d at a tersebut ber upa keterangan, pendapat, pandangan, tanggapan/respon yang berhubungan dengan makna seksualitas. informan dalam penelitian ini adalah remaja, orang tua, guru, dan tokoh masyarakat. sedangkan remaja berasal dari siswa dan siswi sma kawung dari suku jawa yang ada pada saat penelitian dan bersedia di wawancara. teknik pengumpulan data yang digunakan dalam penelitian ini adalah wawancara mendalam (indepth interview). inst r umen yang dig unakan dalam pengumpulan data adalah peneliti sendiri. alat bantu pendukung adalah pedoman wawancara, catatan lapangan, dan tape recorder. 153 makna seksualitas pada remaja etnis jawa (hilmi yumni, dkk.) hasil jumlah informan remaja siswa sebanyak 10 siswa (3 laki-laki dan 7 perempuan), tokoh masyarakat 2 orang (1 orang laki-laki dan 1 orang perempuan), guru 2 orang (semuanya laki-laki) dan orang tua yang mempunyai anak remaja sebanyak 2 orang (1 orang laki-laki dan 1 orang perempuan). semua informan berasal dari suku jawa. hasil dan analisis penelitian yang sesuai dengan pokok permasalahan yaitu makna seksualitas remaja pada etnis jawa dipandang dari persepsi, perilaku remaja terhadap seksualitas dan riwayat psikoseksual. persepsi tentang seksualitas remaja. remaja ketika mendengar kata “seksualitas” yang terbayang adalah aktivitas hubungan badan atau hubungan kelamin yang berlainan jenis. sesuai dengan pernyataan informan sebagai berikut : “seksualitas berkaitan dengan melakukan hubungan badan dengan lawan jenis” (s/4) menurut orang tua, bahwa seksualitas adalah hubungan intim suami istri. sesuai dengan pernyataan informan sebagai berikut “seksualitas adalah hubungan intim suami isteri ...”(o/2) persepsi guru tentang seksualitas juga diartikan sebagai hubungan badan. sesuai dengan pernyataan informan sebagai berikut: “seksualitas itu melakukan hubungan intim antara kedua manusia yang lain jenis” (g/2) menur ut tokoh masyarakat bahwa seksualitas adalah suat u kegiatan yang berhubungan dengan naluri manusia terhadap lawan jenis. sesuai dengan per nyataan informan sebagai berikut: “seksualitas itu adalah kegiatan yang berhubungan dengan naluri manusia terhadap lawan jenis” (t/1) penilaian yang diu ngkapkan oleh remaja terhadap pergaulan remaja sekarang ini berkaitan dengan seksualitas sudah mengarah ke negat if, remaja bera rg u men bahwa pergaulan remaja di surabaya saat ini sudah kelewat batas, karena kemajuan teknologi, mudahnya akses gambar/video porno lewat jaringan internet, kurang perhatian orang tua. hal itu sesuai dengan pernyataan informan sebagai berikut: “remaja saat ini mudah mengakses jaringan internet, sehingga banyak dipengaruhi budaya asing” (s9) menurut orang tua bahwa pergaulan remaja sekarang ini adalah bebas akibat kemajuan teknologi dan kurangnya perhatian orang tua. hal itu sesuai dengan pernyataan informan sebagai berikut: “ remaja pergaulan bebas karena kemajuan teknologi dan kurangnya perhatian orang tua pada anak” (o1) pandangan gur u berkaitan dengan pergaulan remaja sekarang ini tergolong sangat berani, bebas, tidak ada rasa malu pada lingkungan. hal ini dampak dari kemajuan teknologi dan kurangnya perhatian orang tua. hal ini sesuai dengan pernyataan informan sebagai berikut: “pergaulan remaja hampir 70 % sangat berani dan tidak ada rasa malu pada lingkungan, akibat perkembangan teknologi dan kurang perhatian orang tua” (g1/g2) toko h m a s y a r a k a t b e r p e n d a p a t bahwa pergaulan remaja sekarang ini sangat membahayakan bila tidak ada dasar agama. hal ini sesuai dengan pernyataan informan sebagai berikut: “pergaulannya sangat berbahaya bila tidak diberi pengarahan dan pendidikan agama”(t/1) informasi tentang seksualitas yang didapatkan remaja berasal dari media tv, internet, sekolah, guru, kelompok remaja di masyarakat, melalui seminar, majalah, koran, teman sepergaulan, lingkungan rumah (tetangga). informasi yang didapatkan di sekolah berkaitan dengan pengenalan alat reproduksi dan fisiologinya, dampak seks bebas, penyakit hiv/aids. informan remaja tidak ada yang mendapatkan infor masi seksualitas dari lingkungan keluarga. hal tersebut sesuai dengan pernyataan informan sebagai berikut: “saya dapatkan informasi seksualitas dari sekolah, internet, dan tv, tentang organ 154 jurnal ners vol. 9 no. 1 april 2014: 151–157 kelamin laki dan perempuan, proses fertilisasi” (s9) pandangan orang tua informasi tentang seksualitas didapatkan dari sekolah, media cetak, tv. hal ini sesuai dengan pernyataan informan orang tua berikut: “informasi tentang seks dari sekolah, media cetak, tv” (o1/o2) pandangan gur u, bahwa infor masi tentang seksualitas diperoleh dari media televisi. sesuai dengan pernyataan informan berikut: “informasi seksualitas dari televisi....”(g1/g2) menurut tokoh masyarakat informasi seksualitas dari media televisi, internet. sesuai dengan pernyataan informan berikut: “ ....dari media televisi dan internet” (t) pendapat tentang budaya, norma dan larangan yang berkaitan dengan pacaran dan seksualitas dilingkungan. informan yang berasal dari remaja mereka menyatakan tidak setuju melakukan hubungan badan sebelum menikah, karena orang tua mengajarkan tidak boleh melanggar norma agama. hal itu sesuai dengan pernyataan informan berikut: “orang tua melarang melakukan tindakan yang dilarang agama” (s2, s5) “orang tua melarang melakukan hubungan seks sebelum menikah” (s1) pendapat orang tua tentang norma berkaitan dengan pacaran dan seksualitas adalah bahwa hubu ngan seksual har us dilakukan bila ada ikatan pernikahan sebagai suami isteri. hal itu sesuai dengan pernyataan informan berikut: “tidak boleh hubungan intim layaknya suami isteri di luar nikah” (o1) pendapat guru tentang norma pacaran dan seksualitas tidak setuju bila melakukan hubungan seks yang tidak wajar. sesuai dengan pernyataan informan berikut: “ ...melakukan hubungan seks tak wajar” (g2) pendapat dari tokoh masyarakat bahwa dilarang pacaran melebihi batas. hal tersebut sesuai dengan pernyataan informan sebagai berikut: “tidak boleh pacaran melebihi batas” (t1) hal-hal yaang dianggap tabu berkaitan dengan seksualitas juga diungkapkan oleh informan orang tua, guru, tokoh masyarakat seperti membicarakan tentang seks dengan orang lain, menjelaskan secara terbuka pada remaja. hal tersebut sesuai dengan pernyataan informan sebagai berikut: “membicarakan hubungan suami isteri tidak boleh diketahui oleh orang lain”(o1 & o2) “tidak pantas menjelaskan secara vulgar pada remaja tentang seks” (g2) dari pendapat informan orang tua dan guru, membicarakan tentang seksualitas adalah hal yang tidak pantas dibicarakan dengan remaja. informan remaja siswa sebagian besar tinggal di rumah dengan orang tua. remaja merasa nyaman dengan suasana r umah dan terdapat beberapa pendapat berkaitan dengan perlakuan yang didapatkan di rumah. sebagian informan remaja tempat tinggalnya dekat dengan komplek hiburan malam. aktifi tas yang dilakukan sewajarnya sebagai siswa ketika di sekolah dan di rumah sebagai bagian dari anggota keluarga dengan tugas perkembangannya. demikan juga pendapat dari informan orang tua, guru dan tokoh masyarakat. hal ini sesuai dengan pernyataan informan sebagai berikut: “ suasana rumah sangat menyenangkan” (s9/ s8/s7/s4) “kegiatan saya di rumah belajar dan membantu orang tua..”(s2/s6) perilaku remaja terhadap seksualitas. pendapat informan terhadap pergaulan remaja sekarang ini berkaitan dengan perilaku pacaran mereka gambarkan sebagai pergaulan yang sudah melebihi batas norma agama. hal ini sesuai dengan pernyataan informan sebagai berikut: “remaja sekarang banyak yang berhubungan badan yang belum sah/bukan muhrimnya dan memegang bagian yang terlarang” (s3) “pergaulan remaja sangat tidak wajar karena menurut sayapergaulan jaman sekarang di luar batas norma agama” (s8) 155 makna seksualitas pada remaja etnis jawa (hilmi yumni, dkk.) “perilaku remaja sekarang dalam pergaulan sangat berbahaya bila tidak diberi pengarahan dan pendidikan agama” (t1) “pergaulan remaja hampir 70% sangat berani dan tidak ada rasa malu pada lingkungan..”(g2) informan remaja sebagian mengatakan bahwa pacaran itu penting karena bisa menjadi motivasi dalam belajar dan saling membantu dalam memecahkan masalah. hal itu juga diungkapkan oleh informan baik dari guru, tokoh masyarakat maupun orang tua. berikut ini pernyataan informan: “berpacaran untuk memberi semangat belajar, dukungan, tempat curhat..”(s2) pe n g a l a m a n s el a m a b e r p a c a r a n terutama hal-hal yang dilakukan oleh remaja adalah berpegangan tangan, berpelukan, cium pipi, dan cium dahi. mereka tidak berani melakukan hal yang lebih jauh karena merasa melanggar norma agama. aktifi tas lain yang dilakukan selama pacaran antara lain jalan bersama, nonton film, berkirim surat. hal itupun sama pendapatnya dengan informan guru, orang tua dan tokoh masyarakat. sesuai dengan pernyataan informan sebagai berikut: “ ...ciuman pertama saya lakukan ketika ulang tahun kelas 1 sma..”(s2) “...ketika pacar mengajak berhubungan seksual saya tolak karena melanggar norma yang berlaku di keluarga, agama maupun masyarakat dan belum cukup umur..”(s9(t1/ o/g1) perilaku remaja dalam menonton fi lm/ video porno sebagian sudah mengaksesnya lewat internet sejak dari smp. sebagian remaja menganggap bahwa nonton video porno itu belum pantas dan tidak berani menontonnya. respon remaja setelah menonton video porno sebagian biasa saja dan sebagaian memiliki perasaan emosional takut dan menjijikkan. hal itu seperti yang disampaikan oleh informan berikut: “ ...saya nonton luna, cut tari dan ariel bersama teman saya perempuan..”(s2) informan siswa sebagian besar (80%) pernah menonton video porno, tetapi tidak ber pengar uh pada keinginan melakukan hubungan badan dengan lawan jenis. pe r i la k u re m aja juga b e rk h aya l melakukan hubungan seksual, diwujudkan d ala m be nt u k m i mpi, na mu n me rek a mengalihkannya lebih ke arah positif dengan berargumen bahwa hubungan seksual boleh dilakukan oleh pasangan yang sudah menikah. hal itu sesuai dengan yang diungkapkan oleh informan sebagai berikut: “ ...pernah membayangkan melakukan hubungan seksual, kemudian mimpi...”(s9) psikoseksual remaja. perkembangan psikoseksual remaja menurut freud ketika berada pada fase falik dan laten sesuai dengan tahapan perkembangan remaja. fase laten, berdasarkan pendapat dari informan remaja bahwa remaja perempuan sangat dekat dengan ayahnya dan remaja laki-laki sangat dekat dengan ibunya, remaja menganggap hal ini wajar tanpa dapat memberikan alasan yang jelas. sedangkan menurut informan orang tua, tokoh masyarakat dan guru lebih menekankan pada pentingnya memisahkan anak yang sudah akil baligh sewaktu tidur di kamar yang berbeda dengan orang tua. hal itu sesuai dengan pernyataan informan berikut: “....wajar-wajar saja anak perempuan dengan ayahnya dan sebaliknya...”(s3) “ ...setelah akil baligh tidur harus terpisah dengan ibunya bagi anak laki-laki, demikian juga anak perempuan terpisah dengan ayahnya..”(g1) fase genital. pendapat informan tentang perkembangan seksualitas pada fase genital adalah sebagai berikut : “ ...kedekatan dengan lawan jenis hanya sebatas berpacaran dengan aturan yang sudah ditetapkan orang tua” (s9) “...harus bisa jaga diri dan memegang adat ketimuran dan patuh...”(t1) pembahasan berdasarkan data yang disampaikan informan siswa, orang tua, guru, dan tokoh masyarakat bahwa makna seksualitas adalah 156 jurnal ners vol. 9 no. 1 april 2014: 151–157 hubungan badan dengan lawan jenis. dalam kultur masyarakat kita, kata seks hampir selalu berkonotasi negatif begitu mendengar kata “seks” yang terbayang adalah aktifi tas yang terkait dengan hubungan kelamin. seks dalam arti sebenarnya adalah alat kelamin, mengacu pada sifat-sifat biologis yang secara kasat mata berbentuk fi sik yang mendefi nisikan manusia sebagai perempuan atau laki-laki (kemenkes ri, 2009). begitu juga dengan seksualitas sering kali dipahami hanya sebuah aktifi tas fi sik yang didorong oleh hasrat dengan lawan jenis yang sebenarnya adalah aspek dalam kehidupan manusia sepanjang hidupnya yang berkaitan dengan alat kelaminnya. seksualitas dialami dan diungkapkan dalam pikiran, khayalan, gairah kepercayaan, sikap, nilai, perilaku, perbuatan, peran, dan hubungan (kemenkes ri, 2007). penilaian pergaulan remaja dari informan siswa, orang tua, guru, dan tokoh masyarakat dimaknai dengan pergaulan yang bebas antar lawan jenis didukung dengan perhatian yang kurang dari orang tua dan kemajuan teknologi, sehingga akses situs porno dapat dengan mudah diperoleh. sumber informasi tentang seksualitas yang disampaikan para informan siswa, guru, orang tua dan tokoh masyarakat adalah dari media cetak dan elektronik, tidak ada yang menyampaikan sumber informasi tentang seksualitas dari keluarga. berbicara tentang seksualitas maka yang ada dipemikiran masyarakat secara umum adalah sesuatu atau topik yang sangat sensitif bahkan tabu untuk diperbincangkan secara terbuka baik di dalam keluarga atau publik. orang tua dan pendidik jadi tidak mau terbuka atau berterus terang kepada anak-anak atau anak didik mereka tentang seksualitas, takut kalau anak-anak itu ikut-ikutan mau melakukan seks sebelum waktunya (seks sebelum menikah), sehingga tabu untuk dibicarakan (sarwono, 2011). berbagai pendapat informan siswa, orang tua, guru dan tokoh masyarakat tentang norma dan budaya pacaran adalah melarang pacaran melebihi batas seperti melakukan hubungan badan sebelum menikah. akan tetapi menurut informan, perilaku remaja dalam berpacaran sudah melewati batas dan tanpa rasa malu, seperti melakukan hubungan badan sebelum menikah. berdasarkan pendapat informan siswa dan g u r u, ber pacaran juga mempunyai dampak positif yaitu sebagai motivasi dalam belajar dan mencurahkan rasa kasih sayang antar sesama. pendapat dari informan siswa, orang tua, guru, dan tokoh masyarakat tentang perilaku berpacaran adalah tidak sampai melakukan hubungan badan sebelum menikah karena melanggar norma keluarga, agama, dan masyarakat. menurut informan siswa, hubungan seks sebelum menikah merugikan diri sendiri, sehingga apabila ada keinginan untuk melakukan hubungan seks dialihkan kepada hal lain. pe r i l a k u s e k s u a l r e m aja d a l a m ber pacaran sebagian lebih karena alasan motivasi dalam belajar, ingin diperhatikan dan dimanja. perilaku yang ditunjukkan dalam berpacaran seperti ngobrol, curhat, berpegangan tangan, ciuman pipi, dan cium dahi. sebagian remaja juga mengakses fi lm/ video porno, sebagian yang tidak mengakses fi lm/video porno menganggap bahwa itu belum pantas dan tidak berani menontonnya. yuanita (2011) menyatakan bahwa seiring dengan pertumbuhan primer dan sekunder pada remaja kearah kematangan yang sempurna, muncul juga hasrat dan dorongan untuk menyalurkan keinginan seksualnya. perkembangan psikoseksual remaja menurut freud berada pada fase falik dan laten. berdasarkan pendapat informan siswa dan guru, kedekatan anak dengan orang tua dengan berlawanan jenis, anak perempuan dengan ayahnya dan anak laki-laki dengan ibunya. pada fase laten sebenar nya sudah berkembang ke arah interaksi sosial, keingintahuan tentang seksualitas tetap berlanjut dan tahapan ini penting dalam pengembangan komunikasi dan kepercayaan diri. oleh karena itu, pada tahap ini adanya kedekatan dengan orang tua dapat menjembatani dan meluruskan remaja dalam menerima informasi seksualitas yang menyesatkan dari akses media, teman atau sumber lainnya. 157 makna seksualitas pada remaja etnis jawa (hilmi yumni, dkk.) menurut pendapat informan remaja tent ang kedekat an dengan lawan jenis mengatakan bahwa hubungan remaja dengan lawan jenis sewajarnya sebagai teman, saling menghargai. namun, bila remaja tersebut ber peran sebagai pacar maka hubungan kedekatan remaja tersebut sebatas pacaran dengan aturan yang ditetapkan oleh orang tua. sedangkan dari pendapat tokoh masyarakat, orang t ua dan g u r u tentang hubu ngan kedekat a n remaja denga n lawa n jen is mengatakan harus dibatasi dan menjaga diri karena masih memegang adat ketimuran. pada fase fali k (genit al), remaja mengembangkan minat seksual yang kuat pada lawan jenis. menurut remaja bahwa hubungan remaja dengan lawan jenis sewajarnya sebagai teman, saling menghargai, namu n bila remaja tersebut berperan sebagai pacar maka hubungan kedekatan remaja tersebut sebatas pacaran dengan aturan yang ditetapkan oleh orang tua. sedangkan dari pendapat tokoh masyarakat, orang tua dan gur u tentang hubungan kedekatan remaja dengan lawan jenis mengatakan harus dibatasi dan menjaga diri karena masih memegang adat ketimuran. hal ini berkaitan dengan aspek budaya. dalam penelitian ini semua informan berasal dari etnis jawa, sehingga argumen-argumen yang di sampaikan hampir selalu dikaitkan dengan nilai, norma, aturan, bahkan dengan agama. simpulan dan saran simpulan makna seksualitas remaja etnis jawa merupakan hubungan dengan lawan jenis yang masih memperhatikan norma, nilai, budaya dan aturan agama, tidak melakukan hubungan badan sebelum menikah, tidak ada pengaruh untuk melakukan hubungan seksual ketika menonton video porno, dan pacaran yang dilakukan digunakan sebagai semangat untuk belajar dan mencurahkan rasa kasih sayang. saran saran yang ditujukan kepada remaja d i ha rapka n u nt u k tet ap men i ng kat ka n pengetahuan yang baik tentang kesehatan reproduksi remaja dan memper tahankan perilaku seksual yang baik dan bertanggung jawab. bagi orang tua harus bersifat terbuka dalam membicarakan masalah seksual kepada anaknya, disesuaikan dengan perkembangan anak, tidak memandang tabu terhadap informasi seksualitas. kepustakaan bagoes. 2004. demografi umum. jakarta: pustaka pelajar. bungin. 2008. metodologi penelitian kualitatif. jakarta: pt. raja grafi ndo persada. depkes ri. 2002. pedoman pelaksanaan kegiatan, komunikas informasi, edukasi (kie), kesehatan reproduksi: untuk petugas kesehatan di tingkat pelayanan dasar. jakarta: depkes ri. hurlock. 1990. developmental psychology: a lifespan approach. boston: mcgrawhill. hurlock. 1973. adolescent development. tokyo: mcgraw-hill kogakusha. santrock. 2003. adolescence perkembangan remaja. jakarta: erlangga. sarwono. 2011. psikologi remaja ed. revisi cet. 14. jakarta: rajawali pers. tim penulis poltekkes depkes jakarta i. 2010. kesehatan remaja: problem dan solusinya. jakarta: salemba medika. torsina. 2010. seks remaja: isu dan tips. jakarta: bhuana ilmu populer. wawan & dewi. 2010. pengetahuan, sikap, dan perilaku manusia. yogyakarta: nuha medika. wiknjosastro. 2005. ilmu kandungan. jakarta: yaya sa n bi n a p u st a k a sa r wono prawirohardjo. yuanita. 2011. fenomena dan tantangan remaja menjelang dewasa. yogyakarta: brilliant books. vol 6 no 1 april 2011_akreditasi 2013.indd 31 kepemimpinan efektif dan motivasi kerja dalam penerapan komunikasi terapeutik perawat (effective leadership and work motivation in the aplication of nurse therapeutic communication) farida stikes hutama abdi husada, jl. dr. wahidin sudirohusodo no. 1 tulungagung e-mail: dahliafa@yahoo.com abstract introduction: the objective of this study was to identify effective leadership and the work motivation with the implementation of therapeutic communication, method: design used in this study was descriptive design of the correlation with the approach cross sectional study. the population of this study was all of the practising nurse in the in-patient (hospitalized) ward at the dr. iskak tulungagung hospital. all datas were taken by using the method of total population of the 98 practising nurses. result: the result of this study showed that the big proportion of the practising nurses whose ages are less than 30 years old, graduated from diploma, status are single (unmarried), duration of work was less or same as 6 years, generally never followed a training of communication, whereas effective leadership was in the good category and the category of work motivation wasn’t better. analysis using chi-square with alpha 0,05 showed that there was relations between the age, old the work, effective leadership and the work motivation and the implementation of therapeutic communication. the marital status and training had not relationship with the implementation of therapeutic communication. discussion: it is suggested that hospital should encoverage nurse manager to promote therapeutic communication among nurses. keywords: the effective leadership, work motivation, implementation of therapeutic communication pendahuluan persaingan jasa pelayanan kesehatan yang semakin ketat dalam era globalisasi ini, perlu upaya peningkatan mutu pelayanan kesehatan dan hal ini tidak dapat ditundat u n d a l a g i . p e l a y a n a n k e s e h a t a n y a n g bermutu yang dimaksud adalah pelayanan yang dapat memuaskan setiap pemakai jasa pelayanan kesehatan yang sesuai dengan tingkat kepuasan rata-rata penduduk serta yang penyelenggaraannya sesuai dengan standar dan kode etik profesi yang telah ditetapkan (azwar, 1996). mutu rumah sakit sangat dipengaruhi oleh beberapa faktor. faktor yang paling dominan mempengaruhi adalah sumber daya manusia. tenaga kesehatan termasuk fungsi fundamental yang memengaruhi mutu pelayanan kesehatan (wijono, 2000). sumber daya manusia yang cukup dengan kualitas yang tinggi, profesional, sesuai dengan fungsi dan tugas setiap personil merupakan salah satu indikator keberhasilan rumah sakit yang efektif dan efi sien. ilyas (2004) menjelaskan bahwa sumber daya manusia merupakan kunci yang sangat penting untuk keberhasilan dan kemajuan organisasi. sumber daya yang berhubungan langsung dengan manusia dalam pemberian pelayanan kesehatan di rumah sakit yang dimaksud di antaranya adalah tenaga perawat. sumber daya manusia terbesar dalam pelayanan kesehatan di rumah sakit diduduki oleh tenaga perawat, di mana mereka siap membantu pasien setiap saat dan bekerja selama 24 jam setiap harinya, secara bergilir dan berkesinambungan untuk memberikan asuhan keperawatan yang komprehensif dan profesional (departemen kesehatan, 1994). tenaga perawat memiliki posisi yang cukup menentukan dalam tinggi rendahnya mutu pelayanan kesehatan di rumah sakit, karena merekalah yang sehari-harinya mengadakan jurnal ners vol. 6 no. 1 april 2011: 31–41 32 kontak langsung dan mempunyai waktu terbanyak dalam berinteraksi dengan klien. peningkatkan kualitas perawat dalam memberikan asuhan keperawatan yang berkualitas kepada klien membutuhkan peran kepemimpinan dalam memengaruhi dan menggerakkan perawat. seorang pemimpin y a n g e f e k t i f h a r u s d a p a t m e n c i p t a k a n lingkungan kerja yang konduksif bagi staf keperawatan dan mempunyai pengetahuan tentang kepemimpinan dalam keperawatan, kesadaran diri, komunikasi, mobilisasi energi, penentuan tujuan dan tindakan (tappen, 1998). kepala ruangan sebagai seorang pemimpin secara langsung dan tidak langsung dapat memengaruhi motivasi dan kinerja bawahan dalam mencapai tujuan keperawatan. motivasi merupakan salah satu elemen yang ada pada diri seseorang untuk menghasilkan perilaku yang dapat meningkatkan kinerja dengan cara memenuhi kebutuhan. hal ini sesuai dengan yang dijelaskan oleh as’ad (2003) tentang kebutuhan menimbulkan tingkah laku seseorang. motivasi kerja perawat merupakan dorongan dari dalam diri perawat untuk mau meningkatkan kinerjanya untuk memenuhi kebutuhannya. kinerja perawat yang dimaksud adalah kegiatan perawat sesuai dengan tugas yang harus dicapai oleh perawat. salah satunya adalah kegiatan dalam proses keperawatan, di mana dalam setiap langkah-langkah proses keperawatan, perawat diharapkan dapat menerapkan komunikasi terapeutik agar proses keperawatan dapat berjalan secara optimal. penerapan komunikasi terapeutik antara perawat klien merupakan kinerja perawat yang penting untuk dikaji dalam rangka peningkatan mutu pelayanan asuhan keperawatan. kajiankajian mengenai komunikasi terapeutik antara perawat – klien dapat memberikan kejelasan tentang faktor-faktor yang berpengaruh terhadap perilaku dan kinerja perawat khususnya dalam pelaksanaan komunikasi terapeutik. gibson (1997) menjelaskan ada tiga variabel yang berpengaruh terhadap perilaku dan kinerja seseorang yaitu variabel individu, variabel psikologis, dan variabel organisasi. variabel individu menyangkut kemampuan dan keterampilan, latar belakang, dan demografi s, sedangkan variabel psikologis termasuk persepsi, sikap, kepribadian, dan motivasi, dan variabel organisasi terdiri dari sumber daya, kepemimpinan, imbalan, struktur, dan desain pekerjaan. dengan demikian karakteristik individu, kepemimpinan kepala ruangan dan motivasi kerja perawat turut berpengaruh terhadap kinerja perawat. kinerja perawat yang dimaksud di antaranya adalah penerapan komunikasi dalam berhubungan perawatklien. rumah sakit dr. iskak tulungagung terus berusaha meningkatkan mutu pelayanan agar kepuasan pelanggan terpenuhi, karena peningkatan mutu pelayanan adalah tujuan utama rumah sakit. visi rumah sakit yaitu terwujudnya pelayanan kesehatan yang bermutu sehingga menjadi idaman pelanggan, dengan motto kepuasan pelanggan dambaanku. untuk mewujudkan visi tersebut, rumah sakit dr. iskak tulungagung menanamkan budaya kerja “panca karya citra husada” yaitu lima budaya kerja yang di antaranya adalah citra pelayanan, kebersihan lingkungan rumah sakit, tertib pelaksanaan pelayanan, keramahan dan ikhlas bekerja. keramahan yang diperlukan dalam budaya kerja yaitu penampilan yang baik, sopan, murah senyum dan tidak membeda-bedakan. ikhlas dalam arti terampil, ringan tangan, tanpa pamrih dan penuh tanggung jawab. p e n c a p a i a n b o r r u m a h s a k i t adalah 66,4% (2006), dan 82,75% (2007), dengan kapasitas 178 tempat tidur (profi l rs dr. iskak, 2007). menurut wijono (2000), bahwa bor ideal adalah 60%-85%. berdasarkan parameter tersebut, bor rumah sakit dr. iskak tulungagung termasuk ideal. tenaga perawat yang ada di rumah sakit sebagian besar berpendidikan diii keperawatan yaitu sebesar 70% dan sisanya spk, jumlah tenaga kontrak ± 40%. berdasarkan pengamatan peneliti, dari jumlah tersebut masih ada perawat yang belum menggunakan teknik komunikasi terapeutik, hubungan perawat-pasien hanya bersifat melaksanakan tanggung jawab sebagai perawat, bahkan kadang disertai sikap yang kurang bersahabat pada saat merawat pasien. hasil wawancara peneliti tanggal 8 pebruari 2008 dengan kepala bidang kepemimpinan efektif dan motivasi kerja (farida) 33 keperawatan bahwa jabatan kepala ruangan diberikan pada mereka yang telah memasuki masa kerja tertentu, mempunyai kemampuan dalam kepemimpinan, dan berlatar belakang pendidikan akper. peran kepala ruangan sebagai penggerak perawat diharapkan dapat secara optimal mengarahkan bawahan dalam meningkatkan kinerjanya, serta supervisi dapat dilaksanakan secara teratur terhadap perawat pelaksana sehingga motivasi kerja perawat meningkat. penghargaan juga diberikan kepada perawat yang berprestasi baik, kebijakan rumah sakit terhadap perawat pegawai negeri sipil dan perawat kontrak dalam kegiatan dan berprestasi adalah sama dan perawat diberikan kebebasan untuk mengeluarkan pendapat dalam rangka peningkatan kinerja, dengan demikian kinerja perawat diharapkan akan menjadi baik, termasuk penerapan komunikasi terapeutik. data awal melalui wawancara terhadap tiga orang perawat dari 7 ruang rawat inap, mereka mengatakan masih belum merasakan manfaat pengarahan dan bimbingan kepala ruangan terhadap penerapan komunikasi t e r a p e u t i k , s e h i n g g a p e r a w a t k u r a n g termotivasi untuk menerapkan komunikasi terapeutik. kondisi ini dapat mengakibatkan perawat kurang termotivasi untuk menerapkan komunikasi terapeutik, sehingga sering muncul keluhan pasien tentang pelayanan perawat yang kurang ramah. sampai dengan saat ini belum ada p e n e l i t i a n t e n t a n g f a k t o rf a k t o r y a n g memengaruhi kinerja perawat bahkan belum ada juga hasil penelitian tentang penerapan komunikasi terapeutik di ruang rawat inap rs dr. iskak tulungagung. selain itu rumah sakit tersebut merupakan satu-satunya rumah sakit pemerintah di tulungagung, dengan tipe b maka keberadaannya difungsikan sebagai rujukan dari rumah sakit yang berada di wilayah tersebut. melihat pentingnya komunikasi terapeutik dan berdasarkan keluhan yang ada tersebut, maka perlu kiranya melakukan penelitian mengenai penerapan komunikasi terapeutik perawat sehingga dapat diketahui hubungan kepemimpinan efektif kepala ruangan dan motivasi kerja perawat terhadap penerapan komunikasi terapeutik dalam asuhan keperawatan di ruang rawat inap rumah sakit dr. iskak tulungagung. bahan dan metode t u j u a n p e n e l i t i a n i n i u n t u k m e n g i d e n t i f i k a s i h u b u n g a n a n t a r a kepemimpinan efektif dan motivasi kerja dengan penerapan komunikasi terapeutik p e r a w a t p e l a k s a n a d i r u m a h s a k i t dr. iskak tulungagung. desain yang digunakan adalah deskriptif korelasi dengan pendekatan c ro s s s e c t i o n a l . va r i a b e l y a n g d i u k u r adalah karakteristik perawat meliputi umur, pendidikan, status perkawinan, lama kerja, pelatihan komunikasi, kepemimpinan efektif dilihat dari persepsi perawat pelaksana, dan motivasi kerja perawat pelaksana. penelitian dilakukan di 7 ruang rawat inap rumah sakit dr. iskak tulungagung pada total sampel berjumlah 98 perawat pelaksana. data dikumpulkan dengan menggunakan kuesioner. pengumpulan data dilakukan peneliti dan dibantu 7 perawat pembimbing klinik. uji validitas instrumen kepemimpinan efektif didapatkan 1 pernyataan yang nilai r < 0,361 dengan alpha cronbach 0,95, motivasi kerja 1 pernyataan nilai r < 0,361 dengan alpha cronbach 0,9297, dan penerapan komunikasi terapeutik 3 pernyataan yang nilai r < 0,361 dengan alpha cronbach 0,9445. analisa data yang digunakan dalam penelitian ini adalah univariat menggunakan distribusi frekuensi, bivariat menggunakan chi square dan multivariat menggunakan regresi logistik ganda model prediksi. hasil hasil pengumpulan data pada 98 perawat pelaksana yang ada di 7 ruang rawat inap rumah sakit dr. iskak tulungagung didapatkan hasil bahwa perawat berumur < 30 tahun sebesar 52%, berlatar belakang pendidikan akper sebanyak 73,5%, dan yang sudah kawin sebanyak 80,6%. lama kerja perawat pelaksana yang ≤ 6 tahun sebesar 52,2%, dan yang tidak pernah mengikuti pelatihan komunikasi sebesar 95,9%. penerapan komunikasi terapeutik jurnal ners vol. 6 no. 1 april 2011: 31–41 34 perawat pelaksana dalam kategori baik mencapai 55,1%, kepemimpinan efektif kepala ruangan yang dipersepsikan perawat pelaksana dalam kategori baik yaitu 51%, dan motivasi kerja perawat pelaksana dalam kategori baik hanya mencapai 46,9%. ada hubungan yang bermakna antara umur perawat dengan penerapan komunikasi terapeutik (p = 0,003). dari nilai or dapat disimpulkan bahwa perawat yang berumur < 30 tahun berpeluang 6,5 kali untuk menerapkan komunikasi terapeutik baik dibandingkan perawat yang berumur > 40 tahun, dan perawat yang berumur 30–40 tahun berpeluang 3,3 untuk menerapkan komunikasi terapeutik baik dibandingkan perawat yang berumur > 40 tahun. tidak ada hubungan yang bermakna antara tingkat pendidikan dengan penerapan komunikasi terapeutik (p = 0,401). tidak ada hubungan yang bermakna antara status perkawinan dengan penerapan komunikasi terapeutik (p = 0,119). ada hubungan yang bermakna antara lama kerja dengan penerapan komunikasi terapeutik (p = 0,028). tidak ada hubungan yang bermakna antara pelatihan dengan penerapan komunikasi terapeutik (p = 1,00). ada hubungan yang bermakna antara kepemimpinan efektif kepala ruangan yang dipersepsikan perawat pelaksana dengan penerapan komunikasi terapeutik perawat pelaksana (p = 0,016). nilai or dapat disimpulkan bahwa perawat pelaksana yang tabel 1. hubungan karakteristik perawat dengan penerapan komunikasi terapeutik karakteristik perawat penerapan komunikasi terapeutik p value or/ci 95% umur: > 40 tahun 30–40 tahun < 30 tahun 15 (75%) 13 (48,1%) 16 (31,4%) 5 (25%) 14 (51,9%) 35 (68,6%) 0,003* 1 3,231 (0,914–11,420) 6,562 (2,032–21,193) pendidikan: spk akper 14 (53,8%) 30 (41,7%) 12 (46,2%) 42 (58,3%) 0,401 1 1,633 (0,663–4,026) status perkawinan belum kawin kawin 5 (26,3%) 39 (49,4%) 14 (73,7%) 40 (50,6%) 0,119 1 0,366 (0,120–1,114) lama kerja: > 6 tahun ≤ 6 tahun 27 (57,4%) 17 (33,3%) 20 (42,6%) 34 (66,7%) 0,028* 1 2,700 (1,189–6,134) pelatihan: tidak pernah pernah 42 (44,7%) 2 (50%) 52 (55,3%) 2 (50%) 1,000 1 0,808 (0,109–5,978) kepemimpinan efektif dan motivasi kerja (farida) 35 tabel 2. hubungan kepemimpinan efektif kepala ruangan yang dipersepsikan perawat pelaksana dengan penerapan komunikasi terapeutik kepemimpinan efektif penerapan komunikasi terapeutik p value or/ci 95% kurang baik kepemimpinan efektif kurang baik 28 (58,3%) 16 (32%) 20 (41,7%) 34 (68%) 0,016* 1 2,975 (1,302–6,796) pengetahuan kurang baik 28 (51,9%) 16 (36,4) 26 (48,1) 28 (63,6%) 0,184 1 1,885 (0,835–4,252) kesadaran diri kurang baik 29 (48,3%) 15 (39,5%) 31 (51,7%) 23 (60%) 0,515 1 1,434 (0,629–3,271) komunikasi kurang baik 28 (54,9%) 16 (34%) 23 (45,1%) 31 (66%) 0,061 1 2,359 (1,041–5,342) mobilisasi energi kurang baik 24 (54,5%) 20 (37%) 20 (45,5%) 34 (63%) 0,126 1 2,040 (0,907–4,589) tujuan kurang baik 24 (61,5%) 20 (33,9%) 15 (38,5%) 39 (66,1%) 0,013* 1 3,120(1,346–7,232) tindakan kurang baik 28 (50%) 16 (38,1%) 28 (50%) 26 (61,9%) 0,333 1 1,625(0,720–3,667) tabel 3. hubungan motivasi kerja dengan penerapan komunikasi terapeutik perawat pelaksana motivasi kerja penerapan komunikasi terapeutik p. value or/ci 95% kurang baik motivasi kerja: kurang baik 33 (63,5%) 11 (23,9%) 19 (36,5%) 35 (76,1%) 0,000* 1 5,526 (2,288–13,347) kebutuhan berprestasi: kurang baik 29 (53,7%) 15 (34,1%) 25 (46,3%) 29 (65,9%) 0,082 1 2,234 (0,986–5,099) kebutuhan kekuasaan: kurang baik 33 (61,1%) 11 (25%) 21 (38,9%) 33 (75%) 0,001* 1 4,714 (1,966–11,305) kebutuhan afi liasi kurang baik 34 (63%) 10 (22,7%) 20 (37%) 34 (77,3%) 0,000* 1 5,78 (2,36–14,155) mempersepsikan kepemimpinan efektif kepala ruangan baik akan mempunyai peluang sebesar 2,9 kali menerapkan komunikasi terapeutik baik dibanding dengan perawat pelaksana yang mempersepsikan kepemimpinan efektif kepala ruangan kurang baik. apabila ditelusuri hubungan setiap komponen, hanya ada 1 komponen yaitu penetapan tujuan yang berhubungan dengan penerapan komunikasi terapeutik perawat pelaksana. jurnal ners vol. 6 no. 1 april 2011: 31–41 36 hasil analisis variabel motivasi kerja perawat pelaksana dan komponen yang terdiri dari kebutuhan akan berprestasi, kebutuhan akan kekuasaan, dan kebutuhan akan afi liasi dengan penerapan komunikasi terapeutik. ada hubungan yang bermakna antara motivasi kerja perawat pelaksana dengan penerapan komunikasi terapeutik perawat pelaksana (p = 0,000). dari nilai or dapat disimpulkan bahwa perawat pelaksana yang mempunyai motivasi kerja baik, akan mempunyai peluang sebesar 5,5 kali menerapkan komunikasi terapeutik baik dibanding dengan perawat yang mempunyai motivasi kerja kurang. apabila ditelusuri secara rinci hubungan dari masingmasing komponen motivasi kerja perawat pelaksana dapat dijelaskan bahwa hanya kebutuhan akan kekuasaan dan kebutuhan akan afi liasi yang berhubungan dengan penerapan komunikasi terapeutik perawat pelaksana. analisis regresi logistik ganda sebanyak 5 variabel yaitu kepemimpinan efektif, motivasi kerja, umur, status perkawinan, dan lama kerja diuji secara bersama-sama untuk mendapatkan variabel yang paling berhubungan dengan penerapan komunikasi terapeutik. hasil analisis regresi logistik ganda tahap akhir menunjukkan bahwa umur memiliki nilai or lebih besar dibanding dengan motivasi kerja. kesimpulannya variabel umur merupakan variabel yang paling dominan berhubungan dengan penerapan komunikasi terapeutik perawat pelaksana. pembahasan hasil penelitian menggambarkan bahwa penerapan komunikasi terapeutik perawat pelaksana di ruang rawat inap rumah sakit dr. iskak tulungagung secara keseluruhan masuk kategori baik karena diatas rata-rata yaitu sebesar 55,1%, sedangkan kategori kurang baik sebesar 44,9%. penyebab dari belum optimalnya penerapan komunikasi terapeutik tersebut ada beberapa faktor yang mempengaruhi antara lain selama ini rumah sakit belum pernah melakukan pelatihan tentang komunikasi terapeutik terhadap perawat, sehingga perawat menerapkan komunikasi terapeutik berdasarkan ilmu yang diperoleh dari bangku sekolah. notoatmodjo (2003) mengatakan bahwa untuk meningkatkan kemampuan seseorang perlu dilakukan pelatihan, dan ditambahkan triton (2005) bahwa untuk meningkatkan kemampuan dan keterampilan diperlukan pelatihan. pendapat ini telah dibuktikan dari hasil penelitian bhakti (2003) bahwa pelatihan komunikasi menyimpulkan bahwa perawat yang telah mendapat pelatihan melaksanakan fase-fase komunikasi hubungan terapeutik lebih baik dari perawat yang belum pernah mengikuti pelatihan. dengan demikian peneliti yakin bahwa apabila dilakukan pelatihan komunikasi akan meningkatkan kemampuan penerapan komunikasi terapeutik perawat pelaksana. hal ini dapat menyebabkan belum bisa optimalnya penerapan komunikasi terapeutik. berdasarkan hasil observasi penerapan komunikasi terapeutik terhadap 15 perawat pelaksana juga menunjukkan belum sesuai dengan standar. sebagian besar perawat pada fase orientasi dan fase terminasi sudah menggunakan komunikasi dengan baik, tetapi sebagian besar pada fase kerja perawat tidak menjelaskan langkah-langkah pada saat melakukan tindakan keperawatan, mereka hanya menjelaskan maksud dilakukan tabel 4. analisis regresi logistik ganda tahap akhir terhadap karakteristik perawat, kepemimpinan efektif yang dipersepsikan perawat pelaksana, dan motivasi kerja perawat pelaksana variabel b p wald or ci 95% umur (1) umur (2) motivasi kerja 0,993 1,596 1,533 0,146 0,012* 0,001* 2,700 4,934 4,634 0,707–10,313 1,427–17,059 1,856–11,573 -2 log likehood = 111,833 g = 23,002 p = 0,000 kepemimpinan efektif dan motivasi kerja (farida) 37 tindakan. menurut hasil wawancara beberapa kepala ruang rawat inap bahwa perawat belum optimal dalam implementasi standar asuhan keperawatan (sak) dan tidak menggunakan strategi penerapan komunikasi terapeutik (sp). selain itu belum adanya penghargaan khusus dari rumah sakit bagi perawat yang menerapkan komunikasi terapeutik dengan baik sehingga menyebabkan kurang optimalnya penerapan komunikasi terapeutik. untuk meningkatkan penerapan komunikasi terapeutik perlu pihak rumah sakit melakukan penilaian kinerja dan melakukan pelatihan komunikasi, serta usaha peningkatan motivasi kerja. kepemimpinan efektif kepala ruangan yang dipersepsikan perawat pelaksana berhubungan dengan penerapan komunikasi terapeutik perawat pelaksana. hubungan yang bermakna ini kemungkinan disebabkan karena di rumah sakit dr. iskak tulungagung sudah menempatkan kepala ruangan berdasarkan kemampuan atau perawat senior dengan latar belakang pendidikan akper, sehingga kemampuan manajerial sudah dimiliki mereka. mereka mempunyai power dan mampu memengaruhi bawahan dalam bekerja. hal ini sejalan dengan teori tappen (1995) bahwa pemimpin yang efektif adalah seseorang yang berhasil memengaruhi orang lain untuk bekerja sama dalam keadaan produktif dan keadaan yang memuaskan, serta teori gibson (1997) mengatakan bahwa salah satu faktor yang memengaruhi kinerja individu dalam organisasi adalah kepemimpinan. ini artinya jika pemimpin efektif dalam memimpin maka akan memberi dampak positif terhadap kinerja perawat, dan sebaliknya apabila pemimpin tidak efektif akan memberikan dampak yang negatif terhadap kinerja perawat. kualitas kepemimpinan kepala ruangan mempunyai hubungan dengan kualitas perawat dalam penerapan komunikasi terapeutik. kepemimpinan yang efektif akan menciptakan suasana kerja yang nyaman bagi perawat pelaksana sehingga perawat pelaksana akan menyadari dan mau meningkatkan kemampuan penerapan komunikasi terapeutik dalam asuhan keperawatan. bila dilihat dari masing-masing komponen kepemimpinan efektif, proporsi terbesar penerapan komunikasi terapeutik dalam kategori baik, sedangkan dari hasil uji bivariat hanya ada 1 komponen saja yang berhubungan dengan penerapan komunikasi terapeutik yaitu komponen penetapan tujuan di mana diperoleh nilai p = 0,013. berdasarkan observasi masih ada kepala ruangan yang tidak fl eksibel serta tidak selalu menerima usulan bawahan tersebut. hal ini perlu menjadi bahan pemikiran bagi pengelola rumah sakit terutama bidang keperawatan guna meningkatkan kemampuan kepala ruangan dalam kepemimpinan melalui pendidikan berkelanjutan secara formal atau melalui pelatihan-pelatihan yang terkait dengan kepemimpinan efektif sehingga kemampuan kepemimpinan kepala ruangan dapat ditingkatkan. selain itu hasil penelitian ini dapat digunakan sebagai bahan pertimbangan kepala bidang keperawatan dalam menetapkan dan memilih kepala ruangan selanjutnya. motivasi kerja perawat pelaksana berhubungan dengan penerapan komunikasi terapeutik perawat pelaksana. hasil penelitian ini sejalan dengan teori mcclelland bahwa timbulnya motivasi untuk berperilaku karena dipengaruhi oleh kebutuhan-kebutuhan yang ada dalam diri manusia. hal ini mungkin dikarenakan sebagian besar perawat mempunyai masa kerja ≤ 6 tahun dan masih dalam rentang usia produktif yaitu umur ≤ 40 tahun, memiliki semangat cukup tinggi untuk berkompetensi dan bekerja lebih baik dari orang lain, sehingga mereka lebih inovatif dan kreatif dalam menerapkan komunikasi terapeutik (kebutuhan akan berprestasi). masih banyaknya perawat dengan status kepegawaian kontrak (± 40%) mendorong mereka untuk bekerja lebih baik dan berjuang demi persahabatan dalam situasi yang kooperatif agar dapat diterima dalam kelompok (kebutuhan akan afi liasi), serta berjuang agar mendapat wewenang untuk mandiri, dan dihargai orang lain (kebutuhan akan kekuasaan). data tersebut di atas juga dapat dijadikan masukan bagi institusi pelayanan kesehatan terhadap mutu pelayanan kesehatan yang diupayakan saat ini. artinya bahwa dengan sistem pegawai kontrak cenderung meningkatkan motivasi dan kinerja perawat pelaksana. hal tersebut meningkatkan keyakinan penulis tentang hubungan yang bermakna antara prosentase jurnal ners vol. 6 no. 1 april 2011: 31–41 38 pegawai kontrak dengan kinerja perawat pelaksana, khususnya yang berkaitan dengan penerapan komunikasi terapeutik. keyakinan ini didasari adanya peraturan penerimaan dan perpanjangan perawat kontrak berdasarkan keputusan direktur rumah sakit dr. iskak tulungagung tentang penerimaan pegawai kontrak. masa kerja kontrak adalah selama 1 tahun, kemudian apabila kinerjanya baik maka bisa diperpanjang setiap satu tahun sekali. selain itu perawat yang diangkat menjadi pegawai negeri sipil diutamakan pegawai kontrak. hal ini mendorong motivasi kerja perawat termasuk motivasi dalam penerapan komunikasi terapeutik. kinerja yang lebih baik pada pegawai kontrak dengan pegawai negeri sipil, dapat dijadikan bahan pertimbangan rumah sakit untuk mempertahankan sistem kontrak yang ada bahkan bila memungkinkan, jumlah tenaga kontrak dapat ditingkatkan lagi. masih rendahnya prosentase motivasi kerja yang baik (46,9%) dan kebutuhan berprestasi yang tidak signifikan, dapat memberikan dampak penerapan komunikasi terapeutik belum bisa optimal. penerapan komunikasi terapeutik yang tidak optimal akan memberikan dampak terhadap mutu asuhan keperawatan, karena komunikasi terapeutik dapat digunakan sebagai salah satu indikator mutu pelayanan keperawatan. hal ini dapat menjadikan bahan pikiran dari pimpinan rumah sakit terutama bidang keperawatan, untuk mencari penyebab serta solusi dalam rangka meningkatkan motivasi kerja perawat pelaksana. umur perawat berhubungan dengan p e n e r a p a n k o m u n i k a s i t e r a p e u t i k , a d a k e c e n d e r u n g a n p e n e r a p a n k o m u n i k a s i terapeutik dengan baik pada umur muda, sedangkan perawat berumur tua cenderung menerapkan komunikasi terapeutik kurang baik. hal ini kemungkinan disebabkan karena perawat yang berumur muda baru menyelesaikan sekolah sehingga masih segar dalam ingatan tentang penerapan komunikasi terapeutik yang baik, sedangkan pada umur tua semakin menurun karena tidak ada pendidikan berkelanjutan. bila dilihat dari uji regresi logistik ganda ternyata variabel umur merupakan variabel yang paling dominan berhubungan dengan penerapan komunikasi terapeutik. keadaan ini menunjukkan bahwa komunikasi terapeutik sangat dipengaruhi oleh umur perawat pelaksana. jumlah perawat pelaksana di rumah sakit dr. iskak tulungagung lebih banyak umur produktif yaitu sampai umur 40 tahun. secara teori, semakin bertambah umur akan semakin terampil dan akan semakin matang emosinya karena banyak pengalaman yang diperoleh, tetapi bila dilihat dari potensi/ kemauan, umur muda lebih berpotensi karena mempunyai fi sik yang kuat. umur muda lebih ideal sehingga ingin selalu menampilkan jati dirinya, selain itu lebih inovatif dan kreatif sehingga mempunyai kemampuan lebih baik dalam berkomunikasi terapeutik dibanding umur tua. berdasarkan hal tersebut, peneliti sependapat dengan teori sarwono(2000) yang mengatakan usia produktif maksimal umur 40 tahun lebih mampu berkinerja dalam ilmu pengetahuan dan kesenian, karena kreatifitasnya lebih tinggi dibanding umur diatas 40 tahun. juga teori robbin (2003) yang mengatakan bahwa semakin bertambah umur kemampuan dan motivasi kerja akan menurun, sebaliknya semakin muda umur seseorang maka akan semakin kreatif dan inovatif. dalam berinteraksi dengan pasien, perawat membutuhkan pengetahuan, ketrampilan, dan kreatifi tas agar komunikasi terapeutik berjalan dengan baik. pendidikan tidak berhubungan dengan penerapan komunikasi terapeutik. menurut green (1980) bahwa pendidikan merupakan faktor penentu terhadap perilaku kerja seseorang. pendidikan sangat penting dalam menentukan kemampuan maupun ketrampilan, karena semakin tinggi pendidikan akan semakin kritis, logis dan sistematis cara berpikirnya (notoatmodjo, 2003). tidak ada hubungan dalam penelitian ini dimungkinkan karena uraian tugas dan tanggung jawab perawat pelaksana di ruang rawat inap rumah sakit dr. iskak tulungagung antara perawat yang berpendidikan akper dan spk tidak ada perbedaan, termasuk penerapan komunikasi terapeutik dalam asuhan keperawatan, sehingga tidak ada motivasi untuk lebih meningkatkan komunikasi terapeutik pada perawat yang mempunyai latar belakang pendidikan akper. selain itu faktor lain yang dimungkinkan memengaruhi hasil analisis kepemimpinan efektif dan motivasi kerja (farida) 39 tersebut karena perawat di rumah sakit tersebut belum optimal dalam implementasi standar asuhan keperawatan (sak) dan tidak menggunakan strategi penerapan komunikasi terapeutik (sp). meskipun sebagian besar pendidikan akper, tidak akan memberikan arti yang bermakna terhadap peningkatan penerapan komunikasi terapeutik jika pelaksanaan asuhan keperawatan tidak berdasarkan standar. penghargaan juga dapat meningkatkan kinerja perawat, dengan tidak adanya penghargaan bagi perawat yang baik dalam menerapkan komunikasi terapeutik di rumah sakit tersebut dapat menyebabkan menurunnya motivasi, sehingga meskipun pendidikannya akper tidak ada motivasi untuk lebih meningkatkan penerapan komunikasi terapeutik. status perkawinan tidak berhubungan dengan penerapan komunikasi terapeutik. menurut robbins (2003) bahwa karyawan yang telah menikah sedikit absensi karena perkawinan memaksakan peningkatan tanggung jawab yang membuat suatu pekerjaan menjadi lebih berharga dan penting. ditambahkan siagian (1999) bahwa karyawan yang telah menikah memiliki motivasi kerja yang tinggi dibanding yang belum menikah. menurut kedua teori tersebut seharusnya perawat yang sudah menikah cenderung lebih baik penerapan komunikasi terapeutiknya, karena perawat mempunyai harapan dan motivasi yang tinggi. dalam penelitian ini tidak ditemukan hubungan status perkawinan dengan penerapan komunikasi terapeutik, hal ini mungkin disebabkan oleh karena perawat pelaksana yang telah kawin sebagian mempunyai masa kerja > 6 tahun. pada masa kerja tersebut perawat cenderung menurun motivasi kerjanya seperti yang dikemukakan martoyo (1998) bahwa semakin lama kerja makin mundur motivasi kerja, karena tidak ada tantangan dalam pekerjaannya. hal lain yang menjadi penyebab tidak signifi kan hasil analisis ini mungkin dikarenakan budaya komunikasi yang kurang baik dalam keluarga yang sudah melekat pada diri perawat. karena sudah menjadi kebiasaan di rumah, maka dibawa dalam bekerja, sehingga komunikasi dengan pasien menjadi tidak terapeutik. beban kerja yang terlalu banyak dapat menjadi penyebab kurang optimalnya penerapan komunikasi terapeutik. perawat yang telah menikah akan membagi tenaga dan pikirannya dalam pekerjaan dan tanggung jawab dalam keluarga, perhatian banyak di keluarga sehingga tidak mudah untuk berkomunikasi secara terapeutik. l a m a k e r j a b e r h u b u n g a n d e n g a n penerapan komunikasi terapeutik. ada k e c e n d e r u n g a n p e n e r a p a n k o m u n i k a s i terapeutik yang baik pada lama kerja ≤ 6 tahun. penelitian ini didukung teori martoyo (1998) mengatakan bahwa semakin lama kerja makin mundur motivasi kerja, karena tidak ada tantangan dalam pekerjaannya. tetapi teori robbins (2003) mengatakan bahwa semakin lama masa kerja maka karyawan akan menghasilkan produktivitas yang tinggi. lama kerja menentukan seseorang menjalankan fungsinya sehari-hari, makin lama masa kerja perawat maka makin terampil dan berpengalaman menghadapi masalah dalam melaksanakan tugas. hal ini dapat dipahami peneliti bahwa secara tehnik semakin lama seseorang bekerja akan semakin meningkat keterampilan dan pengalamannya dan akan menghasilkan produktivitas tinggi. tetapi penerapan komunikasi terapeutik bukan keterampilan secara teknikal yang dibutuhkan, melainkan perlu kemampuan hubungan interpersonal. untuk mampu berhubungan secara baik dengan pasien diperlukan kemampuan hubungan interpersonal dan ini dapat dilakukan dengan kreativitas seseorang. bila dikaitkan dengan lama kerja, maka lama kerja ≤ 6 tahun terbanyak adalah perawat pelaksana dengan status kepegawaian kontrak dan umur < 40 tahun, mereka mempunyai kreativitas tinggi, lebih inovatif, ingin menunjukkan kemampuannya sehingga komunikasi dapat lebih baik. pelatihan tidak berhubungan dengan penerapan komunikasi terapeutik. menurut n o t o a t m o d j o ( 2 0 0 3 ) b a h w a p e l a t i h a n merupakan bagian dari proses pendidikan untuk memperoleh pengetahuan dan keterampilan dan pendapat triton (2005) bahwa pelatihan bertujuan memperbaiki penguasaan berbagai keterampilan dan tehnik pelaksanaan kerja. program pelatihan sebaiknya diberikan baik pada pegawai baru maupun yang telah ada untuk jurnal ners vol. 6 no. 1 april 2011: 31–41 40 menghadapi situasi-situasi yang berubah. salah satu faktor penyebab tidak ada hubungan yang paling memengaruhi adalah jumlah perawat pelaksana yang telah mengikuti pelatihan hanya 4 orang dari keseluruhan 98 orang. dengan jumlah yang sangat sedikit tersebut bila analisis secara statistik hasilnya akan bias dan tidak dapat memberikan arti yang bermakna. faktor lain adalah mengenai metode pelatihan komunikasi yang cenderung lebih banyak mengulas tentang teori dan konsep komunikasi terapeutik dan tidak ditekankan pada praktik. kualitas pelatihan juga memengaruhi perawat yang mengikuti pelatihan komunikasi, pelatihan yang kurang maksimal akan menghasilkan penerapan komunikasi kurang memadai. selain faktor tersebut adalah mengenai waktu pelaksanaan pelatihan yang pernah diikuti oleh perawat pelaksana sudah lebih dari 2 tahun. artinya hasil pelatihan yang terlalu lama dan tidak segera diimplementasikan akan memberikan dampak yang tidak optimal, apalagi tidak dilakukan supervisi. evaluasi kegiatan pelatihan komunikasi terapeutik juga merupakan faktor yang mempengaruhi, karena kegiatan pelatihan yang tidak diikuti dengan evaluasi cenderung kurang memberikan hasil yang optimal. budaya juga memengaruhi hasil pelatihan, artinya meskipun sudah ikut pelatihan komunikasi tetapi budaya komunikasi yang ada di rumah sakit tersebut kurang baik sehingga memberikan dampak kurang optimal mengimplementasikan hasil pelatihan. simpulan dan saran simpulan perawat pelaksana terbanyak umur < 30 tahun, pendidikan terbanyak akper, pada umumnya belum kawin, dan lama kerja terbanyak ≤ 6 tahun, dan hampir seluruh perawat pelaksana tidak pernah mengikuti pelatihan, kepemimpinan efektif kepala ruangan yang dipersepsikan perawat pelaksana menunjukkan sebagian besar dalam kategori baik, motivasi kerja perawat pelaksana sebagian besar dalam kategori kurang baik, penerapan komunikasi terapeutik perawat pelaksana sudah relatif baik. karakteristik perawat (umur, lama kerja), kepemimpinan efektif, motivasi kerja berhubungan dengan penerapan komunikasi terapeutik perawat pelaksana. umur merupakan variabel paling dominan berhubungan dengan penerapan komunikasi terapeutik perawat pelaksana. saran disarankan kepada pihak rumah sakit terutama manajer keperawatan untuk menggunakan hasil penelitian ini sebagai bahan pertimbangan dalam menyusun program pelatihan komunikasi terutama perawat umur produktif, meningkatkan kemampuan kepala ruangan melalui pendidikan berkelanjutan dan pelatihan kepemimpinan, serta dalam memilih kepala ruangan selanjutnya. perlu m e n i n g k a t k a n m o t i v a s i k e r j a d e n g a n memberikan reward kepada perawat berprestasi baik dan mempertahankan sistem kontrak, serta mengevaluasi penerapan komunikasi terapeutik secara berkesinambungan. kepustakaan as’ad, m., 2003. psikologi industri. yogyakarta: liberty. azwar, a., 1996. pengantar administrasi kesehatan masyarakat edisi ketiga. jakarta: binarupa aksara. departemen kesehatan republik indonesia, 1994. pedoman uraian tugas tenaga kesehatan di rumah sakit. jakarta. ilyas, y., 2004. perencanaan sdm rumah sakit: teori, metoda dan formula. jakarta: pusat kajian ekonomi kesehatan, fkm ui. gibson, l., et al., 1997. organisasi, perilaku, struktur, proses. editor: agus dharma. jakarta: binarupa aksara, green, l., 1980. health education planning. b o s t o n : m y f i e l d p u b l i s h i n g c o , johnhopkins univ. boston. manurung, s., 2003. hubungan karakteristik individu perawat dan organisasi dengan penerapan komunikasi ierapeutik di ruang rawat inap perjan rumah sakit persahabatan jakarta, 2003. tesis tidak dipublikasikan. jakarta: program pascasarjana fik ui. martoyo, s., 1998. manajemen sumber daya manusia, yogyakarta: bpfe yogyakarta. kepemimpinan efektif dan motivasi kerja (farida) 41 notoatmodjo, s., 2003. pendidikan dan perilaku kesehatan. jakarta: penerbit rineka cipta. robbins, s.p., 2003. perilaku organisasi. j a k a r t a : p t i n d e k s k e l o m p o k gramedia. sarwono, s.w., 2000. pengantar umum psikologi. jakarta: pt. bulan bintang. siagian, 1999. manajemen sumber daya manusia. jakarta bumi: aksara. tappen, 1998. essential of nursing leadership a n d m a n a g e m e n t . p h i l a d e l p h i a : fa. davis company. triton, p.b., 2005. paradigma baru manajemen sumber daya manusia; kunci sukses meningkatkan kinerja, produktivitas, m o t i v a s i d a n k e p u a s a n k e r j a . yogyakarta: tugu. wijono, j., 2000. manajemen mutu pelayanan k e s e h a t a n c e t a k a n 2 . s u r a b a y a : airlangga university press. vol 8 no 1 april 2013.indd 165 terapi keluarga dengan pendekatan spiritual terhadap model keyakinan kesehatan keluarga dalam merawat pasien skizofrenia (the effect of family therapy with spiritual approach toward family’s health belief model in taking care of patient with schizophrenia) ah. yusuf s.* *fakultas keperawatan universitas airlangga, kampus c mulyorejo surabaya 60115 e-mail: yusuf_fkp_unair@yahoo.co.id abstrak pendahuluan: skizofrenia adalah suatu masalah dengan kognitif, pikiran dan perilaku mal adaptif. keluarga dengan salah satu anggota keluarga mengalami gangguan jiwa dapat menjadi konfl ik yang serius, beban objektif dan subjektif, saling menyalahkan, terlibat dalam permusuhan antar anggota keluarga. berbagai efek negatif yang dihadapi oleh keluarga dapat disebabkan oleh model keyakinan kesehatan keluarga tentang skizofrenia yang salah sehingga berdampak pada kegagalan dalam memilih pengobatan serta cara perawatan pasien dengan skizofrenia di rumah. seseorang dengan stres berat akan mencari penghiburan dan kekuatan dari tuhan. tapi sejauh ini, model spiritual yang paling efektif untuk meningkatkan model keyakinan kesehatan keluarga dalam merawat pasien dengan skizofrenia belum ditemukan. metode: desain yang digunakan dalam penelitian ini adalah eksperimental ( pre post test control group design). populasi dalam penelitian ini adalah setiap keluarga pasien dengan gangguan jiwa di rumah sakit jiwa menur pada tahun 2010, dipilih dengan alokasi simple random. sampel sebanyak 13 orang di setiap kelompok perlakuan dan kelompok kontrol. intervensi diberikan selama 60-120 menit dalam 8 kali pertemuan dengan interval rata-rata sekitar 1 minggu. analisis data dilakukan dengan menggunakan paired t-test dan independent t-test. hasil: ada perubahan signifi kan dalam model keyakinan kesehatan keluarga (p=0,004), perubahan tersebut terjadi pada aspek persepsi tentang manfaat (p=0,009), persepsi tentang hambatan (p=0,035) dan persepsi tentang self effi cacy (p=0,002). tidak ada perubahan yang signifi kan dalam persepsi tentang kerentanan dan keparahan (p=0,052). diskusi: keluarga masih tetap percaya bahwa semua kejadian yang dialami pasien dan keluarga sudah merupakan kehendak tuhan, mengharap pasien dapat lebih mandiri dari kondisi sebelumnya, dan percaya gangguan jiwa dapat berubah menjadi lebih baik. kesimpulan dalam penelitian ini adalah bahwa pemberian terapi keluarga dengan pendekatan spiritual dapat meningkatkan model keyakinan kesehatan keluarga dalam merawat pasien dengan gangguan mental. kata kunci: model keyakinan kesehatan, spiritual, terapi keluarga, caring, skizofrenia. abstract introduction: schizophrenia is the problem with kognitive, mal-adaptive thought and behavior. family who have a member with mental disorder can experience serious confl ict, become an objective and subjective burden, blame each other, get involved in hostility among family members. various negative effect faced by family can caused by wrong family’s health belief model about schizophrenia, hence the failure on choosing the treatment and taking care of patient at home. someone with severe stress will seek comfort and strength from god. but so far, the most effective spiritual models to improve the health belief model of the family in caring for patients with schizophrenia has not been found. method: design used in this study was experimental (pre post test control group design). the population was every family of patient with mental disorder in menur mental hospital along the year of 2010, chosen by alocation simple random. samples were 13 persons in each treatment and control group. the intervention was given in 60–120 minute in 8 times meeting with average interval 166 jurnal ners vol. 8 no. 1 april 2013: 165–173 about 1 week. data analysis was done using paired t-test and independent t-test. results: there were signifi cant changes in total of family’s health belief model (p=0,004), there was signifi cantly change in aspects of (1) perceptions about benefi ts (p=0,009), (2) perception about barriers (p=0,035) and perception about self effi cacy (p=0,002). there were no signifi cant changing in perception about susceptibility and severity (p=0,052). discussion: family believes that all events experienced by the patient and the family is god's will, hoping the patient can be more independent, and believe mental disorders can be changed for the better. the conclusion of this study is that family therapy with a spiritual approach can improve the health belief model of the family in caring for patients with mental disorders. keywords: health belief model, spiritual, family therapy, caring, schizophrenia. pendahuluan gangguan jiwa khususnya skizofrenia mer upakan masalah yang terkait dengan gangguan kognitif, pikiran dan perilaku mal-adaptif (hawari, 2001; maramis, 1998; sarwono, 2001). keluarga dengan salah satu anggota keluarga mengalami gangguan jiwa dapat menimbulkan konfl ik, menjadi beban obyektif dan subyektif, saling menyalahkan, dan keterlibatan dalam permusuhan antar anggota keluarga (pharoah, 2010; fitryasari, 2009). berbagai masalah bio-psiko-sosialk ult u ral dapat menyebabkan ter jadinya gangguan jiwa, tetapi sampai saat ini penyebab pasti gangguan jiwa masih terus dalam kajian. keadaan ini menyebabkan model keyakinan kesehatan keluarga terhadap gangguan jiwa tidak adekuat, dianggap karena kutukan, roh halus, dibikin orang lain, atau karena hal lain yang belum jelas. model keyakinan kesehatan seseorang a k a n m e m p e n g a r u h i u p ay a m e n c a r i pengobatan. berbagai upaya pendidikan kesehatan, pemberian psiko-edukasi terhadap keluarga yang sedang menunggu salah satu anggota keluarga yang dirawat di rumah sakit jiwa, tetapi sebagian masyarakat masih tetap menjadikan stigma terhadap gangguan jiwa di masyarakat. oleh karena itu, pada penelitian ini berusaha memperbaiki model keyakinan kesehatan keluarga melalui terapi keluarga dengan pendekatan spiritual. penelitian ini bertujuan untuk membuktikan pengaruh terapi keluarga dengan pendekatan spiritual terhadap perbaikan model keyakinan kesehatan keluarga dalam merawat pasien gangguan jiwa. bahan dan metode penelitian ini merupakan penelitian eksperimental ( pre-post test control group design), dengan populasi seluruh keluarga yang salah satu anggota keluarganya dirawat di rumah sakit jiwa menur surabaya pada tahun 2010, dipilih dengan alokasi simple random. jumlah sampel dalam penelitian ini adalah 13 orang kelompok perlakuan dan 13 orang kelompok kontrol. variabel independen dalam penelitian ini adalah terapi keluarga dengan pendekatan spiritual melalui fase direction, obedience, dan acceptance. intervensi dilaksanakan di rumah keluarga sebanyak 8 kali pertemuan, selama 30–60 menit tiap pertemuan, dengan interval waktu sekitar 1 minggu. variabel dependen berupa model keyakinan kesehatan (health belief model) keluarga dalam merawat pasien gangguan jiwa, meliputi persepsi terhadap susceptibility and severity of disease, benefi ts barriers dan self effi cacy keluarga. analisis data dilakukan dengan uji paired t-test untuk data pre-post test dan untuk sampel bebas (data pre-pre dan pos-pos kelompok perlakuan dan kelompok kontrol) dilakukan uji independent t test. hasil hasil keselur uhan pengar uh terapi kelu a rga denga n pendek at a n spi r it u al didapatkan dapat mengubah beberapa aspek health belief model keluarga dalam merawat pasien gangguan jiwa. perubahan tersebut terjadi pada aspek persepsi terhadap manfaat, 167 terapi keluarga dengan pendekatan spiritual (ah. yusuf s.) persepsi terhadap hambatan dan persepso terhadap self effi cacy. tidak ada perubahan pada aspek persepsi terhadap kerentanan dan keparahan penyakit. namun, secara umum terapi keluarga dengan pendekatan spiritual tersebut dapat mengubah model keyakinan kesehatan keluarga tentang skizof renia (tabel 1). pembahasan te r d a p a t p e r b e d a a n s ig n i f i k a n (p=0,004) total health belief model keluarga dalam merawat pasien gangguan jiwa antara kelompok kontrol dan kelompok perlakuan. tetapi, jika dibandingkan dengan hasil uji independent t-test data pre test kelompok perlakuan dan kelompok kontrol, ternyata sejak awal sudah menunjuk kan terdapat perbedaan kepercayaan kesehatan kelompok perlakuan dan kelompok kontrol (p=0,021), jika diperhatikan nilai selisih delta rerata antara pre test-post test pada kelompok perlakuan dan kelompok kontrol menunjukkan terdapat kenaikan selisih rerata pada kelompok perlakuan sebesar 1,84, sedangkan pada kelompok kontrol juga ada peningkatan 1,00. dengan demikian, angka kenaikan lebih tinggi tabel 1. pengaruh terapi keluarga dengan pendekatan spiritual terhadap perubahan berbagai aspek dalam health belief model no . variabel uji perlakuan kontrol independent t test 1 persepsi terhadap susceptibility and severity of disease pre test (x–±sd) 13,23±2,48 (x–±sd) 11,76±2,65 t = 1,449 p = 0,160 post test (x–±sd) 13,92±1,60 (x–±sd) 12,23±2,52 t = 2,041 p = 0,052 paired t test t=-1,389 p=0,190 t=–1,066 p=0,307 δ pre post 0,69 0,47 p = 0,730 2 persepsi terhadap benefi ts pre test (x–±sd) 13,61± 2,10 (x–±sd) 12,84± 2,03 t = 0,948 p = 0,363 post test (x–±sd) 14,15±1,67 (x–±sd) 12,30±1,65 t = 2,828 p = 0,009 paired t test t= -2,214 p=0,047 t=0,797 p=0,441 3 persepsi terhadap barriers pre test (x–±sd) 13,61±1,98 (x–±sd) 10,46±2,14 t = 3,894 p = 0,001 post test (x–±sd) 13,30±2,42 (x–±sd) 11,30±2,13 t = 2,229 p = 0,035 paired t test t=0,617 p=0,549 t=-2,008 p=0,068 δ pre post 0,31 0,84 p = 0,090 4 persepsi terhadap self effi cacy pre test (x–±sd) 13,46±1,76 (x–±sd) 11,92±2,46 t = 1,831 p = 0,080 post test (x–±sd) 14,38±1,04 (x–±sd) 12,15±2,03 t = 3,517 p = 0,002 paired t test t=-2,144 p=0,053 t=-0,640 p=0,534 5 total health belief pre test (x–±sd) 53,92±7,31 (x–±sd) 47,00±6,94 t = 2,475 p = 0,021 post test (x–±sd) 55,76±5,86 (x–±sd) 48,00±6,63 t = 3,165 p = 0,004 paired t test t=-1,310 p=0,215 t=-0,926 p=0,373 δ pre post 1,84 1,00 p = 0,638 168 jurnal ners vol. 8 no. 1 april 2013: 165–173 pada kelompok perlakuan sebesar 0,84. ke percaya a n kesehat a n kelu a rga tertinggi pada pre test kelompok perlakuan adalah responden percaya bahwa semua kejadian yang dialami sudah mer upakan kehendak tuhan. keadaan ini menunjukkan bahwa responden kelompok perla k u a n dapat mener ima apa pu n yang ter jadi denga n menga nggap semu a i n i sud a h kehendak tuhan, tetapi di sisi lain dapat merupakan ketidakberdayaan keluarga dalam menghadapi salah satu anggota keluarga yang mengalami gangguan jiwa. keadaan ini juga mencerminkan keyakinan (self effi cacy) keluarga yang sudah tidak punya pilihan lain dalam menghadapi salah satu anggota keluarga mengalami gangg uan jiwa. jika dilihat dari lamanya pasien mengalami gangguan jiwa, ada yang sudah mencapai 45 tahun, sehingga selama itu pula keluarga mengalami stress, beban fisik, dan psikologis akibat hidup dengan salah satu anggota keluarga mengalami gangguan jiwa. oleh karena itu, keluarga hanya memilih menerima apa pun yang terjadi, dengan menganggap semua ini sudah kehendak tuhan. kepercayaan keluarga menganggap semua ini sudah kehendak tuhan adalah sesuatu yang baik, asal bukan merupakan ketidakberdayaan dan keputusasaan keluarga. sabar bukanlah kelemahan, justr u sabar adalah kekuatan, sabar bukan kelesuan tetapi semangat hidup, sabar bukan kecengengan tetapi ketegaran, sabar bukan pesimis tetapi optimis, dan sabar bukanlah diam membisu tetapi sabar adalah berjuang pantang menyerah (al-hamid, 1995; nahrowi, 2010). hasil diskusi mendalam selama pelaksanaan terapi keluarga, keluarga mengatakan “soal sabar dan berdoa ya sudah dari dulu mas, tapi mau gimana lagi”. peneliti mencoba memberi semangat, motivasi dengan illustrasi falsafah ulat dan kaktus. health belief adalah suatu kepercayaan seseorang terhadap masalah kesehat an (gla n z , 20 02). ke pe rcaya a n t e rha d ap masalah kesehatan dapat menjadi dasar dalam mengembangkan intervensi perilaku kesehatan. kepercayaan seseorang tentang gangguan jiwa, merupakan aspek penting yang har us dikaji karena gangguan jiwa sangat erat dengan stigma, kutukan, penyakit dibuat orang, dan memalukan. glanz (2002) mengidentifikasi empat komponen utama health belief adalah persepsi individu tentang tingkat kerentanan dan keparahan suatu penyakit (susceptibility and severity), persepsi tentang kemungkinan bermanfaatnya sarana pelayanan kesehatan dalam mengatasi masalah (benef its), persepsi tentang kemungkinan pasien mampu mengendalikan diri dalam mengembangkan perilaku sehat (barriers), dan keyakinan diri (self effi cacy) dalam mengatasi berbagai dampak akibat gangguan jiwa. m ayo r it a s r e s p o n d e n kelo m p ok perlakuan sebelum intervensi menganggap pasien gangguan jiwa tidak bisa bekerja se p e r t i seb elu m nya d a n me nga nggap pasien tidak bisa menjaga diri dari keadaan yang membahayakan. hasil diskusi saat pemberian terapi keluarga mayoritas keluarga menganggap gangguan jiwa disebabkan karena penyebab non medis (karena ulah orang lain yang tidak suka), medis (seringnya terjadi benturan/trauma di kepala, epilepsi, atau gangguan fungsi otak lainnya) dan penyebab psikologis seperti stres dan trauma kehidupan. ada keluarga yang tidak tahu apa penyebab gangguan jiwa, tiba-tiba anaknya mengalami gangguan, mungkin tidak tahan dengan masalah kehidupan yang dialami. kenyataan ini menunjukkan bahwa keluarga dalam menghadapi suatu masalah (at r ibusi) masih menganggap penyebab gangguan jiwa adalah karena faktor di luar (eksternal) keluarga, karena penyebab yang lain, penyakit lain, akibat orang lain yang tidak suka. tidak pernah menganggap bahwa keluarga juga berperan dalam munculnya stressor bagi pasien, pembentukan karakter, ketahanan mental anak, dan kesiapan anak dalam menghadapi kehidupan. keadaan inilah yang mencoba diadvokasi peneliti selama pemberian terapi keluarga fase direction dan obedience. bagaimana keluarga bisa memberikan penilaian bahwa semua anggota keluarga juga berperan dalam membentuk karakter anak, kesiapan mental dan memicu munculnya stressor bagi pasien. harapannya keluarga dapat memberikan 169 terapi keluarga dengan pendekatan spiritual (ah. yusuf s.) internalisasi dalam menghadapi masalah yang terjadi, sehingga semua anggota keluarga akan mengubah sikap dan memberikan dukungan fisik dan psikologis bagi pasien gangguan jiwa (keluarga sebagai sumber pendukung bagi pasien). menurut teori stres adaptasi dalam ke pe r awat a n jiwa , mek a n isme coping seseorang dipengaruhi oleh sifat stressor, penilaian terhadap stressor, sumber coping (stuart, 1998; hamid, 2009; keliat, 1996, rasmun, 2002). beberapa sumber coping yang dapat membantu mengembangkan mekanisme coping adalah kebiasaan personal, dukungan sosial, kekayaan materi, dan kepercayaan yang positif (stuart, 1998). kebiasaan personal dapat dibangun dengan mengembangkan peran keluarga adaptif, mengingat keluarga adalah merupakan tempat yang pertama dan utama dalam proses sosialisasi pembelajaran anak. kegiatan ini, mer upakan kegiatan pemberdayaan keluarga agar bisa menjadi support system bagi pasien. ji k a d i k a it k a n d e ng a n d i m e n si spiritualitas manusia, mayoritas responden masih dalam kategori pengalaman spiritual dan kecenderungan ritual, belum masuk pada penemuan makna hidup dan emosi positif. padahal untuk bisa mengembangkan sikap menerima (acceptance) apa pun yang terjadi dalam kehidupan diperlukan emosi positif untuk menemukan makna hidup. b e b e r a p a k e t e r b a t a s a n d a l a m penelit ia n i n i a d ala h t id a k d ila k u ka n pengukuran terhadap tingkat spiritualitas dan spiritual qoutient (sq) responden. pada rancangan penelitian akan dicoba dilakukan pengukuran tingkat keberagamaan responden menggunakan instrument yang dikembangkan oleh hawari, 2009. tetapi indikator dalam instr umen tersebut tidak mencer minkan tingkat spiritualitas manusia, karena hanya berisi penerapan atau pelaksanaan rukun iman dan islam, sementara tingkat ikhsan tidak terdeteksi. ada dua jenis instrumen spiritualitas yang praktis dalam perspektif neurosains (pasiak, 2012 dalam asy’arie, 2012), yaitu spiritual health assessment (sha), dan spiritual past and present (spp). spp dan sha adalah hal baru, bahkan merupakan lompatan kuantum dalam dunia kedokteran. spp lebih sering digunakan untuk melengkapi rekam medis rumah sakit, sedangkan sha terdiri dari 4 dimensi, 24 indikator dengan (rancangan) 120 item per tanyaan, tetapi sampai saat ini sha belum merupakan barang jadi dan masih sedang dikembangkan dalam center for neuro scince health and spirituality (c-net) (asy’arie, 2012). setelah program pengembangan sha selesai, akan dapat digunakan sebagai instrumen terbaru dan handal dalam pengukuran tingkat spiritualitas manusia. te r d a p a t p e r b e d a a n s ig n i f i k a n persepsi keluarga tentang kemungkinan bermanfaatnya sarana pelayanan kesehatan dalam mengatasi masalah (benefi ts) antara kelompok kontrol dan kelompok perlakuan (p=0,009). mayoritas responden mengatakan dapat memberikan perawatan yang baik bagi pasien di rumah. hampir semua responden mengatakan pelayanan kesehatan bermanfaat untuk mengurangi tanda dan gejala yang timbul. beberapa responden mengatakan bagaimanapun keadaan pasien, keluarga tetap ber usaha member ikan perawatan sesuai kemampuan keluarga, satu responden menempatkan pasien di tempat rehabilitasi psikiatri di surabaya. keadaan ini ditunjang oleh hampir semua responden memanfaatkan jaminan kesehatan masyarakat (jamkesmas). hasil kajian mendalam pada awal pertemuan, keluarga jarang bisa berpartisipasi sesuai permasalahan pasien, keluarga hanya menjaga, dan berusaha memenuhi apa yang diinginkan (sesuai kemampuan). beberapa latihan pemenuhan kebutuhan harian yang telah dilatihkan bagi pasien selama di rumah sakit, jarang ditindaklanjuti oleh keluarga di rumah, termasuk upaya antisipasi keluarga untuk mencegah kekambuhan. oleh karena itu, diskusi dalam terapi keluarga difokuskan terkait peran keluarga dalam membantu mengatasi masalah sesuai masalah yang dihadapi pasien. hasil survei didapatkan sepuluh masalah keperawatan terbanyak di rumah sakit jiwa di indonesia (konas jiwa, 2005; keliat, 2009) adalah perilaku kekerasan, risiko 170 jurnal ners vol. 8 no. 1 april 2013: 165–173 perilaku kekerasan (pada diri sendiri, orang lain, dan lingkungan), gangguan persepsi sensori; halusinasi (pendengaran, penglihatan, pengecap, peraba, penghidu), gangguan proses pikir, kerusakan komunikasi verbal, risiko bunuh diri, isolasi sosial, kerusakan interaksi sosial, defi sit perawatan diri (mandi, berhias, bercukur, makan, eliminasi), dan harga diri rendah kronis. bagaimana peran keluarga dalam membantu pasien sesuai permasalahan tersebut tercantum dalam buku modul agar bisa dipelajari keluarga dalam mengembangkan peran keluarga dalam merawat pasien gangguan jiwa di rumah. terdapat perbedaan signifi kan persepsi keluarga tentang kemungkinan pasien mampu mengendalikan diri dalam mengembangkan perilaku sehat (barriers) antara kelompok perlakuan dan kelompok kontrol (p=0,035). jika dibandingkan data pre test antara kelompok kontrol dan perlakuan memang sudah ada p e r b e d a a n ( p = 0,0 01). me mp e rh at i k a n selisih nilai rerata antara pre test-post test pada kelompok perlakuan justru mengalami penurunan sebesar (-0,31), kelompok kontrol meningkat 0,84. jadi sebenarnya terdapat perbedaan, tetapi perbedaan itu justru terjadi pada kelompok kontrol. h a s i l t el a a h p e n el i t i t e r h a d a p rekapitulasi jawaban kuesioner, ditambah kajian saat diskusi dalam terapi keluarga didapatkan mayoritas keluarga menganggap pasien tidak bisa dilepaskan beraktivitas sendiri di luar rumah karena khawatir pasien belum bisa mengendalikan diri sepenuhnya, khawatir mengganggu tetangga sekitar, atau pasien tidak bisa menjaga keselamatan dirinya sendiri. sebenarnya keluarga mengharap pasien dapat lebih mandiri seperti kondisi sebelumnya, tetapi jarang menganggap pasien dapat mengendalikan diri untuk tidak marah. keadaan ini menyebabkan pasien dianggap kurang bisa mengendalikan diri dan kurang mendapatkan du k ungan psikologis dari keluarga. untuk mengatasi keadaan ini, diskusi dalam terapi keluarga difokuskan pada strategi pelaksanaan (sp) tindakan keperawatan bagi keluarga dalam member ikan perawatan pasien gangguan jiwa sesuai masalah yang timbul (materi lengkap terlampir pada modul). beberapa keluarga, dalam pelaksanaan terapi keluarga diikuti langsung oleh pasien (pasien hadir dalam pertemuan terapi keluarga). pada saat seper ti ini, bisa diperagakan langsung bagaimana tindakan keluarga dalam merawat pasien gangguan jiwa, mencegah halusinasi, jangan biarkan sendiri, melamun, me nge mba ng k a n st r at eg i komu n i k a si, mencegah perilaku kekerasan, kepatuhan minum obat, dan melibatkan pasien dalam kegiatan harian. hasil uji independen t-test menunjukkan terdapat perbedaan signif ikan (p=0,002) keya k i na n kelu a rga tent a ng ga ngg u a n jiwa. mayoritas responden percaya bahwa gangguan jiwa dapat berubah menjadi lebih baik, keluarga merasa menjadi orang yang kuat dan tabah dalam menghadapi cobaan kehidupan, dan percaya bahwa semua yang dialami keluarga sudah merupakan kehendak tuhan. kenyataan ini menunjukkan bahwa mayoritas responden sudah menggunakan pendekatan spiritual fase 4 (memilih hidup dengan pasien) dalam menilai permasalahan yang dihadapi keluarga, tetapi di sisi lain dapat merupakan ketidakberdayaan keluarga dalam menghadapi masalah yang dihadapi, menerima karena tidak ada pilihan lain. hasil ini sejalan dengan konsep model yang disampaikan oleh sullivan dan walton (2004) tentang perilaku spiritual individu yang mengalami kanker prostat menghasilkan empat tahapan coping spiritual pada pasien dengan kanker prostat yaitu: facing cancer, partisipan merasa syok karena mereka tidak pernah menduga akan mengalami kanker; choosing treatment, partisipan mendapat informasi tentang treatment dan potensial risiko serta keuntungan dari masing-masing treatment; trusting, partisipan yakin dan percaya terhadap diri sendiri dan tuhan dalam menurunkan ketakutan yang dialami; living day by day, kanker prostat merupakan pengalaman partisipan dalam meningkatkan kesadaran diri tentang bagaimana memaknai atau menghargai kehidupan, demikian juga dengan per masalahan tentang gangguan jiwa. 171 terapi keluarga dengan pendekatan spiritual (ah. yusuf s.) untuk mengatasi keadaan ini, terapi keluarga difokuskan pada fase acceptance, suatu upaya untuk mengembangkan sikap bisa menerima apa pun yang terjadi dengan memperkuat nilai spiritual islam dengan latihan mengambil hikmah (al-jauzi, 2010; hartanto, 2010; hamid, 1999; nahrowi, 2010, mustofa, 2005). beberapa illustrasi tentang berpikir positif dalam buku modul dibahas pada pertemuan ini, “pernahkah kita berpikir bahwa tuhan tidak adil pada kita, kenapa kita diberi salah satu anggota keluarga mengalami gangguan jiwa? pernahkah kita berpikir bahwa kita sudah terlalu banyak berkorban untuk orang lain? pernahkah kita berpikir bahwa tanggungan pekerjaan kita terlalu berat? pernahkah kita merasa sangat terasing, terkucilkan? pernahkah kita berpikir tentang hidup ini yang tidak adil terhadap kita? dan sebagainya. ternyata di luar itu, masih banyak orang yang jauh lebih sengsara, lebih miskin, lebih banyak bisa berbuat, dan lebih bisa menerima kehidupan ini dengan apa adanya, tanpa menggerutu. hidup dijalani dengan bahagia, bahkan selalu bersyukur. kita diberi kesehatan, kekuatan dan ketabahan, tidak ikut mengalami gangguan seperti pasien, kita masih bisa bernapas tanpa gangguan, melihat tanpa gangguan, kita masih bisa makan tiga kali sehari, kita masih dibutuhkan dan bisa berbuat untuk orang lain. semua itu tidak ternilai harganya. kita harus tetap berpikir positif, dan bersyukur dengan apa yang telah dianugerahkan tuhan kepada kita. tetap berdoa dengan sabar. pasti tuhan akan mengabulkan doa kita. peneliti kembali mengingatkan falsafah kaktus dan ulat, yakinlah dengan tuhan, niscaya tuhan akan mengabulkan doa kita. ter nyata doa adalah mer upakan sebuah proses ritual religiusitas manusia yang terdiri dari direction, obedience dan acceptance. peneliti juga memfokuskan diskusi pada penerapan nilai spiritual islam, khususnya pengembangan nilai ikhsan dalam kehidupan. jika kita sudah yakin bahwa gangguan jiwa dan semua masalah yang dialami adalah memang kehendak tuhan, maka buatlah segala tindakan dan perlakuan keluarga terhadap pasien gangguan jiwa sebagai upaya beribadah kepada allah, dan ikhlas dengan semua perbuatan yang dilakukan terhadap pasien, bahwa semua tindakan itu dilakukan atas dasar beribadah kepada allah. menu r ut gw alpot, spi r it ualit as manusia terdiri dari intrinsik dan ekstrinsik. religiusitas ekstrinsik memandang agama sebagai sesuatu yang dapat dimanfaatkan agar dia memperoleh status darinya. ia berpuasa, misa, kebaktian, atau membaca kitab suci, bukan untuk meraih berkah tuhan, melainkan supaya orang lain menghargai dir inya. religiusitas intrinsik adalah cara beragama yang memasukkan nilai agama ke dalam dirinya. ibadah ritual bukan hanya praktik tanpa makna, semua ibadah memiliki pengaruh dalam sikap hidup setiap hari (asy’arie, 2012; bessing, 2010). religiusitas intrinsik harus dibangun dan dikembangkan dalam keluarga, sehingga keluarga dapat menerima pasien seperti apa adanya, beda dengan cara beragama yang ekstrinsik merupakan cara beragama yang tidak tulus, dan melahirkan egoisme. cara beragama yang intrinsik mampu menciptakan lingkungan yang bersih dan penuh kasih sayang. religiusitas ekstrinsik merupakan cara beragama yang tidak tulus, melahirkan egoisme. egoisme bertanggung jawab atas kegagalan manusia mencari kebahagiaan. kebahagiaan tidak terletak pada diri sendiri, tetapi pada kebersamaan. cara beragama int r insi k menciptakan kebersamaan, kebahagiaan dalam diri penganutnya dan lingkungan sosialnya. cara beragama ekstrinsik menjadikan agama sebagai alat politis dan ekonomis. sebuah sikap beragama yang memunculkan sikap hipokrit, kemunafikan (najib, 2007 dalam asy’arie, 2012). ke percaya a n kesehat a n kelu a rga setelah intervensi didapatkan keluarga masih tetap percaya bahwa semua kejadian yang dialami pasien dan keluarga sudah merupakan kehendak tuhan, mengharap pasien dapat lebih mandiri dari kondisi sebelumnya, dan percaya gangguan jiwa dapat berubah menjadi lebih baik. 172 jurnal ners vol. 8 no. 1 april 2013: 165–173 simpulan dan saran simpulan health belief model keluarga mengalami per ubahan pada aspek persepsi terhadap benefits, barriers, dan self efficacy, tidak terdapat perbedaan signifikan pada aspek persepsi terhadap susceptibility and severity gangguan jiwa. saran perlu dikaji lebih lanjut tentang persepsi keluarga terhadap susceptibility and severity gangguan jiwa. kepustakaan ahmadi f., 2006. culture, religion and spirituality in coping, sweden, uppsala university library. asy’arie m., 2012. tuhan empirik dan kesehatan spiritual; pengembangan pemikiran musa asy’arie dalam bidang kesehatan dan kedokteran, center for neoroscience, health and spirituality (c-net), yogjakarta. bessing, yf., 2010. spiritualitas dalam neurobiologi dan kesehatan mental, departemen/smf ilmu kedokteran jiwa fk unair rsud dr. soetomo surabaya. chiu, l, mor row, mar ina, ganesan s. dan clark n., 2005, spirituality and treatment choices by south and east asian women serious mental illness. sage publication: http://tps.sagepub. com, diakses tgl 6 november 2009. dossey, am, keegan, l., guzzetta, ce., 2005. holistic nursing a handbook for practice, fourth edition, jones and bartlet publisher inc. massachusetts. fitryasari, pkr., nihayati, he., yusuf, a. ,2009. pengalaman keluarga selama merawat a nggot a keluarga yang mengalami gangguan jiwa di ruang jiwa c rsu dr. soetomo surabaya; penelitian kulaitatif. laporan hasil pe nelit ia n fk p un air, t id a k d i publikasikan. gladding, st., 2002. family therapy; hystory, theory, and practice (3rd edition). london: perason education, inc. glanz, k., rimer, b., viswanath, k., 2008. health behavior and health education; theory, researh, and practice, 4th edition, usa: jossey-bass. hamid, ay., 1999. aspek spiritual dalam keperawatan. jakarta: widya medika. hartanto, i., 2010, 4 kekuatan mahadahsyat; ikhlas, sabar, syukur, do’a. yogjakarta: syura media utama. hawari, d., 2001. pendekatan holistik pada s k i zof re nia, bag ia n ke dok t e r a n jiwa. jakarta: fakultas kedokteran universitas indonesia. keliat, ba., nancy, p., windarwati, hd., 2009. pengelolaan consultation liaison mental health nursing (clmhn) pada pelayanan umum. materi seminar dan workshop, malang. m a r a m i s , 2 0 0 6. m e n g u r a n g i r i s i k o gangguan jiwa, (online), (http://www. su a r a ka r yaon li ne.com /news.ht m l., diakses tanggal 25 oktober 2009). maramis, wf., 1998. catatan ilmu kedokteran jiwa. surabaya: airlangga university press. mccubbin, hi. dan thompson, ai., 1991. family assessment inventories for research and practice, madison: university of wisconsin. ogden, j., 2007. health psycholog y a textbook, fourth edition. england: open university press. pharoah, f., mari, j., rathbone, j., wong, w., 2010. family inter vention for schizophrenia (review). the cocrane collaboration, wiley publishers. p ut r a , st., 2011. psik on u roim u n olog i ke d ok te ra n, e d isi 2. su r abaya: airlangga university press. sara, w., marlyn, k., 2002. religious/spiritual coping in childhood cystic fibrosis: a qualitative stud, journal of the american academy of pediatrics, 109, 1–11, (online), (www.pediatrics.org., diakses tanggal 2 april 2009). siswono, 2001. sangat besar, beban akibat gangguan jiwa, (online), (http://www. gizi.net., diakses tanggal 26 februari 2009). stuart, gw. dan sundeen, sj. 1995. principles and practice of psychiatric nursing, st. louise: mosby year book. 173 terapi keluarga dengan pendekatan spiritual (ah. yusuf s.) sullivan, n. dan walton, j., 2004. men of prayer: spirituality of men with prostate cancer: a grounded theory study, journal of holistic nursing, 133–151, (online), (error! hyperlink reference not valid., diakses tanggal l 6 november 2010). tanyi, ra., 2006. spirituality and family nursing; spiritual assessment and inter ventions for family. journal compilation, black wall publishing ltd. thohir, m., 2009. menjadi manusia pilihan dengan jiwa besar; 10 langkah praktis menyehatkan jiwa. jakarta: penerbit lentera hati. undang undang republik indonesia, nomor 36 tahun 2009, tentang kesehatan. walton, j., 1996. spiritual relationship: a concept analysis, journal of holistic nursing, 14, 237–250, (online), (error! hyperlink reference not valid., diakses tanggal 6 november 2008). bab 1 jurnal ners vol. 2 no. 1 mei – september 2007 latihan nafas modifikasi meniup balon terhadap pengembangan paru pada pasien hematothoraks dan pneumothoraks tintin sukartini*, sriyono*, nursalam*, ninuk dian k.*, adi sukrisno. abstract collaps is a condition of the absence of air in alveoli. lung collaps result from the presence of air or blood in the cavity. modified ballon blowing respiratory exercise is intended to improve lung ventilation,increase vital capacity and preven atelectasis. the objective of this study was to analyze the effect of modified ballon blowing respiratory on lung compliance in pneumothorax and haemathorax. a quasy experimental design was used in this study with 10 respondens who met the inclusion criteria. the independent variabel was modified ballon blowing respiration exercise and the dependent variable was lung compliance by observing thorax foto, repiratory rate and vital capacity. data were analyzed by using t test, mc.nemar and chi square test. the results showed that modified ballon blowing respiratory execise is effective to assit lung compliance with significant level on vital capacity (p=0.018). keywords: modified balloon blowing respiratory exercise, lung collaps, lung compliance, pnemothorax and haemathorax. pendahuluan paru dapat kolaps pada satu tempat yang terlokalisir, seluruh lobus, atau seluruh paru. kolaps paru dapat diakibatkan oleh pneumothorak atau haemathoraks, yang terjadi karena proses penekanan oleh darah atau udara. paru yang kolaps mengisyaratkan tidak adanya udara dalam alveoli dan kolaps yang masif atau pada pneumothoraks yang besar, maka keseluruhan paru akan terlipat terhadap mediastinum, sehingga terjadi suatu ruangan pleura yang vakum. secara histologi, alveoli yang kolaps berbentuk celah-celah kecil. penatalaksanaan kolaps paru atau atelektasis yang terpenting adalah menegakkan diagnosa dini dan mengupayakan terjadi re-ekspansi dari paru yang terkena, karena perenkim yang kolaps amat peka terjadi infeksi. upaya untuk mengembangkan paru yang mengalami kolaps dapat dilakukan dengan latihan nafas. _______________ * staf pengajar psik fk unair latihan nafas bertujuan untuk meningkatkan ventilasi dan mencegah atelektasis (andarini, 2002). di unit bedah aster latihan nafas dilakukan dengan modifikasi meniup balon. pengamatan pada 12 pasien yang dilakukan latihan nafas modifikasi meniup balon menunjukkan gambaran foto thoraks yang mengembang dengan baik. meskipun demikian keefektifan latihan nafas modifikasi meniup balon yang telah menjadi alternatif latihan nafas, perlu dilakukan penelitian lebih lanjut. kolaps paru mengakibatkan hipoventilasi, selanjutnya pasien akan mengalami hipoksia dengan menunjukkan gejala dyspnea, takipnea, dan sianosis. pasien dengan gangguan paru restriktif pada pemeriksaan faal paru menunjukkan vital capacity menurun atau normal, force expirasi volume one second (fev 1) mengalami penuruan tipis, fev/vc meningkat atau normal, sedangkan pada fungsi residual volume, total lung capasity dan residual volume mengalami penurunan (joice, 1997). jurnal ners vol. 2 no. 1 mei – september 2007 latihan nafas merupakan upaya yang harus dilakukan pada pasien pneumothoraks dan haemathoraks (puruhito, 1993). sedangkan latihan nafas adalah upaya untuk memperbaiki ventilasi paru dan penggunaan otot-otot pernafasan secara wajar dan efisien. latihan nafas memperbaiki kerja alveoli dan mengefektifkan pertukaran gas tanpa meningkatkan kerja nafas. menurut penelitian yang dilakukan pardy (1991) yang dikutip oleh chernis (1991) menunjukkan latihan nafas yang dilakukan dalam 15 menit akan meningkatkan ventilasi paru (nurachmah, 2006). latihan nafas diharapkan dapat mencegah terjadinya atelektasis. berdasarkan hasil foto thoraks pada pasien yang dilakukan latihan nafas modifikasi meniup balon menunjukkan gambaran pengembangan paru yang membaik. latihan nafas meniup balon perlu dijadikan alternatif latihan nafas. bahan dan metode penelitian penelitian ini merupakan penelitian quasy experimental. bahan yang digunakan dalam penelitian adalah balon dengan ukuran dan produk yang sama. adapun alat yang dipakai adalah spirometri, arloji dan alat pemeriksaan x ray thoraks. setelah data terkumpul, kemudian dikelompokkan, ditabulasi dan dilakukan analisis data dengan menggunakan t-test, mc.nemar dan chi square. analisis data t-test digunakan pada data dengan skala interval dan rasio. uji mc. nemar dan chi square digunakan pada data dengan skala nominal, dengan hasil jika p<0.05 berarti ada pengaruh antara variabel yang diukur sedangkan jika p>0.05 maka tidak ada pengaruh antara variabel yang diukur. hasil penelitian 1. foto thoraks. tabel 1: hasil pemeriksaan foto thoraks pre-test dan post-test pada kelompok perlakuan (a) dan kelompok kontrol (b) di unit bedah aster rsu dr. soetomo surabaya bulan januari 2007. no. mc. nemar chi square kelompok a kelompok b kelompok a dan b pretest post test pre test post test post test post test 1 1 2 1 1 2 1 2 1 2 1 1 2 1 3 1 2 1 2 2 2 4 1 2 1 1 2 1 5 1 2 1 1 2 1 n=5 p=0.063 p=0.063 p=0.527 keterangan: 1 = kolaps paru 2 = paru normal jurnal ners vol. 1 no. 2 oktober 2006 – april 2007 dari tabel 1 di atas terlihat bahwa hasil analisis data mc. nemar dan chi square menunjukkan tidak ada pengaruh antara foto thoraks dengan latihan nafas modifikasi meniup balon (p=0.063 dan p=0.527). dilihat dari gambaran foto thoraks 5 responden pada kelompok perlakuan yang mengalami kolaps paru setelah dilakukan intervensi menunjukkan gambaran foto thorak normal. pada kelompok kontrol dari 5 responden, 4 responden menunjukkan gambaran foto thorak tetap kolap dan satu responden normal. hasil pemeriksaan tersebut menunjukkan adanya pengaruh latihan nafas terhadap foto thoraks. 2. frekwensi pernafasan dan vital capacity. tabel 2: hasil pemeriksaan frekuensi pernafasan dan vital capacity pre dan post-test pada kelompok perlakuan (a) dan kelompok kontrol (b) di unit bedah aster rsu dr. soetomo surabaya bulan januari 2007. hasil pemeriksaan klmpk a klmpk b hasil uji paired t-test pre post pre post klmpk a klmpk b klmpk a & b pernafasan _ x=28.60 _ x=21.20 _ x=30.80 _ x=24.40 p= 0.001 p=0.001 p=0.007 vital capacity _ x=0.15 sd=0.10 _ x=0.938 sd=0.46 _ x=0.264 sd=0.20 _ x=0.314 sd=0.22 p=0.018 p=0.020 p=0.026 dari tabel 2 di atas menunjukkan bahwa ada pengaruh antara frekuensi nafas dengan latihan nafas modifikasi meniup balon dengan hasil uji statistik paired t-test p=0.001 (kelompok perlakuan dan kelompok kontrol) dan antara kelompok perlakuan dan kelompok kontrol (p=0.007). hasil pemeriksan vital capacity didapatkan bahwa ada pengaruh antara vital capacity dengan latihan nafas modifikasi meniup balon pada kelompok perlakuan (p=0.018), kelompok kontrol (p=0.020), dan antara kelompok perlakuan dan kelompok kontrol (p=0.026). pembahasan latihan nafas dapat mencegah terjadinya atelektasis paru dan meningkatkan ventilasi (andarini, 2002). latihan nafas dengan modifikasi meniup balon akan mempertahankan volume udara dalam alveoli sehingga paru dapat dicegah menjadi kolaps. pengembangan paru tanpa dilakukan latihan nafas mempunyai waktu yang lebih lama dibandingkan responden yang diberikan latihan nafas modifikasi meniup balon. perbedaan hasil pengembangan paru ini dapat terlihat dari gambaran foto thorak antara kelompok kontrol dan kelompok perlakuan. latihan nafas mempunyai tujuan memperbaiki ventilasi, oksigenasi dan melatih otot pernafasan (kisner, 1990). latihan nafas modifikasi balon berpengaruh terhadap frekwensi nafas. latihan nafas modifikasi balon akan menghasilkan positif expiration pressure (pep) pada paru sehingga meningkatkan ventilasi kolateral dan meningkatkan oksigenasi alveoli, sehingga akan memperbaiki ventilasi paru dan volume paru. perbaikan frekuensi nafas juga diikuti perbaikan keluhan rasa sesak yang berkurang akibat dari oksigenasi yang meningkat. jurnal ners vol. 1 no. 2 oktober 2006 – april 2007 latihan nafas modifikasi balon berpengaruh terhadap vital capacity. latihan nafas modifikasi balon akan memperbaiki ventilasi kolateral alveolus, tekanan trakeobronkial meningkat sehingga saluran nafas tetap terbuka. jumlah udara yang terjaga dalam durasi waktu yang lebih lama akan meningkatkan complaince paru. latihan nafas juga meningkatkan tidal volume, volume cadangan inspirasi dan volume cadangan ekspirasi sehingga memperbaiki vital capacity. latihan nafas juga akan meningkatkan cadangan udara dalam paru (andarini, 2002). simpulan dan saran simpulan latihan nafas modifikasi meniup balon yang dilakukan pada pasien dengan pneumothoraks dan hemathoraks berpengaruh terhadap pengembangan fungsi paru yang ditunjukkan dengan penurunan frekwensi pernafasan dan peningkatan vital capacity. saran 1. hasil penelitian ini diharapkan menjadi dasar penetapan standar operasional prosedur (sop) latihan nafas modifikasi meniup balon. 2. pemberian latihan nafas modifikasi meniup balon sebaiknya dilakukan pada pasien pneumothoraks dengan hasil pemeriksaan analisis gas darah normal. 3. pengembangan penelitian lebih lanjut perlu dilakukan dengan mengukur efektifitas latihan modifikasi meniup balon terhadap volume paru dibanding tekanan jalan nafas. kepustakaan andarini, m., (2002). fisiothepi dada. makalah pelatihan bagi tenaga paramedik rsu dr. soetomo, 30 oktober. cronion, s.m., (1997). mastering medical surgical nursing, pennsylvania: pringhaose corporation, hal: 70. kisner & colby, (1990). therapi exercise foundation and technique, hal: 589. nursalam, (2003). konsep dan penerapan metodologi penelitian ilmu keperawatan, jakarta: salemba medika, hal: 79-220. nurachmah, e (2006). pengaruh latihan nafas diafragma dan pursed lip breathing terhadap aliran udara, skripsi tidak dipublikasikan. universitas airlangga surabaya. puruhito, dkk., (1993). pedoman teknik operasi, surabaya: airlangga university press, hal: 80. price & wilson, (1995). patofisiologi konsep klinis proses-proses penyakit, jakarta: egc, hal: 667-709. rahmad, k., (2002). penanganan trauma thoraks, jakarta: sub bagian bedah thoraks fk ui, hal: 29-38,7-78. sunhaji, (2002). benda asing di thoraks, jakarta: sub bagian bedah thoraks fk ui, hal: 127-144. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 187 indikator kualitas hidup pasien gagal ginjal kronis yang menjalani hemodialisa berdasarkan strategi koping (the indicator of quality life patient with chronic renal failure by hemodialyisis based on coping strategy) evi desnauli*, nursalam**, ferry efendi** *rs adi husada undaan wetan surabaya e-mail: desnauli.tampubolon@yahoo.co.id **fakultas keperawatan universitas airlangga surabaya abstract introduction: chronic kidney disease is a slow, progressive, and irreversible deterioration in renal function. ultimately, it leads to end stage renal disesase which in this condition need for haemodialysis therapy to replace renal function. the coping of patient who undergo haemodialysis therapy is very important to promote the success of the therapy. the aim of this study was to fi nd out the correlation between coping and quality of life in chronic haemodialysis patient. method: this study was a cross sectional study. the sample were 13 patients with chronic kidney disease who undergo haemodialysis therapy. samples were taken by purposive sampling. independent variable was coping, and the dependent variable was quality of life. the data were collected using questionnaire and analyzed using chi square test or fi sher exact test as alternative test from chi square test. result: the result showed that most of respondents had adaptive coping and good quality of life. the result of fi sher exact test showed that p = 0,038 (p < 0.05), it means that there was signifi cant correlation between coping and quality of life of patient with chronic kidney disease who undergo haemodialysis therapy. discussion: the conclusion of this research was coping could improve the quality of life of patient who undergo haemodialysis therapy. further studies are recommended to extend this research using another design and sampling, and observe physical and laboratory examination for measuring quality of life to get better understanding. keywords: chronic kidney disease, haemodialysis, coping, quality of life. pendahuluan gagal ginjal kronis (ggk) saat ini menjadi semakin banyak menarik perhatian, karena walaupun sudah mencapai tahap akhir, pasien tetap dapat hidup panjang dengan kualitas hidup yang cukup baik. lubis (2006) menyatakan bahwa prevalensi gagal ginjal kronik selalu meningkat setiap tahun dan kasus ini semakin banyak dipelajari. pengobatan gagal ginjal kronik stadium akhir bisa dilakukan dengan pemberian terapi pengganti ginjal, salah satunya adalah dengan cara cuci darah atau hemodialisa (hd). individu yang menjalani terapi hd jangka panjang sering merasa khawatir akan kondisi penyakit yang tidak dapat diramalkan dan gangguan yang terjadi dalam kehidupan akibat penyakit yang dialami. bagi sebagian pasien ggk, kualitas hidup merupakan sesuatu yang tidak mudah dicapai, bahkan mereka menganggap hidupnya tinggal dihitung dengan jari dan melampiaskan keputusasaannya dengan tidak mengindahkan petunjuk tim medis. hasil studi pendahuluan yang dilakukan di rumah sakit (rs) adi husada undaan wetan surabaya, didapatkan 70 pasien ggk yang seharusnya menjalani terapi hd reguler, tetapi tidak melaksanakan terapi sesuai program dan sebagian lagi tidak melanjutkan terapi hd reguler di rs adi husada, hal ini disebabkan oleh beberapa faktor, diantaranya adalah faktor biaya, dan kondisi depresi yang dialami oleh pasien sehingga tidak melaksanakan terapi sesuai program. sukandar (2006) menyatakan bahwa program hd yang tidak adekuat dapat jurnal ners vol. 6 no. 2 oktober 2011: 187–191 188 menyebabkan kualitas hidup yang tidak optimal. hubungan koping dengan kualitas hidup pasien gagal ginjal kronis yang menjalani terapi hemodialisa di rumah sakit adi husada undaan wetan surabaya sampai saat ini belum diteliti lebih lanjut. data yang didapat dari pusat data dan informasi perhimpunan rumah sakit seluruh indonesia (pdpersi), menyebutkan bahwa jumlah penderita gagal ginjal kronis di indonesia yang menjalani terapi hemodialisa adalah lima puluh juta orang per satu juta penduduk (soeparman 2003). data yang diperoleh di rs adi husada undaan wetan surabaya seperti yang terlihat pada tabel 1, jumlah pasien yang menjalani hd reguler setiap tahun mengalami penurunan. jumlah pasien ggk yang harus menjalani terapi hd pada tahun 2009 adalah 102 orang, namun dari jumlah tersebut, jumlah pasien yang tercatat menjalani hd reguler lebih dari 3 bulan hanya 50 orang. jumlah pasien yang menjalani terapi hd pada tahun 2010 adalah 108 orang, dan yang menjalani hd reguler adalah 45 orang. data pada tahun 2011 jumlah pasien yang menjalani terapi hd adalah 110 orang, dan dari jumlah tersebut yang menjalani hd reguler hanya 40 orang. penderita yang menjalani terapi hd jangka panjang sering merasa depresi akibat sakit yang kronis dan ketakutan terhadap kematian, selain itu pasien juga mengalami m a s a l a h y a n g l a i n t e r k a i t k o n d i s i n y a , diantaranya masalah fi nansial, kesulitan dalam mempertahankan pekerjaan, dorongan seksual yang hilang serta impotensi dan hal ini akan memengaruhi koping individu dan kualitas hidup mereka (smeltzer dan bare, 2001). koping dengan stres karena penyakit kronis sangat berpengaruh dalam perubahan kualitas hidup seseorang. kondisi emosional dengan sikap bertahan atau membela diri merupakan gaya koping yang cenderung berpengaruh terhadap komponen mental dan fisik pada penilaian kualitas hidup pasien ggk, oleh karena itu penilaian koping dan depresi pada pasien ggk harus diperhatikan dengan tujuan untuk memperbaiki kesehatan mental dan fi sik mereka (kaltsouda, et al, 2011). strategi koping yang digunakan individu dalam menghadapi kesulitan yang mengancam tergantung pada beberapa variabel, di antaranya karakteristik demografi , karakteristik klinis, tantangan yang dihadapi, dan dukungan sosial yang diterima (wahl, et al, 1999). penelitian menunjukkan bahwa baik pasien maupun anggota keluarga menggunakan kombinasi antara koping yang berfokus pada emosi maupun koping yang berfokus pada masalah dalam menghadapi stresor yang berhubungan dengan penyakit. ada lima cara penting dalam menghadapi penyakit yang diidentifi kasi dari menelaah 57 penelitian keperawatan, yaitu mencoba merasa optimis mengenai masa depan, menggunakan dukungan sosial, menggunakan sumber spiritual, mencoba tetap mengontrol situasi m a u p u n p e r a s a a n , m e n c o b a m e n e r i m a kenyataan yang ada, hal ini akan menghasilkan koping yang adaptif pada pasien, sehingga diharapkan dapat memperbaiki kualitas hidup mereka (smeltzer dan bare, 2001). bahan dan metode penelitian ini menggunakan desain cross sectional. populasi pada penelitian ini adalah semua pasien yang menjalani terapi hd reguler di rs adi husada undaan wetan, yaitu sebanyak 52 orang. besar sampel pada penelitian ini adalah 13 orang, yang telah ditentukan menggunakan teknik purposive sampling. variabel independen pada penelitian ini adalah koping, dan variabel dependen adalah kualitas hidup. pengumpulan data dilakukan dengan menggunakan kuesioner. instrumen yang digunakan untuk menilai koping diambil dari tabel 1. data pasien yang menjalani terapi hemodialisa reguler di rs adi husada undaan wetan surabaya tahun jumlah keseluruhan pasien hd jumlah pasien hd reguler lebih dari 3 bulan 2009 2010 2011 102 108 110 50 45 40 sumber: buku kunjungan pasien hemodialisa rs adi husada undaan wetan surabaya indikator kualitas hidup pasien ggk (evi desnauli) 189 ways of coping questionnaire (wcq) yang dikembangkan oleh folkman (1985). instrumen yang digunakan untuk menilai kualitas hidup adalah kuesioner short form (sf) 36, yang digunakan untuk mengukur kualitas hidup pasien yang menjalani terapi hd. data yang telah diperoleh dianalisis menggunakan uji chi square, dan uji fi sher exact sebagai alternatif bila hasil uji chi square tidak memenuhi syarat, dengan derajat kemaknaan p ≤ 0,05. hasil sebagian besar responden (76,9%) memiliki koping adaptif dan sebagian besar responden (84,6%) memiliki kualitas hidup yang baik. hasil analisis data dengan menggunakan fi sher exact test didapatkan nilai signifi kansi p = 0,038, hal ini berarti bahwa ada hubungan antara koping dengan kualitas hidup pasien gagal ginjal kronis yang menjalani terapi hemodialisa di rs adi husada undaan wetan surabaya. tabel 2. deskriptif koping koping distribusi n % adaptif 10 76,9% maladaptif 3 23,1% total 13 100% pembahasan h a s i l p e n e l i t i a n m e n u n j u k k a n bahwa sebagian besar responden memiliki koping adaptif. menurut rasmun (2004), ada beberapa faktor yang memengaruhi respons terhadap stressor, yaitu bagaimana individu mempersepsikan stressor, bagaimana intensitasnya terhadap stimulus, jumlah stressor yang harus dihadapi dalam waktu yang sama, lamanya pemaparan stressor, pengalaman masa lalu, serta tingkat perkembangan. sebagian besar responden pada penelitian ini yang berusia kurang dari sama dengan 50 tahun memiliki koping adaptif, dan sebagian besar responden yang berusia lebih dari 50 tahun juga memiliki koping yang adaptif, namun persentase responden dengan koping maladaptive lebih besar ditemukan pada responden yang berusia lebih dari 50 tahun. hal ini dapat terjadi, mengingat bahwa ada faktor lain yang juga memengaruhi koping seseorang, tetapi tidak diteliti oleh peneliti, yaitu adanya penyakit lain yang dialami sehubungan dengan proses penuaan, sehingga hal ini menyebabkan beban stresor menjadi lebih banyak, dan berpengaruh terhadap koping yang dimiliki. menurut smeltzer dan bare (2001), kondisi koping dipengaruhi oleh faktor internal dan faktor eksternal. faktor internal dari individu yang memengaruhi koping meliputi kondisi kesehatan, sistem kepercayaan, komitmen atau tujuan hidup, perasaan harga diri, pengetahuan, keterampilan pemecahan tabel 4. hubungan koping dengan kualitas hidup pasien ggk yang menjalani terapi hemodialisa di rs adi husada undaan wetan surabaya kualitas hidup baik buruk total fisher exact test koping n % n % n % adaptif 10 76,9% 0 0% 10 76,9% p = 0.038 maladaptif 1 7,7% 2 15,4% 3 23,1% total 11 84,6% 2 15,4% 13 100% hasil signifi cant tabel 3. deskriptif kualitas hidup kualitas hidup distribusi n % baik 11 84,6% buruk 2 15,4% total 13 100% jurnal ners vol. 6 no. 2 oktober 2011: 187–191 190 masalah, dan keterampilan sosial yang meliputi kemampuan untuk berkomunikasi dan berinteraksi dengan orang lain. faktor eksternal yang memengaruhi koping adalah adanya dukungan sosial dan sumber material. hasil penelitian berdasarkan karakteristik responden yang lain, didapatkan bahwa sebagian besar responden yang berjenis kelamin laki-laki memiliki koping adaptif, hal ini dikarenakan laki-laki biasa menggunakan strategi koping yang berfokus pada masalah, sedangkan perempuan lebih sering menggunakan strategi koping yang berfokus pada emosi, sehingga akan memengaruhi koping yang dimiliki, dan akan berpengaruh juga terhadap kualitas hidup. koping maladaptif juga didapatkan pada sebagian responden yang tidak bekerja, hal ini juga berpengaruh terhadap koping, karena untuk menjalani terapi hd reguler memerlukan biaya yang tidak sedikit, hal ini sesuai dengan pernyataan smeltzer dan bare (2001), bahwa individu yang menjalani terapi hemodialisa jangka panjang sering merasa khawatir akan kondisi penyakit yang tidak dapat diramalkan dan gangguan yang terjadi dalam kehidupannya, seperti masalah fi nansial, kesulitan dalam mempertahankan pekerjaan, depresi akibat sakit kronis, dan ketakutan terhadap kematian. hasil penelitian menunjukkan bahwa sebagian besar responden memiliki kualitas hidup yang baik, menurut mc. cartney and larson dalam yuwono (2000) menyatakan bahwa ada hubungan yang berbanding terbalik antara kualitas hidup pasien dengan usia, semakin tua usia seseorang, maka kualitas hidupnya juga akan menurun, hal ini sesuai dengan hasil penelitian yang menunjukkan bahwa semua responden yang berusia kurang dari sama dengan 50 tahun mempunyai kualitas hidup baik. kurtus (2005) menyebutkan bahwa kualitas hidup terdiri dari tiga komponen, yaitu kesehatan, kepemilikan dan harapan, sehingga hal ini tentu juga terkait dengan faktor umur, tingkat pendidikan, dan status pekerjaan. kondisi depresi yang dialami oleh pasien juga akan sangat berpengaruh pada penilaian kualitas hidup, karena komponen yang dinilai pada instrumen sf 36 adalah komponen kesehatan fisik dan kesehatan mental (bohlke, et al, 2008), selain itu, pasien yang mengalami depresi cenderung menunjukkan sikap menentang terhadap program pengobatan, sehingga mereka tidak menjalani terapi hd reguler sesuai jadwal, dan hal ini akan berpengaruh terhadap adekuasi hd, yang akan berdampak pada kesehatan fi sik mereka. hasil uji statistik menggunakan uji alternatif fi sher exact test, menunjukkan bahwa ada hubungan yang signifi kan antara koping dengan kualitas hidup pasien gagal ginjal kronis yang menjalani terapi hemodialisa. hal ini berarti bahwa semakin adaptif koping seseorang, maka kualitas hidupnya juga akan semakin baik. simpulan dan saran simpulan s e b a g i a n b e s a r r e s p o n d e n y a n g menjalani terapi hemodialisa reguler memiliki koping yang adaptif dan kualitas hidup yang baik. koping yang adaptif dapat memperbaiki kualitas hidup pasien gagal ginjal kronis yang menjalani terapi hemodialisa. saran p e r a w a t d i h a r a p k a n m a m p u meningkatkan perannya sebagai konselor dan edukator dalam upaya membantu pasien untuk bisa beradaptasi dengan kondisinya, sehingga pasien memiliki koping adaptif dan kualitas hidup menjadi lebih baik. peneliti selanjutnya diharapkan mampu melakukan penelitian lebih lanjut dengan jumlah sampel yang lebih banyak dan waktu yang lebih panjang dengan menggunakan desain cohort study dan teknik random sampling, serta untuk pengukuran kualitas hidup tidak hanya dinilai secara subjektif, tetapi juga objektif dengan melakukan observasi hasil pemeriksaan fi sik dan laboratorium,sehingga dapat diperoleh kesimpulan yang lebih baik. indikator kualitas hidup pasien ggk (evi desnauli) 191 kepustakaan bohlke, et al., 2008. predictors of quality of life among patients on dialysis in southern brazil, sao paulomedical journal, vol. 126, no. 5, hal. 252–6, (online), (http://www.scielo.br/pdf/ spmj/v126n5/01.pdf., diakses pada tanggal 24 desember 2011) f o l k m a n , s . , 1 9 8 5 . wa y s o f c o p i n g questionnaire, university of california, san fransisco, (online), (http://caps. u c s f . e d u / u p l o a d s / t o o l s / s u r v e y s / ways%20of%20coping.pdf, diakses tanggal 28 desember 2011) kaltsouda, a., et al., 2011. defensive coping and health-related quality of life in chronic kidney disease: a cross sectional study, bmc nephrology, vol. 12, no. 28, hal. 1-9, (online), (http:// www.biomedcentral.com., diakses pada tanggal 24 desember 2011). kurtus, 2005. university of toronto quality of life model, (online), (http://www. school-for-champions.com/life/toronto_ univ_quality_life.htm., diakses pada tanggal 20 oktober 2011). lubis, a.j., 2006. dukungan sosial pada pasien gagal ginjal terminal yang menjalani terapi hemodialisa, (online), (http://library.usu.ac.id/download/ fk/06010311/pdf., diunduh pada tanggal 17 oktober 2011) rasmun, 2004. stres, koping dan adaptasi: teori dan pohon masalah keperawatan, edisi 1, jakarta: sagung seto. smeltzer, s.c., bare, b.g., 2001. buku ajar keperawatan medikal bedah brunner dan suddarth, edisi 8, vol. 2, jakarta: egc soeparman, 2003. ilmu penyakit dalam, jilid ii, edisi 2, jakarta: fkui. sukandar, e., 2006. gagal ginjal dan panduan te r a p i d i a l i s i s . b a n d u n g : p u s a t informasi ilmiah (ppi) bagian ilmu penyakit dalam fakultas kedokteran unpad/rs dr. hasan sadikin. wahl, et al., 1999. coping and quality of life in patients with psoriasis, quality of life research, no. 8, hal: 427–33, (online), (http://springerlink.com., diakses tanggal 16 oktober 2011) yuwono, a., 2000. kualitas hidup pasien, jakarta: fkui, hlm. 1–5. vol 8 no 1 april 2013.indd 9 topikal asi: model asuhan keperawatan tali pusat pada bayi (topical breastmilk: nursing care of newborn umbilical cord model) kasiati*, budi santoso**, esti yunitasari***, nursalam*** *politeknik kesehatan kemenkes malang **rsud dr. soetomo surabaya ***fakultas keperawatan universitas airlangga, kampus c mulyorejo e-mail: kasiatilawang@yahoo.com abstrak pendahuluan: omphalitis dan waktu pelepasan tali pusat berkontribusi terhadap jumlah morbiditas dan mortalitas pada bayi. terdapat berbagai cara perawatan tali pusat, tapi tidak ada perbedaan yang berarti dalam infeksi dan waktu pelepasan tali pusat. asi mengandung anti infeksi dan anti infl amasi dapat digunakan untuk perawatan tali pusat. who merekomendasikan untuk mengembangkannya. tujuan dari penelitian ini adalah untuk menjelaskan pengaruh model perawatan topical asi terhadap kejadian omphalitis dan pemisahan tali pusat pada bayi. metode: desain dalam penelitian ini adalah quasy eksperimental. subjek penelitian ini didapatkan dengan consecutive sampling yaitu bayi baru lahir yang memenuhi kriteria inklusi di rumah sakit ibu dan anak kendangsari surabaya mei–juni 2012 sebanyak 30 bayi. sampel dibagi menjadi 2 kelompok yaitu kelompok intervensi dan kelompok kontrol masing-masing 15 bayi. data kejadian omphalitis dianalisis menggunakan chi-square dan waktu pelepasan tali pusat menggunakan independent t-test dengan tingkat signifi kansi α≤0,05. hasil: tidak terdapat perbedaan kejadian omphalitis pada penggunaan model perawatan tali pusat dengan topikal asi dibandingkan dengan perawatan kering terbuka (p=0,33). namun, ada perbedaan yang signifi kan rerata waktu pelepasan tali pusat antara model perawatan dengan topikal asi dan kering terbuka (p=0,020). diskusi: model perawatan tali pusat dengan topical asi menurunkan risiko kejadian omphalitis dan mempercepat waktu pelepasan tali pusat dibandingkan dengan perawatan kering terbuka. asi dapat digunakan untuk perawatan tali pusat yang aman efektif dan efi sien. kata kunci: topikal asi, perawatan kering terbuka, waktu pelepasan tali pusat, omphalitis abstract introduction: omphalitis and umbilical cord separation time contributing to the number of morbidity and mortality in infants. there are various ways of cord care, but there was no signifi cant difference in prevent of infection and cord separation time. breast milk contains anti-infective and antiinfl ammatory factors that can be used for cord care. who recommends to develop it. the purpose of this study was to analyze the effect of topical breastmilk model on the incidence of omphalitis and separation time of the umbilical cord to the newborn. method: the study design was a quasy experimental. the subjects of this study were 30 newborns obtained by consecutive sampling in rumah sakit ibu dan anak kendangsari surabaya may–june 2012. the samples were divided into 2 groups (topical breastmilk and open dry treatment), each group consists of 15 newborns. data were analyzed using chi-square and independent t-test with a signifi cance level of α≤0.05. results: there was no difference in the incidence of omphalitis in the use of topical breastmilk model compared to open dry treatment (p=0.33). however, there are signifi cant differences in the average of cord separation time between topical breastmilk model and open dry treatment (p=0.020). discussion: model of cord care with topical breastmilk lowers the risk of omphalitis and accelerate the cord separation time compared to open dry treatment. using breastmilk as cord care are safe, effective and effi cient. keywords: topical breastmilk, open treatment, umbilical cord separation, omphalitis 10 jurnal ners vol. 8 no. 1 april 2013: 9–16 pendahuluan omphalitis atau infeksi tali pusat disebabkan oleh bakteri yang memasuki tubuh melalui tali pusat pada bayi. bakteri dapat masuk akibat dari pemotongan tali pusat dengan instrumen yang tidak steril, kontak kulit ke kulit, teknik cuci tangan yang tidak benar, perawatan tali pusat buruk dan infeksi silang. organisasi kesehatan dunia (1998) menjelaskan tetanus dan infeksi salah satu penyebab utama kematian neonatal dan kebanyakan terjadi di negara berkembang. diperkirakan setiap tahunnya 500.000 bayi meninggal karena tetanus neonatorum dan 460.000 bayi meninggal akibat infeksi berat oleh bakteri yang dapat disebabkan oleh infeksi tali pusat. hasil penelitian, 33% kasus tetatus neonatal secara bersamaan juga menderita omphalitis dan septikemia. who menargetkan eleminasi tetanus maternal dan neonatal (tmn) secara global di 58 negara risiko tinggi pada tahun 2015, termasuk indonesia. pada tahun 2010, untuk 3 pulau di indonesia sudah dinyatakan eleminasi tmn yaitu jawa, bali dan sumatra (kementerian kesehatan, 2010). berdasarkan data awal masih terdapat kejadian omphalitis pada bayi baru lahir di rsia kendangsari surabaya. kondisi ini bisa memburuk atau malah sebaliknya, tergantung perawatan yang diberikan pada bayi setelah kembali ke rumah. rumah sakit ibu dan anak kendangsari surabaya memiliki rerata 60 –70 par t us dalam satu bulan. perawatan tali pusat yang dilakukan di rumah sakit tersebut dengan kering terbuka (olesan alkohol) dan terdapat kejadian omphalitis pada satu bayi. rerata pelepasan tali pusat dengan perawatan tersebut kurang lebih 1 minggu. pada tahun 1998, who merekomendasikan perawatan tali pusat saat lahir sebaiknya dijaga agar tetap bersih, kering dan terpapar udara saat di rumah sakit maupun setelah pulang dari rumah sakit. hasil penelitian tidak menunjukkan kesepahaman yang jelas bahwa perawatan antiseptik lebih unggul dari metode yang lain. perawatan tali pusat kering sendiri merupakan tren saat ini yang sedang dikembangkan di berbagai negara berkembang. bukti dari tinjauan sistematik oleh zupan et al. (2004) menyimpulkan bahwa tidak ada perbedaan ber makna kejadian infeksi antara pemberian antibiotik atau antiseptik pada perawatan tali pusat dibanding dengan perawatan kering. upaya pencegahan infeksi tali pusat dan tetanus neonatorum berkontribusi terhadap angka morbiditas dan mortalitas. salah satu tindakan pencegahan adalah dengan perawatan dini tali pusat yang baik, benar dan aman selama di rumah sakit maupun di rumah. pelepasan tali pusat harus terjadi dalam 5 sampai 15 hari, meski dapat saja pelepasan berlangsung lama pada penggunaan antiseptik dan infeksi tali pusat atau omphalitis. perawatan tali pusat menggunakan cara tradisional akan lebih baik dari pada memberikan bahan yang berbahaya pada tali pusat. salah satu intervensi yang dapat di lakukan oleh perawat sebagai caring adalah dengan memberikan asuhan keperawatan pada bayi di rumah sakit maupun setelah pulang dengan pendekatan model perawatan topikal air susu ibu (asi). model asuhan perawatan topikal asi pada tali pusat pada bayi dapat mencegah omphalitis dan mempercepat pelepasan tali pusat pada bayi lahir. model asuhan perawatan topikal asi pada tali pusat merupakan bentuk peran yang dikembangkan perawat dalam hal meningkatkan kepercayaan – harapan (faith – hope) untuk proses carative dan curative dengan alter natif (watson, 1989). asi mengandung imunoglobulin a, g dan m sebagai anti infeksi, sedangkan non immunoglobulin pada asi seperti lactoferin dan lisozim berfungsi sebagai anti bakteri, anti virus atau anti mikroba yang menyebabkan anti infl amasi atau anti radang. pendekatan carative dan berpikir kritis yang dikembangkan melalui perawatan tali pusat dengan asi adalah sebagai praktek perawatan tali pusat yang tidak berbahaya, gratis, tersedia dan steril untuk melindungi bayi dari infeksi tali pusat. who menyarankan hal yang sama untuk diteliti. mullany (2003) berpendapat bahwa asi mempunyai banyak agen imunologis, bahan anti infl amsi dan antimikroba. 11 topikal asi: model asuhan keperawatan tali pusat pada bayi (kasiati, dkk) asi mengandung imun, non imun dan komponen seluler (wahap, 2002). hasil penelitian oleh farahani et al. (2008) perawatan topikal asi menurunkan tingkat kolonisasi dan pelepasan tali pusat lebih pendek dibandingkan perawatan kering. ahmadpoor et al. (2006) menjelaskan waktu pelepasan tali pusat dari yang terpendek hingga terpanjang adalah kelompok asi, alkohol, kering dan silver sulfadiasin. multani (2006), vural dan kisa (2006) dan subiastutik (2011) menjelaskan perawatan tali pusat menggunakan asi yang mengandung kolostrum efektif dalam mengurangi risiko kolonisasi tali pusat dari organisme patogen (staphylococcus) dibanding tidak menggunakan antimikroba atau kering. beberapa penelitian terbukti bahwa perawatan tali pusat dengan topikal asi adalah metode yang aman, efektif dan ef isien maka perlu dikembangkan lebih lanjut. namun, penerapan model asuhan perawatan topikal asi pada tali pusat bayi terhadap kejadian omphalitis dan waktu pelepasan tali pusat pada bayi di rumah sakit dan anak kendangsari surabaya masih belum dapat dijelaskan. bahan dan metode desain penelitian yang digunakan adalah pre eksperimental dengan rancangan post test only control group design. teknik pengambilan sampel pada penelitian ini dilakukan secara consecutive sampling. penelitian ini terdiri dari dua kelompok sampel yaitu kelompok perlakukan sebanyak 15 bayi dengan intervensi model asuhan perawatan topikal asi pada tali pusat dan kelompok kontrol sebanyak 15 bayi dengan intervensi perawatan tali pusat metode kering terbuka atau placebo. kriteria yang digunakan untuk mengambil sampel yaitu bayi lahir dengan berat badan normal (2500–4000 gram), usia kehamilan 36–42 minggu, apgar score 8–9 dan tidak mendapat terapi farmakologis dan bayi baru lahir hari pertama dengan persalinan normal atau sc. pada kelompok perlakuan, ibu harus sudah mengeluarkan asi sehat pada 8 jam persalinan. inst r umen yang dig unakan dalam pengumpulan data untuk kejadian omphalitis berupa lembar observasi tentang tanda-tanda infeksi tali pusat meliputi bau menyengat, keluar cairan merah, nanah, kemerahan dan bengkak, distensi abdomen, keras dan panas. penelitian ini dilakukan di rumah sakit ibu dan anak kendangsari surabaya bulan mei–juni 2012. data yang telah terkumpul kemudian dianalisis dengan uji chi-square (x²) dan independent t-test. hasil k a r a k t e r ist i k r e s p on sde n d a la m penelitian ini mayoritas berjenis kelamin lelaki, memiliki berat badan lahir lebih dari 300 gram dan dilahirkan melalui sc. tabel 1. distribusi responden berdasarkan data bayi karakteristik kelompok topikal asi kelompok kering terbuka (n) (% ) (n) (%) jenis kelamin laki-laki 9 60 11 73,3 perempuan 6 40 4 26,7 total 15 100 15 100,0 berat badan 2500–2999 gr 3 20 3 20 3000–3499 gr 12 80 12 80 total 10 100 15 100,0 cara persalinan spontan 6 40 2 13,3 sectio caesaria 9 60 13 86,7 total 15 100 15 100,0 lama perawatan > 3 hari 10 66,7 13 86,7 < 3 hari 5 33,3 2 13,3 total 15 100,0 15 100,0 rawat gabung < 24 jam 15 100 15 100 > 24 jam 0 0 0 0 total 15 100 15 100,0 perawatan mandi mandi 15 100 15 100 tidak 0 0 0 0 total 15 100 15 100,0 perawatan tali pusat 2 kali/hr 15 100 15 100 > 3 kali/hr 0 0 0 0 total 15 100 15 100,0 12 jurnal ners vol. 8 no. 1 april 2013: 9–16 hasil penelitian di ket ahui bahwa kelompok model perawatan topikal asi memiliki rerata waktu pelepasan tali pusat 5,6 hari (sd 28,30). waktu pelepasan tali pusat terpendek yaitu 97 jam (4,1 hari) dan waktu pelepasan tali pusat terpanjang adalah 199 jam (8,7 hari). pada kelompok model perawatan kering terbuka didapatkan rerata waktu pelepasan tali pusat 6,9 hari (sd 40,28). waktu pelepasan tali pusat tercepat 105 jam (4,9 hari), sedangkan waktu terpanjang adalah 241 jam (10,1 hari). hasil analisis data dengan uji independent t-test didapatkan nilai p=0,02 yang berarti ada perbedaan yang signifi kan wakt u pelepasan tali pusat bayi antara perawatan dengan topical asi dan kering terbuka (tabel 2). kejadian omphalitis pada kelompok yang mendapat perawatan dengan metode kering terbuka sebanyak 4 bayi (26,7%). pada kelompok dengan perlakuan topikal asi didapatkan 1 bayi (6,7%) yang mengalami omphalitis. hasil analisis data dengan uji chi-square, didapatkan tidak ada perbedaan yang signifi kan kejadian omphalitis antara kelompok perlakuan dengan kelompok kontrol ( p=0,33) dengan koreksi dari yates (tabel 3). pembahasan hasil penelitian menunjukkan masih ada 1 bayi yang mengalami omphalitis pada kelompok bayi yang mendapatkan perawatan tali pusat dengan topikal asi. namun, pada kelompok bayi yang mendapat perawatan tali pusat dengan metode kering terbuka didapatkan kejadian omphalitis pada 4 bayi. bayi yang mengalami omphalitis tersebut lahir dengan berat badan kurang dari 3000 gram. tanda omphalitis yang dialami oleh bayi tersebut adalah keluar darah, cairan purulen atau nanah dan bau yang terjadi pada hari ke 3 sampai 8 setelah persalinan, dengan rerata terjadi pada hari ke 4 setelah persalinan. hal ini sesuai dengan yag dikemukakan oleh who (1998) bahwa sekitar 2% bayi baru lahir mengalami tanda infeksi tali pusat yang terjadi rerata pada usia 3,2 hari. omphalitis disebabkan oleh bakteri yang memasuki tubuh melalui tali pusat pada bayi. bakteri dapat masuk ke tubuh bayi melalui pemotongan tali pusat dengan instrumen yang tidak steril, kontak kulit ke kulit, teknik cuci tangan yang tidak benar, perawatan tali pusat yang buruk dan infeksi silang oleh petugas kesehatan (mullany, et al., 2006). infl amasi jaringan di sekitar tali pusat dapat memperlambat maupun mencegah penutupan pembuluh darah sehingga terjadi pendarahan umbilicus, pengeluaran cairan purulen dan organisme dapat masuk secara langsung ke siskulasi darah umbilicus. rekomendasi terkini mengarahkan bahwa bayi bar u lahir sebaik nya tidak dimandikan secara rutin dan membenamkan tali pusat ke air sebelum tali pusat lepas (who, 1998; davies dan donald, 2011). memandikan dengan membenamkan tali pusat dalam air dapat menyebabkan infeksi, mencegah pengeringan dan memperlambat pelepasan. mandi cu k up dila k u kan setelah lah i r, selanjutnya mandi setiap hari dengan spons atau dibasuh sebagai tindakan pengontrolan infeksi. kedua kelompok sudah melakukan upaya untuk mengendalikan faktor yang diduga dapat mengurangi risiko kejadian omphalitis. upaya tersebut sesuai dengan standar rumah sakit yaitu memberikan asi saja pada bayi dan menjalani rawat gabung mulai 8 jam setelah persalinan. pemberian asi dengan segera serta rutin akan memberikan antibodi pada bayi untuk membantu melawan infeksi. sedangkan rooming-in mempunyai berbagai keuntungan antara lain menfasilitasi pemb er ia n asi, b on d i n g a t ta ch m e n t , meningkatkan rasa percaya diri ibu dalam merawat bayi, serta sentuhan kulit ke kulit dengan ibu menyebabkan kolonisasi bakteri non pathogen dari fl ora kulit ibu sehingga bermanfaat untuk pembatasan infeksi. f a k t o r y a n g k e m u n g k i n a n mempengaruhi terjadinya omphalitis yang tidak bisa dikendalikan oleh peneliti adalah kebiasaan cuci tangan yang benar sebelum dan sesudah merawat tali pusat, apalagi setelah bayi keluar dari rumah sakit. cara memandikan bayi selama di r umah juga tidak dapat dikontrol oleh peneliti, apakah dengan cara merendam tali pusat di dalam 13 topikal asi: model asuhan keperawatan tali pusat pada bayi (kasiati, dkk) air atau tidak. selain itu, perawatan tali pusat hendaknya juga dilakukan bila tali pusat basah terkena keringat, kencing dan kotoran tanpa menunggu jadwal bayi dimandikan lebih dahulu. tid a k t e rd apat p e rb e d a a n ya ng signifi kan antara kejadian omphalitis pada kelompok bay i ya ng mend apat model perawatan topikal asi dibandingkan dengan perawatan model kering terbuka. hal ini bukan berarti model asuhan keperawatan topikal asi tidak efektif untuk mencegah kejadian omphalitis. terbukti secara klinis kejadian omphalitis pada kelompok model topikal asi hanya pada 1 bayi yang berarti lebih rendah dari pada kelompok kering terbuka sebanyak 4 bayi. kejadian omphalitis tidak semata-mata dikarenakan oleh model perawatan tali pusat yang digunakan. faktor antibodi dalam tubuh bayi untuk melawan infeksi antara bayi satu dengan lain berbeda-beda sehingga respons klinik terhadap bakteri yang masuk juga berbeda. hasil observasi terbukti tanda-tanda omphalitis pada kedua kelompok pada kategori ringan dengan nilai skor antara 2-3 yaitu keluar cairan berupa darah atau purelen kemudian diikuti bau dan merah di sekitar umbilicus. selain itu metode penilaian omphalitis hanya dengan cara observasi pada indikator respons fi siologis seperti tanda-tanda infeksi tanpa disertai pemeriksaan indikator biokimiawi yaitu pemeriksaan crp untuk hasil yang lebih akurat. kejadian omphalitis model asuhan perawatan topikal asi lebih rendah karena asi mengandung banyak imunologis dan nonimunologis sebagai anti inf lamasi dan antimikroba (mullany, 2003). perawatan tali pusat dengan topikal asi merupakan metode baru yang berasal dari beberapa budaya kenya telah direkomendasikan oleh who (1998) untuk dikembangkan dan dilakukan penelitian. perlindungan non imun diberikan oleh sejumlah besar komponen dalam asi yang berfungsi melindungi dengan cara yang non imun dengan demikian memberikan aktivitas anti infeksi yang luas dan memproteksi mukosa terhadap pathogen dan bakteri yang melekat (roitt, 2003). asi mengandung banyak zat protektif berupa komponen seluler, immunoglobulin dan non immunoglobulin yang memberikan proteksi terhadap bakteri, virus jamur, dan protozoa. asi seharusnya dimanfaatkan untuk mencegah infeksi pada bayi. asuhan perawatan topikal asi pada tali pusat bayi dapat menurunkan kejadian omphalitis dalam penelitian ini selaras denga n sebu a h penelit ia n ra nd omised control study pada 500 bayi baru lahir (100 bayi tiap kelompok) dengan hasil tidak ada kejadian omphalitis dari 500 sampel. aplikasi antimikroba termasuk kolostrum efektif dalam mengurangi risiko kolonisasi tali pusat dari organisme pathogen staphylococcus (multani, 2006). temuan ini sejalan dengan penelitian farahani et al., (2008) yang melakukan tabel 2. hasil uji statistik perbedaan waktu pelepasan tali pusat kelompok topikal asi dan kelompok kering terbuka kelompok mean sd uji statistik topikal asi 135,27 jam (5,6 hari) 28,30 independent t-test p = 0,02kering terbuka 166,73 jam (6,9 hari) 40,28 tabel 3. hasil uji statistik kejadian omphalitis pada kelompok topikal asi dan kering terbuka kelompok omphalitis tidak omphalitis jumlah topikal asi 1 14 15 kering terbuka 4 11 15 jumlah 5 25 30 uji statistik x² =0,96 chi-square test p=0,33 ( dengan koreks’ dari yates ) 14 jurnal ners vol. 8 no. 1 april 2013: 9–16 perawatan topikal asi pada tali pusat bayi, dan hasilnya dapat menurunkan tingkat kolonisasi staphylococcus. fa k t a i n i m e n u nj u k k a n b a hw a intervensi penerapan model asuhan perawatan topikal asi pada tali pusat salah sat u bentuk dari peran perawat sebagai pemberi asuhan (caring) yaitu memberikan asuhan keperawatan pada bayi sebaik-baiknya. asi dapat dipergunakan sebagai pengganti topikal lain untuk perawatan tali pusat bayi karena dapat menurunkan kejadian omphalitis dan perlu dikembangkan. model perawatan topikal asi selaras dengan konsep care yang dapat meningkatkan kepercayaan – harapan (faith – hope) sebagai proses carative dan curative dalam bentuk alternative perawatan untuk mencengah kejadian omphalitis. model asuhan perawatan topikal asi pada tali pusat sesuai teori watson (1999) yang menjelaskan perawat harus memiliki keterampilan merawat dan menyembuhkan klien dengan cara-cara kreatif sebagai bagian dari seni perawatan. model perawatan kering terbuka dengan swabs alkohol yang menjadi trend saat ini perlu di evaluasi lebih lanjut sebelum dipromosikan sebagai praktek perawatan tali pusat yang terbaik dan efektif. kejadian omphalitis dapat dihindari bila perawatan tali pusat menggunakan topikal asi, disertai metode perawatan yang benar seperti melakukan cuci tangan sebelum dan sesudah merawat bayi baik oleh petugas kesehatan maupun orang tua atau pengasuh bayi, melipat popok di bawah tali pusat, merawat tali pusat bila basah terkena keringat, kencing dan tidak mandi dengan cara merendam tali pusat sebelum tali pusat terlepas. hasil penelitian menunjukkan rerata waktu pelepasan tali pusat pada kelompok perla k u a n ad alah 5,6 ha r i, sed a ng ka n kelompok kontrol memerlukan rerata waktu pelepasan 6,9 hari. rerata waktu pelepasan tali pusat pada kedua kelompok dikatakan dalam batas normal, hal ini sejalan dengan teori lorna dan sharon (2011) bahwa pelepasan tali pusat harus selesai dalam 5-15 hari, meski dapat saja berlangsung agak lama dalam hal penggunaan antiseptik dan infeksi. faktor yang mempengaruhi pengeringan dan pelepasan tali pusat difasilitasi dengan paparan udara (perawatan terbuka), infl amasi dan infi ltrasi leukosit. pelepasan tali pusat merupakan proses yang kompleks, tali pusat mengering dan menghitam (gangren) yang dibantu oleh adanya mikroorganisme, maka harus dirawat dengan teliti dan harus dijaga kebersihannya sehingga kuman tidak dapat menginfeksi pada tali pusat. proses pengeringan, infeksi, aktivitas kolagen, nekrosis dan granulosit mempengaruhi waktu pelepasan tali pusat. waktu pelepasan tali pusat antara kelompok perlak uan dengan kelompok kontrol menunjukkan perbedaan yang sangat signifi kan waktu pelepasan tali pusat bayi kelompok model asuhan perawatan topikal asi lebih cepat dengan selisih waktu 31 jam (1,7 hari) dibanding kelompok kontrol. faktor yang mempengaruhi lama pelepasan tali pusat kelompok kontrol adalah belum adanya protap resmi perawatan kering terbuka dengan swabs alkohol 70% sehingga dapat diinterprestasikan berbeda-beda oleh tenaga kesehatan di rumah sakit. teori lorna dan sharon (2011) menjelaskan bahwa tali pusat yang dirawat menggunakan antiseptik memperlama waktu pelepasan tali pusat. swabs alkohol termasuk penggunaan antiseptik, hal ini berkaitan dengan destruksi dari fl ora normal di sekitar umbilicus dan menurunkan jumlah leukosit yang tertarik ke tali pusat sehingga mengganggu proses pengeringan dan pelepasan tali pusat. responsden kelompok model perawatan topikal asi lebih cepat mengalami pelepasan tali pusat dibanding dengan model perawatan kering terbuka. hal tersebut mendukung pendapat bahwa asi mempunyai banyak agen imunologis, bahan anti inf lamasi dan antimikroba yang berguna untuk dapat melawan infeksi sehingga waktu pelepasan tali pusat dapat berlangsung lebih cepat (mullany, 2003). asi merupakan bahan yang mudah tersedia dan efektif untuk perawatan tali pusat yang bisa diterapkan di negara berkembang untuk mengurangi infeksi tali pusat dan mempercepat waktu pelepasan beberapa penelitian membuktikan bahwa perawatan tali pusat dengan topikal asi adalah metode yang aman, efektif dan efi sien maka perlu dikembangkan lebih lanjut. 15 topikal asi: model asuhan keperawatan tali pusat pada bayi (kasiati, dkk) simpulan dan saran simpulan asi terbukti aman, efektif dan efi sien digunakan sebagai topikal dalam perawatan tali pusat bayi. model asuhan perawatan topikal asi pada tali pusat dapat menurunkan kejadian omphalitis serta mempercepat waktu pelepasan tali pusat pada bayi. saran model perawatan topikal asi pada tali pusat dapat dijadikan protap standar perawatan tali pusat pada bayi. perawatan tali pusat dengan topikal asi harus tetap disertai dengan cara perawatan yang baik meliputi cuci tangan, menjaga kebersihan tali pusat dan mandi yang benar. perlu dilakukan sosialisasi pada petugas kesehatan maupun ibu postpartum agar dapat menerapkan metode perawatan tali pusat bayi dengan topikal asi secara benar. daftar pustaka ahmadpour mk., zahedpasha y., hajian k., javadi gh., talebian h., 2006. the effect of topical application of human milk, ethylalcohol 96%, and sulfadiazine on umbilical cord separation time in newborn infant, archives of aranian medicine, vol. 9: 33–38. diakses 30 desember 2011 (http://www.ncbi.nih. gov/pubmed/16649375 alligood, mr. 2006. nursing theories and their work 6th ed. mosby: st. louis missouri. ba d a n pe nel it ia n d a n pe nge mba nga n kesehatan ri, 2010. riset kesehatan dasar, 2nd ed, jakarta: kemkes. bobak, lowdermilk & jensen, 2005. buku ajar keperawatan maternitas, edisi 4, jakarta: egc. cunningham, fg., gant, nf., leveno, kj., hauth, jc., gilstrap, lc., 2006. obstetri williams. edisi ke-21. jakarta: egc, hal. 436–437. departemen kesehatan republik indonesia, 1999. modul safe mother hood, 2nd ed, fkmui, jakarta. departemen kesehatan republik indonesia, 2004. perjalanan menuju indonesia sehat 2010. 2nd ed , depa r temen kesehatan ri. jakarta. departemen kesehatan republik indonesia, 2004. buku acuan pelatihan klinik asuhan persalinan normal, 2nd ed, jakarta: jnpk-kr. hal. 4–6, 4–7. deslidel, hasan z., hevrialni & sartika, 2011. buku ajar asuhan neonates, bayi, dan balita. jakarta: kedokteran, egc. hal 80–81. dharma, kk., 2011. metodologi penelitian keperawatan panduan melaksanakan dan menerapkan hasil penelitian. jakarta: trans info media. 89–95, 197– 202. direktorat jenderal bina pelayanan medik, 2010, tatalaksana bayi baru lahir di rumah sakit, 2nd ed, kemkes, indonesia, hal 9–10. farahani, la., mahammadzadeh, a., tafazzoli, m., esmaeliet, h., & ghazvinni, k., 2008. effect of topical application of breast milk and dry cord care on bacterial colon ization and cord separation time in neonates, journal of chinese clinical medicine 6; vol. 3(6). diakses 28 desember 2011. (http://old.cjmed. net/html/2008636) hanafi ah, ka., 2001. rancangan percobaan teori amplikasi, universitas sriwijaya, palembang, hal. 6–7. hidayat, aa., 2009. asuhan neonates, bayi & balita. kedokteran. jakarta: egc hal. l58–59 kem.kes ri, 2010. tetanus maternal & neonatal. retrieved 28 januari 2012, from www.detikhealth.com reeder, ma r ten & g r if f i n , k., 2011, keperawatan maternitas kesehatan wanita, bayi, & keluarga, volume 2, kedokteran, jakarta: egc. hal 25–28. roch mah, k m., vasra, e. dahliana & sumastri, 2012. asuhan neonatus, bayi, & balita, jakarta: kedokteran, hal 1–3. roitt, im., 2003. imunologi. edisi 8. jakarta: widya medika, 4–7, 40–58, hal. 231– 234. mullany, lc., darmstadt, gl., tielsch, jm., 2003. role of antimicrobial applications to the umbilical cord in neonates to pevent bacter ial colonization and 16 jurnal ners vol. 8 no. 1 april 2013: 9–16 infection: a review of the evidence. pediatr infect dis j, 22(11): 996–1002. diakses 23 januari 2012. mullany, lc., darmstadt, gl., katz, j., khatry, sk., adhikari, rk., et al., 2005. risk factor for umbilical cord infeksi among newborn of southern nepal. departemen of international health, johns hopkins bloomberg school of publik health, diakses 23 januari 2012. (http://aje.oxfordjournal.org/content/165/2/203. short. multani, ks., 2006. ‘randomised control study of umbilical cord care at birt bsing different methods’ dissertation submitted to the rajiv gandhi university of health sciences, departement of pediatrics command hospital air force, bongalore, kartanata. nu rsalam, 2008. konsep & penerapan metodologi penelitian ilmu keperawatan pedoman skripsi, tesis dan instrumen penelitian kepera watan, edisi 2, jakarta: salemba medika, hal 80, 95. prawiroharjo, 2009. ilmu kebidanan, edisi 4, jakarta: bina pustaka, hal 370–371. purwanti, sh., 2004. konsep penerapan asi eksklusif, kedokteran, jakarta: egc. hal 6–24. saifuddin, ab. & wiknjosastro, gh., 2002. buku panduan prak tis pela yanan kesehatan maternal dan neonatal. sa r wono p raw i roha rdjo, ja ka r t a: yayasan bina pustaka. sastroasmoro dan ismael, 1995. dasar-dasar metodologi penelitian klinis. jakarta: binarupa aksara, hal 189–210. sawardekar k. changing, 2004. specturum of neonatal omphalitis, pediatr infect dis j, 23: 22–26. shelov, sp. & hanneman, re., 2005. panduan lengkap perawatan untuk bayi dan balita (ed. 4). argan. the american academy of pediatrics, hal. 144–145. sodikin, 2000. buku saku perawatan tali pusat. jakarta: egc. subiastutik, e., 2011. efektivitas pemberian topikal asi terhadap kecepatan waktu lepas tali pusat dibanding dengan perawatan kering, data & software sastroasmoro dan ismael 1995, dasardasar metodologi penelitian klinis. jakarta: binarupa aksara, hal 189– 210. maintenanced bay ugm. library, diakses 1 januari 2012 abstrak (fi le://g/journal dalam/index.php.htm vural, g. & kiza, s., 2006. ‘umbilical cord care: a pilot study comparing topical human milk, providone-iodine, and dry care,’ journal of obstetric, gynecologic, & neonatal nursing, 35: 123–128. diakses 19 november 2011.(http:// onlinelibrar y.wiley.com/doi:10.1111/ j.1552-6909.00012.x). wahap, as. & julia, m., 2002. sistem imun,imunisasi, & penyakit imun, widya medika, jakarta, hal 2–5. walsh, 2008. buku ajar kebidanan komunitas, jakarta: egc. who/rht/msm, 1998, ’care of the umbilical cord’: a review of evidence. world health organization/reproductive health/maternal safe matherhood. genewa. diakses 17 februari 2012. https://apps.who.int/rht/document/ms m98-4). who/hhd, 2000. dalam kramer, ms & kakuma, the optimal duration of exclusive breast feeding a systematic review. diakses 28 februari 2012. william, sm., 2005. pedoman klinik pediatric. jakarta: egc. zupan, j. & gar ner, p., 2004. ’topical umbilical cord care at birth’ (cochrane rev iew). i n: coch ra n e libra r y, issue 3.chichester, uk: john wiley and: update software.(http://www. thecochonelibray.com vol 6 no 1 april 2011_akreditasi 2013.indd 85 kebutuhan riil tenaga perawat dengan metode workload indicator staff need (wisn) (the real need of nurses based on workload indicator staff need (wisn)) ni luh ade kusuma ernawati*, nursalam**, lilik djuari*** * rumah sakit umum negara bali, e-mail: ade.niluh@yahoo.com ** fakultas keperawatan universitas airlangga *** fakultas kedokteran universitas airlangga abstract introduction: nurses are health workers in hospitals that provide nursing care to patients for 24 hours. workload of nurses was high due to insuffi cient numbers of nurses. it will have an impact on the decrease in work productivity that may affect nurses care for patients. to get the human resources necessary to suit the needs of nursing manpower planning to increase the competitiveness of hospitals in the era of globalization. the research objective was to analyze the real needs of nurses on staff workload indicators need (wisn). method: the study design was observational analytic. analysis of workload using the method of approach to time and motion study. sample were 24 nurses who met the inclusion criteria. analysis of the needs of staff nurses using the workload indicators need (wisn). result: the results obtained based on the calculation of nurses with wisn method needs of nurses in the medical-surgical nurses as many as 54 people. objective workload of nurses in the room medical surgery general state hospital of bali is the average 82.61%, including height. the total time required to complete the productive activities of more than 80%. discussion: conclusion of this study show the number of nurses in the medical-surgical general hospital bali is still lacking as many as 30 people. it is suggest to the hospital management to increase gradually the number of nurses in the medical room. keywords: nursing manpower planning, workload, nurse demand pendahuluan rumah sakit merupakan suatu layanan masyarakat yang penting dan dibutuhkan dalam upaya pemenuhan tuntutan kesehatan. sumber daya manusia adalah salah satu unsur pendukung berfungsinya operasional rumah sakit. perencanaan tenaga keperawatan atau staffi ng merupakan fungsi organik manajemen yang merupakan dasar atau titik tolak dari kegiatan pelaksanaan kegiatan tertentu dalam usaha mencapai tujuan organisasi (arwani, 2006). perencanaan ketenagaan menjadi permasalahan besar di berbagai organisasi keperawatan seperti tatanan rumah sakit, perawatan di rumah (nursing home) dan tempat-tempat pelayanan keperawatan lain. masalah yang sering terjadi dalam organisasi yaitu kurangnya jumlah dan jenis tenaga yang dibutuhkan, kurangnya kompetensi (pengetahuan, keterampilan, sikap dan nilai) dari tenaga perawat serta keterbatasan dana dari rumah sakit sehingga tidak dapat menambah dan merawat sumber daya manusia (sdm) yang mereka butuhkan (ilyas, 2004). hasil laporan kinerja bidang pelayanan medik rumah sakit negara bali tahun 2010 menyatakan bahwa salah satu penyebab belum optimalnya pelayanan kesehatan kepada pasien karena jumlah perawat yang kurang dan kebijakan yang tidak sesuai dengan kebutuhan riil rumah sakit. rumah sakit umum negara bali merupakan rumah sakit kelas c milik pemerintah kabupaten daerah provinsi bali. rumah sakit negara memiliki fasilitas pelayanan yaitu ugd 24 jam, poliklinik rawat jalan, instalasi rawat inap, unit radiologi, unit laboratorium, kamar bedah dan ambulance 24 jam. perbandingan jumlah tempat tidur dengan jumlah tenaga perawat di ruang medikal bedah rumah sakit umum negara bali adalah jurnal ners vol. 6 no. 1 april 2011: 85–92 86 54 tempat tidur: 28 orang perawat. menurut standar departemen kesehatan rasio perawat dan tempat tidur untuk rs kelas c adalah 1:1 (54 tt:54 perawat). ketidaksesuaian antara jumlah perawat dan jumlah tempat tidur, serta jumlah rata-rata bor 84,31%, memberikan gambaran bahwa beban kerja perawat di ruang rawat inap rumah sakit umum negara cukup tinggi. beban kerja perawat adalah seluruh kegiatan atau aktivitas yang dilakukan oleh seorang perawat selama bertugas di suatu unit pelayanan keperawatan (marquis dan houston, 2000). beban kerja yang tinggi akan menimbulkan kelelahan dan stres kerja. kelelahan perawat dalam bekerja dapat menyebabkan terjadinya penyimpangan kerja yang akan menyebabkan kemunduran penampilan kerja. kelelahan kerja perawat juga dapat memberi dampak pada asuhan pelayanan yang diberikan tidak akan optimal. ilyas (2004) mengatakan tingginya beban kerja dapat berefek pada penurunan kinerja personel rumah sakit. penetapan jumlah perawat di rumah sakit disesuaikan dengan kategori yang akan dibutuhkan untuk asuhan keperawatan klien di setiap unit. sejumlah praktisi, peneliti dan asosiasi telah melakukan riset untuk dapat menghitung kebutuhan tenaga perawat dengan mengembangkan metode untuk menghitung kebutuhan tenaga perawat. ada beberapa metode yang dipakai sebagai acuan untuk mennghitung jumlah kebutuhan tenaga perawat. menurut sk menteri kesehatan republik indonesia no. 81/menkes/sk/i/2004 salah satu metode yang telah dikembangkan departemen kesehatan untuk menghitung kebutuhan tenaga rumah sakit adalah metode work load indicator staff need (wisn), yang berakar pada beban kerja personel. metode perhitungan kebutuhan berdasarkan beban kerja (wisn) adalah indikator yang menunjukkan besarnya kebutuhan tenaga pada sarana kesehatan berdasarkan beban kerja, sehingga alokasi/relokasi tenaga akan lebih mudah dan rasional. kelebihan metode ini mudah dioperasikan, mudah digunakan, secara teknis mudah diterapkan, komprehensif dan realistis (departemen kesehatan, 2004). kondisi ini yang mendasari penelitian untuk menganalisi kebutuhan riil tenaga perawat di ruang medikal bedah rumah sakit umum negara bali. di samping itu, manajemen rs belum pernah melaksanakan kajian kebutuhan jumlah tenaga berdasarkan beban kerja nyata. bahan dan metode penelitian ini merupakan penelitian analitik observasional dengan menggunakan metode pendekatan time and motion study yang bertujuan untuk melihat aktivitas atau kegiatan secara menyeluruh dari perawat pelaksana dalam rangka menganalisis beban kerja perawat pelaksana untuk merencanakan jumlah kebutuhan tenaga perawat di ruang medikal bedah rumah sakit umum negara bali. penelitian dilakukan di ruang medikal (ruang flamboyan) dan bedah (ruang dahlia) rumah sakit umum negara bali. sampel dalam penelitian ini adalah semua perawat di ruang medikal bedah yang memenuhi kriteria sampel sebanyak 24 orang perawat. pengumpulan data dibagi menjadi data primer yang dikumpulkan melalui pengamatan langsung terhadap kegiatan yang dilakukan oleh tenaga perawat selama jam kerja dan data sekunder seperti waktu kerja tersedia, bor dan jadwal shift perawat yang diperoleh melalui wawancara dengan bagian bidang keperawanan dan dokumen rumah sakit. pengumpulan data beban kerja objektif perawat di ruang medikal bedah rumah sakit umum negara bali dilakukan oleh peneliti melalui pengamatan dengan metode time and motion study. tenaga keperawatan yang diamati sebanyak 24 orang yaitu 10 orang di ruang dahlia dan 14 orang diruang flamboyan. pengamatan terhadap perawat dilakukan setiap shift, di mana setiap shift mengamati satu orang perawat. dalam satu hari peneliti mengamati satu orang perawat. pengamatan disesuaikan dengan jam kerja tenaga keperawatan yaitu untuk jaga shift pagi, shift sore dan shift malam. setiap perawat diobservasi sebanyak satu kali yaitu pada shift pagi, sore dan malam. selanjutnya dimasukkan ke dalam rumus perhitungan jumlah tenaga dari workload indicators of staff need (wisn). langkah kebutuhan riil tenaga perawat (ni luh ade kusuma ernawati) 87 perhitungan kebutuhan tenaga berdasarkan wisn ini meliputi 5 langkah, yaitu: menetapkan waktu kerja tersedia berdasarkan hari kerja, cuti tahunan, pendidikan dan pelatihan, hari libur nasional dan cuti tahunan, ketidakhadiran kerja dan waktu kerja perawat selama satu tahun; menetapkan unit kerja dan kategori sdm yang dihitung; menyusun standar beban kerja; menyusun standar kelonggaran; menghitung kebutuhan tenaga perunit kerja. hasil jenis kelamin responden dari 24 tenaga perawat di ruang medikal bedah 87,5% adalah berjenis kelamin perempuan dan 12,5% adalah jenis kelamin laki-laki. tingkat pendidikan perawat 62,5% adalah diii keperawatan. tenaga perawat dengan status pns sebanyak 75%. masa kerja tenaga perawat 37,5% lebih dari 10 tahun. beban kerja objektif dinyatakan dalam bentuk proporsi waktu kerja yang dikelompokkan menjadi tindakan keperawatan langsung (tugas pokok) dan tindakan keperawatan tidak langsung (tugas penunjang) merupakan kegiatan produktif tenaga keperawatan. kegiatan non keperawatan merupakan kegiatan non produktif tenaga keperawatan. beban kerja perawat di ruang medikal bedah untuk shift pagi 83,23%, shift sore 82% dan shift malam 72,57%. penghitungan kebutuhan tenaga perawat berdasarkan workload indikator staff need (wisn) menunjukkan berdasarkan waktu kerja tersedia adalah 1.638 jam/tahun, atau 273 hari kerja. segi penetapan unit kerja yang menjadi fokus dalam penelitian ini adalah tenaga perawat pelaksana di ruang medikal bedah rumah sakit umum negara bali, berdasarkan penyusunan standar beban kerja. standar beban kerja tenaga keperawatan di ruang dahlia adalah sebesar 237864,96/tahun dan di ruang flamboyan adalah sebesar 240311,17/tahun, sedangkan dari segi penyusunan standar kelonggaran di ruang dahlia rumah sakit umum negara bali adalah 0,29 dan di ruang flamboyan adalah 0,28. jumlah kebutuhan tenaga perawat di ruang dahlia adalah 22,15 atau 22 orang perawat dan di ruang flamboyan yaitu 31,84 atau 32 orang perawat. interpretasi hasil penghitungan kebutuhan tenaga perawat berdasarkan indeks wisn didapatkan ruang medikal bedah kekurangan 30 orang tenaga perawat. pembahasan beban kerja perawat adalah seluruh kegiatan atau aktivitas yang dilakukan oleh seorang perawat selama bertugas di suatu unit pelayanan keperawatan. pengukuran beban kerja objektif dilakukan untuk mengetahui penggunaan waktu tenaga keperawatan dalam melaksanakan kegiatan produktif dan non produktif pada setiap shift kerja yaitu shift pagi, sore dan malam (marquish, 2010). penelitian ini menunjukkan bahwa beban kerja perawat di ruang dahlia adalah 83,87%. total waktu untuk menyelesaikan kegiatan produktif di ruang dahlia adalah 202,41 jam yang meliputi tindakan keperawatan langsung sebesar 129,66 jam dan tindakan keperawatan tidak langsung sebesar 72,75 jam. beban kerja perawat di ruang flamboyan adalah 81,36%. total waktu untuk menyelesaikan kegiatan produktif di ruang flamboyan adalah 271,96 jam yang meliputi tindakan keperawatan langsung 161,28 jam dan tidak langsung 110,068 jam. tabel 1. beban kerja perawat di ruang dahlia dan flamboyan rumah sakit umum negara bali no shift beban kerja rerata dahlia flamboyan % kategori % kategori % kategori 1 pagi 82,73 tinggi 83,73 tinggi 83,23 tinggi 2 sore 83,21 tinggi 80,80 tinggi 82,00 tinggi 3 malam 85,67 tinggi 79,57 rendah 72,57 rendah rerata 83,87 tinggi 81,36 tinggi 82,62 tinggi jurnal ners vol. 6 no. 1 april 2011: 85–92 88 tabel 2. standar beban berja di ruang medikal bedah (dahlia dan flamboyan) rumah sakit umum negara bali tanggal 18 april–13 juni 2011 no kegiatan produktif ruangan dalia ruangan flamboyan sk (jam) wkt (jam) sbk (wkt/sk) sk (jam) wkt (jam) sbk (wkt/sk) tindakan keperawatan langsung 1 memberikan obat kepada pasien 0,13 1638 13091,82 0,13 1638 12272,00 2 memenuhi kebutuhan cairan & elektrolit, nutrisi 0,10 1638 16325,76 0,10 1638 17144,12 3 memenuhi kebutuhan eliminasi bab 0,35 1638 4621,32 4 memenuhi kebutuhan eliminasi urine 0,26 1638 6271,95 0,22 1638 7428,14 5 memenuhi kebutuhan integritas jaringan 0,47 1638 3456,33 0,31 1638 5533,78 6 memenuhi kebutuhan oksigen 0,04 1638 39480,0 0,14 1638 11982,04 7 menyiapkan spesimen lab 0,28 1638 5896,8 0,10 1638 15876,60 8 memenuhi kebutuhan rasa nyaman dan aman 0,14 1638 11828,57 0,13 1638 12142,51 9 transportasi pasien 0,28 1638 5956,364 0,27 1638 5978,10 10 melakukan resusitasi 0,52 1638 3129,94 11 perawatan jenasah 0,64 1638 2559,38 12 melakukan tindakan ekg 0,35 1638 4729,79 13 mengukur tanda-tanda vital 0,07 1638 23558,64 0,10 1638 15448,54 14 visite dokter 0,11 1638 15470 0,06 1638 19236,30 15 menerima pasien baru 0,17 1638 9927,273 0,08 1638 10616,67 16 observasi 0,08 1638 20705,45 0,08 1638 20860,74 17 pendidikan kesehatan 0,20 1638 8303,226 0,17 1638 9927,27 18 persiapan pasien pre op 0,19 1638 8854,054 0,13 tindakan keperawanan tidak langsung 1 melengkapi catatan medik pasien/pendokumentasian 0,08 1638 19804,91 0,11 1638 14300,00 2 memenuhi kebutuhan kebersihan dan lingkungan 0,42 1638 3876,92 0,12 1638 14184,74 3 administrasi 0,35 1638 4738,40 0,38 1638 3810,94 4 timbang terima pasien 0,11 1638 15276,68 0,10 1638 16207,58 5 sterilisasi alat 0,22 1638 7488,00 0,17 1638 9874,47 total 237864,96 240311,17 keterangan: sk: standar kegiatan, wkt: waktu kerja tersedia, sbk: standard beban kerja kebutuhan riil tenaga perawat (ni luh ade kusuma ernawati) 89 gillies (1994) mengatakan bahwa rerata waktu yang dibutuhkan untuk perawatan langsung (direct care) adalah berkisar 4–5 jam/klien/hari. berdasarkan penelitian perawat di rumah sakit, grace detroit, menyatakan bahwa rerata waktu yang dibutuhkan untuk perawatan tidak langsung adalah 36 menit/ klien/hari. waktu kerja produktif yang optimum berkisar 80%), jika sudah bekerja di atas 80% produktifnya, menunjukkan beban kerja tinggi dan kita perlu mempertimbangkan dan memperhatikan bahwa unit tersebut benar-benar membutuhkan tenaga baru. berdasarkan pendapat ilyas ini dapat dikatakan bahwa beban kerja perawat di ruang medikal bedah rumah sakit umum negara bali adalah tinggi, karena perbandingan antara waktu total waktu produktif dengan total waktu secara keseluruhan diperoleh prosentase diatas 80% yaitu 83,70%. metode penghitungan kebutuhan sumber daya manusia (sdm) perawat berdasarkan beban kerja wisn adalah suatu metode penghitungan kebutuhan sdm perawat berdasarkan pada beban pekerjaan nyata, yang dilaksanakan oleh setiap perawat pada tiap unit kerja di fasilitas kesehatan. menurut departemen kesehatan (2004) mekanisme penghitungan kebutuhan tenaga perawat menggunakan cara ini meliputi 5 tahap yaitu: menetapkan waktu kerja tersedia; menetapkan unit kerja dan kategori sdm: menyusun standar tabel 3. standar kelonggaran di ruang medikal bedah (dahlia dan flamboyan) rumah sakit umum negara bali tanggal 18 april–13 juni 2011 kegiatan non produktif dahlia flamboyan sk wkt fk stk (fk/wkt) sk wkt fk stk (fk/wkt) 1 sembahyang 0,16 1638 36,50 0,02 0,14 1638 31,50 0,02 2 makan/minum 0,30 1638 60,83 0,04 0,28 1638 56,49 0,03 3 toilet 0,09 1638 106,46 0,06 0,09 1638 107,54 0,07 4 telepon pribadi 0,07 1638 111,02 0,07 0,06 1638 108,63 0,07 5 duduk di nurse station 0,21 1638 130,79 0,08 0,20 1638 128,18 0,08 6 gosok gigi 0,25 1638 15,21 0,01 0,25 1638 15,21 0,01 7 ganti baju 0,28 1638 15,21 0,01 0,25 1638 15,21 0,01 total 0,29 0,28 keterangan: sk: standar kegiatan, wkt: waktu kerja tersedia, fk: faktor kelonggaran, stk: standard kelonggaran beban kerja; menyusun standar kelonggaran dan penghitungan tenaga per unit kerja. menetapkan waktu kerja tersedia bertujuan untuk memperoleh waktu kerja perawat yang bekerja di rumah sakit selama kurun waktu satu tahun. data yang dibutuhkan untuk menetapkan waktu tersedia yaitu hari kerja, cuti tahunan, pendidikan dan pelatihan, hari libur nasional dan cuti tahunan, ketidakhadiran kerja dan waktu kerja perawat selama satu tahun. waktu kerja tersedia bagi perawatan di rumah sakit umum negara bali adalah 1,638 jam dalam setahun atau 273 hari dalam setahun. setiap rumah sakit mempunyai penetapan waktu kerja tersedia yang berbeda-beda, sesuai ketentuan peraturan daerah masing-masing. standar beban kerja adalah volume/ kuantitas beban kerja selama 1 tahun perkategori sdm. standar beban kerja untuk suatu kegiatan pokok disusun berdasarkan waktu yang dibutuhkan untuk menyelesaikannya (ratarata waktu) dan waktu yang tersedia pertahun yang dimiliki oleh masing-masing kategori tenaga (departemen kesehatan, 2004). beban kerja dari kategori sdm di unit kerja meliputi kegiatan pokok yang dilaksanakan, rerata waktu yang dibutuhkan untuk menyelesaikan tiap kegiatan pokok dan standar beban kerja per 1 tahun masing-masing kategori sdm. hasil penelitian menunjukkan menunjukkan bahwa standar beban kerja keperawatan di jurnal ners vol. 6 no. 1 april 2011: 85–92 90 tabel 4. kebutuhan tenaga perawat kegiatan produktif dahlia flamboyan kuantitas kegiatan pokok (kkp) standar beban kerja (sbk) kebutuhan sdm (kkp/sbk) (a) kuantitas kegiatan pokok (kkp) standar beban kerja (sbk) kebutuhan sdm (kkp/sbk) (a) tindakan keperawatan langsung 1 memberikan obat kepada pasien 20127 13091,82 1,54 30238,00 12272,00 2,46 2 memenuhi kebutuhan cairan dan elektrolit, nutrisi 25242 16325,76 1,55 38523,57 17144,12 2,25 3 memenuhi kebutuhan elimasi bab 7234,64 4621,32 1,57 4 memenuhi kebutuhan elimasi urine 9669 6271,95 1,54 12001,79 7428,14 1,62 5 memenuhi kebutuhan integritas jaringan 6756 3456,33 1,95 5825,71 5533,78 1,05 6 memenuhi kebutuhan oksigen 42906 39480,00 1,09 19694,29 11982,04 1,64 7 menyiapkan spesimen 7023 5896,80 1,19 17537,86 15876,60 1,10 8 memenuhi kebutuhan rasa nyaman dan aman 14231 11828,57 1,20 18972,50 12142,51 1,56 9 transportasi pasien 6301 5956,36 1,06 6455,36 5978,10 1,08 10 melakukan resusitasi 3378,21 3129,94 1,08 11 melakukan perawatan jenasah 2818,21 2559,38 1,10 12 melakukan tindakan ekg 8395,36 4729,79 1,77 13 mengobservasi tanda-tanda vital 28721 23558,64 1,22 25475,00 15448,54 1,65 14 visite dokter 18081 15470,00 1,17 29871,79 19236,30 1,55 15 menerima pasien baru 8338 9927,27 0,84 12430,00 10616,67 1,17 16 observasi 26719 20705,45 1,29 27866,07 20860,74 1,34 17 pendidikan kesehatan 10201 8303,23 1,23 15263,29 9927,27 18 persipan pre op 8670 8854,05 0,98 kebutuhan riil tenaga perawat (ni luh ade kusuma ernawati) 91 ruang dahlia adalah sebesar 237864,96 jam/ tahun dan di ruang flamboyan adalah sebesar 240311,17 jam/tahun. perbedaan standar beban kerja di ruang dahlia dengan flamboyan karena masing-masing ruangan merawat pasien dengan kasus dan kompleksitas masalah yang berbeda. ruang dahlia adalah ruangan yang khusus merawat pasien bedah dan ruang flamboyan adalah ruangan yang khusus merawat penyakit dalam termasuk penyakit saraf. menurut arwani (20056) menentukan beban kerja perawat memperhatikan hal-hal yaitu jumlah pasien yang dirawat setiap hari, tingkat ketergantungan pasien, rerata waktu perawatan dan frekuensi tindakan keperawatan yang dibutuhkan pasien. penyusunan standar kelonggaran adalah diperolehnya faktor kelonggaran tiap kategori sdm meliputi jenis kegiatan dan kebutuhan waktu untuk menyelesaikan suatu kegiatan yang tidak terkait langsung atau dipengaruhi oleh jumlah kegiatan pokok pelayanan. hal ini diperhitungan dengan pertimbangan bahwa tenaga perawat dalam memberikan asuhan keperawatan kepada pasien tidak hanya melaksanakan kegiatan produktif saja melainkan melakukan kegiatan nonproduktif. standar kelonggaran di ruang medikal bedah rumah sakit umum negara berupa kegiatan pribadi perawat yaitu sembahyang, makan, gosok gigi, toilet, duduk di nurse station. dari hasil penelitian didapatkan bahwa standar kelonggaran di ruang dahlia adalah 0,29 dan di ruang flamboyan adalah 0,28. standar kelonggaran ini akan ditambahkan pada perhitungan kebutuhan tenaga perunit untuk menghasilkan total kebutuhan tenaga. penghitungan rumus wisn menunjukkan bahwa jumlah kebutuhan tenaga perawat di ruang flamboyan adalah 32 orang. jumlah perawat yang ada saat ini adalah sebanyak 14 orang. jadi ruang flamboyan membutuhkan penambahan tenaga sebanyak 18 orang. untuk ruang dahlia, dari hasil penghitungan, tenaga perawat yang dibutuhkan diruang tersebut adalah 22 orang, yang ada saat ini 10 orang, jadi membutuhkan penambahan tenaga perawat sebanyak 12 orang. hasil perhitungan tenaga berdasarkan wisn sesuai bila dibandingkan dengan perhitungan ratio perawat dengan kegiatan produktif dahlia flamboyan kuantitas kegiatan pokok (kkp) standar beban kerja (sbk) kebutuhan sdm (kkp/sbk) (a) kuantitas kegiatan pokok (kkp) standar beban kerja (sbk) kebutuhan sdm (kkp/sbk) (a) tindakan keperawatan tidak langsung 1 melengkapi catatan medik pasien/ pendokumentasian 2 memenuhi kebutuhan kebersihan dan lingkungan 22309 19804,91 1,13 21896,07 14300,00 1,53 3 administrasi 3879 3876,92 1,00 13424,14 14184,74 0,95 4 timbang terima pasien 3861,5 4738,40 0,81 5538,21 3810,94 1,45 steriisasi alat 10386 15276,68 0,68 17265,50 16207,58 1,07 jumlah 21,86 31,56 standar kelonggaran (b) 0,29 0,28 22,15 31,84 lanjutan tabel 4 jurnal ners vol. 6 no. 1 april 2011: 85–92 92 jumlah tempat tidur menurut departemen kesehatan untuk kategori rumah sakit tipe c. simpulan dan saran simpulan beban kerja objektif tenaga perawat diruang medikal bedah rumah sakit umum negara bali termasuk tinggi yaitu rerata 82,61%. kebutuhan tenaga perawat berdasarkan workload indicator staff need (wisn) di medikal bedah rumah sakit umum negara bali adalah 54 orang perawat, tenaga yang ada sebanyak 24 orang sehingga kekurangan 30 orang perawat. saran hasil penelitian dapat dijadikan bahan pertimbangan manajemen rumah sakit untuk mengambil kebijakan penambahan tenaga perawat di ruang medikal bedah secara bertahap. selanjutnya perlu dilakukan penelitian penghitungan kebutuhan tenaga perawat berdasarkan wisn di unit kerja yang lain. kepustakaan aditama, t.y., 2004. manajemen administrasi rumah sakit. jakarta: universitas indonesia. azwar, a., 1996. pengantar administrasi kesehatan. jakarta: binarupa aksara. arwani dan supriyatno, h., 2006. manajemen bangsal keperawatan. jakarta: penerbit buku kedokteran egc. departemen kesehatan republik indonesia, 2005. instrumen evaluasi penerapan s t a n d a r a s u h a n k e p e r a w a t a n d i rumah sakit. jakarta: dirjen pelayanan medik. departemen kesehatan republik indonesia, 2 0 0 4 . p e d o m a n p e n y u s u n a n perencanaan sdm kesehatan di tingkat propinsi, kab/kota serta rumah sakit. jakarta: departemen kesehatan republik indonesia. fredna, j.m.r., 2009. analisis beban kerja perawat pelaksana untuk mengevaluasi kebutuhan tenaga perawat di rumah sakit umum prof. dr kandou manado. tesis tidak dipublikasikan. jakarta: universitas indonesia. gillies, d.a., 1994. nursing management: a system approach. edisi kedua. philadelpia: w.b. sauders. ilyas, y., 2004. perencanaan sumber daya manusia rumah sakit. teori metoda dan formula. jakarta: pusat kajian ekonomi kesehatan fkm ui. marquis, b.l., dan huston, 2010. kepemimpinan dan manajemen keperawatan. teori & aplikasi. jakarta: egc. 16 http://e-journal.unair.ac.id/jners © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 16-24 http://dx.doi.org/10.20473/jn.v18i2.41395 original article open access perceived competence of filipino nursing students graduating during pandemic joshua eugene molanida 1 , tisha jane amar neyra 1 , paolo miguel norada 1 , princess mae` olarte 1 , danish danielle palma 2 , and ryan michael flores oducado 1 * 1 faculty of nursing, visayas state university, visca, baybay, philippines *correspondence: ryan michael flores oducado. address: faculty of nursing, visayas state university, visca, baybay, philippines. email: rmoducado@wvsu.edu.ph responsible editor: ferry efendi received: 10 october 2022 ○ revised: 23 february 2023 ○ accepted: 23 february 2023 abstract introduction: given the importance of maintaining competence, limited published research is conducted in the local setting touching on the competence of nursing students graduating during the pandemic. this study determined graduating nursing students’ perceived fundamental nursing skills and core competence. methods: the research design is quantitative descriptive cross-sectional. the study participants were the 102 graduating nursing students of a public university in iloilo city, philippines. the perceived competence of filipino nurses questionnaire was used to gather data in may 2022 and these were analyzed using spss software version 23. results: the results revealed that, while the majority of nursing students reported that their nursing competencies were greatly affected by the shift to the online learning platform, most still had a high perception of their fundamental nursing skills competence (m=6.97) and core competence (m=8.03). the areas of elimination (m=5.41) and research (m=7.63) were the lowest-ranked fundamental skill and core competencies, respectively. there was a significant difference (p< .05) in nursing students' perceived competence based on self-reported academic performance. conclusions: despite the reduced exposure in the clinical setting due to the pandemic, graduating nursing students perceive themselves to be highly confident in their capabilities as future professional nurses. nonetheless, areas for improvement were identified that warrant further assessment, validation, and enhancement. keywords: competence, nursing skills, nursing students, pandemic, philippines introduction the high transmissibility of coronavirus disease (covid-19) makes healthcare systems worldwide drastically overwhelmed. this catastrophic event highlighted the need for skilled healthcare workers, particularly nurses (lynch & pusey-murray, 2021). to be a skilled professional nurse, one must have the fundamental skills and core competencies (fukada, 2018; xie, 2019). skills and competence are closely related since competence is generally defined as the ability to act accordingly and be recognized by others (nascimento et al., 2021). competence in nursing is defined in various ways, and each focus on a particular educational topic. clinical competence, one of the most tackled definitions, is the knowledge reinforced by a mix of cognitive, psychomotor, and affective or attitudinal abilities appropriately implemented in a given scenario (weeks et al., 2019). being a discipline that is based on hands-on practice, the critical challenge in nursing education is teaching students core competencies and providing various opportunities to sharpen and improve their fundamental skills, especially when performing on actual patients (gregersen et al., 2021; oducado et al., 2019). fukada (2018) defined nursing core competence as the ability to use rational reasoning and accurate nursing skills to provide quality nursing services that satisfy the needs of the clients being cared for. sumagaysay and oducado (2019) identified the core competencies based on the 11 key areas of responsibilities (kar). the kar was incorporated in https://creativecommons.org/licenses/by/4.0/ mailto:rmoducado@wvsu.edu.ph https://orcid.org/0009-0008-7592-4669 https://orcid.org/0009-0002-4242-0233 https://orcid.org/0009-0003-8862-0449 https://orcid.org/0009-0005-0419-5137 https://orcid.org/0009-0001-0079-2787 https://orcid.org/0000-0001-9107-3069 jurnal ners http://e-journal.unair.ac.id/jners 17 2012 in the national nursing core competencies standards, serving as a framework for the practice and education of nursing in the philippines and defining what nursing graduates are expected to perform in professional nursing practice (belo-delariarte et al., 2018; nabizadeh-gharghozar et al., 2021). on the other hand, the term "fundamental nursing skills" is not thoroughly defined in any existing literature. however, it’s usually referred to as basic clinical skills or essential prerequisites for novice nurses when they start working as professionals (missen et al., 2016). in the same study by ubas-sumagaysay and oducado (2019) fundamental clinical nursing skills encompass technical nursing skills. worldwide, nursing practice is generally founded on professional nursing skills and core competence (fukada, 2018; staykova et al., 2017). practical nursing skills involve technical, theoretical, and practical aspects, caring perspectives, as well as ethical and moral considerations (gregersen et al., 2021). in nursing education, the classroom and clinical environment are interconnected and complementary because students must apply in clinical practice what they have learned in the classroom, online, and through other modalities (oducado et al., 2019). when approaching the end of their nursing education, students are expected to have gained adequate skills and competence to fulfill their duties safely and effectively without the need for direct supervision, fully allowing them to build trusting relationships with their patients (cowen et al., 2018; leonardsen et al., 2021). hence, the competence of graduating nursing students is important as it is associated with upholding the culture of high-quality nursing care, professional standards, and patient safety (kajander-unkuri, 2014). with the increasing need for skilled nurses in both local and global healthcare settings, it is vital to determine the fundamental nursing skills and core competence of graduating nursing students, especially as they are nearing graduation and about to enter professional nursing practice. however, previous studies conducted in the pre-pandemic have shown contrasting and inconsistent findings on the level of competence and fundamental skills of graduating nursing students. for instance, the orkaizagirre‐gómara et al. (2020) study conducted in spain and mohamadirizi et al.'s (2015) in iran before the covid-19 pandemic, revealed that final-year or senior nursing students were found to have competent clinical skills. in contrast, single institute-based studies conducted in multiple developed countries, including the usa, australia, and iran, reported deficits in graduating nursing students' clinical skills, and very few of them possessed entry-level competencies and practice readiness (jamshidi et al., 2016; kavanagh, 2017; missen et al., 2016). according to park and han (2013), in clinical settings, freshly graduated nurses fall short of the clinical performance required to fulfill a variety of health-related demands. in addition, research indicates that many graduating or newly graduated nurses desire to be more competent and knowledgeable about the procedures they are expected to become skilled at (sheahan, 2015). to safeguard students from the virus, face-to-face education was replaced by virtual remote learning, and clinical experiences were halted (agu et al., 2021). despite a study claiming that online learning bears the potential to enhance clinical reasoning and knowledge retention (padilha et al., 2019), some nursing students assert that online learning does not consistently deliver prompt feedback and responses when compared to traditional in-person classes (li et al., 2019). additionally, nkenke et al. (2012) claimed that the online setup lacks supervision, which may affect learning performance. due to infection concerns and a lack of personal protective equipment, the covid-19 pandemic has prompted a sudden transition from in-person to remote learning, reducing clinical experience (powers et al., 2021). as there exist contrasting results of different studies on the impact of online learning on the development of the competencies of nursing students, few to no studies, have been conducted yet touching on the graduating nursing students' level of perceived fundamental nursing skills and core competence in the online modality at the time of the pandemic, particularly at the philippine setting. whereas the study of ubassumagaysay and oducado (2020) conducted before the pandemic reported a relatively high level of competency among new graduate filipino nurses, it is unknown whether or not the level of competence of graduating nursing students has worsened with the emergency shifting to online modalities at the time of the pandemic. with the pandemic still prevailing, most, if not all, graduating nursing students in the philippines are still stuck inside their home’s sans clinical experience. as the time of graduation approaches, wherein a new set of fresh graduates will be produced, the importance of assessing how graduating nursing students perceive their competencies should be acknowledged as a crucial need to improve professional nursing practice. therefore, this study focuses on determining the fundamental nursing skills and core competencies reported by the graduating nursing students in a public university in the philippines. molanida, neyra, norada, olarte, palma, and oducado 18 p-issn: 1858-3598  e-issn: 2502-5791 materials and methods a quantitative research design, specifically descriptive-cross sectional research design, was utilized in this study. the study participants included all (135) undergraduate students from the fourth year or graduating class of bachelor of science in nursing in a public university in iloilo city, philippines. there were 102 responses obtained from the electronic survey getting a response rate of 75.56%. based on the cochran (1977) formula, the sample size required given the population of 135 given a 5% level of precision, and a 95% confidence level is only 101. the data for this study were collected using an online questionnaire with four (4) parts. part one, respondents' profile, covers the personal information. in addition, the questionnaire included the students' self-reported academic performance as reported by terry and peck (2020), with responses ranging from "very poor" to "very good." part two and three included the perceived competence for filipino nurses questionnaire (pcfnq) of ubas-sumagaysay and oducado (2020). part two covers the graduating students' fundamental nursing skills, measured using the fundamental nursing skills competency scale (fnscs) of the pcfnq. the fnscs consisted of 99 items with 14 domains. part three covers the graduating students' nursing core competencies, measured using the nursing core competency scale (nccs) of the pcfnq. the original nccs consists of 151 performance indicators. however, we excluded ten (10) items in this study since these performance indicators do not apply to graduating nursing students. hence, the version in this study included a total of 141 items. this part measured the students' degree of self-reported competence based on the 11 key areas of responsibility (kar). responses in the pcfnq were graded on a 10point scale, wherein one (1) corresponds to "not competent" and ten (10) indicates "very highly competent." high scores indicate a high level of competency. the pcfnq has very high internal consistency with cronbach's alpha based on the actual data being 0.987 and 0.996 for fnscs and nccs, respectively. part four covers the extent to which graduating nursing students think the current online learning platform has affected the development of their fundamental nursing skills and core competencies. two questions were asked, "to what extent do you think the current online learning platform has affected the development of your fundamental nursing skills competencies?" and "to what extent do you think the current online learning platform has affected the development of your nursing core competencies?" with five (5) choices ranging from "very low" to "very high." following the approval of the university ethics committee (protocol number wvsu.urerc2022.con_002), the researchers obtained permission to conduct the study from the office of the dean and the division chairperson of the college of nursing. assistance was sought from the level iv division chairperson and curriculum officer in contacting each class chairperson to serve as a link between the researchers and participants through school email or facebook messenger. since the researchers have no access to the respective group chats and the facebook group of the level iv nursing students, the chairpersons were requested to share the link in their group chats and facebook groups. electronic informed consent was included in the first part. as the minimum sample size was met, the responses of the participants were compiled, organized, and consolidated in the spreadsheet. all statistical computations were done via the statistical package for the social sciences (spss) software version 23.0. the kolmogorov-smirnov test was utilized to determine the normality of the data, and descriptives, t-test, and anova set at 0.05 level of significance were used to analyze the data. results in total, 102 responses were included in this analysis. table 1 shows the average age of the participants, which is 22.20 years (sd=0.51), and the majority were female (60.8%) and reported an acceptable level of academic performance (80.4%). table 2 shows that graduating nursing students had a high level (m = 6.97, sd=1.17) of perceived fundamental nursing skills. the graduating nursing students reported a very high level of perceived table 1 profile of the participants categories f % age [m = 22.20; sd = 0.51] sex male 40 39.2% female 62 60.8% academic performance very poor 0 0 low 6 5.9% acceptable 82 80.4% high 14 13.7% very good 0 0 total 102 100% jurnal ners http://e-journal.unair.ac.id/jners 19 fundamental nursing skills in asepsis (m= 8.57, sd=1.02) and lowest in elimination (m= 5.41, sd=1.93) with only a moderate level of competence. table 3 shows that the graduating nursing students had a high level of perceived nursing core competence (m= 8.03, sd=.14). among the 11 kar, the graduating student nurses reported being most competent in personal and professional development (m= 8.37, sd=1.05) and collaboration and teamwork (m= 8.24, sd=1.18) and although high, research (m= 7.63, sd=1.32) ranked lowest among the 11 domains of core nursing competencies. table 4 shows that, when the participants were classified according to sex, there was no significant difference in their perceived fundamental nursing skills competence (t=-.034, p=.973) and their perceived core competencies (t=-.636, p=.526). based on self-reported academic performance, there was a significant difference in their perceived fundamental nursing skills competence (f=4.225, p=.017) and core competencies (f=3.681, p=.029). table 5 shows that the majority reported that the online learning platform has a very high effect on their perceived fundamental skills (48%) and core competence (46.1%). discussions this study assessed the competence of graduating nursing students, with participants posting the highest competency in asepsis, activity and exercise, health assessment, and medications. similar to the result of this study, asepsis, activity and exercise, and medications were among the three essential clinical skills with the highest level of competence identified by new graduate nurses in the philippines in the prepandemic study of ubas-sumagaysay and oducado (2020). with the advent of the pandemic, the importance of hand hygiene and aseptic techniques are continuously reinforced in all settings as protective and preventive measures. given the numerous interventions and campaigns promoting this action, high compliance levels are expected. this finding may also be attributed to the recent clinical exposure in perioperative nursing for completing their scrubs requirements, which coincided during data gathering. nonetheless, these skills are frequently done even in the pre-pandemic setting. moreover, while this study found a high perceived level of competency in medication management, the two studies conducted by clearyholdfort and leufer (2020) in ireland found that medication management was among the areas of concern identified by senior nursing students. table 2 level of perceived fundamental nursing skills competencies fundamental skills min. max m sd interpretation asepsis 5.17 10.00 8.57 1.02 very high activity and exercise 2.27 10.00 7.86 1.43 high health assessment 4.58 9.58 7.84 0.98 high medications 2.69 9.46 7.24 1.38 high fluid, electrolyte, and acid-base balance 1.56 10.00 6.91 1.50 high safety 3.00 9.33 6.80 1.34 high hygiene 2.78 9.33 6.64 6.64 high pain management 1.50 10.00 6.64 1.75 high perioperative nursing 2.00 9.25 6.47 1,61 high oxygenation 1.38 9.50 6.45 1.69 high nutrition 1.20 9.60 6.36 1.82 moderate wound care 1.86 9.14 5.93 1.65 moderate diagnostic testing 2.17 8.50 5.91 1.54 moderate elimination 1.00 9.40 5.41 1.93 moderate composite score 3.26 9.26 6.97 1.17 high note: 1.00-2.79 (very low), 2.80-4.59 (low), 4.60-6.39 (moderate), 6.40-8.19 (high), and 8.20-10.00 (very high) table 3 level of perceived core competencies core skills min. max m sd interpretation personal and professional development 5.86 10.00 8.37 1.05 very high collaboration and teamwork 3.75 10.00 8.24 1.18 very high ethico-moral responsibility 2.57 10.00 8.17 1.43 high records management 2.36 10.00 8.16 1.33 high communication 5.00 10.00 8.14 1.17 high legal responsibility 5.13 10.00 8.12 1.18 high quality improvement 3.55 10.00 8.05 1.20 high health education 3.42 10.00 7.97 1.25 high safe and quality nursing care 3.33 10.00 7.93 1.16 high management of resources and environment 2.36 10.00 7.88 1.25 high research 3.55 10.00 7.63 1.32 high composite score 4.51 10.00 8.03 1.14 high note: 1.00-2.79 (very low), 2.80-4.59 (low), 4.60-6.39 (moderate), 6.40-8.19 (high), and 8.20-10.00 (very high) molanida, neyra, norada, olarte, palma, and oducado 20 p-issn: 1858-3598  e-issn: 2502-5791 by contrast, complex wound care, diagnostic testing, and elimination areas revealed lower means of competence. ubas-sumagaysay and oducado (2020) explained that these skill sets highlight the areas uncommonly practiced by nursing students in a resource-limited setting like the philippines. for instance, ecg recording and interpreting, administering cleansing enemas, changing a stoma appliance, and blood withdrawal may not be part of some nursing schools' routine return demonstration practice (ubassumagaysay & oducado, 2020). in addition, opportunities to perform these skills are rare, especially in a resource-limited setting like the philippines, where most concerns are rooted in the lack of financial resources, equipment, and technological advances (dela cruz & ortega-dela cruz, 2019). given the pandemic with which face-to-face classes were halted, opportunities and chances for the graduating nursing students to have much exposure in the clinical area were also affected, putting the focus more on prioritizing the requirements for graduation. kirwa and gakere (2016) noted that nursing students value the repetitive practice of nursing skills as the continuous hands-on practice of skills demonstrates boosted performance and competence. inadequacy in clinical skills development may also be significantly attributed to the pandemic, where face-to-face classes and clinical exposure were suspended. despite the shift to online learning to address the educational barrier (oducado, 2021), the lack of actual exposure, resources, and supervision may have hampered the practice and enhancement of the nursing students' skills in the complex areas of diagnostic testing and elimination. activities like ostomy care and venipuncture rely heavily on a resource-based learning approach, and virtual experience may not be sufficient to develop these skills. ramos-morcillo et al. (2020) disclosed that nursing students from two spanish public universities perceived clinical training as indispensable and could not be substituted. oducado and estoque (2021) further elaborated that not all areas of nursing education can be performed digitally, such as those entailing more practical aspects. moreover, finalyear nursing students in india were also reported to be least competent in elimination among the nursing skills domains (upashe et al., 2022). it was noted in the same study that only a portion of the nursing students were able to independently perform nursing skills like venipuncture and ostomy care, which was attributed to inadequate clinical experience. furthermore, clinical placements in delivery room and operating room were given priority for this particular sample in the study to comply with academic requirements needed for the nearing graduation and licensure examination, thus resulting in limited clinical experience in other areas. despite the barriers above, graduating nursing students showed favorable results regarding their perceived fundamental nursing skills. furthermore, this study's respondents displayed a high regard for personal and professional development. professional development begins with academic achievement and practice (pullen, 2021). professional practice experience and good role models are important for students' professional identity development (vabo et al. (2021). felstead and springett (2016) also noted that having nursing educators who can role model professional attributes appears crucial to developing professionalism in nursing students. moreover, graduating student nurses reported being highly competent in collaboration and teamwork. effective collaboration and teamwork among nursing students exist with the understanding that conflict is inevitable, and productive conflict resolution is encouraged with open communication (regis college, 2023). nursing students believe that good communication and collaborative decision-making are strengths that can table 4 differences in perceived competence independent variables fundamental skills core skills m sd test statistics p-value m sd test statistics p-value sex -.034 .973 -.636 .526 male 6.97 1.14 7.94 1.00 female 6.97 1.20 8.09 1.22 academic performance 4.225 .017 3.681 .029 high 7.37 0.95 8.59 0.89 acceptable 6.99 1.15 8.00 1.13 low 5.77 1.39 7.16 1.32 note: m (mean), sd (standard deviation) table 5 self-reported extent of effect of online learning platform on perceived competence categories fundamental skills core skills f % f % very high 49 48.0 47 46.1 high 20 19.6 20 19.6 moderate 19 18.6 18 17.6 low 12 11.8 13 12.7 very low 2 2.0 4 3.9 jurnal ners http://e-journal.unair.ac.id/jners 21 help prevent time delays and improve overall management (morphet, 2014). although high levels of competence were reported in resource and environmental management and research, these two areas ranked lowest among the 11 key areas of responsibility. studies show that nursing staff cannot do all the essential nursing tasks due to the scarcity of resources in patient care (primc, 2020). nurses from five teaching hospitals in iran similarly identified inadequate resources as one of the most noteworthy barriers in care environments leading to disrupted, missed, or delayed care nursing delivery (rivaz et al., 2017). moreover, according to the findings of bahadori et al. (2016), the most significant barrier to using research findings from the perspective of nursing students was the need for more time. studies on the factors that impede nurses' research participation included lack of time, knowledge, funding, and support services and poor attitude of nurses toward research (nkrumah et al., 2018). similarly, the results of earlier studies in the philippines conformed to the low selfreported competence in research (oducado & penuela, 2014; ubas-sumagaysay & oducado, 2020). this study showed that sex does not affect graduating nursing students' perceived fundamental nursing skills and core competence. the finding is similar to previous studies, such as a systematic review by chan et al. (2014), which said that male and female nursing students perform similarly in most aspects with minimal differences in some areas. this result is also consistent with prior research concluding that sex had not been shown to influence the skills and competence of nursing students (harrison, 2019; kajander-unkuri et al., 2014; park & choi, 2020; ubas-sumagaysay & oducado, 2020). not surprisingly, this study also demonstrated that the level of self-assessed academic performance affected the level of fundamental nursing skills and core competence. the finding suggests that those with high academic performance, compared to those with low academic performance, are more likely to have higher self-reported nursing skills and core competence. this finding is congruent with a study by kim and kim (2021) conducted in south korea, wherein graduating nursing students with high academic achievement in their classes were also found to have high clinical performance and competence. evidence from the philippines has also demonstrated a correlation between performance in the classroom and clinical setting (oducado et al., 2019). the self-efficacy theory of albert bandura (1977) hypothesized that the level at which individuals perform is directly related to how well they perceive their capabilities. however, it should be noted that this study's academic performance was measured according to selfassessment. kajander-unkuri et al. (2016) disclosed that the self-assessment of graduating nursing students of their competence tends to be incongruent with the assessment of their mentors. specifically, graduating nursing students rate their competence higher than their mentors could observe (kajander-unkuri et al., 2016). another point to consider is that this study was conducted during the covid-19 pandemic when the participants could not have face-to-face classes, skills laboratory practices, and clinical exposure. students may need more learning experiences to solidify their competence. students' relatively high competence evaluation could be attributed to the dunning-kruger effect. according to dunning (2011), those who do not have sufficient knowledge are subject to ignorance. this ignorance may lead to them to being unaware of any mistakes they might commit, leading to an inflated perception of their capabilities. the participants of this study have only been given very little time to practice their skills in the actual care setting. likely, they may need more encounters to test the extent of their nursing skills in real-life clinical environments. given that role transition remains difficult for new graduate nurses and continues to be an unresolved issue for decade (oducado & ubas-sumagaysay, 2019), it may be necessary to provide students who graduated at the time of the pandemic with adequate support, constant feedback, and mentoring in their transition into the nursing workforce. finally, this study showed that the majority of graduating nursing students acknowledged that the online learning environment had a significant impact on their fundamental nursing skills and core competence. however, the current study failed to explore further whether this effect is negative or positive. nonetheless, a systematic review of online learning during the covid19 pandemic found that, on average, students in the health sciences expressed more negative than positive perceptions (abdull mutalib et al., 2022). findings are congruent with numerous studies conducted in the philippines (oducado & soriano, 2021), jordan (maqableh & alia, 2021), and indonesia (pramana et al., 2022; simanullang et al., 2021) that tackle the experiences of students in the virtual setup. most medical students in jeddah and india said online learning affected their clinical skills (ibrahim et al., 2021; khan et al. (2021). oducado and estoque (2021) also molanida, neyra, norada, olarte, palma, and oducado 22 p-issn: 1858-3598  e-issn: 2502-5791 noted that most undergraduate nursing students in the philippines were unsatisfied with the online learning platform, and the pandemic has significantly affected their academic performance. likewise, li et al. (2021) found a low satisfaction rate among international medical and nursing students as influenced by numerous factors, including but not limited to the absence of practical classes. this study has limitations as it only involved graduating nursing students enrolled in one public university in the philippines in the second semester of the school year 2021-2022. thus, the results of this study will only be generalizable among study participants and not to all nursing students in the philippines and other countries. this study focused on the perceived 13 fundamental nursing skills competence and 11 core competencies and whether it is influenced by sex and academic performance. this study did not cover other factors and circumstances that could affect nursing students' competence. as this is a crosssectional study, it cannot establish causal linkages between variables and cannot follow changes over time. also, given the use of online survey questionnaires, another drawback of this study is the biases and limitations related to self-report data. self-reports are subject to the constraints associated with honesty, social desirability, and introspective ability. lastly, the instrument used in this study appears to have a very high cronbach’s alpha, which may be attributed to the relatively lengthy scale. a more robust test of the psychometric properties of the instrument and a shorter version scale is recommended. conclusions the virtual or remote teaching and learning mode has significantly affected nursing students' skills and competence. however, despite limited exposure in the clinical field brought about by the pandemic, the graduating nursing students perceive themselves to be proficient in performing basic nursing skills and in their capabilities in what they are expected to perform in professional nursing practice. nonetheless, areas for improvement warrant further assessment, validation, and enhancement. assessing graduating nursing students' competence is critical for determining their ability and readiness to provide quality healthcare services. despite viewing themselves as proficient, it is still suggested that academic and healthcare institutions give due attention to the clinical practice of graduating nursing students to address areas of concern regarding skills and competence development. new nurses who had limited hands-on clinical experience and graduated during the pandemic may need more appropriate guidance and supervision during their transition to professional practice to supplement the limited handson clinical exposure and facilitate a smooth role transition experience. references abdull mutalib, a. a., md. akim, a., & jaafar, m. h. (2022). a systematic review of health sciences students’ online learning during the covid-19 pandemic. bmc medical education, 22(1), 524. https://doi.org/10.1186/s12909-022-03579-1 agu, c. f., stewart, j., mcfarlane-stewart, n., & rae, t. (2021). covid19 pandemic effects on nursing education: looking through the lens of a developing country. international nursing review, 68(2), 153–158. https://doi.org/10.1111/inr.12663 bahadori, m., raadabadi, m., ravangard, r., & mahaki, b. (2016). the barriers to the application of the research findings from the nurses' perspective: a case study in a teaching hospital. journal of education and health promotion, 5(14). https://doi.org/10.4103/2277-9531.184553 bandura, a. (1977). self-efficacy: toward a unifying theory of behavioral change. psychological review, 84(2), 191–215. https://doi.org/10.1037//0033-295x.84.2.191 chan, z. c. y., chan, y., lui, c., yu, h., law, y., cheung, k., hung, k., kei, s., yu, k., woo, w., & lam, c. (2014). gender differences in the academic and clinical performances of undergraduate nursing students: a systematic review. nurse education today, 34(3), 377–388. https://doi.org/10.1016/j.nedt.2013.06.011 cochran, w. g. (1977). sampling techniques (3rd ed.). new york: john wiley & sons. cleary-holdforth, j., & leufer, t. (2020). senior nursing students' perceptions of their readiness for oral medication administration prior to final year internship: a quantitative descriptive pilot study. dimensions of critical care nursing, 39(1), 23-32. https://doi.org/10.1097/dcc.0000000000000401 cowen, k. j., hubbard, l. j., & hancock, d. c. (2018). expectations and experiences of nursing students in clinical courses: a descriptive study. nurse education today, 67, 15–20. https://doi.org/10.1016/j.nedt.2018.04.024 dela cruz, r. z., & ortega-dela cruz, r. a. (2019). management of public healthcare facilities in the philippines: issues and concerns. british journal of healthcare management, 25(10), 1–17. https://doi.org/10.12968/bjhc.2019.0018 dunning, d. (2011). the dunning–kruger effect. in advances in experimental social psychology (vol. 44, pp. 247–296). elsevier. https://doi.org/10.1016/b978-0-12-385522-0.00005-6 felstead, i. s., & springett, k. (2016). an exploration of role model influence on adult nursing students' professional development: a phenomenological research study. nurse education today, 37, 6670. https://doi.org/10.1016/j.nedt.2015.11.014 fukada, m. (2018) ‘nursing competency: definition, structure and development’, yonago acta medica, 61(1), pp. 1–7. doi: 10.33160/yam.2018.03.001. gregersen, a. g., hansen, m. t., brynhildsen, s. e. a., grøndahl, v. a., & leonardsen, a. c. (2021). students' perspectives on learning practical nursing skills: a focus group study in norway. nursing research and practice, 8870394. https://doi.org/10.1155/2021/8870394 harrison, j. (2019). student nurses’ gender role is a predictor of caring behaviours and critical thinking. evidence-based nursing, 22(3), 89–89. https://doi.org/10.1136/ebnurs-2018-103029 ibrahim, n. k., al raddadi, r., aldarmasi, m., al ghamdi, a., gaddoury, m., albar, h. m., & ramadan, i. k. (2021). medical students’ acceptance and perceptions of e-learning during the covid-19 closure time in king abdulaziz university, jeddah. journal of infection and public health, 14(1), 17–23. https://doi.org/10.1016/j.jiph.2020.11.007 jamshidi, n., molazem, z., sharif, f., torabizadeh, c., & najafi kalyani, m. (2016). the challenges of nursing students in the clinical learning environment: a qualitative study. https://doi.org/10.1111/inr.12663 https://doi.org/10.1016/j.nedt.2013.06.011 https://doi.org/10.1016/b978-0-12-385522-0.00005-6 https://doi.org/10.1016/j.nedt.2015.11.014 jurnal ners http://e-journal.unair.ac.id/jners 23 thescientificworldjournal, 2016, 1846178. https://doi.org/10.1155/2016/1846178 kajander-unkuri, s., leino-kilpi, h., katajisto, j., meretoja, r., räisänen, a., saarikoski, m., salminen, l., & suhonen, r. (2016). congruence between graduating nursing students’ selfassessments and mentors’ assessments of students’ nurse competence. collegian, 23(3), 303–312. https://doi.org/10.1016/j.colegn.2015.06.002 kajander-unkuri, s., meretoja, r., katajisto, j., saarikoski, m., salminen, l., suhonen, r., & leino-kilpi, h. (2014). self-assessed level of competence of graduating nursing students and factors related to it. nurse education today, 34(5), 795–801. https://doi.org/10.1016/j.nedt.2013.08.009 kavanagh, j. m., & szweda, c. (2017). a crisis in competency: the strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. nursing education perspectives, 38(2), 57-62. https://doi.org/10.1097/01.nep.0000000000000112 khan, a. m., patra, s., vaney, n., mehndiratta, m., & chauhan, r. (2021). rapid transition to online practical classes in preclinical subjects during covid-19: experience from a medical college in north india. medical journal armed forces india, 77, s161–s167. https://doi.org/10.1016/j.mjafi.2020.12.030 kim, h.-w., & kim, m.-g. (2021). the relationship among academic achievement, clinical competence, and confidence in clinical performance of nursing students. the journal of korean academic society of nursing education, 27(1), 49–58. https://doi.org/10.5977/jkasne.2021.27.1.49 kirwa, l., & gakere, z. (2016). clinical skills competence of nursing students. https://core.ac.uk/download/pdf/38139172.pdf leonardsen, a.-c. l., brynhildsen, s. e., hansen, m. t., & grøndahl, v. a. (2021). nursing supervisors’ perspectives on student preparedness before clinical placementsa focus group study. plos one, 16(5), e0252483. https://doi.org/10.1371/journal.pone.0252483 li, c., he, j., yuan, c., chen, b., & sun, z. (2019). the effects of blended learning on knowledge, skills, and satisfaction in nursing students: a meta-analysis. nurse education today, 82, 51–57. https://doi.org/10.1016/j.nedt.2019.08.004 li, w., gillies, r., he, m., wu, c., liu, s., gong, z., & sun, h. (2021). barriers and facilitators to online medical and nursing education during the covid-19 pandemic: perspectives from international students from lowand middle-income countries and their teaching staff. human resources for health, 19(1), 64. https://doi.org/10.1186/s12960-021-00609-9 lynch, m. a., & pusey-murray, a. (2021). the effects of covid-19 in the healthcare system. public health research, 11(1), 15–18. maqableh, m., & alia, m. (2021). evaluation online learning of undergraduate students under lockdown amidst covid-19 pandemic: the online learning experience and students’ satisfaction. children and youth services review, 128, 106160. https://doi.org/10.1016/j.childyouth.2021.106160 missen, k., mckenna, l., & beauchamp, a. (2016). registered nurses’ perceptions of new nursing graduates’ clinical competence: a systematic integrative review. nursing & health sciences, 18(2), 143–153. https://doi.org/10.1111/nhs.12249 mohamadirizi, s., kohan, s., shafei, f., & mohamadirizi, s. (2015). the relationship between clinical competence and clinical selfefficacy among nursing and midwifery students. international journal of pediatrics, 3(6.2). https://doi.org/10.22038/ijp.2015.5222 morphet, j., hood, k., cant, r., baulch, j., gilbee, a., & sandry, k. (2014). teaching teamwork: an evaluation of an interprofessional training ward placement for health care students. advances in medical education and practice, 5, 197–204. https://doi.org/10.2147/amep.s61189 nabizadeh-gharghozar, z., alavi, n. m., & ajorpaz, n. m. (2021). clinical competence in nursing: a hybrid concept analysis. nurse education today, 97, 104728. https://doi.org/10.1016/j.nedt.2020.104728 nascimento, j. da s. g., siqueira, t. v., oliveira, j. l. g. de, alves, m. g., regino, d. da s. g., & dalri, m. c. b. (2021). development of clinical competence in nursing in simulation: the perspective of bloom’s taxonomy. revista brasileira de enfermagem, 74. https://doi.org/10.1590/0034-7167-2020-0135 nkenke, e., vairaktaris, e., bauersachs, a., eitner, s., budach, a., knipfer, c., & stelzle, f. (2012). acceptance of technologyenhanced learning for a theoretical radiological science course: a randomized controlled trial. bmc medical education, 12(1), 18. https://doi.org/10.1186/1472-6920-12-18 nkrumah, i., atuhaire, c., priebe, g., & cumber, s. n. (2018). barriers for nurses’ participation in and utilisation of clinical research in three hospitals within the kumasi metropolis, ghana. the pan african medical journal, 30, 24. https://doi.org/10.11604/pamj.2018.30.24.15230 oducado, r. m., & estoque, h. (2021). online learning in nursing education during the covid-19 pandemic: stress, satisfaction, and academic performance (ssrn scholarly paper no. 3814226). https://papers.ssrn.com/abstract=3814226 oducado, r. m., & penuela, a. (2014). predictors of academic performance in professional nursing courses in a private nursing school in kalibo, aklan, philippines. 1, 21–28 oducado, r. m. f. & soriano, g. (2021). shifting the education paradigm amid the covid 19 pandemic: nursing students' attitude to e-learning. africa journal of nursing and midwifery, 23(1). https://doi.org/10.25159/2520-5293/8090 oducado, r. m. f. & ubas-sumagaysay, n. a. (2019). new graduate nurses: transition difficulties, support needed and satisfaction with work environment [paper presentation]. 9th international conference of nurses (icons9), cebu city, philippines. https://doi.org/10.13140/rg.2.2.13683.89125 orkaizagirre-gómara, a., sánchez de miguel, m., ortiz de elguea, j., & ortiz de elguea, a. (2020). testing general self-efficacy, perceived competence, resilience, and stress among nursing students: an integrator evaluation. nursing & health sciences, 22(3), 529–538. https://doi.org/10.1111/nhs.12689 padilha, j. m., machado, p. p., ribeiro, a., ramos, j., & costa, p. (2019). clinical virtual simulation in nursing education: randomized controlled trial. journal of medical internet research, 21(3), e11529. https://doi.org/10.2196/11529 park, e., & choi, j. (2020). attributes associated with person-centered care competence among undergraduate nursing students. research in nursing & health, 43(5), 511–519. https://doi.org/10.1002/nur.22062 park, h.-s., & han, j.-y. (2013). factors influencing clinical competence in nursing students. journal of korean academy of fundamentals of nursing, 20(4), 438–448. https://doi.org/10.7739/jkafn.2013.20.4.438 powers, k., montegrico, j., pate, k., & pagel, j. (2021). nurse faculty perceptions of readiness for practice among new nurses graduating during the pandemic. journal of professional nursing, 37(6), 1132–1139. https://doi.org/10.1016/j.profnurs.2021.09.003 pramana, c., handayani, o. w. k., raharjo, t. j., & rahayu, s. r. (2022). nursing students’ perceptions and acceptance of online learning during the covid-19 pandemic in indonesia. open access macedonian journal of medical sciences, 10(g), 183–188. https://doi.org/10.3889/oamjms.2022.8329 primc, n. (2020). dealing with scarcity of resources in nursing. the scope and limits of individual responsibility. european journal for nursing history and ethics, 2(1). https://doi.org/10.25974/enhe2020-8en pullen, r. l. j. (2016). leadership in nursing practice. nursing made incredibly easy, 14(3), 26–31. https://doi.org/10.1097/01.nme.0000481442.05288.05 ramos-morcillo, a. j., leal-costa, c., moral-garcía, j. e., & ruzafamartínez, m. (2020). experiences of nursing students during the abrupt change from face-to-face to e-learning education during the first month of confinement due to covid-19 in spain. international journal of environmental research and public health, 17(15), 5519. https://doi.org/10.3390/ijerph17155519 regis college. (2023). the importance of teamwork and collaboration in nursing. https://online.regiscollege.edu/online-mastersdegrees/online-master-science-nursing/resources/theimportance-of-teamwork-and-collaboration-in-nursing/ rivaz, m., momennasab, m., yektatalab, s., & ebadi, a. (2017). adequate resources as essential component in the nursing practice environment: a qualitative study. journal of clinical and diagnostic research, 11(6), ic01. https://doi.org/10.1016/j.nedt.2013.08.009 https://doi.org/10.5977/jkasne.2021.27.1.49 https://doi.org/10.1097/01.nme.0000481442.05288.05 molanida, neyra, norada, olarte, palma, and oducado 24 p-issn: 1858-3598  e-issn: 2502-5791 https://doi.org/10.7860/jcdr/2017/25349.9986 simanullang, r. h., wahyu, a., & mendrofa, h. k. (2021). the satisfaction of health students to online learning methods during the covid-19 pandemic. jurnal aisyah : jurnal ilmu kesehatan, 6(2), article 2. https://doi.org/10.30604/jika.v6i2.507 staykova, m. p., stewart, d. v., & staykov, d. i. (2017). back to the basics and beyond: comparing traditional and innovative strategies for teaching in nursing skills laboratories. teaching and learning in nursing, 12(2), 152–157. https://doi.org/10.1016/j.teln.2016.12.001 terry, d., & peck, b. (2020). academic and clinical performance among nursing students: what’s grit go to do with it? nurse education today, 88, 104371. https://doi.org/10.1016/j.nedt.2020.104371 ubas-sumagasyay, n. a., & oducado, r. m. f. (2020). perceived competence and transition experience of new graduate filipino nurses. jurnal keperawatan indonesia. https://doi.org/10.7454/jki.v0i0.1071 upashe, s. p., shil, r., & shetty, s. (2023). self-reported clinical practice skill readiness of final year nursing students studying in bengaluru, karnataka: an institutional-based cross-sectional study. journal of health and allied sciences nu, 13(01), 114-125. https://doi.org/10.1055/s-0042-1744554 vabo, g., slettebø, å., & fossum, m. (2022). nursing students' professional identity development: an integrative review. nordic journal of nursing research, 42(2), 62-75. https://doi.org/10.1177/20571585211029857 weeks, k. w., coben, d., o’neill, d., jones, a., weeks, a., brown, m., & pontin, d. (2019). developing and integrating nursing competence through authentic technology-enhanced clinical simulation education: pedagogies for reconceptualising the theory-practice gap. nurse education in practice, 37, 29–38. https://doi.org/10.1016/j.nepr.2019.04.010 xie, q. (2019, march 19). evaluation of the practical teaching method reform of fundamental nursing in nursing education. 2019 5th international workshop on education, development and social sciences. https://webofproceedings.org/proceedings_series/article/artid/ 6700.html. how to cite this article: molanida, j. e., neyra, t. j. a., norada, p. m., olarte p. m., palma, d. d., and oducado, r. m. f. (2023) ‘ perceived competence of filipino nursing students graduating during pandemic’, jurnal ners, 18(1), pp. 16-24. doi: http://dx.doi.org/10.20473/jn.v18i1.41395 https://doi.org/10.7860/jcdr/2017/25349.9986 https://doi.org/10.7454/jki.v0i0.1071 189 the effect of education on parents’ “speak up” knowledge regarding patients safety in hospital septy nur aini*, sri mulatsih**, patricia suti lasmani*** *magister of nursing, faculty of medicine, universitas gadjah mada **pediatric department rsup dr. sardjito yogyakarta ***pediatric intensive care unit rsup dr. sardjito yogyakarta e-mail: ainis_sky@yahoo.com abstract introduction: safety is a global issue in hospitals. unexpected events or errors related to health services occur in children, and about 75% are associated with medical procedures. parental involvement becomes one of the strategies used to improve patient safety. families who know patient safety can educate themselves to prevent and detect errors that occur during treatment. education can improve the general knowledge about patient safety. the speak up program is recommended by jcaho to improve effective communication, and this program has a preventive impact on human error. this study aims to determine the effect of education on parent‟s „speaking up‟ knowledge regarding patient safety in the children's wards of dr. sardjito hospital in yogyakarta. methods: this research study was quasi-experimental using a one group pre-test and posttest design. the intervention in this research was education. the consecutive sampling technique was used with a total of 62 respondents selected. the speak up questionnaire and observation sheet to get to know the changes in the knowledge of speak up was used to collect the data. the data analysis used a paired sample t-test. result: the result of the paired t-test showed a p-value <0,001 (p <0,05) which means that there was a significant influence by way of education on parent‟s speak up knowledge regarding patient safety. conclusion: education improved the parents' speak up knowledge about patient safety. keywords: education, patient safety, speak up introduction patient safety strategies are designed to avoid, prevent and minimise unexpected events as a result of healthcare practices.the definition of patient safety is to reduce the risk of unnecessary actions to a minimum level in the provision of health services (who, 2009; runciman et al., 2009). safety is a global issue in hospitals. in developing countries, one in ten patients is estimated to be injured during hospitalisation. every 100 patients, approximately seven in developed countries and ten in developing countries, have infections related to health services (who, 2015). based on the reports of patient safety incidents in january to april 2010, the west java province ranks first for adverse events (33,33%), followed by banten and central java (20%), and then dki jakarta (16,67%), bali (6,67%), and east java (3,33%). adverse events are caused by issues with procedures, documentation, and medications (kkprs, 2010). errors associated with health services also occur in children. children are very vulnerable to medical errors as they are totally dependent on the communication and the other behaviours of adults in preventing the occurrence of errors (cox et al., 2012). in addition to vulnerability, as children are in a stage of growth and development, they require special attention when it comes to their safety (schatkoski et al., 2009). parental involvement in improving patient safety is one of the strategies that need to be undertaken to support the quality and safe environments in health care organisations (schatkoski et al., 2009; american academy of pediatrics, 2012). this level of parental involvement has a positive impact on the quality of the health services, patient and family satisfaction and cost-effectiveness (american academy of pediatrics, 2012). according to ottosen (2015), parents want to be involved as a partner in improving their child‟s safety in the hospital. related to these strategies, the joint commission accreditation of health organization (jcaho) recommended speak up as a method that can be used to improve the channels of communication between the health workers with patients and families in achieving patient safety goals. jcaho launched the speak up tm patient safety program in 2002. the program has been used in more than 40 countries (the joint commission, 2015). in a survey conducted by the joint commission regarding the speak up tm patient safety program, it found that 83% of respondents stated that speak up encourages and educates patients and includes them as being partners in their care. 83% of respondents believed that speak up was easy to jurnal ners vol. 12 no. 2 oktober 2017: 189-195 190 use, and 83% of the respondents also believed that speak up carried value for the healthcare organizations. 69% of respondents would recommend the program to their colleagues, friends, family members or patients. the speak up tm patient safety program can be used not only by the patients themselves but also by their families (the joint commission, 2015). the involvement of patients and their families in improving patient safety is influenced by autonomy, awareness, and knowledge (buetow et al., 2013). longtin et al. (2010) suggested that patients and their families with safety knowledge can educate themselves in order to prevent human errors by the health workers while detecting errors occurring during care in the preparation, monitoring, and follow-up of an action. abdi et al. (2012) argued that education increases knowledge, attitudes, and behaviour about patient safety. in some studies,it was also reported that speak up behaviour increased after interventions (sayre et al., 2012; johnson and kimsey, 2012). hesitation in speak up is an important factor in communication errors. hence there needs to be training as an effective way of improving speak up behaviour (okuyama et al., 2014). materials and methods the research was a quasi-experiment with a one group pre-test and post-test design to determine the effect of education on parent‟s knowledge of speak up in relation to patient safety. the study was conducted in the children's wards of one of the public hospitals in yogyakarta from october 2016 until march 2017. the participants in this study were parents with children being treated in the children's wards. samples were taken using the consecutive sampling technique with a total of 62 respondents. the independent variable was education while the dependent variable was speak upknowledge about patient safety. the speak up knowledge questionnaire and the speak up observation sheet were used to collecting the data. data analysis using paired sample t-test with a significance value of α = 0,05 and ci = 95% was used. the study was approved according to the protection of human rights and welfare in the medical research division by the ethical committee of the faculty of medicine at the universitas gadjah mada, yogyakarta. the research flow of the study can be seen in figure 1. figure 1. the flow of the research the effect of education on parents‟ “speak up” knowledge (septy nur aini. et.al.) 191 results the demographic characteristics of the 62 participants included age, gender, education,occupation and their previous knowledge about speak up. most of the participants were aged 31-40 years old (43,5%). more than two thirds (77, 4%) of the participants were female, and almost half of them (41,9%) were high school graduates. more than half of the participants (59,7%) worked as a housewife. the majority of the participants (91,9%) had never heard of the speak up program. table 1 showed that the mean of the parents‟ speak up knowledge increased after the intervention with the highest mean being in relation to the prevention of infection by hand washing. the means of the parent‟s speak up knowledge increased except in the following areas of care advocacy (advisor/supporter), medicine explanation, insertion area infection, hospital accreditation and the health personnel who are in charge of the care. the differences in the parents‟ speak up knowledge about patient safety preand post-education are shown in table 2. the means of speak up knowledge about patient safety was decreased in 8 participants and increased in 44 participants. the paired t-test results showed significance at p<0,001. the p<0,05 and ci scores did not pass through zero which showed significant mean differences in the parents‟ speak up knowledge about patient safety preand post-education (see table 2). table 1. means of parent‟s speak up knowledge about patient safety in children‟s wards of dr. sardjito hospital yogyakarta (n=62) speak up about patient safety items knowledge pre education knowledge post education mean (std. dev.) mean (std. dev.) definition of speak up about patient safety item 1. definition of patient safety 0,9032 (0,29806) 0,9516 (0,21633) speak up if you have questions or concerns item 2. use translator 0,5323 (0,50303) 0,7258 (0,44975) pay attention to the care your children get item 3. infection prevention by washing hands 0,3226 (0,47128) 0,6774 (0,47128) item 4. how to do the patient identification 0,5806 (0,49748) 0,8710 (0,33747) item 5. the time to do patient identification 0,5968 (0,49455) 0,7258 (0,44975) educate yourself and children about the illness item 6. the source of information 1 (0) 1(0) item 7. information recording 0,4677 (0,50303) 0,7903 (0,41040) ask your trusted family member or friend to be advocate on your children care item 8. advocate task 0,8871 (0,31906) 0,7581 (0,43175) item 9. advocate personnel 0,4194 (0,49748) 0,7581 (0,43175) know what medicines your children take and why it is taken item 10. medicines explanation 0,9677 (0,17813) 0,9516 (21633) item 11. the insertion area infection report 1 (0) 0,9839 (0,127) use a health care organization that has been carefully checked out item 12. hospital selection 0,9677 (0,17813) 1 (0) item 13. hospital accreditation 0,6613 (0,47713) 0,6452 (48237) participate in all decisions about your children treatment item 14. family role 0,4355 (0,49987) 0,5161 (0,50382) item 15. health personnel in charge of the care 0,0645 (0,24768) 0,484 (0,21633) jurnal ners vol. 12 no. 2 oktober 2017: 189-195 192 discussion the study was conducted for six months from october 2016 to march 2017 in the children's wards of one public hospital in yogyakarta. the study was conducted in the yogyakarta hospital as it is an accredited hospital (joint commission international accreditation) where one of the accreditation assessments is related to patient safety. the patient‟s involvement through support for speak up is a way of reducing unexpected events and will increase the outcome of patient safety (saufi, 2003). the recognition and support towards speak up for health professionals as well as from the patients and their families is a form of transformation to improve the patient's safety culture in relation to health care (donnelly et al. 2010; blanco et al., 2009; spruce, 2014). research on communication in healthcare has been conducted because it significantly contributes towards the outcomes of unexpected events (pierce, 2016). the study showed that the means of the parent‟s speak up knowledge is higher on the definition of patient safety, drug explanations, reporting insertion area infection, and hospital selection items. there is an increase in knowledge after education on the patient‟s safety definition, the use of a translator, infection prevention, patient identification, information recording, care advocating, hospital selection and the health care personnel in charge. the parents‟ speak up knowledge had the highest increasing means after education on infection prevention by hand washing. in the provision of new patient information, one of the information materials is an explanation of how to handwash correctly. the family are taught the purpose and the technique of hand washing. the new patient information was given for a limited time and included a considerable amount of material. during the parents‟ speak up education about patient safety, the parents were educated on the importance of handwashing and to remind the healthcare personnel to wash their hands as a way to prevent infections in their children. the education is conducted as a way to provide information and to examine the influence on the parent‟s speak up knowledge about patient safety. the study showed that education has a significant influence on improving the parent‟s speak up knowledge about patient safety. the result of this study is supported by the research conducted by o'connor et al. (2013) on interns about the effect of speak up training. in that study, the knowledge increased significantly, and there was a change in the attitude of the interns. however, the training did not affect the behaviour of the trainee to speak up about patient safety. sayre et al. (2012) stated that the educational intervention improved the behaviour of „speaking up‟in the nurses and increased their score of speaking up. lawrence et al. (2011) showed that the parent‟s knowledge increased after being given education using a booklet as the information source. the advantage of using a booklet as the information source was the influence on learning memories as this method can be read over repeatedly (arsyad, 2010). barzallo et al. (2014) did a study on the surgeon‟s speak up training.the motivation to speak up about patient safety was performed by 82% of surgeons in a speak up support group where 30% in the group were not provided support to speak up. the increasing use of speak up knowledge cannot be separated from the support of the healthcare personnel. many factors influence speak up. for patients and families, speak up is influenced by the ability to recognise changes in clinical conditions, confidence, trustworthiness, culture and the health care systems (rainey et al., 2013). there is two main factors affecting speak up; personal and health care organisation (lyndon et al., 2015). according table 2. paired t-test results on parent‟s speak up knowledge about patient safety pre and post education (n=62) mean deviation ci95% p value speak up knowledge pre intervention(n=62) 9,81 (1,62) 1,6 (2,0) 1,09 – 2,11 <0,001 speak up knowledge post intervention (n=62) 11,40 (1,82) the effect of education on parents‟ “speak up” knowledge (septy nur aini. et.al.) 193 to rainer (2015), okuyama et al. (2014), and garon (2012), personal factors that can affect speak up include communication skills and educational background. the current study showed that the parent‟s educational background is dominated by a high school education level. approximately 70% of parent‟s education of high school or below. these results need to be followed by further research to know better about the influence of educational background towards speak up knowledge. the results of the preand posteducational observations indicate that education cannot be attributed to speak up actions in isolation. law and chan (2015) suggested that learning to speak up requires more than one occurrence of training. mentoring in the education process is needed to create a safer environment (law and chan, 2015). hrisos and thomson (2013) stated that sometimes patients and families are afraid to speak up because it may be considered rude and shows no respect towards the healthcare personnel. patients and their families found that they could comfortably speak up with healthcare personnel who were better known than other professionals whom they had just met. obstacles to speak up can include the presence of others, knowledge, limited time and fear of speak (schwappach & gehring, 2014). the parents found that advice directed to the healthcare personnel can be a problem because it is considered as being a form of distrust between the patients and healthcare personnel where the patients or families do not want it to happen (peat et al., 2010). goelts and hatlie (2002), cited in peat et al. (2010) suggested that asking whether the health care personnel were washing their hands or not was a form of speak up that should be conducted by the patients and their families. however, they chose not to ask the question. the parents tended to choose silence and did not ask, implying lack of trust to cause them to avoid mentioning any problems with health care personnel (peat et al., 2010). nacioglu (2016) and garon (2012) stated that one of the factors that affect speak up is cultural background. qingzue (2003) and claramita et al. (2013) reported that communication was strongly related to cultural characteristics. indonesia, as an eastern country, has a different style of communication from western countries. communication for asian people is more often indirect and implicit, in contrast to western culture which is known for being assertive, with aggressive communication behaviours (claramita et al., 2013). conclusions educational interventions influenced the parents‟ speak up knowledge to do with patient safety. there is an increase in knowledge after education on patient safety has been provided. parents need to be educated continuously on speak up about patient safety. further research is required regarding the implementation of patient safety by nurses, the factors influencing the implementation of the parents‟ speak up about patient safety and the effect of education on speaking up using a control group. references abdi, z., delgoshaei, b., ravaghi, h., heyrani, a. (2012). changing medical student‟s knowledge, skills, and attitudes about patient safety. healthmed, volume 6, number 9 american academy of pediatrics.(2011). policy statement: patient and familycentred care and pediatrician’s role. retrieved january 17, 2016, from http://www.pediatrics.org/cgi/doi/10.1 542/peds.2011-3084 arsyad, azhari. (2010). media pembelajaran. jakarta: pt raja grafindopersada barzallo s.m.j., minkoff h., bayya j., gillett b., onoriode h., weedon j., altshuler l., fisher n. (2014). influence of surgeon behavior on trainee willingness to speak up: a randomized control trial. journal of the american college of surgeons. nov, 219(5):1001-7. doi: 10.1016/j.jamcoolsurg.2014.07.933 blanco, m., clarke jr., martindeli d. (2009). wrong site surgery near misses and actual occurrences. association of peri-operative registered nurses journal. ;90(2):215-8,221-2. doi: 10.1016/j.aorn.2009.07.010 buetow, s., davis r., callaghan k., dovey s.(2013). what attributes of patient affect their involvement in safety? a http://www.pediatrics.org/cgi/doi/10.1542/peds.2011-3084 http://www.pediatrics.org/cgi/doi/10.1542/peds.2011-3084 jurnal ners vol. 12 no. 2 oktober 2017: 189-195 194 key opinion leaders perspective. british medical journal open;3:e003104. doi: 10.1136/bmjopen-2013-003104 claramita, m., mubarika d.f., nugraheni, van dalen, j., van der vleuten, c.(2013). doctor-patient communication in southeast asia: a different culture? advance in health sciences education; 18:15-31. doi:10.1007/s10459-012-9352-5 cox, e.d., carayon, p., hansen, k.w., rajamanickam, v.p., brown, r.l., rathouz, p.j., et al. (2012). parent perception of children‟s hospital safety climate. british medical journal quality and safety; 22(8):664671. doi: 10.1136/bmjqs-2012-001727 donelly, fl., dickerson mj, goodfriend am., muething es. (2010). improving patient safety in radiology: concepts for a comprehensive patient safety program. american journal of roentgenology;194(5):1183-7. doi: 10.2214/ajr.09.3875 garon m.(2012). speaking up, being heard: registered nurses perceptions of workplace communication. journal of nursing management; 20(3):36171.doi: 10.1111/j.13652834.2011.01296.x. hrisos, s., thomson, r. (2013). seeing it from both sides: do approaches to involving patients in improving their safety risk damaging the trust between patient and healthcare professionals? an interview study. plos one 8(11): e80759. doi:10.1371/journal.pone.0080759 johnson, hl., kimsey, d. (2012). patient safety: break the silence. association of peri-operative registered nurses journal, 95(5):591–601. doi: 10.1016/j.aorn.2012.03.002 kkprs. (2010). laporan insiden keselamatan pasien. retrieved january 10, 2015, from www.inapatsafetypersi.or.id/umpan_balik/laporan_ikp2. pdf law, y.b., chan, a.e. (2015). the experience of learning to speak up: a narrative inquiry on newly graduated registered nurses. journal of clinical nursing;24(13-14): 1837-48. doi: 10.1111/jocn.12805 lawrence, ks., stilley cs, pollock ja, webber sa, quivers es. (2011). a family-centred educational program to promote independence in pediatric heart transplant recipients. progress in transplantation; 21(1):61-6 longtin, y., sax, h., leape, l.l., sheridan, s.e., donaldson, l., pittet, d. (2010). patient participation: current knowledge and applicability to patient safety. mayo clinicproceedings;85(1):53-62. doi: 10.4065/mcp.2009.0248 lyndon, a., johnson mc., bingham d., napolitani pg., joseph g., maxfield dg., o‟keeffle df. (2015). transforming communication and safety culture in intrapartum care: a multi-organization blueprint. journal of obstetric,gynecologic& neonatal nursing; 44(3):341-9. doi: 10.1111/1552-6909.12575 nacioglu, ahmet. (2016). as a critical behavior to improve quality and patient safety in health care: speaking up!. safety in health (2016) 2:10. doi: 10.1186/s40886-016-0021-x o‟connor, p., byrne d, o‟dea a., mcveigh tp., kerin mj. (2013). “excuse me” teaching intern to speak up. the joint commissionjournal onquality and patient safety; 39(9): 426-31. doi: 10.1016/s1553-7250(13)39056-4 okuyama, a., wagner, c., bijnen, b. (2014). speaking up for patient safety by hospital-based health care professionals: a literature review. biomedcentral health service research, 14:61. doi: 10.1186/14726963-14-61 ottosen, m.j. (2015). parent perceptions of patient safety culture in the neonatal intensive care unit. ut son dissertation. texas medical center library peat, m., entwistle, v., hall, j., birks, y., golder, s. (2010). scoping review and approach to appraisal of interventions intended to involve patients in patient safety. journal of health services research & policy, vol 15 suppl 1. doi: 10.1258/jhsrp.2009.009040 the effect of education on parents‟ “speak up” knowledge (septy nur aini. et.al.) 195 pierce, br. (2016). speaking up: it requires leadership maturity. nurse leader; 14(6):413-418. doi: 10.1016/j.mnl.2016.08.005 rainer, j. (2015). speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy. journal of nursing care quality; 30(1):53-62. doi: 10.1097/ncq.0000000000000081 rainey, h., k. enrich, n. mackintosh, j. sandall. (2013). the role of patient and their relatives in „speaking up‟ about their own safety – a qualitative study of acute illness. health expectation, 18, pp.392-405. doi:10.1111/hex.12044 runciman, w., hibbert, p., thomson, r., van der scaaf, t., sherman, h., lewalle, p. (2009). towards an international classification for patient safety: key concepts and terms. international journal for quality in health care;21(1):18-26. doi: 1.1093/infqhc/mzn057 saufi, n.m. (2003). patient encouraged to “speak up”. retrieved april 4, 2016, from http://ac.elscdn.com.eproxy1.lib.hku.hk/s1089947 203000054/1-s2.0s108947203000054main.pdf?_tid=339caeb8-a6e5-11e5b6c000000aab0f27&acdnat=1450594085_ daf5fe7b7d3660645b216bf2d8000b sayre, m.m., mcneese-smith, d., leach, ls., phillips, lr. (2012). an educational intervention to increase "speakingup" behaviors in nurses and improve patient safety. journal of nursing care quality, 27(2):154–60.doi: 10.1097/ncq.0b013e318241d9ff. schatkoski, a.m., wegner, w., algeri, s., pedro, e.n.r. (2009). safety and protection for hospitalized children: literature review. revista latinoamericana deenfermagem; 17(3):4106. doi: 10.1590/s010411692009000300020 schwappach, dl., gehring k. (2014). tradeoffs, between voice and silence: a qualitative exploration of oncology staff‟s decision to speak up about safety concern. biomed central of health service research. 14;14:303. doi: 10.1186/1472-6963-14-303 spruce, l. (2014). back to basics: preventing surgical site infections. association of peri-operative registered nurses journal; 99(5):600-8. doi: 10.1016/j.aorn.2014.02.002 the joint commission. (2015). facts about speak up. retrieved november 15, 2015, from http://www.jointcommission.org/facts _about_speak_up/ who. (2009). a world alliance for safer health care. more than words: conceptual framework for the international classification for patient safety. version 1.1. final technical report. geneva: who _____.(2015). patient safety. retrieved april 23, 2015, from http://www.who.int/patientsafety/en/ http://dx.doi.org/10.1016/j.mnl.2016.08.005 http://dx.doi.org/10.1016/j.mnl.2016.08.005 http://www.jointcommission.org/facts_about_speak_up/ http://www.jointcommission.org/facts_about_speak_up/ http://www.who.int/patientsafety/en/ bab 1 jurnal ners vol. 2 no. 1 mei – september 2007 hubungan pola asuh orang tua dan lingkungan sosial dengan perilaku seksual remaja usia 14–21 tahun di lingkungan lokalisasi ah. yusuf*, khoridatul b.*, hanik endang*, agung tri wiyono s. abstract the objective of this study was to examine the correlation between parenting and social environtment with sexual behavior for adolescence (14–21 years) who lived in putat jaya prostitution area surabaya. design used in this study was cross sectional design. the population were all adolescence who lived around in putat jaya prostitution area surabaya. total sample were 104 respondents, taken according to inclusion criteria. the independen variables were parenting and social environtment and the dependent variable was sexual behavior in adolescence (14–21 years). data were collected by using structured questionaires with multiple choice and several open questions. data were then analyzed by using spearman’s rho correlation with level of significance p=0.05 and content analyse. result showed that parenting had a strong correlation with sexual behavior in adolescence (p=0.000 and ρ=0.691) and the social environtment had a strong correlation with sexual behavior in adolescence (p=0.000 and ρ= –0.773). conclution: parenting and social environtment has correlation with sexual behavior in adolescence and the most factors that have strong relationship in those correlations is living in prostitution area nearby. it is recommended for nurse, parent and publics to modified the social environtment to be more condusiveness. keywords: adolescences sexual behavior, parenting, social environtment, prostitution area pendahuluan penyimpangan perilaku seksual pada remaja seringkali mencemaskan orang tua, pendidik dan masyarakat luas. periode remaja merupakan masa yang sangat labil, terutama pada rentang usia antara 14–21 tahun sesuai dengan batasan dari who (sarwono, 2004). pada masa tersebut keadaan fisik, psikologis dan seksualitas seorang remaja mengalami pertumbuhan dan perkembangan yang pesat, sehingga perilaku seksual pada usia remaja tersebut cenderung mengalami banyak permasalahan (soetjiningsih, 2004). perilaku seksual seperti pacaran pada remaja saat ini, telah mengalami pergeseran nilai dan norma, karena disertai aktivitas seksual lain yang dapat menyeret remaja melakukan hubungan seksual sebelum menikah (sarwono, 2004). _______________ *staf pengajar psik fk unair sejalan dengan meningkatnya minat terhadap kehidupan seksual, remaja selalu berusaha untuk mencari informasi obyektif mengenai seksualitas. keluarga sebagai tempat interaksi pertama seorang anak seharusnya dapat memberikan informasi seputar seksualitas pada remaja, sebab hal paling membahayakan adalah bila informasi didapatkan remaja berasal dari sumber yang kurang tepat (papalia, 2001). menjadi permasalahan tersendiri bagi keluarga yang tinggal di kawasan lokalisasi dalam melakukan pengasuhan terhadap anakanaknya. adanya konflik antara nilai yang diajarkan oleh orang tua dengan kenyataan yang dilihat langsung oleh anak dalam kehidupan sehari-hari sering bertolak belakang. tidak jarang pendidikan seks tersebut didapatkan oleh remaja langsung dari kegiatankegiatan di lokalisasi. sehingga perilaku remaja cenderung mencontoh perilaku jurnal ners vol. 2 no. 1 mei – september 2007 menyimpang dari penghuni wisma dan tamu lokalisasi, seperti merokok, minuman keras, serta seks bebas (sufiyanto, 2004). data awal yang diperoleh dari hasil wawancara dengan 16 orang remaja usia 14–21 tahun di dua tempat lokalisasi kelurahan putat jaya, yaitu dolly dan jarak, menunjukkan jumlah prosentase yang hampir sama. sebanyak 5 orang remaja (31%) mengaku pernah melakukan hubungan seksual sebelum menikah, 3 orang remaja (19%) mengaku pernah melakukan hubungan seksual tanpa senggama (petting), 6 orang remaja (37.5%) mengaku hanya sebatas berciuman bibir dan hanya 2 orang remaja (12.5%) yang mengaku belum berpengalaman sama sekali. dari 5 orang remaja yang pernah melakukan hubungan seksual tersebut, didapatkan 2 orang remaja (40%) melakukannya dengan pekerja seks komersil (psk) dan sisanya 3 orang remaja (60%) melakukan dengan pacarnya. terjadinya perilaku seksual tidak sehat dan berisiko tinggi di masa remaja tersebut dapat disebabkan oleh berbagai macam faktor, antara lain pola asuh orang tua, lingkungan sosial meliputi masyarakat, sekolah dan teman sebaya, serta faktor genetik biologik (soetjiningsih, 2004). lokalisasi sebagai industri seks komersil, pada satu sisi secara sosial dan moral akan meresahkan, terutama dampaknya terhadap masyarakat sekitar pada umumnya dan keluarga yang tinggal di dalam lingkungan tersebut pada khususnya. sementara bagi remaja yang tinggal di kawasan lokalisasi banyak melihat praktek pelanggaran norma-norma sosial melalui perdagangan seks bebas dalam kehidupan sehari-harinya, sehingga mau tidak mau mereka harus menerima kondisi yang penuh konflik nilai tersebut sebagai suatu rutinitas dalam kehidupan sehari-hari. hal ini akan berdampak pada perkembangan jiwa dan kepribadian remaja yang tumbuh dalam lingkungan lokalisasi terutama dalam hal perkembangan dan kematangan pola perilaku seksualnya (sufiyanto, 2004). bahan dan metode penelitian penelitian ini menggunakan cross sectional design, dengan 104 responden remaja 14-21 tahun. variabel bebas pada penelitian ini hubungan pola asuh orang tua dan lingkungan sosial dan variabel tergantung perilaku seksual remaja usia 14–21 tahun di lingkungan lokalisasi. analisis data dilakukan dengan uji korelasi spearman’s rho dan analisis isi (content analysis) dengan tingkat kemaknaan p≤0.05. hasil penelitian tabel 1: hubungan lingkungan sosial dan pola asuh orang tua terhadap perilaku seksual remaja usia 14–21 tahun di lingkungan lokalisasi kelurahan putat jaya surabaya pada januari 2007. perilaku seksual remaja usia 14 – 21 tahun lingkungan sosial pola asuh orang tua tidak kondusif kurang kondusif kondusif total otoriter demokratik permisif total f % f % f % f % f % f % f % f % normal 0 0 5 23.8 16 76.2 21 100 17 81 4 19 0 0 21 100 ringan sedang 10 17.5 44 77.2 3 5.3 57 100 25 43.9 23 40.4 9 15.8 57 100 berat 22 84.6 4 15.4 0 0 26 100 0 0 3 11.5 23 88.5 26 100 total 32 30.8 53 51 19 18.2 104 100 42 40.4 30 28.8 32 30.8 104 100 p = 0.000 ρ = – 0.773 p = 0.000 ρ = 0.691 jurnal ners vol. 2 no. 1 mei – september 2007 berdasarkan tabel di atas 16 orang (76.2%) remaja tanpa penyimpangan perilaku seksual (normal) tinggal di lingkungan sosial yang kondusif, 22 orang (84.6%) remaja dengan penyimpangan perilaku seksual berat tinggal di lingkungan sosial yang tidak kondusif dan hampir seluruhnya 44 orang remaja dengan penyimpangan seksual ringan sampai sedang tinggal di lingkungan sosial yang kurang kondusif dan hanya sebagian kecil 3 orang (5.3%) remaja dengan penyimpangan seksual ringan sampai sedang tinggal di lingkungan sosial yang kondusif. analisis uji statistik spearman’s rho dengan tingkat kemaknaan p<0.05 didapatkan hasil p=0.000 yang artinya ada hubungan antara lingkungan sosial dengan perilaku seksual remaja dan nilai koefisien korelasi ρ= –0.773 menunjukkan bahwa hasil uji korelasi tersebut mempunyai hubungan signifikan yang berlawanan arah yang berarti semakin kondusif lingkungan sosial maka makin kecil penyimpangan perilaku seksual pada remaja. ada hubungan signifikan yang kuat (p=0.000 dan ρ=0.691) antara pola asuh orang tua dengan perilaku seksual remaja usia 14–21 tahun di lingkungan lokalisasi kelurahan putat jaya surabaya, hubungan tersebut sejajar dan searah yang berarti semakin permisif orang tua maka makin tinggi pula risiko terjadinya penyimpangan perilaku seksual pada remaja. pembahasan informasi seks yang tidak sehat atau tidak sesuai dengan perkembangan usia remaja mengakibatkan terciptanya konflik dan gangguan mental serta ide-ide yang salah yang dapat memungkinkan seorang remaja untuk melakukan perilaku seksual sebelum menikah. pola asuh jenis apapun yang diterapkan orang tua akan menjadi sia-sia apabila tidak didukung oleh peran dari semua pihak terkait, seperti guru, masyarakat, serta perawat. hal tersebut didukung hasil penelitian yang menunjukkan bahwa hampir seluruh remaja usia 14–21 tahun tanpa penyimpangan perilaku seksual (normal) memiliki orang tua yang menerapkan pola asuh otoriter. dapat dilihat pula bahwa pada setiap pola asuh terdapat penyimpangan seksual, terutama disebabkan karena sifat remaja yang masih labil, memiliki rasa ingin tahu sangat besar dan cenderung percaya dengan kelompok sebayanya. sehingga kontrol dan pengawasan perlu dilakukan semua pihak agar perilaku remaja dapat terkendali sesuai dengan nilai dan norma. dari tabel 1 dapat dilihat hampir seluruh remaja usia 14-21 tahun tanpa penyimpangan perilaku seksual (normal) tinggal di lingkungan sosial yang kondusif. yusanti (2002), berpendapat bahwa lingkungan yang dekat atau bahkan membaur dengan lokalisasi merupakan lingkungan yang tidak kondusif dan akan memberikan pengaruh terhadap perkembangan perilaku dan kepribadian seorang anak khususnya pola perilaku seksual seorang remaja, sebab anak-anak dapat bergaul bebas dengan orang-orang yang ada di sekitar tempat tinggal tersebut. kondisi tersebut akan memudahkan munculnya perilaku tanpa kendali, yakni penyimpangan dari berbagai aturan yang ada, seperti perilaku seks bebas yang semakin marak di kalangan remaja. simpulan dan saran simpulan 1. pola asuh orang tua yang otoriter menunjukkan hubungan signifikansi yang kuat dengan perilaku seksual remaja usia 14–21 tahun di lingkungan lokalisasi. 2. lingkungan sosial yang kondusif ada hubungan signifikansi yang kuat dengan perilaku seksual remaja usia 14–21 tahun di lingkungan lokalisasi. saran 1. pengetahuan tentang agama dan nilai-nilai norma serta kegiatan-kegiatan positif harus terus di tingkatkan. 2. pola asuh yang benar perlu diterapkan terhadap anak sejak usia dini. 3. peran serta masyarakat sangat penting dalam melakukan kontrol sosial. jurnal ners vol. 2 no. 1 mei – september 2007 4. pemerintah kotamadya surabaya sebaiknya menerapkan peraturan daerah yang jelas dan tegas dalam mengatur kawasan lokalisasi. kepustakaan arikunto, s., (1998). prosedur penelitian, suatu pendekatan praktek edisi revisi iv, jakarta: rineka cipta, hal: 208-306. atkinson, et al., (2005). pengantar psikologi. jilid 2, jakarta: erlangga, hal: 222-237. balson, maurice (1999). menjadi orang tua yang sukses edisi ke-4, jakarta: grasindo, hal: 147-174. mc. conaghy, n., (1996). sexual behavior, problems and management, new york: plenum press, hal: 39-98. notosoedirjo & latipun. (2002). kesehatan mental, konsep dan penerapan, malang: universitas muhammadiyah malang, hal: 99-117. papalia, (2001). latar belakang perilaku seks pranikah pada remaja. http://www.epsikologi.com/remaja. tanggal 7 november 2006 jam 13.00 wib sarwono, s.w., (2004). psikologi remaja. jakarta: raja grafindo persada, hal: 5156, 97-99, 124-140, 137, 189. singgih, g.s., (2000). psikologi praktis anak, remaja dan orang tua, jakarta: bpk. gunung mulia, hal: 93-95, 125-131, 182190. soetjiningsih, (2004). buku ajar tumbuh kembang remaja dan permasalahannya, jakarta: sagung seto, hal: 25-34, 132-154. steinberg, l.d. (2002). adolescence, sixth edition, new york: mc. graw hill, hal: 11-15, 124-158, 170-174, 346-362. sufiyanto, y., (2004). resistensi keluarga di lokalisasi. skripsi s1 tidak dipublikasikan, program studi sosiologi, fakultas ilmu sosial ilmu politik, universitas airlangga, surabaya. yusanti, n., (2002). sosialisasi anak di lingkungan lokalisasi. skripsi s1 tidak dipublikasikan, program studi antropologi, fakultas ilmu sosial ilmu politik, universitas airlangga, surabaya. http://www.e-psikologi.com/remaja http://www.e-psikologi.com/remaja ners vol 5 no 2 oktober 2010_akreditasi 2013.indd 191 tingkatan domain (bloom) pengetahuan lanjut usia tentang kebutuhan nutrisi (level of knowledge about nutitional need for elderly based on bloom domain) ketjuk herminaju stikes hutama abdi husada tulungagung, jl. dr. wahidin sudirohusodo no. 1 tulungagung telp./fax: (0355) 322738, e-mail: ketjuk_stikeshah@yahoo.co.id abstract introduction: there are still a lot of elderly people who tend not to think about the nutrients they need. the objective of this study was to determine the level of knowledge based on bloom. domain about nutrition in the elderly posyandu. method: design research was descriptive analytical. population were selected all listed in the elderly in the village posyandu rejotangan district, 34 respondents. variable was the level knowledge domain from bloom. the data were collected by questionnaire and they were analyzed by using the descriptive statistical. result: the result of these studies showed the level of knowledge (c1–c6) seniors about nutrition were categorized with the value – average 56%. discussion: it can be concluded that from all of the domain from bloom, the level of knowledge of elderly was categorized on suffi cient level. it is recommended that the involment of the is important to improve the delivery of information through extension or move the elderly to be more active in following posyandu. keywords: knowledge, elderly, nutrition pendahuluan usia lanjut termasuk kelompok yang paling rawan biologinya yaitu lebih mudah sakit serta lama penyembuhannya (depkes jakarta, 2005). proses menua dapat terlihat secara fi sik pada tubuh dan berbagai organ serta penurunan fungsi tubuh serta organ tersebut. perubahan secara biologis ini dapat memengaruhi status gizi pada masa tua antara lain metabolisme basal menurun, kebutuhan kalori menurun, status gizi lansia cenderung mengalami kegemukan atau obesitas. fungsi pengecap atau penciuman menurun atau hilang, makan menjadi tidak enak dan nafsu makan menurun, akibatnya lansia menjadi kurang gizi (kurang energi protein yang kronis). penyakit periodontal (gigi tanggal), akibatnya kesulitan makan yang berserat (sayur, daging) dan cenderung makan makanan yang lunak (tinggi kalori), hal ini menyebabkan lansia cenderung kegemukan/obesitas. penurunan sekresi asam lambung dan enzim pencerna makanan, hal ini mengganggu penyerapan vitamin dan mineral, akibatnya lansia menjadi defi siensi zat-zat gizi mikro. mobilitas usus yang menurun, mengakibatkan susah buang air besar, sehingga lansia menderita wasir yang bisa menimbulkan perdarahan dan memicu terjadinya anemia. sering menggunakan obatobatan atau alkohol, hal ini dapat menurunkan nafsu makan yang menyebabkan kurang gizi dan hepatitis atau kanker hati. (depkes ri. 2003). basal metabolic rage (bmr) pada lansia turun sekitar 20% pada umur 50 tahun dibandingkan umur 30 tahun, demikian pula air tubuh turun secara signifikan karena bertambahnya sel-sel mati yang diganti oleh lemak maupun jaringan ikat, jumlah energi juga turun sangat nyata disertai penurunan metabolisme tubuh (departemen kesehatan jakarta, 2005). solusi yang bisa diberikan langsung pada lansia dengan cara memelihara kesehatan secara mandiri dengan mengkonsumsi makanan yang bergizi dan olah raga teratur. cara lain meminimalkan kelainan yang terjadi pada lansia, dilakukan upaya pencegahan sejak usia dini mengikuti pola sehat, sehingga pada waktu lansia dicapai kondisi tetap sehat dan jurnal ners vol. 5 no. 2 oktober 2010: 191–194 192 dapat berkarya selama mungkin. upaya lain mengatasi hal tersebut diperlukan kerja sama antara petugas kesehatan dengan kelompok lansia yaitu mengatur diit pada lansia agar status gizi terpenuhi secara seimbang, sehingga kesehatan, kesejahteraan dan kapasitas fungsional dapat dicapai secara optimal (depkes ri. 2000). oleh karena itu peneliti tertarik untuk mengetahui tingkat pengetahuan lansia tentang nutrisi di posyandu lansia di desa rejotangan kecamatan rejotangan kabupaten tulungagung. tujuan penelitian ini adalah untuk mengetahui tingkat pengetahuan lansia tentang nutrisi di posyandu lansia di desa rejotangan kecamatan rejotangan kabupaten tulungagung. tabel 1. distribusi frekuensi pengetahuan (tahu) lansia tentang nutrisi di posyandu lansia no. tingkat pengetahuan f persentase (%) rerata 1 baik 6 18% 56% (cukup) 2 cukup 11 32% 3 kurang baik 17 50% jumlah 34 100% tabel 2. distribusi frekuensi pengetahuan (paham) lansia tentang nutrisi di posyandu lansia no. tingkat pengetahuan f persentase (%) rata-rata 1 baik 8 24% 58% (cukup) 2 cukup 9 26% 3 kurang baik 17 50% jumlah 34 100% tabel 3. distribusi frekuensi pengetahuan (aplikasi) lansia tentang nutrisi di posyandu lansia no. tingkat pengetahuan f persentase (%) rerata 1 baik 7 21% 56% (cukup) 2 cukup 9 26% 3 kurang baik 18 53% jumlah 34 100% tabel 4. distribusi frekuensi pengetahuan (analisis) lansia tentang nutrisi di posyandu lansia no. tingkat pengetahuan f persentase (%) rerata 1 baik 5 15 56% (cukup) 2 cukup 13 38 3 kurang baik 16 47 jumlah 34 100 tabel 5. distribusi frekuensi pengetahuan (sintesis) lansia tentang nutrisi di posyandu lansia no. tingkat pengetahuan f persentase (%) rerata 1 baik 15 15 55% (kurang baik) 2 cukup 12 35 3 kurang baik 17 50 jumlah 34 100 tingkatan domain (bloom) pengetahuan lanjut usia (ketjuk herminaju) 193 bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah metode deskriptif. dalam penelitian ini menggunakan populasi semua lansia yang ada di posyandu lansia desa rejotangan dengan sampel yang diteliti meliputi semua lansia di posyandu lansia kecuali lansia yang sakit dan yang mengalami gangguan jiwa, dengan jumlah sampel sebanyak 34 orang. penelitian dilakukan selama bulan juni 2010. variabel independen dalam penelitian ini adalah membuat suatu model upaya peningkatan pengetahuan oleh kader. sedangkan variabel dependen dalam penelitian ini adalah peningkatan pengetahuan. data yang diperoleh dianalisis dengan menggunakan skala guttman dan diinterprestasikan dengan menggunakan skala kualitatif. hasil hasil penelitian dalam penelitian ini menunjukkan bahwa dari segi pengetahuan (tahu) 17 responden (50%) berpengetahuan kurang baik dengan nilai rerata sebesar 56% dalam kategori cukup. pengetahuan (paham) menunjukkan hasil mayoritas 17 responden (58%) berpengetahuan kurang baik dengan nilai rerata 58% dalam kategori cukup. tabel 3 dari segi pengetahuan (aplikasi) menunjukkan bahwa mayoritas 18 responden (53%) berpengetahuan kurang baik dengan nilai rata-rata 56% dalam kategori cukup. hasil dari pengetahuan (analisis) menunjukkan bahwa mayoritas 16 responden (47%) berpengetahuan kurang baik dengan nilai rerata sebesar 56% dalam kategori cukup. pengetahuan (sintesis) menunjukkan hasil mayoritas 17 responden berpengetahuan kurang baik dengan nilai rerata sebesar 55% dalam kategori kurang baik. mayoritas 19 responden (56%) dari segi pengetahuan (evaluasi) menunjukkan rerata sebesar 55% berpengetahuan kurang baik dalam kategori kurang baik. pembahasan pendidikan adalah suatu kegiatan dan proses pembelajaran untuk mengembangkan atau meningkatkan kemampuan tertentu sehingga sasaran pendidikan itu dapat berdiri sendiri. semakin tinggi tingkat pendidikan seseorang maka semakin baik pula tingkat pengetahuannya, demikian juga sebaliknya (notoatmojo, 2003). jika ditinjau dari pendidikan didapatkan 16 responden (47%) mayoritas sd, teori di atas kurang sesuai, mengingat sd merupakan pendidikan yang masih dasar. hal ini disebabkan meski dengan pendidikan yang belum cukup tinggi, tetapi pengalaman yang diperoleh, baik dari diri sendiri maupun orang lain mampu memberikan tambahan ilmu dan pengetahuan seseorang. pengalaman merupakan guru yang paling baik sebab pengalaman dapat digunakan sebagai upaya memperoleh pengetahuan dan menyebutkan bahwa manusia telah mampu menggunakan penalarannya dalam memperoleh pengetahuan. teori di atas sesuai dengan yang didapatkan bahwa mayoritas 16 responden (47%) berumur 60–70 tahun, karena diketahui pada usia lanjut pengalaman yang didapat baik yang dialami sendiri ataupun dari orang lain cukup banyak sehingga dapat menambah pengetahuan yang dimiliki. informasi meningkatkan pengetahuan, menentukan sikap dan perilaku seseorang (notoatmodjo, 1993). menurut j. guilbert, proses interaksi merupakan salah satu yang memengaruhi proses belajar, dari tidak tahu menjadi tahu. jika dilihat dari pekerjaan, mayoritas responden adalah tidak bekerja tabel 6. distribusi frekuensi pengetahuan (evaluasi) lansia tentang nutrisi di posyandu lansia no. tingkat pengetahuan f persentase (%) rerata 1 baik 6 18 55% (kurang baik) 2 cukup 9 26 3 kurang baik 19 56 jumlah 34 100 jurnal ners vol. 5 no. 2 oktober 2010: 191–194 194 (ibu rumah tangga) sebanyak 14 responden (41%) dan dilihat dari jenis kelamin mayoritas responden yaitu wanita sebanyak 28 responden (80%), kemungkinan di mana proses interaksi yang tercipta bisa dicapai melalui kegiatan berbelanja, posyandu, yasinan yang kesemuanya ini bisa lebih meningkatkan pengetahuan, selain yang diperoleh dari media cetak dan elektronik. sebanyak 34 responden dengan nilai rata-rata sebesar 58% berpengetahuan (c2) cukup. menurut notoatmodjo (2003: 122) memahami diartikan sebagai kemampuan untuk menjelaskan secara benar tentang objek yang diketahui. sebanyak 34 responden dengan nilai rata-rata sebesar 56% dengan pengetahuan (c3) cukup. teori yang disampaikan nursalam dan pariani (2003) menyebutkan bahwa bekerja umumnya merupakan kegiatan yang menyita waktu. bekerja bagi wanita akan mempunyai pengaruh terhadap kehidupan keluarga. evaluasi merupakan kemampuan untuk melakukan penilaian terhadap suatu objek (notoatmodjo, 2003). makin tua umur seseorang maka makin konstruktif dalam menerima informasi yang didapat sehingga semakin banyak pengetahuan yang dimiliki (nursalam dan pariani, 2001). dengan mayoritas 16 responden (47%) berumur 60–70 tahun, teori di atas kurang sesuai dengan hal tersebut. hal ini disebabkan pada usia lanjut proses perkembangan mentalnya mulai menurun, dalam hal mengingat, memahami/berfikir dan berkreasi dalam memberikan penilaian terhadap suatu materi/objek. simpulan dan saran simpulan penelitian ini dapat disimpulkan bahwa tingkat pengetahuan dari tingkatan domain dari bloom pada lansia tentang nutrisi di posyandu lansia di desa rejotangan kecamatan rejotangan dikategorikan cukup. meskipun responden mayoritas berpendidikan sd dan berumur 60–70 tahun tetapi pola berpikir dalam mengolah sesuatu itu masih cukup baik karena kemampuan dalam menggunakan penalaran untuk memperoleh pengetahuan, dan pengembangan pemahaman tentang nutrisi. saran peneliti memberikan saran agar tenaga kesehatan dan kader di posyandu lansia lebih meningkatkan informasi tentang pengetahuan lansia tentang nutrisi melalui penyuluhan kepada masyarakat khususnya ibu dan bapak yang sudah lansia agar pengetahuan mereka tentang nutrisi dapat bertambah dan penelitian lebih lanjut dapat dilakukan dengan sampel yang lebih banyak serta mengembangkan model peningkatan pengetahuan berbasis masyarakat pengetahuan yang ada. kepustakaan almatsier, s., 2003. prinsip dasar ilmu gizi. jakarta: pt. gramedia pustaka. alimul, a., 2003. riset keperawatan dan teknik penulisan ilmiah. jakarta: salemba medika. arikunto, suharsimi, 1998. prosedur penelitian suatu pendekatan praktek. jakarta: rineka cipta. departemen kesehatan republik indonesia, 2005. modul pelatihan konseling kesehatan dan gizi bagi usia lanjut. departemen kesehatan republik indonesia, 2003. pedoman pembinaan kesehatan usia lanjut. djaeni, a., 1999. ilmu gizi jilid 1 dan 2. jakarta: diyan paryati. nugroho, wahyudi, 1992. perawatan lanjut usia. jakarta: egc. nursalam, 2008. konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika. notoatmodjo, s., 2001. pendidikan dan perilaku kesehatan. jakarta: rineka cipta. notoatmodjo, s., 2002. metodologi penelitian kesehatan. jakarta: rineka cipta. sugiyono, 2006. metodologi penelitian administrasi dilengkapi dengan metode r and d. bandung: alfabeta. 176 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 176-183 http://dx.doi.org/10.20473/jn.v18i2.44792 original article open access experiences of professional nurses regarding shortage of resources at a tertiary hospital in gauteng province, south africa: qualitative study makoasha philistys jiyane 1 and sisinyana khunou 2 * 1 departement of nursing, ga-rankuwa nursing college, pretoria, south africa 2 department of health studies, university of south africa, pretoria, south africa *correspondence: sisinyana khunou. address: department of health studies, university of south africa, pretoria, south africa. email: khunosh@unisa.ac.za responsible editor: praba diyan rachmawati received: 12 april 2023 ○ revised: 26 june 2023 ○ accepted: 26 june 2023 abstract introduction: the shortage of resources in hospitals is a global problem that includes south africa. this leads to a situation where most healthcare facilities are unable to perform adequately in their provision of quality patient care. the study aimed to explore and describe professional nurses' (pns) experiences concerning the shortage of resources at a tertiary hospital in gauteng province, south africa. methods: an exploratory-descriptive qualitative design was used on a sample of 16 pns, who have worked for two or more years in selected units. to enhance optimum variation and obtain a diverse sample concerning participants’ experiences, the study was conducted in various units at the tertiary hospital under study. unstructured individual conversation with a grand tour question was used. tesch’s method was employed to analyse data. results: the study revealed both negative and positive experiences regarding the deficiency of resources. pns experienced the following under these four themes: 1) experiences about lack of material resources; 2) negative impact of the shortage of resources for patients; 3) experiences on inadequate number of nurses and support staff; 4) dealing with the shortage of resources. conclusions: appropriate measures should be put in place to ensure that resources are adequate at this tertiary hospital. medical machinery should be audited monthly and a daily checklist used to document available stock. appropriate recruitment and retention policies must be implemented by the human resource department to ensure that vacant posts are filled timeously and reduce high staff turnover. perceptions of patients could be explored related to the unavailability of medicine in healthcare facilities. keywords: nurses, health resources shortage, hospital, experience, human resources, material resources introduction insufficiency of health resources is a global concern (who, 2013). it is predicted that, by 2035, there will be a loss of 12.9 million healthcare professionals internationally (who, 2013). yang et al. (2017) state that 97,221 registered nurses are expected to provide services to a population of 37 million in shaanxi province, china. sub-saharan africa (ssa) has a deficiency of healthcare workers (who, 2013), with over 60% of african countries having a diminished number of health personnel. the who (2017) indicated that 22.8 skilled healthcare workers are expected per 10,000 people, nonetheless, 83 countries remain below this level. the scarceness of medical professionals in ssa is attributed to international migration due to unfavourable working conditions (department of health, 2017). ssa is comprised of several different countries and regions lying south of the sahara from east, central, western, and southern africa. these countries are predominantly less developed with half of https://creativecommons.org/licenses/by/4.0/ mailto:khunosh@unisa.ac.za https://orcid.org/0009-0008-8783-2665 https://orcid.org/0000-0002-2853-6048 jurnal ners http://e-journal.unair.ac.id/jners 177 their population living below the poverty line. furthermore, ssa countries are faced with challenges related to conflicts and infectious diseases (world bank, 2021). the south african media have reported medicolegal hazards as being attributable to a lack of resources (rispel et al., 2018). several factors contribute to the shortage of fundamental health resources. according to mammbona and mavhandu-mudzusi (2019), inadequacy of health resources contributes to a decline in treatment standard and well-being of patients. yang et al. (2017) indicated that the human resources for health (hrh) shortage was because of high staff turnover. phuong et al. (2019) revealed that nurses postponed treatment due to unavailability of prescribed medication. in south africa, the department of health introduced the national core standard as a strategy to increase availability of resources at all levels of hospitals (department of health, 2011). domain seven deals with facilities and infrastructure and the requirements for a clean, safe and secure physical infrastructure (department of health, 2011). in accordance with this domain, medical machinery should be regularly serviced to keep them safe for use (department of health, 2011). patients from tshwane district health care facilities and other provinces are referred to the hospital. as one of the biggest academic and referral hospitals in south africa, it needs adequate allocation of resources for quality service delivery. during clinical accompaniment, the researcher observed conditions amounting to a precarious deficiency of resources. overcrowding of patients, lack of medicines, and few nurses were noted. while several studies have been conducted on the shortage of resources there is diminished literature on the experiences of pns about these shortages at the tertiary hospital, hence a need for this study. although prevailing studies have described shortage of resources in diverse contexts, surprisingly, those conducted in the tertiary hospital and focusing on both human and non-human resources were limited. furthermore, in gauteng province, south africa, studies exploring the experiences of professional nurses regarding shortage of resources at tertiary hospital are scarce. the results of reviewed literature revealed only one qualitative study focusing on the perceptions of professional on the impact of shortage of resources on the quality patient care at limpopo province, not on the more in-depth experiences. in addition, mokoena (2017) reveals that one of the causes of staff shortages is absenteeism in the workplace, which contributes to understaffing in the unit and increases workload on the remaining staff. importantly, professional nurses are responsible for managing both human and non-human resources, ensuring smooth running of the unit and ensuring quality patient care. therefore, the purpose of the study was to explore and describe the experiences of professional nurses regarding the shortage of resources in a tertiary hospital in tshwane district. materials and methods research design this study employed a qualitative, explorative, descriptive research design (polit and beck, 2017). this research design was selected to explore and understand the participants’ experiences of working in a hospital with a shortage of resources. with this design, it was envisaged that diverse themes, subthemes and categories would be generated about these experiences. participants this study was conducted in the tertiary hospital from june 2019 until september 2019. the sample size was determined by data saturation at which point new themes were no longer emerging. the inclusion criteria included pns with more than two years’ experience at the selected tertiary hospital, and who were willing and gave their consent to participate in the study. participants were purposively chosen to provide rich information about their experiences regarding the shortage of resources at the tertiary hospital. this resulted in sixteen participants. research instruments the study data collection instruments included demographic data questionnaires, field notes for capturing non-verbal responses, interview guides, and audio tape recorders. the researcher conducted indepth interviews to explore the experiences of pns regarding the shortage of resources. the demographic questionnaires were used to obtain the participants’ age, gender, work experience and qualifications. in addition, the researcher also used an interview guide during the data collection process. the interview guide had a broad opening question which is: “what are your experiences regarding shortage of resources in this hospital?” several probing follow-up questions were used to gain greater clarity and more in-depth information from the participants. field notes, a written record of observed or heard gestures from participants, were kept by the researchers. further, the researcher made use of an audio tape recorder to capture jiyane and khunou (2023) 178 p-issn: 1858-3598  e-issn: 2502-5791 deliberations during the interview and later typed these up verbatim in the form of a transcript. ethical clearance ethical clearance was obtained from the university of south africa‘s higher degree ethics committee (reference number: hshdc /801/2017). permission was also sought from the district ethics committee in gauteng province. the rights of the participants were ensured by obtaining both written and verbal consent prior to data collection. privacy and secrecy were safeguarded by using pseudonyms. confidentiality was ascertained by reassuring the study participants that facts and information shared would be unreachable by any other persons except those involved in the study. anonymity was ensured by using the pseudonyms instead of the participants’ real identities. data collection the individual interviews were conducted in a private secluded office in the hospital under study. the door of the interview office was identified with a “no disturbance identifier” to prevent interruptions. the main researcher collected data through the administration of unstructured face-to-face individual interviews which took 25 to 40 minutes to complete. follow-up questions were asked according to individual participants’ responses. probing was done in order to obtain in-depth clarification from participants. gestures and non-verbal communication were adequately documented with the use of pen and paper, while the participants’ voices were recorded using the audiotape recorder. the researcher provided ample freedom and time for the study participants to freely express their experiences and views regarding their experiences about shortage of resources. data analysis tesch’s approach was implemented to analyse the data obtained from pns (polit and beck, 2017). in step one, the researcher got a sense of the whole findings by reading all transcripts and noting the ideas which emerged. subsequently, in step two, transcripts were read one at a time for emerging topics. step three entailed recording all the topics in one document. all topics were compared, and similar ones were grouped, with the main topics highlighted. in step four, the broad topics were highlighted and abridged as codes. the fifth step included assigning descriptive words to the identified topics and grouping them into categories. consecutively in step six, the researcher abridged these categories by deciding on the final abbreviation, labelling each category and code to avoid duplication. the seventh step involved alignment of the data appropriate to each category. the eighth step included data recording to get the whole sense and significance of the data. trustworthiness trustworthiness is described as grade of assurance and realism that researchers have in their qualitative results (polit and beck, 2017). prolonged engagement was achieved by remaining in the field until data saturation was achieved. the researcher kept an audit trail of the audiotapes and verbatim transcripts. raw data were validated together with an independent coder. figure 1. the four themes and twelve categories that emerged from the study jurnal ners http://e-journal.unair.ac.id/jners 179 results characteristics of participants a total of sixteen pns participated in the study. the age of the participants ranged between 28 and 64 (mean = 41.12 years). the majority of the participants were female (n = 15; 94%). four participants (25%) had between seventeen to twenty years of experience in their current position. thirteen (81.3%) had a diploma in nursing science and midwifery, followed by a bachelor of science in nursing (n = 3; 18.7%). in-depth analysis of data that emerged from the study allowed for greater comprehension of the experiences of these pns on the resource shortages at the tertiary hospital. to that effect, four themes supported by twelve categories emerged from the study (figure 1). these themes and categories are described and elaborated on through direct quotes from the study participants. theme 1: experiences pertaining to lack of material resources category 1.1: linen shortages participants indicated a deficiency of linen, despite several requests from laundry. participants cited the following: “today we don’t have linen to change the beds. so, i phoned laundry yesterday and today, they still don’t have linen. if you can check now, patients are sleeping on top of mattresses without linen” (participant 10; f; 42 years old). category 1.2: lack of consumables it was reported that wound dressing was not done due to a lack of sterile packs: “now recently we did not have dressing material, gauze, and crepe bandage” (participant 7; f; 35 years old) category 1.3: unavailability of medicines the absence of medicines was reported as follows: “currently we don’t have vitamin bco, we used to struggle with epilim but at least we will give an alternative of phenytoin… two months ago, we were out of lignocaine … it was difficult to suture patients without lignocaine” (participant 3; m; 38 years old) theme 2: negative impact of the shortage of resources on patients participants narrated their experiences concerning the negative impact of the shortage of resources on patients. to that effect, the following impacts were highlighted: delayed time for nursing care; increased length of hospital stays; high rates of patients’ complaints; negative patient outcomes. category 2.1. delayed time for nursing care due to the scarcity of resources, participants had to delay time for nursing care. participants mentioned: “it makes our work very difficult and is timeconsuming, because every time when you have to use resources that are not available, you have to ask in other wards” (participant 1; f; 40 years old) category 2.2. a high volume of patients’ complaints in this study, participants reported that patients’ relatives complained of inadequate nursing care because of the shortage of resources. sad-looking participant 12 had this to say: “the other thing is when parents come and find their kids lying on linen with just a drop of blood, they complain” (sad looking participant 12; f; 41 years old ) category 2.3 increased length of hospitalization participants elaborated that patients were not seen on time and care was compromised. with a worrisome look, a participant expressed the following: “patients are not monitored the way it is supposed to be., because a machine is not ours … these means if it is four hourly, is going to be six hourly…so patient’s stay is going to be long in our ward” (participant 13; f; 29 years old) category 2.4 negative patient outcomes participants attributed lack of resources to negative patient outcomes such as death. one participant said: “patients come here but there are no nurses to nurse them. beds might be available but there are no nurses...they end up dying instead of being helped …” (participant 9; f; 33 years old) theme 3: experiences with the shortage of nursing and support staff four categories emerged from this theme, namely: nurse burnout syndrome; impact on the training of nurses; fear of litigation; nurses having to perform nonnursing duties. category 3.1: nurses’ burnout syndrome an overwhelming number of the participants experienced an enormous amount of stress. sad-looking participant 4 said: “we experience burnout, because we cannot achieve our objective of quality care, … because of the stress for jiyane and khunou (2023) 180 p-issn: 1858-3598  e-issn: 2502-5791 being sick, strained emotionally because of not having enough resources” (participant 6; f; 64 years old) category 3.2: impact on the training of nurses participants testified that they did not have an opportunity to advance their development due to nurse shortages. this is evident in this narration: “due to shortage of pns, everyone is minding, checking their own patients, so we end up lacking information like in-service training”. (participant 7; f; 28 years old) category 3.3: fear of litigation in this study, participants reported that they fear litigation. this is apparent from the following: “we are scared of litigations in our unit, because if you are working alone and you have so many patients, you tend to overlook certain patients and if something happens, it is on your shoulder” (participant 11; f; 51 years old) category 3.4: nurses performing non-nursing duties nurses performed non-nursing duties to cover up for lack of support staff. one participant narrated: “there are no clerks, so our statistics is very wrong. sometimes we are even forced to do clerical work so that we can have statistics, especially for patients who are going out of the unit ” (participant 15; f; 31years old) theme 4: dealing with a shortage of resources various coping mechanisms were employed to deal with the scarcity of resources. category 4.1 nurses improvise participants had to improvise to deal with the shortage of resources. nurses had to come up with creative ways of dealing with diminished resources. one participant had this to say: “sometimes we augment the gauze with crepe bandage during dressings...some of items are out of stock, so we have to ask from other wards because central sterilising department have nothing” participant 14; f; 29 years old) discussions the purpose of the study was to explore and describe the experiences of pns concerning the shortage of resources at a tertiary hospital in gauteng province. the study revealed four themes: experiences pertaining to lack of material resources; the negative impact of these resource shortages on patients; experiences on the inadequate number of nurses and support staff; and dealing with the shortage of resources. these themes are discussed in relation to the supportive literature. experiences pertaining to lack of material resources the majority of participants revealed an inadequate supply of linen such as sheets, blankets and pillow slips, despite several requests from laundry. it is apparent that, under these circumstances, patients’ dirty bed linen was not changed, thus predisposing them to hospital infections and bedsores. young (2016) also made a disturbing observation, whereby blood stains in unchanged linen were concealed with a paper towel. this is in contradiction of the infection control domain that highlights the necessity of a clean environment (department of health, 2011). therefore, negligence in hospital linen supplies undercuts the values of quality care and patients’ dignity. it is imperative that hospital managers should ensure that the nurses have adequate bedlinen to preserve patients’ dignity and prevent nosocomial infections. the participants experienced shortages of consumables such as dressing packs, gloves, masks and sanitisers. an overwhelming number of participants reported that wound dressing was not done due to lack of sterile packs. consistently, mammbona and mavhandu-mudzusi (2019) identified lack of gloves and masks, which put pns at risk of contracting infectious diseases. according to liu et al. (2020), adequate ppe is needed to protect both healthcare workers and patients from acquiring hospital infections. it is of great concern that, in this era of infectious diseases such hiv/aids and covid-19, nurses still have to work without ppes such as gloves and masks. participants experienced the unavailability of medicine. the assertion is that the nurses are likely to replace the unavailable medication with the other options, which might contribute to more complications. additionally, hodes et al. (2017) argue that this practice might affect chronic patients by delaying healing and promoting drug resistance. lack of drugs, such as oxytocin, contributes to mishandling of emergencies such as post-partum haemorrhage (mkoka et al., 2014). unavailability of medicine affects both nurses and patients negatively. thus, leading to compromised patient care, non-adherence and noncompliance to guidelines and protocols. negative impact of the shortage of resources on patients participants unanimously linked the shortage of resources to delayed time for nursing care. consistently, mokoena (2017) emphasised that shortage of equipment delays patients’ diagnosis and care. jurnal ners http://e-journal.unair.ac.id/jners 181 unavailability of prescribed medication means that the hospital has to outsource from another, thus contributing to more complications (mokoena, 2017). matinhure et al. (2018) found that a lack of obstetric resuscitation equipment delayed essential care for women in labour. malelelo-ndou et al. (2019) revealed that certain drugs were requested from other hospitals which resulted in late administration. according to malelelo-ndou et al. (2019), delayed treatment has a negative impact on patients’ prognoses. it is apparent that shortage of resources has a negative impact on quality patient care most of the participants reiterated experiences regarding the myriad of complaints from patients and their families. it is apparent that this dissatisfaction could be related to sub-standard nursing care. mkoka et al. (2014) highlighted that the shortage of drugs creates mistrust whereby clients had a misconception that healthcare workers were selling medicines. according to mkoka et al. (2014), allegations from patients and relatives are concerning, hence it is important to ascertain the reasons behind it. participants in this study experienced that patients’ stay in the hospital was prolonged. sub-standard care could be contributory to a prolonged length of stay. it is a clear that patients were not recuperating as expected because of the lack of medication. shortage of equipment and drugs contribute to postponement of operations, which further delays healing and increased hospital stay. the participants blamed unavailability of resource to poor patient outcomes. this could be related to the fact that the quality of care was compromised due to lack of resources. the notion is that effective management of patients’ illnesses requires prompt care with adequate uptake of treatment. consistently, gebrehiwot et al. (2014) associated maternal mortality rates with the inadequate number of midwifery experts and paediatric resuscitation material. mtega et al. (2017) linked shortage of nurses to destructive events such as pressure sores, and nosocomial infections. the assertion is that, with few nurses, it would be difficult to perform procedures such as pressure part care. shortage of drugs has been attributed to deterioration of patients’ condition and deaths (phuong et al., 2019). malatji et al. (2017), admit that staff shortage affect healthcare delivery negatively which, in turn, contributes to poor patient outcomes. experiences with inadequate number of nurses and support staff participants narrated that they experienced burnout and stress due to a shortage of resources. this is relatable because the pns were expected to provide quality patient care amidst this lack of resources. at the same time, they had to deal with patients’ complaints and all other problems related to a lack of resources. malatji et al. (2017) correlated staff shortage to anger, the feeling of inadequacy, burnout and emotional exhaustion. participants attested that lack of resources impeded nurses’ self-development. evidently, given few nurses, they had no option but to prioritize and cover up for this shortage. the same sentiments were shared by malatji et al. (2017) in that midwives did not attend workshops due to the continuing scarcity of nurses. furthermore, supervision and mentoring of novice nurses could also be challenging in light of the shortage of nurses (khunou, 2018). evidently, amidst the shortage of experienced nurses, the novices are likely to be left alone to tend the wards. yang et al. (2017) agreed that lack of career guidance and development from the employer was one of the causes of staff turnover. significantly, the pns in this study feared litigations. this could be ascribed to poor working conditions exacerbated by lack of resources and sub-standard nursing care and increased patient complaints. fear of litigation amongst pns could be attributed to the fact that they could not provide quality patient care. consistently, matlala and lumadi (2019), found that midwives feared litigation as a result of delays in patient care, and poor record keeping. the allocation of unqualified professionals can result in litigation due to poor decision-making. the current study revealed that nurses had no option but to perform non-nursing duties to compensate for the shortage of other healthcare workers. this action is likely to contribute to further nurse shortages, thus exacerbating the entire problem of resource shortages. similarly, bekker et al. (2015) found that, in most cases, nurses had to carry out clerical duties while neglecting core duties such as health education. lack of accomplishment of nursing duties contributes to increased job dissatisfaction (bekker et al., 2015). dealing with resource shortages participants had to improvise to deal with the shortage of resources and come up with creative ways of dealing with diminished resources. in agreement, mutshatshi et al. (2018) revealed lack of notepads for jiyane and khunou (2023) 182 p-issn: 1858-3598  e-issn: 2502-5791 recording patients’ observations. in this regard, nurses had to spend a lot of time making copies in order to document the nursing care rendered (mutshatshi et al., 2018). in addition, mammbona and mavhandu-mudzusi (2019) found that, due to a shortage of gloves, nurses had to use their bare hands when taking care of hiv/aids patients. it is apparent that even though improvisation can be done to ensure continuity of care, it also has negative effects which has the potential to compromise quality care and put the nurses at risk of infection. limitations the study used a qualitative design and purposive sample, which limits the representation of the population. the study was restricted to one tertiary hospital in one district with selected units and a small number of professional nurses. therefore, the findings cannot be generalized to other hospitals. since some participants might not have freely disclosed relevant information, it might hinder the generalisation of results. interviews were conducted in english with approval of the participants. conclusions inadequacy of health resources leads to a deterioration in nursing standards and compromises the welfare of patients in hospitals and clinics. this study was essential to explore and describe the experiences of pns regarding this phenomenon. the study revealed negative and positive experiences regarding the shortage of resources. appropriate measures should be put in place to ensure that resources are adequate at this tertiary hospital. recommendations medical machinery should be audited monthly and a daily checklist used to document available stock. appropriate recruitment and retention policies must be implemented by the hr department to ensure that vacant posts are filled timely and high staff turnover is reduced. debriefing programmes should be established in units such as labour wards, and accident and emergency and intensive care units to provide psychological support to affected staff. sufficient support staff should be hired to free nurses from performing non-nursing duties. the perceptions of patients could also be explored with respect to the unavailability of medicine in healthcare facilities. references bekker, m., coetzee, s. k., klopper, h. c., & ellis, s. m. (2015) ‘nonnursing tasks, nursing tasks left undone and job satisfaction among pns in south african hospitals’, journal of nursing management, 23(8), 1115–1125. https://doi.org/10.1111/jonm.12261 department of health. (2011) ‘national department of health national core standards’, 1–12. https://static.pmg.org.za/docs/120215abridge_0.pdf gebrehiwot, t., san sebastian, m., edin, k., & goicolea, i. (2014) ‘health workers’ perceptions of facilitators of and barriers to institutional delivery in tigray, northern ethiopia’, bmc pregnancy childbirth, 14, 137. https://doi.org/10.1186/1471-2393-14-137 hodes, r., price, i., bungane, n., toska, e., & cluver, l. (2017) ‘how front-line healthcare workers respond to stock-outs of essential medicines in the eastern cape province of south africa’, s. afr. med. j., 107(9), 738–740. https://doi.org/10.7196/samj.2017.v107i9.12476 khunou, s. h. (2018) ‘nurse managers’ perception of mentoring community service nurses in north west province’, south africa african journal biomedical research, 21(2), 237–244. liu, q., luo, d., haase, j. e., guo, q., wang, x. q., liu, s., xia, l., liu, z., yang, j., & yang, b. x. (2020) ‘the experiences of health-care providers during the covid-19 crisis in china: a qualitative study’, lancet glob. health, 8(6), e790–e798. https://doi.org/10.1016/s2214-109x(20)30204-7 malatji, m., ally, h., & makhene, a. (2017) ‘nurses experiences regarding staffing patterns in the surgical wards of a private hospital in gauteng south africa’, health sa gesondheid, 22, 325– 332. https://doi.org/10.1016/j.hsag.2017.04.002 malelelo-ndou, h., ramathuba, d. u., & netshisaulu, k. g. (2019) ‘challenges experienced by health care professionals working in resource-poor intensive care settings in the limpopo province of south africa’, curationis, 42(1), e1–e8. https://doi.org/10.4102/curationis.v42i1.1921 mammbona, a. a., & mavhandu-mudzusi, a. h. (2019) ‘enrolled nurses’ experiences of caring for patients living with hiv in a south african rural hospital’, int. nurs. rev., 66(1), 139–146. https://doi.org/10.1111/inr.12480 matinhure, s., chimbari, m. j., & mapunda, m. s. (2018) ‘capacity for providing caesarean section services in selected health centres and district hospitals in tanzania’, ghana med. j., 52(4), 196. https://doi.org/10.4314/gmj.v52i4.6 matlala, m. s., & lumadi, t. g. (2019) ‘perceptions of midwives on shortage and retention of staff at a public hospital in tshwane district’, curationis, 42(1), e1–e10. https://doi.org/10.4102/curationis.v42i1.1952 mkoka, d. a., goicolea, i., kiwara, a., mwangu, m., & hurtig, a. k. (2014) ‘availability of drugs and medical supplies for emergency obstetric care: experience of health facility mangers in a rural district of tanzania’, bmc pregnancy childbirth, 14(108), 5–6. mokoena, m. j. (2017) ‘perceptions of professional nurses on the impact of shortage of resources for quality patient care in a public hospital: limpopo province’, 22928. https://uir.unisa.ac.za/handle/10500/22928 mtega, b., kibona, l., dhamani, k., & petrucka, p. (2017) ‘perceptions of nurses on patient outcomes related to nursing shortage and retention strategies at a public hospital in the coastal region of tanzania’, open j. nurs., 07(09), 1044–1057. https://doi.org/10.4236/ojn.2017.79076 mutshatshi, t. e., mothiba, t. m., mamogobo, p. m., & mbombi, m. o. (2018) ‘record-keeping: challenges experienced by nurses in selected public hospitals’, curationis, 41(1), 1–6. https://doi.org/10.4102/curationis.v41i1.1931 phuong, j. m., penm, j., chaar, b., oldfield, l. d., & moles, r. (2019) ‘the impacts of medication shortages on patient outcomes: a scoping review’, plos one, 14(5), e0215837. https://doi.org/10.1371/journal.pone.0215837 polit, d. f., & beck, c. t. (2017) ‘nursing research: generating and assessing evidence for nursing practice. in philadelphia: jb lippincott’. who. (2013) ‘global health workforce shortage to reach 12.9 million in coming decades’, world health organization. jurnal ners http://e-journal.unair.ac.id/jners 183 who. (2017) ‘achieving quality universal health coverage through better water, sanitation and hygiene services in health care facilities: a focus on ethiopia’, world health organization. https://apps.who.int/iris/handle/10665/255264 world bank (2021) ‘global economic prospects’, pp. 93–102. yang, h., lv, j., zhou, x., liu, h., & mi, b. (2017) ‘validation of work pressure and associated factors influencing hospital nurse turnover: a cross-sectional investigation in shaanxi province, china’, bmc health serv. res., 17(1), 112. https://doi.org/10.1186/s12913-017-2056-z young, m. (2016) ‘private vs. public healthcare in south africa [western michigan university]’, https://scholarworks.wmich.edu/honors_theses/2741. how to cite this article: jiyane, m. p. and khunou, s. h. (2023) ‘experiences of professional nurses regarding shortage of resources at a tertiary hospital in gauteng province, south africa: qualitative study’, jurnal ners, 18(2), pp. 176-183. doi: http://dx.doi.org/10.20473/jn.v18i2.44792 141 regulasi tekanan darah pada penderita hipertensi primer dengan smoothie pisang (musa paradisiaca) (regulation of blood pressure in patients with primary hypertension with smoothie banana (musa paradisiaca)) eni puji lestari*, abu bakar*, laily hidayati* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya telp/fak: 031-5913257, e-mail: ners.abu.bakar@gmail.com abstract introduction: hypertension is a major problem that often happen in indonesia. hypertension can cause many complications. in indonesia almost patients with hypertension got farmacologic therapy, but there is no difference. banana smoothie is one of nonfarmacologic therapy that can be used to lower blood pressure. the purpose of this study was to analyze the effect of banana smoothie on regulation in patients with primary hypertension. method: this study used quasy experimental design. the population in this study were patients with primary hypertension in kedungturi village taman sidoarjo. the sampling technique used nonprobability sampling type of purposive sampling. the total number of sample were 16 respondents who were selected based on inclusion and exclusion criteria. result: the result of paired t-test at the systolic blood pressure and diastolic blood pressure in experiment group showed p value = 0.000. independent t test between experiment group post-test and control group post-test showed p value = 0.000 for systolic blood pressure and p value = 0.002 for diastolic blood pressure. this result showed that there was a difference value of pretest and post-test systolic and diastolic blood pressure. with the result of independen t-test we know that there is a difference value between exsperiment and control blood pressure. discussion: this study explain that there was signifi cant effect of banana smoothie to regulate blood pressure in patients with primary hypertention. banana smoothie can regulate the blood pressure because of high kalium substance. the function of kalium is to reduce the effect of natrium so the blood pressure can down. it can be conclude that banana smoothie can regulate the blood pressure in patients with primary hypertention. in further day patients with hypertension can choose banana smoothie to regulate their blood pressure. keywords: banana, primary hypertension, regulation blood pressure pendahuluan hipertensi esensial mulai terjadi seiring bertambahnya umur yang sering terjadi saat usia melebihi 30 tahun. penderita hipertensi pada umumnya bergantung pada obat antihipertensi yang harus dikonsumsi seumur hidup sehingga akan meningkatkan biaya pengobatan (junaidi, 2009). penelitian yang dilakukan di kasturba medical college manipal, tekanan darah dapat turun sebesar 10–15% dari tekanan darah sistolik rata-rata 150 mmhg menjadi 130 mmhg dan tekanan darah diastolik ratarata 100 mmhg menjadi 85 mmhg pada 10 responden yang makan dua buah pisang raja setiap harinya selama satu minggu (rao, 1999). pisang raja mempunyai kandungan kalium yang cukup tinggi yaitu sekitar 450 mg dalam setiap 100 gram pisang raja (rao, 1999). pisang dapat diolah menjadi minuman yang lebih segar untuk dapat dinikmati salah satunya adalah dengan pengolahan menjadi smoothie. pisang yang diolah menjadi smoothie pisang merupakan cara tepat untuk memodifikasi buah pisang. pisang yang dapat diolah menjadi smoothie salah satunya adalah pisang hijau. pisang hijau mempunyai kandungan kalium yang lebih baik dari pisang raja sehingga cocok digunakan untuk penderita hipertensi. smoothie tidak mengubah kandungan gizi yang ada dalam buah pisang. masyarakat di desa kedungturi belum membiasakan diri untuk mengkonsumsi buah pisang secara teratur jurnal ners vol. 6 no. 2 oktober 2011: 141–146 142 khususnya pada penderita hipertensi. penelitian smoothie pisang terhadap regulasi tekanan darah pada penderita hipertensi primer masih belum dapat dijelaskan secara pasti, sehingga peneliti ingin membuktikan hal tersebut. data pada bulan januari–april 2011 yang dihimpun dari bidan desa, dokter praktik swasta dan data dari kantor kepala desa penderita hipertensi di rw 06 desa kedungturi terdapat 31 orang (4,23%) dari total penduduk sejumlah 803 jiwa. penderita hipertensi tersebut merupakan pasien yang menderita hipertensi dalam kurun waktu lebih dari satu tahun. buah pisang memiliki kandungan kalium, vitamin c, dan vitamin a yang tinggi. food drug administration (fda) menyatakan bahwa makanan yang mengandung sumber kalium tinggi dan rendah natrium dapat mengurangi terjadinya peningkatan tekanan darah dan juga stroke. bersama natrium, kalium memegang peranan dalam pemeliharaan keseimbangan cairan dan elektrolit serta keseimbangan asam basa (almatzier, 2001). kandungan kalium yang tinggi dalam buah pisang dapat menurunkan efek natrium sehingga tekanan darah menurun (astawan, 2008). vitamin c merupakan salah satu antioksidan yang dapat menyebabkan proses remodeling pada pembuluh darah sehingga dapat menyebabkan vasodilatasi pada pembuluh darah yang mengalami vasokonstriksi (guyton dan hall, 2003). keistimewaan lain dari buah pisang adalah kandungan vitamin a yang dapat menangkal radikal bebas dan juga memproteksi pembuluh darah dari bahaya ldl yang dapat menimbulkan plak pada pembuluh darah, hal inilah yang membuat pembuluh darah vasodilatasi karena menghindari proses aterosklerosis (almatzier, 2001). hipertensi dapat dicegah apabila faktor risikonya dapat dikendalikan. modifi kasi gaya hidup yang meliputi diet sehari-hari sangatlah penting dalam mencegah tekanan darah tinggi dan merupakan suatu bagian yang tidak dapat dipisahkan dalam mengobati penyakit ini. menurut komite dokter ahli hipertensi (joint national committe on detection, evaluation, and treatment of high blood pressure, usa) menyimpulkan bahwa obat diuretika, penyekat beta, antagonis kalsium maupun penghambat ace dapat digunakan sebagai obat tunggal pertama dengan memperhatikan keadaan penderita dan penyakit lain yang menyertainya. kandungan kalium yang tinggi dalam pisang dapat membantu tubuh dalam menurunkkan efek natrium sehingga tekanan darah menurun. perubahan gaya hidup dengan mengkonsumsi pisang yang dijadikan smoothie merupakan tindakan yang bijaksana dan lebih efisien dalam mencegah maupun menurunkan tekanan darah. mengingat semakin tingginya biaya pengobatan medis dan juga banyaknya efek samping dari obat antihipertensi. bahan dan metode desain penelitian yang digunakan dalam penelitian ini yaitu quasy-eksperiment dengan menggunakan pre-post time series desain. populasi pada penelitian ini yaitu penderita hipertensi primer yang tinggal di rw 06 desa kedungturi dengan besar sampel 16 orang. sampel diambil pada tanggal 6–12 juni 2011, dengan teknik purposive sampling, dengan kriteria inklusi tekanan darah sistolik 140–159 mmhg dan atau diastolik 90–99 mmhg dan masih mengkonsumsi obat antihipertensi. variabel independen dalam penelitian ini yaitu smoothie pisang. instrumen yang digunakan untuk mengukur adalah standar operasional prosedur (sop) pembuatan smoothie. smoothie dibuat dengan menghaluskan pisang 580 gram ditambah air 250 ml. smoothie diberikan pada responden setiap hari pada pagi hari selama 7 hari. variabel dependennya adalah tekanan darah, dengan instrumen yang digunakan untuk mengukur adalah sphygnomanometer raksa manual yang kemudian dicatat dalam lembar observasi. tekanan darah diukur pada pagi hari sekitar pukul 06.00 wib pada hari pertama sebelum pemberian smoothie dan pada hari ke-7 setelah pemberian smoothie. data yang diperoleh dianalisis dengan menggunakan uji statistik paired t test dan independent t test dengan derajat kemaknaan α ≤ 0,05. hasil nilai tekanan darah sistolik pada kelompok perlakuan dan kontrol, menunjukkan regulasi tekanan darah (eni puji lestari) 143 bahwa rerata nilai tekanan darah sistolik sebelum intervensi 145,62 mmhg pada kelompok perlakuan dan 146,88 mmhg pada kelompok kontrol. setelah intervensi selama 7 hari rerata nilai tekanan darah sistolik adalah 126,88 mmhg pada kelompok perlakuan dan 143,75 pada kelompok kontrol. hasil pengujian statistik dengan menggunakan uji paired t-test diperoleh nilai p = 0,000 pada tekanan darah sistolik kelompok perlakuan dan p = 0,180 pada tekanan darah sistolik kelompok kontrol. untuk menunjukkan perbedaan nilai tekanan darah yang signifi kan antara kelompok perlakuan dan kelompok kontrol dilakukan uji statistik independen t test. uji statistik independen t-test diperoleh hasil p = 0,701 pada saat pre-test dan p = 0,000 pada saat post-test. nilai tekanan darah diastolik pada kelompok perlakuan dan kontrol, menunjukkan rerata nilai tekanan darah diastolik 92,5 mmhg pada kelompok perlakuan dan 92,5 mmhg pada kelompok kontrol. setelah dilakukan intervensi selama 7 hari rerata nilai tekanan darah diastolik 80,62 mmhg pada kelompok perlakuan dan 90,62 mmhg pada kelompok kontrol. hasil pengujian statistik dengan menggunakan uji paired t-test diperoleh nilai p = 0,000 pada nilai tekanan darah diastolik kelompok perlakuan dan nilai p = 0,197 pada kelompok kontrol. perbedaan nilai tekanan darah yang signifikan antara kelompok perlakuan dan kelompok kontrol ditunjukkan dengan dilakukan uji statistik independen t-test. uji statistik independen t-test diperoleh hasil p = 0,800 pada saat pre test dan p = 0,002 pada saat post-test. pembahasan hasil uji statistik dengan menggunakan uji independen t-test pada saat pre-test antara kelompok perlakuan dengan kelompok kontrol diperoleh hasil tekanan darah yang tidak signifi kan. uji statistik independen t-test pada saat post-test menunjukkan bahwa ada perbedaan nilai tekanan darah yang signifikan antara kelompok perlakuan dan kontrol. beberapa responden pada kelompok perlakuan mengalami penurunan tekanan darah yang signifi kan. hal tersebut dapat dibuktikan dengan uji statistik paired t-test. hasil uji statistik paired t-test tersebut menunjukkan bahwa ada perbedaan nilai tekanan darah saat pre-test dan posttest pada kelompok perlakuan yang berarti ada pengaruh signifi kan pemberian smoothie pisang terhadap responden dengan hipertensi primer. sedangkan pada kelompok kontrol dengan menggunakan uji statistik paired t-test menunjukkan bahwa tidak ada perbedaan nilai tekanan darah yang signifi kan saat pre-test dan juga post-test. pemberian smoothie pisang sebesar 580 gram selama 7 hari mampu menurunkan tekanan darah pada beberapa responden dengan rata-rata penurunan tekanan darah sistolik tabel 1. nilai tekanan darah sistolik pada kelompok perlakuan dan kontrol no kelompok perlakuan kelompok kontrol pre-test post-test perubahan pre-test post-test perubahan mean 145,62 126,88 18,75 146,88 143,75 3,125 paired t-test: perlakuan p = 0,000. kontrol p = 0,180 independen t-test: pre-test p = 0,701 post-test p = 0,000 tabel 2. nilai tekanan darah diastolik pada kelompok perlakuan dan kontrol no kelompok perlakuan kelompok kontrol pre-test post-test perubahan pre-test post-test perubahan mean 92,5 80,62 8,125 92,5 90,62 1,875 paired t-test: perlakuan p = 0,000. kontrol p = 0,197 independen t-test: pre-test p = 0,800 post-test p = 0,002 jurnal ners vol. 6 no. 2 oktober 2011: 141–146 144 sebesar 18,75 mmhg dan rerata penurunan tekanan darah diastolik sebesar 8,125 mmhg. buah pisang mempunyai kandungan kalium yang tinggi, terutama pada pisang hijau sebesar 600 mg dalam setiap 100 gram buah pisang hijau (cabot, 2005). selain terdapat kalium di dalam buah pisang juga terdapat kandungan vitamin a dan vitamin c. kandungan kalium yang tinggi pada buah pisang mampu menurunkan efek natrium sehingga tekanan darah menurun (astawan, 2008). konsumsi kalium yang ideal bagi penderita hipertensi derajat 1 minimum 3500 mg setiap harinya (beevers, 2008). kalium sangat baik bagi penderita hipertensi yang tidak merespon obat antihipertensi (junaidi, 2009). konsumsi kalium sebanyak 2,5–5 gram dapat menurunkan tekanan darah sistolik sebesar 12 mmhg dan tekanan darah distolik sebesar 16 mmhg (junaidi, 2009). vitamin c merupakan salah satu jenis antioksidan dari golongan vitamin yang dapat menyebabkan proses remodeling vaskuler sehingga dapat menyebabkan vasodilatasi pembuluh darah yang mengalami vasokonstriksi (guyton dan hall, 2003). vitamin a dapat menghambat terjadinya radikal bebas dan membuat radikal bebas menjadi non-aktif sehingga memproteksi ldl kolesterol dalam darah. ldl kolesterol merupakan zat yang dapat merusak sistem vaskuler sehingga makrofag disirkulasi darah menurun (guyton dan hall, 2003). mayoritas responden (7 orang) mengalami penurunan tekanan darah sistolik dan diastolik setelah pemberian smoothie pisang. tata laksana pengobatan hipertensi tidak hanya bergantung pada pengobatan farmakologik, tetapi juga membutuhkan kombinasi dari pengobatan non-farmakologik seperti konsumsi smoothie pisang secara teratur. dari hasil pengukuran darah yang dilakukan oleh peneliti diperoleh hasil penurunan tekanan darah yang mulai tampak pada hari ke-3 meskipun tidak semua responden mulai mengalami penurunan pada hari ke-3. hasil yang optimal didapatkan pada hari ke-6 dan pada hari ke-7 cenderung stabil. selain efek positif dari buah pisang sendiri yang mampu menurunkan tekanan darah pada penderita hipertensi, penurunan tekanan darah pada kelompok perlakuan juga disebabkan oleh karena peneliti menggunakan prinsip 5t dalam pemberian intervensi kepada responden yaitu yang pertama adalah tepat obat, buah pisang mengandung banyak senyawa yang dapat menurunkan tekanan darah, senyawa tersebut antara lain kalium, vitamin a dan juga vitamin c, kedua adalah tepat pasien, peneliti memberikan intervensi smoothie pisang kepada responden yang mengalami hipertensi primer, ketiga adalah tepat dosis, peneliti memperhitungkan jumlah buah pisang yang harus dikonsumsi perhari. penentuan dosis buah pisang berdasarkan pada kandungan senyawa kalium yang terdapat pada buah pisang hal ini dikarenakan kalium merupakan mineral yang baik dalam mengendalikan tekanan darah dan juga berdasarkan pada kebutuhan kalium untuk penderita hipertensi. keempat adalah tepat cara, buah pisang dikonsumsi per oral dalam bentuk smoothie. mengkonsumsi buah atau sayuran dalam bentuk smoothie, mineral atau kandungan vitamin yang terdapat dalam buah pisang tersebut akan terserap secara sempurna oleh tubuh, dan yang kelima adalah tepat waktu, peneliti secara konsisten memberikan jadwal intervensi yaitu pagi hari pukul 05.00 wib sebelum responden sarapan. mengkonsumsi smoothie pisang sebaiknya sebelum makan untuk memudahkan nutrisi terserap ke dalam tubuh dan mengkonsumsi smoothie pisang sebaiknya kurang dari satu jam setelah pembuatan agar smoothie pisang tidak teroksidasi oleh udara dan menimbulkan rasa yang masam. penelitian ini terdapat satu responden pada kelompok perlakuan yang tidak mengalami penurunan tekanan darah sistolik maupun diastolik yaitu pada responden nomor 4. responden nomor 4 berjenis kelamin laki-laki, berusia 34 tahun, bekerja sebagai karyawan pabrik dalam melakukan pekerjaan sehari-hari terkadang muncul stres, merupakan perokok aktif (mengkonsumsi rokok > 16 batang/ hari), mempunyai kebiasaan minum kopi (3–4 cangkir/hari), suka makan makanan yang asin sejak remaja, kebiasaan berolahraga (jogging) 1× seminggu selama kurang lebih 30 menit, mendapat obat antihipertensi captopril 2 × 12,5 mg namun jarang kontrol ke regulasi tekanan darah (eni puji lestari) 145 dokter apabila obat habis dan ada riwayat faktor genetik. hal ini bisa terjadi pada responden nomor 4 dikarenakan oleh beberapa faktor. faktor genetik, kebiasaan merokok, kebiasaan minum kopi, konsumsi garam berlebih dan juga stres dapat menjadikan tekanan darah pada responden nomor 4 ini tidak terpengaruh oleh pemberian smoothie pisang. nilai tekanan darah normal sangat bervariasi bergantung pada umur (potter dan perry, 1997). hipertensi umumnya berkembang pada saat usia 35–55 tahun (dewi, 2010). tekanan darah akan meningkat seiring bertambahnya usia, hal ini dikarenakan adanya penurunan elastisitas dinding arteri (johnson, 2004). faktor genetik merupakan faktor yang tidak dapat diubah dan faktor genetik inilah yang menjadi pemicu timbulnya hipertensi terutama hipertensi primer (junaidi, 2009). rokok mengandung senyawa berbahaya antara lain nikotin, tar dan karbon monoksida. nikotin dapat memicu pengeluaran katekolamin seperti hormon adrenalin yang dapat memicu kontraksi jantung lebih kencang hingga 10–20 kali lipat per menit. tar dan karbonmonoksida merupakan zat yang dapat meningkatkan kekentalan dan keasaman sel darah. darah yang mengental akan membentuk plak yang menempel pada pembuluh darah dan menyebabkan penyempitan pembuluh darah sehingga jantung memompa darah lebih kuat yang menyebabkan tekanan darah meningkat (wiryowidagdo, 2006). kopi mengandung kafein yang menghambat kerja hormon adenosin atau merangsang kelenjar adrenal untuk melepaskan hormon adrenalin dan kortisol sehingga arteri berkontraksi lebih cepat (junaidi, 2009). garam mempunyai kecenderungan meretensi air sehingga volume darah meningkat dan menyebabkan pembuluh darah vasokontriksi hal ini akan membuat curah jantung dan tahanan perifer meningkat sehingga tekanan darah juga meningkat (willcox, 2003). saat terjadi stres kelenjar pituitary mengirimkan sinyal dan hormon pada kelenjar endokrin yang kemudian mengalirkan hormon adrenalin dan hidrokortison ke dalam darah sehingga denyut jantung menjadi lebih cepat dan menyebabkan tekanan darah menjadi tinggi (junaidi, 2009). keterbatasan peneliti dalam melakukan penelitian ini peneliti tidak mampu secara total mengendalikan variabel perancu. intervensi yang diberikan terlalu singkat, sehingga pada responden yang mempunyai berbagai macam faktor risiko memberikan respons yang berbeda terhadap intervensi yang diberikan oleh peneliti. penderita hipertensi diharapkan dapat menerapkan pola hidup sehat dimulai dengan hal-hal yang bersifat non-farmakologis. seperti mengurangi berat badan, berhenti merokok, membatasi konsumsi kopi dan garam, olahraga secara teratur dan memperbanyak mengkonsumsi buah dan sayur. temuan penelitian ini secara nyata membuktikan bahwa smoothie pisang dengan dosis 580 gram selama 7 hari mampu menurunkan tekanan darah yang tinggi mendekati keadaan normal. tekanan darah yang turun dan mendekati normal diharapkan dapat meminimalkan komplikasi yang mungkin terjadi pada penderita hipertensi primer dan dapat meningkatkan kualitas hidup penderita hipertensi primer. simpulan dan saran simpulan simpulan yang dapat ditarik adalah pemberian smoothie pisang dengan dosis 580 gram/hari dapat menurunkan tekanan darah serta meregulasi tekanan darah dalam batas normal pada penderita hipertensi primer. saran hasil penelitian ini dapat dijadikan acuan para penderita hipertensi untuk mengubah gaya hidup mereka yang kurang sehat agar mengkonsumsi pisang. perawat diharapkan dapat memberikan pendidikan kesehatan tentang diet yang tepat bagi penderita hipertensi. perlu penelitian lebih lanjut tentang pengaruh buah pisang terhadap regulasi tekanan darah beserta fungsi lainnya. kepustakaan almatzier, s., 2001. prinsip dasar ilmu gizi. jakarta: gramedia pustaka utama. jurnal ners vol. 6 no. 2 oktober 2011: 141–146 146 astawan, m., 2008. cegah hipertensi dengan pola makan,(online), (http://www. depkes.go.id., diakses tanggal 10 april 2011, jam 18.30 wib). beevers, d.g., 2008. seri kesehatan bimbingan dokter pada tekanan darah. jakarta: dian rakyat. cabot, s., 2005. terapi jus yang dapat menyelamatkan hidup anda. jakarta: pt pustaka dellaprasa. dewi, s., 2010. hidup bahagia dengan hipertensi. jogjakarta: a plus book. guyton dan hall, 2003. fisiologi kedokteran. jakarta: egc. johnson, r., 2004. buku ajar praktik kebidanan. jakarta: egc. junaidi, i., 2009. hipertensi. jakarta: pt buana ilmu populer. potter dan perry, 1997. fundamental of nursing: consep and theory. usa: mosby. rao, n., 1999. angiotensin converting enzyme inhibitors from ripened and unripened bananas. current science. 76 (1), (online), (http://www.ias.ac.in/jarch/ currsci/76/1/86.pdf., diakses tanggal 08 april 2011, jam 18.30 wib). willcox, et al., 2003. the high blood pressure remedy report: how to succsesfully tr e a t yo u r h i g h b l o o d p r e s s u r e naturally without drugs. journal food science and nutrition. 43 (1), (online), (http://bartonpublhising. com/bloodpressurenormalized/index. php., diakses tanggal 08 april 2011, jam 18.30 wib). wiryowidagdo, s., 2006. tanaman obat untuk penyakit jantung, darah tinggi, dan kolesterol. jakarta: agromedia pustaka. © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). editorial open access volume 17, issue 2, april 2022, p. 102 http://dx.doi.org/10.20473/jn.v17i2.35400 contemporary in nursing: issues and challenges http://e-journal.unair.ac.id/jners 102 hema malini 1,* 1 faculty of nursing, universitas andalas, indonesia *correspondence: hema malini. address: limau manis, pauh district, padang city, sumatera barat 25175 , indonesia. email: hemamalini@nrs.unand.ac.id the development of technology and modernization in health care is currently a demand for nursing professionals to embrace and adopt in the context of nursing as a profession and nursing education. the urgency for nursing professionals to adapt to the current situation is inevitable since nurses are part of a healthcare service that addresses the needs and demands of high-quality care from patients and families. as a profession in the era of digitalization, nurses are expected to be able to adjust their knowledge and skills in using technology in the health services. the development of care services continues to shift from previously only involving individuals to now involving families to realize more optimal health. with the trend of high-tech treatment, nurses need to improve their skills in optimizing the use of technology in delivering care. for example, using social media to provide health information for patients and families has improved knowledge, skills, and interactions. in addition, using social media in health services provides ongoing support, and at the same time, health services reach a more comprehensive range. on the other hand, the massive changes in how educational institutions to design learning curricula using digital technology are also challenging for nursing education institutions. the next generation of nursing is needed to have the skills of the industrial revolution involving soft skills such as the ability to interact, communicate and work with various people such as colleagues, clients, and leadership, problem-solving, and critical thinking as more a lot of work alongside robots. these skills are needed to survive in the era of disruption. to produce such a generation of nursing, it will impact the demand on how nursing education staff adapt and use technology and conduct innovative student-centered learning experiences. this situation will force nursing educational institutions to take significant steps in providing human resources and facilities that will support the process of producing high-quality nurses. however, some discernable obstacles are faced by the nursing education system, such as the limited ability of resources to keep up with technological developments; the high cost and length of nursing education will hinder the profession's development because not many prospective students are interested in entering the nursing faculty. moreover, the level of welfare of nurses that remains to be questioned is not balanced by the high cost of education. the trend of contemporary issues in nursing is also involving how nurses develop science through research. research is a form of nursing development efforts to adapt to the times so that the latest concepts and technologies in nursing are found. research cannot be separated from nursing problems that are also developing. the ability of nurses in terms of knowledge and skills to conduct multidisciplinary research is still low because the ability of nurses to conduct research independently is still lacking. the influence of contemporary trends and issues in nursing is taunts to challenge the future. modernization is impossible to avoid, so substantial adaptation in this disruptive era will impact the future development of nursing as a profession and education. how nurses as professionals comprise the overall developments around them will determine the future of nursing itself. references booth, r. g., strudwick, g., mcbride, s., o’connor, s., & lopez, a. l. s. (2021). how the nursing profession should adapt for a digital future. bmj, 373. mateo-martínez, g., sellán-soto, m. c., & vázquez-sellán, a. (2021). the construction of contemporary nursing identity from narrative accounts of practice and professional life. heliyon, 7(5). https:// doi.org/10.1016/j.heliyon.2021.e06942 https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0001-7988-9196 rifky pradipta icn2020 who2021 who2020 http://e-journal.unair.ac.id/jners 145 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 145-153 http://dx.doi.org/10.20473/jn.v18i2.45537 original article open access potential effect of green tea extract for adjuvant treatment of acute ischemic stroke by s100ß upregulation in non-thrombolysis patient abdulloh machin 1 * , djoko agus purwanto 2 , anny hanifah 3 , isti suharjanti 1 , muhammad ja'far shodiq 4 , m. fata fatihuddin 1 , beom joon kim 5 , and azizah amimathul firdha 6 1 faculty of medicine, universitas airlangga, surabaya, indonesia 2 faculty of pharmacy, universitas airlangga, surabaya, indonesia 3 faculty of medicine, universitas hang tuah, surabaya, indonesia 4 indonesian medical association (idi) pamekasan, pamekasan, indonesia 5 seoul national university, bundang hospital, seoul, south korea 6 indonesian medical association (idi) surabaya, surabaya, indonesia *correspondence: abdulloh machin. address: faculty of medicine, universitas airlangga, surabaya, indonesia. email: abdulloh.m@fk.unair.ac.id responsible editor: yulis setiya dewi received: 17 may 2023 ○ revised: 19 june 2023 ○ accepted: 19 june 2023 abstract introduction: in ischemic stroke, the cerebral cortex suffers from hypoxia-ischemia, leading to inflammation and oxidative stress. green tea extract has an anti-inflammation effect and antioxidant. this study aimed to determine the efficacy of green tea extract for adjuvant treatment of acute ischemic stroke in non-thrombolysis patients. methods: a double-blind randomised controlled trial was conducted in november 2020-november 2021. the subjects were all acute ischemic stroke patients who presented to the emergency room during recruitment, randomised into control (n=13) and intervention groups (n=18); the intervention groups were given green tea extract 350 mg. treatment was for 30 days. national institutes of health stroke scale (nihss), modified rankin scale (mrs), montreal cognitive assessment indonesia (mocaina), il-10 and s100ß were analysed. results: data were compared with a significance level of p<0.05. the differences in nihss from day 0 to 7, day 0 to 14 and day 0 to 30 were statistically significant in the intervention group (p=0.019, p=0.002 and p=0.000, respectively). the mrs score was statistically significant in the intervention group on day 30 (p=0.46). the differences in mrs score from day 0 to 14 and day 0 to 30 were statistically significant (p=0.042 and p=0.001, respectively) the s100ß were statistically significant in day 7 (p=0.006). the difference in s100ß from day 0 to 7 was statistically significant (p=0.001). conclusions: the green tea extract, through up-regulation s100ß, can improve the clinical outcomes of acute ischemic stroke. keywords: acute ischemic stroke, egcg, green tea extract, s100ß introduction stroke is the second leading cause of death and the first cause of disability worldwide (caplan and caplan, 2016; powers et al., 2019). thrombolysis using intravenous recombinant tissue plasminogen activator (iv-rtpa) in 3-4,5 hours after stroke attack is the only treatment approved by the food and drug administration (fda) (che et al., 2019). another drug class for acute stroke is neuroprotectant, but it has not been mentioned in aha stroke guidelines since 2007 because of a lack of evidence. searching for alternative treatment for acute stroke is ongoing. there are many https://creativecommons.org/licenses/by/4.0/ mailto:abdulloh.m@fk.unair.ac.id https://orcid.org/0000-0003-0369-0898 https://orcid.org/0000-0002-4747-3150 https://orcid.org/0009-0008-5916-3126 https://orcid.org/0000-0002-2719-3012 https://orcid.org/0000-0002-5584-7570 supremo, bacason, and sañosa (2022) jurnal ners 146 p-issn: 1858-3598  e-issn: 2502-5791 drug candidates for acute stroke, about 430 drug candidates for stroke treatment, and many of them have failed to show benefit in acute stroke patients. stroke is a complex event; it begins with decreased blood flow and causes energy depletion that will cause cell membrane impairment. ischemic brain tissue can cause neuronal cells to secrete some danger associated molecular patterns (damps); one of the damps is s100ß (michetti et al., 2012). s100ß is normally very low, and the event is not detectable; its level will be only detected during certain pathological conditions. serum s100ß represent infarct volume in stroke patients (einav et al., 2012). it suggests that the blood-brain barrier is leaked during ischemic stroke, so its level will increase in the serum (nash, bellolio and stead, 2008). ischemic brain tissue can also induce inflammatory pathways. il-10 is an anti-inflammatory cytokine (arponen et al., 2015). increased il-10 concentration may have a neuroprotective effect, according to some research. spera et al. (1998) said that administration of il-10 in the mcao model significantly reduces infarct volume and percent hemisphere infarct. green tea is the second most common drink in the world. it has polyphenols that have some benefits for health. one of its polyphenols is epigallocatechin-3gallate (egcg) which has a potent antioxidant effect. egcg has an anti-inflammation effect and prevents cell death during ischemic events (singh, mandal and khan, 2016; zhang et al., 2017). an epidemiological study in 2019 showed that green tea consumption of > 1 cup daily can prevent a cerebrovascular event, and in a patient who has had a cerebrovascular event, those who routinely consume green tea have better outcomes compared to those who do not (lee and kim, 2019). previous animal model studies show that either egcg or green tea extract can prevent necroptosis and apoptosis. it can decrease rip3 expression in the mcao model compared to the control mcao. it also decreases inflammatory markers. egcg and green tea extract can inhibit caspase-3, a proapoptotic protein, and increase the expression of the anti-apoptotic protein, bcl-2 (machin, susilo and purwanto, 2021). based on previous research, there is need to conduct clinical research to determine the efficacy of green tea extract for adjuvant treatment of acute ischemic stroke in non-thrombolysis patients. materials and methods the study has received permission from the research ethics committee of universitas airlangga hospital which examined and approved study procedure with the certificate number 176/kep/2022 on 8 september, 2020. anwar medika general hospital and siti khodijah islamic hospital have agreed and given permission to include the study ethic process from airlangga hospital. study design this study is a double-blind, randomised controlled trial to know the effect of green tea extract on acute ischemic stroke. study participants were recruited from november 2020 to november 2021 and included 31 acute ischemic stroke patients. the study was conducted at universitas airlangga hospital, anwar medika general hospital, and siti khodijah islamic hospital. since the research was conducted during the covid-19 pandemic and the same doctor handled the patients, we chose these three hospitals since it was simpler to collect samples there. selection of patients total sampling is used in the sampling method. the sample size was determined based on the total sample acquired from november 2020 to november 2021. the study participants were divided into two groups. the first group consisted of acute ischemic stroke patients who received a placebo, while the second group consisted of acute ischemic stroke patients who received green tea extract. to be included in this study, the subject must have a first-time stroke, the onset of the stroke is less than 24 hours, age 18-70 years, and the first nihss score is 4-18. nihss score of less than 4 is considered a mild stroke, whereas a score of more than 18 is considered a severe stroke. there may be an ethical issue with research when the score is higher than 18, which has a significant mortality risk. because of this, we adopt nihss 4-18, which is considered a moderate stroke. the exclusion criteria are seizure at stroke onset, sepsis, blood sugar at er <70 mg/dl or >450 mg/dl, patient with dysphagia, and patient covid-19 positive. the subject will be dropped from this research if they get sepsis or has bad compliance during research. randomisation and treatment each eligible subject was given informed consent and information for consent forms at the time of admission to the emergency room. participation in this study was completely voluntary, and the subject was allowed to withdraw from it at any time. each patient received a randomly generated computer ticket assigned to one of the two groups. this ticket will be exchanged in the pharmacy for either a placebo or green tea sachet for 30 machin, purwanto, hanifah, suharjanti, shodiq, fatihuddin, kim, and firdha (2023) http://e-journal.unair.ac.id/jners 147 days. on the first and seventh days of this study, blood was drawn. on the first, seventh, fourteenth, and thirty days of this research, the nihss, mrs score, and mocaina score were conducted. we use a green tea extract from meditea (bpom 192233901), agaricus sido makmur sentosa, malang, indonesia, which comes in sachet powder form. each sachet included 2 grams of maltodextrin and 50 milligrams of egcg. we also provide a placebo regimen with the same components but only 2 grams of maltodextrin. for 30 days, each group was instructed to consume a sachet of powder diluted with 50 ml of water three times a day, two sachets in the morning, two sachets in the afternoon, and three sachets in the evening. outcome the outcome of this research is the change of nihss, mrs score, and mocaina score from baseline at day 0, 7, 14, and 30t. the il-10 and s100ß change from day 0 to 7th days. statistical analysis we perform descriptive statistics for each variable and kolmogorov-smirnov for each variable to describe the normality of data. we perform an independent ttest if the distribution is normal, and we perform the mann-whitney test if the data is abnormal. we compare control and intervention groups for delta nihss between nihss score on day 0 and day 7, day 0 and day 14, day 0 and day 30. we also conduct a chi-square analysis for the comparing of nihss score of more than 2 on the observation day. results result should be presented continuously start from main result until supporting results. our study was conducted from january to november 2021. of the 31 patients, 20 were male, and 11 were female. the mean of patient’s ages was 56.48. the patient’s last education was 14 (45%) elementary school, four (12.9%) junior high school, and 13 (41.9%) senior high school. ten patients (30.3%) did not work. the patients were divided into two races, 30 (96.8%) javanese and 1 (3.2%) madurese. twenty-nine patients (93.5%) presented with hypertension, six patients (19.4%) suffered from diabetes mellitus type 2, two patients (6.5%) had cardiac table 1. characteristics of the subjects characteristic n (%) mean intervention(n=18) control (n=13) p value n (%) mean n (%) mean gender male female 20 (64.5) 11 (35.5) 13 (72.2%) 5 (27.8%) 7 (53.8%) 6 (46.2%) 0.291 age group (years) 56.48 56.50 56.46 education elementary school junior high school senior high school 14 (45.2) 4 (12.9) 13 (41.9) 7 (38.9%) 3 (16.7%) 8 (44.4%) 7 (53.8%) 1 (7.7%) 5 (38.5%) 0.635 profession does not work housewife labourer merchant had retired / pensionary taxi bike security farmer driver 10 (30.3) 8 (24.2) 5 (15.2) 2 (6.1) 2 (6.1) 1 (3.0) 1 (3.0) 1 (3.0) 1 (3.0) 6 (33.3%) 4 (22.2%) 2 (11.1) 1 (5.6%) 2 (11.1%) 0 1 (5.6%) 1 (5.6%) 1 (5.6%) 4 (30.8%) 4 (30.8%) 3 (23.1%) 1 (7.7%) 0 1 (7.7%) 0 0 0 0.653 race javanese madurese 30 (96.8) 1 (3.2) 17 (94.4%) 1(5.6%) 13 (100%) 0 0.388 history of diseases hypertension diabetes mellitus type 2 cardiac disease hyper-cholesterol atrial fibrilysis malignancy depression dementia 29 (93.5) 6 (19.4) 2 (6.5) 1 (3.0) 0 (0) 0 (0) 0 (0) 0 (0) 18 (100%) 3 (23.1%) 2 (11.1%) 1 (5.6%) 0 0 0 0 11 (84.6%) 3 (16.7%) 0 0 0 0 0 0 0.085 0.656 0.214 0.388 risk factors smoking history alcohol 12 (38.7) 1 (3.2) 8 (44.4%) 1 (5,6%) 4 (30.8%) 0 0.440 supremo, bacason, and sañosa (2022) jurnal ners 148 p-issn: 1858-3598  e-issn: 2502-5791 disease, and one patient (3%) had hyper-cholesterol. twelve patients (38.7%) had smoking history, and one patient (2%) consumed alcohol (table 1). nihss differences between the control group and the interventional group table 2 presents the nihss differences between the control and interventional groups. the nihss control groups were lower than the interventional group, except on days 14 and 30. the nihss days 14 and 30 seemed to be higher in the control group (4 (0–10) and 3 (0–9), respectively) than in the interventional group (3 (0–9) and 2 (0–14), respectively). there was no significant difference in nihss between groups for days 0,7,14, and 30 (p=0.186, p=0.984, p=0.650, p=0.242, respectively). all the data of delta-nihss showed that the control group’s median was lower than the interventional group’s. all the delta-nihss (day 0 to 7, day 0 to 14, day 0 to 30) were found to be statistically significant (p=0.019, p=0.002 and p<0.001, respectively). improvement of nihss between the control group and the intervention group table 3 presents the improvement of nihss between the control and intervention groups. from day 0 to day 7, there was no nihss improvement in the placebo group, while the nihss of five patients (27.78%) improved in the intervention group. the relative risk was 8.105, which means the intervention group will improve 8.105 times compared to the placebo group. there is no significance for the intervention (p=0.058). from day 0 until day 14, there were two patients (15.38%) with nihss improvement in the placebo group. while the nihss of 10 patients (55.56%) improved in the intervention group. the relative risk was 3.611, which means the intervention group will improve 3.611 times compared to the placebo group. there is no significance for the intervention (p=0.058). from day 0 until day, w while the nihss score of 95%f 12 patients (66.67%) improved in the intervention group. the relative risk was 4.333, which means the intervention group will improve 4.333 times compared to the placebo group. there is a significant result for the intervention (p=0.014). differences in mrs score between the control group and intervention group table 4 shows the differences in mrs scores between the control and intervention groups. the control group’s average mrs score on day 0 was lower than the intervention group. these three groups (day 0, 7 and 14) had non-significant results (p=0.341, p=0.869, p=0.447, respectively). there was a significant difference in mrs day 30 between control and intervention groups (p=0.046). of the delta-mrs day 0 to 7, the control group’s median was 0 (-1–0), and the intervention group’s median was 0 (-1–3). there was no significance for the intervention (p=0.134). the mean delta-mrs for day 0 to 14 was -1 (-1–0) for the control group and -1 (-1– (-4)) for the intervention group (p=0.042). for day 0 to 30, the mean is -1 (-1 – 0) for the control group and 2 (-4–0) for the intervention group (p=0.001). the intervention for these two groups is found to be statistically significant differences in mocaina score between the control group and the intervention group table 5 shows the differences in mocaina scores between the control and intervention groups. the table 2. nihss differences between the control group and the interventional group group median (minmax) kolmogorovsmirnov pvalue nihss day 0 control (n = 13) 6 (4–10) 0.005 0. 186 intervention (n =18) 8 (3–16) nihss day 7 control (n = 13) 4 (2–10) 0.021 0. 984 intervention (n =18) 4.5 (0–16) nihss day 14 control (n = 13) 4 (0–10) 0.010 0. 650 intervention (n =18) 3 (0–14) nihss day 30 control (n = 13) 3 (0–9) 0.013 0.242 intervention (n =18) 2 (0–14) delta nihss day 0 to 7 control (n = 13) 0 (0–2) 0.000 0. 019 intervention (n =18) 2.5 (0–8) delta nihss day 0 to 14 control (n = 13) 1 (0–4) 0.012 0.002 intervention (n =18) 4 (1–9) delta nihss day 0 to 30 control (n = 13) 2 (0–4) 0.029 0. 000 intervention (n =18) 4.5 (1– 9) table 3. improvement of nihss between the control group and the intervention group group rr (ci 95%) p control green tea extract nihss improvement day 0 to 7 0 (0,00%) 5 (27,78%) 8,105 (0,487 – 134,843) 0,058 day 0 to 14 2 (15,38%) 10 (55,56%) 3,611 (0,945 – 13,793) 0,058 day 0 to 30 2 (15,38%) 12 (66,67%) 4,333 (1,162 – 16,157) 0.014* note : *p<0.05; **p<0.01; ***p<0.001 machin, purwanto, hanifah, suharjanti, shodiq, fatihuddin, kim, and firdha (2023) http://e-journal.unair.ac.id/jners 149 median mocaina scores on days 7, 14 and 30 in the control group were 17 (9–26), 27 (13–30), and 18 (13– 30), respectively. the median mocaina scores on day 7, 14 and 30 in the intervention group were 20 (7–27), 22.5 (7–28), and 23.5 (7–28), respectively. these three groups (days 7, 14 and 30) had non-significant results (p=0.984, p=0.643, p=0.587, respectively). the median delta-mocaina day 7 to 14 in the control group was 1 (-1–7), and the intervention group was 1 (0– 7) with no significant result (p=0.933). the median deltamocaina day 7 to 30 in the control group was 1 (0–7) and the intervention group was 2 (0–9) with no significant result (p=0.373). differences in il-10 level between the control group and the intervention group table 6 presents the differences in il-10 level between the control group and the intervention group. the mean il-10 day 0 in the control group was 0.339 (0.250002), and in the intervention group was 0.255 (0.160689) with no significant result (p=0.264). the median il-10 day 7 in the control group was 0.235 (0.084–2.235), and in the intervention group was 0.318 (0.136 –0.696) with no significant result (p=0.123). the delta-il-10 day7-0 in the control and intervention groups were -0.040 (-0.450–1.150) and 0.143 (-0.400– 0.600). the delta il-10 had no significant result (p = 0.157). differences in s100β level between the control group and the intervention group table 7 presents the differences in s100β level between the control and intervention groups. the mean s100β day 0 in the control group was 2.49554 (2.0033259), and in the intervention group was 1.30733 (1.396559). there was no significance for the intervention (p=0.084). the mean s100β day 7 in the control group was 1.11015 (0.706374), and in the intervention group was 2.67072 (2.031395). there was a significant difference in s100ß day 7 between the control and intervention groups (p=0.006). the delta s100β day7-0 in the control and intervention groups were -1.3854 (1.95609) and 1.3634 (2.04562). there was a significant difference in delta s100ß day 0 to 7 between the control and intervention groups (p=0.001). discussions green tea (camellia sinensis) has polyphenols that act as antioxidants to counteract oxidative stress, which is known to cause various neurodegenerative disorders and neuronal injuries. polyphenols have an antiinflammation effect and prevent cell death during ischemic events (singh, mandal and khan, 2016; zhang et al., 2017). epigallocatechin-3-gallate (egcg), epicatechin (ec), epigallocatechin (egc), and (-) epicatechin-gallate are the four primary types of monomers found in each polyphenol (ecg). egcg has the strongest biological activity. tea has the largest egcg concentration. an epidemiological study shows that green tea consumption can prevent a cerebrovascular event, and for patients who have a table 4. differences in mrs score between the control group and the intervention group grou p median (min-max) kolmogo rovsmirnov pvalue mrs day 0 control (n = 13) 3 (2–4) 0.000 0. 341 interventio n (n =18) 4 (2–4) mrs day 7 control (n = 13) 2 (1–4) 0.003 0. 869 interventio n (n =18) 2 (0–4) mrs day 14 control (n = 13) 2 (1–4) 0.018 0. 447 interventio n (n =18) 2 (0–4) mrs day 30 control (n = 13) 2 (1–4) 0.001 0. 046 interventio n (n =18) 1 (0–4) delta mrs day 0 to 7 control (n = 13) 0 (-1–0) 0.000 0. 134 interventio n (n =18) 0 (-1–3) delta mrs day 0 to 14 control (n = 13) -1 (-1–0) 0.000 0. 042 interventio n (n =18) -1 (-1–(-4)) delta mrs day 0 to 30 control (n = 13) -1 (-1–0) 0.001 0. 001 interventio n (n =18) -2 (-4–0) table 5. differences in mocaina score between the control group and the intervention group group median (min-max) kolmo gorovsmirn ov pvalue mocaina day 7 control (n = 13) 17 (9–26) 0.012 0.984 interventio n (n =18) 20 (7–27) mocaina day 14 control (n = 13) 27 (13–30) 0.016 0.643 interventio n (n =18) 22.5 (7–28) mocaina day 30 control (n = 13) 18 (13–30) 0.029 0.587 interventio n (n =18) 23.5 (7–28) delta mocaina day 7 to 14 control (n = 13) 1 (-1–7) 0.000 0.933 interventio n (n =18) 1 (0–7) delta mocaina day 7 to 30 control (n = 13) 1 (0–7) 0.000 0.373 interventio n (n =18) 2 (0–9) supremo, bacason, and sañosa (2022) jurnal ners 150 p-issn: 1858-3598  e-issn: 2502-5791 cerebrovascular event, the outcome in those who routinely consume green tea has better outcomes compared to those who do not. nan et al. (2018) found that egcg protects mcao animal models by regulating the pi3k/akt/enos signalling pathway. as a free-radical scavenger, egcg can prevent oxidative damage to brain cells by pro-oxidant agents. according to several animal researches, egcg improves mitochondrial function while reducing oxidative stress (machin et al., 2021). stroke is a complex event that causes ischemic brain tissue. thrombolysis is the first choice for treating acute ischemic stroke. however, it has narrow therapeutic windows. because of that, not all patients can receive thrombolysis (che et al., 2019). another drug class for acute stroke is neuroprotectants, but it has not been mentioned in aha stroke guidelines since 2007 because of a lack of evidence. searching for alternative treatment for acute stroke is ongoing. there are many drug candidates for acute stroke, about 430 for stroke treatment, and many of them have failed to show benefit in acute stroke patients. our previous study in animal models shows that either egcg or green tea extract can prevent necroptosis and apoptosis. it can decrease rip3 expression in the mcao model compared to the control mcao. it also reduces inflammatory markers. egcg and green tea extract can inhibit caspase-3, a proapoptotic protein, and increase the expression of the antiapoptotic protein, bcl-2 (machin, susilo and purwanto, 2021). this study was conducted from november 2020 until november 2021. a total of 31 stroke patients were enrolled in the study, considering this study was conducted during the covid-19 pandemic. of 31 patients, 20 patients (64.5%) were female, with a mean age of 56.48. most of them have the risk factor of stroke, such as hypertension (93.5%), diabetes mellitus type 2 (19.4%), cardiac disease (6.5%), hyper cholesterol (3%) and smoking history (38.7%). the national institutes of health stroke scale (nihss) measures the neurological deficit in stroke patients. in previous study, the nihss score significantly related to the clinical outcomes at three months after stroke attack (sari aslani, rezaeian and safari, 2020). in 1995, the national institute of neurological disorders and stroke (ninds) study group reported that patients with acute ischemic stroke who received r-tpa within three hours after onset had no significant difference in neurological improvement at 24 hours as assessed by the nihss, compared with the placebo group. but the group given r-tpa had a favourable outcome as assessed by the nihss on three months follow-up (‘tissue plasminogen activator for acute ischemic stroke’, 1995). aoki et al. (2013) and sari aslani, rezaeian and safari (2020) reported that patients with r-tpa treatment improved nihss score at three months after stroke onset 2020. our present study shows the difference in nihss score between the control and intervention groups taking green tea extract in 30 days. the delta nihss on day 07, 0-14, and 0-30 were statistically significant, especially in the difference on day 0-30. the difference was more prominent in the intervention group than in the control group. the intervention group had an nihss improvement and was statistically significant on day 30 (ci 95% = 4.333; p-value = 0.014). lim et al. (2010) found that treatment with egcg improved forelimb function in the mcao rat model at two weeks after stroke onset. the forelimb function is one of the categories in the nihss score. the modified rankin scale (mrs) score is used to measure the disability outcome of stroke patients. the mrs score has been valuable in clinical outcomes when evaluated three months after stroke onset (chalos et al., table 6. differences in il-10 level between the control group and the intervention group group kolmogorov-smirnov p-value il-10 day 0 (mean+sd) control (n = 13) 0.339 (0.250002) 0.067 0.264 intervention (n =18) 0.255 (0.160689) il-10 day 7 (median [min-max]) control (n = 13) 0.235(0.084 – 2.235) 0.000 0.123 intervention (n =18) 0.318 (0.136 – 0.696) delta il-10 day 0 to 7 (median [min-max]) control (n = 13) -0.04 (-0.45 – 1.15) 0.025 0.157 intervention (n =18) 0.143 (-0.4 – 0.6) table 7. differences in s100β level between the control group and the intervention group group mean (sd) kolmogorovsmirnov pvalue s100ß day 0 control (n = 13) 2.49554 (2.0033259) 0.165 0.084 intervention (n =18) 1.30733 (1.396559) s100ß day 7 control (n = 13) 1.11015 (0.706374) 0.148 0.006 intervention (n =18) 2.67072 (2.031395) delta s100ß day 0 to 7 control (n = 13) -1.3854 (1.95609) 0.133 0.001 intervention (n =18) 1.3634 (2.04562) machin, purwanto, hanifah, suharjanti, shodiq, fatihuddin, kim, and firdha (2023) http://e-journal.unair.ac.id/jners 151 2020; sari aslani, rezaeian, and safari, 2020; elhabr et al., 2021). our study shows the intervention group had a lower mrs score, especially on day 30 and was more statistically significant than mrs score in the control group. the delta mrs scores on day 0-14 and 0-30 were found to be statistically significant. elhabr et al. (2021) found the mrs score between 30 days and 90 days after stroke onset had changed significantly in two-thirds of patients (⅓ improved, ⅓ unchanged, and ⅓ worsened) with following treatment such as r-tpa, evt, or both). it needs further study to have more follow-up time. the montreal cognitive assessment indonesia (moca-ina) score is an assessment instrument to determine the cognitive impairment in neurological patients (abzhandadze et al., 2019). our study found differences in moca-ina scores between both groups, but they were not statistically significant. this condition may be because the patients only had 30 days of followup. moca-ina score can predict post-stroke cognitive impairment progression at 3,6, and 12 months (with accuracy > 90%) (chiti and pantoni, 2014; sitepu, loebis and husada, 2022). il-10 is an anti-inflammatory cytokine (arponen et al., 2015). increased il-10 concentration may have a neuroprotective effect, according to some research. spera et al. (1998) found that administration of il-10 in the mcao model significantly reduces infarct volume and percent hemisphere infarct. our study shows no difference in the il-10 between the control and intervention groups. it shows that green tea extract doesn’t influence the level of il-10 in stroke patients. previous study showed that green tea extract could improve the clinical outcome of stroke patients but not through the inflammatory pathways (machin, susilo and purwanto, 2021). the mechanism of how ecgc inhibits inflammatory pathways is unclear (ellis et al., 2011). s100ß is a calcium-binding protein mainly in the cytosol of glial and schwann cells (nash, bellolio and stead, 2008; einav et al., 2012). s100ß is a marker for neurological damage and blood-brain barrier dysfunction. s100ß can be detected at a low level in healthy individuals. nash, bellolio and stead (2008) found that s100ß is a marker of acute brain ischemic and significantly increased after stroke onset. s100ß peak level is 12 to 120 hours after the neural damage (nash, bellolio and stead, 2008). s100ß interacts with rage and can release damage-associated molecular pattern molecules (damps) and other endogen molecules that participate in pro-inflammatory pathways (michetti et al., 2012). activation of rage causes neural death and increased reactive oxygen species (ros) production (rodrigues et al., 2013). our study shows the difference in s100ß between the intervention and control groups. the s100ß level in the intervention group was higher than the control group, and it was statistically significant on day 7. the delta s100ß day 0-7 was found to be statistically significant. the study result differed from einav et al. (2012), which said patients with good outcomes had lower s100ß levels than poor outcomes patients after leaving hospital. however, einav et al. evaluated the s100ß on day 0 and day 3, meanwhile our study did so on days 0 and 7. other studies found s100ß has neuroprotective and neurotrophic effects in the nanomolecular concentration (yardan et al., 2011; rodrigues et al., 2013). the s100ß-induced proliferation and neuron formation of hippocampal progenitor cells can repair brain damage. the neurotrophic and gliotrophic actions of s100ß had essential roles in cns development and recovery after brain injury (willoughby et al., 2004; yardan et al., 2011). rodrigues et al. (2013 ) found the long-term increased nanomolar s100ß level did not promote astrogliosis but decreased hippocampal glial fibrillary acidic protein (gfap) content. gfap is a marker of mature astrocytes or astroglial reactivity. the long-term increased nanomolar s100ß level correlated with the proliferation marker such as brdu and ki67. brdu and ki67 are effective content for measuring neurogenesis. they did not find any long-term increased s100ß level effect on rage expression. to interpret this finding, the administration of green tea extract in acute cerebral infarction patients increases the s100ß level in nanomolecular concentrations resulting in ischemic brain repair. in summary, our study highlights the role of green tea extract in acute cerebral infarction through s100ß upregulation. this present study has improved clinical outcomes in acute cerebral infarction patients with green tea extract as assessed by the nihss, mrs, and moca-ina scores. this finding suggests that green tea extract is a promising stroke therapy. this is the first study that reports the effect of green tea extract on acute cerebral infarction patients with a double-blind controlled trial in humans. the limitations of our study are the small number of patients and the short duration of the follow-up period, and the administration of green tea extract. our study does not consider other factors, such as revascularisation conditions and risk factors for stroke. further study is needed with a multicentre randomised control trial; long-term therapy, and follow-up (3-6 months); also considering the revascularisation condition. supremo, bacason, and sañosa (2022) jurnal ners 152 p-issn: 1858-3598  e-issn: 2502-5791 conclusion green tea (camellia sinensis) has polyphenols that act as antioxidants to counteract oxidative stress, which is known to cause various neurodegenerative disorders and neuronal injuries. this study found that acute ischemic stroke patients with green tea extract treatment have improved clinical outcomes as assessed by the nihss, mrs, and moca-ina scores. the green tea extract with epigallocatechin-3-gallate (egcg) increases s100ß expression. this approach suggests that green tea extract is a promising stroke therapy. recommendation for further study is needed with multicentre randomised control trial; long-term therapy, and follow-up (3-6 months); also considering the revascularisation condition. acknowledgement this work was supported by all the staffs of department of neurology faculty of medicine, airlangga university dr. soetomo regional public hospital. funding source universitas airlangga provided the funding this study. conflict of interest all authors in this article declared no potential conflict of interest. references abzhandadze, t. et al. (2019) ‘very early moca can predict functional dependence at 3 months after stroke: a longitudinal, cohort study’, frontiers in neurology, 10, p. 1051. available at: https://doi.org/10.3389/fneur.2019.01051. aoki, j. et al. (2013) ‘nihss-time score easily predicts outcomes in rtpa patients: the samurai rt-pa registry’, journal of the neurological sciences, 327(1–2), pp. 6–11. available at: https://doi.org/10.1016/j.jns.2013.01.029. arponen, o. et al. (2015) ‘acute phase il-10 plasma concentration associates with the high risk sources of cardiogenic stroke’, plos one. edited by c. bursill, 10(4), p. e0120910. available at: https://doi.org/10.1371/journal.pone.0120910. caplan, l.r. and caplan, l.r. (eds) (2016) caplan’s stroke: a clinical approach. fifth edition. cambridge ; new york: cambridge university press. chalos, v. et al. (2020) ‘national institutes of health stroke scale: an alternative primary outcome measure for trials of acute treatment for ischemic stroke’, stroke, 51(1), pp. 282–290. available at: https://doi.org/10.1161/strokeaha.119.026791. che, r. et al. (2019) ‘rt-pa with remote ischemic postconditioning for acute ischemic stroke’, annals of clinical and translational neurology, 6(2), pp. 364–372. available at: https://doi.org/10.1002/acn3.713. chiti, g. and pantoni, l. (2014) ‘use of montreal cognitive assessment in patients with stroke’, stroke, 45(10), pp. 3135–3140. available at: https://doi.org/10.1161/strokeaha.114.004590. einav, s. et al. (2012) ‘modeling serum biomarkers s100 beta and neuron-specific enolase as predictors of outcome after out-ofhospital cardiac arrest’, journal of the american college of cardiology, 60(4), pp. 304–311. available at: https://doi.org/10.1016/j.jacc.2012.04.020. elhabr, a.k. et al. (2021) ‘predicting 90-day modified rankin scale score with discharge information in acute ischaemic stroke patients following treatment’, bmj neurology open, 3(1), p. e000177. available at: https://doi.org/10.1136/bmjno-2021000177. ellis, l.z. et al. (2011) ‘green tea polyphenol epigallocatechin-3-gallate suppresses melanoma growth by inhibiting inflammasome and il1β secretion’, biochemical and biophysical research communications, 414(3), pp. 551–556. available at: https://doi.org/10.1016/j.bbrc.2011.09.115. lee, j. and kim, y. (2019) ‘association between green tea consumption and risk of stroke in middle-aged and older korean men: the health examinees (hexa) study’, preventive nutrition and food science, 24(1), pp. 24–31. available at: https://doi.org/10.3746/pnf.2019.24.1.24. lim, s.h. et al. (2010) ‘the functional effect of epigallocatechin gallate on ischemic stroke in rats’. machin, a. et al. (2021) ‘the effect of camellia sinensis (green tea) with its active compound egcg on neuronal cell necroptosis in rattus norvegicus middle cerebral artery occlusion (mcao) model’, journal of basic and clinical physiology and pharmacology, 32(4), pp. 527–531. available at: https://doi.org/10.1515/jbcpp-20200438. machin, a., susilo, i. and purwanto, d.a. (2021) ‘green tea and its active compound epigallocathechin-3-gallate (egcg) inhibit neuronal apoptosis in a middle cerebral artery occlusion (mcao) model’, journal of basic and clinical physiology and pharmacology, 32(4), pp. 319–325. available at: https://doi.org/10.1515/jbcpp-2020-0454. michetti, f. et al. (2012) ‘the s100b protein in biological fluids: more than a lifelong biomarker of brain distress: s100b in biological fluids’, journal of neurochemistry, 120(5), pp. 644–659. available at: https://doi.org/10.1111/j.1471-4159.2011.07612.x. nan, w. et al. (2018) ‘epigallocatechin-3-gallate reduces neuronal apoptosis in rats after middle cerebral artery occlusion injury via pi3k/akt/enos signaling pathway’, biomed research international, 2018. available at: https://doi.org/10.1155/2018/6473580. nash, d.l., bellolio, m.f. and stead, l.g. (2008) ‘s100 as a marker of acute brain ischemia: a systematic review’, neurocritical care, 8(2), pp. 301–307. available at: https://doi.org/10.1007/s12028007-9019-x. powers, w.j. et al. (2019) ‘guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the american heart association/american stroke association’, stroke, 50(12). available at: https://doi.org/10.1161/str.0000000000000211. rodrigues, j. et al. (2013) ‘protective effects of a catechin-rich extract on the hippocampal formation and spatial memory in aging rats’, behavioural brain research, 246, pp. 94–102. available at: https://doi.org/10.1016/j.bbr.2013.02.040. sari aslani, p., rezaeian, s. and safari, e. (2020) ‘3-month outcome of ischemic stroke patients underwent thrombolytic therapy; a cohort study’, archives of academic emergency medicine, 8(1), p. e6. singh, n.a., mandal, a.k.a. and khan, z.a. (2016) ‘potential neuroprotective properties of epigallocatechin-3-gallate (egcg)’, nutrition journal, 15(1). available at: https://doi.org/10.1186/s12937-016-0179-4. sitepu, a., loebis, b. and husada, m.s. (2022) ‘correlation between indonesian version of montreal cognitive assessment score and hospital anxiety and depression scale scores for post-stroke patients’, open access macedonian journal of medical sciences, 10(t7), pp. 54–58. available at: https://doi.org/10.3889/oamjms.2022.9245. spera, p.a. et al. (1998) ‘il-10 reduces rat brain injury following focal stroke’, neuroscience letters, 251(3), pp. 189–192. available at: https://doi.org/10.1016/s0304-3940(98)00537-0. ‘tissue plasminogen activator for acute ischemic stroke’ (1995) new england journal of medicine, 333(24), pp. 1581–1588. available at: https://doi.org/10.1056/nejm199512143332401. machin, purwanto, hanifah, suharjanti, shodiq, fatihuddin, kim, and firdha (2023) http://e-journal.unair.ac.id/jners 153 willoughby, k.a. et al. (2004) ‘s100b protein is released by in vitro trauma and reduces delayed neuronal injury: s100b and in vitro neuronal trauma’, journal of neurochemistry, 91(6), pp. 1284– 1291. available at: https://doi.org/10.1111/j.14714159.2004.02812.x. yardan, t. et al. (2011) ‘usefulness of s100b protein in neurological disorders’, j pak med assoc, 61(3). zhang, j.c. et al. (2017) ‘delayed treatment with green tea polyphenol egcg promotes neurogenesis after ischemic stroke in adult mice’, molecular neurobiology, 54(5), pp. 3652–3664. available at: https://doi.org/10.1007/s12035-016-9924-0. how to cite this article: machin, a., purwanto, d. a., hanifah, a., suharjanti, i., shodiq, m. j., kim, b. j., and firdha, a. a. (2023) ‘potential effect of green tea extract for adjuvant treatment of acute ischemic stroke by s100ß upregulation in non-thrombolysis patient [state the method here]’, jurnal ners, 18(2), pp. 145-153. doi: http://dx.doi.org/10.20473/jn.v18i2.44167 31 konsep diri, dukungan sosial dan kecemasan menghadapi keadaan sakit pada pasien fraktur (self concept, social support, and anxiety in dealing with fractured patient) dini kurniawati* *program studi ilmu keperawatan universitas jember, jalan kalimantan no. 37 jember, e-mail: dini_psikunej10@yahoo.com abstract introduction: the self-concept on fractured-patient is the way of the patient views himself as a whole. the view may cause the patient to feel less confi dent and may lead the patient to experience anxiety. such condition requires serious attention in the form of social support. the objective of this research was to identify the association of the self-concept, social support, and anxiety in dealing with fracturedpatient. method: this research employed correlational design. the samples of this research were in-patients who suffered from femur fractures, underwent treatments for at least three days, aged 25–45 and were conscious and, willing to be involved in the research. the technique used in this research was purposive sampling. result: results of the research, when analyzed statistically using the regression analysis, revealed that the correlation between the self-concept and anxiety generated rx1y = –0.476 with p = 0.007 (p < 0.01). furthermore, the correlation between social support and anxiety generated rx2y = –0.531 with p = 0.003 (p < 0.01) while the correlation among self-concept, social support, and anxiety generated f = 4,758 at p = 0.009 (p < 0.01). the determination coeffi cient (r2) = 0.293 while the fi gures of the effective contribution (ec) were as follows: the effective contribution (ec) of the self-concept to anxiety was 1.051%, while the effective contribution (ec) of the social support to anxiety was 28.216%. discussion: the higher the one’s self-concept, the lower the anxiety level would be, and vice versa. the same thing applied to the relation between social support and anxiety. the higher the social support one got, the lower the anxiety level would be. the correlation between self-concept and social support and anxiety in dealing fractured patient existed. self-concept contributed to anxiety. according to the behavioral theories, anxiety arouses from one’s fear of being rejected or not being accepted in terms of interpersonal relationship. therefore, the high self-concept (high self acceptance) lowers the fear for rejection (anxiety). keywords: self-concept, social support, anxiety, fractured-patient pendahuluan manusia merupakan makhluk komplek, masalah yang terjadi merupakan masalah fi sik maupun psikologis (isaacs, 2005). masalah yang terjadi akan membuat seseorang untuk beradaptasi atau melakukan penyesuaian diri terhadap masalahnya. manusia mempunyai kemampuan beradaptasi baik secara biologis dan psikologis. tujuan dari adaptasi biologis adalah mempertahankan kelangsungan hidup atau proses internal tetap stabil. adaptasi psikologis salah satunya bertujuan untuk memberikan rasa nyaman dan aman. masalah psikologi yang banyak terjadi pada manusia adalah rasa ansietas atau kecemasan (suliswati, 2005). konsep diri didefinisikan semua ide, pikiran dan keyakinan yang diketahui individu dalam berhubungan dengan orang lain (stuart dan sundeen, 1998). konsep diri seseorang tidak terbentuk waktu lahir, tetapi dipelajari sebagai hasil pengalaman unik seseorang dalam dirinya sendiri, dengan orang terdekat dan realitas dunia. di samping konsep diri hal yang paling membantu pasien dalam mengatasi masalah adalah support sistem atau dukungan dari keluarga, teman maupun orang lain (alami, e, 2009). individu yang mengalami kecelakaan dan menderita patah tulang atau fraktur, dapat timbul rasa cemas dan tidak berdaya akibat penyakit tersebut (muttaqin, 2008). jurnal ners vol. 7 no. 1 april 2012: 31–36 32 fraktur merupakan penyakit yang paling sering terjadi karena kecelakaan (smeltzer, 2002). hal ini terjadi secara mendadak yang tidak pernah diprediksikan oleh individu (muttaqin, 2008). insiden fraktur di rsud dr. soebandi pada tahun 2007 adalah 34% dari pasien seluruh pasien yang rawat inap yang diakibatkan oleh kecelakaan. dari kasus di atas yang menjalani terapi imobilisasi dan bed rest adalah 69%. berdasarkan data yang diperoleh dari rekam medik didapatkan dari 947 pasien fraktur yang rawat inap selama tahun 2007 sekitar 79% mengalami kecemasan dan 30% mengalami gangguan konsep diri karena keadaannya. sedangkan 21% pasien yang tidak mengalami kecemasan juga ada yang mengalami gangguan konsep diri. di samping itu hampir 80% dari semua pasien yang rawat inap karena fraktur mendapatkan dukungan sosial yang baik. kecemasan pada data di atas terjadi karena fraktur dianggap merupakan suatu penyakit yang menakutkan, karena mempunyai dampak negatif yang komplek terhadap kelangsungan kualitas hidup individu. salah satu di antaranya adalah amputasi, apabila luka sampai menyebabkan tulang remuk dan mengancam jiwa. kecemasan terjadi karena seseorang merasa terancam baik secara fi sik maupun psikologis seperti: harga diri, ideal diri, body image, atau identitas diri (smeltzer, 2002). kecemasan ini sangat berhubungan bagaimana konsep diri seseorang tersebut dan bagaimana dukungan sosial yang ada (burns, 1993). salah satu upaya dalam mengatasi pasien dengan gangguan konsep diri dan kecemasan adalah dengan pemberian pendidikan kesehatan (dalami e., 2009). pendidikan kesehatan diberikan agar pasien dapat menerima kondisinya sekarang, dapat menyukai dan menghargai diri sendiri sehingga akan terbentuk suatu sikap yang sehat (copel, 2007). sikap adalah tidak lebih dari kebiasaan berpikir dan kebiasaan itu dapat diperoleh, sehingga sikap itu dapat dibentuk dan dipelajari. sikap yang sehat harus terus dipupuk dan dibiasakan dalam keseharian sehingga terbentuk harga diri seseorang yang positif atau tinggi. selain itu, dukungan keluarga sangat diperlukan untuk meningkatkan rasa percaya diri pasien (sarason, 1983). untuk menurunkan kecemasan pasien fraktur dengan meningkatkan konsep diri dan memaksimalkan dukungan sosial yang ada. berdasarkan hal tersebut di atas, maka peneliti tertarik untuk meneliti hubungan antara konsep diri, dukungan sosial dengan kecemasan menghadapi keadaan sakit pada pasien fraktur. bahan dan metode penelitian ini menggunakan desain penelitian korelasi (arikunto, 2002). parameter pengukuran kecemasan disusun berdasarkan perubahan yang terjadi di dalam individu yang meliputi perubahan fi siologis, perilaku, kognitif dan afektif. untuk skala pengukuran konsep diri disusun berdasarkan dimensi konsep diri yang meliputi konsep diri fi sik, konsep diri psikologis, konsep diri sosial dan konsep diri moral etik. sedangkan untuk parameter pengukuran dukungan sosial disusun berdasarkan jenis dukungan sosial di antaranya adalah dukungan informasional, dukungan instrumental, dukungan penghargaan, dukungan emosional dan integritas sosial. data diperoleh dari kuesioner yang diberikan kepada pasien rawat inap di rsu dr. soebandi jember. sampel pada penelitian ini adalah pasien fraktur femur yang menjalani rawat inap dan dalam keadaan sadar, usia 25–45 tahun, minimal rawat inap di rumah sakit selama 3 hari dan bersedia untuk diteliti. teknik yang digunakan dalam mengambil sampel adalah purposive sampling yaitu memilih sampel yang sesuai dengan kriteria inklusi dengan jumlah sampel sebanyak 26 orang. pengumpulan data dilakukan dengan menggunakan kuesioner yang telah diuji validitas dan reabilitasnya (azwar, 1992). perhitungan uji validitas butir skala kecemasan menghadapi keadaan sakit dengan koefi sien korelasi yang bergerak dari rxy = 0,384–0,788 dan rpq = 0,336–0,767 pada p = 0,000–0,045 (p < 0,05) sedangkan uji reliabilitas dengan teknik hyot (azwar, 1992) mempunyai koefisien korelasi rtt = 0,947 pada p = 0,000. uji keandalan mempunyai koefisien reliabilitas dengan p < 0,05. perhitungan uji validitas butir skala konsep diri sahih dengan melihat koefisien korelasi yang bergerak dari rxy = 0,483–0,808 dan rbt = 0,435–0,790 pada p = 0,000–0,012 konsep diri, dukungan sosial (dini kurniawati) 33 (p < 0,05) sedangkan uji reliabilitas dengan teknik hyot terhadap skala konsep diri mempunyai koefi sien korelasi rtt = 0,952 pada p = 0,000. uji keandalan mempunyai koefi sien reliabilitas dengan p < 0,01. perhitungan uji validitas butir skala dukungan sosial terlihat sahih dengan melihat koefi sien korelasi yang bergerak dari rxy = 0,387–0,744 dan rbt = 0,354–0,724 pada p = 0,000–0,037 (p < 0,05) sedangkan uji reliabilitas dengan teknik hyot terhadap skala dukungan sosial mempunyai koefi sien korelasi rtt = 0,950 pada p = 0,000. uji keandalan mempunyai koefisien reliabilitas dengan p < 0,01. hasil uji normalitas sebaran dilakukan terhadap ketiga variabel yaitu variabel pertama (x1) yaitu konsep diri, varibel kedua (x2) yaitu dukungan sosial dan variabel ketiga (y) yaitu kecemasan menghadapi keadaan sakit. hasil uji normalitas variabel konsep diri didapatkan kai kuadrat x1 = 10,710 pada db = 9 dan p = 0,296. karena p > 0,05 maka sebaran variabel konsep diri normal. hasil uji normalitas variabel dukungan sosial didapatkan kai kuadrat x2 = 8,733 pada db = 9 dan p = 0,462. karena p > 0,05 maka sebaran variabel dukungan sosial normal. sedangkan hasil uji normalitas variabel kecemasan menghadapi keadaan sakit (y) didapatkan kai kuadrat y = 9,262 pada db = 9 dan p = 0,413. hasil uji normalitas variabel kecemasan menghadapi keadaan sakit p > 0,05 maka sebaran variabel kecemasan menghadapi keadaan sakit normal. hasil hasil penelitian dianalisis secara statistik. penelitian ini menggunakan desain penelitian korelasi (arikunto, 2002). parameter pengukuran kecemasan disusun berdasarkan perubahan yang terjadi di dalam individu yang meliputi perubahan fi siologis, perilaku, kognitif dan afektif. untuk skala pengukuran konsep diri disusun berdasarkan dimensi konsep diri yang meliputi konsep diri fi sik, konsep diri psikologis, konsep diri sosial dan konsep diri moral etik. sedangkan untuk parameter pengukuran dukungan sosial disusun berdasarkan jenis dukungan sosial di antaranya adalah dukungan informasional, dukungan instrumental, dukungan penghargaan, dukungan emosional dan integritas sosial. data diperoleh dari kuesioner yang diberikan kepada pasien rawat inap di rumah sakit umum dr. soebandi jember. sampel pada penelitian ini adalah pasien fraktur femur yang menjalani rawat inap dan dalam keadaan sadar, usia 25–45 tahun, minimal rawat inap di rumah sakit selama 3 hari dan bersedia untuk diteliti. teknik yang digunakan dalam mengambil sampel adalah purposive sampling yaitu memilih sampel yang sesuai dengan kriteria inklusi dengan jumlah sampel sebanyak 26 orang. pengumpulan data dilakukan dengan menggunakan kuesioner yang telah diuji validitas dan reabilitasnya (azwar, 1992). perhitungan uji validitas butir skala kecemasan menghadapi keadaan sakit dengan koefisien korelasi yang bergerak dari rxy = 0,384–0,788 dan rpq = 0,336–0,767 pada p = 0,000–0,045 (p < 0,05) sedangkan uji reliabilitas dengan teknik hyot (azwar, 1992) mempunyai koefi sien korelasi rtt = 0,947 pada p = 0,000. uji keandalan mempunyai koefisien reliabilitas dengan p < 0,05. perhitungan uji validitas butir skala konsep diri sahih dengan melihat koefisien korelasi yang bergerak dari rxy = 0,483–0,808 dan rbt = 0,435–0,790 pada p = 0,000–0,012 (p < 0,05) sedangkan uji reliabilitas dengan teknik hyot terhadap skala konsep diri mempunyai koefisien korelasi rtt = 0,952 pada p = 0,000. uji keandalan mempunyai koefisien reliabilitas dengan p < 0,01. p e r h i t u n g a n u j i v a l i d i t a s b u t i r s k a l a dukungan sosial terlihat sahih dengan melihat koefisien korelasi yang bergerak dari rxy = 0,387–0,744 dan rbt = 0,354–0,724 pada p = 0,000–0,037 (p < 0,05) sedangkan uji reliabilitas dengan teknik hyot terhadap skala dukungan sosial mempunyai koefi sien korelasi rtt = 0,950 pada p = 0,000. uji keandalan mempunyai koefi sien reliabilitas dengan p < 0,01. hasil uji normalitas sebaran dilakukan terhadap ketiga variabel yaitu variabel pertama (x1) yaitu konsep diri, varibel kedua (x2) yaitu dukungan sosial dan variabel ketiga (y) yaitu kecemasan menghadapi keadaan sakit. hasil uji normalitas variabel konsep diri didapatkan kai kuadrat x1 = 10,710 pada db = 9 dan p = 0,296. karena p > 0,05 maka sebaran variabel jurnal ners vol. 7 no. 1 april 2012: 31–36 34 konsep diri normal. hasil uji normalitas variabel dukungan sosial didapatkan kai kuadrat x2 = 8,733 pada db = 9 dan p = 0,462. karena p > 0,05 maka sebaran variabel dukungan sosial normal. sedangkan hasil uji normalitas variabel kecemasan menghadapi keadaan sakit (y) didapatkan kai kuadrat y = 9,262 pada db = 9 dan p = 0,413. hasil uji normalitas variabel kecemasan menghadapi keadaan sakit p > 0,05 maka sebaran variabel kecemasan menghadapi keadaan sakit normal. hubungan antarvariabel menggunakan analisis regresi dengan uji kemaknaan p > 0,05 dengan menggunakan seri program staistik (sps-2000) edisi sutrino hadi dan yuni parmadiningsih. sebelum data dianalisis di dalam analisa regresi, terlebih dahulu data dilakukan uji asumsi untuk mengetahui normalitas dan homogenitas data pada masingmasing variabel (hadi sutrisno, 2000). hasil analisis data penelitian didapatkan koefi sien determinasi (r2) sebesar 0,293 yang berarti bahwa sumbangan kedua variabel bebas (konsep diri dan dukungan sosial) terhadap kecemasan menghadapi keadaan sakit pada pasien fraktur sebesar 29,3%. sedangkan bobot sumbangan efektif (se) masing-masing variabel yaitu sumbangan efektif konsep diri terhadap kecemasan sebesar 1,051% sedangkan variabel dukungan sosial terhadap kecemasan sebesar 28,216%. pembahasan k o n s e p d i r i m e m p u n y a i p e r a n a n dalam kecemasan. hal ini sesuai dengan teori pembentukan kecemasan oleh stuart dan sundeen (1998) bahwa kecemasan berdasarkan teori perilaku timbul dari perasaan takut terhadap tidak adanya penerimaan dan penolakan interpersonal. penerimaan dan penolakan interpersonal ini merupakan bagian dari konsep diri (stuart dan lararia, 1995). menurut fitts (1972) konsep diri adalah cara diri diamati dan dipersepsikan oleh orang tersebut, karena makna konsep diri ini mengandung unsur penilaian dan memengaruhi perilaku seseorang dalam berinteraksi dengan orang lain, dengan adanya konsep diri yang tinggi (penerimaan dari orang tinggi) maka ketakutan akan penolakan (kecemasan) akan semakin berkurang (burns, 1993). dukungan sosial mempunyai peranan dalam kecemasan (wahyuni, 2007). menurut thois (1998) dukungan sosial adalah derajat dimana kebutuhan dasar individu adakan afeksi, persetujuan, kepemilikan dan keamanan didapat lewat interaksi dengan orang lain (wortman dan conwey, 1985). menurut wicklund dan frey (1980) bahwa dukungan sosial dapat menurunkan kecenderungan munculnya kejadian yang mengakibatkan stres. menurut lubis (2006) dukungan sosial juga dapat mengubah hubungan antara respons individu pada kejadian yang dapat menimbulkan ansietas (kecemasan) dan ansietas itu sendiri, memengaruhi strategi untuk mengatasi ansietas dan dengan begitu memodifikasi hubungan antara kejadian yang menimbulkan ansietas dan efeknya. brehm dan kassim (1990) mengemukakan teori mengenai dampak dukungan sosial yaitu yang pertama adalah dampak langsung. dukungan sosial dapat menciptakan situasi yang menyenangkan dan tidak menekan. menurut wicklund, dan frey, (1980) menyatakan bahwa dukungan dari atasan atau penyelia dan teman sekerja akan dapat mengurangi stres, kedua dampak tidak langsung. dampak tidak langsung dukungan sosial dapat berpengaruh pada stres yang dihadapi individu dengan adanya penerimaan sosial yang dapat memengaruhi self esteem. self esteem akan berpengaruh terhadap kesehatan jiwa seseorang dan ketiga dampak penghambat. dukungan sosial dapat menghambat hubungan antara stres dan sumber stres. berdasarkan teori tersebut maka dukungan sosial bekerja sebagai pelindung untuk melawan perubahan-perubahan peristiwa kehidupan yang berpotensi penuh stres. dengan demikian maka dukungan sosial mempunyai peranan terhadap kecemasan menghadapi keadaan sakit. semakin tinggi dukungan sosial yang diterima oleh seseorang maka semakin rendah kecemasan yang dirasakan. hal ini sesuai dengan hipotesis yang peneliti ajukan. kedua variabel bebas yaitu konsep diri dan dukungan sosial memberikan sumbangan konsep diri, dukungan sosial (dini kurniawati) 35 efektif terhadap kecemasan menghadapi keadaan sakit pada pasien fraktur sebesar 29%. hal ini menunjukkan bahwa ada faktor lain yang memengaruhi kecemasan yang tidak diteliti oleh peneliti. menurut carpenito (2007) faktor-faktor yang memengaruhi kecemasan adalah situasi (personal, lingkungan) yang berhubungan dengan nyata atau merasa terganggu pada integritas biologis sekunder terhadap serangan, prosedur invasif dan penyakit. adanya perubahan nyata atau merasakan adanya perubahan lingkungan sekunder terhadap perawatan di rumah sakit, tingkat maturasi individu akan memengaruhi tingkat kecemasan. pada bayi kecemasan lebih disebabkan karena perpisahan, lingkungan atau orang yang tidak dikenal dan perubahan hubungan dalam kelompok sebaya. kecemasan pada remaja mayoritas disebabkan oleh perkembangan seksual. pada dewasa berhubungan dengan ancaman konsep diri, sedangkan pada lansia kecemasan berhubungan dengan kehilangan fungsi, tingkat pendidikan, di mana individu yang berpendidikan tinggi akan mempunyai koping yang lebih baik dari pada yang berpendidikan rendah sehingga dapat mengeliminir kecemasan yang terjadi, karakteristik stimulus yang meliputi intensitas stresor, lama stresor, jumlah stresor, dan karakteristik individu yang meliputi makna stresor bagi individu, sumber yang dapat dimanfaatkan dan respons koping serta status kesehatan individu. faktor-faktor yang di atas adalah faktor lain yang belum diteliti oleh peneliti yang mempunyai sumbangan terhadap kecemasan. dari kedua variabel bebas konsep diri dan dukungan sosial masing-masing memberikan kontribusi atau sumbangan efektif sebesar 1, 051% untuk konsep diri, sedangkan variabel dukungan sosial memberikan sumbangan efektif sebesar 28,216%. dukungan sosial memberikan sumbangan lebih besar daripada konsep diri dikarenakan dukungan sosial dapat mengubah hubungan antara respons individu pada kejadian yang dapat menimbulkan stres dan stres itu sendiri, memengaruhi strategi untuk mengatasi stres dan dengan begitu memodifi kasi hubungan antara kejadian yang menimbulkan stres dan efeknya. dukungan sosial merupakan dukungan yang diberikan oleh orang di sekitar sehingga dukungan sosial lebih mampu membantu individu dalam menghadapi stres yang menimbulkan kecemasan daripada konsep diri. di samping itu, dukungan sosial mampu bekerja sebagai pelindung untuk melawan perubahan-perubahan peristiwa kehidupan yang berpotensi penuh stres. simpulan dan saran simpulan konsep diri pada pasien fraktur merupakan cara pandang pasien fraktur dalam melihat pribadinya secara utuh. kondisi tersebut dapat membuat perasaan pasien kurang sempurna dalam memandang dirinya dan pasien akan merasa cemas sehingga memerlukan dukungan sosial. penelitian ini didapatkan hasil bahwa semakin tinggi konsep diri maka semakin rendah kecemasan begitu juga sebaliknya. semakin tinggi dukungan sosial maka semakin rendah kecemasan, begitu juga sebaliknya. ada hubungan antara konsep diri dan dukungan sosial dengan kecemasan menghadapi keadaan sakit pada pasien fraktur. saran hasil penelitian ini dapat diterapkan oleh para praktisi yang berada di rumah sakit, khususnya perawat dalam memberikan asuhan keperawatan pada pasien fraktur agar mampu membantu pasien dalam mengatasi kecemasan menghadapi keadaan sakit dengan memaksimalkan dukungan sosial yang ada. sedangkan pada pasien fraktur diharapkan mampu memanfaatkan dukungan sosial yang ada dalam menghadapi keadaan sakit sehingga kecemasan yang dirasakan dapat diatasi, serta keluarga pasien diharapkan memberikan dukungan sosial yang maksimal guna membantu pasien dalam mengatasi kecemasan menghadapi keadaan sakit. peneliti selanjutnya diharapkan mampu mengembangkan faktor-faktor lain yang memengaruhi kecemasan yang belum diteliti pada penelitian seperti faktor situasi, tingkat maturasi individu, tingkat pendidikan, karakteristik stimulus dan karakteristik individu. jurnal ners vol. 7 no. 1 april 2012: 31–36 36 kepustakaan arikunto, s., 2002. prosedur penelitian suatu pendekatan praktek. jakarta: pt. rineka cipta. azwar, s., 1992. reliabilitas dan validitas, yogyakarta: sigma alpha. azwar, s., 1992. metode penelitian, yogyakarta: pustaka pelajar. brehm dan kassin. 1990. social psychology. new jersey: hougthon miff lin. princenton. burns, 1993. the self concept: theory, m e a s u re m e n t , d e v e l o p m e n t a n d behaviour. london: longman group. carpenito, l., 2007. nursing diagnosis. aranggement with lippincott williams & wilkins inc. copel, 2007. psychiatric and mental health care: nurse’s clinical guide. usa: lippicottwilliams & wilkins. dalami, e., 2009. asuhan keperawatan jiwa dengan masalah psikososial. jakarta: trans info media. fitts, 1972. the self concept and behavior: overview and supplement. california: research monogram no vii. library of conggress catalog card number 72–80269. issacs, a. 2005. mental health and psychiatric nursing. usa: linppicott williams and wilkins inc. muttaqin, a., 2008. buku ajar asuhan keperawatan klien gangguan system muskuluskeletal. jakarta: egc. sarason, 1983. assessing social support: the social support questionnaire. journal of personality and social psychology, 44, 127–139. stuart dan sundeen, 1998. buku saku keperawatan jiwa. jakarta: egc. smeltzer, 2002. brunener & suddarth’s textbook of medical surgical nursing. p h i l a d e l p h i a : l i p p i c o o t r a v e n publishers. stuart and lararia, 1995. principles practice psychiatric nursing, st. louis: mosby. suliswati, 2005. konsep dasar keperawatan kesehatan jiwa. jakarta: egc. wahyuni, 2007. hubungan dukungan sosial dan percaya diri dengan kecemasan siswa smu dalam menghadapi ujian. tesis tidak dipublikasikan. surabaya: universitas 17 agustus 1945. wicklund, r.a. dan frey, d., 1980. self awareness. theory: when the self makes a difference, dalam d.m wegner dan rr vallacher (editor) the self in social psychology. new york: oxford university press. wortman, c.b., dan conwey, t., 1985. social support helath, cohen, s and syme, s (eds). orlando florida: academic press inc. efek pemberian terapi sinar 24jam terhadap penurunan kadar total serum bilirubin pada neonatus aterm dengan ikterus neonatorum jurnal ners vol. 2 no. 1 mei – september 2007 teknik relaksasi imagery terhadap respons penerimaan (psikologis dan biologis) dalam prosedur invasif pada anak usia sekolah (8-12 tahun) nursalam*, kristiawati*, yuni s.a*, nuzul qur’aniati*, dyah surya k. abstract the objective of this study was to explain the effect of the imagery relaxation technique on psychological acceptance and biologic response in school age (8-12 years) on the invasive procedure. the design used in this study was static group comparison. the population was the school age patient, around 8-12 years in melati room rsup dr. soedono madiun. sample of this study were 20 respondent, recruited by using purposive sampling consisting of 10 respondents as the control group and 10 respondents as the experiment group, who met the inclusion criteria. the independent variable was the imagery relaxation technique and the dependent variable was the psychological and biological acceptance responses. data were collected by using observation paper. the result showed that there were some differences between the control group and the experiment group in heart rate (p=0.000) and the respiratory rate (p=0.000), but there were no differences in the control group`s systole (p=0.476) and diastole (p=0.630). conclusion: the imagery relaxation technique has significantly effect on the psychological acceptance response and the biological response (the respiratory rate and the heart rate). keywords: imagery relaxation technique, psychological acceptance response, invasive procedur, biological response pendahuluan hospitalisasi merupakan keadaan yang tidak menyenangkan bagi anak, termasuk pada anak usia sekolah. hal tersebut dapat menyebabkan kecemasan dan stres pada anak. penyebab dari kecemasan dipengaruhi oleh banyak faktor, antara lain dari petugas (perawat, dokter dan tenaga kesehatan lainnya), lingkungan baru, maupun keluarga yang mendampingi selama perawatan (nursalam, 2005). selama menjalani perawatan, berbagai prosedur perawatan yang dilakukan pada anak merupakan hal yang asing baginya sehingga menjadi sumber stres bagi anak. salah satu tindakan yang menyebabkan stresor tinggi adalah prosedur invasif dengan menggunakan jarum. prosedur tersebut menyebabkan nyeri dan perlukaan tubuh yang dapat menjadi trauma bagi anak (ellis, 2004). ___________ * staf pengajar psik fk unair konsep perawatan atraumatik diperlukan saat melakukan tindakan ini. prinsip perawatan atraumatik yang dapat digunakan yaitu menyiapkan anak sebelum prosedur dengan menggunakan teknik relaksasi imagery untuk mengurangi nyeri. pemberian teknik relaksasi imagery diharapkan dapat merubah respons penerimaan anak menjadi positif pada saat prosedur invasif. namun, pengaruh teknik relaksasi imagery terhadap respons penerimaan (psikologis dan biologis) dalam prosedur invasif belum dapat dijelaskan. penyakit dan hospitalisasi mengancam pengendalian anak dalam hal kemandiriannya (perry & potter, 2005). berbagai cara bisa digunakan untuk meningkatkan respons penerimaan pada anak, antara lain dengan menghadirkan orang tua, distraksi dan teknik relaksasi imagery (the american journal of cardiothoracic, 2006). jurnal ners vol. 2 no. 1 mei – september 2007 penelitian menunjukkan 80% anak umur 4-11 tahun menginginkan orang tua mereka hadir dalam setiap tindakan. sedangkan penelitian lain tentang teknik relaksasi imagery menyebutkan 65% bisa mengurangi kecemasan sebelum dan sesudah dilakukan tindakan, 30% mengurangi rasa sakit, dan 5% mengurangi efek samping dari dampak hospitalisasi (church, 2006). teknik relaksasi imagery efektif diberikan pada anak usia sekolah karena dalam perkembangan kognitif menurut piaget masuk dalam tahap operasional konkret dimana mereka bisa berpikir secara abstrak dan mampu menggunakan simbol dalam pemikiran (wong, 1999). teknik relaksasi imagery bisa dijadikan terapi non farmakologi untuk mengatasi nyeri dan membuat anak menerima prosedur tersebut (case western university, 2004). dengan dilakukannya teknik relaksasi ini diharapkan setiap anak bisa menjalani prosedur invasif dengan tenang dan kooperatif. anak merasa nyaman selama perawatan dengan adanya dukungan sosial keluarga, lingkungan perawatan yang terapeutik dan sikap perawat yang penuh perhatian akan mempercepat proses penyembuhan (nursalam, 2005). bahan dan metode penelitian penelitian ini menggunakan static group comparison pre post test design. populasi dalam penelitian ini adalah anak usia sekolah yang dirawat di ruang melati rsup dr. soedono madiun. besar sampel adalah 20 responden diambil dengan menggunakan tehnik purposive sampling. variabel independen dalam penelitian ini adalah teknik relaksasi imagery. variabel dependen adalah respons penerimaan (psikologis dan biologis). metode pengumpulan data yang digunakan untuk respons psikologis menggunakan lembar observasi modifikasi donna l. wong (2004), sedangkan untuk respons biologis dinilai dari tanda-tanda vital tubuh yaitu frekuensi pernapasan, tekanan darah dan denyut nadi. analisis data untuk respons psikologis dengan menggunakan uji statistik mann whitney test dengan tingkat kemaknaan p≤0,05 dan untuk respons biologis menggunakan uji statistik independent t-test dengan tingkat kemaknaan p≤0,05. hasil penelitian 1. data respons psikologis. tabel 1: data hasil observasi dan analisis uji perbedaan respons penerimaan (psikologis) pada responden di ruang melati rsup dr. soedono madiun. no. perlakuan kontrol jmlh % jmlh % 1 20 100 2 10 2 20 100 10 50 3 20 100 5 25 4 20 100 4 20 5 18 90 3 15 6 20 100 6 30 7 19 95 2 10 8 19 95 2 10 9 20 100 12 60 10 20 100 2 10 ( x ) 15.50 5.50 sd 7.997 0.513 mann whitney test z = 3.879 p = 0.000 tabel 1 menunjukkan hasil yang signifikan, yaitu p=0.000 yang artinya ada pengaruh teknik relaksasi imagery terhadap respons psikologis (penerimaan anak untuk dilakukan tindakan). jurnal ners vol. 2 no. 1 mei – september 2007 2. data respons biologis. tabel 2: data hasil pengukuran dan uji analisis perbedaan tekanan darah, pernafasan dan nadi pada responden di ruang melati rsup dr. soedono madiun. no sistole distole pernafasan nadi p k p k p k p k rerata rerata rerata rerata rerata rerata rerata rerata 1 100 80 70 60 22 28 89 90 2 100 100 90 80 25 29 82 93 3 90 100 70 70 21 27 91 99 4 90 90 60 60 22 30 77 91 5 100 100 70 80 22 27 79 90 6 100 90 60 60 18 26 74 93 7 100 90 60 60 20 29 82 99 8 90 100 60 70 25 31 89 97 9 100 90 70 70 20 28 86 90 10 90 100 60 80 19 29 88 98 ( )x 96.00 94.00 67.00 69.00 21.40 28.40 83.70 94.00 sd 5.164 6.992 9.487 8.756 2.319 1.506 5.774 3.859 independen t t-test p = 0.476 p = 0.630 p = 0.000 p = 0.000 keterangan: p = perlakuan k = kontrol dari tabel 2 diperoleh hasil untuk tekanan darah (sistole) didapatkan hasil p=0.476, artinya tidak ada perbedaan tekanan darah sistole antara kelompok perlakuan dan kelompok kontrol. teknik relaksasi imagery juga tidak berpengaruh pada tekanan darah (diastole) dengan hasil p=0.630. untuk pernafasan diperoleh hasil yang signifikan antara kelompok perlakuan dengan kelompok kontrol (p=0.000). perbedaan tersebut menunjukkan bahwa ada pengaruh teknik relaksasi imagery terhadap frekuensi pernafasan. sedangkan untuk nadi diperoleh hasil yang signifikan antara kelompok perlakuan dengan kontrol (p=0.000). dengan kata lain menunjukkan bahwa ada pengaruh teknik relaksasi imagery terhadap nadi. pembahasan berdasarkan hasil penelitian menunjukkan bahwa ada pengaruh teknik relaksasi imagery terhadap respons penerimaan (psikologis) pada anak usia sekolah yang akan dilakukan tindakan pungsi vena. teknik relaksasi imagery dapat membuat seorang anak menjadi tenang dan rileks saat mendapatkan tindakan pungsi vena. hal tersebut ditunjang dengan hasil wawancara terstruktur. berikut ini hasil content analysis dengan beberapa responden setelah mendapatkan teknik relaksasi imagery. pertanyaan yang diberikan: “bagaimana tanggapan kamu setelah mendengarkan kaset tadi?” jawaban: “senang, ada suara musiknya jadi bisa santai sambil dengerin suaranya, jadi gak terlalu sakit pas diambil darahnya…” “ya cuma senang aja” (sambil tersenyum). jurnal ners vol. 2 no. 1 mei – september 2007 teknik relaksasi imagery adalah teknik relaksasi dengan menggunakan pikiran untuk membayangkan gambar, tempat favorit dan sensasi yang menyenangkan, sehingga mendapatkan ketenangan, menghilangkan rasa sakit dan mempercepat penyembuhan (holisticonline, 2006). stres hospitalisasi yang dialami oleh anak yang menjalani perawatan di rumah sakit akan berpengaruh pada proses perawatan. berdasarkan konsep psikoneuroimunologi, stres selain mempengaruhi imunologi juga mempengaruhi tingkah laku dan emosi. teknik relaksasi imagery dapat menurunkan stres melalui proses kognisi dan emosi di otak, sehingga memberikan respons emosi yang positif (tenang dan rileks) (national safety council, 2004). saat anak diberi teknik relaksasi imagery dengan membayangkan tempat favorit mereka, akan menimbulkan persepsi yang menyenangkan bagi anak. setelah melalui serangkaian proses di otak, persepsi yang menyenangkan tersebut akan memberikan respons emosi yang positif, anak menjadi tenang dan rileks (the texas cancer council, 1999) sehingga menerima saat akan dilakukan tindakan pungsi vena. dari observasi diperoleh responden yang mendapatkan teknik relaksasi imagery selalu kooperatif dan bersedia mengikuti instruksi dari perawat yang akan melakukan pungsi vena. selain itu anak juga dapat mentolerir rasa nyeri pada saat penusukan jarum. berdasarkan hasil analisis dengan independent t-test, dapat disimpulkan bahwa teknik relaksasi imagery hanya berpengaruh pada frekuensi pernafasan dan denyut nadi, namun tidak berpengaruh pada tekanan darah. teknik relaksasi imagery dapat menurunkan stres hospitalisasi yang terjadi pada anak melalui proses kognisi dan emosi. saat koping anak menjadi positif dengan mau menerima tindakan, akan direspons secara biologis melalui jalur hpa axis yang mempengaruhi sistem neuro endokrin (guyton, 1997). hasil penelitian yang didapatkan tidak semuanya mendukung teori yang sudah ada, yaitu tekanan darah. dari hasil yang didapat, diketahui tidak ada perbedaan tekanan darah pada kelompok perlakuan dan kontrol. hal ini diduga bahwa fisiologis tekanan darah dipengaruhi oleh cardiac output, volume darah, resistensi perifer, viskositas darah dan elastisitas pembuluh darah (perry & potter, 2005), sehingga banyak sekali faktor yang menentukan besarnya tekanan darah. tidak ada perbedaan tekanan darah bisa disebabkan oleh penyakit yang diderita responden tidak sama namun semuanya dalam kondisi stabil, sehingga diperkirakan tekanan darah pada semua responden stabil. nyeri yang terjadi pada saat tindakan pungsi vena tersebut berpengaruh pada frekuensi pernafasan dan denyut jantung yang menjadi semakin cepat (guyton, 1997). pada kelompok perlakuan semua responden dapat mentolerir rasa nyeri sehingga frekuensi pernafasan dan denyut jantung atau nadi juga menjadi stabil. namun, ada 2 responden pada kelompok perlakuan yang rerata pernafasannya berada di atas nilai normal. penyebabnya karena derajat reaksi seseorang terhadap nyeri bervariasi. keadaan ini sebagian disebabkan oleh kemampuan otak sendiri untuk menekan besarnya sinyal nyeri yang masuk ke dalam sistem saraf, yaitu dengan mengaktifkan sistem pengatur nyeri disebut sistem analgesik (guyton, 1997). simpulan dan saran simpulan 1. teknik relaksasi imagery memberikan stimulus pada korteks serebri yang akan membuat anak merasa berada di tempat yang aman sehingga menimbulkan persepsi yang menyenangkan bagi anak. hal tersebut berperan dalam aspek emosi sehingga respons psikologis menjadi positif dan anak bisa menerima prosedur invasif. 2. teknik relaksasi imagery melalui jalur hpa axis membantu menghambat rangsangan saraf simpatis di jantung yang berpengaruh terhadap tanda-tanda vital: denyut jantung, tekanan darah dan rerata pernafasan. jurnal ners vol. 2 no. 1 mei – september 2007 saran 1. teknik relaksasi imagery dapat dijadikan prosedur tetap di rumah sakit sebelum melakukan prosedur invasif dengan memperhatikan lingkungan dan suasana rumah sakit yang tenang dan kondusif. 2. perlu adanya pendampingan dari perawat untuk memberikan teknik relaksasi imagery pada saat pelaksanaan pungsi vena untuk mengatasi dampak yang ditimbulkan oleh stresor hospitalisasi yang berupa nyeri dan perlukaan tubuh. 3. penelitian selanjutnya tentang pengaruh teknik relaksasi imagery terhadap respons biologis dapat dilakukan dengan mengukur kadar katekolamin dalam darah dan menggunakan sampel yang lebih besar. kepustakaan american pain society, (2003). pain management in children needs improvement. http://www.jama.com. tanggal 22 maret 2006. jam 11.30 wib. case western reserve university, (2004). imagery reduces children’s postoperative pain. http://www.docguide.com. tanggal 26 maret 2006. jam 10.05 wib. church, j., et al., (2006). guided imagery in colateral surgery. http://www.guidedimageryinc.com. tanggal 21 maret 2006. jam 11.20 wib. ellis, j. a. (2004). survey of intervention for needle procedures. http://www.medscape.com. tanggal 21 maret 2006. jam 10.05 wib. holistic online, (2003). guided imagery or visualitation, http://www.holisticonline.com. tanggal 22 maret 2006. jam 11.20 wib. national safety council, (2004). manajemen stres, jakarta: egc. nursalam, dkk, (2005). asuhan keperawatan bayi dan anak, jakarta: salemba. perry & potter, (2005). fundamental keperawatan, jakarta: egc. the american journal of cardiotoracic. (2006). cardiotoracic surgery. http://www.guidedimageyinc.com. tanggal 21 maret 2006. jam 11.20 wib. wong, d.l., (1999). nursing care of infant and children, st. louis missouri: mosby year book. guyton & hall, (1997). fisiologi kedokteran, jakarta: egc. the texas cancer council, (1999). guided imagery. http://www.childcancerpain.com. tanggal 22 maret 2006. jam 11.43 wib. http://www.jama.com/ http://www.docguide.com/ http://www.guidedimageryinc.com/ http://www.medscape.com/ http://www.holistic-online.com/ http://www.holistic-online.com/ http://www.guidedimageyinc.com/ http://www.childcancerpain.com/ 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 196 physical function–tardive dyskinesia (pftd) on critical patients in intensive care unit heru suwardianto*, selvia david richard*, awal prasetyo**, reni sulung utami** *adult nursing, critical nursing department, kediri baptist hospital health science college, jl. mayjend panjaitan no. 3b, kediri, jawa timur, indonesia **faculty of medicine, diponegoro university, jl. prof. soedarto, tembalang, kota semarang, jawa tengah, indonesia e-mail: herusuwardianto@gmail.com abstract introduction: critical patients are patients who potentially get reversible dysfunction in one or more life-threatening organs and require care in the intensive care unit (icu). methods: the objective of this research is to analyse the physical function-tardive dyskinesia in critical patients with sedation in the icu. the design of this research is cross-sectional. the population is all of the critical patients in the icu of the baptist hospital in kediri. the purposive sample population was 41 respondents based on the inclusion and exclusion criteria. the variables are ‘giving the sedation’ and ‘physical functiontardive dyskinesia’. the data was collected using a motor activity assessment, and the sedation scale for critically ill patients and tardive dyskinesia screening. results: the results showed that giving sedation can slow physical function in the form of motor activity; the response of noxious stimuli (7.3%), response to touch or calling name (19.5%) and an increasing score of agitation and co-operative (4.9%). symptoms of tardive dyskinesia increased after sedation in the form of tongue protrusion (4.9%), lip-smacking, puckering and pursing (2.4%), and rapid movements of the arms and legs. the administration of sedation in the first 24-hours in icu patients affects the physical function of the critical patients (p = 0.005). conclusions: giving sedation affects the patients’ physical functions. therefore, the prevention of the effects of sedation and treatment during icu is needed in order to avoid a decrease in the physical function of critical patients. keywords: critical patient, icu, physical function, sedation, tardive dyskinesia introduction critical patients are patients who potentially get reversible dysfunction in one or more life-threatening organs, and require treatment in the intensive care unit (icu) (ireland, 2011; marianne, 2016). the prevalence of critical patients in icus continues to increase every year. the world health organization (who) in 2016 reported that deaths from critical illness through to chronic illness in the world increased by 1.1 to 7.4 million people and that there were 9.8 to 24.6 critical ill patients and treated in icu per 100,000 population (garland et al., 2013). post-icu patients have a wide range of potential health problems from previous treatments in the icu. patients with post-icu problems are commonly referred to as having post-intensive care syndrome (pics). postintensive care syndrome is a health problem that persists for long periods after the patient leaves the icu and it is a very important nursing problem that needs to be resolved (davidson et al., 2013). post-intensive care syndrome is a collection of three symptoms of a given problem or disorder in the form of the worsening picture of the weakness status of physical function, cognitive function and anxiety (mental health) during critical illness and after the patient is out of the icu (needham et al., 2012). critical patients directly relate to the discomfort that has noncooperative effects. the patient will describe pain with various verbal or non-verbal manifestations. critical patients treated in an intensive space with discomfort will receive sedation therapy. critical patients experience sedation due to the medical management performed by health workers in intensive care. giving opioids to reduce the pain response, anxiety or involuntary motions is important because the pathological disease makes it necessary. sedation in the form of opioids can affect the condition of the bodily functions and depress the central nervous system. sleep deprivation is the result of agitation-sedation. sedation management can have the side effects of sedation and the risk factors are highest amongst the elderly to do with analgesic and sedative treatment (carson et al., 2006). respiratory depression may occur as a frequent effect. nurses should be able to identify and analyse the agitation state of the given sedation. the visible effects can be either verbal or non-verbal in relation to the patient response. if the nurse cannot know and analyse the end result of the sedation effect and the action to be taken, then the patient's condition may get worse because they cannot be assessed quickly by the nurse. the patient's physical function–tardive dyskinesia (pftd) on ... (heru suwardianto, et.al.) 197 critical condition needs a quick and precise assessment. critical patients during icu will lose 20% of their muscle volume, and 70% of their proteins in a week (pandharipande et al., 2013). the study also found that out of 476,862 patients (60% -80% of total post-icu patients), 30% of them were unable to return to work (non-productive) due to muscle loss of 1% -2% each day after the patient left the icu (cartwright, 2012; davidson et al., 2013). patients with a loss of muscle function can be observed from the motor activity and reaction conditions of the sedation process. the decreased cognitive function is associated with decreased brain oxidative metabolism that causes neurotransmitter changes in the prefrontal and subcortical regions, or when there is a decrease in cholinergic and increased dopaminergic activity when serotonin levels and gaba (gamma-aminobutyric acid) levels are significant (nathan e, brummel, james c. jackson, 2013). the results showed that cognitive impairment occurred in 24% 34% of the patient sample. the decrease in cognitive function is similar to that of traumatic brain injury (34%) and the patients are similar to those with alzheimer's disease and delirium (24%). (cartwright, 2012; iwashyna et al., 2012; needham, 2012; davidson et al., 2013; pandharipande et al., 2013; jackson et al., 2014; t. j. iwashyna, 2014; sottile, peter, amy nordon-craft, daniel malone, darcie m. luby, margaret schenkman, 2015). physical and cognitive impairment is caused by a history of mechanical ventilation (33%), infection or sepsis (50%), spending 2 weeks to >1 week in icu (> 50%), delirium and various critical illnesses or sepsis (70%), coronary heart disease (36.6%), chd unstable angina (ua) (41.5%), hypertension (19.5%), supraventricular tachycardia (svt) (2.4%), and the signs and symptoms of tardive dyskinesia (davidson et al., 2013; t. j. iwashyna, 2014; hoffman and guttendorf, 2015; suwardianto, 2016). the main causative factors are long-term care (≥2 days) and minimal mobilisation. other causative factors include previous medical history (health status and previous disease history), acute illness, critical illness (liver disease, hypoxia, hypotension, glucose dysregulation, respiratory failure, shock, chf (congestive heart failure), sepsis and other diseases of similar severity, inflammation, loss of strength, sedation, and increased anxiety levels (needham, 2012; needham et al., 2012; hopkins, 2013; jackson et al., 2014; t. iwashyna, 2014). if in icu, then the problem will arise and impact on the health of post-icu patients. the impact of the decreased physical functions associated with motor degradation (motor activity) will worsen and weaken the function of the other organs if not immediately prevented in icu (nathan e, brummel, james c. jackson, 2013). the impact of physical function in icu patients and after they are out of the icu is down to the increased length of treatment, decreased cognitive function, decreased physical function (organs, muscle contractions, function and pain, vitality, fatigue), and worsening mental health (anxiety), emotional responsiveness, depression, reflectiveness, loneliness and the inability to perform activities and the use of instruments in everyday life. the phenomenon of post-icu post-cognitive decline in relation to physical function and cognitive implications indicates a decline in the health of the patients, especially to do with the physical, cognitive and mental health functions of anxiety, and the need for intervention strategies in the icu in its prevention. the prevention to minimise the incidences of post-icu physical and cognitive impairment should be performed in accordance with the role of critical nurses. materials and methods the design of this research is crosssectional. the population is all of the critical patients in the intensive care installation of baptist hospital, kediri. the sample population size is 41 respondents according to the inclusion criteria of patients who received the first 24 hours of their treatment in intensive care. the data collected was done using an instrument of motor activity assessment, the sedation scale for critically ill patients and tardive dyskinesia screening. the motor activity assessment scale (mass) was developed by devlin in 1999. maas is valid and reliable for use on patients in the icu (devlin, 1999). the data collection has been done after completing the research proposal. the researcher get ethical clearance from kepk medical faculty of diponegoro university with letter number 150 / ec / fkjurnal ners vol. 12 no. 2 oktober 2017: 196-204 198 table 1. characteristics of respondent (n=41) characteristics frequency (f) percentage (%) gender male 15 36,6 female 26 63,4 age < 35 1 2,4 35 – 39 years 1 2,4 40 – 44 years 4 9,8 45 – 49 years 7 17,1 50 – 54 years 3 7,3 > 55 years 25 61,0 medical diagnosis chd 15 36,6 chd ua 17 41,5 chd ua+ht 8 19,5 chd svt 1 2,4 sedation morphine 2,5 mg iv prn 41 100 note: chd: coronary heart disease; ua: unstable angina; ht: hypertension; svt: supraventricular tachycardia; mg: milligrams; prn: pro re nata. rsdk / iv / 2017, and the researcher submitted and achieved research permission from diponegoro university semarang to director of rs. baptist kediri. the researchers also obtained approval from the director of the hospital, baptist kediri, and initiated data collection at the icu. the researcher obtained informed consent before doing the research. the subjects, if willing, signed the approval sheet. the researcher gave clear information to the respondent's family/guardian regarding the purpose and procedure of the research before collecting the data. the researcher convinced the respondent's family that the research had an adverse effect on the prospective respondent, and the researcher gave the opportunity for them to ask if it was not clear. the study was conducted for 1 month in july 2017. the data was collected by direct measurements from the patients and an observation of the patient’s response. the data analysis was done with distribution frequency, cross-tabulation and an independent t-test with < 0,05. results the results of the research of critical patients in relation to general data, cardiac workload, sedation scale for the critical ill and physical function-tardive dyskinesia are described in table 1. table 1 shows that most of the respondents are male (63.4%). most of the respondents are >55 years of age (61.0%). the respondents diagnosed with ua (unstable angina) was 41.5% of respondents. all of the respondents were given morphine sedation of 2.5 mg iv prn. the demographic data of the critical patients in icu shows that most of the women were aged >55 years old. this is possible because after 55 or 60 years (menopausal stage), hypertension is more prevalent in women (estrogen-prevalent hormone loss) than in men (suwardianto and selvia, 2015). the respondents, in the first 24hours of assessment in icu, showed that the patients were installed heart monitors, oximetry monitors to measure oxygen saturation, and identification of the patient’s gender, age, and medical diagnosis. when the critical patients had anxiety and showed noncooperative behaviour, then the nurses gave them morphine; 2,5 mg iv. table 2 shows that there was a decrease in systolic blood pressure (sbp) (7.0 mmhg), diastolic blood pressure (dbp) (6.4 mmhg), heat rate (1.5 times/min) and respiration rate (0.5 times / min). an increase in oxygen saturation was as high as 0.2%. the data shows the systolic blood pressure before giving sedation consisting of morphine 2.5 mg having a mean of 131.7 mmhg and 15 minutes after sedation decrease 7.0 mmhg with a mean systolic blood pressure of 124,7 mmhg. the diastolic blood pressure prior to morphine sedation of 2.5 mg was the mean of 88.1 mmhg and 15 minutes after sedation; this decreased by 6.4 mmhg with a mean of diastolic blood pressure of 81.7 mmhg. heart rate before being given morphine of 2.5 mg had a mean of 87.0 times / minute and 15 minutes after sedation; this decreased the heart rate by 1.5 times per minute with a mean of 85.5 times per minute. respiration rate prior to morphine sedation od 2.5 mg had a mean of 24.4 times / min (tachypnea) and 15 minutes after sedation this decreased by 0.5 times per minute with a mean respiration rate of 23.4 times per minute (tachypnea). oxygen physical function–tardive dyskinesia (pftd) on ... (heru suwardianto, et.al.) 199 saturation prior to morphine sedation of 2.5 mg had a mean of 98.5% and 15 minutes after sedation this increased by 0.3% to 98.8% oxygen saturation. chd patients treated at the intensive care installation performed the overall observation using a pre-set cardiac monitor. based on figure 1, it was found that the sedation scale for critically ill patients before and after the patient got sedation was on a scale of 2 (36.6% to 34.4%). figure 2 shows that the decrease in physical function was found prior to sedation. physical function of scale 2 (responsive to touch or name) was in as much as 15 respondents (36.6%), and after sedation, most critical patients had a physical function measurement of scale 3 (calm and cooperative) in as many as 25 respondents (61.0%). critical patients who had decreased physical function and cognitive function were patients observed as being agitated through to agitative. physical function occurred in the form of motor activity after sedation in conditions that were responsive only to noxious stimuli (7.3%), responsive to touch or name (19.5%) and had an agitation and cooperative score (4.9%). the characteristics of physical dysfunction in patients with tardive dyskinesia signalling approach in patients with chd before sedation showed 5 signs of tardive dyskinesia whereas 15 minutes after morphine sedation of 2.5 mg via iv, all signs of tardive dyskinesia arose, despite an increase in the respondents who showed no signs of tardive dyskinesia in 26 respondents to 30 respondents. the patients showed repetitive grimacing, lip smacking, puckering, pursing and rapid movements of the arms and legs. it is a response to the discomfort interpreted throughout the central nervous system after the termination of treatment. signs and symptoms of tardive dyskinesia increased after sedation in the form of tongue protrusion (4.9%), lip smacking, puckering and pursing (2.4%), and rapid movements of the arms and legs. a paired sample t-test was conducted to compare tardive dyskinesia before sedation and 15 minutes after sedation. there was no significant difference in the score before sedation and 15 minutes after sedation (p=0,317, mean=9, sd=1.9). a paired sample t-test was conducted to compare physical function before sedation and 15 minutes after sedation. there was a significant difference in the score before sedation and 15 minutes after sedation (p=0.005, mean=0.09, sd=2.4). these results suggest that sedation really does have an effect on the physical function of critically ill patients in icu. discussion based on the results of the study, the provision of sedation does not affect the changes in the physical function indicator of tardive dyskinesia (0.317). the characteristics of a physical function under tardive dyskinesia in critical patients before and after sedation shows that the patients have repetitive grimacing, lip smacking, puckering, pursing, and rapid movements of the arms and legs. it is a response to the discomfort interpreted through the myelin of the central nerves. the decline in the physical function aspect of tardive dyskinesia is a neurological syndrome associated with the prolonged use of neuroleptic drugs. the characteristics of tardive dyskinesia are repetitive facial movements, uncontrolled movements (involuntary) and unintentional movements. tardive dyskinesia is found by the cessation of table 2. characteristics of cardiac workload respondents (n=41) indicators mean x1x2 before sedation (x1) 15 minutes after sedation (x2) systolic blood pressure (mmhg) 131,7 124,7 -7,0 mmhg diastolic blood pressure (mmhg) 88,1 81,7 -6,4 mmhg heart rate (beat/minute) 87 85,5 -1,5 time/minutes respiration rate (beat/minute) 24,4 23,4 -0,5 time/minutes oxygen saturation (%) 98,5 98,8 0,30 % jurnal ners vol. 12 no. 2 oktober 2017: 196-204 200 figure 1. characteristics of sedation scale for critically ill patients on critical patients in intensive care unit (n=41) notes: (barr et al., 2013; aitken, marshall and chaboyer, 2016): scale 0: unresponsive; scale 1: responsive only to noxious stimuli; scale 2: responsive to touch or name; scale 3: calm and cooperative; scale 4: agitated; scale 5: dangerously agitated uncooperative. figure 2. physical function on critical patients in intensive care installation (n=41) suffix treatment. the symptoms may be present during treatment and after treatment was discontinued. tardive dyskinesia includes repetitive grimacing, tongue protrusion, lip smacking, puckering, pursing, rapid eye blinking, and rapid movements of the arms and legs. the results showed that no significant change was possible as the respondents still responded to neuroleptic associations and some of the respondents still received a strong sedation titration (morphine). tardive dyskinesia presented in the patients because of rapidly changing neurologic myelin due to changes in the sedation dose or the cessation of sedation. based on the results of the research, it was found that sedation has an influence significantly on physical function (p = 0,005) and the condition of the decreasing of physical and cognitive function manifests in the form of agitation. based on the results of the research, it was found that the physical function measurements before being given sedation resulted in the patients responding when touched or called by their name manifested in 15 respondents (36.6%). physical function after the sedation of most critical patients resulted in them being calm and cooperative manifested in 25 respondents (61.0%). physical function, which is described as a decrease in physical and cognitive function, is possible in patients who get sedation and can lead to a state of agitation. the patients can be described as being unresponsive – those that cannot move or move with the noxious stimulus (suctioning, sternal pain response). the patients could also respond to noxious stimuli; i.e. opening their eyes, raising their eyebrows, turning their head and arm movements. the respondents could also show responsiveness towards touch or their name (scale 2), using their eyebrows, turning their head, arm movements by touch or calling their name aloud. the patients are expected to be calm and cooperative in their response (scale 3) i.e. no external stimulus that occurs for the occurrence of movement, and the patient means that they can adjust to the movement and follow the command. restless and cooperative patients (scale 4) means that the patient can take a blanket or glass, cover himself, and follow orders. patients experiencing agitated circumstances (scale 5) i.e. no external stimuli are patients trying to stand, have the movement of their arms out of bed and do not consistently follow commands. in this condition, the patients can be in a dangerously agitated and uncooperative (scale 6). uncooperative patients are patients that withdraw their gastric tube or urinary catheter, whack/attack officers and are not calm when asked. the results showed that sedation significantly influenced physical function where the sedation response was in the form of morphine 2.5 mg. it could decrease the motor activity level of the patient which initially means that patients with agitation could be lowered to a more cooperative level. the role of the nurse in knowing the condition of the patient before and after the sedation changes physical function–tardive dyskinesia (pftd) on ... (heru suwardianto, et.al.) 201 the motor response due to relaxation. the nurse must be able to know the conditions through the motor activity indicator. excessive motor responses can increase heart burden and anxiety in patients, but patients who are able to achieve relaxation with or without sedation will be warned of the potential parasympathetic activity of the nerves, particularly those of the vagus (suwardianto, 2014). this can decrease the cardiac workload in critical patients with anxiety. based on the results of the sedation studies, sedation affects the sedation scale for critically ill patients (0.005). the result showed that the sedation scale for critically ill patients before and after the patient got sedation was on a scale of 2 (36.6% to 34.4%). poor agitation is where the movement of the body, unwillingness to undergo treatment/procedures or restrictions of the movement of the body significantly endangers both patients and officers. the sedation scale for critically ill patients is an assessment tool specifically used by nurses in identifying the agitation scale in critical patients. indicators of the sedation scale for critically ill patients are consciousness, agitation, anxiety, sleep, and patients with attached ventilators. consciousness identifies that the patient is awake, conscious of himself and the environment (good orientation). agitation identifies that the patient affects the patient's body/patient safety. the anxiety indicator is that the nurses see the patient's anxiety (faces anxiety). the sleep indicator is when the nurse observes sleep and the sleep quality perceived by the patient. the indicator of the patient with an attached ventilator is where the nurse observes the respiratory pattern relative to the ventilator. the results show that there is a significant change in agitation scale that indicates that agitation decreases with sedation. the agitation scale gets worse; the worse the patient's condition, the more it also affects the condition of the patient's response in healing in the nursing area. patients, after being given morphine sedation 2.5 mg iv, were at level 2 before and after. the better the patient and the patient’s cooperativeness, the table 4. tardive dyskinesia in critical patients at intensive care installation (n=41)* indicators before sedation (x1) 15 minutes after sedation (x2) x1x2 fr % ff % % there is no sign of tardive dyskinesia 26 63,4 30 73,1 9,7 have signs and symptoms of tardive dyskinesia 15 36,6 11 26,9 -9,7  repetition grimacing 5 12,2 3 7,3 -4,9  tongue protrusion 1 2,4 3 7,3 4,9  lip smacking, puckering, and pursing 0 0 1 2,4 2,4  rapid eye blinking 1 2,4 1 2,4 0  rapid movements of the arms and legs 11 26,8 7 17,1 -9,7 notes: *) the patient may show more than one sign on the tardive dyskinesia indicator or even none at all. sign (-) is a decline in value; fr: frequency) table 5. analysis of variables on sedation administration in critical patients at intensive care installation (n=41) paired differences t df sig. (2tailed) mean std. deviation std. error mean 95% confidence interval of the difference lower upper pair 1 tardive dyskinesia 9.00000 1.90010 .40510 -.75155 .93337 .224 21 ,317 pair 2 physical function .09091 2.44949 .52223 7.91396 10.08604 17.234 21 ,005 jurnal ners vol. 12 no. 2 oktober 2017: 196-204 202 more the patient will be able to show good conscience. the results show that there is a decrease in systolic blood pressure (sbp) (7.0 mmhg, diastolic blood pressure (dbp) (6.4 mmhg, heat rate (1.5 times / min), respiration rate (0, 5 times / min.) and a 0.2% oxygen saturation increase. critical patients with chd have a disease condition in which the blood vessels that supply food and oxygen to the heart muscle are blocked. the blockage is most often the result of cholesterol build-up in the coronary vein wall (kurniadi, 2013). the combination of hypoxia, decreased energy availability and acidosis rapidly will impair the function of the left ventricle. the contraction of the affected part of the heart muscle will decrease because the muscle fibres are not sufficiently shortened so that the strength and acceleration of the resulting flow decreases. moreover, in the ventricular wall, an abnormal movement occurs in ischemia so that the blood circulated in each contraction will decrease. blood through the coronary arteries will restore normal aerobic metabolism and cardiac contractility. however, if the blood flow cannot be recovered, then myocardial infarction will occur. the results of the research show that there is a change before and after being given sedation on cardiac workload, i.e. sbp decreased by 7.0 mmhg, dbp decreased by 6.4 mmhg, hr decreased 1.5 times/ min, rr decreased 0.5 times / minute, and there was an increase of 0.2% oxygen saturation in critical patients. the role of the nurse in identifying the cardiac workload needs to be improved, and there is a need for collaboration in nursing actions to improve the repair of the cardiac workload. the identified cardiac workload, i.e., blood pressure, hr, rr, and sao2 have all changed from the baseline before sedation. the administration of sedation to provide a calming effect may result in a change in the value of the cardiac workload after 15 minutes after sedation in the form of morphine 2.5 ml. giving sedation improves the parasympathetic response to the cardiac workload, so the nurses should be able to monitor meaningful changes after sedation. the role of the nurse becomes very important in identifying and implementing independent actions as the result of anxiety identification rather than strengthening the effects of sedation alone. they must be able to support patients in reducing anxiety, agitation, or pain by providing self-interventions and environmental modification. critical nurses are expected to be able to apply effective management (transformation) by developing themselves in their communication, critical thinking and being able to change the environment (suwardianto, 2015), so that nursing care in critical patients can have a gold standard in establishing the quality of nursing care in patients. conclusions the characteristics of physical dysfunction in patients with tardive dyskinesia signalling approach in patients showed 5 common signs. patients show repetitive grimacing, lip smacking, puckering, pursing and rapid movements of the arms and legs. it is a response to the discomfort interpreted throughout the central nervous system after termination of treatment. signs and symptoms of tardive dyskinesia increased after sedation in the form of tongue protrusion, lip smacking. puckering, pursing and the rapid movement of the arms and legs. the results of this research suggest that sedation really does have an effect on physical function in the critically ill patients in icu. the research shows that patients with the administration of sedation in the first 24-hours of icu care effects physical function. the results of the study on these interventions only measure the effectiveness of the long-term disruption of physical-cognitive function and when the patient returns from the hospital. as the result of the research into early activity intervention, intervention only measures the improvement of physical function in the posticu patient. the results of the cognitive therapy intervention study in critical patients in the icu only measures the increase in physical function in isolation in post-icu patients so any other problems will still occur. as a recommendation, sedation can affect the physical functioning of critical patients. deep and immeasurable sedation will further impair physical functioning. sedation management is required in the provision of collaborative nursing care. giving sedation significantly affects the decrease in physical function. critical care nurses are expected to be able to identify the decline in physical and cognitive function in the icu in order to physical function–tardive dyskinesia (pftd) on ... (heru suwardianto, et.al.) 203 improve the quality of care and quality of life of the patient after discharge from the icu. recommendations for nursing care that can be given include the management of pain and sedation. proper management of pain and sedation is very useful in the determination of subsequent management. the icu nurses prior to giving patients better sedation should perform pain management first. the decrease in physical function that occurs in critical patients in icu can be countered with physical therapy to increase muscle strength and to avoid apoptosis. references aitken, l., marshall, a. and chaboyer, w. (2016) acccn’s critical care nursing. 3rd edn. australia: elsevier health sciences. barr, j. et al. (2013) ‘clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit’, society of critical care medicine, the american college of critical care medicine (accm), 41(1), pp. 263– 306. carson, s. s. et al. (2006) ‘the changing epidemiology of mechanical ventilation: a population-based study’, j intensive care med, 21. doi: 10.1177/0885066605282784. cartwright, m. m. (2012) the high incidence of post intensive care unit (icu) anxiety and depression, psychology today. davidson, j. e. et al. (2013) ‘post-intensive care syndrome’, society of critical care medicine, 1(1), pp. 1–4. devlin (1999) ‘motor activity assessment scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit’, crit care med, 27(7), pp. 1271–5. garland, a. et al. (2013) ‘epidemiology of critically ill patients in intensive care units: a population-based observational study’, critical care, 17(5), p. r212. doi: 10.1186/cc13026. hoffman, l. a. and guttendorf, j. (2015) post intensive care syndrome: risk factors and prevention strategies, ahc media. hopkins, r. o. (2013) ‘strategies to ensure long-term quality of life in icu survivors’, society of critical care medicine, 1(1), p. 1. ireland (2011) national standards for adult critical care services. ireland: joint faculty of intensive care medicine of ireland (jfcmi) in association with the intensive care society of ireland (icsi). iwashyna, t. (2014) ‘what you need to know about post-intensive care syndrome (pics)’, health system-university of michigan, 1(1), pp. 1–3. iwashyna, t. j. et al. (2012) ‘population burden of long-term survivorship after severe sepsis in older americans’, journal compilation © 2012, the american geriatrics society, 60(6), pp. 1070–1077. iwashyna, t. j. (2014) ‘post-intensive care syndrome: improving the future of icu patients’, 24nd critical care congress review, 1(1), pp. 13–16. jackson, j. et al. (2014) ‘depression, posttraumatic stress disorder, and functional disability in survivors of critical illness in the brain-icu study: a longitudinal cohort study’, the lancet respiratory medicine, 2(5), pp. 369– 379. kurniadi, h. (2013) stop gejala penyakit jantung koroner. 2013: familia. marianne (2016) ‘about critical care nursing’, american association of critical-care nurses, p. 1. nathan e, brummel, james c. jackson, t. d. g. (2013) ‘a combined early cognititive and physical rehabilitation program for people who are critically iil: the activity and cognitive therapy in the intensive care unit (act-icu) trial’, physical therapy critical illness, 92(12), pp. 1580–1592. needham, d. m. et al. (2012) ‘improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference’, the society of critical care medicine and lippincott williams & wilkins, 40(2), pp. 502–509. needham, d. m. (2012) ‘improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference’, critical care medicine, 40(2), pp. 502–509. jurnal ners vol. 12 no. 2 oktober 2017: 196-204 204 pandharipande, p. et al. (2013) ‘long-term cognitive impairment after critical illness’, the new england journal medicine, 369(14), pp. 1306–1316. doi: 10.1056/nejmoa1301373. sottile, peter, amy nordon-craft, daniel malone, darcie m. luby, margaret schenkman, m. m. (2015) ‘physical therapis treatment of patients in the neurogical intensive care unit: description of practice’, physical therapy, 95(7), pp. 1006–1014. suwardianto, h. (2014) ‘the effectiveness of deep breathing and slow stroke back massage to decrease the blood pressure on a patient with hypertension’, indonesian nursing journal of education and clinic (injec), 1(1), pp. 1–12. suwardianto, h. (2015) buku ajar keperawatan kegawatdaruratan (perspektif, konsep, prinsip, dan penatalaksanaan kegawatdaruratan). 1st edn. surabaya: pt. revka petra media. suwardianto, h. (2016) ‘tardive dyskenesia, motor activity, sedation scale, and cardiac workload in baptis kediri hospital’, tardive dyskenesia, motor activity, sedation scale, dan cardiac workload, 4(1), p. 1. suwardianto, h. and selvia, d. (2015) buku ajar keperawatan kegawatdaruratan (perspektif, konsep, prinsip, dan penatalaksanaan kegawatdaruratan). surabaya: pt. revka petra media. 81 peningkatan kebersihan diri pada pasien halusinasi dengan pendekatan metode partisipatif dan rewards (the increase of self personal hygiene patient with hallusination by nursing methods of partisipatif and rewards approach) sirajudin noor*, heny desyi rubiyana*, adijani al-alabij* *akper intan martapura banjarmasin sulawesi selatan jl. samadi no. 1 martapura banjar, kalimantan selatan email: judin@gmail.com abstract introduction: the number of mental disorder has been increased dramatically and it is predicted that one out of four citizen suffered with mental disorder. the commonest problem for the patient schizophrenia with hallusination is unfullfi ll of basic needs. the objective of the study was to analyse the effect of partisipatif and reward approach on the need of basic human in term of feeding, toileting, dressing, bathing, and moving patient with halusination sambang lihum hospital in banjarmasin. method: design of the study was pra-experimental, static-group comparison design. fifty fi ve (55) sampel was recruited by purposive sampling for patient schizophrenia with halusination stabil condition and calm.the sample were divided into two goups contol and intervention group. data were collected by check list and observation of the status of self personal care. data were analysed by wilcoxon and mannwhitney with signifi cancy level α < 0.05. result: result showed that methods of partisipatif and rewards effect on the self personal hygiene for the patient with hallusination, with p = 0.001. discussion: partisipatif and reward methods was effective on the increase of self personal hygienne for the patient with hallusination. keywords: methods of partisipatif and rewards, hallusination, self personal hygiene pendahuluan gangguan jiwa (mental disorder) merupakan salah satu dari empat masalah kesehatan yang utama selain penyakit degeneratif, kanker dan kecelakaan. meskipun tidak menyebabkan kematian secara langsung namun gangguan jiwa dapat menyebabkan ketidakmampuan serta invaliditas baik secara individu maupun kelompok sehingga berpotensi menghambat pembangunan (hawari, 2001), serta pengaruhnya pada produktivitas manusia dan juga kaitannya dengan kasus-kasus kriminal seperti bunuh diri (departemen kesehatan, 2000). menurut data empiris world health organitation (who) menyebutkan tahun 2007, tiga per mil penduduk suatu wilayah mengalami gangguan jiwa dan 19 per mil mengalami stres bahkan diperkirakan pada saat ini, 450 juta orang di seluruh dunia terkena dampak permasalahan jiwa, saraf, maupun perilaku dan jumlahnya terus meningkat. lebih jauh telah diprediksi oleh who bahwa satu dari empat keluarga memiliki sekurang-kurangnya satu anggota keluarga yang memiliki gangguan mental. survei badan pusat statistik (bps) kalimantan selatan tahun 2003, jumlah permintaan pelayanan kesehatan jiwa di kalimantan selatan pada tahun 2003 sebanyak 3.201.962 jiwa diketahui angka kesakitan jiwa berat dengan jumlah 128.079 jiwa, sedangkan populasi anak sebanyak 128.079 jiwa dan yang perlu penanganan jiwa 192.000 jiwa. sebagian besar pasien gangguan jiwa yang dirawat di rumah sakit mengalami halusinasi. pasien dengan halusinasi adalah sering mengalami gangguan pemenuhan perawatan diri (baihaqi,dkk. 2005). banyak gangguan kesehatan yang diderita seseorang karena tidak terpeliharanya kebersihan perorangan dengan baik, gangguan fi sik yang paling sering terjadi adalah gangguan membran mukosa mulut, infeksi pada mata dan telinga, gangguan fi sik pada kuku dan yang jurnal ners vol. 7 no. 1 april 2012: 81–87 82 paling banyak ditemukan penyakit kulit dan gangguan integritas kulit. masalah sosial yang berhubungan dengan kebersihan diri adalah gangguan kebutuhan rasa nyaman, kebutuhan dicintai dan mencintai, kebutuhan harga diri, aktualisasi diri dan gangguan interaksi sosial (folkman, 1985). ekpresi secara verbal apa yang dirasakan pasien, menumbuhkan perasaan positif terhadap diri, penerimaan diri dan konsep dirinya, dengan cara mengkomunikasikan dan memberikan motivasi serta dukungan berupa nasehat dan reward (hadiah) agar pasien dapat berinteraksi dan bekerja sama dengan peneliti. upaya untuk meningkatkan perawatan diri pada pasien halusinasi yaitu dengan menggunakan metode partisipatif dan metode pemberian reward (hadiah) berupa alat mandi (sabun) untuk memberikan motivasi pasien halusinasi melakukan status pemeliharaan kebersihan dirinya sendiri. tujuan penelitian ini adalah untuk menganalisis pengaruh metode partisipatif dan metode pemberian reward (hadiah) terhadap perawatan diri pada pasien halusinasi di rumah sakit jantung (rsj) sambang lihum banjarmasin. bahan dan metode rancangan penelitian ini menggunakan ekperimen dengan pendekatan pra eksperimen, yaitu mengukur perawatan diisi sesudah pemberian intervensi metode partisipasif dan reward pada kedua kelompok. populasi pada penelitian ini adalah semua klien halusinasi yang dirawat di rsj sambang lihum banjarmasin dengan jumlah 118 orang. teknik sampling yang digunakan adalah dengan menggunakan nonprobability sampling dengan pendekatan purposive sampling, yaitu berdasarkan pada pertimbangan tertentu yang dibuat oleh peneliti sendiri yaitu pada klien halusinasi (nursalam, 2008). sampel pasien halusinasi dengan jumlah 55 orang dengan kriteria inklusi klien halusinasi yang tidak mengarah keperilaku kekerasan dan tenang. sampel pasien halusinasi pada kriteria inklusi adalah 55 orang kemudian dibagi menjadi kelompok a 25 orang dan kelompok b 30 orang. instrumen yang digunakan adalah dengan observasi dan wawancara. alat yang digunakan pada penelitian ini adalah alat mandi sabun, shampo (untuk keramas), dan pasta gigi (gosok gigi) yang digabung dengan peralatan mandi pasien lainnya; buku catatan dan pulpen; dan jadwal kegiatan klien. evaluasi dilakukan saat proses tak berlangsung, khususnya pada tahap kerja. aspek yang dievaluasi adalah kemampuan klien sesuai tujuan tak. kemampuan yang diharapkan melakukan apa yang telah diberikan oleh terapis. pengumpulan data dan analisis. kelompok a dengan mengisi lembar check list materi yang diisi oleh peneliti mengenai hal-hal yang telah disampaikan menggunakan metode partisipatif (tak) pada setiap indikator ada empat point pemberian yang harus disampaikan, sedangkan kelompok b dengan menggunakan lembar observasi yang akan diisi oleh orang kedua. tempat penelitian dilaksanakan di rumah sakit jiwa sambang lihum banjarmasin. waktu penelitian dilaksanakan pada hari kamis, tanggal 9–16 juni 2011. analisis data yang dilakukan setelah semua data terkumpul berupa observasi yang diisi oleh pihak kedua, kemudian data tersebut diperiksa peneliti untuk mengetahui kelengkapan isi datanya. setelah data lengkap, dikelompokkan berdasarkan indikator (kulit, rambut, gigi dan mulut). analisis statistik yang digunakan adalah uji mann-whitney u-test. untuk menguji beda mean dari dua sampel. uji u ini tidak memerlukan asumsi distribusi normal dan homogenitas varians. hasil secara geografis rumah sakit jiwa sambang lihum terletak di wilayah kecamatan gambut kabupaten banjar provinsi kalimantan selatan. rumah sakit ini terletak 600 m dari jalan gubernur syarkawi km 3,9 arah timur. jalan gubernur syarkawi merupakan rencana jalan lintas kalimantan selatan kalimantan tengah. rumah sakit ini didirikan pada area ± 10 hektar, luas bangunan yang ada saat ini adalah 11.530 m² dan tanah yang ditempati merupakan tanah milik pemerintah provinsi kalimantan selatan (profil rsj sambang lihum tahun 2007–2009). pada tahun 2008 peningkatan kebersihan diri (sirajudin noor) 83 rumah sakit ini memiliki 75 kapasitas tempat tidur tahun 2009 memiliki 200 kapasitas tempat tidur dan pada tahun 2010 telah memiliki 300 kapasitas tempat tidur. jumlah ruang rawat inap yang ada di rumah sakit ini terdiri dari 16 ruangan yang terdiri dari 2 ruang rehabilitasi napza dan 13 ruangan lainnya dibagi menjadi tiga jenis ruangan yaitu ruangan akut antara lain akut pria dan akut wanita, ruang intermediate yang terdiri dari ruang anggrek dan ruang melati, serta ruang tenang yang terdiri dari ruang akasia, ruang cemara, ruang cendana, ruang keruing, ruang mahoni, ruang meranti, ruang pinus dan ruangan detoxifi kasi. jumlah tenaga perawat pada ruang akut sebanyak 26 ruang, jumlah tenaga perawat pada ruang intermediate sebanyak 22 orang, jumlah tenaga perawat diruang tenang sebanyak 76 orang dan jumlah tenaga perawat di ruang napza sebanyak 20 orang. jumlah jam kerja mengacu pada keputusan presiden republik indonesia nomor 58 tahun 1964 (37,5 jam/ minggu atau 150 jam/bulan) dengan pembagian dinas pagi 7×/bulan, dinas sore dan dinas malam masing-masing 6 kali/bulan. metode partisipatif mayoritas lama perawatan 1–3 bulan 15 orang (60%) (tabel 1). pada metode reward (hadiah) mayoritas lama perawatan 1–3 bulan 20 orang (66,66%) (tabel 2). adapun hasil penelitian untuk mengetahui perbedaan pengaruh antara dua metode yang diberikan. pada kelompok perlakuan metode partisipatif 25 orang dan pada perlakuan kelompok metode reward (hadiah) 30 orang. dilakukan sesudah pemberian perlakuan menggunakan uji mann whitney dengan tingkat kemaknaan 0,05. analisis univariat dalam penelitian ini bertujuan untuk melihat karakteristik responden dari variabel bebas yaitu perlakuan metode partisipatif dan perlakuan metode pemberian reward (hadiah) tentang pemeliharaan kesehatan fisik terhadap status kebersihan diri pada pasien halusinasi di rsj sambang lihum banjarmasin. responden dalam kategori bersih 8 orang (32%) dan status kebersihan diri kurang 11 orang (44%) dengan sampel 25 orang metode partisipatif menggunakan uji mann whitney p value 0,001 (tabel 3). kategori bersih 4 orang (13,34%) dan status kebersihan diri kurang 20 orang (66,66%) dengan sampel 30 orang metode reward (hadiah) menggunakan uji mann whitney p value 0,001 (tabel 4). tabel 1. karakteristik responden dengan p e r l a k u a n m e t o d e p a r t i s i p a t i f berdasarkan lama perawatan lama perawatan metode partisipatifn % 1–3 bulan 15 60 2–4 bulan 5 20 5–8 bulan 3 12 1–2 tahun 2 8 total 25 100 tabel 2. karakteristik responden dengan perlakuan metode reward (hadiah) berdasarkan lama perawatan lama perawatan metode reward (hadiah) n % 1–3 bulan 20 66,66 2–4 bulan 5 16,67 5–8 bulan 2 6,67 1–2 tahun 3 10 total 30 100 tabel 3. s t a t u s k e b e r s i h a n d i r i p a d a pasien halusinasi dengan metode partisipatif status kebersihan diri kelompok patisipatif n = 25 p value bersih 8 orang 32% 0,001cukup 6 orang 24% kurang 11 orang 44% jumlah 25 orang 100% tabel 4. status kebersihan diri pada pasien halusinasi dengan metode reward (hadiah) status kebersihan diri kelompok reward (hadiah) n = 30 p value bersih 4 orang 13,34% 0,001cukup 6 orang 20% kurang 20 orang 66,66% jumlah 30 orang 100% jurnal ners vol. 7 no. 1 april 2012: 81–87 84 analisis bivariat dilakukan untuk mengetahui perbedaan pengaruh metode partisipatif dan metode pemberian reward (hadiah) tentang pemeliharaan kesehatan fi sik terhadap status kebersihan diri pada pasien halusinasi di rsj sambang lihum banjarmasin. hasil perhitungan dengan uji mann whitney pada pasien halusinasi setelah pemberian perlakuan dengan metode partisipatif dan metode pemberian reward (hadiah) didapat tingkat signifi kan (ρ) = 0,001, oleh karena tingkat signifi kan (ρ) lebih kecil dari 0,05 dapat disimpulkan bahwa ada perbedaan pengaruh metode partisipatif dan metode pemberian reward (hadiah) tentang pemeliharaan kesehatan fi sik terhadap status kebersihan diri pada pasien halusinasi di rsj sambang lihum banjarmasin. kelompok perlakuan metode partisipatif nilai kategori bersih yang paling tinggi pada indikator rambut, semua sampel pada tiap indikator tidak ada pada bagian kutu dan nilai terendah pada indikator kulit pada bagian daki. sedangkan kelompok perlakuan metode reward (hadiah) kategori bersih (baik) pada indikator tabel 5. jumlah pada tiap indikator kebersihan dan kondisi kulit, rambut, gigi dan mulut no. variabel tiap indikator metode partisipatif metode reward (hadiah)n % n % kebersihan dan kondisi kulit 1 lesi 24 96 30 100 2 daki 7 28 3 10 3 edema/bengkak (benjolan) 22 88 13 43,3 4 bintik-bintik 14 56 10 33,3 5 kemerahan 9 36 10 33,3 6 alergi 19 76 9 30 7 gatal-gatal (penyakit kulit) 12 48 9 30 kebersihan dan kondisi rambut 1 rontok 12 48 8 26,6 2 infeksi kulit kepala 21 84 21 70 3 ketombe 9 36 5 16,6 4 kutu 25 100 27 90 5 kusam/kusut 12 848 26,6 kebersihan dan kondisi gigi dan mulut gigi dan mulut 1 nyeri 19 76 17 56,6 2 karies gigi 14 56 4 13,3 3 perdarahan gigi dan mulut 22 88 24 80 4 lesi gusi dan mulut 24 96 11 36,6 5 sulit menguyah 23 92 18 60 6 gigi berlubang 9 36 6 20 7 infeksi gigi dan mulut 15 60 14 46,6 8 iritasi/bengkak pada mulut 19 76 10 43,3 kulit bagian lesi dan nilai terendah (kurang) pada kebersihan kulit adanya daki karena hanya tiga orang dari 30 sampel yang tidak ada daki (tabel 5). hasil uji mann whitney didapatkan nilai p = 0,001 di mana nilai kemaknaan maka (alpa < 0,05), maka dapat dikatakan bahwa analisis dari kedua kelompok menunjukkan ada perbedaan. pembahasan pembahasan hasil penelitian yang diuraikan adalah status kebersihan diri pada pasien halusinasi di rsj sambang lihum banjarmasin setelah diberikan metode partisipatif dan metode pemberian reward (hadiah) tentang pemeliharaan kesehatan fi sik. berdasarkan hasil penelitian perbedaan metode partisipatif dan metode pemberian reward (hadiah) pada kelompok a dengan metode partisipatif (tak) sampel terdiri dari 25 orang karena lima orang lainnya meninggalkan ruangan sehingga sulit dilakukan pengamatan dan pengukuran didapatkan hasil peningkatan kebersihan diri (sirajudin noor) 85 dengan kategori bersih 8 orang, kategori cukup 6 orang dan kurang 11 orang. sedangkan pada kelompok b dengan metode pemberian reward (hadiah) jumlah sampel 30 orang didapatkan hasil kategori bersih 4 orang, cukup 6 orang dan kurang 20 orang. status kebersihan diri baik (bersih) kelompok a pada indikator rambut pada bagian kutu karena dari 25 sampel tidak ada yang kutuan dan nilai terendah pada indikator kulit bagian daki. pada kelompok b status kebersihan diri baik pada indikator kulit bagian lesi karena 30 sampel tidak ada lesi dan terendah pada bagian daki karena hanya tiga orang yang tidak ada. metode partisipatif (tak) terhadap status kebersihan diri pada pasien halusinasi. pada kategori ini pasien sudah menunjukkan peningkatan untuk menjaga status kebersihan diri. pada kelompok a dengan metode partisipatif lebih efektif digunakan pada pasien halusinasi. metode partisipatif pada penelitian ini melibatkan seseorang (pasien halusinasi) dalam mengikuti pembelajaran (mendapatkan pengalaman) tentang pemeliharaan kebersihan diri yang mencakup keterlibatan klien secara aktif dalam hal mandi, keramas dan gosok gigi. metode pemberian reward (hadiah) dalam penelitian ini adalah dengan memberikan sabun yang bertujuan menjaga pemeliharaan kesehatan fi sik (mandi, keramas dan gosok gigi) pada pasien halusinasi. pengaruh metode partisipatif dan metode pemberian reward (hadiah) tentang pemeliharaan kesehatan fisik terhadap status kebersihan diri pemeliharaan fi sik adalah terpeliharanya kebersihan perorangan dengan baik, tidak terjadi gangguan kesehatan pada fi sik individu dari ujung rambut sampai ujung kaki. kulit yang lembab akan mudah dilalui oleh bahan yang dapat menyebabkan iritasi dan lebih mudah terinfeksi jamur atau kuman dan juga rentan terhadap gesekan, sehingga kulit mudah lecet yang akan lebih mudah iritasi (nursalam, 2005). kebersihan diri adalah suatu upaya untuk memelihara kebersihan tubuh dari ujung rambut sampai ujung kaki. perawatan diri adalah salah satu kemampuan dasar manusia dalam memenuhi kebutuhannya guna mempertahankan kehidupan, kesehatan dan kesejahteraan sesuai dan kondisi kesehatannya, klien dinyatakan terganggu keperawatan dirinya jika tidak dapat melakukan perawatan diri (departemen kesehatan, 2000). banyak gangguan kesehatan yang diderita seseorang karena tidak terpeliharanya kebersihan perorangan dengan baik, gangguan fi sik yang sering terjadi adalah gangguan integritas kulit, gangguan membran mukosa mulut, infeksi pada mata dan telinga dan gangguan fi sik pada kuku (keliat, 2005). manfaat mandi ialah menghilangkan bau, menghilangkan kotoran, merangsang peredaran darah, dan memberi kesegaran pada tubuh. menurut supadmi (2000) pelatihan dengan metode partisipatif adalah proses pembelajaran dengan landasan utama dari keterlibatan atau partisipasi aktif dari peserta latih melalui penerapan pengetahuan-pengetahuan teoritis ke dalam situasi kehidupan sebenarnya dengan cara menggabungkan dan mengatur metode pembelajaran agar dapat menambah semangat belajar dan mengurangi kelelahan peserta karena tidak membosankan. makin aktif keterlibatan peserta latih di dalam proses metode partisipatif akan semakin tinggi motivasinya dan semakin besar daya retensinya. selanjutnya berakibat peserta latih lebih siap untuk mempratikkannya. pembelajaran pada pasien gangguan jiwa dapat dilakukan dengan pemberian terapi aktivitas kelompok. tak merupakan salah satu pedoman terapi yang dilakukan perawat kepada sekelompok klien yang mempunyai masalah yang sama dalam ilmu keperawatan jiwa. aktivitas digunakan sebagai terapi, dan kelompok adalah kumpulan individu yang memiliki hubungan satu dengan yang lain, saling bergantung dan mempunyai norma yang sama (stuart, 2001). di dalam kelompok terjadi dinamika interaksi yang sangat bergantung, saling membutuhkan dan menjadi tempat klien berlatih perilaku baru yang adaptif untuk memperbaiki perilaku lama maladaptif. metode partisipatif pada penelitian ini melibatkan seseorang (pasien halusinasi) dalam mengikuti pembelajaran (mendapatkan pengalaman) tentang pemeliharaan kebersihan diri yang jurnal ners vol. 7 no. 1 april 2012: 81–87 86 mencakup keterlibatan klien secara aktif dalam hal mengajarkan, menjelaskan tujuan, manfaat mandi, keramas dan gosok gigi. reward atau reinforcement sebagai faktor terpenting dalam proses belajar. tujuan psikologi adalah meramal dan mengontrol tingkah laku (baihaqi, dkk., 2005). teori ini mengenai stimulus-respons, yang mempercayai bahwa setiap tingkah laku itu dapat diamati dan didasari oleh respons positif atau negatif yang diterima. respons positif akan mendapatkan hadiah sebaliknya respons negatif menandakan akan mendapatkan hukuman. skinner yakin bahwa manusia akan berusaha untuk mendapatkan respons positif atau hadiah dari apa yang dilakukannya. pemberian reward (hadiah) sangat berpengaruh dengan teori skinner karena apabila diidentifi kasi hadiah-hadiah tersebut dapat dilakukan pembentukan kebiasaan yang positif (rasmun, 2004). reinforce itu sendiri adalah stimulus yang meningkatkan kemungkinan timbulnya sejumlah respons tertentu, namun tidak sengaja diadakan sebagai pasangan stimulus. metode pemberian reward (hadiah) dalam penelitian ini adalah dengan memberikan sabun yang bertujuan menjaga pemeliharaan kesehatan fi sik (mandi, keramas dan gosok gigi) pada pasien halusinasi. metode partisipatif lebih baik dan efektif digunakan untuk digunakan sebagai pemeliharaan kesehatan fi sik terhadap status kebersihan diri pada pasien halusinasi di rsj sambang lihum banjarmasin karena dengan melibatkan langsung dengan pasien, makin aktif keterlibatan pasien di dalam proses metode partisipatif akan semakin tinggi motivasinya dan semakin besar daya retensinya. selanjutnya berakibat pasien lebih siap dan mampu untuk mempraktikkannya. metode reward (hadiah) kurang baik dan efektif untuk pasien berespons karena hanya memberikan stimulus tanpa banyak komunikasi, sehingga kurang efektif diberikan pada pasien gangguan jiwa karena pasien mengalami ingatan, persepsi dan perhatian yang kurang dengan lingkungan sekitarnya. simpulan dan saran simpulan metode partisipatif lebih efektif dalam meningkatkan kebersihan diri dibandingkan dengan metode reward, sehingga ada perbedaan pengaruh metode partisipatif dan metode pemberian reward (hadiah) pada pasien halusinasi di rsj sambang lihum banjarmasin. saran pemeliharaan kesehatan fi sik terhadap status kebersihan diri pada pada pasien halusinasi di rsj sambang lihum banjarmasin dioptimalkan melalui metode partisipatif yaitu dengan melibatkan pasien dalam melakukan metode partisipatif agar dapat langsung mempraktikkannya. hasil penelitian ini, dapat dilanjutkan atau diteruskan oleh peneliti lain, terutama bagi peneliti agar meneliti pengaruh kebutuhan dasar yang memengaruhi kebersihan diri menggunakan terapi sosialisasi atau lingkungan sehingga dapat meningkatkan status kebersihan diri pada pasien halusinasi. kepustakaan baihaqi, dkk., 2005. psikiatri konsep dasar dan gangguan-gangguan. bandung: refi ka aditama. departemen kesehatan republik indonesia, 2000. pedoman perawatan kesehatan di rumah. jakarta: direktorat keperawatan dan keteknisian dirjen yanmed. folkman, s., 1985. ways of coping questionnaire, university of california, san fransisco, (online), (http://caps.ucsf.edu/uploads/ tools/surveys/ways%20of%20coping. pdf., diakses tanggal 28 desember 2011), jam 15.00. hawari, d., 2008. managemen stres, cemas dan depresi. jakarta: balai penerbit fkui jakarta. keliat, budi anna, dkk., 2005. keperawatan jiwa terapi aktivitas kelompok. cetakan 1. jakarta: buku kedokteran egc. nursalam, 2008. konsep dan penerapan metodelogi penelitian ilmu keperawatan peningkatan kebersihan diri (sirajudin noor) 87 pedoman skripsi, tesis, dan instrument penelitian keperawatan ed. 4. jakarta: salemba medika. nursalam, 2011. model asuhan keperawatan terhadap peningkatan adaptasi kognisi dan biologis pada pasien terinveksi hiv. jurnal ners, 6(2). rasmun, 2004. stres, koping dan adaptasi: teori dan pohon masalah keperawatan. edisi 1, jakarta: sagung seto. stuart, gail w. 2006. buku saku keperawatan jiwa, edisi 5. jakarta: buku kedokteran egc. supadmi, siti. 2000. pengaruh pelatihan partisipatif dalam meningkatkan kinerja pelayanan di kotamadya surakarta. yogyakarta: program pascasarjana universitas gadjah mada. modifikasi miring kiri dan elevasi kepala menurunkan back pain post percutaneous coronary intervention (modified left lateral and head elevation reduces post percutaneous coronary intervention back pain) harmayetty*, sriyono*, adi cahyo fajarianto** * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496, e-mail: zanno_yet@yahoo.com ** rumah sakit surabaya internasional abstract introduction: modified left lateral position and head elevation is a very important for 6 hours patient immobility after percutaneous coronary intervention. patient immobility have higher risk of discomfort or back pain and leg pain. the objective of this study was to identify the effect of modified left lateral position and head elevation on pain reduction after percutaneous coronary intervention (pci) with vascular closure device. method: a quasy experimental design was used in this study with population were percutaneous coronary intervention (pci) patient in surabaya international hospital. there were 20 respondents who met to the inclusion criteria which taken by using purposive sampling technique and divided into two groups, 10 respondents as experiment group and 10 respondents as control group. data were collected by using questionnaire and observation for pain respons and distal pulsation (dorsalis pedis artery), then data were analyzed by using mann whitney u test and independent t-test with significance level =0.01. result: the results showed that there was a significance effect of modified left lateral position and head elevation on reducing back pain with mann whitney u test (p=0.00) and there was a significance effect of modified left lateral position and head elevation on the change of dorsalis pedis pulsation with independent t-test (p=0.00). discussion: it can be concluded that modified left lateral position and head elevation reduce back pain on patients post percutaneous coronary intervention. further studies should be developed to identify the effect of modified left lateral position and head elevation on other variables of pain and stress. keywords: modified position, back pain, percutaneous coronary intervention pendahuluan penyakit kardiovaskuler merupakan penyebab kematian nomor satu di amerika. american heart association (aha) memperkirakan 500.000 dari mereka meninggal akibat serangan jantung (hudak dan gallo, 1997). pada penderita dengan coronary artery disease, 10% penderita diberikan tindakan coronary artery bypass surgery (aha, 2002). tindakan alternatif dari penyakit jantung koroner adalah pci (percutaneous coronary intervension). prosedur pci melalui transfemoral dapat menimbulkan komplikasi 5-10%, antara lain terjadi hematom, infeksi, pseudoaneurisma, arteri vena fistula atau perdarahan retroperineal. pengurangan komplikasi paska pci dapat dilakukan dengan imobilisasi seperti tidur terlentang di tempat tidur selama 6-8 jam. pengaruh imobilisasi yang lama paska pci ini sering menimbulkan back pain dan nyeri pada kaki, hipotensi orthostatik, dan kesemutan (syam, 1992). survey pada bulan agustus 2005 sampai dengan agustus 2006 dari 80 pasien dengan pci, 70% pasien mengalami back pain sesudah pci. perubahan posisi waktu imobilisasi penting bagi pasien paska pci. back pain menjadikan suatu masalah yang dialami pasien. chair, 2004 (dalam ebn, 2004) melakukan studi di china terhadap 419 pasien paska coronary angiografi, 207 pasien diberikan intervensi perubahan posisi miring kanan-miring kiri, 212 dengan bedrest dengan posisi mendatar. perubahan posisi pada pasien yang diberikan intervensi menunjukkan penurunan back pain tanpa komplikasi seperti perdarahan. namun pengaruh perubahan posisi tehadap penurunan back pain pada pasien paska pci dengan vascular closure device masih belum jelas. proses imobilisasi pasien akan menimbulkan keluhan back pain sebagai pemicu reseptor nyeri (nociceptor) untuk mempengaruhi keluarnya bradikinin, histamin dan prostaglandin, bahan yang bersifat sensitif terhadap nyeri. sinyal nyeri ini akan diteruskan oleh neuron sensori di spinal cord, memicu keluarnya glutamat sebagai neurotransmiter yang menghantarkan sinyal nyeri dari satu neuron ke neuron yang lain. sinyal nyeri ini akan diterima oleh thalamus, kemudian diteruskan ke somatosensory cortex di cerebrum dimana nyeri akan di lokalisir. melalui proses ini pasien merasakan nyeri dan rasa tidak nyaman pada bagian belakang tubuh akibat dari imobilisasi (ebn, 2004 dalam silber, 2006). pengurangan nyeri akibat dari imobilisasi dilakukan dengan memberikan posisi modifikasi elevasi kepala dan miring kiri pada pasien. untuk menghindari terjadinya komplikasi dilakukan observasi kekuatan nadi distal setelah prosedur pci dan penurunan nyeri yang dirasakan pasien waktu menjalani imobilisasi. survey pada bulan september 2006 sebanyak 20 pasien coronary intervention di rumah sakit surabaya internasional yang diambil secara acak, 15 pasien (75%) menyatakan keluhan back pain. pemberian posisi miring kiri dan mobilisasi pada kaki kecuali kaki tempat insersi arteri femoralis kanan yang selama ini dilakukan belum mengurangi back pain yang dirasakan pasien. hasil pengamatan oleh peneliti, pemberian perubahan posisi miring kiri dan elevasi kepala yang di berikan terhadap pasien paska coronary intervention dapat membantu menurunkan keluhan back pain, seperti nyeri menjalar, kelemahan, gelisah, rasa tidak nyaman pada pasien. merujuk pada kondisi tersebut maka peneliti terdorong untuk melakukan penelitian lebih lanjut tentang pengaruh posisi modifikasi miring kiri dan elevasi kepala terhadap penurunan back pain pada pasien paska percutaneous coronary intervention (pci) dengan vascular closure device di rumah sakit surabaya internasional. bahan dan metode desain penelitian yang digunakan adalah quasy eksperimental post test only control group design. populasi dalam penelitian ini adalah semua pasien yang dilakukan kateterisasi jantung dan pci pada bulan oktober-november 2006 sebanyak 20 pasien di rumah sakit surabaya internasional. tehnik sampling yang digunakan dalam penelitian ini adalah dengan menggunakan teknik purposive sampling. sampel yang diambil ditentukan berdasarkan kriteria inklusi, yang meliputi pasien dewasa berumur antara usia 30-60 tahun, pasien paska pci 1 jam, tidak menggunakan obat analgesik (morphine, dormicum), area punksi pada arteri femoralis kanan, tidak ada komplikasi dan pemakaian obat-obatan jantung (aspirin, plavix, cedocard). variabel independen dalam penelitian ini adalah posisi modifikasi miring kiri dan elevasi kepala dan variabel dependen adalah skala nyeri dan pulsasi distal (arteri dorsalis pedis). intervensi dilakukan setelah satu jam paska tindakan prosedur pci dengan vascular closure device, responden diberikan posisi elevasi kepala selama 6 jam dan posisi miring kiri 2 kali dalam 6 jam. pengumpulan data diperoleh melalui observasi. responden diobservasi dengan dua jenis lembar observasi yaitu lembar observasi skala nyeri (skala nyeri bourbonis) dan lembar pulsasi distal (setiap 15 menit selama 1 jam). data yang diperoleh ditabulasi dan dianalisis dengan menggunakan uji statistik mann whitney u test dengan α=0,05 untuk skala nyeri dan uji statistik independent t-test dengan α=0,05 untuk pulsasi distal arteri dorsalis pedis. hasil tabel 1 menunjukkan bahwa pada menit ke-15 post pci, tidak didapatkan perbedaan skala nyeri yang bermakna antara kelompok perlakuan dan kelompok kontrol namun pada menit ke-30 mulai terlihat bahwa skala nyeri responden pada kelompok perlakuan lebih rendah. tabel 1. skala nyeri kelompok perlakuan dan kelompok kontrol pada pasien paska pci. no . skala nyeri (pada menit ke-) frekuensi arteri dorsalis pedis (pada menit ke-) p k p k p k p k p k p k p k p k 15 30 45 60 15 30 45 60 1. 1 1 1 2 1 3 1 3 72 70 74 74 74 78 76 80 2. 1 1 1 2 1 2 1 3 70 76 72 78 74 80 78 86 3. 2 2 1 2 1 3 1 3 66 74 68 76 68 77 70 78 4. 2 2 2 3 1 3 1 3 70 74 72 74 72 76 72 78 5. 2 2 2 3 1 3 1 3 68 78 70 79 72 82 72 84 6. 1 1 1 2 1 3 1 3 72 78 74 82 74 82 78 86 7. 1 2 1 2 1 3 1 3 70 68 70 76 72 78 72 80 8. 2 1 1 3 1 3 1 3 72 80 72 82 76 88 78 92 9. 1 2 1 2 1 2 1 2 66 72 66 74 70 76 72 78 10 1 1 1 2 1 2 1 3 70 74 70 76 74 78 76 82 sd 0,5 0,5 0,4 0,4 0,0 0,4 0,0 0,3 mann whitney u test independent t-test p=0,661 p=0,000 p=0,000 p=0,000 p=0,03 p=0,00 p=0,02 p=0,00 keterangan: p = kelompok perlakuan k = kelompok kontrol p = signifikansi sd = standar deviasi skala nyeri pada menit ke-45 dan ke60 kelompok perlakuan menunjukkan 100% tidak nyeri, sedangkan pada kelompok kontrol 30% mengalami nyeri ringan dan 80% nyeri sedang. skala nyeri yang timbul pada kelompok responden yang diberikan posisi modifikasi miring kiri dan elevasi kepala, pada menit ke-15 didapatkan hasil yang tidak signifikan dengan uji statistik mann whitney u test (p=0,661). pada menit ke-30 dan ke-60 terdapat pengaruh yang signifikan dari pemberian posisi modifikasi miring kiri dan elevasi kepala terhadap penurunan skala nyeri (back pain) paska pci dengan uji statistik mann whitney u test (p=0,000). perbandingan frekuensi arteri dorsalis pedis pada kelompok perlakuan dan kontrol didapatkan tidak ada perubahan frekuensi arteri dorsalis pedis yang bermakna pada kedua kelompok. pada kelompok perlakuan (yang diberikan posisi modifikasi miring kiri dan elevasi kepala) dan kelompok kontrol pada menit ke-15 dan ke-45 didapatkan tidak ada perbedaan yang signifikan frekuensi arteri dorsalis pedis dengan hasil uji statistik independent t-test, sedangkan pada menit ke-30 dan menit ke-60 menunjukkan posisi modifikasi miring kiri dan elevasi kepala berpengaruh terhadap frekuensi arteri dorsalis pedis. pembahasan pemberian posisi modifikasi miring kiri dan elevasi kepala paska pci dengan vascular closure device merupakan kombinasi perubahan posisi saat imobilisasi pada pasien dengan miring dan elevasi kepala 15-45, membantu menurunkan keluhan back pain dan membantu memenuhi kebutuhan pasien seperti makan, minum dan kebutuhan eliminasi pasien (benson dalam bigatello, 2006). pada kelompok perlakuan yang diberikan posisi modifikasi miring kiri dan elevasi kepala paska pci dengan vascular closure device didapatkan adanya respons penurunan nyeri (back pain) yang bermakna. pada menit ke-15 paska perlakuan menunjukkan tidak ada pengaruh yang signifikan terhadap penurunan nyeri, hal ini dapat disebabkan oleh karena respons seseorang terhadap nyeri tidak sama, faktor usia dan pada menit-menit pertama pasien belum menunjukkan respons terhadap nyeri yang dirasakan, makin lama waktu imobilisasi yang diberikan maka respons nyeri makin dapat dirasakan oleh pasien, beragamnya usia responden dapat mempengaruhi pemahaman tentang nyeri setelah ada pencetus rangsangan nyeri seperti proses imobilisasi paska pci. menurut brunner dan suddarth (2002) menyatakan bahwa faktor-faktor yang mempengaruhi rasa nyeri sebagai berikut: arti nyeri terhadap individu (setiap individu mempunyai arti yang berbeda dalam memandang respons nyeri, baik pada waktu yang berbeda pada individu yang sama maupun keluhan yang sama. sebagian individu mempunyai respons positif dan lebih cepat dari individu yang lain, hal tersebut tergantung pada kondisi dan intepretasi individu terhadap nyeri tersebut). faktor kedua toleransi individu terhadap nyeri, toleransi seseorang yang berhubungan dengan intensitas nyeri dimana individu dapat merespons dengan baik atau sebaliknya. faktor ketiga yaitu ambang nyerisuatu batas kemampuan seseorang untuk mau beradaptasi serta berespons terhadap nyeri dimana mempengaruhi perilaku seseorang dan faktor keempat yaitu usia, perbedaan usia seseorang mempunyai pengaruh yang berbeda-beda dalam memandang suatu rasa nyeri. pada usia dewasa biasanya lebih dapat mentoleransi rasa sakit dengan baik, tetapi pada anak-anak ambang batas atas nyeri rendah untuk membedakan rasa sakit dan tekanan, sedangkan orang yang berusia lanjut mengalami kegagalan dalam merasakan kerusakan jaringan, akibat perubahan degeneratif pada jalur saraf nyeri dibandingkan dengan usia muda. pemberian posisi modifikasi miring kiri dan elevasi kepala yang diberikan kepada pasien paska pci dengan vascular closure device berpengaruh terhadap penurunan nyeri (back pain). pada pasien yang imobilisasi maka pasien tersebut harus terlentang di tempat tidur, tekanan gravitasi akan meningkat, beban berada pada punggung pasien sehingga mikrosirkulasi terganggu, respons nyeri pasien akan muncul (ebn, 2004). pada kelompok perlakuan setelah diberikan posisi modifikasi miring kiri dan elevasi kepala, respons nyeri berkurang karena beban gravitasi pada punggung pasien terbagi sehingga tidak mengganggu mikrosirkulasi. dengan demikian sirkulasi tidak mengalami hambatan sehingga rangsangan nyeri tidak timbul. respons frekuensi arteri dorsalis pedis pada menit ke-15 tidak menunjukkan perbedaan yang signifikan. pada menit ke-30 dan ke-60 menunjukkan pemberian posisi modifikasi miring kiri dan elevasi kepala berpengaruh terhadap frekuensi arteri dorsalis pedis yang signifikan. nadi merupakan indikator status sirkulasi. faktor mekanis, neural dan kimia tidak dapat mengubah volumenya, tetapi perubahan frekuensi jantung akan mengakibatkan perubahan pada nadi. karakter nadi dapat dikaji melalui frekuensi, kekuatan, irama dan kesamaannya (perry dan potter, 2005). semua denyut nadi perifer diukur untuk keseimbangan dan kesimetrisannya. nadi dorsalis pedis kanan dibandingkan dengan yang kiri. ketidakseimbangan dapat mengidentifikasikan adanya obstruksi lokal atau arteri yang terletak abnormal. untuk mengetahui adanya oklusi arteri pada ekstremitas biasanya ditandai dengan nyeri karena tidak adanya aliran darah. nyeri terjadi dibagian distal sampai ke tempat oklusi. karakteristik oklusi antara lain: pain (nyeri), pallor (pucat), pulselessness (tidak ada denyut) (perry dan potter, 2005). simpulan dan saran simpulan posisi modifikasi miring kiri dan elevasi kepala menurunkan skala nyeri pasien paska pci saran penelitian lebih lanjut dapat menggunakan variabel umur yang lebih homogen serta memfokuskan sampel pada laki-laki atau perempuan saja pada paska pci sehingga dapat memberikan hasil penelitian dengan karakteristik penurunan nyeri yang berbeda yang dapat menjadi tolok ukur dalam memberikan pelayanan keperawatan yang optimal kepada pasien dan menambah pengetahuan dalam bidang keperawatan dimasa yang akan datang. kepustakaan aha. 2002. coronary artery disease, (online), (http://circ.ahajournals.org., diakses tanggal 20 desember 2006, jam 18.00 wib). aha. 2002. coronary heart disease, (online), (http://en.wikipedia.org/wiki/coronary http://circ.ahajournals.org/ http://en.wikipedia.org/wiki/coronary_heart_disease _heart_disease., diakses tanggal 28 desember 2006, jam 17.00 wib). bigatello. 2006. critical care handbook of the massachusetts general hospital fourth edition. philadelphia: lippincott williams and wilkins. brunner dan suddarth. 2002. buku ajar keperawatan medikal bedah. jakarta: penerbit buku kedokteran egc. ebn. 2004. changing patient in bed after non emergency coronary angiography reduced back pain, (online), (http://ebn.bmj.com., diakses tanggal 9 desember 2006, jam 18.00 wib). hudak dan gallo, 1997. keperawatan kritis pendekatan holistik. edisi vi. jakarta: egc. kozier b. 1997. fundamental of nursing: concept process and practice fourth edition. california: redwood city. perry dan potter. 2005. buku ajar fundamental keperawatan konsep, proses, praktek. edisi 4. jakarta: penerbit buku kedokteran egc. silber, s. 2006. vascular closure device for immediate sheath removal after coronary intervention, (online), (http://www.sigmundselber.com., diakses tanggal 10 desember 2006, jam 10.00 wib). syam, h. 1992. ilmu kedokteran fisip dan rehabilitasi. surabaya: urm rsud dr. soetomo. http://en.wikipedia.org/wiki/coronary_heart_disease http://ebn.bmj.com/ konsumsi jus wortel selama kemoterapi meningkatkan kadar hemoglobin pasien kanker serviks stadium ii-b (carrot juice consumption during chemotherapy increases haemoglobin level on patients with cancer of cervix stage ii-b ) ni ketut alit a*, sri yuniarti **, alvarea enggusti n.* * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496. e-mail: alitnik@yahoo.com ** rsud dr. soetomo surabaya abstract introduction: ca cervix patients who had a chemotherapy may experience depletion of hb level. hb level can increase by giving a natural carrot juice. the nutritional content of carrot juice such as beta karoten, ferrum, calcium, vitamin b, vitamin c and protein can assist bone marrow produce hb and lymphosite. the objective of this study was to analyze the effect of carrot juice consumption during chemotherapy on hb level of patients with ca cervix stage ii-b. method: this study used a quasy experimental design and the population was the patients who stayed at gynecology room. the sampling technique was used consecutive sampling, with the total sample were 16 respondents. data were collected by taken the blood sample and analyzed by using paired t-test and independent t-test. result: the result showed that carrot juice influent on the change of rate of hb with significance level (p=0.005). discussion: it can be concluded that by giving carrot juice to the patients with experiencing chemotherapy, can increase hb level. further studies are recommended to analyze the effect of carrot juice on patient with low hb level during chemotherapy for further possibilities. keywords: carrot juice, chemotherapy, hb level, ca cervix pendahuluan ca serviks sering ditemukan diantara penyakit kanker ginekologik dan menjadi penyebab kematian utama wanita penderita kanker di negara berkembang, termasuk indonesia (elvina, 2000). hal ini tidak terlepas dari penderita yang datang ke rumah sakit sudah pada kondisi lanjut. ca serviks biasanya terjadi pada wanita yang telah berumur, akan tetapi tidak jarang bila ca serviks dapat menyerang wanita yang berumur 20-30 tahun. pengobatan ca serviks sangat bergantung pada berat ringannya penyakit atau disebut juga sebagai stadium. pada stadium awal, maka operasi menjadi pilihan pertama. pada stadium lanjut atau mulai memasuki stadium ii-b, pengobatan operasi tidak dapat dilakukan lagi melainkan dengan cara radiasi (andrijono, 2005). apabila operasi dan radiasi tidak memungkinkan lagi maka dilakukan kemoterapi (fielda, 2006). pasien ca serviks stadium ii b yang menjalani kemoterapi sangat berisiko mengalami penurunan kadar hemoglobin (hb) karena mengalami supresi sumsum tulang (sukardja, 1996). kemoterapi pada kanker juga dapat menimbulkan defisiensi sub klinis seperti vitamin b1, b12, a, c, niasin, asam folat dan vitamin k (wilkes, 2000). pengobatan secara alami seperti pemberian jus wortel pada pasien ca serviks yang menjalani kemoterapi selama ini jarang dilakukan, padahal penelitian menunjukkan jus wortel memiliki kandungan nutrisi yang dibutuhkan dalam pembentukan sel darah merah dan sel darah putih pada sumsum tulang (moehji, 2002). fakta menunjukkan, setiap tahun sekitar 200.000 wanita di indonesia didiagnosis menderita ca serviks. pasien ca serviks di rsu dr. soetomo surabaya pada tahun 2006 tercatat 512 pasien yang terdiagnosis dengan ca serviks, sekitar 265 pasien ca serviks berada dalam stadium ii-b dan hampir 98 % dari pasien stadium tersebut menjalani kemoterapi. kemoterapi bersifat toksik terhadap sumsum tulang. sumsum tulang memproduksi sel darah merah, sel darah putih dan trombosit yang beredar dalam tubuh, jika produksi sel-sel darah tersebut terganggu maka pasien akan lebih berisiko terjadinya infeksi, sedangkan pengaruhnya terhadap kemoterapi terjadi penundaan jadwal serta penurunan dosis yang mengakibatkan kondisi pasien semakin buruk dan menurunkan kualitas hidup pasien (noorwati, 2006). diet yang baik bagi penderita kanker dengan kemoterapi adalah makanan yang banyak mengandung beta karoten, vitamin c dan e serta selenium (hartono, 1997). sumber beta karoten adalah sayursayuran dan buah-buahan yang berwarna kuning-jingga seperti wortel dan tomat. wortel mempunyai kandungan beta karoten yang tinggi. kandungan beta karoten pada wortel rerata 12.000 iu. para ahli menganjurkan 15.000-25.000 iu per hari. kandungan tinggi beta karoten dari wortel mempunyai sifat antioksidan yang melawan kerja destruktif sel-sel kanker. beta karoten juga dapat membantu proses pembentukan sel darah merah pada sumsum tulang dan membantu sistem kekebalan tubuh yang menghasilkan killer cell alami atau limfosit (youngson, 2005). wortel mempunyai beberapa kandungan nutrisi yang dibutuhkan dalam pembentukan hb dan limfosit seperti vitamin b1, c, zat besi (fe), kalsium (ca) dan protein (varona, 2003). jika penurunan hemoglobin dan limfosit pada pasien ca serviks yang menjalani kemoterapi dapat diminimalkan, maka risiko pasien mengalami anemia dan penurunan sistem kekebalan tubuh dapat berkurang. peran perawat sangat diperlukan untuk memfasilitasi pasien ca serviks dalam membantu mengurangi penurunan hb akibat kemoterapi dengan metode alamiah menggunakan jus wortel. tujuan dari penelitian ini adalah untuk menganalisis pengaruh jus wortel selama kemoterapi terhadap peningkatan kadar hb pada pasien ca serviks stadium ii b di ruang kandungan rsu dr. soetomo surabaya. bahan dan metode desain penelitian yang digunakan adalah quasy-experiment dengan rancangan penelitian pre-post test control group design. sampel pada penelitian ini adalah pasien ca. serviks stadium ii-b sedang menjalani kemoterapi dan dirawat di ruang kandungan rsu dr. soetomo surabaya. penelitian ini dilaksanakan pada bulan juni 2007. penelitian ini menggunakan sampling non-probability dengan metode consecutive sampling. intervensi yang dilakukan berupa pemberian 150 gr jus wortel jenis chantenang setiap hari satu kali sampai masa kemoterapi selesai. instrumen yang digunakan dalam penelitian ini adalah pengukuran dengan mengambil spesimen darah dari pasien untuk mengukur kadar hb yang dilakukan sebelum intervensi dan di akhir intervensi (habis masa seri pemberian kemoterapi). data yang telah dikumpulkan kemudian diolah dan dianalisis dengan menggunakan paired t-test dan independent t-test dengan tingkat kemaknaan α0,05. hasil kenaikan kadar hb pada kelompok perlakuan (diberi jus wortel) antara 0,1-1,1 g/dl (5 responden) dan 3 responden mengalami penurunan kadar hb sekitar 0,32,3 g/dl, sedangkan pada kelompok kontrol 7 responden yang mengalami penurunan kadar hb antara 0,8-7,6 g/dl dan 1 responden yang mengalami peningkatan kadar hb 0,16 g/dl. pada tabel 1 dapat dilihat pada kedua kelompok mengalami penurunan kadar hb pada rerata hitungnya, akan tetapi dengan pemberian jus wortel selama kemoterapi dapat membantu kenaikan kadar hb. hal ini dapat dilihat dari nilai delta (perubahan antara pre dan post). kelompok yang diberikan jus wortel mempunyai nilai yang lebih tinggi yaitu -0,11 daripada kelompok yang tidak diberikan jus wortel yaitu -2,42, yang berarti bahwa jus wortel dapat meningkatkan kadar hb pasien ca serviks stadium ii-b yang menjalani kemoterapi. terdapat pengaruh pemberian jus wortel selama kemoterapi pada kelompok perlakuan terhadap perubahan kadar hb pada pasien ca serviks stadium ii-b dengan hasil uji statistik independent t-test menunjukkan p=0,005. pada kelompok perlakuan tidak terdapat beda namun pemberian jus wortel berpengaruh terhadap kadar hb pada pasien ca serviks dengan hasil uji statistik paired ttest p=0,764, sedangkan pada kelompok kontrol yang tidak diberikan jus wortel menunjukkan nilai p=0,024. tabel 1. hasil pemeriksaan darah (hb) dalam g/dl pada pasien ca serviks stadium ii b yang menjalani kemoterapi di ruang kandungan rsu dr.soetomo surabaya. no. responden kontrol delta no. responden perlakuan delta pre post pre post mean 11,6 9,18 -2,42 mean 11,9 11,79 -0,11 sd 1,17473 2,06500 sd 1,07571 0,84926 paired t-test p=0,024 paired t-test p=0,764 independent t-test p=0,005 keterangan: p = signifikansi sd = standar deviasi mean = rerata pembahasan ca serviks merupakan jenis kanker yang biasanya tumbuh lambat pada wanita dan mempengaruhi mulut rahim, bagian yang menyambungkan antara rahim dan vagina. pengobatan ca serviks pada stadium awal dilakukan dengan operasi, apabila sudah memasuki stadium ii-b maka pengobatan radiasi dan kemoterapi yang harus dilakukan. radiasi mempunyai banyak sekali efek samping, sehingga banyak pasien ca serviks yang memilih pengobatan kemoterapi (fielda, 2006). pasien ca serviks stadium iib yang menjalani kemoterapi sangat berisiko mengalami penurunan kadar hb dan jumlah limfosit karena mengalami supresi sumsum tulang (sukardja, 1996). pada produksi eritrosit normal, sumsum tulang memerlukan besi, vitamin b12, asam folat, vitamin c, vitamin b6 dan protein. besi (fe) penting bagi pembentukan hb. pada supresi sumsum tulang, simpanan besi akan berkurang sehingga sintesis hb tertekan dan sel darah merah yang dihasilkan sumsum tulang lebih kecil serta rendah kadar hb-nya. keadaan ini biasa disebut dengan anemia. timbulnya anemia mencerminkan adanya kegagalan sumsum (berkurangnya eritropoesis), dapat terjadi karena pajanan toksik, invasi tumor dan kehilangan sel darah merah berlebihan (sacher dan mc.pherson, 2004). pasien ca serviks stadium ii-b yang menjalani kemoterapi berisiko mengalami supresi sumsum tulang akibat obat sitostatika karena obat-obat tersebut dapat merusak sel-sel kanker maupun sel-sel yang degenerasi atau berkembang, sedangkan proses pembentukan hb berasal dari sel-sel yang degenerasi (kusmardi, 2007). pada penelitian ini terbukti bahwa pemberian jus wortel dapat meningkatkan kadar hb meskipun hasil peningkatannya rendah. pasien ca serviks yang sudah terbiasa mengkonsumsi jus wortel saat dirumah memiliki peningkatan kadar hb jauh lebih tinggi daripada pasien yang baru pertama kali mengkonsumsi jus wortel saat penelitian saja. wortel merupakan sumber beta karoten, vitamin c dan kalsium. wortel juga dapat membantu membentuk sel darah merah, melancarkan peredaran darah dan meningkatkan kadar hb (selby, 2005). wortel mengandung zat-zat yang dibutuhkan dalam proses pembentukan hb seperti zat besi (fe), kalsium (ca), vitamin c dan b serta protein. zat-zat tersebut diserap dan masuk ke pembuluh darah kemudian di metabolisme dan digunakan di sumsum tulang untuk membantu proses pembentukan hb (ardiansyah, 2007). wortel yang digunakan dalam penelitian ini adalah wortel jenis chantenang yang lebih pekat warna orangenya dan rasanya manis. warna wortel yang lebih orange menandakan kandungan beta karoten dan airnya lebih banyak. digunakan 150 gram wortel segar yang diperkirakan mempunyai kandungan beta karoten sebesar 18.000 iu (wilkes, 2000). komposisi kandungan unsur lain dalam wortel adalah kalori sebesar 63 kalori, protein 1,8 gr, lemak 0,45 gr, hidrat arang 13,95 gr, besi 1,2 mg, kalsium 58,5 mg, fosfor 55,5 mg, vitamin b1 0,09 dan vitamin c 9 mg. komposisi di atas sesuai dengan kebutuhan tubuh akan zat-zat tersebut. simpulan dan saran simpulan pemberian jus wortel selama kemoterapi meningkatkan kadar hb pada pasien ca serviks stadium ii-b. jus wortel mempunyai kandungan beta karoten yang tinggi, zat besi (fe), kalsium (ca), vitamin b1, vitamin c dan protein. saran peneliti menyarankan agar pasien tetap mengkonsumsi jus wortel sesuai dengan dosis yang ditentukan selama di rumah, dengan harapan apabila sewaktu-waktu pasien menjalani kemoterapi, kadar hb yang dimiliki tetap stabil dan dapat dipertahankan dalam rentang normal. jus wortel dapat diberikan pada pasien kanker lainnya yang mengalami supresi sumsum tulang serta pasien ca serviks stadium ii-b yang menjalani kemoterapi seri 1 untuk mencegah penurunan kadar hb dan menjaga supaya kadar hb tetap normal dan dapat diberikan pada kemoterapi seri selanjutnya. jus wortel dapat dijadikan sebagai nutrisi tambahan untuk membantu perbaikan kadar hb akibat supresi sumsum tulang pada pasien ca serviks yang sedang menjalani kemoterapi. kepustakaan andrijono. 2005. kanker ginekologi. jakarta: fakultas kedokteran universitas indonesia, hlm. 25. ardiansyah. 2007. antioksidan dan peranannya bagi kesehatan, (online), (http//.www.berita-iptek-online.com, diakses tanggal 23 januari 2007, jam 00.01 wib). elvina. 2000. remaja lesu, remaja kurang darah, (online), (http//intisari_onthe.net., diakses tanggal 5 april 2007, jam 12.50 wib). fielda. 2006. kanker leher rahim, (online), (http//www.medicastore.com, diakses tanggal 7 maret 2007, jam 21:36 wib). hartono, a. 1997. asuhan nutrisi rumah sakit. jakarta: egc, hlm. 15, 109. kusmardi, 2007. beta karoten menekan pertumbuhan tumor, (online), (http//kompas cybermediabetakaroten.htm., diakses tanggal 7 april 2007, jam 14.35 wib). moehji, s. 2002. ilmu gizi: pengetahuan dasar. jakarta: papas sinar sinanti, hlm. 59-63. noorwati. 2006. pengetahuan dasar tentang kemoterapi, (online), (http//cancerina.htm., diakses tanggal 5 april 2007, jam 12.46 wib). sacher dan mc.pherson, 2004. tinjauan klinis hasil pemeriksaan laboratorium. jakarta: egc, hlm. 2158. selby, a. 2005. makanan berkhasiat. jakarta: pt. erlangga, hlm. 50-51. sukardja, d.g. 1996. onkologi klinik. surabaya: airlangga university press, hlm. 189-206. wilkes, g.m. 2000. buku saku gizi pada kanker dan infeksi hiv. jakarta: egc, hlm. 59, 67. varona, b.m., et al. 2003. makanan penyembuh ajaib. bandung: indonesia publishing house, hlm. 39-40. youngson, r. 2005. antioksidan: manfaat vitamin c dan e bagi kesehatan. jakarta: arcan, hlm.85, 102-104. hubungan faktor risiko asma dan perilaku pencegahan 50 paket edukasi menurunkan keluhan fisik dan psikologis pasien kanker serviks dengan kemoterapi (education package reduce physical and psychological complaint in cervical cancer patient with chemotherapy) mira triharini* abstract introduction : patient with cervix cancer who receives chemotherapy experience problems in physical or psychological. physical complaints such as nausea, vomiting and fatigue. psychological responses such as anxiety and depression can be reduced by providing education about the care package for themselves at home. the education package at the gynecology ward rsu dr. soetomo surabaya has been developed which contains about nutrition, activity, psychological aspects and progressive muscle relaxation exercise. the objective of this study explore the relationship of the educational package with physical and psychological complaints of cervical cancer patients with chemotherapy. method : this research use cross-sectional design. the sampling technique used total population. the sample was taken from those suitable with inclusion criteria, with the total sample 25 patients. data were collected by using a questionnaire. data analysis using the t test and chi-squere. result : results showed that there are differences level of nausea, vomiting, fatigue and the entry psychological response to the respondents before and after intervention (p<0.05). the results showed that there is relationship between age with anxiety (p=0,032), relationship between the status of work with fatigue (p=0,003) and relationship between the frequency of chemotherapy with fatigue (p=0,015). analysis : it can be concluded that education package can reduce physical and psychological complaint in serviks cancer patient with chemoteraphy. discussion : implications the results of this research is the educational package can be developed as part of the nursing care of cervical cancer patients with chemotherapy to reduce physical and psychological complaints. keywords: cervical cancer, education package, fatigue complaint, nausea, vomiting complaint, psychological response *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: mira.tri_ners@unair.ac.id pendahuluan kanker serviks sampai saat ini merupakan salah satu penyebab kematian kaum perempuan yang cukup tinggi di berbagai negara (yki, 2008). pada tahun 2005 telah terjadi sekitar 260.000 kematian akibat kanker serviks dan sekitar 95% terjadi di negara-negara sedang berkembang (who, 2006). di indonesia, diperkirakan setiap harinya terjadi 41 kasus baru kanker serviks dan 20 perempuan meninggal dunia karena penyakit tersebut (yki, 2008). kemoterapi mempunyai kontribusi terjadinya malnutrisi karena menimbulkan mual, muntah, stomatitis, dan penurunan nafsu makan. dalam sebuah penelitian pada pasien yang mendapat kemoterapi dengan efek muntah berat didapatkan hasil 35% mengalami mual akut dan 60% mengalami muntah akut, 60% mengalami mual lambat dan 50% mengalami muntah lambat (grunberg, deuson & mavros, 2004). keluhan fisik selain mual muntah yang dialami oleh pasien kanker serviks yang menjalani kemoterapi adalah fatigue/ lemah dan lesu. national comprehensive cancer network/ nccn (2009) menyatakan bahwa sekitar 70%-100% pasien kanker mengalami fatigue. lemah dan lesu sebagai akibat dari kemoterapi berhubungan dengan mekanisme kerja kemoterapi yang berdampak pada toksisitas hematologi(otto, 2001). masalah psikologis utama yang dialami oleh penderita kanker serviks stadium lanjut adalah distress psikologis berkaitan paket edukasi menurunkan keluhan fisik dan psikologis (mira triharini) 51 dengan diagnosis kanker atau masalah fisik dan sosial. sebuah penelitian tentang distress psikologis pada 265 pasien kanker pada awal kemoterapi didapatkan hasil bahwa kondisi tersebut secara signifikan mempengaruhi tingkat kecemasan dan depresi serta menurunkan kualitas kehidupan mereka (iconomou, et all (2008). teknik relaksasi juga dapat diajarkan pada pasien untuk meningkatkan kondisi fisik dan psikologis. salah satu teknik relaksasi yang dikenal adalah teknik relaksasi otot progresif/ progressif muscle relaxation. teknik relaksasi ini sesuai untuk dilakukan pada pasien kanker yang mendapatkan kemoterapi karena terbukti efektif mengurangi mual muntah (yoo, et al. 2005). di beberapa rumah sakit mulai dikembangkan paket edukasi tentang perawatan di rumah untuk mengatasi keluhan fisik dan psikologis pada pasien kanker yang menjalani kemoterapi. paket edukasi diberikan dengan materi meliputi pengaturan nutrisi, pengaturan aktivitas, aspek psikologis, serta latihan relaksasi otot progresif. pada studi ini peneliti ingin mengetahui hubungan pelaksanaan paket edukasi yang berisi tentang perawatan diri pasca kemoterapi dengan keluhan fisik dan psikologis pada pasien kanker serviks yang menjalani kemoterapi. bahan dan metode penelitian penelitian ini menggunakan metode cross seksional . populasi dalam penelitian ini yaitu seluruh pasien kanker serviks yang menjalani kemoterapi di ruang rawat. sampel penelitian yang diambil sebanyak 25 orang dengan metode total populasi sesuai kriteria inklusi. penelitian dilakukan di ruang kandungan rsu dr. soetomo surabaya, selama 5 minggu. instrumen yang digunakan yaitu kuesioner untuk melihat karakteristik responden, kuesioner keluhan mual muntah, keluhan lemah lesu, dan respon psikologis. pengumpulan data diawali dengan peneliti menentukan responden sesuai kriteria inklusi. setelah diberi penjelasan, responden menandatangani surat persetujuan (informed consent). pasien sebelum mendapatkan paket edukasi dilakukan pengukuran keluhan mual muntah, lemah lesu, dan respon psikologis. pada saat pasien kembali lagi untuk kemoterapi berikutnya dilakukan pengukuran kembali keluhan mual muntah, lemah lesu, dan respon psikologis. analisis data dilakukan dengan menggunakan uji statistic univariat dan bivariat.. hasil penelitian hasil analisis ditemukan tidak ada hubungan antara karakteristik dengan keluhan mual muntah. hasil analisis didapatkan ada hubungan yang signifikan antara frekuensi kemoterapi dengan keluhan lemah lesu (p=0,015). hasil analisis diperoleh pula nilai or=0,091 artinya responden dengan frekuensi kemoterapi >2 kali akan mempunyai peluang 0,091 kali untuk memiliki keluhan lemah lesu berat dibandingkan dengan responden dengan frekuensi kemoterapi 2 kali. hasil analisis ditemukan terdapat hubungan signifikan antara umur dengan kecemasan (p=0,032). dari hasil analisis diperoleh pula nilai or=10,67 artinya responden dengan umur ≥45 tahun akan mempunyai peluang sebesar 10,67 kali untuk memiliki kecemasan berat dibandingkan dengan yang berumur <45 tahun. hasil analisis didapatkan terdapat hubungan signifikan antara pekerjaan dengan kecemasan (p=0,003). hasil analisis diperoleh pula nilai or=0,03 artinya responden bekerja akan mempunyai peluang sebesar 0,03 kali untuk memiliki kecemasan berat dibandingkan dengan responden tidak bekerja (tabel.1). analisis tentang perbedaan mual muntah didapatkan ada perbedaan yang bermakna proporsi keluhan mual muntah sebelum dan sesudah pelaksanaan paket edukasi (p=0,039) (tabel.2). hasil analisis tentang keluhan lemah lesu didapatkan ada perbedaan yang signifikan proporsi keluhan lemah lesu pada responden sebelum dan sesudah pelaksanaan paket edukasi (p=0,021) (tabel.3). hasil analisis tentang keluhan kecemasan didapatkan ada perbedaan yang signifikan proporsi kecemasan pada responden sebelum dan sesudah pelaksanaan paket edukasi (p=0,038) (tabel.4). hasil analisis tentang keluhan depresi didapatkan terdapat perbedaan yang signifikan proporsi depresi pada responden sebelum dan sesudah pelaksanaan paket edukasi (p=0,020) (tabel.5). jurnal ners vol.4 no.1 april 2009: 50-55 52 tabel 1. distribusi hubungan menurut karakteristik responden dengan keluhan mual muntah, lemah lesu, dan respon psikologis karakteristik mual muntah lemah lesu cemas depresi or (95% ci) p or (95% ci) p or (95% ci) p or (95% ci) p umur < 45 tahun ≥ 45 tahun 0,75 (0,0678,38) 1,000 1,11 (0,176,97) 1,000 10,67 1,30086,93 0,032 6,87 0,6770,81 0,160 pendidikan rendah tinggi 0,26 (0,032,32) 0,252 0,54 (0,074,00) 0,645 1,71 0,15018,73 1,000 6,00 (0,5663,98) 0,160 pekerjaan tidak bekerja bekerja 2,67 (0,2528,43) 0,621 2,57 0,4614,10 0,411 0,03 0,0030,388 0,003 0,389 0,0712,13 0,41 lama didiagnosa ≤ 3 bulan > 3 bulan 0,54 (0,074,00) 0,645 0,61 (0,120,29) 0,695 0.60 (0,103,49) 0,673 1,16 (0,245,61) 1,000 frekuensi kemoterapi 2 kali > 2 kali 1,83 (0,2513,4) 1,000 0,091 (0,010,62) 0,015 0,848 (0,144,99) 1,000 1,14 (0,235,67) 1,000 tabel 2. distribusi responden menurut keluhan mual muntah sebelum dan sesudah pelaksanaan paket edukasi pelaksanaan paket edukasi berat ringan total p n % n % n % sebelum 13 52,0 12 48,0 25 100 0,039 sesudah 5 20,0 20 80,0 25 100 tabel 3. distribusi responden menurut keluhan lemah lesu sebelum dan sesudah pelaksanaan paket edukasi pelaksanaan paket edukasi berat sedang ringan total p n % n % n % n % sebelum 8 32,0 13 52,0 4 16,0 25 100 0,021 sesudah 3 12,0 9 36,0 13 52,0 25 100 tabel 4. distribusi responden menurut respon psikologis:kecemasan sebelum dan setelah pelaksanaan paket edukasi paket edukasi berat sedang ringan total p n % n % n % n % sebelum 9 36,0 7 28,0 9 36,0 25 100 0,038 sesudah 4 16,0 3 12,0 18 72,0 25 100 tabel 5. distribusi responden menurut respon psikologis:depresi sebelum dan sesudah pelaksanaan paket edukasi kelompok berat sedang ringan total p n % n % n % n % sebelum intervensi 8 32,0 14 56,0 3 12,0 25 100 0,020 sesudah intervensi 4 16,0 9 36,0 12 48,0 25 100 keterangan : p = signifikansi %= prosentase n = jumlah or= odd ratio paket edukasi menurunkan keluhan fisik dan psikologis (mira triharini) 53 pembahasan hasil penelitian menunjukkan rerata responden berumur 48,56 tahun. menurut data dari yayasan kanker indonesia, kanker serviks umumnya menyerang perempuan usia produkstif antara 30-50 tahun dan banyak di antara mereka merasa tidak beresiko sehingga tidak memeriksakan diri untuk melakukan pencegahan (yki, 2008). hasil penelitian tentang tingkat pendidikan responden menunjukkan hasil bahwa mayoritas pendidikan responden adalah pendidikan rendah yaitu meliputi sekolah dasar (sd) dan sekolah menengah pertama (smp). tingkat pendidikan formal yang rendah akan mempengaruhi terbatasnya tingkat pengetahuan ibu tentang hal-hal yang mempengaruhi berkembangnya penyakit kanker serviks. hal ini selaras dengan pendapat notoatmodjo (1993) bahwa salah satu faktor yang mempengaruhi pengetahuan seseorang adalah tingkat pendidikan. pendidikan dapat membawa wawasan atau pengetahuan seseorang. hasil penelitian tentang status pekerjaan menunjukkan bahwa mayoritas responden tidak bekerja sehingga tidak mempunyai penghasilan tambahan dalam keluarga. keterbatasan keuangan dapat mempengaruhi asupan nutrisi. hal ini sesuai dengan faktor resiko dari terjadinya kanker serviks yaitu defisiensi nutrisi yaitu kekurangan beta karoten, vitamin c, dan perokok (sjamsuddin, 2001). hasil penelitian tentang lama didiagnosa kanker menunjukkan rata-rata lebih dari 3 bulan. lama individu didiagnosis kanker berpengaruh terhadap respon psikologis. respon depresi akan dirasakan pada waktu sekitar 3 bulan setelah didiagnosis kanker (craven, 2000). hasil penelitian yang menunjukkan bahwa karakteristik tidak berhubungan dengan keluhan mual muntah tidak sejalan dengan penelitian dari bahl, et al, (2006) dan zachariae, et al (2007). penelitian tersebut menemukan adanya hubungan antara frekuensi kemoterapi dengan perubahan keluhan mual muntah. kemoterapi menimbulkan cedera pada sel-sel usus halus dan menyebabkab pelepasan serotonin. syaraf aferen lambung yang distimulasi serotonin akan mengirimkan impuls ke pusat muntah (burke, 1996). dari hasil penelitian didapatkan adanya hubungan yang signifikan antara frekuensi kemoterapi dengan keluhan lemah lesu. kemoterapi tidak hanya mempengaruhi sel kanker tetapi juga mengganggu fungsi siklus sel normal dengan menurunkan absorbsi nutrien sel yang penting. gangguan pada pembentukan sel darah pada sumsum tulang atau myelosupresi menyebabkan penurunan sel darah merah, trombosit dan leukosit yang ikut mempengaruhi terjadinya lemah dan lesu (otto, 2001). kondisi ini dapat makin meningkat dengan semakin seringnya pemberian kemoterapi karena ketidakmampuan untuk melakukan adaptasi terhadap perubahan akibat efek kemoterapi. hal ini sesuai dengan hasil penelitian zachariae, et al (2007) yang menunjukkan adanya hubungan keluhan lemah lesu pada pasien kanker dengan frekuensi kemoterapi. hasil penelitian menunjukkan bahwa umur berhubungan dengan kecemasan pada pasien kanker serviks. mayoritas responden adalah berada pada usia dewasa tengah, dimana menurut potter dan perry (2000), pada usia 40-60 tahun seringkali mengalami masalah psikologis seperti kecemasan dan depresi. penyakit kanker serviks beserta kemoterapi yang dijalani akan menimbulkan berbagai masalah yang akan mempengaruhi peran dan tanggung jawab yang dipikul oleh dewasa tengah sehingga semakin meningkatkan kecemasan. status pekerjaan memiliki hubungan dengan kecemasan pada pasien kanker serviks. hal ini didukung oleh curt (2000) menyatakan bahwa lemah dan lesu yang dialami oleh pasien kanker memiliki dampak secara fisik, emosi, mental, sosial dan ekonomi.pada individu yang bekerja, perubahan kondisi fisik akibat perkembangan kanker serviks serta efek samping kemoterapi akan menimbulkan dampak yang besar. kondisi ini yang berlangsung dalam waktu yang lama akan dapat meningkatkan rasa kecemasan bagi pasien. paket edukasi yang diberikan tentang penyebab mual muntah, serta cara-cara untuk menurunkan mual muntah akan meningkatkan pengetahuan pasien tentang hal tersebut. pengetahuan responden yang baik tentang tentang cara mengatasi mual muntah merupakan salah satu faktor yang menyebabkan pasien mampu untuk melakukan perawatan diri sehingga mual muntah akan berkurang. hal ini didukung lawrence green jurnal ners vol.4 no.1 april 2009: 50-55 54 dalam notoatmodjo (1993) yang menyatakan bahwa perilaku kesehatan seseorang dapat ditentukan oleh faktor–faktor pengaruh (predisposing factor) yang terwujud dalam pengetahuan, sikap, kepercayaan, dan keyakinan. paket edukasi yang diberikan juga meliputi berbagi pengalaman antar responden dengan penyakit yang sama sebagai support sistem. adanya kesempatan untuk saling bertukar informasi antar responden akan mampu memberikan dukungan psikologis sehingga kecemasan dapat berkurang. hal ini sejalan dengan hasil penelitian yang menyatakan bahwa meningkatnya harapan dan menurunnya kecemasan dapat menurunkan keluhan mual muntah (higgins, montgomery, bubjerg, 2007; roscoe, et al, 2004). paket edukasi yang diberikan juga meliputi demonstrasi teknik relaksasi otot progresif. teknik relaksasi ini sesuai untuk dilakukan pada pasien kanker yang mendapatkan kemoterapi karena terbukti efektif mengurangi mual muntah antisipatori ataupun setelah pemberian kemoterapi (yoo, et al, 2005). paket edukasi meliputi pendidikan kesehatan tentang penyebab terjadinya lemah lesu setelah kemoterapi serta cara mengatasi kondisi lemah lesu. hal yang dijelaskan untuk mengurangi lemah lesu yaitu seperti menyeimbangkan waktu istirahat dan bekerja, mendahulukan aktivitas yang penting, atau meminta bantuan dari anggota keluarga saat beraktivitas. hal ini didukung oleh sebuah penelitian tentang intervensi konservasi energi pada pasien kanker yang menunjukkan hasil bahwa terdapat penurunan keluhan lemah lesu akibat kanker (barsevick, et al, 2004). paket edukasi yang didapatkan responden juga meliputi latihan relaksasi otot progresif. berdasarkan penelitian dalam berbagai jurnal, relaksasi otot progresif efektif dalam menurunkan masalah fisik seperti lemah dan lesu pada pasien kanker yang menjalani terapi kanker (chan, et al, 2007). pentingnya pendidikan kesehatan dan dukungan sosial bagi pasien kanker untuk menurunkan kecemasan dan depresi sesuai dengan beberapa hasil penelitian. sebuah penelitian menunjukkan bahwa pendidikan kesehatan tentang terapi dan perawatan seharihari mampu menurunkan kecemasan pada pasien kanker serviks stadium lanjut (maryati, 2006). penelitian lain tentang psikososial grup yang meliputi pendidikan kesehatan, pelatihan teknik koping, manajemen stres serta dukungan psikologis pada pasien kanker payudara di jepang menunjukkan hasil adanya penurunan kecemasan dan depresi (fukui, et al, 2000). simpulan dan saran simpulan paket edukasi (pengaturan nutrisi, pengaturan aktivitas, aspek psikologis, serta latihan relaksasi otot progresif) dapat menurunkan keluhan fisik (mual, muntah, lemah dan lesu) dan respon psikologis (kecemasan dan depresi) pasien kanker serviks yang mendapatkan kemoterapi. saran saran yang dapat diberikan bagi tenaga pelayanan keperawatan adalah setelah pemberian paket edukasi pada pasien kanker serviks di rumah sakit, perlu untuk dilakukan monitoring pelaksanaan paket edukasi selama di rumah dengan melibatkan tim kesehatan yang lain. saran bagi perkembangan ilmu keperawatan, hasil penelitian ini dapat dijadikan dasar untuk mengembangkan asuhan keperawatan terutama bentuk pendidikan kesehatan yang sesuai pada pasien kanker serviks yang menjalani kemoterapi. kepustakaan bahl, a., sharma, d.n., julka, p.k., & rath, g.k, 2006. chemotheraphy related toxicity in locally advanced non small cel lung cancer. journal of cancer research and therapeutics, 2 (1), hlm. 14-16. barsevick, a.m., dudley, w.i., beck,s., sweeney, c., whitmer, k., & nail, l., 2004. a randomized clinical trial of energy conservation for patient with cancer related fatigue. american cancer society, 100(6), hlm. 1302-1310. burke, m.b., wilkes, g.m., ingwersen, k.c., bean, c.k., & berg, d., 1996. cancer chemotheraphy: a nursing process approach. london: jones and barlett publisher inc. paket edukasi menurunkan keluhan fisik dan psikologis (mira triharini) 55 carvalho, e.c., martins, f.t., & santos, c.b., 2007. a pilot study of a relaxation technique for management of nausea and vomiting in patients receiving cancer chemotherapy. cancer nursing journal, 30(2), hlm. 163-167. chan, w.h.c., chang, a.m., leung, s.f., & mak, s.s.s., 2007. reducing breathlessness, fatigue, and anxiety in chinese patients undergoing lung cancer radiotherapy in hong kong. hong kong medical journal, 13(l2), hlm. 4-7 craven, r.f., & hirnle, c.j., 2000. fundamental of nursing: human health and function. philadelphia: lippincott. curt, 2000. the impact of fatigue on patients with cancer: overview of fatigue 1 and 2. the oncologist journal, 5(2),hlm. 9-12. fukui, s., kugaya, a., okamura, h., kamigaya, m., koike, m., nakanishi, t., et al., 2000. a psychosocial group intervention for japanese women with primary breast carcinoma: a randomized controlled trial. american cancer society, 89(5), hlm. 10261036. grunberg, s.m., deuson, r.r., mavros, p., geling, o., hansen, m., cruciani, g., et al., 2004. incident of chemotheraphy-induced nausea and emesis after modern antiemetics. american journal cancer society, 100(10), hlm. 2261-2268. higgins, s.c., montgomery, g.h., & bovbjerg, d.h., 2007. distress before chemotherapy predicts delayed but not acute nausea. support care cancer journal, 15(2), hlm. 171-177. iconomou, g., iconomou, a.v., argyriou, a.a., nikolopoulos, a., ifanti, a.a., & kalofonos, h.p., 2008. emotional distress in cancer patients at the beginning of chemotherapy and its relation to quality of life. journal of clinical oncology, 13(2), hlm. 21722. maryati, i, rustina, y., & gayatri, d, 2006. efektivitas pendidikan kesehatan terhadap aktivitas selfcare dan kecemasan wanita dengan kanker serviks stadium lanjut di jawa barat. tesis, jakarta: fik ui, tidak dipublikasikan. national comprehensive cancer network, 2009. clinical practice guidelines in oncology: cancer related fatigue. ncci. notoadmodjo, s., 1993. pengantar pendidikan kesehatan dan ilmu perilaku kesehatan. yogyakarta: andi offcet. otto, s.e., 2001. oncologi nursing. 4th ed. st louis: mosby inc. potter, p.a., & perry, a.g., 2000. fundamentals of nursing: concept, process and practice. st louis: mosbyyear book. roscoe, j.a., bushunow, p., & morrow, g.r., 2004. patient expectation is a strong predictor of severe nausea after chemotherapy: a university of rochester community clinical oncology program study of patients with breast carcinoma. cancer journal, 101(11). hlm. 2701-2708. sjamsuddin, 2001. pencegahan dan deteksi dini kanker serviks. cermin dunia kedokteran, no 133, hlm. 8-13. who, 2006. comprehensive cervical cancer control: a guide to essential practice. geneva: who. yayasan kanker indonesia, 2008. kampanye bantu cegah kanker serviks. (online), (http://www.cegahkankerserviks. org. diakses tanggal 5 februari 2009). yoo, h.j., ahn, s.h., kim, s.b., & han, o.s., 2005. efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. supportive care cancer journal, 13(10), hlm. 826-833. chariae, r., paulsen, k., mehlsen, m., jensen, a.b., johansson, a., & maase, h. ,2007. chemotheraphy-induced nausea, vomiting, and fatigue-the role of individual differences related to sensory perception and autonomic reactivity. psychotheraphy psychosomatic journal, 76(6), hlm. 376-384. efek pemberian terapi sinar 24jam terhadap penurunan kadar total serum bilirubin pada neonatus aterm dengan ikterus neonatorum jurnal ners vol. 2 no. 1 mei – september 2007 efektifitas distraksi visual dan pernafasan irama lambat dalam menurunkan nyeri akibat injeksi intra kutan nikmatur rohmah* abstract the objective of this study is to examine the effectiveness of visual distraction usage and slow rhytm respiratory on pain relief which is caused by intra cutan injection. a quasy experimental design was used in this study. sample of this study were 78 students of nursing academy jember muhammadiyah university at the second semester, recruited by using total sampling. data were collected by using observation and questionnaire, then analyzed with independent t-test with significance level p<0.05. the result showed that visual distraction and slow rhytm respiratory technique had significantly effect on the effort of decreasing pain (p= 0.000), and there was a correlation between visual distraction and slow rhytm respiratory technique had significantly effect with the effort of decreasing pain (p=0.019). conclusion: slow rhytm respiratory technique was more effective than visual distraction technique to relief pain. keywords: visual distraction, slow rhythm respiratory, pain, intra cutan injection pendahuluan nyeri dapat timbul karena berbagai sebab, antara lain: kimiawi, mekanik, listrik, termal dan psikologis. mekanisme nyeri dapat berupa terputusnya jaringan, tersayat, terdesak atau rusaknya ujung syaraf (priharjo, 1996). salah satu tindakan yang dapat menimbulkan nyeri adalah prosedur injeksi. ada dua pemikiran yang mendasari timbulnya nyeri akibat injeksi: 1) tusukan jarum pada kulit menyebabkan terputusnya jaringan, 2) masuknya massa obat ke dalam jaringan tubuh akan merangsang ujung saraf nyeri. pengalaman di laboratorium ilmu keperawatan dasar akademi keperawatan universitas muhammadiyah jember, pada pelaksanaan praktek prosedur injeksi, mahasiswa sering diliputi perasaan takut, khawatir dan ragu-ragu sebelum mereka latihan injeksi. bagi mahasiswa yang menjadi model selalu membayangkan rasa sakit bila diinjeksi. ___________ * staf pengajar akper unmuh jember respons yang muncul pada mahasiswa yang menjadi model antara lain: merintih, menangis, mengeluh kesakitan dan ingin menjerit. schecter (1987) dalam carpenito (2000) menyatakan bahwa tiap individu mengalami dan mengekspresikan nyeri dengan caranya sendiri. seseorang yang mengalami nyeri merasa seolah tubuh dan kehidupan mereka diluar kontrol. latihan yang dapat digunakan untuk meningkatkan kontrol nyeri menurut mc.guire dan schecter (1993) dalam carpenito (2000) adalah intervensi non farmakologis, yaitu melakukan aktifitas yang dapat menurunkan stres dan ansietas. intervensi non farmakologis dapat berupa stimulasi kognitif, perilaku dan counter iritan kutan. intervensi kognitif adalah usaha memodifikasi proses berfikir untuk menurunkan nyeri. aktfitas kognitif dapat berupa mendistraksi persepsi nyeri (misalnya berhitung, bermain game, bercakap-cakap, dan latihan nafas), imajinasi. tindakan stimulasi kognitif yang sederhana namun mempunyai kompleksitas yang tinggi adalah distraksi dan tehnik jurnal ners vol. 2 no. 1 mei – september 2007 pernafasan irama lambat. berdasarkan pendekatan konsep orem yang menekankan pada mengoptimalkan peran serta dan kemandirian pasien, maka distraksi dan teknik pernafasan ini sangat sesuai. bahan dan metode penelitian penelitian ini menggunakan quasi eksperimental design. populasi dalam penelitian ini adalah mahasiswa semester ii akademi keperawatan universitas muhammadiyah jember. besar sampel adalah 78 responden diambil dengan menggunakan tehnik total sampling. variabel independen dalam penelitian ini adalah distraksi visual dan tehnik pernafasan irama lambat, sedangkan variabel dependennya adalah penurunan nyeri pada injeksi intra kutan. instrumen yang digunakan dalam penelitian ini adalah observasi dengan berpedoman pada skala intensitas nyeri (skala 0-5). kuesioner dipakai sebagai data pendukung yang memvalidasi hasil pengamatan. pemilihan tehnik penurun nyeri tiap responden diberikan kebebasan untuk memilih. untuk distraksi visual disediakan dua alat bantu yaitu game dan gambar. pernafasan dilakukan dengan memejamkan mata dan relaksasi, sebelum dan sesudah injeksi dilakukan. analisis data dengan menggunakan uji statistik independent t-test dengan tingkat kemaknaan p≤0,05. hasil penelitian tabel 1: perbandingan skala nyeri saat injeksi intra kutan dengan penggunaan distraksi visual dan pernafasan irama lambat. skala nyeri distraksi visual pernafasan irama lambat 0 2 (4.65%) 4 (11.43%) 1 30 (69.77%) 27 (77.14%) 2 9 (20.93%) 4 (11.43%) 3 2 (4.65%) 0 (0%) 4 0 (0%) 0 (0%) 5 0 (0%) 0 (0%) total 48 (100%) 35 (100 %) mean 1.12 0.88 independent t-test p = 0.000 pada tabel 1 di atas terlihat hasil yang signifikan, yaitu p=0.000 yang artinya distraksi visual dan pernafasan irama lambat efektif dalam menurunkan nyeri akibat injeksi intra kutan. pembahasan ditraksi visual dan pernafasan irama lambat secara efektif dapat menurunkan nyeri. penggunaan distraksi visual yang tepat dan pernafasan irama lambat yang benar dapat meningkatkan toleransi terhadap nyeri dan menurunkan persepsi nyeri. nyeri yang timbul akibat tusukan jarum injeksi merupakan impuls saraf yang akan menyebar disepanjang serabut saraf perifer aferen. serabut saraf yang akan mengkonduksi stimulus ini akan dihantarkan oleh serabut a-delta (bermielin dan cepat) yang menghantarkan sensasi nyeri tajam, terlokalisir. serabut a-delta mentransmisikan impuls dari serabut saraf perifer, sehingga terjadi pelepasan mediator kimia yang mengaktifkan respons nyeri. transmisi stimulus nyeri akan berlanjut di sepanjang serabut saraf aferen sampai transmisi tersebut berakhir di bagian kornu dorsalis, kemudian neurotransmitter seperti subtansi p dilepaskan sehingga menyebabkan suatu transmisi sinapsis dari saraf perifer ke jurnal ners vol. 2 no. 1 mei – september 2007 saraf traktus spinotalamus (paice, 1991 dalam potter & perry, 2006). hal ini memungkinkan impuls nyeri ditransmisikan lebih jauh ke dalam sistem saraf pusat, sistim limbik, thalamus, kortek sensori dan kortek asosiasi. kemudian melalui serabut sistem nyeri desenden persepsi akan dikirim sehingga menimbulkan respons nyeri yang sangat individual. tehnik distraksi merupakan usaha untuk menurunkan nyeri dengan upaya melepaskan endorfin. pada saat individu melakukan distraksi dan stimulus nyeri sudah mencapai otak, maka pusat kortek di otak akan memodifikasi persepsi nyeri, kemudian alur saraf desenden pnghantar persepsi nyeri akan melepaskan opiat endogen (endorfin) yang akan menurunkan nyeri. neuromodulator ini bekerja dengan cara memodifikasi aktivitas neuron dan menyesuaikan atau memvariasikan transmisi stimulus nyeri. dalam teori gate control disebutkan bahwa distraksi dapat mengaktivasi serabut kecil yang dapat meningkatkan subtansia gelatinosa di dalam medula spinalis. dengan adanya subtansia gelatinosa ini maka produksi dari tcell akan dihambat. t-cell ini berfungsi sebagai serabut penghantar nyeri, jika t-cell dihambat produksinya maka hantaran nyeri akan dihambat pula. dalam teori ini disebutkan sebagai mekanisme penutupan pintu gerbang (guyton, 1990). menurut perry & potter (2006), teknik pernafasan irama lambat dapat menurunkan nyeri dengan mekanisme ganda. pertama pelaksanaan tehnik pernafasan ini mengandung unsur distraksi (pengalihan perhatian nyeri pada konsentrasi bernafas) sehingga mekanismenya berlangsung sebagaimana mekanisme distraksi. kedua, dalam teknik pernafasan ini juga mengandung unsur relaksasi dan peningkatan masukan oksigen. ketegangan akan meningkatkan persepsi nyeri. keadekuatan masukan oksigen dan relaksasi akan menurunkan persepsi nyeri. pernafasan irama lambat lebih efektif dibandingkan dengan distraksi visual. hal ini disebabkan oleh karena tehnik pernafasan lebih mudah dilakukan dan dapat dilakukan dalam segala situasi, serta tidak memerlukan alat bantu. teknik pernafasan yang dilakukan dengan benar mempunyai efek pengalih perhatian karena mempunyai unsur konsentrasi pada pernafasan dan efek relaksasi. pada distraksi visual seseorang diharapkan dapat memusatkan perhatiannya pada suatu obyek melalui indra pengelihatan. hal ini akan sulit dilakukan pada orang yang tidak mudah berkonsentrasi. distraksi visual juga memerlukan alat bantu tertentu, dimana tidak semua alat dapat dengan mudah digunakan oleh semua orang. simpulan dan saran simpulan 1. distraksi visual dan pernafasan irama lambat secara efektif dapat menurunkan nyeri akibat injeksi intra kutan. 2. pernafasan irama lambat secara signifikan lebih efektif dibandingkan dengan distraksi visual dalam menurunkan nyeri akibat injeksi intra kutan. saran 1. setiap individu yang akan diinjeksi hendaknya dapat menggunakan salah satu metode penurun nyeri non farmakologis yaitu pernafasan irama lambat atau distraksi visual. 2. pelaksanaan pengalaman belajar praktika bagi mahasiswa keperawatan khususnya praktik prosedur injeksi hendaknya dapat dilaksanakan secara terpadu dengan praktek prosedur penurunan nyeri non farmakologis, sehingga kompetensi belajar dapat dicapai dengan lebih baik. 3. perlu dilakukan penelitian lebih lanjut tentang pengalaman belajar praktika secara terpadu dengan topik-topik yang lain, misalnya praktek komunikasi terapeutik dengan praktek pemenuhan kebutuhan nutrisi. jurnal ners vol. 2 no. 1 mei – september 2007 kepustakaan burn, n. & groove, s.k., (2000), dasar-dasar riset keperawatan, jakarta: egc. carpenito, l.j., (2000), diagnosa keperawatan aplikasi pada praktek klinik, jakarta: egc. guyton, (1990), fisiologi manusia dan mekanisme penyakit, jakarta: egc. junaidi, p., (1995), pengantar analisa data, jakarta: rineka cipta. nursalam, (2003), konsep dan penerapan metodologi penelitian ilmu keperawatan edisi i, jakarta: salemba medika. peter & perry, (2006), fundamental keperawatan vol. 2 edisi 4, jakarta: egc. priharjo. r., (1996), perawatan nyeri: asuhan keperawatan dalam memenuhi kebutuhan aktifitas istirahat pasien, jakarta: egc. wolf, et.all., (1984), dasar-dasar ilmu keperawatan, jakarta: pt gunung agung. 131 p-issn: 1858-3598  e-issn: 2502-5791 © 2022 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 17, issue 2, october 2022, p. 131-137 http://dx.doi.org/10.20473/jn.v17i2.38318 original article open access analysis of the causes of low-birth-weight infants in terms of nutritional status and maternal health history sri utami1 and rekawati susilaningrum1,* 1 polytechnic of health ministry of health the republic of indonesia, surabaya, indonesia *correspondence: rekawati susilaningrum. address: polytechnic of health ministry of health the republic of indonesia, surabaya, indonesia. email: rekawati.susilaningrum01@gmail.com responsible editor: ferry efendi received: 15 august 2022 ○ revised: 6 september 2022 ○ accepted: 15 september 2022 abstract introduction: the incidence of low-birth-weight infants is still high and requires serious attention to prevent infant mortality. this study aimed to analyze the causes of low-birth-weight infants' nutritional status and maternal health history. methods: this cross-sectional study was conducted in may to july 2021 at two hospitals in surabaya. the study involved 498 mothers who had newborns within three years from 2019 and were recruited using simple random sampling. the inferential test was conducted using logistics regression with a significance level of 0.05. results: according to the adjusted model, variables that were significantly associated with the incidence of low-birthweight infants were the husband's job as private worker (or=0.021; 95% ci = 0.023-0.123), child number as one (or=0.214; 95% ci = 0.114-3.428), parity as prime (or=0.749; 95% ci = 0.197-3.652) and history of low-birth-weight infants in previous births (or=0.015; 95% ci = 0.004-0.006). conclusions: individual and family factors remand an essential variable in low-birth-weight prevalence. nurses are responsible for providing socialization to mothers and fathers who are having and planning to have children. cultural factors in the family and community where the mother lives also need to be carried out in further research. keywords: low birth weight infants; nutrition; history of illness; pregnancy introduction child development begins after conception or early pregnancy. since then, mothers need to take care of their physical and psychological conditions so that the fetus they contain can grow and develop optimally (evenson et al., 2014). maternal nutrition is very influential on fetal growth and development. undernourished mothers, before or during pregnancy, more often give birth to low birth weight (lbw) infants or are born with health problems (stephenson et al., 2018). lbw is an infant whose birth weight is less than 2500 grams. the incidence of lbw contributes to the neonatal mortality rate because of the various problems it causes. infants with lbw are more at risk of experiencing health problems than term infants, so efforts are needed to prevent the occurrence of lbw (dencker et al., 2016; gilbert et al., 2019). since the fetus is in the womb until age 18, the government has carried out child health efforts with integrated antenatal care (anc) programs, neonatal visits, immunizations, detection of growth and development, etc. this effort aims to prepare healthy, intelligent, and quality future generations and to reduce child mortality (marangoni et al., 2016; rogozinska et al., 2016). child health efforts have shown good results, as seen in the child mortality rate from year to year, which shows a decline. the results of the indonesia demographic and health survey (idhs) in 2017 showed a neonatal mortality rate (nmr) of 15 per 1,000 live births, infant mortality rate (imr) of 24 per 1,000 live births, and under-five mortality rate (u5mr) 32 per https://creativecommons.org/licenses/by/4.0/ https://orcid.org/0000-0002-0504-2379 https://orcid.org/0000-0002-2821-9106 supremo, bacason, and sañosa (2022) 132 p-issn: 1858-3598  e-issn: 2502-5791 1,000 live births. the child mortality rate (cmr) has reached the 2030 sustainable development goals (sdgs), which is 25/1,000 live births, and it is hoped that nmr can also reach the target of 12/1,000 live births (schmidt et al., 2016). imr and maternal mortality rate (mmr) are important indicators to determine the health status of the community. indonesia is expected to reduce mmr and imr to support the achievement of sustainable development goals (sdgs), namely ending preventable maternal, infant, and under-five mortality, which is targeted for a maternal mortality rate of 70 per 100,000 live births. for infants, 12 per 1000 live births and the under-five mortality rate is 25 per 1000 live births (rauh et al., 2014). there is a tendency to decrease the proportion of birth weight to less than 2500 grams. in 2013, the proportion of lbw was 5.7, in 2018 it was 6.2. the national mid-term development plan (nmtdp) target in 2019 is 8%, but the 2016 national health indicator survey (nhis) results in the proportion being around 6.9%, while the percentage of lbw in surabaya in 2018 was around 1.96 (kennelly et al., 2016). based on the health profile of the surabaya city health office, the imr per 1,000 live births in surabaya in 2018 was 6.43 per 1,000 live births. the percentage of lbw in surabaya in 2018 was around 1.96 (surabaya health office, 2019). from research on risk factors for lbw, the results show that the dominant factors that cause preterm labour include occupational factors at 0.385 times greater risk, pregnancy complications factors at 7.813 times greater risk, and antepartum bleeding factors at 26.886 times greater risk of preterm birth (naja et al., 2016; van dijk et al., 2017). detection of lbw is also related to maternal education, which affects maternal health and the health of infants in the womb (salsabiila et al., 2021). knowledge of pregnant women is at risk of maternal anemia because pregnant women do not know nutritious foods to consume. anemia in the mother also causes lbw (figueiredo et al., 2018). one of the risk factors for the occurrence of lbw infants is a history of high-risk maternal pregnancies. estimates of pregnant women at high risk or complications in surabaya in 2016 amounted to 9,496 people. the coverage of high-risk pregnant women or complications treated in health facilities is 90.24% (naja et al., 2016). in addition to giving birth to lbw infants, pregnant women are at high risk, leading to uneven delivery/stuck, dead fetuses in the womb, pregnant women/maternal deaths, and so on. the government has made various efforts to prevent the incidence of lbw, including integrated anc during pregnancy and giving supplementary food to pregnant women with a lack of chronic energy (lce). another effort that can be done is to detect pregnant women at risk of giving birth to lbw infants by collaborating with primary healthcare (jones et al., 2014; stang & huffman, 2016). unfortunately, there are still barriers that make the government's efforts still ineffective in preventing lbw. one of these barriers comes from internal factors of pregnant women. thus, this study aimed to identify the factors that cause low birth weight in terms of nutritional status and maternal disease history. materials and methods research design this type of research was included in the category of quantitative research with a cross-sectional approach. the study was conducted in may – july 2021 at haji hospital and soewandi hospital, surabaya, on mothers who had newborns within three years from 2019. the study was conducted by analyzing the factors that cause low-birth-weight infants seen from nutritional status and maternal history during pregnancy. respondent the population in this study were all newborns born at soewandi hospital and haji hospital surabaya in the last three years, consisting of two groups, namely newborns weighing <2,500 grams and infants born weighing 2,500 grams or more. a total of 498 mothers with infants born were recruited using simple random sampling. research variables the variables of this study were factors that were reviewed from the mother's nutritional status, namely body mass index, upper arm circumference, hemoglobin levels, and consumption of supplements. while in terms of disease history, factors are parity, previous history of low birth weight, comorbidities, birth interval, history of smoking, and alcohol consumption. the dependent variable in this study was the incidence of low-birthweight infants. data collection and research instrument data collection was done by looking at the data through the mother's medical record during hospitalization and identifying according to the required category. measurement of socio-demographic data was using a questionnaire consisting of age, education, occupation, income, husband's occupation, gestational age, and the number of children. body mass index and upper arm circumference were measured using the jurnal ners http://e-journal.unair.ac.id/jners 133 midline by measuring weight and height to calculate maternal body categories, which were classified into underweight <18.5 kg/m2, normal 18.5 – 25.9 kg/m2, overweight 25 – 29.9 kg /m2 and obesity > 30 kg/m2. while the size of the upper arm circumference <23.5 cm was in the category of malnutrition. hemoglobin levels were seen based on blood laboratory results with a highrisk category if <11 grams/dl, and supplement consumption was measured based on interviews with mothers. history of parity, previous lbw, comorbidities, pregnancy gap, history of smoking and alcohol consumption seen through the patient's medical record while in hospital. data analysis the data obtained were then carried out in descriptive data processing, with the frequency distribution of each variable studied and displayed based on percentages. the inferential test was carried out using the spss program for windows version 22 and tested using logistics regression with a significance value of 0.05. ethical consideration compliance with ethical guidelines. this research was first tested ethically and declared to have passed ethics at the ethics commission of soewandi hospital and haji hospital surabaya with ethical worthy certificate numbers 003/ke/kepk/2021 and 073/13/kom.etik/2021. results sociodemographic factors of respondents according to table 1, the socio-demographic of respondents, namely mothers who gave birth at haji hospital and soewandi hospital, surabaya with the most characteristic age 20-35 years, was as many as 361 respondents (72.5%). educational history at the high school level as many as 254 respondents (51.0%). most pregnant women do not work, as many as 460 respondents (92.4%), with the most income below the regional minimum wage, as many as 448 respondents (90.0%). a total of 460 respondents (92.4%) has a husband working in the private sector, and the maximum number of children is two children (57.6%). mother nutrition status according to table 1, nutritional status in mothers was measured by body mass index, upper arm circumference, hemoglobin level and consumption of supplements such as milk, blood-enhancing tablets, vitamins, and calcium in mothers during pregnancy. the body mass index of pregnant women was mostly in the normal category, total 268 respondents (53.8%), while women with abnormal conditions were underweight. a total 60 respondents (12.0%), overweight a total 108 respondents (21.7%), and obesity a total 62 respondents (12.4%). the arm circumferences of pregnant women who were less than normal (<23.5 cm) was 60 respondents (12.0%) and ≥ 23.5 cm are 438 respondents (88.0%), and the hemoglobin levels of pregnant women who were in anemic condition were 192 respondents (38.6%). despite the abnormal nutritional status, there were still mothers who did not take pregnancy supplements, as many as 192 respondents (38.6%). maternal health history during pregnancy also contributes to the incidence of low-birth-weight infants, which includes a history of previous low-birth-weight table 1 socio-demographic factors and mother health status (n=498) socio-demographic frequency (n) percentage (%) age under 20 years 20 – 35 years more than 35 years 127 361 10 25.5 72.5 2.0 education basic school high school university 161 254 83 32.3 51.0 16.7 job employed unemployed 38 460 7.6 92.4 income under and same as minimum regional income above minimum regional income 448 50 90.0 10.0 husband's job private sectors civil sectors 460 38 92.4 7.6 child amount one child two children three or more children 194 287 17 40.0 57.6 3.4 body mass index underweight normal overweight obesity 60 268 108 62 12.0 53.8 21.7 12.4 upper arm circumference < 23.5 cm ≥ 23.5 cm 60 438 12.0 88.0 hemoglobin level anemia normal 192 306 38.6 61.4 supplement consumption no yes 192 306 38.6 61.4 low-birth-weight infant history yes no never gave birth 170 195 133 34.1 39.2 26.7 comorbid of illness yes no 263 235 52.8 47.2 child born alive yes no 240 258 48.2 51.8 supremo, bacason, and sañosa (2022) 134 p-issn: 1858-3598  e-issn: 2502-5791 infants and comorbidities. most mothers were in a multi-parity condition with a history of low-birth-weight infants, as much as 34.1%. mothers who had comorbidities were 52.8% consisting of gestational diabetes, hypertension, obesity, and asthma. incidence of low-birthweight infants at haji and soewandi hospitals surabaya over the previous three years still showed poor results. as many as 48.2% of low-birthweight infants were born alive from a vaginal birth or sectio caesarea. unfortunately, 51.8% of low-birthweight infants did not survive. cross-tabulation of socio-demographic and mother with low-birth-weight infant the results of cross-tabulation of sociodemographic factors, nutritional status and history of maternal disease with the incidence of low-birth-weight infants showed that at risky ages, namely under 20 years and above 35 years, 70 respondents (14.1%) gave birth to low-birth-weight infants. mothers with basic education, namely elementary school and junior high school, showed the most births of infants with low-birth weight, a total 108 respondents (21.3%). the highest number of children showed the incidence of low-birthweight infants as much as 46.8% on nutritional factors, the incidence of mothers giving birth to children with low infant weight is almost balanced, both in normal and less than normal conditions. deficiency of hemoglobin level (anemia) also contributed to the risk of 48.2%. mothers who did not take supplements during pregnancy had a 15.5% incidence. mothers with a history of giving birth to low-birth-weight infants had an incidence of 28.7%, and mothers with comorbidities had an incidence rate of 28.1%. in contrast, in mothers with a history of smoking and drinking alcohol, the incidence of low-birth-weight infants is 50% (from two mothers who smoke and drink alcohol). one mother drinking alcohol gave birth to a low-birth-weight infant (table 2). low-birth-weight infants based on nutritional status and maternal disease history based on table 3 concerning to the results of the logistic regression analysis of factors for low-birthweight infants in terms of nutrition in terms of table 2. cross-tabulation of socio-demographic and mother with low-birth-weight infant factors variable low-birth-weight infant p-value no yes age under 20 years 20 – 35 years more than 35 years 61 (12.2%) 191 (38.4%) 6 (1.2%) 66 (13.3%) 170 (34.1%) 4 (0.8%) 0.557 educational background basic school high school university 52 (10.5%) 150 (30.2%) 56 (11.3%) 108 (21.7%) 24 (4.8%) 27 (3.4%) 0.000* number of children one child two children three children or more 77 (15.5%) 171 (34.3%) 10 (2%) 117 (23.5%) 116 (23.3%) 7 (1.4%) 0.000* body mass index underweight normal overweight obesity 29 (5.8%) 142 (28.5%) 62 (12.4%) 25 (5.0%) 31 (6.2%) 126 (25.3%) 46 (9.2%) 37 (7.4%) 0.091** upper arm circumference < 23.5 cm ≥ 23.5 cm 29 (5.8%) 229 (46.0%) 31 (6.2%) 209 (42.0%) 0.566 hemoglobin level anemia normal 115 (23.1%) 143 (28.7%) 77 (15.5%) 163 (32.7%) 0.004* supplement consumption no yes 115 (23.1%) 143 (28.7%) 77 (15.5%) 163 (32.7%) 0.004* parity prime parity multi parity 77 (15.5%) 181 (35.4%) 117 (23.5%) 123 (24.7%) 0.000* low-birth-weight infant history yes no never giving birth 27 (5.4%) 168 (33.7%) 63 (12.7%) 143 (28.7%) 27 (5.4%) 70 (14.1%) 0.000* comorbid of illness yes no 123 (24.7%) 135 (27.1%) 140 (28.1%) 100 (20.1%) 0.017* pregnancy gap under 2 years ≥ 2 years 18 (6.1%) 160 (54.4%) 11 (3.7%) 105 (35.7%) 0.860 * p = <0.05 ** p = <0.1 jurnal ners http://e-journal.unair.ac.id/jners 135 nutritional status, and maternal disease history. out of twenty-one variables only four variables are associated with low birth weight, those variables consist of the husband's job, the number of children, parity, and history of low-birth-weight, each of that variable calculation are explained as follow according to the adjusted model above, each of these variables associated with the incidence of low-birth-weight babies is the husband's job which consists of the private sector (or = 0.021, 95% ci = 0.023 – 0.123). number of children that include one child (or = 0.214, 95% ci = 0.114 – 3.428) and two children (or = 0.309, 95% ci = 0.156 – 2.431), parity that consisted of prime parity (or = 0.749. 95% ci = 0.197 – 3.652), history of low-birth-weight babies in previous birth consisted of experience lowbirth-weight (or = 0.015, 95% ci = 1.006 – 1.073). discussions low-birth-weight infants often occur at birth at any time if the mother's condition and factors that cause high risk are not immediately addressed. one of the main causes that often occur is due to maternal factors, especially problems related to pregnancy and nutritional status. based on the study's results, it was found that the factors that are more likely to influence the incidence of low birth weight are the husband's job, the number of children, the incidence of parity, and low birth weight history. a husband's job is closely associated with the incidence of low birth weight (husanah & machdalena, 2019). husbands who do not earn or have insufficient income cannot meet the needs of their pregnant wives, such as the need for additional nutrition and vitamins for table 3. the results of the logistic regression analysis of factors for low-birth-weight infants in terms of nutritional status and maternal disease history (n=498) factors contributed odds ratio 95% ci p-value lower upper age under 20 years (ref) 20 – 35 years 35 years and above 1 1.270 1.560 0.512 0.786 0.178 4.899 0.334 0.456 educational background basic school (ref) high school university 1 1.670 0.998 0.782 0.332 4.112 5.543 0.925 0.772 husband's job civil sectors private sectors 1 0.021 0.023 0.123 0.020* number of children one child two children three or more children 0.214 0.309 1 0.114 0.156 3.428 2.431 0.021* 0.011* body mass index underweight normal overweight obesity 1 1.321 1.742 1.002 0.436 0.055 0.321 3.212 2.412 3.781 0.123 0.228 0.451 upper arm circumference < 23.5 cm ≥ 23.5 cm 1 1.379 0.386 6.312 0.410 hemoglobin level anemia normal 1 1.901 0.903 2.114 0.432 supplement consumption no yes 1 1.650 0.907 1.219 0.690 parity multi parity prime parity 1 0.749 0.197 3.652 0.040* history of low-birth-weight infant yes no never 0.015 0.005 1 0.006 0.004 1.073 0.006 0.010* 0.441 comorbid of illness yes no 1 1.131 0.112 4.460 0.790 pregnancy gap under 2 years ≥ 2 years 1 0.450 0.997 2.901 0.145 * p = <0.05 supremo, bacason, and sañosa (2022) 136 p-issn: 1858-3598  e-issn: 2502-5791 pregnant women (elaabsi et al., 2022; merklingergruchala et al., 2019). another thing that causes the husband's job to be at risk for making lbw is the limited cost of conducting routine pregnancy check-ups (anc) (rm et al., 2020). this burden increases if the spouse of the jobless father already has dependent children from previous births (hinkle et al., 2014; merklinger-gruchala et al., 2019). husband's jobs whose salary cannot meet their daily needs will also make pregnant women stressed. the level of stress will affect the mother's health problems; the hormone cortisol, which is produced as a chemical mediator in the body, makes the sympathetic and parasympathetic nerves work more, accordingly, it will also have an impact on the fetus in the womb (rauh et al., 2014; schmidt et al., 2016). the number of children and the incidence of parity cause the birth of low-birth-weight infants as much as six times more than other factors. the number of children and the number of parities that pose a high risk of having an infant are mothers with more children or who have given birth for the first time. the risk of mothers with too many children, especially at such a close distance between pregnancy and child-birth, makes the condition of the mother's uterus not fully ready for implantation of the fertilized fetus (razeeni et al., 2021). the mother's uterus takes about two years to prepare to receive new implantation to be more fertile in maintaining the fetus to stay healthy because a properly regenerated uterus will make the placenta stick firmly so that the circulation of air, blood, and nutrients from mother to child is not disturbed (jelsma et al., 2016; zhang et al., 2014). previous low birth weight history in the mother is also more likely to have been associated with the incident of low birth weight. this condition is closely related to the mother's nutritional status during pregnancy (desta et al., 2020). mothers who experience ced will risk giving birth to children with low birth weight. ced in pregnant women can not only cause severe nausea and vomiting, weakness, and fatigue but is also dangerous for the fetus because of the risk of miscarriage, low birth weight, premature birth, stunting, also giving birth to infants who also experience chronic energy deficiency later (aisy & kurniasari, 2022; girma et al., 2019). therefore, chronic energy deficiency in pregnant women needs to be detected and treated early so that the fetus born later can be healthier. this ced can have many possible triggers, including stress, viral infections, weak immunity, and hormonal balance disorders (deriba & jemal, 2021; diani et al., 2020). if a pregnant woman with ced gets pregnant again and her ced has not been handled properly, then there is a great risk that she will experience problems with the fetus again, as mentioned above. therefore, before planning another pregnancy, pregnant women with a history of ced are advised to consult with their obstetrician and nutritionist to handle their condition optimally. that way, she can contain a healthier fetus in her next pregnancy. conclusions generally, the results of this study highlight the need to improve the level of knowledge and increase the trust in the covid-19 vaccines to expedite their uptake in the older adult population. educating them on the benefits of the covid-19 vaccine is an essential milestone in preventing further morbidity and mortality cases of the covid-19 disease, considering their highrisk category. moreover, the local government should intensify its public awareness campaigns to reach everyone in the community. providing rewards or incentives can also be a strategy to improve the level of vaccine uptake. funding source this research received funding from the indonesian ministry of health in the form of lecturer research grants in the form of basic research grants for superior universities. references aisy, r. rahadatu., & kurniasari, l. (2022). hubungan riwayat persalinan dan riwayat bblr dengan kejadian stunting pada anak. literature review. borneo student research, 3(2), 1734–1745. dencker, a., premberg, å., olander, e. k., mccourt, c., haby, k., dencker, s., glantz, a., & berg, m. (2016). adopting a healthy lifestyle when pregnant and obese an interview study three years after childbirth. bmc pregnancy and childbirth, 16(1). https://doi.org/10.1186/s12884-016-0969-x deriba, b. s., & jemal, k. (2021). determinants of low birth weight among women who gave birth at public health facilities in north shewa zone : unmatched case-control study. the journal of health care organization, provision, and financing, 58(2021), 1– 11. https://doi.org/10.1177/00469580211047199 desta, s. a., damte, a., & hailu, t. (2020). maternal factors associated with low birth weight in public hospitals of mekelle city , ethiopia : a case-control study. italian journal of pediatric, 46(124), 1–9. https://doi.org/10.1186/s13052-020-00890-9 diani, m. w., mogi, a. k., & rahmi, k. a. (2020). differentiate factors of pregnant women with chronic energy deficiency occurrence in bajulmati village, wongsorejo district, banyuwangi regency 2019. journal of community medicine and public health research, 1(1), 24–32. https://doi.org/10.20473/jcmphr.v1i1.20297 dijk, m. r., oostingh, e. c., koster, m. p. h., willemsen, s. p., laven, j. s. e., & steegers-theunissen, r. p. m. (2017). the use of the mhealth program smarter pregnancy in preconception care: rationale, study design and data collection of a randomized controlled trial. bmc pregnancy and childbirth, 17(1). https://doi.org/10.1186/s12884-017-1228-5 elaabsi, m., loukid, m., & lamtali, s. (2022). socio-economic and cultural determinants of mothers and fathers for low birth weight newborns in the region of marrakech (morocco): a case-control study. plos one, 17(6), 269832. jurnal ners http://e-journal.unair.ac.id/jners 137 https://doi.org/10.1371/journal.pone.0269832 evenson, k. r., barakat, r., brown, w. j., dargent-molina, p., haruna, m., mikkelsen, e. m., mottola, m. f., owe, k. m., rousham, e. k., & yeo, s. a. (2014). guidelines for physical activity during pregnancy: comparisons from around the world. american journal of lifestyle medicine, 8(ue 2), 102–121. https://doi.org/10.1177/1559827613498204 figueiredo, a. c. m. g., gomes-filho, i. s., silva, r. b., pereira, p. p. s., mata, f. a. f. d., lyrio, a. o., souza, e. s., cruz, s. s., & pereira, m. g. (2018). no title. maternal anemia and low birth weight: a systematic review and meta-analysis. nutrients, 10(5). https://doi.org/10.3390/nu10050601 gilbert, l., gross, j., lanzi, s., quansah, d. y., puder, j., & horsch, a. (2019). how diet, physical activity and psychosocial well-being interact in women with gestational diabetes mellitus: an integrative review. bmc pregnancy and childbirth, 19(1). https://doi.org/10.1186/s12884-019-2185-y girma, s., fikadu, t., agdew, e., haftu, d., gedamu, g., & dewana, z. (2019). factors associated with low birthweight among newborns delivered at public health facilities of nekemte town , west ethiopia : a case control study. bmc pregnancy and childbirth, 19(220), 1–6. https://doi.org/10.1186/s12884-019-2372-x hinkle, s. n., albert, p. s., mendola, p., sjaarda, l. a., yeung, e., boghossian, n. s., & laughon, s. k. (2014). the association between parity and birthweight in a longitudinal consecutive pregnancy cohort. paediatric and perinatal epidemiology, 28(2), 106–115. https://doi.org/10.1111/ppe.12099 husanah, e., & machdalena, m. (2019). perilaku suami berhubungan dengan kejadian bayi berat lahir rendah (bblr) di arifin achmad pekanbaru. prosiding hang tuah pekanbaru, 1(1), 71–76. https://doi.org/10.25311/prosiding.vol1.iss1.18 jelsma, j. g. m., leeuwen, k. m., oostdam, n., bunn, c., simmons, d., desoye, g., corcoy, r., adelantado, j. m., kautzky-willer, a., harreiter, j., assche, f. a., devlieger, r., timmerman, d., hill, d., damm, p., mathiesen, e. r., wender-ozegowska, e., zawiejska, a., rebollo, p., & poppel, m. n. m. (2016). beliefs, barriers, and preferences of european overweight women to adopt a healthier lifestyle in pregnancy to minimize risk of developing gestational diabetes mellitus: an explorative study. journal of pregnancy. https://doi.org/10.1155/2016/3435791 jones, i., chandra, p. s., dazzan, p., & howard, l. m. (2014). bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. the lancet, 384(ue 9956), 1789–1799. https://doi.org/10.1016/s0140-6736(14)61278-2 kennelly, m. a., ainscough, k., lindsay, k., gibney, e., mc carthy, m., & mcauliffe, f. m. (2016). pregnancy, exercise and nutrition research study with smart phone app support (pears): study protocol of a randomized controlled trial. contemporary clinical trials, 46, 92–99. https://doi.org/10.1016/j.cct.2015.11.018 marangoni, f., cetin, i., verduci, e., canzone, g., giovannini, m., scollo, p., corsello, g., & poli, a. (2016). maternal diet and nutrient requirements in pregnancy and breastfeeding. an italian consensus document. nutrients, 8(ue 10)). https://doi.org/10.3390/nu8100629 merklinger-gruchala, a., jasienska, g., & kapiszewska, m. (2019). paternal investment and low birth weight – the mediating role of parity. plos one, 14(1), 210715. https://doi.org/10.1371/journal.pone.0210715 naja, f., nasreddine, l., al thani, a. a., yunis, k., clinton, m., nassar, a., farhat jarrar, s., moghames, p., ghazeeri, g., rahman, s., alchetachi, w., sadoun, e., lubbad, n., bashwar, z., bawadi, h., & hwalla, n. (2016). study protocol: mother and infant nutritional assessment (mina) cohort study in qatar and lebanon. bmc pregnancy and childbirth, 16(1). https://doi.org/10.1186/s12884016-0864-5 rauh, k., kunath, j., rosenfeld, e., kick, l., ulm, k., & hauner, h. (2014). healthy living in pregnancy: a cluster-randomized controlled trial to prevent excessive gestational weight gain rationale and design of the gelis study. bmc pregnancy and childbirth, 14(1). https://doi.org/10.1186/1471-2393-14-119 razeeni, d. m. a., al-wathinani, a., alhazmi, r., samarkandi, o. a., aditya, r. s., salameh, b., & alenazi, a. (2021). the preparedness of emergency medical services students for coronavirus disease 2019: a cross-sectional study among paramedic students. indian journal of pharmaceutical sciences, 5(october). rm, c. m., ba, a. w., & bsocsc, b. c. (2020). barriers and facilitators perceived by women while homeless and pregnant in accessing antenatal and or postnatal healthcare : a qualitative evidence synthesis. february, 1380–1393. https://doi.org/10.1111/hsc.12972 rogozinska, e., d’amico, m. i., khan, k. s., cecatti, j. g., teede, h., yeo, s., vinter, c. a., rayanagoudar, g., barakat, r., perales, m., dodd, j. m., devlieger, r., bogaerts, a., poppel, m. n. m., haakstad, l., shen, g. x., shub, a., luoto, r., kinnunen, t. i., & thangaratinam, s. (2016). development of composite outcomes for individual patient data (ipd) meta-analysis on the effects of diet and lifestyle in pregnancy: a delphi survey. bjog: an international journal of obstetrics and gynaecology, 123(ue 2), 190–198. https://doi.org/10.1111/1471-0528.13764 salsabiila, j. h., joewono, h. t., & sulistiawati, s. (2021). maternal educational status as one of the risk factors affecting the incidence of infants with low birth weight in dr. m. soewandhie general hospital surabaya. juxta: jurnal ilmiah mahasiswa kedokteran universitas airlangga, 12(1), 10. https://doi.org/10.20473/juxta.v12i12021.10-13 schmidt, m. i., duncan, b. b., castilhos, c., wendland, e. m., hallal, p. c., schaan, b. d. a., drehmer, m., costa, forti, a., façanha, c., & nunes, m. a. (2016). lifestyle intervention for diabetes prevention after pregnancy (linda-brasil): study protocol for a multicenter randomized controlled trial. bmc pregnancy and childbirth, 16(1). https://doi.org/10.1186/s12884-016-0851-x stang, j., & huffman, l. g. (2016). position of the academy of nutrition and dietetics: obesity, reproduction, and pregnancy outcomes. journal of the academy of nutrition and dietetics, 116(4), 677– 691. https://doi.org/10.1016/j.jand.2016.01.008 stephenson, j., heslehurst, n., hall, j., schoenaker, d. a. j. m., hutchinson, j., cade, j. e., poston, l., barrett, g., crozier, s. r., barker, m., kumaran, k., yajnik, c. s., baird, j., & mishra, g. d. (2018). before the beginning: nutrition and lifestyle in the preconception period and its importance for future health. the lancet, 391(ue 10132), 1830–1841. https://doi.org/10.1016/s0140-6736(18)30311-8 zhang, c., tobias, d. k., chavarro, j. e., bao, w., wang, d., ley, s. h., & hu, f. b. (2014). adherence to healthy lifestyle and risk of gestational diabetes mellitus: prospective cohort study. bmj (online, 349. https://doi.org/10.1136/bmj.g5450 how to cite this article: utami, s., and susilaningrum, r. (2022) ‘analysis of the causes of low birth weight infants in terof of nutritional status and maternal health history’, jurnal ners, 17(2), pp. 131-137. doi: http://dx.doi.org/10.20473/jn.v17i2.38318 hubungan faktor risiko asma dan perilaku pencegahan 128 perbedaan efektivitas penyembuhan luka bakar dengan propolis dan silver sufadiazin 1% (comparison of the effectiveness between propolis and silver sulfadiazine 1% on burn wound healing) i ketut sudiana*, walida pangestuti*, wahyuni tri lestari* abstract introduction: silver sulfadiazine 1% is often used as topical agent in burn wound due to its antimicrobial effect. moreover, this agent has toxigenic effect on fibroblast and keratinocyte. propolis is a honey bee product and has been used for a long time in burn wound related to antimicrobial effect, anti-inflammation, anti-oxidant and increasing fibroblast. the purpose of this study was to examining the differences between propolis and silver sulfadiazine 1% on burn wound healing process. method: design used in this study was true experimental design. the samples were 18 guinea pigs divided randomizely into three group. the groups were control group, propolis group, and silver sulfadiazine group. the independent variables were the using of propolis and silver sulfadiazine 1%. the dependent variables were inflammation phase (erythema, oedema, wound fluid) and proliferation phase (wound granulation, wound size) which were observed on the 3 rd , 7 th , 14 th days. data were collected by using observation paper based on the sign of inflammation and proliferation. data were analyzed using oneway anova and kruskal-wallis test with level of significance of α ≤ 0.05. result: results showed that there were differences between propolis and silver sulfadiazine 1% in erythema (p=0.00) and oedema (p=0.001) on 3 rd day and erythema (p=0.00) and oedema (p=0.00) on7 th day, furthermore burn wound size (p=0.00) on14 th day was also attenuated by propolis and silver sulfadiazine 1 %. analysis: it can be concluded that the using of propolis was more effective than silver sulfadiazine 1% in burn wound healing. discussion: further studies involved microscopic observation of collagen, pmn cell (neutrophile), lymphocyte and monocyte cell are needed. keywords: propolis, silver sulfadiazine 1%, burn wound healing *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail : ik.sudiana@yahoo.com pendahuluan luka bakar adalah kerusakan kulit tubuh yang disebabkan oleh api, atau oleh penyebab lain seperti air panas, listrik, bahan kimia dan radiasi (sudjatmiko, 2007). luka bakar memerlukan perawatan berupa agen topikal untuk mendukung penyembuhan luka. silver sulfadiazin 1% (ssd 1%) merupakan bahan yang biasa digunakan sebagai agen topikal pada luka bakar (smeltzer & bare, 2002). selain efektif terhadap luka bakar, bahan ini juga diketahui memiliki beberapa efek samping seperti leukopenia, alergi, menghambat proliferasi fibroblas dan epitelisasi sehingga memperlambat penyembuhan luka (lee & moon, 2008). menurut tsauri (2006) dalam afrina (2009) menyebutkan bahwa salah satu cara yang dapat dilakukan agar perawatan terhadap luka tidak banyak menimbulkan efek samping adalah dengan menggunakan bahan-bahan dari alam. keunggulan pengobatan alami adalah bahan mudah didapat, ekonomis, mudah digunakan, dan hanya menimbulkan efek samping minimal. salah satu bahan alami yang dapat digunakan untuk penyembuhan luka bakar adalah propolis. propolis merupakan salah satu produk yang dihasilkan oleh lebah dan mengandung komposisi kimia yang kompleks yang bersifat sebagai antibakteri, anti-inflamasi dan anti-oksidan (lotfy, 2006). penggunaan propolis secara topikal terbukti mampu mempercepat penyembuhan luka bakar, meningkatkan produksi sel epitel, serta mengurangi pembentukan jaringan parut mailto:ik.sudiana@yahoo.com penyembuhan luka dengan propolis dan ssd 1% 129 (krell, 1996 dalam dzik et al., 2003). namun sampai saat ini, perbedaan efektivitas antara propolis dan silver sulfadiazin 1% terhadap proses penyembuhan luka bakar masih belum diketahui. sekitar 2,5 juta orang mengalami luka bakar di amerika serikat setiap tahunnya. dari kelompok ini, 200.000 pasien memerlukan penanganan rawat jalan dan 100.000 pasien dirawat di rumah sakit. sekitar 12.000 orang meninggal setiap tahun akibat luka bakar dan cedera inhalasi yang berhubungan dengan luka bakar (smeltzer & bare, 2002). di unit luka bakar rsup dr. cipto mangunkusumo, pada tahun 1998 di laporkan 107 kasus luka bakar yang dirawat. di unit luka bakar rsu dr. soetomo surabaya jumlah kasus yang dirawat selama satu tahun (januari 2000 sampai desember 2000) sebanyak 106 kasus luka bakar atau 48,4% dari seluruh penderita bedah plastik (noer dkk., 2006). luka bakar menyebabkan kerusakan integritas kulit yang memungkinkan masuknya mikroba ke luka sehingga dapat terjadi infeksi pada luka. luka bakar yang terinfeksi akan menyebabkan infeksi sistemik yang merupakan penyebab utama kematian pasien luka bakar (shuid et al, 2005). oleh karena itu, diperlukan suatu alternatif obat topikal pada luka bakar yang aman dan efektif pada luka agar tidak berlanjut ke kondisi yang lebih parah. luka bakar merupakan suatu bentuk kerusakan atau kehilangan jaringan yang disebabkan kontak dengan sumber panas seperti api, air panas, bahan kimia, listrik dan radiasi (sudjatmiko, 2007). luka bakar disebabkan oleh pengalihan energi dari suatu sumber panas kepada tubuh. panas dapat dipindahkan lewat hantaran atau radiasi elektromagnetik. luka bakar dapat menyebabkan kerusakan jaringan yang akan memicu serangkaian proses dari host yang bertujuan untuk memperbaiki integritas jaringan (smeltzer & bare, 2002). proses penyembuhan luka bakar terjadi melalui beberapa fase, diantaranya fase inflamasi, fase proliferasi, dan maturasi. apabila proes ini tidak terkontrol dan berlebih akan menimbulkan berbagai masalah. luka bakar yang tidak ditangani secara baik akan berisiko untuk menjadi jaringan parut hipertrofik atau keloid (noer dkk., 2006) penggunaan bahan alam baik sebagai obat maupun tujuan lain cenderung meningkat, terlebih dengan adanya isu back to nature. sementara ini banyak orang beranggapan bahwa penggunaan obat tradisional relatif lebih aman dibandingkan obat sintetis (katno & pramono, 2009). salah satu obat tradisional yang dapat dijadikan sebagai salah satu altenatif terapi pada luka bakar adalah propolis. menurut koichi et al. (2006) propolis merupakan bahan resin yang melekat pada bunga, pucuk dan kulit kayu yang dikumpulkan oleh lebah madu (apis mellifera) dan sekarang banyak dipakai sebagai obat persediaan di rumah dalam bentuk kapsul, obat tetes, obat kumur, krim dan bubuk. propolis memiliki efek antibiotik, anti-oksidan, dan anti-inflamasi yang mampu mempercepat penyembuhan luka bakar. efek anti-inflamasi propolis disebabkan oleh senyawa caffeic acid phenethyl ester (cape) dan bioflavonoid yang dapat menekan mediator inflamasi (ramos&miranda, 2007). kedua bahan tersebut juga bersifat sebagai anti-oksidan yang mampu mengikat radikal bebas yang dihasilkan oleh sel-sel peradangan (song et al., 2008 dalam nijveldt et al., 2001). senyawa cape dalam propolis terbukti mampu meningkatkan pembentukan fibroblas yang berarti juga meningkatkan pembentukan kolagen pada luka (song et al., 2008). menurut lotfy (2006) menyatakan bahwa propolis memiliki sifat antibakteri yang kuat yang dapat mencegah infeksi pada luka bakar. karena efek yang menguntungkan dari propolis terhadap penyembuhan luka, peneliti ingin membandingkan antara propolis dan pengobatan standar pada luka bakar yaitu ssd 1% terhadap proses penyembuhan luka bakar. sehubungan penelitian ini masih belum dapat diterapkan pada manusia, maka digunakan hewan coba yaitu marmut (cavia cobaya). metode penelitian penelitian menggunakan true eksperimental design menggunakan post test only control group. pemilihan sampel dilakukan dengan simple random sampling. penelitian ini menggunakan hewan coba marmut (cavia cobaya) dan untuk menghindari sampel yang drop out, peneliti telah menetapkan kriteria sampel subyek penelitian: 1) usia marmut 3 bulan, 2) berat badan 350450 gram, 3) jenis lokal dan 4) jenis kelamin jantan. variabel independen dalam penelitian jurnal ners vol.4 no.2: 128 138 130 ini adalah pemberian propolis dan silver sulfadiazin 1%. variabel dependen pada penelitian ini adalah proses penyembuhan luka yang terdiri atas fase inflamasi (kemerahan di sekitar luka, edema di sekitar luka dan cairan pada luka) dan fase proliferasi (granulasi pada jaringan luka dan ukuran diameter luka). instrumen yang digunakan yaitu lembar observasi yang berisi kriteria penyembuhan luka menurut rainey (2002) dan modifikasi dari watono (2007). sampel yang terpilih dibagi dalam 3 kelompok: kelompok propolis, kelompok sulfadiazin dan kelompok kontrol masing-masing berjumlah 6 ekor marmut. pembuatan luka bakar dilakukan pada seluruh kelompok dengan cara memanaskan logam berdimeter 1 cm di atas api selama 13 menit, kemudian ditempelkan pada punggung marmut selama 6 detik. luka bakar pada kelompok propolis dirawat dengan propolis, pada kelompok sulfadiazin dirawat dengan sulfadiazin 1 % dan kelompok kontrol hanya dibilas dengan normal saline. perawatan luka bakar ini dilakukan setiap hari sekali selama 14 hari. penilaian terhadap proses penyembuhan luka dilakukan pada hari ke-3 (fase inflamasi), hari ke-7 (peralihan fase inflamasi ke fase proliferasi) dan hari ke-14 (fase proliferasi). data yang didapat kemudian dianalisis menggunkakan uji one way anova dan kruskal wallis dengan derajat kemaknaan α≤0,05. hasil penelitian hasil perawatan luka pada hari ke-3 dengan propolis menunjukkan tidak terbentuk cairan pus pada luka, ada kemerahan dan edema di sekeliling luka, jaringan granulasi belum nampak dan diameter luka bakar belum mengecil. kelompok perawatan silver sulfadiazin 1% menunjukkan tidak ada cairan pada luka, ada kemerahan dan edema yang cukup lebar di sekeliling luka, jaringan granulasi belum nampak dan diameter luka bakar belum mengecil. kelompok kontrol normal salin 0,9% memiliki luka yang kering dan tidak ada cairan pus pada luka, ada kemerahan dan edema yang lebar di sekeliling luka, jaringan granulasi belum nampak dan diameter luka bakar belum mengecil. kondisi luka bakar pada hari ke-7 kelompok propolis terlihat tidak ada cairan luka, ada sedikit kemerahan dan edema di sekeliling luka, jaringan granulasi belum nampak, diameter luka bakar belum mengecil dan luka masih berukuran 1 cm. kelompok perlakuan dengan silver sulfadiazin 1% terlihat tidak ada cairan pada luka, ada kemerahan dan edema yang cukup lebar di sekeliling luka, jaringan granulasi belum nampak, luka bakar semakin melebar dan meradang. kelompok kontrol normal salin 0,9 % pada hari ke-7 menunjukkan kondisi luka yang terlihat kering dan tidak ada cairan luka, kemerahan di sekeliling luka masih cukup lebar, ada edema, jaringan granulasi belum nampak, diameter luka bakar tetap berukuran 1 cm. hari ke-14 perawatan luka bakar pada kelompok propolis memiliki luka yang terlihat kering atau tidak terdapat cairan pus pada luka, tidak ada kemerahan dan edema di sekeliling luka, terdapat jaringan granulasi di seluruh bagian luka, ukuran luka bakar mengecil. kelompok silver sulfadiazin 1% terlihat tidak ada cairan luka, tidak ada edema dan kemerahan di sekeliling luka, terlihat jaringan granulasi di seluruh bagian luka, luka bakar semakin mengecil. kelompok kontrol normal salin menunjukkan luka yang terlihat kering, tidak tampak kemerahan dan edema di sekitar luka, pada bagian tengah luka tertutup oleh keropeng dan dibagian tepi luka sudah muncul granulasi, diameter luka bakar sedikit mengecil. berdasarkan hasil perawatan selama 14 hari, kelompok propolis memiliki diameter ukuran luka terkecil di antara semua kelompok. kelompok ssd 1% dan kontrol memiliki ukuran diameter luka bakar yang hampir sama pada hari ke-14 post pembuatan luka. hal ini menunjukkan bahwa propolis lebih efektif dalam penyembuhan luka bakar dibanding ssd 1%. berikut ini merupakan data yang diperoleh mengenai tanda inflamasi luka bakar pada tiap kelompok pada hari ke-3, 7, 14 post pembuatan luka bakar. penyembuhan luka dengan propolis dan ssd 1% 131 tabel 1. ukuran kemerahan dari tepi luka pada hari ke-3, 7, 14 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 1428 juni 2009 tabel 2. hasil post hoc test ukuran kemerahan dari tepi luka pada hari ke-3 dan 7 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 14-28 juni 2009 tabel 3 ukuran edema dari tepi luka pada hari ke-3, 7, 14 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 1428 juni 2009 tabel 4. hasil post hoc test ukuran edema dari tepi luka pada hari ke-3 dan 7 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 14-28 juni 2009 edema hari kekelompok p value 3 propolis ssd 1% 0.001 propolis kontrol 0.013 ssd 1% kontrol 0.215 7 propolis ssd 1% 0.00 propolis kontrol 0.00 ssd 1% kontrol 0.794 kelompok n rata-rata kemerahan dari tepi luka hari ke(cm) 3 7 14 propolis 6 0,41 ± 0,058 0,13 ± 0,075 0 ssd 1% 6 0,60 ± 0,077 0,32 ± 0,026 0 kontrol 6 0,54 ± 0,049 0,33 ± 0,026 0 one-way anova p = 0.00 p = 0.00 p = kemerahan hari ke kelompok p value 3 propolis ssd 1% 0.00 propolis kontrol 0.002 ssd 1% kontrol 0.129 7 propolis ssd 1% 0.00 propolis kontrol 0.00 ssd 1% kontrol 0.559 kelompok n rata-rata edema dari tepi luka hari ke(cm) 3 7 14 propolis 6 0,44 ± 0,066 0,14 ± 0,086 0 ssd 1% 6 0,60 ± 0,077 0,32 ± 0,026 0 kontrol 6 0,55 ± 0,055 0,33 ± 0,027 0 one-way anova p = 0.003 p = 0.00 p = jurnal ners vol.4 no.2: 128 138 132 tabel 5. cairan luka pada hari ke-3, 7, 14 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 14-28 juni 2009 tabel 6. granulasi luka pada hari ke-3, 7, 14 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 14-28 juni 2009 tabel 7. ukuran diameter luka bakar pada hari ke-3, 7, 14 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 1428 juni 2009 tabel 8. hasil post hoc test ukuran diameter luka bakar pada hari ke-14 post pembuatan luka bakar di laboratorium biokimia fakultas kedokteran universitas airlangga surabaya tanggal 14-28 juni 2009 pembahasan fase inflamasi merupakan tahapan yang penting pada penyembuhan luka. walaupun inflamasi diperlukan untuk penyembuhan luka, namun bila terjadi perpanjangan inflamasi justru akan memperlambat penyembuhan luka. fase inflamasi dimulai setelah beberapa menit terjadi luka dan berlangsung selama sekitar 3 hari setelah cedera (potter & perry, 2006; ramos & miranda, 2007). fase inflamasi kelompok hari ke-3 hari ke-7 hari ke-14 cairan dengan pus ada cairan tidak ada cairan cairan dengan pus ada cairan tidak ada cairan cairan dengan pus ada cairan tidak ada cairan propolis 0 0 6 0 0 6 0 0 6 ssd 1% 0 0 6 0 0 6 0 0 6 kontrol 0 0 6 0 0 6 0 0 6 kruskalwallis p = 1.00 p = 1.00 p = 1.00 kelompok hari ke-3 hari ke-7 hari ke-14 tidak ada granulasi sebagian luka seluruh bagian luka tidak ada granulasi sebagian luka seluruh bagian luka tidak ada granulasi sebagian luka seluruh bagian luka propolis 6 0 0 6 0 0 0 0 6 ssd 1% 6 0 0 6 0 0 0 0 6 kontrol 6 0 0 6 0 0 0 6 0 kruskalwallis p = 1.00 p = 1.00 p = 0.00 kelompok n rata-rata ukuran diameter luka hari ke(cm) 3 7 14 propolis 6 1 ± 0,00 1 ± 0,00 0,48 ± 0,044 ssd 1% 6 1 ± 0,00 1,41 ± 0,053 0,69 ± 0,066 kontrol 6 1 ± 0,00 1 ± 0,00 0,75 ± 0,064 uji statistik one-way anova p = kruskal-wallis: p = 0.00 one-way anova p = 0.00 diameter luka hari ke kelompok p value 14 propolis ssd 1% 0.00 propolis kontrol 0.00 ssd 1% kontrol 0.105 penyembuhan luka dengan propolis dan ssd 1% 133 dapat diobservasi secara makrokopis dari tanda-tanda yang muncul seperti kemerahan di sekitar luka, edema, dan adanya cairan pada luka. kemerahan hari ke-3 pada kelompok propolis berukuran rata-rata 0,41 cm dari tepi luka, sedangkan nilai kemerahan ssd 1% adalah 0,6 cm dan kontrol 0,54 cm. ukuran kemerahan pada ketiga kelompok tersebut mengalami penurunan pada hari ke-7, dimana ukuran kemerahan kelompok propolis menjadi sebesar 0,13 cm, kelompok ssd 1% sebesar 0,32 cm, dan kontrol sebesar 0,33 cm. hal ini menunjukkan bahwa baik penggunaan propolis maupun ssd 1% dapat menurunkan kemerahan. kerusakan jaringan menyebabkan terbentuknya asam arakhidonat yang akan dikonversi melalui dua jalur yang berbeda, yaitu jalur siklooksigenase dan lipoksigenase yang dapat menghasilkan mediator inflamasi seperti tromboksan, prostaglandin dan leukotrien. mediator inflamasi menyebabkan vasodilatasi yang memungkinkan lebih banyak darah mengalir ke daerah yang cedera, sehingga terjadi kemerahan lokal pada peradangan akut (price & wilson, 2006). propolis mampu meningkatkan hilangnya kemerahan karena memiliki kemampuan antiinflamasi dan antibakteri. komponen bioflavanoid dan cape dapat meregulasi inflamasi dengan jalan menghambat jalur siklooksigenase dan lipoksigenase yang menghasilkan mediator inflamasi (tromboksan, prostaglandin, leukotrien) dari konversi asam arakidonat, menghambat pelepasan histamin, atau aktivitas "radical scavenging" suatu molekul (ramos & miranda, 2007). pemberian propolis akan mencegah terjadinya peningkatan inflamasi sehingga regenerasi jaringan berlangsung lebih cepat karena ada indikasi bahwa peningkatan inflamasi menyebabkan produksi berlebih dari il-8 dan sitokin inflamasi yang lain yang menghambat replikasi keratinosit sehingga mengganggu pembentukan matriks baru dan memperlambat penutupan luka (cho lee et al., 2005). menurut lotfy (2006) menyatakan bahwa flavonoid dalam propolis juga bersifat sebagai antibakteri yang dapat mencegah infeksi pada luka sehingga inflamasi menjadi lebih terkendali. penggunaan ssd 1% dapat menurunkan kemerahan karena kandungan antibakteri yang dimilikinya. sulfadiazine dalam ssd 1% merupakan antibakteri yang bersifat sebagai kompetitor paba (para aminobenzoic acid) yang diperlukan kuman untuk membentuk asam folat yang digunakan untuk sintesis purin dan asam-asam nukleat (mariana & setiabudi, 2006). kelompok propolis maupun ssd 1% mengalami penurunan kemerahan yang ditandai oleh semakin mengecilnya ukuran kemerahan pada hari ke-7 dan menghilang pada hari ke-14. bahan anti-inflamasi dalam propolis membuat regulasi inflamasi berjalan optimal sehingga efektif dalam menurunkan kemerahan. begitu juga dengan penggunaan ssd 1% yang mencegah infeksi mikroba pada luka sehingga inflamasi menjadi terkendali yang ditandai oleh adanya penurunan kemerahan. edema hari ke-3 pada kelompok propolis berukuran rata-rata 0,44 cm dari tepi luka, sedangkan nilai edema ssd 1% adalah 0,6 cm dan kontrol 0,55 cm. ukuran edema pada ketiga kelompok tersebut mengalami penurunan pada hari ke-7, dimana ukuran edema kelompok propolis menjadi sebesar 0,14 cm, kelompok ssd 1% sebesar 0,32 cm, dan kontrol sebesar 0,33 cm. hal ini menunjukkan bahwa baik penggunaan propolis maupun ssd 1% dapat menurunkan edema. respon jaringan luka pada fase inflamasi adalah terjadinya edema lokal yang disebabkan karena meningkatnya permeabilitas pembuluh darah akibat mediator inflamasi pada daerah peradangan dan mengakibatkan kebocoran protein (price & wilson, 2006). propolis yang memiliki kandungan antiinflamasi yaitu flavonoid dan cape mampu mencegah terbentuknya mediator inflamasi dari konversi asam arakhidonat tanpa mengganggu terbentuknya sel-sel peradangan yang bermanfaat bagi penyembuhan luka (ramos &miranda, 2007). hal ini menyebabkan regulasi inflamasi menjadi lebih optimal. menurut tanu dalam afrina (2009), adanya aktivitas anti-inflamasi dan anti-oksidan pada propolis membuat sel lebih terlindung dari pengaruh negatif, sehingga dapat meningkatkan viabilitas sel. dengan meningkatnya viabilitas sel, neutrofil-neutrofil yang dibawa oleh darah ke jaringan yang meradang akan semakin meningkat dan monosit yang masuk ke daerah peradangan akan cepat membesar menjadi makrofag. pembentukan makrofag membuat lebih banyak bakteri yang difagosit, kecepatan jurnal ners vol.4 no.2: 128 138 134 makrofag dalam memfagositosis bakteri ini lebih cepat daripada neutrofil. hal ini membuat bakteri tidak dapat mengkontaminasi luka dan memungkinkan fase inflamasi berjalan normal. begitu juga perawatan luka bakar dengan menggunakan ssd 1%. bahan tersebut mengandung perak yang dapat membunuh bakteri patogen pada luka sehingga fase inflamasi menjadi terkendali (almeida, 2000). edema merupakan salah satu tanda inflamasi dan bila edema yang muncul semakin parah berarti inflamasi yang terjadi juga semakin meningkat, hal ini dapat memperlambat penyembuhan luka. baik penggunaan propolis maupun ssd 1% dapat menurunkan edema pada luka bakar yang ditandai oleh ukuran edema hari ke-7 yang lebih kecil dibanding hari ke-3. penggunaan propolis dapat menurunkan edema yang terjadi karena kandungan anti-inflamasi dan antibakteri yang dapat meregulasi inflamasi. penggunaan ssd 1% juga dapat menurunkan edema karena terdapat kandungan antibakteri yang mampu mencegah infeksi mikroba pada luka bakar. berdasarkan hasil penelitian yang dilakukan di laboratorium biokimia fk unair surabaya, hasil perawatan luka dengan menggunakan propolis, ssd 1% dan kontrol normal salin 0,9% didapatkan data bahwa tidak ada cairan pus pada semua kelompok pada hari ke-3,7, dan 14. hal ini menunjukkan bahwa ketiga kelompok tidak mengalami infeksi mikroba pada luka bakar. adanya cairan pus pada luka merupakan indikasi adanya infeksi pada luka, neutrofil yang mati akan meninggalkan pus (potter & perry, 2006). kemampuan propolis dalam mencegah terbentuknya cairan pada luka dikarenakan propolis mengandung senyawa flavonoid yang bersifat sebagai antibakteri. flavonoid menyebabkan tidak berfungsinya pompa na+-k+ pada bakteri, keadaan ini menyebabkan ion sodium tertahan di dalam sel, sehingga terjadi perubahan kepolaran pada plasma sel yang berakibat terjadinya osmosis cairan ke dalam plasma sel. hal inilah yang menyebabkan sel membengkak dan akhirnya pecah. membran yang pecah ini menyebabkan gangguan pertukaran zat yang dibutuhkan bakteri untuk mempertahankan hidupnya sehingga terjadi kematian pada bakteri (harborne, 2000). ssd 1% merupakan anti bakteri yang bersifat sebagai kompetitor paba (para aminobenzoic acid) yang diperlukan kuman untuk membentuk asam folat yang digunakan untuk sintesis purin dan asam-asam nukleat (mariana & setiabudi, 2006). ssd 1% menghambat replikasi dna dan merusak dinding sel bakteri. kandungan perak dalam ssd juga berfungsi sebagai anti-mikroba (almeida, 2000). hal tersebut mengakibatkan luka bakar terhindar dari infeksi mikroba yang ditunjukkan oleh tidak terdapatnya cairan pada luka selama penelitian. penggunaan propolis dan ssd 1% membuat luka tidak mengalami infeksi yang ditunjukkan tidak terdapatnya cairan pada luka. hal ini membuktikan bahwa propolis dan ssd 1% merupakan agen topikal yang efektif dalam mencegah infeksi mikroba pada luka bakar. fase proliferasi disebut juga fase fibroplasia karena yang menonjol adalah proses proliferasi fibroblas. fase ini berlangsung dari akhir fase inflamasi sampai kira-kira akhir minggu ketiga (sjamsuhidayat & jong, 2005). fase proliferasi dapat diamati secara makroskopis melalui jaringan granulasi yang terbentuk pada luka dan mengecilnya diameter luka bakar. kelompok propolis, ssd 1% dan kontrol 100% pada hari ke-3 dan ke-7 tidak terdapat granulasi luka. jaringan granulasi baru terlihat pada hari ke-14 dimana kelompok propolis 100% terdapat granulasi di seluruh bagian luka, kelompok ssd 1% juga 100% terdapat granulasi di seluruh bagian luka, dan kelompok kontrol 100% hanya terdapat granulasi di sebagian luka. hal ini menunjukkan bahwa baik penggunaan propolis dan ssd 1% mampu meningkatkan granulasi pada luka. pada fase proliferasi, luka akan dipenuhi sel radang, fibroblas , dan kolagen, membentuk jaringan berwarna kemerahan dengan permukaan yang berbenjol halus yang disebut jaringan granulasi (sjamsuhidayat & jong, 2005). jaringan granulasi merupakan salah satu bentuk jaringan penyambung yang memiliki lebih banyak suplai darah daripada kolagen (potter & perry, 2006). propolis mengandung senyawa cape dan flavonoid yang bersifat sebagai anti-oksidan. pemberian anti-oksidan lokal akan mengikat ros dan menurunkan kerusakan jaringan akibat radikal bebas sehingga perbaikan jaringan berlangsung dengan baik (song et al., 2008 dalam nijveldt et al., 2001). flavonoid akan berikatan dengan komponen reaktif radikal bebas sehingga radikal bebas menjadi lebih stabil (nijveldt et al., 2001). penyembuhan luka dengan propolis dan ssd 1% 135 flavanoid sebagai anti-inflamasi dan anti-oksidan akan menghambat jalur metabolisme asam arakhidonat, pembentukan prostaglandin, pelepasan histamin, atau aktivitas "radical scavenging" suatu molekul. melalui mekanisme tersebut, sel lebih terlindung dari pengaruh negatif, sehingga dapat meningkatkan viabilitas sel. hal ini membuat neutrofil yang dibawa oleh darah ke jaringan yang meradang akan semakin meningkat dan monosit yang masuk ke daerah peradangan akan cepat membesar menjadi makrofag (tanu dalam afrina, 2009). makrofag merangsang pembentukan fibroblas, mengatur proliferasi sel, sintesa matrik, dan angiogenesis (brunicardi et al., 2005). kemampuan ssd 1% dalam membentuk granulasi pada luka bakar karena ssd 1% berbentuk salep yang bersifat melembabkan sehingga meningkatkan granulasi luka. granulasi luka baru terlihat pada hari ke-14 dimana perawatan dengan propolis dan ssd 1% membuat jaringan granulasi muncul di seluruh bagian luka. hal ini mengindikasikan bahwa penggunaan propolis dan ssd 1% dapat meningkatkan pembentukan granulasi luka bakar. semua kelompok mengalami penurunan atau pengecilan ukuran diameter luka pada hari ke-14 dimana luka bakar yang semula berukuran 1 cm menjadi sebesar 0,48 cm pada kelompok propolis, 0,69 cm pada kelompok ssd 1% , dan 0,75 cm pada kelompok kontrol. hal ini berarti bahwa perawatan luka dengan ssd 1% dan propolis dapat membuat ukuran diameter luka bakar semakin mengecil. luka yang tidak memiliki tepi luka yang berdekatan, kontraksi luka akan membuat ukuran luka mengecil (penyembuhan sekunder) (sabiston 1995). proses re-epiteliasi tergatung pada proliferasi keratinosit dan proses kontraksi bergantung pada proliferasi fibroblast (cho lee et al., 2005). kemampuan propolis dalam meningkatkan kecepatan kontraksi luka dikarenakan adanya senyawa flavonoid dan cape didalamnya. flavonoid dan cape yang terkandung dalam propolis bersifat sebagai anti-oksidan. pemberian anti-oksidan lokal akan mengikat ros dan menurunkan kerusakan jaringan akibat radikal bebas sehingga perbaikan jaringan berlangsung dengan baik. kedua senyawa tersebut mampu mengikat radikal bebas yang merupakan penyebab kerusakan sel (song et al., 2008 dalam nijveldt et al., 2001). flavonoid akan berikatan dengan komponen reaktif radikal bebas sehingga radikal bebas menjadi lebih stabil (nijveldt et al., 2001). senyawa cape meningkatkan pembentukan fibroblas yang berarti juga meningkatkan pembentukan kolagen. proliferasi fibroblas akan menghasilkan kolagen yang membuat luka semakin mengecil dan merupakan tahapan yang sangat penting bagi perbaikan jaringan dan penyembuhan luka (song et al., 2008). ssd 1% merupakan bahan yang bersifat antibakterial yang membuat luka bersih dari mikroba sehingga regenerasi jaringan menjadi tidak terganggu (atiyeh et al., 2007). kondisi ini sangat mendukung proses penyembuhan luka yang optimal. kandungan krim pada ssd 1% mampu melembabkan luka sehingga mendukung pembentukan jaringan granulasi. penggunaan propolis dan ssd 1% berpengaruh terhadap pengecilan ukuran diameter luka bakar dimana baik kelompok propolis maupun ssd 1% sama-sama membuat ukuran luka mengecil. hal ini terjadi karena propolis mengandung senyawa yang dapat meningkatkan proliferasi fibroblast. sedangkan penggunaan ssd 1% dapat membuat luka mengecil pada hari ke-14 dikarenakan kandungan anti-bakteri yang membuat luka terhindar dari infeksi mikroba, selain itu sediaan yang berbentuk krim membuat bahan ini bersifat melembabkan luka sehingga meningkatkan granulasi yang membuat luka bakar semakin mengecil. penelitian yang telah dilakukan di laboratorium biokimia fk unair pada tanggal 14-28 juni 2009 memberikan hasil sebagai berikut. post hoc test menunjukkan bahwa kelompok yang berbeda secara signifikan dalam menurunkan kemerahan hari ke-3 dan ke-7 adalah kelompok propolis dibanding ssd 1% dan kelompok propolis dibanding kontrol, sedangkan kelompok ssd 1% dibanding kontrol tidak terdapat perbedaan yang bermakna dalam menurunkan kemerahan. ukuran edema hari ke-3 dan ke-7 juga terdapat perbedaan antar kelompok dalam menurunkan edema. hasil post hoc test menunjukkan bahwa kelompok yang berbeda secara signifikan dalam menurunkan edema hari ke-3 dan ke-7 adalah kelompok propolis dibanding ssd 1% dan kelompok propolis dibanding kontrol, sedangkan kelompok ssd 1% jurnal ners vol.4 no.2: 128 138 136 dibanding kontrol tidak terdapat perbedaan yang bermakna. baik pada hari ke-3 maupun ke-7 kemerahan dan edema kelompok propolis berukuran paling kecil diantara kelompok yang lain. sedangkan tanda fase inflamasi yang lain yaitu cairan luka, tidak didapatkan perbedaan yang signifikan antara ketiga kelompok dalam hal cairan luka dimana semua kelompok tidak memiliki cairan pada luka. perbedaan juga terlihat pada proses penyembuhan luka bakar fase proliferasi. perbedaan baru terlihat pada hari ke-14 dimana kelompok propolis dibanding kontrol dan kelompok ssd 1% dibanding kontrol terdapat perbedaan dalam meningkatkan granulasi luka, sedangkan propolis dibanding ssd 1% samasama efektif dalam meningkatkan granulasi luka. uji post hoc test menunjukkan bahwa ada kelompok yang berbeda secara signifikan dalam mengecilkan ukuran diameter luka bakar hari ke-14 yaitu kelompok propolis dibandingkan dengan kelompok ssd 1% dan kelompok propolis dibandingkan dengan kontrol, serta tidak ada perbedaan yang signifikan antara kelompok ssd 1% dibanding dengan kelompok kontrol. ukuran diameter luka propolis adalah yang terkecil diantara semua kelompok dan berarti bahwa penggunaan propolis paling efektif dalam memperkecil ukuran diameter luka bakar. peran propolis dalam mempercepat penyembuhan luka bakar berasal dari kandungan antibakteri, antioksidan, dan antiinflamasi di dalamnya. bioflavonoid adalah senyawa yang dominan pada propolis dan memberikan efek antibiotik, anti oksidan, dan anti inflamasi. propolis sebagai anti-inflamasi bekerja dengan menghambat jalur siklooksigenase dan lipoksigenase yang menghasilkan mediator inflamasi (tromboksan, prostaglandin, leukotrien) dari konversi asam arakidonat (ramos & miranda, 2007). flavonoid dan cape yang terkandung dalam propolis bersifat sebagai antioksidan. kedua senyawa tersebut mampu mengikat radikal bebas yang merupakan penyebab kerusakan sel (song et al., 2008 dalam nijveldt et al., 2001). penyembuhan luka akan berjalan optimal bila tidak terjadi infeksi mikroba pada luka yang dapat memperparah inflamasi. flavonoid dalam propolis bekerja sebagai antimokroba dengan cara menghambat sintesa protein pada mikroorganisme sampai menjadi inaktif, mencegah pembelahan sel bakteri, menghancurkan dinding sel dan membran sitoplasma bakteri (lotfy, 2006). dari penelitian yang dilakukan song et al. (2008), juga diketahui bahwa senyawa cape meningkatkan pembentukan fibroblas pada luka bakar. penggunaan ssd 1% menyebabkan perlambatan penyembuhan luka karena kandungan krim yang larut air (water soluble cream base) yang membuat inflamasi pada luka bakar semakin meningkat (atiyah et al., 2007). ssd 1% juga merusak keratinosit yang berperan terhadap re-epitelisasi luka, serta merusak fibroblas sehingga menganggu maturasi matriks kolagen (lee & moon, 2003). ssd 1% merusak penyembuhan luka secara langsung dengan cara menghambat mitosis fibroblas, keratinosit, dan sel-sel peradangan (cho lee et al., 2005). kandungan perak dalam ssd 1% tidak dapat membedakan antara bakteri yang jahat dan sel-sel yang sehat yang terlibat dalam penyembuhan luka (atiyah et al., 2007). hal tersebut membuat penurunan kontraksi luka bakar yang mengakibatkan lambatnya pengecilan ukuran diameter luka bakar pada kelompok ssd 1%. hasil penelitian menunjukkan bahwa tingkat kemerahan dan edema yang merupakan tanda fase inflamasi lebih kecil pada kelompok propolis dibandingkan dengan kelompok ssd 1%. walaupun kemerahan dan edema masih terlihat pada kelompok propolis dan ssd 1% pada hari ke-7 post pembuatan luka bakar yang menandakan bahwa kedua kelompok mengalami perpanjangan fase inflamasi, tetapi kelompok propolis memiliki nilai kemerahan dan edema yang lebih kecil daripada kelompok ssd 1%. hal ini menandakan bahwa propolis lebih efektif dalam menghilangkan kemerahan dan edema yang merupakan tanda inflamasi pada luka bakar. penggunaan propolis dan ssd 1% membuat diameter luka bakar semakin mengecil tetapi diameter kelompok propolis lebih kecil daripada kelompok ssd 1% sehingga penggunaan propolis lebih efektif dalam memperkecil ukuran diameter luka bakar yang merupakan tanda fase proliferasi dibandingkan ssd 1%. hal tersebut membuktikan bahwa penggunaan propolis lebih efektif dalam penyembuhan luka bakar dibandingkan dengan ssd 1%. penyembuhan luka dengan propolis dan ssd 1% 137 simpulan dan saran simpulan propolis lebih efektif menghilangkan kemerahan dan edema pada fase inflamasi serta memperkecil ukuran diameter luka bakar pada fase proliferasi dibanding ssd 1%. hal ini disebabkan senyawa bioflavonoid dan cape dalam propolis yang bersifat sebagai antiinflamasi, anti-oksidan, antibakteri, dan merangsang pembentukan fibroblas pada luka bakar. saran peneliti menyarankan agar dilakukan penelitian lebih lanjut tentang luka bakar dengan observasi secara mikroskopis agar dapat melihat berbagai perubahan yang terjadi pada sel kolagen, sel pmn (neutrofil), dan sel limfosit dan monosit selama proses penyembuhan luka baik fase inflamasi maupun fase proliferasi perlu dilakukan. penelitian lebih lanjut dengan menggunakan sampel manusia perlu dilakukan. kepustakaan afrina, n., 2009. perbedaan efektivitas antara propolis dan madu lebah untuk mempercepat hilangnya eritema pada luka bakar derajat ii dalam pada tikus putih (rattus norvegicus) galur wistar. skripsi tidak dipublikasikan. malang: psik fk universitas brawijaya. almeida, a,.& noronha, c., 2000. local burn treatment-topical antimicrobial agents. annuals of burns and fire disasters, 13 (4), pp. 216-219. atiyah, b., michael c & shady w. h, 2007. effect of silver on burn wound infection control and healing: review of literatur. burns, 33, pp.139-148. brunicardi, c, 2005. schwartz’s principles of surgery. new york: mcgraw-hill companies, pp: 190-191 dan 224-330 cho l, et al., 2005. reversal of silver sulfadiazine impaired wound healing by epidermal growth factor. journal of biomaterilas, 26, pp. 4670-4676. harborne, 2000. advances research flavonoid since 1992. phytochemistry, 55, pp. 499-500. katno & pramono, 2002. tingkat manfaat dan keamanan tanaman obat dan obat tradisional, (online), (www.tanamanobat.com, diakses tanggal 4 mei 2009, jam 15.00 wib). koichi, et al., 2006. anti-inflammatory effects of propolis through inhibition of nitric oxide production on carrageenin-induced mouse paw edema.biol. pharm. bull, 29 (1), pp. 96-99 krell, r., 1996. value-added products from beekeeping, (online), (www.fao.org/dorcep.htm, diakses tanggal 4 mei 2009, jam 15.00 wib). lee, a. & moon, h., 2003. effect of topically applied silver sulfadiazine on fibroblast cell proliferation and biomechanical properties of the wound. archives of pharmacal research, 26 (10), pp. 856-860. lotfy, m., 2006. biological activity of bee propolis in health and disease. asian pacific journal of cancer prevention, 7, pp. 22-31. mariana & setiabudi, 2006. farmakologi dan terapi. jakarta: gaya baru, hlm. 587-588 nijveldt, r., et al., 2001. flavonoids: a review of probable mechanism of action and potential applications. the american journal of clinical nutrition, 74, pp. 418-423. noer, s., iswinarno, ds. & david p., 2006. penanganan luka bakar. surabaya: airlangga university press, hlm. 5-6. potter & perry, 2006. buku ajar fundamental keperawatan; konsep, proses, dan praktik. edisi 4, volume 2. jakarta: egc, hlm. 1854-1859. price, s. & wilson, lm., 2006. patofisiologi: konsep klinis proses-proses penyakit. edisi 6. jakarta: egc, hlm. 61-62. rainey, j., 2002. wound care: a handbook for community nurses. london: whurr publishers, pp. 12-15. ramos & miranda, 2007. propolis: a rivew of its anti-inflammatory and healing actions. journal venom. anim. http://www.tanamanobat.com/ http://www.fao.org/dorcep.htm,%20diakses%20tanggal%20%204%20mei%202009 http://www.fao.org/dorcep.htm,%20diakses%20tanggal%20%204%20mei%202009 jurnal ners vol.4 no.2: 128 138 138 toxins incl. trop. dis, 13 (4), pp. 697-710. sabiston, 1995. buku ajar bedah bagian 1, jakarta: egc, hlm. 146-148. shuid, a., anwar, m. &yusof, a., 2005. the effects of carica papaya linn latex on the healing of burn wounds in rats. jurnal sains kesihatan malaysia,. 3 (2), hlm. 39-47. sjamsuhidayat & jong, w., 2005. buku ajar ilmu bedah, edisi 2, jakarta: egc, hlm. 67-79. smeltzer, s. & bare, brenda g., 2002. buku ajar keperawatan medikal bedah brunner & suddarth. jakarta: egc, hlm. 1934-1935. sudjatmiko, g., 2007. petunjuk praktis ilmu bedah plastik rekonstruksi. jakarta: yayasan khazanah kebajikan, hlm. 79-80. watono, 2007. efektivitas penggunaan aloe vera dan chlorhexidine gluconate terhadap proses penyembuhan luka insisi pada marmut. skripsi tidak dipublikasikan. surabaya: psik fk unair. 168 status gizi mempengaruhi usia menarche (nutritional status effects the age of menarche) esti yunitasari*, retno indarwati*, devi rahma sofia* abstract introduction: the improved nutritional status, which shown by increasing bmi and body fat percentage associated to a decrease in menarche's. this study was aimed to analyse correlation between the nutritional status with the age of menarche. method:. design used in this study was cross-sectional. samples in this study were student at traditional muslim school and were taken using purposive sampling, that was based from inclusion and exclusion criteria. data were analyzed using spearman rank correlation with significance level α ≤ 0.05. result: the result showed that most (73%) of the students at traditional muslim boarding school had normal nutritional status. the majority of samples got menarche at age > 13 years old. the result showed that there was correlation between nutritional status and age of menarche (p: 0.001). analysis: it can be concluded that the girl’s muslim boarding school with better nutritional status got earlier the age of menarche. discussion: it is recommended to do routine evaluation about nutritional status in muslim boarding school and to pay attention about consumption since early ages so the students at traditional muslim school would not get menarche in later time. keywords: nutritional status, age of menarche, girl’s muslim boarding school * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: esty.yun_ners@unair.ac.id pendahuluan remaja masa kini mengalami pertumbuhan dan perkembangan yang lebih cepat, termasuk percepatan maturasi dalam hal ini yaitu menarche (soetjiningsih, 2004). rerata pencapaian usia menarche di indonesia diperkirakan pada usia 10-13 tahun (remaja awal) (santrock, jw, 2008). fenomena ini diperkirakan terjadi karena peningkatan variasi makanan yang berpengaruh pada pola konsumsi remaja sehingga mempengaruhi pertumbuhan dan perkembangan. opini di masyarakat remaja putri yang gemuk cenderung mengalami menstruasi pertama lebih awal dan remaja putri yang kurus cenderung mengalami menstruasi pertama lebih lambat (nita, 2009). pencapaian usia menarche santri di pondok pesantren putri al-mawaddah kabupaten ponorogo mayoritas terjadi pada saat santri berada di kelas 2 tsanawiyah yang diperkirakan berusia 13-14 tahun. status gizi merupakan salah satu faktor yang menjadi penyebab pencapaian usia menarche yang berbeda-beda. keadaan tubuh yang diakibatkan oleh konsumsi penyerapan dan penggunaan makanan diartikan sebagai status gizi (supariasa, 2002). pencapaian usia menarche dalam hubungannya dengan status gizi pada santri pondok pesantren putri almawaddah kabupaten ponorogo belum diketahui dengan pasti. penelitian status gizi di pondok pesantren yang dilakukan oleh pangastutik (1999), menyatakan bahwa 21,4% santri putri di pondok pesantren islam as salam surakarta berada dalam status gizi kurang. didukung pula oleh aisyah (2006), pada penelitiannya di pondok pesantren at-tauhid sidosermo surabaya didapatkan 57,5% santri putri dalam kondisi kurus yang berarti status gizi dinyatakan kurang. kondisi ini berkaitan dengan gizi yang didapatkan tubuh untuk menstimulasi hormon-hormon yang diperlukan remaja dalam pertumbuhan dan perkembangan, termasuk dalam hal perkembangan maturitas. data awal pada santri ditemukan 210 santri (87,5%) sudah mengalami menarche dan 30 santri (13.5%) belum mengalami menarche. penelitian di jogjakarta ditemukan rerata pencapaian usia jurnal ners vol. 4 no. 2: 168-175 169 menarche 12,9% (widodo, 2002) dengan presentase status gizi terbesar normal. hendrawati (1993) menyatakan dalam penelitiannya didapatkan hasil pencapaian usia menarche 12,81 tahun dengan asupan gizi cukup. makanan yang didapat santri berasal dari pondok pesantren sendiri. kondisi ini menyebabkan variasi makanan pada santri menjadi kurang bervariasi. kadar asupan energi yang berbeda pada santri mengakibatkan keadaan gizi yang berbeda pula bagi santri. hal ini terlihat dari kondisi fisik santri yang berbeda. bentuk tubuh gemuk atau kurus diindikasikan berdasarkan penimbunan lemak dalam tubuhnya. nutrisi dalam makanan dan minuman akan mempengaruhi pembentukan lemak tubuh, secara tidak langsung akan mempengaruhi metabolisme lemak oleh beberapa hormon, di antaranya hormon estrogen (burhanuddin, 2002). hormon estrogen akan terbentuk secara alamiah dan akan merangsang perkembangan ciri kelamin sekunder, antara lain pertumbuhan rambut, pembesaran payudara dan penimbunan jaringan lemak (manuaba, 1998). helm (1997) menjelaskan, terdapat korelasi positif antara usia menarche dengan kelebihan berat badan. kelebihan berat badan mempengaruhi derajat atau status gizi seseorang, sehingga dapat menjadi status gizi lebih serta mengakibatkan bentuk tubuh menjadi lebih gemuk. semakin berat status kekurangan gizi akan semakin nyata kelainan bentuk tubuh yang mengarah kepada bentuk tubuh badan kurus dan hal ini akan memperlambat pembentukan dan perkembangan hormon dalam masa remaja. demikian pula yang terjadi pada beberapa santri putri di pondok pesantren putri almawaddah kabupaten ponorogo. hasil penelitian terdahulu menyatakan bahwa usia menarche dalam proses pertumbuhan dan perkembangan anak satu sama lain berbeda. umur yang normal saat tercapainya suatu perubahan dalam pertumbuhan dan perkembangan tidak dapat ditentukan dengan pasti melainkan hanya dapat dikatakan pada umur rata-rata anak (soetjiningsih, 2004). penelitian dilakukan untuk mengungkap hubungan antara status gizi dengan usia menarche di pondok pesantren putri al-mawaddah kabupaten ponorogo, sehingga akan diperoleh kesimpulan tentang hubungan status gizi dengan pencapaian usia menarche pada santri pondok pesantren putri al-mawaddah kabupaten ponorogo. bahan dan metode penelitian penelitian ini menggunakan desain penelitian cross sectional. populasi penelitian ini yaitu santri putri mts pondok pesantren putri al-mawaddah kabupaten ponorogo yang sudah menarche. sampel penelitian ini yaitu santri putri mts. pondok pesantren putri al-mawaddah kabupaten ponorogo yang baru menarche dalam 3 bulan terakhir. teknik sampling yang digunakan yaitu purposive sampling. kriteria inklusi dalam penelitian ini antara lain: 1) santri putri yang sudah berada di pondok lebih dari 1 tahun, 2) santri putri kelas 2 dan 3 madrasah tsanawiyah dan 3) santri putri yang bersedia diteliti. kriteria eksklusi dalam penelitian antara lain :1) santri putri yang mempunyai penyakit yang menyertai dan 2) santri putri yang sedang sakit saat penelitian. penelitian dilaksanakan di pondok pesantren putri almawaddah kabupaten ponorogo bulan juli 2009 (selama 2 minggu). variabel dependen penelitian ini yaitu tingkat usia menarche dan variabel independen yaitu status gizi. instrumen yang digunakan untuk variabel independen yaitu kuesioner dan pengukuran antropometri, sedangkan untuk variabel dependen yaitu kuesioner. pengumpulan data dilakukan dalam 3 pertemuan. pertemuan pertama bertujuan untuk tahap awal mengidentifikasi status gizi responden dengan metode pengukuran antropometri. responden yang menjadi sampel diminta menandatangani informed consent yang disediakan. responden mengisi kuesioner yang terdiri dari data demografi, usia reponden, usia menarche. peneliti melakukan kontrak dengan responden untuk pertemuan berikutnya yang meliputi waktu, tempat dan maksud dari pertemuan yang kedua yaitu untuk mengetahui pola konsumsi responden. pertemuan kedua, responden mengisi food frequency dan food recall 2x24 jam. peneliti meminta bantuan bagian pengasuhan santri untuk memanggil responden yang akan diteliti pada hari itu dengan target 1 hari 6 responden. akhir pertemuan, peneliti melakukan kontrak untuk pertemuan berikutnya. peneliti melakukan pertemuan ketiga seminggu berikutnya dan status gizi mempengaruhi status menarche (esti yunitasari) 170 responden diminta mengisi kembali formulir food recall 2x 24 jam. prosedur kerja dalam pengukuran antropometri pada responden antara lain: 1) berat badan responden ditimbang dengan menggunakan timbangan injak, ketelitian 0,1 kg. pakaian yang digunakan seminimal mungkin ( seperti sepatu atau sandal dilepas dan tidak memakai jaket), harus tenang dan berdiri ditengah-tengah timbangan tanpa menggenggam atau menyentuh sesuatu. satuan ukuran berat badan adalah kilogram (kg), 2) tinggi badan santri diukur menggunakan alat mikrotoise dengan ketelitian 0,1 cm. cara pelaksanaan pengukuran antara lain: (1) pastikan dinding dan lantai rata dan (2) tempelkan dengan paku mikrotoa tersebut pada dinding tepat 2 meter. angka 0 (nol) pada lantai. responden yang diukur berdiri tegak seperti sikap siap sempurna dalam baris berbaris, kaki lurus, tumit, pantat, punggung, dan kepala bagian belakang harus menempel pada dinding dan muka menghadap lurus dengan pandangan ke depan. turunkan mikrotoa sampai rapat pada kepala bagian atas. siku-siku harus lurus menempel di dinding. baca angka pada skala yang nampak pada lubang dalam gulungan mikrotoa. angka tersebut menunjukkan tinggi responden yang diukur. kemudian hasil pengukuran dicatat ke dalam kuesioner masing-masing responden. peneliti melakukan kontrak dan menjelaskan secara singkat maksud dari pertemuan berikutnya sebelum pertemuan pertama selesai. lima hari kemudian, dilakukan pertemuan yang kedua. pertemuan yang kedua, peneliti hanya menyebarkan formulir food recall 2x24 jam saja. hasil studi awal terdapat 46 responden dari kelas 1,2, dan 3 madrasah tsanawiyah. pertengahan bulan juni merupakan tahun ajaran baru sehingga responden di tingkat pendidikan kelas 3 naik kelas menjadi siswi madrasah aliyah, sehingga diperoleh jumlah sebanyak 41 responden. penelitian menggunakan korelasi bivariat untuk menerangkan keeratan hubungan antara dua variabel (arikunto, 2006). penelitian ini menggunakan uji statistik non parametrik, korelasi spearman’s rho dengan tingkat kemaknaan  ≤ 0,05 hasil penelitian data menunjukkan dari 41 responden sebagian yaitu (44%) yang mengalami menarche pada usia < 13 tahun, 2 orang (5%) memiliki status gizi gemuk dan 16 orang (39%) memiliki status gizi normal. sebanyak 23 orang (56%) yang memiliki usia menarche >13 tahun, 1 orang (2%) sangat kurus, 8 orang (20%) kurus, dan 14 orang (34%) memiliki status gizi normal. hasil uji statistik non parametrik, korelasi spearman rank correlation nilai r=0,509 dan nilai p=0,001. hasil statistik menunjukkan ada hubungan yang signifikan antara status gizi dengan usia menarche pada santri pondok pesantren putri al-mawaddah kabupaten ponorogo. hal ini berarti semakin baik status gizi yang dimiliki, semakin awal juga seseorang mengalami menarche (tabel 1). tabel 1. tabulasi silang hubungan antara status gizi dengan usia menarche pada santri mts.di pondok pesantren putri al-mawaddah kabupaten ponorogo 14-21 juli 2009 .usia menarche status gizi sangat kurus kurus normal gemuk obesitas total ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % <13 tahun 16 39 2 5 18 44 >13 tahun 1 2 8 20 14 34 23 56 total 1 2 8 20 30 73 2 5 41 100 uji statistik spearman rank correlation ; p= 0,001; r= -0,509 keterangan: r = tingkat korelasi p = signifikansi % = prosentase ∑= jumlah pembahasan pengidentifikasian status gizi pada santri menunjukkan 30 responden berada pada status gizi normal. faktor yang mempengaruhi status gizi yaitu pola konsumsi. pola konsumsi responden dipengaruhi langsung oleh faktor eksternal jurnal ners vol. 4 no. 2: 168-175 171 yaitu ekonomi keluarga (pekerjaan, pendapatan, dan pengeluaran keluarga). konsumsi keluarga merupakan kegiatan ekonomi keluarga untuk memenuhi berbagai kebutuhan. konsumsi seringkali dijadikan salah satu indikator kesejahteraan keluarga. makin besar pengeluaran untuk konsumsi keluarga, makin tinggi tahap kesejahteraan keluarga tersebut (haris & andika, 2002). berdasarkan data penunjang yakni food frequency, selain nasi yang menjadi makanan utama, sebagian besar mengatakan mengkonsumsi mie instan 1-3 kali/minggu yang merupakan sumber dukungan kedua bagi pemenuhan karbohidrat. sebagian besar responden mengungkapkan keseringan dalam mengkonsumsi ayam, telur ayam dan ikan sebagai sumber protein hewani masingmasing dalam 1-3 kali/minggu, dalam 1-3 kali/ minggu tahu dan tempe sebagai sumber protein nabati juga selalu dikonsumsi. sayuran yang sering disajikan antara lain bayam, buncis, kacang panjang, nangka muda, wortel, kangkung, dan terong (1-3 kali/ minggu) dalam bentuk masakan yang sudah dijadwalkan. lauk yang sering di konsumsi kerupuk. jadwal pergantian menu sangat jarang dilakukan. data food frequency menunjukkan responden juga mengkonsumsi roti tawar/ biskuit sebagai sumber karbohidrat ketiga setelah mie instan dalam frekuensi 4-6 kali/minggu. buah sebagai penambah gizi bagi santri paling sering dikonsumsi dalam 13 kali/ minggu, yaitu buah pisang, dan semangka. konsumsi dari menu utama tidak maksimal tetapi gizi santri terpenuhi dari konsumsi makanan selingan. status gizi merupakan keadaan fisik seseorang atau sekelompok orang yang ditentukan dengan salah satu atau kombinasi dari ukuran-ukuran gizi tertentu (soekirman, 2000). bahan makanan tersebut mempunyai kandungan dari zat gizi makro (karbohidrat, protein, dan lemak) yang berkaitan erat dengan keadaan fisik seseorang. kecukupan gizi masingmasing zat gizi di atas dapat dinilai dari food recall 2x24 jam yang kemudian di bandingkan dengan akg (angka kecukupan gizi) standar bagi orang indonesia. hasil penghitungan food recall 2x24 jam untuk pemenuhan energi yaitu sebagian besar tingkat pemenuhan baik. data demografi menunjukkan hasil distribusi dari suku asal responden yang sebagian besar berasal dari suku jawa. suku asal merupakan salah satu faktor dari adat kebiasaan. adat kebiasaan dalam masyarakat mempengaruhi pola konsumsi pada masyarakat dalam hal ini adalah responden. terbentuknya rasa suka terhadap makanan tertentu merupakan hasil dari kesenangan sebelumnya yang diperoleh pada saat mereka makan untuk memenuhi rasa laparnya serta dari hubungan emosional antara anak-anak dengan yang memberi makan mereka (khumaidi, 1994). pengaruh sosial budaya kuat terhadap makanan, tetapi penerima makan dan kebiasaan makan tidak menghalangi perbaikan status gizi melalui pengenalan pangan yang baru dan berbeda dalam wacana konsumsi makanan (khumaidi, 1994). data penelitian menyatakan responden mengalami status gizi sangat kurus, status gizi kurus dan status gizi gemuk. hal ini terjadi karena ketidakseimbangan antara pemasukan dan penggunaan zat gizi. energi tubuh didapatkan dari sumber karbohidrat, protein dan lemak tubuh. jumlah karbohidrat dalam tubuh tidak selalu seimbang dengan jumlah karbohidrat yang diperlukan. konsumsi karbohidrat yang berlebih, maka akan terjadi kelebihan karbohidrat. kelebihan karbohidrat tidak dibuang begitu saja oleh tubuh, tetapi dapat disimpan. kelebihan ini dapat digunakan sewaktu-waktu jika tubuh memerlukan. konsumsi karbohidrat yang kurang sedangkan aktivitas meningkat, maka kebutuhan tubuh akan karbohidrat dapat dipenuhi dari cadangan. hal ini apabila terjadi dalam jangka waktu lama, maka akan terjadi defisiensi zat gizi yang berdampak pada munculnya penyakit tertentu. kekurangan karbohidrat dalam waktu yang lama memaksa tubuh untuk mengambil cadangan energi yang berasal dari lemak dan protein. hal ini menyebabkan cadangan protein dan lemak semakin berkurang. cadangan karbohidrat yang berlebih akan tersimpan dalam bentuk lemak di bawah jaringan kulit. hal ini menyebabkan terjadinya kelebihan berat badan yang menimbulkan obesitas (burhanuddin, 2003). aktivitas yang dimaksud terkait dengan kepadatan jadwal kegiatan di dalam pondok. responden yang berasal dari kelas 2 dan kelas 3 tsanawiyah memiliki jadwal akademik yang berbeda. persiapan ujian, banyaknya jumlah pelajaran dengan tingkat status gizi mempengaruhi status menarche (esti yunitasari) 172 yang lebih sulit pada responden kelas 3 dan kegiatan belajar-mengajar khusus keagamaan serta keaktifan di kegiatan ekstrakurikuler, menuntut responden untuk selalu menjaga kondisi tubuhnya. kondisi tubuh yang kurang terjaga akan menjadi stressor tersendiri bagi tubuh. hasil penelitian menunjukkan frekuensi status gizi kurus lebih banyak terjadi pada responden di kelas 3 tsanawiyah. deborah stewart, m.d., profesor ilmu kesehatan anak di university of california davis school of medicine, menyatakan perkembangan fisik pada tahap remaja memang ditandai oleh ketidakpastian tampilan fisik. hal ini membuat remaja sering membandingkan tubuhnya dengan tubuh teman-temannya atau disebut dengan masalah body image yang bisa muncul pada tahap ini. hal ini umumnya berkembang di akhir masa kanak-kanak dan selama pubertas yang mendasari gangguan makan, yakni anoreksia nervosa (takut makan karena takut gemuk) dan bulimia nervosa (rakus makan, tapi berusaha memuntahkannya). psikologis seperti ini dapat mengganggu kondisi tubuh yang dapat mempengaruhi keseimbangan gizi. hasil penelitian pengidentifiksian usia menarche menunjukkan sebagian besar responden mengalami menarche pada usia > 13 tahun. usia menarche normal adalah 1016 tahun, dan akan dialami oleh remaja pada masa remaja awal yaitu usia 10-13 tahun (santrock, jw, 2008). remaja adalah tahapan perkembangan dari masa kanak-kanak menuju masa dewasa. psikolog membagi tahap ini menjadi tiga, yaitu masa remaja awal (10-13 tahun), masa remaja pertengahan (14-18 tahun), dan masa remaja akhir (19-23 tahun). siswi yang duduk di bangku sd akhir serta smp awal berada pada tahap remaja awal. siswa yang duduk di bangku smp pertengahan sampai sma akhir berada di tahap remaja pertengahan (syamsu, 2007). pada usia 10-13 tahun, kelenjar susu mulai berkembang dan bagian luar dari alat-alat reproduksi mulai sempurna. fase ini juga ditandai dengan bertambahnya lemak di bawah kulit pada bagian-bagian tertentu dari tubuh, bertambahnya tinggi badan, dan bertambahnya berat badan 4-6 kg pertahun. munculnya menstruasi merupakan tanda berakhirnya fase awal ini. pada remaja pertengahan pertumbuhan badan berlangsung lebih lambat. tanda-tanda seksualitas bisa mencapai dua kali lipat, seperti tumbuhnya rambut di bawah ketiak dan membesarnya payudara. pada akhir fase ini seorang remaja putri siap menjadi seorang ibu (samadi, 2008). perbedaan usia menarche di pondok ini bisa disebabkan oleh berbagai faktor, antara lain genetik (keturunan), hormon, konsumsi makanan, dan budaya. perubahan keadaan faktor genetik dapat berakibat timbulnya gangguan. faktor genetik merupakan modal dasar dalam mencapai hasil proses tumbuh kembang seorang anak yang disebut potensi biologis. lingkungan sangat berpengaruh pada lebih awal atau lebih akhirnya pencapaian usia menarche, tetapi faktor genetik tetap memegang peranan cukup besar (supariasa, 2001). faktor lain yang berpengaruh yaitu makanan. makanan merupakan faktor utama dalam kehidupan yang dibutuhkan untuk menjamin berbagai proses fisiologis tubuh. hal ini terkait dengan data demografi yaitu suku asal responden. setiap suku mempunyai kepercayaan dan kebiasaan makan yang berbeda-beda. suku minang cenderung untuk mengkonsumsi makanan yang mengandung tinggi protein dan lemak, berbeda dengan suku sunda yang lebih suka mengkonsumsi sayur-sayuran. kebiasaan makan yang didasarkan pada kebiasaan memasak, kepercayaan, dan pantangan-pantangan sering berkembang menjadi sebuah produk budaya. ahli antropologi budaya sepakat menempatkan peranan dalam kebudayaan sebagai kegiatan ekspresif yang memperkuat hubungan sosial. kebiasaan makan memainkan peranan sosial dasar yang jauh dalam mengatasi soal makanan untuk tubuh manusia. nutrisi yang terkandung dalam makanan dan minuman akan mempengaruhi pembentukan lemak tubuh, yang secara tidak langsung akan mempengaruhi metabolisme lemak oleh beberapa hormon, di antaranya hormon estrogen (burhanuddin, 2003). hormon ini merupakan salah satu hormon yang membantu dalam pertumbuhan dan perkembangan remaja, termasuk menarche. adanya aktivitas fisik yang teratur akan meningkatkan hormon prolaktin serum, salah satu hormon yang disekresi oleh kelenjar hipofisis. peningkatan prolaktin akan menghambat hormon lain yang berguna untuk pematangan ovarium, yaitu folliclejurnal ners vol. 4 no. 2: 168-175 173 stimulating hormone (fsh). penghambatan pematangan ovarium akan menghambat terjadinya menarche. hal ini mengingat kepadatan jadwal kegiatan baik intra maupun ekstrakurikuler, dan sebagian besar dari responden yang mengalami menarche > 13 tahun yaitu santri yang aktif mengikuti kegiatan ekstrakulikuler. data demografi menunjukkan distribusi responden berdasarkan tingkat pendidikan di tsanawiyah. hal ini untuk mengetahui seberapa jauh distribusi responden yang telah menarche baik di kelas 2 maupun di kelas 3. perbedaan usia menarche terjadi di tingkat pendidikan yang berbeda berhubungan dengan tingkat stress responden. pertama stressor biologik yang disebabkan karena mikroba, bakteri, virus dan jasad renik lainnya, hewan, bermacam tumbuhan dan makhluk hidup lainnya yang dapat mempengaruhi kesehatan. kedua stressor fisik yang disebabkan karena perubahan iklim, alam, cuaca, suhu, geografi; yang meliputi letak tempat tinggal, domisili, demografi; berupa jumlah anggota dalam keluarga, nutrisi, radiasi, kepadatan penduduk, imigrasi, kebisingan, dll. ketiga stressor kimia yang disebabkan oleh serum darah glukosa (dari dalam tubuh), obat, pengobatan, pemakaian alkohol, nikotin, kafein, polusi udara, gas beracun, insektisida, pencemaran lingkungan, bahan-bahan kosmetika, bahan-bahan pengawet, dll. keempat stressor sosial psikologik yang disebabkan karena prasangka, ketidakpuasan terhadap diri sendiri, konflik peran, percaya diri rendah, perubahan ekonomi, dan emosi yang negatif. tuntutan peningkatan taraf aktivitas akademik, kegiatan rutin didalam pondok, serta aktivitas penunjang lain seperti kegiatan ekstrakurikuler, apabila tidak dilakukan manajemen yang baik, bisa menjadi stressor fisik dan psikologik bagi responden. stres akan menyebabkan hipothalamus menghambat kerja gnrh (gonadotrophins releasing hormone). hasil analisis data yang dilakukan dengan menggunakan korelasi spearman rho didapatkan bahwa ada hubungan antara status gizi dengan usia menarche. perbedaan bb akan menimbulkan perbedaan ukuran tubuh. pencapaian usia menarche yang lebih akhir, dapat terjadi karena bb sangat rendah yang mengakibatkan jumlah absolut lemak tubuh rendah, sehingga ukuran tubuh kelihatan kurus. bb yang berlebih dapat mempercepat pencapaian usia menarche (secara dini). hal ini lebih dikaitkan dengan jumlah absolut lemak tubuh yang tinggi, sehingga menjadi pencetus dan penstimulasi sekresi hormon pengatur menstruasi (helm, 1997). penyebab perbedaan status gizi pada santri berbeda-beda. hal ini terjadi karena pengaruh pola konsumsi pada santri. konsumsi yang berpengaruh dengan absolut lemak yaitu konsumsi karbohidrat, protein dan lemak (bole, et al., 1996). hasil distribusi silang membuktikan santri dengan status gizi gemuk mengalami menarche sebelum 13 tahun. santri dengan status gizi sangat kurus dan kurus mengalami menarche di atas usia 13 tahun. hal ini terkait dengan pembentukan hormon estrogen yang merupakan salah satu pemicu pertumbuhan dan perkembangan pada remaja. pada data distribusi silang, terdapat santri dengan status gizi normal tapi ada yang pencapaian usia menarche nya < 13 tahun dan ada pula yang > 13 tahun. hal ini dipengaruhi oleh faktor pencapaian menarche yang lainnya, seperti genetik, aktivitas fisik, dan faktor budaya. status gizi senantiasa dikaitkan dengan postur tubuh. semakin ideal postur tubuh seseorang akan semakin baik status gizinya. hal ini sesuai dengan tata cara pengukuran status gizi, yang umumnya mengukur perbandingan bb dan tb, lingkar lengan atas, dan ketebalan lemak tubuh pada beberapa bagian tubuh. banyak ahli yang menggunakan indikator bb dan tb untuk menetapkan proporsi tubuh yang normal dan untuk pengklasifikasian anak yang kurus dan gemuk (almatsier, 2001). status gizi gemuk ditentukan oleh perbandingan bb dan tb. peningkatan bb pada periode pra pubertas baik laki-laki maupun perempuan lebih banyak disebabkan karena: (a) bertambahnya kepadatan dan kematangan tulang, (b) massa otot dan jaringan lemak, (c) pertumbuhan organ. usia kanak-kanak sampai usia pubertas memiliki lebih besar bmi (body mass index). hal ini dapat dijelaskan sebagai berikut: pada masa kanak-kanak, berbagai parameter fisiobiologik dan psikologik mulai tumbuhkembang menuju masa percepatan pertumbuhan dan perkembangan. masa tersebut terus berlanjut sampai ke masa puncak percepatan pertumbuhan dan perkembangan pubertas. faktor internal status gizi mempengaruhi status menarche (esti yunitasari) 174 dipengaruhi oleh sistem hormonal dan bekerja sama dengan sistem saraf pusat, dalam mewujudkan karakteristik biofisiologik-psikologik. pada masa pubertas, peningkatan masa lemak dan masa tubuh sangat pesat, sehingga bmi menjadi lebih besar (muchtadi, 1993). simpulan dan saran simpulan semakin baik status gizi anak maka semakin muda pula usia menache. saran berdasarkan hasil penelitian, maka peneliti memberi saran antara lain :1) perlu upaya sosialisasi tentang status gizi ke lapisan masyarakat terutama remaja mengenai pentingnya status gizi yang dimiliki terhadap fungsi reproduksi wanita, 2) bagi pengurus podok perlu meningkatkan fungsi pemantauan status gizi terutama di daerah pondok pesantren setempat, 3) perlu meningkatkan fungsi bagian kesehatan di pondok pesantren putri al-mawaddah kabupaten ponorogo dengan memfasilitasi konsultasi tentang masalah menstruasi dan melakukan evaluasi rutin untuk mengetahui status gizi santri, dan evaluasi rutin juga untuk bagian dapur umum mengenai menu dan variasi menu yang mampu mencukupi kebutuhan gizi santri dan 4) sosialisasi kepada santri mts. di pondok pesantren putri al-mawaddah kabupaten ponorogo tentang status gizi dan pengaruhnya agar wawasan santri bisa bertambah dan bisa menjaga kondisi masing-masing karena gizi dapat mempengaruhi sistem reproduksi tentang menstruasi. kepustakaan almatsier, s,. 2001. prinsip-prinsip ilmu gizi. jakarta: gramedia pustaka. arikunto, s., 2006. prosedur penelitian : suatu pendekatan praktik. jakarta : rineka cipta, hlm. 6-50. bole, et al., 1996. gymnastts, distance runners, anorexiscs body composition and menstrual status. j sports med phys fitness, 1, pp. 49-53. burhanuddin, 2002. analisis faktor yang berhubungan dengan perbedaan pencapaian usia menarche di bugis, sulawesi selatan. disertasi tidak dipublikasikan. surabaya: universitas airlangga. helm pm., 1997. menarche in relation to infertility and adult hight and weight. ugeskr laeger 18, p. 158. khumaidi, m., 1994. gizi masyarakat. jakarta: gunung mulia. manuaba, 1998. memahami kesehatan reproduksi wanita. jakarta: arcan. muchtadi, dkk., 1993. metabolisme zat gizi, sumber fungsi dan kebutuhan bagi tubuh manusia. jakarta: pustaka sinar harapan, hal.: 2429. nita, 2009. remaja putri dan siklus menstruasi, (online), (medicastore.com/index.php?mod =artikel&id=249, diakses tanggal 27 mei 2009, jam 19.15 wib). samadi, f., 2008. besahabat dengan putri anda: panduan islami dalam memahami remaja putri masa kini, zahra.. santrock, j.w., 2008. adolescence, edisi 6, jakarta: erlangga supariasa, 2002. penilaian status gizi, buku kedokteran. jakarta: egc, hlm. 18-23,27,28,69-295. soetjiningsih, 2004. tumbuh kembang remaja dan permasalahannya. jakarta: sagoeng seto, hlm. 63. syamsu, y,. 2007. kesehatan reproduksi remaja, (online), seksologi.infogue.com/kesehatan_r eproduksi_remaja, diakses tanggal 21 agustus 2009, jam 09.30 wib). widodo, joko, 2002. hubungan beberapa karakteristik orang tua siswi dengan umur menarche pada siswi sltp negeri 2 imogiri, kabupaten bantul, yogyakarta. skripsi tidak dipublikasikan, semarang: fkm undip. 278 effectiveness of health education family planning guidelines on health beliefs and behaviours regarding family planning methods among married men in myanmar zay yar tun*, tintin sukartini** * military institute of nursing and paramedical sciences, myanmar ** faculty of nursing universitas airlangga, kampus c mulyorejo surabaya, 60115 email: zayyarprince@gmail.com abstract introduction: males are the most important members and care-takers of the family, but they are considered to be uncooperative when it comes to the usage of family planning methods. traditionally, family planning programs have focused primarily on women, and most of the methods are designed for women considering that it is the women who become pregnant and it is easy to deliver reproductive health services as part of maternal and child health programs. the main objective of this study was to study the effectiveness of health education (he) family planning guidelines on health belief and behaviours regarding family planning methods among married men methods: a quasi-experimental study design was used to compare the results of the effectiveness of health education on the health beliefs and behaviours regarding family planning methods among married men. mann-whitney test and manova test were used to analyse the data. results: it was found that there was a difference of health belief with p= 0.038, knowledge with p= 0.000 and attitude with p= 0.000 between the treatment and control group. conclusions: there was an impact on the improvement of health belief and behaviours regarding family planning methods in the study group which was significantly improved after intervention. as the predetermined hypothesis, a difference was found between the knowledge, attitude and health beliefs of the married men who received health education and those who did not receive health education. keywords: behaviours, family planning, health belief, married men introduction family planning is a way of thinking and living that is adopted voluntarily on the basis of knowledge, attitude and responsible decisions by individuals and couples in order to promote health and welfare of the family, groups and thus to contribute effectively to the social development of the country (who, 2011). males are the most important members and caretakers of the family, but they are considered to be uncooperative when it comes to the usage of family planning methods. traditionally, family planning programs have focused primarily on women, and most of the methods are designed for women considering that it is the women who become pregnant and it is easy to deliver reproductive health services as part of maternal and child health programs (adelekan et al., 2014). despite global recognition of the importance of male involvement in family planning, myanmar has not developed a program in family planning that fully involves men. most family planning programs in our environment seem to focus on women only. the non-inclusion of men in various family planning programs by the program planners has made men not know much about family planning and the benefits to their spouses and family, especially in rural communities. yet men can participate in family planning either as the users of male methods or as supportive partners of users (fumilayo and kolawole, 2000, chinma, 2014). men have rarely been involved in either receiving or providing information on sexuality, reproductive health, or birth spacing. they have also been ignored or excluded in one way or another from participating in many fp programs as fp is viewed as a woman’s affair (walle et al., 2014). in the global society, 1,600 women and more than 10,000 newborns die from preventable complications during pregnancy and childbirth every day. almost 99% of the maternal and 90% of the neonatal deaths occur in developing countries. as the first pillar of safe motherhood and as an essential component of primary health care, family planning plays a major role in reducing maternal and newborn morbidity and mortality (who, 2012). the maternal mortality ratio in developing countries in 2015 was 239 per 100 000 live births versus 12 per 100 000 live births in developed countries. there are large disparities between countries, but also within countries, between women with high and low income, and women living in rural versus urban areas (who, 2015). rapid population growth represents one of the major population concerns in myanmar where the population effectiveness of health education family planning guidelines... (zay yar tun, tintin sukartini) 279 growth rate is 1.0%, and this is estimated to exceed 58.6 million in 2050. in 2014, the population of myanmar was about 51 million people. the sex ratio of the total population is 0.93 comprising of 93 males per 100 females (moh, 2014). family planning plays one of the more important roles in controlling the population growth rate of the country. in general, the consequences of a lack of access to fp are not only a high number of undesired pregnancies but also the increased risk of sexually transmitted diseases and a high number of abortions (who, 2014). the unmet needs for fp in myanmar stand at 19%, compared with only 3% in neighbouring thailand (mio, 2014). a total of 70% of the population live in rural areas with little or no access to fp and maternal health services (mio, 2014). maternal mortality in myanmar is 200 per 100,000 live births (dop, 2014). the united nations population fund reports that 87% of maternal deaths occur in rural areas, largely due to poor infrastructure and a lack of reproductive health access and awareness (world bank, 2013). the reduction of unintended pregnancies can also result in fewer abortions, which can carry a high mortality risk when there are complications (siri & munsawaengsub, 2016). it is now increasingly recognised that the actions required to achieve improvements in family planning should also encourage the active participation of men (rekha et al., 2015). the myanmar ministry of health reports the contraceptive use of the whole country at 46% and hopes to increase this to 50% (moh, 2012). in wundwin township, the total population is 235000. among them, the total birth population is 3500, stillbirths are 50, abortions are 80, and maternal deaths were 5 in 2015. according to the 2015 report of lay myat nar and pin ta lae rural health centres (rhc), the total live-births is 100 per 5158 population. among them, there were included 4 still-births, 15 abortion cases and 2 maternal deaths. based on the description in the background of the formulation of the problem, the researcher will determine the knowledge and attitude regarding family planning methods among married men who live in lay myat nar village, pin ta lae village in the mandalay region in myanmar based on the health belief model. materials and methods the study design was a forum to answer the research questions or to test the hypothesis expertise (nursalam, 2008). in this study, a quasi-experimental study design was used to compare the results of the effectiveness of health education on health belief and behaviours regarding family planning methods among married men. each group had 45 married men in whose wives were still of female reproductive age. this study was conducted at pin ta lae and lay myat nar villages, in the wundwin township of the mandalay region in myanmar. the data was collected from the sample population by conducting face to face interviews using a structured interview questionnaire. a mannwhitney test and an anova test was used to analyse the data. approval and permission to conduct the study were given by the research ethics committee of the military institute of nursing and paramedical sciences, myanmar, and a recommendation for the protection of human rights and welfare in medical research came from the ethical committee of the faculty of nursing, of the universitas airlangga in surabaya, indonesia. the approval and permission to conduct this study were obtained from the department of medical science, in the department of health, of the ministry of health of nay pyi taw, myanmar. results table 1 shows that the characteristics of the respondents in the intervention group based the respondent’s age which was between 36-45 years for as many as 20 respondents (44.4%). characteristics of all of the respondents of the buddhist religion were as many as 45 respondents (100%). the most popular education level of the respondents was primary school level that was 16 respondents (35.6%). characteristics based on the occupation of the respondents was that of a farmer, which was 31 respondents (68.9%). the characteristics of the respondents based on the total family income were 1 lakh and under for as many as 27 of the respondents (60.0%). most of the respondents had children; 37 respondents (82.2%).in the control group, it showed that the characteristics of the respondents in the control group based on the respondent’s age jurnal ners vol. 12 no. 2 oktober 2017: 278-285 280 was that those aged between 36-45 years was 18 of the respondents (40%). the characteristics of all of the respondents were of the buddhist religion; 45 respondents (100%). the education level of the respondents who went to high school was 18 respondents (40%). the characteristic based on the occupation of the respondent was that of a farmer; 20 respondents (44.4%). the characteristic of the respondents based on the total family income was 1 lakh and under as the most frequent; 27 respondents (60.0%). most of the respondents have children; 33 respondents (73.3%). table 2 shows that the knowledge of the respondents in the intervention group in the pre-test was that 18 respondents (40%) were in the poor category, 26 respondents (57.78%) were in enough category and 1 respondent (2.22%) was in a good category. in the post-test, there were 24 respondents (53.33%) in enough category and 21 respondents (46.67%) in the good category. in the control group, there were 21 respondents (46.67%) in the poor category, 20 respondents (44.44%) in enough category and 4 respondents (8.89%) in the good category. there were 31 respondents (68.89%) in the poor category, 12 respondents (26.67%) in enough category and 2 respondents (4.44%) in the good category in the post-test. table 3 shows that the attitude of the respondents in the intervention group in the pre-test was 40 respondents (88.89%) had a positive attitude and 5 respondents (11.11%) had a negative attitude. in the post-test, all of the respondents (100%) had a positive attitude. in the pre-test of the control group, there were 39 respondents (86.67%) that had a positive attitude and 6 respondents (13.33%) that had a negative attitude. in the post-test, there were 38 respondents (84.44%) that had a positive table 1 distribution of respondents based on the characteristics of respondents in the treatment group and control group characteristics intervention group control group f % f % age < 25 years 26 – 35 years 36 – 45 years 46 – 55 years 56 or older 4 9 20 12 8.9 20.0 44.4 26.7 4 17 18 4 2 8.9 37.8 40.0 8.9 4.4 religion buddish 45 100 45 100 education illiterate can read & write primary school level middle school level high school level 2 16 15 12 4.4 35.6 33.3 26.7 2 4 8 13 18 4.4 8.9 17.8 28.9 40.0 occupation farmer government employee merchant private employee daily labourer 31 1 3 2 8 68.9 2.2 6.7 4.4 17.8 20 5 5 2 13 44.4 11.1 11.1 4.4 28.9 total family income 1 lakh and under 100001 to 200000 200001 to 300000 more than 300000 27 13 5 60.0 28.9 11.1 27 15 2 1 60.0 33.3 4.4 2.2 having child no yes 8 37 17.8 82.2 12 33 26.7 73.3 child number 0 1 2 3 4 5 6 8 9 13 11 3 1 17.8 20 28.4 24.4 6.7 2.2 12 10 11 7 2 2 1 26.7 22.2 24.4 5.6 4.4 4.4 2.2 age 1 2 3 10 15 20 22.2 33.3 44.4 21 19 5 46.7 42.2 11.1 table 2. distribution of knowledge (pre and post-test) knowledge group intervention control f % f % pre test poor 18 40 21 46.67 enough 26 57.78 20 44.44 good 1 2.22 4 8.89 total 45 100 45 100 post test poor 31 68.89 enough 24 53.33 12 26.67 good 21 46.67 2 4.44 total 45 100 45 100 table 3. distribution of attitude (pre and post-test) attitude group intervention control f % f % pre test positive 40 88.89 39 86.67 negative 5 11.11 6 13.33 post test positive 45 100 38 84.44 negative 7 15.56 effectiveness of health education family planning guidelines... (zay yar tun, tintin sukartini) 281 attitude and 7 respondents (15.56%) that had a negative attitude. table 4 shows that the majority of the respondents to do with perceived susceptibility in the intervention group in pre-test were in a good category, and only three respondents were in enough category. in the post-test, 9 respondents (20%) increased into the very good category. in the control group of the pretest, the majority of the respondents were in a good category, and 8 respondents (20%) were in enough category. in the post-test, three respondents were decreased from the very good category into the good category. the majority of the respondents in relation to the perceived severity in the intervention group in the pre-test were in a good category, and only 4 respondents were in enough category. in the post-test, 17 respondents were increased into the very good category. in the control group of the pre-test, the majority of the respondents were in a good category, and only 2 respondents were in enough category. in the post-test, 11 respondents were increased into the very good category. the majority of respondents in relation to the perceived benefit of the respondents in the intervention group in the pre-test were in the very good category, and only 2 respondents were in enough category. in the table 4. distribution of health belief scores (pre and post-test) variable category group intervention control amount % amount % perceived susceptibility pre test poor enough 3 6.67 % 8 17.78% good 37 82.82 % 28 62.22% very good 5 11.11% 9 20% post test poor enough 8 17.78% good 36 80% 31 68.89% very good 9 20% 6 13.33% perceived severity pre test poor enough 4 8.89% 2 4.44% good 27 60% 28 62.22% very good 14 31.11% 15 33.33% post test poor enough 1 2.22% good 14 31.11% 18 40% very good 31 68.89% 26 57.78% perceived benefit pre test poor enough 2 4.44% good 20 44.44% 31 68.89% very good 23 51.11% 14 31.11% post test poor enough 7 15.56% good 14 31.11% 33 73.33% very good 31 68.89% 5 11.11% perceived barrier pre test poor enough 1 2.22% 3 6.67% good 38 84.44% 36 80% very good 6 13.33% 6 13.33% post test poor enough 1 2.22% 3 6.67% good 18 40% 39 86.67% very good 26 57.78% 3 6.67% self-efficacy pre test poor enough 2 4.44% 5 11.11% good 29 64.44% 28 62.22% very good 14 31.11% 12 26.67% post test poor enough 4 8.89% good 17 37.78% 34 75.56% very good 28 62.22% 7 15.56% jurnal ners vol. 12 no. 2 oktober 2017: 278-285 282 post-test, 8 respondents were increased into the very good category. in the control group of the pre-test, the majority of the respondents were in a good category. in the post-test, 7 respondents were decreased into enough category. the majority of the respondents in the perceived barrier of respondents in the intervention group in the pre-test were in a good category, and only one respondent was in enough category. in the post-test, 20 respondents were increased into the very good category, and one respondent was still in enough category. in the control group of the pre-test, the majority of the respondents were in a good category, and only 3 respondents were in enough category. in the post-test, 3 respondents were decreased from the very good category into the good category. table 5 shows that based on the mann whitney test, significant p< 0.05 for all of the variables and sub-variables. there were differences between the intervention and control group. health education is effective on health belief. table 6 shows that in general, there were differences in average knowledge, attitude and health belief between the intervention and control groups. the results show that the value of hotteling's trace was sig. 0.000 which means that is smaller than α 0.05. it is stated that there was a difference in knowledge, attitude and health belief between the intervention group and control group. table 7 shows that there was a difference in knowledge with p = 0.000 and attitude with p = 0.000, health belief with p = 0.000, perceived susceptibility with p = 0.000, perceived severity with p = 0.017, perceived benefit with p = 0.000, perceived barrier with p = 0.000 and self-efficacy with p = 0.000 between the intervention group and control group. discussion to my knowledge, this is the first study conducted in analysing the effect of health education family planning guidelines on health belief and behaviours regarding family planning methods among married men in myanmar. in this study, the majority of the intervention group have enough knowledge about family planning methods before they had any health education. after giving health education about family planning guidelines, 21 respondents were increased into the good knowledge category. in the control group, there were 21 respondents in the poor category, 20 respondents in enough category and 4 respondents in the good category in the table 5 the results of mann whitney test variables sig. knowledge post intervention and post control .000 attitude post intervention and post control .000 perceived susceptibility post intervention and post control .000 perceived severity post intervention and post control .000 perceived benefit post intervention and post control .000 perceived barrier post intervention and post control .000 self-efficacy post intervention and post control .000 table 6 test the difference between the treatment group and the control group by using manova test effect value f hypothesis df sig he pillai’s trace .661 55.962 b 3.000 .000 wilk’s lambda .339 55.962 b 3.000 .000 hotteling’s trace 1.952 55.962 b 3.000 .000 roy’s largest root 1.952 55.962 b 3.000 .000 tabel 7 the results of the analysis on the intervention group and the control group by using manova test variables df mean f p value knowledge 1 852.544 124.726 .000 attitude 1 915.211 37.500 .000 health belief 1 3397.878 52.294 .000 perceived susceptibility 1 122.500 22.777 .000 perceived severity 1 30.044 5.961 .017 perceived benefit 1 380.278 51.103 .000 perceived barrier 1 313.600 60.402 .000 self-efficacy 1 74.711 15.816 .000 effectiveness of health education family planning guidelines... (zay yar tun, tintin sukartini) 283 pre-test and 31 respondents in the poor category, 12 respondents in enough category and 2 respondents in the good category in the post-test. in this study, most of the respondents had knowledge about contraceptive methods from their friends. some respondents knew from their health care provider and their wives. a similar study conducted by chaudhary et al. (2015) showed that 19.1% of married men had good knowledge about family planning methods while the majority of men (58.4%) had average knowledge. others (22.5%) had poor knowledge about the same. berhane et al. (2011) revealed that most of the male respondents had information about family planning. about 36.6% of the respondents knew more than one method of family planning. nanji et al. (2015) stated that knowledge of family planning from the urban respondents was higher than from the rural respondents. family planning education could increase the knowledge of men about modern contraceptives, but the use of contraceptives by men may not increase which indicates that the behaviour change process may take a longer time to have an effect (shahamfar et al., 2007). mahamed (2012) stated that educational method is effective in increasing the knowledge and improving the attitude of family planning. the use of family planning methods depends on the person’s knowledge of the different family planning methods available and the willingness of both spouses to participate in the family planning program. in order to determine the interest of the participants in the subject of family planning, the study sought to establish the participants’ general knowledge about the various family planning methods they were familiar and regularly used (sossou, 2008). in this study, most of the respondents had a primary and middle-high school level of education. one-third of the respondents had poor knowledge level. the increased knowledge of the respondents in the intervention group may be influenced by factors such as educational level, age and previous information on family planning guidelines. as a result, health education was required to improve the knowledge about family planning methods among married men. health education about family planning guidelines can also increase the score of knowledge in the treatment group. in this study, the researcher gave health education about family planning guidelines by group teaching methods by using booklets and a computer as a visual aid. the researcher assumed that the increase of the knowledge score could be caused by providing health education with group teaching methods. the majority of the respondents of the intervention group had a positive attitude, and five respondents had a negative attitude before the intervention. after the intervention, all of the respondents increased into having a positive attitude. in the control group, the majority of the respondents had a positive attitude, and six respondents had a negative attitude. in the post-test of the control group, the majority of the respondents had a positive attitude, and seven respondents had a negative attitude. khamis (2007) stated that most of the husbands (89.3%) had positive attitudes towards family planning and agreed that modern methods are more effective than traditional methods. chaudhary et al. (2015) showed that only (10%) of married men had a positive attitude towards family planning while the majority (64.4%) had an average attitude. (25.6%) men had a negative attitude towards the same. ayub et al. (2015) revealed that most of the respondents had a positive attitude towards family planning and appreciated the effectiveness of modern methods over traditional methods. mahamed (2012) stated that there was a significant improvement in the respondents’ attitude after undergoing the educational program in the experimental group. bani et al. (2014) revealed that more than half of the men (52.8%) had good knowledge about the family planning program. however, most men (84.1%) had a positive attitude regarding family planning programs, and also they had (66.6%) an increased rate of participation. it will be noteworthy that attitude is a response that comes from knowledge and experience. attitude consists of three elements; cognitive, affective and behavioural. an affective domain is related to bad or good, negative or positive, helpful or not helpful feelings in every individual. the behavioural aspect is the individual's readiness for action. in this study, most of the respondents had a positive attitude about family planning. it may be that they have proper knowledge about family planning methods. however, jurnal ners vol. 12 no. 2 oktober 2017: 278-285 284 their information about family planning can still be inadequate. they do not know the different family planning methods, and how and where they are inserted. in addition, they do not know the side effects of the different family planning methods. in this study, the researcher mentioned the benefits of family planning and the advantages and side effects of the male contraceptive methods to improve the attitude level and to decrease the misconceptions about married men. group teaching methods using booklets and a laptop was effective in improving the attitude level of married men. the men’s attitude was much more important in the adaptation of family planning methods. men should have a good attitude level about family planning. the majority of the respondents in the intervention group in relation to perceived susceptibility had a good score before the intervention, and nine respondents were increased into the very good score after the intervention. in the control group, the majority of the respondents in perceived susceptibility had a good score both preand post-test. the majority of the respondents of the intervention group in perceived severity had a good score before the intervention, and 17 respondents were increased into the very good score after the intervention. in the control group, the majority of the respondents in perceived severity had a good score in both the preand post-test. the majority of the respondents in the intervention group in perceived benefit had a very good score before the intervention, and eight respondents were increased into the very good score category after the intervention. in the control group, the majority of the respondents in perceived benefit had a good score both preand post-test. the majority of the respondents in the intervention group in perceived barrier had a good score before the intervention, and the majority of respondents had a very good score after the intervention. in the control group, the majority of the respondents in perceived barrier had a good score in both preand post-test. the majority of the respondents in the intervention group in self-efficacy had a good score before the intervention, and majority of the respondents were increased to a very good score after the intervention. in the control group, the majority of the respondents in self-efficacy had a good score both preand post-test. mahmoodi et al. (2011) stated that there was a significant difference between before and after education. the result of the paired t-test between the before and after scores of perceived threat, perceived benefits and perceived barriers reveals that education improves the individuals’ perceptions about participation in family planning programs. in this study, married men from both groups had a good level of health belief, and the post-test score of the intervention group was increased significantly. in this study, the researcher gave a health education program by using group teaching methods among married men. when giving the health education, the intervention group was divided into three groups, and each group involved 15 respondents. the researcher used booklets and a laptop as visual aids for a more effective learning process. the researcher assumed that the increase in the health belief score could be caused by offering health education with group teaching methods. conclusion health education family planning guidelines significantly affect health belief and behaviours regarding family planning methods among married men in myanmar. this study can be used as a preliminary study to identify the effectiveness of health education family planning guidelines on health belief and behaviours regarding family planning methods among married men. men are encouraged to participate in family planning programs, and the appropriate centres and departments should promote health education family planning guidelines for men to improve their knowledge. references adelekan, a., omoregie, p. & edoni, e., 2014. male involvement in family planning : challenges and way forward. , 2014. ayub, a., kibria, z., & khan, f., 2015. assessment of knowledge, attitude and contraceptive use in married women of peshawar, vol. 9 (1):1-2 bani, s. et al. (2014) ‘international journal of awareness, attitude and participation rate of men in family planning programs in iran’, 2(1). berhane, a., biadgilign, s., amberbir, a., morankar, s., berhane, a., & deribe, effectiveness of health education family planning guidelines... (zay yar tun, tintin sukartini) 285 k. (2011). men ’ s knowledge and spousal communication about modern family planning methods in ethiopia, 15(december), 24–32. chaudhary, b. k., wantamutte, a. s., & sah, j. k. (2015). knowledge , attitude and practices regarding family planning methods among married men in urban field practice area of ramnagar urban health center , belagavia crosssectional study, 8, 212–219. department of population, ministry of immigration and population. the population and housing census of myanmar 2014 summary of the provision results. http://country office.unfpa.org/myanmar/drive/sum mmary of the provisional results.pdf. accessed january 2015. fumilayo, o. and kolawole, k. o. (2000) training hand book for family planning clinics, services providers, fertility research unit, college of medicine university of ibadan. khamis, y., & almualm, a. (2007). knowledge, attitude and practice of husbands towards modern family planning in mukalla, yemin. mahamed, f. (2012) ‘impact of family planning health education on the knowledge and attitude among yasoujian women’, 4(2), pp. 110– 118. doi: 10.5539/gjhs.v4n2p110. mahmoodi, a. et al. (2011) ‘ the impact of education using health belief model on awareness and attitude of male teachers regarding their participation in family planning’, (1), pp. 45–49. ministry of immigration and population. summary of the provisional result 2014. http://unstats.un.org/unsd/ demographic/sources/census/2010_ phc/myanmar/mmr-2015-05.pdf. accessed july 2014. ministry of health. health in myanmar, 2013. naypyidaw, myanmar: ministry of health; 2014. ministry of health. township health report. naypyidaw, myanmar: township health department, aung lan township; 2012. nnaji, g. a., eze, p. n., ugwoke, u. m., & ifeadike, c. o. (2015). comparative assessment of family planning knowledge and attitude of men in urban and rural areas of anambra state , south-east of nigeria, 2. http://doi.org/10.7243/2054-9865-2-3 nursalam 2008, concept and application of research methodology of nursing science. thesis and nursing research instrument. jakarta: salemba medika rekha, t., unnikrishnan, b., mithra, p. p., & kumar, n. (2015). married men ’ s involvement in family planning – a study from coastal, 9(4), 7–10. shahamfar, j., kishore, j., & shokhvash, b. (2007). effect of educational intervention on male participation in family planning in iran, alketa(4), 292–299. siri, s. & munsawaengsub, c., 2016. family planning practice among rural reproductive-age married women in myanmar. , alketa. sossou, m. a. n. s. (2008) ‘attitudes toward and use of knowledge about family planning among ghanaian men’, 7(2), pp. 109–120. doi: 10.3149/jmh 0702.109. the world bank. working for a world free of poverty, unmet need for contraception (% of married women ages 15-49) facts sheet. http://data.worldbank.org/ indicator/sp.uwt.tfrt.accessed july 2013. walle, y., & alamrew, z. (2014). the current states of male involvement on family planning and factors correlated with among male factory workers in bahir dar city, 2(5), 188–197. http://doi.org/10.12691/ajphr-2-5-2 who, (2011). world health organization (2011) family planning a global handbook for providers. who geneva. who. addressing the challenges of women’s health in africa. the commission on women’s health in africa report. who africa office.2012. who (2015). family planning. available at: http://www.who.int/mediacentre/ factsheets/ fs351/en/ [accessed 9 april 2015]. world health organization. family planning.http://www.who.int/topics/fa mily_planning/en/. accessed may 2014. http://unstats.un.org/ 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no: 64a/dikti/kep/2010 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. iqlima dwi kurnia, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep technical editor: gading ekapuja aurizki, s.kep., ns. nadia rohmatul laily, s.kep., ns., m.kep. lingga curnia dewi, s.kep., ns., m.kep. dimas dwi arbi, s.kom. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. mailto:secretariat_jurnalners@fkp.unair.ac.id http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners. 1. anna kurniati, s.km, ma bppsdmk, ministry of health, indonesia 2. dr. chong mei chan university of malaya, malaysia 3. prof. eileen savage university college cork, ireland 4. ferry efendi, s.kep., ns., m.sc., phd universitas airlangga, indonesia 5. kusman ibrahim, s.kp., mns, ph.d universitas padjadjaran, indonesia 6. laily hidayati, s.kep., ns., m.kep. universitas airlangga, indonesia 7. prof. dr. nursalam, m.nurs (hons) universitas airlangga, indonesia 8. susy katikana sebayang, ph.d universitas airlangga, indonesia 9. dr. sonia reisenhofer la trobe university, australia 10. dr. wendy abigail flinders university, australia 11. ya-ping yang, ph.d kaohsiung medical university, taiwan p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no: 64a/dikti/kep/2010 table of content 1. factors affecting the compliance of myanmar nurses in performing standard precaution sa sa, nursalam, yulis setiya dewi 1-8 2. the effectiveness of mangosteen peels extract against the total of t lymphocytes in hiv patients maria dyah kurniasari, edi dharmana, hussein gasem 9-13 3. quality improvement model of nursing education in muhammadiyah universities toward competitive advantage abdul aziz alimul hidayat, musrifatul uliyah, sukadiono 14-18 4. nurse behavior in implementation of diabetes mellitus education based on theory of planned behavior nadia rohmatul laili, sulistiawati, ika yuni widyawati 19-26 5. consumption of fruit and vegetable with risk of obesity in school-age children agnes sevelina anggraeni, tintin sukartini, kristiawati 27-32 6. determinants factors of vasectomy method selection esti yunitasari, retnayu pradanie, hardiansyah 33-40 7. modeling participant toward self-care deficit on schizophrenic clients ah yusuf, hanik endang nihayati, krisna eka kurniawan 41-48 8. development of transactional communication model for midwife and postpartum mother on exclusive breastfeeding rekawati susilaningrum, sri utami, susilorini 49-59 9. psikoneuroimunology approach to improve recovery motivation, decrease cortisol and blood glucose of dm type 2 patients with dhikr therapy rifka pahlevi, suhartono taat putra, sriyono 60-65 10. health care-seeking behaviour of coastal communities in banyuwangi, indonesia: results of a cross-sectional survey susy k. sebayang, erni astutik, desak made sintha kurnia dewi, ayik mirayanti mandagi, septa indra puspikawati 66-73 11. the adaptation model of care giver in treating family members with schizophrenia in kediri east java byba melda suhita, chatarina umbul wahyuni, hari basuki, ah yusuf 74-80 12. coping mechanism of career women with breast cancer rosnani 81-87 13. prolanis implementation effective to control fasting blood sugar, hba1c and total cholesterol levels in patients with type 2 diabetes musfirah ahmad, rini rachmawaty, elly l. sjattar, saldy yusuf 88-98 14. enculturation in the life pattern of breast cancer patients: an ethno-nursing study on sundanese women witdiawati, laili rahayuwati, sheizi prita sari 99-107 15. development of performance assessment instrument for nurses based on web in inpatient unit aprilia nuryanti, nursalam, mira triharini 108-112 16. red rosella tea and avocado as simvastatin therapy support reduce total cholesterol budi artini, elyana asnar, ika yuni widyawati 113-118 17. factors related to open defecation behavior among school age children in west lombok makhfudli, praba diyan rachmawati, saskiyanti ari andini 119-125 18. bullying behaviour of adolescents based on gender, gang and family kadek ayu erika, dian atma pertiwi, tuti seniwati 126-132 19. preventing medication error based on knowledge management against adverse event apriyani puji hastuti*, nursalam**, mira triharini 133-141 20. jigsaw puzzle improve fine motor abilities of upper extremities in post-stroke ischemic clients kusnanto, eska dwi prajayanti, harmayetty 142-150 editorial nowadays, we live in globalization era, in which people worldwide can migrate easily to one place to another place and leads the emerging of multicultural society. in such society, culture difference can be sensitive issues regarding the ignorance towards other people’s customs and beliefs. the lack of information about the cultures can lead to cultural stresses and cultural conflicts among health care professional and patients who have different cultures. in some cases, the patients misunderstand and feel frustrated about health care service because the nurses ignore their beliefs and values. therefore, basic understanding of cross cultures is imperative for healthcare professionals, especially nurses, due to their intensive interactions with patients from diverse backgrounds. to respond this issue, madeleine m. leininger had developed the theory of culture care diversity and universality in the early 1960’s as an essential guidance for nurses to discover and implement transcultural nursing practices. indonesia as multi-culture country, as well as south east asian countries, are potential places to implement transcultural nursing research. there are a lot of cultures related to health behavior and practices which have not been explored well. regarding this problem, we encourage researchers to conduct research which generate evidencebased to reduce the gap between health care service and patients’ cultures, local customs, or beliefs. furthermore, we expect that in the future health care services can be more hospitable for patients with different cultures. ners vol 5 no 1 april 2010_akreditasi 2013.indd 1 upaya meningkatkan kebersihan perorangan pada anak prasekolah melalui buku cerita kontemporer (changing the personal hygiene behavior of preschool by reading stories from contemporary books) yuni sufyanti arief*, ifa maftukhatin farokha*, ni ketut alit armini* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya 60115 telp/fax: (031) 5913257, e-mail: yuni_psik@ yahoo.com abstract introduction: personal hygiene is an action to maintain a hygiene and body health. this condition must be caring by everyone, because various of desease can happen in lack consequence of hygiene. this study was aimed to investigate the effect of health education with contemporary book story on preschool personal hygiene behaviour (knowledge, attitude, action) at ra perwanida, mojokerto. method: design use in this study was quasy experimental design. the population had taken from ra perwanida, mojokerto, in july 2009, whom deal directly with the preschool parents. total sample was 22 respondents who met b class in ra perwanida, mojokerto. they were divided into 2 groups, treatment and control groups. data were collected by using questionnaire and observation sheet. data were analyzed by using wilcoxon signed rank test with signifi cance level of α ≤ 0.05 and mann whitney u test with signifi cance level of α ≤ 0.05. result: results revealed the presence of effect in treatment and control groups. in treatment group the level of dependence due to preschool knowledge had signifi cance level of p = 0.002, while that in control group was p = 1.000, to preschool attitude p = 0.034 in treatment, and p = 0.014 in control group, to preschool action p=0.001, and p = 0.317 in control group. discussion: it can be concluded that there are signifi cant infl uence of health education with contemporary book story on preschool personal hygiene behaviour. further study should measure qualitation of understanding about personal hygiene behaviour for teacher in ra perwanida, mojokerto. keywords: health education, contemporary book story, personal hygiene, preschool pendahuluan perilaku baik tidak bisa dipelajari dalam semalam, tetapi secara bertahap selama bertahun-tahun, seiring dengan pertumbuhan anak (thomson dalam toddlercare, 2003). pembelajaran dini dapat dimulai selama masa prasekolah, di mana inisiatif anak mulai berkembang dan anak ingin mengetahui lebih banyak mengenai berbagai hal di sekitarnya. menurut havigrust, tugas dan fase perkembangan dalam masa ini adalah anak dapat membedakan hal yang baik/benar dengan yang buruk/salah. oleh karena itu, anak prasekolah mudah dibimbing, diarahkan dan ditanamkan kebiasaan yang baik, termasuk kebiasaan hidup sehat (nototoatmodjo, 2005). kebiasaan hidup sehat meliputi personal hygiene, olahraga teratur dan tidak merokok. lingkungan dan fasilitas rumah yang tidak memadai dalam pengajaran perilaku hidup sehat serta kebiasaan anak yang kurang memperhatikan kebersihan diri misalnya jarang mandi, tidak memotong kuku dan sikat gigi menjadi faktor risiko terjadinya penyakit. menurut gunarsa (2000) kebersihan perorangan yang terabaikan dalam aktivitas sehari-hari menjadi faktor risiko gangguan kesehatan pada anak. pendidikan kesehatan berupaya agar masyarakat menyadari atau mengetahui cara memelihara kesehatan, mencegah hal yang merugikan kesehatan mereka dan kesehatan orang lain (notoatmodjo, 2007). alat bantu pembelajaran dalam pendidikan kesehatan meliputi alat bantu pandang (gambar), alat bantu dengar (suara), dan alat bantu pandang dengar (audio visual aid) yang dapat berupa jurnal ners vol. 5 no. 1 april 2010: 1–9 2 sederhana (buku cerita) maupun yang rumit (film). buku cerita kontemporer mempunyai struktur penceritaan yang sesuai untuk anak, kemasan dirancang menarik untuk dilihat dan penuh kata, sehingga dapat digunakan untuk merangsang minat baca serta perkembangan bahasa anak. di dalamnya juga terdapat berbagai pesan sertaan (hidden message), yang dapat berpengaruh pada perkembangan kognitif dan sosial anak. penelitian di amerika serikat (2006) menunjukkan bahwa buku cerita anak dapat menjadi acuan dalam pembelajaran perilaku dalam kehidupan sehari-hari. tetapi saat ini belum dilakukan penelitian tentang sejauh mana pengaruh dari pembelajaran dengan buku cerita terhadap perilaku kebersihan perorangan anak prasekolah. televisi menyuguhkan berita atau tayangan kekerasan, kejahatan, kemaksiatan, dan berbagai program acara yang tidak sesuai bagi anak kecil hampir setiap hari (diah, 2008). menurut murray, rerata anak prasekolah menghabiskan setengah dari waktu kerja orang dewasa selama seminggu untuk duduk di depan layar televisi (hurlock, 2005). menonton televisi terlalu sering terutama pada masa balita, berpengaruh pada sistem kontrol eksekutif otak, atau prefrontral cortex, yang bertanggung jawab terhadap perencanaan, pengorganisasian, dan perilaku sekuensing untuk kendali diri, penilaian akhlak (moral judgment), dan perhatian (adhim, 2004). dunia pendidikan dianggap seharusnya berperan besar dalam mengurangi dampak negatif media. oleh karena itu, hal yang sangat penting diperhatikan oleh guru adalah menciptakan pendidikan yang mampu membina watak siswa. keadaan hygiene pribadi dan sanitasi lingkungan merupakan masalah yang cukup berat di indonesia, karenanya diperlukan partisipasi masyarakat secara menyeluruh dalam usaha peningkatannya (entjang, 1997). anak prasekolah mempunyai aktivitas kebersihan perorangan yang rendah, sehingga mudah terserang penyakit (obeng, 2008). 1191 anak prasekolah di korea (dari 25 unit pelayanan kesehatan), terinfeksi enterobius vermicularis (enterobiasis) yang dikarenakan kebersihan tempat tidur dan frekuensi mandi yang kurang. angka kematian yang dikarenakan enterobiasis sangat signifikan (song et al., 2003). berdasarkan studi pendahuluan pada bulan mei yang dilakukan peneliti di ra perwanida, 3 penyakit tersering yang diderita siswa adalah penyakit ispa, diare dan sakit gigi. tiga belas siswa dari 24 siswa kelas b, atau sekitar 54,17% siswa tetap mempunyai kuku panjang dan kotor, walaupun setiap hari sabtu terdapat pemeriksaan kuku rutin. para pengajar mengatakan telah memberikan pembelajaran mengenai kebersihan, namun keadaan di sekitar sekolah tidak mendukung terciptanya kebersihan. salah satu bukti yang terlihat adalah terdapat banyak tong sampah tetapi masih banyak juga sampah yang berserakan di mana-mana. para siswa juga tidak pernah mencuci tangan setelah bermain di luar kelas, padahal telah tersedia tempat cuci tangan. lingkungan sekolah dan perilaku anak yang kurang bersih dapat memengaruhi terjadinya penyakit. membacakan cerita, jika dilihat dari aspek perkembangan kognitif untuk anak merupakan sarana yang tepat untuk pembelajaran tanpa harus menyebabkan anak merasa terbebani. membacakan cerita untuk anak sangat efektif sebagai media menanamkan nilai keimanan, akidah, dan akhlaqul–karimah secara mantap. ucapan dan tindakan tokoh utama sebuah cerita yang sedang dibaca merupakan sebuah kepastian nilai kebenaran bagi anak (adhim, 2004). cerita juga mengandung ide pemikiran, pesan, imajinasi, dan bahasa tertentu. setiap unsur ini akan membekas dalam membentuk pribadi seorang anak (madjid, 2003). awal masa kanak-kanak merupakan saat yang tepat untuk belajar mencapai berbagai keterampilan. anak mempunyai ciri senang mengulang-ulang, berani dan senang mencoba sesuatu yang baru, di mana semua hal tersebut mempunyai arti penting bagi anak dalam belajar keterampilan (alisuf, 1993). keterampilan baru ini dapat berupa perilaku sehat, seperti personal hygiene. kebersihan perorangan yang perlu diperhatikan antara lain kebersihan kulit, kuku, rambut, telinga, hidung, mulut dan gigi, kebersihan pakaian, dan lain-lain (notoatmodjo, 2005). menurut penelitian yang dilakukan oleh siti hani istiqomah (2007) yang dikutip oleh upaya meningkatkan kebersihan perorangan pada anak (yuni sufyanti arief) 3 muscari (2005), kondisi sanitasi rumah, sekolah dan kebersihan perseorangan siswa merupakan faktor risiko terhadap kejadian penyakit berbasis lingkungan antara lain diare, cacingan, demam berdarah, infeksi saluran nafas atas. dalam kehidupan sehari-hari kebersihan merupakan hal yang sangat penting dan harus diperhatikan karena kebersihan akan memengaruhi kesehatan secara umum dan psikis seseorang (tarwoto–wartonah, 2004). masalah kesehatan bukan satu-satunya akibat yang dapat ditimbulkan dari kebersihan perorangan yang kurang tetapi juga akan memengaruhi pada prestasi belajar (muscari, 2005). menurut diah (2008) mendongeng adalah salah satu metode membina watak siswa. sebagian besar anak senang mendengar dongeng karena banyak hal menarik dalam dongeng tersebut. hal menarik itu terletak pada perubahan nasib pelaku cerita, konflik yang terjadi, dan amanat yang diambil sebagai suatu nilai didik (atikah, 2008). walaupun dongeng sering bersifat khayal, kehadirannya tetap diperlukan di tengah arus modernisasi saat ini, sebab dongeng mengandung berbagai nilai moral dan didik yang patut diteladani. berbagai nilai didik ini dapat berupa pembelajaran perilaku hidup sehat, termasuk pendidikan tentang kebersihan perorangan. menurut robert (2008) pendidikan kesehatan sebaiknya d i m u l a i s e d i n i m u n g k i n k a r e n a a k a n menimbulkan kebiasaan dan berpengaruh p a d a p e r i l a k u s e h a t l a i n n y a . p r o s e s pengenalan dan pembelajaran perilaku kebersihan perorangan ini bisa dilakukan melalui buku bacaan atau buku cerita anak yang kontemporer (modern). sosialisasi melalui buku cerita kontemporer ini akan m e n j a d i s a r a n a p e m b e l a j a r a n p e r i l a k u kebersihan perorangan yang sangat baik jika sudah dimulai sejak usia dini karena hal ini akan tertanam dalam pemahaman anak dan dibawa hingga mereka dewasa. dari uraian di atas penulis tertarik untuk melakukan penelitian mengenai pengaruh pendidikan kesehatan dengan pembelajaran buku cerita kontemporer terhadap perilaku kebersihan perorangan anak prasekolah. bahan dan metode penelitian ini bersifat quasy experiment dengan pre–post test control group design. populasi dalam penelitian ini adalah siswasiswi kelas b, ra perwanida mojokerto. sampel sebanyak 22 anak diperoleh melalui teknik simple random sampling pada bulan juli 2009. sampel tersebut kemudian dibagi menjadi kelompok perlakuan dan kelompok control. variabel independen dalam penelitian ini adalah pendidikan kesehatan dengan buku cerita kontemporer, sedangkan variabel dependen dalam penelitian ini adalah perilaku kebersihan perorangan anak prasekolah. buku cerita kontemporer yang digunakan berisi 4 cerita pendek dengan judul: “menjaga kesehatan dengan mencuci tangan”, “aku bisa gosok gigi sendiri”, “aku bisa mandi sendiri” dan “aku bisa keramas sendiri”. perilaku kebersihan perorangan pada anak meliputi pengetahuan, sikap dan tindakan anak tentang kebersihan perorangan. instrumen yang digunakan adalah closed ended multiple choice questioner untuk pengetahuan, sikap menggunakan kuesioner skala data likert, tindakan menggunakan observasi yang dilakukan oleh guru dan peneliti, dengan menggunakan lembar observasi yang dibuat peneliti. pengetahuan, sikap, dan tindakan menggunakan data ordinal. semua instrumen yang digunakan adalah modifikasi dari hurlock (2005) dan potter perry (2005). data yang didapat kemudian diolah menggunakan uji wilcoxon signed rank test untuk mengetahui perbedaan variabel sebelum dan sesudah perlakuan dan mann–whitney u-test untuk mengetahui perbedaan post-test antara kelompok perlakuan dan control dengan tingkat kemaknaan α ≤ 0,05. hasil p e n g e t a h u a n r e s p o n d e n s e b e l u m diberikan intervensi berupa membaca buku cerita kontemporer sebagian besar mempunyai kriteria kurang yaitu 9 orang (81,8%) pada kelompok perlakuan dan 10 orang (90,9%) pada kelompok kontrol. setelah dilakukan intervensi pada kelompok perlakuan mengalami peningkatan yaitu sebagian besar responden jurnal ners vol. 5 no. 1 april 2010: 1–9 4 mempunyai pengetahuan dengan kriteria baik yaitu sebanyak 10 orang (90%). sedangkan pada kelompok kontrol tidak mengalami perubahan. hasil uji statistik menunjukkan ada perbedaan pengetahuan sebelum dan sesudah intervensi pada kelompok perlakuan. terdapat perbedaan pengetahuan pada nilai post-test antara kelompok perlakuan dan kelompok kontrol (tabel 1). hasil pengumpulan data tentang sikap anak dalam kebersihan perorangan anak prasekolah pada kelompok perlakuan sebelum diberikan intervensi sebagian besar responden bersikap negatif yaitu sebesar 10 orang (90,9%) dan mengalami perubahan setelah diberikan intervensi yaitu sebesar 7 orang (63,6%) bersikap positif. sedangkan pada kelompok kontrol yang tidak diberikan intervensi sebagian besar responden bersikap positif yaitu sebesar 7 orang (63,6%) dan sesudah intervensi sebesar 90,9% responden bersikap negatif yaitu sebesar 10 orang. uji wilcoxon signed rank test menunjukan perbedaan sikap antara pre-test dan post test pada kelompok perlakuan. uji mann–whitney u-test menunjukkan perbedaan sikap pada nilai post-test antara kelompok perlakuan dan kelompok kontrol (tabel 2). tindakan sebelum diberikan intervensi pada kelompok perlakuan sebagian besar responden yaitu 10 orang (90,9%) dengan praktik kurang dan sisanya 1 orang (9,1%) dengan praktik cukup. pada kelompok kontrol yang tidak mendapatkan intervensi sebagian besar responden yaitu 9 orang (81,8%) dengan praktik kurang dan 2 orang (18,2%) dengan praktik cukup. setelah dilakukan intervensi pada kelompok perlakuan mengalami peningkatan yaitu sebagian besar responden dengan tabel 1. tingkat pengetahuan anak dalam kebersihan perorangan anak prasekolah di ra perwanida, mojokerto pada juli 2009 perlakuan kontrol pre post pre post mean 9,18 23,18 12,18 12,09 sd 3,28 2,48 1,54 1,92 wilcoxon signed rank test p = 0,002 p = 1,000 mann–whitney u-test p = 0,000 tabel 2. tingkat sikap anak dalam kebersihan perorangan anak prasekolah di ra perwanida, mojokerto pada juli 2009 perlakuan kontrol pre post pre post mean 49,98 49,99 49,99 49,98 sd 10,02 10,005 10,013 10,0176 wilcoxon signed rank test p = 0,034 p = 0,014 mann whitney u-test p = 0,009 tabel 3. tingkat tindakan anak dalam kebersihan perorangan anak prasekolah di ra perwanida, mojokerto pada juli 2009 perlakuan kontrol pre post pre post mean 5,45 9,55 6,00 6,18 sd 1,29 0,93 1,84 1,94 wilcoxon signed rank test p = 0,001 p = 0,317 mann whitney u-test p = 0,001 keterangan: mean = rerata sd = standar deviasi p = signifi kansi upaya meningkatkan kebersihan perorangan pada anak (yuni sufyanti arief) 5 kriteria praktik cukup yaitu sebanyak yaitu 9 orang (81,8%) dan sisanya 2 orang (18,2%) dengan kriteria praktik baik. sedangkan pada kelompok kontrol tidak mengalami perubahan, yaitu sebagian besar responden 8 orang (72,7%) dengan kriteria praktik kurang dan 3 orang (27,3%) dengan kriteria praktik cukup. perbedaan terlihat antara tindakan sebelum dan sesudah intervensi pada kelompok perlakuan dan perbedaan nilai post-test antara kelompok perlakuan dan kontrol (tabel 3). pembahasan hasil penelitian menunjukkan bahwa terjadi peningkatan perilaku (pengetahuan, sikap dan tindakan) anak prasekolah tentang kebersihan diri perorangan dengan membaca buku cerita kontemporer. hal tersebut disebabkan karena pemberian informasi melalui suatu proses pembelajaran dengan buku cerita kontemporer yang diberikan secara kelompok merupakan media yang tepat bagi anak prasekolah, di mana perkembangan kognitif anak prasekolah masih bersifat simple, yang termasuk pada tahap praoperasional, sehingga semakin mudah dalam menguasai materi. pendidikan kesehatan (penyuluhan) merupakan proses belajar pada individu, kelompok, dan masyarakat dari tidak tahu berbagai nilai kesehatan menjadi tahu, dari tidak mampu mengatasi masalah menjadi mampu mengatasi sendiri, dengan pemberian informasi (notoatmodjo, 2007). buku cerita kontemporer terdapat berbagai informasi mengenai perilaku kebersihan perorangan. pendidikan kesehatan dengan buku cerita kontemporer ini tidak diberikan pada kelompok kontrol, sehingga mereka tidak mendapatkan informasi dan akhirnya pengetahuan mengenai perilaku kebersihan perorangan pun tidak mengalami perubahan. pengetahuan atau kognitif merupakan domain penting untuk menentukan tindakan seseorang (notoatmodjo, 2003). tingkat p e n g e t a h u a n d i p e n g a r u h i o l e h p r o s e s pembelajaran. pembelajaran dimaksudkan untuk memberikan pengetahuan pada anak sehingga terjadi perubahan perilaku. proses kontrol kognator berhubungan dengan fungsi otak yang tinggi terhadap proses informasi, pengambilan keputusan, dan emosi, sehingga mekanisme belajar merupakan suatu proses di dalam system adaptasi (cognator) yang mencakup mempersepsikan suatu informasi (nursalam, 2003). dengan kata lain, sebelum terjadi perubahan perilaku, seseorang akan mempunyai persepsi terhadap apa yang akan dijalaninya. persepsi yang tercipta berhubungan dengan tingkat pengetahuan yang diperoleh, sehingga bila informasi yang diterima kurang jelas, hasil pembelajaran yang didapat juga tidak optimal. pembelajaran yang tidak optimal akan memengaruhi persepsi seseorang sehingga perubahan perilaku akan sulit didapatkan. persepsi proses informasi juga berhubungan dengan seleksi perhatian, kode, dan ingatan (nursalam, 2003). perubahan pengetahuan terjadi melalui 4 tahap yaitu tahu (know), m e m a h a m i ( c o m p re h e n s i o n ) , a n a l i s i s (analysis), sinesis (synthesis), dan evaluasi (evaluation). perubahan pengetahuan yang diperoleh merupakan hasil dari pendidikan kesehatan dengan buku cerita kontemporer. buku merupakan jendela dunia, pintu gerbang masuk untuk memperoleh ilmu. berinteraksi dengan buku akan memengaruhi pertumbuhan dan perkembangan anak, terutama aspek intelegensia, sosial budaya, agama dan aspek lainnya. semua proses belajar sangat tergantung pada aktivitas membaca buku. seorang anak mempunyai potensi untuk menyerap segala hal lebih cepat sehingga lebih mudah membentuk dan mengarahkan dirinya (madjid, 2003). pendidikan kesehatan dengan buku cerita kontemporer dapat menjadi salah satu metode untuk mengubah tingkat pengetahuan anak tentang kebersihan perorangan. cerita mengandung ide pemikiran, pesan, imajinasi, dan bahasa tertentu. setiap unsur ini akan membekas dan membentuk pribadi seorang anak. semua informasi dan peristiwa yang tercakup dalam sebuah cerita akan berdampak sekali dalam pembentukan akal dan moral seorang anak, baik dari segi budi, imajinasi, maupun bahasa keseharian. buku cerita kontemporer juga memudahkan proses masuknya informasi tentang kebersihan perorangan karena selain berisi huruf dan jurnal ners vol. 5 no. 1 april 2010: 1–9 6 kata juga disertai berbagai gambar yang menarik serta menggunakan kekayaan warna untuk menarik minat baca anak. fasilitator yang membantu anak menangkap informasi melalui diskusi menyebabkan anak dapat menerima informasi dengan jelas dan benar. penerimaan informasi yang jelas dan benar memengaruhi proses pembelajaran anak sehingga meningkatkan pengetahuan anak tentang kebersihan perorangan. b u k u c e r i t a k o n t e m p o r e r d a p a t meningkatkan pengetahuan anak melalui tahap tahu, memahami, analisis, sintesis, bahkan hingga tahap evaluasi, di mana anak sudah dapat melakukan penilaian terhadap suatu materi tentang objek mana yang benar dan salah. pembelajaran tentang kebersihan perorangan melalui pendidikan kesehatan dengan buku cerita kontemporer dapat memberi kesempatan pada anak untuk lebih dini memahami tentang berbagai perilaku yang menguntungkan bagi kesehatan. perubahan sikap menjadi lebih positif juga terlihat setelah anak mendapatkan intervensi berupa membaca buku cerita kontemporer. hal tersebut dipengaruhi oleh informasi atau stimulus dari luar sehingga pengetahuan dan pemahaman anak tentang kebersihan perorangan meningkat. tugas perkembangan anak prasekolah yang mulai dapat mengidentifikasi dan membedakan antara perilaku yang baik dan yang buruk atau yang benar dan yang salah, memicu timbulnya proses stimulus dari luar dalam ranah kognitif anak. terdapat 4 responden yang mengalami penurunan sikap pada kelompok perlakuan antara sebelum dan sesudah diberikan pendidikan kesehatan dengan buku cerita kontemporer. perubahan sikap tersebut dipengaruhi oleh berbagai hal antara lain pendidikan orang tua. keempat responden tersebut memiliki ibu dengan pendidikan terakhir smp. padahal dengan pendidikan yang tinggi tentu akan lebih dapat menyeleksi berbagai buku cerita kontemporer yang baik dan mengandung pelajaran moral yang positif, begitu pula jika sebaliknya. masa muda merupakan masa stabilitas sikap yang masih sangat rendah sehingga lebih mudah menerima persuasi (krosnick & alwin, 1989 dalam baron & byrne, 1991, yang dikutip oleh azwar, 2007). data hasil penelitian menunjukkan bahwa sebagian besar responden memiliki usia relatif muda sehingga memiliki tingkat penerimaan/persuasi yang baik dan cepat menerima informasi namun tingkat pemahaman kurang baik, sehingga sikap belum mengakar kuat dan belum stabil pada responden. menurut piaget anak prasekolah termasuk pada tahap praoperasional dalam perkembangan ranah kognitif, di mana perkembangan anak masih bersifat egosentris. egosentris di sini bukan berarti egois, namun merupakan ketidakmampuan anak untuk menempatkan diri di posisi orang lain. pada masa ini pikiran anak bersifat transduktif, yaitu jika dua peristiwa terjadi bersamaan, maka yang satu menjadi penyebab yang lain, atau menyamakan pengetahuan tentang suatu karakteristik ke hal yang lain. hal tersebut pula yang mendasari perubahan sikap pada beberapa responden pada kelompok kontrol yang diawal mempunyai sikap positif menjadi bersikap negatif pada saat post-test. sikap belum merupakan suatu tindakan atau aktivitas akan tetapi merupakan reaksi tertutup terhadap suatu objek (notoatmodjo, 2007). pembentukan sikap dapat terjadi karena pengalaman pribadi, pengaruh orang lain yang dianggap penting, kebudayaan, media massa, lembaga pendidikan dan lembaga moral maupun faktor emosional (azwar, 2007). pendidikan kesehatan melalui kegiatan pembelajaran sebagai sarana perubahan perilaku terutama domain afektif (sikap), kognitif (pengetahuan), dan psikomotor (tindakan). impressionable– years hypothesis menyatakan bahwa sikap akan terbentuk kuat dan stabil untuk jangka waktu lama, sedangkan increasing–persistance hypothesis yang mengatakan bahwa orang akan lebih rawan terhadap persuasi sewaktu masih muda (azwar, 2007). diharapkan setelah diberikan pendidikan kesehatan anak mampu membangun suatu kepercayaan sehingga dapat melakukan tindakan yang benar mengenai kebersihan perorangan. sikap muncul dari berbagai bentuk penilaian. kebanyakan sikap individu adalah hasil belajar sosial dari lingkungannya. faktor upaya meningkatkan kebersihan perorangan pada anak (yuni sufyanti arief) 7 pendidikan orang tua juga sangat berperan dalam pembelajaran anak tentang kebersihan perorangan karena orang tua sebagai sumber belajar anak yang pertama. proses perubahan pengetahuan yang terjadi pada anak melalui buku cerita kontemporer, akan menghasilkan perubahan dalam sikap anak tentang kebersihan perorangan. setelah anak mampu membedakan yang benar dan yang salah, kemudian anak akan menerima (receiving) pilihan yang menurutnya baik, kemudian merespon (responding), menghargai (valuing), dan bertanggungjawab (responsible) terhadap pilihannya. hal tersebut dapat diaplikasikan dalam bentuk sikap positif. menurut peneliti kebiasaan kebersihan perorangan yang dilakukan oleh orang tua menjadi salah satu faktor dalam memotivasi anak untuk melakukan kebersihan anak. latar belakang pendidikan orang tua secara tidak langsung memengaruhi tingkat pengetahuan anak. pengetahuan orang tua tentang penyakit dapat memberikan pemahaman kepada anak untuk melakukan kebersihan sehingga dapat terhindar dari penyakit. pendidikan yang tinggi dari orang tua memengaruhi wawasan, pola pikir, dan pola komunikasi, terutama dalam mengasuh anak. posisi anak yang sebagian besar anak terakhir dapat memengaruhi tindakan keluarga dalam stimulasi. sesuai dengan teori yang dikemukakan suganda (2002) menyatakan bahwa perkembangan memerlukan rangsangan atau stimulasi khususnya dalam keluarga misalnya keterlibatan ibu dan anggota keluarga lain terhadap kegiatan anak, perlakuan ibu terhadap perilaku anak meskipun secara alamiah manusia akan tumbuh dan berkembang sejak lahir sampai batas-batas tertentu mengikuti kaidah pertumbuhan dan perkembangan yang lazim. anak terkecil yang termuda usianya dalam keluarga biasanya mendapat perhatian penuh dari semua anggota keluarga termasuk pemberian stimulasi yang lebih daripada anak sulung (supartini, 2004). menurut notoatmodjo (2007) setelah orang mengetahui stimulus atau objek, kemudian mengadakan penilaian atau pendapat terhadap apa yang diketahuinya. proses selanjutnya diharapkan ia akan melaksanakan atau mempraktekkan apa yang diketahui atau disikapinya dengan baik. inilah yang disebut tindakan (practice). proses tindakan melalui tahapan-tahapan persepsi, respon terpimpin, mekanisme dan adopsi. dalam setiap proses perubahan ini, peran orang tua sangat penting dalam mengarahkan persepsi anak, membimbing respon, dan proses adopsi. persepsi anak tentang kebersihan perorangan yang bersumber pada informasi yang tercantum dalam buku cerita kontemporer, membuat anak menilai apa yang diyakininya. selanjutnya anak akan mengaplikasikannya dalam bentuk tindakan (practice) yang kemudian diadopsi anak. dengan memberikan pengajaran baru yang bersumber dari pengetahuan, maka diharapkan praktik/tindakan anak yang sudah diadopsi, tetap terpelihara (notoatmodjo, 2007). tindakan yang benar mengenai kesehatannya sendiri akan menciptakan suasana yang nyaman tentang perilaku hidup sehat. suatu sikap belum selalu terwujud dalam suatu tindakan. untuk mewujudkan sikap menjadi suatu perbuatan nyata diperlukan faktor-faktor pendukung atau suatu kondisi yang memungkinkan, seperti faktor lingkungan, pendidikan orang tua, dan pekerjaan ibu. pendidikan orang tua yang tinggi pada mayoritas responden akan memengaruhi proses perubahan tindakan karena menunjukkan tingginya kemampuan orang tua dalam mengarahkan proses perubahan tindakan yang akan terjadi. pekerjaan ibu juga berpengaruh terhadap peningkatan tindakan anak dalam melaksanakan kebersihan perorangan. menurut notoatmodjo (2003), ibu yang mempunyai karier memiliki waktu yang sangat sedikit dalam pengasuhan anak, sehingga peran pengasuhan anak diserahkan kepada saudara atau pelayan. dengan demikian, ibu yang tidak bekerja memiliki cukup waktu dalam pengasuhan anak. pendidikan kesehatan dengan buku cerita kontemporer mempunyai pengaruh terhadap perilaku kebersihan perorangan anak prasekolah. upaya peningkatan kesehatan dengan cara preventif dan promotif oleh perawat hanya dilakukan dalam 2 bulan sekali. hal ini dapat dilihat dari data gambaran umum lokasi penelitian yang didapatkan oleh jurnal ners vol. 5 no. 1 april 2010: 1–9 8 peneliti. menurut herawani (2002), pendidikan kesehatan pada tatanan sekolah minimal dilakukan 1 kali dalam seminggu. pendidikan kesehatan merupakan salah satu dari upaya preventif dan promotif untuk peningkatan kesehatan. selama ini, upaya peningkatan kesehatan di ra perwanida, mojokerto hanya dilakukan dengan cara kuratif saja. setiap hari jumat, ada perawat atau dokter yang datang ke sekolah tersebut. upaya preventif dan promotif jarang dilakukan. hal ini juga merupakan faktor pendukung yang memengaruhi tingkat pengetahuan yang kurang pada responden. cara kuratif saja tidak dapat mengurangi angka kesakitan secara signifikan. menurut herawani (2002), selama ini kelompok orang sehat kurang memperoleh perhatian dalam upaya kesehatan masyarakat. sedangkan jumlah kelompok orang sehat ini di suatu komunitas sekitar 80–85% dari populasi. jumlah kelompok orang sehat dibandingkan dengan kelompok orang yang tidak sehat sungguh jauh berbeda. derajat kesehatan adalah dinamis, oleh sebab itu meskipun seseorang telah dalam kondisi sehat tetapi perlu ditingkatkan dan dibina lagi kesehatannya, misalnya dengan pendidikan kesehatan (promotif dan preventif). slogan ‘mencegah lebih baik daripada mengobati’ adalah salah satu simbol pelaksanaan program di puskesmas kutorejo. tetapi pada kenyataannya, para petugas kesehatan (perawat dan dokter) hanya melakukannya dalam 2 bulan sekali. kalaupun ada pendidikan kesehatan oleh petugas kesehatan, diberikan hanya secara lisan saja, tanpa ada alat/media secara visual seperti leaflet dan booklet. buku bacaan di ra perwanida mojokerto hanya terdapat sekitar 15 buku bacaan saja. judul buku yang ada misalnya tentang baju adat daerah, rumah adat daerah, jenis buahbuahan, tempat peribadatan umat beragama, dan lainnya. dari ke-15 buku tersebut tidak ada yang mencantumkan tentang kebersihan perorangan maupun kesehatan tubuh. perilaku kesehatan yang diajarkan sedini mungkin akan menimbulkan kebiasaan dan perubahan perilaku yang terjadi akan langgeng karena merupakan suatu pemahaman bukan paksaan (robert, 2008). buku cerita kontemporer yang peneliti berikan dapat dijadikan acuan dalam pemilihan buku-buku cerita yang bermanfaat bagi pertumbuhan anak. buku cerita kontemporer yang dibagikan oleh peneliti terdapat berbagai materi tentang kebersihan perorangan. materi tersebut dijelaskan tentang pengertian kebersihan perorangan, tujuan kebersihan perorangan, macam-macam kebersihan perorangan, caracara perawatan kebersihan perorangan yang meliputi cara gosok gigi, cara keramas, cara cuci tangan, dan cara mandi, beserta alat-alat yang dibutuhkan dalam perawatan tersebut. sedangkan akibat apabila tidak melakukan kebersihan perorangan juga dijelaskan di dalam buku cerita. semua informasi yang dijelaskan di dalam buku cerita kontemporer, akan menambah pengetahuan tentang perilaku kebersihan perorangan yang masih kurang pada anak prasekolah. suatu pembentukan perilaku kebersihan perorangan dipengaruhi oleh beberapa faktor, di antaranya body image, praktik sosial, status sosio–ekonomi, budaya, kebiasaan seseorang, kondisi fisik, dan pengetahuan. pengetahuan dapat diperoleh dari berbagai sumber. salah satu sumber informasi perilaku kebersihan perorangan adalah buku cerita kontemporer. media ini sangat sesuai dengan usia anak yang masih prasekolah, di mana pola pikir anak masih simple, dan perkembangan kognitifnya masih dalam tahap praoperasional. buku cerita kontemporer memiliki banyak keunggulan antara lain warna-warni yang mencolok akan merangsang minat membaca anak, sekaligus menggugah rasa ingin tahu anak. selain itu penggambaran tokoh yang mudah dipahami anak. citra tokoh akan berpengaruh pada proses identifikasi pembaca (anak) pada tokohnya. kemasan buku cerita yang penuh warna memudahkan anak untuk belajar lebih cepat dan buku cerita anak mempunyai ilustrasi yang dapat menarik minat membaca, baik ilustrasi melalui kekuatan gambar, kemampuan merancang karakter, serta kecerdasan menggunakan kekayaan warna (adhim, 2004). selain itu, di dalam buku cerita kontemporer dapat diambil beberapa nilai cerita yang sesuai dengan perkembangan anak. nilai cerita pada perkembangan anak upaya meningkatkan kebersihan perorangan pada anak (yuni sufyanti arief) 9 meliputi perkembangan holistik, emosional, kognitif, moral, bahasa, dan sosial. melalui cerita anak akan mengalami perkembangan ranah kognitif karena cerita adalah cerminan berbagai macam kebudayaan, keterampilan dan perilaku kehidupan sehari-hari, misalnya perilaku hidup bersih dan sehat (perilaku kebersihan perorangan). perubahan perilaku yang diinginkan atau diharapkan pada proses pembelajaran, dapat terjadi melalui perubahan pengetahuan, sikap, dan tindakan. proses perubahan tersebut dipengaruhi oleh faktor intern yang mencakup pengetahuan/pendidikan orang tua, persepsi dan emosi anak dan motivasi baik dari orang tua, saudara, guru, maupun peer group. sedangkan faktor ekstern meliputi keadaan lingkungan seperti status sosial ekonomi, kebudayaan, praktik sosial, dan sebagainya (notoatmodjo, 2007). simpulan dan saran simpulan buku cerita kontemporer merupakan alternatif media pembelajaran yang sesuai untuk anak prasekolah dalam meningkatkan perilaku kebersihan perorangan pada anak melalui peningkatan pengetahuan, sikap dan tindakan anak. saran materi mengenai kebersihan diri perorangan pada anak prasekolah perlu ditingkatkan untuk mengajarkan mengenai tindakan kesehatan sejak dini. tenaga pengajar (guru) dan orang tua sebaiknya lebih kreatif dalam memberikan pembelajaran pada anak, misalnya dengan buku cerita kontemporer. untuk mempertahankan perilaku kebersihan perorangan yang telah terbentuk pada anak diperlukan pemantauan dari support system antara lain guru, orang tua dan peer group. kepustakaan adhim, m.f., 2004. membuat anak gila membaca. bandung: al–bayan mizan. alisuf, m.s., 1993. pengantar psikologi umum dan perkembangan. jakarta: pedoman ilmu jaya. a n i e s , 2 0 0 5 . s e r i k e s e h a t a n u m u m : pencegahan dini gangguan kesehatan. jakarta: elex media komputindo. azwar, s., 2007. sikap manusia teori dan pengukurannya. yogyakarta: pustaka pelajar. diah, p., 2008. nilai didik dongeng membangun watak siswa. surabaya: jawa pos. tanggal 24 desember 2008. entjang, i., 1997. ilmu kesehatan masyarakat. bandung: citra aditya bakti. gunarsa dan gunarsa, 2000. psikologi praktis: anak, remaja dan keluarga. jakarta: bpk gunung mulia. herawani, dkk., 2002. pendidikan kesehatan dalam keperawatan. jakarta:egc. hurlock, e.b., 2005a. perkembangan anak jilid 1. jakarta: erlangga. hurlock, e.b., 2005b. perkembangan anak jilid 2 edisi 6. jakarta: erlangga. madjid, a.a.a., 2003. mendidik anak lewat cerita: dilengkapi 30 cerita pilihan. jakarta: mustaqim. muscari, m.e., 2005. keperawatan pediatrik. jakarta: egc. notoatmodjo, s., 2005. ilmu kesehatan masyarakat: prinsip–prinsip dasar. jakarta: rineka cipta. notoatmodjo, s., 2007. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta. notoatmodjo, s., 2003. pendidikan dan perilaku kesehatan. jakarta: rineka cipta. nursalam, rekawati dan utami, 2005. asuhan keperawatan bayi dan anak (untuk perawat dan bidan). jakarta: salemba medika. obeng, c.s., 2008. personal cleanliness activities in preschool classroom. journal of springer: early childhood education j, 36th; 93–99. potter, p.a. dan perry, a.g., 2005. buku ajar fundamental keperawatan: konsep, proses, dan praktik. vol. 1 ed. 4. jakarta: egc. song, et al., 2003. prevalence and risk factors for enterobiasis among preschool children in a metropolitan city in korea. journal of springer: parasitol res, 91th; 46–50. tarwoto dan wartonah, 2004. kebutuhan dasar manusia dan proses keperawatan edisi 1. jakarta: salemba medika. 106 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.5942 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research implementation of discharge planning in hospital inpatient room by nurses asmuji asmuji1, faridah faridah2 and luh titi handayani1 1 faculty of health science, university muhammadiyah of jember, east java, indonesia 2 bachelor of nursing program, insan unggul health science college surabaya, east java, indonesia abstract introduction: discharge planning is still become a problem for health services in hospital in-patient rooms. discharge planning commonly is only done when the patients leave hospital by giving them an explanation about the content of the controlling card. discharge planning is a routine activity that must be done by nurses in order to give information to the patients about their condition and any actions can or should be undertaken by them. in fact, the importance of discharge planning is not yet balanced, nor effectively applied in field. this research was conducted to find out about the implementation of discharge planning by nurses in one of the hospital in-patient rooms at the hospital of study. methods: this research was a qualitative research study conducted with the phenomenological approach. the informants were 6 patients and 6 nurses in first, second and third class nursing wards. the instruments used in this research were the researchers themselves with interview guidance, field notes and a tape recorder. the data was collected through an in-depth interview. results: there were three themes found through the analysis, which were 1) the information dimension involving room orientation, rights and obligations, and patient health problems as the sub-themes; 2) the understanding dimension with knowing and understanding the discharge planning as the sub-themes; 3) the implementation dimension with the time of implementation and content of discharge planning as the sub-themes. discussion: complete information given to the patients will bring about a positive impact, so then they can help themselves in relation to their curing time at home. a lack of and unclear information will bring about negative impacts such as mistakes when taking drugs, poor diet, neglecting activity while staying at home article history received: september 18, 2017 accepted: july 05, 2018 keywords discharge planning; nurses; inpatient room contact asmuji asmuji asmuji@unmuhjember.ac.id  faculty of health science, university muhammadiyah of jember, east java, indonesia cite this as: asmuji, a., faridah, f., & handayani, l. (2018). implementation of discharge planning in hospital inpatient room by nurses. jurnal ners, 13(1). 106-113. doi:http://dx.doi.org/10.20473/jn.v13i1.5942 introduction the important elements involved when providing health-care services to patients does not only focus on the adequacy of the infrastructure facilities that can be used as a mirror of quality services, but it is about the fulfilment of the rights of the patient from the beginning of entry until their discharge from the hospital. one of the inherent rights of the patients and their families when admitted to hospital for treatment is to get comprehensive information about their health when it comes to discharge planning. delgado-passler et al (2006) explained that discharge planning should be done comprehensively. discharge planning services are the responsibility of all health-care professionals in hospital, such as nutritionists, pharmacists, doctors and nurses, as the perpetrators of the 24-hour service that accompany patients during hospitalization. the discharge planning program is focused on providing health education to patients covering nutrition, activities or training, medicine and special instructions on the signs and symptoms of the disease that the patient has (perry et al, 2006). before discharge, patients and their families need to know how to manage their condition and/or recovery. teaching the patients and their families is the duty of the nurses as part of an innovative strategy that is at the forefront of patient care (bastable et al., 2002). both patients and their families need a health-care system that enables them to meet their needs, facilitated by self-care services (mullen et al, 2006). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 107 the process of discharge planning is used to prepare the patient to leave the hospital (goodman et al, 2013). nurses have an importance role in discharge planning (holliman et al, 2003; sturdy et al, 2010; kerr, 2012), so as it can reduce re-visits for patients (jha et al, 2009; bailey, 2012; holland et al, 2012; mathews et al, 2014; goodman, 2016). patient discharge programs, also known as discharge planning, in hospitals must have standard operational procedures. this is so then each patient gets a discharge program of equal standard regardless of who gives it. discharge planning that is not good can be one factor that prolongs the duration of healing at home. patients are declared ready for discharge if the patient is aware of their treatment, signs of harm, activities that need to be performed, and can conduct follow-up care at home (the royal marsden hospital, 2004). an effective discharge plan should include an ongoing assessment to obtain comprehensive information about any changing patient needs, nursing diagnostic statements and extensive planning to ensure that the patient needs are met according to what healthcare provider they can access (kozier, 2004). it can be said that discharge planning is a broad and complex process (durstenfeld et al, 2014). field studies have found that a discharge plan can still become a problem for health services in hospital in-patient rooms (kraft, 2013), where discharge planning is commonly only done when the patients leave the hospital by giving them an explanation about the content of the control card. popejoy (2008) stated that bad discharge planning could cause serious consequences for the patient. the research done by lindo et al (2016) at three hospitals in jamaica showed that discharge planning was done 72 hours after hospitalization. joanne (2006) stated that the nurses did not have the education and experience needed to provide complex health care to the patients. materials and methods the design of this research was qualitative with a phenomenological approach, which aimed to dig into the subjective experiences presented and to gain better perspective awareness (moleong, 2010) of the patients and nurses involved related to the implementation of discharge planning in the inpatient room of one of the hospitals. this research was conducted from march to june 2017. the population in this study were patients and nurses in class i, ii, and iii inpatient rooms. the informants of this research study were 6 patients/families and 6 nurses chosen via purposive sampling with the criterion being the that the patient was an adult aged 21 60 years old or a paediatric patient represented by a parent who accompanied them during the time in the hospital. the informants in the nursing element were chosen with the criteria that they had been working for at least one year in the hospital, had a diploma-level of education and that they were ners-qualified. the determination of the number of samples or informants was that it should be between 5 and 25 people (creswell, 2009). there were 6 people for each sample group (mason, 2010), since the researchers obtained saturated data by the sixth informant. the research instrument was the researchers themselves, with the help of a question guide, field notes, and a video or tape recorder. the methods of data collection was an in-depth interview with a duration of time between 45 and 60 minutes. the data analysis of this research used the stages proposed by colaizzi in 1978: 1) describing the phenomenon; 2) collecting the description of the phenomenon on based on the information submitted by the informants; 3) reading the entire description of the phenomenon obtained from the informants; 4) re-reading the transcripts, further reciting any significant statements; 5) attempting to decipher the meaning of each significant statement; 6) organising the set of meanings formed into groups of themes; 7) writing a complete and in-depth description; 8) returning to the participants to obtain validation of the description of the results and 9) validating the results of the analysis directly to the informants (speziale et al, 2007). as an effort to protect the respondents from any violations of ethics, the research planning study was evaluated by the ethics team in addition to its’ application in the field. the researcher gave an informed consent form to each candidate about the advantages, possible risks of the research, and kept the confidentiality of the respondent's name. results informant characteristics the informants in this research were patients consisting of 6 people; 4 people of the female sex, and 2 male. the informant’s age was between 19 and 60 years old. the education level of the informants consisted of elementary school students (4 people), senior high school students (1 person) and a university student (1 person). the treatment period is between 2-4 days. the nurses who were on duty at the time of the data collection amounted to 6 people. out of the total, 5 people were female, and there was 1 male aged between 25-45 years. analysis results 1. patient informants the following questions were asked: “how was your experience while hospitalized here?” and “what kind of service do you want?” after passing the recommended stages, then came the discovery of the themes of the analysis. the analysis results obtained the main theme and subthemes as follows. a. asmuji et al. 108 | pissn: 1858-3598  eissn: 2502-5791 information dimension the results of the interviews with the patient informants or the family of the patients found a poor level of expression that led to incomplete information being received by the patients from their first time getting to the inpatient room until leaving the hospital. this certainly can cause the patients and their families to not understand what they should do during the treatment period. the information dimension consists of the sub-themes of room orientation, rights and obligations, and health issues. room orientation the interviews related to patient orientation and family orientation were found to have no spatial orientation upon first admission. …i want, when i enter here, i get information where is my room directly (p1) … in order to enjoy when get nursing care here, is needed to know the name of the room (p2) …i never introduced before (p1, p3, p4, p5, p6) .... if the information about the room yes ... i was not introduced (p1) ... the explanation of the room, there is no such thing, sir. (p3) "delivered here ... moved to bed, that's all" (p4) "i just know the name of this room.... after my second days here (p5) "my family got the wrong room .... because they did not know" (p6). patient rights and obligations while an inpatient keywords found in this sub-theme were: i want to know what might be done (p3, p4, p5) …i afraid to ask (p1, p2, p6) i don’t know, i only obey it (p1) "the nurse only conveys to obey the rules to be obeyed" ...... but did not tell the rules (p1)... .. it seems that there is taped-stick on the wall ...., but not explained (p2)... ... afraid of mistaken, i am as villager mistakenly disobeying '(p6) health issues faced by the patients keywords on the health issues faced by the patients were: ……i want to know about my condition? (p2, p3, p4, p5) "nurses do not tell ... if they did not asked. they just told me"(p2)... ....they explain only when asked (p3, p4, p5) 2. nurse informants the following questions were asked of the nurse informants: “how about your experience in discharge planning?” and “what kind of service that you want?” knowledge dimension the results of the interviews with the nursing informants obtained findings about the inappropriate discharge planning in place. some of the nurses said that they did not know the term ‘discharge planning’. if nurses do not know the term ‘discharge planning’, then they will automatically not be able to do it properly. knowing discharge planning keywords in this sub-theme were: …what….discharge planning is? (p1) …what sir, because i’ve been one year here (nurse1) …not yet, sir because i’ve been only one year here (nurse 1) …i know a little, if not mistaken when i was in college, but now i forget it, sir (nurse 5) about discharge planning keywords in this sub-theme were: ...... i don’t really understand. what i know is that it is the plan for the patient going home (nurse 2, nurse 3) "i did not know about discharge planning ... is it a kind of resume nursing? (nurse 5) implementation dimension the results of the interviews with the nurse informants about the implementation of discharge planning led to the discovery of discharge planning not being as suitable as it should be. the implementation dimension obtained two subthemes, namely implementation time and discharge planning content. discharge planning time keywords in this sub-theme were: table 1. results of the interview analysis with the patient informants or the patient's family theme sub-theme information dimension room orientation rights and obligation health issues table 2. the results of the interview analysis from the nurse informants obtained two themes theme sub-theme knowledge dimension knowing of discharge planning about discharge planning discharge planning implementation dimension discharge planning time content of discharge planning jurnal ners http://e-journal.unair.ac.id/jners | 109 …yes…when the patients get permission to leave the hospital (nurse 2) ...... when the patient has been discharged from the hospital (nurse 2) ...... patients who will go home, right sir? (nurse 1) “i do it when the patient wants to go home, not at other times" (nurse 4) …... give it only when the patient will go home (nurse 3) "if that's usually done when taking-over, sir" (nurse 5)" i once gave discharge planning when the patient was going home..." (nurse 6) the contents of discharge planning keywords in this sub-theme were: ... the contents of discharge planning are just about drugs and control dates only ... (nurse 1) ... which must be done are call the patient, give the drug schedule, home care, schedule control, risk prevention and diet (nurse 2) "control schedule, take-home medicine, time for control, how to go home" (nurse 3) the activities are….related with explanation about giving medicines, control date, day and control time…like that (nurse4) "its activities are related to drug administration, control dates, days and hours of control" (nurse 4) discussion information dimension the results of this research are based on in-depth interviews with the informants, which indicate some problems in the discharge planning performed by nurses. the informant stated that at first admission, they were not given an explanation of the room where they were to be hospitalised and an explanation of their rights and obligations as the patient. the explanation about the patient's health problem was done by the nurse when asked by the patient or family. the discharge time, according to berry et al (2014), was the transitional time usually experienced by the patients regarding some of the problems in understanding the instructions. whereas, before discharge, the patients and families must know how to manage their condition at home. teaching the patients and their families is the duty of the nurses as an innovative strategy that is at the forefront of patient care (bastable et al., 2002). the patient and their family needs a care system for health that allows them to meet their own care needs (mullen et al, 2006). thus, the method of re-teaching (sawin et al, 2017) should always be done by the nurse. brooten et al (2002) demonstrated that the teaching should begin as soon as possible during hospitalisation and frequently repeated to ensure the success of patient learning. information is the data that has been processed into a form that has meaning for the recipient and is useful for current or future decision-making (mcleod et al, 2001). in the activity of providing nursing care, information for the patients is needed from the beginning of them becoming an inpatient up to the time of discharge. thus, the discharge planning should begin as soon as possible after the patient is admitted to the inpatient unit (haber, 1992). this process can help the patients achieve stable health at home, a smooth recovery, and to see improvement in their quality of life (backer et al, 2007). the information needed at the beginning of hospitalisation is not only about the patient's health condition, but also information about the room and hospital where the hospitalisation takes place. the provision of early information about anything related to hospitalization can be useful to building the trust between nurses and patients. simple, clear, and informative information will give the patients and their families an understanding of the hospital and hospitalisation, their health condition and their rights and responsibilities. the provision of information will also improve patient compliance and reduce errors during inpatient care, and later, their time of recovery. the adherence of patients to the medical advice provided is also strongly influenced by the important role of health communication. there are two things that affect the patient's compliance with accepted medical advice, namely that the patient must first understand the health issues or health problems faced. for that, he must be able to interpret and understand all of the health information communicated by the medical personnel on him. the patient should be able to remember (and memorise) the medical advice provided. when communicating information about the health of the patient, the medical experts should not use medical terms that are difficult to understand and ensure that the information provided is not too complicated. that way, the patient can easily recall all of the health information (medical advice) that has been submitted for him. for example, how many doses for each drug and so on (rahmadiana, 2012). the provision of incomplete and unclear information will affect the patient's understanding of their condition. the impact is the mistakes involved from acting, behaving and making decisions based on misunderstanding. this is certainly very dangerous for the life and health of the patients. mcbride (2002) said that the failure to communicate health information to patients and their families could result in the patient's lack of understanding of the outcomes of the tests (rahmadiana, 2012). providing incomplete and unclear information could have an influence on the patients’ understanding about their condition. discontinuity in providing information could cause health results that are worse (wang et al, 2008). this condition is very dangerous for the patient’s health and their life. rahmadiana (2012) stated that failure to communicate the health information to the patient and their families can cause the patients to misunderstand their test results. a. asmuji et al. 110 | pissn: 1858-3598  eissn: 2502-5791 providing suitable health information is an important part of disease prevention and health promotion. health communication is also considered to be relevant to several contexts in the field of health, including 1) the relationship between medical experts and patients; 2) the reach of individuals in accessing and utilising health information; 3) individual compliance with the treatment process that is to be followed and compliance with advice on the medicines received; 4) conveying health advice and health campaigns; 5) the dissemination of information about health risks to individuals and the population and 6) an overview of health profiles in the mass media (rahmadiana, 2012). the value of information that is closely related to the decision to be made, whereas if there is no choice or decision, then information will not be required. decisions can range from simple recurring decisions to long-term decisions (alandari, 2013). incomplete health information may cause patients and their families to be incorrect in making decisions, whether they are taking medication, working on a set diet and other allowable or prohibited actions. communication between the patient and nursing staff is a key component of effective health care and lays the foundation for a safe and comfortable nursing environment (williams et al, 2001). mccormack, (2003) also underscored the importance of patient-centered communication functions. with this in mind, it is important for the nursing staff to take part in planning the discharge of patients to communicate useful information. this is as well as fostering the attitude of sharing knowledge, experiences, hopes and concerns to resolve and describe the work routine for discharge planning. health information is not only addressed to the patients. their families are a part of the inseparable environment of the individual, and have a very important role in realising the individual’s health and them being someone who needs emotional support, education, and follow up (purdy et al, 2015). the family as a support system should always be involved in efforts to solve health problems in individuals. the medical mutual of ohio (2008) stated that patients and all of their family members should be informed of all discharge plans. smith et al (2013) said that the provision of information to the patients and their families enables them to focus on discharge planning. dimension of the nurse's knowledge on discharge planning the results of the interviews with the nurse informants found surprising data, as there were informants who said that they were not familiar with the term discharge planning. as a nurse, the term discharge planning should not be a strange thing. how can a nurse perform the activities related to discharge planning correctly, if they do not know the term? knowing something is the first step to action. a deeper introduction enables a person to understand, and if it is already understood, then they can act or apply it. sparbel et al (2000) stated that the problem of understanding related to a better health care continuity could help to ensure the delivery of high quality of health care services for all patients. the problem about the lack of nurses’ knowledge related to discharge planning is not only happening in indonesia, but also occurs in other countries. chaboyer et al (2002), in a survey of 58 nurses working in an intensive care unit, obtained that 43% lacked an understanding of return planning processes, and only 14% stated that the doctors trusted them enough for the nurses to plan the discharge. 14% stated that the doctors had given enough referrals for the nurses to design the discharge planning. dimension of discharge planning implementation by the nurses discharge planning for patients should be made from the beginning of their admission to the hospital (rudd et al, 2002). some research results abroad also showed the same information. goodman's (2010) study obtained data from nurse respondents stating that the patient's discharge planning should begin at the pre-admission clinic or when they are admitted to the hospital. morris (2012) also obtained data stating that nearly 80% of respondents agreed that the planning for at-home patients should be started upon their entry to the health care unit. watts et al, (2005) found from most of the notations in their study that discharge planning was initiated from admission when the patients hospitalized up until they were discharged. based on the data above, the planning of patient discharge is not only done when the patient is in the process of being discharged, but haber (1992) said that it must be done from the beginning when the patient goes the treatment room. it can be said that discharge planning starts from the orientation of the room, an explanation of the rights and obligations of the patient, when conducting a comprehensive assessment, formulating the nursing diagnosis correctly, creating an appropriate nursing plan, performing the planned nursing actions, and evaluating both short and long term treatment plans. however, looking at the above interview results leading to the timing and content of the discharge planning, it was found that the nurse's understanding of discharge planning was lacking. the nurse informant said that the implementation of discharge planning is the time before discharging the patient, while the content is to provide an explanation of the contents of the control card. chaboyer et al. (2004), in his research, found that 54% of nurses stated that the implementation of discharge planning was conducted just before the patient leave the service unit. there is concern, as many nurses do not know how to do discharge planning properly. jurnal ners http://e-journal.unair.ac.id/jners | 111 the implementation of discharge planning information that is important to be delivered to the patient is the possibility of the date of discharge (lees et al, 2006; rudd et al, 2002). the provision of this information at the treatment time will be able to provide them with motivation and the spirit to heal. morris (2012) stated that it is important to remember that most patients want to know how long they are likely to remain in the hospital. but the reality is different, according to lees (2003), who said that where the patient is not always given information about the possible date of discharge, their motivation was lower. the implementation of discharge planning in health services in this research area could not be released from the control card. this can be seen from the results of the interviews that say when talking about discharge planning, then in the mind of the nurse, the purpose is to give and explain the control card to the patient. there was even a nurse informant who said that they gave the control card without any explanation of its contents. kozier (2004) stated that discharge planning is a starting process of the patient to getting health care, followed by a continuity of care, both in the process of healing and in maintaining their health status until the patient feels ready to return to his environment. the discharge planning in health services that is still not understood by most of the nurses has become homework that must be completed soon. this fact is not only the responsibility of the nurses, but it should be the joint responsibility of various parties, including the management of the health services and hospitals. hospital policy related to discharge planning must be enforced, by making standard operating procedures (sops). the department of health (2010) said that hospitals should make and distribute guidance about the patient discharge planning process. the policy, coupled with a sop for discharge planning, will strengthen the position of its implementation. rudd et al (2002) also noted that the nurses should be pushed into being more active in performing patient discharge planning based on the given standard. conclusion the implementation of discharge planning in one of the hospital’s inpatient rooms in jember found that the results led to incomplete information being received by the patients from the first time entering the inpatient room up to leaving the hospital. another finding is that there are nurses who are not familiar with the term discharge planning, and who do not understand about the implementation of discharge planning both in terms of time and the content. based on the conclusions above, the researchers have suggested that the management develop the human resources side of nursing by conducting socialization and discharge planning training. in addition, management should issue a policy in the form of a decree on the implementation of discharge planning and standard operational procedures (sops). references alandari, f. (2013). peran sistem informasi manajemen berbasis komputer dalam meningkatkan pelayanan publik di lingkungan kantor bupati kabupaten berau. ejoournal ilmu pemerintahan, 1(1). retrieved from http://ejournal.ip.fisip-unmul.ac.id/site/?p=584 backer, t. e., howard, e. a., & moran, g. e. (2007). the role of effective discharge planning in preventing homelessness. journal of primary prevention; new york, 28(3–4), 229–243. bailey, c. (2012). reducing readmissions through discharge communication, 43, 12, 14–16. bastable, s. b., wulandari, g., widiyanto, g., & widyastuti, p. (2002). perawat sebagai pendidik : prinsip-prinsip pengajaran dan pembelajaran (nurse as educator : principles of teaching and learning). jakarta: egc. berry, d. l., cunningham, t., eisenberg, s., wickline, m., hammer, m., & al., e. (2014). improving patient knowledge of discharge medications in an oncology setting. clinical journal of oncology nursing; pittsburgh, 18(1), 35–37. brooten, d., naylor, m. d., york, r., brown, l. p., & al., e. (2002). lessons learned from testing the quality cost model of advanced practice nursing (apn) transitional care. journal of nursing scholarship; indianapolis, 34(4), 369–375. chaboyer, w., foster, m., kendall, e., & james, h. (2002). icu nurses’ perceptions of discharge planning: a preliminary study. intensive and critical care nursing. intensive and critical care nursing, 18(2), 90–95. http://dx.doi.org/ 10.1016/s0964-3397(02)00022-8 chaboyer, w., foster, m., kendall, e., & james, h. (2004). the impact of a liaison nurse on icu nurses’ perceptions of discharge planning. australian critical care, 17(1), 25–32. https://doi.org/http://dx.doi.org/10.1016/s103 6-7314(05)80047-5 creswell, j. w. (2009). research design qualitative, quantitative, and mixed method approaches (3rd ed.). los angeles: sage publications, inc. delgado-passler, p., & mccaffrey, r. (2006). the influences of postdischarge management by nurse practitioners on hospital readmission for heart failure. journal of the american academy of nurse practitioners, 18(4), 154–160. department of health (2010). discharge planning a summary of the department of health’s guidance ready to go? planning the discharge and the transfer of patients from hospital and intermediate care. durstenfeld, m. s., saybolt, m. d., praestgaard, a., & kimmel, s. e. (2014). abstract 353: physicians do not accurately predict length of stay of patients admitted with heart failure. circulation: cardiovascular quality and outcomes. aha a. asmuji et al. 112 | pissn: 1858-3598  eissn: 2502-5791 journals, 7(1). retrieved from http://circoutcomes.ahajournals.org/content/7/ suppl_1/a353 goodman, d. m., & burke, a. e. (2013). discharge planning. jama (the journal of american medical assosiation; chicago, 309(4), 406. goodman, h. (2010). discharge from hospital: the importance of planning. british journal of cardiac nursing, 5(6), 274–279. goodman, h. (2016). discharging patients from acute care hospitals. london, 30(24), 49. https://doi.org/10.7748/ns.30.24.49.s47 haber, j. (1992). comprehensive psychiatric nursing (4th ed.). mosby-year book. holland, d. e., & bowles, k. h. (2012). standardized discharge planning assesement: impact on patient outcomes. journal of nursing care quality, 27(3), 200–208. https://doi.org/22437249 10.1097/ ncq.0b013e31824ebc59 holliman, d., dziegielewski, s. f., & teare, r. (2003). differences and similarities between sosial work and nurse discharge planners. health & social work, 28(3), 224. jha, a. k., orav, e. j., & epstein, a. m. (2009). public reporting of discharge planning and rates of readmissions. the new england journal of medicine, 361(27), 2637–2645. joanne, m. (2006). nurse dose as a concept. kerr, p. (2012). stroke rehabilitation and discharge planning. nursing standard (through 2013); london, 27(1), 35–39. kozier, b. (2004). fundamentals of nursing : concepts, process, and practice (7th ed.). upper saddle river, n.j. : prentice hall health. kraft, s. ., wise, h. h., jacques, p. f., & burik, j. k. (2013). discharge planning simulation: training the interprofesional team for the future workplace. journal of allied health; washington, 42(3), 175–81. lees, l. (2003). the key principles of effective discharge planning. nursing times, 109(3), 18–9. retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/23431715 lees, l., & emmerson, k. (2006). identifying discharge practice training needs. nursing standard, 20(29), 47–51. lindo, j., stennet, r., stephenson-wilson, k., barrett, k. a., & bunnaman, d. (2016). an audit of nursing documentation at three public hospitals in jamaica. journal of nursing scholarship; indianapolis, 48(5), 508–516. mason, m. (2010). sample size and saturation in phd studies using qualitative interviews. forum qualitative social research. retrieved from http://www.qualitative-research.net/index.php /fqs/article/view/1428/3028 mathews, k. s., corso, p., bacon, s., & jenq, g. . (2014). using the red/yellow/green discharge tool to improve the timeliness of hospital discharge. joint commission journal on quality and patient safety, 40(6), 243–252. https://doi.org/25016672 mccormack, b. (2003). a conceptual framework for person-centred practice with older people. international journal of nursing practice, 9(3), 202–209. https://doi.org/10.1046/j.1440172x.2003.00423.x mcleod, r., & schell, g. (2001). management information systems (8th ed.). london: prentice hall. medical mutual of ohio. (2008). discharge planning guidelines. retrieved january 1, 2017, from http://www.medmutual.com/proviver/resource s/hospitalservices/dischargeplanning.aspx moleong, l. j. (2010). metodologi penelitian kualitatif (revisi). bandung: pt remaja rosdakarya. morris, j. (2012). registered nurses’ perceptions of the discharge planning process for adult patients in an acute hospital. journal of nursing education and practice, 2(1), 28. https://doi.org/10.5430/jnep.v2n1p28 mullen, b. a., & watts kelley, p. a. (2006). diabetes nurse case management: an effective tool. journal of the american academy of nurse practitioners, 18(1), 22–30. perry, a. g., & potter, p. a. (2006). clinical nursing skills & tecnique (6th ed.). missouri: mosby inc. popejoy, l. l. (2008). adult protective services use for older adults at the time of hospital discharge. journal of nursing scholarship; indianapolis, 40(4), 326–332. purdy, i. b., craig, j. w., & zeanah, p. (2015). review nicu discharge planning and beyond : recommendations for parent psychosocial support. journal of perinatology, 35(s1), s24–s28. https://doi.org/10.1038/jp.2015.146 rahmadiana, m. (2012). komunikasi kesehatan : sebuah tinjauan. jurnal psikogenesis, 1(1), 88–94. rudd, c., & smith, j. (2002). discharge planning. nursing standard, 17(5), 33–37. sawin, k. j., weiss, m. e., johnson, n., gralton, k., & malin, s. (2017). development of a selfmanagement theory-guided discharge intervention for parents of hospitalized children. journal of nursing scholarship; indianapolis, 49(2), 202–23. smith, v. c., hwang, s. s., dukhovny, d., young, s., & pursley, d. m. (2013). neonatal intensive care unit discharge preparation , family readiness and infant outcomes : connecting the dots. journal of perinatology, 33(6), 415–421. https://doi.org/10.1038/jp.2013.23 sparbel, k. j. h., & anderson, m. a. (2000). integrated literature review of continuity of care: part 1, conseptual issues. journal of nursing scholarship; indianapolis, 32(1), 17–24. speziale, h. s., & carpenter, d. r. (2007). qualitative research in nursing: advancing the humanistic imperative nursing research (revised). philadelphia: lippincott williams & wilkins. sturdy, d., & heath, h. (2010). support for discharge planning. nursing standard (through 2013), 24(28), 15. the royal marsden, h. (2004). discharge planning. jurnal ners http://e-journal.unair.ac.id/jners | 113 wang, e. a., white, m. c., jamison, r., goldenson, j., & estes, m. (2008). discharge planning and continuity of health care: findings from the san francisco county jail. american journal of public health; washington, 98(12), 2182–4. watts, r., & gardner, h. (2005). nurses’ perceptions of discharge planning. nursing and health sciences, 7(3). https://doi.org/10.1111/j.14422018.2005.00229.x williams, c. a., & gossett, m. t. (2001). nursing communication: advocacy for the patient or physician? clinical nursing research, 10(3), 332– 340. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 184 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 184-191 http://dx.doi.org/10.20473/jn.v18i2.41408 original article open access predictive factors of family health management for caring toddlers with acute respiratory infections marisna eka yulianita 1 * , andi yulia kasma 1 , and andi ayumar 1 1 nursing program, institut of health sciences makassar, makassar, indonesia *correspondence: marisna eka yulianita. address: nursing program, institut of health sciences makassar, makassar, indonesia. email: ichanaey@yahoo.co.id responsible editor: praba diyan rachmawati received: 11 december 2022 ○ revised: 27 june 2023 ○ accepted: 27 june 2023 abstract introduction: poor air quality due to air pollution, unhealthy lifestyle, and easily transmittable viruses further increases the incidence of acute respiratory infections, especially in toddlers. this study aimed to determine the predictive factors, namely knowledge, attitude, and anxiety, of family health management in preventive and curative areas for caring toddlers with acute respiratory infections. methods: this type of research is correlational predictive. the sample was mothers who have toddler with a history of ari. a total of 392 mothers were involved and selected using purposive sampling. the instrument used was a questionnaire of knowledge, attitudes, anxiety, and family health management. bivariate data analysis used the chi square test and multivariate analysis used the logistic regression test. results: bivariate analysis showed that there was a relationship between knowledge, attitudes, and anxiety with family health management (p-value=0.000). multivariate analysis showed that variables significantly related to family health management were knowledge (or=19.791; 95% ci=10.349 to 37.847), attitude (or=9.265; 95% ci = 3.969 to 21.628), and anxiety (or=0.137; 95% ci = 0.066 to 0.285). conclusions: good knowledge and positive attitudes were related to effective family health management in the care of toddlers with acute respiratory infections. furthermore, an increase in anxiety will reduce the effectiveness of family health management in the care of toddlers with ari. nurses need to optimize the role of the family through health education that focuses on increasing the mother's knowledge and attitudes in family health management, as well as managing anxiety in caring for children with ari. keywords: family health management, toddler, acute respiratory infection introduction the world health organization (who) states that acute respiratory infections are the main cause of morbidity and mortality from infectious diseases in the world. nearly 4 million people die from acute respiratory infections each year. the death rate is very high in children and is one of the most common causes of consultation or treatment in healthcare facilities (who, 2020). globally, southeast asia has the highest incidence of ari and is the third leading cause of individual death in both developed and developing countries. it was reported that bangladesh, india, indonesia, and nepal together accounted for 40% of global ari deaths. it was recorded that the prevalence of ari was 50.4% and caused 20% of deaths of underfive children (murarkar et al., 2021). the who and unicef designed the integrated management of childhood illness (imci) strategy which aims to reduce preventable mortality, minimize illness and disability, and promote healthy growth and development of children under five years of age. this strategy includes both preventive and curative elements https://creativecommons.org/licenses/by/4.0/ mailto:ichanaey@yahoo.co.idmailto https://orcid.org/0000-0001-8610-1336 https://orcid.org/0000-0003-2167-295x https://orcid.org/0000-0002-8479-3743 jurnal ners http://e-journal.unair.ac.id/jners 185 that can be implemented by families. this strategy was noted to have contributed to 15% reduction in child mortality due to infectious diseases (who, 2023). therefore, efforts to overcome health problems in preventive and curative areas should be handled early and independently by the family. moreover, this disease is closely related to changes in environmental conditions, human behavior and environmental factors (sinulingga, 2017). these factors can be controlled through the right lifestyle. a meta-analysis study on treatment of children with upper respiratory tract infections stated that most mild cases will recover with conservative treatment alone (panda et al., 2021). family health management is a pattern of managing and integrating health programs into daily life sufficient to meet health goals (ppni, 2017). family health management cannot be separated from family health tasks, namely the family's ability to recognize health problems, to make the right decisions, to care for sick family members, to modify the environment, and to access health services (clara & wardani, 2020). this form of family empowerment is a process of enabling families to improve or control their health status (nies & mcewen, 2015). indonesia is a maritime country that has many islands; however, not all islands have health service centers even though these islands are in the same district. this causes difficulties in accessing health services. thus, the urgency for optimizing family health management, especially for pangkajene and island district, which have 117 islands. the government of pangkajene and islands regency (2022) recorded 21,482 toddlers and in the last year 686 new ari cases appeared. this district location is an area with two different geographical dimensions, mainland and islands. this factor allows for independence and access to health information that people receive differently. the high number of cases of transmission which are disseminated through the information media causes parents to panic more quickly when their children experience symptoms of ari. exposure to invalid sources of information makes parents even more confused about differentiating the symptoms of respiratory infections experienced by toddlers. in addition, the increase in the number of cases and the easier transmission of the omicron has affected the psychology of parents. parents are worried about the stigma of being confirmed positive for covid-19 in toddlers. on the other hand, environmental factors and parents' experiences regarding health problems experienced by toddler will be interpreted into parents' attitudes, whereby these attitudes can be positive or negative. the purpose of this study was to analyze the factors of knowledge, attitudes and anxiety in regard to family health management in caring for toddlers with ari. materials and methods research design this type of research is correlative predictive, namely discriminant predictive analytical research. this research was conducted between july and september 2022 at pangkajene and island district. participants participants of this study were mothers who had toddlers with a history of or currently experiencing ari, which were obtained using purposive sampling of 392 mothers. the sample size in this study was obtained using slovin’s formula (firdaus, 2021). the exclusion criterion was mothers who had toddler with confirmed covid-19. this is because covid-19 has similar symptoms to ari, while this research focuses on the independence of mothers in caring of toddlers with ari. recruitment and identification of participants was carried out in two ways: first by participating in integrated service post (posyandu) activities and looking for samples that match the inclusion criteria. second, by seeking health data for toddlers with a history of ari at the community health centers and visiting the participant's house directly. research variables the variables of this study were factors that were reviewed from mother’s knowledge, attitude, and anxiety. knowledge was a collection of health information owned by mothers regarding ari and was divided into two categories, namely good and less. the attitude variable was the mother's perception in treating ari in toddlers which was divided into two categories, namely positive and negative attitudes. anxiety was a set of symptoms experienced by mothers in caring for toddlers with ari where anxiety was divided into two categories, namely anxious and not anxious. the dependent variable was family health management in the care of toddler with ari. family health management was the efforts and behavior of mothers in caring for toddlers with ari where this variable was divided into two categories, namely effective and ineffective yulianita, kasma, and ayumar (2023) 186 p-issn: 1858-3598  e-issn: 2502-5791 data collection and research instrument data collection began with informed consent and using three questionnaires, namely knowledge, attitude, and the depression anxiety stress scales (dass). this questionnaire on knowledge, attitudes, and family health management was adopted and translated into indonesian from previous research (prakash et al., 2020). anxiety was measured using the depression, anxiety stress scales (dass) questionnaire. the attitude questionnaire contained 16 questions, the reliability value of cronbach's alpha was 0.818 and the value of sig. (2-tailed) = 0.000 and the pearson correlation was 0.656 (r>0.4973), which means the questionnaire used was valid and reliable. meanwhile, the family health management questionnaire contained 15 questions with a reliability value of cronbach's alpha 0.659 and a value of sig. (2-tailed) = 0.000 and a pearson correlation of 0.564 (r>0.5140), which means the questionnaire used was valid and reliable. data analysis bivariate analysis to see the relationship between variables was carried out using the chi-square test while multivariate analysis was using the logistic regression test. the hosmer and lemeshow test showed a sig value of 0.603, which means the model is feasible to use. logistic regression test analysis was used in assessing the predictive factors. ethical consideration ethical clearance and approval was obtained from the health research ethics committee of nani hasanuddin makassar health science institute (no.664/stikes-nh/kepk/viii/2022). before conducting the research, we explained the purpose of the research, the type of data to be collected and the benefits to be obtained by the participants. after that, we gave consent forms to be signed by willing participants. results table 1 shows that participants who were in the mainland area were 242 (61.7%) mothers and in the island area were 150 (38.3%) mothers. the participants in this study were dominated by 324 (82.7%) housewives with a 17-30 years age group of 206 (52.6%) mothers. mother's level of education was dominated by senior high school as many as 113 (28.8%) mothers. table 2 shows that the dominant participants have good knowledge (70.9%), positive attitude (85.5%), no worries (54.1%), and effective family health management (73.5%). however, based on demographic location, the dominant problems that occur in mainland areas are lack of knowledge (33.9%) and ineffective family health management (36.8%), whereas, in island areas, the dominant problems that occur are negative attitudes (18.7) and anxiety in caring for toddlers (74%). cross-tabulation results in table 3 show that effective family health management is contributed by good knowledge (87.5%) and positive attitude (93.4%). meanwhile, non-anxiety conditions contribute to the ineffectiveness of family health management, in other words, anxiety is needed to stimulate participants (mothers) so that health management in the care of toddlers with ari runs effectively. the results of statistical tests showed that there was a relationship between knowledge and family health management (pvalue=0.000), attitudes and family health management (p-value=0.000), and anxiety and family health management (p-value=0.000). table 4 show the results of the logistic regression test in which the variables significantly related to family health management were knowledge (or=19.791; 95% ci=10.349 to 37.847), attitude (or=9.265; 95% ci = table 1. participants’ characteristics (n=392) participants’ characteristics demography amount mainland island n % n % n % mother’s age (years old) 17-30 31-43 126 116 52 48 80 70 53.3 46.7 206 186 52.6 47.4 mother’s education no school elementary school junior high school senior high school bachelor 2 82 53 64 41 0.8 33.8 22 26.4 17 12 10 52 49 27 8 6.7 34.7 32.6 18 14 92 105 113 68 3.6 23.5 26.8 28.8 17.3 mother’s job housewife employee home entrepreneur farmer part time worker 206 10 9 2 15 85.1 4.1 3.8 0.8 6.2 118 10 6 0 16 78.7 6.7 4 0 10.6 324 20 15 2 31 82.7 5.1 3.8 0.5 7.9 table 2. frequency distribution factors of family health management for caring for toddlers with acute respiratory infections (n=392) variable demography amount mainland island n % n % n % knowledge less good 82 160 33.9 66.1 32 118 21.3 78.7 114 278 29.1 70.9 attitude negative positive 29 213 12 88 28 122 18.7 81.3 242 150 14.5 85.5 anxiety anxious no worries 69 173 28.5 71.5 111 39 74 26 180 212 45.9 54.1 family health management ineffective effective 89 153 36.8 63.2 15 135 10 90 104 288 26.5 73.5 jurnal ners http://e-journal.unair.ac.id/jners 187 3.969 to 21.628), and anxiety (or=0.137; 95% ci = 0.066 to 0.285). these results also show that knowledge and attitude have a positive coefficient value where each increase of 1 point of knowledge will improve family health management in the care of toddlers with ari by 2.985 point and each increase of 1 point of attitude will increase family health management in the care of toddlers with ari by 2.226 point. meanwhile, every 1 point increase in anxiety will reduce the effectiveness of family health management in the care of toddlers with ari by 1.989 point. table 5 shows that the negelkerke r square value shows that knowledge, attitudes and anxiety have a 58.6% influence on family health management in the care of toddlers with ari. discussions this study aims to determine the predictive factors, namely knowledge, attitude, and anxiety, of family health management for caring for toddlers with ari. the initial symptoms of acute respiratory infection that occurs in the upper respiratory tract are such as congestion, fever, difficulty sleeping, and fussiness, sometimes accompanied by vomiting and diarrhea. other visible symptoms are a red nose, runny nose, itchy throat, watery eyes, cough, headache and lethargy (hulu et al., 2020). the general symptoms of sufferers make everyone feel the same worries, especially mothers with toddlers. the average number of patients in the united arab emirates is mostly children, with the most common initial symptom being an upper respiratory tract infection (al mansoori et al., 2021). parents are now more inclined not to take their toddler to healthcare facilities for fear of contracting various diseases in the hospital. in addition, the coverage of health services following the emergence of covid-19 has minimal accessibility because health service providers will be very dependent on the availability of human and logistical resources (kumar et al., 2020). therefore, health promotion and disease prevention are fundamental in the current situation, where most diseases originate from lifestyles that are not in accordance with health protocols. new strategies to deal with health problems need to be developed toward self-sufficiency (salamung et al., 2021). before deciding to seek a healthcare center, the community can manage family health in the form of first aid for ari toddlers. the intervention of choice is in the form of fever management by providing thin clothing and minimizing contact with cigarette smoke, which can trigger ari. these results are in line with previous research (sari et al., 2021) which shows that there is a relationship between parental health management and the incidence of ari, in which parents had good behavior in preventing ari. family health management can be in the form of first aid to sick family members. through appropriate assessments and interventions, families will be able to alleviate suffering, promote healing, and reduce injury. so that in the end it can improve the health and safety of family members who experience health problems (habeeb & alarfaj, 2020). the family health management process can be influenced by several factors including knowledge, anxiety, and attitudes of the family. knowledge, emotional control, and awareness reflected through a positive attitude are needed to support safe family health management. appropriate care and preventing contact other than with health workers can reduce the possibility of complications due to wrong health management in children (bhalla et al., 2019). knowledge is related to risk factors for disease in children; good knowledge has an impact on parents' awareness of the conditions experienced by children and they will tend to take preventive measures so that their children do not contract the disease and they are able to provide good treatment (saputra et al., 2020). prevention is a pillar of the health strategy so that, to reduce the incidence of disease and minimize its impact, a greater focus is needed, especially on precautionary measures and knowledge about disease management. currently, we generally know that table 3. factors of family health management for caring for toddlers with acute respiratory infections (n=392) variable family health management pvalue ineffective effective n % n % knowledge less 78 75 36 12.5 0.000 good 26 25 252 87.5 attitude negative 38 36.5 19 6.6 0.000 positive 66 63.5 269 93.4 anxiety anxious 20 19.2 160 55.6 0.000 no worries 84 80.8 128 44.4 table 4. logistic regression test variable b df odds ratio 95% ci pvalue lower upper knowledge 2.985 1 19.791 10.349 37.847 0.000 attitude 2.226 1 9.265 3.969 21.628 0.000 anxiety 1.989 1 0.137 0.066 0.285 0.000 table 5. model summary step -2 log likelihood cox & snell r square nagelkerke r square 1 252.155a .402 .586 yulianita, kasma, and ayumar (2023) 188 p-issn: 1858-3598  e-issn: 2502-5791 prevention is better than cure so further efforts are needed to optimize effective disease prevention, especially in the family sphere. mother's knowledge in this study was in the good category. even so, some mothers who still have less knowledge should be of concern given the importance of mothers in family health management. the lack of knowledge of the mother in this study is related to the pathophysiological concept of the cause of the disease and prevention efforts which are still considered wrong by the mother. the results of the statistical tests of this study also show that there is a relationship between good mother's knowledge and the effectiveness of family health management in the care of toddlers with ari. the concept of the pathophysiology of a disease that is not understood by mothers is in line with research (basiouny & hamad, 2019) which states that about twothirds of them gave incomplete answers regarding causes, signs and symptoms of ari. whereas prevention efforts that are still considered wrong by mothers are in line with research (akteruzzaman et al., 2018) which states that only 19% of mothers' knowledge in preventing ari is related to cough ethics and 32% related to knowledge of hand washing with soap. efforts are needed to increase knowledge so that mothers have better performance in caring for ari children. other studies also state that, as the main care provider at home, mother's knowledge of disease conditions can reduce mortality and morbidity if caught early (kumar et al., 2022). mother's knowledge needs to be increased because mothers play an important role in the process of caring for children (momoh et al., 2022). previous research shows parents with higher education have better first aid knowledge than those with less education (al-johani et al., 2018). therefore, the right and maximum investment of knowledge in mothers can maximize the child's recovery time. previous research also shows that there is an effect of health education on the level of mother's knowledge in preventing ari in toddler, where health education can increase mother's knowledge so as to encourage self-efficacy, self-management and increase awareness in disease prevention (tunny et al., 2020). in addition, the increasing number of hospitalized patients has prompted the health system to make efforts to prevent patients with mild to moderate symptoms coming to the hospital, so that home healthcare becomes important and can help solve problems such as a shortage of hospital beds and health workers. home care can be made easier and safer for patients. this home health management scheme can provide a good alternative to doing home-based care for low income patients (hussein et al., 2021). attitudes in managing family health problems are inseparable from the mother's knowledge. as previously explained, the mother's poor knowledge about prevention efforts was also reflected in her attitude. the results of this study indicate that the mother's attitude is dominated by a positive attitude. this positive attitude includes things that can cause children to have difficulty breathing when experiencing ari, such as the influence of cigarettes smoked by family members who live at home with the sufferer. meanwhile, a negative attitude is reflected in an inaccurate understanding of how immunization can make children sick and the importance of ventilation to maximize circulation. in addition, the results of statistical tests showed that there was a positive relationship between mother's attitude and the effectiveness of family health management in the care of toddlers with ari. demographically, mothers in the island region in this study had a greater percentage of negative attitudes than those in the mainland. this is due to access to information that cannot be obtained independently due to network limitations so that the transfer of information is also hampered. in addition, it is also due to the strong culture associated with the myths and beliefs of previous generations in managing health problems. the results of this study are in line with previous research (handayuni et al., 2019) which states that there are misperceptions of mothers in interpreting healthy and sick life according to their views, which are influenced by life experiences or values passed down from previous generations. when ari is perceived as a disease that is not serious and not life threatening, then prevention of ari will not be optimal. conversely, if the mother of the toddler perceives ari as a health problem that needs to be watched out for, then automatically the mother of the toddler will take this disease seriously by developing preventive behavior. this is in line with research (barni & mardiah, 2022) which states that a person's attitude will influence health behavior. a positive attitude or attitude that is in accordance with one's health values will result in positive health behavior. meanwhile, a negative attitude that is contrary to health values will result in negative health behavior as well. efforts to promote health and prevent disease are fundamental today, when most of the potential for disease can originate from inappropriate lifestyles. previous research explains that health education and information dissemination must be given as early as jurnal ners http://e-journal.unair.ac.id/jners 189 possible to create positive attitudes and practices in disease prevention and management efforts (workie et al., 2018). the capacity of the family to nurture, care for, protect, teach and influence throughout life makes it an effective entry point in the promotion and maintenance of individual health (hanson et al., 2019). apart from the mother's side, several family characteristics are also related to good and bad health outcomes. family closeness, skills in care, mutually supportive relationships, flexibility and adaptability, and good communication can lead to better treatment outcomes. the role of the family in optimizing health through promoting healthy choices and changing behavior makes the family an important basis for supporting public health (crandall et al., 2019). health management that is oriented toward family independence has the potential for efficiency in terms of financing because it does not require the use of sophisticated technology. family health can be mediated through increased awareness and reflection and adaptation (smith et al., 2017). because the family is where health behaviors emerge, using this approach in clinical preventive care can significantly improve people's health. the effectiveness of family-oriented care has advantages, especially in the health problems of children, the elderly and mental health. nursing interventions can be maximized by improving relationships within the family and increasing knowledge and skills in disease management (barnes et al., 2020). mental health problems are common, yet often overlooked in the treatment process. these problems can greatly affect the quality of care leading to a state of physical health and eventual well-being (abu-ghname et al., 2019). when one family member has a health problem, the whole family environment is involved. however, the role of parents has an important meaning in efforts to cure children with ari because, if the health management is carried out badly, it will affect the course of the disease from mild to severe, which will interfere with the child's development in the future (angelina, 2022). the importance of the role of parents can be achieved through family-centered health education so they are more active in providing a safe home without infection. nonetheless, the mother as the executor of the nurturing, caring, and caring functions within the family has a greater obligation to manage family health problems. however, in carrying out this role, events that have never been experienced before can make the mother experience anxiety. psychologically, research (chandra et al., 2022) shows that women show greater increases in anxiety, depression, and stress than men. the results of this study were that the mother's anxiety was in the category of not worrying when her toddler has an ari. it is known that the results of the regression analysis show that every 1 increase in anxiety will reduce the effectiveness of family health management in the care of toddlers with ari. some mothers who experience anxiety describe several behaviors such as how easily mothers become angry and annoyed over small things when their child is sick. in addition, excessive anxiety in dealing with these situations makes mothers experience fatigue more quickly. in providing care to sick children, mothers often experience fatigue. therefore, there is a need for support for mothers in maximizing their parenting functions (rakhmani et al., 2020). if this prolonged fatigue is not resolved, it will cause the mother to not be optimal in providing care. some important points in the process of caring for families with health problems are concern for the physical and mental well-being of caregivers, including rest periods (holliday et al., 2022). the psychological reactions of family members are very vulnerable to problems related to a toddler's health. this condition will naturally form a family coping mechanism. however, conflicts with healthcare providers should be avoided as they can cause stress. a pattern of long-term support and care that can lighten the burden on family members is urgently needed. in addition, systems theory in the family looks at problems in a circular way, where each individual in the family will influence each other. understanding family health problems requires an assessment of several patterns of interaction such as emphasizing more on what happened, not why the problem occurred. this is seen as effective in avoiding dysfunctional dynamics of one of the family members and is the best solution in solving health problems in the family (al ubaidi, 2017). the limitations of this research are, first, this study has not examined family composition; in this study, several families still live in the same place, while ari is a disease that is easily transmitted and can be inherited from lifestyle. second, cultural factors related to myths and beliefs of mothers in managing health problems. this factor cannot be ruled out because some families live with the extended family which makes the nuclear family dependent on the extended family culture. therefore, researchers need to identify these two factors in the future. yulianita, kasma, and ayumar (2023) 190 p-issn: 1858-3598  e-issn: 2502-5791 conclusions the role of the mother in a family is important, especially in terms of family health management. good mother's knowledge, positive mother's attitude, and mother's anxiety are closely related to health management in the care of toddlers with ari. good mother’s knowledge can maximize the care of toddlers with ari at home, which is also a form of family empowerment, especially for the low-income family category. a positive mother's attitude can maximize skills in disease management in the family. the new finding in this study was that an increase in anxiety will reduce the effectiveness of family health management in the care of toddlers with ari. therefore, family health management should be a shared responsibility and not only be borne by the mother because it will have an impact on the fatigue that the mother feels, both physically and mentally. support from all family members is highly expected so that family health management can run effectively. researchers strongly suggest that the focus of services can be maximized on family independence in health management. in addition, it is hoped that health providers will pay more attention to increasing knowledge as well as patterns of managing anxiety related to the treatment process in the context of family health management. acknowledgment the researcher thanks the parties who contributed to the implementation of this research including the ministry of education and culture, indonesian research and technology, chair of the makassar college of health sciences, pangkajene and island district governments in administrative and health service institutions, as well as mothers who agreed to be participants in this study. funding source this research received funding from ministry of education and culture, indonesian research and technology in the form of novice lecturer research grants. references abu-ghname, a., clementi, m., marton, s.a., schwarzwald, h., giwa, e., hollier, l. & chapman, s. g. (2019) ‘behavioral health service utilization: trends in utilization within a patient-centered medical home for low-income children and women’, journal of family medicine and primary care, 8(12), 3983–3989. https://doi.org/10.4103/jfmpc.jfmpc_412_!9 akteruzzaman, m., habib, r., praveen, s., ahmed, s., khalil, i., khan, k. a., sharifa, t., khatun, a., mukit, saha, b. k. & r. (2018) ‘knowledge, attitude and practice of mothers about acute respiratory tract infections in under five children’, 1(1), 2–9. https://www.researchgate.net/publication/352180142 al-johani, a.a., sabor, s. & aldubai, s. a. (2018) ‘knowledge and practice of first aid among parents attending primary health care centers in madinah city, saudi arabia, a cross sectional study’, journal of family medicine and primary care, 7(2), 380–388. https://doi.org/10.4103/jfmpc.jfmpc_64_18 al mansoori, l., al kaabi, s., nair, s.c., al katheeri, m., ghatasheh, g., al dhanhani, h. & al kaabi, a. (2021) ‘epidemiological characteristics of children with coronavirus at a joint commission‑accredited hospital in the united arab emirates’, journal of family medicine and primary care, 10(6), 2348–2352. https://doi.org/10.4103/jfmpc.jfmpc_2161_20 al ubaidi, b. a. (2017) ‘cost of growing up in dysfunctional family’, journal of family medicine and disease prevention, 3(59), 1–6. https://doi.org/10.23937/2469-5793/1510059 angelina, r. (2022) ‘peran dan tindakan orangtua dalam pencegahan ispa dengan kejadian ispa pada balita di kelurahan babakan asih kota bandung’ jurnal perawat indonesia, 6(3), 1161–1172. https://journal.ppnijateng.org/index.php/jpi/article/view/1826/7 71 barnes, m. d., hanson, c. l., novilla, l. b., magnusson, b. m., crandall, a. c., & bradford, g. (2020) ‘family-centered health promotion: perspectives for engaging families and achieving better health outcomes. inquiry (united states)’, 57, 1–6. https://doi.org/10.1177/0046958020923537 barni & mardiah, m. (2022) ‘description of knowledge attitude and behavior of patients of acute respiratory tract infection (ari) in gumelem wetan village susukan district banjarnegara regency in 2021’, jurnal ilmiah medsains, 8(01), 45–50. https://jurnal.polibara.ac.id/index.php/medsains/article/view/23 5 basiouny, n. s. &, & hamad, n. i. (2019) ‘mothers’ knowledge and practices regarding management of their children with acute respiratory infection’, international journal of novel research in healthcare and nursing, 6(1), 657–670. https://www.noveltyjournals.com/upload/paper/mothers knowledge and practices-1718.pdf bhalla, k., gupta, a., nanda, s., mehra, s. & verma, s. (2019) ‘parental knowledge and common practices regarding acute respiratory infections in children admitted in a hospital in rural setting’, journal of family medicine and primary care, 8(9), 2908–2911. https://doi.org/10.4103/jfmpc.jfmpc_510_19 chandra, r., kumar, s., supehia, s., das, a. & agarwal, d. (2022) ‘psychological distress and well-being assessment among indian people during covid-19 pandemic’, journal of family medicine and primary care, 11(4), 1341–1347. https://doi.org/10.4103/jfmpc.jfmpc_1203_21 clara, e. & wardani, a. a. d. (2020) ‘family sociology’, unj press. crandall, a., novilla, l.k.b., hanson, c.l., barnes, m.d. & novilla, m. l. b. (2019) ‘the public health family impact checklist: a tool to help practitioners think family’, frontiers in public health, 7(331), 1–7. https://doi.org/10.3389/fpubh.2019.00331 firdaus. (2021) ‘metodologi penelitian kuantitatif’, dotplus publisher. habeeb, k.a. & alarfaj, g. (2020) ‘saudi parents awareness regarding burn, choking, and drowning first aid in children’, journal of family medicine and primary care, 9(3), 1370–1375. https://doi.org/10.4103/jfmpc.jfmpc_1064_19 handayuni, l., alfian, a. r., amran, a. & razak, a. (2019) ‘knowledge of mother about the household environment againt acute respiratory infection in padang pasir: a literature study’, iop conference series: earth and environmental science, 314(1), 1–5. https://doi.org/10.1088/1755-1315/314/1/012076 hanson. c.l., crandall, a., barnes, m. d., & magnusson, b., novilla, m.l.b. & king, j. (2019) ‘family-focused public health: supporting homes and families in policy and practic’, frontiers in public health, 7(59), 1–6. https://doi.org/10.3389/fpubh.2019.00059 holliday, a.m., quinlan, c.m. & schwartz, a. w. (2022) ‘the hidden patient: the care framework to care for caregivers’, journal of family medicine and primary care, 11(1), 5–9. https://doi.org/10.4103/jfmpc.jfmpc_719_21 hulu, v. t., salman, supinganto, a., khairi, l. a., sianturi, e., nilasari, siagian, n., hastuti, p. & s. (2020) ‘epidemiology of infectious diseases: history, transmission, and prevention’, yayasan kita menulis. jurnal ners http://e-journal.unair.ac.id/jners 191 hussein, n.r., saleem, z.s.m., rashad, b.h., naqid. i.a., ibrahim, n., musa, d.h., khezaqia, n. d. & yousif, a. h. (2021) ‘home management scheme for patients with severe covid‑19 in duhok city, kurdistan region of iraq: a possible role for family physicians’, journal of family medicine and primary care, 10(11), 4260–4263. https://doi.org/10.4103/jfmpc.jfmpc_166_21 kumar, m.m., karpaga, p. p., panigrahi, s.k., raj.u., pathak, v. k. (2020) ‘impact of covid‑19 pandemic on adolescent health in india’, journal of family medicine and primary care, 9(11), 5484–5489. https://doi.org/10.4103/jfmpc.jfmpc_1266_20 kumar, p., patra, p., paul, r., roy, m., khatun, s., ghosh, l., dutta, s., roy, r., sadhu, d., setara, a., naiya, s., routh, s., thoki, s., bomzan, s. & barman, m. (2022) ‘a study to assess the level of knowledge regarding prevention and management of acute respiratory infection among mothers of children 0-5 years in selected hospital in siliguri’, international journal of research in medical sciences, 10(9), 1979–1982. https://doi.org/10.18203/2320-6012.ijrms20222276 momoh, f. e., olufela, o. e., adejimi, a. a., roberts, a. a., oluwole, e. o., ayankogbe, o. o., & onajole, a. t. (2022) ‘mothers’ knowledge, attitude and home management of diarrhoea among children under five years old in lagos, nigeria’, african journal of primary health care and family medicine, 14(1), 1–10. https://doi.org/10.4102/phcfm.v14i1.3119 murarkar, s., gothankar, j., doke, p., dhumale, g., pore, p. d., lalwani, s., quraishi, s., patil, r. s., waghachavare, v., dhobale, r., rasote, k., palkar, s., malshe, n., & deshmukh, r. (2021) ‘prevalence of the acute respiratory infections and associated factors in the rural areas and urban slum areas of western maharashtra, india: a community-based cross-sectional study’, frontiers in public health, 9(october), 1–7. https://doi.org/10.3389/fpubh.2021.723807 nies, m. a. & mcewen, m. (2015) ‘promoting the health of population (6th ed.)’, elsevier health sciences. https://doi.org/10.1136/bmj.g6195 nurmalitasari, y. k. & indarjo, s. (2021) ‘pola asuh ibu dengan kejadian ispa balita di puskesmas geyer’, indonesian journal of public health and nutrition, 1(3), 428–432. https://doi.org/10.15294/ ijphn.v1i3.46518 panda, p. k., sharawat, i. k., natarajan, v., bhakat, r., panda, p. & d. (2021) ‘covid‑19 treatment in children: a systematic review and meta‑analysis’, journal of family medicine and primary care, 10(9), 3292–3302. https://doi.org/10.4103/jfmpc.jfmpc_2583_20 the government of pangkajene and islands regency. (2022). total population according to age in semester ii of 2021. ppni. (2017) ‘standar diagnosa keperawatan indonesia’, dpp ppni. prakash, s. d., reddy, b. k., athul, k., swamy, s., bhodaji, s., desmukh, a., sanskurti, t., lalremruati & singh, j. d. (2020) ‘knowledge, attitude, awareness and practice towards covid-19 pandemic in indian citizens during the national lockdown period: a quick online cross-sectional study’, international journal of physiotherapy and research, 8(3), 3504–3515. https://doi.org/10.16965/ijpr.2020.139 rakhmani, a. n., arisanti, n., dhamayanti, m., wiwaha, g., mutyara, k., & setiawati, e. p. (2020) ‘a qualitative study on family role in the care and prevention of acute respiratory infection among children in primary health care’, global pediatric health, 7, 1–8. https://doi.org/10.1177/2333794x20969273 salamung, n., pertiwi, m. r., ifansyah, m. n., riskika, s., maurida, n., suhariyati, primasari, n. a., rasiman, n. b., mari, d. & rumbo, h. (2021) ‘family nursing’, duta media publishing. saputra, m. r., rakhmawati, w., hendrawati, s., & adistie, f. (2020) ‘knowledge, attitude, and healthcare-seeking behavior among families of children with tuberculosis’, belitung nursing journal, 6(4), 127–135. https://doi.org/10.33546/bnj.1156 sari, e. n., tinambunan, e. s. l., prameswari, g., kartika, l. & tahapary, p. a. (2021) ‘the relationship between parents’ knowledge and behaviors with the acute respiratory infection incidence of children under five in tangerang’, strada journal, 10(1), 1403– 1411. https://doi.org/10.30994/sjik.v10i1.815 sinulingga, s. r. (2017) ‘hubungan dukungan keluarga dengan kepatuhan konsumsi obat infeksi saluran pernapasan akut (ispa) masyarakat pulau pongok’, jurnal kesehatan, 8(2), 186–190. https://doi.org/10.26630/jk.v8i2.470 smith, s. l., degrace, b., ciro, c., bax, a., hambrick, a., james, j. & evans, a. (2017) ‘exploring families’ experiences of health: contributions to a model of family health’, psychology, health & medicine, 22(10), 1239–1247. https://doi.org/10.1080/13548506.2017.1319069 tunny, i. a., soamole, i., wibowo, s. a., purnamasari, i. & rumaolat, w. (2020) ‘effect of health education on mothers’ knowledge in the prevention of acute respiratory infection in toddlers in waimital village, maluku’, jurnal ners, 15(2), 188–192. https://doi.org/10.20473/jn.v15i1sp.18968 who. (2020) ‘treatment center for severe acute respiratory infections’, https://www.who.int/docs/defaultsource/searo/indonesia/covid19/who-2019-ncov-pusatpengobatan-infeksi-saluran-pernapasan-akutberat.pdf?sfvrsn=3e00f2b7_2 who. (2023) ‘integrated management of childhood illness’, https://www.who.int/teams/maternal-newborn-childadolescent-health-and-ageing/child-health/integratedmanagement-of-childhood-illness workie, h. m., sharifabdilahi, a. s., & addis, e. m. (2018) ‘mothers’ knowledge, attitude and practice towards the prevention and home-based management of diarrheal disease among under-five children in diredawa, eastern ethiopia, 2016: a cross-sectional study’, bmc pediatrics, 18(1), 1–9. https://doi.org/10.1186/s12887-018-1321-6. how to cite this article: yulianita, m. k., kasma, a. y., and ayumar, a. (2023) ‘predictive factors of family health management for caring toddlers with acute respiratory infections’, jurnal ners, 18(2), pp. 184-191. doi: http://dx.doi.org/10.20473/jn.v18i2.41408 267 development of leadership and communication skill model on midwifery students in physiological delivery practice sri utami, rekawati susilaningrum, susilorini susilorini poltekkes kemenkes surabaya, jl. pucang jajar tengah no. 56 surabaya, 60282 email: bu.sri.utami67@gmail.com abstract introduction: currently there is a tendency for students only prioritising hard skills without improving their soft skills. this is indicated by the negative attitudes and actions such as delay task submission, bad time management, and a lack of commitment towards a task. the purpose of this research is to find out the model of leadership skill development and communication skill of the vocational midwifery course. methods: this study consists of two stages. the research type was observational and explanatory. the first stage used a cross-sectional design and the second stage was quasi-experimental. the subjects of the study for the first stage was 130 respondents, calculated by “rule of the thumb” and by purposive sampling. the second stage consisted of 38 respondents taken by random sampling. the exogenous variables are motivation, self-leadership strategies, job satisfaction, psychological empowerment, self-efficacy, and task commitment. the endogenous variables are leadership skill and communication skills. in the first stage, the data were analysed using pls and the second stage used a wilcoxon test with α = 0,05. results: the variables of motivation, self-leadership and job satisfaction could improve communication skills. in stage 2 (after training), all of the variables increased significantly with p <0,05. conclusions: training using the self-leadership module can improve the ability of motivation, self-leadership strategies, job satisfaction, self-efficacy, psychological empowerment, task commitment, communication and student leadership skills. keywords: communication skills, motivation, self-leadership introduction education is a major factor in the personal development of humans. several studies related to soft skills show that grade point average (gpa) can only describe the quality of a person in the cognitive aspect and cannot indicate a person's qualifications in relation to soft skills, also called social skills (puliam, 2008). harvard university revealed that the success of one's career is 80% determined by soft skills and only about 20% determined by hard skills. the survey of the national association of college and employers (nace), usa 2002 in (wanarto, guntur budi., 2014) taken by 457 leaders in america showed that out of about 20 important qualities possessed by successful people, the result was mostly soft skills, and only two of them considered it to be hard skills (kuswara, 2008). looking at the research results above, demanding education including in relation to midwifery to prepare graduates will mean that they not only have academic achievements with a high gpa score but also have skills ready to use in the world of work. besides mastering the academic and technical skills of midwifery, midwifery students must also have communication and leadership skills. the importance of soft skill mastery when the midwife enters the world of work should use the midwifery education institution to design a soft skills development program as a means of building work ethics with the students that is included in the direct learning within the community (suryani, 2015). students, as the next generation of the nation, must have the ability, skills and a personality that is strong and polite. soft skills are skills that can form a formidable personality. the more soft skills that a person possesses, it is expected that they will have a stronger personality when facing the challenges of the learning process on campus, work challenges, and other life challenges. soft skills are a person's skill in dealing with others. college graduates expect that the workforce should have positive soft skills, a strong attitude, are honest, passionate, able to work together, polite in communicating, good at negotiating, have a high work motivation, are creative and adaptable, and so are able to work intensively. “the lessons from the top” written by thomas j. neff and james m. citrin (1999) in (wirawan, 2013) says that the key to success is determined by 90% soft skills and only 10% is determined by hard skills. the ministry of national education’s study in 2009 states that one's success in education is 85% determined by soft skills. the sutomo midwifery major is one of the educational institutions that implement an educational program with the vision of producing competent midwives who are independent and are able to compete in the jurnal ners vol. 12 no. 2 oktober 2017: 267-277 268 global era, by upholding values and professional ethics. to realise that, the students are required to have both hard skills and soft skills that can be demonstrated by the abilities of the students in relation to leadership skills, communication skills, the ability to interact, to not procrastinate on tasks and many other things. the most recent fact is that the majority of students still limited with just the hard skills that are shown by their academic achievements, with less care given to their soft skills. observations have found recently that students often (65%) delay on their task completion, and that 70% of students tend to learn only when faced with exams have bad time management and a lack of commitment in performing their duties as a student. various steps can be undertaken to improve soft skills such as leadership skills and student communication skills in the practice of physiological midwifery care. the novelty of this research is to create a development model of self-leadership strategies to improve leadership and communication skills. from the previous research, the ability of self-leadership is an important variable in relation to performed improvement measured in quantity. in this research, it is assumed that there are motivational variables that can improve the ability of self-leadership strategies as an effort to improve various positive aspects that impact on the increase of students’ soft skills, especially leadership skill and communication skills in the physiological delivery practice (wanarto, guntur budi., 2014). materials and methods this research type is observational and explanatory. the first stage used a crosssectional design and the second stage used a quasi-experimental approach. the subjects of the study were vocational students of the dr sutomo midwifery course on surabaya; the first stage consisted of 130 respondents taken by purposive sampling. the second stage sample was 38 respondents taken by random sampling. the exogenous variables were motivation, self-leadership strategies, job satisfaction, psychological empowerment, selfefficacy, and task commitment, while the endogenous variable was communication skill. the instrument used was a questionnaire. the data collection procedure in the first stage began with an explanation of the research objectives and the willingness to become a respondent as evidenced by the provision of informed consent. furthermore, the respondents were given a questionnaire to explore data about all of the variables. the second stage began with the giving of informed consent. before the students performed clinical practice, a pre-test on all of the variables was conducted. this was followed by two days training in selfleadership strategies. the control group was not given any training. both groups then performed physiological midwifery care clinical practice for 1.5 months. after 1.5 months, both groups performed a post-test. the further data obtained was analysed descriptively and inferentially; the first stage using pls and the second stage using a wilcoxon test with value α = 0,05. results the first stage results: analysis of the structural models (inner model) in the structural model analysis, the effect of the exogenous factors on the endogenous factors was tested. the reference value used was that if the t-statistical value of the processing was greater than the t-table value, then it was concluded that the exogenous factors have a significant effect on the endogenous factors. error tolerance (α) = 5% and total data 130 then the value of t-table = t(df=n-1;α/2) = t(129;0,025) = 1,96. the results of the significance test are described in the following table. table1 shows that each exogenous variable has a significant effect on an endogenous variable, except for the job satisfaction variable and leadership skill, task commitment and leadership skill, psychological empowerment and communication skill, psychological empowerment and leadership skill, selfefficacy and communication skill and selfefficacy and leadership skills. furthermore, the insignificant relationships were omitted. the final model was formed from the new tstatistics value, and the details are in the following table 1. 269 table 1. t-test result of the exogenous latent variable to the endogenous variables and line coefficient parameters in the early structural model (inner model) no line original sample (o) t statistics (|o/sterr|) t tabel information 1 (x1) motivation(x2) self leadership strategies 0.566 21.684 1,96 significant 2 (x1) motivation (x3) psychological empowerment 0.805 36.230 1,96 significant 3 (x1) motivation (x4) job satisfaction 0.759 31.692 1,96 significant 4 (x1) motivation (x5) self efficacy 0.588 15.661 1,96 significant 5 (x1) motivation (x6) task commitment 0.261 6.106 1,96 significant 6 (x1) motivation (y1) communication skill 0.274 3.334 1,96 significant 7 (x1) motivation (y2) leadership skill 0.711 11.212 1,96 significant 8 (x2) self leadership  (x3) psychological 0.133 5.001 1,96 significant 9 (x2) self leadership  (x4) job satisfaaction 0.231 7.475 1,96 significant 10 (x2) self leadership  (x5) self efficacy 0.214 4.544 1,96 significant 11 (x2) self leadership  (x6) task commitment 0.137 6.670 1,96 significant 12 (x2) self leadership  (y1) communication skill 0.173 4.174 1,96 significant 13 (x2) self leadership  (y2) leadership skill 0.337 7.396 1,96 significant 14 (x3) psychological  (x6) task commitment 0.135 4.109 1,96 significant 15.. (x3) psychological  (y1) communication skill -0.020 0.477 1,96 not significant 16.. (x3) psychological  (y2) leadership skill -0.053 0.938 1,96 not significant 17 (x4) job satisfaaction  x6) task commitment 0.306 6.224 1,96 significant 18 x4) job satisfaaction  (y1) communication skill 0.297 4.808 1,96 significant 19 (x4) job satisfaaction  (y2) leadership skill -0.060 0.600 1,96 not significant 20 (x5) self-efficacy  x6) task commitment 0.217 6.824 1,96 significant 21.. (x5) self-efficacy  (y1) communication skill 0.009 0.252 1,96 not significant 22.. (x5) self-efficacy  (y2) leadership skill -0.033 0.565 1,96 not significant 23 (x6) task commitment  (y1) communication skill 0.244 2.968 1,96 significant 24 (x6) task commitment  (y2) leadership skill -0.075 0.630 1,96 not significant jurnal ners vol. 12 no. 2 oktober 2017: 267-277 270 tabel 2. t-test result of the exogenous latent variable to the endogenous variables and line coefficient parameters in the finale structural model (inner model) no line original sample (o) t statistics (|o/sterr|) t table information 1 (x1) motivation(x2) self leadership strategies 0.566 23.108 1,96 significant 2 (x1) motivation (x3) psychological empowerment 0.805 38.621 1,96 significant 3 (x1) motivation (x4) job satisfaction 0.759 29.006 1,96 significant 4 (x1) motivation (x5) self efficacy 0.588 14.551 1,96 significant 5 (x1) motivation (x6) task commitment 0.262 6.335 1,96 significant 6 (x1) motivation (y1) communication skill 0.264 3.898 1,96 significant 7 (x1) motivation (y2) leadership skill 0.549 19.940 1,96 significant 8 (x2) self leadership  (x3) psychological 0.133 5.627 1,96 significant 9 (x2) self leadership  (x4) job satisfaaction 0.231 6.879 1,96 significant 10 (x2) self leadership  (x5) self efficacy 0.214 4.499 1,96 significant 11 (x2) self leadership  (x6) task commitment 0.136 5.954 1,96 significant 12 (x2) self leadership  (y1) communication skill 0.172 4.180 1,96 significant 13 (x2) self leadership  (y2) leadership skill 0.288 7.249 1,96 significant 14 (x3) psychological  (x6) task commitment 0.135 4.103 1,96 significant 15 (x4) job satisfaaction  x6) task commitment 0.306 6.485 1,96 significant 16 x4) job satisfaaction  (y1) communication skill 0.296 4.427 1,96 significant 17 (x5) self-efficacy  x6) task commitment 0.217 7.514 1,96 significant 18 (x6) task commitment  (y1) communication skill 0.245 2.750 1,96 significant development of leadership and communication skill model... (sri utami et al.) 271 figure 1. finale inner model goodness of fit index (gof) the last one was to found to have the value of goodness of fit (gof). in contrast to cbsem, for gof, the values in pls-sem must be searched manually. the formula is: the calculation of the average ave is 0.952511, while the average r2 is 0.676291, so the value of gof is 0.802605 according to tenenhaus (2004), gof small value = 0.1, gof medium = 0.25 and large gof = 0.38. since the gof value in this study was 0.802605, the gof value was large. the second stage statistical analysis result in the second stage, the data were analysed using the wilcoxon statistics test, and the results obtained are shown in table 3. from these results, it indicates that the training given to the students about the development of self-leadership capabilities based on student motivation can improve the various positive aspects that can support the implementation of the learning process, especially the clinical practice of physiological midwifery care. discussion the development of self-leadership skills and the student skill model explains that motivation can improve the students' selfleadership strategies in the clinical practice of physiological midwifery care. this is in accordance with (mccanse, 1991) in wirawan (2013) which stated that motivation is an important element in leadership. wirawan (2013) explained that motivation plays an important role in leadership, which will encourage individual motives to act. without motivation, people will not act, move and work well for themselves or for the organisation. high and low individual motivation determines high level of effort and a variety of individual behaviours. motivation can improve the students' job satisfaction in jurnal ners vol. 12 no. 2 oktober 2017: 267-277 272 the midwifery practice. this is consistent with the statement by wirawan (2013) which describes that motivation will increase the stability of work. this is where individuals who have a high work motivation will have high job satisfaction. according to david mcclelland in wirawan (1991), it was stated that motivation is a need for achievement as a state of the individual’s internal drive to how much success reflects an important and valuable focus for a person. these factors can lead to job satisfaction and a willingness to work harder. if these factors exist, they will encourage more effort, but if they do not exist, then it will result in job dissatisfaction. there is the motivation to improve the student’s psychological empowerment in midwifery practice. according to spreitzer (1995) in utami & hargono (2016), psychological empowerment refers to the experience of the individual’s intrinsic motivation based on the individual's orientation to their job role. psychological empowerment is not a fixed personality attribute. it consists of the cognition formed by the work environment. various thoughts about psychological empowerment have evolved, including in the work of conger and kanungo (1988), thomas and velthouse (1990) in spreitzer (1995) in utami & hargono (2016). motivations can improve the student’s selfefficacy in midwifery practice. this is in accordance with the statement of victor vroom (1964) in wirawan (2013), which states that work motivation relates to a person's faith or beliefs about effort, so the effort involved will produce the expected output. the theory of motivation according to vroom is famous for the expectancy theory or the theory that states that the individual's perception of the possibility that an effort will lead to the achievement of a predetermined level of performance. if the expectation equals 0 (zero), then it is not possible to reach the level of performance that has been set. expectation equals one if the person is 100 percent sure that they can achieve the specified performance. a person with self-efficacy is the belief of someone who is able to do or complete a task. motivation improves a student's taskcommitment in the midwifery practice. this is consistent with the motivational theory of mcclellan in wirawan (2013), which stated that motivation is the need for achievement, where the need for achievement is a need to achieve something difficult. this is often to master, manipulate, or organise physical objects, human beings, or ideas. this also involves doing so as quickly and independently as possible, to solve obstacles and to obtain a high standard, to excel yourself. it also means to increase self-esteem by implementing talents successfully. according to mcclelland, someone who has a high level of achievement has three characteristics, namely: he or she have a strong desire to take personal responsibility, tend to set a medium goal when faced with difficult situations and they have a great desire to get a better level of performance. there is the motivation to improve the student’s skill in leadership in the midwifery practice. this is in accordance with mccanse 1991 in wanarto, guntur budi (2014), which states that motivation is an important element table 3. results of the preand post-data analysis training of self leadership capability development in students of midwifery in sutomo surabaya n o variable pre post p inf min max mean +sd min max mean +sd 1 motivation 1.10 2.30 1.39 .37 2.80 3.70 3.07 .19 0,00 sign 2. self leadership 1.06 2.25 1.33 .39 1.95 3.63 2.88 .34 0,00 sign 3. job satisfaaction 2.00 3.18 2.26 .39 2.18 3.53 2.73 .35 0,00 sign 4. psychological empowerment 1.08 2.42 1.43 .42 2.42 3.58 2.89 .29 0,00 sign 5. self efficacy 128 0 135 0 1301.8 19.29 107 0 164 0 1397.9 133.4 0,01 sign 6. task commitment 2.14 2.52 2.24 .116 2.79 3.83 3.14 .25 0,00 sign 7. leadership skill 2.00 3.11 2.29 .330 2.11 3.11 2.51 .29 0,00 8 sign 8. comunication skill 2.00 2.40 2.11 .122 2.44 3.81 2.89 .280 0,00 sign development of leadership and communication skill model... (sri utami et al.) 273 in leadership. wirawan (2013) explains that motivation plays an important role in leadership, which will encourage the individual motivation to act. without motivation, people will not act, move and work well for themselves or for the organisation. katz & kahn (1978) argue that leadership is an increase of the gradual influence on and above the mechanical adherence to routine organisational briefings. leadership is the process of influencing the activities of a group that is organised towards the achievement of goals (rauch, 1984). many studies focused on leadership skills are discussed from various perspectives that have been conducted by the researchers. leadership is a behaviour with a specific purpose to influence the activities of group members to achieve common goals designed to provide individual and organisational benefits (cheok san lam, 2012). communication skills are one of the parameters of soft interpersonal skills, which are a skill that is used for oneself and relates to others, cooperating with other groups, and so on. to be able to connect with other people requires a good communication process. for communication to run well by the set purpose, a person must have the ability or communication skills to do so. based on the results of the national association of colleges and employers nace, 2002 in (wanarto, guntur budi., 2014), the survey cited by wanarto (2014) explained that there are 19 capabilities needed in the job market, which is where communication skills occupy the first necessary urgency. according to hasibuan (2005), their study states that motivation is important because motivation is the cause, channel and support of human behaviour, so they must be willing to work hard and be enthusiastic to achieve the optimal results. midwifery students are midwives who have the role of giving midwifery care to the client, hence needing the communication skill. the self-leadership strategy can improve the student's sense of job satisfaction in physiological obstetric care practice. students who have good self-leadership abilities will feel satisfied with the task of implementing the practice of physiological midwifery care. this is in line with the results of sri utami’s (2016) study that found that self-leadership strategies can improve the midwife's job satisfaction in implementing the early detection of the growth drift of toddlers. the results of this study also support the results of politis’s research (2006) which found a direct relationship between the dimensions of the strategy focused on selfleadership behaviour with positive and statistically significant work satisfaction. the results of yutthana's research (2010) explains that self-leadership has a direct effect on job satisfaction. this is consistent with us research studies that have found a correlation between self-leadership training and its positive impact on employee job satisfaction neck & manz, 1996 (in yutthana, 2010). self-leadership can improve the students' psychological empowerment in the practice of physiological obstetric care. students with a good self-leadership strategy also have high psychological empowerment. it can be explained that each self-leadership strategy has its own role. the constructive thought patterns strategies which are associated with psychological empowerment are designed to facilitate the formation of constructive thinking and thinking in a positive way (neck & manz, 2010). this is in line with the results of sri utami’s (2016) study which explains that self-leadership strategies can improve the psychological empowerment of midwives in implementing the early detection of deviations in child growth and development. psychological empowerment is a predictable outcome of self-leadership. selfleadership has been established as the main mechanism to facilitate empowerment by creating perceptions of meaning, purpose, selfdirection/self-determination, and competence. natural rewards from oneself can encourage feelings of self-direction, competence, and setting their own goals (wirawan, 2013). self-leadership improves the students' self-efficacy in the practice of physiological obstetric care. students with good selfleadership strategies have high self-efficacy. the results of this study support the results of (utami & hargono, 2016), whose research states that self-leadership strategies can improve the self-efficacy of midwives in implementing the early detection of child growth drift. the results of this study also support the research conducted by prussia et al., (1998) in (yutthana c, 2010) in his study of 151 employees; the results obtained showed that self-leadership has a positive effect on self-efficacy. yutthana (2010) explained that jurnal ners vol. 12 no. 2 oktober 2017: 267-277 274 self-leadership has a direct effect on selfefficacy. the use of some strategic selfleadership will affect the perception of selfefficacy in a particular task. self-leadership can increase the task commitment of students in the midwifery care practice. students with good self-leadership skills are committed to their high tasks as well. commitment is the outcome of self-leadership; individuals who have strategies in selfleadership often develop a sense of belonging to their tasks and work processes. the result state that individuals can lead themselves, and that they are highly committed to their tasks and goals, both at the individual, team and organisational level, compared to individuals who cannot apply self-leadership (wirawan, 2013). self-leadership increases leadership skills according to blanchard k., susan f, laurie h (2006). the study explained that the earliest level of leadership is self-leadership followed by group/team leadership, organisation leadership, and the last is community/society leadership. this stage will be passed through by everyone, only the speed of each person through these stages varies. this is why there are people who, at a young age, have been able to reach a high level of leadership, but on the other hand, there is still slow development involved. self-control is to conquer and control yourself. those who understand others are wise; he who knows himself is intelligent. he who overpowers others is strong; he who beats himself nobly (kaswan, 2013). self-leadership increases communication skills in the midwifery practice. according to kaswan (2013), communication skills are needed in every individual, especially for those who work in an organisation or company. a person's communication skills can make it easier for individuals to convey their bright ideas to their superiors, co-workers and subordinates. many people can explore ideas in their thoughts or imagination, but few people can effectively communicate their thoughts and imaginations to their superiors, co-workers and subordinates. communication skills require the ability to be able to know other people, but the most important requires the ability to know oneself. a person will be able to recognise and control themselves if the individual has good self-leadership skills. job satisfaction can improve task commitment; this is in line with the results of sri utami’s (2016) study which explains that job satisfaction can improve the task of a midwife in implementing the early detection of deviations in child growth and development. (wibowo, 2013) explained that there is a significant relationship between job satisfaction with commitment. managers are advised to increase job satisfaction to generate higher commitment. furthermore, higher commitment can facilitate higher productivity. the level of employee satisfaction can lead to greater commitment. otherwise, when employees feel dissatisfied, it leads to smaller commitment, which can then affect the efforts of the employees (lijan, 2016). psychological empowerment can increase the task commitment in the practice of physiological midwifery care, where students who have high psychological empowerment will have a high level of task commitment as well. scott et al., (2011) found a strong relationship between intrinsic motivation and affective commitment, meaning that the psychological dimension of empowerment has a role in increasing affective commitment. also, meaningful feelings, competencies and impacts tend to increase individual commitment to the organisation, as they will further enhance the ability of the individuals to express their values and interests through their work. psychological empowerment is an intensive form of work regardless of the addition of rewards or salaries. psychological empowerment does not improve the students' communication skills in the midwifery practice. this is not in accordance with rober moss kanter (1977) directed by wirawan (2013), which states that empowerment empowers people to operate in unfavourable situations in an organisation. the psychological empowerment of the individual will produce positive things, namely improving the work, work processes, sharing knowledge and skills and experience. psychological empowerment can improve the work process. someone in work or doing a set job process will need to interact with others. for communication to work effectively, one must have good communication skills. mardatillah (2016) explained that communication skills are required by every individual, especially for development of leadership and communication skill model... (sri utami et al.) 275 those who work in an organisation or company. a person's communication skills can make it easier for individuals to convey their brilliant ideas to their boss or colleagues. with good communication skills, it will be easy to tell the ideas better so then it can be accepted. although in this study, psychological empowerment cannot improve student skill communication, but psychological empowerment improvement is still very necessary because psychology can have a positive impact towards increasing of the other variables that can improve performance. psychological empowerment does not improve student skill leadership in the midwifery practice. this result is not in line with wirawan (2013), who states that empowerment is one aspect of organisational development concerning human resource development. empowerment means making allowing or permitting either one's own initiative or that of others. empowerment is an interactive process based on synergism, not from zero assumptions about power. the empowerment process enlarges power in the opposite situation by merely redistributing power. individuals who have their own perception are highly empowered as they have a broad view of the future. wirawan (2013) declared that empowerment aims to describe humans which have the characteristics of having views about the world and their selfconcept accurately, seeing themselves as having a benefit/use, having the ability to do something, knowing the meaning of someone sought, and progressing in life, being able to see the reason for the output and to evaluate in a compelling way. finally, empowerment can envision the success that is capable of carrying out meaningful activities, concentrating efforts, initiating actions and flexible interactions. although the results of this study indicated that psychological empowerment could not improve leadership skills, for educational institutions or other organisations, it is very important to keep improving the psychology of the students or employees in the organisation. this is because many positive outcomes can be generated from good or high psychological empowerment. according to sri utami’s (2016) research, psychological empowerment affects increasing task commitment and performance either directly or when mediated by the task commitment variable. self-efficacy can increase the student's commitment task in the midwifery practice. students with high self-efficacy have high task commitment. a person with high self-efficacy will try to accomplish their tasks with various amounts of efforts; they will face obstacles that they will encounter that will not make them give up. a person with high self-efficacy will tend to set themselves goals that are more challenging, and they will be more committed to the goals of the task performed. conversely, someone with low self-efficacy will easily give up when faced with challenges or difficulties (bandura, 1986). self-efficacy does not improve the students' communication skills in the midwifery practice. lack of access to media, unavailability to use the media, the individual’s educational level, and the language used in dissemination were some of the major factors hindering effective communication to the youths (judy, box, & box, 2015). in persuasive communication, the role of the communicator is very important and influential. thus, it must have a highperformance value. a communicator who has a high-performance value can be characterised by readiness, sincerity, trust, tranquillity, friendliness and simplicity in conveying the message. with a high self-efficacy, one will be sure to achieve the communication objectives that he has set. in this study, however, most of the students' communication skills in the practice of physiological obstetric care are mostly in the insufficient category, as well as self-efficacy also being in the insufficient category. there is an effort to improve both of these factors so that students have high-quality soft skills too because communication is one of the soft skills (hassan et al., 2013). self-efficacy can not improve student skill leadership in the midwifery practice (study et al., 2017). this is not in accordance with agus mulyanto (2011), who in their study stated the factors that influence teacher leadership in key learning, and that leadership qualities are superior if they have at least 8 to 9 of the best leadership qualities. one of these is always positive thinking. according to bandura, self-efficacy is the self-perception of how well the self can function in certain situations. bandura 1991 in (utami, hargono, & susilaningrum, 2016) stated that jurnal ners vol. 12 no. 2 oktober 2017: 267-277 276 individuals who have high self-efficacy would achieve better performance because these individuals have strong motivation, clear goals, stable emotions and the ability to deliver performance in relation to a successful activity or behaviour. individuals with high selfefficacy have the following characteristics: able to handle problems they face effectively, confident of success in dealing with problems or obstacles, problems are seen as a challenge that must be faced and not avoided, believe in the abilities they have, quickly rise from the failure they face and like to seek new situations. in this study, it obtained results that stated that most of the respondents have moderate self-efficacy up to high, but when viewed in relation to leadership skill, most are in the less and moderate category. this shows that high self-efficacy must be accompanied by other variables to equal good leadership skills. self-efficacy or beliefs about selfesteem can lead to overconfident attitudes. sri utami’s (2016) attitude about overconfident is that someone’s self-esteem can cause the person to become negligent to their duties and responsibilities; this causes a person's performance to no longer be maximised. job satisfaction improves the student’s skills in communication in midwifery practice. in accordance with frederick herzeberg (1959) cited by wirawan (2013), it states that the factors of job satisfaction are a good initial input to develop a model of job satisfaction. job satisfaction and job dissatisfaction are caused by several factors or dimensions that cause satisfaction or dissatisfaction in relation to work. if the perception of the employees or individuals towards the dimensions of the cause of job satisfaction is positive, then the individual will feel satisfied, and vice versa. job satisfaction does not improve the students' leadership skills in the midwifery practice. the results of this study are in accordance with the results of the metaanalysis by organ and ryan (1985) in wirawan (2013), who found no relationship between job satisfaction and leadership effectiveness. this is not in accordance with the opinion of lijan p.s. (2016), who stated that job satisfaction would lead to employee commitment. one of the characteristics of effective leadership is that a leader has a high commitment both to the task and to the organisation. according to benard m. bass (1990) cited by wirawan (2013), their study suggests a list of attributes that leaders possess as a result of the research conducted between 1948 and 1970 to do with high task motivation. someone with high job satisfaction will have a high commitment to work, innovate and be creative. these are all characteristics of an effective leader. although in the research study, job satisfaction cannot improve leadership skills, but the two variables should still be improved in the midwifery students. job satisfaction owned by the students must be accompanied by the commitment and high responsibility because high job satisfaction and is an important attitude in relation to leadership skills. task commitment improves the students skills in midwifery care. communication skills are important in building a successful relationship within both personal and professional relationships. with good communication skills, it will produce an effective communication process. relationships work well if built from a strong commitment to carry out promises, and how to respond to challenges. mardatillah (2016) explained that commitment always reflects a strong sense of belief, sincerity and desire always to be willing to sincerely develop, maintain and work for the benefit of the organisation without wishing to not belong to the organisation. task commitment alone cannot improve the students' leadership skills in the midwifery practice. this is not in accordance with benard m. bass (1990) cited by wirawan (2013), who suggests a list of attributes that leaders possess as a result of the research between 1948 and 1970 which has a firm stand against obstacles, responsibility for achieving results, and is task-oriented. these traits are characteristic of a person who commits to tasks. conclusions self-leadership supported by motivation is an important first step in shaping leadership and communication skills. selfleadership students will be able to improve their psychological empowerment, selfefficacy, job satisfaction, task commitment, communication skills and leadership skills. job satisfaction and high self-efficacy from the students must be followed by high task development of leadership and communication skill model... (sri utami et al.) 277 commitment as well. without task commitment, self-efficacy and the job satisfaction of the students cannot improve their communication skills. motivation strategy, self-leadership and task commitment are three important factors in improving the student’s skills in communication in the midwifery care practice. the development model of self-leadership and communication skills has been built based on motivation, selfleadership and task commitment through various channels. training using the selfleadership module can improve the ability of motivation, self-leadership strategies, job satisfaction, self-efficacy, psychological empowerment, task commitment, communication and student leadership skills. there needs to be an important effort to improve the student's learning motivation, giving opportunities to the student to develop their ability in developing a self-leadership strategy by giving them limited autonomy according to the tasks and responsibilities of the student, giving them responsibility in every activity to finish the tasks that are targeted and in the goals of the educational institution. the next researcher is expected to research about the other variables that influence selfleadership, leadership and communication skills. the model in this study can be used as an inspiration to develop the other variables to improve the communication and leadership skills. there needs to be further research done on the parameters and other indicators of the soft skills, such as relationship skills, presentation skills, public speaking skills and stress management. references blanchard k., susan f, laurie h, (2006) selfleadership and the one minute manager. harper collins: new york cheok san lam, e. r. e. o. (2012). enhancing employee outcomes: the interrelated influences of managers’ emotional intelligence and leadership style. leadership & organization development journal, vol. 33 is, 149– 174. hassan, a., maharoff, m., zainal abiddin, n., super, to, s., progress, a. r., … yadav, a. (2013). soft skills competency tool for secondary teachers in strengthening effective. university of portland, usa, 2(march), 146–155. https://doi.org/10.9790/7388-0251929 judy, c. b., box, p. o., & box, p. o. (2015). factors that influence effective communication of the youth enterprise development fund to the youth in kabianga division , kericho county , kenya, 5(4), 172–178. kuswara, h., apapun mata kuliah yang diasuh berikan muatan soft skills didalamnya. availabel at: www.frieyadie.com.htm. diakses tanggal 3 maret 2017. mardatillah, a. (2016) think and grow success by soft skill, solo: ary haeko sinergi persada (asp). puliam, m.g. (2008). skill employer seek. career corner, excelsior college. https://www.excelsior.edu/excelsior_ college/ publications/skills_ employers_ seek_16 pdf , diakses tanggal 10 april 2015 suryani, e.s. (2015) peningkatan kemampuan soft skills kepemimpinan dan komunikasi mahasiswa kebidanan melalui community based medical education (cbme). jurnal ilmiah kebidanan, vol. 6 no.1, pp.23–33. utami, s., & hargono, r. (2016). task commitment of midwife as an effort to enhance performance in early deviations detection on children growth and development based on self-leadership at working area of health agency surabaya indonesia, 4(4), 8–15. utami, s., hargono, r., & susilaningrum, r. (2016). midwives performance in early detection of growth and development irregularities of children based on task commitment, 5(4), 300–305. wanarto, guntur budi., s. (2014). soft skill dan perilaku kesehatan. surabaya: forikes. wirawan. (2013). kepemimpinan teori, psikologi, perilaku organisasi, aplikasi dan penelitian,. jakarta: pt raja grafindo persada. yutthana c. (2010). an examination of selfleadership performance mechanism model in thai private organization,. the journal of behavioral science, 5(1), 15–32. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru cara menurunkan keluhan sesak pasien tb paru (tintin s) 21 active cycle of breathing menurunkan keluhan sesak nafas penderita tuberkulosis paru (active cycle of breathing decrease dyspneu on tuberculosis patient) tintin sukartini*, sriyono*, iwan widia sasmita** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: tintin_bios@yahoo.com. ** stikes wiyata husada blitar abstract introduction: active cycle of breathing as one of the nursing intervention can solve respiratory problems (such as caused by tuberculosis). tuberculosis can cause fibrosis tissue in lung. fibrosis makes elasticity and compliance of lung decrease result in air ventilation and oxygenation disorder, so it will increase respiratory rate (rr) and dyspnea. the objective of this study was to analyze the effect of active cycle of breathing technique on reducing rr and dyspnea. method: a quasy experimental purposive sampling design was used in this study. there were 14 respondents who met to the inclusion criteria, divided into 7 respondents for intervention group and 7 respondents for control group. data were analyzed by using paired t-test, independent t-test, wilcoxon signed rank test and mann whitney u-test with significance levelα≤0.05. result: the result showed that active cycle of breathing had significance level on decreased rr (p=0.002) and dyspnea (p=0.014). discussion: it can be concluded that active cycle of breathing has effect decrease rr and dyspnea. it recommended to use active cycle of breathing continuously to decrease dyspnea and to enhance quality of life on tuberculosis patient. keywords: active cycle of breathing, dyspnea, rr, tuberculosis _______________________________________________________________________________ pendahuluan latihan penafasan merupakan tindakan keperawatan dalam penatalaksanaan pasien dengan masalah gangguan sistem pernafasan. termasuk didalamnya adalah latihan pernafasan active cycle of breathing. latihan pernafasan active cycle of breathing merupakan salah satu latihan pernafasan yang selain berfungsi untuk membersihkan sekret juga dapat mempertahankan fungsi paru (pyor and webber, 1998). latihan pernafasan ini dapat mengkoordinasikan dan dapat melatih pengembangan (compliance) dan pengempisan (elastisitas) paru secara optimal (pyor and webber, 1998), serta pengaliran udara dari dalam paru menuju keluar saluran pernafasan secara maksimal (falling, 1993). salah satu penyakit yang menimbulkan dampak pada penurunan elastisitas dan compliance paru yaitu penyakit tuberkulosis paru. kondisi tersebut berdampak pada peningkatan kerja otot pernafasan dan penurunan kemampuan ekspirasi maksimum (guyton dan hall, 1996). penurunan elastisitas dan compliance paru dapat pula menyebabkan ventilasi paru yang tidak maksimal dan jika tidak ditangani dengan maksimal dapat menyebabkan kecacatan paru dan bahkan atelektasis yang berujung pada kematian pasien (mulyono, 1997). penyakit tuberkulosis paru merupakan penyakit penyebab kematian pertama pada golongan penyakit infeksi (rahayu, 2007). di indonesia penyakit ini merupakan penyakit rakyat nomor satu dan sebagai penyebab kematian nomor dua setelah sistem sirkulasi (skrt, 1995 dan gusti, a., 2003). pada umumnya gejala respiratorik yang ditimbulkan setelah seseorang terkena tuberkulosis adalah batuk lebih dari 3 minggu, berdahak, batuk darah, nyeri dada, serta sesak nafas (alsagaaf dan mukty, 1995). pada perjalanan penyakit tuberkulosis selanjutnya menimbulkan kecacatan berupa destruksi atau fibrosis dari saluran nafas dan parenkim paru, dengan mailto:tintin_bios@yahoo.com jurnal ners vol.3 no.1april 2008 : 21-25 22 tintin sukartini manifestasi klinis berupa sesak nafas dan batuk (aida, 1996). who menyatakan bahwa 1/3 penduduk dunia telah terinfeksi kuman tuberkulosis. saat ini di negara maju diperkirakan setiap tahun terdapat 10–20 kasus baru setiap 100.000 penduduk dengan kematian 1-5 per 100.000 penduduk sedang di negara berkembang masih tinggi. who memperkirakan di indonesia setiap tahun terjadi 175.000 kematian akibat tuberkulosis dan terdapat 550.000 kasus tuberkulosis. data departemen kesehatan ri menyebutkan pada tahun 2001 di indonesia terdapat 50.443 penderita tuberkulosis paru dengan bta positif yang diobati (helmia dan lulu, 2004). jawa timur merupakan penyumbang kedua kasus tuberkulosis positif di indonesia setelah jawa barat. berdasarkan data dinas kesehatan jatim 2006, sedikitnya 39.371 penderita tb bta positif di surabaya, jumlah penderita tb sedikitnya 812 orang pada 2005 dan meningkat menjadi 3.005 pada 2006. penderita yang berobat di rsu dr soetomo surabaya sedikitnya 365 penderita (martiana, 2007). penyakit ini bermula saat individu menghirup basil tuberkulosis dan menjadi terinfeksi. bakteri menuju ke alveoli dan memperbanyak diri melalui jalan nafas. sistem imun tubuh merespons dalam bentuk respons inflamasi. fagosit (neutrofil dan makrofag) menelan banyak bakteri. massa jaringan baru yang disebut granuloma yang merupakan gumpalan jaringan granulasi yang berisi basil yang masih hidup dan yang sudah mati dikelilingi oleh makrofag membentuk dinding protektif. granuloma diubah menjadi massa jaringan fibrosa. bahan (bakteri dan makrofag) menjadi nekrotik, membentuk massa seperti keju, massa ini mengalami kalsifikasi, membentuk skar kolagenase (brunner dan suddarth, 2002). pembentukan jaringan ini mengakibatkan berkurangnya luas permukaan membran pernafasan total dan meningkatkan ketebalan membran pernafasan dan seringkali menyebabkan kerusakan jaringan paru yang hebat. penggunaan latihan pernafasan active cycle of breathing oleh penderita tuberkulosis diharapkan dapat menurunkan sesak nafas yang dialami. menurut penelitian yang dilakukan pardy et al. (1991) dalam cherniack (1991) menunjukkan latihan nafas yang dilakukan 15 menit akan meningkatkan ventilasi paru, namun latihan pernafasan active cycle of breathing ini belum diketahui pengaruhnya terhadap penurunan sesak nafas terhadap penderita tuberkulosis paru. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah quasy experimental purposive sampling pre-posttest design. sampel diambil sesuai dengan kriteria inklusi yang telah ditentukan, dengan sampel sebanyak 14 responden, dibagi menjadi kelompok perlakuan (diberikan intervensi latihan pernafasan active cycle of breathing setiap 1 kali / hari selama 10 hari, dengan durasi pertemuan 20-30 menit) dan kelompok kontrol (tanpa latihan pernafasan) dengan jumlah sampel masing-masing 7 orang. penelitian dilakukan selama bulan juni sampai dengan juli 2007. variabel independen dalam penelitian ini adalah teknik penafasan active cycle of breathing, sedangkan variabel dependen adalah penurunan sesak nafas yang ditandai dengan adanya hasil observasi respiration rate dan observasi terhadap keluhan sesak dengan menggunakan teknik fifteen-count breathlesness score. instrumen yang digunakan dalam penelitian ini adalah lembar observasi terhadap rr dan penilaian terhadap keluhan sesak. data yang diperoleh, dianalisis dengan menggunakan uji statistik mann whitney u test, wilcoxon signed rank test, paired t-test dan independent t-test, dengan derajat kemaknaan α<0,05. hasil tabel 1 menunjukkan bahwa terdapat perbedaan hasil post respiratory rate (rr) yang signifikan antara kelompok perlakuan dan kelompok kontrol dengan hasil uji stastistik independent t-test (p=0,008). pada kelompok perlakuan terjadi penurunan nilai rerata rr dari 28,86 menjadi 24,86. dengan menggunakan uji paired t-test diperoleh hasil dengan nilai signifikansi p=0,002 yang berarti terdapat perbedaan yang signifikan rr antara pre dan post. pada kelompok kontrol nilai rerata tidak menunjukkan perbedaan yang besar yaitu dari 27,43 menjadi 27,14 dengan hasil uji statistik paired t-test (p=0,356) yang berarti tidak cara menurunkan keluhan sesak pasien tb paru (tintin s) 23 terdapat perbedaan pre dan post terhadap rr kelompok kontrol. terdapat perbedaan hasil post latihan nafas active cycle of breathing yang signifikan terhadap keluhan sesak nafas antara kerlompok perlakuan dan kelompok kontrol dengan hasil uji statistik mann whitney u-test (p=0,010). pada masingmasing kelompok menunjukkan rerata penurunan nilai dari 3,00 menjadi 2,14. terdapat perbedaan pre post yang signifikan pada kelompok perlakuan dengan hasil analisis statistik wilcoxon signed rank test (p=0,014), sedangkan pada kelompok kontrol didapatkan nilai p=0,317 yang berarti tidak ada perbedaan pre post keluhan sesak pada kelompok kontrol (lihat tabel 2). pembahasan hasil penelitian pada kelompok perlakuan menunjukkan penurunan yang signifikan rr dan penurunan sesak pada penderita tuberkulosis paru setelah diberikan latihan nafas active cycle of breathing. penebalan dan pembentukan perkejuan sampai fibrosis akan mengakibatkan turunnya luas permukaan membran dan meningkatkan penebalan jaringan paru, hal ini mengakibatkan penurunan ventilasi udara yang masuk menuju paru-paru akibat turunnya compliance paru dan elastisitas paru (guyton dan hall, 1997). ventilasi diatur oleh kadar co2, o2 dan konsentrasi ion hidrogen (ph) dalam arteri. faktor paling penting dalam pengontrolan ventilasi adalah kadar co2 (karbia) dalam darah arteri. peningkatan paco2 mengakibatkan sistem kontrol pernafasan di otak meningkatkan frekuensi dan kedalaman pernafasan. usaha ventilasi yang meningkat mengeluarkan kelebihan co2 kronik dalam darah arteri. kemoreseptor pada arteri karotid dan aorta sensitif terhadap hipoksemia atau kadar o2 arteri yang rendah. jika terjadi hipoksemia reseptor ini memberi tanda pada otak untuk meningkatkan frekuensi pernafasan (perry dan potter, 2005). tabel 1. respiratory rate (rr) pada penderita tuberkulosis di ruang paru laki rsu dr. soetomo no. perlakuan kontrol perlakuan kontrol pre post pre post post post mean 28,86 24,86 27,43 27,14 24,86 27,14 sd 1,574 1,574 0,976 1,069 1,574 1.069 paired t-test (p=0,002) paired t-test (p=0,356) independent t-test (p=0,008) tabel 2. keluhan sesak pada penderita tubekulosis di ruang paru laki rsu dr. soetomo no. perlakuan kontrol perlakuan kontrol pre post pre post post post 1 sedang ringan sedang sedang ringan sedang 2 sedang ringan sedang ringan ringan ringan 3 sedang ringan sedang sedang ringan sedang 4 sedang ringan sedang sedang ringan sedang 5 sedang ringan sedang sedang ringan sedang 6 sedang ringan sedang sedang ringan sedang 7 sedang ringan sedang sedang ringan sedang mean 3,00 2,14 3,00 2,14 2,14 2,14 sd 0,000 0,378 0,000 0,378 0,378 0,378 wilcoxon signed rank test (p=0,014) wilcoxon signed rank test (p=0,317) mann whitney u-test (p=0,010) keterangan: p = signifikansi sd = standar deviasi mean = rerata jurnal ners vol.3 no.1april 2008 : 21-25 24 latihan pernafasan active cycle of breathing dapat mengembalikan kepada nafas yang normal serta memperbaiki ventilasi dan oksigenasi (falling, 1993). selain itu latihan pernafasan dapat meningkatkan inflasi alveolar maksimal serta merelaksasikan otot, menghilangkan ansietas, menyingkirkan pola aktivitas otot pernafasan yang tidak terkoordinasi, melambatkan frekuensi dan mengurangi kerja bernafas (brunner dan suddarth, 2002). otot pernafasan yang dilatih memungkinkan peningkatan volume pernafasan sehingga meningkatkan ventilasi paru. ventilasi paru yang meningkat menyebabkan volume udara yang menuju ke paru dan yang meninggalkan paru juga mengalami peningkatan. hasil akhir menunjukkan pasokan o2 dan pengeluaran co2 yang semakin optimal, sehingga upaya fisiologis tubuh untuk meningkatkan pernafasan dalam memenuhi kebutuhan oksigenasi dengan meningkatkan frekuensi menjadi berkurang. keluhan sesak ini terjadi sebagai akibat kurang terpenuhinya sirkulasi paru karena terhambatnya compliance dan elastisitas paru serta terdapatnya sekret yang menutupi saluran pernafasan. pemberian latihan pernafasan active cycle of breathing dapat meningkatkan sirkulasi paru pada tahap breathing control dengan mengontrol pernafasan seperti orang normal. pada tahap thoracic expansion exercise dapat mengembangkan jaringan paru dan meningkatkan volume paru. forced expiration technique dapat mencegah terjadinya bronkospasme saluran pernafasan dan dapat mengeluarkan sekret yang menutupi saluran pernafasan (pyor and webber, 1998). pada orang sehat, mampu menyelesaikan hitungan dengan hanya satu kali tarikan nafas saja. namun tidak demikian dengan penderita tuberkulosis, karena proses fibrosis dan pembentukan jaringan kolagen menyebabkan pengembangan serta pengempisan paru terhambat. penderita juga mengalami penyempitan pada saluran pernafasan akibat basil tuberkulosis pada saluran pernafasan yang mengakibatkan gangguan sirkulasi udara yang menuju paru pasokan o2 dalam tubuh berkurang. ketika diminta untuk menyelesaikan hitungan secara cepat, membuat penderita harus menahan nafas sebentar sehingga tidak ada o2 baru dalam rentang 7-8 detik. hal ini yang mengakibatkan penderita biasanya menarik nafas lagi di pertengahan penghitungan. latihan nafas active cycle of breathing yang dilakukan penderita tuberkulosis paru dapat meningkatkan sirkulasi paru serta pengembangan paru yang lebih optimal, teknik pernafasan ini dapat mencegah bronkospasme pada saluran pernafasan sehingga tetap terbuka walaupun pada saat ekspirasi. pada fase thoracic expansion exercise pengembangan paru lebih optimal sehingga pada saat diukur dengan menggunakan teknik fifteen-count breathlesness score yaitu kemampuan menghitung angka 1-15 dalam waktu 7-8 detik lebih meningkat yang mencerminkan semakin menurunnya keluhan sesak pada penderita. setelah selesai melakukan latihan pernafasan penderita juga menyatakan secara spontan dapat bernafas dengan lega. simpulan dan saran simpulan teknik pernafasan active cycle of breathing mampu menurunkan respiratory rate (rr) karena terjadi peningkatan elastisitas dan compliance paru yang pada akhirnya meningkatkan ventilasi paru, dimana pengeluaran co2 dan pemasukan o2 meningkat. penurunan keluhan sesak penderita tuberkulosis lebih cepat dicapai dengan latihan nafas active cycle of breathing. hal ini karena terjadi pengeluaran mukus dari saluran pernafasan serta peningkatan pemasukan o2. saran hasil penelitian ini, peneliti menyarankan agar latihan nafas active cycle of breathing hendaknya dilakukan secara kontinyu pada penderita tuberkulosis paru untuk mengurangi gangguan pernafasan dan meningkatkan kualitas hidup. kepustakaan cara menurunkan keluhan sesak pasien tb paru (tintin s) 25 aida, n. 1996. kekerapan hiperaktivitas bronkus pada bekas tb paru di rsup persahabatan jakarta. jakarta: bagian pulmonologi fkui jakarta, hlm. 16. alsagaff dan mukty. 1995. dasar-dasar ilmu penyakit paru. surabaya: airlangga university press, hlm. 7,11,13-15,7392. brunner dan suddarth, 2002. buku ajar keperawatan medikal bedah. edisi 8 vol.1. alih bahasa oleh agung waluyo. jakarta: egc, hlm. 584-589, 671. cherniack, n.s. 1991. chronic obstructive pulmonary disease 1 st edition, usa: saunders company, pp. 500-534. falling, j. 1993. principles and practice of pulmonary rehabilitation, philadelphia: wb saunders, hlm. 176. gusti, a. 2003. kekerapan tb paru pada pasangan suami istri penderita tb paru yang berobat di bagian paru rsu adam malik. skripsi tidak dipublikasikan. medan: universitas sumatra utara, hlm. 57-68. guyton dan hall. 1996. buku ajar fisiologi kedokteran. alih bahasa oleh brahm u. pendit. jakarta: egc, hlm. 598, 603-604, 671, 676. helmia dan lulu. 2004. buku ajar ilmu penyakit paru. surabaya: graha masyarakat ilmiah kedokteran universitas airlangga, hlm. 10-21. martiana. 2007. daftar 10 penyakit terbanyak (september 2007), (online), (http://www.surabayaehealth.org., diakses tanggal 17 april 2007, jam 09.00 wib). mulyono, d. 1997. rehabilitasi pada penderita penyakit paru obstruktif menahun. cermin dunia kedokteran, 129, 33-37. perry dan potter. 2005. fundamental keperawatan. alih bahasa oleh yasmin asih. jakarta: egc, hlm. 791. pyor and webber. 1998. physioterapy for respiratory and cardiac problem, eidenburgh: churcill livingston, pp. 139-145. rahayu. 2007. jatim penyumbang tb ke-2 di indonesia, (online), (http://www.jatim.co.id., diakses tanggal 14 april 2007, jam 20.00 wib). http://www.surabaya-ehealth.org/ http://www.surabaya-ehealth.org/ http://www.jatim.co.id/ http://e-journal.unair.ac.id/jners | 37 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.6746 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research social care in improving self-concept of leprosy patients nur hamim1, mariani mariani1, and sismulyanto sismulyanto2 1sekolah tinggi ilmu kesehatan hafshawaty zainul hasan, probolinggo, east java, indonesia 2sekolah tinggi ilmu kesehatan qomarul huda mataram, west nusa tenggara, indonesia abstract introduction: many infectious diseases occur in developing countries with low socioeconomic conditions. one such is leprosy. leprosy is common in developing countries as a result of the country's limited ability to provide adequate services, including among some health workers. such health workers are lacking knowledge and understanding of the false beliefs of leprosy and its resulting disabilities. the purpose of this research is to formulate a social care model in improving self-concept of leprosy patients in probolinggo district. methods: this research used explanatory research survey method with a crosssectional approach. the sample was 56 respondents. the variables were family support, social care and self-concept. the data were collected using a questionnaire modelled on liandi, richard h's concept and the tennessee selfconcept scale. the data were then analyzed by partial least squares (pls) to test the hypothesis and form the empirical model. results: the results showed social care was able to improve the self-concept of leprosy patients (t=5.800, t >1.96). conclusion: therefore, it is expected that nurses continuously synergize in maintaining social care conditions with the community in order to improve the self-concept of leprosy patients. article history received: september 7, 2018 accepted: april 21, 2020 keywords leprosy patients; self-concept; social care contact nur hamim  hnurhamim@gmail.com  nursing study program of hafzhawaty zainul hasan probolinggo cite this as: hamim, n., mariani, m., & sismulyanto, s. (2020). social care in improving self-concept of leprosy patients. jurnal ners, 15(1), 37-41. doi:http://dx.doi.org/10.20473/jn.v15i1.6746 introduction infectious diseases are common in developing countries with low socioeconomic conditions. one such is leprosy (montaya, 2010). leprosy is common in developing countries as a result of the country's limited ability to provide adequate services in the areas of health, education, and socioeconomic welfare in the community; leprosy is still feared by the community, among families, and even including some health workers (lucinda, 2014). the world health organization (who) (2013) indicates that indonesia has 17,012 cases of leprosy, although its leprosy prevention is better, as indicated by being ranked 4th after india, brazil and nepal. as of december 2015, in the preceding ten years, indonesia succeeded in reducing leprosy morbidity by 85% from 107,271 people to 17,012 people (who, 2013). from these data, east java is the province with the most leprosy patients, with the number of patients reaching 4,293 cases, with patients who have a lifelong disability as many as 184 and, childhood sufferers as many as 117 in the region of madura, tapal kuda and pantura (ministry of helath (moh), 2015). the case of leprosy patients in probolinggo regency ranks seventh after tuban, while the first order is sampang regency (ministry of helath (moh), 2015). leprosy patients will experience body image or present their individual self-image. illness and serious injury can damage self-concept, including disability. adapting the behavior of illness can affect a person's feelings about their identity (hobfolf, 2006). threats to body image as well as self-esteem are often accompanied by feelings of shame, inadequacy and guilt. in a healthcare setting, people sometimes have to adjust to a situation that threatens their self-esteem, (hasselhorn, 2010) and leprosy patients will experience some problems, both physically, psychologically, socially, and economically (misch, 2010). a preliminary survey conducted in february 2016 from medical records at glagah puskesmas https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ n. hanim et al. 38 | pissn: 1858-3598  eissn: 2502-5791 probolinggo district showed that there were 34 patients recorded from 2012 to 2015 and that most of the patients (41.03%) had experienced disability of busier pausi (pb), while those with disability level of multi basiler (mb) was as much as 58.97%. from the results of field observations with the help of health cadres from glagah puskesmas, researchers found that leprosy patients feel their self-esteem (selfconcept) is very low. patients isolate themselves from society, even families. the main goal is for patients to socialize to the community to improve their selfconcept through s social approach. social care in the provision of health services needs to be done (curtis, van der heijden,kümmerlin, van dam, & van der schoot, 2009) so that,hopefully, the family is not just resigned to the state of patients who also isolate themselves from the family.thus the nurse must also attend the family and patient to provide health education. the purpose of this research is to formulate a social care model in improving the selfconcept of leprosy patients. materials and methods this research used explanatory research survey method with a cross-sectional approch. the sample was 56 respondents. the variables in this study were family support, social care and self-concept. the data were collected by three kinds of instruments. the family support was measured by questionnaireadopted from liandi (2011). the social care using questionnaires whas developed by researchers based on richard h's concept (2015). the tennessee self-concept scale (fitts, 1965) was used for measuring self-concept. the analysis technique used is a model based on variance or componentbased, known as partial least squares (pls). pls is a powerful analysis, since it does not assume that data should be of a certain scale, can work with a small sample, and can also be used to confirm the theory (ghozali, 2009). this study was approved by the hafshawaty pesantren zainul hasan institute of table.1 respondents’ characteristics of leprosy patients in probolinggo district. variable n ( % ) gender male female 32 24 57 43 age (years old) 20 – 30 31 – 40 >40 11 18 27 20 32 48 marital status married not married 35 21 62 38 duration of suffering (years) 1-5 6-10 >10 24 19 13 43 34 23 table. 2 family support to leprosy patients in probolinggo district. no family support category good enough low total n % n % n % n % 1 empathy 6 10 25 45 25 45 56 100 2 encouragement 6 10 25 45 25 45 56 100 3 facilitative 7 12 24 43 25 45 56 100 4 participatory 9 16 23 41 24 43 56 100 table. 3 social care of leprosy patients in probolinggo district social care category good enough low total n % n % n % n % opportunity 6 10 25 45 25 45 56 100 freedom 6 10 25 45 25 45 56 100 attention 7 12 24 43 25 45 56 100 table 4. self-concept in leprosy patients in probolinggo district self-concept category high medium low total n % n % n % n % self-image 6 10 25 45 25 45 56 100 self-esteem 7 12 24 43 25 45 56 100 role 9 16 23 41 24 43 56 100 jurnal ners http://e-journal.unair.ac.id/jners | 39 health sciences, under report no. kepk/001/stikes-pzh/ii/2017. results the results showed respondents’ characteristics consist of gender, age, education level, marital status and time of leprosy diagnozed. according to table 1, most respondents were male (57%, 32 respondents), 27 % were over 40 years old, 62% of them were married, and had suffered from leprosy for 1-5 years (43%). table 2 explains about family support. most of the family have low empathy for leprosy patients (45%), low encouragement of leprosy sufferers (45%), provide less facilitation for patients (45%) and also low participation (43%) to leprosy patients. based on table 3, social care can be explained asdominated by low levels in all domain. the respondents received low opportunity, freedom and attention (45%). table 4 decribes the leprosy patient’ self-concept. selfimage category was 45% in moderate scale, and a mostly low scale for the self-esteem (45%) and role dimensions (43%). table 5 shows that the indicator of the family support (encouragement and facilitative) was not significant (p value > 0.05), so the indicator should be discarded and only family support variable 1 is significant as an indicator of the family support variable. all indicators of the social care were significant (p value <0.05), so that all indicators are maintained as indicators of social care variables. indicator of self-concept variable (self-role and self-ideal) was not significant (p value > 0.05), so the indicator must be discarded and only selfimage, self-esteem and personal identity were significant and maintained in the model. inner model test result table 6 explains the path coefficient of paramaters based on pls test. individual reflective size is said to be valid if it has a loading correlation loading with the latent variable construct measured, ≥ 5%, or the tstatistic value must be greater than 1,96 (two-party test) at the significance level α = 5%. table 6 shows that family support influences the self-concept of leprosy patients (t=4.953), family support affects social care (t=3.960), and social care influences the self-concept of leprosy patients (t=6.285). the self-concept model of leprosy patients is composed of three variables: family support, social care and self-concept. self-concept in leprosy patients is directly affected by family support and social care. self-care conditions of leprosy patients can be reinforced indirectly through social care channels reinforced by family support (hamim, 2015). based on the outer weights of the outer model test, there are several indicators of each latent variable that are not significant, so it must be reconstructed first to obtain the ideal model. based on table 7, the results of the reconstruction of the leprosy self-concept model developed from three main variables, including family support, social care and self-concept, show the self-concept of lepers is directly influenced by family support and social care. among family support for the latent variable is empathy, while the conditions of leprosy self-care on the latent variable, which is the main determinant, are self-image, self-esteem and role, which can be strengthened indirectly through social care channels with the latent variables among them, freedom. and attention, reinforced by family support. the result showed that the model formed from this prediction has good predictability relevance. based on q2 interpretation, a construct has a good predictor relevance when it has a value of q2> 0 (chin, 1998). in this model q2 was 0.459 (q2> 0). discussion the influence of family support on self-concept of leprosy patients based on the results of research, it shows the influence of family support on the self-concept of leprosy patients with a t-statistics value of 4.718 (t >1.96). there is influence of family support to self concept of leprosy patients as all four types of social support (i.e., emotional, instrumental or real support, information support, and assessment support) are involved in the interactive process between the social network of individuals (i.e, family and peers) and individuals with heart failure in maintaining self-care behavior that improves health and wellbeing. however, further research is needed, in particular longitudinal and experimental design, to determine the effectiveness of social support on self-care behavior in individuals with heart failure, as this review reveals most of the cross-sectional, correlational research limits the ability to infer causality (lucinda, 2014). thus, the important role of family support is to change the mindset of lepers and other people to bring about the quality of a better work life. these conditions will cause the desire of the patient to socialize with the surrounding environment and includes activities that exist within each household, . this is directed to improve working life conditions, which can raise the spirit of the sufferers in carrying out the task of achieving a normal life. similarly, people around the patient will feel an integral part of their everyday life. the influence of family support on social care the condition of the influence of family support on social care has t-statistics of 3.977 (t > 1.96). thus, there is influence of family support to social care. the condition of good support will have an impact on good culture so that the patient's activity can be improved maximally; the nurse will also benefit from the positive activity. therefore, all components in the society are expected to maintain the existing conditions so that society will continue to be part of table 5. values of outer weights in outer model of self-concept of leprosy patients variable original sample (o) sample mean (m) standard deviation (stdev) t statistic p value information empathy 0.999 0.897 0.115 8.697 0.000 significant encouragement 0.086 0.085 0.294 0.295 0.769 not significant facilitative -0.164 -0.162 0.206 0.799 0.425 not significant opportunity 0.519 0.520 0.108 4.800 0.000 significant freedom 0.323 0.299 0.101 3.205 0.001 significant attention 0.338 0.338 0.095 3.572 0.000 significant participation 0.371 0.361 0.094 3.937 0.000 significant self-image 0.416 0.406 0.079 5.238 0.000 significant self-esteem 0.293 0.277 0.068 4.312 0.000 significant self-role -0.090 -0.083 0.093 0.964 0.336 not significant personal identity 0.542 0.518 0.076 7.108 0.000 significant self-ideal 0.136 0.120 0.122 1.115 0.266 not significant table 6. t-statistic value on inner model of selfconcept of leprosy patients direct and indirect causality relationships between exogenous and endogenous variables path parameter coefficient sample mean (m) standard dev t statistic p value information the influence of family support (x1) on self-concept (y1) 0.448 0.447 0.091 4.953 0.000 significant the influence of family support (x1) on social care (x2) 0.344 0.393 0.087 3.960 0.000 significant the influence of social care (x2) on self-concept (y1) 0.549 0.536 0.087 6.285 0.000 significant n. hanim et al. 40 | pissn: 1858-3598  eissn: 2502-5791 the initial conditions expected by the patient (friedman, 2013). social services are divided into two groups. first is social services, which are very complicated and comprehensive and so difficult to determine identity (curtis et al., 2009). these services include education, social assistance in the form of money by the government, medical care and public housing. the second is clear social service scope and its services, although these are always changing. this service can stand on its own, for example child welfare and family welfare, but it can also be a part of other institutions, such as social work in schools, medical social work, social work in public housing and social work in industry. social service in the broad sense is any service intended to improve the social welfare of human, while, in the narrow sense, it is the service given to some people who are less fortunate (desi, 2011). thus, in a synergy,the better the support of the family will have an impact on the overall social attention, because how can social attention can be maximized if there is no support from the family on the patient. the effect of social care on the self-concept of leprosy patients the results showed the influence of social care on the self-concept of leprosy patients. table shows the influence of social care on self-concept of leprosy patients with a t-statistics score of 5.800 (t >1.96). there is influence of social care to self-concept of leprosy patients. the concept of self defines all ideas, thoughts, feelings, and beliefs that involve individual knowledge about self and affects the relationship with others (stuart & sundeen, 2006). self-concept consists of self-image, self-esteem, role of self, selfidentity and self-ideal, while the factor that influences the formation and development of self-concept is age. self-concept is formed along with increasing age whereby this difference is more related to development tasks. education also influences selfconcept. a person with a high level of education improves his achievement. if his achievement increases, then his self-concept will change. socioeconomic status affects the acceptance of others toward him. family relationships of a person figure 1. self-concept model of leprosy patients based on path analysis before reconstruction figure 2. test result model after reconstruction jurnal ners http://e-journal.unair.ac.id/jners | 41 who has a close relationship with his or her family members will identify with others and want to develop the same personality pattern, if this is a same-sex character it will develop a self-concept worthy of his sex. other people make us know ourselves by knowing others first. how another knows ourself will contribute to form self-concept. individuals are accepted by others, respected and liked because of their condition and individuals will tend to be respectful and accept him. conversely, when others always underestimate themselves, blame, and reject, they will tend to not like him. conclusion there is influence of family support to the self concept of leprosy patients. the findings show the influence of family support on the self-concept of leprosy patients. the better the family support, the higher the self-concept of leprosy patients. there is influence of family support to social care. from the results of analysis, it shows the influence of family support to social care, the better the family support, the better the social attention of society to leprosy patients.there is influence of social care to selfconcept of leprosy patients. results analysis shows an influence of social care on self-concept of leprosy patients; the better social care or social attention of people to leprosy patients, the higher the self-concept of leprosy patients. references chin, w. w. (1998). the partial least squares aproach to structural equation modeling. modern methods for business research. curtis, l. b. van der heijden a. kümmerling k. van dam, e. van der schoot, m. e.-b. (2009). unit cost of health and social care, university of kent canterbury. desi, r. . (2011). dukungan psikososial keluarga penderita kusta di kabupaten pekalongan. jurnal.unimus.ac.id. friedman. (2013). keperawatan keluarga: teori, dan praktek. edisi 3. jakarta: egc. ghozali, i. (2009). model persamaan struktural konsep dan aplikasi denganprogram amos vers 5.0. semarang: badan penerbit–undip. hamim, n. (2015). caring behaviors nurse based on quality of nursing work life and self-concept in nursing nurses in hospital. international journal of development research october 2015, 5 (10), 5803–5808. hasselhorn, h. m. (2010). the impact of social support upon intention to leave among female nurses in europe: secondary analysis of data from the next survey. international journal of nursing studies, 4(47), 434–445. hobfolf, s. e., london, p. (2006). the relationship of self-concept and social support to emotional distress among women during war. journal of social and clinical psychology 4.2, june 2006, 4.2, 189–203. https://doi.org/https://doi.org/10.1016/j.womb i.2013.09.004 lucinda, j. g., & j. s. g. (2014). social support and selfcare behaviors in individuals with heart failure: an integrative review. iinternational journal of nursing studies international journal of nursing studies february 2014, 51(2), 320–333. ministry of helath (moh), r. (2015). buku pedoman nasional pengendalian penyakit penyakit kusta.direktorat jendral pengendalian penyakit dan penyehatanlingkungan departemen kesehatan ri. misch, e. a. (2010). microbiol. mol. biol. rev. journal american society for microbiology (asm), 74(589– 620). montaya d. (2010). learning from leprosy : insight into the human innate immune response. advance in immunology, 105, 1–24. stuart & sundeen. (2006). buku saku keperawatan. edisi3.jakarta : egc. who. (2013). seventh expert committee.leprosy elimination.retrieved may 4, 2013, from http://www.who.int/lep/resources/expert/en/ind ex2.html. table 7. t-statistic value of inner model selfconcept of leprosy patients after reconstruction direct and indirect causality relationships between exogenous and endogenous variables path parameter coefficient sample mean standard dev t statistic p value information the influence of family support (x1) on self -concept (y1) 0.441 0.433 0.093 4.718 0.000 significant the influence of family support (x1) on social care (x2) 0.344 0.363 0.086 3.977 0.000 significant the influence of social care (x2) on self concept (y1) 0.556 0.563 0.096 5.800 0.000 significant 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 efek limitasi konsumsi garam dan kopi pada lansia penderita hipertensi (the effect of coffee and salt on elderly restriction with hypertension) joni haryanto*, marini** * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. prof. dr.moestopo 47 surabaya. telp/fax: (031) 5012496, e-mail: jurnalners_psikunair@yahoo.com ** sekolah tinggi ilmu kesehatan icme bali abstract introduction: one of elderly’s problem in health center karambitan ii tabanan bali was hypertension. elderly usually likes or has a habit consuming coffee and salty food everyday. this study was used a pre-experimental one group pre-post test design. the objective of this study was to analyze the effect of consumption limitation of coffee and salt on vital sign in elderly with hypertension. the subjects were elderly with hypertension which stay with their family who lived at karambitan ii tabanan bali health center region. method: there were 28 samples which recruited by using total sampling who met to the inclusion criteria. data were analyzed by using wilcoxon sign rank test, with significance level α≤0.05. result: the result showed that there was an effect of consumption limitation of coffee and salt on systolic blood pressure (p=0.00000), diastolic blood pressure (p=0.00000) and heart rate (p=0.00000). discussion: it can be concluded that there was an effect of consumption limitation of coffee and salt to decrease blood pressure and heart rate in elderly with hypertension who lived at karambitan ii tabanan bali health center regio. community nurses should give health education for elderly in public health center periodically for reducing incidence of hypertension. keywords: salt, coffee, elderly, hypertension pendahuluan masyarakat bali pada umumnya gemar mengkonsumsi makanan tinggi garam dan minum kopi. kegemaran mengkonsumsi makanan yang mengandung tinggi garam dan minum kopi ini akan berdampak pada kerja jantung dan ginjal. kopi mengandung kafein yang dapat meningkatkan kontraksi jantung dan dapat meningkatkan risiko cidera (gordon, 2002). pembatasan garam dapat menimbulkan keseimbangan volume darah dan memperingan kerja ginjal, sehingga sekresi renin minimal dan disertai penurunan tekanan darah (kaplan, 2002). namun pengaruh pembatasan konsumsi garam dan kopi pada lansia penderita hipertensi terhadap perubahan vital sign masih belum jelas. data the national health and nutrition examination survey ii, menunjukkan bahwa 54,3% lansia dengan usia 65-74 tahun menderita hipertensi. di puskesmas karambitan ii tabanan bali terdapat 70 lansia yang berusia lebih dari 60 tahun, dimana 28% mengalami hipertensi dengan tekanan darah lebih dari 160/95 mmhg. hipertensi pada lansia lebih berisiko menimbulkan komplikasi penyakit arteri koroner, gagal jantung kongestif, stroke dan kematian (duthie and katz, 1998 dalam chintanadilok, et al., 2001). lansia pada umumnya mengalami peningkatan kekakuan arteri yang disebabkan oleh penurunan elastisitas jaringan penghubung dan kejadian arteriosklerosis (black, 1999). pembatasan minum kopi dan konsumsi garam dapat menjadi salah satu penanganan nonfarmakologis untuk menurunkan tekanan darah pada lansia dengan hipertensi. hipertensi pada lansia apabila tidak segera dilakukan tindakan untuk menurunkan tekanan darah akan menimbulkan komplikasi. komplikasi yang sering adalah stroke. kondisi stroke pada lansia memerlukan perawatan di rumah sakit yang menghabiskan banyak biaya dan perhatian mailto:jurnalners_psikunair@yahoo.com keluarga, sehingga waktu bekerja keluarga berkurang yang dapat menurunkan produktivitas ekonomi keluarga. stroke yang tidak segera diatasi dapat menimbulkan kecacatan bahkan kematian. pemberian pengobatan pada lansia dengan hipertensi bukan saja menimbulkan efek medis namun tidak jarang menimbulkan efek samping. dengan demikian tindakan nonfarmakologis seperti pembatasan konsumsi kopi dan garam dalam diet merupakan salah satu alternatif penanganan hipertensi pada lansia. tindakan preventif tersebut tidak menimbulkan efek samping, namun memerlukan pengawasan ketat. lansia juga dianjurkan melakukan latihan dengan intensitas sedang, yaitu antara 50-69% dari denyut jantung maksimal (izzo and black, 1999). hasil studi pendahuluan yang dilakukan peneliti menunjukkan latihan yang dilakukan di wilayah puskesmas karambitan ii tabanan bali masih belum cukup untuk mendapatkan peningkatan kesehatan yang berarti. pembatasan garam yang cukup lebih efektif menurunkan tekanan darah dari pada latihan yang berat (higashi, et al., 1999). pembatasan konsumsi garam dan kopi dapat dipilih sebagai alternatif menurunkan tekanan darah bagi lansia dengan hipertensi. pembatasan konsumsi garam dan kopi ini mudah dilakukan dan tidak memerlukan tempat yang luas, namun memerlukan komitmen yang tinggi sehingga para lansia dapat melakukannya setiap saat secara mandiri. merujuk pada kondisi tersebut di atas maka peneliti tertarik untuk mengetahui pengaruh pembatasan konsumsi garam dan kopi pada lansia yang menderita hipertensi terhadap vital sign di wilayah puskesmas karambitan ii tabanan bali. tujuan dari penelitian ini adalah untuk mempelajari pengaruh pembatasan konsumsi garam dan kopi pada penderita hipertensi terhadap vital sign di wilayah puskesmas karambitan ii tabanan bali. bahan dan metode penelitian ini menggunakan desain penelitian pre experimental one group prepost test. populasi adalah penderita hipertensi lansia di wilayah puskesmas karambitan ii tabanan bali, dengan besar sampel 28 yang diperoleh berdasarkan teknik total sampling. variabel independen dalam penelitian ini adalah pembatasan konsumsi garam dan kopi, sedangkan variabel dependen adalah vital sign yang meliputi tekanan darah (sistolik dan diastolik) dan nadi. penelitian ini dilakukan di wilayah puskesmas karambitan ii tabanan bali pada agustus sampai dengan september 2007. subjek penelitian sebelum diberikan perlakuan akan dilakukan pre test dengan mengukur tekanan darah awal dan frekwensi nadi. intervensi yang diberikan berupa pembatasan konsumsi garam dan kopi selama 2 minggu. pembatasan garam dapur diberikan sebanyak 1,25 gram setiap hari dan sama sekali tidak mengkonsumsi kopi selama 2 minggu, kemudian dilakukan post test berupa pengukuran tekanan darah dan frekwensi nadi di akhir minggu ke-2 perlakuan. instrumen yang digunakan dalam penelitian ini adalah manometer air raksa, stetoskop dan jam tangan. data yang diperoleh dianalisis dan diuji dengan menggunakan uji statistik kolmogorov smirnoff untuk mengetahui distribusi normal atau tidak, apabila skala data berdistribusi normal digunakan uji statistik independent ttest sedangkan apabila skala data tidak berdistribusi normal digunakan uji statistik wilcoxon signed rank test dengan derajat kemaknaan α≤0,05. hasil distribusi lansia yang menjadi sampel berdasarkan lama minum kopi 10-20 tahun sebanyak 32,14% dan yang lebih dari 20 tahun 67,86%. distribusi lansia berdasarkan frekwensi minum kopi perhari 21,43% satu gelas perhari, 28,57% minum kopi 2-3 gelas per hari dan sisanya 50% minum kopi lebih dari 3 gelas perhari. tabel 1 menunjukkan bahwa pengaruh pembatasan konsumsi garam dan kopi pada tekanan darah sistolik, diastolik dan frekwensi nadi lansia penderita hipertensi. hasil dari 28 responden menunjukkan 82,14% mengalami penurunan tekanan darah sistolik, 14,29% tidak mengalami perubahan tekanan darah sistolik dan 3,57% malah terjadi peningkatan. tekanan darah sistolik mengalami penurunan yang bermakna pada lansia penderita hipertensi setelah pembatasan konsumsi garam dan kopi yang ditunjukkan dengan hasil uji statistik wilcoxon signed rank test p=0,00000. pada tekanan darah diastolik menunjukkan 75% mengalami penurunan, 25% tidak mengalami perubahan tekanan darah diastolik dan tidak terdapat kejadian peningkatan tekanan darah diastolik. terdapat penurunan yang bermakna pada tekanan darah diastolik lansia penderita hipertensi setelah pembatasan konsumsi garam dan kopi yang ditunjukkan dengan hasil uji statistik wilcoxon signed rank test yang ditunjukkan dengan hasil uji statistik wilcoxon signed rank test p=0,00000. frekwensi nadi responden menunjukkan 71,43% mengalami penurunan frekwensi nadi dan 28,57% tidak mengalami perubahan frekwensi nadi. terdapat penurunan yang bermakna pada frekwensi nadi lansia penderita hipertensi setelah pembatasan konsumsi garam dan kopi yang ditunjukkan dengan hasil uji statistik wilcoxon signed rank test p=0,00000. pembahasan berdasarkan hasil penelitian menunjukkan adanya perbedaan yang signifikan baik tekanan darah sistolik maupun tekanan darah diastolik antara sebelum dan sesudah dilakukan pembatasan konsumsi garam dan kopi. hal tersebut disebabkan oleh sodium residu yang dapat mengikat air dan berakibat peningkatan volume dalam pembuluh darah. kadar sodium juga menimbulkan stres ginjal yang dipengaruhi oleh faktor usia, aktifitas saraf simpatis dan penurunan respons nitric oxide (higashi, et al., 1999 dan izzo and black, 1999 dalam kaplan, 2002). peningkatan sodium darah akan meningkatkan aktifitas saraf simpatis dan membuat kontraksi otot jantung meningkat. pada ginjal dapat meningkatkan sekresi renin, akibatnya liver akan memproduksi angiotensinogen dan diubah dalam darah menjadi angiotensin i, yang akan menstimulasi kelenjar adrenal untuk mensekresi aldosteron dan kerja aldosteron dalam tubulus distal ginjal adalah re-uptake sodium dan air yang dapat meningkatkan volume dalam vaskuler. akibat lain di ginjal dapat menurunkan aliran darah ginjal dan rerata filtrasi glomerulus. asupan garam lebih berperan dalam peningkatan tekanan darah dari pada asupan air, karena air secara normal diekskresi oleh ginjal hampir secepat asupannya, tetapi sodium tidak diekskresi begitu mudah. residu sodium secara tidak langsung meningkatkan volume cairan ekstraseluler. apabila tubuh kelebihan sodium, osmolalitas cairan akan meningkat dan akan merangsang pusat haus, yang membuat orang minum lebih banyak untuk mengencerkan sodium tubuh. pada hipofise posterior, peningkatan osmolalitas darah dapat menstimulasi pengeluaran hormon antidiuretik, yang dapat mereabsorpsi air dalam jumlah besar di tubulus ginjal, sehingga mengurangi volume urine dan peningkatan volume ekstraseluler. dari berbagai kondisi tersebut, maka garam dapat meningkatkan tekanan darah, sehingga sangat penting untuk membatasi asupan garam dalam diet lansia yang mengalami hipertensi. tabel 1. tekanan darah sistolik, diastolik dan frekwensi nadi pre test dan post test pembatasan konsumsi garam dan kopi pada lansia penderita hipertensi di wilayah puskesmas kerambitan ii tabanan bali, 2007 tekanan darah sistolik (mmhg) tekanan darah diastolik (mmhg) frekwensi nadi (x/menit) pre post pre post pre post mean 153 147.5 92.75 88.25 78.8 76.5 wilcoxon signed rank test p=0,00000 p=0,00000 p=0,00000 keterangan: p = signifikansi pembatasan konsumsi kopi pada lansia penderita hipertensi menurunkan tekanan darah baik sistolik maupun diastolik. menurut silva (1997) kopi dapat mengubah aktifitas endotel pembuluh darah pada otot polos yang dapat meningkatkan komplains pembuluh darah atau secara langsung mengubah aktifitas baroreseptor. menurut kaplan (2002) baroreseptor mempunyai peranan penting pada pengaturan aktifitas saraf simpatis, namun mekanisme tersebut tidak terjadi pada lansia penderita hipertensi karena terjadi penurunan sensitifitas baroreseptor. pembatasan kafein dapat meningkatkan sentifitas baroreseptor, sehingga mekanisme ini akan normal kembali. hal ini dipengaruhi oleh beberapa faktor seperti usia, riwayat penyakit dan frekwensi mengkonsumsi kafein. pembatasan kafein dapat meningkatkan pelepasan no (nitric oxide) (kimura, 2003). pelepasan no diikuti oleh vasorelaksasi yang tergantung oleh endotel dalam perannya menurunkan tekanan darah. no menyebabkan vasodilatasi dan merupakan faktor anti atherosklerotik (kaplan, 2002). hal ini akan menurunkan resistensi perifer dan menurunkan tekanan darah. kopi mengandung kafein yang dapat meningkatkan bradikardi baroreflek secara akut. hal ini disebabkan kafein dapat meningkatkan sensitifitas barorefleks. kafein juga dapat menyebabkan peningkatan kekuatan dan frekuensi tekanan berulang pada sel endotel, melepaskan beberapa faktor endotel yang dapat meningkatkan tekanan darah baik pada orang hipertensi atau normal (silva, 1997). disfungsi baroreseptor jangka panjang pada hipertensi sering dihubungkan dengan perubahan struktur pada arteri besar, dimana baroreseptor berada. pembatasan kafein dapat meningkatkan aliran darah berulang yang meningkatkan produksi no. peningkatan aliran darah berulang juga bermanfaat terhadap struktur dan reaktifitas vaskuler (higashi, et al., 1999). mekanisme ini didasari pada peran ldl (low density lipoprotein)teroksidasi pada pembentukan no dan secara langsung membentuk no tidak aktif. jadi pembatasan kafein dapat menurunkan ldl dan menurunkan supresi pembentukan no oleh ldl teroksidasi. frekwensi nadi juga mengalami penurunan setelah dilakukan pembatasan konsumsi garam sebanyak 1,25 gram dalam diet dan tanpa diberikan kopi selama 2 minggu. ternyata bahan aktif natrium dan kafein mampu menurunkan kinerja saraf simpatis. frekwensi jantung sebagian besar berada dibawah pengaturan ekstrinsik sistem saraf otonom. serabut saraf simpatis dan parasimpatis mempersarafi nodus sa dan av, yang dapat mempengaruhi kecepatan impuls dan frekwensi konduksi impuls. perangsangan simpatis akan mempercepat denyut jantung dan meningkatkan kekuatan kontraksi otot jantung, sedangkan perangsangan parasimpatis yang kuat akan mengurangi frekwensi denyut jantung dan kekuatan kontraksinya (guyton dan hall, 1996). pada jantung normal dalam keadaan istirahat, maka pengaruh sistem parasimpatis tampak dominan dalam mempertahankan kecepatan denyut jantung sekitar 80 kali per menit (price dan wilson, 1995). pembatasan kafein dapat meningkatkan komplains pembuluh darah, hal ini dapat meningkatkan sensitifitas baroreseptor. mekanisme lain yang mungkin adalah aktifitas faktor endotel pada otot polos yang meningkatkan komplains pembuluh darah atau secara langsung mengubah aktifitas baroreseptor (silva, 1997). baroreseptor punya peranan penting pada pengaturan aktifitas saraf simpatis. peningkatan tekanan darah akan mengaktifkan barorefleks dengan menghambat aktifitas saraf simpatis, yang mengembalikan frekwensi nadi menjadi normal (kaplan, 2002). mekanisme ini tidak terjadi pada penderita hipertensi, karena terjadi penurunan sensitifitas baroreseptor, sedangkan pembatasan kafein dapat meningkatkan sensitifitas baroreseptor, sehingga mekanisme ini akan kembali normal. pembatasan kafein selain meningkatkan sensitifitas baroreseptor juga dapat meningkatkan pelepasan no dan peningkatan aliran darah berulang, yang bermanfaat terhadap struktur dan reaktifitas vaskuler. mekanisme lain seperti ldl teroksidasi berperan pada pembentukaan no dan bahkan penurunan ldl dapat menurunkan supresi pembentukan no oleh ldl teroksidasi (kimura, et al., 2003, higashi, et al., 1999 dan kaplan, 2002). pelepasan no yang diikuti oleh vasorelaksasi tergantung peran endotel. begitu juga no dapat menimbulkan vasodilatasi dan merupakan faktor anti-atherosklerotik. hal ini yang akan menurunkan resistensi perifer dan menurunkan tekanan darah yang pada akhirnya juga akan menurunkan frekwensi nadi. pada penderita hipertensi, terdapat aktifitas saraf simpatis, yang akan meningkatkan kerja jantung, sehingga tekanan darah dan frekwensi nadi menjadi meningkat. sensitifitas terhadap sodium terjadi akibat aktifitas simpatis yang kuat. kafein yang terdapat pada kopi dapat meningkatkan kekuatan dan frekwensi tekanan berulang pada endotel untuk melepaskan beberapa faktor seperti tgf, pdgf, il-8 dan endotelin, yang dapat meningkatkan tekanan darah dan frekwensi nadi baik pada orang normal maupun penderita hipertensi. oleh karena itu alasan pembatasan sodium dalam diet dan pembatasan kafein pada lansia penderita hipertensi sangat dibenarkan. simpulan dan saran simpulan pembatasan konsumsi garam dan kopi dapat menurunkan tekanan darah (baik sistolik maupun diastolik) dan frekwensi nadi pada lansia yang menderita hipertensi. saran upaya pembatasan sodium 1,25 gram dalam menu makanan dan pembatasan konsumsi kafein dapat dipilih sebagai alternatif pengobatan non farmakologis dan diterapkan oleh petugas kesehatan dalam menurunkan tekanan darah pada lansia yang menderita hipertensi karena efek limitasi konsumsi kopi dan garam terbukti bermanfaat dan lebih efektif. kepustakaan chintanadilok, et al. 2002. exercise in treating hypertension. aha journals, vol. 274, 190-197, (online), (http:// hyper.ahajournals.org., diakses tanggal 11 september 2007, jam 10.00 wita). duthie and katz. 1998. practice of geriatrics. 3 rd edition. philadelpia: w.b. saunders, pp. 375-381. gordon, n.f. 2002. radang sendi panduan latihan lengkap. alih bahasa oleh eri d. nasution. jakarta: pt raja grafindo persada, hlm. 48-50. guyton dan hall. 1996. buku ajar fisiologi kedokteran. edisi ix. alih bahasa oleh irawati setiawan. jakarta: penerbit buku kedokteran egc, hlm. 261-282. higashi, et al. 1999. daily aerobics exercise improves reactive hyperemia in patients with essential hypertension, aha journals, 21, 23-27, (online), (http://hyper.aha journals.org., diakses tanggal 11 september 2007, jam 09.00 wita). izzo and black, 1999. hypertension primer: the essential of high blood pressure. texas: lippincott, pp. 121-122, 160, 259-262. kaplan, n.m. 2002. kaplans clinical hypertension. 8 th edition. philadelpia: lippincott, hlm. 67-110, 221-223. kimura, et al. 2003. nos3 genotype dependent correlation between blood pressure and physical activity, journal of undergraduate research, 4, 1-4, (online), (http:// hyper.ahajournals.org., diakses tanggal 25 agustus 2007, jam 11.00 wita). price dan wilson. 1995. patofisiologi. konsep klinis proses-proses penyakit. alih bahasa oleh caroline wijaya. jakarta: penerbit buku kedokteran egc, hlm. 486-489. silva, et al. 1997. influence of exercise training on neurogenic control of blood pressure in shr, aha journals, 7, 530-534, (online), (http://hyper.ahajournals.org., diakses tanggal 26 agustus 2007, jam 10.00 wita). http://hyper.ahajournals.org/ http://e-journal.unair.ac.id/jners | 137 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.7755 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effectiveness of prone and supine nesting positions on changes of oxygen saturation and weight in premature babies ayu prawesti, etika emaliyawati, ristina mirwanti and aan nuraeni faculty of nursing, universitas padjadjaran, bandung, indonesia abstract introduction: stress experienced by the baby will affect the body’s function by increasing the body’s metabolism. nesting is used to reduce stress in premature babies. nesting can be done in a supine or prone position. few studies have examined the effects of body position on body weight and oxygen saturation. the objective of the study was to determine the difference in oxygen saturation and weight change on the use of nesting in the prone and supine positions in premature babies. methods: the research used a quasi-experimental design. the sample consisted of 30 premature babies, which was obtained using a consecutive sample technique. the independent variables were nesting positioning (supine and prone), and the dependent variables were oxygen saturation and body weight. the data of oxygen saturation and the baby’s weight were collected using pulse oximetry; the baby’s weight scale used observation sheets. the data was analysed using the t-test, wilcoxon sign ranks test, and mann whitney u test. results: the results showed that there was a difference in oxygen saturation before and after the use of nesting in the supine (p=0.001) and prone position (p=0.000). there was a weight difference before and after the use of nesting in both supine (p=0.000) and prone position (p=0.000). there was no difference in oxygen saturation value and infant weight, before or after, between the supine position and the prone position (p=0.18; p=0.9). conclusion: the use of nesting in both positions (supine or prone) can increase oxygen saturation and infant weight. researchers recommend the use of nesting with supine or prone positions routinely in premature babies. article history received: feb 26, 2018 accepted: dec 12, 2019 keywords nesting; oxygen saturation; premature babies; weight contact ayu prawesti  ayu.prawesti@unpad.ac.id  emergency and critical care nursing departement, faculty of nursing, universitas padjadjaran, bandung, indonesia cite this as: prawesti, a., emaliyawati, e., mirwanti, r., & nuraeni, a. (2019). the effectiveness of prone and supine nesting positions on changes of oxygen saturation and weight in premature babies. jurnal ners, 14(2), 138144. doi:http://dx.doi.org/10.20473/jn.v14i2.7755 introduction the process of environment adjustment for premature babies is going to be more difficult. this difficulty of adjustment is due to immaturity of the organ system (sari, 2018). immunity of organs in premature babies includes immaturity of the nervous system and low stability in the physiological functions of the infant, low ability to solve stress in the infant will affect the body’s function, and will affect the function of the hypothalamus, which will adversely affect growth, heat production and neurological mechanisms (hockenberry & wilson, 2013). stress in the baby will affect the function of the body by increasing its metabolism, so it requires more oxygen consumption to stabilize physiological functions. the who stated that 44% of infant deaths in the world in 2012 occurred within the first 28 days, and the major cause was premature birth, accounting for approximately 37% (who, 2012). in indonesia, based on data from the health profile of indonesia in 2014, it states that the highest incidence of deaths in babies occurred during the neonatal stage. basic health research (ministry of health of the republic of indonesia, 2018) showed that 78.5% of deaths occurred in neonates at 0-6 days). increased oxygen consumption will cause a risk of respiratory distress, acidosis and hypoxia (hockenberry & wilson, 2013). physiological changes in increasing stress hormones increase pulse rate and decrease oxygen saturation (oken, chamine, & wakeland, 2015). another impact of stress https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ a. prawesti, et al. 138 | pissn: 1858-3598  eissn: 2502-5791 experienced by premature babies can lead to excessive use of energy, causing barriers to energy conservation resulting in weight gain difficulties (hockenberry &wilson 2013). low-weight babies will have a much heavier adaptation than high-weight babies (bayuningsih, 2011). one effort in the provision of developmental care is to set a comfortable position on the neonate using nesting. nesting is a material made of phlanyl fabric with the length adjusted to the baby's body length which acts as a protective position for the baby so that it is not in an extension condition, and also keeps the baby's position changing as a result of gravity (kahraman, başbakkal, yalaz, & sözmen, 2018). the benefit of using nesting in neonates is to facilitate hand to hand and hand to mouth position patterns so that the flexion position is maintained (priya & biljani, 2005). another study on the benefits of nesting explains that nesting is effective in improving comfort and hemodynamic stability in weight babies in the neonatal intensive care unit (nicu) (anju & paulose, 2015). the use of nesting in premature babies is done in the prone or supine position. bayuningsih, rustina, & widyatuti (2011) conducted a study of the effectiveness of nesting and prone position against oxygen saturation and pulse frequency in premature babies. it was found that there was a significant difference in oxygen saturation in infants using nesting in the prone position. based on studies in the perinatology room of one of the referral hospitals in bandung, where nesting is used with supine position, the baby looks more comfortable, sleeps longer and allows the nurse to observe it. based on a previous study on 6 infants with 3 infants using the prone position while in nesting, and 3 infants positioned in supine flexion. it was found that oxygen saturation was increased in all infants, but increases were found in oxygen saturation in 2 infants in the prone position, which is lower than the others because the two infants look uncomfortable and always moved; after their position was changed in the supine, they did not move much, and oxygen saturation increased. from the results of previous study and existing phenomena in the room, researchers were interested in examining whether using nesting and the supine baby position influences oxygen saturation and infant weight in response to physiological stability. thus, the objective of this study was to identify oxygen saturation and body weight in premature babies before and after using nesting in the supine and prone positions. materials and methods the design of this study used a quasi-experimental design. the population in this study were premature babies treated in the perinatology ward in one of the referral hospitals in west java province, and the average number of babies undergoing treatment each month was 40 babies. the research sample used a consecutive sampling technique. the sample inclusion criteria were premature babies weighing 1500-2000 grams, premature babies get nutrition through sonde, premature babies are treated in incubators and the baby's parents allowed the baby to be the subject of the research. sample exclusion criteria are premature babies with nec (necrotic enterocolitis), anemia, sepsis and hyperbilirubinemia, premature babies with lung problems and respiratory function and premature babies with congenital abnormalities. drop out criteria is premature babies who died during ongoing research. based on inclusion and exclusion criteria, 15 infants were in the supine position and the other 15 infants were in the prone position. the instruments used in this study include an observation sheet, pulse oximetry and a baby weight scale. the observation sheet contains patient data consisting of name, gender, gestation, age. further data are vital signs such as temperature, type of nutrition, oxygen saturation and weight. pulse oximetry was used to measure oxygen saturation and used a new pulse oximetry, with a blue brand fingertip pulse oximeter pulse rate and spo2 monitor, which was calibrated at the time of removal by the manufacturer. the baby weight scale was used to measure the baby’s weight, that is in perinatology room that was scale calibrated on 28 march 2016. before data collection, the researcher gained informed consent from the parents of premature babies; all the parents had been informed and signed the consent form. data retrieval began by determining the respondent according to the criteria. oxygen saturation and weight gain had been recorded before using nesting in the supine and prone positions and then documenting them on observation sheets. the nesting position is the position where premature babies are placed in a circle, similar to a position taken when in the womb with two hands in front of the chest, with the chin touching the chest. with this same position the baby in nesting can be placed in a supine or prone position. in the final stage, data for oxygen saturation were collected before the premature babies slept in the nesting position (pre-test) and then they were positioned nesting supine (for group supine) and prone (for prone group) for 20 minutes. their saturation were measured, after which they were positioned into the nesting prone position and supine position (post-test nesting supine and prone). this intervention was only held once a day for 7 days. after 7 days the baby slept in the nesting position, baby weight was weighed and the result of the assessment was written on the observation sheet. data analysis used in this research is univariate analysis, normality test, and bivariate analysis. univariate analysis explains and describes characteristics of variables to be studied, that is oxygen saturation frequency distribution before and after using nesting and distribution of frequency of body weight before and after using nesting. jurnal ners http://e-journal.unair.ac.id/jners | 139 the data normality test used shapiro wilk. bivariate analysis was conducted to see the effect of nesting (supine and prone) toward oxygen saturation and body weight in premature babies in the perinatology room. prone position data including oxygen saturation and weight had normal data distribution and they were tested by a paired t-test, and supine position data had abnormal data distribution, so the test was conducted using wilcoxon difference test. to see the differences of oxygen saturation value change and body weight between using nesting at prone position and supine position they were tested using the mann whitney test. then the results of the analysis were interpreted by using significance test α = 0.05 and confidence interval (ci) 95%. ethical clearance for data collection had been obtained from the research ethics committee of the general hospital no. lb.02.01/c02/1329/1/2017. all respondents had been informed consent and agreed to participate in the research. results based on the table 1, it can be explained that the respondents in supine groups were mostly female, as many as 11 premature babies (73.3%) with 33 weeks' gestation age of 6 premature babies (40 %). however, the respondents in prone groups were mostly male, as many as 10 premature babies (66.67%) with 34 weeks' gestation age of 8 premature babies (53.33 %). all the respondent's body temperatures were within the normal body temperature range, which is between 36.5oc 36.9oc and for the type of food given to infants as a whole (100%), respondents were given a similar type of food, namely breast milk and formula milk. table 2 showed that oxygen saturation of infants after 20 minutes using nesting in supine and prone positions increased oxygen saturation. in the supine position, the minimum oxygen saturation after intervention was 93%, and in some of the infants the saturation could increase up to 98%. furthermore, there is a difference in oxygen saturation before and after using nesting in the supine position (p = 0.001 < 0.005). otherwise, after a prone position, the infants’ oxygen saturation was in the range of 95% to 98%, and there is a difference in oxygen saturation before and after using nesting in the prone position (p = 0.000 < 0.005). based on the mann whitney test, there is no difference in oxygen difference between the supine and prone positions (p = 0.180 > 0.005). based on table 2, it can be seen that after seven days using nesting in the supine and prone position, the baby’s increased their weight. the amount of babies who reached their weight of more than 2000 grams was increased. there are differences in body weight before and after using nesting both in the position of supine (p = 0.000 < 0.005) and prone position (p = 0.000 < 0.005), but there was no difference in weight gain in the supine and prone positions (p = 0.900 > 0.005) discussion effect of nesting on oxygen saturation based on table 2 the results showed that the baby’s oxygen saturation after 20 minutes using nesting in supine and prone positions increased oxygen saturation. the results of this study are reinforced by the results of different test analyses, considering the change in oxygen saturation value after using nesting. according to table 2 there is no decrease in oxygen saturation between before and after using nesting in the supine position. in 15 respondents there was an increase in oxygen saturation before and after using nesting in the supine position. as can be seen on rank ties, which is 0, so there is no equal oxygen saturation value between before and after using nesting in the supine position. furthermore, the value of p-value, which is 0.001, then p-value <alpha value (0.05) shows that there is difference in oxygen saturation before and after using nesting in the supine position. in the supine position, increases in oxygen saturation are due to the supine position having table 1. characteristic demographic (n=30) characteristics supine prone n % n % sex male 4 26.67 10 66.67 female 11 73.33 5 33.33 gestational age 32 weeks 4 26.67 3 20 33 weeks 6 40 4 26.67 34 weeks 5 33.33 8 53.33 body temperature 36.5 c 4 26.67 1 6.67 36.6 c 3 20 3 20 36.7 c 4 26.67 4 26.67 36.8 c 3 20 6 40 36.9 c 1 6.66 1 6.66 food supply breast milk + formula milk 15 100 15 100 a. prawesti, et al. 140 | pissn: 1858-3598  eissn: 2502-5791 better respiratory muscle strength and low episodes of hyposexuality. this occurs mainly in the supine position with a 45 degree head elevation, where the development of the lungs becomes maximal (spooner et al., 2014). the use of nesting in the supine position may affect the increase in oxygen saturation value in premature babies because using nesting can adjust the infant in a flexible position. the flexible position can serve as a safety measure to prevent heat loss caused by body surfaces exposed to room temperature. heat loss in premature or hypotermic infants will require many calories for the stability of body temperature, so it will cause increasing oxygen consumption, and nesting ensures the flexible position, so the metabolic rate will be decreased, the oxygen in the body is enough, so the saturation rate will be increased. the flexible position in premature babies is a good position because it will affect relaxation and reduce metabolism (kahraman et al. 2018) . the use of nesting in prone positions in table 2 indicates that there is a difference in oxygen saturation before and after using nesting. this is proven by a higher mean value in oxygen saturation after using nesting and p-value (0.000) <alpha value (0.05), indicates that there is an influence of using nesting in prone position to oxygen saturation value. the results of this research are in line with another study (bayuningsih et al., 2011), that using nesting affects the increase of oxygen saturation by p value = 0.001. in the study (bayuningsih et al., 2011) the baby position in nesting is prone. the prone position can reduce pressure on the diagfragma, decrease the apneu period and reduce the esophageal reflex, so it can increase lung volume capacity (abdeyazdan, nematollahi, ghazavi, & mohhamadizadeh, 2010). based on the results of the study, it showed that the use of nesting in supine and prone positions influences the change of oxygen saturation value. this research conducted a different test to the oxygen saturation value change between nesting in prone position and nesting in supine position. this is conducted to find out the best position to get a better oxygen saturation value. based on table 7 it is found that there is no difference in the difference value of oxygen saturation change in the supine and prone positions, it is proven by p-value> alpha (0.05). the results of this study contrast with (abdeyazdan et al., 2010)’s research that the prone position obtained oxygen saturation value is higher than in the supine position (abdeyazdan et al., 2010). in a study conducted by abdeyazdan, oxygen saturation measurement was performed for 120 minutes of using nesting, while in this research it is only measured oxygen saturation after nesting for just 20 minutes. the inhabitant factor of nesting can affect the increase in oxygen saturation. several studies have shown that there is an increase in the oxygen saturation value during the use of nesting in the prone position of about 1.18 to 4.36% (rivasfernandez, roqué i figuls, diez-izquierdo, escribano, & balaguer, 2016) based on the results of the research, it showed that the use of nesting in infants has an effect on increases in the oxygen saturation value. differences in supine or prone positions in using nesting do not differ in effect on increasing oxygen saturation, since both cause an increase in oxygen saturation value in nesting usage. nesting is a barrier that serves to support the baby's body. nesting can reduce acute stress in infants due to sudden and surprising movements (borle, 2015). another study proves that nesting can reduce stress in premature babies. table 2. oxygen saturation and weigh before and after using nesting in supine and prone position (n=30) variables supine position (n=15) prone position (n=15) before after before after n % n % n % n % saturation 90 91 92 93 94 95 96 97 98 1 2 0 2 3 3 4 0 0 6.7 13.3 0 13.3 20 20 26.7 0 0 0 0 0 1 0 4 3 4 3 0 0 0 6.7 0 26.7 20 26.7 20 0 2 3 2 4 3 1 0 0 0 13.3 20 13.3 26.7 20 6.7 0 0 0 0 0 0 0 6 5 2 2 0 0 0 0 0 40 33.3 13.3 13.3 mean ± sd 93.4±1.549 96±1.069 93.4±1.549 95.00±1.604 p* 0.001 p** 0.000 p*** 0.180 body weigh 1500-2000 > 2000 13 2 86.7 13.3 9 6 60 40 14 1 93.3 6.7 12 3 80 20 mean ± sd 1782±193 1919±175 1724±162 1870±161 p** 0.000 0.000 p*** 0.900 p*: wilcoxon; p**: paired t test; p***: mann-whitney u test; body weigh in gram jurnal ners http://e-journal.unair.ac.id/jners | 141 nesting can reduce stress and pain levels in premature babies compared to non-nesting infants at the time of diaper replacement (comaru & miura, 2009). the use of nesting has a positive impact on reducing stress in premature babies, because stress in premature babies can activate the stress hormone which will further affect the increase in pulse rate and decrease oxygen saturation (maguire et al., 2009). factors of oxygen saturation according to (brooker chris, 2009) are body temperature, hemoglobin, hyperbilirubin and hypoxemia. body temperature can affect oxygen saturation because if there is an increase or decrease in body temperature this will increase metabolism. increased metabolism requires more oxygen levels and will cause a decrease in oxygen saturation. in this research preterm babies, as the sample of the research, had a normal body temperature, which is 36.5-36.8, it will not affect the results of this research. another factor that affects oxygen saturation is anemia. anemia is decreasing of hemoglobin, so it will decrease oxygen levels that bind to hb and will decrease the oxygen saturation value. in addition, hyperbilirubin and hypoxemia will affect oxygen saturation, but in this study the three factors did not affect the results of the study because infants with anemia, hyperbilirubin and hypoxemia were included in the exclusion criteria. oxygen saturation levels in infants are very important to be known because when the oxygen saturation level in infants is low, there is a risk of hemodynamic abnormalities. normal values of oxygen saturation range from 95% to 100%, at 28-34 weeks of normal oxygen saturation value 88% to 94% and in infants with gestational age, <28 weeks, the normal value of oxygen saturation 85% to 92% is still considered normal (snoek et al, 2016). effect of nesting on oxygen saturation table 2 shows that after 7 days of using nesting in supine and prone positions weight was gained. the results of this research are reinforced by the results of different test analyses by considering changes in infant weight after using nesting in supine and prone positions. based on table 2, it can be concluded that there are differences in body weight before and after using nesting both in prone and supine positions, evidenced by the value of p-value (0.000) <value alpha (0.05), but the difference in average infant weight gain before and after using nesting is greater in preterm infants positioned in the prone rather than the supine position. the research also compared differences in changes in infant weight gain between using nesting in the supine and prone positions. this is done to find a better position to increase the weight of premature babies. the comparison of the difference in oxygen saturation value difference between the two positions (supine and prone) was explained in table 2., it is found that there is no difference in the difference value of change and there is no difference of weight in supine and prone position, it is proved by p-value> alpha (0.05). based on the results above, it can be concluded that the use of nesting in supine position and prone positions affect weight gain. different positions during the use of nesting for infant weight gain show no significant difference in outcome, so nesting can be used in either the supine or prone position. nesting facilitates the baby in a flexible position that protects the baby from increased metabolism due to stimuli from the environment that can lead to stress and improve the quality of the baby’s sleep, so there is no excessive use of energy. energy that is not used by the body will be stored in the adipose system and increases body weight (reyhani, ramezani, boskabadi, 2016). nesting can increase infant growth. it is known from several studies including research of (kahramen et al., 2017) that improving the quality of sleep will reduce energy consumption or resting energy expenditure (ree). decreasing ree will improve efficiency and metabolism, thereby increasing the weight of premature babies. nesting will increase growth because the use of nesting can facilitate the baby to have a longer deep sleep period (prasanna & radhika, 2015). in a deep sleep state, 75% of the growth hormone is produced. this is in line with (reyhani, ramezani, boskabadi, & mazlom, 2016) study that deep sleep in premature babies reduces the crying period which can lead to excessive energy consumption, so no extra energy can be stored, finally it can lead to weight loss (reyhani, ramezani, boskabadi, 2016). human growth hormone is an anabolic hormone that plays a very big role in the growth and formation of the body, especially in childhood and puberty. growth hormone (gh) plays a role in increasing the size and volume of brain, hair, muscles and organs in the body. gh is responsible for human growth from birth. the growth secretion of growth hormone is physiologically regulated by the hypothalamus. the hypothalamus produces growth hormone releasing factor (ghrf) which stimulates the secretion of growth hormones. the secretion is increased in the state of deep sleep (kim et al 2015). according to (indriansari, 2011) using a quasiexperimental method with a sample of 15 low birth weight babies results in an increase in sleep duration in infants using nesting compared to infants in the control group. achieving deep sleep is very important in infants as it facilitates low birth weight infants to grow and develop optimally (rahmawaty, 2016) deep sleep is essential for energy conservation, decreased peripheral muscle tone and arterial blood pressure, decreased pulse rate, and resting muscles during deep sleep. infants who fall asleep in nesting as an indicator of decreased stress due to stress reduction will elicit a relaxed response induced by muscle relaxation and sleep. the sleep phase is a very important phase for the baby because during this phase the secretion of growth hormone and body immunity occurs (irwin, 2015) . a. prawesti, et al. 142 | pissn: 1858-3598  eissn: 2502-5791 in general, in this research the weight of respondents experienced an increase after using nesting. the median weight of infants before using nesting was 1753.5 grams and after using nesting was 1894 grams, the weight of premature babies rose in 140.5 grams for 7 days, this is in line with (mohrbacher, n. & stock, 2010) that the baby's weight gain will increase by 15-20 grams/day in early life. this happens either in term infants or in premature babies. body weight is the result of increasing or decreasing all existing system in the body and a parameter can provide a picture of body mass. body mass is very sensitive to sudden changes, such as infectious diseases, decreased amount of food consumed and increased metabolism (drassinower, friedman, običan, levin, & gyamfi-bannerman, 2016). factors that affect weight gain are nutrients because the fulfilment of nutritional and fluid needs in premature babies in the room are adjusted for weight and gestational age. fulfil the needs of infants by 60-80 cc/kg bw/day which gradually increases up to 100-200c/kg bw/day after the first week. the initial fluid given early in the baby’s life is breast milk. if no breast milk is given, then pregestimil with 2x dilution is provided. premature babies have only a small amount of energy reserves because of the lack of glycogen reserves under the skin. the need for premature babies is divided into 2 important components that need to be maintained for body functions and the need to grow (johnson & marlow, 2017). all respondents in this research obtained a combined nutrition between breast milk and formula milk. nutrition obtained by all respondents is the same, so the nutritional factors have no effect on the results of the study. limitation this study has limitations, the number of respondents in this study was small, besides saturation measurements were only performed once for saturation oxygen, even though the intervention was carried out for seven days. conclusion nesting in a supine position and in a prone position affects oxygen saturation and weight gain. this is proven by the difference in oxygen saturation and weight gain that increases before and after using nesting. differences in the position of infants during the use of nesting did not affect the difference in the increase in oxygen saturation values and body weight. furthermore, it is recommended that nesting in supine and prone positions can be chosen as one of the interventions to care for premature babies in improving oxygen saturation and weight. the results of this study can be used as a reference for the manufacture of standard operating procedures in the nicu ward because the process involves nurses, doctors, families and other officers, so it can run well. future researchers should conduct research in more samples and with a longer observation time (120 minutes) using the control group of supine and prone positions on the use of nesting, so the results will be more significant. references abdeyazdan, z., nematollahi, m., ghazavi, z., & mohhamadizadeh, m. (2010). the effects of supine and prone positions on oxygenation in premature infants undergoing mechanical ventilation. iranian journal of nursing and midwifery research, 15(4), 229 – 233. anju, t. r., & paulose, c. s. (2015). long term effects of neonatal hypoglycaemia on pancreatic function. archives of physiology and biochemistry, 121(1), 1– 12. https://doi.org/10.3109/13813455.2014.96087 4 bayuningsih, r. (2011). efektifitas penggunaan nesting dan posisi prone terhadap saturasi oksigen dan frekuensi nadi pada bayi prematur di rumah sakit umum daerah bekasi. bayuningsih, r., rustina, y., & widyatuti. (2011). efektivitas penggunaan nesting dan posisi prone terhadap saturasi oksigen dan frekuensi nadi pada bayi prematur di rumah sakit umum daerah (rsud) kota bekasi. jurnal fik ui. borle, p. s. (2015). effectiveness of nesting on posture and movement of upper extremities in healthy preterm infants, (july), 143–146. brooker chris. (2009). churchill livingstone’s mini encyclopedia of nursing. (b. chris, ed.). jakarta: egc. comaru, t., & miura, e. (2009). postural support improves distress and pain during diaper change in preterm infants. journal of perinatology, 29(7), 504–507. https://doi.org/10.1038/jp.2009.13 deprtemen kesehatan republik indonesia. (2013). riset kesehatan dasar. jakarta. https://doi.org/1 desember 2013 dimitriou, g., greenough, a., pink, l., mcghee, a., hickey, a., & rafferty, g. f. (2002). effect of posture on oxygenation and respiratory muscle strength in convalescent infants. arch dis child fetal neonatal ed, 86(3), f147-50. https://doi.org/10.1136/fn.86.3.f147 drassinower, d., friedman, a. m., običan, s. g., levin, h., & gyamfi-bannerman, c. (2016). prolonged latency of preterm premature rupture of membranes and risk of neonatal sepsis. american journal of obstetrics and gynecology, 214(6), 743e1. https://doi.org/10.1016/j.ajog.2015.12.031 hockenberry, m. j., & wilson, d. (2013). wong’s essentials of pediatric nursing. elsevier health sciences. indriansari, a. (2011). pengaruh developmental care terhadap fungsi fisiologis dan perilaku tidur terjaga bayi berat lahir rendah di rsup fatmawati jakarta. fik ui. irwin, m. r. (2015). why sleep is important for health: a psychoneuroimmunology perspective. annual jurnal ners http://e-journal.unair.ac.id/jners | 143 review of psychology, 66, 143–172. https://dx.doi.org/10.1146%2fannurev-psych010213-115205 johnson, s., & marlow, n. (2017). early and long-term outcome of infants born extremely preterm. archives of disease in childhood, 102(1), 97–102. https://doi.org/10.1136/archdischild-2015309581 kahraman, a., başbakkal, z., yalaz, m., & sözmen, e. y. (2018). the effect of nesting positions on pain, stress and comfort during heel lance in premature infants. pediatrics & neonatology, 59(4), 352–359. https://doi.org/10.1016/j.pedneo.2017.11.010 lubetzky, r., mimouni, f. b., dollberg, s., reifen, r., ashbel, g., & mandel, d. (2010). effect of music by mozart on energy expenditure in growing preterm infants. pediatrics, 125(1), e24–e28. https://doi.org/10.1542/peds.2009-0990 maguire, c. m., walther, f. j., sprij, a. j., le cessie, s., wit, j. m., & veen, s. (2009). effects of individualized developmental care in a randomized trial of preterm infants &lt;32 weeks. pediatrics, 124(4), 1021–1030. https://doi.org/10.1542/peds.2008-1881 ministry of health of the republic of indonesia. (2018). hasil riset kesehatan dasar 2018 [basic health research results]. jakarta. mohrbacher, n. & stock, j. (2010). breast feeding answer made simple a guide for helping mother. scaunbur, illinois: l .: a leche league international. moller, h. j. (ed.). (2012). pediatric cardiovascular medicine, 2nd edition. wiley-blackwell. nair, m. n. g., & raghuraman, t. s. (2004). nicu environment. can we be ignorant? (multiple letters) [4]. medical journal armed forces india, 60(1), 97. https://doi.org/10.1016/s03771237(03)80046-1 oken, b. s., chamine, i., & wakeland, w. (2015). a systems approach to stress, stressors and resilience in humans. behavioural brain research, 282, 144–154. https://doi.org/10.1016/j.bbr.2014.12.047 prasanna, m. k., & radhika, m. (2015). effectiveness of nesting on posture and motor performance among, (2277), 4–7. priya, g. s. k., & biljani, j. (2005). low cost positioning device for nesting preterm and low birth weight neonates. pratical on call child health care, 5(3), 54–59. rahmawaty. (2016). pengaruh nesting terhadap saturasi oksigen dan berat badan pada bayi prematur di ruang perinatologi rup dr hasan sadikin. unpad. reyhani, ramezani, boskabadi, m. (2016). evaluation of the effect of nest posture on the sleep wake state of premature infants, 6, 29–36. reyhani, t., ramezani, s., boskabadi, h., & mazlom, s. (2016). evaluation of the effect of nest posture on the sleep-wake state of premature infants. evidence based care, 6(1), 29–36. rivas-fernandez, m., roqué i figuls, m., diezizquierdo, a., escribano, j., & balaguer, a. (2016). infant position in neonates receiving mechanical ventilation. cochrane database of systematic reviews. https://doi.org/10.1002/14651858.cd003668.p ub4 saifuddin, a. (2001). buku acuan nasional pelayanan kesehatan maternal dan neonatal. jakarta: yayasan bina pustaka sarwono prawirohardjo. sari, w. . (2018). effect of implementation of developmental care: nesting on sleep and physiological parameters baby premature in hospital x bandung. in international conference on heath care and management. bandung. who. (2012). born too soon. pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru hypnobirthing meningkatkan toleransi nyeri dan menurunkan kecemasan ibu inpartu kala i fase aktif (hypnobirthing increase pain tolerance and anxiety in active phase labor) nursalam*, retnayu pradanie*, ida ayu trisnadewi* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: nursalam_psik@yahoo.com abstract introduction: the main problem of inpartu mother was a labour pain and anxiety. the etiology of labour pain has been determained by dilatation and cervic’s tickness. the objective of this study was to examine the effect of hypnobirthing relaxation on the pain tolerance and anxiety responses in labor. method: a pre experimental static group comparison purposive sampling design was used in this study. population were all pregnant women in age of pregnancies between 38 until 39 weeks at rsud wangaya denpasar. there were 12 respondents who met to the inclusion criteria divided into 6 respondents were given hypnobirthing relaxation intervention and 6 respondents as the control group. the independent variable was hypnobirthing relaxation and dependent variables were tolerance of pain and anxiety responses. data were collected by using observation and questionnaire, then data were analyzed by using mann whitney u test with significance level p=0.05. result: the result showed that hypnobirthing relaxation had an effect on the pain tolerance and anxiety responses (p=0.015. discussion: it can be concluded that the hypnobirthing relaxation has an effect to increase the pain tolerance and to decrease anxiety responses in active phase of labour. it is recommended to the hospital that have an ante natal care to hypnobirthing relaxation technique. further studies should measure the effect of hynobirthing relaxation on increasing of β-endorfin in active phase labour. keywords: anxiety, hypnobirthing, labour, tolerance of pain . pendahuluan rasa tidak nyaman (nyeri) muncul pada saat ibu inpartu mulai memasuki kala i persalinan. pada fase aktif ibu hanya mengalami nyeri pada saat kontraksi dan bebas dari rasa nyeri pada interval antar kontraksi. kontraksi yang terjadi pada fase aktif semakin kuat dan lama dalam selang waktu sekitar 3 sampai 6 menit selama 60 sampai 90 detik (andriana, 2007). toleransi nyeri bervariasi pada setiap individu. sebagian ibu tidak dapat mentoleransi nyeri yang terjadi saat persalinan. faktor yang dapat menurunkan toleransi seseorang terhadap nyeri antara lain rasa cemas dan ketakutan (price dan wilson, 2006). menurut kuswandi (2007) dalam andriana (2007), sebagian besar ibu memiliki toleransi yang rendah terhadap nyeri dan peningkatan kecemasan saat persalinan. rasa tegang, cemas dan nyeri berlangsung secara beriringan sehingga diperlukan tindakan untuk meningkatkan toleransi nyeri dan menurunkan respons kecemasan (dick-read, 1959 dalam bobak, lawdermilk, dan jensen, 2005). pada akhir tahun 2007, tercatat 4.625.400 orang hamil atau sekitar 3% dari jumlah penduduk indonesia. sebesar 70-80% mengharapkan persalinan tanpa rasa sakit, salah satunya dengan operasi caesar. di indonesia persentase operasi caesar sekitar 5%, rerata di rumah sakit pemerintah 11%, sementara di rumah sakit swasta dapat lebih dari 30% (wiknyosastro, 2007 dalam andriana, 2007). operasi caesar yang tinggi disebabkan para ibu lebih memilih persalinan yang relatif tidak nyeri (abidin, 2007). diketahui 60% wanita hamil mengalami stres, hanya 10% yang merasa tenang menanti kelahiran bayinya (kusuma, 2007). wanita hamil cenderung dihantui perasaan cemas dan ketakutan pada nyeri yang akan mailto:nursalam_psik@yahoo.com hypnobirthing meningkatkan toleransi nyeri dan menurunkan kecemasan (nursalam) dirasakan saat persalinan. persalinan seringkali dikaitkan dengan penderitaan akibat ibu tidak dapat mentoleransi nyeri yang mengiringi, walaupun hal ini merupakan suatu proses fisiologis (rita, 2007). di rsud wangaya denpasar, belum ada angka pasti yang menunjukkan toleransi nyeri dan respons kecemasan pada ibu saat inpartu kala i fase aktif. beberapa teknik relaksasi yang telah dilakukan di rsud wangaya denpasar saat persalinan yaitu teknik efflurage yang dilakukan oleh suami dan teknik napas dalam yang dipandu oleh bidan yang bertugas. sebagian ibu yang tidak dapat mentoleransi nyeri saat persalinannya memilih menggunakan intrathecal labour analgesia (ila) (susilo, 2007 dalam andriana, 2007). rasa nyeri muncul akibat respons psikis dan reflek fisik. nyeri pada kala i diakibatkan oleh dilatasi dan penipisan serviks serta iskemia rahim (bobak, lawdermilk, dan jensen, 2005). rasa nyeri berbeda pada setiap individu. ketegangan emosi akibat rasa cemas hingga rasa takut dapat memperberat persepsi nyeri selama persalinan (dick-read, 1959 dalam bobak, lawdermilk, dan jensen, 2005). nyeri dapat menginduksi ketakutan, sehingga timbul kecemasan yang berakhir pada kepanikan. nyeri yang tidak dapat ditoleransi dan respons kecemasan yang meningkat pada kala i dapat menimbulkan respons fisiologis yang mengurangi kemampuan rahim berkontraksi sehingga dapat memperpanjang proses persalinan (bobak, lawdermilk, dan jensen, 2005). menurut cyana et al. (2006), hampir sebagian dari responden yang melakukan self-hypnosis selama kehamilan tidak membutuhkan anastesi untuk mengatasi nyeri dan kecemasan yang mengiringi proses persalinan. berdasarkan hasil penelitian madyastuti (2006), dari 11 orang yang melakukan teknik relaksasi abdominal breathing pada kala i fase aktif hanya 1 orang yang tidak mengalami penurunan nyeri. berdasarkan penelitian santi (2005) tentang studi teknik efflurage terhadap respons nyeri kala i fase aktif, 6 dari 10 orang responden mengalami perubahan respons nyeri sedangkan 4 lainnya mengatakan nyeri tetap. teknik relaksasi lain yang dapat diterapkan untuk meningkatkan toleransi nyeri dan menurunkan kecemasan adalah metode relaksasi hypnobirthing. hypnobirthing merupakan metode relaksasi alamiah yang dipergunakan untuk menghilangkan rasa takut, panik, tegang dan berbagai tekanan lain yang menghantui ibu dalam proses persalinan sehingga ibu dapat mentoleransi nyeri yang dirasakan (abidin, 2007). kuswandi (2007) dalam andriana (2007) menyebutkan bahwa relaksasi hypnobirthing merupakan suatu metode baru yang dikhususkan untuk wanita hamil dengan melakukan relaksasi mendalam, bertujuan untuk mempersiapkan proses kelahiran normal yang lancar, nyaman dengan rasa sakit yang minimum. hampir 80% dari ibu hamil yang melakukan relaksasi hypnobirthing selama kehamilan di klinik pro-v dan rs bunda jakarta tidak mengalami kesulitan untuk mengontrol nyeri dan kecemasan saat persalinan (kuswandi, 2007 dalam andriana, 2007). proses hypnobirthing bekerja berdasarkan kekuatan sugesti. proses ini menggunakan afirmasi positif, sugesti dan visualisasi untuk menenangkan tubuh, memandu pikiran, serta mengendalikan nafas. metode ini tidak memiliki potensi efek samping terhadap bayi, mampu menghadirkan rasa nyaman, rileks dan aman menjelang kelahiran, menurunkan stres serta ketakutan dan kekhawatiran menjelang kelahiran, membuat ibu tetap pada kondisi terjaga dan sadar (andriana, 2007). metode relaksasi hypnobirthing yang berupaya untuk meningkatkan toleransi nyeri dan menurunkan respons kecemasan pada ibu inpartu kala i fase aktif di rsud wangaya denpasar belum pernah dilakukan secara khusus. hal inilah yang membuat peneliti tertarik untuk melakukan penelitian untuk mengetahui pengaruh metode relaksasi hypnobirthing terhadap toleransi nyeri dan respons kecemasan pada ibu inpartu kala i fase aktif. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah pre experimental static group comparison purposive sampling design. populasi pada penelitian ini adalah para ibu primigravida yang melakukan ante natal care (anc) di rsud wangaya denpasar. sampel dalam penelitian ini jurnal ners vol.3 no.1 april 2008 : 54-60 sebanyak 12 orang, yang dibagi menjadi 6 orang diberikan perlakuan metode relaksasi hypnobirthing, sedangkan 6 orang yang lain tanpa metode relaksasi hypnobirthing. variabel independen dalam penelitian ini adalah metode relaksasi hypnobirthing, sedangkan variabel dependennya adalah toleransi nyeri dan respons kecemasan. instrumen yang digunakan dalam penelitian ini meliputi lembar observasi untuk toleransi nyeri dengan item penilaian terdiri dari vokalisasi, ekspresi wajah, gerakan tubuh dan interaksi sosial (potter dan perry, 2005); respons kecemasan diukur dengan modifikasi instrumen covi anxiety rating scale (calliaud dan lorencau, 1995). item yang dinilai untuk respons kecemasan meliputi respons verbal, perilaku/sikap dan gejala-gejala somatik. penelitian dilakukan selama bulan juni 2008. data yang diperoleh, ditabulasi dan dianalisis dengan menggunakan uji statistik mann whitney u-test dengan derajat kemaknaan α≤0,05. hasil hasil penelitian menunjukkan bahwa seluruh responden (100%) pada kelompok kontrol memiliki toleransi rendah terhadap nyeri, sedangkan pada kelompok perlakuan 5 responden (83,33%) memiliki toleransi yang tinggi terhadap nyeri dan 1 responden (16,67%) memiliki toleransi rendah. (lihat gambar 1). seluruh responden (100%) pada kelompok kontrol menunjukkan respons sedang terhadap kecemasan, sedangkan pada kelompok perlakuan hanya 1 responden (16,67%) menunjukkan respons sedang dan 5 responden (83,33%) menunjukkan respons ringan terhadap kecemasan (lihat gambar 2). hasil analisis statistik dengan menggunakan mann whitney u-test menunjukkan bahwa terdapat perbedaan antara kelompok perlakuan yang melakukan relaksasi hypnobirthing dengan kelompok kontrol yang tidak melakukan relaksasi hypnobirthing dengan nilai signifikansi p=0,015 (tabel 1). tabel 2 dapat dilihat hasil analisis statistik untuk respons kecemasan yang menunjukkan bahwa terdapat perbedaan respons kecemasan pada kelompok perlakuan dan kelompok kontrol dengan nilai signifikansi p=0,015. pembahasan responden pada kelompok perlakuan sebagian besar berespons tinggi terhadap toleransi nyeri, hanya 1 orang responden yang bertoleransi rendah terhadap nyeri. perbedaan nilai toleransi nyeri pada kelompok perlakuan ini disebabkan karena ibu memasuki masa inpartu 1 hari sebelum taksiran partus. pada kelompok kontrol diketahui 100% ibu memiliki toleransi rendah terhadap nyeri saat inpartu kala i fase aktif. pada kelompok perlakuan diterapkan metode relaksasi hypnobirthing yang dimulai 1 minggu sebelum taksiran partus. latihan ini dilakukan setiap hari selama 30 menit, sedangkan pada kelompok kontrol tidak tanpa relaksasi hypnobirthing. nyeri yang dirasakan pada kala i persalinan disebabkan oleh adanya kontraksi rahim yang menyebabkan dilatasi dan penipisan serviks serta iskemia rahim (penurunan aliran darah sehingga oksigen lokal menjadi defisit) akibat kontraksi arteri miometrium (bobak, lawdermilk, dan jensen, 2005). nyeri ini berasal dari bagian bawah abdomen dan menyebar ke daerah lumbal punggung dan menurun ke area paha. biasanya ibu hanya mengalami rasa nyeri ini selama kontraksi dan bebas dari rasa nyeri di antara kontraksi. individu bereaksi terhadap nyeri dengan cara yang berbedabeda. toleransi nyeri individu yaitu kondisi untuk menerima nyeri dengan tingkat keparahan yang lebih tinggi dan durasi yang lebih lama. toleransi bergantung pada sikap, motivasi dan nilai yang diyakini seseorang (potter dan perry, 2005). nyeri mengancam kesejahteraan fisik dan fisiologis. pasien mungkin memilih tidak mengekpresikan nyeri apabila mereka yakin bahwa nyeri tersebut akan membuat orang lain merasa tidak nyaman atau hal itu merupakan tanda bahwa mereka akan kehilangan kontrol diri (potter dan perry, 2005). pasien yang memiliki toleransi yang tinggi terhadap nyeri mampu menahan nyeri tanpa bantuan. sebaliknya seseorang pasien yang memiliki toleransi nyeri yang rendah dapat mencari upaya untuk menghilangkan nyeri yang terjadi. jurnal ners vol.3 no.1 april 2008 : 54-60 gambar 1. distribusi responden berdasarkan toleransi nyeri pada kelompok perlakuan dan kelompok kontrol di rsud wangaya denpasar bulan juni 2008 gambar 2. distribusi responden berdasarkan respons kecemasan pada kelompok perlakuan dan kelompok kontrol di rsud wangaya denpasar bulan juni 2008 tabel 1. hasil analisis statistik toleransi nyeri ibu inpartu kala i fase aktif di rsud wangaya denpasar bulan juni 2008 keterangan : p = signifikansi mean = rerata sd = standar deviasi no. responden skor post test kelompok perlakuan kelompok kontrol nilai % keterangan nilai % keterangan 1 9 45 rendah 7 35 rendah 2 12 60 tinggi 8 40 rendah 3 11 55 tinggi 5 25 rendah 4 10 50 tinggi 8 40 rendah 5 11 55 tinggi 9 45 rendah 6 10 50 tinggi 9 45 rendah mean sd 10,50 1, 05 3,83 0,75 hasil analisis statistik mann whitney u test p=0,015 6 0 1 5 0 1 2 3 4 5 6 kontrol perlakuan sedang ringan 0 6 5 1 0 1 2 3 4 5 6 kontrol perlakuan tinggi rendah hypnobirthing meningkatkan toleransi nyeri dan menurunkan kecemasan (nursalam) tabel 2. hasil analisis statistik respons kecemasan ibu inpartu kala i fase aktif di rsud wangaya denpasar bulan juni 2008 keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata relaksasi hypnobirthing memberikan sugesti positif pada diri ibu. sugesti ini mengubah gelombang otak beta (conscious mind) menjadi gelombang otak alpha (unconscious mind). di korteks serebri kemudian terjadi proses asosiasi penginderaan dimana rangsangan dianalisis, dipahami dan disusun menjadi suatu yang nyata sehingga otak mengenali objek dan arti kehadiran tersebut. pikiran adalah hasil dari “pola” perangsangan berbagai bagian sistem saraf pada saat bersamaan dan dalam urutan yang pasti, dimana melibatkan korteks serebri, thalamus, sistem limbik dan bagian atas formasio retikularis batang otak. daerah sistem limbik, thalamus dan formasio retikularis yang terangsang menimbulkan rasa senang, rasa tidak senang dan rasa sakit (guyton, 1996). dalam hipothalamus terjadi peningkatan beta endorfin yang berasal dari fragmen peptida pomc. sekresi beta endorfin ini akan membantu ibu meningkatkan toleransi nyeri saat persalinan. relaksasi hypnobirthing akan menuntun agar tetap dalam kondisi rileks dan sama sekali tidak memikirkan dan merasakan nyeri yang ditimbulkan oleh kontraksi rahim (andriana, 2007). hampir seluruh ibu pada kelompok perlakuan mampu mentoleransi nyeri yang diakibatkan oleh kontraksi. ibu dapat mengontrol respons verbalnya saat terjadi kontraksi misalnya dengan tidak berteriak dan menangis sehingga ibu tidak membuang tenaga yang dapat digunakan saat proses pengeluaran bayi saat kala ii. sebaliknya ibu yang tidak dapat mentoleransi nyeri atau memiliki toleransi yang rendah tampak sangat kelelahan dan memiliki interaksi sosial yang kurang. toleransi nyeri berbanding lurus dengan respons kecemasan pada ibu inpartu kala i fase aktif. seluruh responden dalam kelompok kontrol memiliki respons sedang terhadap kecemasan sedangkan pada kelompok perlakuan 5 dari 6 responden berespons ringan terhadap kecemasan. 1 orang dalam kelompok perlakuan yang memiliki respons sedang terhadap kecemasan disebabkan karena partus terjadi sebelum taksiran sehingga latihan yang dilakukan kurang dari 7 kali. respons kecemasan pada ibu inpartu kala i fase aktif dapat disebabkan oleh lama waktu kontraksi, khawatir pada keadaan bayi dan pengalaman persalinan yang pertama. respons kecemasan pada kelompok perlakuan umumnya ringan, hal ini disebabkan responden berada dalam kondisi yang rileks. kondisi rileks ini menyebabkan ketenangan jiwa dan emosi ibu sehingga siap untuk menghadapi proses persalinan. seluruh responden pada kelompok kontrol memiliki respons sedang terhadap kecemasan diakibatkan karena ibu tegang dan panik menanti kelahiran bayi. sebagian dari mereka merasa gelisah dan khawatir akan no. responden skor post test perlakuan kontrol nilai keterangan nilai keterangan 1 5 sedang 7 sedang 2 3 ringan 7 sedang 3 3 ringan 9 sedang 4 4 ringan 7 sedang 5 4 ringan 7 sedang 6 4 ringan 7 sedang mean sd 3,83 0,75 7,33 0,82 hasil analisis statistik mann whitney u test p = 0,015 hypnobirthing meningkatkan toleransi nyeri dan menurunkan kecemasan (nursalam) nursalam keselamatan bayinya akibat rasa nyeri yang tidak dapat ditoleransi oleh ibu. responden pada kelompok kontrol dan perlakuan sebagian besar merasa tidak bisa istirahat dengan tenang, namun responden kelompok perlakuan terlihat jauh lebih rileks dibandingkan dengan kelompok kontrol. kecemasan adalah respons emosional terhadap penilaian yang berkaitan dengan perasaan tidak pasti dan tidak berdaya. keadaan emosi ini tidak memiliki objek yang spesifik. kecemasan berbeda dengan rasa takut, yang merupakan penilaian intelektual terhadap sesuatu yang berbahaya (stuart dan sundeen, 1995). respons kecemasan dipengaruhi oleh banyak faktor diantaranya adalah perkembangan kepribadian, maturasional, tingkat pengetahuan dan karakteristik stimulus (stuart dan sundeen, 1995). menurut stuart dan sundeen (1995), kecemasan ringan biasa terjadi dalam kehidupan sehari-hari dan dapat membantu individu menjadi waspada dan mencegah berbagai kemungkinan terjadi. individu yang mengalami respons kecemasan sedang lebih memfokuskan hal penting saat ini dan mengesampingkan hal lain sehingga mempersempit lahan persepsinya. relaksasi hypnobirthing membuat ibu merasa rileks dan tenang saat timbul kontraksi yang makin lama makin kuat. latihan relaksasi hypnobirthing terdiri dari relaksasi otot, relaksasi pernapasan dan relaksasi pikiran. relaksasi otot bertujuan untuk mengurangi ketegangan dan kecemasan dengan cara melepaskan otot-otot badan (prawitasari et al., 2002). relaksasi pernapasan berguna untuk persiapan ketika ibu dalam keadaan inpartu. relaksasi pikiran digunakan untuk memasukkan sugesti positif ke dalam pikiran bawah sadar ibu (andriana, 2007). informasi tersebut akan terprogram di otak sehingga ibu merasa tenang. ibu akan merasa damai, tidak mudah emosi dan menjadi lebih antusias menyambut kelahiran bayinya (kuswandi, 2007 dalam andriana, 2007). respons ini menghasilkan koping positif pada ibu yang akhirnya akan menurunkan respons kecemasan ibu. keberhasilan dari latihan relaksasi hypnobirthing berbeda pada setiap individu. hal ini disebabkan setiap individu memiliki kemampuan konsentrasi berbeda-beda sehingga kemampuan untuk rileks berbeda pula pada setiap individu. perbedaan ini dapat disebabkan karena umur, pekerjaan ibu dan kondisi penyakit yang pernah dan sedang diderita. semakin tua umur, ibu semakin mudah untuk berkonsentrasi. ibu yang tidak bekerja jauh lebih mudah untuk berkonsentrasi dibandingkan dengan ibu yang bekerja. ibu yang bekerja biasanya kelelahan saat latihan sehingga sulit untuk berkonsentrasi simpulan dan saran simpulan metode relaksasi hypnobirthing terbukti meningkatkan toleransi nyeri dan menurunkan respons kecemasan pada ibu inpartu kala i fase aktif. stimulus relaksasi hypnobirthing merangsang pituitary mengeluarkan pomc sehingga dapat meningkatkan sekresi beta endorfin. pengeluaran beta endorfin meningkatkan toleransi ibu terhadap nyeri. sugesti positif dari relaksasi hypnobirthing menyebabkan respons kognitif dan emosi ibu positif. respons ini menghasilkan koping positif pada ibu sehingga terjadi penurunan respons kecemasan pada ibu. saran peneliti menyarankan agar latihan relaksasi hypnobirthing perlu diberikan pada ibu hamil ketika memasuki trimester iii sehingga ibu lebih tenang dan siap menghadapi persalinan. metode relaksasi hypnobirthing dapat diterapkan sebagai salah satu tindakan keperawatan di poli hamil (sejak ibu melakukan anc) sehingga ibu dapat lebih mentoleransi nyeri dan kecemasannya saat inpartu kemudian penelitian lebih lanjut dapat dilakukan untuk mengetahui pengaruh relaksasi hypnobirthing terhadap beta endorfin pada ibu inpartu kala i fase aktif. kepustakaan abidin. 2007. melahirkan tanpa rasa sakit. makalah disajikan dalam talkshow melahirkan tanpa rasa sakit dengan metode hypnobirthing, hotel arjuna, bandung, 24 februari. jurnal ners vol.3 no.1 april 2008 : 54-60 andriana. 2007. melahirkan tanpa rasa sakit dengan metode relaksasi hypnobirthing. jakarta: penerbit pt bhuana ilmu populer, hlm. 78-80. bobak, lawdermilk dan jensen, 2005. buku ajar keperawatan maternitas. edisi 4. alih bahasa oleh maria a. wijayarini. jakarta: egc, hlm. 235-261. calliaud dan lorencau. 1995. rating depresi dan anxiety. usa: stablor international, pp. 100-110. cyana, et al. 2006. antenatal self-hipnosis for labour and childbirth: a pilot study. anaesthesia and intensive care, 464-469. guyton dan hall. 1996. buku ajar fisiologi kedokteran. alih bahasa oleh brahm u. pendit. jakarta: egc, hlm. 598, 603-604, 671, 676. kusuma. 2007. kebugaran dalam kehamilan. jakarta: prestasi pustaka, hlm. 33-45. madyastuti. 2006. pengaruh teknik abdominal breathing terhadap penurunan nyeri ibu inpartu pada kala i fase aktif persalinan fisiologis. skripsi tidak dipublikasikan. surabaya: universitas airlangga, hlm. 68-79. perry dan potter. 2005. fundamentals of nursing: concepts, process and practice, usa: mosby incompany, pp. 1153-1188. prawitasari, et al. 2002. psikoterapi, yogyakarta: pustaka pelajar (anggota ikapi), hlm. 139-179. price dan wilson. 2006. patofisiologi: konsep klinis proses-proses penyakit. alih bahasa oleh brahm u. pendit. jakarta: egc, hlm. 1063-1088. rita. 2007. mempersiapkan kelahiran bayi anda. jakarta: penerbit arcan, hlm. 79-83. santi. 2005. pengaruh teknik efflurage oleh petugas kesehatan terhadap penurunan persepsi nyeri kala i fase aktif persalinan fisiologis. skripsi tidak dipublikasikan. surabaya: universitas airlangga. stuart dan sundeen, 1995. principles and practice of psychiatric nursing fifth edition, missouri: mosby inc, pp. 7882. author index volume 12 number 1 april 2017 and volume 12 number 2 october 2017 africia, fresty, 164 ahmad, musfirah, 88 ahsan, ahsan, 261 aini, septy nur, 189 andini, saskiyanti ari, 119 anggraeni, agnes sevelina, 27 artini, budi, 113 asnar, elyana, 113 astutik, erni, 66 aung, sa sa, 1 deviantony, fitrio, 261 dewi, desak made sintha kurnia, 66 dewi, yulis setiya, 1 dewie, novia shinthia, 286 dharmana, edi, 9 ediyati, anastasia, 212 efendi, ferry, 151, 180 erika, kadek ayu, 126 gasem, hussein, 9 hamid, achir yani s., 151 hanafi, mochamad cholid, 225 hardiansyah, hardiansyah, 33 harmayetty, harmayetty, 142 hartono, h., 253 has, eka misbahatul mar'ah, 286 hastuti, apriyani puji, 133 hendrawati, sri, 239 hermayanti, yanti, 180 hidayat, abdul aziz alimul, 14 hidayati, laily, 233 ibrahim, kusman, 239 kamso, sudijanto, 151 krisnana, ilya, 171 kristiawati, kristiawati, 27 kurniasari, maria dyah, 9 kurniawan, krisna eka, 41 kusnanto, kusnanto, 142 kusumaningrum, tiyas, 164 laili, nadia rohmatul, 19 lasmani, patricia suti, 189 makhfudli, makhfudli, 119 mandagi, ayik mirayanti, 66 maulidiawati, ita, 158 muhammad hadi 151 mulatsih, sri, 189 nihayati, hanik endang, 41, 158 notobroto, hari basuki, 74 nur’aeni, aan, 239 nursalam, nursalam, 1, 108, 133, 151, 158, 212, 225 nuryanti, aprilia, 108 pahlevi, rifka, 60 peristiowati, yuly, 247 pertiwi, dian atma, 126 pradanie, retnayu, 33 prajayanti, eska dwi,142 prasetyo, awal, 196 pratiknya, ahmad watik, 151 priambodo, ayu prawesti, 239 pujiyanto, tri ismu, 212 puspikawati, septa indra, 66 putra, suhartono taat, 60 rachmawati, praba diyan, 119 rachmawaty, rini, 88 rahayuwati, laili, 99 ramadhani, febrina, 233 richard, selvia david, 196 rifai, akhmad, 296 rosnani, rosnani, 81 sari, sheizi prita, 99 sari, yunita, 253 saryono, s., 253 sebayang, susy katikana, 66 seniwati, tuti, 126 setyoadi, setyoadi, 261 sjattar, elly l., 88 sriwulaningdyah, martini, 219 sriyono, sriyono, 60 suhita, byba melda, 74 sukadiono, sukadiono, 14 sukartini, tintin, 27, 171, 205, 233, 278 sulistiawati, sulistiawati, 19 sumardino, sumardino, 296 suprihati, suprihati, 212 supriyanto, stefanus, 164 susilaningrum, rekawati, 49, 267 susilorini, susilorini, 49, 267 sutoto, sutoto, 151 sutrisna, eman, 253 suwardianto, heru, 196 thu, hein, 205 triharini, mira, 108, 133 tun, zay yar, 278 ulfiana, elida, 225 uliyah, musrifatul, 14 utami, reni sulung, 196 utami, sri, 49, 267 wahyuni, chatarina umbul, 74 wahyuni, erna dwi, 219 widodo, widodo, 296 widyawati, ika yuni, 19, 113 witdiawati, witdiawati, 99 wulandari, sarah kartika, 180 yamin, ahmad, 180 yunitasari, esti, 33 yusuf, ah, 41, 74 yusuf, saldy, 88 zatihulwani, eliza zihni, 171 subject index volume 12 number 1 april 2017 and volume 12 number 2 october 2017 a adaptation, 74, 180 adverse events (ae), 133, 219 aorta, 247 assessment instrument, 108 avocado, 113 b basic conditioning factor, 286 behaviours, 278 blood glucose, 60 boarding time, 261 breast cancer, 81, 99, 180 bullying, 126 burnout syndrome, 212 c cancer, 205 career women, 81 caregiver, 74, 180 catechins, 247 civil service police unit, 296 coastal communities, 66 colostomy, 239 communication skills, 267 community, 225 competence, 151, 259 competitive advantage, 14 complementary therapy, 253 consumption pattern, 19 coping mechanism, 81 coping proactive, 233 cortisol, 60 critical patient, 196 customer expectation, 164 d demographic characteristics, 239 dhikr, 60 diabetes mellitus, 19 diabetes mellitus type 2, 60, 88 diabetic ulcer, 253 e education, 19, 189 educational staff, 164 elderly, 225 electrical stimulation, 253 emergency department, 261 endothelial progenitor cells, 247 ethno-nursing, 99 experiential learning, 158 f family, 126 family planning, 33, 278 fasting blood sugar, 88 first aid emergency training, 296 g gang, 126 gender, 126 geriatric health programme, 225 h hba1c, 88 health belief, 278 health care service, 66 health care-seeking behavior, 66 hospitals, 151 hypercholesterolemia, 113 hyperglycemia, 247 i icu, 196 ischemic stroke, 142 jigsaw puzzle, 142 k knowledge, 1 knowledge management, 133 l lawrence green, 33 life-pattern, 99 loyalty, 164 lymphocytes, 9 m mangosteen peels extract, 9 married men, 278 maternal health care, 66 medication error, 133 modeling participant, 41 mother self-efficacy, 171 motivation, 267 myanmar, 205 n nurse, 19 nurses’ performance, 108 nursing education 14, 151 o obedience, 1 open defecation, 119 p pain management program, 205 parent’s behavior, 119 partnership, 151 patient safety, 189 patient safety goals, 158 perceived quality, 164 physical function, 196 physical immobilized patient, 286 practice of exclusive breast feeding, 49 prevention, 219 prevention non-pneumonia ari, 171 primary health center, 88 prolanis, 88 pulmonary tuberculosis, 233 q quality, 14 quality of life, 205, 239 quality of nursing work life model, 212 r recovery motivation, 60 risk of obesity, 27 rosella tea, 113 s satisfaction, 164, 225 schizophrenia, 41, 74 school-age children, 27, 119 sedation, 196 self-achievement, 212 self-care, 41, 286 self-care management, 233 self-leadership, 267 service quality, 225 simvastatin, 113 six sigma, 219 speak up, 189 standard precautions, 1 stress, 180 supervision, 158 t tardive dyskinesia, 196 theory of planned behavior, 19 transactional communication, 49 transcultural nursing theory, 119 u ulcus decubitus, 219 upper extremity fine motor, 142 v vasectomy, 33 vibration, 253 w web, 108 wound healing, 253 y yellow zone, 261 1 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of:  a highly respected journal in the nursing field.  it is indexed in major databases: science and technology index (sinta), indonesian publication index (ipi), google scholar, bielefeld academic search engine (base).  rapid initial screening for suitability and editorial interest. jurnal ners has been accredited by the ministry of science, research, technology and higher education of indonesia since 2010. ii. focus and scope the scope of this journal includes, but is not limited to the research results of:  fundamentals of nursing  management in nursing  medical-surgical nursing  critical care nursing  emergency and trauma nursing  oncology nursing  community health nursing  occupational health nursing  mental health nursing  holistic nursing  geriatric nursing  family nursing  maternity nursing  women's health  pediatric nursing  education in nursing  nursing policies  legal nursing  advanced practice nursing  nursing informatics author information pack update: june 10th 2017 please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing https://drive.google.com/file/d/0b5ormcrmctnwq0dix2dictffdlk/view?usp=sharing 2 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam, m.nurs (hons), universitas airlangga, indonesia international advisory board reviewers prof. eileen savage, university college cork, ireland dr. wendy abigail, flinders university, australia dr. chong mei chan, university of malaya, malaysia dr. sonia reisenhofer, la trobe university, australia dr. ya-ping yang, kaohsiung medical university, taiwan editor: ferry efendi, s.kep., ns., m.sc., ph.d., universitas airlangga, indonesia retnayu pradanie, s.kep., ns., m.kep., universitas airlangga, indonesia praba diyan rachmawati, s.kep., ns., m.kep., universitas airlangga, indonesia laily hidayati, s.kep., ns., m.kep., universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., universitas airlangga, indonesia nadia rohmatul laily, s.kep., ns., m.kep., universitas airlangga, indonesia lingga curnia dewi, s.kep., ns., m.kep., universitas airlangga, indonesia dimas dwi arbi, s.kom., universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. mailto:secretariat_jurnalners@fkp.unair.ac.id http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 3 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on apriori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and metaanalyses will be dealt with as original articles are, as far as the editorial process is concerned. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and post-publication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following:  introduction: one or two sentences on the background and purpose of the study.  method: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics).  results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals.  conclusions: should relate to the study aims and hypotheses.  keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. 4 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. acknowledgment (optional). acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below:  observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/  qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq  quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/  randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/  study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/  systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/  systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 publication fee jurnal ners charges the author a publication fee amounted to idr 1.000.000 (indonesian author) and usd 100 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within two working days. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 5 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: ………………………………………………………………………………………………….. f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 7 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 9 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 9th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.zotero.org/styles?q=apa ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. https://www.zotero.org/styles?q=apa 10 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author,  hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language.  have read the final version of the manuscript and responsible for what is said in it.  have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website.  hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below.  acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk pengaruh stimulasi kulit abdomen dengan teknik effleurage terhadap penurunan persepsi nyeri kala i fase aktif persal 51 pengaruh cat stretch exercise terhadap penurunan intensitas nyeri menstruasi (dysmenorrhea) dan tanda-tanda vital pada remaja purwaningsih*, ni ketut alit a.*, agus sulistyono **, esti y.*, mira t.*, anita nurmasitoh abstract menstruation is a period of uterine fluid discharge to endometrial detachment, often accompanied with pain called dysmenorrhea. the objective of this study was to analyze the effect of cat stretch exercise on the relief of menstrual pain and characteristics of vital sign in adolescence. pre experimental design (one group pre-post test) was used in this study, 12 samples were recruited by purposive sampling. observation and questionnaire were applied to measure patient’s pain scale. data were analyzed by using wilcoxon signed rank test (p<0.05). conclusion: the cat stretch exercise has effect on relieve of menstrual pain (dysmenorrhea) and normalized of vital sign: blood pressure, hearth rate and respiratory rate. key words: dysmenorrhea, cat stretch exercise, blood pressure, hearth rate, respiratory rate. pendahuluan nyeri menstruasi, disebut juga dysmenorrhea merupakan salah satu masalah ginekologi yang paling umum dialami remaja putri dan wanita usia produktif (jameison, 1996 dikutip dari alzubaidi, 2004). nyeri menstruasi ini dialami oleh 55% dari wanita usia produktif di indonesia. faktor penyebab timbulnya nyeri pada saat menstruasi sampai saat ini belum diketahui secara pasti. berdasarkan pendekatan teori hormonal, dysmenorrhea dihubungkan dengan perubahan hormon yang cukup signifikan pada periode menstruasi. perubahan tersebut disebabkan oleh prostaglandin f2alpha (pgf2-alpha) yang diproduksi oleh endometrium uterus setelah ovulasi terjadi (hale, 2004). terdapat beberapa tipe dysmenorrhea, antara lain tipe primer, yaitu yang disebabkan oleh ketidakseimbangan hormon, dan tipe sekunder yang terjadi akibat adanya suatu kelainan organ dalam pelvik (mc. kesson, 2004). _______________ * staf pengajar psik fk unair ** lab. obstetri ginekologi rsu dr. soetomo surabaya angka kejadian tipe primer di indonesia adalah sekitar 54,89%, sedangkan sisanya adalah penderita dengan tipe sekunder (abidin, 2004). dysmennorhea menimbulkan rasa yang tidak nyaman dan kesulitan berkonsentasi, yang dapat membatasi wanita untuk melakukan aktivitas sehari-hari (hamilton, 1995) berbagai upaya telah dilakukan oleh para wanita untuk dapat mengatasi masalah ini termasuk berbagai modifikasi latihan fisik (bobak, et. all., 2005). cat stretch excercise merupakan salah satu gerakan yoga yang dipercaya dapat menurunkan dan menghilangkan nyeri menstruasi (lie, 2004). bahan dan metode penelitian penelitian ini menggunakan desain pra eksperimental (one group pre-post test design). dua belas orang sampel di rt 06 rw iv rungkut menanggal harapan surabaya dilibatkan dalam penelitian ini. variabel bebas dalam penelitian ini adalah cat stretch exercise yang diberikan sebanyak 3 kali berturut-turut saat nyeri menstruasi, variabel tergantung adalah nyeri menstruasi (dysmenorrhea) dan perubahan tanda-tanda vital (tekanan darah, nadi dan pernapasan). analisis data dilakukan dengan uji statistik wilcoxon signed rank test 52 dan paired t-test dengan tingkat kemaknaan p 0.05. instrumen yang digunakan dalam penelitian meliputi: observasi respons nyeri (tekanan darah, nadi dan jumlah pernapasan tiap menit) dan kuisioner skala intensitas nyeri bourbonais yang diisi oleh responden. hasil penelitian 1. pengaruh cat stretch excercise terhadap intensitas nyeri menstruasi (dysmenorrhea) tabel 1: tabel intensitas nyeri remaja putri mean sd analisis wilcoxon sign rank test (p 0.05) sebelum perlakuan 4.67 1.15 p=0.002 setelah perlakuan 1.42 1.08 dari tabel 1 dapat dilihat bahwa terdapat pengaruh cat stretch excercise terhadap intensitas nyeri menstruasi (p= 0.002). 2. pengaruh cat stretch excercise terhadap perubahan tanda-tanda vital (tekanan darah, nadi dan pernapasan) tabel 2: tabel perubahan tanda-tanda vital vital sign sebelum perlakuan setelah perlakuan analisis paired ttest (p0.05) mean sd mean sd td sistolik 113.33 6.68 103.33 9.00 p= 0.001 td diastolik 70 7.93 63.33 5.15 p= 0.001 nadi 77.25 9.63 73.33 10.06 p= 0.001 rr 18.67 1.15 17.33 0.78 p= 0.002 keterangan: td = tekanan darah rr = respiratory rate dari tabel 2 dapat dilihat bahwa terdapat pengaruh cat stretch excercise terhadap perubahan tekanan darah (p=0.001), nadi (p=0.001), pernapasan (p=0.002). pembahasan setiap kerusakan jaringan memicu pengeluaran substansi kimia, dalam hal ini endometrium uterus yang mengalami peluruhan memproduksi prostaglandin f2alpha yang merangsang kontraksi miometrium (guyton, 1998). kontraksi yang terlalu kuat menyebabkan suplai darah ke uterus terhenti untuk sementara, sehingga otot uterus kekurangan oksigen dan mengalami suatu iskemia dan menimbulkan nyeri (hale, 2004). berdasarkan tabel 1 dapat dilihat bahwa terdapat pengaruh pemberian cat stretch excercise terhadap intensitas nyeri pada remaja putri. sebelum pemberian cat stretch excercise diketahui bahwa seluruh responden mengalami nyeri menstruasi pada skala sedang dan berat. setelah melakukan cat stretch excercise seluruh responden berada pada tingkat nyeri sedang. respons tubuh terhadap nyeri merupakan proses yang sangat kompleks dan melibatkan berbagai aspek. perbedaan persepsi nyeri yang terjadi, dikarenakan perbedaan kemampuan tiap individu dalam merespons dan mempersepsikan nyeri. kemampuan merespons dan mempersepsikan nyeri ini menurut brunner & suddarth (2002) dipengaruhi oleh banyak faktor antara lain: 1) faktor lingkungan (suara, suhu udara, cahaya, dan lain-lain), 2) faktor usia, 3) faktor budaya, 4) faktor kecemasan dan stres individu, 5) faktor kepercayaan/agama dan 6)fpengalaman nyeri sebelumnya. cat stretch excercise merupakan rangkaian peregangan yang mempengaruhi perubahan tanda-tanda vital melalui sistem hpa-axis. 53 pada sistem ini hipotalamus melepas hormon corticotropin releasing factor (crf) yang menstimulasi medula adrenal untuk meningkatkan produksi propioidmelanocortin (pomc) sehingga pembentukan enkephalin juga meningkat. kelenjar pituitari menghasilkan -endorphin yang dapat mempengaruhi suasana hati seseorang menjadi lebih rileks. peningkatan -endorphin dan enkhepalin menurunkan aktifitas saraf simpatis (sherwood, 2001). penurunan aktifitas saraf simpatis ini menyebabkan penurunan cardiac output yang pada akhirnya menyebabkan penurunan tekanan darah, tahanan perifer, nadi dan respiratory rate (guyton, 1998). simpulan dan saran simpulan 1. pemberian cat stretch excercise efektif dalam menurunkan intensitas nyeri menstruasi pada remaja putri. 2. pemberian cat stretch excercise berperan terhadap perubahan tanda-tanda vital pada remaja putri dengan nyeri menstruasi (dysmenorrhea). saran 1. pelaksanaan cat stretch excercise sebaiknya dilakukan pada saat nyeri menstruasi. durasi kegiatan ini sebanyak tiga kali berturut-turut. 2. perlu dilakukan pemberian pendidikan kesehatan dan pelatihan tentang cat stretch excercise pada remaja putri oleh perawat puskesmas yang kompeten. 3. perlu dilakukan penelitian lanjutan tentang cat stretch excercise dengan menambah jumlah responden, waktu penelitian dan variabel tergantung. juga dengan memberikan suatu kelompok kontrol. kepustakaan abidin, b., (2004). atasi nyeri haid dengan herbal alami. http://www.multibusindo.co/kesehatan/b eritasehat/detail.php?id=2800. tanggal 22 maret 2006 alzubaidi, n., (2004). dysmenorrhea. http://www.emedicine.com/med/akses. tanggal 23 maret 2006 jam 11.12. bobak, l. & jensen, (2005). buku ajar keperawatan maternitas edisi 4. jakarta: egc, hal: 989-990. brunner & suddarth, (2002). keperawatan medikal bedah, jakarta: egc. hal: 153. guyton & hall, (1997). buku ajar fisiologi kedokteran edisi 9, jakarta: egc, hal: 761-770. hale, e., (2004). taming menstrual cramps. http://www.fda.gov/bbs/topics/consumer /con00004.html. tanggal 20 maret 2006 jam 12.06. hamilton, p.m., (1995) dasar-dasar keperawatan maternitas edisi 6. jakarta: egc. hal: 16 lie, s., (2004). terapi vegetarian untuk penyakit kewanitaan, jakarta: prestasi pustaka. hal: 105-111. mc. kesson, (2004). menstrual cramps (dysmenorrhea). http://www.med.umich.edu/1libr/aha/aha _dysmen_crs.htm. tanggal 23 maret 2006 jam 13.25 sherwood, l., (2001), fisiologi manusia: dari sel ke sistem, jakarta: egc, hal: 156158, 282. turkington, c.a., (2004). dysmenorrhea. http://www.caremark.com/wps. tanggal 23 maret 2006 jam 11.51 wib http://www.multibusindo.co/kesehatan/beritasehat/detail.php?id=2800 http://www.multibusindo.co/kesehatan/beritasehat/detail.php?id=2800 http://www.emedicine.com/med/akses http://www.fda.gov/bbs/topics/consumer/con00004.html http://www.fda.gov/bbs/topics/consumer/con00004.html http://www.med.umich.edu/1libr/aha/aha_dysmen_crs.htm http://www.med.umich.edu/1libr/aha/aha_dysmen_crs.htm http://www.caremark.com/wps http://e-journal.unair.ac.id/jners 117 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 117-123 http://dx.doi.org/10.20473/jn.v18i2.44167 original article open access insights from leaders on effectively addressing overweight and obesity in the thai community duangporn piyakong 1 * , sangduan apiratanawong 1 , and chanikan suasing 1 1 faculty of nursing, naresuan university, phitsanulok, thailand *correspondence: duangporn piyakong. address: faculty of nursing, naresuan university, phitsanulok, thailand. email: duangporn@nu.ac.th responsible editor: retnayu pradanie received: 15 march 2023 ○ revised: 13 june 2023 ○ accepted: 13 june 2023 abstract introduction: effective management of healthcare system at the district level through an important health project can improve health and quality of life of people in the district. key factors to drive a successful project are important. the purpose of this study was to explore perspectives of leaders managing the healthcare system at a district level on preventing and resolving issues of overweight and obesity within their communities. methods: the participants of this study consisted of nine district health board committees, ten members of the district health system startup team and twenty-three village health system managers. data were collected by using focus group interviews, observation and documents analysis, also analyzing data by summarizing and categorizing the data of main points. results: the study results indicated that managing successful health problems at the district level needed: 1. creating clear and equal understanding, 2. having precious community capital and 3. integrating effective incentives for people in the community. conclusions: the findings of the study can be used as a guideline for managing the healthcare system at a district level through a project for the development of health issues and the quality of life among people in a community. this successful health system management can help develop the sustainability of public healthcare at the district level. keywords: district health system, health system management, improving health problems, success introduction healthcare reform under the concept of the district health system (dhs) is an important strategy that the ministry of public health of thailand has pushed to strengthen health services to people in communities based on the context of each community since 2013 (tejativaddhana et al., 2018). the concept focuses on integrating the participation of populations in each community and collaborating with multisectoral partners in the community to manage the population’s health problems and develop knowledge and abilities of people in that community regarding their way of life and their culture (office of permanent secretary ministry of public health, 2014); tejativaddhana et al., 2016). the important aim of using dhs is to enable people in the community to improve their quality of life, be self-reliant and take care of their health continuously and effectively, leading to a strong community healthcare system (saelee, 2014, 2020; tejativaddhana et al., 2018). the management of dhs in each district in thailand has been run by the district health board (dhb), the dhs startup team, and the village health system managers (vhsms) since 2016. dhb consists of leaders from public, private and people sectors of each sub-district (ministry of public health, 2016; thojampa, 2019) while the dhs startup team is comprised of healthcare providers from a district hospital and health promoting hospitals of that district. in addition, the vhsms consist of village chiefs and village health volunteers from each https://creativecommons.org/licenses/by/4.0/ mailto:duangporn@nu.ac.th https://orcid.org/0000-0003-3283-0423 supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 118 village in each district. they manage and govern the dhs based on one district health project which is an important health problem for most population in the district. they also support knowledge, guidelines, budget, resources to improve quality of life among the population in that district (jariya et al., 2018). several districts of thailand were selected to run dhs projects, including a district located in the north of thailand. this district has crucial health problems such as hypertension (ht), diabetes mellitus (dm), and especially overweight and obesity. evidence showed that children and adolescents of this district had obesity at 11.06% and 11.34% in 2017 and 2018, respectively, and people aged 30-59 years old had obesity at 37.68% (kamphaeng phet provincial public health office, 2019). overweight and obesity have become a significant health problem in thailand and the second highest prevalence of obesity in asia. around 37.7% of thai population aged ≥ fifteen years old were overweight and obese (pinchaleaw, 2018). overweight and obesity can cause metabolic syndrome, resulting in increasing in ht, dm, cardiovascular diseases and stroke (karnjanapiboonwong, 2020; lalam, chaimai, & fukfon, 2022). rates of dm patients with obesity from 2015 to 2017 were 9.23%, 11.42%, and 12.20%, respectively (kamphaeng phet provincial public health office, 2019). overweight and obesity is an important district health issue for most citizens with all ages in this district. before using dhs under one important project of the district, healthcare providers of the district dealt with overweight and obesity problems through giving nutrition and physical activity education to the population in the district and following the government’s policies, such as the fatless belly thais policy and the soda ban policy. unfortunately, there was a lack of serious cooperation from every sector and participation of populations in this district. overweight and obesity control and prevention among population in the targeted district did not succeed. therefore, in 2018, solving overweight and obesity and non-communicable diseases of the population at this district was run through a dhs startup project, titled “we all far away from obesity,” with the aim to decrease overweight or obesity, dm, and ht among citizens in this district. the results of this operation over two years found that not only the number of citizens who were overweight and were obese was reduced, but also rates of new patients with dm and ht decreased (kamphaeng phet province, 2020). it is important to learn success stories in management of dhs through a district health project. therefore, the researchers were interested in exploring successful health system management at the district level from direct experiences of the dhs leaders. the findings would provide important information to guide the development and strengthening of dhs management through a dhs project among people in other areas according to the dhs concept. materials and methods the purpose of this study was to explore perspectives of leaders managing the healthcare system at a district level on preventing and resolving issues of overweight and obesity within their communities. the study was conducted at a district located in the lower northern region of thailand in 2020. the population of the study was 21 dhb members, 25 dhs startup team members, and 100 village health system managers (vhsms). participants were eligible for participation in this study if they were (a) aged 20 years old and over, (b) had no physical or mental health problems, (c) selfidentified as thai speaking and (d) were willing to share their perspectives on driving the district healthcare system in a focus group. convenience sampling was used as the sampling methods. there were 9 -12 people for each focus group. data were obtained through four focus group discussions with a total of 42 participants. there were nine district health board committees, 10 members of the dhs startup team and 23 vhsms. the participants who could not complete the focus group process were excluded.the researchers divided focus group based on homogenous group.therefore, there were one dhb group, one dhs startup team group and two vhsm groups. the researchers collected the data based on guideline questions regarding success of driving the “we all far away from obesity” project. the focus group interview guidelines were developed by the researchers. key questions were perspectives of participants on operational processes, outcomes, success factors and any suggestions to drive the project to effectively improve quality of life of the people in the district. the focus group interview guideline was pilot tested with eight vhsms who were not the targeted participants. four focus group discussions took place in a meeting room at the district hospital. the focus group discussions continued until there was no new relevant information. at the end of the fourth focus group, the researchers felt that data saturation had been met because no new theme emerged, so the researchers stopped recruitment. the duration of the focus group interviews for each group was about 100-120 minutes. in addition, piyakong, apiranatawong, and suasing (2023) jurnal ners 119 p-issn: 1858-3598  e-issn: 2502-5791 data collection was also performed through nonparticipant observation and documents. ethical approval for the study was obtained from the institutional review board (irb) of the university (project no.0750/62). after ethical approvals were obtained, a researcher contacted the leader of the dhb, the dhs startup team, and the vhsms in order to introduce themselves, inform the research study, and ask for help about recruitment participants. at the beginning of group discussions, the researchers explained the rules and participated in the discussions as a facilitator to create a positive interactive atmosphere throughout the discussion and let the participants express their perspectives freely. the researchers recorded the focus group interviews, using a tape recorder, following the consent of the interviewees. afterwards, the recorded contents were transcribed verbatim. the data analysis began with the researchers transcribing the focus group discussions’ audio files verbatim. data were coded using the content analysis method. main themes were derived from the data and identified from the codes. finally, the researchers integrated main themes and data to compare perspectives among the dhb, the dhs startup team, and the vhsms. to ensure the validity of the research data, the researchers used methods of triangulation. the researchers used different data collection methods on the same subject, including observation, focus group discussions, and information from related documents. the researchers analyzed documents related to implementations of the dhs startup project, “we all far away from obesity.” the researchers examined goals, implementations, or activities of the project and correlated the data with the perspectives provided by the participants from group discussions. the results indicated that the information obtained from different data collection was consistent. results study sample a total of 42 participants attended the four focus groups. the dhb group included the deputy district chief, the chief executive of subdistrict administrative organization, the subdistrict headman, the director of the hospital, the district public healthcare center director, a policeman, a school director, a community developer, and an agricultural research officer. for the dhs startup team group, there were five public health officers, four registered nurses, and one nutritionist. moreover, the vhsms group included 13 village chiefs and 10 village healthcare volunteers. characteristics of all participants are shown in table 1. leaders’ perspectives on preventing and resolving issues of overweight and obesity of the population in their communities the results of this study revealed that the participants viewed that driving district-level health system management successfully through the startup project: “we all far away from obesity” which used the dhs concept, consisting of three major themes: creating clear and equal understanding, having precious community capital, and integrating effective incentives. details are as follows: theme 1: creating clear and equal understanding in the theme of creating clear and equal understanding, the participants explained that an effective dhs management process is necessary to ensure that everyone in the district has understanding of the problem and methods of solving the problem clearly and equally. the participants referred to creating clear and equal understanding of citizens in the district through continuous meetings and giving enough information to the public. “the community meeting every month between the dhs startup team and the leader from every community was very helpful because we could know the progress and we could inform them of our plans to manage this project correctly. we also let them tell us what they would like us to help them, and so on. so, i believe that everyone in the meeting knows the problems of others and knew the solving methods of each area equally and they applied them to their areas.” (fgd2, public health officer, dhs startup team) “i think giving the information about methods and results of the project every three months to people in the community has really worked because this could affect people to be willing to cooperate in solving health problems at the district level in various ways.” (fgd1, sub-district headman, dhb) table 1. participant demographics the dhb team (9) the dhs startup team (10) the vhsm team (23) n % n % n % gender male female 7 2 77.78 22.22 6 4 60.00 40.00 12 11 52.17 47.83 age (years) 30-40 40-50 60-65 3 6 33.33 66.67 5 5 50.00 50.00 8 10 5 34.78 43.48 21.74 experiences of work in dhs 2-3 years 4-5 6-8 4 5 44.44 55.56 2 6 2 20.00 60.00 20.00 10 13 43.06 56.94 supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 120 “we gave them knowledge about causes, impacts, prevention, and reducing of overweight, obesity, ht, and dm through all kinds of communication method as we could, such as community meetings, billboards or announcements, on line application, our facebook page, or public address system (pa system) so that everyone and every age may gain this knowledge. when they knew, they were concerned with the issue and joined every activity of the project.” (fgd2, registered nurse1, dhs startup) “…complete understanding from every team and every person in the district about the real health problem and what our district should change is a very important point. this can help us to drive the project to the direct way easily....” (fgd4, village headman, vhsm group) theme 2: having precious community capital most participants explained successful management of dhs in terms of having precious community capital. precious community capital in this district consists of social capital, human capital and physical capital. half of the participants explained social capital in this area as cooperation of people and other organizations in the district and strong networks in the district. “we are very lucky because most people and every organization in this district have cooperated in every activity very well, including this project.” (fgd1, deputy district chief, dhb) “luckily, we have strong networks. every sector, such as schools, temples, and other community organizations, has worked with us continuously and actively so far…. if we don’t have this connection, the project could not be successful.” (fgd2, public health technical officer2, dhs startup team) almost all participants expressed that important human capital in this district included effective leaders and community health volunteers. “i think we were very lucky to have good community leaders. they were very knowledgeable members… they knew very well about what, when and where to do and whom to do with.” (fgd2, physician1, dhs startup team) “every community leader and most community health volunteers are very helpful for operating the project continuously and effectively. they knew how to get people involved in the project continuously. if we didn’t have them, the project could not be successful for sure.” (fgd1, community developer, dhb) in addition, almost half of the participants clarified physical capital in terms of a model community farm and healthy food markets as follows: “i’m very proud to say that we have already had a model community farm for organic farming. ... many people from both in the district and other districts came to visit it continuously.” “…. the farm could encourage people to be aware of eating healthy foods to prevent many diseases and obesity.” (fgd3, village headman3, vhsm) “we also have health food markets to sell many healthy foods and they are accepted by people across the district very well.” (fgd1, sub-district headman, dhb) theme 3: integrating effective incentives there were a variety of effective incentives that the participants used to support the “we far away from obesity” project, including their favorite sports, competition and rewards, and interesting campaigning. most participants viewed that providing various types of sports for citizens in each sub-district was a good incentive to encourage people to do exercise based on their preference. there were a lot of exercises, including aerobic dance, thai dance, football, jogging, cycling, petanque and bar slope dance. they could select a sport they liked. “we tried to encourage people in our area to control weight by setting up exercising clubs such as a petanque club and a cycling club for everyone. however, some elderly people asked for other exercises…. finally, we set up a thai dance club and bar slope dance as well. they work very well…all clubs haven’t been closed yet.” (fgd3, village headman5, vhsm) “the aerobics club always opened every evening. this sport could attract people all ages, especially adults, very well because we usually turned on fun music and people in this sub-district like music very much… so, almost everyone joined the sport they like.” (fgd4, village health volunteer2, vhsm) many participants shared their experiences of success, driving the project through providing competitions and rewards. “our district had a sport competition among a subdistrict. i think this method really worked. people in each sub-district tried to practice for winning the competition and receiving rewards. i saw they played football and did aerobic dance and thai dance almost every day before the competition.” (fgd1, the deputy district chief, dhb) “we announced that we would give rewards to whoever can lose weight from exercising or eating. you know? afterwards, many people were interested in this piyakong, apiranatawong, and suasing (2023) jurnal ners 121 p-issn: 1858-3598  e-issn: 2502-5791 project. they followed the announcement and many people got rewards when they lost weight.” (fgd1, chief executive of the sub-district administrative organization, dhb) “our sub-district used a competition through a project of growing vegetables by themselves. we ran a vegetable gardening competition. almost every house had planted. you know? after that, most of them cooked it or someone sold it in a health food market in our district.” (fgd3, village headman, vhsm) in addition, many participants focused on interesting campaigns, for instance, growing vegetables, cooking foods, monthly physical examination and waist measurement. “we had a monthly waist and blood pressure measurement project for everyone in our district. this method could monitor people’s health very well…many citizens told me that waist and blood pressure measurements were good indicators to control their weight and health.” (fgd2, registered nurse1, dhs startup team) “we also had a continuous campaign to encourage our citizens to grow vegetables, cook their own foods, and reduce eating salty, fatty and sweet foods. ones who joined this campaign said that they could control their weight and health very well.” (fgd2, nutritionist, dhs startup team) discussions healthcare system management in the district of this study was an operation with the participation of all sectors based on major health issues of people in the community. the dhb team, the dhs startup team and the village health system manager team of this district focused on the importance of solving district health problems through creating clear and equal understanding of the problem and operation, using precious community capital, and integrating effective incentives. clear and equal understanding regarding health-related issues might be able to promote problem perceptions in the same way and raise self-awareness to all people in the district. in addition, clear and equal understanding about methods to solve the problems might encourage people to be willing to participate in the project for improving their quality of life and health problems. the results of this study are consistent with a study by koompai (2016), which found that clear understanding could encourage participation of people in the community. this is also consistent with a study by wanaratwichit et al. (2018), which indicated that understanding the problem and the project is an important mechanism to drive a project within the dhs and can be a factor to help the project to be successful. moreover, the present study is consistent with a study by nilsen et al. (2020) and thojampa et al. (2023), who found that clear communication could increase the chance of successful changes. the result of the study which is similar to several previous studies can demonstrate that clear and equal understanding from populations and every sector in the district is an important method to prevent or reduce overweight and obesity. in addition, this method might be able to be applied to manage ncds. therefore, it is important in creating understanding through continuous meetings and giving appropriate and complete information with various forms of communication, such as online application, community bulletin board, pa system, and meetings, with people and organizations in the district to have them understand and improve the ability to practice easily (indharatana, 2014), leading to health improvement. in addition, the leaders at all levels of this study indicated that community capital, including human capital, social capital and physical capital, plays an important role in driving the project success. strong leaders and community health volunteers, popular model community farms, well-established health food markets, and good networks at all levels fostered participation of people in the community in all sectors. when people in the district cooperated in the project, they managed their health problems by themselves. finally, the community health problems could be continuously and directly solved, leading to improving quality of life and sustainable health development. the findings of this study are consistent with some previous studies (dhammasaccakarn et al, 2022; nithisirawat, 2020; sanarmkate & kabjan, 2021; supabhato et al., 2020) which concluded that the community capital influences self-management for sustainable development of a local community. the present research study is also consistent with a study by wanaratwichit et al. (2018) which reported that using community capital is an important strategy because it is familiar to people in the community. when applied, it can be easily practiced in normal life. another important key to drive the project successfully is that participants referred to providing various effective incentives. this theme means providing a variety of incentives based on one’s satisfaction. the participants explained incentives as sports, competitions and rewards, and campaigning about foods and monthly waist measurement in each supremo, bacason, and sañosa (2022) http://e-journal.unair.ac.id/jners 122 sub-district. the findings of the study are consistent with previous incentives studies revealed that incentives, such as sports, competitions, rewards, and campaigning, could motivate people’s actions (dimenichi & tricomi, 2015; giles et al., 2014; hafner et al., 2020; plangger et al., 2022; sibanda et al., 2017). an incentive is a mechanism that motivates a person to act or influences the decision of each person (bradley et al., 2018). therefore, integrating favorite incentives into any activities of the “we all far away from obesity” project might be a power to encourage people in the district of this study to participate in any activities to change their behavior and lead to better health. various incentives based on ones’ satisfaction are a very useful motivation (bradley et al., 2018). therefore, providing effective incentives should be of concern about types and satisfaction of incentives. the participants in the study provided various incentives based on their citizens’ wants. limitations although this study’s findings provide waypoints of how to drive dhs through a project successfully, the study explored perspectives from only leaders who managed the project, not people in the district. this is a limitation of this study. therefore, further studies should consider the perspectives of people in the district about the operation and results of the project. implications driving the dhs under one project based on creating clear and equal understanding, having precious community capital, and integrating effective incentives is a strategy that should be applied to prevent or control overweight and obesity in other areas where rates of overweight and obesity remain challenging. in addition, it should be possible to apply the strategy to manage chronic non-communicable diseases or diseases caused by health behavior. this strategy will help improve health lifestyles and address overweight, obesity, related non-communicable diseases effectively and sustainably. conclusion the results of this study have shown valuable methods to drive the dhs under one project successfully, based on perspectives of leaders, consisting of creating clear and equal understanding, having precious community capital, and integrating effective incentives to improve health problems of people in the district. the findings of this study offer important methods to manage health system successfully to healthcare leaders and community leaders in other communities having health problems, especially overweight or obese, to apply these methods to solve their citizens’ health problems continuously and effectively, leading to developing the sustainability of public healthcare at the district level. conflict of interest statement no conflict of interest has been declared by the authors. references bradley, k. l., shachmut, k., viswanathan, s., griffin, b., & vielehr, d. (2018) ‘the role of incentives in health closing the gap’, military medicine, 183(suppl_3), 208–212. https://doi.org/10.1093/milmed/usy216 dhammasaccakarn, w., ratchapolsit, a., shoteshoung, p., dhammasajjakan, a., & sanguankaew, s. (2022) ‘community capital and self-management potential for the sustainable development of local communities’, narkbhutparitat journal, 14(1), 23–32. dimenichi, b. c., & tricomi, e. (2015) ‘the power of competition: effects of social motivation on attention, sustained physical effort, and learning’, frontiers in. psychology, 6, 1282. https://doi.org/10.3389/fpsyg.2015.01282 giles, e. l., robalino, s., mccoll, e., sniehotta, f. f., & adams, j. (2014) ‘the effectiveness of financial incentives for health behaviour change: systematic review and meta-analysis’, plos one, 9(3), e90347. https://doi.org/10.1371/journal.pone.0090347 hafner, m., pollard, j., & van stolk, c. (2020) ‘incentives and physical activity: an assessment of the association between vitality’s active rewards with apple watch benefit and sustained physical activity improvements’, rand health quaterly, 9(1), 4. https://www.ncbi.nlm.nih.gov/pubmed/32742746 indgraratana, a. (2014) ‘health literacy of health professional’, journal of the royal army nurses, 15(3), 174-178 https://he01.tcithaijo.org/index.php/jrtan/article/view/30480/26293 jariya, w., wanwonsin, a., & noosorn, n. (2018) ‘district health system: international experiences and the development in thailand’, eau heritage journal science and technology, 12(1), 182–195. kamphaeng phet provincial public health office. (2018) ‘civil service inspection and supervision in normal cases for ministry of public health year 2018’, http://kpo.moph.go.th/webkpo/kpp.pdf kamphaeng phet province. (2020) ‘the development of the district quality of life development committee, sai thong watthana district, kamphaeng phet province’, https://mis.kpo.go.th/ita/ita_evidence/20201223204943.pdf karnjanapiboonwong, a. (2020) ‘non-communicable disease situation according to 9 global targets of thailand, in karnjanapiboonwong, a., khamwangsa-nga, p., and kaewtha, s. (eds.) ncds status report: diabetes, hypertension and related risk factors 2019’, bangkok: graphic and design publishing, (pp. 1-24). koompai, s. (2016) ‘factors affecting the participation of the people in modelled subdistrict administrative organizationsin nakhon si thammarat’, veridian e-journal silpakorn university, https://he02.tci-thaijo.org/index.php/veridian-ejournal/article/view/66119/54062 lalam, p., chaimai, a., and fukfon, k. (2022) ‘metabolic syndrome in older persons: impacts and nursing roles’, journal of nursing and health research, 23(2), 13-27. available at: file:///c:/users/user/downloads/13-27%20(1).pdf ministry of public health. (2016) ‘guideline on the operation of primary care cluster for health providers (in thai)’, http://bps.moph.go.th/ new_bps/sites/default/files/guidelines pcc.pdf https://mis.kpo.go.th/ita/ita_evidence/20201223204943.pdf piyakong, apiranatawong, and suasing (2023) jurnal ners 123 p-issn: 1858-3598  e-issn: 2502-5791 nilsen, p., seing, i., ericsson, c., birken, s. a., & schildmeijer, k. (2020) ‘characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses’, bmc health service research, 20(1), 147. https://doi.org/10.1186/s12913-020-4999-8 nithisirawat, t. (2020) ‘social capital affecting strong community development case study: ban na’, samai community na samai subdistrict, mueang yasothon district, yasothon province, ratanabuth journal, 3(2), 52-60. https://so07.tcithaijo.org/index.php/rtnb/article/view/638 office of permanent secretary ministry of public health. (2014) ‘district health system (dhs) for thailand edition. nontaburi: ministry of public health’ (in thai) pinchaleaw, d. (2018) ‘the management of the obesity for community nurses practitioner’, journal of the police nurses, 10(2), 433-441. https://he01.tcithaijo.org/index.php/policenurse/article/view/153775/118266 plangger, k., campbell, c., robson, k., & montecchi, m. (2022) ‘little rewards, big changes: using exercise analytics to motivate sustainable changes in physical activity’ information and management, 59(5), 103216. https://doi.org/10.1016/j.im.2019.103216 saelee, d. (2014) ‘primary care value added with dhs (in thai). bangkok: national health security office (nhs)’ saelee, d. (2020) ‘district health system. ministry of public health’ sanarmkate, t., & kabjan, n. (2021) ‘guidelines for strengthening community capital to determine success factors at uttaradit province’, the journal of research and academics, 5(1), 129-144. https://so06.tci-thaijo.org/index.php/jra/article/view/247367 sibanda, e. l., tumushime, m., mufuka, j., mavedzenge, s. n., gudukeya, s., bautista-arredondo, s., hatzold, k., thirumurthy, h., mccoy, s. i., padian, n., copas, a., & cowan, f. m. (2017) ‘effect of non-monetary incentives on uptake of couples’ counselling and testing among clients attending mobile hiv services in rural zimbabwe: a cluster-randomised trial’, the lancet global health, 5(9), e907–e915. https://doi.org/10.1016/s2214-109x(17)302966 supabhato, p. ., sirimedho, p. ., & rungmuang, t. (2020) ‘social capital and community development wat samrong nakhon chai si district, nahon pathom province (in thai)’, journal of mcu peace studies, 8(3), 828-840. https://so03.tcithaijo.org/index.php/journal-peace/article/view/240828/164866 tejativaddhana, p., briggs, d., singhadej, o., & hinoguin, r. (2018) ‘developing primary health care in thailand’ public administration and policy, 21(1), 36–49. https://doi.org/10.1108/pap-06-2018005 tejativaddhana, p., briggs, d., & thonglor, r. (2016) ‘from global to local: strengthening district health systems management as entry point to achieve health-related sustainable development goals’, asia pacific journal of health management, 11(3), 81-86. https://doi.org/10.24083/apjhm.v11i3.165 thojampa, somsak, wannapornsiri, c., & daengthern, l. (2023) ‘lessons learned and synthesized knowledge of the district health management model drive implementation at ban tak district, tak province, thailand’ https://www.internationaljournalofcaringsciences.org/docs/62_s omsakthojampa_special_12_3.pdf wanaratwichit, c., mekrungrongwong, s., & keeratisiroj, o. (2018) ‘development of a district health system (dhs) for solving the chronic disease problems by the xiao tie’, the south college network journal of nursing and public health, 5(3), 138–151. how to cite this article: piyakong, d., , apiranatawong, s., suasing, c. (2023) ‘insights from leaders on effectively addressing overweight and obesity in the thai community’, jurnal ners, 18(2), pp. 117-123. doi: http://dx.doi.org/10.20473/jn.v18i2.44167 99 enculturation in the life pattern of breast cancer patients: an ethno-nursing study on sundanese women witdiawati, laili rahayuwati, sheizi prita sari faculty of nursing, universitas padjadjaran email: laili.rahayuwati@unpad.ac.id abstract introduction: death of breast cancer remains the highest position in the totem of incidents not only in indonesia but also in the world. its treatment process, which in fact brings huge impacts to the life quality of breast cancer patients regarding physique, psychology, and social life, shapes some behavioral patterns throughout their life. the aim of this research is thus to explore patterns of breast cancer patients in sustaining their lifespan. method: this research is designed using ethno-nursing qualitative approach. the sampling technique is done purposively to 6 informants, all of whom are breast cancer patients in garut district, west java, indonesia. data collecting is done through interviews and participatory observation. data transcription is analyzed using ethno-nursing analysis method. results: the result of the research shows four domains occurring as a pattern of inculturation of breast cancer patients in sundanese culture, namely 1) dedication as wife and mother of sundanese breast cancer patients, 2) medicine seeking for the rest of their life, 3) factors affecting to breast cancer patients adaptation for daily routines, and 4) family gathering as a meaning for end of life. discussion: the result of this research shows an interconnected cultural pattern in the life of these patients. it is thus advised that nurses provide service to breast cancer clients by applying nursing care inherent to their cultural values. keywords: life-pattern, breast cancer, ethno-nursing. _____________________________________________________________________________________ introduction any diagnosis is a life-changing experience for some people; breast cancer is no exempt. it is considered the road to death by some people in general. this consideration might more or less destabilize life quality of breast cancer clients and their family. upon being diagnosed with breast cancer, the client must undergo several medical procedures that obviously takes a long time or even for the rest of their life, during which many changes will emerge in their daily routines. the resulting condition of this process brings impacts to their life regarding physique, psychology, and social life. changes of role, perception, coping mechanism and behavior of seeking healthcare have come to be seen as a response to the meaning of cancer itself. furthermore, trauma and indeterminacy of breast cancer diagnosis can affect the client’s psychological and spiritual prosperity (lopez-class et al. 2011). some cultures believe that, for women, having breast cancer is a heavy burden to carry. however, the state of ill and healthy is highly relative due to some relevant factors. the term ―ill‖ per se contains many different meanings regarding culture, social, and occupation. it is the fundamental aspect in determining illness, for it is a social recognition with which someone can play their normal role as people expect them to. therefore, many social and cultural factors do affect the life of these clients. such social aspects of illness as physique, mental, and medics will shape illness behavior. it is understood, as lambert & loiselle (2007) puts it, as ways to which symptoms are responded, evaluated, and played by an individual is subjected to that illness, feels uncomfortable or reads other mal-bodily signs. having that in mind, she can act out his normal roles partially or entirely. illness behavior is highly affected by such factors as social classes, ethnics, and cultural differences. humans, as we all know, cannot live alone, for they are interdependent to each other, which applies the same way to breast cancer’s clients. they have a lot of needs to fulfill and maintain their health and life quality. however, due to their powerlessness, not all of those needs could be fulfilled on their own. this is exactly mailto:laili.rahayuwati@unpad.ac.id jurnal ners vol. 12 no. 1 april 2017: 99-107 100 why they are exceptionally dependent on their family members and the environment. the family is the closest part of the life of breast cancer clients. as social theory claims it, it is defined as a group of people unified by marital, blood, or adoptive bond, in which they belong to the same house and place to live, interact and communicate to each other, play their roles as either husband, wife, mom, dad, son, daughter, brother, sister. in other words, families attempt to create and sustain general culture (khakbazan et al. 2014). in maintaining life quality, these clients must be able to not only receive holistic care from nurses but also nurse themselves. leininger (2005) mentions several factors of a social and cultural dimension such as technology, religion, and philosophy, social and intimacy, cultural values, belief, ways of life, laws, and politics, economy and education. all of them affect and are affected by, how someone would be able to nurse herself. all those factors will enable the breast cancer clients to make a decision in undergoing the process of treatment and therapy. regarding social life, garut district of west java is one of the districts that embrace the sundanese culture, which grows and lives in sundanese society. this explains why the majority of garut people are of sundanese descent, although recently many ethnics have come to coexist. sundanese is the mother tongue passed for many generations and thus becomes the main language for communication amongst garut people. it is also known with politeness culture, enabling their characteristics to be easygoing, amiable (someah), smiley (love to smile), and highly respectful of the elderly. the people in west java or, broadly speaking, tatar sunda, including garut, are known as softspoken, religious, and spiritual. as the proverb silih asih, silih asah and silih asuh, meaning be passionate to yourself (welas asih), guide, selfimprove, and protect yourself and other people through education and many other fields. in sundanese culture, religious harmony is maintained by rituals while social harmony by gotong royong (mutual cooperation) (ekadjati 2014). the familial system in garut is bilateral, in which the descendant line is drawn from both the father and the mother. therefore, the right and position of a family member are linear. the meaning of family for sundanese people is seen as a shelter not only for wife and husband but also between families. a strong familial bond and islamic teachings do affect the customs of sundanese ethnic, or more ubiquitously known as pancakaki. in sundanese family, the husband holds the position of head of the family responsible for the prosperity of all its members. meanwhile, the wife has the duty to manage the household and take care of the children. as for widows, the chance of becoming the head of the family is bigger than wives. in sundanese culture also, particularly in the village areas, there is a tendency for men to make decisions due to his high status in the familial hierarchy. this happens not only inside the family institution but also in the society in general. levels of sundanese familial bond based on generational differences become paramount. such difference is divided into three compartments, namely (1) the elderly (sepuh)— that is, grandfather, grandmother, father, mother, and upper-age generations, (2) siblings (sadulur): spouses and stepsiblings, or also known as lanceuk if older in age and adi or rayi if younger, (3) children—that is, the descendants. the elderly (uncle, aunt, ua—those younger in age than one’s mother or father) in sundanese are considered as ―the old‖, even when they have passed away. they still have the right to be involved in a familial discussion. they must be respected, for it is their obligation to guide the young. the role of illness for a sundanese woman pesters herself, especially those who are married and have children. the duty of a wife is that she must fully submit fully to her husband (dulang tinande). however, her role as a mother is deity-like, cognizant that her child must respect her because she endured pregnancy and the inevitable pain and struggled to carry (indung anu ngandung). the illness, undoubtedly, brings significant impacts to the change of role and social status for breast cancer clients, in their relations to their role as sundanese women. the role of nurses as health provider is crucial in resuscitating the society of the danger of breast cancer, as well as advantages from the enculturation in the life pattern of breast cancer patients: 99-107 101 actions done to prevent breast cancer itself. in creating plans and implementing those plans, communal nurses must balance cultural values, universal human experiences, and general needs of every person. having that in mind, they need to understand important cultural aspects of nursing, which will foster community health through skill improvement. although the management of breast cancer has rapidly grown, the reality says otherwise. only a few scientific studies have observed what these breast cancer clients do throughout their life. in the framework of ethnonursing methodology, the focus of this research is on experiences and daily events of breast cancer clients in maintaining their life quality, as well as their perceptions and meanings of those experiences. their life patterns, thus, becomes the main focus of this research. method in the practice of nursing, the ethnographical approach is more commonly known as ethno-nursing. in other words, the nurses utilize ethnography as the basis of nursing care. furthermore, such approach enables them to study explicitly nursing phenomena from cross-cultural perspectives. the method of ethno-nursing research, designed by leininger, proves helpful to use, knowing that it is a unique and essential qualitative method to study nursing and treatment practice, beliefs, and varying cultural and environmental values. leininger (2005) also shows that this method is used to understand the meaning of the daily life of those who work in the field of nursing, healthcare, and human prosperity, in a different or similar environmental context. the number of informants in this qualitative research is previously indeterminable, meaning the sampling might escalate throughout the research. according to leininger (2005) and wanchai et al. (2010), when doing a macro ethno-nursing study, 12 to 15 key informants and 24 – 30 general informants have great daily needs to fulfill. on the other one, when doing micro ethno-nursing, the researcher needs 6 – 8 key informants and 12 – 16 general informants. however, the majority of informants cannot be the parameter, for it can lead to skewing perspective and limited reasoning of how the treatment of special phenomena is carried out. therefore, the aim of this research is to reach the proper number of key, general, and participatory informants, from which the data reaches its vantage point. in this research, data saturation or no new information is reached at the 6 th informant, meaning the number of the informants for this research is limited to 6 people only. meanwhile, participatory informants include family (2 husbands as two key informants, one child as a key informant, as well as one friend as a key informant). research instruments interview the guideline for interviews focuses on the mundane life of breast cancer clients. this is done by trying to understand daily phenomena in the effort of maintaining their life quality. the open-ended interview is applied and probes are used and prepared by the researcher. main data are obtained based on probing question used in the interview, during which researcher gives zero limits to clients’ responses. however, supposing the informants digress in their answers, the researcher will lead them back to the main discussion. the theme of the interview includes informant’s life experience from their diagnosis to their attempts to maintain their life quality. this is done in between informant’s activities, as far as the researcher observes. participatory observation this research uses three observatory steps, as leininger would put it, namely observation, participation, and reflection. the observation is done on daily activities of breast cancer patients in maintaining their life quality. its goal is to observe behaviors and interactions among individuals of those groups in their social life. the behaviors include acts demonstrated both verbally and nonverbally. documentary study this study provides information regarding unobtainable information from (in) direct interviews. it hugely concerns both written and unwritten documents. while the former includes breast cancer client’s medical records, therapy, jurnal ners vol. 12 no. 1 april 2017: 99-107 102 and treatment, the latter includes photos taken by researcher during observation. however, not all informant’s activities are documented through pictures due to some ethical reasons. one of the results is an unabridged medical record of each informant. by using medical record, it is easier for researcher to identify at which stage of cancer. besides, it helps identify kinds of therapy and treatment that these informants have done or are doing. tape recorder the tape recorder is used as one of datacollecting equipment. some information to be recorded are impressions of experience, thought, and feeling as contemplated by these informants. it is only used during the first interview only. field note much of this research applies field note as data-collecting equipment. it is used throughout the interview and during observation to some informant’s activities. researcher as instrument the researcher attempts to fulfill his competence as a researcher in digging out the informants’ experiences. for some observatory activities, researcher mingles with the patients. this includes cooking, taking part in posyandu (maternal and child health center) activities as well as in therapy and treatment activities. data analysis this research is done by involving detailed description about the setting or individual with breast cancer, followed by data analysis through 4 steps according to leininger (2005), as drawn in diagram 1. diagram 1. research data analysis (leininger, 2005) research ethics this research is done with permission from ethical committee of medicine faculty universitas padjadjaran. results based on the result there are four domains: 1) dedication as a wife and mother from sundanese woman with breast cancer, 2) medicine discovery throughout the life of sundanese woman with breast cancer, 3) factors affecting adaptation patterns of breast cancer clients in their routine and 4) gathering with family as the meaning before their life ends. the resulting category and domain will be discussed separately to reveal the meaning of breast cancer patient’s life. however, those categories are interdependent in construing and describing the meaning of life in maintaining their life quality in this research. the schematic elaboration on research results of life pattern of breast cancer clients in maintaining their life quality based on a transcription of interview data and participatory observation shown in diagram 2. discussion living life as breast cancer clients is not an easy thing. naturally, someone will have to adjust to harmonize her life based on the culture she believes in. however, the behavior could only be done by studying and learning it as a culture of life. koentjaraningrat (2009) states that humans could walk because of his fundamental nature to walk, and it happens as is. on the other hand, walking like a soldier or a model could only be learned using brain. thus, it is called ―culture‖ defined by all thoughts and actions functionally and non-functionally determined by the society. the illness in life will bring about different response and meaning to each individual. transcription of the interview and participatory observation describe that illness is seen as the life cycle of breast cancer patients. the awareness of life passage is based on the role she has to play, which is a woman. for a particular culture, being a woman means carrying a huge responsibility in their life, enabling her to view illness not as a problem but a cycle to undergo. mayor themes, research findings, theoritical formulatins and recommendations identification and categorization of descriptor and component collecting, describing, and documenting raw data pattern and contextual analysis enculturation in the life pattern of breast cancer patients: 99-107 103 diagram 2. life pattern of breast cancer patients saefullah (2008) claims that, in sundanese culture, different views on sundanese women are affected by traditional values growing in sundanese culture and islamic teachings, which are the most adhered to religions in sunda. thus, a role of a woman is highly respected and holds a high position in life, as the proverb says it: indung tunggul rahayu bapa tangkal darajat (safety, happiness, and prosperity lie on mother’s and father’s prayers), which goes to the next expression: indung anu ngandung bapa anu ngayuga (there will be no child without the affection of mother and father). those expressions explain the importance of women’s role to their children and husband. the view of illness and death as illness becomes a pattern drawn in breast cancer clients. thus, many attempts are made to overcome those adversities. the life pattern to endure by breast cancer clients is different from many people, which encourages them to try many things to balance life with culture. helman (2007) describes the proposition of illness as follows: (1) not all social or cultural groups respond to illness with the same way, (2) the way people see and respond to their illness, whether it is on their own or others, could be affected by their cultural background, (3) the way and the kind of communication of their illness for health professionals and other people, are also affected by cultural factor. the interval between healthy and ill undergone by breast cancer clients need treatment and therapy attempt to prosper their life quality. it is learned, understood, and applied in their life, to map out as a form of ―inculturation.‖ koentjaraningrat (2009) claims that the process of inculturation is a learning process and adapting to mind, behavior, and custom, norm systems, and all existing laws related to a particular culture. much of the same way with what sadono (2016) has to say: inculturation has two meanings. the first refers to the attempt of inculcating a value, behavior, feeling, view, or knowledge growing and developing in society to the members. the second refers to value aspects, norms, and behaviors under the consent of any living member of a community, which controls and factors affecting adaptation patterns for sundanese women with breast cancer enculturation of sundanese women with breast cancer treatment seeking for breast cancer throughout the life of sundanese women dedication as wife and mother by sundanese woman with breast cancer gathering with family as the meaning of “end of life” women dedication housewife role and conflict perception of life cycle information seeking behavior physical health psychological health spiritual health family support social support networking support the strength of relatives as support for breast cancer clients economic condition as limitation of treatment seeking jurnal ners vol. 12 no. 1 april 2017: 99-107 104 directs the behaviors with specific objectives. thus, inculturation might as well be called as ―culturing.‖ seeking behavior is a behavior constantly done by breast cancer clients throughout their life. rankin (2011) demonstrates that, after the client being diagnosed, the family’s first attempt is seek information regarding treatment of cancer. he goes on to say that problem solving and positive assessment is also positive and significant predictors from family’s tendency to seek social support as caregivers. in line with that, jenkins et al. (2001) also claim that most patients want as much information as they could obtain about treatment and their illness. a very important finding from their research is that 98% of patients feel that they need to know what cancer is and 95% want to know the probability of their recovery. therefore, information on prognosis does not need avoiding. the awareness of cancer among the people and treatment system from doctor or alternatives are paramount. thus, the information regarding diagnostic and treatment is a dire necessity (pati et al. 2013). the individual will actively look for information on treatment and therapy (case et al. 2005). this is linear with balneaves et.al. (2007) in their qualitative research, claim that aftershock, anxiety, and fear of knowing their diagnosis, women with breast cancer will start to consider their choices in looking for treatment that exceeds the conventional one to maximize the benefit of treatment itself, and minimize possibility of cancer restoration. the choice of kinds of medication done by the clients is not only that of conventional but also an alternative. wanchai et al. (2010) claim that such choice is based on the perception that they could give benefits by fulfilling patients’ need to return to mother nature and improving psychological and emotional recovery so that their mind becomes safe and peaceful. on the other hand, koentjaraningrat (2009) claims that in every society, humans won’t be able to ignore knowledge about others. such knowledge on anatomy in cultures rarely touched by medical studies is surprisingly extensive too. the knowledge to cure illness in villages are done by witches or shamans and masseurs. witchcraft typically uses much of dark magic. besides, they also have broad knowledge about characteristics of human organs, their positions, and the structure of nerves and stuff. moreover, the improvement of physical health and psychological prosperity is another attempt constantly done by the clients. eating pattern or diet as well as other nutrition fulfilling efforts are also included. this is relevant to what ansa, et.al (2016) have to say: most respondents believe that obesity (52,7%), less physical activity (48.7%) and high-fat diet (63.2%) are related to cancer restoration. another attempt is to minimize effect from symptoms of breast cancer, such as pain. on the other hand, the attempt to maintain psychological prosperity is made by avoiding stressor and keep her mind calm. as (livneh 2000) says that personal control or self/cognitive restraint is another strategy employed by cancer survivors to overcome stress by the illness. this is the predictor of positive psychosocial adaptation and relieves stress. the attempt of psychological prosperity is based on a good belief about giving meaning about illness in spiritual terms. koltko-riverra (2004) and vidal (2008) claim that the view based on someone religious, spiritual, existential, or natural, is the basis of mind and behavior of that person alone. a chain of treatment and therapy attempts to balance her life with the existing culture becomes a continuous subject to learn and do for the rest of their life. therefore, struggling to face breast cancer becomes a constant meaning event for a sundanese woman, thus becomes part of her culture. the result of such inculturation is described in a mapped pattern in the life of breast cancer clients. a life cycle will be seen and learned differently from the life of everyone else. it is necessary to have a positive coping mechanism in making that happen. adaptation pattern in someone will determine how she will live her life. those who live in a place with a particular culture will have to submit to several universal factors affecting their life. it goes the same way with breast cancer clients. from the result, the researcher describes two factors affecting adaptation patterns of breast cancer clients in living their life: economy and socio-relative. enculturation in the life pattern of breast cancer patients: 99-107 105 economic factors are one of the meaningful factors to the life of breast cancer clients. change of economic conditions due to illness affects adaptation pattern of their life. yan et al. (2016) in their research revealed that cancer is a high-class illness for patients and their health. therefore, high income from family and health insurance plan could improve life quality of breast cancer. lack of social and economic factors are main predictors of death among breast cancer patients (walsh et al. 2014). in line with that, pisu et al. (2010) claim that ―out of pocket‖ money is a significant burden for survivors even after early treatment. cancer economic burden is also complementary cost and psychosocial burden. this cost, which is time value spent with illness, represents the time that could not be dedicated to common activities and considered the loss of productivity for patients and society. meanwhile, psychosocial cost refers to the loss of life quality regarding cancer. this cost is related to anxiety, depression, cancer burden, marriage conflict, social negative change and family relation, and future indeterminacy. the total cost consists of that of productivity loss (89% of it) and health treatment cost (11%) (broekx et al. 2011). besides economic factor, social factor and relative factors are paramount factors for breast cancer clients. social support from family, relative, friend, bosses from work and government also affects the adaptation pattern of breast cancer clients in living their life. yan, et.al (2016) mentions that available social support from family member, friend, and neighbor, related significantly to improve life quality of breast cancer patients. mokuau & braun (2007) concludes family as the most important source of emotional and concrete support for women with cancer. therefore it is necessary to identify the needs to improve informational support for patients and family. the family is the closest part of the life of breast cancer patients. they are defined as two individuals or interdependent for emotional and physical bond as well as economic support. meanwhile, in social theory, family is a group of people united by marital, blood, and adoptive bond, where they live in one household, interact and communicate each other in their role as wife and husband, mother and father, child and daughter, brother and sister; and try to create and maintain general culture. besides, family support is an interpersonal relation that protects someone from bad stress effect (kaplan and sadock, 2002). the research of livneh (2000), another strategy directed to relieve stress among people with cancer is to find support from other. the result of this research shows a positive relation between seeking and reporting satisfaction of social support an emotional digression and psychological restraints, psychosocial and subjective perception is higher than prosperity. all life pattern and cycle ends up in a belief about the meaning of the end of life. it goes the same way with informants in this research. the meaning of ―end of life‖ is described based on the life cycle of the clients as a manifestation of the illness. many attempts to maintain life quality has been made, but there is one time where all that must stop. izumi et al. (2012) define ―end of life‖ as a wise period where one realizes that her life must end. it’s not a period medically determined before death. the awareness of ―end of life‖ could be raised by patient’s own knowledge or result from medical assessment without patients’ notice. breast cancer is one of death causes. this general stereotype goes all over patients with different kinds of cancer. where attempts are made to maintain function well with illness or diagnosis that threatens life for the long term. it is then followed by extreme fizzling of condition for few weeks or months before death. this stereotype is relatively predicted after tumors become unresponsive to the medication and escalate (izumi et al. 2012). in other words, ―end of life‖ becomes an inseparable meaning from life undergone by breast cancer clients. however, there is one final goal they want for the ―end of life‖ phase—that is, gathering with family members before until their last moments. such meaningfulness in a sundanese culture highly affects the life of these clients up to their deathbed. the life cycle of sundanese women with breast cancer describes that there is one enculturation pattern in their life. not only does it become a part connected directly to their life jurnal ners vol. 12 no. 1 april 2017: 99-107 106 but also to other domains therefore creating an inseparable unified pattern. conclusion based on the result of research and analytical observation of all emerging domains, it is concluded that there is a cultural pattern in the life of breast cancer clients in living their life. this pattern becomes the behavioral basis for them throughout their life, all attempts were made to support one another in maintaining their life. based on the existing cultural patterns, the illness they possess brings them to give meaning to life cycle so that it makes them learn, study, and apply the characteristics of treatment and medication in between their illness period to become a culture, which might be different from other people. there is no exempt from adaptation pattern for breast cancer clients in living their life. some universal factors also affect such pattern, which is social and kinship as well as the economy. both factors become paramount factors in their life. although the end of their life pattern will meet with the phase of the end of life, they have attempted to maintain their life quality from the beginning of diagnosis to the end of their life. the result of this research shows an interconnected cultural pattern in the life of these patients. it is thus advised that nurses provide service to breast cancer clients by applying nursing care inherent to their cultural values. acknowledgment the opportunity and financial support for this research were provided by ministry of research technology and higher education of indonesia. references broekx, s. et al., 2011. the costs of breast cancer prior to and following diagnosis. the european journal of health economics, 12(4), pp.311–317. available at: http://www.ncbi.nlm.nih.gov/pubmed/2030 6109 [accessed may 31, 2017]. case, d.o. et al., 2005. avoiding versus seeking: the relationship of information seeking to avoidance, blunting, coping, dissonance, and related concepts. journal of the medical library association : jmla, 93(3), pp.353–62. available at: http://www.ncbi.nlm.nih.gov/pubmed/1605 9425 [accessed may 31, 2017]. ekadjati, e., 2014. kebudayaan sunda. suatu pendekatan sejarah., bandung: pt dunia pustaka. helman, c., 2007. culture, health and illness 5th ed., hodder arnold. oxford university press. izumi, s. et al., 2012. defining end-of-life care from perspectives of nursing ethics. nursing ethics, 19(5), pp.608–618. available at: http://www.ncbi.nlm.nih.gov/pubmed/2299 0423 [accessed may 31, 2017]. jenkins, v., fallowfield, l. & saul, j., 2001. information needs of patients with cancer: results from a large study in uk cancer centres. british journal of cancer, 84(1), pp.48–51. available at: http://www.ncbi.nlm.nih.gov/pubmed/1113 9312 [accessed may 31, 2017]. khakbazan, z. et al., 2014. help seeking behavior of women with self-discovered breast cancer symptoms: a metaethnographic synthesis of patient delay f. harris, ed. plos one, 9(12), p.e110262. available at: http://dx.plos.org/10.1371/journal.pone.01 10262 [accessed may 31, 2017]. koentjaraningrat, 2009. pengantar antropologi. pokok-pokok etnografi ii, jakarta: pt rinekacipta. lambert, s.d. & loiselle, c.g., 2007. health information seeking behavior. qualitative health research, 17(8), pp.1006–1019. available at: http://qhr.sagepub.com/cgi/doi/10.1177/10 49732307305199 [accessed may 31, 2017]. leininger, m., 2005. overview of leininger’s ethnonursing research method and process. available at: http://www.madeleineleininger.com/cc/researchmethod.pdf [accessed may 31, 2017]. enculturation in the life pattern of breast cancer patients: 99-107 107 livneh, h., 2000. psychosocial adaptation to cancer: the role of coping strategies. the journal of rehabilitation, 66(2), p.40. available at: https://www.questia.com/library/journal/1 g1-62980227/psychosocial-adaptation-tocancer-the-role-of-coping [accessed may 31, 2017]. lopez-class, m. et al., 2011. quality of life among immigrant latina breast cancer survivors: realities of culture and enhancing cancer care. journal of cancer education, 26(4), pp.724–733. available at: http://www.ncbi.nlm.nih.gov/pubmed/2170 6194 [accessed may 31, 2017]. mokuau, n. & braun, k.l., 2007. family support for native hawaiian women with breast cancer. journal of cancer education, 22(3), pp.191–196. available at: http://link.springer.com/10.1007/bf03174 336 [accessed may 31, 2017]. pati, s. et al., 2013. patient navigation pathway and barriers to treatment seeking in cancer in india: a qualitative inquiry. cancer epidemiology, 37(6), pp.973–978. available at: http://www.ncbi.nlm.nih.gov/pubmed/2421 1153 [accessed may 31, 2017]. pisu, m. et al., 2010. the out of pocket cost of breast cancer survivors: a review. journal of cancer survivorship : research and practice, 4(3), pp.202–9. available at: http://www.ncbi.nlm.nih.gov/pubmed/2040 1542 [accessed may 31, 2017]. rankin, s., 2011. influence of coping styles on social support seeking among cancer patient family caregivers. walden dissertations and doctoral studies. available at: http://scholarworks.waldenu.edu/dissertatio ns/908 [accessed may 31, 2017]. walsh, p.m. et al., 2014. socioeconomic disparity in survival after breast cancer in ireland: observational study. k. metze, ed. plos one, 9(11), p.e111729. available at: http://dx.plos.org/10.1371/journal.pone.01 11729 [accessed may 31, 2017]. wanchai, a., armer, j.m. & stewart, b.r., 2010. breast cancer survivors’ perspectives of care practices in western and alternative medicine. oncology nursing forum, 37(4), pp.494–500. available at: http://www.ncbi.nlm.nih.gov/pubmed/2059 1809 [accessed may 31, 2017]. yan, b. et al., 2016. determinants of quality of life for breast cancer patients in shanghai, china r. m. lafrenie, ed. plos one, 11(4), p.e0153714. available at: http://dx.plos.org/10.1371/journal.pone.01 53714 [accessed may 31, 2017]. bermain lego meningkatan perkembangan kognitif anak usia prasekolah (4-5 tahun ) bermain lego meningkatan perkembangan kognitif anak usia prasekolah (4-5 tahun) (playing lego increase cognitive development on preschool child (4-5 years old)) sri utami*, nuzul qur’aniati**, erlita kusuma r.** * poltekes soetomo prodi kebidanan jln. mayjend. prof. dr. moestopo no. 8a surabaya 60286 e-mail: sriutami_prodikesby@yahoo.co.id **fakultas keperawatan universitas airlangga surabaya abstract introduction: the preschool cognitive development can be stimulated with playing activity. the preschool child who stimulateless, their creativity will be checked and it can effect their cognitive development. playing lego is one of the stimulation which give chance to the preschool child to express creativity and explorate their skill in playing construction. this research was aimed to analyze the effect of playing lego to the preschool cognitive development. method: quasy experimental pre post test design was used in this research. total sample were 18 preschool child (4-5 years old). the independent variable was playing lego and the dependent variable was the cognitive development. data were analyzed by wilcoxon signed rank test and mann whitney u test with the significance α<0.05. result: result showed that the control group has significance level p=0.059 and the treatment group has significance level p=0.008. the result of mann whitney u test showed p=0.001. discussion: it can be concluded that playing lego can effect the preschool cognitive development in spatial factor, reasoning, memory, and perceptual speed. it can be suggested to the further research to examine the effect of playing lego to the motoric development or social development. keywords : lego, cognitive development, preschool pendahuluan pertumbuhan dan perkembangan merupakan peristiwa yang pasti terjadi pada manusia mulai dari konsepsi sampai akhir hayat. perkembangan anak terjadi mulai dari aspek sosial, emosional, dan intelektual yang berkembang pesat saat anak memasuki masa prasekolah (3-5 tahun) dan biasa disebut dengan golden age. masa prasekolah adalah masa dimana kognitif anak mulai menunjukkan perkembangan dan anak telah mempersiapkan diri untuk memasuki sekolah (hidayat, 2005). pengalaman belajar yang diperlukan usia prasekolah diantaranya mengenal warna, mengerti kata sifat, mengenal huruf dan angka, berhitung sederhana, mengerti perintah sederhana, dan mengenal bentuk suatu obyek. kemampuan lain seperti mengelompokkan, mengamati, menganggap dan membayangkan hal yang lebih abstrak juga berkembang. kemampuan tersebut seharusnya sudah dapat dicapai oleh anak prasekolah. dengan adanya taman kanak-kanak (tk), diharapkan anak prasekolah mulai mempelajari kemampuan tersebut melalui bermain. metode bermain yang telah digunakan di tk misalnya bermain balok kayu, meronce, permainan memasangkan gambar dan warna, maze (mencari jejak) dan puzzle (depdiknas, 2007). evaluasi hasil penilaian rapor pada anak masih didapatkan anak yang belum mencapai tugas perkembangan kognitifnya secara optimal. metode yang dapat menstimulasi perkembangan kognitif anak sangat bervariatif, salah satunya dengan lego tetapi pengaruh lego terhadap perkembangan kognitif disini masih perlu dijelaskan. perkembangan kognitif anak prasekolah dapat dilihat dari kemampuan secara simbol maupun abstrak seperti berbicara, bermain, berhitung, membaca, dan lain-lain. data yang diperoleh dari hasil penelitian yang dilakukan oleh idaibkkbn pada tanggal 13 januari-3 februari 1996 di salah satu desa di propinsi bali didapatkan 3,3% dari 215 sampel mengalami penyimpangan perkembangan dari pemeriksaan denver ii. data yang diperoleh dari hasil evaluasi raport tentang perkembangan kognitif semester 1 tahun ajaran 2007/2008 di tk pertiwi dharma wanita trenggalek menunjukkan bahwa dari 38 anak, jumlah anak yang belum dapat mengenal konsep bilangan dan menyebut bentuk-bentuk geometri dengan baik (21,4%), belum mampu mengelompokkan benda sesuai warna, bentuk, maupun ukuran (14,3%), belum mampu menggambar lingkaran dan bujursangkar (17,9%), belum dapat membuat perkiraan urutan suatu benda (28,6%). stimulasi merupakan hal yang penting dalam tumbuh kembang anak. anak yang mendapat stimulasi terarah dan teratur akan lebih cepat berkembang (soetjiningsih, 1998). menstimulasi anak prasekolah dapat dilakukan dengan bermain. bermain secara tidak langsung akan membuat anak mengembangkan kemampuan fisik-motorik, sosial-emosional, dan kognisinya (davida, 2004). banyak orangtua tidak menyadari bahwa dengan bermain anak usia prasekolah dapat melatih kreatifitas, yang merupakan aspek kecerdasan. anak yang waktu bermainnya kurang akan menyebabkan anak tidak ceria, kurang percaya diri, kurang supel, bahkan mudah takut pada temantemannya, dan kurang kreatif (budiman, 2006). perkembangan anak, dan kreatifitas menurut psikolog berhubungan erat dengan perkembangan kognitif. anak prasekolah yang kurang mendapat stimulus bermain akan menekan kreatifitas dan berpengaruh pula terhadap perkembangan kognitif (menstimulasi kreatifitas anak, 2006). masa prasekolah ini diperlukan rangsangan/stimulasi yang berguna agar potensi anak berkembang optimal. berdasarkan pada uraian sebelumnya, dapat disimpulkan bahwa anak prasekolah sebaiknya mendapatkan cukup stimulasi dengan bermain. salah satu permainan yang dapat merangsang perkembangan kognitif anak usia prasekolah adalah lego (nad, 2005). lego merupakan permainan konstruktif berupa kepingan plastik yang dapat disusun dan dirangkai menjadi aneka bentuk. anak yang terbiasa memainkan permainan bongkar pasang ini dapat memenuhi ketiga aspek perkembangan yaitu perkembangan motorik kasar, halus, dan kognitif sekaligus (handayani, 2005). anak prasekolah juga akan belajar untuk berpikir, berpendapat, menyelesaikan masalah, mengasah keterampilan melalui kemampuannya menyusun lego, serta membangun koordinasi mata dan tangan sehingga dapat menyiapkan anak untuk belajar membaca. lego memiliki berbagai macam warna yang dapat membantu anak belajar membedakan bentuk dan pola-pola, serta dari bentuk-bentuk yang dibuat, anak akan belajar mengenal simetri (davida, 2004). bahan dan metode desain yang digunakan dalam penelitian ini adalah quasy experimental. sampel dalam penelitian ini adalah seluruh populasi, yaitu murid tk a pertiwi dharma wanita trenggalek dengan usia 4-5 tahun sebanyak 18 anak. variabel independen dalam penelitian ini adalah bermain lego. variabel dependen dalam penelitian ini adalah perkembangan kognitif. instrumen yang digunakan berupa lembar observasi model checklist. berisi 15 tugas tentang perkembangan kognitif anak yang meliputi kemampuan mengingat (memory), kemampuan nalar/berpikir logis (reasoning), kemampuan tilikan ruang (spatial factor), dan kemampuan mengamati dengan cermat dan cepat (perceptual speed). data yang dikumpulkan dianalisis secara sistematik dan disajikan dalam bentuk tabulasi silang antara variabel independen dan variabel dependen. selanjutnya, data analisa dengan uji statistik wilcoxon signed rank test untuk membandingkan perkembangan kognitif sebelum dan setelah dilakukan intervensi, kemudian dilakukan uji statistik mann whitney u test untuk membandingkan perkembangan kognitif antara kelompok kontrol dengan kelompok perlakuan. hasil hasil penelitian ini menunjukkan bahwa pada kelompok perlakuan 9 anak (100%) menunjukkan perbedaan perkembangan kognitif sebelum dan sesudah intervensi. sedangkan pada kelompok kontrol tidak terjadi perubahan (tabel 1). pada tabel 1 dapat dilihat bahwa bermain lego mempunyai pengaruh yang signifikan terhadap perkembangan kognitif dengan hasil analisis statistik wilcoxon signed rank test didapatkan nilai signifikansi p=0,008. hasil penelitian ini menunjukkan terdapat perbedaan perkembangan kognitif yang signifikan antara kelompok kontrol dan kelompok perlakuan pada anak usia prasekolah dengan hasil analisis statistik mann whitney u test menunjukkan nilai signifikansi p=0,001. pada kelompok perlakuan terjadi perubahan perkembangan kognitif pada pra tes (rerata 39; standar deviasi 4) menjadi (rerata 47; standar deviasi 2,345). pembahasan hasil yang didapatkan dari penelitian ini, melalui uji wilcoxon signed rank test setelah dilakukan intervensi berupa permainan lego selama tiga minggu, menunjukkan nilai p=0,05 pada kelompok perlakuan yang berarti terjadi perbedaan perkembangan kognitif yang signifikan sebelum dan sesudah intervensi, sedangkan untuk kelompok kontrol bernilai p=0,05 yang berarti tidak ada perbedaan perkembangan kognitif sebelum dan sesudah dilakukan aktifitas selain bermain lego. hasil uji mann whitney u test menunjukkan p=0,05 yang berarti ada pengaruh bermain lego terhadap perkembangan kognitif anak usia prasekolah. hasil ini sesuai dengan penelitian sebelumnya oleh willy (2006), bahwa dengan bermain konstruktif lego akan membantu mengembangkan kemampuan kognitif anak. hasil ini juga sesuai dengan teori davida (2004) yang menyebutkan bahwa melalui permainan lego akan terjadi pengenalan terhadap konsep warna, geometri, ukuran dan tekstur benda, selanjutnya hasil pengamatan anak terhadap konsep-konsep tersebut akan tersimpan dalam benak anak sehingga anak akan mengalami proses belajar, mencoba menggali ingatan dalam benak anak yang telah didapatkan, serta belajar mengungkapkan pendapat. kemampuan anak dalam membayangkan hal yang lebih abstrak dan imajinatif juga semakin berkembang (50 tahun mainan lego masih tetap jadi favorit, 2006). hal ini dikarenakan tahap perkembangan kognitif anak prasekolah berada pada tahap pemikiran praoperasional dimana kemampuan anak untuk berpikir lebih komplek didemonstrasikan dengan kemampuan mengklasifikasikan benda dan pengetahuan anak tentang dunia terhubung erat pada pengalaman konkret, bahkan kehidupan anak yang kaya fantasi didasarkan pada persepsi tentang realitas (perry dan potter, 2005). tabel 1 perkembangan kognitif reponden di tk pertiwi sebelum dan setelah diberikan permainan lego. kontrol perlakuan kontrol perlakuan pre post pre post post post mean 38,667 39,222 39 47 39,222 47 sd 3,905 4,295 4 2,345 4,295 2,345 wilcoxon signed rank test p=0,059 wilcoxon signed rank test p=0,008 mann whitney u test p=0,001 keterangan : p = signifikansi sifat permainan konstruksi lego sendiri adalah aktif, dimana anak akan selalu ingin menyelesaikan tugas-tugas dalam permainan dan dapat membangun kecerdasan anak (hidayat, 2005). selain itu, lego merupakan permainan yang bersifat membina keterampilan dan rangsangan bagi kreatifitas anak, karena melalui eksperimentasi dalam bermain anak akan menemukan bahwa merancang sesuatu yang baru dan berbeda dapat menimbulkan kepuasan (hurlock, 2005). selanjutnya, kreatifitas anak akan semakin terasah dan anak lebih eksploratif dan terampil dalam memainkan lego (50 tahun mainan lego masih tetap jadi favorit, 2006). pada penelitian ini tampak variasi perubahan perkembangan kognitif pada tiaptiap responden setelah diberikan intervensi berupa permainan lego. hal ini mungkin disebabkan oleh beberapa faktor yang dapat mempengaruhi perkembangan, diantaranya usia anak, jenis kelamin, jumlah saudara, mainan yang tersedia, usia orang tua, serta pendidikan dan pekerjaan orang tua, sehingga hasil yang diperoleh juga berbeda pada tiaptiap responden. menurut soetjiningsih (1998), faktor-faktor yang dapat mempengaruhi perkembangan anak diantaranya faktor genetik dan faktor lingkungan. faktor lingkungan terbagi menjadi lingkungan prenatal dan postnatal. termasuk dalam lingkungan prenatal adalah gizi pada waktu hamil, toksin, endokrin, radiasi, infeksi, stres, imunitas, sedangkan yang termasuk dalam lingkungan postnatal antara lain usia, suku, gizi, perawatan kesehatan, kepekaan terhadap penyakit, cuaca, keadaan geografis, keadaan rumah, stimulasi, motivasi belajar, kasih sayang, interaksi orang tua-anak, pekerjaan/ penghasilan orang tua, pendidikan orang tua, jumlah saudara, stabilitas rumah tangga, dan lain-lain. pada penelitian ini responden paling banyak berjenis kelamin laki-laki dan merupakan anak pertama. sebesar 44% responden memiliki seorang saudara di rumah. sebanyak 28% responden memiliki hanya satu jenis mainan dan 3 jenis mainan. usia ayah responden antara 21-30 tahun adalah 50 % dan 67% usia ibu responden adalah antara 21-30 tahun. sebagian besar pendidikan orang tua responden adalah sma (61%), sedangkan pekerjaan orang tua terbanyak adalah pekerja swasta (55,6%). hurlock (2005) menyatakan bahwa pada awal masa kanak-kanak anak laki-laki cenderung lebih menunjukkan perhatian dan kemampuan menguasai berbagai jenis permainan yang lebih banyak daripada anak perempuan. ini disebabkan perlakuan terhadap anak laki-laki yang diberikan kesempatan lebih untuk mandiri, desakan teman sebaya untuk mengambil resiko lebih dalam bermain, dan dorongan untuk menunjukkan inisiatif dan orisinalitas dalam menghasilkan suatu karya, sehingga kreatifitas anak laki-laki juga lebih baik. jumlah saudara dalam satu rumah juga akan mempengaruhi perkembangan anak karena semakin banyak jumlah saudara yang dimiliki maka perhatian orang tua terhadap masing-masing anak akan semakin kecil. selain itu, jumlah dan jenis alat permainan yang diberikan pada anak akan berpengaruh pula. jika permainan yang diberikan tidak sesuai dengan usia anak atau bahkan anak hanya memiliki satu jenis mainan saja maka anak akan bosan untuk memainkannya sehingga proses perkembangannya akan terhambat. usia, pendidikan dan pekerjaan orang tua juga berperan penting dalam proses perkembangan anak. semakin sibuk orang tua dalam bekerja maka perhatian dan kedekatan anak dengan orang tuanya semakin kecil dibandingkan dengan orang tua yang senantiasa mempunyai cukup waktu untuk berkumpul bersama keluarga. pada kelompok kontrol, kemampuan kognitif semua responden sebelum intervensi bernilai antara 31-45 yang berarti anak mampu mengerjakan dengan sedikit / tanpa bantuan guru. setelah diberikan intervensi, responden 3, 4, 7, dan 9 mengalami perubahan perkembangan kognitif meskipun tidak terlalu berarti sedangkan 5 responden lainnya tidak mengalami perubahan. dari hasil pengumpulan data, tiga dari keempat responden yang mengalami perubahan ini adalah anak laki-laki. seorang responden adalah anak tunggal, dua responden memiliki seorang saudara, dan seorang responden memiliki dua saudara. jumlah permainan yang dimiliki di rumah yaitu dua responden memiliki 2 jenis mainan, seorang memiliki 3 jenis mainan, seorang lainnya memiliki hanya satu jenis mainan. rata-rata usia orang tua keempat responden antara 21-30 tahun sri utami dan pendidikannya adalah sma, serta tiga diantaranya bekerja di swasta. pada kelompok perlakuan, sebelum diberikan intervensi kemampuan kognitif semua responden bernilai antara 31-45 yang berarti sama dengan kemampuan responden kelompok kontrol. setelah diberikan intervensi bermain lego, semua responden mengalami perubahan perkembangan kognitif. empat dari sembilan responden (responden 2, 3, 4, 9) perubahannya cukup banyak, akan tetapi skor kognitifnya masih terbatas pada skor antara 31-45 sehingga masih dalam kategori mampu mengerjakan dengan sedikit/tanpa bantuan guru. sedangkan responden 1, 5, 6, 7, 8 mencapai kategori mampu mengerjakan tanpa bantuan guru dan dapat melakukan tugas lebih. hasil pengumpulan data menunjukakkan, tiga dari lima responden yang mengalami peningkatan pesat adalah anak laki-laki, sedangkan dua lainnya adalah perempuan. jumlah saudara yang dimiliki antara lain dua saudara, seorang saudara, dan anak tunggal. mainan yang dimiliki antara lain berjumlah 4 jenis, 2 jenis, dan 1 jenis mainan. sebagian besar usia orang tua responden adalah antara 21-30 tahun. beberapa orang tua berpendidikan sma, tetapi ada pula yang berpendidikan smp dan perguruan tinggi. empat orang tua dari lima responden bekerja di swasta, seorang lainnya sebagai pedagang. hal ini sesuai teori bahwa responden yang mengalami perubahan terbanyak adalah anak laki-laki, jumlah saudara yang tidak terlalu banyak, jumlah mainan sebagian responden juga cukup banyak, usia orang tua yang tergolong muda, serta pekerjaan dan pendidikan orang tua yang cukup tinggi. responden 1, 2, dan 6 mengalami peningkatan tertinggi. hal ini kemungkinan disebabkan tersedianya mainan yang cukup banyak di rumah, sehingga stimulasi juga didapatkan anak di rumah. selain itu, pendidikan ketiga orang tua responden yang lebih tinggi, yaitu sma dan perguruan tinggi. sedangkan responden 4 mengalami peningkatan paling sedikit dan kemungkinan ini disebabkan jumlah mainan yang dimiliki hanya satu jenis dan pendidikan orang tua yang lebih rendah (smp). perkembangan kognitif yang meningkat terlihat pada hampir semua indikator penilaian, akan tetapi peningkatan yang lebih besar terjadi pada indikator penilaian 1 (mengelompokkan benda berdasarkan warna), 9 (mengenal sifat panjang-pendek), 10 (mengenal sifat besarkecil), 11 (mengenal sifat tinggi-rendah), 12 (memperkirakan dan mengikuti urutan berdasarkan bentuk dan warna benda), 13 (menggambar bebas dari lingkaran dan bujur sangkar), 14 (menggambar orang secara bebas), dan 15 (menyusun/membuat konstruksi dari lego sesuai dengan imajinasi anak). indikator-indikator tersebut di atas sesuai dengan hasil penelitian terdahulu bahwa dengan bermain konstruksi lego, kemampuan anak mengenal simbol-simbol yang sama dan tidak sama semakin meningkat, sehingga perkembangan kognitif anak semakin optimal. hal tersebut juga mewakili dimensi karakteristik perkembangan kognitif anak prasekolah menurut depdiknas (2007), diantaranya dapat memahami konsep berlawanan seperti tinggi-rendah, dapat memadankan bentuk geometri dengan obyek nyata atau visualisasi gambar, dapat menumpuk benda sesuai ukuran secara berurutan, dapat mengelompokkan benda yang memiliki persamaan, dan dapat menyebut pasangan benda. peningkatan yang lebih besar pada indikator penilaian 1 dan 12 dikarenakan lego adalah balok-balok dengan berbagai macam warna sehingga kemampuan mengingat pada anak lebih baik pada konsep warna. kemampuan pengenalan sifat-sifat pada indikator 9, 10, dan 11 dikarenakan lego adalah balok-balok dengan beberapa macam ukuran. sedangkan pada indikator 13, 14, dan 15 peningkatan dikarenakan kemampuan imajinasi abstraksi anak lebih baik dan lego sendiri memberikan manfaat belajar art sehingga anak lebih memahami dan mengerti tentang seni dan keindahan dalam menghasilkan suatu karya. hasil dari penelitian ini menunjukkan bahwa pada kelompok perlakuan melalui uji wilcoxon signed rank test setelah dilakukan intervensi berupa permainan lego selama tiga minggu, menunjukkan nilai p>0,05 pada kelompok perlakuan yang berarti terjadi perbedaan perkembangan kognitif yang signifikan sebelum dan sesudah intervensi, sedangkan bermain lego meningkatan perkembangan kognitif anak usia prasekolah (4-5 tahun) untuk kelompok kontrol bernilai p>0,05 yang berarti tidak ada perbedaan perkembangan kognitif sebelum dan sesudah dilakukan aktifitas selain bermain lego. hasil uji mann whitney u test menunjukkan p<0,05 yang berarti ada pengaruh bermain lego terhadap perkembangan kognitif anak usia prasekolah. hasil ini sesuai dengan penelitian sebelumnya oleh willy (2006), bahwa dengan bermain konstruktif lego akan membantu mengembangkan kemampuan kognitif anak. selain itu, hasil ini sesuai dengan teori davida (2004) yang menyebutkan bahwa melalui permainan lego akan terjadi pengenalan terhadap konsep warna, geometri, ukuran dan tekstur benda, selanjutnya hasil pengamatan anak terhadap konsep-konsep tersebut akan tersimpan dalam benak anak sehingga anak akan mengalami proses belajar, mencoba menggali ingatan dalam benak anak yang telah didapatkan, serta belajar mengungkapkan pendapatnya. kemampuan anak dalam membayangkan hal yang lebih abstrak dan imajinatif juga semakin berkembang (50 tahun mainan lego masih tetap jadi favorit, 2006). hal ini dikarenakan tahap perkembangan kognitif anak prasekolah berada pada tahap pemikiran praoperasional dimana kemampuan anak untuk berpikir lebih komplek didemonstrasikan dengan kemampuan mengklasifikasikan benda dan pengetahuan anak tentang dunia terhubung erat pada pengalaman konkret, bahkan kehidupan anak yang kaya fantasi didasarkan pada persepsi tentang realitas (perry&potter, 2005). sifat permainan konstruksi lego sendiri adalah aktif, dimana anak akan selalu ingin menyelesaikan tugas-tugas dalam permainan dan dapat membangun kecerdasan anak (hidayat, 2005). lego merupakan permainan yang bersifat membina keterampilan dan rangsangan bagi kreatifitas anak, karena melalui eksperimentasi dalam bermain anak akan menemukan bahwa merancang sesuatu yang baru dan berbeda dapat menimbulkan kepuasan (hurlock, 2005). selanjutnya, kreatifitas anak akan semakin terasah dan anak lebih eksploratif dan terampil dalam memainkan lego (50 tahun mainan lego masih tetap jadi favorit, 2006). pada penelitian ini tampak variasi perubahan perkembangan kognitif pada tiap-tiap responden setelah diberikan intervensi berupa permainan lego. hal ini mungkin disebabkan oleh beberapa faktor yang dapat mempengaruhi perkembangan, diantaranya usia anak, jenis kelamin, jumlah saudara, mainan yang tersedia, usia orang tua, serta pendidikan dan pekerjaan orang tua, sehingga hasil yang diperoleh juga berbeda pada tiaptiap responden. soetjiningsih (1998) menyatakan bahwa faktor-faktor yang dapat mempengaruhi perkembangan anak diantaranya faktor genetik dan faktor lingkungan. faktor lingkungan terbagi menjadi lingkungan prenatal dan postnatal. yang termasuk dalam lingkungan prenatal adalah gizi pada waktu hamil, toksin, endokrin, radiasi, infeksi, stres, imunitas. sedangkan yang termasuk dalam lingkungan postnatal antara lain usia, suku, gizi, perawatan kesehatan, kepekaan terhadap penyakit, cuaca, keadaan geografis, keadaan rumah, stimulasi, motivasi belajar, kasih sayang, interaksi orang tua-anak, pekerjaan / penghasilan orang tua, pendidikan orang tua, jumlah saudara, stabilitas rumah tangga, dan lain-lain. pada penelitian ini, paling banyak responden berjenis kelamin laki-laki (56%), sebagian besar responden (67%) merupakan anak pertama. jumlah saudara responden sebesar 44% responden memiliki seorang saudara di rumah dan sebanyak 28% responden memiliki hanya satu jenis mainan dan 3 jenis mainan. lima puluh persen usia ayah responden adalah antara 21-30 tahun dan 67% usia ibu responden adalah antara 21-30 tahun. sebagian besar pendidikan orang tua responden adalah sma (61%), sedangkan pekerjaan orang tua terbanyak adalah pekerja swasta (55,6%). simpulan dan saran simpulan perkembangan kognitif anak prasekolah mengalami peningkatan yang lebih baik setelah diberikan permainan lego. dimana sebelum dilakukan permainan lego, kemampuan anak adalah mampu mengerjakan dengan sedikit atau tanpa bantuan guru dan setelah dilakukan permainan lego, kemampuan anak adalah mampu mengerjakan tanpa bantuan sama sekali dan dapat melakukan tugas lebih. bermain lego mempengaruhi perkembangan kognitif anak prasekolah (4-5 tahun) dalam hal kemampuan tilikan ruang, berpikir logis, mengingat, dan mengamati dengan cepat dan cermat. saran peneliti menyarankan supaya para orang tua dan perawat diharapkan dapat menggunakan permainan lego sebagai alternatif alat permainan untuk menunjang perkembangan anak, khususnya perkembangan kognitif usia prasekolah, bagi institusi pendidikan prasekolah diharapkan dapat menyediakan permainan lego sebagai variasi jenis permainan di taman kanakkanak dan dapat dimasukkan ke dalam kurikulum pendidikan taman kanak-kanak. kepustakaan budiman, a. 2006. bermain? hmm, bukan main…!, (online), (http://www.ummigroup.co.id., diakses tanggal 6 maret 2008, jam 15.30 wib). davida. 2004a. bermain sambil belajar, (online), (http://www.sabda.org., diakses tanggal 8 april 2008, jam 11.00 wib). davida. 2004b. permainan yang mengasah ketrampilan, (online), (http://www.sabda.org., diakses tanggal 8 april 2008, jam 11.05 wib). departemen pendidikan nasional. 2007. pedoman pembelajaran bidang pengembangan kognitif di taman kanak-kanak. jakarta, hlm. 3-9. handayani, f. 2005. mainan dan permainan berdasarkan perkembangan usia, (online), (http://www.tabloidnakita.com., diakses tanggal 8 april 2008, jam 10.53 wib). hidayat, a.a. 2005. pengantar ilmu keperawatan anak 1. jakarta: salemba medika, hlm. 59 hurlock, e.b. 2005. perkembangan anak jilid 1. jakarta: erlangga nad. 2005. mainan yang mencerdaskan, (online), (http://info.balitacerdas.com., diakses tanggal 6 maret 2008, jam 15.43 wib). perry dan potter. 2005. fundamental keperawatan. jakarta: egc, hlm. 639, 664-665. soetjiningsih, dsak. 1998. tumbuh kembang anak. jakarta: egc, hlm. 2-11, 106-111 willy, d. dkk. 2006. pengembangan piranti permainan alternatif bagi pendidikan anak dini usia (padu), (online), (http://willydeni.wordpress.com., diakses tanggal 8 mei 2008, jam 12.46 wib). http://www.ummigroup.co.id/ http://www.sabda.org/ http://www.sabda.org/ http://www.tabloid-nakita.com/ http://www.tabloid-nakita.com/ http://info.balitacerdas.com/ http://willydeni.wordpress.com/ 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 93 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.8373 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effectiveness of spiritual emotional breathing towards respiratory function and immune response of tuberculosis patients kusnanto kusnanto, joni haryanto, tintin sukartini, elida ulfiana and made mahaguna putra faculty of nursing universitas airlangga, surabaya, indonesia abstract introduction: tuberculosis is one cause of infectious death worldwide. in relation to the healing of pulmonary tuberculosis in indonesia, there are still certain areas where the cure rate is still low. this study aims to identify the effect of spiritual emotional breathing (seb) on the quality of respiratory function and the modulation of immune response in tuberculosis patients. methods: the study used a quasi-experimental design with two groups of prepost-test design. the population was 34 patients with tuberculosis in east perak’s primary health care. the independent variable was seb (spiritual emotional breathing). the dependent variables were peak expiratory flow rate (pefr), pulse, oxygen saturation, breath frequency, breath sound, stiffness complaints, human il2, human cortisol, igg. results: the results showed that there was a significant difference in pefr, pulse, oxygen saturation, respiratory rate, respiratory sound, stiffness, human il-2, human cortisol, igg. conclusion: seb can improve the quality of respiratory function and the modulation of immune response in tuberculosis patients. the emotional spiritual approach is part of the science of energy psychology that aims to turn the negative energy in a person into positive energy that can help the healing process. this therapy is performed as a complementary therapy for tb patients to improve their quality of life and the control of symptoms. article history received: may 19, 2018 accepted: june 8, 2018 keywords immune; spiritual emotional breathing; respiratory function; tuberculosis contact kusnanto kusnanto  kusnanto@fkp.unair.ac.id  faculty of nursing universitas airlangga, surabaya, indonesia cite this as: kusnanto, k., haryanto, j., sukartini, t., ulfiana, e., & putra, m. (2018). the effectiveness of spiritual emotional breathing towards respiratory function and immune response of tuberculosis patients. jurnal ners, 13(1). 93-97. doi:http://dx.doi.org/10.20473/jn.v13i1.8373 introduction tuberculosis is one cause of infectious death worldwide (who, 2008). the healing of pulmonary tuberculosis in indonesia is still low in certain areas. the disease is chronic, and can affect the quality of life of the sufferer. patients living with tuberculosis (tb) experience the significant disruption of their social life and are exposed to both stigma and discrimination. pulmonary tuberculosis poses serious problems, relating to the concept of quality of life consisting of the aspects of physical, psychological, social, and environmental health (kusnanto, pradanie and karima, 2016). tb is a common cause of death in people with hiv. the duration of the treatment for tuberculosis is prolonged, and is at least 6 months for drug-prone tb and 18-24 months for multi-drug resistant tb (mdr-tb), which does not respond to the two most effective anti-tb drugs, isoniazid and rifampicin. long-term treatment, adverse drug reactions during the tb treatment, stigma and financial burden contribute to poor treatment and treatment outcomes. in addition, ensuring patient adherence to treatment through a direct facility for observation therapy (dot) competes with patient-centered services, adding to the involved finances. the costs come from out-of-pocket and there are indirect costs associated with the treatment. this is even though anti-tb drugs are given free of charge in most countries. rapid healing of the symptoms of tb at the onset of treatment also contributes to improper patient care (i.e. people who are lost to follow-up) as competing interests are prioritised. poor treatment obedience and the negligence of follow-up increases the morbidity, mortality, and risk of developing drug resistance, and can lead to prolonged tb transmission (hoorn et al., 2016). eft (emotional freedom technique) is one of the therapeutic groups that is referred to as https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ k. kusnanto et al. 94 | pissn: 1858-3598  eissn: 2502-5791 psychological energy (church et al., 2012). eft is a mild and non-invasive form of emotional acupressure by using an acupuncture meridian called "acupuncture without needles". tapping the meridian point on the upper body releases the energy blockage ("energy therapy") and reinforces the patient's cognitive change for them to take full responsibility for their own health and well-being (bougea et al., 2013). in addition, there is a repetition of self-acceptance statements, which are suggested to contribute to cognitive restructuring, a well-known psychotherapeutic technique, in which individuals identify and correct negative thoughts (patterson, 2016). the effectiveness of seft (spiritual emotional freedom technique) lies in the merging of spiritual power with energy psychology. spiritual power contains the five main principles of sincerity, confidence, gratitude, and patience. energy psychology is a set of principles and techniques utilising the body's energy system to improve the state of the person’s mind, emotions, and behaviour. chemical imbalances and energy disturbances in the human body can cause emotional distress, including depression. seft intervention in the body's energy system can change the chemical conditions in the brain (neurotransmitter), which can further change the emotional condition of a person, including the condition of depression. in addition, seft is effective, easy, fast, cheap, the effect can be permanent and there are no side effects. it is universal and empowers the individual (so they are not dependent on the therapist), and it can be explained scientifically (astuti, yosep and susanti, 2015). spiritual emotional breathing (seb) is a therapy using the spiritual emotion freedom technique (seft), which is then followed by breathing exercises. the emotional spiritual approach is a part of the science of energy psychology that aims to turn the negative energy in a person into positive energy that can help the healing process. (zainudin, 2006). this approach is done using the body's energy system to cure patients, as in acupuncture or acupressure, but with simple techniques. the process consists of three stages, namely the set-up, the tune-in and the tapping. the set-up aims to ensure the proper flow of bodily energy. the tune-in aims to direct our mind to the pain and to feel the pain that we experience. the tapping is a light tap on certain points that neutralises emotional and pain disorders (zainudin, 2006). in improving the immunological factor, our study shows that eft can increase lymphocyte proliferation. there is the assumption that greater proliferation is associated with more effectiveness when it comes to an immune response (aggarwal and gurney, 2002). furthermore, eft can increase il-17 in the peripheral blood of chemically and pulmonary injured veterans. il-17 is a proinflammatory cytokine produced by activated memory t cells, that has a key role in the host's defence against microbial infections such as mycobacterium tuberculosis (jovanovic et al., 1998). it has a key role in the initiation and maintenance of inflammatory responses (zhang et al., 2012). the cells that produce il-17 have an important role in controlling both immune and inflammatory reactions (lutgendorf and costanzo, 2003). many studies have shown that stress can affect the function and number of immune cells (carlson et al., 2004), the production of many cytokines, like il-4, ifn-γ, l-10 and the reduction of lymphocyte proliferation (lengacher et al., 2013). the main objectives of this study were to analyse changes in breath frequency, pefr, oxygen saturation, breath sound, congested, cortisol, il-2, and ig. the second goal was to explain the relationship between the variables. materials and methods this research was a quasi-experimental research study with a non-randomised (purposive sampling) control group pre-test and post-test design. the sample in this study was made up of 34 people with the inclusion criteria of 1) positive acid-resistant bacteria tb patient, 2) productive age and 3) got standard therapy from primary health care. the exclusion criteria in this study were that they were tb patients with complications. the independent variable in this research was seb (spiritual emotional breathing), while the dependent variables in this research were cortisol, il-2, igm, pefr, oxygen saturation, respiratory rate (rr), pulse, complaints, and breath sound. first, we selected patients who met the inclusion criteria from each group in the first part of the study, and we enrolled those patients into the second part of the study. the patients were divided into 2 groups of 17 patients, and they were trained using an original program. the patients were also instructed to practice daily exercise at home. before the exercises, the patient was trained beforehand and given guidance. compliance with daily exercise was assessed weekly using an observation sheet filled in with the patients at home. the assessments were repeated 12 weeks after the beginning of the seb program. seb involves focusing on the situation identified as causing distress and tapping on specific meridian points of the body with breathing retraining, which consisted of relaxation, pursed lip breathing, and slow-deep breathing with training occurring in both the supine and sitting positions using the classic method of miller (miller, 1954), with slight modifications. intervention was performed once a day. the control group was given treatment according to the standard of care in the primary health care centre. the respondent's sampling was done by the purposive sampling method. the sample was taken by a nurse in primary health care. the samples were then analysed at the institute of tropical diseases. the place of study was east perak primary health care, january february 2015. the instrument used jurnal ners http://e-journal.unair.ac.id/jners | 95 was a peak flow meter to measure pefr. pulse oximetry was used to measure sao2. salivary cortisol elisa was used for the cortisol examination. the lowest detectable level of cortisol that can be distinguished from the zero standard is 0.537 mg/ml or 0.0537 µg/dl at the 95% confidence limit. legend max human il-2 elisa used for the human il2 examination, and the minimum detectable concentration of il-2 is 4 pg/ml. gen way mycobacterium igg was used for the examination of igg, with a clinical sensitivity of 100%. the salivary cortisol and igg concentration were determined using an enzyme-linked immunosorbent assay. the collected data was analyzed using a paired t-test. the instrument used in the research was made in japan. the analysis was conducted using spss with paired t-test (p ≤ 0.05). the ethical considerations were met, as the participants signed an informed consent form. moreover, their privacy, confidentiality, and voluntary participation was ensured. the study was approved by the health research ethics committee faculty of nursing universitas airlangga (no. 57kepk). results based on table 1, the number of the intervention and control group respondents was 17 people. the number of male respondents in the intervention group was 76.47% and in the control, it was 52.94%. the female respondents in the intervention group were 23.52% and 47.05% respectively. the mean age of the respondent intervention group was 41.17 years and in the control group, it was 47.76 years. the mean human value of il-2 in the intervention group before intervention was 30.95, and after intervention, it was 45.52. the mean values of the human cortisol group before and after intervention were 156.64 and 137.60 respectively. the mean igg groups of before and after intervention were respectively 10.75 and 14.58. discussion based on table 2, there was an seb effect on human il-2, human cortisol, and ig g. in improving immunologic factors, (babamahmoodi et al., 2015) shows that eft may increase lymphocyte proliferation. it is assumed that greater proliferation is associated with a more effective immune response. furthermore, eft may increase il-17 in chemically-injured veteran’s peripheral blood. il-17 is a pro-inflammatory cytokine produced by activated memory t cells and has a key role in host defense against microbial infections, such as mycobacterium tuberculosis. it has a key role in the initiation and maintenance of the inflammatory response. the cells that produce il-17 have an important role in controlling immune and inflammatory reactions. many studies have shown that stress can affect the function and number of immune cells, the production of many cytokines, such as il-4, ifn-γ, l-10 and the reduction of lymphocyte proliferation. furthermore, stress management intervention can reduce the immunosuppressive effects of stressors. there are many papers on the effect of other stress management techniques such as mindfulness-based stress reduction (mbsr) on immunological factors, but no studies of eft and immunity. in table 2, it can be seen that the decrease of the cortisol in the control group occurred because the respondent was able to manage the stress. cortisol can be associated with emotions, and can cause long-term physiological effects (trial, 2012). the exercise of the respiratory muscles and chest muscles can increase lung capacity. the results showed a strong correlation between the diffusion capacity of vital pulmonary capacity. exercise in the form of breathing exercises such as deep breathing exercises can be done by healthy people or lung problem sufferers in order to increase lung volume and capacity. the lung function status is identified by the ability of gas exchange to provide oxygen to the alveoli, so it is mutually sustainable to determine the oxygen saturation value. doing deep breathing exercises can help in the process of oxygenation so that the saturation levels can persist within the normal range (priyanto, 2010). deep breathing will reduce sympathetic reactions to improve respiratory patterns and decrease inspiratory and expiratory muscle contractions (yadav, singh and singh, 2009). shortness of breath may decrease as the breathing pattern changes from the rapid rate, which is under the control of the involuntary respiratory centre of the brain stem, and the pattern thus becomes more controlled. (nusdwinuringtya, 2000). our study had some limitations. to elucidate the effectiveness of seb on non-tbc patients, a prospective, randomised, controlled study is necessary. another limitation of our study was the difficulty of proving statistical equivalence. in general, to prove statistical equivalence, there needs to be a large sample size. table 1 demographic and baseline characteristics characteristics intervention control gender male female 13 (76.47%) 9 (52.94%) 4 (23.52%) 8 (47.05%) age (year) 41.17 47.76 breathing pattern pre test dyspnea 12 (70.59%) 10 (58.82%) normal 5 (29.41%) 7 (41.18%) post test dyspnea 0 (00.00%) 12 (70.59%) normal 17 (100.00%) 5 (29.41%) breathing sound pre test vesicular 11 (64.71%) 13 (76.47%) not vesicular 6 (35.29%) 4 (23.53) post test vesicular 17 (100.00%) 15 (88.24) not vesicular 0 (00.00%) 2 (11.76) k. kusnanto et al. 96 | pissn: 1858-3598  eissn: 2502-5791 conclusion spiritual emotional breathing (seb) can decrease human il-2, human cortisol, and ig g. using an emotional spiritual approach is a part of the science of psychological energy that is capable of improving the immune system. this therapy is performed as a complementary therapy for tb patients to improve their quality of life and the control of their symptoms. it is used as a therapy that supports major treatment therapies. references aggarwal, s. and gurney, a. l. (2002) ‘il-17: prototype member of an emerging cytokine family’, journal of leukocyte biology, 71(1), pp. 1– 8. available at: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elin k.fcgi?dbfrom=pubmed&id=11781375&retmode =ref&cmd=prlinks%5cnpapers3://publication/u uid/c6b73d07-6483-4b7c-b182bae723f8a26a. (accessed: january 1, 2017). ando, m. et al. (1999) ‘a study of the long-term effectiveness of an outpatient pulmonary rehabilitation program’, nihon kokyuki gakkai zasshi = the journal of the japanese respiratory society, 37(9), pp. 680–687. astuti, r., yosep, i. and susanti, r. d. (2015) ‘effect of intervention spiritual emotional freedom technique toward decrease the level of depression housewife with hiv’, jurnal keperawatan padjadjaran, 3(april 2015), pp. 44– 56. babamahmoodi, a. et al. (2015) ‘emotional freedom technique (eft) effects on psychoimmunological factors of chemically pulmonary injured veterans’, journal allergy asthma immunology, 14(february), pp. 37–47. bougea, a. m. et al. (2013) ‘effect of the emotional freedom technique on perceived stress , quality of life , and cortisol salivary levels intension type headache sufferers : a randomized controlled trial’, jsch. elsevier inc., 9(2), pp. 91– 99. doi: 10.1016/j.explore.2012.12.005. carlson, l. e. et al. (2004) ‘mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (dheas) and melatonin in breast and prostate cancer outpatients’, psychoneuroendocrinology, 29(4), pp. 448–474. doi: 10.1016/s03064530(03)00054-4. church, d. et al. (2012) ‘single-session reduction of the intensity of traumatic memories in abused adolescents after eft : a randomized controlled pilot study’, traumatology, 18(3). doi: 10.1177/1534765611426788. clark, c. j., cochrane, l. and mackay, e. (1996) ‘low intensity peripheral muscle conditioning improves exercise tolerance and breathlessness in copd’, european respiratory journal, 9(12), pp. 2590–2596. doi: 10.1183/09031936.96.09122590. hoorn, r. van et al. (2016) ‘the effects of psychoemotional and socioeconomic support for tuberculosis patients on treatment adherence and treatment outcomes – a systematic review and metaanalysis’, pp. 1–27. doi: 10.1371/journal.pone.0154095. jovanovic, d. v et al. (1998) ‘il-17 stimulates the production and expression of proinflammatory cytokines, il-beta and tnf-alpha, by human macrophages’, journal of immunology, 160(7), pp. 3513–21. kusnanto, k., pradanie, r. and karima, i. a. (2016) ‘spiritual emotional freedom technique ( seft ) terhadap kualitas hidup penderita tuberkulosis paru spiritual emotional freedom technique ( seft ) and the quality of life of people living with lung tuberculosis’, jurnal keperawatan padjadjaran, 4, pp. 213–224. available at: http://jkp.fkep.unpad.ac.id/index.php/jkp/articl e/view/284/134. (accessed: january 1, 2017). lengacher, c. a. et al. (2013) ‘lymphocyte recovery after breast cancer treatment and mindfulnessbased stress reduction (mbsr) therapy’, biological research for nursing, 15(1), pp. 37–47. doi: 10.1177/1099800411419245. lutgendorf, s. k. and costanzo, e. s. (2003) ‘psychoneuroimmunology and health psychology: an integrative model’, brain, behavior, and immunity, pp. 225–232. doi: 10.1016/s08891591(03)00033-3. miller, w. f. (1954) ‘a physiologic evaluation of the effects of diaphragmatic breathing training in patients with chronic pulmonary emphysema’, the american journal of medicine, 17(4), pp. 471– 477. doi: 10.1016/0002-9343(54)90122-9. nusdwinuringtya, n. (2000) efek latihan otot-otot pernafasan pada penyakit paru obstruksi kronis di instalasi rehabilitasi medik rsupn dr. table 2 statistical analysis variable intervention (mean) p value control (mean) p value before after before after human il-2 30.95 45.52 0.00 32.75 44.06 0.01 human cortisol 156.64 137.60 0.01 131.02 43.52 0.79 igg 10.75 14.58 0.00 8.29 3.48 0.10 pefr 221.18 254.71 0.00 236.47 242.94 0.28 heart rate 87.29 79.64 0.00 87.41 91.29 0.00 saturation o2 98.29 95.70 0.00 87.41 95.94 0.00 respiratory rate 22.70 17.94 0.00 21.29 23.11 0.03 http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=11781375&retmode=ref&cmd=prlinks%5cnpapers3://publication/uuid/c6b73d07-6483-4b7c-b182-bae723f8a26a http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=11781375&retmode=ref&cmd=prlinks%5cnpapers3://publication/uuid/c6b73d07-6483-4b7c-b182-bae723f8a26a http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=11781375&retmode=ref&cmd=prlinks%5cnpapers3://publication/uuid/c6b73d07-6483-4b7c-b182-bae723f8a26a http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=11781375&retmode=ref&cmd=prlinks%5cnpapers3://publication/uuid/c6b73d07-6483-4b7c-b182-bae723f8a26a http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=11781375&retmode=ref&cmd=prlinks%5cnpapers3://publication/uuid/c6b73d07-6483-4b7c-b182-bae723f8a26a http://jkp.fkep.unpad.ac.id/index.php/jkp/article/view/284/134 http://jkp.fkep.unpad.ac.id/index.php/jkp/article/view/284/134 jurnal ners http://e-journal.unair.ac.id/jners | 97 ciptomangunkusumo jakarta. universitas indonesia. patterson, s. l. (2016) ‘the effect of emotional freedom technique on stress and anxiety in nursing students: a pilot study’, nurse education today. elsevier b.v. doi: 10.1016/j.nedt.2016.02.003. priyanto (2010) pengaruh deep breathing exercise terhadap fungsi ventilasi oksigen paru pada klien post ventilasi mekanik. universitas airlangga. trial, a. r. c. (2012) ‘the effect of emotional freedom techniques on stress biochemistry’, 200(10), pp. 891–896. doi: 10.1097/nmd.0b013e31826b9fc1. who (2008) global burden of disease 2004 update. who. yadav, a., singh, s. and singh, k. . (2009) ‘ ’role of pranayama breathing exercise in rehabilitation of coronary artery disease patient-a pilot study’, indian journal of traditional knowledge, 8(3). zhang, l. et al. (2012) ‘effects and mechanism of arsenic trioxide on reversing the asthma pathologies including th17-il-17 axis in a mouse model’, iranian journal of allergy, asthma and immunology, 11(2), pp. 133–145. doi: 011.02/ijaai.133145. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 http://e-journal.unair.ac.id/jners | 41 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.9406 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors influencing mothers’ intention to immunize children younger than five years of age in west borneo: a cross-sectional study setho hadisuyatmana1, ilya krisnana1, muhammad adil sipahutar2 1 faculty of nursing, universitas airlangga, east java, indonesia 2 health office of pontianak abstract introduction: immunisations for bcg, dtp, poliomyelitis, hepatitis, and mmr are compulsory for children under 5 years old in indonesia and government-provided free services. however, the available records indicated that adherence to the program remains a challenge. this study aimed to investigate factors associated with mothers’ intention to comply with the immunization program, particularly among those who had children of younger than one year old. methods: the study was conducted through a cross-sectional analysis. fourty-six mothers self-registered them selves as participants of this study. the data were collected through check-listed interviews, to investigate the correlations between social factors, information factors, attitude toward behaviour, subjective norm, perceived behavioural control, and intention to adhere to the compulsory immunization program. the data were then analysed using logistic regression and spearman rank test with significance level of α=0.05. results: mothers’ attitude, subjective norm, perceived behavioral control, and knowledge have significant correlations with the intention in completing the immunisation program for their children (respectively p = 0.009; 0.014; 0.025; 0.038). their intention positively correlated with adherence to complete the program (p=0,002). however, other factors studied did not correlate either with mothers’ intention to adherence to the program. conclusion: this study suggests that mothers’ intention is influenced by family members suggestions, indicating that their capacity in decision making was limited and relying to other member. further investigation is required to unveil the underlying reasons of being non-adherence. article history received: august 16, 2018 accepted: sept 09, 2019 keywords icu; children; immunization compliance; intention; mother contact setho hadisuyatmana  setho.h@fkp.unair.ac.id  faculty of nursing, universitas airlangga, east java, indonesia cite this as: hadisuyatmana, s., krisnana, i., sipahutar, m.a. (2019 factors influencing mothers’ intention to immunize children younger than five years of age in west borneo: a cross-sectional study. jurnal ners, 14(1),41-46. doi:http://dx.doi.org/10.20473/jn.v14i1.9406 introduction immunisations for bcg, dtp, poliomyelitis, hepatitis, and mmr are compulsory in indonesia to protect children younger than 5 years old from contracting the diseases (kemenkes ri 2016). this program is provided as a free-paid service in public hospitals and public health centers (known as puskesmas). otherwise, mothers have to access it under an out-ofpocket service in private practitioners. the success of a 100% compliance is expected to prevent outbreaks and premature deaths among the children (destiyanta et al. 2015). the government of indonesia has set a target of 100% immunization rate as the success indicator. nevertheless, only 82.30% of the targeted children complied the program (kemenkes ri 2016). this indicates that the program was yet successfull. the available literature admited that adherence to immunization remains a challenging issue all over the world. like in the united states of america, parental religious perspective had pushed 17 states to allow a philosophical exemption towards compulsory immunization program (womack, 2010). another issues raised in low and middle income countries (lmics) such as in india and lao (phimmasane et al., 2010, masand et al., 2012). these studies reason the parental knowledge around the necessity of immunization and their low social-economic capacity as major hindrance to the non-compliance behaviour. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.94065 y. s. dewi et al. 42 | pissn: 1858-3598  eissn: 2502-5791 the world health organization (who 2015) supported that the similar cases in 2014 had caused over 11.3 million children who lived in lmics unable to access health services for vaccination. the who asserts that the situation is responsible for more than two million of premature deaths in these countries. therefore, the organization (2015) prioritizes 100% coverage of immunization program in lmics, including indonesia. however, it was reported that more than 32.1% of children in indonesia failed complete the compulsory program, and more than 13.5% others were never immunized (kementerian kesehatan republik indonesia 2013). particularly in pontianak, the capital city of west borneo, there were more than 27.58% of the babies did not comply to the immunization program during 2015 (dinkes kota pontianak 2016). the puskesmas of siantan tengah, one of the public health centers in the city, reported that there were only 50.2% of the babies accessed to get the immunization. this reasoned the outbreaks of diphtheria, neonatal tetanus, measles, and hepatitis b. local investigation informed that none of these children complied with the program (dinkes kota pontianak 2016). on the other hand, it is reported that a mother’s lack-ofawareness toward health significantly contributed to the situation (satgas idai 2011). adekeye et al. (2015), barkun (2012), febriastuti et al. (2014) and rizani et al. (2009) agreed that this could also be influenced by mothers’ personal attitude and past experience about immunization. harmasdiyani (2015) added that family support, level of education, and the accessibility of health service also determined the compliance toward the program. ajzen’s planned behaviour theory (2005) offers a way to further understand this phenomenon. it explains that intention, attitude or valuation, and perceptions on social norm could affect one’s behavior. particular to the studied phenomenon, this theory lends a light to explain the underlying factors (uddin et al. 2012). the behavior belief refers to an individual’s notion toward the results of acts (belief strength) and its evaluation (outcome evaluation). the normative belief refers to expectations toward other’s expectation, and a personal motivation to fulfill the expectations, while control belief adresses the accessibility of supports against attempts to bring out the intention into action (nursalam 2013). this study aimed to examined factors that influenced mothers’ intention to immunize their children of younger than one year old. materials and methods research design this study targeted at 178 mothers of babies aged ranging from 9 to 12 months old in the work area of a public health center (puskesmas) in pontianak, west borneo, as population. we selected the sample purposively following inclusion criteria: have at least one child who were currently aged between 9-12 months old, registered in the monthly screening cohort, literate, and have the mother and child health manual book that were government-provided. we approached targeted mothers when they were coming for a routine check for their babies, provided information regarding the study, and offer them written consents upon their agreement. mothers who were registered as regular clients of the puskesmas and owned a mother and child health manual book, were offered as participants in this study. this study was conducted under the light of crosssectional approach, where by we examined the correlations between participants social factors (age, gender, education, ethnicity, income, and religious belief), information (experience, knowledge, and media exposure), attitude, subjective norm, and perceived behavior control and their intention and the adherence to immunization program. the predictors were investigated using a questionnaire adapted from ajzen’s (2006) planned behavior questionnaire that has been translated and validated in jerman, amerika, italia, uganda, china (adekeye et al. 2015). we use the bahasa indonesia version developed by and tested for validity and reliability by febriastuti, arif, & kusumaningrum (2014). the questionnaire used in this study was originally designed to collect non-continuous data. participants’ intention and the adherence to immunization program were identified using the nationalstandardized mother and child health manual book. a verbal permission was granted from kusumaningrum (febriastuti, arif, & kusumaningrum 2014) through a phonecall. the validity and reliability issues of questionnaires used in this study have been evaluated by the original authors. the validity test used r table = 0.561using the significance level of 95% resulted the score of 0.816-0.915 for all the questions. the reliability of the questionnaire was tested using cronbach’s alpha resulted the score of 0.975. data collection and analysis we collected the data between october-december 2016, at one of the puskesmas in the region of siantan tengah, the province of west kalimantan. the questionnaire was distributed to participating mothers, following written consent. each mother was given time to look the given questionaires and provided assistance if required to guide in filling up the questions. the data collection process was conducted afte the mothers finished meeting with the doctor. we provided chairs and table and utensils for mothers to fill questionnaire sheet. souvenirs equal to 100.000 indonesian rupiah were distributed after the data collection process or for those who decided not to continue their participations. the collected data were then cleaned and analysed using univariate, bivariate, and multivariate modes of analysis spearman rank’s test using the significant level of α<0.05. a logistic regression was employed to examine the interrelationship of multiple independent variables (social, information, attitude, jurnal ners http://e-journal.unair.ac.id/jners | 43 subjective norm, and perceived behavior factors) and mothers’ intention to adhere to the immunization program. these multivariate analyses were tested using the significant level of α<0.05. ethical consideration the universitas airlangga’s human-health research ethical committee has approved this study under the article number 267-kepk. results demographic details a total of 46 mothers were voluntarily participating in this study. most of the participating mothers were younger than 21 years old (50%) and graduated from primary school (39.1%), indicating that they might lacked education. they were mostly lived in poorly financial-support (71.7%) and coming from madura as cultural background (54.3%) (see table 1). most participants relied on the puskesmas as the main source of information in relate with the immunization program (93.5%), while the electronic-based and printed media were less likely accessed. the majority of the participants (54.3%) have sufficient knowledge about the necessity of the compulsory immunizations for their children (see table 2). attitude, subjective norm, and perceived behavioural control toward immunization program in regard to attitude, more than half of participants (56.5%) refused to follow the program, and about 43.5% of the others were being supportive. in term of their subjective norm, 56.5% of participants ignored the supports from their immediate family, friends, and health personnel. the majority of participants (63%) have poor perception toward the immunization program, only about 28.3% of mothers viewed the program positively. most mothers (60.9%) have low intention to follow the immunization program. respectively, most children younger than five years of age (56.5%) failed to comply with the compulsory immunization program (see table 3). the interrelationship of age, education background, household income, religious view, ethnic, past experience, media exposure, and intention to adhere the compulsory immunization program the findings in this study show that age, the highest level of education, family income, religious view, ethnical background, personal past experience, and media exposure have no correlation with participants’ intention to adhere to the program despite the odds ratio inform significant figures (or < 0.05) (see table 4). the interrelationship between knowledge, personal belief and family support, awareness, and intention adhere to the compulsory immunization program this study suggests that mothers who acquired sufficient understandings about the significance of immunization have higher intention to access puskesmas on behalf of their children (p=0.038) when compared with their counterparts (see table 5). the odd ratio of this variable indicates that acquired knowledge on immunization would improve the probability of mothers being adhered to the program by 3.127 times higher. the regression analysis suggests that mothers’ attitude toward immunization has a significant interrelation with their intention to follow the program (p=0.009) the odd ratio of this correlation indicates that mothers’ belief toward the result of immunization contributes as many as 8.037 times higher to influence their adherence to the immunization program (see table 5). likewise, supports from immediate families inclucing husbands and parents (subjective norm) also strengthen participants’ intention to immunize their children (logistic regression test of p = 0.014, with its odd ratio of 5.056). additionally, all of the aforementioned factors also determine mothers’ awareness toward the importance of immunizations for their children. as the regression test shows that the awareness (perceived behaviour control) has a close interrelationship with mothers’ intention to adhere to the immunization program (p = 0.025, or = 0.445). the analisys of the results suggest that mothers’ intention correlates with childrens’ completion in following the compulsory immunization provided by the indonesian government. the spearman rank test (p of 0.002) infers that the higher the mother intention the higher possibility of children’s compliance to the immunization program. discussion the findings in this study showed that the majority of the participants gave birth at a young age with low level of education, and half of the children were not completely immunized. this study also finds a strong and positive correlation between mothers’ level of understanding and intention to comply the children’s compulsory immunization program. ajzen (2005) lends a support to this finding and reasons the low participation in the compulsory immunization program as a result from mothers’ insufficient knowledge. this leads to a notion that the low understanding and awareness among mothers determines the low adherence, as well as negative perception towards the program (gustin, 2012). this indicates that participants’ poor perception and rejection to adhere with the program were most likely as a result from their unfamiliarity on the importance of immunization for their children. however, the current study argues that there is no significant y. s. dewi et al. 44 | pissn: 1858-3598  eissn: 2502-5791 correlation between mothers’ age, level of formal education, and intention to comply with the program. also, this rejects prior finding by (kusnanto et al., 2017), whereby the authors underscored the highest level of formal education as a determinant in baby’s immunization status. instead, this study implies that mothers’ knowledge on children’s immunization was not determined by their young age and low level of formal education. rather, they may be non-formally exposed by different source of information, which is yet explored in this study. the positive and strong correlation between attitude and intention shown in this study indicate that good understanding is fundamental for mothers whose children need to be immunized. another finding in this study infers the local public health centre (puskesmas) is viewed as the most reliable and accessible source of information regarding the immunization program. the participants heavily relied to the puskesmas to gain important updates regarding the program. participants who acquired sufficient understandings about the significance of immunization have higher intention to access the puskesmas when compared with their counterparts. this finding underscores the role of puskesmas in promoting immunization program to mothers (mulyanti, 2014). however, this did not guarantee that they would comply with the program, despite the finding suggest that mothers’ awareness has a strong correlation with their intention to adhere to the program. the finding indicates that most participants could only access puskesmas for an immunization provider due to their low economic background. most participants lived under the insufficient household income, lower than the regional minimum wage of us$ 150 per month (sulistiawati, 2013). thus, it is unlikely that they would spend out-of-pocket money to get the immunization from private health practices. this suggests that being absence in a puskesmasscheduled immunization was a non-adhere behavior (puspitaningrum 2015), otherwise program’s misinformation or other possible causes that have not been explored under this study. this finding suggests further investigation on the underlying reasons of being non-adherence, given the free services by local puskesmas and mothers good knowledge around children immunization. the strong correlation between family supports and intention found in this study implies that mothers’ intention to immunize children is strongly influenced by supports given by families (including husbands, parents, or peer). in further analysis, positive correlation is found between mothers’ intention and children compliance to immunization program. this raises the significant role of family members as determinant for children’s immunization status and rate improvement. this study informs that there is a tendency among participants to have higher intention in following the program, with regard to the positive supports given by family members, including parents and siblings and husbands. this finding lends a support to earlier studies by ismet (2013) and sarimin, ismanto & worang (2014), whereby the authors underscored the necessary of supports from immediate parents and siblings. this finding further suggests the necessity to involve family members as a strategy to improve children immunization rate. this indicates that mothers’ intention is more a result of cumulative thought than sole decision. however, one study showed that women’s inferiority in family decision-making significantly contributes to the non-compliance behaviour in regards to children immunization program (afriani et al., 2014) that lead to failure in completing the compulsory immunizations (puspitaningrum 2015). this can be another reason to the non-adhere behaviour among mothers and low rate of immunization. however, this remains unclear and requires future studies in attempt to unveil the best strategy in improving children immunization rate. conclusion this study finds that mothers’ age, education background, ethnics and religion, and perspective did not play roles to children immunization rate. rather, there is an indication that mothers were unable to comply by themselves due to the interplay in family decision-making. therefore, it is suggested that family members within or those influencing the household need to be involved in health promotions, particularly to improve the immunization rate. however, these results can only be generalized to mothers lived in the area of siantan tengah, one region in the province of west kalimantan. the limitations of this study are around the questionnaire details and the number of mothers as participants. the age of participants when first become a mother was not asked; this raised a loose argument to imply that the participants were novice to the immunization program. secondly, the small number of participants in this study informs that the finding should be generalized with considerate manner. this study, however, adds new evidence and suggests a further study to involved families in investigating their roles to children immunization rate and uptake. acknowledge prof eileen savage rgn who contributed in her kind assistance to review this article for submission. references adekeye, o.a., chenube, o.o. & adekeye, b.t., 2015. knowledge , attitude and barriers towards children immunization among women in selected rural primary health centres fred ahmadu. ife psycholoia, 23(1), pp.89–97. afriani, t., 2009. kelengkapan imunisasi dasar anak balita dan faktor-faktor yang berhubungan di poliklinik anak beberapa rumah sakit di jakarta jurnal ners http://e-journal.unair.ac.id/jners | 45 dan sekitarnya pada bulan maret 2008. buletin penelitian sistem kesehatan, 11(1), pp.1–7. doi: http://dx.doi.org/10.14238/sp11.1.2009.1-7 afriani, t., andrajati, r. & supardi, s., 2014. faktorfaktor yang berhubungan dengan kelengkapan imunisasi dasar pada anak dan pengelolaan vaksin di puskesmas dan posyandu kecamatan x kota depok. buletin penelitian sistem kesehatan, 17(2), pp.135–142. ajzen, i., 2005. attitudes, personality and behavior second., buckingham: open university press. ajzen, i., 2006. contructing a tpb questionnaire: conceptual and metodological considerations. september., buckingham: open university press, milton keynes. anggraeni, d., 2013. hubungan perilaku ibu mengimunisasikan dpt dengan status kelengkapan imunisasi dpt dasar pada bayi usia 11 bulan di kesa kaliwates kecamatan kaliwates kabupaten jember. universitas jember. arumsari, d.r., 2015. fakto-faktor yang berhubungan dengan status imunisasi dasar pada bayi. jurnal stik maharani malang, 3(6), pp.76– 88. doi: 10.33085/jkg.v1i3.3955 azwar, s., 2010. sikap manusia teori dan pengukurannya, yogyakarta: pustaka pelajar. babirye, j.n. et al., 2011. more support for mothers : a qualitative study on factors affecting immunisation behaviour in kampala , uganda. bmc public health, 11(1), p.723. doi: 10.1186/1471-2458-11-723 barkun, a.l., 2012. imunisasi 2nd ed., jakarta: balai penerbit fkui. burke s, d. et al., 2011. protecting the frontline in biodefense research the special immunizations program fifth., washington, dc: the national academies press. https://doi.org/10.17226/13112. conis, e., 2015. vaccine nation, america’s changing relationship with immunization, chicago and london: the university of chicago press. destiyanta, a.p., kusumawati, y. & catur, a.w., 2015. hubungan tingkat pendidikan, pekerjaan dan pengetahuan ibu dengan ketepatan jadwal mengikuti imunisasi campak di wilayah kerja puskesmas weru sukoharjo. jurnal fik ums, 3(6), pp.78–90. dharma, k.k., 2011. metodologi penelitian keerawatan (pedoman melaksanakan dan menrapkan hasil penelitian), jakarta: trans info media. dinkes kota pontianak, 2016. profil kesahatan kota pontianak r. mustika, i. rossa, & fakhurrozi, eds., pontianak: dinas kesehatan kota pontianak. fajriyah, i., 2014. hubungan pengetahuan ibu dan dukungan keluarga dengan status imunisasi td pada sub pin difteri. jurnal berkala epidemiologi, 2(3), pp.404–415. http://dx.doi.org/10.20473/jbe.v6i22018.103111 febriastuti, n., arif, y.s. & kusumaningrum, t., 2014. kepatuhan orang tua dalam pemberian kelengkapan imunisasi dasar pada bayi 4-11 bulan. jurnal ners unair, 3(31), pp.45–52. http://dx.doi.org/10.20473/pmnj.v2i2.11793 gustin, r.k., 2012. hubungan pengetahuan dan sikap tentang imunisasiterhadap pemberian imunisasi dasar lengkap pada balita di wilayah kerja puskesmas malak kabupaten agam. jurnal kesehatan stikes prima bukittinggi, 3(2), pp.10– 16. harmasdiyani, r., 2015. pengaruh karakteristik ibu terhadap ketidakpatuhan pemberian imunisasi dasar lengkap pada anak bawah dua tahun. jurnal berkala epidemiologi, 3(3), pp.304–314. doi: 10.20473/jbe.v6i12018.86-94 irawati, d., 2011. faktor karakteristik ibu yang berhbungan dengan ketepatan imunisasi dpt combo dan campak di pasuruan. hospital majapahit, 3(1), pp.1–14. ismet, f., 2013. analisis faktor-faktor yang berhubungan dengan imunisasi dasar lengkap pada balita di desa botubarani kecamatan kabila bone kabupaten bone bolango. universitas negeri gorontalo, 1(1), pp.4–24. kemenkes ri, 2013. penyelenggaraan imunisasi, jakarta: kementerian kesehatan republik indonesia. kemenkes ri, 2013. riset kesehatan dasar, jakarta: kementerian kesehatan ri. kemenkes ri, 2015. panduan pekan imunisasi sedunia tahun 2015, jakarta: kementerian kesehatan republik indonesia. kemenkes ri, 2016. profil kesehatan indonesia tahun 2015, jakarta: kementerian kesehatan republik indonesia. kusnanto, k., ulfiana, e. & hadarani, m. 2017. behavior of family in practice hepatitis b immunization at baby 0-7 days old. jurnal ners, 3, 151-156. doi.org/10.20473/jn.v3i2.4998 maramis, w.f., 2006. ilmu perilaku dalam pelayanan kesehatan, surabaya: airlangga university press. masand, r., dixit, a. m. & gupta, r. k. 2012. study of immunisation status of rural children (12-23 months age) of district jaipur, rajasthan and factors influencing it: a hospital based study. journal of the indian medical association, 110, 795799. y. s. dewi et al. 46 | pissn: 1858-3598  eissn: 2502-5791 mohamud, a.n. et al., 2014. immunization coverage of 12 – 23 months old children and associated factors in jigjiga district , somali national regional state , ethiopia. bmc public health, 14(1), pp.1–9. doi: 10.1186/1471-2458-14-865. mulyanti, y. 2014. faktor-faktor internal yang berhubungan dengan kelengkapan imunisasi dasar balita usia 1-5 tahun di wilayah kerja puskesmas situ gintung ciputat tahun 2013. ningrum, e.p. & sulastri, 2008. faktor-faktor yang mempengaruhi kelengkapan imunisasi dasar pada bayi di puskesmas banyudono kabupaten boyolali. berita ilmu keperawatan issn 19792697, 1(1), pp.7–12. notoatmodjo, s., 2010. ilmu perilaku kesehatan, jakarta: pt renika cipta. nursalam, 2013. metodologi penelitian ilmu keperawatan: pendekatan praktis edisi 3., jakarta: salemba medika. phimmasane, m., douangmala, s., koffi, p., reinharz, d. & buisson, y. 2010. factors affecting compliance with measles vaccination in lao pdr. vaccine, 28, 6723-6729. doi: 10.1016/j.vaccine.2010.07.077 puspitaningrum, 2015. hubungan tingkat pengetahuan dengan kepatuhan ibu dalam pemberian imunisasi pentavalen di wilayah kerja uptd puskesmas gilingan surakarta. stikes kusuma husada, 2(1), pp.6–19. rahmawati, a.i. & umbul, c.w., 2014. faktor yang mempengaruhi kelengkapan imunisasi dasar di kelurahan krembangan utara. jurnal berkala epidemiologi, 1(4), pp.59–70. rhamadhani, r.b., 2013. faktor-faktor yang berhubungan dengan kelengkapan imunisasi dasar balita di desa balegondo kecamatan ngariboyo kabupaten magetan. jurnal fik ums, 2(3), pp.18–26. rizani, a., hakimi, m. & ismail, d., 2009. hubungan pengetahuan, sikap dan perilaku ibu dalam pemberian imunisasi hepatitis b 0-7 hari di kota banjarmasin. berita kedokteran masyarakat, 25(1), pp.12–20. sarimin, s., ismanto, a.y. & worang, r., 2014. analisis faktor-faktor yang berhubungan dengan perilaku ibu dalam pemberian imunisasi dasar pada balita di desa taraitak satu kecamatan langowan utara wilayah kerja puskesmas walatakan. jurnal universitas sam ratulangi manado, 8(1), pp.20– 28. satgas idai, 2011. panduan imunisasi anak 1st ed. j. a. wempi, ed., jakarta: badan penerbit ikatan dokter anak indonesia. satgas imunisasi idai, 2011. pedoman imunisasi di indonesia 4th ed. i. g. g. ranuh et al., eds., jakarta: badan penerbit ikatan dokter anak indonesia. somantri, a. & muhidin, s.al., 2014. aplikasi statistika dalam penelitian, bandung: pustaka setia bandung. sunaryo, 2013. psikologi untuk keperawatan 2nd ed. b. bariid, ed., jakarta: egc. sulistiawati, r. 2013. pengaruh upah minimum terhadap penyerapan tenaga kerja dan kesejahteraan masyarakat di provinsi di indonesia. triana, v., 2016. faktor yang berhubungan dengan pemberian imunisasi dasar lengkap pada bayi tahun 2015. jurnal kesehatan masyarakat andalas, 10(2), pp.123–135. doi: 10.22216/jen.v3i1.2820 uddin, j. et al., 2012. improving low coverage of child immunization in rural hard-to-reach areas of bangladesh : findings from a project using multiple interventions. vaccine, 30(2), pp.168– 179. .doi.org/10.1016/j.vaccine.2011.11.030. visser, o. et al., 2016. intention to accept pertussis vaccination for cocooning : a qualitative study of the determinants. plos one, 11(6), pp.1–19. doi: 10.1371/journal.pone.0155861 wagner, a.l. et al., 2014. timely measles vaccination in tianjin , china : a cross-sectional study of immunization records and mothers. bmc public health, 14(1), pp.1–7. doi: 10.1186/1471-245814-888. weiner, j.l. et al., 2015. childhood immunizations first-time expectant mothers ’ knowledge , beliefs , intentions , and behaviors. vaccine, 33(9), pp.d92–d98. doi: 10.1016/j.amepre.2015.07.002 who, 2015. world health statistics 2015 indicator compendium, new york: world health organization. wiradharma, d., rusli, i. & wiradarma, k., 2012. konsep dasar vaksinasi k. dr. wiradarma, ed., jakarta: sagung seto. womack, j. m. 2010. safety and adherence: issues that hinder childhood vaccinations. jaapa : official journal of the american academy of physician assistants, 23, 42-47. doi: 10.1097/01720610201001000-00010. 110 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 110-116 http://dx.doi.org/10.20473/jn.v18i2.45700 original article open access determinant of functional disability in instrumental activities of daily living among elderly living in a rural area in bali: a crosssectional study i gede putu darma suyasa 1 * , ni kadek sutini 1 , ni putu kamaryati 1 , and i kadek nuryanto 1 1 nursing program, institute of technology and health bali, bali, indonesia *correspondence: i gede putu darma suyasa. address: nursing program, institute of technology and health bali, bali, indonesia. email: putudarma.stikesbali@gmail.com responsible editor: ferry efendi received: 24 may 2023 ○ revised: 9 june 2023 ○ accepted: 9 june 2023 abstract introduction: little do we understand factors associated with functional disability in instrumental activities of daily living among the elderly living at home. this study aimed to explore determinants of functional disability in instrumental activities of daily living (iadl) among the elderly living in a rural area in bali. methods: this cross-sectional study involved 1,053 elderly aged 60 years and above living in a rural area in bali. a structured interview by trained data collectors was conducted. questionnaires used were the lawton iadl scale, the 5-item of geriatric depression scale, and the adoption of questionnaires for vision, hearing, and communication problems from the washington group short set of questions on disability. a logistic regression model was applied to explore determinant factors. results: findings indicated that 26.1% of participants aged 75+ and 52.3% were female. eight percent experienced functional disability in iadl, 1.9% lived alone, 11.8% indicated depression, 5.1%, 4.7%, and 1.6% had vision loss, hearing impairment, and communication problems, respectively. the strongest determinant factor for functional disability in iadl was depression (or 7.869; 95% ci 4.657-13.296), followed by age (or 4.602; 95% ci 2.764-7.663), and hearing impairment (or 2.903; 95% ci 1.190-7.083). conclusions: depression is the strongest determinant for functional disability in iadl. nurses in rural areas should actively screen for depression to increase the ability of the elderly to fulfill their iadls. keywords: aged, depression, epidemiology, indonesia introduction the number of elderly in indonesia has increased significantly by 11 million in the last decade. in 2010, the number was 18 million (7.6% of the total population), and, in 2020, the number reached 29 million or 10.5 % of the total population (badan pusat statistik, 2022). consequently, indonesia now faces an increase in degenerative diseases, higher independency, and higher healthcare system usage. bali is among the three highest percentages of elderly in indonesia, with 13.5% (badan pusat statistik, 2022). therefore, conducting a study on elderly in bali is essential. forty-four percent of the elderly in indonesia live in rural areas (badan pusat statistik, 2022). the elderly living in rural areas face several problems where access to healthcare services and social support is more limited than in urban areas (banerjee, 2021). likewise, the usage of health facilities in rural areas is lower than in urban areas (wulandari et al., 2022). in addition, there is a tendency for social changes due to more young people moving from rural https://creativecommons.org/licenses/by/4.0/ mailto:putudarma.stikesbali@gmail.com https://orcid.org/0000-0002-5817-8018 https://orcid.org/0000-0003-4721-6215 https://orcid.org/0000-0001-5617-792x jurnal ners http://e-journal.unair.ac.id/jners 111 areas to urban areas for economic reasons. consequently, maintaining independence is essential for the elderly living in rural areas, especially in fulfilling instrumental activities of daily living (iadl). iadls are crucial activities necessary to maintain the elderly’ independence, such as their capacity to use a phone, travel, shop, prepare their food, clean their homes, do their laundry, manage their medications, and manage their finances (lawton & brody, 1969). however, little has been done to explore the functional disability of iadl and its determinant factors in rural areas. a study conducted in southeastern poland reports a high prevalence of iadl disability (35.8%), with age, environmental factors, lack of social contact, increased pain, and multimorbidity as determinant factors (ćwirlej-sozańska et al., 2019). depressive symptoms are evident as having a significant association with iadl decline in a study in japan (kiyoshige et al., 2019). a study in china and europe reports that the elderly with iadl disability are at risk of developing multimorbidity, disability, and chronic diseases (qiao et al., 2021). another study in india reports 6% of elderly experience severe iadl disability (chauhan et al., 2022). a recent systematic review shows the prevalence of iadl disability in asean countries is 46.8% (yau et al., 2022). however, the review also reveals that no study is included from the indonesian perspective, highlighting the importance of the current study in the indonesian context. similar studies focusing on elderly living in rural areas are currently absent in indonesia, although a recent study indicates that living in rural areas is associated with a higher risk of dependency in fulfilling their activity daily living (handajani et al., 2022). handajani et al. (2022) also report that age, gender, and depression are associated with limitations in iadl. another study reports some functional disability in iadl among the elderly living in an institutional aged care facility in indonesia (fitriana et al., 2019). with the absence of a similar study, this current study will be the first in indonesia to explore determinants of functional disability in instrumental activities of daily living (iadl) among the elderly, focusing only on those living in a rural area. determinant factors include age, gender, depression, living arrangement, vision loss, hearing impairment, and communication problems. findings from this study will contribute to science and nursing practice by providing data and information on determinant factors of iadl disability. materials and methods research design this study employed a cross-sectional design. the setting of the study was a village in a rural area of bali, indonesia. this village was chosen because the number of elderly was high, 1,118, and it is classified as a rural area (badan pusat statistik, 2023). data collection was from august-october 2022. a structured interview by trained data collectors was conducted for data collection in this study. prior to data collection, all data collectors attended a 2-day training session. during the data collection, data collectors read all questions and filled out the questionnaire. we allowed the presence of family during the interview if it was necessary. the independent variable of this study was iadl, and the dependent variables were age, gender, depression, living arrangement, vision loss, hearing impairment, and communication problems. population, samples, and sampling the population of this study was 1,118 elderly living at home in a rural area of bali, indonesia. during data collection, all potential participants were approached in their own homes. inclusion criteria were elderly aged 60 years and above and living in melinggih village. we excluded those who were hospitalized and critically ill during data collection. among 1,118 elderly, 1,053 were willing to participate in the study (response rate 94.2%). a convenience sampling technique was applied for the study. instruments questionnaires used to measure iadl were the lawton iadl scale (lawton & brody, 1969). scores of 2 or less were considered functional disability in iadl (table 1). depression was measured using the 5-item geriatric depression scale (hoyl et al., 1999). scores of 2 and above were considered depression (table 2). for vision loss, hearing impairment, and communication problems, the washington group short set of questions on disability was adopted (washington group on disability statistics, 2020). respondents were considered as having vision loss, hearing impairment, and communication problems if they answered either “yes – a lot of difficulty” or “cannot do at all” in three related questions (table 3). all instruments measured all participants’ current condition at the present time. in addition, all instruments have been tested and widely used in indonesia (kementerian kesehatan, 2017). suyasa, sutini, karmayati, and nuryanto (2023) 112 p-issn: 1858-3598  e-issn: 2502-5791 data analysis statistical analyses for this study were conducted using spss version 20. bivariate analyses were conducted using a chi-square test with fisher’s test as an alternative when appropriate. all statistical analyses were two-tailed, with statistical significance defined as p < 0.05. effect sizes were calculated and reported as phi coefficient. all variables with p < 0.25 in bivariate analysis were entered into a logistic regression to find the determinant (bursac et al., 2008). ethical consideration statistical analyses for this study were conducted using spss version 20. bivariate analyses were conducted using a chi-square. results missing data there were no missing data in this study. with structured interviews conducted by trained data collectors, all respondents were willing to answer all questions. prevalence of functional disability in iadl, depression, vision loss, hearing impairment, and communication problems about 20.5% of respondents could use a phone, 23.6% could travel alone, 65.8% could handle all of their shopping needs alone, 65.2% could prepare adequate meals alone, 40.4% could maintain their home alone or with occasional help, 66% could do their laundry, 84.5% could take their medications in the correct dosages at the correct times, and 27% could handle financial matters alone (table 1). around 10.3% of respondents were unsatisfied with their life, and 36.1% preferred staying home (table 2). eighty-five out of 1,053 elderly (8%) experienced functional disability in iadl, 11.8% indicated depression, and 5.1%, 4.7%, and 1.6% of them had vision loss, hearing impairment, and communication problems, respectively (table 4). determinant factors of functional disability in iadl the bivariate analyses (table 4) indicated that factors potentially associated with the functional disability of iadl were age, depression, vision loss, hearing impairment, and communication problems (p < 0.001). however, it is essential to highlight that the effect size of age, vision loss, hearing impairment, and communication problems were low (less than 0.3). only depression showed a medium association with an effect size of 0.3 (cohen, 1988). gender and living arrangement were not significantly associated with the functional disability of iadl. we applied logistic regression to determine the impact of various factors on the likelihood that respondents will have an iadl functional disability. the model contained seven independent variables (age, gender, depression, living arrangement, vision loss, hearing impairment, and communication problems). chi-square (7, n = 1,053) = 144.371, p 0.001, suggesting that the whole model, including predictors, was statistically significant and could distinguish between respondents who had and did not experience functional disability of iadl. the whole model explained between 12.7% (cox & snell r square) and 29.6% (nagelkerke r square) of the variance in functional disability of iadl and correctly classified 92.5% of cases. the strongest predictors for functional disability in iadl were depression (or 7.869; 95% ci 4.657-13.296), followed by age (or 4.602; 95% ci 2.764-7.663) and hearing table 1. frequency of functional disability in iadl among elderly living in rural area in bali (n=1,053) description (score) n % ability to use telephone independently uses a phone (1) 216 20.5 makes a couple of standard phone calls (1) 31 2.9 answers the phone but doesn't make a call (1) 146 13.9 not at all a telephone user (0) 660 62.7 mode of transportation independently uses public transport or has a vehicle (1) 248 23.6 taxi is arranged for personal travel; other than that, no public transit is used (1) 377 35.8 uses a companion when using public transit (1) 273 25.9 doesn't go anywhere at all (0) 155 14.7 shopping independently takes care of all shopping (1) 693 65.8 uses a companion when shopping (0) 212 20.1 unable to shop (0) 148 14.1 food preparation independently creates, prepares, and serves a sufficient meal (1) 687 65.2 provides adequate meals if given the necessary components (0) 103 9.8 makes meals, or prepares meals but does not keep a sufficient diet (0) 126 12.0 needs to have meals prepared and served (0) 137 13.0 housekeeping maintains home alone or sporadically with aid (1) 425 40.4 carries out minor daily activities like making the bed and washing the dishes (1) 372 35.3 needs assistance with all household upkeep jobs (1) 181 17.2 does not assist with any cleaning duties (0) 75 7.1 laundry completes personal laundry (1) 695 66.0 launders small items-rinses stockings, etc. (1) 210 19.9 the others must do all the laundry (0) 148 14.1 responsibility for own medications is in charge of taking medication at the proper times and in the proper dosages (1) 890 84.5 is unable to dispense his or her own medication (0) 163 15.5 ability to handle finances independently manages financial matters (1) 284 27.0 organizes daily purchases but need assistance with banking, large purchases (1) 515 48.9 unable to manage money (0) 254 24.1 jurnal ners http://e-journal.unair.ac.id/jners 113 impairment (or 2.903; 95% ci 1.190-7.083). the findings indicated that elderly living in rural areas and experiencing depression were 7.869 times more likely to experience functional disability of iadl (table 5). discussions in the last decade in indonesia and other countries, life expectancy has significantly increased the number of elderly. with aging, some anatomical and physiological changes in the normal aging process may decrease the intrinsic capacity and functional ability of the elderly (michel et al., 2021). our current study provides determinant factors and the prevalence of functional disability in iadl. functional ability is a significant predictive variable of iadl (tornero-quiñones et al., 2020). in our study, we found a lower prevalence of functional disability of iadl (8%) compared to an 11% prevalence in a study in ireland and a 35.8% prevalence in a study in poland (ćwirlej-sozańska et al., 2019). in germany, the prevalence rate of disability in iadl is even higher, 45.8%, but the mean age of the study in germany is 80.7 years (beltz et al., 2022), compared to the mean age of 70 years in our study. among eight items of lawton iadl, the inability to use a phone (62.7%) and being incapable to handle money (24.1%) were two distinguished disabilities found in our study. these inabilities may be related to the nature of the study setting where people in rural areas do not necessarily use phones and or manage their own finances, as evidenced by current data where, in bali, only 34% of the elderly in rural areas use phones (badan pusat statistik, 2022). these responsibilities are given to other family members. it was found in this study that only 1.9% of the elderly lived alone, while others lived with family members or other extended families. although prevalence rates are different between studies, our current study and previous studies in ireland, poland, and germany indicated similarity in terms of advancing age and its association with disability in iadl (beltz et al., 2022; ćwirlej-sozańska et al., 2019; ismail et al., 2021; tornero-quiñones et al., 2020). our logistic regression indicated that the elderly aged 75 years and above were 4.602 times more likely to experience disability in iadl than those aged below 75. our study also found 2.9% disability in iadl in age 60-74 vs. 5.1% in age 75 years and above. compared to previous studies, in poland, the elderly aged 65 years and above reported 42.4% of disability in iadl (ćwirlejsozańska et al., 2019). in malaysia, the elderly aged 70 and above are 3.52 more likely to experience functional disability in iadl (ismail et al., 2021). the finding of this current study is also in line with previous studies that age is a determinant factor for disability in iadl (yau et al., 2022). this finding also highlights the importance of conducting our current study, especially in the indonesian setting; as life expectancy increases, the number of elderly in the advanced age group may potentially experience an increased disability in iadl. this finding implies that nurses, other health workers, and other parties must address this issue and primarily assist especially those with iadl problems. previous studies indicate that iadl problems link to poor quality of life (beltz et al., 2022;fumes-ghantous et al., 2020). although our study did not measure the relationship between quality of life and iadl, previous studies in india focusing on functional status as indicated by disability in iadl found a significant effect on the quality of life of the elderly (sharma, 2020). therefore, to maintain and increase the quality of life of the elderly, maintaining adequate iadl is imperative. a further study exploring iadl and quality of life in the indonesian context is also necessary. hearing impairments are also common among the elderly. several causes include cerumen occlusion, middle ear ossification, viruses, and bacteria (patel & mckinnon, 2018; sahoo et al., 2020). there are some concerns reported by previous studies that hearing impairment reduces the social relationship of the elderly (ogawa et al., 2019) and is associated with cognitive table 2. frequency of depression among elderly living in rural area in bali (n=1,053) question (in the last week) yes n(%) no n(%) satisfaction with own life 945(89.7) 108(10.3) feel bored 95(9.0) 958(91.0) feel helpless 74(7.0) 979(93.0) prefer to stay at home, rather than going out and doing new things 380(36.1) 673(63.9) feel pretty worthless the way you are now 31(2.9) 1,022(97.1) table 3. frequency of vision loss, hearing impairment and communication problem among elderly living in rural area in bali (n=1,053) description and score n % difficulty seeing, even if wearing glasses cannot do at all (1) 2 0.2 yes – a lot of difficulty (1) 52 4.9 yes – some difficulty (0) 405 38.5 no – no difficulty (0) 594 56.4 difficulty hearing, even if using a hearing aid cannot do at all (1) 5 0.5 yes – a lot of difficulty (1) 45 4.3 yes – some difficulty (0) 197 18.7 no – no difficulty (0) 806 76.5 difficulty in communication cannot do at all (1) 2 0.2 yes – a lot of difficulty (1) 15 1.4 yes – some difficulty (0) 82 7.8 no – no difficulty (0) 954 90.6 suyasa, sutini, karmayati, and nuryanto (2023) 114 p-issn: 1858-3598  e-issn: 2502-5791 impairment (saji et al., 2021). our current study found that hearing impairment is a determinant factor of iadl problems. this finding aligns with a previous study in china that hearing loss is associated with difficulties in performing iadl (heine et al., 2019). another study also supports our finding in that, in turkey, the probability of experiencing functional disability in iadl is around five times higher in elderly with hearing impairments than in those without (mercan et al., 2021). with the support from findings that align with our current study, caring for the elderly with a hearing impairment needs to be strengthened as it affects their functional ability to perform iadl. strengthening caring could be made by using effective communication strategies such as appropriate verbal tones, eye contact, and nonverbal communication strategies when communicating with the elderly. depression among the elderly is a common issue. according to a systematic review and meta-analysis, depression affects 13.3% of seniors globally (abdoli et al., 2022). another systematic review and meta-analysis also found that 34.4% of the elderly in india experience depression (pilania et al., 2019). our current study found a lower prevalence (11.8%) of elderly in rural areas experiencing depression. the two most common symptoms of depression were not satisfied with own life and the preference to stay home more than usual. in further logistic regression analyses, depression was found as the strongest determinant factor for functional disability in iadl. a study in china also reveals a similar finding that depressive symptoms among low-income elderly families in urban areas are associated with being three times more likely to experience problems with iadl (zhao et al., 2022). depression and disability in iadl are not new issues, as some previous studies also indicate similar findings (ćwirlej-sozańska et al., 2019; hossain et al., 2021; sharma, 2020; zhao et al., 2022). depression decreases mood and motivation to activity and reduces the physical functioning of the elderly (sharma, 2020). physical activities and mobility affect depressive symptoms levels. these symptoms may be due to the fact that the elderly begin to depend on other family members for everyday tasks and it is believed that limitations in their activities further stimulate psychological distress (hossain et al., 2021). considering that depression affects the elderly’s functional ability in rural areas in fulfilling their iadl, nurses should consider this in their practice setting by conducting active screening and applying further assessment, nursing intervention, and further referral as necessary. this study is the first in the indonesian context to provide evidence around the determinant of disability in iadl among the elderly in a rural area in indonesia. this study has some limitations. first, it was conducted only in one rural area in bali. however, this study managed to recruit a large number of elderly to participate in the table 4. bivariate analyses of disability in iadls (n=1,053) variable categories disability in iadl p-value effect size (φ) yes n (%) no n (%) overall n (%) age 60-74 31(2.9) 747(70.9) 778(73.9) 0.000§ 0.252 75+ 54(5.1) 221(21.0) 275(26.1) gender male 34(3.2) 468(44.4) 502(47.7) 0.173§ 0.046 female 51(4.8) 500(47.5) 551(52.3) living alone yes 3(0.3) 17(1.6) 20(1.9) 0.215¶ 0.035 no 82(7.8) 951(90.3) 1,033(98.1) depression yes 41(3.9) 83(7.9) 124(11.8) 0.000§ 0.335 no 44(4.2) 885(84.0) 929(88.2) vision loss yes 13(1.2) 41(3.9) 54(5.1) 0.000¶ 0.137 no 72(6.8) 927(88.0) 999(94.9) hearing impairment yes 18(1.7) 32(3.0) 50(4.7) 0.000¶ 0.229 no 67(6.4) 936(88.9) 1,003(95.3) communication problem yes 7(0.7) 10(0.9) 17(1.6) 0.000¶ 0.156 no 78(7.4) 958(91.0) 1,036(98.4) §chi square; ¶fischer exact test table 5. logistic regression determinant factors of functional disability in iadl among elderly living in rural area in bali (n=1,053) b s.e. wald df sig. exp(b) 95% c.i. for exp(b) lower upper age 1.527 0.260 34.449 1 0.000 4.602 2.764 7.663 gender 0.280 0.263 1.136 1 0.287 1.323 0.791 2.213 living alone 0.792 0.743 1.136 1 0.287 2.207 0.515 9.465 depression 2.063 0.268 59.426 1 0.000 7.869 4.657 13.296 vision loss 0.760 0.425 3.198 1 0.074 2.139 0.930 4.922 hearing impairment 1.066 0.455 5.484 1 0.019 2.903 1.190 7.083 communication problem 0.721 0.664 1.177 1 0.278 2.056 0.559 7.563 constant -3.256 1.006 10.481 1 0.001 0.039 na na na=not applicable jurnal ners http://e-journal.unair.ac.id/jners 115 study, making the sample size adequate. in addition, the final logistic regression model correctly classified 92.5% of cases of functional disability in iadl. secondly, our study only measured seven dependent variables: age, gender, depression, living arrangement, vision loss, hearing impairment, and communication problems. some potential determinant factors found in previous studies, such as cognitive function, social support, nutritional status, pain, and multimorbidity (beltz et al., 2022; ćwirlej-sozańska et al., 2019; tornero-quiñones et al., 2020) were not measured because we considered the need to manage the appropriate length of time for interviews with participants. thirdly, our study did not explore the quality of life among those with iadl disability. a further study exploring this is essential. conclusions depression is the strongest predictor for functional disability in iadl. nurses in rural areas should actively screen for depression to increase the ability of the elderly to fulfill their iadl and assist their iadl accordingly. increasing age and hearing impairment are the other predictors. effective communication among the elderly with hearing problems and their caregivers is also essential in increasing the ability to fulfill the iadl of the elderly. nurses should also train in effective communication with family caregivers, especially for the elderly with hearing problems. future studies are suggested to expand the research settings in more than one rural area and add potential determinants such as cognitive function, social support, nutritional status, pain, and multimorbidity. another study exploring the quality of life among those with iadl disability is also essential. acknowledgment we thank all participants, families, and data collectors for contributing to this study. funding source the institute of technology and health bali (itekes bali) internal research grant funds this study. itekes bali provides all funding support for all research processes and publications. conflict of interest all authors have no conflict of interest related to this study. references abdoli, n., salari, n., darvishi, n., jafarpour, s., solaymani, m., mohammadi, m., & shohaimi, s. (2022) ‘the global prevalence of major depressive disorder (mdd) among the elderly: a systematic review and meta-analysis’, neuroscience & biobehavioral reviews, 132, 1067-1073. badan pusat statistik. (2022) ‘statistik penduduk lanjut usia 2022’, badan pusat statistik. badan pusat statistik kabupaten gianyar. (2023) ‘kabupaten gianyar dalam angka 2023’, badan pusat statistik kabupaten gianyar. banerjee, s. (2021) ‘determinants of rural-urban differential in healthcare utilization among the elderly population in india’, bmc public health, 21(1), 1-18. beltz, s., gloystein, s., litschko, t., laag, s., & van den berg, n. (2022) ‘multivariate analysis of independent determinants of adl/iadl and quality of life in the elderly’, bmc geriatrics, 22(1), 1-16. bursac, z., gauss, c. h., williams, d. k., & hosmer, d. w. (2008) ‘purposeful selection of variables in logistic regression’, source code for biology and medicine, 3(1), 1-8. chauhan, s., kumar, s., bharti, r., & patel, r. (2022) ‘prevalence and determinants of activity of daily living and instrumental activity of daily living among elderly in india’, bmc geriatrics, 22(1), 1-10. cohen, j. (1988) ‘statistical power analysis for the behavor al s ciences’, new york, n y: rout l edge. ćwirlej-sozańska, a., wiśniowska-szurlej, a., wilmowskapietruszyńska, a., & sozański, b. (2019) ‘determinants of adl and iadl disability in older adults in southeastern poland’, bmc geriatrics, 19(1), 1-13. fitriana, l. a., ufamy, n., anggadiredja, k., setiawan, s., & adnyana, i. k. (2019) ‘hubungan tingkat kemandirian (basic dan instrumental activities of daily living) dengan pendidikan, status marital, dan demensia pada lansia di panti wredha’, jurnal pendidikan keperawatan indonesia, 5(2), 177-183. fumes-ghantous, g., corrente, j. e., & tatis, a. f. g. (2020). factors related to functional capacity and quality of life for elderly people in a middle-sized city of são paulo, brazil. health, 12(12), 1562-1574. handajani, y. s., schröder-butterfill, e., hogervorst, e., turana, y., & hengky, a. (2022) ‘functional dependency and its associated factors among older adults in indonesia’, aging medicine and healthcare. heine, c., gong, c. h., & browning, c. (2019) ‘dual sensory loss, mental health, and wellbeing of older adults living in china’, frontiers in public health, 7, 92. hossain, b., yadav, p. k., nagargoje, v. p., & vinod joseph, k. (2021) ‘association between physical limitations and depressive symptoms among indian elderly: marital status as a moderator’, bmc psychiatry, 21(1), 1-11. hoyl, m. t., alessi, c. a., harker, j. o., josephson, k. r., pietruszka, f. m., koelfgen, m., mervis, j. r., fitten, l. j., & rubenstein, l. z. (1999) ‘development and testing of a five‐item version of the geriatric depression scale’, journal of the american geriatrics society, 47(7), 873-878. ismail, n. r., hamid, a. a., ab razak, a., & hamid, n. a. a. (2021) ‘factors influencing instrumental activities of daily living (iadl) disability among elderly attending health clinics in kelantan’, malaysian applied biology, 50(2), 37-45. kementerian kesehatan ri. (2017) ‘juknis instrumen pengkajian paripurna pasien geriatri (p3g)’, kementerian kesehatan ri. kiyoshige, e., kabayama, m., gondo, y., masui, y., inagaki, h., ogawa, m., nakagawa, t., yasumoto, s., akasaka, h., & sugimoto, k. (2019) ‘age group differences in association between iadl decline and depressive symptoms in community-dwelling elderly’, bmc geriatrics, 19(1), 1-8. lawton, m. p., & brody, e. m. (1969) ‘assessment of older people: selfmaintaining and instrumental activities of daily living’, the gerontologist, 9(3_part_1), 179-186. mercan, y., selçuk, k. t., & sayılan, a. a. (2021) ‘the relationship between types of physical disabilities and the instrumental activities of daily living (iadl) in the elderly’, family medicine and primary care review. michel, j.-p., leonardi, m., martin, m., & prina, m. (2021) ‘who's report for the decade of healthy ageing 2021–30 sets the stage for suyasa, sutini, karmayati, and nuryanto (2023) 116 p-issn: 1858-3598  e-issn: 2502-5791 globally comparable data on healthy ageing’, the lancet healthy longevity, 2(3), e121-e122. ogawa, t., uchida, y., nishita, y., tange, c., sugiura, s., ueda, h., nakada, t., suzuki, h., otsuka, r., & ando, f. (2019) ‘hearingimpaired elderly people have smaller social networks: a population-based aging study’, archives of gerontology and geriatrics, 83, 75-80. patel, r., & mckinnon, b. j. (2018) ‘hearing loss in the elderly’ clinics in geriatric medicine, 34(2), 163-174. pilania, m., yadav, v., bairwa, m., behera, p., gupta, s. d., khurana, h., mohan, v., baniya, g., & poongothai, s. (2019) ‘prevalence of depression among the elderly (60 years and above) population in india, 1997–2016: a systematic review and meta-analysis’, bmc public health, 19, 1-18. qiao, y., liu, s., li, g., lu, y., wu, y., shen, y., & ke, c. (2021) ‘longitudinal follow-up studies on the bidirectional association between adl/iadl disability and multimorbidity: results from two national sample cohorts of middle-aged and elderly adults’, gerontology, 67(5), 563-571. sahoo, l., swain, s. k., das, a., nahak, b., & munjal, s. (2020) ‘clinical concerns of hearing loss in old age: an indian perspective’, j geriatr care res, 7(2), 56-63. saji, n., makizako, h., suzuki, h., nakai, y., tabira, t., obuchi, s., kawai, h., murotani, k., katayama, n., & toba, k. (2021) ‘hearing impairment is associated with cognitive function in communitydwelling older adults: a cross-sectional study’, archives of gerontology and geriatrics, 93, 104302. sharma, r. (2020) ‘functional status, social support and quality of life as determinant of successful aging’, gerontology & geriatrics: research, 6(1), 1041. tornero-quiñones, i., sáez-padilla, j., espina díaz, a., abad robles, m. t., & sierra robles, á. (2020) ‘functional ability, frailty and risk of falls in the elderly: relations with autonomy in daily living’, international journal of environmental research and public health, 17(3), 1006. washington group on disability statistics. (2020) ‘the washington group short set on functioning (wg-ss)’, wg-ss. wulandari, r. d., laksono, a. d., nantabah, z. k., rohmah, n., & zuardin, z. (2022) ‘hospital utilization in indonesia in 2018: do urban–rural disparities exist?’, bmc health services research, 22(1), 1-11. yau, p. n., foo, c. j. e., cheah, n. l. j., tang, k. f., & lee, s. w. h. (2022) ‘the prevalence of functional disability and its impact on older adults in the asean region: a systematic review and metaanalysis’, epidemiology and health, 44, e2022058. zhao, l., wang, j., deng, h., chen, j., & ding, d. (2022) ‘depressive symptoms and adl/iadl disabilities among older adults from low-income families in dalian, liaoning’, clinical interventions in aging, 733-743. how to cite this article: suyasa, i. g. p. d., sutini, n. k., kamaryati, n. p., and nuryanto, i. k. (2023) ‘determinant of functional disability in instrumental activities of daily living among elderly living in a rural area in bali: a cross-sectional study’, jurnal ners, 18(2), pp. 110-116. doi: http://dx.doi.org/10.20473/jn.v18i2.45700 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 28 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.9928 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effort to prevent anaemia during menstruation among female adolescent in islamic boarding school esti yunitasari, praba diyan rachmawati and desy indah nur lestari faculty of nursing, universitas airlangga, east java, indonesia abstract introduction: female adolescents are generally prone to be infected by anaemia due to the growing menstruation cycle which causes the loss of bloods in significant amount every month and the needs of ferrum substance can be doubled. the aimed of the research was to analyse factors related to the effort of anaemia prevention during menstruation among female adolescents in islamic boarding school. methods: this research applied correlational descriptive design through the approach of cross-sectional study. total samples were 214 female students in 3 islamic boarding schools with criteria of female students aged 11-20 years old and had experienced menstruation. sample obtained by random sampling. independent variables were knowledge, attitude, friends support, health facility, health efforts, and dependent variables was the efforts to prevention anaemia. data obtained by questionnaire and analyzed by spearman rho with significance level α,0.005 results: the result showed significant correlation between knowledge (p=0.000; r=0.318). attitude (p=0.001; r=0.232). friends support (p=0.003; r=0.203). health facility (p=0.000; r=0.260). and health efforts (p=0.001; r=0.227) on prevention effort of anaemia on adolescents female menstruation in islamic boarding school. conclusion: level of knowledge, posstive attitude, friends support, health facility, and health efforts can prevent anemia during menstruation. article history received: october 04, 2018 accepted: march 19, 2019 keywords anaemia; knowledge; attitude friends support; health facility; health efforts contact esti yunitasari  esti-y@fkp.unair.ac.id  faculty of nursing, universitas airlangga east java, indonesia cite this as: yunitasari, e., rachmawati, p.d., & lestari, d. i. n. (2019). effort to prevent anaemia during menstruation among female adolescent in islamic boarding school. jurnal ners, 14(1), 28-32. doi:http://dx.doi.org/10.20473/jn.v14i1.9928 introduction anaemia is a condition whereby the level of haemoglobin (hb) within blood is lower than the normal scale (world health organization, 2011). diagnosis of anaemia can be upheld once the degree of haemoglobin is ˂12 g/dl on female and ˂13 g/dl on male. anaemia needs to be overcome due to its ability to degrade body endurance, hence, sufferers of anaemia are prone to infectious disease. it can reduce physical fitness. and thinking agility due to the lack of oxygen support to muscle cell and in the other hand. it may also decrease learning achievement and work productivity (kementrian kesehatan indonesia, 2016). female adolescents are prone to anaemia. the existence of monthly menstruation cycle is one of the causal factors of female adolescents to be infected by anaemia even it was supported by their fine understanding over anaemia (mularsih, 2017) the number of anaemia cases for adolescents in 2011 stood at 11.7% and 6.7% of these anaemia evidences occurred during the period of menstruation (dinas kesehatan jawa timur, 2011). the regional office of public health of tuba district had administered during the last 5 years that there has been 69 cases for maternal death (dinas kesehatan kabupaten tuban. 2016). the symptom of maternal death cane be generated from a number of diseases which may worsen maternal condition before and after giving birth. one of the symptoms of maternal death is intensive bleeding during childbirth due to the mother during her adolescence experienced prolonged. unhandled. and sustained anaemia until her childbirth moment. this issue has been proven to the population of boarding school when the researcher was undertaking preliminary data collection on 18 march 2018 in boarding school of x. tuban it was identified that 8 out of 10 female https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 29 students experienced the symptoms of anaemia in times of menstruation. the complained over headache. body weakening. lethargic and weary over their bodies. another few numbers were also complained to be sleepy in times of performing regular activities at school. the importance of countermeasure program against anaemia towards female adolescents is for the female adolescents to be physically prepared before pregnancy in order to be fit to become a healthy mother. and during their pregnancy are immune to anaemia. therefore, it is necessary to perform the research regarding the effort to prevent anaemia for female adolescents based on the level of understanding over anaemia, attitude, and friends support, and health efforts in the effort of preventing anaemia to infect female adolescents in islamic boarding school. the purpose of this study was to explain the factors related to the effort of anemia prevention during menstruation on female adolescents in islamic boarding school. materials and methods the research was cross sectional design, population were female adolescents studying in 3 different boarding schools that chose randomly in tuban in july 2018. total sample obtained 214 respondents by random sampling. independent variables were knowledge, attitude, friends support, health facility, health efforts, and dependent variables are the effort of anaemia prevention. to pretend bias we used inclusion criteria including adolescents aged between 11-20 years old and had experienced menstruation. data is generated through questionnaire arranged by puspah (2017). knowledge questionnaire consists of 10 questions with score of 0 to 2. category: favourable knowledge (76-100%), adequate knowledge (56-76%), and deficient knowledge (≤55%), and obtained chronbach alfa 0.893. attitude questionnaire consists of 16 questions with score between 0-5 and minimum score to be achieved was 0 and maximum score was 80. category: possitive (≥62.5%) negative (˂62.5%) and obtained chronbach alfa 0.939. friends support questionnaire consists of 7 questions with optional answer of 0 to 4 with maximum score of 28 and minimum score of 0. category: favourable support (76-100%), adequate support (56-76%), deficient support (≤55%), and obtained chronbach alfa 0.811. health facility questionnaire consists of 5 questions with optional answer of 0 to 2. the maximum score was 10 and the minimum score was 0. the category: favourable (76100%). adequate (56-75%). deficient (≤55%) and obtained chronbach alfa 0.783. health efforts questionnaire consists of 6 questions with range answers are 0 until 4. the maximum score is 0 and the minimum score was 24. category: favourable (76-100%), adequate (56-75%), deficient (≤55%), and obtained chronbach alfa 0.779. the questionnaire of effort to prevent anaemia consists of 6 questions with optional answers from 0 to 4, the maximum score was 24 and the minimum score was 0. the category: favourable (76-100%). adequate (56-75%). deficient (≤55%) and obtained chronbach alfa 0.783. the data analyzed by using spearman rho with level of significance α<0.005. this research has been declared to have passed the ethical review and obtained an ethical approval certificate with no. 992 kepk issued by the nursing faculty of airlangga university. results table 1 shows that during these ages’ respondents were situated in all levels of adolescences but can be discovered more in the middle level of adolescence that is between 15-17 years old amounting to 48.6 %. early adolescents (11-14 years old) in the amount of 76 respondents or 35.5% and late adolescents (18-20 years old) amounting to 34 or 15.8%. the majority of respondents encountered menstruation for the first time in the age of 9-12 years old in amount of 144 respondents or equivalent to 67.3% and those with the first menstruation in the age of 13 years onwards is around 70 respondents or 32.7% and half of the respondents are studying in high school level that is as much as 107 respondents (50%). the result of this analysis shows the existence of connection between knowledge with the effort of anaemia prevention during menstruation (p=0.000; r=0.318). it can be inferred that the occurred relationship is weak. the particular analytical result unveils the existence of connection between attitude and the effort of anaemia prevention during menstruation with weak relationship (p=0.001; r=0.232). the friends support also correlate with the effort of anaemia prevention during menstruation (p=0.003; r=0.203). the relationship between health facility with the effort of anaemia during menstruation obtained a weak relationship (p=0.000 and r=0.260), and the relationship there is a weak correlation between health-based undertaking with the effort of anaemia prevention during menstruation (p=0.001; r=0.227). discussion knowledge the relationship between knowledge with the effort of anaemia prevention in times of menstruation. from the aforementioned illustration. it can be inferred that the result is a weak result. this is shown by a favourable percentage over knowledge that is closely equivalent. frequency distribution of knowledge and the effort of anaemia prevention with the largest percentage can be found in the categories of favourable and deficient. this is influenced by the educational background of respondents who in majority are sitting in high school due to an existing probability that these students obtained the e. yunitasari et al. 30 | pissn: 1858-3598  eissn: 2502-5791 information regarding anaemia through the subject of science. although living in boarding school. female adolescents are also obtaining the similar general education with those who are not living in boarding school. education is a prominent factor for those who pay critical attention to preserve their health. however, every of which will be ended up in vain should the intention is not accompanied with awareness and willingness to commence change in their undertakings (makhfudli, rachmawati, and andini, 2017). the relationship between knowledge and anaemia prevention effort for female adolescents illustrates that female adolescents with minimum knowledge over anaemia leads themselves to the lack of selfawareness to initiate the effort of anaemia prevention. the result if this research is in line with the research carried out by (mularsih, 2017) whereby respondents with favourable knowledge over anaemia tends to behave supportive to the prevention of anaemia in times of menstruation. in contrary. the respondents with deficient knowledge over anaemia were unlikely to behave supportive in the effort of anaemia prevention in times of menstruation. the other supportive research was carried out by (puspah, 2017) regarding the factors connected to the prevention of anaemia towards female adolescents in accordance with lawrence green theory in smpn banjarbaru, banjarbaru city. south kalimantan. which shows the existence of relationship between knowledge and anaemia prevention. knowledge is determined by education. information from mass media. socio-culture. family support. environment. and age. according to (leineger, 2002), background of education is influential to the absorbance of information, a person who possess high level of education will also be equipped with a favourable knowledge. knowledge without favourable education will allow an individual to commit unfavourable decision. attitude respondents have positive attitude over the prevention of anaemia. those are amounting to 24 respondents (11.2%). in the other hand. respondents with negative attitude are entirely have deficient effort of anaemia prevention in amount of (17.8%). this finding implies that the better the attitude of respondents. it may increase the effort of anaemia prevention in times of menstruation. therefore, it can be concluded that there is a relationship between attitude and the effort of anaemia prevention in times of menstruation for female adolescents in boarding schools within the area of jen, tuba district. this research is linier with the research carried out by (caturiyaningtyas, 2015) regarding the relation between knowledge. attitude. and behaviour with the case of anaemia towards female adolescents in grade x and xi of state senior high school 1 polokarto which mentioned that there is a relationship between attitude and the case of anaemia within female adolescents in grade x and xi state senior high school 1 polokarto. the research of (panyuluh and nugraha, 2018) mentioned that there is no significant relationship between attitude and anaemia prevention within female adolescents in darul ulum islamic boarding school, kendal district. according to notoatmojo (2012) attitude is not yet to be determined as a form of action or activity. however, it was a pre-disposition of actions towards a certain behaviour. the attitude of an individual is in line with the level of knowledge they previously attained. positive attitude shapes positive behaviour. and vice versa. this matter is linier with sarwono on ningrum (2011), that the change of attitude within an individual start with identification step and later on become internalization. female students with favourable behaviour towards the effort of anaemia prevention own empathy towards the anaemia prevention in times of menstruation. friends support the amount of respondent with the friends support is deficient (69.63) or a number of 149 respondents are in adequate category in the effort of anaemia prevention (31.8%) and the category of deficient in the effort of anaemia prevention in times of menstruation (33.2), this shows that female adolescents with deficient support from friends with the same age will commence a minimum effort to anaemia prevention primarily in the sense of supports from friends with the same age to obtain iron supplement. according to yuswanto (2015) the friends support was a support given for and by a person in similar situation. the similar support consists of an individual who experiences the same challenges with a medical patient who suffer certain infection. certain community. and individuals with similar problems. hurlock (1980) and luthfi (2012) argue that social support from friends with the same age is realized in form of the feeling of shared fate which nurtures the existence of understanding relationship towards each other’s problem. advice-giving and sympathy that are not obtainable from parents due the parents contribute in desicion making of an adolescent (yunitasari, pradanie, and susilawati, 2016). medium of health the relationship established within it is a weak relationship and the relationship among these two variables are single-oriented which means the better the health facility obtained. hence. the better as well the effort of anaemia prevention in times of menstruation towards female adolescents in islamic boarding school. the relationship between health facility with the effort of anaemia prevention in times of menstruation towards female adolescents in islamic boarding school. the best value is discovered in the statement which unveils that in islamic boarding school. logistic has provided foods with rich containment of protein and ferrum substance including tofu, soybean, egg, green vegetable in daily jurnal ners http://e-journal.unair.ac.id/jners | 31 manner. meanwhile, the least value can be found in the statement which unveils that in islamic boarding school there is an absence of blood cell examination tools for female students. the research which against this statement is the research carried out by (panyuluh and nugraha, 2018) which mentioned that there is no significant relationship between the availability of health facility towards anaemia prevention for female students of darul ulum islamic boarding school, kendal district. health supports the relationship established within it is a weak relationship and the relationship among these two variables are single-oriented which means the better the health efforts committed. hence. the better as well the effort of anaemia prevention in times of menstruation towards female adolescents in islamic boarding school. almost half of the respondents have deficient health efforts (67.29%) from the number of respondents who have uncertain health efforts in the number of 144. there are 73 respondents who are identified with deficient health efforts. this explanation shows that the less the health-relating undertaking committed. the less as well the effort of anaemia prevention in times of menstruation within adolescents in islamic boarding school. the existence of relationship between health efforts with the effort of anaemia prevention shows the female adolescents with lack of action in responding to health issues are also lack in undertaking prevention effort to anaemia primarily in the case of stockpiling iron supplement. conclusion the factors that are influential towards the effort of anaemia prevention in times of menstruation for female adolescents in islamic boarding school are knowledge. attitude. friends support. health facility. and health efforts. from the aforementioned factors. the most influential factor is the knowledge of female students over the effort of anaemia prevention. it is expected that islamic boarding school as a stakeholder seeks to preserve the availability of healthy and nutritious food as well as for health entities to be able to intensify promotional and preventive events over the importance of anaemia prevention towards adolescents in times of menstruation. references a. goudarzi, m. . m. and k. g. (2008) ‘the effect of iron deficiency anemia on intelligence quotient (iq) in under years old students’. pakistan journal of biologi sciences, 15;11(10): 398-400 achmad djaeni soediaoetomo (2008) ilmu gizi untuk mahasiswa dan profesi. jakarta: dian rakyat. alvarez-uria, g. et al. (2014) ‘prevalence and severity of anaemia stratified by age and gender in rural india’, 2014, pp. 1–6. doi:10.1155/2014/176182 anwar, m., baziad, a., & prabowo, r. . (2011) ilmu kandungan. jakarta: bina pustaka sarwono prawirohardjo. astuti, r. and rosidi, a. (2015) ‘faktor resiko anemia pada siswi pondok pesantren’, prosiding seminar nasional, (who 2001), pp. 247–253. batubara jrl (2010) ‘sari pediatri’, in departemen ilmu kesehatan anak fkui/rscm. jakarta. chandyo, r. k. et al. (2007) ‘prevalence of iron deficiency and anemia among healthy women of reproductive age in bhaktapur , nepal’, pp. 262– 269. doi: 10.1038/sj.ejcn.1602508. citrakesumasari (2012) anemia gizi masalah dan pencegahanna. yogyakarta: kalika. departemen agama ri (2000) pola perkembangan pondok pesantren. jakarta: depag ri. departemen kesehatan (2011) ‘kajian profil penduduk remaja di indonesia’. depkes ri (2007) ‘kesehatan, pedoman pelenggaraan dan pembinaan pos kesehatan pesantren’, in. jakarta: departemen kesehatan ri direktorat jendral bina kesehatan masyarakat. dhenok citra penyuluh, priyadi nugraha p, e. r. (2018) ‘faktor-faktor yang behubungan dengan perilaku penyebab anemia pada santri wati pondok pesantren darul ulum kabupaten kendal’, jurnal kesehatan masyarakat, 6(april), pp. 156– 162. doi: issn:2356-3346. dinas kesehatan jawa timur (2011) ‘data laporan gizi’. handayani, w. dan a. s. h. (2008) asuhan keperawatan pada klien dengan gangguan sistem hematologi. jakarta: salemba medika. puspah hairun (2017), faktor-faktor yang berhubungan dengan upaya pencegahan anemia pada remaja putri berbasis teori lawrence green di smpn 3 banjarbarukota banjarbaru kalimantan selatan. hapzah, r. y. (2012) ‘hubungan tingkat pengetahuan dan status gizi terhadap kejadian anemia remaja putri pada siswi kelas iii di sman tinambung kabupaten polewali mandar’, media gizi pangan, xiii. doi: 10.16182/j.cnki.joss.2007.21.002 john w. santrock (2007) ‘perkembangan anak’, in. jakarta: pt. erlangga. kementrian kesehatan indonesia (2016) pedoman pencegahan dan penanggulangan anemia pada remaja putri dan wanita usia subur (wus). jakarta. leininger, m., 2002. culture care theory: a major contribution to advance transcultural nursing knowledge and practices. journal of transcultural nursing, 13(3), pp.189–192. doi: 10.1177/10459602013003005 makhfudli, rachmawati, p. and andini, s. (2017) ‘factors related to open defecation behavior among school-age children in west lombok’, jurnal ners, 12(leininger 2002), pp. 119–125. doi: 10.20473/jn.v12i1.4028 manuaba, i. b. g. (2009) ‘memahami kesehatan reproduksi wanita’, in. jakarta: egc. http://dx.doi.org/10.1155/2014/176182 https://doi.org/10.1177/10459602013003005 http://dx.doi.org/10.20473/jn.v12i1.4028 e. yunitasari et al. 32 | pissn: 1858-3598  eissn: 2502-5791 manuaba, i. g. b. (2006) buku ajar patalogi obstetri untuk mahasiswa kebidanan (cetakan i). jakarta: penerbit buku kedokteran egc. masrizal (2007) ‘studi literatur anmeia defisiensi besi’, kesehatan masyarakat. masuthu (2014) dinamika sistem pendidikan pesantren. jakarta: indonesia corporation in islamic studies. nicki l. potts & barbara l. mandleco (2007) ‘pediatric nursing caring for children and theis families second edition’. nizomy, r. (2002) ‘mekanisme fisiologi perdarahan haid’, in jurnal berkala kedokteran vol 2. meiagustu. jakarta. nur ia kaimudin, hariati lestari, j. r. a. (2017) ‘skrining dan determinan kejadian anemia pada remaja putri sma negeri 3 kendari tahun 2017’, jurnal ilmiah mahasiswa kesehatan masyarakat, 2(6), pp. 1–10. nursalam (2016) ‘metodologi penelitian ilmu keperawatan : pendekatan praktis’, in. jakarta: salemba medika, p. 454. prawiroharjo, s. (2011) ilmu kandungan. jakarta: pt bina pustaka. proverawati, a. (2011) anemia dan anemia kehamilan. yogyakarta: nuha medika. puspah hairun (2017) faktor-faktor yang berhubungan dengan pencegahan anemia pada remaja putri berbasis teori lawrence green di smpn 3 banjarbaru kota banjarbaru kalimantan selatan. raindi, a. b. (2011) pola pembinaan pesantren daar al-taubah terhadap akhlak mulia wanita tuna susila. repository upi. sri, y. (2013) laporan kegiatan pelayanan kesehatan masyarakat primer (pmkp) dan usaha kesehatan masyarakat. wonosobo: puskesmas mojotengah. sri mularsih (2017) ‘hubungan pengetahuan remaja putri tentang anemia dengan perilaku pencegahan anemia pada saat menstruasi di smk nusa bhakti kota semarang’, 6(2), pp. 80–85. doi: 10.26714/jk.6.2.2017.80-85 titin caturiyantiningtyas (2015) ‘hubungan antara pengetahuan, sikap dan perilaku dengan kejadian anemia remaja putri kelas x dan xi sma negeri 1 polokarto’. tarwoto dkk (2010) kesehatan remaja problem dan solusinya. jakarta: salemba medika. tarwoto dkk (2010) kesehatan remaja problem dan solusinya. jakarta: salemba medika. temi chintia risva, suyatno, m. z. r. (2016) ‘faktorfaktor yang berhubungan dengan kebiasaan konsumsi tablet tambah darah sebagai upaya pencegahan anemia pada remaja putri (studi pada mahasiswa tahun pertama di fakultas kesehatan masyarakat universitas diponegoro’, 4(april), pp. 243–250. dinas kesehatan tuban, (2016) ‘profil kesehatan kabupaten tuban tahun 2016’. wong, d.l, hockenberry, m, et al. (2009) buku ajar keperawatan pediatri. 6th edn. jakarta: egc. world health organization (2011) ‘haemoglobin concentrations for the diagnosis of anaemia and assessment of severity’. world health organization, stoltzfus, r. j. and dreyfuss, m. l. (2013) ‘prevention of iron deficiency anaemia in adolescents role of weekly iron acid supplementation’, pediatrics, 138(1), p. 46. doi: 10.3390/nu6125915. yunitasari, e., pradanie, r. and susilawati, a. (2016) kecamatan torjun sampang madura (early marriage based on transcultural nursing theory in kara village sampang)’, jurnal ners, 11(2015),pp. 164–169. doi: 10.20473/jn.v11i22016.164-169. https://doi.org/10.26714/jk.6.2.2017.80-85 http://dx.doi.org/10.20473/jn.v11i22016.164-169 latihan yoga dapat memenuhi kebutuhan tidur lansia (yoga exercise fulfillment of the sleep needs in elderly) tintin sukartini*, retno indarwati*, anggraheni* *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: tintin_bios@yahoo.com abstract introduction: sleep disorder is one among problems faced by elderly. yoga is one of methods which can be chose to fulfill the need of sleep. the objective of this study was to analyze the effect of yoga exercise on the fulfillment of the sleep needs in elderly. method: the design used in this study was pre experimental. the population was elderly with sleep disorder in panti werdha mojopahit mojokerto. the sample was recruited using purposive sampling,15 respondents, taken according to the inclusion criteria. the independent variable of this study was yoga exercise and the dependent variable was the fulfillment of sleep in elderly. data were collected by using structured questionnaire and the measurement of respondent vital sign, and were then analyzed using wilcoxon signed rank test and paired t-test with level of significance α≤0.05. result: result showed that yoga exercise increases the fulfillment the need of sleep beside it could reduce heart rate (p=0.001), and respiratory rate (p=0.001). discussion: however, yoga exercise did not reduce of systolic (p=0.433) and diastolic blood pressure (p=0.055). keywords: yoga exercise, the need of sleep, elderly pendahuluan lanjut usia merupakan salah satu kenyataan yang tidak dapat dihindari dimana seseorang mengalami perubahan secara biologis, psikologis maupun sosial. seseorang yang bertambah tua akan mengalami penurunan kemampuan fisik dan mental hidup secara perlahan tetapi pasti (nugroho w., 2000). salah satu perubahan yang sering dikeluhkan adalah gangguan pemenuhan istirahat tidur. lansia sulit tertidur, mudah terbangun, menghabiskan waktu dalam tahap mengantuk dan sangat sedikit waktu dalam tahap mimpi serta jumlah total jam tidur perhari yang menurun (millier, 1995 dalam carpenito, 2000). tidur merupakan bagian dari kegiatan sehari-hari yang berlangsung secara alami. beberapa penyebab mampu mengakibatkan seseorang mudah mengalami stress psikologis atau depresi sehingga sulit untuk tidur. kondisi demikian dapat menyebabkan gangguan kesehatan. salah satu cara dalam menanggulangi masalah tersebut adalah dengan relaksasi. efek relaksasi bisa didapatkan dari mendengarkan musik, pemberian aroma terapi, atau dapat juga dengan melakukan yoga. melalui yoga diharapkan dapat diperoleh kembali cara alami untuk tidur nyenyak (budi dharma surya, 2004). bulan oktober di panti werdha mojopahit mojokerto didapatkan sebanyak 46% dari penghuni mengalami gangguan pemenuhan tidur (insomnia). survey epidemiologi yang dilakukan oleh melinger (morin, 1992 dan lacks, 1992) menunjukkan bahwa 35% dari populasi diindikasikan mengalami insomnia tahap terakhir. seorang dewasa normal membutuhkan waktu tidur 78 jam semalam. pada dewasa tua membutuhkan tidur sekitar 6 jam sehari (asmadi, 2008). pada siklus tidur dewasa tua mengalami penurunan sebanyak 20-25% tidur pada tahap rems dan tidur tahap iv berkurang bahkan terkadang tidak ada. tidur yang cukup dan berkualitas akan memberi dampak segar pada tubuh dan semangat baru untuk beraktivitas dan bekerja. sebaliknya kualitas tidur yang buruk membuat tubuh terasa sakit bahkan mengganggu konsentrasi kerja dan mood (muriani harsono, 2007). kehilangan waktu tidur akan sangat mempengaruhi semangat, kemampuan konsentrasi, produktivitas, kinerja, ketrampilan komunikasi, dan kesehatan secara umum, termasuk sistem gastrointestinal, fungsi kardiovaskuler dan sistem kekebalan tubuh. banyak kesalahan dalam tugas rutin dapat terjadi, dan penurunan kemampuan memusatkan perhatian sebagai akibat kualitas tidur yang rendah dari seseorang. faktor-faktor yang dapat menyebabkan lansia mengalami insomnia antara lain nyeri, kecemasan, ketakutan, tekanan jiwa, dan kondisi yang tidak menunjang untuk tidur. pada usia lanjut tidur nrem stadium 1 dan 2 cenderung meningkat, aktivitas gelombang alfa menurun, sementara pada stadium 3 dan 4 aktivitas gelombang delta menurun atau hilang. sehingga kondisi terjaga yang dapat timbul 2-4 kali selama tidur normal pada dewasa muda dan pada orang tua akan meningkat. lansia lebih mudah terjaga oleh stimulasi internal atau eksternal dan lebih menyolok pada pria dibandingkan wanita. kontinuitas tidur pada lansia berkurang sehingga menurunkan efisiensi tidur sebanyak 20% dibandingkan dewasa muda. efisiensi tidur yang berkurang, merasa lebih letih dan merasa harus lebih banyak tidur menyebabkan para lanjut usia lebih banyak menghabiskan waktu di tempat tidur, walau sebenarnya rerata waktu tidur total pada usia lanjut hampir sama dengan dewasa muda. jam biologik pada usia lanjut menjadi lebih pendek, fase tidur lebih maju, sehingga memulai tidur lebih awal dan bangun lebih awal pula, sering terbangun pada malam hari sehingga bangun pagi terasa tak segar, siang hari mengalami kelelahan dan lebih sering tertidur sejenak. waktu tidur malam tampak lebih kurang sehingga mereka merasa mengantuk sepanjang hari. tidur rem pada lansia menjadi lebih pendek. tidur delta yang pada orang normal ditemukan sejumlah 20-30%, pada lansia menjadi berkurang yang menyebabkan lansia mengeluh kurang pulas saat tidur. lansia akan mengalami penurunan tidur rems sebanyak 10%. rem menunjukkan bahwa seseorang sedang bermimpi. di laboratorium tidur, 85% partisipan yang dibangunkan pada waktu tidur rem mengaku sedang bermimpi. secara fisiologis kekurangan tidur rem itu harus dibayar kembali. dampak dari hal tersebut adalah orang jadi sulit tidur nyenyak yang pada akhirnya menyebabkan sampah di dalam tubuh tidak bisa dimusnahkan karena dengan tidur seseorang melakukan pembersihan diri dari sampah penyebab kelelahan. carbone mengungkapkan bahwa dalam sehari, produk sampah yang berasal dari seluruh kegiatan otot tubuh, sebagian besar terdiri atas dioksida dan asam laktat yang menumpuk dalam darah dan mempunyai efek toksik terhadap saraf sehingga menyebabkan rasa lelah dan mengantuk. selama tidur sampah ini dimusnahkan sehingga saat bangun tubuh terasa segar. salah satu solusi untuk mengatasi gangguan kebutuhan tidur atau insomnia pada lansia adalah melalui pelatihan gerakan yoga. yoga merupakan bentuk latihan yang memadukan gerak dan olah nafas. latihan yoga bermanfaat bagi kesehatan tubuh, stabilitas emosi, serta jiwa yang tenang dan merupakan salah satu olah raga yang dianjurkan untuk lansia. gerakan yoga akan mempengaruhi hipotalamus untuk meningkatkan produksi beta endorphin yaitu suatu morfin alami tubuh yang akan menyebabkan stabilitas emosi serta menenangkan. kondisi tenang dan rileks inilah yang dibutuhkan untuk kualitas tidur yang baik. bahan dan metode metode penelitian yang digunakan pra-eksperimental dengan rancangan penelitian pre-post test dalam satu kelompok (one-group pre-post test design). populasi dalam penelitian ini adalah lansia yang mengalami gangguan pemenuhan istirahat tidur di panti wredha mojopahit mojokerto dengan besar sampel sebanyak 15 orang. instrumen yang digunakan dalam penelitian ini ialah kuesioner dan sop yoga. kuesioner atau angket dibuat terstruktur sehingga memungkinkan responden dapat menjawab semua pertanyaan yang diajukan. intervensi pelatihan yoga diberikan selama 30 menit setiap hari selama seminggu. terapi yoga diberikan oleh peneliti dan dibantu oleh instruktur yang sudah terlatih pada malam hari mulai pukul 19.00 wib. sebelum melakukan yoga, tandatanda vital responden diperiksa, meliputi tekanan darah, nadi dan rerata pernafasan per tintin s latihan yoga dapat memenuhi kebutuhan tidur lansia di panti wredha menit, kemudian lansia disiapkan untuk tidur dengan posisi yang nyaman. hasil hasil uji wilcoxon signed rank test menunjukkan perbedaan yang signifikan antara kebutuhan tidur secara kualitas saat sebelum diberi dan sesudah diberikan intervensi berupa senam yoga pada lansia (tabel 1). perbedaan yang signifikan juga terlihat pada kualitas tidur secara kuantitas pada lansia yang meliputi lama tidur, nadi, rerata pernafasan dan tekanan darah yang dihitung dengan menggunakan uji paired ttest (tabel 2). tabel.1 pengaruh pemberian yoga terhadap pemenuhan kebutuhan tidur secara kualitas pada lansia di panti werdha mojopahit mojokerto. responden sebelum sesudah 1 5 9 2 5 9 3 4 6 4 5 9 5 4 6 6 4 7 7 3 7 8 4 9 9 5 7 10 5 8 11 4 7 12 4 9 13 5 6 14 4 9 15 5 8 wilcoxon signed ranks test z = -3,416 dan p = 0,001 tabel.2 pengaruh pemberian yoga terhadap pemenuhan kebutuhan tidur secara kuantitas : lama tidur pada lansia di panti werdha mojopahit mojokerto tanggal 23-29 januari 2009. kuantitas tidur keterangan sebelum sesudah lama tidur rerata 4,7 6,7 sd 0,535 0,743 paired t-test t = -12.602 dan p = 0,00001 nadi rerata 87,87 80,40 sd 8,999 5,742 paired t-test t = 4,920 dan p = 0,001 rerata pernafasan rerata 25,53 23,40 sd 2,532 1,957 paired t-test t = 4,384 dan p = 0,001 tekanan darah sistolik rerata 146,00 144,67 sd 13,522 11,255 paired t-test t = 0,807 dan p = 0,433 tekanan darah diastolik rerata 84,67 81,33 sd 9,904 7,432 paired t-test t = 2,092 dan p = 0,055 keterangan : x = nilai rerata sd = standart deviasi p = signifikansi pembahasan tidur merupakan kebutuhan dasar yang dibutuhkan setiap manusia, namun dalam keadaan sakit kebutuhan tidur akan terganggu. faktor-faktor yang dapat menyebabkan gangguan yaitu faktor psikologis, faktor fisik dan lingkungan. hasil penelitian menunjukkan bahwa sebagian besar responden melakukan kebiasaan sebelum tidur seperti mengobrol di dalam kamar, melihat tv atau masuk kamar tidur lebih awal, yang juga dapat mempengaruhi tidur. data penelitian menunjukkan sebagian besar lansia masuk kamar tidur pada pukul 19.00-20.00 wib atau setelah melakukan sholat isya’ berjamaah. lansia seharusnya masuk kamar tidur apabila benarbenar merasa mengantuk. berdasarkan data yang diperoleh sebagian besar responden baru tinggal dipanti sekitar 0-2 tahun. lama menghuni panti dapat berpengaruh pada pemenuhan kebutuhan tidur pada lansia. hal ini dapat dikarenakan lansia harus beradaptasi dengan suasana panti dimana lansia harus membiasakan diri dengan fasilitas yang disediakan oleh panti, lansia harus bisa menerima keberadaan lansia yang lain. terjadi peningkatan pemenuhan kebutuhan tidur pada lansia setelah pemberian yoga. sebanyak 6 orang responden (30%) mampu memenuhi kriteria yang menunjukkan pemenuhan kebutuhan tidur baik, dan 9 orang responden (60%) memenuhi kriteria tidur cukup. sebelum diberikan yoga kebutuhan tidur keseluruhan responden berada dalam kategori kurang. hal ini menunjukkan terdapat pengaruh pemberian yoga terhadap pemenuhan kebutuhan tidur secara kualitas pada lansia yang ditunjukkan oleh hasil uji statistik wilcoxon signed rank test dengan derajat kemaknaan p=0,001. peranan yoga dalam membantu kesulitan tidur adalah dengan menyeimbangkan antar sistem dalam tubuh (pangkalan ide, 2008). relaksasi merupakan keadaan dimana seseorang dalam keadaan sadar namun rileks, istirahat, pikiran, otototot rileks, pernafasan dalam yang teratur. melakukan latihan fisik yang lembut, penarikan nafas yang dalam serta peregangan tubuh merupakan metode relaksasi yang ideal untuk rutinitas sebelum tidur. keadaan ini menurunkan rangsangan dari luar terhadap formasio retikularis. gerakan yoga yang lembut dan teratur juga dapat membantu menjaga keseimbangan homeostasis tubuh melalui jalur hpa axis yang dapat merangsang produksi β-endhorpin dan enkephalin neurotransmitter tidur. βendorphin dan enkephalin dapat membuat tubuh menjadi rileks yang dapat menyebabkan perasaan senang sehingga lansia dapat tertidur (khare, 2000 dan udjiati, 2002 dalam erna, 2006). melakukan gerakan yoga dengan baik akan tercipta suasana rileks bagi lansia, sehingga lansia dapat memusatkan pikiran sehingga stressor dari luar yang bersifat negatif atau kurang mendukung bagi lansia dapat dialihkan walau hanya sementara, sehingga membuat lansia dapat segera tertidur. tidur merupakan kebutuhan yang sangat penting bagi manusia. pada waktu lansia tertidur terjadi pelemasan otot dan penormalan sistem tubuh, sehingga sistem tubuh bisa kembali berfungsi efektif dan optimal yang dapat ditunjukkan oleh gejala dan tanda dari kondisi yang ditimbulkan oleh tidur yang berkualitas, seperti mampu berkonsentrasi, memiliki hubungan sosial yang luas, tidak merasa pusing setelah bangun tidur dan lain-lain. pemberian yoga pada lansia dapat membantu lansia dalam memenuhi kebutuhan tidur dimana lansia tersebut mengalami kesulitan dalam memulai tidurnya. pengetahuan responden (output indicator) akan mempengaruhi (outcome indicator) yakni kondisi (reaksi dan kecacatan kusta) sebagai fokus dari hasil kinerja pada akhir periode waktu atau aktifitas yang merefleksikan keberhasilan atau aktifitas dan keputusan yang telah dilaksanakan. pemberian yoga dapat meningkatkan pemenuhan kebutuhan tidur secara kuantitas, yaitu lama tidur pada lansia yang ditunjukkan oleh uji statistik paired t-test dengan derajat kemaknaan p=0,0001. lama tidur sebagian besar responden sebelum diberikan yoga berada dalam <6 jam dan sesudah diberikan yoga lama tidur responden menjadi ≥6 jam. peningkatan kebutuhan tidur secara kuantitas tersebut dapat disebabkan karena yoga merupakan salah satu latihan fisik yang menenangkan dengan menerapkan latihan pernafasan dan teknik relaksasi (pangkalan ide, 2008). latihan relaksasi dapat digunakan untuk memasuki kondisi tidur karena dengan mengendorkan otot secara sengaja akan membentuk suasana tenang dan santai. suasana ini diperlukan untuk mencapai kondisi gelombang alpha yaitu suatu keadaan yang diperlukan seseorang untuk memasuki fase tidur awal. keadaan tenang dan rileks yang ditandai dengan gelombang alpha diharapkan dapat berlanjut hingga mencapai gelombang delta sehingga lansia dapat mencapai ketenangan dan dapat tidur terlelap. gerakan yoga yang lembut dan teratur juga dapat membantu menjaga keseimbangan homeostasis tubuh melalui jalur hpa axis yang dapat merangsang produksi β endhorpin dan enkephalin yang merupakan neurotransmitter tidur atau dengan kata lain lansia lebih cepat untuk memulai tidur dan dapat mencukupi waktu tidur. sebagian lansia sudah dapat dikategorikan baik dalam lama waktu tidur dan sebagian besar lansia yang lain bisa dikategorikan cukup. faktor yang mempengaruhi hal tersebut di panti werdha mojopahit mojokerto adalah sebagian besar lansia bangun pada dini hari ± pukul 02.00-03.00 wib untuk melakukan sholat malam. berdasarkan hasil analisis ditunjukkan bahwa ada perbedaan yang signifikan pada nadi serta rerata pernafasan sebelum dan sesudah pemberian yoga, yaitu menunjukkan jumlah penurunan jumlah nadi per menit dan penurunan rerata pernafasan. sedangkan pada hasil tekanan darah tidak menunjukkan hasil yang signifikan sebelum dan sesudah pemberian yoga. penurunan nadi dan rerata pernafasan dapat disebabkan karena nadi dan rerata pernafasan terpengaruh oleh pemberian yoga. jika kebutuhan lansia terpenuhi, lansia menjadi sehat fisik dan mental sehingga akan menurunkan katekolamin dan menyebabkan penurunan denyut jantung dan rerata pernafasan. katekolamin berfungsi sebagai transmisi adrenergik, yang dapat memperantarai efek langsung pada relaksasi otot polos dan bronchial serta mengaktifkan reseptor beta pada jantung untuk meningkatkan denyut jantung (guyton dan hall, 1997). gerakan yoga yang menggunakan latihan pernafasan dan teknik relaksasi dapat membuat tubuh menjadi tenang dan santai. keadaan ini direspon oleh hipotalamus melalui jalur hpa axis untuk menurunkan aktivitas sistem saraf otonom simpatis, yang selanjutnya mempengaruhi medulla adrenal untuk mensekresi katekolamin dalam jumlah sedikit sehingga akan terjadi penurunan denyut dan rerata pernafasan. hasil penelitian terhadap tekanan darah tidak menunjukkan hasil yang signifikan walaupun terjadi penurunan nilai rerata. hal ini diduga karena proses penuaan dimana lansia terjadi kehilangan elastisitas pembuluh darah, kemampuan jantung memompa darah menurun dan kebiasaan lansia yang banyak menghabiskan waktu di tempat tidur. selain itu juga disebabkan karena proses fisiologis tekanan darah melalui proses yang panjang dan tidak dipengaruhi oleh pusat vasomotor dari medulla oblongata, pengaruh pengeluaran hormon katekolamin dan renin-angiotensin serta dipengaruhi perubahan-perubahan pada kadar ikatan kalsium dalam sel-sel tunika media (hudak dan gallo, 1997). pemberian yoga dapat berpengaruh terhadap pemenuhan kebutuhan tidur pada lansia. gerakan yoga yang lembut dapat membuat lansia merasa tenang dan santai dapat menyeimbangkan gelombang otak menuju gelombang alpha yang menandakan ketenangan, menstabilkan pernafasan, mempengaruhi denyut jantung, denyut nadi dan mengurangi ketegangan otot. simpulan dan saran simpulan pemberian yoga berpengaruh terhadap kualitas tidur lansia karena yoga dapat membantu menjaga keseimbangan homeostasis tubuh melalui jalur hpa axis yang dapat merangsang produksi βendhorpin dan enkephalin yang merupakan neurotransmitter tidur. β endorphin dan enkephalin dapat membuat tubuh menjadi rileks yang dapat menyebabkan perasaan senang sehingga lansia dapat tertidur. pemberian yoga dapat berpengaruh terhadap kuantitas tidur lansia karena lansia dapat mencapai keadaan rileks yang mampu menurunkan kegiatan saraf simpatis dan ditunjukkan dengan penurunan tanda-tanda vital. pemberian yoga berpengaruh terhadap pemenuhan kebutuhan tidur pada lansia baik secara kualitas maupun kuantitas. hal ini dapat disebabkan karena gerakan yoga lembut sehingga tercipta keadaan tenang dan santai sehingga mengatur keseimbangan antar sistem yang bekerja dalam tubuh. saran pemberian yoga dapat digunakan sebagai salah satu alternatif yang digunakan pada lansia untuk mangatasi gangguan tidur. pemberian yoga dapat dilakukan secara berkelompok baik individual dan sebaiknya dilakukan 30 menit sebelum tidur. bagi panti agar yoga dapat dijadikan sebagai suatu alternatif dalam memenuhi kebutuhan tidur baik kualitas maupun kuantitas pada lansia. penelitian selanjutnya dapat meneliti tentang yoga terhadap pemenuhan kebutuhan tidur dengan waktu yang lebih lama agar didapatkan hasil yang lebih maksimal. kepustakaan asmadi. 2008. konsep dan aplikasi kebutuhan dasar klien. jakarta: salemba medika, hlm. 133-143. budi dharma surya. 2004. tidur nyenyak bersama yoga, (online), (www.kalbe.co.id/, diakses tanggal 13 oktober 2008, jam 06.35 wib). carpenito, l. j. 2000. diagnosa keperawatan aplikasi pada praktek klinis. jakarta : egc, hlm. 116,122. erna dwi. 2006. pengaruh terapi musik langgam jawa terhadap pemenuhan kebutuhan tidur pada lansia.skripsi tidak dipublikasikan. surabaya: psik fk unair. guyton dan hall. 1997. buku ajar fisiologi kedokteran. jakarta : egc, hlm. 187197. hudak dan gallo. 1997. keperawatan kritis pendekatan holistik. edisi 6. jakarta : egc, hlm. 163,168. muriani harsono. 2008. insomnia, (online), (http://murianiharsono.blogspot.com/2 007/11/insomnia.html., diakses tanggal 17 november 2008, jam 11.20 wib). nugroho, w. (2000). keperawatan gerontik. jakarta : egc, hlm. 15-19 pangkalan ide. 2008. yoga insomnia. jakarta : pt elex komputindo, hlm. 23,28,37,45 . http://www.kalbe.co.id/ http://murianiharsono.blogspot.com/2007/11/insomnia.html http://murianiharsono.blogspot.com/2007/11/insomnia.html bab 1 jurnal ners vol. 2 no. 1 mei – september 2007 manfaat senam lansia terhadap kadar imunoglobulin g (igg) tintin sukartini* abstract the health problem is frequently found for elderly with age more than 55 years old. it has adverse effect on cardiovascular and immunological system. the objective of this study was to analyze the effect of elderly exercise on the increase of fitness in elderly. the design of this study was quasy experiment design involving two groups subject. the study took 12 respondents of elderly recruited by purposive sampling. the independent variable was elderly exercise and the dependent variable was igg. data were collected by laboratory test and analyzed by using t-test with significance level of  ≤ 0.05. result showed that elderly exercise had significant effect on the igg level (p = 0,002). further studies are recommended on the effect of elderly exercise on the increase immunity system concerning with the role of interferon gamma. keywords: elderly, exercise, immunoglobulin pendahuluan keberhasilan pemerintah dalam pembangunan nasional, telah mewujudkan hasil yang positif di berbagai bidang, yaitu adanya kemajuan ekonomi, perbaikan lingkungan hidup, kemajuan ilmu pengetahuan dan teknologi, terutama di bidang kesehatan, sehingga dapat meningkatkan kualitas kesehatan penduduk serta meningkatkan umur harapan hidup manusia. pada tahun 2000 jumlah lanjut usia meningkat menjadi 9.99% dari seluruh penduduk indonesia dengan umur harapan hidup 65-70 tahun, sedangkan jumlah penduduk jawa timur tahun 2002 sebanyak 35.3 juta orang terdapat lansia diatas 65 tahun 2.1 juta (6.0%) (badan pusat statistik propinsi jawa timur, 2002). lanjut usia merupakan suatu bagian dari tahap perjalanan hidup manusia yang keberadaannya senantiasa harus diperhatikan. pandangan sebagian masyarakat yang menganggap lansia sebagai manusia yang tidak mampu, lemah dan sakit-sakitan menyebabkan mereka _______________ * staf pengajar psik fk unair memperlakukan lansia sebagai manusia yang tidak berdaya, sehingga segala aktivitas sangat dibatasi. kondisi ini diperparah oleh tidak adanya waktu, tempat dan kesempatan bagi lansia dalam melakukan aktivitas untuk mengisi sisa hidupnya, sehingga lansia menjadi kehilangan self efficacy. latihan atau exercise sangat penting untuk menghindari perubahan yang tiba-tiba dan gaya hidup aktif kegaya hidup sederhana. menurut scotch yang dikutip oleh darmojo dan martono (1999), kaum lansia akan mengalami stres karena perubahan secara drastis dan kesedihan yang sangat, serta kehinaan dari akibat perubahan pola hidup tersebut. jenis olahraga yang bisa dilakukan pada lansia antara lain senam lansia. senam lansia disamping memiliki dampak positif terhadap peningkatan fungsi organ tubuh juga berpengaruh dalam meningkatkan imunitas dalam tubuh manusia setelah latihan teratur (depkes, 1995). tingkat imunitas dapat diukur berdasarkan imunoglobulin dalam tubuh lansia. jurnal ners vol. 2 no. 1 mei – september 2007 bahan dan metode penelitian penelitian ini menggunakan desain quasy experiment, dengan responden 12 lansia di pokja lansia duduk sampean gresik. variabel bebas pada penelitian ini senam lansia yang diberikan 30 menit 2 kali seminggu selama 8 minggu dan variabel tergantung adalah kadar immunoglobulin g dalam darah. analisis data dilakukan dengan uji statistik independent ttest, dengan tingkat kemaknaan ≤0.05. instrumen yang digunakan meliputi prosedur gerakan senam lansia dan pengukuran kadar immunoglobulin g darah yang diambil dari darah vena cubiti. hasil penelitian tabel 1: pengaruh latihan senam lansia terhadap kadar immunoglobulin pada lansia di pokja lansia duduk sampean gresik pada bulan mei – agustus 2006 no. immunoglobulin (mg/dl) perlakuan kontrol perbedaan 1. 1437 2151 714 2. 1206 2081 875 3. 1559 2081 522 4. 1748 2365 617 5. 1875 2663 788 6. 1984 2740 756 x 1634.83 2346.83 711.5 sd 290.238 294.807 t-test p=0.002 dari tabel 1 dapat dilihat ada pengaruh latihan senam lansia terhadap perubahan kadar immunoglobulin g yang ditunjukkan dengan perbedaan kadar immunoglobulin pada kelompok kontrol dan perlakuan (p=0.002). pembahasan dari penelitian ini diketahui adanya pengaruh senam lansia terhadap kadar immunoglobulin g pada lansia. hal ini dapat dilihat kadar immunoglobulin g pada kelompok perlakuan memiliki nilai dalam rentang normal dibandingkan kelompok kontrol. olahraga merupakan aktivitas yang sangat berguna untuk kebugaran tubuh. dengan berolahraga jasmani dan rohani dapat selalu tetap bugar dan sehat, sehingga olahraga sangat penting untuk menjaga kebugaran tubuh secara keseluruhan. aktivitas olahraga ini akan membantu tubuh tetap bugar dan segar karena melatih tulang tetap kuat, mendorong jantung bekerja optimal, dan membantu menghilangkan radikal bebas yang berkeliaran di dalam tubuh. dapat dikatakan bugar, atau dengan perkataan lain mempunyai kesegaran jasmani yang baik bila jantung dan peredaran darah baik sehingga tubuh seluruhnya dapat menjalankan fungsinya dalam waktu yang cukup lama (sumosardjuno, 1998). pada umumnya tujuan dari latihan olahraga adalah memperbaiki komponen khusus dari kebugaran sehingga jantung dan paru berfungsi baik, menghindari lemak yang terlalu banyak, tulang punggung dan sendi lentur dan mudah bergerak, dan otot kencang, kuat, dan mempunyai daya tahan yang tinggi (donovan et all, 2001). latihan yang berulang–ulang merangsang otak secara progresif menjadi lebih mampu untuk menghasilkan sejumlah sinyal otak yang sesuai, yang dibutuhkan untuk mempertahankan faktor kimia darah pada nilai normalnya (guyton & hall, 1997). olahraga mempengaruhi imunitas seseorang karena dapat memperpanjang fungsi natural killer cells, limfosit t dan b, serta monosit atau makrofag. pada intensitas olahraga sedang memberikan dampak imun yang baik, sedangkan pada intensitas tinggi (pada orang yang belum terkondisi) tampak penurunan secara drastis pada kemampuan sel imun (bullock, et. all., 2000). latihan olahraga juga mengembangkan kebugaran mental, meningkatkan rasa percaya diri, dan meningkatkan harga diri. setiap komponen kebugaran dapat dengan mudah ditingkatkan dengan program latihan yang jurnal ners vol. 2 no. 1 mei – september 2007 bertahap, teratur, dan berimbang (donovan et all, 2001). olahraga dapat meningkatkan konsentrasi sejumlah hormon stres di dalam darah yang meliputi epineprin, norepineprin, growth hormon, -endorphins, testosteron, estrogen dan kortisol. dalm hal ini olahraga merubah interaksi neuroimun yang merangsang terjadinya perubahan imunitas (penderson, 2000) senam lansia merupakan gerakan senam yang gerakannya disesuaikan dengan kondisi anatomi dan fisiologi tubuh lansia. selain meningkatkan kebugaran senam ini dapat meningkatkan sistem imunitas. pada lansia terjadi peningkatan il-2 dan cd-4+ baik fungsi dan jumlahnya (guntur h). jika hal ini distimulus dengan senam lansia yang teratur diharapkan il-2 dapat merangsang th-2 untuk mengeluarkan il-4. il-4 akan merangsang bcell untuk meningkatkan kadar imunoglobulin. simpulan dan saran simpulan senam lansia yang dilakukan secara teratur dan benar meningkatkan kadar ig. g pada lansia. saran 1. perlu dilakukan penelitian lebih lanjut mengenai dosis senam lansia sehingga diperoleh dosis yang tepat untuk menstabilkan kadar immunoglobulin darah. 2. latihan senam lansia berintensitas rendah dapat dilakukan bagi yang belum pernah melakukan latihan senam lansia untuk meningkatkan kebugaran tubuh. 3. latihan senam lansia dapat menjadi program kegiatan olahraga rutin yang dapat dilaksanakan di panti-panti wredha. 4. lakukan senam dengan senang hati untuk memperoleh hasil latihan yang lebih baik yaitu kebugaran tubuh dan kebugaran mental. kepustakaan bullock, et. all., (2001). human on pathophysiologi, lippincott: philadelphia. badan pusat statistik propinsi jawa timur, 2002. darmojo dan martono, (1999). geriatri. jakarta: percetakan yudistira. djojosugito, a.h.m., (2000). wujud nyata pelayanan individu dari profesi perawat.bandung. (makalah disampaikan dalam munas ppni vi ). donovan, et. al., (2001). koreksi gerakan senam yang membahayakan. cet 2. jakarta: raja grafindo persada. guyton & hall, (1997). buku ajar fisiologi kedoklansian edisi 9, jakarta: egc. guntur, h., (2005). the role immune response in elderly, makalah seminar. pendersen, et. all., (2000) exercise and the immune system, the american physiological society. sumosardjuno, s., (1998). pengetahuan praktis kesehatan dalam olahraga, jakarta: gramedia. pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru strategi pemasaran peningkatan bed occupancy rate (bor) (marketing strategy to increase bed occupancy rate) purwaningsih*, esti yunitasari* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: jurnalners.psik@gmail.com abstract introduction: a hospital is an institution for health care providing treatment by specialized staff and equipment, more often but not always providing for longer-term patient stays. today, hospitals are very complex institution, not only survive in dynamic environment but also make a profit based on their services. the aimed of this research was to know marketing mix concept (product, price, place, promotion, people, process and provision of customer service) in formulating marketing strategy to increased bed occupancy rate of obstetric gynecology ward 2. method: the population are health care personnel including midwife, midwife associate, administrator and also client or consumer. the variable were product, price, place, promotion, people, process and provision of customer service. data were collected by using structured questionnaire. result: the result showed that product (type of services, infrastructure and facility), relative price, comfortable and safe place, targeted promotion, trained human resources, standard process and provision of customer service are an important aspect to implement strategy marketing to increase bed occupancy rate. analysis: the result of this study has enlightened the importance of strategy marketing in health care services based on seven principle of marketing mix. discussion: implementation of marketing mix in obstetric gynecology ward 2 need to be considered. keywords: strategy marketing, bor, marketing mix pendahuluan rumah sakit merupakan institusi yang kompleks, dinamis, padat modal dan padat karya, tidak saja harus bertahan tetapi juga harus memperoleh penghasilan atau keuntungan yang digunakan untuk meningkatkan mutu dan mengembangkan pelayanan. rumah sakit secara konsisten tetap dituntut untuk menjalankan misi sebagai institusi pelayanan sosial dengan mengutamakan pelayanan kepada masyarakat dan harus selalu memperhatikan etika pelayanan. pada sisi lain sebagai unit usaha, rumah sakit harus tetap memperhatikan prinsip ekonomi. adanya tuntutan persaingan diantara institusi pelayanan kesehatan, sehingga para manajer institusi pelayanan kesehatan harus berfikir business like dan berinovasi terhadap bentuk layanan yang diberikan. inovasi yang diberikan harus disesuaikan dengan kebutuhan dan harapan masyarakat pada umumnya dan konsumen pada khususnya. oleh karena itu perlu dirumuskan strategi pemasaran yang tepat dan sesuai dengan karakteristik pengguna jasa pelayanan sehingga bed occupancy rate (bor) rumah sakit dapat dioptimalkan. bor di ruang bersalin ii rsu dr. soetomo surabaya semakin lama semakin rendah, seperti terlihat pada tabel 1. tabel 1. bor di ruang bersalin ii rsu. dr soetomo surabaya tahun 2002 2003 2004 bor 41,12% 30,73% 13,4% pada tabel 1 terlihat bahwa bor di ruang bersalin ii masih rendah jika dibandingkan dengan nilai bor ideal yaitu 70-80% (erwati et al., 2006). beberapa faktor yang kemungkinan dapat mempengaruhi rendahnya bor, diantaranya adalah sumber daya manusia, sarana dan prasarana, mutu pelayanan, sistem informasi manajemen rumah sakit, pemasaran rumah mailto:jurnalners.psik@gmail.com http://en.wikipedia.org/wiki/health_care jurnal ners vol.3 no.1 april 2008 : 87-90 sakit, karakteristik konsumen dan ketidakpuasan konsumen. berdasarkan latar belakang tersebut, yang menjadi permasalahan dalam penelitian ini adalah rendahnya bor, yaitu 13,4% di ruang bersalin ii rsu dr soetomo surabaya pada tahun 2004. bahan dan metode penelitian ini merupakan penelitian pemasaran, yang dimulai dengan mencari informasi mengenai kekuatan kompetitif (competitive force) yang dimiliki rumah sakit sebagai dasar untuk merumuskan strategi korporat. selanjutnya strategi korporat yang telah dirumuskan dipakai sebagai landasan atau acuan di dalam perumusan strategi fungsional (strategi pemasaran). penelitian ini terlebih dahulu akan mencari informasi pada beberapa rumah sakit pesaing dalam memberikan pelayanan ruang bersalin. penelitian ini juga mencari informasi mengenai kualitas pelayanan di ruang bersalin ii rsu dr. soetomo surabaya kepada para pelanggan dalam hal ini adalah pasien dan dokter. populasi dari penelitian ini adalah para petugas di ruang bersalin ii rsu dr. soetomo surabaya, terdiri dari para bidan, pembantu bidan dan tenaga administrasi. penelitian ini juga memberikan kuesioner kepada para pengguna jasa pelayanan di ruang bersalin ii yaitu ibu melahirkan di ruang bersalin ii pada bulan agustus sampai dengan november 2006. variabel pada penelitian ini adalah marketing mix 7p, yaitu product, price, place, promotion, people, process dan provision of custumor service. hasil beberapa alasan bor menurun di ruang bersalin ii rsu dr. soetomo surabaya periode agustus sampai dengan november 2006 menurut petugas kesehatan di ruang bersalin ii rsu dr. soetomo surabaya: 1) papan nama yang gelap, pasien tidak begitu mengerti keberadaan ruang bersalin, 2) banyaknya bps (bidan praktik swasta), 3) prosedur pasien sulit, 4) pasien tidak betah karena di rs banyak nyamuk, 5) persalinan normal harus menunggu 2 hari untuk pulang, 6) pasien banyak diarahkan ke vk ird, 7) pasien sering memilih tempat yang tidak sering dirujuk dan 8) jumlah ibu hamil sedikit karena kb berhasil. beberapa harapan baik dari petugas kesehatan maupun dari pasien di ruang bersalin ii rsu dr. soetomo surabaya: 1) papan nama rb ii dibuat menarik dan dapat dibaca, 2) memberikan pelayanan sebaik mungkin dengan sepenuh hati supaya pasien pulang bisa cerita ke orang lain, 3) prosedur di rb ii dipermudah, 4) persalinan normal dan bayi lahir normal 1x24 jam boleh pulang, 5) vk diberi ac, 6) bekerjasama dengan poli dan ppds, 7) pasien yang anc di ph i dengan kasus fisiologis di anjurkan untuk melahirkan di rb ii, 8) kerjasama antara pimpinan dan karyawan dan 9) bidan lebih perhatian. pembahasan perumusan stategi pemasaran ruang bersalin ii rsu dr. soetomo surabaya disusun berdasarkan hasil kuesioner dan diskusi yang kami lakukan dengan para responden yang dirangkum dalam aspek marketing mix. produk merupakan kombinasi barang dan jasa yang ditawarkan perusahaan kepada pasar untuk memuaskan keinginan pelanggan. produk dalam pelayanan rumah sakit merupakan jenis pelayanan serta kelengkapan peralatan dan sarana. berdasarkan hasil kuesioner dan diskusi, maka dalam product dilakukan strategi sebagai berikut: jenis pelayanan yang diberikan pada ruang bersalin ii rsu dr. soetomo sudah fokus pada pelayanan ibu yang melakukan persalinan normal sehingga tidak perlu dirubah atau ditambahkan lagi jenis pelayanan lain dan peralatan dan sarana yang tersedia sudah memenuhi standar minimal, tidak perlu penambahan peralatan mengingat pengguna jasa pelayanan masih kurang. menurut porter (1980) price, dapat diartikan sebagai sejumlah uang yang harus dibayar oleh konsunen untuk mendapatkan produk (bukan hanya dalam bentuk uang tetapi lebih manusiawi, seperti waktu, kasih sayang, kekuatan, kebanggaan, persahabatan dan kesukaan). price dalam hal ini adalah tarif pelayanan kepada masyarakat penguna jasa di ruang bersalin ii rsu dr. soetomo surabaya. tarif yang sudah ada tetap strategi meningkatkan bor (purwaningsih) dipertahankan tetapi upaya peningkatan mutu tetap harus dilakukan. hal ini disebabkan karena sebagian besar pengguna jasa pelayanan di ruang bersalin ii adalah masyarakat dengan tingkat ekonomi menengah ke bawah. sebagian besar pengguna jasa menggunakan kartu sehat dalam menggunakan jasa pelayanan di ruang bersalin ii. place, tempat distribusi produk atau jasa dari penyedia barang atau jasa kepada konsumen sehingga produk atau jasa itu mudah didapat, dengan memperhatikan lokasi atau outlet dan aksesnya. tempat ruang bersalin ii rsu dr. soetomo terpisah dengan tempat layanan lain di rsu dr. soetomo. hal ini membuat para konsumen masih banyak yang belum mengetahui keberadaan ruang bersalin ii rsu dr. soetomo surabaya. promosi mengenai keberadaan ruang bersalin ii harus terus dilakukan sehingga masyarakat mengetahui atau mengenal keberadaan ruang bersalin ii rsu dr. soetomo surabaya. promotion, merupakan berbagai kegiatan yang dilakukan oleh perusahaan untuk meyakinkan pelanggan mengetahui produk apa yang ada, apa kegunaannya, bagaimana menggunakannya, dimana tersedia dan apa saja yang membuat konsumen membelinya. promosi merupakan salah satu faktor penentu keberhasilan suatu program pemasaran. bagaimanapun baiknya suatu produk, bila konsumen tidak mengenal dan tidak yakin terhadap kegunaan barang tersebut, maka konsumen tidak akan membeli. hampir 50% pengguna jasa pelayanan di ruang bersalin ii rsu dr. soetomo surabaya sebelumnya tidak mengetahui keberadaan atau lokasi ruang bersalin ii. promosi yang harus dilakukan untuk ruang bersalin ii rsu dr. soetomo surabaya adalah dengan memberi arah petunjuk jalan menuju ruang bersalin ii. papan nama yang besar perlu dibuat agar mudah dibaca oleh masyarakat. promosi juga dapat dilakukan dengan melakukan berbagai kegiatan yang melibatkan masyarakat luas, misal lomba bayi sehat atau mengadakan senam nifas yang dapat diikuti oleh masyarakat luas. people, artinya sebagai perilaku staf yang efektif untuk menarik konsumen agar mau datang ke perusahaan atau pemberi jasa pelayanan. keunggulan dalam pemilihan personil, seleksi dan pemberian motivasi kepada personil sangat diperlukan. people atau sumber daya manusia merupakan unsur yang paling penting, baik dalam produksi maupun penyampaian pelayanan kepada pelanggan dan masyarakat. people secara bertahap menjadi bagian diferensiasi sebagai upaya perusahaan untuk menciptakan nilai tambah dan memperoleh keunggulan kompetitif. payne (1993) mengemukakan bahwa perusahaan semakin menyadari bahwa untuk berhasil dalam pemasaran para konsumen eksternal, maka pemasaran internal juga harus diperhatikan. rerata para pengguna jasa pelayanan di ruang bersalin ii rsu dr. soetomo mengemukakan puas terhadap pelayanan yang diberikan oleh para petugas di ruang bersalin ii. para bidan sudah cukup memberikan pengetahuan dan wawasan yang cukup berhubungan dengan perawatan bayi di rumah. pelayanan administrasi dirasakan cukup memberikan pelayanan yang baik, karena pengurusan administrasi tidak mengalami kesulitan dan cukup cepat. kondisi ini disebabkan karena sebagian besar petugas di ruang bersalin ii rsu dr. soetomo surabaya sudah mempunyai pengalaman kerja rerata di atas 10 tahun (kustianingsih, 2005). process, merupakan semua aktivitas pekerjaan, termasuk prosedur, mekanisme dan hal rutin, tempat jasa dibuat maupun diberikan ke konsumen. manajemen proses merupakan salah satu kunci untuk pengembangan mutu pelayanan. proses pemberian pelayanan kesehatan mencakup prosedur, mekanisme dan hal rutin lainnya. jasa dibuat dan diberikan kepada pelanggan melalui proses tersebut. alur penerimaan pasien di ruang bersalin ii rsu dr. soetomo masih cukup memuaskan, tetapi kemudahan transportasi pasien dari dan ke ruangan lain di wilayah rsu dr. soetomo surabaya agak jauh karena lokasi yang terpisah dengan rumah sakit. sebagian besar ibu yang melahirkan di ruang bersalin ii berasal dari rujukan instlasi rawat darurat (ird) rsu dr. soetomo dan ird juga menerima pelayanan ibu melahirkan. hal ini merupakan salah satu penyebab rendahnya bor di ruang bersalin ii. standar operasional prosedur (sop) mengenai jurnal ners vol.3 no.1 april 2008 : 87-90 purwaningsih purwaningsih indikasi persalinan yang boleh dilakukan di ird dan ruang bersalin ii perlu dipertegas lagi. provision of custumor service, adalah kegiatan menampung konsumen, mendekatkan diri dengan konsumen dan mengamati kemampuan bersaing. kegiatan yang dapat dilakukan di ruang bersalin ii rsu dr. soetomo suarabaya adalah dengan melakukan kegiatan untuk masyarakat luas misalnya melakukan kegiatan senam nifas bagi masyarakat. simpulan dan saran simpulan simpulan dari penelitian ini: 1) sebagian besar pengguna jasa pelayanan di ruang bersalin ii rsu dr. soetomo surabaya adalah masyarakat tingkat ekonomi menengah ke bawah, 2) sebagian besar pengguna jasa menggunakan kartu sehat untuk membayar jasa pelayanan di ruang bersalin ii rsu dr. soetomo surabaya, 3) sebagian besar pengguna jasa pelayanan di ruang bersalin ii rsu dr. soetomo berasal dari rujukan ird rsu dr. soetomo surabaya, 4) ird rsu dr. soetomo juga memberikan pelayanan ibu melahirkan sehingga perlu dipertegas lagi indikasi pertolongan persalinan yang dapat dilakuan di ird, 5) jenis pelayanan yang diberikan pada ruang bersalin ii rsu dr. soetomo tidak perlu dirubah atau ditambahkan lagi jenis pelayanan lain, 6) peralatan yang tersedia di ruang bersalin ii rsu dr. soetomo surabaya tidak perlu ditambahkan dulu mengingat pengguna jasa pelayanan masih kurang, 7) tarif yang sudah ada tetap dipertahankan karena sebagian besar pengguna jasa pelayanan di ruang bersalin ii adalah masyarakat dengan tingkat ekonomi menengah ke bawah, 8) ruang bersalin ii rsu dr. soetomo yang terpisah dengan tempat layanan lain di rsu dr. setomo membuat para konsumen masih banyak yang belum mengetahui keberadaan ruang bersalin ii rsu dr. soetomo surabaya, 9) papan nama dan petunjuk arah menuju ruang bersalin ii rsu dr. soetomo belum banyak diketahui oleh masyarakat, 10) para pengguna jasa pelayanan di ruang bersalin ii rsu dr. soetomo rata-rata, 11) alur penerimaan pasien di ruang bersalin ii rsu dr. soetomo masih cukup memuaskan, tetapi kemudahan transportasi pasien dari dan ke ruangan lain di wilayah rsu dr. soetomo surabaya agak jauh karena lokasi yang terpisah dengan rumah sakit masih dirasakan kurang mengemukakan puas terhadap pelayanan yang diberikan para petugas di ruang bersalin ii, 12) belum terdapat kegiatan yang dilakukan di ruang bersalin ii rsu dr. soetomo yang melibatkan masyarakat. saran berdasar hasil penelitian ini, peneliti menyarankan agar: 1) pengelola rsu dr. soetomo sebaiknya mempertegas mengenai indikasi pelaksanaan tindakan persalinan di ird dan ruang bersalin ii, 2) papan nama dan petunjuk arah ke ruang bersalin ii rsu dr. soetomo surabaya perlu diperbesar sehingga masyarakat mengetahui keberadaan ruang bersalin ii, 3) upaya pengenalan kepada masyarakat perlu dilakukan melalui kegiatan yang melibatkan masyarakat luas di ruang bersalin ii rsu dr. soetomo surabaya, misalnya melakukan senam nifas. kepustakaan payne. 1993. competitive strategy: the basic a la michael porter, (online), (http://www.home.att.net/., diakses tanggal 7 juni 2005, jam 11.50 wib). porter. 1980. porter generic strategies, (online), (http://www.marketingteacher.com., diakses tanggal 7 juni 2005, jam 13.00 wib). kustianingsih. 2005. analysis on customer expectation. jurnal administrasi dan kebijakan kesehatan, 3(1), (online), (http://www.journal.unair.ac.id., diakses tanggal 20 agustus 2006, jam 11.00 wib). erwati, et al. 2006. analysis of customer buying behaviour to increase the utilization of bangli regional hospital. jurnal administrasi dan kebijakan kesehatan, 4(1), (online), (http://www.journal.unair.ac.id/detail_j urnal.php., diakses tanggal 20 agustus 2006, jam 10.00 wib). http://www.home.att.net/ http://www.marketingteacher.com/ http://www.journal.unair.ac.id/ strategi meningkatkan bor (purwaningsih) oksigenasi dengan bag and mask 10 lpm memperbaiki asidosis respiratorik (oxygenation by using 10 lpm bag and mask improves respiratory acidosis) sunarko setyawan*, tintin sukartini**, sriyono**, kusmiati** * fakultas kedokteran universitas airlangga ** program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496, e-mail: sriyono_70@yahoo.com abstract introduction: alo (acute lung oedema) is the most common and remarkably life threatening medical emergency. it is not unusual that clients come to the hospital in critical condition. alo occurs due to fluid accumulation in the alveoly, thereby impairing gas exchange and the client will experience respiratory acidosis and hypoxemia. the alo management that must be urgently carried out is high concentration oxygenation with peep (positive end expiratory pressure) to prevent alveolar collapse by means of bag and mask oxygenation, cpap (continous positive airway pressure) mask and mechanical ventilation. the objective of this study was to explain the effect of oxygenation by using 10 lpm (liters per minute) bag and mask on respiratory acidosis improvement in alo client. method: a pre-experimental one group pre post test design was used in this study. the population were all alo clients in icu (intensive care unit), adi husada kapasari hospital. there were 12 respondents which taken by using total sampling. data were collected by using observation on the blood gas analyze (ph, paco2 and pao2) then analyzed by using paired t-test with significance level ≤0.05. result: the result showed that 12 respondents experienced respiratory acidosis and hypoxemia before intervention with 10 lpm bag and mask oxygenation was gave to them. after intervention for 1 hour, the result showed that ph increased (p=0.003), paco2 reduced (p=0.004) and pao2 increased (p=0.005). discussion: it can be concluded that 10 lpm bag and mask oxygenation had significance effect on the improvement of respiratory acidosis in alo clients. further studies should involve more respondents and more reliable measurement tools to obtain better accuracy. keywords: bag and mask oxygenation, acute lung oedema, respiratory acidosis, hypoxemia pendahuluan edema paru akut merupakan medical emergency yang paling sering dan sangat mengancam jiwa. edema paru akut terjadi karena adanya penumpukan cairan di alveolar dan mengakibatkan alveoli kolaps sehingga terjadi gangguan pertukaran gas dan proses difusi tidak berjalan dengan normal. apabila hal tersebut berlanjut maka akan terjadi asidosis respiratorik (peningkatan paco2 dan penurunan ph). asidosis respiratorik selalu diikuti oleh hipoksemia atau penurunan pao2 (anderson, 2005). pemberian oksigen konsentrasi tinggi dengan tekanan positif sangat dibutuhkan untuk mengatasi keluhan edema paru akut, diantaranya dengan ventilator, bag and mask dan continous positive airway pressure (cpap) mask (bersten, et al., 1991dalam bidang diklat rsud dr soetomo, 2005). terapi medis diberikan berdasarkan penyebab dari penyakit dasarnya, namun efek atau respons obat tidak selalu segera terlihat, memerlukan beberapa menit bahkan beberapa jam. pemakaian ventilator membutuhkan biaya yang cukup besar dan dalam pelaksanaannya memerlukan seorang ahli anastesi yang tidak selalu standby di rumah sakit adi husada kapasari, sehingga membutuhkan waktu ± 1-2 jam, disamping itu untuk mendapatkan persetujuan keluarga klien juga membutuhkan waktu antara 1-2 jam. dalam waktu yang cukup lama, oksigenasi mutlak harus tetap diberikan untuk mencegah klien jatuh dalam kondisi yang lebih buruk. bag and mask 10 lpm (liter per menit) merupakan oksigenasi dosis tinggi dengan closed system (masker ketat) yang paling mudah dan dapat segera dilakukan pada saat klien masuk rumah sakit. bag and mask dilengkapi dengan reservoir untuk memberi tekanan positif pada edema paru akut, namun pengaruhnya terhadap perbaikan asidosis respiratorik belum diketahui secara pasti. angka kejadian edema paru belum dapat secara pasti dihitung karena banyaknya variasi derajat dan penyebab edema paru. di rumah sakit adi husada kapasari (rsahk) surabaya pasien edema paru akut yang masuk ruang icu dari tahun 2005 sampai tahun 2006 rerata ± 9-11 kasus per bulan dan 80% dari kasus tersebut mengalami asidosis respiratorik. edema paru akut merupakan penimbunan cairan serosa atau serosanguinosa secara berlebihan dalam ruang interstisial dan alveolus paru-paru secara mendadak karena adanya tekanan hidrostatik kapiler meningkat dan penurunan tekanan koloid osmotik serta kerusakan dinding kapiler, sehingga dapat menyebabkan kebocoran kapiler ke ruang interstisial dan menjadi edema alveolar. apabila berlanjut maka akan terjadi kerusakan pertukaran gas atau proses difusi tidak berjalan normal, respiration rate (rr) meningkat, perfusi dingin, sianosis dan gelisah akibat terjadi peningkatan co2 dan penurunan o2. penyebab terbanyak edema paru akut adalah kardiogenik, yang disebabkan karena kegagalan ventrikel kiri, seperti mitral stenosis, infark miokard akut dan berbagai penyakit jantung bawaan (pikir, 2006). penanganan yang tidak adekuat dapat menyebabkan kematian (hudak dan gallo, 1990). penatalaksanaan edema paru sangat kompleks disamping mengobati keluhan klinis juga mengatasi penyakit dasar, seperti pemberian diuretik, morphin dan oksigen (paul, l. marino, 1997). pemberian oksigen dengan tekanan positif merupakan hal utama yang harus dilakukan bila klien mengalami gangguan pertukaran gas untuk memperbaiki proses difusi (mims, et al., 2004). ventilator sangat efektif untuk oksigenasi pada edema paru akut yang berat, namun karena biaya yang cukup mahal dan dalam pelaksanaan memerlukan waktu maka bag and mask 10 lpm merupakan alternatif untuk mengatasi keluhan pada edema paru akut, namun pengaruh oksigenasi bag and mask 10 lpm belum diketahui secara pasti. merujuk pada kondisi tersebut, peneliti tertarik untuk mengetahui pengaruh oksigenasi dengan bag and mask 10 lpm terhadap perbaikan asidosis respiratorik pada klien edema paru akut. tujuan dari penelitian ini adalah untuk menganalisis pengaruh oksigenasi dengan bag and mask 10 lpm terhadap perbaikan asidosis respiratorik pada klien edema paru akut. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah pre experimental one-group pre-posttest design. populasi dalam penelitian ini adalah semua pasien edema paru akut kardiogenik di icu rumah sakit adi husada kapasari surabaya. teknik sampling yang digunakan adalah total sampling, dengan besar sampel 12 responden. penelitian dilakukan mulai 29 november 2006 sampai dengan 10 januari 2007. variabel independen dalam penelitian ini adalah pemberian oksigen dengan bag and mask 10 lpm, sedangkan variabel dependen adalah kondisi asidosis respiratorik. parameter untuk asidosis respiratorik adalah hasil pemeriksaan agd yang meliputi ph, paco2 dan pao2. instrumen yang digunakan dalam penelitian ini dalam bentuk lembar observasi untuk menuliskan perubahan tanda-tanda vital dan saturasi oksigen, dimulai saat pasien baru masuk rumah sakit dengan menggunakan alat pulse oxymetri (hewlett packard) dan pemeriksaan agd. pengumpulan data dilakukan dengan melakukan pemeriksaan agd pada saat klien baru masuk sebelum intervensi dilakukan dan setelah 1 jam setelah intervensi diberikan. data yang diperoleh ditabulasi dan dianalisis dengan menggunakan uji statistik paired ttest dengan derajat kemaknaan <0,05. hasil tabel 1 menunjukkan bahwa 10 responden (83%) terjadi peningkatan pao2 dan 2 responden (17%) tidak mengalami peningkatan pao2. hasil pao2 menunjukkan rerata pao2 78.05 mmhg sebelum oksigenasi dan rerata 110.27 mmhg setelah oksigenasi dengan bag and mask 10 lpm. terdapat peningkatan pao2 yang signifikan sebelum dam sesudah oksigenasi dengan bag and mask 10 lpm pada klien edema paru akut yang ditunjukkan dengan hasil analisis statistik paired t-test p=0,005. pada ph didapatkan hasil rerata ph 7.280 sebelum oksigenasi dan rerata 7.343 setelah oksigenasi dengan bag and mask 10 lpm. sepuluh responden (83%) mengalami peningkatan ph dan 2 responden (17%) tidak terjadi peningkatan ph. terdapat peningkatan ph yang signifikan sebelum dan sesudah oksigenasi dengan bag and mask 10 lpm pada klien edema paru akut dengan hasil analisis statistik paired t-test diperoleh p=0,003. hasil paco2 didapatkan hasil rerata paco2 53,6 mmhg sebelum oksigenasi dan 49,5 mmhg setelah oksigenasi dengan bag and mask 10 lpm. delapan responden (67%) mengalami penurunan paco2 dan 4 responden (33%) tidak terjadi penurunan paco2. terdapat perbedaan yang signifikan pada hasil paco2 antara sebelum dan sesudah oksigenasi dengan bag and mask 10 lpm, pada klien edema paru akut yang ditunjukkan dengan hasil analisis statistik paired t-test p=0,004. pembahasan menurut djayanegara (2006) oksigenasi dengan bag and mask 10 lpm merupakan metode pemberian oksigen dengan closed system (masker ketat) dimana tidak boleh ada kebocoran untuk mendapatkan fio2 100% dan berfungsi sebagai continous positive airway pressure (cpap) manual untuk mendapatkan peep. dalam keadaan normal udara yang dihirup akan dikeluarkan seluruhnya dan sebagai hasilnya aliran udara yang dikeluarkan akan berhenti pada saat akhir ekspirasi diatas tekanan atmosfir, keadaan inilah yang disebut peep. peep bermanfaat untuk mempertahankan alveoli agar tetap terbuka dan dapat mendorong cairan dari intra alveolar ke interstisial (sandhi, 2006), agar dapat menjamin terjadinya pertukaran gas yang efektif, hal ini akan meningkatkan pao2 dan menurunkan paco2. oksigenasi akan berhasil apabila tidak ada faktor penghambat seperti klien gelisah (bernafas melawan atau tidak seirama dengan bantuan nafas), hipoksemia yang terlalu lama, tahanan jalan nafas, compliance paru menurun dan metode pemberian oksigen yang tidak sesuai (djayanegara, 2006). oksigenasi adalah suatu proses untuk mendapatkan o2 dan mengeluarkan co2. proses oksigenasi melibatkan sistim pernafasan dan sistim kardiovaskuler. dalam proses oksigenasi terdiri dari 3 tahapan yaitu ventilasi, difusi gas dan transportasi gas. pada edema paru akut yang terganggu adalah proses difusi gas yaitu pertukaran o2 dan co2 di alveoli dengan kapiler paru, yang disebabkan adanya penumpukan cairan di alveoli (price dan wilson, 2005). oksigenasi dengan bag and mask 10 lpm bertujuan untuk meningkatkan tekanan partial oksigen pada inspirasi yang dapat dilakukan dengan cara meningkatkan kadar fio2 maupun meningkatkan tekanan o2 (sandhi, 2006). tabel 1. perubahan pao2, ph dan paco2 pre dan post oksigenasi bag and mask 10 lpm pada klien edema paru akut di rs adi husada kapasari no pao2 ph paco2 pre post pre post pre post mean 78.05 110.27 7,280 7,344 53.6 49,5 sd 14.777 39,418 6.27e-02 6.98e-02 4.366 9.480 hasil analisis statistik (paired t-test) p=0,005 p=0,003 p=0,004 keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata pemberian oksigenasi dengan bag and mask 10 lpm dapat menurunkan ph. ph yang konstan secara bersama dipelihara oleh sistim penyangga tubuh, ginjal dan paruparu. melalui paru-paru kadar co2 dikendalikan dalam cairan tubuh melalui ventilasi alveolar (guyton dan hall, 1996). dalam persamaan henderson-hasselbach dikatakan bahwa peningkatan paco2 akan menurunkan ph, oleh karena itu paru secara efektif dapat mengatur konsentrasi ion h + cairan ekstraseluler (price dan wilson, 2005). penurunan ph pada klien edema paru akut disebabkan adanya metabolisme anaerobik akibat hipoksemia sehingga asam laktat meningkat dan meningkatkan ion hidrogen (ph menurun). perbaikan ventilasi dengan oksigenasi dapat mengurangi asam laktat sebagai penyebab asidosis, karena metabolisme akan berubah menjadi aerobik, sehingga ph akan meningkat (guyton dan hall, 1996). co2 adalah hasil metabolisme aerob dalam jaringan perifer. dalam darah 70% co2 diangkut dan diubah menjadi asam karbonat (hco3 ) dengan bantuan enzim carbamic anhidrase (ca), 23% co2 larut dalam plasma dan sisanya 7% diikat oleh hb dalam sel eritrosit (said, 2002). pembuangan co2 melalui 2 cara, yang pertama perubahan gas co2 menjadi asam karbonat yang berdisosiasi menjadi h + dan hco3 . h + dikeluarkan oleh ginjal terutama dalam bentuk nh4 + . cara yang kedua adalah pelepasan co2 oleh paru-paru (guyton & hall, 1996). pembuangan gas co2 adalah fungsi utama paru dan adanya hubungan yang sangat penting antara jumlah ventilasi dan jumlah pco2 dalam darah terlalu tinggi, ini berarti bahwa paru tidak cukup memberikan ventilasi (carolyne, 1997). perbaikan ventilasi dengan oksigenasi bag and mask 10 lpm dapat meningkatkan kadar pao2, sehingga pertukaran gas kembali efektif dan co2 dapat dibuang kembali melalui paru-paru, karena pembuangan melalui ginjal kurang efektif apabila terjadi gangguan diuresis. responden yang tidak mengalami penurunan paco2 disebabkan sebelum intervensi menunjukkan hasil paco2 yang tinggi (> 60 mmhg). perbaikan ventilasi dan eliminasi co2 membutuhkan peep > 5 cmh2o yang hanya bisa didapatkan dari alat ventilasi mekanik. responden dengan hasil paco2 < 60 mmhg setelah intervensi dengan bag and mask 10 lpm paco2 tidak bisa turun, hal ini kemungkinan disebabkan oleh kondisi klien yang mengalami hipoksemia (pao2 52 mmhg), klien gelisah dan tidak ada respons terhadap terapi morphin, sehingga oksigenasi tidak efektif. morphin berguna untuk mengurangi kecemasan dan menurunkan tekanan perifer, sehingga darah dapat didistribusikan dari sirkulasi paru ke bagian tubuh lain. hal tersebut akan menurunkan tekanan dalam kapiler paru dan mengurangi perembesan cairan ke jaringan paru. edema paru akut terjadi karena adanya penumpukan cairan di alveolar dan menyebabkan alveoli kolaps sehingga terjadi gangguan pertukaran gas yang berlanjut pada terjadinya hipoksemia yang apabila berlanjut klien akan mengalami asidosis respiratorik. asidosis respiratorik ditandai dengan peningkatan primer paco2 dan penurunan ph, sedang hipoksemia (pao2 rendah) selalu menyertai asidosis respiratorik (price dan wilson, 2005). peningkatan pao2 dan perbaikan ventilasi akan menyebabkan eliminasi co2 melalui paru efektif, sehingga hipoksemia dan asidosis respiratorik pada klien edema paru akut teratasi. simpulan dan saran simpulan pemberian oksigen dengan bag and mask 10 lpm mencegah hipoksemia dan perbaikan asidosis pada klien edema paru akut. saran berdasar hasil penelitian, maka peneliti menyarankan agar pemberian oksigen dengan bag and mask 10 lpm diberikan oleh perawat terlatih dan mempunyai kemampuan tentang oksigenasi dan didasarkan dari hasil pemeriksaan agd atau minimal mengacu pada hasil spo2 dan gejala klinis. klien yang dicurigai edema paru akut sebaiknya segera diberikan oksigen konsentrasi tinggi dengan bag and mask 10 lpm dengan tetap berdasarkan pada hasil spo2 dan gejala klinis, karena oksigenasi dengan bag and mask 10 lpm efektif untuk mengatasi hipoksemia dan asidosis respiratorik pada edema paru akut. kepustakaan bersten, et al. 1991. treatment of severe cardiogenic pulmonary edema with cpap delivered fase mask, j med. england, 1825-1830. bidang diklat rsud dr soetomo. 2005. materi pelatihan icu tingkat dasar. surabaya, hlm. 39-42. brunner dan suddarth. 2002. buku ajar keperawatan medikal bedah. edisi 8 vol. 1. jakarta: egc, hlm. 798-802. guyton dan hall. 1996. buku ajar fisiologi kedokteran. jakarta: egc, hlm. 292302. price dan wilson. 2005. patofisiologi. edisi 4. jakarta: egc, hlm.652-660. carolyne, m.h. 1997. keperawatan kritis. alih bahasa oleh allenidekania dkk. jakarta: egc. djayanegara, i.d.g.n. 2006. pemeriksaan gas darah 1 jam pasca ventilator. surabaya: lab anastesiologi dan reanimasi fk unair. hudak and gallo, 1990. critical of nursing. philadelphia: jb lippincort company, pp. 452-461. mims, et al. 2004. critical care skills: a clinical handbook. usa: wb saunders, pp.143-157. marino, p.l. 1997. icu book. california: william and wilkins, pp. 441-445. pikir, s.b. 2006. diagnosis dan pengelolaan edema paru kardiogenik akut. surabaya: lab kardiologi fk unair, hlm.1-6. sandhi, c. 2006. perubahan aado2 pasien edema paru akut sebelum dan sesudah pemberian peep. surabaya: lab anastesiologi dan reanimasi fk unair. 1 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published semi-annually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of:  a highly respected journal in the nursing field.  it is indexed in major databases: science and technology index (sinta), indonesian publication index (ipi), google scholar, bielefeld academic search engine (base).  rapid initial screening for suitability and editorial interest. jurnal ners has been accredited by the ministry of science, research, technology and higher education of indonesia since 2010. ii. focus and scope the scope of this journal includes, but is not limited to the research results of:  fundamentals of nursing  management in nursing  medical-surgical nursing  critical care nursing  emergency and trauma nursing  oncology nursing  community health nursing  occupational health nursing  mental health nursing  holistic nursing  geriatric nursing  family nursing  maternity nursing  women's health  pediatric nursing  education in nursing  nursing policies  legal nursing  advanced practice nursing  nursing informatics author information pack update: june 10th 2017 please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing https://drive.google.com/file/d/0b5ormcrmctnwq0dix2dictffdlk/view?usp=sharing 2 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam, m.nurs (hons), universitas airlangga, indonesia international advisory board reviewers prof. eileen savage, university college cork, ireland dr. wendy abigail, flinders university, australia dr. chong mei chan, university of malaya, malaysia dr. sonia reisenhofer, la trobe university, australia dr. ya-ping yang, kaohsiung medical university, taiwan editor: ferry efendi, s.kep., ns., m.sc., ph.d., universitas airlangga, indonesia retnayu pradanie, s.kep., ns., m.kep., universitas airlangga, indonesia praba diyan rachmawati, s.kep., ns., m.kep., universitas airlangga, indonesia laily hidayati, s.kep., ns., m.kep., universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., universitas airlangga, indonesia nadia rohmatul laily, s.kep., ns., m.kep., universitas airlangga, indonesia lingga curnia dewi, s.kep., ns., m.kep., universitas airlangga, indonesia dimas dwi arbi, s.kom., universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this 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exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and metaanalyses will be dealt with as original articles are, as far as the editorial process is concerned. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a 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epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 publication fee jurnal ners charges the author a publication fee amounted to idr 1.000.000 (indonesian author) and usd 100 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within two working days. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 5 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: ………………………………………………………………………………………………….. f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. 6 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 title page example vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 7 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 8 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: 𝐇′ = −∑ (𝑃𝑖)(log2 𝑃𝑖) 𝑠 𝑖=1 ………............................................................................................... (1) remarks: .............................................................................................................................................. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old type of care age groups (years) <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 9 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 9th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.zotero.org/styles?q=apa ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. https://www.zotero.org/styles?q=apa 10 | a u t h o r i n f o r m a t i o n p a c k m a r c h 2 8 , 2 0 1 8 vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author,  hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language.  have read the final version of the manuscript and responsible for what is said in it.  have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website.  hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below.  acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk efektifitas senam aerobik dan yoga dalam meningkatkan daya tahan kardiorespirasi wanita pekerja 43 efektifitas senam aerobik dan yoga dalam meningkatkan daya tahan kardiorespirasi wanita pekerja (effectivenes of aerobic and yoga exercise to increase cardiorespiration stamina in carier women) *esti yunitasari, *nuzul qur’aniati, *ida arunia abstract introduction : cardiorespiratory endurance is one of the components of fitness. cardiorespiratory endurance is considered to have relation with health because the low grade of fitness connected to high risk of immature death especially cardiovascular disease. sport such as aerobic exercise and yoga exercise is one of efforts to increase cardiorespiratory endurance. this study was aimed to analyze the effectiveness aerobic exercise and yoga exercise to increase of cardiorespiratory endurance in female employee. method : the design of the study was quasy experimental by using non-probability sampling (purposive sampling). total sample of this study were 21 respondents. seven respondents as treatment aerobic exerciser, 7 respondents as treatment yoga exerciser and 7 respondents as control group. the independent variables were aerobic exercise and yoga exercise. the dependent variables were the increase cardiorespiratory endurance. the data were collected and analyzed by using paired t test and anova with significance level  < 0,05. result : the result showed that there were no differences effectiveness aerobic exercise and yoga exercise to increase cardiorespiratory endurance for female employee which were indicated by pulse (p=0,388), blood pressure systole (p= 0,520), blood pressure diastole (p=0,131) and respiration (p=0,432). analysis : it can be concluded that both of gymnastic aerobic and yoga effective on increasing immunity of cardiovascular for the female. discussion : female employee can consider aerobic and yoga as an effort to increase cardiorespiratory endurance. keyword : cardiorespiratory endurance, female employe, exersice *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: esty.yun_ners@unair.ac.id pendahuluan komponen dari kebugaran yaitu daya tahan kardiorespirasi, kekuatan dan daya tahan otot, kelenturan serta komposisi tubuh (gilang, 2002). daya tahan kardiorespirasi dianggap berkaitan dengan kesehatan karena tingkat kebugaran yang rendah telah dikaitkan dengan risiko tinggi kematian dini dari semua sebab dan khususnya dari penyakit kardiovaskuler (acsm, 2003). akibat dari daya tahan kardiorespirasi yang rendah adalah memiliki resiko tinggi untuk terserang penyakit seperti penyakit jantung koroner dan tekanan darah tinggi (situmeang, 2005). senam aerobik dan senam yoga adalah salah satu bentuk olahraga yang dapat dilakukan untuk meningkatkan atau memelihara daya tahan kardiorespirasi. jumlah pekerja wanita tiap tahun terus meningkat. peningkatan jumlah pekerja wanita tidak didukung dengan upaya pelayanan kesehatan untuk meningkatkan derajat kesehatan pekerja wanita (depkes, 2009). hasil penelitian yang dilakukan oleh dr. elaine d. eaker dari eaker epidemiology enterprises wisconsin (as) menyatakan bahwa kaum pekerja wanita yang memiliki aktifitas tinggi termasuk tekanan ditempat kerja kemungkinan akan mengalami resiko terkena masalah yang berhubungan dengan jantung (tutut, 2004). banyak wanita yang bekerja sambil duduk dan pada waktu luang tidak melakukan aktifitas fisik secara teratur dan bertahap. wanita sering kali menjadikan kesibukan bekerja dan aktivitas lainnya sebagai alasan untuk tidak berolahraga (rai, 2009). hasil penelitian dari bhutkar dkk. (2008) department of physiology, mahadevappa rampure medical college, india menunjukkan bahwa senam yoga dapat mempengaruhi kardiorespirasi yang jurnal ners vol.4 no.1 april 2009: 43-49 44 ditunjukkan dengan penurunan tekanan darah dan denyut nadi saat insirahat. hasil penelitian yang dilakukan oleh irmayana (2003) menunjukkan bahwa senam aerobik low impact mempengaruhi indeks kebugaran salah satunya terhadap daya tahan kardiorespirasi yang ditandai dengan penurunan denyut nadi istirahat, tekanan darah dan frekuensi nafas. efektifitas dari senam aerobik dan senam yoga terhadap daya tahan kardiorespirasi belum diketahui maka diperlukan penelitian lebih lanjut. us centers for desease control and prevention (cdc) dan american collage of sport medicine melaporkan bahwa sebanyak 250.000 jiwa melayang setiap tahun karena gaya hidup yang pasif. ketidakaktifan olahraga memberikan kontribusi kematian yang besar (34%) dan menelan biaya $5,7 milyar pertahun (sharkey, 2003). keterlibatan yang kurang secara aktif dalam berolahraga dapat menyebabkan derajat kebugaran yang rendah. hasil penelitian survey daya tahan kardiorespirasi pada usia kerja yang dilakukan oleh departemen kesehatan pada tahun 1993 yaitu 92,4% termasuk kategori kurang. cv mulya abadi adalah sebuah pabrik yang memproduksi tas di dsn. banjarmlati ds. lengkong mojokerto. total pekerja sebanyak 150 orang dengan rincian wanita sebanyak 125 orang dan laki-laki sebanyak 25 orang dan kerja 7 jam/hari. mayoritas para pekerja bekerja dengan posisi duduk. dari pengambilan data awal yang dilakukan peneliti pada bulan mei di cv mulya abadi didapatkan 75 pekerja wanita tidak aktif berolahraga dan 2 dari 4 pekerja wanita yang tidak aktif berolahraga memiliki daya tahan kardiorespirasi pada kategori kurang. seseorang dengan daya tahan kardiorespirasi yang baik, memiliki jantung yang efisien, paru-paru yang efektif, peredaran darah yang baik, dapat mensuplai otot-otot sehingga yang bersangkutan mampu bekerja secara kontinu tanpa mengalami kelelahan yang berlebihan. selama bergerak pada senam aerobik, otot membutuhkan oksigen untuk bekerja secara efisien, ketika beban kerja otot meningkat, tubuh menanggapi dengan meningkatkan jumlah oksigen yang dikirim ke dalam otot-otot dan jantung. akibatnya, kerja jantung, sirkulasi maupun sistem pernafasan akan meningkat sesuai kebutuhan yang ditandai oleh detak jantung dan frekuensi nafas meningkat sesuai kebutuhan yang ditandai dengan detak jantung dan frekuensi nafas meningkat (brick, 2002). senam yoga menyebabkan meningkatkan aktivitas kontraksi otot sehingga kebutuhan oksigen meningkat. di setiap gerakan yoga selalu disertai pengaturan napas untuk memenuhi kebutuhan oksigen. peningkatan kapasitas paru-paru akan meningkatkan transportasi oksigen ke dalam otot (sindhu, 2007). tubuh akan beradaptasi dengan program olahraga, organel yang ada di dalam otot mioglobin maupun sistem enzim untuk penyediaan energi dan sistem transport oksigen meningkat. keadaan inilah yang menyebabkan kinerja kardiovaskuler dan respirasi lebih efisien yang ditandai dengan denyut nadi, tekanan darah dan frekuensi nafas yang lebih lebih rendah saat istirahat (brick, 2002). apabila komponen kardiorespirasi kurang diupayakan maka akan timbul penyakit akibat kurang gerak yang disebut hipokinetik. akibat lanjutan hipokinetik adalah ancaman jantung koroner, diabetes mellitus, obesitas, hipertensi (gilang, 2002). american heart association merekomendasikan bahwa olahraga yang dapat meningkatkan kesehatan jantung, paru dan sirkulasi adalah olahraga sedang sampai berat dengan jenis aerobik paling sedikit 30 menit (dwpp, 2008). senam aerobik dan senam yoga merupakan olahraga aerobik yang dapat meningkatkan daya tahan kardiorespirasi. senam aerobik memiliki gerakan yang sporadis dan memberikan penekanan pada otot, mempelancar peredaran darah dengan memberikan penekanan pada jantung tanpa ada untuk memperhatikan nafas (brick, 2002). senam yoga memiliki gerakan yang pelan, cenderung menghindari gerakan otot yang tibatiba, dilakukan dengan kesadaran penuh nafas, memperlancar peredaran darah dan tidak memberikan penekanan berlebihan pada jantung (ida, 2008). berdasarkan uraian diatas maka peneliti mencoba untuk menganalisis efektifitas senam aerobik dan senam yoga terhadap peningkatan daya tahan kardiorespirasi pada pekerja wanita di cv mulya abadi. bahan dan metode penelitian penelitian ini menggunakan quasy experiment pre-post test control group design. esti y efektivitas senam aerobik dan yoga (esty yunitasari) 45 populasi dalam penelitian ini adalah pekerja wanita di cv mulya abadi mojokerto sebanyak 125 orang. sampel sebanyak 21 orang didapat dengan teknik purposive sampling sesuai dengan kiteria inklusi dan eksklusi yang telah ditetapkan. kriteria inklusi: 1) bersedia menjadi responden, 2) kooperatif, 3) wanita usia 20-30 tahun, 4) pekerja wanita yang tidak pernah berolah raga, 5) imt normal. kriteria eksklusi: 1) merokok, 2) mempunyai penyakit jantung, asma, nyeri dada, nyeri sendi. penelitian ini dilaksanakan pada tanggal 23 juni sampai 12 juli 2009. variabel independen dalam penelitian ini adalah senam aerobik dan senam yoga, sedangkan variabel dependen adalah daya tahan kardiorespirasi (nadi, tekanan darah dan rerata pernafasan saat istirahat). data yang diperoleh dianalisis dengan menggunakan uji statistik paired t-test dan anova dengan tingkat signifikansi α≤0,05. hasil penelitian penelitian ini mengukur daya tahan kardiorespirasi (nadi, tekanan darah dan rerata pernafasan saat istirahat). hasil uji statistik paired t test pada kelompok senam aerobik dengan nilai p=0,008 yang berarti bahwa terdapat perbedaan nadi istirahat sebelum dan sesudah dilakukan perlakuan. hasil uji statistik paired t test pada kelompok senam yoga dengan nilai p=0,131 yang berarti bahwa tidak ada perbedaan sebelum dan sesudah perlakuan. pada kelompok kontrol didapatkan perbedaan nadi istirahat sebelum dan sesudah dengan nilai p=0,022. hasil uji statistik anova diperoleh hasil p=0,438 (untuk pre test) dan p=0,388 (untuk post test) berarti tidak ada perbedaan antara kelompok senam aerobik dan kelompok senam yoga terhadap nadi istirahat sehingga hipotesis ditolak. hasil uji statistik paired t test pada kelompok senam aerobik dengan nilai p=0,047, yang berarti bahwa terdapat perbedaan tekanan sistolik sebelum dan sesudah dilakukan perlakuan. hasil uji statistik paired t test pada kelompok senam yoga dengan nilai p=0,93 yang berarti bahwa tidak ada perbedaan tekanan sistolik sebelum dan sesudah dilakukan perlakuan. pada kelompok kontrol dengan nilai p= 0,094. hasil uji statistik anova diperoleh hasil p=0,511 (untuk pre test) dan p=0,520 (untuk post test) berarti tidak ada perbedaan antara kelompok senam aerobik dan kelompok senam yoga terhadap tekanan darah sehingga hipotesis ditolak. berdasarkan uji statistik paired t test pada kelompok senam aerobik dengan nilai p=0,03 yang berarti terdapat perbedaan sebelum dan sesudah dilakukan perlakuan. berdasarkan uji statistik paired t test pada kelompok senam yoga dengan nilai p=0,103 yang berarti tidak terdapat perbedaan sebelum dan sesudah perlakuan. pada kelompok kontrol dengan nilai p=0,078. hasil uji statistik anova diperoleh hasil p=0,357 (untuk pre test) dan p=0,131 (untuk post test) berarti tidak ada perbedaan antara kelompok senam aerobik dan kelompok senam yoga terhadap tekanan darah sehingga hipotesis ditolak. hasil uji statistik paired t test pada kelompok senam aerobik dengan nilai p=0,01, yang berarti bahwa terdapat perbedaan yang signifikan sebelum dan sesudah dilakukan perlakuan. berdasarkan uji statistik paired t test pada kelompok senam yoga dengan nilai p=1,000 yang berarti bahwa tidak terdapat perbedaan sebelum dan sesudah dilakukan perlakuan. pada kelompok kontrol dengan nilai p=0,818. hasil uji statistik anova diperoleh hasil p=0,507 (untuk pre test) dan p=0,432 (untuk post test) berarti tidak ada perbedaan antara kelompok senam aerobik dan kelompok senam yoga terhadap frekuensi nafas sehingga hipotesis ditolak. pembahasan nadi istirahat responden setelah diberikan senam aerobik berkisar 57-72 kali/menit, pada responden yang diberikan perlakuan senam yoga berkisar 62-73 kali/menit sedangkan pada kelompok kontrol berkisar 60-79 kali/menit. denyut nadi adalah irama yang ritmik pada pembuluh darah arteri karena adanya tekanan oleh darah yang sedang dipompakan oleh jantung. secara teori dikatakan bahwa denyut nadi normal berkisar antara 60-100 kali/menit (potter&perry, 2005). denyut nadi istirahat normal pada orang dewasa berkisar antara 60-80 kali/menit (brunner&suddarth, 2001). faktor-faktor yang mempengaruhi denyut nadi adalah usia, posisi pengukuran, stres, nyeri, jenis kelamin dan aktifitas fisik. olahraga merupakan salah satu jenis aktifitas fisik. salah satu masalah kesehatan pada pekerja wanita adalah terlalu jurnal ners vol.4 no.1 april 2009: 43-49 46 banyak bekerja, aktivitas fisik seperti olahraga jarang dilakukan sehingga dapat menimbulkan hipertensi dan penyakit jantung. nadi istirahat adalah parameter kardiovaskuler yang paling sederhana. mengukur nadi istirahat pada wanita dapat membantu memprediski risiko kematian karena penyakit jantung (cook, 2006). gerakan dari senam aerobik yang cenderung sporadis, cepat dan memberikan penekanan pada jantung. senam aerobik akan meningkatkan tonus maupun kontraksi otot. kebutuhan oksigen maupun sumber energi juga akan meningkat sesuai kebutuhan kalori untuk kerja yang dilakukan. akibatnya, kerja jantung, sirkulasi maupun sistem pernafasan akan meningkat sesuai dengan kebutuhan. apabila aktivitas otot atau olahraga, termasuk disini adalah senam aerobik dilakukan terus menerus, teratur dan terukur maka organel yang ada didalam otot mioglobin maupun sistem enzim untuk penyediaan energi dan sistem transport oksigen intraseluler akan meningkat. keadaan inilah yang menyebabkan kinerja sistem kardiovaskuler orang terlatih lebih efisien dan efektif. akibatnya frekuensi denyut jantung istirahat orang terlatih akan lebih rendah (williford, 1989; engels, 1998; de angelis, 1998; laukkanen, 2001; wardani, 2008). pada kelompok yang mendapat perlakuan senam yoga tidak ditemukan perbedaan nadi istirahat sebelum dan sesudah perlakuan secara signifikan. hal ini berbeda dengan penelitian sebelumnya yang dilakukan oleh marniyah (2005), fakultas keperawatan universitas airlangga dan penelitian dari bhutkar dkk (2008) department of physiology, mahadewavappa rampure medical college, india yang membuktikan senam yoga dapat menurunkan nadi istirahat. ketidaksesuaian hasil pada penelitian kali ini dapat disebabkan oleh beberapa hal. pertama, salah satu responden mengalami penurunan nadi sebanyak 8 kali/menit, nilai tersebut sangat signifikan dibandingkan dengan penurunan pada responden yang lainnya. penurunan yang sangat signifikan dapat mempengaruhi penghitungan. penurunan tersebut menurut peneliti disebabkan saat pengukuran awal (pre test) terdapat variabel perancu yang tidak dikaji dan dikendalikan oleh peneliti misalnya faktor stres, aktivitas fisik selain senam, nyeri, dan emosi. kedua, gerakan yoga cenderung pelan, sedikit penekanan pada jantung sehingga kerja jantung kurang optimal dibandingkan senam aerobik. ketiga, senam yoga dilakukan dengan kesadaran penuh nafas dan membutuhkan kesabaran. motivasi dan keseriusan reponden itu sendiri sangat berpengaruh terhadap hasil penelitian. kenyataan dilapangan, ada beberapa responden yang mengikuti gerakan yoga namun tidak mengikuti pengarahan dari instruktur tentang pengaturan nafas yang benar, padahal penelitian yang dilakukan oleh jerath r dkk (2006), united states, membuktikan bahwa pengaturan nafas pada senam yoga dapat menurunkan konsumsi oksigen, menurunkan tekanan darah dan menurunkan denyut jantung melalui interaksi dengan sistem saraf pusat. pada kelompok kontrol yaitu kelompok yang tidak mendapat perlakuan terdapat 6 responden yang mengalami peningkatan nadi istirahat dan hanya 1 responden yang mengalami penurunan nadi istirahat. olahraga mengurangi denyut jantung waktu istirahat dan meningkatkan stroke volume yaitu jumlah darah yang dipompa pada setiap denyut jantung (sharkey, 2003). sehingga pada kelompok yang tidak mendapat perlakuan seharusnya tidak ada perbedaan antara pre dan post test. menurut peneliti, hal ini disebabkan oleh faktor-faktor yang mempengaruhi nadi istirahat misalnya stres, aktivitas fisik, nyeri dan emosi sebelum dilakukan pengukuran yang tidak dikendalikan dalam penelitian. hal ini dapat dilihat dari hasil observasi yang dilakukan dilakukan peneliti terdapat beberapa responden pada kelompok kontrol yang tiap minggunya didapatkan peningkatan nadi istirahat yang bervariasi. stres merangsang saraf simpatis mengeluarkan katekolamin, mobilisasi meningkat, beban jantung bertambah berat sehingga nadi meningkat. nyeri, pada saat impuls nyeri naik ke medulla spinalis menuju ke batang otak dan talamus, sistem saraf otonom menjadi terstimulasi sebagai bagian dari respon. stimulasi pada cabang simpatis pada sistem saraf otonom menghasilkan respon fisiologis salah satunya adalah peningkatan frekuensi denyut jantung (potter&perry, 2006). emosi dapat pengaktifan bagian simpatis sistem saraf otonom, sistem simpatis mendorong seseorang untuk mengeluarkan energi dan menyebabkan menurunnya sistem esti y efektivitas senam aerobik dan yoga (esty yunitasari) 47 parasimpatis yang mengakibatkan nadi meningkat. aktivitas fisik ringan seperti mencuci, menyapu yang dilakukan responden sebelum pengukuran dapat meningkatkan nadi istirahat. rerata tekanan sistolik dan diastolik responden setelah senam aerobik adalah 100 mmhg dan 63 mmhg. pada responden yang diberikan perlakuan senam yoga adalah 103 mmhg dan 66 mmhg. sedangkan pada kelompok kontrol yaitu 106 mmhg dan 70 mmhg. tekanan darah merupakan kekuatan lateral pada dinding arteri oleh darah yang didorong dengan tekanan dari jantung. tekanan sistemik atau arteri darah, tekanan darah dalam sistem arteri tubuh, adalah indikator yang baik tentang kesehatan kardiovaskuler (potter&perry, 2005). tekanan sistolik adalah tekanan tekanan pada dinding pembuluh darah pada waktu jantung memompakan darah keseluruh tubuh dan tekanan diastolik adalah tekanan pada dinding pembuluh darah dari seluruh tubuh kembali ke jantung. tekanan darah normal menurut national high blood pressure education program (1993) adalah <130/<85 (potter&perry, 2005). olahraga dapat meningkatkan kerja jantung dan pembuluh darah. respon fisiologis terhadap olahraga adalah meningkatnya curah jantung yang akan disertai meningkatnya distribusi oksigen ke bagian tubuh yang membutuhkan. hal ini juga direspon pembuluh darah dengan melebarkan diameter pembuluh darah (vasodilatasi) sehingga akan berdampak pada tekanan darah individu tersebut. pada kelompok senam aerobik didapatkan perbedaan tekanan sistolik dan diastolik setelah dilakukan perlakuan. hal ini disebabkan karena aktifitas fisik yang teratur mampu meningkatkan kemampuan sistem kardiovaskuler, meningkatkan curah jantung, menurunkan frekuensi denyut nadi dan tekanan darah sehingga meningkatkan efisiensi jantung. senam yoga merupakan salah satu bentuk olahraga. namun sebelum dan setelah dilakukan perlakuan tidak terdapat perbedaan tekanan darah yang signifikan terhadap sistolik dan diastoliknya. hal ini tidak sesuai dengan penelitian sebelumnya yang dilakukan oleh marniyah (2005). ketidaksesuaian hasil pada penelitian kali ini dapat disebabkan oleh beberapa hal. salah satunya menurut peneliti adalah gerakan yoga yang cenderung pelan mengakibatkan sedikit penekanan di jantung sehingga kerja jantung kurang maksimal. selain itu hasil observasi pada minggu pertama menunjukkan hasil yang bervariasi. pada minggu pertama sebanyak 5 responden mengalami penurunan pada sistoliknya dan 3 responden yang mengalami penurunan pada diastoliknya. penurunan tekanan darah dapat terjadi karena terganggunya kemampuan sistem jantung dan sirkulasi mempertahankan tekanan darah yang normal yang dapat disebabkan oleh volume darah berkurang oleh karena haid atau diare. frekuensi nafas responden setelah diberikan senam aerobik berkisar 14-18 kali/menit, pada responden yang diberikan perlakuan senam yoga berkisar 15-21 kali/menit sedangkan pada kelompok kontrol berkisar 15-20 kali/menit. pernafasan adalah mekanisme tubuh menggunakan pertukaran udara antara atmosir dengan darah serta darah dengan sel. pernafasan termasuk ventilasi (pergerakan udara masuk dan keluar dari paru), difusi (pergerakan oksigen dan karbondioksida antara alveoli dan sel darah merah), dan perfusi (distribusi sel darah merah ke dan dari kapiler paru). frekuensi, kedalaman dan irama gerakan ventilasi menandakan kualitas dan efisiensi ventilasi. ventilasi diatur oleh kadar co2, o2 dan konsentrasi ion hidrogen (ph) dalam darah arteri (potter&perry, 2005). frekuensi ventilasi dan pernafasan dihitung dengan mengobservasi inspirasi dan ekspirasi penuh. frekuensi pernafasan bervariasi sesuai dengan usia. frekuensi pernafasan rata-rata normal menurut usia yaitu pada orang dewasa adalah 12-20 kali/menit (potter&perry, 2005). faktor-faktor yang mempengaruhi pernafasan adalah usia, kecemasan, merokok, anemia, aktifitas fisik, dll. pada kelompok yang mendapatkan perlakuan senam aerobik, peneliti menemukan adanya perbedaan frekuensi nafas sebelum dan sesudah perlakuan secara signifikan. saat melakukan senam aerobik, otot membutuhkan oksigen untuk bekerja secara efisien. ketika beban kerja otot meningkat, tubuh menanggapi dengan meningkatkan jumlah oksigen yang dikirim ke otot dan jantung, sebagai akibatnya denyut jantung dan frekuensi nafas meningkat sampai memenuhi kebutuhannya (brick, 2002). senam aerobik yang teratur dapat meningkatkan vo2 max dengan membuat jantung dan sistem pernapasan lebih efisien jurnal ners vol.4 no.1 april 2009: 43-49 48 sehingga penyaluran o2 ke otot yang aktif lebih banyak (sherwood, 2001). pada kelompok yang mendapat perlakuan senam yoga tidak ditemukan perbedaan frekuensi nafas secara signifikan. hal ini tidak sesuai dengan literatur yang menyatakan bahwa teknik bernapas dalam senam yoga dapat meningkatkan kapasitas paru-paru sehingga proses bernapas menjadi lebih optimal (sindhu, 2007), selain itu literatur lain menyatakan bahwa gerak badan dapat meningkatkan kemampuan sistem pernafasan yaitu kapasitas vital paru-paru dan ventilasi seperti efisiensi pertukaran gas yang terjadi di paru-paru (hardjana, 2000). ketidaksesuaian hasil pada penelitian dapat disebabkan oleh beberapa hal. misalnya keseriusan responden, ada beberapa responden yang tidak mengikuti pengarahan dari instruktur tentang pengaturan nafas yang benar. hal ini dapat dilihat sebanyak 3 reponden tidak mengalami perubahan frekuensi nafas setelah dilakukan intervensi. dua responden mengalami peningkatan frekunesi nafas. faktor yang mempengaruhi pernafasan yang tidak dikendalikan dalam penelitian ini misalnya kecemasan, anemia, kontrol volunter dan aktifitas fisik. kecemasan meningkatkan frekuensi dan kedalaman nafas sebagai akibat stimulasi simpatik. pada anemia, penurunan kadar hemoglobin menurunkan jumlah pembawa oksigen dalam darah sehingga individu bernafas dengan lebih cepat untuk meningkatkan penghantaran oksigen (potter&perry, 1999). manusia juga memiliki kontrol volunter yang cukup besar terhadap ventilasi. kontrol bernapas secara volunter dilakukan oleh korteks serebrum, yang tidak bekerja pada pusat pernapasan di otak, tetapi melalui impuls yang dikirim secara langsung ke neuronneuron motorik di korda spinalis yang mempersarafi otot pernapasan. seseorang dapat secara sengaja melakukan hiperventilasi atau pada keadaan ekstrim yang lain, menahan napas, tetapi hanya untuk jangka waktu yang singkat. sesorang juga mengontrol pernapasan untuk melakukan berbagai tindakan volunter misalnya berbicara (sherwood, 2001). aktifitas fisik yang berlebihan dapat mengakibatkan kelelahan yang dapat meningkatan frekuensi nafas. hasil uji anova menunjukkan tidak terdapat perbedaan secara signifikan terhadap nadi istirahat, tekanan darah dan frekuensi nafas antara senam aerobik dan senam yoga. senam aerobik memiliki gerakan yang sporadis dan memberikan penekanan pada jantung tanpa ada untuk memperhatikan nafas (brick, 2002). senam yoga memiliki gerakan yang pelan, dilakukan dengan kesadaran penuh nafas dan tidak memberikan penekanan berlebihan pada jantung (ida, 2008). senam aerobik dan senam yoga meskipun termasuk olahraga aerobik namun gerakannya cenderung berbeda. menurut peneliti, dari pernyataan diatas seharusnya terdapat perbedaan antar senam aerobik dan senam yoga. ketidaksesuaian hasil dapat disebabkan, waktu perlakuan (durasi dan frekuensi) kurang lama sehingga kurang memberikan efek terhadap kerja kardiorespirasi. dan variabel perancu yang tidak dikendalikan oleh peneliti. simpulan dan saran simpulan senam aerobik dan senam yoga efektif dalam meningkatkan daya tahan kardiorespirasi meliputi nadi istirahat, tekanan darah dan frekuensi nafas. kedua jenis senam tersebut (senam aerobik dan yoga) dapat meningkatkan daya tahan tubuh. saran penulis menyarankan: 1) pekerja wanita di cv mulya abadi disarankan meluangkan waktunya untuk melakukan senam aerobik atau senam yoga minimal 3 kali dalam seminggu dan maksimal 5 kali seminggu selama ± 30 menit. senam yang dilakukan lebih dari 5 kali seminggu akan mengakibatkan stres fisik dan psikis, 2) kepada pihak cv mulya abadi diharapkan ada perawat keselamatan dan kesehatan kerja (k3) yang nantinya dapat mempengaruhi pekerja wanita untuk menjadi lebih aktif dan membantu mereka mengembangkan suatu program olahraga seperti senam aerobik atau senam yoga untuk meningkatan daya tahan kardiorespirasi, 3) pada penelitian selanjutnya diharapkan variabel perancu dapat dikendalikan sehingga dapat hasil penelitian lebih sempurna, 4) olahraga senam aerobik atau senam yoga dapat dijadikan program rutin cv.mulya abadi untuk meningkatkan daya esti y efektivitas senam aerobik dan yoga (esty yunitasari) 49 tahan kardiorespirasi dan kesehatan para pekerja wanita. kepustakaan acsm, 2004. panduan uji latihan jasmani dan peresepannya. edisi 5. jakarta: penerbit buku kedokteran egc. hlm. 54-55, 145-148. brick, l., 2002. bugar dengan senam aerobik. jakarta: pt raja grafindo persada. hlm. 4-6, 28-29, 45-47, 51-55. depkes, 2009. kesehatan bagi pekerja wanita, (online), (http/ www.depkes.go.id, diakses tanggal 10 agustus 2009, jam 08.00 wib). dwpp., 2008. olahraga atasi keropos tulang, (online), (dwp.kbri-islamabad.go.id, diakses tanggal 6 juni 2009, jam 20.00 wib). gilang, 2002. hindari terkena ptm, dengan aktivitas fisik yang optimal, (online), (http/www. pdpersi.co.id, (diakses tanggal 29 april 2009, jam 20.00 wib). ida, 2008. yoga dan kesehatan, (online),( http://www. robida.multiply.com, diakses tanggal 6 juni 2009, jam 19.00 wib). jerath, r; edry, j.w; barnes, v.a; jerath, v., 2006. physiology of long pranayamic breathing: neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system, (online), (http://intl.elsevierhealth.com/journals/m ehy, diakses tanggal 6 juni 2009, jam 19.00 wib). potter&perry, 2005. buku ajar fundamental keperawatan, konsep, proses dan praktik edisi 4. jakarta: buku penerbit kedokteran egc, hlm. 781, 789-798. rai, 2009. sibuk bukan alasan tidak berolahraga, (online), (http://www.analisadaily.com, diakses tanggal 8 juni 2009, jam 21.00 wib). sharkey, b., 2003. kebugaran & kesehatan edisi 1. jakarta: pt raja grafindo persada, hlm. 80-85, 94-102. sherwood, l., 2001. fisiologi manusia dari sel ke sistem edisi 2. jakarta: penerbit buku kedokteran egc, hlm. 303, 325326. situmeang, t., 2005. olahraga penting bagi penderita sakit paru, (online), (http:// cybermed.cbn.net.id, diakses tanggal 21 mei 2009, jam 22.00 wib). sindhu, p. 2007. hidup sehat dan seimbang dengan yoga. jakarta: pt mizan pustaka. hlm. 53-157. http://www.depkes.go.id/ http://www.analisadaily.com/ hubungan faktor risiko asma dan perilaku pencegahan 9 faktor risiko asma dan perilaku pencegahan berhubungan dengan tingkat kontrol penyakit asma (asthma risk factors and prevention behaviour relate to asthma level of control) nursalam*, laily hidayati*, ni putu wulan purnama sari* abstract introduction : asthma’s symptoms are commonly persistent in each asthmatic client, but they could be controlled. this control directly refers to asthma level of control. it could be affected by asthma risk factors and preventive behavior to exposures, but the correlation between them is still unclear because the development of asthma is not fully understood and very complex. the objective of this study was to explain the correlation between asthma risk factors and preventive behavior to exposures to asthma level of control. method : this study used cross-sectional design and involved 41 respondents which are taken by simple random sampling. data were collected using questionnaires and then analyzed by using spearman rho correlation with level of significance ≤0.05. result : result showed that asthma risk factors had correlation with asthma level of control (p=0,032), but preventive behavior to exposures had no correlation with asthma level of control (p=0,095). analysis : it can be concluded that asthma level of control has correlation with asthma risk factors. preventive behavior has no correlation with asthma level of control could be caused by the differences between the respondents preventive behavior and the recommended one. discussion : it indicates possible errors or unsuitability in preventive behavior to asthma risk factor exposures. however, preventive behavior to asthma risk factors exposures is still necessary in order to decrease asthma symptoms. keywords: asthma risk factors, preventive behavior, asthma level of control. *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: nursalam_psik@yahoo.com pendahuluan asma merupakan penyakit paru obstruktif kronis yang sering diderita oleh anak-anak, orang dewasa, maupun para lanjut usia. penyakit ini memiliki karakteristik serangan periodik yang stabil (sykes, et al, 2008). terapi farmakologis yang ada selama ini efektif untuk mengatasi serangan asma, namun kurang efektif untuk mengontrol perkembangan asma. hal ini dibuktikan dengan jumlah penderita asma yang semakin meningkat dewasa ini, di saat kemajuan dalam bidang pengobatan asma telah dicapai (arief, 2009). asma tidak bisa disembuhkan, namun manifestasi klinis dari asma bisa dikendalikan (gina, 2008). mengingat terapi farmakologis tidak dirancang untuk menyembuhkan asma, maka perilaku pencegahan terhadap paparan faktor risiko asma lebih diutamakan dari pengobatan. intervensi awal untuk menghentikan atau mengurangi paparan terhadap faktor risiko asma yang menyebabkan hipereaktivitas saluran nafas dapat membantu meningkatkan kontrol penderita terhadap penyakit asma (gina, 2008). hubungan antara faktor risiko asma dan perilaku pencegahan tentang paparan dengan tingkat kontrol penyakit pada penderita asma masih belum jelas, mengingat perkembangan penyakit ini sangat kompleks dan belum sepenuhnya dimengerti. world health report di tahun 2000 menunjukkan asma menduduki peringkat ke-5 sebagai penyakit paru utama yang menyebabkan kematian di dunia. saat itu penderita asma di dunia mencapai 100-150 juta orang, dan terus bertambah sekitar 180 ribu orang pertahun (who, 2000). jumlah terkini di tahun 2008 mencapai 300 juta orang (gina, 2008). asma mencapai perkembangan hingga dua kali lipat dari jumlah awal dalam 8 tahun terakhir. prevalensi asma di indonesia sendiri berkisar antara 5-7% (suyono, 2001). asma juga terbukti menurunkan kualitas hidup penderita. riset terhadap 3207 kasus asma menunjukkan 44-51% penderita mengalami batuk malam dalam sebulan terakhir, bahkan jurnal ners vol.4 no.1 april 2009: 9-18 10 28,3% penderita mengaku mengalami gangguan tidur paling tidak sekali dalam seminggu. penderita yang mengaku mengalami keterbatasan dalam berekreasi atau berolahraga sebanyak 52,7%, aktivitas sosial 38%, aktivitas fisik 44,1%, cara hidup 37,1%, pemilihan karier 37,9%, dan pekerjaan rumah tangga 32,6%. absen dari sekolah maupun pekerjaan dalam setahun terakhir dialami oleh 36,5% anak dan 26,5% orang dewasa (journal of allergy and clinical immunology, 2003 ; dikutip oleh arief, 2009). faktor risiko asma dapat dibagi menjadi 3 domain besar, yaitu alergen, iritan, dan hal-hal lain yang tidak tergolong dalam alergen maupun iritan (state of the region’s health, 2002). faktor risiko asma yang mempengaruhi perkembangan dan ekspresi asma terdiri dari faktor internal (host factor) dan faktor eksternal (environmental factor). faktor internal terdiri dari genetik, obesitas, jenis kelamin, usia, aktivitas fisik, dan ekspresi emosi yang kuat atau berlebihan. sedangkan faktor eksternal meliputi occupational irritant, infeksi virus di saluran nafas, alergen, asap rokok, polusi udara, obat-obatan, dan perubahan suhu terkait perubahan musim atau kondisi geografis lainnya (suyono, 2001 ; gina, 2008). faktor eksternal menjadi berperan dominan sejalan dengan perkembangan ilmu pengetahuan dan teknologi. banyak penelitian telah membuktikan hal ini. riset di kanada menunjukkan bahwa infeksi virus, olahraga, asap rokok, debu, dan serbuk sari bunga menempati lima peringkat teratas sebagai penyebab asma terbanyak di semua golongan usia (state of region’s health, 2002). di lingkungan kerja, dimana asma meliputi asma kerja (occupational asthma) dan asma diperberat di tempat kerja (work-aggravated asthma), occupational irritant yang paling sering menginduksi asma tersebut adalah isosianat (dari cat semprot) sehingga disebut isocyanate-induced asthma (wahyuningsih, et al, 2003). selain itu, riset di london menunjukkan bahwa berjalan selama 2 jam di sepanjang jalan yang padat kendaraan bermesin diesel mempengaruhi efek fungsional dan reaksi inflamasi pada orang dewasa dengan asma (kaufman, 2007). di wilayah kerja puskesmas selat kabupaten karangasem bali, asma termasuk dalam 5 besar penyakit dengan angka kunjungan tertinggi di awal tahun 2009. penduduk setempat melaporkan bahwa faktor yang paling sering menginduksi asma adalah polusi udara terkait daerah pertambangan dan perubahan suhu terkait kondisi geografis wilayah yang ada di daerah dataran tinggi. peningkatan intensitas paparan faktor risiko asma akan menyebabkan ekspresi asma lebih sering muncul. hal ini menunjukkan kontrol penderita yang rendah terhadap penyakit asma, dan secara tidak langsung menunjukkan kegagalan terapi asma, sehingga perlu peninjauan kembali. perilaku pencegahan terhadap paparan faktor risiko asma yang dilakukan terus-menerus, seperti memakai alat pelindung diri saat bekerja, akan sangat membantu penderita asma untuk meningkatkan kontrol terhadap penyakit asma. semakin baik kontrol penderita terhadap asma, terapi farmakologis dapat diminimalkan sehingga sangat berguna dalam menghindari efek samping obat-obat anti asma. hubungan antara faktor risiko asma dan perilaku pencegahan tentang paparan dengan tingkat kontrol penyakit pada penderita asma perlu diteliti lebih lanjut. dengan ini diharapkan tingkat kontrol penyakit yang maksimal atau controlled asthma semakin mudah dicapai oleh penderita asma, sehingga kualitas hidup para penderita asma akan meningkat. bahan dan metode penelitian penelitian ini menggunakan crosssectional design dan simple random sampling. besar populasi 54 orang penderita asma di wilayah kerja puskesmas selat berdasarkan laporan bulan april 2009. sampel yang memenuhi kiteria inklusi dan eksklusi sebanyak 41 orang. penelitian ini dilaksanakan pada tanggal 17-22 juni 2009. variabel independen dalam penelitian ini adalah faktor risiko asma dan perilaku pencegahan tentang paparan, sedangkan variabel dependen adalah tingkat kontrol penyakit pada penderita asma. instrumen pengumpulan kedua jenis variabel tersebut adalah kuesioner. data yang diperoleh dianalisis dengan menggunakan uji statistik korelasi spearman rho dengan tingkat signifikansi α≤0,05. hasil penelitian faktor resiko asma dan perilaku pencegahan (nursalam) 11 hasil uji statistik dengan korelasi spearman rho menunjukkan ada hubungan antara faktor resiko asma dengan tingkat kontrol penyakit pada penderita asma yang dibuktikan dengan r=0,336 dan p=0,032 (tabel 1). uji korelasi spearman rho menunjukkan tidak ada hubungan antara perilaku pencegahan tentang paparan faktor risiko asma dengan tingkat kontrol penyakit pada penderita asma (r=0,264 dan p=0,095) yang berarti korelasi tidak bermakna (tabel 2). tabel 1. hubungan faktor resiko asma dengan tingkat kontrol penyakit asma faktor risiko asma tingkat kontrol penyakit asma mean = 12,58 mean = 2,51 sd = 4,18 sd = 0,64 r= 0,336 dan p=0,032 tabel 2. hubungan perilaku pencegahan dengan tingkat kontrol penyakit asma perilaku pencegahan tingkat kontrol penyakit asma mean = 7,95 mean – 2,51 sd = 2,16 sd = 0,64 r= 0,264 dan p=0,095 keterangan: mean = rerata sd = standar deviasi r = koefisien korelasi p = signifikansi pembahasan berdasarkan hasil penelitian di lapangan, faktor risiko asma yang sering menyebabkan kemunculan gejala asma menurut intensitasnya terdiri dari perubahan suhu terkait kondisi geografis, alergen, aktivitas fisik, asap rokok, ekspresi emosi yang berlebihan, dan polusi udara. faktor risiko yang tersering menyebabkan kemunculan gejala asma dalam setahun terakhir adalah perubahan suhu terkait kondisi geografis (27,90%). penderita asma mayoritas memilih faktor risiko ini, yaitu sebanyak 37 orang (90,24%). ini merupakan faktor risiko asma yang terbukti dominan menginduksi kemunculan gejala asma. menurut data statistik tahun 2007 dari bps kabupaten karangasem, wilayah kecamatan selat memiliki ketinggian 544 meter dari permukaan laut, dengan suhu maksimum 240c, penyinaran matahari rata-rata 68,75%, dan kelembaban udara rata-rata 86,75%. volume curah hujan adalah 1.165 mm/tahun dan jumlah hari dengan curah hujan terbanyak adalah 40 hari. bentuk wilayah datar hingga berombak sebanyak 49,8%, berombak hingga berbukit 20%, dan berbukit hingga bergunung 30,2%. mata pencaharian penduduk sebagian besar adalah petani dengan tanah sawah seluas 856,370 hektar, dan perkebunan seluas 328 hektar (bps, 2007). tingkat kelembaban yang tinggi dan penyinaran matahari yang cukup membuat wilayah selat cukup panas di siang hari, namun suhu udara turun drastis pada malam hingga pagi hari. kondisi geografis suatu wilayah yang berakibat pada perubahan cuaca maupun iklim yang menyebabkan perubahan suhu setempat menjadi ekstrim dapat memperburuk kondisi tubuh penderita asma. udara dingin dan kering merupakan iritan yang sangat poten bagi penderita asma. perubahan cuaca yang mungkin menjadi iritan seperti cuaca yang panas dan lembab, sangat dingin, perubahan suhu/kelembaban/tekanan udara yang tiba-tiba, angin kencang, badai bergemuruh, cuaca yang ekstrim, dan lain-lain (macnaughton, 2008). data di atas menunjukkan bahwa wilayah selat cenderung bersuhu rendah dengan kelembaban udara yang tinggi, yang mengakibatkan udara di wilayah selat menjadi dingin dan kering. penderita asma yang sudah lama bertempat tinggal di wilayah ini ternyata tetap tidak mampu mentolerir keadaan tersebut. iritan di saluran pernafasan seperti udara dingin dan kering dirasakan sangat cepat menginduksi penyempitan jalan nafas, akibat saluran nafas yang sangat sensitif pada penderita asma (macnaughton, 2008). penderita asma yang bekerja sebagai petani perkebunan (19,51%) yang mayoritas bertempat tinggal di dalam wilayah perkebunan tentu saja merasakan perubahan suhu yang lebih ekstrim dibanding penderita asma yang bertempat tinggal jauh dari area perkebunan. selain itu, tindakan pencegahan terhadap udara dingin dan kering juga berpengaruh terhadap kondisi tubuh penderita asma. tindakan seperti memakai pakaian yang tebal kurang efektif pada keadaan ini, karena yang terlindungi adalah tubuh, bukan jalan nafas padahal bagi orang asma yang membutuhkan perlindungan adalah jalan nafas, seperti rongga hidung dan rongga mulut jurnal ners vol.4 no.1 april 2009: 9-18 12 (gina, 2008). maka, tindakan pencegahan yang mereka lakukan tidak efektif untuk mengurangi frekuensi maupun intensitas kemunculan gejala asma akibat perubahan suhu yang mereka rasakan. faktor risiko asma terbanyak kedua adalah alergen (24,80%). pada penelitian ini, penderita asma yang memilih alergen sebagai penyebab kemunculan gejala asma dalam setahun terakhir sebanyak 30 orang (73,17%) dengan rincian alergi makanan sebanyak 30 orang (100%), alergi bahan bakar memasak sebanyak 29 orang (96,67%), alergi hewan peliharaan sebanyak 18 orang (60 %), dan alergi jamur atau lumut sebanyak 6 orang (20%). asma yang saat ini dipandang sebagai penyakit inflamasi jalan nafas memang tidak bisa lepas dari pengaruh alergen (suyono, 2001). alergen spesifik sifatnya sangat subyektif, tergantung kepekaan masing-masing penderita asma. paparan berulang terhadap suatu jenis alergen spesifik akan menyebabkan reaksi alergi langsung, seperti reaksi hipersensitivitas tipe i pada asma (aafa, 2008). penyakit alergi tidak bisa disembuhkan, satu-satunya cara adalah dengan menghindari paparan terhadap alergen spesifik, yang sumber terbesarnya adalah dari lingkungan (arruda, 2006). alergen spesifik dapat berupa makanan, minuman, bagian tubuh hewan atau tumbuhan, dan lain-lain. dalam kehidupan sehari-hari, penderita asma tidak dapat bebas sepenuhnya dari alergen spesifik ini. alergen makanan seperti sayuran hijau dan buah segar misalnya, penderita asma memiliki kecenderungan untuk tetap mengkonsumsi makanan tersebut walaupun frekuensinya dikurangi, dengan berbagai alasan. salah satunya adalah karena tersedianya obat-obatan jenis reliever di rumah. hal ini sangat mengkhawatirkan, karena efek samping obat anti asma juga berbahaya (gina, 2008). walau demikian, penderita asma lebih memilih rajin mengkonsumsi obat-obatan dibandingkan menghindari paparan terhadap alergen spesifik. maka dari itu, manifestasi klinis asma juga tidak dapat dihindari. penyebab kemunculan gejala asma terbanyak ketiga adalah aktivitas fisik (17,82%). penderita asma yang memilih faktor risiko ini sebanyak 24 orang (58,54%) dengan rincian olahraga (100%) dan kerja berat (100%). aktivitas fisik yang sering menyebabkan kemunculan gejala asma adalah olahraga dan melakukan pekerjaan berat, sehingga penderita asma tidak mampu mentolerir rasa lelah yang dirasakan (aafa, 2008). bila tubuh lelah akibat aktivitas fisik yang dilakukan, maka tubuh akan mengkompensasi dengan bernafas lebih cepat, dengan tujuan memperoleh oksigen yang lebih banyak untuk kepentingan metabolisme (canadian lung association, 2008). gejala asma akibat aktivitas fisik juga akan semakin parah dengan tambahan iritan dari faktor risiko asma lainnya, seperti udara dingin (macnaughton, 2008). hal ini terbukti di lapangan. penderita asma yang memilih faktor risiko aktivitas fisik juga memilih faktor risiko perubahan suhu akibat kondisi geografis, yaitu sebanyak 21 orang (51,22%). aktivitas fisik tidak mampu dihindari oleh penderita asma di wilayah selat. hal ini disebabkan oleh profesi mereka, yaitu 24,39% sebagai petani dan 19,51% sebagai wirausahawan. mereka sering harus melakukan aktivitas fisik yang berat dan dalam waktu yang lama. pada wirausahawan misalnya, pesanan yang menumpuk juga menjadi beban karena harus segera dikerjakan. petani perkebunan juga bukan pekerjaan mudah, karena mereka mengejar target panen yang sudah ditetapkan oleh pemilik perkebunan. penderita asma yang tidak tahan lelah akan sangat cepat menunjukkan tandatanda kekambuhan asma. walau demikian, aktivitas fisik juga tidak dapat dihindari, sehubungan dengan masalah ekonomi. dalam kondisi seperti ini, penderita asma memang harus mampu menyesuaikan diri dengan pekerjaan, sehingga waktu istirahat mereka cukup dan tidak mengorbankan tubuhnya. faktor risiko asma terbanyak keempat adalah asap rokok (17,05%). penderita asma yang memilih faktor risiko ini sebanyak 22 orang (53,66%) dengan rincian perokok aktif 10 orang (45,45%), dan perokok pasif 12 orang (54,54%). asap rokok merupakan partikel yang paling mampu menembus hingga sistem pernafasan paling akhir, yaitu alveolus di antara seluruh partikel yang ada di udara bebas (ricky, 2009). hal ini setara dengan kemampuan difusi virus. asap rokok juga faktor resiko asma dan perilaku pencegahan (nursalam) 13 mampu membuat sel-sel epitel jalan nafas memproduksi mucus lebih banyak. gerakan paru-paru untuk membersihkan diri juga terganggu, sehingga dahak dan iritan lain tidak bisa dikeluarkan. hal ini berarti penderita asma akan lebih mudah terkena penyakit infeksi saluran nafas. gejala asma juga akan muncul akibat infeksi di saluran nafas (green, et al, 2002). merokok dapat menyebabkan penurunan fungsi paru yang cepat, meningkatkan derajat keparahan asma, menjadikan penderita kurang responsif terhadap terapi glukokortikosteroid, dan menurunkan tingkat kontrol penyakit asma (gina, 2008). sebenarnya, kuantitas paparan asap rokok pada penderita asma dapat diketahui dengan mengukur kadar cotinin pada air ludah, sehingga penderita asma bisa lebih waspada (ricky, 2009). paparan terhadap asap rokok sangat mudah dihindari. namun, kenyataannya manifestasi klinis asma juga banyak yang diakibatkan oleh asap rokok, walaupun penderita asma sudah berusaha menghindar. udara sekitar tetap tercemar dengan adanya partikel-partikel asap rokok yang mengandung 4000 senyawa kimia yang berbahaya ini (aafa, 2008). selain itu budaya merokok pada pria juga sulit dihindari, dengan berbagai alasan pribadi. maka dari itu, untuk menciptakan kondisi lingkungan yang bebas asap rokok bukanlah hal yang mudah, walaupun penderita asma tidak merokok. perokok pasif bahkan menghirup bahan kimia yang lebih berbahaya dari perokok itu sendiri, karena sidestream smoke (asap yang berasal dari ujung batang rokok yang terbakar) lebih berbahaya dibandingkan asap yang dihirup oleh perokok. asap rokok sangat cepat memicu serangan asma, dan juga dapat meningkatkan frekuensi terjadinya serangan asma. faktor risiko asma terbanyak kelima yang sering menyebabkan kemunculan gejala asma dalam setahun terakhir adalah ekspresi emosi yang berlebihan (10,08%). penderita asma yang memilih faktor risiko ini sebanyak 13 orang (31,70%). asma dipengaruhi oleh stres psikologis, yang menunjukkan hubungan timbal balik antara faktor periferal yang meregulasi reaksi inflamasi dan respon saraf pusat terkait stress dan reaktivitas emosi (rosenkranz, et al, 2005). emosi dan perasaan seperti khawatir, cemas, takut, dan panik, dapat menyebabkan ketegangan muskuler dan kontraksi di sekitar bronkiolus, sehingga bronkiolus menjadi lemah dan kejang (silva, 2006). ekspresi emosi yang ekstrim dapat menyebabkan hiperventilasi dan hipokapnia, yang menyebabkan penyempitan jalan nafas (gina, 2008). penderita asma dengan stress kerja yang tinggi biasanya memiliki banyak beban pikiran, yang terkadang tidak bisa dilimpahkan pada orang lain. hal ini membuat manifestasi klinis asma sering muncul akibat stress. selain karena pekerjaan, umur juga berpengaruh. pada lansia, kecenderungan untuk tidak diperhatikan oleh sekitarnya, termasuk keluarganya, sangat besar. hal ini menimbulkan suatu kondisi seperti depresi, kesepian, merasa tidak dicintai, sedih, dan lainlain (silva, 2006). di saat seperti ini, gejala asma sering muncul. maka dari itu, penderita asma sebaiknya mampu mengendalikan pikiran dan perasaannya. keluarga juga diharapkan mampu mengkondisikan lingkungannya agar ekspresi asma tidak muncul akibat emosi yang dirasakan oleh penderita asma. faktor risiko terbanyak keenam adalah polusi udara (2,32%). penderita asma yang memilih faktor risiko ini sebanyak 3 orang (7,32%). berdasarkan data statistik di tahun 2007 dari bps kabupaten karangasem, kelurahan duda utara dan kelurahan muncan merupakan 2 kelurahan yang memiliki wilayah pertambangan dan penggalian (bps, 2007). kelurahan ini memiliki kadar polutan yang cukup tinggi terkait aktivitas pertambangan dan penggalian tersebut. berdasarkan laporan puskesmas bulan april 2009, penderita asma yang berasal dari 2 kelurahan ini sebanyak 11 orang (26,82%). polusi udara dapat memperburuk gejala asma (aafa, 2008). polusi udara di suatu wilayah berkaitan dengan peningkatan kadar polutan atau alergen spesifik dimana penderita asma tersensitisasi (gina, 2008). gejala asma akan mulai terasa parah bila nilai psi berada di angka 50-100, dengan kata lain tingkat polusinya sedang (arb, 2008). partikel-partikel yang secara normal tidak terdapat dalam udara bebas sangat poten menyebabkan penyempitan jalan nafas, dengan cara kerja seperti alergen bagi penderita asma. cara agar ekspresi asma tidak muncul adalah hanya dengan menghindari paparan polutan ini. namun, bila bertempat tinggal di wilayah jurnal ners vol.4 no.1 april 2009: 9-18 14 yang merupakan kawasan pertambangan dan penggalian, hal ini tentu sulit dilakukan. faktor risiko asma yang tidak pernah menyebabkan kemunculan gejala asma dalam setahun terakhir adalah obat-obatan (0%). walaupun banyak reaksi yang tidak diharapkan dari penggunaan obat-obatan muncul seperti reaksi hipersensitivitas, kejadian seperti ini jarang terjadi. obat yang menginduksi bronkospasme misalnya, jarang terjadi walaupun sangat potensial mengancam nyawa (virchow, 2001). hal ini terbukti di lapangan. obat-obatan reliever dan controller yang digunakan oleh penderita asma dirasakan sangat besar manfaatnya, bahkan banyak di antara mereka yang selalu mengandalkan obatobatan ini untuk mengontrol manifestasi klinis asma. obat-obatan ini tidak menimbulkan reaksi alergi, dan memang sangat efektif bagi penderita asma. terkait dengan paparan faktor risiko asma, perilaku pencegahan tentang paparan juga merupakan sesuatu yang esensial. seperti telah disinggung di atas, penyakit asma tidak bisa disembuhkan. perilaku pencegahan tentang paparan faktor risiko asma sangat berguna dalam mengendalikan ekspresi asma (gina, 2008). berdasarkan pedoman dari beberapa organisasi penyakit paru-paru di dunia, panduan tentang hal-hal yang bisa dilakukan untuk mengurangi paparan faktor risiko asma sangat mudah diperoleh. namun, kenyataannya tidak semua penderita asma melakukannya dalam kehidupan sehari-hari, dengan berbagai alasan pribadi. ada yang melakukan semua tindakan yang dianjurkan, ada yang hanya melakukan sebagian, bahkan ada yang tidak melakukan sama sekali. faktor risiko asma yang mudah tindakan pencegahannya dan dilakukan seluruhnya oleh penderita asma adalah alergen (3,57%), karena cukup dengan menghindarinya saja. faktor risiko asma yang sebagian besar tindakan pencegahannya dilakukan sebagian saja oleh penderita asma diurutkan berdasarkan intensitasnya adalah: ekspresi emosi yang berlebihan dan polusi udara (masing-masing 100%), alergen (96,42%), asap rokok (36,36%), perubahan suhu terkait kondisi geografis (13,88%), dan aktivitas fisik (13,04%). sedangkan faktor risiko yang tindakan pencegahannya sulit dilakukan dan membuat penderita asma sama sekali tidak melakukan tindakan pencegahan terhadap paparannya adalah aktivitas fisik (86,96%), perubahan suhu terkait kondisi geografis (86,11%), dan asap rokok (63,64%). perilaku manusia terdiri dari 3 domain, yaitu pengetahuan, sikap, dan tindakan. menurut teori perilaku dari lawrence green, perilaku manusia dipengaruhi oleh faktorfaktor predisposisi, pendukung, dan penguat (notoatmodjo, 2003). meskipun perilaku merupakan bentuk respon atau reaksi terhadap stimulus atau rangsangan dari luar organisme, namun dalam memberikan tanggapan sangat tergantung pada karakteristik atau faktor-faktor lain dari orang yang bersangkutan. hal ini berarti bahwa meskipun stimulusnya sama bagi beberapa orang, namun respon tiap-tiap orang berbeda. faktor-faktor yang membedakan respon terhadap stimulus yang berbeda ini disebut determinan perilaku, yang terdiri dari determinan internal (yang bersifat bawaan) dan determinan eksternal (berasal dari lingkungan), yang keberadaannya membuat perilaku manusia menjadi sangat beragam (notoatmodjo, 2003). hal ini terbukti di lapangan. pada responden yang sama, tindakan pencegahan yang berbeda ditunjukkan untuk paparan faktor risiko yang berbeda pula. sedangkan pada responden yang berbeda, tindakan pencegahan yang sama dapat ditunjukkan untuk paparan faktor risiko yang sama pula. keanekaragaman jenis perilaku ini sangat wajar ditemukan di lapangan. tindakan pencegahan yang berbedabeda terhadap berbagai paparan faktor risiko asma sudah diprediksi dengan baik sebelumnya. ada beberapa faktor risiko yang tindakan pencegahannya mudah dilakukan, namun ada juga yang sangat sulit dilakukan, sehingga mempengaruhi perilaku penderita asma terhadap anjuran tindakan pencegahan yang direkomendasikan. selain itu, ada juga penderita asma yang melakukan tindakan pencegahan berdasarkan pengalamannya selama menderita asma karena sebagian besar penderita menderita asma sejak kecil dan juga ada keterlibatan faktor genetik, atau berdasarkan mitos yang ada di masyarakat, atau juga berdasarkan determinan internal (nilai-nilai yang diyakini). namun, tindakan ini tidak termasuk dalam tindakan pencegahan yang direkomendasikan terhadap paparan faktor risiko asma sehingga kesesuaian dan faktor resiko asma dan perilaku pencegahan (nursalam) 15 efektivitasnya terhadap faktor risiko asma yang spesifik untuk mereka juga masih diragukan. faktor risiko asma dan tindakan pencegahan terhadap paparannya akan berpengaruh pada tingkat kontrol penyakit asma oleh penderitanya. hasil penelitian menunjukkan angka yang sangat mengkhawatirkan, yaitu: uncontrolled asthma sebanyak 24 orang penderita (58,54%), partly controlled asthma sebanyak 14 orang penderita (34,14%), dan controlled asthma hanya mampu dicapai oleh 3 orang penderita (7,32%). pada penelitian ini, menurut intensitasnya, buruknya tingkat kontrol penyakit pada penderita asma disebabkan oleh kemunculan gejala harian (29,16%), kemunculan gejala di malam hari (24,16%), frekuensi penggunaan reliever (19,16%), limitasi aktivitas (14,16%), dan frekuensi serangan asma (13,33%). untuk fungsi paruparu tidak dilakukan penilaian karena membutuhkan spirometer atau peak flow meter, yang tidak tersedia di lapangan. tingkat kontrol penyakit asma merujuk langsung pada pengendalian manifestasi klinis penyakit asma. tingkat kontrol ini ditentukan oleh beberapa indikator yaitu: kemunculan gejala harian, limitasi aktivitas, kemunculan gejala di malam hari, frekuensi penggunaan reliever, frekuensi serangan asma, dan penilaian fungsi paru-paru (gina, 2008). kontrol penyakit asma dapat diketahui dengan banyak cara. umumnya, tingkat kontrol penyakit asma dapat mengindikasikan pencegahan penyakit, dan bahkan pengobatan. bagaimanapun, dalam asma, dimana tidak satupun hal ini diterapkan di lapangan, maka merujuk langsung pada kontrol terhadap manifestasi klinis penyakit. idealnya tingkat kontrol penyakit ini diterapkan tidak hanya pada manifestasi klinis asma tetapi juga diterapkan pada hasil laboratorium terkait reaksi inflamasi dan gambaran patofisiologis penyakit asma. mengurangi respon inflamasi dengan controller telah terbukti meningkatkan taraf kontrol penyakit, namun karena tingginya biaya dan tidak tersedianya pemeriksaan seperti biopsi endobronchial dan penghitungan jumlah eosinofil dalam sputum serta nitric oxide yang terekshalasi, maka direkomendasikan agar terapi difokuskan pada pengendalian manifestasi klinis penyakit asma, meliputi juga kelainan fungsi paru (gina, 2008). kontrol penyakit yang maksimal pada asma biasanya dicapai dengan terapi controller, tujuannya untuk mencapai dan mempertahankan kontrol dalam waktu yang lama, dengan tetap memperhatikan keamanan terapi yang diberikan, potensi efek samping obat, dan biaya terapi yang dibutuhkan untuk mencapai tujuan tersebut (gina, 2008). tingkat kontrol penyakit yang maksimal (controlled asthma) tampaknya sangat sulit dicapai oleh penderita asma di lapangan. hal ini potensial disebabkan oleh kegiatan mereka sehari-hari yang berhubungan langsung dengan paparan faktor risiko asma yang sulit untuk dihindari, sehingga gejala harian menjadi sangat sering muncul. selain itu, cara mereka menindaklanjuti paparan faktor risiko spesifik juga penting disesuaikan dengan paparan faktor risikonya sehingga efektif untuk mencegah, dan taraf kontrolnya bisa meningkat serta dapat dipertahankan. hasil uji statistikal data dengan uji korelasi spearman rho memberikan hasil koefisien korelasi spearman 0,336 dengan tingkat signifikansi data 0,032 untuk variabel faktor risiko asma dan tingkat kontrol penyakit pada penderita asma. hal ini berarti ada hubungan positif antara faktor risiko asma dengan tingkat kontrol penyakit pada penderita asma. dengan kata lain, semakin sering seorang penderita asma terpapar oleh faktor risiko spesifik maka tingkat kontrolnya terhadap penyakit asma cenderung turun atau menjadi semakin buruk, yang ditandai dengan peningkatan frekuensi kemunculan gejala asma harian, perburukan kondisi asma dengan munculnya gejala di malam hari, adanya limitasi aktivitas, peningkatan frekuensi penggunaan obat-obatan reliever, dan kejadian serangan asma. peningkatan intensitas paparan faktor risiko asma akan mengakibatkan ekspresi asma lebih sering muncul. ekspresi asma dimaksud langsung merujuk pada tingkat kontrol penyakit asma (gina, 2008). tingkat kontrol penyakit asma yang maksimal (controlled asthma) dapat dicapai dan dipertahankan salah satunya dengan cara mengendalikan faktor risiko asma, namun akan lebih mudah dicapai dengan rajin mengkonsumsi medikasi controller (gina, 2008). hasil penelitian di lapangan menunjukkan terdapat hubungan yang lemah jurnal ners vol.4 no.1 april 2009: 9-18 16 dan signifikan antara paparan faktor risiko asma dengan tingkat kontrol penyakit pada penderita asma. lemahnya hubungan ini potensial disebabkan oleh adaptasi yang dilakukan oleh penderita asma terhadap paparan faktor risiko spesifik. perubahan suhu terkait kondisi geografis misalnya. penderita asma yang bertempat tinggal di wilayah selat sudah bertempat tinggal di wilayah ini sejak lama dan mayoritas tidak pernah berpindah tempat tinggal. maka dari itu mereka potensial memiliki cara-cara pribadi untuk mencegah gejala asma yang mungkin akan mereka rasakan akibat udara dingin, tentu saja berdasarkan pengalaman mereka selama ini. bila cara tersebut berhasil, dan gejala asma tidak muncul, maka tingkat kontrol penyakitnya dapat dipertahankan. selain adaptasi yang dilakukan penderita asma terhadap paparan faktor risiko spesifik, potensial ada sebab lain yang menyebabkan lemahnya hubungan antara faktor risiko asma dengan tingkat kontrol penyakit pada penderita asma. misalnya, penderita asma rajin mengkonsumsi obat-obatan jenis controller, karena tingkat kontrol penyakit asma yang maksimal akan mudah dicapai dan dapat dipertahankan dengan cara ini. sebab-sebab lainnya belum teridentifikasi secara jelas. hasil uji statistikal data dengan uji korelasi spearman rho memberikan hasil koefisien korelasi spearman 0,264 dengan tingkat signifikansi data 0,095 untuk variabel perilaku pencegahan tentang paparan faktor risiko asma dan tingkat kontrol penyakit pada penderita asma. hal ini berarti tidak ada hubungan antara perilaku pencegahan tentang paparan faktor risiko asma dengan tingkat kontrol penyakit pada penderita asma. gina menyatakan bahwa intervensi awal untuk menghentikan atau mengurangi paparan terhadap faktor risiko asma yang menyebabkan hipereaktivitas saluran nafas dapat membantu meningkatkan kontrol penderita terhadap penyakit asma (gina, 2008). hal ini berarti tindakan pencegahan terhadap paparan faktor risiko asma dapat membantu meningkatkan taraf kontrol penyakit asma, atau ekspresi asma menjadi dapat dikendalikan dengan melakukan tindakan pencegahan tersebut. namun, hasil penelitian bertentangan dengan pernyataan gina ini. dengan kata lain, tingkat kontrol penyakit asma dapat turun atau menjadi buruk walaupun tindakan pencegahan terhadap paparan faktor risiko spesifik telah dilakukan oleh penderita asma. atau sebaliknya, tingkat kontrol penyakit asma dapat naik atau menjadi baik walaupun penderita asma tidak melakukan tindakan pencegahan terhadap paparan faktor risiko spesifik. tingkat kontrol penyakit asma ditentukan berdasarkan indikator dari masingmasing tingkat kontrol penyakit pada penderita asma terkait manifestasi klinis penyakit, faktor-faktor yang mempengaruhi tingkat kontrol penyakit asma belum teridentifikasi secara jelas. hasil penelitian yang berlawanan dengan pernyataan gina tersebut potensial disebabkan oleh variatifnya tindakan pencegahan yang dilakukan oleh penderita asma, karena tidak semua orang melakukan tindakan pencegahan yang direkomendasikan. ada beberapa penderita asma yang melakukan tindakan pencegahan berdasarkan pada pengalamannya selama menderita asma (karena sudah mengalaminya sejak kecil dan anggota keluarga lain juga ada yang menderita asma) atau berdasarkan mitos yang ada di masyarakat, dan atau berdasarkan determinan internal (nilai-nilai yang diyakini), namun tindakan pencegahan ini tidak termasuk dalam tindakan pencegahan yang direkomendasikan terhadap faktor risiko spesifik, sehingga kesesuaian dan efektivitasnya juga masih diragukan. selain itu, tindakan pencegahan dalam penelitian ini tidak diobservasi, sehingga rentan mengalami bias. determinan perilaku yang sangat mempengaruhi perilaku seseorang ternyata juga menunjukkan pengaruhnya pada tingkat kontrol penyakit asma. kecenderungan seseorang untuk intens melakukan atau tidak melakukan tindakan pencegahan terhadap paparan faktor risiko asma dipengaruhi oleh banyak hal, selain karena ada beberapa faktor risiko asma yang tidak mudah tindakan pencegahannya. walau demikian, setidaknya tindakan pencegahan yang dilakukan dapat membantu meredakan gejala asma pada saat aktual penderita asma terpapar oleh faktor risiko spesifik. simpulan dan saran simpulan faktor resiko asma dan perilaku pencegahan (nursalam) 17 faktor risiko asma yang sering menginduksi gejala asma adalah perubahan suhu terkait kondisi geografis, alergen, aktivitas fisik, asap rokok, ekspresi emosi yang berlebihan, dan polusi udara. penderita asma tidak melakukan tindakan pencegahan yang direkomendasikan terhadap paparan faktor risiko asma. perburukan tingkat kontrol penyakit asma terjadi akibat kemunculan gejala harian yang sering. ditemukan hubungan yang signifikan antara faktor risiko asma dengan tingkat kontrol penyakit asma, namun perilaku pencegahan tentang paparan tidak memiliki hubungan dengan tingkat kontrol penyakit asma. saran penulis menyarankan agar penderita asma melakukan upaya-upaya untuk menghentikan atau mengurangi paparan faktor risiko asma spesifik, dan perawat dapat memberikan penyuluhan terkait upaya-upaya tersebut. penelitian selanjutnya dapat menggunakan metode content analysis agar semua jawaban tercover. kepustakaan air resources board (arb), 2008. asthma and air pollution, (online), (http:// www.arb.org., diakses pada tanggal 15 mei 2009, jam13.44 wib). arief, 2009. asma bronkial, (online), (http://www.blogger.com, diakses pada tanggal 13 april 2009, jam 21.44 wib). arruda, l., 2006. environmental control in asthma – to recommend or not recommend : that is the question!, (online), (http:// www.scielo.br, diakses pada tanggal 29 april 2009, jam 14.43 wib). asthma and allergy foundation of america (aafa), 2008. asthma triggers,(online), (http://www.aafa.org, diakses pada tanggal 15 mei 2009, jam 13.44 wib). bps, 2007. selat district in figures 2007. karangasem: badan pusat statistik kabupaten karangasem. hlm. 1, 2, 4, 40, 41, 42, 62, 63, 77, 78. bps, 2007. buku monografi. karangasem : badan pusat statistik kabupaten karangasem. hlm. 1. canadian lung association, 2008. exercise & asthma, (online), (http://www.lung.ca.org, diakses pada tanggal 14 mei 2009 jam 10.46 wib). global initiative for asthma (gina), 2008. asthma control questionnaire, (online), (http:// www.qoltech.co.uk, diakses pada tanggal 29 april 2009, jam 13.04 wib). global initiative for asthma (gina), 2008. asthma therapy assessment questionnair, (online), (http://www.ataqinstrument.com, dikases pada tanggal 20 april 2009, jam 09.52 wib). global initiative for asthma gina, 2008. global strategy for asthma management and prevention, (online), (http://www.ginasthma.org, diakses pada tanggal 8 april 2009, jam 15.14 wib). global initiative for asthma gina, 2008. pocket guide for asthma management and prevention, (online), (http://www.ginasthma.org, diakses pada tanggal 8 april 2009, jam 15.14 wib). green, et al., 2002. synergism between allergens and viruses and risk of hospital admission with asthma : case control study, (online), (http:// www.pubmedcentral.nih.gov, diakses pada tanggal 29 april 2009, jam 14.50 wib). kaufman, j. d., 2007. air pollution and mortality : are we close to understanding the how?, (online), (http://www.ajrccm.atsjournals.org, diakses pada tanggal 29 april 2009, jam 13.35 wib). macnaughton, k., 2008. exercise induced asthma : facts about eia, (online), (http://www.asthma.about.com, diakses pada tanggal 14 mei 2009, jam 19.00 wib). macnaughton, k., 2008. extreme weather – asthma trigger and irritant. (online),(http:// www.asthma.about.com, diakses pada tanggal 14 mei 2009, jam 19.31 wib). http://www.arb.org/ http://www.blogger.com/ http://www.scielo.br/ http://www.aafa.org/ http://www.lung.ca.org/ http://www.qoltech.co.uk/ http://www.ataqinstrument.com/ http://www.ginasthma.org/ http://www.ginasthma.org/ http://www.pubmedcentral.nih.gov/ http://www.ajrccm.atsjournals.org/ http://www.asthma.about.com/ http://www.asthma.about.com/ jurnal ners vol.4 no.1 april 2009: 9-18 18 ricky, 2009. asap rokok dan asthma, (online), (http://www.marnalom.com, diakses pada tanggal 14 juli 2009, jam 14.46 wib). rosenkranz, et al., 2005. neural circuitry underlying the interaction between emotion and asthma symptom exacerbation, ( online), (http:// www.pnas.org, diakses pada tanggal 12 mei 2009, jam 15.13 wib). silva, r., 2006. the emotional cause of asthma, (online), (http:// www.ezinearticles.com, diakses pada tanggal 12 mei 2009, jam 15.13 wib). state of region health, 2002. asthma risk factors and triggers. canada : the regional municipality of peel, hlm. 9. suyono, s., 2001. buku ajar ilmu penyakit dalam, jilid 2, edisi 3. jakarta : balai penerbit fk – ui, hlm. 21, 22, 23, 27, 28, 29, 31, 33, 41. sykes, and johnston, 2008. etiology of asthma exacerbations, (online), (http:// www.aaaai.org, diakses pada tanggal 8 april 2009, jam 12.01 wib). virchow, c. j., 2001. drug-induced bronchospasm – a negligible phenomenon?, (online), (http:// www.content.karger.com, diakses pada tanggal 14 mei 2009, jam 11.43 wib). wahyuningsih, et al., 2003. dampak inhalasi cat semprot terhadap kesehatan paru, (online), (http:// www.cerminduniakedokteran.com, diakses pada tanggal 18 maret 2009, jam 17.21 wib). who, 2000. pocket book of hospital care for children : guidelines for the management of common illness with limited resources. china : who library cataloguing-in-publication data. hlm. 87. http://www.marnalom.com/ http://www.pnas.org/ http://www.ezinearticles.com/ http://www.aaaai.org/ http://www.content.karger.com/ http://www.cerminduniakedokteran.com/ 36 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.6341 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effects of health education on leptospirosis prevention through dasawisma sri mulyanti and athanasia budi astuti department of nursing, poltekkes kemenkes surakarta, central java, indonesia abstract introduction: globally, leptospirosis is still a major health problem in african and developing countries, including indonesia. the best control effort is with prevention through health education. health education with conventional methods is considered less effective, so there is a need to look for other health education methods. methods: aims of the research are to know the difference of effectiveness of health education methods between conventional classical method and dasawisma or peer group in (1) improvement of knowledge of leptospirosis disease prevention; (2) effectiveness in prevention of leptospirosis. research is quasi-experimental research with a two-group control trial design. the sample consisted of 40 respondents treated by health education through dasawisma using a leptospirosis module as a media of health education, and 40 control group respondents who were given education using conventional method. sampling technique used purposive sampling. data were statistically analyzed with independent t-test. results: (1) meaning of treatment group = 21.77 higher than control group = 19.62 (2) mean prevention effort of leptospirosis disease treatment group = 54.35 better than control group = 48.15 (3) health education through dasawisma was effective to increase knowledge prevention of leptospirosis (t = 2.943; p = 0.004) (4) health education through dasawisma was effective for increasing prevention effort of leptospirosis (t=4.695; p=0.001). conclusion: health education through dasawisma and leptospirosis module is significantly effective to improve knowledge of leptospirosis disease and in prevention efforts of leptospirosis. article history received: oct 29, 2017 accepted: april 27, 2018 keywords dasawisma; health education; leptospirosis; module of leptospirosis contact sri mulyanti  di_yanti96@yahoo.com  department of nursing, poltekkes kemenkes surakarta, central java, indonesia cite this as: mulyanti, s., & astuti, a. (2018). effects of health education on leptospirosis prevention through dasawisma. jurnal ners, 13(1), 36-41. doi:http://dx.doi.org/10.20473/jn.v13i1.6341 introduction globally, tropical infectious diseases are still a very worrying health problem, especially in african countries and other developing countries, including indonesia. leptospirosis is a zoonotic disease caused by infection of bacterial microorganisms of leptospira introgans irrespective of its specific serotype form. the incidence of leptospirosis in indonesia is still high. according to the international leptospirosis society (ils), indonesia is a country with leptospirosis incidence ranked third below china and india. in leptospirosis patients with yellow eye lining (damage to liver tissue), the risk of death will be higher. in some publications, the mortality rate is reported to be between 3% 54% depending on the system of the infected organs (depkes, 2012). according to the world health organization (who), in developing countries, especially those with hot or tropical climates, the incidence of leptospirosis is more than 1000 times compared with subtropics countries with a greater risk of illness. the incidence rate of leptospirosis in tropical countries is estimated to reach 5-20/100,000 population per year. leptospirosis is spread throughout the world. for example, the highest ever reported epidemiological study was the incidence rate of leptospirosis in new zealand between 1990 and 1998 of 44 per 100.000 population. the highest incidence rates occurred in meat-related workers (163/100,000 inhabitants), farmers (91.7/100,000 inhabitants) and forest-related workers by 24.1 per 100,000 population (who, 2010). based on reports from the central java provincial health office in 2011 the number of cases of https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:di_yanti96@yahoo.com jurnal ners http://e-journal.unair.ac.id/jners | 37 leptospirosis in 155 residents caused the death of 23 people. this number increased compared to the year 2010, which was 133 victims of leptospira bacteria, 14 of whom died (dinas kesehatan propinsi jawa tengah, 2011). one of the areas in central java province that often occurs cases of leptospirosis is in the area of the boyolali regency. based on data from boyolali district health office obtained information shows that the positive diagnosis of leptospirosis incidence first occurred in 2012 with the incidence of two cases found in the work area of the ngemplak boyolali health center. then, in 2013, incidence of six cases was found. and in 2014, this increased to 17 cases of whom seven died (case fatality rate 43.75%) (dinas kesehatan kabupaten boyolali, 2014). ngemplak health center officers have also undertaken health education several times in posyandu, but the results from year to year regarding the incidence of leptospirosis shows a continued increase. this is in contrast to existing research, which shows that health education affects leptospirosis prevention efforts. the results of kusumastuti’s research (2011) showed health education had an effective influence on leptospirosis prevention efforts. the results of research also providing evidence of the influence of health education on leptospirosis prevention efforts come from nurjanah, sugiyanto and kun (2013) on the relationship between public knowledge about leptospirosis prevention and behavior of health officers. puskesmas kedungmundu’s practice of leptospirosis prevention in kelurahan tandang kota semarang also provides evidence there is a relationship between knowledge and leptospirosis prevention efforts. during this period, general health education is generally done when there is posyandu activity and it has not been tried through a dasawisma or small peer group families by using the module. dasawisma is a small family group of 8-10 families. materials and methods this research used quasi-experimental with two group control trial design. the sample consisted of 40 respondents treated by health education through dasawisma using the module and 40 control group respondents using conventional method. dasawisma is a small family group of 8-10 families. the leptopsirosis module is a small book that is distributed to respondents to read and take home. the leptospirosis module contains the concept of leptospirosis and simple precautions to be easily understood by the audience. data were collected by a leptospirosis cognitive test and questionnaire on leptospirosis incidence. knowledge is measured by cognitive tests with 30 questions divided into two categories (good and less). leptospirosis prevention measures were measured using a questionnaire with a number of guttman scale statements (always, occasionally, never). instrument validity test used pearson correlation with spss 18. sampling technique used purposive sampling. data were analyzed with independent t-test. ethical clearance was received from the ethical committee at the health polytechnic of surakarta (number ecpks/x/002/2017 on 20 february, 2017. results the characteristics of respondents are shown in table 1. demographically, based on the age category in the treatment group, the majority are in the 31 to 40 years category by as much as 32.5%, while, in the control group, most are in the age group of 20 – 30, accounting for 37.5%. characteristics of religion followed by the majority of respondents is islam with 95% in the treatment group and 97.5% in control group. regarding education, it is generally seen equal wherein most treatment groups have high school education of 40% and, in the control group, as many as 47.5%. table 2 illustrates both the treatment group and the control group in which no one had ever been suspected of leptospirosis disease. however, the risk of contracting the disease is quite large, namely the presence of rat vectors in the treatment group by as much as 75% and in the control group 72.5%. besides, there is also the environmental factor, which is the water channel around the house in the control group, with 92.5% while, in the treatment group it is 87.5%. related to whether the daily respondents were often exposed or had contact with sewer water or sewerage channels, both groups showed the same result, 22.5%. table 3 shows the level of knowledge of respondents before health counseling about leptospirosis in the treatment group with the highest percentage in the less category of 82.5%, while, in the control group, the majority was also in the less category with 90%. the result of univariate analysis was obtained in the treatment group with an average value of 18.6, minimum 11, maximum 25, with deviation standard 3.57. while, in the control group, the average value was of 17.6 maximum 26, minimum 7 and standard deviation 4.38. while the description of the level of knowledge of respondents after health education, as shown in table 4, shows that the level of knowledge of the respondents in the treatment group is the highest in the category less, by 55%, and the good category is 45%. however, in the control group, the percentage of knowledge level in the category of less is more 77.5% and in the good category 22.5%. the result of univariate analysis showed, in the treatment group, average value of 21.77, maximum value 27, minimum value 16 and standard deviation 2.67, while the control group obtained average value of 19.62, with maximum value 27 and minimum value 12 with a standard deviation value of 3.7. independent t test obtained that health education through dasawisma had significant effect on knowledge level of the respondents (t value = 2.943 with p = 0.004). the mean value of treatment group s. mulyanti et al. 38 | pissn: 1858-3598  eissn: 2502-5791 (21.77) is higher than the control group (19.62), so it means that health education through dasawisma using the module is more effective in improving leptospirosis knowledge compared with the conventional method. leptospirosis prevention effort prevention efforts for leptospirosis infection were measured twice (pre-test and post-test). pretest to determine the prevention efforts of respondents before being given health education, while post-test was to know the value of respondent knowledge level after being given health education by using the module in the dasawisma group. table 6 shows the prevention of leptospirosis before health counseling; in both the treatment group and the control group, the number in the good category is more than the less category. univariate analysis results obtained data on the treatment group which showed the mean of 51.42, maximum value 60.00, minimum value 39 and standard deviation of 7.07. while, in the control group, there was average value of 48.00, maximum value 58, and minimum value 22 with standard deviation of 7.69. the value of prevention of leptospirosis after health education as shown in table 7 shows the value in the treatment group is much better than the control group, that is for the category of either 97.5% versus 70%, while in the category less 2.5% is much less than control group that reached 30%. univariate analysis result showed the increase of value in both treatment and control group that is in the mean treatment group 54.35 maximum value 64 and minimum value 41 with standard deviation 4.59. as for the control group shows the average value of 48.18 maximum value 58 minimum value 28 and value standard deviation 7.00. table 8 shows that health education through dasawisma and leptospirosis module is effective for increasing prevention of leptospirosis disease as table 4. description of knowledge level of respondents about leptospirosis having been given health education categories treatment control f % f % less 22 55 31 77.5 good 18 45 9 22.5 table 5. effect of health education on knowledge level of respondents about leptospirosis group treatment control mean 21.77 19.62 std 2.67 3.76 t 2.943 sig (2-tailed) p 0.004 table 6. description of leptospirosis prevention efforts before being given health education categories treatment n = 40 control n = 40 f % f % less 9 22.5 8 20 good 31 77.5 32 80 table 7. description of leptospirosis prevention efforts having been given health education categories treatment n = 40 control n = 40 f % f % less 1 2.5 12 30 good 39 97.5 28 70 table 8. effect of health education on prevention of leptospirosis group treatment control mean 54.35 48.15 std 4.54 7.00 t 4.695 sig (2-tailed) p 0.001 table 1. demographic characteristics variables treatment (n = 40) controls (n = 40) f % f % age 20 30 12 30 15 37.5 31 40 13 32.5 11 27.5 41 50 11 27.5 9 22,5 >50 4 10 5 12.5 religion islam 38 95 39 97.5 christian 1 2.5 1 2.5 catholic 1 2.5 0 0 education elementary 7 17.5 10 25 junior high school 12 30 12 30 senior high school 16 40 17 47.5 diploma 2 5 0 0 bachelor 3 7.5 1 2.5 table 2. characteristics of respondents based on leptospirosis risk factors variables treatment control f % f % have experience of sick yes 0 0 0 0 no 40 100 40 100 environment rat 30 75 29 72.5 ditch 35 87.5 37 92.5 contact 9 22.5 9 22.5 table 3. description of knowledge level of respondents about leptospirosis before being given health education categories treatment control f % f % less 33 82.5 36 90 good 7 17.5 4 10 jurnal ners http://e-journal.unair.ac.id/jners | 39 shown by t = 4.695 (p = 0.001) and median value of treatment group 54.35 is much better than control group (48.15). discussion effectiveness of health education through dasawisma and leptospirosis module regarding knowledge leptospirosis is a disease caused by pathogenic leptospires. symptoms of leptospirosis are similar to other infectious diseases, such as influenza, meningitis, hepatitis, dengue fever, dengue hemorrhagic fever and other viral fevers (sudoyo, 2006). leptospirosis usually occurs endemically in densely populated areas. however, it can also occur in rural areas where the distance between houses is far away, but sanitation of water disposal is not hygienic, so it is easy to become a medium for leprosy vector transmission of leptospirosis. according to lehman (2014), the pathogenesis of leptospirosis has not been fully understood. the leptospires enter the body of the host through iris / abrasion lesions on the skin, conjunctiva or intact mucosa that lines the mouth, pharynx, esophagus, bronchus or alveolus and can enter by inhalation droplet infection and by drinking contaminated water. to be able to perform the prevention and control of endemic leptospirosis disease requires public awareness to always maintain a lively environment so as not to become a medium for rat breeding as a means of transmission of leptospirosis disease or through other creatures such as goats, cattle, sheep and others. awareness will form naturally after the individual knows or knows about an object that is around it, including leptospirosis disease. promotional action is the most inexpensive and safe strategy to control a disease. health promotion can be done through health education or health counseling. through health counseling, health workers can provide information to individuals, families, or communities so that knowledge will increase. knowledge is the result of knowing, and this happens after people have sensed a particular object. knowledge or cognition is a very important domain in shaping one's actions (over behavior). behavior based on knowledge will be better than behavior that is not based on knowledge (notoatmodjo, 2011). according to azwar (as cited in fitriani, 2011), educational activities or health education is a health promotion method that is done by spreading the message, instilling confidence so that people are not only aware, know and understand, but are also willing and able to see that there is a relationship with health. the results of okatini, purwana and djaja’s (2007) studies provide similar evidence with this study wherein the dominant factors affecting leptospirosis occurrence are education (or = 3.7), knowledge (or = 33.1), clean water (or = 4.5), and component home structuring (or = 8.2). the results of this study are also similar to priyanto's (2008) research where community behavior has an influence on the incidence of leptospirosis. thus, leptospirosis prevention efforts should be pursued by changing the behavior of the community through health education activities. the success of health education is influenced by several factors, one of which is the size of audience or the target of counseling. according to fitriani (2011), the smaller the target or the audience then the easier is the management of the extension process. according to harsono’s (2004) model of learning with small groups, where the audience is divided into small groups consisting of 8-10 learners, this will be more effective in achieving learning objectives. in application, this small group can be realized in the form of homelessness. each dasawisma group consists of about 10-20 members. the results of this study provide empirical evidence that health education methods of leptospirosis disease through dasawisma are more effective than classical methods. table 5 shows the value t = 2.943 with p = 0.004, so it can be concluded that h0 rejected and ha accepted, which means there is difference between the treatment group and the control group. because the mean value of the treatment group, 21.77, is higher than the control group value of 19.62, it can be concluded that health education through dasawisma using the module is more effective in improving leptospirosis knowledge compared with the conventional method, which is by lecturing through a large group or class. with the small group method of dasawisma, a counselor or tutor will be easier to control the class or audience. the dasawisma of this study consists of 10 members who are mostly mothers or women, who, in fact, have a better effect of nature in terms of increasing knowledge and public participation in prevention of leptospirosis disease. the interaction between counselor and audience is also closer and more intense, so that the counseling process will be more interactive and the material will be more easily remembered and understood by the audience. in counseling or learning, using small groups of media are good modules. in the module, it has been arranged so that the written material is concise, clear and applicable. in the module, there are also problems of training so that with a relatively small number of audience then the material will be more easily remembered. the results of this study are in line with research by rahmawati (2012) which proves that the number of mice as a vector of leptospirosis transmission is increasingly in line with the participation of mothers in installing a mousetrap. health education through dasawisma will be more effective, because dasawisma is a vehicle for community participation in the field of health by self-help at family level, directly controlled by the pkk village team. one of the family members in the tenth group is chosen to be the group leader or liaison with the coach or counselor. s. mulyanti et al. 40 | pissn: 1858-3598  eissn: 2502-5791 effect of module on dasawisma on prevention of leptospirosis disease individual behavior can be distinguished from the level of knowledge which then shapes attitudes. attitude is a reaction or a person's response to a stimulus or object. manifestations of attitudes cannot be directly seen, but are only interpreted first from closed behaviors. from this understanding, it can be underlined that, as long as the behavior is still closed, then it is called attitude, whereas, when it is open, the actual behavior is shown as health (adnani, 2011). according to fitriani (2011), the factors that influence the formation of behavior include knowledge, perception and attitudes of a person to a health problem. this study provides empirical evidence that health education through dasawisma can change or increase public awareness and efforts in prevention and control of leptospirosis disease. table 7 shows that health education through homelessness and the leptospirosis module is effective to increase prevention of leptospirosis disease as indicated by t value 4.695 (p = 0.001) and median value of treatment group 54.35, which is much better than the control group of only 48.15. according to lehman (2014), prevention and control of leptospirosis can be done by providing intervention on the source of infection and intervention in the path of transmission and human host. such actions can be carried out by, for example, reducing rat populations in several ways, such as rat poison, trapping, rodenticide use and rodent predators, eliminating rats’ access to settlements, food and drinking water by building agricultural warehouses as sources of water reservoirs and moor-resistant yards, and by throwing away food and trash far from the reach of rats. preventing rodents and other wildlife from living in human habitats by maintaining a clean environment, removing trash from grass and shrubs, and maintaining sanitation, especially by building good sewage and bathroom facilities and providing clean drinking water. these actions can be done well, if the community has sufficient knowledge and perception of how to prevent leptospirosis disease. the results of this study are in line with the research of murti, prabandari and riyanto (2006) in which the peer education method through homelessness was effective in the discovery of lung tuberculosis. although the goal of peer education was the discovery of suspected tbc lung, in principle it provides evidence that peer education methods through small groups are effective for improving public health efforts. conclusion health education with dasawisma is effective to increase knowledge about prevention of leptospirosis, hence increasing prevention of leptospirosis. based on the conclusions of this research, nurses are expected to use the dasawisma medium in an effort to improve the levying and prevention efforts of leptospirosis disease and they should be able to use and develop the leptospirosis module as a medium of education and health promotion on prevention efforts of leptospirosis disease. references adnani, h. (2011). ilmu kesehatan masyarakat.nuha medika: yogyakarta depkes ri. (2012). panduan promosi kesehatan di daerah bermasalah kesehatan: panduan untuk tenaga kesehatan di puskesmas [online] www.depkes.go.id/.../promosi-kesehatan (accessed: january 1, 2017). dinas kesehatan kabupaten boyolali. (2014). laporan leptospirosis dikabupaten boyolali. boyolali:dinas kesehatan kabupatenboyolali dinas kesehatan provinsi jawa tengah. (2011). evaluasi nkbjkn programp2b2 di jateng. semarang: dinaskesehatan provinsi jawa tengah fitriani, sinta. (2011). promosi kesehatan. jakarta: graha ilmu. harsono. (2008). pengantar problem based learning. yogyakarta: medika fakultas kedokteran ugm. kusumastuti d. (2011). pengaruh penyuluhan kesehatan tentang leptospirosis terhadap perilaku pencegahan leptospirosis pada petani di sleman yogyakarta. [online] http://digilib.unisayogya.ac.id/1014/1/naskah %20publikasi.pdf (accessed: january 1, 2017). lehman, j. s. (2014). leptospiral pathogenomics. pathogens. [online] www.mdpi.com/jurnal/pathogens.issn 20760817. (accessed: january 1, 2017). murti. e.s., prabandari, y., suryo, and riyanto bambang s.: efektivitas promosi kesehatan dengan peer education (dasawisma) dalam menemukan pasien tersangka tuberkulosis (tbc) paru di kabupaten badung . jurnal.ugm.ac.id/bkm/article/view/3649/3131.2 014. (accessed: january 1, 2017). notoatmodjo, soekidjo. (2011). kesehatan masyarakat ilmu dan seni. jakarta: salemba medika nurjanah, s., zaenal sugiyanto, and kriswiharsi kun hubungan antara pengetahuan masyarakat tentang pencegahan leptospirosis dan perilaku petugas kesehatan puskesmas kedungmundu dengan praktik pencegahan leptospirosis di kelurahan tandang kota semarang tahun 2013 http://eprints.dinus.ac.id/6568/1/jurnal_12745. pdf (accessed: january 1, 2017). okatini, m., purwana, r. and djaja, i. m. (2007). hubungan faktor lingkungan dan karakteristik individu terhadap kejadian penyakit leptospirosis di jakarta, 2003-2005. journal makara, 11(1), 17-24. priyanto, a. (2008). faktor-faktor risiko yang berpengaruh terhadap kejadian leptospirosis http://www.depkes.go.id/.../promosi-kesehatan/panduan-promosi http://www.depkes.go.id/.../promosi-kesehatan http://digilib.unisayogya.ac.id/1014/1/naskah%20publikasi.pdf http://digilib.unisayogya.ac.id/1014/1/naskah%20publikasi.pdf http://www.mdpi.com/jurnal/pathogens.issn%202076-0817 http://www.mdpi.com/jurnal/pathogens.issn%202076-0817 http://eprints.dinus.ac.id/6568/1/jurnal_12745.pdf http://eprints.dinus.ac.id/6568/1/jurnal_12745.pdf jurnal ners http://e-journal.unair.ac.id/jners | 41 (studi kasus di kabupaten demak). jurnal epidemiologi rahmawati. (2013). partisipasi ibu dalam pemasangan live trapp terhadap jumlah tangkapan tikus dan pinjal di desa sukabumi kecamatan cepogo kabupaten boyolali http://lib.unnes.ac.id/18486/1/6450408037.pdf (accessed: january 1, 2017). sudoyo, aru.w. (ed). (2006). buku ajar ilmu penyakit dalam. jilid iii. edisi iv. jakarta : pusat penerbit ilmu penyakit dalam fakultas kedokteran indonesia who. (2010). human leptospirosis: guidance for diagnosis, surveillance and control. international leptospirosis society. http://lib.unnes.ac.id/18486/1/6450408037.pdf stres memperlambat penyembuhan luka paska seksio sesarea (stress prolongs wound healing post cesarean section) ahmad yusuf*, ni ketut alit a.*, arina nurfianti* * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga, jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496, e-mail: yusuf@fk.unair.ac.id abstract introduction: decision for cesarean section may lead to the stress for women in delivery. stress response requires longer recovery time in post cesarean section patients. most of patients who experience stress before and after surgical is associated with wound healing delay. when this condition continues, the wound will have a higher risk of infection. the objective of this study was to analyze correlation between stress and wound healing phase in post cesarean section patients. method: a cross sectional design was used in this study. the population were women with cesarean section, both elective or emergency, in delivery room i rsu dr. soetomo surabaya. samples were recruited by using purposive sampling, with 28 samples who met to the inclusion criterias. the observed variables were stress and wound healing phase in post cesarean section patient. stress data were collected by interview and wound healing measurement done by observation on the 3 rd day post cesarean section. result: the result showed that women with stress experience wound healing delay. the characteristic of wound healing delay was prolonged on inflammation phase, nevertheless there was presence of granulation tissue. spearman’s rho correlation showed that correlation value r=0.675 with p=0.000. discussion: it can be concluded that there was strong significant correlation between stress and wound healing phase in post cesarean section patients. it is important to give this information to the patients with cesarean section in order to prevent stress and delay in wound healing phase. keywords: stress, wound healing phase, post cesarean section patients. pendahuluan risiko kematian ibu karena menjalani seksio sesaria adalah tiga kali risiko kematian ketika menjalani persalinan normal (menacker and dentzer, 2006). persalinan dengan seksio sesarea dengan jelas menambah beban psikologis dan fisik bagi ibu maupun keluarga dibandingkan dengan persalinan per vaginam (h.s.t.a.t, 2007). stres yang terjadi sebelum persalinan maupun trauma pengalaman persalinan akan ikut menyebabkan depresi pasca persalinan (alegent, 2007). stres karena ketakutan sebelum dilakukan tindakan operasi dihubungkan dengan berbagai akibat buruk yang akan terjadi pada ibu, termasuk komplikasi pada luka insisi. luka dapat terinfeksi dan mengalami gangguan penutupan luka (mundy, 2005). hal ini juga merupakan kunci mekanisme psikobiologi yang menunjukkan bahwa stres memperlambat penyembuhan luka (glaser dkk., 1999 dalam mochtar, 1998). sebanyak 25% ibu yang menjalani seksio sesarea melaporkan perasaan tertekan dari para tenaga kesehatan karena menetapkan prosedur tersebut. sebagian besar wanita membutuhkan informasi tentang komplikasi akibat pembedahan sebelum mereka menyetujui prosedur tersebut (menacker and dentzer, 2006). menurut koenker (1994), seseorang yang terpapar stres menunjukkan peningkatan rerata infeksi yaitu 74-90%. stres menunjukkan 25-40% berdampak pada keterlambatan dalam penyembuhan luka (marucha, 2007). adanya infeksi pada luka setelah pembedahan merupakan masalah yang serius bagi pasien, terutama adanya komplikasi pada luka tersebut baik komplikasi lokal maupun sistemik (suriadi, 2007). stres mempengaruhi aktivasi kortisol sehingga menyebabkan penurunan inflamasi dan memperpanjang waktu penyembuhan. proses awal penyembuhan luka ditandai dengan adanya inflamasi, hal ini merupakan model yang menarik untuk mengidentifikasi hubungan antara stres dan berbagai faktor psikososial (marucha, p., 2007). penelitian ini bertujuan untuk menganalisis hubungan antara stres dengan fase penyembuhan luka. jika hasil penelitian menunjukkan hubungan yang bermakna, maka perlu diterapkan pendekatan psikologis dalam asuhan keperawatan pada ibu yang akan dan telah menjalani operasi seksio sesarea. bahan dan metode desain penelitian yang digunakan pada penelitian ini adalah cross sectional design, dengan 28 responden ibu pasca seksio sesarea berusia 20-40 tahun dan dengan indeks masa tubuh (imt) 18,5-25,0. penelitian ini dilaksanakan di ruang bersalin i rsu dr. soetomo pada mei sampai dengan juni 2007. variabel independen pada penelitian ini adalah stres, sedangkan variabel dependen dalam penelitian ini adalah fase penyembuhan luka. instrumen yang digunakan untuk pengukuran tingkat stres adalah lembar wawancara terstruktur yang diadaptasi dari depression anxiety stress scale (dass) (lovibond, 1995 dalam nieuwenhuijsen, 2003), dengan jumlah pertanyaan 42 butir. pengukuran fase penyembuhan luka, dilakukan pada hari ke-3 pasca seksio sesarea dengan menggunakan instrumen observasi penyembuhan luka yang diadaptasi dan dimodifikasi oleh peneliti berdasarkan model pengkajian bates-jensen wound assessment tool (jensen, 2001). data yang telah dikumpulkan kemudian diolah dan dianalisis dengan menggunakan uji korelasi spearman’s rho dengan tingkat kemaknaan α≤0,05 dan derajat hubungan r=0,05. hasil berdasarkan identifikasi yang dilakukan peneliti terhadap 28 orang responden, sebanyak 16 orang mengalami stres dengan berbagai tingkatan yang bervariasi. dari 42 pertanyaan yang diajukan, sebagian besar responden mengalami perubahan fisiologis dan psikologis akibat stres sebelum tindakan seksio sesarea hingga setelah tindakan. perubahan fisiologis yang ditunjukkan oleh responden adalah 82% responden mengalami mulut kering, 75% mengalami kelelahan, 61% menunjukkan perubahan denyut jantung dan denyut nadi, sedangkan 57% mengalami kesulitan untuk beristirahat. dampak psikologis yang dialami adalah ketakutan (82%), cemas yang berlebihan dalam suatu situasi (78,6%), keadaan tegang (61%), gelisah (53,6%), serta sedih dan depresi (43%). tabel 1. hubungan stres dengan fase penyembuhan luka pada pasien paska seksio sesarea di ruang bersalin i rsu dr. soetomo surabaya pada mei-juni 2007. kategori stres tingkat penyembuhan luka total baik kurang buruk sangat buruk normal 9 (32%) 3 (11%) 0 (0%) 0 (0%) 12 (43%) ringan 0 (0%) 4 (14%) 1 (4%) 0 (0%) 5 (18%) sedang 0 (0%) 2 (7%) 0 (0%) 0 (0%) 2 (7%) berat 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) sangat berat 0 (0%) 7 (25%) 2 (7%) 0 (0%) 9 (32%) total 9 (32%) 16 (57%) 3 (11%) 0 (0%) 28 (100%) p=0,000 r=0,675 keterangan: p = signifikansi r = derajat hubungan hasil identifikasi terhadap fase penyembuhan luka menunjukkan bahwa dari 28 orang responden, sebanyak 19 orang (68%) mengalami gangguan fase penyembuhan luka pada hari ke-3 pasca seksio sesarea dan 9 orang (32%) mengalami penyembuhan luka yang baik. dari 19 orang tersebut, sebanyak 16 orang (57%) mengalami tingkat penyembuhan luka yang kurang dan 3 orang (11%) dengan tingkat penyembuhan luka yang buruk. karakteristik gangguan fase penyembuhan luka seksio sesarea yang ditemukan pada 19 orang responden tersebut adalah eritema (36%), edema lokal area sekitar luka (7%), adanya eksudat berupa eksudat serous (14%), eksudat sanguin (11%) dan eksudat purulen (4%), nyeri berupa nyeri ringan (36%), nyeri sedang (14%) dan nyeri berat (14%) dan adanya bau pada luka (18%). namun adanya jaringan granulasi sebagai tanda awal fase proliferasi sudah mulai terlihat. pada tabel 1 dapat dilihat bahwa ada hubungan signifikan yang kuat antara stres dengan fase penyembuhan luka pada pasien pasca seksio sesarea dengan tingkat kemaknaan p=0,000 dan derajat hubungan antara keduanya r=0,675. pembahasan glaser (1999) menjelaskan bahwa stres psikologis telah dapat diukur sebagai kunci imunologis pada sisi luka. wanita dengan stres yang lebih tinggi menghasilkan dua proinflammatory cytokines yang rendah. proinflammatory cytokines penting bagi awal fase penyembuhan luka untuk menghasilkan interleukin 1 (il-1α) dan il-8. menurut petrie (2003) terdapat hasil signifikan antara stres dengan penyembuhan luka, yaitu stres menghambat munculnya proinflammatory cytokines pada awal fase perbaikan luka, yaitu fase inflamasi. stres menginduksi peningkatan glukokortikoid dan mengubah sistem dinamis yang mengontrol perkembangan respons inflamasi, menekan il-1α, il-8, dan produksi tnf (petrie and debbie , 2003 dalam sheridan, 2007). berdasarkan hasil penelitian didapatkan bahwa seluruh responden wanita yang mengalami stres sebelum hingga setelah tindakan seksio sesarea mengalami keterlambatan fase penyembuhan luka, yaitu pada fase pertama proses penyembuhan luka (fase inflamasi). stres ibu yang terjadi sebelum dan setelah tindakan seksio sesarea mempengaruhi fase-fase dalam penyembuhan luka seksio sesarea. stres mengganggu proses penyembuhan luka sejak fase inflamasi. menurut glaser (2007) wanita dengan skor stres lebih tinggi menghasilkan kortisol di saliva yang tinggi pula. intervensi psikologis dan farmakologis sebelum operasi seharusnya dapat memberikan efek baik pada kualitas hidup pasien dan keluarga. simpulan dan saran simpulan fase penyembuhan luka seksio sesarea berhubungan dengan tingkat stres pasien. stres memicu peningkatan kortisol yang berdampak terhadap supresi imunitas seluler. saran peneliti menyarankan agar ibu yang akan menjalani seksio sesarea sebaiknya berusaha meminimalkan stres. dukungan dari keluarga dan tenaga kesehatan baik dukungan materiil, moril dan informasi yang mudah dipahami ibu sangat diperlukan sebelum dan setelah prosedur pembedahan. pendekatan psikologis yang berkesinambungan kepada ibu yang menjalani seksio sesarea hingga masa pemulihan paska bedah harus diterapkan oleh tenaga kesehatan. kepustakaan alegent, h. 2007. post-partum depression (baby blues), (online), (http://www.alegent.com., diakses tanggal 7 april 2007, jam 13.28 wib). debbie, n. 2003. the effects of stress on wound healing and leg ulceration, (online), (http://www.cat.inist.fr., diakses tanggal 13 maret 2007, jam 12.01 wib). glaser, j.k. 2007. relaxation, optimism and wound healing, (online), (http:// www.medicine.osu.edu/mindbody/kiec olt_glaser.com., diakses tanggal 13 maret 2007, jam 11.42 wib). glaser, j.k. 1999. researchers learn how stress slows wound healing, (online), (http:// www.researchnews.osu.edu., http://www.alegent.com/ http://www.cat.inist.fr/ http://www.medicine.osu.edu/ diakses tanggal 20 februari 2007, jam 04.42 wib). glaser, et al. 1999. stress-related changes in proinflammatory cytokine production in wounds, archives of general psychiatry, vol. 56, 450-455. h.s.t.a.t. 2007. what are the medical and psychological effects of cesarean delivery on the mother, infant, and family?, (online), (http://www.ncbi.nlm.nih.gov., diakses tanggal 7 april 2007, jam 12.26 wib). jensen, b.b. 2001. bates-jensen wound assesment tool, (online), (http://www.bradenscale.com., diakses tanggal 7 maret 2007, jam 15.13 wib). koenker, h. 1994. stress and the immune system, (online), (http://www.econ.uiuc.edu., diakses tanggal 13 maret 2007, jam 12.38 wib). lovallo, w.r. 2005. stress and health: biological and psychological interaction. second edition.california: sage publications inc., pp. 116-151. lovibond. 1995. depression anxiety stress scale 42 (dass 42), (online), (http://www.swin.edu.au., diakses tanggal 11 maret 2007, jam 22.05 wib). marucha, p. 2007. modulation of inflammation by stress and psychosocial factors, (online), (http:// www.medicine.osu.edu., diakses tanggal 13 maret 2007, jam 11.43 wib). menacker and dentzer, 2006. alert and responses: nih cesarean conference interpreting meeting and media reports, (online), (http:// www.childbirthconnection.org., diakses tanggal 7 april 2007, jam 12.53 wib). mochtar, r. 1998. sinopsis obstetri: obstetri operatif obstetri sosial. jakarta: egc, hlm. 117-156. mundy, g. 2005. pemulihan pasca operasi caesar. alih bahasa oleh anita purnamasari. jakarta: egc, hlm. 12-15 dan 34-35. nieuwenhuijsen, et al. 2003. dass: detecting anxiety disorder and depression in employees absent from work because of mental health problems, (online), (http://www.oem.bmj.com., diakses tanggal 5 juni 2007, jam 19.21 wib). petrie, k. 2003. stress slows wound healing following surgery, (online), (http://www.health.auckland.ac.nz., diakses tanggal 13 maret 2007, jam 12.09 wib). sheridan, j. 2007. mechanisms of behavioral and neuroendocrine regulation of wound healing, (online), (http://www.medicine.osu.edu., diakses tanggal 13 maret 2007, jam 11.45 wib). suriadi. 2007. manajemen luka. pontianak: percetakan romeo grafika, hlm. 1-48, 93-98, 159-163, dan 210. http://www.ncbi.nlm.nih.gov/ http://www.econ.uiuc.edu/ http://www.swin.edu.au/ http://www.medicine.osu.edu/ http://www.childbirthconnection.org/ http://www.oem.bmj.com/ http://www.medicine.osu.edu/ 66 health care-seeking behaviour of coastal communities in banyuwangi, indonesia: results of a cross-sectional survey susy k. sebayang, erni astutik, desak made sintha kurnia dewi, ayik mirayanti mandagi, septa indra puspikawati faculty of public health, universitas airlangga – banyuwangi campus, jl. wijaya kusuma no 113 banyuwangi, east java indonesia email: sksebayang@fkm.unair.ac.id abstract introduction: improving health care-seeking behaviour of the coastal communities is a pathway to improving their health. this analysis aims to explore the health care-seeking behaviour of coastal communities in banyuwangi district to recommend room for improvement for health promotion and health service improvement for these communities. method: data from a cross-sectional survey of metabolic syndrome and mental health conducted in coastal communities in banyuwangi were used for analysis. randomly selected participants from a list of members of the family welfare development group (pembinaan kesejahteraan keluarga/pkk) were asked for an interview at corresponding village offices in ketapang, bangsring, bulu agung, grajagan and kampung mandar village. distribution of health care-seeking behaviors was analysed individually and where possible segregated by gender and age. results: more than half of the coastal communities in banyuwangi district went to health care services to seek health and 7 out of 10 turned to health care services to seek health for their family members. women more than men turned to health care services when they or their family members fell ill. private doctors rather than puskesmas were more popular. private midwives were the most popular service for antenatal care (anc) and delivery. although there was not a clear increase in health care service utilisation over time, we found that contraceptive utilisation increased with time. conclusion: the utilisation of health care services in banyuwangi needs to be further promoted especially for men’s health. keywords: health care-seeking behaviour, health care services, maternal health care, coastal communities introduction as an archipelagic country, indonesia has a long coastline and abundant marine and coastal resources (hutomo & moosa 2005). under joko widodo’s government, indonesia is currently focusing its efforts on developing its marine and coastal resources to build an independent, advanced and strong maritime country (kementerian perencanaan pembangunan nasional/badan perencanaan pembangunan nasional 2014). in addition, the government of indonesia also has a mission to create a high and advanced quality of life for indonesians (kementerian perencanaan pembangunan nasional/badan perencanaan pembangunan nasional 2014). consequently, development of human resources in the coastal communities is an obvious pathway to take. however, the health of the coastal communities, as one important factor for quality human resources, is yet to be optimally improved. understanding health care-seeking behaviour is an important factor in providing for the needs of community (musoke et al. 2014). coastal communities in indonesia are usually poor and have low education (cahaya 2015). these two factors alone may affect their health care-seeking behaviour in a way that will eventually affect their health. basic health research 2013 reported that only 88.5% of farmers and fishermen access antenatal care service (anc) and 71.2% went for anc at least 4 times. it was also reported that 25% of people from these groups of the population give birth without assistance from health professionals (kementerian kesehatan ri 2013a). banyuwangi, a district located in east java, has ten coastal subdistricts and 176 km of coastline (badan pusat statistik kabupaten banyuwangi 2015). banyuwangi district government is rapidly developing its tourism industry throughout the region including in coastal areas (pemerintah kabupaten banyuwangi 2011). banyuwangi government also set improving health and access to healthcare as one of its development strategies (pemerintah kabupaten banyuwangi 2011). therefore, health care-seeking behaviour is expected to change either through specific targeting of health improvement or the growing economy of the district. however, studies on health care-seeking behaviour of banyuwangi’s coastal communities and the change over time is scarce. this study aims to health care seeking-behavior of coastal communities (susy k. sebayang et. al.) 67 explore health care-seeking behaviours of the coastal communities in banyuwangi to discover room for improvement in health services and health promotion in this area. methods the analyses used data from a survey of metabolic syndrome and mental health conducted in coastal communities in banyuwangi in september – november 2016. a permit for the survey was obtained from banyuwangi’s badan kesatuan bangsa dan politik and banyuwangi district health office. ethical clearance was approved by the ethical committee of the faculty of public health of universitas airlangga in surabaya, indonesia no 521-kepk. the original cross-sectional survey was conducted on 100 women and 51 men randomly selected from members of the family welfare development groups (pembinaan kesejahteraan keluarga/pkk) in five randomly selected villages. the selected villages were ketapang in kalipuro subdistrict, bangsring in wongsorejo subdistrict, bulu agung in silir agung subdistrict, grajagan in purwoharjo subdistrict and kampung mandar in banyuwangi subdistrict. the respondents were requested to come to their corresponding village office for an interview and health checks. the interview was conducted one on one with trained data collectors after the consent process. for the analysis of overall health careseeking behaviour, we included from the dataset men and women of productive age (aged 15–64 years old). for maternal and child health care-seeking behaviour we limited our analysis to women of reproductive age (15–45 years old). distributions of health care-seeking behaviours were analysed individually and where possible were segregated by gender and age. descriptive analysis was conducted using stata 11. results there were 97 women (66.4%) and 49 men (33.6%) in the analysis of overall health care-seeking behaviour. most respondents were 40–49 years old (43.2%) and the mean age was 44.04 ± 10.21). table 2 shows that most respondents reported going to health care services (55.2%) when they fell ill. slightly more women (58.3%) than men (48.9%) preferred to go to health care services. men preferred to purchase medicine over the counter when they were sick. for those who went to health care services, most respondents reported they went to private doctors (48.1%), followed by community health centres (puskesmas) or auxiliary community health centres (pustu) (29.1%). when their family members became sick, most respondents also reported taking their family members to health care services. the proportion of respondents who took their family members to health care services was greater than when they were sick (70.4% vs. 55.2%). more women reported taking their family members to health care services. the top three choices for health services for family members were private doctors (40%), puskesmas/pustu (31%) and private midwives (23%). we did not find a clear increase in health care service utilisation with decreasing age. women were involved in all decisions regarding their health, including going to health services for a cure or health checks or for purchasing medicine or vitamins (table 2). most men reported that their spouse was not involved in the decisions regarding men’s health. in fact, only 36,2% of men reported that their spouse alone or together with him made decisions to go to health services when he had fallen ill; 38.6% reported that their spouse was involved in the decisions to go to health service for disease prevention or health checks, and 40.8% reported women’s involvement in purchasing medicine for their spouse. nearly 70% of women of reproductive age went to a private midwife for anc for her youngest child. the utilisation of private midwives tended to reduce with time. village level services such as posyandu, polindes or poskesdes were accessed more by women aged 30–39 years old. for delivery, 67.2% of women chose maternity clinics or health professionals’ private practices, followed by hospital birth (23%). although most women breastfed their children, only 48.4% of women exclusively breastfed their children. however, younger women exclusively breastfed their children (63.6%) compared to older women (54.6% for 30–39 years old and 37.9% for 40– jurnal ners vol. 12 no. 1 april 2017: 66-73 68 45 years old), showing an increase in the practice over time (table 3). seventy percent of women reported using contraception currently. there was an apparent increase in trends towards birth control use with time. younger women used contraception more commonly compared to older women (figure 1). most women used injectables (48%) followed by pills (20%) and intrauterine devices (iuds) (17%). there was an increasing trend towards the use of pills and implants as more younger women used pills and implants than older women (figure 2). we found a similar tendency when we limited our analysis to maternal health careseeking behaviour amongst women with children under five years old (n=27). in this subset of women, 51.8% went to private midwives for anc, 51.9% went to maternity clinics or private health professionals followed by 40.7% who went to hospitals for delivery, and 48.2% exclusively breastfed their children. more women currently used contraceptive methods in this subset of women (89%), with birth control injectables and pills remaining the top two favourite contraceptive methods. table 1. health care-seeking behaviour of male and female respondents aged 15–64 years old questions and categories women men total n % n % n % what do you do when you are sick? nothing 1 1.0 2 4.3 3 2.1 buy medicine in shops 25 26.0 16 34.0 41 28.7 buy medicine in pharmacies without prescription 4 4.2 3 6.4 7 4.9 go to health care services 56 58.3 23 48.9 79 55.2 other 10 10.4 3 6.4 13 9.09 if you go to health care services which health care services do you go to? community health centre (puskesmas) / auxiliary puskesmas 17 30.4 6 26.1 23 29.1 private midwife 10 17.9 2 8.7 12 15.2 private nurse 3 5.4 2 8.7 5 6.3 private doctor 26 46.4 12 52.2 38 48.1 private hospital 0 0.0 1 4.4 1 1.3 what do you do if a member of your family is sick nothing 1 1.1 0 0.0 1 0.7 buy medicine in shops 17 17.9 12 25.5 29 20.4 buy medicine in pharmacies without prescription 3 3.2 3 6.4 6 4.2 go to health care services 69 72.6 31 66.0 100 70.4 other 5 5.3 1 2.1 6 4.2 if you take your family members to health services which health care services do you take them to? community health centre (puskesmas) / auxiliary puskesmas 21 30.4 10 32.3 31 31.0 private midwife 17 24.6 6 19.4 23 23.0 private nurse 1 1.5 3 9.7 4 4.0 private doctor 30 43.5 10 32.3 40 40.0 private hospital 0 0.0 2 6.5 2 2.0 health care seeking-behavior of coastal communities (susy k. sebayang et. al.) 69 table 2. women’s involvement in household decision-making type of decisions women men total n % n % n % to go to health services when sick women not involved 21 22.3 30 63.8 51 36.2 women involved 73 77.7 17 36.2 90 63.8 to go to health services for disease prevention or health checks women not involved 12 15.2 27 61.4 39 31.7 women involved 67 84.8 17 38.6 84 68.3 to purchase pharmaceutical medicine, herbal medicine, or vitamins women not involved 18 19.0 29 59.2 47 32.6 women involved 77 81.1 20 40.8 97 67.4 table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15– 45 years old age groups (years) type of care <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas atau pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 jurnal ners vol. 12 no. 1 april 2017: 66-73 70 figure 1. current contraception use among women aged 15–45 years old by age group figure 2. type of contraceptive methods used by women aged 15–45 years old by age group discussion our study found that more than half of the coastal communities in banyuwangi district went to health care services to seek health and 7 out of 10 turned to health care services to seek health for their family members. women more than men turned to health care services when they or their family members fell ill. interestingly, they chose to go to private doctors more than puskesmas. in these communities women took part in household decision-making for their health and men reported that women were less involved in the decision-making for men’s health. private midwives were the most popular service for anc and delivery. we found that these coastal communities accessed health care services more than traditional coastal communities such as in south east sulawesi or east kalimantan where traditional healers remained the primary providers of health care (martiyana and handayani 2015; nurrachmawati and anggraeni 2010). more women than men in our study went to seek help from health care services. this fact is also reported for other countries especially for cases of sexually transmitted diseases (cornell 2013). that men’s health care seeking behaviour is lower than that of women for any disease in indonesian coastal communities is an interesting finding. in fact, a study on gender inequalities in health care-seeking behaviour in indonesia and globally are rarely conducted (cornell 2013), and this finding contributes to the knowledge of gender differentials in health care-seeking behaviour. our study found that most women in our study area (67.2%) gave health care seeking-behavior of coastal communities (susy k. sebayang et. al.) 71 birth at maternity clinics or private health professional practices, followed by hospital births (23%). our findings are similar in trend to the results from basic health research in 2013 in banyuwangi. the 2013 survey reported that most mothers (76.1%) in banyuwangi went to maternity clinics or private health professionals to give birth, followed by hospital births (10.7%) (kementerian kesehatan ri 2013b). although similar in trend, compared to the general banyuwangi population, there is a lower proportion of women who gave birth in maternity clinics, or private practices and more women gave birth in a hospital in our study population. our estimate was slightly lower for women’s involvement in decision-making on their health compared to an estimate for east java from a national survey that found 82% of women in east java were involved in decisionmaking for their health (statistics indonesia 2013). current contraceptive use in our study area was 75% which was higher than the reported current contraceptive use for all banyuwangi subdistricts (63%) (kementerian kesehatan ri 2013b). the fact that more women went to seek health care services than men may indicate that health care services were more popular for women as they provided more maternal and child care than specific men’s health care. lower access by men to health care services can partly be explained by less involvement of women in the decision-making for men’s health. although we did not find a clear increase in the proportion of health care service utilisation over time, there was an increase in contraception utilisation over time. the fact that private doctors were more popular than puskesmas can be explained by the fact that we randomly selected respondents from pkk members who usually come from middle-upper socio-economic status. studies have shown that availability of health insurance improved formal health facility utilization (fenny et al. 2015), especially among the low-income groups (paek et al. 2016). however, despite the availability of national free delivery program (jampersal) and national health insurance program, access of puskesmas for birth in these communities has not increased with time. this, however, needs to be further studied as the number of women with children under five years old in this study, that can represent maternal health care-seeking behavior in the last five years, was limited. although most women accessed institutionalized service for anc and delivery, the quality of health care services received, however, may not be enough to impact exclusive breastfeeding. this supports the fact that although the trend of exclusive breastfeeding increased, the number was still low at 63.6% for women <30 years old. the strength of this study was that we randomly selected respondents from five different subdistricts and as such we covered all the major and minor ethnic groups in the coastal areas including javanese, maduranese, osing and other ethnic groups. although the sample size was not balanced between men and women, we were able to present segregated analysis of health care-seeking behavior. our samples were randomly selected from pkk members. although pkk members usually represent the upper middle class of the communities, we were still able to find that access to health care service in this community was low (55.2%). another weakness of the study was that the number of pkk members who had under five-year-old children was limited and thus our estimates of maternal and child health care-seeking behavior must be interpreted with caution. our study suggests the need for promotions on the utilization of health care service especially puskesmas in coastal communities of banyuwangi. there is especially need to focus on improving men’s access to health care. in indonesia and many other developing countries, health care has been promoted more on providing health care for women and children as they are considered to be more vulnerable compared to men. health promotion with a specific message for improving access to health care utilization among men is very scarce. brotherhood system in which men become a member of the male group may also be utilized to create peer pressure towards health care service utilization (grande et al. 2013). the programmatic implication above may be applicable not only to banyuwangi’s coastal communities but also to other coastal communities in indonesia. however, studies for other coastal communities are needed to assess how culture affect health care seeking differently. there need to be further studies on gender inequalities in health care for men. further studies are also needed to assess the jurnal ners vol. 12 no. 1 april 2017: 66-73 72 changes in health care-seeking behavior about the utilization of national health insurance scheme in coastal communities. as teen pregnancy in banyuwangi is still frequent, this study should include factors affecting maternal health care-seeking behavior of adolescent mothers at the individual, interpersonal and family, community and social as well as organizational and health systems level (shahabuddin et al. 2017). our findings also implied the need for promotion of exclusive breastfeeding in these coastal communities. in addition, there also needs to be more studies on the quality of available health care services in these coastal communities. there are 12,827 coastal villages in indonesia (badan pusat statistik 2015). health care-seeking behavior in other coastal villages in indonesia may differ from banyuwangi. therefore, more studies need to be done in other coastal villages to help design appropriate health promotion strategies for coastal communities. conclusion slightly half of the community members in the coasts of banyuwangi accessed health care service for themselves and 7 out of 10 accessed it for their family members. private midwives were the most popular service for anc and delivery. the utilization of health care service needs to be more promoted in coastal communities, especially for men’s health. references badan pusat statistik, 2015. jumlah desa/kelurahan menurut provinsi dan letak geografi, 2003 – 2014. cahaya, a., 2015. fishermen community in the coastal area: a note from indonesian poor family. procedia economics and finance, 26, pp.29–33. available at: http://linkinghub.elsevier.com/retrieve/pii /s2212567115008011. cornell m, 2013. gender inequality: bad for men’s health. south afr j hiv med, 14(1), pp.12–14. fenny, a.p. et al., 2015. treatment-seeking behaviour and social health insurance in africa: the case of ghana under the national health insurance scheme. global journal of health science, 7(1). grande, s.w., sherman, l. & shaw-ridley, m., 2013. a brotherhood perspective. american journal of men’s health, 7(6), pp.494–503. hutomo, m. & moosa, m.k., 2005. indonesian marine and coastal biodiversity: present status. indian journal of marine sciences, 34(1), pp.88–97. available at: http://nopr.niscair.res.in/handle/12345678 9/1546. kementerian kesehatan ri, 2013a. riset kesehatan dasar 2013 dalam angka, kementerian kesehatan ri, 2013b. riset kesehatan dasar dalam angkariskesdas 2013: provinsi jawa timur, kementerian perencanaan pembangunan nasional/badan perencanaan pembangunan nasional, 2014. rancangan awal rencana pembangunan jangka menengah nasional 2015 – 2019: buku i -agenda pembangunan nasional, jakarta: kementerian perencanaan pembangunan nasional/badan perencanaan pembangunan nasional. martiyana, c. & handayani, l., 2016. health seeking behaviour of non communicable disease in sulaho village, lasusua sub district, north kolaka regency. buletin penelitian sistem kesehatan, 18(4), pp.377–386. musoke, d. et al., 2014. health seeking behaviour and challenges in utilising health facilities in wakiso district, uganda. african health sciences, 14(4), pp.1046–55. available at: http://www.ncbi.nlm.nih.gov/pubmed/25 834516. nurrachmawati a and anggraeni i., 2010. tradisi kepercayaan masyarakat pesisir mengenai kesehatan ibu di desa tanjung limau muara badak kalimantan timur tahun 2008. jurnal kesehatan reproduksi, 1(1), pp.42–50. paek, s.c., meemon, n. & wan, t.t.h., 2016. thailand’s universal coverage scheme and its impact on health-seeking behavior. springerplus, 5(1), p.1952. pemerintah kabupaten banyuwangi, 2011. rencana pembangunan jangka menengah daerah kabupaten banyuwangi tahun 2010 – 2015, banyuwangi: pemerintah kabupaten banyuwangi. shahabuddin, a. et al., 2017. exploring maternal health care-seeking behavior health care seeking-behavior of coastal communities (susy k. sebayang et. al.) 73 of married adolescent girls in bangladesh: a social-ecological approach u. simeoni, ed. plos one, 12(1), p.e0169109. statistics indonesia, 2013. survey demografi dan kesehatan indonesia indonesia demographic and health survey. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 175 persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan (perception of tb bta (+) patients about treatment with healing status) purwaningsih*, hanik endang nihayati*, khikmatul mu’jizah* abstract introduction: tuberculosis (tb) is infection disease that remains a major global public-health problem. although it is curable and preventable, tb remains a major cause of morbidity and mortality. wrong perception about tb and treatment often make non-adherence to treatment regimen. this study was aimed to analyze the correlation between perception of tb bta (+) patients about treatment with healing status. method: this research used cross sectional-retrospective design. the sample were 23 tb bta (+). the independent variable was perception of tb bta (+) patients about treatment and dependent variable was healing status. the data were analyzed by kolmogorovsmirnov test with significance α≤ 0.05. result: the result showed that perception of tb bta (+) patients about treatment did not has significance level with healing status (p=1,00). analysis: it can be concluded that perception of tb bta (+) patients about treatment did not has correlation with healing status. discussion: it is recommended to the turen public health center about tb programme to include health education for tb patients and family regularly in addition to increase patients adherence. keywords : tuberculosis, perception, treatment, healing status * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: purwaningsih_ners@unair.ac.id pendahuluan penyakit tuberculosis (tb), masih menjadi masalah kesehatan masyarakat. who memperkirakan bakteri ini membunuh sekitar 2 juta jiwa setiap tahun. jika dihitung, pertambahan jumlah pasien tb akan bertambah sekitar 2,8-5,6 juta setiap tahun, dan 1,1-2,2 juta jiwa meninggal setiap tahun karena tb (rs. infeksi prof. dr. sulianti saroso, 2007). indonesia tercatat menduduki peringkat ke-3 tertinggi dunia, setelah cina dan india dengan jumlah pasien sekitar 10% dari total jumlah pasien tb di dunia. insidens kasus bta positif (menular) tahun 2005 diperkirakan 107 kasus baru/100.000 penduduk (246.000 kasus baru setiap tahun) dan prevalensi 597.000 kasus dalam semua kasus. berdasarkan pedoman nasional penanggulangan tuberkulosis di indonesia, who mentargetkan angka kesembuhan yang harus dicapai adalah >85% dengan merekomendasikan dots (directly observed treatment shortcourse) sejak tahun 1991 dan baru diterapkan di indonesia tahun 1995. dots adalah strategi yang paling efektif untuk menangani penderita tb saat ini, dengan angka kesembuhan 87% pada tahun 19951998 dan 89,7% pada tahun 2007 melebihi target who (depkes ri, 2007). tetapi pada tahun 2004, angka kesembuhan menurun menjadi 60%. bahkan, angka kesembuhan bagi penderita tb di rumah sakit masih rendah yaitu 47% (siswono, 2004). angka kesembuhan yang rendah mengindikasikan adanya ketidakberhasilan pengobatan tb. penelitian yang dilakukan di india, swaziland, thailand dan zambia menunjukkan bahwa banyak penderita tb yang mengalami kegagalan dalam pengobatan karena mereka menghentikan pengobatan segera setelah mereka merasa kondisinya lebih baik dan/ atau selama 2 bulan menjalani pengobatan (waisbord , 2005), misalnya di india, penderita menghentikan pengobatan disebabkan kesalahan persepsi penderita tb tentang pengobatan dengan kesembuhan, juga adanya penderita yang tidak tahu tentang potensial efek samping dari obat. mailto:purwaningsih_ners@unair.ac.id jurnal ners vol. 4 no. 2: 175-181 176 pada saat peneliti melakukan pendataan awal pada tanggal 29 april 2009 – 12 mei 2009 di puskesmas turen kabupaten malang, diperoleh data angka kesembuhan pasien tb pada tahun 2006 mencapai 80% dan tahun 2007 mencapai 79,5%. namun pada tahun 2008 mengalami penurunan menjadi 59,26 %. pada tahun 2008, terhitung dari bulan januari sampai bulan november 2008 angka kesembuhan diperoleh dari jumlah penderita tb bta (+) yang dinyatakan sembuh sebanyak 32 orang dibagi dengan jumlah penderita tb bta (+) yang diobati sebanyak 54 orang. menurut dyahsih mukti lestari, 2009 (koordinator bidang tb paru puskesmas turen), beberapa faktor yang menyebabkan menurunnya angka kesembuhan tersebut seperti ketidakpatuhan pasien tb dalam melaksanakan regimen pengobatan tb dan pemeriksaan sputum di akhir intensif (bulan ke-2), 1 bulan sebelum ap/akhir pengobatan (bulan ke-5) dan ap (bulan ke-7 atau setelah obat terakhir habis). pemeriksaan sputum ulang pada ap sangat penting karena sebagai evaluasi hasil pengobatan dan penentu status kesembuhan pasien. target angka kesembuhan yang belum tercapai dapat menjadi masalah serius yang dihadapi tenaga kesehatan karena menunjukkan status kesembuhan pasien tidak diketahui. sehingga pihak unit pelayanan kesehatan yang menangani tidak mengetahui keberhasilan dari pengobatan yang diberikan. apabila banyak pasien yang belum sembuh tapi tidak terdeteksi, maka masalah yang bisa muncul adalah banyaknya pasien tb yang tersebar di indonesia tanpa penanganan yang tepat, sehingga dapat mempermudah penularan pada orang sehat disekitarnya. dampak pasien yang tanpa pengobatan, setelah lima tahun 50 % dari penderita tb akan meninggal, 25 % akan sembuh sendiri dengan daya tahan tubuh tinggi dan 25 % sebagai kasus kronik yang tetap menular (who, 1996 dikutip oleh rs. infeksi prof. dr. sulianti saroso, 2007). jika satu orang pasien bisa menularkan ke 10-15 orang, pada tahun berikutnya jumlah yang tertular adalah 5,8 juta orang (rs. infeksi prof. dr. sulianti saroso, 2007). dampak dari ketidakberhasilan pengobatan di masa lalu yang menjadikan penderita dinyatakan tidak sembuh, juga memungkinkan timbulnya kekebalan kuman tb terhadap oat (obat anti tuberkulosis) secara meluas atau multi drug resistance (mdr). jika pasien mdr masih tidak patuh juga, ia akan menjadi pasien xdr-tb yaitu resistensi obat yang sudah tahap ekstrem. biasanya kuman sudah resisten terhadap dua jenis obat atau lebih. biaya pengobatan pun bisa 25 kali lipat dari pengobatan tb biasa (yohan, 2008). tb adalah penyakit yang sangat perlu mendapat perhatian untuk ditanggulangi. permasalahan yang penting untuk difokuskan adalah persepsi penderita tb tentang pengobatan yang dimungkinkan memiliki hubungan dengan kejadian penurunan angka kesembuhan penderita tb. jadi, yang menjadi masalah dalam penelitian ini adalah angka kesembuhan penderita tb tahun 2008 di puskesmas turen kabupaten malang baru mencapai 59,26 %. oleh karena itu, hubungan persepsi penderita tb tentang pengobatan dengan status kesembuhan perlu diteliti lebih lanjut. bahan dan metode penelitian desain dalam penelitian ini adalah cross sectional secara retrospektif. populasi yang digunakan adalah seluruh penderita tb tahun 2008 di wilayah cakupan puskesmas turen kabupaten malang dengan besar sampel 23 orang, diperoleh dengan menggunakan tehnik purposive sampling yang memenuhi kriteria inklusi sebagai berikut 1) penderita baru tb bta (+) tahun 2008 2) tidak sedang minum oat atau telah selesai menjalani pengobatan (baik lengkap maupun tidak) variabel independen dalam penelitian ini yaitu persepsi penderita tb sedangkan variabel dependen adalah status kesembuhan. instrumen yang digunakan untuk mengukur variabel independen menggunakan kuesioner tentang pengobatan berdasarkan kuesioner yang dimodifikasi dari treatment perceptions questionnaire (tpq) oleh john marsden et al (1998). sedangkan untuk mengukur variabel dependen yaitu status kesembuhan adalah dengan observasi menggunakan data tb 03 puskesmas turen kabupaten malang yang berisi tentang seluruh data penderita tb. data diolah dan dianalisis dengan menggunakan uji statistik two-sample kolmogorovsmirnov test dengan tingkat kemaknaan α ≤0,05, yang berarti ada hubungan bermakna antara dua variabel yang diukur yaitu ada persepsi penderita tb bta (+) (purwaningsih) 177 hubungan antara persepsi penderita tb tentang kesembuhan dengan angka kesembuhan. hasil penelitian tabel 1 merupakan hasil hubungan persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan menunjukan bahwa terdapat 13 orang penderita (56,52%) telah sembuh, 5 orang penderita (21,74%) pengobatan lengkap dan 5 orang penderita (56,52%) berstatus default (putus berobat). dari tabel 1 tersebut juga terlihat bahwa hampir seluruh responden memiliki persepsi positif terhadap pengobatan yang telah dijalaninya, yaitu sebanyak 12 orang penderita (52,17%). sedangkan terdapat 11 orang penderita (47,83%) memiliki persepsi negatif. analisis menggunakan uji statistik 2-sample kolmogorov smirnov diperoleh nilai p = 1,00. artinya tidak ada hubungan yang bermakna antara persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan. pembahasan hasil penelitian menunjukkan bahwa mayoritas responden berpersepsi positif. hal ini disebabkan karena mereka menganggap seluruh rangkaian pengobatan yang telah dijalani sudah baik dan sesuai prosedur. walaupun terdapat beberapa responden yang masih menganggap kurang, tetapi sebagian responden tetap memberi tanggapan bagus pada item-item yang tercantum pada kuesioner. penelitian yang dilakukan oleh zhang dkk (2007) menunjukan hasil bahwa adanya beberapa faktor yang berhubungan dengan pengetahuan dan persepsi, yaitu usia, jenis kelamin, etnis (suku bangsa), tingkat pendapatan dan pendidikan. menurut robbins & judge (2008), terdapat beberapa faktor yang berperan untuk membentuk dan terkadang mengubah persepsi, yaitu bisa terletak dalam diri pembentuk persepsi, dalam diri objek atau target yang diartikan dan konteks situasi dimana persepsi tersebut dibuat. widayatun (1999) menjelaskan bahwa seseorang dalam mempersepsikan sesuatu dipengaruhi oleh dua faktor, yaitu faktor intrinsik : 1) usia, 2) pembawaan, 3) kebutuhan, 4) kematangan, 5) pengalaman dan 6) fisik dan kesehatan. faktor ekstrinsik, meliputi : 1) lingkungan, 2) keluarga, 3) teman sebaya, 4) sosial budaya, 5) norma masyarakat, dan lainlain. walgito (2003) menyatakan persepsi ada 3 macam, meliputi : 1) persepsi diri yaitu bila objek persepsi diri pribadi seseorang mengenai ciri-ciri dan kualitas dirinya sendiri. pada persepsi diri sendiri, orang akan mengerti dirinya sendiri sehingga seseorang dapat mengevaluasi tentang dirinya sendiri, 2) persepsi benda, yaitu bila objek persepsi berwujud benda-benda dan 3) persepsi orang yaitu bila objek persepsi berwujud manusia atau orang. data mengenai persepsi responden dalam penelitian ini menunjukkan bahwa distribusi persepsi penderita seimbang. persepsi positif dimiliki oleh responden yang berasal dari segala kategori umur, jenis kelamin, tingkat pendapatan maupun berbagai macam tingkat pendidikan, begitu juga pada responden yang berpersepsi negatif. responden yang berstatus sembuh, pengobatan lengkap serta default juga memiliki distribusi yang rata baik pada persepsi positif maupun negatif. pada penelitian ini karakteristik demografi tidak mempengaruhi persepsi responden. terdapat beberapa responden yang bercerita bahwa seburuk apapun atau sesulit apapun pengobatan tb yang harus dijalaninya, mereka akan tetap berusaha berjuang menjalaninya karena adanya keinginan yang kuat untuk sembuh. sebagian besar dari responden menganggap bahwa sebenarnya pelayanan yang diberikan petugas kesehatan, fasilitas yang diberikan, prosedur tentang pengobatan dan pemeriksaan dahak sudah sangat baik. tetapi jika terdapat beberapa kesalahan dalam pelaksanaan pengobatan, misalnya tidak mengikuti tes dahak ulang atau berhenti berobat, kesalahan tersebut berasal dari penderita sendiri. mereka mengaku bahwa rasa malas, bosan, bahkan tidak mau minum obat memang dikarenakan kurangnya kesadaran penderita. padahal mereka juga sering mendapatkan penyuluhan dari petugas kesehatan di puskesmas turen yang menangani dan pengawasan dari pmo yang ditunjuk. selain itu, juga ada beberapa responden yang merasa takut karena menganggap hasil penelitian ini akan berdampak nantinya bagi dia, ada juga yang takut karena ini berhubungan dengan puskesmas. jurnal ners vol. 4 no. 2: 175-181 178 tabel 1. tabulasi silang persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan di puskesmas turen kab. malang 13-18 juli 2009 keterangan: p = signifikansi ∑ = jumlah % = prosentase data hasil juga menunjukkan bahwa mayoritas responden memiliki tingkat pendidikan rendah, yaitu sd dan cukup banyak yang berusia >50 tahun hal ini menyebabkan responden bisa berpikiran seperti yang telah dijelaskan sebelumnya. sehingga mereka lebih memilih untuk menjawab yang baik-baik saja daripada nantinya ada dampak buruk pada mereka. responden yang memiliki persepsi negatif beberapa diantaranya memiliki tingkat pendidikan paling tinggi diantara yang lain, yaitu sma dan berusia pada rentang 21-35 tahun serta beberapa juga memiliki tingkat pendapatan cukup yaitu pada rentang 500.0001.000.000. beberapa alasan yang menyebabkan hasil persepsi mereka negatif berdasarkan kuesioner adalah mereka masih merasa kurang mendapatkan pelayanan yang maksimal dari puskesmas dan pmo yang ditunjuk selama pelaksanaan pengobatannya berlangsung, tidak menyukai pengobatan dan peraturan dari pengobatan dikarenakan lamanya pengobatan serta mengganggu aktivitas sehari-hari mereka. buku pedoman nasional penanggulangan tuberkulosis oleh departemen kesehatan ri (2008) menunjukkan bahwa status kesembuhan penderita tb dapat dilihat dari hasil pengobatan yang dikategorikan sebagai berikut : 1) sembuh yaitu pasien telah menyelesaikan pengobatannya secara lengkap dan pemeriksaan ulang dahak (follow-up) hasilnya negatif pada akhir pengobatan (ap) serta minimal satu pemeriksaan follow-up sebelumnya negatif, 2) pengobatan lengkap adalah pasien yang telah menyelesaikan pengobatannya secara lengkap tetapi tidak memenuhi persyaratan sembuh atau gagal, 3) meninggal adalah pasien yang meninggal dalam masa pengobatan karena sebab apapun, 4) pindah adalah pasien yang pindah berobat ke unit dengan register tb 03 yang lain dan hasil pengobatannya tidak diketahui, 5) default (putus berobat) adalah pasien yang tidak berobat 2 bulan berturut-turut atau lebih sebelum masa pengobatannya selesai dan 6) gagal adalah pasien dengan hasil pemeriksaan dahak tetap positif atau kembali menjadi positif pada bulan kelima atau lebih selama pengobatan. responden yang telah dinyatakan sembuh mengatakan bahwa mereka selalu rajin menjalani pengobatan dan tes pemeriksaan dahak ulang sesuai dengan yang dianjurkan oleh petugas. walaupun banyak kesibukan mereka tetap rutin mengambil obat ke puskesmas tiap satu minggu sekali. responden mengatakan bahwa penyakit mereka menular dan juga mengetahui resiko jika mereka menghentikan minum obat dan tidak tes dahak, yaitu bakteri akan kebal dan pengobatannya akan jauh lebih mahal, bahkan bisa meninggal dunia. sehingga mereka tetap menganggap pengobatan selama 6 bulan dan tes pemeriksaan dahak ulang wajib dilaksanakan jika mereka menginginkan cepat sembuh dan tidak mau menularkan penyakitnya pada keluarga di rumah. data responden menunjukkan bahwa mayoritas berpendidikan sd, hal ini sedikit berlawanan, karena walaupun dengan tingkat pendidikan yang rendah, penderita dan keluarga tetap memiliki kesadaran yang cukup tinggi untuk persepsi penderita tb bta (+) tentang pengobatan status pengobatan sembuh pengobatan lengkap default (putus berobat) total ∑ % ∑ % ∑ % ∑ % positif 7 30,43 2 8,7 3 13,04 12 52,17 negatif 6 26,09 3 13,04 2 8,7 11 47,83 total 13 56,52 5 21,74 5 21,74 23 100 two-sample kolmogorov-smirnov test p=1,00 persepsi penderita tb bta (+) (purwaningsih) 179 tetap menjalankan prosedur pengobatan sebagaimana mestinya. responden yang berstatus pengobatan lengkap ada yang menganggap bahwa tes pemeriksaan dahak pada akhir pengobatan (ap) tidak perlu sehingga dia cukup melaksanakan minum obat saja. selain itu beberapa alasan lain adalah adanya kebosanan minum obat di bulan-bulan akhir masa pengobatan, ketidaktahuan bahwa setelah masa berobat habis diharuskan mengikuti tes dahak pada akhir pengobatan (ap) dan juga ada yang harus pergi ke luar kota sehingga mereka tidak sempat mengikuti tes dahak pada akhir pengobatan (ap). responden yang mengalami default (putus berobat) mengatakan bahwa alasan mereka menghentikan pengobatan disebabkan tidak punya biaya untuk datang berulang kali mengambil obat ke puskesmas karena jarak rumah yang jauh, kurangnya pemahaman tentang penyakit tb dan dampak penghentian obat anti tuberkulosis (oat), dan tidak menyukai lamanya regimen pengobatan karena bosan. selain itu juga ada responden yang sebenarnya mau menjalankan pengobatan dan tahu dampak jika dia tidak menjalankan pengobatan. tetapi karena tidak sabar dengan lamanya pengobatan, baru minum obat beberapa saja sudah menganggap obat dari puskesmas kurang manjur dan penyakitnya tidak kunjung sembuh, sehingga memutuskan untuk pindah ke unit pelayanan kesehatan yang lain. hasil uji statistik kormogorovsmirnov dengan tingkat kemaknaan α<0,05 menunjukkan nilai p=1,00. artinya tidak ada hubungan yang bermakna antara persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan. dalam sosiologi kesehatan dikenal perbedaan antara konsep disease dan illness. effendi (2009) merumuskan disease (penyakit) adalah gangguan fungsi fisiologis dari suatu organisme sebagai akibat dari infeksi atau tekanan dari lingkungan, baginya disease bersifat objektif. sedangkan illness (sakit) sebagai penilaian individu terhadap pengalaman menderita penyakit; baginya illness bersifat subjektif. penyakit merupakan suatu produk budaya. konsep sakit berkembang berbeda-beda di masyarakat. anggota masyarakat yang merasakan penyakit akan menampilkan perilaku sakit. effendi (2009) menambahkan, perilaku sakit merupakan segala bentuk tindakan yang dilakukan oleh individu yang sedang sakit agar memperoleh kesembuhan. sedangkan berdasarkan teori perilaku sakit menurut mechanic dalam effendi (2009) yang dikenal sebagai coping response theory, mengatakan bahwa perilaku sakit adalah reaksi optimal dari individu jika dia terkena suatu penyakit. terdapat 2 faktor utama yang menentukan perilaku sakit, yaitu: 1) persepsi atau definisi individu tentang suatu situasi atau penyakit dan 2) kemampuan individu untuk melawan serangan penyakit tersebut. tanggapan seseorang terhadap suatu penyakit ditentukan oleh berbagai faktor. subyektifitas masyarakat dalam menanggapi kondisi sakitnya dipengaruhi oleh faktorfaktor ekonomi, budaya dan sosial (effendi, 2009). menurut mechanic dalam effendi (2009) berbagai faktor yang menyebabkan orang bereaksi terhadap penyakit adalah : 1) dirasakannya gejala/tanda yang menyimpang dari keadaan biasa, 2) banyaknya gejala yang dianggap serius, 3) dampak gejala terhadap hubungan social, 4) frekuensi dari gejala yang tampak dan persistennya, 5) susceptibility atau kemungkinan individu untuk diserang penyakit itu, 6) informasi dan asumsi budaya tentang penyakit itu, 7) perbedaan interpretasi terhadap gejala yang dikenalnya, 8) adanya kebutuhan untuk bertindak mengatasi gejala sakit dan 9) tersedianya sarana kesehatan. tanggapan dan persepsi akan mempengaruhi motivasi seseorang untuk berupaya mencari pelayanan kesehatan. menurut teori kaitan imbalan dengan prestasi, motivasi seorang individu sangat dipengaruhi oleh berbagai faktor, baik yang bersifat internal maupun eksternal. selain itu juga ada beberapa faktor yang mempengaruhi perilaku individu mencari pertolongan yaitu faktor sosio demografi (umur, jenis kelamin, status sosial, status ekonomi, pendidikan dan budaya), interaksi sosial dan faktor internal. termasuk pada faktor internal yaitu: a) persepsi seseorang, b) harga diri, c) harapan pribadi, d) kebutuhan, e) keinginan, f) kepuasan dan g) prestasi yang dihasilkan (sudrajat, 2008). perilaku upaya kesehatan ini memungkinkan orang yang sakit untuk mengakses pelayanan kesehatan dan memperoleh kesehatannya kembali. sesuai jurnal ners vol. 4 no. 2: 175-181 180 dengan beberapa teori yang telah dijelaskan di atas, maka harapannya penelitian tentang hubungan persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan memiliki hubungan yang bermakna. sejak penderita terdiagnosa tb terutama tb dengan bta (+), maka penderita sudah mulai direncanakan jadwal pengobatan selama 6 bulan disertai tes pemeriksaan dahak ulang secara rutin. tanggapan setiap penderita tentang penyakit yang diderita tentunya berbeda-beda. perbedaan inilah yang nantinya menentukan tinggi rendahnya motivasi penderita untuk berobat dan melanjutkan pengobatan serta mematuhi berbagai peraturan pengobatan hinggga akhir. adanya latar belakang pendidikan, umur, jenis kelamin, suku bangsa dan tingkat pendidikan memiliki pengaruh yang cukup kuat terhadap persepsi mereka. jika mereka menganggap penyakitnya adalah bahaya dan harus disembuhkan, maka mereka akan memutuskan pergi mencari bantuan kesehatan ke unit pelayanan kesehatan (puskesmas). persepsi yang positif dari penderita akan memunculkan motivasi yang tinggi dan akan berpengaruh pada tindakannnya, yaitu akan muncul kepatuhan yang tinggi pula dalam menjalani pengobatan dan peraturan yang ada. hasil uji statistik yang telah dijelaskan sebelumnya, menunjukkan bahwa tidak adanya hubungan yang bermakna antara persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan. berdasarkan teori dan penelitian yang telah dilakukan oleh zhang sebelumnya bahwa wanita, penderita dengan usia lanjut, tingkat pendapatan rendah dan tingkat pendidikan rendah lebih cenderung memiliki kemauan rendah untuk datang dan mencari bantuan ke unit pelayanan kesehatan. sehingga harapannya, pada penelitian ini bisa menghasilkan bahwa dengan tingkat kemauan yang rendah untuk datang ke puskesmas turen, penderita tidak mau memulai atau melanjutkan pengobatan, sehingga akan banyak ditemukan penderita yang default (putus berobat), gagal, tidak sembuh atau pengobatan lengkap oleh karena distribusi karakteristik demografi responden cukup banyak yang berusia lanjut (>50 tahun), mayoritas berpendidikan rendah, dan tingkat pendapatan rendah. dengan karakteristik seperti itu, dimungkinkan mereka memiliki tingkat pemahaman yang rendah sehingga mungkin muncul persepsi negatif. oleh karena itu, diharapkan pula jika responden memiliki persepsi negatif maka ia akan memiliki status kesembuhan yang tidak baik, yaitu default, gagal, atau pengobatan lengkap. begitu juga sebaliknya, jika responden berpersepsi positif maka status kesembuhan mereka bagus, yaitu sembuh. hasil yang menarik pada penelitian ini yaitu walaupun mayoritas responden memiliki tingkat pendidikan dan pendapatan yang rendah serta berada pada usia lanjut, hampir terbagi sama bahwa responden memiliki persepsi positif maupun negatif. begitu juga dengan status kesembuhannya, baik yang sembuh maupun yang telah default (putus berobat) ada yang memiliki persepsi positif maupun negatif terhadap pengobatan yang telah dijalaninya sehingga sulit untuk dikategorikan bahwa yang persepsi positif akan sembuh atau sebaliknya. hal ini menunjukkan bahwa tidak adanya hubungan karakteristik demografi responden terhadap persepsi maupun perilaku responden untuk datang mencari pelayanan kesehatan yang nantinya menentukan status kesembuhannya. persepsi dihubungkan dengan perilaku mencari kesehatan atau perilaku penderita untuk datang ke unit pelayanan kesehatan. dapat juga dihubungkan dengan tingkat kepatuhan penderita tb untuk menyelesaikan pengobatan atau menghentikan pengobatan. beberapa kondisi di lapangan yang memungkinkan tidak adanya hubungan lurus antara persepsi dengan status kesembuhan seperti, di puskesmas turen tidak memungut biaya yang tinggi, jarak yang perlu ditempuh antara rumah dengan puskesmas masih dapat terjangkau, pelayanan yang diberikan oleh petugas tetap berkualitas dan sesuai dengan standard prosedur yang seharusnya dan dukungan yang kuat dari keluarga maupun pmo yang ditunjuk. bila ada kesalahan, ini penyebabnya adalah penderita sendiri. beberapa hal inilah yang menurut peneliti memungkinkan responden tetap berpersepsi positif dan tetap antusias untuk menyelesaikan pengobatan hingga akhir serta tetap patuh menjalani tes pemeriksaan dahak ulang. walaupun ada beberapa responden yang memang dengan sengaja menghentikan pengobatannya karena terkendala dengan biaya untuk datang berulang kali ke persepsi penderita tb bta (+) (purwaningsih) 181 puskesmas dikarenakan jarak yang jauh sementara tidak memiliki kendaraan pribadi, selain itu ada yang menghentikan pengobatannya karena memang pengetahuannya yang rendah tentang pengobatan dan bahaya tb jika tidak menyelesaikan pengobatan hingga tuntas, sehingga membuat status kesembuhan mereka default ataupun pengobatan lengkap. namun mereka tetap berpersepsi positif terhadap pengobatan yang telah dijalaninya berdasarkan beberapa pernyataan yang tercantum di kuesioner. hasil yang terlalu bias ini akhirnya dapat menghasilkan tidak adanya hubungan antara persepsi penderita tb bta (+) tentang pengobatan dengan status kesembuhan. simpulan dan saran simpulan persepsi yang baik pada penderita tb bta (+) tentang pengobatan tidak berperan langsung terhadap status kesembuhan. saran berdasar hasil penelitian, peneliti memberikan saran agar bagi koordinator bidang tb paru puskesmas turen, perlu mengadakan jadwal pertemuan rutin untuk melaksanakan penyuluhan tentang tb dengan mengundang seluruh penderita, keluarga, pmo dan petugas kesehatan yang terlibat untuk datang ke puskesmas setiap 1 bulan sekali secara berkala dengan mengadakan diskusi bersama dan pengarahan tentang tb disertai pembagian selebaran-selebaran yang berguna bagi penderita dan keluarga di rumah. kepustakaan departemen kesehatan ri, 2008. pedoman nasional penanggulangan tuberkulosis edisi kedua. jakarta: dep. kes. ri. hlm. 4-7, 14-24, 29-37, 91-92 . effendi, luqman, 2009. persepsi sehat-sakit dan perilaku sakit, (online), (http://www.ditpsmk.net, diakses tanggal 10 agustus 2009, jam 13.09 wib). marsden, john, et al., 1998. treatment perceptions questionnaire (tpq), (online), (http:// eib.emcdda.europa.eu, diakses tanggal 07 juni 2009, jam 19.19 wib). rs. penyakit infeksi prof. dr. sulianti saroso, 2007. tuberkulosis, (online), (http://www.infeksi.com, di akses tanggal 02 mei 2009, jam 13.55 wib). siswono, 2004. target bebas tuberkulosis pada 2015 tak tercapai, angka kesembuhan masih rendah, (online), (http://www.gizi.net, diakses tanggal 18 mei 2009, jam 19.17 wib). sudrajat, akhmad, 2008. teori-teori motivasi, (online), (http://eko13.wordpress.com, diakses tanggal 10 agustus 2009, jam 12.50 wib). waisbord, sylvio, 2005. behavioral barriers in tuberculosis control: a literature review, (online), (www.stoptb.org, diakses tanggal 30 juni 2009, jam 15.00 wib). walgito, bimo 2003. psikologi sosial (suatu pengantar), yogyakarta: c.v andi offset, hlm. 53-55. widayatun, tri rusmi, 1999. ilmu perilaku, jakarta : sagung seto, hlm. 112, 115. yohan, 2008. tbc bisa sembuh, (online) http://www.activeboard.com, diakses tanggal 02 mei 2009, jam 13.43 wib). zhang, tuohong; liu, xiaoyun; bromley, helen & tang, shenglan, 2006. perceptions of tuberculosis and health seeking behaviour in rural inner mongolia, china. health policy, 81, pp. 155-165. http://www.ditpsmk.net/ http://www.infeksi.com/ http://www.gizi.net/ http://eko13.wordpress.com/ http://www.stoptb.org/ http://www.activeboard.com/ hubungan shift kerja dengan stres kerja dan circadian rhythm perawat (the correlation between work roster with work stres and nurses’s circadian rhythm) nursalam*, arie sunarno**, rahmatul fitriyah* * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496 e-mail: nursalam_psik@yahoo.com ** rsu dr.soetomo surabaya abstract introduction: shift work, primarily night shift may worsen some health disturbances because it changes especially circadian rhythm. therefore, it may lead to sleep disturbance, increased vital signs (heart rate, respiration rate and blood pressure), bowel disturbance, reaction times, conscious stage and increased work stress. the objective of this study was to analyze the correlation between shift work and nurse’s circadian rhythm. method: these study was cross sectional with nurses in flamboyant intermediate surgical ward dr. soetomo hospital surabaya as subjects. samples were recruited by using total sampling and there were 15 samples as on inclusion criteria. data were analyzed using paired t-test, krusskall-wallis, wilcoxon, mannwhitney, anova and chi-square with significance level α≤0.05. result: the result showed that shift work had no correlation with nurses’ work stress (p=0.221). nurses stress stage had no differences in three of shift (p=0.757). while shift work had correlation with nurse’s circadian rhythm disturbance (p=0.038) and night shift had differences circadian rhythm disturbance (p=0.038). discussion: it can be concluded that there was correlation between shift work and circadian rhythm disturbance, however there is no correlation between shift work and work stress. further studies are recommended to identify the dominant factor which cause work stress for nurses. keywords: shift work, work stress, circadian rhythm pendahuluan rumah sakit merupakan salah satu instansi yang menuntut kerja selama 24 jam sehingga tenaga medis khususnya perawat yang merupakan tenaga yang paling lama berhubungan dengan pasien dituntut kehadirannya setiap saat (wijaya, 2006 dan amriyati, 2003). dengan demikian diperlukan tenaga perawat yang bersedia bekerja dengan sistem shift. sistem kerja bergilir (shift) mengakibatkan gangguan circadian rhythm dan stres kerja. stres terjadi karena tubuh berusaha beradaptasi dengan sistem shift kerja dengan waktu yang relatif singkat (pease and raether, 2003). pekerja shift, terutama shift malam mengalami gangguan dalam ritme biologi atau apa yang dinamakan circadian rhythm disebabkan pekerja tersebut menentang perubahan alamiah dari ritme tubuh tersebut yang ditandai dengan gangguan tidur. perubahan ritme tubuh tersebut bisa menghambat pemulihan stres kerja (rafknowledge, 2004). stres kerja pada perawat dapat merangsang hpa axis yang kemudian merangsang korteks adrenal memproduksi kortisol. perubahan circadian rhythm akan mempengaruhi hpa axis juga yang akan mempengaruhi hormon kortisol. stres juga akan mempengaruhi hipotalamus yang melalui batang otak akan mengaktifkan sistem saraf simpatis merangsang medula adrenal untuk memproduksi epinefrin dan norepinefrin (lovallo, 2005, vitaterna, 2001, ganong, 2003, greenspan, 1991). kelelahan kerja pada perawat yang bekerja dengan sistem mailto:nursalam_psik@yahoo.com shift dapat menyebabkan penurunan kapasitas kerja dan ketahanan tubuh serta risiko kecelakaan kendaraan dan kecelakaan di tempat kerja meningkat. kekurangan tidur pada perawat menyebabkan kemampuan berpikir dan bergerak menjadi lambat, lebih banyak membuat kesalahan dan mempunyai kesulitan untuk mengingat sesuatu sehingga dapat menurunkan produktivitas kerja dan juga dapat menyebabkan kecelakaan. hasil penelitian ini diharapkan dapat dijadikan bahan masukan bagi manajer dalam menentukan kebijakan yang berkaitan dengan shift kerja dan dalam upaya menurunkan tingkat stres sehingga dapat mencapai pelayanan yang optimal. dapat juga digunakan sebagai bahan masukan bagi instansi rumah sakit untuk memelihara kesehatan karyawannya sehingga dapat memberikan pelayanan yang optimal pada pasien. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah cross sectional. populasinya adalah semua perawat yang bekerja di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya. sampel yang diambil adalah perawat yang memenuhi kriteria inklusi yaitu sebanyak 15 orang dan dibagi menjadi 3 shift yaitu shift pagi, sore dan malam. penelitian ini dilaksanakan pada tanggal 14-30 juni 2007. variabel independen dari penelitian ini adalah shift kerja, sedangkan variabel dependen adalah stres kerja dan circadian rhythm diukur mengunakan kuesioner dan pengukuran tanda-tanda vital meliputi tekanan darah, nadi dan frekuensi pernapasan. pengambilan data dilakukan dengan membagikan kuesioner sebelum dan sesudah perawat melaksanakan shift kerja. data yang diperoleh dari kuesioner dianalisis dengan menggunakan uji chi-square, paired t-test, kruskall-wallis, wilcoxon, mannwhitney dan anova. hasil tingkat stres kerja perawat di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya sebelum dan sesudah menjalani shift pagi, sore dan malam, sebagian besar termasuk dalam kategori ringan. hanya satu responden termasuk dalam kategori sedang. terdapat peningkatan penilaian stres kerja namun masih dalam kategori ringan-sedang (tabel 1). hasil uji statistik tentang tingkat stres seperti yang terlihat pada tabel 1, menunjukkan tidak adanya perbedaan tingkat stres perawat sebelum dan sesudah menjalani shift pagi dengan hasil uji statistik wilcoxon signed ranked test p=0,068. pada shift sore, menunjukkan adanya perbedaan tingkat stres perawat sebelum dan sesudah menjalani shift sore (p=0,041). pada shift malam, menunjukkan ada perbedaan tingkat stres perawat sebelum dan sesudah menjalani shift malam (p=0,043). hasil uji statistik dengan menggunakan kruskal-wallis test sebelum menjalani shift didapatkan nilai p=0,451, setelah menjalani shift didapatkan nilai p=0,757, menunjukkan tingkat stres ketiga kelompok tidak mempunyai perbedaan signifikan. gangguan circadian rhythm perawat di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya sebelum dan sesudah menjalani shift pagi, sore dan malam termasuk dalam kategori ringan-sedang. terdapat peningkatan namun masih dalam kategori ringan-sedang (tabel 2). tabel 1. tingkat stres perawat sebelum dan sesudah menjalani shift pagi, sore dan malam di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya shift sebelum shif sesudah shift uji statistik wilcoxon signed rank test tingkat stres tingkat stres ringan (n) sedang (n) berat (n) ringan (n) sedang (n) berat (n) pagi 5 0 0 5 0 0 p=0,068 sore 5 0 0 4 1 0 p=0,041 malam 3 2 0 2 3 0 p=0,043 uji kruskallwallis uji kruskall-wallis p=0,451 p=0,757 tabel 2. tingkat circadian rhythm perawat sebelum dan sesudah menjalani shift pagi, sore dan malam di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya shift sebelum shif sesudah shift uji statistik wilcoxon signed rank test circadian rhythm circadian rhythm ringan (n) sedang (n) berat (n) ringan (n) sedang (n) berat (n) pagi 5 0 0 5 0 0 p=0,109 sore 5 0 0 5 0 0 p=0,066 malam 4 1 0 4 1 0 p=0,066 uji kruskallwallis p=0,021 uji kruskall-wallis p=0,038 keterangan: n=jumlah p=signifikansi hasil uji statistik menggunakan wilcoxon signed ranked test didapatkan nilai p=0,109, menunjukkan tidak ada perbedaan perubahan circadian rhythm perawat sebelum dan sesudah menjalani shift pagi. pada shift sore didapatkan nilai p=0,066, menunjukkan tidak adanya perbedaan perubahan circadian rhythm perawat sebelum dan sesudah menjalani shift sore. pada shift malam didapatkan nilai p=0,066, menunjukkan tidak adanya perbedaan perubahan circadian rhythm perawat sebelum dan sesudah menjalani shift malam. hasil uji statistik dengan menggunakan kruskal-wallis test didapatkan nilai p=0,021, menunjukkan minimal satu dari ketiga kelompok mempunyai perbedaan signifikan. hasil uji statistik dengan menggunakan mann-whitney test menunjukkan adanya perbedaan yang signifikan antara shift pagi dengan shift malam dengan nilai p=0,016 dan adanya perbedaan yang signifikan antara shift sore dengan shift malam dengan nilai p=0,016. namun antara shift pagi dengan shift sore tidak mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan kruskal-wallis test didapatkan nilai p=0,038, menunjukkan minimal satu dari ketiga kelompok mempunyai perbedaan signifikan. hasil uji statistik dengan menggunakan mann-whitney test menunjukkan adanya perbedaan yang signifikan antara shift pagi dengan shift malam dengan nilai p=0,014. namun tidak adanya perbedaan yang signifikan antara shift sore dengan shift malam dengan nilai p=0,056 dan untuk shift pagi dengan shift sore tidak mempunyai perbedaan yang signifikan pula dengan nilai signifikansi p=0,74. hasil kenaikan tekanan darah dianalisis dengan menggunakan uji statistik one way anova dan paired t-test. hasil uji statistik dengan menggunakan one way anova sebelum menjalani shift kerja didapatkan nilai p=0,89, menunjukkan rerata tekanan darah systole untuk ketiga shift tidak mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan one way anova setelah menjalani shift kerja didapatkan nilai p=0,02, menunjukkan rerata tekanan darah systole untuk ketiga shift mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan paired t-test didapatkan pada shift pagi nilai p=0,477, shift sore p=0,189 dan untuk shift malam p=0,099. hal ini menunjukkan kenaikan tekanan darah systole sebelum dan sesudah menjalani shift pagi, sore dan malam tidak signifikan. hasil uji statistik dengan menggunakan one way anova sebelum menjalani shift kerja didapatkan nilai p=0,038, menunjukkan rerata tekanan darah diastole untuk ketiga shift mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan one way anova dari data kuesioner didapatkan nilai p=0,11, menunjukkan rerata tekanan darah diastole untuk ketiga shift tidak mempunyai perbedaan yang signifikan. hasil uji statistik paired t-test untuk tekanan darah diastole sebelum dan sesudah menjalani shift pagi didapatkan nilai p=0,016, berarti kenaikan tekanan darah diastole sebelum dan sesudah menjalani shift pagi signifikan. pada shift sore nilai p=0,07, menunjukkan kenaikan tekanan darah diastole sebelum dan sesudah menjalani shift sore tidak signifikan. pada shift malam nilai p=0,005, yang berarti kenaikan tekanan darah diastole sebelum dan sesudah menjalani shift malam signifikan (lihat tabel 3). tabel 4 menunjukkan hasil kenaikan nadi dan rr (respiration rate) yang dianalisis dengan menggunakan uji statistik one way anova dan paired t-test. hasil uji statistik dengan menggunakan one way anova sebelum menjalani shift didapatkan nilai p=0,855, menunjukkan rerata frekuensi nadi untuk ketiga shift tidak mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan one way anova sesudah menjalani shift didapatkan nilai p=0,558, menunjukkan rerata frekuensi nadi untuk ketiga shift tidak mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan paired t-test didapatkan nilai p=0,023 untuk nadi sebelum dan sesudah menjalani shift pagi, pada shift sore nilai p=0,009 dan pada shift malam nilai p=0,034. nilai p untuk ketiga shift kurang dari 0,05 yang berarti kenaikan frekuensi nadi sebelum dan sesudah menjalani shift signifikan. hasil uji statistik dengan menggunakan one way anova sebelum menjalani shift didapatkan nilai p=0,607, menunjukkan rerata frekuensi pernapasan (respiration rate) untuk ketiga shift tidak mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan one way anova sesudah menjalani shift didapatkan nilai p=0,812, menunjukkan rerata frekuensi pernapasan (respiration rate) untuk ketiga shift tidak mempunyai perbedaan yang signifikan. hasil uji statistik dengan menggunakan paired t-test didapatkan nilai p=0,12 untuk frekuensi pernapasan sebelum dan sesudah menjalani shift pagi. pada shift sore nilai p=0,0572 dan pada shift malam nilai p=0,399. nilai p untuk ketiga shift lebih dari 0,05 yang berarti kenaikan frekuensi pernapasan sebelum dan sesudah menjalani shift tidak signifikan. hubungan shift kerja dengan stres kerja dan circadian rhythm dianalisis dengan menggunakan uji statistik chi square (lihat tabel 5 dan 6). berdasarkan hasil uji statistik diperoleh nilai p=0,221 untuk hubungan antara shift kerja dengan stres kerja yang berarti tidak ada hubungan shift kerja dengan stres kerja. pada hubungan antara shift kerja dengan circadian rhythm diperoleh nilai p=0,038 yang berarti ada hubungan antara shift kerja dengan circadian rhythm. tabel 3. rekapitulasi uji statistik kenaikan tekanan darah sebelum dan sesudah menjalani shift pagi, sore dan malam di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya uji statistik tekanan darah (sistolik) tekanan darah (diastolik) pagi sore malam pagi sore malam anova pre p=0,89 ; post p=0,02 pre p=0,038; post p=0,11 paired t-test p=0,477 p=0,189 p=0,099 p=0,016 p=0,07 p=0,005 tabel 4. rekapitulasi uji statistik kenaikan nadi dan rr (respiration rate) perawat sebelum dan sesudah menjalani shift pagi, sore dan malam di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya uji statistik nadi rr pagi sore malam pagi sore malam anova pre p=0,855; post p=0,558 pre p=0,607 ; post p=0,812 paired t-test p=0,023 p=0,009 p=0,034 p=0,12 p=0,0572 p=0,399 keterangan: p = derajat kemaknaan tabel 5. hubungan shift kerja dengan stres kerja di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya stres kerja tingkat stres total ringan sedang berat shift pagi 5 (33,33%) 0 (0%) 0 (0%) 15 (100%) shift sore 5 (33,33%) 0 (0%) 0 (0%) shift malam 4 (26,67%) 1 (6,67%) 0 (0%) chi-square (p=0,221) tabel 6. hubungan shift kerja dengan circadian rhythm di ruang intermediet bedah flamboyan rsu dr. soetomo surabaya circadian rhythm gangguan circadian rhythm total ringan sedang berat shift pagi 5 (33,33%) 0 (0%) 0 (0%) 15 (100%) shift sore 4 (26,67%) 1 (6,67%) 0 (0%) shift malam 2 (13,33%) 3 (20%) 0 (0%) chi-square (p=0,038) keterangan: p = derajat kemaknaan pembahasan berdasarkan hasil penelitian menunjukkan bahwa tidak ada perbedaan yang signifikan tingkat stres perawat pada shift pagi, sore dan malam serta tidak adanya hubungan yang signifikan antara shift kerja dengan stress kerja. penyebab stres di tempat kerja, yaitu pertama faktor intrinsik pekerjaan (lingkungan yang tidak nyaman, tempat kerja yang tidak ergonomis, jam kerja panjang, pembebanan berlebih. kedua faktor peran individu dalam organisasi kerja. ketiga faktor hubungan kerja. keempat faktor pengembangan karier. kelima faktor struktur organisasi dan suasana kerja dan keenam faktor di luar pekerjaan seperti kepribadian seseorang yang bersifat introvert dan extrovert. stres dipengaruhi oleh kondisi individu yang meliputi umur, jenis kelamin, temperamental, genetik, intelegensia, pendidikan dan kebudayaan. faktor kedua yang mempengaruhi stresa dalah sosialkognitif seperti dukungan sosial, hubungan sosial dengan lingkungan sekitar, strategi untuk menghadapi stres yang muncul serta organisasi kerja (costa, 2004 dan tarwaka, 2004). stresor dapat berasal dari dalam (internal) dan luar (eksternal). perubahan dalam lingkungan internal dan eksternal dapat mengganggu fungsi dari individu tersebut sehingga individu tersebut berusaha beradaptasi agar dapat bertahan (bernard, 1867 dalam potter dan perry, 2005). para pekerja yang biasa bekerja shift lama kelamaan akan merasa berkurang stresnya secara fisik (selye dikutip dari munandar 2001). ruang intermediet bedah flamboyan rsu dr. soetomo merupakan ruang dengan mobilitas tinggi sehingga beban kerja perawat meningkat. beban kerja yang tinggi tersebut terdapat pada ketiga shift. perawat di ruangan tersebut sudah terbiasa dengan beban kerja demikian, mengingat responden adalah perawat dengan masa kerja minimal 2 tahun sehingga pada waktu pemeriksaan, responden sudah mengalami proses adaptasi dengan lingkungan pekerjaan. peneliti mengobservasi adanya hubungan sosial yang harmonis antar perawat dan antara perawat dengan tenaga kesehatan lain dimana hubungan sosial yang baik dapat mengurangi tingkat stres perawat. terdapat perbedaan perubahan circadian rhythm yang pada perawat shift pagi, sore dan malam serta terdapat hubungan yang signifikan antara shift kerja dengan circadian rythm. circadian rhythm merupakan jam tubuh alami yang mengikuti siklus 25 jam. pola ini mempengaruhi siklus tidur bangun, suhu tubuh, pola sekresi hormon, tekanan darah, tingkat kesadaran, reaction times, denyut jantung, kemampuan sensorik dan suasana hati (potter dan perry, 2005 dan hedge, 2006). jika siklus tidur bangun seseorang berubah secara bermakna maka akan menghasilkan kualitas tidur yang buruk serta fungsi fisiologis di atas berubah. sistem shift kerja juga mengakibatkan gangguan sosial (pati, 2001). pekerja shift terutama shift malam mengalami adaptasi internal dan eksternal. adaptasi internal dipengaruhi oleh umur, jenis kelamin, status kesehatan, status emosional, pengalaman menjalani shift sebelumnya, kualitas dan kuantitas tidur, toleransi terhadap shift malam, dll. sedangkan adaptasi eksternal dipengaruhi oleh faktor sosial politik ekonomi psikososial, rotasi dan penjadwalan shift, motivasi, status nutrisi dan siklus terang gelap lingkungan sekitar (pati, 2001). saat menjalani rotasi shift kerja, tubuh berusaha beradaptasi, baik internal mapun eksternal. jika pekerja tidak dapat beradaptasi dengan baik maka akan meningkatkan terjadinya stres kerja. adaptasi pekerja malam yang menetap lebih baik dibandingkan dengan pekerja yang bekerja dengan rotasi shift (fujino, 2001). gangguan circadian rhythm yang terjadi pada perawat mempengaruhi suprachiasmatic nucleus pada hipotalamus yang kemudian mempengaruhi paraventricular nucleus memacu peningkatan crf (corticotropin releasing factor). melalui hpa-axis menyebabkan respons fisik seperti peningkatan frekuensi pernapasan, nadi dan tekanan darah. tubuh memerlukan waktu untuk beradaptasi terhadap perubahan jadwal bekerja antara 3 sampai 14 hari (ganong, 2003). beberapa orang mampu menyesuaikan dengan tipe shift yang mempengaruhi keseimbangan aktivitas bekerja. beberapa faktor yang mempengaruhi toleransi terhadap sistem shift adalah motivasi, penerimaan karyawan terhadap sistem shift kerja dan pengawasan terhadap sistem kerja shift (nicholson, 1999). tingkat aktivitas beberapa fungsi biologis mulai mengalami penurunan pada malam hari. tuntutan tugas pada malam hari yang semestinya harus didukung oleh kondisi tubuh yang siap bekerja dihadapi oleh tubuh dengan kondisi irama circadian rhythm yang menurun. kenaikan tekanan darah, frekuensi nadi dan frekuensi pernapasan juga dipengaruhi oleh aktivitas yang dilakukan perawat dalam menangani pasien di ruangan tersebut. pada shift malam, perawat tetap melakukan tugas dimana secara umum manusia melakukan aktivitas di siang hari. tidur pada malam hari dapat mengoptimalkan produksi hormon melatonin yang mempengaruhi estrogen dan berfungsi sebagai antioksidan. hormon melatonin yang diproduksi oleh pineal body membantu tubuh untuk tidur. ketika hormon tersebut tidak diproduksi dengan optimal mengakibatkan gangguan tidur selanjutnya mengakibatkan penurunan daya tahan tubuh, penurunan konsentrasi, mudah lupa karena fungsi restoratif dari tidur tidak berjalan dengan baik (spiegel, 2002). simpulan dan saran simpulan simpulan dari penelitian ini adalah perawat yang bekerja di ruang intermediet bedah flamboyan rsu dr. soetomo mengalami gangguan circadian rhythm kategori ringan-sedang, terutama yang bekerja pada shift malam karena tubuh melawan perubahan siklus alamiah yang ditandai dengan gangguan tidur, kenaikan tekanan darah, nadi dan frekuensi pernapasan. shift kerja bukan merupakan faktor dominan yang meningkatkan stres kerja perawat, karena perawat yang bekerja pada shift pagi, sore dan malam di ruang intermediet bedah flamboyan rsu dr. soetomo menunjukkan stres kerja dalam kategori ringan-sedang. saran berdasar hasil penelitian ini peneliti menyarankan bahwa perlu dipertimbangkan kembali pembagian kerja pada tiap shift kerja, dimana saat ini pembagian waktu kerjanya shift pagi bekerja selama 7 jam, shift sore bekerja selama 7 jam dan shift malam bekerja selama 10 jam menjadi shift pagi 8 jam, shift sore 8 jam dan shift malam 8 jam. diharapkan dilaksanakan pemberian reward system bagi perawat yang menjalani shift malam karena tingkat stres kerja dan gangguan circadian rhythm paling tinggi pada shift malam yang akan mempengaruhi kesehatan dan kinerja perawat. perawat hendaknya memanfaatkan waktu istirahat dengan sebaik mungkin sebelum menjalani shift sore dan malam dan penelitian lebih lanjut tentang stres kerja perlu dilakukan terkait dengan faktor yang dominan mempengaruhi stres kerja perawat dengan jumlah responden yang lebih banyak, rentang waktu yang lebih lama sehingga dapat mewakili perawat secara keseluruhan. kepustakaan amriyati, dkk.,2003. kinerja perawat ditinjau dari lingkungan kerja dan karakteristik individu. sains kesehatan, 16(2), hlm. 331-345. costa, g. 2004. multidimensional aspects related to shiftworker’s health and well being. rev saude publica, vol. 38, hlm. 86-91. fujino, y., et al. 2001. job stress and mental health among permanent shift workers. journal of occupational health, vol. 43, hlm. 301-306. ganong, w.f. 2003. buku ajar fisiologi kedokteran. jakarta: egc, hlm. 186195. greenspan, f.s.1991. basic and clinical endocrinology third edition. london: prentice-hall international inc., hlm. 47-48. hedge, a. 2006. biological rhythm, (online), (http://ergo.human.cornell.edu., diakses tanggal 23 maret 2007, jam 08.30 wib). lovallo, w. 2005. stress and health: bological and psychological interactions. second edition, california: sage publications. munandar, a.s. 2001. psikologi industri dan organisasi. jakarta: ui press, hlm. 370-401. nicholson, p.j. 1999. shift work, health, the working time regulations and health assessments, occupational medical, 49(3), hlm. 127-137. pati, a.k. 2001. shift work: consequences and management, journal of occupational health, vol. 81, hlm. 32-52. pease and raether. 2003. shift working and well-being: a phisiological and psychological analysis of shift workers. journal of undergraduate research vi, hlm. 1-4. potter dan perry. 2005. buku ajar fundamental keperawatan: konsep, proses dan praktik. volume 1 edisi 4. jakarta: egc, hlm. 476-493, 14701482. rafknowledge. 2004. insomnia dan gangguan tidur lainnya. jakarta: pt elex media komputindo gramedia, hlm. 1-186. spiegel, d., et al. 2002. night shift work, light at night, and risk of breast cancer. journal of the national cancer institute, 94(2), hlm. 530-534. tarwaka, dkk. 2004. ergonomi untuk keselamatan, kesehatan kerja dan produktivitas. surakarta: uniba press, hlm. 145-150. wijaya, dkk. 2006. hubungan antara shift kerja dengan gangguan tidur dan kelelahan kerja perawat instalasi rawat darurat rumah sakit dr. sardjito yogyakarta. sains kesehatan, 19(2), hlm. 235-245. vitaterna, m.h., et al. 2001. overview of circadian rhythms. alkohol, research and health, 25(2), hlm. 85-91. http://ergo.human.cornell.edu/ pengaruh terapi aktifitas kelompok (tak) stimulasi persepsi modifikasi terhadap pengendalian halusinasi dengar pada jurnal ners vol. 2 no. 1 mei – september 2007 terapi aktifitas kelompok (tak): stimulasi persepsi modifikasi sebagai alternatif pengendalian halusinasi dengar pada klien skizofrenia ah. yusuf*, rizki f.*, nursalam*, iskandar abstract the objective of this study was to examine the effect of modified group activity therapy (gat) perception stimulation on auditory halucination controlling in schizophrenia. modification means using only 3 sessions in gat. a quasi-experimental pre post test design was used in this study. eighteen samples with auditory halucination at male third’s class wards menur mental hospital surabaya were used in this study and divided into 2 groups. observation was applied to measure patient’s responses and data were analyzed by wilcoxon signed rank test and mann whitney test with significance level of α<0.05. conclusion: modified perception stimulation of gat is able to increase patient’s ability for making differences between reality and non-reality and motivated patient to choose and use the best way for controlling halucination. keywords: auditory halucination, perception stimulation group activity therapy. pendahuluan halusinasi merupakan bentuk gangguan persepsi dimana individu mengalami kehilangan kemampuan dalam membedakan rangsangan internal (pikiran) dan rangsangan eksternal (dunia luar). klien dengan diagnosa skizofrenia, 70% mengalami halusinasi dan 30% mengalami waham. dari klien yang mengalami waham ditemukan 35%-nya mengalami halusinasi. klien skizofrenia dan psikotik lain, 20% mengalami campuran halusinasi pendengaran dan pengelihatan (stuart & sundeen, 1995). rumah sakit jiwa menur surabaya pada tahun 2006 merawat rerata 150 pasien skizofrenia perbulan, yang mengalami halusinasi sekitar 60%, kerusakan interaksi dan gangguan konsep diri 25%, perilaku kekerasan 10% dan klien dengan waham sekitar 5%. dari 60% (90 klien) yang mengalami halusinasi, 50% mengalami halusinasi dengar, halusinasi penglihatan 45% dan halusinasi jenis lain sekitar 5% (medical record rsj menur surabaya, 2005). _____________ * staf pengajar psik fk unair halusinasi yang tidak segera mendapatkan terapi atau penanganan akan menimbulkan masalah-masalah yang lebih banyak dan lebih buruk. dampak yang dapat ditimbulkan oleh halusinasi pada klien skizofrenia adalah: 1) perilaku kekerasan baik ditujukan pada diri sendiri maupun orang lain, 2) risiko tinggi tindakan bunuh diri, 3) gangguan interaksi sosial dan 4) kerusakan komunikasi verbal dan non verbal. pendekatan yang dapat dilakukan untuk mengatasi halusinasi dengar antara lain dengan terapi psikofarmaka, terapi somatik (elektro convulsi therapy), terapi lingkungan, terapi bermain, terapi okupasi dan terapi aktifitas kelompok yang bertujuan untuk mengorientasikan klien pada realita. orientasi pada realitas akan mengurangi persepsi sensorik yang salah dan meningkatkan rasa makna diri dan keluhuran pribadi klien (townsend, 1998). orientasi klien pada realita diperoleh dengan pendekatan terapi aktifitas kelompok stimulasi persepsi. dalam kegiatan aktivitas kelompok, tujuan ditetapkan berdasarkan kebutuhan dan jurnal ners vol. 2 no. 1 mei – september 2007 masalah yang dihadapi oleh sebagian besar peserta. terapi aktifitas kelompok (tak) stimulasi persepsi adalah terapi yang menggunakan aktifitas mempersepsikan berbagai stimulus yang terkait dengan pengalaman dan atau kehidupan untuk didiskusikan dalam kelompok. hasil diskusi kelompok dapat berupa kesepakatan persepsi atau alternatif penyelesaian masalah (keliat, 2002). namun kenyataan yang diperoleh di rumah sakit jiwa menur surabaya pelaksanaan tak stimulasi persepsi belum dapat dilaksanakan secara optimal hal ini disebabkan oleh beberapa faktor: 1) kurangnya pemahaman perawat tentang tak, 2) adanya anggapan bahwa proses tak terlalu panjang namun hasil nyatanya belum nampak, 3) kurangnya tenaga perawat yang ada diruang rawat inap untuk dapat mengaplikasikan tak secara teratur. modifikasi tak stimulasi persepsi perlu dilakukan agar dapat diterapkan dilapangan dan menilai pengaruh tak stimulasi persepsi modifikasi terhadap pengendalian halusinasi dengar pada klien skizofrenia di rumah sakit jiwa menur surabaya. bahan dan metode penelitian penelitian ini menggunakan quasy eksperiment dengan pendekatan (nonequaivalen control group atau non randomized control group pretest-posttest design). populasi dalam penelitian ini adalah klien halusinasi yang sedang menjalani rawat inap di rumah sakit jiwa menur surabaya yang terdiri dari 3 ruang rawat inap kelas iii laki-laki dengan besar sampel 18 responden. tak stimulasi persepsi modifikasi terdiri atas tiga sesi, dilaksanakan tiga kali selama tiga hari. instrumen yang digunakan dalam penelitian ini adalah: 1) panduan tak, 2) lembar observasi dan wawancara. analisis data dilakukan dengan menggunakan wilcoxon signed rank test dan mann whitney test dengan derajat kemaknaan α<0.05. hasil penelitian tabel 1: pengendalian halusinasi dengar responden kelompok perlakuan dan kelompok kontrol. pengendalian halusinasi kelompok perlakuan kelompok kontrol kelompok perlakuan kelompok kontrol pre post pre post pre post bisa mengendalikan 0 0% 9 100% 0 0% 1 10% 9 100% 1 11,1% tidak bisa mengendalikan 9 100% 0 0% 9 100% 8 90% 0 0% 8 88,89% total 9 100% 9 100% 9 100% 9 100% 9 100% 9 100% wilcoxon sign rank test mann whitney test z = -2.692 p = 0.007 z = -0.577 p = 0.564 z = -3.648 p = 0.000 ket: p = probabilitas pembahasan pemberian tak stimulasi persepsi modifikasi secara signifikan memberikan perubahan terhadap pengendalian halusinasi dengar pada klien skizofrenia yaitu p=0,007. perubahan kemampuan klien dalam mengendalikan halusinasi antara kelompok perlakuan dan kelompok kontrol menunjukkan hal yang sangat jurnal ners vol. 2 no. 1 mei – september 2007 signifikan dengan p=0.000. sebelum diberikan tak stimulasi persepsi modifikasi 100% responden baik kontrol maupun perlakuan tidak mampu mengendalikan halusinasi dengar. pengendalian halusinasi adalah kemampuan klien dalam mengendalikan stimulus yang datang dikaitkan dengan penurunan, berlebihan, distorsi atau kerusakan terhadap stimulasi (nurjannah, 2001). menurut townsend (1998), ketidakmampuan klien mengenal halusinasi dipengaruhi oleh beberapa hal antara lain: 1) klien merupakan penderita yang baru mengalami gangguan jiwa dan menjalani rawat inap, sehingga klien belum bisa membedahkan antara realita dan non realita. hal tersebut menyebabkan mekanisme koping klien saat terjadi halusinasi tidak efektif dan cenderung terjadi perilaku kekerasan pada diri sendiri maupun orang lain. 2) ketidaktahuan klien dalam mengenal cara mengendalikan halusinasi. klien merasa apa yang didengar (halusinasi) adalah suatu hal yang nyata. kemampuan untuk mengontrol halusinasi bisa diajarkan. 3) klien rerata menjalani masa perawatan di minggu ke-2. hal tersebut mempengaruhi kondisi mental atau psikis dari klien. keadaan umum klien pada minggu ke-2 lebih tenang dan kooperatif, akan tetapi gejala halusinasi masih nampak dan klien belum bisa mengendalikan halusinasinya. 4) tak belum menjadi protap penanganan klien halusinasi di rumah sakit jiwa menur, terapi klien hanya terfokus pada pemberian obat psikofarmaka saja. setelah diberikan tak stimulasi persepsi modifikasi, pada kelompok perlakuan 100% responden mampu mengendalikan halusinasi. sedangkan pada kelompok kontrol 90% responden tidak bisa mengendalikan halusinasi. townsend (1998) menyatakan bahwa orientasi pada realitas akan mengurangi persepsi sensorik yang salah dan meningkatkan rasa makna diri dan keluhuran pribadi klien. hal-hal yang mempengaruhi keberhasilan atau perubahan pengendalian halusinasi pada kelompok perlakuan antara lain: 1) homogenitas jenis halusinasi yaitu halusinasi dengar. kesamaan suatu masalah yang dihadapi oleh responden dalam suatu kelompok mempermudah pencapaian tujuan terapi. 2) pelaksanaan tak yang berkelanjutan mengakibatkan responden saling mengenal, bertukar pengalaman, berkomunikasi dan menggali pengetahuan tentang pengendalian halusinasi dengar, 3) responden berusia 21-45 tahun, yang merupakan tahap usia dewasa dimana kepribadian seseorang lebih matang secara emosional sehingga perubahan mekanisme koping setelah tak akan lebih mudah diadopsi 4) seluruh responden berjenis kelamin laki-laki sehingga mempermudah kelompok dalam pertukaran pengalaman secara terbuka. pada kelompok kontrol hanya terjadi perubahan yang tidak terlalu signifikan yaitu 10% (1 orang), keadaan ini disebabkan oleh karena: 1) perbedaan mekanisme koping antar individu dalam kemampuannya untuk mengendalikan halusinasi dengar yang mempengaruhi percepatan klien dalam mengontrol halusinasi, 2) perbedaan terapi yang diterima klien yaitu adanya pemberian elektro convulsi therapy (ect). simpulan dan saran simpulan 1. tak stimulasi persepsi modifikasi berpengaruh terhadap pengendalian halusinasi dengar yang meliputi aspek kognitif, afektif dan psikomotor dimana klien lebih terkendali dalam menanggapi setiap halusinasi yang muncul. 2. pemberian tak stimulasi persepsi modifikasi dapat merubah perilaku klien dalam mengendalikan halusinasi yaitu dengan timbulnya kemampuan membedakan realita dan non realita serta memilih dan menggunakan cara untuk mengendalikan halusinasi. saran 1. tak ditetapkan sebagai kegiatan terapi dan dilaksanakan secara tyerencana dan berkelanjutan sebagai jurnal ners vol. 2 no. 1 mei – september 2007 upaya untuk mempercepat kesembuhan klien di rumah sakit jiwa menur surabaya. 2. tak stimulasi persepsi ditetapkan sebagai prosedur tetap (protap) dalam menyelesaikan masalah halusinasi pada klien skizofrenia di rumah sakit jiwa menur surabaya. 3. perlu dilaksanakan pelatihan tentang tak untuk melatih terapis yang menjalankan tak dengan benar dan sesuai dengan tujuan. 4. perlu diadakan penelitian lebih lanjut tentang jenis tak yang lain agar memperluas wawasan tentang terapi modalitas khususnya tak untuk klien skizofrenia kepustakaan arikunto, s., (2002). prosedur penelitian, suatu pendekatan praktek, jakarta: pt. ribeka cipta, hal. 215. hawari, d., (2003). pendekatan holistik pada gangguan jiwa: skizofrenia, jakarta: gaya baru, hal. 41 nurjannah, i., (2001). pedoman penanganan pada gangguan jiwa: manajemen, proses keperawatan dan hubungan terapeutik perawatklien, yogyakarta: mocomedia, hal.102 nurjannah, i., (2001). aplikasi proses keperawatan: pada diagnosa risiko kekerasan diarahkan pada orang lain dan gangguan sensori persepsi, yogyakarta: mocomedika hal.91147 keliat, b.a., (2004). keperawatan jiwa: terapi aktifitas kelompok, jakarta: egc, hal. 3-15 keliat, b.a., (2005). proses keperawatan kesehatan jiwa edisi 2, jakarta: egc, hal. 46 nursalam, (2003). konsep dan penerapan metodologi penelitihan ilmu keperawatan, jakarta: salemba medika, hal.102 rasmun, (2001). keperawatan kesehatan mental psikiatri terintegrasi dengan keluarga, jakarta: cv. agung seto, hal. 23. stuart & sundeen, (1998). buku saku keperawatan jiwa, jakarta: egc, hal. 227-237. suliswati, dkk, (2005). konsep dasar keperawatan kesehatan jiwa, jakarta: egc, hal. 129. townsend, m.c., (1998). buku saku diagnosa keperawatan psikiatri: pedoman untuk pembuatan rencana perawatan, jakarta: egc, hal. 156157. ----------, (2005). medical record, rumah sakit jiwa menur surabaya. 139 teka-teki silang meningkatkan perhatian anak adhd (crossword puzzle increase attention of children with adhd ) ahmad yusuf*, khoridatul bahiyah*, iga wadmi j* abstract introduction: attention deficit is one of three main problems of children with attention deficit hyperactivity disorder (adhd). children experience difficulty of paying attention and concentrating to one or more things or objects. as a results these children cannot perform the task well. crossword puzzle is one of games that may increase attention and concentration. the aim of this study was to analyze the effect of crossword puzzle to increase attention of children with adhd. method: preexperimental design was employed in this study. the population was adhd students in cakra autisme therapy. seven students were recruited by means of purposive sampling. the independent variable was crossword puzzle and the dependent variable was the increase of attention. data were collected using observation sheet and analyzed using wilcoxon signed rank test with level of significance of α≤ 0.05. result: result showed that crossword puzzle could increase attention. respondent’s attention improved from less to good attention, particularly in playing activities (p=0.014). analysis: this finding suggests that there was differences of attention between pre and post-test. it can be concluded that crossword puzzle can increase attention of the students with adhd. discussion: it is recommended for teachers and parents of adhd children to give them crossword puzzle game everyday at school or at home. further studies should involve larger sample size and employs another game not only to increase attention, but also reduce hyperactivity and impulsivity of adhd child. keywords: crossword puzzle, attention, adhd * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: yusuf@fk.unair.ac.id pendahuluan anak yang memiliki gangguan defisit perhatian dan hiperaktivitas (attention deficit hyperactivity disorder/adhd) menunjukkan tiga gejala perilaku utama: penurunan perhatian, impulsif, dan hiperaktivitas (behrman, dkk., 1999). terdapat ketidakmampuan untuk memusatkan perhatiannya pada sesuatu yang dihadapi pada anak adhd, sehingga memiliki rentang perhatian sangat singkat dibandingkan anak lain yang seusia (judarwanto, 2000). berbagai macam terapi diberikan, salah satunya adalah terapi bermain yang merupakan terapi perilaku. terapi bermain dapat dilakukan untuk membantu mengendalikan agresivitas dan aktivitas yang berlebihan (misalnya permainan melempar bola dan hula hup), melatih kemampuan mempertahankan perhatian pada objek tertentu (misalnya puzzle dan sudoku) dan mengembangkan keterampilan menunggu giliran (misalnya permainan monopoli dan ular tangga) (purwanto, 2007). salah satu permainan yang dapat meningkatkan perhatian dan konsentrasi adalah permainan teka-teki silang (tts/crossword puzzle) (tarigan, 2008). menurut penelitian yang dilakukan laurienti, dkk. (2007) menyatakan bahwa dengan mengerjakan tekateki silang dapat mempengaruhi aliran darah dan aktivitas otak, aktivitas yang berhubungan dengan mata meningkat, sementara yang berhubungan dengan telinga berkurang. cakra autisme terapi merupakan salah satu tempat terapi anak dengan kebutuhan khusus. awalnya sekolah ini hanya menerima anak autis saja. namun seiring dengan banyaknya permintaan terapi, sekolah ini pun menerima anak dengan kebutuhan khusus lainnya, seperti adhd dan keterlambatan bicara. persentase anak adhd sekitar 25% dari total anak yang mailto:yusuf@fk.unair.ac.id jurnal ners vol. 4 no.2 : 139-143 140 ada. tempat ini memberikan berbagai macam terapi terhadap siswanya, seperti terapi okupasi, sensory integration, terapi musik, dan terapi perilaku yang meliputi terapi bermain. namun, jenis permainannya masih mengutamakan dalam hal menanggulangi perilaku agresif/hiperaktif anak, seperti menangkap bola, hula hup, dan meletakkan bendera pada botol. permainan untuk meningkatkan perhatian anak masih minim diberikan. permainan menyusun puzzle sudah diberikan, namun teka-teki silang belum pernah diterapkan. hingga saat ini, khususnya di indonesia, belum ada penelitian yang menjelaskan pengaruh permainan teka-teki silang terhadap peningkatan perhatian pada anak dengan adhd. adhd merupakan salah satu kelainan yang sering dijumpai pada gangguan perilaku anak. semakin lama kejadiannya semakin meningkat (judarwanto, 2000). sering dijumpai pada anak usia pra sekolah dan usia sekolah, terdapat kecenderungan keluhan ini akan berkurang setelah usia sekolah dasar. meskipun tak jarang beberapa manifestasi klinis tersebut dijumpai pada remaja atau orang dewasa. adhd mempunyai onset gejala sebelum usia 7 tahun. setelah usia tersebut, apabila tidak ditangani dengan baik akan menetap saat remaja atau dewasa. diperkirakan penderita adhd akan menetap sekitar 15-20% saat dewasa. sekitar 65% akan mengalami gejala sisa saat usia dewasa atau kadang secara perlahan menghilang. angka kejadian adhd saat usia dewasa sekitar 2-7%. angka kejadian kelainan ini adalah sekitar 3 – 10%, di amerika serikat sekitar 3-7%, sedangkan di jerman, kanada dan selandia baru sekitar 5-10% (judarwanto, 2000). angka kejadian adhd di indonesia masih belum menunjukkan angka yang pasti, meskipun kelainan ini cukup banyak terjadi (judarwanto, 2000). adhd memiliki kecenderungan lebih sering pada anak laki-laki dibandingkan anak perempuan. dengan rasio 4 : 1 (behrman, dkk., 1999), bahkan menurut santrock (2000), rasionya meningkat sampai 9 kali lebih banyak pada anak laki-laki. jika tidak ditanggulangi dengan baik, dapat menetap hingga dewasa selain itu gejala-gejala adhd dapat menimbulkan masalah bagi anak, baik dari segi akademis, seperti gangguan belajar, maupun non-akademis, seperti perilaku, komunikasi, dan sosialisasi (judarwanto, 2000). penyebab pasti dari adhd masih belum terungkap secara jelas seperti halnya gangguan autisme. adhd merupakan status kelainan yang bersifat multi faktorial. banyak faktor yang dianggap sebagai penyebab gangguan ini, diantaranya adalah faktor genetik, keturunan, maturation lack, alergi makanan, cedera otak, penyakit medis, efek samping obat, keracunan timah hitam dan faktor risiko lainnya. semua faktor dapat mempengaruhi daerah frontal pada susunan saraf pusat sehingga pusat perhatian tidak bekerja sebagaimana mestinya. gangguan ini akan mengakibatkan beberapa masalah tingkah laku. anak akan menampakkan gejala impulsif, hiperaktivitas dan penurunan perhatian. permainan teka-teki silang, akan mengkoordinasikan mata dan tangan mereka ketika mulai mencocokan urutan pertanyaan dengan letak kotak secara mendatar atau menurun. pada saat itulah anak membiasakan diri untuk fokus serta berkonsentrasi agar menuliskan jawaban pada kotak yang tepat. selain itu, dengan memikirkan dan mengisi jawaban, anak dapat terhindar dari stimulus yang menggangu sehingga lebih dapat berkonsentrasi (mozolic, 2007). menurut myers (2008), teka-teki silang merupakan salah satu jenis permainan latihan otak yang dapat digunakan sebagai standard practice untuk pasien dengan trauma neurologis dan yang memerlukan terapi neuropsikologis, termasuk pada anak adhd. berdasarkan uraian tersebut, permainan tekateki silang dapat digunakan sebagai alternatif dalam meningkatkan perhatian dan konsentrasi anak adhd. pada anak adhd, teka-teki silang dapat diberikan ketika anak sudah mampu membaca dan menulis, yaitu ketika anak berusia sekitar 5-11 tahun (hidayat, 2004). bahan dan metode penelitian penelitian ini menggunakan metode penelitian pra-eksperimental one-group prepost test design, dengan jumlah populasi terjangkau dari anak adhd di cakra autisme terapi yang berjumlah 14 orang. sampel yang memenuhi kriteria inklusi dan eksklusi sebanyak 7 orang. teka-teki silang untuk anak adhd (ahmad yusuf) 141 variabel independen dalam penelitian ini adalah permainan teka-teki silang sedangkan variabel dependen adalah atensi atau perhatian anak adhd. instrumen penelitian untuk variabel dependen (perubahan perhatian pada anak adhd) menggunakan lembar observasi snap iv rating scale for adhd yang terdiri dari 9 pertanyaan sesuai dengan gejala-gejala penurunan perhatian adhd pada dsm-iv. data yang terkumpul kemudian dianalisa perbedaan perhatian anak sebelum dan sesudah diberikan aktivitas permainan teka-teki silang. analisa dilakukan dengan menggunakan willcoxon sign rank test menggunakan dengan tingkat kemaknaan α≤0,05. hasil penelitian tabel. 1 menunjukkan bahwa semua responden berada pada positive ranks yang berarti hasil perhatian meningkat. keadaan ini dibuktikan juga oleh hasil uji statistik wilcoxon signed rank test yang menunjukkan derajat kemaknaan p=0,014. hal ini membuktikan bahwa ada perbedaan yang signifikan antara sebelum dan sesudah diberikan permainan teka-teki silang pembahasan hasil dari observasi perhatian snapiv rating scale pada awal minggu pertama penelitian, sebagian besar anak mengalami gejala perhatian kurang baik. terutama mendapat nilai 1 (kadang-kadang) dalam hal memberikan perhatian secara mendetail, tidak membuat kesalahan fatal dalam mengerjakan tugas disekolah maupun di rumah, memberikan perhatian pada tugas atau aktivitas bermain, memperhatikan jika orang lain berbicara secara langsung, dapat menyusun tugas dan aktivitas, mau ikut serta dalam tugas yang memerlukan usaha pengendalian mental, tidak kehilangan benda-benda yang diperlukan untuk aktivitas, tidak mudah dikacaukan dengan stimulus lain, dan tidak lupa dalam kegiatan sehari-hari. namun ada satu anak yang memperoleh nilai 0 (tidak pernah) dalam hal mengikuti instruksi, dapat mengerjakan pekerjaan sehari-hari dan dapat menyusun tugas dan aktivitas. dari 71,4% anak yang berjenis kelamin laki-laki, 60% mengalami perhatian kurang baik. hal ini memperkuat teori bahwa penderita adhd dominan terjadi pada anak laki-laki daripada anak perempuan. menurut behrman (1999), terdapat kecenderungan adhd lebih sering terjadi pada anak laki-laki dibandingkan anak perempuan dengan rasio secara epidemiologis 4 : 1. hal ini disebabkan karena anak laki-laki lebih berisiko memiliki hampir setiap masalah perilaku atau emosi pada masa kanak-kanak (martin, 2008). namun tidak teridentifikasi adanya masalah biologis khusus yang mendasarinya (copel, 2007). faktor genetik dan kromosom mungkin terlibat disini. beberapa gen yang berkaitan dengan kode drd4, drd5, dat, dbh, 5htt, dan 5-htr1b, banyak dikaitkan dengan adhd (judarwanto, 2000). sebagian besar anak yang mengalami perhatian kurang baik ini memiliki orangtua yang keduanya bekerja. hal ini menandakan bahwa anak yang kedua orang tuanya bekerja, terutama di luar rumah, terdapat kecenderungan untuk mengalami gejala gangguan perhatian. perilaku ini dipelajari anak sebagai cara untuk mendapatkan perhatian orang dewasa. komunikasi yang kurang dan interaksi orang tua dengan anak mempertahankan atau bahkan meningkatkan intensitas gangguan. orang tua yang kurang memperhatikan dan mengawasi anak karena lebih sering bekerja di luar rumah tidak akan mengetahui dengan baik kondisi anak. jika seorang anak atau remaja kurang mendapatkan perhatian dari orang tua, besar kemungkinan dia akan menjadi seorang anak dan remaja yang temperamental. anak akan menjadi bebas dalam melakukan segala hal, baik dalam hal baik maupun buruk (susriana, 2009). hasil penelitian menunjukkan sebagian besar orangtua dari anak yang mengalami gejala perhatian kurang baik memiliki latar belakang pendidikan perguruan tinggi dan sma. kondisi ini menunjukkan bahwa meskipun orang tua berpendidikan tinggi, tidak dapat menentukan anaknya tidak akan mengalami gangguan perhatian. tingkat pendidikan orang tua akan mempengaruhi kemampuan orang tua dalam membimbing anak. orang tua dengan pendidikan yang baik dapat menerima segala informasi tentang cara pengasuhan anak, menjaga kesehatan anak dan mendidik anak dengan baik (soejiningsih, 2002). jurnal ners vol. 4 no.2 : 139-143 142 tabel 1. perhatian anak adhd sebelum dan sesudah diberikan permainan teka-teki silang di cakra autisme terapi surabaya dari tanggal 15-26 juni 2009 ∑ mean rank sum of ranks negative rank 0a 0,00 0,00 positive rank 7b 4,00 28,00 ties 0c 0,00 0,00 total 7 wilcoxon signed rank test p=0,014 keterangan: a = perhatian setelah perlakuan < sebelum perlakuan b = perhatian setelah perlakuan > sebelum perlakuan c = perhatian setelah perlakuan = sebelum perlakuan hasil penelitian menunjukkan bahwa sebagian besar anak memperoleh kriteria perhatian baik, ditandai dengan hampir semua anak mendapat nilai 3 (sering) terutama dalam hal perhatian jangka pendek, seperti perhatian dalam hal melakukan aktivitas bermain, memperhatikan ketika orang lain berbicara secara langsung, mengikuti instruksi dan tidak mudah dikacaukan oleh stimulus lain. ternyata anak yang mengalami peningkatan perhatian menjadi baik memiliki ibu yang bekerja sebagai ibu rumah tangga. permainan teka-teki silang, yang diberikan sebagai sarana untuk meningkatkan perhatian anak adhd. peningkatan perhatian tersebut terutama dalam hal perhatian jangka pendek, seperti perhatian dalam hal melakukan aktivitas bermain, memperhatikan ketika orang lain berbicara secara langsung, mengikuti intsruksi, dan tidak mudah dikacaukan oleh stimulus lain. melalui proses mengerjakan teka-teki silang aliran darah dan aktivitas otak anak meningkat. ketika anak membaca soal, informasi dipindahkan dari mata melalui jalanjalan visual ke suatu bagian otak yang disebut lobus oksipital. citra visual tidak berarti apaapa sebelum dikoordinasikan dengan daerah lobus parietal. kemudian anak baru dapat memahami jenis pertanyannya lalu menyelesaikan persoalan tersebut. informasi kemudian dikirimkan ke daerah lobus frontal yaitu respon diterjemahkan menjadi sebuah jawaban verbal atau tertulis. jika seorang anak memiliki masalah dengan perhatian dan kemudahan mengalami gangguan, daerah lobus frontal ini hanya terlibat sebagian. setelah pusat perhatian ini memperoleh pesan kemudian akan berkomunikasi dengan otak lainnya untuk mengatur tingkat perhatian dan konsentrasi. lobus frontal juga merupakan tempat sel otak distimulasi untuk mengeluarkan neurotransmiter, khususnya dopamin yang berkaitan dengan pemusatan perhatian (konsentrasi). namun dalam penelitian ini tidak dilakukan pengukuran kadar neurotransmiter dopamin. melalui pelepasan dopamin, informasi dapat berjalan dari satu neuron ke neuron berikutnya melalui neuropathways. dopamin akan mengoptimalkan transmisi impuls dan informasi dari dan ke neuron otak, khususnya pada sistem limbik dan korteks frontal. dopamin juga memiliki sasaran di beberapa bagian otak, khususnya korteks frontalis (korteks prefrontal dan korteks motorik primer). dopamin dapat mengoptimalkan transmisi impuls ke korteks prefrontal sehingga terjadi peningkatan kemampuan menganalisa dan menyeleksi impuls sensori. aktivitas yang berhubungan dengan mata meningkat, sementara yang berhubungan dengan telinga berkurang. anak akan dapat mempertahankan impuls yang adekuat dan mengabaikan impuls yang tidak adekuat sehingga dapat meningkatkan perhatian (konsentrasi). saat mengerjakan teka-teki silang, anak akan mengkoordinasikan mata dan tangan ketika mulai mencocokan urutan pertanyaan dengan letak kotak secara mendatar atau menurun. pada saat itulah anak membiasakan diri untuk fokus serta berkonsentrasi agar menuliskan jawaban pada kotak yang tepat. ketika harus fokus, sistem meninggikan tingkat konsentrasi melalui reaksi biokimia. ketika pikiran terbagi dengan hal-hal disekiling, sistem mengurangi tingkat konsentrasi. namun dalam hali ini, dengan memikirkan dan mengisi jawaban, anak dapat terhindar dari stimulus yang menggangu teka-teki silang untuk anak adhd (ahmad yusuf) 143 sehingga lebih dapat berkonsentrasi (mozolic, 2007). simpulan dan saran simpulan permainan teka-teki silang dapat meningkatkan perhatian anak adhd perhatian tersebut terutama dalam hal melakukan aktivitas bermain, memperhatikan ketika orang lain berbicara secara langsung, mengikuti intsruksi, dan tidah mudah dikacaukan oleh stimulus lain. saran penulis menyarankan agar: 1) anak yang mengalami gejala perhatian kurang baik, sebaiknya diberikan penanganan yang lebih intensif, terutama bgi orangtua yang keduanya bekerja di luar rumah agar lebih meluangkan waktu untuk berinteraksi dengan anaknya, 2) permainan teka-teki silang agar bdiberikan pada anak adhd untuk meningkatkan perhatiannya, 3) perawat di rumah sakit, guru di sekolah anak dengan kebutuhan khusus, dan orangtua dirumah disarankan memberikan permainan teka-teki silang untuk anak dengan gangguan perhatian sebagai alternatif terapi perilaku/terapi bermain bagi anak dan 4) peneliti selanjutnya diharapkan melaksanakan penelitian dengan responden yang lebih besar mengenai pengaruh permainan/sarana lainnya terhadap peningkatan perhatian, penurunan hiperaktivitas dan impulsivitas anak adhd. kepustakaan behrman, richard e.; kliegman, robert m. & arvin, ann m., 1999. ilmu kesehatan anak. edisi 15. jakarta: egc, hlm. 114. copel, linda carman, 2007. kesehatan jiwa dan psikiatri, pedoman klinis perawat. edisi 2. jakarta: egc, hlm. 39-40. hidayat, aziz alimul, 2004. pengantar ilmu keperawatan anak i. surabaya: direktorat pembinaan, penelitian, dan pengabdian kepada masyarakat dan direktorat jendral pendidikan tinggi, hlm. 73-75. judarwanto, 2000. penatalaksanaan attention deficit/hyperactivity disorder pada anak, (online) , (http://propolisdiamond.com/index.php ?view=article&catid=76%3aterapipen yakit&id=81%3aadhd&format=pdf&o ption=com_content&itemid=96, diakses tanggal 20 november 2008, jam 11.01 wib). martin, grant l., 2008. terapi untuk anak adhd. jakarta: pt bhuana ilmu populer, hlm. 61-77. mozolic, jennifer & laurienti, paul, 2007. attention training may help older adults improve concentration, (online), (http://www.sciencedaily.com/releases/ 2007/11/071104191548.htm, diakses tanggal 17 november 2008, jam 11.24 wib). myers, robert, 2008. what good are crossword puzzles?,(online), (http://vocabulary.co.il/blog/learning_vo cabulary/what-good-are-crosswordpuzzles/, diakses tanggal 28 november 2008, jam 12.57 wib). purwanto, setiyo, 2007. penerapan terapi bermain bagi penyandang adhd,(online), (http://melianaaryuni.wordpress.com/200 8/08/12/penerapan-terapi-bermain-bagipenyandang-adhd/, diakses tanggal 24 november 2008, jam 10.19 wib). santrock, john w., 2000. children, sixth edition. united states of america: mcgraw-hill company, inc., pp. 348350. soetjiningsih, 2002. tumbuh kembang anak. jakarta: egc, hlm. 2-11. susriana, 2009. peran orang tua terhadap perkembangan anak dan remaja, (online), (http://www.ubb.ac.id/menulengkap.php ?judul=peran%20orang%20tua%20terh adap%20perkembangan%20anak%20da n%20remaja&&nomorurut_artikel=375, diakses tanggal 4 agustus 2009, jam 20.23 wib). http://propolisdiamond.com/index.php?view=article&catid=76%3aterapipenyakit&id=81%3aadhd&format=pdf&option=com_content&itemid=96 http://propolisdiamond.com/index.php?view=article&catid=76%3aterapipenyakit&id=81%3aadhd&format=pdf&option=com_content&itemid=96 http://propolisdiamond.com/index.php?view=article&catid=76%3aterapipenyakit&id=81%3aadhd&format=pdf&option=com_content&itemid=96 http://propolisdiamond.com/index.php?view=article&catid=76%3aterapipenyakit&id=81%3aadhd&format=pdf&option=com_content&itemid=96 http://www.sciencedaily.com/releases/2007/11/071104191548.htm http://www.sciencedaily.com/releases/2007/11/071104191548.htm http://vocabulary.co.il/blog/learning_vocabulary/what-good-are-crossword-puzzles/ http://vocabulary.co.il/blog/learning_vocabulary/what-good-are-crossword-puzzles/ http://vocabulary.co.il/blog/learning_vocabulary/what-good-are-crossword-puzzles/ http://melianaaryuni.wordpress.com/2008/08/12/penerapan-terapi-bermain-bagi-penyandang-adhd/ http://melianaaryuni.wordpress.com/2008/08/12/penerapan-terapi-bermain-bagi-penyandang-adhd/ http://melianaaryuni.wordpress.com/2008/08/12/penerapan-terapi-bermain-bagi-penyandang-adhd/ http://www.ubb.ac.id/menulengkap.php?judul=peran%20orang%20tua%20terhadap%20perkembangan%20anak%20dan%20remaja&&nomorurut_artikel=375 http://www.ubb.ac.id/menulengkap.php?judul=peran%20orang%20tua%20terhadap%20perkembangan%20anak%20dan%20remaja&&nomorurut_artikel=375 http://www.ubb.ac.id/menulengkap.php?judul=peran%20orang%20tua%20terhadap%20perkembangan%20anak%20dan%20remaja&&nomorurut_artikel=375 http://www.ubb.ac.id/menulengkap.php?judul=peran%20orang%20tua%20terhadap%20perkembangan%20anak%20dan%20remaja&&nomorurut_artikel=375 80 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.7518 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research differences between nrs-2002 and must in relation to the metabolic condition of trauma patients oktaffrastya widhamurti septafani1, suharto suharto2 and harmayetty harmayetty1 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 faculty of medicine, universitas airlangga, surabaya, indonesia abstract introduction: flow phase with high cardiac output and increased metabolic conditions. when metabolic conditions are not stable there will be a long duration of complications until death. one of the benefits of nutrition risk screening (nrs2002) is reliable inpatient care for critical patients. while the malnutrition universal screening tool (must) shows speed in the classification of nutritional disorders. methods: this study used the observational design method. the sampling technique in this study used consecutive sampling in accordance with the criteria consisting of 31 respondents. this was to determine the specificity and sensitivity values of nrs 2002 and must using contingency table analysis and for the area under curve (auc) using receiver operating characteristic (roc) curve analysis. results: the sensitivity values in must was predicted for metabolic conditions which was higher than when using nrs 2002, but the specificity and value of auc (area under curve) was higher using nrs 2002 than using must when it came to predicting metabolic conditions. conclusions: there were differences in effectiveness between use of nutritional risk screening (nrs-2002) with the malnutrition universal screening tool (must) in relation to changes in metabolic conditions of trauma patients. nrs2002 is more effective than must. nrs 2002 has the ability to identify patients more precisely who are likely to have a negative outcome. article history received: february 01, 2018 accepted: june 07, 2018 keywords nrs 2002; must; metabolic response; trauma contact oktaffrastya widhamurti septafani oktaffrastyaws@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: septafani, o., suharto, s., & harmayetty, h. (2018). differences between nrs-2002 and must in relation to the metabolic condition of trauma patients. jurnal ners, 13(1), 80-86. doi:http://dx.doi.org/10.20473/jn.v13i1.7518 introduction trauma is the most common cause of death in the productive age group of 16-44 years old worldwide (macleod, 2005). the metabolic response to human trauma has been defined as having 3 stages: ebb phase or decreased metabolic rate in the early shock phase, flow phase or catabolic phase, and the anabolic phase. the ebb phase begins immediately after the injury or trauma and lasts for 0-48 hours. the ebb phase is characterised by tissue hypoperfusion and decreased overall metabolic activity. the flow phase, which includes a catabolic phase characterized by high cardiac output and increased metabolic conditions. typically, the peak flow phase is about 3-5 days, and this will drop in 7-10 days. late death is when the patient dies several days or weeks after the trauma. the prevalence of trauma deaths occurring in this period is 10% -20% (sobrino & shafi, 2013). increased metabolic conditions include the hyper-dynamic characteristics of heart rate, increased energy expenditures, increased solubility of glycogen and protein, and a loss of muscle mass and weight, leading to delayed wound healing and immune system depression (lee, benjamin & herndon, 2005). if the metabolic condition is not handled properly then it will lead to a longer period of treatment, complications and death. so far predicting metabolic condition is based on laboratory results by looking at the magnitude of plasma proteins, nitrogen balance and the result of immunological function tests. however, there are often errors in the pre-analytic stages of laboratory examination when it comes to initial preparation compared to errors in the analytical phase (plebani, 2012). as a result there are still some specimens received by the laboratory experiencing hemolysis, so it cannot be checked according to clinical request. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 81 in a study conducted by chen et al., the sensitivity (94.5%) of nutritional risk screening (nrs-2002) was high when it came to identifying nutritional disorders compared to routine clinical laboratory measurements (rclms) (chen et al., 2015). for nutrition risk screening in adult patients, the european society for clinical nutrition and metabolism currently recommend nutritional risk screening (nrs-2002) as the screening tool of choice (kuppinger et al., 2013). nrs-2002 showed superior performance (higher sensitivity and specificity for predicting complications) compared to other screening tools such as the malnutrition universal screening tool (must). the study comparing must with nrs 2002 showed that must is significantly associated with complications in postoperative patients. with a sensitivity value of 23.1% and a specificity of 86.8% (lomivorotov et al., 2013). the results of nutritional screening can determine the patient's status and detect some of the complications of critical illness (al kalaldeh & shahin, 2014). based on the recommendation of the british association of parenteral and enteral nutrition (bapen), simple and easy nutrition observation devices can be used to demonstrate the risks of nutritional problems in patients requiring comprehensive advanced examination. every nutritional screening device should have the property of being easy and fast to use and interpret, be valid and have a good level of acceptance so each patient can subsequently receive a nutrition care pattern that is appropriate to their condition (weekes, elia, & emery, 2004). currently, many nutrition observation devices in hospitals have been developed for various purposes, such as to adjust the measured population, or to find new methods that are faster and easier to use. one of the recommendations of the european society for parenteral and enteral nutrition (espen) is nutrition risk screening (nrs-2002) which assesses patients based on two components, malnutrition and the severity of disease with no category, mild, moderate, and severe being in the result categories respectively. the nrs-2002 device is also known to be valid and easy to use in european trial populations (kondrup, et al., 2003). in some studies, it showed nutrition risk screening (nrs-2002) has a high specificity and sensitivity value compared to other nutritional screening values. bapen developed the malnutrition universal screening tools (must) that performs an examination with 3 main criteria: current weight, a large amount of unwanted weight loss, and the presence of acute illness. the score each criterion is between 0, 1, or 2. based on the must assessment, patients are classified as low, moderate, and high risk (malnutrition advisory group, 2003). in jayawardena et al.’s study (2016), there is a malnutrition universal screening tools (must) relationship to the patient's clinical situation. the study demonstrated the high specificity of malnutrition universal screening tools (must) in predicting outcome value of patients with heart failure. the purpose of this study was to explain the difference in effectiveness between the uses of nutritional risk screening instruments (nrs-2002) with the malnutrition universal screening tool (must) in relation to changes in metabolic conditions in trauma patients. materials and methods the committee of ethical approval in the faculty of nursing universitas airlangga has carefully reviewed the research proposal presented and approved this research study by way the full board method. this study used an observational design. observational studies are an alternative to experimental studies. an observational study is sometimes termed a natural experiment. the study subjects were classified into groups with the presence or absence of a disease respectively, which is called a casecontrol study. in this design, an observation or posttest measurement was performed. diagnostic analysis by examination of albumin and hemoglobin were gold standard. the population in this study was made up of all trauma patients who were treated at petrokimia gresik hospital. the patients who became part of sample must have meet the inclusion criterion. the establishment of the inclusion is criteria as follows: (1) treatment of trauma > 2 days (in flow phase). (2) patients who are trauma by serious trauma. severe trauma based on ais (abbreviated injury scale). the while the exclusion criteria that the researchers set include (1) patients with hyperthyroid disease; (2) patients with heart failure; (3) hypertensive patients on beta-blocker therapy; (4) the patient is pregnant; (5) patients with diabetes and (6) patients with impaired renal function. the independent variables were the nutritional risk screening (nrs-2002) and the malnutrition universal screening tool (must). dependent variable was metabolic condition measured by blood urea and blood sugar. gold standard nutritional status was measured by the albumin and hemoglobin blood levels of the trauma patients. each respondent recorded the results of the blood urea examination, blood sugar and the examination of albumin and hemoglobin was done as standard by seeing the patient's medical record. if there was no data in their medical record, then a blood test was done. according to leuenberger (2010), nrs 2002 devices have been accepted and widely used in europe. the device uses four pre-screening statements to separate patients at lower risk of malnutrition from those with a higher risk. this include forms of disease severity, making this device capable of covering patients in all categories of illness in hospitals. nrs 2002 is a device that is easy to use and fast (its use takes only 2-3 minutes). based on screening conducted with this method, the patients are classified in the normal category (score o. w. septafani et al. 82 | pissn: 1858-3598  eissn: 2502-5791 = 0), mild category (score = 1), moderate category (score = 2), or weight category (score = 3). there are 5 step to perform when screening using must, i.e. [1] the collection of anthropometric data collection such as height, weight, and bmi, [2] the scoring of malnutrition risk based on undesirable weight loss, [3] if there is an acute illness which affects the risk of malnutrition, and then the score plus 2, [4] the summation of the scores based on measurements, where the score 0 = low risk, score 1 = medium risk, or score ≥2 high risk malnutrition, and [5] is the last step where planning measures are undertaken thet are appropriate to the patient's malnutrition risks. to determine the specificity and sensitivity of nutritional risk screening (nrs-2002) and the malnutrition universal screening tool (must) in relation to metabolic conditions (the values of urea and blood sugar levels) and standard nutritional status (albumin and hemoglobin values) using contingency table analysis, and for the area under curve (auc) using receiver operating characteristic (roc) curve analysis. results based on the analysis of table 1, it was found that the sensitivity value of nrs 2002 in relation to the risk of malnutrition seen in the results of laboratory test was 62.5%. nrs-2002 has the ability to screen trauma patients who are at risk of malnutrition which was 62.5%. the specificity value of nrs 2002 against the risk of malnutrition as seen from the laboratory results was 100%. nrs-2002 has the ability to detect negative results in trauma patients, so the ability of nrs-2002 to screen trauma patients with absolutely no risk of malnutrition was 100%. positive predictive value a / (a + b) × 100 = 5 / (5 +0) × 100 = 100%. this indicates that the true proportion of trauma patients included in the category of malnutrition risk was 100%. the negative predictive value d/(c + d) × 100 = 17 / (3 +17) × 100 = 85%. this indicates that the proportion of trauma patients who are not actually included in the malnutrition risk category was 85%. based on the analysis of table 2 it was found that the must sensitivity value in relation to the risk malnutrition risk seen laboratory result was 75%. must has the ability to screen trauma patients who are at risk of malnutrition standing at 75%. must specificity value against malnutrition risk seen from laboratory result was 64.7%. must has the ability to detect negative outcomes in trauma patients, so the ability of must to screen trauma patients with absolutely no risk of malnutrition was 64.7%. positive predictive value a / (a + b) × 100 = 6 / (6 + 6) × 100 = 50%. this suggests that the true proportion of trauma patients included in the category of malnutrition risk was 50%. the negative predictive value d/(c + d) × 100 = 11 / (2 + 11) × 100 = 84%. this indicates that the true proportion of table 1. the results of the test validity (specificity and sensitivity) in relation to the use of nutritional risk screening (nrs-2002) used to calculate the risk of malnutrition as seen from the laboratory test (albumin and hemoglobin) nrs 2002 malnutrition risk (low albumin and hemoglobin levels) normal (normal albumin and hemoglobin levels) n n malnutrition risk 5 0 normal 3 17 se = % sp = % table 2. the results of the test validity (specificity and sensitivity) on the use of the malnutritional universal screening tool (must) used to calculate the risk of malnutrition as seen from the laboratory test (albumin and hemoglobin) must malnutrition risk (low albumin and hemoglobin levels) normal (normal albumin and hemoglobin levels) n n malnutrition risk 6 6 normal 2 11 se sp = % table 3. the result of the test validity (specificity and sensitivity) on the use of nutritional risk screening (nrs-2002) in relation to metabolic response as seen from laboratory test (bun and blood glucose) nrs 2002 metabolic response (high bun and blood glucose levels normal (normal bun and blood glucose levels) n n malnutrition risk 4 0 normal 11 7 se sp = % table 4. the results of the test validity (specificity and sensitivity) on the use of the malnutritional universal screening tool (must) in relation to metabolic response as seen from laboratory test (bun and blood glucose) nrs 2002 metabolic response (high bun and blood glucose levels normal (normal bun and blood glucose levels) n n malnutrition risk 7 3 normal 8 4 se sp = % jurnal ners http://e-journal.unair.ac.id/jners | 83 trauma patients not included in the malnutrition risk category was at 84%. based on the analysis of table 3, it was found that the sensitivity value of nrs 2002 in relation to metabolic response as seen results of laboratory results was 26.7%, which means that nrs-2002 has the ability to screen trauma patients who actually enter a metabolic response condition at 26.7% . the specificity value of nrs 2002 to metabolic response as seen from laboratory result was 100%. the ability of nrs-2002 to screen trauma patients who are completely excluded from metabolic conditions was 100%. positive predictive value a / (a + b) × 100 = 4 / (4 + 0) × 100 = 100%. this indicates that the true proportion of trauma patients included in the metabolic condition was 100%. the negative predictive value d / (c + d) × 100 = 7 / (11 + 7) × 100 = 38%. this suggests that the proportion of trauma patients actually excluded from entry into metabolic conditions was as much as 38%. based on analysis of table 4, it was found that must’s sensitivity value in relation to metabolic response seen in the result of laboratory test was 46.6%. must has the ability to screen trauma patients who actually experience entry with metabolic conditions at 46.6%. the specificity of must was 57.1%. must has the ability to detect negative outcomes in trauma patients. the ability of must to screen trauma patients who are completely excluded from metabolic conditions was 57.1%. positive predictive value a / (a + b) × 100 = 7 / (7 + 3) × 100 = 70%. this suggests that the true proportion of trauma patients included in the metabolic condition was as much as 70%. the negative predictive value d/(c + d) × 100 = 4 / (8 + 4) × 100 = 33%. this suggests that the proportion of trauma patients who are completely excluded from metabolic conditions was 33%. discussion comparing specificity, sensitivity and auc (area under curve) on the use of nutritional risk screening (nrs-2002) in relation to metabolic response in trauma patients and gold standards of nutrition based on the analysis of table 3, it was found that the sensitivity value of nrs 2002 in relation to metabolic response s seen in laboratory results was 26.7%, which means that nrs-2002 has the ability to screen trauma patients who actually enter at metabolic response condition at 26,7%. based on the analysis table 1, it was found that the sensitivity value of nrs 2002 used to calculate the risk of malnutrition as seen in the laboratory test was 62.5%. nrs-2002 has the ability to screen trauma patients who are actually at risk of malnutrition: the result was 62.5%. it can be seen that the sensitivity of nrs-2002 in relation to metabolic response was low compared to the gold standard. however, the nrs-2002 sensitivity value against the standard was still low, when compared to the research conducted by ansari, et al. (2014). in the study conducted by ansari, et al. (2014), obtaining a sensitivity score against the gold standard was 82.4%. this is in contrast to research conducted by simanjuntak (2010), which obtained a sensitivity value of 53.7% against the standard. this suggests that the higher albumin and hemoglobin levels the lower the nrs2002 score, which means that there is less risk of malnutrition. high sensitivity is required if the disease is highly lethal and early detection can significantly improve prognosis (richard, et al., 2003). the purpose of screening itself is to prevent disease or disease by identifying individuals at a point when the disease process can be changed through intervention. since the nrs-2002 sensitivity rating for metabolic conditions is low, it cannot be said that the higher the metabolic response value of bun and blood glucose, that the nrs-2002 score is also small. this is although the metabolic response is associated with the risk of malnutrition. low sensitivity values indicate a high false negative value, which occurred in as many as 11 patients. this was where the patients experience a metabolic response characterised by increased bun and blood glucose but no risk of malnutrition. the risk of malnutrition is strongly related to the total amount of protein taken in per day (william, et al., 2004). this is because it is directly related to albumin and blood hemoglobin levels. in this study, the majority of patients were elective surgery patients, but here the researchers did not classify which patients were due elective surgery and which were not. in a study conducted by azizah (2010), it showed that a high intake of daily protein will increase bun and blood glucose. the specificity value of nrs 2002 in relation to metabolic response as seen from the laboratory test was 100%. the ability of nrs-2002 to screen trauma patients who were completely excluded from having a metabolic conditions was 100%. the specificity value of nrs 2002 used to calculate the risk of malnutrition as seen from the laboratory results was 100%. nrs-2002 has the ability to detect negative results in trauma patients, so the ability of nrs-2002 to screen trauma patients with absolutely no risk of malnutrition was 100%. here the specificity value of nrs-2002 in relation to metabolic response was very high. this is consistent with richard, et al.’s study (2003) who state that if you want to get a specificity value of 100% then the value of sensitivity should be less than 100%. an increase in sensitivity will cause a decrease in specificity, and vice versa. nrs-2002 obtains a perfect specificity value because a falsepositive value is equal to 0. the value of auc between nrs 2002 in relation to bun and blood glucose levels was 58% and 59% with 95% confidence interval. the value of auc between nrs-2002 on relation to albumin and hemoglobin levels was 77.3% and 64.3% with 95% confidence interval. nrs-2002 has a moderate value of accuracy to calculate the risk of malnutrition, but o. w. septafani et al. 84 | pissn: 1858-3598  eissn: 2502-5791 nrs 2002 has a weak accuracy to relation to metabolic conditions. the research conducted by ansari, et al. (2013), it showed that get an auc’s value of 58.3% to calculate albumin levels. comparing specificity, sensitivity and auc (area under curve) on the use the malnutrition universal screening tool (must) in relation to metabolic conditions in trauma patients and gold standards of a nutrition based on the analysis of table 4 it was found that the sensitivity of must in relation to the metabolic response as seen results of the laboratory test was 46.6%. must has the ability to screen trauma patients. based on the analysis conducted on table 2, it was found that the must sensitivity value against malnutrition risk as seen in laboratory test was 75%. must has the ability to screen trauma patients who are actually at risk of malnutrition at 75%. this suggests that the must sensitivity value of the metabolic response is lower when compared to the must sensitivity of the risk of malnutrition. the specificity of must on metabolic response as seen from the laboratory test was 57.1%. must has the ability to detect negative outcomes in trauma patients. the ability of must to screen trauma patients who are completely excluded from metabolic conditions was 57.1%. must’s specificity value on malnutrition risk as seen from the laboratory test was 64.7%. must has the ability to detect negative outcomes in trauma patients, so the ability of must to screen trauma patients with absolutely no risk of malnutrition was 64.7%. this suggests that must’s specificity value for metabolic response is lower than that of must and the risk of malnutrition. the low specificity of the specificity is not a problem, since most of the trauma patients in this study were post-operative patients, there may be various complications (lomivorotov et al., 2013). malnutrition itself still means thet there are less extensive and different understandings of the nutritional risks, which can be interpreted as a change in nutritional status for the better or worse because the results of the disease or post-trauma, depending on the actual or potential nutrients and metabolic status (sun, et al 2015). the theory between trauma, metabolic response and death is related (simsek, et al, 2014). the body responds to trauma with a state of tachycardia, an increased use of oxygen, increased respiratory rate, an increase in body temperature as well as an increase in the negative nitrogen balance of, for example catabolism. the flow phase, also called catabolism, can occurs more than 2 days post-trauma. the flow phase is an early period of catabolism that provides a compensatory response to early trauma and volume replacement, except in the case of most minor injuries. in this phase, the metabolic response is directly related to the supply of energy substrates and proteins to protect the repair of tissue damage and the function of critical organs. the increased body oxygen consumption and metabolic rate is among these responses. in the early catabolic stages, catecholamine (adrenaline) is responsible for increased production and energy consumption. high plasma urea is one of the abnormal features of the protein catabolism process accompanied by a negative nitrogen balance. in the research conducted, not all patients have increased bun. according to simsek, et al. (2014) elective surgery and minor surgery may show decreased protein synthesis and protein degradation. increased levels of nitrogen urine and negative nitrogen balance can be detected early after surgery and the peak is on the 7th day. protein catabolism can last for 3-7 weeks. all patients were measured on day 2 so not all patients showed an increase in bun. after trauma lipolysis increases and fat is used as a source of energy. lipoprotein lipase is attached to the capillary endothelium which will convert triglycerides into glycerol and free fatty acids. heparin will release the lipoprotein lipase enzyme into the circulation resulting in intravascular hydrolysis. in trauma lipoprotein lipase muscle activity increases but in adipose tissue decreases in contrast to sepsis this lipase activity in muscle decreases. surgery affects metabolism and substrate utilization. post-operation, glucose utilization decreases as insulin time becomes resistant with elevated triglycerides and free fatty acids. insulin resistance post-operatively is prevented in elective surgery, e.g. the administrations of carbohydrates prior to surgery (soop, et al., 2007). in this study, the majority of patients were elective surgery patients, but the researchers did not classify between patients who were undergoing elective surgery and who were not. the value of auc between must to bun and blood glucose levels was 56.8% and 46.1% with 95% confidence interval. while the auc value between must to albumin and hemoglobin levels was 64.3% and 64.3% with 95% confidence interval. must has a moderate value of accuracy to calculate the risk of malnutrition, but must has a very weak accuracy value in relation to metabolic conditions. differences in the effectiveness of using nutritional risk screening (nrs-2002) and the malnutrition universal screening tool (must) in relation to metabolic conditions in trauma patients according to schieccer, et al. (2008), a higher 2002 nrs score was found to be quite predictive of the risk of complications and death. in raslan, et al. (2011) which compared the area under curve (auc) between nrs 2002 and must, it shows that nrs 2002 is better than must. a study conducted by ozkhalanli, et al (2009), nrs showed good predictive validity for the occurrence of post-operative complications. must was originally designed to not only determine nutritional status, but also to predict outcomes in adults, as well as the elderly inpatients. in the study conducted by henderson, et al. (2008) jurnal ners http://e-journal.unair.ac.id/jners | 85 must with nrs 2002 was used to predict mortality in older patients who were inpatients, in which the studies examined indicated less mortality, so must therefore has poor predictive validity. further study of must’s predictive validity in the elderly population is needed. in 2006, the association dietician indonesia (asdi) began introducing the proses asuhan gizi terstandar (pagt) adopted from the nutrition care process, created by the american dietetic association (ncp-ada). the pgat was prepared as an effort to provide quality nutritional care. the process supports and leads to individual nutritional care. the standard nutrition care process consists of 4 steps ranging from nutritional assessment, nutrition diagnosis, nutritional intervention, monitoring and evaluation. the advantage of this study, is that it can quickly and easily predict the trauma patient's nutritional condition. so the risk of metabolic conditions can be treated early. a limitation of this study was not examining the hormone levels, during the biochemical examination. this is because the metabolic response is strongly influenced by the hormone levels of trauma patients. in hospitals, the nrs-2002 instrument is better suited to predicting the presence of metabolic conditions in trauma patients than must. nutrition screening is an entry into the pagt cycle, with the goal being to obtain sufficient information to identify any relationships with nutritional problems. patients who are identified as malnourished need nutritional care through screening and referral. nutrition screening should be a simple and quick process that can be done by nurses and medical staff (barendregt, 2008). the assessment of the nutritional status of hospitalised patients will result in better accuracy when it comes nutritional interventions so as to enhance biochemical and clinical indicators. this has an impact on the outcome of hospitalisation, accelerating the disease and reducing the complication of disease, so that it can shorten the length of hospitalisation and preventing the malnutrition of the hospital patient. nutrition services in hospitals are the right of everyone, and require a guideline to obtain quality service results. quality nutrition services in hospitals will assist the patient's healing process, which means shortening the length of their stay, which can save medical expenses. conclusion there is a significant difference in effectiveness between the uses of nutritional risk screening (nrs2002) with the malnutrition universal screening tool (must) in relation to change in the metabolic conditions of trauma patients. the use of the nrs2002 instruments is more effective than the must for measuring changes in the metabolic conditions of trauma patients. nrs 2002 has the ability to identify patients not in metabolic negative state, and the value of nrs 2002 accuracy is higher than must. references al kalaldeh, m., & shahin, m. (2014). nurses’ knowledge and responsibility toward nutritional assessment for patients in intensive care units. journal of health sciences, 4(2), 90. retrieved from http://ezproxy.stir.ac.uk/login?url=http://search .ebscohost.com/login.aspx?direct=true&db=edb& an=100323167&site=eds-live ansari, m. r., susetyowati, & pramantara, i. (2014). uji validitas skrining status gizi nrs 2002 dengan asesmen biokimia untuk mendeteksi risiko malnutrition di rsup dr. sardjito yogyakarta. gizi indon, 37((1)), 1–12. barendregt, k., p.b. soeters, s.p. allison and j.kondrup, 2008. basic concepts in nutrition: diagnosis of malnutrition: screening and assessment. e-spen, e. spen. eur. e. j. clin. nutr. metab., 3: 121-125. chen, z. y., gao, c., ye, t., zuo, x. z., wang, g. h., xu, x. s., & yao, y. (2015). association between nutritional risk and routine clinical laboratory measurements and adverse outcomes: a prospective study in hospitalized patients of wuhan tongji hospital. european journal of clinical nutrition, 69(5), 552–557. https://doi.org/10.1038/ejcn.2014.239 jayawardena, r., lokunarangoda, n. c., ranathunga, i., santharaj, w. s., walawwatta, a. o., & pathirana, a. k. (2016). predicting clinical outcome of cardiac patients by six malnutrition screening tools. bmc nutrition, 2(1), 5. https://doi.org/10.1186/s40795-016-0044-z kondrup, j., allison, s. p., elia, m., vellas, b., & plauth, m. (2003). espen guidelines for nutrition screening 2002. clinical nutrition, 22(4), 415– 421. https://doi.org/10.1016/s02615614(03)00098-0 kuppinger, d., hartl, w. h., bertok, m., hoffmann, j. m., cederbaum, j., bender, a., … rittler, p. (2013). nutritional screening for risk prediction in patients scheduled for extra-abdominal surgery. nutrition, 29(2), 399–404. https://doi.org/10.1016/j.nut.2012.06.013 lee, j. o., benjamin, d., & herndon, d. n. (2005). nutrition support strategies for severely burned patients. nutricion on clinical practice, 20(june), 325–330. leuenberger, m., kurmann, s. & stanga, z. support care cancer (2010) 18(suppl 2): 17. https://doi.org/10.1007/s00520-009-0805-1 lomivorotov, v. v., efremov, s. m., boboshko, v. a., nikolaev, d. a., vedernikov, p. e., lomivorotov, v. n., & karaskov, a. m. (2013). evaluation of nutritional screening tools for patients scheduled for cardiac surgery. nutrition, 29(2), 436–442. https://doi.org/10.1016/j.nut.2012.08.006 o. w. septafani et al. 86 | pissn: 1858-3598  eissn: 2502-5791 macleod, j. b. a. (2005). guidelines for essential trauma care. the journal of trauma: injury, infection, and critical care, 58(3), 652–653. https://doi.org/10.1097/01.ta.0000157822.402 27.f2 nugrahani, azizah. (2007). hubungan asupan protein terhadap kadar urea nitrogen, kreatinin, dan albumin darah pasien penyakit gagal ginjal kronik yang menjalani hemodialisis di rsup dr. sardjito yogyakarta. skripsi. yogyarkarta:universitas gadjah mada, 2007. plebani, m. (2012). （2013）quality indicators to detect pre-analytical errors in laboratory testing.pdf, 33(august), 85–88. raslan, m., gonzalez, m. c., torrinhas, r. s. m. m., ravacci, g. r., pereira, j. c. r., & waitzberg, d. l. (2011). complementarity of subjective global assessment (sga) and nutritional risk screening 2002 (nrs 2002) for predicting poor clinical outcomes in hospitalized patients. clinical nutrition (edinburgh, scotland), 30(1), 49–53. https://doi.org/10.1016/j.clnu.2010.07.002 schiesser, m., muller, s., kirchhoff, p., breitenstein, s., schafer, m., & clavien, p.-a. (2008). assessment of a novel screening score for nutritional risk in predicting complications in gastro-intestinal surgery. clinical nutrition (edinburgh, scotland), 27(4), 565–570. https://doi.org/10.1016/j.clnu.2008.01.010 sobrino, j., & shafi, s. (2013). timing and causes of death after injuries. proceedings (baylor university. medical center), 26(2), 120–3. retrieved from http://www.pubmedcentral.nih.gov/articlerende r.fcgi?artid=3603725&tool=pmcentrez&renderty pe=abstract şimşek, t., şimşek, h. u., & cantürk, n. z. (2014). response to trauma and metabolic changes : posttraumatic metabolism, 153–159. https://doi.org/10.5152/ucd.2014.2653jakob, s. m., & stanga, z. (2010). perioperative metabolic changes in patients undergoing cardiac surgery. nutrition, 26(4), 349–353. https://doi.org/10.1016/j.nut.2009.07.014 soop, m., nygren, j., thorell, a., & ljungqvist, o. (2007). stress-induced insulin resistance: recent developments. current opinion in clinical nutrition and metabolic care, 10(2), 181–186. https://doi.org/10.1097/mco.0b013e32801481 df simanjuntak, t. (2010). hubungan skrinning gizi nrs 2002 dan must dengan asesmen biokimia pada pasien bangsal penyakit dalam dan syarap rsup dr. sardjitoyogyakarta. skripsi. yogyakarta:universitas gajah mada, 2010. weekes, c. e., elia, m., & emery, p. w. (2004). the development, validation and reliability of a nutrition screening tool based on the recommendations of the british association for parenteral and enteral nutrition (bapen). clinical nutrition (edinburgh, scotland), 23(5), 1104–1112. https://doi.org/10.1016/j.clnu.2004.02.003 219 the development of a six sigma–based ulcus decubitus prevention model to respond to adverse events martini sriwulaningdyah, erna dwi wahyuni faculty of nursing, universitas airlangga e-mail: wulan_nal@yahoo.com abstract introduction: based on the number of incidences of ulcus decubitus in 2015 which was 2.4 ‰ and 1.59 ‰ in 2016, the incidences of ulcus decubitus is an indicator of patient safety. in one of the public hospitals in surabaya, it showed that the achievement of a ulcus decubitus indicator had not been reached yet (the standard is 1.5 ‰ per year). one of the efforts that can be done to prevent the occurrence of ulcus decubitus is by way of six sigma-based ulcus decubitus prevention. methods: the design of this research was an explanatory research study using a cross-sectional approach. the research respondents were nurses at inpatient wards (4 rooms); 57 nurses via the purposive sampling technique. the research data was analysed with partial least square (pls) results: individual factors (path coefficient 0,200 t: 6,580), organisational factors (path coefficient 0,373 t: 9,278) and management factors (path coefficient 0.099 t: 2.184) are all significantly correlated with the six sigma-based ulcus decubitus prevention. conclusions: individual, organisational and management factors are important factors in the six sigma-based ulcus decubitus prevention model. it needs advanced research to find out how much the influence of six sigma-based ulcus decubitus prevention implementation will decrease the incidences of ulcus decubitus keywords: adverse events, prevention, six sigma, ulcus decubitus introduction a hospital is an organisation that provides services to patients that should pay attention to the quality of the servicer, especially about the issue of patient safety (iskandar, maksum and nafisah, 2014). therefore patient safety is a top priority in relation to providing services to patients related to the quality issue and hospital image (christoher, sk, david, a, spahlinger, md dan john, 2009). the incidences of ulcus decubitus patients is an indicator of patient safety in nursing care at the clinic (nenny puji lestari, deni kurniadi sunjaya and avip syaefullah, 2013). if the patient's safety indicator has not reached the standard (1.5 % per year), then it will affect the quality of nursing services (kars, 2012). as a result of the frequent occurrence of ulcus decubitus, the patient is at risk of adverse events (christoher, sk, david, a, spahlinger, md dan john, 2009). the problem is in relation to the provision of nursing care in treated patients is the unoptimised care focusing on the prevention of ulcus decubitus (laureani, brady and antony, 2013). one of the efforts that can be done to prevent the occurrence of ulcus decubitus is by six sigma-based ulcus decubitus prevention. diversity and service routine in the hospital, if not managed properly, can result in adverse events (ktd) (austin, 2013). the institute of medicine (iom) in 1999 published a report presenting research results in utah and colorado, as well as new york. in utah and colorado there were found to be adverse events at 2.9% in which 6.6% of them led to death (mulyadi, 2010). while in new york, the number of adverse events was 3.7% with 13.6% mortality. the number of deaths due to adverse events occurred within inpatients (33.6 million per year) in the united states ranges from 44,000-98,000 per year (chassin, mr, mayer, c dan nether, 2015). based on the 2004 world health organisation (who) publication collecting hospital research figures in various countries: america, england, denmark and australia, adverse events were found to range from 3.2 to 16.6% (churchman, 1957). the institute of medicine (iom) about the 21st-century new health system stated that in the provision of health services, patients should be safe from negligence caused by the service system (buchbinder, bs dan shanks, 2014). today, the increasing complexity of health has contributed to the problem of negligence in service (hasibuan, 2014). nursing care service is one part of the services provided in the service hospital (kurniadi, 2013). quality nursing care is the desire of every individual and society who receive the health care services (cipto, 2010). nurses as service providers need to know the standard measurement of services. the jurnal ners vol. 12 no. 2 oktober 2017: 219-224 220 table 1. respondent characteristics (n=57) respondent category n % age 20-25 years 26-30 years 31-35 years 36-40 years > 40years 8 27 9 1 12 14.0 47.4 15.8 1.8 21.1 length of supervisor position < 1years 1-5 years 5-10 years 10-15 years > 15 years 30 6 8 2 11 52.6 10.5 14.0 3.5 19.3 last education nursing vocational school 0 0 nursing diploma 42 73.7 bachelor degree of nursing 15 26.3 employment status permanent employee 33 57,9 contract employee 24 42,1 measurement of one of the clinical indicators of nursing quality is ulcus decubitus, which is coordinated by the patient safety team (graban, 2011). one of the clinical indicators of nursing quality related to patient safety namely ulcus decubitus – is still a problem because the achievement figure has not yet matched the standard (≤1,5 ‰) found in 20142016 (hamming, m dan nurnajamuddin, 2014). the currently used ulcus decubitus prevention system is in the nursing process but it is still incomplete (adisasmito, 2007). the assessment is still not focused on ulcus decubitus prevention. the nursing diagnoses and the nursing plans are not yet standardised, the implementation is still not optimal while monitoring and evaluations have not been done; hence there is no standard system for ulcus decubitus prevention (darmawan, 2014). the nursing care system in indonesia is still not widely published because the quality of the system is not well managed. therefore the results of care quality have not met the expected standards yet (komalawati; veronica, 2010). it is necessary to conduct this research expecting that the results of this study can be useful to improve the quality of ulcus decubitus prevention. materials and methods the design of this research is a crosssectional explanatory research study. the population to raise the strategic issue was sought by providing questionnaires to the nurses of an inpatient ward in one of the public hospitals in surabaya, including four rooms, selected by the purposive sampling method which involved 57 managing nurses. the data was collected using a questionnaire and observation. the analysis was performed using partial least square (pls). the results of pls and the strategic issues were then raised into fgds with the aim of developing a module of six sigma-based prevention. the ethical examination was conducted on 16 march 2017 based on the ethical statement no 073/11/kom.etik/2017. results the majority of the respondents are in adulthood, i.e. 26-30 years old (47.4%), with a working period as a supervisor / team chief for less than one year (52.6%), while for the last education stage undertaken by most of the respondents is a nursing diploma of nursing education (73.7%). most of their employment status was permanent (57.9%) (table 1). data of the individual, organisational, and management factors the majority of the individual factors are at a good level (77.2%). this is because the majority of the respondents have good knowledge, skills and attitude. major organizational factors are in good level (70.2%) because respondents more than half responded to the environment/ provision of good infrastructure, most respondents provided good feedback, and the decision-making majority of the respondents good. next, the majority management factor was at a good level (75.4%) because most of the respondents answered well in relation to patient safety culture and good organisational culture. results of pls (partial least square output) analysis results of model examination (outer model) the pathway coefficient is comprehensively presented in table 3. individual factors include skill and attitude significantly influence six sigma-based ulcus decubitus prevention. individual knowledge the development of a six sigma–based... (martini sriwulaningdyah and erna dwi wahyuni) 221 factors have no significant effect on six sigma-based ulcus decubitus prevention. organisation and management factors have a significant effect on six sigma-based ulcus decubitus prevention because their outer loading numbers are more than 0.5. analysis results of reliability test (composite reliability) composite reliability tests help to find the reliability value of an indicator of a construct. a constructor variable is said to satisfy the reliability test if it has a composite reliability value > 0.7. all of the variables (individual factor, organisational factor, management factor and six sigma-based ulcus decubitus prevention) have a composite reliability > 0.7 (table 4). inner model the inner model evaluation aims to determine the magnitude of influence or causality relationships among the variables in the study. from the table, there is an influence from the individual factors (skills, attitudes) to the prevention of ulcus decubitus based on the six sigma method. the results of partial least square analysis got a statistical t value of 6,580. also, there is the influence of the organisational factors (environment, feedback, decision making) on the prevention of ulcus decubitus based on the six sigma method indicated by the results of the partial least square analysis as it obtained a statistical t value of 9,278. there is an influence from the management factor (organisational culture, patient safety culture) on the the prevention of six sigma-based ulcus decubitus. the result of the partial least square analysis got a statistic t value of 2.184 (table 5). discussion the effects of individual factor on six sigma-based ulcus decubitus prevention to inpatient ward of hospital the results of this study found that individual factors affect six sigma-based ulcus decubitus prevention. the sub-variables of the individual factors consist of the skill, knowledge and attitude of a nurse. in this case, they are related to the prevention of ulcus decubitus which is conducted by the nurse including assessments, planning, implementtation, and evaluation (ardana, 2012). table 2. individual factors, organisational factor and management factor in the development of a ulcus decubitus model based on six sigma on unexpected event (ktd) in inpatient room (n=57) factors n % individual factor poor 0 0 fair 13 22.8 good 44 77.2 organizational factor poor 2 3.5 fair 15 26.3 good 40 70.2 management factor poor 0 0 fair 14 24.6 good 42 75.4 figure 1. analysis of the test of six sigma-based ulcus decubitus prevention model jurnal ners vol. 12 no. 2 oktober 2017: 219-224 222 knowledge is the result of understanding, and it occurs after sensing the object (notoadmodjo, 2013). after a person or object has a judgment or opinion on what is known, the next process is expected to be to implement or practice what is understood (martini, 2009). through action and learning, one will gain trust and attitude towards something which in turn will affect behaviour (umar, 2001). the results of this study indicate that skills, knowledge and attitudes significantly influence six sigma-based ulcus decubitus prevention. knowledge has two main functions, first as a background in analysing something, perceiving and interpreting it and then proceeding with a necessary action decision. the second role of knowledge in taking the necessary actions to be the background in articulating some options for possible actions, choosing one of the several possibilities and implementing the choices (fursule, nv; bansod, 2012). knowledge is needed as a support in growing confidence and attitude as well as behaviour every day, so it can be said that knowledge is a fact that supports someone’s attitude and actions (notoadmodjo, 2013). the results of the study indicate that more than 50% of nurses have skills, knowledge and a good attitude but they have undertaken less precautionary actions against ulcus decubitus. this is due to the low intention/motivation to work on patient care in ulcus decubitus prevention. the regulation/ nursing care standard of ulcus decubitus table 3. recapitulation of the results of the hypothesis test of the development of a prevention model for six sigma based ulcers and unexpected events (ktd) in the inpatient room variables indicators outer loading remark individual factor x1.1 skill 0.892 significant x1.2 knowledge 0.406 not significant x1.3 attitude 0,976 significant organisational factor x2.1 environment 0.715 significant x2.2 feedback 0.730 significant x2.3 decision making 0.507 significant management factor x3.1 patient safety culture 0.772 significant x3.2 organisation culture 0.912 significant six sigma-based ulcus decubitus prevention model y.1 assessment 0.992 significant y.2 planning 0.992 significant y.3 implementation 0.994 significant y.4 evaluation 0.953 significant table 4. variable reliability results of individual, organisational, and management factors toward six sigma-based ulcus decubitus prevention based on six sigma on unexpected events (ktd) in the inpatient room variable composite reliability remark individual factor 0.947 valid organisational factor 0.722 valid management factor 0.833 valid six sigma-based ulcus decubitus prevention 0.991 valid table 5. hypothesis value of the variables of the individual factors, organisational factors and management factor on the prevention of ulcus decubitus based on six sigma on unexpected event (ktd) in the inpatient room variable deviation standard t statistic remark individual factor 0.030 6,580 significant organisational factor 0.040 9,278 significant management factor 0.046 2,184 significant the development of a six sigma–based... (martini sriwulaningdyah and erna dwi wahyuni) 223 prevention has not been adjusted to the current condition, and the monitoring-evaluation of ulcus decubitus prevention effort has not been optimally conducted. the effects of the organisational factor on six sigma-based ulcus decubitus prevention in the inpatient ward the organisational factor has subvariables such as environment, feedback and decision-making. from the results of the research, based on pls analysis, it obtained a t value statistic of 9,278.this result indicates that there is a significant influence between the variables of the organisational factor and six sigma-based ulcus decubitus prevention. a positive work environment can reduce fatigue, attract employees and maintain work quality for the nurses (wuryanto, 2010). the working environment consists of medical equipment and the necessary infrastructures to achieve the goal of working in a hospital (jiwanto, a., 2015). feedback is one of the important things in improving the performance of a nurse (depkes ri, 2008). the complexity of the responsibilities to be performed is very important for the nurse whenever there is an event in relation to the patient's safety so that a similar event will not happen again (asmuji, 2014). decision-making is a decision-making process in certain situations and is the main key for the health professionals in service delivery which affects various outcomes (ammenwertha, elske; kutscha, ulrike; kutscha, ansgar; mahler, cornelia; eichstädter, ronal; hauxa, 2001). the results of the study on nurses states that more than 50% of the environmental factors (facilities/air mattress), for ulcus decubitus prevention have not matched the patients’ needs. more than 50% of the nurses stated that feedback on the success rate on the ulcus decubitus prevention system currently has not been reinformed. this is due to the lack of existing information systems. the effects of management factors on six sigma-based ulcus decubitus prevention management factors have subvariables such as patient safety culture and organisational culture. from the results of this research, based on the pls analysis, the statistical t value was 2,184. the result indicates that there is a significant influence between the variables of the management factor and six sigma-based ulcus decubitus prevention. total safety culture mentions that there are 3 factor groups that affect patient safety culture: personal factors that tend to be from people who work in the hospital organisation, consisting of knowledge, attitude, motivation, competence and personality; organisational behavior factors that are the conditions of the work environment measured in terms of the the organisation of the health services in general, consisting of leadership, situation alertness, communication, teamwork, stress, fatigue, team leadership, and decision making; environment factors are supporters of the service processes in health organisations consisting of equipments, tools, machinery, cleanliness, and techniques (furfari, 2010). the results of this study states that most of the patient safety culture factors are sufficient, but it lacks the implementation of ulcus decubitus prevention. this is due to the lack of information about patient safety, especially about the incidence of ulcus decubitus which is a type of adverse event (ktd). conclusions individual factors (skills, knowledge, attitudes), organisational factors (environment, feedback, decision making) and management factors (patient safety culture, organisational culture) have an influence on six sigma-based ulcus decubitus prevention. it needs advanced research to find out how much the influence of six sigma-based ulcus decubitus prevention implementation will decrease the incidences of ulcus decubitus so that the achievement standard/indicator of ulcus decubitus cases can be achieved. references adisasmito, w. (2007) sistem manajemen lingkungan rumah sakit. jakarta: raja grafindo persada. ammenwertha, elske; kutscha, ulrike; kutscha, ansgar; mahler, cornelia; eichstädter, ronal; hauxa, r. (2001) ‘nursing process documentation systems in clinical routine— prerequisites and experiences’, jurnal ners vol. 12 no. 2 oktober 2017: 219-224 224 international journal of medical informatics, 64, pp. 187–200. doi: https://doi.org/10.1016/s1386-5056 (01) 00216-7. ardana, k. (2012) manajemen sumber daya manusia, ed 1. jogyakarta: graha ilmu. asmuji (2014) manjemen keperawatan: konsep dan aplikasi,. jakarta: arruzz media. austin, m. (2013) ‘safety in numbers: the development of leapfrog’s composite patient safety score for u.s. hospitals. safety in numbers.’, the johns hopkins university school of medicine, 9, p. 750. buchbinder, bs dan shanks, h. (2014) buku ajar manajemenpelayanan kesehatan. jakarta: egc. chassin, mr, mayer, c dan nether, k. (2015) ‘improving hand hygiene at eight hospitals in the united states by targeting specific causes of noncompliance’, the joint commission journal on quality and patient safety. elsevier, 41(1), pp. 4– 12. doi: 10.1016/s15537250(15)41002-5. christoher, sk, david, a, spahlinger, md dan john, e. . (2009) ‘creating value in health care : the case for lean thinking.’, jcom, 16(12). cipto (2010) jaminan mutu layanan kesehatan, dasar-dasar pengertian dan penerapan. jakarta: egc. darmawan, d. (2014) metode penelitian kuantitatif. bandung: remaja rosdakarya. depkes ri (2008) panduan nasional keselamatan pasien rumah sakit (patient safety). edited by 2. jakarta: bakti husada. furfari, k. (2010) the lean hospital: what does it mean? the university of colorado hospital. fursule, nv; bansod, s. (2012) ‘understanding the benefits and limitations of six sigma methodology.’, international journal of scientific and research publications, 2(1). graban, m. (2011) lean hospital. boca raton: crc press. haming, m dan nurnajamuddin, m. (2014) manajemen produksi modern, operasi manufaktur faktor dan jasa. 3rd edn. jakarta: bumi aksara. hasibuan, s. (2014) manajemen sumber daya manusia,. jakarta: bumi aksara. iskandar, h., maksum, h. and nafisah, n. (2014) ‘faktor penyebab penurunan pelaporan insiden keselamatan pasien rumah sakit’, jurnal kedokteran brawijaya, 28(1), pp. 72–77. doi: 10.21776/ub.jkb.2014.028.01.27. jiwanto, a., e. (2015) standarisasi proses layanan terkait keselamatan pasien melalui pendekatan lean hospital di rumah sakit petrokimia gresik. universitas airlangga. kars (2012) panduan penyusunan dokumen akreditasi, komisi akreditasi rumah sakit. jakarta. komalawati; veronica (2010) community dan patient safety dalam perspektif hukum kesehatan. jakarta. kurniadi, a. (2013) manajemen keperawatan dan prospektifnya, teori, konsep dan aplikasi. jakarta: badan penerbit fkui. laureani, a., brady, m. and antony, j. (2013) ‘applications of lean six sigma in an irish hospital’, leadership in health services, 26(4), pp. 322–337. doi: 10.1108/lhs-01-2012-0002. mulyadi (2010) sistem perencanaan dan pengendalian manajemen. jakarta: salemba empat. nenny puji lestari, deni kurniadi sunjaya and avip syaefullah (2013) ‘konsep manajemen keselamatan pasien berbasis program di rsud kapuas provinsi kalimantan tengah’. available at: http://repository.unpad.ac.id/18193/ (accessed: 14 november 2017). notoadmodjo (2013) promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta. wuryanto, e. (2010) hubungan lingkungan kerja dan karakteristik individu dengan kepuasan kerja perawat di rumah sakit umum daerah tugurejo semarang. universitas indonesia. pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru 62 peran pengawas minum obat (pmo) dalam keberhasilan pengobatan tuberculosis paru di masyarakat (the role of direct observed treatment in tuberculosis treatment successful at community) *nursalam, *makhfudli, **dominikus rato abstract introduction : the succeeded of the tuberculosis treatment depends on the obedience of the patient in taking the tuberculosis’s medication assisted by the direct observed treatment shortcourse (dots) to refrain resistancy and dropping out of the program. the aimed of this study was to analyze the correlation between dots’s role with the successfullness of lung’s tuberculosis treatment program at bajawa city. method : a cross sectional simple random sampling design was used in this study. population were all the direct observed treatment supervisors and patients who have had finished their treatment of tuberculosis. sample were 43 respondents. the independent variables in this study were the role of the dotss, education level, family support, motivation and the dotss attitude. the dependent variables were the patient’s obedience in taking medication and the evaluation of the acid fast bacterias in their sputum. data were collected by using questionnaire and observation sputum the to evaluate acid fast bacteria. data were analyzed by using spearman rho with significance level with α<0.05.result : the result showed that role of the dotss had significance correlation with the succeeding program of tuberculosis (=0.023), education level had significance correlation (=0.043), family support as the dots had significance correlation (=0.021), motivation (=0.032) and attitude (=0.014). analysis : it can be concluded that the role of the dots has correlation with succesing tuberculosis treatment. discussion : the role of pmo cause the succesfully of tb treatment for the community in bajawa city, ngada ntt. keywords: dots’s role, family support, motivation, attitude, medication successfulness. *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail : nursalam_psik@yahoo.com ** rsud bajawa kab. ngada flores ntt pendahuluan salah satu penyakit penyebab kematian utama yang disebabkan oleh infeksi adalah tuberkulosis (tb). pada tahun 2004 bertambah penderita baru sebanyak seperempat juta orang dan sekitar 140.000 kematian setiap tahunnya. sebagian besar penderita tb adalah penduduk yang berusia produktif antara 15-55 tahun. penyakit ini merupakan penyebab kematian nomor tiga setelah penyakit jantung dan penyakit pernafasan akut pada seluruh kalangan usia (depkes ri, 2003). nusa tenggara timur merupakan salah satu propinsi dengan keberhasilan pengobatan hanya mencapai 72% dibawah standar nasional (95%). kabupaten ngada menduduki urutan ke 4 dari 18 kabupaten kota di nusa tenggara timur yang mencapai keberhasilan pengobatan tb (dinkes propinsi ntt, 2008). puskesmas kota bajawa di kabupaten ngada merupakan salah satu puskesmas yang melayani dan menangani kasus tb dengan rerata usia 18-65 tahun. jumlah penderita di puskesmas kota bajawa dari bulan januari-mei 2008 yang sudah melakukan pengobatan berjumlah 48 orang yang terdiri dari 30 laki-laki, 18 perempuan. hasil pengobatan 45 penderita sembuh (bta negatif), 3 pengobatan lengkap (bta positif), 0 meninggal, 0 gagal, 0 default (drop out) dan 0 pindah pengobatan (dinkes kabupaten ngada, 2008). keberhasilan pengobatan tb tidak lepas dari keteraturan mailto:nursalam_psik@yahoo.com jurnal ners vol.4 no.1 april 2009: 62-67 63 penderita tb paru dalam minum obat. keteraturan minum obat dapat dicapai dengan adanya pengawas minum obat oat (pmo) yang dipilih dari orang dekat (keluarga) dan harus disegani oleh penderita (depkes ri, 2003). di puskesmas kota bajawa semua pmo diambil dari keluarga penderita sendiri yang berjumlah 48 orang (sesuai jumlah penderita tb paru) berdasarkan kesepakatan yang dibuat bersama oleh pengelola tb paru kabupaten ngada dengan seluruh puskesmas yang berada di wilayah kerja dinas kesehatan kabupaten ngada (dinkes kabupaten ngada, 2007). penanggulangan tb paru merupakan suatu gerakan yang bukan saja menjadi tanggung jawab pemerintah, swasta namun juga masyarakat. salah satu kegiatan dalam gerakan terpadu nasional (gardunas) tb adalah pelaksanaan strategi directly observed treatment shortcourse (dots) dengan tujuan untuk menjamin dan mencegah resistensi, keteraturan pengobatan dan mencegah drop out penderita tb dengan cara melakukan pengawasan dan pengendalian pengobatan penderita tuberkulosis. target program penanggulangan tb adalah tercapainya penemuan penderita baru tb dengan bta positif paling sedikit 70% dari perkiraan dan menyembuhkan 85% dari semua penderita tersebut serta mempertahankannya. target ini diharapkan dapat menurunkan tingkat prevalensi dan kematian akibat tb hingga separuhnya pada tahun 2010 dibanding tahun 1990 dan mencapai tujuan millenium development goals (mdgs) pada tahun 2015. indonesia memang telah banyak mencapai kemajuan, yakni penemuan kasus baru 51,6% dari target global 70% dan penyediaan obat anti tb yang mencukupi kebutuhan perkiraan kasus di seluruh indonesia, namun tb belum dapat diberantas, bahkan diperkirakan jumlah penderita tb terus meningkat (depkes ri, 2003). pada tahun 1999 who global surveillance memperkirakan di indonesia terdapat 583.000 penderita tb baru pertahun dengan 262.000 bta positif atau insidens rate kira-kira 130 per 100.000 penduduk. kematian akibat tb diperkirakan menimpa 140.000 penduduk tiap tahun (depkes ri, 2003). kenyataan mengenai penyakit tb di indonesia begitu mengkhawatirkan, sehingga kita harus waspada sejak dini dan mendapatkan informasi lengkap tentang penyakit tb. apabila hal ini tidak mendapat perhatian dan penanganan yang tepat, cepat, segera dan intensif, maka prevalensi penyakit ini akan terus meningkat serta risiko penularan pun semakin tinggi. penyakit tb paru menyerang sebagian besar kelompok kerja produktif, penderita tb paru kebanyakan dari kelompok sosial ekonomi rendah. hal ini disebabkan oleh pengetahuan yang rendah tentang penyakit dan bagaimana cara merawat penderita tb paru dengan baik. berbagai upaya telah dilakukan oleh pemerintah untuk mengurangi virulensi dan menekan jumlah penderita tuberkulosis, diantaranya dengan dicanangkannya gerakan terpadu nasional (gardunas tb) oleh menkes ri pada tanggal 24 maret 1999. pemerintah melalui program nasional pengendalian tb telah melakukan berbagai upaya untuk menanggulangi tb, yakni dengan strategi dots. world health organization (who) merekomendasikan 5 komponen strategi dots, antara lain dengan pengawasan langsung pengawas minum obat (pmo). pelaksanaan strategi dots sudah dilaksanakan tetapi sampai saat ini penderita tuberkulosis di indonesia masih tinggi. perlu dilakukan suatu modifikasi strategi untuk meningkatkan keteraturan minum oat bagi penderita tb. penderita tb perlu pengawasan langsung agar meminum obat secara teratur sampai sembuh (depkes ri, 2003). orang yang mengawasi dikenal dengan istilah pmo (pengawas minum obat). pmo sebaiknya orang yang dekat dan disegani oleh penderita tbc, misalnya keluarga, tetangga, atau kader kesehatan. pmo bertanggung jawab untuk memastikan penderita tb meminum obat sesuai anjuran petugas puskesmas/upk (unit pelayanan kesehatan). penderita tb mungkin saja merasa malu atau kesakitan karena mengidap tb, maka pmo harus bisa menjadi sahabat yang siap mendengarkan keluhan penderita dan bisa membuat penderita merasa nyaman (bachti, 2008). berdasarkan permasalahan di atas, peneliti ingin mengetahui tentang hubungan peran pengawas minum obat (pmo), faktor eksternal dan internal seperti tingkat pendidikan pmo, dukungan keluarga sebagai pmo, usia, motivasi serta sikap dari pmo http://www.koalisi.org/detail.php?m=3&sm=9&id=75 peran pengawas minum obat (nursalam) 64 dengan keberhasilan pengobatan tb paru di puskesmas kota bajawa kabupaten ngada. bahan dan metode penelitian desain penelitian yang digunakan dalam penelitian ini adalah crosssectional simple random sampling design. populasi pada penelitian ini adalah pmo dan penderita tb paru yang telah menyelesaikan pengobatan oat kategori satu di puskesmas kota bajawa kabupaten ngada yang berjumlah 48 orang. sampel yang digunakan dalam penelitian ini adalah pmo dan penderita tuberkulosis paru yang telah menyelesaikan pengobatan di puskesmas kota bajawa kabupaten ngada, dengan kriteria inklusi untuk pmo: 1) merupakan pmo dari penderita tb paru di puskesmas kota bajawa kabupaten ngada, 2) usia pmo >18 tahun dan 3) bersedia menjadi responden. adapun kriteria inklusi untuk penderita tb paru sebagai berikut: 1) mendapatkan pengobatan selama 6 bulan dan 2) telah menyelesaikan pengobatan oat kategori 1 yaitu 2rhzs(e). penelitian ini dilakukan selama januari 2009. variabel independen dalam penelitian ini adalah peran pmo dan faktor internal seperti tingkat pendidikan, umur, motivasi dan sikap dari pmo serta faktor eksternal yaitu dukungan keluarga sebagai pmo. variabel dependen adalah keberhasilan pengobatan penderita tb paru. instrumen yang digunakan dalam penelitian ini adalah closed ended questionnare yang disusun oleh peneliti berdasarkan pada berbagai teori antara lain untuk data peran pengawas minum obat (depkes ri, 2005), dukungan keluarga sebagai pmo (suprajitno, 2004), motivasi (handoko, 1995) dan sikap (notoadmojo, 2003) yang kemudian dimodifikasi dengan mempertimbangkan kebutuhan data. data yang diperoleh ditabulasi kemudian dianalisis dengan menggunakan uji statistik corelations spearman rho dengan derajat kemaknaan <0,05. interpretasi nilai sebagai berikut 0,80-1,00: tinggi; 0,60-0,80: cukup; 0,400,60: agak rendah; 0,20-0,40: rendah dan 0,00-0,20: sangat rendah (tidak berkorelasi) (arikunto, 2006). hasil penelitian hasil penelitian menunjukkan bahwa 76% (33 responden) peran pmo dalam kategori baik (gambar 1), sebesar 45 % (20 responden) mempunyai tingkat pendidikan smp. sebesar 81% (35 responden) dukungan keluarga sebagai pmo dalam kategori baik, 90% (39 responden) motivasi pmo dalam kategori baik., 93,0 % (40 responden) sikap pmo dalam kategori positif. hasil pemeriksaan dahak/sputum awal di mana 100% (43 responden) dalam kategori positif. sembilan puluh tiga persen (40 responden) pada pemeriksaan dahak/sputum ulangan (follow up) menunjukkan kategori bta negatif (gambar 2). hasil lain yang diperoleh yaitu 100% (43 responden) memperoleh pengobatan kategori satu, mengkonsumsi obat anti tuberkulosis (oat) selama 2-6 dan 93% (40 responden) minum oat secara teratur (gambar 3). sebagian besar (95%) orang yang berperan sebagai pmo adalah mempunyai hubungan keluarga dengan penderita tb paru. berdasarkan hasil analisis statistik corelations spearman rho menunjukkan bahwa terdapat hubungan bermakna antara keberhasilan pengobatan penderita tb paru di puskesmas kota bajawa dengan 1) peran pmo (p=0,023), 2) tingkat pendidikan pmo (p=0,043), 3) dukungan keluarga (p=0,021), 4) motivasi pmo (p=0,032) dan 5) sikap pmo (p=0,014). 76% 12% 12% baik cukup kurang gambar 1. distribusi peran pmo dalam keberhasilan pengobatan tb paru di puskesmas kota bajawa, januari 2009. jurnal ners vol.4 no.1 april 2009: 62-67 65 7% 93% positif negatif gambar 2. distribusi hasil pemeriksaan dahak/sputum ulangan (follow up) pada program pengobatan tb paru di puskesmas kota bajawa, januari 2009. 93% 7% teratur tidak teratur gambar 3. distribusi keteraturan minum oat pada penderita tb paru di puskesmas kota bajawa, januari 2009. pembahasan terdapat hubungan yang bermakna antara peran pmo dengan keberhasilan pengobatan penderita tb paru di puskesmas kota bajawa. menurut depkes ri (2005) peran seorang pmo dipengaruhi oleh faktor external berupa dukungan keluarga sebagai pmo dan faktor internal yang berupa tingkat pendidikan pmo, serta motivasi dan sikap dari pmo. dalam penelitian ini terbukti peran seorang pmo dalam kategori baik karena hal tersebut ditunjang oleh tingkat pendidikan dari pmo yang cukup sehingga dalam menjalankan peran, pmo memiliki pengetahuan yang cukup memadai dalam mendampingi dan mengawasi penderita minum oat. pmo termotivasi untuk berperan membantu anggota keluarga yang sakit sesuai tugas dan fungsi kelurga serta dalam pendampingannya pmo selalu bersikap positif. hal ini mendorong pasien untuk minum oat secara rutin sesuai jangka waktu pengobatan yang ditentukan yakni 6 bulan. terdapat hubungan bermakna antara tingkat pendidikan pmo dengan keberhasilan pengobatan penderita tb paru di puskesmas kota bajawa. menurut notoadmojo (2000) tingkat pendidikan dapat mempengaruhi peran seseorang dalam melaksanakan tugas dan fungsi sosial di masyarakat. pendidikan yang baik dan cukup dapat meningkatkan pengetahuan seseorang untuk bertindak dan berperan dalam bidang kesehatan (swamburg, 2000). pernyataan ini secara tidak langsung mendukung hubungan yang positif antara pendidikan dan motivasi. petugas kesehatan/pengelola program tb paru di puskesmas harus memberikan pembekalan berupa pendidikan kesehatan kepada pmo dan penderita sebelum di mulainya program pengobatan tentang penyakit tb paru, cara pencegahan, pengobatan, serta peran dan fungsi dari pmo dalam bertugas mengawasi dan mendampingi penderita minum oat secara benar dan teratur. hal tersebut dapat memberikan tambahan pengetahuan bagi pmo dan bagi penderita tb mampu melakukan pencegahan kekambuhan dan drop out. terdapat hubungan bermakna antara dukungan keluarga sebagai pmo dengan keberhasilan pengobatan penderita tb paru di puskesmas kota bajawa. menurut friedman (1998) fungsi keluarga dalam bidang kesehatan adalah mengenal masalah kesehatan, membuat keputusan yang tepat, memberi perawatan kepada anggota keluarga yang sakit, mempertahankan dan menciptakan suasana yang sehat dengan mempertahankan hubungan dengan petugas dan fasilitas kesehatan yang ada di masyarakat. notoadmojo (2003) menyatakan persepsi keluarga terhadap keadaan sehat dan sakit erat hubungannya dengan perilaku mencari pengobatan. kedua pokok pikiran tersebut akan mempengaruhi atas dipakai atau tidaknya fasilitas yang tersedia. penderita tb paru/keluarga memanfaatkan fasilitas kesehatan dalam usaha pengobatan serta mau mematuhi aturan minum oat sesuai dengan anjuran petugas kesehatan maka besar kemungkinan penderita dapat disembuhkan sehingga tidak terjadi kekambuhan atau resistensi. dukungan yang baik dari pmo harus diberikan kepada penderita secara terus menerus dan nursalam peran pengawas minum obat (nursalam) 66 berkesinambungan mengingat jangka pengobatan bagi penderita cukup lama yaitu 6 bulan. hal ini sangat bermafaat dalam mencegah terjadinya kegagalan pengobatan dan menurunkan angka kematian akibat penyakit tuberkulosis paru. terdapat hubungan bermakna antara motivasi pmo dengan keberhasilan pengobatan penderita tb paru di puskesmas kota bajawa. menurut handoko (1995) motivasi adalah keadaan pribadi seseorang yang mendorong keinginan individu di masyarakat dalam melaksanakan kegiatan atau peran dalam mencapai suatu tujuan. ini berarti bahwa sebagian besar pmo memiliki motivasi yang baik dalam mendampingi dan mengawasi penderita tb paru minum oat secara tepat dan teratur. motivasi itu timbul karena adanya suatu keinginan atau kebutuhan yang harus dipenuhi serta motivasi itu dapat timbul akibat kombinasi dari dalam diri orang itu sendiri dan lingkungan sosial terdekat misal keluarga. motivasi itu diwujudkan dalam bentuk tindakan atau perilaku dalam peran (sarwono, 1997). nugroho (2000) menyatakan bahwa ada hubungan yang positif antara kelompok umur dengan motivasi seseorang. orang dewasa memiliki motivasi yang sangat kuat dalam menjalankan peran di masyarakat dan motivasi itu akan melemah apabila seseorang itu memasuki usia lanjut. peningkatan motivasi seorang pmo dapat dilakukan dengan cara petugas kesehatan/pengelola program tb paru selalu melibatkan pmo dalam pengambilan keputusan berkaitan dengan program pengobatan tb paru, dengan demikian kerjasama yang baik akan selalu terjaga. pmo akan merasa dihargai dan terus termotivasi serta siap bekerja sama membantu mendampingi dan mengawasi selama masa pengobatan penderita tb paru. terdapat hubungan bermakna antara sikap pmo dengan keberhasilan pengobatan penderita tb paru di puskesmas kota bajawa. seorang ahli psikologi menyatakan bahwa sikap itu mengandung faktor perasaan dan motivasi. hal ini berarti bahwa sikap terhadap suatu obyek atau peran tertentu akan selalu diikuti oleh perasaan yang positif/menyenangkan dan negatif/tidak menyenangkan sedangkan sikap yang mengandung motivasi berarti bahwa sikap itu memiliki daya dorong bagi individu untuk berperilaku dalam perannya. sikap merupakan kegiatan atau kesediaan seseorang untuk bertindak dalam melakukan pengawasan dan pendampingan yang bersahabat utuk membantu seorang penderita tb paru minum oat sesuai jangka waktu pengobatan yang ditentukan (notoadmojo, 2003). sikap yang paling tinggi tingkatnya adalah tanggung jawab (responsible) terhadap apa yang diyakini dan diterima sebagai suatu tugas untuk diperankan. dalam menjalankan peran sebagai pmo harus bisa menjadi sahabat yang siap mendengarkan keluhan penderita serta bisa membuat pasien tb paru merasa nyaman. hasil penelitian ini menunjukkan sikap yang baik (positif) yang ditunjang oleh motivasi yang baik dari pmo terbukti dapat menunjang keberhasilan pengobatan tb paru di puskesmas kota bajawa. mengingat sikap tidak dibawa sejak lahir tetapi terbentuk pada masa perkembangan individu seseorang maka kepada petugas kesehatan/pengelola program tb paru untuk secara terus menerus mempelajari sikap seseorang yang akan direkrut menjadi pmo. sikap yang baik (positif) juga harus ditunjukkan oleh petugas kesehatan yang terlibat dalam pelayanan kesehatan yang berhubungan kepada penderita dan pmo. hal tersebut dapat menjadi penentu pencapaian keberhasilan. simpulan dan saran simpulan peran pmo dalam keberhasilan pengobatan tb paru mayoritas dalam kategori baik. hal ini dipengaruhi oleh tingkat pendidikan pmo yang mayoritas smp, dukungan keluarga sebagai pmo yang baik, dan motivasi dari pmo yang baik serta sikap yang positif dari pmo dalam mendampingi dan mengawasi penderita tb paru. saran dari hasil penelitian ini, peneliti menyarankan agar: 1) adanya penghargaan kepada pmo atas partisipasi dalam keberhasilan pengobatan penderita tb paru, 2) petugas kesehatan perlu memberikan jurnal ners vol.4 no.1 april 2009: 62-67 67 penyuluhan dan pembagian brosur (leaflet) kepada pmo dan penderita tb paru tentang peran dan fungsi pmo, penyakit, pengobatan dan cara pencegahan tb paru, 3) adanya pembekalan kepada petugas kesehatan (pengelola program tb paru) dalam bentuk latihan dan seminar untuk meningkatkan kualitas pelayanan kesehatan dan 4) evaluasi perlu dilakukan minimal setiap 1 bulan sekali untuk mengetahui kekurangan dan hasil pencapaian sebagai bahan acuan pelaksanaan program pengobatan tb paru selanjutnya. kepustakaan arikunto, s., 2006. prosedur penelitian. jakarta: pt rineka cipta, hlm. 71-81. azwar, 1995. sikap manusia teori dan pengukurannya. yogyakarta: pustaka pelajar, hlm. 25-27. bachti, 2008. tbc sembuh total dengan pelayanan dots, (online) (http://www.pikiranrakyat.com.net.id, diakses tanggal 15 november 2008, jam 20.15 wib). depkes ri, 2003. pedoman penanggulangan penyakit tb paru. jakarta: dirjen ppm dan plp, hlm.8-16. depkes ri, 2005. pedoman penanggulangan tuberkulosis paru. jakarta: dirjen ppm dan plp, hlm. 14-20. depkes ri, 2007. pedoman penanggulangan tuberkulosis. jakarta: dirjen ppm dan ppl, hlm. 6-23. dinkes kabupaten ngada, 2007. nota kesepakatan bersama (pengelola tb paru kabupaten ngada dengan seluruh puskesmas yang berada di wilayah kerja dinas kesehatan kabupaten ngada. dinkes kabupaten ngada, 2008. jumlah penderita di puskesmas kota bajawa dari bulan januari-mei 2008. dinkes propinsi ntt, 2008. data pencapaian keberhasilan pengobatan tb seluruh kabupaten kota di nusa tenggara timur. friedman, 1998. keperawatan keluarga, teori dan praktek, jakarta: egc, hlm. 24-26. handoko, 1995. motivasi penggerak tingkah laku, jogyakarta: kanisius, hlm. 4-8. notoadmojo, 2003. pendidikan dan perilaku kesehatan edisi 3. jakarta: penerbit rineka cipta, hlm. 45-47. notoadmojo, 2000. pengantar pendidikan kesehatan dan ilmu perilaku kesehatan. yogyakarta: andi offset, hlm. 21-27. swamburg, 2001. kepemimpinan dalam manajemen keperawatan. jakarta: egc, hlm. 23-25. suprajitno, 2004. asuhan keperawatan keluarga: aplikasi dalam praktek. jakarta: egc, hlm. 43. nursalam http://www.pikiranrakyat.com.net.id/ motivasi ekstrinsik terhadap adversity quotient penderita hiv dan aids jurnal ners vol.3 no.1 april 2008: 26-33 motivasi ekstrinsik terhadap adversity quotient penderita hiv/aids (the effect of extrinsic motivation on adversity quotient in patients with hiv/aids) nursalam*, misutarno**, yulia dewi puspitawati* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: nursalam_psik@yahoo.com ** rsud dr. soetomo surabaya abstract introduction: patients with hiv/aids may have various types of psychological responses. it was very difficult situation for them. difficulty can measured by using adversity quotient. as a nurse, we can give extrinsic motivation to bring back the patient hiv/aids’s quality of life. the objective of this study was to identify the presence effect of extrinsic motivation on adversity quotient in patients with hiv/aids in infectious disease intermediateatery treatment unit, dr. soetomo hospital, surabaya. method: this study was used a quasy experimental purposive sampling design. the population was taken from ambulatory patients. there were 16 respondents who met to the inclusion criteria. the independent variable was extrinsic motivation and dependent variable was adversity quotient. data were collected by using questionnaire and interview, then analyzed by using wilcoxon signed rank test and mann whitney u test with significance level p=0.05. result: the result revealed that there was an effect of extrinsic motivation on adversity quotient of patients with hiv/aids (p=0.017). the extrinsic motivation was found to have an effect on control response (p=0.027) and origin response (p=0.028), there was no influence of extrinsic motivation on ownership response (p=0.334), reach (p=0.129) and endurance (p=0.161). discussion: it can be concluded that the extrinsic motivation with intervention of social support has a positive effect on the improvement of adversity quotient in patients with hiv/aids. further studies should measure the effectiveness of adversity quotient training on acceptance response in patients with hiv/aids. keywords: adversity quotient, extrinsic motivation, hiv/aids patients pendahuluan pengidap aids umumnya berada dalam situasi yang membuat mereka merasakan menjelang kematian dalam waktu dekat. situasi tersebut mereka antisipasi secara khusus. ketika individu dinyatakan terinfeksi hiv, sebagian besar menunjukkan perubahan karakter psikososial (hidup dalam stres, depresi, merasa kurangnya dukungan sosial dan perubahan perilaku) (nasronudin, 2005). respons psikologis hingga adaptasi psikologis tergantung pada 3 faktor penting meliputi faktor biologis (berbagai gejala perjalanan penyakit), faktor psikologis (kepribadian dan kemampuan mengatasi masalah serta dukungan interpersonal), dan faktor sosiokultural (stigma sosial yang melekat pada infeksi hiv) (muma et al, 1997). sistem psikologis menekankan efek faktor psikodinamik, motivasi, dan kepribadian terhadap pengalaman sakit serta reaksi terhadap penyakit (tandiono, et al., 2007). psikoterapi transpersonal (termasuk motivasi) merupakan salah satu pilihan untuk mereka yang merasa mendekati kematian, terisolasi, maupun mengalami masalah psikis lainnya sehingga akan mengalami keselarasan harmoni internal maupun eksternal (maramis, 2005). motivasi yang tinggi dapat mempengaruhi perilaku melalui peningkatan pengetahuan dan skill (colquite, 2000 dalam niniek, 2004). individu yang memiliki adversity quotient (aq) yang tinggi secara emosional dan fisik cukup lentur dalam menghadapi kesulitan (stoltz, 2004). namun pengaruh motivasi ekstrinsik terhadap adversity quotient pada penderita hiv/aids belum jelas. mailto:nursalam_psik@yahoo.com jurnal ners vol.3 no.1 april 2008: 26-33 nursalam berdasarkan data awal uji instrumen pada tanggal 9 mei 2008 di upipi rsu dr. soetomo, 4 penderita mempunyai tingkat adversity quotient sebagai berikut 25% aq sedang, 50% aq cukup tinggi dan 25% aq tinggi. bagi individu yang positif terinfeksi hiv, menjalani kehidupannya akan terasa sulit karena dari segi fisik individu tersebut akan mengalami perubahan yang berkaitan dengan perkembangan penyakitnya. prevalensi depresi pada penderita dengan hiv/aids meningkat dua kali lipat dibandingkan dengan populasi biasa. pada penderita yang dirawat, angka ini lebih tinggi lagi (40%). pada suatu studi longitudinal ditemukan hasil di mana jumlah cd4+ limfosit menurun 38% lebih besar pada penderita hiv dengan depresi dibandingkan kelompok penderita hiv yang tidak mengalami depresi. pada suatu studi longitudinal dilaporkan prevalensi depresi meningkat dari 15-27% pada 36 bulan sebelum diagnosis aids hingga 34% pada saat 6 bulan sebelum diagnosis aids dan 43% pada saat 6 bulan sesudah diagnosis (tandiono, et al., 2007). penolakan terhadap diagnosis hiv akan membuat penderita jatuh pada keadaan stres berkepanjangan dan berdampak pada penurunan sistem imun, sehingga mempercepat progresivitas hiv ke aids. berdasarkan pendekatan ilmu psychoneuroimunology dapat dijelaskan, kondisi emosional berupa penolakan dan stres yang dialami penderita terinfeksi hiv akan memodulasi sistem imun melalui jalur hipothalamic-pituitary-adenocortical (hpa) axis dan sistem limbik (kontrol emosi dan learning process), melepaskan neuroleptik corticotropin releasing factor (crf). counter regulasi ini meningkatkan produksi dari kotekolamin, kortisol dan argininvasopresin (avp) (nasronudin, 2005). stoltz (2004) mengadakan riset selama 19 tahun dan penerapannya selama 10 tahun. hasilnya adalah tingkat aq mendasari kinerja, produktivitas, kreativitas, ketekunan, daya tahan, kesehatan dan vitalitas. aq dapat melihat bagaimana seseorang mampu menerima suatu masalah dan seberapa jauh individu mampu beradaptasi dengan masalah tersebut (wardhani, 2003). reaksi intrapsikis akan menimbulkan suatu interpretasi kognitif atau pemaknaan terhadap situasi yang menyebabkan reaksi emosional. hal ini bersifat subyektif feeling (tidak disadari dan tidak dipelajari) melibatkan aspek kognitif (kesadaran dari pengalaman subyektif). motivasi sangat besar pengaruhnya dalam kehidupan seseorang baik itu berupa motivasi ekstrinsik, contohnya dukungan orang tua, teman dan sebagainya maupun motivasi instrinsik yakni motivasi yang datang dari dalam individu itu sendiri. dukungan sosial mempengaruhi kesehatan dan melindungi seseorang terhadap efek negatif stres berat (nursalam dan kurniawati, 2007) penderita hiv/aids diarahkan untuk mengembangkan diri dengan transformasi kesadaran agar nantinya dapat mengelola emosinya secara mandiri sehingga dapat melakukan aktivitas seperti layaknya orang sehat sehingga dapat meningkatkan kualitas hidupnya. berdasarkan fenomena bahwa kondisi psikologis dan motivasi pada penderita hiv/aids menyebabkan respons psikologis yang berbeda dan juga didukung selama ini belum ada yang meneliti tentang pengaruh motivasi ekstrinsik terhadap adversity quotient pada penderita hiv/aids, maka peneliti mengangkat masalah ini. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah quasy experimental pre posttest purposive sampling design. populasi pada penelitian ini adalah penderita hiv/aids yang rawat jalan di unit perawatan intermediet penyakit infeksi rumah sakit umum dr. soetomo surabaya. sampel dalam penelitian ini sebanyak 16 orang, yang dibagi menjadi 8 orang diberikan perlakuan motivasi ekstrinsik (dukungan sosial), 6 kali intervensi (6x50 menit) selama 3 minggu (2x50 menit/minggu); sedangkan 8 orang yang lain memperoleh intervensi rutin. variabel independen dalam penelitian ini adalah motivasi ekstrinsik berupa dukungan sosial, sedangkan variabel dependennya adalah adversity quotient. instrumen yang digunakan dalam penelitian ini meliputi sap untuk mengukur motivasi ekstrinsik dengan intervensi dukungan sosial, sedangkan untuk mengetahui tingkat adversity quotient digunakan kuesioner skala stoltz (2004) dengan dimensi co2re (control, origin, ownership, reach and endurance). adversity quotient penderita hiv/aids (nursalam) 32 nursalam penelitian dilakukan selama bulan juni sampai dengan juli 2008. data yang diperoleh, ditabulasi dan dianalisis dengan menggunakan uji statistik wilcoxon signed rank test dan mann whitney u test dengan derajat kemaknaan α≤0,05. hasil hasil penelitian menunjukkan nilai p=0,017. berarti ada pengaruh motivasi ekstrinsik terhadap adversity quotient pada penderita hiv/aids. terdapat peningkatan hasil dari 70,75 menjadi 77. hal ini menunjukkan bahwa tingkat adversity quotient penderita meningkat setelah diberikan intervensi, sedangkan untuk kelompok kontrol peningkatan sangat sedikit sekali yaitu dari 70,625 menjadi 70,875 dengan nilai signifikansi p=0,943. tabel 2 menjelaskan tentang pengaruh motivasi ekstrinsik terhadap respons control penderita hiv/aids. hasil penelitian menunjukkan nilai p=0,027. berarti ada pengaruh motivasi ekstrinsik terhadap respons control pada penderita hiv/aids. terdapat peningkatan hasil dari 14,5 menjadi 16,38. hal ini menunjukkan respons control penderita bertambah setelah diberikan intervensi, sedangkan untuk kelompok kontrol peningkatan sangat sedikit sekali yaitu dari 14,375 menjadi 15,00 dengan nilai signifikansi p=0,236. tabel 3 menjelaskan tentang pengaruh motivasi ekstrinsik terhadap respons origin penderita hiv/aids. hasil penelitian menunjukkan nilai p=0,028. berarti ada pengaruh motivasi ekstrinsik terhadap respons origin pada penderita hiv/aids, terdapat peningkatan hasil dari 16,5 menjadi 18,5. hal ini menunjukkan respons origin penderita bertambah setelah diberikan intervensi, sedangkan untuk kelompok kontrol peningkatan sangat sedikit sekali yaitu dari 15,75 menjadi 18,5 dengan nilai signifikansi p=0,366. tabel 4 menjelaskan tentang pengaruh motivasi ekstrinsik terhadap respons ownership penderita hiv/aids. hasil penelitian menunjukkan nilai p=0,334 yang berarti tidak ada pengaruh motivasi ekstrinsik terhadap respons ownership pada penderita hiv/aids, peningkatan hasil sangat sedikit antara kelompok kontrol dan perlakuan peningkatan hampir sama dari 16,87 menjadi 17,25 pada kelompok perlakuan dan 16,87 menjadi 17,25. tabel 5 menjelaskan tentang pengaruh motivasi ekstrinsik terhadap respons reach penderita hiv/aids. hasil penelitian menunjukkan tidak ada pengaruh motivasi ekstrinsik terhadap respons reach pada penderita hiv/aids dengan nilai p=0,129. peningkatan hasil sangat sedikit antara kelompok kontrol dan perlakuan peningkatan hampir sama dari 9,00 menjadi 9,62 pada kelompok perlakuan dan 6,87 menjadi 6,75. tabel 6 menjelaskan tentang pengaruh motivasi ekstrinsik terhadap respons endurance penderita hiv/aids. hasil penelitian menunjukkan tidak ada pengaruh motivasi ekstrinsik terhadap respons endurance pada penderita hiv/aids dengan nilai p=0,161. peningkatan hasil sangat sedikit antara kelompok kontrol dan perlakuan peningkatan hampir sama dari 14,125 menjadi 15,125 pada kelompok perlakuan dan 15,375 menjadi 15,5. tabel 1. tingkat adversity quotient penderita hiv/aids di rawat jalan upipi rsu dr. soetomo tanggal 6 juni sampai dengan 2 juli 2008. kelompok intervensi kelompok kontrol kelompok intervensi kelompok kontrol pre post pre post post post mean 70,75 77 70,62 70,87 77 70,87 sd 5,34 2,83 4,84 3.,44 2,83 3,44 hasil analisis statistik wilcoxon signed rank test p=0,017 wilcoxon signed rank test p=0,943 mann whitney u test p=0,003 jurnal ners vol.3 no.1 april 2008: 26-33 tabel 2. respons dimensi kendali (control) penderita hiv/aids di rawat jalan upipi rsu dr. soetomo tanggal 6 juni sampai dengan 2 juli 2008. tabel 3. respons dimensi penyebab (origin) penderita hiv/aids di rawat jalan upipi rsu dr. soetomo tanggal 6 juni sampai dengan 2 juli 2008. kelompok intervensi kelompok kontrol kelompok intervensi kelompok kontrol pre post pre post post post mean 16,5 18,5 16,375 15,75 18,5 15,75 sd 2,72 1,93 2,77 2,43 1,93 2,43 hasil analisis statistik wilcoxon signed rank test p=0,028 wilcoxon signed rank test p=0,366 mann whitney u test p=0,028 tabel 4. respons dimensi pengakuan (ownership) penderita hiv/aids di rawat jalan upipi rsu dr. soetomo tanggal 6 juni sampai dengan 2 juli 2008. tabel 5. respons dimensi jangkauan (reach) penderita hiv/aids di rawat jalan upipi rsu dr. soetomo tanggal 6 juni sampai dengan 2 juli 2008. kelompok intervensi kelompok kontrol kelompok intervensi kelompok kontrol pre post pre post post post mean 9,00 9,62 6,87 6,75 9,625 6,75 sd 1,60 1,51 1,46 1,67 1,51 1,67 hasil analisis statistik wilcoxon signed rank test p=0,129 wilcoxon signed rank test p=0,705 mann whitney u test p=0,003 keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata kelompok intervensi kelompok kontrol kelompok intervensi kelompok kontrol pre post pre post post post mean 14,5 16,37 14,37 15,00 16,37 15,00 sd 1,93 1,41 1,92 1,31 1,41 1,31 hasil analisis statistik wilcoxon signed rank test p=0,027 wilcoxon signed rank test p=0,236 mann whitney u test p=0,008 kelompok intervensi kelompok kontrol kelompok intervensi kelompok kontrol pre post pre post post post mean 16,875 17,25 17,125 16,875 17,25 16,875 sd 1,25 1,49 1,36 2,10 1,49 2,10 hasil analisis statistik wilcoxon signed rank test p=0,334 wilcoxon signed rank test p=0,589 mann whitney u test p=0,721 adversity quotient penderita hiv/aids (nursalam) 32 nursalam tabel 6. respons dimensi daya tahan (endurance) penderita hiv/aids di rawat jalan upipi rsu dr. soetomo tanggal 6 juni sampai dengan 2 juli 2008. keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata pembahasan hasil penelitian menunjukkan terdapat pengaruh motivasi ekstrinsik terhadap respons adversity quotient pada penderita hiv/aids namun masih terdapat responden yang belum maksimal dalam mengatasi masa sulit sejak terdiagnosis hiv. hal ini ditunjukkan dengan penderita yang kurang meningkatkan nilai adversity quotient, responden tn. r menyatakan: “iya, mbak saya sangat kaget setelah hasil darah saya positif, saya sempat mengurung diri, ada keinginan kabur dari rumah, akhirnya saya tidur di gerbong kereta api, dan minum sprite banyak tapi ko ga mati-mati, ya akhirnya saya sadar sudah di rumah sakit”. stoltz (2004) menyatakan bahwa adversity quotient merupakan suatu gambaran (snapshot) dari kebiasaan respons seseorang terhadap kesulitan, suatu ukuran pola bawah sadar yang konsisten yang telah dikembangkan oleh individu selama bertahun-tahun. adversity quotient merupakan suatu kerangka konseptual yang mampu meramalkan tingkat kemampuan seseorang untuk mengatasi kesulitankesulitan hidupnya, dimana perjuangan meraih tujuan dan perjuangan menghadapi hambatan yang ada dianalogikan dengan perjalanan mendaki gunung, adversity quotient merupakan kerangka konseptual yang dapat meramalkan individu mana yang mampu dan tidak mampu mengatasi kesulitan hidupnya. nasronudin (2005) menyatakan penderita hiv/aids mengalami adaptasi psikologis yang berat akibat dari hasil positif sampel darah penderita. hal ini sangat mempengaruhi mental psikologis penderita dan berpengaruh terhadap tingkat imunitas penderita, dihubungkan dengan teori psikoneuroimunologi sebagai dasar pembentuk adversity quotient terdapat pengaruh yang signifikan jika dihubungkan dengan ketahanan penderita terhadap proses perjalanan penyakit (meningkatnya virus hiv yang mengakibatkan penurunan cd4). adversity quotient sebagai bentuk penilaian terhadap kemampuan atau ketahanan dalam menghadapi kesulitan dalam menghadapi penyakit yang dideritanya, meliputi penilaian apakah diri seseorang itu merasa sebagai orang yang berguna, memiliki banyak kemampuan dan keyakinan untuk dapat hidup normal meskipun dirinya terjangkit hiv, memiliki ketahanan dalam menghadapi masalah dan memiliki kendali terhadap sebuah peristiwa yang menimbulkan kesulitan. hal ini akan mempunyai pengaruh yang besar terhadap daya tahan dan kekebalan penderita. seseorang dengan tingkat adversity quotient yang tinggi akan cenderung memiliki sikap yang positif terhadap segala sesuatu. sikap positif terhadap kesembuhan penyakitnya, membantu penderita terhadap koping yang lebih konstruktif serta harapan yang lebih meningkat, dengan motivasi ekstrinsik berupa dukungan sosial, membantu penderita dalam mengungkapkan perasaan saat pertama kali terdiagnosis, membantu penderita untuk tetap menghargai dirinya dan menerima kondisi tersebut dengan ikhlas, no kelompok intervensi kelompok kontrol kelompok intervensi kelompok kontrol pre post pre post post post mean 14,13 15,13 15,37 15,5 15,12 15,5 sd 2,75 2,59 1,85 1,60 2,59 1,60 hasil analisis statistik wilcoxon signed rank test p=0,334 wilcoxon signed rank test p=0,589 mann whitney u test p=0,721 jurnal ners vol.3 no.1 april 2008: 26-33 nursalam nursalam menegaskan pentingnya penderita bagi orang lain serta mengarahkan penderita untuk tetap aktif dalam mengikuti berbagai kegiatan yang bermanfaat bagi penderita dan bisa berguna bagi orang lain. sikap optimis ini akan mensinergikan segala kegiatan terhadap peningkatan kesehatan yang dilakukan penderita itu sendiri, kontrol yang teratur, patuh dalam minum arv serta kegiatan lain yang menunjang kesembuhan penderita. hasil penelitian menunjukkan terdapat pengaruh motivasi ekstrinsik terhadap respons kendali pada penderita hiv/aids, dengan signifikansi p=0,027. hal tersebut didukung seperti yang disampaikan responden nn. n: “saya tu sekarang agak cuek mbak, ma tetangga-tetangga yang nggunjing dan bilang saya cewek ga bener, keluyuran malam, ora ngurus..!! tapi saya kasihan sama ibu kalo ada tetangga yang usil seperti itu”. hal ini memberikan gambaran bahwa kemampuan penderita kelompok perlakuan untuk membalik kesulitan dan kemudian mengubahnya menjadi kesempatan serta merubah rasa tidak berdaya menjadi berdaya masih bervariasi, tetapi kecenderungan menunjukkan nilai relatif sedang. respons control melihat bagaimana seseorang mengendalikan suatu peristiwa yang menimbulkan kesulitan dalam hidupnya. respons control penderita hiv/aids mengalami peningkatan ditunjukkan pada perasaan penderita lebih baik saat dokter menyatakan diagnosis dan penderita tetap yakin kalau penyakit ada obatnya serta yakin terdapat jalan keluar dalam masalah yang dialami. semangat untuk tetap berjuang meskipun dengan hiv positif terdapat setelah dilakukan motivasi ekstrinsik. welles (2000) mengatakan bahwa orang-orang yang memiliki control yang baik cenderung untuk memiliki aq tinggi. mereka tidak menyalahkan orang lain atas penyakitnya dan memiliki tanggungjawab akibat perbuatan yang dilakukannya dulu dan mereka yakin dapat menghadapinya. berdasarkan hasil analisis pada tabel 3 terdapat adanya pengaruh motivasi ekstrinsik terhadap dimensi penyebab pada penderita hiv/aids. disini disebutkan penderita tn. j bahwa: ”ya risiko mbak..tau sakit gini meski dulunya ada awal-mulanya, saya mengakui klo pernah tinggal dan kumpul sama waria, tapi itu saya saat remaja, setelah itu saya menikah, istri saya melahirkan, bayi saya hanya bertahan 6 bulan, kemudian tak lama istri saya meninggal, sekarang saya baru tahu kalo saya menularkan penyakit ke istri sama anak saya”. penderita yang mempunyai aq rendah cenderung menempatkan rasa bersalah yang tidak semestinya atas berbagai peristiwa buruk yang terjadi. respons origin yang rendah bisa menghentikan umpan balik karena beban mempersalahkan diri sendiri yang terus-menerus. seperti kritik, rasa bersalah dan penyesalan hanya akan sedikit bermanfaat. rasa bersalah memiliki dua fungsi penting. rasa bersalah dalam ukuran yang tepat akan menyebabkan seseorang bertindak ke arah perbaikan dan membantu mencapai kesembuhan. rasa bersalah yang terlalu besar dapat melemahkan semangat dan menjadi dekstruktif, sehingga menghancurkan energi, harapan, harga diri dan sistem kekebalan. respons origin pada penderita hiv/aids meningkat ditunjukkan dengan rasa bersalah penderita terhadap keluarga serta teman dekat akibat diagnosis hiv positif. hasil penelitian menunjukkan tidak terdapat pengaruh motivasi ekstrinsik terhadap dimensi pengakuan (ownership) pada penderita hiv/aids. stolz (2004) menyatakan semakin sedikit tingkat pengakuan, semakin besar kemungkinan tidak mengakui akibat yang ditimbulkan. kecenderungan untuk menepis peristiwa buruk atau menghindari tanggungjawab merupakan sikap yang tidak diinginkan. respons ownership mengungkapkan aspek pengakuan terhadap kesulitan yang timbul. penderita yang memiliki aq tinggi cenderung mengakui berbagai akibat yang ditimbulkan oleh kesulitan dan seringkali dapat mengingat penyebabnya. rasa tanggung jawab tersebut memaksa mereka untuk bertindak, membuat penderita lebih meningkatkan kesehatan. dari hasil penelitian ini dapat diasumsikan bahwa penderita hiv/aids kurang mengakui apa yang menjadi penyebab kesulitan yang timbul, tetapi masih ada rasa tanggung jawab untuk mengatasi kondisi tersebut. tidak adanya pengaruh dalam dimensi ini disebabkan karena penderita kurang bisa menegaskan tentang pentingnya penderita bagi orang lain. responden mbak adversity quotient penderita hiv/aids (nursalam) 32 nursalam d mengatakan: ”apa ya bisa mbak saya berguna bagi orang lain, sakit kaya gini saya bisanya cuma merepotkan orang lain, apalagi klo kondisi saya drop pasti saya jadi ramut-ramutan orang banyak”. hasil analisis pada tabel 5 menunjukkan tidak terdapat pengaruh motivasi ekstrinsik terhadap dimensi jangkauan (reach) pada penderita hiv/aids. stolz (2004) menyatakan respons dengan aq yang rendah akan memperluas kesulitan ke dalam kehidupan. hasil ini memberikan gambaran bahwa kemampuan penderita hiv/aids untuk membatasi dampak kesulitan dari progresif penyakitnya terhadap bagian lain dari kehidupan berada pada tingkat sedang. reach menggambarkan bahwa sejauh mana kesulitan yang timbul akan menjangkau berbagai bagian lain kehidupan seseorang. respons reach pada penderita ditunjukkan dengan adanya keluarga yang merawat penderita, namun penderita sendiri merasa dirinya telah merepotkan orang lain. jangkauan disini meliputi kedekatan penderita dengan keluarga dan teman dekat. penderita akan terpuruk dan drop jika keluarga menyalahkan penderita tersebut. responden menyatakan: ”saya ini memang ndableg mbak, dinasehati orang tua ga pernah tak dengerin. semuanya sak karepku..sampai akhirnya saya menanggung akibatnya sekarang. jujur saya minder sama teman-teman mbak. saya tertutup. tapi bisa berbagi cerita disini bersama teman-teman senasib, saya jadi plong mbak” demikian ungkap mas s yang baru terdiagnosis bulan juni 2008 kemarin. hasil analisis pada tabel 6 menunjukkan tidak terdapat pengaruh motivasi ekstrinsik terhadap dimensi daya tahan (endurance) pada penderita hiv/aids. hasil ini menunjukkan bahwa daya tahan (endurance) berada pada kategori rendah. hasil ini juga memberikan gambaran bahwa penderita hiv/aids cenderung menganggap masalah atau kesulitan yang terjadi bersifat permanen dan bukan sebagai suatu dinamika yang bersifat sementara. respons endurance mempertanyakan sejauh mana kesulitan akan berlangsung. berdasarkan penelitian seligman, riset tentang teori atribusi menunjukkan perbedaan dramatis antara orang yang mengaitkan kesulitan dengan sesuatu yang sifatnya sementara versus sesuatu yang lebih permanen atau abadi. stoltz (2004) menyatakan seseorang yang memiliki nilai respons endurance tinggi menganggap bahwa penyebab kesulitan sebagai suatu yang bersifat sementara, cepat berlalu dan kecil kemungkinannya terjadi lagi. motivasi ekstrinsik tidak berpengaruh terhadap dimensi daya tahan (endurance) karena masa sulit yang dialami oleh penderita hiv/aids termasuk permanen. hal ini disebabkan penderita harus mengkonsumsi obat terus-menerus dan selalu menjaga kondisi tubuh agar tidak menurun. seperti yang diungkapkan responden mas d: ”bosen lho mbak, arv ga boleh telat, padahal awal minum tu dulu saya mual-mual ngga doyan makan. tapi lama-lama saya ya terbiasa, saya pasrah, untungnya keluarga saya selalu mengingatkan”. simpulan dan saran simpulan penelitian ini menunjukkan bahwa motivasi ekstrinsik dengan intervensi dukungan sosial berpengaruh positif dalam peningkatan adversity quotient pada penderita hiv/aids. motivasi ekstrinsik berpengaruh positif terhadap respons dimensi asal-usul (origin) pada penderita hiv/aids. penderita hiv/aids yang mendapatkan motivasi ekstrinsik tidak menunjukkan perubahan yang bermakna terhadap respons dimensi pengakuan (ownership), dimensi jangkauan (reach) dan dimensi daya tahan (endurance). saran berdasarkan pada hasil penelitian ini peneliti menyarankan agar pada penderita dibentuk kelompok diskusi kecil yang terdiri dari 7-10 orang untuk meningkatkan interaksi antar penderita, saling memberikan dorongan untuk tetap mempertahankan kualitas hidup dan berbagi pengalaman tentang perawatan dan pengobatan sakit yang diderita (yang diadakan setelah kontrol). perawat diharapkan untuk meningkatkan intervensi dengan pendekatan psikologis agar tercipta keperawatan biopsikososiospritual yang holistik. perawat diharapkan memberikan kesempatan pada penderita untuk jurnal ners vol.3 no.1 april 2008: 26-33 nursalam nursalam mendapatkan informasi yang lengkap dan mempersiapkan mental penderita sebelum dilakukan pemeriksaan tes hiv/aids yang dimaksudkan untuk mengurangi tingkat kecemasan penderita. selanjutnya perlu adanya kerjasama dengan tenaga ruang jiwa c atau lembaga psikologis lain dalam pendekatan yang lebih pada psikososial penderita hiv/aids. kepustakaan maramis, m.m. 2005. manfaat psikoterapi dalam psikoneuroimunologi kedokteran. surabaya: gideon offset, hlm. 77-79. muma, r.d., et al. 1997. aspek sosial dan psikologis dari aids. hiv manual untuk tenaga kesehatan. alih bahasa oleh prawitasari s. jakarta: egc, hlm. 275. nasronudin. 2005. pengaruh psikososial terhadap perkembangan infeksi hiv menjadi aids dalam psikoneuroimunologi kedokteran. surabaya: gideon offset, hlm. 80-89. nursalam dan kurniawati. 2007. asuhan keperawatan pada penderita terinfeksi hiv dan aids. jakarta: salemba medika, hlm. 15-16, 24-27, 30. niniek. 2004. pengaruh self eficacy melalui kemampuan kognitif, motivasi dan afektif kader kesehatan gigi terhadap perilaku sehat gigi. disertasi tidak dipublikasikan. surabaya : universitas airlangga, hlm. 89-95. stoltz. 2004. adversity quotient mengubah hambatan jadi peluang, alih bahasa oleh hermaya t. jakarta: gramedia, hlm. 100-104. tandiono, et al. 2007. peran consultationliaison psychiatry pada penatalaksanaan penderita dengan hiv dan aids. ppds bagian psikiatri. jakarta: fakultas kedokteran universitas indonesia, hlm. 69-75. wardhani. 2003. pengaruh tingkat adversity quotient (aq) terhadap orientasi karir di pt. danzas surabaya dan jakarta. tesis tidak dipublikasikan. surabaya: universitas airlangga, hlm. 110-128. 180 family process with breast cancer patient in indonesia sarah kartika wulandari*, yanti hermayanti*, ahmad yamin*, ferry efendi** * faculty of nursing, universitas padjadjaran ** faculty of nursing, universitas airlangga email: sarahwulandari88@gmail.com abstract introduction: breast cancer occupies the first position in asia’s women cancer cases in recent years. signs and symptoms experienced by the patient affect the stress condition of the patient as well as the family as a caregiver. the condition changes to deal with problems during patient assistance as a major problem in an outpatient setting. the demands of adaptation to through the needs during the period of assistance by the family is more complex. the study aimed to determine the experience of stress and adaptation of breast cancer patient’s family. methods: the qualitative method used with in-depth interviews on seven respondents who were the family caregiver of breast cancer patients. setting carried out at the shelter house in bandung. the analysis process used thematic analysis based on braun & clarke. results: the results found five main themes are: 1) stressor on breast cancer patients, 2) crisis fulfillment of companion needs, 3) crisis accompaniment, 4) coping mechanisms of caregiver, and 5) ability in adaptation. conclusions: family experience in assisting breast cancer patients who undergo outpatient also impact families tension who traversed with a subjective effort optimally to adapt in accompanying patients and the needs of other resource support system. suggestions for future step are early recognition of stress by health workers especially nurses to be able to provide targeted interventions to develop positive adaptation to clients. the development through research is needed in applying family center care both the outpatient and inpatient care in an integrated manner. keywords: adaptation, breast cancer, caregiver, stress ___________________________________________________________________________ introduction the indonesian profile in the who (2014) shows the statistics of cancer incidence reaching 103,100 new cases compared to new cases in the world of 14.1 million cases. specific cases of breast cancer in west java show an incidence of 1.0 ‰ of the population (riskesdas) (2014). anderson and jakesz (2008) state that developing countries need practical, cost-effective resource interventions in the treatment of breast cancer. hopkinson (2016) proven eating disorders often occur in cancer patients and affect the family diet until cachexia syndrome. while the family as an informal caregiver who became the primary caregiver tended to experience depression, physical & mental fatigue (buyck et al. (2011); papastavrou, charalambous, and tsangari (2012). limited resources in socioeconomic problems made consequence of improper treatment (obrist et al., 2014). especially for patients with outpatient treatment. the role of the family to be the companion not only affects the patient but also the condition of the resources around the family. resources for handling breast cancer include healthcare facilities, skilled health workers, and support resources including family and social. resources that can be exploited and influential one of which is the family (beaver, williamson, & briggs, 2016). family assistance can be a support to optimize the condition of breast cancer patients. controlling signs & symptoms such as fatigue, anemia, hot flashes, hair loss, impaired mobility, decreased appetite and activity intolerance (jones, eves, haykowsky, freedland, & mackey, 2009); tachi et al. (2015); tsitsis and lavdaniti (2014) and family confusion accompanying breast cancer patients. the stressors in the treatment process will affect family status (govina et al., 2014). changes in family psychological conditions according to khanjari, langius-ekl€of, oskouie, and sundberg (2014) appear at least after six months of patients diagnosed with breast cancer. some treatment options for breast cancer include surgery, chemotherapy, radiotherapy and a combination of these therapies that have therapeutic effects as well as side effects in patients starting during preparation, during implementation and after treatment (kumar & bhasker, 2015). conditional conditions should be explored to prepare the process of treatment, especially in the outpatient care. the healthcare process as one of the functions of the family in addition to reproductive, socializing, economic and affective functions (kaakinen, gedaly-duff, coehlo, & hanson, 2010) began to be developed with a team of health professionals. this is aligned with the development of family center care methods in several health facilities that want to involve families actively to family process with breast cancer patient... (sarah kartika wulandari et.al.) 181 improve the quality of services and satisfaction of clients and health workers in the treatment and care process. family increasing caring ability showed decreasing burden and indicated a calming bereavement (k.-c. lee, yiin, & chao, 2016). it becomes important to know the condition and potential sources of family. based on the text above, the research aimed to determine the experience of stress and adaptation process of family who had breast cancer patients in the area of bandung city. this study aims to know and understands the experience of stress and adaptation of family of breast cancer patients in bandung. materials and methods the research used the qualitative method and purposive sampling with an interview with the informal caregiver of breast cancer patients who undergo treatment and outpatient setting in bandung. interview guide developed by the first researcher with content validity by the second and third researcher using the middle range theory ‘the family stress and adaptation’ (geri lobiondo-wood, 2008). participants targeted using purposive sampling with inclusion criteria such as: family members of breast cancer patients who have been assisting and actively involved in care (primary caregiver) at least 6 months (khanjari et al., 2014) to the patient since being diagnosed by the doctor, has signed informed consent at the beginning of the research, the participants are located in bandung city. for the exclusion criteria depends on children or adolescents (<16 years old), participants with communication disorders and participants with mental disorders. the recruitment settled by the first researcher by visited the manager of shelter house and sorted out the participant that fit the criteria. the anonymity used initials coding to each participant. ethical approval number 519/un6.c10/pn/2017 by research ethics commission medical faculty of padjadjaran university. the study was conducted from april to june 2017 when the saturation data was obtained through intense meetings with participants. in hence conducted the rigor and trustworthiness interview used an optimal interview from the 3-5 session, triangulation data & investigator, and peer debriefing. the time spent on interviews averaged 51 minutes. the research setting was in a shelter house called rumah teduh inn located in bandung city, west java. participants lived as long got some cancer medication and/or treatment where lived periodically in 4 separate houses. specifically for this study focused on the 1st and 2nd houses. this is because the existence of patients appropriate for inclusion criteria focused on that location. this research used indepth interview technique with tape recorder and field note assistance prepared during the interview process. analysis of this study using thematic analysis (braun & clarke, 2006). results this study obtained seven (7) participants who were related to their position as a caregiver/companion for breast cancer patients who underwent treatment in bandung city. participants consisted of six patient as husbands and one child of the patient and all of whom were men. the educational level of participants is in the range of elementary schoolsenior high school level. participants have been accompanied the patient through the illness begun now at least 6 months and a maximum of 4 years. table 1. participant demographic information age kinship employment status lengthy as caregiver 53 years husband no job 1 year 35 years husband no job 2 years 71 years husband no job 4 years 23 years son no job 7 months 54 years husband no job 3 years 44 years husband no job 2 years 30 years husband no job 1 year jurnal ners vol. 12 no. 2 oktober 2017: 180-186 182 we found out five main themes: 1) stressor on the caregiver, 2) crisis of caregiver fulfillment needs, 3) caring crisis, 4) coping mechanism of caregiver, and 5) ability in adaptation as depicted in figure 1. the first theme, stressor on caregiver: the demands of family problems are elaborated through sub-themes, according to delays in recognizing and managing disease; and family economic difficulties, as an internal stressor. meanwhile, external stressors, according to assessing the limitations of patient activity, the complexity of health insurance, long treatment process, and suspicion on the surrounding community. the second theme, crisis of caregiver fulfillment needs (reaction to internal and external impacts) is elaborated with subthemes, such as internal conflicts (changes in the family, difficulty working, physical and mental fatigue, separated grief with the nearest member of the family, conflicts of treatment decision-making). the sub-theme builds the internal tension that occurs in the family companion. meanwhile, external conflict consists of limited assistance and support to the family, the shock of the patient's condition worsened. third, the conflict that occurred causing tension that manifested into the core theme of this research, namely caring crisis. the caring crisis is described as a family stress condition in the face of unresolved problems after utilizing optimal existing resources and requiring additional resources. the crisis manifests in the form of limited economic resources (prolonged), the progressive condition of declining patients, death threats, and social environmental conditions. fourth, in the coping mechanism of caregiver is divided into three main components were (1) internal resources, (2) caregiver coping, and (3) external resources. internal resources are understood as all assets, kinship, core family support that has been optimized by the companion. while external resources consist of alternative medicine, third party, social support in patient-family, assistance from shelter home. the coping consists of trying to obey the treatment for the conviction of healed, resignation to family conditions, entrusted to professional health workers, build coping with prayer and gratitude. in the theme adaptability capability, there are four sub-themes: additional nutrition, adaptation, pain relief, health system adjustment. nutrition information need of patient was focusing by the caregiver for preparation in next phase of treatment (radiation and/or chemotherapy). caregiver used pain relief as simple intervention such as massage and hot compress applied in shelter house after the treatment in hospital. discussion caregiver burden in cancer patient was complex and progressive, influenced by resource conditions inside and outside the family. factors that affected the burden condition was the available resources such as daily activities competences, education level, gender, and financial status by the caregiver (vahidi et al., 2016). this study found that level of education of participants was a range of elementarysenior high school level and equal, the condition of economic limitations and changes in daily activities experienced by all participants whose all male. other research by alptekin, gonullu, yucel, and yarıs (2010) stated that informal female companions are more susceptible to decreased quality of life due to being a companion of cancer patients than male counterparts. in this research, the opposite occurred when the caregiver was all figure 1. the themes scheme of stress and adaptation process in breast cancer caregiver family process with breast cancer patient... (sarah kartika wulandari et.al.) 183 man who was six are husband, and one is the son of the patient. in case they also feel the stress but not expressed verbally that much as they kept the pride as the head of the family. however, jaafar et al. (2014) stated depression experienced by breast cancer patients related to ethnicity, duration of mentoring, patient functional status, and level education of caregiver. in this study participant open to all gender but because of caregiver and patient came from outside bandung so that they prefer accompanied by the family were men or because there is no other family member as a caregiver. the other related results are described in detail in each sub-theme below. in the sub-themes of internal stressors related to the delay in recognizing & managing of the disease and the economic difficulties of the families that are sources of internal stressor are perceived as internal stressors arising from limited capacity of companion resources. “yes… that time ..delay happened. so its delay about two months. two months finished the regular medicine i didn’t get here; i was so busy with (work)” (r1) the recognizing & managing also delayed significantly attributable to the patient's doubt whether his disease is benign or malignant (taib, yip, ibrahim, cj, & farizah, 2007). although there are also other factors such as residence distance were far away from health care facilities, marital status and the presence of children to be cared for. the financial problem tends to be the main burden of cancer patients (vahidi et al., 2016), in line with kaplan, madden, mijanovich, and purcaro (2013) that explained of stressor in weak economic community group which one of them was overcome with helped by the coadministered funds between government and private parties (moffat, noble & white, 2012). the conditions become problem associated with early treatment for breast cancer patients within the family that can lead to the quality of life of patients and caregiver (family). the financial problem becomes a stressor from the beginning until the end of the breast cancer treatment and care. “but from me, i couldn’t get it (pay by out of pocket its self). because i work as daily worker only” (r7) in the subtheme, the external stressor described as it 1) assessing the limitations of patient activity, 2) the complexity of health insurance, 3) lengthy treatment process, and 4) suspicion on the surrounding community. the patient's activity ability does indeed decrease during the disease process and treatment but still important to 'normalize' the patient to make sure they feel 'alive' and useful to others (walshe et al., 2017). it certainly decreased the auxiliary load for adl activity which is on the average increase in line with the improvement of conditions during the treatment process of the disease (vahidi et al., 2016). treatment time tends to be long since the diagnosis of disease has a positive correlation with the social burden and family life (rha, park, song, lee, & lee, 2015). in the other hand health insurance for long way treatment needed. chongsuvivatwong et al. (2011) state that health-related insurance implemented in indonesia with decentralization system (swadana) in implementation still needs stabilization because of the lack of supporting infrastructure. while a lack of understanding in national health insurance coverage may contribute to treatment inadequacy (obrist et al., 2014). accumulation of this stressor turns into caregiver burden of the family both internally and externally which then affects the family condition to respond to overcome it. “honestly we have (bpjs/national health insurance), but i didn’t know how to use it, how the procedure….so i didn’t know it before, so when it happens (illness comes) that time we knew as it is.” (r4) the crisis of fulfillment of caregiver needs were elaborated through the sub-themes component of the internal conflict that is 1) the change in the family, 2) the difficulty of working, tired of the physical & mind, 3) the sadness of separation with the nearest person, and 4) the conflict of decision-making treatment. the hope for appreciated, listened and accompanied was not only happened to the patient but also on the caregiver (kardiyudiani, 2012). regan, levesque, lambert, and kelly (2015) claimed the change in the role of the couple was an absolute matter in the condition of couples who have cancer and not infrequently the contradictions within the family or spouse in the process of disease and treatment. role-shifting more on jurnal ners vol. 12 no. 2 oktober 2017: 180-188 184 practical help in everyday activities occurred as a result. meanwhile, for a caregiver functional change requires a qualified ability to perform several tasks with special skills, such as treating injuries, treating patients congested, pain, memorizing drug delivery patients (regan et al., 2015). adjustment to the condition of the patient may affect both physical and psychological companions, including sleep disturbances (zhang, yao, yang, & zhou, 2014) as presented by participant 1: “last night i couldn’t sleep, so i did not sleep at all.” (r1). they felt hard to continuing their life whether the spouse must be ill every time. the other conditions of difficulty in working were more complicated problem with increased financial needs in accompanying cancer patients ultimately decrease the ability of a caregiver in full-time work (vahidi et al., 2016). a time-consuming maintenance burden becomes a major problem that occurs in many caregivers (govina et al., 2014). farewell during the treatment and treatment process contributes to the burden during side-by-side treatment (govina et al., 2015) in addition to gender, family status, education, previous caring experience, occupational status, the difficulty of care, anxiety, and depression. so that caregivers end up adjusting job options or stopping working to care for sick family members. “yes, i quit the job..strait away calling for my boss. boss, i couldn’t send the packet (work as courier), my wife was got sick again.” (r1) sub-theme component in the external conflict in this research, such as 5) limited support & support to the family, 6) shock the patient's condition worsened. the deterioration of the patient's condition results in increased emotional distress on the caregiver (burridge, barnett, & clavarino, 2009). treatment decisions become the focus of counseling and sometimes between patients, spouses and families or relatives to differences in responding and choosing treatment options (regan et al., 2015). then there was the process of discussion (bargaining) in the selection of treatment. limitations of assistance to families are linked to the growing needs of family conditions and long-term disease processes so that the needs and resources become unbalanced. the tension arises in the caregiver when creates a crisis that cannot resolve with the usual coping strategies and mechanisms (barker, 2009); townsend (2008). the development needed about uses resources and coping strategies additional broader than before. components of caregiver coping mechanism themes are elaborated with coping sub-themes covered by four topics, 1) endeavoring for a cure, 2) resignation of the family condition, 3) entrusting to professional health officers, and 4) building coping with prayer & gratitude. the family entrusted the professional health staff (walshe et al., 2017) is a key form of emotional accompaniment, practice, and social support that positively impacts the patient and accompanies the treatment. the ambiguity of resignation is perceived as the dilemma faced by the caregiver for the limitation of their ability to care for the patient with the complexity of complaints and needs to lead to emotional distress (regan et al. (2015); papastavrou et al. (2012). the hope of recovered (as normal) after treatment at health service delivered family to support patient in treatment (anggraeni & ekowati, 2010). sometimes this requires another self-help coping of the companion one of which holds on to the belief or belief that it has. the sub-theme of external resources is four topics, 5) alternative medicine as treatment shortcut, 6) the third party in treatment, 7) impact of social support on patient-family, and 8) meaningful assistance from the shelter. peer group communication is effective as one of social support apart from the community and family. this gives a different effect to the communication experience with the professional staff. because they learn from those, who experience the same thing as they share strategies to get through the problem (walshe et al., 2017). the use of other treatment options such as traditional and alternative is still the most favorite in breast cancer patients such as kota bharu, malaysia (taib et al., 2007) who are still both malay with indonesia. the reasons for its use are various, ranging from operating fears, friend influences, possible treatment success beliefs, and bad experiences in previous hospitals. a comparison of both countries showed that cancer patients in family process with breast cancer patient... (sarah kartika wulandari et.al.) 185 indonesia attacked the younger age group (<48 years) with a higher cancer stage in indonesia than malaysia (ng et al., 2011). “alternative medicine advise came from our neighbor. they said alternative could do it (healing) without operation.” (r7) other resources that need to be developed for further access was the shelter service. shelter service as the temporary place is managed by government and private sector through empowerment of government accredited foundation in indonesia. the results of other health care facilities resemble as the study by y. s. lee et al. (2017) suggest that care at the hospice indicates a decrease in hospital admission rate, the comfort of living with a companion, active visits from doctors and nurses optimizing end of life care. so this contributes to late checks and treatment into a problem that can increase the burden of health in indonesia and requires coping and management strategies of the participants and all parties involved. developing trust implemented by the form of praying and developing hope was done as a form of self-support in dealing with problems based on the value of spirituality that is believed (anggraeni & ekowati, 2010). although other studies show avoidance behavior and rejection are still significantly occurring as coping with higher levels of depression of facilitation (papastavrou et al., 2012). mostly the caregiver in this research again built trust submit to fate and praying as once of coping mechanism. components of themes of adaptability found four topics, 1) additional nutrition efforts, 2) adapt to each other, 3) help with pain and 4) adjustment to the health system. information on nutrition is one of the main information needed by patients other than disease management information (kamiafar, sarbaz, sales, & esmaeili, 2016). this information is not only the patient but also required by the companion. this is because the provision of nutrients will be further diverted to the task of caregiver especially in the condition of outpatients as in this study. caregiver education programs are proven effective in improving the quality of life of patients with topics of food support, care services, welfare services (massage), and symptomatic management (belgacem et al., 2013). adjustment to the health system is a form of adaptation developed by a companion to succeed the patient's smooth treatment. in this process is not uncommon caregiver experience obstacles and confusion when told the procedure to be passed for patients get treatment (anggraeni & ekowati, 2010). this certainly hampers the process of health care assistance by the family. family health care in this study is based on theory of family stress and adaptation (g. lobiondo-wood, 2008) which is the middle-range theory group. components of the theory are synergistic with the concept of the nursing paradigm that has four components: human, health, environment and nursing (potter & perry, 2010). the nursing approach is more focused on the individual (client) and the environment is not a disease according to the nursing concept assumption f. nightingale (parker & smith, 2010) in harmony with theory of family stress and adaptation (lobiondo-wood, 2008). so the results of the study are expected to be in line with the philosophy of nursing. regan et al. (2015) addressed the themes of response to cancer, how to deal with cancer, experience with health workers, and transition to survivorship status. compared to this study, we describe the components according to the setting of the shelter house in the process and the time span that marks the mentoring process in the care of cancer patients. travel assistance of cancer patients through the mechanism of action long-term reaction. response to cancer, elaborated through a stress process divided into primary stressors (direct effects) and secondary (side effects), perceptions of the condition that is individual that builds self-efficacy. this has an impact on how to address the mentoring process in the course of the disease (fletcher, miaskowski, given, & schumacher, 2012). the emerging crisis results from the inability to cope with existing problems with family coping mechanisms normally used (barker, 2009). to develop other coping mechanisms with additional resources that exist around to achieve balance and adaptation. conclusions the conclusion of this research is the experience of stress and adaptation of the family of breast cancer patient in bandung is a jurnal ners vol. 12 no. 2 oktober 2017: 180-188 186 continuous stage of the stressor to the formation of crisis that requires continued coping until the formation of adaptation by the breast cancer patient. this continuous process is evident in the themes gained through research on participant experience as a companion. support from professional nurses may be needed to minimize the stress and pass on the adaptation process. acknowledgment our appreciation goes to all caregivers and patients and ngo who help each other to combat cancer out there. the research supported by a scholarship from the education and cultural ministry of indonesia. references riskesdas (2014). profil kesehatan provinsi jawa barat tahun 2014. indonesia: dinas kesehatan provinsi jawa barat. alptekin, s., gonullu, g., yucel, i., & yarıs, f. (2010). characteristics and quality of life analysis of caregivers of cancer patients. medical oncology, 27, 607617. doi: doi 10.1007/s12032-0099256-2 anderson, b., & jakesz, r. (2008). breast cancer issues in developing countries: an overview of the breast health global initiative. world journal of surgery, 32, 2578-2585. doi: 10.1007/s00268-007-9454-z anggraeni, m., & ekowati, w. (2010). peran keluarga dalam memberikan dukungan terhadap pencapaian integritas diri pasien kanker payudara post radikal mastektomi. the soedirman journal of nursing, 5(2), 105-114. barker, p. (2009). psychiatric and mental health nursing: the craft of caring (2 ed.). london-uk: hodder arnold (publishers) ltd. beaver, k., williamson, s., & briggs, j. (2016). exploring patient experiences of neo-adjuvant chemotherapy for breast cancer. european journal of oncology nursing, 20(1), 77-86. doi: http://dx.doi.org/10.1016/j.ejon.2015.0 6.001 belgacem, b., auclair, c., fedor, m.-c., brugnon, d., blanquet, m., tournilhac, o., & gerbaud, l. (2013). a caregiver educational program improves quality of life and burden for cancer patients and their caregivers: a randomised clinical trial. european journal of oncology nursing, 2013, 17. doi: http://dx.doi.org/10.1016/j.ejon.2013.0 4.006 braun, v., & clarke, v. (2006). using thematic analysis in psychology. qualitative research in psychology, 3, 77-101. doi: 10.1191/1478088706qp063oa burridge, l. h., barnett, a. g., & clavarino, a. m. (2009). the impact of perceived stage of cancer on caregivers’ anxiety and depression during the patients’ final year of life. psycho-oncology, 18, 615–623. doi: 10.1002/pon.1435 buyck, j.-f. m. d. m., bonnaud, s. m., boumendil, a. p., andrieu, s. m. d. p., bonenfant, s. m., goldberg, m. m. d. p., . . . ankri, j. m. d. p. (2011). informal caregiving and selfreported mental and physical health: results from the gazel cohort study. american journal of public health, 101(10), 1971-1979. chongsuvivatwong, v., phua, k. h., yap, m. t., pocock, n. s., hashim, j. h., chhem, r., . . . lopez, a. d. (2011). health and health-care systems in southeast asia: diversity and transitions. lancet, 377, 429-437. doi: doi:10.1016/s0140-6736(10)61507-3 fletcher, b. s., miaskowski, c., given, b., & schumacher, k. (2012). the cancer family caregiving experience: an updated and expanded conceptual model. european journal of oncology nursing, 16, 387-398. doi: 10.1016/j.ejon.2011.09.001 govina, o., kotronoulas, g., mystakidou, k., katsaragakis, s., vlachou, e., & patiraki, e. (2015). effects of patient and personal demographic, clinical and psychosocial characteristics on the burden of family members caring for patients with advanced cancer in greece. european journal of oncology nursing, 19, 81-88. doi: http://dx.doi.org/10.1016/j.ejon.2014.0 6.009 govina, o., vlachou, e., kavga-paltoglou, a., kalemikerakis, i., papageorgiou, d., fasoi, g., & patiraki, e. (2014). http://dx.doi.org/10.1016/j.ejon.2015.06.001 http://dx.doi.org/10.1016/j.ejon.2015.06.001 http://dx.doi.org/10.1016/j.ejon.2013.04.006 http://dx.doi.org/10.1016/j.ejon.2013.04.006 http://dx.doi.org/10.1016/j.ejon.2014.06.009 http://dx.doi.org/10.1016/j.ejon.2014.06.009 family process with breast cancer patient... (sarah kartika wulandari et.al.) 187 exploring the factors influencing time and difficulty of tasks provided by family caregivers of patients with advanced cancer in greece. health science journal, 8(4), 438-451. hopkinson, j. b. (2016). food connections: a qualitative exploratory study of weightand eating-related distress in families affected by advanced cancer european journal of oncology nursing, 20, 87-96. doi: http://dx.doi.org/10.1016/j.ejon.2015.0 6.002 jaafar, n. r. n., din, s. h. s., saini, s. m., ahmad, s. n. a., midin, m., sidi, h., . . . baharudin, a. (2014). clinical depression while caring for loved ones with breast cancer. comprehensive psychiatry, 55, s52-s59. doi: http://dx.doi.org/10.1016/j.comppsych .2013.03.003 jones, l. w., eves, n. d., haykowsky, m., freedland, s. j., & mackey, j. r. (2009). exercise intolerance in cancer and the role of exercise therapy to reverse dysfunction. the lancet oncology, 10, 598-605. doi: http://dx.doi.org/10.1016/s14702045(09)70031-2 kaakinen, j. r., gedaly-duff, v., coehlo, d. p., & hanson, s. m. h. (2010). family health care nursing : theory, practice, and research (4th ed.). united states of america: f. a. davis company. kaplan, s. a., madden, v. p., mijanovich, t., & purcaro, e. (2013). the perception of stress and its impact on health in poor communities. journal of community health, 38(1), 142-149. doi: http://dx.doi.org/10.1007/s10900012-9593-5 kardiyudiani, n. k. (2012). phenomenology study; hope of breast cancer patients who have chemotherapy about family support in cancer dharmais hospital jakarta. (master), university of indonesia, jakarta-indonesia. khanjari, s., langius-ekl€of, a., oskouie, f., & sundberg, k. (2014). family caregivers of women with breast cancer in iran report high psychological impact six months after diagnosis. european journal of oncology nursing, 1-6. doi: http://dx.doi.org/10.1016/j.ejon.2014.0 6.002 kumar, r. v., & bhasker, s. (2015). healthcare related supportive-care factors may be responsible for poorer survival of cancer patients in developing countries. journal of cancer policy, 5, 31-47. doi: http://dx.doi.org/10.1016/j.jcpo.2015.0 5.002 lee, k.-c., yiin, j.-j., & chao, y.-f. (2016). effect of integrated caregiver support on caregiver burden for people taking care of people with cancer at the end of life: a cohort and quasi-experimental clinical trial. international journal of nursing studies, 56, 17-26. doi: http://dx.doi.org/10.1016/j.ijnurstu.20 16.01.002 lee, y. s., akhileswaran, r., hock, m. o. e., wah, w., hui, d., ng, s. h.-x., & koh, g. (2017). clinical and sociodemographic predictors of home hospice patients dying at home: a retrospective analysis of hospice care association’s database in singapore. journal of pain and symptom management, 2017. doi: 10.1016/j.jpainsymman.2017.01.008 lobiondo-wood, g. (2008). theory of family stress and adaptation. in m. j. smith & p. r. liehr (eds.), middle range theory of nursing (2 ed., pp. 225-238). united state of america: springer publishing company, llc. lobiondo-wood, g. (2008). theory of family stress and adaptation middle range theory fo nursing (2 ed.). new york, usa: springer publishing company, llc. moffatt, s., noble, e., & white, m. (2012). addressing the financial consequences of cancer: qualitative evaluation of a welfare rights advice service. plos one, 7(8). doi: 10.1371/journal.pone.0042979 http://dx.doi.org/10.1371/journal.pone. 0042979 ng, c., pathy, n. b., taib, n., teh, y., mun, k., amiruddin, a., . . . yip, c. (2011). comparison of breast cancer in indonesia and malaysia – a clinicopathological study between dharmais cancer centre jakarta and university http://dx.doi.org/10.1016/j.ejon.2015.06.002 http://dx.doi.org/10.1016/j.ejon.2015.06.002 http://dx.doi.org/10.1016/j.comppsych.2013.03.003 http://dx.doi.org/10.1016/j.comppsych.2013.03.003 http://dx.doi.org/10.1016/s1470-2045(09)70031-2 http://dx.doi.org/10.1016/s1470-2045(09)70031-2 http://dx.doi.org/10.1007/s10900-012-9593-5 http://dx.doi.org/10.1007/s10900-012-9593-5 http://dx.doi.org/10.1016/j.ejon.2014.06.002 http://dx.doi.org/10.1016/j.ejon.2014.06.002 http://dx.doi.org/10.1016/j.jcpo.2015.05.002 http://dx.doi.org/10.1016/j.jcpo.2015.05.002 http://dx.doi.org/10.1016/j.ijnurstu.2016.01.002 http://dx.doi.org/10.1016/j.ijnurstu.2016.01.002 http://dx.doi.org/10.1371/journal.pone.0042979 http://dx.doi.org/10.1371/journal.pone.0042979 jurnal ners vol. 12 no. 2 oktober 2017: 180-188 188 malaya medical centre, kuala lumpur. asian pacific journal of cancer prevention, 12, 2943-2946. obrist, m., osei-bonsu, e., ahwah, b., watanabe-galloway, s., merajver, s. d., schmid, k., & soliman, a. s. (2014). factors related to incomplete treatment of breast cancer in kumasi, ghana. breast, 23(6), 821828. doi: 10.1016/j.breast.2014.08.014 papastavrou, e., charalambous, a., & tsangari, h. (2012). how do informal caregivers of patients with cancer cope: a descriptive study of the coping strategies employed. european journal of oncology nursing, 16(1), 258e263. doi: doi:10.1016/j.ejon.2011.06.001 parker, m., & smith, m. c. (2010). nursing theories and nursing practice (3 ed.). usa: f.a. davis company. potter, p. a., & perry, a. g. (2010). fundamental keperawatan (7 ed.). jakarta: salemba medika. regan, t., levesque, j. v., lambert, s. d., & kelly, b. (2015). a qualitative investigation of health care professionals', patients' and partners' views on psychosocial issues and related interventions for couples coping with cancer. plos one, 10(7). doi: 10.1371/journal.pone.0133837 http://dx.doi.org/10.1371/journal.pone. 0133837 rha, s. y., park, y., song, s. k., lee, c. e., & lee, j. (2015). caregiving burden and the quality of life of family caregivers of cancer patients: the relationship and correlates. european journal of oncology nursing, 2015, 1-7. doi: http://dx.doi.org/10.1016/j.ejon.2015.0 1.004 tachi, t., teramachi, h., tanaka, k., asano, s., osawa, t., kawashima, a., . . . goto, c. (2015). the impact of outpatient chemotherapy-related adverse events on the quality of life of breast cancer patients. plos one, 10(4). doi: 10.1371/journal.pone.0124169 http://dx.doi.org/10.1371/journal.pone. 0124169 taib, n. a., yip, c. h., ibrahim, m., cj, n., & farizah, h. (2007). breast cancer in malaysia : are our women getting the right message? 10 yearexperience in a single institution in malaysia. asian pacific journal of cancer prevention, 8, 141-145. townsend, m. (2008). essentials of psychiatric mental health nursing (4 ed.). usa: f. a. davis company. tsitsis, n., & lavdaniti, m. (2014). quality of life in women with breast cancer. international journal of caring sciences, 7(1), 38-42. vahidi, m., mahdavi, n., asghari, e., ebrahimi, h., ziaei, j. e., hosseinzadeh, m., . . . kermani, i. a. (2016). other side of breast cancer: factors associated with caregiver burden. asian nursing research, 10, 201-206. doi: http://dx.doi.org/10.1016/j.anr.2016.0 6.002 walshe, c., roberts, d., appleton, l., calman, l., large, p., lloydwilliams, m., & grande, g. (2017). coping well with advanced cancer: a serial qualitative interview study with patients and family caregivers. plos one, 12(1). doi: 10.1371/journal.pone.0169071http://d x.doi.org/10.1371/journal.pone.01690 71 who. (2014). indonesia world health organizationcancer country profiles (vol. 2014): who. zhang, q., yao, d., yang, j., & zhou, y. (2014). factors influencing sleep disturbances among spouse caregivers of cancer patients in northeast china. plos one, 9(10). doi: 10.1371/journal.pone.0108614 http://dx.doi.org/10.1371/journal.pone. 0108614 http://dx.doi.org/10.1371/journal.pone.0133837 http://dx.doi.org/10.1371/journal.pone.0133837 http://dx.doi.org/10.1016/j.ejon.2015.01.004 http://dx.doi.org/10.1016/j.ejon.2015.01.004 http://dx.doi.org/10.1371/journal.pone.0124169 http://dx.doi.org/10.1371/journal.pone.0124169 http://dx.doi.org/10.1016/j.anr.2016.06.002 http://dx.doi.org/10.1016/j.anr.2016.06.002 http://dx.doi.org/10.1371/journal.pone.0169071 http://dx.doi.org/10.1371/journal.pone.0169071 http://dx.doi.org/10.1371/journal.pone.0169071 http://dx.doi.org/10.1371/journal.pone.0108614 http://dx.doi.org/10.1371/journal.pone.0108614 http://e-journal.unair.ac.id/jners 169 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 169-175 http://dx.doi.org/10.20473/jn.v18i2.45799 original article open access the predictors need for complementary interventions using mobile application technology in women with breast cancer inggriane dewi 1 * , anggriyana tri widianti 1 , ariani fatmawati 1 , silfia wulandari 1 , and tita indah sarirudi 1 1 faculty of health, universitas 'aisyiyah bandung, bandung, indonesia *correspondence: inggriane dewi. address: faculty of health, universitas 'aisyiyah bandung, bandung, indonesia. email: inggriane.puspita@unisa-bandung.ac.id responsible editor: ferry efendi received: 29 may 2023 ○ revised: 24 june 2023 ○ accepted: 24 june 2023 abstract introduction: some women with breast cancer tend to have psycho-social stress, embarrassment from the disease’s treatment, and difficulty asking for help. furthermore, several studies indicate limited use of complementary online intervention in mental and spiritual health care, particularly when using mobile-based technologies. this study identifies the key factors that affect the need for mobile-app complementary interventions and the variables affecting them among indonesian breast cancer patients methods: a cross-sectional survey study with a simple random sampling technique included 112 patients between may and july 2022. the research instrument used is the quality of life-breast cancer questionnaire, functional assessment of chronic illness therapy–spiritual well-being (facit-sp), palliative performa scale version 2, and the need for complementary interventions using mobile-app technology (ncim) to measure predictors of the need for complementary interventions. meanwhile, multiple linear stepwise regression was used, and the potential multicollinearity effects among ncim predictive variables were assessed through the collinearity analysis of variable inflation factors results: the psychological-social dimension of quality of life and the faith–peace dimension of facit-sp (f =11.255; p = 0.001). the most strongly correlated variable is the psychological dimension (t = -3.35, p <0.001). conclusions: the key factors that affect the need for mobile-app complementary interventions and the variables affecting them among indonesian breast cancer patients are psychological and social dimensions of quality of life and faith and peace in the spiritual dimension. this study can provide the development of complementary intervention using mobile application technology. keywords: breast cancer, complementary intervention, mobile-app technology introduction women are having high risk to develop breast, colorectal, lung, cervical, and thyroid cancer (who, 2022). the prevalence has risen from 1.40/00 to 1.490/00 between 2013 and 2018. globocan data for 2020, the number of new cases of breast cancer reached 68,858 cases (16.6%) of a total of 396,914 new cases of cancer in indonesia. meanwhile, the number of deaths reached more than 22 thousand cases. west java is the 25th-ranking province, with 202 and 594 cervical and breast cancer cases reported in 2019 (center for data and information ministry of health republic indonesia, 2019). the breasts are a woman’s second sexual organ that enhances physical beauty. furthermore, breast cancer impacts self-image and produces psycho-social stress, including melancholy, inadequacy, sorrow, and embarrassment from the disease’s treatment (zhang et https://creativecommons.org/licenses/by/4.0/ mailto:inggriane.puspita@unisa-bandung.ac.id https://orcid.org/0000-0002-6731-507x https://orcid.org/0000-0002-9457-4149 https://orcid.org/0000-0002-7812-5685 https://orcid.org/0000-0003-1818-8649 https://orcid.org/0000-0001-6828-989x supremo, bacason, and sañosa (2022) jurnal ners 170 p-issn: 1858-3598  e-issn: 2502-5791 al., 2019). many women with breast cancer isolate themselves because they feel ashamed and cannot form meaningful relationships with others (najmabadi et al., 2014). therefore, sufferers tend to have difficulty asking for help, disrupting their quality of life. one of the objectives of healthcare providers is to actively manage patients’ disease and treatment-related health issues (santos et al., 2021). nurses need to think of holistic intervention strategies, including complementary interventions ones that safeguard their privacy (galutira, 2018). nurses and other healthcare professionals have thought about incorporating complementary interventions, such as acupuncture, music therapy, hypnosis, and massage therapy, into clinical practice to give their patients a more holistic treatment and care (anisa, erika and rachmawaty, 2018). the theory of unity by martha e. rogers stated that humans are open systems. they can be influenced by external factors (berman, snyder and frandsen, 2016), hence the role of nurses in influencing illness individuals with appropriate interventions is very important, because they value a holistic approach to health, nurses often have a positive attitude toward complementary and alternative medicine (elfaki, 2022). the discipline of ehealth (health informatics/medical informatics) is expanding globally as a result of recognition from renowned organizations like the world health organization, institute of medicine in the usa, and many others (qureshi, farooq and qureshi, 2021). mobile technology in nursing and ehealth has revolutionized how nurses execute interventions and interact with patients and other medical professionals (silva et al., 2018). it allows nurses to improve relationships with patients and families, systematize their job, and give advice on treatment. participation in health care positions nurses as consultants. and advisors, improving results, particularly in managing chronic diseases (nezamdoust, abdekhoda and rahmani, 2022). there are reports of considerable outcomes from several online therapies. meanwhile, people with ptsd and co-occurring depressive symptoms can benefit from internet cbt (sijbrandij, kunovski and cuijpers, 2016). numerous apps have beneficial, evidence-based components such as high-quality data, reliable measurements, and practical meditation techniques. mobile-app significantly improve mental health treatment in china (yin et al., 2020). indonesia has a very high need for mental health treatments due to a 500% growth in the internet between 2001 and 2015, 95% of whom are active smartphone users. mental health services might be employed for this issue (sukmawati et al., 2019). the indonesian government issued a decree of the minister of health regarding the policy of using e-health, where e-health is very supportive from planning, implementing, and evaluating health programs in indonesia (ministry of health of the republic of indonesia, 2022). several studies indicate that there is still limited use of complementary intervention in health care, particularly when using mobile-app technologies (gijsberts et al., 2019). this concerns the requirements for getting this intervention, which is unclear. predictors and status of the need for mobile-app complementary interventions should be determined first, referring to the quality of life and the functional assessment of chronic illness therapy. this cross-sectional descriptive study was created with the goals of (a) assessing the status of the need for mobile-app complementary interventions in indonesian women with breast cancer and (b) identifying the key factors affecting the status of needs in this population. this study aimed to examine the need for mobile-app complementary interventions and the variables affecting the concept among indonesian breast cancer patients. to aid in the development of complementary types of mobile-app interventions, it is critical to identify the key factors relating to the state of this demand. for nurses, this study provides information about the needs of women with breast cancer for complementary interventions utilizing technology, which focus on the quality of life domain. materials and methods research design the study design used a cross-sectional study to identify the predictors of the need for complementary interventions for mobile-app technology. setting and samples the outpatient and inpatient oncology department of a teaching hospital in bandung served as the recruitment site for this cross-sectional survey. the populations consist of 1,433 women who had breast cancer at al-ihsan hospital bandung in the last 6 months. sample calculation was obtained using the slovin formula n = n / (1 + (n x e²)), with a tolerance degree of 10% (sugiyono, 2017). about 112 participants were selected by simple random sampling, n (number of population): n (sample). the interval is 1433 people: 112 people = 13, then the member of the population affected by the sample is every person's name that has a multiple of 13 serial number who met the inclusion dewi, widianti, fatmawati, wulandari, and sarirudi (2023) http://e-journal.unair.ac.id/jners 171 criteria, were at least 18 years old, with a minimum palliative performa scale version 2 (ppsv2) score of 60%, and could give a signed agreement. breast cancer recurrence history, severe organ dysfunction, and inability to read or write indonesian were all grounds for exclusion criteria. measurement and data collection the demographic questionnaire includes age (early adult (26 – 35 years), late adult (>35-45 years), early elderly (>45-55 years) and late elderly (>55 years)), occupation (employee and unemployed), education (elementary, junior high school, senior high school and university), co-morbidities (present and absent), illness period (<1 year, >1 – 2 year, >2 year) , type of therapy (surgery; chemotherapy; surgery and chemotherapy; surgery, radiation, and chemotherapy; surgery and radiation), the habit of taking herbal supplements (yes or no), and cancer stage ( i, ii, iii and iv). the quality of life (qol) has been recognized as a subjective measurement reported by patients of the health status of breast cancer women. this instrument is adapted from the quality of life-breast cancer questionnaire (ferrell, dow and grant, 2012) with indonesian language adjustment and has 38 statement items covering the physical, psychological, social, and spiritual domains. the spiritual domain leads to the participants’s spiritual position based on beliefs. the questionnaire’s validity test produced the results of r = 0.361 and 0.938 for cronbach’s alpha, and the instrument uses a scale of 1 to 10. score calculation was obtained by adding all items in the subscale and making an average score. each quality of life domain will also be calculated separately. subsequently, the total score is categorized based on the calculation of the predetermined category. quality of life score categories is 0 – 19% (very poor), 20 – 39% (p,oor) 40 – 59% (enough), 60 – 79% (good) and 80 – 100% (very good). the 12-item spiritual wellbeing scale (facit-sp-12) is the most widely used tool for measuring spiritual wellbeing among those with cancer. the facit-sp distinguishes between meaning, peace, and faith (arnold, bredle and lent, 2021). the version’s construct validity and reliability (α cronbach = 0.931) consist of 10 statements with a likert scale. the lowest and highest scores are 0 and 48. meanwhile, facit-sp categories are low < mean score and high ≥ mean score. palliative performance scale version 2 an instrument for swiftly communicating individuals’ present functional level is the palliative performance scale (ppsv2) version 2, which provides more common terminology to describe the status. the ppsv2 measures ambulation, activity and signs of disease, self-care, intake, and conscious level using five observer-rated dimensions. dependability for the pps between the two groups with an absolute intraclass correlation coefficient of 0.959 (society, 2009; cleary, 2015). questionnaire was made referring to the supportive care needs survey (scns) (macleduff et al., 2004) and the acceptability of mental health mobile app survey (amms) (sukmawati et al., 2019), which has 10 statement items covering the physical, social, psychological and spiritual dimension. the validity instrument is 0.377, with a cronbach alpha score of 0.836. the instrument uses a likert scale, and the status of the need categories are low < mean score and high ≥ mean score. the efforts to minimize bias are to make the questionnaire short and easy to understand and set the time for the survey. therefore, filling out the questionnaire is only about 10-15 minutes, informing participants that the survey is short. the participants should be informed that the poll is anonymous and responses will not have any consequences for the continuity of treatment data collection data collection was done through 1) sample selection, using samples from teaching hospitals in bandung, the ppsv2 observation sheet identified eligible table 1. distribution frequencies characteristics of participants (n=112) characteristics n (%) mean sd age 50 10,4 early adult (26 – 35 years) 3 3 late adult (>35-45 years) 30 27 early elderly (>45-55 years) 51 46 late elderly (>55 years) 28 25 work employee 19 17 unemployed 93 83 education elementary 41 37 junior high school 27 24 senior high school 33 29 university 11 10 cancer stadium i 4 4 ii 54 48 iii 44 39 iv 10 9 comorbid present 13 12 absent 99 88 illness period < 1 year 35 31 ≥ 1 s.d 2 year 13 12 > 2 year 64 57 therapy surgery 17 15 chemotherapy 30 27 surgery and chemotherapy 53 47 surgery, radiation, and chemotherapy 9 8 surgery and radiation 3 3 *spearmen correlation supremo, bacason, and sañosa (2022) jurnal ners 172 p-issn: 1858-3598  e-issn: 2502-5791 participants. 2) provide informed consent for all participants after the study’s objectives and the confidentiality principle are stated. 3) meanwhile, enumerators followed the standard instructions, assisting with item-by-item questioning and objectively documenting answers. there were 112 individuals recruited, and the participants’ completed questionnaire has no missing data. data analysis data analysis was conducted using ibm spss statistics, version 22.0 (ibm, armonk, ny, usa). descriptive analysis was performed using mean, standard deviation, and distribution statistics for the survey’s participant characteristics and each subscale. furthermore, pearson correlation analysis was used to determine the impact of patient factors on ncim scores. multiple linear stepwise regression was used to identify the variables affecting ncim in breast cancer patients. the potential multicollinearity effects among predictive variables were assessed using the collinearity analysis of variable inflation factors. ethical consideration the ethical test is performed with the letter number 123/kep. 01/unisa-bandung/iii/2022. patients who agreed to take part signed written consent papers and received guarantees of their confidentiality and anonymity results participant characteristics table 1 shows that the average age of the participants was 50 years (sd = 10.4), more at stage ii (n = 54.48%), received types of surgery and radiation therapy (n = 53.47%) and a period of cancer more than 2 years (n=64.57%). about 83% or 93 individuals unemployed, with the highest education level being elementary at 37%. the correlation between continuous variables and the need for complementary interventions using mobil application (ncim) table 2 shows the mean score ncim 25.17 at an sd of 8.57. about 56% or 63 participants have high needs for complementary interventions using mobel application. meanwhile, 57% or 64 had a poorer quality of life than other categories, but 51% or 57 had high spiritual well-being. based on table 3 below, social (r = -2.42, p = 0.010) and psychological dimensions (r = -3.05, p = 0.001) of the quality of life of cancer patients have a significant relationship with ncim. the facit-sp dimension faith (r = 0.066, p = 0.489) and peace (r = 0.065, p = 0.049) have a relationship with ncim, while age and ppsv2 were not associated with ncim. according to table 4, the f value 11.255 with a probability of 0.001 (<0.05) shows that the regression coefficient of the quality of life and the facit-sp dimension simultaneously affect the ncim. psychological dimensions (t = -3.35 p = < 0.001) of life have a very significant influence on participants in their needs for complementary interventions using mobile app technology (ncim). furthermore, there is no linear relationship between the independent variables influenced by the dependent variable (vif<10). table 2. variables scores and categories variables mean sd min max ncim 25,17 8,57 10 40 subscales ncim physical dimension 5.10 1.97 2 8 social dimension 4.47 1.64 2 8 spiritual dimension 10.34 3.76 4 16 psychological dimension 5.26 2.08 2 8 ncim categories n % low 49 44 high 63 56 qol categories n % very poor 28 25 poor 36 32 enough 25 22 good 22 20 very good 1 1 facit-sp categories n % low 55 49 high 57 51 table 3. correlation between continuous variables and need complementary interventions using mobil application (ncim) (n = 112) variables mean sd r p age 50 10.04 0,129 0,175 quality of life physical dimension 29.57 14.75 -0.168 0.077 social dimension 47.63 18.43 -2.42 0.010 spiritual dimension 38.91 8.64 -0.246 0.009 psychological dimension 97.89 32.66 -3.05 0.001 facit-sp meaning 8.92 2.28 0.021 0.830 faith 10.29 3.75 0.066 0.489 peace 8.50 2.48 0.065 0.049 ppsv2 74.82 13.01 0.108 0.256 pearson correlation, correlation is significant at the 0.05 level (2tailed) dewi, widianti, fatmawati, wulandari, and sarirudi (2023) http://e-journal.unair.ac.id/jners 173 discussions the key factors that affect the need for mobile-app complementary interventions and the variables affecting them among indonesian breast cancer patients are psychological and social dimensions of quality of life and faith and peace in the spiritual dimension. this study can provide the development of complementary intervention using mobile application technology. breast cancer causes psycho-social stress, which includes depression, a sense of inadequacy, sorrow, and shame due to the disease’s treatment. previous studies show that cancer mortality was predicted by psychological discomfort. community-based cohorts, including participants with a history of cancer, may exaggerate the relationship between psychological distress and subsequent mortality (hamer, chida and molloy, 2009). socioeconomic challenges, limited access to supportive treatment, late breast cancer diagnosis, self-perception of the disease, social restraints, and other religious/cultural restrictions are potential factors contributing to the projected discrepancy (haidari et al., 2020). health professionals can use technology to provide complementary interventions for patients because of face-to-face limitations with health workers. most women with breast cancer need complementary interventions based on mobile technology, which has no relationship with the characteristics, as shown in table 1. the nmci questionnaire is an instrument created to identify the need for complementary therapies based on mobile technology to support cancer patient’s physical, psychological, spiritual, and social health. similar studies include internet technology in providing interventions to improve the life of cancer patients, such as research about telehealth medicine. a telemedicine intervention was linked to improved selfefficacy and decreased depression (chen et al., 2018). other studies stated that web-based psycho-social oncology programs successfully lowered stress and depression (leslie et al., 2022). psycho-social problems of breast cancer patients tend to be depressive symptoms such as being down, empty, dismal, and gloomy (velosa, caldeira and capelas, 2017). in addition to being irritated or moody, they may find it difficult to cry or weep without severe precipitation and emotional distress (veeraiah, kayser and sudhakar, 2022). according to previous research, fear of the sickness progressing, inability to engage in one’s interests, and having to revisit the hospital are the three most common causes of psycho-social problems in breast cancer patients (herschbach et al., 2004). poor mental health can affect the immune system and cause the manifestation of distressing somatic symptoms (zapała et al., 2022). a major component of spiritual suffering is a lack of meaning in life, which appears to be connected to depression. spirituality significantly impacts the quality of life and psychological well-being after accounting for a health state. most spirituality assessments include the religious and existential components (levine and targ, 2003). however, faith and peace affect the need for mobile-app complementary interventions, but most participants always worship as their religious activity. the possible reason for the correlation between faith and peace with ncim is that it encourages patients to seek support through complementary interventions. this is based on mobile app in accepting the possibility of physical disability and other negative effects of breast cancer. a similar study stated that the positive influence on breast cancer patient’s quality of life (qol) is spiritual well-being (spwb). spwb is not always limited to a particular type of behavior or idea. the meaning, purpose, fulfillment, and peace experienced in life stem largely from their faith in themselves, others, and god (yilmaz and cengiz, 2020). furthermore, spiritual welltable 4. multivariate regression analysis predicting ncim scores (n = 112) model b β t p vif step 1 (constant) 31.69 8.10 0.00 qol_psychologis -0.07 -0.265 -2.21 0.03 1.714 qol_social -0.03 -0.064 -0.52 0.60 1.778 facitsp_faith 0.10 0.043 0.33 0.74 2.007 facitsp_peace 0.08 0.024 0.19 0.85 1.930 step 2 (constant) 32.01 9.16 0.00 qol_psychologis -0.07 -0.266 -2.23 0.03 1.713 qol_social -0.03 -0.063 -0.52 0.60 1.778 facitsp_faith 0.14 0.059 0.63 0.53 1.075 step 3 (constant) 31.33 9.69 0.00 qol_psychologis -0.08 -0.306 -3.36 0.00 1.000 facitsp_faith 0.17 0.072 0.79 0.43 1.000 step 4 (constant) 33.00 13.42 0.00 qol_psychologis -0.08 -0.305 -3.35 <0.001 1.000 dependent variable: ncim (need complementary interventions using moble application), vif = variable inflation factor. r2 = .093, adjusted r2 = .085 f = 11,255 (p = 0,001) supremo, bacason, and sañosa (2022) jurnal ners 174 p-issn: 1858-3598  e-issn: 2502-5791 being is linked to lower anxiety and sadness and a higher quality of life (chen et al., 2021). nurses need to consider complementary interventions based on the mobile app to support the psychosocial dimension and also spiritual well-being, especially faith and peace, in women with breast cancer. therefore, breast cancer patients have a good quality of life characterized by good mental and social health. conclusion women with breast cancer who participated in this study had a need for ncim. furthermore, predictors that were found to affect the level of need are the psychological-social dimension of quality of life and faith-peace facit-sp. the results suggest that an effective mobile-app-based complementary intervention model should be developed based on these dimensions. in clinical practice, the nurse team should pay special attention to patients with low quality-of-life scores and poor spiritual well-being. they should organize support activities, including family members, patient colleagues, friends, and clinical staff. furthermore, nurses should provide various complementary therapies to help patients develop healthy coping mechanisms. the findings also point out a positive direction, recommending that research nurses collaborate closely with information technology specialists to create complementary therapies appropriate for mobile-app. complementary interventions that might be developed are guided spiritual mindfulness through mobile applications. the technology used needs to be considered in patients who are often senile. acknowledgement acknowledgments to education council center for research and development center muhammadiyahyogyakarta, the institute for research and community service at the university of 'aisyiyah bandung and all participants involved in this research. funding source the authors thank the muhammadiyah's council for higher education research and development (cherd) for its generous financing support provided through program hibah risetmu. conflict of interest the absence of any conflicts of interest between the subjects and the researcher is ensured by this study. no ties to family, relatives, or other relationships will have an impact on the study's outcomes. references anisa, n. r., erika, k. a. and rachmawaty, r. (2018) ‘nurse’s spiritual care competencies to patient with end stage breast cancer’, journal of public health, 7(4), pp. 268–273. doi: 10.11591/ijphs.v7i4.14742. arnold, b., bredle, j. and lent, l. (2021) facit-sp: functional assessment of chronic illness therapy spiritual well-being, facit.org. available at: https://www.facit.org/measures/facit-sp (accessed: 30 july 2022). berman, a., snyder, s. and frandsen, g. (2016) kozier and erb’s fundamentals of nursing: concepts, process and practice. 10th edn, nurse education in practice. 10th edn. boston: pearson. doi: 10.1016/j.nepr.2011.09.002. center for data and information ministry of health republic indonesia (2019) the burden of cancer in indonesia, center for data and information ministry of health republic indonesia. jakarta. available at: https://pusdatin.kemenkes.go.id. chen, j. et al. (2021) ‘association between spiritual well-being, quality of life, anxiety and depression in patients with gynaecological cancer in china’, medicine, 100(1), p. e24264. doi: 10.1097/md.0000000000024264. chen, y.-y. y. et al. (2018) ‘effect of telehealth intervention on breast cancer patients’ quality of life and psychological outcomes: a meta-analysis’, journal of telemedicine and telecare, 24(3), pp. 157–167. doi: https://doi.org/10.1177/1357633x16686777. cleary, t. a. (2015) ‘the palliative performance scale (ppsv2) version 2.’, try this: best practices in nursing care to older adults, (32), pp. 1–2. doi: 10.1186/1472-684x-7-10.institute. elfaki, b. a. (2022) ‘perspectives on complementary and alternative medicine: the role of nurses and health care providers: a review’, journal of positive school psychology, 6(4), pp. 5978–5984. ferrell, b., dow, k. h. and grant, m. (2012) ‘quality of life instrument breast cancer patient version (qol-bc)’, measurement instrument database for the social science. available at: www.midss.ie. galutira, g. d. (2018) ‘theory of reflective practice in nursing’, international journal of nursing science, 8(3), pp. 51–56. doi: 10.5923/j.nursing.20180803.02. gijsberts, m.-j. h. e. et al. (2019) ‘spiritual care in palliative care: a systematic review of the recent european literature’, medical sciences, 7(2), p. 25. doi: 10.3390/medsci7020025. haidari, r. el et al. (2020) ‘factors associated with health-related quality of life in women with breast cancer in the middle east: a systematic review’, cancers, 12(3), pp. 1–19. doi: 10.3390/cancers12030696. hamer, m., chida, y. and molloy, g. j. (2009) ‘psychological distress and cancer mortality’, journal of psychosomatic research, 66(3), pp. 255–258. doi: 10.1016/j.jpsychores.2008.11.002. herschbach, p. et al. (2004) ‘psychological problems of cancer patients: a cancer distress screening with a cancer-specific questionnaire’, british journal of cancer, 91(3), pp. 504–511. doi: 10.1038/sj.bjc.6601986. leslie, m. et al. (2022) ‘web-based psychological interventions for people living with and beyond cancer: a meta-review of what works and what doesn’t for maximising recruitment, engagement, and efficacy (preprint)’, jmir cancer, 8. doi: 10.2196/36255. dewi, widianti, fatmawati, wulandari, and sarirudi (2023) http://e-journal.unair.ac.id/jners 175 levine, e. g. and targ, e. (2003) ‘spiritual correlates of functional wellbeing in women with breast cancer’, integrative cancer therapies, 1(2), pp. 166–174. doi: 10.1177/1534735402001002008. macleduff, p. et al. (2004) ‘supportive care needs survey : a guide to administration , scoring and analysis’, australia: university of new castle, (january). ministry of health of the republic of indonesia (2022) decree of the minister of health of the republic of indonesia concerning the implementation of an electronic-based government system in the health sector and transformation strategy digital kesehatan. indonesia. available at: https://yankes.kemkes.go.id/unduhan/fileunduhan_1669623021 _65288.pdf. najmabadi, k. m. et al. (2014) ‘self-disclosure of breast cancer diagnosis by iranian women to friends and colleagues’, asian pacific journal of cancer prevention, 15(6), pp. 2879–2882. doi: 10.7314/apjcp.2014.15.6.2879. nezamdoust, s., abdekhoda, m. and rahmani, a. (2022) ‘determinant factors in adopting mobile health application in healthcare by nurses’, bmc medical informatics and decision making, 22(1), pp. 1–10. doi: 10.1186/s12911-022-01784-y. qureshi, muhammad mudassar, farooq, a. and qureshi, muhammad mazhar (2021) ‘current ehealth challenges and recent trends in ehealth’. lahore, pp. 1–11. available at: http://arxiv.org/abs/2103.01756. santos, a. d. et al. (2021) ‘oncology patients’ experiences with novel electronic patient portals to support care and treatment: qualitative study with early users and nonusers of portals in alberta, canada’, jmir cancer, 7(4). doi: 10.2196/32609. sijbrandij, m., kunovski, i. and cuijpers, p. (2016) ‘effectiveness of internet-delivered cognitive behavioral therapy for posttraumatic stress disorder: a systematic review and metaanalysis’, depression and anxiety, 33(9), pp. 783–791. doi: 10.1002/da.22533. silva, a. m. de a. et al. (2018) ‘mobile technologies in the nursing area’, revista brasileira de enfermagem, 71(5), pp. 2570–2578. doi: 10.1590/0034-7167-2017-0513. society, v. h. (2009) palliative performance scale. sugiyono (2017) metodologi penelitian kuantitatif, kualitatif dan r&d quantitative, qualitative and r&d research methodology. bandung: alfabeta. sukmawati, i. et al. (2019) ‘development and validation of acceptability of mental-health mobile app survey (amms) for android-based online counseling service assessment’, journal of physics: conference series, 1339(1), pp. 1–8. doi: 10.1088/17426596/1339/1/012124. veeraiah, s., kayser, k. and sudhakar, r. (2022) ‘psychosocial factors influencing distress among cancer patients in south india’, journal of psychosocial oncology research & practice, 4(1), p. e067. doi: 10.1097/or9.0000000000000067. velosa, t., caldeira, s. and capelas, m. l. (2017) ‘depression and spiritual distress in adult palliative patients: a cross-sectional study’, religions, 8(8), pp. 1–19. doi: 10.3390/rel8080156. who (2022) cancer. available at: https://www.who.int/healthtopics/cancer#tab=tab_1. yilmaz, m. and cengiz, h. ö. (2020) ‘the relationship between spiritual well-being and quality of life in cancer survivors’, palliat support care, 18(1), pp. 55–62. doi: 10.1017/s1478951519000464. yin, h. et al. (2020) ‘mobile mental health apps in china: systematic app store search’, journal of medical internet research, 22(7), pp. 1–14. doi: 10.2196/14915. zapała, j. et al. (2022) ‘the needs of cancer patients during the covid19 pandemic — psychosocial, ethical and spiritual aspects — systematic review’, peer journal, 10(e), p. 13480. doi: 10.7717/peerj.13480. zhang, q. et al. (2019) ‘psychosocial predictors of adjustment to disability among patients with breast cancer: a cross-sectional descriptive study’, journal of nursing research, 27(2), pp. 1–7. doi: 10.1097/jnr.0000000000000283. how to cite this article: dewi, i., widianti, a. t., fatmawati, a., wulandari, s. and sarirudi, t. i. (2023) ‘the predictors need for complementary interventions using mobile application technology in women with breast cancer’, jurnal ners, 18(2), pp. 169-175. doi: http://dx.doi.org/10.20473/jn.v18i2.45799 pengaruh peer group support terhadap tingkat depresi wanita menopause peer group support menurunkan tingkat depresi wanita menopause (peer group support decrease depression level in menopause woman) ahmad yusuf*, ni ketut alit a*, deka hardiyan* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: yusuf@fk.unair.ac.id. abstract introduction: menopause woman has higher depression level than pre and postmenopause woman. many woman who are getting menopause will feel lonely and don’t have any friends to talk, if this situation continue it can cause menopausal depression. peer group support is one of group therapy which gives opportunity to menopause woman to get mutual support and help them to face the problem. this aimed of this study was to analyze the effect of peer group support in the menopause woman depression level. method: a quasy experimental pre-post test design was used in this study. there were 16 menopause women taken from cepokomulyo kepanjen. the independent variable was peer group support and the dependent variable was the depression level. data were analyzed by wilcoxon signed rank test and mann whitney u test with the significance level α<0.05. result: result showed that there was an effect of peer group support in the menopause woman depression level with significance level p=0.011 (treatment group) and p=0.23 (controlled group) and the result of mann whitney u test showed that p=0.02. discussion: it can be concluded that peer group support can reduce the menopause woman depression level. it can be suggested to the institutional to practice peer group support to help menopause woman reduce their depression level. keywords: peer group support, depression level, menopause woman pendahuluan perhatian terhadap menopause saat ini semakin besar seiring dengan meningkatnya usia harapan hidup (uhh) wanita. uhh yang mencapai 70 tahun menyebabkan hampir sepertiga usia wanita dijalani dalam masa perimenopause dan paskamenopause karena masa ini terjadi sekitar usia 50 tahun (kusumawardhani, 2006). menopause adalah proses alami dari penuaan, ketika wanita tidak lagi mendapatkan haid selama 1 tahun. rerata wanita mengalami menopause pada usia sekitar 50 tahun (sutanto dan sutanto, 2007). menopause berlangsung pada masa sekitar perimenopause. perimenopause merupakan periode terjadi berbagai keluhan yang memuncak dengan rentang 1-2 tahun sebelum dan sesudah menopause (kasdu, 2004). pengamatan epidemiologis menunjukkan 50-85% wanita di awal masa perimenopause mengalami berbagai keluhan akibat berkurangnya produksi esterogen (darmojo dan martono, 2006). gambaran klinis dari defisiensi esterogen dapat berupa gangguan neurovegetatif, gangguan psikis dan gangguan somatik. gambaran psikis dapat muncul dalam bentuk mudah tersinggung, depresi, kelelahan, semangat berkurang dan susah tidur (jacoeb, 2005). kriteria depresi sama untuk semua jenis kelamin. wanita lebih mudah merasakan perasaan bersalah, cemas, peningkatan bahkan penurunan nafsu makan, gangguan tidur serta gangguan makan. wanita mengalami depresi satu setengah sampai dua kali dibandingkan pria (hapsari, 2007). wanita perimenopause memiliki tingkat depresi lebih tinggi daripada wanita pramenopause dan paskamenopause (parry, 2008). penatalaksanaan depresi menurut dharmono (2000) ada 2, yaitu terapi psikososial dan terapi biologik. terapi psikososial antara lain konseling dan terapi kelompok. terapi kelompok dapat berupa terapi aktivitas kelompok (tak) dan peer group support (pgs). peer group support adalah suatu dukungan yang diberikan oleh kelompok untuk membantu anggota dalam menghadapi masalah seperti gangguan, stres mailto:yusuf@fk.unair.ac.id http://www.litbang.depkes.go.id/ jurnal ners vol.3 no.1 april 2008 : 61-66 atau masalah emosional lainnya. bantuan yang diberikan berupa pemberian informasi tentang masalah yang dialami anggota dikaitkan dengan pengalaman anggota kelompok yang lain dengan cara saling mendengarkan dan menerima satu sama lain. di kelurahan cepokomulyo kepanjen malang, pengaruh peer group support terhadap tingkat depresi wanita menopause masih belum dapat dijelaskan. sindroma menopause dialami oleh banyak wanita hampir di seluruh dunia yaitu sekitar 70-80% di eropa, 60% di amerika, 57% di malaysia, 18% di cina, dan 10% di jepang dan indonesia (urnobasuki, 2003). rerata wanita memasuki masa menopause berbeda pada setiap ras, walaupun dalam satu ras tidak sama pada setiap orang. perempuan ras asia mengalami menopause pada usia 44 tahun, sementara perempuan eropa sekitar usia 47 tahun (yatim, 2001; dalam kasdu, 2004). di indonesia usia menopause berkisar antara 48-53 tahun (andra, 2007). jumlah penduduk indonesia pada tahun 2020 diperkirakan mencapai 262,6 juta jiwa dengan jumlah perempuan yang hidup dalam usia menopause sekitar 30,3 juta jiwa (departemen kesehatan ri, 2005). berdasarkan data statistik indonesia (2005) menunjukkan jumlah penduduk propinsi jawa timur yaitu secara keseluruhan adalah 2.336.363 orang. wanita yang berusia 45-54 tahun di kabupaten malang berjumlah 141.750 orang (departemen kesehatan ri, 2005). studi pendahuluan yang dilakukan di kelurahan cepokomulyo kepanjen malang pada bulan mei 2008, diperoleh data jumlah penduduk sekitar 6696 orang dengan jumlah wanita 3342 orang. wanita usia subur (wus) dengan usia 15-49 tahun berjumlah 1756 orang dan wanita yang berusia 45-55 tahun sekitar 597 orang. wawancara yang dilakukan peneliti terhadap 10 orang penduduk dengan rentang usia 45-55 tahun di kelurahan cepokomulyo kepanjen malang, ditemukan bahwa 5 orang dari mereka mengalami beberapa keluhan menopause yaitu sulit tidur, sakit kepala, mudah lelah, rasa panas didaerah muka, berkeringat di malam hari, dan gangguan mood yang membuat mereka mudah tersinggung atau marah. berbagai keluhan yang dialami tersebut kebanyakan tidak disadari dan dianggap wajar oleh sebagian penduduk. perubahan mood, iritabilitas, ansietas dan depresi seringkali dihubungkan dengan masa perimenopause. pada masa ini wanita secara emosional merasa lebih labil, gugup atau gelisah (bobak, et al., 2005). penelitian yang dilakukan choirah (2004) dalam kusumawardhani (2006), menemukan bahwa ada hubungan antara penurunan kadar esterogen dengan perubahan mood yang terjadi pada masa perimenopause. sebanyak 37,9% perempuan perimenopause dengan penurunan kadar esterogen mengalami depresi. kadar esterogen yang rendah memiliki risiko untuk menjadi depresi 3,7 kali lebih besar dibandingkan dengan yang tidak mengalami penurunan esterogen. wanita yang mencapai usia sekitar 45 tahun akan mengalami penuaan indung telur sehingga tidak sanggup memenuhi kebutuhan hormon esterogen. sistem hormonal di seluruh tubuh akan mengalami kemunduran dalam mengeluarkan hormon. terjadi kemunduran pada kelenjar tiroid dengan hormon tiroksin yang berfungsi untuk metabolisme umum, kemunduran kelenjar paratiroid yang mengatur metabolisme kalsium dan terdapat pula peningkatan fsh dan lh. perubahan pengeluaran hormon yang terjadi menyebabkan berbagai perubahan pada fisik dan psikis (manuaba, 1998). penurunan hormon esterogen menyebabkan peningkatan enzim monoamin oksidase (mao). enzim ini membuat serotonin dan noradrenalin menjadi tidak aktif. berkurangnya aktivitas serotonin di otak menyebabkan terjadinya depresi pada wanita yang mengalami penurunan esterogen (baziad, 2003). perasaan depresi pada wanita menopause juga dapat disebabkan oleh faktor psikososial dan kultural. faktor psikososial berupa kehilangan kemampuan bereproduksi, ditinggal anak-anak dan penyesuaian peran baru. faktor kultural dihubungkan dengan cara pandang dan penerimaan wanita terhadap menopause serta gejalanya (chait, 2008). keluhan akibat perubahan fisik dan psikis dapat mengganggu kesehatan dan kualitas hidup wanita pada saat menopause terjadi (kasdu, 2004). kelompok dapat menjadi tempat yang sangat berguna bagi wanita untuk membicarakan masalah yang terjadi karena menopause, untuk menilai kembali pengalaman dan kesuksesan masa lalu, serta sebagai modal untuk menatap masa depan peer group support (ahmad yusuf) (hunter, 1996). kelompok pendukung berfungsi memberikan bimbingan dalam mengatasi masalah kehidupan yang mengganggu terkait dengan diagnosa dan pengobatan (nurachmah, 1999). hubungan dengan banyak wanita seusia, yaitu setengah baya dan tua, yang mempunyai strategi positif, humor, harga diri, imajinasi dan ketetapan hati, dapat mengubah pandangan seorang wanita (o’brien, 1994). seorang wanita yang mengalami menopause membutuhkan pengertian emosi dan dukungan praktis dari orang lain (maulana, 2005). menurut randall (2003) peer group support adalah tempat bagi seseorang untuk saling memberi dan mendapatkan dukungan secara emosi dan praktis dengan cara bertukar informasi. bahan dan metode penelitian ini menggunakan quasy experiment purposive sampling design. populasi target pada penelitian ini adalah wanita menopause yang berusia antara 45-55 tahun di kelurahan cepokomulyo kepanjen malang. sampel dalam penelitian ini 16 orang yang dibagi menjadi 8 orang kelompok perlakuan (peer group support) dan 8 orang kelompok kontrol. variabel independen pada penelitian ini adalah peer group support, sedangkan variabel dependen adalah tingkat depresi wanita menopause. instrumen yang digunakan untuk mengukur tingkat depresi adalah beck depression inventory-ii (bdi-ii) yang diberikan sebelum dan setelah intervensi peer group support. bdi-ii berisi tentang 21 pertanyaan yang berhubungan dengan karakteristik depresi (beck, 1996). seluruh nilai dari 21 pertanyaan tersebut akan dijumlahkan dan dicocokkan dengan skoring tingkat depresi bdi-ii, yaitu: depresi minimal (0-13), depresi ringan (14-19), depresi sedang (20-28) dan depresi berat (2963) (chait, 2008). analisis data menggunakan wilcoxon sign rank test dan mann whitney u test dengan tingkat kemaknaan nilai p≤0,05. hasil pada tabel 1 tampak perbedaan tingkat depresi antara responden yang diberikan perlakuan berupa peer group support dengan yang tidak. terdapat perubahan tingkat depresi pada kelompok perlakuan sebelum dan sesudah dilakukan peer group support dengan hasil analisis statistik wilcoxon signed rank test dengan nilai signifikansi p=0,011. pada kelompok kontrol tidak ditemukan perubahan tingkat depresi yang bermakna sebelum dan sesudah peer group support dengan nilai signifikansi p=0,23. terdapat perbedaan antara kelompok perlakuan dan kelompok kontrol dengan hasil analisis statistik mann whitney u test diperoleh nilai signifikansi p=0,02. pembahasan tingkat depresi responden sebelum peer group support berada pada tingkat depresi minimal, depresi ringan, dan depresi sedang baik pada kelompok perlakuan maupun kontrol. tingkat depresi dipengaruhi oleh penerimaan responden terhadap berbagai perubahan yang terjadi pada masa menopause. hasil penilaian tingkat depresi pada setiap kelompok dengan menggunakan kuisioner bdi-ii ini adalah menyatakan kehilangan kebahagiaan, agitasi, kesulitan dalam pengambilan keputusan dan kehilangan energi. kondisi mutlak yang dialami seluruh responden meliputi perubahan pola tidur, perubahan nafsu makan, kelelahan atau kelemahan dan kehilangan gairah seksual. depresi menopause merupakan penyakit komplikasi yang disebabkan karena banyak hal yang terjadi pada kehidupan setengah baya (dowling, 2006). masa menopause sering bertepatan dengan keadaan menegangkan dalam kehidupan wanita seperti merawat orang tua lanjut usia, melihat anak-anak tumbuh dewasa dan meninggalkan rumah, serta berbagai penyesuaian lain dalam kehidupan setengah baya. ketegangan ini dapat menimbulkan gejala pada fisik dan emosi, termasuk menjadi pelupa, kurang dapat memusatkan perhatian, kecemasan, sifat mudah marah dan depresi, yang secara keliru dianggap sebagai akibat dari menopause (maulana, 2005). keluhan pada wanita menopause yang berusia antara 45-54 tahun menurut baziad (2003) antara lain mudah tersinggung, merasa takut, gelisah, dan lekas marah (90%), gelora panas (hot jurnal ners vol.3 no.1 april 2008 : 61-66 flushes) (70%), sakit kepala (70%), depresi (70%), cepat lelah, sulit konsentrasi, mudah lupa, kurang bertenaga (65%), berat badan bertambah (60%), gangguan tidur (50%), nyeri tulang dan otot (50%), jantung berdebar-debar (40%), obstipasi (40%), gangguan libido (30%), kesemutan (25%), dan berkunang-kunang (20%). berbagai keluhan menopause memuncak pada usia 1-2 tahun sebelum dan sesudah menopause (kasdu, 2004). banyak wanita yang mengalami menopause merasa sangat kesepian dan tidak mempunyai teman untuk diajak bicara atau dimintai nasihat (purwoastuti, 2008). menurut rosenthal (2000), wanita menopause yang mengalami depresi tidak mampu berfungsi normal, sangat memerlukan suatu konseling, perawatan, atau dukungan kelompok dari wanita yang telah berpengalaman tentang menopause. peer group support yang telah dilakukan dapat menurunkan tingkat depresi wanita menopause. tingkat depresi yang menurun banyak terjadi pada kelompok perlakuan, sedangkan pada kelompok kontrol relatif tidak banyak terjadi perubahan. pada kelompok perlakuan sebagian besar telah mencapai tingkat depresi minimal. pada kelompok kontrol tingkat depresi minimal ditunjukkan oleh kurang dari 50% responden. depresi berat tidak ditemukan lagi pada kelompok perlakuan, namun masih dijumpai pada responden kelompok kontrol. menurut training in human rights and citizenship education council of europe (1997), peer group support merupakan salah satu terapi kelompok yang memberikan kesempatan pada wanita menopause untuk mendapatkan dukungan dan bantuan pemecahan masalah dalam menghadapi berbagai keluhan terkait dengan perubahan yang terjadi pada masa menopause. peer group support menciptakan suatu ikatan persahabatan dan rasa saling peduli antar anggota kelompok. secara tidak langsung peer group support meningkatkan interaksi sosial dan respons psikologis yang adaptif sehingga dapat menurunkan tingkat depresi wanita menopause. keterbukaan dan kebersamaan yang terjadi saat kegiatan peer group support juga membuat anggota kelompok lainnya merasa dipercaya untuk ikut menyelesaikan masalah yang terjadi. masalah yang terselesaikan dan dukungan yang diperoleh dari kelompok membuat tingkat depresi responden menurun sehingga mereka lebih mantap dalam menghadapi masa menopause tanpa ada rasa khawatir. karakteristik demografi yang berpengaruh meliputi usia, pendidikan terakhir, pekerjaan saat ini, kegiatan yang diikuti, waktu terakhir haid, dan jenis kepribadian. usia antara 51-55 tahun dan waktu terakhir haid dapat berhubungan. semakin lama responden mengalami menopause maka responden semakin dapat beradaptasi dengan berbagai perubahan yang terjadi dalam hidupnya. responden menjadi lebih mudah menerima dengan dukungan dari teman sebaya. pendidikan responden pun cukup tinggi dibandingkan yang lain. pemahaman yang baik mengenai permasalahan menopause membuat responden bisa beradaptasi dan mengatasi berbagai keluhan yang terjadi. kegiatan yang banyak diikuti dan pekerjaan yang dimiliki juga membantu responden lebih banyak berinteraksi dan merasa lebih berguna bagi orang lain, dengan demikian kepercayaan diri responden pun meningkat. tingkat depresi yang menurun tidak hanya terjadi pada responden yang memiliki kepribadian extrovert namun juga pada responden dengan kepribadian introvert. peer group support memberikan stimulasi pada responden introvert untuk menceritakan masalah dan berpendapat secara terbuka, hal ini yang membuat perasaan menjadi lebih tenang dan tingkat depresi menurun. peer group support lebih banyak mempengaruhi aspek psikologis daripada aspek fisik. respons psikologis menunjukkan peningkatan lebih baik, ditandai dengan ungkapan perasaan responden melalui hasil kuisioner bdi-ii. hal ini membuktikan bahwa aspek psikologis dapat cepat berubah dengan peer group support, sementara perubahan aspek fisik membutuhkan waktu lebih lama karena terjadi perubahan perilaku dari responden. perubahan perilaku yang dimaksud seperti perubahan pola hidup responden dalam menyesuaikan diri dengan masa menopause. ah.yusuf peer group support (ahmad yusuf) tabel 1. tingkat depresi sebelum dan setelah peer group support kategori depresi perlakuan kontrol pre post pre post ∑ ∑ ∑ ∑ minimal 2 6 2 3 ringan 4 2 4 4 sedang 2 0 2 1 mean 17,375 (ringan) 8,875 (minimal) 15,375 (ringan) 14,625 (ringan) sd 4,24 3,681 4,838 5,235 hasil analisis statistik wilcoxon signed rank test (p=0,011) wilcoxon signed rank test (p=0,23) mann whitney u test (p=0,02) keterangan: p = signifikansi sd = standar deviasi mean = rerata simpulan dan saran simpulan peer group support yang diterapkan dalam penelitian ini mampu menurunkan depresi wanita menopause. peer group support memberikan stimulus berupa aktivitas menceritakan masalah dan kelompok memberikan masukan sebagai jalan keluar. masalah yang terselesaikan dan dukungan yang diperoleh dari kelompok akan membuat respons psikologis menjadi adaptif. saran peneliti menyarankan agar wanita mengembangkan kegiatan peer group support dengan harapan dapat meningkatkan kualitas hidup wanita dalam menghadapi dan menjalani masa menopause serta mencegah depresi menopause. perawat diharapkan dapat menerapkan kegiatan peer group support sebagai salah satu alternatif tindakan keperawatan untuk menurunkan tingkat depresi wanita menopause dan penelitian selanjutnya dapat dilakukan dengan menggunakan instrumen mmpi (minessota multiphasic personality inventory), sehingga lebih tepat dalam mengidentifikasi jenis kepribadian responden dalam kaitan dengan tingkat depresi. kepustakaan andra. 2007. plus-minus terapi sulih hormon, (online), (http://www.majalah-farmacia.com., diakses tanggal 15 april 2008, jam 21.00 wib) baziad. 2003. menopause dan andropause. edisi pertama. jakarta: yayasan bina pustaka sarwono prawirohardjo, hlm. 1-3, 7-8, 12, 46. beck. 1996. beck depression inventory, (online), (http://www.ibogaine.desk.nl/graphics/ 3639b1c_23.pdf., diakses tanggal 18 juni 2008, jam 11.00 wib). bobak, et al. 2005. buku ajar keperawatan maternitas edisi keempat. alih bahasa oleh maria a. wijayarini. jakarta: egc, hlm. 1016. chait. 2008. depression inventory, (online), (http://www.lovetoknow.com., diakses tanggal 15 mei 2008, jam 15.00 wib). darmojo dan martono. 2006. buku ajar geriatri (ilmu kesehatan usia lanjut). edisi ketiga. jakarta: balai penerbit fakultas kedokteran universitas indonesia, hlm. 512-518. data statistik indonesia. 2005. jumlah penduduk menurut kelompok umur, jenis kelamin, provinsi, dan kabupaten, (online), (http://www.datastatistikhttp://www.majalah-farmacia.com/ http://www.ibogaine.desk.nl/graphics/3639b1c_23.pdf http://www.ibogaine.desk.nl/graphics/3639b1c_23.pdf http://www.lovetoknow.com/ http://www.datastatistik-indonesia.com/ jurnal ners vol.3 no.1 april 2008 : 61-66 indonesia.com., diakses tanggal 21 april 2008, jam 21.15 wib). departemen kesehatan ri. 2005. terjadi pergeseran umur menopause, (online), (http://www.depkes.go.id., diakses tanggal 22 april 2008, jam 20.30 wib). dharmono. 2000. depresi. pedoman pengelolaan pasien geriatri. jakarta: pusat informasi dan penerbitan bagian ilmu penyakit dalam fk ui, hlm. 158-151. dowling. 2006. menopausal depression is common and can be treated, (online), (http://www.womenswellbeing-andmentalhealth.com/menopausaldepression.html., diakses tanggal 16 juni 2008, jam 13.00 wib). hapsari. 2007. wanita lebih rentan depresi, (online), (http://www.litbang.departemen kesehatan ri.go.id., diakses tanggal 14 april 2008, jam 19.00 wib). hunter. 1996. depression and the menopause. british medical journal, 313, (online), (http://www.proquest.umi.com., diakses tanggal 18 juni 2008, jam 10.00 wib). jacoeb. 2005. endrokinologi reproduksi pada wanita. ilmu kandungan, jakarta: yayasan bina pustaka sarwono prawirohardjo, hlm. 74-77, 96-98. kasdu. 2004. kiat sehat dan bahagia di usia menopause. jakarta: puspa swara, hlm. 2-7, 25-35, 84-124. kusumawardhani. 2006. depresi perimenopause. jakarta: balai penerbit fakultas kedokteran universitas indonesia, hlm. 1-12, 1620. manuaba. 1998. memahami kesehatan reproduksi wanita. jakarta: arcan, hlm. 188. maulana. 2005. pemahaman yang lebih baik tentang menopause, (online), (http://www.mail-achieve.com/balitaanda@balitaanda.com/msg78216.html., diakses tanggal 16 juni 2008, jam 15.00 wib). nurachmah. 1999. dampak kanker payudara dan pengobatannya terhadap aspek bio-psiko-sosio-spiritual klien yang berpartisipasi dalam kelompok pendukung. jurnal keperawatan indonesia, 2(6), 187-188. o’brien. 1994. menghadapi masa menopause dengan penuh kebahagiaan. jakarta: binarupa aksara, hlm. 78-82. parry. 2008. perimenopausal depression. the american journal of psychiatry, 165(1), (online), (http://www.proquest.umi.com., diakses tanggal 7 mei 2008, jam 13.00 wib). peplau, et al. 1992. social psychology 7 th , new jersey: prentice hall, hlm. 50-54. purwoastuti. 2008. menopause, siapa takut?. yogyakarta: kanisius, hlm. 20, 27-28. randall. 2003. support group: what they are and what they do, (online), (www.genetichealth.com., diakses tanggal 22 april 2008, jam 21.00 wib). rosenthal. 2000. women and depression. los angeles: lowell house, hlm. 106107. sutanto dan sutanto. 2007. menopause, jakarta: balai penerbit fakultas kedokteran universitas indonesia, hlm. 6, 39-40. training in human rights and citizenship education council of europe. 1997. peer support group, (online), (http://www.dadalos.org., diakses tanggal 11 maret 2008, jam 19.30 wib). urnobasuki. 2003. takut menghadapi menopause, cobalah minuman kedelai, (online), (http://www.sinarharapan.co.id/iptek/k esehatan/2004/0430/kes2.html., diakses tanggal 16 juni 2008, jam 14.00 wib). ah.yusuf http://www.datastatistik-indonesia.com/ http://www.depkes.go.id/ http://www.womens-wellbeing-and-mentalhealth.com/menopausal-depression.html http://www.womens-wellbeing-and-mentalhealth.com/menopausal-depression.html http://www.womens-wellbeing-and-mentalhealth.com/menopausal-depression.html http://www.womens-wellbeing-and-mentalhealth.com/menopausal-depression.html http://www.litbang.depkes.go.id/ http://www.litbang.depkes.go.id/ http://www.proquest.umi.com/ http://www.mail-achieve.com/balita-anda@balita-anda.com/msg78216.html http://www.mail-achieve.com/balita-anda@balita-anda.com/msg78216.html http://www.mail-achieve.com/balita-anda@balita-anda.com/msg78216.html http://www.proquest.umi.com/ http://www.genetichealth.com/ http://www.dadalos.org/ http://www.sinarharapan.co.id/iptek/kesehatan/2004/0430/kes2.html http://www.sinarharapan.co.id/iptek/kesehatan/2004/0430/kes2.html 286 self-care needs in patients with physical immobilization novia shinthia dewie, eka misbahatul mar’ah has faculty of nursing universitas airlangga, kampus c mulyorejo surabaya, 60115 email: eka.m.has@fkp.unair.ac.id abstract introduction: the quantity of unfulfilment of self-care in patients with physical immobilisation can decrease the quality indicator of nursing care. self-care for physically immobilised patients is affected by basic condition factors. the study aimed to analyse the factors that can affect the fulfilment of self-care needs in patients with physical immobilisation. methods: the study design was descriptive cross-sectional, with purposive sampling technique and the samples were 36 nurses and 36 physically immobilised patients. the independent variable was the fulfilment of self-care needs. dependent variables were patient demography (age, sex), nurse (knowledge, action, motivation), and health care factors (occupation design/nursing care method). the instrument used was a questionnaire and observation form. data were then analysed using double linear regression analysis, with significance ɑ ≤ 0.05. results: from the double linear regression test result was obtained p-value (sig) = 0.000 r square = 0.889. partially it was obtained p-value of age p(sig)=0,005, sex p(sig)=0.038, knowledge p(sig)=0.889, action p(sig)= 0.000, and motivation p(sig)=0.003. conclusion: factors of patients (age, sex) and nurses (action, motivation) influence the fulfilment of self-care needs for patients with physical immobilisation. however, nurses’ knowledge does not have any influence. the study result can be considered as input for nurses in developing the quality of nursing care in the fulfilment of self-care needs. keywords: basic conditioning factor, physical immobilized patient, self-care introduction basic human needs are the focus in nursing care. physical needs are the greatest needs, including nutrition, rest, oxygen, elimination and sexual activity, and should be fulfilled more; therefore, the nurse must have the ability and knowledge regarding the fulfilment of basic human needs, with the ability to monitor and follow the development of the patient in carrying out the activities of daily life to meet the basic needs, especially in patients with immobilisation (damayanti 2010). orem (1979, cited in galegos, 1997) states that personal care (self-care) as an activity of daily life is made to meet the physical needs. self-care is influenced by factors of the basic conditions (basic conditioning factor). these factors are classified into 3 categories, namely individual factors (age, gender, stage of development), factors of individual situations with family and social group (orientation sociocultural and family systems, and placements factor, health status, health care system/health, lifestyle, environment, and the availability and adequacy of resources). patients’ physical immobilisation needs, especially the needs of self-care, cannot be met without the help of a nurse; the nurse must establish a therapeutic relationship with the patient in order to create a relationship of trust and caregivers for better understanding the needs of the patient (thistle 2010). immobility or immobilisation is the inability to move freely due to a condition whereby the movement is interrupted or limited (potter and perry 2013). immobilisation is an inability to transfer or change position or bed rest for 3 days or more, with the motion of the anatomical body disappearing due to changes in physiological functioning (setiati et al. 2015). it prevents immobile patients with physical immobilisation from meeting their own needs independently. nurses and family members should assist in the fulfilment of their needs, including the self-care needs (thistle 2010). nurses have some role in carrying out their duties in accordance with the rights and responsibilities that exist (asmadi 2008). one of the nurse's roles is as a care provider. the role of the nurse as care provider must be implemented comprehensively and completely, not just focusing on the actions of promotion but also on preventative measures such as the implementation of personal hygiene in self-care needs. the role of the nurse as care provider in the implementation of personal hygiene will be more dominant when involving patients with physical immobilisation. it is meaningful in professional nursing care in accordance with the rules of nursing as a profession. one of the characteristics of the profession is oriented to service using expertise for the sake of the needs of patients, including the fulfilment of basic needs (hidayat, 2008). based on gunadi (2001), at cipto self-care needs in patients with... (novia shinthia dewie, eka misbahatul mar’ah has) 287 mangunkusumo orthopedic surgery suggests that nurses have not implemented to give selfcare needs optimally. another study states that the role of nurses in the implementation of personal hygiene according to the patients’ perceptions on physical immobilisation showed that as many as 64 respondents (45.4%) found it to be poor (sulistyowati and hand, 2012). based on the initial survey conducted by researchers during two weeks in november 2016, in the inpatient unit graha afiyah rsu haji surabaya nuur data showed that there were as many as 21 patients with physical immobility. patients’ self-care needs (bathing, eating, dressing, and elimination) were not fulfilled by 90% (19 patients), and self-care needs were met by 10% (2 patients). the results of interviews with several nurses mentioned that self-care needs are unfulfilled because the implementation takes quite a long time. for example, to meet the needs of selfcare (bathing and attiring) requires approximately 30 minutes per patient. from the observation it was found that 10% (2 patients) of self-care needs were delivered by nurses and 90% (19 patients) of self-care needs were met by family members and some were not delivered by the family. we conducted an initial survey and found that the daily average was 11 patients with partial dependency care, and 2 patients with total dependency care. based on the interviews with several nurses, it was also found that nurses rarely address the self-care needs of patients, especially for personal hygiene, because they consider that it can be done by families. in addition, nurses tend to prioritise dependent and collaborative interventions rather than fulfilling the basic needs of patients. it causes the unfulfilled self-care needs of patients with physical immobilisation. a self-care deficit problem would influence body hygiene such as skin infections, altered circulatory system, uncomfortable and less confident. from the results of the community satisfaction index (csi) data at an inpatient ward in one of a public hospital in surabaya in 2010 were in the good category (7.78%), but nursing care had the lowest value of 2.91 compared to medical and pharmacy services. it was found that there was an increasing number of complaints due to unfulfilled personal hygiene needs from 2010 to 2016. the existence of this phenomenon proves that the implementation of nursing care still is not optimal, especially in self-care needs, thus greatly affecting the quality of service of health care. analysis of the factors affecting selfcare needs could be conducted as problem solving in patients with physical immobilisation. patients could understand the most dominant factors and appropriate interventions to fulfil their self-care needs. thus, the aim of this study was to analyse the factors that can affect the fulfilment of selfcare needs in patients with physical immobilisation. materials and methods this study design was cross-sectional, where research is done by focusing on the time of measurement as well as observation of the independent and dependent variable data at one time only. independent variables and the dependent variable were rated simultaneously and there was no follow-up (nursalam, 2013). the population in this study was all patients with physical immobilisation treated in graha nuur afiyah inpatient rsu haji surabaya on 2 nd , 3 rd and 4 th floors, with the total respondents numbering 36 patients and 42 nurses. sampling was selected by purposive sampling, to obtain the patient and nurse respondents who met the inclusion criteria, totalling 36 respondents. the data were analysed using multiple linear regression test with a significance level of p <0.05. this study has been conducted with ethical clearance by the ethics commission, faculty of nursing, universitas airlangga. the ethical principles applied in this study include the benefiency principle, the principle of respect for human diginity, justice ti right principle, and the principle of right to freedom. results this section will present the results of the study based on factors of patients towards self-care needs, implementation of nursing care and fulfilment of self-care needs. table 1 shows that most respondents were elderly with an age range between 56-65 years as many as 16 people (44.4%) and the majority of the patients were male with as many as 19 people (52.8%). based on table 2, showed that most of the respondents had good knowledge of as jurnal ners vol. 12 no. 2 oktober 2017: 286-295 288 many as 29 people (80.6%), acts less as many as 19 people (52.8%), and motivation that are as many as 21 people (58.3% ) in meeting the needs of self-care (self-care) in patients with physical immobilisation. table 3 shows that in the implementation of nursing care methods based on role nursing unit manager, primary nurse, associate nurse, and teamwork, the average was poor. table 4 shows that most respondents with physical immobilisation (72.2%) were not satisfied in terms of their self-care needs (self-care). most patients (41.7%) had unfulfilled self-care needs for eating, elimination was 26 patients (72.2%), attiring in a total of 27 patients (75%), and the elimination a total of 27 patients (75%). based on the test results anova pvalue (sig.) = 0.000, it indicates that the variable age of the patient, gender of the patient, the nurse's knowledge, the intervention of nurses and nurse motivation simultaneously affect self-care in patients with physical immobilisation. the coefficient of determination (r square) = 0.889 88.9%; this means that care needs (self-care) in patients with physical immobilisation can be explained by patient age, gender of the patient, the nurse's knowledge, the actions of nurses and nurse motivation, while the remaining 11.1% (100% 88.9% = 11.1%) can be explained by other variables that are not included in this study. the partial test results showed that the patient's age variable with p value (sig.) 0.005. it means that h1 was accepted; age significantly affects patients’ care needs (selfcare) in patients with physical immobilisation. patients’ gender variable p value (sig.) 0.038; thus, h1 is accepted, which means that the sex table 1 distribution of factors of patients toward self-care needs in patients with physical immobilization variable freq percentage (%) age (years) 26-35 5 13,9 36-45 5 13,9 46-55 4 11,1 56-65 16 44,4 >65 6 16,7 total 36 100,0 sex male 19 52,8 female 17 47,2 total 36 100,00 table 2 distribution of factors of nurse toward self-care needs in patients with physical immobilization variable frequency % knowledge poor 0 0 fair 7 19,4 good 29 80,6 total 36 100,00 intervention poor 19 52,8 fair 9 25,0 good 8 22,2 total 36 100,00 motivation poor 13 36,1 fair 21 58,3 good 2 5,6 total 36 100,00 table 3 implementation of nursing care methods implementation of nursing care methods freq (%) classification graha nuur afiyah 2 nd floor duty and responsibility of nurse leader 23,3 poor duty and responsibility of primary nurse 26,1 poor duty and responsibility of associate nurse 21,7 poor teamwork 29,0 poor total 100 graha nuur afiyah 3 rd floor duty and responsibility of nurse leader 22,2 poor duty and responsibility of primary nurse 26,0 poor duty and responsibility of associate nurse 19,3 poor teamwork 29,6 poor total 100 graha nuur afiyah 4 th floor duty and responsibility of nurse leader 23,1 poor duty and responsibility of primary nurse 27,2 poor duty and responsibility of associate nurse 21,7 poor teamwork 28,0 poor total 100 self-care needs in patients with... (novia shinthia dewie, eka misbahatul mar’ah has) 289 of the patient significantly influences the care needs (self-care) in patients with physical immobilisation. nurses’ knowledge variable p value (sig.) 0.889; thus, h1 is accepted, so nurses’ knowledge does not significantly affect the care needs (self-care) in patients with physical immobilisation. nurse implementation variable p value (sig.) 0.000 means that actions significantly affect the care needs (self-care) in patients with physical immobilisation. nurses’ motivation variable p value (sig.) 0.003 means that actions significantly affect the care needs (self-care) in patients with physical immobilisation. the results showed that the most dominant variable was factors of nurses, with standard regression koefisien 0.523; the nurse care implementation is able to explain the variable y (self-care) amounting to 44.2%, while the patient factors, the dominant variables (factors nurse) (number 3), are the age of the standard regression coefficient -0.270, wherein the variables of age are able to explain the variable y (selfcare) of 21.5%. discussion correlation between patient’s age and selfcare needs in patients with physical immobilisation based on the results of the research, most respondents aged 56-65 years reported that the patient care needs (self-care) in patients with physical immobilisation are not met. from the test results, statistical regression analysis of patients’ age variable (x1) has a significant correlative relationship partially or simultaneously to variable care needs (selfcare) (y). hermawati (2016) showed that most respondents were over 50 years old. based on statistical test results, the p value was 0.006, which means that there was a significant correlation between age and self-care related to self-care in patients undergoing hemodialysis. orem (2001, cited in purwoastuti, 2016) found that infants, the elderly and sick people need assistance to meet their self-care needs. the age factor is related to people’s experience in dealing with various stressors, the ability to use support resources and skills in coping mechanisms (stuart & laraia 2005). the self-care ability of a person is affected by age, stage of development, life experiences, socio-cultural background, health, and resources (marriner 2001). normal growth and development according to age include changes in the biological, cognitive, and socioemotional functions that occur during the life of the individual (santrock 2007). growth includes physical changes that have occurred from the prenatal period to adulthood, which continue to be progress or setbacks. the development is dynamic and involves a progression and a decrease (berger 2005). in the elderly, the aging process occurs in a linear manner and can be described in three phases: table 4 fulfilment of self-care needs in patients with physical immobilization self-care items freq (%) classification eating unfulfilled 15 41,7 poor eating fulfilled 21 58,3 poor total 36 100 bathing unfulfilled 26 72,2 poor bathing fulfilled 10 27,8 poor total 36 100 attiring unfulfilled poor 27 75,0 attiring fulfilled 9 25,0 poor total 36 100 elimination unfulfilled poor 27 75,0 elimination fulfilled 9 25,0 poor total 36 100 table 5 factors affecting the fulfilment of self-care needs in patients with physical immobilization independent variable konstanta beta (coeficien regression) r r square p-value (sig.) anova (simultant) p-value (sig.) (partial) age 0,702 -0,093 0,943 0,889 0,000 0,005 sex 0,147 0,038 knowledge -0,010 0,889 action 0,289 0,000 motivation 0,180 0,003 jurnal ners vol. 12 no. 2 oktober 2017: 286-295 290 impairment, functional limitations and disability, and handicap will be experienced simultaneously with the process of degeneration (bondan 2006). age will lead to changes in the structure and physiological bases of various cells / tissues / organs and systems in the human body. this process causes physical and psychological deterioration. setbacks to psyche that occur in the form of an increase in emotional sensitivity, decreased arousal, increased interest in self-esteem, lack of interest in the appearance, increasing interest in the material, and interest in leisure activities has not changed (only the orientation and subjects are different), and there is a downward trend in taking care of themselves (mubarak, 2009). this showed that the older the ability in selfcare will be decreased so that the self-care needs of the elderly (aged 56-65 years) were unfulfilled. correlation between patient’s sex and selfcare needs in patients with physical immobilisation the survey results revealed that most respondents were male patients and the selfcare needs of patients with physical immobilisation are not met. the test results obtained that statistical regression analysis of patients’ gender variable (x2) shows a partial significant correlation to the care needs (selfcare) (y) variable in patients with physical immobilisation. research conducted by mahanani (2013) also explained that calculations using correlation chi-square test with a level of 95% obtained p value 0.008 <0.05, so the hypothesis is accepted, which means it can be seen that there was a relationship between gender and care specialising in leprosy patients at blora in 2011. sex includes the physical traits, character and different properties that affect the cleanliness of a person (stuart & laraia, 2005). problemsolving skills, analytical skills, competitive urge, motivation, sociability and ability to learn are the same between men and women (rohman, 2007). gender relates to the role of life and the different behaviour between men and women in society. in maintaining their health, women typically fare better than men. differences ill behaviour are also influenced by gender, as women more often take care of themselves than men. hermawati’s study (2016) explains that the statistical test results with p value 0.793 mean that there was no significant relationship between gender and self-care. in self-care, gender is one of the factors that influence self-care. women usually tend to be more concerned with their physical appearance than men. correlation between nurses’ knowledge and self-care needs in patients with physical immobilisation the results of this study found that most respondents felt that nurses have good knowledge of the self-care needs of patients and care needs (self-care) of patients with physical immobilisation are unfulfilled. the regression analysis showed that nurses’ knowledge (x3) had no significant correlation to the care needs variable (self-care) (y) in patients with physical immobilisation. notoatmodjo (2007) explained that knowledge is a process of knowing what happens after someone did sensing through the five senses of sight, hearing, smell, taste, and touch on a specific object. nurses should have the knowledge to give professional nursing care. the level of knowledge of each individual is different. it is influenced by many factors, including age, level of education, resources, experience, economic, environmental, and socio-cultural (notoatmodjo, 2007). in the field of nursing, nurses’ knowledge can continue to evolve with different variations depending on experience, education and nursing initiatives in reading literature or other information sources. the depth and breadth of nurses’ knowledge can also affect their ability of critical thinking and their ability to deal with problems (potter & perry, 2010). research conducted by darmiati (2008) in the city of napier showed that there was a relationship between knowledge to require the needs of personal hygiene. patients with immobilisation could not take care for themselves; patients need assistance to fulfil self-care. in this case, nurses’ awareness needed to be more attentive and more active. self-care is often considered a trivial issue, but it also affects a person's health and psyche; therefore, the nurse should always want to self-care needs in patients with... (novia shinthia dewie, eka misbahatul mar’ah has) 291 motivate patients to maintain self-care (nurhaeni 2012). level achieved perfection nursing care depends on the willingness, ability, knowledge and skills are both nurses (nursalam 2016). based on this theory, researchers assume that even if a nurse at graha nuur afiyah rsu haji surabaya has a level of knowledge in the range of sufficient to good, if it is not supported by a strong willingness to take care, it will affect the nurse in the implementation of caring for the needs of the patients, which can cause unfulfilment of the patient’s needs, especially for a patient with physical immobility. correlation between nurse’s implementation of self-care needs in patients with physical immobilisation the survey showed that most nurses had less action in giving the needs of self-care in patients with physical immobilisation. from the statistical regression analysis the nurse action variable (x4) has a significant correlation partially or simultaneously with variable care needs (self-care) (y) in patients with physical immobilisation. the test results show that the action variable is the dominant factor in influencing the self-care needs (selfcare) of patients with physical immobilisation. orem (2001, in aligood, 2014) explains that the theory of the nursing system describes and explains how patients’ self-care needs are fulfilled by nurses or patients themselves; orem argues about the fulfilment itself, the needs of the patient, and the patient's ability to perform self-care. measures to help meet the needs of personal hygiene and selfcare are not a skill that can only be learned in a short time; there is a need for customs, experience and good communication. nurses always perform personal hygiene measures to be more skilled in providing services and will get excellent results (sandyarman 2014). this is according to research by gunadi (2001) on the fulfilment of self-care performed by nurses for immobilised patients; services to provide personal hygiene measures are maximised if the nurse has a good skill in providing nursing care. skill can be increased with training and improved ability to get the maximum results. the result showed that the majority of nurses less action care needs (self-care); thus, patients’ care needs are unfulfilled. based on interviews with several nurses during the initial survey, the exercise of self-care (selfcare), especially personal hygiene, among others requires longer periods of time, because nurses have to finish other nursing care. in addition, nurses rarely address the self-care needs of patients, especially for personal hygiene, because they consider that it can be done by families and caregivers and they only help if needed. nurses tend to prioritise other independent and collaborative action other than to address the basic needs of patients. it could cause the unfulfilment of self-care in patients with physical immobilisation. maria (2010) said that immobilised patients depend on the self-care nurse, so the nurse providing personal hygiene must have the desire to achieve satisfactory results. patients will be satisfied if the perception is equal to or higher than expected. excellent nursing in providing self-care will lead to the satisfaction of the patient. damayanti (2010) showed that there was a significant difference in patient satisfaction before and after the implementation of personal hygiene in patients with immobilisation. based on several studies and theories that have been described and facts obtained during the study, the implementation or intervention is a dominant factor in determining self-care needs. nurses are expected to provide self-care by both the patient and the nursing care according to the standards that have been made, in order to increase the satisfaction of patients and to prevent negative impacts on the physical immobilisation as a result of unfulfilled demand for self-care. correlation between nurse’s motivation and self-care needs in patients with physical immobilisation based on the results, it can be seen that most nurses had moderate and poor motivation in fulfilling the self-care needs of patients with physical immobilisation. statistical regression analysis showed that nurses’ motivation variable (x5) has a significant correlation, partially or simultaneously, to variable care needs (selfcare) (y) in patients with physical immobilisation. according to suarli (2009), motivation is one of the factors that may affect performance. performance of the nurses to fulfil patient needs. riyadi and kusnanto jurnal ners vol. 12 no. 2 oktober 2017: 286-295 292 (2007) stated that in improving the quality of health services, every nurse should have high motivation for obtaining a good performance. the higher the motivation of the nurse, the higher the performance of nurse will be. motivation is a feeling or a thought that drives someone to do something or the exercise of power, especially in the action (sortell & kaluzny, 1994 in suarli and bahtiar, 2009). motivation is composed of intrinsic and extrinsic motivation. one of the most visible is intrinsic motivation. nawawi (2004) defined intrinsic motivation as a condition that encourages an activity that is within in the activity itself. conditions shape awareness about the meaning and benefits of an action or activity, either for themselves or others and the wider community. raatikainen (1997) in his research found that someone who gets the willingness to become a nurse has professional knowledge and motivation and understands the actions of nursing and also can be a source to provide support for the patient. nursing services can be effective when there is motivation as the driving passion, driving someone to do something desired. it will be well maintained when there is a good communication (mundzakir 2006). this study demonstrates that the motivation of nurses was poor or fair. poor motivation leads to the lower performance of nurses in terms of addressing self-care needs that should be independent nurse care. based on the demographic data, half of the nurses have also had a long working life of 16-20 years. maryoto (1990, in ismael, 2009) argues that if a person has not worked long enough, it will result in the poor, among others not yet appreciate the work that they are responsible. the tenure of the person that is too long in an organisation is a symptom that is not healthy. possible consequences include boredom of doing the same job for a long time, passivity and resignation of motivation and initiative in work, affecting one's creativity because there is no challenge. job satisfaction is relatively high at the time of first starting but declines gradually over the next 5-6 years and increases the satisfaction to a peak after 20 years. such long working lives will also affect the decline in motivation of nurses in terms of patients’ self-care needs. in addition, based on the items on the questionnaire respondents about c11 nurses, it was found that the majority of respondents stated that the salary / award obtained from the hospital is not in accordance with the toil issued; in this case, when the nurse helps to meet patients’ care needs. landy and becker, cited in nursalam (2016), grouped into 5 categories of motivational theories, one of which is the theory of justice. the theory of justice is based on the assumption that the main factor in the motivation of the work is the evaluation of the individual or the fairness of awards received. individuals will be motivated if they get balanced with the business they do. various explanations above can explain the decline in the motivation of nurses to meet the self-care needs of patients due to the average age of nurses in the room and the imbalanced awards received by nurses, thus causing the self-care needs of patients to remain unfulfilled. correlation between nursing care and self-care needs in patients with physical immobilisation based on the survey results, the conduct of the nursing care method is in fair range. murwani (2008) stated in the health sciences consortium in 1989 that the role of nursing is that of a care giver. the role as care giver of nursing care can be done when nurses pay more attention to the basic human needs through the provision of nursing care using the nursing process, so nursing diagnosis can be planned and implemented appropriately in accordance with the level of basic human needs, then evaluated for its development. nursing care is carried out from simple to complex. in this study, nurses play an important role in nursing care, especially in the self-care needs of patients. the results showed that the nursing care is in the fair range. this is because each element of the nursing care method (head nurse, primary nurse, and associate nurse) was not optimal in carrying out its duties and responsibilities. from the analysis of questionnaires, it is clear that the duty and responsibility of the head nurse was not optimal. this is indicated by the fact that the head of the room sometimes (with frequency 1-2x a week) had discussions with a pn or an to provide guidance on the issue of self-care needs, and rarely undertook supervision on the fulfilment of self-care needs. in addition, the duties and responsibilities of the pn were also not self-care needs in patients with... (novia shinthia dewie, eka misbahatul mar’ah has) 293 optimal, as indicated by the pn occasionally during the study evaluating nursing care with regard to self-care needs, as well as rarely meeting with patients and families to discuss the issue of self-care. the an observed during the study sometimes performed acts addressing self-care needs. this is in line with the results of interviews conducted by the researchers as a preliminary survey on some of the nurses; the an only performed these activities when families of patients asked for help to meet the needs of self-care such as personal hygiene (bathing and dressing) and elimination. craven, in agustin (2002), explained that the quality of health care in hospitals is determined by the circumstances of nurses both in terms of quantity and quality. nurses in providing nursing care to patients using nursing care management is the implementation of the nursing process. the nursing process is the basis of nursing practice that applies knowledge and theory in practice. pinedendi (2016) explained that there was a significant impact on the implementation of nursing care in the patients’ self-care deficit (p = 0.003); personal hygiene before and after intervention was in the fair category. it could be concluded that the implementation of the nursing care method may contribute to addressing patients’ care needs. nurses are expected to be able to apply the method to give nursing care optimally and carry out their duties and responsibilities. conclusions based on the results of research and discussio based on the results of the research and discussion, the researchers can make several conclusions that patient factors, nursing factors and health service factors can determine the care needs (self-care) in patients with physical immobilisation. patient factors, especially in the elderly (55-65 years), will impact on reducing self-care needs (self-care) in patients with physical immobilisation, while the female gender will be affected by increasing care needs (self-care) in patients with physical immobilisation. in nursing factors, nurses’ increased knowledge does not affect increasing care needs (self-care) in patients with physical immobilisation (selfcare needs are met). nurses with less motivation will impact on reducing self-care needs (self-care) in patients with physical immobilisation (self-care is unfulfilled). in the health service factors, the implementation of the primary nursing care team at graha nuur afiyah was in the fair range, which probably has an impact on reducing self-care needs (self-care) in patients with physical immobilisation (self-care needs are not met). improvements to the quality of nursing services should also be supported by good nursing performance. it was suggested that the hospital should hold seminars, workshops and training, especially with regard to fulfilling the self-care needs of patients. subsequent researchers could expand on the sampling technique by cluster and stratified sampling, and may make observations on meeting the needs of self-care with greater observational frequency. references alligood, mr. 2013. nursing theory: utilization & application, fifth edition. st louis, missouri: elsevier mosby. alligood, mr. 2014. nursing theorists and their work, eight edition. st louis, missouri: elsevier mosby alimul, a. 2009. pengantar kebutuhan dasar manusia: aplikasi konsep dan proses keperawatan, buku 1. jakarta: salemba medika anonemous. 2012. nursing theoris a companion to nursing theori andmodels http://currentnursing.com/nursing_th eory/self_care_deficit_theory.html asmadi. 2008. konsep dasar keperawatan. jakarta: egc basudewo, y., 2012. hubungan motivasi intrinsik menjadi perawat dengan caring perawat di rs mardi waluyo metro lampung tengah (doctoral dissertation, program studi psikologi fpsi-uksw) berger, k. (2005). the developing person: throught the life span. new york: worth. damayanti, m.d. 2010. efektifitas tindakan personal hygiene terhadap tingkat kepuasan pasien imobilisasi di rs. mardi rahayu kudus (doctoral disertation, universitas diponegoro) darmiati. 2008. faktor-faktor yang http://currentnursing.com/nursing_theory/self_care_deficit_theory.html http://currentnursing.com/nursing_theory/self_care_deficit_theory.html jurnal ners vol. 12 no. 2 oktober 2017: 286-295 294 berhubungan dengan pemenuhan kebutuhan personal hygiene pasien rawat inap makasar. depkes ri (2009). profil kesehatan indonesia. jakarta: depertemen republik indonesia gallegos, ec. 1997. the effect of social, family, and individual factors on self-care agency and self-care of adult mexican women. desertasi, wayne state university. graven and himle. 2000. fundamental of nursing, human health and function, third edition. philladelpia: j.b. lippincolt gunadi. 2002. pemenuhan perawatan diri yang dilakukan oleh perawat pada pasien yang immobilisasi. tesis. laporan penelitian, universitas indonesia haryono, i. 2011. hubungan antara beban kerja perawat dengan pemenuhan kebutuhan personal hygiene ( kebersihan diri ) pasien di ruang pavilyun lantai 3 rumah sakit umum haji surabaya. skripsi. universitas muhammadiyah surabaya hermawati., hidayati, titiek., chayati, nur. 2016. faktor-faktor yang mempengaruhi self-care diet nutrisi pasien hemodialisa di rsud dr. moewardi surakarta. stikes ‘aisyiyah surakarta. gaster vol. xiv no. 2 agustus 2016 hidayat, a.a. 2009. metode penelitian keperawatan dan teknik analisis data. edisi pertama. jakarta: salemba medika ismael. 2009. hubungan karakteristik perawat terhadap penatalaksanaan klien prilaku bunuh diri di rsj.prof. dr. hb. sa’anin padang tahun 2009. sumatera barat : program studi diii keperawatan stikes perintis bukittinggi johnson, b. 2015. an introduction to theory and reasoning in nursing. wolters kluwer lippincott williams wilkins khasanah, s., susanti, i.h., safitri, m., wita, w. and tiva, t. 2014. hubungan tindakan mandiri personal hygiene oleh perawat dengan tingkat kepuasan pasien imobilisasi di ruang rawat inap rsud dr. r goetheng taroenadibrata purbalingga. viva medika,7(13). mangkunegara, p.a.a. 2009. manajemen sumber daya manusia. cetakan kesembilan. bandung : remaja rodakarya marlina, a. 2011. faktor – faktor yang berhubungan dengan pemenuhan kebutuhan personal hygiene pasien rawat inap di ruang interna rumah sakit umum sawerigading kota palopo periode april mei 2011. skripsi marriner, a. (2001). nursing theorist and their work. (alih bahasa: ekawijaya, i. & riyono, r.). india: mosbycompany. muhlisin, a. & irdawati, 2010. teori self-care dari orem dan pendekatan dalam praktek keperawatn. berita ilmu keperawatan, 2(2), pp.97–100 natalia, mn. 2014. pemberian tindakan personal hygiene terhadap kepuasan pasien immobilisasi pada asuhan keperawatan ny s dengan efusi pleura di ruang aster 5 rsud dr moewardi surakarta notoatmodjo, s. 2012. metodologi penelitian kesehatan. jakarta: rineka cipta notoatmodjo, s. 2014. ilmu perilaku kesehatan. jakarta: rineka cipta nurhaeni, h., suryati, t. r. l., taufiqurrachman, k. p., manurung, s., & chairani, r. 2012. pengaruh intervensi personal higiene terhadap kepuasan pasien immobilisasi. caring, 1(03), 190196 nursalam. 2014. metodologi penelitian ilmu keperawatan pendekatan praktis, edisi 3. jakarta: salemba medika nursalam. 2016. manajemen keperawatan aplikasi dalam praktik keperawatan profesional edisi 5. jakarta: salemba medika orem, d.e. 2001. nursing concept of practiced. st. louis: the cv mosby company orem, a. t., & wisma, t. 2007. aplikasi teori self-care deficit orem dalam konteks tuna wisma (studi literatur) (the application of orem ’ s self-care deficit in homeless setting) megah andriany *, 1 pancaningrum, d. 2011. faktor-faktor yang self-care needs in patients with... (novia shinthia dewie, eka misbahatul mar’ah has) 295 mempengaruhi kinerja perawat pelaksana di ruang rawat inap dalam pencegahan infeksi nosokomial di rs haji jakarta tahun 2011. tesis. universitas indonesia pinedendi, novita., rottie, julia villy., wowiling, ferdinand. 2016. pengaruh penerapan asuhan keperawatan defisit perawatan diri terhadap kemandirian personal hygiene pada pasien di rsj. prof. v. l. ratumbuysang manado. e journal keperawatan (e-kp) vol 4 no 2, juli 2016 potter & perry. 2013. fundamentals of nursing eighth edition. missouri: elsevier mosby riyadi, sujono, harmoko. 2012. standard operating procedure dalam praktik klinik keperawatan dasar. yogyakarta: pustaka pelajar santrock, j. 2007. life span development.9th ed.new york: mcgraw–hill. setiadi. 2007. konsep dan penulisan riset keperawatan. yogyakarta: graha ilmu setiati, s. 2015. penatalaksanaan imobilisasi dan komplikasi akibat imobilisasi pada orang usia lanjut. divisi geriatri departemen ilmu penyakit dalam fkui rscm slevin, o & basford, l. 2006. teori dan praktik keperawatan pendekatan integral pada asuhan pasien. jakarta: egc stuart, g. w. & laraia, m. t. 2005. principle and practice of psychiatric nursing. 6th ed. philadelphia: mosbyinc. suarli, s & bahtiar, y. 2009. manajemen keperawatan dengan pendekatan praktis. jakarta: penerbit erlangga sulistyowati, d. & handayani, f. 2012. peran perawat dalam pelaksanaan personal hygiene menurut persepsi pasien imobilisasi fisik. jurnal nursing studies, 1, pp.169-174. susanti, h. 2010. defisit perawatan diri pada klien skizofrenia: aplikasi teori keperawatan orem. jurnal keperawatan indonesia. http://jki.ui.ac.id/index.php/jki/art icle/viewfile/237/pdf_166 sandyarman, i nyoman gede. 2014. hubungan personal hygiene oleh perawat dengan tingkat kepuasan pasien imobilisasi di rumah sakit jember klinik. artikel jurnal. universitas muhammadiyah jember taylor, s., & renpenning, k. 2011. self-care science, nursing theory and evidence based practice. new york: springer publishing company, llc tommey, a.m., dan alligood, m.r. 2006. nursing theory and their work. missouri: mosby uno, h. 2011. teori motivasi dan pengukuranya: analisis di bidang pendidikan. jakarta: bumi aksara wasis. (2008). pedoman riset praktis untuk profesi perawat. jakarta : egc. wahyudi, as & wahid, a. 2016. buku ajar ilmu keperawatan dasar. jakarta: mitra wacana media widuri, h. 2010. kebutuhan dasar manusia: aspek mobilitas da istirahat tidur. yogyakarta: gosyen publishin http://jki.ui.ac.id/index.php/jki/article/viewfile/237/pdf_166 http://jki.ui.ac.id/index.php/jki/article/viewfile/237/pdf_166 64 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.8005 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research grieving as an internal factor of nurse-patient interaction in a dialysis unit ika yuni widyawati1, nursalam nursalam2, kusnanto kusnanto2, rachmat hargono3 and pei-lun hsieh4 1 doctoral student, faculty of public health, universitas airlangga, surabaya, indonesia 2 faculty of nursing, universitas airlangga, surabaya, indonesia 3 faculty of public health, universitas airlangga, surabaya, indonesia 4 chung hwa university of medical technology, taiwan abstract introduction: the quality of the nurse-patient interaction is one factor that affects the patient adherence, but a study that provides an overview of factors in the nurse-patient interaction in improving or maintaining dialysis patient adherence has not been found. the aim of this study was to provide an overview of the various factors involved in the interaction process between nurses and patients undergoing dialysis in relation to their adherence to fluid and dietary restrictions. methods: a qualitative research design with an interpretive phenomenology approach was used in this study. the researcher intends to interpret the findings of the research, in this case the activity of the dialysis patients, in order to get a picture of the various factors involved in the process of interaction between nurse and dialysis patient. the unit of analysis used in this study was the disclosure or exposure of the internal factors of the nurse-patient interaction process, especially in relation to fluid and dietary restrictions. there were 15 participants who were selected based on the inclusion criteria. in-depth interviews, with field notes, were used in this study as the data collection method. results: the analysis of the theme based on the goal of the research includes grieving, needs and values/morals, but in this article, the researchers only describe one theme grieving. conclusion: this result provides an overview of the findings on nurse-patient interaction factors that can serve as baseline data for the development of nursing care, both in nursing assessments and interventions aimed at improving dietary adherence and the fluid restriction of dialysis patients. article history received: april 02, 2018 accepted: june 25, 2018 keywords dialysis patient; grieving; nurse-patient interactions contact ika yuni widyawati iy.widyawati@gmail.com  faculty of public health, universitas airlangga, surabaya, indonesia cite this as: widyawati, i., nursalam, n., kusnanto, k., hargono, r., & hsieh, p. (2018). grieving as an internal factor of nurse-patient interaction in a dialysis unit. jurnal ners, 13(1), 64-71. doi:http://dx.doi.org/10.20473/jn.v13i1.8005 introduction dialysis is a treatment that can improve the quality of life of patients with end stage renal disease (chow & wong, 2010; elliott, gessert, larson, & russ, 2014; ginieri-coccossis, theofilou, synodinou, tomaras, & soldatos, 2008) despite the high cost of the therapy (klarenbach, tonelli, chui, & manns, 2014). dialysis has a wide range of consequences on various aspects of the patient's life, including physical, biological, psychological and social (wijaya, 2005), and even death (bradbury et al., 2007). according to perkumpulan nefrologi indonesia (2014), renal replacement therapy haemodialysis has become the most common treatment with a percentage of 82%. according to the data, in indonesia, the percentage of regular haemodialysis measures reached 95% (703,139 patients) and in east java, there have been more than 90,000 haemodialysis patients in this time (pernefri, 2014). patients on dialysis have to face many challenges in their life, where they have to recognise the disease https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:iy.widyawati@gmail.com http://dx.doi.org/10.20473/jn.v13i1.8005 jurnal ners http://e-journal.unair.ac.id/jners | 65 and the treatment that should be followed, as well as learning to cope with and adapt to all of the changes and new behaviours in their life (royani, rayyani, behnampour, arab, & goleij, 2013). various stressors are experienced, making the dialysis patients unable to accept the changes and causing them to feel as if they have no control over their lives (warrior, 2015). the inability of the patient to execute self-control behaviours affects patients who are not always in favour of the treatment process (warrior, 2015; wijaya, 2005). patients with chronic diseases are expected to be the manager of themselves who are focused on the concept of patient-centered care. the failure of management and the treatment of dialysis patients is more often due to the non-adherence of patients (addo, 2015). adherence issues patients undergoing haemodialysis mainly focus on adherence to fluid restrictions, diet, medication and long (hours) implementation dialysis (al-khattabi, 2014; al-orabi et al., 2015; denhaerynck et al., 2007; park et al., 2014; vardanjani, parvin, & shan, 2015). the non-adherence of patients on dialysis to program fluid restriction and diet has an impact on the occurrence of complications, promotes an increased length of stay, decreases productivity and can even cause death (alikari, matziou, tsironi, theofilou, & zyga, 2015; payne, eaton, mee, & blount, 2013; saran et al., 2003). the quality of patient health depends on the patient’s adherence to the treatment regimens recommended (martin, williams, haskard, & dimatteo, 2005). few interventions to improve adherence diet and fluid restrictions in dialysis patients have been conducted. the success of interventions to improve adherence depends on a series of factors, such as the realistic assessment of the knowledge and understanding of the patient on the regimen of therapy given and clear communication between the health professionals and patients, as well as fostering a sense of trust in the therapeutic relationship (martin et al., 2005). nurses play an important role in this regard. in addition to providing care, nurses also provide additional assistance to patients in the form of support that is interpersonal that aims to help patients effectively cope with stress, improve their welfare, as well as accelerating the recovery of their health (de los ríos castillo & sánchez-sosa, 2002). the partnership and collaboration that exists between health professionals and patients can maximise compliance, foster patient satisfaction, and improve the health of the patients (martin et al., 2005). the nurse-patient relationship is a means of exchanging information and the ability to (millard, hallett, & luker, 2006), therefore the interpersonal nurse-patient interaction should be an important element in patient involvement in care. it helps to determine the success of the patients’ treatment, including the patients' adherence to their treatment recommendations (chatwin, 2008; nordby, 2007; stoddart et al., 2012). a study of the literature gives an overview of the research results outside indonesia with different communication cultures. the results from the literature studies (from various national journals) show that some studies confirm that nurse-patient interactions contribute to patient compliance. the research conducted by ningsih, rachmadi, & hammad (2012) revealed that the rate of patient compliance does not depend on demographic data, but on the quality of the interactions and other factors. other studies showed that the factors affecting fluid intake include education, self-concept, the knowledge of the patients, the health professionals and family involvement (kamaluddin, 2009). the research is quantitative in nature, while the interaction of the patient and nurse is a subjective process, so it is necessary to conduct the research using a qualitative design. qualitative research conducted prior to the topic interaction involving the factor of nurse-patient in patients with conditions of psychiatric disorder has been executed by cleary, edwards, & meehan (1999). qualitative research on the excavation of the factors that influence the communication aspects of the nurse-patient's family was conducted by loghmani, borhani, & abbaszadeh (2014). research that provides an overview of the nurse-patient interaction factors in relation to fluid-limiting and dietary adherence in dialysis units is relatively limited and needs to be done. the aim of this study is to provide an overview of the various factors in the interaction process of nurses and patients undergoing dialysis in compliance with fluid and dietary restrictions. materials and methods this research uses a qualitative research design with the chosen approach being an interpretive phenomenology. this is because the researcher intends to interpret the findings of the research, in this case, the activity of the nurses and dialysis patients in order to get a picture of the various factors involved in the nurse interaction process with the dialysis patients. the unit of analysis used in this study is the disclosure or exposure of internal factors in the nurse-patient interaction process. in this study, the researcher used interpretative phenomenological analysis (ipa) to clarify each participant’s experience in detail and to find out any psychological meanings. the researcher choose ipa as the analysis method to examine the complex and emotionally laden topics. ipa is an useful methodology for examining that such topics (smith & osborn, 2015). the process of analysis includes reading and re-reading, initial notes, developing emergent themes, searching for connections across the emergent themes, moving case by case and finally looking for any patterns across the cases. i. y. widyawati et al. 66 | pissn: 1858-3598  eissn: 2502-5791 stages of grieving feelings denial feeling uncertain rejection sadness disappointed anger depression physical psychological bargaining expectation/ hope acceptance sincere following process grateful causes of grieving feelings disease & therapy lifelong therapy new rule change of role in family not optimal in work being burden for the family efforts to overcome feelings of grief initiate communication with the nurse establish communication with felow patients improve communication with spouse interpersonal relationship personal reinforcement more grateful sincere the impact of grieving feelings psychological problems frightened/fear difficulty worries suffering anger social problems rejected to direct communication with the nurse social limitation with family aim: internal factor in nursepatient interaction theme: grieving figure 1: theme analysis jurnal ners http://e-journal.unair.ac.id/jners | 67 the inclusion criteria were that the patients had a minimum age of 18 years, were receiving similar dialysis therapy for at least 3 months, had a stable medical conditions (not currently in an acute condition requiring immediate medical treatment) and were not experiencing any psychological problems. as for the number of participants involved in the qualitative research, the method of selecting the participants in this study was not directed by quantity but based on the principle of conformity and adequacy until the number reached data saturation. the researcher reached data saturation when the information was repeated by the participants. the participants in this study included 15 patients who were selected based on the inclusion criteria and data that was saturated. in-depth interviews complete with field notes were used in this study. the validity of the data was measured by validating the transcription of the interview results from the participants. interresearcher and theory triangulation were used to maintain data stability and to maintain the objectivity of the data. the aim of triangulating the data by involving fellow researchers was to enrich the findings, while the theory triangulation conducted by researchers using the theory of nursepatient interactions from imogene king was in order to have another perspective about what the nursepatient interaction is. the research study was ethically approved by medical research ethics commission faculty of nursing universitas airlangga no.: 326-kepk. results characteristics of participants there were 15 participants involve in this study. all of the participants live in surabaya. the gender of the participants was 7 women and 8 men. the age of the participants varied with the age of the youngest participant being 21 years old and the oldest, 63 years of age. the education level of the participants ranged from elementary school to holding a graduate degree. the type of the work that the participants did consisted of private employees, retired village officials, retired soldiers and housewives. theme analysis the mourning feeling became one of the themes that emerged as an internal factor of the nursepatient interaction process. feeling heartbroken was conveyed by several participants, and in this theme, there were several sub-themes, namely the stages of grieving, the causes of the grieving feelings, the impact of the grieving feelings and efforts undertaken to overcome the feelings of grief (figure 1). discussion grieving is a response of the neuropsychological experience of loss of an object or subject that has a meaning in the individual’s life and is associated with the degree of suffering experienced (bruce, 2007). the mourning feeling in this research consists of sub-themes that include the stages of grief, the cause of grief, the impact of grief and the overcoming of grief. this finding revealed a new theme in the influencing factors of the nurse-patient interactions in an effort to realise patient compliance with fluid and diet restrictions. other studies which focus on the factors that influence nurse-patient interactions take up the area of mental nursing as conducted by cleary, edwards, & meehan (1999) and sharac et al. (2010). the results of this study were different from the other mentioned two studies. in the research conducted by cleary, edwards, & meehan (1999), patient factors lead to the increased severity of the disease, whereas in this study, it was found that the three themes in the internal factors of the patient involved was feeling sorrow, needs and norms / morals (which will be described separately). the differences that arose according to the researchers was due to several things. in this study, the researchers conducted in-depth interviews with the participants (dialysis patients) and their caregivers to gain an overview of the various things that affect the interaction of the nurse-patient within the setting of the room (a dialysis unit). in the research conducted by cleary, edwards, & meehan (1999), the participants selected were nurses with patients with psychiatric disorders in a psychiatric unit setting. the research conducted by sharac et al. (2010) was a research study that aimed to obtain a picture of the activity of the nurse-patient interaction in the psychiatry room by reviewing some of the research results. the grief experienced by the patient has an impact on the nurse-patient interaction initiation process, which is indicated by the results of this study. the nurse-patient interaction is a fundamental aspect in the process of providing and receiving nursing care (chatwin, 2008; nordby, 2007; shattell, 2004; williams & irurita, 2004). the expression of feelings by the patients refers to each stage of grieving, according to the theory of mourning conveyed by kubler ross (1969), quoted by potter & perry (2006). this result is consistent with the theory expressed by bruce (2002), in that the mourning process begins at the stage of diagnosis due to changes in their experienced status which changes the trajectory of sadness to some degree. some of the participants said that in the initial phase of diagnosis, the participants felt like they had not been able to accept their condition, which was shown by the expression of denial, anger and depression. this study has not delved deeper into how the stages of grieving over a certain time frame, so it is not known whether the stages of grieving is an iterative process or a process that is stagnant and stops at a certain point in time. the researcher focused on the nurse-patient interaction process in the beginning (by having participants recall the i. y. widyawati et al. 68 | pissn: 1858-3598  eissn: 2502-5791 initial interaction process) to the continuous nursepatient interaction process at the time of the meeting (which refers to the patient's continuation of their compliance with diet and fluid restrictions). the causes of grief identified in this study include illness, action and the role change in the family. the verdict of the disease, the therapy to be followed, the suggestions to be followed and the physical changes experienced are important experiences for the participants and cause physical and psychological discomfort. the initiation of patient interaction and the interaction itself becomes fundamental to the development of the nurse-patient relationship (stoddart et al., 2012). the nurse-patient relationship can be realised by the active involvement between individuals who both feel comfortable and in good condition or who are healthy (hagerty & patusky, 2003). depression experienced by the participants and their perceptions of the impact of the disease experienced was an important response of the patients with endstage renal disease (kimmel, 2000, 2001), which needs to be considered by the nurses when initiating interactions with the patients. another cause of grief that was identified in this research was the change of role in the family. categories that are in this sub-theme are that they are no longer optimal at work and become a burden on the family. the role change in the family became a unique finding of this study. another study that has discussed the role-related changes in families that affects the interaction process has not been found by the researchers. it is important to realise that the stress and frustration that is felt when experiencing kidney failure as well as therapy and the rules to be followed is a real condition and it is difficult for those who experience it. for patients, this is a great crisis and it transforms a large part of their life. the patients undergo confusion and tension facing the disease, and they remain concerned about the process of the therapy or the health problems that can suddenly arise as a complication or consequence of noncompliance, even when it comes to distractions in everyday life. kidney failure requires lifestyle changes. routines and activities that require physical strength are more difficult for the patients to do, so their family or friends may have to take on additional responsibilities. this role change is also a burden felt by the participants of this study. the effects of the grieving feelings that can be identified in this study include both psychological and social problems. categories included in the psychological problems are the emergence of fear, distress, worry, and feelings of pain and anger. in patients with end-stage renal disease, those undergoing routine dialysis were upset because the disease had happened to them. there was also the fear of the possibility that they could die (for those who were not ready to face death). the patients feel helpless because they cannot do anything about the disease. this gives rise to feelings of frustration and anger against the health workers. anger can arise due to their dependence on others (national kidney foundation, 2017). the participants’ 6 examples convey that the initial pain and needing dialysis makes the participants feel afraid to start communicating with the nurses, their partner or their children. the six participants explained that the condition gradually began to change after the nurse continuously approached and provided an explanation of the various things brought into question by the participant and their family. this will be explained further in the internal factors (nurse) and externally, in the interaction process. feelings of grieving are actually a normal process, although sometimes the process can take a long time and be complicated (bruce, 2007). in patients with chronic diseases, the feelings that arise because of the disease experienced (more predominantly, the existence of a negative perception) often causes conflict in their relationships with others (wortman & dunkel-schetter, 1979). this conflict resulted in behavioural responses that inadvertently harmed the patient, including avoiding open discussion of the disease (wortman & dunkel-schetter, 1979). researchers classify this condition as a social problem, which is a behavioural response that impacts on any interpersonal relationship problems. efforts to avoid open discussion of the disease were indicated by 9 participants who refused direct communication with the nurses, while 13 participants limited socialising with their family. another study by rogers (2002) also showed the same characteristics in the nurse-patient interaction, in that the patient will cooperate with the nurse when the interaction is considered beneficial and is done actively. the patient became uncooperative when the interaction was not considered beneficial for them. thus, it should be an important concern of the nurses when interacting with patients. efforts to overcome the feelings of grieving shown by the participants in this study include strengthening their interpersonal relationships and personal factors. the results of this study have shown that every participant who experiences feelings of mourning (because of pain conditions, therapy and lifestyle changes) have different reactions. this is in line with the results of the research conducted by silva et al. (2016), where the reaction to the disease and the strategies used by each individual can lead to treatment that focuses on emotion or focuses on the medical issue itself. handling the focus on emotions in the study by silva et al. (2016) is characterised by supporting their religion / faith, the search for family support, denial and avoidance. in this study, the treatment or remedy is indicated by communicating with fellow patients and improving communication with their partner. both are forms of interpersonal relationship that lead to finding good support from family and their fellow patients (peers). in the study by silva et al. (2016), it reveals the countermeasures found by focusing on the problems that are represented by resilience as a way to give jurnal ners http://e-journal.unair.ac.id/jners | 69 new meaning to their experience, in order for them to realise the importance of adherence to therapy and their treatment in an effort to minimise the problem. in this study, the treatment or remedy is indicated by strengthening personal efforts where the individuals show reception prior to the problem they are facing and then look for a solution to the problem. the handling is an important factor that must be considered for health promotion and to improve the quality of life of the patients. knowledge of countermeasures would allow the health care team to provide adequate support to prevent pessimism and despair in terms of living with the disease (da silva et al., 2016). conclusion based on the research results, we were able to conclude that there are two factors that affect the nurse-patient interaction; internal factors and external factors. feelings of mourning were one of the themes that emerged as an internal factors of the nurse-patient interaction process in the dialysis unit. feelings of mourning in this study consisted of subthemes, namely the stages of grieving, the cause of the feeling of mourning, grieving and feeling the impact of their efforts to overcome the feelings of grief. the results of this study are expected to be a material consideration in proper nursing care and the development of appropriate nursing interventions for each of the issues that arise in each phase experienced by the patient. this is as well as the materials for the professional development of the nurses and nursing quality improvement. the limitations of this study are based on the limitations of the supporting literature and other research results when discussing this topic in a specific area such as that of dialysis patients. references addo, e. (2015). chronic care model staff education and adherence with end-stage renal disease patients. walden university. retrieved from http://search.proquest.com/docview/17506457 91?accountid=13042%5cnhttp://oxfordsfx.host ed.exlibrisgroup.com/oxford?url_ver=z39.8820 04&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertatio n&genre=dissertations+&+theses&sid=proq:pro quest+dissertations+&+theses+glo/(accessed: march 27, 2018). al-khattabi, g. h. (2014). prevalence of treatment adherence among attendance at hemodialysis in makah. international journal of medical science and public health, 3(5), 592–598. https://doi.org/10.5455/ijmsph.2014.1703201 41/ (accessed:march 27, 2018). al-orabi, m. q., alshalawi, n. n., alotaibi, m. m., abdallah, m. a. a., yousif, & elbur, a. i. (2015). prevalence and predictors of non-adherence to medication among patients on hemodialysis in a tertiary care hospital, taif, kingdom of saudi arabia. european journal of pharmaceutical and medical research, 2(6), 18–23. alikari, v., matziou, v., tsironi, m., theofilou, p., & zyga, s. (2015). the effect of nursing counseling on improving knowledge, adherence to treatment and quality of life of patients undergoing hemodialysis. international journal of caring sciences, 8(2), 514–518. bradbury, b. d., fissell, r. b., albert, j. m., anthony, m. s., critchlow, c. w., pisoni, r. l., … gillespie, b. w. (2007). predictors of early mortality among incident us hemodialysis patients in the dialysis outcomes and practice patterns study (dopps). clinical journal of the american society of nephrology, 2(1), 89–99. https://doi.org/10.2215/cjn.01170905 bruce, c. a. (2002). the grief process for patient, family, and physician. journal of the american osteopathic association, 102(9 suppl 3), s28–s32. bruce, c. a. (2007). helping patients, families, caregivers, and physicians in the grieving process. journal of american osteopathic association, 107(7), 33–40. https://doi.org/10.1016/j.pec.2003.12.009 chatwin, j. (2008). hidden dimensions: the analysis of interaction in nurse – patient encounters. quality in primary care, 16, 109–115. chow, s. k. y., & wong, f. k. y. (2010). health-related quality of life in patients undergoing peritoneal dialysis: effects of a nurse-led case management programme. journal of advanced nursing, 66(8), 1780–1792. https://doi.org/10.1111/j.13652648.2010.0532 4.x cleary, m., edwards, c., & meehan, t. (1999). factors influencing nurse-patient interaction in the acute psychiatric setting: an exploratory investigation. the australian and new zealand journal of mental health nursing, 8(3), 109–116. https://doi.org/10.1046/j.13652850.1999.0024 8.x da silva, r. a. r., de souza, v. l., de oliveira, g. j. n., da silva, b. c. o., rocha, c. c. t., & holanda, j. r. r. (2016). coping strategies used by chronic renal failure patients on hemodialysis. escola anna nery, 20(1), 147–154. https://doi.org/10.5935/14148145.20160020 de los ríos castillo, j. l., & sánchez-sosa, j. j. (2002). well-being and medical recovery in the critical care unit: the role of the nurse-patient interaction. salud mental, 25(2), 21–31. denhaerynck, k., manhaeve, d., dobbels, f., garzoni, d., nolte, c., & de geest, s. (2007). prevalence and consequences of nonadherence to hemodialysis regimens. american journal of critical care, 16(3), 222–236. retrieved from http://www.scopus.com/inward/record.url?eid =2s2.034250818890&partnerid=tzotx3y1 elliott, b. a., gessert, c. e., larson, p. m., & russ, t. e. (2014). shifting responses in quality of life: people living with dialysis. quality of life i. y. widyawati et al. 70 | pissn: 1858-3598  eissn: 2502-5791 research, 23, 1497–1504. https://doi.org/10.1007/s11136-013-0600-9 ginieri-coccossis, m., theofilou, p., synodinou, c., tomaras, v., & soldatos, c. (2008). quality of life, mental health and health beliefs in haemodialysis and peritoneal dialysis patients: investigating differences in early and later years of current treatment. bmc nephrology, 9(1), 14. https://doi.org/10.1186/1471-2369-9-14 hagerty, b. m., & patusky, k. l. (2003). reconceptualizing the nurse-patient relationship. journal of nursing scholarship, 35(2), 145–150. kamaluddin, r. (2009). analisis faktor yang mempengaruhi kepatuhan asupan cairan pada pasien gagal ginjal kronik dengan hemodialisis. jurnal keperawatan soedirman, 4, 20–25. kimmel, p. l. (2000). psychosocial factors in adult end-stage renal disease patients treated with hemodialysis: correlates and outcomes. american journal of kidney diseases, 35(4), 132– 140. https://doi.org/10.1016/s02726386(00)70240x kimmel, p. l. (2001). psychosocial factors in dialysis patients. kidney international, 59(4), 1599–1613. https://doi.org/10.1046/j.15231755.2001.0590041599.x king, i. m. (2007). king’s conceptual system, theory of goal attainment, and transaction process in the 21st century. nursing science quarterly, 20(2), 109– 111.https://doi.org/10.1177/08943184072998 46 klarenbach, s. w., tonelli, m., chui, b., & manns, b. j. (2014). economic evaluation of dialysis therapies. nature reviews nephrology, 10(11), 644–652. https://doi.org/10.1038/nrneph.2014.145 loghmani, l., borhani, f., & abbaszadeh, a. (2014). factors affecting the nursepatients ’ family communication in intensive care unit of kerman: a qualitative study. journal of caring sciences, 3(1), 67–82. https://doi.org/10.5681/jcs.2014.008 martin, l. r., williams, s. l., haskard, k. b., & dimatteo, m. r. (2005). the challenge of patient adherence. therapeutics and clinical rrsk management, 1(3), 189–199. retrieved fromhttp://www.ncbi.nlm.nih.gov/pubmed/183 60559/(accessed:march 27, 2018). millard, l., hallett, c., & luker, k. (2006). nursepatient interaction and decision-making in care: patient involvement in community nursing. journal of advanced nursing, 55(2), 142–150. https://doi.org/10.1111/j.13652648.2006.03904.x national kidney foundation. (2017). coping effectively: a guide for patients and their families. retrieved november 1, 2017, from https://www.kidney.org/atoz/copingeffectively-guide-patients-and-their-families ningsih, e. s. p., rachmadi, a., & hammad. (2012). tingkat kepatuhan pasien gagal ginjal kronik dalam pembatasan cairan pada terapi hemodialisa. media jurnal ners, 7(1). nordby, h. (2007). meaning and normativity in nurse-patient interaction. nursing philosophy, 8(1), 16–27. https://doi.org/10.1111/j.1466769x.2007.0029 3.x park, h., rascati, k. l., lawson, k. a., barner, j. c., richards, k. m., & malone, d. c. (2014). adherence and persistence to prescribed medication therapy among medicare part d beneficiaries on dialysis: comparisons of benefit type and benefit phase. journal of managed care & specialty pharmacy, 20(8), 862–876. payne, m. e., eaton, c. k., mee, l. l., & blount, r. l. (2013). promoting medication adherence and regimen responsibility in two adolescents on hemodialysis for end-stage renal disease: a case study. clinical case studies, 12(2), 95–110. https://doi.org/10.1177/1534650112467079 perkumpulan nefrologi indonesia [pernefri]. (2014). 7th report of indonesian renal registry 2014. retrieved from http://www.indonesianrenalregistry.org/#cmt3 / (accessed:march 27, 2018). potter, p. a., & perry, a. g. (2006). buku ajar fundamental keperawatan. konsep, proses, dan praktik. (d. yulianti & m. ester, eds.) (4th ed.). jakarta: penerbit egc. rogers, s. r. (2002). nurse-patient interactions: what do patients have to say? the university of texas. royani, z., rayyani, m., behnampour, n., arab, m., & goleij, j. (2013). the effect of empowerment program on empowerment level and self-care self-efficacy of patients on hemodialysis treatment. iranian journal of nursing and midwifery research, 18(1), 84–87.retrieved from http://www.pubmedcentral.nih.gov/articlerend er.fcgi?artid=3748561&tool=pmcentrez&render type=abstract/ (accessed:march 27, 2018). saran, r., bragg-gresham, j. l., rayner, h. c., goodkin, d. a., keen, m. l., van dijk, p. c., … port, f. k. (2003). nonadherence in hemodialysis: associations with mortality, hospitalization and practice in the dopps. kidney international, 64(1), 254–262. https://doi.org/doi:10.1046/j.15231755.2003.00064.x sharac, j., mccrone, p., sabes-figuera, r., csipke, e., wood, a., & wykes, t. (2010). nurse and patient activities and interaction on psychiatric inpatients wards: a literature review. international journal of nursing studies, 47(7), 909–917. https://doi.org/10.1016/j.ijnurstu.2010.03.012 shattell, m. (2004). nurse-patient interaction: a review of the literature. journal of clinical nursing, 13(6), 714–722. https://doi.org/10.1111/j.13652702.2004.0096 5.x jurnal ners http://e-journal.unair.ac.id/jners | 71 smeltzer, s., & bare, b. (2008). brunner and suddarth’s textbook of medical-surgical nursing (10th ed.). philadelphia: lippincott williams & wilkins. smith, j. a., & osborn, m. (2015). interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain. british journal of pain, 9(1),41–42. https://doi.org/10.1177/2049463714541642 stoddart, k. m., shattel, m., chatwin, j., williams, a., irurita, v., seiger, m., … svensson, r. (2012). social meanings and understandings in patient-nurse interaction in the community practice setting: a grounded theory study. bmc nursing, 11(1), 14. https://doi.org/10.1186/1472-6955-11-14 vardanjani, l. r., parvin, n., & shan, g. m. (2015). the effects of an individual, multistep intervention on adherence to treatment in hemodialysis patients. disability and rehabilitation, 38(8), 1–5. https://doi.org/10.3109/09638288.2015.10616 01 warrior, a. m. (2015). the emotional experience of american indians receiving hemodialysis and how it relates to treatment adherence. university of nebraska. wijaya, a. (2005). kualitas hidup pasien penyakit ginjal kronik yang menjalani hemodialisis dan mengalami depresi. universitas indonesia. williams, a. m., & irurita, v. f. (2004). therapeutic and non-therapeutic interpersonal interactions: the patient’s perspective. journal of clinical nursing, 13(7), 806–815. https://doi.org/10.1111/j.13652702.2004.01020.x wortman, c. b., & dunkel-schetter, c. (1979). interpersonal relationships and cancer: a theoretical analysis. journal of social issues, 35(1), 35. zhang, z. x., luk, w., arthur, d., & wong, t. (2001). nursing competencies: personal characteristics contributing to effective nursing performance. journal of advanced nursing, 33(4), 467–474. https://doi.org/10.1046/j.13652648.2001.0168 8.x perbedaan pertumbuhan bakteri di humidifier dan non humidifier pada pasien yang mendapat terapi oksigen (the difference between bacterial growth in humidifier and non humidifier at the patient who got oxygen therapy) abu bakar*, krisna yetti**, hanny handiyani** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: abu_psik@yahoo.co.id ** fakultas ilmu keperawatan universitas indonesia abstract introduction: humidifier is a device for delivering oxygen to the patients. before using it, the humidifier tube should fill with sterile water. there was a recent study that administering oxygen less than five liter per minutes, the tube was not load with the sterile water. this research aim was to describe the difference between bacterial growth in the humidifier and non humidifier at the patient who got oxygen therapy. method: the design was the analytic survey with purposive sampling method. the samples were 24 patients. they were divided into two groups. group one, consisted of 12 patients with humidifier and the others with non humidifier. the instrument was culture equipments diagnostic test and observation guidance. the hypothesis was there was no difference bacterial growth existence in humidifier and non humidifier at the patient who got oxygen therapy. result: the results showed that there was no significance difference of bacterial growth at time of zero hour (p=0.131). meanwhile, there was significance different of bacterial growth at time of 12 hour (p=0.046), and time of 24 hour (p=0.046). there was also significance different between bacterial growth in humidifier and non humidifier at the patient who got oxygen therapy (p=0.010). discussion : the conclusion is a non humidifier device could prevent bacterial and reduce nosocomial infection. it was recommended that hospital should use non humidifier and the humidifier had to disinfect and change the water every 12 hours. keywords : humidifier, non humidifier, bacterium growth pendahuluan humidifier adalah suatu alat untuk melembabkan oksigen sebelum diterima oleh pasien (pavlovic, 2000). humidifikasi bertujuan untuk mencegah terjadinya iritasi mukosa saluran nafas pasien (kozier, erb, berman dan snyder, 2004). pelembab udara yang mengeluarkan uap dingin merupakan jenis humidifier dingin (rita, 2001). pemakaian humidifier penting untuk dicermati karena tabung humidifier yang terisi air dapat menjadi reservoir infeksi yang baik bagi bakteri (scaffer, et al., 1996). bakteri dapat tumbuh di humidifier diperkirakan karena lingkungan yang lembab (perry dan potter, 2006). pertumbuhan bakteri di humidifier sudah diketahui tahun 1987 dari penelitian cameron, reese, taval, clark, kelso, gonzalez, at al, yang menemukan banyak bakteri tumbuh pada humidifier, tabung oksigen ambulan. penelitian yang terbaru menemukan bahwa pemakaian humidifier selama lebih dari 24 jam sudah mulai ditumbuhi bakteri (nafisah, 2007). pertumbuhan bakteri di humidifier, dapat menjadi salah satu infeksi nosokomial pneumoni (scaffer, et al., 1996). pencegahan yang dapat dilakukan dengan memperhatikan beberapa hal antara lain tabung humidifier harus dalam kondisi bersih, air dalam humidifier harus air steril dan diganti setiap 24 jam, dan bila cairan hendak ditambahkan sisa cairan harus dibuang terlebih dahulu (nafisah, 2007). pencegahan lain yaitu pemakaian humidifier dengan aliran oksigen kurang dari 5 liter per menit (lpm) tidak perlu mengisi air (kenji, 2004). pemakaian humidifier yang tidak diisi air diistilahkan penulis dengan non humidifier. pencegahan dengan penggantian air setiap 24 jam sekali masih kurang efektif bila dibandingkan dengan waktu pajanan alat mulai dari steril sampai terdapat bakteri kurang lebih 6-10 jam (scaffer, burnett, crowford, duffy, fontaine, et al., 1996). penggunaan non humidifier sesuai teori tetapi belum ditemukan hasil penelitian yang menyebutkan tidak ditumbuhi bakteri. penting bagi perawat untuk mengevaluasi perbedaan pertumbuhan bakteri di humidifier dan non humidifier pada pasien yang mendapat terapi oksigen. bahan dan metode penelitian ini menggunakan metode survei analitik dengan rancangan studi kohort ganda. populasi dalam penelitian ini adalah seluruh tabung humidifier dingin yang digunakan pasien di ruang rawat yang berjumlah 12 pasien. sampel penelitian yang diambil 12 responden setiap kelompok, total sampel 24 responden. pengambilan sampel menggunakan metode purposive sampling dimana sampel diambil sesuai dengan kriteria inklusi yaitu pasien dengan kesadaran komposmentis, oksigen yang digunakan 1-6 lpm menggunakan nasal canule/simple mask, tidak menderita penyakit saluran nafas. penelitian dilakukan di ruang jantung dan ruang observasi intensif rsu dr. soetomo surabaya, selama 2 minggu (mei minggu keiv sampai juni minggu ke-i 2009). instrumen yang digunakan adalah sarung tangan steril, lidi kapas steril, tabung transport steril, peralatan laboratorium yang terstandar international standardization of organization (iso), dan pedoman observasi. pedoman observasi terdiri dari lembar observasi data karakteristik responden, lembar observasi responden, dan lembar observasi hasil pemeriksaan. pengumpulan data diawali dengan peneliti menentukan responden sesuai kriteria inklusi. setelah diberi penjelasan, responden menandatangani surat persetujuan (informed consent). pasien yang menjadi responden di ruang jantung dipakaikan humidifier dan responden di roi dipakaikan non humidifier yang sudah didesinfeksi. spesimen pertama diambil pada jam ke-0 yang dilakukan sesaat sebelum dipasang ke pasien dengan melakukan swab pada dinding tabung dengan teknik melingkar. pengambilan berikutnya pada jam ke-12 dan jam ke-24. spesimen dikirim ke laboratorium untuk dilakukan pemeriksaan. analisis data dilakukan dengan menggunakan uji statistic univariat dan bivariat. analisis univariat karakteristik responden dan pertumbuhan bakteri digunakan jumlah dan proporsi/deskriptif frekuensi. analisis bivariat perbedaan pertumbuhan bakteri pada jam ke-0, jam ke12, dan jam ke-24 digunakan mann-whitney. analisis perbedaan pertumbuhan bakteri di humidifier dan non humidifier digunakan uji kolmogorov smirnov. hasil hasil distribusi responden dan uji omogenitas dilakukan berdasarkan perawatan tabung, air yang digunakan, lama penggantian air, dan pemakaian selang oksigen. perawatan tabung dilakukan dengan teknik desinfeksi yaitu dicuci dengan fenol 5% dan dibilas dengan air mengalir kemudian dikeringkan, setelah kering bagian dalam dicuci ulang dengan menggunakan alkohol 70%, kemudian dibilas dengan cairan aquades steril. hasil uji statistik analisis univariat menunjukkan bahwa tidak ada perbedaan pada karakteristik perawatan tabung antara humidifier dan non humidifier dengan p=1,000 lebih besar dari α (0,05). karakteristik air yang digunakan yaitu pada humidifier tabung diisi dengan cairan aquades dan pada non humidifier tidak diiisi dengan air menunjukkan hasil bahwa terdapat perbedaan (p=0,000 < α 0,05). karakteristik lama penggantian air pada kelompok humidifier dan non humidifier, mempunyai perbedaan (p=0,000 < α 0,05). karakteristik pemakaian selang oksigen pada kelompok humidifier dan non humidifier, tidak ada perbedaan dengan (p=0,847 > α 0,05). hasil dapat dilihat pada tabel 1. hasil pertumbuhan bakteri didapatkan pada jam ke-0 rerata pertumbuhan bakteri pada humidifier 1,50 dan non humidifier bernilai 0,00. hasil uji statistik analisis bivariat menunjukkan tidak ada perbedaan yang signifikan. rerata pertumbuhan bakteri pada humidifier maupun non humidifier pada jam ke-0 dengan nilai p=0,131 (α<0,05). rerata pada jam ke-12 pada humidifier 1,25 dan non humidifier 0,00. hasil uji statistik menunjukkan ada perbedaan yang signifikan rerata pertumbuhan bakteri pada humidifier dan non humidifier dengan nilai p=0,046, (α <0,05). rerata jam ke 24 humidifier 3,25 dan non humidifier 0,00. hasil uji statistik menunjukkan ada perbedaan yang signifikan rerata pertumbuhan bakteri pada humidifier dan non humidifier dengan nilai p=0,046 (α< 0,05). secara umum ditemukan bahwa 33,3% humidifier ada bakteri dan 16,7% tidak ada bakteri. pada non humidifier 50% responden tidak ada bakteri. hasil uji statistik ditemukan ada perbedaan yang signifikan pertumbuhan bakteri pada humidifier dan non humidifier dengan nilai p=0,010 (α<0,05). bakteri yang ditemukan yaitu yaitu enterobacter aeruginosa sebanyak 4,2% dan staphylococcus epidermidis 4,2%, sedangkan 91,7% koloni bakteri tidak dapat dievaluasi. hasil dapat dilihat di tabel 2. tabel 1. distribusi responden dan uji homogenitas berdasarkan perawatan tabung, air yang digunakan, lama penggantian air, dan pemakaian selang oksigen variabel non humidifier humidifier uji homogenitas n % n % p 1. perawatan tabung dicuci 12 50 12 50 1,000 2. air yang digunakan steril tanpa air 0 12 0 50 12 0 50 0 0,000 3. lama penggantian air 24 jam tanpa air 0 12 0 50 12 0 50 0 0,000 4. pemakaian selang oksigen dicuci baru 12 0 50 0 9 3 37,5 12,5 0,847 tabel 2. analisis perbedaan rerata hasil pemeriksaan jam ke-0, jam ke-12, jam ke-24, pada humidifier dan non humidifier resiko non humidifier humidifier hasil uji mann whitney jam ke-0 mean sd 0,00 0,000 1,50 2,380 p= 0,131 jam ke-12 mean sd 0,00 0,000 1,25 0,957 p= 0,046 jam ke-24 mean sd 0,00 0,000 3,25 3,202 p= 0,046 keterangan : n = jumlah % = persentase p = signifikansi sd = standar deviasi pembahasan karakteristik perawatan tabung pada kelompok humidifier dan non humidifier, keduanya dicuci (desinfeksi) sebelum dipasang ke pasien. kondisi awal yang sama diharapkan bakteri tidak tumbuh, karena desinfektan tingkat sedang membunuh bakteri, beberapa virus dan jamur kecuali spora bakteri (scaffer, et al., 1996). air yang digunakan untuk mengisi tabung humidifier berbeda dengan non humidifier. perbedaan karakteristik ini juga ditunjukkan pada lama penggantian. perbedaan karakteristik tersebut menjadi identitas responden dijelaskan dalam metode penelitian di mana kelompok resiko adalah responden humidifier dan kelompok tidak mempunyai resiko adalah non humidifier. dilihat dari sifat bakteri, yaitu bakteri akan membentuk spora bila dalam kondisi yang tidak kondusif (gibson, 1990). gould dan brooker (2000) menyebutkan bahwa bakteri gram positif tahan terhadap kondisi kering. pemakaian selang oksigen kelompok humidifier ditemukan 12,5% menggunakan selang baru dan sisanya sama dengan non humidifier yaitu menggunakan selang yang di cuci (desinfeksi). kondisi selang baru atau selang yang didesinfeksi dimungkinkan tidak ada pertumbuhan bakteri, ditunjukkan dari selang baru yang digunakan sesuai standar dari iso. selang yang didesinfektan dapat membunuh bakteri (scaffer, et al., 1996). perbedaan pertumbuhan bakteri di humidifier dan non humidifier pada jam ke-0 tidak ditemukan perbedaan. hal ini membuktikan bahwa tabung humidifier yang didesinfeksi telah terkontrol pertumbuhan bakterinya. scaffer, at al (1996) menyebutkan bahwa desinfektan tingkat sedang dengan menggunakan fenol 5% dan alkohol 70% akan sangat efektif membunuh bakteri dan beberapa virus. humidifier ditemukan 25% ditumbuhi bakteri. keadaan ini dimungkinkan karena tabung humidifier sering dipergunakan pasien dan selalu menggunakan air, sehingga diperkirakan masih terdapat spora. pernyataan ini didukung oleh scaffer, et al. (1996) bahwa desinfektan tingkat sedang tidak dapat membunuh spora. diperkuat gibson (1990) bakteri akan membentuk spora bila dalam kondisi yang tidak kondusif. perbedaan pertumbuhan bakteri di humidifier dan non humidifier pada jam ke12 berbeda. hasil uji statistik ini membuktikan bahwa non humidifier lebih terjaga kesterilannya. pertumbuhan bakteri setelah digunakan selama 12 jam ditumbuhi bakteri secara teori dapat terjadi karena menurut scaffer, et al. (1996) bakteri dapat tumbuh kurang lebih 6 jam setelah disterilkan. bakteri yang ditemukan, semua berada di sampel yang menggunakan humidifier. kondisi ini dimungkinkan karena faktor resiko yang terdapat di humidifier yaitu dalam pemakaiannya menggunakan air sehingga mudah ditumbuhi bakteri. jrank (2009) menyebutkan bahwa bakteri 80-90% terdiri air dan membutuhkan air untuk tumbuh dan mendapatkan nutrisi. pernyataan ini didukung oleh gibson (1990) yang menyatakan bahwa bakteri membutuhkan air untuk pertumbuhan dan bila kondisi tidak kondusif akan menjadi spora. terdapat perbedaan pertumbuhan bakteri yang bermakna di humidifier dan non humidifier pada jam ke-24. keadaan ini sama dengan pada sampel pemeriksaan pada jam ke-12. perbedaan yang jelas ada pada rerata pertumbuhan bakteri, dimana pada jam ke-12 ratarata bakteri yang tumbuh 1,25 sedang pada jam ke-24 sebesar 3,25. data tersebut menunjukkan adanya peningkatan jumlah pertumbuhan bakteri. todar (2008) menyebutkan bahwa bakteri dapat melakukan pembelahan secara umum 15 menit sampai 1 jam, meski ada yang lebih cepat atau lebih lambat. thiel (1999) menyebutkan bahwa bakteri akan membelah menjadi dua kali lipat tiap 20 menit. pertumbuhan bakteri pada humidifier dan non humidifier dilihat dari proporsinya terlihat ada perbedaan bermakna pada kedua tabung. keadaan ini membuktikan bahwa air dalam tabung humidifier sebagai pelembab dan juga dapat menjadi tempat pertumbuhan bakteri, seperti yang disebutkan scaffer, et al. (1996) air dalam tabung humidifier sebagai reservoir pertumbuhan bakteri yang dapat mengakibatkan infeksi nosokomial. bakteri yang ditemukan dari kultur sampel adalah staphylococcus epidermidis dan enterobakter aeruginosa. dalam penelitian ini sama dengan bakteri yang ditemukan oleh cameron, et al. (1987) dan cahill and heath (1990). staphylococcus epidermidis merupakan flora normal yang dapat ditemukan pada tubuh manusia, banyak di kulit dan mukosa (ogara and humphreys, 2001). handiyani (2001) menambahkan bakteri ini juga ditemukan di udara, bakteri tersebut merupakan bakteri oportunistik yang mampu menimbulkan infeksi pada orang yang sakit berat, tapi tidak bila pada orang sehat (bukhari, 2004). enterobakter aeruginosa merupakan flora norma yang dapat ditemukan di tubuh manusia khususnya di system pencernaan dan di air. bakteri ini dapat menjadi bakteri patogen bila memasuki tubuh manusia di luar habitatnya. enterobakter aeruginosa sangat berperan terjadinya infeksi nosokomial (thelabrat, 2005). sejumlah bakteri yang ditemukan tidak dapat di evaluasi. petugas laboratorium mengungkapkan bahwa bakteri yang tidak dapat dievaluasi diakibatkan karena bakteri berada di dalam agar (medium pembiakan). simpulan dan saran simpulan tidak ada perbedan yang signifikan pertumbuhan bakteri pada jam ke-0 antara yang menggunakan humidifier dengan non humidifier , tetapi pada jam ke12 dan 24 didapatkan perbedan pertumbuhan bakteri yang signifikan antara humidifier dengan non humidifirr. terdapat perbedaan pertumbuhan bakteri pada humidifier dengan non humidifier pada klien yang mendapat terapi oksigen. bakteri yang ditemukan adalah adalah staphylococcus epidermidis dan enterobakter aeruginosa yang merupakan bakteri flora normal. bakteri ini dapat menjadi patogen bila masuk ke individu yang sangat lemah, sehingga menjadi infeksi nosokomial. saran saran yang dapat diberikan antara lain rumah sakit yang menerapkan pemakaian humidifier diharapkan setiap ganti dinas atau maksimal 12 jam sekali tabung humidifier harus di cuci dan dibersihkan dengan alkohol. humidifier yang tidak dipergunakan langsung didesinfeksi dan disimpan ditempat yang bersih, sehingga pada saat akan digunakan tinggal mengisi dengan air steril, sehingga perlu membentuk perawat terapi oksigen atau melatih asisten perawat untuk menangani tabung humidifier, bagi peneliti selanjutnya agar dilakukan penelitian lanjutan tentang biaya yang dibutuhkan untuk pemakaian humidifier, aqua pack, atau non humidifier, penelitian dengan pemakain air mineral kemasan dapat dilakukan, instansi gawat darurat sangat dianjurkan menggunakan non humidifier karena mobilitas pasien yang tinggi dan lama perawatan yang tidak lebih dari 4 jam sehingga dapat memudahkan perawatan tabung humidifier, pemakaian non humidifier dapat dilakukan bila oksigen yang diberikan diberikan kurang dari 5 liter permenit, bila terapi oksigen lebih dari 5 liter per menit bisa diberikan kurang dari 4 jam. penelitian lebih lanjut efek bakteri yang ditemukan pada pasien dengan menggunakan hewan coba supaya tidak melanggar kode etik. kepustakaan bukhari, m. 2004. student presentation: staphylococcus epidermidis, , diakses tanggal 16 juni 2009. cahill, c.k. and heath, j. 1990. sterile water used for humidification in lowflow oxygen therapy: it is necessary?, , diakses tanggal 14 januari 2009. cameron, j.l., reese, w.a., taval, v.s., clark, r.f., kelso, d., gonzalez, e.r., et al. 1986. bacterial contamination of ambulance oxygen humidifier water reservoirs: a potential source of pulmonary infection, (online), (http://www.ncbi.nlm.nih.gov/pubme d/3535586/, diakses tanggal 14 januari 2009). gibson, j.m. 1990. modern microbiology and pathology for nurse. oxford: blackwell scientific publications. gould, d. and brooker, c. 2000. applied microbiology for nurses. basingstoke: macmillan press ltd. handiyani, h. 2001. hubungan antara waktu membersihkan ruangan dengan peningkatan jumlah mikroorganisme melalui aliran udara. jurnal keperawatan indonesia, 5(2), hlm. 44-49. http://www.ncbi.nlm.nih.gov/pubmed/3535586/ http://www.ncbi.nlm.nih.gov/pubmed/3535586/ jrank. 2009. bacteria characteristics of bacteria, bacterial growth, physical and chemical requirements for bacterial growth, the role of bacteria in fermentation aerobic and anaerobic bacteria,, diakses tanggal 16 juni 2009. kenji, m. 2004. is it necessary to humidify inhaled low-flow oxygen or lowconcentration oxygen?. journal of the japanese respiratory society, 42(2), 138-144. kozier, b., erb, g., berman, a., and snyder, s.j. 2004. fundamentals of nursing: concepts, process, and practice, 7th ed. new jersey: person education. nafisah, s. 2007. pengaruh lama penggantian air humidifier lebih dari 24 jam terhadap pertumbuhan bakteri pada terapi oksigen system low flow low concentration di ruang rawat inap interna rsud dr. soebandi jember, skripsi tidak dipublikasikan, surabaya: universitas airlangga. ogara, j.p and humphreys, h. 2001. staphylococcus epidermidis biofilms: importance and implications. journal med. microbiol. 50, 582-587, diakses tanggal 16 juni 2009. pavlovic. 2000. inhalation therapyproducts for humidification and nebulisation, , diakses tanggal 23 november 2008. perry, a.g. and potter, p.a. 2006. fundamentals of nursing: concepts, process, and practice. st. louis: cv mosby company rita, a.s. 2001. terapi oksigen dan fisoterapi napas. makalah disajikan dalam simposium critical care nursing. surabaya : lab/ upf anestesiologi fk unairrsud dr. soetomo, hlm. 1-10. scaffer, s.d., burnett, c.b., crowford, p.e., duffy, j.r., fontaine, d.k., et al. 1996. pocket guide to infection prevention and safe practice. virginia: mosby year book inc. thelabrat. 2005. enterobacter aerogenes, diakses tanggal 03 maret 2009. thiel, t. 1999. introduction to bacteria. diakses tanggal 16 juni 2009. tim pascasarjana fik-ui. (2008). pedoman penulisan tesis fakultas ilmu keperawatan universitas indonesia. depok. fik-ui. todar, k. 2008. the growth of bacterial population (page 3). diakses tanggal 10 juni 2009. abu bakar abu bakar 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 pernafasan active cycle of breathing meningkatkan aliran ekspirasi maksimum penderita tuberkulosis paru (active cycle of breathing raises peak expiratory flow rate (pefr) on tuberculose patients) tintin sukartini*,sriyono*, iwan widia sasmita* program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496 e-mail: tintin_bios@yahoo.com abstract introduction: tuberculosis bacterial can cause fibrosis tissue in lung. fibrosis decrease elasticity and compliance of lung as a result, there will be air ventilation and oxygenation disorder, thus it will decrease peak expiratory flow rate (pefr). the objective of this study was to analyze the effect of active cycle of breathing technique on raised peak expiratory flow rate (pefr). method: a quasy experimental purposive sampling design was used in this study. there were 14 sample who met in inclusion criteria divided into 7 subjects for intervention group and 7 subject for control group. data were analyzed by using paired t-test, independent t-test, wilcoxon signed rank test, and mann whitney u test with significance level α≤0.05. result: the result showed that active cycle of breathing had significance level on increased peak expiratory flow rate (pefr) (p=0.001). discussion: it can be concluded that active cycle of breathing has effect on raise peak expiratory flow rate. further study are recommended to measure the effect of active cycle of breathing on raised maximum midexpiratory flow rate (mmfr50-75%) keywords: tuberculosis, active cycle of breathing, pefr pendahuluan penyakit tuberkulosis paru merupakan penyakit penyebab kematian pertama pada golongan penyakit infeksi (rahayu, 2007). di indonesia penyakit ini merupakan penyakit rakyat nomor satu dan sebagai penyebab kematian nomor dua setelah sistem sirkulasi (skrt, 1995 dan arlina gusti, 2003). pada umumnya gejala respiratorik yang ditimbulkan setelah seseorang terkena tuberkulosis adalah batuk lebih dari 3 minggu, berdahak, batuk darah, nyeri dada, serta sesak nafas (alsagaaf dan mukty, 1995). pada perjalanan penyakit tuberkulosis selanjutnya menimbulkan kecacatan baik berupa destruksi atau fibrosis dari saluran napas maupun parenkim paru, dengan manifestasi klinis berupa sesak napas dan batuk (aida, 1996). manifestasi dari kerusakan ini juga membawa dampak terganggunya fungsi atau faal paru penderita, yang berupa kelainan restriktif maupun obstruktif. kelainan ini berdampak pada penurunan volume ekspirasi maksimum (judyanto, 2004). who menyatakan bahwa 1/3 penduduk dunia telah terinfeksi kuman tuberkulosis. saat ini di negara maju diperkirakan setiap tahun terdapat 10–20 kasus baru setiap 100.000 penduduk dengan kematian 1-5 per 100.000 penduduk sedang di negara berkembang masih tinggi. who memperkirakan di indonesia setiap tahunnya terjadi 175.000 kematian akibat tuberkulosis dan terdapat 550.000 kasus tuberkulosis. data departemen kesehatan ri menyebutkan pada tahun 2001 di indonesia terdapat 50.443 penderita tuberkulosis paru dengan bta positif yang diobati (helmia dan lulu, 2004). jawa timur merupakan penyumbang kedua kasus tuberkulosis positif di indonesia setelah jawa barat. berdasarkan data dinas kesehatan jatim 2006, sedikitnya 39.371 penderita tb bta positif di surabaya, jumlah penderita tb sedikitnya 812 orang pada 2005 dan meningkat menjadi 3.005 pada 2006. penderita yang berobat di rsu dr soetomo surabaya sedikitnya 365 penderita (esti, m., 2007). menurut penelitian yang dilakukan oleh judyanto (2004) terhadap 40 orang yang menderita tb di rsu dr. soetomo berdasarkan parameter mmfr (maximum midexpiratory flow rate) yaitu salah satu parameter untuk mengukur aliran ekspirasi maksimum, didapatkan 5 orang (12,5%) penderita mempunyai nilai diatas predicted, 35 orang (87,5%) penderita dibawah nilai predicted. bila mmfr >75 predicted dianggap normal (kriteria navy), maka terdapat 15 orang (37,5%) penderita normal, 25 (62,5%) penderita abnormal. dampak yang terjadi adalah terganggunya fungsi oksigenasi sehingga akan mempengaruhi produktifitas kerja, kualitas hidup dan peningkatan biaya perawatan (antarudin, 2003 dalam judyanto, 2004). penyakit ini bermula saat individu menghirup basil tuberkulosis dan menjadi terinfeksi. melalui jalan napas bakteri menuju ke alveoli dan memperbanyak diri. sistem imun tubuh berespons dengan melakukan respons inflamasi. fagosit (neutrofil dan makrofag) menelan banyak bakteri. massa jaringan baru yang disebut granulomas yang merupakan gumpalan basil yang masih hidup dan yang sudah mati dikelilingi oleh makrofag membentuk dinding protektif. granulomas diubah menjadi massa jaringan fibrosa. bahan (bakteri dan makrofag) menjadi nekrotik, membentuk massa seperti keju, massa ini mengalami kalsifikasi, membentuk skar kolagenase (brunner dan suddarth, 1997). pembentukan jaringan ini mengakibatkan berkurangnya luas permukaan membran pernapasan total dan meningkatkan ketebalan membran pernapasan dan seringkali menyebabkan kerusakan jaringan paru yang hebat. keadaan ini berdampak pada berkurangnya elastisitas dan compliance paru sehinngga meningkatkan kerja otot pernapasan dan menurunkan kemampuan ekspirasi maksimum (guyton dan hall, 1996). penurunan elastisitas dan compliance paru dapat pula menyebabkan ventilasi paru yang tidak maksimal dan jika tidak ditangani dengan maksimal dapat menyebabkan kecacatan paru dan bahkan atelektasis yang berujung pada kematian pasien (mulyono, 1997). latihan penapasan merupakan tindakan keperawatan dalam penatalaksanaan pasien dengan masalah gangguan sistem pernapasan. termasuk didalamnya adalah latihan pernapasan active cycle of breathing. latihan pernapasan active cycle of breathing merupakan salah satu latihan pernapasan yang selain berfungsi untuk membersihkan sekret juga dapat mempertahankan fungsi paru (pyor and webber, 1998) termasuk didalamnya dalam meningkatkan aliran ekspirasi maksimum (peterson, 1998 dalam judyanto, 2004). latihan pernapasan ini dapat mengkoordinasikan dan dapat melatih pengembangan (compliance) dan pengempisan (elastisitas) paru secara optimal (pyor and webber, 1998), serta pengaliran udara dari dalam paru menuju keluar saluran pernapasan secara maksimal (falling, 1993). dengan metode diatas diharapkan terjadi peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis. menurut penelitian yang dilakukan pardy dkk. (1991) yang dikutip dari ellida (2006) menunjukkan latihan napas yang dilakukan 15 menit akan meningkatkan ventilasi paru. hasil penelitian yang dilakukan holland (2004) dalam elida, (2006) menunjukkan pasien dengan cyctic fibrosis paru didapatkan hasil yang signifikan terhadap peningkatan aliran ekspirasi maksimum dengan teknik pernapasan active cycle of breathing, namun latihan pernapasan active cycle of breathing ini belum pernah dilakukan terhadap penderita tuberkulosis paru dan belum diketahui pengaruhnya. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah quasy experimental purposive sampling pre-posttest design. sampel diambil sesuai dengan kriteria inklusi yang telah ditentukan, dengan jumlah sampel sebanyak 14 responden, dibagi menjadi kelompok perlakuan (diberikan intervensi latihan pernapasan active cycle of breathing setiap 1 kali / hari selama 10 hari, dengan durasi pertemuan 2030 menit) dan kelompok kontrol (tanpa latihan pernafasan) dengan jumlah sampel masing-masing 7 orang. penelitian dilakukan selama bulan juni sampai dengan juli 2007. variabel independen dalam penelitian ini adalah teknik penapasan active cycle of breathing, sedangkan variabel dependen adalah peningkatan aliran ekspirasi maksimum yang ditandai dengan adanya hasil pemeriksaan pefr. instrumen yang digunakan dalam penelitian ini adalah alat peak flow meter untuk pengukuran aliran ekspirasi maksimum dan lembar observasi terhadap pefr (skala dalam bentuk skor). data yang diperoleh, dianalisis dengan menggunakan uji statistik mann whitney u test, wilcoxon signed rank test, paired ttest dan independent t-test, dengan derajat kemaknaan α<0,05. hasil hasil pada tabel 1 dapat dilihat bahwa terdapat perbedaan yang signifikan hasil post pefr antara kelompok perlakuan dan kelompok kontrol dengan hasil uji statistik dengan menggunakan independent ttest (p=0,020). pada kelompok perlakuan terjadi peningkatan nilai rerata pefr dari 138,57 menjadi 178,57 dengan hasil uji statistik menggunakan paired t-test didapatkan nilai yang signifikan antara pre dan post terhadap peningkatan pefr dengan nilai p=0,001 yang berarti ada pengaruh latihan napas active cycle of breathing terhadap peningkatan pefr. pada kelompok kontrol nilai rerata meningkat sedikit dari 117,14 menjadi 120,00 namun dengan menggunakan uji statistik paired t-test tidak didapatkan nilai yang signifikan antara pre dan post (p=0,457). pembahasan pada penyakit tuberkulosis, paru mengalami pengkejuan dan nekrosis (alsagaaf dan mukty, 1995) perubahan komposisi jaringan paru ini akan berakibat terhadap turunnya luas permukaan membran pernapasan total dan meningkatkan ketebalan membran pernapasan (guyton dan hall, 1996), hal ini akan menurunkan kemampuan mengembang paru (compliance) dan kemampuan mengempis paru (elastisitas) (alsagaaf dan mukty, 1995). penurunan compliance dan elastisitas paru tersebut apabila dibiarkan terus menerus akan mengakibatkan menurunnya volume udara yang mengisi ruang paru, sehingga pefr juga akan menurun karena pefr akan lebih besar jika volume paru juga terisi dengan volume udara yang besar pula (guyton dan hall, 1996). penyakit tuberkulosis juga mengakibatkan kelainan saluran pernapasan berupa radang atau mukosa disertai dengan kelainan penyempitan saluran pernapasan maupun penimbunan sekret (alsagaaf dan mukty, 1995). adanya obstruksi saluran pernapasan mengakibatkan penurunan nilai pefr (guyton dan hall, 1995). latihan pernapasan active cycle of breathing, terdiri atas tiga urutan pernapasan yang pertama adalah breathing control, kemudian thoracic expansion exercise dan forced expiration technique (rasmin, 2001 dan hughes and pride, 2001). pada breathing control pernapasan dikontrol seperti pernapasan orang normal dengan inspirasi 3 detik dan ekspirasi 2 detik sehingga udara yang masuk dan keluar paru lebih maksimum. dilanjutkan dengan thoracic expansion exercise, pada latihan ini dada dikembangkan dengan menahan napas selama 4 detik sebelum dihembuskan (kisner and colby, 1990). hal ini bertujuan untuk mengembangkan rongga toraks, peningkatan volume paru dan mereekspansi jaringan paru. tabel 1. pefr pada penderita tuberkulosis di ruang paru laki rsu dr. soetomo no. perlakuan kontrol perlakuan kontrol pre post pre post post post mean 138,57 178,57 117,14 120,00 178,57 120,00 sd 56,400 49,473 22,147 20,00 49,473 20,00 paired t-test (p=0,001) paired t-test (p=0,457) independent t-test (p=0,020) keterangan: p = signifikansi sd = standar deviasi mean = rerata forced expiration technique adalah hembusan kuat tanpa menutup glotis mengakibatkan pengaliran udara dari paru bagian bawah menuju paru bagian atas serta udara yang berada dalam saluran napas kecil menuju keluar, dengan hembusan kuat tanpa menutup glotis mukus yang menutupi saluran pernapasan juga dapat keluar dengan mudah sehingga udara akan keluar dengan maksimum (pyor and webber, 1998). pada penyakit paru kronis dan pengempisan paru mengakibatkan penyempitan saluran pernapasan. latihan napas dapat mengaktifkan serat-serat saraf simpatis yang sifatnya lemah, karena beberapa serat ini menembus masuk ke bagian pusat dari paru. batang bronkus berkontak secara sangat luas dengan norepinefrin dan epinefrin dalam sirkulasi, yang dilepaskan ke dalam tubuh oleh perangsangan simpatis dari medulla glandula adrenal. kedua hormon ini, terutama epinefrin menyebabkan dilatasi pada batang bronkus akibat kuatnya perangsangan pada reseptor beta (guyton dan hall, 1996). penderita tuberkulosis mengalami kelainan restriktif maupun obstruktif pada paru. kelainan restriktif membawa dampak terhadap pengembangan paru, suatu latihan pernapasan dapat melatih pengembangan dada, pengembangan dada merupakan salah satu teknik yang digunakan dalam pengembangan paru, sehingga udara yang keluar paru juga dapat meningkat karena proses ekspirasi merupakan proses yang pasif tergantung terhadap daya lenting atau elastisitas paru itu sendiri. kelainan obstruktif membawa dampak terhadap menurunnya volume udara baik yang menuju paru ataupun yang meninggalkan ruang paru dengan limitisasi ini maka nilai pefr pada penderita sangat menurun. pefr pada responden tidak dapat mencapai ≥ 400 l/menit sebagaimana pada orang normal. namun dengan melakukan active cycle of breathing technique sekali dalam 10 hari selama 20 menit mampu memperoleh nilai pefr stabil. simpulan dan saran simpulan teknik pernapasan active cycle of breathing dapat meningkatkan dan menstabilkan nilai pefr. latihan pernapasan active cycle of breathing meningkatkan elastisitas dan compliance paru pada penderita tuberkulosis sehingga volume udara meningkat dan berdampak pada peningkatan (peak expiratory flow rate) pefr. saran berdasarkan hasil penelitian ini, peneliti menyarankan agar latihan napas active cycle of breathing 1 kali dalam waktu 20 menit dapat diterapkan pada penderita tuberkulosis terutama dengan gangguan pernapasan dan hendaknya dilakukan secara kontinyu untuk mengurangi gangguan pernafasan dan meningkatkan kualitas hidup. hasil penelitian dapat menjadi dasar penetapan standar operasional (sop) latihan napas active cycle of breathing di ruang paru rsu dr. soetomo surabaya dan penelitian lebih lanjut dapat dilakukan tentang pengaruh latihan pernapasan active cycle of breathing terhadap peningkatan mmfr50-75% . kepustakaan aida, n. 1996. kekerapan hiperaktivitas bronkus pada bekas tb paru di rsup persahabatan jakarta. jakarta: bagian pulmonologi fkui jakarta, hlm. 16. alsagaff dan mukty, 1995. dasar-dasar ilmu penyakit paru. surabaya: airlangga university press, hlm. 7,11,13-15,7392. brunner dan suddarth. 2002. buku ajar keperawatan medikal bedah. edisi 8 vol.1. jakarta: egc, hlm. 584-589, 671. ellida, i. 2006. pengaruh breathing exercise: pursed lip breathing dan diafragma breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita ppok di rsu dr. soetomo. skripsi tidak dipublikasikan. surabaya: program studi ilmu keperawatan fakultas kedokteran universitas airlangga, hlm. 5-8. martiana, e. 2007. jatim penyumbang tb ke-2 di indonesia, (online), (http://www.jatim.co.id., diakses tanggal 14 april 2007, jam 20.00 wib). mulyono, d. 1997. rehabilitasi pada penderita penyakit paru obstruktif menahun. cermin dunia kedokteran, 33-37. guyton dan hall, 1996. buku ajar fisiologi kedokteran. jakarta: egc, hlm. 598, 603-604, 671, 676. gusti, a. 2003. kekerapan tb paru pada pasangan suami istri penderita tb paru yang berobat di bagian paru rsu adam malik. usu: digitalized library, (online), diakses tanggal 14 april 2007, jam 20.00 wib. falling, j. 1993. principles and practice of pulmonary rehabilitation. philadelphia: wb saunders, hlm. 176. helmia dan lulu, 2004. buku ajar ilmu penyakit paru. surabaya: graha masyarakat ilmiah kedokteran universitas airlangga, hlm. 10-21. hughes and pride, 2001. lung function test physiological principles and clinical aplication. london: wb saunders, hlm. 23. judyanto. 2004. fungsi faal paru pada penderita tuberkulosis paru di rsu dr. soetomo program studi dokter spesialis paru fakultas kedokteran universitas airlangga, penelitian tidak dipublikasikan, hlm. 16-18, 30. kisner and colby. 1990. therapeutic exercise foundation and techniques. philadelphia: fa davis, hlm. 591-592. potter dan perry. 2005. fundamental keperawatan. alih bahasa oleh yasmin asih. egc: jakarta, hlm. 791. pyor, et al. 1998. physioterapy for respiratory and cardiac problem. eidenburgh: churcill livingston, hlm. 139-145. rahayu. 2007. jatim penyumbang tb ke-2 di indonesia, (online), (http://www.jatim.co.id., diakses tanggal 14 april 2007, jam 20.00 wib). rasmin, et al. 2001. prosedur tindakan bidang paru dan pernapasan. jakarta: balai penerbit fkui, hlm. 33. http://www.jatim.co.id/ http://www.jatim.co.id/ pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru terapi kognitif menurunkan tingkat depresi lansia (cognitive therapy decrease the level of depression) ahmad yusuf*, hanik endang nihayati*, zaenal abidin** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: yusuf@fk.unair.ac.id ** sekolah tinggi ilmu kesehatan bhakti mulia pare kediri abstract introduction: aging is a natural process in individuals. most of the elderly have problems in dealing with this natural process. lost of occupation, friends and loneliness may result in depression in this age group. cognitive therapy changes pessimistic idea, unrealistic hopes and excessive self evaluation may result and justify depression. cognitive therapy may help elderly to recognize the problem in life, to develop positive objective of life and to create more positive personality. the aimed of this study was to analyze the effect of cognitive therapy to reduce the level of depression. method: this study was used a pre experimental pre post test design. sample were 10 elderly people who met to the inclusion criteria. the independent variable was cognitive therapy and dependent variable was the level of depression in elderly. data were collected by using geriatric depression scale (gds) 15, then analyzed by using wilcoxon signed rank test with significance levelα≤0.05. result: the result showed that cognitive therapy has an effect on reducing depression with significance level p=0.005. discussion: it can be concluded that cognitive therapy was effective in reducing depression level in elderly. further studies are recommended to analyze the effect of cognitive therapy on decreasing anxiety in elderly by measuring cathecolamin. keywords: cognitive therapy, depression, elderly pendahuluan lanjut usia (lansia) sebagai tahap akhir dari siklus kehidupan manusia, sering diwarnai dengan kondisi yang tidak sesuai dengan harapan. banyak faktor yang menyebabkan seorang lansia mengalami gangguan mental seperti depresi. lansia merupakan masa dimana semua orang berharap akan menjalani hidup dengan tenang, damai, serta menikmati masa pensiun bersama anak dan cucu tercinta dengan penuh kasih sayang. pada kenyataannya tidak semua lansia mendapatkan sesuai dengan yang diinginkan (syamsuddin, 2006). depresi dapat terjadi karena lansia banyak mendapat stressor. pada lansia, gangguan depresif merupakan suasana alam perasaan utama bagi lansia dengan penyakit fisik kronik dan kerusakan fungsi kognitif yang disebabkan oleh adanya penderitaan, disabilitas, perhatian keluarga yang kurang serta penyakit fisik yang bertambah buruk. adanya musibah psikososial seperti kemiskinan, isolasi sosial dan lain-lain akan meningkatkan kerentanan untuk mengalami depresi atau untuk mencetuskan kondisi depresi pada lansia yang rentan akan hal tersebut (bongsoe, 2007). beberapa stressor akan semakin kompleks saat lansia tinggal di suatu panti werdha sebagai tempat penampungan, pembuangan dan tempat menanti kematian (oswari, 1997). berbagai stressor ini membuat lansia mengalami depresi. depresi ditandai dengan pandangan negatif pada diri sendiri, lingkungan dan masa depan (beck, 1976 dalam blackburn, 1990). pandangan-pandangan negatif ini disebut distorsi kognitif. sebagai salah satu upaya untuk mengurangi dan menghentikan pikiran negatif ini dengan menggunakan terapi kognitif (nancy, 2007). lansia diharapkan dapat mengalami penurunan tingkat depresi melalui terapi kognitif. namun, pengaruh terapi kognitif terhadap ah. yusuf penurunan tingkat depresi belum dapat dijelaskan. prevalensi lanjut usia (lansia) semakin lama semakin meningkat. demikian pula dengan angka harapan hidup. jumlah penduduk lansia pada tahun 2006 sebesar kurang lebih 19 juta, usia harapan hidup 66,2 tahun, pada tahun 2010 diperkirakan sebesar 23,9 juta (9,77%), usia harapan hidupnya 67,4 tahun dan pada tahun 2020 diperkirakan sebesar 28,8 juta (11,34%), dengan usia harapan hidup 71,1 tahun. data prevalensi untuk gangguan mental lansia bervariasi secara luas. depresi adalah masalah psikiatrik yang paling sering terjadi pada lansia, menyerang paling sedikit 1 dari 6 klien yang diobati pada praktik medik umum dan menunjukkan persentase yang lebih tinggi di rumah sakit dan panti jompo. menurut who (2006) menyebutkan bahwa terdapat 121 juta penderita depresi dengan perbandingan 5,8% laki-laki dan 9,5% perempuan mengalami episode depresi dalam kehidupan mereka. di panti tresna werdha pare terdapat 10 lansia dengan depresi. depresi lansia telah menjadi masalah kesehatan utama dan dihubungkan dengan kematian dan kejadian bunuh diri (jones, 2002). penderita depresi cenderung memiliki penilaian dan pandangan yang negatif terhadap diri, lingkungan dan masa depan. pemikiran (pandangan) negatif ini mempengaruhi lansia untuk berperilaku negatif. secara global 50% dari penderita depresi berpikiran untuk bunuh diri, tetapi hanya 15% mengakhiri hidupnya. depresi berat juga dapat menimbulkan berbagai penyakit fisik, seperti gangguan pencernaan (gastritis), asma, gangguan pada pembuluh darah (kardiovaskular), serta menurunkan produktivitas. sejak depresi sering didiagnosis, who memperkirakan depresi akan menjadi penyebab utama masalah penyakit dunia pada tahun 2020 (gsianturi, 2006). banyak bukti yang mendukung efektivitas dari terapi kognitif dalam menangani depresi mayor dan mengurangi risiko episode kekambuhan (de rubeis et al., 1999; 2001; jareth et a.l, 2001; leichsenring, 2001). keuntungan yang dicapai dari terapi kognitif paling tidak sama dengan yang dicapai dari pengobatan antidepresan dalam hal menangani depresi (de rubeis, et a.l, 1999, 2001; jareth, et al., 1999). the national institute of mental health treatment of depression (2006) dengan program penelitian membandingkan efektivitas 2 bentuk psikoterapi (contohnya terapi interpersonal dan cbt) dengan inipramin (sofranil) atau placebo pada terapi 250 klien dengan gangguan depresi mayor. studi ini menemukan tidak ada perbedaan signifikan antara kedua terapi. pada studi lain 169 klien dengan depresi mayor menunjukkan hasil sama antara antidepresan trisiklik dan cbt. fakta ini menunjukkan bahwa terapi kognitif adalah antidepresan alternatif untuk klien depresi ringan sampai sedang dan mungkin depresi yang lebih berat. david et al. (2008) membandingkan keampuhan rebt (rational emotive behavior therapy), cognitive therapy dan farmakoterapi pada pengobatan 170 klien dengan non psikotik gangguan depresi mayor. klien secara acak diberi 14 minggu rebt, 14 minggu ct atau 14 minggu farmakoterapi (flukoxentin). hasilnya diukur dengan hamilton rating scale for depression and beck depression inventory. tidak ada perbedaan di antara perlakuan pada hasil post test. de rubeis et al (2002) menyatakan bahwa terapi kognitif efektif untuk menangani depresi berat dalam jangka panjang dan biayanya lebih murah dibandingkan obat antidepresan. banyaknya masalah yang ditimbulkan oleh terjadinya depresi pada lansia membuat kita semakin peka untuk terus mencari terapi yang cocok untuk mengatasinya. bukti klinis menunjukkan bahwa psikoterapi bermanfaat untuk mengatasi depresi (buschman, 1995 dikutip oleh jones, 2002). psikoterapi yang dapat dilakukan dapat berupa terapi suportif atau kombinasi terapi kognitif dan terapi behavioral (marpaung, 2003). ada dugaan bahwa penderita depresi adalah orang yang “belajar menjadi tak berdaya”. depresi diterapi dengan memberikan klien latihan ketrampilan dan memberikan berbagai pengalaman tentang kesuksesan. terapi kognitif bertujuan untuk menghilangkan gejala depresi melalui usaha yang sistematis yaitu mengubah cara pikir maladaptif dan otomatik pada klien depresi. dasar pendekatan yang digunakan adalah suatu terapi kognitif menurunkan tingkat depresi lansia asumsi bahwa kepercayaan yang mengalami distorsi tentang diri sendiri, dunia dan masa depan dapat menyebabkan depresi. klien harus menyadari cara berpikirnya yang salah, kemudian ia harus belajar cara merespons cara pikir yang salah tersebut dengan cara yang lebih adaptif. dari perspektif kognitif, klien dilatih untuk mengenal dan menghilangkan berbagai pikiran dan harapan negatif. terapi kognitif mempengaruhi korteks serebri yang memiliki dimensi kognisi dan emosi. terapi kognitif membantu klien mengenali pikiran negatif yang muncul, sehingga hal ini akan membuat persepsi yang positif. persepsi yang positif akan mempengaruhi koping yang positif. koping yang positif akan membuat dimensi kognitif menjadi positif (kognisi yang baik) dan peningkatan ini akan menyebabkan penurunan tingkat depresi. terapi kognitif diharapkan dapat menambah jenis terapi dalam penanganan depresi pada lansia dengan merubah pikiran negatif tentang diri, lingkungan serta masa depan menjadi berbagai pikiran yang positif dan realistis sehingga perilaku lansia menjadi positif. tujuan penelitian ini adalah untuk menjelaskan pengaruh terapi kognitif terhadap penurunan tingkat depresi pada lansia. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah pre experimental pre-post test purposive sampling design. populasi pada penelitian ini adalah lansia di unit pelayanan sosial tresna werdha (upstw) pare. sampel diambil sesuai dengan kriteria inklusi dan diperoleh 10 responden yang sesuai dengan kriteria inklusi. penelitian ini dilakukan selama bulan juni sampai dengan juli 2008. variabel independen adalah terapi kognitif, sedangkan variabel dependen adalah tingkat depresi. instrumen yang digunakan dalam penelitian ini adalah kuesioner geriatric depression scale (gds) yang berisi 15 butir pertanyaan untuk menilai tingkat depresi lansia (yessage et al) dan kuesioner dimensi kognitif blackburn (1990) yang telah dimodifikasi sesuai masalah psikologis lansia dengan menggunakan skala likert. data yang diperoleh, dianalisis dengan menggunakan uji statistik analisis dengan uji wilcoxon signed rank test dengan derajat kemaknaan ≤0,05. hasil pada tabel 1 dapat dilihat bahwa tampak perbedaan tingkat depresi sebelum dan sesudah diberikan terapi kognitif dengan hasil analisis statistik wilcoxon signed rank test p=0,005. terdapat perbedaan antara sebelum dan sesudah diberikan terapi kognitif (lihat gambar 1). pada gambar 2 dapat dilihat bahwa 90% responden menunjukkan dimensi kognitif negatif (kognisi yang buruk) sebelum terapi kognitif dan 90% memiliki dimensi kognitif positif (kognisi yang baik) setelah diberikan terapi kognitif. tabel 1. tingkat depresi dan dimensi kognitif lansia sebelum dan sesudah terapi kognitif. tingkat depresi dimensi kognitif pre post pre post mean 10,60 4,90 33,10 62,70 sd 1,260 2,469 0,737 2,452 hasil analisis statistik wilcoxon signed rank test (p= 0,005) wilcoxon signed rank test (p=0,004) keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata tingkatan depresi 70% 30% depresi kemungkinan depresi tingkatan depresi 10% 30% 60% depresi kemungkinan depresi tidak depresi dimensi kognitif 10% 90% positif negatif dimensi kognitif 90% 10% positif negatif gambar 1. tingkat depresi sebelum dan sesudah diberikan terapi kognitif di pstw pare kediri bulan juni 2008. gambar 2. dimensi kognitif sebelum dan sesudah terapi kognitif di pstw pare kediri bulan juni 2008 pembahasan berdasarkan hasil penelitian menunjukkan bahwa terapi kognitif berpengaruh terhadap penurunan tingkat depresi pada lansia. terapi kognitif terbukti mampu merubah pikiran negatif menjadi pikiran yang positif. gangguan depresi pada lansia disebabkan karena lansia cukup banyak mengalami berbagai peristiwa kehidupan yang tidak menyenangkan atau yang cukup berat sehingga terjadinya gangguan depresi sebagai respons perilaku terhadap berbagai stressor kehidupan yang dialami (bongsoe, 2007). banyak lansia dihadapkan pada situasi yang penuh stres seperti kematian teman atau keluarga, penurunan kesehatan dan kemampuan fisik, kesepian serta sulit membangun hubungan pertemanan baru. keadaan ini mempengaruhi lansia secara mental (stuart dan sundeen, 1995). orang depresi cenderung berfokus pada bagaimana perasaan mereka dan bukan pada pikiran yang mungkin mendasari kondisi perasaan mereka, artinya mereka biasanya memberikan lebih banyak perhatian pada bagaimana buruk perasaan mereka dibandingkan pada pikiran yang kemungkinan memicu dan mempertahankan mood yang terdepresi (nevid, et al., 2005). fungsi kognitif dan psikomotor pada lansia mengalami penurunan. perubahan fisik pada lansia pun dapat menyebabkan perubahan pada kondisi jiwa. lansia berpikir bahwa dirinya tidak dapat mengerjakan berbagai aktifitas sebaik pada saat muda dulu yang disebabkan adanya berbagai perubahan fisik pada lansia. sikap sosial yang tidak menyenangkan yang beranggapan bahwa lansia sering dianggap tidak berguna lagi. hal tersebut membuat lansia tidak semangat dalam mengerjakan apapun. kehilangan pekerjaan yang pernah ditekuni, berada di panti, tidak punya keluarga atau sanak saudara karena hidup membujang, atau punya pasangan hidup namun tidak punya anak dan pasangannya sudah meninggal juga membuat lansia berpikir bahwa mereka adalah orang yang gagal dan tidak lagi berguna seperti dulu. ah. yusuf kaum lansia sering dianggap tidak berdaya, sakit-sakitan, tidak produktif dan sebagainya. tak jarang mereka diperlakukan sebagai beban keluarga, masyarakat, hingga negara. lansia sering tidak disukai dan dikucilkan. panti werdha merupakan salah satu tempat yang dipilih (bahkan oleh keluarga) sebagai tempat tinggal. kesepian, merasa terbuang dan bosan dengan hidupnya sering dialami oleh lansia yang tinggal di panti. kondisi ini yang kemudian akan menyebabkan lansia menarik diri dari lingkungan sosial dan merasa semakin tidak berguna, kehilangan harga diri bahkan menjadi semakin depresi. seseorang yang depresi memiliki kecenderungan untuk membesar-besarkan masalah. kekecewaan kecil dan kegagalan pribadi dibesar-besarkan melampaui proporsinya, bahkan dapat menjadi ancaman yang merusak. pada banyak kasus, depresi adalah hasil dari kebiasaan berpikir negatif baik terhadap diri, lingkungan dan masa depan. ketika hal buruk terjadi, seseorang mulai mengikuti apa yang dia pikirkan dan pikiran negatif inilah yang menjadikan seseorang depresi. orang yang depresi cenderung memegang pandangan yang lebih pesimistis akan masa depan serta lebih kritis terhadap dirinya sendiri dan orang lain (glara et al, 1993). depresi seseorang dapat diatasi dengan menghentikan berbagai pikiran negatif dan menggantinya dengan pikiran positif. terapi kognitif akan membantu orang yang mengalami depresi mengenali masalah kehidupan yang buruk dan juga membantu untuk mengembangkan tujuan hidup yang positif dan mengkaji kepribadian yang lebih positif (donald, 2003). terapi kognitif yang diberikan diharapkan dapat membantu lansia mengenali pikiran negatif yang muncul, sehingga hal ini akan membuat persepsi positif. persepsi positif akan mempengaruhi koping yang positif. koping yang positif akan membuat dimensi kognitif menjadi positif (kognisi baik) dan ini akan menyebabkan penurunan tingkat depresi. terapi kognitif bertujuan membantu klien mengenali dan mengkaji kembali pola kognitif negatif ini dan menggantinya dengan pola kognitif yang positif sehingga terjadi penurunan tingkat depresi (nancy, 2007). terapi kognitif merubah pemikiran pesimis, harapan yang tidak realistik dan evaluasi diri yang mencela yang membuat depresi. melalui kegiatan terapi kognitif lansia dapat mengungkapkan hal yang positif melalui tulisan sehingga dapat meningkatkan kepercayaan diri dan harga diri lansia. hal ini akan merubah pandangan terhadap diri, lingkungan dan masa depan ke arah positif. terapi kognitif membuat asumsi bahwa pikiran yang mendahului mood dan kepercayaan diri yang salah menuntun emosi yang negatif. klien depresi menunjukkan penyimpangan dalam pengetahuan, proses kognitif dan hasil kognitif. pengetahuan dibentuk dari keyakinan pendapat tentang diri kita, orang lain dan dunia. pengetahuan ini akan menentukan proses jalan pintas dan berbagai kesalahan dalam cara berpikir kita yang pada akhirnya menentukan isi dan hasil kognitif. aspek berpikir ini diharapkan dapat membantu untuk memahami mengapa dan bagaimana orang yang mengalami depresi (beck dalam blackburn, 1990). tingkat depresi pada penelitian ini menunjukkan perubahan setelah dilakukan terapi kognitif demikian pula dengan dimensi kognitif. terlihat perbedaan antara sebelum dan sesudah diberikan terapi kognitif. pada lansia, gangguan depresi disebabkan karena kerusakan fungsi kognitif yang disebabkan oleh adanya penderitaan, disabilitas, perhatian keluarga yang kurang serta bertambah buruknya penyakit fisik yang banyak dialaminya. gangguan depresif merupakan suasana alam perasaan yang utama bagi lansia (bongsoe, 2007). menurut teori aktivitas, peran yang disandang oleh lansia adalah sumber kepuasan yang besar; semakin besar mereka kehilangan peran setelah masa pensiun, menjanda, jauh dari anak-anak, atau infirmitas, maka semakin merasa tidak puaslah mereka. hubungan antara berpikir negatif dan depresi bergantung pada keseimbangan antara pikiran positif dan negatif bukan hanya pada keberadaan dari pikiran negatif saja. orang yang berfungsi baik secara psikologis mengalami baik pikiran positif dan negatif sekaligus, namun pikiran positif muncul satu setengah hingga dua kali lebih sering sering dari pada pikiran negatif (brunch, 1997; lightsey, 1994a, 1994b). ah. yusuf kognisi mempengaruhi aliran kesadaran mereka yang mencerminkan tentang diri mereka sendiri, dunia mereka, masa lalu serta masa depan mereka. klien depresi memiliki dimensi kognitif yang negatif berkaitan dengan pandangan terhadap diri, lingkungan serta masa depan. proses kognitif mengacu pada aturan yang berlaku bagi stimulus dalam memproses informasi. teori kognitif meyakini bahwa orang depresi mengadopsi cara berpikir yang negatif. keyakinan ini akan membuat mereka menjadi lebih sensitif dalam kehidupan selanjutnya sehingga mengintepretasikan kegagalan atau kekecewaan apapun sebagai refleksi dari sesuatu yang pada dasarnya salah atau tidak adekuat mengenai diri mereka sendiri (beck, 1976; beck et al., 1979). terapis kognitif berfokus untuk membantu klien mengidentifikasi dan memperbaiki berbagai keyakinan maladaptif, berpikir otomatis dan sikap self-defeating yang menghasilkan atau menambah masalah emosional. mereka percaya bahwa emosi negatif seperti kecemasan dan depresi disebabkan oleh interpretasi kita terhadap peristiwa yang mengganggu, bukan pada peristiwa itu sendiri (nevid et al., 2005). simpulan dan saran simpulan terapi kognitif mempunyai pengaruh terhadap tingkat depresi pada lansia dengan memberikan stimulus berupa merubah pemikiran lansia yang negatif terhadap permasalahan yang mereka hadapi dengan merubah kognisi lansia yang negatif (buruk) terhadap diri, lingkungan serta masa depan mereka sehingga menjadi kognisi yang positif (baik). hal tersebut dibuktikan dengan adanya perubahan tingkat depresi dan dimensi kognitif lansia ke arah yang lebih baik setelah diberikan terapi kognitif. saran peneliti menyarankan supaya lansia disarankan untuk tetap menerapkan terapi kognitif secara rutin, terapi kognitif diharapkan dapat terus diterapkan di panti werdha pare kediri dapat diteruskan dengan memfasilitasi lansia untuk selalu mendengarkan permasalahan lansia dipanti dan mengenali pikiran-pikiran negatif lansia yang muncul sehingga lansia tidak akan mengalami depresi, terapi kognitif menjadi salah satu tindakan keperawatan dalam mencegah atau menurunkan tingkat depresi lansia, serta diharapkan penelitian lebih lanjut dapat dilakukan tentang pengaruh terapi kognitif terhadap kecemasan pada lansia dengan mengukur katekolamin. kepustakaan beck, j. s. 2008. questions and answers about cognitive therapy, diakses tanggal 5 mei 2008, jam 11.00 wib. blackburn, i.m dan davidson, k. 1990. terapi kognitif untuk depresi dan kecemasan. terjemahan oleh rusdakotosutadi 1990, semarang: ikip semarang, hlm. 23-33. bongsoe, s. 2007. pengenalan gangguan depresif pada orang usia lanjut, diakses tanggal 4 mei 2008, jam 11.30 wib. david, d., et al. 2008. rational emotive behavior therapy, cognitive therapy, and medication in the treatment of major depressive disorder. a randomized clinical trial, post treatment outcomes, and six month follow up, journal of clinical psycology, 64(6), hlm. 728-733. donald, j.f. 2003. cognitive therapy for depression, (online), (http://www.psychologyinfo.com., diakses tanggal 20 mei 2008, jam 11.30 wib). gallo, j.j. 1998. buku saku gerontology. alih bahasa oleh james veldman, 1998. jakarta: egc, hlm. 80-97. gsianturi. 2006. depresi, pintu masuk berbagai penyakit, (online), (http://www.suarapembaharuan.comdi akses tanggal 4 mei 2008, jam 12.00 wib). marpaung, v. 2003. depresi pada penderita epilepsy umum dengan kejang klonik tonik dan epilepsy parsial sederhana, (online), (http://www.library.usu.ac.id., diakses tanggal 5 mei 2008, jam 11.00 wib). http://www.psychologyinfo.com/ http://www.suarapembaharuan.com/ http://www.library.usu.ac.id/ nevid, j.s., et al. 2005. psikologi abnormal. terjemahan oleh murad, j. dkk. jakarta: erlangga. stuart and sundeen. 1995. principles and practice of psychiatric nursing fifth edition, missouri: mosby inc., pp. 751753. syamsuddin. 2006. depresi pada lansia, (online), (http://www.depsos.go.id., diakses tanggal 5 mei 2008, jam 10.00 wib). http://www.depsos.go.id/ 106 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.9950 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research diabetic foot spa implementation in early neuropathy diagnosis based on blood glucose levels, foot sensitivity and the ankle brachial index in patients with diabetes mellitus erika martining wardani, chilyatiz zahroh and nur ainiyah university of nahdlatul ulama surabaya, indonesia abstract introduction: diabetes mellitus (dm) is a cause of morbidity mainly due to vascular complications. the prevention of diabetic foot problems can be done through metabolic control and foot exercises. the purpose of this study was to determine the effect of diabetes foot spa measures on blood glucose levels, foot sensitivity and the ankle brachial index. methods: this research was a pre-experimental design. the population totaled 170 dm patients and the sample was finalized at 30 respondents. the independent variable was diabetic foot spa, while the dependent variables were blood glucose levels, blood sensitivity and the ankle brachial index. the data was analyzed using a t-test and wilcoxon rank test. results: diabetic foot spa in early neuropathy detection testing has a blood glucose level of t=9.523 and a p value=0.000. diabetic foot spa also significantly affects foot sensitivity with a ρ <α (0.001<0.05) and an ankle brachial index of (abi) ρ<α (0.008 < 0.05). conclusion: diabetic foot spa conducted regularly and independently can reduce the level of complications in diabetes mellitus patients. furthermore, the tingling and pain in the feet can be reduced or even disappear as well as preventing complications such as foot ulcers that can often become amputations. article history received: oct 05, 2018 accepted: oct 29, 2019 keywords ankle brachial index; blood glucose levels; diabetic foot spa; diabetes mellitus; foot sensitivity contact erika martining wardani  erika@unusa.ac.id  university of nahdlatul ulama surabaya, indonesia cite this as: wardani, e., m., zahroh, c., & aniyah, n. (2019). diabetic foot spa implementation in early neuropathy diagnosis based on blood glucose levels, foot sensitivity and the ankle brachial index in patients with diabetes mellitus. jurnal ners, 14(1), 106-110. doi:http://dx.doi.org/10.20473/jn.v14i1.9950 introduction diabetes mellitus is one of the metabolism disorders that is very common in the world. urbanization has led to histrionic changes in lifestyle, especially in developing countries with rapid transitions along with an increase in the risk factors of noncommunicable disease such as dm. diabetes mellitus type 2 can cause various complications for the patients, either acute or chronic. the chronic complications that can occur include motor neuropathy and vascular peripheral disease. almost 60% of patients suffer from these complications (black & hawks, 2014). complications can cause an obstruction of blood flow to organs via microangiopathy and macroangiopathy (smeltzer & bare, 2001). dm patients with gangrene often require amputations. dm patients have a higher chance of experiencing lower leg amputations; up to 15 times more than those without dm (greenstein & wood, 2010). the international diabetes federation has shown that 382 million people are suffering from dm to date. the amount will increase to become 592 million people in 2035. out of this amount, 175 million people are unaware of their condition. more than 80% of ailed people are living in a low earning country and are from the middle class. the incidence of dm in the age range of 40 59 years old in 2014 reached 387 million people. this number is expected to increase to 529 million by 2035 (international diabetes federation) [idf], 2013). according to (idf, 2013), there are 9.1 million dm cases in indonesia. the high rate of dm in indonesia has positioned indonesia as having the largest number of dm cases in the world after china, india, brazil, and the united states (idf, 2013). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 107 based on the 2012 annual hospital report, the largest number of outpatients (as of may 31st, 2013) in type b and c hospitals in east java was for dm (137,427 cases). the highest number of inpatients in hospitals b and c was for dm (17,990 cases) (riskesdas, 2018). dm in surabaya has seen an increase in the number of cases from 15,961 in 2009 to 21,729 in 2010. then it increased to 26,613 in 2011. thus, the number of dm patients has increased from 2009 2011. in 2012, it increased to 21,268 cases (riskesdas, 2018). diabetic foot prevention can be done through metabolism control that places an emphasis on nutritional status, blood glucose levels, vascular control by doing foot exercises and non-invasive vascular examinations such as the ankle brachial index, toe pressure, and ankle pressure checks regularly. this is as well as the modification of the risk factors such as quitting smoking and putting on special footwear (ganong, 2008). there are various ways to prevent, cure, and control the complications that are a part of dm characteristics (tang, et al., 2013), manage stress, because stress can increase glucose level (bistara, et al., 2019) and dietary compliance (bistara & ainiyah, 2017). foot treatment for dm patients can prevent the risk of diabetic foot ulcers (mahfud, 2012). foot care or foot treatment is one factor which can affect peripheral blood circulation. diabetic foot spa is a foot care series in which the activities include foot exercises, warm water cleansing and massage (purwanti, 2013). regular foot care can reduce the number of amputations by around 50% (windasari, 2015). this is according to the program of dm control in indonesia, which is focused on controlling the risk factors to reduce the number of illnesses, deformity and death that are caused by dm (perkeni, 2011). related research with the title ‘the effect of foot exercises on the blood glucose level of diabetes mellitus patients type ii’. this was conducted in cawas public health center with the result that there is an effect from foot exercises on the blood glucose level of the diabetes mellitus type ii patient (eraydin & avsar, 2017). warm water therapy is useful to improve blood circulation, to reduce muscle tone stiffness, to activate relaxed feeling and to stimulate the nerve endings to create a refreshing feeling (suandika, 2016). warm compress also as pain release (zahroh & faiza, 2018). this study has the purpose of determining the effect of diabetic foot spa actions on blood glucose levels, foot sensitivity and the ankle brachial index. materials and methods the design of this study was a pre-experiment, which the researcher measures blood glucose levels, foot sensitivity, ankle brachial index (abi) scores before and after the diabetic foot spa intervention. the population of this research totaled 170 respondents. the samples were obtained through probability sampling (simple random sampling technique) focused initially on 30 respondents. the blood glucose level measurement, foot sensitivity, and abi score was taken before and after the intervention. the patients with dm type ii were from waru health center sidoarjo. the data process began from taking permission to conduct the research. to determine the neuropathy diagnosis, the researcher used the medical record available from the public health center. the number of samples used in each intervention and control group totaled 30 people who met the inclusion criteria, namely type 2 dm patients who did not have lower limb complications such as diabetic ulcers, no broken bones in the legs, in the age range of 41 60 years old, with a blood glucose level that was less than 600 mg%, where they had had diabetes mellitus for less than 5 years, and where they had no chronic disease. the diabetic foot spa consists of various activities such as diabetic foot exercises before the foot spa is conducted, skin cleansing using the gentle and light baby bath soap, a pedicure if the respondents have long nails, cutting and scraping their nails and a foot mask by applying a scrub to clean off the dead skin cells. however, this cannot be done every day due to avoiding the skin from becoming slighter. a foot massage is a superficial massage of the foot for the purpose of increasing the circulation of the blood. the last step is applying a moisturizing cream to the skin. this is useful for avoiding dry skin. the diabetic foot spa was done ± 30 minutes over 3 days consecutively in the group treatment (wardani, et al., 2019). the implementation of the spa for diabetic feet began with diabetic foot exercises with the aim of making the blood circulation smooth. the activity is then continued by soaking the feet in warm water at a temperature of 40-410c. moreover, a sphygmomanometer was used to measure the ankle brachial index score. foot sensitivity was measured using a cotton and hammer, scratched on the sole of the foot. glucose level was measured using a glucometer. the data analysis used for the blood glucose level was a t test. the data from the sensitivity and abi score were measured using the wilcoxon sign rank test. this research had ethical clearence and it was conducted in unusa, no. 183/ec/kepk/unusa/2018. results table 1 shows that of the distribution respondents from the group, most of them (56,6%) were 56 65 years old, female (66,6 %) and occupation as traders (70%). the mean score of anckle branchial index before the intervention was 3.23, after the intervention showed an increase of 3.77. the mean value of foot sensitivity before the intervention shows 2.5, this value has increased after getting intervention that is equal to 3, while the average value of blood glucose level, has decreased, before the intervention shows e. m. wardani et al. 108 | pissn: 1858-3598  eissn: 2502-5791 the number 289.23 after being given an intervention of 124.57. the results of this study indicate that the diabetic foot spa has a significant effect on the anckle branchial index (p=0.001), foot sensitivity (p =0.001) and blood glucose levels (p=0.001) (table 2). discussion the activities not only improve blood flow but they also make the patients feel comfortable and relaxed. diabetic foot exercise is an effective way to improve the abi score. foot exercises are a way to improve circulation, especially of the feet. foot exercises, which are an aerobic, are focused on the movement variations in the foot area that meet the criteria of continuous, rhythmical, interval, progressive and focused on endurance. each step should be done completely (wahyuni, 2013). the recommended exercise for dm patients is aerobics, meaning that it needs oxygen that can help the circulation of the blood, to strengthen the main muscles of the foot, to prevent the foot deformities that can reduce the potential of diabetic foot wound and to improve the insulin production used for glucose transport to the cells. this can help to reduce the level of blood glucose (dewi, et al., 2012). during the skin cleansing, the client’s feet are soaked in warm water at a temperature of 41 – 420 c. according to the research of suandika, soaking the feet in to warm water at a certain temperature can improve the blood circulation, reduce edema and increase the circulation to promote muscle relaxation. the heat of the warm water can cause blood vessel dilation which leads to an improvement in blood circulation (suandika, 2016) and release pain (zahroh & faiza, 2018). through foot exercise therapy and soaking the feet in warm water, this activity also increases the abi score. the nerve point of people with type 2 diabetes mellitus is the pancreas. this is a pancreatic point closely related to the hormone insulin which affects the blood levels in the body (ruben, et al., 2016). emphasizing the point of reflection on the foot with that of the pancreas, it is located on both the right and left sides of the foot. the inside of the nerve receptors will work and the stimulation will turn into electricity or bioelectrics. this will spread to the brain and start in the pancreas, thereby increasing the hormone insulin. this allows the calcium levels in the blood to become balanced. in this study, we also added massage to the points between the thumb and forefinger of the foot (mahendra, et al., 2008). the emphasis is on repetition focused on the area of the foot reflection points which also makes the blood circulation system become smooth because of the bioelectricity stimulation. this helps to destroy clots in the bloodstream, thus helping to neutralize the excessive carbohydrates in the blood. this will lead to the improvement of the abi. in this study, the researcher used an acupressure technique 30 times with a clockwise emphasizes (mahendra, et al., 2008). based on the research above, it is shown that the abi of a person with dm can be controlled and enhanced by doing the aforementioned activities, especially focused on the movements of the foot. the activities should be done regularly in a measured manner, in addition to properly and correctly. a diabetic foot spa activity that is done seriously will stimulate the blood vessels to circulate smoothly which is shown by the perspiration on the body. this can increase the insulin production of the pancreas, thus improving the ankle brachial index score (wardani, et al., 2019). it is shown that the blood glucose levels of a person with diabetes mellitus can be controlled or reduced by using such energy in an activity. diabetic foot prevention cannot be separated from general disease control including blood glucose level control, nutritional status, blood pressure, cholesterol level and a healthy lifestyle. if the foot sensitivity is not continuously kept in a good condition, then it is likely that people with diabetes will experience diabetic foot disorders. this increases the risk of amputation and even the risk of death. this therapy can increase the sensitivity and circulation of the foot. the foot spa affects the decrease in blood sugar levels and it can increase the sensitivity of the foot. this research has positive implications. that is, it can have an impact related to increasing the sensitivity of the foot when it is done within 2 weeks properly and according to the sop spa guidelines for diabetic feet. puskesmas nurses should be given training through training of trainer (tot). monitoring the effectiveness of the interventions and providing motivation can be carried out by the cadres in each table 1. frequency distribution of age, gender and profession (n=30) demographic data n % age 36-45 46-55 56-65 0 13 17 0 43,.4 56.6 gender male female 10 20 33.4 66.6 occupation unemployed government employees traders house work assistance security 6 1 21 2 0 20 3.4 70 6.6 0 jurnal ners http://e-journal.unair.ac.id/jners | 109 region. the health service places nurses in the puskemas with a minimum education level of a bachelor’s of nursing. they strive to have specialist nurses that are responsible for developing and managing non-communicable diseases control programs, especially diabetes mellitus, through empowering programs and developing diabetic foot spa center (jansink, 2010). the scope of nursing education in terms of community service assists in managing health problems, especially diabetes mellitus, by the means of students being equipped with how to properly practice diabetic foot spa. therefore, health education is important when it comes to providing nursing care to people with diabetes mellitus due to their limited ability, including the prevention of the risk of injury due to diabetes. the limitation of this study was not examining the characteristics of the respondents who may have a relationship with foot sensitivity and/or blood sugar levels. the characteristics that were not examined include culture, the consumption of food that is carried out, the daily activities undertaken and the patient’s compliance with carrying out the therapies recommended by doctors, nurses and other health professionals. conclusion a foot spa is an intervention which it is carried out regularly and independently. this will result in the tingling sensation and pain in the feet being reduced. moreover, these problems can be removed and the patients can avoid complications such as ulcerations and amputation. references bistara, d. n. & ainiyah, n., 2017. hubungan pengetahuan dengan kepatuhan diet pada penderita diabetes mellitus di posuandu lansia cempaka kelurahan tembok. journal of health sciences, 11(1), pp. 51-57. https://doi.org/10.33086/jhs.v11i1.117 bistara, d. n., zahroh, c. & wardani, e. m., 2019. tingkat stress dengan peningkatan kadar gula darah pada penderita diabetes mellitus. jurnal ilmiah keperawatan, 5(1), pp. 77-82. black, j. & hawks, j., 2014. keperawatan medikal bedah. jakarta: salemba emban patria. dewi, p., sumarni, t. & sundari, r., 2012. pengaruh senam diabetes mellitus dengan nilai abi (ankle brachial index) pada pasien diabetes mellitus di puskesmas padamara purbalingga. jurnal stikes harapan bunda, volume 5, pp. 1-6. eraydin, s. & avsar, g., 2017. the effect of foot excercise on wound healing in type ii diabetic patients with a foot ulcer. journal wound ostomy continence nurs, 45(2), pp. 123-130. doi: 10.1097/won.0000000000000405 ganong, w. f., 2008. fisiologi kedokteran. jakarta: egc. greenstein, b. & wood, d., 2010. at a glance system endocrine. jakarta: erlangga. idf, 2013. international deabetes mellitus atlas. usa: idf. jansink, r., 2010. primary care nurses struggle with lifestyle counseling in diabetes care. bmc family practice, 11(1), p. 41. https://dx.doi.org/10.1186%2f1471-229611-41 mahendra, b., kruinastuti, d., tobing, a. & alting, b. z., 2008. care yourself diabetes mellitus. jakarta: penebar plus. mahfud, m., 2012. hubungan perawatan kaki pasien diabetes mellitus tipe ii dengan kejadian ulkus diabetik di rsud dr. muwardi. surakarta: fakultas kedokteran universitas muhammadiyah surakarta. perkeni, 2011. konsensus pengelolaan dan pencegahan diabetes mellitus tipe 2 di indonesia. jakarta: perkeni. table 2. the dispute of the ankle brachial index, foot sensitivity, and. the blood glucose levels before and after the intervention of diabetic foot spa (n=30) variable mean std. deviation std. error mean p-value ankle brachial index pre-test 3.23 0.817 0.149 0.001 post-test 3.77 0.430 0.079 foot sensitivity pre-test 2.50 0.630 0.115 0.001 post-test 3.00 0.000 0.000 blood glucose levels pre-test 289.23 99.524 18.171 0.001 post-test 124.57 33.056 6.035 e. m. wardani et al. 110 | pissn: 1858-3598  eissn: 2502-5791 purwanti, o., 2013. analisis faktor risiko terjadi ulkus kaki pada pasien diabetes mellitus di rsud dr. muwardi. jakarta: fakultas kedokteran universitas indonesia. riskesdas, 2018. laporan hasil riset kesehatan dasar nasional 2018. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan ri. ruben, g., rottie, j. v. & karundeng, m. y., 2016. pengaruh senam kaki diabetes terhadap perubahan kadar gula darah pada pasien diabetes mellitus tipe 2 di wilayah kerja puskesmas enemawira. ejurnal keperawatan, 4(1). smeltzer, s. & bare, b., 2001. buku ajar keperawatan medikal bedah. jakarta: egc. suandika, m., 2016. pengaruh rendam kaki air hangat terhadap peningkatan sirkulasi darah perifer dilihat dari ankle brachial index (abi) pada pasien diabetes mellitus di desa purwojati. medisains, 14(1). tang, z.-h., fang, z. & zhou, l., 2013. human genetic of diabetic vascular complications. journal of genetics, 92(3), pp. 677-694. https://doi.org/10.1007/s12041-013-02881 wahyuni, t., 2013. ankle brachial index sesudah senam kaki diabtes pada penderita diabetes mellitus tipe ii. jurnal keperawatan, 4(2). wardani, e. m., wijayanti, l. & ainiyah, n., 2019. the effect of diabetic foot spa on ancle brachial index and foot sensitivity of diabetes mellitu type 2. jurnal keperawatan respati yogyakarta, 6(3), pp. 672-676. https://doi.org/10.35842/jkry.v6i3.391 windasari, n., 2015. pendidikan kesehatan dalam meningkatan kepatuhan merawat kaki pada pasien diabetes mellitus tipe ii. muhammadiyah journal of nursing, 2(1), pp. 79-90. zahroh, c. & faiza, k., 2018. pengaruh kompres hangat terhadap penurunan nyeri pada penderita penyakit arthtitis gout. journal of ners and midwifery, 5(3), pp. 182-187. https://doi.org/10.26699/jnk.v5i3.art.p18 2-187 pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru breathing exercise meningkatkan respons penerimaan psikologis anak usia pra sekolah (breathing exercise relaxation increase phsycological response preschool children) yuni sufyanti arief*, nuzul qur’aniati*, fransisca kristiningsih* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: yuni_psik@ yahoo.com abstract introduction: being hospitalize will be made the children become stress. hospitalization response of the child particularly is afraid sense regard to painfull procedure and increase to attack the invasive procedure. the aimed of this study was to describe the influence of breathing exercise relaxation technique regarded to phsycological receiving responses in the preeliminary school chidren while they were receiving invasive procedure. method: a quasy experimental purposive sampling design was used in this study. there were 20 respondents who met to the inclusion criteria. the independent variable was the breathing exercise relaxation technique and the dependent variable was phsycological receiving responses. data for phsylogical response were collected by using observation form then analyzed by using wilcoxon signed rank test and mann whitney u test with significance level α≤0.05. result : the result showed that breathing exercise relaxation technique had significance influence to phsycological response (p=0.000). discussion: it,s can be concluded that breathing exercise relaxation technique has an effect to increase pshycological response in preeliminary school children who received invasive procedure. keywords: breathing exercise, phsycological response, invasive procedure, preeliminary school children pendahuluan rumah sakit secara umum dapat mengakibatkan stres karena berbagai faktor yang berkaitan dengan stres perpisahan, perubahan rutinitas, kondisi tidak familiar dengan orang serta lingkungan sekitar dan ketakutan serta nyeri yang berkaitan dengan kondisi sakit serta pengobatan (rudolph, 2006). hospitalisasi menggambarkan ketegangan dan merupakan krisis yang tampak pada anak, karena anak mengalami stres akibat perubahan lingkungan, perubahan status kesehatannya dan anak mempunyai sejumlah keterbatasan dalam mekanisme koping. anak usia prasekolah menginterpretasikan hospitalisasi sebagai hukuman dan perpisahan dengan orangtua sebagai kehilangan kasih sayang. reaksi yang dapat ditunjukkan anak usia prasekolah selama hospitalisasi antara lain menolak makan, kurang kooperatif, sering bertanya, menangis dan bahkan dapat menimbulkan reaksi agresif seperti marah dan berontak baik secara perilaku maupun verbal (supartini, 2004). keterbatasan pengetahuan mengenai tubuh meningkatkan rasa takut yang khas antara lain rasa takut terhadap prosedur yang menyakitkan, sebagai contoh takut akan kerusakan kulit akibat tindakan pemasangan infus atau pengambilan darah (muscari, 2005). prosedur tersebut menyebabkan nyeri dan perlukaan tubuh yang dapat menjadi trauma bagi anak dan berlanjut pada penolakan anak terhadap prosedur invasif (ellis, 2004). menurut wong (2004), bentuk reaksi perilaku anak pra sekolah terhadap cedera dan nyeri tubuh akibat prosedur invasif salah satunya ditunjukkan dengan regresi dan respons fisiologis yang akan berlanjut pada penolakan anak terhadap tindakan perawatan yang diberikan. hasil pengamatan suparto (2006) yang dikutip oleh ni luh (2008), melaporkan bahwa 70% anak yang dirawat di rumah sakit menunjukkan perilaku awal yang negatif (agresif maupun depresif), dengan tidak memandang jenis penyakit utamanya. hasil dari pengamatan lain yang dilakukan yasmara (2007) terhadap 18 anak di ruang anak rsu dr. soetomo menunjukkan bahwa sebagian besar anak usia prasekolah yang mendapat prosedur tindakan invasif selama hospitalisasi memperlihatkan respons penerimaan yang negatif terhadap prosedur invasif (injeksi obat) yaitu 83% anak menangis/menjerit, 67% menarik anggota tubuh dan membutuhkan penahanan fisik. niven (2005) menyatakan bahwa pada saat stres akan terjadi peningkatan kortisol yang dapat menghambat pembentukan antibodi dan menurunkan pembentukan sel darah putih. penurunan antibodi akan menurunkan imunitas tubuh. jika hal ini dibiarkan maka akan berakibat pada proses penyembuhan penyakit menjadi terhambat, waktu perawatan lebih lama dan meningkatkan risiko terjadinya komplikasi selama perawatan (nursalam dan susilaningrum, 2005). berdasarkan hal tersebut penting dilakukan suatu upaya untuk menghilangkan kecemasan tersebut. penanggulangan stres hospitalisasi pada anak dapat menggunakan beberapa tehnik antara lain dengan tehnik relaksasi breathing exercise dalam bentuk permainan. bentuk sederhana dari relaksasi adalah apa yang kita sebut “bernafas dan meniup”. cara ini dapat diajarkan pada usia lebih dari 3 tahun, tehnik ini sangat efektif untuk membantu anak rileks dan memberi mereka kontrol dalam situasi yang membuat nyeri dan melukai (patti, 2005). pada tahun 2006, kusumawati mencoba menggunakan tehnik relaksasi imagery terhadap respons penerimaan (psikologis dan biologis) dalam pelaksanaan prosedur invasif pada anak usia sekolah di ruang melati rsu dr. soedono madiun. aktifitas bermain maupun berbagai terapi lain yang pernah diteliti sebenarnya juga pernah diberikan, namun pelaksanaannya masih belum rutin dan belum disesuaikan dengan protap yang telah ada di ruangan. di paviliun 14 rsk st. vincentius a paulo surabaya selama ini belum pernah melakukan aktivitas bermain dengan nafas dalam, khususnya pada anak usia prasekolah yang menjalani prosedur invasif. pemberian tehnik relaksasi breathing exercise ini diharapkan dapat merubah respons penerimaan anak pada saat prosedur invasif menjadi adaptif. berdasarkan gambaran di atas maka peneliti mencoba menjelaskan pengaruh tehnik relaksasi breathing exercise terhadap respons penerimaan psikologis pada anak usia prasekolah yang menjalani prosedur invasif di paviliun 14 rsk st. vincentius a paulo surabaya. bahan dan metode desain yang digunakan dalam penelitian ini adalah quasy experimental prepost test design. populasi dalam penelitian ini adalah semua pasien anak usia prasekolah yang dirawat di paviliun 14 rsk st. vincentius a paulo surabaya. besar sampel dalam penelitian ini adalah 20 anak yang diperoleh dengan menggunakan tehnik purposive sampling. kriteria inklusi pada penelitian ini antara lain pasien anak usia prasekolah (3-6 tahun), baru pertama kali dirawat di rumah sakit dengan hari rawat 1 sampai 7 hari, pasien mendapatkan prosedur invasif seperti pemasangan infus, pemberian obat melalui iv atau im dengan jenis obat yang sama atau hampir sama viskositasnya, dalam keadaan sadar, belum pernah mendapatkan terapi pernafasan selama perawatan dan orang tua pasien bersedia menjadi responden. penelitian ini dilakukan selama januari 2009. sampel yang diperoleh dibagi menjadi 2 kelompok yaitu kelompok kontrol dan kelompok perlakuan. pengambilan sampel dilakukan dari 2 ruangan yang berbeda di paviliun 14 rsk st. vincentius a paulo surabaya dengan maksud agar terapi pernafasan yang diberikan tidak saling mempengaruhi. variabel independen dalam penelitian ini yaitu tehnik relaksasi breathing exercise sedangkan variabel dependen adalah respons penerimaan psikologis yang menjalani prosedur invasif. data respons penerimaan psikologis diperoleh dengan menggunakan lembar observasi. data tersebut kemudian ditabulasi dan dianalisis dengan menggunakan uji statistik wilcoxon signed rank test dan mann whitney u test dengan derajat kemaknaan α<0,05. hasil yuni s hasil penelitian ini menunjukkan bahwa pada saat pra tes 9 anak (90%) baik pada kelompok kontrol maupun perlakuan memiliki respons penerimaan psikologis yang maladaptif. pada paska tes 10 anak pada kelompok perlakuan (100%) menunjukkan respons penerimaan psikologis yang adaptif, sedangkan pada kelompok kontrol tidak terjadi perubahan. pada tabel 1 dapat dilihat bahwa tehnik relaksasi breathing exercise mempunyai pengaruh yang signifikan terhadap respons psikologis dengan hasil analisis statistik wilcoxon signed rank test didapatkan nilai signifikansi p=0,004. hasil penelitian ini menunjukkan terdapat perbedaan respons penerimaan psikologis yang signifikan antara kelompok kontrol dan kelompok perlakuan pada anak usia prasekolah dengan hasil analisis statistik mann whitney u test menunjukkan nilai signifikansi p=0,000. pada kelompok perlakuan terjadi perubahan respons maladaptif pada pra tes (rerata 48; standar deviasi 15,492) menjadi respons adaptif paska tindakan breathing exercise (rerata 74; standar deviasi 10,750). pembahasan hasil penelitian menunjukkan bahwa 90% responden baik pada kelompok kontrol maupun kelompok perlakuan saat dilakukan pra tes menunjukkan respons psikologis maladaptif yang terlihat pada sikap anak yang menolak kehadiran perawat, tidak bersedia mendengarkan instruksi perawat, anak tidak kooperatif dan anak menangis keras saat dilakukan perawatan. kondisi ini terjadi karena pada saat anak dirawat di rumah sakit, anak akan mengalami berbagai perasaan yang tidak menyenangkan seperti marah, takut, cemas, sedih dan nyeri. perasaan tersebut merupakan dampak dari hospitalisasi karena berbagai faktor yang berkaitan dengan stres perpisahan, perubahan rutinitas, kondisi tidak familiar dengan orang atau lingkungan sekitar, ketakutan dan nyeri yang berkaitan dengan kondisi sakit serta pengobatan (rudolph, 2006). wong (2004) menyatakan bahwa respons hospitalisasi pada anak dapat berupa protes, putus asa, pelepasan, agresi fisik dan verbal serta regresi. hal ini juga sesuai dengan teori menurut muscari (2005) bahwa mekanisme pertahanan utama anak usia prasekolah adalah regresi, mereka akan bereaksi terhadap perpisahan dengan regresi atau menolak untuk bekerja sama. paska diberikan tindakan tehnik relaksasi breathing exercise melalui media permainan, semua responden (100%) pada kelompok perlakuan menunjukkan respons psikologis adaptif terhadap prosedur invasif, yang terlihat dengan respons anak yang menerima kehadiran perawat, bersedia mendengarkan instruksi perawat, anak komunikatif dan anak tidak trauma saat bertemu lagi dengan perawat. menurut teori, salah satu prinsip dalam perawatan atraumatik adalah dengan mencegah atau mengurangi cedera baik fisik maupun psikologis. rasa nyeri karena tindakan (misalnya: disuntik) tidak akan bisa dihilangkan, tapi dapat dikurangi dengan menggunakan tehnik distraksi dan relaksasi (hidayat, 2005). asuhan yang terapeutik tersebut dapat dilakukan dengan intervensi melalui pendekatan psikologis misalnya menyiapkan anak untuk prosedur fisik dengan mengajarkan tehnik pernafasan dan relaksasi yang dapat membantu mereka untuk rileks dan memberi kontrol dalam situasi yang membuat nyeri dan melukai. tehnik pernafasan sangat penting dan efektif untuk semua anak karena dapat membantu mencegah kepanikan, agresi atau mencairkan kemarahan (patti, 2005). hal ini sesuai dengan teori bahwa tehnik relaksasi breathing exercise melalui media permainan juga merupakan tehnik distraksi yang melibatkan indera visual atau auditorik dan mungkin akan lebih efektif dalam menurunkan nyeri dibanding stimulasi satu indera saja (smeltzer dan bare, 2003). melalui permainan yang terapeutik ini dapat memudahkan komunikasi verbal tidak langsung dan non verbal tentang kebutuhan, rasa takut dan keinginan mereka (wong, 2004). menurut rudolph (2006), nafas dalam sebagai bentuk aktivitas bermain antara lain bisa dilakukan dengan menggunakan media latihan “pura-pura” meniup lilin ulang tahun, tiup gelembung dengan sedotan (tanpa sabun), tiup tisu, bulu, bola kapas, pinwheel, balon atau terompet mainan. menurut wong (2004) dengan yuni s melakukan permainan, anak akan terlepas dari ketegangan dan stres yang disebabkan oleh pembatasan lingkungan terhadap perilaku mereka. permainan yang terapeutik dapat mengalihkan rasa sakit dan anak akan mengalami relaksasi melalui kesenangan melakukan permainan sehingga meningkatkan kemampuan untuk mempunyai tingkah laku yang positif yaitu koping adaptif (supartini, 2004). intervensi kognitif ini dapat secara aktif mengurangi nyeri dengan mengalihkan perhatian anak menjauh dari rangsang yang menyakitkan ke arah pengalaman yang tidak mengancam dan menyenangkan. hal ini kemudian akan berlanjut pada respons penerimaan anak terhadap prosedur invasif meningkat dan selanjutnya anak akan mempunyai koping yang positif serta respons yang adaptif. simpulan dan saran simpulan tehnik relaksasi breathing exercise merubah respons penerimaan (psikologis) terhadap prosedur invasif menjadi adaptif karena intervensi ini melibatkan proses kognitif melalui permainan yang dapat membuat pasien anak usia prasekolah menjadi interest dan perhatian anak akan prosedur invasif yang dialami dapat dialihkan. saran peneliti menyarankan supaya tehnik breathing exercise dilakukan sebagai salah satu intervensi keperawatan yang merupakan alternatif bentuk terapi bermain dalam mengatasi respons penolakan anak usia pra sekolah terhadap prosedur invasif dan penelitian selanjutnya dapat dilakukan untuk mengetahui pengaruh tehnik breathing exercise terhadap penerimaan prosedur invasif dengan mengukur kadar kortisol dan menggunakan sampel yang lebih besar dan spesifik. kepustakaan ellis, j.a. 2004. survey of intervention for needle procedures, (online), (http://www.medscape.com, diakses tanggal 14 september 2008, jam 10.05 wib). hidayat, a.a. 2005. pengantar ilmu keperawatan anak 1. jakarta: salemba medika, hlm. 43-45. kusumawati, m.d. 2006. pengaruh tehnik relaksasi imagery terhadap respons penerimaan (psikologis dan biologis) dalam prosedur invasif pada anak usia sekolah (8-12 tahun) di ruang melati rsup dr. soedono madiun, skripsi tidak dipublikasikan. surabaya: program studi ilmu keperawatan fakultas kedokteran universitas airlangga. muscari, e.m. 2005. panduan belajar keperawatan pediatrik. jakarta: egc, hlm. 59-69. ni luh. 2008. pengaruh terapi bermain terhadap penurunan stres hospitalisasi anak usia pra sekolah di paviliun 14 rsk st. vincentius a paulo surabaya. skripsi tidak dipublikasikan. surabaya: program studi ilmu keperawatan stikes katolik st. vincentius a paulo. niven, n. 2002. psikologi kesehatan pengantar untuk perawat dan profesional kesehatan lain. jakarta: egc, hlm. 53-54. nursalam dan susilaningrum, r. 2005. asuhan keperawatan bayi dan anak (untuk perawat dan bidan). jakarta: salemba medika, hlm. 17, 25-30, 7484. patti, t. 2005. breathing technique to relax your child, (online), (http://breathingtechniquetorelaxyour child/specialchildren.about.com/od/ mentalhealthissues/a/breathing.htm., diakses tanggal 12 oktober 2008, jam 11.00 wib). rudolph, et al. 2006. rudolph’s pediatrics 21 st edition. usa: the mc. graw hill companies. smeltzer, s.c. dan bare, b. 2002. brunner and suddarth’s buku ajar keperawatan medikal bedah. edisi 8 vol 1. jakarta: egc, hlm. 232-249. supartini, y. 2004. konsep dasar keperawatan anak. jakarta: egc, hlm. 81-85. http://www.medscape.com/ http://breathingtechniquetorelaxyourchild/specialchildren.about.com/od/mentalhealthissues/a/breathing.htm http://breathingtechniquetorelaxyourchild/specialchildren.about.com/od/mentalhealthissues/a/breathing.htm http://breathingtechniquetorelaxyourchild/specialchildren.about.com/od/mentalhealthissues/a/breathing.htm wong, d.l. 2004. pedoman klinis keperawatan pediatrik. edisi 4. jakarta: egc, hlm. 281-283. yasmara, d. 2007. pengaruh aktifitas bermain peran dengan boneka tangan terhadap respons penerimaan prosedur invasif pada anak usia pra sekolah di ruang anak lantai 1 rsu dr. soetomo surabaya. skripsi tidak dipublikasikan. surabaya: program studi ilmu keperawatan fakultas kedokteran universitas airlangga. tabel 1. hasil analisis statistik respons penerimaan psikologis anak usia prasekolah terhadap prosedur invasif di paviliun 14 rumah sakit katolik st. vincentius a paulo surabaya, januari 2009. kelompok kontrol kelompok perlakuan pre post pre post mean 37 42 48 74 sd 13,375 13,984 15,492 10,750 hasil analisis statistik wilcoxon signed rank test (p=0,059) wilcoxon signed rank test (p=0,004) mann whitney u test (p=0,000) keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata 72 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.7762 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research predictors of family stress in taking care of patients with schizophrenia rizky fitryasari1, nursalam nursalam2, ah yusuf2, rachmat hargono3 and chong-mei chan4 1 doctoral student, faculty of public health, universitas airlangga, surabaya, indonesia 2 faculty of nursing, universitas airlangga, surabaya, indonesia 3 faculty of public health, universitas airlangga, surabaya, indonesia 4 department of nursing science, university of malaya, kuala lumpur, malaysia abstract introduction: taking care of schizophrenia patients is challenging and causes stress for the family involved. the study was conducted to identify the predictors of family stress present when taking care of a patient with schizophrenia. the abcx stress theory of hill was used as the theoretical framework. methods: this study used a correlational design. the sample was 137 families who were caring for patients with schizophrenia at the menur mental hospital, surabaya, indonesia. the sample was obtained by way of purposive sampling. the data was collected by a questionnaire and analysed by multiple regression to determine the relationship of the family’s structure, family knowledge, the burden of care, stigma, social support, the patient's illness duration, the patient’s frequency of relapse and the patient's severity level with family stress. results: the results showed that the family’s stress was predicted by the family’s structure (p=0.029), stigma (p=0.000), the burden of care (p=0.000), and the patient’s frequency of relapse (p=0.005). the burden of care was the strongest predictor of family stress (beta= 0.619). conclusion: the patient's frequency of relapse and stigma were other kinds of family stressor. the stressors stimulated a negative perception, called the care burden. limited adequacy of the family structure-function will inhibit the family in using other resources, creating family stress. nurses may develop an assessment format that consists of the family stress predictors in order to create a nursing care plan specific to reframing the techniques of family stress management. article history received: feb 27, 2018 accepted: june 26, 2018 keywords family stress predictors; family; schizophrenia contact rizky fitryasari  risqiv@yahoo.com.sg  faculty of public health, universitas airlangga, surabaya, indonesia cite this as: fitryasari, r., nursalam, n., yusuf, a., hargono, r., & chan, c. (2018). predictors of family stress in taking care of patients with schizophrenia. jurnal ners, 13(1), 72-79. doi:http://dx.doi.org/10.20473/jn.v13i1.7762 introduction schizophrenia is a chronic mental disorder and is a cause of morbidity. schizophrenia is a persistent and serious brain disease that results in psychotic behaviour, concrete thinking difficulties, an inability to communicate, abnormal affection and difficulties in solving problems and meeting daily needs (levine & levine, 2009; g. stuart & sundeen, 2012). the prevalence of severe mental illness, including schizophrenia, according to riskesdas (kemenkes ri, 2013) is 1.7 per 1000 inhabitants, meaning more than 400,000 people suffer from severe mental disorders in indonesia. the incidence percentage of schizophrenia in east java was 0.22%, while in surabaya, it was was 0.2%. the incidence rate of schizophrenia is difficult to decrease due to the high recurrence rates. based on a preliminary study at the menur soul hospital of surabaya conducted february-april 2016, the number of inpatients reached 5,925 patients, where 90% had schizophrenia. the data showed that 80% of patients with schizophrenia had been treated in previous psychiatric care or had a relapse (medical record rsj menur, 2016). schizophrenia, not only cause suffering for the patients, but also for the people who are closest to the patient as well. usually, the family is the most affected by the mental disorder. in the interviews with 10 families of patients during the preliminary study at menur hospital, 100% stated that the family experienced high tension during the treatment of the schizophrenic patients at home. the families feel anxious, sad, depressed and angry when faced with https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 73 uncontrollable patient behavior. the families also complained about being physically exhausted by having to keep up with the patient at all times. additionally, 4 out of 10 families complained of frequent headaches, hypertension, and gastritis after more than 2 years of treating patients with schizophrenia. the families felt like there was a lack of time to do activities because they must always keep with the patients with schizophrenia every day. the situation experienced by families over a long period of time can cause the family to experience stress and anxiety (biegel, 1995; stuart & sundeen, 2005). suhita's (2015) study of 87 family members acting as the main caregiver in east java's kediri city stated that 75% had moderate to severe stress. with the presence of schizophrenia patients being a stressor in the family system, 67.8% of them feel pressure (darwin, hadisukanto, & elvira, 2013). families, as the main caregiver, are susceptible to psychological problems, fostering family conflict and mutual abuse. 76.7% of families show negative symptoms, including depression and influencing family behavior when treating patients at home. the family often induces irritation due to their inability to cope with the burden. this is done by blaming the patient and disregarding the patient's condition (brillianita & munawir, 2014; pharoah, mari, rathbone, & wong, 2010). stress experienced by the family is caused by the high burden of care, including feeling worried about the patient's condition related to their health status, future, financial condition, and the fulfillment of their daily needs. the financial condition of the family experienced problems during the treatment of a 12-month schizophrenia patient, as a result of financing the treatment, the fulfillment of the patient's needs, hospital transportation and accommodation costs (djatmiko, 2007; ennis & bunting, 2013; hadryś, adamowski, & kiejna, 2011). the presence of schizophrenia patients makes the family face social stigma. related to the stigma attached to both the patients and their families, 37.5% of the families had a negative perception of the illness suffered by the patients with schizophrenia. the families are embarrassed and often excluded from community activities involving all family members. the magnitude of the burden, the strength of the stigma both from the family and society, the lack of support for the family and the fluctuating condition of the patients may cause family stress. there are many obstacles faced by the family when taking care and living together with the schizophrenic patient. the lack of knowledge about schizophrenia, the social stigma and social alienation, the cost of treatment, the decrease of the families’ health, anxiety, depression, and other things are a series of social problems encountered in the family with the schizophrenic patient (el tantawy, raya, & zaki, 2010; suhita et al., 2015). an insurmountable family stress situation creates an unfavorable environment and causes the schizophrenia patients to relapse. the inability of the family to control the emotions and the existence of a stressful family life causes issues and continuous criticism is a cause of patient relapse (akbar, 2008; amaresha & venkatasubramanian, 2012; fadli & mitra, 2013). abcx hill’s theory, stated by rice (1987), is the theory that was used in this research study. the theory explains if the families facing uncomfortable situations represented by the letter a, they will make an adaptation effort by utilising social support and personal strengths of the family which are described as letter b. letter c explains the family's perception during a stressful event, which includes how the family defines the uncomfortable events in their life. the letter x represents the degree of crisis experienced by the family as a result of the interactions between letters a, b, and c. based on this model, families who care for schizophrenic patient have limited resources and have a negative view of the situation. they will experience a crisis or more severe stress than other families who are faced with the same pressing event who are better adapted. the researcher, as a mental health nurse, tried to combine hill’s theory with the assessment stage of family-centered nursing theory (friedman, 2003). family-centered nursing is a family theory with a nursing care approach. an important step in this theory is the nurse's ability to conduct a family situation assessment, which includes assessing the family and patient factors. the family factors are the strength of the family structure, their economic capacity and the level of family knowledge about schizophrenia. the patient factors are the frequency of relapse, the duration of illness and the illness severity. based on hill's theory, family-centered nursing theory (friedman, 2003) and some of the studies discussed above, the burden of care, stigma and social support for families has the potential to affect the stress experienced by the involved families. this study aims to analyze the influence of family structure, economic ability, knowledge level, the burden of care, stigma, social support, the frequency of relapse, the duration of the illness and the patient’s severity level as the predictors of family stress. the results of the study are expected to contribute to nursing science in determining the stress’s predictors on the families who care for patients with schizophrenia. materials and methods research design this study used a correlation research design that explained the relationship of the factors causing family stress when treating patients with schizophrenia. the study was conducted from june through to september 2017. the study involved 137 family members as respondents, who were obtained by purposive sampling. the inclusion criteria were the families being the primary caregivers of the patients, the patient being more than 20 years old r. fitryasari et al. 74 | pissn: 1858-3598  eissn: 2502-5791 and them living in one house with the patient for at least one year. the patient should have been diagnosed with schizophrenia for at least three years (proven by medical records), and have already experienced at least one recurrence. the dependent variable was family stress, while the independent variables included family structure, knowledge level, care burden, stigma, social support, the patient’s duration of illness, the frequency of relapse and severity. instruments the data was obtained through of a questionnaire. the demographic data was assessed using a single item: age. economic status was measured using a closed questionnaire with questions about the average family’s fixed income in a month. the family’s structural variables were adapted from the family assessment questionnaire as according to friedman (2003). the respondents were asked what is their role was when related to the patient (mother, father, spouse, child or other family member). family knowledge about schizophrenia was measured using a questionnaire modified from mccubbin & thompson (1991). ten-item questions assessed the family knowledge related to the definition of illness, the effect on the family and the schizophrenia treatment. each item was rated on a scale of 1 (strongly disagree) to 5 (strongly agree). the items were summed, with the higher scores indicating higher knowledge. the burden of care variable instrument was prepared based on the caregiver strain index questionnaire (thornton & travis, 2003) and the concept of burden according to the world health organization (2008) modified according to the condition of the family who cared for the schizophrenia patient. the instrument consisted of eight-item statements on subjective and objective burden measured using a likert-scale ranging from 1 (never) to 5 (always). the stigma instrument was developed based on the stigma’s dimension (goffman, 1963) and the definition of stigma (link & phelan, 2001). the instrument consisted of ten-item statements asking about labelling, stereotyping, separation and discrimination. they were measured on a five-point scale (1: strongly disagree to 5: strongly agree). the social support variable was obtained by way of a modified instrument of the social support index (h. i. mccubbin, paterson, & glynn, 1987). the instrument consisted of ten-item statements focused on emotional, informational, instrumental and award support. frequency was measured on a five-point scale (1: never to 5: always). the data from the patients was collected related to their illness history. the patient’s duration of illness was explained as the first time that the symptoms of schizophrenia appeared up to the current date, expressed in years. the frequency of relapse referred to the number of recurrences and hospitalisations within a year. the severity of illness was measured using the modified brief psychiatry rating scale (bprs) (overall & gorham, 1988) 1988). the questionnaire consisted of 18-item statements filled in by a doctor or nurse in charge, assessing the positive, negative and affective symptoms performed by the patient. each item was rated on a scale of 1 (no symptoms) to 4 (severe). all items were added together, while ahigher score indicated higher severity symptoms. the family stress variable was measured using a modified questionnaire using the symptom rating test (kellner & sheffield, 1973). the questionnaire consisted of a ten-item statement on the psychological and physical symptoms felt by the family over the last three months, rated in 5-point of scale ranging from 1 (never) to 5 (always). all items are totalled, with a higher score indicating a higher severity of family stress. all of the instruments had been already tested for validity and reliability, in a pilot study consisting of 25 respondents. each item in the statements reached validity (r>0.514) and each questionnaire reached reliability as well (>0.8). data analysis descriptive analysis was used for the respondents’ characteristic and for the variable description (table 1 and 2). we used multiple regression analysis to identify the predictors of family stress during the treatment of patients. we created a p-value table between the independent variables and the dependent variable (table 3). based on this table, we removed economic status, family knowledge and social support from the regression model because these three independent variables have a p-value <0.25. further testing was performed to determine which variables are valid for being a family stress predictor. a regression test was done until all of the variables had a value< 0.05. valid variables that can be used as a predictor of family stress are family structure, maintenance burden, stigma and the frequency of relapse. the four variables have been able to prove the existential assumptions (mean: 0.000, sd: 5.824), interdependence assumptions (durbin watson: 1.913), linearity assumptions (p = 0.000), homoscedasticity (norms of data spreads along or zero) data (normal distributed data and on pp residual plot of data spread around the diagonal line) and the multi-collateral assessment (vif <10). the four independent variables were used in simultaneous regression analyses. the level of statistical significance was set at p <0.05. ethical clearance the respondents were families who accompanied patients to the outpatient unit of the mental hospital of menur. the participants were recruited on the basis of ethical principles. the participants involved in the study had previously received a written explanation of the purpose of the research, and the procedures, rights and obligations, benefits and jurnal ners http://e-journal.unair.ac.id/jners | 75 disadvantages involved in the study. only the participants who had been given informed consent were involved in the study. this study was given ethical approval from the ethical committee of menur mental hospital, number 423.4 / 72/305/2017. results characteristics of the respondent the characteristics of respondents have been presented in table 1. the majority of respondents were between the ages of 46 to 65 years old. a lot of them were the mother of a patient with schizophrenia. the others were made up of their siblings, relatives, children, spouse and father. almost half of the monthly family income was more than 4.000.000 idr. most of the patients had been diagnosed with schizophrenia for more than ten years and almost half of them were experience relapse one to three times each year. variables description the variables’ description has been explained in table 2. the average of family knowledge was 37.93 (sd= 3.843). the family-felt burden of care average was 23.39 (sd=7.792). the family also experienced stigma from the environment, which averaged 25.09 (sd= 6.358). the family receiving social support had an average of 31.10 (sd= 5.721). schizophrenia patients had a level of severity of 28.11 (sd 6.954). the overall family experiencing stress had an average of 27.08 (sd=10.524) variables’ correlation pearson's correlation was computed between the family's stress and all of the research variables (table 2). the result of testing on the nine research variables showed that there was a strong relationship between burden of care (r = 0.804; p = 0.00) and stigma (r = 0.677; p = 0.00) on family stress. subsequently, there was a weak correlation between the patient’s duration of illness (r = 0.193, p = 0.024), the patient’s frequency of relapse (r = 0.392, p = 0.00) and the level of severity (r = 0.267, p = 0.002) with family stress. the variables of economic status, family structure, knowledge and social support are not related to family stress during the care of patients with schizophrenia. predictors of family stress as shown in table 4, the higher the burden of care (p = 0.000; beta = 0.619), the more frequent the patient’s frequency of relapse (p = 0.005; beta = 0.145), the higher the perceived family stigma (p = 0.000; beta = 0.194) and the lower functioning of the family structure (p = 0.029; beta = -0.106). the aforementioned will increase stress in the family. all of the independent variables may explain the variation of family stress as 69.4% (r2=0.694). the variable that has the greatest role as a predictor of family stress is the burden of care (beta = 0.619). discussion stress experienced by the family in assisting and treating patients with schizophrenia can be predicted using the variables burden of care, stigma from the environment, the patient’s frequency of relapse and the functioning within the family structure. the results of this study are in line with family stress according to hill (rice, 1987), which mentions that family stress is caused by the interaction between stressors, family perception, and the resources owned by the family. the patient's frequency of relapse and the stigma from the environment is a stressor for the family. stressors cause a negative perception for the families in the form of care burden. a lack of adequate functioning in the structure of the family means that the family cannot utilise the resources they own, so then the table 1. characteristics of the respondents variable frequency percentage age (years) 26-35 years old 19 13,9 36-45 years old 20 14,6 46-55 years old 34 24,8 56-65 years old 43 31,4 >65 years old 21 15,3 family’s structure father 11 8.0 mother 41 29.9 spouse 13 9.5 child 18 13.1 siblings 30 21.9 relatives 24 17.5 family monthly income <3.500.000 idr 54 39.4 3.500.000 – 4.000.000 idr 20 14.6 > 4.000.000 idr 63 46.0 patient’s duration of illness (years) 3 years 16 11.7 >3-5 years 18 13.1 >5-10 years 31 22.6 >10 years 72 52.6 patient’s frequency of relapse (times) 1-3 x 63 46.0 >3-5 x 41 29.9 >5 x 33 24.1 table 2. variables’ description variable mean sd dependent knowledge 37.93 3.843 burden care 23.39 7.792 stigma 25.09 6.358 social support 31.10 5.721 level of severity 28.11 6.954 independent family stress 27,08 10,524 r. fitryasari et al. 76 | pissn: 1858-3598  eissn: 2502-5791 families experience stress when caring for patients with schizophrenia. the stressors perceived by the family comes from within the family, namely the patient’s frequency of relapse. the other stressors come from outside the family, including stigma. the findings of the study showed that out of all of the family members with schizophrenia, 46 % experienced a relapse at least one to three times and the others, more than three times. if repeated relapse continues in patients with schizophrenia, it can have negative consequences for the caregivers (rexha, jose, golay, & favrod, 2006). recurrent schizophrenic patients exhibit uncontrollable behavior, such as being angry without cause, and suspicious excessive and unnatural behavior. the behavior is often exhibited not only at home, but also within the environment, which causes unrest in the community. an unpleasant response from the environment related to the patient’s behavior is the stigma towards patients with schizophrenia and their families (ariananda, 2015). stigma becomes a stressor for the families. stigma is the assessment of a situation or object that is considered to be a bad thing, so their value is lower than that of a normal person. this assumption causes the family to experience discrimination and thus to lose the opportunity to engage in activities that are important in life. stigma keeps the family impeded from the activities of daily life (goffman, 1963 in heatherton, 2003). the dominant stigma felt by families in this research study were discrimination and separation. the local community treats the family differently, with them being disallowed from participating in community activities involving all of the family members. community concerns about the uncontrollable behavior of schizophrenia patients cause people to distance themselves from the patients and their families during joint activities. neighbours who live near the family also rarely visit and avoid communicating with the patients. the results of this study are in accordance with the research of ariananda (2015), which conveyed that the community avoids interactions involving the presence of patients and their families. stigma causes the family to have negative perceptions, affects their emotions and causes stress (raguram, raghu, vounatsu, & weiss, 2004; singh, matto, & grover, 2016). the high amount of stigma and the patient’s frequency of relapse are stressors for the family, and affect the family's perspective of caring for schizophrenic patients at home. the stress experienced by the family is influenced by the family's perception of the perceived stressors. the results showed that the families, in treating patients with schizophrenia, felt various forms of care burden. the perceived burden is the result of the perceptions regarding the presence of the schizophrenia patients and high stigma from the community. treatment burden occurs as a result of the family interaction process with the sick family member in order to provide treatment. the burden table 3 inter-correlation of the variables family structure knowledge burden of care stigma social support patient’s duration of illness patient’s frequency of relapse level of severity family’s stress monthly family income 0.311** 0.481** 0.085 0.125 0.163 0.208* 0.098 -0.107 -0.093 family structure 0.492** 0.046 0.010 0.132 0.195* 0.016 0.038 -0.074 knowledge -0.072 -0.102 0.291** 0.070 -0.019 -0.134 -0.159 burden of care 0.731** 0.027 0.173* 0.330** 0.189* 0.804** stigma -0.093 0.072 0.221** 0.234** 0.677** social support 0.086 0.027 0-.037 -0.027 patient’s duration of illness 0.507** 0.174* 0.193* patient’s frequency of relapse 0.603** 0.391** level of severity 0.267** **. correlation is significant at the 0.01 level (2-tailed). *. correlation is significant at the 0.05 level (2-tailed). table 4. regression of the family's stress on family structure, care burden, stigma and patient’s recurrence independent variables dependent variable: family stress beta p-value family structure -0.106 0.029 burden of care 0.619 0.000 stigma 0.194 0.007 patient’s frequency of relapse 0.145 0.005 r2=0.694;adjusted r2 =0 .684 ; (p= 0.000 ) jurnal ners http://e-journal.unair.ac.id/jners | 77 felt is both subjective and objective (chou, fu, & lin, 2011). the treatment and care of schizophrenic patients takes a long time. the family, as the closest environment, should be able to accept the fact that sick family members should be helped to achieve better conditions for the patient. in line with the opinion of chou (2011), this explains that the caregiver's perception of an objective burden is influenced by a number of care needs that must be met by the caregiver. the state of the schizophrenia patient is less independent and has many needs that must be fulfilled, both in relation to the needs of treatment and daily needs. this situation requires the family to provide time, energy, thought and funds. this situation creates an inconvenience for other family members. families limit the time they have to work and interact with the social environment because they have to treat the patients with schizophrenia. several studies have concluded that the suffering experienced by schizophrenia patients also interferes with the caregiver’s comfort because they feel burdened by the regular and continuous care (fitrikasari, kadarman, & woroasih, 2012; maldonado, urizar, & kavanagh, 2005; ochoa et al., 2008). the prolonged course of the disease, uncertain patient behaviour and family incompetence to care for the disease causes discomfort and affect the family's perspective. this study proves that the burden of patient care in relation to schizophrenia one of the predictors of family stress. the burden felt by the family is perceived negatively by the family as it is an uncomfortable situation and poses a threat to the stability of family life. negative perceptions that continue to grow and that are not managed properly will cause the family to fall into a stressful situation. the process of stress in the family is also influenced by the resources owned by the family. the results showed that one family resource, namely the family structure, has a role in reducing family stress. the family structure is the strength that is owned by the family to arrange their values, communication patterns and family role as a lifestyle so then the family is able to perform its function properly (friedman, 2003). the dominant family structure in this study was the role of the mother as the primary caregiver of the schizophrenia patients (29.9%), followed by sibling and child. the situation is influenced by the cultural structure of indonesia that still holds true to strong family ties, so if there is one family member who is sick, then the nuclear family will take on the caregiver role to provide care. parents or children as part of the nuclear family is a family structure that plays an important role in providing long-term care to family members who experience chronic disease, such as mental disorders (karp, 2001; sapin, widmer, & iglesias, 2016). this situation is also in line with the research conducted in india, in that the core family in asian families is strong enough that the family members consider caregiving as their moral obligation (kate, grover, kulhara, & nehra, 2012). families have a tendency to regulate their family structure when they know that one member of their family is experiencing schizophrenia. mothers who act as the household manager will have a greater parenting role compared to the fathers, who have to work for a living. similarly, siblings, only when the family has no parents, become the managers of the household and will therefore be selected as the primary caregivers for the familial schizophrenia patient. effective role sharing will help the families accept reality more quickly so as to reduce the stress experienced. an important role in the family when caring for a sick family member involves the process of making the decision to seek immediate solutions and to begin the treatment process (carpentier, 2013; sapin et al., 2016). however, it is possible for there to be a conflict within the family due to an imbalance of role sharing within the family structure (sapin et al., 2016; widmer, 2010). the primary caregiver feels a heavier burden than the other family members who do not accompany the patient. therefore, the family needs resources from outside of the family, such as social support from the environment. the social support received by families is a positive indicator of the family burden during the care of patients with schizophrenia (chow, 2013 in poegoeh & hamidah, 2016). the results of this study found that social support is not a predictor of family stress. according to widmer (2010) and sapin (2013), social support sourced from the environment (community and extended family) is very effective and necessary for the families caring for schizophrenia patients early in their treatment that does not impact on long-term care. sadath (2017) explained that social support is not one of the factors that determines the emotional expression of families that have been predicted to experience family stress. this is because families have limited access to social support while caring for patients. families who treat patients with schizophrenia tend to limit themselves in order to take advantage of the social support provided by the surrounding environment. the family assumes that the existence of the patient is a disgrace to the family (hawari, 2009), so the family feels that they do not want to tell anyone about the illness. in addition to these assumptions, families who have tried to ask for support from neighbours and their extended families, do not feel the benefit, so the family feels isolated and discriminated against by the environment. as a result of resource utilisation in reducing stress, families choose to optimise the family structure when caring for schizophrenic patients and do not use social support from the environment. research implications the research findings reinforce the abcx theory according to hill (rice, 1987). the frequency of patient relapse and the stigma experienced by the family were stressors. the presence of stressors is interpreted by the family as a burden of care. r. fitryasari et al. 78 | pissn: 1858-3598  eissn: 2502-5791 families try to optimise the family's strength, called family structure, as a resource for managing stressors, but if the family may think that if the stressors are threatening to the family stability, then this may result in a family burden. this situation brings families into stressful situations. nurses, as health professionals who are willing to interact directly with the family, can develop family nursing interventions, especially in relation to stress management. nurses can do stimulations that helps the families to modify the family perceptions of the stressor, which was originally considered to be a challenge in treating patients with schizophrenia. the findings of the study have proven that the patient’s frequency of relapse, stigma, the burden of care, and family structure can predict the stress experienced by the families during the care of schizophrenic patients. based on the theory of family centre and nursing (friedman, 2003), the results of this study have implications for nurses. this is as they seek to conduct a family assessment which pays attention to the patient factors, especially the frequency of patient relapse. the nurses also must be attentive to the family factors, namely family structure and the family perceptions related to burden and stigma. the nurses should be able to identify the patient's relapse frequency, family structure, the burden of care and stigma as the family’s stress indicators, so they can help the family to manage stress. research limitation this research has several limitations. the sample of the study was obtained from the families who accompany the patients to the outpatient unit. the perception of stress experienced by the family was strongly influenced by the situation and the acute condition of the patient at that time. this caused less access to the social support that was used. another limitation is that the results of this study has a limited potential for generalisation, especially for the family’s stress when the patients are hospitalised. conclusion the stress experienced by the family when taking care of patients with schizophrenia is determined by the family's perception of the stressor. family stress can be predicted based on the patient frequency of relapse, the stigma felt by the family, the large burden of care and the family structure, which may not function optimally. nurses as health care providers can develop an assessment format that focuses on the family stress predictors, helping them to develop family stress management that focuses on establishing positive perceptions and enhancing the functioning of the family structures, enabling them to manage the burden of care and stigma experienced. references akbar, m. (2008). schizophrenia: psikosis (mental illnes). jakarta: balai pustaka. amaresha, a. c., & venkatasubramanian, g. (2012). expressed emotion in schizophrenia: an overview. indian j psychol med, 34(1), 12–20. http://doi.org/10.4103/0253-7176.96149 ariananda, r. e. (2015). public stigma toward to schizophrenia patients. skripsi. universitas negeri semarang, semarang. biegel. (1995). innovations in practice and service across the lifespan. new york: oxford university. brillianita, k. a., & munawir, a. (2014). hubungan antara gejala positif dan negatif skizofrenia dengan tingkat depresi pada caregiver pasien skizofrenia. artikel ilmiah hasil penelitian 2014. jember. retrieved from http://dspace.unej.ac.id/bitstream/handle/1234 56789/67526 carpentier, n. (2013). entry into a care trajectory: individualization process, network, and emerging project. sage open, 1–9. http://doi.org/http://dx.doi.org/10.1177/21582 44013494215 chou, y.-c., fu, l.-y., & lin, l.-c. (2011). predictors of subjective and objective caregiving burden in older female caregivers of adults with intellectual disabilities. international psychogeriatrics, 23(4), 562–572. http://doi.org/10.1017/s1041610210001225 darwin, p., hadisukanto, g., & elvira, s. d. (2013). burden of care and emotional expression of nurses work with schizophrenia patient in mental hospital. journal of indonesian medical association, 63(2), 46–51. djatmiko. (2007). berbagai indikator taraf kesehatan jiwa masyarakat. retrieved january 5, 2016, from http://pdskjijaya.com el tantawy, a. m. a., raya, y. m., & zaki, a. m. k. (2010). depressive disorders among caregivers of schizophrenic patients in relation to burden of care and perceived stigma. current psychiatry, 17(3). ennis, e., & bunting, b. p. (2013). family burden , family health and personal mental health. bmc public health, 13(1), 1. http://doi.org/10.1186/1471-2458-13-255 fadli, s. m., & mitra. (2013). knowledge and emotional expression of family and relaps frequency of schizophrenic patients. jurnal kesehatan masyarakat nasional, 7(10), 466–470. fitrikasari, a., kadarman, a., & woroasih, s. (2012). gambaran beban caregiver penderita skizofrenia di poliklinik rawat jalan rsj amino gondohutomo semarang. medica hospitalia, 1(2), 118–122. friedman, m. m. (2003). keperawatan keluarga: teori dan praktek. jakarta: egc. hadryś, t., adamowski, t., & kiejna, a. (2011). mental disorder in polish families: is diagnosis a predictor of caregiver’s burden? social psychiatry and psychiatric epidemiology, 46(5), 363–372. http://doi.org/10.1007/s00127-010-0200-8 hawari, d. (2009). pendekatan holistik pada jurnal ners http://e-journal.unair.ac.id/jners | 79 gangguan jiwa: skizofrenia. jakarta: fkui. heatherton, t. f. (2003). the social psychology of stigma. new york: the guilford press. karp, d. (2001). the burden of sympathy: how families cope with mental illness. new york: oxford university press. kate, n., grover, s., kulhara, p., & nehra, r. (2012). relationship of quality of life with coping and burden in primary caregivers of patients with schizophrenia. the international journal of social psychiatry, 10(2), 1–10. http://doi.org/10.1177/0020764012467598 kellner, r., & sheffield, b. (1973). a self-rating scale of distress. psychological medicine, 3, 88–100. kemenkes ri. (2013). riset kesehatan dasar. badan penelitian dan pengembangan kemenkes ri. jakarta. indonesia. levine, j., & levine, i. (2009). schizophrenia for dummies. new jersey: jhon whily publishing inc. link, b. g., & phelan, j. c. (2001). conceptualizing stigma. annual review of sociology, 27, 363–385. maldonado, j., urizar, a., & kavanagh, d. (2005). burden of care and general health in families of patients with schizophrenia. social psychiatry and psychiatric epidemiology, 40, 899–904. mccubbin, h. i., paterson, j., & glynn, t. (1987). family assessment: resiliency, coping and adaptation: inventories of research and practice. madison, wisconsin: university of wisconsin publisher. mccubbin, h., & thompson, a. (1991). family assessment inventories for research and practice. madison: university of wisconsin. ochoa, s., vilaplana, m., haro, j., villalta-gil, v., martinez, f., negredo, m., … autonell, j. (2008). do needs, symptoms or disability of outpatiens with schizophrenia influence family burden? social psychiatry and psychiatric epidemiology, 43(3), 612–618. overall, j. e., & gorham, d. r. (1988). the brief psychiatric rating scale (bprs): recent developments in ascertainment and scaling. psychopharmacology bulletin, 24, 97–99. pharoah, f., mari, j., rathbone, j., & wong, w. (2010). family intervention for schizophrenia (review). wiley publishers. poegoeh, d. ., & hamidah. (2016). peran dukungan sosial dan regulasi emosi terhadap resiliensi keluarga penderita skizofrenia. insan, 1(1). raguram, r., raghu, t., vounatsu, p., & weiss, m. (2004). schizophrenia and the cultural epidemiology of stigma in bangalore, india. journal nerv. mental disorder, 192, 734–744. rexha, p. ., jose, a., golay, p., & favrod, j. (2006). perceptions of schizophrenia and coping styles in caregivers: comparison between india and switzerland. journal of psychiatric and mental health nursing, 23, 585–594. rice, v. h. (1987). handbook of stress, coping and health : implications of nursing research, theory and practice. thaousand oaks: sage publications. sadath, a., muralidhar, d., varambally, s., gangadhar, b., & jose. jp. (2017). do stress and suppoer matter of caring? the role of perceived stres and social support on emotional expression of carers of person with first episode of psychosis. asian journal of psychiatry, 25, 163–168. sapin, m. (2013). configurations de proches et adaptation dans le parcourse de vie d’individus en situation de vulnerabilite. university of laussane. sapin, m., widmer, e., & iglesias, k. (2016). from support to overload: patterns of positive and negative family relationships of adults with mental illness over tima. social networks, 47, 59– 72. http://doi.org/http://dx.doi.org/10.1016/j.socne t.2016.04.002 singh, a., matto, s., & grover, s. (2016). stigma and its correlates among caregivers of schizofrenia: a study from north india. psychiatry research, 241, 302–308. stuart, g., & sundeen, s. (2012). principles and practice of psychiatric nursing. st. louis: mosby year book. stuart, g. w., & sundeen. (2005). buku saku keperawatan jiwa (3rd ed.). jakarta: egc. suhita, b. m., siyoto, s., wardhani, r., puspitasari, y., & wahyuni, c. u. (2015). the identification of families stress level with adversity quotient in caring schizophrenia family members in kediri city. journal of appied environmrnt and biological science, 5(12), 106–113. thornton, m., & travis, s. (2003). analysis of the reliability of the modified cargivere strain index. the journals of gerontology, 58(2), s127–s132. widmer, e. (2010). family configuration: a structral approach to family diversity. london: ashgate publishing. world health organization. (2008). investing in mental health. geneva. peningkatan kepercayaan ibu postpartum dalam merawat bayinya melalui bonding attachment (bonding attachment enhances postpartum mother’s confidence in caring her baby) ratna hidayati* *program studi s1 keperawatan stikes karya husada jl. soekarno hatta po box 53 pare kediri kode pos 64277 telp.: (0354) 395203, fax.: (0354) 393888 email: wildanss@yahoo.com (hp: 081-359303299) abstract introduction: bonding attachment is one of the methods to support an excessively interaction between mother and her’s baby. this interaction may facilitate a mother to be more confident to take care of the baby. method: this study was used a quasy-eksperimental design which is the objective of this study was to examine the influence of facilitated bonding attachment to mother’s confidence to take care of her baby at early postpartum period in amelia pare kediri hospital. there were 90 respondents who met to the inclusion criteria and taken by using purposive sampling technique, divided into control group and intervention group. data were collected by using questionnaire, then it were analyzed by using chi square and t-test. result: the result showed that nurse behaviour had significance effect on facilitated bonding attachment to mother/women self confidence to take care of her baby at early postpartum period (p=0.000). discussion: it can be concluded that nurses behaviour who facilitated bonding attachment influenced mother’s confidence to take care of her baby at early postpartum periode. then family center nursing care plan should applied in all of health care setting to promote family empower and to obtain bonding attachment since newborn. moreover, nursing companion during the care is also important to facilitate mother’s ability to take care of the baby. keywords: nurse behaviour, bonding attachment, mother’s confidence, postpartum pendahuluan setelah melahirkan anak pertama, seorang perempuan akan mengalami perubahan peran yaitu menjadi ibu. situasi ini merupakan periode ketidakstabilan yang menuntut perubahan perilaku untuk menjadi orang tua. steele dan pollack (1968) dalam bobak and jensen (1996) mengatakan bahwa tugas, tanggung jawab dan sikap yang membentuk peran sebagai orangtua merupakan fungsi menjadi ibu. pencapaian peran tersebut memerlukan proses pendewasaan diri yang dapat dicapai salah satunya dengan mulai mengasuh bayinya. kemampuan untuk menunjukkan kelembutan, ikatan kasih sayang dan meletakkan kepentingan orang lain diatas kepentingan diri sendiri merupakan karakteristik individu seorang ibu (bobak and jensen, 1996). hubungan/kontak dini ibu dan bayi melalui tatap muka, suara, bau, sentuhan dan pelukan bertujuan untuk memberikan kehangatan pada bayi, memberi rasa nyaman, serta meningkatkan perkembangan emosi, intelektual dan fisik bayi sejak awal sampai dengan dewasa. kekuatan dan kualitas ikatan cinta yang terbentuk antara ibu dan bayi dalam minggu pertama setelah persalinan mewarnai semua hubungan sang bayi kelak di masa depan, selain kemampuannya untuk mencintai (klaus and kennell, 1982, mercer and ferketich, 1994, mercer, 1982 dalam matteson, 2001). mengingat pentingnya awal kehidupan tersebut bagi ibu dan bayi, maka peningkatan hubungan tali kasih dan keterikatan atau bonding attachment antara ibu dan bayi sangatlah bermakna. ketidakpercayaan diri ibu terhadap kemampuannya merawat bayi disebabkan ibu tidak melakukan kontak awal dengan bayinya. hal tersebut dapat mempengaruhi kesejahteraan bayi dikemudian hari. menurut klaus and kennell (1982), pemisahan yang lama akibat prematuritas atau sakit, dapat meningkatkan risiko kejadian penelantaran, kekerasan dan gangguan perkembangan. gangguan perkembangan yang dapat terjadi pada bayi adalah kondisi gagal tumbuh tanpa penyakit organik, mudah terserang penyakit, atau timbul masalah emosional yang dikarenakan perilaku kekerasan dan penelantaran ibu. pola melalaikan dalam mengasuh bayi berkaitan erat dengan adanya kegelisahan, kecemasan dan penolakan ibu untuk dekat dengan bayinya (shaw and bell, 1993 dalam wong, perry and hess, 1998). manfaat lain bonding attachment antara lain memberikan kehangatan, menurunkan rasa sakit ibu, memberikan rasa nyaman, identitas peran bagi seorang ibu serta membantu ibu untuk segera menyusui, yang bermanfaat untuk merangsang oksitosin dan prolaktin hormon sehingga meningkatkan kontraksi uterus, mencegah perdarahan postpartum dan meningkatkan produksi asi (lowdermilk, perry and bobak, 1999). bonding attachment yang dilakukan sejak dini juga meningkatkan keterikatan ibu dan bayi, sehingga akan mendorong ibu untuk kompeten dan lebih percaya diri dalam merawat bayinya (rubin, 1974 dalam bobak and jensen, 1996). fasilitas yang diberikan oleh pemberi asuhan untuk bonding attachment akan menciptakan lingkungan yang meningkatkan kontak orang tua dan bayi sejak di ruang persalinan sampai keluar dari rumah sakit, membantu orang tua untuk mengenal respons bayi dan kemampuan bayi untuk berkomunikasi, meningkatkan dan mendukung kepercayaan diri dan ego orang tua untuk menjadi kompeten dan mencintai perannya (wong, perry and hess, 1998). merujuk dari kondisi tersebut, peneliti tertarik untuk meneliti pengaruh dari perlakuan perawat yang memfasilitasi bonding attachment yang diberikan sejak kelahiran sampai dengan periode awal postpartum terhadap kepercayaan diri ibu untuk merawat bayinya. tujuan dari penelitian ini untuk mengidentifikasi pengaruh dari perilaku perawat yang memfasilitasi bonding attachment terhadap peningkatan kepercayaan diri ibu postpartum dalam merawat bayinya. bahan dan metode penelitian ini menggunakan rancangan penelitian quasy eksperimental post test only, dengan populasi ibu primipara pada masa persalinan sampai dengan awal postpartum/nifas dengan persalinan spontan pervaginam tanpa komplikasi dan bayinya sehat. sampel penelitian diperoleh dengan menggunakan teknik quota sampling dengan besar sampel 90 orang yang dibagi menjadi 2 kelompok yaitu kelompok perlakuan dan kelompok kontrol. penelitian dilaksanakan pada bulan juni 2006 di rumah sakit amelia pare kediri. variabel independen dalam penelitian ini adalah perilaku perawat memfasilitasi bonding attachment, sedangkan variabel dependen adalah kepercayaan diri ibu untuk merawat bayinya pada masa awal postpartum. instrumen yang digunakan dalam penelitian ini adalah kuesioner. analisis data dalam penelitian ini menggunakan chi square dan t-test dengan nilai kemaknaan α≤0,05. hasil karakteristik responden antara kelompok kontrol dan intervensi tidak ada perbedaan bermakna menurut usia, pendidikan, pekerjaan, lama perkawinan, dan anak yang direncanakan (lihat tabel 1). distribusi usia responden kelompok kontrol dan intervensi sebagian besar usia 20-34 tahun, berpendidikan sma, tidak bekerja, lama perkawinan ≤ 2 tahun dan anak yang dilahirkan tersebut adalah anak yang direncanakan. rerata kepercayaan diri ibu dalam merawat bayinya pada kelompok kontrol adalah 35,40 dan pada kelompok intervensi adalah 62,00. hasil uji statistik didapatkan nilai p=0,000 artinya perilaku perawat yang memfasilitasi bonding attachment berpengaruh dalam meningkatkan kepercayaan diri ibu dalam merawat bayinya. tabel 1. distribusi karakteristik dan hasil analisis kepercayaan diri ibu dalam merawat bayinya menurut usia & pendidikan di rs amelia kediri bulan juni 2006. keterangan: p = derajat kemaknaan mean = rerata sd = standar deviasi  = jumlah pembahasan sesuai dengan pendapat mccloskey and bulechek (1996) serta wong, perry and hess (1998), bahwa tindakan keperawatan yang memfasilitasi interaksi ibu-bayi selama periode awal postpartum, ditunjang dengan sikap profesional perawat yang ramah, asertif, suportif dan sikap yang positif dalam memberikan asuhan keperawatan kepada ibu, bayi baru lahir, dan keluarganya akan sangat berperan terhadap pengalaman yang positif bagi ibu selama berada di rumah sakit. selain itu, tindakan tersebut dapat mencegah dan mengatasi munculnya gangguan psikologis seperti ketakutan, ketegangan yang tinggi, kelelahan, serta kualitas bonding attachment yang kurang, sehingga berpengaruh terhadap kepercayaan diri ibu akan kemampuannya untuk merawat bayinya dan akan mengurangi sekresi asi. lamb et al. (1973) dalam bullock and pridham (1988) juga berpendapat bahwa ibu yang yakin akan merawat bayinya sendiri menjadikannya lebih competent dan terlihat nyaman ketika berinteraksi dengan bayinya. sejalan dengan hasil penelitian djuwitaningsih (2004) bahwa ibu yang dirawat dengan metode rawat gabung berpeluang lebih besar untuk berinteraksi dengan bayinya dibandingkan dengan rawat terpisah. kondisi ini memungkinkan ibu untuk berinteraksi dengan bayinya, sehingga terjalin bonding attachment yang efektif pada periode yang sensitif dan ibu berkesempatan memperoleh edukasi maupun role model dari perawat yang merawat ibu tersebut beserta bayinya, yang pada akhirnya meningkatkan pengetahuan ibu dan berdampak pada peningkatan kepercayaan diri untuk mampu merawat bayinya (affonso, 1976 dan zahr, 1991). teori yang dikemukakan oleh lowdermilk, perry and bobak (1999) menyebutkan bahwa dengan terjalinnya bonding attachment sejak dini, selain bermanfaat meningkatkan pengeluaran oksitosin yang dapat mencegah perdarahan postpartum, meningkatkan produksi asi, juga menurunkan kecemasan pada ibu dan meningkatkan partisipasi ibu dalam memberikan asuhan pada bayinya. partisipasi ibu dalam hal ini ditunjang oleh adanya rasa percaya diri ibu untuk mampu melakukan variabel kel. kontrol (n=45) kel. intervensi (n=45) σ mean sd σ mean sd usia  < 20 th  20 – 34 th  > 34 th 5 35 5 32,60 36,29 32,00 9,29 8,25 4,90 3 34 8 60,00 62,56 60,38 5,57 5,14 5,73 pendidikan  sd  smp  sma  pt 2 20 21 2 32,00 36,85 34,67 32,00 12,73 8,51 7,88 0,00 1 10 28 6 55,00 62,80 62,25 60,67 5,88 4,86 6,19 pekerjaan  tidak bekerja  bekerja 24 21 35,04 35,81 8,45 7,85 29 16 61,52 62,88 4,95 5,78 lama perkawinan  ≤ 2 th  > 2 th 34 11 35,00 36,64 8,32 7,57 30 15 62,10 61,80 5,24 5,41 anak yang direncanakan  tidak direncanakan  direncanakan 8 37 30,63 36,43 8,48 7,74 12 33 62,08 91,97 5,85 5,09 35,40 8,09 62,00 5,24 p=0,000 perawatan. hasil penelitian ini menunjukkan bahwa tindakan perawat yang memfasilitasi bonding attachment yang didalamnya juga termasuk adanya rawat gabung, dapat memberikan dampak ibu lebih percaya diri, merasa lebih kompeten dalam perawatan bayinya dan tampak lebih sensitif terhadap tangisan bayi. peningkatan kepercayaan diri ibu dalam merawat bayinya pada masa awal postpartum ini dikarenakan responden mendapatkan manfaat yang besar dalam membantu proses adaptasi parental dengan memperoleh pendidikan cara merawat bayi dan cara memberikan asi. hal tersebut diperoleh melalui komunikasi langsung, demonstrasi, role model, maupun keterlibatan ibu bersama perawat disaat merawat bayinya ketika masih berada di rumah sakit. pendapat ini sesuai juga dengan prinsip belajar yang dikemukakan notoatmodjo (2002), pada proses emosional dan intelektual yang sesuai dengan kondisi ibu pada fase letting hold, dimana ibu ingin mencari informasi yang sebanyak-banyaknya dalam cara perawatan bayi dan dirinya. simpulan dan saran simpulan tindakan keperawatan dalam memfasilitasi bonding attachment meningkatkan kepercayaan diri ibu dalam merawat bayinya pada masa awal postpartum. hal ini ditunjukkan dengan adanya peningkatan kepercayaan diri yang baik dari ibu dengan meningkatnya keinginan untuk merawat bayinya sedini mungkin pada masa awal postpartum. 1. saran peneliti menyarankan agar penerapan asuhan keperawatan yang berbasis family centered care di semua tatanan pelayanan kesehatan untuk memfasilitasi keberadaan keluarga dan terjalinnya bonding attachment sejak proses kelahiran. pendampingan oleh perawat pada saat ibu belajar merawat bayi dengan memulai dari tahap awal seperti memberikan penjelasan, demonstrasi, memotivasi ibu untuk mencoba merawat bayinya, sekaligus mengenalkan karakteristik masing-masing bayi pada ibunya untuk meningkatkan kemampuan ibu dalam merawat bayinya. kepustakaan affonso, d. 1976. the newborn’s potential for interaction. journal of obstetric, gynecologic, and neonatal nursing, 5 (6), 9-14. bobak and jensen, 1996. essentials of maternity nursing. st. louis: mosby company. bobak, et al. 1995. maternity nursing. 4 th edition. st. louis: mosby year book inc. bullock and pridham. 1988. sources of maternal confidence and uncertain and perceptions of problem-solving competence. journal of advanced nursing, vol. 13, 321-329. djuwitaningsih, s. 2004. hubungan dukungan suami dan pelayanan keperawatan dengan interaksi ibu-bayi pada periode awal nifas dalam konteks keperawatan maternitas, tesis tidak dipublikasikan, jakarta: fik-ui. klaus and kennel, 1982. parent infant bonding, st. louis: mosby co. lowdermilk, perry and bobak, 1999. maternity nursing. 5 th edition. st. louis: mosby inc. matteson, p.s. 2001. women’s health during the chllidbearing years: a community based approach. st. louis: mosby inc. mccloskey and bulechek, 1996. nursing intervention classification (nic). st.louis: mosby year book inc. mercer and ferketich. 1994. maternal-infant attachment of experienced and inexperienced mother during infancy, nursing research, 43(6), 344-351. notoatmojo, s. 2002. metodologi penelitian kesehatan. jakarta: rineka cipta. wong, perry and hess. 1998. maternal child nursing care. st.louis: mosby inc. zahr, l.k. 1991. the relationship between maternal confidence and mother-infant behaviors in prematur infant. research in nursing and health, vol. 14, 279286. terapi aktivitas kelompok (tak) stimulasi persepsi meningkatkan harga diri anak di lembaga pemasyarakatan (perception stimulation group activity therapy increases e children self esteem at prison) ahmad yusuf*, rizki fityasari*, wiwin sulistyawati* *program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496, e-mail: yusuf@fk.unair.ac.id abstract introduction: prison is societal implementer unit which accommodate care and develop the delinquent children. it was recorded that 57% of children at blitar child prison undergo some self concept problems such as low self esteem. this was caused by some factors such as society’s stigmatization toward criminals, development pattern and education, and less support from family. if the self esteem problem is not being overcome soon, the children may fell useless, disable to control their self and recrime when they are back to society. the objective of this study was to analyze the influence of gat (group activity therapy) perception stimulation in increasing the children self esteem at prison. method: a quasy experimental pre post control design was used in this study. samples were recruited by using total sampling and there were 22 samples as on inclusion criteria. the independent variable was gat perception stimulation and the dependent variable was increasing self esteem of these childen. data were collected by using questionnare and analyzed by using wilcoxon signed ranks test and mann whitney u test with the significance level α≤0.05.result: the result showed that controlled group has significance level was p=0.654, it is mean there was no self esteem change before and after gat perception stimulation was given. whereas treatment group has significance level was p=0.001, it revealed that there was self esteem change before and after gat perception stimulation was given. the result of mann whitney u test showed p=0.000 which means was accepted. discussion: it can be concluded that perception stimulation can increase the children self esteem at prison. further studies are recommended to study the effect of gat perception stimulation modified by skill therapy in increasing children self esteem in prison. keywords: gat perception stimulation, self esteem, children, prison. pendahuluan lembaga pemasyarakatan (lapas) merupakan unit pelaksana pemasyarakatan yang menampung, merawat dan membina anak negara (keputusan menteri kehakiman, 1999 dalam teguh, 2006). pembinaan bertujuan untuk memantapkan kembali harga diri dan kepercayaan diri para narapidana agar mereka bersikap optimis akan masa depannya. sayangnya, banyak anak di lapas yang mengalami gangguan harga diri baik dalam tingkat rendah maupun sedang. cara meningkatkan harga diri pada anak usia remaja antara lain dengan mengidentifikasi penyebab rendahnya harga diri dan domaindomain kompetensi diri yang penting, dukungan emosional dan penerimaan sosial, prestasi dan mengatasi masalah (koping). tak stimulasi persepsi meliputi sesi mengidentifikasi aspek yang menyebabkan harga diri rendah dan aspek positif kemampuan yang dimiliki selama hidup (di rumah dan di lapas), serta sesi melatih kemampuan yang dapat digunakan di lapas dan di rumah (kembali ke masyarakat). namun pengaruh tak stimulasi persepsi terhadap peningkatan harga diri pada anak di lapas masih belum jelas. penghuni lapas anak blitar pada tanggal 4 april 2007 jam 11.00 wib sebanyak 170 anak yang berumur antara 1121 tahun. dari 170 anak tersebut, 41% masuk karena kasus pencurian, 21% karena kasus kesusilaan, 15% karena melanggar uu no 23 tahun 2007 tentang psikotropika dan 23% lain-lain. berdasarkan studi pendahuluan yang dilakukan peneliti pada 42 anak di lapas menunjukkan 57% anak mengalami gangguan harga diri baik dalam tingkat rendah maupun sedang. jumlah ini bisa mengalami peningkatan seiring dengan peningkatan jumlah anak yang melakukan kejahatan. angka kejahatan remaja yang meningkat terkait dengan adanya gangguan tumbuh kembang pada usia remaja. masa remaja merupakan masa pencarian identitas dimana mereka dihadapkan pada banyak peran baru dan status dewasa yang menyangkut pekerjaan dan percintaan. bila masa pencarian identitas ini tidak terlaksana dengan baik bisa menyebabkan kekacauan identitas seperti penarikan diri sendiri atau meleburkan diri ke dalam identitas temanteman sebayanya dan kehilangan identitas sendiri (erik-erikson dalam kozier, 2000). masa remaja juga waktu penjelajahan dan eksperimen, fantasi seksual dan kenyataan seksual, untuk menjadikan seksualitas sebagai identitas seseorang. bila masa-masa rawan dan kebingungan seksual ini tidak teratasi dengan baik maka mereka bisa terlibat dalam perilaku seksual yang menyimpang seperti hubungan seksual yang bebas baik atas dasar suka sama suka ataupun paksaan, kehamilan usia remaja dan penyakit menular seksual (sigmund freud dalam santrock, 1998). masa remaja juga berada dalam tahap operasional formal, mereka mulai berfikir tentang karakteristik ideal. baik orang tua ideal maupun ideal diri pribadi. pemikiran semacam ini seringkali membuat remaja membandingkan dirinya dengan orang lain berkaitan dengan patokan ideal tersebut. ideal diri yang tidak realistik menyebabkan remaja tidak mampu membentuk ideal diri sehingga dia merasa tidak mempunyai kompetensi yang akhirnya berisiko mengalami gangguan harga diri (santrock, 2003). berbagai masalah yang dialami remaja terkait dengan tumbuh kembangnya memicu terjadinya perilaku menyimpang yang disebut orang tua sebagai kenakalan/kejahatan. etiologi kompleks mengenai kejahatan mengandung banyak unsur mengenai konsep diri yang tidak memadai, mengenai citra diri yang berbeda dengan orang lain, mengenai identifikasi seksual yang tidak jelas yang berdampak pada upaya-upaya antisosial untuk mendapatkan kembali harga diri (burns, 2000). gangguan harga diri pada anak di lapas disebabkan oleh beberapa faktor antara lain stigmatisasi masyarakat, pola pembinaan dan bimbingan di lapas dan kurangnya dukungan dari keluarga (purnianti, 1993 dalam teguh, 2006). masalah gangguan harga diri pada anak di lapas ini apabila tidak segera diatasi akan mengakibatkan anak merasa rendah diri, tidak berguna, tidak mampu mengontrol diri dalam menghadapi kehidupan sehingga setelah keluar dari lapas anak berisiko melakukan kejahatan lagi. menurut keliat (2004) harga diri akan rendah jika kehilangan kasih sayang dan penghargaan dari orang lain. intervensi perlu dilakukan kepada anak di lapas untuk meningkatkan harga diri mereka. tak stimulasi persepsi bisa digunakan untuk meningkatkan harga diri anak di lapas terkait usia anak yang sebagian besar remaja. berdasarkan tumbuh kembangnya, secara kognitif remaja berada dalam tahap operasional formal yang mulai berfikir tentang karakteristik ideal (santrock, 1998). dalam tak stimulasi persepsi, klien dilatih untuk mengidentifikasi aspek positif diri dan membuat ideal diri yang realistis yang bermanfaat untuk meningkatkan harga diri mereka. dengan penerapan tak stimulasi persepsi diharapkan anak di lapas bisa mengidentifikasi dan melatih aspek positif dalam dirinya, membuat ideal diri yang realistis, sehingga setelah keluar dari lapas mereka bisa diterima oleh masyarakat, berperilaku sesuai norma yang ada dan tidak melakukan kejahatan lagi. tujuan penelitian ini adalah menganalisis pengaruh tak stimulasi persepsi terhadap peningkatan harga diri anak di lembaga pemasyarakatan klas iia anak blitar. bahan dan metode desain penelitian yang digunakan adalah quasy eksperimental pre post test control design. populasi dalam penelitian ini adalah anak yang berada di lapas anak blitar jalan bali no 41 blitar selama bulan juni 2007. sampel yang digunakan adalah 22 anak yang memenuhi kriteria inklusi dan dibagi atas 11 anak untuk kelompok yang mendapatkan tak stimulasi persepsi dan 11 anak yang tidak mendapatkan tak stimulasi persepsi. adapun kriteria inklusi sebagai berikut: anak negara(anak sipil dan anak pidana), usia 12–21 tahun, batas waktu selesainya pembinaan kurang dari 1 tahun, pada saat dilakukan penelitian, jenis kelamin laki-laki, pendidikan minimal sd, mengalami gangguan konsep diri (harga diri rendah) dan bersedia menjadi responden penelitian. variabel independen dalam penelitian ini adalah tak stimulasi persepsi dan variabel dependen adalah harga diri. instrumen pengumpulan data untuk variabel independen yaitu panduan tak stimulasi persepsi yang dikutip dari keliat dan akemat (2004), sedangkan untuk variabel dependen mempergunakan lembar kuesioner harga diri yang diadopsi dari adawiyah (2000), dengan penilaian harga diri seperti terlihat pada tabel 1. pengambilan data dilakukan dengan menggunakan check list tunggal yang digunakan sebelum dan sesudah perlakuan. alat yang dipergunakan dalam penelitian ini adalah tape recorder dan kamera. pemberian tak stimulasi persepsi terdiri dari 2 sesi, setiap sesi dilakukan selama 90 menit. data yang diperoleh dari kuesioner dianalisis dengan menggunakan uji wilcoxon signed ranks test dan mannwhitney u test dengan nilai probabilitas masing-masing p<0,05. hasil data tentang harga diri sebelum dan sesudah dilakukan tak stimulasi persepsi (seperti terlihat pada tabel 2) didapatkan pada kelompok perlakuan saat pra tes sebagian besar (81,82%) mempunyai harga diri sedang (total skor=74–94) dengan rerata skor harga diri 81,09. pada pasca tes sebagian besar kelompok perlakuan mempunyai harga diri tinggi yaitu 81,82% (total skor 95–132), dengan rerata peningkatan skor harga diri 14,18. pada kelompok kontrol pra tes 72,73% mempunyai harga diri sedang dan paska tes 63,64% mempunyai harga diri sedang dengan peningkatan harga diri yaitu – 0,64. tabel 1. penilaian harga diri (adawiyah, 2000) item penilaian skoring (dari total 5 item penilaian) 1. percaya diri 2. optimis 3. penerimaan diri 4. penyesuaian diri 5. perasaan signifikan < 74 = rendah 74-94 = sedang 95-132 = tinggi hasil uji statistik wilcoxon signed rank test pada kelompok perlakuan ditemukan adanya perubahan harga diri sebelum dan sesudah diberikan tak stimulasi persepsi dengan nilai p=0,001. pada kelompok kontrol didapatkan nilai p=0,564, hal ini menunjukkan tidak ditemukannya perubahan harga diri sebelum dan sesudah tak stimulasi persepsi. tabel 2. harga diri anak di lapas sebelum dan sesudah dilakukan tak stimulasi persepsi di lembaga pemasyarakatan klas iia anak blitar harga diri perlakuan kontrol sebelum sesudah sebelum sesudah rendah 3 0 3 4 sedang 8 2 8 7 tinggi 0 9 0 0 mean 81,09 95,27 76,64 76 sd 9,792 10,669 7,131 6,261 wilcoxon signed rank test (p=0,001) wilcoxon signed rank test (p=0,564) man whitney u test (p=0,000) keterangan: p = signifikansi mean = rerata sd = standar deviasi hasil uji statistik mann whitney u test didapatkan pada pra tes harga diri kelompok perlakuan dan kontrol berbeda dengan nilai p=0,000 berarti ada perbedaan harga diri anak antara kelompok yang diberikan tak stimulasi persepsi dengan yang tidak diberikan tak stimulasi persepsi. pembahasan anak yang tinggal di lapas mayoritas mengalami gangguan harga diri baik dalam tingkat sedang maupun rendah. harga diri rendah meliputi penilaian diri yang negatif dan diikuti dengan perasaan menjadi orang yang lemah, tidak mempunyai harapan, ketakutan (stuart dan sundeen, 1995). menurut erik-erikson dalam santrock (1998) remaja berada dalam tahap identitas versus kekacauan identitas. kekacauan identitas tersebut menyebabkan 2 hal yaitu penarikan diri individu, mengisolasi diri dari teman sebayanya dan keluarga atau meleburkan diri dengan dunia temannya dan kehilangan identitas dirinya (santrock, 1998). harga diri rendah pada anak yang berada di lapas disebabkan karena anak belum mampu menerima keadaan yang menimpa dirinya. stigma dari masyarakat, perlakuan masyarakat yang berbeda kepada mereka juga turut mempengaruhi harga diri anak tersebut. harga diri rendah kronis ditunjukkan oleh anak yang masuk lapas karena ikutan teman. hal ini terjadi karena anak belum mampu menemukan identitas dirinya dan masih dalam tahap pencarian identitas diri. masalah internal anak seperti sering mengalami kegagalan, merasa banyak kekurangan, tidak mempunyai kelebihan, tidak yakin dengan masa depannya serta kesulitan untuk mencari pekerjaan setelah keluar membuat responden merasa menjadi beban keluarga sehingga membuat harga diri mereka semakin rendah. masalah eksternal yang menyebabkan harga diri rendah pada anak di lapas yaitu kegiatan di lapas yang kurang sesuai dengan minat dan bakat anak menjadikan anak malas mengikuti kegiatan di lapas sehingga belum mempunyai keterampilan cukup untuk bekal hidup. tak stimulasi persepsi yang diberikan dapat membuat individu mempunyai kemampuan untuk menyelesaikan masalah yang diakibatkan oleh paparan stimulus kepadanya. tak stimulasi persepsi merupakan terapi yang menggunakan aktivitas sebagai stimulus dan terkait dengan pengalaman dalam kehidupan untuk didiskusikan dalam kelompok (keliat dan akemat, 2004). saat anak diberikan tak stimulasi persepsi, anak akan mempersepsikan stimulus yang diberikan selanjutnya merangsang daya ingat yang ada di otak untuk berfikir guna pemecahan masalah yang terjadi (santrock, 1998). dengan diberikannya tak stimulasi persepsi maka anak mendapat stimulus berupa penyebab harga diri rendah pada anak. dalam hal ini adalah penyebab anak masuk lapas dan identifikasi aspek positif diri serta potensi yang dimiliki. stimulus tadi akan menjadi perhatian anak dan dihantarkan oleh serabut mielin ke formatio retikuler di otak. selanjutnya otak akan memberikan respons balik berupa persepsi anak terhadap stimulus tersebut dan menyimpan hasil analisis perseptualnya terhadap stimulus tadi dalam jangka waktu tertentu (ingatan) (kozier, 2000). tahap selanjutnya adalah proses berfikir yaitu elaborasi terhadap hasil persepsi dan ingatan. hasil akhir dari proses berfikir tersebut adalah pemecahan masalah berupa respons positif yaitu anak mampu menerima kondisi diri bahwa dia seorang narapidana, mengetahui aspek positif diri dan cara mengembangkannya untuk selanjutnya mempersiapkan diri untuk kembali ke masyarakat dengan membuat ideal diri yang realistis. dengan demikian harga diri anak secara kognitif meningkat dan anak lebih siap untuk kembali ke masyarakat serta tidak berisiko melakukan kejahatan lagi. tak stimulasi persepsi memotivasi anak untuk menceritakan pengalaman masa lalu yang tidak menyenangkan, sehingga anak menjadi lebih terbuka pada kelompok. anggota kelompok yang lain menyumbangkan saran untuk memecahkan masalah yang dihadapi oleh temannya. dengan begitu anak menerima penghargaan dari orang lain yang bisa meningkatkan harga diri mereka. kehilangan kasih sayang dan penghargaan dari orang lain terutama keluarga yang dialami bisa tergantikan dengan penghargaan dan penerimaan dari anggota kelompok. perasaan senasib dan sependeritaan menyebabkan mereka bisa memahami dan menerima satu sama lain. dukungan emosional dan persetujuan sosial mempunyai pengaruh yang penting bagi harga diri anak (santrock, 1998). menurut analisis psikologi terutama dikaji dari sudut perkembangan rasional masa adolesen sangat besar artinya. oleh sebab itu keseluruhan pemahaman yang sengaja diberikan kepada anak delinquent sebaiknya memenuhi bekal hidup masa mendatang (sudarsono, 2004). aktivitas mengidentifikasi aspek positif diri dan membuat ideal diri yang realistis sangat cocok sebagai bekal anak keluar dari lapas dan menata kembali masa depannya. ditinjau dari segi perkembangan secara menyeluruh usia 13-21 tahun merupakan fase yang paling memungkinkan untuk dibina, demikian pula bagi anak delinquent (hadisuprapto, 1997 dalam cobb, 2000). responden yang sebagian besar berusia 16-18 tahun memungkinkan pembinaan bisa dilakukan secara optimal. anak yang tergabung dalam kelompok perlakuan mayoritas mengalami peningkatan harga diri. anak dalam kelompok perlakuan mampu mempersepsikan semua stimulus yang diberikan dengan baik, sehingga mereka mampu berfikir untuk menyelesaikan masalah yang dihadapi dan diperoleh hasil peningkatan harga diri yang memuaskan. perubahan harga diri positif ditunjukkan melalui kemampuan menyelesaikan masalahnya sendiri, bisa menerima keadaan dirinya, mengaku menyesal dengan apa yang telah mereka lakukan dan sudah tidak merasa sedih lagi memikirkan keadaan dirinya. hal ini menunjukkan bahwa responden sudah mampu menerima kondisi diri. peningkatan rasa percaya diri responden kelompok perlakuan terlihat dari responden yang mengatakan bahwa mereka mengetahui dan mempunyai kelebihannya, merasa tidak kesulitan lagi mencari pekerjaan setelah keluar dari lapas, merasa yakin dengan masa depannya karena mereka mampu untuk mencapai apa yang dicitacitakan meskipun dengan kondisi mereka sebagai narapidana serta tidak merasa kesulitan lagi menyatu kembali dengan masyarakat karena sebagian besar mereka akan pindah dan bekerja ke luar kota. harga diri positif sangat penting karena ketika seseorang memilikinya mereka merasa baik, efektif dan produktif (clarke, j., 1998). individu yang mempunyai harga diri tinggi mempunyai kemampuan untuk mengatasi dan mengantisipasi permasalahan, memiliki self acceptance tinggi, keyakinan diri tinggi dan menilai dirinya secara positif, mudah bergaul, menerima feedback positif dan mempertahankan diri dari feedback yang negatif (winarni, 1994). satu responden tidak mengalami peningkatan harga diri, dikarenakan kondisi harga diri rendah yang kronis, kurangnya dukungan keluarga (keluarga tidak pernah mengunjungi), alasan melakukan pelanggaran serta perasaan setelah melakukan pelanggaran (tidak adanya perasaan menyesal setelah melakukan pelanggaran). pada kelompok kontrol ditemukan mayoritas tidak adanya peningkatan harga diri. hal ini disebabkan karena anak tidak memperoleh stimulus, sehingga tidak proses persepsi dan ingatan yang berkembang menjadi proses berfikir. tidak adanya dukungan baik sosial maupun emosional yang diperoleh baik dari keluarga maupun oleh teman di dalam lingkungan lapas itu sendiri. hanya 1 responden mengalami peningkatan harga diri. peningkatan harga diri yang dialami oleh anak tersebut disebabkan karena dukungan dari keluarga (sering dikunjungi oleh keluarga), maupun karena pembinaan keterampilan yang dilakukan di lapas sehingga mengalami peningkatan harga diri. simpulan dan saran simpulan tak stimulasi persepsi meningkatkan harga diri anak di lapas blitar. perubahan harga diri positif ditunjukkan melalui kemampuan menyelesaikan masalahnya sendiri, bisa menerima keadaan dirinya, mengaku menyesal dengan apa yang telah mereka lakukan dan sudah tidak merasa sedih lagi memikirkan keadaan dirinya. saran berdasar hasil penelitian ini, peneliti menyarankan agar modifikasi pembinaan budi pekerti dengan terapi aktivitas kelompok (tak) stimulasi persepsi agar tujuan pembinaan lembaga pemasyarakatan bisa tercapai yakni memantapkan kembali harga diri dan kepercayaan diri narapidana sehingga mereka mampu optimis terhadap masa depannya, pemilihan kegiatan yang akan diikuti anak selama menjalani masa pemidanaan hendaknya sesuai dengan minat dan bakat yang mereka miliki dan penelitian lebih lanjut tentang pengaruh tak stimulasi persepsi dengan modifikasi terapi keterampilan terhadap peningkatan harga diri baik secara kognitif maupun psikomotor. kepustakaan adawiyah, r. 2000. hubungan antara harga diri dan intensitas depresi pada penyandang epilepsi grand mal di rsu dr. soetomo. skripsi tidak dipublikasikan. surabaya: universitas airlangga. burns, r.b. 2000. konsep diri: teori, pengukuran, perkembangan perilaku. jakarta: arcan. clarke, j. 1998. self esteem: a familiy affair. usa: hazelden, p.5. cobb, n. 2000. adolescence: continuity, change and diversity. usa: mayfield publishing company, pp. 127-131. hadisuprapto. 1997. juvenile delinquency. bandung: citra aditya bakti, hlm. 1930. kozier. 2000. fundamental nursing: concept, proses and practice. new jersey: pearson education, p. 960. keliat, b.a. 2004. gangguan konsep diri. jakarta: egc, hlm.345-349. keliat dan akemat, 2004. keperawatan jiwa: terapi aktivitas kelompok. jakarta: egc, hlm. 3-7, 49-51, 98-101, 116-117. purnianti. 1992. pertemuan ilmiah tentang pola pemidanaan, penerimaan bekas narapidana dan santunan terhadap korban tindak pidana. jakarta: bphn, hlm. 45-51. santrock, j. 1998. adolescence. united states of america: mc.graw hill. savitri. 2000. anak yang berkonflik dengan hukum. skripsi tidak dipublikasikan. surabaya: universitas airlangga. sudarsono. 2004. kenakalan remaja, prevensi, rehabilitasi dan resosialisasi. skripsi tidak dipublikasikan. surabaya: universitas airlangga, hlm. 95-96. stuart dan sundeen, 1998. buku saku ilmu keperawatan jiwa. jakarta: egc, hlm. 227-229. teguh. 2006. implikasi penerapan pola pidana pada anak. skripsi tidak dipublikasikan. surabaya: universitas airlangga. winarni. 1994. perbedaan kecenderungan perilaku koping antara individu yang memiliki tingkat self esteem tinggi dan individu yang memiliki tingkat self esteem rendah. skripsi tidak dipublikasikan, surabaya: universitas airlangga, hlm. 48. http://e-journal.unair.ac.id/jners | 87 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.8568 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research individual coaching during hospitalization improves the spirituality of muslim patients hamdan hariawan¹, oedojo soedirham² and abu bakar1 1 faculty of nursing, universitas airlangga, surabaya, east java, indonesia 2 faculty of public health, universitas airlangga, surabaya, east java, indonesia abstract introduction: patients treated in hospital often experience an uncomfortable condition. this condition can lead to a decrease in performing salat as a muslim prayer. the purpose of this study was to determine the effect of individual coaching on the spirituality of muslims including knowledge, attitude, and the practice of salat. methods: this study used a quasi-experimental design. the sample consisted of 36 muslim inpatients. the data was collected through a selfconstructed questionnaire and it was analyzed using the independent ttest and mann whitney test with α ≤ 0.05. results: there was no significant difference in the scores for knowledge (p=0.941), attitude (p=0.924) and practice (p=0.635) between the two groups before the intervention. however, after being given the intervention, the scores increased for the treatment group, thus creating a significant difference between the treatment and control groups for knowledge (p=0.000), attitude (p=0.003) and practice (p=0.000). conclusion: coaching is a suitable method to use to increase the muslim inpatients' knowledge, attitude, and ability to practice salat. this study recommends that the nurses conduct coaching as a nursing intervention to help the patient to perform salat. article history received: june 44, 2018 accepted: nov 27, 2019 keywords attitude; individual coaching; knowledge; muslim; salat contact abu bakar  abu.bakar@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, east java, indonesia cite this as: hariawan, h., soedirham, o., bakar, a. (2019). individual coaching during hospitalization improves the spirituality of muslim patients. jurnal ners, 14(1), 87-91. doi:http://dx.doi.org/10.20473/jn.v14i1.8568 introduction nowadays, inpatients often have problems related to doing all of the physical activities related to worship (hubbartt, corey, & kautz, 2012). the patient will potentially be equipped with medical devices such as for the purpose of medication infusion, catheter tubing, and oxygen tubes up the nose which causes inconvenient and unconfident conditions concerning the patients performing (praying) salat in the hospital. salat is a spiritual activity that is a form of worship of the creator of the universe. it is about moving certain parts of the body while reciting doa. salat is an obligation for all muslims in either a healthy or critical condition (al-obaidi, wall, mulekar, & al-mutairie, 2012); mohamed, nelson, wood, & moss, 2015 ;( akgul & karadag, 2016). based on a study conducted in langkawi hospital involving 166 muslim inpatients, 53.6% had a poor level of knowledge of performing salat, 61.4% had a poor level of attitude when performing salat and 78.9% patients did not perform salat during their stay in the inpatient care facility. this study also revealed that 77.7% patients did not know how to perform salat during their medical treatment, while 47.6% of patients did not know how to purify themselves of impurities (wudu) and 48.2% patients said that nobody was there to teach them how to perform salat and the required ritual purification (aris, rani, jaafar, norazmi, & umar, 2017). salat is a fundamental and spiritual need for muslims during their inpatient care facility. salat performed in a critical condition can increase the sense of convenience and decrease anxiety, depression, and stress (kurniawati, 2017). salat is also useful when related to the patient's readiness and mentality when facing a critical health condition (saniotis, 2015) . the patients who cannot perform https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1. h. hariawan et al. 88 | pissn: 1858-3598  eissn: 2502-5791 salat due to their physical disabilities easily encounter spiritual distress (herdman & kamitsuru, 2014). the patients deem it necessary to get information and education regarding the implementation of salat when in a critical condition (mohamed et al., 2015). the method used to provide information on how to perform salat in the hospital is coaching (palmer, 2012). coaching does not only contain education but also encouragement when it comes to the patients being able to worship according to their own will. this method is started by identifying the ability level of the patient for practicing salat based on their background knowledge. the patient will be prepared and motivated before performing salat (macadam, 2013). the previous study showed that the use of the coaching method provides solutions in both the clinic and the community, such as increasing self-efficacy, health education, life quality and the self-treatment of the patient (bennett et al., 2009; vanacker et al., 2017; wagner et al., 2017). based on the concept of spirituality and spiritual self-care within orem's selfcare deficit nursing theory, salat is directly influenced by self-care agency and increasing the knowledge and attitude of the patient through the intervention (white, peters, & schim, 2011). therefore, the purpose of the study is to examine the influence of individual coaching towards the knowledge, attitude, and practice of salat among muslim inpatients. materials and methods this study applied a quasi-experimental design and it consisted of a preand post-test of the control group. the sample involved 36 muslim inpatients and they were selected using a random sampling technique. the independent variable was modular individual coaching while the dependent variable was spiritual muslims (referring to the knowledge, attitude, and practice of salat). the data was collected using questionnaires developed from yusuf (ah yusuf, nihayati, iswari, & okviasanti, 2017). the questionnaire on knowledge covered the concept of ritual purification, salat practice during the critical condition, and the benefits of salat. the questionnaire of attitude covered the implementation of ritual purification, salat during the critical condition, and family support. the questionnaires have been tested for reliability and they had a cronbach’s alpha score of 0.571. the criteria for the patients in this study were as follows: 1) muslim patients aged 18 65 years old, 2) cooperative patients with compos mentis, 3) patients with a degree of partial and total dependence and 4) female patients who are not menstruating. the intervention group was given the intervention (a module of individual coaching) by a spiritual guidance counselor from the hospital over 7 days for a duration of 10 60 minutes while the control group was not. the statistical test used in this study was the independent t-test for the knowledge variable and the mann whitney test for the attitude and practice variables. this study received an ethical agreement from the ethics committee of rumah sakit umum daerah nusa tenggara barat number: 070.1/01/kep/2018. results the characteristics of the respondents based on sex both in the treatment group and in the control group, showed that they were almost entirely male, totalling 14 respondents (77.8%) in the treatment group and 12 respondents (66.7%) in the control group. the characteristics of the respondents based on age in the treatment group showed that almost half were in the age range of 36 45 years, with 8 respondents (44.4) in each group. the characteristics of the respondents based on education in the treatment group showed that almost half of them were in junior and senior high school, each of which was 6 respondents (33.3%). in the control group, almost half had an elementary school education, totalling 7 respondents (38.9%). the characteristics based on length of stay before the data collection showed that almost all of the respondents had been hospitalized for more than 3 days with a total of 15 respondents in the treatment group (83.3%) and 13 respondents in the control group (72.2%). based on table 1, the mean score of the intervention group was lower than that of the control group. after receiving the intervention, the mean score of the treatment group was higher than that of the control group in three aspects (knowledge, attitude, and salat practice). based on the statistical test, after receiving the intervention, the knowledge aspect reached p=0.000, the attitude aspect reached p=0.003 and the practice aspect reached p=0.000. this result shows that there is a difference between the two groups after receiving the intervention. this difference indicates that table 1. data on knowledge, attitude, and the practice of salat (spiritually) variables groups pre (mean+sd) min-max post (mean+sd) min-max knowledge intervention 14.33+2.17 11-19 19.00+1.72 14-20 control 14.39+2.28 11-19 14.89+2.29 11-19 p value p = 0.941 p = 0.000 attitude intervention 26.17+2.31 22-31 29.67+2.25 25-32 control 26.50+3.17 22-32 26.61+2.81 23-32 p value p = 0.924 p = 0.003 practice intervention 10.00+2.91 9-18 15.33+3.80 9-18 control 10.50+3.45 9-18 10.50+3.45 9-18 p value p = 0.635 p = 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 89 individual coaching influences the knowledge, attitude, and practice of salat in patients who are hospitalized. discussion the results of the study show that individual coaching influences the knowledge, attitude, and practice of salat among muslim inpatients. based on the average score of the preand post-test, the treatment group is higher than the control group in knowledge, attitude, and the practice of salat after receiving individual coaching. coaching is given to increase individual knowledge. coaching is also defined as a patientcentered education method aimed at motivating an individual to promote health through selfmanagement (anna, dejonghe, becker, froboese, & schaller, 2017). the increase in knowledge can be obtained through education, which is a part of coaching (cheng & chan, 2009 ; calderón garcidueñas et al., 2015). training is an essential part of helping the patient by equipping them with visual aids when explaining the procedure of specific actions independently. moreover, education should be provided by the experts based on their expertise, and this could create self-confidence in the patient. coaching is beneficial for increasing knowledge among elderly patients with cognitive disorders. the increase in knowledge does not take a short time due to the cognitive development remaining decreased according to the process of aging (güçlü & tabak, 2013 ; omori et al., 2017). the level of knowledge among the patients after receiving the intervention gradually increases their cognitive development. they already know about the concept of ritual purification using dust (tayammum), and the parts of the body that should be wiped by the motes of dust. the patient's knowledge will improve gradually about salat in either a sitting or standing condition. individual coaching is thus useful for the patient to perform salat in the hospital. moreover, the patient is equipped with a flipchart, wudu spray bottles, and motes of dust to directly practice what the coach has taught. education with a spiritual value can increase the spiritual well-being of the patient which leads to confidence and increased religiosity focused on the god almighty. thus the patient will obtain additional motivation to implement the obligation of the worship of god (hasanshahi & mazaheri, 2016). the increase in the attitude of the patient occurred due to the motivation given during the coaching session. the coaching consists of motivational interviewing that influences the attitude of the patient and that is directed to encouraging the obedience to commit something (david h. thom et al., 2016 ; románrodríguez et al., 2017). the attitude aspect has been formed due to the reciprocal relationship between individuals and the environment in establishing personal behavior (azwar, 2003). social interaction is considered to be important in terms of affecting individual behavior while performing salat, which was conducted by the patient, nurse, coach, and other medical staff. salat is a form of spiritual self-care. in the theory of self-care deficit nursing, a supportive-educative aspect is aimed at supporting an individual to obtain additional motivation and information before conducting self-treatment. the nurse's action is to organize training and self-treatment agencies for the patient while the patient's action is to promote selfcare until the end of their treatment (alligood, 2014). if self-care deficit nursing is connected by spirituality, then the self-care agency of the patient will involve power components such as knowledge and attitude regarding their spiritual practices. the existence of self-care agency can improve the power component. therefore, this study used a nursing agency to provide the individual coaching intervention. the development of attitude among the patients after receiving the intervention occurs due to the increase in their sense of comfort. primarily, the patient can perform salat in emergency conditions (not purified), such as where there are dirty clothes or a strange place. it can be achieved if there is individual coaching in the form of personal motivation. salat is a form of spiritual self-care and it is a fundamental principle for muslims. it can be used to solve the daily problems of life, such as illness, anxiety, and depression. for muslims, salat and praying to allah swt increases convenience instead of anxiety, stress, and depression. thus, the biological response in the form of the modulation of their immunity will promote the patient's health as well (rezaei, adib-hajbaghery, seyedfatemi, & hoseini, 2008 ; saniotis, 2015 ; yusuf, nihayati, iswari, & okviansanti, 2017). according to the islamic principle, muslims should perceive salat as an obligatory order even when in a critical condition (illness) (kurniawati, 2017). the nurse plays a series of important roles, such as reviewing the patient, giving the intervention (supporting religious activities), and cooperating with the spiritual counselor as a part of fulfilling the patient's needs (yusuf et al., 2017). individual coaching consists of five stages, namely reviewing, educating, training, motivating, and evaluating all of the activities regarding spiritual self-care between the medical staff and spiritual counselor. the education and training stages will increase spiritual well-being, as well as spiritual self-care (white et al., 2011 ; hasanshahi & mazaheri, 2016). the existence of individual coaching influences the difference between the control and treatment groups. the influence of individual coaching towards self-action (attitude) can be achieved through education, personal motivation, and training regarding the implementation of salat during treatment in the hospital. hence the collaboration between the nurse and spiritual counselor is highly important in terms of promoting patient health. h. hariawan et al. 90 | pissn: 1858-3598  eissn: 2502-5791 coaching helps the patient to transform behavior into health and welfare promotions as a part of motivating their mental condition. the researcher and spiritual counselor are collaborating to deliver the information and education regarding the implementation of salat when in a critical condition (illness), in addition to the ritual purification practice (wudu), personal motivation, and self-control. the patient is facilitated by the provision of tayammum dust and a spray for wudu. as a consequence, individual coaching is essential for helping the patient to fulfill their spiritual needs (the practice of salat). the limitations in this study are the characteristics of the patient regarding the patient's understanding related to hadith prayers not having been examined. the research sample is limited but the characteristics of muslims in indonesia are the same, so there is little bias. conclusion there is an improvement in the spirituality of muslims (knowledge, attitude, and practice of salat) in a state of illness or a critical condition after receiving individual coaching. the nurses in the hospital are expected to provide coaching as a nursing intervention and to cooperate with a spiritual counselor as a part of helping the inpatient to perform salat. references akgul, b., & karadag, a. (2016). the effect of colostomy and ileostomy on acts of worship in the islamic faith. journal of wound, ostomy, and continence nursing: official publication of the wound, ostomy and continence nurses society / wocn, 43(4), 392–397. https://doi.org/10.1097/won.0000000000000 237 al-obaidi, s., wall, j. c., mulekar, m. s., & al-mutairie, r. (2012). the reliability of prayer-based selfefficacy scale to assess self-confidence of muslims with low back pain. physiotherapy research international, 17(2), 110–120. https://doi.org/10.1002/pri.522 alligood, m. r. (2014). nursing theories and their work 8th ed (8th ed.). st. louis, missouri: mosby. anna, l., dejonghe, l., becker, j., froboese, i., & schaller, a. (2017). long-term effectiveness of health coaching in rehabilitation and prevention: a systematic review. patient education and counseling, 100, 1643–1653. https://doi.org/10.1016/j.pec.2017.04.012 aris, m. s. m., rani, m. d. m., jaafar, m. h., norazmi, a. ‘ubaidah a., & umar, n. s. (2017). knowledge, attitude, and practice of performing prayers (salat) among muslim patients in hospital langkawi, kedah: roles of muslim healthcare providers. advanced science letters, 23(5), 4955–4959. https://doi.org/10.1166/asl.2017.8975 azwar, s. (2003). sikap manusia, teori dan pengukurannya. yogyakarta: pustaka pelajar. bennett, h., laird, k., margolius, d., ngo, v., thom, d. h., & bodenheimer, t. (2009). the effectiveness of health coaching, home blood pressure monitoring, and home-titration in controlling hypertension among low-income patients: protocol for a randomized controlled trial. bmc public health, 9(1), 456. https://doi.org/10.1186/1471-2458-9-456 calderóngarcidueñas, a. l., flores-peña, y., de leónleal, s., vázquez-martínez, c. a., farías-calderón, a. g., melo-santiesteban, g., … cerda-flores, r. m. (2015). an educational strategy for improving knowledge about breast and cervical cancer prevention among mexican middle school students. preventive medicine reports, 2, 250– 254. https://doi.org/10.1016/j.pmedr.2015.02.006 cheng, a. s., & chan, e. p. (2009). the effect of individual job coaching and use of health threat in a job-specific occupational health education program on prevention of work-related musculoskeletal back injury. journal of occupational and environmental medicine / american college of occupational and environmental medicine, 51(12), 1413–1421. https://doi.org/10.1097/jom.0b013e3181bfb2a 8 david h. thom, jessica wolf, heather gardner, denise devore, ba, michael lin, … george saba. (2016). a qualitative study of how health coaches support patients in making health...: ebscohost. annals of family medicine, 14(6), 509–517. https://doi.org/10.1370/afm.1988.introduct ion güçlü, s., & tabak, r. s. (2013). impact of health education on improving women’ s knowledge and awareness of. 2006(2), 18–23. hasanshahi, m., & mazaheri, m. a. (2016). the effects of education on spirituality through virtual social media on the spiritual wellbeing of the public health students of isfahan university of medical sciences in 2015. ijcbnm, 4(2), 168–175. herdman, t. h., & kamitsuru, s. (2014). nanda intenational nursing diagnoses: definitions & classification, 2015-2017 (10th ed.). oxford: wiley blackwell. hubbartt, b., corey, d., & kautz, d. (2012). prayer at the bedside. international journal for human caring, 16(1), 42–47. kurniawati, n. d. (2017). mind-body-spiritual nursing care in intensive care unit. advances in health sciences research, 3(inc), 223–228. macadam, c. (2013). health coaching – a powerful approach to support self-care. mohamed, c. r., nelson, k., wood, p., & moss, c. (2015). issues post-stroke for muslim people in maintaining the practice of salat (prayer): a qualitative study. collegian, 22(3), 243–249. https://doi.org/10.1016/j.colegn.2014.01.001 jurnal ners http://e-journal.unair.ac.id/jners | 91 omori, k., kawamura, t., urata, m., matsuura, m., kusama, m., imamine, r., … hotta, n. (2017). effect of re-coaching on self-injection of insulin in older diabetic patients – impact of cognitive impairment. diabetes research and clinical practice, 130, 34–42. https://doi.org/10.1016/j.diabres.2017.05.011 palmer, a. s. (2012). multimodal coaching and its application to workplace, life and health coaching. the danish journal of coaching psychology, 2(october), 91–98. rezaei, m., adib-hajbaghery, m., seyedfatemi, n., & hoseini, f. (2008). prayer in iranian cancer patients undergoing chemotherapy. complementary therapies in clinical practice, 14(2), 90–97. https://doi.org/10.1016/j.ctcp.2008.01.001 román-rodríguez, m., ibarrola-ruiz, l., mora, f., plaza, v., sastre, j., torrego, a., … sánchezherrero, g. (2017). motivational interviewing for adherence: post-training attitudes and perceptions of physicians who treat asthma patients. patient preference and adherence, 11, 811–820. https://doi.org/10.2147/ppa.s127645 saniotis, a. (2015). understanding mind/body medicine from muslim religious practices of salat and dhikr. journal of religion and health. https://doi.org/10.1007/s10943-014-9992-2 vanacker, p., standaert, d., libbrecht, n., vansteenkiste, i., bernard, d., yperzeele, l., & vanhooren, g. (2017). an individualized coaching program for patients with acute ischemic stroke: feasibility study. clinical neurology and neurosurgery, 154, 89–93. https://doi.org/10.1016/j.clineuro.2017.01.017 wagner, k. a., braun, e., armah, s. m., horan, d., smith, l. g., pike, j., … gletsu-miller, n. (2017). dietary intervention for glucose tolerance in teens (dig it): protocol of a randomized controlled trial using health coaching to prevent youth-onset type 2 diabetes. contemporary clinical trials, 53, 171–177. https://doi.org/10.1016/j.cct.2016.12.018 white, m. l., peters, r., & schim, s. m. (2011). spirituality and spiritual self-care: nursing science quarterly, 24(i), 48–56. https://doi.org/10.1177/0894318410389059 yusuf, a., nihayati, h., iswari, m., & okviansanti, f. (2017). kebutuhan spiritual: konsep dan aolikasi dalam asuhan keperawatan (pertama). jakarta: mitra wacana medika. organizational role stressors dengan tingkat stres kerja perawat icu 89 karakteristik individu dan reward system berhubungan dengan kinerja perawat (individual characteristic and reward system relate to nurses’ performance) kusnanto*, siti guntarlin**, endah purnihasti* abstract introduction : nurses are one of the most important profession in health care system. lack of reward systems and different of individual nurse’s characteristic will be contributed to the quality of nursing service given. this study was aimed to explain the correlation between individual characteristic and nurse reward system with nurse’s performance at rsud bontang. method : this study used cross-sectional design involved 39 respondents, taken by purposive sampling. the independent variable were individual characteristic and nurse reward system and the dependent variable was nurse’s performance. data were collected by using questionnaires and analyzed using linier regression with level of significance α≤0,05. result : results showed that there were significant correlation between nurse’s performance with individual characteristic and reward system. analysis : it can be concluded that individual nurse’s characteristic and nurse reward system had correlation between nurse’s performance nursing care quality. discussion : individual characteristic factors (sex, age, education, seniority or work period) and nurse’s reward system must be considered to make judgement policy efficiency by human research. further research must be done for identification factors who related nurse’s performance. . keyword : characteristic individual, reward system, and nurse’s performance *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: kusnanto_ners@yahoo.com ** rsud dr.soetomo surabaya pendahuluan perawat merupakan tenaga profesional yang mempunyai peran penting dalam memberikan pelayanan kepada pasien di rumah sakit. perawat mempunyai kontak 24 jam dengan pasien. kinerja perawat dapat dilihat dari mutu asuhan keperawatan yang diberikan pada pasien. mutu pelayanan keperawatan yang baik dapat meningkatkan kepuasan pasien. asuhan keperawatan yang bermutu dapat dibentuk melalui penggunaan pendekatan proses keperawatan. sistem dukungan dan penghargaan bagi perawat akan memberikan pengaruh yang cukup baik bagi kinerja perawat. kinerja perawat diharapkan dapat menunjukkan kontribusi profesional secara nyata dalam meningkatkan mutu pelayanan keperawatan yang berkualitas dan profesional. kepuasan kerja tenaga keperawatan di rsud kota bontang pada tanggal 10 juli 2009 didapatkan data pada 30 perawat rawat inap rsud bontang sebanyak 46,67% merasa tidak puas, 40% merasa cukup puas, dan 13,3% merasa puas. kepuasan kerja diukur berdasarkan hirarki kebutuhan maslow yaitu kebutuhan fisiologis, keamanan, sosial, ego/harga diri, dan aktualisasi diri. kebutuhan mendasar yang dibutuhkan pekerja adalah kebutuhan fisiologis. upah dan gaji yang layak termasuk di dalam kebutuhan fisiologis yang merupakan sistem penghargaan kepada perawat. rumah sakit umum daerah kota bontang sebagai institusi pelayanan kesehatan selalu berusaha meningkatkan mutu pelayanan. sumber daya manusia berkualitas dan mempunyai motivasi tinggi menjadi penentu mutu pelayanan rumah sakit. pelaksanaan pelayanan keperawatan di ruang rawat inap rsud kota bontang tak lepas dari potensi sumber daya keperawatan yang didukung oleh sekitar 125 personil yang terdiri dari berbagai latar belakang jurnal ners vol.4 no.1 april 2009: 89-93 90 pendidikan yang berbeda, diantaranya spk/spr: 20%, sprg: 1,6%, d3 anastesi: 1,6%, d3 kebidanan: 9,6%, d4 kebidanan: 0,8%, bidan: 2,4%, d3 keperawatan: 60% serta 4% berpendidikan s1 keperawatan (bidang keperawatan, 2008). pada tahun 2000 direktorat pelayanan keperawatan depkes bekerja sama dengan who mengadakan penelitian tentang pelayanan keperawatan di kaltim, sumut, sulut, jabar dan dki menunjukkan gambaran: 1) 70,9% perawat selama 3 tahun terakhir tidak pernah mengikuti pelatihan, 2) 39,8% perawat masih melakukan tugastugas non keperawatan, 3) 47,4% perawat tidak memiliki uraian tugas secara tertulis, dan 4) belum dikembangkan monitoring dan evaluasi kinerja perawat secara khusus. mustar, l (1999) dalam tesisnya di rsjp surakarta menyatakan bahwa hubungan karakteristik individu terhadap kinerja perawat dalam melaksanakan asuhan keperawatan yang berdasarkan standar berkisar 57%. penelitian yang dilakukan oleh institute of medicine di amerika serikat pada tahun 2006 merekomendasikan bahwa sistem pembayaran gaji berbasis kinerja memberikan rangsangan untuk peningkatan kinerja dalam pelayanan kesehatan di rumah sakit dan meningkatkan pendapatan para dokter sebesar 20% dari sebelumnya. penelitian yang dilakukan lindernauer tahun 2007 di rumah sakit pemerintah dan swasta amerika serikat menunjukan bahwa kompensasi berbasis kinerja dapat meningkatkan perubahan mutu pelayanan di rumah sakit berkisar antara 2,6% sampai 4,1% dalam waktu dua tahun sejak diberlakukan sistem kompensasi berbasis kinerja. kinerja yang baik merupakan cerminan mutu pelayanan keperawatan. permasalahan yang sering dihadapi dari kinerja perawat ruang inap yaitu lingkungan yang kurang kondusif, kurangnya umpan balik/pengawasan, kurangnya reward system atau imbalan atau tidak ada promosi (rosemary, 1999 dalam widiastuti, 2005). dampak reward system yang kurang terstruktur dapat mempengaruhi kinerja dan penampilan karakteristik individu perawat. kinerja perawat yang kurang baik akan menghambat proses penyembuhan pasien, proses pelayanan medik, produktivitas perawat maupun proses pelayanan keperawatan. penampilan karakteristik individu perawat yang kurang kondusif, sehingga dapat mengakibatkan rendahnya mutu asuhan keperawatan (oetomo, i., 2002). faktor lain yang dapat mempengaruhi kinerja perawat adalah faktor umur, jenis kelamin, tingkat pendidikan dan masa kerja perawat yang bekerja di ruang rawat inap (dessler, g., 1997). keinginan untuk berinovasi dan berkreativitas para perawat merupakan aktualisasi diri dari keinginan untuk berkembang (need of achievement). teori perubahan yang disampaikan oleh kurt lewin memberikan penjelasan bahwa perubahan terjadi melalui dua mekanisme, yaitu : (1) mengurangi hambatan (barriers) dan (2) meningkatkan dukungan (schein, 1997). perawat perlu mengkondisikan lingkungan agar kondusif untuk mengekspresikan inovasi dan kreativitas. pelatihan tentang pengelolaan penampilan individu perawat profesional serta menciptakan perubahan suasana keterbukaan, kejujuran secara langsung sesuai nilai-nilai yang diyakini dapat membentuk lingkungan dan karakteristik perawat profesional (porter dan o’grady, 1986 dalam nursalam, 2002). menurut rogers (1995) dalam hebert (2000), langkah strategis upaya adopsi inovasi dalam rangka peningkatan standar praktik keperawatan adalah meningkatkan kesempatan pelatihan dan pendidikan berkelanjutan (continuing education) bagi para perawat. bahan dan metode penelitian penelitian ini menggunakan metode cross-sectional dengan seluruh perawat yang bekerja di ruang rawat inap rumah sakit umum daerah taman husada kota bontang. besar populasi penelitian ini adalah 94 orang perawat. sampel penelitian sebanyak 39 perawat diambil berdasarkan kriteria inklusi yang telah ditetapkan yaitu : 1) pendidikan minimal d3 keperawatan, 2) umur minimal 22 tahun, 3) berstatus sebagai pegawai tetap (pns/cpns), 4) lama kerja minimal 1 tahun. penelitian ini dilaksanakan pada bulan juli 2009. variabel independen dalam penelitian ini yaitu karakteristik individu (umur, jenis kelamin, pendidikan, dan senioritas atau masa kerja) dan reward system karakteristik individu dan reward system (kusnanto) 91 perawat. variabel dependen yaitu kinerja perawat dalam melaksanakan asuhan keperawatan. instrumen pengumpulan data dengan menggunakan kuesioner digunakan untuk mengukur karakteristik individu dan reward system. kinerja perawat diukur menggunakan lembar observasi berdasarkan pendekatan proses keperawatan yang berisi item pertanyaan tentang pengkajian, perencanaan, implementasi, evaluasi, catatan asuhan keperawatan, keterampilan komunikasi, dan harapan institusi maupun profesi. kinerja perawat diobservasi satu kali oleh peneliti pada saat shift pagi dan sore. data yang diperoleh ditabulasi dan dianalisis menggunakan uji statistik regresi linier dengan tingkat kemaknaan α≤0,05. hasil penelitian kinerja perawat diukur melalui observasi berdasarkan pendekatan proses keperawatan pada shift pagi dan sore. hasil penelitian menunjukkan hampir setengah responden mempunyai kinerja cukup baik sebanyak 19 orang (48,7%). karakteristik individu diukur berdasarkan umur, jenis kelamin, pendidikan, dan senioritas atau masa kerja. responden yang diteliti berjumlah 39 perawat dengan jeni kelamin 6 orang laki-laki dan 33 orang perempuan. hasil penelitian menunjukkan bahwa sebagian besar perawat perempuan mempunyai kinerja cukup baik 19 orang (57,57%). sedangkan responden laki-laki sebagian besar mempunyai kinerja kurang baik (83,3%). hasil uji regresi linier menunjukkan nilai terdapat hubungan antara jenis kelamin dengan kinerja perawat dalam melaksanakan asuhan keperawatan (p=0,007). karakteristik umur responden menunjukkan sebagian besar berada dalam rentang usia 22-30 tahun sebanyak 23 orang (59%) dengan kinerja cukup baik sebanyak 13 responden (39,39%) tidak ada responden yang mempunyai kinerja baik. responden yang berumur 31-40 tahun sebanyak 16 orang dengan kinerja baik 10 orang (62,5%), tidak ada responden yang mempunyai kinerja kurang baik. hasil uji regresi linier menunjukkan nilai signifikan p=0,025, berarti ada hubungan antara umur dengan kinerja perawat dalam melaksanakan asuhan keperawatan. karakteristik responden berdasarkan pendidikan menunjukkan terdapat dua jenjang pendidikan perawat yaitu d3 keperawatan berjumlah 29 responden dan 10 responden berpendidikan s1 keperawatan. responden yang berpendidikan d3 keperawatan mempunyai kinerja cukup baik sebanyak 18 responden (62%). responden yang berpendidikan s1 keperawatan sebanyak 9 (90%) orang mempunyai kinerja baik, tidak ada responden yang mampunyai kinerja kurang baik. hasil uji regresi linier menunjukkan nilai signifikan p=0,001, menunjukkan bahwa ada hubungan antara pendidikan dengan kinerja perawat dalam melaksanakan asuhan keperawatan, dengan tingkat hubungan yang kuat . karakteristik responden berdasarkan status perkawinan menunjukkan bahwa 61% responden berstatus menikah, sebanyak 36% belum menikah, sebesar 3% berstatus janda. responden dengan status menikah/kawin sebanyak 14 reponden (58,35) mempunyai kinerja cukup baik dan responden dengan status belum menikah sebagian besar (64,3%) memiliki kinerja baik. hasil uji regresi linier menunjukkan nilai signifikan p=0,024, menunjukkan bahwa ada hubungan antara status perkawinan dengan kinerja perawat dalam melaksanakan asuhan keperawatan. karakteristik responden berdasarkan masa kerja dibedakan menjadi dua masa kerja yaitu 1-5 tahun dan 6-15 tahun. sebagian besar responden (67%) mempunyai masa kerja 1-5 tahun. sebagian besar responden (57,7%) dengan masa kerja 1-5 tahun mempunyai kinerja baik, sedangkan masa kerja 6-15 tahun sebesar 38,4% mempunyai kinerja baik. hasil uji regresi linier menunjukkan nilai signifikan p=0,278, menunjukkan bahwa tidak ada hubungan antara senioritas dengan kinerja perawat dalam melaksanakan asuhan keperawatan. karakteristik responden berdasarkan status pegawai dibedakan menjadi pns dan cpns. status pegawai pns mempunyai porsi yan lebih besar daripada cpns. sebagian besar responden cpns dan pns mempunyai kinerja cukup baik. hasil uji regresi linier menunjukkan nilai signifikan p=0,830, menunjukkan bahwa tidak ada hubungan antara status pegawai dengan kinerja perawat dalam melaksanakan asuhan keperawatan. rekapitulasi hasil uji statistik karakteristik individu disajikan dalam tabel1. jurnal ners vol.4 no.1 april 2009: 89-93 92 reward system (imbalan) yang diberikan kepada perawata dibagi menjadi dua yaitu: imbalan intrinsik dan ekstrinsik. imbalan intrinsik lebih dari cukup menciptakan kinerja cukup baik sebesar 38,5%. imbalan ekstrinsik sebagian besar adalah cukup, menciptakan kinerja cukup baik (35,9%). hasil uji regresi linier menunjukkan nilai signifikan p=0,003, menunjukkan ada hubungan antara imbalan ekstrinsik dengan kinerja perawat dalam melaksanakan asuhan keperawatan. pembahasan hasil uji statistik menunjukkan bahwa tidak semua karakteristik individu (umur, jenis kelamin, pendidikan, status perkawinan, masa kerja, dan status pegawai) berpengaruh terhadap kinerja perawat dalam melaksanakan asuhan keperawatan. menurut hasil penelitian yang diperoleh dari faktor karakteristik individu, jenis kelamin dapat mempengaruhi kinerja perawat dalam melaksanakan asuhan keperawatan dengan kategori hubungan yang sangat lemah, perawat perempuan mempunyai kinerja yang lebih baik daripada laki-laki. secara kodrati dan sifat kepribadian antara perawat laki-laki dan perempuan berbeda. perawat perempuan lebih rapi, lebih rajin, lebih bersih, lebih sabar, lebih teliti, lebih perhatian, dan lebih telaten dalam menghadapi pasien. hasil tabulasi penelitian didapatkan terdapat hubungan antara umur dengan kinerja perawat dalam menjalankan asuhan keperawatan. perawat yang menjadi responden berada pada tingkat umur 22-30 tahun dengan tingkat kinerja yang cukup baik. semakin tinggi umur semakin baik pula kinerja perawat dalam menjalankan asuhan keperawatan. siagian (1995) menyatakan semakin lanjut usia seseorang diharapkan kedewasaan tehnik meningkat, demikian pula psikologisnya mampu menunjukkan kematangan jiwa. usia yang semakin tinggi menimbulkan kemampuan seseorang dalam mengambil keputusan semakin bijaksana, mampu berpikir rasional, mampu mengendalikan emosi, dan toleransi terhadap pandangan orang lain. pendidikan terakhir berhubungan dengan kinerja perawat dalam melaksanakan asuhan keperawatan. semakin tinggi tingkat perawat semakin tinggi pula kinerja perawat. nursalam (2008) meyatakan bahwa semakin tinggi tingkat pendidikan seseorang, makin mudah menerima informasi, sehingga semakin banyak pula pengetahuan yang dimiliki. sebaliknya pendidikan yang kurang akan menghambat perkembangan sikap seseorang terhadap nilai-nilai yang baru diperkenalkan. seorang perawat yang memperoleh pendidikan dan pelatihan akan lebih dapat dipercaya, semua konseptual tenaga keperawatan termasuk dalam kriteria profesional adalah perawat dengan pendidikan formal minimal d iii. status perkawinan berhubungan dengan kinerja. semakin banyak perawat yang belum menikah semakin rendah kontribusi kinerja yang diberikan. sejalan dengan pendapat noor a. s. dan didik purbadi (2006), bahwa perawat yang telah menikah memiliki kemampuan bijaksana dalam mengambil keputusan serta mempunyai rasa percaya diri dan ketenangan dalam melakukan kegiatan, karena mereka pernah mengalami menjadi bagian dari keluarga, maupun sebagai anggota masyarakat, sehingga diharapkan dapat memahami keberadaannya. masa kerja dan status pegawai tidak berhubungan dengan kinerja perawat dalam menjalankan asuhan keperawatan. faktor dominan yang berhubungan dengan kinerja perawat dalam pelayanan kesehatan adalah pengetahuan karena pengetahuan didapat dari pengalaman dan sangat erat hubungannya dengan lama bekerja serta adanya tambahan pegawai baru, baik pegawai negeri sipil (pns) maupun calon pegawai negeri sipil (cpns) dengan masa kerja < 5 tahun. selain itu bukan berarti faktor status pegawai tidak memiliki peran dalam melaksanakan standar asuhan keperawatan, sebab status pegawai dipengaruhi oleh faktor umur, senioritas, dan status perkawinan yang mendukungnya. perawat di ruang rawat inap rsud bontang mengandalkan pegawai yang berstatus pegawai negeri yang mempunyai pengetahuan dan pengalaman dengan menggunakan pendekatan ilmiah dan sistematis dalam melaksanakan asuhan keperawatan. carpenito (1989) dalam keliat (1999) mengatakan bahwa penerapan asuhan keperawatan harus menggunakan metode ilmiah, logis, sistematis, dan terorganisir dalam memenuhi kebutuhan pasien, dan ini hanya dapat dilakukan perawat profesional. karakteristik individu dan reward system (kusnanto) 93 tabel 1. rekapitulasi hubungan karakteristik individu dengan kinerja perawat dalam melaksanakan asuhan keperawatan di unit rawat inap rsud bontang 9-27 juli 2009 variabel signifikansi (p) koefisien (r) hubungan jenis kelamin 0,007 -0,457 sangat lemah umur 0,025 0,383 cukup pendidikan terakhir 0,001 0,565 kuat status perkawinan 0,024 -0,387 sangat lemah masa kerja 0,278 -0,192 tidak ada hubungan status pegawai 0,830 0,038 tidak ada hubungan sistem penghargaan intrinsik (intrinsic reward system) dengan kinerja perawat menunjukkan ada hubungan yang signifikan diantara keduanya dengan kekuatan hubungan yang lemah. hal ini disebabkan karena sebagian besar perawat rsud kota bontang merasa tidak perlu adanya pengawasan dalam bekerja. simpulan dan saran simpulan kinerja perawat dalam memberikan asuhan keperawatan berhubungan dengan karakteristik individu yaitu jenis kelamin, umur, pendidikan dan status perkawinan. pendidikan mempunyai hubungan yang kuat diantara berbagai karakteristik individu yang lain. kinerja perawat juga berhubungan dengan reward system (imbalan ekstrinsik dan intrinsik). saran peneliti memberikan saran : 1) bagi kepala ruangan di ruang rawat inap rsud bontang hendaknya melakukan supervisi yang lebih intensif tentang standar asuhan keperawatan mengenai catatan asuhan keperawatan sehingga dalam pelaksanaan pendokumentasian dapat terlaksana dengan baik, 2) pihak instansi dan kepala ruangan hendaknya memberi dukungan atau penghargaan kepada perawat pelaksana dalam bentuk pujian atau apresiasi terhadap hasil kerja perawat dan memberikan kesempatan kepada perawat untuk mengembangkan diri melalui pelatihan dan pendidikan ke jenjang yang lebih tinggi kepustakaan desler, g., 1997. manajemen sumber daya manusia. edisi bahasa indonesia jilid ke-2. jakarta: pt prenhallindo. mustar, l., 1999. hubungan antara karakteristik demografik dengan kepuasan kerja dan komitmen karyawan di bangsal rawat inap rsjp surakarta. tesis tidak dipublikasikan. yogyakarta: gm, nursalam, 2008. manajemen keperawatan aplikasi dalam praktik keperawatan proofesional. edisi ke-2. jakarta: salemba medika. oetomo, i., 2002. penampilan perawat dalam pelayanan keperawatan (pelayanan prima untuk rumah sakit). makalah seminar pada keperawatan dalam rangka dies natalis xvii prodi keperawatan soetomo surabaya tidak dipublikasikan. simamora, h., 1999. manajemen sumber daya manusia. edisi kedua. yogyakarta: bagian penerbitan stie. widiastuti, e., 2005. hubungan karakteristik individu dan lingkungan kerja dengan kinerja perawat di rumah sakit umum daerah kota bontang kalimantan timur. skripsi tidak dipublikasikan. 171 development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddlers eliza zihni zatihulwani, tintin sukartini, ilya krisnana faculty of nursing universitas airlangga, kampus c mulyorejo surabaya, 60115 email: eliza.zihni@gmail.com abstract introduction: acute respiratory infection (ari) is the leading cause of morbidity and mortality in children. a cough and cold diseases such as rhinitis, pharyngitis, tonsillitis and other upper respiratory diseases are classified as non-pneumonia. aris that are not appropriately handled will affect the lung tissue and cause severity and even death. the purpose of this study is to develop a model of self-efficacy (se) among mother to prevent recurrent (pr) non pneumonia (np)-ari on toddlers based on the integration of precede-proceed model and health belief model. method: this study used crosssectional design. the population were a mother with a toddler in tanggalrejo village of mojoagung jombang. a hundred toddler’s mothers were recruited as samples by cluster sampling. variables in this study were predisposing-enablingreinforcing factors, main constructs of perceived (mcp), perceived threat, se and prnp-ari. data were collected using questionnaire, and focus group discussion then analyzed using partial least square (pls). results: the se improvement model for the prnp-ari was formed from predisposing-enabling-reinforcing factors, mcp, perceived threat, and maternal se. the greatest effect was on mcp against a perceived threat with t statistic value = 11.07. conclusion and recommendation: increasing se of toddler's mother can be done by educating mother about ari concept, conventional ari treatment, environmental modification, benefits of mask use, clean and healthy life behavior, proper hand washing, nutrition feeding, exclusive breastfeeding, stress management; create peer support group for toddlers mother; and optimizing the role of health officers and family support. keywords: mother self-efficacy; prevention non-pneumonia ari introduction acute respiratory infection (ari) is the leading cause of morbidity and mortality in children (idai, 2010). ari that is not handled properly can cause pneumonia or even death. cough and cold diseases such as rhinitis, pharyngitis, tonsillitis and other upper respiratory infections are classified as nonpneumonia (kemenkes, 2012). prevention recurrent non-pneumonia ari will reduce the illness of children through ari and reduce the risk of severe toddler conditions. the incidence of non-pneumonia ari in september 2016 from 34 puskesmas in jombang amount of 3,277 children under fiveyear-old. puskesmas mojoagung had the third largest incidence of non-pneumonia ari. from january 2016 to august 2016 found the incidence of np-ari were 3,834 on toddlers and five cases of pneumonia. the largest number (540 toddlers) of np-ari was found in tanggalrejo village. the preliminary study obtained that mother beliefs about the importance of prevention recurrent nonpneumonia ari were still not convincing. most of them remained to assume that the recurrent of ari was normal and usual. however, kemenkes explained some efforts to prevent the recurrence of np-ari include immunization of measles and pertussis, child nutrition improvement including the promotion of breastfeeding, improving health for pregnant women to prevent low birth weight (lbw), reducing inhouse or out-door populations, reducing population density, improving home ventilation, and improving health hygiene. mother already know about the prevention, but not all of them can implement them. if a person believes a new behaviour is useful (perceived benefits), but does not think he or she is capable of doing it (perceived barriers), it is likely that the behaviour will not be adapted (jones & bartlet, 2010). self-efficacy will determine how a person feels, thinks, and motivates herself to act or behave (bandura, 2013). self-efficacy is a person's belief about his ability in doing an activity that has a specific purpose that will affect his life (bandura, 1997). in the other hand, selfefficacy is influenced by several factors consisting of performance accomplishment, vicarious experience, verbal persuasion, emotional arousal. the main construct of perceived and self-efficacy is part of health belief model (hbm) (rosenstock, 1974). jurnal ners vol. 12 no. 2 oktober 2017: 171-179 172 hbm is a concept that reveals the reasons for the person to want or will not engage in healthy behaviour (becker, 1984). the health belief model (hbm) theory was used as the theoretical framework of this study by focusing on the mother self-efficacy for preventing recurrent non-pneumonia ari. in addition to hbm studies, the precede-proceed model is used in complementing the development of hbm application models that would be built on mothers to prevent the recurrence of non-pneumonia ari. the precede-proceed model examines the issues of human behaviour and the factors that influence it, and how to follow up by trying to change, maintain or enhance the behaviour toward a more positive (green, 1991). the study aimed to develop the model on mother self-efficacy preventing recurrence non-pneumonia ari among toddlers based on the integration of health belief model and precede-proceed model. further, this study can be used to improve the self-efficacy of the mother in the prevention of recurrent non-pneumonia ari so that no toddler has pneumonia or even death. materials and methods this study used cross-sectional approach and conducted in tanggalrejo village in mojoagung jombang in march 2017. the population were 325 mothers with a toddler who registered in posyandu, and 100 mothers with a toddler were recruited as samples by cluster sampling. the inclusion criteria in this study included: 1) mothers with toddlers (1-3 years); 2) mothers who lived in the same house with children; 3) mothers who have children with non-pneumonia ari; 4) mothers with toddlers registered at posyandu. while the exclusion criteria were mothers, who had toddlers with complicated diseases especially respiratory disease (example asthma). the variables involve in this study were predisposing factors (mother's age, mother's education, family income, mother's knowledge, and mother's attitude), enabling factors (the use of health services and access to health resources), drivers or reinforcing factors sand family support), main perceived constructions (perceived susceptibility, perceived severity, perceived benefits, perceived barriers). data were collected through questionnaires. the questions asked in the questionnaire of this study have been tested for validity and reliability. the validity of each item was tested using the pearson correlation using the level of significance of 0.05. the reliability of the items was tested using cronbach alpha. fgd was conducted on mothers who selected from the pool of survey. the fgd did twice, with eight toddler mother then six experts (one doctor, one programmer of ari, one academician, three midwives). data obtained were analyzed using smartpls 3. the human research ethic committee granted the ethic of this study from the faculty of nursing universitas airlangga under the letter number 346-kepk dated february 17th, 2017. results in this study, the outer model was evaluated by testing the validity and reliability on the model and outer model evaluation by looking at the t statistic score. a validity test of the model can be seen from outer loading value in table 1. it showed that three indicators were invalid (age=0.30, education=0.47, income=0.13) and sixteen indicators were valid with outer loading value>0.5. three invalid indicators were excluded from the model. outer loading value of predisposing factors consisting of two indicators: knowledge (0.61) and attitude (0.78); enabling factors consisting of two indicators: the use of health services (0.89) and the accessibility of health resources (0.81); reinforcing factors consisting of two indicators, namely the role of health officer (0.95) and family support (0.71); main perceived construction consist of four indicators: perceived susceptibility (0.71), perceived severity (0.69), perceived benefits (0.79), perceived barriers (-0.53); perceived threat (1.00); self efficacy which had four indicators of performance accomplishment (0.88), vicarious experience (0.84), verbal persuasion (0.71), emotional arousal (0.51) and prevention of recurrent non-pneumonia ari (1.00). table 2 showed the reliability test of the model. reliability test can be seen from cronbach alpha and composite reliability value. a construct or variable was said to satisfy the reliability test if it has a value of composite reliability >0.7 and the value of cronbach alpha >0.6. cronbach alpha value of development of model on mothers self-efficacy in ... (eliza zihni, et.al.) 173 enabling factors (0.60), reinforcing factors (0.65), perceived threat (1.00), self-efficacy (0.74), and prevention of recurrent nonpneumonia ari (1.00) were satisfied reliability test. cronbach alpha value of predisposing factors (0.32) and main constructs of perceived (0.21) was not satisfied reliability test. the values of the composite reliability of enabling factors (0.83), reinforcing factors (0.65), perceived threat (1.00), self-efficacy (0.83), and prevention of recurrent non-pneumonia ari (1.00) were satisfied reliability test. the values of the composite reliability of predisposing factors (0.59) and main constructs of perceived (0.57) were not satisfied reliability test. based on the expert's recommendation, all the constructs or variables were tested in the model because all of the variables support the prevention of recurrent non-pneumonia ari. table 3 showed the hypothesis test. there was a significant influence if the variables had value t>1. from table 3, it can be seen that (1) there was a significant table 1. validity test results development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddler in tanggalrejo village no. variable indicator outer loading description 1. predisposing factors x1.1 age x1.2 education x1.3 income x1.4 knowledge x1.5 attitude 0.302 0.476 0.139 0.615 0.787 invalid invalid invalid valid valid 2. enabling factors x2.1 using of health services x2.2 accessibility to health resource 0.896 0.811 valid valid 3. reinforcing factors x3.1 role of health officer x3.2 family support 0.959 0.711 valid valid 4. main construct of perceived x4.1 perceived susceptibility x4.2 perceived severity x4.3 perceived benefits x4.4 perceived barrier 0.714 0.697 0.798 -0.531 valid valid valid valid 5. perceived threat 1.000 valid 6. self-efficacy x6.1 performance accomplishment x6.2 vicarious experience x6.3 verbal persuasion x6.4 emotional arousal 0.886 0.840 0.718 0.515 valid valid valid valid 7. prevention of recurrent nonpneumonia ari 1.000 valid tabel 2 reliability test results development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddler in tanggalrejo village no. variable cronbach alpha composite reliability description 1. predisposing factors 0.326 0.595 invalid 2. enabling factors 0.600 0.832 valid 3. reinforcing factors 0.652 0.829 valid 4. main construct of perceived 0.210 0.575 invalid 5. perceived threat 1.000 1.000 valid 6. self-efficacy 0.743 0.835 valid 7. prevention of recurrent non pneumonia ari 1.000 1.000 valid jurnal ners vol. 12 no. 2 oktober 2017: 171-179 174 influence between predisposing factors toward main perceived construction (t=2.80). (2) there was a significant influence between enabling factors toward main perceived construction (t=2.77). (3) there was a significant influence between reinforcing factors toward main perceived construction (t=2.25). (4) there was a significant influence between main perceived construction toward self-efficacy (t=8.20). (5) there was a significant influence between main perceived construction toward perceived threat tabel 3. hypothesis test results development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddler in tanggalrejo village no. variabel path coefisien standard deviation t statistics explanation 1. predisposing factor toward main perceived construction 0.276 0.098 2.808 significant 2. enabling factors toward main perceived construction 0.260 0.094 2.776 significant 3. reinforcing factors toward main perceived construction 0.231 0.102 2.255 significant 4. main perceived construction toward self-efficacy 0.597 0.073 8.205 significant 5. main perceived construction toward perceived threat 0.670 0.061 11.073 significant 6. perceived threat toward prevention 0.218 0.081 2.698 significant 7. self efficacy toward prevention 0.350 0.087 4.009 significant figure 1. analysis test results development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddler in tanggalrejo village development of model on mothers self-efficacy in ... (eliza zihni, et.al.) 175 (t=11.07). (6) there was a significant influence between perceived threat toward prevention of recurrent in pneumonia ari (t=2.69). (7) there was a significant influence on self-efficacy toward prevention of recurrent in pneumonia ari (t=4.00). analysis test results development of model can be seen in figure 1. recommendation results of fgd with mothers with toddler and experts: 1) increase awareness of health workers to provide education and evaluate programs about ari and prevention of recurrent npari. 2) mothers with toddler should be educated routinely about ari and prevention of recurrent np-ari by an easy-to-understand method, include the risk of recurrent nonpneumonia ari in toddlers, clean and healthy behavior and proper hand washing, immunization, providing vitamin a and good nutrition, exclusive breastfeeding, stress management, signs-symptoms and the emergency of ari and the use of mask. 3) mothers with toddler and families need to know how to modify the environment to prevent recurrent np-ari in toddlers. 4) improve the function of village’s clinic that supported by health workers and good facilities. 5) make the peer group among mothers with a toddler for support each other. all the result of this study were integrated into the module as a guide to increase mother self-efficacy in preventing recurrence of non-pneumonia ari. discussion predisposing factors in forming the main perceived construction the pls analysis showed that there was a significant influence between predisposing factors toward main perceived construction. the pls analysis results on the indicator of predisposing factors obtained that the value of outer loading met the level of knowledge and attitude. in line with that, the results of guvenc, seven and akyuz (2016) shows that high knowledge will increase perceived susceptibility, perceived severity and perceived benefits, and decrease perceived barriers. based on the questionnaires, almost all respondents had good knowledge. the finding from fgd showed that mothers with a toddler knew non-pneumonia ari based on their experience, either their own experience or others experience. this result was in line with notoatmojo's opinion that experience was onefactor influence knowledge (notoatmojo, 2012). however, for non-pneumonia ari terminology has not understood but they understood about a cough, runny nose and breathlessness or respiratory disorders. mothers with a toddler who knows good prevention of recurrent non-pneumonic ari can improve the perception in preventing recurrent of nonpneumonia ari. this study showed that most respondents had a positive attitude. based on fgd, the habit was the most difficult cause to change attitude. habits related to the prevention of recurrent non-pneumonia ari, such as smoking by family members, the used of masks on family members who were experiencing ari, and awareness to maintain personal hygiene were difficult to change. positive attitude toward the prevention of recurrent non-pneumonia ari will increase the main perceived construction in preventing of recurrent non-pneumonia ari. this result was in line with robbin opinion; perceptions are influenced by attitudes, motives, interests, experiences, and expectations (robbins, 2006). enabling factors in forming the main perceived construction enabling factors manifest in the physical environment and the availability of health facilities. enabling factors include the using of health services, accessibility to health resources, government regulations, and health skills (green, 1991). this study only uses health services and accessibility of health resources as indicators of supporting factors. the pls analysis result showed that there was a significant influence between the variable of enabling factors toward main perceived construction. the using of health services greatly affects the severity of ari. in some developing countries, the utilization of health facilities is still low. the using of health facilities could reflect the high incidence of ari, that was 60% of outpatient visits in puskesmas and 20-40% of outpatient visited in hospitals (idai, 2010). the results show that there is a relationship between the use of health services with the public’s health jurnal ners vol. 12 no. 2 oktober 2017: 171-179 176 perception (napirah et al., 2016). similar to this study, wahyuni (2012) shows that there was a significant relationship between the utilisation of health services with the illness perception. it can be seen from the survey that the availability of health services, affordable costs and excellent health services were important factors to prevent the recurrence of a pneumonia ari. fgd showed that mothers with a toddler took their toddlers to health services such as puskesmas or to private health services when they had ari. the choice of using health service facility was due to the suitability or cost reason. mothers who choose to took their toddlers to private health services because they felt that there was no change in their condition after took at the puskesmas. however, there were mothers who still took their toddlers to the puskesmas for free services. good health services will increase the main perceived construction in preventing of recurrent nonpneumonia ari. accessibility is an indicator of the place to be easily reached from other locations through the transport system. indicators of affordability include the time, cost, and way in moving from place to another place. some factors that affect accessibility include distance, transportation network, road availability, transportation facilities, and road quality (muta’ali, 2015). there was a relationship between travel time and the use of health facilities (nainggalon, 2012). retnaningsih et al. (2007) show that variables related to respondent’s access to health service are knowledge, health insurance, advice, cost, and distance to health service (retnaningsih, 2007). health-source accessibility was found to be well accessibility. it can be seen from the distance, cost and transportation facilities to reach health services. fgd showed that village clinic could be used for treatment including toddlers who had non-pneumonia ari. good health source’s accessibility will increase the main perceived construction in preventing recurrent non-pneumonia ards. reinforcing factors in forming the main perceived construction reinforcing factors manifest in attitudes and behaviours of health workers, peers, parents, and community reference groups. reinforcing factor consist of family, peers, teachers, co-workers, health workers, traditional leaders, and decision makers. pls analysis showed that there was a significant influence between reinforcing factors toward main perceived construction. this study only uses the role of health worker and family support as variables. result study showed that the role of health care workers is related to the mother’s perception and may affect mother's behaviour. in line with this study, asri (2013) reported a relationship between the role of healthcare workers and behavioural changes. there was a relationship between perception of the mother about the role of health workers in preventing pneumonia (wahyuningsih, 2013). health worker played a significant role in educating mothers. it can be seen from the frequency and implementation of education. experts in fgd revealed that the ari counselling was given once in three months. fgd also indicated existing programs and implementation of education program in the community should be alignment. thus, it was expected that mothers with a toddler could get the proper information about the prevention of recurrent in pneumonia ari. good role of health worker will improve the main perceived construction in preventing recurrent nonpneumonia ari. family support in this study focused on emotional, appreciation, information and instrumental support. study of bahar (2013) shows that family support related to exclusive breastfeeding behaviour. in line with this study, family support affects a person's behaviour. in this study, the family was an important factor in preventing recurrent nonpneumonia ari in toddlers. families should realize the importance of prevention of recurrent non-pneumonia, so they expected to improve their effort in preventing recurrent non pneumonia ari. good family support will improve the main perceived construction (primary perceptual construction) in preventing recurrent non-pneumonia ari. main perceived construction in forming the perceived threat the pls analysis result showed that there was a significant influence on main perceived construction toward the perceived threat. the results of perceived threat indicated that the respondents had a high score. it was seen from the perception of threat through development of model on mothers self-efficacy in ... (eliza zihni, et.al.) 177 several aspects, which are: vitamin deficiency, incomplete immunisation, history of exclusive breastfeeding, non-supportive environment, the impact of recurrent non-pneumonia ari. mother with toddler fgd results were found that some mothers who did not give exclusive breastfeeding. following up on this, fgd experts discussed the importance of exclusive breastfeeding socialisation on how to exclusive breastfeeding and tools hygiene when using asip (breast milk). perceived threat in forming the prevention of recurrent non-pneumonia ari in this study, health promotion that could be given starting from the concept of ari, ari care, environmental modification, phbs or clean and healthy behavior program, hand washing, balanced nutrition, breastfeeding. special protection was done by immunization. disability restrictions by alerting alertness to ards. rehabilitation was done to maintain the quality toddlers life. prevention is the effort to direct some activities to protect clients from potential health threats. according to leavell and clark there are five levels of prevention, including health promotion, specific protection, early diagnosis and prompt treatment, and also disability limitation. pls analysis results showed that there was a significant influence between perceived threat variables on the prevention of recurrent no-pneumonia ari. the study shows that perceived threat have a positive relationship to behavioural change (sundstrom et al., 2015). efforts to ari prevention include immunisation against measles and pertussis, improving child nutrition including promotion of breastfeeding, improving health for pregnant women to prevent low birth weight (lbw), reducing in-house or out-of-home populations, reducing the population. the prevention of non-pneumonia ari recurrent showed that the behaviour of providing nutritious food, environmental modification, immunisation completion, exclusive breastfeeding, vitamin a administration. based on fgds results with experts, it was necessary to socialise the prevention and treatment of non-pneumonia ari easily or traditionally and to review the need for medical treatment such as a nebulizer. self-efficacy in forming the prevention of recurrent non-pneumonia ari pls analysis results showed that there was a significant influence between selfefficacy toward the prevention of recurrent non-pneumonia ari. in line with the results, the study about self-efficacy showed that selfefficacy as a predictor of behaviour (buglar, white and robinson, 2010). in the sundstorm (2015) study, the behaviour change influenced by perceptions of susceptibility, severity, benefits, barriers, self-efficacy and cues to action. based on fgd, most of their family members smoking at home. mothers also acknowledged that it was challenging to change smoking of family member inside the house. the vicarious experience showed that largely an experience gained from others. based on the fgd, the experience of others could trigger the mother to keep the toddler's health including doing the prevention of recurrent non-pneumonia ari. based on the results of fgd found that it was hard to prevent children from play outside the house. the emotional arousal had good value for each item of the statement. based on the results of fgd found that most toddlers felt anxious when toddlers had ari. prevention of disease is the effort to direct some activities to protect clients from potential health threats. efforts to prevent ari include immunization against measles and pertussis, improving child nutrition such as breastfeeding promotion, improving health for pregnant women to prevent low birth weight (lbw), reducing in-house or out-of-home populations, reducing population density, home ventilation addition, health hygiene improvement (kemenkes, 2012). results showed that the prevention of recurrent non-pneumonia ari of some mothers with toddlers was good. based on fgd results showed that they were almost never used a mask when they had ari. they were still lack of confidence in preventing the non-pneumonia ard recurrence. they considered that non-pneumonia respiratory problem was a common and reasonable event. mothers with toddlers were less aware that non-pneumonia ari can cause complications if not treated properly. also, respondents also do not understand that non-pneumonia ari can be prevented. good self-efficacy is jurnal ners vol. 12 no. 2 oktober 2017: 171-179 178 expected to improve the prevention of nonpneumonia ari recurrence. conclusions mother self-efficacy improvement model toward prevention of recurrent nonpneumonia ari on toddlers can be formed by predisposing factors, enabling factors, main perceived construction, perceived threat, selfefficacy and prevention of recurrent nonpneumonia ari. the greatest result was in the influence of main perceived construction to perceived threat (t=11.07). increasing selfefficacy of mothers with toddler can be done by educating about ari concept, conventional ari treatment, environmental modification, benefits of using mask, clean and healthy life behavior, proper hand washing, nutrition feeding, exclusive breastfeeding, stress management; create peer group support for toddlers mother; and optimizing the role of health officers and family support. mothers with a toddler and their family need a simple health education about ari and prevention of recurrent np-ari. mothers with toddler need to make peer group to share information and experience in preventing recurrent np-ari. the results of the study can be used to review the policy of existing ari control programs. further research is expected to examine the relationship of other variables in precede proceeded model or on the health belief model in preventing of recurrent non-pneumonia ari on toddlers. references asri, n. (2013) hubungan peran petugas kesehatan dan media informasi dengan perilaku seksual pada ibu pasca nifas di wilayah kerja puskesmas peukan bada kabupaten aceh besar. sekolah tinggi ilmu kesehatan u’budiyah banda aceh. bahar, b. (2013) hubungan antara karakteristik ibu, peran pettugas kesehatan, dan dukungan keluarga dengan pemberian asi eksklusif di wilayah kerja puskesmaas bonto cani kabupaten bone. fakultas kesehatan masyarakat universitas hasanuddin makasar. bandura (1997) self efficacy: the exercise of control. new york: w.h. freeman and company. bandura, a. (2013) ‘self efficacy’, kognitiog paedagogik, (83), pp. 16–35. becker, j. & (1984) ‘the health belief model: a decade later’, health education quarterly, 1(11), pp. 1–47. buglar, m. e., white, k. m. and robinson, n. g. (2010) ‘patient education and counseling the role of self-efficacy in dental patients ’ brushing and flossing : testing an extended health belief model’, 78, pp. 269–272. doi: 10.1016/j.pec.2009.06.014. green (1991) health promotion planning. an educational and environment approach. 2nd edn. ed. mountain view: mayfield publishing co. guvenc, g., seven, m. and akyuz, a. (2016) ‘health belief model scale for human papilloma virus and its vaccination: adaptation and psychometric testing’, journal of pediatric and adolescent gynecology. elsevier inc, 29(3), pp. 252–258. doi: 10.1016/j.jpag.2015.09.007. idai (2010) buku ajar respirologi anak. pertama. jakarta: badan penerbit idai. jones & bartlet (2010) ‘helath belief model’, in design and implementation of an osteoporosis prevention program using the health belief program, pp. 31–44. kemenkes (2012) pedoman pengendalian infeksi saluran pernafasan akut. jakarta: kementrian kesehatan republik indonesia. muta’ali, l. (2015) teknik analisis regional untuk perencanaan wilayah, tata ruang dan lingkungan, yogyakarta: badan penerbit fakultas geografi. yogyakarta: badan penerbit fakultas geografi. nainggalon (2012) ‘hubungan perilaku ibu dengan peran petugas kesehatan di wilayah kerja puskesmass namorambe kecamatan deli tua’, universitas sumatera utara, 17. napirah, m. r. et al. (2016) ‘faktorfaktor yang berhubungan utara kabupaten poso’, 7062. doi: 10.14710/jpk.4.1.29-39. notoatmojo, s. (2012) promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta. development of model on mothers self-efficacy in ... (eliza zihni, et.al.) 179 retnaningsih (2007) ‘analisis multilevel model akses layanan kesehatan suspek pederita tuberkulosis di indonesia’, buletin panel kesehatan, 4(35), pp. 156–166. robbins (2006) perilaku organisasi. edisi baha. pearson education. rosenstock (1974) ‘historical origin of the health belief model’, health behaviour & education, pp. 328–335. doi: 10.1177/109019817400200405. sundstrom, b. et al. (2015) ‘protecting the next generation : elaborating the health belief model to increase hpv vaccination among college-age women’, 21(3), pp. 173–188. doi: 10.1177/1524500415598984. wahyuningsih (2013) hubungan persepsi ibu tentang peran serta tenaga kesehatan dengan perilaku pencegahan pneumonia pada ibu balita usia 1-5 tahun di puskesmas ngesrep kota semarang. universitas muhammadiyah semarang. issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no. 58/dikti/kep/2013 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep technical editor: gading ekapuja aurizki, s.kep., ns. nadia rohmatul laily, s.kep., ns., m.kep. lingga curnia dewi, s.kep., ns., m.kep. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 13 no. 1 april 2018. 1. dr. abu bakar, s.kep., ns., m.kep., sp.kep.mb. universitas airlangga, indonesia 2. anna kurniati, s.km, ma bppsdmk, ministry of health, indonesia 3. bayhakki, phd, rn universitas riau, indonesia 4. dr. chong mei chan university of malaya, malaysia 5. elida ulfiana, s.kep., ns., m.kep. universitas airlangga, indonesia 6. dr. farhan alshammari university of hail, saudi arabia 7. dr. hilmi yumni, s.kep., ns., m.kep., sp. mat poltekes kemenkes surabaya, indonesia 8. joko gunawan, phd (cand.) chulalongkorn university, thailand 9. josefina a. tuazon, drph, rn university of the philippines manila, the philippines 10. dr. kai-li chen tajen university, taiwan 11. muhammad arsyad subu, phd gulf medical university, united arab emirates 12. pi-ming yeh, bs, ms, phd, rn missouri western state university, united states 13. dr. retno indarwati, s.kep., ns., m.kep. universitas airlangga, indonesia 14. rini handayani universitas indonesia, indonesia 15. saryono, s.kp., m.kes universitas jenderal soedirman, indonesia 16. susy katikana sebayang, ph.d universitas airlangga, indonesia 17. tika dwi tama universitas negeri malang, indonesia 18. dr. wendy abigail flinders university, australia 19. yunita sari, phd universitas jenderal soedirman, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no. 58/dikti/kep/2013 table of content 1. collaborative model of teachers, students, and families to improve parents knowledge and skills on food safety of elementary school students sigit mulyono, elly nurachmah, junaiti sahar, sabarinah prasetyo 1-8 2. self-care training improves the attitudes and skills of caregivers for children with physical disability warti ningsih, purwanta purwanta, sri hartini 9-17 3. family-based maternal sensitivity model as a strategy to optimize family perception on the role of parents and the growth of infants diyan indriyani, susi wahyuning asih 18-23 4. responsive feeding-play (resfeed-play) intervention on children aged 6-24 months with malnutrition dwi cahya rahmadiyah, agus setiawan, poppy fitriyani 24-30 5. nurses education and motivation towards nursing documentation devi mediarti, rehana rehana, abunyamin abunyamin 31-35 6. effects of health education on leptospirosis prevention through dasawisma sri mulyanti, athanasia budi astuti 36-41 7. the influence of peer health education toward the decreasing risk of heart disease riza fikriana, al afik 42-49 8. self-efficacy and the competency of nursing students toward the implementation of evidence-based practice yusshy kurnia herliani, hasniatisari harun, anita setyawati, kusman ibrahim 50-56 9. comparison of attitudes towards meditation healing exercise between the elderly living with chronic illness in bangkok and surabaya ni putu wulan purnama sari, jintana artsanthia 57-63 10. grieving as an internal factor of nurse-patient interaction in a dialysis unit ika yuni widyawati, nursalam nursalam, kusnanto kusnanto, rachmat hargono, pei-lun hsieh 64-71 11. predictors of family stress in taking care of patients with schizophrenia rizki fitryasari, nursalam nursalam, ah yusuf, rachmat hargono, chong-mei chan 72-79 12. differences between nrs-2002 and must in relation to the metabolic condition of trauma patients oktaffrastya widhamurti septafani, suharto suharto, harmayetty harmayetty 80-86 13. demographical factors, not lifestyle factors, associated with the increase of random blood glucose in coastal areas nilam yusika sari, susy k. sebayang, septa indra puspikawati, desak made sintha kurnia dewi, ayik m. mandagi, erni astutik 87-92 14. the effectiveness of spiritual emotional breathing towards respiratory function and immune response of tuberculosis patients kusnanto kusnanto, joni haryanto, tintin sukartini, elida ulfiana, made mahaguna putra 93-97 15. the development of model family-centered empowerment on caring for children with leukemia yuni sufyanti arief, nursalam nursalam, i dewa gede ugrasena, shrimarti rukmini devy, eileen savage 98-105 16. implementation of discharge planning in hospital inpatient room by nurses asmuji asmuji, faridah faridah, luh titi handayani 106-113 17. predictors of mortality among patients lost to follow up antiretroviral therapy putu dian prima kusuma dewi, gede budi widiarta 114-121 18. factors correlated with the intention of iron tablet consumption among female adolescents riri aprianti, gadis meinar sari, tiyas kusumaningrum 122-127 editorial indonesia has had many positive changes since the millennium development goals (mdg)—now sustainable development goals (sdg) were enacted. one of indonesia's targets is to reduce child mortality rate. according to the ministry of health of the republic of indonesia, the child mortality rate in indonesia has decreased from 97 per 1000 live births in 1991 to 26.2 per 1,000 live births in 2015. these data portrays that indonesia has seriously carried out its commitment to reduce child mortality. the success of these achievements certainly cannot be separated from the programs and strategies that have been pursued by the indonesian government. the government efforts to run well cannot be separated from the important role of health workers as field implementers. nurses as one of the health workers have a role in improving the health status of the community as optimal as possible through health promotion and disease prevention. behind the success of the government in reducing the mortality rate of children and toddlers, it seems that the government still finds some obstacles, as stated by the summary of unicef indonesia’s study in 2012 that inappropriate behavior and lack of knowledge of the community especially mothers in maintaining health is one of the factors influencing child mortality and toddlers. nurses are a profession which based on the knowledge and specific abilities must be able to carry out health promotion at the preventive level, especially the health problems of children and toddlers, the importance of vaccination, as well as the prevention of stunting and malnutrition. 50 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.6359 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research self-efficacy and the competency of nursing students toward the implementation of evidence-based practice yusshy kurnia herliani, hasniatisari harun, anita setyawati and kusman ibrahim faculty of nursing, universitas padjadjaran, west java, indonesia abstract introduction: professional nurses should have adequate competency in order to apply evidence based practice (ebp) in their nursing care. however, many nurses provide nursing care based on traditions, habits and personal experience. less confidence in the feeling of nurses about their competency when employing ebp could inhibit successful ebp implementation in nursing care. therefore, introducing and applying ebp during clinical placements in the ners program is essential to form a professional attitude and to provide a basic level of experience when applying ebp in patient care. however, the self-efficacy and competence of the students when applying ebp has not yet been evaluated properly and there is little known about the nursing students’ competences and self-efficacy toward ebp implementation during clinical practice. thus, the study aims to describe the self-efficacy and competency of nursing students toward the implementation of ebp, while also investigating the relationship between self-efficacy and the competency of nursing students in the implementation of ebp. methods: this descriptive correlational study involved 120 nursing students who were actively registered on the ners program 2016/2017. the data was collected by using the self-reporting evidence-based practice questionnaire (ebpq), which was then analysed descriptively and inferentially using statistics. results: the results of this study revealed that more than half (55%) of the participants had a high score of self-efficacy and almost half (49%) were categorised as having a high competence when implementing ebp. the selfefficacy score was significantly correlated to the score of competency (r = 0.607, p < 0.01). conclusion: this study recommends that the development of the students’ competence in implementing ebp is essential to promote self-efficacy when applying ebp, and vice versa. article history received: october 31, 2017 accepted: june 05, 2018 keywords competence; evidence-based practice; nursing student; selfefficacy contact yusshy kurnia herliani yusshy.kurnia@unpad.ac.id  faculty of nursing, universitas padjadjaran, west java, indonesia cite this as: herliani, y., harun, h., setyawati, a., & ibrahim, k. (2018). self-efficacy and the competency of nursing students toward the implementation of evidence-based practice. jurnal ners, 13(1), 50-56. doi:http://dx.doi.org/10.20473/jn.v13i1.6359 introduction nursing, as an integral part of the national health system, contributes to support the needs of the health services, since nurses spend the most time with patients to provide direct care (sin & bliquez, 2017). nurses, as the largest group of health care providers, have a significant role in promoting health care and providing better services for patients (khammarnia, mohammadi, amani, rezaeian, & setoodehzadeh, 2015). nursing care is a physiological, psychological, social, cultural and spiritual service provided to the clients in order to address the actual or potential disruption of basic human needs. the future challenges faced by the nursing care services are global competition that requires professional nurses to provide effective problem solving, to ensure patient safety and quality nursing care (aglen, 2016). professional nurses can be prepared through the nursing educational program. the nursing educational program via a bachelor’s degree in indonesia comprises of academic and clinical https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:yusshy.kurnia@unpad.ac.id http://dx.doi.org/10.20473/jn.v13i1.6359 jurnal ners http://e-journal.unair.ac.id/jners | 51 education (ners program). the ners program refers to the professional clinical education in the bachelor’s degree program, which is aimed at comprehensively building the students' abilities and attitude to make them a professional nurse through field and clinical learning experience (suba & scruth, 2015). the ners program in indonesia is conducted after the student has completed the academic nursing education program in order to prepare the healthcare professional. nevertheless, many healthcare professionals still decide that clinical intervention is based on traditional practices, assumptions, personal experiences and individual beliefs and skills (azmoude, farkhondeh, ahour, & kabirian, 2017). therefore, the students of the ners program should learn and practice the implementation of evidencebased practice (ebp) during their clinical practice. evidence-based practice (ebp) is a mechanism of nursing practice focused on providing safe and highquality patient care based on the evidence of research and professional expertise, rather than tradition, myths, hunches, advice from peers, or outdated books (masters, 2015). ebp implementation is essential for nurses in the clinical setting to effectively communicate with their patients and the healthcare team about the rationale for decision-making and care plans (oh, yang, sung, park, & chang, 2016). ebp has an integral role in providing high-quality patient care by encouraging problem-solving to make better healthcare decisions in health care implementation, based on recent best available research within the clinical context (elham azmoude et al., 2017). unfortunately, many nurses cannot implement ebp in the clinical setting since they feel insecure about their competency in employing the ebp skills that are used in their decision-making process as a professional (oh et al., 2016). nursing education institutions have the responsibility to prepare the nursing students in terms of ebp mastery (e. azmoude, f. farkhondeh, m. ahour, & m. kabirian, 2017). teaching ebp to undergraduate students is essential as a major preparation to perform the professional role of a registered nurse (sin & bliquez, 2017). however, a previous study reported that undergraduate nursing students experienced a lack of support and the opportunity to practice ebp, and also a lack of confidence when it came to independently utilising ebp (ryan, 2016). a previous study related to evidence-based practice was conducted by legita in 2012, on 66 general hospital nurses in pontianak. the results showed that the nurses did not have sufficient preparation in terms of knowledge and the habit of doing research and reading in support of the implementation (legita, 2012). moreover, previous research conducted among midwives in east iran also revealed that the level of knowledge and confidence in one’s ability to apply ebp were correlated with its effective implementation (elham azmoude et al., 2017). another significant variable affecting the implementation of ebp is self-efficacy. self-efficacy is defined as an individual’s belief in their own ability to perform specific skills (elham azmoude et al., 2017). numerous studies have reported that the majority of nurses did not have the desired level of self-efficacy in the implementation of ebp (farokhzadian, khajouei, & ahmadian, 2015). in addition, the majority of the nurses (60%) were not familiar with the concept of ebp, and their self‐efficacy skills related to ebp were poor (farokhzadian et al., 2015). the students of the ners program of the faculty of nursing universitas padjadjaran have learned about ebp theory in the second year of the bachelor’s degree nursing program. they exercised analysing the case and solving the nursing problem using ebp analysis. however, the self-efficacy and competence of the students in applying ebp has not been evaluated properly and there is little known about the nursing students’ competences and their self-efficacy toward ebp implementation during clinical practice. the study aims to describe self-efficacy and the competency of the nursing students toward implementation of ebp, and also to investigate the relationship between self-efficacy and the competency of the nursing students in the implementation of ebp. materials and methods this study was a descriptive correlational study. the sample of this study was made up of 120 nursing students who had completed the ners program at the nursing faculty of universitas padjadjaran. total sampling was used as the sampling procedure of this study. all of the participants were approached to ascertain their willingness to participate in the study. then, the researcher explained to the potential participants the purpose of the study, gained their informed consent, and outlined the procedure, risks, benefits, and confidentiality. the participants had the right to refuse to participate in the study or to withdraw at any time without any negative consequences. quantitative data collection was performed by asking the students to fill in the questionnaire. evidence-based practice questionnaire (ebpq) was the self-reported instrument used in this study to assess competence and self-efficacy when applying evidence-based practice. ebpq was composed of 24 items, each with a 7 point rating scale. the internal consistency was 0.87 (upton & upton, 2006). the filled questionnaires were returned directly, and then the researcher checked the questionnaires for completion, and coded the questionnaires to ensure the anonymity of the participants. this study was approved by the research ethics committee of faculty of medicine, universitas padjadjaran no 861/un6.c.10/pn/2017. the data was analysed using descriptive and correlational statistics. descriptive statistics were used to describe self-efficacy and competency of the y. k. herliani et al. 52 | pissn: 1858-3598  eissn: 2502-5791 sample by using frequency, percentage, mean, and standard deviation. preliminary testing was done to meet the assumption of parametric testing prior to running the parametric tests. pearson’s productmoment correlation statistic (r) was calculated to examine the relationship between self-efficacy and the competency of nursing students towards the implementation of evidence-based practice. results most of the participants in this study were women (90.8%), with an average age of 25.53 years, and ranging from 21 to 45 years. the majority of the participants were registered on the regular program (80%). 79.2 % of the participants had a gpa range from 3.0 to 3.5. table 2 presents that the mean competency scores in implementing ebp in clinical table 1. frequency, percentage, mean, and standard deviations of the patients' demographic data (n = 120) characteristic n % age (range 21-45) mean = 25.53 sd = 5.79 gender male 11 9.2 female 109 90.8 program regular 96 80.0 transfer 24 20.0 occupation nurse 23 19.2 fresh graduate 97 80.8 gpa <3 16 13.3 3.0-3.5 95 79.2 >3.5 9 7.5 table 2. mean score and standard deviation of students’ competency in implementing ebp in clinical practice (n = 120) no competency m sd 1 ability to identify gaps in your professional practice 4.99 0.992 2 ability to search new evidence 4.93 0.968 3 ability to obtain new evidence of nursing practice 4.94 1.117 4 ability to analyze evidence critically 4.87 0.913 5 ability to determine validity of evidence of nursing practice 5.12 1.034 6 ability to determine beneficial of invention in the literature 5.36 1.019 7 ability to update new evidence in clinical practice for patient 4.86 1.311 8 ability to apply evidence into practice 5.39 1.189 table 3. mean score and standard deviation of students’ self-efficacy in implementing ebp in clinical practice (n = 120) no self-efficacy m sd 1 ability to search new evidence 5.03 0.879 2 ability to identify gaps in your professional practice 4.91 0.789 3 ability to obtain new evidence of nursing practice 4.96 0.834 4 ability to analyze evidence critically 4.79 0.849 5 ability to determine validity of evidence of nursing practice 4.76 0.889 6 ability to determine beneficial of invention in the literature 5.10 0.854 7 ability to apply evidence into practice 5.17 0.929 table 4. mean, standard deviation, frequency, and percentage level of self-efficacy and competency in implementing ebp in clinical practice (n = 120) low high mean sd category n % n % self-efficacy 54 45.0 66 55.0 34.72 4.813 high competency 62 51.7 58 48.3 40.47 5.930 high table 5. correlation (r) between self-efficacy and competency of nursing students in implementing ebp in clinical practice (n = 120) competency self-efficacy 0.607** **. correlation is significant at the 0.01 level (2-tailed). jurnal ners http://e-journal.unair.ac.id/jners | 53 practice for all subscales were high (a score more than 3.5). the highest mean score of the sub-scales of competency in implementing ebp in clinical practice was the ability to apply evidence into practice (m = 5.39, sd = 1.189) and the lowest mean score of the sub-scales of competency in implementing ebp in clinical practice was the ability to update based on new evidence in clinical practice for the benefit of the patient (m = 4.86, sd = 1.311). table 3 depicts that the mean scores of selfefficacy in implementing ebp in clinical practice for all sub-scales was high (score above 3.5). the highest mean score of the sub-scales of self-efficacy in implementing ebp in clinical practice was the ability to apply evidence into practice (m = 5.17, sd = .929) and the lowest mean score of the sub-scales of selfefficacy in implementing ebp in clinical practice was to determine the validity of the evidence of nursing practice (m = 4.76, sd = .889). table 4 presents the mean, standard deviation, frequency, and percentage level of self-efficacy and competency in implementing ebp in clinical practice. the mean score of self-efficacy in implementing ebp was 34.72 (sd=4.813) with more than half (55%) of the participants having a high score of self-efficacy. the mean score of competency in implementing ebp was 40.47 (sd=5.930) with almost half (49%) of the participants categorised as high competence for implementing ebp. table 5 depicts the results of the bivariate correlational analysis using pearson correlation coefficients (r) between self-efficacy and competency in implementing ebp in clinical practice. the self-efficacy score was significantly correlated to the score of competency in implementing ebp (r = .607, p < 0.01). discussion most of the participants in this study were women (90.8%), with an average age of 25.53 years, ranging from 21 to 45 years. the majority of the participants were registered on the regular program (80%). there were 79.2% of the participants had gpa range from 3.0 to 3.5. the professional nursing educational program (ners program) is a part of the nursing education program where the learning process occurs inside the clinic. the ners program refers to professional clinical placement program in bachelor degree program, which was aimed at comprehensively building the students' ability and attitude for them to become professional nurse through field and clinical learning experience (suba & scruth, 2015). the ners program is conducted for one year in which the students get education and experience as a nurse in practice, whether in hospitals, community health centres, and various other health services. the ners program students are those who have graduated from an academic program at bachelor’s degree and passed the examination of the general registrar. the students will implement the prior knowledge that they had from the academic program. student who complete the ners program receive the title of ners (upoyo & sumarwati, 2011). evidence-based practice (ebp) is defined as the delivery of health care that integrates the best evidence from well-designed studies with a patient’s preferences and values, a clinician’s expertise, and the patient’s data to solve the problem (melnyk, gallagher-ford, long, & fineout-overholt, 2014). ebp is defined as a framework to test, evaluate and apply research findings with the aim of improving nursing services to patients. there are seven steps in the ebp process: (a) cultivate a spirit of inquiry; (b) formulate an answerable question; (c) systematically search for the research evidence; (d) appraise the validity, relevance, and applicability of the research evidence; (e) integrate the research evidence with the clinical expertise of the practitioner and the wishes and desires of the patient and the family; (f) implement the ebp decision and evaluate the outcomes; and (g) disseminate the results (melnyk, fineout-overholt, stillwell, & williamson, 2010). in the school of nursing (son), the first four steps are considered competencies for bachelor’s degree level. this is congruent with the bachelor’s degree competencies identified by the american association of colleges of nursing (stevens, 2009). the undergraduate curriculum in the son is designed to assist students in their development of beginner’s knowledge and skills with respect to the first four steps of the ebp process (bloom, olinzock, radjenovic, & trice, 2013). the ebp project was designed based on the first four steps of the 5 a's of the ebp process (ask, acquire, appraise, apply, assess) (sin & bliquez, 2017). asking a question is the first step of the ebp process. in the first step, the faculty framed questions in a scenario format instead of having the students form questions in order to enhance the clinical relevance of ebp in their daily practice. formulating a question will yield the most suitable answer (melnyk et al., 2010). the pico technique (patient, intervention, comparison, and outcome) is used to frame and answer a clinical or health care-related question. the next important step in ebp is acquiring evidence. selecting the most relevant evidence-based resources through literature searches or clinical guidelines is the activity of acquiring evidence (melnyk et al., 2010; sin & bliquez, 2017). then, appraising the evidence is the following step of acquiring evidence. in this section, the students should identify the best intervention from the synthesised literature by performing a critical evaluation of the evidence and its validity, relevance and feasibility, and then state the rationale for implementing the intervention (melnyk et al., 2010; sin & bliquez, 2017). the fourth step of the ebp process is applying evidence. this section is an implementation phase. students should integrate research evidence with clinical experience, the patients’ values and preferences (melnyk et al., 2010). the last step is assessing the treatment outcome. ebp for bachelor’s degree level is limited to the third step. y. k. herliani et al. 54 | pissn: 1858-3598  eissn: 2502-5791 since the ebp project is based on hypothetical clinical scenarios, the students are not asked to implement the intervention (sin & bliquez, 2017). however, the competencies for the ners program students could be implemented up to assessing the treatment process with clinical instructor supervision. ebp competencies the results of this study present that almost half (49%) of the participants had a high score of competence in implementing ebp. the mean score of competency in implementing ebp in clinical practice was high. competencies are defined as a system that supports health care professionals in providing highquality and safe care that consists of knowledge, psychomotor skills, and affective skills. meanwhile, the nurses’ competencies are the various patient care activities related to the critical issue of how practicing nurses approach decision-making (melnyk et al., 2014). ebp competencies in this study include identifying gaps with professional practice, searching for new evidence, obtaining new evidence of nursing practice, analysing the evidence critically, determining the validity of the evidence, determining the benefits of invention in the literature, updating new evidence and applying the evidence into practice. the highest mean score of the sub-scales of competency in implementing ebp in clinical practice was the ability to apply evidence into practice (m = 5.39, sd = 1.189) and the lowest mean score of the sub-scales of competency in implementing ebp in clinical practice was the ability to update new evidence in clinical practice for the patient (m = 4.86, sd = 1.311). the most important supporting factor was mentoring by nurses who have adequate ebp experience, and the biggest barrier was the difficulty in judging the quality of research papers and reports. there was a moderate demand for training in all areas of ebp (j. farokhzadian et al., 2015). students at bachelor’s degree level are introduced to ebp concepts to construct the foundation for the ebp process. they begin to identify the potential clinical questions as they become aware of current generalist nursing care problems. using the ebp process to address practice issues, the students are guided through the sequence of steps to review research and to develop an ebp implementation plan (hande, williams, robbins, kennedy, & christenbery, 2017). then, the students search the available scholarly literature to gain information related to the problems, and to critically appraise the information for determining a best intervention. the ability to apply interventions based on the most applicable evidence was also one of the highest priorities identified (farokhzadian, khajouei, & ahmadian, 2015). interventions should provide the students with sufficient competences for implementing every step of ebp, with special focus on the implementation of evidence in patient care (häggman-laitila et al., 2016). self-efficacy of ebp implementation more than half of the participants (55%) had a high score of self-efficacy in implementing ebp in clinical practice. the important variable affecting the implementation of ebp was self-efficacy, which is defined as an individual’s belief in their own ability to execute skills at a designated level of performance (e. azmoude et al., 2017). self-efficacy (se) is the belief that one is capable of performing a task or a desired action (bandura, 1977). this study depicted that the mean scores of self-efficacy in implementing ebp in clinical practice were high. the self-efficacy of implementing ebp among the nursing students in this study included searching for new evidence, identifying gaps in professional practice, obtaining new evidence of nursing practices, analysing the evidence critically, determining the validity of the evidence, determining the benefits of intervention in the literature and applying the evidence into practice. the highest mean score of the sub-scales of selfefficacy in implementing ebp in clinical practice was ability to apply evidence into practice (m = 5.17, sd = .929) and the lowest mean score of the sub-scales of self-efficacy in implementing ebp in clinical practice was to determine the validity of the evidence of nursing practice (m = 4.76, sd = .889). in contrast, several studies have revealed that the majority of healthcare professionals did not have the desired level of self-efficacy in the implementation of ebp (e. azmoude et al., 2017). previous research has also revealed that nurses have a low mean when it comes to their self-efficacy score (farokhzadian et al., 2015). correspondingly, most clinical nurse specialists identified had no confidence in their ability to translate clinical problems into well-formulated questions (mohsen, safaan, & okby, 2016). in addition, a study reported that undergraduate nursing students experienced a lack of support and the opportunity to practice ebp and also a lack of confidence in employing ebp independently (ryan, 2016). the low self-efficacy score of the nurses and nursing students was identified as the result of a lack of personal experience in performing evidence-based practice in clinical practice. the personal mastery of performing tasks indicates that self-efficacy is essential in the process of behaviour change (shinnick & woo, 2014). furthermore, the low scores of self-efficacy among healthcare professionals in implementing ebp was related to several barriers at the individual level included a lack of time to read the literature (83.7%), a lack of ability to work with a computer (68.8%), and insufficient proficiency in the english language (62.0%) (khammarnia et al., 2015). whereas the nursing students in this study could have more time to read the literature, have the ability to work with a computer and have a sufficient english proficiency. these factors are important to investigate in future research. jurnal ners http://e-journal.unair.ac.id/jners | 55 correlation findings the present study revealed that the self-efficacy score was significantly correlated to the score of competency in implementing ebp (r = .607, p < 0.01). this result is in line with the previous research conducted among midwifes in iran, which conveyed that self-efficacy scores were significantly correlated with practice (azmoude et al., 2017). the positive association between the previous experience of ebp education and the self-efficacy in implementing ebp (se-ebp) indicated that the exposure to ebp may increase the confidence in ebp of the clinical nurses (oh et al., 2016). furthermore, adopting ebp empowers nurses to become confident professionals, enabling the nurses to take legal accountability for their practice (oh et al., 2016), resulting in the increase of ebp competencies. a previous study revealed different aspects, in that education level had a significant relationship with competency in conducting ebp. the higher education levels of a person means better competency in performing ebp (elysabeth, libranty, & natalia, 2015). the study of eizenberg (2010) revealed that education could lead a person to be skilled in finding the source of research, being organised and being professional in their work, increasing access-access to improve and implement practices based on ebp (eizenberg, 2011). previous research also observed that there was no significant relationship between self-efficacy and academic degree (farokhzadian et al., 2015). however, the education levels of the participants in the present study were similar, since they had just finished the ners program. therefore, the education level could not be compared. in the present study, age, program, and working experience are not likely to be correlated with selfefficacy and competencies when conducting ebp. this result is similar to the results of previous studies, revealing that the midwives who were older and had more working experience were not significantly more likely to have greater ebp knowledge, self-efficacy or practice (farokhzadian et al., 2015). conclusion the results of the study revealed that more than half of the participants had a high score of self-efficacy and almost half were categorised as having high competence in relation to implementing ebp. moreover, the self-efficacy score was significantly correlated to the score of competency when it came to implementing ebp. despite this study having a big sample population, the participants were only from one institution, so the results cannot be generalised. therefore, future research should be involving nursing students from various nursing education institutions in order to investigate the factors affecting self-efficacy and competency in implementing ebp in clinical practice. in addition, this study recommends that the development of the students competence in implementing ebp is essential to promote self-efficacy in applying ebp, and vice versa. we would like to express our deep appreciation and thanks to the faculty of nursing, universitas padjadjaran, which allowed this study to be undertaken and the directorate of research and community service of universitas padjadjaran which provided research funding support. in addition, i would like to thank all of the participants who took part in this study. references aglen, b. (2016). pedagogical strategies to teach bachelor students evidence-based practice: a systematic review. nurse education today, 36(supplement c), pp.255-263. doi: https://doi.org/10.1016/j.nedt.2015.08.025 azmoude, e., farkhondeh, f., ahour, m., & kabirian, m. (2017). knowledge, practice and self-efficacy in evidence-based practice among midwives in east iran. sultan qaboos university medical journal, 17(1), e66-e73. doi: 10.18295/squmj.2016.17.01.012 bandura, a. (1977). self-efficacy: toward a unifying theory of behavioral change. psychological review, 84(2), p.191. bloom, k. c., olinzock, b. j., radjenovic, d., & trice, l. b. (2013). leveling ebp content for undergraduate nursing students. journal of professional nursing, 29(4), pp.217-224. elysabeth, d., libranty, g., & natalia, s. (2015). hubungan tingkat pendidikan perawat dengan kompetensi aplikasi evidence-based practice correlation between nurse’s education level with the competency to do evidence-based practice. jurnal skolastik keperawatan, 1(01). farokhzadian, j., khajouei, r., & ahmadian, l. (2015). evaluating factors associated with implementing evidence-based practice in nursing. journal of evaluation in clinical practice, 21(6), 1107-1113. doi: 10.1111/jep.12480 farokhzadian, j., khajouei, r., & ahmadian, l. (2015). evaluating factors associated with implementing evidence‐based practice in nursing. journal of evaluation in clinical practice, 21(6), pp.11071113. häggman-laitila, a., mattila, l.-r., & melender, h.-l. (2016). educational interventions on evidencebased nursing in clinical practice: a systematic review with qualitative analysis. nurse education today, 43, p.50-59. hande, k., williams, c. t., robbins, h. m., kennedy, b. b., & christenbery, t. (2017). leveling evidencebased practice across the nursing curriculum. the journal for nurse practitioners, 13(1), e17-e22. khammarnia, m., haj mohammadi, m., amani, z., rezaeian, s., & setoodehzadeh, f. (2015). barriers to implementation of evidence-based practice in zahedan teaching hospitals, iran, 2014. nursing research and practice, 2015. https://doi.org/10.1016/j.nedt.2015.08.025 y. k. herliani et al. 56 | pissn: 1858-3598  eissn: 2502-5791 legita, t. (2012). pengetahuan, sikap dan kesiapan perawat klinisi dalam implementasi evidencebase practice. ners jurnal keperawatan, 8(1), pp.84-97. mashiach eizenberg, m. (2011). implementation of evidence‐based nursing practice: nurses’ personal and professional factors? journal of advanced nursing, 67(1), pp.33-42. masters, k. (2015). role development in professional nursing practice. jones & bartlett publishers. melnyk, b. m., fineout-overholt, e., stillwell, s. b., & williamson, k. m. (2010). evidence-based practice: step by step: the seven steps of evidencebased practice. the american journal of nursing, 110(1), pp.51-53. melnyk, b. m., gallagher‐ford, l., long, l. e., & fineout‐overholt, e. (2014). the establishment of evidence‐based practice competencies for practicing registered nurses and advanced practice nurses in real‐world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. worldviews on evidence‐based nursing, 11(1), pp.5-15. mohsen, m. m., safaan, n. a., & okby, o. m. (2016). nurses’ perceptions and barriers for adoption of evidence-based practice in primary care: bridging the gap. american journal of nursing research, 4(2), pp.25-33. oh, e. g., yang, y. l., sung, j. h., park, c. g., & chang, a. m. (2016). psychometric properties of korean version of self-efficacy of evidence-based practice scale. asian nursing research, 10(3), pp.207-212. ryan, e. j. (2016). undergraduate nursing students’ attitudes and use of research and evidence‐based practice–an integrative literature review. journal of clinical nursing, 25(11-12), 1548-1556. shinnick, m. a., & woo, m. a. (2014). does nursing student self-efficacy correlate with knowledge when using human patient simulation? clinical simulation in nursing, 10(2), e71-e79. sin, m.-k., & bliquez, r. (2017). teaching evidencebased practice to undergraduate nursing students. journal of professional nursing. stevens, k. r. (2009). essential competencies for evidence-based practice in nursing. academic center for evidence-based practice, university of texas health science center at san antonio. suba, s., & scruth, e. a. (2015). a new era of nursing in indonesia and a vision for developing the role of the clinical nurse specialist. clinical nurse specialist, 29(5), 255-257. upton, d., & upton, p. (2006). development of an evidence-based practice questionnaire for nurses. journal of advanced nursing , 53(4), pp.454-458. doi: 10.1111/j.1365-2648.2006.03739.x https://www.ncbi.nlm.nih.gov/labs/journals/j-adv-nurs/ http://e-journal.unair.ac.id/jners 1 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 1-2 http://dx.doi.org/10.20473/jn.v18i2.44482 original article open access reshaping the future of nursing education through leadership chong mei-chan 1 * 1 faculty of medicine, universiti malaya, malaya, malaysia *correspondence: mei-chan chong. address: faculty of medicine, universiti malaya, malaya, malaysia. email: mcchong@um.edu.my the experiences in the covid 19 pandemic have raised the concern of reshaping the future of nursing education to prepare nurses who are more resilient in facing the challenges of vulnerable infection. good leadership in nursing will be the navigator in reshaping the future direction of nursing education. the future of nursing education will need to be focused on the emergence of nursing practice which is likely to involve a continued emphasis on primary health care and holistic care. the increasing rate of the aging population and non-communicable rapid advancement in information communication technology will need to call for more nurses to be more ict savvy and, to become more technology-driven, with the use of electronic health records, telehealth, and other digital tools becoming more prevalent. this will enable nurses to access patient information more easily and provide care remotely, which can improve access to healthcare for patients in remote or underserved areas (marzilli, 2022) evidence-based practice and interprofessional collaboration will be crucial to help ensure that nurses have the knowledge and skills to provide safe and effective care in an ever-changing healthcare environment. nursing leaders must develop and test new learning and assessment methods, especially for the delivery of remote learning, open distance learning, and care delivery. nursing leaders in academia and practice can advocate for increased nursing involvement in the planning, design, and evaluation of care delivery services. strong, ongoing academic practice partnerships are needed to support planning for future scenarios and the preparation of new nurses who are resilient. nurse scientists to be more assertive in generating the knowledge critical to addressing future emergencies (cynthia, 2022). effective leaders in nursing education need to be nurtured and supported by the organizations in which they are educated, trained, and work (swanwick,2011). aspiring and current leaders can be identified, trained, and assessed through formal leadership development programs, and through supportive organizational cultures. this requires embedding leadership training programs, opportunities for leadership practice, and promotion of professional networks within and beyond the organization. mentorship within healthcare education is important to further enhance nursing leadership and engagement within the workforce and interprofessional collaboration (burgess et al., 2018). leadership consists of a learnable set of practices and skills that can be developed by reading literature and attending leadership courses (burgess et al, 2016). additionally, investment in the social capital of organizations, fostering interprofessional learning and communication in the work setting, and collaboration across organizations assist in leadership development. developing leadership skills is a life-long process. in conclusion, the provision of opportunities for leadership development is crucial in improving nursing education and leading to effecting change. the leaders in nursing education who demonstrate excellence in teamwork, clinical skills, patient-centered care, and embracing ict and responsibly balance accountability with autonomy will definitely lead the future of nursing education way forward to prepare a competent task force to face any challenges in the future (van diggele, et al., 2020). https://creativecommons.org/licenses/by/4.0/ mailto:mcchong@um.edu.my https://orcid.org/0000-0002-8599-3018 chan (2023) 2 p-issn: 1858-3598  e-issn: 2502-5791 references burgess a, van diggele c, mellis c. mentorship in the health professions: a review. clin teach. 2018;14:1–6. burgess a, dornan t, clarke a, menezes a, mellis c. peer tutoring in a medical school: perceptions of tutors and tutees. bmc medical education. 2016;16:85. cynthia a. leaver (2022). impact of the covid-19 pandemic on the future of nursing education academic medicine, vol. 97, no. 3s. supplement. doi: 10.1097/acm.0000000000004528 marzilli, c. (2022). creating the future of nursing in the post-pandemic world. belitung nursing journal, 8(3), 185-186. https://doi.org/10.3354 6/bnj.2186 swanwick t, mckimm j.(2011) what is clinical leadership and why is it important. clin teach. 8:22–6. van diggele et al (2020). leadership in healthcare education bmc medical education (suppl 2):456 pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru 19 efektifitas kombinasi klorin 0,5% dan alkohol 70% terhadap pertumbuhan kuman (the effect of combination between chlorine 0.5% and alcohol 70% to bacteria’s growth) muzhidah*, tintin sukartini**, arie sunarno*** abstract introduction : desinfection process at laringoscope by using alcohol 70% was not effective for hidrofil’s viruses. the activity mechanism of alcohol 70% is protein denaturation, baktericid for vegetative’s and tuberculoside’s cell. decontamination with chlorine 0.5% and alcohol 70% have an enzyme inactivity, protein denaturation and inactivity sour of nukleat, so that alcohol desinfectan 70% and chlorine 0.5% much better in pursuing growth of microorganism, but the effectivities of chlorine 0.5% and alcohol 70% for amount of germ’s colony at laringoskop still need furthermore clarification. objective of this study was aimed to explain the effectiveness of combination of alcohol 70% disinfectant and chlorine 0.5% to decrease germ’s colony in laringoscope. methode : a quasy eksperimental (control group pre-post test) total sampling design was used in this study. population were all of laringoscope which used at room operate of emergency departemen 5th floor dr. soetomo general hospital of surabaya. the independent variable was 1) combination of alcohol 70% disinfectant and chlorine 0.5%, 2) alcohol 70% disinfectant only and dependent variable was germ’s colony. data were analyzed by using paired t-test with significance level p<0.05. result : the result showed that there was an effectiveness combination of chlorine 0.5% and alcohol 70% to decrease germ’s colony (p=0.000) and the effectiveness of alcohol 70% to decrease germ’s colony (p=0.591). analysis : it can be concluded that combination of chlorine 0.5% and alcohol 70% more effective to decrease germ’s colony in laringoscope. discussion: it is recomended that the existence of periodical inspection of laryngoscope to decrease risk of nosocomial infection. keywords: chlorine 0.5%, alcohol 70%, germ’s colony * ird rsud dr.soetomo jl. prof.dr. mooestopo 6-8 surabaya, e-mail: ida-ird-lt5@yahoo.com **fakultas keperawatan universitas airlangga surabaya *** irna bedah rsu dr. soetomo surabaya pendahuluan infeksi nosokomial masih menjadi masalah untuk pasien yang dirawat di rumah sakit karena peningkatan kesakitan, kematian serta biaya perawatan. pengendalian infeksi nosokomial telah dilakukan termasuk upaya desinfeksi berbagai alat kesehatan, diantaranya adalah laringoskop. intensitas penggunaan laringoskop yang tinggi di kamar operasi berisiko terhadap kejadian penularan penyakit dari satu pasien ke pasien lain. proses desinfeksi pada laringoskop selama ini dilakukan dengan cara menggunakan alkohol 70% yang mempunyai mekanisme kerja denaturasi protein, bakterisid terhadap sel vegetatif, tuberkulosid, namun tidak efektif terhadap virus hidrofil. menurut gardner (1997) dekontaminasi dengan larutan klorin 0,5% yang dikombinasikan dengan desinfektan alkohol 70% lebih baik dalam menghambat pertumbuhan mikroorganisme. keduanya merupakan bahan yang bekerja dengan inaktifasi enzim, denaturasi protein dan inaktivasi asam nukleat, namun efektifitas kombinasi dekontaminasi dengan larutan klorin 0,5% dan desinfeksi alkohol 70% terhadap jumlah koloni kuman pada laringoskop masih memerlukan penjelasan lebih lanjut. mailto:ida-ird-lt5@yahoo.com jurnal ners vol.4 no.1 april 2009: 19-23 20 data dari hasil pemeriksaan mikrobiologi didapatkan bahwa 47% pertumbuhan koloni kuman pada pembiakan dari semua laringoskop adalah staphylococcus aureus dan coagulasenegative staphylococci. sebanyak 87% koloni kuman staphylococcus aureus yang resisten terhadap methycillin didapatkan pada blade laringoskop (64,3%) sedangkan 38,5% merupakan coagulase-negative staphylococci yang hanya didesinfeksi menggunakan alkohol 70% (erica, 2004). prosedur desinfeksi alat laringoskop di rsu dr. soetomo surabaya selama ini masih dengan cara manual yaitu dengan menyemprotkan alkohol 70% ke seluruh permukaan laringoskop, namun berdasarkan pemeriksaan mikrobiologi di atas masih didapatkan koloni kuman yang sangat tinggi. mencuci dan merendam alat tersebut dalam larutan klorin 0,5% kemudian dibilas dengan air dan dikeringkan, lalu di semprot dengan alkohol 70% diharapkan mampu mengurangi pertumbuhan koloni kuman pada laringoskop. instrumen harus tetap bersih hingga saat dipakai, sehingga setelah proses dekontaminasi dan desinfeksi dilanjutkan dengan proses penyimpanan. penyimpanan yang baik sama penting dengan proses sterilisasi itu sendiri, karena penyimpanan yang kurang baik akan menyebabkan instrumen tersebut tidak steril lagi (erica, 2004). lamanya sterilitas tergantung dari tempat di mana instrumen itu disimpan dan bahan yang dipakai untuk membungkus. jalur utama terjadinya penularan penyakit infeksi dalam bidang kesehatan yaitu melalui kulit atau mukosa yang terluka oleh benda tajam atau jarum suntik, termasuk penyebaran penyakit yang disebabkan oleh penggunaan laringoskop (buckey et al., 2007). koloni kuman masih didapatkan dengan desinfeksi menggunakan alkohol 70%. prosedur desinfeksi dengan cara mencuci dan merendam alat tersebut dalam larutan klorin 0,5% kemudian dibilas dengan air dan dikeringkan, lalu di semprot dengan alkohol 70% dinyatakan dapat menurunkan atau mengurangi jumlah koloni kuman pada laringoskop, namun hal tersebut memerlukan penjelasan lebih lanjut. berdasarkan penjelasan di atas peneliti tertarik untuk melakukan penelitian untuk menilai apakah ada perbedaan pertumbuhan kuman pada laringoskop yang didesinfeksi menggunakan alkohol 70% dan klorin 0,5% dibandingkan dengan laringoskop yang hanya didesinfeksi menggunakan alkohol 70% dengan melakukan pemeriksaan mikrobiologi. bahan dan metode penelitian desain penelitian yang digunakan dalam penelitian ini adalah quasy experimental control group pre-post test total sampling design. populasi pada penelitian ini adalah seluruh laringoskop yang digunakan pada pasien intubasi di ird lantai v rsu dr. soetomo surabaya selama juli 2008 sebanyak 20 buah alat. sampel yang digunakan dalam penelitian ini adalah seluruh laringoskop yang digunakan pada pasien intubasi di ird lantai v rsu dr. soetomo surabaya. dua puluh orang sampel tersebut dibagi menjadi 2 kelompok yaitu kelompok 1 dengan intervensi desinfeksi menggunakan larutan alkohol 70% (10 orang) dan kelompok 2 dengan intervensi desinfeksi kombinasi larutan klorin 0,5% dan alkohol 70% (10 orang). penelitian ini dilakukan selama januari 2009. variabel independen dalam penelitian ini adalah penggunaan larutan desinfektan (larutan alkohol 70% dan gabungan larutan klorin 0,5% dan alkohol 70%), sedangkan variabel dependen adalah pertumbuhan koloni kuman. instrumen yang digunakan dalam penelitian ini adalah lembar observasi (check list) dan pemeriksaan hasil hapusan laringoskop pada mikrobiologi klinik. data yang diperoleh ditabulasi kemudian dianalisis dengan menggunakan uji statistik paired t-test dengan derajat kemaknaan α<0,05. hasil penelitian hasil penelitian menunjukkan bahwa pada laringoskop yang didesinfeksi menggunakan alkohol 70% saat dilakukan pemeriksaan koloni kuman dengan media mc conkey tidak didapatkan pertumbuhan kuman, sedangkan pada pemeriksaan koloni kuman dengan menggunakan media blood agar plate masih didapatkan pertumbuhan koloni kuman jenis bacillus subtillis dan staphylococcus epidermis dengan rerata jumlah koloni sebanyak 2,31 koloni/ml (sd=0,568 koloni/ml). laringoskop yang didesinfeksi dengan menggunakan kombinasi efektivitas kombinasi klorin (muzhidah) 21 larutan klorin 0,5% dan alkohol 70% pada pemeriksaan menggunakan media blood agar plate maupun mc conkey tidak didapatkan pertumbuhan koloni kuman. terdapat pengaruh yang signifikan antara desinfeksi kombinasi larutan klorin 0,5% dan alkohol 70% dengan pertumbuhan jumlah koloni kuman pada laringoskop, yang ditunjukkan dengan hasil analisis statistik paired t-test p=0,000 (tabel.1). pembahasan hasil penelitian ini menunjukkan bahwa pada laringoskop yang didesinfeksi menggunakan kombinasi larutan klorin 0,5% dan alkohol 70% pada pemeriksaan menggunakan media blood agar plate dan mc conkey tidak didapatkan pertumbuhan koloni kuman. etil-alkohol, pada konsentrasi 60-80%, adalah suatu agen virucidal yang kuat untuk semua virus yang lipofili (herpes, vaccinia, virus influensa) dan berbagai virus yang hidrofilik dan rotaviruses tetapi bukan virus hepatitis a. studi juga sudah menunjukkan kemampuan etil dan isopropil alkohol pada inaktivasi hbv dan virus herpes dan etil-alkohol dalam inaktivasi hiv, rotavirus, ekovirus dan astrovirus (markus, 2000). alkohol tidak direkomendasikan untuk mensterilkan berbagai bahan yang berhubungan dengan pembedahan dan medis, karena alkohol tidak bekerja secara sporisidal dan ketidakmampuan alkohol untuk menembus bahan kaya protein (morton, 1997). berdasarkan hasil penelitian, masih adanya pertumbuhan koloni kuman pada laringoskop yang didesinfeksi menggunakan alkohol 70% berkaitan dengan cara kerja alkohol yaitu dengan denaturasi protein, bakterisid sel vegetatif dan tidak efektif pada virus hidrofil. tabel 1. jenis dan jumlah koloni kuman pada laringoskop di kamar operasi ird lantai v rsu dr. soetomo surabaya, januari 2009 no jenis kuman alkohol 70% kombinasi klorin 0,5%-alkohol 70% blood agar plate ( koloni/ml) mc. conkey ( koloni/ml) blood agar plate ( koloni/ml) mc. conkey ( koloni/ml) 1 bacillus subtillis 2 0 0 0 2 staphylococcus epidermis 3 0 0 0 3 staphylococcus epidermis 3 0 0 0 4 staphylococcus epidermis 3 0 0 0 5 bacillus subtillis 2 0 0 0 6 staphylococcus epidermis 3 0 0 0 7 staphylococcus epidermis 3 0 0 0 8 bacillus subtillis 2 0 0 0 9 bacillus subtillis 2 0 0 0 10 staphylococcus epidermis 3 0 0 0 mean 2,31 0 0 0 sd 0,568 0 0 0 hasil analisis statistik paired t-test (p=0,591) paired t-test (p=0,000) keterangan: mean = rerata sd = standar deviasi p = signifikansi alkohol tidak mempunyai efek membunuh yang persisten, pengurangan cepat mikroorganisme di kulit, melindungi organisme tumbuh kembali bahkan di bawah jurnal ners vol.4 no.1 april 2009: 19-23 22 sarung tangan selama beberapa jam, namun setelah terjadi aktivasi bakterisid sel vegetatif maka koloni kuman akan mengalami pertumbuhan. intensitas penggunaan laringoskop yang tinggi di kamar operasi berisiko terhadap terjadinya penularan penyakit dari satu pasien ke pasien lain. pertumbuhan kuman tidak didapatkan pada laringoskop yang didesinfeksi dengan menggunakan kombinasi larutan klorin 0,5% dan alkohol 70% disebabkan karena mekanisme kerja klorin adalah dengan menghancurkan jasad renik dengan oksidasi enzim sulfhydral dan asam amino, sintesis protein, penurunan ambilan oksigen, oksidasi berbagai komponen yang berhubungan dengan pernapasan, penurunan produksi adenosin trifosfat (adp), menjalankan dna dan menekan sintesa dna. aktivitas tersebut bekerjasama dengan kemampuan alkohol 70% untuk denaturasi protein, inaktivasi enzim, inaktivasi asam nukleat dan sangat efektif pada virus hidrofil, sehingga dengan desinfeksi menggunakan kombinasi larutan klorin 0,5% dan alkohol 70% tidak ditemukan bakterisid sel vegetatif pada saat pemeriksaan mikrobiologi karena kuman mengalami kerusakan sampai pada tingkat enzim. konsentrasi rendah khlorin tersedia dalam bentuk hocl, ocl-, dan chlorine, mempunyai suatu biocidal yang mempengaruhi mikoplasma (25 ppm) dan bakteri (<5 ppm) dalam hitungan detik. konsentrasi yang lebih tinggi (1.000 ppm) dari khlorin untuk membunuh tuberculocidal test. suatu konsentrasi dari 100 ppm akan membunuh b.atrophaeus dalam waktu 5 menit dan menghancurkan agen mycotic dalam waktu kurang dari 1 jam. beberapa studi sudah mempertunjukkan efektivitas dari natrium hipoklorit yang dilemahkan dan obat pembasmi hama lain pada inaktivasi hiv. khlorin (500 ppm) menunjukkan efektivitas dalam membunuh candida setelah 30 detik. eksperimen yang menggunakan klorin menunjukkan bahwa 100 ppm dari klorin bebas akan membunuh 106 sampai 107 s.aureus, salmonella choleraesuis dan p.aeruginosa dalam waktu kurang dari 10 menit (markus, 2000). keuntungan penggunaan klorin adalah menginaktivasi semua virus, termasuk hbv, hcv dan hiv, juga membunuh basil tbc dengan cepat, sangat berguna untuk dekontaminasi peralatan bedah, sarung tangan, benda lain dan permukaan luas yang kotor. desinfeksi tingkat tinggi (dtt) memerlukan waktu 20 menit, sedang dekontaminasi hanya cukup 60 detik untuk membunuh hiv. adapun kerugian penggunaan klorin adalah diinaktivasi oleh material organik (kloramin t, komponen alternatif yang juga mengeluarkan klorin, tidak diinaktivasi oleh material organik seperti hipoklorit), dapat menyebabkan korosi pada alat logam dengan paparan lama pada konsentrasi lebih dari 0,5%. korosi dapat dikurangi dengan menghindari penyimpanan larutan dalam wadah logam (gunakan wadah plastik, jika ada), waktu paparan tidak lebih dari 20 menit dan bendabenda logam harus segera dibilas dengan air, keringkan sesudah dekontaminasi, atau dapat ditaruh dalam air bersih selama 1 jam sebelum dicuci. simpulan dan saran simpulan desinfeksi laringoskop dengan kombinasi larutan klorin 0,5% dan alkohol 70% lebih efektif menghambat pertumbuhan koloni kuman pada laringoskop dibandingkan desinfeksi dengan menggunakan larutan alkohol 70%. jenis kuman yang didapatkan pada laringoskop yang didesinfeksi menggunakan larutan alkohol 70% pada media blood agar plate adalah bacillus subtillis dan staphylococcus epidermis, namun tidak ditemukan jenis kuman apapun pada laringoskop yang didesinfeksi dengan kombinasi larutan klorin 0,5% dan alkohol 70%. saran dari hasil penelitian ini, peneliti menyarankan agar: 1) adanya pemeriksaan secara berkala dari pihak rumah sakit terhadap berbagai alat kesehatan reuse yang bersifat invasif dengan menggunakan uji mikrobiologi yang lebih sederhana serta murah yang dapat digunakan sebagai evaluasi pertumbuhan koloni kuman yang tidak terdeteksi agar risiko terjadinya infeksi nosokomial dapat diturunkan, 2) perlu dilakukan penelitian lebih lanjut terhadap berbagai alat kesehatan reuse yang bersifat efektivitas kombinasi klorin (muzhidah) 23 invasif untuk meningkatkan patient safety, menciptakan keadaan yang aman dan nyaman pada pasien dan 3) hasil penelitian ini diharapkan dapat menjadi bahan pertimbangan untuk perbaikan standar operasional prosedur penanganan alat-alat invasif khususnya laringoskop yang digunakan berulang-ulang. kepustakaan buckey, m.j., et al., 2007. decontamination laryngoscope. netherlands british journal of anesthesia, 89 (1). depkes ri, 2007. pedoman pencegahan dan pengendalian infeksi di rumah sakit dan fasilitas pelayanan kesehatan lainnya, editor astrid sulistomo, jakarta: perhimpunan dalin, jhpiego. erica, g., 2004. efektifitas desinfektan alkohol 70% pada penggunaan ulang endotracheal tube. surabaya: lab./smf anestesiologi dan reanimasi fk unair. gardner, d.r., 1997. chlorine and chlorine compounds, 2nd ed., philadelpia: j.b. lipincott company. markus, d.w.l., et al., 2000. mikrobiological, mikrostructure and material science examination of reprocessed combitube after multiple reuse. anesthesia and analgesia, 91 (3). morton, h.e., 1997. disinfection, sterlization, and preservation, 1st ed., philadelpia: j.b. lipincott company. rutald, w., 2006. guideline for selection and use of disinfectan. american journal of infection control (ajic), 24 (4p). stoelting, r.k., 1997. antiseptic and disinfectan. pharmacology and physiology in anesthetic practice, 1st ed., philadelphia: j.b. lipincott company. bab 1 jurnal ners vol.2 no.1 mei – september 2007 manfaat aromaterapi lavender terhadap penurunan insomnia pada lansia kusnanto*, harmayetty*, ira suarilah*, ninuk dian k.*, ulin marliana abstract insomnia is the primary sleeping problem experienced mostly by elderly. the objective of this study was to examine the effect of lavender aromatherapy for insomnia reduction in elderly. this study used pre-experimental design, with 15 samples, recruited by using total sampling. the independent variable was aromatherapy and the dependent variable was insomnia. data were collected by using structured interview with questionnaire and observation. data were analyzed by using wilcoxon signed rank test with significance level of p≤0.05. the results showed that lavender aromatherapy given to elderly had beneficial effect on sleep quality and quantity of this age group. the sign and symptoms of insomnia become reduced with significance level of p=0.001.lavender aromatherapy can be used as alternative intervention for overcoming insomnia in elderly. keywords: aromatherapy, insomnia, elderly pendahuluan insomnia pada lansia sering dikaitkan dengan gangguan tidur yang dialami oleh penderita (diahwati, 2001). berbagai gejala insomnia seperti: selalu merasa letih, lelah sepanjang hari dan terus menerus, mengalami kesulitan untuk tidur atau selalu terbangun ditengah malam dan tidak dapat tidur kembali. masalah ini terjadi di panti wreda hargo dedali surabaya, dari 33 lansia yang tinggal disana 28 diantaranya mengalami insomnia. dalam sehari normalnya lansia membutuhkan waktu tidur 5-8 jam semalam. tetapi lansia sering kurang terpenuhi kebutuhan tidur setiap malam (lumbantobing, 2004). salah satu upaya yang dilakukan untuk mengatasi masalah insomnia dengan menggunakan aromaterapi lavender. aromaterapi lavender dapat memberikan efek relaksasi dan sedatif. tanaman lavender yang berjenis lavandula angustifolia terutama mengandung ester dan alkohol, minyak esensialnya merupakan minyak penenang yang penggunaannya dianjurkan untuk memudahkan tidur. _______________ * staf pengajar psik fk unair lavender mengandung linalil asetat dan linalool. linalil asetat dan linalool tidak mempunyai efek samping yang berbahaya terhadap kesehatan. zat ini bersifat antibakteri, fungisida, virisida, parasitisida serta vermifugal dan mempunyai kerja neurotonik serta uterotonik. aromaterapi lavender bekerja dengan cara mempengaruhi kerja otak. harum dan segarnya aromaterapi lavender ternyata memberikan banyak manfaat bagi kesehatan psikologis seseorang. namun pengaruh pemberian aromaterapi lavender belum dibuktikan (nurkhasanah, 2005). bahan dan metode penelitian penelitian ini menggunakan desain pra eksperimental (one-group pra-posttest design). populasi pada penelitian ini adalah lansia dengan insomnia yang tinggal di panti wreda hargo dedali surabaya dengan besar sampel yang sesuai kriteria inklusi berjumlah 15 orang. tehnik sampling yang digunakan adalah total sampling. dalam penelitian ini variabel independen adalah pemberian 27 jurnal ners vol.2 no.1 mei – september 2007 aromaterapi lavender sedangkan variabel dependen adalah insomnia. instrumen yang digunakan dalam penelitian ini adalah kuesioner yang diadaptasi dari selamihardja, potter dan perry. setelah data terkumpul kemudian dikelompokkan, ditabulasi dan dianalisis dengan menggunakan uji statistik “wilcoxon signed rank test” dengan tingkat kemaknaan p0,05. hasil penelitian 1. kualitas tidur pada lansia. kualitas tidur lansia 0 2 4 6 8 1 3 5 7 9 11 13 15 responden n il a i pre pos1 pos2 pos3 pos4 pos5 pos6 pos7 gambar 1: distribusi pasien insomnia berdasarkan kualitas tidur berdasarkan gambar 1 di atas terlihat bahwa data kualitas tidur responden sebelum diberikan lavender menunjukkan bahwa yang kualitas tidur sedang sebanyak 7 orang (46.7%), yang kualitas tidur kurang sebanyak 8 orang (53.3%) dan setelah diberikan aromaterapi yang kualitas tidur baik sebanyak 15 orang (100%). 2. kuantitas tidur pada lansia. kuantitas tidur lansia 0 2 4 6 8 10 1 3 5 7 9 11 13 15 responden n il a i pre pos 1 pos 2 pos 3 pos 4 pos 5 pos 6 pos 7 gambar 2: distribusi pasien insomnia berdasarkan kuantitas tidur berdasarkan gambar 2 dapat dilihat data kuantitas tidur responden sebelum diberikan lavender menunjukkan yang kuantitas tidur sedang sebanyak 10 orang (66.7%), yang mengalami kuantitas tidur kurang sebanyak 5 orang (33.3%) dan setelah diberikan aromaterapi yang kuantitas tidur baik sebanyak 15 orang (100%). 28 jurnal ners vol.2 no.1 mei – september 2007 3. pengaruh aromaterapi lavender terhadap penurunan insomnia pada lansia. tabel 1: tabel pengaruh aromaterapi lavender terhadap penurunan insomnia pada lansia di panti wreda hargo dedali surabaya tanggal 15 s/d 21 januari 2007. no. responden pre lavender post no. responden pre lavender post hari 1 hari 7 selisih hari 1 hari 7 selisih 1 3 6 6 0 1 4 5 7 2 2 4 5 6 1 2 3 6 7 1 3 3 5 7 2 3 3 5 6 1 4 5 5 6 1 4 4 4 8 4 5 4 5 7 2 5 5 5 7 2 6 3 6 7 1 6 4 5 7 2 7 3 5 7 2 7 5 5 6 1 8 3 6 7 1 8 4 5 6 1 9 4 5 6 1 9 4 5 6 1 10 3 4 6 2 10 3 5 7 2 11 4 5 6 1 11 3 5 7 2 12 5 6 7 1 12 5 5 6 1 13 3 5 6 1 13 5 5 7 2 14 4 6 7 1 14 4 5 7 2 15 3 6 7 1 15 3 5 7 2 wilcoxon signed rank test p=0.001 p=0.002 p=0.001 berdasarkan tabel 1 di atas menunjukkan dari 15 responden mengalami penurunan insomnia dengan uji wilcoxon signed rank test dengan nilai kualitas p=0.001 pada hari pertama setelah pemberian aromaterapi lavender dan p=0.001 pada hari ke 7 setelah pemberian aromaterapi lavender. nilai kuantitas p=0.002 pada hari pertama setelah pemberian aromaterapi lavender dan p=0.001 pada hari ke 7. pembahasan menurut diahwati (2001) salah satu penyebab kronik insomnia yang paling umum adalah depresi. penyebab lain bisa berupa arthritis, gagal ginjal, gagal jantung, sleep apnea, parkinson dan hiperthyroidisme. lansia yang mengalami insomnia akan sulit sekali memenuhi kebutuhan tidur karena lansia mengalami berbagai perubahan khususnya perubahan fisik. pada pineal gland ini mengalami penurunan untuk memproduksi melatonin sehingga melatonin berkurang dan menyebabkan produksi sirkadian juga menurun. lansia yang diberikan aromaterapi lavender menunjukkan perubahan pada pineal gland yang bisa meningkatkan produksi melatonin yang memberi efek pada kenaikan sirkadian. produksi sirkadian yang menurun ini menyebabkan tidur nrem dan rem. dari tahap-tahap nrem dan rem ini akan terpenuhi kebutuhan tidurnya baik secara kualitas maupun kuantitas. setelah pemberian aromaterapi lavender terjadi penurunan insomnia pada lansia. sebagian besar responden sebelum diberikan aromaterapi lavender kualitas dan kuantitas tidurnya kurang baik dan setelah diberikan aromaterapi lavender kualitas dan kuantitasnya sebagian besar menjadi lebih baik. menurut agusta (2000), aromaterapi lavender dapat membantu memudahkan tidur, mengurangi ketegangan dan emosi. lavender bekerja dengan cara mempengaruhi kerja otak. saraf penciuman terangsang dengan adanya lavender 29 jurnal ners vol.2 no.1 mei – september 2007 secara langsung berhubungan dengan hipotalamus dan limbik, bagian otak yang mengendalikan sistem kelenjar mengatur beberapa hormon, mempengaruhi pertumbuhan, ingatan dan aktivitas tubuh lain. simpulan dan saran simpulan 1. aromaterapi lavender dapat meningkatkan kualitas dan kuantitas tidur lansia yang mencapai 1 2 jam pada malam hari. 2. beberapa tanda insomnia seperti: mudah capai, bingung dan disorientasi terhadap tempat dan waktu, koordinasi menurun, bicara tidak jelas, mudah tersinggung dan tidak rileks berkurang setelah diberikan aromaterapi lavender. saran 1. pemberian aromaterapi lavender dapat dijadikan alternatif pengobatan untuk mengatasi insomnia pada lansia. 2. melakukan sosialisasi kepada perawat panti tentang pemberian aromaterapi lavender sebagai alternatif untuk mengatasi insomnia pada lansia. 3. menanam lavender dapat dijadikan sebagai salah satu terapi aktivitas untuk mengisi waktu luang lansia di panti maupun lansia di dalam keluarga. kepustakaan agusta, a., (2000). aromatherapy, jakarta: penebar swadaya. hal: 1-3, 45 diahwati, d., (2001). serba serbi manfaat dan gangguan tidur, bandung: cv pionir jaya. hal: 44 ganong, f.w., (2003). buku ajar fisiologi kedokteran edisi 20, jakarta: egc. hal: 946-951 guyton & hall, (1997). buku ajar fisiologis kedokteran, jakarta: egc. hal: 187-197. hardywinoto, d & setiabudhi, t. (1999). panduan geromtologi tinjauan dari berbagai aspek, jakarta: pt gramedia pustaka utama. hal: 65-67. lumbantobing, (2004). gangguan tidur, jakarta: balai penerbit fk-ui. hal: 1-16 notoatmodjo, s., (2002). metodologi penelitian kesehatan edisi ke-2, jakarta: rineka cipta. hal: 146-148. nugroho, w., (2000). keperawatan gerontik, jakarta: egc, hal: 13-28. nurkhasanah, (2005). aromaterapi. http://www.holistikaromaterapi.com. tanggal 2 desember 2006, jam 15.50 wib. potter & perry. (2006). buku ajar fundamental keperawatan, konsep proses dan praktik edisi 4 volume ii, jakarta: egc, hal: 1469-1497. price, s., (1997). aromaterapi bagi profesi kesehatan, jakarta: egc. hal:15,18,19,105. selamihardja, n., (1997). insomnia dan rahasia tidur nyaman, http://www.indomedia.com. tanggal 2 desember 2006, jam16.06 wib. 29 http://www.holistikaromaterapi.com/ http://www.indomedia.com/ dukungan keluarga menurunkan stress remaja pasca vonis penjara 182 dukungan keluarga menurunkan stress remaja pasca vonis penjara (family social support reduces post judegemental stress in teenagers) nursalam*, ni ketut alit*, rista fauziningtyas* abstract introduction: justicial proceeding is able to make any stress or anxiety for everyone that through on it, especially if the process happens on teenagers. the stressor which can make stress in justicial proceeding are the justicial proceeding that doesn’t go along with uu ri no. 3 tahun 1997, i. e. children justicial process, fearness of parents and friend lost, worried about his future, and new neighborhood that is not appropriate with the child’s psychology development. the presence of family is very important to give a social support to the arrested teenagers.the objective of this study was to know the correlation between family social support and post judegement stress in teenagers and the factors of stress in teenagers. method: this study use cross sectional design. population had taken from teenagers from 13 until 17 years old. sample was comprised in to 12 individuals who fit with the inclusion criteria. the independent variable in this study was family social support and factors of stress in teenagers, and the dependent variable was post judgement stress in teenagers. data was collected by measurement using mood and feeling questionnaire (mfq) for stress, questionnaire of family social support, and interviewed. they were analyzed by spearman’s test with significance level α<0.05 and content analysis for interview result. result: the result showed that there is a correlation between family social support and post judgement stress in teenagers with significance level p=0.013. analysis: it means, content analysis’ results showed that the factors which related with stress in teenagers are environment, caring type, interfamily member’s relationship, bad event, and characteristic of children. discussion: higher family social support makes teenagers have higher self esteem and more optimistic view, so the teenagers will able to face their problem. keywords : family social support, teenagers, post judgement stress, factors of stres. * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: nursalam_psik@yahoo.com pendahuluan proses peradilan dapat menimbulkan stres dan kecemasan bagi seseorang, terutama bagi remaja. hal ini disebabkan oleh proses persidangan yang tidak sesuai dengan uu ri no.3 tahun 1997 yaitu tentang persidangan anak, takut kehilangan orang tua dan teman, khawatir tentang masa depan, dan lingkungan baru yang kurang layak. untuk mengatasinya, petugas di rumah tahanan kelas i, surabaya telah mengadakan kegiatan, yaitu olahraga bersama, hiburan orkes dangdut dan bimbingan rohani. namun kegiatan tersebut belum memberikan hasil yang maksimal, masih ada remaja yang mengalami stres ringan sampai sedang. hal ini dikarenakan kegiatan tersebut tidak menyentuh remaja secara individu dan tidak melibatkan keluarga. pada remaja yang bermasalah dengan hukum keluarga memiliki kontribusi yang besar, yaitu melalui dukungan keluarga dan manajemen keluarga. dukungan sosial keluarga merupakan faktor penting dalam manajemen stres (niven, 2000). dukungan keluarga dapat berupa kunjungan ke rutan, membawakan makanan, dan memberikan dukungan emosi pada remaja. orang tua yang anaknya berada di penjara sering malu dengan kondisi anak. hal ini yang membuat seorang anak tidak dijenguk oleh keluarganya (kurniasari, 2007). penelitian yang dilakukan di amerika ditemukan semakin tinggi tingkat stres dan semakin sedikit dukungan dari keluarga akan meningkatkan resiko terjadinya depresi pada jurnal ners vol. 4 no. 2: 182-189 183 remaja di proses peradilan (mccarty, 2006). di indonesia belum ada penelitian mengenai hubungan dukungan sosial keluarga dengan tingkat stres pasca vonis penjara pada remaja. remaja yang bermasalah dengan hukum lebih rentan mengalami gangguan mental dibandingkan dengan remaja pada populasi biasa. data yang didapatkan oleh national mental health association di amerika pada tahun 2001 menyebutkan bahwa prevalensi gangguan mental diantara remaja pada masyarakat umum diperkirakan sebesar 22%, dan prevalensi gangguan mental pada remaja di sistem peradilan anak diperkirakan sebesar 60%. gangguan mental tersebut termasuk depresi, stres, bunuh diri, dan tindak kekerasan. (otto dkk., 1992 dalam kurniasari, 2007). lembaga advokasi hak anak (laha) bandung 2004 menemukan berbagai pelanggaran hak anak, seperti anak tidak didampingi penasihat hukum pada tahap penyidikan, dan proses penuntutan. sebesar 95% responden saat akan ditahan tidak didampingi oleh orang tua/wali dan 60% orang tua wali tidak mendapatkan surat tembusan. saat pemeriksaan, hanya 50% responden yang mendapat pendampingan, namun sebagian besar tidak diberitahukan hak-hak mereka (kurniasari, 2007). data yang diperoleh penulis dari pengambilan data terhadap 4 orang pada tanggal 13 mei 2009 di rutan kelas i surabaya didapatkan 1 orang mengalami stres ringan, 2 orang stres sedang, dan sisanya stres berat. data mengenai dukungan sosial keluarga didapatkan peneliti, 2 responden menerima dukungan sosial kelarga yang cukup dan 2 lainnya kurang. proses hukum pada anak diawali dari penangkapan, selanjutnya adalah penyidikan. pada saat penyidikan inilah seorang remaja kerap kali mendapatkan perilaku kekerasan dan intimidasi oleh aparat. proses berlanjut dengan persidangan yang dilakukan secara tertutup dan kekeluargaan, akan tetapi masih banyak ditemukan remaja menjalani proses ini tanpa didampingi orang tua dan pendamping hukum (kurniasari, 2007). setelah proses persidangan remaja dapat dikenai hukuman penjara disinilah tekanan terberat pada seorang remaja. kehidupan remaja dipenjara sangat jauh dari layak, tidak ada fasilitas kamar mandi yang memadai, tempat hunian yang seringkali bercampur dengan orang dewasa dan seringkali adanya perilaku kekerasan bahkan pelecehan seksual dari sesama narapidana. kunjungan dapat dilakukan oleh keluarga meskipun waktunya dibatasi. litbang departemen hukum dan ham tahun 2004 menyatakan bahwa pengalaman anak hidup di penjara dapat menimbulkan trauma psikologis, memunculkan stigmatisasi sebagai anak jahat dan berpeluang menjadi residivis (kurniasari, 2007). selye (1983) dalam buku nursalam & kurniawati, d.n. (2007) mengatakan bahwa perubahan psikologis pada remaja yang mengalami stres berupa kecemasan, depresi, perubahan kebiasaan makan, tidur dan pola aktivitas, menangis, dan menarik diri. salah satu cara mengatasi masalah stres tersebut perlu keterlibatan keluarga dengan memberikan dukungan kepada remaja pasca vonis penjara. dukungan sosial keluarga terdiri dari dukungan informasi, material, dan emosional. dukungan emosional berupa cinta kasih, kepercayaan, dan penghargaan membuat seseorang merasa tidak sendirian dalam menghadapi masalah. dukungan materi bertujuan untuk membantu mengatasi masalah finansial. dukungan informasi akan membuat remaja merasa diperhatikan dan dicintai (smeltzer, 2001). melalui dukungan sosial keluarga, remaja dapat melepaskan ketegangannya, menceritakan kondisi yang dialaminya sebagai salah satu cara mengatasi stres yaitu seeking social support, usaha untuk mendapatkan kenyamanan emosional dan bantuan informasi dari orang lain (lazarus & folkman, 1986 & 1988). bahan dan metode penelitian desain penelitian yang digunakan dalam penelitian ini adalah crosssectional purposive sampling design. populasi pada penelitian ini yaitu remaja usia 12-17 tahun di rumah tahanan negara kelas i, surabaya yang berjumlah 12 orang. sampel yang digunakan dalam penelitian ini yaitu remaja usia 12-17 tahun di rumah tahanan negara kelas i, surabaya yang memenuhi kriteria inklusi:1) sedang menjalani hukuman penjara < 1 bulan sejak vonis penjara, 2) masih menjalani hukuman penjara selama penelitian berakhir, 3) baru pertama kali masuk penjara, dan 4) memiliki keluarga yang dapat dihubungi oleh peneliti. lokasi penelitian ini adalah di rumah tahanan negara kelas i, stress remaja pasca vonis penjara (nursalam) 184 surabaya. pelaksanaan penelitian dan pengambilan data dilakukan selama 3 minggu, pada tanggal 25 mei – 15 juni 2009. variabel independen dalam penelitian ini yaitu dukungan sosial keluarga dan faktor-faktor yang berhubungan dengan stres. variabel dependen yaitu tingkat stres yang dialami remaja pasca vonis penjara. instrumen yang digunakan dalam pengumpulan data tingkat stres adalah mood and feelings questinnaire yang dimodifikasi oleh penulis sebanyak 30 item. instrumen yang digunakan untuk observasi dukungan sosial keluarga adalah kuisioner yang berjumlah 11 item yang diadopsi dari niven (2002) dan smet (1994). instrumen yang digunakan untuk analisis faktor-faktor yang mempengaruhi stres pada remaja pasca vonis penjara adalah pertanyaan terbuka yang berjumlah 19 pertanyaan yang mengacu pada richardson dan katzenellenbogen (2005) yang meliputi 4 faktor, yaitu genetik, karakteristik anak, lingkungan dan kejadian buruk dalam hidup. data tingkat stres dan dukungan sosial keluarga ditabulasi kemudian dianalisis dengan menggunakan uji statistik corelations spearman rho dengan derajat kemaknaan α<0,05. interpretasi nilai sebagai berikut 0,80-1,00: tinggi; 0,60-0,80: cukup; 0,40-0,60: agak rendah; 0,20-0,40: rendah dan 0,00-0,20: sangat rendah (tidak berkorelasi). berbagai faktor yang berhubungan dengan stres yang diperoleh melalui wawancara dilakukan content analysis. hasil penelitian hasil penelitian menunjukkan didapatkan sebanyak 2 (16,7%) responden menerima dukungan sosial keluarga cukup dengan tingkat stres ringan, 2 (16,7%) responden menerima dukungan sosial keluarga baik dengan tingkat stres ringan, 5 (41,7%) responden menerima dukungan sosial keluarga cukup dengan tingkat stres sedang, 1 (8,3%) responden menerima dukungan sosial keluarga baik dengan tingkat stres ringan, dan 2 (16,7%) responden menerima dukungan sosial keluarga pkurang dengan tingkat stres berat. berdasarkan hasil uji statistik dengan menggunakan uji spearman dengan derajat kemaknaan α ≤ 0,05 diperoleh p=0,013 dengan koefisien korelasi r=-0,689 yang berarti ada hubungan yang berbanding terbalik antara dukungan sosial keluarga dengan tingkat stres pasca vonis penjara pada remaja di rumah tahanan kelas 1, surabaya. hubungan yang berbanding terbalik artinya semakin baik dukungan sosial keluarga maka tingkat stres pasca vonis penjara yang dialami oleh tahanan remaja semakin menurun. analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif atas pertanyaan tentang faktor genetik adalah jawaban dari pertanyaan “apakah ayah, ibu atau saudara kandung anda pernah mengalami gangguan jiwa atau stres?” “apakah ada anggota keluarga lain yang pernah mengalami gangguan jiwa atau stres?” dari dua pertanyaan di atas didapatkan jawaban sebanyak 66,6 % responden menjawab tidak memiliki riwayat keluarga dengan stres, depresi dan gangguan jiwa, 16,7% memiliki riwayat saudara kandung dengan stres, depresi dan gangguan jiwa, dan 16,7% sisanya memiliki riwayat saudara jauh dengan stres, depresi dan gangguan jiwa lain. berikut analisis isi (content analysis) dari wawancara yang mendukung data di atas: “setahuku ga ada si mbak, ibu dulu waktu ditinggal bapak ya cuma nangis terus sedih, tapi gak lama koq.” “sepupuku dari ibu, stres, gila gitu, mbak.” analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif atas pertanyaan tentang faktor lingkungan : “menurut anda bagaimana keadaan lingkungan di penjara?” sebagian besar responden 66,7% menjawab tidak nyaman, 25% mengatakan biasa saja, dan sisanya 8,3% menjawab enak. hal ini didukung dengan jawaban berikut: “mbak ini gimana se, ya gak enak lah. mosok dipenjara enak. wis turune duselan koyok pindang mbak (sudah tidurnya berdesakan seperti ikan pindang, mbak red.).” “lumayan mbak, bersih koq, paling nyamuke rodo’ akeh.” “enak, mbak. bersih, nyman. disini bisa makan gratis, gak bingung besok makan apa, banyak temennya, terus gonta-ganti.” pertanyaan kedua menanyakan mengenai aktivitas di waktu luang. jurnal ners vol. 4 no. 2: 182-189 185 “kegiatan apa yang sering anda lakukan dengan teman di waktu luang?” sebanyak 66,7% kegiatan yang dilakukan monoton seperti ngobrol dengan teman, tiduran, membaca majalah, nonton tv dan bermain dengan teman dan 33,3% responden memiliki kegiatan lain untuk mengisi waktu yaitu ikut kursus bahasa inggris dan pelatihan membuat mebel. dari pertanyaan tersebut juga diketahui sebanyak 66,7% responden mengaku bosan dengan aktivitasnya seharihari dan 33,3% menjawab tidak bosan. data di atas diperkuat dengan hasil wawancara di bawah ini: “maen ma temen, ngobrol. terus bersih-bersih, di sini aku jadi tamping kebersihan mbak (petugas kebersihan red.)” “tidur, jalan-jalan, nonton tv ngobrol, paling akeh si tidur. kadang bosen banget mbak. kalo bosen gitu aku tidur.” pertanyaan ketiga yang diajukan untuk mengetahui perekonomian keluarga. “bagaimana keadaaan perekonomian keluarga?” sebagian besar responden (75%) menjawab bapak, ibu dan saudaranya bekerja kasar yaitu sebagai kuli, buruh tani, buruh pabrik, pedagang asongan, cleaning services, dan lain-lain. sisanya sebanyak 25% menjawab orang tuanya mempunyai usaha yang cukup besar yaitu pemilik toko, pemilik dealer mobil, dan pemotongan kayu. data di atas didukung pernyataan berikut: “yang kerja ibu, mbak, jaga toko di depan rumah. ditanyakan, “toko milik sendiri ta, dek?” bukan mbak, punya orang, tetangga.” “bapak punya dealer mobil, lumayan gedhe. cukup banget, mbak.” pertanyaan keempat untuk mengetahui pola asuh keluarga. “bagaimanakah keluarga anda mengasuh anda? apakah anda selalu dituntut untuk melakukan sesuatu? atau anda diberi kebebasan untuk melakukan sesuatu?” sebanyak 54,3% responden menjawab menerima pola asuh demokratis, 25% pola asuh permisif, dan sisanya 16,7% pola asuh otoriter dari keluarganya. hal ini diperkuat dari jawaban responden, yaitu sebagai berikut: “dulu waktu ada bapak aku sering gak boleh kemana-kemana dikekang mbak, tapi sekarang sudah agak bebas.” “kadang boleh, kadang juga gak boleh, tapi bapak sama ibu selalu ngasih alasan kenapa gak boleh. kalo saya niatnya baik pasti boleh. “orang tua gak pernah nglarang apapun, mereka sibuk. kalo minta apa-apa tinggal bilang terus dikasih.” analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif atas pertanyaan tentang faktor kejadian buruk dalam hidup: “bagaimana hubungan perkawinan ayah dan ibu, orang tua-anda, dan antar saudara?” sebanyak 66,37% responden berasal dari keluarga broken home dan tidak adanya komunikasi antar keluarga dan sisa 33,33% responden mengaku memiliki keluarga yang harmonis. pernyataan tersebut diperkuat dengan hasil wawancara berikut: “bapak ibu harmonis mbak, sama orang tua aku deket banget.” “embuh mbak, bapakku ga pernah pulang, ga peduli aku mbek wong iku (aku tidak perduli dengan orang itu red.). gak jelas.” pertanyaan kedua adalah: “apakah anda pernah kehilangan seseorang yang sangat berarti untuk anda?” sebagian besar responden (58,4%) menjawab tidak pernah kehilangan seseorang, 33,3% mengaku pernah kehilangan anggota keluarganya, dan sisanya 8,3% pernah kehilangan pacar atau sahabat. hal ini diperkuat dengan jawaban responden, yaitu: “ya bapakku itu, mbak. ditanyakan, “kapan meninggalnya?” baru ja mbak, waktu aku dapat 2 mingguan di sini. waktu dikasih tau bapak meninggal, aku pingsan.” “pacarku mbak, dulu pernah pacaran sekali sekitar 2 tahunan, tapi sekarang dia sudah menikah. sampe sekarang aku sebenarnya masih sayang, makanya sekarang masih belum punya pacar lagi.” pertanyaan ketiga untuk mengetahui perlakuan buruk yang pernah diterima, selama dipenjara dan sebelum dipenjara. “pernahkah anda mengalami perlakuan yang buruk yang sangat mempengaruhi diri anda? seperti apakah perlakuan tersebut? (sebelum dipenjara dan selama dipenjara)” setengah responden (50%) mengaku tidak pernah menerima perlakuan yang buruk dan sisanya 50% pernah mengalami perlakuan buruk berupa pemukulan dari sesama narapidana (8,3%), pemukulan oleh oknum polisi (16,7%), perilaku bermusuhan dari sesama narapidana (8,3%), dan pengkhianatan stress remaja pasca vonis penjara (nursalam) 186 sahabat dan atau teman (16,7%). hal ini didukung oleh hasil wawancara berikut ini: “gak ada si mbak. ditanyakan “bertengkar atau dipukul temen di sini mungkin?” pernah sih tengkar, tapi biasa ja koq.” “dulu juga pernah dikhianati temen, ini yang bikin aku masuk penjara. ditanyakan “dulu waktu di polres pernah dipukul, mbak. ditanyakan, “siapa yang mukul?” ya polisinya, mbak. ditanyakan “kamu mau lari mungkin?” gak, mbak, aku nyesel banget.” “di sini saya pernah ditempeleng, mbak sama temen. sakit mbak.” pertanyaan keempat adalah: “pernahkah anda mengalami bencana yang sangat membekas pada anda? bisakah anda menceritakannya?” semua responden menyatakan tidak pernah mengalami bencana apapun. pertanyaan kelima untuk mengetahui adanya benda yang hilang. “apakah anda pernah kehilangan benda yang sangat berharga bagi anda? benda apakah itu? bisakah anda menceritakan bagaimana anda bisa kehilangan benda tersebut? (sebelum dipenjara dan selama dipenjara).” sebanyak 38,6% responden mengaku tidak pernah kehilangan sesuatu, baik sebelum maupun selama di penjara dan 61,4% responden mengaku pernah kehilangan barang-barangnya selama di penjara. barang yang hilang antara lain pakaian, alat mandi, uang, dan lain-lain. hal ini didukung hasil wawancara berikut: “gak pernah, mbak. di sini aman-aman saja.”, “kemarin sandal saya hilang, mbak. ” pembahasan faktor genetik merupakan faktor internal yang berhubungan dengan stres pada individu. menurut richardson dan katzenellenbogen (2005), anak yang memiliki orang tua mengalami stres dan depresi memiliki kecenderungan tiga kali lipat mengalami stres dan depresi daripada anak yang tidak memiliki riwayat keluarga stres dan depresi. meskipun hubungan faktor genetik dengan stres pada individu masih belum dapat dijelaskan, namun berdasar penelitian yang ada 20-50% remaja yang mengalami stres dan depresi memiliki riwayat keluarga stress dan depresi. hasil penelitian ini menunjukkan lebih banyak responden yang tidak memiliki riwayat keluarga dengan stres. faktor genetik stres tidak akan muncul jika tidak ada faktor pencetus lain, biasanya peristiwa yang sangat buruk, atau kondisi lingkungan yang kurang mendukung. terbentuknya kondisi lingkungan yang baik faktor genetik ini dapat diminimalkan. perawat dapat membantu keluarga untuk membentuk lingkungan yang baik bagi perkembangan psikologis anak dengan memberikan pengetahuan tentang perkembangan remaja dan bagaimana cara mengatasi. salah satu cara yaitu orang tua dapat melakukan komunikasi dan stimulus yang tepat pada anak. komunikasi yang baik membuat anak mampu menceritakan permasalahannya, terutama jika anak sudah menginjak usia remaja. menurut richardson dan katzenellenbogen (2005), lingkungan tempat tinggal juga menjadi faktor stres dan depresi. kondisi penjara yang tidak seperti di rumah, ramai dan kumuh menimbulkan kesan jauh dari nyaman. kondisi tempat tinggal yang tidak nyaman dapat meningkatkan stres pada responden. sedikit dari responden yang mengatakan bahwa lingkungan rutan enak dan nyaman. responden yang berpendapat demikian adalah mereka yang tidak memiliki kedekatan hubungan dengan keluarga. perawat dapat membantu mengkondisikan lingkungan menjadi lebih baik, misalnya memberikan buku atau majalah sebagai sarana membaca, memberikan jadwal piket agar lingkungan penjara tetap bersih, sehingga para tahanan merasa nyaman. jika memungkinkan perawat juga dapat berkoordinasi dengan pihak rutan agar dapat mengatur jumlah penghuni dalam setiap blok, khususnya blok tahahan anak, agar tidak terlalu berdesakan dan dipisahkan dengan tahanan lansia. aktivitas yang dilakukan di dalam penjara memiliki hubungan dengan stres yang dialami remaja. responden yang memiliki aktivitas sehari-hari monoton cenderung mengalami stres, dibandingkan dengan responden yang memiliki aktivitas lain. aktivitas yang menyenangkan digunakan sebagai salah satu bentuk pengalihan stres. salah satu bentuk koping stres adalah kompromi, yaitu berusaha untuk menyesuaikan diri dengan masalah yang dihadapi (maramis, 2004). koping stres jurnal ners vol. 4 no. 2: 182-189 187 kompromi dapat dilakukan dengan cara mencari aktivitas yang lebih menyenangkan dan disukai. penerapan pola asuh yang benar memberikan dampak positif terhadap sikap dan perilaku anak. pola asuh orang tua yang otoriter menerapkan segala sesuatu harus taat dan patuh sesuai dengan apa yang telah ditentukan oleh orang tua. pada orang tua yang bersifat demokratis, akan memberi kesempatan kepada anak untuk tumbuh dan berkembang sesuai dengan pertumbuhan dan perkembangan anak tersebut. pola asuh demokratis dari orang tua membuat anak lebih percaya diri dan mandiri. pola asuh permisif menyebabkan anak cenderung menjadi kurang bertanggung jawab dan semaunya sendiri sehingga anak kurang mandiri. (hurlock, 1997). pola asuh orang tua yang otoriter menyebabkan anak selalu merasa ketakutan, kurang percaya diri, dan penakut sehingga kurang mandiri, anak akan lebih rentan mengalami stres jika mendapatkan masalah. pola asuh tersebut menyebabkan anak merasa tidak dihargai keberadaannya dan keinginannya, apabila hal ini terus terjadi maka dapat menimbulkan frustasi pada diri anak. pola asuh demokratis, orang tua mampu memberikan kasih sayang secara wajar, tidak memanjakan, dan tidak mengekang. orang tua mampu menciptakan hubungan yang hangat dengan anak sehingga anak merasa aman dan senang. pola asuh demokratis membentuk anak lebih adaptif dalam menghadapi masalah, sehingga ketika dia menghadapi masalah, mampu menyesuaikan diri dan memberikan koping adaptif dalam penyelesaian masalah. anak yang diasuh dengan pola asuh permisif biasanya menjadi tidak peduli dengan apa yang terjadi pada dirinya, masalah yang terjadi dijadikan sebagai alat untuk menarik perhatian orang tua. seperti yang terjadi pada an.f yang melakukan pencurian dengan alasan hanya ingin masuk penjara. dalam segi ekonomi an.f berasal dari keluarga berkecukupan, kenakalan tersebut sengaja dilakukan untuk menarik perhatian orang tuanya. menurut richardson dan katzenellenbogen (2005), keadaan sosioekonomi keluarga yang rendah meningkatkan terjadinya stres dan depresi pada anak dan remaja. remaja dan anak-anak yang tumbuh dengan kondisi ekonomi terbatas, sering merasa malu dengan kondisinya. mereka dituntut untuk lebih berhati-hati dalam menggunakan keuangan, tidak jarang dari mereka bekerja untuk membantu perekonomian keluarga. karena beban dan tanggung jawab yang berlebih ini akan menyebabkan ketegangan dan mempermudah terjadinya stres. sebagian besar responden pernah mengalami kejadian buruk dalam hidup. kejadian tersebut berupa hubungan keluarga yang tidak harmonis dan kurang komunikasi. anak yang berasal dari keluarga broken home seringkali mencari perhatian dari lingkungan dengan berbuat kenakalan, terkadang remaja tersebut bisa menjadi lebih pendiam dan menarik diri dari lingkungan. mereka butuh perhatian dari kedua orang tuanya. anak mendapatkan stresor yang besar dari perpisahan orang tuanya. kejadian lainnya adalah kehilangan orang yang berarti. kejadian buruk yang pernah dialami juga bisa berupa perlakuan yang tidak menyenangkan misal: pelecehan seksual, pemukulan, dan pertengkaran. menurut richardson dan katzenellenbogen (2005), anak dan remaja yang mengalami stres dan depresi memiliki riwayat kejadian buruk di masa lalu, seperti kehilangan orang yang dicintai, terpisah dari orang tua, kematian anggota keluarga atau teman, kehilangan barang berharga miliknya dan lain sebagainya. kejadian lainnya yang kurang menyenangkan adalah kehilangan barangbarang berharga milik responden. sebagian besar responden pernah kehilangan barang selama di dalam penjara, hanya 38,6% responden yang menyatakan tidak pernah kehilangan barang. meskipun di dalam penjara barang-barang berharga tersebut hanya sebatas kebutuhan pokok yaitu pakaian, uang dan peralatan mandi, namun barang-barang tersebut sangat berarti bagi para tahanan remaja. kehilangan barangbarang tersebut juga menyebabkan permasalahan dalam diri responden, jika tidak teratasi dapat menyebabkan stres. menurut caplan (1976) dalam friedman (1998) dukungan keluarga diperlukan untuk memberikan dukungan informasional (keluarga berfungsi sebagai suatu kolektor dan diseminator/penyebar informasi tentang dunia), dukungan penilaian stress remaja pasca vonis penjara (nursalam) 188 (keluarga bertindak sebagai sebuah bimbingan umpan balik, membimbing dan menengahi pemecahan masalah dan sebagai sumber dan validator identitas anggota), dukungan instrumental (keluarga merupakan sebuah sumber pertolongan praktis dan konkrit), dan dukungan emosional (keluarga sebagai sebuah tempat yang aman dan damai untuk istirahat dan pemulihan serta membantu penguasaan terhadap emosi) kepada remaja dalam menghadapi pasca vonis penjara dan menjalani hukuman penjaranya. friedman (1998) menyatakan beberapa alasan mengenai keterlibatan keluarga dalam perawatan kesehatan dan perkembangan anak, yaitu dalam sebuah unit keluarga, disfungsi apa saja (penyakit, cedera, perpisahan) yang mempengaruhi satu atau lebih anggota keluarga, dalam hal tertentu, seringkali akan mempengaruhi anggota keluarga yang lain dan unit secara keseluruhan. perbedaan persepsi mengenai bentuk dukungan sosial keluarga menyebabkan perbedaan pemberian dukungan. ada keluarga yang hanya memberikan dukungan materi tanpa ada komunikasi dengan anaknya. ketiga bentuk dukungan, yaitu emosional, informasi dan materi dibutuhkan oleh seorang remaja dan harus diberikan secara berimbang terutama ketika sedang menghadapi masa sulit, dalam hal ini adalah proses sidang dan vonis penjara. apabila kebutuhan dukungan sosial keluarga tidak dapat dirasakan secara adekuat maka akan muncul gejala-gejala stres yang dialami oleh angota keluarga, dalam hal ini adalah remaja yang dipenjara. gejala-gejala yang muncul meliputi perasaan marah, ansietas, stres dan depresi. selanjutnya jika hal ini tidak teratasi maka akan menghambat dan merusak komunikasi dalam keluarga tersebut. perbedaan tingkat stres berhubungan dengan beberapa faktor, yaitu genetik (riwayat keluarga dengan stres dan depresi), faktor lingkungan (keadaan keluarga dan lingkungan tempat tinggal), kejadian buruk dalam hidup (kehilangan orang yang dicintai, perceraian), dan karakteristik anak (richardson & katzenellenbogen, 2005). stres yang terjadi pasca vonis sebagian besar diakibatkan oleh ketakutan remaja, tidak bisa bertemu keluarga. rasa kehilangan keluarga yang dialami oleh remaja menimbulkan kesedihan dan stres yang mendalam, maka dibutuhkan dukungan, keluarga yang sangat besar. stres akan membaik jika seorang dapat beradaptasi dengan lingkungan di sekitarnya. responden yang sudah lama menjalani hukuman penjara cenderung dapat mengatasi stres pada dirinya. selain itu perbedaan koping setiap individu dalam menghadapi stresor juga berhubungan dengan tingkat stres yang terjadi. koping adaptif individu dapat menurunkan tingkat stres yang dialami. remaja yang lebih terbuka untuk mengungkapkan emosi mereka lebih berhasil dalam menyesuaikan diri terhadap masalah yang dihadapinya. hasil penelitian didapatkan hubungan yang signifikan antara dukungan sosial keluarga dengan tingkat stres pasca vonis penjara pada remaja di rumah tahanan kelas 1, surabaya. hasil uji statistik dengan menggunakan uji spearman dengan derajat kemaknaan α≤0,05 diperoleh p=0,013 dengan koefisien korelasi r=-0,689 sehingga ho ditolak dan h1 diterima. nilai negatif menunjukkan hubungan yang berbanding terbalik. berdasarkan hasil tersebut dapat dijelaskan bahwa semakin baik dukungan sosial keluarga maka semakin rendah tingkat stres pasca vonis penjara yang dialami oleh remaja, atau semakin kurang dukungan sosial keluarga yang diterima oleh responden maka semakin tinggi tingkat stres yang dialami. friedman (1998) menyatakan bahwa orang yang hidup dalam lingkungan yang bersifat suportif, kondisinya jauh lebih daripada mereka yang tidak memiliki keuntungan ini. secara lebih spesifik, karena dukungan sosial dukungan sosial juga dapat berfungsi sebagai strategi preventif untuk mengurangi stres dan konsekuensi negatifnya. secara lebih spesifik, keberadaan dukungan sosial yang adekuat terbukti berhubungan dengan menurunnya mortalitas, lebih mudah sembuh dari sakit, dan dikalangan kaum tua, fungsi kognitif, fisik, dan kesehatan emosi (ryan dan austin, 1989 dalam friedman, 1998). simpulan dan saran simpulan semakin baik dukungan sosial keluarga yang diterima oleh tahanan remaja maka semakin menurun tingkat stres yang jurnal ners vol. 4 no. 2: 182-189 189 dialami, karena dukungan sosial dapat mengurangi stres, memperkokoh kesehatan mental individual dan keluarga. dukungan sosial kelurga yang lebih efektif untuk menurunkan stres pada remaja pasca vonis penjara adalah dukungan materi dan emosi. saran peneliti menyarankan: 1) keluarga harus dilibatkan dalam setiap proses hukum yang dijalani oleh tahanan remaja, 2) perlu dipertimbangkan untuk menambah ijin waktu kunjungan keluarga, 3) memberikan fasilitas tempat yang nyaman dan layak, misalnya dengan mengurangi jumlah penghuni dalam tiap blok, dan tidak mencampur tahanan remaja dengan tahanan dewasa dan atau lansia, 4) diadakan kegiatan yang dapat mendukung perkembangan dan pertumbuhan remaja, 5) perawat dapat memaksimalkan peran keluarga dengan memberikan konseling pada keluarga. dan 6) penelitian lebih lanjut mengenai cara untuk mengatasi stres pada remaja yang divonis penjara, yaitu melalui kegiatan konseling keluarga dalam rangka meningkatkan dukungan sosial keluarga dan menurunkan stres pada remaja. kepustakaan friedman, m.m, 1998. keperawatn keluarga teori dan praktik. alih bahasa oleh ina debora r.l & yoakim asy. jakarta: egc, hlm. 6-7, 100, 195-198. hurlock, e.b, 1997. psikologi perkembangan suatu pendekatan sepanjang rentang kehidupan. edisi 5. jakarta: erlangga, hlm. 205-209. hurlock, e.b, 1997. perkembangan anak. edisi 6. jakarta : erlangga, hlm. 256. kurniasari, a, 2007. studi penanganan anka berkonflik hukum, (online), www.depsos.go.id/modules.phpname= downloads&d_op=getit&lid=13, diakses tanggal 19 april 2009, jam 09.15 wib). maramis, 2004. catatan ilmu kedokteran jiwa. surabaya: airlangga university press, hlm. 63-83. mccarty, c.a dkk., 2006. depressive symptoms among delinquent youth: testing models of association with stress and support,(online), http://www.pubmedcentral.nih.gov/pic render.fcgi?artid=2140000&amp;blob type=pdf, diakses tanggal 19 april 2009, jam 09.30 wib). national mental health asociation, 2001. mental health treatment for youth in the juvenile justice system: a compendium of promising practices, (online), (www.isc.idaho.gov/jjcompendiumof bestpractices.pdf, diakses tanggal 19 april 2009, jam 09.00 wib). niven, n., 2002. psikologi kesehatan: pengantar untuk perawat dan profesional kesehatan lain. jakarta: salemba medika, hlm. 53-54. nursalam & kurniawati, d.n., 2007. asuhan keperawatan pada pasien terinfeksi hiv/aids. jakarta: salemba medika, hlm. 6-10. richardson, l.p. and katzenellenbogen, r. 2005. childhood and adolescent depression: the role of primary care providers in diagnosis and treatment, (online), (http//www.hogg.utexas.edu/pdfchild &adolescent_depression.pdf, diakses tanggal 21 april 2009, jam 09.00 wib). smet, b., 1994. psikologi kesehatan. alih bahasa oleh kunta r. jakarta: anggota ikapi, hlm. 135-137. http://www.depsos.go.id/modules.phpname=downloads&d_op=getit&lid=13 http://www.depsos.go.id/modules.phpname=downloads&d_op=getit&lid=13 http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2140000&amp;blobtype=pdf http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2140000&amp;blobtype=pdf http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2140000&amp;blobtype=pdf http://www.isc.idaho.gov/jjcompendiumofbestpractices.pdf http://www.isc.idaho.gov/jjcompendiumofbestpractices.pdf 108 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 108-109 http://dx.doi.org/10.20473/jn.v18i2.47055 original article open access healthcare technology, innovation and nursing challenges in disruptive era duangporn piyakong 1 * and naphaklacha pholanun 1 1 faculty of nursing, naresuan university, phitsanulok, thailand *correspondence: duangporn piyakong. address: faculty of nursing, naresuan university, phitsanulok, thailand. email: duangporn@nu.ac.th many technologies and innovations have been increasingly introduced into healthcare system to improve the efficiency, effectiveness and quality of care as a result of social and environmental changes. the elderly population needs care from health care providers, health technologies and innovations to maintain their health or support their life as independently as possible. in addition, the increasingly complex chronic illnesses in patients require advanced technology to save patients with complicated illnesses. there is an increase in both non-communicable and communicable diseases, especially emerging infectious diseases, and the digital disruption era which are major causes of an extreme increase in the use of technologies and innovations in every sector, especially the healthcare sector. it is expected that health technologies and innovations would result in better health outcomes, higher quality of care, patient safety, and the increasing of patients’ satisfaction. the infiltration of technologies and innovations into healthcare have affected a drastic change in the role of healthcare providers, including nursing professions (aloini, benevento, stefanini, & zerbino, 2023; flessa, & huebner, 2021). in this rapidly changing context or disruptive era, the role of nurses is more complicated. besides providing nursing care, nurses are challenged to learn new technologies and innovations inevitably. they need to keep pace with health care technology and innovation through having knowledge, skills and competences in using and administering of healthcare technologies and innovations to deliver the best nursing care to patients. in addition, being in a digital world, nurses need to have another role which is more than just as sophisticated technological users. they might also be a nurseinnovator for nursing practice because nurses understand their own needs better than other professions (glasgow et al., 2018). nurses might be a designer or a creator of new technologies or innovation for nursing practice. developing new technologies or innovations related to nursing practice can help nurses meet patients’ physical and emotional needs because technologies and innovations can bring nurses closer to their patients and give nurses deep and correct data of the patients (barchielli, marullo, bonciani, & vainieri, 2021). therefore, nurses should develop characteristics of innovators by thinking outside the box, having positive emotions, and having team synergy (bahari, talosig, & pizarro, 2021). technologies and innovations in nursing could improve not only quality of patient care, but also quality of work, quality of nursing profession, and quality of organization, such as saving a patient’s life, saving working time, and preventing errors in nursing practice. however, working with a lot of technologies might interfere with nursing practice, workload, data security, and caring behaviors (glasgow et al., 2018). over technologic management in patient care affects time limitation to provide nursing practice to patients and can cause work overload, leading to physical and psychological health problems of nurses. using over technologies and innovations might also affect increased cost of care (okpala, 2018). in addition, concentrating on a lot of healthcare technologies and innovations might diminish the nurses’ ability to demonstrate caring behavior. caring is the central focus in nursing practice to improve health or well-being of patients. it helps nurses know, understand and perceive problems or needs of patients and their family, leading to appropriate and correct nursing care (boykin & schoenhofer, 2001). therefore, nurses in this disruptive era need to be concerned about advantages and disadvantages of working with healthcare technologies and innovations. https://creativecommons.org/licenses/by/4.0/ mailto:duangporn@nu.ac.th https://orcid.org/0000-0003-3283-0423 https://orcid.org/0000-0002-1992-6618 jurnal ners http://e-journal.unair.ac.id/jners 109 in conclusion, the use of technology and innovation in the healthcare sector is continuously increasing. nurses are encountering not only the phenomena of technological dependence, but also the demand to develop technology and innovation for nursing practice. roles of nurses should not remain the users, but should be the developers of technologies and innovations in nursing in order to provide nursing care that meets the patients’ needs and covers health prevention, health promotion, and rehabilitation. however, nurses should consider positive and negative impacts of using technologies and innovations in clinical and community setting. references aloini, d., benevento, e, stefanini, a, & zerbino, p. (2023) ‘transforming healthcare ecosystems through blockchain: opportunities and capabilities for business process innovation’, technovation, 119, 102557. https://doi:10.1016/j.technovation.2022.102557 bahari, k., talosig, a. t., & pizarro, j. b. (2021) ‘nursing technologies creativity as an expression of caring: a grounded theory study’, global qualitative nursing research, 8, 1-10. https: doi:10.1177/2333393621997397 barchielli, c., marullo, c., bonciani, m., & vainieri, m. (2021) ‘nurses and the acceptance of innovations in technology-intensive contexts: the need for tailored management strategies’, bmc health services research, 21, 639. https://doi.org/10.1186/s12913-021-06628-5 bellucci, n. (2022) ‘disruptive innovation and technological influences on healthcare’, journal of radiological nurses, 41, 98–101. boykin, a., & schoenhofer, s. o. (2001) ‘nursing as caring: a model for transforming practice’, sudbury, ma: jones and bartlett publishers. flessa, s., & huebner, c. (2021) ‘innovations in health care—a conceptual framework’, international journal of environmental research and public health, 18(19), 10026. https://doi.10.3390/ijerph181910026 glasgow, m. e. s., colbert, a., viator, j., & cavanagh, s. (2018) ‘the nurse-engineer: a new role to improve nurse technology interface and patient care device innovations’, journal of nursing scholarship, 50(6), 601-611. https://doi.org/10.1111/jnu.12431 okpala, p. (2018) ‘assessment of the influence of technology on the cost of healthcare service and patient's satisfaction’, international journal of healthcare management, 11 (4), 351-355. admission orientation menurunkan stres pasien awal masuk rumah sakit (admission orientation reduces the level stress of early hospitalized patients) kusnanto*, siti guntarlin**, dian nur arisandi* *program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496 e-mail: kusnanto_ners@yahoo.com ** rsu dr.soetomo surabaya abstract introduction: being hospitalized, some people may encounter a strange environment and situation which trigger stress to the patients. by giving an orientation, patients will learn how to adapt to this stressful event. admission orientation is a type of orientation which can be given to the patient on early stage of hospitalization. the main purpose of admission orientation is to facilitate the patients to cope with hospital environment and situation at first 24-48 hours. the objective of this study was to analyze the effect of admission orientation to reduce the stress level in early hospitalized patients. method: a quasy experimental design was used in this study. population had taken from new patient in c (cempaka) surgical ward, on june 2007. sample were recruited by using total sampling and there were 12 samples who met to the inclusion criterias, divided into 6 samples for intervention group and 6 samples for control group. the independent variable was admission orientation and the dependent variable was stress responses. data were collected by using questionnaire and analyzed by using wilcoxon signed ranks test and mann-whitney u test with significance level α≤0.05. result: the result showed that admission orientation reduce the stress level in early hospitalized patients with p=0.025 in intervention group, p=0.157 in control group. discussion: it can be concluded that admission orientation reduce patient’s level of stress. therefore, admission orientation should be applied on hospitals as a program that can promote patient’s adaptation in early hospitalization. keywords: admission orientation, stress, early hospitalized patients. pendahuluan rumah sakit (hospital) merupakan sebuah institusi perawatan kesehatan profesional yang pelayanannya disediakan oleh dokter, perawat dan tenaga ahli kesehatan lainnya (rumah sakit, 2007). klien yang baru masuk untuk rawat inap di rumah sakit akan menghadapi situasi yang belum pernah dikenali dan dihadapi sebelumnya. situasi tersebut kadang merupakan hal yang menakutkan bagi beberapa orang dan menjadi penyebab stres yang utama (reality orientation: a historical study of patient progress, 2007). kondisi stres dapat memicu munculnya respons fisik dan psikologis yang dapat mempengaruhi kondisi sakit seseorang. program seperti pengelolaan terhadap gejala, orientasi lingkungan perawatan, pengkajian status psikologis, konseling dan pemberian pendidikan kesehatan berkelanjutan dapat memberikan positive feed back bagi klien dalam menghadapi situasi yang asing. orientasi lingkungan atau ruangan pada saat pasien pertama kali datang di pelayanan kesehatan (rs) dapat membantu menurunkan kecemasan dan ketakutannya (aditama, 2003). salah satu bentuk program orientasi yang diberikan pada 24 jam pertama pasien tiba di ruang rawat inap adalah admission orientation atau orientasi awal masuk rumah sakit (harris, 2005). lingkungan yang baru, situasi asing, banyak orang tidak dikenal dan rumitnya prosedur administrasi akan memicu timbulnya kecemasan dan ketakutan pada hampir semua pasien. hasil survey dari the mailto:kusnanto_ners@yahoo.com http://id.wikipedia.org/wiki/rumah_sakit http://www.tde.sagepub.com/ http://www.tde.sagepub.com/ agency for healthcare research and quality (ahrq) (the orientation program prd, 2006), dari 100 orang pasien baru yang datang rawat inap di rumah sakit, 95% pasien mengalami stres akut pada 24-48 jam pertama dirawat dan hanya 25% yang mampu beradaptasi dengan baik. pada pasien yang pernah mempunyai pengalaman mendapatkan perawatan di instansi pelayanan kesehatan sebelumnya, angka kejadian stres akut berkurang menjadi 47% (the orientation program prd, 2007). stres merupakan kejadian yang sering dialami manusia selama masa hidupnya (rasmun, 2004). sangat sulit mengukur angka kejadian stres pada pasien yang baru pertama kali di rawat di instansi pelayanan kesehatan. menurut data dari woodside receiving hospital, youngstown, ohio, amerika serikat (the orientation program prd, 2007) sebagai salah satu rumah sakit yang telah melaksanakan program admission orientation, kecemasan dan ketakutan adalah dua respons stres yang sering timbul pada 78% pasien awal mrs dan dari 10 orang pasien, 7 diantaranya mengalami kecemasan dan 3 lainnya mengalami ketakutan sebagai respons stres utama (harris, 2005). pengaruh pemberian orientasi terhadap penurunan stres pada pasien awal masuk rumah sakit yang belum diketahui menyebabkan sedikitnya instansi pelayanan kesehatan yang melaksanakan prosedur ini. kecemasan dan ketakutan merupakan perasaan yang sering dirasakan oleh pasien ketika tiba di sebuah instansi pelayanan kesehatan. rumah sakit merupakan salah satu pusat pelayanan kesehatan yang berfungsi sebagai tempat rehabilitasi bagi individu yang berada pada rentang sakit dengan multiprofesi bekerja di dalamnya seperti dokter, perawat, ahli gizi, petugas farmasi dan tenaga kerja lainnya. kejadian stres akut memberikan respons fisik dan psikologis dapat mempengaruhi proses perkembangan penyakit pasien. kejadian stres dapat memicu pengeluaran kortisol sebagai related stress hormone yang dapat mengacaukan metabolisme tubuh sehingga kondisi kesehatan pasien menjadi lebih parah (rasmun, 2004). ruang bedah c sebagai salah satu ruang rawat inap bedah di rsu dr. soetomo yang merupakan ruang percontohan manajemen keperawatan dengan menggunakan model asuhan keperawatan profesional (makp) modifikasi tim primer, telah melaksanakan prosedur penerimaan pasien baru yang dilakukan oleh perawat primer (pp) merujuk pada prosedur tetap yang telah ditetapkan oleh direktur rsu dr. soetomo surabaya. terdapat perbedaan utama antara admission orientation dan prosedur penerimaan pasien baru di ruang bedah c rsu dr soetomo. perbedaan tersebut terletak pada adanya sesi diskusi bersama antara perawat, pasien dan keluarganya pada admission orientation. pada penerimaan pasien baru biasa tidak terdapat sesi diskusi seperti pada admission orientation. sesi diskusi tersebut merupakan sarana untuk mengetahui permasalahan pasien dan saat paling tepat untuk memberikan positive feedback pada pasien guna menurunkan tingkat stres pada pasien. namun sampai saat ini, pemberian admission orientation yang dapat menurunkan tingkat stres dengan cara membantu percepatan adaptasi dengan lingkungan perawatan pada pasien awal masuk rumah sakit (mrs) belum banyak dilakukan oleh instansi rumah sakit di indonesia baik negeri maupun swasta. salah satu upaya yang dapat dilakukan untuk mengurangi kecemasan dan ketakutan pada pasien adalah dengan memberikan orientasi pada awal pasien masuk rumah sakit (mrs). admission orientation dapat dijadikan sebagai salah satu program untuk membantu mempercepat proses adaptasi pasien dengan lingkungan perawatan. menyambut kedatangan pasien, mengorientasikan pasien dengan ruang perawatan, memperkenalkan pasien dengan komponen di ruang perawatan dan memberikan kesempatan pada pasien dan keluarganya berdiskusi tentang masalahnya serta memberikan possitive feedback akan membantu proses adaptasi pasien yang diharapkan dapat menurunkan tingkat stres pasien. bahan dan metode desain yang digunakan dalam penelitian ini adalah quasy experimental, dengan menggunakan total populasi terjangkau (accessible population), yaitu pasien awal masuk rumah sakit (mrs) dan datang di ruang perawatan pada 24-48 jam pertama rawat inap di ruang bedah c rsu dr. soetomo surabaya dan memenuhi kriteria inklusi. jumlah sampel 12 responden yang dibagi menjadi 6 responden kelompok perlakuan dan 6 responden kelompok kontrol. variabel independen dalam penelitian ini adalah admission orientation, sedangkan variabel dependen adalah respons stres. instrumen yang digunakan untuk mengukur respons stres adalah lembar kuisioner yang diadaptasi dari stressless inc. (2007) dan dass (depression anxiety stress scale) diadaptasi dari lovibond and lovibond (1995). penelitian dilaksanakan tanggal 11 – 22 juni 2007 di ruang bedah c rsu dr. soetomo surabaya. hasil identifikasi stres pada pasien awal masuk rumah sakit (mrs) di ruang bedah c (cempaka) rsu dr. soetomo surabaya menunjukkan mayoritas pasien mengalami stres sedang (67%) (lihat gambar 1). pada gambar 2 dapat dilihat pengaruh pemberian admission orientation terhadap stres pada pasien awal masuk rumah sakit (mrs) di ruang bedah c (cempaka) rsu dr. soetomo surabaya. pemberian admission orientation berpengaruh terhadap stres pada pasien awal masuk rumah sakit (mrs), hal ini dibuktikan melalui uji statistik wilcoxon signed ranks test (p=0,025) dan dengan uji statistik mann whitney u test (p=0,027) seperti terlihat pada tabel 1. pembahasan ruang bedah c (cempaka) rsu dr. soetomo surabaya adalah salah satu ruang rawat inap bedah kelas 1 dan 2 dengan pasien terbanyak memiliki kasus bedah elektif meliputi kasus bedah urologi, bedah digestif, bedah saraf, bedah kepala leher, bedah plastik dan lain-lain. pasien yang menjalani rawat inap di ruangan tersebut adalah pasien pra operasi yang telah direncanakan sebelumnya melalui irj poli bedah rsu dr. soetomo surabaya meskipun ada beberapa diantaranya langsung datang dari ird rsu dr. soetomo surabaya. waktu perencanaan operasi setiap pasien berbeda-beda terhitung mulai diputuskannya seorang pasien untuk menjalani operasi dari irj poli bedah. proses dari mulai diputuskan operasi hingga pasien mrs membutuhkan waktu yang lama. hal ini dikarenakan pasien dan keluarganya harus mengantri untuk mendapatkan ruang rawat inap. dari 12 responden rata-rata membutuhkan waktu 5-10 hari untuk mendapatkan ruang perawatan yang tepat sesuai dengan kondisi sakit dan keinginan pasien. 1 1 4 4 1 1 0 2 4 stres berat stres sedang stres ringan stres pada pasien awal mrs perlakuan kontrol gambar 1. stres pada pasien awal masuk rumah sakit (mrs) selama 24-48 jam pertama perawatan. 0 2 4 6 stres berat stres ringan stres kelom pok kontrol pre test post test 0 1 2 3 4 5 stres berat stres sedang stres ringan stres kelompok perlakuan pres test post test gambar 2. stres pada kelompok perlakuan dan kelompok kontrol pasien awal masuk rumah sakit (mrs) selama 24-48 jam pertama perawatan. admission orientation tabel 1. hasil uji statistik pemberian admission orientation dalam menurunkan stres pada pasien awal masuk rumah sakit (mrs) tingkat stres perlakuan kontrol pre post pre post (n) (n) (n) (n) ringan 1 4 1 1 sedang 3 1 4 4 berat 1 0 0 0 hasil uji statistik wilcoxon signed ranks test (p=0,025) wilcoxon signed ranks test (p=0,157) mann-whitney u test (p=0,027) keterangan: n = jumlah p = signifikansi klien datang ke rumah sakit karena membutuhkan pemantauan dan pengawasan kontinyu serta mengalami defisit perawatan dan gangguan status fungsi. klien yang baru masuk untuk rawat inap di rumah sakit akan menghadapi situasi yang belum pernah dikenali dan dihadapi sebelumnya. situasi ini kadang merupakan hal yang menakutkan bagi beberapa orang dan menjadi penyebab stres yang utama (reality orientation: a historical study of patient progress, 2007). stres merupakan kejadian yang sering dialami manusia selama masa hidupnya (rasmun, 2004). menurut stressless (2007), stres merupakan kombinasi dari psikologis, fisiologis dan reaksi perilaku sehingga seseorang berespons pada berbagai kejadian yang mengancam atau menantang mereka. respons stres juga terdiri dari respons psikologis, fisiologis dan reaksi perilaku terhadap stresor (stimulus yang menyebabkan stres), stres dapat menjadi baik ataupun buruk. menurut selye dalam cohen (2007) serta kozier dan erb (2004) stres dibagi menjadi 3 tahap yaitu alarm reaction, tahap resistence dan tahap exhaustion. secara umum, tiga faktor utama yang mempengaruhi tahap stres adalah faktor individu, asal stres, dan lingkungan sekitar. pengalaman yang dilalui pada masa anak-anak, ciri-ciri personalitas seseorang dan faktor genetik adalah berbagai faktor yang mempengaruhi tahap stres seseorang. selang waktu dan kualitas kejenuhan serta faktor lingkungan sekitar seperti dukungan sosial juga mempengaruhi tahap stres seseorang (hawari, 2004). adanya selang waktu antara mulai diputuskannya seorang pasien untuk menjalani operasi hingga saat mrs setelah mendapatkan ruang yang tepat inilah yang membuat mayoritas responden mengalami stres sedang. hal ini dikarenakan adanya kesempatan bagi seorang pasien untuk mempersiapkan dirinya terlebih dahulu sebelum mrs, baik persiapan fisik maupun mental. persiapan mental dan spiritual dengan lebih mendekatkan diri dengan tuhan yme serta mengambil hikmah atas penyakitnya sedangkan persiapan dari luar biasanya berupa motivasi dari orang terdekat seperti keluarga dan juga adanya dukungan sosial dari orang lain yang pernah mempunyai pengalaman mrs sebelumnya. berdasarkan data kuesioner pada responden yang seluruhnya belum pernah dirawat di rs, responden yang menjalani rawat inap di ruang bedah c (cempaka) berasal dari rujukan irj poli bedah rsu dr. soetomo surabaya merasakan takut dan cemas ketika dokter mengharuskan mereka operasi dan menjalani rawat inap di rs. pada responden yang berasal dari ird rasa takut dan cemas tampak pada sikap dan tingkah lakunya yang gelisah. kuesioner stressless (2007) mengkaji stres dari lima aspek yaitu fisik, mental, emosional, perilaku individu (personal behaviour) dan perilaku kerja (work behaviour). pada aspek fisik, responden banyak yang menunjukkan keluhan pusing, susah tidur, detak jantung dan nadi meningkat, nafsu makan hilang serta nyeri otot. dari hasil observasi sebagian besar responden tidak menunjukkan stres yang jelas. pada aspek mental, respons yang http://www.tde.sagepub.com/ http://www.tde.sagepub.com/ banyak dialami responden yaitu pikiran kacau, konsentrasi menurun dan rasa khawatir. pada aspek emosional, responden banyak menunjukkan rasa cemas, panik, takut, kesepian, merasa bersalah atas apa yang terjadi pada dirinya, tidak sabar serta merasa sangat bergantung pada orang lain. pada aspek perilaku individu (personal behaviour), sikap tidak berani mengambil resiko, pasif, tergantung dan rasa dikontrol orang lain, merasa menjadi orang asing, malas berkomunikasi dengan orang lain serta sulit percaya pada orang lain adalah respons yang paling banyak dikeluhkan oleh pasien dan keluarganya. pada aspek perilaku kerja (work behaviour), respons yang paling banyak ditunjukkan oleh pasien dan dilaporkan oleh keluarganya yaitu penurunan motivasi, komunikasi buruk, serta kehilangan kemampuan interpersonal yang baik. manifestasi klinik dari stres sangat individual dan hakekatnya merupakan kumpulan dari beberapa hal yang berpengaruh, antara lain jenis dan berat ringannya stres, persepsi dan penderitaan yang dirasakan oleh orang yang mengalami stres (kozier and erb, 2004). hal inilah yang menyebabkan adanya perbedaan tingkat stres pada responden penelitian. admission orientation adalah salah satu bentuk orientasi yang diberikan pada pasien awal masuk rumah sakit untuk menjalani perawatan atas kondisi sakitnya pada 24 jam pertama berada di ruang perawatan dengan harapan dapat membantu adaptasi pasien dengan situasi yang asing di rumah sakit. komponen dari admission orientation meliputi menyambut kedatangan pasien, memperkenalkan pasien dengan komponen di ruang perawatan, mengorientasikan pasien dengan ruang perawatan serta memberikan waktu untuk diskusi terbimbing antara pp, pasien dan keluarga (the orientation program prd, 2007). perbedaan hasil tampak pada kelompok perlakuan dan kelompok kontrol. hal ini disebabkan karena jenis orientasi yang didapatkan berbeda. responden kelompok kontrol tidak diberikan admission orientation tetapi mendapat prosedur penerimaan pasien baru dimana dalam prosesnya hanya diberikan penjelasan secara sepintas terutama mengenai kondisi lingkungan perawatan dan aturan di rumah sakit tanpa diberikan media pelengkap seperti gambar denah ruang perawatan dan lembar tata aturan rumah sakit. selain itu tidak adanya sesi diskusi terbimbing antara pp, pasien dan keluarga sehingga perawat tidak dapat memberikan feed back terhadap masalah pasien yang berkaitan dengan kondisinya di awal mrs. sesi diskusi terbimbing juga merupakan saat yang tepat bagi perawat untuk membangun kepercayaan pada pasien dan keluarga yang berguna bagi proses perawatan selanjutnya serta membangun motivasi pada diri pasien. pemberian admission orientation pada pasien awal masuk rumah sakit diharapkan dapat memfasilitasi adaptasi pasien dengan lingkungan dan situasi asing di ruang perawatan. dengan memberikan orientasi ini seorang perawat dapat membantu pasien membangun persepsi yang baik sebagai awal proses pembelajaran terhadap lingkungan dan situasi asing tersebut. keberhasilan dalam proses pembelajaran ini akan mampu menciptakan koping positif pada diri pasien terhadap masalah yang dihadapi. hal inilah yang mampu meningkatkan kemampuan adaptasi pasien dengan lingkungan dan situasi ruang perawatan yang asing bagi mereka sehingga stres pada pasien awal mrs dapat menurun pada 24-48 jam pertama perawatan. simpulan dan saran simpulan perubahan stres yang ditunjukkan oleh kelompok pasien yang diberikan admission orientation lebih baik dibandingkan dengan kelompok yang tidak diberikan perlakuan. pemberian admission orientation sebagai salah satu metode yang dapat menurunkan stres pada pasien awal mrs, karena admission orientation dapat memfasilitasi proses adaptasi yang memicu terciptanya koping positif sebagai dasar meningkatkan kemampuan adaptasi sehingga stres pada pasien awal mrs dapat berkurang pada 24-48 jam pertama perawatan. saran admission orientation seharusnya diterapkan pada setiap rumah sakit sebagai program yang membantu proses adaptasi pada awal perawatan (awal masuk rumah sakit). kepustakaan aditama. 2003. manajemen administrasi rumah sakit. edisi kedua. jakarta: ui press. reality orientation: a historical study of patient progress. 2007. (online), (http:// psychservices.psychiatryonline.org., diakses tanggal 22 april 2007, jam 14.31 wib). rumah sakit. 2007. (online), (http://www.id.wikipedia.org/wiki/ru mah_sakit., diakses tanggal 27 april 2007, jam 12.59 wib). the orientation program prd. 2007. (online), (http://www.ons.org/orientation., diakses tanggal 19 april 2007, jam 14.05 wib). cohen, s. 2007. perceived stress scale, (online), (http://www.psy.cmu.edu., diakses tanggal 11 maret 2007, jam 21.26 wib). harris, j.w. 2005. admission orientation_a good beginning, (online), (http://www.psychservices.psychiatryo nline.org., diakses tanggal 22 april 2007, jam 10.15 wib). hawari, d. 2004. manajemen stres, cemas dan depresi. jakarta: balai penerbit fkui. koenker, h. 1994. stress and the immune system, (online), (http://www.econ.uiuc.edu., diakses tanggal 13 maret 2007, jam 12.38 wib). kozier and erb. 2004. fundamentals of nursing: concepts, process and practice. 7 th edition. new jersey: pearson education. lovallo, w.r. 2005. stress and health: biological and psychological interaction. california: sage publication. lovibond and lovibond. 1995. depression anxiety stress scale (dass), (online), (http://www.swin.edu.au., diakses tanggal 11 maret 2007, jam 22.05 wib). rasmun. 2004. stres, koping dan adaptasi: teori dan pohon masalah keperawatan. jakarta: sagung seto, hlm. 41-49. stressless inc. 2007. stress related information, (online), (http://www.stressless.com., diakses tanggal 30 maret 2007, jam 09.38 wib). http://www.id.wikipedia.org/wiki/rumah_sakit http://www.id.wikipedia.org/wiki/rumah_sakit http://www.ons.org/orientation http://www.psy.cmu.edu/ http://www.econ.uiuc.edu/ http://www.swin.edu.au/ http://www.stressless.com/ 144 perilaku caring perawat meningkatkan kepuasan ibu pasien (nurse’ caring behaviour improve the satisfaction of patient’s mother) yuni sufyanti arief*, ertawati**, durrotul laili* abstract introduction: satisfaction of mother is the success indicator of nursing care in children ward. most research show that nurses have a low motivation to provide on others caring behaviour. they pay more attention to curing. thus most patient’s mother still not satisfied with the nurse care behavior. the aim of this study was to investigate correlation between nurse caring behaviour with satisfaction of patients’ mother in nursing care services.method: a correlation study design was used in this study.there were 27 respondents who met the inclusion criteria. the independent variable was the nurse caring behavior and the dependent variable was satisfaction of patients’ mother. data were collected by using questionnaire then analyzed by using spearman rank correlation with significance level of α≤0.05. result: the result showed that the nurse caring behaviour and the patients’ mother satisfaction had significance correlation (p=0.038). analysis: it can be concluded that nurse caring behaviour correlates to patient’s mother satisfaction in children ward. discussion: nurses should apply caring behavior for the patients and family to built patients’ mother satisfaction. keywords: caring, nurse caring behavior, satisfaction *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: yuni_psik@ yahoo.com ** rsud dr.soetomo surabaya pendahuluan pada era globalisasi, tuntutan masyarakat terhadap pelayanan kesehatan yang memadai semakin meningkat dan memacu rumah sakit untuk memberikan layanan terbaik agar tidak dimarginalkan oleh masyarakat. salah satu bagian pelayanan yang perlu ditingkatkan adalah pelayanan keperawatan. berbagai faktor dapat berpengaruh terhadap pelayanan keperawatan, salah satu factor tersebut adalah sikap caring perawat (wijayana m., 2008). menurut taber’s (1993) dalam vance t (2009) perilaku caring merupakan suatu perilaku yang dibuktikan oleh caring perawat kepada pasien. sepuluh perilaku caring perawat diantaranya adalah: perhatian ketika mendengarkan, nyaman, tulus ikhlas, sabar, bertanggung jawab, memberikan informasi kepada pasien sehingga pasien dapat membuat keputusan, sentuhan, kepekaan, rasa hormat, dan memanggil pasien dengan namanya. beberapa penelitian menyebutkan bahwa perilaku caring perawat masih rendah. hal ini disebabkan karena sebagian perawat terlibat secara aktif dan memusatkan diri pada fenomena medik. perawatan anak membutuhkan penangan yang berbeda dibandingkan dengan perawatan pada orang dewasa. hal ini disebabkan karena anak merupakan individu yang unik, mempunyai pola pertumbuhan dan perkembangan menuju proses kematangan, sehingga dalam melakukan pendekatan pada anak diperlukan metode khusus, salah satunya dengan perilaku caring perawat. perawat harus memperhatikan tiga filosofi dari keperawatan anak, yaitu: keluarga (family centered care), pencegahan terhadap trauma (attraumatic care), dan manajemen kasus. seorang perawat dalam memberikan asuhan keperawatan, pemberdayaan (empowering), pemupukan kemampuan (enabling), dan keterlibatan/partisipasi keluarga dalam merawat anak merupakan dasar dalam pemberian asuhan keperawatan yang berfokus pada keluarga, salah satu perilaku caring perawat (yuni sufyanti arief) 145 anggota keluarga yang berperan dalam memberikan asuhan keperawatan adalah ibu pasien. diharapkan agar dapat terbentuk kerjasama yang utuh antara peran dan fungsi ibu pasien dengan perawat dalam memberikan asuhan keperawatan sehingga dapat meningkatkan kepuasan terhadap pelayanan keperawatan. penelitian yang dilakukan oleh haryadi (2007) di irna anak rsud. dr. soetomo surabaya menyatakan bahwa keterampilan interpersonal perawat rendah dan kualitas pelayanan yang diberikan masih kurang baik. keterampilan interpersonal merupakan bagian dari perilaku caring perawat. namun sampai saat ini penelitian tentang hubungan perilaku caring perawat dengan tingkat kepuasan ibu pasien pada pelayanan asuhan keperawatan masih belum ada. perawat merupakan anggota dari kelompok profesi yang menggunakan ungkapan nursing care. j. watson dan m. leininger telah menempatkan caring sebagai pusat dan sangat mendasar dalam praktek keperawatan (basford & lynn, 2006). diperkirakan bahwa 3/4 pelayanan kesehatan adalah caring sedangkan 1/4 adalah curing. berdasarkan hasil survey kepuasan pasien yang dilakukan oleh depkes ri pada beberapa rumah sakit di jakarta, menunjukkan bahwa 14% pasien tidak puas terhadap pelayanan kesehatan yang diberikan. dalam penelitian yang telah dilakukan oleh hariyadi (2007) menyebutkan bahwa kualitas pelayanan di rawat inap anak rsud. dr. soetomo surabaya yang diberikan oleh perawat kurang baik yaitu sangat baik=1,81%, baik=29,09%, kurang=40%, dan sangat kurang=29,09%, sedangkan untuk keterampilan interpersonal sangat baik=3,63%, baik=29,09%, kurang=36,36%, sangat kurang=30,90%. sedangkan pengambilan data awal yang telah dilakukan oleh hariyadi melalui interview dengan orang tua pasien 10% mengatakan pelayanan di rawat inap anak rsud. dr. soetomo surabaya tergolong biasa. berdasarkan hasil penelitian diatas, tidak hanya pengetahuan dan keterampilan interpersonal saja yang dibutuhkan melainkan komunikasi yang baik terhadap pasien maupun keluarga (hariyadi m., 2007). berdasarkan pada penelitian diatas, maka dibutuhkan penelitian lanjut yang lebih dapat mencakup masalah tersebut, yaitu melalui perilaku caring perawat. kepuasan pelanggan dipengaruhi oleh kualitas pelayanan rumah sakit. salah satu faktor yang mempengaruhi adalah pelayanan keperawatan. keperawatan merupakan suatu interaksi antara perawat, klien, dan profesional kesehatan lain. perawat yang berkomunikasi secara efektif lebih mampu membina hubungan antar diri mereka sendiri dan orang lain, termasuk klien dan keluarga serta komponen masyarakat lainnya. untuk perilaku caring perawat sangat diperlukan dalam membina hubungan agar tercipta hubungan yang baik antara perawat, klien dan keluarga. keluarga merupakan unsur penting dalam perawatan anak mengingat kehidupan anak dapat ditentukan oleh lingkungan keluarga. untuk itu keperawatan anak harus mengenal keluarga sebagai tempat tinggal atau konstanta tetap dalam kehidupan anak (wong, perry & hockenberry, 2002 dalam hidayat, a., 2008). anggota keluarga yang terlibat yaitu ibu. ibu merupakan salah satu bagian dari anggota yang merawat dan mendampingi pasien selama di rumah sakit. perilaku caring yang diberikan perawat akan memberikan kepuasan ibu pasien pada pelayanan yang diberikan. jika perawat yang bekerja selama 24 jam di rumah sakit lebih menekankan caring sebagai pusat dan aspek yang dominan dalam pelayanannya maka mutu dan pelayanan keperawatan akan meningkat. namun jika hal diatas tidak terpenuhi maka akan mempengaruhi hubungan antara perawat dan ibu pasien, sehingga keterlibatan ibu pasien dalam merawat anak akan berkurang. jika keadaan yang demikian terus berlanjut maka asuhan keperawatan yang diberikan tidak dapat optimal dan mutu pelayanan keperawatan akan menurun. sehingga berdampak pada penurunan kepuasan ibu pasien yang turut mempengaruhi jumlah pelanggan sebelumnya. bahan dan metode penelitian desain yang digunakan dalam penelitian ini yaitu correlation study. populasi dalam penelitian ini adalah ibu pasien anak yang sedang dirawat selama ≥ 3 hari di irna anak rsud. dr. soetomo surabaya. besar sampel dalam penelitian ini yuni s jurnal ners vol.4 no. 2: 144-148 146 adalah 27 responden yang diperoleh dengan menggunakan tehnik purposive sampling. kriteria inklusi pada penelitian ini sebagai berikut: 1) keluarga pasien yang pertama kali mrs, 2) ibu pasien, 3) dirawat selama ≥ 3 hari, 4) pasien berada di kelas 3, 4) ibu dan pasien berada dalam 1 ruangan rawat inap (rooming in) variabel independen dalam penelitian ini yaitu perilaku caring perawat sedangkan variabel dependen adalah kepuasan ibu pasien, untuk mengukur perilaku caring perawat dan pengukuran kepuasan pasien dengan menggunakan kuesioner .data tersebut kemudian ditabulasi dan dianalisis dengan menggunakan uji statistik spearman rank correlation dengan derajat kemaknaan α<0,05. hasil penelitian hasil penelitian menunjukkan bahwa 27 responden hampir seluruhnya yaitu 20 responden (74,1%) menilai perilaku caring perawat baik, sedangkan yang memberikan penilaian perilaku caring perawat kurang hanya 1 responden (3,7%). hasil penelitian tentang kepuasan ibu didapatkan bahwa sebagian besar ibu yaitu 22 responden (81,5%) tingkat kepuasannya baik sedangkan sisanya 5 responden (18,5%) tingkat kepuasannya sedang. tabel. 1 menunjukkan bahwa semua ibu yang memberikan penilaian perilaku caring perawat dalam kategori kurang dapat membentuk kepuasan tingkat sedang. perilaku caring perawat tingkat sedang dapat membentuk kepuasan yang baik bagi ibu sebesar 67,7 %. perilaku caring perawat yang baik dapat membentuk kepuasan yang baik pula bagi ibu pasien. hal ini dibuktikan dengan sebesar 90% ibu memiliki tingkat kepuasan yang baik bagi ibu. hasil analisis hubungan kedua variabel diatas dengan menggunakan uji statistik spearman rho menunjukkan koefesien korelasi r=0,401. sedangkan signifikansi dari hubungan kedua variabel tersebut adalah p=0,038. hasil ini menunjukkan bahwa terdapat hubungan antara perilaku caring dengan kepuasan ibu pasien. pembahasan hasil penelitian tentang perilaku caring perawat, sebagian besar responden menilai perilaku caring perawat baik. perilaku caring perawat merupakan interaksi yang terjadi antara perawat dengan pasien baik secara fisik, emosional dan spiritual yang dipersepsikan oleh pasien sehingga dapat menghasilkan kepuasan pada pemenuhan kebutuhan mereka (kimble, 2003). interaksi yang terjadi antara perawat dan ibu pasien tersebut membutuhkan nilainilai yang dapat dijadikan landasan dalam menerapkan perilaku caring perawat pada pelayanan asuhan keperawatan. nilai-nilai tersebut adalah carative factor, dimana carative factor mencoba menghargai dimensi manusia dalam perawatan dan pengalaman-pengalaman subjektif dari orang yang dirawat. sepuluh carative factor itu meliputi: nilai-nilai kemanusiaan dan altruistik (mendahulukan kepentingan orang lain daripada kepentingan diri sendiri); mengajarkan agar orang lain percaya dan mempunyai pengharapan fasilitas optimisme, menyesuaikan diri; peka pada diri sendiri dan kepada orang lain; membina hubungan saling percaya: jujur, empati; pengekspresian perasaan positif dan negatif; mengambil keputusan dengan mengunakan metode pemecahan masalah yang ilmiah dan sistematis; meningkatkan proses belajar mengajar; memberikan lingkungan mental, fisik, sosio cultural dan spiritual yang bersifat suportif, protektif dan korektif; membantu dalam pemenuhan kebutuhan dasar; dan memberikan kesempatan untuk mengekspresikan aspek manusia. (dossey, b. & lynn, k., 2008). hasil identifikasi kepusaan ibu pasien pada pelayanan asuhan keperawatan menunjukkan sebagian besar berada pada tingkat kepuasan baik (81,5%). perilaku caring perawat (yuni sufyanti arief) 147 tabel 1. analisis hubungan perilaku caring perawat terhadap kepuasan ibu pasien pada pelayanan asuhan keperawatan perilaku caring perawat kepuasan ibu pasien kurang sedang baik total n % n % n % n % kurang 0 0 1 100 0 0 1 100 sedang 0 0 2 33,3 4 67,7 6 100 baik 0 0 2 10 18 90 20 100 total 0 0 5 18,5 22 81,5 27 100 signifikansi (p) = 0, 038 koefisien korelasi spearman rho (r) = 0, 401 faktor yang mempengaruhi perilaku caring perawat diantaranya adalah perawat dan karakteristik pasien. dengan perawat menerapkan 10 carative factor dan 5 c (compassion (belas kasih), competence (kompetensi), confidence (percaya diri), conscience (hati nurani), commitment (komitmen)) dengan baik maka persepsi ibu pasien tentang perilaku perawat juga baik. perilaku caring perawat yang baik pada pemberian pelayanan asuhan keperawatan akan dinilai oleh ibu pasien dengan baik. secara teoritis menyebutkan bahwa interaksi antara perawat dan pasien/ibu pasien baik secara fisik, emosi dan spiritual akan dipersepsikan oleh penerima palayanan asuhan keperawatan. dengan adanya perilaku caring yang baik, maka persepsi ibu pasien tantang perawat sebagai pemberi pelayanan asuhan keperawatan akan baik. sehingga kepuasan akan pelayanan asuhan keperawatan juga akan baik. hal ini sudah dibuktikan diatas, bahwa semakin baik perilaku caring perawat, maka semakin baik pula kepuasan ibu pasien. simpulan dan saran simpulan perilaku caring perawat yang baik dapat membentuk tingkat kepuasan yang baik pula bagi ibu pasien. saran peneliti menyarankan agar institusi rumah sakit dan profesi keperawatan membuat kebijakan yang dapat memotivasi perawat dalam melakukan perilaku caring pada asuhan keperawatan pada pasien, misalnya dengan memberikan reward (reward untuk didelegasikan mengikuti seminar), sehingga pengetahuan dan informasi yang didapatkan oleh perawat dapat bertambah; membuat kebijakan tentang protap atau metode orientasi ruangan bagi perawat untuk pasien yang baru pertama kali masuk rumah sakit di rsud. dr. soetomo kepustakaan basford & lynn, 2006. teori dan praktik keperawatan: pendekatan integral pada asuhan pasien. jakarta: egc, hlm.190-194. dossey b., & lynn k., 2008. holistic nursing a handbook for practice. american nursing association: jones & barlette publisher, pp.91-92. hariyadi, m., 2007. hubungan antara keterampilan interpersonal dengan kualitas pelayanan keperawatan pada perawat di instalasi rawat inap anak rsu. dr. soetomo surabaya. buletin penelitian rsu dr. soetomo, 9 (3), hlm.146-149. hidayat, a., 2008. pengantar ilmu keperawatan anak. jilid 1. jakarta: salemba medika, hlm.1-4. kimble l, 2003. patients’ perceptions of nurse caring behaviors in an emergency department. thesis tidak dipublikasikan. nursing administration. marshall university college of nursing and health professions, (online), (http://www.marshall.edu/etd/master s/kimble-lynn-2003-msn.pdf, diakses http://www.marshall.edu/etd/masters/kimble-lynn-2003-msn.pdf http://www.marshall.edu/etd/masters/kimble-lynn-2003-msn.pdf jurnal ners vol.4 no. 2: 144-148 148 tanggal 3 mei 2009, jam 18.44 wib). vance t, 2009. caring and the professional practice of nursing, (online), (http://www.rnjournal.com/journal_o f_nursing/caring.htm, diakses tanggal 23 mei 2009, jam18.40 wib). wijayana m, 2008. membangun pribadi perawat, (online), (http://www. 52.118.148.220/ppko/ files/membangun%20pribadi%20cari ng%20perawat, diakses tanggal 18 april 2009, jam 10.00 wib http://www.rnjournal.com/journal_of_nursing/caring.htm http://www.rnjournal.com/journal_of_nursing/caring.htm hubungan faktor risiko asma dan perilaku pencegahan 68 implementasi health belief model pada analisis keputusan keluarga melakukan kunjungan ke puskesmas (health believe model implementation on the analyze of family decision to visit the public health center) purwaningsih*, ni ketut alit armini*, susanti* abstract introduction : dengue haemorhagic fever (dhf) is one of infecsius deseases. these deseases can have serious complications and kill the patients. dengue haemorhagic fever (dhf) deseases that is suffered to the patients has become a heavy complication in tembok dukuh village. by the health belief model implementation, the patients got earlier response as soon as possible. the objective of the study was to analyze family’s decision for visiting puskesmas in earlier response of dengue haemorhagic fever (dhf). this descriptive analytic was conducted at work area of puskesmas tembok dukuh surabaya. the population was the family with dengue haemorhagic fever (dhf) patient from januari 2007 until july 2009. method : clustered design was used to take the sample. total sample were 65 respondents, taken according to inclusion criteria. the independent variables were health belief model about perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers, and cues to action. the dependent variable was family’s decision for visiting puskesmas in earlier response of dengue haemorhagic fever (dhf). data was collecting using structured questionnaire. data that had collected were later analyzed with frequency distribution of each category. result : result showed that perceived susceptibility most family was in middle category, perceived seriousness most family was in high category, most of family got the benefits, most of family also got the barriers, and all of the respondents have cues to action. the family’s decision to visit puskesmas for the earlier dengue haemorhagic fever (dhf) response was founded in a few of family. analysis : it can be concluded that most of the family didn’t have a steady decisison to visit puskesmas for the earlier dengue haemorhagic fever response. it can be proved by there are most of family chose the others health service. discussion : health workers in desease eradication departement (p2m) should sosialize the puskesmas program related with the earlier dengue haemorhagic fever (dhf) response. so that, the family has believed that visiting puskesmas is important for the earlier dengue haemorhagic fever (dhf) response. keywords: decisison making, health belief model *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: purwaningsih_ners@unair.ac.id pendahuluan model kepercayaan kesehatan atau health belief model merupakan salah satu model penggunaan pelayanan kesehatan yang didasarkan pada kenyataan bahwa beberapa problem kesehatan ditandai oleh kegagalan masyarakat untuk menerima usaha pencegahan dan penyembuhan penyakit yang diselenggarakan oleh provider (notoatmodjo, 2007). masyarakat yang menderita penyakit dan tidak merasakan sakit tidak akan bertindak terhadap penyakit tersebut. tetapi bila masyarakat diserang penyakit dan juga merasakan sakit, maka baru akan timbul berbagai macam perilaku dan usaha (notoatmodjo, 2007). puskesmas merupakan lini terdepan yang memberikan pelayanan kesehatan masyarakat secara menyeluruh (susilo, 2008). penyakit demam berdarah dengue (dbd) merupakan salah satu penyakit menular yang masih menjadi masalah kesehatan pada negara berkembang termasuk indonesia (depkes ri, 2005). berdasarkan survey yang dilakukan oleh peneliti dari jumlah surat rujukan jurnal ners vol.4 no.1 april 2009: 68-78 69 penderita dengan kasus demam berdarah dengue (dbd) yang dikeluarkan puskesmas, penyakit demam berdarah yang diderita keluarga di kelurahan tembok dukuh, wilayah kerja puskesmas tembok dukuh surabaya, pada tahun 2007 sebanyak 28 orang (36,37%) sudah pada manifestasi klinis yang berat, tahun 2008, 18 orang (23,38%), dan tahun 2009 (januari-juli) 19 orang (24,68%) atau 84% dari 65 keluarga tidak menggunakan puskesmas dalam penanganan dini demam berdarah. penerapan health belief model terhadap keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd) masih perlu dijelaskan. berdasarkan data dari dinas kesehatan kota surabaya yang menunjukkan bahwa sejak ditemukan pertama kali pada tahun 1968, penyakit demam berdarah dengue (dbd) terus menerus ditemukan di surabaya yang merupakan salah satu daerah endemis di jawa timur. kasus demam berdarah dengue (dbd) di surabaya pada tahun 2003, 2004, dan 2005 mengalami peningkatan seiring bertambahnya jumlah penduduk. pada tahun 2006 sebanyak 4.187 kasus (34,62%) dibandingkan tahun 2005 yaitu sebanyak 2.568 kasus (21,23%) mengalami peningkatan sebesar (13,39%). sedangkan pada tahun 2007 mengalami penurunan kembali, yaitu jumlah kasus sebanyak 3.214 kasus (26,58%). hal ini menunjukkan bahwa program pemberantasan penyakit demam berdarah dengue (dbd) di surabaya masih perlu ditingkatkan. insidens risk (ir) dari tahun 2003 sampai dengan tahun 2006 menunjukkan kenaikan yaitu dari dari 36 per 100.000 menjadi 149 per 100.000, sedangkan pada tahun 2007 menunjukkan jumlah yang turun yaitu 113 per 100.000. nilai case fatality rate (cfr) menunjukkan nilai yang naik turun dari tahun 2003 sampai dengan tahun 2007. pada tahun 2003 sebanyak 0.9% mengalami peningkatan dibandingkan tahun 2004 sebanyak 0.7%. pada tahun 2005 sebanyak 1.3% mengalami peningkatan dibandingkan tahun 2006 sebanyak 0.5%, dan pada tahun 2007 sebanyak 0.7% juga mengalami peningkatan dibandingkan tahun 2006. hal ini menunjukkan bahwa seorang penderita demam berdarah dengue (dbd) masih perlu deteksi dini untuk mencegah terjadinya kegawatan akibat penyakit demam berdarah dengue (dbd). kasus demam berdarah dengue (dbd) di puskesmas tembok dukuh surabaya berada diurutan kedua di wilayah surabaya. oleh sebab itu, berdasarkan program pokok puskesmas, prioritas kinerja pada upaya penanggulangan demam berdarah dengue (dbd) lebih ditingkatkan. pemilihan prioritas upaya penanggulangan demam berdarah dengue (dbd) dikarenakan demam berdarah dengue (dbd) selalu ada di wilayah kerja puskesmas, salah satunya adalah kelurahan tembok dukuh di kecamatan bubutan yang merupakan salah satu kelurahan yang endemis. berdasarkan data awal yang didapatkan oleh peneliti pada tanggal 15 juni 2009 di puskesmas tembok dukuh, keluarga di kelurahan tembok dukuh surabaya yang menderita demam berdarah dengue (dbd) pada tahun 2007 sebanyak 34 orang (44,16%), pada tahun 2008 sebanyak 22 orang (28,57%), dan pada tahun 2009 sebanyak 21 orang (27,27%). pada tahun 2008 mengalami penurunan sebesar 15,59% sedangkan pada tahun 2009 mengalami peningkatan. hal ini dapat ditunjukkan dari bulan januari sampai dengan juli 2009 jumlah penderita sudah mencapai 27,27%. hal ini menunjukkan bahwa kasus demam berdarah dengue (dbd) di kelurahan tembok dukuh masih perlu mendapat perhatian khusus karena jika tidak segera ditangani maka jumlah kematian penderita demam berdarah akan semakin meningkat. oleh sebab itu, program pemberantasan penyakit demam berdarah dengue (dbd) di kelurahan tembok dukuh masih perlu ditingkatkan untuk lebih menekan jumlah penderita. kasus kematian penderita akibat demam berdarah dengue (dbd) yang tinggi terjadi karena penderita terlambat dibawa berobat ke rumah sakit atau puskesmas. jika penderita demam berdarah dengue (dbd) terlambat untuk ditangani, akibatnya sering fatal, yaitu bisa langsung merenggut nyawa karena gejala dan tanda demam berdarah dengue (dbd) tidak selalu tampil nyata sehingga tidak selalu mudah dikenali (nadesul, 2007). menurut rosenstock (1982) dalam sarwono (2004), masyarakat atau keluarga tidak akan mencari pertolongan medis atau pencegahan penyakit bila keluarga kurang mempunyai pengetahuan dan motivasi minimal yang relevan dengan kesehatan, bila keluarga memandang keadaan tidak cukup berbahaya, implementasi health belief model (purwaningsih) 70 bila tidak yakin terhadap keberhasilan suatu intervensi medis, dan bila keluarga melihat adanya beberapa kesulitan dalam melaksanakan perilaku kesehatan yang disarankan. model kepercayaan kesehatan (health belief model) dari rosenstock (1982) dalam sarwono (2004), meliputi: kerentanan yang dirasakan terhadap suatu penyakit, keseriusan yang dirasakan, manfaat yang diterima, rintangan-ritangan yang dialami dalam tindakannya melawan penyakit, dan isyarat atau tanda-tanda yang mendorong tindakan tersebut. kelima variabel tersebut merupakan variabel health belief model yang dapat diterapkan bagi keluarga terhadap keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd) guna meningkatkan derajat kesehatan keluarga. kepercayaan keluarga mengunjungi puskesmas dapat menolong proses penyembuhan penyakit termasuk penanganan dini penderita demam berdarah dengue (dbd) diharapkan mampu menurunkan jumlah penderita demam berdarah dengue (dbd) di wilayah penelitian yaitu wilayah kerja puskesmas tembok dukuh dengan cara deteksi dini terhadap tanda dan gejala yang ditimbulkan sehingga penderita tidak terlambat mendapatkan pertolongan. salah satu fungsi puskesmas adalah membina peran serta masyarakat di wilayah kerjanya dalam rangka meningkatkan kemampuan untuk hidup sehat. oleh sebab itu, keputusan keluarga untuk melakukan kunjungan ke puskesmas tersebut merupakan langkah awal terhadap perubahan perilaku dalam menghadapi masalah kesehatan yang berkelanjutan serta demi terwujudnya kemandirian dalam bidang kesehatan di dalam keluarga dan masyarakat. berdasarkan fakta di atas, peneliti tertarik untuk menganalisis penerapan health belief model terhadap keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd). bahan dan metode penelitian rancangan penelitian yang digunakan adalah penelitian deskriptif. sampel didapat dengan menggunakan cluster sampling dengan kriteria inklusi: 1) keluarga yang memiliki anggota keluarga dengan demam berdarah dengue (dbd) mulai januari 2007-juli 2009, 2) orang tua (ayah atau ibu) sebagai pengambil keputusan yang berusia 25-65 tahun. jumlah sampel yang didapat sebanyak 65 orang terdiri dari 19 orang dari rw 3, 21 orang dari rw 7 dan 25 orang dari rw 10. data untuk variabel independen yaitu penerapan health belief model meliputi: kerentanan, keseriusan, manfaat, rintangan, dan faktor pendorong yang dirasakan oleh keluarga yang memiliki anggota keluarga penderita demam berdarah dengue (dbd) diperoleh melalui pengisian kuesioner jenis close ended dichotomy question. variabel dependen dalam penelitian ini adalah keputusan keluarga untuk melakukan kunjungan ke puskesmas yang didapat melalui kusioner terstruktur dengan hasil berupa content analysis. penelitian ini dilakukan di wilayah puskesmas tembok dukuh surabaya pada tanggal 23 juni sampai 6 juli 2009. hasil penelitian data mengenai kerentanan yang dirasakan keluarga (perceive susceptibility) menunjukkan dari 65 keluarga yang menjadi responden dalam penelitian ini, lebih dari setengah responden (55%) mengalami kerentanan yang sedang terhadap penyakit dbd. sub variabel mengenai keseriusan yang dirasakan keluarga (perceived seriousness) hampir setengah responden (46%) mengalami keseriusan yang tinggi terhadap kegawatan akibat penyakit dbd apabila penderita tidak segera mendapatkan penanganan. berdasarkan manfaat yang dirasakan keluarga (perceived benefits) sebanyak 62% dari 65 responden merasakan manfaat ketika keluarga melakukan kunjungan ke puskesmas dalam penanganan dini anggota keluarga yang menderita dbd (tabel 1). identifikasi rintangan yang dirasakan keluarga (perceived barrier) menunjukkan bahwa dari 65 keluarga sebanyak 74% mengalami rintangan ketika akan melakukan kunjungan ke puskesmas dalam penanganan dini anggota keluarga yang menderita dbd (tabel 2). pengetahuan keluarga untuk melakukan penanganan dini penyakit dbd berasal dari sumber informasi yang didapatkan keluarga seperti pada distribusi tabel 3. faktor pendorong utama (cues to action) keluarga melakukan kunjungan ke puskesmas dapat dilihat tabel 4. jurnal ners vol.4 no.1 april 2009: 68-78 71 tabel 1. manfaat yang dirasakan (perceived benefits) keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd) di kelurahan tembok dukuh kecamatan bubutan, surabaya 23 juni-6 juli 2009 manfaat yang dirasakan frekuensi persentase (%) penderita mendapatkan penanganan dengan cepat 21 52,5% penderita dapat terhindar dari kegawatan akibat penyakit demam berdarah 11 27,5% penderita dapat terhindar dari kematian akibat keterlambatan penanganan 8 20% jumlah 40 100% tabel 2. rintangan yang dialami (perceived barriers) keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd) di kelurahan tembok dukuh kecamatan bubutan, surabaya 23 juni-6 juli 2009 rintangan yang dialami frekuensi persentase (%) jarak rumah ke puskesmas sangat jauh 28 58,3% tidak ada transportasi atau kendaraan 11 22,9% biaya pengobatan di puskesmas mahal 0 0% pelayanan petugas puskesmas yang kurang memuaskan 9 18,8% jumlah 48 100% tabel 3. sumber informasi keluarga tentang penanganan dini demam berdarah dengue (dbd) di kelurahan tembok dukuh kecamatan bubutan, surabaya 23 juni-6 juli 2009 sumber informasi frekuensi persentase (%) media massa (televisi, radio, surat kabar, majalah, internet) 40 61,5% mencari sendiri dengan membaca-baca buku tentang penanganan dini demam berdarah 5 7,7% teman-teman dan tetangga 9 13,9% petugas puskesmas 11 16,9% jumlah 65 100% tabel 4. pendorong utama (cues to action) keluarga untuk melakukan kunjungan ke puskesmas atau sarana kesehatan yang lain dalam penanganan dini demam berdarah dengue (dbd) di kelurahan tembok dukuh kecamatan bubutan, surabaya 23 juni-6 juli 2009 pendorong utama frekuensi persentase (%) gejala dan tingkat keparahan penyakit demam berdarah 44 67,7% informasi dari keluarga 6 9,2% penjelasan petugas puskesmas 15 23,1% jumlah 65 100% sebanyak 51% responden melakukan kunjungan ke puskesmas jika ada anggota keluarga yang dicurigai menderita demam berdarah dengue (dbd) atas inisiatif keluarga sendiri, sebagian besar responden (75%) membicarakan terlebih dahulu dengan anggota keluarga yang lain dalam proses pengambilan keputusan untuk melakukan kunjungan ke puskesmas dalam penanganan dini penderita demam berdarah dengue (dbd). adapun content analysis dari hasil kuesioner terstruktur yang mendukung data tersebut dengan pertanyaan: apa saja yang anda bicarakan dengan keluarga mengenai keputusan anda untuk membawa anggota keluarga yang sakit ke puskesmas? jawaban dapat disimpulkan sebagai berikut: “kami implementasi health belief model (purwaningsih) 72 sebelumnya selalu membicarakan terkait dengan penanganan yang dilakukan oleh puskesmas untuk segera mengetahui penyakit yang diderita anggota keluarga agar dapat segera disembuhkan.” (15 responden). “saya berbicara tentang kemungkinan mendapatkan surat rujukan dengan cepat jika anggota keluarga yang sakit dicurigai mengalami kegawatan.” (6 responden). “saya berbicara terlebih dahulu kepada keluarga (suami atau istri) perihal keberadaan dokter yang bertugas saat itu karena biasanya tidak langsung ditangani oleh dokter yang bertugas dan juga tentang obat-obatan yang nanti diterima dari puskesmas. selain itu, kami juga memperhitungkan jarak puskesmas dengan rumah kami” (17 responden). “yang dibicarakan adalah mempertimbangkan biaya yang dikeluarkan untuk berobat ke puskesmas sebab biayanya cukup terjangkau” (4 responden). “kami membicarakan perihal pelayanan petugas puskesmas apakah dapat memberikan pelayanan secara maksimal kepada masyarakat yang berobat ke puskesmas tersebut” (7 responden). delapan puluh lima persen (55 responden) memiliki keinginan untuk berobat ke tempat pelayanan kesehatan yang lain selain di puskesmas, dengan distribusi 76,4 % (42 responden) berobat ke dokter praktik, 23,6% (13 responden) ingin berobat ke rumah sakit. kurang dari setengah responden (45%) memutuskan untuk berobat ke puskesmas jika ada anggota keluarga yang dicurigai menderita demam berdarah dengue (dbd). hasil tabulasi silang antara kerentanan yang dirasakan keluarga (perceived susceptibility) dan keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd) menunjukkan sebagian besar keluarga memiliki keputusan yang mantap untuk berobat ke puskesmas jika terdapat anggota keluarga yang menderita demam berdarah dengue (dbd) berada pada tingkat kerentanan yang sedang yaitu sebesar (65,5%). sementara, keluarga yang tidak memiliki kemantapan untuk berobat ke puskesmas sebagian besar berada pada kerentanan yang sedang yaitu sebesar (47,2%). tabulasi silang antara keseriusan yang dirasakan keluarga (perceived seriousness) dan keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd) dapat diketahui bahwa sebagian besar keluarga memiliki keputusan yang mantap untuk berobat ke puskesmas jika terdapat anggota keluarga yang menderita demam berdarah dengue (dbd) berada pada tingkat keseriusan yang rendah yaitu sebesar (41,4%). sebaliknya, keluarga yang tidak memiliki kemantapan untuk berobat ke puskesmas jika terdapat anggota keluarga yang menderita demam berdarah dengue (dbd) karena keluarga menganggap berobat ke puskesmas adalah keputusan yang kurang tepat, sebagian besar pada tingkat keseriusan yang tinggi yaitu sebesar (55,5%). pembahasan kerentanan yang dirasakan keluarga (perceived susceptibility) meliputi riwayat kesehatan anggota keluarga, kebersihan lingkungan tempat tinggal keluarga, dan kebiasaan yang dilakukan anggota keluarga di dalam rumah. menurut notoatmodjo (2007), kerentanan yang dirasakan keluarga (perceived susceptibility) adalah suatu tindakan pencegahan terhadap suatu penyakit akan timbul bila seseorang telah merasakan bahwa seseorang mengetahui keluarganya rentan terhadap penyakit tersebut. kerentanan yang dialami timbul dari pendapat subyektif yang merupakan kunci dari dilakukannya atau dihindarinya suatu tindakan kesehatan. dalam hal ini, keluarga baru akan melakukan suatu tindakan untuk menyembuhkan penyakit jika keluarga merasa terancam oleh penyakit tersebut. dalam hal ini, keluarga dikatakan memiliki kerentanan yang tinggi jika keluarga memiliki pola hidup yang tidak sehat terkait dengan pemeliharan kesehatan keluarga yang tidak optimal serta keluarga kurang memahami cara hidup yang sehat untuk mencegah terjadinya penyakit demam berdarah degue (dbd). sebaliknya, jika keluarga memahami cara hidup sehat untuk pemeliharaan kesehatan anggota keluarga maka keluarga dikatakan memiliki kerentanan yang rendah. dalam penelitian ini sebagian besar responden (55%) mengalami kerentanan yang sedang terhadap penyakit demam berdarah dengue (dbd) karena sebagian besar keluarga telah mendapakan informasi mengenai penyakit demam berdarah dengue (dbd) dan penanganannya melalui media massa, seperti televisi, radio, surat kabar, majalah, internet. jurnal ners vol.4 no.1 april 2009: 68-78 73 hasil penelitian diperoleh sebagian besar responden (75%) berpendidikan menengah ke atas dan lebih dari setengah responden (61,5%) mendapatkan informasi tentang penyakit demam berdarah dengue (dbd) dan penanganannya. semakin tinggi tingkat pendidikan seseorang maka semakin mudah orang tersebut menerima informasi, baik dari orang lain maupun dari media massa. notoatmodjo (2007) menyatakan bahwa tingkat pendidikan mempunyai efek tidak langsung pada perilaku yang berpengaruh pada pengertian dari kerentanan yang dirasakan, keseriusan yang dirasakan, serta manfaat dan penghalang dalam pengambilan tindakan pencegahan dan pengobatan terhadap penyakit. terdapat beberapa faktor lain yang dapat mempengaruhi kecemasan terhadap kerentanan yang dirasakan oleh keluarga, antara lain: perbedaan demografi (usia, jenis kelamin, pendidikan, pekerjaan, tingkat ekonomi, kelompok etnis, dan agama), pengetahuan, pengalaman, sumber informasi, dan latar belakang yang lain. menurut who yang dikutip oleh notoatmodjo (2003), pengetahuan dapat diperoleh dari pengalaman sendiri atau orang lain. sampel dalam penelitian ini adalah keluarga dengan penderita demam berdarah dengue (dbd) sebagai pengambil keputusan dengan rentang usia 25-65 tahun. semakin bertambah dewasa usia seseorang akan mempengaruhi tindakan orang tersebut dalam pengambilan keputusan untuk memelihara dan meningkatkan kesehatan anggota keluarganya. sebagian responden berada pada rentang usia 25-34 tahun. hal ini merupakan salah satu faktor yang menyebabkan kerentanan sebagian keluarga tinggi karena pengalaman maupun informasi yang dimiliki anggota keluarga sebagai pengambil keputusan di dalam keluarga terkait dengan bahaya penyakit dan penanganan dini penderita demam berdarah dengue (dbd) belum optimal. kerentanan terhadap suatu penyakit akan mempengaruhi seseorang untuk bertindak mengobati dan mencegah penyakitnya. salah satu dasar pengambilan keputusan adalah pengalaman karena pengalaman seseorang dapat memperkirakan keadaan sesuatu, dapat memperhitungkan untung rugi, baik buruknya keputusan yang akan diambil (hasan, 2004). umumnya, seseorang menggunakan pengetahuan, pertimbangan, dan pengalamannya untuk memutuskan alternatif yang dianggap lebih menguntungkan dan yang paling kecil kerugiannya dari masing-masing alternatif yang tersedia. identifikasi keseriusan yang dirasakan keluarga (perceiveed seriousness) dari 65 keluarga yang menjadi responden, diperoleh hasi penelitian yang menunjukkan bahwa (22%) responden mengalami keseriusan yang rendah, (32%) responden mengalami keseriusan yang sedang, dan (46%) responden mengalami keseriusan yang tinggi terhadap kegawatan akibat penyakit demam berdarah dengue (dbd) apabila penderita tidak segera mendapatkan penanganan. keseriusan yang dirasakan keluarga (perceived seriousness) tersebut meliputi pemahaman keluarga tentang penyakit demam berdarah dengue (dbd), kegawatan penyakit demam berdarah dengue (dbd), dan kecemasan akan kondisi anggota keluarga yang menderita demam berdarah dengue (dbd). notoatmodjo (2002) menyatakan bahwa keseriusan yang dirasakan (perceived seriousness) keluarga merupakan tindakan individu untuk mencari pertolongan pengobatan atau pencegahan penyakit akan didorong oleh keseriusan penyakit tersebut terhadap individu atau masyarakat. dalam penelitian ini sebagian besar responden (92%) beragama islam. menurut notoatmodjo (2005), beberapa anggota masyarakat dikalangan kelompok yang beragama islam percaya bahwa anak adalah titipan tuhan, dan sakit atau mati itu adalah takdir, sehingga masyarakat kurang berusaha untuk segera mencari pertolongan pengobatan bagi anak atau anggota keluarga yang sakit. hasil penelitian menunjukkan dari 65 responden di kelurahan tembok dukuh kecamatan bubutan, surabaya sebagian kecil dari jumlah keluarga yang menjadi responden (21,5%) memiliki keputusan yang mantap untuk berobat ke puskesmas jika terdapat anggota keluarga yang menderita demam berdarah dengue (dbd) berada pada tingkat keseriusan yang rendah (41,4%). sebaliknya, hampir setengah dari jumlah responden (46,2%) berada pada tingkat keseriusan yang tinggi (55,5%) memiliki keputusan yang tidak mantap untuk berobat ke puskesmas karena keluarga menganggap bahwa puskesmas tidak dapat memberikan penanganan dengan cepat implementasi health belief model (purwaningsih) 74 dan tepat. notoatmodjo (2002) menyatakan bahwa keseriusan yang dirasakan keluarga berasal dari banyaknya gejala, kecemasan, dan kesulitan yang dihadapi keluarga apabila anggota keluarga yang sakit tidak mendapatkan pemeliharaan dan perawatan yang baik dan tepat. dalam hal ini, keluarga beranggapan bahwa jika penyakit yang diderita anggota keluarga dirasa cukup serius atau dianggap gawat oleh keluarga maka keluarga lebih memutuskan berobat ke dokter praktik karena penanganannya lebih cepat. sebaliknya, jika penyakit yang diderita keluarga dirasa tidak serius oleh keluarga maka keluarga memutuskan berobat ke puskesmas sebab tidak membutuhkan penanganan secara serius. hal tersebut mempengaruhi keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini penderita demam berdarah dengue (dbd). dalam penelitian ini sebagian besar responden (67,7%) terdorong untuk melakukan kunjungan ke puskesmas atau sarana kesehatan yang lain dalam penanganan dini penderita demam berdarah dengue (dbd) karena gejala dan tingkat keparahan penyakit demam berdarah yang tampak pada penderita. sesuai dengan pendapat sarwono (2004) yang menyatakan bahwa keseriusan merupakan resiko kesulitan yang akan dirasakan individu terhadap suatu penyakit. semakin besar resiko suatu penyakit dan semakin besar kemungkinannya bahwa individu dapat terserang penyakit, semakin besar pula keseriusan yang dirasakan individu. individu akan mengambil tindakan pencegahan apabila mereka percaya bahwa penyakit tersebut berpontensi menimbulkan dampak yang serius. identifikasi manfaat yang dirasakan keluarga (perceived benefits) dari hasil penelitian menunjukkan bahwa dari 65 responden, diperoleh data (62%) responden merasakan manfaat, dan (38%) responden tidak merasakan manfaat ketika keluarga melakukan kunjungan ke puskesmas dalam penanganan dini anggota keluarga yang menderita demam berdarah dengue (dbd). menurut notoatmodjo (2007), semakin besar manfaat yang diperoleh akan memperkuat individu untuk mengambil keputusan melakukan tindakan tersebut, yaitu memilih berobat ke puskesmas walaupun harus disertai dengan rintangan yang dialami. manfaat yang dirasakan keluarga beragam dan merupakan persepsi individu mengenai manfaat yang diperoleh apabila melakukan tindakan tertentu yang berkaitan dengan kesehatan. menurut rosenstock dalam sarwono (2004), manfaat tersebut dapat berupa berkurangnya ancaman dan tingkat bahaya. sedangkan menurut notoatmodjo (2002), individu akan melakukan tindakan tertentu apabila individu merasa dirinya rentan terhadap penyakit yang dianggap serius dan dapat membahayakan diri sendiri dan orangorang disekitar. tindakan tersebut tergantung pada manfaat yang dirasakan dan rintangan yang ditemukan dalam mengambil tindakan tersebut. pada umumnya, besarnya manfaat tindakan akan lebih menentukan daripada rintangan yang mungkin dtemukan dalam melakukan tindakan tersebut. semakin besar manfaat yang akan diperoleh akan memperkuat individu untuk mengambil keputusan dalam melakukan tindakan tersebut, walaupun harus disertai dengan rintangan yang mungkin akan dialami. berdasarkan hasil penelitian, manfaat yang dirasakan keluarga (perceived benefits) dari (62%) responden, sebesar (52,5%) responden adalah mendapatkan penanganan dengan cepat saat melakukan kunjungan ke puskesmas jika salah satu anggota keluarga dicurigai menderita demam berdarah dengue (dbd). manfaat lain yang dirasakan keluarga saat melakukan kunjungan ke puskesmas adalah penderita dapat terhindar dari kegawatan akibat penyakit demam berdarah dengue (dbd), dan penderita juga terhindar dari kematian akibat keterlambatan penanganan. identifikasi rintangan yang dialami keluarga (perceived barriers) dari hasil penelitian menunjukkan bahwa dari 65 responden, diperoleh data (74%) responden mengalami rintangan, dan (26%) responden tidak mengalami rintangan ketika akan melakukan kunjungan ke puskesmas dalam penanganan dini anggota keluarga yang menderita demam berdarah dengue (dbd). rintangan yang dialami keluarga (perceived barriers) tersebut meliputi keterjangkauan fisik, pengorbanan tenaga, dan pengorbanan waktu. maggie davies dan wendy macdowall (2006) menyatakan bahwa individu akan melakukan suatu tindakan pencegahan dan pemeliharaan kesehatan apabila dalam diri jurnal ners vol.4 no.1 april 2009: 68-78 75 individu terdapat keyakinan bahwa manfaat yang akan diperoleh dari suatu tindakan jauh lebih besar apabila dibandingkan dengan rintangan yang mungkin dialami ketika memutuskan untuk melakukan tindakan tersebut. pendapat yang serupa juga dikemukakan oleh notoatmodjo (2007) yang menyatakan bahwa pada umumnya manfat dari tindakan lebih menentukan bila dibandingkan dengan rintangan atau kesulitan yang mungkin dialami dalam melakukan tindakan yang berkaitan dengan kesehatan. namun, terkait dengan hasil penelitian, pada umumnya keluarga lebih memperhatikan hal-hal yang menjadi rintangan ketika akan berobat ke puskesmas karena rintangan tersebut menjadi hambatan atau kendala bagi keluarga untuk segera mendapatkan pertolongan atau penanganan anggota keluarga yang menderita demam berdarah dengue (dbd). berdasarkan hasil penelitian, rintangan yang dialami keluarga (perceived barriers) dari (74%) responden sebesar (58,3%) responden adalah jarak rumah ke puskesmas yang cukup jauh sehingga keluarga lebih memilih berkunjung ke sarana kesehatan yang lain, dan beberapa responden juga memperhatikan pertimbangan-pertimbangan yang lain ketika memutuskan untuk berobat ke puskesmas. rintangan lain yang dialami keluarga saat melakukan kunjungan ke puskesmas adalah pelayanan petugas puskesmas yang kurang memuaskan, tidak ada transportasi atau kendaraan untuk menuju ke puskesmas. namun, responden tidak menganggap biaya pengobatan di puskesmas sebagai rintangan karena pada umumnya biaya pengobatan di puskesmas cukup terjangkau bagi masyarakat. identifikasi faktor pendorong (cues to action) bagi keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini penderita demam berdarah dengue (dbd), diperoleh data bahwa semua responden (100%) memiliki faktor pendorong untuk melakukan kunjungan ke puskesmas maupun sarana kesehatan yang lain dalam penanganan dini penderita demam berdarah dengue (dbd). faktor pendorong keluarga untuk bertindak (cues to action) tersebut meliputi media informasi tentang penanganan dini penyakit demam berdarah dengue (dbd). informasi mengenai penanganan dini penderita demam berdarah dengue (dbd) dapat diperoleh dari berbagai sumber, diantaranya adalah melalui media massa, seperti televisi, radio, surat kabar, majalah, internet, dan dapat pula diperoleh dari penjelasan atau penyuluhan petugas puskesmas, dan informasi yang diberikan oleh teman atau para tetangga yang mempunyai pengalaman terkait dengan peyakit demam berdarah dengue (dbd). selain media cetak maupun media elektronik, petugas kesehatan dan kader posyandu (pkk) juga memegang peranan penting dalam menyampaikan informasi kesehatan kepada masyarakat. gambaran tersebut sesuai dengan hasil penelitian yang menunjukkan bahwa (61,5%) responden memperoleh informasi mengenai penyakit demam berdarah dengue (dbd) dan penanganannya melalui media massa, seperti televisi, radio, surat kabar, majalah, internet dan (16,9%) informasi diperoleh responden dari penjelasan atau penyuluhan petugas puskesmas. petugas kesehatan mempunyai peranan yang cukup besar dalam menyampaikan informasi tentang memelihara dan meningkatkan kesehatan keluarga. namun, sampai saat ini peran petugas puskesmas tersebut kurang optimal. keterjangkauan informasi tersebut terkait dengan pengambilan keputusan atau tindakan yang tepat. ahmadi (2002) menyatakan bahwa individu akan melakukan suatu tindakan apabila telah memperoleh informasi yang lengkap. dalam hal ini, keluarga akan melakukan kunjungan ke puskesmas dalam penanganan dini penderita demam berdarah dengue (dbd) apabila keluarga tersebut memperoleh penjelasan yang lengkap tentang bahaya penyakit demam berdarah dengue (dbd) beserta penanganannya dari petugas puskesmas. berdasarkan hasil penelitian, (67,7%) responden terdorong untuk melakukan kunjungan ke puskesmas maupun sarana kesehatan yang lain dalam penanganan dini penderita demam berdarah dengue (dbd) karena gejala dan tingkat keparahan penyakit demam berdarah, (23,1%) responden terdorong karena penjelasan dari petugas puskesmas, dan (9,2%) responden terdorong untuk melakukan kunjungan ke puskesmas dalam penanganan dini penderita demam berdarah dengue (dbd) karena informasi dari keluarga. faktor pendorong merupakan faktor eksternal keluarga yang berasal dari luar individu dan berguna untuk mendapatkan tingkat implementasi health belief model (purwaningsih) 76 penerimaan yang benar mengenai kerentanan, kegawatan, dan keuntungan suatu perilaku (notoatmodjo, 2002). gejala dan tingkat keparahan penyakit demam berdarah dengue (dbd) merupakan salah satu bentuk kecemasan akan keseriusan penyakit yang dirasakan keluarga yang akan mepengaruhi pengambilan keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd). hasil penelitian menunjukkan bahwa sebesar (51%) responden yang melakukan kunjungan ke puskesmas jika ada anggota keluarga yang dicurigai menderita demam berdarah dengue (dbd) atas inisiatif keluarga sendiri, (32%) responden atas saran dari tetangga disekitar rumah, dan (17%) responden atas saran dari kader posyandu atau kader pkk. hal ini sesuai dengan penjelasan notoatmodjo (2003), bahwa keluarga merupakan bagian terpenting yang akan mempengaruhi pengambilan keputusan keluarga dalam pemeliharaan kesehatan anggota keluarga. hasil penelitian menunjukkan bahwa sebagian besar responden (75%) membicarakan terlebih dahulu dengan anggota keluarga yang lain tentang keputusan keluarga berobat ke puskesmas. sisanya, (25%) responden tidak membicarakannya terlebih dahulu. sementara jawaban dari pertanyaan terbuka tentang topik yang dibicarakan keluarga, diantaranya: “kami sebelumnya selalu membicarakan terkait dengan penanganan yang dilakukan oleh puskesmas untuk segera mengetahui penyakit yang diderita anggota keluarga agar dapat segera disembuhkan” (15 responden). “saya berbicara tentang kemungkinan mendapatkan surat rujukan dengan cepat jika anggota keluarga yang sakit dicurigai mengalami kegawatan” (6 responden). “saya berbicara terlebih dahulu kepada keluarga (suami atau istri) perihal keberadaan dokter yang bertugas saat itu karena biasanya tidak langsung ditangani oleh dokter yang bertugas dan juga tentang obatobatan yang nanti diterima dari puskesmas. selain itu, kami juga memperhitungkan jarak puskesmas dengan rumah kami” (17 responden). “yang dibicarakan adalah mempertimbangkan biaya yang dikeluarkan untuk berobat ke puskesmas sebab biayanya cukup terjangkau” (4 responden). “kami membicarakan perihal pelayanan petugas puskesmas apakah dapat memberikan pelayanan secara maksimal kepada masyarakat yang berobat ke puskesmas tersebut” (7 responden). sebagaimana yang diungkapkan gitosudarmo dan sudita (2000), salah satu unsur dalam pengambilan keputusan adalah sarana atau alat untuk mengevaluasi atau mengukur hasil dari suatu pengambilan keputusan, pengambil keputusan harus menentukan nilai dan manfaat dari hasil yang kemungkinan dicapai. hal ini juga berlaku dalam pengambilan keputusan untuk melakukan kunjungan ke puskesmas jika ada anggota keluarga yang dicurigai menderita demam berdarah dengue (dbd), pendapat keluarga tentang keuntungan dan kerugian berobat ke puskesmas dapat mempengaruhi proses pengambilan keputusan tersebut. hasil penelitian menunjukkan bahwa sebagian besar responden (85%) memiliki keinginan untuk berobat ke tempat pelayanan kesehatan yang lain selain di puskesmas, (15%) responden sisanya tidak. menurut hasan (2004), dasar-dasar pengambilan keputusan, diantaranya meliputi intuisi, pengalaman, fakta, wewenang, dan rasional. pada umumnya, keluarga dalam pengambilan keputusan berdasarkan pengalaman karena dari pengalaman seseorang dapat memperkirakan keadaan sesuatu, dapat memperhitungkan untung rugi, baik buruknya keputusan yang akan diambil. berdasarkan penelitian menunjukkan bahwa sebagian besar responden (85%) dari 65 keluarga yang menjadi responden memiliki keinginan untuk berobat ke tempat pelayanan kesehatan yang lain, (76,4%) responden berobat ke dokter praktik dan (23,6%) responden berobat ke rumah sakit. sementara jawaban dari pertanyaan terbuka tentang alasan keluarga memilih pelayanan kesehatan tersebut untuk berobat terutama dalam penanganan dini penderita demam berdarah dengue (dbd), diantaranya: ”karena lebih dekat dari rumah dan sudah cocok dengan dokternya” (20 responden). ”karena keluarga saya sudah mendapatkan fasilitas di rumah sakit tersebut sebagai rekomendasi dari suami saya bekerja” (13 responden). ”karena penanganannya lebih tepat dan cepat” (7 responden). “karena sudah terbiasa berobat disana meskipun lebih mahal jurnal ners vol.4 no.1 april 2009: 68-78 77 dari puskesmas yang penting ditangani oleh dokternya langsung” (15 responden). pengambilan keputusan diawali dengan dirasanya masalah tertentu yang memerlukan pemecahan. terhadap suatu masalah yang timbul pada umumnya dapat dilakukan berbagai cara pemecahan. setiap pemecahan mengandung kelebihan dan kelemahan tertentu. untuk dapat membuat keputusan yang paling menguntungkan atau keputusan yang rasional perlu dikembangkan semua alternatif yang melekat pada masalah pengambilan keputusan (pangewa, 2004). dengan adanya masukan atau saran dari keluarga maupun dari petugas kesehatan mengenai penanganan dini penderita demam berdarah dengue (dbd) yang sesuai dengan harapan kesehatan keluarga, diharapkan keluarga mampu mengambil keputusan yang tepat ketika memutuskan untuk berobat ke tempat pelayanan kesehatan yang dipih keluarga. identifikasi keputusan keluarga untuk melakukan kunjungan ke puskesmas dalam penanganan dini demam berdarah dengue (dbd), dari hasil penelitian menunjukkan bahwa dari 65 responden, diperoleh data (45%) responden memutuskan untuk berobat ke puskesmas jika ada anggota keluarga yang dicurigai menderita demam berdarah dengue (dbd). sisanya, (55%) responden tidak mantap untuk berobat ke puskesmas karena keluarga menganggap berobat ke puskesmas adalah keputusan yang kurang tepat. sementara jawaban dari pertanyaan terbuka tentang alasan keluarga memutuskan untuk berobat ke puskesmas terutama dalam penanganan dini penderita demam berdarah dengue (dbd), diantaranya: “karena pelayanannya di puskesmas sudah cukup baik, selain itu biaya juga cukup terjangkau bagi masyarakat” (12 responden). “karena pertolongan di puskesmas sudah agak cepat dan di puskesmas juga ada penyuluhan yang dapat menambah pengetahuan” (3 responden). “karena saya percaya bahwa puskesmas dapat menjadi tempat pertolongan pertama untuk segara mengetahui penyakitnya” (1 responden). “karena biaya sangat murah dan dapat dijangkau” (6 responden). “karena rumah saya lebih dekat dengan puskesmas dan biayanya juga murah” (4 responden). “karena pelayanan puskesmas sudah cukup baik dan dapat terjangkau dalam hal biaya, selain itu dekat dengan rumah” (1 responden). “karena rumah saya lebih dekat dengan puskesmas dan saya rasa pelayanan di puskesmas sudah cukup baik tidak kalah dengan dokter praktik swasta” (2 responden). sebagaimana yang diungkapkan gitosudarmo dan sudita (2000), nilai-nilai individu pengambil keputusan terkait dengan salah satu fungsi puskesmas, yaitu memberikan pelayanan kesehatan secara menyeluruh dan terpadu kepada masyarakat merupakan keyakinan dasar yang digunakan seseorang jika dihadapkan pada permasalahan dan harus mengambil suatu keputusan. hal ini juga berlaku dalam pengambilan keputusan keluarga untuk melakukan kunjungan ke puskesmas jika ada anggota keluarga yang dicurigai menderita demam berdarah dengue (dbd), diharapkan keluarga mampu memgambil keputusan yang tepat ketika memutuskan untuk berobat ke puskesmas. penerapan health belief model yang meliputi kerentanan, keseriusan, manfaat, rintangan, dan faktor pendorong sangat diperlukan bagi keluarga untuk menangani masalah kesehatan yang dialami oleh anggota keluarga seperti penyakit demam berdarah dengue (dbd), agar tidak terjadi kegawatan akibat keterlambatan penanganan penyakit demam berdarah dengue (dbd) dan untuk mempercepat proses penyembuhan penderita agat terhindar dari bahaya kematian. salah satu upaya yang dapat dilakukan yaitu dengan deteksi dini penyakit demam berdarah dengue (dbd) sehingga kegawatan dapat dicegah. keputusan keluarga untuk melakukan kunjungan ke puskesmas dapat mengetahui penyakit yang diderita anggota keluarga lebih cepat, sehingga apabila ditemukan tanda-tanda kegawatan, maka penderita segera mendapatkan penanganan yang tepat sejak dini. simpulan dan saran simpulan sebagian besar keluarga jarang memutuskan untuk membawa anggota keluarga yang mengalami gejala dhf ke puskesmas secara dini, dibuktikan dengan sebagian besar keluarga memilih pelayanan kesehatan lain. implementasi health belief model (purwaningsih) 78 saran hendaknya keluarga di kelurahan tembok dukuh surabaya khususnya di rw iii, rw vii dan rw x mendapatkan penyuluhan rutin dengan cara mengundang tim puskesmas tembok dukuh dalam kegiatan arisan rutin pkk setiap satu bulan sekali. puskesmas tembok dukuh surabaya hendaknya mensosialisasikan penanganan pada penderita dbd yaitu dengan memberikan surat rujukan secara cepat ke rumah sakit bila penderita sudah menunjukkan tanda dan gejala kegawatan sehingga keluarga dapat lebih merasakan manfaat ketika berobat ke puskesmas tembok dukuh. petugas puskesmas tembok dukuh surabaya harus memberikan informasi dan pelatihan kepada ibu pemantau jentik (bumantik) tentang pencegahan dan penanganan dini penderita dbd sehingga dapat memberikan pemahaman yang diperlukan. dinas kesehatan harus memberikan fasilitas media, seperti poster dan leaflet untuk menunjang keberhasilan pendidikan kesehatan sehingga diharapakan dapat memberikan pemahaman lebih bagi keluarga mengenai bahaya penyakit dbd. kepustakaan davies, m dan wendy macdowall, 2004. health promotion theory. new york: london school of hygiene medicine, hlm. 173-175 depkes ri., 2005. kajian masalah kesehatan demam berdarah dengue. jakarta: badan litbang dan pegembangan kesehatan dinas kesehatan kota surabaya, 2008. profil kesehatan kota surabaya. surabaya: dkk dinas kesehatan kota surabaya, 2008. program pokok puskesmas. surabaya: dkk dinas kesehatan kota surabaya, 2008. sosialisasikan penanggulangan demam berdarah dengue (dbd) yang paling efektif, (online), (http://www.surabaya-ehealth.org/eteam/berita/dinkes-kota-surabayagalakkan-lagi-kelompok-kerjaoperasional-dbd. diakses tanggal 13 juni 2009. jam 13.51 wib). gitosudarmo, i dan sudita, n.i., 2000. perilaku keorganisasian. edisi pertama. yogyakarta: bpfe, hlm.163165 hasan, m.i., 2004. pokok-pokok materi: teori pengambilan keputusan. bogor: ghalia indonesia, hlm. 9-12 nadesul, h., 2007. cara mudah mengalahkan demam berdarah. jakarta: pt kompas media nusantara, hlm. 9-12 notoatmodjo, s., 2007. promosi kesehatan dan ilmu perilaku. jakarta: pt. rineka cipta, hlm. 205-207, 213-215 notoatmodjo, s., 2005. promosi kesehatan teori dan aplikasi. cetakan pertama. jakarta: rineka cipta, hlm. 167, 169 notoatmodjo, s., 2003. ilmu kesehatan masyarakat (prinsip-prinsip dasar). cetakan kedua. jakarta: rineka cipta, hlm. 87-89 notoatmodjo, s., 2003. pendidikan dan perilaku kesehatan. jakarta: rineka cipta, hlm. 73-75 notoatmodjo, s., 2002. metodologi penelitian kesehatan. jakarta: pt. rineka cipta, hlm. 138-139 pangewa, m., 2004. perilaku keorganisasian. jakarta: depdiknas, hlm. 159 sarwono, s., 2004. sosiologi kesehatan. yogyakarta: gajah mada university press, hlm. 66-68 susilo, j., 2008. pembuatan sistem informasi puskesmas di kecamatan ‘xxx’ berbasis web dengan php dan mysql, (online), (http://www.bandung.go.id/images/rag aminfo/puskesmas.pdf. diakses tanggal 12 mei 2009. jam 19.00 wib) who, 2004. panduan lengkap pencegahan dan pengendalian dengue dan demam berdarah dengue. jakarta: egc, hlm. 13, 20 who, 2000. panduan lengkap pencegahan dan pengendalian dengue dan demam berdarah dengue. jakarta: egc, hlm. 8-10 http://www.surabaya-ehealth.org/e-team/berita/dinkes-kota-surabaya-galakkan-lagi-kelompok-kerja-operasional-dbd.%20diakses%20tanggal%2013%20juni%202009 http://www.surabaya-ehealth.org/e-team/berita/dinkes-kota-surabaya-galakkan-lagi-kelompok-kerja-operasional-dbd.%20diakses%20tanggal%2013%20juni%202009 http://www.surabaya-ehealth.org/e-team/berita/dinkes-kota-surabaya-galakkan-lagi-kelompok-kerja-operasional-dbd.%20diakses%20tanggal%2013%20juni%202009 http://www.surabaya-ehealth.org/e-team/berita/dinkes-kota-surabaya-galakkan-lagi-kelompok-kerja-operasional-dbd.%20diakses%20tanggal%2013%20juni%202009 http://www.surabaya-ehealth.org/e-team/berita/dinkes-kota-surabaya-galakkan-lagi-kelompok-kerja-operasional-dbd.%20diakses%20tanggal%2013%20juni%202009 http://www.bandung.go.id/images/ragaminfo/puskesmas.pdf http://www.bandung.go.id/images/ragaminfo/puskesmas.pdf http://e-journal.unair.ac.id/jners | 9 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.5613 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research self-care training improves the attitudes and skills of caregivers for children with physical disability warti ningsih1, purwanta purwanta2 and sri hartini2 1 master of nursing student, medical faculty, gadjah mada university, sleman, indonesia 2 department of nursing, medical faculty, gadjah mada university, sleman, indonesia abstract introduction: the physical condition of a child with physical disabilities makes them dependent on others. carers are the closest to children with physical disability and must have the ability to assist and teach children to do self-care activities. this study was aimed to determine the effect of self-care training on the knowledge, attitudes and skills of caregivers about the care of children with physical disability. methods: the experiment was pre-experimental with one group pre-test-post-test design. the study was conducted on 23 caregivers who experienced caring of children with physical disability. the research instruments are knowledge and attitude of self care on children with physical disability questionnaire and observation sheet of self care on children with physical disability, which have tested the validity and reliability to measure knowledge and attitude. skill observation uses a check list with the validity test of expert opinion. training on self-care using lecture, audiovisual, practice and discussion methods was conducted in two sessions on different days with 120 minutes per session. data analysis used paired sample t-test with significance level <0.05. results: self-care training significantly influenced caregivers’ attitude (p = 0.038) and skill (p = 0.002), but training has no effect on caregivers’ knowledge (p = 0.225). conclusion: self-care training improved attitudes and skills of caregivers for children with physical disability, but did not affect caregivers’ knowledge. article history received: aug 23, 2017 accepted: april 30, 2018 keywords self-care training; caregiver; children with physical disability; knowledge; attitude; skill contact warti ningsih  warti_ns@yahoo.com  medical faculty, gadjah mada university, sleman, indonesia cite this as: ningsih, w., purwanta, p., & hartini, s. (2018). self-care training improves the attitudes and skills of caregivers for children with physical disability. jurnal ners, 13(1), 9-17. doi:http://dx.doi.org/10.20473/jn.v13i1.5613 introduction according to who, disability is a limitation or inability to perform an activity in a way that is within the range considered normal for humans, largely due to decreased ability (barbotte and chau, 2011). globally, who estimates the number of children with disabilities as about 7-10% of the total child population. according to 2007 national statistics agency data, there are 8.3 million children with disabilities among a child population of nearly 83 million in indonesia, or about 10%. based on social protection program data collection (pendataan program perlindungan sosial/ppls), in 2011 there were 130,572 children with disabilities from poor families, including physically disabled children (32,990 children); children with hearing impairment, speech disorder and physically disabled (4,242 children); and children with hearing impairment, speech disorder, blind, and physically disabled (2,991 children). the data are spread across indonesia with the highest proportion in central java, east java, and west java (riskesdas, 2013). infants and children with physical disabilities such as cerebral palsy always show difficulty in performing daily activities. this is related to their difficulty to move and positioning their body similar to the limitations in other neurological damage (chung, et al., 2008). difficulties often faced by children in routine activities include bathing, morning activities (using cutlery at breakfast, wearing clothes and school supplies, or leaving for school on their own), afternoon activities (changing clothes and doing school work), meal time, play, leaving the house, gathering with family, physical activity and recreation (kling, et al, 2010). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:warti_ns@yahoo.com http://dx.doi.org/10.20473/jn.v13i1.5613 w. ningsih et al. 10 | pissn: 1858-3598  eissn: 2502-5791 schools for children with physical disabilities (ypac) in surakarta are classified into two divisions, that is the slb d for physically disabled children and slb d-1 for the physically and mentally disabled children. the mental condition of children was determined by a team of psychologists who had worked with ypac. the divisions were made because the ability to learn in children with mental disabilities is different from those who only experience physical disabilities. according to interview data conducted on 12 parents, parents did not know how to teach their children to take care of themselves and had never attended training about it. they said they only found out about it from friends, relatives, therapists and by reading. parents also said children needed more help in eating, dressing, bathing, toileting and they couldn’t bear to see their child’s condition. so, even though they felt tired, they tried to enjoy it. based on observation, there were five children who had uncleaned teeth, five children had dirty hair, four children were sweaty, not tidy and had body odor among 10 children with physical disability. education is a combination of learning experiences designed to help individuals and communities in improving their health through increased knowledge or influencing their attitudes and behaviors (who, 2015). in heubner and milgrom's (2014) study, which was conducted by providing parental training consisting of the provision of materials related to the importance of toothbrushes, practices and discussions for 90 minutes, there were significant changes before and after intervention in the self-confidence, attitude and self-efficacy of parents. this study also showed that the training of parents improved their caring ability, which would be good for the children. this study was aimed to determine the effect of self-care training on the knowledge, attitudes and skills of caregivers about the care of children with physical disability. materials and methods the research was held at the foundation of ypac surakarta. it was chosen because ypac surakarta is the only foundation that runs an exceptional school for physical disabilities (slb d) where parents have little knowledge about child self-care with physical disability and no training on self-care. the study was held from march to april 2017 and consisted of pretest from 13 until 26 march, 2017, intervention from 29 until 30 march, 2017, and post-test from 17 until 30 april, 2017. the population in this research is 26 parents with physically disabled children without mental disorder, limited to children with moderate and light physical disability. the sample is caregivers who attend full sessions, including pre-test, intervention and posttest. criteria selection of disability level was based on the classification of social service provisions. the sampling technique in this research was determined by total sampling technique. the study was a preexperimental with a one group pre-test-post-test design without control group. the sample is 23 caregivers. there are three caregivers who were excluded from this study because they refused to be respondents, could not attend the intervention session or the intervention sessions were attended by two different caregivers for the same child on different days. research interventions are self-care training for caregivers with physically disabled children by providing materials, videos, demonstration and discussion. the pre-test was conducted within two weeks, followed by two sessions of intervention which consisted of 120 minutes per session on different days. the questionnaire was given directly after a full session of intervention. the material given in the first session of intervention was about self-grooming, dressing and eating and, in the second session of intervention, for bathing and toileting. for effectiveness, respondents were divided into two groups consisted of 13 and 11 caregivers based on the agreement of the time chosen by the respondents. material was provided by a certified trainer as a speaker and a perception equation was held beforehand between speaker and researcher. the training was conducted for two sessions with 120 minutes per session. the session consisted of 30 minutes of material provision by the trainer, 15 minutes video presentation, 45 minutes independent practice and 30 minutes discussion. the data collection was assisted by research assistants. interclass correlation coefficient was used as inter-rater reliability of 12 observers. the average agreement between raters is 0.998, which means a very good accuracy on assessment object, and the consistency of a rater is 0.972, which means that the rater is very consistent in the assessment of the assessed object. the data collection instrument is knowledge and attitude of self care on children with physical disability questionnaire, which has been tested for validity and reliability. there are 18 questions for the assessment of knowledge and 20 statements for a valid attitude assessment with a reliability value of 0.673 and 0.818, respectively. the skill was assessed by observation sheet of self care on children with physical disability which has been tested for validity by expert opinion, and observation by 12 raters that has been tested for reliability with intraclass correlation coefficients (icc) by observing five similar objects. the statistical test result achieved average agreement inter-rater of 0.998 while for an individual rater the consistency is 0.972. prior to the research, research assistants collected the pre-test data using questionnaire by going to the respondent's house to assess the knowledge and attitudes of how to teach self-care in children. the caregivers’ skills data were collected by observing the skills of how to teach self-care in children with physical disability. two weeks after intervention, jurnal ners http://e-journal.unair.ac.id/jners | 11 post-test data was collected with a home visit by a different research assistant. the effect of self-care training on caregivers’ knowledge, attitudes and skills on self-care was analyzed using mean values between pre-test, posttest and standard deviation. the normality test was held by using shapiro wilk with the result of knowledge and attitude, and skill scores being 0.784, 0.478 and 0.417, respectively. it is concluded from the values that all data are normally distributed because of the significance value >0.05. the data were analyzed using paired sample t test to determine the effect of self-care training on caregivers’ knowledge, attitude and skill with confidence level 95%. results characteristics of respondents consisted of child demographic data and caregiver demographic data, showing that more than half the children were boys (52.17%), aged 11-15 years (56.6%) with average age of 10.18 years with standard deviation 2.07. most of the children were in grade 2 (26.9%) and had moderate disabilities categories with 73.91%. most of the caregivers were female of whom mothers of the children accounted for 78.26% and more than half had senior high school as educational level (56.51%). almost half of the respondents were aged 31-40 (47.83%) with average age 41.4 years and most of them were housewives (69.57%). based on information and participation in training on self-care of children with physical disability, more than half (69.57%) had not received information about children's physical disability care before and 82.61% had never attended self-care training. the description of knowledge, attitude and skill was determined by a cutoff point using normative value that is the mean of pre-test because the data were normally distributed. based on table 2, almost half of the caregivers had good knowledge before training (47.8%) and this increased after training (69.6%). the caregivers’ attitudes increased from 56.5% to 82.6% after training as well as the skills, which increased from 43.5% to 95.7%. the characteristics of caregivers including sex, education level, occupation and relationship with children, had no effect on knowledge, attitude and skill of caregivers after receiving self-care training on children with physical disability (table 3). based on table 4, there are four questions items that had decreased score after the training; the declining scores were on the questions about definition of self-care, bath stages, taught during toileting and toileting tools. there are two item questions that were answered correctly before and after training, which are about equipment for bathing and tools for dressing and dressing. based on table 5, there are 10 item statements that were 100% answered agree after training, namely, the statement about baths must be with running water, using soap on the whole body, introducing shirt front and back, praising the child if possible, using the bathroom for toileting, teaching handwashing with soap after toileting, holding a spoon and trying other ways while eating, providing light cutlery during exercise, and teaching to chew food before swallowing. there are some item statements which did not change after self-care training; the attitude of bathing without using soap, teaching children how to clean after toileting, teaching children to drink with a straw, and providing a special table for children. other attitudes increased after training. almost all of the caregivers’ skills increased after self-care training. the only skill decrease after self-care training was the skill about teaching children how to choose clothes. there are some skills that previously only few caregivers had which all subsequently acquired (100%): the skills of teaching to dry the body after bathing, undressing, cleaning after toileting, exiting the bathroom, washing hands after bowing, mouth, holding and drinking from the cup, and wearing the upper garment. the description of skills performed by the caregivers of children with physical disabilities before and after self-care training is shown in table 6. the effectiveness of the training process based on the respondents’ responses is shown in table 7. the results of the evaluation of the training process showed no respondents who rated very less or less in the training process. the results showed the training time is sufficient (13.1%), mostly judging both in terms of training facilities and training time with 78.3%, and more than half rated very good on training benefits with 60.9%. the effects of self-care training on knowledge, attitudes and skills were analyzed by paired sample t test. based on table 8, the effect of self-care training on the knowledge, attitudes and skills of the caregiver by using paired sample t test showed that the training had an effect on the attitude and skill of the caregiver with respective values of (p 0.038) and (p 0.002) with 95% significance level. the training did not affect the caregivers’ knowledge (p 0.225) although there was a slight increase in mean value with differentiation of 0.826 where t counts showed 1.249 smaller than t table, which means self-care training had no effect on caregivers’ knowledge. discussion the study discussion describes the effect of self-care training on the response of physically disabled children's caregivers in training, knowledge, attitudes and skills. the discussion further reviews the correlation between the assessment’s aspects with respondents’ characteristics and analyzes supporting factors to determine the research intervention’s effectiveness. almost half (47.8%) of caregivers’ knowledge before and after physical disability children’s selfcare training is good, and the knowledge increased in the majority (69.6%) of caregivers after training. the w. ningsih et al. 12 | pissn: 1858-3598  eissn: 2502-5791 caregivers’ knowledge is good because some (30.43%) of them had already obtained information about self-care on physically disabled children from school and other sources. based on research by tristani et al. (2017), 70% of parents have sought to find sources of information about physical activity for children with physical disability through websites using common sources to increase their knowledge. in a unicef study (2014), among 247 mothers, 65% of mothers had completed their primary education and 81% of parents with high school education levels had the knowledge and readiness for education of their children at home increased. this is in accordance with research result which finds that the highest education level of caregivers (56.51%) is senior high school. the older the person's age, the better the mental development process, but, at a certain age, the increase in mental development process is not as fast as in their teens. in addition, a person's memory is affected by age. therefore, the age of a person can affect the acquisition of obtained knowledge, but, at certain ages, the ability to accept or remember will be reduced. the knowledge of 40-yearolds will be different from the current knowledge of 60-year-olds (notoatmodjo, 2007). the increase in the caregivers’ knowledge is less significant because the average age of caregivers is 41.43 years, where 47.83% are aged 31-40 years. the decrease of correct answers to some questions on knowledge was also due to the fact that most caregivers (47.83%) are aged 31-40 years, at which point there is difficulty in the process of remembering. according to aizpurua, et al. (2009), the brain is particularly vulnerable in long-term memory processes as age grows. in this study, posttable 1. distribution of respondents of children and caregivers meeting the research criteria at ypac surakarta march-april 2017 (n= 23) category child caregivers f % mean (sd) f % mean (sd) sex male female 12 11 52.17 47.83 3 20 13.04 86.96 ages 6-10 year 11-15 year 16-20 year 21-30 year 31-40 year 41-50 year >50 year 10 13 43.5 56.5 10.87 (2.07) 1 11 9 2 4.35 47.83 39.13 8.71 41.43 (7.54) class i ii iii iv v vi 5 6 4 3 4 1 21.74 26.09 17.39 13.04 17.39 4.35 disabilities categories moderate mild 17 6 73.91 26.09 level of education primary school junior high school senior high school diploma bachelor 5 1 13 2 2 21.74 4.35 56.51 8.70 8.70 occupational house wife private entrepreneur 16 3 4 69.57 13.04 17.39 relation with children mother father grandmother brother 18 2 2 1 78.26 8.70 8.70 4.34 getting information about self-care already not, yet 7 16 30.43 69.57 have training about self-care ever never 4 19 17.39 82.61 jurnal ners http://e-journal.unair.ac.id/jners | 13 test was conducted two weeks after training and there was no intervention in the form of recall about the materials, but the training equipped caregivers with the module. the questions that the caregivers found difficult to answer were more about theories, such as the definition of self-care and the bath stages and what is taught during toileting. in the choice of answers, they used words that were less familiar and also ambiguous because they related to caregiver habits. information will be easy to remember if using the traits or characteristics typical of the stimulus (bhinetty, 2008). there is no distinctive form of training module, so the parents were less interested to read back on the modules that were being given. before the training, over half (56.5%) of the caregivers already had a positive attitude and this increased after the training. parental awareness in guiding children with physical disability and preparing them to be able to engage in activities independently could form a positive attitude in the parents (dziubanek, et al., 2013). this is evident from the enthusiasm of caregivers in training indicated by their involvement in following the training process. the response of the training process becomes very important to determine the success in transferring a material so that participants are able to understand, determine their attitude, be responsible in applying it and be able to make someone become more creative (campbell, 2010 cited in mcmahon and archer, 2010). caregivers participated in the training because they saw that the training was very useful for their lives, as illustrated by the questionnaire result where the benefits of the training became the best judgment in that more than half of (60.9%) the caregivers responded very good to the benefits of training aspect. in line with fickert and ross, (2012), activities that have direct implications on a person are likely to be the reason to join the education program. this indicates the appeal of training because the respondents felt that the training materials were what they needed in daily life to teach children how to take care of themselves. in line with huebner and milgrom's research results (2014), the benefits of intervention in their lives became the motivation of parents in joining the training program. before training, almost half (43.5%) of the caregivers’ skills were good and, after training, about 95.7% of the caregivers’ skills in teaching self-care to children with physical disability became good. in table 2. distribution of knowledge level description, attitude and skills of caregivers before and after selfcare training (n= 23) variable before after f % f % knowledge good >13.17 less <13.17 11 12 47.8 52.2 16 7 69.6 30.4 attitudes positive >59.57 negative <59.57 13 10 56.5 43.5 19 4 82.6 17.4 skills good >26.74 less <26.74 10 13 43.5 56.5 22 1 95.7 4.3 table 3. analysis of chi square test characteristics of child caregivers with physical disability with knowledge, attitude and skills (n = 23) respondents’ characteristics knowledge attitudes skills good f (%) less f (%) p value positive f (%) negative f (%) p value good f (%) less f (%) p value sex male female 2 (8.7) 14(60.9) 1 (4.3) 6(26.1) 0.907 2 (8.7) 17(73.9) 1 (4.3) 3 (13.1) 0.435 3 (13.1) 19(82.6) 0 (0) 1(4.3) 0.692 level of education under senior high school senior high school bachelor 4 (17.4) 10(43.5) 2 (8.7) 3(13.0) 2 (8.7) 2 (8.7) 0.315 6 (26.1) 10(43.5) 3 (13.1) 1 (4.3) 2 (8.7) 1 (4.3) 0.899 7 (30.4) 12(52.2) 3 (13.1) 0 (0) 0 (0) 1(4.3) 0.083 occupational housewife private entrepreneur 11(47.8) 3 (13.1) 2 (8.7) 5(21.7) 0 (0) 2 (8.7) 0.360 14(60.9) 2 (8.7) 3 (13.1) 2 (8.7) 1 (4.3) 1 (4.3) 0.619 15(65.2) 3 (13.1) 4 (17.4) 1(4.3) 0 (0) 0 (0) 0.796 relationship parents grandmother brother 14(60.9) 1 (4.3) 1 (4.3) 6(26.2) 1 (4.3) 0 (0) 0.470 17 (74) 1 (4.3) 1 (4.3) 3 (13.1) 1 (4.3) 0 (0) 0.413 19(82.7) 2 (8.7) 1 (4.3) 1(4.3) 0 (0) 0 (0) 0.925 w. ningsih et al. 14 | pissn: 1858-3598  eissn: 2502-5791 caring for children, mothers have more ability than the father. the mother's ability to provide support and action on the development of children is better. mothers simply use their experience and cultural values in caring for the child (unicef, 2014). mother dominates in this study and the increase of skill to become good is because most of the respondents are mothers (78.26%). the parenting skills that changed considerably after the training were in the activities of teaching to regulate the temperature of the water, cleaning the closet, putting clothes in the closet, buttoning clothes, zipper closing, wearing socks, wearing shoes and tidying clothes. after training, all self-care activities were taught to children with physical disability. the challenge of physically disabled children in dressing activities is how they manage positions to perform these activities. difficulties that are often experienced include wearing underwear, wearing socks and shoes. the clothes difficult for children with a physical disability to wear are skirts, underwear and uniforms (kabel, et al., 2017). kling, et al. (2010) showed the most difficult routine for children with a physical disability is bathtime. based on information, parents still find difficulty to find a washing tool for the child's hair, table 4. overview of knowledge before and after self-care training in physically disabled child's caregiver (n= 23) question before after right f (%) false f (%) right f (%) false f (%) 1. definition of self-care 2. self-care benefits 3. factors that do not affect self-care 4. factors that affect self-care 5. understanding the bath 6. step by step bathing 7. equipment for bathing 8. noticed in bathing activities 9. dressing activities 10. purpose of makeup and dressing 11. stages of dating 12. tools to practice dressing up and dressing 13. what is taught in defecation/urination 14. tool for toileting 15. purpose of toileting activities 16. purpose of eating 17. what a nanny should not do when the child eats 18. what to consider when eating 19 (82.6) 19 (82.6) 11 (47.8) 11 (47.8) 18 (78.3) 7 (30.4) 23 (100) 20 (86.9) 18 (78.3) 17 (73.9) 14 (60.9) 21 (91.3) 20 (86.9) 19 (82.6) 19 (82.6) 10 (43.5) 15 (65.2) 22 (95.7) 4 (17.4) 4 (17.4) 12 (52.2) 12 (52.2) 5 (21.7) 16 (69.6) 0 (0) 3 (13.1) 5 (21.7) 6 (26.1) 9 (39.1) 2 (8.7) 3 (13.1) 4 (17.4) 4 (17.4) 13 (56.5) 8 (34.8) 1 (4.3) 7 (30.4) 22 (95.7) 18 (78.3) 17 (73.9) 20 (86.9) 5 (21.7) 23 (100) 21 (91.3) 21 (91.3) 20 (86.9) 17 (73.9) 21 (91.3) 18 (78.3) 17 (73.9) 20 (86.9) 17 (73.9) 18 (78.3) 20 (86.9) 16 (69.6) 1 (4.3) 5 (21.7) 6 (26.1) 3 (13.1) 18 (78.3) 0 (0) 2 (8.7) 2 (8.7) 3 (13.1) 6 (26.1) 2 (8.7) 5 (21.7) 6 (26.1) 3 (13.1) 6 (26.1) 5 (21.7) 3 (13.1) table 5. overview of attitude before and after self-care training in a physically disabled child's caregiver (n= 23) attitudes statement before after agree f (%) disagree f (%) agree f (%) disagree f (%) 1. help the child bathe with wipes 2. bathing with water does not use soap 3. dry the body with a towel after bathing 4. bathing with running water 5. using soap in all parts of the body 6. introduce the front and back of the shirt 7. involve children in dress 8. praise the child if you can 9. give opportunity to choose clothes 10. teach finding the way to the bathroom if they want to defecate/urinate 11. teach hand washing with soap after defecation/urination 12. tell others when they want defecation/urination 13. teach your child how to make a bath 14. teach opening and closing clothes during defecation/urination 15. hold the spoon and try other ways to eat 16. provide light cutlery during exercise 17. teach children to drink with a straw 18. cleaning the mouth before the child finishes eating 19. provide special tables and chairs for children 20. teach to chew food before swallowing 3 (13.1) 2 (8.7) 11 (47.8) 22 (95.7) 19 (82.6) 23 (100) 7 (30.4) 19 (82.6) 21 (91.3) 21 (91.3) 20 (86.9) 7 (30.4) 2 (8.7) 21 (91.3) 20 (86.9) 20 (86.9) 4 (17.4) 11 (47.8) 10 (43.5) 22 (95.7) 20 (86.9) 21 (91.3) 12 (52.2) 1 (4.3) 4 (17.4) 0 (0) 16 (69.6) 4 (17.4) 2 (8.7) 2 (8.7) 3 (13.1) 16 (69.6) 21 (91.3) 2 (8.7) 3 (13.1) 3 (13.1) 19 (82.6) 12 (52.2) 13 (56.5) 1 (4.3) 9 (39.1) 2 (8.7) 7 (30.4) 23 (100) 23 (100) 23 (100) 2 (8.7) 23 (100) 23 (100) 23 (100) 23 (100) 6 (26.1) 2 (8.7) 22 (95.7) 23 (100) 23 (100) 4 (17.4) 6 (26.1) 10 (43.5) 23 (100) 14 (60.9) 21 (91.3) 16 (69.6) 0 (0) 0 (0) 0 (0) 21 (91.3) 0 (0) 0 (0) 0 (0) 0 (0) 17 (73.9) 21 (91.3) 1 (4.3) 0 (0) 0 (0) 19 (82.6) 17 (73.9) 13 (56.5) 0 (0) jurnal ners http://e-journal.unair.ac.id/jners | 15 vibrating toothbrush, and a special chair to change the position of the body when the child is in the bathroom. difficulties often experienced in toileting activities by children with physical disability is the difficulty of moving and positioning themselves in the closet, needing a special seat for them to move. the difficulties that are often experienced by children having incontinence are in opening underwear before toileting, difficulty in cleaning after toileting and difficulty closing zippers (noble, 2014). self-care training for caregivers of children with physical disability does not have a significant effect on knowledge where the p value is 0.225. it can be seen from the mean value, that there less significant increase from before and after training, i.e. 13.17 to 14.00, where the difference test shows a difference mean of 0.826 with value t count 1.249, smaller than t table, 2.0739, which means that the training does not have a significant influence on knowledge. less knowledge is increased due to the giving of materials done in the classroom where the information is given by the trainer to some people in front of the class. according to vahdaniya, et al. (2015), giving the material in the class is less likely to increase knowledge compared with telling stories. the study of the instruments of knowledge assessment has become a concern as a result of caregiver knowledge being insignificant. according to nunally (1978 cited in widhiarso, 2005), instruments that have a reliability value <0.7 are less adequate as a measuring tool. in this research, the reliability of the knowledge instrument questionnaire is 0.673, which means that the instrument is less consistent to be used as a measuring tool; this happens because it is difficult to find the subjects for a validity and reliability test. testing the validity of reliability was only followed by 34 people out of 30 question items with only 18 valid questions. of the 18 questions, there were three (16.7%) questions that experienced a decrease in mean value after self-care training, namely, the question of the definition of self-care, bath steps and toileting tools. there was one question table 6. descriptions of before and after skills self-care training of a physically disabled child's caregiver (n= 23) educational skills items in.. before after done f (%) no f (%) done f (%) no f (%) 1. in the bathroom 2. take a shower 3. preparing water 4. adjust the water temperature 5. adjust the flow of water 6. cleaning all body parts 7. dry the body after bathing 8. exit the bathroom 9. in the bathroom when you want bab / bak 10. uncover the underwear 11. positioning yourself in the toilet 12. cleaning yourself after the bak 13. cleaning after bab 14. clean the closet 15. make clothes after bab / bak 16. exit the bathroom 17. wash hands after bab / bak 18. preparing food 19. open the food cover 20. using cutlery (plates, spoons, forks) 21. put food in cutlery 22. put food into the mouth 23. chew food 24. swallowing food 25. spend the food 26. hold and drink from a cup 27. choosing clothes 28. take the clothes from the closet 29. wear upper garment 30. buttoning clothes 31. wear underwear 32. closing the zipper 33. wear socks 34. wear shoes 35. tidy clothes 36. take off the upper shirt 37. unfold underwear 19 (82.6) 20 (86.9) 14 (60.9) 10 (43.5) 17 (73.9) 19 (82.6) 21 (91.3) 17 (73.9) 18 (78.3) 17 (73.9) 19 (82.6) 19 (82.6) 17 (73.9) 11 (47.8) 17 (73.9) 18 (78.3) 19 (82.6) 15 (65.2) 15 (65.2) 22 (95.7) 17 (73.9) 21 (91.3) 21 (91.3) 21 (91.3) 19 (82.6) 22 (95.7) 15 (65.2) 13 (56.5) 14 (60.9) 10 (43.5) 14 (60.9) 12 (52.2) 11 (47.8) 12 (52.2) 13 (56.5) 19 (82.6) 17 (73.9) 4 (17.4) 3 (13.1) 9 (39.1) 13 (56.5) 6 (26.1) 4 (17.4) 2 (8.6) 6 (26.1) 5 (21.7) 6 (26.1) 4 (17.4) 4 (17.4) 6 (26.1) 12 (52.2) 6 (26.1) 5 (21.7) 4 (17.4) 8 (34.8) 8 (34.8) 1 (4.3) 6 (26.1) 2 (86) 2 (8.6) 2 (8.6) 4 (17.4) 1 (4.3) 8 (34.8) 10 (43.5) 9 (39.1) 13 (56.5) 9 (39.1) 11 (47.8) 12 (52.2) 11 (47.8) 10 (43.5) 4 (17.4) 6 (26.1) 22 (95.7) 22 (95.7) 18 (78.3) 16 (69.6) 18 (78.3) 22 (95.7) 23 (100) 21 (91.3) 21 (91.3) 23 (100) 21 (91.3) 23 (100) 22 (95.7) 18 (78.3) 22 (95.7) 23 (100) 23 (100) 17 (73.9) 17 (73.9) 22 (95.7) 20 (86.9) 23 (100) 22 (95.7) 22 (95.7) 22 (95.7) 23 (100) 14 (60.9) 15 (65.2) 23 (100) 15 (65.3) 22 (95.7) 17 (73.9) 20 (86.9) 18 (78.3) 20 (86.9) 21 (91.3) 22 (95.7) 1 (4.3) 1 (4.3) 5 (21.7) 7 (30.4) 5 (21.7) 1 (4.3) 0 (0) 2 (8.6) 2 (8.6) 0 (0) 2 (8.6) 0 (0) 1 (4.3) 5 (21.7) 1 (4.3) 0 (0) 0 (0) 6 (26.1) 6 (26.1) 1 (4.3) 3 (13.1) 0 (0) 1 (4.3) 1 (4.3) 1 (4.3) 0 (0) 9 (39.1) 8 (34.8) 0 (0) 8 (34.8) 1 (4.3) 6 (26.1) 3 (13.1) 5 (21.7) 3 (13.1) 2 (8.6) 1 (4.3) w. ningsih et al. 16 | pissn: 1858-3598  eissn: 2502-5791 that did not change after the training, which was about equipment for bathing. self-care training improves the attitude of caregivers for children with physical disability. based on the result of the paired sample t test, p value of 0.038 and t value 2.213 were greater than t table; this means self-care training had an effect on the attitude of the caregivers. in the kling, et al. (2010) study, after training on supportive technology for children with physical disability, there was increase in attitude of caregivers and they were able to choose a solution to their problem with the appropriate support tools. after the training, caregivers’ skills increased significantly based on the results of the paired sample t test and obtained p 0.002, which means the skills of parents were better after the training. training can improve parenting skills more compared to those who only seek information from the literature (kling, et al., 2010). the success of the training in this study is based on the evaluation obtained from the caregivers, as it assessed for both the media training (52.2%), speaker (60.9%) and time and training facilities (78.3%). the improvement of caregiver skills was supported by an audiovisual learning media where parents were given the opportunity to see videos on how to teach children with physical disabilities. in addition, caregivers were given the opportunity to practice firsthand the materials that had been given by involving the child in the training activities of bathing, toileting, eating and dressing. in a study conducted by lehna, et al. (2013), which aimed to compare educational methods of classroom meetings, dvds, home visits, leaflets, telephone contacts, pamphlets, and short messages on research subjects with parents with physically disabled children, visual disturbances and control groups showed the most effective method of education on such parent groups is classroom meetings, dvds and home visits. based on the theory of learning outcome, training is effective in improving skills. according to bandura (1971), a person's behavior is formed from the process of observation (attentional phase), retention phase, reproduction phase and motivation to do something (motivation phase). the phases are done by parents in the training process where they observe through audiovisual and demonstration, being given the material, imitating through practice activities and then practice at home. conclusion almost half the knowledge before self-care training was good and, after training, the majority became good. more than half of the caregivers had a positive attitude before training and this improved to almost all after training. self-care training for caregivers of children with physical disability could improve their attitude and skills, but did not affect their knowledge. this study had a limited number of respondents. in future research, a greater number of respondents could be used as a more valid reference source. better caregivers are always looking for an adequate source of information on how to help children in self-care activities. providing facilities that enable children to run self-care activities, always give the opportunity and enables the child to perform self-care activities independently. table 7. caregiver response to the training on caring for a physically disabled child march-april 2017 (n= 23) no. item f (%) total very less less sufficient good very good preparation 0 (0) 0 (0) 0 (0) 11 (47.8) 12 (52.2) 23 (100) training facilities 0 (0) 0 (0) 1 (4.3) 18 (78.3) 4 (17.4) 23 (100) training materials 0 (0) 0 (0) 1 (4.3) 10 (43.5) 12 (52.2) 23 (100) training media 0 (0) 0 (0) 1 (4.3) 12 (52.2) 10 (43.5) 23 (100) trainer 0 (0) 0 (0) 1 (4.3) 14 (60.9) 8 (34.8) 23 (100) training benefits 0 (0) 0 (0) 0 (0) 9 (39.1) 14 (60.9) 23 (100) training time 0 (0) 0 (0) 3 (13.1) 18 (78.3) 2 (8.7) 23 (100) table 8. effects of self-care training on knowledge, attitudes and skills of caregivers regarding the care of a physically disabled child (n= 23) outcomes min max mean (sd) t (df) p value knowledge pretest posttest pretest-posttest 9 8 18 17 13.17 (2.443) 14.00 (2.195) 0.826 (3.172) 1.249 (22) 0.225 attitudes pretest posttest pretest-posttest 37 56 71 68 59.57 (6.451) 62.61 (3.905) 3.043 (6.595) 2.213 (22) 0.038* skills pretest posttest pretest-posttest 4 26 37 37 26.74 (7.794) 33.17 (3.537) 6.435 (8.659) 3.564 (22) 0.002* t table value with df (22) = 2.0739 with significance level 95% jurnal ners http://e-journal.unair.ac.id/jners | 17 health services need to pay attention to the right media in providing education, and shape the purpose according to the needs of the audience. work with schools should include self-care training curriculum programs involving physical disability caregivers. work should be done with stakeholders to provide facilities that help children with a physical disability to meet self-care needs, such as bathing, toileting, cutlery, dressing and dressing facilities that are easy to use for them. further research using more valid and reliable research instruments should be undertaken. there should be development of skills assessment tools that fit the child's physical disability-related disability. observations need to be made on the appropriate schedule according to the child's activities. references aizpurua, a., bajos, a.g. and migueles, m. (2009). false memories for a robbery in young and older adults. applied cognitive psychology, 23, pp. 174187. doi: 10.1002/acp.1461. barbotte, e.g. and chau. f, (2011). prevalence of impairments, disabilities, handicaps and quality of life in the general population: a review of recent literature. bulletin of the world health organization, 79 (11), p. 1047. bhinnety, m. 2008. struktur dan proses memori. buletin psikologi, 16 (2), pp. 74-88. universitas gadjah mada. chung, j., evans, j., lee, c., lee, j., rabbani, y. and roxborough, l. (2008). effectiveness of adaptive seating on sitting posture and postural control in children with cerebral palsy. pediatric physical therapy, 20, pp. 303–317. http://dx.doi.org/10.1097/pep.0b013e31818b7 bdd. dziubanek, g., marchwinska, w.e., piekut, a., hajok, i., bilewicz, w.t. and kuraszewska, b. (2013). environmental risk perception—a study of the awareness of families to threats in areas with increased health disorders in children. annals of agricultural and environmental medicine, 20(3), pp. 555-558. fickert, n.a. and ross, d. (2012). effectiveness of a caregiver education program on providing oral care to individuals with intellectual and development disabilities. intellectual and developmental disabilities, 50(3), pp. 219-232. doi: 10.1352/1934-9556-50.3.219. heubner, c.e. and milgrom, p. (2014). evaluation of a parent-designed programme to support tooth brushing of infants and young children. international journal of dental hygiene. doi:10.1111/idh.12100 kabel, a., dimka, j. and black, k.m. (2017). clothingrelated barriers experienced by people with mobility disabilities and impairments. applied ergonomics, 59, pp. 165-169. http://dx.doi.org/10.1016/j.apergo.2016.08.036. kling, a., campbell, p.a. and wilcox, j. (2010). young children with physical disabilities caregiver perspectives about assistive technology. infant & young children. wolters kluwer health. lippincott williams & wilkins, 23(3), pp. 169–183. lehna, c., janes, e.g., rengers, s., graviss, j., scrivener, s.d., knabel, s.t. and myers, j.a. (2013). impact of children with special needs on differences in fire-safety education priorities, preferred method of education, and parent actions. journal of burn care & research. doi: 10.1097/bcr.0b013e31828a480a. mcmahon, g. and archer, a. (2010). 101 coaching strategies and techniques. london and new york: routledge taylor & francis group. noble, e. (2014). using prompts to improve toilet training for children with physical disabilities. [online] available at: https://cdnrifton.azureedge.net/-/media/files/rifton/whitepapers/toilet-training-children-physicaldisabilities.pdf?la=en (accessed: april 27, 2017). notoatmodjo. (1993). pengantar pendidikan kesehatan dan ilmu perilaku kesehatan. andi offset. yogyakarta. riset kesehatan dasar (riskesdas). 2013. badan penelitian dan pengembangan kesehatan kementerian ri tahun [online] available at: http://www.depkes.go.id/resources/download/ general/hasil%20riskesdas%202013.pdf (accessed: april 27, 2017). tristani, l.k., gunter, r.b. and tanna, s. (2017). evaluating internet-based information on physical activity for children and youth with physical disabilities. adapted physical activity quarterly, 34, pp.55-71. https://doi.org/10.1123/apaq.2016-0012. unicef. (2014). study of parental knowledge, attitudes, and practice related to early childhood development. [online] available at: https://www.unicef.org/pacificislands/ecd_kap _solomon_islands.pdf (accessed: april 27, 2017). vahdaninya, z., nakhaei, m., nasiri, a. and sharifzadeh, g. 2015. training based on orem’s model on knowledge, attitude and self-efficacy of mothers in preventing domestic accidents. modern care journal, 12(3), pp.119-124. who. (2015). health education. [online] available at: http://www.who.int/topics/health_education/en / (accessed: april 27, 2017). widhiarso, w. (2005). mengestimasi reliabelitas. fakultas psikologi ugm. yogyakarta. ypac. 2016. laporan akademik tahun surakarta: yayasan pembinaan anak cacat. http://dx.doi.org/10.1016/j.apergo.2016.08.036 pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru musik tembang kenangan (harmayetty) musik tembang kenangan menurunkan depresi pasien stroke (memory songs decrease depression for stroke patients) harmayetty*, ika yuni widyawati*, anggun perwita sari* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: zanno_yet@yahoo.com. abstract introduction: biological, physical and phsycosocial changes in stroke patient could be a stressor that induced a depression state. there would be an emotional disturbance in stroke patient and stroke attack would be recurrent, if it was not treated. one of the alternative techniques to reduce depression is musical therapy especially memory songs. method: this study was used a quasy experimental pre-post test purposive sampling design. the population was stroke patients who treated in neurological ward a and stroke unit dr soetomo hospital surabaya. there were 12 respondents divided into 6 respondents for treatment group and 6 respondents for control group. the independent variable was music (memory song) and dependent variable was depression. data were collected by using questionnaire which adapted from hamilton depression rating scale and geriatric depression rating scale, then analyzed by using wilcoxon signed rank test and mann whitney u test with significance level α≤0.05. result: the result showed that there was a difference between pre test and post test in depression (p=0.0196) and there was a difference in the depression between treatment group and control group (p=0.002). discussion: it can be concluded that music (memory songs) has an effect to the depression of stroke patient. further studies are needed to concerning other factors that may affect the relaxation technique especially in listening music. keywords: stroke, depression, music (memory songs) _______________________________________________________________________________ pendahuluan musik sebagai bahasa universal dapat menjadi salah satu terapi relaksasi. pada penelitian cross, et al. (2002), pemberian musik pada penderita stroke di klinik rehabilitasi stroke di amerika, didapatkan bahwa dari 40 penderita stroke yang diberi terapi musik terdapat penurunan gangguan stabilitas emosi, mobilitas dan sosialisasi dari skala berat menjadi sedang sebanyak 49% dan 26% dari skala sedang ke ringan. stroke merupakan penyakit yang berdampak kompleks bagi kehidupan penderita baik berupa keterbatasan fisik, gangguan emosional maupun psikososial penderita. serangan stroke yang dialami sering menimbulkan depresi bagi penderita yang ditandai dengan perasaan takut mati, tidak berguna atau takut mendapat serangan ulang (misbach, 1999). penderita yang mengalami gangguan emosional akibat stroke sebanyak 20-60% (caplan, 1999). pada penderita stroke angka kejadian depresi sebanyak 41% sedangkan untuk penderita yang mengalami serangan pertama sejumlah 33% (shuaib, 1999). penyebab depresi penderita stroke adalah berbagai tekanan akibat dampak yang dialami setelah serangan. dampak stroke meliputi berbagai perubahan, baik keterbatasan fisik, emosional maupun perubahan regulasi neurotransmiter terutama gaba, serotonin dan norepineprin yang berpengaruh pada keadaan emosi penderita (shuaib, 1999). kasus stroke di negara berkembang cenderung terjadi pada usia semakin muda antara 30-40 tahun, termasuk di indonesia (siswono, 2001). di ruang saraf a rsu dr soetomo, angka kejadian stroke mulai bulan januari sampai bulan maret 2005 rerata pasien stroke per bulan sebanyak 187 pasien. pemberian musik sebagai teknik relaksasi di tempat penelitian belum optimal sehingga perlu dilakukan penelitian dengan harapan dapat membantu menurunkan depresi pada pasien stroke. mailto:zanno_yet@yahoo.com jurnal ners vol.3 no.1 april 2008 : 34-36 bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah quasy experimental non randomized control group pre-post test design. sampel diambil sesuai dengan kriteria inklusi yang telah ditentukan, dengan sampel sebanyak 12 responden, dibagi menjadi kelompok perlakuan (diberikan intervensi musik tembang kenangan 1 kali per hari selama 7 hari, dengan durasi pertemuan 30 menit) dan kelompok kontrol (tanpa pemberian musik tembang kenangan) dengan jumlah sampel masing-masing 6 orang. penelitian dilakukan selama bulan januari sampai dengan februari 2007. variabel independen dalam penelitian ini adalah musik tembang kenangan, sedangkan variabel dependen adalah depresi. instrumen yang digunakan dalam penelitian ini berupa kuesioner yang diadaptasi dari hamilton depresion rating scale (7 pertanyaan) dan geriatric depresion rating scale (9 pertanyaan). data yang diperoleh, dianalisis dengan menggunakan uji statistik kolmogorov smirnov test, mann whitney u test dan wilcoxon signed rank test dengan derajat kemaknaan α<0,05. hasil hasil penelitian menunjukkan bahwa didapatkan perubahan nilai depresi yang signifikan pada kelompok perlakuan dengan hasil analisis statistik wilcoxon signed rank test (p=0,0196), sedangkan pada kelompok kontrol tidak didapatkan perubahan pada nilai depresi dengan hasil analisis statistik wilcoxon signed rank test (p=0,109). pada hasil analisis statistik mann whitney u test didapatkan perbedaan nilai depresi antara kelompok perlakuan dan kelompok kontrol dengan nilai sgnifikansi (p=0,002). pembahasan berdasar hasil penelitian dapat dilihat bahwa terdapat perubahan nilai depresi pada pasien stroke sebelum dan sesudah diberikan intervensi mendengarkan musik tembang kenangan. depresi yang terjadi pada pasien stroke berkaitan dengan disregulasi neurotransmiter terutama gaba, glutamat, serotonin dan norepineprin yang mengakibatkan adanya perubahan emosional, dimana penderita lebih mengalami depresi. perubahan disregulasi neurotransmiter akan berpengaruh pada emosi penderita stroke (caplan, 1999). rose, et al. dikutip dari lumbantobing (2001), menyatakan terdapat kemungkinan perbedaan depresi pada pasien stroke antara gangguan di hemisfer kanan dengan kiri. depresi yang disebabkan gangguan di hemisfer kanan lebih berespons terhadap farmakoterapi sedangkan depresi pada gangguan di hemisfer kiri walaupun kurang berespons terhadap farmakoterapi tetapi lebih berespons terhadap terapi psikologis. menurut lumbantobing (2001), terdapat beberapa faktor yang mempengaruhi frekuensi kejadian dan berat depresi yang dialami penderita stroke yaitu tingkat intelektual, gangguan fungsi fisik, kualitas dukungan sosial yang tersedia, serta usia penderita. penderita berusia muda mempunyai kemungkinan depresi yang lebih berat. kemampuan penderita untuk melakukan kegiatan sehari-hari dan bersosialisasi pun berpengaruh pada tingkat depresi yang dialami. tabel 1. nilai depresi pada pasien stroke di ruang saraf a dan unit stroke rsu dr. soetomo perlakuan kontrol pre post pre post mean 11.00 5.67 8.67 9.83 sd 1.41 1.03 1.21 2.14 hasil analisis statistik wilcoxon signed rank test (p=0,0196) wilcoxon signed rank t test (p=0,109) mann whitney u test (p=0,002) keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata musik tembang kenangan (harmayetty) harmayetty dalam rehabilitasi, stres dapat dikurangi dengan kesibukan penderita dalam mengikuti kegiatan program rehabilitasi, sehingga resiko untuk mengalami depresi berkurang (shuaib, 1999). mendengarkan musik merupakan salah satu kegiatan rehabilitasi psikologis yang dapat dilaksanakan untuk mengurangi stres penderita. terapi musik merupakan penggunaan musik dan elemennya untuk mengembangkan, mempertahankan dan memulihkan kesehatan mental, fisik, emosional dan spiritual, mempunyai sifat non verbal, kreatif, struktural, dan emosional dimana sifat-sifat ini digunakan dalam hubungan terapeutik untuk memudahkan kontak, interaksi, self awareness, proses belajar, ekspresi diri, komunikasi dan perkembangan pribadi (siswono, 1999). musik yang diberikan merupakan stimulus agar penderita stroke dapat merasa relaks dan dapat mengurangi gangguan emosional penderita. musik yang didengar akan mempengaruhi kemampuan penderita untuk mencapai keadaan relaks, sehingga depresi yang dialami akan berkurang (djohan, 2005). penderita stroke yang mencapai keadaan relaks dan tenang maka hipotalamus akan menyesuaikan dengan menghasilkan respons yang berpengaruh pada penurunan aktivitas simpatis dan parasimpatis (smeltzer dan bare, 2002). simpulan dan saran simpulan musik tembang kenangan mampu menurunkan depresi pasien stroke. pemberian musik tembang kenangan akan membuat pasien stroke menjadi lebih relaks dan menstimulasi hipothalamus untuk berespons dengan menurunkan aktivitas simpatis dan parasimpatis. saran peneliti menyarankan agar pemberian musik tembang kenangan dilakukan secara kontinyu pada perawatan pasien stroke yang tidak mengalami gangguan pada fungsi kognitif agar pasien lebih relaks dan mengurangi perubahan emosional yang dialami. penelitian selanjutnya dapat dilakukan dengan menilai kadar kortisol darah, hasil perekaman ekg dan jenis musik disesuaikan dengan keinginan responden. kepustakaan caplan. 1999. stroke. new york: marcel dekker inc., pp. 2-60, 529-539. cross, et al. 2002. effect on the use of music in rehabilitations of stroke patients, (online), (http://www.pubmed.gov., diakses tanggal 24 desember 2006, jam 13.00 wib). djohan. 2005. psikologi musik. yogyakarta: buku baik, hlm. 223-224, 234. lumbantobing. 2001. neurogeriatri, jakarta: balai penerbit fkui, hlm. 93-171. misbach. 1999. stroke: aspek diagnostik, patofisiologi, manajemen. jakarta: balai penerbit fkui, hlm. 77-80. shuaib. 1999. management of acute stroke. new york: marcel dekker inc., pp. 120-121, 243-269. siswono. 2001. stroke: si pembunuh nomor 1, (online), (http://www.gizi.net/cgibin., diakses tanggal 25 desember 2006, jam 11.00 wib). smeltzer dan bare. 2002. buku ajar keperawatan medikal bedah brunner dan suddarth. alih bahasa oleh monika ester, jakarta: egc, pp. 123137, 295-296, 379. http://www.pubmed.gov/ http://www.gizi.net/cgi-bin. http://www.gizi.net/cgi-bin. issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief ferry efendi, s.kep., ns., m.sc., ph.d editor: prof. angeline bushy, phd, rn, phcns-bc, faan prof. ching-min chen, rn, dns prof. eileen savage, bns., msc., p.hd. prof. josefina a. tuazon, rn, mn, drph dr. david pickles dr. farhan alshammari dr. chong mei chan, scm, bnsc, msc, phd dr. sonia reisenhofer assistant professor pei-lun hsieh prof. dr. ah. yusuf, s.kp., m.kes. dr. yulis setiya dewi, s.kep.ns., m.ng. dr. esti yunitasari, s.kep., ns., m.kep.. dr. rizki fitryasari, s. kep., ns., m. kep. dr. ilya krisnana, s.kep., ns., m.kep. retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. quality control: gading ekapuja aurizki, s.kep., ns., m.sc technical editor: rifky octavia pradipta, s.kep., ns., m.kep. editorial address: faculty of nursing universitas airlangga campus c, mulyorejo street 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 811-3287-877 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners publication schedule since 2023, jurnal ners is published three times a year, in march, june, and september. manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. http://e-journal.unair.ac.id/index.php/jners acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 18 no. 1 march 2023. 1. anna kurniati, s.km, ma, ph.d. bppsdmk, ministry of health, indonesia 2. amir su’udi, skm., mkm national research and innovation agency 3. ahmad hasyim wibisono, s.kep., ns., m.ng universitas brawijaya, indonesia 4. awatiful azza, s.kep., ns., m.kep. sp. kep. mat universitas muhammadiyah jember 5. dr. bagus aulia mahdi universitas airlangga, indonesia 6. bayhakki, m.kep, sp.kmb, ph.d universitas riau, indonesia 7. associate prof. dr. chong mei chan university of malaya, malaysia 8. deena clare thomas, ph.d universiti malaysia sabah, malaysia 9. dian tristiana, s.kep., ns., m.kep universitas airlangga, indonesia 10. dianis wulan sari, s. kep., ns., mhs., ph.d. universitas airlangga, indonesia 11. ika yuni widyawati, m.kep., ns., sp.kep.mb universitas airlangga, indonesia 12. lukman handoyo, s.kep., ns., m.kep. stikes widya darma husada 13. dr. mahendra tri arif sampurna, sp.a universitas airlangga, indonesia 14. ni ketut alit armini, s.kep., ns., m.kep universitas airlangga, indonesia 15. nuzul qur’aniati, s.kep., ns., m.sc., ph.d universitas airlangga, indonesia 16. pratuma rithpo, ph.d naresuan university, thailand 17. qorinah estiningtyas sakilah adnani, sst, m.keb, ph.d. universitas padjadjaran, bandung 18. rista fauziningtyas., s.kep., ns., m. kep., ph.d universitas airlangga, indonesia 19. saldy yusuf, ph.d universitas hasanuddin, indonesia 20. dr. sarni maniar berliana, m.si 21. politeknik statistika stis 22. dr. saryono, s.kp., m.kes universitas jenderal soedirman, indonesia 23. sirikanok klankhajhon, ph.d naresuan university, thailand 24. tantut susanto, ns., m.kep, sp.kep.kom, ph.d universitas jember, indonesia 25. dr. yohanes andy rias institut ilmu kesehatan karya husada, kediri 26. dr. yuni sufyanti arief, s. kp., m. kes. universitas airlangga, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 table of content jurnal ners vol. 18 no. 1 march 2023 1. 1-2 2. 3-8 3. 9-15 4. 16-24 5. 25-30 6. 31-39 7. 40-46 8. 47-53 9. 54-60 10. 61-69 11. editorial: reshaping the future of nursing education through leadership chong mei chan coping strategies and family support to the adjustment of adolescents who have parents working as migrant workers praba diyan rachmawati, rizki fitryasari, dewita pramesti , deena clare thomas , yuni sufyanti arief the correlation between parents interaction conflict with online game addiction in adolescents iqlima dwi kurnia, bangun mukti ardi , ilya krisnana , aria aulia nastiti , pratuma rithpo , yuni sufyanti arief perceived competence of filipino nursing students graduating during pandemic joshua eugene p. molanida, tisha jane a. neyra, paolo miguel m. norada , princess mae s. olarte , danish danielle o. palma , ryan michael f. oducado effect of isometric handgrip exercise on blood pressure and comfort among hypertensive patients veralia veralia, hema malini, reni prima gusty exploring the supportive care needs for people with cancer undergoing chemotherapy: a qualitative descriptive study muhamad zulfatul a'la, khanitta nuntaboot determinant factors of anemia in pregnancy based on health belief model: a correlational study mira triharini, eka mishbahatul mar’ah has, gita nofita resilience after stroke and its correlation with functional independence heltty heltty, zahalim zahalim health literacy and post-vaccination covid-19 prevention behavior in the community: a crosssectional study in indonesia jon hafan sutawardana, yofita refvinda desfiani , nur widayati effects of the tailored intervention program in lowering blood glucose levels and diabetes distress among patients with diabetes in indonesia: a randomized controlled trial satriya pranata , shu-fang vivienne wu , tsae-jyy tiffany wang , shu-yuan liang , difran nobel bistara , yeu-hui chuang , kuo-cheng lu , aric vranada gabra6 and slc6a4 genotypes are correlated with the fasting blood glucose and physical fitness in the seemingly healthy young adults 70-77 12. 78-90 13. 91-100 13. viskasari p kalanjati , mariana wahjudi , kusuma e. purwantari , visuddho , peppy nawangsasi , rury t. oktariza , krisnawan a. pradana , dzanuar rahmawan , bambang e. suwito the experience of nurses in providing holistic nursing care for covid-19 patients at banyuwangi hospital atik pramesti wilujeng , akhmad yanuar fahmi pamunhgkas , dwiky rizal mahardika , essy sonontiko a systematic review of illness representations in patients with mild traumatic brain injury mulyadi mulyadi , santo imanuel tonapa , heriyana amir , bih-o lee wireless stethoscope for auscultation of the heart and lungs in critically ill patients: a systematic review suhartini ismail, ricky prawira, andrew johan, rifky ismail 101-107 pengaruh dukungan sosial keluarga terhadap perilaku antisipasi tanda bahaya kehamilan pada ibu primigravida manfaat dukungan sosial keluarga pada perilaku antisipasi tanda bahaya kehamilan pada ibu primigravida (the beneficience of family social support toward anticipatory behaviour of pregnancies sign’s alert in primigravida) aditiawarman*, ni ketut alit armini**, yunita ike kristanti** * rsud dr. soetomo surabaya. jl. prof. moestopo. telp/fax: (031) 5913257. e-mail: jurnalpsik@yahoo.com ** fakultas keperawatan universitas airlangga surabaya abstract introduction: complication in pregnancy can be endangering both mother and fetus. pregnant woman and her family must be able to recognize risk factors of the complication. family support make pregnant woman feel more confident, happy and ready to face her pregnancy. the aimed of this study was to learn the influences of social family support toward anticipatory behavior of pregnancies sign’s alert in primigravida. method: a quasy experimental purposive sampling design was used in this study. there were 20 respondents who met the inclusion criteria. they were divided into 2 groups, intervention and control groups, each comprising 10 respondents. the independent variable in this study was social family support and the dependent variable was the anticipatory behavior of pregnancies sign’s alert in primigravida. data were collected by using questionnaire, observation and structured interview and then analyzed by using wilcoxon signed rank test and mann whitney u test with significance level α≤0.05. result: the result showed that the social family support influencing the knowledge of pregnant woman with significant level p=0.011, social family support also influencing the attitude of pregnant woman with significant level p=0.008 and the action of pregnant woman p=0.017. there were difference knowledge, attitude and action between intervention and control groups after treatment with significant level p=0.000 for knowledge, p=0.015 for attitude and p=0.002 for action. discussion: it can be concluded that social family support influence anticipatory behavior (knowledge, attitude and action) of pregnancies sign’s alert in primigravida. further studies should be concern to the other factors that influencing the anticipatory behavior of pregnancies sign’s alert in primigravida, both of internal and external factors. keywords: social family support, pregnant women, behavior, pregnancy’s risk factor pendahuluan setiap kehamilan mempunyai kemungkinan terjadi komplikasi atau penyulit yang dapat membahayakan ibu atau bayi, baik yang berupa kesakitan maupun kematian (rochjati, 2005). sedikitnya 40% dari ibu hamil pernah mengalami salah satu bentuk komplikasi selama kehamilan dan sekitar 15% komplikasi ini secara potensial mengancam jiwa dan membutuhkan penanganan obstretik darurat (badan koordinasi keluarga berencana nasional, 2005). menurut skrt (2001), penyebab komplikasi obstetrik langsung sebesar 90%, sebagian besar adalah perdarahan (28%), eklampsia (24%) dan infeksi (11%). penyebab tak langsung berupa kondisi kesehatan yang diderita ibu misalnya kurang energi kronis (kek) 37%, anemia (hb<11 g%) 40% dan penyakit kardiovaskuler. menurut data dinkes kabupaten magetan terdapat 2 puskesmas dengan jumlah kehamilan risiko tinggi terbesar, salah satunya di puskesmas karangrejo. jumlah kehamilan risiko tinggi di puskesmas karangrejo tahun 2006 mencapai 26 orang (37,14%) dan mengalami peningkatan pada tahun 2007 yaitu sebesar 40 orang (57,97%) antara lain karena kelainan letak sebanyak 8 orang (11,59%), usia ibu >35 tahun sebanyak 4 orang (5,79%), hipertensi sebanyak 10 orang (15,94%), anemia sebanyak 12 orang jurnal ners vol. 3 no. 1: (17,39%) dan tingginya paritas sebanyak 6 orang (7,25%). banyak faktor yang mempengaruhi tingginya angka kematian ibu hamil dan melahirkan, antara lain faktor pendidikan dan pengetahuan ibu yang masih relatif rendah, kondisi sosial ekonomi dan lingkungan keluarga wanita yang tidak mendukung, kehidupan sosial budaya masyarakat yang masih bias gender, aksesabilitas ibu hamil pada fasilitas kesehatan modern sangat kurang, serta pelayanan kehamilan yang kurang memadai dan pertolongan persalinan terhadap ibu hamil (chairunnisya, 2002). ibu hamil yang diidentifikasi mempunyai risiko komplikasi tidak memperoleh jaminan perawatan yang dibutuhkan. di satu pihak pemerintah belum dapat menyediakan pelayanan kesehatan yang memadai, di sisi lain ibu hamil tidak dapat dan tidak mau mencari pertolongan kesehatan meskipun termasuk kategori risiko tinggi. hal ini disebabkan oleh ketidakmampuan membayar biaya perawatan, sibuk, tidak diperbolehkan oleh suami dan keluarga atau malas memeriksakan kesehatan (badan koordinasi keluarga berencana nasional, 2005). deteksi dini dari gejala dan tanda bahaya selama kehamilan merupakan upaya terbaik untuk mencegah terjadinya gangguan yang serius terhadap kehamilan maupun keselamatan ibu (wiludjeng, 2005). melakukan pengenalan secara dini terhadap faktor risiko dalam kehamilan dan persalinan, sedapat mungkin dilakukan oleh ibu hamil sendiri, suami dan atau keluarga (rochjati, 2005). menurut gjerdingens et al. (1991) dalam perry et al. (1999), dukungan sosial yang diperoleh ibu selama masa kehamilan dan persalinan dari lingkungan sekitar berkaitan erat dengan adaptasi positif terhadap peran sebagai ibu selama masa transisi sebagai orang tua baru. keluarga diharapkan berperan sebagai support system terdekat bagi ibu hamil karena di dalam keluarga terdapat ikatan emosional yang kuat, sehingga ibu hamil akan merasa lebih percaya diri, lebih bahagia dan siap dalam menjalani kehamilan, persalinan dan masa nifas (fauzi, 2003). menurut friedman (1998) keluarga memainkan peran yang bersifat mendukung selama penyembuhan dan pemulihan anggota keluarga. hal inilah yang mendorong penulis untuk meneliti pengaruh dukungan keluarga terhadap perilaku antisipasi tanda bahaya kehamilan pada ibu primigravida. tujuan dari penelitian ini adalah mempelajari pengaruh dukungan sosial keluarga terhadap perilaku antisipasi tanda bahaya kehamilan pada ibu primigravida. bahan dan metode penelitian ini menggunakan quasy experimental design. populasi yang digunakan adalah ibu primigravida yang melakukan kunjungan anc di puskesmas karangrejo magetan. responden yang memenuhi kriteria sebanyak 20 orang. penelitian dilaksanakan pada bulan juni sampai dengan juli 2008. variabel independen dalam penelitian ini adalah dukungan sosial keluarga, sedangkan variabel dependen dalam penelitian ini adalah perilaku antisipasi tanda bahaya kehamilan pada ibu primigravida. pengumpulan data untuk dukungan sosial keluarga menggunakan kuesioner, sedangkan pengumpulan data untuk perilaku antisipasi tanda bahaya kehamilan menggunakan kuesioner, wawancara terstruktur dan observasi kms ibu hamil. analisis data yang digunakan wilcoxon signed rank test dan mann whitney u test, dengan tingkat kemaknaan α<0,05. hasil tabel 1 menunjukkan terdapat pengaruh dukungan sosial keluarga terhadap pengetahuan ibu hamil mengenai antisipasi tanda bahaya kehamilan dengan hasil analisis statistik wilcoxon signed rank test menunjukkan nilai signifikansi p=0,011 dan mann whitney u test p=0,000. hasil rerata pengetahuan ibu primigravida dalam antisipasi tanda bahaya kehamilan, secara kuantitatif meningkat dari 15,9 (pre test) menjadi 18,5 (post test) setelah diberikan intervensi. pengaruh dukungan sosial keluarga terhadap sikap ibu hamil dalam antisipasi tanda bahaya kehamilan dapat dilihat pada tabel 2 dengan hasil analisis statistik wilcoxon signed rank test menunjukkan nilai signifikansi p=0,008 dan dengan mann whitney u test menunjukkan nilai http://www.bikor.wordpress.com/ manfaat dukungan sosial keluarga (aditiawarman) signifikansi p=0,015. sikap ibu hamil dalam antisipasi tanda bahaya kehamilan secara kuantitatif meningkat dengan hasil rerata 69,9 (pre test) menjadi 75,7 (post test). terdapat pengaruh dukungan sosial keluarga terhadap tindakan pada ibu hamil dalam antisipasi tanda bahaya kehamilan dengan hasil analisis statistik wilcoxon signed rank test menunjukkan nilai signifikansi p=0,017 dan dengan mann whitney u test menunjukkan p=0,002. hasil rerata menunjukkan peningkatan dari 13,2 (pre test) menjadi 14,5 (post test) (lihat tabel 3). pembahasan berdasarkan hasil penelitian didapatkan tingkat pengetahuan ibu hamil dalam antisipasi tanda bahaya kehamilan sebelum intervensi baik kelompok perlakuan maupun kelompok kontrol sebagian besar dengan kategori cukup dan pada kelompok perlakuan mengalami peningkatan setelah diberikan intervensi menunjukkan kategori baik. hal ini diperkuat dengan hasil analisis isi (content analyze) dari wawancara terstruktur. berikut kutipan jawaban dari salah satu responden atas pertanyaan: apa saja tanda bahaya kehamilan yang ibu ketahui? “setelah saya membaca brosur dari mbak, ternyata ada banyak ya mbak tanda bahaya kehamilan. perdarahan, bayi tidak bergerak, nyeri perut dan cairan ketuban berwarna keruh”. sesuai dengan pendapat caplan yang dikutip oleh friedman (1998) yang menerangkan bahwa keluarga memiliki fungsi suportif yaitu melalui dukungan informasional, keluarga berfungsi memberikan bimbingan dan menyebarkan informasi kepada anggota keluarga lain. keluarga dari wanita yang sedang hamil harus mempunyai pengertian dan pengetahuan yang cukup tentang proses atau perubahan yang dialami oleh wanita hamil sehingga dapat menghindari atau mengatasi kemungkinan bahaya pada kehamilan. pengetahuan responden pada kelompok perlakuan mengalami peningkatan 100% setelah diberikan intervensi. hal ini disebabkan pemberian informasi kepada keluarga dan ibu hamil mengenai tanda bahaya kehamilan. peneliti memberikan intervensi berupa informasi kepada keluarga tentang pentingnya antisipasi tanda bahaya kehamilan dan memotivasi keluarga untuk terus memberikan dukungan informatif kepada ibu hamil, sehingga ibu hamil mendapatkan kejelasan informasi mengenai macam tanda bahaya kehamilan, bahaya ibu hamil risiko tinggi dan cara menjaga kesehatan selama hamil. semakin banyak informasi yang diperoleh, maka pengetahuan ibu hamil mengenai antisipasi tanda bahaya kehamilan juga akan semakin baik. tabel 1. hasil analisis statistik pengetahuan responden dalam antisipasi tanda bahaya kehamilan di wilayah kerja puskesmas karangrejo magetan kelompok perlakuan kelompok kontrol perlakuan kontrol pre post pre post post post mean 15,9 18,5 15,3 15,6 18,5 15,6 sd 2,424 1,178 1,418 1,173 1,178 1,173 hasil analisis statistik wilcoxon signed rank test (p=0,011) wilcoxon signed rank test (p=0,317) mann-whitney u test (p=0,000) tabel 2. hasil analisis statistik sikap responden dalam antisipasi tanda bahaya kehamilan di wilayah kerja puskesmas karangrejo magetan kelompok perlakuan kelompok kontrol perlakuan kontrol pre post pre post post post mean 69,9 75,7 70,6 70,6 75,7 70,6 sd 6,951 5,396 3,339 3,339 5,396 3,339 hasil analisis statistik wilcoxon signed rank test (p=0,008) wilcoxon signed rank test (p=0,083) mann-whitney u test (p=0,015) jurnal ners vol. 3 no. 1: tabel 3. hasil analisis statistik tindakan responden dalam antisipasi tanda bahaya kehamilan di wilayah kerja puskesmas karangrejo magetan kelompok perlakuan kelompok kontrol perlakuan kontrol pre post pre post post post mean 13,2 14,5 12,6 13,0 14,5 13,0 sd 1,229 0,527 1,264 1,333 0,527 1,333 hasil analisis statistik wilcoxon signed rank test (p=0,017) wilcoxon signed rank test (p=0,157) mann-whitney u test (p=0,002) keterangan: p = signifikansi sd = standar deviasi mean = rerata hasil penelitian menunjukkan sebagian besar responden pada kelompok perlakuan dan kontrol mempunyai sikap positif yaitu sebanyak 6 orang (60%) sebelum diberikan intervensi. responden yang bersikap positif adalah responden yang mampu memberikan pernyataan positif dalam hal menerima, merespons, menghargai dan bertanggung jawab dalam menjaga kesehatan selama hamil. pada kelompok perlakuan mengalami peningkatan yaitu sebagian besar responden mempunyai sikap positif sebanyak 7 orang (70%), sedangkan pada kelompok kontrol tidak mengalami perubahan setelah diberikan intervensi. menurut notoatmodjo (2003), suatu sikap belum otomatis terwujud dalam suatu tindakan (overt behaviour), diperlukan faktor pendukung atau situasi yang memungkinkan, antara lain adalah fasilitas dan faktor dukungan (support) untuk mewujudkan sikap menjadi suatu perbuatan yang nyata. pengaruh lingkungan maupun kepercayaan dari keluarga dapat mempengaruhi sikap ibu hamil. keluarga sangat berpengaruh bagi ibu hamil karena merupakan sumber dukungan terbesar. bagi ibu primigravida yang belum mempunyai cukup pengalaman, keluarga terutama orang tua merupakan tempat memperoleh informasi dan meminta nasehat terkait dengan kehamilan. dukungan keluarga yang didapatkan ibu hamil akan menimbulkan perasaan tenang, sikap positif terhadap diri sendiri dan kehamilan, sehingga diharapkan ibu dapat menjaga kehamilan dengan baik sampai saat persalinan. dari hasil penelitian tindakan ibu hamil dalam antisipasi tanda bahaya kehamilan sebelum diberikan intervensi menunjukkan pada kelompok perlakuan sebagian besar dengan kategori baik, sedangkan pada kelompok kontrol dengan kategori cukup. peningkatan setelah intervensi terjadi baik pada kelompok perlakuan maupun kelompok kontrol dengan kategori baik. hal tersebut diperkuat dengan hasil analisis isi (content analyze), berikut kutipan jawaban dari salah satu responden atas pertanyaan: apa saja upaya ibu selama ini untuk mengantisipasi tanda bahaya kehamilan tersebut? “dengan rutin periksa ke bidan/dokter dan berolahraga secara teratur dan mengikuti semua saran dari bidan”. dukungan utama yang dapat diberikan untuk meningkatkan tindakan ibu hamil dalam antisipasi tanda bahaya kehamilan antara lain dengan pemberian dukungan emosional dan penghargaan serta dukungan instrumental secara optimal. menurut smet (1994), dukungan emosional ditunjukkan dengan adanya penerimaan atau pemahaman oleh keluarga, kepedulian, perhatian, pujian atas keberhasilan responden, dan penerimaan terhadap keluh kesah responden. dukungan instrumental mencakup bantuan langsung yaitu bantuan keuangan, bantuan sarana, bantuan tenaga dan berbagai fasilitas lain yang diberikan secara langsung ketika responden memerlukan. bantuan ini diberikan dengan tujuan mempermudah ibu hamil dalam melakukan perawatan dan pemantauan kehamilan. kepedulian dan dorongan dari keluarga membuat ibu hamil merasa diperhatikan dan termotivasi untuk merawat dan menjaga kehamilan dengan hati-hati. simpulan dan saran simpulan dukungan sosial terutama dukungan keluarga memegang peran penting pada perilaku ibu primigravida dalam merawat dan menjaga kehamilan. ibu hamil manfaat dukungan sosial keluarga (aditiawarman) terutama ibu primigravida membutuhkan dukungan fisik dan psikologis yang harus dipenuhi. ibu hamil pun membutuhkan pengobatan, istirahat dan akan merasa bahagia mendapat pertolongan praktis. dukungan yang diberikan oleh keluarga (sebagai sumber terdekat yang dimiliki responden) akan menimbulkan respons antara lain merasa diterima, merasa diperhatikan, merasa dihargai, mendapatkan rasa aman dan mendapatkan kemudahan menyelesaikan kesulitan, sehingga dapat menghadapi kehamilan dengan lancar. saran peneliti menyarankan agar ibu hamil memerlukan perawatan dan pemantauan kehamilan intensif untuk menjaga kesehatan dan keselamatan ibu dan janin. peningkatan keterlibatan keluarga dengan memberikan dukungan kepada ibu hamil perlu dilakukan agar dapat membuat ibu hamil merasa nyaman. puskesmas perlu memberikan pendidikan kesehatan kepada keluarga terkait dengan pentingnya dukungan keluarga dan menyediakan jasa konsultasi bagi ibu hamil untuk mengantisipasi tanda bahaya kehamilan dan penelitian lebih lanjut dapat dilakukan untuk meneliti pengaruh dukungan keluarga terhadap motivasi ibu hamil dalam melakukan kunjungan anc. kepustakaan badan koordinasi keluarga berencana nasional. 2005. kehamilan dan risiko pemahaman terhadap kesejahteraan ibu, (online), (http://www.gemapria.bkkbn.go.id., diakses tanggal 19 april 2008, jam 12.00 wib). chairunnisya. 2002. isu mutakhir tentang komplikasi kehamilan, (online), (http://www.library.usu.ac.id., diakses tanggal 20 april 2008, jam 11.30 wib). fauzi. 2003. 17 darurat saat hamil, (online), (http://www.kesrepro.info.com., diakses tanggal 17 april 2008, jam 11.00 wib). friedman. 1998. keperawatan keluarga. edisi 3. jakarta: egc, hlm. 10-11. notoatmodjo. 2003. pendidikan dan perilaku kesehatan. jakarta: rineka cipta, hlm. 96. perry, et al. 1999. maternity nursing fifth edition. st. louis: mosby inc, pp. 7984. rochjati. 2005. skrining antenatal pada ibu hamil. surabaya: airlangga university press, hlm. 39, 138-155. skrt. 2001. fungsi ibu memang sulit diganti, (online), (http://www.balipost.co.id/balipostceta k/2006/12/17/kel2.html., diakses tanggal 18 april 2008, jam 07.00 wib). smet. 1994. psikologi kesehatan. jakarta: grasindo, hlm. 133, 136, 137, 140-143. wiludjeng, 2005. gambaran penyebab kematian maternal di rumah sakit, (online), (http://www.kalbe.co.id., diakses tanggal 20 april 2008, jam 08.00 wib). http://www.gemapria.bkkbn.go.id/ http://www.library.usu.ac.id/ http://www.kesrepro.info.com/ http://www.balipost.co.id/balipostcetak/2006/12/17/kel2.html http://www.balipost.co.id/balipostcetak/2006/12/17/kel2.html http://www.kalbe.co.id/ buah apel (romebeauty) menurunkan kadar gula darah pasien diabetes mellitus (apples (romebeauty) decrease blood glucose level on patient with diabetes mellitus) harmayetty*, yulis setya dewi*, dwi astutik* program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496 e-mail: zanno_yet@yahoo.com abstract introduction: the number of patients with diabetes mellitus (dm) in year 2001 was 5.6 million. in the year 2020, it is expected to reach 8.2 million. the diet of dm patients in pulorejo village comprised low calorie, sugar free, and low fiber diet. fiber consumed by these patients was taken from vegetables and banana. unfortunately, the use of such diet keep the patient's blood sugar level remains increasing. the content of water-soluble fiber (pectin) in apple is higher and is able to reduce blood sugar level. the objective of this study was to analyze the effect of apple consumption on blood sugar level. method: this study was used a quasy-experimental pre-post test purposive sampling design. samples who met to the inclusion criteria were 14 persons divided into treatment and control group. data were analyzed by using paired t-test (α=0.05) and independent t-test (α=0.05). result: the result showed that there was an effect of apple consumption on blood sugar level with paired t-test (p=0.000) for blood glucose level before and after intervention in treatment group, and (p=0.100) for blood glucose level before and after intervention in control group. the results of independent t-test revealed p=0.000 for blood glucose level after intervention in treatment and control groups. discussion: it’s can be concluded that there was an effect of apple consumption on blood sugar level in dm patients. the apple should be given in the best dose that can reduce blood sugar level, which is 2 x 150 g. the result of this study can be considered in as a material for diet promotion for the patients. further studies should be developed to measure the variables of stress and sex of the patients. keywords: apple, blood glucose level, diabetes mellitus pendahuluan penyebab peningkatan kadar gula darah pada pasien diabetes mellitus 75% karena tidak menjalani pengelolaan diet dengan tepat (savitri, 2006). pola makan pasien diabetes mellitus sama dengan pola makan orang sehat, namun pasien diabetes mellitus dianjurkan untuk mengkonsumsi diet rendah kalori, diet bebas gula dan diet kaya serat. diet rendah kalori terutama ditujukan pada pasien diabetes mellitus yang mempunyai kelebihan berat badan. total kalori yang dianjurkan tidak boleh melebihi kecukupan kalori pada pasien diabetes mellitus dengan berat badan normal yaitu 1500 kalori. diet bebas gula pada pasien diabetes mellitus dapat dilakukan dengan dua cara yaitu tidak mengkonsumsi gula sama sekali atau mengurangi konsumsi makanan yang berasal dari hidrat arang (siburian, 2004). pasien dm mengkonsumsi serat makanan yang lebih banyak diperoleh dari sayuran daripada buah. buah yang dikonsumsi sebagai makanan selingan dalam diet sehari-hari adalah buah pisang. dengan diet seperti yang tersebut di atas kadar gula darah pasien tetap tinggi. serat makanan terutama serat larut air diperlukan bagi pasien guna mengontrol kadar gula darah (almatsier, 2006). kebutuhan serat terutama serat larut air pasien diabetes mellitus adalah 25 gr/hari (hartono, 2000). sampai saat ini diet pasien diabetes mellitus di desa pulorejo masih terdiri dari diet rendah kalori, bebas gula dan rendah serat. selama ini pengetahuan pasien tentang diet tinggi serat terutama serat larut air kurang, sehingga pemilihan jenis makanan kurang tepat. akibat yang ditimbulkan adalah kadar gula darah yang tidak terkontrol. angka kejadian penyakit diabetes mellitus terus meningkat seiring dengan meningkatnya tingkat kemakmuran, berubahnya gaya hidup, pola makan dan bertambahnya usia. menurut mc. carty dan zimmet dikutip dari tjokroprawiro (2004) pada tahun 1994 terdapat 110,4 juta pasien diabetes mellitus di dunia, pada tahun 2000 diperkirakan akan meningkat menjadi 175,4 juta dan tahun 2010 menjadi 239,3 juta. menurut diabetic federation jumlah pasien diabetes mellitus pada tahun 2001 adalah 5,6 juta pada usia lebih dari 20 tahun dan pada tahun 2020 diperkirakan menjadi 8,2 juta (depkes ri, 2005). di indonesia pada tahun 1994 pasien diabetes mellitus mencapai 2,5 juta, tahun 2000 menjadi 4 juta dan tahun 2010 menjadi 5 juta. di jawa timur pasien diabetes mellitus pada tahun 1994 adalah 300 orang dari 33 juta penduduk (tjokroprawiro, 2004). di desa pulorejo jumlah pasien diabetes mellitus pada bulan januari sampai dengan desember adalah 25 orang (rekam medik puskesmas mentikan, 2006). jumlah pasien diabetes mellitus yang rajin kontrol ke puskesmas adalah 18 orang (rekam medik puskesmas mentikan, 2006). pada pasien diabetes mellitus untuk meningkatkan diet serat larut air salah satunya dengan mengkonsumsi buah apel. kandungan serat larut air (pektin) pada buah apel lebih besar dibandingkan kandungan serat larut air pada buah pisang yaitu 24% (0,7 gr) (moehyi, 1999). pasien diabetes mellitus di desa pulorejo tidak mengetahui manfaat buah apel terhadap pengontrolan kadar gula darah dan tidak ada yang menggunakan, sehingga pengaruh pemberian buah apel terhadap kadar gula darah belum diketahui dengan jelas. komponen penting pada buah apel adalah pektin, yang merupakan salah satu jenis serat larut air (aditama, 2006) dan dalam lambung pektin membentuk gel (hartono, 1996). bentukan gel tersebut menyebabkan penurunan waktu pengosongan lambung. hal tersebut menyebabkan penurunan waktu penyerapan glukosa di usus halus. akibat dari penurunan waktu penyerapan glukosa adalah kadar glukosa di dalam darah meningkat secara perlahan. peningkatan kadar glukosa darah secara perlahan tersebut tidak merangsang insulin yang berlebihan sehingga menyebabkan translokasi glut-4 (glucose transporter-4) ke membran sel untuk memudahkan glukosa masuk ke jaringan. masuknya glukosa ke dalam jaringan menyebabkan kadar glukosa di dalam darah turun. buah apel juga mempunyai nilai indeks glikemik yang rendah yaitu 38 (jelita, 2006). indeks glikemik adalah perhitungan kontribusi glikemik relatif dari berbagai makanan karbohidrat dibandingkan dengan daerah yang terbentuk sesudah pemberian makanan acuan dalam jumlah yang sama (greenspan and baxter, 2000). hal ini berarti bahwa kadar gula yang terdapat secara alami pada apel tidak akan memacu kecepatan naiknya gula darah. pemberian buah apel pada pasien diabetes mellitus sebaiknya diberikan 2 kali sehari yaitu pagi dan sore secara rutin (khomsan, 2006). berdasarkan penelitian sebelumnya tentang manfaat buah apel dalam menstabilkan gula darah, peneliti ingin meneliti tentang besar penurunan kadar gula darah pasien diabetes mellitus dengan pemberian buah apel dalam pengelolaan diet. tujuan dari penelitian ini untuk menganalisis pengaruh pemberian buah apel terhadap kadar gula darah pada pasien dengan diabetes mellitus di desa pulorejo wilayah kerja puskesmas mentikan prajurit kulon kota mojokerto. bahan dan metode penelitian ini menggunakan desain penelitian quasy eksperimental nonrandomized control group pre–post test design. populasi dalam penelitian ini adalah semua pasien diabetes mellitus (tipe 1 dan tipe 2) di desa pulorejo wilayah kerja puskesmas mentikan prajurit kulon kota mojokerto. teknik sampling yang digunakan dalam penelitian ini adalah purposive sampling, dengan besar sampel 14 responden yang terdiri dari 7 responden kelompok perlakuan (gda 383-590 mg/dl) dan 7 responden kelompok kontrol (gda 201-379 mg/dl). penelitian dilaksanakan pada tanggal 9–22 januari 2007. variabel independen dalam penelitian ini adalah buah apel, sedangkan variabel dependen adalah kadar gula darah pasien diabetes mellitus. peneliti melakukan observasi sebelum pemberian buah apel dan sesudah pemberian buah apel pada kelompok kontrol dan kelompok intervensi. instrumen yang digunakan dalam penelitian ini adalah lembar observasi tentang diet, olahraga, obat dan kadar gula darah acak. alat yang digunakan untuk melakukan pemeriksaan kadar gula darah acak adalah smart scan. data yang diperoleh, dianalisis dengan menggunakan uji statistik kolmogorovsmirnov test, independen t-test dan paired ttest dengan α≤0,05. hasil berdasarkan gambar 1 didapatkan data responden bedasarkan usia, pada kelompok perlakuan 6 orang (86%) berusia 40-50 tahun dan 1 orang (14%) berusia 51-60 tahun. pada kelompok kontrol 3 orang (43%) berusia 4050 tahun dan 4 orang (57%) berusia 51-60 tahun. pada tabel 1 juga dapat dilihat kadar gula darah pasien sebelum pemberian buah apel sangat bervariasi dari rentang 201-590 mg/dl. penurunan rerata gula darah setelah pemberian buah apel pada kelompok perlakuan (dosis 2x150 gr) adalah 211 mg/dl. penurunan rerata gula darah setelah pemberian buah apel pada kelompok kontrol (dosis 2x100 gr) adalah 52,14 mg/dl. pada 2 responden kelompok perlakuan (dosis 2x150 gr) dengan kadar gula darah awal yang sama, menghasilkan penurunan kadar gula darah yang berbeda yaitu 200 mg/dl dan 284 mg/dl. pada 2 responden kelompok kontrol hasil kadar gula darah setelah pemberian buah apel mengalami kenaikan yaitu 38 mg/dl dan 46 mg/dl. hasil ini menunjukkan bahwa penurunan gula darah setelah pemberian buah apel dosis 2x150 gr lebih besar dibandingkan dosis 2x100 gr. hasil uji statistik paired t-test menunjukkan p=0,000, yang berarti ada pengaruh pemberian buah apel terhadap kadar gula darah pasien diabetes mellitus. pada kelompok kontrol (dosis 2x100 gr) terdapat penurunan rerata gula darah 52,14 mg/dl. hasil uji statistik paired t-test menunjukkan p=0,100, berarti tidak ada pengaruh penurunan kadar gula darah dengan pemberian buah apel terhadap kadar gula darah pasien diabetes mellitus. hasil uji statistik independent t-test kadar gula darah setelah pemberian buah apel pada kelompok perlakuan dan kelompok kontrol menunjukkan p=0,000, berarti ada pengaruh pemberian buah apel terhadap kadar gula darah pasien diabetes mellitus. gambar 1. distribusi pasien diabetes mellitus berdasarkan usia pada tanggal 9-22 januari 2007 di desa pulorejo. tabel 1. kadar gula darah pasien diabetes melitus antara kelompok perlakuan dan kelompok kontrol di desa pulorejo tanggal 9-22 januari 2007 no perlakuan kontrol perlakuan kontrol apel 2 x 150 gram apel 2 x 100 gram pre post selisih pre post selisih post post rerata 489,29 278,29 211 257,14 205 52,143 278,29 205 sd 74,683 64,778 35,861 60,309 57,752 71,015 64,778 57,7523 uji analisis paired t-test (p=0,000) paired t-test (p=0,100) independent t-test p=0,000 keterangan: p = signifikansi sd = standar deviasi pembahasan berdasarkan hasil pemeriksaan kadar gula darah acak sebelum dan setelah kelompok kontrol 4(57%) 3 (43%) 51-60 tahun 40-50 tahun kelompok perlakuan 6 (86%) 1(14%) 40-50 tahun 51-60 tahun pemberian buah apel antara kelompok perlakuan dan kelompok kontrol didapatkan bahwa setelah diberikan buah apel terdapat penurunan rerata kadar gula darah. komponen penting pada buah apel adalah pektin 24% (0,7 gr). selain pektin tiap 100 gr buah apel mengandung 58 kkal energi, 4 gr lemak, 3 gr protein, 14,9 gr karbohidrat, 900 iu vitamin a, 7 mg tiamin, 3 mg riboflavin, 2 mg niacin, 5 mg vitamin c, 0,04 mg vitamin b1, 0,04 mg vitamin b2, 6 mg kalsium, 3 mg zat besi, 10 mg fosfor dan 130 mg potasium. apel juga memiliki karoten sebagai vitamin a dan antioksidan (sianturi, 2003). kandungan buah apel yang berperan dalam menstabilkan kadar gula darah adalah pektin (aditama, 2006) yang akan membentuk gel di dalam lambung (hartono, 1996). bentukan gel tersebut menyebabkan penurunan waktu pengosongan lambung dan peningkatan rasa kenyang. penurunan waktu pengosongan lambung dapat menyebabkan penurunan waktu penyerapan glukosa di usus halus (brunner dan suddarth, 2002). dengan demikian kadar glukosa di dalam darah meningkat secara perlahan dan tidak merangsang sekresi insulin yang berlebihan sehingga menyebabkan translokasi glut-4 ke membran sel (apache, 2001, guyton dan hall, 1997). hal ini memudahkan masuknya glukosa ke dalam jaringan. masuknya glukosa ke dalam jaringan menyebabkan kadar gula di dalam darah turun. diet pasien diabetes mellitus terdiri dari diet rendah kalori, bebas gula dan diet kaya serat terutama serat larut air. kebutuhan serat larut air pasien diabetes mellitus adalah 25 gr/hari (hartono, 2000). kebutuhan serat ini dapat diperoleh dari sayuran dan buah. tiap 100 gr buah apel mengandung pektin 24% (0,7 gr). dengan pemberian buah apel 2x150 gr/hari memberikan kontribusi pada kebutuhan serat sebesar 2,2 gr. dengan pemberian buah apel 2x100 gr memberikan kontribusi pada kebutuhan serat sebesar 1,4 gr. dari hasil di atas menunjukkan bahwa semakin banyak jumlah serat yang dikonsumsi, maka semakin besar jumlah penurunan kadar gula darah (jelita, 2006). simpulan dan saran simpulan pemberian buah apel dosis 2x150 gr dapat menurunkan kadar gula darah pasien diabetes mellitus dan pengaturan diet pada pasien diabetes mellitus harus tetap memperhatikan kaidah terapi nutrisi pada pasien diabetes mellitus yaitu tepat jumlah, jenis dan jam pemberian. saran peneliti menyarankan agar hasil penelitian ini dapat dijadikan sebagai materi penyuluhan diet pasien diabetes mellitus pada puskesmas setempat dan perlu dilakukan penelitian lebih lanjut dengan mempertimbangkan variabel yang lain seperti jumlah kalori yang dikonsumsi, stres, jenis kelamin dan aktivitas. kepustakaan aditama, c. 2006. gaya hidup sehat (online), (http//www. portal.cbn.net.id., diakses tanggal 7 nopember 2006, jam 10.53 wib). almatsier, s. 2006. penuntun diet edisi baru. jakarta: gramedia pustaka utama, hlm. 137-138. apache. 2001. transpor glucose, (online), (http//web.macam.ac.id., diakses tanggal 14 nopember 2006, jam 12.15 wib). brunner dan suddarth. 2002. keperawatan medikal bedah. edisi 8 vol. 2. jakarta: buku kedokteran egc, hlm. 12201274. departemen kesehatan r.i. 2005. diabetes mellitus masalah kesehatan masyarakat yang serius, (online), (http//www.depkes.go.id., diakses tanggal 27 september 2006, jam 09.15 wib). “dietary treatment of diabetes mellitus”, 2006. the new england journal of medicine, (online), (http//www.content.nejm.org., diakses tanggal 7 nopember 2006, jam 10.12 wib). greenspan dan baxter, 2000. endokrinologi dasar dan klinik. edisi 4. jakarta: buku kedokteran egc. guyton dan hall. 1997. fisiologi kedokteran. edisi 9. jakarta: buku kedokteran egc, hlm. 1221-1222. hartono, a. 1996. tanya jawab diet penyakit gula. jakarta: arcan, hlm. 19. hartono, a. 2000. asuhan nutrisi rumah sakit. jakarta: buku kedokteran egc. jelita. 2006. fungsi serat. (online), (http//www.sabah.htm., diakses tanggal 12 oktober 2006, jam 20.00 wib). khomsan, a. 2006. sehat dengan makanan berkhasiat. jakarta: buku kompas, hlm. 25-27. moehyi, s. 1999. pengaturan makanan dan diet untuk penyembuhan penyakit. jakarta: gramedia pustaka utama, hlm. 106-108. rekam medik puskesmas mentikan, 2006. data pasien diabetes mellitus tahun 2006. savitri. 2006. pusat perawatan diabetes, (online), (http//www.thamrinhospital.com., diakses tanggal 17 agustus 2006, jam 09.30 wib). sianturi, g. 2003. apel buah ajaib penangkal penyakit, (online), (http//www.gizi.net., diakses tanggal 27 september 2006, jam 09.30 wib). siburian, p. 2004. pemberian makanan pengganti pada penderita diabetes melitus, (online), (http//www.waspada.co.id., diakses tanggal 17 agustus 2006, jam 09.20 wib). tjokroprawiro, a. 2004. hidup sehat dan bahagia bersama diabetes. jakarta: gramedia. http://e-journal.unair.ac.id/jners 101 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 101-107 http://dx.doi.org/10.20473/jn.v18i2.41471 original article open access wireless stethoscope for auscultation of the heart and lungs in critically ill patients: a systematic review suhartini ismail 1 * , ricky prawira 1 , andrew johan 1 , and rifky ismail 2 1 faculty of medicine, universitas diponegoro, semarang, indonesia 2 faculty of engineering, universitas diponegoro, semarang, indonesia *correspondence: suhartini ismail. address: faculty of medicine, universitas diponegoro, semarang, indonesia. email: suhartini.ismail@fk.undip.ac.id responsible editor: ilya krisnana received: 12 december 2022 ○ revised: 29 march 2023 ○ accepted: 30 march 2023 abstract introduction: examining the heart and lungs is necessary for critically ill patients, as these individuals may have abnormalities with either or both of these organs. this review systematically determined how the auscultation of the heart and lungs using a wireless stethoscope affected the results. methods: the research design used was a systematic review following preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. databases were searched using the search terms “auscultation," "critical patients," and "stethoscope wireless” and associated mesh terms. the abstracts of the selected articles were examined independently by two researchers. a systematic search was conducted through several databases (scopus, pubmed, jstor, and springer-link), which were published from july 2012 to july 2022 .after reading the full content of the included studies, key themes and concepts were extracted and synthesized. results: in total 142 articles were screened. five articles met the inclusion criteria and were analyzed. the analysis revealed that wireless stethoscopes have increased sensitivity with indicators capable of diagnosing abnormal auscultation results in patients who have abnormal aucultation results on the gold standard. three out of five studies suggested that the auscultation of the heart and lungs by wireless stethoscopes are more sensitive, while two other studies stated that wireless stethoscopes have the same sensitivity as manual acoustic stethoscopes. conclusions: based on this systematic review, a wireless stethoscope may be more sensitive than an acoustic one. nevertheless, due to limited studies, a more well-controlled human study is warranted to be done. keywords: auscultation, critical patient, stethoscope wireless introduction technological advances are currently growing very rapidly in all fields, including the health sector, which affects both patients and health workers. technological advancements in the health sector, particularly medical devices, are needed by health workers because those devices play a pivotal role in supporting their work (tian et al., 2019). since its first invention, the stethoscope has undergone some transformative improvements, including the introduction of electronic systems in the last two decades. improvement in technology has led to the advancement of electronic stethoscope design that dramatically reduces external noise contamination through hardware redesign and dynamic signal processing (mclane et al., 2021). a stethoscope is a typical medical acoustic equipment used to listen to the noise in the human body, making it one of the most important tools used by nurses and other healthcare professionals (qu et al., 2021). stethoscopes are considered one of the most valuable medical devices because they are non-invasive, real-time, and provide informative information (sarkar https://creativecommons.org/licenses/by/4.0/ mailto:suhartini.ismail@fk.undip.ac.id https://orcid.org/0000-0002-6714-3212 https://orcid.org/0000-0001-5172-0823 https://orcid.org/0000-0002-9854-7607 https://orcid.org/0000-0003-0445-3405 ismail, prawira, johan, and ismail (2023) 102 p-issn: 1858-3598  e-issn: 2502-5791 et al., 2015). in professional healthcare, nurses frequently use stethoscopes to assist the voice or auscultate both when listening to heart sounds, lungs, and systolic and diastolic pressures, thus, making the stethoscope an indispensable tool in carrying out its work (pratiwi et al., 2021). patient monitoring has evolved over the years, including critically ill patients, from the use of monitors to the development of devices that can be used to monitor patients, especially monitoring the patient's vital signs, to check whether their health is normal or deteriorating for some time (barnett et al., 2022). in addition to monitoring vital signs, finding the cause of decreased vital signs must be done by carrying out a physical examination of these vital organs, one of which is by auscultation. the critical patient is physiologically unstable patient and experiences dysfunctional disorder, namely multi-organ failure, and his survival depends on sophisticated therapy and monitoring tools. in addition, in addition, critical patients have changes in physiological function which affect vital signs and these changes can get worse at any time so this situation can be life-threatening (saketkoo et al., 2021). one of the physical examinations that must be carried out by nurses in critical patients is by carrying out auscultation of the heart and lungs to find out any abnormalities in these organs (harcharran, 2022). abnormal sounds that are usually heard when auscultating the lungs in critical patients, namely wheezes, stridor, crackles while on auscultation of the heart, friction rub and gallop, although not all critical patients have these sounds (mehmood et al., 2014). poor auscultation results can affect the accuracy in carrying out care and treatment so that the treatment of patients is not optimal and causes lengthy treatment (hu et al., 2017). factors that can improve the quality of auscultation, namely the use of a stethoscope that has a good level of sensitivity as well as the use of a more flexible stethoscope can assist nurses in carrying out auscultation, especially in critical patients because such patients often have other tools in their bodies that interfere with the auscultation process (goldsworthy et al., 2021). stethoscopes have experienced better development starting from the use of wireless which can help stethoscopes become more flexible, this is because there is no dangling tubing which limits auscultation (andrès et al., 2018; swarup & makaryus, 2018). some studies have compared acoustic and wireless stethoscopes in clinical settings. wireless stethoscopes were compared with standard stethoscopes and concluded that acoustic stethoscopes were preferred. however, they suggested that an ideal stethoscope would combine the advantages of both acoustic and wireless stethoscopes (høyte et al., 2005; iversen et al., 2006). wireless stethoscope is a solution to solve the problem of remote auscultation (perri, 2010). additionally, wireless stethoscopes have another advantage over classic stethoscopes, namely that they can increase the sound produced (a‐mohannadi et al., 2022); and contribute to better performance on auscultation, as personalized adjustments can be made (høyte et al., 2005b). they cannot, however, be used in noisy environments because wireless stethoscopes are very sensitive to sound waves. however, there is limited evidence that compares the sensitivity of wireless stethoscopes for diagnostic purposes with an acoustic stethoscope. thus, this review systematically assessed studies investigating the sensitivity of using a wireless stethoscope compared to acoustic wireless in critically ill patients. materials and methods this systematic review was conducted by the prisma guidelines (page et al., 2021). systematic reviews can facilitate the critical roles in providing a synthesis of knowledge statements and addressing answered phenomena. search strategy we conducted an exploration of the title and abstract in four databases: scopus, pubmed, jstor, and springer-link. articles published from july 2012 to july 2022 were searched using a comprehensive search strategy. we constructed the search keywords in this systematic review based on picos (patient, intervention, control, outcome, and study design). in this review, the subject was a critically ill patient; the study used a digital wireless stethoscope, compared wireless stethoscopes and acoustic stethoscopes, and the outcome was sensitivity in determining auscultation for diagnostics. therefore, we used several main keywords such as (stethoscope wireless or digital stethoscope) and (auscultation) and (critical ill or critical patients). a complete search can be found in supplementary table 3. inclusion and exclusion criteria the inclusion criteria were full paper articles with quantitative research methods comparing the sensitivity of wireless stethoscopes and acoustic stethoscopes. the jurnal ners http://e-journal.unair.ac.id/jners 103 exclusion criteria in this study were non-quantitative studies, the articles were not full text and were not published in english. search outcomes a total of 142 potentially relevant articles were initially identified in the four databases. a total of 135 of those remained after duplications were removed using endnote software. next, the titles and abstracts of those articles were read one by one for further screening, after which the remaining 10 full-text articles were further assessed for eligibility. subsequently, five of those articles were excluded for various reasons (i.e., did not compare the sensitivity of wireless stethoscopes and was not tested by health workers). finally, five studies were deemed eligible for inclusion in this review (figure 1). the study selection process was carried out by two of this study's authors (rp and si) independently, after which they reached an agreement. there was no disagreement between the two authors during the selection process. assessment of methodological quality the methodological quality of the articles was assessed using the jbi critical assessment checklist guidelines. the instruments used consist of two types which are adjusted based on the research design according to the screening in this screening system. the instruments were the jbi critical appraisal checklist for randomized controlled trial studies which consists of 13 questions, and the jbi critical appraisal checklist for analytical cross-sectional studies which consists of eight questions. the jbi critical assessment checklist is an instrument used to assess the methodological quality of figure 1 prisma diagram of the systematic data searching and extraction identification of studies via databases and registers records identified through database searching (n = 142): scopus (n = 81), pubmed (n = 3), jstor (n = 5), springerlink (n = 53). records removed before the screening: duplicate records removed (n = 7) records after duplicates removed (n = 135) records excluded based on title/abstract (n = 123) reports sought for retrieval. (n = 12) reports not retrieved not full-text (n = 2) reports assessed for eligibility (n = 10) reports excluded: not quantitative studies not discuss the sensitivity of wireless stethoscopes (n = 5) studies included in the review (n = 5) id e n ti fi c a ti o n s c r e e n in g in c lu d e a d table 1. quality assessment for rct studies authors checklist criteria for rct studies 1 2 3 4 5 6 7 8 9 10 11 12 13 (kalinauskienė et al., 2019) y y y y y y y y y y y y y (hirosawa et al., 2021b) y y y y y y y y y y y y y (gottlieb et al., 2018) y y y y y y y y y y y y y (islam et al., 2019) y y y y y y y y y y y y y y = yes; n = no; u = unclear. 1. was true randomization used for assignment of participants to treatment groups? 2. was allocation to treatment groups concealed? 3. were treatment groups similar at the baseline? 4. were participants blind to treatment assignment? 5. were those delivering treatment blind to treatment assignment? 6. were outcomes assessors blind to treatment assignment? 7. were treatment groups treated identically other than the intervention of interest? 8. was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? 9. were participants analyzed in the groups to which they were randomized? 10. were outcomes measured in the same way for treatment groups? 11. were outcomes measured in a reliable way? 12. was appropriate statistical analysis used? 13. was the trial design appropriate, and any deviations from the standard rct design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial? ismail, prawira, johan, and ismail (2023) 104 p-issn: 1858-3598  e-issn: 2502-5791 a study and to assess the extent to which the review has addressed possible biases in its design, intervention, and analysis. data extraction and synthesis two authors (rp and si) independently extracted data from all of the included studies into excel spreadsheets. any disagreements during the data extraction process were resolved through un-blinded discussion. the authors extracted data into five main categories: (a) study information including the author(s), year of publication, and study country; (b) populations; (c) research design; (d) measurements; and (e) findings. narrative synthesis was applied to analyze and explain the findings in this study (popay et al., 2006). the process included listing data for the included studies, identifying the type of study being performed, and displaying the sensitivity results of the wireless stethoscope. results characteristics of included studies the number of participants in those studies ranged from 30 to 60. two of the studies were conducted in the united states of america (gottlieb et al., 2018; kalinauskienė et al., 2019), one in japan (hirosawa et al., 2021), one in china (zhang et al., 2021), and one in bangladesh (islam et al., 2019). four of the studies collected their data using randomized controlled trial design (gottlieb et al., 2018; hirosawa et al., 2021; islam et al., 2019; kalinauskienė et al., 2019), and one used a cross-sectional design (zhang et al., 2021). all studies compared wireless stethoscopes to the gold standard for sensitivity (gottlieb et al., 2018; hirosawa et al., 2021; islam et al., 2019; kalinauskienė et al., 2019; zhang et al., 2021) type of wireless stethoscope sensitivity table 2 quality assessment for cross-sectional studies authors checklist criteria for cross-sectional studies 1 2 3 4 5 6 7 8 (zhang et al., 2021) y y y y y y y y y = yes; n = no; u = unclear. 1.were the criteria for inclusion in the sample clearly defined? 2.were the study subjects and the setting described in detail? 3.was the exposure measured in a valid and reliable way? 4.were objective, standard criteria used for measurement of the condition? 5.were confounding factors identified? 6.were strategies to deal with confounding factors stated? 7.were the outcomes measured in a valid and reliable way? 8.was appropriate statistical analysis used? table 3 summary of articles included in the systematic review authors, year, country population research design type of wireless stethoscopes findings kalinauskiene et al. (2019) usa patients with body mass index >30 kg/m2 (obese), were older than 18 years, were referred for an echocardiogram, and agreed to participate in the study. randomized controlled trial (rct) compare the 3m littmann 3200 electronic stethoscope and 3m littman cardiology iii mechanical stethoscope wireless stethoscopes have a higher sensitivity value than acoustic stethoscopes, namely 60.1% vs 45.7%, p<0.0001. zhang et al. (2021) china patients with sars-cov2 pneumonia. cross-sectional assessing a wireless stethoscope in critically ill patients with sarscov-2 pneumonia there was no significant difference between the traditional acoustic stethoscope and the stethoscope for lung and heart auscultation. however, the stemoscope used in this study is easy and comfortable to use. hirosawa et al. (2021) japan senior residents and faculty in the department of general internal medicine of a university hospital. randomized controlled trial (rct) compare the electronic stethoscope wireless and traditional stethoscope a listening system using a bluetoothconnected electronic stethoscope has comparable results to listening with a traditional stethoscope; other than that the total combined test score was 80/110 (72.7%) in the intervention group and 71/90 (78.9%) in the control group, with no differences between the groups (p=.32). gottlieb et al. (2018) usa internal medicine resident participants were randomly selected to hear either the analog or electronic lung sounds. randomized controlled trial (rct) compare the electronic stethoscope wireless and analog stethoscope there was no significant difference in overall auscultation scores of lung sounds using analog and electronic stethoscopes. islam et al. (2019) bangladesh pediatric patients who have abnormal and normal heart sounds. randomized controlled trial (rct) assessing pediatric patients with abnormal and normal heart sounds using the wireless electronic stethoscope there is an increase in the sensitivity of the wireless stethoscope and has high accuracy. stethoscopes have a sensitivity value of 95 (12%). jurnal ners http://e-journal.unair.ac.id/jners 105 all data collection techniques were performed by comparing the wireless stethoscope auscultation results with the gold standard. several types of stethoscopes were found that had been designed using a wireless network (gottlieb et al., 2018; hirosawa et al., 2021; islam et al., 2019; zhang et al., 2021), while another study used a 3m littmann 3200 electronic stethoscope connected wirelessly (kalinauskienė et al., 2019). all studies were tested by experts, namely: internal medicine (gottlieb et al., 2018; hirosawa et al., 2021; zhang et al., 2021), cardiologist (kalinauskienė et al., 2019), and pediatrician islam et al., 2019). outcomes three out of five studies stated that auscultation of the heart and lungs using a wireless stethoscope was more sensitive, this is because wireless stethoscopes are very sensitive to sound waves and have features that can amplify sound volume compared to acoustic stethoscopes (hirosawa et al., 2021; islam et al., 2019; kalinauskienė et al., 2019), whereas two other studies suggested that wireless stethoscopes have the same sensitivity as acoustic stethoscopes (gottlieb et al., 2018; zhang et al., 2021). wireless stethoscopes have a higher sensitivity value than acoustic stethoscopes, namely (60.1% vs 45.7% , p <0.0001) (kalinauskienė et al., 2019), while other studies state that wireless stethoscopes have a sensitivity value of 95.12% (islam et al., 2019), other than that the total combined test score was 80/110 (72.7%) in the intervention group and 71/90 (78.9%) in the control group, with no differences between the groups (p=.32) on wireless stethoscope testing (hirosawa et al., 2021). two other studies state that wireless stethoscopes and acoustic stethoscopes do not have a significant difference in value for listening to heart and lung sounds (gottlieb et al., 2018; zhang et al., 2021). advantages associated with wireless stethoscopes this overview found that wireless stethoscopes are more flexible in their use because wireless stethoscopes do not have dangling tubing, besides which wireless stethoscopes can amplify the auscultation of the sound produced so that they are more sensitive in their use (hirosawa et al., 2021; islam et al., 2019; kalinauskienė et al., 2019). another study stated that wireless stethoscopes have drawbacks, namely they are very sensitive to sound waves from very noisy environments, so they can affect the auscultation results (gottlieb et al., 2018; zhang et al., 2021). discussions this literature review analyzed the findings of five articles featuring digital stethoscope testing that met inclusion criteria in various populations. although the results of this review are not representative of the healthcare profession as a whole, they can provide an overview of digital stethoscope testing. we analyzed research papers on the sensitivity and specificity results of digital stethoscopes. this systematic review found that wireless stethoscopes may have increased sensitivity concerning auscultation in the heart and lung compared with manual acoustic stethoscopes. this may be because digital stethoscopes can improve the quality of the sound produced during auscultation. visualizing sonograms during auscultation may facilitate discrimination between different types of heart and lung sounds (hirosawa et al., 2021b), and may improve sound quality (tavel, 1996), which may contribute to improved auscultatory performance. adjustments can also be made (høyte et al., 2005). additionally, findings regarding wireless stethoscopes and manual acoustic stethoscopes show they have the same sensitivity. this is obtained because the development of manual acoustic stethoscopes that have tubing has often been carried out so that the auscultation results produced have high sensitivity. in addition, another study on a bluetooth-based wireless stethoscope found that the measurement results were comparable to direct auscultation (hirosawa et al., 2021), can eliminate external noise by using a bandpass filter and adaptive line enhancement techniques (lakhe et al., 2016), use can be made using data transmission using bluetooth with a distance of 3 meters 17 and a bluetooth-based wireless stethoscope has the same function as an acoustic stethoscope (sumartono, 2021). more and more evidence shows that wireless stethoscopes have advantages over manual acoustic stethoscopes, including wireless stethoscopes that are considered more flexible in their use (zhang et al., 2021). the wireless statoscope positively impacts healthcare providers, particularly nurses, while taking care of patients during pandemic sessions (hidayat et al., 2021). a study showed that the development of a programmed wireless statoscope based on an efficient net would give accurate information to detect heartbeat sounds (haq et al., 2021). in development of a wireless stethoscope with no modifications, the tube can be carried easily and flexibly because this device only consists of two parts, namely a modified diaphragm chest piece and for listening to it through a headset. ismail, prawira, johan, and ismail (2023) 106 p-issn: 1858-3598  e-issn: 2502-5791 this device is suitable for use by nurses in critical areas because of its high mobility without disturbing the function of the stethoscope, namely to assist nurses in performing auscultation of the heart and lungs. in addition, several other studies on bluetooth-based wireless stethoscopes explain that the design of wireless electronic stethoscopes eliminates the cable connecting conventional stethoscopes, which offers ease of use and mobility, makes them easy to carry everywhere, minimizes the spread of infection and facilitates auscultation training for health practitioners where it can be used simultaneously for evaluation (mills et al., 2012). based on studies that found that wireless stethoscopes have a suggestion of increased sensitivity of auscultation heart and lungs compared with manual acoustic stethoscopes, the increased sensitivity makes wireless stethoscopes to be considered for use, particularly in critical patients with heart and lung problems (hirosawa et al., 2021b; islam et al., 2019; kalinauskienė et al., 2019). additionally, wireless stethoscopes can be used in auscultated obese patients, wherein they can hear a smaller sound, while wireless stethoscopes that use digital products can amplify the sound produced (chowdhury et al., 2019). the resulting sound enhancement is because the wireless stethoscope has a special feature, namely filter settings. previous research explained that the filter setting can produce low and strong heart and lung signal frequencies and is quite sensitive (jusak et al., 2020). with this, wireless stethoscopes have better auscultation results and can become assistive technologies from existing manual systems. in addition, a wireless-based stethoscope can reduce noise and improve listening to heart or lung sounds to minimize errors. previous research has reported that a digital stethoscope with a condenser mic feature connected to a pre-amplifier can amplify voice signals up to 28.2 times; this can make a solution to the current stethoscope problem (kurniawan, 2017). the use of a wireless stethoscope still has problems, namely that it can be influenced by other signals around the environment so that it disrupts the sound transmission process. besides that, a noisy environment can affect the quality of auscultation results, this is because wireless stethoscopes are very sensitive to sound waves from the surrounding environment. this wireless stethoscope problem should continue to be addressed to produce a higher quality stethoscope (mclane et al., 2021). conclusions a wireless stethoscope to assist patients in a physical examination can be recommended for further research. the usefulness and ease of a wireless stethoscope in the practical patient assessment can be used by the patients and their families too. we agree that a wireless stethoscope for auscultation of the heart and lungs in critically ill patients can facilitate professional healthcare for the assessment of the patients without any obstacles. acknowledgment this study is supported by the ministry of education and culture with the scheme of research for master students, 2022. funding source this research uses ministry of education and culture funding with the scheme of research for master students, 2022. conflict of interest there is no conflict of interest. references a‐mohannadi, a., kunhoth, j., najeeb, a. a., al‐maadeed, s., & sadasivuni, k. k. (2022). conventional clinical methods for predicting heart disease. predicting heart failure: invasive, non‐ invasive, machine learning and artificial intelligence based methods, 23–46. andrès, e., gass, r., charloux, a., brandt, c., & hentzler, a. (2018). respiratory sound analysis in the era of evidence-based medicine and the world of medicine 2.0. journal of medicine and life, 11(2), 89–106. barnett, c. f., o’brien, c., & de marco, t. (2022). critical care management of the patient with pulmonary hypertension. european heart journal. acute cardiovascular care, 11(1), 77–83. https://doi.org/10.1093/ehjacc/zuab113 chowdhury, m. e. h., khandakar, a., alzoubi, k., mansoor, s., tahir, a. m., ibne reaz, m. bin, & emadi, n. al. (2019). real-time smartdigital stethoscope system for heart diseases monitoring. sensors (switzerland), 19(12). https://doi.org/10.3390/s19122781 goldsworthy, s., gomes, p., coimbra, m., patterson, j. d., langille, j., perez, g., & fasken, l. (2021). do basic auscultation skills need to be resuscitated? a new strategy for improving competency among nursing students. nurse education today, 97, 104722. gottlieb, e. r., aliotta, j. m., & tammaro, d. (2018). comparison of analogue and electronic stethoscopes for pulmonary auscultation by internal medicine residents. postgraduate medical journal, 94(1118), 700–703. https://doi.org/10.1136/postgradmedj-2018136052 haq, h. f. d. u., ismail, r., ismail, s., purnama, s. r., warsito, b., setiawan, j. d., & wibowo, a. (2021). efficientnet optimization on heartbeats sound classification. 2021 5th international conference on informatics and computational sciences (icicos), 216–221. https://doi.org/10.1109/icicos53627.2021.9651818 harcharran, m. (2022). assessment and examination of the cardiovascular system. practice nursing, 33(3), 98–104. hidayat, l., ismail, r., mesin, d. t., teknik, f., diponegoro, u., material, b., mechatronics, b., keperawatan, d. i., kedokteran, f., & diponegoro, u. (2021). evaluasi persepsi kegunaan , dan kemudahan , wireless stethoscope. 9(1), 143–148. hirosawa, t., harada, y., ikenoya, k., kakimoto, s., aizawa, y., & jurnal ners http://e-journal.unair.ac.id/jners 107 shimizu, t. (2021a). the utility of real-time remote auscultation using a bluetooth-connected electronic stethoscope: open-label randomized controlled pilot trial. jmir mhealth and uhealth, 9(7), 1–11. https://doi.org/10.2196/23109 hirosawa, t., harada, y., ikenoya, k., kakimoto, s., aizawa, y., & shimizu, t. (2021b). the utility of real-time remote auscultation using a bluetooth-connected electronic stethoscope: open-label randomized controlled pilot trial. jmir mhealth and uhealth, 9(7), e23109. https://doi.org/10.2196/23109 høyte, h., jensen, t., & gjesdal, k. (2005a). cardiac auscultation training of medical students: a comparison of electronic sensorbased and acoustic stethoscopes. bmc medical education, 5, 1–6. https://doi.org/10.1186/1472-6920-5-14 høyte, h., jensen, t., & gjesdal, k. (2005b). cardiac auscultation training of medical students: a comparison of electronic sensorbased and acoustic stethoscopes. bmc medical education, 5(1), 14. https://doi.org/10.1186/1472-6920-5-14 hu, x., ma, x., zhao, q., yan, w., ge, x., jia, b., liu, f., wu, l., ye, m., & liang, x. (2017). pulse oximetry and auscultation for congenital heart disease detection. pediatrics, 140(4). islam, m. r., hassan, m. m., raihan, m., datto, s. k., shahriar, a., & more, a. (2019). a wireless electronic stethoscope to classify children heart sound abnormalities. 2019 22nd international conference on computer and information technology (iccit), 1– 6. https://doi.org/10.1109/iccit48885.2019.9038406 iversen, k., søgaard teisner, a., dalsgaard, m., greibe, r., timm, h. b., skovgaard, l. t., hróbjartsson, a., copenhagen, ø., copenhagen, s., & copenhagen, k. (2006). effect of teaching and type of stethoscope on cardiac auscultatory performance. american heart journal, 152(1), 85.e1-85.e7. https://doi.org/https://doi.org/10.1016/j.ahj.2006.04.013 jusak, j., puspasari, i., & kusumawati, w. i. (2020). pengolahan sinyal phonocardiography (pcg) teori, aplikasi dan riset. kalinauskienė, e., razvadauskas, h., morse, d. j., maxey, g. e., & naudžiūnas, a. (2019). a comparison of electronic and traditional stethoscopes in the heart auscultation of obese patients. medicina (lithuania), 55(4). https://doi.org/10.3390/medicina55040094 kurniawan, d. (2017). rancang bangun alat deteksi suara paru-paru untuk menganalisa kelainan paru-paru berbasis android. elinvo (electronics, informatics, and vocational education), 2(2), 156– 168. lakhe, a., sodhi, i., warrier, j., & sinha, v. (2016). development of digital stethoscope for telemedicine. journal of medical engineering & technology, 40(1), 20–24. mclane, i., emmanouilidou, d., west, j. e., & elhilali, m. (2021). design and comparative performance of a robust lung auscultation system for noisy clinical settings. ieee journal of biomedical and health informatics, 25(7), 2583–2594. https://doi.org/10.1109/jbhi.2021.3056916 mehmood, m., abu grara, h. l., stewart, j. s., & khasawneh, f. a. (2014). comparing the auscultatory accuracy of health care professionals using three different brands of stethoscopes on a simulator. medical devices (auckland, n.z.), 7, 273–281. https://doi.org/10.2147/mder.s67784 mills, g. a., nketia, t. a., oppong, i. a., & kaufmann, e. e. (2012). wireless digital stethoscope using bluetooth technology. international journal of engineering science and technology (ijest), 4(08). page, m. j., mckenzie, j. e., bossuyt, p. m., boutron, i., hoffmann, t. c., mulrow, c. d., shamseer, l., tetzlaff, j. m., akl, e. a., brennan, s. e., chou, r., glanville, j., grimshaw, j. m., hróbjartsson, a., lalu, m. m., li, t., loder, e. w., mayo-wilson, e., mcdonald, s., … moher, d. (2021). the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj, 372. https://doi.org/10.1136/bmj.n71 perri, a. g. (2010). high quality heart and lung auscultation system for diagnostic use on remote patients in real time. the open biomedical engineering journal, 4(1), 250–256. https://doi.org/10.2174/1874120701004010250 popay, j., roberts, h., sowden, a., petticrew, m., arai, l., rodgers, m., britten, n., roen, k., & duffy, s. (2006). guidance on the conduct of narrative synthesis in systematic reviews. a product from the esrc methods programme version, 1(1), b92. pratiwi, n. g., setiawan, a. w., naufal, d., & lindayani, l. (2021). a review of equipment and signal processing of the automated auscultation for blood pressure measurement. 2021 3rd international symposium on material and electrical engineering conference (ismee), 26–31. https://doi.org/10.1109/ismee54273.2021.9774036 qu, m., chen, x., yang, d., li, d., zhu, k., guo, x., & xie, j. (2021). monitoring of physiological sounds with wearable device based on piezoelectric mems acoustic sensor. journal of micromechanics and microengineering, 32(1), 14001. saketkoo, l. a., russell, a.-m., jensen, k., mandizha, j., tavee, j., newton, j., rivera, f., howie, m., reese, r., & goodman, m. (2021). health-related quality of life (hrqol) in sarcoidosis: diagnosis, management, and health outcomes. diagnostics, 11(6), 1089. sarkar, m., madabhavi, i., niranjan, n., & dogra, m. (2015). auscultation of the respiratory system. annals of thoracic medicine, 10(3), 158–168. https://doi.org/10.4103/18171737.160831 sumartono, a. a. (2021). stetoskop bluetooth menggunakan sensor max 9814 berbasis esp 32. swarup, s., & makaryus, a. n. (2018). digital stethoscope: technology update. medical devices (auckland, n.z.), 11, 29–36. https://doi.org/10.2147/mder.s135882 tavel, m. e. (1996). cardiac auscultation. a glorious past--but does it have a future? circulation, 93(6), 1250–1253. https://doi.org/10.1161/01.cir.93.6.1250 tian, s., yang, w., le grange, j. m., wang, p., huang, w., & ye, z. (2019). smart healthcare: making medical care more intelligent. global health journal, 3(3), 62–65. zhang, p., wang, b., liu, y., fan, m., ji, y., xu, h., xu, m., chen, s., li, q., & zhang, ez. (2021). lung auscultation of hospitalized patients with sarscov2 pneumonia via a wireless stethoscope. international journal of medical sciences, 18(6), 1415–1422. https://doi.org/10.7150/ijms.54987. how to cite this article: ismail, s., prawira, r., johan, a., and ismail, r. (2023) ‘wireless stethoscope for auscultation of the heart and lungs in critically ill patients: a systematic review’, jurnal ners, 18(1), pp. 101-107. doi: http://dx.doi.org/10.20473/jn.v18i1.41471 pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru peer group support meningkatkan konsep diri klien dengan kanker serviks post histerektomi radikal (peer group support increase self concept on post-radical hysterectomy patients) esty yunitasari* * fakultas keperawatan universitas airlangga surabaya kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: esty.yun_ners@unair.ac.id abstract introduction: cervical cancer is one of the disease that can be found among women in all over the world, including in indonesia. this disease remains a significant problem as the primary cause of death among other cancer diseases in women. cervical cancer may influence all aspects of human life, whether it is physiological, psychological or social. stress in patients with cervical cancer is generally increasing due to the rejection of their degrading health condition. the aimed of this study was to analyze the influence of peer group support on the improvement of self concept in patients with post-radical hysterectomy cervical cancer in obstetric wards, dr soetomo hospital, surabaya. method: a quasy experimental with static group comparison and consecutive sampling design was used in this study. population in this study was patients with post radical hysterectomy cervical cancer treated in obstetric wards, dr soetomo hospital, surabaya. there were 20 respondents divided into each 10 respondents for control group and treatment group. the independent variable was peer group support and the dependent variable was self concept. data for self concept were collected by using questionaire then analyzed by using wilcoxon signed rank test and mann whitney u test with significance level α≤0.05. result: the results revealed that peer group support had significance influence to the improvement of self concept in post-radical hysterectomy patients (p=0.000). discussion: it,s can be concluded that peer group support increase of self concept in post-radical hysterectomy patients. keywords: peer group support, self concept, post radical hysterectomy cervical cancer pendahuluan peer group support merupakan salah satu bentuk terapi paliatif yang ditawarkan untuk menangani klien dengan kasus terminal. kelompok dukungan ini berperan untuk menciptakan suasana nyaman, menjaga kerahasiaan, mendapatkan kesempatan untuk berkenalan, bicara secara terbuka, didengarkan dan mendapatkan dukungan. prinsip dalam kelompok ini, tidak ada yang salah atau yang benar; tidak ada yang lebih tinggi atau lebih rendah dari yang lain. para anggota dalam kelompok dukungan tersebut didorong untuk merenungkan diri dan belajar dari diri sendiri serta orang lain. peer group support di negara maju diterapkan sebagai salah satu bentuk terapi untuk penderita kanker. dukungan kelompok sesama penderita atau peer group support dapat merubah respons psikologis maladaptif pada penderita penyakit terminal (seperti kanker serviks) menjadi respons yang adaptif. kanker serviks merupakan penyakit yang dapat dialami wanita di seluruh dunia termasuk indonesia dan merupakan masalah yang signifikan di indonesia. kanker serviks saat ini di indonesia masih menduduki peringkat pertama dan merupakan penyebab kematian tertinggi diantara penyakit kanker pada wanita dengan insiden tertinggi yaitu 27%. penderita kanker serviks umumnya berusia 30-60 tahun ke atas. insiden kanker serviks pada dekade terakhir memperlihatkan kecenderungan meningkat. kejadian wanita usia produktif terserang kanker serviks meningkat sebesar 60%. kanker serviks berkembang secara bertahap dan progresif, oleh karena itu penyakit ini sebenarnya dapat dicegah bila diketahui secara dini. penderita kanker serviks sebagian besar datang berobat dalam keadaan stadium lanjut, sehingga keberhasilan pengobatan sangat rendah. penderita kanker serviks invasif sebanyak 525.000 atau sekitar 12% kanker pada wanita dan 240.000 diantaranya mengalami kematian. canadian cancer society (2007) mencatatn bahwa kematian kanker akibat kanker serviks di dunia sekitar 6.000-7.000 setiap tahunnya. data 13 pusat patologi di indonesia menunjukkan kanker serviks mempunyai frekuensi tertinggi yaitu 36% dari kasus kanker pada wanita. data dari rsu dr. soetomo surabaya menunjukkan bahwa kanker serviks pada tahun 2002 sebanyak 500 orang, tahun 2003 sejumlah 437 orang sedangkan pada tahun 2004 sebanyak 500 orang. penderita kanker serviks rentan terhadap kondisi stres. kejadian stres pada seorang wanita dengan kanker serviks dapat disebabkan baik oleh penyakit atau oleh prosedur pengobatan salah satunya tindakan operasi histerektomi. stres yang dialami ketika akan menjalani prosedur histerektomi bukan karena mereka takut akan proses operasi, namun oleh dampak psikologis yang ditimbulkan. rasa takut pada beberapa wanita tersebut juga diiringi dengan keinginan untuk sembuh, sehingga mereka merasa harus melakukan tindakan histerektomi. stres pada penderita kanker serviks umumnya meningkat disebabkan oleh penolakan atas kondisi kesehatan yang semakin memburuk (mariana, 2007). kanker serviks merupakan penyakit yang dapat mempengaruhi setiap aspek kehidupan manusia, baik aspek fisiologis, psikologis, dan sosial klien (nurachmah,1999). peer group support diharapkan dapat menjadi bentuk kegiatan sosialisasi antara sesama penderita kanker serviks, sehingga berbagai masalah yang timbul baik dari aspek fisiologis, psikologis maupun sosial dapat ditemukan jalan keluar penyelesaian masalah. berdasarkan penjelasan tersebut maka peneliti tertarik untuk meneliti tentang pengaruh peer group support terhadap konsep diri klien dengan kanker serviks post radical hysterectomy, karena di ruang kandungan rsu dr. soetomo surabaya peer group support belum dilakukan. bahan dan metode design yang digunakan pada penelitian ini yaitu quasy experimental dengan menggunakan metode static group comparison. subyek dalam penelitian ini yaitu pasien post histerektomi radikal di rumah sakit dr. soetomo surabaya dengan besar sampel 20 orang yang ditentukan dengan menggunakan tehnik consecutive sampling. sampel tersebut dibagi menjadi kelompok kontrol dan kelompok perlakuan masing-masing dengan 10 sampel. penelitian ini dilakukan pada bulan mei sampai dengan juli 2008. variabel independen dalam penelitian ini yaitu peer group support, sedangkan variabel dependen yaitu konsep diri. peneliti juga mengidentifikasi kepribadian dan stadium kanker serviks sebagai variabel perancu. data konsep diri pada pasien kanker serviks post histerektomi radikal diperoleh dengan menggunakan kuesioner yang diberikan sebelum dan sesudah tindakan peer group support dilakukan. data tersebut kemudian ditabulasi dan dianalisis dengan menggunakan uji statistik wilcoxon signed rank test dan mann whitney u test dengan derajat kemaknaan α<0,05. hasil konsep diri pada kedua kelompok menunjukkan bahwa sebelum diberikan tindakan masih rendah (gambar 1). pada gambar 2 terlihat bahwa sesudah terlibat dalam peer group support kelompok perlakuan menunjukkan perubahan konsep diri. hasil penelitian ini menunjukkan bahwa peer group support mempunyai pengaruh yang signifikan terhadap konsep diri dengan hasil analisis statistik wilcoxon signed rank test didapatkan nilai signifikansi p=0,000 dan terdapat perbedaan konsep diri yang signifikan antara kelompok kontrol dan kelompok perlakuan dengan hasil analisis statistik mann whitney u test menunjukkan nilai signifikansi p=0,000 (tabel 1). tabel 1. hasil analisis statistik konsep diri pada klien dengan kanker serviks paska radikal histerektomi. kelompok kontrol kelompok perlakuan pre post pre post mean 37 42 48 74 sd 13,375 13,984 15,492 10,750 hasil analisis statistik wilcoxon signed rank test (p=0,000) wilcoxon signed rank test (p=0,000) mann whitney u test (p=0,000) keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata pembahasan hasil penelitian menunjukkan bahwa sebelum dilakukan peer group support semua responden baik pada kelompok kontrol maupun pada kelompok perlakuan memiliki konsep diri yang rendah. keadaan ini disebabkan karena beberapa dari mereka mengalami efek samping karena kemoterapi seperti mual muntah, rambut rontok, kulit hitam dan yang paling membuat mereka merasa konsep dirinya rendah adalah pengalaman terapi histerektomi radikal. histerektomi radikal merupakan pengangkatan uterus, ovarium dan semua jaringan parametrium pada rongga pelvis dan bagian atas vagina. pada tindakan histerektomi radikal dilakukan pengambilan semua kelenjar getah bening di sekitar pembuluh darah dan ureter di rongga pelvis, ureter dan vesika urinaria dibebaskan dari jaringan sekitarnya. pengangkatan organ reproduksi interna (uterus) merupakan hal yang sensitif bagi beberapa wanita terutama bagi mereka yang masih mempunyai pasangan hidup dan berusia produktif. konsep diri pasien kanker serviks post histerektomi radikal pada kelompok perlakuan mengalami peningkatan menjadi sedang dan tinggi dengan adanya peer group support. perubahan ini memang bukan semata karena peer group support namun terdapat beberapa hal yang mempengaruhi misal kepribadian dan stadium kanker, akan tetapi kedua hal tersebut sudah dilakukan uji homogenitas dan hasilnya homogen sehingga dapat dibuktikan bahwa peer group support sangat berpengaruh terhadap peningkatan konsep diri responden. terbentuknya peer group support penderita kanker serviks post histerektomi radikal secara tidak langsung mengubah persepsi yang negatif menjadi positif, sehingga pasien akan berusaha untuk belajar mengubah sikap yang tidak baik dan segera mengambil keputusan yang tegas untuk menentukan tindakan pengobatan dan mengikuti anjuran tim medis (wagner, 2000). konsep diri berkaitan erat dengan diri individu. kehidupan yang sehat, baik fisik maupun psikologi didukung salah satunya oleh konsep diri yang baik dan stabil. semakin sehat kondisi seseorang, idealnya mereka mempunyai konsep diri yang tinggi, sedangkan seseorang yang divonis menderita penyakit mematikan apalagi yang menyangkut pengangkatan organ tertentu (seperti payudara pada kanker payudara, rahim pada kanker rahim atau serviks), akan mempunyai konsep diri yang rendah. kunci keberhasilan hidup adalah konsep diri positif. konsep diri memainkan peran yang sangat besar dalam menentukan keberhasilan hidup seseorang, karena konsep diri dapat dianalogikan sebagai suatu operating system yang menjalankan suatu komputer. konsep diri mempengaruhi kemampuan berpikir seseorang. konsep diri juga akan di pelajari oleh individu melalui kontak dan pengalaman dengan orang lain termasuk berbagai stressor yang dilalui individu tersebut. konsep diri dapat dibentuk melalui pandangan diri dan pengalaman yang positif, sehingga konsep diri merupakan aspek yang kritikal dan dasar dari perilaku individu. individu dengan konsep diri yang positif dapat berfungsi lebih efektif yang dapat dilihat dari kemampuan interpersonal, kemampuan intelektual dan penguasaan lingkungan, sedangkan konsep diri yang negatif dapat dilihat dari hubungan individu dan sosial yang terganggu (stuart dan sundeen, 2000). konsep diri yang rendah akan mengakibatkan rasa tidak percaya diri, tidak berani mencoba berbagai hal baru, tidak berani mencoba hal yang menantang, takut gagal, takut sukses, merasa diri bodoh, rendah diri, merasa diri tidak berharga, merasa tidak layak untuk sukses, pesimis, dan masih banyak perilaku inferior lainnya. sebaliknya seseorang yang memiliki konsep diri tinggi akan selalu optimis, berani mencoba berbagai hal baru, berani sukses, berani gagal, percaya diri, antusias, merasa diri berharga, berani menetapkan tujuan hidup, bersikap dan berpikir positif dan dapat menjadi seorang pemimpin yang handal (gunawan, 2007). peer group support merupakan salah satu bentuk terapi paliatif yang ditawarkan untuk menangani pasien dengan kasus terminal. kegiatan peer group support dapat meningkatkan konsep diri pasien kanker serviks post hiterektomi radikal, karena dengan pemberian peer group support, penderita akan dapat merasakan kebersamaan dengan orang yang memiliki kondisi yang sama dengan dirinya dan mengetahui pemecahan masalah yang dialaminya. penderita kanker dan keluarganya merasakan hidup lebih baik ketika mereka mengikuti support group melalui diskusi online, chatting dan mailing list dengan sesama penderita maupun keluarga penderita lainnya. peer support group juga bisa dilaksanakan dengan mempertemukan anggota kelompok yang mempunyai masalah sama, sehingga mereka dapat berdiskusi langsung permasalahan yang dialami oleh masingmasing penderita pada saat itu juga. pada saat kegiatan berlangsung responden diminta untuk mengungkapkan permasalahan, apabila salah seorang dari responden lain pernah memiliki masalah yang sama, maka responden tersebut akan berbagi pengalaman tentang hal tersebut, dengan demikian solusi akan diperoleh. peranan utama kelompok dukungan adalah menciptakan suasana nyaman, menjaga kerahasiaan, mendapatkan kesempatan untuk bersosialisasi, bicara secara terbuka, didengarkan dan mendapatkan dukungan. dalam kelompok, tidak ada yang salah atau yang benar, tidak ada yang lebih tinggi atau lebih rendah dari yang lainnya. melalui peer group support, para anggota didorong untuk merenungkan diri dan belajar dari diri sendiri serta orang lain. di ruang kandungan rsu dr. soetomo surabaya belum terbentuk peer group support bagi penderita kanker serviks post histerektomi radikal maupun kasus penyakit kandungan yang terminal (seperti kanker ovarium, kanker vulva dan kasus ginekologi yang lain). pada dasarnya semua pasien setiap hari secara tidak langsung sudah melakukan kegiatan peer group support secara tidak sengaja seperti kegiatan makan bersama. kegiatan makan bersama ini yang digunakan oleh para penderita tersebut untuk saling bertukar informasi dan pendapat, namun tanpa fasilitator khusus yang mendampingi. kelemahan dari kegiatan yang tidak terstruktur tersebut antara lain bagi mereka yang dengan tipe kepribadian introvert mereka hanya sebagai pendengar yang aktif tanpa mengemukakan pendapat. disamping itu ketidaksamaan kasus membuat dengar pendapat tidak maksimal, sehingga diperlukan optimalisasi kegiatan peer group support agar konsep diri pasien dengan kasus terminal dapat meningkat. simpulan dan saran simpulan kegiatan peer group support mampu meningkatkan konsep diri pada klien kanker serviks post histerektomy radikal. peer group support merupakan salah satu bentuk terapi paliatif yang menjadi penguat bagi para anggotanya dengan pemberian dukungan terutama dukungan yang bersifat informasional sehingga para anggota mampu merenungkan diri dan belajar dari diri sendiri serta orang lain. saran esty y esty y peneliti menyarankan supaya pembentukan peer group support khususnya di ruang kandungan rsu dr. soetomo surabaya terfasilitasi dengan baik, kegiatan peer group support hendaknya dilanjutkan meskipun klien sudah tidak dirawat di rumah sakit, disediakannya waktu khusus untuk pelaksanaan peer group support, tersedianya fasilitas berupa ruangan/ tempat dan tenaga profesional sebagai fasilitator yang dapat digunakan untuk kegiatan peer group support sebagai terapist bagi penderita di rumah sakit atau pelayanan kesehatan yang menangani kasus kanker dan klien yang mengalami kanker serviks hendaknya dapat mengikuti kegiatan support therapy seperti peer group support untuk meningkatkan kualitas hidup. kepustakaan canadian cancer society. 2007. tips for spending time with someone who has cancer, (online), (http://www.cancer.ca/ccs/internet/stan dard/0,3182.3172_369341_274004_la ngld-en,00.html, diakses tanggal 15 januari 2008, jam 13.00 wib). stuart and sundeen.1995. principles and precticeof psiciatric nursing.fifth edition.united state of america: mosby stuart, gw. dan sundeen. 2000. buku saku keperawatan jiwa, jakarta : egc http://www.cancer.ca/ccs/internet/standard/0,3182.3172_369341_274004_langld-en,00.html http://www.cancer.ca/ccs/internet/standard/0,3182.3172_369341_274004_langld-en,00.html http://www.cancer.ca/ccs/internet/standard/0,3182.3172_369341_274004_langld-en,00.html pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru air rebusan biji buncis (phaseolus vulgaris l.) menurunkan kadar glukosa darah (seed bean’s boiled water (phaseolus vulgaris l.) decrease blood glucose level) i ketut sudiana*, sukma randani ismono*, fitriya faristiowati* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: ik.sudiana@yaho.com abstract introdouction: diabetes mellitus as the global health problem was manifested by increasing blood glucose. the aetiology of increasing blood glucose was absolute or relative deficiency of insulin. the seed bean’s boiled water known can controlled diabetes by lowering blood glucose level. the seed bean contained a matters beta cytosterol and stigmasterol can iniciate a pancreas to increase of insulin production. the aimed of this study was to analyze the effect of taking seed bean’s boiled water on decreasing of blood glucose level in patients with diabetes mellitus in sopa'ah village worked area of puskesmas sopa'ah pademawu region pamekasan city. method : this study was used a quasy experimental purposive sampling design. sample were 12 respondents who met the inclusion criteria. the independent variable was seed bean’s boiled water (phaseolus vulgaris l.) and dependent variable was blood glucose level. data were analyzed by using paired t-test and independent t-test with significance level α≤0.05. result: the result showed that seed bean’s boiled water (phaseolus vulgaris l.) has an effect on decreasing blood glucose between pre test and post test for blood glucose nuchter (p=0.03) and for 2 hours post prandial (p=0.01), whereas between treatment group and control group the result showed that blood glucose nuchter (p=0.01) and 2 hours post prandial (p=0.00). discussion: it can be concluded that seed bean’s boiled water (phaseolus vulgaris l.) has an effect on blood glucose level in patients with diabetes mellitus. keywords: seed bean’s boiled water (phaseolus vulgaris l.), blood glucose, diabetes mellitus pendahuluan pengobatan alternatif saat ini lebih banyak dipilih oleh masyarakat untuk mengatasi berbagai masalah kesehatan. masyarakat menengah ke bawah pada umumnya memanfaatkan tanaman obat sebagai upaya preventif dan rehabilitatif, terlebih dengan adanya isu back to nature. beberapa alasan masyarakat beralih ke tanaman obat lebih disebabkan karena dengan pengobatan medis timbul efek samping, peningkatan biaya jika terjadi komplikasi dan hal ini menjadi beban ekonomi khususnya bagi masyarakat menengah ke bawah. buncis selain lebih banyak dikenal sebagai salah satu jenis sayuran ternyata dapat dimanfaatkan sebagai obat alami untuk mengatasi peningkatan kadar gula darah pada klien diabetes mellitus (ramainah, 2003). tanaman ini murah dan mudah didapat. di dalam buncis terdapat zat yang dinamakan βsitosterol dan stigmasterol, kedua zat inilah yang mampu merangsang pankreas untuk meningkatkan produksi insulin (aiyaarmad, 2007). dengan merebus 120 gram biji buncis dalam 3 gelas air yang diminum 1 kali sehari, diharapkan dapat menurunkan kadar glukosa darah sehingga buncis dapat dijadikan alternatif pengobatan pada klien dm. pengobatan komplementer dan alternatif (terapi herbal) untuk pengobatan dm memiliki prospek yang cerah (mahendra, et al., 2008). sampai saat ini pengaruh pemberian air rebusan biji buncis dalam menurunkan kadar glukosa darah pada klien diabetes mellitus belum dapat dijelaskan. diabetes mellitus (dm) semakin menjadi masalah kesehatan global. diabetes mellitus merupakan sekumpulan gejala yang timbul pada seseorang, ditandai dengan kadar glukosa darah yang melebihi normal (hiperglikemia) akibat tubuh kekurangan insulin baik absolut maupun relatif (mahendra, et al., 2008). insulin disekresikan oleh sel-sel beta yang merupakan salah satu dari empat tipe sel dalam pulau langerhans pankreas. fungsi insulin ialah mendorong gula dalam darah masuk ke dalam sel dan menyimpan glukosa yang berlebihan di hati (mahendra, et al., 2008). diabetes mellitus terjadi jika tubuh tidak menghasilkan insulin yang cukup untuk mempertahankan kadar gula darah yang normal atau jika sel tidak memberikan respons yang tepat terhadap insulin (viviroy, 2008). diabetes melitus ditandai dengan kadar glukosa darah yang tinggi (hiperglikemia) dan adanya glukosa dalam urin (glukosuria). dalam jangka panjang, penyakit ini dapat mengakibatkan risiko gangguan lebih lanjut pada retina dan ginjal, kerusakan saraf perifer dan mendorong terjadinya penyakit aterosklerosis pada jantung, kaki dan otak. komplikasi dm pada retina, ginjal dan sistem saraf perifer serta peningkatan mortalitas dan risiko penyakit vaskuler dapat dicegah dengan mempertahankan kadar gula darah dalam batas normal. menjaga agar kadar lipid dan tekanan darah tetap normal juga mencegah peningkatan risiko tersebut di atas (kiranawati, 2007). modalitas penatalaksanaan dm (tipe ii) diarahkan pada terapi non farmakologis yang meliputi perubahan gaya hidup dengan melakukan pengaturan pola makan, meningkatkan aktivitas jasmani dan edukasi berbagai masalah yang berkaitan dengan penyakit dm secara terus menerus. terapi farmakologis yang meliputi pemberian obat anti diabetes oral dan injeksi insulin juga diberikan sejalan dengan terapi non farmakologis untuk mengendalikan kadar glukosa darah sebagaimana yang diharapkan. banyak diantara klien yang berusaha mengendalikan kadar glukosa darah dengan cara tradisional yaitu menggunakan bahan dari alam. berbagai jenis obat antidiabetik oral banyak ditemukan di apotik dan biasanya tergolong obat yang mahal dan harus terus menerus digunakan, hingga bagi yang tidak mampu sulit memperoleh obat tersebut. daerah yang tidak mempunyai apotik akan mengalami kesulitan memperoleh obat ini, sehingga diperlukan alternatif obat lain seperti tanaman obat. kebijaksanaan obat nasional menyatakan bahwa penyediaan obat merupakan salah satu unsur yang penting dalam upaya pembangunan di bidang kesehatan. obat tradisional yang terbukti berkhasiat harus dikembangkan dan digunakan dalam upaya kesehatan (widowati, 1997). masyarakat pademawu diketahui banyak yang berhenti menggunakan obat medis dan menggantinya dengan mengkonsumsi obat tradisional, namun masyarakat pademawu masih belum mengenal buncis sebagai tanaman obat yang bermanfaat bagi klien dm. salah satu ramuan herbal yang direkomendasikan untuk pengobatan alami dm adalah buncis (ramainah, 2003). diabetes mellitus telah menjadi penyebab kematian terbesar keempat di dunia. setiap tahun ada 3,2 juta kematian yang disebabkan langsung oleh diabetes (tandra, 2007). prevalensi terjadinya dm tipe 1 hanya sekitar 5-10% dari semua kasus diabetes jika dibandingkan dengan dm tipe 2 yang mencapai 90-95% (kiranawati, 2007). pada tahun 2003, badan kesehatan dunia atau who memperkirakan, 194 juta jiwa atau 5,1 persen dari 3,8 miliar penduduk dunia usia 20-79 tahun menderita dm dan pada tahun 2025 diperkirakan meningkat menjadi 333 juta jiwa. di indonesia, klien dm juga mengalami kenaikan dari 8,4 juta jiwa pada tahun 2000 menjadi sekitar 21,3 juta jiwa pada tahun 2020. tingginya angka kesakitan itu menjadikan indonesia menempati urutan keempat dunia setelah amerika serikat, india dan cina sebagaimana dicantumkan dalam diabetes care tahun 2004. survei kesehatan rumah tangga (skrt) memberi gambaran terjadinya peningkatan prevalensi dm dari tahun 2001 sebesar 7,5% menjadi 10,4% pada tahun 2004 (evy, 2008). total klien dm di indonesia berdasarkan data who, saat ini sekitar 8 juta jiwa dan diperkirakan jumlahnya melebihi 21 jiwa pada tahun 2025 mendatang (irawati, 2008). data yang diperoleh dari puskesmas sopa'ah pademawu pada tanggal 16 oktober 2008, jumlah klien dm rawat jalan dari bulan mei sampai september tahun 2008 sebanyak 30 orang. i ketut berdasarkan penjelasan di atas peneliti tertarik untuk mengetahui pengaruh pemberian air rebusan biji buncis (phaseolus vulgaris l.) terhadap penurunan kadar glukosa darah pada klien dm di desa sopa'ah wilayah kerja puskesmas sopa'ah kecamatan pademawu kabupaten pamekasan. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah quasy experimental control group pre-post test purposive sampling design. populasi pada penelitian ini adalah klien dm di desa sopa'ah wilayah kerja puskesmas sopa'ah kecamatan pademawu kabupaten pamekasan sebanyak 30 orang. sampel diambil sesuai dengan kriteria inklusi dan diperoleh 12 responden yang sesuai dengan kriteria inklusi kemudian dibagi menjadi masing-masing 6 responden untuk kelompok perlakuan dan kelompok kontrol. kriteria inklusi yang ditetapkan oleh peneliti antara lain klien dm, gula darah awal (pre test): bsn>120 mg/dl dan 2j pp> 200 mg/dl dan bersedia menjadi subjek penelitian. penelitian ini dilakukan selama januari 2009. variabel independen dalam penelitian ini adalah air rebusan biji buncis, sedangkan variabel dependen adalah kadar gula darah. instrumen yang digunakan dalam penelitian ini adalah alat glukometer untuk pengukuran kadar gula darah. kadar gula darah yang diamati adalah kadar gula darah puasa/blood sugar nuchter (bsn) dan gula darah 2 jam post pandrial (2 jam setelah makan) yang diukur pada saat pre test dan setelah 12 hari perlakuan. pada kelompok perlakuan diberi air rebusan biji buncis dengan cara merebus 120 gram biji buncis dalam 3 gelas air hingga tersisa 1 gelas yang diminum 1 kali sehari selama 12 hari sedangkan kelompok kontrol tidak diberi air rebusan biji buncis. data yang diperoleh ditabulasi kemudian dianalisis dengan menggunakan uji statistik analisis dengan uji paired t-test dan independent t-test dengan derajat kemaknaan ≤0,05. hasil pada tabel 1 dapat dilihat bahwa pada kelompok perlakuan terjadi penurunan kadar glukosa darah puasa (bsn) dan kadar gula darah 2 jam post prandial dengan nilai rerata kadar gula darah puasa (bsn) post test pada kelompok perlakuan adalah 234 mg/dl dan untuk kadar gula darah 2 jam post prandial (2j pp) adalah 314,83 mg/dl. hasil analisis statistik paired t-test menunjukkan untuk kadar gula darah puasa (bsn) p=0,003 dan kadar gula darah 2 jam post prandial p=0,011. terdapat pengaruh pemberian air rebusan biji buncis (phaseolus vulgaris l) terhadap penurunan kadar glukosa darah pada klien dm dengan hasil analisis statistik independent t-test untuk kadar glukosa darah puasa (bsn) p=0,01 dan kadar glukosa darah 2 jam post prandial p=0,00. pembahasan hasil pengukuran kadar gula darah puasa (bsn) dan kadar gula darah 2 jam post prandial pada klien dm sebelum pemberian air rebusan biji buncis (phaseolus vulgaris l) pada kelompok perlakuan dan kelompok kontrol didapatkan nilai rerata lebih dari normal. saat ini diketahui paling tidak terdapat 4 penyebab timbulnya hiperglikemia sebagai gejala klinis utama dm. empat penyebab itu adalah peningkatan asupan karbohidrat, penurunan sekresi insulin, peningkatan keluaran glukosa hati dan peningkatan asupan glukosa peripheral (resistensi insulin) (mahendr, et al., 2008). tingkat gula darah diatur melalui umpan balik negatif untuk mempertahankan keseimbangan di dalam tubuh. kadar glukosa di dalam darah dimonitor oleh pankreas. bila konsentrasi glukosa menurun, karena dikonsumsi untuk memenuhi kebutuhan energi tubuh, pankreas melepaskan glukagon, hormon yang menargetkan sel-sel di lever (hati). selanjutnya sel-sel ini mengubah glikogen menjadi glukosa (proses ini disebut glikogenolisis). glukosa dilepaskan ke dalam aliran darah, hingga meningkatkan kadar gula darah (smeltzer dan bare, 2003). peningkatan kadar glukosa darah puasa lebih ditentukan oleh peningkatan produksi glukosa endogen yang berasal dari proses air rebusan biji buncis (phaseolus vulgaris l.) menurunkan kadar glukosa darah glukoneogenesis dan glikogenolisis di jaringan hepar (sudoyo, et al., 2006). makanan akan meningkatkan glukosa darah. satu sampai dua jam setelah makan glukosa darah mencapai angka paling tinggi. makanan yang berbeda juga menimbulkan efek yang berbeda (tandra, 2007). glukosa diserap melalui dinding usus dan disalurkan dalam darah. setelah makan, kadar glukosa dalam darah akan lebih tinggi melebihi glukosa yang dibutuhkan dalam pembentukan energi tubuh. jika kadar gula darah menurun maka simpanan glikogen akan kembali ke dalam darah. proses ini membutuhkan glukagon. glikogen yang disimpan dalam hati bisa bertahan 8-10 jam. apabila tidak digunakan dalam waktu yang ditentukan maka simpanan ini akan berubah menjadi lemak. oleh karena itu, sewaktu seseorang mengkonsumsi makanan secara berlebihan maka kadar gula dalam darah akan terus beranjak naik sehingga glikogen dalam hati tidak digunakan maksimal. hal ini akan menimbulkan penumpukan lemak tubuh (obesitas), penumpukan lemak dalam pembuluh (artheriosclerosis), bahkan penumpukan lemak dalam hati (fatty liver) (mahendra et al., 2008). berdasarkan penelitian, pada orang yang obesitas dengan jaringan lemak yang banyak dan luas memiliki jumlah reseptor insulin yang lebih sedikit dari orang yang tidak obesitas. hal ini menyebabkan terhambatnya efek insulin di perifer meskipun sekresi insulin sudah cukup. akibatnya, transpor glukosa ke dalam sel menurun sementara kadar glukosa dalam darah akan meningkat di atas kadar glukosa normal (dinda, 2008). proses penuaaan juga menjadi penyebab penyusutan sel-sel beta yang progresif sehingga sekresi insulin semakin berkurang dan kepekaan reseptor turut menurun (mahendra, et al., 2008). proses menua merupakan proses alamiah yang akan dialami setiap makhluk hidup yang mana pada usia tersebut terjadi perubahan fisiologis hampir seluruh sistem tubuh. hal ini menjadi salah satu faktor penyebab dari sekian banyak faktor yang dapat menyebabkan peningkatan kadar glukosa darah karena penyusutan sel beta pankreas yang terjadi dan dapat mengganggu sekresi insulin. sebagian besar responden di desa sopa’ah wilayah kerja puskesmas sopa’ah kecamatan pademawu kabupaten pamekasan berusia >45 tahun. responden menyadari bahwa dirinya telah menderita diabetes mellitus tetapi mereka masih belum bisa mengontrol pola makan dengan baik. pola makan yang berlebihan serta kurangnya aktivitas fisik dari sebagian besar responden menyebabkan terjadinya peningkatan kadar glukosa darah. responden sering menghentikan pengobatan dengan alasan tidak adanya lagi keluhan seperti badan terasa panas, banyak minum, sering buang air kecil dan mudah capek. faktor lain seperti stres juga dapat meningkatkan kadar glukosa darah pada klien dm. beberapa hormon yang dilepaskan selama stres bisa menghambat efek insulin atas sel-sel dan menyebabkan dm (ramainah, 2003). air rebusan biji buncis (phaseolus vulgaris l) terbukti menurunkan kadar glukosa darah secara signifikan pada klien dm di desa sopa’ah wilayah kerja puskesmas sopa’ah kecamatan pademawu kabupaten pamekasan. kadar glukosa darah puasa dalam keadaan normal adalah 80-90 mg/100 ml darah. apabila glukosa darah meningkat melebihi 100 mg/100 ml darah, maka sekresi insulin dari pankreas dengan cepat meningkat dan kembali ke tingkat basal dalam 2-3 jam. insulin adalah hormon utama pada stadium absorptif pencernaan yang muncul segera setelah makan. di antara waktu makan, kadar insulin rendah (corwin, 2000). kadar insulin perifer mulai meningkat kira-kira 8-10 menit sesudah menelan makanan dan mencapai puncak sesudah 3045 menit. keadaan ini diikuti penurunan cepat kadar glukosa plasma post prandial, yang akan kembali ke nilai normal dalam 90120 menit (kartini et al., 1998). insulin berperan penting pada berbagai proses biologis dalam tubuh terutama menyangkut metabolisme karbohidrat. pada jaringan perifer seperti jaringan otot dan lemak, insulin berikatan dengan reseptor (insulin receptor substrate=irs) yang terdapat pada membran sel. ikatan antara insulin dan reseptor akan menghasilkan semacam signal yang berguna bagi proses regulasi atau metabolisme glukosa di dalam sel otot dan lemak, dengan mekanisme kerja yang belum begitu jelas. peningkatan kuantitas glut-4 (glucose i ketut transporter-4) pada membran sel, disebabkan karena proses translokasi glut4 dari dalam sel diaktivasi oleh adanya transduksi signal (sudoyo, et al., 2006). regulasi glukosa tidak hanya ditentukan oleh metabolisme glukosa di jaringan perifer, tapi juga di jaringan hepar. jaringan hepar juga ikut berperan dalam mengatur homeostasis glukosa tubuh. metabolisme glukosa mencapai nilai normal memerlukan mekanisme sekresi insulin disertai kerja insulin yang berlangsung normal (sudoyo, et al., 2006). biji buncis sebagai tanaman herbal memiliki kandungan kimia antara lain glucoprotein, tripsin inhibitor, phytohemaglutinin, stigmasterol, β-sitosterol, kaempesterol, allantoin, inositol. kulit biji mengandung leukopelargonodin, leukosianidin, leukodelfinidin, kaempferol, kuersetin, mirisetin, pelargonidin, sianidin, delfinidin, petunididin dan malvidin (hernani et al., 2005). di dalam buncis terkandung zat yang dinamakan β-sitosterol dan stigmasterol. ternyata zat tersebut mampu merangsang pankreas untuk meningkatkan produksi insulin (yartati, 2007). pemberian air rebusan biji buncis selama 12 hari dapat menurunkan kadar glukosa darah pada klien diabetes mellitus kelompok perlakuan di desa sopa’ah wilayah kerja puskesmas sopa’ah kecamatan pademawu kabupaten pamekasan. peningkatan insulin menyebabkan translokasi glut-4 meningkat sehingga transportasi glukosa ke sel terpenuhi dan pada akhirnya menurunkan glukosa darah. penurunan glukosa darah klien diabetes mellitus pada kelompok perlakuan di desa sopa’ah wilayah kerja puskesmas sopa’ah kecamatan pademawu kabupaten pamekasan tidak hanya dipengaruhi oleh pemberian air rebusan biji buncis tetapi juga ditunjang oleh pola makan dan aktivitas fisik/olahraga responden selama penelitian berlangsung. semua gerak badan dan olah raga akan menurunkan glukosa darah. olah raga mengurangi resistensi insulin sehingga kerja insulin lebih baik dan mempercepat pengangkutan glukosa masuk ke dalam sel untuk kebutuhan energi (tandra, 2007). kegiatan fisik pada keadaan post absorbsi makanan meningkatkan kebutuhan energi otot yang bekerja yang akan dipenuhi oleh proses pemecahan glikogen intramuskuler, cadangan trigliserida dan juga peningkatan sediaan glukosa hati dan asam lemak bebas dari cadangan trigliserida ekstramuskular. latihan jasmani pada diabetesi akan menimbulkan perubahan metabolik, yang dipengaruhi selain oleh lama, berat latihan dan tingkat kebugaran, juga oleh kadar insulin plasma, kadar glukosa darah, kadar badan keton dan imbangan cairan tubuh (sudoyo et al., 2006). tabel 1. distribusi kadar glukosa darah pada klien diabetes mellitus di desa sopa’ah wilayah kerja puskesmas sopa’ah pademawu kabupaten pamekasan selama 12 hari pemberian air rebusan biji buncis (phaseolus vulgaris l) keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata kelompok perlakuan kelompok kontrol pre post pre post bsn (g/dl) 2jpp (g/dl) bsn (g/dl) 2jpp (g/dl) bsn (g/dl) 2jpp (g/dl) bsn (g/dl) 2jpp (g/dl) mean 281 385,83 234 314,83 236,33 277,33 264,83 373,17 sd 90,171 95,267 70,970 109,005 66,292 95,970 88,797 105,725 hasil analisis statistik paired t-test kadar bsn (p=0,003) paired t-test kadar 2j pp (p=0,011) paired t-test kadar bsn (p=0,117) paired t-test kadar 2j pp (p=0,012) independent t-test kadar bsn (p=0,01) independent t-test kadar 2j pp (p=0,00) air rebusan biji buncis (phaseolus vulgaris l.) menurunkan kadar glukosa darah makanan pun akan menaikkan glukosa darah. satu sampai dua jam setelah makan glukosa darah mencapai angka paling tinggi. makanan yang berbeda juga menimbulkan efek yang berbeda. makanan terdiri dari karbohidrat, protein dan lemak. ketiganya menaikkan glukosa tetapi karbohidratlah yang paling kuat menaikkan glukosa darah (tandra, 2007). pada konsensus perkumpulan endrokinologi indonesia (perkeni) telah ditetapkan bahwa standar yang dianjurkan adalah santapan dengan komposisi seimbang berupa karbohidrat (60-70%), protein (10-15%), dan lemak (20-25%). jumlah kalori disesuaikan dengan pertumbuhan, status gizi, umur, stres akut, dan kegiatan jasmani untuk mencapai berat badan ideal. pemanis dapat digunakan secukupnya (smeltzer dan bare, 2001). diabetesi harus dapat melakukan perubahan pola makan ini secara konsisten baik dalam jadwal, jumlah dan jenis makanan sehari-hari (sudoyo, et al., 2006). perbedaan kebiasaan pola makan dan aktivitas antara kelompok perlakuan dan kontrol memberikan hasil kadar glukosa darah yang berbeda. simpulan dan saran simpulan pemberian air rebusan biji buncis (phaseolus vulgaris l.) menurunkan kadar glukosa darah pada klien dm di desa sopa’ah wilayah kerja puskesmas sopa’ah kecamatan pademawu kabupaten pamekasan. saran peneliti menyarankan supaya air rebusan biji buncis dapat diberikan pada klien dm dengan waktu pemberian 1 kali sehari selama 12 hari, penelitian lebih lanjut perlu dilakukan pada hewan coba untuk mengetahui proliferasi sel beta pankreas dan peningkatan reseptor insulin dengan mempertimbangkan faktor perancu seperti diet dan aktivitas responden dan petugas puskesmas diharapkan mampu memberikan penyuluhan tentang pengaruh pemberian air rebusan biji buncis dalam menurunkan kadar glukosa darah kepada klien diabetes mellitus. kepustakaan aiyaarmad. 2007. buncis, obat kencing manis yang bagus dan murah, (online), (http://www.halamansatu.net, diakses tanggal 28 november 2008, jam 15.09 wib). corwin, e.j. 2000. buku saku patofisiologi. jakarta: egc, hlm. 539, 542, 545. dinda. 2008. diabetes mellitus tipe 2, (online), (http://medicafarma.blogspot.com, diakses tanggal 23 desember 2008, jam 20.01 wib). evy. 2008. waspadai ancaman diabetes mellitus, (online), (http://www.kompas.com, diakses tanggal 29 november 2008, jam 16.24 wib). hernani et al. 2005. tanaman berkhasiat antioksidan. jakarta: penebar swadaya, hlm. 31-32. irawati, d. 2008. indonesia peringkat empat dunia klien diabetes, (online), (http://www.kompas.com, diakses tanggal 29 november 2008, jam 16.24 wib). kartini, a., et al. 1998. endrokinologi dasar dan klinik. jakarta: egc, hlm. 746747,751, 768-769. kiranawati, s. 2007. penggunaan insulin pada klien diabetes mellitus, (online), (http://yosefw.wordpress.com, diakses tanggal 28 oktober 2008, jam 19.24 wib). mahendra, b. 2008. care yourself, diabetes mellitus. jakarta: penebar plus, hlm. 11-12, 16, 51, 88. ramainah, s. 2003. diabetes. jakarta: pt bhuana ilmu populer, hlm. 11-14, 151. smeltzer, s.c. dan bare, b. 2001. brunner & suddarth buku ajar keperawatan medikal bedah. jakarta: buku kedokteran egc, hlm. 1222-1223, 1256-1257, 1268-1269. sudoyo, a.w., et al. 2006. ilmu penyakit dalam, jakarta: pusat penerbitan departemen ilmu penyakit dalam fk universitas indonesia, hlm. 1858, 1866. tandra, h. 2007. segala sesuatu yang harus anda ketahui tentang diabetes. http://www.halamansatu.net/ http://medicafarma.blogspot.com/ http://www.kompas.com/ http://www.kompas.com/ http://yosefw.wordpress.com/ jakarta: pt gramedia pustaka utama, hlm. 2, 45-46, 50-52. viviroy. 2008. bulu penyakit autoimmune, (online), (http://one.indoskripsi.com, diakses tanggal 29 november 2008, jam 16.24 wib). widowati, l., et al. 1997. tanaman obat untuk diabetes mellitus, (online), diakses tanggal 22 desember 2008, jam 19.00 wib. yartati. 2007. lawan kencing manis dengan buncis, diakses tanggal 28 november 2008, jam 15.09 wib. http://one.indoskripsi.com/ musik klasik menurunkan tingkat stres dan tekanan darah dan nadi ibu primigravida trimester ketiga berg balance test (bbt) dan time up and go test (tugt) sebagai indikator prediksi jatuh lansia ( berg balance test (bbt) and time up and go tes (tugt) as falls prediction on elderly) nursalam*, retno indarwati* , mikhael caraka kristi* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: nursalam_psik@yahoo.com abstract introduction: aging process represent the natural process which cannot obtivated. it caused by biological factor that goes naturaly and continuously that influence the anatomical, biochemical and physiological change. the natural change in this aspect giving contribution of falling on elderly. the objective of this study was to compare falls prediction on elderly using berg balance test and time up and go test. method: design used in this study was comparative study design. the population was 28 elderly. total sample was 20 elderly enrolled by means of purposive sampling, taken according to inclusion criteria. the independent variabels were berg balance test and time up and go test the dependent variabels were falls prediction, falls, and falls influence factors. data were colected using berg balance test, time up and go test and questionnaire that modify from minnesota safety council fall prevention checklist. data were then analyzed using kruskall-wallis test and mann-withney test with level of significance α≤0.05. result: the result showed that berg balance test (bbt) and time up and go test (tugt) had differences falls prediction with significance level of p=0.014. analyze :the dominant factors that caused of falls was gait. time up and go test (tugt) has valid prediction than berg balance test (bbt) it showed by difference smaller score from comparator test score. discussion: it can be concluded that tugt more appropriate than bbt to predict the falls insident in elderly. further studies should be consider to used carioca activity model as falls prevention in elderly. keywords: falls prediction, berg balance test, time up and go test, elderly pendahuluan proses menjadi tua merupakan proses alami yang tidak dapat dihindarkan. proses ini disebabkan oleh faktor biologis yang berlangsung secara alamiah, terus menerus dan berkelanjutan yang dapat menyebabkan perubahan anatomis, fisiologis, biokemis pada jaringan tubuh sehingga mempengaruhi fungsi, kemampuan badan dan jiwa (constantinides, 1994). kemunduran atau perubahan morfologis pada lansia sering terjadi pada sistem muskuloskeletal yang berdampak pada perubahan fungsional pada otot, yaitu penurunan kekuatan, kontraksi, elastisitas, fleksibilitas, kecepatan dan waktu reaksi. dua per tiga dari kecelakaan yang menjadi penyebab kematian kelima pada tahun 1994 untuk lansia terjadi akibat jatuh. penyebab utama yang sering mengakibatkan seorang lansia mudah jatuh adalah gangguan keseimbangan. hasil studi pendahuluan melalui wawancara dengan pendamping panti wredha santo yoseph kediri menunjukkan selama 2 tahun terakhir 16 orang lansia (60%) mengalami jatuh akibat kelemahan otot ekstremitas bawah yang mengganggu keseimbangan postural. delapan orang lansia (50%) dari prosentase lansia yang mengalami jatuh mengalami fraktur femur. dua puluh orang lansia yang mengalami jatuh lebih dari 1 kali terjadi dalam 3 bulan terakhir dan sebagian besar tidak sampai mengalami luka yang mengganggu aktivitas maupun trauma psikis. fraktur collum femuris merupakan komplikasi utama akibat jatuh pada lebih dari 200 ribu lansia di amerika serikat dan sebagian besar diderita oleh wanita. satu persen lansia yang jatuh diperkirakan akan mengalami fraktur collum femuris, 5% akan mengalami perlukaan jaringan lunak dan 5% mengalami fraktur tulang lain seperti iga, humerus, pelvis, dan lain-lain. perlukaan jaringan lunak yang serius seperti sub dural hematome, hemarthroses, memar, dan keseleo otot juga sering merupakan komplikasi akibat jatuh (kane, et al., 1994 isnaini herawati dan wahyuni 2004). pemeriksaan prediksi jatuh penting untuk dilakukan. hasil penelitian yang dilakukan oleh carpino pada tahun 2007 menyatakan bahwa berg balance test memiliki sensitifitas yang cukup tinggi dalam memprediksi kejadian jatuh pada pasien yang memiliki riwayat cva di rehabilitation centre toronto, canada. sebuah studi descriptive meta-analysis yang dilakukan oleh bohannon pada tahun 2006 terhadap referensi nilai dari pemeriksaan tugt pada lansia usia 60-90 tahun dengan masalah penuaan patologis seperti arthritis mendapatkan hasil bahwa pemeriksaan tersebut memang dapat digunakan untuk mengidentifikasi ketidakmampuan mobilitas pada lansia serta memiliki satu kesensitifan yang cukup tinggi dalam memprediksi kejadian jatuh pada lansia. lansia yang memiliki riwayat jatuh, dimungkinkan untuk kembali mengalami kejadian jatuh berulang (barr, 2004). pengulangan kejadian jatuh tersebut dapat diprediksi dengan melakukan pemeriksaan keseimbangan (balance assessment) sebagai upaya pencegahan (muir, 2008). beberapa ahli seperti burbank, butler, evans, nied & franklin dan wailmore menyarankan untuk melakukan pemeriksaan keseimbangan (balance assessment) pada lansia yang memiliki riwayat jatuh maupun yang tidak memiliki untuk mengetahui kecenderungan kejadian jatuh di waktu yang akan datang. time up and go test dan berg balance test merupakan beberapa contoh pemeriksaan keseimbangan yang dapat digunakan untuk memprediksi kejadian jatuh pada lansia, dengan cara menilai kemampuan lansia dalam mengintegrasikan persepsi, sensori serta mobilitas (tooru, et al., 2002). pemeriksaan tugt dan bbt menilai kesanggupan lansia untuk melakukan aktivitas berpindah, berputar, berdiri, serta duduk untuk mendapatkan score for independent safe ambulation, sehingga dapat diketahui batas kemampuan lansia terhadap kemampuan tersebut yang dapat digunakan untuk memprediksi kejadian jatuh. bahan dan metode penelitian ini menggunakan metode studi komparasi dengan jumlah populasi 28 lansia perempuan yang tinggal di panti wredha santo yoseph kediri. sampel sebanyak 20 orang lansia diambil berdasarkan kriteria inklusi yang telah ditetapkan antara lain usia ≥ 65 tahun, mampu beraktivitas, dapat berkomunikasi dengan baik, mampu melihat dan mendengar dengan baik. penelitian ini dilaksanakan pada bulan mei 2009. variabel independen dalam penelitian ini yaitu prediksi jatuh dan faktorfaktor kejadian jatuh. pemeriksaan bbt dan tugt sebagai variabel dependen. instrumen pengumpulan data dengan menggunakan kuisioner faktor-faktor kejadian jatuh hasil modifikasi dari minnesota fall prevention home safety checklist untuk faktor dominan kejadian jatuh dan lembar observasi pemeriksaan bbt, tugt dan hcanj (health care association of new jersey) fall risk assesment untuk prediksi jatuh. hcanj digunakan sebagai pembanding yang dianggap suatu standar prediksi jatuh oleh suatu negara. data yang diperoleh ditabulasi dan dianalisis menggunakan uji statistik krusskal-wallis test, mann whitney u test dengan tingkat kemaknaan α≤0,05. hasil perbandingan hasil prediksi jatuh antara tugt dan hcanj memiliki perbedaan yang tidak terlalu besar, terlihat dari selisih persentase hanya sebesar 10%. hasil perbandingan antara bbt dan hcanj menunjukkan selisih sekitar 30-40%. hal ini menunjukan bahwa tugt memiliki tingkat akurasi yang lebih tinggi dibandingkan bbt (gambar 1). hasil analisis statistik prediksi jatuh pada lansia dengan menggunakan krusskal-wallis test menunjukkan bahwa terdapat perbedaan prediksi jatuh antara bbt, tugt dan pemeriksaan pembanding yaitu hcanj dengan nilai signifikansi p=0,018. uji statistik mann whitney u test antara bbt dan tugt menunjukkan ada perbedaan hasil prediksi dengan nilai signifikansi p = 0,005. perbandingan hasil prediksi antara bbt dan hcanj menunjukkan nilai p=0,107 sedangkan hasil tugt dan hcanj menunjukkan nilai p=0,202. kedua hasil tersebut menunjukkan bahwa tidak ada perbedaan hasil prediksi antara bbt dan hcanj, begitu juga hasil prediksi antara tugt dan hcanj. pembahasan berdasarkan hasil penelitian didapatkan bahwa frekwensi kejadian jatuh pada lansia di panti wredha santo yosep kediri selama bulan maret sampai dengan mei 2009 sebanyak 1-2 kali. frekuensi jatuh lansia dalam 1 tahun idealnya hanya 1-2 kali (klebe, 2004). kejadian jatuh lebih dari 1 kali dalam 1 tahun dapat meningkatkan risiko pengulangan kejadian jatuh di waktu yang akan datang (barr, 2004). kejadian jatuh yang dialami sebagian besar responden bukan kejadian jatuh yang pertama namun merupakan pengulangan kejadian jatuh yang sudah pernah terjadi pada waktu lalu. frekuensi jatuh yang dialami lansia dipengaruhi oleh berbagai faktor baik internal maupun eksternal. faktor internal yang mempengaruhi antara lain psikis, sistem muskuloskeletal, kondisi panca indera, sistem genitourinaria, sistem neurologi, medikasi, dan riwayat penyakit. faktor eksternal yang berpengaruh seperti mobilitas, gaya berjalan, tempat tidur, kamar mandi, dan dapur. hasil penelitian tentang faktor-faktor dominan yang mempengaruhi jatuh pada lansia di panti tersebut menunjukan bahwa faktor eksternal khususnya gaya berjalan menjadi faktor yang paling berperan. gaya berjalan mereka pada dasarnya dipengaruhi oleh kekuatan otot dan alas kaki. jenis bahan alas kaki akan mempengaruhi pergerakan kaki. bahan alas kaki yang terbuat dari plastik cenderung mudah mengalami perubahan tekstur menjadi licin ketika terkena air, sedangkan bahan dari karet cenderung lebih memiliki tekstur yang tetap ketika terkena air sehingga bahan ini lebih aman apabila di pakai oleh lansia. sebagian besar lansia di panti tersebut menggunakan alas kaki atau sandal yang terbuat dari bahan plastik. hal ini ternyata membuat lansia yang pada awalnya telah mengalami penurunan kekuatan otot menjadi kehilangan kestabilan ketika berjalan akibat tekstur alas kaki yang berubah menjadi licin. alas kaki yang digunakan lansia selama ini merupakan alas kaki yang sudah disediakan oleh pihak pengelola panti ketika masuk pertama kali, namun lansia boleh memakai alas kaki lain selain yang telah diberikan pihak pengelola panti ketika masuk. terdapat beberapa lansia yang memakai alas kaki dengan bahan dari karet yang mereka dapatkan dari keluarga yang berkunjung. lansia yang memakai alas kaki dari bahan karet memiliki tingkat kestabilan yang lebih baik ketika berjalan dengan kondisi alas kaki yang basah bila dibandingkan dengan lansia yang memakai alas kaki yang terbuat dari plastik. pengaruh kekuatan otot terhadap gaya berjalan akan menyebabkan perubahan pada kekuatan stepping, kecepatan berjalan, serta frekuensi langkah. sebagian besar lansia yang memiliki kekuatan otot rendah memiliki gaya berjalan yang lamban, dengan langkah yang pendek-pendek, kaki tidak dapat menapak dengan kuat dan cenderung tampak goyah. kondisi ini dapat diperbaiki melalui latihan keseimbangan postural dinamik, namun selama ini jenis latihan yang dilakukan dipanti hanya sebatas latihan kebugaran fisik berupa senam lansia, sehingga yang mengalami perbaikan hanya kebugaran fisik saja sedangkan gaya berjalan tetap. faktor internal tidak terlalu mempengaruhi kejadian jatuh pada lansia di panti ini. faktor internal yang memiliki persentase cukup besar antara lain adalah kondisi psikis dan aktivitas. kondisi psikis sangat dipengaruhi oleh beberapa hal seperti status perkawinan dan trauma psikis terhadap jatuh. perubahan status perkawinan dan trauma psikis terhadap jatuh pada lansia akan menyebabkan perubahan kondisi psikologis kearah negatif yang akan mempengaruhi kejadian jatuh (hawari, 1999). b b t h c a n j t u g t b b t h c a n j t u g t b b t h c a n j t u g t 0.00% 20.00% 40.00% 60.00% 80.00% low risk medium risk high risk perbandingan prediksi jatuh bbt hcanj tugt gambar 1. distribusi responden berdasarkan prediksi jatuh dengan hcanj falls risk assessment, tugt, bbt pada lansia di panti wredha santo yoseph kediri, mei 2009 sebagian besar lansia dipanti ini adalah janda namun ada beberapa lansia yang tidak menikah. lansia yang sudah lama menjanda dan sudah beradaptasi dengan kondisi panti cenderung lebih jarang terjatuh. lansia yang pernah mengalami jatuh sampai terjadi luka yang cukup parah cenderung lebih memilih untuk tidak terlalu melakukan mobilitas. lansia tersebut menolak ketika diminta untuk mengangkat satu kaki selama 3 detik karena merasa akan jatuh, demikian juga ketika diminta untuk berdiri sambil menutup mata. mereka akan cenderung goyang dan mengatakan merasa badan seperti tertarik untuk jatuh sehingga waktu membuka mata cenderung lebih cepat dari waktu yang ditentukan. berdasarkan teori kontinuitas dapat diketahui bahwa riwayat pekerjaan lansia akan mempengaruhi kebiasaan frekuensi aktivitas setelah berada di panti sebagai cara penyesuaian diri lansia terhadap situasi lingkungan yang baru. menurut probosuseno (2008) tingkat aktivitas menjadi salah satu penyebab kejadian jatuh pada lansia, sehingga lansia yang aktif akan memiliki risiko jatuh lebih besar dari pada lansia yang tidak aktif. sebagian besar responden adalah lansia yang aktif. pihak panti memfasilitasi lansia tersebut yang masih sehat untuk membantu kegiatan rumah tangga sehari-hari seperti memasak, mengambil pakaian kering dari tempat jemuran, berbelanja ke pasar maupun toko-toko di sekitar panti. kondisi aktif di masa tua berdasarkan teori aktivitas merupakan kriteria sukses sebuah proses penuaan, namun yang perlu diperhatikan adalah kondisi aktif atau aktivitas pada lansia yang terlalu berlebihan akan meningkatkan risiko jatuh. hasil perbandingan antara bbt dan tugt dengan pembanding pemeriksaan hcanj, diketahui bahwa pemeriksaan tugt memiliki persentase nilai yang mendekati hcanj. pengukuran tugt melibatkan 3 faktor antara lain ankle, yaitu menggunakan aktivasi otot-otot plantar fleksor pergelangan kaki untuk meggerakan pusat massa tubuh, hip, yaitu menggunakan aktivitas otot fleksor hip dan otot trunkus untuk menggerakan pusat massa tubuh secara cepat, stepping yaitu melibatkan aktivasi otot abduktor sendi paha dan kontraksi otot pergelangan kaki (mufidah, 2007). sebagian besar responden dalam penelitian ini memiliki masalah pada faktor stepping, hal ini ternyata menyebabkan gaya berjalan yang menjadi lebih lamban, dan cenderung mudah goyang. gangguan gaya berjalan akan membuat waktu yang dibutuhkan untuk menyelesaikan instruksi pemeriksaan menjadi lebih lama. pemeriksaan bbt di pakai untuk mengetahui status keseimbangan postural statis lansia sedangkan pemeriksaan tugt dipakai untuk mengetahui status keseimbangan postural dinamis. perbedaan prediksi jatuh bbt dan tugt dalam nursalam penelitian ini dilihat melalui sebuah perbandingan dengan pemeriksaan pembanding yaitu hcanj. pemeriksaan ini dijadikan sebagai pedoman pencegahan jatuh di new jearsy yang didalamnya terdapat unsur pemeriksaan status keseimbangan postural statis dan dinamis sebagai indikator prediksi jatuh dalam penelitian ini. gangguan gaya berjalan yang dialami sebagian besar lansia di panti ini mengindikasikan masalah pada keseimbangan postural dinamis yang menyebabkan risiko jatuh akan meningkat akibat gangguan dalam proses pergerakan tubuh. simpulan dan saran simpulan kejadian jatuh yang dialami sebagian besar lansia di panti wredha santo yoseph kediri merupakan pengulangan dari kejadian jatuh pada waktu yang lalu dengan frekuensi melebihi kondisi yang seharusnya yaitu1 kali jatuh dalam rentang waktu 1 tahun. faktor yang paling dominan mempengaruhi kejadian jatuh pada lansia di panti wredha santo yoseph kediri adalah faktor gaya berjalan, akibat gangguan pada proses steping. pemeriksaan tugt lebih sesuai untuk memprediksi jatuh pada lansia dengan gangguan keseimbangan postural dinamis sedangkan pemeriksaan bbt lebih sesuai untuk memprediksi jatuh pada lansia dengan gangguan keseimbangan postural statis. saran penulis menyarankan agar lansia dianjurkan untuk mengikuti pemeriksaan keseimbangan postural setiap 3-6 bulan sekali yang diselenggarakan pihak pengelola panti, lansia dianjurkan untuk melakukan latihan keseimbangan postural dinamis seperti jalan kaki untuk memperbaiki steping, hip, dan ankle, pengelola panti memasukkan pemeriksaan prediksi jatuh ke dalam salah satu rangkaian pemeriksaan rutin yang dilakukan setiap 3 bulan sekali, pengelola panti mengadakan latihan keseimbangan postural dinamik secara bergantian dengan senam lansia sebagai upaya pencegahan kejadian jatuh pada lansia melalui perbaikan steping, bahan alas kaki yang digunakan lansia di panti, apabila memungkinkan diganti dengan bahan karet untuk mengurangi risiko jatuh, tenaga kesehatan yang bertugas dapat melakukan pemeriksaan keseimbangan postural dengan memperhatikan faktor dominan yang mempengaruhi kejadian jatuh, penelitian selanjutnya diharapkan agar meneliti tentang pengaruh model aktivitas jalan kaki terhadap perbaikan keseimbangan postural dinamis sebagai alternatif pencegahan jatuh pada lansia. kepustakaan bohannon, w richard. 2006. reference values for the timed up and go test: a descriptive meta-analysis. journal of geriatric physical therapy, 29, 1216 carpino, chris.2007. new ideas in balance and falls prevention. 3 ed. st.louis: elsevier saunders, p. 51. constantinides, p. 1994. general pathobiology. appleton and lange. hawari, dadang . 1999. manajemen stress cemas dan depresi. jakarta: gaya baru,hlm.12 health care association of new jersy.2005. fall management guidelines, (online), (www.hcanj.org., diakses tanggal 26 maret 2009, jam 13.00 wib). hideomi s tk, tooru a, et al. 2002.the relationship between the balance function and the elderly’s ability to walk. using the berg balance scale [in japanese]. journal hokkaido physio theraphist, 19, pp. 42-44. isnaini herawati dan wahyuni. (2004). perbedaan pengaruh senam otak dan senam lansia terhadap keseimbangan oang lanjut usia. infokes, 8(1), 1-9. kane rl, ouslander jg and abrass it. 1994. evaluating the elderly patient. in essentials of clinical geriatrics. mc. graw-hill inform. sev.coy. mufidah, nisfil. 2007. peningkatan keseimbangan postural manula dengan latihan balance exercise. skripsi tidak dipublikasikan keperawatan, surabaya: psik fk unair. probosuseno dan sukendro sendjaja. 2008. hubungan antara pemeriksaan time http://www.hcanj.org/ up dan go test (tug-test) dan riwayat roboh (falls) pada populasi lanjut usia di panti sosial tresna werdha abiyoso pakem sleman yogyakarta. kumpulan makalah temu ilmiah geriatri semarang tidak dipublikasikan. 28 – 30 maret 2008 rj., barr 2005. screening elderly women for risk of future fracture – participation rate and impact on incidence of falls and fracktures, calcified tissue international, 76, 243248) stephan klebe, henning stolze, christiane zechlin, christoph baecker, lars friege, günther deuschl.(2004). falls in frequent neurological diseases prevalence, risk factors and etiology. journal of neurology, 251, 79-84 susan.w. muir, katherine berg .2008. use berg balance scale for predicting multiple falls in community – dweling elderly people: prospective study. journal of physical therapy 88 (44), hal 449-459. perilaku pemulung tentang demam berdarah dengue dengan keberadaan jentik aedes aegypti (waste picker’s behaviour on dhf and it’s correlation with the presence of aedes aegypti larva) sulistiawati*, joni haryanto**, tintin sukartini**, mardiana** * departemen ilmu kedokteran masyarakat fakultas kedokteran universitas airlangga ** program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. prof. dr.moestopo 47 surabaya. telp/fax: (031) 5012496, e-mail: jurnalners_psikunair@yahoo.com abstract introduction: dengue haemorhagic fever is an endemic disease caused by dengue virus with aedes aegypti as the vector. most of waste pickers in waste goods pool refuse fogging, 3m programme and abatization, so that dhf outbreak occurs in that area every year. larva free rate also remains under the target. therefore, it was necessary to improve dhf relation with behaviour of waste pickers. this study was used a cross sectional design. the objective of this study was to identify waste picker’s behaviour on dhf and its correlation with the presence of aedes aegypti larva. method: the subjects were waste picker which live at sidokumpul and kebomas village. there were 36 samples which recruited by using cluster random sampling. data were collected by using questionnaire (structured intervied) and observation, then analyzed by using fisher’s exact test with significance level α≤0.05. result: the result showed that there was not a correlation between waste picker’s knowledge with the presence of aedes aegypti larva (p=0.236), no correlation between waste picker’s attitude with the presence of aedes aegypti larva (p=0.422) and there was a significance correlation between waste picker’s behaviour with the presence of aedes aegypti larva (p=0.03). discussion: it can be concluded that there was not a correlation between waste picker’s knowledge and waste picker’s attitude with the presence of aedes aegypti larva. moreover, the waste picker’s behaviour has a significance correlation with the presence of aedes aegypti larva.the waste picker should improve their participation in mosquito’s nest eradication programme. keywords: waste picker’s behaviour, dhf, aedes aegypti larvae pendahuluan penyakit demam berdarah dengue (dbd) merupakan penyakit endemis yang disebabkan oleh virus dengue dengan vektor aedes aegypti dan masih menjadi masalah kesehatan di indonesia (soegijanto, 1997 dalam who, 2004). hampir semua pemulung di tempat pengepulan barang bekas menolak apabila diadakan fogging, begitu juga program 3 m (menguras, menutup dan mengubur) tidak pernah terlaksana, sehingga selalu ada kejadian luar biasa (klb) setiap tahun di kota gresik (dinkes kota gresik, 2007). terutama di kelurahan sidokumpul tahun 2006 angka bebas jentik (abj) masih 84,92% dan kelurahan kebomas sebesar 89,73%, hal ini menunjukkan tingkat populasi nyamuk aedes aegypti masih cukup tinggi, sedangkan target propinsi jawa timur angka bebas jentik sama atau lebih dari 95%. di kedua kelurahan tersebut di atas pada bulan maret 2007 masih terjadi kejadian luar biasa (klb). sampai saat ini hubungan perilaku pemulung tentang dbd dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas masih belum diketahui. penyakit dbd di indonesia merupakan salah satu emerging disease dengan insiden yang meningkat dari tahun ke tahun. demam berdarah dengue pertama kali dilaporkan di surabaya dan jakarta tahun 1968 dengan case fatality rate (cfr) 41,3%. kejadian dbd cenderung meningkat antara 1994-1998, meskipun cfr berhasil diturunkan dari 2,5% (1994) menjadi 2% (1998) (soegijanto, 2004). jumlah pasien dbd di indonesia tahun 2002 sebanyak 40.337 orang, tahun 2003 sebanyak 50.131 orang, tahun 2004 sebanyak 79.480 orang, tahun 2005 sebanyak 95.000 orang dan sepanjang tahun 2006 menurun menjadi 85.000 orang (kristina, 2004 dalam depkes ri., 2006). kabupaten gresik merupakan daerah endemik dbd. jumlah kasus dbd di kabupaten gresik tahun 2002 sebanyak 139 orang, tahun 2003 167 orang, tahun 2004 sebanyak 69 orang, tahun 2005 sebanyak 84 orang, tahun 2006 meningkat 4 kali lipat dari tahun 2005 sebanyak 358 orang, cfr 2,5%, ir 33,8 per 100.000 penduduk, angka bebas jentik (abj) 89,34%. kelurahan sidokumpul dan kelurahan kebomas merupakan daerah klb dbd. tahun 2006 jumlah pasien dbd di kelurahan sidokumpul sebanyak 23 orang dan sampai bulan maret 2007 tercatat sebanyak 20 orang, 4 orang diantaranya bertempat tinggal di tempat pengepulan barang bekas, sedangkan di kelurahan kebomas tahun 2006 sebanyak 39 orang dan sampai bulan maret 2007 tercatat 3 orang (dinkes kota gresik, 2007). keberadaan jentik nyamuk aedes aegypti di suatu daerah merupakan indikator terdapat populasi nyamuk aedes aegypti di daerah tersebut. pengendalian nyamuk aedes aegypti pada umumnya belum berhasil, karena sampai saat ini belum ada vaksin yang dapat mencegah infeksi dengue dan belum ada obat khusus untuk mengobatinya (who, 2004). pemberantasan dbd yang paling mudah dilakukan adalah dengan memberantas vektor untuk memutus rantai penularan. program penanggulangan dbd telah dilakukan oleh departemen kesehatan dengan kegiatan meliputi: penyemprotan insektisida, psn dan abatisasi (depkes ri, 2000). pemberantasan sarang nyamuk (psn) merupakan program pemerintah yang paling diandalkan daripada penggunaan insektisida yang berupa pengasapan (fogging) dengan malathion dan penaburan abate temephos. kedua cara ini belum memberikan hasil yang optimal, dalam arti belum dapat menaikkan angka bebas jentik sama atau lebih besar dari 95%. halstead (2000) menyatakan bahwa salah satu faktor gagalnya pemberantasan dbd adalah kurangnya pengetahuan, sikap dan tindakan masyarakat mengenai dbd. penelitian ghufron (2003) di tempat pembuangan sampah di tamangapa makassar menyatakan bahwa masalah kesehatan di lingkungan pemulung sangat terabaikan, hal ini karena pengetahuan pemulung terhadap masalah kesehatan terutama dbd sangat kurang, perilaku pemulung dalam mengumpulkan barangbarang bekas tidak mendukung adanya program gerakan 3 m. kesadaran masyarakat akan pentingnya gerakan psn dbd yang meliputi 3m yaitu menguras, mengubur dan menutup kontainer yang berpotensi sebagai sarang nyamuk yang masih belum optimal. hal ini disebabkan oleh dua faktor yaitu faktor internal dan eksternal. faktor internal meliputi pendidikan, pekerjaan dan nilai yang diyakini masyarakat. faktor eksternal meliputi ketersediaan sumber informasi, keaktifan petugas penyuluh dan fasilitas unit kesehatan (bambang, 1998). apabila usaha pemberantasan sarang nyamuk ini dilaksanakan oleh seluruh masyarakat, maka nyamuk aedes aegypti dapat dikendalikan. peningkatan kasus dbd disebabkan adanya faktor yang menunjang perkembangbiakan vektor. faktor tersebut perlu diteliti agar dapat diambil tindakan untuk pencegahan, salah satu usaha yang baik adalah dengan mengontrol keberadaan jentik secara berkesinambungan terutama pada tempat-tempat yang selama ini kurang mendapat perhatian seperti tempat pengepulan barang bekas. hubungan perilaku pemulung tentang dbd dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas perlu di teliti. perilaku pemulung di tempat pengepulan barang bekas sebagai dasar dalam penentuan kebijakan selanjutnya. dengan harapan semakin baik perilaku pemulung mengenai dbd maka kasus dbd tidak terjadi di daerah tersebut. tujuan dari penelitian ini adalah untuk menganalisis hubungan perilaku pemulung tentang dbd dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas. bahan dan metode penelitian ini menggunakan desain penelitian cross sectional. populasi dalam sikap 56% 44% positif negatif tindakan 3% 36% 61% baik cukup kurang pengetahuan 14% 44% 42% baik cukup kurang penelitian ini adalah semua pemulung yang ada di tempat pengepulan barang bekas yang ada di kelurahan sidokumpul (21 orang) dan di kelurahan kebomas gresik (15 orang), yang diperoleh berdasarkan teknik cluster random sampling. variabel independen dalam penelitian ini adalah perilaku pemulung tentang dbd meliputi pengetahuan, sikap dan tindakan, sedangkan variabel dependen adalah keberadaan jentik aedes aegypti. penelitian ini dilakukan di di tempat-tempat pengepulan barang-barang bekas yang ada di kelurahan sidokumpul dan kelurahan kebomas gresik pada mei 2007. instrumen yang digunakan dalam penelitian ini adalah kuesioner (wawancara terstruktur), lembar observasi jentik, mikroskop dan senter. data yang diperoleh dianalisis dan diuji dengan menggunakan uji statistik chisquare dengan derajat kemaknaan α≤0,05 dan apabila tidak memenuhi syarat digunakan uji alternatif yaitu fisher exact test. hasil berdasar hasil penelitian bahwa dari 36 tempat pengepulan barang bekas yang diteliti, sebagian besar ditemukan jentik aedes aegypti yaitu sebanyak 28 tempat (77,8%), 6 tempat (16,6%) tidak ditemukan jentik dan 2 tempat (5,6%) ditemukan jentik culex. pada gambar 1 dapat dilihat dari 36 orang pemulung yang diteliti, sebagian besar pemulung memiliki tingkat pengetahuan cukup yaitu sebanyak 16 orang (44,4%), 20 orang (55,6%) memiliki sikap positif terhadap pencegahan dan psn dbd dan 22 orang (61,1%) memiliki tindakan yang kurang dalam upaya pencegahan dan psn dbd. pada tabel 1 dapat dilihat dari 36 tempat pengepulan barang bekas yang diteliti, terdapat 28 tempat pengepulan barang bekas ditemukan jentik aedes aegypti dan 8 tempat tidak ditemukan jentik aedes aegypti. tidak ada hubungan yang bermakna antara tingkat pengetahuan pemulung tentang demam berdarah dengue dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas yang ditunjukkan dengan hasil analisis statistik fisher’s exact test p=0,236. sikap pemulung yang positif tentang upaya pencegahan dan psn dbd ditemukan jentik aedes aegypti di 17 tempat (47,3%) sedangkan pada sikap pemulung yang negatif ditemukan jentik aedes aegypti di 11 tempat (30,5%). hasil penelitian menunjukkan bahwa dari 36 tempat pengepulan barang bekas tersebut, pemulung yang memiliki tindakan kurang tentang pencegahan dan psn dbd ditemukan jentik aedes aegypti sebanyak 21 tempat (58,4%), pada pemulung yang memiliki tindakan cukup dan baik ditemukan jentik aedes aegypti sebanyak 7 tempat (19,4%). gambar 1. perilaku (pengetahuan, sikap dan tindakan) pemulung tentang demam berdarah dengue dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas di kelurahan sidokumpul dan kelurahan kebomas gresik, mei 2007. tabel 1. hubungan tingkat pengetahuan, sikap dan tindakan pemulung tentang demam berdarah dengue dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas no. perilaku keberadaan jentik aedes aegypti total hasil uji statistik (fisher’s exact test) tidak ada ada 1. tingkat pengetahuan kurang 5 (13,8%) 10 (27,9%) 15 (41,7%) p=0,236 cukup + baik 3 (8,3%) 18 (49,9%) 21 (58,3%) 2. sikap pemulung sikap positif 3 (8,3%) 17 (47,3%) 20 (55,6%) p=0,422 sikap negatif 5 (13,9%) 11 (30,5%) 16 (44,4%) 3. tindakan pemulung kurang 1 (2,8%) 21 (58,4%) 22 (61,2%) p=0,03 cukup + baik 7 (19,4%) 7 (19,4%) 14 (38,8%) keterangan: p = signifikansi terdapat hubungan yang bermakna antara tindakan pemulung tentang dbd dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas yang ditunjukkan dengan hasil analisis statistik fisher’s exact test p=0,03. pembahasan hasil penelitian menunjukkan bahwa sebagian besar tempat pengepulan barang bekas positif ditemukan jentik aedes aegypti. nadesul (1999) menyatakan, kebersihan lingkungan sangat berkaitan erat dengan tempat perkembangbiakan jentik aedes aegypti, terutama di lingkungan yang terdapat tempat-tempat penampungan air sebagai media breeding place, misal bak mandi, tempayan, kaleng-kaleng bekas dan barang-barang bekas lainnya yang dapat menampung air. tempat pengepulan barang bekas merupakan suatu tempat dimana para pemulung mengumpulkan barang hasil memulung yang ditimbun sebelum dijual. barang-barang bekas tersebut diletakkan diruang terbuka. pada saat musim hujan barang-barang bekas tersebut akan terisi air dan menjadi tempat perkembangbiakan nyamuk aedes aegypti. penyebab ditemukan jentik aedes aegypti pada sebagian besar tempat pengepulan barang bekas yang diteliti adalah banyaknya barang-barang bekas yang menjadi sarang nyamuk, tempat-tempat penampungan air yang ada belum dikuras dan tidak ditutup, selain itu abatisasi juga tidak pernah dilaksanakan. sebagian kecil tempat pengepulan barang bekas tidak ditemukan jentik aedes aegypti. hal ini disebabkan oleh beberapa faktor seperti pada saat dilakukan penelitian barang-barang bekas tersebut sebagian besar sudah dijual, barang-barang bekas tersebut dalam posisi terbalik sehingga tidak dapat menampung air hujan, barang bekas tergenang air kotor bercampur sampah sehingga didalam barang bekas ini ditemukan jentik culex, tempat penampungan air yang terdapat di tempat pengepulan barang bekas tersebut juga sebagian sudah dikuras dan beberapa pemulung memelihara ikan pemakan jentik di tempat penampungan air seperti bak mandi, sehingga tidak ditemukan jentik. sebagian besar pemulung memiliki pengetahuan cukup tentang dbd. hal ini berarti informasi atau pengetahuan pemulung tentang dbd yang meliputi penyebab dan vektor dbd, tanda/gejala dan penanganan serta upaya pencegahan dan pemberantasan sarang nyamuk aedes aegypti (psn-dbd) sebagian besar cukup, namun jumlah pemulung yang memiliki pengetahuan kurang pun masih banyak. hal ini didukung oleh pendidikan responden (pemulung) yang sebagian besar masih rendah dimana 13 orang (36,1%) sd tidak tamat, 10 orang (27,78%) tidak sekolah, 8 orang (22,22%) lulus sd, 5 orang (13,89%) lulus smp. pemulung yang berpengetahuan kurang dan cukup lebih banyak jumlahnya disebabkan oleh kurangnya informasi tentang dbd yang diperoleh dari media cetak atau elektronik, sehingga informasi tentang dbd kurang. pendidikan kesehatan tentang dbd tidak pernah diadakan di tempat pengepulan barang bekas. matra dalam notoatmodjo (2003), menyatakan bahwa semakin tinggi tingkat pendidikan seseorang maka semakin mudah orang tersebut untuk menerima informasi baik dari orang lain maupun dari media massa, sehingga semakin banyak informasi yang masuk, semakin banyak pula pengetahuan yang didapat. menurut notoatmodjo (2003) pendidikan merupakan suatu proses belajar yang berarti didalam pendidikan itu terjadi proses pertumbuhan, perkembangan atau perubahan ke arah lebih dewasa, lebih baik dan lebih matang pada diri individu, kelompok atau masyarakat. martaadisubrata (2003) menyebutkan pendidikan yang rendah menyebabkan seseorang acuh tak acuh terhadap masalah kesehatan, sehingga mereka tidak mengenal bahaya yang akan terjadi. hal ini dialami oleh para pemulung karena pendidikan yang rendah maka pengetahuan mereka tentang dbd dan bahayanya juga masih sedikit, akibatnya meskipun kasus dbd hampir terjadi setiap tahun di tempat mereka, namun para pemulung tersebut menganggap masalah tersebut sebagai masalah sederhana dan tidak ada tindakan pencegahan yang dilakukan. pengetahuan pemulung tentang dbd tidak ada hubungan dengan keberadaan jentik aedes aegypti ditempat pengepulan barang bekas yang ada di kelurahan sidokumpul dan kelurahan kebomas. pemulung tahu tentang dbd tetapi tidak melaksanakan program 3m. hal ini dapat dibuktikan dengan pemulung yang berpengetahuan cukup dan baik terdapat lebih banyak jentik aedes aegypti di tempat pengepulannya dibandingkan pemulung yang berpengetahuan kurang. menurut notoatmodjo (2003), pengetahuan merupakan domain yang sangat penting dalam membentuk tindakan seseorang (overt behaviour). perilaku yang didasari oleh pengetahuan akan lebih langgeng daripada perilaku yang tidak didasari oleh pengetahuan. seseorang yang mempunyai pengetahuan tentang dbd yang baik akan berperilaku baik pula dalam pencegahan dan psn dbd, namun dalam penelitian ini pemulung meskipun sebagian besar pengetahuan mereka tentang dbd cukup, tetapi pemulung tidak mengaplikasikan pengetahuan mereka dalam suatu tindakan. hal ini kemungkinan karena pemulung tersebut tahu tapi tidak mau melaksanakan tindakan pencegahan atau mereka tahu tentang demam berdarah tetapi mereka tidak mampu melaksanakan tindakan pencegahan sehinggga masih ditemukan jentik aedes aegypti ditempat pengepulan barang bekas. pelaksanaan psn dbd tidak cukup dengan pengetahuan yang baik saja. dapat dilihat dari hasil penelitian dimana pemulung yang berpengetahuan baik pada tempat pengepulan barang bekas masih ditemukan jentik aedes aegypti. hal ini menunjukkan bahwa pada orang yang berpengetahuan baik belum tentu melaksanakan tindakan pencegahan, karena hal tersebut tergantung juga pada niat seseorang untuk melakukan tindakan. tidak terdapat hubungan antara sikap dengan keberadaan jentik aedes aegypti di tempat pengepulan barang bekas. hal ini menunjukkan bahwa sebagian besar pemulung memiliki sikap positif terhadap upaya pencegahan dan psn dbd. persepsi pemulung tentang pencegahan dan psn dbd sudah baik. sebagian besar pemulung yang bersikap positif terhadap upaya pencegahan dan psn dbd, di tempat pengepulannya ditemukan lebih banyak jentik aedes aegypti dibanding pemulung yang bersikap negatif. menurut notoatmodjo (2003), sikap merupakan reaksi atau respons seseorang yang masih tertutup terhadap stimulus atau obyek, yang sudah melibatkan faktor pendapat dan emosi yang bersangkutan. sikap belum tentu merupakan tindakan (reaksi terbuka) atau aktivitas tetapi merupakan predisposisi tindakan atau perilaku. hal ini dapat dibuktikan pada pemulung yang bersikap positif terhadap upaya pencegahan dan psn dbd, namun mereka tidak mewujudkan dalam tindakan nyata sehingga di tempat pengepulan barang bekas masih ditemukan adanya jentik aedes aegypti. notoatmodjo (2003) menyatakan bahwa suatu sikap belum tentu otomatis terwujud dalam suatu tindakan (overt behaviour), untuk terwujudnya sikap menjadi suatu tindakan nyata diperlukan faktor pendukung atau suatu kondisi yang memungkinkan antara lain tersedianya fasilitas. pada penelitian ini didapatkan bahwa meskipun sebagian besar pemulung bersikap positif terhadap upaya pencegahan dan pemberantasan sarang nyamuk (psndbd), karena tidak tersedianya fasilitas abatisasi gratis dari pemerintah setempat maka program abatisasi di tempat pengepulan barang bekas tersebut tidak dapat terlaksana, selain itu dipengaruhi juga oleh penghasilan para pemulung yang hanya cukup untuk memenuhi kebutuhan hidup sehari-hari, sehingga untuk membeli obat abate sendiri tidak mencukupi. faktor pekerjaan pun sangat berpengaruh terhadap terwujudnya sikap mereka menjadi tindakan nyata, meskipun para pemulung tersebut bersikap positif terhadap pencegahan dan psn dbd namun pekerjaan sebagai pemulung membuat mereka mengumpulkan barang-barang bekas dari berbagai tempat kemudian ditimbun sebelum dijual. hal ini sangat bertolak belakang dengan upaya pencegahan dan psn dbd, akibatnya para pemulung tersebut tidak dapat mewujudkan sikap positif mereka menjadi tindakan yang nyata. penentuan sikap yang utuh baik pengetahuan, pikiran dan emosi memegang peranan penting. sesuai dengan azwar (2003) hal tersebut sama halnya dengan komponen kognitif (apa yang dipercayai), afektif (perasaan yang menyangkut aspek emosional) dan komponen perilaku (kecenderungan berperilaku). dari ketiga komponen tersebut, komponen afektif yang paling kuat dan kompleks, akan lebih sukar berubah walaupun dimasukkan informasi baru yang berlawanan dengan objek sikap. sikap diikuti atau tidak diikuti oleh suatu tindakan dipengaruhi juga oleh pengalaman seseorang, situasi saat itu, nilai yang menjadi pegangan masyarakat. sebagian besar pemulung memiliki tindakan yang kurang dalam pencegahan dan psn dbd yang ditunjukkan dengan terdapatnya jentik aedes aegypti di tempat pengepulan pada 21 orang (58,4%) pemulung dengan kategori tindakan kurang, pemulung dengan kategori tindakan cukup dan baik ditemukan terdapat jentik aedes aegypti ditempat pengepulannya sebanyak 7 orang (19,4%). para pemulung belum optimal dalam melakukan tindakan pencegahan dan psn dbd yang ditunjukkan dengan abatisasi 0% dan gerakan 3m belum terlaksana dengan baik. saat observasi hanya sebagian kecil pemulung yang menguras dan menutup tempat penampungan air, sedangkan yang mengubur barang-barang bekas tidak ada sama sekali, sehingga barang-barang bekas tersebut menjadi sarang nyamuk. who (2004) menyatakan bahwa barang-barang bekas seperti kaleng-kaleng, plastik, ban bekas dan lain-lain merupakan tempat yang potensial bagi perkembangan nyamuk aedes aegypti, terutama pada musim hujan, dimana barang-barang bekas tersebut akan tergenang air dan telur-telur nyamuk yang ada akan menetas menjadi jentik yang akhirnya tumbuh menjadi nyamuk dewasa. tindakan pemulung yang kurang baik dapat menciptakan kondisi yang baik bagi perkembangbiakan nyamuk aedes aegypti, sehingga mempengaruhi keberadaan jentik aedes aegypti. notoatmodjo (2003) menyatakan bahwa perilaku masyarakat mempunyai pengaruh terhadap lingkungan karena lingkungan merupakan lahan untuk pekembangan perilaku tersebut. apabila perilaku manusia baik maka lingkungan yang mendapat campur tangan manusia yang berperilaku baik maka akan menjadi baik pula, begitu pula sebaliknya. blum dalam notoatmodjo (2003) menyimpulkan bahwa faktor perilaku mempunyai peranan yang besar terhadap tingkat kesehatan, jadi perilaku masyarakat yang kurang baik terhadap kesehatan dalam menjaga kebersihan lingkungan dapat menciptakan tempat yang baik bagi perkembangbiakan aedes aegypti. simpulan dan saran simpulan perilaku pemulung berperan dalam keberadaan jentik di tempat tinggal. perilaku yang kurang baik menunjukkan peningkatan keberadaan jentik aedes aegyti, khususnya di tempat pengepulan barang bekas. saran peneliti menyarankan diterapkan upaya peningkatan kewaspadaan dini para pemulung terhadap penyakit demam berdarah dengue (dbd) dengan cara ikut serta dan aktif dalam pemberantasan sarang nyamuk demam berdarah dengue (psn dbd), pelaksanaan secara rutin dan berkesinambungan kegiatan penyuluhan kesehatan di tempat pengepulan barang bekas (pemukiman pemulung) tentang dbd, diadakan program abatisasi dan fogging gratis bagi pemulung, pelaksanaan kegiatan pemantauan jentik aedes aegypti secara berkala 3 bulan sekali di tempat pengepulan barang bekas untuk mengetahui keberadaan jentik aedes aegypti dan pembentukan kader kesehatan (kelompok dasawisma). kepustakaan azwar, s. 2003. sikap manusia teori dan pengukurannya. edisi 2. yogyakarta: pustaka pelajar, hlm. 5-9. bambang, h. 1998. faktor-faktor penyebab klb dbd di indonesia, (online), (http://www.infomedika.com, diakses tanggal 20 februari 2007, jam 20.00 wib). depkes r.i. 2000. pencegahan dan penanggulangan dbd dan db. jakarta: dirjen ppm dan plp, hlm. 1215. depkes r.i., 2000. kasus demam berdarah dengue di indonesia, buletin harian tim penanggulangan dbd departemen kesehatan ri, edisi senin 8 maret 2004, (online), (http://www.ppmplp.depkes.go.id., diakses tanggal 12 april 2007, jam 06.30 wib). depkes r.i., 2006. pencegahan dan pemberantasan dbnd di indonesia. jakarta: dirjen ppm dan plp, hlm. 215. dinkes kota gresik, 2000. jumlah kasus dbd di kelurahan sidokumpul dan kelurahan kebomas gresik bulan maret 2006 sampai dengan maret 2007. gresik: kasubdin ppm & plp. ghufron, et al. 2003. aku dan rumahku di pembuangan sampah: profil anak pemulung di tpas tamangapa makassar. makassar: hasannudin university, hlm. 1-4. halstead, s.b. 2000. successes and failure in dengue control global experiences, dengue bulletin, vol.24, 60-70. kristina, et al. 2004. demam berdarah dengue: kajian masalah kesehatan, laporan badan litbangkes depkes ri, (online), (http://www.ppmplp.depkes.go.id., diakses tanggal 7 april 2007, jam 10.00 wib). martaadisubrata, 2003. obstetri sosial. bandung: fakultas padjajaran, hlm. 33. nadesul, h. 1999. penyebab, pencegahan, dan pengobatan demam berdarah. jakarta: puspa swara, hlm. 28-31. notoatmodjo, s. 2003. ilmu kesehatan masyarakat. jakarta: rineka cipta, hlm. 120-130. notoatmodjo, s. 2003. pendidikan dan perilaku kesehatan. jakarta: rineka cipta, hlm. 20-45. soegijanto, s. 1997. international seminar on dengue fever: new strategy controlling and prevention of dhf in south east asia. surabaya: tropical disease center airlangga university, hlm.78-80. soegijanto, s.2004. aspek imunologi penyakit dbd dalam dbd: tinjauan dan temuan baru di era 2003. surabaya: airlangga university press, hlm. 27-33. who, 2004. panduan lengkap pencegahan dan pengendalian dengue dan demam berdarah dengue. jakarta: egc. http://www.infomedika.com/ http://www.ppmplp.depkes.go.id/ http://www.ppmplp.depkes.go.id/ http://e-journal.unair.ac.id/jners | 219 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.9986 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors associated with nurses’ self-efficacy in applying palliative care in intensive care unit theresia avila kurnia1, yanny trisyani2 and ayu prawesti2 1 diploma of nursing programme, poltekkes kemenkes kupang, east nusa tenggara, indonesia 2 faculty of nursing, universitas padjadjaran, bandung, west java, indonesia abstract introduction: the increasing need for palliative care (pc) in the intensive care unit (icu) is characterised by an increasing number of patients with critical and terminals conditions. it requires comprehensive treatment of nurses, through pc. self-efficacy is a major predictor that affects the application of pc in icu. therefore, nurses need to have high self-efficacy to provide quality pc for patients and their families. this study aimed to analyse the factors that dominant relates to nurses' self-efficacy in implementing of providing pc in icu. methods: this research was correlational research with cross-sectional survey design. the sampling technique used was total sampling, which involved 127 critical nurses who were actively working at a general hospital in bandung, indonesia. data were collected using questionnaires. bivariate analysis using pearson correlation and rank-spearman test and multivariate analysis using linear regression. results: the results showed that the majority of respondents had high self-efficacy, working experience >15 years, enough interest to the nursing profession had less knowledge and negative perception related to the pc in icu. there was a significant relationship between self-efficacy with work experience, nurses' interest in the nursing profession, knowledge and perception variables. the most dominant factors related to self-efficacy, namely knowledge and perceptions of nurses related to pc. conclusion: this study indicates that majority of the respondents lacked knowledge and had negative perceptions related to pc in icu, it is necessary to socialise and training related to it by focusing on self-belief or self-efficacy of nurses on their ability. article history received: october 10, 2018 accepted: february 28, 2019 keywords icu; nurse; palliative care; selfefficacy contact theresia avila kurnia  theresia16003@mail.unpad.ac.id  diploma of nursing programme, poltekkes kemenkes kupang, east nusa tenggara, indonesia cite this as: kurnia, t.a., trisyani, y., & prawesti, a. (2018). factors associated with nurses’ self-efficacy in applying palliative care in intensive care unit. jurnal ners, 13(2), 219-226. doi:http://dx.doi.org/10.20473/jn.v13i2.9986 introduction palliative care (pc) is primarily comprehensive care given to patients with life-threatening or lifelimiting diseases (shreves, 2014). the increasing need for pc arose since the introduction of the importance of this program in the health care area in the united states (us). there was an increase of up to 125% from 2000-2008 (urden, stacy & lough, 2014). pc is not only given in community settings but also given in the care of inpatient services in hospitals, such as medical ward and even the intensive care unit (icu) (payne, seymour & ingleton, 2008). icu is a treatment area which is full of various sophisticated technological innovation tools aiming to extend the lives of patients with critical conditions (cox, handy & blay, 2012). this critical patient condition often causes pain that is not recognized or treated, shortness of breath, delirium, fatigue, lack of appetite, drowsiness, dyspnea, anxiety, depressive mood and weakness, constipation, tightness, nausea and vomiting, fever and infection, edema, anxiety, delirium, and metabolic disorders (ayasrah, o’neill, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:theresia16003@mail.unpad.ac.id http://dx.doi.org/10.20473/jn.v13i2. t.a. kurnia et al. 220 | pissn: 1858-3598  eissn: 2502-5791 abdalrahim, sutary & kharabsheh, 2014; wilkie & ezenwa, 2012; delgado‐guay, parsons, li, palmer & bruera, 2009; national clinical effectiveness committee, 2015; nelson, mulkerin, adams & pronovost, 2006; urden, stacy & lough, 2014). the pc provided in icu contributes positively to the patient, family and clinician team (aslakson, curtis & nelson, 2014). in providing high-quality and effective pc in icu, nurses play a strategic role for being the primary liaison between patients, families and other members of the multi-professional team. however, professional nurses nowadays may not always be ready to provide qualified pc for patients and families (fitch, fliedner, & o’connor, 2015; world health organization/who, 2018). self-efficacy is an internal factor that greatly influences nurses in implementing pc (gaffney, 2015). this is supported by the statements of lenz & shortridge (2002), that self-efficacy is the most important predictor in influencing changes in individual behavior and providing satisfactory results. it is also a predictor that influences nurses in providing quality pc (ferrel, coyle & paice, 2015). self-efficacy is someone’s belief in his/her ability to do something to achieve his/her goals (bandura, 2005). within the context of nursing, selfefficacy is an important aspect that supports nurses’ skill performance (tyler, bourbon, cox, day, fineran, rexford, & ward-smith, 2012). nurses’ self-efficacy correlates with professional autonomy and empowerment. nurses with high self-efficacy perceive obstacles as opportunities instead of threats (manoilovich, 2005). high self-efficacy also influences the quality of clinical performance which later leads to the satisfactory outcome of patients (joy, 2015). according to gaffney (2015), the current phenomenon happened is that nurses' self-efficacy is not balanced. some nurses have low self-efficacy while some others have high self-efficacy. this problem relates to several factors, among others: age, gender, knowledge, perception, and experience (bandura, 2004). soudagar, et al (2015) added that other factors affect the self-efficacy of nurses, namely interest to the nursing profession. research shows that there are still many nurses who have never received information regarding pc and have a low knowledge score related to pc (al qadire, 2014; ayed, ahmad, sayej, harazneh, fashafsheh & eqtait, 2015; kalogeropoulou, maria, evanthia, petros & dimitris, 2016; agustina, anna and praptiwi, 2014). this shows that there are still nurses who have not been exposed to information related to pc, thus affecting the knowledge they have. in addition, johnston and lorraine (2006) state that nurses' perceptions of pc currently vary, which is only given to patients with severe illness and who are dying or patients nearing death, especially for cancer patients, care to relieve pain and aggravating symptoms at the end of life (rodriguez, barnato & arnold, 2007; sarfo, et al, 2016). these perceptual differences about the pc referral process result in a lack of utilisation of palliative services and can result in a decrease in nurses' self-efficacy in achieving the goals to be carried out (rodriguez, et al., 2007; gaffney, 2015). individual self-efficacy is also influenced by the experience of the individual, which is formed through a process of adaptation and learning that recurs in the situation. the longer the individual is in the situation, the more self-efficacy they have will be improved or high (bandura, 2004). successful experiences experienced by individuals can increase their selfconfidence and self-efficacy. on the other hand, experiences of failures that have been experienced can reduce individual self-efficacy (zulkosky, 2009). interest is a situation where individuals have special attention to something and have the desire to know and learn more (darmadi, 2017). the higher the individual has an interest in something, the higher the self-efficacy he has. high individual self-efficacy is an important predictor of how individuals behave towards choices to be made, mindset, emotional reactions, motivations, and ways of acting (soudagar, 2015). lack of interest into the nursing profession, working experiences, knowledge and differences in perceptions experienced by nurses as described previously can influence nurses' self-efficacy in implementing pc. this study aimed to analyse the factors that dominant relates to nurses' self-efficacy in implementing of providing pc in the icu. materials and methods this research was quantitative research which used descriptive analytic study with cross-sectional survey design. the location of the study was in the icu of the general hospital in bandung. the study was conducted for one month, may to june 2018. the sampling technique used in the study was a nonprobability sampling technique, namely total sampling. there were 127 actively working nurses involved in this research. this study employed four questionnaires, namely demographic questionnaire, knowledge questionnaire, perception questionnaire and nurse self-efficacy in the application of intensive palliative questionnaire. questionnaire on respondents' characteristics contained age, sex, icu, religion, recent education, ethnicity and palliative education activities, working experiences and level of interest to the nursing profession. standardised questionnaires were employed in this research, among others on knowledge questionnaire proposed by nakazawa, miyashita, morita, umeda, oyagi, & ogaswara (2009), on perception proposed by white & coyne (2011) and the one on self-efficacy designed by desbiens, et al. (2011). a survey questionnaire namely palliative care knowledge test (pckt) which contained 18 statements with choices of right, wrong, and unsure answers. this questionnaire had been adjusted to the who palliative definition (2014) by nakazawa. this knowledge questionnaire consisted of some conceptual content about the philosophy and principles of pc (2 items), pain and other symptoms jurnal ners http://e-journal.unair.ac.id/jners | 221 management (symptoms of pain: 6 items, dyspnea: 3 items, gastrointestinal: 4 items) and aspects psychosocial (3 items) (nakazawa, et al., 2009). palliative care practice of registered nurses (pcpcrn) questionnaire proposed by white and coyne since 1999 was employed to collect data on nurses’ perception about pc. this instrument consisted of some questions which were categorised into two parts based on the level of importance of pc (10 domains) and the level of individuals’ competence in performing pc (10 domains) (white, roczen, coyne, & wiencek, 2014). nurses’ self-efficacy was measured using a survey questionnaire namely palliative care nursing self-competence scale (pcnsc) questionnaire developed by desbiens & fillion since 2011. in this research, surveys were conducted to measure nurses’ self-efficacy based on ten categories or ten pc dimensions which included physical needs: pain (5 items), physical needs: other symptoms (5 items), psychological needs (5 items), social needs (5 items), spiritual needs (5 items), needs related to patients’ functional status (5 items), ethical and legal issues (5 items), inter-professional collaboration and communication (5 items), personal and professional issues related to nursing care (5 items) and end-of-life care (5 items) (desbiens, gagnon, & fillion, 2012). the results of the measurement of knowledge were then analysed using the percentage score, with a score range of 0-100%. the percentage results were then categorised as follows the category of low (score> 56%), enough (score 56-75%), and good (score 76-100%) (nursalam, 2011). the results of measurement on perception and self-efficacy were then analyzed using t score using this following formula (azwar, 2010). the score obtained from the test were then categorised into these following categories: positive perception or high efficacy = if t score ≥ mean score, whereas, negative perception or low efficacy = if t score is lesser than the mean t score. the researcher categorised the variables to make it easier to describe the results of research based on those categories, which results were not to be analysed. the researcher did a back translation and retested the validity and reliability of the questionnaire on 42 intensive nurses using pearson product moment correlation for validity and kr-20 and alpha cronbach for reliability. one item on the knowledge questionnaire was not valid and all items on the perception and self-efficacy questionnaire were valid. the pckt, pcpcrn and pcnsc questionnaire were reliability because the reliability coefficient value was greater than 0.7 (kr-20 = 0.718 for knowledge, alpha cronbach = 0.841 for perception about importance of pc, alpha cronbach = 0.888 for perception about individuals’ competence in performing pc, alpha cronbach = 0.908 for physical needs: pain, alpha cronbach = 0.948 for physical needs: other symptoms, alpha cronbach = 0.873 for psychological needs, alpha cronbach = 0.913 for social needs, alpha cronbach = 0.889 for spiritual needs, alpha cronbach = 0.903 for needs related to patients’ functional status, alpha cronbach = 0.927 for ethical and legal issues, alpha cronbach = 0.952 for interprofessional collaboration and communication, alpha cronbach = 0.959 for personal and professional issues related to nursing care and alpha cronbach = 0.930 for end-oflife care). univariate analysis was used to determine the frequency of each variable. for bivariate test analysis, rank spearman test was used if the data were not normally distributed while the pearson correlation test was used if the data were normally distributed. before collecting data, the researcher conducted ethical clearance from the ethics committee of hasan sadikin general hospital (rsup) bandung on march 29, 2018 number: 1193/un6.l6/lt/2018. results based on the results of the statistical analysis in table 1, the data on respondents' characteristics showed that the majority of respondents were female (73.2%), came from the general icu (gicu) treatment room (57.5%), had the last education of diploma’s degree in nursing (d3) (62.2%) and had not attended education related to pc (75.6%). also, almost all respondents aged 26-45 years (86.6%), were muslim (97.6%) and were sundanese (76.4%). based on the results of data analysis in table 2, most respondents had high self-efficacy (56.7%), working experience >15 years (36.2%), enough interest to the nursing profession (50.4%), lack of knowledge (81.1%) and had negative perceptions (52%) related to the practice of pc in icu. based on the results of data analysis in table 3, the significance value was α = <0.05 in all variables, working experiences (p = 0.014), interest to nursing profession (p = 0.017), knowledge (p = 0.000) and perception variable (p = 0.000). it showed that the research hypothesis was accepted. this showed that there was a correlation between nurses' working experiences, interest to the nursing profession, knowledge, perception and self-efficacy variables in implementing of providing pc in icu in a general hospital in bandung. the result of linear regression analysis (table 4) shows that perception and knowledge are the variables that were dominant related factors to nurses’self-efficacy in implementing of providing pc in icu, meaning each increase of one unit of knowledge, giving self-efficacy improvement and every increase of one unit of perception, giving selfefficacy improvement. the coefficient of determination r2 = 0.363, it means that total of efficacy variability which can be explained by knowledge and nurse perception variable equal to 36.3%. t.a. kurnia et al. 222 | pissn: 1858-3598  eissn: 2502-5791 discussion the relationship between work experience and self-efficacy in the application of pc based on table 3, it shows that nurses' work experience in nursing has a significant relationship with self-efficacy in applying pc in icu (p-value = 0.014). this is supported by research data which shows that most respondents (65%) who have a high level of self-efficacy and over 15 years of work experience, compared to respondents with less than five years of work. the results of this study are in accordance with the results of research conducted by soudagar (2015), where his research showed a relationship between nurse experience with selfefficacy (p-value = 0.01) in working in the field of nursing. respondents with >six years or more experience have higher self-efficacy score when compared with respondents with less than or five years of experience in the nursing field. bandura (2004) in his theory suggests that individual self-efficacy is influenced by experience, which is formed through a process of repeated adaptation and learning in these situations. the longer an individual is in the situation, the better his self-efficacy will be. also, the experience of personal expertise possessed in the face of failure will result in satisfactory performance (bandura, 2004). nurses’ interest relation to nursing professions with self-efficacy application of pc there is a relationship between the nurse’s interest in the nursing profession with self-efficacy in implementing pc in the icu (p-value = 0.017) (table 3). respondents with low interest tend to occur in individuals with low self-efficacy, and individuals who have a good enough interest in the nursing profession will have good self-efficacy against palliative management in patients in the icu. research data support this data that individuals with high interest are more likely to have high self-efficacy (47.1%), whereas individuals with slightly more interest tend to have low self-efficacy (12.7%). the results of this study are following the opinion of soudagar (2015), stating that increased willingness or interest to work in the nursing unit can lead to good or high self-efficacy. this high self-efficacy can affect how someone thinks, feels, motivates, and acts. individual self-confidence in their ability to perform certain behaviors is an important predictor of how they behave toward choice behavior, mindset, and emotional reactions. the statement is evidenced table 1 characteristics of icu nurses in general hospital in bandung characteristics n = 127 frequency % age (years) 17-25 3 2.4 26 35 52 40.9 36-45 58 45.7 46 55 12 9.4 56 65 2 1.6 gender male 34 26.8 female 93 73.2 icu cicu (cardiac icu) 20 15.7 gicu (general icu) 73 57.5 nicu (neonatal icu) 19 15.0 picu (pediatric icu) 15 11.8 religion islam 124 97.6 non – islam 3 2.4 last education diploma’s degree (d3) 79 62.2 bachelor’s degree (s1) 45 35.4 master’s degree (s2) 3 2.4 ethnicity sunda 97 76.4 java 19 15.0 others 11 8.7 palliative education never joined any 96 75.6 non-formal education 20 15.7 formal education 2 1.6 formal and non-formal education 9 7.1 jurnal ners http://e-journal.unair.ac.id/jners | 223 through his research where obtained data showed that individuals who have an interest in the field of nursing have high self-efficacy. knowledge relationship with self-efficacy in the application of pc the result of bivariate analysis based on table 3 shows the correlation between respondent knowledge to self-efficacy in applying pc in icu (pvalue = 0.000). this is supported by the results of research showing that individuals with inadequate knowledge, have low efficacy (81.8%). otherwise, individuals with sufficient knowledge, have high selfefficacy (19.4%). the results of this study are in accordance with the results of research conducted by nakhaei & mofrad (2015) which shows the relationship between nurse knowledge with selfefficacy of nurses in applying infection control principle in the operating room (p = 0.033). also supported by the assertion aslesoleymani (2009), that knowledge and self-efficacy are closely related, where the more knowledge the individual has, the higher the self-efficacy he has, the better the behavior will be shown by the individual. bandura (2004) also revealed that knowledge is the primary substance of self-efficacy. knowledge owned by individuals can change beliefs about the ability of individuals in achieving the desired goals, this can positively affect the behavioral changes and motivation in displaying the desired behavior. so, in conclusion, knowledge affects individual self-efficacy (hossenialhashemi, 2014). perception relationships with self-efficacy application of pc the results of the bivariate analysis showed that there is a positive correlation between perceptions of respondents about pc practice with self-efficacy in applying pc in icu (p-value = 0.000). this is supported by research data indicating that most respondents who have positive perception, have high self-efficacy (62.5%). it is also supported that most respondents realised the importance of supporting and resource assessment (51.2%) as well as sensitive care for patients and families (53.5%), important enough to be implemented. the results of this study in accordance with the opinion of sunaryo (2004) which states that perception is the final process of observation, in which individuals will recognise and understand the condition of the surrounding environment (external perception) as well as the condition within themselves (internal perception). eventually, the perception affects one’s self-efficacy in determining the objective of specific action to do (sunaryo, 2004; bandura, 2004). table 2. frequency distribution of nurses’ work experience, interest to nursing profession, knowledge, perception and self-efficacy variables in implementing of providing pc in icu (n = 127) no. variable frequency % 1. self-efficacy low 55 43.3 high 72 56.7 2. working experiences (in years) <5 12 9.4 6-10 33 26 11-15 36 28.3 >15 46 36.2 3. interest to the nursing profession little 11 8.7 enough 64 50.4 very 52 40.9 4. nurses' knowledge (%) lack 103 81.1 fair/enough 24 18.9 5. nurses’ perception negative 66 52 positive 61 48 table 3. bivariate analysis of dependent and independent variables of icu nurses (n = 127) independent variable mean ± sd min – max self-efficacy p-value work experience (years) 14 ± 7 1 – 34 0.014*a nurses' interest in to nursing profession 2,8 ± 0,9 1 – 3.8 0.017*a nurses' knowledge (%) 39 ± 15 6 – 71 0.000*a nurses’ perception 44 ± 7 27 – 60 0.000*b *description: analysis was used a: a rank spearman test and b pearson correlation test, *the significance value was α = <0.05 t.a. kurnia et al. 224 | pissn: 1858-3598  eissn: 2502-5791 factors most associated with self-efficacy application of pc the results of linear regression analysis showed that the factors that dominant contributed to the selfefficacy of nurses in applying pc in the icu were the perception and the knowledge factor of the nurses related to pc practice with the ability to explain the self-efficacy of 36.3%. the linear regression equation obtained in this study is self-efficacy = 34.798 + 0.606 x knowledge + 2.047 x perception. the results of this study in accordance with the theory of bandura (2004) which states that knowledge is the basic substance of self-efficacy. through the knowledge they have, the individual will believe in the capabilities they have. johnston & lorraine (2006) adds that the nurses’ perception of pc is a major predictor for individuals in believing their abilities. it can support behavioral changes and improve therapeutic relationships between nurses and patients. positive perceptions of nurse respondents related to pc, supported by respondents' statements through data in the analysis of the study table show that almost all respondents (76.4%) mentioned that it is essential for nurses to get education related pc. through the education gained, the individual can know, interpret, and live to it, then interpret it (through perception) (sunaryo, 2004). the results of this study differ from the results of research soudagar (2015), where the interest factor of nurses to the nursing profession and work experience is a predictor in affecting self-efficacy nurse with p-value = 0.000 in multiple regression analysis tests. this shows that the factors of knowledge and perceptions of respondents in the study are stronger than other factors. knowledge of the individual, through the thinking process, will be transformed into perception. where perception is the terminology or the final process that stimulation can come from within and even outside the individual. nurses' perceptions of pc currently vary. research conducted by rodriguez, et al. (2007) support this statement, where there are still many nurses who think that pc is only given to patients with severe and dying conditions, especially in cancer patients only, treatments to relieve pain and symptoms which incriminates at the end of life (rodriguez, et al., 2007). this perceptual difference inhibits the pc referral process and results in a lack of pc (rodriguez, et al., 2007), and may result in a decrease in self-efficacy of nurses in achieving the objectives (gaffney, 2015). therefore, efforts need to be made to address this gap, namely the importance of identifying and adapting the nursing education curriculum, continuing education programs, and adding resources within the practice environment (white, roczen, coyne, & wiencek, 2014). conclusion the researchers concluded that the majority of nurses have high self-efficacy in applying all domains of pc in icu. the high level of self-efficacy of the nurses in applying pc is related to the factors of working experience, nurses’ interest into the nursing profession, nurses’ knowledge and perception related to pc practice. factors of knowledge and perception are dominant factors that have a relationship with self-efficacy of nurses in applying pc in icu. this study indicated that there were still many nurses who had insufficient knowledge related to symptom management and psychosocial aspects and negative perceptions related to competence in implementing pc in the icu. it was due to the lack of information and training related to pc. therefore, it was important for the hospital to provide socialization and training related to pc in the icu for all intensive nurses. acknowledgment the authors express the deepest gratitude to all respondents who sincerely want to be involved in this research, and to all who were actively involved directly or indirectly to make this research completed on time. references agustina, anna dan praptiwi. (2014). kajian pengetahuan, sikap, praktik dan kesulitan table 4. multivariate analysis of the dominant related factors with nurses’ self-efficacy in implementing of providing pc in icu unstandardized coefficients standardized coefficients p value r2 b std. error beta step 1 (constant) 32.042 15.620 0.042 0.363 nurses’ knowledge 0.586 0.141 0.304 0.000 nurses’ perception 1.954 0.319 0.458 0.000 working experience -0.053 0.290 -0.013 0.856 nurses’ interest 2.986 2.480 0.089 0.231 step 2 (constant) 30.953 14.372 0.033 nurses’ knowledge 0.583 0.140 0.302 0.000 nurses’ perception 1.963 0.314 0.460 0.000 nurses’ interest 3.009 2.467 0.090 0.225 step 3 (constant) 34.798 14.050 0.015 nurses’ knowledge 0.606 0.139 0.314 0.000 nurses’ perception 2.047 0.307 0.479 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 225 perawat dalam melaksanakan perawatan paliatif di rumah sakit pemerintah di propinsi jawa barat (laporan akhir penelitian hibah fakultas). fakultas ilmu keperawatan universitas padjadjaran. al qadire, m. (2014). nurses’ knowledge about pc: a cross-sectional survey. journal of hospice & palliative nursing, 16(1), 23-30 aslakson, r. a., curtis, j. r., & nelson, j. e. (2014). the changing role of pc in the icu. critical care medicine, 42(11), 2418. aslesoleymani h, afhami s. (2009). prevention and control of nosocomial infections. 4th ed. tehran: teimourzadeh: nashr-e tabib. ayasrah, s. m., o’neill, t. m., abdalrahim, m. s., sutary, m. m., & kharabsheh, m. s. (2014). pain assessment and management in critically ill intubated patients in jordan: a prospective study. international journal of health sciences, 8(3), 287298. ayed, a., sayej, s., harazneh, l., fashafsheh, i., & eqtait, f. (2015). the nurses' knowledge and attitudes towards the pc. journal of education and practice, 6(4), 91-99. azwar, s. (2010). sikap manusia: teori dan pengukurannya. yogyakarta: pustaka pelajar. bandura, a. (2004). self-efficacy. in n. b. anderson (ed.) encyclopedia of health & behavior (vol. 2, pp. 708-714). thousand oaks: sage publications. bandura, a. (2004). self-efficacy. in e. w. craighead & c. b. nemeroff (eds.). the concise corsini encyclopedia of psychology and behavioral sciences. (pp. 859-862). new york: wiley. bandura a. (2005). the evolution of social cognitive theory. in k. g. smith & m. a. hitt (eds.) great minds in management (pp. 9-35). oxford: oxford university press. bandura, a. (2006). guide for constructing self-efficacy scales. in f. pajares & t. urdan (eds.). self-efficacy beliefs of adolescents, (vol. 5., pp. 307-337). greenwich, ct: information age publishing. cox, s., handy, j. m., & blay, a. (2012). pc in the icu. journal of intensive care society, 13(4), 320-326. darmadi, h. (2017). pengembangan model dan metode pembelajaran dalam dinamika belajar siswa. yogyakarta: deepublish. delgado‐guay, m. o., parsons, h. a., li, z., palmer, l. j., & bruera, e. (2009). symptom distress, interventions, and outcomes of icu cancer patients referred to a pc consult team. pc and rehabilitation medicine, 115, 437-445, doi:10.1002/cncr.24017. desbiens, j. f., gagnon, j., & fillion, l. (2012). development of a shared theory in pc to enhance nursing competence. journal of advanced nursing, 68(9), 2113-2124. ferrell, betty r., coyle & paice. (2015). oxford textbook of palliative nursing, fourth edition. new york: oxford university press. fitch, m. i., fliedner, m. c., & o’connor, m. (2015). nursing perspectives on pc 2015. annals of palliative medicine, 4(3), 150-155. gaffney, mary kathryn. (2015). critical care nurses' perceptions of their knowledge and self-efficacy about providing end of life care (dissertations). walden dissertations and doctoral studies, walden university. 1934-1943. hosseinialhashemi, m., kermani, f. s., palenik, c. j., pourasghari, h., & askarian, m. (2015). knowledge, attitudes, and practices of health care personnel concerning hand hygiene in shiraz university of medical sciences hospitals, 20132014. american journal of infection control, 43(9), 1009-1011. johnston, b., & smith, l. n. (2006). nurses’ and patients’ perceptions of expert palliative nursing care. journal of advanced nursing, 54(6), 700-709. joy, yvonne l. (2015). the influence of a pc education intervention in increasing knowledge and selfefficacy of nurses practising in long-term care. doctoral dissertations retrieved from http://digitalcommons.uconn.edu/dissertations/ 911. kalogeropoulou, maria, evanthia, petros & dimitris. (2016). assessment of knowledge and associated factors towards pc among greek nurses. world journal of social science research, 3(3), 381-395. lenz, e. r., & shortridge-baggett, l. m. (2002). selfefficacy in nursing: research and measurement perspectives. springer publishing company. nakazawa, y., miyashita, m., morita, t., umeda, m., oyagi, y., & ogaswara, t. (2010). the pc selfreported practices scale and the pc difficulties scale: reliability and validity of two scales evaluating self-reported practices and difficulties experienced in pc by health professionals. journal of palliative medicine, 13(4), 427-437. nakhaei & mofrad, (2015). investigating nurses’ knowledge and self-efficacy regarding the principles of infection control in the operating room. modern care journal, 12(2), 79-83. national clinical effectiveness committee. (2015). management of constipation in adult patients receiving palliative care. dublin: department of health. nelson, j. e., mulkerin, c. m., adams, l. l., & pronovost, p. j. (2006). improving comfort and communication in the icu: a practical new tool for pc performance measurement and feedback. bmj quality & safety, 15(4), 264-271. doi:10.1136/qshc.2005.017707 nursalam. (2011). konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika payne, s., seymour, j., & ingleton, c. (2008). pc nursing: principles and evidence for practice second edition. england: open university press. rodriguez, k. l., barnato, a. e., & arnold, r. m. (2007). perceptions and utilization of pc services in acute care hospitals. journal of palliative medicine, 10(1), 99-110. sarfo, l. a., opare, m., awuah-peasah, d., & asamoah, f. (2017). knowledge and perception of nurses on t.a. kurnia et al. 226 | pissn: 1858-3598  eissn: 2502-5791 pc. a case study at agogo presbyterian hospital. applied research journal, 2(1). shreves, marcolini e. (2014). end of life/pc/ethics. emergency medical clinic, 32(9), 55–74. sunaryo. (2004). psikologi untuk keperawatan. jakarta: egc. tyler, s., bourbon, e., cox, s., day, n., fineran, c., rexford, d., ... & ward-smith, p. (2012). clinical competency, self-efficacy, and job satisfaction: perceptions of the staff nurse. journal for nurses in professional development, 28(1), 32-35. urden, l. d., stacy, k. m., & lough, m. e. (2014). critical care nursing: diagnosis and management. missouri: elsevier inc.white, k.r., & coyne, p.j. (2011). nurses’ perceptions of educational gaps in delivering end-of-life care. oncology nursing forum, 38, 711-717. white, k. r., roczen, m. l., coyne, p. j., & wiencek, c. (2014). acute and critical care nurses’ perceptions of pc competencies: a pilot study. the journal of continuing education in nursing. wilkie, d. j., & ezenwa, m. o. (2012). pain and symptom management in pc and at end of life. nursing outlook, 60(6), 357–364. world health organization. (2018). who definition of pc retrieved from http://www.who.int/cancer/palliative/definition /en/ zulkosky, k. (2009, april). self‐efficacy: a concept analysis. in nursing forum (vol. 44, no. 2, pp. 93-102). malden, usa: blackwell publishing inc. 1 | a u t h o r i n f o r m a t i o n p a c k table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health-related professions. jurnal ners is a scientific peer-reviewed nursing journal which is published biannually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the indonesian national nurses association, east java province. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of (1) a highly respected journal in the nursing field; (2) indexed in major databases, such as directory of open access journal (doaj), index copernicus international (ici), asean citation index (aci), pkp index, science and technology index (sinta), worldcat, indonesian publication index (ipi), google scholar, bielefeld academic search engine (base); (3) rapid initial screening for suitability and editorial interest. jurnal ners proposed the first national accreditation in 2010 and obtain b rank since volume 10 no. 2 october 2010. in 2013, the journal had been reaccredited and obtain b rank based on sk no. 58/dikti/kep/2013 valid until 23 august 2018. ii. focus and scope the scope of this journal includes, but is not limited to the research results of:  fundamentals of nursing  management in nursing  medical-surgical nursing  critical care nursing  emergency and trauma nursing  oncology nursing  community health nursing  occupational health nursing  mental health nursing  holistic nursing  geriatric nursing  family nursing  maternity nursing  women's health  pediatric nursing  education in nursing  nursing policies  legal nursing  advanced practice nursing  nursing informatics author information pack update: april 1 st 2018 please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing https://drive.google.com/file/d/0b5ormcrmctnwq0dix2dictffdlk/view?usp=sharing 2 | a u t h o r i n f o r m a t i o n p a c k jurnal ners accepts submission from all over the world. all accepted articles will be published on an open access basis, and will be freely available to all readers with worldwide visibility and coverage. iii. editorial board editor-in-chief: prof. dr. nursalam, m.nurs (hons), universitas airlangga, indonesia international advisory board reviewers prof. eileen savage, university college cork, ireland dr. wendy abigail, flinders university, australia dr. chong mei chan, university of malaya, malaysia dr. sonia reisenhofer, la trobe university, australia dr. ya-ping yang, kaohsiung medical university, taiwan editor: ferry efendi, s.kep., ns., m.sc., ph.d., universitas airlangga, indonesia retnayu pradanie, s.kep., ns., m.kep., universitas airlangga, indonesia praba diyan rachmawati, s.kep., ns., m.kep., universitas airlangga, indonesia laily hidayati, s.kep., ns., m.kep., universitas airlangga, indonesia technical editor: gading ekapuja aurizki, s.kep., ns., universitas airlangga, indonesia nadia rohmatul laily, s.kep., ns., m.kep., universitas airlangga, indonesia lingga curnia dewi, s.kep., ns., m.kep., universitas airlangga, indonesia editorial address: faculty of nursing universitas airlangga campus c mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners iv. author guidelines we now differentiate between the requirements for new and revised submissions. you may choose to submit your manuscript as a single word file to be used in the refereeing process. only when your paper is at the revision stage, will you be requested to put your paper into a 'correct format' for acceptance and provide the items required for the publication of your article. selection of papers for publication is based on their scientific excellence, distinctive contribution to knowledge (including methodological development) and their importance to contemporary nursing, midwifery or related professions. submission to this journal proceeds fully online, and you will be guided stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. mailto:secretariat_jurnalners@fkp.unair.ac.id http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 3 | a u t h o r i n f o r m a t i o n p a c k types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on apriori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and metaanalyses will be dealt with as original articles are, as far as the editorial process is concerned. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and post-publication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following:  introduction: one or two sentences on the background and purpose of the study.  methods: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics).  results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals.  conclusion: should relate to the study aims and hypotheses.  keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. 4 | a u t h o r i n f o r m a t i o n p a c k text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. acknowledgment (optional). acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below:  observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/  qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq  quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/  randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/  study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/  systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/  systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 publication fee jurnal ners charges the author a publication fee amounted to idr 1.000.000 (indonesian author) and usd 100 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within two working days. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s 5 | a u t h o r i n f o r m a t i o n p a c k title page format must be written in times new roman font 12 a. manuscript title b. first author * , second author ** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: …………………………………………………………………………………………………… e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: ………………………………………………………………………………………………….. f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orchid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. h. funding source ………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. 6 | a u t h o r i n f o r m a t i o n p a c k title page example vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. orchid id : http://orcid.org/0000-0002-6669-0767 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. orchid id : (if the author doesn’t have the id please register at https://orcid.org/) 5. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 7 | a u t h o r i n f o r m a t i o n p a c k main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................................................... ............................................................................................................................................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, non-standard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... 8 | a u t h o r i n f o r m a t i o n p a c k results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... equation: ∑ ………............................................................................................... (1) remarks: .............................................................................................................................................. discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using american psychological association (apa) 6th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.zotero.org/styles?q=apa ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... reference to a journal publication: efendi, f., chen, c. m., nursalam, n., indarwati, r., & ulfiana, e. (2016). lived experience of indonesian nurses in japan: a phenomenological study. japan journal nursing science, 13(2), 284-293. doi:10.1111/jjns.12108 https://www.zotero.org/styles?q=apa 9 | a u t h o r i n f o r m a t i o n p a c k reference to a book: kurniati, & efendi, f. (2013). human resources for health country profile of indonesia. new delhi: who south-east asia region. reference to a website: moh. (2013). sosialisasi global code of practice on the international recruitment of health personnel [dissemination global code of practice on the international recruitment of health personnel]. retrieved december 2, 2014, from http://bppsdmk.depkes.go.id/tkki/data/uploads/docs/workshop-sosialisasi-gcp.pdf reference in conference: nursalam, efendi, f., dang, l. t. n., & arief, y. s. (2009). nursing education in indonesia: todays and future role. paper presented at the shanghai international conference, shanghai. figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 o c after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old type of care age groups (years) <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 10 | a u t h o r i n f o r m a t i o n p a c k vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: ners@journal.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or can be downloaded here): jurnal ners author’s declaration and copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. article title: …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… author: …………………………………………………………………………………………………………………… i, who is acted as the corresponding author,  hereby declare that the above manuscript which is submitted for publication in jurnal ners is not under consideration elsewhere in any language.  have read the final version of the manuscript and responsible for what is said in it.  have read and agree with the terms and conditions stated on publication ethics page of the jurnal ners website.  hereby confirm the transfer of all copyrights in and relating to the above-named manuscript, in all forms and media, now or hereafter known, to jurnal ners, effective from the date stated below.  acknowledge that jurnal ners is relying on this agreement in publishing the above-named manuscript. however, this agreement will be null and void if the manuscript is not published in jurnal ners. signature of copyright owner(s): name (printed): title (if employer representative): company or institution: date: mailto:secretariat_jurnalners@fkp.unair.ac.id https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief ferry efendi, s.kep., ns., m.sc., ph.d editor: prof. angeline bushy, phd, rn, phcns-bc, faan prof. ching-min chen, rn, dns prof. eileen savage, bns., msc., p.hd. prof. josefina a. tuazon, rn, mn, drph dr. david pickles dr. farhan alshammari dr. chong mei chan, scm, bnsc, msc, phd dr. sonia reisenhofer assistant professor pei-lun hsieh prof. dr. ah. yusuf, s.kp., m.kes. yulis setiya dewi, s.kep.ns., m.ng. dr. esti yunitasari, s.kep., ns., m.kep.. dr. rizki fitryasari, s. kep., ns., m. kep. dr. ilya krisnana, s.kep., ns., m.kep. retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep. quality control: gading ekapuja aurizki, s.kep., ns., m.sc technical editor: rifky octavia pradipta, s.kep., ns., m.kep. editorial address: faculty of nursing universitas airlangga campus c, mulyorejo street 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 811-3287-877 e-mail: ners@journal.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners mailto:ners@journal.unair.ac.id http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. http://e-journal.unair.ac.id/index.php/jners acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 18 no. 2 june 2023. 1. dr. agung dwi laksono skm., m.kes. national research and innovation agency republic of indonesia, indonesia 2. anna kurniati, s.km, ma, ph.d. bppsdmk, ministry of health, indonesia 3. bayhakki, s.kep., sp. kmb., phd. universitas riau, indonesia 4. erni astutik s.k.m., m.epid. universitas airlangga, indonesia 5. kristiawati, s.kp., m.kep., sp. kep., an. universitas airlangga, indonesia 6. lukman handoyo, s.kep., ns., m.kep. stikes widya darma husada 7. qorinah estiningtyas sakilah adnani, sst, m.keb, ph.d. universitas padjadjaran, bandung 8. rista fauziningtyas s.kep., ns., m.kep. universitas airlangga, indonesia 9. ronal surya aditya s.kep., ns., m.kep. universitas negeri malang, malang 10. asst. prof. dr. pratuma rithpho naresuan university, indonesia 11. rr dian tristiana, s.kep., ns., m.kep. universitas airlangga, indonesia 12. santo imanuel tonapa, s.kep., ns., msn. universitas sam ratulangi, indonesia 13. setho hadisuyatmana, s.kep.ns.,m.ns(commhlth&pc) universitas airlangga, indonesia 14. dr. wendy abigail, phd. flinders university, australia 15. yohanes andy rias s.kep., ns., m.kep., ph.d institut ilmu kesehatan, kediri, indonesia p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no.85/m/kpt/2020 table of content jurnal ners vol.18 no. 2 june 2023 1. healthcare technology, innovation, and nursing challenges in disruptive era duangporn piyakong, naphaklacha pholanun 108-109 2. determinant of functional disability in instrumental activities of daily living among elderly living in a rural area in bali: a cross-sectional study i gede putu darma suyasa, ni kadek sutini, ni putu kamaryati, i kadek nuryanto 110-116 3. insights from leaders on effectively addressing overweight and obesity in the thai community duangporn piyakong, sangduan apiratanawong, chanikan suasing 117-123 4. the effectiveness of modified conventional cpr training among north borneo university hospital healthcare providers nazrin ahmad, walton wider, fairrul kadir, aizuddin hidrus, hamidah hassan 124-130 5. exploring children’s condition of adolescent mothers in east kalimantan indonesia: an ethnography study tri wahyuni, somporn rungreangkulkij 131-144 6. potential effect of green tea extract for adjuvant treatment of acute ischemic stroke by s100ß upregulation in non-thrombolysis patient [state the method here] abdulloh machin, djoko agus suprapto, anny hanifah, isti suharjanti, jakfar shodiq, m fata fatihuddin, beom joon kim, azizah amimathul firdha 145-153 7. knowledge, attitudes, and practice against covid-19 in west nusa tenggara, indonesia menap menap, sismulyanto, mursaka mursaka, made mahaguna putra 154-158 8. a simple awareness for women about (sawa) stages of labor on women's childbirth experience using the childbirth roadmap tool: a quasi-experimental study howieda fouly, mervat gaber zaghloul, intisar alshiekh, ayat masoud 159-168 9. the predictors need for complementary interventions using mobile application technology in women with breast cancer inggriane dewi, anggriyana tri widianti, ariani fatmawati, silfia wulandari, tita indah sarirudi 169-175 10. experiences of professional nurses regarding shortage of resources at a tertiary hospital in gauteng province, south africa: qualitative study makoasha philistus jiyane, sisinyana hannah khunou 176-183 11. predictive factors of family health management for caring toddlers with acute respiratory infections marisna eka yulianita, andi yulia kasma, andi ayumar 184-191 12. how to live longer: lived experience of older adults in thailand kittisak kumpeera, laddawan daengthern, somsak thojampa, kunchayarat udkhammee 192-199 13. effectiveness of m-health based self-management on self-efficacy in patients with cancer: a systematic review and meta-analysis olivya anakotta, erna rochmawati, sanisah binti saidi 200-209 http://e-journal.unair.ac.id/jners | 161 jurnal ners vol. 14, no. 2, oktober 2019 http://dx.doi.org/10.20473/jn.v14i2.7519 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research differences in clinical simulation with audio-visual and practicum-based standard operating procedures in nursing student competencies hendri palupi1, kusnanto kusnanto2 and slamet riyadi yuwono3 faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the biggest challenge in nursing education is to produce nurses who are professional and competent. effective and efficient learning through appropriate methods and media is very important. practical learning based on standard operating procedures (sop) has been widely applied, but clinical simulation approaches with audio-visual media have not been scientifically proven. the purpose of this study is to compare student competencies through clinical simulation learning with audio-visual media and practicums based on sop. methods: this was a quasi-experimental study with a pretest-posttest control group design. the sample consisted of 40 students recruited using simple random sampling and then divided into 2 groups: 20 respondents were given clinical simulation methods using audio-visual materials and 20 respondents were given practicum based on sop. the independent variables were clinical simulation with audio-visual media and practicum based on standard operating procedures. the dependent variable was student competency, assessed using competency assessment including cognitive, affective, and psychomotor methods. data analysis was conducted using the wilcoxon test. results: the use of clinical simulations with audio-visual media and practicum based on sop can increase the value of competency in nursing students, but the median value on the use of clinical simulations using audio-visual sources is higher than practicum based on sop. conclusion: clinical simulations with audio-visual media can be recommended as effective learning methods and media for nursing students. article history received: february 1, 2018 accepted: december 30, 2019 keywords clinical simulation; audiovisual; practicum; standard operating procedure; competence contact hendri palupi  palupi962@gmail.com  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: palupi, h., kusnanto, k., yuwono, s.r. (2019). differences in clinical simulation with audio-visual and practicum-based standard operating procedures in nursing student competencies. jurnal ners, 14(2), 161164. doi:http://dx.doi.org/10.20473/jn.v14i2.7519 introduction nowadays, health problems are increasingly complex and demands for health services are also increasing. nursing education must prepare competent graduates to be able to compete both nationally and globally. national nursing competency test graduation rates increased, but not significantly, in 2015 by 38%, and in 2016 by 51%. in east java province it increased from june 2014 (45.8%), november 2014 (68.2%), september 2015 (82.6%), but in 2016 it decreased to 51.6%. based on a preliminary study conducted at one of the high school health sciences in nganjuk district, it was found that the passing level of nurses' competency tests had not yet reached maximum results. only 17 of 63 students passed the competency test in june 2015 (26.9%), and in 2016 out of 2 competency tests students passed 32 of 98 students in april 2016 (32.6%), and 21 out of 78 students (26.9%). one of the efforts to increase the level of graduation of students in the national competency test is through a learning process that is supported by various learning components to achieve the desired goals. the use of audio-visual media is one form of intervention that can be given in addition to conventional methods. audio-visual media provides stimulation to hearing and vision, so that the results obtained are more optimal (maulana, 2009). another strategy that can be used to optimize learning outcomes is through clinical simulation methods. the use of simulation as an educational technique has https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:palupi962@gmail.com http://dx.doi.org/10.20473/jn.v14i2.7519 h. palupi et. al 162 | pissn: 1858-3598  eissn: 2502-5791 been widely adapted in the health field, both for evaluation of training and nurse performance. initial uses of simulation include teaching psychomotor skills and competency tests (larew c, lessans s, spunt d, foster d, 2006). simulation plays an important role in clinical education and evaluating the competencies of graduates of nursing students. clinical simulations were developed to provide opportunities for students to identify patients in general, think critically, and be able to show appropriate interventions (levett-jones & lapkin, 2014). the application of clinical simulation with audio-visual materials is expected to be able to make students practice as in real situations so as to achieve the expected competence. the purpose of this study was to determine the effectiveness of clinical simulations using audio-visual media compare to practicums based on sop toward nursing student competencies. materials and methods this study used a quasi-experimental with a pretestposttest control group design. the population of this study were all students in one of the health sciences at a high school in nganjuk district who were in the 6th semester and who had completed the neurobehavioural system course. the research sample consisted of 40 nursing students recruited using simple random sampling. the samples were divided into 2 groups: 20 students who were given clinical simulations with audio-visual sources and 20 students who were given practicum based on sop. the independent variables were clinical simulation with audio-visual media and practicum based on sop. the dependent variable was student competence. data collection tools used observation sheets and competency assessment sheets (cognitive, affective, and psychomotor). the intervention for treatment group given by using simulation modules and audio-visual media (15 – 20 minutes) was conducted 8 times. while the control group were given case scenarios and standard operating procedures for 100 minutes held 4 times. all of the respondents were tested for competencies before and after intervention. data were analysed using the wilcoxon test to determine differences in competency values (cognitive, affective, and psychomotor) in the clinical simulation with the audio-visual group and practicum based on sop groups with a significance level of 95%. the study has obtained an ethics approval certificate from the health research ethics commission of the faculty of nursing, universitas airlangga surabaya, with the certificate number 528kepk in 2017. results the characteristics of respondents from both groups are shown in table 1. in both groups, 40 respondents (100%) were aged ≤ 25 years and had previous practical experience and most of the 24 respondents (60%) were female. table 2 shows that cognitive, affective, and psychomotor abilities in the clinical simulation group with audio-visual media have a higher median value than the practicum group based on sop. wilcoxon test results measuring the differences in competence obtained p value 0,000 (<0.05) in the clinical simulation group with audio-visual media and p value 0.001 (<0.05) in the practicum group based on sop. in both groups, both used clinical simulations with audio-visual media and practicum-based sop have an influence on the competence of nursing students despite the difference in median values. discussion the results of data analysis proves that the clinical simulation method with audio-visual media can improve nursing student competencies. these competencies include cognitive, affective, and psychomotor abilities. the selection and use of media and method is one important component in supporting the implementation of learning. problembased learning is one of the learning methods that stimulates students to learn independently so as to enable students to practice with real situations (castro-sánchez et al., 2012). research conducted by (bloch & bloch, 2013) proved that 220 emergency room nurses received written instructions and 216 with video contained significant knowledge. instructions that use video can increase the emergency room nurse's knowledge in 2 to 5 days quicker rather than written instructions. the satisfaction of the er nurse is also greater than in writing. in line with (armstrong et al., 2010) audiovisual media can present informed consent and wound care instructions more effectively and produce higher satisfaction than verbally. (lin, khaira, & khairuzzaman, 2014) also proved that multimedia-based health education is not only limited to information providers but can increase the motivation, skills, and self-efficacy needed in taking actions related to improving health. rosen et al (2010) also proves that entertainment education (ee) through audio-visual media aims to deliver health education messages in an interesting and entertaining way. the study of hand washing through audio-visual media contributes to changing unhealthy behaviours into healthy ones. the media is able to stimulate or enter information through sensory sharing. the more stimulation, the easier the information is to accept. audio-visual media provide stimulation through the eyes and ears. the combination of information channels through the eye reaches 75% and the ear 13%, will provide stimulation that is good enough so that it can provide optimal results (maulana, 2009). the use of appropriate methods in one presentation of material is very important in order to achieve the desired goals. (levett-jones & lapkin, 2014) define simulation as a technique used to jurnal ners http://e-journal.unair.ac.id/jners | 163 replace or strengthen real experiences guided by experiences that evoke or replace substantial aspects of the real world in a fully interactive way. (woodworth, chen, horn, & aziz, 2014) compared respondents that were given video exposure and video-based simulations. the results showed that there was a significant increase in knowledge related to usg anatomy and skills, but in the two groups there was no significant improvement in procedures. the results of the study show that instructional videos and simulations can be effective tools to explicitly increase knowledge. computer-based simulations combined with several types of procedural training can improve technical skills (mcgaghie, issenberg, cohen, barsuk, & wayne, 2011). (lippe & becker, 2015) assessed the learning process of simulation in providing care to critically ill patients. the results of statistical tests show that the attitude and competency scores of students have significantly increased. therefore, it can be concluded that clinical simulations offer strong teaching strategies to improve students' attitudes and competencies in treating comatose patients. other studies conducted by (przybyl, androwich, & evans, 2015) showed the use of simulations proved effective in increasing nurse satisfaction, understanding of the principles of crrt (continuous renal replacement therapy), and critical thinking skills with crrt operations, scores increased from pre-simulation to questionnaire post simulation. (blake, 2014) also reinforces that instructional-based simulations equip medical students with knowledge, skills, attitudes, and behaviours towards clinical conditions in various situations. (dalton, head, & levett-jones rn, 2015) simulation scenarios create opportunities for students to apply and practice the knowledge gained from learning materials, and collaborative and supportive arrangements. students will more easily understand cases through scenarios rather than theory in class so that they can reduce their failure rate when taking clinical action in the hospital. table 1 characteristics of respondents in clinical simulation groups with audio-visual and practicum groups based on standard operating procedures characteristics clinical simulation groups with audio-visual media practicum groups based on standard operating procedures total % n % n % age (year) a. <25 b. ≥ 25 20 0 100 0 20 0 100 0 40 0 100 0 gender a. male b. female 7 13 35 65 9 11 45 55 16 24 40 60 practicum experiences a. don’t have experiences b. have experiences 0 20 0 100 0 20 0 100 0 40 0 100 table 2 obtaining competency, cognitive, affective, and psychomotor scores according to pre-test and post-test in the clinical simulation group with audio-visual and practicum groups based on standard operating procedures group variable med ±min-max ρ value practicum group based on standard operating procedures (n=20) cognitive pre test post test 7,50±5-10 8,00±5-12 0,002 affective pre test post test 46,50±42-63 47,50±42-63 0,004 psychomotor pre test post test 42,50±29-52 43,50±28-56 0,001 competency pre test post test 97,00±84-108 99,50±84-115 0,001 clinical simulation groups with audiovisual media l (n=20) cognitive pre test post test 7,00±3-10 9,00±5-13 0,000 affective pre test post test 48,00±42-63 55,50±42-67 0,000 psychomotor pre test post test 47,00±29-63 59,00±28-71 0,000 competency pre test post test 103,00±84-120 120,50±84-145 0,000 h. palupi et. al 164 | pissn: 1858-3598  eissn: 2502-5791 the limitation of this study is that there is no specific clinical simulation space available that is designed as a visual environment that is visually, auditory, and kinaesthetic. implementation of clinical simulations with audio-visual media can be continued and recommended for nursing students by providing facilities and competent instructors according to their expertise. conclusion in both the clinical simulation group with audiovisual media and practicum groups based on standard operational procedures affect cognitive abilities, affective, and psychomotor, but the higher median values were obtained by the clinical simulation group with audio-visual media than practicum groups based on standard operating procedures. clinical simulation methods with audio-visual media have proven to be effective on the competency abilities of nursing students. references armstrong, a. w., alikhan, a., cheng, l. s., schupp, c., kurlinkus, c., & eisen, d. b. (2010). portable video media for presenting informed consent and wound care instructions for skin biopsies: a randomized controlled trial. british journal of dermatology, 163(5), 1014–1019. https://doi.org/10.1111/j.13652133.2010.10067.x blake, t. (2014). teaching musculoskeletal examination skills to uk medical students: a comparative survey of rheumatology and orthopaedic education practice. bmc medical education, 14(1). https://doi.org/10.1186/1472-6920-14-62 bloch, s. a., & bloch, a. j. (2013). using video discharge instructions as an adjunct to standard written instructions improved caregivers’ understanding of their child’s emergency department visit, plan, and follow-up: a randomized controlled trial. pediatric emergency care, 29(6), 699–704. https://doi.org/10.1097/pec.0b013e3182955 480 castro-sánchez, a. m., encarnación, m., aguilarferrándiz, m. e., matarán-peñarrocha, g. a. g., iglesias-alonso, a. a., fernández-fernández, m. j. m., & moreno-lorenzo, c. c. (2012). problem based learning approaches to the technology education of physical therapy students. medical teacher, 34(1). https://doi.org/10.3109/0142159x.2012.6380 11 dalton, l., head, a., & levett-jones rn, t. (2015). using clinical reasoning and simulation-based education to “flip” the enrolled nurse curriculum authors. in australian journal of advanced nursing (vol. 33). larew c, lessans s, spunt d, foster d, c. b. (2006). innovations in clinical simulation: application of benner’s theory in an interactive patient care simulation. nursing educatiin perspectives, 27(1), 16–21. retrieved from https://www.ncbi.nlm.nih.gov/pubmed/1661 3127 levett-jones, t., & lapkin, s. (2014). a systematic review of the effectiveness of simulation debriefing in health professional education. nurse education today, vol. 34. https://doi.org/10.1016/j.nedt.2013.09.020 lin, l. p., khaira, n., & khairuzzaman, w. (2014). a brief review on multimedia-based health education applications: current trend and future potential. education in medicine journal, 6(4). https://doi.org/10.5959/eimj.v6i4.310 lippe, m. p., & becker, h. (2015). improving attitudes and perceived competence in caring for dying patients: an end-of-life simulation. nursing education perspectives, 36(6), 372–378. https://doi.org/10.5480/14-1540 maulana. (2009). promosi kesehatan. jakarta: egc. mcgaghie, w. c., issenberg, s. b., cohen, e. r., barsuk, j. h., & wayne, d. b. (2011). does simulationbased medical education with deliberate practice yield better results than traditional clinical education? a meta-analytic comparative review of the evidence. academic medicine, 86(6), 706–711. https://doi.org/10.1097/acm.0b013e318217e 119 przybyl, h., androwich, i., & evans, j. (2015). using high-fidelity simulation to assess knowledge, skills, and attitudes in nurses performing crrt. nephrology nursing journal : journal of the american nephrology nurses’ association, 42(2), 135–147; quiz 148. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26207 275 woodworth, g. e., chen, e. m., horn, j. l. e., & aziz, m. f. (2014). efficacy of computer-based video and simulation in ultrasound-guided regional anesthesia training. journal of clinical anesthesia, 26(3), 212–221. https://doi.org/10.1016/j.jclinane.2013.10.01 3 peningkatan berat badan pada bayi (3-6 bulan) melalui infant exercise (increasing infant’s body weigth with infant exercise) i ketut sudiana*, yuni sufyanti a*, puteri indah d* * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen. prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496. e-mail: yuni_psik@yahoo.com abstract introduction: infant body weigth is used as a best indicator to measure infant growth and nutritional status. body weight that not related on age, does not gain at least 500-600 gram for about three months, or over body weight, can be used to predict heath problem. infant exercise stimulation is an effort to increase body weight so that infant gain on a normal pattern of weight. the objective of this study was to analyze the influence of infant exercise to weight gain related on age on infant (3-6 month). method: a quasy-experimental non-randomized control group preposttest design was used in this study. the subjects were infants in 3-6 month aged lived in wates negoro and manduro village, subdistrict ngoro, mojokerto. there were 14 infants who met to the inclusion criteria. data were collected by using body weight observation scale after infant exercise had been done for 4 week. data were analyzed by using independent t-test and paired ttest with significance level of α≤0.05. result: result showed that infant exercise had effect on weight gain related on age on infant (3-6 month). paired t-test to the treatment group showed a significant differences between pre test and post test (p=0.00000). control group showed a significant differences between pre test and post test (p=0.00005). independent t-test in pre test showed body weight (p=0.74) and increasing of body weight (p=0.000). discussion: it can be concluded that there were significant effect of infant execise to weight gain related on age on infant (3-6 month). the limitation was that quality and quantity of the infant’s nutrition can not be controlled by the researcher. keywords: infant exercise, body weight gain, infant pendahuluan berat badan merupakan salah satu parameter pertumbuhan seorang anak, disamping faktor tinggi badan (hendarto, 2007). berat badan yang tidak sesuai dengan umur, tidak ada kenaikan berat badan dalam jangka waktu tertentu (1-3) bulan atau berat badan berlebih, bisa menjadi petunjuk adanya gangguan kesehatan (handajani, 2006). pada kondisi tertentu seperti terserang infeksi misalnya diare, konsumsi makan yang menurun sangat mudah mempengaruhi berat badan yang pada akhirnya dapat menurunkan keadaan gizi (retnowati, 2002). infant exercise merupakan salah satu cara yang dapat digunakan untuk meningkatkan berat badan bayi. namun saat ini pengaruh infant exercise terhadap peningkatan berat badan sesuai umur pada bayi (3-6) bulan belum diketahui. hasil studi pendahuluan yang dilakukan di desa wates negoro kecamatan ngoro didapatkan 4 bayi dari 14 bayi yang berumur 3-6 bulan mengalami gizi kurang. sebagaimana negara berkembang yang lain, di indonesia masalah kesehatan dan pertumbuhan anak sangat dipengaruhi oleh dua masalah utama yaitu keadaan gizi yang tidak baik dan penyakit infeksi. anak yang menderita kurang gizi mempunyai kemungkinan yang lebih besar untuk menderita infeksi yang menyebabkan terjadinya diare atau campak yang tidak jarang membawa kematian. penelitian yang dilakukan di berbagai negara menunjukkan bahwa kematian bayi akan menjadi lebih tinggi jika jumlah penderita gizi buruk infant exercise meningkat (moehji, 1992). narendra (1995) menyatakan bahwa di indonesia masih terdapat kekurangan gizi kronis akibat gangguan pertumbuhan yang menurut unicef sebesar 46% pada kelompok bayi. berdasarkan survey yang dilakukan retnowati (2002) status gizi balita di jatim tahun 1999 sejumlah 3,8% balita mengalami gizi lebih, 68,4% gizi baik, 22,31% gizi kurang dan 0,52% mengalami gizi buruk. berat badan merupakan hasil peningkatan atau penurunan semua jaringan yang ada pada tubuh, antara lain tulang, otot, lemak, cairan tubuh dan lain-lain. berat badan dipakai sebagai indikator yang terbaik pada saat ini untuk mengetahui keadaan gizi dan pertumbuhan bayi (soetjiningsih, 1995). suatu pengamatan yang dilakukan setelah perang di jerman waktu terjadi kelaparan, anak-anak mengalami keterlambatan pertumbuhan 10-20 bulan dibandingkan dengan anak-anak yang tumbuh normal (narendra, dkk., 2002). setiap bentuk gangguan gizi merupakan petanda awal dari terganggunya kekebalan tubuh terhadap penyakit infeksi. dua puluh lima persen bayi mengalami masalah kesulitan makan dan meningkat sebesar 40-70% pada anak yang lahir prematur atau dengan penyakit kronik (judarwanto, 2004). infant exercise sebagai alternatif untuk mempertahankan berat badan bayi normal sesuai dengan umur. berat badan sangat dipengaruhi oleh pemberian gizi, sehingga orang tua harus memperhatikan asupan nutrisi yang juga dipengaruhi oleh nafsu makan. nafsu makan dapat ditingkatkan dengan memberikan stimulasi dan latihan fisik berupa infant exercise. kusyarini, 2006 (mengutip penelitian burton l. white, universitas chicago) menyebutkan bahwa bayi yang melakukan infant exercise lebih cepat dalam berbicara, nafsu makan lebih baik, tidur lebih lelap dan dalam proses perkembangan gerak lebih cepat dibandingkan bayi yang tidak mengikuti infant exercise. dengan melakukan infant exercise, otot akan berkontraksi dan mengakibatkan pemecahan atp (adenosin trifosfat) menjadi sejumlah adp (adenosin difosfat). sejumlah energi akan terpakai saat otot berkontraksi sehingga cadangan energi akan berkurang. hal ini akan merangsang pusat lapar hipotalamus (guyton, 1997). nafsu makan akan meningkat dan berat badan akan bertambah. merujuk dari kondisi tersebut di atas peneliti tertarik untuk mengidentifikasi pengaruh infant exercise terhadap peningkatan berat badan sesuai umur pada bayi (3-6) bulan. bahan dan metode desain penelitian yang digunakan pada penelitian ini adalah quasi-eksperimen dengan pendekatan non-randomized control group pre-postest design. populasi yang digunakan adalah semua bayi yang berusia 36 bulan yang tinggal di wilayah posyandu kecamatan ngoro kabupaten mojokerto. sampel yang diambil adalah bayi yang memenuhi kriteria inklusi yaitu sebanyak 14 orang yang dibagi menjadi 7 orang kelompok kontrol dan 7 orang kelompok perlakuan. penelitian ini dilaksanakan pada tanggal 27 mei–24 juni 2007. variabel independen dari penelitian ini adalah infant exercise dengan metode yang berbeda-beda untuk masing-masing usia, sedangkan variabel dependen adalah berat badan yang diukur dengan melakukan penimbangan selama 4 minggu setelah diberikan infant exercise. data yang diperoleh dianalisis dengan uji statistik independent t-test dan paired t-test dengan tingkat kemaknaan adalah α≤0,05. hasil hasil pengumpulan data didapatkan peningkatan berat badan sesuai umur pada bayi (3-6 bulan) sebelum dan sesudah dilakukan infant exercise. pada kelompok perlakuan terjadi peningkatan rerata berat badan yaitu sebelum diberikan perlakuan 6142,9 gram menjadi 6757,1 gram setelah dilakukan stimulasi infant exercise selama 4 minggu. peningkatan yang terjadi dengan nilai terkecil 600 gram dan nilai terbesar 700 gram. analisis dengan menggunakan uji statistik paired t-test pada kelompok perlakuan dengan membandingkan berat badan sebelum dan sesudah dilakukan infant exercise diperoleh nilai p≤0,05 (p=0,0000). hal ini berarti terdapat perbedaan yang bermakna pada berat badan sebelum (rerata=6142,9; sd=435,343) dan sesudah (rerata=6757,1; sd=450,397) dilakukan infant exercise pada kelompok perlakuan (tabel 1). tabel 1. hasil perubahan berat badan pada kelompok perlakuan dan kontrol perlakuan kontrol berat badan (gram) berat badan (gram) sebelum sesudah perubahan sebelum sesudah perubahan rerata 6142,9 6757,1 614,3 5571,4 5871,4 300,0 sd 435,343 450,397 639,568 639,568 paired t-test p=0,0000 paired t-test p=0,0005 independent t-test (p=0,000) keterangan: p = signifikansi sd = standar deviasi pada kelompok kontrol terjadi peningkatan rerata berat badan yaitu sebelum diberikan perlakuan 5571,4 gram menjadi 5871,4 gram sesudah diberikan perlakuan, seperti terlihat pada tabel 2. peningkatan yang terjadi dengan nilai terkecil 200 gram dan nilai terbesar 500 gram. melalui uji paired t-test pada kelompok kontrol dengan membandingkan berat badan sebelum dan sesudah dilakukan infant exercise menunjukkan bahwa terdapat perbedaan yang bermakna pada berat badan sebelum (rerata =5571,4; sd=639,568) dan sesudah (rerata =5871,4; sd=639,568) dilakukan infant exercise pada kelompok kontrol dengan nilai p≤0,05 (p=0,0005). sebelum intervensi (infant exercise) diberikan, berat badan antara kelompok perlakuan dan kelompok kontrol tidak menunjukkan perbedaan yang bermakna dengan nilai p≥0,05 (p=0,074), tetapi setelah dilakukan intervensi stimulasi infant exercise selama 4 minggu terdapat perbedaan yang bermakna pada kedua kelompok. berdasarkan hasil uji independent t-test dengan membandingkan perubahan berat badan bayi kelompok perlakuan dan kelompok kontrol menunjukkan terdapat perbedaan yang bermakna, dengan nilai p≤0,05 (p=0,000) (tabel 1). pada kelompok perlakuan menunjukkan peningkatan rerata berat badan sebesar 614,3 gram, sedangkan pada kelompok kontrol terjadi peningkatan berat badan sebesar 300 gram. hal ini berarti terdapat perbedaan yang bermakna pada perubahan berat badan antara kelompok yang diberikan perlakuan infant exercise dan kelompok yang tidak diberikan perlakuan infant exercise. dengan demikian intervensi stimulasi infant exercise berpengaruh terhadap peningkatan berat badan sesuai umur pada bayi (3-6 bulan). pembahasan bayi dengan berat badan rendah berisiko terserang penyakit yang lebih besar dibanding dengan bayi yang mempunyai berat badan normal (rubiati, 2006). pertumbuhan fisik yang terganggu akan menimbulkan banyak komplikasi, diantaranya gangguan pertumbuhan, kurang gizi, kurang vitamin dan mineral, serta gangguan perkembangan kecerdasan di masa selanjutnya. berat badan ideal sesuai umur sangat ditentukan oleh kuantitas dan kualitas makanan. mereka yang mengalami kegagalan pertumbuhan (berat badan tetap atau turun dalam penimbangan bulan berikutnya) sering disebabkan oleh kekurangan gizi (judarwanto, 2004). beberapa faktor yang mempengaruhi pertumbuhan anak antara lain faktor herediter (tergantung ras, genetik, jenis kelamin dan kelainan bawaan), faktor hormonal (insulin, tiroid, hormon seks dan steroid), faktor lingkungan selama dan sesudah lahir (gizi, trauma, sosio–ekonomi, iklim, aktivitas fisik, penyakit, dll.). intervensi stimulasi berupa infant exercise diberikan oleh ibu dari responden yang dapat memberikan respons fisiologis yang positif (keseimbangan pola aktifitas dan pola makan). saat dilakukan infant exercise terjadi pelepasan sejumlah energi yang akan menurunkan cadangan energi. hal ini akan meningkatkan kecepatan penggunaan zat makanan selanjutnya mengaktifkan pusat lapar di hipotalamus, sehingga akan meningkatkan nafsu makan (guyton, 1997). pada bayi yang diberi stimulasi infant exercise otot-otot yang bekerja akan mengalami kontraksi. saat otot-otot berkontraksi terjadi pemecahan atp menjadi adp. salah satu sumber dihasilkannya adp adalah melalui proses glikolisis. pada proses glikolisis, glukosa diubah menjadi adp maka kadar glukosa dalam darah akan menurun, hal ini akan menyebabkan terjadinya peningkatan peletupan neuron glukosensitif yang berada di pusat lapar hipotalamus (lateral) yang selanjutnya mengaktifkan pusat lapar di hipotalamus. hal ini akan meningkatkan nafsu makan. peningkatan absorbsi zat nutrisi akan terjadi akibat dari intake makanan yang meningkat. dengan demikian berat badan bayi akan meningkat (guyton, 1997). hasil penelitian ini sesuai dengan kusyarini berdasarkan penelitian dari burton l white, universitas chicago yaitu bayi yang dilakukan infant exercise lebih cepat berbicara, nafsu makannya lebih baik, tidur lelap serta proses perkembangan gerak lebih cepat dibandingkan tidak mengikuti infant exercise (kusyarini, 2006). perubahan peningkatan berat badan yang tidak sesuai dengan umur (<500 gram) pada kelompok kontrol dapat disebabkan oleh asupan makan yang tidak adekuat baik dari kualitas maupun kuantitas. pada kelompok perlakuan dari 7 responden, sebagian besar bayi mendapat asupan asi yaitu 4 responden. pada kelompok kontrol sebagian besar bayi mendapat asupan pasi yaitu 4 responden. pada triwulan i, perubahan peningkatan berat badan berkisar 150-250 gram per minggu, triwulan ii kenaikannya 500-600 gram per bulan. antara 1 sampai 6 bulan pertambahan berat badan bayi terbilang cepat (rubiati, 2006). pertumbuhan dan perkembangan bayi, membutuhkan zat makanan yang adekuat (narendra, 2002). pemberian asi atau menyusui adalah periode ekstragestasi dengan payudara sebagai plasenta eksternal, karena payudara menggantikan fungsi plasenta tidak hanya dalam memberikan nutrisi bagi bayi, tetapi juga sangat penting bagi pertumbuhan dan perkembangannya. bagi bayi selain nilai gizi yang tinggi, dalam asi juga terdapat zat anti bodi yang dapat melindungi bayi terhadap penyakit infeksi (soetjiningsih, 1995). persediaan zat gizi akan sangat berpengaruh terhadap pertumbuhan anak. asi merupakan makanan bayi yang penting dalam memenuhi zat gizi yang dibutuhkan bayi. asupan asi yang terpenuhi akan memperbaiki keadaan gizi bayi sehingga proses pertumbuhan bayi akan terpenuhi secara maksimal. simpulan dan saran simpulan infant exercise berperan sebagai intervensi yang efektif untuk meningkatkan berat badan bayi. terdapat peningkatan berat badan pada bayi usia 3-6 bulan setelah dilakukan infant exercise selama 4 minggu. saran peneliti menyarankan bahwa perlunya sosialisasi tentang infant exercise oleh petugas puskesmas bekerja sama dengan kader kesehatan melalui posyandu, infant exercise dapat dijadikan sebagai salah satu alternatif untuk meningkatkan berat badan pada bayi dengan dengan gizi buruk (bawah garis merah) yang tidak mengalami gangguan kesehatan, infant exercise hendaknya diikuti dengan penimbangan berat badan secara rutin untuk mengetahui peningkatan berat badan bayi secara berkala, dan penelitian lebih lanjut diharapkan dapat dikembangkan dengan menggunakan variabel spesifik lainnya seperti kemampuan motorik kasar dan motorik halus pada bayi. kepustakaan guyton, a. 1997. buku ajar fisiologi kedokteran. edisi 9. jakarta: egc, hlm. 93-97, 1114-1116. handajani, d. 2006. berbobot lebih belum tentu sehat, (online), (http://www.ayahbundaonline.com/info_ayahbunda/info_detai l.asp?id=prekonsepsi&info_id=100., diakses tanggal 23 maret 2007, jam 10.15 wib). hendarto, a. 2007. anak kurus vs anak sehat, (online), (http://www.tabloidnakita.com/artikel.php3?edisi=02092& rubrik=sehat., diakses tanggal 12 april 2007, jam 11.30 wib). http://www.ayahbunda-online.com/info_ayahbunda/info_detail.asp?id=prekonsepsi&info_id=100 http://www.ayahbunda-online.com/info_ayahbunda/info_detail.asp?id=prekonsepsi&info_id=100 http://www.ayahbunda-online.com/info_ayahbunda/info_detail.asp?id=prekonsepsi&info_id=100 http://www.tabloid-nakita.com/artikel.php3?edisi=02092&rubrik=sehat http://www.tabloid-nakita.com/artikel.php3?edisi=02092&rubrik=sehat http://www.tabloid-nakita.com/artikel.php3?edisi=02092&rubrik=sehat judarwanto, w. 2004. mengatasi kesulitan makan pada anak. jakarta: puspa sehat, hlm. 3-5, 11. kusyarini, i. 2006. panduan senam bayi. jakarta: puspa swara, hlm. 4, 13-33. narendra, m., dkk. 2002. buku ajar tumbuh kembang anak dan remaja. jakarta: sagung seto, hlm. 31, 52-121. retnowati, s. 2002. pengaruh pola pemberian susu terhadap status gizi bayi, tesis tidak dipublikasikan . surabaya: fakultas kedokteran universitas airlangga, hlm. 19, 23. rubiati, a. 2006. bayi kurus berarti kurang gizi, (online), (http://www.tabloidnakita.com/artikel.php3?edisi=07331& rubrik=bayi., diakses tanggal 23 maret 2007, jam 10.30 wib). soetjiningsih. 1995. tumbuh kembang anak. jakarta: egc, hlm. 18, 38-42. wong and whaley. 1995. nursing care of infant and children. missouri: mosby inc., pp. 51-54, 95. wong, d.l. 2003. pedoman klinis keperawatan pediatrik. edisi 4. jakarta: egc, hlm. 182-184. http://www.tabloid-nakita.com/artikel.php3?edisi=07331&rubrik=bayi http://www.tabloid-nakita.com/artikel.php3?edisi=07331&rubrik=bayi http://www.tabloid-nakita.com/artikel.php3?edisi=07331&rubrik=bayi 247 protective effects of catechin isolate from gmb4 clone green tea against epc in type 2 diabetes mellitus yuly peristiowati stikes surya mitra husada kediri, east java, indonesia email: yulystikes@gmail.com abstract introduction: type 2 diabetes mellitus is a cause of morbidity and mortality, especially due to vascular complications. this study aims to evaluate the role of catechin isolates from gmb4 clone green tea in the dynamic of endothelial progenitor cells (epc) in type 2 diabetes mellitus (dm). methods: 25 wistar rats were divided into 5 groups, including a control group, type 2 diabetes mellitus group, treated daily with the administration of extract of catechin isolate from gmb4 clone green tea at 20; 40; and 60 mg/kgbb doses for 6 weeks. epcs analysis was performed by flow cytometry, and the level of no was analysed using a spectrophotometer, and the serum levels of sdf-1 were performed with an elisa technique. the analysis of the expression of sdf-1 and cxcr-4 was performed using immunohistochemistry techniques. results: the cd34+ and cd133+ count was lower in the dm group compared to the control group (p< 0.05). of the three doses of catechin, only the highest dose was able to significantly increase the cd34+ count compared to the rats in the diabetes mellitus group (p< 0.05). the serum no level was significantly higher in the dm control group (p < 0.05). all three doses of catechin were able to significantly increase the expression of sdf-1 and cxcr4 in the aorta compared to the dm group or the control group (p<0.05). conclusion: it can be concluded that a high dose of cathecin isolate from gmb-4 clone green tea (60 mg/kgbb) may trigger the proliferation and maturation of epcs in rats with type 2 dm in an environment with a high level of no, involving the interaction between sdf-1 and cxcr4 in the aorta. keywords: aorta; catechins; endothelial progenitor cells; hyperglycemia. introduction type 2 diabetes mellitus is a chronic multi-factorial metabolic disease caused by a complex interaction between various environmental and genetic factors (g. p. fadini et al., 2006). type 2 diabetes mellitus is a cause of morbidity and mortality, especially due to vascular complications that lead to retinopathy, nephropathy, ischemic heart disease and peripheral vasculopathy (tang, fang and zhou, 2013). a severe decrease in the population of circulatory precursor cells (cd34+ dan cd133+) with the ability for them to differentiate into mature endothelial cells and to play a role in vascular homeostasis and neoangiogenesis has been characterised in diabetes mellitus (gian paolo fadini, saverio sartore, 2007). in order to maintain vascular homeostasis, vascular endothelial cells will produce several biofactors (vanhoutte, 2003). during endothelial injury, there is an increase in endothelial cell division to trigger regeneration in the damaged endothelial cells (brandes, fleming and busse, 2005). endothelial progenitor cell will inhibit the senecence of endothelial cells, preserving endothelial homeostasis, and supporting vascular recovery involved in various diseases, including type 2 diabetes mellitus (urbich and dimmeler, 2004). stromal cell-derived factor 1 (sdf-1) belongs to a group of -chemokines that will bind to the cxcr4 transmembrane protein receptor(g. p. fadini et al., 2006). one of the main physiological functions of sdf1/cxcr4 is to regulate homing and the self-defence system of the stem cells and hematopoietic progenitor cells (christopherson, 2003). sdf1 also functions to increase the proliferation of hematopoietic progenitor cells, attracting cxcr4-expressing progenitor cells to the bone marrow microenvironment (liles et al., 2003). various plant products have been used as a therapeutic substance, including green tea (wardhana, ratnawati and suyuti, 2013). the tea and quinine research association in gambung have developed a variety of green teas with higher catechins compared to other tea plants, called gmb4 clone (mawarti, ratnawati and lyrawati, 2012). previous studies have shown that the catechins isolated from gmb4 clone green tea are metabolically beneficial due to the fact that they inhibit insulin resistance in visceral adipose cells and adipose tissues (susanti, rudijanto and ratnawati, 2012) and the decrease of c/ebp expression in cultured mice pre-adiposites (mawarti, ratnawati and lyrawati, 2012). on the other hand, in the in-vivo studies, the catechins isolated from gmb4 clone green tea were shown to be able to reduce enos, to jurnal ners vol. 12 no. 2 oktober 2017: 247-252 248 increase the expression of pi3k and to decrease the activity of p38 mapk in rats with high fat diet (wardhana, ratnawati and suyuti, 2013). to our knowledge, there have been no studies conducted to identify the benefit of catechins isolated from gmb4 clone green tea towards the endothelial progenitor cells in type 2 diabetes. therefore, in this study, we have evaluated the role of catechins isolated from gmb4 clone green tea on the dynamics of endothelial progenitor cells in type 2 diabetes mellitus. materials and methods subjects twenty five 3-4 months old male wistar rats were divided into five groups, namely the control group, type 2 diabetes mellitus group, and three groups of rats with type 2 diabetes mellitus treated with catechins isolated from gmb4 clone green tea in 20; 40; and 60 mg/kgbw doses respectively, every day for 6 weeks. we had to induce type 2 diabetes mellitus in rats. before being treated, the rats underwent an adaptation phase for 2 weeks with a standard diet. the induction of type 2 diabetes mellitus started with a hypercholesterol diet for 45 days, followed by an intraperitoneal injection of 30 mg/kgbw streptozotocin. three days after the induction of streptozotocin, their blood glucose was examined after a 6 hour fast. if the blood glucose level reached above 250 mg/dl, the rat was categorised as having hyperglycemia. administration of catechins isolates the catechins isolated from gmb-4 clone green tea were administered via an ngt to the animals in the doses described above, with a maximum of 10 ml/day. before touching the animals, the ngt must first be filled with an isolate dose with no air bubble, as that would generate pain and cause the rat to struggle. the ngt was equipped with a round tip needle to reduce the possibility of tracheal injection. the isolates was administered in 20; 40; and 60 mg/kgbw doses daily for 6 weeks. euthanasia after 6 weeks of treatment with catechins isolated from the gmb-4 clone green tea, the animals were then dissected as follows: the animals were locally anesthesised with ether followed with a dissection of the abdominal region and diaphragm. five ml blood samples were then collected from the animal's heart using a syringe. the blood samples collected were then examined. the deceased animals were buried in a location provided by the physiology laboratorium of brawijaya university. epcs count analysis the epcs count analysis was performed using flow cytometry. the epcs were characterised by cd34+ and cd133+cells. nitrite oxide measurement the nitrite oxide was measured using the colorimetric technique. the analysis procedure was performed according to the detailed instructions provided in the kit. sdf1- level and concentration measurement the sdf1- serum concentration measurement was performed using a sdf1- elisa kit. the analysis procedure was performed according to the detailed instructions provided in the kit. the measurement of sdf1- expression in the aorta was performed using the immunohistochemistry technique. measurement of cxcr-4 expression the measurement of cxcr-4 expression in the aorta was performed using the immunohistochemistry technique (schmidt -lucke et al., 2005) (leone et al., 2009). ethics the care of the animal subjects and the experimental procedure was approved by the research ethics committee of brawijaya university medical school, malang, east java, indonesia. statistical analysis the data was presented in means ± sd and the difference between treatment groups was analysed using a one-way anova test in spss 16.0 software. the post-hoc test performed in the anova test generated a significant difference. p value of < 0.05 which was deemed statistically significant. protective effects of catechins isolate... (yuly peristiowati) 249 results the cd34+ count was lower in the diabetes mellitus group compared to the control group (p < 0.05). of the three catechin doses, only the highest dose was able to significantly increase the cd34+ count compared to the diabetes mellitus group (p < 0.05). this increased cd34+ count reached a level comparable to that of the control group (p > 0.05), as seen in figure 1. the cd133+ count was lower in the diabetes mellitus group compared to the control group (p < 0.05). of all three catechin doses, only the second highest dose was able to significantly increase the cd133+ count figure 1. the cd34 + count in each experimental groups. values are presented as mean ± sd; a p < 0.05 in comparison with control (c) group; b p < 0.05 in comparison with diabetes mellitus (dm) group. dm + c1: diabetes mellitus group received first dose of catechin; dm + c2: diabetes mellitus group received second dose of catechin; dm + c3: diabetes mellitus group received third dose of catechin; %: percentage. figure 2. the cd133 + count in each experimental groups. values are presented as mean ± sd; a p < 0.05 in comparison with control (c) group; b p < 0.05 in comparison with diabetes mellitus (dm) group; c p < 0.05 in comparison with first dose catechin administered (dm + c1) group; dm + c2: diabetes mellitus group received second dose of catechin; dm + c3: diabetes mellitus group received third dose of catechin; %: percentage figure 3. the serum no level in each experimental groups. values are presented as mean ± sd; a p < 0.05 in comparison with control (c) group; b p < 0.05 in comparison with diabetes mellitus (dm) group; c p < 0.05 in comparison with first dose catechin administered (dm + c1) group; d p < 0.05 in comparison with second dose catechin administered (dm + c2) group. dm + c3: diabetes mellitus group received third dose of catechin; m: micromolar. figure 4. the serum sdf-1 level (a) and aorta expression of sdf-1 (b) in each experimental groups. values are presented as mean ± sd; a p < 0.05 in comparison with control (c) group; b p < 0.05 in comparison with diabetes mellitus (dm) group; c p < 0.05 in comparison with first dose catechin administered (dm + c1) group; dm + c2: diabetes mellitus group received second dose of catechin; dm + c3: diabetes mellitus group received third dose of catechin; sdf-1: stromal derived factor-1; ng/ml: nanogram/mililiter. jurnal ners vol. 12 no. 2 oktober 2017: 247-252 250 compare to the diabetes mellitus group (p < 0.05), and this increased cd133+ count was comparable to that of the control group (p > 0.05). in addition, there was no difference in the cd133+ count between both highest doses (p > 0.05) (figure 2). the serum level of no was significantly higher in the diabetes mellitus compared to the control group (p < 0.05). of all three catechin doses, only the first and second doses were able to significantly reduce the no level compared to the diabetes mellitus group (p < 0.05). however, only the rats administered with second doses have no levels comparable to that of the control group (p > 0.05), as seen in figure 3. for the serum sdf-1 concentration, there was no significant difference between all of the treatment groups (p > 0.05) (figure 4a). meanwhile, the expression of sdf-1 in the aorta was significantly lower in the diabetes mellitus group compared to the control group (p < 0.05). all three doses of catechin were able to significantly increase the expression of sdf-1 in the aorta compared to the rats in the diabetes mellitus group or the control group (p < 0.05) (figure 4b). figure 5 presents the cxcr4 level in the aorta between groups. there was no significant difference in terms of the expression of cxcr4 in the aorta between the diabetes mellitus group and the control group (p > 0.05). all three doses of catechin seemed able to significantly increase the expression of cxcr4 in the aorta compared to the rats in the diabetes mellitus group or the control group (p < 0.05). there was no significant difference for cxcr4 expression in the aorta between the first and second doses of catechin (p > 0.05). discussion to fight against endothelial cell injury due to diabetes, several recovery mechanisms will ensue. traditionally, the permanent proliferation of cells in the vascular tissue is responsible for microvascular recovery. to date, there has been numerous evidence that epcs play a role in the recovery and homeostasis of endothelial cells. epcs are produced in the bone marrow, mobilised in the circulation and recruited in the location of injury. in the location of injury, epcs will differentiate into endothelial cells to replace the damaged endothelial cells or to provide paracrine support to the vascular cells. enos plays a role in the differentiation of epcs and no from the enos that are able to regulate endothelial recovery and reendothelialisation through the differentiation of epcs. in the current study, the serum no level was found to be significantly higher in the diabetes mellitus group compared to the control group (p < 0.05). this indicates that the increase of no is a compensational mechanism aimed to regulate endothelial recovery and reendothelialisation through the differentiation of epc into endothelial cells. in this study, the cd34+ and cd133+ count was found to be lower in the diabetes mellitus group compared to the control group (p < 0.05). this indicates that despite the existence of a homeostasis mechanism through the increase of the no level, hyperglycemia is still able to trigger a decrease in the cd34+ and cd133+ cell population. various studies have mentioned that diabetic patients experienced a decrease in epcs as well as the functional disruption of epcs, including a decrease in proliferation, adhesion, migration and incorporation (boos, lip and blann, 2006) (gian paolo fadini et al., 2006) (gallagher et al., 2007) (peristiowati, indasah and ratnawati, 2015). this study is consistent with previous studies in finding a reduced population, migration and proliferation of epcs in rats with type 2 figure 5. the aorta expression of cxcr4 in each experimental groups. values are presented as mean ± sd; a p < 0.05 in comparison with control (c) group; b p < 0.05 in comparison with diabetes mellitus (dm) group; c p < 0.05 in comparison with first dose catechin administered (dm + c1) group; d p < 0.05 in comparison with second dose catechin administered (dm + c2) group; dm + c3: diabetes mellitus group received third dose of catechin; %: percentage. protective effects of catechins isolate... (yuly peristiowati) 251 diabetes mellitus (tikhonenko et al., 2013) (chen et al., 2010). the increased sdf-1 was able to induce chemotaxis of epcs via the hif pathway by binding with cxcr4. the defect of epcs mobilisation in rats with diabetes was associated with the insufficiency of sdf-1 release (gill et al., 2001) (chen et al., 2010) (gallagher et al., 2007). in the current study, there was no significant difference in terms of serum sdf1- concentration between all of the treatment groups (p > 0.05). this indicates that there was no insufficiency in sdf-1 release. however, the expression of sdf-1 in the aorta was significantly lower in the diabetes mellitus group compared to the control group (p < 0.05). in addition, there was also no significant difference in terms of the expression of cxcr4 in the aorta between diabetes mellitus group and the control group (p > 0.05). this indicates that hyperglycemia reduces the bond between sdf-1 and cxcr4 in the aorta. thus, in the rat model of type 2 diabetes mellitus, hyperglycemia will trigger a decrease in cd34 + and cd133 + cell population as well as its homing capacity, despite the existence of a compensational mechanism in the form of increased no level. in previous studies, catechins were found to be able to accelerate endothelial progenitor cell proliferation along with an increased dose and duration of incubation (boos, lip and blann, 2006). in the current study, the highest dose was found to be able to significantly increase cd34 + count compared to the rats in the diabetes mellitus group (p < 0.05), and this increase is comparable to that of the control group (p > 0.05). meanwhile, the maturation function of epcs was found to be significantly increased in the groups treated with the second and third doses compared to the diabetes mellitus group (p < 0.05), and there were no significant difference in terms of cd133+ count between the two highest doses (p > 0.05). however, all three doses of cathecin were able to significantly increase the expression of sdf1- and cxcr4 in the aorta compared to the diabetes mellitus or control group (p < 0.05). this indicates that all of the doses of catechin were able to increase the bond between sdf-1 and cxcr4, despite the fact that epcs proliferation and endothelial maturation only optimally occurs in the highest dose. when associated with the no level, it was found that the group treated with the third dose had a very high level of no, therefore, it can be concluded that the recovery of the proliferation and maturation of epcs in rats with type 2 diabetes mellitus occur optimally in the highest dose and in environments with high no levels. conclusions it can be concluded that a high dose of cathecin isolate from gmb-4 clone green tea (60 mg/kgbb) may trigger the proliferation and maturation of epcs in rats with type 2 diabetes mellitus in an environment with a high level of no, involving the interaction between sdf-1 and cxcr4 in the aorta. references boos, c. j., lip, g. y. h. and blann, a. d. (2006) ‘circulating endothelial cells in cardiovascular disease’, journal of the american college of cardiology, 48(8), pp. 1538–1547. brandes, r. p., fleming, i. and busse, r. (2005) ‘endothelial aging’, cardiovascular research, 66(2), pp. 286–294. doi: 10.1016/j.cardiores.2004.12.027. chen, l. et al. (2010) ‘cxcr4 gene transfer contributes to in vivo reendothelialization capacity of endothelial progenitor cells’, cardiovascular research, 88(3), pp. 462–470. christopherson, k. w. (2003) ‘cell surface peptidase cd26/dppiv mediates gcsf mobilization of mouse progenitor cells’, blood, 101(>12), pp. 4680– 4686. fadini, g. p. et al. (2006) ‘diabetes impairs progenitor cell mobilisation after hindlimb ischaemia-reperfusion injury in rats’, diabetologia, 49(12), pp. 3075–3084. fadini, g. p. et al. (2006) ‘number and function of endothelial progenitor cells as a marker of severity for diabetic vasculopathy’, arteriosclerosis, thrombosis, and vascular biology, 26(9), pp. 2140–2146. gallagher, k. a. et al. (2007) ‘diabetic impairments in no-mediated endothelial progenitor cell mobilization and homing are reversed jurnal ners vol. 12 no. 2 oktober 2017: 247-252 252 by hyperoxia and sdf-1??’, journal of clinical investigation, 117(5), pp. 1249–1259. gian paolo fadini, saverio sartore, c. a. and a. a. (2007) ‘significance of endothelial progenitor cells’, diabetes care, 30(5), pp. 1305–1313. gill, m. et al. (2001) ‘vascular trauma induces rapid but transient mobilization of vegfr2+ac133+ endothelial precursor cells’, circulation research, 88(2), pp. 167– 174. leone, a. m. et al. (2009) ‘from bone marrow to the arterial wall: the ongoing tale of endothelial progenitor cells’, european heart journal, 30(8), pp. 890–899. liles, w. c. et al. (2003) ‘brief report mobilization of hematopoietic progenitor cells in healthy volunteers by amd3100 , a cxcr4 antagonist’, october, 102(8), pp. 2728–2730. mawarti, h., ratnawati, r. and lyrawati, d. (2012) ‘epigallocatechin gallate menghambat resistensi insulin pada tikus dengan diet tinggi lemak inhibitory effect of epigallocatechin gallate on insulin resistance in rat with high fat diet’, jurnal kedokteran brawijaya, 27(1), pp. 43– 50. peristiowati, y., indasah, i. and ratnawati, r. (2015) ‘the effects of catechin isolated from green tea gmb-4 on nadph and nitric oxide levels in endothelial cells exposed to high glucose.’, journal of intercultural ethnopharmacology, 4(2), pp. 114–7. doi: 10.5455/jice.20141224104135. schmidt-lucke, c. et al. (2005) ‘reduced number of circulating endothelial progenitor cells predicts future cardiovascular events: proof of concept for the clinical importance of endogenous vascular repair’, circulation, 111(22), pp. 2981–2987. susanti, e., rudijanto, a. and ratnawati, r. (2012) ‘catechins inhibit atherosclerosis in male rats on a high fat diet’, 31(2), pp. 81–87. tang, z.-h., fang, z. and zhou, l. (2013) ‘human genetics of diabetic vascular complications’, journal of genetics, 92(3), pp. 677–694. tikhonenko, m. et al. (2013) ‘n-3 polyunsaturated fatty acids prevent diabetic retinopathy by inhibition of retinal vascular damage and enhanced endothelial progenitor cell reparative function’, plos one, 8(1), pp. 1–10. doi: 10.1371/journal.pone.0055177. urbich, c. and dimmeler, s. (2004) ‘endothelial progenitor cells: characterization and role in vascular biology’, circulation research, 95(4), pp. 343–353. doi: 10.1161/01.res.0000137877.89448.7 8. vanhoutte, p. m. (2003) ‘endothelial control of vasomotor function: from health to coronary disease.’, circulation journal : official journal of the japanese circulation society, 67(july), pp. 572–575. wardhana, a. w., ratnawati, r. and suyuti, h. (2013) ‘isolat egcg teh hijau klon gmb4 menurunkan ekspresi protein faktor transkripsi c / ebp α dan kadar leptin pada kultur sel preadiposit visceral tikus’, jurnal kedokteran brawijaya, 27(4), pp. 212–216. 239 quality of life and characteristics of colostomy patients kusman ibrahim, ayu prawesti priambodo, aan nur’aeni, sri hendrawati faculty of nursing, universitas padjadjaran bandung, west java, indonesia email: k.ibrahim@unpad.ac.id abstract introduction: colostomy imposed multiple impacts on the patient’s life including physical, psychological, social, and spiritual. this study aims to identify the level of quality of life as well as to examine the differences of quality of life among colostomy patients with regards to certain demographic characteristics. methods: this study used a cross-sectional and descriptive analytical approach. seventy-one colostomy patients were recruited purposively to participate in the study. the studied variables included quality of life and demographic characteristics. the data was collected by using the who quality of life – bref instrument. one-way anova and an independent t-test were employed to analyse the differences in quality of life with regards to certain demographic characteristics. results: the study found that the majority of subjects perceived that their level of quality of life ranged between very low to moderate (77.4%). satisfaction with support from friends was rated as the highest item of quality of life, whereas satisfaction with sexual relationships was rated as the lowest item of quality of life. there was no significant difference in the patients’ quality of life with regards to age group, educational background, occupation, length of being ostomate, sex, and other health problems. conclusions: the study implied that nurses need to realise and pay attention to multiple aspects of stoma patient’s quality of life. nursing care should not merely focus on stoma care but also holistically consider on meeting sexual needs, as well as the psychological, social, and spiritual needs of the patients. keywords: colostomy, demographic characteristics, quality of life. introduction colorectal cancers remain a serious public health problem in indonesia. the number of people living with colorectal cancer increases year to year. the data shows that colorectal cancer is listed as the third most prevalent cancer after lung cancer and prostate cancer (sudoyo, 2012). in europe and the united states, the number of people living with colorectal cancer was more than in asia. american cancer society (2017) estimates for the number of colorectal cancer cases in the united states for 2017 is 95,520 new cases of colon cancer. colorectal cancer is the second leading cause of cancer-related deaths in men and the third leading cause in women in the united states. during 2017, it is expected to cause about 50,260 deaths. one of the common treatments for the colorectal cancer is surgery by removing the section of affected colon, followed by making a hole (stoma) in the abdominal wall to eliminate faeces (siassi et al., 2008; carlsson et al., 2010; edwards et al., 2014). this procedure is known as a colostomy. there are two types of colostomy according to the duration of the treatment that is required: temporary or permanent (williams and hopper, 2003; dabirian et al., 2010). those who are undergoing colostomy permanently means that they have to live with the colostomy for the rest of their life. such a condition would impact to multiple-facets of the patients’ life including their physical, psychological, social, and spiritual well-being (grant et al., 2011; swan, 2011; liao and qin, 2014; rangki et al., 2014; faury et al., 2017). in the other words, this may also impact on the life satisfaction, well-being, and quality of life of the patients. quality of life has become a major concern among health care professionals since it can be an outcome of health care interventions. data regarding the quality of life also determine the appropriate interventions for the patients. several studies have been done to investigate health-related quality of life among colostomy patients. liao and qin (2014) found that stoma patients faced difficulties functioning in work and social activities, sexuality and body image, and several problems with leakage and finding privacy to empty the pouch. this included types of personality, specific ego defence mechanisms, spirituality influenced healthrelated quality of life among colorectal cancer patients (baldwin, c.m., grant, m., wendel, c., rawl, s., schmidt, ko and krouse, 2008; sales et al., 2014). in addition, the type of ostomy (temporary/permanent), the underlying disease, depression, problem with the location of the ostomy, and changes in clothing style had significant effects on the quality of life of stoma patients (anaraki et al., 2012). difficulties with sleep, problems with body jurnal ners vol. 12 no. 2 oktober 2017: 239-246 240 image and depression have also been reported in association with quality of life (grant et al., 2011). in term of the patients’ characteristics, jayarajah and samarasekera (2017) found that higher quality of life was associated with female sex, colostomies, comfortable income and satisfactory sexual activity, whereas lower quality of life was associated with significant changes in the style of dressing, feeling depressed, having thoughts of self-harm soon after surgery, and taking longer time to learn to take care of the stoma. in the indonesian population, so far, there is a little known robust study on the quality of life and characteristics of colostomy patients. in fact, understanding the quality of life of patients who have undergone a colostomy is essential for evaluating the full impact of the colostomy on the individual, their family and their community. according to a member of the indonesian enterostomal therapist nurse association bandung chapter (personal communication with nunung nurhayati, ners, etn), there are more than 100 patients currently undergoing colostomy permanently in bandung city, and their quality of life has not been evaluated. therefore, the study aims to describe the level of quality of life of colostomy patients, as well as to test the difference in the quality of life of colostomy patients with regards to certain demographic characteristics. materials and methods the study used a cross-sectional and descriptive analytical approach. seventy-one respondents were recruited purposively. the inclusion criteria of the recruited respondents were being an adult, able to write and read in indonesian, having no serious health problems such as severe heart disease, severe pulmonary problems, and severe neurologic impairment which would have made them unable to respond to the questionnaire properly, and who are voluntarily willing to participate in the study. the studied variables included quality of life and demographic characteristics. the data was collected using the self-administered who-bref quality of life instrument which has already been translated into indonesian language using a back translation technique by a panel expert (world health organization, 1996). quality of life includes dimensions and items of quality of life that were analysed descriptively. one-way anova and an independent t-test were used to test the difference quality of life-based on certain characteristics. approval and permission to conduct this study were taken from rsup dr. hasan sadikin bandung. results characteristics of the respondents the demographic and health characteristics of the respondents are presented in table 1 and table 2. table 1. demographic characteristics of the respondents (n = 71) characteristics n % 1. age (year) < 20 6 8.5 21 30 6 8.5 31 40 11 15.5 41 50 17 23.9 51 60 17 23.9 >60 14 19.7 m = 46.59 sd = 15.31 r = 17 – 78 2. sex male 49 69.0 female 22 31.0 3. religion islam 61 85.9 christian 10 14.1 4. education primary school 18 25.4 junior high school 16 22.5 senior high school 20 28.2 university/college 17 23.9 5. occupation unemployed 15 21.1 farmer 7 9.9 civil servant 6 8.5 employee 7 9.9 self-employed 11 15.5 retirement 12 16.9 housewives 11 15.5 labour 2 2.8 6. monthly income (indonesian rupiah) no income 27 38.0 < 500,000 9 12.7 500,000 – 1,000,000 13 18.3 1,000,001 – 2,000,000 18 25.4 > 2,000,000 4 5.6 7. ethnicity sundanese 43 60.6 javanese 16 22.5 malay 7 9.9 bataknese 4 5.6 chinese 1 1.4 quality of life and characteristics... (kusman ibrahim et al.) 241 the majority of the respondents (77.4%) perceived their level of quality of life as ranging from very poor to moderate, and most of them (83.1%) reported being very unsatisfied to moderate satisfaction in relation to their current health status, as presented in table 3. as shown in table 4, the core of each dimension of quality of life, standard deviation, and range. it seems that environmental dimension is the highest mean score chosen by the respondents, and followed by physical health, psychological, and social. according to table 5, the ranking of the five top items of quality of life that were selected by the respondents as highly satisfactory items in their quality of life. satisfaction with support from friends was selected as the highest item in relation to their quality of life. oppositely, table 6 presents the ranking of the five lowest items of quality of life that were selected by the respondents as the lower satisfactory items of their quality of life. it seems that satisfaction with their sexual relationship was selected by most of the respondents as the lowest satisfactory item of their quality of life. results from the statistical test using anova and the independent t-test found that there were no significant differences in the total quality of life score with regards to age group, education, occupation, the length of time of being ostomate, sex, and other health problems, as presented in table 7. discussion the results of the study show that the majority of the respondents perceived that their level quality of life ranged from very poor to moderate. none of them perceived that their level of quality of life was very good. it is argued that the presence of the stoma on the part their body may interfere with their daily activities as well as their body image which influences their interactions with others. thus, the presentation of a stoma would influence their perception of themselves which determines their life satisfaction. this is relevant to the previous study conducted by liao and qin (2014) that found that patients with a stoma experienced difficulties functioning in work and social situations. the patients also encountered issues with sexuality and body image, and difficulties with stoma function. in our study, the environmental dimension was the highest mean score chosen by the respondents, followed by physical health, psychological, and social. our findings are consistent with previous studies that found that the stoma patients had more difficulty participating in social activities (dabirian et al., 2010; anaraki et al., 2012). swan (2011) table 2. health characteristics of the respondents (n = 71) characteristic n % 1. other health problems none 58 81.7 hypertension 8 11.3 infection 1 1.4 genitourinary 2 2.8 diabetes mellitus 2 2.8 2. social activity no 50 70.4 yes 21 29.6 3. length of time of being ostomate < 12 month 60 84.5 13 – 24 month 8 11.3 25 – 36 month 2 2.8 37 – 48 month 1 1.4 m = 7.62 sd = 7.9 r = 1 – 48 4. cost of stoma care/ month (thousand rupiah) m = 995 sd = 784.5 r = 20 – 4000 5. perception toward selfhealth status good 16 22.5 moderate 39 54.9 poor 16 22.5 6. family relationship good 69 97.2 moderate 2 2.8 table 3. perceived quality of life and current health status (n = 71) frequency (f) percentage (%) perceived quality of life: very poor poor moderate good very good perceived current health status: very unsatisfied unsatisfied moderate satisfied satisfied very satisfied 5 15 35 16 0 1 18 40 12 7.0 21.1 49.3 22.5 0.0 1.4 25.4 56.3 16.9 jurnal ners vol. 12 no. 2 oktober 2017: 239-246 242 and mcmullen et al. (2008) pointed out that the colostomy application might have a negative impact on the patients’ quality of life with regards to both social and family relationships, travelling, physical activity, sexual function and finances. the meaning of quality of life was constructed from a transactional process between an individual with an environment that is influenced by personal background, health, social situation, culture, and age. anaraki et al., (2012) argued that the underlying disease of the stoma, the type of ostomy (temporary/permanent), location of ostomy, depression, and changes in life style had a significant effect on overall quality of life. the majority of the respondents rated their general health at a level of very unsatisfied to moderately satisfied. results from the identification of other health problems (table 2) indicated that a few of the respondents reported other health problems such as hypertension, infection, genitourinary, and diabetes mellitus. in addition, 16 of 71 respondents reported that their perception of self-health status was poor, and more than half of them perceived it as being moderate and good. it explained that other health problems being faced by the respondents influenced their perception towards their general health. the general health condition of colostomy patients was usually good as long as there were no associated complications which might impact on their general health. satisfaction with support from friends was selected by the respondents as the most satisfactory item of quality of life (m = 3.39, sd = 0.75), followed by satisfaction with their living place, health assistance, the meaning of life, and enjoying life. this result reflects the culture of collectivity that is commonly embedded in eastern society, including the sundanese culture which constitutes the majority of the respondents. the sundanese philosophy of saling asah, saling asih, dan saling asuh (reciprocity in caring and empowerment) has underlying moral values to provide care, assistance, help, and support among family members, relatives, neighbours, and the community at a larger scope (garna, 1984). it was a common phenomenon in sundanese society that when a community members is sick, he/she would receive a lot of attention from their relatives, neighbours, and table 4. mean, standard deviation, and range for each dimension of quality of life range mean sd physical health psychological health social relationship environmental total score 15 – 27 12 – 25 5 – 14 14 – 31 52 – 91 19.24 17.68 8.32 23.45 68.69 2.73 2.37 2.13 3.39 8.77 table 5. mean and standard deviation of the five top items quality of life quality of life items range mean sd satisfied with support from friends 1 – 5 3.39 0.75 satisfied with the living place 1 – 5 3.38 0.66 satisfied with health assistances 1 – 5 3.25 0.95 meaning of life 1 – 5 3.15 0.75 enjoying life 1 – 5 3.13 0.67 note: the range of each item is from 1 to 5, the higher of mean score for each item indicated the higher level of quality of life. table 6. mean score and standard deviation of the five low items quality of life quality of life items range mean sd financial sufficiency 1 – 5 2.63 0.76 ability to do activity daily living 1 – 5 2.62 0.82 ability to work 1 – 5 2.45 0.81 ability to walk or going around 1 – 5 2.34 0.91 satisfaction with sexual relationship 1 – 5 2.01 1.08 note: the range of each item is from 1 to 5, the lower of mean score for each item indicated the lower level of quality of life. quality of life and characteristics... (kusman ibrahim et al.) 243 community s which emphasises on providing support, comfort, and prayers for the sick. it is supported by the data that almost all of the respondents (97.2%) acknowledged support from their family. like other studies demonstrate that patients with a permanent stoma had satisfactory family support (ciorogar, g., zaharie, f., ciorogar, a., birta, d., degan et al., 2016). satisfaction with their living place indicated that most of the respondents felt comfort with their home condition. it can be a base level of data to help develop home-based care for colostomy patients. in terms of health assistance received, most of the respondents felt satisfied with the health service given by the health care provider. although the respondents have to undergo a stoma on their abdomen, they are still able to enjoy their life and experience the meaning of life. satisfaction with their sexual relationship was chosen as the lowest item in relation to quality of life by most respondents. the findings of the study are consistent with previous studies that reported that stoma patients experienced a loss in their sexual activity after stoma surgery (gemmill et al., 2010; anaraki et al., 2012). this condition has table 7. the differences of total mean score of quality of life-based on age group, education, occupation, length of time of being ostomate, sex, and other health problems variable n mean sd 95% ci/se* p-value age (year) < 20 21 – 30 31 – 40 41 – 50 51 – 60 > 60 6 6 11 17 17 14 69.67 64.50 68.64 70.59 70.41 65.71 6.976 8.666 10.053 7.001 10.168 8.651 62.35 – 76.99 55.41 – 73.59 61.88 – 75.39 66.99– 74.19 65.18 – 75.64 60.72 – 70.71 0.49 education primary school junior high school senior high school university/college 18 16 20 17 68.61 69.69 68.15 68.47 9.172 10.084 7.372 9.274 64.05 – 73.17 64.31 – 75.06 64.70 – 71.60 63.70 – 73.24 0.96 occupation unemployed farmer civil servant employee self-employee retirement housewives labor length of time of being ostomate < 12 month 13 – 24 month 25 – 36 month 37 – 48 month 15 7 6 7 11 12 11 2 60 8 2 1 66.80 75.00 73.50 67.29 70.09 65.83 65.45 78.50 69.13 66.75 63.00 69.00 8.521 4.243 11.675 8.381 8.893 6.780 7.992 17.678 1.155 3.075 4.000 62.08 – 71.52 71.08 – 78.92 61.25 – 85.75 59.53 – 75.04 64.12 – 76.07 61.53 – 70.14 60.09 – 70.82 -80.33 –237.33 66.82 – 71.44 59.48 – 74.02 12.18 – 113.82 0.96 0.96 sex male female 49 22 69.61 66.64 9.14 7.68 1.30 1.64 0.19 other health problems yes no 13 58 68.85 68.66 5.90 9.34 1.22 1.64 0.93 *95% ci for variable age group, education, occupation, and length of time of being ostomate; and se for variable sex and other health problems. jurnal ners vol. 12 no. 2 oktober 2017: 239-246 244 resulted in low self-confidence of the respondents in performing sexual activities. the majority of the respondents’ ages ranged from 21 to 60 years old, and they were married. in the range of age, they were considered to be sexually active, particularly the males. the presentation of the stoma hole on the abdomen often resulted in a negative self-perception towards their body image, and they had become less sexually attractive to the spouses. as a consequence, their sexual desire might decrease. several socio-demographic and disease parameters have been identified to correlate with the health parameter of the quality of life of patients with colorectal cancer and a stoma (dunn et al., 2003; sales et al., 2014). the results of the study revealed that there were no significant differences between the quality of life score with regards to age groups, education background, occupation, the length of being ostomate, sex, and other health problems experienced. this is possibly due to the respondents’ variations regarding their characteristics not being very much different, which led them to selecting the same items in relation to quality of life. there was difficultly to drawing up a heterogeneous subject in this study. the findings of the study were also consistent with the previous study that found that there was no significant correlation between sex or age group and the quality of life in a patient with colorectal cancer (dunn et al., 2003). however, a few studies reported that there was a significant difference in the patients’ quality of life with regards to sex which was that women with stoma scored consistently lower than men with a stoma for the overall quality of life domains (krouse et al., 2007, 2009; grant et al., 2011)(grant et al., 2011) . this study found that the majority of patients were young or of middle adult age (< 60 years), their monthly income was less than idr 2,000,000 ($ 140), and their length of being ostomate was under 12 months. previous studies documented that younger patients with rectal cancer felt more stigmatised than older patients. in addition, low-income earners were more likely to have a lower quality of life compared to patients with higher incomes (dunn et al., 2003). the study conducted by showed jansen et al. (2010) that colorectal cancer survivors who have been living with the disease for more than five years indicated that their overall domains of quality of life were better than those who had ived with it for under five years. the other study demonstrated that ostomy patients with more than two years experience had shown a better quality of life (fucini et al., 2008; sales et al., 2014). it is understandable that the more time the survivors live for, the more chance there is to learn and adjust to the new conditions of living with cancer and stoma treatment. conclusions colorectal cancer and colostomy treatment have caused several health problems to arise which have impacted on the quality of life of the survivors. the majority of the subjects in the study reported that their level of quality of life was from very low to moderate. the variation of personal characteristics and experience in dealing with the disease could affect their perception regarding quality of life. this study highlighted the common phenomenon of the impact of colostomy on the quality of life and several characteristic factors that may influence the quality of life. it implies that nurses need to take into consideration evaluating the quality of life of colostomy patients following colostomy surgery as an integrated part of comprehensive nursing care. references american cancer society (2017) cancer facts and figures 2017, atlanta. doi: 10.1101/gad.1593107. anaraki, f. et al. (2012) ‘quality of life outcomes in patients living with stoma’, indian j palliat care, 18(3), pp. 176–80. doi: 10.4103/09731075.105687. baldwin, c.m., grant, m., wendel, c., rawl, s., schmidt, c. m., ko, c. and krouse, r. (2008) ‘influence of intestinal stoma on spiritual quality of life of u.s. veterans’, j holist nurs, 26(3), pp. 185–94. doi: 10.1177/0898010108315185. carlsson, e. et al. (2010) ‘concerns and quality of life before surgery and during the recovery period in patients with rectal cancer and an ostomy’, j wound ostomy continence nurs, 37(6), pp. 654–61. doi: quality of life and characteristics... (kusman ibrahim et al.) 245 10.1097/won.0b013e3181f90f0c. ciorogar, g., zaharie, f., ciorogar, a., birta, d., degan, a. et al. (2016) ‘quality of life outcomes in patients living with stoma’, international journal of the bioflux society, 8(3), pp. 137–140. available at: http://www.hvm.bioflux.com.ro/docs/2 016.137-140.pdf. dabirian, a. et al. (2010) ‘quality of life in ostomy patients: a qualitative study’, patient preference and adherence, 5, pp. 1–5. doi: 10.2147/ppa.s14508. dunn, j. et al. (2003) ‘quality of life and colorectal cancer: a review’, australian and new zealand journal of public health, 7(1), pp. 41–53. doi: 10.1111/j.1467-842x.2003.tb00378.x. edwards, b. k. et al. (2014) annual report to the nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast or prostate cancer. united state. doi: 10.1007/978-1-62703-6733. faury, s. et al. (2017) ‘patient education interventions for colorectal cancer patients with stoma: a systematic review’, patient education and counseling. elsevier ireland ltd, 100(10), pp. 1807–1819. doi: 10.1016/j.pec.2017.05.034. fucini, c. et al. (2008) ‘quality of life among five-year survivors after treatment for very low rectal cancer with or without a permanent abdominal stoma.’, annals of surgical oncology, 15(4), pp. 1099–1106. doi: 10.1245/s10434-0079748-2. garna, j. (1984) ‘gambaran umum daerah jawa barat’, in ekadjati, e. s. (ed.) masyarakat sunda dan kebudayaannya. jakarta: girimukti pusaka, pp. 9–74. gemmill, r. et al. (2010) ‘going with the flow: quality-of-life outcomes of cancer survivors with urinary diversion’, journal of wound, ostomy, and continence nursing, 37(1), pp. 65– 72. doi: 10.1097/won.0b013e3181c68e8f. grant, m. et al. (2011) ‘gender differences in quality of life among longterm colorectal cancer survivors with ostomies’, oncol nurs forum., 38(5), pp. 587–596. doi: 10.1188/11.onf.587-596.gender. jansen, l. et al. (2010) ‘quality of life among long-term (>5 years) colorectal cancer survivors systematic review’, european journal of cancer. elsevier ltd, 46(16), pp. 2879–2888. doi: 10.1016/j.ejca.2010.06.010. jayarajah, u. and samarasekera, d. n. (2017) ‘a cross ‑ sectional study of quality of life in a cohort of enteral ostomy patients presenting to a tertiary care hospital in a developing country in south asia’, bmc research notes. biomed central, 10(75), pp. 4–11. doi: 10.1186/s13104-017-2406-2. krouse, r. et al. (2007) ‘quality of life outcomes in 599 cancer and noncancer patients with colostomies’, journal of surgical research, 87(1), pp. 79–8. doi: 10.1016/j.jss.2006.04.033. krouse, r. s. et al. (2009) ‘health-related quality of life among long-term rectal cancer survivors with an ostomy : manifestations by sex’, journal of clinical oncology, 27(28), pp. 4664–4670. doi: 10.1200/jco.2008.20.9502. liao, c. and qin, y. (2014) ‘factors associated with stoma quality of life among stoma patients’, international journal of nursing sciences. elsevier ltd, 1(2), pp. 196–201. doi: 10.1016/j.ijnss.2014.05.007. mcmullen, c. k. et al. (2008) ‘the greatest challenges reported by long-term colorectal cancer survivors with stomas’, j support oncol, 6(4), pp. 175–82. rangki, l. et al. (2014) ‘pengalaman hidup pasien stoma pascakolostomi’, jurnal keperawatan padjajaran, 2(2). sales, p. m. g. et al. (2014) ‘psychosocial predictors of health outcomes in colorectal cancer : a comprehensive review’, cancer treatment reviews. elsevier ltd, 40(6), pp. 800–809. doi: 10.1016/j.ctrv.2014.03.001. siassi, m. et al. (2008) ‘quality of life and patient’s expectations after closure of a temporary stoma’, international journal of colorectal disease, 23(12), pp. 1207–1212. doi: 10.1007/s00384jurnal ners vol. 12 no. 2 oktober 2017: 239-246 246 008-0549-2. sudoyo, a. (2012) ‘kanker usus besar apakah masih ada harapan?’, in. semarang. swan, e. (2011) ‘colostomy, management and quality of life for the patient’, british journal of nursing, 20(1), pp. 24–8. doi: 10.12968/bjon.2011.20.sup11.s22. williams, l. s. and hopper, p. d. (2003) understanding medical-surgical nursing. 2nd edn. philadelphia: f.a. davis company. world health organization (1996) introduction , administration , scoring and generic version of the assessment field trial version december 1996 program of mental health world health organization. geneva. available at: http://www.who.int/mental_health/me dia/en/76.pdf. hubungan organizational role stressors dengan tingkat stres kerja perawat icu 94 hubungan organizational role stressors dengan tingkat stres kerja perawat icu (the correlation of organizational role stressors with stress level of icu nurses) nursalam*, ferry efendi*, ni luh putu dewi puspawati* abstract introduction : work stress which is often experienced by icu nurses may affects nurse’s performance, nurse’s health and wealth so that the factors which may affect work stress such as organizational role stressors must be noticed. this study was aimed to explain the correlation between organizational role stressors and work stress level in icu nurses. method : this study used cross-sectional design involved 13 respondents, taken by purposive sampling. the independent variable was organizational role stressors and the dependent variable was work stress. data were collected by using questionnaires and analyzed using spearman’s rho with level of significance α ≤ 0.05. result : results showed that there was no significant correlation between organizational role stressors and work stress level in icu nurses with significance value p ≤ 0.139. analysis : it can be concluded that the organizational role stressors had no correlation with work stress level because there are so many factors that may affect work stress in icu nurses. discussion : role overload however was experienced by icu nurses as a mild stressors. this indicates the importance of increasing nurse’s quality and quantity by training and recruiting new nursing staffs. keywords : organizational role stressors, work stress, icu nurses *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: nursalam_psik@yahoo.com pendahuluan keperawatan merupakan salah satu dari pekerjaan yang mempunyai stres kerja berat (smith, et.al, 2000). stres kerja juga dialami oleh perawat intensive care unit (icu). ruang perawatan yang menangani kasus akut dan kritis seperti icu telah terbukti menyebabkan stres kerja pada perawat yang bertugas di icu (aaccn, 2002). stres kerja yang berat dapat berpengaruh pada kesehatan perawat dan berlanjut pada terganggunya kinerja perawat. rsud dr. soetomo merupakan rs rujukan sehingga perawat seringkali harus menangani berbagai macam kasus dengan tingkat keparahan dan kondisi pasien yang berbeda. keadaan demikian dapat menimbulkan stres kerja pada perawat. salah satu faktor yang dapat mempengaruhi timbulnya stres kerja adalah organizational role stressors (cooper (1976) dalam vokic & bogdanic (2007)). faktor ini dapat menimbulkan stres kerja pada setiap individu yang mempunyai peran dan terlibat dalam suatu organisasi dan lingkungan yang dalam hal ini adalah perawat, rumah sakit dan profesi lainnya dalam organisasi tersebut. berbagai peran yang dilaksanakan oleh perawat icu baik yang terkait dengan lingkungan pekerjaan/organisasi maupun non-organisasi dapat menjadi stresor tersendiri bagi perawat. data awal menunjukkan 70% responden perawat di icu rsud dr. soetomo menyatakan bahwa tugas dan peran yang harus dilakukan belum jelas dan 60% responden menyatakan bahwa sering terdapat konflik antara berbagai peran yang dilakukan baik yang terkait dengan organisasi maupun non-organisasi. survei yang dilakukan oleh ppni pada tahun 2006 menyatakan bahwa sekitar 50,9% perawat yang bekerja di empat provinsi mengalami stres kerja (depkes, 2007). stres kerja dalam keperawatan berdampak pada kesehatan dan kesejahteraan perawat. dampak tersebut di antaranya; penurunan kinerja perawat, peningkatan gangguan kejiwaan ringan, kesehatan fisik, masalah muskuloskeletal dan depresi (ilo, mailto:nursalam_psik@yahoo.com jurnal ners vol.4 no.1 april 2009: 94-102 95 2000). kinerja perawat yang tidak baik dapat menyebabkan perawatan pasien tidak optimal sehingga proses penyembuhan/rehabilitasi dapat terganggu. salah satu contoh kinerja yang tidak baik adalah kesalahan pemberian obat disebabkan oleh stres di icu termasuk stres kerja perawat (moyen et.al., 2008). lingkungan kerja di icu sudah terbukti dapat menimbulkan stres. di amerika 40% karyawan perawat di icu mengalami tingkat stres kerja yang lebih berat daripada perawat di unit perawatan lainnya (yobel, 2005). stres kerja yang berat dan terus menerus dapat mengakibatkan ketidakpuasan terhadap pekerjaan, burnout dan bahkan kerugian material bagi rumah sakit maupun perawat itu sendiri (smith et al., 2001). cooper (1976) dalam vokic (2007) menyatakan bahwa sumber stres dalam pekerjaan meliputi faktor intrinsik pekerjaan, organizational role stressors, pengembangan karier, relasi dalam pekerjaan, iklim dan struktur organisasi serta extra-organizational sources of stress. organizational role stressors meliputi 10 dimensi yang memaparkan stres karena peran individu dalam sebuah organisasi yaitu: inter-role distance, role stagnation, role expectation conflict, role erosion, role overload, role isolation, personal inadequacy, self-role distance, role ambiguity dan resource inadequacy (lu, 2008). hasil penelitian dari katz & kahn (1978) menjelaskan bahwa peran yang dilaksanakan oleh individu adalah sumber stres (wijono, 2006). peran dan tipe kepribadian a terbukti mempunyai efek pada timbulnya stres kerja yang dialami oleh manajer madya (wijono, 2006). penelitian yang dilakukan oleh lu (2008) menyatakan bahwa stresor ini bahkan dapat menyebabkan terjadinya burnout. stres akibat peran di antara perawat juga dapat menyebabkan dampak negatif pada kepuasan kerja mereka (ho et.al., 2009). konflik peran juga terbukti berpengaruh secara tidak langsung terhadap komitmen pada organisasi (churiyah, 2007). stres kerja dapat menurunkan prestasi kerja, kinerja dan kepuasan perawat sehingga stres kerja harus diatasi, dicegah dan dikurangi. stres kerja dapat dicegah dan dikurangi dengan cara mengidentifikasi dan mengendalikan faktor-faktor penyebabnya termasuk organizational role stressors. stresor dari peran dalam organisasi ini dapat dikendalikan dengan strategi koping psikologis yang baik. oleh karena itu faktorfaktor yang mempengaruhi stres kerja pada perawat di icu khususnya organizational role stressors perlu diteliti lebih lanjut sehingga bisa dikendalikan untuk mengurangi stres kerja pada perawat icu (keller (1990) dalam mims (2003)). bahan dan metode penelitian penelitian ini menggunakan metode cross-sectional dengan jumlah populasi semua perawat icu rsud dr. soetomo yang berjumlah 45 orang. sampel sebanyak 13 perawat diambil berdasarkan kriteria inklusi yang telah ditetapkan yaitu : 1) perawat yang dinas saat pengumpulan data, 2) pelaksana perawatan, 3) perawat perempuan, 3) bekerja > 1 tahun, 4) sudah menikah dan mempunyai anak. penelitian ini dilaksanakan pada tanggal 23 juni 2009. variabel independen dalam penelitian ini adalah organi-zational role stressors dan variabel dependennya yaitu tingkat stress kerja. instrumen pengumpulan data dengan menggunakan kuisioner. tingkat stres kerja diukur dengan kuesioner modifikasi dari as (2002) dan yobel (2005) berupa 30 pernyataan, sedangkan pengukuran organizational role stressors digunakan kuesioner modifikasi dari pareekh (1981) dan lu (2008). kuesioner terdiri atas pernyataan: inter-role distance, role stagnation, role expectation conflict, role erosion, role overload, role isolation, personal inadequacy, self-role distance, role ambiguity dan resource inadequacy. tingkat stressor diketegorikan dalam 4 tingkatan yaitu : tidak berpengaruh, stressor ringan, sedang dan berat. data yang diperoleh ditabulasi dan dianalisis menggunakan uji statistik krusskal-wallis test, mann whitney u test dengan tingkat kemaknaan α≤0,05. hasil penelitian hasil penelitian menunjukkan bahwa sebagian besar responden yaitu sebanyak 12 orang (92,3%) memiliki stres kerja yang tergolong tingkat ringan dan 1 orang (7,7%) responden mengalami stres kerja tingkat sedang. tidak ada responden yang tidak organizational role stressors dan tingkat stress kerja perawat icu (nursalam) 96 mengalami stres kerja dan tidak ada responden yang mengalami stres kerja berat. hasil pengumpulan data tentang organizational role stressors pada perawat responden di icu rsud dr. soetomo. gambar tersebut menunjukkan bahwa sebagian besar responden yaitu sebanyak 9 orang (69,2%) merasakan organizational role stressors sebagai stresor yang ringan. organizational role stressors dirasakan sebagai stresor sedang oleh 4 orang (30,8%) responden. tidak ada responden yang merasakan organizational role stressors sebagai stresor yang tidak berpengaruh ataupun sebagai stresor yang berat. hasil uji statistik korelasi spearman’s rho dengan α≤0,05 untuk menentukan hubungan antara organizational role stressors dengan tingkat stres kerja pada perawat icu adalah: r=0,433 dan p=0,139. hal tersebut menunjukkan korelasi tidak signifikan atau tidak bermakna sehingga hipotesis penelitian ditolak dengan tingkat kepercayaan sebesar 95%. hal ini berarti tidak ada hubungan antara organizational role stressors dengan tingkat stres kerja perawat icu (tabel 1). pembahasan sebagian besar responden (92,3%) mengalami tingkat stres kerja yang ringan. hanya 7,7% responden yang mengalami stres kerja tingkat sedang. indikator stres yang paling banyak dialami berupa gejala ketidakstabilan psikologis, gejala fisik dan indikator yang paling sedikit dialami responden adalah gejala perilaku. terbentuknya respons stres ditentukan oleh interpretasi dari stresor (lazarus (1965) dalam niven (2000)). menurut lazarus hal tersebut terbagi menjadi dua bagian yaitu penilaian stres dan mekanisme koping untuk mengatasinya. tahap pertama adalah penilaian terhadap ancaman/stresor yang dipengaruhi oleh latar belakang sosial, budaya individu dan pengalaman masa lalu. mekanisme koping diklasifikasikan menjadi dua kategori yaitu tindakan langsung dan tindakan paliatif. tindakan langsung secara langsung mencoba mengurangi atau menghilangkan sumber stres. sebaliknya, tindakan paliatif memodifikasi respons internal individu terhadap stimulus. potensi stresor masih tetap ada tetapi individu dapat mengatasi dengan lebih baik. bakal (1979) menyatakan bahwa alasan mengapa tenaga kesehatan tidak merasakan stres kerja karena mereka sudah mengurangi aspek/potensi yang mengancam dari suatu situasi (stresor) dengan menggunakan penilaian kognitif (niven, 2000). berdasarkan uraian di atas, tingkat stres kerja ringan yang paling banyak dialami responden dalam penelitian ini disebabkan mereka sudah mengurangi potensi ancaman dari suatu stresor dengan menggunakan penilaian kognitif, sehingga respons stres berupa respons emosional dapat dikendalikan. selain itu tingkat stres kerja ringan juga dapat disebabkan karena mekanisme koping yaitu tindakan paliatif yang memodifikasi respons internal individu terhadap stimulus. pendidikan minimal responden adalah diii keperawatan (92,3%) dan sebagian besar (92,3%) responden sudah mendapat pelatihan icu serta mempunyai pengalaman kerja lebih dari satu tahun, bahkan ada yang sudah bekerja sampai kurun waktu 20-25 tahun (15,4%). berdasarkan latar belakang pendidikan, pelatihan dan masa kerja yang lama memungkinkan berlangsungnya proses pembelajaran sehingga individu dapat beradaptasi melalaui penggunaan mekanisme koping yang sesuai. ancaman berupa stresor masih tetap ada tetapi individu dapat mengatasi dengan lebih baik sehingga stres kerja yang muncul berada pada tingkat yang ringan. indikator stres yang paling banyak dialami oleh responden berupa gejala psikologis. respons gejala psikologis yang dialami sebagian besar berupa perasaan lelah, kehilangan konsentrasi dan mudah jengkel dalam bekerja. perbedaan individual (gender) juga dapat membedakan bagaimana orang menerima dan berrespons terhadap stres. perempuan lebih cenderung mengalami respons stres psikologis (davidson & cooper, (1987); jick & mitz, (1985)) dalam sulsky & smith (2005)). perempuan yang bekerja lebih sering mengalami gangguan psikosomatis seperti kelelahan, kejengkelan dan kecemasan (cooper & davidson, 1982), distress mental (piltch et.al., 1994) dan depresi daripada pria (murphy et.al. (1994) dalam sulsky & smith (2005)). kelelahan disebabkan karena banyak energi yang jurnal ners vol.4 no.1 april 2009: 94-102 97 dikeluarkan dalam keadaan stres. saat keadaan stres tubuh akan mengaktifkan respons melawan atau menghindar, baik pada saat memilih untuk tetap aktif ataupun diam saja (nsc, 2003). beberapa hasil penelitian menunjukkan perempuan mengalami tingkatan burn out dan diskriminasi pekerjaan yang lebih berat daripada pria. meskipun demikian perbedaan respons stres dan penjelasan mekanisme perbedaan respons tersebut belum sepenuhnya dimengerti (sulsky & smith, 2005). responden dalam penelitian ini semuanya perempuan. perempuan cenderung mengalami respons stres psikologis. hal tersebut sesuai dengan penelitian sebelumnya bahwa perempuan yang bekerja lebih sering mengalami gangguan psikosomatis seperti kelelahan, kejengkelan dan kecemasan. perasaan lelah muncul disebabkan karena banyak energi yang dikeluarkan dalam keadaan stres. berbagai stresor yang menuntut perhatian misalnya, tugas yang harus dikerjakan dalam waktu yang relatif singkat, jumlah pasien yang banyak, catatan produktivitas (monitoring) dapat menyebabkan kejengkelan dan konsentrasi berkurang. indikator stres yang paling banyak dialami setelah gejala psikologis adalah gejala fisik dengan rerata prosentase sebesar 37,98%. gejala fisik yang paling banyak dialami berupa sakit kepala, otot kaku saat bekerja dan gangguan tidur. stres adalah respons umum terhadap adanya tuntutan pada tubuh yang mengharuskan untuk menyesuaikan diri dan karenanya keseimbangan tubuh dapat terganggu (selye (2000) dalam yobel (2005)). contoh gejala fisik yang sering diamati sebagai gejala stres adalah ketegangan otot, sakit kepala (karena tegang dan migrain) dan insomnia. ketegangan otot merupakan gejala stres paling utama. gejala ini kemungkinan muncul dalam bentuk sakit kepala karena tegang, rahang terkatup, leher kaku dan nyeri punggung bawah. insomnia merupakan gejala pasti akibat kerja sistem saraf yang terlalu aktif/berlebihan. stimulasi saraf yang berlebihan pada jaringan otak dan otot dapat menyebabkan rasa gelisah atau resah baik di siang hari maupun di malam hari (nsc, 2003). sakit kepala yang dialami perawat dapat disebabkan karena ketegangan otot ataupun peningkatan aliran darah dan sekresi zat kimia ke bagian kepala. ketegangan otot juga dapat menyebabkan kekakuan otot. gangguan tidur disebabkan karena kerja sistem saraf yang terlalu aktif/berlebihan. di ruang perawatan akut dan kritis seperti icu perawat memerlukan konsentrasi dan kewaspasdaan lebih tinggi daripada ruang rawat inap lain dalam melaksanakan perawatan pada pasien. oleh karena itu selama bekerja sistem saraf dituntut untuk aktif sehingga perawat mampu berkonsentrasi. selain itu kerja sistem shift juga menyebabkan perubahan pola tidur dan akhirnya menyebabkan gangguan tidur. indikator stres kerja yang paling sedikit dialami responden adalah gejala perilaku dengan rerata prosentase sebesar 33,01%. gejala perilaku yang paling jarang dan bahkan tidak pernah dilakukan adalah meninggalkan kerja. saat mengalami stres perempuan cenderung mengatasi dengan tending dan befriending tidak dengan cara fight atau flight. tending meliputi aktivitas bermanfaat yang dapat mengurangi stres seperti meluangkan waktu untuk rekreasi bersama keluarga. sedangkan befriending adalah kreasi dan pemeliharaan hubungan sosial yang dapat membantu pengurangan stres (taylor, 2006). hasil pengkategorian organizational role stressors menunjukkan sebagian besar perawat di icu rsud dr. soetomo merasakan sebagai stresor tingkat ringan. sedangkan 30,8% perawat merasakannya sebagai stresor yang sedang. dimensi yang paling tinggi dengan kategori sebagai stresor sedang adalah role overload. skor tertinggi diperoleh untuk pernyataan ”mengalami kesulitan dengan besarnya tanggung jawab dan lamanya jam kerja di rs”. role overload menggambarkan situasi karyawan merasa bahwa tanggung jawab atau tugas yang harus dilakukan terlalu banyak dan tidak seimbang dengan kemampuan dan waktu yang mereka miliki (ahmady et.al., 2007). role overload juga termasuk melakukan beberapa fungsi atau harus merawat banyak pasien dalam waktu bersamaan (maslach and jackson (1986) dalam lu (2008)). rasio perawat dan pasien untuk unit perawatan kritis seperti icu biasanya diterapkan satu perawat : satu pasien sesuai dengan makp kasus (nursalam, 2007). organizational role stressors dan tingkat stress kerja perawat icu (nursalam) 98 tabel 1. hubungan organizational role stressors dengan tingkat stres kerja perawat icu di rsud dr. soetomo tanggal 23 juni 2009 tingkat stres kerja tingkat organizational role stressors total tidak berpengaruh ringan sedang berat jml % jml % jml % jml % jml % tidak stres 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% ringan 0 0,0% 9 69,2% 3 23,1% 0 0,0% 12 92,3% sedang 0 0,0% 0 0,0% 1 7,7% 0 0,0% 1 7,7% berat 0 0,0% 0 0,0% 0 0,0% 0 0,0% 0 0,0% total 0 0,0% 9 69,2% 4 30,8% 0 0,0% 13 100% r= 0,433 ; p= 0,139 keterangan: r = koefisien korelasi p = signifikansi role overload yang dirasakan oleh responden disebabkan oleh tugas dan tanggung jawab yang besar harus dilakukan berkaitan dengan perawatan pasien. di icu rsud dr. soetomo makp yang diterapkan adalah model asuhan keperawatan yang sudah dimodifikasi dari makp tim, kasus dan fungsional. hal tersebut disesuaikan dengan jumlah perawat. ketua tim juga turut memberikan intervensi kepada pasien yang menjadi tanggung jawabnya. satu perawat bisa menangani lebih dari satu pasien. sebagian besar ketua tim memperoleh persentase skor yang tinggi (57,5%) karena tanggung jawab mereka sebagai ketua tim yang sekaligus melakukan perawatan langsung pada pasien. rerata prosentase terbesar kedua adalah personal inadequacy. skor tertinggi diperoleh pada pernyataan ”anda berpikir bahwa anda mungkin lebih baik daripada saat ini jika pernah dilatih dan mempunyai persiapan lebih” diikuti dengan pernyataan ”merasa belum adekuat dalam hal pengetahuan dan keterampilan sebagai perawat”. personal inadequacy meliputi pengetahuan, keterampilan dan persiapan yang tidak adekuat untuk dapat berperan secara efektif. keadaan ini dapat terjadi ketika suatu organisasi tidak memberikan kesempatan pelatihan/seminar yang memungkinkan karyawan mampu beradaptasi untuk menghadapi perubahan (pareekh, 1981 dalam aziz (2007)). personal inadequacy dapat muncul saat adanya perasaan subyektif berupa keraguan terhadap kemampuan diri sendiri (lopez, 2005) dalam lu (2008). perawat di icu rsud dr. soetomo yang menjadi responden sebagian besar pernah mengikuti pelatihan icu, hanya 7,7% yang belum pernah mengikuti pelatihan. berdasarkan uraian tersebut, personal inadequacy pada perawat responden di icu rsud dr. soetomo muncul sebagai stresor kemungkinan disebabkan oleh adanya perasaan subyektif berupa keraguan terhadap kemampuan diri sendiri sehingga perawat berpikir jika ada pelatihan dan persiapan lebih, mereka akan mampu melaksanakan peran dan tugasnya dengan lebih baik. dimensi yang rerata persentase skornya tertinggi ketiga adalah role ambiguity. skor tertinggi diperoleh pada pernyataan ”rs tidak memberikan umpan balik yang adekuat terhadap kinerja anda”. role ambiguity adalah ketidakjelasan peran yang dapat terjadi ketika karyawan tidak memiliki cukup informasi untuk dapat melaksanakan tugasnya atau tidak mengerti realisasi harapan-harapan terhadap perannya. menurut everly dan giordano dalam munandar (2001), salah satu faktor yang dapat menimbulkan ketidakjelasan peran ialah kurang adanya umpan balik atau ketidakpastian tentang kinerja pekerjaan. berdasarkan uraian tersebut role ambiguity yang muncul pada perawat di icu rsud dr. soetomo disebabkan karena kurangnya umpan balik terhadap kinerja perawat. umpan balik terhadap kinerja dapat berupa evaluasi dan penghargaan. dimensi keempat yang masih mempunyai kriteria stresor sedang adalah resource inadequacy dengan skor tertinggi pada pernyataan ”anda berpikir bahwa anda mungkin dapat melakukan tugas dengan lebih baik daripada saat ini jika terdapat sumber daya rs yang adekuat”. resource inadequacy adalah suatu keadaan di mana sumber daya yang tidak adekuat untuk jurnal ners vol.4 no.1 april 2009: 94-102 99 melakukan peran individu secara efektif (pareekh, 1981 dalam aziz (2007)). sebagian besar perawat berpendapat bahwa rs dalam hal ini icu rsud dr. soetomo belum memiliki sarana yang cukup bagi perawat untuk dapat melaksanakan tugas dan perannya dengan baik. hal itu dapat dilihat dari penerapan makp modifikasi tim dan kasus yang menyertakan metode asuhan keperawatan fungsional karena kurangnya fasilitas untuk pelaksanaan perawatan pasien. sebagai contoh jumlah troli rawat luka yang terbatas sehingga untuk rawat luka dilakukan oleh perawat fungsional. oleh sebab itu perawat berpendapat bahwa mereka dapat melakukan tugas dengan lebih baik jika terdapat sumber daya yang sudah adekuat dari rumah sakit khususnya di icu rsud dr. soetomo. dimensi role expectation conflict memperoleh rerata persentase skor sebesar 48,08% dan termasuk dalam kategori stresor ringan. skor tertinggi diperoleh pada pernyataan ”berbagai tuntutan dan tuntutan yang kontras dari pekerjaan membuat anda stres”. role expectation conflict menggambarkan konflik yang terjadi karena perbedaan tuntutan dan harapan dari orang lain yang berbeda terhadap suatu peran individu (pareekh, 1981) dalam aziz (2007)). role expectation conflict yang dapat menjadi stresor bagi perawat icu di rsud dr. soetomo berupa banyaknya tuntutan dan tuntutan kontras yang harus dipenuhi oleh perawat selain perbedaan harapan dari pasien maupun atasan. role expectation conflict termasuk dalam kategori stresor ringan karena jarang sekali ditemui tuntutan yang kontras pada peran perawat. dimensi role isolation diperoleh rerata prosentase sebesar 47,44% dan termasuk dalam kategori stresor ringan. skor tertinggi diperoleh pada pernyataan ”berharap diikutsertakan dalam pengambilan keputusan untuk perawatan pasien”. role isolation dapat berupa perasaan terisolasi dari akses informasi tentang apa yang terjadi dan tidak menjadi bagian yang penting dari hal tersebut (ahmady et.al., 2007). perawat di icu rsud dr. soetomo berharap untuk lebih diikutsertakan dalam pengambilan keputusan untuk perawatan pasien kemungkinan disebabkan karena selama ini perawat merasa partisipasi mereka masih kurang dalam pengambilan keputusan padahal yang paling intensif merawat pasien di icu adalah perawat. namun hal ini dirasakan perawat sebagai stresor ringan karena perawat di icu rsud dr. soetomo diperkenankan memberikan saran kepada dokter mengenai perawatan pasien. saran tersebut bisa disampaikan secara langsung ataupun melalui ketua tim dan kepala ruangan. dimensi role stagnation memperoleh rerata prosentase sebesar 37,18% dan termasuk dalam kriteria stresor ringan. skor tertinggi diperoleh pada pernyataan ”anda mengharapkan tanggung jawab dan kesempatan lebih dalam bekerja”. role stagnation berupa perasaan terperangkap dalam suatu peran dan menghasilkan persepsi bahwa tidak ada kesempatan untuk pengembangan karir (pareekh (1981) dalam aziz (2007)). perawat di icu rsud dr. soetomo sebagian besar tidak menyetujui bahwa profesi perawat tidak memberikan peluang ke arah profesionalisme dan kesempatan pengembangan karir. perawat berharap dapat memperoleh tanggung jawab dan kesempatan lebih dalam bekerja agar pengembangan ke arah profesionalisme dan pengembangan karir dapat terwujud. rsud dr. soetomo memberikan kesempatan pada perawat icu untuk melanjutkan pendidikan ke jenjang yang lebih tinggi misalnya dari diii keperawatan ke s1 keperawatan dan jika sudah menyelesaikan tugas belajar perawat tersebut mendapat tanggung jawab yang lebih tinggi misalnya menjadi ketua tim. perawat diseleksi berdasarkan loyalitas dan kinerja. oleh karena itu perawat mengharapkan tanggung jawab dan kesempatan lebih dalam bekerja sehingga mereka dapat menunjukkan kinerja yang terbaik. dimensi inter-role distance memperoleh rerata persentase skor sebesar 30,77% dan termasuk dalam kriteria stresor ringan. pernyataan yang memperoleh skor tertinggi adalah ”pernah mengalami konflik antara peran dan fungsi di tempat kerja dan di rumah”. inter-role distance dapat terjadi saat tuntutan pekerjaan di rumah sakit berbenturan dengan tuntutan di rumah (penson et al. (2000) dalam lu (2008)). selain itu menyeimbangkan karier dan keluarga dapat menyebabkan stres tersendiri bagi perempuan yang bekerja di luar rumah (lucas & wilson, 1995). responden dalam nursalam organizational role stressors dan tingkat stress kerja perawat icu (nursalam) 100 penelitian ini semuanya adalah perempuan dan berstatus sebagai ibu. responden dalam penelitian ini memiliki peran ganda yaitu peran domestik dan peran publik. peran domestik meliputi peran dalam rumah tangga yakni sebagai istri dan ibu. peran publik meliputi peran yang terkait dengan pekerjaan/profesi. masing-masing peran mengharuskan perawat untuk mampu beradaptasi dan dapat menimbulkan stres jika kepentingan kedua peran tersebut berbenturan. meskipun demikian stresor dirasakan masih ringan karena perawat diperbolehkan untuk mengambil cuti atau ijin jika ada keperluan di luar pekerjaan yang tidak bisa dikesampingkan. untuk dimensi role erosion diperoleh rerata persentase sebesar 27,57% dan termasuk dalam kategori stresor tidak berpengaruh. role erosion adalah suatu keadaan di mana peran dan fungsi yang seharusnya dilaksanakan oleh individu yang berwenang namun diambil alih oleh orang lain yang mempunyai tanggung jawab dan peran yang berbeda. manifestasi lain berupa penggunaan peran yang dirasa kurang (underutilization) (pareekh (1981) dalam aziz (2007)). responden tidak merasakan role erosion sebagai stresor karena jarang sekali terjadi pengambilalihan tanggung jawab perawat. perawat di icu rsud dr. soetomo bahkan mempunyai banyak tugas terkait dengan peran yang harus dilakukan. dimensi self-role distance diperoleh rerata prosentase sebesar 11,54% yang termasuk kategori stresor yang tidak berpengaruh. self-role distance adalah konflik yang terjadi antara nilai-nilai individu dengan tuntutan yang harus dilakukan sesuai perannya dalam organisasi (pareekh (1981) dalam aziz (2007)). responden tidak merasakan self-role distance sebagai stresor karena jarang sekali terjadi konflik antara nilai-nilai individu dengan tugas yang harus dilakukan di icu. uji statistik korelasi spearman’s rho dalam penentuan hubungan antara organizational role stressors dengan tingkat stres kerja pada perawat icu memperoleh hasil bahwa tidak ada hubungan antara organizational role stressors dengan tingkat stres kerja perawat icu. stres terbentuk oleh stresor yang berupa stres kerja. stresor tersebut diterima oleh individu dan dilanjutkan dengan proses persepsi yang terdiri dari seleksi, organisasi dan interpretasi stimuli. stres ditentukan pula oleh individu sendiri. perbedaan individual yang perlu diperhatikan dalam proses stres adalah berupa jenis kelamin (gender), ras, usia, status sosial, pengalaman terdahulu, hereditas, intelligence dan tipe kepribadian. menurut payne (1988) perbedaan individual mempunyai peran sentral dalam proses stres. secara teknis variabel ini dapat mengubah atau sebagai moderator antara stressorsstrains relationship (sulsky & smith, 2005). dalam penelitian ini diperoleh bahwa tidak ada hubungan yang signifikan antara organizational role stressors dengan tingkat stres kerja pada perawat di icu rsud dr. soetomo. hal itu dapat disebabkan karena efek moderator berupa perbedaan/ karakteristik individual yang dimiliki dan mempengaruhi proses stress perception pada perawat. karakteristik individu yang mungkin mempengaruhi hubungan antara stresor dan respons stres ini adalah: jenis kelamin, usia dan pengalaman terdahulu. semua responden dalam penelitian ini berjenis kelamin perempuan dengan sebagian besar berusia di atas 30 tahun dan masa kerja sebagian besar 5 tahun ke atas. dengan karakteristik tersebut perawat sudah berpengalaman dan mampu beradaptasi dengan stresor yang ada sehingga stres kerja yang dialami perawat sebagian besar masih dalam tingkat ringan meskipun ada stresor yang dirasakan dalam tingkat sedang. untuk mengatasi stres kerja secara positif diperlukan sebuah strategi koping. terdapat berbagai macam strategi koping, namun tidak semuanya efektif. koping yang efektif didefinisikan sebagai suatu proses mental untuk mengatasi tuntutan yang dianggap sebagai tantangan terhadap sifat pada diri seseorang. diperlukan sifat internal dan eksternal untuk dapat melakukan koping. kreativitas, kesabaran, optimisme dan intuisi, rasa humor, hasrat dan kasih sayang merupakan contoh sifat internal. sifat eksternal meliputi waktu, uang dan dukungan sosial (nsc, 2003). salah satu cara yang dapat digunakan untuk mengurangi stres adalah emotional outlets yaitu dengan cara berdiskusi dengan kelompok pendukung, rekan sejawat dan keluarga (rcn, 2005). perawat di icu rsud dr. soetomo mengalami stres kerja tingkat ringan meskipun ada dimensi organizational role jurnal ners vol.4 no.1 april 2009: 94-102 101 stressors dirasakan dalam tingkat sedang. hal itu dipengaruhi juga oleh strategi koping yang sudah baik dari perawat di icu rsud dr. soetomo. koping tersebut kemungkinan didukung oleh kreativitas, kesabaran, optimisme dan intuisi, rasa humor, hasrat dan kasih sayang yang merupakan sifat internal. sedangkan sifat eksternal meliputi dukungan sosial dari rekan sejawat maupun tenaga kesehatan lain. perawat di icu rsud dr. soetomo memanfaatkan waktu luang di selasela rutinitas pekerjaan untuk berdiskusi dengan rekan sejawat maupun dengan tenaga kesehatan lainnya tentang masalah dalam pekerjaan maupun luar pekerjaan yang dapat menyebabkan stres pada perawat tersebut. dengan demikian perawat mampu mengelola stres sehingga stress response yang muncul berupa stres kerja yang ringan. simpulan dan saran simpulan organizational role stressors tidak berdampak terhadap tingkat stres kerja perawat icu di rsud dr. soetomo. saran peneliti menyarankan: 1) bagi instansi irir, icu dan bidang keperawatan diharapkan untuk merencanakan jadwal pelatihan yang berkelanjutan serta penambahan jumlah tenaga keperawatan disesuaikan dengan kebutuhan, 2) perawat diharapkan dapat menerapkan strategi koping efektif melalui komunikasi dan diskusi situasi potensial serta strategi koping yang efektif dalam pertemuan formal (rapat) maupun pertemuan informal di sela-sela rutinitas sehari-hari, 3) bagi peneliti selanjutnya dapat hubungan organizational role stressors dengan tingkat stres kerja perawat agar lebih mengeksplorasi persepsi subyek mengenai stres kerja, organizational role stressors dan proses terbentuknya respons stres beserta faktor-faktor lain yang mungkin mempengaruhi proses tersebut. kepustakaan aacn, 2002 . american association of critical care nurses backgrounder, the nursing shortage. (online), (http://www.aacn.org/aacn/pubpolcy. nsf/), diakses tanggal 4 mei 2009, jam 18.03 wib). ahmady, et.al., 2007. organizational role stress among medical school faculty members in iran: dealing with role conflict. bmc medical education 7 (14), hlm. 2-3, 6-8. aziz, m., 2007. organizational role stress: an investigation of gender differences. studia psychologica, 49 (1), hlm. 53-61. churiyah, m., 2007. pengaruh konflik peran (role conflict) terhadap kepuasan kerja perawat serta komitmen pada organisasi. jurnal ekonomi modernisasi, 3 (1). depkes ri., 2007. kompetensi perawat perlu ditingkatkan. (online), (http://www.tenagakesehatan.or.id/publikasi.php?do, diakses tanggal 9 juni 2009, jam 12.14 wib). ho, et.al., 2007. effects of job rotation and role stress among nurses on job satisfaction and organizational commitment. (online), (http://www.pubmedcentral.nih.gov/t ocrender.fcgi?iid=175725. diakses tanggal 12 mei 2009, jam 20.04 wib) ilo, 2000. work-related stress in nursing. (online), (http://www.ilo.org/public/english/pr otection/safework/index.htm. diakses tanggal 9 mei 2009, jam 16.04 wib) lu, j.l., 2008. organizational role stress indices affecting burnout among nurses. journal of international women’s studies, 9, hlm. 63-78. lucas & wilson, 1995. memelihara gairah kerja, alih bahasa: ansis kleden. jakarta: arcan, hlm. 188. mims & stanford, 2003. stress and burnout among critical care nurses, (online), (http://www.lagrange.edu/resources/ pdf/citations/nursing/stress%20and% 20burnout.pdf, diakses tanggal 16 mei 2009, jam 17.08 wib). moyen, et.al., 2008. clinical review: medication errors in critical care. critical care, 12 (2), hlm. 3. http://www.aacn.org/aacn/pubpolcy.nsf/72fe271374e4c5338825688e00776c20/2b8e43a0fd740c988256b81008168d1?opendocument http://www.aacn.org/aacn/pubpolcy.nsf/72fe271374e4c5338825688e00776c20/2b8e43a0fd740c988256b81008168d1?opendocument http://www.tenaga-kesehatan.or.id/publikasi.php?do http://www.tenaga-kesehatan.or.id/publikasi.php?do http://www.pubmedcentral.nih.gov/tocrender.fcgi?iid=175725 http://www.pubmedcentral.nih.gov/tocrender.fcgi?iid=175725 http://www.ilo.org/public/english/protection/safework/index.htm http://www.ilo.org/public/english/protection/safework/index.htm http://www.lagrange.edu/resources/pdf/citations/nursing/stress%20and%20burnout.pdf http://www.lagrange.edu/resources/pdf/citations/nursing/stress%20and%20burnout.pdf http://www.lagrange.edu/resources/pdf/citations/nursing/stress%20and%20burnout.pdf organizational role stressors dan tingkat stress kerja perawat icu (nursalam) 102 munandar, a.s., 2001. psikologi industri dan organisasi. jakarta: ui-press, hlm. 380-409. nsc, 2003. manajemen stres. jakarta: egc, hlm. 11, 17-20, 27-28. taylor, s.e., 2006. tend and befriend biobehavioral bases of affiliation under stress. association for psychological science. 15 (6), hlm. 273. niven, n., 2000. psikologi kesehatan, alih bahasa: agung waluyo. jakarta: egc, hlm. 120-127. nursalam, 2007. manajemen keperawatan: aplikasi dalam praktik keperawatan profesional. jakarta: salemba medika, hlm. 142-145, 148-149. rcn, 2005. managing your stress: a guide for nurses. london: royal college of nursing, hlm. 6. smith, et.al., 2000. a further analysis of the impact of demographic factors and type of job. california: crown, hlm. 52. smith, et.al., 2001. a preliminary analysis of psychophysiological variables and nursing performance of increasing criticality, (online), (http://www.mayo.edu/proceedings/2 001/mar/7603a5.pdf. diakses tanggal 4 mei 2009, jam 18.09 wib). sulsky & smith, 2005. work stress. california: wadsworth, hlm. 4-6. vokic & bogdanic, 2007. individual differences and occupational stress perceived: a croatian survey, (online), (http://web.efzg.hr/repec/pdf/clanak %2007-05.pdf. diakses tanggal 4 mei 2009, jam 17.01 wib). wijono, s., 2006. pengaruh kepribadian type a dan peran terhadap stres kerja manajer madya. insan. 8 (3), hlm. 188-197. yobel, s., 2005. hubungan tingkat stres kerja dengan kinerja perawat di unit perawatan kritis (icu). skripsi tidak dipublikasikan, universitas airlangga, surabaya, hlm. 1-5, 25 & 66-67. http://www.mayo.edu/proceedings/2001/mar/7603a5.pdf http://www.mayo.edu/proceedings/2001/mar/7603a5.pdf http://web.efzg.hr/repec/pdf/clanak%2007-05.pdf http://web.efzg.hr/repec/pdf/clanak%2007-05.pdf 128 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.8995 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research structural equation modeling on effects of community empowerment and supplementary feeding on health status and nutritional status of pregnant women lantin sulistyorini faculty of nursing, universitas jember, east java, indonesia abstract introduction: rates of health problems related to a chronic lack of energy in pregnant women in indonesia remain prevalence. this study aimed to develop community empowerment and supplementary feeding on health status and nutritional status among pregnant women. methods: the sample included 189 pregnant women living in the six villages in the jember district. the research used a cluster random sampling technique. the variables included community empowerment, supplementary feeding, health status, and nutritional status of pregnant women. data analysis was performed using structural equation modeling (sem) with parameter data estimation using software (analysis of moment structures (amos) version 21). results: estimations of the direct effects were as follows: community empowerment on health status (0.224), supplementary feeding on health status (0.169), health status on nutritional status of pregnant women (0.001), community empowerment on nutritional status of pregnant women (2.857), supplementary feeding on nutritional status of pregnant women (-0.537), community empowerment on nutritional status of pregnant women through health status (0.000), supplementary feeding on nutritional status of pregnant women through health status (0.000), community empowerment on health status (0.224), supplementary feeding on health status (0.169). conclusion: community empowerment remains an important key in improving the engagement of women in maternal health issues. combined intervention with supplementary feeding based on locality may improve the health outcomes. article history received: august 18, 2018 accepted: sept 14, 2018 keywords community empowerment; health status; nutritional status, supplementary feeding. contact lantin sulistyorini  lantin_s.psik@unej.ac.id  faculty of nursing, universitas jember, east java, indonesia cite this as: sulistyorini, l. (2018). structural equation modeling on effects of community empowerment and supplementary feeding on health status and nutritional status of pregnant women. jurnal ners, 13(2), 128137. doi:http://dx.doi.org/10.20473/jn.v13i2.8995 introduction in indonesia, data from october 2013 show the upper arm circumference threshold for chronic lack of energy risk is 23.5 cm (ministry of health, 2010). this illustrates that mothers with a chronic lack of energy risk will give birth to babies with low birth weights. when a baby is born with low birth weight, it is at risk of death, lack of nutrition, growth disorders, and developmental disorders. efforts to prevent the risk of chronic lack of energy in pregnant women before pregnancy include increasing the nutritional intake of women of childbearing age to ensure the size of the upper arm circumference in women of childbearing age is at least 23.5 cm (ministry of health, 2009). if the circumference of the mother's upper arm before pregnancy is below this number, then it is better to delay the pregnancy in advance so as not to risk giving birth to a baby with low birth weight. however, the ministry of health, republic of indonesia (2009) showed that pregnant women with a chronic lack of energy and an upper arm circumference less than 23 cm are twice as likely to give birth to low-birth-weight infants compared with mothers who have an upper arm circumference of more than 23 cm. other health problems among pregnant women are related to low economic levels, low education, unhealthy environment, irregular eating patterns, and poor health conditions (ministry of health, 2010). rates of health problems related to a chronic lack of energy in pregnant women in some villages in the jelbuk sub-district of indonesia’s jember regency are high (department of religious of jember, 2011). the problem of a chronic lack of energy in the jelbuk sub-district of the jember regency remains common. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i2.8995 jurnal ners http://e-journal.unair.ac.id/jners | 129 in 2015, there were reported to be 48 pregnant women with a chronic lack of energy in six villages: jelbuk, panduman, sukowiryo, sucopangepok, sukojember, and sugerkidul. data from the public health center of jelbuk (october 2015) indicated there were 40 pregnant women with a chronic lack of energy that had been handled. of the 40 pregnant women with a chronic lack of energy, there were four cases of infants with low birth weight (department of religious of jember, 2011). one of the principal factors that influence the health status of pregnant women is nutrition. risk factors that affect the nutritional status of pregnant women include low economic levels, low education, unhealthy environment, irregular eating patterns, and poor health conditions. the nutritional status of pregnant women affects the growth and development of the fetus (bobak, 2004). assessing the nutritional status of pregnant women includes monitoring weight gain during pregnancy, measuring the upper arm circumference, and measuring hemoglobin levels. weight gain during pregnancy is approximately 10–12 kg (trimester 1: less than 1 kg; trimester 2: about 3 kg; trimester 3: about 6 kg). weight gain each trimester is used to monitor fetal growth (ministry of health, 2010). one solution to the problem of a chronic lack of energy in pregnant women is empowering the community to provide additional food to the local community health service program. public health service programs are expected by the world health organization to reduce maternal and infant mortality and low-birth-weight cases. these can be implemented by organizing, mobilizing, and empowering the community by involving community leaders, religious leaders, and health cadres directly in families who have pregnant women. they aim to keep pregnant women well and ensure safe and healthy childbirth. this study aimed to develop community empowerment and supplementary feeding model on health status and nutritional status among pregnant women. materials and methods this study was conducted from july 2017 to august 2017 at jember regency, indonesia. this study adopted a cross-sectional approach by recruiting pregnant women living in those regency. inclusion criteria for research sites included: 1) jelbuk, panduman, sukowiryo, sucopangepok, sukojember, and sugerkidul in jelbuk, jember district; 2) pregnant women in these 6 villages who have a very young age of marriage and pregnancy; 3) pregnant women in the 6 villages who are lazy to come to the posyandu; 4) pregnant women in these 6 villages whose nutritional needs are not met due to low economic income so that food nutrition patterns are not met properly; 5) pregnant women in these 6 villages who have low family and community knowledge about the condition or initial symptoms of lack of calorie energy so that they are not given early treatment and become more severe with the occurrence of low birth weight or maternal and infant mortality; 6) posyandu in these 6 villages that are still less than optimal is related to cadre training on protein lack of energy; 7) the coverage of the target on the lack of protein energy in the 6 villages that still have no screening plans for pregnant women by posyandu and dukun cadres; 8) the use of plantation resources and local agriculture in these 6 villages is less than optimal as an effort to improve family nutrition in overcoming protein lack of energy. the sampling technique was cluster random sampling, because the population was separated according to certain clusters (i.e., villages). the sample included pregnant women (n=189) in the villages of sukowiryo, jelbuk, sugerkidul, sukojember, sucopangepok, and panduman, jember regency. the research instruments used were a likert-scale questionnaire to find out the level of knowledge (low, medium, and high), attitude (i.e., behavior attitude), and motivation (i.e., level of enthusiasm). weight scales were used to find out the increase or decrease in weight, and a meter stick was used to find out the height increase. health status was assessed using a questionnaire. the level of pregnancy knowledge and level of nutrition knowledge were assessed. an upper arm circumference meter was used to find out the increase or decrease in the upper arm circumference, and a gestational age card was used to control pregnancy health. a tetanus toxoid (tt) immunization card was used to find out the completeness of tt immunization, and a ferrous (fe) tablet was used to find out the supplementary supplement fulfillment. the height of the uterine fundus was measured to determine the growth and development of the uterus, and a sphygmomanometer was used to detect high or low blood pressure. data collection techniques included having participants fill out the questionnaire on knowledge level, attitude, motivation, pregnancy knowledge level, and nutritional knowledge level; having participants fill out the tt immunization data form; ferrous tablets; and measuring body weight, height, circumference of the upper arm, height of the uterine fundus, and blood pressure. data analysis was performed using structural equation modeling (sem) with parameter data estimation using software (analysis of moment structures (amos) (byrne, 2013). sem functioned to assess the latent variables at the observation level (bagossi & yi, 2012). the sem test simultaneously tested the model (kline, 2015), which estimated the effect of community empowerment and supplementary feeding on the health status and nutritional status of pregnant women. the study analyzed the estimated direct effects, estimated indirect effects, and estimated total effects between and among variables. the estimated direct effects of l. sulistyorini 130 | pissn: 1858-3598  eissn: 2502-5791 the following variables were examined: 1) community empowerment (x1) on health status (y1); 2) supplementary feeding (x2) on health status (y1); 3) health status (y1) on nutritional status of pregnant women (y2); 4) community empowerment (x1) on nutritional status of pregnant women (y2); 5) supplementary feeding (x2) on nutritional status of pregnant women (y2). the estimated indirect effects of the following variables were examined: 1) community empowerment (x1) on nutritional status of pregnant women (y2) through health status (y1); 2) supplementary feeding (x2) on nutritional status of pregnant women (y2) through health status (y1). the estimated total effects of the following variables were examined: 1) the sum of all direct effects of community empowerment (x1) on health status (y1) and indirect effects of community empowerment (x1) on health status (y1); 2) the sum of all direct effects of supplementary feeding (x2) on health status (y1) and indirect effects of supplementary feeding (x2) on health status (y1). results figure 1. hypothesis model on effect of community empowerment and supplementary feeding on health status and nutritional status of pregnant women. figure 2. structural equation model: effect of community empowerment and supplementary feeding on health status and nutritional status of pregnant women. variables of community empowerment (x1) included knowledge level (x1.1), attitude (x1.2), and motivation (x1.3). supplementary feeding variables (x2) included body weight before pregnancy (x2.1), weight after pregnancy (x2.2), and height (x2.3). the health status variables (y1) included pre-pregnancy knowledge level (y1.1), post-pregnancy knowledge level (y1.2), pre-pregnancy nutritional status (y1.3), and post-pregnancy nutritional status (y1.4). maternal nutritional status variables (y2) included upper arm circumference (y2.1), gestational age (y2.2), tt immunization (y2.3), fe tablet (y2.4), high uterine fundus (y2.5), and blood pressure (y2.6). all of the variables and indicators are shown in figure 1. in figure 2 it is found that there is a direct influence of community empowerment (x1) on health status (y1) of 0.224. there is a direct effect of supplementary feeding (x2) on health status (y1) of 0.169. there is a direct effect of health status (y1) on the nutritional status of pregnant women (y2) of 0.001. there is a direct influence of community empowerment (x1) on the nutritional status of pregnant women (y2) of 2,857. there is a direct effect of supplementary feeding (x2) on the nutritional status of pregnant women (y2) of -0.537. estimation of direct effects based on table 1, the value of 0.224 is the estimation of the direct effect (unstandardized structural loading) of community empowerment (x1) on health status (y1). this value means that if the level of community empowerment (x1) increases 1 unit, then the health status level (y1) will increase by 0.224 units. the value of 0.169 is the estimation of the direct effect (unstandardized structural loading) of supplementary feeding (x2) on health status (y1). this value means if the level of supplementary feeding (x2) increases 1 unit, then the health status level (y1) will increase by 0.169 units. the value of 0.001 is the estimation of the direct effect (unstandardized structural loading) of health status (y1) on the nutritional status of pregnant women (y2). this value means that if the health status level (y1) increases 1 unit, then the nutritional status of pregnant women (y2) will increase by 0.001 units. the value of 2.857 is the estimation of the direct effect (unstandardized structural loading) of community empowerment (x1) on the nutritional status of pregnant women (y2). this value means that if the level of community empowerment (x1) increases 1 unit, then the nutritional status of pregnant women (y2) will increase by 2.857 units. the value of -0.537 is the estimation of the direct effect (unstandardized structural loading) of supplementary feeding (x2) on the nutritional status of pregnant women (y2). this value means that if the supplementary feeding rate (x2) increases 1 unit, then the nutritional status of pregnant women (y2) will increase by -0.537 units. estimation of indirect effects based on table 1, the estimation of the individual indirect effect of community empowerment (x1) on the nutritional status of pregnant women (y2) through health status (y1) is 0.224 * 0.001 = 0.000. this means the level of nutritional status of pregnant women (y2) will increase by 0.000 units per 1-unit increase of community empowerment (x1) after mediation by health status (y1). therefore, the total coefficient of the indirect effect of community jurnal ners http://e-journal.unair.ac.id/jners | 131 empowerment (x1) on the nutritional status of pregnant women (y2) is equal to 0.000. the estimation of the individual indirect effect of supplementary feeding (x2) on the nutritional status of pregnant women (y2) through health status (y1) is 0.169 * 0.001 = 0.000. this means the level of nutritional status of pregnant women (y2) will increase by 0.000 units per 1-unit increase in supplementary feeding (x2) after mediation by health status (y1). therefore, the total coefficient of the indirect effect of supplementary feeding (x2) on maternal nutritional status (y2) is 0.000. estimation of total effects the estimation of total effects is as follows: x1 -> y1, x2 -> y1. in table 1, it was found that the estimated direct effect of community empowerment (x1) on health status (y1) = 0.224. in table 1, it was found that the estimated total indirect effect of community empowerment (x1) on health status (y1) = 0.000. thus, the estimated total effect of community empowerment (x1) on health status (y1) = 0.224 + 0.000 = 0.224. these results can be interpreted as follows: the health status (y1) will rise by 0.224 units for each 1-unit increase in community empowerment (x1) after passing all the paths between the two variables. in table 1, it was found that the estimated direct effect of supplementary feeding (x2) on health status (y1) = 0.169. in table 1, it was found that the estimated total indirect effect of supplementary feeding (x2) on health status (y1) = 0.000. thus, the estimated total effect of supplementary feeding (x2) on health status (y1) = 0.169 + 0.000 = 0.169. this result can be interpreted as follows: the health status (y1) will rise by 0.169 units for each 1-unit supplementary feeding increase (x2) after passing all the paths between the two variables. discussion direct effect estimation effect of community empowerment on health status the value of 0.224 is the estimation of the direct effect (unstandardized structural loading) of community empowerment (x1) on health status (y1). this value means that if the level of community empowerment (x1) rises 1 unit, then the health status level (y1) will rise by 0.224 units. variables of community empowerment include level of knowledge, attitude, and motivation. the concept varies according to cultural influences (olmedo-alguacil et al., 2015). the level of knowledge of pregnant women about quality of life is associated with different health statuses for individuals with different cultural or ethnic backgrounds (kagawa-singer et al., 2010). pregnancy is a unique time in a mother's life. striking physiological, metabolic, social, and psychological changes can modify the ability of pregnant women to perform traditional roles and improve their health status associated with maternal life (montoya et al., 2010). the physiological effects of pregnancy can result in sleep disturbances. thus, fatigue the physical and mental state associated with maternal knowledge levels about the quality of life during pregnancy and in non-obese pregnant women (tsai et al., 2016). this suggests that the maternal knowledge level of quality of life is related to health status. similarly, a mexican study reported that physical and mental component scores were significantly lower in obese pregnant women than in non-obese pregnant women (amador-licona & table 1. the direct, indirect and total effects of community empowerment and supplementary feeding on health status and nutritional status of pregnant women variables direct indirect total y1 < x1 estimate 0.224 p-value 0.000 y1 < x2 estimate 0.169 p-value 0.000 y2 < y1 estimate 0.001 p-value 0.000 y2 < x1 estimate 2.857 p-value 0.000 y2 < x2 estimate -0.537 p-value 0.000 x1 -> y1 estimate 0.224 p-value 0.000 y1 -> y2 estimate 0.001 p-value 0.000 x2 -> y1 estimate 0.169 p-value 0.000 y1 -> y2 estimate 0.001 p-value 0.000 y1 < x1 estimate 0.224 p-value 0.000 y1 < x2 estimate 0.169 p-value 0.000 y2 < y1 estimate 0.001 p-value 0.000 y2 < x1 estimate 2.857 p-value 0.000 y2 < x2 estimate 0.537 p-value 0.000 l. sulistyorini 132 | pissn: 1858-3598  eissn: 2502-5791 guizar-mendoza, 2012; amador et al., 2008). the level of knowledge of pregnant women about their quality of health is associated with women's lives in terms of their self-confidence and breastfeeding motivation (zubaran & foresti, 2011). increasing pregnant women’s level of knowledge about quality of life can improve their health status (ministry of health, republic of indonesia, 2004). effect of supplementary feeding on health status the value of 0.167 is the estimated standardized non-standard loading effect of supplemental feeding (x2) on health status (y1). this value means if the level of supplementary feeding (x2) goes up 1 unit, then the health status level (y1) will rise by 0.169 units. supplementary feeding variables include body weight and height. pregnant women of normal weight with higher education levels have higher levels of nutritional knowledge along with positive breastfeeding preparation attitudes (lau et al., 2016). the results of a study in singapore indicated that the prevalence of overweight or obesity prepregnancy is 25% and that pre-pregnancy obesity can affect the health status of pregnant women, leading to conditions such as preeclampsia. this figure is lower than the proportion of overweight or obese pregnant women aged 18 to 69 years (ministry of health, 2010), which was 45% worldwide in 2014 (world health organization, 2016). the differences are due to different age and race composition factors. the results of research in singapore show that overweight and obesity rates increased by about 1% per year, especially in malay and indian races (ministry of health, 2010). it is related to the comfort factor of eating outdoors. as many as 60% of singaporeans regularly eat in public places, such as hawker centers, food courts, and coffee shops, and singaporeans consume excessive calories and fat (health promotion board, 2010). the results suggest that malay and indian diets contain more saturated fats and highly nutritious foods (neelakantan et al., 2016). other research finds that women alter their physical activity and dietary patterns during pregnancy (chen et al., 2013; padmapriya et al., 2015). pregnant women in singapore refuse physical activity and increase sitting time, television viewing time (padmapriya et al., 2015), and consumption of milk, fruit, vegetables, rice, noodles, and bread (chen et al., 2013). pregnant women of the malay and indian races more often increase sitting time during pregnancy compared to the chinese race in singapore. lifestyle changes, especially pregnant women's knowledge of nutrition, can increase the number of overweight or obese pregnant women in singapore (padmapriya et al., 2015). effect of health status on nutritional status of pregnant women the value of 0.001 is an estimate of the (unstandardized structural loading) effect of health status (y1) on the nutritional status of pregnant women (y2). this value means that if the health status level (y1) rises 1 unit, then the nutritional status of pregnant women (y2) will increase by 0.001 units. variables of health status include the level of knowledge of pregnancy and the level of nutritional knowledge. a study of the effects of maternal knowledge levels of pregnancy on body weight during pregnancy found that the prevalence of overweight or obesity around the world is 39% and 13%, respectively, in women of reproductive age (world health organization, 2016). the results showed that knowledge of breastfeeding preparation is influenced by maternal obesity (turcksin et al., 2014). this is because mothers’ overweight or obesity significantly affects the initiation and duration of breastfeeding but only slightly affects their attitude in preparation for breastfeeding (amir & donath, 2007; turcksin et al., 2014). the results of the study showed that pregnant women are less likely to be obese during breastfeeding preparation than non-obese women (guelinckx et al., 2012). other results found that obese pregnant women were no different from non-obese pregnant women in motivation for breastfeeding preparation (hauff et al., 2014). effect of community empowerment on nutritional status of pregnant women the value of 2.857 is the estimation of the nonstandardized impact of loading (structural loading) from community empowerment (x1) on the nutritional status of pregnant women (y2). this value means that if the level of community empowerment (x1) rises 1 unit, then the nutritional status of pregnant women (y2) will increase by 2.857 units. variables of community empowerment include pregnant women’s level of knowledge, attitude, and motivation. the attitude of pregnant women is very important in optimizing fetal health and well-being, as it is beneficial in the shortand long-term to mother, child, family, and society (victora et al., 2016; lau et al., 2016). this is one of the factors associated with the behavior of breastfeeding (linares et al., 2015). the attitude of pregnant women is a predictive factor of exclusive breastfeeding initiation (cox et al., 2015; linares et al., 2015; wang et al., 2014). it is also present in the antenatal period and is influenced by multidimensional factors (roll & cheater, 2016). factors affecting maternal attitude to breastfeeding include maternal characteristics, including age (nouer et al., 2015), ethnicity (linares et al., 2015), education level, occupational status (ishak et al. 2014), household income (persad & mensinger, 2008), parity (buckles & kolka, 2014), pregnancy intentions (kost & lindberg, 2015), caregivers (fok jurnal ners http://e-journal.unair.ac.id/jners | 133 et al., 2016), and previous exclusive breastfeeding experience (mitra et al., 2004). community empowerment, such as a good level of knowledge, can influence maternal attitudes on improving health status. effect of supplementary feeding on pregnant women’s nutritional status the value of -0.537 is the estimated standardized non-standard loading effect of supplementary feeding (x2) on the nutritional status of pregnant women (y2). this value means that if the supplementary feeding rate (x2) rises 1 unit, then the nutritional status of pregnant women (y2) will rise by -0.537 units. supplementary feeding variables include the weight and height of pregnant women. according to the nutritional adequacy rate of 2004, a pregnant mother is encouraged to consume the following additional amounts of energy and protein: (1) first trimester: 100 calories and 17 grams of protein; (2) second trimester: 300 calories and 17 grams of protein; (3) third trimester: 300 calories and 17 grams of protein. in this way, expectations can be met in three consecutive trimesters. the need for vitamins and minerals in all three trimesters also increases. pregnant women need additional vitamin a (300 re), thiamin (0.3 mg), riboflavin (0.3 mg), niacin (0.3 mg), folic acid (200 mcg), pyridoxine (0.4 mg), vitamin b (0.2 mcg), vitamin c (10 mg), calcium (150 mg), magnesium (30 mg), iodine (50 mcg), selenium (5 mcg), manganese (0.2 mg), and fluoride (0.2 mg). the additional iron requirement in pregnant women varies. in the first trimester, they do not require additional iron. however, in trimester 2, they require as much as 9 mg, and in trimester 3, they require as much as 13 mg. the additional need for zinc is as follows: trimester 1: 1.7 mg; trimester 2: 4.2 mg; trimester 3: 9 mg. indirect effect estimation effect of community empowerment on nutritional status of pregnant women through health status the estimation of the individual indirect influence of community empowerment (x1) on the nutritional status of pregnant women (y2) through health status (y1) is 0.224 * 0.001 = 0.000. this means that the level of nutritional status of pregnant women (y2) will increase by 0.000 units per 1-unit increase of community empowerment (x1) after mediation by health status (y1). therefore, the total coefficient of the indirect effect of community empowerment (x1) on the nutritional status of pregnant women (y2) is equal to 0.000. during pregnancy, pregnant women should prepare to welcome the birth of a baby by increasing their knowledge about pregnancy and complete nutrition. a healthy mother will give birth to a healthy baby. maternal nutrition during pregnancy is one of the determining factors that affect the baby's birth. during pregnancy, there is an increased need for nutrients, such as carbohydrates, proteins, vitamins, and minerals (hasugian, 2012). therefore, pregnant women with adequate knowledge can increase their nutritional intake as needed during pregnancy to improve health status. effect of supplementary feeding on nutritional status of pregnant women through health status the estimation of the individual indirect effect of supplementary feeding (x2) on the nutritional status of pregnant women (y2) through health status (y1) is 0.169 * 0.001 = 0.000. this means the level of nutritional status of pregnant women (y2) will increase by 0.000 units per 1-unit supplementary feeding increase (x2) after mediation by health status (y1). therefore, the total coefficient of the indirect effect of supplementary feeding (x2) on maternal nutritional status (y2) is 0.000. fulfillment of nutritional needs is very important, especially related to changes in the mother's body and fetal development. during pregnancy in the mother, there are various physical and physiological changes. in a normal pregnancy, there is a change in maternal weight gain in accordance with fetal growth and development due to the addition of fat reserves, placental formation and development, increased body fluids, and breast enlargement. due to hormonal changes, pregnant women will experience psychological, social, and emotional changes. a fetus that grows optimally will be born alive with a weight of 2500–3500 grams. to achieve that goal, the mother's weight should rise during pregnancy by about 7–12 kg. nutritional requirements during pregnancy are higher compared to pre-pregnant conditions. as gestation progresses, mothers need a higher number of nutrients and additional foods. the aim of optimizing nutritional intake according to gestational age is to achieve a healthy pregnancy. the quantity, quality, and timeliness of supplementary feeding in pregnant women are adjusted to the rate of fetal growth in each trimester. in the first trimester, there is an increase in the number of cells and the formation of organs. this process needs to be supported by the intake of nutrients, especially protein, folic acid, vitamin b12, zinc, and iodine. although fetal growth is not rapid in the first trimester, all necessary nutrients must be sufficient in preparation for faster growth in the next trimester. in the second and third trimesters, the fetus grows rapidly to 90% of all growth processes during pregnancy. nutrients needed are protein, iron, calcium, magnesium, vitamin b complex, and omega 3 and omega 6 fatty acids. additional energy needs during pregnancy are different in each trimester. in the first trimester, the major nutrient additions are proteins, vitamins, and minerals necessary for the growth of the brain and nerve cells, which mostly takes place during the first trimester. in the second and third trimesters, average energy l. sulistyorini 134 | pissn: 1858-3598  eissn: 2502-5791 requirements increase by 350 to 500 calories per day. the energy and nutrient needs of pregnant women are very diverse, because it relates to the size of the body and lifestyle of each pregnant woman. simply, nutritional adequacy during pregnancy can be monitored by weight gain appropriate to gestational age (ministry of health, 2009). there is a relationship between community empowerment/providing additional food and health status. this is seen in pregnant women who consume nutritious foods derived from carbohydrates, proteins, vitamins, and minerals needed during pregnancy. total effect estimation effect of community empowerment on health status in table 1, it was found that the estimated direct influence of community empowerment (x1) on health status (y1) = 0.224. it was also found that the total estimated indirect effect of community empowerment (x1) on health status (y1) = 0.000. thus, the estimated effect of total community empowerment (x1) on health status (y1) = 0.224 + 0.000 = 0.224. these results can be interpreted as follows: the health status (y1) will rise by 0.224 units for each 1-unit increase in community empowerment (x1) after passing all the paths between the two variables. variables of community empowerment include level of knowledge, attitude, and motivation. negative perceptions of pregnant women on health status during pregnancy can lead to a decrease in the quality of life associated with health status (kolu et al., 2014). respecting cultural differences in understanding quality of life as it relates to health status is important, because the dimensions and sources of social and religious support may differ between cultures (kagawa-singer et al., 2010). research results in the united states show that asians have a quality of life associated with better health status than whites and other ethnic groups (chowdhury et al. 2008; zahran et al., 2005). because asians are very respectful of culture, a clean and healthy lifestyle has become one of their core beliefs. intellectual factors influence pregnant women making decisions on breastfeeding preparation (chin et al., 2008), and pregnant women with high levels of education have more accurate breastfeeding knowledge than those with low levels of education (zhou et al., 2010). this study is consistent with studies showing a positive relationship between knowledge of infant feeding and maternal decisionmaking on infant feeding (radzyminski & callister, 2016; roll & cheater, 2016). with a high level of knowledge and understanding, pregnant women can make informed decisions about the preparation for childbirth and breastfeeding. effect of supplementary feeding on health status table 1 shows that the estimated direct effect of supplementary feeding (x2) on health status (y1) = 0.169. in table 4, it was found that the total estimated indirect effect of supplementary feeding (x2) on health status (y1) = 0.000. thus, the estimated total effect of supplementary feeding (x2) on health status (y1) = 0.169 + 0.000 = 0.169. this result can be interpreted as follows: the health status (y1) will rise by 0.169 units for each 1-unit supplementary feeding increase (x2) after passing all the paths between the two variables. supplementary feeding variables include weight and height. the normal weight indicator shows the quality of life associated with a person's health status (amador-licona & guizar-mendoza, 2012), especially the level of knowledge of pregnancy and nutrition. pregnant women of normal weight with a high level of education have high levels of pregnancy knowledge and positive breastfeeding attitudes (ishak et al., 2014; nouer et al., 2015). the results show that pregnant women who are in good health and leading happy lives have important health. pregnant women today are more likely to consider breastfeeding an important part because of the many benefits of breastfeeding on health, and they are willing to participate in healthy breastfeeding behavior (bakas et al., 2012). pregnant women with a high quality of life associated with a better health status have positive attitudes toward breastfeeding. in contrast, the following characteristics of health status are associated with poor quality of life: poverty, fatigue, energy loss, depression, anxiety, labor difficulties (ware et al., 1995). this illustrates that inadequate quality of life in pregnant women is associated with poor health status and low use of antenatal care services (nisar et al., 2016). the results of previous studies suggest that pregnant women with few antenatal visits have a quality of life associated with low health status (de oliveira et al., 2015). during an antenatal visit, attendance of healthcare support is crucial in the selection of baby food (meedya et al., 2010). the results of research in hong kong show that pregnant women with low levels of antenatal knowledge have poor breastfeeding attitudes (lau, 2010) because pregnant women decide to breastfeed during early pregnancy (brand et al., 2011). this has an impact on pregnant women with a quality of life associated with poor health status and negative breastfeeding attitudes. a good level of understanding of supplementary feeding can create a positive attitude for pregnant women on health status. conclusion community empowerment and supplementary feeding aspect remain a critical part in improving general health and nutritional status of pregnant women. health workers need to develop specific intervention in engaging community around maternal health areas. supplementary feeding jurnal ners http://e-journal.unair.ac.id/jners | 135 intervention also need to be done within villages by cooperating with local governments. references amador, n., juarez, j.m., guizar, j.m., & linares, b. (2008). quality of life in obese pregnant women: a longitudinal study. am. j. obstet. gynecol. 198 (2), 203. doi: http: //dx.doi.org/10.1016/j.ajog.20 07.08.037 e201-205. amador-licona, n., & guizar-mendoza, j.m. (2012). daytime sleepiness and quality of life: are they related in obese pregnant women? arch. gynecol. obstet. 285 (1), 105–109. doi: http: //dx.doi.org/10.10 07 / s0 0 404 -011-1879-9. amir, l.h., & donath, s. (2007). a systematic review of maternal obesity and breastfeeding intention, initiation and duration. bmc pregnancy childbirth. 7, 9. doi: http: //dx.doi.org/10.1186/1471-2393-7-9. bagozzi, r.p., & yi, y. (2012). specifications, evaluation, and interpretation of structural equation models. j. acad. mark. sci. 40, 8–34. doi: http://dx.doi.org/10.10 07/s11747-011-0278-x. bakas, t., mclennon, s.m., carpenter, j.s., buelow, j.m., otte, j.l., hanna, k.m., ellett, m.l., hadler, k.a., & welch, j.l. (2012). systematic review of health-related quality of life models. health qual. life outcomes. 10, 134. doi: http://dx.doi.org/10.1186/1477-7525-10-134. bobak. (2004). maternity nursing teaching book. jakarta: egc. brand, e., kothari, c., & stark, m.a. (2011). factors related to breastfeeding discontinuation between hospital discharge and 2 weeks postpartum. j. perinat. educ. 20 (1), 36–44. doi: http://dx.doi.org/10.1891/1058-1243.20.1.36. buckles, k., & kolka, s. (2014). prenatal investments, breastfeeding, and birth order. soc. sci. med. 118, 66–70. doi: http://dx.doi.org/10.1016/j.socscimed.2014.07.0 55. byrne, b.m. (2013). structural equation modeling with amos: basic concepts, applications, and programming. new york, ny: routledge. chen, l.w., low, y.l., fok, d., han, w.m., chong, y.s., gluckman, p., godfrey, k., kwek, k., saw, s.m., soh, s.e., tan, k.h., chong, m.f.f., & van dam, r.m. (2013). dietary changes during pregnancy and the postpartum period in singaporean chinese, malay, and indian women: the gusto birth cohort study recommendations for prevention of excessive weight gain during pregnancy. public health nutr. 17 (9), 1930–1938. doi: http://dx.doi.org/10.1017/s13689 80 0130 01730. chin, a.c., myers, l., & magnus, j.h. (2008). race, education, and breastfeeding initiation in louisiana, 2000–2004. j. hum. lact. 24 (2), 175– 185. doi: http://dx.doi.org/10.1177/0890334 408316074. chowdhury, p.p., balluz, l., & strine, t.w. (2008). health-related quality of life among minority populations in the united states, brfss 2001– 2002. ethn. dis. 18 (4),483–487. cox, k.n., giglia, r.c., & binns, c.w. (2015). the influence of infant feeding attitudes on breastfeeding duration: evidence from a cohort study in rural western australia. int. breastfeed. j. 10, 25. doi: http://dx.doi.org/10.1186/s130 0 6015-0 0 4 83. de oliveira, m.f., parker, l., ahn, h., catunda, h.l.o., bernardo, e.b.r., de oliveira, m.f., ribeiro, s.g., calou, c.g.p., antezana, f.j., almeida, p.c., & castro, r.c.m.b. (2015). maternal predictors for quality of life during the postpartum in brazilian mothers. health. 7 (03), 371. doi: http://dx.doi.org/10.4236/health.2015.730 42. department of religious of jember. (2011). the profile of health jember district 2011. jember: published bereau of health office jember district. ministry of health, republic of indonesia. (2009). national health system. jakarta: department kesehatan. fok, d., aris, i.m., ho, j., lim, s.b., chua, m.c., pang, w.w., saw, s.m., kwek, k., godfrey, k.m., kramer, m.s., & chong, y.s. (2016). a comparison of practices during the confinement period among chinese, malay, and indian mothers in singapore. birth. 1–8. doi: http://dx.doi.org/10.1111/birt.12233. guelinckx, i., devlieger, r., bogaerts, a., pauwels, s., & vansant, g. (2012). the effect of pre-pregnancy bmi on intention, initiation, and duration of breast-feeding. public health nutr. 15 (5), 840– 848. doi: http://dx.doi.org/10.1017/s13689 80 0110 026 67. hasugian, t.p. (2012). knowledge, attitude, and behavior of pregnant women against high risk pregnancy at rsup h. adam malik medan. unpublished thesis. sumatera utara: fakultas kedokteran universitas sumatera utara. hauff, l.e., leonard, s.a., & rasmussen, k.m. (2014). associations of maternal obesity and psychosocial factors with breastfeeding intention, initiation, and duration. am. j. clin. nutr. 99 (3), 524–534. doi: http://dx.doi.org/10.3945/ajcn.113.071191. health promotion board. (2010). national nutrition survey 2010. health promotion board, singapore. ishak, s., adzan, n., a.m., quan, l.k., shafie, m.h., rani, n.a., & ramli, k.g. (2014). knowledge and beliefs about breastfeeding are not determinants for successful breastfeeding. breastfeed. med. 9 (6), 308–312. doi: http://dx.doi.org/10.1089/bfm.2013.0124. kagawa-singer, m., padilla, g.v., & ashing-giwa, k. (2010). health-related quality of life and culture. semin. oncol. nurs. 26 (1), 59–67. doi: http://dx.doi.org/10.1016/j.soncn.20 09.11.0 08. l. sulistyorini 136 | pissn: 1858-3598  eissn: 2502-5791 kline, r.b. (2015). principles and practice of structural equation modeling. new york, ny: guilford publications. kolu, p., raitanen, j., & luoto, r. (2014). physical activity and health-related quality of life during pregnancy: a secondary analysis of a clusterrandomised trial. matern. child health j. 18 (9), 2098–2105. doi: http://dx.doi.org/10.10 07/s10995-014-1457-4. kost, k., & lindberg, l. (2015). pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. demography. 52 (1), 83–111. doi: http://dx.doi.org/10.10 07/s13524-014-03599. lau, y., htun, t.p., lim, p.i., ho-limb, s.s.t., chi, c., tsai, c., ong, k.w., & klainin-yobas, p. (2016). breastfeeding attitude, health-related quality of life, and maternal obesity among multi-ethnic pregnant women: a multi-group structural equation approach. international journal of nursing studies. 67 (2017) 71–82. linares, a.m., rayens, m.k., gomez, m.l., gokun, y., & dignan, m.b. (2015). intention to breastfeed as a predictor of initiation of exclusive breastfeeding in hispanic women. j. immigr. minor. health. 17, 1192–1198. doi: http://dx.doi.org/10.10 07/s10903-014-0 0 49-0. meedya, s., fahy, k., & kable, a. (2010). factors that positively in fluence breastfeeding duration to 6 months: a literature review. women birth. 23 (4), 135–145. doi: http://dx.doi.org/10.1016/j.wombi.2010.02.0 02. ministry of health. (2010). national health survey. epidemiology and disease control division. ministry of health, singapore. mitra, a.k., khoury, a.j., hinton, a.w., & carothers, c. (2004). predictors of breastfeeding intention among low-income women. matern. child health j. 8 (2), 65–69. doi: http://dx.doi.org/10.1023/b:maci.0 0 0 0 025728.54271.27. montoya arizabaleta, a.v., orozco buitrago, l., aguilar de plata, a.c., mosquer escudero, m., & ramirez-velez, r. (2010). aerobic exercise during pregnancy improves health-related quality of life: a randomised trial. j. physiother. 56 (4), 253–258. doi: http://dx.doi.org/10.1016/s18369553(10)70 0 08-4. neelakantan, n., whitton, c., seah, s., koh, h., rebello, s.a., lim, j.y., chen, s., chan, m.f., chew, l., & van dam, r.m. (2016). development of a semi-quantitative food frequency questionnaire to assess the dietary intake of a multi-ethnic urban asian population. nutrients. 8 (9) doi: http://dx.doi.org/10.3390/nu8090528. nisar, y.b., aurangzeb, b., dibley, m.j., & alam, a. (2016). qualitative exploration of facilitating factors and barriers to use of antenatal care services by pregnant women in urban and rural settings in pakistan. bmc pregnancy childbirth. 16 (42), 1–9. doi: http://dx.doi.org/10.1186/s12884-016-0829-8. nouer, s.s., ware, j.l., baldwin, k.m., hare, & m.e. (2015). changes in breastfeeding attitudes in a metropolitan community in tennessee. j. hum lact. 31 (3), 519-529. doi: http://dx.doi.org/10.1177/0890334 4155786 48. olmedo-alguacil, m.m., ramirez-rodrigo, j., villaverde-gutierrez, c., sanchez caravaca, m.a., aguilar ferrandiz, e., & ruiz-villaverde, a. (2015). health related quality of life, gender, and culture of older people users of health services in the multicultural landscape of the city of ceuta (spain): a cross-sectional study. j. transcult. nurs. 1–8. doi: http://dx.doi.org/10.1177/1043 659615597042. padmapriya, n., shen, l., soh, s.e., shen, z., kwek, k., godfrey, k.m., gluckman, p.d., chong, y.s., saw, s.m., & müller-riemenschneider, f. (2015). physical activity and sedentary behavior patterns before and during pregnancy in a multi-ethnic sample of asian women in singapore. matern. child health j. 19 (11), 2523–2535. doi: http://dx.doi.org/10.10 07/s10995-015-1773-3. persad, m.d., & mensinger, j.l. (2008). maternal breastfeeding attitudes: association with breastfeeding intent and socio-demographics among urban primiparas. j. commun. health. 33 (2), 53– 60. doi: http://dx.doi.org/10.10 07/s1090 0-0 07-90 6 8-2. radzyminski, s., & callister, l.c. (2016). mother's beliefs, attitudes, and decision making related to infant feeding choices. j. perinat. educ. 25 (1), 18– 28. doi: http://dx.doi.org/10.1891/10581243.25.1.18. roll, c.l., & cheater, f. (2016). expectant parents' views of factors influencing infant feeding decisions in the antenatal period: a systematic review. int. j. nurs. stud. 60, 145–155. doi: http://dx.doi.org/10.1016/j.ijnurstu.2016.0 4.011. saraswati, e. (1998). resiko ibu hamil kurang energi kronis (kek) dan anemia untuk melahirkan bayi dengan berat badan lahir rendah (bblr). jakarta: penerbit jawa barat. tsai, s.y., lee, p.l., lin, j.w., & lee, c.n. (2016). cross-sectional and longitudinal associations between sleep and health-related quality of life in pregnant women: a prospective observational study. int. j. nurs. stud. 56, 45–53. doi: http://dx.doi.org/10.1016/j.ijnurstu.2016.01.0 01. turcksin, r., bel, s., galjaard, s., & devlieger, r. (2014). maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review. matern. child nutr. 10 (2), 166–183. doi: http://dx.doi.org/10.1111/j.17408709.2012.004 3 9.x. jurnal ners http://e-journal.unair.ac.id/jners | 137 victora, c.g., bahl, r., barros, a.j., franca, g.v., horton, s., krasevec, j., murch, s., sankar, m.j., walker, n., & rollins, n.c. (2016). lancet breastfeeding series, g. 2016. breastfeeding in the 21st century: epidemiology, mechanisms, and life-long effect. lancet. 387 (10017), 475–490. doi: http://dx.doi.org/10.1016/s01406736(15)01024-7. wang, w., lau, y., chow, a., & chan, k.s. (2014). breast-feeding intention, initiation, and duration among hong kong chinese women: a prospective longitudinal study. midwifery. 30 (6), 678–687. doi:http://dx.doi.org/10.1016/j.midw.2013.07.0 15. ware, j.e., kolinski, m., & keller, s.d. (1995). how to score the sf-12 physical and mental health summaries: a user’s manual. the health institute, new england medical centre, boston, ma. world health organization. (2016). obesity and overweight. world health organization. http://www.who.int/mediacentre/factsheets/fs3 11/en/. (accessed : june 2, 2018) zahran, h.s., kobau, r., moriarty, d.g., zack, m.m., holt, j., & donehoo, r. (2005). health-related quality of life surveillance–united states, 1993– 2002. mmwr surveill. summ. 54 (4), 1–35. zhou, q., younger, k.m., & kearney, j.m. (2010). an exploration of the knowledge and attitudes towards breastfeeding among a sample of chinese mothers in ireland. bmc public health. 10 (722), 1–11. doi: http://dx.doi.org/10.1186/1471-2458-10-722. zubaran, c., & foresti, k. (2011). the correlation between breastfeeding and maternal quality in southern brazil. breastfeed. med. 6 (1), 25–30. doi: http://dx.doi.org/10.1089/bfm.2010.0 017. http://www.who.int/mediacentre/factsheets/fs311/en/ http://www.who.int/mediacentre/factsheets/fs311/en/ http://e-journal.unair.ac.id/jners | 87 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.8148 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research demographical factors, not lifestyle factors, associated with the increase of random blood glucose in coastal areas nilam yusika sari, susy k. sebayang, septa indra puspikawati, desak made sintha kurnia dewi, ayik m. mandagi and erni astutik faculty of public health, universitas airlangga, banyuwangi, indonesia abstract introduction: blood glucose is an important component in the body produced by the consumption of carbohydrates, proteins, and fats. a blood glucose imbalance causes an increase in the blood glucose level in the body. the occurrence of economic changes due to tourism may lead to a change in diet that can lead to increased blood glucose levels. this study aims to analyse the factors related to random blood glucose in people living in coastal tourism areas in banyuwangi methods: the study used a cross-sectional survey. a total of 112 respondents were recruited using the random sampling method, using two-stage cluster sampling techniques taken from the head of household data in multiple villages. the factors studied included demographic, socioeconomic, lifestyle, and family health history. results: the results showed that men had 28% higher random blood glucose compared to woman. people living in bangsring had 31% higher random blood glucose compared to those in buluagung. conclusion: local health care services should put extra effort into include men and those living in bangsring in programs to prevent diabetes mellitus in coastal areas. article history received: april 19, 2018 accepted: june 22, 2018 keywords random blood glucose; coastal area; tourism contact erni astutik erniastutik@fkm.unair.ac.id  faculty of public health, universitas airlangga, banyuwangi, indonesia cite this as: sari, n., sebayang, s., puspikawati, s., dewi, d., mandagi, a., & astutik, e. (2018). demographical factors, not lifestyle factors, associated with the increase of random blood glucose in coastal areas. jurnal ners, 13(1), 87-92. doi:http://dx.doi.org/10.20473/jn.v13i1.8148 introduction diabetes mellitus is now a serious health problem in the community. this disease has become a burden on a global level. since 2000, the world health organisation (who) estimated that asia would become the continent with the world's largest number of diabetes mellitus sufferers, reaching 82 million people. the number would continue to increase for the next 25 years (sucipto, 2012). meanwhile, diabetes mellitus prevalence in indonesia had increased by 1% from 2007 to 2013. the three provinces with the highest frequency of diabetes mellitus are yogyakarta, jakarta and north sulawesi (fehni et al., 2017). people with random blood glucose are at a higher risk of developing diabetes mellitus. uncontrolled diabetes mellitus disease can have both long-term and short-term effects that are harmful to overall health. long-term effects that may occur include the emergence of other degenerative diseases, such as heart disease, stroke, nerves, kidneys, and other health disorders. meanwhile, in the short term, diabetes mellitus causes visual disturbances, fatigue, frequent thirst, and increased urination (arif, 2014). in addition, this disease can affect quality of life. efforts to manage living with diabetes mellitus are not easy and can even cause stress, triggered by the fear of complications (american diabetes association, 2000). the increase of diabetes mellitus is not only happening in urban areas, but also in rural, coastal and tourism areas. tourism indirectly affects the health of the community living near to the tourism destination. influential factors such as age, sex, education, occupation, lifestyle, and health history play an important role. this needs to be resolved and a solution found in order to maintain optimal public health status. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i1.8148 n. y. sari et al. 88 | pissn: 1858-3598  eissn: 2502-5791 there are many items of literature that have analysed the determinants of high blood glucose. a study conducted by sudaryanto (2014) states that those with a family health history of high blood glucose levels had a 25-fold chance of the incidence of type ii diabetes mellitus in the working area of the community health centre of nusukan, banjarsari. in addition, there was also a relationship between age and the incidences of diabetes mellitus in the community health centre of nipah panjang east jabung regency, with those aged > 45 years having the highest risk (erris, 2015). a study conducted by wicaksono (2011) showed that those who were overweight respondents had double, those with smoking habits had triple, and those with bad dietary pattern had double the risk of developing type ii diabetes mellitus. however, studies on the determinant of high blood glucose level in coastal tourism areas in indonesia are scarce. this has become an important problem, considering the increasing number of coastal tourism destinations. economic improvements in the coastal tourism areas may change dietary patterns and lifestyle, and thus increase the overall blood glucose level of the community. therefore, this study assessed the determinants of elevated blood glucose levels in people living in coastal tourism areas in banyuwangi, which included demographic, socioeconomic, lifestyle, and family history factors. materials and methods this study analysed the data taken from the results of a cross-sectional survey that assessed the factors related to metabolic syndrome in people living in coastal tourism areas in banyuwangi. the survey was conducted from september to november 2016. the survey was approved by the ethics committee of the faculty of public health, universitas airlangga. sampling two-stage cluster sampling was employed in order to select the participants. participating subdistricts included all of the 5 sub-districts with coastal tourism destinations in banyuwangi. of the 52 villages in the participating sub-districts, 22 villages had a coastline and thus fell within the selection criteria. based on this, 5 villages were randomly selected to become the study locations: kampung mandar (banyuwangi sub-district), ketapang (kalipuro sub-district), grajagan (purwoharjo subdistrict), bangsring (wongsorejo sub-district), and buluagung (siliragung sub-district). a sample of 112 respondents were randomly selected from a list of heads of the household. the inclusion criteria were that the participants were within the age range of 18 – 59 years old, and looked healthy. the number of samples was sufficient enough to detect a 67% difference in the proportion of the determinants of elevated blood glucose levels with a 5% error, 90% power, 2 design effects and 25% rejection probability (lemeshow et al, 1990). data collection the data was collected by trained officers consisting of students with a public health science background who had taken at least 3 semesters of university-level education. blood collection was done by a trained nurse using accu check. anthropometric measurements were performed by the students using seca 213 for stature and seca 869 for the scales. the participant’s mental and emotional status was measured using a self-reported questionnaire used by the national survey in indonesia (basic health research, 2007). the research questionnaire was tested for validity and reliability in kepatihan village in banyuwangi district on october 1st, 2016. the cronbach alpha was 0.72. the questionnaire was found to be valid as the r count was greater than the r table. data analysis the dependent factor in this study was random blood glucose. this was transformed using log transformation because the distribution was skewed to the right. the independent factors consisted of demographic factors (age, sex, location), socioeconomic factors (education level, occupation, socioeconomic status), lifestyle factors (smoking habit, stress level and nutritional status) and family health history, which included any one of the three following diseases: diabetes mellitus, high blood pressure, and obesity. the demographic factors included age, sex, and location. age was categorised into: young (<43 years) and old (≥43 years) based on the median value. sex was divided into men and women. the location of the research were the five aforementioned study locations. the socioeconomic factors included levels of education: low (no school, not finished primary school, finished primary school), medium (finished junior high school or high school), and high (had higher education). occupation was categorised into not working and working. wealth status was obtained using a principal component analysis of the respondent’s asset ownership and was grouped into very poor, poor, medium, rich, and very rich. lifestyle factors included smoking habits (smoking and nonsmoking), as well as mental-emotional status score: low (value <6) and high (value ≥6); and nutritional status: normal (bmi <24.9) and overweight (≥25). family health history was divided into their relatives having at least one history of disease and not having any history of hypertension, obesity, and diabetes mellitus. bivariate and multivariate analysis was done using a linear regression test. the factors that have an association with blood glucose level with p < 0.25 jurnal ners http://e-journal.unair.ac.id/jners | 89 were included in the multivariate analysis. the final regression model was selected using a backward elimination technique. the assumption for regression was also tested. results the study was conducted with the participation of 112 respondents, 99.1% of which had breakfast before their blood was drawn.the results showed that 52.7% of the respondents were ≥ 43 years old. more than half of the respondents were women (59.8%) and the largest number of respondents came from bangsring (26.8%). the least number came from buluagung (16.1%). most of the respondents had a medium level of education, i.e. they had attended junior and senior high school (61.6%) and most of the respondents worked (58.9%). for the lifestyle factors, most of the respondents did not smoke (81.3%) and 25.9% had a high-stress level. in addition, most of the respondents were overweight (80.4%). when viewing the family health history, 75% of the respondents did not have any history of health problems associated with increased blood glucose in their family (table 1). based on the bivariate analysis, age, gender, location, education, and social economy were associated with random blood glucose with a p-value <0.25. after backward elimination was conducted in the multivariate analysis, sex and location had a significant relationship with increased random blood glucose. age was maintained in the final model because of its confounding with gender. when we used age as a continuous variable, the association remained insignificant. after adjustment for the covariates, the male respondents had 28% higher blood glucose levels than the women (95% ci: 10.5 – 49.2, p < 0.001).the respondents in bangsring had 31% higher blood glucose levels than those in buluagung (95% ci: 5.1 – 61.6, p = 0.02). discussion our study showed that there was a significant relationship between increased random blood glucose levels and the demographic factors table 1. characteristics of respondents factor frequency percentage (%) means (log blood glucose) demographic factors age young < 43 years 53 47.3 4.63 old ≥ 43 years 59 52.7 4.79 sex female 67 59.8 4.60 male 45 40.2 4.89 location buluagung 18 16.1 4.56 kampung mandar 19 17 4.80 ketapang 21 18.8 4.78 bangsring 30 26.8 4.77 grajagan 24 21.4 4.64 socio-economy factors level of education low 27 24.1 4.64 medium 69 61.6 4.70 high 16 14.3 4.92 work not working 46 41.1 4.70 working 66 58.9 4.73 social economy very rich 20 17.9 4.62 rich 21 18.8 4.70 medium 26 23.2 4.75 poor 21 18.8 4.77 very poor 24 21.4 4.76 life style factors smoking smoking 21 18.8 4.72 non-smoking 91 81.3 4.69 stress level high >=6 29 25.9 4.69 low <6 83 74.1 4.72 nutritional status based on imt normal 42 37.5 4.70 overweight 70 62.5 4.72 family health history factors with history 28 25.0 4.70 no history 84 75.0 4.72 n. y. sari et al. 90 | pissn: 1858-3598  eissn: 2502-5791 represented by sex and the location of the study, but not with socioeconomic status, lifestyle, or family health history. the male respondents had higher random blood glucose levels compared to women, and those living in bangsring village had higher random blood glucose levels than those living in buluagung. our results showing that men had more elevated blood glucose levels compared to women, which is not in line with the research conducted by wicaksono (2011) and tjekyan in the palembang municipality (2010). another study showed that women experience more dramatic changes in relation to hormones and their bodies due to the reproductive factors that fluctuate over the duration of their lifetime. therefore, women have higher blood glucose levels than men (willer, et al., 2016). in addition, another study focused on the coastal area of india showed that women had a 1.4 times greater risk of mild diabetes (rao et al., 2010), which is different from our results. however, in line with our study, ohtaet al. (2014) showed that increased levels of blood glucose characterised by hyperglycemia occurred faster in male compared to female rats. we cannot offer an explanation as to why men had higher blood glucose level compared to women in our study, other than the possibility of having a higher food intake during breakfast. those living in bangsring had higher blood glucose levels compared to buluagung. although not statistically significant, those living in ketapang and kampung mandar also had similar estimates to bangsring. two possible explanations for this was that people in these villages depend more on fishing and have a lower socioeconomic status. the lack of association between random blood glucose and lifestyle may indicate that the lifestyle factors may not have changed much within this particular community. to date, this is the first study on random blood glucose level focused on the coastal areas of banyuwangi. the advantages of this study are that we assessed various determinants, including the demographic, social economy, lifestyle, and family health history factors. the study, however, did not measure fasting and two hours post-prandial blood glucose level. therefore, it is not known with certainty the tendency for diabetes mellitus. however, random blood glucose tests were been used table 2. determinants of increased random blood glucose levels factors category coef. 95% ci p value adjusted coefficient 95% ci p value demographic factors age < 43 years ref ref ≥ 43 years 0.17 0.02 – 0.31 0.03 0.12 -0.04 – 0.27 0.13 sex female ref ref male 0.29 0.15 – 0.43 0.00 0.25 0.10 – 0.40 0.00 location buluagung ref ref kampungmandar 0.24 -0.01 – 0.49 0.06 0.23 -0.10 – 0.46 0.06 ketapang 0.22 -0.03 – 0.47 0.08 0.20 -0.03 – 0.43 0.08 bangsring 0.20 -0.02 – 0.43 0.08 0.27 0.05 – 0.48 0.02 grajagan 0.08 -0.16 – 0.32 0.50 0.07 -0.15 – 0.29 0.54 socio-economy factors level of education low ref medium 0.06 -0.11 – 0.24 0.49 high 0.29 0.05 – 0.53 0.02 work not working ref working 0.02 -0.13 – 0.17 0.80 social economy very rich ref rich 0.08 -0.15 – 0.32 0.49 medium 0.13 -0.09 – 0.35 0.24 poor 0.16 -0.08 – 0.39 0.19 very poor 0.13 -0.09 – 0.38 0.28 life style factors smoking smoking ref non smoking 0.05 -0.15 – 0.24 0.64 stress level high >=6 ref low <6 0.03 -0.13 – 0.20 0.69 nutritional status based on imt weigt ref overweight 0.02 -0.13 – 0.17 0.80 family health history factors with history ref no history 0.03 -0.15 – 0.20 0.77 jurnal ners http://e-journal.unair.ac.id/jners | 91 to screen for diabetes mellitus. in addition, the study did not measure food intake and thus, we could not take into account this important factor as a possible determinant. the results showed that men and those living in bangsring village may need extra attention when it comes to diabetes mellitus prevention programs. a previous research study showed that more women in the community sought access to the available health care services compared to men (sebayang, 2017). the large number of men with potential diabetes mellitus may neglect their health, and this must be addressed immediately. one thing that can be done is to optimise the implementation of posbindu ptm (integrated non-communicable disease management post) for both women and men with anthropometric measurements, blood pressure measurements, blood glucose checks, cholesterol checks and health counselling regularly and periodically, especially for those living in bangsring. future studies need to look for changes in food intake in this community and to assess its possible impact on health. conclusion research conducted in the coastal tourism areas of banyuwangi showed that demographic factors had a significant association with elevated random blood glucose levels in the male respondents. those living in bangsring also had a higher random blood glucose. the health care system should make an extra effort to include men and those living in bangsring in their diabetes mellitus prevention program. references badan pusat statistik kabupaten banyuwangi. (2014). banyuwangi dalam angka tahun in figures 2014. banyuwangi: bps kabupaten banyuwangi. badan penelitian dan pengembangan kesehatan kementrian kesehatan ri. (2013). riskesdas biomedis: riset kesehatan dasar 2013. pdf dolongseda, f.v. dkk. (2017). hubungan pola aktivitas fisik dan pola makan dengan kadar gula darah sewaktu pada pasien diabetes mellitus tipe ii di poli penyakit dalam rumah sakit pancaran kasih gmim manado. journal keperawatan (e-kp). volume 5 nomor 1, februari 2017. erris. (2015). faktor risiko kejadian diabetes mellitus di wilayah kerja puskesmas nipah panjang kabupaten tanjung jabung timur tahun 2015. scientia journalstikes prima jambi. nomer 3 volume 4 desember 2015.. kurniawan, i. (2014). hubungan antara indeks masa tubuh dengan kadar gula darah prospandial pada anggota kepolisian resor karanganyar. naskah publikasi ilmiah fakultas kedokteran universitas muhammadiyah surakarta. kusuma, b.m.a. (2014). pembangunan terintegrasi dalam mewujudkan kota pariwisata bertaraf internasional: studi kasus di kabupaten banyuwangi jawa timur. jkmp (issn. 2338-445x) volume 2 nomer 2 september 2014 halaman 103220. kementrian kesehatan republik indonesia. (2014). infodatin: situasi dan analisis diabetes. jakarta selatan: pusat data dan informasi kementrian kesehatan republik indonesia. laila, alfi, dkk. (2017). analisis faktor-faktor risiko kejadian katarak di daerah pesisirkendari. ___. volume 4 nomor 2 bulan april 2017 issn: 23391006. lanywati, e. (2001).diabetes mellitus penyakit kencing manis.yogyakarta: penerbit kanisius. murdiyatmoko, j. (2007). sosiologi: memahami dan mengkaji masyarakat. bandung: pt. grafindo media pratama. nugroho, dkk. (2010). hubungan antara tingkat stress dengan kadar gula darah pada pasien diabetes mellitus di wilayah kerja puskesmas sukoharjo i kabupaten sukoharjo. ______ (diakses pada tanggal 26 desember 2017). ohta, dkk. (2014). gender differences in metabolic disorder and related diseases in spontaneously diabetic torii-leprfarats.journal of diabetes research. website: https://www.ncbi.nlm.nih.gov/pmc/articles/pm c4033479/ (accessed : march 01,2018). pangkalan ide. (2007). diet south beach: gendut, no way! kurustapiberesiko? nggak-lah. aduhai tanpa diabetes sih oke. jakarta. pt. elex media komputindo kelompok gramedia. isbn: 78-97927-0203-3. prabowo, dkk. (2015). hubungan pendidikan dan dukungan keluarga dengan kepatuhan diit pada penderita diabetes mellitus di wilayah puskesmas plosorejo giribangun matesih kabupaten karanganyar. _______. program studi diploma iii ilmu keperawatan sekolah tinggi ilmu kesehatan pku muhammadiyah surakarta. rao, dkk. (2010). a study on the prevalence of type 2 diabetes in coastal karnataka. int j diabetes ctries, 30. diakses pada tanggal 23 juni 2018. website: https://www.ncbi.nlm.nih.gov/pmc/articles/pm c2878695/(accessed : march 01,2018). salami. (2017). faktor sosiodemografi dan self efficacy penderita diabetes mellitus tipe 2 (study pada peserta prolanis) di puskesmas talaga bodas bandung. medika cendikia. volume 4 nomer 1 2017. sudaryanto. dkk. (2014). hubungan antara pola makan, genetik dan kebiasaan olahraga terhadap kejadian diabetes mellitus tipe ii di wilayah kerja puskesmas nusukan, banjarsari. prosiding snst ke-5 tahun 2014 fakultas teknik universitas wahid hasyim semarang isbn 978602-99334-3-7. sebayang, s. k., dkk. (2017). health care-seeking behaviour of coastal communities in banyuwangi, indonesia: results of a cross-sectional survey. jurnal ners, 12 (1), pp.66-73. tjekyan dan suryadi. (2014). angka kejadian dan faktor risiko diabetes mellitus tipe 2 di 78 rt https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4033479/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4033479/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2878695/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2878695/ n. y. sari et al. 92 | pissn: 1858-3598  eissn: 2502-5791 kotamadya palembang tahun 2010. mks. tahun 46 nomer 2, april 2014. wijayakusuma, m. hembing. (2004). bebas diabetes mellitus ala hembing. jakarta: puspaswara. wicaksono, r.p. (2011). faktor-faktor yang berhubungan dengan kejadian diabetes mellitus tipe 2(studikasus di poliklinik penyakit dalam rumah sakit dr.kariadi). skripsi. program pendidikan sarjana kedokteran fakultas kedokteran universitas diponegoro. wiyadi, dkk. (2013). hubungan tingkat kecemasan dengan kadar gula darah pada penderita diabetes mellitus. jurnal husada mahakam. volume iii nomer 6 nopember 2013 halaman 263318. willer, dkk. (2016). sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus. journal endocr rev, 37, pp.278-316. diakses pada tanggal 23 juni 2018. website: https://www.ncbi.nlm.nih.gov/pmc/articles/pm c4890267/(accessed : march 01,2018). wulandari, dkk. (2013). perbedaan kejadian komplikasi penderita diabetes mellitus tipe 2 menurut gula darah acak. jurnal berkala epidemiologi. volume 1 nomer 2 september 2013 halaman 182–191. yanita, dkk. (2016). faktor-faktor yang berhubungan dengan kejadian diabetes mellitus tipe ii. majority. volume 5 nomer 2 april 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4890267/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4890267/ 225 the elderly’s satisfaction with the service quality of a community geriatric health programme in indonesia: a crosssectional study nursalam nursalam, mochamad cholid hanafi, elida ulfiana faculty of nursing, universitas airlangga e-mail: cholidcoy@gmail.com abstract introduction: the achievement of the geriatric health programme is still under a number of government targets and the research about the satisfaction of elderly in contributing to this program still limited. this study aims to identify the correlation between the service quality of a geriatric health programme in the community with the satisfaction of older adults. methods: the research design was cross-sectional and involved 277 elderly people as the respondents. the service quality was measured using a service quality (servqual) questionnaire with three different sub-variables of input, process and outcome. the elderly people’s satisfaction was examined using several parameters including reliability, assurance, tangibles, empathy and responsiveness (rater). the data obtained from the questionnaires was analysed using the spearman rho test with a significance level of <0.05 to determine the correlation between the variables. results: good service quality provided satisfaction among the elderly. the spearman rho test result for input quality was p = 0.000 with a correlation coefficient of 0.705, while the test result for process quality was p = 0.000 with a correlation coefficient of 0.750. the outcome quality was p = 0.000 with a correlation coefficient of 0.766. the results showed that there is a relationship between the independent and dependent variables. conclusions: good service quality regarding the input, process and output of the service can enhance the satisfaction levels of the elderly. this study can be referred to as a parameter and evaluation for the phc to maintain and improve the service quality standards for the elderly. key words: community, elderly, geriatric health programme, satisfaction, service quality introduction indonesia has a programme for the elderly in the community named pos layanan terpadu lansia or an integrated health service post for the elderly (ihspe). this programme aims to improve elderly people’s quality of life and well-being. the service quality of ihspe is significantly important in order to enhance the satisfaction of the elderly; higher service quality will lead to higher satisfaction levels perceived by the elderly. according to badan penelitian dan pengembangan kesehatan (bppk) (2012), the number of public health centres (phcs) that have implemented the comprehensive geriatric health programme encompassing promotive, preventive, curative and rehabilitative care from the level of family and society to the secondary or advanced level was only 42.3%. the low number of phcs implementing the programme was caused by several problems including the unavailability of standardised human resources, facilities, documentation and the reporting system of the geriatric health service as well as the multi-programme coordination, which was not been optimal for maintaining the health of elderly people (permenkes nomor 2, 2016). in 2015, the coverage of the geriatric health programme in the central java province was only 52.83%, with the lowest prevalence in cilacap regency reaching only 9.21%, which is far from the minimum service standard target of 60% (dinas kesehatan provinsi jawa tengah, 2016). the coverage of the programme in surabaya city was 68.31% in 2015 out of a total population of 219,164 elderly people (dinas kesehatan kota surabaya, 2016). the low results were caused by several factors including facilities, type of activities, human resources and the distance from the elderly individuals’ houses to the ihspe location (herdining wp 2013). customer satisfaction is a factor that strongly determines the service marketing; otherwise, customer dissatisfaction will lead to low service quality standards in the future (kotler & kevin lane k, 2009). a study conducted in rembang, central java province, in 2015 showed that 77.6% of the respondents were dissatisfied with the ihspe programme, which was provided by the phc (rizqiana a, 2015). in jember, the dissatisfaction prevalence was 34.38%, while in surabaya it was 46.20% (dony s, 2013; uswatun h, 2012). an initial study conducted by researchers showed that pucang sewu had 5,673 elderly, who were divided into 13 ihspe programmes. however, the achievement of the geriatric health programme from the phc was mailto:cholidcoy@gmail.com jurnal ners vol. 12 no. 2 oktober 2017: 225-232 226 3,030 people or only 52.22% of the total population of the elderly, which is still under the minimum service standard targeted by surabaya city municipality, which reached 70%. the interviews were performed with elderly people involving questions around the service quality of the three ihspes, including the ihspes of bratang, kertajaya, and pucang, in which 8 of 10 respondents expressed their dissatisfaction with the activities of the ihspe. the dissatisfaction levels were caused by the activities, which were held in a narrow place, with limited seats and parking. on the other hand, the health care provider from the phc only attended once a month, with the rest of the activities being handled by the cadres. of the total number of elderly people registered in the ihspe, the attendance rate was only 60-70, which means that 30-40% of the elderly did not attend the ihspe’s activities. satisfaction is a feeling of pleasure or displeasure that comes from a comparison between the impression of a performance or the results of a service and the expectation of it. if the impression is lower than the expectation, then the clients will be dissatisfied, which leads to them becoming reluctant to revisit the service and to seek another service provider. in contrast, if the impression meets their expectation or is higher than it, then the clients will be satisfied or even strongly satisfied, which tends to attract the clients’ loyalty (lupiyopadi, 2009). in the case of the service quality of the ihspe, if the ihspe ignores its clients’ level of satisfaction, the dissatisfaction will increase, and their attendance rate will decrease. according to pusat data dan informasi kemenkes ri (2013), 52.12% of the elderly on average complain about their health condition, comprising of 50.22% men and 53.74% women. based on the data, the phc as a health care provider on the first level is expected to provide high-quality health services to the elderly, using the ihspe to maintain independence, productivity and health among the elderly. according to the data, the researchers are interested in studying the relationship between elderly people's satisfaction levels and the service quality of the ihspe in the pucangsewu district, surabaya. materials and methods the study used a cross-sectional design with the cluster sampling method. a total of 1144 elderly people from the 13 ihspes of the pucangsewu district, surabaya, were randomly selected. 10 ihspes with a total membership number of 887 elderly, were then recalculated to 277 elderly individuals as the sample. the data was analysed using rank spearman, with a significance level of p <0.05. the service quality was calculated from the reduction of the expectation value average to the realisation value average. the level of expectation was measured using a four-point likert scale, from 1 (“not important”) to 4 (“very important”), while the realisation was measured using a likert scale from 1 (“very bad”) to 4 (“very good”). a final score of 1-3 means “excellent”, 0 means “fair” and (-1)-(-3) means “poor”. the satisfaction level was calculated from the percentage of the total score to the maximum score. a percentage of 80100% means “high”, 60-79% means “moderate” and <60% means “low”. the score was measured using a four-point likert scale, from 1 (“very dissatisfied”) to 4 (“very satisfied”). the ethical clearance of this study has been assessed and verified by the ethical committee of the faculty of public health universitas airlangga with approval letter no. 263-kepk. the ethical principles applied in this study include the principles of beneficence, respect for human dignity, right to justice and right to freedom. results a total of 215 respondents (77.6%) rated the input as excellent, and 232 respondents (83.3%) also rated the process as excellent (table 1). a total of 193 people (69.7%) perceived a moderate level of satisfaction for the dimension of reliability and 184 people (66.4%) also perceived the level of satisfaction with responsiveness as being moderate (table 2). based on spearman's rho test for the quality of input, the p-value = 0.000 (<0.05) and r = 0.705, which means that h1 is accepted, in which there is a strong correlation between the quality of input and the satisfaction of the elderly. for the quality of process, the p-value = the elderly’s satisfaction with the service quality... (nursalam nursalam et.al) 227 0.000 (<0.05) and r = 0.750, which means that h1 was accepted, in which there was a strong correlation between the quality of the process and the satisfaction of the elderly. meanwhile, the quality of the outcome had p-value = 0.000 (<0.05) and r = 0.766, which means that h1 was accepted, in which there was a strong correlation between the quality of the outcome and the satisfaction of the elderly (table 3). discussion according to the study, there is a strong correlation between the quality of process and the satisfaction of the elderly. in the quality service process, 147 respondents (53.1%) perceived that the process quality was excellent, with a fair level of satisfaction. the service quality process of the ihspe is a process of interaction between the elderly and the phc’s officers, as well as with the cadres by providing services according to their professional knowledge, considering the values believed by each elderly person. the assessment of the quality process was based on the first question in the questionnaire regarding patient safety, in which the officers always disposed of the used needles in the safety box prepared by the officers after blood sugar and cholesterol checking, so that it would not cause any harm to the elderly after the check-up. question number 2 and the satisfaction questionnaire question numbers 3 and 4 were about the dimensions of reliability and assurance, while question number 5 was about the information delivery from the cadres and the officers when conducting health education and promotion activities. the elderly are always involved in determining the theme for the promotion by their needs; thus, they will have aims when coming to the programme. the point of question number 3 in the process quality questionnaire and number 2 in the satisfaction table 1. cross tabulation between service quality of ihspe and satisfaction level of elderly sub variable service quality satisfaction level total (%) category frequency percentage category frequency percentage input excellent 215 77.6 high 83 30.0 100.0 moderate 132 47.7 low 0 0 fair 36 13.0 high 3 1.1 moderate 33 11.9 low 0 0 poor 26 9.4 high 0 0 moderate 0 0 low 26 9.4 process excellent 232 83.8 high 85 30.7 100.0 moderate 147 53.1 low 0 0 fair 19 6.9 high 1 0.4 moderate 18 6.5 low 0 0 poor 26 9.4 high 0 0 moderate 0 0 low 26 9.4 outcome excellent 136 49.1 high 80 28.9 100.0 moderate 56 20.2 low 0 0 fair 115 41.5 high 6 2.2 moderate 109 39.4 low 0 0 poor 26 9.4 high 0 0 moderate 0 0 low 26 9.4 jurnal ners vol. 12 no. 2 oktober 2017: 225-232 228 questionnaire in the assurance dimension relates to the honesty of officers in conveying the check-up results to the elderly people and the satisfaction questionnaire in the responsiveness dimension was an indicator of the excellent service in the service process of the ihspe. the results of the check-up were always conveyed honestly to the elderly about their health condition and further examination if necessary, either in the phc or hospital. the officers also explained what kind of services would be could be conducted in the hospital for the elderly so that they would understand the limitations of the service and would not have inflated expectations of the health services in the ihspe. the quality of input question number 5 was about the manners and appearance of the cadres of the ihspe programmes; all of the health cadres always show good manners and communicate well with the elderly in the ihspe programme. the results of this study correspond with those of the study conducted by desi suci (2014) in jakarta, which showed that the majority of the respondents stated that the cadres were well-behaved in the ihspe programmes, paid attention to the elderly, were friendly, and invited the elderly to communicate with them. these results show that the elderly were satisfied with the performance of the ihspe cadres. parasuraman in nursalam (2015) described the assurance dimension in the concept of the service quality rater, whereby a service provider organisation guarantees that the service quality will provide satisfaction and high work commitment in accordance with the form of the work integration, work ethic, and work culture according to the vision and mission of the organisation in order to convince people about their service and performance. the quality of process questionnaire number 3 and satisfaction questionnaire of assurance dimension number 3 and reliability dimension number 5 contained the accuracey and skill of the officers in providing ihspe services, which means that the officers delivered satisfaction to the elderly by showing their skills in medical examination and treatment by providing the appropriate prescription and drugs to the elderly in accordance with the results of the examination so the elderly perceived the officers as having given a good performance. question number 7 in the quality questionnaire and satisfaction questionnaire in assurance dimension number 4 was about the disadvantages arising from the ihspe towards the elderly. during the ihspe activities, the elderly have never felt disadvantaged, either morally or materially. officers were always well-behaved when interacting with the elderly, such as using polite word choices and making no distinction regarding grade, class, religion, or ethnicity so that the elderly people felt the officers respected them according to the question number 5 and 6 in the service quality process questionnaire. the results correspond with those of donnabedian in nursalam (2015). the aims of iso 9001: 2000 ensures the suitability of the service process about the requirements that are specified by the customer and agency service table 2. frequency distribution based on satisfaction dimension of the elderly in the ihspe quality dimension satisfaction level low % moderate % high % reliability 11 4.0 193 69.7 73 26.4 assurance 28 10.1 151 54.5 98 35.4 tangible 32 11.6 141 50.9 104 37.5 empathy 31 11.2 153 55.2 93 33.6 responsiveness 18 6.5 184 66.4 75 27.1 table 3. data tabulation of correlation between service quality and elderly’s satisfaction quality r correlation strength p results input 0.705 strong 0.000 significant process 0.750 strong 0.000 significant outcome 0.766 strong 0.000 significant the elderly’s satisfaction with the service quality... (nursalam nursalam et.al) 229 providers to maintain the principles of ethics; namely beneficence, non-maleficence, respect and justice in providing the services. in the quality of the process, 26 respondents (9.4%) answered that the process was poor with low satisfaction. the low rating was a result of the services received being lower than the expectation. the elderly were not satisfied regarding the empathy dimension and their complaints about health problems to the cadre and their solution, as reported in the questionnaire of the quality of process number 8 and 9, as well as the questionnaire of empathy satisfaction numbers 1, 3, 4, and 5. these problems happened because of the limited number of officers who have to serve all of the elderly people in the location. some of the elderly people did not have the opportunity to consult about their health problems. these results correspond with those in the study conducted by anggri (2011), in which the respondents stated that they were less satisfied with the level of empathy performance and the public service because the cadres often did not pay attention to the elderly person’s needs and did administrative work instead. another study, conducted by wulansari (2015), stated that the good service and patience of the cadres in dealing with the elderly were two of the factors leading to high satisfaction levels among the elderly in the ihspe programmes, as they perceived that the benefits of the ihspe programme that can help to maintain their health condition. the gap in servqual theory, according to nursalam (2015), is a gap between the quality specifications and service delivery, whereby the service standard and delivery are in good order, but the front-line staff have not received specific training on the delivery of the services, which has caused the gap. it prevented the service from meeting the standards set by the service provider. some organisations have to adapt to the satisfaction preference of their clients as well as to the best effort that they can provide (nursalam,2015). in providing the services, the ihspe must correspond with the job commitment by performing attractive, convincing and trustworthy behaviour as well as the actualisation and reflection of the job performance. it can be achieved including competence in the form of the skills and knowledge possessed by the employees to perform the services; courtesy, including hospitality, the attention and attitude of the employee and then credibility encompassing matters related to the trust towards the company, such as reputation, achievements and any other matters. based on demographic data, nearly half of the elderly people’s education level was primary school, amounting to 133 respondents (48.0%). the education level of the elderly could affect quality perception in the information transmitted by the officers which could have an impact on the level of satisfaction towards the information received by the elderly. the results were in line with the study conducted by kristina b w (2015), who found that education level could affect the level of the understanding of the respondents about the information received by them. with higher education, the elderly could obtain more information, both from other people and from the media. if they obtained more information, they would also obtain more knowledge. a high level of education also makes it easier for them to access information, so it would improve their competence in performing tasks and have an impact on quality improvement in providing an assessment of the information. this study has showed that there is a strong correlation between the quality of the outcomes and the satisfaction of the elderly. 109 respondents (39.4%) perceived that the quality of outcomes was excellent, with a moderate level of satisfaction. the outcome is a result of the services provided by the service provider institutions, in the form of changes perceived by the consumers including their satisfaction. in the quality of outcomes questionnaire, question numbers 2 and three about clean and healthy lifestyle behaviour gave an indicator of the success of the quality outcome, in which the elderly had adopted a clean and healthy lifestyle and conducted physical activities for maintaining their health. there were 26 respondents (9.4%) who perceived a poor quality level of outcome with a low level of satisfaction. these low results were caused by the outcome that the ihspe could not jurnal ners vol. 12 no. 2 oktober 2017: 225-232 230 provide satisfaction to the elderly, as the service received by them was lower than their expectation about the quality of outcomes. the quality of outcome questionnaire question number 1 about blood pressure and blood glucose condition was one factor to do with the low rating of service quality of the ihspe outcome. the elderly people who come upon the ihspe treatment activities will be reliant on medication to maintain their blood glucose level and blood pressure. some health promotion activities that are held in the ihspe educate the elderly people about how to control their blood pressure and blood glucose levels in other ways besides medication, such as a healthy diet, physical activities, stress management and routine control. the expectation of the elderly about their treatment and medication in the ihspe can lead to them providing a poor assessment of the quality level because they may not understand that there is another alternative to keep their blood glucose and blood pressure under control due to their absence in several ihspe sections. these results support the research conducted by kristina b w (2015), who found that respondents with less experience in ihspe activities have less appreciation of the benefits of ihspe activities, and end up giving a low rating because of their negative attitude. based on the demographic data, most of the elderly still had routine activities or work numbering 186 respondents (67.1%). one factor preventing the respondents from attending the ihspe routinely was their routine activity; for example, working as traders, either in the home or at a market. the elderly assumed that their activities were more important than coming to the ihspe because they had no financial benefits from the ihspe so could not establish a positive attitude. the results of this study support hutabarat (2012)’s statement that the respondents who gained a benefit from the ihspe showed a positive attitude because of their good experience towards the benefits they perceived, so the elderly stated that the ihspe was very important for both healthy and sick elderly people. among the respondents who did not benefit from the ihspe, most had a negative attitude towards ihspe. they assumed that ihspe activities were not useful because the doctors never performed a medical check-up. this result corresponds with those of a study conducted by zarniyeti (2011), which stated that the respondents who benefited from ihspe had a more positive attitude towards the ihspe activities compared to the respondents who did not benefit from ihspe, causing a negative attitude towards the existing services of the ihspe. personal experience could affect someone’s attitude; something that has previously happened or is currently happening in our lives will influence our appreciation of the stimulus. little or no experience of an object tends to form a negative attitude towards the object (anwar, 2008). elderly people who rarely come to the ihspe activities and only come during treatment activities are likely to show a negative attitude towards the ihspe activities because they cannot perceive the benefit of the ihspe activities. some of the elderly people just came because of necessity, for a health check-up and for the treatment of their disease. this is in line with parasuraman’s statement in nursalam (2015), that the rating related to the quality and satisfaction depends on the personal needs in which the customers’ expectations vary, depending on the individual’s characteristics and the circumstances that affect their personal needs. elderly people who only expect treatment in the ihspe are likely to provide a low rating for the quality of the other ihspe activities besides the medical check-up and treatment, and do not perceive any benefit (outcomes) resulting from the ihspe overall. conclusions the service quality among the three subvariables encompassing input, process, and outcome could determine the elderly people’s level of satisfaction towards the ihspe service. the good quality of input increases the elderly people’s satisfaction through the development of human resources, cost and facilities as well as the implementation of modern technology in the ihspe service. a good quality of process can increase the elderly person’s satisfaction through upholding service ethics encompassing a good attitude, non-maleficence, respect for the elderly, and the right to justice in the ihspe service. a good quality outcome can increase the elderly’s satisfaction with the service quality... (nursalam nursalam et.al) 231 the elderly people’s satisfaction through their health status, behaviour and the attitude of the elderly in the ihspe. this study can be used by the phc as a reference to enhance the quality of input, process, and the outcomes of the ihspe service. this study also provides an insight for the elderly on how to give an appraisal of the ihspe service, allowing the elderly to contribute to maintaining and enhancing the quality of the ihspe service. further study is needed to conduct an internal study of the service quality of the phc and ihspe programme so that it can be compared to the external study of the perceptions of the elderly, as currently conducted by the authors. references aaker, d, a., 1996. measuring brand equity across products and market. california manajemen review, 38, pp.102. angga, d, s., 2014. pengukuran tingkat kepuasan pelanggan terhadap kualitas pelayanan dengan metode servqual “studi kasus pada pusat oleh oleh harum manis.” universitas brawijaya. anggri, v., 2011. analisis kepuasan pelanggan terhadap kualitas pelayanan jasa pos express di pt. pos indonesia cabang surakarta. universitas sebelas maret surakarta. azwar 2008. sikap manusia, teori dan pengukurannya 2nd ed., yogyakarta: pustaka pelajar. badan penelitian dan pengembangan kesehatan., 2012. riset fasilitas kesehatan, jakarta: kementerian kesehatan republik indonesia. christine, h., 2012. studi kulaitatif pemanfaatanposyandu lansia di wilayah puskesmas sarudik kabupaten tapanuli tengah. fakultaskesehatan masyarakat universitas indonesia. desi, s, a., 2014. hubungan antara kinerja kader posyandu terhadap kepuasan lansia di kelurahan rempoa timur jakarta. universitas islam negeri syarif hidayatullah. dewi, e, h., 2012. pemanfaatan pos pembinaan terpadu oleh lanjut usia di kecamatan ciomas kabupaten bogor tahun 2012 dan faktor yang berhubungan, jakarta. fakultas kesehatan masyarakat program sarjana kesehatan masyarakat universitas indonesia. diana, s., 2010. manajemen pemasaran usaha kesehatan 4th ed., yogyakarta: nuha medika. dinas kesehatan kota surabaya., 2016. profil dinas kesehatan kota surabaya tahun 2015, surabaya: dinas kesehatan kota surabaya. dinas kesehatan provinsi jawa tengah., 2016. profil kesehatan kabupaten dan kota di jawa tengah tahun 2015, semarang: dinas kesehatan provinsi jawa tengah. dony, s., 2013. hubungan pelayanan posyandu lansia dengan tingkat kepuasan lansia di wilayah kerja puskesmas sukorambi kabupaten jember. stikes bhakti negara jember. fitrah, w., 2010. memahami kesehatan pada lansia 3rd ed., jakarta: cv. trans info media. green, l w., 1980. health program planning an educational and ecological approach, marshall w. kreuter: rollins school of public health of emory university. herdining, w, p., 2013. faktor-faktor yang berhubungan dengan frekuensi kehadiran lanjut usia di posyandu lansia. jurnal ilmiah kebidanan, 2(4 juni 2013), pp.1 hesti, w., 2010. analisis faktor-faktor yang mempengaruhi pemanfaatan posyandu lansia di gantungan makam haji surakarta. universitas muhammadiyah surakarta. kementerian kesehatan republik indonesia., 2010., pedoman pengelolaan kesehatan di kelompok lanjut usia, jakarta: direktorat bina upaya kesehatan. kementerian kesehatan republik indonesia., 2009. undang undang kesehatan nomor 36, jakarta: kementerian kesehatan republik indonesia. kementerian kesehatan republik indonesia., 2013. pedoman pembinaan kesehatan usia lanjut., jakarta: direktorat bina jurnal ners vol. 12 no. 2 oktober 2017: 225-232 232 upaya kesehatan. kepmenkes nomor 52., 2015. rencana strategis kementerian kesehatan tahun 2015 2019, jakarta: kementerian kesehatan republik indonesia. kotler, k, l., 2009. manajemen pemasaran 13th ed., jakarta: erlangga. kristina, b, w, 2015., pengaruh pendidikan kesehatan dengan media audio visual terhadap perilaku ibu dalam penanganan infeksi saluran pernafasan akut pada balita di kelurahan lebijaga kabupeten ngada. universitas airlangga surabaya. lupiyopadi, r., 2009. manajemen pemasaran jasa 2nd ed., jakarta: salemba empat. nursalam, 2015. manajemen keperawatan, aplikasi dalam praktek keperawatan profesional, jakarta: salemba medika. nursalam, 2013. metodologi penelitian ilmu keperawatan, pendekatan praktis, jakarta: salemba medika. parasuraman & zeithaml, a., 1985. a conceptual model of service quality and its impact for future research. journal of marketing, iii, pp.41–50. parasuraman & zeithaml 1988. servqual : a multiple item scale for measuring consumer perception of service quality. research gate, ii, pp.13–16. permenkes nomor 25., 2016. rencana aksi nasional kesehatan lanjut usia tahun 2016 2019, jakarta: kementerian kesehatan republik indonesia. permenkes nomor 75., 2014. pusat kesehatan masyarakat, jakarta: kementerian kesehatan republik indonesia. pusat data dan informasi kemenkes ri., 2013. buletin lansia : gambaran kesehatan lansia di indonesia, jakarta: kementerian kesehatan republik indonesia. rizqiana, a., 2015. kualitas pelayanan kesehatan di puskesmas sedan kabupaten rembang. program studi ilmu keperawatan, fakultas kedokteran uin syarif hidayatullah jakarta. sulistyorini., 2010. posyandu dan desa siaga 1st ed., yogyakarta: nuha medika. titi, w., 2015. studi deskriptif implementasi program posyandu lanjut usia di rw iv kelurahan tanah kali kedinding kecamatan kenjeran surabaya. kebijakan dan manajemen publik, 3(januari-april 2015). uswatun, h., 2012. faktor faktor yang mempengaruhi kepuasan lansia di posyandu lansia kelurahan wonokusumo kecamatan semampir kota surabaya, surabaya. fakultas ilmu kesehatan universitas muhammadiyah surabaya. yunus, m, b., 2013. pengaruh kualitas pelayanan terhadap kepuasan pelanggan pada pt. pln (persero) rayon makassar barat. universitas hasanudin makasar. zarniyeti., 2011. analisis faktor-faktor yang berhubungan dengan pemanfaatan posyandu lansia oleh lanjut usia ( > 60 tahun) di wilayah kota pariaman sumatera barat tahun 2011. fakultas kesehatan masyarakat universitas indonesia. zulian, y., 2013. manajemen kualitas produk dan jasa, yogyakarta: fakultas ekonomi universitas islam indonesia. 98 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.7774 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the development of model family-centered empowerment on caring for children with leukemia yuni sufyanti arief1, nursalam nursalam1, i dewa gede ugrasena2,shrimarti rukmini devy3 and eileen savage4 1 faculty of nursing, universitas airlangga, kampus c mulyorejo, surabaya, indonesia 2 faculty of medicine, universitas airlangga, jl. prof. dr. moestopo 47, surabaya, indonesia 3 faculty of nursing, universitas airlangga, kampus c mulyorejo, surabaya, indonesia 4 school of nursing and midwifery, university college cork, cork, ireland abstract introduction: children with leukemia desperately need serious attention, commitment and it is a hard struggle for family members. powerlessness experienced by the family will affect the ability of the families to provide care for their children. many factors can affect the empowerment of families in providing care to their families methods: the purpose of this study was to develop a family-centered empowerment model related to the family's ability to care for their child suffering from leukemia. the research design used was an explanation survey. the sample consisted of 140 families with children suffering from leukemia in the pediatric ward of dr. soetomo hospital. results: the family-centered empowerment model was formed from the family factor, patient factor and nurse factor. the greatest effect was on the nurse factor, with the t statistic value = 6.590. conclusion: family factors and nurse factors need to be taken into account in familycentered empowerment. the patient factor has little influence on family empowerment in relation to caring for children. more research is needed on familycentered empowerment models in relation to their ability to care for children with leukemia. for example, a nurse providing a nursing intervention, especially a pediatric nurse, in relation to empowering a parent at the time of caring for their child with leukemia. article history received: march 02, 2018 accepted: july 24, 2018 keywords family; empowerment; family factor; leukemia contact yuni sufyanti arief yuni_sa@fkp.unair.ac.id  faculty of nursing, universitas airlangga, kampus c mulyorejo, surabaya, indonesia cite this as: arief, y., nursalam, n., ugrasena, i., devy, s., & savage, e. (2018). the development of model familycentered empowerment on caring for children with leukemia. jurnal ners, 13(1), 98-105. doi:http://dx.doi.org/10.20473/jn.v13i1.7774 introduction every child with a chronic illness such as leukemia grows and develops in a unique family and cultural environment with many different variations. with children with chronic health conditions, it is often assumed that meeting the health needs of the children and sustaining their family life are two major challenges faced by the families (deatrick & knafl, 1990; dunst, 2011; wuest & stern, 1991). families and children with chronic health conditions often feel helpless when trying to meet their child's health care needs and when trying to sustain their family life (popp, conway, & pantaleao, 2015). based on the results of the interviews with mothers whose children were being treated for leukemia, related to the needs of childcare, the mothers stated that much of the daily health care advice is time-consuming, unpleasant, and that it felt burdensome. family empowerment is an intervention that nurses can use to help families (wright & leahey, 2000). these interactive interventions are designed to help the family through a process of empowerment, consisting of several stages that can increase trust and family decisionmaking to allow them to work better with health professionals (johansson, 2006). activities are based on assumptions that everyone has the power, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 99 capability and capacity to grow and become more competent. family empowerment is influenced by several factors such as the demands of care, family factors, patient factors and health care factors (jones, winslow, lee, burns, & zhang, 2011). the constituent attributes of family empowerment can be assessed using self-efficacy, motivation, acceptance of threats, responsibility, respect, and care. the expected outcomes for families with such empowerment include the ability to negotiate with health professionals, minimising the effects of chronic conditions on children and their siblings, rearranging the family roles and responsibilities, satisfying their child’s health care needs, and lowering their use of health care and costs (chiu, wei, lee, choovanichvong, & wong, 2013). integrated and holistic cancer prevention should involve all of the components of the family factor because the needs of pediatric patients with cancer are complex, including the need to be pain-free, the need for attention, and the need for psychological support (elcigil & conk, 2010). to help people with cancer thoroughly, it takes serious effort and the family role is very important. therefore, it is important to consider whether the family-centered empowerment model can improve the family's ability to treat children with leukemia. materials and methods this research used an explanatory survey research design and was conducted in the pediatric ward of dr. soetomo hospital surabaya in the period june to september 2017. the population in this study consisted of families that have children suffering from leukemia in the pediatric ward, with a large sample of 140 respondents the sampling technique in this study was the consecutive method. the selection of samples was according to the criteria. the inclusion criteria in this study was mothers of pre-school-aged children with leukemia > 1 year who were undergoing chemotherapy treatment and mothers directly treating the child suffering from leukemia. the exclusion criteria of this study were unhealthy mothers and mothers who could not read and write. the variables in this research were the family factor (motivation, cognition, perceived threat, structure & family function, stress, coping, social support, care receiver impairment, competing role demands, caregiving activities), nurse factor (empowering, enabling, supporting) patient (age, child status, duration of illness, disease severity). the data was collected through questionnaires. the questions in the questionnaire used in this study have been tested for their validity and reliability. the validity of each item was done by the pearson correlation test using a significance level of 0.005. the reliability of the items was tested using cronbach’s alpha. the questionnaire in this study was developed based on the concept of supporting theories. the indicator instrument of the family factor was developed based on the supporting theoretical concepts. data related to motivation was measured using a likert scale questionnaire, made by the researchers themselves based on the indicators of abraham maslow's theory. cognitive data collection was measured based on the family's trust in the ability to treat childhood leukemia. the instrument used to collect the confidence data was done using a self efficacy instrument from albert bandura. data relating to perceived threats was measured using a self-made questionnaire by the researchers based on the concept of the health belief model (hbm). data relating to family structure and function were measured using a fad (family assessment device) questionnaire. data related to stress was measured using the zung self-rating anxiety scale (sas / sras). data relating to family coping was measured using a checklist list of variables contained in the family coping index (fci) nursing service and johns hopkins school of hygiene and public health, which includes the competence of the family in the care of their sick family members. data related to social support was measured using a self-made questionnaire by the researchers based on the friedman & marylin family assessment concept (2003). data relating to the parenting demands was measured using the caregiver reaction assessment. data collection related to the nursing factor (empowering, enabling, supporting), which can influence family empowerment, was measured using a self-made instrument by the researcher based on the family centre care concept on nursing care in children and a modification of the family empowerment scale questionnaire. data relating to filial value was measured using a filial value scale. data related to the family's ability to treat children with leukemia used a revised caregiving appraisal scale (rcas) questionnaire consisting of 27-items in a self-administered questionnaire, using a 4-point likert scale for item responses (lee, friedmann, j.picot, ann thomas, & ja kim, 2007). data relating to perceived health was measured using the questionnaire health status questioner (hsq-12). data relating to personal growth measurements was measured using the personal growth initiative scale (pgis) questionnaire from cristhine robitschek (robitschek, 1999). data relating to the existential well being measurements was measured using the spiritual well being scale (swbs) questionnaire from ellison. the development of the family-centered empowerment (face) model was done through focus group discussion activities with informants who played a role in the formation of the face model, including the families caring for children with leukemia, and nurses. the data was collected and analyzed using smartpls. an ethical test was conducted by team ethics rsud dr. soetomo number 385 / panke.kke / v / 2017 dated: may 30, 2017. y.s. arief et al. 100 | pissn: 1858-3598  eissn: 2502-5791 results in this study, the outer model test was evaluated by performing the validity and reliability test on the outer model evaluated by the statistical t score. the validity of the test of the model can be seen from the value of outer loading in table 1. table 1 shows that there are 2 invalid indicators (structure and function of family = 0.325, stress = -0.188, illness length = 0.133) and 25 valid indicators with outer loading values >0.5. the value of outer loading in the family factor consists of motivation (0.692), cognition (0.799), perceived threat (0.870), coping (0.596), social support (0.767), care receiver impairment table 1 validity test results showing the development of the model for family-centered empowerment on the family ability of caring for children with leukemia. no variable factor outer loading description 1 family factor x1.1 motivation 0.692 valid x1.2 cognition 0.799 valid x1.3 perceived threat 0.870 valid x1.4 structure & family function 0.325 in valid x1.5 stress -0.188 in valid x1.6 coping 0.596 valid x1.7 social support 0.767 valid x1.8 care receiver impairment 0.672 valid x1.9 competing role demands 0.589 valid x1.10 caregiving activities 0.645 valid 2 patient factor x2.1 age 0.817 valid x2.2 child status 0.789 valid x2.3 duration of illness 0.133 in valid x2.4 disease severity 0.856 valid 3 nurse factor x3.1 empowering 0.899 valid x3.2 enabling 0.875 valid x3.3 supporting 0.879 valid 4 filial value x4.1 responsibility 0.914 valid x4.2 respect 0.883 valid x4.3 care 0.831 valid 5 family appraisal x5.1 challenge 0.924 valid x5.2 stressor 0.706 valid 6 caregiver outcome y1.1 perceived health 0.866 valid y1.2 personal growth 0.869 valid y1.3 existential wellbeing 0.687 valid 7 child indicator y2.1 nutrition status 0.801 valid y2.2 secunder infection 0.893 valid y2.3 frequecies of bleeding 0.746 valid table 2 reliability test result on the development of the model for family-centered empowerment on the family ability of caring for children with leukemia. no variable chronbach alpha composite reliability description 1 family factor 0.508335 0.8905 valid 2 patient factor 0.675922 0.8621 valid 3 nurse factor 0.776507 0.9125 valid 4 family appraisal 0.676337 0.8041 valid 5 filial value 0.768920 0.9088 valid 6 child indicator 0.664848 0.8555 valid 7 caregiver outcome 0.650083 0.8461 valid table 3 -hypothesis test results in relation to the development of the model for family-centered empowerment on the family ability to care for children with leukemia. no variable path coefficient standar deviation t statistic explanation 1 family factor -> filial value 0.315307 0.082952 3.8011 significant 2 family factor -> caregiver outcome 0.083559 0.075237 1.1106 no significance 3 patient factor -> filial value 0.054482 0.077104 0.7066 no significance 4 patient factor -> caregiver outcome -0.164653 0.065742 2.5046 significant 5 nurse factor -> filial value 0.464863 0.070538 6.5903 significant 6 nurse factor -> caregiver outcome 0.053407 0.091932 0.5809 no significance 7 family apprasial -> caregiver outcome 0.232694 0.083830 2.7758 significant 8 filial value -> family apprasial 0.497954 0.072752 6.8445 significant 9 filial value -> caregiver outcome 0.340145 0.086861 3.9159 significant 10 caregiver outcome -> indicator 0.288713 0.075624 3.8177 significant jurnal ners http://e-journal.unair.ac.id/jners | 101 (0.672), competing role demands (0.589) and caregiving activities (0.645). the factors of the patient consist of the indicators of age (0.817), child status (0.789) and disease severity (0.856). the nurse factor consists of empowering (0.899), enabling (0.875) and supporting (0.879). filial value consists of the indicators of responsibility (0.914), respect (0.883), and care (0.831). family appraisal consists of the challenge indicator (0.924) and stressors (0.706). table 2 shows the reliability test results of the model. the reliability test results can be seen from the cronbach’s alpha and composite reliability values. the construct or variable is said to be reliable when the value of the composite variable > 0.7. the value of cronbach’s lpha > 0.6. (0.862), nurse factor (0.912), filial value (0.908), family appraisal (0.804), family ability (0.846) and child indicator (0.855) were all satisfied. table 3 shows the results of the hypothesis test. it is said that there is an influence if the value of variable t> 1. based on table 3, it can be seen that there is a significant influence between the family factors and filial value (t = 3.801), there is influence from the patient factor on caring ability (t = 2,504), there is an influence from the nurse factor on filial value (t = 6,590) family appraisal on nursing ability (t = 2.776), filial value on family appraisal (6,844), filial value on caring ability (t = 3.92)), and caring ability towards the child indicator (t = 3.82). an analysis of the test results of the model development can be seen in figure 1. the recommendations of the fgd results are as follows: (1) to increase family motivation in caring for children with leukemia by providing assistance to the family; (2) teaching the family to form positive coping methods when giving care to children suffering from leukemia; (3) to enhance communication between nurses and families to remind one another in terms of the actions that are always performed when caring for children with leukemia; (4) providing family health education on psychospiritual needs to increase family confidence in caring for children with leukemia; 5) preparation of guidelines for nursing interventions in providing assistance to the family for family empowerment in caring for children leukemia and (6) health education about specific things that must be known by the family when treating childhood leukemia that is easy to understand by the family. all of the results of this study were integrated into a module as a guide to improve family empowerment when treating childhood leukemia. discussion family factors forming family empowerment family factors in the application of family-centered care are formed by the indicators of motivation, cognition, perceived threat, coping, social support, care receiver impairment, competing role demands, and caregiving activities. the family is the main source of the child’s support when providing stability to children in times of childhood trauma. family-tofamily support can benefit the mental health status of the mothers of children suffering from chronic diseases (academy, pediatrics, & care, 2018; ireys, chernoff, devet, & kim, 2015). alhani et al (2003) explained that in order to empower families in improving optimal health, any response must involve the 3 dimensions of motivation, cognition, and the basic properties of the individual. intrinsic motivation involves the positive and valuable experience that individuals derive directly from a task. individuals try to motivate themselves by establishing confidence in the action that is to be taken, and planning the action to be realised. motivation is needed to improve family empowerment when treating child leukemia. another dimension in the family factors that makes up family-centered care is cognition. cognition, in this case, is the family knowledge of treating childhood leukemia. knowledge is the result of knowing, and this occurs after the person senses a particular object. sensing occurs through the human senses of the sense of sight, hearing, smell, taste, and touch. much of human knowledge is obtained through the eyes and ears (notoadmodjo, 2003). knowledge can also be defined as the facts or information that we think is correct based on thoughts involving empirical testing (the thought of phenomena being observed directly) or based on other thought processes such as giving logical reasons or problem-solving (hidayat, 2007). family knowledge can provide information for the family to improve its ability to care for children with leukemia. the perceived threat dimension (perceived threat) is also one of the basic family building factors involved in fostering empowerment. families perceiving threats to the severity of the condition of childhood illness can be a matter of increasing the ability of the family to care for children with leukemia. threats encourage individuals to take preventive or cure measures, but too much of a threat creates fear that impedes action by the individual feeling helpless (resigned). it supports this research that perceived threat (perceived threat) by the family is an indicator of the formation of a sense of empowerment in the family, in improving the ability of the families to treat childhood leukemia. another indicator of empowerment is family coping. family coupling in relation to treating patients with chronic disease is the family adaptation ability in the face of severe and long-term stressors (chronic) due to one family member suffering from chronic illness. according to mc cubbin (2001), when a family member suffers from chronic illness or disability, including mental disorders, the family should provide long-term care and must continue to support the patient to perform their daily routine activities. family support is the attitude, action, and acceptance of the family to its members. family members are seen of as an integral part of the family environment (friedman & marylin, 2010). family support is the verbal information, targets, real assistance or behaviour provided by people who are y.s. arief et al. 102 | pissn: 1858-3598  eissn: 2502-5791 familiar with the subject in their social environment or in the form of attendance and things that can provide emotional support or influence the behaviour of acceptance. low social support is the support of families of people with chronic diseases that can affect individual behaviour, such as increased stress, helplessness and despair. these things ultimately reduce health status. decreased health status means a decrease in the quality of life of the patient (antari, 2013). caregiver demands is another dimension of family factors as an indicator of the formation of familycentered empowerment, consisting of care receiver impairment, competing for role demands, and caregiving activities. the demands of family care in this study were mostly in the moderate category, indicating that family reactions in providing care to children with leukemia are still complex. this is in accordance with the opinion of given (1992) in that the family reaction to caring for sick family members is complex and may vary over time. the caregiver's reaction results from an effective assessment of the existing parenting tasks, the effort being made, the status or needs of the patient and the care environment. age, gender, cultural background, ethnicity, socioeconomic status, educational level, personal health, and family dynamics work together as an integral factor in predicting caregiver reactions to demanding roles (baider & bengel, 2001; hagedorn et al, 2000; langer, abrams, & syrjala, 2003; northouse et al, 2000). the results of govina et al. (2015) also explain that the burden of familyperceived care is related to mood, the difficulty of parenting, family status, employment status and past experience. the nurturing burden that the family perceives in treating the child with leukemia becomes an intervention that should be done by empowering the family in order to increase their ability to caring for their child suffering from leukemia. patients factors forming family empowerment family-centered care is formed by the indicators of age and child status, the duration of treatment and the severity of the disease. the results of this study are consistent with the study by pott & mandleco (2012), who suggested that the experience of suffering from an illness is very confusing for children, especially for children who have cognitive development skills that are not enough to understand and help children to respond to stress. the presence of the stress of hospitalisation that occurs in children will affect the parents. research by franck et al. (2015) explains that the hospitalisation process causes stress for the elderly. anxiety and depression in the elderly that occurs during hospitalisation is associated with negative coping mechanisms and post-traumatic stress symptoms. if the child is sick, the parents also feel the pain experienced by the child (wong, hockenberry, winkelstein, & wilson, 2009). the well-being of the caregiver depends on the patient's condition and the individual characteristics of the caregiver (weitzner et al, 1999). families who care for children with leukemia should be able to know about the condition of their children so that the families are more vigilant in caring for children with chronic pain conditions. figure 1: analysis test results on the development of a model for family-centered empowerment on the ability of the family to care for children with leukemia. jurnal ners http://e-journal.unair.ac.id/jners | 103 nurse factors forming family empowerment the nurse factor in the application of familycentered care is formed by the indicators of empowering, enabling, and supporting. a nurse is a member of a health team working with both the children and their parents (supartini, 2004). florence nightingale (in priharjo, 2008) stated that a nurse is concerned with maintaining the patient's condition in response to the health problems that he or she is experiencing. according to ellis & hartley (1980, in priharjo, 2008), a nurse is a person who cares for and protects the sick, elderly and wounded. a major focus in nursing services is the promotion of health and disease prevention in relation to family-focused and therapeutic care. the concept underlying the cooperation between the family and the nurse is that the nurse facilitates the family in remaining active in the nursing care of their child in the hospital and empowers the family's knowledge and skill related to the care of the child in the hospital (supartini, 2004). family-centered nursing explains that nursing skills are needed to provide family nursing care, thus enabling family members to achieve improved health of all family members. this leaves the families able to address health problems (friedman & marylin, 2010). this is in accordance with the results of this study, in that the nurse indicator becomes the determining factor in growing the family's basic values (filial value) so then the family can finally empower themselves in treating the child's chronic condition, in this case, leukemia. family-centered empowerment (family filial values) on family appraisal the results of the statistical tests show that filial value (base value) as a form of family-centered empowerment significantly affects family appraisal (family assessment) in the ability to care for children with leukemia. family filial values are indicators of the formation of empowerment within the family, which consists of the indicators of responsibility, respect and care. empowerment is an ongoing process to improve people's ability and independence in improving their standard of living. the process is done by generating their empowerment, in order for them to improve their lives on their own strengths. gibson defines empowerment as a social process; recognising, promoting and enhancing people's ability to find their own needs, solving their own problems and mobilising the resources needed to control their lives (graves, 2007). family empowerment is a mechanism that enables the transformation of the family capacity as a positive impact of family-centered nursing orders, health promotion measures and cultural suitability that influences treatment and family development (graves, 2007). empowerment is defined as the process of discovery and the development of the personal capacity to be responsible for their life because they have the necessary knowledge and resources to acquire and apply reasoned decisions and sufficient experience to evaluate the effectiveness of decisions (masoodi et al., n.d). the indicators of family appraisal formed in this study are challenges and stressors. the family assessed whether the treatment of a children with leukemia was a challenge or if it became a stressor for the family. family disease assessment is defined as the family’s trust when assessing and treating illness (doherty, 2002). the family has an important role in the process of disease assessment and treatment. family assessment establishes the value, purpose, and priority of the family members in response to disease. the above supports the results of this study, in that the basic values of a family as a form of family empowerment can empower families further when providing a positive family appraisal. family-centered empowerment (family filial value) and the family ability to care for childhood leukemia family filial values as a family-centered empowerment builder significantly affect the ability of the families to care for children with leukemia. filial values are the attitudes and beliefs about parental responsibility on the health of their children. confidence and commitment to maintaining traditional values can influence the caregiver's motivation to provide care to their child. there are 3 dimensions in measuring filial value: 1) a sense of parental responsibility when caring for the child; 2) respect and admiration of the parents towards their children and 3) the desire of the parents to care for their children. these three dimensions of filial value are expected to: 1) alter how parents value the demands of parenting, whether as a challenge or stressor; 2) contribute to the resources available to overcome the sense of purpose and strong meaning associated with giving back to the parents; 3) influence access to family resources and the use of community resources and 4) indirectly affect the resource outcomes and assessments (jones et al., 2011). people are able to change previous behaviours and display their abilities according to the situational needs (popp et al., 2015). the calgary intervention in the cognitive domain is one of the enabling factors of behaviour formation. knowledge and attitude also plays a role as a predisposing factor (notoatmodjo, 2003). knowledge of successful cancer treatment will bring out a response in the respondents in the form of a positive attitude. a positive attitude will be reflected in the individual's behaviour when applying the cancer treatment. the act of care from the families with good cancer treatment being conducted in the family is in line with the concept of cybernetics, and the ability to organise themselves through the feedback process. intrapersonal systems can be seen in the feedback that occurs due to the behaviour of a person that influences and is influenced by the behaviour of another. actions in family cancer care can also be influenced by the availability of the y.s. arief et al. 104 | pissn: 1858-3598  eissn: 2502-5791 facilities owned by the family and the family motivation in applying care. the family's ability as an indicator of child health status the results of statistical tests showed that the ability of the family significantly influences the indicator of child health status. the family's ability, in this study, includes the indicators of family care outcomes in relation to treating children with leukemia, which in consists of the indicators of perception about healthy, personal and family growth, and the existence of prosperous conditions. in this study, most of the respondents were in the medium category. the indicators of child health status in this study were the nutritional status of the child, the incidence of secondary infection, and the occurrence of bleeding. the results showed that most of the child health indicators were in the medium category. this indicates that the health indicators of children with leukemia can be seen from the increased ability of the families in treating children leukemia. family ability in this study includes the indicators of family care which consists of perceived health, personal growth, and existensial well-being. the ability of families to care for children with leukemia increases in line with the increase in family appraisal when giving an assessment of themselves, in relation to caring for children with leukemia being a challenge for them, as they want to be able to do their best for the health of their child. familycentered empowerment will improve the family's ability to provide an appraisal. family-centered empowerment is the process of parental involvement to improve their ability to care for their child (olin et al., 2010). the family's ability to care for a child with leukemia requires an effort by the health care provider so then the family's ability to care for their child with leukemia increases and the child's health indicators can be improved. conclusion the family's ability to care for their child with leukemia can be enhanced by fostering a sense of empowerment. family-centered empowerment can be maximised to improve their positive outcomes, which in turn will improve the indicator of health status in relation to the child with leukemia. based on the results of this study, the family factors, patient factors and nurse factors have a direct influence on family empowerment (responsibility, respect, and care) when treating children with leukemia. the existence of a sense of empowerment in the family can increase certain behaviours when doing a family appraisal of their ability to care for their child with leukemia. the importance of family appraisal has a role in the efforts undertaken to improve the ability of families to treat children with leukemia. this is evidenced by its role in facilitating family empowerment before establishing positive care outcomes. it is known that if the family filial values are strong, then it will affect the family appraisal so that ultimately, the ability of the family to care for their child with leukemia increases. increased family ability will affect the child’s health indicators. references academy, a., pediatrics, o. f., & care, f. (2018). committee on hospital care, 112(3). alhani, f., niknami, s., kimiyagar, s., kazem, n., & heidarnia, a. (2003). family-centered empowerment model and assess its impact on the prevention of iron deficiency anemia in adolescent girls. journal of birjand university of medical sciences, 8(4), 9–15. baider, l., & bengel, j. (2001). cancer and the spouse : gender-related differences in dealing with health care and illness, 40, 115–123. chiu, m. y. l., wei, g. f. w., lee, s., choovanichvong, s., & wong, f. h. t. (2013). empowering caregivers: impact analysis of familylink education programme (flep) in hong kong, taipei and bangkok. the international journal of social psychiatry, 59(1), 28–39. https://doi.org/10.1177/0020764011423171 deatrick, j. a., & knafl, k. a. (1990). management behavior: day-to day adjustments to childhood chronic condition. journal of pediatric nursing, 5, 15–22. doherty, w. j. (2002). family health social work practice: a amcro level approach. (j. t. pardeck, ed.). united state of america: auburn house, westport, connectut, london. dunst, c. j. (2011). family-centered practices, parent engagement, and parent and family functioning. elcigil, a., & conk, z. (2010). determining the burden of mother with children who have cancer. ed 3: deuhyo. franck, l. s., wray, j., gay, c., dearmun, a. k., lee, k., & cooper, b. a. (2015). predictors of parent posttraumatic stress symptoms after child hospitalization on general pediatric wards: a prospective cohort study. international journal of nursing studies, 52(1), 10–21. https://doi.org/10.1016/j.ijnurstu.2014.06.011 friedman, & marylin, m. (2010). buku ajar keperawatan keluarga riset, teori, dan praktik. (e. tiar, ed.) (5th ed.). jakarta: egc. govina, o., kotronoulas, g., mystakidou, k., katsaragakis, s., vlachou, e., & patiraki, e. (2015). effects of patient and personal demographic, clinical and psychosocial characteristics on the burden of family members caring for patients with advanced cancer in greece. european journal of oncology nursing, 19(1), 81–88. https://doi.org/10.1016/j.ejon.2014.06.009 graves, k. . (2007). family empowerment as a mediator between family centered system of care and changes in child functioning: identifying an important mechanism of change. washington: springer science and business media. ireys, h. t., chernoff, r., devet, k. a., & kim, y. (2015). jurnal ners http://e-journal.unair.ac.id/jners | 105 maternal outcomes of a randomized controlled trial of a community-based support program for families of children with chronic illnesses, 155(july 2001), 771–777. johansson, a. (2006). empowermental nursing experiences of empowerment and disempowerment made by patients in need of long term nursing. jones, p. s., winslow, b. w., lee, j. w., burns, m., & zhang, x. e. (2011). development of a caregiver empowerment model to promote positive outcomes. j.fam.nurs., 17(1552-549x (electronic)), 11–28. https://doi.org/10.1177/1074840710394854 lee, j., friedmann, e., j.picot, s., ann thomas, s., & ja kim, c. (2007). korean version of the revised caregiving appraisal scale: a translation and validation study. journal of advanced nursing, 59(4), 407–415. https://doi.org/10.1016/j.biotechadv.2011.08.02 1.secreted masoodi, r., alhani, f., moghadassi, j., ghorbani, m., the effect of .(.n.d) .م ,قربانی … ,.ف ,الحانی ,.ر ,مسعودی family-centered empowerment model on skill, attitude , and knowledge of multiple sclerosis caregivers. journal of birjand university of medical sciences. olin, s. s., hoagwood, k. e., rodriguez, j., ramos, b., burton, g., penn, m., … jensen, p. s. (2010). the application of behavior change theory to familybased services: improving parent empowerment in children’s mental health. journal of child and family studies, 19(4), 462–470. https://doi.org/10.1007/s10826-009-9317-3 popp, j. m., conway, m., & pantaleao, a. (2015). parents’ experience with their child's cancer diagnosis: do hopefulness, family functioning, and perceptions of care matter? journal of pediatric oncology nursing, 32(4), 253–260. https://doi.org/10.1177/1043454214563404 pott, n. l., & mandleco, b. l. (2012). pediatric nursing caring for children and their families (third edit). usa: delmar. priharjo, r. (2008). konsep & perspektif praktik keperawatan profesional (edisi 2). jakarta: egc. robitschek, c. (1999). personal growth initiative scale (pgis), 6. https://doi.org/http://dx.doi.org/10.1037/t042 61-000 supartini, y. (2004). konsep dasar keperawatan anak. jakarta: egc. weitzner, m. a., jacobsen, p. b., wagner, h. j., friedland, j., & cox, c. (1999). the caregiver quality of life index–cancer (cqolc) scale: development and validation of an instrument to measure quality of life of the family caregiver of patients with cancer. quality of life research, 8(1), 55–63. https://doi.org/10.1023/a:1026407010614 wong, d. l., hockenberry, m., winkelstein, m., & wilson, d. (2009). buku ajar keperawatan pediatrik. in a. hartono, s. kurnianingsih, & setiawan (eds.), jakarta, egc. wright, l., & leahey, m. (2000). nurses and families: a guide in family assessment and intervention. philadelphia: davis. wuest, j., & stern, p. . (1991). empowerment in primary health care: the cg=hallenge for nurses. qualitative health research, 1, 80–99. povidon iodine 1% dan normal saline sebagai obat kumur mencegah mukositis oral 103 povidon iodin 1% dan normal salin sebagai obat kumur mencegah mukositis oral (povidone iodine 1 % and normal saline as a gargling solution to prevent oral mucousitis) nursalam*, ertawati**, putri kristyaningsih* abstract introduction: oral mucositis could affect children’s health status. the purpose of this study was to identify the difference of effectiveness between gargling with povidone iodine 1% and normal saline solutions in 5-15 years old children who received chemotherapy. method: this study used pre-experiment static group comparison design. there were 18 respondents who divided into 2 treatment groups and 1 control group. the independent variable was gargling use solutions of povidone iodine 1% and normal saline and the dependent variable was oral mucositis.the level of mucositis measured using multiple variable mucositis rating scales then analyzed by means of statistical test mann whitney u test with significance level of α≤0.05. result: the result showed that there were no difference between gargling use solutions of povidone iodine 1% and normal saline (p=0.930). analysis: thus normal saline as good as povidone iodine 1% to prevent oral mucositis. it can be concluded that there was no difference between the use of povidone iodine 1% and normal saline as mouthwash to prevent oral mucositis. discussion: it is recommended that patient with chemotherapy should be gorgled with povidone iodine and normal saline. keywords : gargling, mouthwash solutions, oral mucositis . * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: nursalam_psik@yahoo.com ** rsud dr.soetomo surabaya pendahuluan mukositis oral merupakan masalah kesehatan yang harus segera ditangani. pasien yang menderita kanker dan menjalani kemoterapi mungkin akan mengalami efek samping (treister, 2008), salah satunya adalah mukositis oral (popa, 2008). indonesia setiap tahunnya diperkirakan sekitar 4100 kasus kanker baru yang menyerang anak (japardi, 2009), sedangkan di ruang perawatan anak rsud dr. soetomo selama 3 tahun terakhir jumlah pasien anak yang menderita kanker (leukimia) mengalami peningkatan. 74 pasien pada tahun 2005, 76 pasien pada tahun 2006, dan 88 pasien pada tahun 2008 (ugrasena, 2009). jumlah pasien anak yang menjalani kemoterapi di ruang perawatan anak lantai 1 rsud dr. soetomo pada bulan januari-februari 2009 tercatat 29 pasien. sementara itu sampai tanggal 12 juni 2009 tercatat 16 pasien yang menjalani kemoterapi (ruang perawatan anak lantai 1 rsud dr. soetomo, 2009). mukositis oral dapat kita cegah dengan melakukan oral hygiene (berkumur) yang benar dan secara teratur (ogatha, 2004). diantara larutan yang dapat digunakan untuk berkumur adalah normal salin dan povidon iodin 1%. penelitian yang dilakukan oleh samuel vokurka pada tahun 2005, larutan povidon iodin 1% telah terbukti mampu mencegah terjadinya mukositis oral pada pasien dengan kemoterapi, karena larutan povidon iodin mempunyai sifat yang antibakteri. penelitian lain yang dilakukan mailto:nursalam_psik@yahoo.com jurnal ners vol. 4 no. 2: 103-109 104 oleh wohlschleager pada tahun 2004 juga menyebutkan bahwa normal salin juga efektif sebagai obat kumur untuk mencegah mukositis oral. di ruang perawatan anak lantai 1 rsud dr. soetomo surabaya hanya mengggunakan air biasa untuk berkumur. keefektifan larutan povidon iodin dan normal salin dalam mencegah mukositis oral karena kemoterapi telah terbukti. namun efektifitas antara larutan povidon iodin 1% dan normal salin unuk mencegah mukositis oral pada pasien anak yang menerima kemoterapi belum dapat diketahui. tahun 2008 jumlah pasien anak dengan kanker di rs dr. sardjito yogyakarta terdapat 250 pasien, tahun 2009 sampai bulan april tercatat 60 pasien anak (sutaryo, 2009). mukositis oral harus segera ditangani, karena hal ini akan berpengaruh terhadap asupan nutrisi pasien (japardi, 2009). mukositis oral yang parah akan berdampak terhadap status nutrisi pasien, pasien lebih berisiko untuk terkena infeksi, dan waktu hospitalisasi yang lama (weill, 2005). kostler pada tahun 2001 menunjukkan bahwa sekitar 60% pasien anak yang menderita kanker dan menerima kemoterapi, mengalami mukositis oral. rata-rata mukositis karena kemoterapi tergantung pada terapi yang diterima, 12% pada adjuvant chemotherapy, 37% pada kemoterapi untuk tumor, dan 90-100% pada myeloablative chemotherapy. mukositis yang dikarenakan oleh terapi radiasi kanker yang terdapat di kepala dan leher tercatat 80%. persentase kejadian mukositis lebih tinggi pada pasien dengan terapi radiasi daripada pasien dengan kemoterapi, hampir 100% pasien dengan kemoterapi dengan dosis yang tinggi mengalami mukositis oral, dan 40% bagi pasien yang menerima kemoterapi dosis standar (www.qualityhealth.com, 2009). angka kejadian mukositis pada perempuan 60% sedangkan pada laki-laki 40% (vokurka, 2005). dari penelitian yang dilakukan oleh donelly (2006) diketahui 75-90% mukositis terjadi pada pasien yang mengalami hsct (hematopoietic stem cell transplantation), dengan paling banyak pada pasien yang menerima tbi (total body irradition) dan dikombinasi dengan kemoterapi. mukositis bisa menjadi efek samping yang paling bermasalah dari terapi radiasi dan kemoterapi. hasil penelitian yang dilakukan oleh anne w (2004) menunjukkan dari 40 sampel yang diteliti (20 sampel berkumur dengan normal salin dan 20 sampel berkumur dengan hydrogen peroxida) sampel yang berkumur dengan normal salin tingkat kebersihan mulutnya lebih baik daripada sampel yang tidak menggunakan normal salin. juga angka mukositis pada sampel yang berkumur dengan normal salin lebih rendah. nagatake (2002) dalam penelitiannya, 19 sampel yang berkumur menggunakan povidon iodin, hanya 2% (3 sampel) yang mengalami mukositis jika dibandingkan dengan sampel yang berkumur tidak menggunakan povidon iodin. penelitian lain dilakukan oleh vokurka (2005) menunjukkan bahwa normal salin dan povidon iodin mampu mencegah dan mempercepat proses penyembuhan mukositis oral pada pasien kemoterapi. normal salin adalah cairan fisiologis (sesuai dengan cairan tubuh) yang dapat membersihkan debris, tidak mengiritasi, juga tidak mengubah ph saliva. karena tidak mengubah ph saliva, buffer alami mulut tidak akan terganggu. fisiologis mulut akan terjaga karena tidak terjadi iritasi. berkurangnya jumlah debris akan mengakibatkan berkurangnya bakteri yang ada dalam mulut. bila pasien berkumur dengan normal salin maka diharapkan ketahanan (oral) pasien akan meningkat (kramer, 2004). larutan povidon iodin 1% mampu membunuh dan mencegah kolonisasi bakteri dalam mulut, karena povidon iodin ini bersifat anti bakteri. dengan berkumur menggunakan normal salin dan povidon iodin mampu mengurangi risiko kejadian mukositis oral pada pasien anak dengan kemoterapi (vokurka, 2005). bahan dan metode penelitian desain penelitian yang digunakan dalam penelitian ini yaitu preexperiment static group comparison. sampel diambil dengan teknik simple random sampling, sebanyak 18 responden, dibagi menjadi 2 kelompok perlakuan (diberikan intervensi berkumur dengan povidon iodin 1% dan http://www.kompas.com/ http://www.qualityhealth.com/ pencegahan mukositis oral (nursalam) 105 normal salin sebanyak 4 kali sehari dan setelah makan atau minum selama 30”-60” selama 5 hari) dan kelompok kontrol (berkumur dengan air biasa) dengan jumlah sampel masing-masing 6 orang. penelitian dilakukan pada tangal 10-25 juli 2009. variabel independen dalam penelitian ini yaitu berkumur dengan menggunakan larutan normal salin dan povidon iodin, sedangkan variabel dependen dalam penelitian ini adalah kejadian mukositis oral. bahan yang digunakan oleh peneliti adalah: 1) larutan povidon iodin 1% dimana peneliti menggunakan betadine obat kumur, 2) larutan normal salin, 3) gelas, 4) baskom kecil, 5) handuk kecil atau tisu. pengumpulan data pada penelitian ini dengan melakukan observasi pada responden. instrumen yang digunakan adalah multiple variable mucositis rating scales yang diadopsi dari napenas (2007). isi dari multiple variable mucositis rating scales adalah 1) saliva tipis berair, mulut merah, 2) saliva bertambah, mulut agak pucat, 3) saliva jumlahnya sedikit, mulut kering, 4) saliva tebal dan kental, mulut sangat kering. nilai diperoleh bedasarkan skala pada multiple variable mucositis rating scales. data yang diperoleh, dianalisis dengan menggunakan uji statistik mann whitney u test, dengan derajat kemaknaan α<0,05. hasil penelitian hasil penelitian menunjukkan bahwa kelompok povidon iodin 1% diketahui bahwa terdapat satu sampel yang mengalami saliva tebal kental dan mulut sangat kering, 3 sampel mengalami saliva bertambah dan mulut agak pucat, dan 2 sampel mengalami saliva yang tipis berair dan mulut berwarna merah. pada kelompok normal salin diketahui 1 sampel mengalami saliva jumlahnya sedikit dan mulut kering, 3 sampel mengalami saliva bertambah dan mulut agak pucat, dan 2 sampel yang mengalami saliva tipis berair dan mulut merah. sementara pada kelompok kontrol terdapat 4 sampel yang mengalami saliva tebal kental dan mulut sangat kering, 1 sampel mengalami saliva jumlahnya sedikit dan mulut kering, dan 1 sampel yang mengalami saliva bertambah dan mulutnya agak pucat (tabel 1). hasil analisis uji mann whitney u test untuk kedua kelompok perlakuan setelah diobservasi pada hari kelima perlakuan. pada kelompok povidon iodin 1% dan kelompok kontrol didapatkan nilai p=0,034, hasil ini menunjukkan bahwa povidon iodin 1% efektif mencegah mukositis oral. pada kelompok normal salin dan kelompok kontrol didapatkan nilai p=0,012, hasil ini menujukkan bahwa normal salin efektif mencegah mukositis oral. hasil uji statistik pada kelompok povidon iodin 1% dan normal salin didapatkan nilai p=0, 930. hasil ini menunjukkan bahwa tidak terdapat perbedaan efektifitas penggunaan normal salin dan povidon iodin 1% sebagai obat kumur untuk mencegah mukositis oral (tabel 2). pembahasan hasil data demografi dapat diketahui sampel pada kelompok povidon iodin 1% yang menderita leukemia berjumlah 4 sampel, pada kelompok normal salin berjumlah 3 sampel dan pada kelompok kontrol semua sampel menderita leukemia. pada pasien leukemia akan mengalami kegagalan sumsum tulang (anemia, leukositopenia, trombositopenia) dapat disertai dengan pendarahan atau infeksi. pada pasien yang mengalami leukemia akan mengalami leukositopenia (van de velde, et al.,1999). jumlah leukosit yang berkurang akan mengakibatkan pertahanan tubuh melemah (silbernagl & lang, 2007). apabila ada benda asing (bakteri, virus, atau jamur) dalam tubuh (mis. : rongga mulut) maka akan sangat mudah terjadi infeksi (mis. : mukositis oral). sistem imunologik pasien yang menderita leukemia juga menurun sehingga sangat rentan terhadap infeksi. seringkali infeksi terjadi dalam rongga mulut dan tenggorokan (van de velde et al., 1999). jurnal ners vol. 4 no. 2: 103-109 106 tabel 1. keadaan saliva dan mulut sampel setelah observasi pada hari ke-5 kategori saliva kelompok povidon iodin 1% (jumlah) normal salin (jumlah) kontrol (jumlah) tipis berair&mulut merah 2 2 bertambah&mulut agak pucat 3 3 1 sedikit dan mulut kering 1 1 tebal kental dan mulut sangat kering 1 4 total 6 6 6 tabel 2. hasil saliva dan mulut pada hari ke-5 kelompok povidon iodin 1%, normal salin dan kelompok kontrol no. kelompok pi 1% kontrol (jumlah) ns – kontrol (jumlah) pi 1% ns (jumlah) tipis berair&mulut merah 2 2 4 bertambah&mulut agak pucat 4 4 6 sedikit dan mulut kering 1 2 1 tebal kental dan mulut sangat kering 5 4 1 total 12 12 12 rerata 2.75 2.67 1.92 sd 1.215 1.155 0.900 mann whitney u test p=0,034 p=0,012 p=0,930 keterangan : p= signifikansi sd= standar deviasi pasien yang menerima kemoterapi maka lapisan mukosa dalam tubuhnya akan terganggu, demikian pula dengan mukosa oral (gipsland oncology nurses group, 2007). semakin sering pasien menerima kemoterapi, semakin mukosa oral akan mengalami pengikisan, sehingga semakin tipis. mukosa mulut sendiri merupakan salah satu sistem pertahanan mulut (keshav, 2004). apabila mukosa terganggu maka akan sangat rentan terkena infeksi, sehingga jika terdapat bakteri, virus, atau jamur meskipun dalam jumlah yang sedikit maka kemungkinan untuk terjadinya infeksi sangatlah besar (pavlatos et al., 2008). jumlah sampel yang pernah mengalami mukositis oral sebelumnya pada kelompok povidon iodin 1% adalah 6 sampel, pada kelompok normal salin berjumlah 5 sampel, sementara itu pada kelompok kontrol 4 sampel. penyebab terjadinya mukositis oral adalah terdapatnya bakteri, virus, atau jamur di dalam mulut. pasien yang mempunyai riwayat pernah mengalami mukositis oral sebelumnya juga akan lebih rentan untuk mengalami mukositis oral lagi, karena meskipun secara klinis mukosa mulutnya telah terbentuk kembali, mukosa ini telah berubah secara permanen dengan adanya sisa angiogenesis, kondisi ini meningkatkan risiko terjadinya mukositis ulang pada pasien (napenas dkk, 2007). distribusi sampel berdasar jenis obat kemoterapi yang diterima pada dua kelompok perlakuan diketahui berjumlah sama, yaitu 4 sampel menerima jenis obat pertama dan 2 sampel menerima obat jenis kedua. pada jenis obat kemoterapi tertentu mukositis oral memang merupakan efek samping yang pasti muncul. obat kemoterapi yang mempunyai efek samping mukositis oral yaitu methotrexate (antimetabolites). hasil observasi menunjukkan pada kelompok povidon iodin 1% terdapat 1 sampel yang mengalami mukositis oral, sedangkan pada kelompok normal salin tidak ada. dengan demikian dapat dilihat bahwa untuk jenis obat kemoterapi yang mempunyai efek samping mukositis oral normal salin lebih efektif sebagai obat kumur. salah satu tanda awal dari mukositis oral adalah cairan ludah yang mengental pencegahan mukositis oral (nursalam) 107 (napenas, 2007). selain mukosa mulut, cairan ludah merupakan salah satu yang berfungsi untuk menjaga keadaan fisiologis mulut (keshav, 2004). ludah mengandung sejumlah enzim yang membantu proses pencernaan dan mampu membunuh bakteri karena mengandung antibakteri (silbernagl & lang, 2007). apabila terdapat bakteri, virus, atau jamur dalam rongga mulut maka kelenjar ludah akan meningkatkan ekskresinya. kelenjar ludah meningkatkan ekskresi karena ludah mengenali baktei, virus, dan jamur sebagai benda asing dalam rongga mulut. selain meningkatkan ekskresi, ludah juga akan meningkatkan kandungan dalam ludah itu sendiri. sehingga ludah akan terlihat lengket dan terasa kental. kelenjar ludah akan melakukannya dengan tujuan untuk menghilangkan benda asing yang ada dalam rongga mulut, dengan begitu fisiologis mulut akan terjaga (keshav, 2004). sampel pada masing-masing kelompok dalam penelitian ini diminta untuk berkumur sebanyak 4 kali sehari selama 30”60” dan setiap selesai makan dan minum. pada akhir observasi menunjukkan bahwa terdapat 1 sampel pada kelompok povidon iodin 1% yang mengalami pengentalan salivasi, sementara pada kelompok normal salin tidak ada yang mengalami pengentalan salivasi. dari segi kenyamanan kelompok povidon iodin 1% merasa kurang nyaman. hal ini dikarenakan rasa dari povidon iodin yang masam. pada kelompok povidon iodin 1% juga terdapat sampel yang merasakan nyeri dalam rongga mulutnya. sedangkan dalam kelompok normal salin tidak ada sampel yang mengeluhkan mengenai kenyamanan. kelompok perlakuan yang berkumur dengan normal salin tidak ada yang mengalami pengentalan salivasi. normal salin tidak mengubah ph dan komposisinya sesuai dengan cairan tubuh (wohlschlaeger, 2004), sehingga apabila sampel berkumur dengan normal salin dan dalam keadaan status kesehatan yang kurang hal ini tidak akan terlalu berpengaruh terhadap status mukosa oral sampel. berkumur dengan povidon iodin 1% dan normal salin sama-sama efektif untuk mencegah mukositis oral pada pasien anak dengan kemoterapi. tidak ada sampel yang mengalami pengentalan salivasi pada kelompok perlakuan yang berkumur dengan normal salin akan tetapi pada kelompok perlakuan berkumur dengan povidon iodin 1% terdapat satu sampel yang mengalami pengentalan salivasi (1 anak), sedangkan pada kelompok kontrol terdapat 4 sampel yang mengalami salivasi tebal kental dan mulut sangat kering. berkumur untuk pasien dengan kemoterapi sendiri sebenarnya berfungsi untuk mengurangi atau membunuh bakteri, virus, atau jamur yang terdapat dalam mulut pasien (joanna bridge institute, 1998). berkumur dengan povidon iodin 1% akan membunuh bakteri dalam mulut, karena povidon iodin merupakan bakterisida dengan spektrum luas. penggunaan povidon iodin ini akan mencegah kolonisasi bakteri, dan juga akan mengurangi jumlah bakteri jahat (ogatha, 2004). akan tetapi povidon iodin sendiri juga mampu menghambat proliferasi sel. povidon iodin juga akan menyebabkan iritasi, toksisitas dan noda pada daerah yang terkena povidon iodin apabila digunakan dalam bentuk terlarut dengan air yang berlebih (kwong, 2004). kolonisasi mikroflora bisa menghasilkan endotoksin, sebuah substan yang sangat mampu menimbulkan inflamasi, sehingga meningkatkan proses inflamasi dan kerusakan mukosa yang lebih parah (shuin dkk, 2008). normal salin merupakan cairan fisiologis yang sesuai dengan cairan tubuh (hartanto, 2007). oleh karena itu banyak digunakan untuk resusuitassi cairan (oreopoulus et al., 2006). normal salin bisa digunakan sebagai obat kumur karena tidak mengubah ph saliva, sehingga buffer alami mulut akan terjaga (wohlschlaeger, 2004). penumpukan debris dalam mulut tidak akan terjadi. bakteri di dalam rongga mulut juga akan berkurang karena tidak adanya penumpukan debris. selain itu larutan normal salin ini juga tidak bersifat iritatif sehingga fisiologi mulut akan tetap terjaga. dengan demikian pertahanan mulut akan meningkat dan risiko terkena infeksi mulut akan berkurang bahkan mungkin tidak akan terjadi (kramer, 2004). hasil penelitian ini sesuai dengan penelitian yang dilakukan oleh samuel vokurka (2005) dimana ternyata terbukti normal salin dan povidon iodin 1% efektif jurnal ners vol. 4 no. 2: 103-109 108 untuk mencegah mukositis oral pada pasien anak dengan kemoterapi. hasil penelitian ini juga sesuai dengan penelitian yang dilakukan oleh nagatake (2002). bahwa povidon iodin 1% lebih efektif untuk mencegah mukositis oral pada pasien anak dengan kemoterapi bila dibandingkan dengan air biasa. dari 19 sampel penelitian nagatake yang berkumur dengan povidon iodin 1% hanya 2 sampel yang mengalami mukositis oral. simpulan dan saran simpulan povidon iodin 1% dan larutan normal salin efektif digunakan untuk berkumur sebagai pencegah terjadinya mukositis oral pada pasien yang mendapatkan kemoterapi. saran peneliti menyarankan agar: 1) tenaga kesehatan di ruangan sebaiknya menggunakan normal salin atau povidon iodin 1% sebagai bahan untuk melakukan oral hygiene, 2) perawat dalam memberikan intervensi keperawatan dapat menggunakan normal salin atau povidon iodin 1%, 3) sebaiknya digunakan larutan normal salin sebagai obat kumur karena lebih nyaman, aman dan ekonomis kepustakaan gipsland oncology nurses group, 2007. cancer care guidelines. gippsland: gong publishing, pp.1-4. hartanto, w., 2007. terapi cairan dan elektrolit perioperatif. thesis tidak untuk dipublikasikan. bogor: fakultas kedokteran universitas padjajaran, hlm. 28-29. japardi, i., 2009. gejala kanker pada anakanak., (online), (http://rumahkanker.com/content/ view/64/62/, diakses tanggal 21 mei 2009, jam 13.00 wib). joanna bridge intitute, 1998. prevention and treatment of oral mucositis in cancer patients. journal of best practice, 2 (3) , pp. 1-6. keshav, s., 2004. the gastro intestinal system at a glance. massachussets: black well publishing, pp.12-17. kramer, s., 2004. effect of povidon iodin on wound healing: a review. journal of vascular nursing, 17 (1), pp.17-21. kwong, 2004. prevention and treatment of oropharyngeal mucositis following cancer therapy. journal of cancer nursing. 27 (3), pp.183-205. nagatake, t., 2002. prevention of respiratory infetions by povidon iodin gargle. journal of dermatololgy, 204 (1), pp.32-36. napenas, et al., 2007. mucositis: review of pathogenesis, diagnosis, prevention, and management. journal of general dentistry. july-august edition, pp. 335-344. ogatha, j., et al., 2004. gargling with povidon iodin reduces the transport of bacteria during oral intubation. journal of canadian journal of anasthesia. 51 (59), pp. 932-936. oreopoulos, et al., 2005. is normal salin harmful for the peritoneum?. journal of peritoneal dialysis international, 25, pp. 67-70. popa, et al., 2008. cancer therapy induced oral mucositis a review of epidemiology, pathophysiology, and treatment. journal of tmj. 58 (1-2), pp. 104-107. silbernagl & lang, 2007. teks dan atlas berwana patofisiologi. jakarta: egc, hlm.: 134. sutaryo, 2009. jumlah penderita kanker anak makin meningkat, (online), (http://kompas.com, diakses tanggal 01 mei 2009, jam 09.00 wib). treister, ns., 2008. chemotherapy induced oral mucositis, (online) http://emedicine.com, diakses tanggal 25 mei 2009, jam 16.00 wib). ugrasena, 2008. leukemia makin belia (online), (http://www.lintasberita.com/sains /leukemia_makin_belia, diakses tanggal 01 mei 2009, jam 09.00 wib). van de velde, dkk., 1999). onkologi edisi kelima revisi. yogyakarta: gadjah mada university press, hlm..657-667. http://rumahkanker.com/content/%20view/64/62/ http://rumahkanker.com/content/%20view/64/62/ http://kompas.com/ http://emedicine.com/ http://www.lintasberita.com/sains%20/leukemia_makin_belia http://www.lintasberita.com/sains%20/leukemia_makin_belia pencegahan mukositis oral (nursalam) 109 vokurka, s., et al., 2005. the comparative effects of povidon iodin and normal salin mouthwashes on oral mucositis in patients after high dose chemotherapy and apbsct result of a randomized multicentre study. journal of support care cancer, 13, pp. 554-558. weill, a., 2005. efek kemoterapi dan pencegahannya, (online), (http://nirmala.com/april, diakses tanggal 12 mei 2009, jam 15.00 wib). wohlschleager, a., et al.,2004. prevention and treatment of mucositis: a guide for nurses. journal of pediatric oncology nursing. 21 (5), pp. 281-287. http://nirmala.com/april musik klasik menurunkan tingkat stres dan tekanan darah dan nadi ibu primigravida trimester ketiga 149 konseling memperbaiki perilaku pencegahan anemia ibu hamil (counseling improves anemia prevention behavior of pregnant women) mira triharini*, tiyas kusumaningrum*, christine octaviani* abstract introduction: pregnancy closely associated with anemia, where the condition of mothers with hb under 11gr% in 1 st and 3 rd trimester or haemoglobin (hb) levels below 10.5 g% in 2 nd trimester. knowledge, attitudes and practices of pregnant women on preventing anemia during pregnancy is one of the factors that influence incidence of anemia which affects the health of babies. objective of this study was to explain the effect of counseling toward anemia prevention behaviour (knowledge, attitude, practice) of pregnant women. method: a pre-experimental (one group pretest-posttest) simple random sampling design was used in this study. population of this study was all pregnant women in mrs. wolita midwife practice surabaya ( as many as 30 pregnant women a month). sample of these 28 pregnant women were recruited over period of this study. independent variable was counseling, while the dependent variable were knowledge, attitudes and practice. data were collected by using questionnaires and analyzed with the wilcoxon signed rank test with significance levelof α ≤0.05. result: the result showed that counseling effected behaviour (knowledge, attitude and practice) of pregnant women on anemia prevention with significance level p=0.000 (knowledge); p=0.007 (attitude) and p=0.027 (practice). analysis: it can be concluded that counseling or health education about prevention of pregnancy anemia is needed for pregnant women. discussion: it is recomended that regular counseling must be provided by counselor to prevent anemia during pregnancy. haemoglobin of pregnant women should also be checked regularly in the midwife practices, as a first step effort to decrease the incidence of anemia in pregnant women. keywords : anemia during pregnancy, behaviour, counseling. * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: mira.tri_ners@unair.ac.id pendahuluan selama kehamilan terjadi peningkatan volume plasma dan sel darah merah ibu sekitar 45% diatas volume sebelum hamil. tetapi peningkatan jumlah sel darah merah lebih kecil daripada peningkatan volume plasma sehingga terjadi anemia delusional (sarwono, 2002). kehamilan erat hubungannya dangan anemia, yaitu kondisi ibu dengan kadar hb dibawah 11 gr % pada trimester i dan iii atau kadar hb < 10.5 gr % pada trimester ii. nilai batas dan perbedaan dengan kondisi tidak hamil terjadi karena hemodilusi (sarwono, 2002). hertanto (2006) menyatakan bahwa banyaknya ibu hamil yang menderita anemia, disebabkan oleh pengetahuan ibu hamil yang kurang tentang upaya pencegahan anemia pada masa kehamilan. pengetahuan, sikap, dan tindakan ibu dalam mencegah anemia pada masa kehamilan merupakan salah satu faktor yang ikut mempengaruhi kejadian anemia yang berdampak pada kesehatan bayi. pengetahuan ibu hamil yang kurang akan berakibat pada sikap dan tindakan ibu yang kurang optimal. pengetahuan yang kurang tentang makanan yang banyak mengandung zat besi serta cara pengolahan yang benar juga menjadi faktor asupan zat besi yang tidak adekuat. upaya yang telah dilakukan mailto:mira.tri_ners@unair.ac.id jurnal ners vol.4 no. 2: 149-154 150 selama ini adalah dengan pemberian suplemen tablet besi. di bps wilayah mojo (ibu wolita), konseling yang diberikan meliputi waktu mengkomsumsi tablet besi yaitu sebelum tidur, mengkonsumsi makanan yang bergizi dan anjuran rutin melakukan pemeriksaan kehamilan. data di indonesia menunjukkan bahwa sekitar 20% wanita, 50% wanita hamil dan 3% pria kekurangan zat besi, yang merupakan salah satu penyebab anemia (djumhana, 2006). berdasarkan data world health organization (who) pada tahun 2005, bahwa setiap tahun wanita yang bersalin meninggal dunia mencapai lebih dari 500.000 orang (wiknjosastro, 2005). kematian ibu di sebabkan oleh faktor perdarahan, eklampsi dan penyebab tidak langsung yaitu anemia (yeni, 2009). didapatkan angka prevalensi anemia yang sangat tinggi di new delhi, india yaitu dari 1150 orang wanita, 96% di antaranya terkena anemia (89,8% anemia sedang, 5,3% anemia berat). kejadian anemia di dapatkan 96,18% pada wanita vegetarian, dan 95,3% pada wanita mengkonsumsi daging halal. tingginya kejadian anemia masa kehamilan di new delhi mungkin juga di sebabkan karena jarangnya frekuensi mengkonsumsi daging (sharma et al, 2003). menurut survey demografi kesehatan indonesia (sdki) pada tahun 2005 angka kematian ibu (aki) di indonesia yaitu 262/100.000 kelahiran hidup. (yeni, 2009). mayoritas kematian ibu disebabkan oleh perdarahan yang tidak dapat di toleransi karena anemia. hasil survey pendahuluan di bps wilayah mojo (ibu wolita) didapatkan data pada pemeriksaan hb 10 orang ibu hamil, 70% terkena anemia. pengetahuan yang kurang tentang upaya pencegahan anemia dapat menimbulkan sikap dan tindakan yang kurang tepat dalam penatalaksanaan mengurangi kejadian anemia. beberapa ibu hamil memiliki pengetahuan kurang tentang cara mengkonsumsi tablet besi yang baik, seperti meminumnya dengan teh hangat atau juga setelah makan. cara mengkonsumsi tablet besi yang kurang tepat akan mengakibatkan penyerapan terhadap tablet besi kurang baik. sehingga tidak terjadi peningkatan kadar hb yang di harapkan. anemia pada masa kehamilan berdampak pada ibu dan janin. anemia dapat menyebabkan terhambatnya pertumbuhan janin, bayi lahir dengan bblr (berat badan bayi rendah), bayi lahir dengan anemia, mudah terinfeksi, dan pertumbuhan bayi setelah lahir dapat terhambat. pada ibu dapat terjadi persalinan lama, distosia, pendarahan post partum dan mudah terinfeksi post partum (manuaba, 2002). penjelasan tentang upaya pencegahan anemia masa kehamilan dapat dilakukan melalui pendidikan kesehatan sehingga pengetahuan ibu akan bertambah. pendidikan kesehatan merupakan proses belajar pada individu, kelompok, atau masyarakat dari tidak tahu tentang nilai kesehatan menjadi tahu, dan dari yang tidak mampu mengatasi masalah kesehatan sendiri menjadi mandiri. konseling adalah suatu proses saling belajar yang menyangkut dua individu dalam suasana edukatif. pihak pertama adalah konseli atau klien yang meminta atau memerlukan bantuan dari pihak kedua (konselor). upaya pencegahan anemia yang dilakukan secara efektif sangat diperlukan untuk keberhasilan menekan prevalensi terjadinya anemia pada ibu hamil. bahan dan metode penelitian desain yang digunakan dalam penelitian ini yaitu pre-experimental dengan pre-posttest design . populasi dalam penelitian ini adalah seluruh ibu hamil di bps wilayah mojo surabaya selama satu bulan yakni sebanyak 30 pasien. sampel diambil sesuai dengan kriteria inklusi dan diperoleh 28 responden. adapun kriteria inklusi yaitu: 1) ibu yang bersedia menjadi responden, 2) ibu yang tinggal serumah dengan anaknya. penelitian ini dilaksanakan pada bulan desember 2009. variabel independen dalam penelitian ini yaitu konseling. variabel dependen dalam penelitian ini adalah perilaku ibu dengan sub variabel: 1) pengetahuan ibu tentang pecegahan anemia masa kehamilan, 2) sikap ibu tentang pencegahan anemia masa kehamilan dan 3) tindakan ibu tentang pencegahan anemia masa kehamilan. instrumen pengumpulan data dalam penelitian ini menggunakan kuesioner. pengumpulan data pretest tentang pengetahuan, sikap dan tindakan dilakukan kepada ibu hamil yang telah selesai di periksa. kemudian diberikan pendidikan konseling dan pencegahan anemia ibu hamil (mira triharini) 151 kesehatan tentang pencegahan anemia masa kehamilan dengan konseling menggunakan media flipchart dan leaflet selama ± 15-20 menit. konseling yang kedua dilakukan tujuh hari setelah konseling pertama yaitu waktu dan tempat berdasarkan kesepakatan peneliti dan ibu hamil. pengumpulan data post test tantang pengetahuan, sikap dan tindakan dilakukan tujuh hari setelah konseling kedua. hasil penelitian pengumpulan perilaku data (pengetahuan, sikap dan tindakan) responden diperoleh menggunakan instrumen yang berupa kuesioner. tingkat pengetahuan dibagi menjadi tiga kategori yaitu baik, cukup dan kurang. hasil penelitian menunjukkan bahwa sebelum diberikan konseling sebanyak 16 responden (63%) memiliki tingkat pengetahuan cukup, sebanyak 8 responden (31%) memiliki tingkat pengetahuan kurang, dan sebesar 6% memiliki tingkat pengetahuan baik. sesudah diberikan konseling sebagian besar (89%) memiliki pengetahuan baik, 11% memiliki pengetahuan cukup, dan tidak ada responden yang memiliki pengetahuan kurang. hasil analisis statistik dengan uji wilcoxon signed rank test antara pengetahuan sebelum dan sesudah pendidikan kesehatan didapatkan nilai p=0,000, berarti terdapat pengaruh konseling terhadap perubahan pengetahuan ibu dalam pencegahan anemia masa kehamilan (tabel 1). sikap dibagi menjadi dua kategori yaitu sikap positif dan negatif. hasil penelitian sikap responden menunjukkan bahwa sebelum diberikan konseling sebagian besar responden (64%) bersikap negatif dan sebesar 36% bersikap positif tentang upaya pencegahan anemia masa kehamilan. sesudah diberikan konseling terdapat 12 responden (43%) mempunyai sikap positif dan 16 responden (57%) memiliki sikap negatif. berdasar hasil uji statistik wilcoxon signed rank test didapatkan nilai signifikansi p=0,007, berarti terdapat pengaruh konseling terhadap sikap ibu dalam pencegahan anemia masa kehamilan (tabel 2). tindakan dibagi menjadi tiga kategori yaitu baik, cukup dan kurang. hasil penelitian menunjukkan bahwa sebelum diberikan konseling, lebih dari sebagian (57%) memiliki tindakan cukup, 4 responden (14%) memiliki tindakan kurang, dan sisa responden memiliki tindakan baik. sesudah diberikan konseling sebanyak 14 responden (50%) memiliki tindakan baik, 14 responden (50%) memiliki tindakan cukup dan tidak ada responden yang memiliki tindakan yang kurang. hasil analisis statistik menggunakan wilcoxon signed rank test didapatkan p=0,027. hasil ini menunjukkan bahwa konseling berpengaruh terhadap tindakan pencegahan anemia pada ibu hamil (tabel 3). tabel. 1 pengetahuan ibu hamil sebelum dan sesudah diberikan konseling tentang upaya pencegahan anemia masa kehamilan di bps ibu wolita surabaya 1-22 januari 2010 no. pengetahuan sebelum sesudah jumlah % jumlah % 1. baik 4 6 25 89 2. cukup 16 63 3 11 3. kurang 8 31 uji wilcoxon signed rank test p=0,000 tabel. 2 sikap ibu hamil sebelum dan sesudah diberikan konseling tentang upaya pencegahan anemia masa kehamilan di bps ibu wolita surabaya 1 januari2010 22 januari 2010 no. pengetahuan sebelum sesudah jumlah % jumlah % 1. negatif 18 64 16 57 2. positif 10 36 12 43 uji wilcoxon signed rank test p=0,007 jurnal ners vol.4 no. 2: 149-154 152 tabel. 3 tindakan ibu hamil sebelum dan sesudah diberikan konseling tentang upaya pencegahan anemia masa kehamilan di bps ibu wolita surabaya 1 januari2010 22 januari 2010 no. tindakan sebelum sesudah jumlah % jumlah % 1. baik 8 19 14 50 2. cukup 16 57 14 50 3. kurang 4 14 uji wilcoxon signed rank test p=0,027 keterangan : p = tingkat signifikansi % = prosentase pembahasan hasil penelitian didapatkan bahwa pengetahuan ibu hamil tentang upaya pancegahan anemia masa kehamilan mengalami perubahan. setelah diberikan konseling lebih dari sebagian besar responden memiliki tngkat pengetahuan baik dan sisanya memiliki tingkat pengetahuan cukup. menurut notoadmodjo (2005), salah satu cara memperoleh pengetahuan yaitu melalui kebiasaan atau otoritas. pengetahuan tersebut diperoleh berdasarkan pada otoritas atau kekuasaan, baik tradisi, otoritas pemerintahan, otoritas pemimpin agama maupun ahli pengetahuan. petugas kesehatan baik bidan ataupun perawat dianggap ahli dalam ilmu pengetahuan sehingga ibu hamil menerima apa yang disampaikan dalam konseling. faktor-faktor yang mempengaruhi pengetahuan yaitu pendidikan, semakin tinggi pendidikan seseorang semakin mudah menerima informasi sehingga banyak pengetahuan yang dimiliki. responden dalam penelitian ini sebagian besar berpendidikan smu sehingga mereka mudah menerima konseling yang diberikan. sesuai dengan pendapat notoadmojo (2003) bahwa pendidikan kesehatan merupakan proses belajar pada individu, kelompok dan masyarakat dari yang tidak tahu nilai-nilai kesehatan menjadi tahu, dari tidak mampu mengatasi masalah menjadi mampu mengatasi masalah sendiri. konseling adalah suatu hubungan membantu (helping relationship) antara individu, yang bertujuan agar individu yang dibantu memperoleh insight terhadap masalahnya, mau bertanggung jawab dan mampu mengambil keputusan yang efektif. dari data diatas menunjukkan tingkat signifikasi yang tinggi antara sebelum dan sesudah diberikan konseling, hal tersebut disebabkan: 1) sebagian besar responden mempunyai latar belakang pendidikan smu dan memiliki pengetahuan cukup, 2) metode pendidikan kesehatan yang diberikan adalah individual, materi yang diberikan berfokus pada individu sehingga responden akan menerima dan memahami materi yang diberikan, setelah mendapatkan konseling akan menambah pengetahuan responden tentang upaya pencegahan anemia masa kehamilan dan 3) alat peraga yang digunakan mempermudah penerimaan informasi oleh sasaran pendidikan. menurut notoadmojo (2007) indera yang paling banyak menyalurkan pengetahuan ke dalam otak adalah mata. sehingga alat peraga lebih mempermudah cara penyampaian dan penerimaan informasi atau bahan pendidikan. berdasarkan hasil penelitian didapatkan adanya perubahan sikap ibu hamil tentang pencegahan anemia masa kehamilan. setelah diberikan konseling. lebih dari separo jumlah responden masih memiliki sikap negatif dan sisanya memiliki sikap positif. berdasarkan teori yang dikemukakan azwar (2003) menyatakan bahwa pembentukan sikap dipengaruhi oleh beberapa faktor antara lain: 1) faktor budaya yang dianut oleh keluarga, 2) perhatian yang diberikan. teori yang dikemukakan oleh soemadi (1996) mendefinisikan sikap merupakan respon yang berhubungan dengan interest (perhatian), apresiasi (penghargaan), dan persepsi (perasaan), 3) lingkungan tempat tinggal yang merupakan faktor yang paling besar yang dapat mempengaruhi pembentukan sikap seseorang, 4) media konseling dan pencegahan anemia ibu hamil (mira triharini) 153 massa sebagai sarana komunikasi yang dapat mempunyai pengaruh besar dalam pembentukan opini dan kepercayaan orang. informasi baru memberikan landasan kognitif yang baru bagi terbentuknya sikap, 5) lembaga agama sebagai suatu system mempunyai pengaruh dalam pembentukan sikap karena merupakan dasar pengertian dan konsep moral dalam diri individu orang lain yang dianggap penting, 6) emosi, apabila terlalu tua atau muda memungkinkan untuk tidak dapat menjalankan peran pengasuh secara optimal karena diperlukan kekuatan psikis terutama dalam kaitannya dengan strategi koping yang dimiliki dalam upaya pencegahan anemia masa kehamilan. responden yang memiliki sikap negatif sesudah konseling, dari data demografi dapat diketahui bahwa mayaoritas adalah multigravida. dapat diduga mereka mempunyai anggapan bahwa upaya pencegahan anemia tidak terlalu penting untuk dilaksanakan karena semua anak lahir dengan lancar dan lahir normal walaupun saat hamil tidak rutin meminum tablet besi. hasil penelitian menunjukkan bahwa sebelum diberikan konseling lebih dari separuh jumlah responden bersikap negatif. sedangkan sesudah diberikan konseling mayoritas, masih memiliki sikap negatif dan sisanya memiliki sikap positif. dari data tersebut menunjukkan bahwa sikap positif antara sesudah dan sebelum diberikan konseling mengalami sedikit peningkatan. sikap memerlukan proses internal yang membutuhkan waktu dan setiap individu akan memberikan respon yang berbeda untuk berubah. proses perubahan sikap dimulai saat responden menerima pendidikan kesehatan yang diberikan dan mau memperhatikan. responden kemudian merespon stimulus tersebut dengan menanyakan kembali hal yang belum jelas atau menjawab jika peneliti bertanya pada responden. responden juga menghargai peneliti yang memberikan pendidikan kesehatan, selanjutnya bertanggung jawab memilih sikap yang baru tentang upaya pencegahan anemia masa kehamilan. berdasarkan hasil penelitian didapatkan bahwa tindakan ibu hamil dalam upaya pencegahan anemia masa kehamilan mengalami perubahan. sebelum diberikan konseling mayoritas responden memiliki tindakan yang cukup. sesudah diberikan konseling separuh responden memiliki tindakan yang baik, sebagian lagi memiliki tindakan cukup dan tidak ada esponden yang memiliki tindakan yang kurang. menurut notoatmodjo (2003) mengungkapkan bahwa sebelum mengadopsi perilaku baru, di dalam diri orang tersebut terjadi proses berurutan yaitu: 1) awarness (kesadaran), yakni orang tersebut menyadari dalam arti mengetahui stimulus (objek) terlebih dahulu, 2) interest, yakni orang mulai tertari pada stimulus, 3) evaluation, menimbang baik tidaknya stimulus tersebut terhadap dirinya, 4) trial, orang telah mencoba perilaku baru dan 5) adoption, subjek telah berperilaku sesuai pengalaman, kesadaran dan sikapnya terhadap stimulus. tindakan responden mengalami peningkatan sesudah diberikan konseling. tindakan dipengaruhi oleh beberapa faktor antara lain pengetahuan yang baik tentang upaya pencegahan anemia masa kehamilan dan sikap ibu hamil yang menerima sehingga tindakan ibu hamil menjadi lebih baik dalam upaya pencegahan anemia masa kehamilan. responden telah mengetahui upaya pencegahan anemia masa kehamilan, kemudian mulai tertarik pada stimulus tersebut, sehingga responden mempertimbangkan apakah upaya pencegahan anemia masa kehamilan memang perlu dilakukan. responden yang yakin bahwa upaya pencegahan anemia masa kehamilan memang perlu dilakukan akan mencoba melakukan upaya tersebut. responden tersebut seterusnya akan berperilaku baru yaitu melakukan upaya pencegahan anemia masa kehamilan. hasil uji statistik menunjukkan bahwa terjadi perubahan tindakan yang signifikan hal ini menunjukkan bahwa terdapat perbedaan yang bermakna antara tindakan responden sebelum dan sesudah mendapatkan konseling. sesuai dengan teori lawrence green, perilaku manusia dipengaruhi oleh: 1) presdisposing factor yaitu pengetahuan responden tentang cara pencegahan anemia masa kehamilan, 2) enabling factor, pemberian leaflet dan lembar balik/flipchart kepada setiap responden dan kesempatan untuk menanyakan hal yang kurang jelas baik pada konselor atau pada bidan yang bertugas dan 3) reinforcing factor yaitu sikap, tindakan dan perhatian petugas kesehatan jurnal ners vol.4 no. 2: 149-154 154 dalam memperhatikan ibu hamil khususnya dalam memberikan pendidikan kesehatan tentang upaya pencegahan anemia, dimana salah satu cara dengan mengkonsumsi tablet besi. sehingga ibu hamil akan terdorong untuk mengkonsumsi tablet besi dan vitamin c yang diberikan secara rutin. simpulan dan saran simpulan konseling dapat merubah memperbaiki perilaku (pengetahuan, sikap dan tindakan) ibu hamil tentang pencegahan anemia selama kehamilan. saran penulis menyarankan: 1) perlu diadakan pemeriksaan hb bagi ibu hamil di bidan praktek swasta sebagai langkah awal dalam upaya penurunan angka kejadian anemia pada ibu hamil, 2) perlu dilakukan pendidikan kesehatan dan tentang upaya pencegahan anemia masa kahamilan secara rutin atau terjadwal di bidan praktek swasta agar hasil lebih optimal. 4) perlu diadakan penelitian lebih lanjut tentang ‘pengaruh dukungan keluarga terhadap tindakan ibu hamil dalam upaya pencegahan anemia masa kehamilan’. kepustakaan azwar, s., 2003. sikap manusia, teori dan pengukurannya. yogjakarta: pustaka pelajar. djumhana, 2006. penanganan anemia pada wanita. journal ethical digest, 4 (32). hertanto, 2006. suplemen zat besi terhadap anemia,(online), (http://www.kompas.com/new.kes, diakses tanggal 12 desember 2007, jam 08:56 wib). notoatmodjo, s., 2007. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta, hlm. 57,62,134,139-140, 144. notoatmodjo, s., 2003. pendidikan dan tindakan kesehatan. jakarta: rineke cipta, hlm.12-15, 62-63, 114-117, 120-123, 130. sarwono, 2002. pelayanan kesehatan maternal dan neonatal. jakarta: egc, hlm. 281, 282. sharma, et al., 2003. effect of dietary habits on prevalence of anemia in pregnant women of delhi, (online) , (http://sciencelinks.jp, diakses tanggal 8 november 2009, jam 05:40 wib). wijaya, p., 2008. perkembangan motorik anak (part 2), (online), (http://www.putrawijaya.co.cc/200 8/10/perkembangan-motorik-anakpart-2.html, diakses tanggal 1 desember 2009, jam 06.00 wib). wiknjosastro, h., 2005. ilmu kebidanan. jakarta: yayasan bina cipta. yeni, 2009. hubungan karakteristik ibu hamil dengan kejadian anemia di pkm banjaran,(online) (http://one.indoskripsi.com, diakses tanggal 10 agustus 2009, jam 14:17 wib). http://sciencelinks.jp/ http://www.putrawijaya.co.cc/2008/10/perkembangan-motorik-anak-part-2.html,%20diakses%20tanggal%201%20desember%202009 http://www.putrawijaya.co.cc/2008/10/perkembangan-motorik-anak-part-2.html,%20diakses%20tanggal%201%20desember%202009 http://www.putrawijaya.co.cc/2008/10/perkembangan-motorik-anak-part-2.html,%20diakses%20tanggal%201%20desember%202009 http://www.putrawijaya.co.cc/2008/10/perkembangan-motorik-anak-part-2.html,%20diakses%20tanggal%201%20desember%202009 http://one.indoskripsi.com/ pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru metode applied behaviour analyze (aba) meningkatkan interaksi sosial anak autis usia 2-5 tahun (applied behaviour analyze method increase social interaction children with autisme, 2-5 years old) khoridatul bahiyah*, ahmad yusuf*, sri kusmawati** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail : rida.ners@ymail.com ** rsud dr. soetomo abstract introduction: autism is social interaction disorder in children. they were seemingly living in their own world. aba method was a technique to decrease behaviour disorder or social interaction in autism children. the aimed of this research was to evaluate correlation between aba method implementation and parents role with social interaction development in children with autism. method: this research was used a cross sectional with purposive sampling. there were 22 respondents who met to the inclusion criteria. the independent variable was aba methode and the dependent variable was social interaction development. data were collected by using questionnaire and observation, then analyzed by using spearman rho correlation with significance level α≤0.05. result: the result showed that there was a correlation between aba method and social interaction development in autism children with p<0.30. discussion: it can be concluded that aba method has a correlation with social interaction in autism children. it is recommended that aba method can be used as a technique to decrease social interaction disorder on autism children. keywords : aba methods, social interaction development, autism children pendahuluan autisme merupakan sindroma yang saat ini masih sangat sulit ditangani dengan hasil pengobatan yang tidak begitu menggembirakan (erny, 2003). adapun autisme adalah gangguan perkembangan pervasif khususnya pada masa anak-anak, yang membuat seseorang tidak mampu mengadakan interaksi sosial dan seolah-olah hidup dalam dunianya sendiri (papinto, 2007). gejala autisme sangat beragam sehingga memerlukan terapi terpadu bagi setiap anak. intervensi yang baik haruslah mempunyai program dan tujuan yang jelas sehingga dapat mencapai sasaran. salah satu cara yang memenuhi kriteria adalah metode applied behaviour analyze (aba) (idjas, 2001). selain metode aba terdapat metode lain yang dapat diterapkan antara lain floor time, treatment and education of autistic and related communication handicapped children (teacch) dan learning experience an alternative program for preshoolers and parents (leap). metode aba memiliki kelebihan yaitu terstruktur, terarah dan terukur. melalui metode ini, anak autis tanpa penyulit mampu menjadi normal (baik perilaku maupun penampilan), pada jenis tertentu gejala autis dapat dihilangkan dan anak bisa sekolah reguler, berkembang dan hidup mandiri di masyarakat (rudi, 1999). berdasarkan data di ruang jiwa anak rsu dr. soetomo diketahui bahwa tingkat kesembuhan autis sangat fluktuatif, dipengaruhi beberapa faktor antara lain diet, disiplin kontrol, dan obat yang diberikan. autisme di indonesia mengalami peningkatan luar biasa (mazra, 2002). sepuluh tahun yang lalu jumlah autisme jurnal ners vol.3 no.1 april 2008 : 37-41 khoridatul diperkirakan satu per 5000 anak, sekarang meningkat menjadi satu per 500 anak. autisme lebih sering terjadi pada anak lakilaki daripada anak perempuan (3 : 1). pada ruang jiwa anak rsu dr. soetomo surabaya didapatkan peningkatan jumlah pasien baru dengan autis 7 kali lipat dari tahun 1997-2001, pada tahun 2002 mengalami penurunan kemudian meningkat kembali pada tahun 2003-2004 (sekitar 50%), tahun 2005 52%, tahun 2006 50%. (berdasarkan data kunjungan per tahun di ruang jiwa anak rsu dr. soetomo surabaya). angka kejadian penyandang autisme menduduki urutan pertama dari sepuluh kasus terbanyak di ruang jiwa anak rsu dr. soetomo surabaya. anak autis bila tidak segera dilakukan terapi akan mengalami berbagai gejala seperti sering menyendiri, melamun, melakukan berbagai perilaku yang tidak wajar atau aneh dan anak asyik dengan dunianya sendiri. dampak yang ditimbulkan ke depan, anak akan mengalami gangguan hubungan sosial, tidak memiliki kemandirian, tidak mampu melakukan komunikasi dua arah, tidak mampu bersosialisasi ke dalam masyarakat umum (sehingga anak menjadi depresi pada saat remaja ketika menyadari bahwa mereka tidak mampu membina hubungan dengan teman) dan anak mengalami gangguan perilaku, kurang percaya diri dan introvert (retno, 2005). anak autis dapat ditangani dengan metode tatalaksana perilaku yang dikembangkan berdasarkan konsep aba (applied behaviour analyze) yaitu menggunakan metode lovas yang dilaksanakan dengan cara pengajaran abc (antecendent behaviour consequence) dan dtt (discrete trial training) atau yang disebut tatalaksana perilaku (sutadi, 1998). keberhasilan terapi dipengaruhi oleh ketepatan dan keterpaduan meliputi tatalaksana perilaku, medikamentosa, diet yang tepat, okupasi, terapi bicara, dukungan orang tua dan partisipasi keluarga (papinto, 2007). berdasarkan penjelasan di atas peneliti ingin mengetahui bagaimana hubungan penerapan metode aba (applied behaviour analyze) dengan perkembangan interaksi sosial pada anak autis di ruang jiwa anak rsu dr. soetomo surabaya. bahan dan metode desain yang digunakan dalam penelitian ini adalah cross sectional design. populasi dalam penelitian ini adalah seluruh anak autis yang menjalani terapi di ruang jiwa anak rsu dr. soetomo surabaya berjumlah 40 anak. besar sampel yang dipergunakan dalam penelitian ini 22 anak dengan kriteria inklusi sebagai berikut: anak autis ringan dan sedang, anak autis yang disiplin kontrol, anak autis yang telah menjalani terapi aba minimal 3 bulan maksimal 2 tahun, anak autis yang kooperatif, berusia 2-5 tahun. penelitian ini dilaksanakan pada bulan januari 2008. variabel independen dalam penelitian ini adalah penerapan metode aba (applied behaviour analyze) sedangkan variabel dependen adalah perkembangan interaksi sosial. instrumen yang dipergunakan untuk variabel independen yaitu panduan penerapan metode aba yang dikutip dari puspita (2003), sedangkan untuk variabel dependen menggunakan instrumen berdasarkan referensi alisjahbana (2003) yang dibagi dalam dua kategori yaitu untuk usia toddler 2-3 tahun dan usia pre school usia 4-5 tahun. data yang diperoleh kemudian ditabulasi dan dianalisis dengan menggunakan uji statistik spearman rho correlation dengan tingkat kemaknaan α≤0,05. hasil tabel 1 menunjukkan hasil analisis statistik dengan spearman rho correlation didapatkan nilai koefisien korelasi 0,625 dan nilai signifikansi p=0,03 yang berarti terdapat hubungan yang signifikan antara penerapan metode aba dengan perkembangan interaksi sosial pada anak autis usia toddler. pada tabel 2 dapat dilihat hasil analisis statistik dengan spearman rho correlation didapatkan nilai koefisien korelasi 0,679 dan p=0,031 yang berarti bahwa terdapat hubungan yang signifikan antara penerapan metode aba dengan perkembangan interaksi sosial pada anak autis usia pre school. metode applied behavior analyze (khoridatul b) tabel 1. hubungan penerapan metode aba dengan perkembangan interaksi sosial pada anak autis usia toddler (2-3 tahun) di ruang jiwa anak rsu dr. soetomo surabaya no. kategori penerapan metode aba perkembangan interaksi sosial n n 1 baik 8 8 2 cukup 2 2 3 kurang 2 2 hasil analisis statistik spearman rho correlation (p=0,030; r=0,625) keterangan: p = signifikansi r = koefisien korelasi n = jumlah tabel 2 hubungan penerapan metode aba dengan perkembangan interaksi sosial pada anak autis usia pre school (4-5 tahun) di ruang jiwa anak rsu dr. soetomo surabaya no. kategori penerapan metode aba perkembangan interaksi sosial n n 1 baik 8 7 2 cukup 2 3 3 kurang 0 0 hasil analisis statistik spearman rho correlation (p=0,031; r=0,679) keterangan: p = signifikansi r = koefisien korelasi n = jumlah pembahasan berdasarkan hasil penelitian penerapan aba pada anak autis baik usia toddler (2-3 tahun) maupun pre school (4-5 tahun) menunjukkan kategori baik dengan kriteria observasi pada metode aba seperti kemampuan mengikuti pelajaran, menirukan, bahasa receptif kognitif, bahasa ekspresif, dan kemampuan mengikuti pelajaran pra akademik. hasil ini sesuai dengan teori yang mengatakan bahwa metode aba mempunyai kelebihan terstruktur, terarah, dan terukur. hasil penelitian menunjukkan bahwa masih didapatkan penerapan metode aba yang kurang pada usia toddler (2-3 tahun). hal ini dikarenakan orang tua tidak melakukan latihan secara konsisten di rumah, anak dibiarkan bermain sendiri dan orang tua tidak memberikan diet yang sesuai. inilah yang membuat anak memiliki perilaku yang tidak terkontrol, menjadi hiperaktif, sehingga anak menjadi tidak patuh pada saat dilakukan latihan aba dan anak kurang memahami apa yang diinstruksikan oleh terapis. menurut budiman (2006), berbagai faktor yang mempengaruhi keberhasilan suatu terapi meliputi berat ringan gejala, usia (semakin muda usia anak pada saat diterapi dimulai makin besar kemungkinan untuk berhasil). usia yang paling baik antara 2-5 tahun dimana sel otak masih dapat dirangsang untuk membentuk percabangan baru. faktor lain yang berpengaruh adalah kecerdasan, terapi yang intensif dan terpadu dan terapis yang mempunyai kasih sayang, jurnal ners vol.3 no.1 april 2008 : 37-41 profesional, disiplin dan etika. hal inilah yang mempercepat anak beradaptasi dengan lingkungan (handoyo, 2003). fenomena di atas diperkuat oleh hasil observasi yang dilakukan oleh peneliti. hal ini ditunjang dengan content analyze dari kuisioner yang diberikan pada terapis yaitu terapis melakukan latihan dengan metode aba sesuai dengan standar kriteria latihan untuk aba yaitu one to one, dengan prinsip dtt, teknik abc, ruangan bebas distraksi, dan pengajaran diberikan sesuai dengan kemampuan anak (puspita, 2003). evaluasi dilakukan secara periodik, setiap latihan dilakukan penilaian untuk mengetahui peningkatan anak dan mengganti materi yang sudah mampu dicapai. penerapan metode aba pada dasarnya terbagi atas membagi keterampilan tertentu ke dalam beberapa bagian yang kecil, mengajarkan satu bagian keterampilan satu persatu hingga dikuasai, memastikan proses belajar terfokus, memberikan bantuan bilamana perlu, secara bertahap mengurangi bantuan dan memakai prosedur penguat perilaku. hasil observasi interaksi sosial pada anak autis diperoleh data bahwa anak usia toddler (2-3 tahun) maupun pre school (4-5 tahun) mempunyai interaksi sosial baik, namun masih terdapat 2 anak usia toddler yang menunjukkan interaksi sosial kurang. hal ini disebabkan karena orang tua kurang konsisten dalam melakukan hubungan baik dengan anak, anak dibiarkan bermain sendiri, tidak diberikan diet yang sesuai (orang tua memberi anak makanan yang banyak mengandung gluten seperti kue yang terbuat dari tepung terigu atau mie instant yang mengandung msg) sehingga anak sangat hiperaktif dan perilaku tidak terkontrol. hasil penelitian ini menunjukkan bahwa terdapat hubungan signifikan antara metode aba dan interaksi sosial. interaksi sosial adalah hubungan dalam masyarakat yang mempengaruhi perkembangan sosial individu, perkembangan sosial berubah dari penuh ketergantungan menuju kemandirian (susanto, 1997). interaksi sosial yang terjadi pada anak autis adalah kurangnya hubungan atau anak tidak mampu menjalin interaksi sosial yang cukup memadai dengan lingkungan. anak cuek, gerakan tidak tertuju, anak menangis tanpa sebab, tidak bisa bermain dengan teman sebaya, tidak ada empati, tidak mampu mengadakan hubungan timbal balik dengan teman sebaya. simpulan dan saran simpulan metode aba mempunyai hubungan yang signifikan dengan interaksi sosial pada anak autis. penerapan metode aba tepat dilakukan pada anak autis usia toddler (2-3 tahun) maupun pre school (4-5 tahun) karena dapat meningkatkan kemampuan interaksi sosial anak. metode aba yang dilaksanakan pada anak adalah terstruktur, terarah dan terukur dengan teknik dasar membagi keterampilan tertentu ke dalam beberapa bagian kecil, mengajarkan satu bagian keterampilan satu persatu hingga dikuasai, memastikan proses belajar terfokus, memberikan bantuan bilamana perlu dan secara bertahap mengurangi bantuan dan memakai prosedur penguat perilaku. saran peneliti menyarankan agar setiap orang tua dengan anak autis hendaknya aktif mencari informasi tentang penanganan yang tepat pada anak autis, keberhasilan metode aba tidak hanya tergantung pada terapis namun juga diit, disiplin kontrol, obat yang diberikan dan keaktifan orang tua dalam stimulasi atau melatih anak di rumah, oleh sebab itu hendaknya orang tua diberikan informasi yang jelas tentang berbagai hal tersebut. sebaiknya disediakan media informasi (leaflet) yang berkaitan tentang autis di tempat terapi, sehingga orang tua anak autis mudah memperoleh informasi secara cepat. kepustakaan alisjahbana, a. 2003. tanda–tanda awal autisme. makalah disajikan dalam konferensi nasional autisme i, di hotel sahid jaya, jakarta, 2-4 juli. budiman, m. 2006. pentingnya intervensi dini untuk anak autis, (online), (http:// www.keluargasehat.com., diakses tanggal 20 november 2007, jam 18.00 wib). rekam medis rsud dr. soetomo. 2007. catatan medical record ruang day http://www.keluargasehat.com/ metode applied behavior analyze (khoridatul b) care jiwa anak rsud dr. soetomo surabaya. erny. 2003. patofisiologi autisme. media idi, 28(i), 35. handoyo. 2003. petunjuk praktis dan pedoman materi untuk mengajar anak normal dan autisme. jakarta: gramedia, hlm. 45-56. idjas, i. 2001. autisme. journal of health science, 3(9), 382. mazra, f. 2002. gangguan perkembangan anak, jurnal kedokteran dan karman medika, 7, 102-106. papinto. 2007. terapi autisme, (online), (http://www.autisme/blogspot.com.08/ 01/archive.html., diakses tanggal 30 november 2007, jam 16.00 wib). puspita, d. 2003. terapi aba yang menyenangkan bagi anak sd. makalah disajikan dalam konferensi nasional autisme i, di hotel sahid jaya, jakarta, 2-4 juli. retno. 2005. mengenal anak autisme sejak dini, (online), (http://www.bali.post.co.id/2005/2/2/k es.htm., diakses tanggal 17 november 2007, jam 17.08 wib). rudi. 1999. pentingnya intervensi dini untuk anak autisme, (online), (http://www.keluargasehat.com., diakses tanggal 20 november 2007, jam 19.00 wib). susanto, a. 1997. perkembangan sosial, jakarta: gunung agung, hlm. 79. sutadi, r. 1998. harapan bagi anak autisme, (online), (http://www.indomedia.com/intisari/a utisme/htm., diakses tanggal 20 november 2007, jam 17.18 wib). http://www.autisme/blogspot.com.08/01/archive.html http://www.autisme/blogspot.com.08/01/archive.html http://www.bali.post.co.id/2005/2/2/kes.htm http://www.bali.post.co.id/2005/2/2/kes.htm http://www.keluargasehat.com/ http://www.indomedia.com/intisari/autisme/htm http://www.indomedia.com/intisari/autisme/htm senam pernafasan satria nusantara berpengaruh terhadap tingkat kebugaran lansia 190 senam pernafasan satria nusantara meningkatkan kebugaran lansia (satria nusantara breathing exercise improves the senior citizens’ level of fitness) kusnanto*, makhfudli*, rumdiana surya dewi* abstract introduction: aging is a slowly losing process of the ability of tissues to regenerate and keep their normal structure and function in order to stand on from any disturbance, including infection. in older people degeneration of organs like muscles, bones, heart, blood vessels and nerve systems cause decrease in hearty. satria nusantara gym are an alternative solution to increase hearty. the objective of this study was to examine the effect of satria nusantara gym on fitness level to old people. method: the research use the pre eksperimental design by using approach of one group pre test post test design. sampling technique in this research is non probability sampling by using saturated sampling. samples taken as much 20 old people which is following satria nusantara gym. data were analyzed using paired ttest with significance level α≤0.05. result: the result showed that satria nusantara gym give positive effect to old people. analysis: it can be cocluded that satria nusantara gym cause increase fitness level to old people. discussion: it’s recommended further research need more variable for representative result.. keywords : satria nusantara gym, hearty, older people * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail : kusnanto_ners@yahoo.com pendahuluan menua (menjadi tua) adalah satu proses menghilangnya secara perlahan-lahan kemampuan jaringan untuk mempertahankan struktur dan fungsi normal sehingga tidak dapat bertahan terhadap jejas (termasuk infeksi) dan memperbaiki kerusakan yang diderita (contantinides, 1994 dalam darmojo, 2006). menurunnya fungsi berbagai alat tubuh karena proses menjadi tua, sel-sel banyak diganti, produksi hormon menurun dan produksi zat-zat untuk daya tahan tubuh berkurang menyebabkan penyakit seperti rheumatik, hipertensi, penyakit jantung, penyakit paru, diabetes mellitus, jatuh, lumpuh separuh badan, tbc paru, patah tulang kanker dan kekurangan gizi (darmodjo, 2006). peningkatan dan penurunan yang terjadi dari penuaan disebabkan oleh kurang latihan dan penyembuhannya adalah latihan sederhana (kusuma, w., 2000). bukti yang ada menunjukkan bahwa latihan dan olahraga pada lanjut usia dapat mencegah atau melambatkan kehilangan fungsional, bahkan latihan teratur dapat memperbaiki mortalitas dan morbiditas yang diakibatkan oleh penyakit kardiovaskuler (darmodjo, 2006). latihan fisik yang dapat meningkatkan derajat kesehatan fisik dan mental adalah senam pernafasan satria nusantara, yaitu latihan dengan metode khusus yang mencoba mengembangkan satu sistem olahraga pernafasan tenaga dalam melalui nafas, gerak dan konsentrasi sehingga menghasilkan olahraga sekaligus olahmental dan olahsosial yang diharapkan dapat menghasilkan kualitas sumber daya manusia seutuhnya. studi pendahuluan yang dilakukan pada lansia yang mengikuti senam pernafasan satria nusantara di unit pelatihan senam pernafasan satria nusantara rumah sakit angkatan laut dr. ramelan surabaya sebagian besar mengatakan lebih jarang sakit dan merasa lebih bugar setelah mengikuti senam pernafasan satria nusantara tetapi pengaruh senam pernafasan satria nusantara terhadap tingkat kebugaran lansia belum dapat dijelaskan. meningkatnya status kesehatan masyarakat, selain digambarkan dengan mailto:kusnanto_ners@yahoo.com jurnal ners vol. 4 no. 2: 190-196 191 angka kesakitan dan kematian yang menurun, juga digambarkan dengan meningkatnya umur harapan hidup (djojosugito, 2000). penelitian who tahun 1999, menyatakan penyakit tidak menular atau degeneratif merupakan penyebab 60% kematian dan 40% beban penyakit global (www.panduan kesehatan.com). penelitian prospektif lain membuktikan kemungkinan ketergantungan fungsional pada lanjut usia yang inaktif akan meningkat sebanyak 40-60% dibanding lansia yang bugar dan aktif secara fisik (ruben et. al, 1996 dalam darmojo, 2006). tahun 2020 diperkirakan penyakit tidak menular menjadi penyebab 73% kematian dan 60% beban penyakit global. studi morbiditas menunjukkan tingkat keluhan sakit dari penduduk indonesia dan lansia berdasarkan susenas 1992 sebesar 21,0 % dan menunjukkan peningkatan pada tahun 1995 yakni sebesar 55,8 % (djojosugito, 2000). penyebab kematian dibeberapa negara berkembang 25 tahun terakhir ini dikarenakan penyakit tidak menular. studi pandahuluan yang dilakukan pada lansia di unit pelatihan senam pernafasan satria nusantara di rumah sakit angkatan laut dr. ramelan surabaya bulan november 2008 dari 20 orang yang mengikuti senam pernafasan, 10 diantaranya menderita hipertensi, 10 orang sesak nafas saat melakukan aktifitas berat dan 15 dari 20 orang menderita nyeri sendi. keadaan ini disebabkan oleh penurunan tingkat kebugaran serta kurangnya latihan fisik pada lansia. organ tubuh pada lansia banyak mengalami proses degenerasi atau menua. proses menua dapat mengubah jaringan ikat dan jaringan yang bersifat elastis menjadi kurang elastis, akibatnya jaringan menjadi lebih kaku, pengisian darah kejantung terutama kebilik kiri menjadi terganggu, fungsi jantung akan menurun. gangguan pada fungsi jantung juga mengganggu aliran darah balik otak, ginjal, dan paru-paru. paru berkurang daya hirupnya sehingga kapasitas fisik berkurang dan orangpun mudah lelah (takasihaeng, 2002 dalam marniyah, 2007). penurunan yang terjadi pada lansia juga disebabkan karena duduk terlalu lama dan tidak berolahraga, hal ini menyebabkan kapasitas aerobik menurun, proporsi lemak tubuh meningkat, keseimbangan melemah, kecenderungan darah untuk membeku meningkat, efisiensi termostat tubuh menurun, pengeluaran kalsium dari tulang meningkat, dan kekuatan insulin menurun sehingga mempengaruhi tingkat kebugaran pada lansia (kusuma, 2000). menurunnya tingkat kebugaran pada lansia mengakibatkan penurunan vo2 max, penurunan laju jantung maksimal dan penurunan isi jantung sekuncup sehingga suplai o2 kejaringan tidak optimal (darmojo, 2006). melakukan senam pernafasan satria nusantara dapat meningkatkan kemampuan untuk mengembangkan sistem pernafasan yaitu meningkatnya kapasitas vital paruparu, melatih otot-otot pernafasan dan memperlancar aliran darah balik dari vena di daerah perut menuju jantung sehingga meningkatkan kelancaran peredaran darah sistemik serta dapat meningkatkan derajat kesehatan fisik dan mental sekaligus (maryanto, 1999). penelitian ini perlu dilakukan guna mengetahui pengaruh senam pernafasan satria nusantara terhadap tingkat kebugaran pada lansia di unit pelatihan senam pernafasan satria nusantara rumah sakit angkatan laut dr. ramelan surabaya. bahan dan metode penelitian desain penelitian yang digunakan yaitu pre eksperiment dengan pendekatan one group pre test-post test design atau non randomized one group pretest design.. populasi penelitan ini yaitu seluruh lansia di rumah sakit angkatan laut dr. ramelan surabaya yang melakukan senam pernafasan satria nusantara sebanyak 20 responden. sampel dalam penelitian ini yaitu lansia di rumah sakit angkatan laut dr. ramelan surabaya yang melakukan senam pernafasan satria nusantara sebanyak 20 responden. teknik sampling dalam penelitian ini menggunakan teknik “non-probality sampling” dengan menggunakan sampling jenuh . penelitian dilakukan di unit pelatihan senam pernafasan satria nusantara di rumah sakit angkatan laut dr. ramelan surabaya bulan desember 2008 sampai januari 2009. variabel independen dalam penelitian ini yaitu senam pernafasan satria nusantara, sedangkan variabel dependen yaitu tingkat kebugaran lansia. langkah awal responden diberi pretest menggunakan lembar observasi tanda-tanda vital meliputi nadi istirahat, tekanan darah dan frekuensi nafas, sehingga diperoleh skor awal sebelum http://www.panduan/ senam pernafasan satria nusantara (kusnanto) 192 dilakukan intervensi. setelah responden melakukan senam pernafasan selama 3x/minggu selama 4 minggu dilakukan post test sebagai evaluasi dengan menggunakan instrumen yang sama dengan pre test sehingga diperoleh skor akhir. data yang diperoleh diolah dengan uji paired t-test dengan derajat kemaknaan α≤0,05. hasil penelitian responden diukur tanda-tanda vital meliputi, tekanan darah, nadi istirahat dan frekuensi pernafasan sebelum dan sesudah intervensi senam satria nusantara. hasil penelitian menunjukkan terdapat pengaruh senam pernapasan satria nusantara terhadap tingkat kebugaran yang ditandai tekanan darah yang stabil pada lansia. hal ini dibuktikan hasil uji paired t-test” tekanan darah sistolik p=0,01 dan tekanan darah diastolik p=0,001 (tabel.1). hasil pengukuran denyut nadi istitahat terdapat perubah yang signifikan, yaitu terjadi penurunan denyut nadi istirahat setelah dilakukan senam satria nusantara. rerata denyut nadi sebelum tindakan sebesar 85x/menit, rerata denyut nadi setelah tindakan yaitu 77,45x/menit sehingga terjadi perubahan denyut nadi sebesar 7,35x/menit. hasil uji statistik denyut nadi istirahat menunjukkan p=0,000 berarti terdapat pengaruh senam pernafasan satria nusantara terhadap tingkat kebugaran ditunjukkan dengan denyut nadi istirahat yang stabil pada lansia. hasil pengukuran frekuensi pernafasan setelah diberikan senam satria nusantara menunjukkan terjadi perubahan yang signifikan, yaitu terjadi penurunan frekuensi pernafasan dalam batas normal pada responden. pengukuran frekuensi nafas sebelum tindakan didapatkan rerata 23,2x/menit, rerata frekuensi nafas setelah tindakan didapatkan sebesar 19,45x/menit. nilai perubahan frekuensi nafas sebelum dan sesudah tindakan 3,75x/menit. hasil uji statistik menunjukkan p=0,000, berarti terdapat pengaruh senam pernafasan satria nusantara terhadap tingkat kebugaran ditunjukkan dengan frekuensi nafas yang stabil pada lansia pembahasan hasil penelitian menunjukkan nilai tekanan darah sistolik p=0,01 sedangkan tekanan darah diastoliknya didapatkan nilai p=0,001,nilai dari denyut nadi istirahat p= 0,000 dan nilai dari frekuensi nafas p=0,000. hal itu menunjukkan terdapat pengaruh senam pernafasan satria nusantara terhadap tingkat kebugaran lansia yang ditunjukkan dengan perubahan tekanan darah, denyut nadi istirahat dan frekuensi nafas. penelitian menyatakan bahwa ada beberapa faktor yang mempengaruhi tekanan darah, denyut nadi istirahat dan frekuensi nafas pada lansia yaitu genetis, umur, jenis kelamin, gaya hidup seperti stress, obesitas (kegemukan), kurang olahraga, merokok, alkohol dan makanan yang tinggi kadar lemaknya serta perubahan biologis yang disebabkan proses menua. potter & perry (2005) mengungkapkan bahwa faktor lain yang mempengaruhi tekanan darah adalah jenis kelamin. secara klinis tidak ada perbedaan yang signifikan dari tekanan darah pada anak laki-laki dan perempuan. setelah pubertas pria cenderung memiliki tekanan darah yang lebih tinggi, tetapi setelah menopause, wanita cenderung memiliki tekanan darah yang lebih tinggi. data dari responden menunjukkan bahwa jenis kelamin perempuan cenderung mempunyai tekanan darah lebih tinggi dibandingkan laki-laki. hal itu dikarenakan responden perempuan lebih banyak menderita penyakit seperti diabetes melitus, paru-paru, jantung dan hipertensi yang berpengaruh terhadap perubahan tekanan darah. faktor lain yang mempengaruhi yaitu perubahan hormonal yang mempengaruhi siklus tubuh, sehingga mempengaruhi perubahan tekanan darah. tabel 1. tabulasi perubahan tekanan darah sistolik dan diastolic pada lansia di unit pelatihan senam pernafasan satria nusantara rumah sakit angkatan laut dr. ramelan surabaya jurnal ners vol. 4 no. 2: 190-196 193 tekanan darah (mmhg) sistolik diastolik perubahan pre post pre post sistolik diastolik rerata 130,5 123,65 88,15 79,35 11,05 10,4 uji paired ttest p=0,01 p=0,001 keterangan : p = signifikansi potter & perry (2005) menyatakan bahwa tekanan darah adalah tekanan yang ditimbulkan pada dinding arteri. tekanan ini sangat dipengaruhi oleh beberapa faktor antara lain usia. tingkat normal tekanan darah bervariasi sepanjang kehidupan. tekanan darah dewasa cenderung meningkat seiring dengan pertambahan usia. pada lansia tekanan sistoliknya meningkat sehubungan dengan penurunan elastisitas pembuluh. tekanan darah lansia normalnya yaitu 140/90mmhg. meta (2008) mengungkapkan dari penelitian menunjukkan makin tinggi umur seseorang makin tinggi juga tekanan darahnya, sehingga menyebabkan peluang hipertensi bertambah seiring bertambahnya usia, terutama tekanan darah sistolnya. orang yang lebih tua cenderung mempunyai tekanan darah lebih tinggi dari orang yang berusia lebih muda. hipertensi pada orang berusia 60 tahun ke atas perlu ditangani secara khusus. hal ini disebabkan pada usia tersebut fungsi ginjal dan hati mulai menurun. penelitian menunjukkan responden dengan usia diatas 65 tahun cenderung memiliki tekanan darah lebih tinggi. hal ini dikarenakan pada usia tersebut fungsi organ semakin menurun terutama sistem kardiovaskuler. lansia yang merokok saat usia muda, konsumsi makanan yang tinggi kadar lemak serta kurangnya aktifitas pada lansia juga mempengaruhi perubahan tekanan darah pada lansia. pada lansia terjadi penurunan aktifitas fisik yang mengakibatkan menurunnya kontraksi dan volume jantung, peningkatan dan penurunan tekanan darah, penurunan oksigen dan densitas tulang sehingga tulang menjadi rapuh dan otot mudah kram. aktifitas fisik yang teratur mampu meningkatkan kemampuan system kardiorespirasi, meningkatkan curah jantung, menurunkan frekuensi denyut nadi dan tekanan darah sehingga meningkatkan efisiensi jantung (moeloek, 1984, dalam suci darmayanti, 2007). peningkatan aktivitas fisik berupa olahraga secara teratur, terbukti dapat menurunkan tekanan darah ke tingkat normal dan menurunkan risiko serangan hipertensi 50 persen lebih besar pada seseorang yang aktif berolahraga. satu sesi olahraga rata-rata menurunkan tekanan darah lima hingga tujuh mmhg. pengaruh penurunan tekanan darah ini dapat berlangsung sampai 22 jam setelah berolahraga (nora sutarina, 2008). nora mengatakan, aktivitas fisik berupa latihan jasmani secara teratur merupakan intervensi pertama untuk pencegahan dan pengobatan hipertensi. penelitian tentang manfaat olahraga untuk mengendalikan berbagai penyakit degeneratif, seperti hipertensi, jantung koroner, diabetes, dan sebagainya, sudah dilakukan di berbagai negara. olahraga secara teratur terbukti bermanfaat untuk menurunkan tekanan darah, mengurangi risiko stroke, serangan jantung, gagal ginjal, dan penyakit pembuluh darah lainnya. menurut nora, pengaruh olahraga dalam jangka panjang sekitar empat hingga enam bulan, dapat menurunkan tekanan darah sebesar 7,4/5,8 mmhg tanpa bantuan obat hipertensi. penurunan tekanan darah sebanyak dua mmhg saja baik secara sistolik maupun diastolik dapat mengurangi risiko stroke sampai 14 hingga 17 persen dan menekan risiko penyakit kardiovaskuler sampai sembilan persen. manfaat lain dari olah raga yaitu menurunkan berat badan bagi penderita obesitas (kegemukan). hal itu karena penurunan berat badan empat hingga lima kilogram dapat menurunkan tekanan darah pada penderita hipertensi. menurut nora, olahraga secara teratur idealnya dilakukan tiga hingga lima kali seminggu, minimal 30 menit setiap sesi, dengan intensitas sedang. olah raga yang isotonik dan teratur (aktivitas fisik aerobik selama 3045 menit/hari) dapat menurunkan tahanan perifer yang akan menurunkan tekanan darah. senam pernafasan satria nusantara (kusnanto) 194 faktor lain yang mempengaruhi perubahan tekanan darah lansia juga disebabkan karena melakukan senam pernafasan satria nusantara secara teratur dan konsisten, karena pada senam pernafasan satria nusantara terjadi mekanisme pernafasan, khususnya pernafasan perut yang memperlancar aliran darah balik dari pembuluh darah vena di daerah perut menuju kejantung. hal ini disebabkan karena pada waktu inspirasi (tarik nafas) tekanan rongga perut meningkat, sedangkan tekanan dirongga dada menurun, sehingga darah dari arah perut ditekan, sedangkan dari arah dada dihisap. semakin tingginya tekanan di dalam abdominal pressing maka terjadi semacam pijatan terhadap alat-alat disekitar perut, sehingga aliran darah dalam alat-alat tubuh di rongga perut dan aliran darah balik ke jantung semaki lancar. nadi adalah aliran darah yang menonjol dan dapat diraba diberbagai tempat pada tubuh. nadi merupakan indikator status sirkulasi. sirkulasi merupakan alat melalui apa sel menerima nutrient dan membuang sampah yang dihasilkan dari metabolisme. supaya sel berfungsi secara normal, harus ada aliran darah yang kontinyu dan volume sesuai yang didistribusikan darah ke sel-sel yang membutuhkan nutrient (potter & perry, 2005). peningkatan denyut jantung selama aktivitas fisik dipengaruhi oleh faktor intrinsik dan ekstrinsik. faktor intrinsik dimulai dari pusat pengatur kardiovaskuler di medulla yang kemudian dijalarkan melalui sns dan parasympatetic nerves system pada autonomic nervous system (ans). ketika cardioccelerator nerves distimulus, katekolamin (epinefrin dan norepinefrin) dilepaskan. hormon ini memacu depolarisasi sinus node, yang menyebabkan denyut jantung lebih kencang. hal ini menyebabkan peningkatan denyut jantung maksimal. faktor yang mempengaruhi denyut jantung maksimal antara lain : usia, jenis kelamin, level dan jenis olahraga dan penyakit kardiovaskuler (bullock et al, 2000). aktifitas fisik yang teratur membantu meningkatkan efisiensi jantung secara keseluruhan. salah satu petunjuk kearah itu adalah denyut jantung yang lebih lambat dari seseorang yang terlatih dengan baik dibandingkan dengan seseorang yang tidak terlatih (giam, 1997 dalam prajasetia, 2008). senam pernafasan satria nusantara melatih lansia untuk terbiasa bernafas pelan dan dalam serta selalu ingat kepada sang pencipta dalam kehidupan sehari-hari akan menghasilkan ketenangan jiwa, mental yang stabil, sehingga akan memberikan pengaruh terhadap stabilitas fungsi syaraf otonom dengan semakin meningkatnya fungsi syaraf parasimpatik. fungsi syaraf parasimpatik berhubungan erat dengan anabolisme yaitu metabolisme yang bersifat membangun, mengarah kepada perbaikan terhadap kerusakan jaringan dan gangguan fungsional. inspirasi memberikan oksigen kepada darah sehingga darah (arteri) bersifat basa. setelah lama ditahan maka karbon dioksida menumpuk, suasana menjadi asam. asam dan basa merupakan katalisator dalam reaksi organik. pada katalisa asam umum, biasanya efektifitas sebagai katalisator sesuai dengan kekuatan asamnya. penahanan nafas yang semakin lama menyebabkan suasana darah semakin asam sehingga reaksi organik dalam darah semakin dipacu dan meningkat, maka energi akhir yang dihasilkan semakin besar. saat dalam keadaan asam larutan, elektron-elektron akan diserap dari lingkungan (asam merupakan akseptor pasangan elektron) sehingga elektronelektron juga akan banyak dihasilkan dengan latihan pernafasan ini. gerakan jurus-jurus, energi dan elektron yang dihasilkan diarahkan keseluruh organ, kelenjar dan jaringan tubuh lain sehingga seluruh generator listrik yang terdapat dalam jaringan akan mendapat suplai energi dan elektron (charged) yang memadai (sutanbetuah, 1999). guytton (1997) mengungkapkan bahwa semakin besar kekuatan otot jantung yang diregangkan selama pengisian, semakin besar kekuatan kontraksi dan semakin besar jumlah darah yang dipompakan ke dalam aorta (stroke volume). peningkatan stroke volume selama latihan membuat nadi istirahat menurun yang berarti efisiensi jantung meningkat. kecepatan denyut jantung waktu istirahat harus menurun supaya menjadi bugar (powell, 2000). pada lansia terjadi perubahan sistem respirasi yaitu otot pernafasan kehilangan kekuatannya dan menjadi kaku, menurunnya aktifitas dari silia, paru-paru kehilangan elastisitas, kapasitas residu meningkat, jurnal ners vol. 4 no. 2: 190-196 195 menarik nafas lebih berat, kapasitas pernafasan maksimal menurun, dan kedalaman nafas menurun, alveoli ukurannya melebar dari biasa dan jumlahnya berkurang, oksigen pada arteri menurun, karbondioksida pada arteri tidak berganti, kemampuan untuk batuk berkurang. faal paru dan olahraga mempunyai hubungan timbal balik. gangguan faal paru dapat mempengaruhi kemampuan olahraga. olahraga dapat meningkatkan faal paru (yunus, 1997 dalam desy silviasary, 2007). daya tahan kardiorespirasi, yaitu kesanggupan jantung, paru dan pembuluh darah untuk berfungsi secara optimal pada keadaan istirahat dan latihan untuk mengambil oksigen dan mendistribusikan ke jaringan yang aktif untuk metabolisme tubuh, dipengaruhi oleh berbagai faktor fisiologis, antara lain: 1) keturunan/genetik, penelitian menunjukkan 93,4% vo2 max ditentukan oleh faktor genetik. hal ini dapat dirubah dengan melakukan latihan yang optimal, 2) usia, daya tahan kardiorespirasi meningkat dari masa anak-anak dan mencapai puncaknya usia 20 – 30 tahun dan puncaknya pada usia 19 – 21 tahun. sesudah usia ini daya tahan kardiorespirasi akan menurun. penurunan ini terjadi karena paru, jantung dan pembuluh darah mulai menurun fungsinya. kecuraman penurunan dapat dikurangi dengan melakukan olahraga aerobik secara teratur, 3) jenis kelamin, sampai usia pubertas, daya tahan kardiorespirasi antara anak perempuan dan laki-laki tidak berbeda, tetapi setelah usia tersebut, nilai pada wanita lebih rendah 15 – 25% dari pria. perbedaan ini antara lain disebabkan oleh perbedaan kekuatan otot maksimal, luas permukaan tubuh, komposisi tubuh, kekuatan otot, jumlah hemoglobin dan kapasitas paru dan 4) aktivitas fisik, daya tahan kardiorespirasi akan menurun 17 – 27% bila seseorang beristirahat di tempat tidur selama 3 minggu. seseorang yang melakukan olahraga lari jarak jauh, daya tahan kardorespirasinya meningkat lebih tinggi dibandingkan orang yang berolahraga senam atau anggar (yunus, 1997 dalam desy silviasari, 2007). latihan fisik akan menyebabkan otot menjadi kuat. perbaikan fungsi otot, terutama otot pernapasan menyebabkan pernapasan lebih efisien pada saat istirahat. ventilasi paru pada orang yang terlatih dan tidak terlatih relatif sama besar, tetapi orang yang berlatih bernapas lebih lambat dan lebih dalam. hal ini menyebabkan oksigen yang diperlukan untuk kerja otot pada proses ventilasi berkurang, sehingga dengan jumlah oksigen sama, otot yang terlatih akan lebih efektif kerjanya (yunus, 1997 dalam desi silviasary, 2007). pada orang yang dilatih selama beberapa bulan terjadi perbaikan pengaturan pernapasan. perbaikan ini terjadi karena menurunnya kadar asam laktat darah, yang seimbang dengan pengurangan penggunaan oksigen oleh jaringan tubuh. latihan fisik akan mempengaruhi organ sehingga kerja organ lebih efisien dan kapasitas kerja maksimum yang dicapai lebih besar. faktor yang paling penting dalam perbaikan kemampuan pernapasan untuk mencapai tingkat optimal yaitu kesanggupan untuk meningkatkan capillary bed yang aktif, sehingga jumlah darah yang mengalir di paru lebih banyak, dan darah yang berikatan dengan oksigen per unit waktu juga akan meningkat. peningkatan ini digunakan untuk memenuhi kebutuhan jaringan terhadap oksigen (yunus, 1997 dalam desi silviasary, 2007). penurunan fungsi paru orang yang tidak berolahraga atau usia tua terutama disebabkan oleh hilangnya elastisitas paruparu dan otot dinding dada. hal ini menyebabkan penurunan nilai kapasitas vital dan nilai forced expiratory volume, serta meningkatkan volume residual paru (wilmore & costill, 1994 dalam desi silviasary, 2007). senam pernafasan satria nusantara meningkatkan kemampuan untuk mengembangkan sistem pernafasan yaitu dengan meningkatnya kapasitas vital paru paru. kapasitas vital merupakan salah satu tolok ukur bagi kemampuan fungsional sistem pernafasan. latihan pernafasan duduk akan menyebabkan seluruh gelembung paru (alveoli) mengembang dan menjadi aktif dalam proses pernafasan, suatu cara pelatihan yang baik untuk kesehatan pernafasan. pada olah raga biasa, pernafasan juga menjadi lebih dalam dan cepat, tetapi bertambah dalamnya pernafasan tidak pemah mencapai maksimal seperti halnya pada latihan pernafasan duduk ini. dengan pola pernafasan duduk yang melakukan ekspirasi maksimal, inspirasi maksimal dan abdominal senam pernafasan satria nusantara (kusnanto) 196 pressing, maka tidak hanya otot-otot pernafasan biasa yang dilatih, tetapi juga otot-otot pernafasan pembantu, bahkan juga otot-otot dinding perut dan dasar panggul, khususnya pada saat abdominal pressing. otot-otot pernafasan pembantu ialah otot-otot tubuh (togok) yang akan menjadi aktif membantu pernafasan sehingga jumlah vo2 menjadi maksimal yang digunakan sebagai parameter kebugaran. simpulan dan saran simpulan senam pernafasan satria nusantara dapat meningkatkan kebugaran lansia melalui stabilitas tanda-tanda vital yaitu : tekanan darah, nadi istirahat dan frekuensi pernafasan saran peneliti memberikan saran agar :1) penanggung jawab senam pernapasan satria nusantara melakukan pendekatan interpersonal agar lansia mengikuti senam secara teratur dan didapatkan hasil yang maksimal dan 2) melakukan penelitian lebih lanjut dengan menambah jumlah dan variasi sampel, serta menambah alat ukur tingkat kebugaran seperti komposisi tubuh,kelenturan/fleksibilitas tubuh, kekuatan otot, dan daya tahan otot. kepustakaan desy, silviasari, 2008. nilai kapasitas vital paru.bandung : hlm.86. darmojo, 2006. geriatri (ilmu kesehatan usia lanjut). edisi ke-3. jakarta: fkui, hlm.3-7, 46-50, 56-66, 93-101. djojosugito, 2000. wujud nyata pelayanan individu dari profesi perawat, bandung, makalah diasampaikan dalam munas ppni vi. guyton & hall, 2002. buku ajar kedokteran.edisi ke-2. jakarta : egc, hlm.656. kusuma, w., 2000. rahasia untuk melawan proses penuaan.batam: interaksara, hlm.44-50. marniyah, 2007. pengaruh senam yoga terhadap penongkatan kebugaran pada lansia di panthi werdhahargo dedali surabaya. skripsi tidak dipublikasikan. surabaya: universitas airlangga, hlm.1. maryanto, 1995. ilmu satria nusantara. yayasan satria nusantara, hlm.196. meta, 2008. hipertensi, (online), (http://www.keluargasehat.com, diakses tanggal 28 desember 2009). nora, sutarina, 2008. olahraga baik bagi kesehatan,(online), (http://nora.blog.com/, diakses tanggal 28 desember 2009, jam 10.30 wib). potter, p. a., & perry, a. g., 2005. fundamental keperawatan. edisi ke-4. jakarta: egc, hlm.781782, 787-799. powell, d.r., 2000. tips hidup sehat. jakarta : pustaka delapratasa, hlm.147-148, 167. suci, damayanti, 2007. pengaruh latihan senam tai chi terhadap peningkatan kebugaran pada manula. skripsi tidak dipublikasikan, surabaya : psik universitas airlangga, hlm.72. sutanbetuah, 1999. ilmu satria, (online), (http://www.nusantara.sutan@eudo ramail.com, diakses tanggal 24 november 2008, jam 09.00 wib). wijoseno, 2006. 30 menit untuk jantung sehat, (online), (http://wijoseno.tblog.com/, diakses tanggal 15 april 2008, jam10.30 wib http://www.keluargasehat.com/ http://nora.blog.com/ mailto:nusantara.sutan@eudoramail.com mailto:nusantara.sutan@eudoramail.com http://wijoseno.tblog.com/ pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru tepid sponge bath suhu 320c dan 370c (kusnanto) 1 efektifitas tepid sponge bath suhu 32oc dan 37oc dalam menurunkan suhu tubuh anak demam (the effectiveness of tepid sponge bath with 32oc and 37oc to decrease body temperature at toddler with fever) kusnanto*, ika yuni widyawati*, indah sri cahyanti* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: kusnanto_ners@yahoo.com abstract introduction: tepid sponge bath is a therapeutic bath by washing all around of the body with warm water to decrease body temperature. warm water that used were 32 o c (nail warm) and 37 o c (warm). the aimed of this study was to compare the effectivity of tepid sponge bath with 32 o c and 37 o c warm water on decreasing body temperature at toddler with fever. method: a quasy experimental pre post test design was used in this study. the population was toddler who had body temperature ≥38 o c which treated in anggrek pediatric room dr. iskak public hospital tulungagung. there were 26 respondents recruited by using purposive sampling technique and divided into two group, each of 13 respondents received tepid sponge bath with 32 o c and others received tepid sponge bath with 37 o c warm water. the independent variable was tepid sponge bath and dependent variable was body temperature. data were collected by using digital termometere and noted in respondent observation, then analyzed by using paired t-test and mann withney utest. result: the result showed that there was an effectivity on decreasing body temperature by giving tepid sponge bath with 32 o c and 37 o c warm water with significance level p=0.000 and there was a difference decreasing body temperature among both of them with significance level p=0.016. discussion: it can be concluded that tepid sponge bath with 37 o c warm water was more effective than tepid sponge bath with 32 o c warm water. further studies should be observed the effectivity of tepid sponge bath with more specific age, fever character and more time and respondent. keywords: body temperature, fever, tepid sponge bath pendahuluan selama proses pertumbuhan dan perkembangan, anak sering mengalami sakit. berbagai penyakit khususnya penyakit yang disebabkan oleh infeksi hampir selalu disertai demam. chusid, 1984 (dalam soedarmo et al, 2002) menyebutkan bahwa penyebab demam 50% karena infeksi, demam tersebut terjadi karena benda asing yang masuk dalam tubuh merangsang sistem pertahanan tubuh untuk melepaskan zat pirogen endogen penyebab demam (roper, 2002). upaya untuk menurunkan suhu tubuh telah dilakukan, baik secara medikamentosa maupun dengan cara mekanik sebagai pendukung. penanganan demam pada anak biasanya dengan pemberian obat antipiretik, di mana pemberian kombinasi obat antipiretik yang tidak tepat pada anak, dapat menimbulkan komplikasi kerusakan hati dan perdarahan saluran cerna (pusponegoro, 1999). salah satu cara mekanik untuk menurunkan suhu tubuh adalah pemberian tepid sponge bath. studi yang dilakukan sharber (1997) dalam wong (2007) mengatakan bahwa pemberian tepid sponge bath yang dikombinasikan dengan obat antipiretik mampu menurunkan suhu tubuh dengan cepat selama jam pertama serangan demam pada anak-anak. pemberian tepid sponge bath yang dikombinasikan dengan obat antipiretik baru dianjurkan jika suhu tubuh anak ≥40oc, mengingat efek samping obat yang berbahaya bagi anak (pujiarto, 2000). suhu tubuh anak demam yang masih di bawah 40oc masih relatif aman, belum mengakibatkan kerusakan jaringan (pusponegoro, 1999). mailto:kusnanto_ners@yahoo.com jurnal ners vol. 3 no. 1april 2008 : 1-7 2 prosedur tepid sponge bath meningkatkan kontrol kehilangan panas dengan cara evaporasi dan konveksi (perry dan potter, 2005). pemberian tepid sponge bath ini menggunakan air hangat di mana prosedurnya hampir sama dengan pemberian kompres hangat. menurut penelitian yang telah dilakukan membuktikan bahwa kompres hangat efektif menurunkan suhu tubuh balita yang mengalami demam. air yang digunakan dalam penelitian tersebut adalah air hangat dengan suhu 30-32oc (zulkifli dan huriani, 2005). pemberian kompres hangat dilakukan di tempat-tempat tertentu di bagian tubuh, sedangkan pemberian tepid sponge bath dilakukan dengan cara menyeka seluruh tubuh klien dengan air hangat. pemberian tepid sponge bath yang diusapkan merata di seluruh tubuh diharapkan makin banyak pembuluh darah perifer di kulit yang mengalami vasodilatasi. suhu air dalam pemberian tepid sponge bath adalah air hangat (34-37 oc) yang mendekati suhu inti tubuh (37,1oc) diharapkan mampu menurunkan suhu tubuh anak demam dengan optimal. sampai saat ini belum diketahui secara pasti ketepatan suhu air pada teknik pemberian tepid sponge bath yang dapat menurunkan suhu tubuh anak demam. demam juga menyebabkan anak merasa gelisah dan tidak dapat tidur. pemberian tepid sponge bath selain dapat menurunkan suhu tubuh juga dapat memberikan kenyamanan pada anak. tubuh dapat mengalami pelepasan panas melalui empat cara yaitu konduksi, konveksi, radiasi dan evaporasi (tambayong, 2001). pemberian tepid sponge bath dapat melepaskan panas tubuh dengan cara evaporasi dan konveksi. pemberian tepid sponge bath memungkinkan aliran udara lembab membantu pelepasan panas tubuh dengan cara konveksi. suhu tubuh lebih hangat dari pada suhu udara atau suhu air memungkinkan panas akan pindah ke molekul udara melalui kontak langsung dengan permukaan kulit (guyton, 1997). terapi yang diberikan dengan menggunakan air hangat diharapkan selain memberikan kenyamanan yang lebih utama mampu merangsang reseptor suhu yang terdapat di kulit untuk diteruskan ke otak, khususnya hipotalamus, sebagai tempat pusat pengaturan suhu tubuh. hipotalamus akan merangsang saraf simpatis untuk memberikan respons vasodilatasi pembuluh darah sehingga melepaskan panas tubuh dengan cara evaporasi (guyton, 1997). demam yang tidak ditangani dengan benar, anak akan berisiko mengalami kejang serta kerusakan otak, otot, darah dan ginjal bila suhu tubuh mencapai >40oc (pujiarto, 2000). suhu air yang digunakan 32oc dimaksudkan bahwa suhu tersebut berada di bawah temperatur suhu normal (36-38oc) dan masih dalam kategori hangat untuk mengalirkan darah ke kulit (polsdorfer, 2002). pengeluaran panas yang lebih besar mampu diaktifkan oleh suatu tindakan kontrol (tepid sponge bath) dengan suhu diatas suhu tubuh dalam rentang waktu tertentu (lion, lym, dan zhang, 2003). suhu air yang diberikan di atas suhu tubuh normal memungkinkan pengeluaran panas tubuh akan semakin efektif, tetapi pemberian suhu air yang terlalu hangat berisiko melukai kulit. peneliti ingin menerapkan metode baru dalam penggunaan suhu air hangat 37oc dengan alasan suhu tersebut mendekati suhu inti tubuh (37,1oc) yang merupakan patokan set point tubuh sebelum memunculkan reaksi demam. suhu tersebut masih dalam kategori hangat yang aman jika diberikan pada kulit anak. reseptor suhu tubuh di kulit akan memperoleh rangsangan suhu dengan kapasitas lebih. rangsangan tersebut mempengaruhi hipotalamus dan memberikan efek vasodilatasi, sehingga proses pelepasan tubuh dapat berlangsung dengan lebih cepat. selama ini telah dilakukan tepid sponge bath dengan menggunakan air hangat dalam usaha untuk menurunkan suhu tubuh, tetapi ketepatan suhu yang dapat menurunkan suhu tubuh secara efektif belum diketahui. oleh karena itu peneliti tertarik untuk mengetahui perbedaan efektifitas pemberian tepid sponge bath dengan air hangat suhu 32oc dan 37oc terhadap penurunan suhu tubuh pada anak demam di ruang anggrek rsu dr. iskak tulungagung. tujuan dari penelitian ini adalah untuk menganalisis efektifitas pemberian tepid sponge bath dengan air hangat suhu 32oc dan 37oc terhadap penurunan suhu tubuh pada anak demam di ruang anggrek rsu dr. iskak tulungagung. bahan dan metode tepid sponge bath suhu 320c dan 370c (kusnanto) 3 desain penelitian yang digunakan dalam penelitian ini adalah quasyeksperimental pre-post test purposive sampling design. sampel diambil sesuai dengan kriteria inklusi yang telah ditentukan sebagai berikut: kelompok usia toddler (berumur 1-3 tahun), mengalami demam akibat penyakit infeksi virus, tidak mengalami kejang, tidak diberikan obat antipiretik, tidak memiliki luka pada kulit dan keluarga bersedia menjadi responden. jumlah sampel sebanyak 28 responden, dibagi menjadi kelompok perlakuan (diberikan intervensi tepid sponge bath dengan suhu air hangat 37oc) dan kelompok kontrol (diberikan intervensi tepid sponge bath dengan suhu air hangat 32oc) dengan jumlah sampel pada masing-masing kelompok sebanyak 14 orang. penelitian dilakukan selama bulan januari 2008. variabel independen dalam penelitian ini adalah tepid sponge bath dengan air hangat suhu 32oc dan tepid sponge bath dengan air hangat suhu 37oc, dengan lama pemberian masing-masing 10 menit. variabel dependen dalam penelitian ini adalah suhu tubuh, diukur sebelum dan selang 30 menit setiap pemberian tepid sponge bath selesai dilakukan. data yang diperoleh, dianalisis dengan menggunakan uji kolmogorov smirnov untuk mengetahui kenormalan distribusi sampel dan selanjutnya dianalisis dengan menggunakan uji statistik paired t test dan mann whitney u test dengan derajat kemaknaan α<0,05. hasil tabel 1 menunjukkan rerata penurunan suhu tubuh setelah dilakukan pemberian tepid sponge bath dengan air hangat dengan suhu 32oc sebesar 0,523oc dan rerata penurunan suhu tubuh setelah dilakukan pemberian tepid sponge bath dengan air hangat dengan suhu 37oc sebesar 0,815oc. berdasarkan hasil analisis statistik paired t test pada pemberian tepid sponge bath dengan air hangat suhu 32oc maupun dengan air hangat suhu 37oc diperoleh nilai p=0,000, yang berarti pemberian tepid sponge bath dengan air hangat suhu 32oc maupun air hangat suhu 37oc efektif menurunkan suhu tubuh pada anak demam. pada gambar 1 dapat dilihat bahwa rerata penurunan suhu tubuh anak demam setelah pemberian tepid sponge bath dengan air hangat suhu 37oc lebih besar dari pada rerata penurunan suhu tubuh anak demam setelah pemberian tepid sponge bath dengan air hangat suhu 32oc. hasil analisis statistik dengan menggunakan mann whitney u test menunjukkan p=0,016, yang berarti terdapat perbedaan yang signifikan antara pemberian tepid sponge bath dengan air hangat suhu 32oc dan 37oc terhadap penurunan suhu tubuh pada anak demam. 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1 2 3 4 5 6 7 8 9 10 11 12 13 responden p e n u ru n a n s u h u t u b u h suhu 32 suhu 37 gambar 1. rerata selisih penurunan suhu tubuh setelah dilakukan pemberian tepid sponge bath dengan air hangat suhu 32oc dan suhu 37oc di ruang anggrek rsu dr. iskak tulungagung, januari 2008. jurnal ners vol. 3 no. 1april 2008 : 1-7 4 tabel 1. penurunan suhu tubuh setelah dilakukan pemberian tepid sponge bath dengan air hangat suhu 32oc dan 37oc di ruang anggrek rsu dr. iskak tulungagung, januari 2008 no. responden suhu 32oc suhu 37oc suhu awal (0c) suhu akhir (0c) penurunan suhu (0c) suhu awal (0c) suhu akhir (0c) penurunan suhu (0c) 1 38,2 37,8 0,4 39,2 38,7 0,5 2 38,3 38,0 0,3 39,4 38,7 0,7 3 38,0 37,6 0,4 39,5 38,9 0,6 4 38,1 37,2 0,9 40,0 38,8 1,2 5 38,1 37,8 0,3 39,0 38,8 0,2 6 38,2 37,5 0,7 39,3 38,4 0,9 7 38,1 37,2 0,9 39,0 38,5 0,5 8 38,5 37,9 0,6 39,2 37,9 1,3 9 38,7 38,3 0,4 39,0 37,9 1,1 10 38,6 38,1 0,5 39,8 38,9 0,9 11 38,4 38,0 0,4 39,1 38,5 0,6 12 38,3 37,6 0,7 39,7 38,7 1,0 13 38,4 38,1 0,3 39,6 38,5 1,1 rerata 0,523 0,815 hasil analisis statistik paired t test (p=0,000) paired t test (p=0,000) mann whitney u test (p=0,016) keterangan : p = signifikansi 0c = derajat celcius pembahasan berdasarkan hasil penelitian yang menunjukkan bahwa pemberian tepid sponge bath dengan air hangat suhu 32oc dan 37oc efektif menurunkan suhu tubuh pada anak demam. hal ini sesuai dengan teori yang menyebutkan bahwa pemberian tepid sponge bath dilakukan dengan menggunakan air hangat efektif menurunkan suhu tubuh (polsdorfer, 2002). suhu air hangat 32oc termasuk dalam kategori hangat kuku 2634oc (80-93of), sedangkan suhu air 37oc dikategorikan dalam keadaan hangat 34-37oc (93-98of) (wolf, w. dan fuerst, 1984). suhu air 37oc tersebut mendekati suhu inti tubuh (37,1oc) dan masih dalam batas aman untuk kulit bayi yang cenderung sensitif terhadap perubahan suhu. kulit merupakan sistem radiator yang efektif dan aliran darah ke kulit merupakan mekanisme transfer panas yang utama dari inti tubuh ke kulit (guyton, 1997). pemberian tepid sponge bath meningkatkan kontrol kehilangan panas tubuh melalui evaporasi dan konveksi (perry dan potter, 2005). pelepasan panas melalui evaporasi lebih besar dari pada pelepasan panas melalui konveksi. usia merupakan salah satu faktor yang mempengaruhi suhu tubuh (hegner, 2003). kebanyakan anak berumur 1 tahun, perkembangan otak belum mengalami kematangan sehingga peran hipotalamus dalam usaha penurunan suhu tubuh melalui vasodilatasi pembuluh darah dan pengeluaran panas tubuh dengan cara evaporasi kurang optimal. penurunan suhu tubuh pada pemberian tepid sponge bath lebih dipengaruhi oleh konveksi yaitu pelepasan panas tubuh yang tergantung pada suhu udara atau air yang ada di sekitar tubuh anak. perbedaan suhu tubuh dan suhu lingkungan (suhu air dan udara) dapat menyebabkan kehilangan panas tubuh dengan cara konveksi (tambayong, 2001). usia anak secara tidak langsung mempengaruhi luas permukaan tubuh anak, di mana luas permukaan tubuh dihitung dari tinggi badan dan berat badan anak. rerata tinggi badan dan berat badan anak usia 1 tepid sponge bath suhu 320c dan 370c (kusnanto) 5 tahun adalah 75-85 cm dan 10-12 kg (behrman, kliegman, dan arvin, 1999). anak yang umurnya lebih besar atau tinggi badan dan berat badan yang lebih, memiliki permukaan tubuh yang lebih luas. pemberian tepid sponge bath adalah mengusapkan waslap ke seluruh permukaan tubuh anak, semakin luas permukaan tubuh anak semakin luas kulit yang kontak dengan waslap dan air hangat sehingga pelepasan panas baik melalui cara evaporasi maupun konveksi lebih optimal. responden dalam penelitian ini meskipun sebagian besar berumur 1 tahun tetapi penurunan suhu tubuh setelah diberikan tepid sponge bath menunjukkan rerata selisih penurunan suhu tubuh yang cukup besar berarti anak yang memiliki permukaan tubuh yang relatif lebih sempit dapat mengalami penurunan suhu tubuh yang cukup besar. responden yang berumur lebih dari 1 tahun (1,5-3 tahun) juga menunjukkan rerata selisih penurunan suhu tubuh yang cukup besar. hal ini membuktikan bahwa luas permukaan tubuh yang secara tidak langsung dilihat dari umur anak, tidak mempengaruhi penurunan suhu tubuh. jenis kelamin bukan salah satu faktor yang mempengaruhi suhu tubuh, tetapi secara tidak langsung dapat dihubungkan dengan tingkat aktifitas anak dan ketebalan lemak. responden dalam penelitian ini sebagian besar adalah laki-laki. anak lakilaki pada umumnya memiliki karakteristik lebih banyak melakukan aktifitas dibandingkan dengan anak perempuan, tetapi dalam keadaan sakit mereka mengalami kelemahan dan lebih banyak menghabiskan waktu istirahat di tempat tidur. aktifitas meningkatkan metabolisme anak, di mana dalam metabolisme akan terbentuk panas sehingga akan memperlambat penurunan suhu tubuh pada anak yang sedang mengalami demam. anak laki-laki dalam keadaan sakit tidak melakukan banyak aktifitas sehingga setelah diberikan tepid sponge bath mengalami banyak penurunan suhu tubuh. hasil penelitian menunjukkan bahwa rerata selisih penurunan suhu tubuh pada anak perempuan tidak terlalu besar bila dibandingkan dengan anak laki-laki. hal ini sesuai dengan teori yang menyebutkan bahwa anak perempuan cenderung memiliki lemak yang lebih tebal daripada anak lakilaki. pengeluaran panas dipengaruhi oleh ketebalan lemak. lemak merupakan isolator tubuh yang baik dalam menghambat pelepasan panas tubuh melalui kulit (guyton, 1997). pemberian tepid sponge bath dengan suhu air hangat selain dapat menurunkan suhu tubuh, juga memberikan kenyamanan pada anak (widyanti, fatimah, dan mardhiyah, 2004). kenyamanan yang dirasakan anak merupakan respons dari sensasi hangat pada air yang digunakan dalam pemberian tepid sponge bath, selain itu efek dari usapan waslap yang disertai massage juga memberikan rasa nyaman. responden yang mengalami ketidaknyamanan yang diekspresikan dengan menangis mengalami sedikit penurunan suhu tubuh. hal itu disebabkan oleh aktifitas menangis anak memerlukan energi. energi diperoleh dari hasil metabolisme tubuh, hasil samping metabolisme adalah pembentukan panas yang dapat menyebabkan peningkatan suhu tubuh (scanlon, 2006), apalagi ditunjang dengan adanya suatu penyakit. dampak hospitalisasi yang dihadapi anak juga mempengaruhi kenyamanan anak. anak mengalami stres psikologis yang disebabkan oleh ketidaknyamanan terhadap kondisi penyakitnya, adaptasi dengan lingkungan rumah sakit, serta keterbatasan anak dalam melakukan mekanisme koping. salah satu stressor pada anak yang dirawat di rumah sakit adalah cemas karena perpisahan dengan orang terdekat atau orangtua (nursalam, susilaningrum, dan utami, 2005). responden yang mengalami ketidaknyamanan dan diekspresikan dengan menangis selain disebabkan oleh prosedur, juga karena pada umur toddler anak berada dalam tahap perkembangan individu parental (tripolar). anak lebih nyaman bersama orangtuanya, sehingga anak kurang nyaman dengan orang lain (peneliti) pada saat dilakukan pemberian tepid sponge bath. keefektifan pemberian tepid sponge bath dipengaruhi oleh sikap kooperatif anak. anak yang kooperatif menunjang ketepatan prosedur dan waktu pemberian tepid sponge bath. hasil penelitian ini menunjukkan bahwa terdapat perbedaan yang signifikan antara pemberian tepid sponge bath dengan air hangat suhu 32oc dan 37oc terhadap penurunan suhu tubuh pada anak demam. hal ini disebabkan suhu air hangat yang jurnal ners vol. 3 no. 1april 2008 : 1-7 6 digunakan (32oc dan 37oc) berada dalam kategori yang berbeda (hangat kuku dan hangat). perbedaan hasil penurunan suhu tubuh tersebut dipengaruhi oleh perbedaan awal peningkatan suhu tubuh anak. pemberian tepid sponge bath dengan pengelompokan responden sesuai kategori peningkatan suhu tubuh (suhu air 32oc untuk peningkatan suhu tubuh 38,0-38,9oc dan suhu air 37oc untuk peningkatan suhu tubuh 39,0-40,0oc) memberikan rerata hasil penurunan suhu tubuh yang berbeda. pemberian tepid sponge bath dengan air hangat efektif menurunkan demam tinggi (perry dan potter, 2005). hal ini sesuai dengan penelitian sebelumnya bahwa penurunan suhu tubuh dengan metode tepid sponge bath pada suhu tubuh di atas 39oc memberikan selisih penurunan suhu yang lebih besar dari pada peningkatan suhu tubuh di bawah 39oc (widyanti, fatimah, dan mardhiyah, 2004). suhu air yang digunakan 37oc mendekati suhu inti tubuh (37,1oc), sehingga memberikan stimulus pada saraf eferen untuk mempengaruhi hipotalamus untuk mengeset suhu tubuh sesuai dengan suhu tubuh normal. suhu air 37oc mempunyai rentan yang lebih jauh dari suhu udara (± 24oc) dari pada suhu air 32oc, sehingga perbedaan suhu udara dan tubuh menyebabkan proses pelepasan panas secara konveksi lebih besar. suhu lingkungan dipengaruhi oleh besar ruangan, jumlah individu/pasien yang menghuni ruangan tersebut, tersedianya alat pendingin ruangan serta cuaca. waktu pemberian tepid sponge bath yang tidak sama yaitu siang hari pukul 11.00 wib dan sore hari pukul 15.00 wib, juga mempengaruhi perbedaan hasil rerata penurunan suhu tubuh dari perbedaan kontrol suhu lingkungan. simpulan dan saran simpulan pada penelitian ini dapat disimpulkan bahwa pemberian tepid sponge bath dengan menggunakan air hangat suhu 32oc atau 37oc efektif menurunkan suhu tubuh pada anak demam dan pemberian tepid sponge bath dengan air hangat suhu 37oc lebih efektif dalam menurunkan suhu tubuh pada anak demam di ruang anggrek rsu dr. iskak tulungagung dibandingkan dengan pemberian tepid sponge bath dengan air hangat suhu 32oc. saran dari hasil penelitian ini, peneliti menyarankan agar pemberian tepid sponge bath dengan air hangat kuku (suhu 32oc) atau air hangat (suhu 37oc) dapat dilaksanakan sebagai salah satu asuhan keperawatan dalam usaha penurunan suhu tubuh anak demam dan penelitian tentang tepid sponge bath dapat dilanjutkan dengan sampel yang lebih banyak, waktu yang lebih lama dan menspesifikkan reponden berdasarkan rentang peningkatan suhu tubuh, karakteristik demam yang sama serta kontrol lingkungan yang ketat. kepustakaan behrman, kliegman, dan arvin. 1999. ilmu kesehatan anak nelson. edisi 15 volume i. jakarta: egc, hlm. 11181120, 1134-1136. guyton. 1997. buku ajar fisiologi kedokteran. jakarta: egc, hlm. 774775, 1141-1154. hegner. 2003. asisten keperawatan: suatu pendekatan proses keperawatan, jakarta: egc, hlm. 227-240, 362-376. lyon, lym, dan zhang. 2003. merawat balita satu sampai lima tahun, jakarta: pt gramedia pustaka utama, hlm. 48-52. nursalam, susilaningrum, dan utami. 2005. asuhan keperawatan bayi dan anak. jakarta: salemba medika, hlm. 55-67. perry dan potter. 2005. buku ajar fundamental keperawatan: konsep, proses dan praktik. edisi 4 volume 1, jakarta: egc, hlm. 760-779. polsdorfer, j. 2002. cooling treatments, (online), (http://www.healthatoz.com., diakses tanggal 05 november 2007, jam 07.30 wib). pujiarto. 2000. bayi terlahir dari ibu pengidap hepatitis b. sari pediatri, 2 (1), 20-35. pusponegoro, h. 1999. penatalaksanaan demam. karya tulis ilmiah, 1, 21-25. roper, n. 2002. prinsip-prinsip keperawatan. yogyakarta: yayasan essentia medika, hlm. 268-286. http://www.healthatoz.com/ tepid sponge bath suhu 320c dan 370c (kusnanto) 7 scanlon, v. 2006. buku ajar anatomi dan fisiologi. edisi 3. jakarta: egc, hlm. 368-373. soedarmo, et al. 2002. buku ajar ilmu kesehatan anak, infeksi dan penyakit tropis. edisi i. jakarta: bagian ilmu kesehatan anak fkui, hlm. 89-97. tambayong, j. 2001. anatomi dan fisiologi untuk keperawatan. jakarta: egc, hlm. 33-37. widyanti, fatimah, dan mardhiyah. 2004. gambaran pemeliharaan suhu tubuh pada anak tifoid melalui metode tepid sponge dan kompres dingin dengan kombinasi antipiretik di ruang a.1 perjan rs hasan sadikin bandung. artikel penelitian, 5(9), 7585. wong. 2007. tepid sponge bath and fever management, (online), (http://www.mosbysdrugconsult.com/ wow/op033.htm., diakses tanggal 05 november 2007, jam 08.30 wib). wolf, weitzel, dan fuerst. 1984. dasar dasar ilmu keperawatan. jakarta: pt gunung agung, hlm. 33-47. zulkifli dan huriani. 2005. keefektifan pemberian kompres dalam menurunkan suhu tubuh balita. ners jurnal keperawatan universitas andalas, 1(1), 1-6. http://www.mosbysdrugconsult.com/wow/op033.htm http://www.mosbysdrugconsult.com/wow/op033.htm pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru perilaku homoseksual yang baik menurunkan prevalensi penyakit menular seksual (good homosexual behaviour decrease prevalence of sexual transmitted dissease) purwaningsih*, ika yuni widyawati*, mohammad nur firdaus* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 . e-mail: purwaningsih_ners@unair.ac.id abstract introduction: the homosexual behaviour were become indicators of sexually transmitted diseases’s (stds) prevalencies. prevalence of sexually transmitted diseases in homosexual community was very high but until recently study it was conducted sporadically. the objective of this study was to analyze the correlation of homosexual behaviour with prevalence of sexually transmitted diseases (stds) in mobile clinic community centre of igama collaborating with public health centre sumberpucung of malang regency. method: analytic design with cross sectional methode was used in this study. the population were all visitors of mobile clinic community centre of igama collaborating with public health centre sumberpucung of malang regency (353 people). sample were 40 people who met to the inclusion criteria. the independent variable was homosexual behaviour and the dependent variable was prevalence of sexually transmitted diseases (stds). data for homosexual behaviour were collected by using questionnaire and indhept interview with content analyze and data for prevalence of sexually transmitted diseases (stds) were collected by using laboratorium test for stds. result: the research result was presented in the form diagram, table of cross tabulation and analyzed by using spearman rho with significance level ρ=0.005. the result showed that there was correlation of homosexual knowledge (ρ=0.001), attitude (ρ=0.000) and practice (ρ=0.000) with prevalence of stds. dsicussion: it can be concluded that the better knowledge, attitude and practice of homosexual could be decrease prevalence of stds. futher studies are recomended to analyze the correlation between homosexual behaviour and prevalence of stds with health believe approach. keywords: homosexual behaviour, prevalence of sexually transmitted diseases pendahuluan peningkatan perilaku seksual berisiko di indonesia, khususnya jawa timur, tidak hanya terbatas pada kelompok heteroseksual, tetapi juga pada kelompok lelaki yang menyukai hubungan seksual sesama jenis. perilaku seksual lelaki suka lelaki (lsl) ternyata jauh lebih kompleks karena tidak hanya berasal dari berbagai strata sosial ekonomi dan budaya tetapi juga berbagai ragam identitas seksual (kepedulian untuk mencegah ims dan hiv/aids, 2004). perilaku seksual gay yang tidak aman dan berisiko tinggi inilah yang merupakan faktor penyebab peningkatan prevalensi infeksi menular seksual (ims) yang merupakan indikator penularan hiv/aids (thaczuk, 2007), namun prevalensi ims pada komunitas gay di indonesia baru diukur secara sporadis (raharjo, 2003). prevalensi ims di kalangan gay termasuk tinggi (0,5; artinya terdapat 5 orang dengan hiv/aids (odha) di antara 10.000 homoseksual dan transeksual (jalu, 2007). laporan dari beberapa lokasi pada tahun 1999-2001 menunjukkan prevalensi infeksi gonore dan chlamydia yang tinggi antara 20-35% dan prevalensi serologi sifilis positif sebesar 12,9%. bagian tubuh yang terinfeksi antara lain dubur 2,2%, tenggorokan 2,2% dan uretra 9,5% (raharjo, 2003). prevalensi pengidap ims pada tahun 2003 mencapai 22%, sedangkan pada tahun 2006 prevaiensi pengidap ims 23%, serta pada juli 2007 mencapai 56% pada kelompok msm yang mempunyai perilaku berisiko tinggi di kabupaten malang (gozali, 2007). berdasarkan estimasi pada lokakarya peta respons propinsi jawa timur september 2005 di tretes jumlah gay di kabupaten malang sebesar 1430 orang. data di klinik kespro igama menunjukkan bahwa prevalensi dan insidensi ims semakin lama semakin meningkat. persentase seluruh ims yang ditemukan dibandingkan seluruh pengunjung yang diperiksa semakin meningkat pada juni sampai dengan november 2007 (gambar 1). infeksi menular seksual (ims) merupakan indikator adanya perilaku seksual berisiko. prevalensi ims yang tinggi pada suatu populasi di suatu tempat merupakan pertanda awal akan risiko penyebaran hiv/aids. di lain pihak, peningkatan penggunaan kondom akan lebih cepat tergambar melalui penurunan prevalensi ims daripada prevalensi hiv/aids. data di klinik kespro igama menunjukkan tingkat penggunaan kondom pada komunitas gay rendah. sebanyak 61,39% gay yang terdaftar di klinik kespro igama tidak menggunakan kondom saat berhubungan seksual dengan pasangannya. perilaku seksual yang tidak aman ini tidak sesuai dengan tingkat pendidikan gay yang relatif tinggi, dari 353 gay yang tercatat berpendidikan smu dan sederajat 53,41%; 21,66% berpendidikan smp; 12,17% mahasiswa; 7,12% berpendidikan sd; 4,15% berpendidikan diploma; 1,48% berpendidikan sarjana dan 0,01% berpendidikan magister. penurunan prevalensi ims selain menggambarkan perubahan perilaku dapat memberikan gambaran perluasan cakupan dan peningkatan kualitas program penanggulangan ims. data prevalensi ims yang diamati secara periodik berperan penting untuk melihat kecenderungan perilaku seksual, potensi penyebaran hiv/aids dan untuk memonitor, mengevaluasi serta merencanakan upaya penanggulangan ims/hiv/aids (jazan, 2003). pada tahun 2002 telah dilakukan survei perilaku berisiko yang dilakukan pada subpopulasi lsl di tiga kota, yakni jakarta, surabaya dan batam. hasil survei mengindikasikan bahwa perilaku seks pada subpopulasi lsl jauh lebih kompleks, tidak hanya terbatas perilaku tertentu saja dan rendahnya pemakaian kondom ketika melakukan seks anal sehingga meningkatkan risiko terkena ims. program pencegahan dan pengobatan ims sesuai rencana strategi penanggulangan hiv/aids 2003-2007 departemen kesehatan republik indonesia terdiri dari melakukan advokasi kepada para pengambil keputusan untuk mendukung upaya penanggulangan ims, meningkatkan komunikasi-informasi-edukasi (kie) pencegahan ims, pemeriksaan ims dan pengobatan ims secara dini, pendidikan dan pelatihan bagi petugas kesehatan dalam penatalaksanaan penderita ims berdasarkan pendekatan sindrom dan etiologi, mengembangkan klinik ims di lokalisasi, bar, karaoke dan panti pijat. sejalan dengan strategi nasional tersebut sangat diharapkan para gay melakukan perilaku seksual yang aman dan sehat (memakai kondom) dengan harapan prevalensi ims dapat diturunkan. berdasarkan fenomena tersebut peneliti tertarik untuk melakukan penelitian yang terkait dengan perilaku gay terhadap prevalensi ims khususnya di mobile clinic community center igama kerjasama dengan puskesmas sumberpucung kabupaten malang. bahan dan metode desain yang digunakan dalam penelitian ini adalah desain non eksperimen yaitu deskriptif-analitik-korelasional dengan pendekatan cross sectional. populasi dalam penelitian ini adalah komunitas gay di malang yang memeriksakan diri di klinik kespro igama sejumlah 353 orang. dari populasi tersebut terpilih 40 orang sebagai sampel penelitian dengan menggunakan tehnik purposive sampling yaitu sampel yang sesuai dengan kriteria inklusi. adapun kriteria inklusi yang ditetapkan dalam penelitian ini sebagai berikut: gay yang berkunjung secara rutin 3 dan 6 bulan terakhir di klinik kespro igama wilayah kerja puskesmas sumberpucung kabupaten malang dan gay yang berkunjung di klinik kespro igama pada saat penelitian dan bersedia dengan sukarela menjadi responden. purwaningsih penelitian ini dilakukan pada selama januarifebruari 2008. variabel independen dalam penelitian ini adalah perilaku (pengetahuan, sikap dan tindakan) gay sedangkan variabel dependen adalah prevalensi infeksi menular seksual. pada penelitian ini data diperoleh dengan menggunakan kuesioner, melakukan pengamatan langsung, wawancara (indepht interview dengan content analyze) dan pemeriksaan laboratorium. kuesioner yang dipergunakan memuat berbagai pertanyaan tentang pengetahuan ims dan kondom, sikap gay terhadap hubungan seksual yang aman dan berisiko dan tindakan gay untuk mendapatkan pelayanan kesehatan pada sarana dan fasilitas kesehatan. kuesioner disusun dan dikembangkan oleh peneliti dengan mengacu pada definisi variabel, tujuan penelitian dan memodifikasi kuesioner pengetahuan dan sikap terhadap ims dari family health international (fhi) (2005). data yang diperoleh kemudian ditabulasi dan dianalisis dengan menggunakan uji statistik spearman’s rho dengan derajat kemaknaan ρ≤0,05. hasil hasil penelitian ini menunjukkan bahwa seluruh responden yang diteliti sejumlah 40 orang (100%) mempunyai pengetahuan yang baik tentang ims dan kondom (gambar 2). pada gambar 3 dapat dilihat bahwa sikap responden dalam berperilaku seksual yaitu sebanyak 21 orang responden (52%) mempunyai sikap yang positif dan 19 orang responden (48%) mempunyai sikap negatif. sebagian besar responden yaitu 33 orang (82%) mempunyai tindakan yang cukup dalam berperilaku menjaga kesehatan organ reproduksi, mencegah penularan infeksi menular seksual dan mencari pengobatan, 4 orang (10%) responden mempunyai tindakan yang baik dan 3 orang (8%) mempunyai tindakan yang kurang. hal ini mengindikasikan bahwa perilaku responden dalam menjaga kesehatan organ reproduksi, mencegah penularan infeksi menular seksual dan mencari pengobatan sudah cukup (gambar 4). gambar 5 menunjukkan bahwa 25 responden (62%) diketahui berstatus ims negatif. pada tabel 1 dapat dilihat bahwa terdapat hubungan yang bermakna antara variabel pengetahuan dan prevalensi ims (ρ=0,001); variabel sikap dan prevalensi ims (ρ=0,000) dan antara variabel tindakan dan prevalensi ims (ρ=0,000). tabel 1 hasil analisis statistik pengetahuan, sikap dan tindakan terhadap prevalensi ims di mobile clinic community centre igama kerjasama dengan pkm sumberpucung kabupaten malang, februari 2008 prevalensi ims pengetahuan tindakan sikap baik cuku p kuran g baik cukup kurang positif negatif n % n % n % n % n % n % n % n % ims positif 15 38 0 0 0 0 1 7 13 86 2 7 4 27 11 73 ims negatif 25 62 0 0 0 0 3 12 20 84 1 4 17 68 8 32 total 40 100 0 0 0 0 4 10 33 82 3 8 21 53 19 47 hasil analisis statistik spearman rho (p=0,001) spearman rho (p=0,000) spearman rho (p=0,000) keterangan : n = jumlah responden p = signifikansi perilaku homoseksual yang baik menurunkan prevalensi penyakit menular seksual perilaku homoseksual yang baik menurunkan prevalensi penyakit menular seksual pembahasan penelitian ini dilakukan hanya satu kali dalam satu waktu yaitu pada saat berlangsungnya pemeriksaan klinik oleh mobile clinic community centre igama yang bekerjasama dengan pkm sumberpucung kabupaten malang. hasil penelitian ini menunjukkan bahwa terdapat hubungan yang signifikan antara pendidikan, sikap dan tindakan responden dengan prevalensi ims. hasil lain yang diperoleh yaitu diketahui bahwa usia responden merupakan usia produktif dimana sangat rawan terhadap perilaku seksual baik perilaku seksual aman atau berisiko (dan, 2007). tingkat pendidikan formal rerata responden merupakan lulusan smu dan sederajat yang menunjukkan bahwa responden mempunyai pengetahuan yang cukup baik untuk menerima informasi tentang ims dan kondom (faugier, 2006). sebagian besar responden mempunyai pekerjaan tetap dan sebagian besar lagi tidak mempunyai pekerjaan, hal ini dapat menciptakan banyak perilaku yang negatif seperti membenarkan diri untuk menjual diri sebagai alasan ekonomi (jalu, 2007). pengetahuan mempunyai hubungan terhadap prevalensi ims yang signifikan, hal ini sangat dimungkinkan karena pengetahuan bisa menjadikan seseorang berbuat lebih baik atau sebaliknya. hal ini didukung dengan latar belakang tingkat pendidikan responden yang mayoritas merupakan lulusan smu dan sederajat dan responden merupakan pengunjung klinik rutin selama 3 atau 6 bulan terakhir sehingga responden sudah mendapatkan informasi dan pengetahuan yang cukup tentang ims dan kondom melalui berbagai program dari igama misalnya penyuluhan dan pembagian materi kie (seperti leaflet, booklet, stiker dan lainlain). benyamin blomm (dalam notoatmodjo, 2003) mendefinisikan pengetahuan sebagai hasil dari tahu dan ini terjadi setelah orang melakukan penginderaan terhadap suatu obyek tertentu. penginderaan terjadi melalui indera penglihatan, pendengaran, penciuman, rasa dan raba. sebagian besar pengetahuan manusia diperoleh melalui mata dan hidung. notoatmodjo 2003 berpendapat bahwa sebelum seseorang mengadopsi perilaku (berperilaku baru) maka dia harus tahu terlebih dahulu apa arti atau manfaat perilaku tersebut bagi diri atau keluarga. indikator yang dapat digunakan untuk mengetahui tingkat pengetahuan atau kesadaran terhadap kesehatan dapat dikelompokkan menjadi pengetahuan tentang sehat dan penyakit, pengetahuan tentang cara pemeliharaan kesehatan dan cara hidup sehat dan pengetahuan tentang kesehatan lingkungan. dapat disimpulkan bahwa pengetahuan merupakan faktor predisposisi penting untuk menghasilkan suatu bentuk perilaku kesehatan baru. faktor predisposisi ini memberikan alasan yang rasional dan memotivasi terjadinya suatu bentuk perilaku, faktor ini mendukung maupun menghambat terjadinya suatu perilaku yang berkaitan dengan timbulnya tindakan kesehatan. faktor predisposisi memberikan dukungan bahwa perilaku akan menetap lama bila ada isyarat yang cukup kuat untuk memotivasi seseorang untuk bertindak atau berubah atas dasar pengetahuan yang dimiliki. pengetahuan yang baik dari responden tentang ims dan kondom dapat mengurangi atau mencegah penularan infeksi menular seksual sehingga prevalensi ims menjadi rendah. sikap responden dalam penelitian ini mempunyai hubungan signifikan terhadap prevalensi ims. sikap positif responden sangat mendukung terjadinya perubahan perilaku baru yang positif karena dengan adanya sikap positif responden terhadap perilaku seksual dapat diartikan bahwa responden sangat berhati-hati dalam mengambil sikap terutama dalam berperilaku seksual yang berisiko menularkan ims. hal ini didukung pernyataan responden berikut: “selalu mas, untuk menghindari ims. saya dapat kondom dari kantor igama, cara menggunakan kondom yang benar dengan melihat tanggal kadaluwarsa kemudian rusak apa tidak” sikap positif responden mendorong perilaku seksual yang sehat serta dapat mengurangi atau mencegah penularan ims seperti pernyataan beberapa responden berikut: “saya menggunakan kondom karena takut tertular ims” “tetap setia pada satu pasangan” sikap responden yang lain yang mendukung antara lain kemauan menjaga purwaningsih kebersihan organ reproduksi atau sama sekali tidak melakukan hubungan seksual. sikap positif responden terhadap perilaku seksual sangat didukung oleh adanya faktor predisposisi antara lain pengetahuan responden yang baik dan sikap responden terhadap kesehatan, tradisi, kepercayaan, tingkat pendidikan, motivasi, tingkat sosial ekonomi dan sebagainya yang sudah cukup memadai sehingga responden mengetahui apa yang harus dilakukan untuk mencegah terjadinya penularan ims. faktor pendukung sikap positif responden antara lain ketersediaan sarana dan prasarana atau fasilitas kesehatan bagi masyarakat misalnya puskesmas, rumah sakit dan klinik sebagai tempat untuk melakukan pemeriksaan (seperti mobile clinic community centre igama yang bekerjasama dengan pkm sumberpucung kabupaten malang), apotik atau toko sebagai tempat membeli kondom. fasilitas ini pada hakekatnya mendukung atau memungkinkan terwujudnya perilaku kesehatan. faktor penguat sikap positif responden meliputi faktor peran lembaga swadaya masyarakat (lsm), perilaku tenaga kesehatan, termasuk undang-undang yang terkait dengan kesehatan. masyarakat bukan hanya memerlukan pengetahuan, sikap positif dan dukungan fasilitas kesehatan saja untuk berperilaku sehat, namun diperlukan juga perilaku contoh (acuan) dari para tokoh agama, petugas kesehatan dan peran lembaga swadaya masyarakat (lsm) terkait dalam menanggulangi dan mengurangi penyebaran ims di komunitas gay di malang. igama dalam hal ini mempunyai banyak kegiatan program kesehatan yang bertujuan membentuk sikap positif dari responden misalnya penjangkauan dan pendampingan; community outreach; pelatihan dan pembinaan peer educater; penyuluhan dan focus groups discussion yang dilakukan secara aktif dan pasif; kampanye atau penyiaran radio terarah; rujukan klinik ims yaitu suatu program yang menyediakan layanan mobile clinic community centre igama yang diselenggarakan atas kerjasama dengan pkm sumberpucung dengan dukungan dana dari fhi (family health international); konseling dan rujukan vct; layanan manager kasus; kelompok dukungan sebaya yaitu kelompok dukungan yang disebut "astaga"; hotline service; layanan info melalui website; distribusi materi kie (leaflet, stiker, poster, booklet, kalender, bloknote dan lainnya); distribusi kondom dan pelicin (safer pack); outlet kondom; kegiatan koordinasi jaringan peduli aids malang raya. jaringan lsm yang terdiri atas beberapa lembaga seperti igama, kk wamarapa, sadar hati, paramitra serta beberapa lembaga atau organisasi lain juga turut berpartisipasi (german, smart, paguyuban kakang bakyu malang dan lainnya). sikap negatif responden dalam berperilaku seksual dapat dipengaruhi oleh beberapa faktor antara lain kurangnya pengetahuan responden terhadap perilaku seksual yang aman, adanya keterbatasan sarana dan prasarana serta fasilitas yang diperoleh responden, belum pernah mendapatkan pelayanan atau penyuluhan kesehatan oleh petugas kesehatan atau responden sangat sulit merubah sikapnya seperti pernyataan beberapa responden berikut: ”saya tergantung lawan maen mas, dia mau pake kondom apa enggak karena saya tidak mau memaksa” “gak pernah mas, make kondom iku gak enak“ ”gak pernah buat apa mas karena kita sama-sama bersih jadi ngak perlu pake kondom” perilaku negatif responden mempunyai potensial untuk meningkatkan penularan ims melalui hubungan seksual yang tidak aman karena menurut responden bahwa sikap yang selama ini dianutnya adalah benar sehingga bisa berpengaruh terhadap peningkatan prevalensi ims. tindakan responden dalam menjaga kesehatan organ reproduksi, mencegah penularan infeksi menular seksual dan mencari pengobatan bila sakit mempunyai hubungan yang signifikan terhadap prevalensi ims. hal ini mengindikasikan bahwa perilaku responden dalam menjaga kesehatan organ reproduksi dengan mencari pengobatan mampu mencegah penularan ims. beberapa faktor yang mempengaruhi antara lain kesadaran responden untuk berperilaku sehat sangat tinggi, dimana perilaku homoseksual yang baik menurunkan prevalensi penyakit menular seksual responden menganggap bahwa kesehatan adalah yang terpenting. becker (dalam notoatmodjo, 2003) membuat klasifikasi tentang perilaku kesehatan antara lain perilaku hidup sehat yang mencakup perilaku atau gaya hidup yang positif bagi kesehatan; perilaku sakit (illness behaviour) mencakup respons seseorang terhadap sakit dan penyakit, persepsinya tehadap sakit, pengetahuan tentang penyebab dan gejala penyakit, pengobatan penyakit dan lain sebagainya; perilaku peran sakit (the sick role behaviour) meliputi tindakan memperoleh kesembuhan, mengenal/ mengetahui fasilitas pelayanan atau penyembuhan penyakit yang layak, mengetahui hak dan kewajiban orang sakit. berbagai perilaku tersebut tergambar dari pernyataan reponden berikut: ”saya selalu memeriksakan diri secara rutin ke klinik igama, rutin check up, tidak ngeseks, rutin minum obat, ke igama karena tempatnya nyaman dan rahasia dijamin” simpulan dan saran simpulan pengetahuan, sikap dan tindakan responden menunjukkan hubungan yang signifikan dengan prevalensi ims. semakin rendah pengetahuan, semakin negatif sikap dan semakin kurang tindakan maka potensial tertular ims semakin meningkat. pengetahuan dari seluruh responden tentang ims dan kondom di mobile clinic community centre igama kerjasama dengan pkm sumberpucung kabupaten malang adalah baik. pengetahuan merupakan salah satu faktor predisposisi yang penting untuk membentuk perilaku kesehatan baru. sikap merupakan salah satu indikator yang penting selain pengetahuan dalam membentuk suatu perilaku baru, apakah perilaku tersebut negatif maupun positif. pada penelitian ini didapatkan sebagian besar dari responden di mobile clinic community centre igama kerjasama dengan pkm sumberpucung kabupaten malang mempunyai sikap positif. tindakan responden di mobile clinic community centre igama kerjasama dengan pkm sumberpucung kabupaten malang dalam menjaga kesehatan organ reproduksi, mencegah penularan ims dan mencari pengobatan sebagian besar adalah cukup. hal ini disebabkan karena responden sudah mempunyai kesadaran yang cukup tinggi dalam menggunakan layanan atau fasilitas kesehatan. saran peneliti menyarankan agar: pengetahuan, sikap dan tindakan bisa membentuk perilaku baru baik perilaku yang positif atau perilaku yang negatif dibuktikan dengan menggunakan pendekatan health believe sehingga perilaku gay dapat dirubah dan prevalensi ims dapat dikendalikan. kepustakaan dan, j. 2007. sains bicara homoseksual, (online), (http://www.north.com/, diakses tanggal 17 november 2007, jam 01.25 wib). family health intenational. 2005. kuesioner pengetahuan dan sikap terhadap infeksi menular seksual dan hiv/aids, (online), (http://www.certi.org/cma/training/mo dule1-5-indonesian/ modul2hiv.htm., diakses tanggal 17 november 2007, jam 02.15 wib). faugier, j. 2006. aids and hiv the nursing respons. london: chapman and hall. jalu. 2007. kepedulian mencegah ims dan hiv/aids, (online), (http://www.kompas.com/kompascetak/0611/17/jogja/1030831.htm., diakses tanggal 17 november 2007, jam 00.55 wib). notoatmodjo, s. 2003. pendidikan dan perilaku kesehatan. jakarta: rineka cipta. thaczuck, d. 2007. ims meningkatkan risiko penularan hiv yang resisten, (online), (http://www.aidsmap.com., diakses tanggal 17 november 2007, jam 02.30 wib). purwaningsih http://www.north.com/ http://www.certi.org/cma/training/module1-5-indonesian/%20modul2hiv.htm http://www.certi.org/cma/training/module1-5-indonesian/%20modul2hiv.htm http://www.kompas.com/kompas-cetak/0611/17/jogja/1030831.htm http://www.kompas.com/kompas-cetak/0611/17/jogja/1030831.htm http://www.aidsmap.com/ musik klasik menurunkan tingkat stres dan tekanan darah dan nadi ibu primigravida trimester ketiga musik klasik menurunkan tingkat stres dan tekanan darah ibu primigravida trimester ketiga (classical music decrease stress level and blood pressure primigravida in the third trimester) ni ketut alit a*, erna dwi w*, praba diyan r* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: alitnik@yahoo.com abstract introduction: many changes in psychology and biology increase primigravida’s stress in the third trimester. the stress response makes blood pressure being unstable, it causes bad effect for pregnancy. classical music can be used as one of relaxation facilities that can reduce stress. the aimed of this study were to analyze the effect of classical music on stress level and blood pressure. method: this study was used a quasy experimental purposive sampling design. the sample in this study were 14 pregnancy women in the third trimester in rsia cempaka putih permata surabaya. the independent variable in this study was classical music and the dependent variable were stress level and blood pressure. data were analyzed by wilcoxon signed rank test, mann withney u test, paired t test and independent t test with significance level α≤0.05. result: the result showed that the stress level in controlled group with p=0.567 and intervention group with p=0.025. the result of blood pressure in controlled group with p=0.522 in systolic blood pressure, p=0.35 in diastolic blood pressure and intervention group showed p=0.103 in systolic blood pressure and p=1.00 in diastolic blood pressure. discussion: it can be concluded that listening classical music can reduce stress level, stabilize blood pressure, although blood pressure hasn’t significant result but mean of blood pressure show that it was stable. further studies should be considered to used cortisol to identify stress biology response spesifically. keywords: primigravida, classical music, stress, blood pressure. pendahuluan kehamilan merupakan masa dimana terjadi perubahan besar secara fisiologis dan psikologis (tiran, 2007). perubahan besar yang terjadi selama kehamilan dapat memicu kecemasan pada ibu primigravida karena pengalaman kehamilan yang pertama (chahaya, 2003 dalam mulyata, 2007) dan hal ini dapat berkembang menjadi stres (niven, 1992 dalam mulyata, 2007). efek kehamilan secara fisiologis seperti perubahan suasana hati akibat adanya perubahan hormon, kelelahan, sakit punggung, kekhawatiran yang muncul terhadap keadaan janin serta aspek negatif dari kehamilan dan persalinan yang sering ibu primigravida dengar merupakan keadaan yang dapat menimbulkan stres (dewi, 2005). hasil studi pendahuluan di rs khusus ibu dan anak cempaka putih permata surabaya menunjukkan 7 dari 10 ibu hamil mengalami gejala stres. pada trimester ketiga, stres pada ibu hamil meningkat yang terjadi karena kehamilan semakin membesar dan waktu persalinan yang bertambah dekat (susanti, 2007). secara fisiologis ibu hamil mengalami perubahan pada tekanan darah (mochtar, 1998). respons terhadap stres meningkatkan tekanan darah (fiori, 2005). berdasarkan hasil survei kesehatan jiwa pada ibu hamil dan menyusui oleh dinas kesehatan provinsi jawa barat tahun 2003, 27% dari 2.928 responden ibu hamil dan menyusui, menunjukkan tanda gangguan psikiatri berupa kecemasan (43%), gangguan depresi berupa perasaan tak bahagia, nafsu makan berkurang, minat kerja berkurang, konsentrasi terganggu, napas sesak, pegalpegal di punggung, minat seksual berkurang, gangguan tidur (41%). stres pada ibu hamil merupakan masalah penting yang harus diatasi. hasil survei di jawa barat tahun 2006 terjadi sedikit peningkatan dari tahun 2003 dimana hasil survei menunjukkan dari 95 responden ibu hamil dan menyusui 43,2% jurnal ners vol.3 no.1 april 2008 : 72-76 menunjukkan kecemasan sedang dan 11, 6% mengalami depresi ringan. dari hasil survei tersebut dapat dilihat tingkat kecemasan yang tinggi pada ibu hamil, dimana kecemasan merupakan manifestasi psikologis dari stres (rasmun, 2004). masa kehamilan merupakan masa transisi dalam kehidupan yang menuntut adaptasi dalam segala bidang (dunkel et al, 1999 dalam dewi, 2005). proses adaptasi ini merupakan suatu proses sulit bagi ibu primigravida karena pada masa ini terdapat perubahan hormon yang dapat mempengaruhi mood secara keseluruhan sehingga ibu sering merasa kesal, jenuh ataupun sedih (dewi, 2005) dan mengalami berbagai ketidaknyamanan (tiran, 2007) seperti mengalami kesulitan tidur, keletihan serta kekhawatiran tentang keadaan janin maupun ketakutan dalam menghadapi persalinan. berbagai keadaan tersebut yang terjadi secara terus menerus selama masa kehamilan akan membawa ibu pada kondisi tertekan dan pada akhirnya dapat mengakibatkan stres (dewi, 2005). stres memicu sistem saraf simpatis sehingga meningkatkan aktivitas jantung dan tekanan darah (bobak, et al., 2005). dalam kehamilan normal kadar aldosteron meningkat (cunningham, 2005) dan curah jantung meningkat (bobak, et al., 2005), sehingga ibu hamil dengan stres lebih berisiko mengalami hipertensi kehamilan (suririnah, 2007). hipertensi pada ibu hamil merupakan penyebab dari 15% kematian maternal budiarso et al. (1994) dalam mulyata (2007). menurut hadisudarmo (2007) dalam mulyata (2007) stres pada wanita hamil akan meningkatkan kadar renin angiotensin, sehingga berdampak pada penurunan sirkulasi rahim-plasenta-janin yang dapat menyebabkan pasokan nutrisi dan oksigen kepada janin berkurang. hal ini berdampak pada perkembangan janin menjadi terhambat. berdasarkan penelitian, stres pada ibu hamil akan meningkatkan risiko melahirkan bayi dengan berat badan lahir rendah dan prematur (handayani, 2007 dalam mulyata, 2007) serta berisiko mengalami keguguran (greenfield, 2001). relaksasi merupakan salah satu cara menghilangkan stres (dewi, 2005). musik dikenal melalui penelitian sebagai fasilitas relaksasi yang aman, murah dan efektif (prasetyo, 2005). bagi ibu hamil, musik dapat menurunkan stres akibat kehamilan (sefrizal, 2007). jenis musik yang sesuai untuk menenangkan adalah musik dengan tempo lamban sekitar 60 beat/menit seperti musik klasik, new age, serta musik religious (chlan, 1998). musik dengan tempo lamban bisa memperlambat gelombang otak menuju gelombang otak α yang menandakan ketenangan, menstabilkan pernafasan, denyut jantung, denyut nadi dan tekanan darah (campbell, 2002). suara bass drum maupun suara bass gitar dalam musik klasik sangat minim, jika bass drum dipukul berulang dan keras akan mengakibatkan jantung berdebar lebih keras dan cepat, sebaliknya pada musik klasik bunyi alat gesek lebih dominan dengan frekuensi tengah (220 hz s/d 2000 hz) sehingga lebih banyak diterima oleh telinga daripada dada yang selanjutnya akan mempengaruhi otak (sukendro, 2008). ibu hamil yang terbebas dari stres dapat menurunkan risiko yang membahayakan ibu dan janin. musik klasik diharapkan dapat menurunkan tingkat stres dan menstabilkan tekanan darah ibu primigravida trimester ketiga. bahan dan metode penelitian ini menggunakan metode penelitian quasy experimental purposive sampling design dengan jumlah populasi 35 ibu primigravida yang melakukan anc di rs khusus ibu dan anak cempaka putih permata surabaya. sampel yang memenuhi kriteria inklusi dan eksklusi sebanyak 14 orang. penelitian ini dilaksanakan pada bulan juni 2008. variabel independen dalam penelitian ini adalah musik klasik sedangkan variabel dependen adalah tingkat stres dan tekanan darah. instrumen pengumpulan data dengan menggunakan kuisioner untuk tingkat stres dan lembar observasi untuk tekanan darah. data yang diperoleh ditabulasi dan dianalisis dengan menggunakan uji statistik wilcoxon signed rank test, mann whitney u test, paired t test, independent t test dengan tingkat kemaknaan α<0,05. hasil hasil analisis statistik tingkat stres pada kelompok perlakuan dengan menggunakan wilcoxon signed rank test nk.alit ni ketut alit a. musik klasik untuk ibu primigravida (nk alit) menunjukkan bahwa terdapat perbedaan sebelum dan sesudah diberikan intervensi dengan nilai signifikansi p=0,025, sedangkan pada kelompok kontrol tidak menunjukkan hasil yang signifikan. terdapat perbedaan antara kelompok perlakuan dan kelompok kontrol, hal ini ditunjukkan dengan hasil analisis statistik mann whitney u test p=0,017. pada hasil analisis tekanan darah sistolik maupun diastolik pada kelompok perlakuan maupun kelompok kontrol sebelum dan sesudah diberikan intervensi (musik klasik) tidak menunjukkan hasil yang signifikan, namun dilihat dari nilai rerata menunjukkan penurunan atau dalam batas normal yang cukup stabil (lihat tabel 1 dan 2). pembahasan sebagian besar (90%) tingkat stres kelompok perlakuan mengalami penurunan sedangkan pada kelompok kontrol tidak menunjukkan perbedaan yang signifikan. hasil penelitian menunjukkan bahwa terdapat pengaruh musik klasik terhadap tingkat stres ibu primigravida trimester ketiga yaitu dapat menurunkan tingkat stres. stres merupakan segala situasi dimana tuntutan non spesifik mengharuskan seorang individu untuk berespons atau melakukan tindakan. respons atau tindakan ini termasuk respons fisiologis dan psikologis (selye, 1976 dalam potter dan perry, 2005). informasi (dalam bentuk cerita) tentang aspek negatif kehamilan dan persalinan yang diperoleh ibu hamil (khususnya primigravida) menimbulkan persepsi yang kurang baik terhadap kehamilan dan persalinan sehingga keadaan ini dapat memicu kecemasan dan kegelisahan (mulyata, 2007) yang merupakan salah satu gejala dari stres (hardjana, 1994). stres pada ibu primigravida ini akan meningkat pada trimester ketiga (susanti, 2007). menurut niven dan gijsbers (1984) dalam mulyata (2007) relaksasi merupakan salah satu teknik untuk menimbulkan koping. tomatis (1991) dalam campbell (2002), menyebutkan bahwa musik dengan frekuensi sedang (musik klasik) dapat berpengaruh terhadap emosi karena musik klasik dapat membuat otak menjadi lebih santai. dari hasil penelitian ini dapat diketahui bahwa terdapat pengaruh yang signifikan musik klasik terhadap tingkat stres yang diperkuat dengan jawaban kuisioner oleh kelompok perlakuan yang menunjukkan 57,14% responden merasa tenang, tidak merasakan kecemasan atau gelisah, 71,42% responden tidak merasakan kekhawatiran yang berlebihan setelah mendengarkan musik klasik selama 30 menit setiap hari selama 7 hari. tabel 1. hasil analisis tekanan darah sistolik sebelum dan sesudah diberikan musik klasik di rs khusus ibu dan anak cempaka putih tanggal 2-15 juni 2008 perlakuan kontrol perlakuan kontrol pre post pre post post post mean 111,43 105,71 110 107,14 105,71 107,14 sd 6,9 5,34 8,16 7,56 5,34 7,56 hasil analisis statistik paired ttest (p=0,103) paired ttest (p=0,522) independent ttest (p=0,69) tabel 2. hasil analisis tekanan darah diastolik sebelum dan sesudah diberikan musik klasik di rs khusus ibu dan anak cempaka putih tanggal 2-15 juni 2008 perlakuan kontrol perlakuan kontrol pre post pre post post post mean 72,86 72,86 71,43 74,29 72,86 74,29 sd 7,56 7,56 3,77 5,34 7,56 5,34 hasil analisis statistik paired t test (p=1,00) paired t test (p=0,35) independent t test (p=0,69) keterangan: p = signifikansi sd = standar deviasi mean = rerata jurnal ners vol.3 no.1 april 2008 : 72-76 musik klasik yang memiliki tempo lamban akan merubah aktivitas gelombang otak, terjadi pelepasan impuls yang sinkron dari banyak neuron di korteks serebri pada frekuensi sekitar 12 per detik yang akan menghasilkan gelombang α sehingga akan terjadi suatu kondisi rileks yang ditandai dengan perasaan tenang dan nyaman. perasaan yang tenang dan nyaman ini merupakan suatu mekanisme koping positif, sehingga stres yang dialami ibu primigravida trimester ketiga akan menurun. penurunan stres akan mempengaruhi jalur hpa axis dimana pituitary akan mengeluarkan β endorphin yang menimbulkan individu merasakan suasana hati yang menyenangkan. responden pada kelompok perlakuan yang tidak mengalami penurunan tingkat stres kemungkinan disebabkan oleh faktor lain yang turut mempengaruhi stres antara lain tingkat pendidikan responden dimana tingkat pendidikan yang rendah mempengaruhi kemampuan menerima penjelasan teknik mendengarkan musik klasik yang berpengaruh pada konsentrasi responden saat mendengarkan musik klasik. tekanan darah pada hasil penelitian menunjukkan bahwa tidak terdapat pengaruh yang signifikan musik klasik terhadap tekanan darah baik sistolik maupun diastolik. tekanan darah merupakan kekuatan lateral pada dinding arteri oleh darah yang didorong dengan tekanan dari jantung. tekanan darah dari sistem arteri tubuh merupakan indikator kesehatan kardiovaskuler yang baik. tekanan darah menggambarkan interelasi dari curah jantung, tahanan vaskular perifer, volume darah, viskositas darah dan elastisitas arteri (potter dan perry, 2005). pada ibu hamil curah jantung meningkat dari 30-50% pada minggu ke 32 gestasi (bobak, et al., 2005). pada minggu ke 15, kelenjar adrenal ibu akan mensekresi aldosteron dalam jumlah yang meningkat. pada trimester ketiga disekresi sekitar 1 mg/hari (cunningham, 2005). hal ini menyebabkan kecenderungan hipertensi (henderson, 2006). perubahan yang normal ini meskipun dapat meningkatkan tekanan darah namun diimbangi oleh efek progesteron pada dinding pembuluh darah yang menimbulkan penurunan tahanan perifer pembuluh darah. tekanan darah mulai menurun pada trimester pertama kehamilan, pada saat efek progesteron mulai muncul, sebelum volume darah meningkat sampai titik maksimal pada trimester ketiga (johnson dan taylor, 2005). pemberian musik klasik merupakan salah satu cara untuk relaksasi (prasetyo, 2005) dimana relaksasi dapat menurunkan tanda vital (tekanan darah) pada tingkat yang stabil (potter dan perry, 2005), sehingga tekanan darah ibu hamil yang berisiko mengalami peningkatan pada trimester ketiga masih tetap berada pada kondisi stabil dalam batas normal. hal ini menunjukkan bahwa dengan mendengarkan musik klasik berfungsi menjaga kestabilan tekanan darah ibu primigravida trimester ketiga. faktor lain yang membuat tekanan darah ibu primigravida trimester ketiga tetap stabil yaitu adanya efek dari hormon progesteron yang mendilatasi pembuluh darah maka akan membuat tahanan perifer menurun sehingga tekanan darah dipertahankan dalam rentang yang sesuai (henderson, 2006). hal ini menjelaskan bagaimana tekanan darah pada kelompok kontrol tetap berada pada rentang batas normal meskipun kelompok kontrol tidak diberikan intervensi. nilai rerata tekanan darah kelompok perlakuan dan kontrol setelah intervensi dapat dijadikan acuan pemberian musik klasik secara tidak langsung bermanfaat dalam menurunkan tekanan darah, hal ini ditunjukkan oleh hasil tekanan darah sistolik maupun diastolik kelompok perlakuan menunjukkan nilai rerata yang lebih rendah daripada kelompok kontrol. simpulan dan saran simpulan musik klasik dapat menurunkan tingkat stres ibu primigravida trimester ketiga. tidak ada pengaruh musik klasik terhadap tekanan darah (sistolik dan diastolik) ibu primigravida trimester ketiga berdasarkan hasil analisis statistik, namun berdasarkan nilai rerata tekanan darah sistolik dan diastolik, kelompok perlakuan memiliki rerata yang lebih kecil dan tetap berada pada batas normal, yang berarti secara tidak langsung musik klasik menurunkan tekanan darah karena ibu menjadi lebih rileks saat mendengarkan musik tersebut. musik klasik untuk ibu primigravida (nk alit) saran penulis menyarankan agar ibu hamil menggunakan musik klasik sebagai salah satu fasilitas relaksasi untuk menghilangkan stres yang sering dialami selama kehamilan. keluarga hendaknya memfasilitasi relaksasi dengan penggunaan musik klasik. musik klasik dapat dijadikan sebagai intervensi asuhan keperawatan untuk ibu hamil dan penelitian selanjutnya diharapkan menggunakan pengukuran indikator stres yang lebih bervariasi seperti pengukuran kadar kortisol dan pernafasan. kepustakaan bobak, et al. 2005. keperawatan maternitas. edisi 4. jakarta: egc, hlm. 107-122. campbell. 2002. efek mozart memanfaatkan kekuatan musik untuk mempertajam pikiran, meningkatkan kreatifitas, dan menyehatkan tubuh. jakarta: gramedia pustaka utama, hlm. 79-87, 306. chlan. 1998. music teraphy for anxiety of respiration rate. heart-lung, 27(3), 169-176. cunningham. 2005. obstetri williams, jakarta: egc, hlm. 198-211. dewi. 2005. pengaruh latihan pernafasan terhadap penurunan tingkat stres ibu hamil yang bekerja. skripsi tidak dipublikasikan. surabaya: universitas airlangga, hlm. 78-85. fiori. 2005. pregnancy fitness. jakarta: prestasi pustaka, hlm. 185-190. greenfield. 2001. stress and pregnancy: what are the effects, (online), (http://www.drspock.com., diakses tanggal 13 november 2007, jam 19.00 wib). hardjana. 1994. stres tanpa distres: seni mengolah stres. yogyakarta: kanisius, hlm. 23-26. henderson. 2006. buku ajar konsep kebidanan. jakarta: egc, hlm. 107110, 142, 150. johnson dan taylor. 2005. buku ajar praktik kebidanan. jakarta: egc, hlm. 47-50, 53-57. mochtar. 1998. sinopsis obstetri, jakarta: egc, hlm. 35-39. mulyata. 2007. paket penyuluhan kognitif dan senam prapersalinan pada primigravida mengurangi cemas dan nyeri persalinan, meningkatkan skor apgar bayi, serta mempercepat penyembuhan luka persalinan. disertasi tidak dipublikasikan. surabaya: universitas airlangga, hlm. 85-90. potter dan perry. 2005. fundamental keperawatan: konsep, proses, dan praktik. jakarta: egc, hlm. 476-482, 781-796. prasetyo. 2005. peran musik sebagai fasilitas dalam praktek dokter gigi untuk mengurangi kecemasan pasien, (online), (http://www.journal.unair.ac.id., diakses tanggal 28 november 2007, jam 14.00 wib). rasmun. 2004. stres, koping dan adaptasi. jakarta: sagung seto, hlm. 9, 25-26. sefrizal. 2007. anak cerdas dan kreatif berkat alunan musik, (online), (http://www.shvoong.com., diakses tanggal 11 november 2007, jam 13.00 wib). sukendro. 2008. musik dan dampaknya bagi kehidupan, (online), (http://www.inchrist.net/musik., diakses tanggal 9 maret 2008, jam 15.00 wib). suririnah. 2007. stres dalam kehamilan berpengaruh buruk, (online), (http://www.infoibu.com., diakses tanggal 11 november 2007, jam 13.00 wib). susanti. 2007. tips mengatasi stress saat kehamilan, (online), (http://www.nusaku.com., diakses tanggal 14 april 2008, jam 18.00 wib). tiran. 2007. mengatasi mual dan gangguan lain selama kehamilan. yogyakarta: diglosia, hlm. 83, 103. http://www.drspock.com/ http://www.journal.unair.ac.id/ http://www.shvoong.com/ http://www.inchrist.net/musik http://www.in-christ.net/musik%20dan%20%20dampaknya%20%20bagi%20%20kehidupan.%20tanggal%209%20maret%20%202008 http://www.infoibu.com/ http://www.nusaku.com/ efektivitas penurunan stres hospitalisasi anak dengan terapi bermain dan terapi musik (the effectiveness of play therapy and musical therapy in reducing the hospitalization stress) yuni sufyanti a.*, i ketut sudiana*, kristiawati*, dewi indah p.* * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. mayjen prof. dr. moestopo no. 47 surabaya. telp/fax: (031) 5012496. e-mail: yuni_psik@yahoo.com abstract introduction: hospitalization in pediatric patients may caused an anxiety and stress in all age levels. several techniques can be applied to reduced hospitalization stress in children, such as playing therapy and music therapy. the objective of this study was to analyze the difference of effectiveness between both therapies in reducing the hospitalization stress in 4-6 years old children. method: a quasy-experimental pre-posttest design was used in this study. there were 18 respondents, divided into three groups, i.e. group one receiving playing therapy, group two receiving music therapy and the last group as control group. data were collected by using observation sheet before and after intervention to recognize the hospitalization stress. data were analyzed by using wilcoxon signed rank test and mann whitney u test with significance level of α<0.05. result: result showed that playing therapy and music therapy had significant effect to reduce the hospitalization stress with p=0.027 for play therapy, p=0.024 for musical therapy, and p=0.068 for control. mann whitney u test revealed that there were no difference in the effectiveness of play therapy and musical therapy in reducing the hospitalization stress with p=0.009 for play therapy and control group, p=0.012 for music therapy and control group, and p=0.684 for playing therapy and musical therapy. discussion: it can be concluded that play therapy and musical therapy are equally effective to reduce the hospitalization stress in children. it’s recommended for nurses in pediatric ward to do playg therapy and musical therapy periodically. keywords: hospitalization stress, playing therapy, music therapy pendahuluan menjalani perawatan di rumah sakit (hospitalisasi) dapat menimbulkan stres pada anak. hospitalisasi merupakan suatu proses karena suatu alasan yang terencana atau darurat, mengharuskan anak untuk tinggal di rumah sakit, menjalani terapi dan perawatan sampai pemulangannya kembali ke rumah. selama proses tersebut, anak dan orang tua dapat mengalami berbagai kejadian yang menurut berbagai penelitian ditunjukkan dengan pengalaman yang sangat traumatik dan penuh dengan stres (supartini, 2004). hasil observasi yang dilakukan oleh penulis di ruang anak rsu dr. soetomo surabaya terhadap anak yang sedang menjalani perawatan menunjukkan berbagai reaksi saat masuk rumah sakit seperti menangis, berteriak, memanggil orang tuanya. hal ini disebabkan karena adanya faktor perpisahan dengan orang terdekat, kehilangan kontrol, injuri fisik dan nyeri yang menimbulkan stres pada anak. penanggulangan stres hospitalisasi pada anak dapat menggunakan beberapa tehnik, antara lain terapi bermain (menggambar dan mewarnai) dan terapi musik. kedua cara tersebut dapat menurunkan stres emosional pada manusia terutama pada anak. pengaruh tehnik terapi yang lebih efektif antara terapi bermain dan terapi musik untuk menurunkan stres hospitalisasi pada anak sampai saat ini belum diketahui. berdasarkan data awal yang diperoleh di ruang anak rsu dr. soetomo surabaya pada bulan agustus 2006, jumlah anak usia 4-6 tahun yang sedang menjalani rawat inap sebesar 35 anak, dimana penyakit yang banyak ditemukan yaitu anak dengan gangguan sistem hematologi. menurut penelitian, klien yang dirawat di rumah sakit umum mengalami stres dan masalah psikologi yang berkaitan dengan penyakitnya sekitar 30–60% (keliat, 1999). terjadinya stres hospitalisasi pada anak dapat berpengaruh terhadap perawatan anak selama di rumah sakit dan dapat berpengaruh terhadap proses penyembuhan. reaksi hospitalisasi yang ditunjukkan oleh anak bersifat individual dan sangat bergantung pada tahapan usia perkembangan anak, pengalaman sebelumnya terhadap sakit, sistem pendukung yang tersedia dan kemampuan koping yang dimiliki (supartini, 2004). anak yang mengalami stres selama dalam masa perawatan, dapat membuat orang tua menjadi stres dan stres orang tua akan membuat tingkat stres anak semakin meningkat (supartini, 2004). terutama pada mereka yang baru pertama kali mengalami perawatan di rumah sakit dan orang tua yang kurang mendapat dukungan emosi dan sosial dari keluarga, kerabat, bahkan petugas kesehatan akan menunjukkan perasaan cemasnya. menurut irawati (2006) bermain dapat membantu anak mengurangi stres dan mengembangkan rasa humornya. bagi anak yang sakit dan dirawat di rumah sakit, bermain tidak hanya berfungsi untuk kesenangan anak, tetapi dapat menjadi satu media yang dapat mengekspresikan pikiran dan perasaan cemas, takut, nyeri dan rasa bersalah. anak dapat mengalihkan perhatiannya dari faktor penyebab yang menimbulkan stres. saat anak melakukan permainan maka perhatian akan dipusatkan pada permainan yang dilakukan sehingga anak dapat menjadi rileks. anak memerlukan media untuk dapat mengekspresikan perasaan tersebut dan mampu bekerja sama dengan petugas kesehatan selama dalam perawatan (supartini, 2004). jenis terapi bermain menggambar dan mewarnai dapat dijadikan media terapi anak sakit selama di rumah sakit untuk mengekspresikan perasaan dan pikiran sehingga stres yang dialami dapat menurun. berdasarkan penelitian yang dilakukan oleh lilis silviana (2004) dalam litbang (2004) menyatakan bahwa pemberian terapi musik dapat menurunkan stres hospitalisasi. pada pemberian terapi musik, tubuh akan menerima melalui sistem pendengaran, sehingga tubuh akan membuat suasana hati menjadi positif dan membuat koping dan emosi anak menjadi lebih baik sehingga stres dapat menurun. terapi musik juga dapat menyembuhkan, merehabilitasi, mendidik dan melatih anak serta orang dewasa yang menderita gangguan fisik dan mental atau emosional (lidwina, 2005). banyak cara yang dilakukan untuk mengatasi stres hospitalisasi pada anak tetapi cara yang paling banyak digunakan yaitu dengan menggunakan terapi bermain dan terapi musik, namun sampai saat ini belum ada yang membandingkan kedua cara tersebut. hal tersebut di atas mendorong peneliti untuk melakukan penelitian tentang perbedaan efektifitas terapi bermain dan terapi musik terhadap penurunan stres hospitalisasi pada anak. dari hasil penelitian ini apabila ada perbedaan efektivitas di antara keduanya, diharapkan hasil tersebut dapat bermanfaat bagi praktik klinik keperawatan dimana perawat dapat memilih metode yang lebih efektif dalam mengatasi stres hospitalisasi sebagai bagian dari asuhan keperawatan pada anak sehingga dapat mempercepat proses penyembuhan. bahan dan metode desain penelitian yang digunakan pada penelitian ini adalah quasi eksperimen dengan rancangan pre-post test control group design. populasi dalam penelitian ini adalah seluruh klien anak yang sedang menjalani perawatan di ruang anak sal c rumah sakit umum dr. soetomo surabaya berjumlah 18 responden yang dibagi menjadi 6 orang diberikan terapi bermain, 6 orang diberikan terapi musik dan 6 orang sebagai kelompok kontrol. sampel yang diambil adalah anak yang memenuhi kriteria inklusi sebagai berikut: anak usia 4-6 tahun, baru pertama kali masuk rumah sakit, hari pertama masuk rumah sakit, keadaan sakitnya pada tingkat sedang dengan gangguan sistem hematologi dan orang tua bersedia untuk diteliti. penelitian ini dilaksanakan pada tanggal 28 desember 2006 sampai dengan 19 januari 2007. variabel independen dari penelitian ini meliputi terapi bermain (berupa menggambar dan mewarnai dengan tema bebas sesuai keinginan responden) dan terapi musik (dengan tema lagu anak-anak yang berirama riang). kedua intervensi dilakukan selama 30 menit sampai dengan 1 jam selama 2 hari. variabel dependen pada penelitian ini adalah stres hospitalisasi yang diukur dengan menggunakan lembar observasi. data yang diperoleh dianalisis dengan uji statistik wilcoxon signed rank test dan mann whitney u test dengan tingkat kemaknaan adalah α≤0,05. hasil hasil penelitian didapatkan bahwa dari 6 responden sebelum diberikan intervensi terapi bermain 4 anak mengalami stres berat, 2 anak mengalami stres sedang dan setelah diberikan intervensi 5 anak mengalami stres ringan dan hanya 1 anak yang mengalami stres sedang. pada responden yang diberikan intervensi terapi musik sebelum diberi intervensi 4 anak mengalami stres berat, 2 anak mengalami stres sedang dan setelah diberikan intervensi 4 anak mengalami stres ringan dan 2 anak mengalami stres sedang. pada kelompok kontrol yang tidak mendapatkan intervensi terapi bermain maupun terapi musik tetap mengalami stres berat (gambar 1). pada tabel 1 dapat dilihat bahwa pemberian terapi bermain dan terapi musik berpengaruh terhadap penurunan stres hospitalisasi pada anak dengan hasil uji statistik wilcoxon signed rank test menunjukkan pada kelompok terapi bermain p=0,027 dan pada kelompok terapi musik didapatkan p=0,024. hasil uji statistik mann whitney u test didapatkan p=0,009 yang menunjukkan terdapat perbedaan efektifitas antara kelompok yang mendapatkan intervensi terapi bermain dengan kelompok kontrol terhadap penurunan stres hospitalisasi pada anak. setelah mendapatkan intervensi terapi musik juga terlihat hasil uji mann whitney u test didapatkan p=0,012 yang menunjukkan terdapat perbedaan efektivitas antara kelompok yang mendapat terapi musik dengan kelompok kontrol terhadap penurunan stres hospitalisasi pada anak. pada kelompok yang diberikan intervensi terapi bermain dan terapi musik terlihat hasil uji mann whitney u test didapatkan p=0,684 yang menunjukkan tidak ada perbedaan efektivitas antara kelompok terapi bermain dan kelompok terapi musik terhadap penurunan stres hospitalisasi pada anak. gambar 1. tingkat stres hospitalisasi pada kelompok perlakuan sebelum dan sesudah diberi intervensi (terapi bermain dan terapi musik) serta pada kelompok kontrol di ruang anak sal c rsu dr. soetomo surabaya. 0 1 2 3 4 5 6 jumlah pre post pre post pre post terapi bermain terapi musik kelompok kontrol tingkat stres hospitalisasi anak stres berat stres sedang stres ringan tidak stres tabel 1. tingkat stres hospitalisasi pada kelompok perlakuan sebelum dan sesudah diberi intervensi (terapi bermain dan terapi musik) serta pada kelompok kontrol di ruang anak sal c rsu dr. soetomo surabaya. no stres hospitalisasi terapi bermain terapi musik kelompok kontrol pre (%) post (%) pre (%) post (%) pre (%) post (%) mean 81,1 48,9 79,4 50 93,8 89,4 sd 2,25 2,19 2,23 wilcoxon signed rank test (p=0,027) wilcoxon signed rank test (p=0,024) wilcoxon signed rank test (p=0,068) mann whitney u test (p=0,009) mann whitney u test (p=0,012) mann whitney u test (p=0,684) keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata pembahasan dirawat di rumah sakit merupakan krisis utama yang dialami oleh seorang anak. hal ini disebabkan oleh anak mengalami stres akibat perubahan, baik terhadap status kesehatan maupun kondisi lingkungan seharihari dan anak mempunyai sejumlah keterbatasan dalam mekanisme koping untuk mengatasi masalah maupun kejadian yang bersifat menekan (nursalam, 2005). hospitalisasi anak dapat menjadi suatu pengalaman yang menimbulkan reaksi tertentu yang akan sangat berdampak pada kerja sama anak dan orang tua dalam perawatan anak selama di rumah sakit (supartini, 2004) dan dapat mempengaruhi juga terhadap proses penyembuhan anak. menurut wong and whaley (1997) stres hospitalisasi pada anak dikarenakan adanya kecemasan karena perpisahan, kehilangan kontrol, perlukaan tubuh dan nyeri. terjadinya stres hospitalisasi juga dipengaruhi oleh beberapa faktor antara lain perkembangan anak, pengalaman terhadap sakit, sistem pendukung, serta kemampuan koping yang dimiliki. peran perawat dalam meminimalkan stres akibat hospitalisasi pada anak sangat penting. perawat perlu mengetahui beberapa cara dalam menanggulangi stres akibat hospitalisasi pada anak. penanggulangan stres hospitalisasi pada anak dapat menggunakan beberapa tehnik. irawati (2006) berpendapat bahwa permainan yang terapeutik adalah aktivitas yang sehat dan diperlukan untuk kelangsungan tumbuh kembang anak dan memungkinkan anak untuk dapat menggali dan mengekspresikan perasaan dan pikiran. berdasarkan hasil penelitian didapatkan bahwa terjadi penurunan tingkat stres hospitalisasi pada anak sebelum dan sesudah dilakukan intervensi terapi bermain menggambar dan mewarnai. hal ini berarti pemberian terapi bermain menggambar dan mewarnai berpengaruh terhadap penurunan stres hospitalisasi pada anak. bermain adalah tindakan atau kesibukan suka rela yang dilakukan dalam batas-batas tempat dan waktu, berdasarkan berbagai aturan yang mengikat tetapi diakui secara suka rela dengan tujuan sesuai yang ada dalam dirinya sendiri, disertai dengan perasaan tegang dan senang serta dengan pengertian bahwa bermain merupakan suatu yang lain dari kehidupan biasa (suherman, 2000). pada saat di rumah sakit anak akan mengalami berbagai perasaan yang tidak menyenangkan, seperti marah, takut, cemas, sedih dan nyeri. perasaan tersebut merupakan dampak dari hospitalisasi yang dialami anak karena menghadapi berbagai stressor yang ada di lingkungan rumah sakit. permainan yang dilakukan akan berdampak pada terlepasnya anak dari ketegangan dan stres yang dialami karena dengan melakukan permainan, anak akan dapat mengalihkan rasa sakit (distraksi) dan relaksasi melalui kesenangan saat melakukan permainan (supartini, 2004). tujuan bermain di rumah sakit pada prinsipnya adalah agar anak dapat melanjutkan fase tumbuh kembangnya secara optimal, mengembangkan kreativitas anak dan anak dapat beradaptasi secara efektif terhadap stres (nursalam, 2005). pemainan anak di rumah sakit tidak hanya memberikan rasa senang pada anak, tetapi juga akan membantu anak mengekspresikan perasaan dan pikiran cemas, takut, sedih, tegang dan nyeri (supartini, 2004). dalam kondisi sakit atau saat anak dirawat di rumah sakit, aktivitas bermain tetap perlu dilaksanakan dengan menyesuaikan terhadap kondisi anak. efektivitas dalam bermain di rumah sakit, perlu memperhatikan prinsip-prinsip sebagai berikut: anak tidak banyak menggunakan energi, waktu bermain lebih singkat untuk menghindari kelelahan, relatif aman dan terhindar dari infeksi silang, 3) sesuai dengan kelompok usia, tidak bertentangan dengan terapi dan perlu partisipasi orang tua dan keluarga. menurut supartini (2004), keuntungan aktifitas bermain yang dilakukan perawat di rumah sakit antara lain dapat meningkatkan hubungan antara klien (anak dan keluarga) dan perawat, dapat memulihkan perasaan mandiri pada anak. permainan yang terapeutik akan dapat meningkatkan kemampuan anak untuk mempunyai tingkah laku yang positif. pada saat anak mengikuti aktifitas bermain menggambar dan mewarnai, melalui media kertas, pensil, pensil warna dan krayon, anak berusaha untuk menuangkan semua perasaan yang ada dipikirannya, sehingga anak dapat mengalihkan perhatiannya dari faktor yang menyebabkan timbulnya stres pada dirinya. perbedaan penurunan tingkat stres hospitalisasi pada anak yang diberikan terapi bermain dapat dipengaruhi oleh beberapa faktor antara lain tingkat adaptasi anak terhadap stres yang berbeda, umur anak, minat anak terhadap permainan, kreativitas dan ketrampilan anak, tingkat pendidikan orang tua serta dukungan orang tua anak. anak yang berusia lebih tua tentunya mempunyai kreativitas dan ketrampilan lebih baik dibandingkan dengan anak yang lebih muda, karena diusia yang lebih tua maka pertumbuhan dan perkembangan anak juga lebih matang. dalam terapi bermain menggambar dan mewarnai ini, dukungan orang tua juga sangat berarti bagi anak, karena anak merupakan bagian dari kehidupan orang tuanya sehingga apabila orang tua mendukung kegiatan anak, anak akan lebih baik dalam mengekspresikan perasaan dan pikirannya. pada pemberian intervensi terapi musik didapatkan bahwa terdapat penurunan tingkat stres hospitalisasi pada anak sebelum dan sesudah dilakukan intervensi terapi musik. hal ini berarti pemberian terapi musik berpengaruh terhadap penurunan stres hospitalisasi pada anak. menurut rara (2006) terapi musik membantu orang yang memiliki masalah emosional dalam mengeluarkan perasaan mereka, membuat perubahan positif dengan suasana hati, membantu memecahkan masalah dan memperbaiki konflik. musik dapat menstimulasi respons relaksasi, motivasi atau menstimulasi pikiran, imajinasi dan emosi (djohan, 2005). musik dapat membuat kita rileks dan senang hati yang merupakan emosi positif. emosi positif inilah yang membuat fungsi berpikir seseorang menjadi maksimal. musik juga bagus untuk perkembangan emosional anak, misalnya dengan mendengarkan musik lembut, maka anak akan tenang, kalau musik riang anakpun akan terlihat gembira (handayani, 2004). terapi musik dapat meningkatkan ketrampilan berkomunikasi, mengurangi perilaku yang tidak selaras, memperbaiki prestasi anak didik, memperbaiki gerakan psikomotorik, menambah perhatian, memperbaiki hubungan interpersonal, pengelolaan nyeri dan pengurangan stres (esge, 2004). perbedaan penurunan tingkat stres hospitalisasi pada anak yang diberikan terapi musik dapat dipengaruhi oleh beberapa faktor antara lain tingkat adaptasi anak terhadap stres, pendidikan orang tua anak, dukungan orang tua, serta lingkungan perawatan yang kurang mendukung. lingkungan yang mendukung atau tenang dapat membantu anak dalam menikmati lagu yang diberikan sehingga anak merasa rileks dan senang. anak dapat mengekspresikan perasaan dengan cara bernyanyi mengikuti lagu yang sedang dimainkan. lingkungan yang ramai dapat mengganggu konsentrasi anak dalam mendengarkan lagu selama proses terapi musik, maka anak akan sulit untuk menikmati lagu sehingga untuk mencapai perasaan rileks dan senang hati membutuhkan waktu yang lama. tingkat pendidikan orang tua anak menentukan peran orang tua pada saat pelaksanaan terapi. orang tua anak yang berpendidikan tinggi ikut aktif dalam proses terapi sehingga dengan adanya dukungan orang tua selama terapi berlangsung anak akan lebih bersemangat sehingga dapat mempercepat proses penurunan stres hospitalisasi anak. tidak terdapat penurunan stres hospitalisasi pada kelompok kontrol. hal ini disebabkan karena pada kelompok kontrol anak bersifat pasif, sehingga dalam diri anak dapat timbul perasaan bosan yang menyebabkan anak bertambah stres selama menjalani perawatan. dalam kelompok kontrol tidak diberikan intervensi terapi bermain maupun terapi musik. anak hanya mengamati lingkungan sekitar atau teman yang sedang bermain tanpa ada inisiatif untuk ikut dalam permainan yang menurut karakteristik sosialnya termasuk dalam onlooker play (supartini, 2004). efektifitas terapi bermain dan terapi musik menunjukkan tidak terdapat perbedaan terhadap penurunan stres hospitalisasi pada anak. keduanya efektif dalam menurunkan stres hospitalisasi pada anak. menurut donna l. wong (2004) salah satu fungsi bermain antara lain sebagai nilai terapeutik yang dapat memberikan pelepasan stres dan ketegangan. bermain dapat mengurangi tekanan atau stres dari lingkungan. dengan bermain anak dapat mengekspresikan emosi dan ketidakpuasan atas situasi sosial serta rasa takutnya yang tidak dapat diekspresikan di dunia nyata (nursalam, 2005). menurut rara (2006) terapi musik sangat efektif dalam meredakan kegelisahan dan stres, mendorong perasaan rileks serta meredakan depresi. jadi salah satu tindakan tersebut dapat digunakan sebagai alternatif pilihan untuk menurunkan tingkat stres hospitalisasi pada anak. tidak adanya perbedaan efektifitas antara terapi bermain dan terapi musik disebabkan karena pada prinsipnya kedua intervensi tersebut merupakan terapi yang dapat digunakan untuk mengurangi ketegangan dan stres. responden pada penelitian ini berada pada tahap perkembangan yang sama yaitu usia prasekolah. anak usia prasekolah sudah memiliki perkembangan kognitif yang baik, jadi dalam pelaksanaan terapi bermain dan terapi musik anak lebih mudah memahami maksud dari terapi yang diberikan sehingga mempercepat proses penurunan stres hospitalisasi pada anak. pada anak usia prasekolah lebih dekat dengan dunia bermain dan bernyanyi seperti yang diperoleh pada saat berada dalam lingkungan sekolah (taman kanak-kanak) maupun tempat tinggalnya. perbedaan nilai signifikansi antara penurunan stres hospitalisasi pada anak dengan menggunakan terapi bermain dan terapi musik dapat juga disebabkan karena tingkat adaptasi anak yang berbeda-beda serta adanya berbagai faktor yang mempengaruhi stres hospitalisasi pada anak antara lain perkembangan anak, pengalaman terhadap sakit, adanya sistem pendukung dan kemampuan koping yang dimiliki. reaksi orang tua terhadap hospitalisasi seperti perasaan takut, cemas, rasa bersalah, sedih bahkan adanya konflik karena harus menunggui anak di rumah sakit juga sangat mempengaruhi anak selama menjalani perawatan. orang tua yang mengalami kondisi stres selama dalam anak dalam proses perawatan, mengakibatkan tingkat stres anak juga akan semakin meningkat. peran dan dukungan orang tua akan sangat membantu dalam menurunkan stres hospitalisasi pada anak. simpulan dan saran simpulan terapi bermain dan terapi musik dapat menurunkan stres hospitalisasi pada anak secara efektif. kedua jenis terapi tersebut dapat membuat tubuh menjadi rileks dan membuat perubahan emosi menjadi lebih positif dan koping anak menjadi lebih baik sehingga dapat menurunkan tingkat stres hospitalisasi pada anak. saran peneliti menyarankan agar terapi bermain (menggambar, mewarnai) dan atau terapi musik (lagu anak-anak yang berirama riang) dapat digunakan sebagai terapi alternatif dalam mengatasi stres hospitalisasi pada anak usia prasekolah dan penelitian lebih lanjut diharapkan dapat dikembangkan dengan menggunakan jenis permainan lain yang sesuai tingkat perkembangan anak dan jenis musik yang lain serta jumlah sampel yang lebih banyak. kepustakaan djohan. 2005. psikologi musik. yogyakarta: buku baik, hlm. 223-224 dan 234. esge. 2004. terapi musik, (online), (http://www.pikiranrakyat.com., diakses tanggal 26 november 2006, jam 10.26 wib). handayani, a. 2004. terjadi sejak dalam kandungan musik memiliki pengaruh dalam kepribadian, (online), (http://www.pikiranrakyat.com., diakses tanggal 26 november 2006, jam 10.26 wib). irawati, m. 2006. menggali kecerdasan jamak melalui bermain, (online), (http://www.google.com., diakses tanggal 20 oktober 2006, jam 07.43 wib). keliat, b.a. 1999. penatalaksanaan stres. jakarta: egc. litbang, 2004. musik, (online), (http://www.balipost.com., diakses tanggal 20 oktober 2006, jam 08.00 wib). lidwina. 2005. musik dan senam rangsang kecerdasan anak, (online), (http://www.supreme.indonesia., diakses tanggal 20 oktober 2006, jam 08.15 wib). nursalam, rekha dan utami. 2005. asuhan keperawatan bayi dan anak. jakarta: salemba medika, hlm. 18-19. rara, 2006. musik dan kesehatan, (online), (http://www.kapanlagi.com., diakses tanggal 20 oktober 2006, jam 08.00 wib). suherman. 2000. buku saku perkembangan anak. jakarta: egc, hlm. 12, 57-77. supartini. 2004. buku ajar konsep dasar keperawatan anak. jakarta: egc, hlm. 124-148, 187-192. wong, d.l. 2004. pedoman klinis keperawatan pediatrik. jakarta: egc, hlm. 270, 276. wong and whaley. 1997. essential of pediatric nursing fifth edition. st.louis: mosby inc., pp. 95-98, 609617. http://www.pikiranrakyat.com/ http://www.pikiranrakyat.com/ http://www.google.com/ http://www.balipost.com/ http://www.supreme.indonesia/ http://www.kapanlagi.com/ http://e-journal.unair.ac.id/jners | 57 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.7607 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research comparison of attitudes towards meditation healing exercise between the elderly living with chronic illness in bangkok and surabaya ni putu wulan purnama sari1 and jintana artsanthia2 1 faculty of nursing, widya mandala catholic university surabaya, indonesia 2 faculty of nursing, saint louis college, bangkok, thailand abstract introduction: meditation healing exercise (mhe) using the skt technique is popular in bangkok, thailand, while in surabaya, indonesia, it is relatively new and unpopular. the attitude towards mhe depends on various internal and external factors. this study aimed to compare the attitude towards mhe between the elderly who are living with hypertension (ht) and/or diabetes mellitus (dm) in bangkok and surabaya. methods: this was a comparative study involving 96 and 100 elderly individuals with ht and/or dm in the communities of surabaya and bangkok respectively. the sample was chosen according to the aforementioned criteria. the sample size was 196. the instrument used was a valid and reliable questionnaire. descriptive statistics, the levene test, and an independent sample t test were used for the data analysis. results: the majority showed a positive attitude towards mhe; the higher mean and lower sd was found in bangkok (19.43 and 2.41). out of the total, 87.5% and 96.0% elderly had good attitude towards mhe in surabaya and bangkok respectively. there was a significant attitude difference in relation to the aspect of preferring to practice mhe between bangkok and surabaya (p=0.004). overall, there was no significant attitude difference between bangkok and surabaya (p=0.17). conclusion: the elderly attitude towards mhe was mostly positive and good. the elderly in bangkok prefer to practice mhe more than in surabaya. there was no significant attitude difference in the elderly who are living with ht and/or dm between bangkok and surabaya. the implementation of mhe using the skt technique has a high possibility of being accepted personally by the elderly in both sites. article history received: february 09, 2018 accepted: june 29, 2018 keywords attitude; elderly; meditation healing exercise contact ni putu wulan purnama sari wulanpurnama@ukwms.ac.id  faculty of nursing, widya mandala catholic university surabaya, indonesia cite this as: comparison of attitudes towards meditation healing exercise between the elderly living with chronic illness in bangkok and surabaya. jurnal ners, 13(1), 57-63. doi:http://dx.doi.org/10.20473/jn.v13i1.7607 introduction non-communicable diseases (ncds), or chronic diseases, are not passed from person to person. they are of a long duration and have a generally slow progression. the four main types of noncommunicable diseases are cardiovascular (e.g. hypertension), cancers, chronic respiratory diseases and diabetes mellitus (dm). 80% of all ncd deaths occur in lowand middle-income countries. almost three quarters of ncd deaths 28 million occur in lowand middle-income countries. 16 million ncd deaths occur before the age of 70; 82% of these "premature" deaths occurred in lowand middleincome countries. the greatest public health benefits are gained through the prevention of ncd (particularly cardiovascular diseases, cancers, and dm), injuries, and mental health disorders. these benefits can be achieved if the risk factors are identified and mitigated through appropriate interventions. if ncds and mental illnesses are detected at an early stage and the appropriate controls initiated, then their severity can be significantly reduced (who, 2015). both thailand and indonesia are developing countries that face the threat of economic loss due to the burden of ncd. efforts to optimise the clinical outcomes and quality of life are necessary to reduce https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:wulanpurnama@ukwms.ac.id http://dx.doi.org/10.20473/jn.v13i1.7607 n. p. w. p. sari et al. 58 | pissn: 1858-3598  eissn: 2502-5791 the health expenditure associated with ncd. one way of doing this is by implementing nonpharmacological interventions, such as meditation practice on a daily basis. meditation is an umbrella term that encompasses a family of practices that share some distinctive features, but vary in important ways in the context of their purpose and practice. cardoso, et al. (2004) developed a detailed operational definition of meditation that was broad enough to include traditional belief-based practices and those that have been developed specifically for use in clinical settings. using a systematic approach based on consensus techniques, they defined any practice as meditation if it (1) utilises a specific and clearly defined technique, (2) involves muscle relaxation somewhere during the process, (3) involves logic relaxation to analyse the possible psychophysical effects, not “to intend” to judge the possible results and not “to intend” to create any type of expectation regarding the process), (4) is a self-induced state, and (5) involves the use of a selffocus skill or “anchor” for attention. evidence of meditation healing exercise (mhe) effect on both physiological and neuropsychological aspects has been evaluated in 311 studies. the majority of studies have been conducted in healthy participants. meta-analysis has revealed that the most consistent and strongest physiological effects from meditation practices in healthy populations occur in the reduction of heart rate, blood pressure, and cholesterol. the strongest neuropsychological effect was an increase in verbal creativity. there was also some evidence in before-and-after studies to support the hypothesis that certain meditation practices decrease visual reaction time, intraocular pressure, and increase breath holding time (artsanthia & sari, 2017). thailand is famous for its meditation technique. most of the citizens are buddhist, and meditation is really close to buddhist religious practice. one of the meditation experts from bangkok, s. k. triamchaisri, proposed eight new techniques for doing mhe named skt 1-8. each technique has its own health benefit. for instance, a study of triamchaisri, et al. (2013) found that after practicing the skt3 and skt5 meditation exercises, the function of visual illusions was reduced, hearing problems and posture disorientation was 30% improved, and the quality of life of the patient related to eating, standing, sleeping was improved within one week. the improvement in relation to walking, posturing, hearing, sleeping, memory losing, and walking status was reported after regularly practicing three times a day for one month. 80% of the patient’s spatial orientation was met after practicing for one month. there was a 90% level of holistic improvement in the visual and vestibular functions, which improved as per a healthy person within three months of practicing the meditation exercise. meditation practice in indonesia, especially in surabaya, is relatively new and unpopular in society, especially amongst the elderly who are living with ht and/or dm in the communities. most of the citizens in surabaya are moslem, and their daily religious practice does not involve any practice related to meditation. mhe is potentially being recognised as a new way of treating diseases. meditation-related knowledge is potentially low, as well as the attitude towards mhe itself remaining unclear. although most of thailand citizens are familiar with meditation in practice, the elderly’s attitude towards mhe, especially the skt technique, remains unclear. attitude has always been a subject of interest to many researchers. it is considered exciting and mysterious. attitude is the positive or negative evaluation or feeling that people have towards other people, objects, issues or events. attitude includes the general way that people feel towards socially significant objects. having a certain attitude in life could help people to live in harmony and be better understanding of the things around them. attitude affects the way that people perceive and act towards other people, as well as the objects or events that they encounter (abidin, et al, 2011). this study aims to compare the attitude towards mhe between the elderly who are living with ht and/or dm in bangkok (familiar with daily meditation practice) and surabaya (relatively new to daily meditation practice). our upcoming study aims to analyse the effect of mhe towards a handful of physical and psychological parameters in the elderly who are living with ht and/or dm in bangkok and surabaya. this prior study on attitude was important to conduct in order to ensure that there was a positive/good attitude towards mhe in both sites, so then the elderly would accept the study intervention personally and be determined to do meditation practice on a daily basis. this is important to assure that the mhe effects on the physical and psychological parameters are measured properly in the upcoming study. in our upcoming study, we will implement the skt1 technique as proposed by s. t. kantharadussadee, which could be useful for managing ht and/or dm with a good outcome, especially related to lowering blood pressure (bp) and blood sugar (bs) level. materials and methods it was a comparative study involving 196 elderly individuals with dm and/or ht in communities around bangkok and surabaya. there were 100 and 96 cases compiled from bangkok and surabaya respectively. the sample distribution between the two study sites has been presented in table 1. table 1. sample distribution case bangkok surabaya total dm 30 30 60 ht 35 33 68 dm&ht 35 33 68 total 100 96 196 jurnal ners http://e-journal.unair.ac.id/jners | 59 the sample was chosen according to a set of criteria, who were then totally included in the study (total sampling). the inclusion criteria consisted of (1) elderly people who are willing to practice mhe using the skt1 technique, and (2) they are consuming medication from a medical doctor to treat an appropriate disease. the exclusion criteria consisted of (1) elderly people who have heart and/or lung disease, and (2) they cannot communicate using pasa thai or bahasa indonesia. the instrument used to measure attitude was developed by the researchers. it consisted of five items in the likert scale format (1 = disagree until 5 = strongly agree). the attitude questionnaire was proven to be a valid and reliable instrument for measuring attitude towards mhe (r = 0.437-0.574; ioc = 0.574; cronbach’s alpha = 0.880). a positive attitude is evident if the score ≥ 3, while a negative attitude is evident if the score ≤ 2 in each item. the total score was then categorised into four categories: 5-10 = strongly negative, 11-15 = negative, 16-20 = positive, and 21-25 = strongly positive. these four categories were then merged at the end into two big categories of good and bad attitude. good attitude was if the total score ≥ 16, while bad attitude was if the total score ≤ 15. descriptive statistics, the levene test, and an independent sample t test were used for the data analysis (α = 0.05). ethical clearance was issued by the ethical committee of saint louis college (slc), bangkok, thailand (november, 2016); certificate number: e.038/2559. the attitude data was collected in the beginning of 2017 in the communities around bangkok and surabaya, while the pre-experimental study of the effect of mhe using the skt1 technique on various physical and psychological parameters was conducted for the rest of the year. the principal investigator for our upcoming study is jintana artsanthia, from slc, bangkok. in bangkok, there were five communities used as the study sites. in surabaya, there were three communities used as study sites; rw v, vi, and vii in the district of mojo. results in total, the study respondents were composed of 15.82% men and 84.18% women. the age range was 60 – 78 years old. the educational background of the sample in bangkok was mostly primary school level (53%), while in surabaya, it was mostly secondary school level (64.58%). the income of the sample in bangkok was 43% at thb 2000-6000 per month, while in surabaya, it was 53.13% at less than idr 800 thousand per month. in bangkok, most of the respondents had relatives who suffered from dm/ht (66%), while in surabaya, it was the opposite (69.79%). details of demography characteristic of study respondents are presented in table 2. from table 3, the average of the attitude score in bangkok and surabaya was 3.88 and 3.76 respectively, representing a positive attitude in both sites. the highest possible total score of attitude was 25. the results showed that the total score for attitude in bangkok and surabaya was 19.43 and 18.77, representing a good attitude in both sites. these results indicate that the study respondents could accept mhe on a personal level. there is a high possibility that the upcoming study respondents will do meditation practice regularly on a daily basis, allowing the mhe effects towards lowering bp and bs level to exist. from table 4, we can see that a 0% strongly negative attitude was found in bangkok. this indicates that the communities in bangkok were really familiar with meditation practice and the positive value of meditation already exists in the selected society. the most surprising fact was that a 19.79% strongly positive attitude was found in surabaya. this result was even better than in bangkok. this indicates that although the surabaya communities are not really familiar with meditation practice and that the knowledge related to it is potentially low, the study respondents were optimistic towards meditation’s benefit for their health. from table 5, we can see that even in bangkok, most of the citizens are familiar with meditation practice. however, 4% of the study respondents had a bad attitude. it was not surprising that we found a higher result in surabaya (12.5%), because meditation practice is relatively new and unpopular in society. the relieving fact is that 62.24% respondents had a good attitude towards mhe in both sites. there was a high possibility that the upcoming study respondents will do meditation practice regularly on a daily basis, so that the mhe effect of lowering bp and bs level could exist. from table 6, we can see that the attitude in bangkok was better than that in surabaya because of the higher mean and lower sd. this result indicates that the respondents in bangkok had a good attitude towards mhe, in which the positive value was not really different between the focused societies. all of the attitude data was normally distributed (p>α). there was significant attitude difference in the aspect of preferring to practice mhe (item 4) between bangkok and surabaya (p = .004). this result indicates that the respondents from bangkok like to practice meditation more than surabaya’s respondents. based on the total score of attitude, overall, there was no significant attitude difference in the elderly who are living with ht and/or dm between bangkok and surabaya (p = .17) discussion attitudes have long been considered to be a central concept of social psychology. the concept of attitudes has changed over the years. the initial definitions were broad and encompassed cognitive, affective, motivational, and behavioral components. the current conception of attitude does not adequately distinguish between attitudes and factual beliefs on the one hand, or between attitudes and n. p. w. p. sari et al. 60 | pissn: 1858-3598  eissn: 2502-5791 preferences on the other. to hold an attitude is to ascribe an objective moral property to the attitude‐object. however, the conception of such properties rests on an incoherent theory of relations as being constitutive of their terms, and the belief in them has only pseudo‐cognitive content. attitudes serve as rationalizations for concealed or unconscious impulses and are themselves defended by further rationalization. some apparent exceptions, namely ‘aesthetic attitudes’ and table 2. demographic characteristics characteristic bangkok (n=100) surabaya (n=96) ∑ % ∑ % sex male female 20 80 20.0 80.0 11 85 11.45 88.54 age 60-69 48 48.0 75 78.13 70 up 52 52.0 21 21.87 education primary school 53 53.0 25 26.04 secondary school 25 25.0 62 64.58 bachelor’s degree 8 8.0 9 9.38 no study 14 14.0 0 0 occupation agriculture or farmer 1 1 0 0 shopkeeper or own business 10 10.0 12 12.50 government officer 2 2.0 1 1.04 other: housewife, retired, etc 87 87.0 83 86.46 income per month -<2,000 baht (< idr 800 thousand) 18 18.0 51 53.13 2,000 -6,000 baht (idr 800 thousand – 2.4 million) 43 43.0 31 32.29 6,001 -10,000 baht (idr 2.41 – 4 million) 19 19.0 10 10.42 -> 10,000 baht (> idr 4 million) 20 20.0 4 4.17 relative has dm/ht yes no 66 34 66 34 29 67 30.21 69.79 table 3. frequency of the elderly attitude towards mhe item attitude bangkok (n=100) surabaya (n=96) 1 2 3 4 5 mean 1 2 3 4 5 mean 1. feel calm when practicing mhe 2 18 71 9 3.87 5 7 14 55 15 3.71 2. feel good when practicing mhe 4 23 63 10 3.79 4 2 21 56 13 3.76 3. believe that working on the body and mind can allow them to cooperate 20 68 12 3.92 6 2 16 55 17 3.79 4. prefer to practice mhe 25 61 14 3.89 4 10 23 48 11 3.55 5. believe in the concept of mhe, and that it can improve immunity and heal symptoms 1 18 65 16 3.96 4 6 7 49 30 4.00 average of attitude for each item 3.88 (+) 3.76 (+) average of the total attitude score 19.43 (good) 18.77 (good) jurnal ners http://e-journal.unair.ac.id/jners | 61 ‘authentic values’, reveal themselves to be either (a) factual beliefs about aesthetic properties or about human motivation respectively, (b) preferences, or (c) moral attitudes as defined (maze, 2008). conceptualisations of the attitude construct advances the possibility that attitudes can form in multiple ways. the three key means of attitude formation implicates cognitive, affective, or behavioral processes. an attitude is formed on the table 4. level of the elderly attitude towards mhe based on the total score bangkok (n=100) surabaya (n=96) total score ∑ % ∑ % meaning 5-10 5 5.21 strongly negative 11-15 4 4 7 7.29 negative 16-20 82 82 65 67.71 positive 21-25 14 14 19 19.79 strongly positive total 100 100 96 100 table 5. category of the elderly attitude towards mhe based on the level of attitude category bangkok ∑ % surabaya ∑ % total % good attitude (positive + strongly positive) 96 96 84 87.5 122 62.24 bad attitude (negative + strongly negative) 4 4 12 12.5 74 37.76 total 100 100 96 100 196 100 table 6. descriptive statistics of the elderly attitude towards mhe attitude in site ∑ mean std. deviation attitude in bangkok 100 19.43 2.41 attitude in surabaya 96 18.77 4.15 total average 196 19.10 3.55 table 7. statistical test results on the elderly attitude differences towards mhe attitude levene's test for equality of variances independent t-test for equality of means f sig. t df sig. (2tailed) mean difference std. error difference 95% ci lower upper item1 equal variances assumed 19.440 .000 -1.398 194 .164 -.16167 .11567 -.38981 .06647 equal variances not assumed -1.384 151.724 .169 -.16167 .11685 -.39253 .06919 item2 equal variances assumed 2.294 .132 -.268 194 .789 -.02958 .11053 -.24757 .18841 equal variances not assumed -.266 178.868 .790 -.02958 .11110 -.24882 .18965 item3 equal variances assumed 14.773 .000 -1.226 194 .222 -.13875 .11320 -.36202 .08452 equal variances not assumed -1.213 150.653 .227 -.13875 .11437 -.36473 .08723 item4 equal variances assumed 23.456 .000 -2.917 194 .004 -.33792 .11585 -.56640 -.10943 equal variances not assumed -2.892 159.911 .004 -.33792 .11686 -.56871 -.10712 item5 equal variances assumed 7.823 .006 .248 194 .804 .02958 .11912 -.20535 .26452 equal variances not assumed .246 156.197 .806 .02958 .12024 -.20792 .26708 total equal variances assumed 9.165 .003 -1.365 194 .174 -.65917 .48308 -1.61193 .29360 equal variances not assumed -1.351 151.459 .179 -.65917 .48800 -1.62334 .30500 n. p. w. p. sari et al. 62 | pissn: 1858-3598  eissn: 2502-5791 basis of cognitions when one comes to believe either that the attitude-object possesses (un)desired outcomes. the expectancy-value model argues that an attitude toward a given object is the sum of the expected value of the attributes of the object. an overall attitude toward the object is reached by taking the sum of the expected values of all of the attributes that an attitude object is thought to have. they claim that all attitudes are based on beliefs about the attitude object, and that all attitudes are formed via the summation of its subjective probabilities and values (wigfield & cambria, 2010). most people seem to agree that an attitude involves at least three things: an attitude object which is defined by the attitude holder, a set of beliefs towards the object, and a tendency to behave in a certain way. other underlying dimensions of attitude are knowledge level and strength or resistance to change. if the attitude intensity is high, then strength is also apt to be high. strength may be high if one has lots of knowledge. there are also times when attitude seems to be change resistant despite a lack of knowledge. there is a reason to believe that an attitude that is high in intensity, strength, and knowledge is apt to be a good predictor of behavior; but attitude alone does not determine behavior (hulleman, et al, 2010). based on table 2, we can see that all of the respondents possessed a relatively low knowledge level based on their educational background (84.18% in total). from table 3, we can see that regarding the 5 items in the attitude questionnaire, most of the respondents tend to choose a higher score (3/ 4/ 5) for each item. it is expected then that the respondents will practice mhe regularly, because 1) they intensely feel about mhe, 2) enough information was given prior to the study period, and 3) the high attitude intensity has made it change resistant. other than cognition, attitude forms from the effect that stems from an emotional reaction to the attitude object. one can be said to have an affectively-cased attitude when either positive or negative feelings are evoked when considering the attitude object. as seen in table 3, 4 and 5, most of the respondents have a positive/good attitude toward mhe (91.84% in total). although most of the bad attitude was found to be in surabaya (12.5%), the overall attitude was mostly positive/good. there are three primary ways in which attitudes might be formed on the basis of affect: operant conditioning, classical conditioning, and mere exposure. without clear feelings or beliefs about a potential attitude object, one may still have had past experiences with it. the past behavior can be used to infer the attitude toward an object through self-perception (nagengast, et al, 2011). one of the reasons that attitudes are practically and theoretically important is because they have predictable and very powerful effects on behavior (nagengast, et al, 2011). people care passionately about some attitudes and consider them to be deeply important, and they accord no particular significance to other attitudes. determining which attitudes most accurately predict which behavior under what circumstances has turned out to be a highly complex enterprise. some research has revealed that some kinds of individuals are more likely than others to act on their held attitudes (singh, et al, 2012). in addition, some kinds of situation are more likely than others to promote attitude-congruent behaviors (tang, et al, 2014). in addition to differences across people and across situations, there are also marked differences across types of attitude – some kinds of attitude are more likely than others to motivate and guide behavior (eaton & visser, 2008). it is generally understood that a person’s attitude has a primary influence on behavior. banaji & eiphetz (2009) stated that if attitude is a predisposition to act favorably or unfavorably, then the attitude that one has should predict one’s behavior. from the 1930s on, however, studies have shown the weak prediction of behavior from attitude (abidin, et al, 2011); there are situational factors whose influence is stronger than mere attitude. people’s expressed attitudes hardly predict their varying behavior (wicker, 2010). behavior and expressed attitude differs because both are subject to other influences. on any occasion, it’s not only inner attitudes that guide us, but also the situation that we are face with. the attitude model suggests that how you feel about some person, object, or idea will influence your behavior toward that object. however, it is not uncommon for people to have feelings one way and to behave differently. this difference may lead one to raise question about the relationship between attitude and behavior. it is apparent that there are intervening factors influencing the attitude – behavior relationship: habit, social norms, and the expected consequences of behavior. habits are automatic ways of behaving in appropriate situations with minimum thinking. social norms include the role expectations of a certain behavior that members of a group, community, or society share. the expected consequences of a behavior produce an apparent inconsistency between what a person says and what a person does. therefore, attitude is not always a good predictor of behavior (tesser & schwarz, 2001). the information that a person has about an object will influence the attitude that the person holds about that object. many beliefs may underlie a given attitude. individuals also use attitudes to express their basic values and to portray to others the sort of persons that they are. generally, people maintain a consistent relationship between their beliefs, values, and attitudes. attitudes are also influenced by personal needs, such as the need for reward, defending the ego, and understanding the environment. these three basic personal needs which attitudes serve are very important. often, a set of beliefs and values are used to provide reasonable justification for an attitude. however, the real jurnal ners http://e-journal.unair.ac.id/jners | 63 motivation for the attitude in question may be basic personal needs (prasad, et al, 2011). the attitude towards mhe in the elderly who are living with ncd, especially ht and/or dm, in bangkok and surabaya, was mostly positive/good and insignificantly different overall. both thailand and indonesia are located in the south east asia region, which is relatively similar regarding culture, habits, customs, and daily life. the beliefs, values, social norms, personal needs and expected consequences of behavior are also relatively similar in the study context. by way of this positive/good attitude regarding mhe expressed through the five items in the attitude questionnaire, the upcoming respondents are expected to practice mhe regularly on a daily basis so then its benefits for health can be assured. conclusion the elderly attitude towards mhe was mostly positive/good in both sites. the elderly in bangkok prefer to practice mhe more than in surabaya. overall, there was no significant attitude difference towards mhe between the elderly who are living with ht and/or dm in bangkok or surabaya. the implementation of mhe, especially using the skt1 technique, in the elderly communities of bangkok and surabaya has the high possibility of being accepted on a personal level. its effects on the various physical and psychological parameters involved in ht and dm management also possibly exist. references abidin, a.a.z., ibrahim, r., akiah, s.a. (2011). attitude (part 1). retrieved from: prints.utm.my/19940/1/001.pdf). (accessed: november 19, 2017). artsanthia, j., sari, n.p.w.p. (2017). the effects of meditation healing exercise in elderly who are lliving with non-communicable disease in bangkok and surabaya. bangkok: faculty of nursing, saint louis college. banaji, m.r., eiphetz, l. (2009). attitudes. retrieved from: www.fas.harvard.edu/~mrbworks/articles/2010 _attitudes.pdf. (accessed: november 19, 2017). cardoso, r., de souza, e., camano, l., et al. (2004). meditation in health: an operational definition. brain res protoc; 14(1): 58-60. eaton, a.a., visser, p.s. (2008). attitude importance: understanding the causes and consequences of passionately held views. social and personality psychology compass. pp. 1719-1736. hulleman, c. s., schrager, s. m., bodmann, s. m., harackiewicz, j. m. (2010). a meta-analytic review of achievement goal measures: different labels for the same constructs or different constructs with similar labels?. psychological bulletin, 136(3), 422. maze, j.r. (2008). the concept of attitude. retrieved from: http://aap.tandfonline.com/doi/abs/10.1080/00 201747308601684?journalcode=sinq20 (accessed: november 19, 2017). nagengast, b., marsh, h. w., scalas, l. f., xu, m. k., hau, k. t., trautwein, u. (2011). who took the "×" out of expectancy-value theory? a psychological mystery, a substantive-methodological synergy, and a cross-national generalization. psychological science, 22(8), 1058-1066. prasad, k., wahner-roedler, d.l., cha, s.s., sood, a. (2011). effect of a single-session meditation training to reduce stress and improve quality of life among health care professionals: a “doseranging feasibility study. alternative therapies; 17(3). retrieved from: www.proquest.com. (accessed: november 19, 2017). singh, y., sharma, r., talwar, a. (2012). immediate and long-term effects of meditation on acute stress reactivity, cognitive functions, and intelligence. alternative therapies; 18(6). retrieved from: www.proquest.com. triamchaisri, s.k., triamchaisri, s., sresumatchai, v. (2013). effectiveness of skt meditation innovation exercise on spatial disorientation: thai traditional medicine. alternative & integrative medicine. doi: 10.4172/23275162.s1.004. tang, y.y., posner, m.i., rothbart, m.k. (2014). meditation improves self-regulation over the life span. ann ny acad sci.jan;1307:104-11. doi: 10.1111/nyas.12227. tesser, a., schwarz, n. (2001). intrapersonal processes (blackwell handbook of social psychology). oxford, uk: blackwell, pp. 436-457. wicker, a.w. (2010). attitudes versus actions: the relationship of verbal and overt behavioral responses to attitude objects. journal of social issues 25(4):41 – 78. · wigfield, a., cambria, j. (2010). expectancy-value theory: retrospective and prospective. advances in motivation and achievement, 16, 35-70. world health organization (who). (2015). noncommunicable diseases progress monitor 2015. isbn: 978 92 4 150945 9. http://www.fas.harvard.edu/~mrbworks/articles/2010_attitudes.pdf http://www.fas.harvard.edu/~mrbworks/articles/2010_attitudes.pdf http://aap.tandfonline.com/doi/abs/10.1080/00201747308601684?journalcode=sinq20 http://aap.tandfonline.com/doi/abs/10.1080/00201747308601684?journalcode=sinq20 http://www.proquest.com/ http://e-journal.unair.ac.id/jners 31 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 1, march 2023, p. 31-39 http://dx.doi.org/10.20473/jn.v18i2.41837 original article open access exploring the supportive care needs for people with cancer undergoing chemotherapy: a qualitative descriptive study muhamad zulfatul a’la 1 and khanitta nuntaboot 2 * 1 faculty of nursing, university of jember, jember, indonesia 2 faculty of nursing, khon kaen university, khon kaen, thailand *correspondence: khanitta nuntaboot. address: faculty of nursing, khon kaen university, khon kaen, thailand. email: khanitta@kku.ac.th responsible editor: ferry efendi received: 23 december 2022 ○ revised: 18 march 2023 ○ accepted: 20 march 2023 abstract introduction: chemotherapy's side effects cause people with cancer to encounter difficult situations that might impact their supportive care needs. exploration of supportive care needs may assist the nurse in improving the quality of life of people with cancer undergoing chemotherapy (pwcuc). therefore, this study aims to explore the supportive care needs of pwcucs. methods: a qualitative descriptive study from november 2021 until may 2022 was utilized through in-depth interviews and focus group discussions (fgd) in three public health centers in jember, indonesia. data saturation was achieved after the researcher conducted an in-depth interview of 27 informants and fgd of 13 informants. a total 40 informants from pwcucs, family of pwcucs, doctors, and nurses was recruited based on inclusion criteria using purposive sampling technique. the researcher developed an in-depth interview and fgd guidelines to collect the data. six-step thematic analysis was used. triangulation, member-checking, and thick description were performed to maintain trustworthiness. results: the study yielded four themes that represent participants’ voices. these were 1) social support needs, 2) accompanying needs, 3) information needs, and 4) healthcare service support. conclusions: supportive care needs for pwcucs is a complex and contextual phenomenon. this study revealed that pwcucs required individual, social, and healthcare service support to meet their needs. therefore, further study is required regarding developing a nursing care plan for pwcucs based on cultural-sensitive supportive care needs. keywords: healthcare service system, people with cancer, supportive care needs, qualitative study introduction cancer is still a major public health issue across the world. cancer is the cause of death in one in six persons (who, 2020). in 2020, there were 19.3 million new cases with mortality. up by 10 million (sung et al., 2021). cancer incidences in indonesia grew to 2.6 million in 2021, up from 1 million in 2018 (ministry of health, 2022). furthermore, in sdgs issues, globally, premature death (30-69 years) because of cancer decreases but insignificantly. whereas, the sdgs aim to reduce one third premature death by 2030 relative to 2015 level (bennett et al., 2020). as a result, reaching this goal will need a concerted effort. the who already has a priority plan for dealing with cancer issues, particularly in order to meet the sdg’s objectives. improving the quality of treatment for people with cancer is a part of their aims (who, 2020). one of the cancer treatments is cytotoxic chemotherapy. chemotherapy can improve the quality of life of people with cancers and also increase their life expectancy (parkes et al., 2019). in indonesia, people with cancer with chemotherapy are 24.9% of the total https://creativecommons.org/licenses/by/4.0/ mailto:khanitta@kku.ac.th https://orcid.org/0000-0002-7207-6739 https://orcid.org/0000-0003-0357-0749 a’la and nuntaboot (2023) 32 p-issn: 1858-3598  e-issn: 2502-5791 people with cancer (ministry of health, 2018). however, chemotherapy can affect the physical, psychological, and social life of people with cancers (suwankhong and liamputtong, 2018). people with cancer undergoing chemotherapy have a complex problem. in general, chemotherapy will affect the patient's physical condition due to the side effects and will cause trauma to daily life activities (wampaalu et al., 2016). moreover, people with cancer with chemotherapy need adequate social support in facing the chemotherapy process, which is a long-term care treatment (shahrokni et al., 2020). therefore, people with cancer and during the chemotherapy process make pwc have complex needs and needs to be explored. supportive care is defined as providing health promotion, curative support, palliative care, and bereavement services to patients and caregivers that meet their physical, psychological, social, informational, and spiritual needs during their diagnostic, treatment, or rehabilitation phases (boyes, girgis and lecathelinais, 2009; hui et al., 2013; hui, 2014). supportive care aims to improve the qol of patients with severe or lifethreatening diseases (choi et al., 2022). in the context of people with cancer, supportive care is constructed from human needs, cognitive appraisal, and coping adaptation conceptualized from the cancer experience (fitch, 2008). in previous study in the cancer context, several studies regarding supportive care needs have been performed in quantitative, qualitative and systematic review approaches. in iran, a qualitative study on cancer patients found that the main needs of cancer patients are deficiencies in disease management and the importance of a sympathetic and knowledgeable caregiver (mazhari and khoshnood, 2021). in another context, chua and tan (2020) found that the supportive needs of cancer patients with ambulatory treatment including chemotherapy in singapore were focused on psychosocial and supportive care needs, information needs and information delivery by health professionals. furthermore, boyes, girgis and lecathelinais (2009) have formulated a tool to measure supportive care needs for cancer patients with five domains. this questionnaire has been performed in brazil for all cancer patients with ambulatory treatment (calvo, sepulvedacarrillo and judith, 2017), in japan for colorectal cancer (sakamoto et al., 2017), in indonesia for gynecological cancer (putri et al., 2018) and in the netherlands for head and neck cancer (jansen et al., 2016). those studies explored the supportive care needs in various cancer patients' contexts using five domains with different results. nonetheless, many scholars argue that expanding supportive care needs through a subjective view could see the nature of supportive care needs in people with cancer holistically and comprehensively (chua and tan, 2020; mazhari and khoshnood, 2021; khan et al., 2022). in another research approach, wabula, yunitasari and wahyudi (2020) and webb et al. (2021) reviewed quantitative and qualitative articles to expose a synthesis of support and care needs in people with cancer. although existing studies have discussed supportive care needs in many contexts and approaches, surprisingly, studies focusing on cancer patients undergoing chemotherapy (pwcuc) are rarely conducted, even though the complex conditions of chemotherapy may differ from cancer with other treatments. furthermore, in indonesia, studies discussing supportive care needs are scarce. from the literature review results, only one quantitative study was found related to supportive care needs, but focusing on gynecological cancer, not general cancer cases. in addition, in terms of meeting the needs for supportive care, pwcucs are linked to other social support systems (tamulee, 2013; røen et al., 2019). families and healthcare providers are the significant support systems that influence pwcucs in meeting their supportive care needs (berman et al., 2020). description of supportive care needs requires study with multiperspective views from other systems of pwcucs. supportive and care needs are multidimensional, contextual, subjective and ambiguous; this study aimed to explore the supportive and care needs of pwcucs using a qualitative approach. materials and methods. this study utilized a qualitative descriptive study design (doyle et al., 2020). in addition, the multiple perspective interviews (mpi) method was used for triangulation analysis. mpi is a type of qualitative analysis that involves the use of multiple informant groups. mpi can also be used to preserve the credibility of qualitative data (vogl, schmidt and zartler, 2019). three public health center areas: kaliwates, jember kidul, and gladak pakem, were involved in the jember region of indonesia. these three public health centers have the highest number of cancer patients in the jember area. this research was conducted on pwcucs diagnosed as cancer by a doctor, registered in the public health center, aged 18-70 years, able to communicate without memory and hearing impairment, and had jurnal ners http://e-journal.unair.ac.id/jners 33 chemotherapy treatment in one of the private hospitals in jember. moreover, in seeing multiple perspectives, other informants were recruited. other informants are families of pwcucs at least 18 years old, have no memory impairment, average hearing ability, can communicate and live together with patients and care for patients' daily lives for more than one year during the chemotherapy process. furthermore, the informants were also healthcare providers (doctors and nurses) who worked in the hospital or community. purposive sampling was utilized in this study. the data were collected through in-depth interviews and focus group discussions (fgd) with three groups of informants (pwcucs, family of pwcucs and healthcare providers). as many as 27 informants were recruited for in-depth interview: nine pwcuc, eight families of pwcucs, eight nurses, and two doctors. in-depth interviews used interview guidelines and were conducted in two sessions for each informant. the indepth interview duration was 40-60 minutes per session face-to-face with informants and were held from november 2021 to march 2022. all researchers conducted in-depth interviews at the informant's home and used a tape recorder. researchers obtained patient address information from medical records in one of the private hospitals in jember. saturation of data is an indicator of the number of recruited informants. researchers discussed to determine data saturation in every informant. the list of questions from the in-depth interview can be seen in table 1. the indonesian language was used in the in-depth interview and fgd. moreover, in the fgd method, three groups were recruited. there were four informants in pwc undergoing chemotherapy, four in the family of pwc undergoing chemotherapy, and five healthcare providers (hcp) including one doctor and four nurses. fgd was conducted in one session of 60-90 minutes. the fgd was held in april-may 2022. the fgd was conducted online through the zoom application and the fgd process recorded using application tools. to ensure that the online fgd activities ran well, the researchers added inclusion criteria for informants in the fgds by having a compatible device for google/zoom meetings, either mobile phones or personal computers. mza conducted both in-depth interviews and fgds and kn provided input regarding the interview guide. all transcripts of both in-depth interviews and fgds were translated into english. it is important because the research was conducted in indonesia, and kn is a nonindonesian researcher. for the translating framework, the researcher used the abfalter, mueller-seeger and raich (2021) framework translated from all stages. furthermore, researchers used code to facilitate analysis and maintain the confidentiality of informants. the codes used for in-depth interviews and pwc fgds were idi-p 1-9 and fgd-p 1-4. then, the code for the family of a pwc was idi-f 1-8 and fgd-f 1-4. lastly, idih 1-10 and fgd-h 1-5 were used for hcps. in this study, researchers utilized a six-step thematic analysis from braun and clarke (2019): familiarizing the data: generating initial codes: searching for themes: reviewing themes: defining and naming themes: producing the report. after making transcripts of all indepth interviews and fgds, mza and kn did the initial codes from each sentence with meaning and searching themes. next, kn reviewed the themes based on the supportive care needs’ theoretical framework to help researchers to analyze the themes. finally, mza and kn defined and named the themes and produced the report. in addition, researchers utilized multiple perspective interview analyses. researchers compared each datum to understand contrasts and overlaps in every group of informants (vogl, schmidt and zartler, 2019). after compiling the themes and making a report, mza returned the analysis results to the informants for correction and feedback. researchers utilized atlas.ti table 1 list of questions for informant in in-depth interview and fgd list of questions for pwcuc 1. how do you feel about conducting chemotherapy treatment? 2. could you tell me, what your important needs are during chemotherapy? 3. how does your family respond to your condition? 4. how do hcps or volunteers near you respond to your condition? 5. how do you fulfill your basic needs when you undergo chemotherapy? 6. what support and care do you expect from family, hcps and volunteers related to your condition now? for family of pwcuc 1. what do you think about chemotherapy? 2. as your experience, what do people with cancer want during her/his treatment? 3. do you think people with cancer are satisfied with the healthcare service and volunteering service? 4. as family, what do you expect from hcps and volunteers related to your family’s condition? for hcp 1. what do you think about pwcucs? 2. could you talk about your experience during caring for a pwcuc? 3. in your experience, what do people with cancer want during her/his treatment? 4. do you think people with cancer are satisfied with the healthcare service and volunteering service? a’la and nuntaboot (2023) 34 p-issn: 1858-3598  e-issn: 2502-5791 version 8.4.4 to help manage data. to maintain quality for this research report, the 32 items of the consolidated criteria for reporting qualitative research (coreq) checklist were utilized (tong et al., 2012). in maintaining accurate interpretation (credibility), the researcher used triangulation in informants and methods. in the triangulation technique, given a complete result, the researcher recruited not only pwcucs as informants but also the family of pwcucs and hcps. also, triangulation data utilized the fgd method to complement the in-depth interview method. moreover, the researchers also did member checking by involving 31 informants to provide feedback on the themes that had been made. in ensuring that the result can be transferred in another context (transferability), the researcher conducted a thick description by contrasting and comparing the results with experienced researchers. the researcher conducted an audit trail to maintain the stability of findings (dependability and confirmability). researchers recorded the research process from the beginning to the end of the research process. this research obtained a permit from the khon kaen university ethics committee with number he642139 on august 12, 2021. the researcher has also obtained permission from the jember health department, the public health centre and the private hospital. when collecting data, the informants could choose to withdraw without further prejudice. the researcher ensured that all informants remained anonymous. in addition, the researcher verified that the informants' privacy and confidentiality were protected. the researcher did not use a specific name and relied on the code instead. the researcher also kept all documents from informants securely. results forty participants agreed to be informants in the indepth interviews and fgds from 42 targets of the participants who met the inclusion criteria. one pwcuc and one family of a pwcuc refused to be an informant because of family conditions. however, using 40 informants, the data met saturation. the majority of informants of pwc, either in-depth interview or fgd, were married women with a mean age of 52.3±10.9 and 44±6.3, respectively. in the family of pwc, the majority in in-depth interviews were men and a husband. the fgd group mainly included the husband and the same proportion between men and women. the average age of the family of pwc was 47.9±13.1 in an in-depth interview and 40.7±12.6 in fgd. furthermore, in hcps, the majority was a nurse, either in fgd or in-depth interview. the in-depth interviews had the same proportion between men and women, with 38.7±9.2 in average age. however, in fgd, all informants were women with 34.2±3.6 in average age. details can be seen in table 2 and table 3. all researchers analyzed transcript results from indepth interviews and fgds. using mip analysis, researchers also compared each group of informants, namely pwcucs, the family of pwcucs, and hcps. twenty-seven codes were found in in-depth interviews and fgds. then the researchers extracted four themes based on grouping codes that had been discussed together. the themes are 1) social support needs, 2) accompanying needs, 3) information needs, and 4) healthcare service support. table 2 informants’ characteristics in in-depth interview informant characteristic frequency percentages (%) pwcuc (n=9) gender female 8 88.9 male 1 11.1 age (meansd) 52.310.9 married status married 6 66.7 widowed 3 33.3 level of education elementary school 1 9.1 junior high school 0 0 senior high school 3 33.3 bachelor 5 55.6 duration of chemotherapy 2 years 4 44.4 more than 2 years 5 55.6 family of pwcuc (n=8) gender female 3 37.5 male 5 62.5 age (meansd) 47.913.1 married status married 8 100 widowed 0 0 level of education elementary school 0 0 junior high school 0 0 senior high school 2 25 bachelor 6 75 pwc relationship husband/wife 4 50 child 3 37.5 sister/brother 0 0 others 1 12.5 hcps (n=10) gender female 5 50 male 5 50 age (meansd) 38.79.2 profession chemotherapy nurse 2 20 public health center’s nurse 6 60 chemotherapy doctor 1 10 public health center’s doctor 1 10 jurnal ners http://e-journal.unair.ac.id/jners 35 theme 1: social support needs based on the informants' results, the social support needs of pwcucs consisted of environmental, peer, and family support. in environmental support, the informants stated that environmental management such as public health center (phc), neighbors and surroundings from pwcucs needed optimal management. moreover, supportive management of the environment can reduce pwc stress and is an essential requirement for pwcucs. it can be seen in the statement in the in-depth interview: “we need support from neighbors, not only from family. neighbors know more about our condition. support from the environment, such as neighbors or from cadres, is important to us.” (idi-p 7). “apart support from the family, also support from the puskesmas (phc), from the surrounding environment support, it’s also possible, cancer patients need support like that.” (idi-h 2) then, the need for peer support is part of pwcuc's social support needs. the peer support referred to support from cancer survivors and close friends. the informant explained that having peer support, both from cancer survival and close friends, can have a different impact and increase pwcucs’ resilience in dealing with their condition, as in the quote below: “sometimes a cancer survivor has more support (from friends) than family in my opinion.” (idi-p 9) “it might just be prayer and support from those who were close to me to pray for me to be tough to face this problem. then, i could be resilient, it's been incredible for me."(idi-p 3) lastly, the social support needs expressed by the informants were family support needs. informants explained that family support could come from husband/wife, children, and siblings. the informants also explained that the form of support is a prayer given to pwc. in addition, support can take the form of helping all pwcucs’ needs, both physical and psychological. several informants also mentioned that support motivates pwcucs to be more decisive in dealing with their illness. it can be seen in the quotes from pwcucs below: “family is really important, it's important to me. if anything happens, first, i will contact the family." (idi-p 9) “support from my family is very meaningful. they helped me when i was weak.” (fgd-p 2) a hcp also confirmed that family needs are essential support for pwcucs. the hcp said: “in my opinion, they need support from my family about the disease, right? some chemotherapy programs are long, some are short, so it needs support from family too.” (fgd-h 2) theme 2: accompanying needs according to informants, accompanying needs are the needs for pwcucs to be accompanied by family, peers, or significant others, such as volunteers. accompanying is a "being there" and is not deeply involved in the patient's treatment process. table 3 informants’ characteristics in in fgd informant characteristic frequency percentages (%) pwcuc group (n=4) gender female 4 100 male 0 0 age (meansd) 446.3 married status married 3 75 widowed 1 25 level of education elementary school 0 0 junior high school 0 0 senior high school 1 25 bachelor 3 75 duration of chemotherapy 2 years 2 50 more than 2 years 2 50 family of pwcuc group (n=4) gender female 2 50 male 2 50 age (meansd) 40.712.6 married status married 3 75 widowed 0 0 not married 1 25 level of education elementary school 1 25 junior high school 0 0 senior high school 1 25 bachelor 2 50 pwcuc relationship husband/wife 2 50 child 1 25 sister/brother 1 25 others 0 0 hcps group (n=5) gender female 5 100 male 0 age (meansd) 34.23.6 profession chemotherapy nurse 2 40 public health center’s nurse 2 40 chemotherapy doctor 0 public health center’s doctor 1 20 a’la and nuntaboot (2023) 36 p-issn: 1858-3598  e-issn: 2502-5791 accompanying needs focus on intimacy and the presence of a significant other. the situation stated by an informant was that when a friend or colleague who was there accompanied him at home or in the hospital, it was thought that he was assisting the patient in the healing process without any further support. accompanying needs can be seen in the quotes below: “i also involve the children to accompany my mother while in the hospital. my child is waiting with my mother and my mother feels that there is still someone who cares, so she doesn't feel lonely.” (idi-f 2) “accompanying patients has reduced this pain percentage. the patient is getting weaker, sometimes he is sad, sometimes he is anxious. if someone accompanies them, it can at least reduce the pain a little bit.” (idi-f 4) theme 3: information needs information needs based on findings from informants are the need for openness and clarity of information about the disease from hcps, clarity in questions from pwcucs and re-energized information. pwcs want clarification of questions arising from the disease and its treatment process from hcps or volunteers. one of the pwcuc informants stated that: “many question that need to be clarified. it (cancer) is no ordinary disease, so many questions from me, it is so important." (idi-p 2)) moreover, information about treatment delivered by informants is an essential requirement for pwcucs. informants, in detail, stated that they needed information about problems after chemotherapy, mental treatment and cancer treatment. one informant stated that: “from my mother's stories, there are still many cancer people who don't know about cancer, such as the treatment and how to treat it, how it is, and information about mental treatment as well.” (fgd-f 2) then, information about the medication process was stated by the informants as information needs from pwcs. informants revealed administration process and document preparation is an essential requirement for pwcs. the informant said: “sometimes at the first, it we do not know, like in this hospital, what we should do?” (idi-f 3) another information needed by pwcs undergoing chemotherapy is re-energize information. informants mentioned that sometimes pwcs and their families experience bad conditions due to cancer and the chemotherapy process. thus, re-energized information needs to be provided by hcps or volunteers to patients and families to strengthen their psychological state. an informant stated that: “most people, if someone suffers from cancer, they immediately, that is, it was a drop. so they need information on how to re-energize patients and families.” (idi-h 3) theme 4. healthcare services support based on the informants’ subjective experience, healthcare services support is a pwcuc requirement that must be met in the chemotherapy process. the desired support is support from medical equipment and hcps. support from medical equipment includes the completeness of medical equipment in the chemotherapy process, both in the hospital and in the community (at home or at phc). one informant said: “i hope that there is more complete medical device, sir. not only in this hospital but also in other hospitals in jember.” (idi-p 4) healthcare provider support was also widely disclosed by informants. the support needed is how the nurse or doctor treats pwcucs. informants mentioned that good communication and a professional hcp is a form of hcp support. informants revealed that good communication in hcps should be better. one informant said: “communication from nurses also needs to be better to support us. sometimes i don't understand what the doctor is saying about my condition. nurses should help us to translate the doctor's language so that it is more understandable.” (idi-p 5) then, informants revealed that hcps should also be professional in caring for pwcucs and their family. informants mentioned that nurses should be thoughtful in carrying out their caring activities. informants stated that pwcucs mostly had high sensitivity due to their illness. furthermore, pwcucs also need special attention from hcps. informants think that pwcucs have different conditions from people with other diseases. some informants expressed: “nurses should be more thoughtful, sir. they have to be more patient in dealing with cancer patients because cancer patients are really sensitive.” (idi-p 6) “cancer patients should get special attention from hcp for these rather severe diseases, such as cancer. i personally think the patient should be considered as a relative by the hcp.” (fgd-f 1) jurnal ners http://e-journal.unair.ac.id/jners 37 “cancer patients are really different from patients with cases like the usual internal medicine. it’s very different.” (idi-h 8) discussions this study revealed four themes: social support needs, accompanying needs, information needs, and health care service support. the first theme revealed was social support needs. environmental, peer, and family support are social support needs conveyed by informants. this theme is similar to social, spiritual and emotional in webb's framework. moreover, in boyes' framework, social support needs are similar to patient care and support, although the emphasis on each domain is slightly different. in this study context, environment, peer and family support are part of social support needs. peer support is the need for cancer patients to get information, strengthen their emotions and empower themselves (ziegler et al., 2022). family or caregiver is also a component of the social aspect of cancer patients as their support system. a qualitative study from mazhari and khoshnood (2021) in iran states that one of the needs of cancer patients is the need for sympathetic and knowledgeable caregivers. next, environmental support is also needed by cancer patients. the environmental aspect is part of the social support for cancer patients. in their scoping review, lehto et al. (2021) found environmental aspects, especially the natural environment, play a role in improving the psychological status of cancer patients and their families. however, a more profound research exploration in environmental needs aspect in pwcucs is needed. second theme revealed was accompanying needs. informants argued that accompanying needs are the needs for pwcucs to be accompanied by family, peers, or significant others, such as volunteers. this theme is not explicitly seen in the domains presented in previous conceptual frameworks, either boyes et al. (2009) or webb et al. (2021). however, if this theme is analyzed from its context and essence, accompanying needs are part of the sexual needs of cancer patients. the stressing point of this equation is the intimacy of cancer patients' partners, children, or close friends. the results of quantitative research by hawkins et al. (2009) in australia stated that there was a decrease in intimacy, which is part of sexual needs, in cancer patients. wang (2022) added that countries in the asian region still have barriers to conveying and expressing those related to their sexual needs. it is one of the reasons intimacy in this context appears as accompanying needs, not sexual needs. furthermore, chemotherapy treatment is a longterm treatment for cancer patients, requiring pwcucs to rely on close friends or family for support during their treatment. third theme revealed was information needs: openness and clarity of information about the disease from hcps, clarity in questions from pwcucs and reenergized information are information needs argued by informants. information needs are similar with webb or boyes' frameworks. however, in the previous frameworks, the informational need is not the primary need for cancer patients. webb et al. (2021) webb revealed that informational needs are part of workrelated illness and argued that information needs are related to cancer treatment support. khoshnood et al. (2019) also found that cancer patients in iran needed information about cancer diagnosis and treatment. in this study, the information needs found were beyond that. informants wanted information not only related to treatment and disease but also about how to come to terms with the condition and how the cancer patient could recover from the side effects of his chemotherapy. fourth theme revealed was healthcare services support. for the healthcare service system, the webb or boyes' framework focuses on the hcp's ability to treat patients related to how the hcp provides services and treats patients. mazhari and khoshnood (2021) found that healthcare equipment is also a need expressed by pwcuc. however, this research was conducted in a rural area, so access to services for cancer patients is still limited. in contrast, the previous studies were done in the cancer centre in urban areas with complete equipment and an optimal health support system. supportive care is a concept developed by nursing scholars in 1994. fitch created a framework related to specific supportive care for cancer patients. this framework aimed to assist nurses in preparing care planning for cancer patients with a holistic and multidisciplinary approach (fitch, 2008). this framework also explains that supportive care should be patientcentered because the needs of cancer patients vary. therefore, a study with a subjective approach is needed to explore the needs of cancer patients. the theme in this study can serve as a basis for helping nurses in the hospital and the community to develop nursing care plans for pwcucs based on fitch's framework. the qualitative approach is one of the strengths of this study. it can provide in-depth results on the support and care needs of pwcucs. also, this study involves various perspectives to provide comprehensive results. furthermore, the research used multi-method to a’la and nuntaboot (2023) 38 p-issn: 1858-3598  e-issn: 2502-5791 triangulate data and enrich research results. subjective view, besides having strengths, also has weaknesses in seeing phenomena or social problems. this view allows the resulting theme to be influenced by the author. however, we used bracketing techniques and memberchecking with another author to minimize subjectivity. moreover, in limitations, we were not quite sure whether our findings were generalizable to the greater pwcuc population because we only interviewed a small percentage of informants. conclusions this qualitative study gives insight into the supportive care needs of people with cancer undergoing chemotherapy. pwcucs need not only individual support but also social support and support from healthcare services in dealing with their condition. healthcare services support has an essential role that needs to be addressed. pwcucs have to be investigated more in terms of healthcare services support and its relationship to the health system to improve pwcucs’ quality of life. as a result, this study can serve as a foundation for nurses to build supportive care planning for pwcucs, particularly in community settings involving the healthcare service system. acknowledgment we would like to thank khon kaen university for funding this work through the gms-asean scholarship. funding source khon kaen university gms-asean scholarship. there was no influence from funders in the research process. conflict of interest the authors have declared no conflicts of interest. references abfalter, d., mueller-seeger, j., & raich, m. (2021). translation decisions in qualitative research: a systematic framework. international journal of social research methodology, 24(4), 469– 486. https://doi.org/10.1080/13645579.2020.1805549 bennett, j. e., kontis, v., mathers, c. d., guillot, m., rehm, j., chalkidou, k., kengne, a. p., carrillo-larco, r. m., bawah, a. a., dain, k., varghese, c., riley, l. m., bonita, r., kruk, m. e., beaglehole, r., & ezzati, m. (2020). ncd countdown 2030: pathways to achieving sustainable development goal target 3.4. the lancet, 396(10255), 918–934. https://doi.org/10.1016/s0140-6736(20)31761-x berman, r., davies, a., cooksley, t., gralla, r., carter, l., darlington, e., scott, f., & higham, c. (2020). supportive care: an indispensable component of modern oncology. clinical oncology, 32(2020), 781–788. https://doi.org/10.1016/j.clon.2020.07.020 boyes, a., girgis, a., & lecathelinais, c. (2009). brief assessment of adult cancer patients’ perceived needs: development and validation of the 34-item supportive care needs survey (scnssf34). journal of evaluation in clinical practice, 15(4), 602–606. https://doi.org/10.1111/j.1365-2753.2008.01057.x braun, v., & clarke, v. (2019). reflecting on reflexive thematic analysis. qualitative research in sport, exercise and health, 11(4), 589– 597. https://doi.org/10.1080/2159676x.2019.1628806 calvo, a. de, sepulveda-carrillo, l. e., & judith, g. (2017). care needs of cancer patients undergoing ambulatory treatment. enfermería global, 45, 353–368. https://doi.org/http://dx.doi.org/10.6018/eglobal.16.1.231681 choi, y. y., rha, s. y., cho, s., lee, h. s., hong, b., & lee, j. (2022). enhanced supportive care for advanced cancer patients: study protocol for a randomized controlled trial. bmc nursing, 21(1), 1– 10. https://doi.org/10.1186/s12912-022-01097-5 chua, g. p., & tan, h. k. (2020). a qualitative approach in determining the patient-centered information and supportive care needs of cancer patients in singapore. bmj open, 10(2), 1–10. https://doi.org/10.1136/bmjopen-2019-034178 doyle, l., mccabe, c., keogh, b., brady, a., & mccann, m. (2020). an overview of the qualitative descriptive design within nursing research. journal of research in nursing, 25(5), 443–455. https://doi.org/10.1177/1744987119880234 fitch, m. (2008). supportive care framework. canadian oncology nursing journal = revue canadienne de nursing oncologique, 18(1), 6–24. https://doi.org/10.5737/1181912x181614 hawkins, y., ussher, j., gilbert, e., perz, j., sandoval, m., & sundquist, k. (2009). changes in sexuality and intimacy after the diagnosis and treatment of cancer. cancer nursing, 32(4), 271–280. https://doi.org/10.1097/ncc.0b013e31819b5a93 hui, d. (2014). definition of supportive care: does the semantic matter? current opinion in oncology, 26(4), 372–379. https://doi.org/10.1097/cco.0000000000000086 hui, d., de la cruz, m., mori, m., parsons, h. a., kwon, j. h., torresvigil, i., kim, s. h., dev, r., hutchins, r., liem, c., kang, d. h., & bruera, e. (2013). concepts and definitions for “supportive care,” “best supportive care,” “palliative care,” and “hospice care” in the published literature, dictionaries, and textbooks. supportive care in cancer, 21(3), 659–685. https://doi.org/10.1007/s00520-0121564-y jansen, f., witte, b. i., van uden-kraan, c. f., braspenning, a. m., leemans, c. r., & verdonck-de leeuw, i. m. (2016). the need for supportive care among head and neck cancer patients: psychometric assessment of the dutch version of the supportive care needs survey short-form (scns-sf34) and the newly developed head and neck cancer module (scns-hnc). supportive care in cancer, 24(11), 4639–4649. https://doi.org/10.1007/s00520-016-3307-y khan, n. n., maharaj, a., evans, s., pilgrim, c., zalcberg, j., brown, w., cashin, p., croagh, d., michael, n., shapiro, j., white, k., & ioannou, l. (2022). a qualitative investigation of the supportive care experiences of people living with pancreatic and oesophagogastric cancer. bmc health services research, 22(1), 1– 11. https://doi.org/10.1186/s12913-022-07625-y khoshnood, z., dehghan, m., & iranmanesh, s. (2019). informational needs of patients with cancer : a qualitative content analysis. asian pac j cancer prev, 20(2), 557–562. https://doi.org/10.31557/apjcp.2019.20.2.557 lehto, r. h., wyatt, g., sender, j., & miller, s. e. (2021). an evaluation of natural environment interventions for informal cancer caregivers in the community. international journal of environmental research and public health, 18(21). https://doi.org/10.3390/ijerph182111124 mazhari, f., & khoshnood, z. (2021). exploring the care needs of iranian patients with cancer: a qualitative content analysis. bmc nursing, 20(1), 1–7. https://doi.org/10.1186/s12912-021-00659-3 ministry of health. (2018). laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2018 (report on the results of jurnal ners http://e-journal.unair.ac.id/jners 39 indonesia’s basic health research (riskesdas) 2018). badan penelitian dan pengembangan kesehatan. ministry of health. (2022). profil kesehatan indonesia 2021 (indonesia health profile 2021). kementerian kesehatan republik indonesia. parkes, a., nusrat, m., di tomasso, p. m., davis, l., ogbonnaya, s., iwuorie, m., patel, s., abraham, t. g., mack, r., bhadkamkar, n. a., ma, h., nazario, l. a., ramondetta, l., rosenstock, a., & rieber, a. g. (2019). successful implementation of a multidisciplinary chemotherapy efficiency initiative at a community hospital. journal of oncology practice, 15(6), e576–e582. https://doi.org/10.1200/jop.18.00541 putri, r. h., afiyanti, y., ungsianik, t., & milanti, a. (2018). supportive care needs and quality of life of patients with gynecological cancer undergoing therapy. enfermería clínica, 28, 222–226. røen, i., stifoss-hanssen, h., grande, g., kaasa, s., sand, k., & knudsen, a. k. (2019). supporting carers: health care professionals in need of system improvements and education a qualitative study. bmc palliative care, 18(1), 1–11. https://doi.org/10.1186/s12904-0190444-3 sakamoto, n., takiguchi, s., komatsu, h., okuyama, t., nakaguchi, t., kubota, y., ito, y., sugano, k., wada, m., & akechi, t. (2017). supportive care needs and psychological distress and/or quality of life in ambulatory advanced colorectal cancer patients receiving chemotherapy: a cross-sectional study. japanese journal of clinical oncology, 47(12), 1157–1161. https://doi.org/10.1093/jjco/hyx152 shahrokni, a., sun, c. l., tew, w. p., mohile, s. g., ma, h., owusu, c., klepin, h. d., gross, c. p., lichtman, s. m., gajra, a., katheria, v., cohen, h. j., & hurria, a. (2020). the association between social support and chemotherapy-related toxicity in older patients with cancer. journal of geriatric oncology, 11(2), 274–279. https://doi.org/10.1016/j.jgo.2019.08.015 sung, h., ferlay, j., siegel, r. l., laversanne, m., soerjomataram, i., jemal, a., & bray, f. (2021). global cancer statistics 2020: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: a cancer journal for clinicians, 71(3), 209–249. https://doi.org/10.3322/caac.21660 suwankhong, d., & liamputtong, p. (2018). physical and emotional experiences of chemotherapy: a qualitative study among women with breast cancer in southern thailand. asian pacific journal of cancer prevention, 19(2), 521–528. https://doi.org/10.22034/apjcp.2018.19.2.521 tamulee, p. (2013). social support system in cancer care: understanding dynamics of women patients. international journal of scientific and research publications, 3(1), 2250–3153. tong, a., flemming, k., mcinnes, e., oliver, s., & craig, j. (2012). enhancing transparency in reporting the synthesis of qualitative research: entreq. bmc medical research methodology, 12(figure 1), 1–8. https://doi.org/10.1186/1471-2288-12-181 vogl, s., schmidt, e. m., & zartler, u. (2019). triangulating perspectives: ontology and epistemology in the analysis of qualitative multiple perspective interviews. international journal of social research methodology, 22(6), 611–624. https://doi.org/10.1080/13645579.2019.1630901 wabula, i., yunitasari, e., & wahyudi, a. s. (2020). supportive care needs of women with breast cancer: a systematic review. jurnal ners, 15(1sp), 142–148. https://doi.org/10.20473/jn.v15i1sp.18999 wampaalu, p. b., eriksson, l. e., naamala, a., nabirye, r. c., & wettergren, l. (2016). experiences of patients undergoing chemotherapy a qualitative study of adults attending uganda cancer institute. african health sciences, 16(3), 744–749. https://doi.org/10.4314/ahs.v16i3.14 wang, c. (2022). analysis of how sex education in asia is expressed in the media. proceedings of the 2021 international conference on public art and human development ( icpahd 2021), 638, 951– 954. https://doi.org/10.2991/assehr.k.220110.180 webb, m. e., murray, e., younger, z. w., goodfellow, h., & ross, j. (2021). the supportive care needs of cancer patients: a systematic review. journal of cancer education, 36(5), 899–908. https://doi.org/10.1007/s13187-020-01941-9 world health organization (who). (2020). who report on cancer. world health organization (who). ziegler, e., hill, j., lieske, b., klein, j., dem, o. von, & kofahl, c. (2022). empowerment in cancer patients: does peer support make a difference? a systematic review. psycho-oncology, 31(5), 683– 704. https://doi.org/10.1002/pon.5869. how to cite this article: a’la, m. z., and nuntaboot, k. (2023) ‘exploring the supportive care needs for people with cancer undergoing chemotherapy: a qualitative descriptive study’, jurnal ners, 18(1), pp. 31-39. doi: http://dx.doi.org/10.20473/jn.v18i1.41837 pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru peer group support meningkatkan respon penerimaan psikologis pegawai menghadapi masa persiapan pensiun (mpp) (peer group support increase psychological responses changes from public servant in retirement preparation phase) nursalam*, ferry efendi*, ulfa husnul fata* * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: nursalam_psik@yahoo.com abstract introduction :retirement is separation process of individual from their work that is being paid from their position or occupation. retirement may change psychological responses. the aimed of this study was to analyze the influence of peer group support in psychological responses changes from public servant in retirement preparation phase. method : this study was used an quasy experimental pre-post test purposive sampling design. population were 18 respondents who will retire on 2009 and 2010 in mardiwaluyo general hospital blitar. sample were 16 respondents divided into 8 respondents each for treatment and control group. the independent variable was peer group support and dependent variable was psychological responses. data were collected by using questionnaire before and after peer group support intervention. data then analyzed by using mann whitney u test and wilcoxon signed rank test with significance level α≤0.05. result: the result showed that peer group support didn’t have an influenced in denial respons (p=0.301), anger respons (p=0.317), bargaining respons (p=0.079) and depression respons (p=0.300). otherwise peer group support have an influenced in acceptance respons (p=0.049). discussion: the result of this study has enlightened the important of retirement preparation phase to provide positive psychological responses. further studies are recommended to extend this recearch with considering biological and spiritual responses. keywords: peer group support, retire, psychological responses pendahuluan pensiun merupakan keadaan dimana seseorang tidak bekerja lagi karena masa tugas sudah berakhir (depdiknas, 2005). batas usia pensiun merupakan batas usia pegawai negeri sipil harus diberhentikan sebagai pegawai negeri sipil yaitu usia 56 tahun (pp ri no 32 tahun 1979). seseorang yang merasa pekerjaannya sebagai hidup dan identitas diri, maka mereka akan merasa kehilangan saat pensiun tiba (danko, 2002). pensiun seharusnya membuat orang senang karena dapat menikmati hari tua, namun banyak orang bingung bahkan cemas ketika akan menghadapi pensiun. memasuki masa pensiun, seseorang akan kehilangan peran sosial di masyarakat, prestige, kekuasaan, kontak sosial, bahkan harga diri akan mengalami perubahan karena kehilangan peran (eliana, 2003). dukungan sosial merupakan suatu jaringan keluarga, teman, rekan kerja dan kenalan lain untuk memberikan masukan pada saat terjadi krisis (mayoclinic, 2005). peer group support merupakan media yang memungkinkan seseorang melakukan interaksi sosial dan mendapatkan dukungan dari orang lain (wikipedia, 2006). di indonesia, khususnya rumah sakit daerah mardiwaluyo kota blitar, metode peer group support maupun berbagai kegiatan yang melibatkan para pensiunan belum pernah dilakukan. jumlah pegawai di rumah sakit daerah (rsd) mardiwaluyo kota blitar pada tahun 2008 tercatat 409 orang dengan jumlah pegawai yang pensiun tercatat 9 orang atau sekitar 2,07% dari total pegawai (2 orang pindah rumah). respons psikologis yang didapatkan antara lain: 100% respons penyangkalan adaptif, 100% respons marah adaptif, 83,7% respons tawar menawar adaptif, 100% respons depresi adaptif dan 83,3% respons penerimaan adaptif. faktor risiko yang paling utama yang dialami pekerja tua atau usia 50 tahun berhubungan dengan tekanan pekerjaan yang menghadapi masa tua adalah perilaku maladaptif (seperti mabuk berlebihan, berjudi, perilaku yang tidak baik seperti menembak atau melakukan kekerasan terhadap orang lain, penyalahgunaan alkohol dan perilaku agresif) (gershon, lin and li xian, 2002). holmes dan rahe (1967) dalam eliana (2003) menyatakan bahwa pensiun menempati rangking 10 besar untuk posisi penyebab stres. hasil penelitian universitas michigan yang meneliti para pensiunan menunjukkan bahwa sebanyak 75% pekerja yang mempersiapkan masa pensiun akan menikmati masa pensiun dengan lebih bahagia dibandingkan 25% lainnya yang tidak mempersiapkan masa pensiun (sutarto dan ismulcokro, 2008). bagi mereka yang memiliki persiapan, masa pensiun justru menjadi masa paling bahagia dalam menikmati hidup (eliana, 2003). bagi para pensiunan yang tidak memiliki persiapan yang matang, tidak menutup kemungkinan akan mengalami tekanan psikologis. tekanan psikologis diawali sebagai akibat dari post power syndrome (pps) atau sindrom hilangnya kekuatan. apabila dibiarkan berlarut-larut, tekanan psikologis tersebut bertambah berat dan dapat menyebabkan ganguan jiwa (sutarto dan ismulcokro, 2008). masa pensiun dapat menimbulkan masalah karena tidak semua orang siap menghadapinya. pensiun akan memutuskan seseorang dari kegiatan rutin yang telah dilakukan selama bertahun-tahun, memutuskan rantai sosial yang sudah terbina dengan rekan kerja dan yang paling vital adalah menghilangkan identitas seseorang yang sudah melekat begitu lama (offord, 1992 dalam eliana, 2003). memasuki masa pensiun seseorang kehilangan pekerjaan, status sosial, fasilitas, materi, anak-anak sudah besar dan pergi dari rumah. teman dan relasi tidak lagi mengunjungi dan berakhir dalam kesepian. seseorang yang memasuki masa pensiun sering kali merasa malu karena menganggap diri sebagai pengangguran sehingga menimbulkan perasaan minder, rasa tidak berguna, tidak dikehendaki, dilupakan, tersisihkan, tanpa tempat berpijak dan seperti tanpa rumah. sumber daya psikologis merupakan kepribadian dan kemampuan individu dalam menghadapi stres yang disebabkan situasi dan lingkungan (pearlin dan schooler, 1978 dalam nursalam dan kurniawati, 2007). dukungan sosial terdiri atas informasi atau nasihat verbal dan atau nonverbal, bantuan nyata atau tindakan yang diberikan melalui kedekatan sosial (gottlieb, 1983 dikutip smet, 1994 dalam nursalam dan kurniawati, 2007). berdasarkan penelitian gitawati (2007), peer group support mempunyai pengaruh tehadap harga diri lanjut usia (lansia). peer group support merupakan salah satu terapi kelompok yang memberikan kesempatan pada lansia untuk mendapatkan dukungan yang saling menguntungkan dan suatu bantuan yang dapat menolong lansia menghadapi stres dalam beradaptasi dengan penurunan kekuatan. anggota kelompok memberikan dukungan saat terjadi masalah dan memiliki kesempatan untuk membantu satu sama lain (kapplan and saddock, 1997 dalam gitawati, 2007). bahan dan metode design yang digunakan pada penelitian ini adalah quasy experimental (pre-post test). populasi penelitian ini adalah semua pegawai yang akan pensiun tahun 2009 dan tahun 2010 di rsd mardiwaluyo kota blitar sebanyak 18 orang. subyek dalam penelitian ini adalah pegawai yang akan pensiun tahun 2009 dan tahun 2010 di rsd mardiwaluyo kota blitar dan bersedia menjadi responden dengan besar sampel 16 responden yang ditentukan menggunakan tehnik purposive sampling. sampel tersebut dibagi menjadi kelompok kontrol dan kelompok perlakuan masing-masing dengan 8 sampel. penelitian ini dilakukan pada bulan november 2008 sampai dengan januari 2009. variabel independen penelitian ini adalah peer group support, dan variabel dependen adalah respons psikologis. data respons psikologis diperoleh dengan menggunakan kuesioner yang diberikan nursalam sebelum dan sesudah tindakan peer group support dilakukan. kuesioner respons psikologis terdiri dari fase pengingkaran (denial), kemarahan (anger), tawar-menawar (bergaining), depresi (depression) dan penerimaan (acceptence) merupakan modifikasi dari kuesioner respons psikologis kubler ross (1969 dalam nursalam dan kurniawati, 2007). data dianalisis menggunakan uji statistik wilcoxon signed rank test dan mann whitney u test dengan derajat kemaknaan α<0,05. peneliti mempergunakan metode content analyze untuk memperkuat hasil yang diperoleh. hasil hasil penelitian menunjukkan bahwa respons psikologis responden berada dalam kategori adaptif dan terjadi perubahan yang tidak signifikan pada masing-masing fase dari respons psikologis (gambar 1). kelompok perlakuan untuk respons penyangkalan menunjukkan kategori adaptif baik sebelum maupun sesudah diberikan perlakuan peer group support. perubahan respons penyangkalan ditunjukkan dengan rerata 31,2% (sebelum perlakuan) menjadi 30% (sesudah perlakuan). analisis data menggunakan uji wilcoxon signed ranks test didapatkan nilai signifikansi p=0,465, yang berarti tidak ada perubahan respons penyangkalan sebelum dan sesudah perlakuan. hasil lain menunjukkan tidak terdapat perbedaan respons penyangkalan pada kelompok perlakuan dan kelompok kontrol dengan hasil analisis statistik mann whitney u test p=0,301 (tabel 1). analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif adalah jawaban dari pertanyaan: bagaimana perasaan anda setelah mengetahui bahwa anda akan pensiun? sebelum intervensi responden menjawab: “biasa saja mas, insya allah ya siap, waktunya pensiun ya pensiun, siap tidak siap ya harus siap” (a1) sesudah intervensi responden menjawab: “perasaan saya lebih baik, saya lebih siap menghadapi masa pensiun” (a1) kelompok perlakuan untuk respons marah menunjukkan kategori adaptif baik sebelum maupun sesudah diberikan perlakuan peer group support. perubahan respons marah ditunjukkan dengan rerata 25,6% (sebelum perlakuan) menjadi 26,8% (sesudah perlakuan). analisis data menggunakan uji wilcoxon signed ranks test didapatkan nilai signifikansi p=0,655, berarti tidak ada perubahan respons marah sebelum dan sesudah perlakuan. hasil lain menunjukkan tidak terdapat perbedaan respons marah kelompok perlakuan dan kelompok kontrol dengan hasil analisis statistik mann whitney u test p=0,317 (tabel 2). analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif adalah jawaban dari pertanyaan: menurut anda, karena salah siapa anda pensiun? berikut adalah kutipan jawaban salah satu responden sebelum intervensi: “pensiun ya bukan salah salah siapasiapa, masak mau menyalahkan orang lain?“ (a5) sesudah intervensi responden menjawab: “kalau pensiun ya bukan salah siapasiapa, khan memang sudah waktunya” (a5) kelompok perlakuan untuk respons tawar-menawar menunjukkan kategori adaptif baik sebelum maupun sesudah diberikan perlakuan peer group support. perubahan respons tawar-menawar ditunjukkan dengan rerata 38,1% (sebelum perlakuan) menjadi 28,1% (sesudah perlakuan). analisis data dengan menggunakan uji wilcoxon signed ranks test didapatkan nilai signifikansi p=0,068, berarti tidak ada perubahan respons tawarmenawar sebelum dan sesudah perlakuan. hasil lain menunjukkan tidak terdapat perbedaan respons tawar-menawar pada kelompok perlakuan dan kelompok kontrol dengan analisis statistik mann whitney u test p=0,079 (tabel 3). analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif adalah jawaban dari pertanyaan: seandainya anda tidak pensiun, apa yang akan anda lakukan? jawaban responden sebelum intervensi: “apa iya.....? khan sudah waktunya pensiun, tentunya saya akan bekerja lebih baik lagi” (a1) nursalam sesudah intervensi jawaban responden: “kalau tidak pensiun ya saya akan bekerja lagi, lebih giat lagi” (a1) kelompok perlakuan untuk respons depresi menunjukkan kategori adaptif baik sebelum maupun sesudah diberikan perlakuan peer group support. perubahan respons depresi ditunjukkan dengan rerata 35% (sebelum perlakuan) menjadi 27,9% (sesudah perlakuan). analisis data dengan menggunakan uji wilcoxon signed ranks test didapatkan nilai dengan signifikansi p=0,128, berarti tidak ada perubahan respons depresi sebelum dan sesudah perlakuan. hasil lain menunjukkan tidak terdapat perbedaan respons depresi pada kelompok perlakuan dan kelompok kontrol dengan hasil analisis statistik mann whitney u test p=0,300 (tabel 4). analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif adalah jawaban dari pertanyaan: bagaimana tanggapan anda terhadap pensiun yang anda alami? jawaban responden sebelum intervensi: “pensiun biasa-biasa saja” (a6) jawaban sesudah intervensi: “kalau pensiun ya biasa saja, tidak ada masalah” (a6) kelompok perlakuan untuk respons penerimaan menunjukkan kategori adaptif baik sebelum maupun sesudah diberikan perlakuan peer group support. perubahan respons penerimaan ditunjukkan dengan rerata 41,25% (sebelum perlakuan) menjadi 52,5% (sesudah perlakuan). analisis data menggunakan uji wilcoxon signed ranks test didapatkan nilai dengan signifikansi p=0,798, yang berarti tidak ada perubahan respons penerimaan sebelum dan sesudah perlakuan. hasil lain menunjukkan tidak terdapat perbedaan respons penerimaan pada kelompok perlakuan dan kelompok kontrol dengan hasil analisis statistik mann whitney u test p=0,049 (tabel 5). analisis isi (content analysis) dari hasil wawancara yang memperkuat hasil data kuantitatif adalah jawaban dari pertanyaan: apakah anda bisa menerima pensiun anda saat ini? jawaban sebelum intervensi: “saya agak sedih karena saya akan kehilangan pekerjaan dan pendapatan saya berkurang” (a3) jawaban sesudah mendapat intervensi: “yah namanya saja sudah pensiun, saya ya harus menerima” (a3) pembahasan hasil penelitian menunjukkan tidak ada perubahan yang signifikan pada masingmasing fase dalam respons psikologis (penyangkalan, marah, tawar-menawar, depresi dan penerimaan). respons penerimaan menunjukkan perbedaan yang signifikan antara kelompok perlakuan dan kelompok kontrol, berarti peer group support dapat meningkatkan respons psikologis (respons penerimaan dibandingkan dengan kelompok yang tidak terlibat peer group support. mayoritas reponden baik setelah maupun sebelum dilakukan peer group support tidak menunjukkan respons penyangkalan terhadap datangnya masa pensiun. kenyataannya pada hasil analisis didapatkan responden tidak menunjukkan respons penyangkalan. hal ini terjadi karena mayoritas responden memang telah mempunyai persiapan dalam menghadapi masa pensiun, sehingga mereka tidak mengalami respons penyangkalan menjelang masa pensiun. adanya masa persiapan pensiun (mpp) memungkinkan responden beradaptasi menjelang kehilangan (pekerjaan). menyangkal merupakan mekanisme pertahanan individu di mana seseorang menghadapi fakta yang sangat tidak nyaman untuk diterima dan cenderung untuk menolak (davidhizar et al., 1998). pada tahap ini seseorang tidak mampu berpikir apa yang seharusnya dia lakukan untuk keluar dari masalah. masa persiapan pensiun (mpp) memfasilitasi lanjut usia agar lebih mudah beradaptasi ketika menghadapi fase pensiun. oleh karena itu untuk selanjutnya perlu diidentifikasi dampak kehilangan (pensiun) yang lainnya seperti post power syndrom dan lain-lain terhadap respons penyangkalan. nursalam respons marah pada kelompok kontrol dan perlakuan tidak menunjukkan perbedaan yang signifikan sesudah diberikan tindakan peer group support. hal ini dimungkinkan karena adanya rasa kebersamaan yang sudah terbentuk secara kolektif. faktor lain yang memungkinkan tidak berpengaruhnya peer group support terhadap perubahan respons marah adalah faktor pertemuan dalam kegiatan peer group support yang seharusnya dilaksanakan minimal tiga kali pertemuan, namun dalam pelaksanaannya hanya dilaksanakan dalam satu kali pertemuan, sehingga didapatkan hasil yang kurang maksimal. peer group support memungkinkan seseorang yang mengalami masalah akan bisa menerima masalah tersebut. pada umumnya seseorang yang akan dan sedang mengalami kehilangan yang tidak dapat melewati fase penyangkalan atau penyangkalan, akan jatuh pada fase berikut yaitu marah. marah dapat dipandang sebagai keadaan emosi yang dirasakan oleh manusia dalam rentang hidupnya yang berfungsi untuk pertahanan. marah dapat mendorong mekanisme psikologis untuk melakukan tindakan yang bersifat evaluasi diri (kemp, 1995). terlewatinya fase marah dapat disebabkan oleh dua faktor yaitu terlewatinya fase pengingkaran secara asertif dan menuju fase marah dan fase penyangkalan yang maladaptif yang berlanjut pada fase marah. kehilangan adalah suatu keadaan ketika individu berpisah dengan sesuatu yang sebelumnya ada atau dimiliki, baik sebagian atau keseluruhan (suliswati et al., 2005). setiap orang yang akan atau sedang mengalami kehilangan menunjukkan respons psikologis yang secara umum sama. secara hirarki fase kehilangan akan saling berhubungan antara fase satu dengan fase berikutnya, ketika fase penolakan dan marah terlewati seseorang akan jatuh pada fase tawar-menawar. kubler-ross (1969) dalam potter dan perry (2005) menyatakan bahwa dalam tahap tawar-menawar terjadi penundaan kehilangan. individu mungkin berupaya untuk membuat perjanjian dengan cara yang halus atau jelas untuk mencegah kehilangan. teori kepribadian dalam tawarmenawar menekankan bahwa jenis-jenis kepribadian menentukan proses tawarmenawar dan hasil. pada analisis didapatkan bahwa tidak ada perbedaan respon tawarmenawar sebelum dan sesudah peer group support. hal tersebut dapat disebabkan karena mayoritas responden menerima datangnya masa pensiun, sehingga individu tidak melawan kehilangan (pekerjaan) tersebut. mayoritas responden sudah memikirkan kegiatan apa yang akan dilakukan untuk mengisi masa pensiun. responden juga tidak terbebani oleh masa pensiun yang segera datang. berbagai faktor yang menyebabkan para pegawai tidak menunjukkan fase tawar-menawar pada masa menjelang pensiun, antara lain adanya tukar pendapat dalam kehidupan sehari-hari, status ekonomi yang sudah mapan dan penerimaan keluarga serta tingkat partisipatif di masyaraat. hasil penelitian juga menunjukkan bahwa peer group support tidak berpengaruh terhadap respons psikologis depresi. kublerross (1969) dalam potter dan perry (2005) menyatakan bahwa tahap depresi terjadi ketika kehilangan disadari dan timbul dampak nyata dari makna kehilangan tersebut, realitas dan sifat ketetapan dari kehilangan telah dikenali dan dirasa sangat menyakitkan dan mengecewakan. seseorang merasa terlalu sangat kesepian dan menarik diri. tetapi tahap depresi memberi kesempatan untuk berupaya melewati kehilangan dan mulai memecahkan masalah. goodman (1999 dalam nurachmah, 1999) menyatakan bahwa kelompok pendukung berfungsi sebagai kelompok pengobat sejawat (peer therapy group/peer group support), tukar pendapat antar sejawat yang mempunyai masalah yang sama cukup efektif dalam mengatasi dampak masalah terutama masalah psikologis dan sosial. sumber daya psikologis merupakan kepribadian dan kemampuan individu dalam memanfaatkannya menghadapi stress yang disebabkan situasi dan lingkungan (pearlin dan schooler, 1978 dalam nursalam dan kurniawati, 2007). hal ini sesuai dengan pernyataan kubbler ross (1998) dalam potter dan perry (2005) bahwa seseorang yang mampu memahami atau memaknai tidak akan mengalami kesulitan dalam mengungkapkan penyebab depresi dan meredakan perasaan bersalah atau malu yang tidak realistis yang menyertai depresi. peer group support dapat memberikan dukungan kepada kelompok sebaya, menumbuhkan rasa optimisme dan menumbuhkan pikiran positif dalam menghadapi suatu permasalahan. hal ini memungkinkan seseorang tetap produktif secara psikologis dan sosial setelah pensiun. kegiatan ini dapat menjadi wadah untuk berdiskusi, memecahkan atau mencari solusi dari suatu permasalahan yang dihadapi. disamping itu, mayoritas responden berstatus menikah. hal ini menyebabkan responden masih memiliki tempat untuk berbagi dengan orang yang disayangi, merasa masih ada teman atau pendamping yang sangat dekat. faktor inilah yang menyebabkan responden tidak mengalami depresi walaupun terjadi kehilangan (pekerjaan). fase terakhir yang menentukan seseorang jatuh pada exshaution distress atau eustress terhadap kehilangan adalah fase penerimaan akan kehilangan yang dihadapi. individu menerima kehilangan dan mulai merencanakan untuk mengatasi hal tersebut. reaksi fisiologis menurun dan interaksi sosial berlanjut. individu mulai berbagi perasaan tentang kehilangan, mengenang kejadian masa lalu dan hidup mulai menjadi stabil. pada analisis didapatkan bahwa tidak ada pengaruh yang bermakna sebelum dan sesudah peer group support terhadap respons penerimaan. penerimaan merupakan kondisi atau situasi yang dialami oleh seseorang (sering situasi yang tidak nyaman atau negatif tanpa suatu usaha untuk merubah, menyangkal atau mencari solusi). seseorang menentukan untuk mengambil tindakan apapun dalam melawan situasi yang dirasakan pada fase ini (friedman & james, 2008). gitawati (2007) menyatakan bahwa peer group support mempunyai pengaruh pada harga diri lanjut usia (lansia). hasil penelitian menunjukkan tidak ada perbedaan sebelum dan sesudah peer group support terhadap respons penerimaan, namun terdapat perbedaan antara kelompok yang melakukan peer group support dengan kelompok yang tidak melakukan. hal ini disebabkan karena pegawai sudah saling beradaptasi menjelang pensiun. respons penerimaan yang positif dikarenakan responden menerima datangnya masa pensiun dengan persiapan yang matang dan juga telah melewati fase psikologis secara adaptif. tabel 1. respons psikologis penyangkalan (denial) pegawai pada masa persiapan pensiun di rsd mardiwaluyo kota blitar, desember 2008 sampai dengan januari 2009. perlakuan kontrol skor (%) skor (%) pre post pre post mean 31,25 30 41,88 37,50 sd 14,14 25,91 28,28 25,91 hasil analisis statistik wilcoxon signed ranks test (p=0,465) wilcoxon signed ranks test (p=0,655) mann whitney u test (p=0,301) tabel 2. respons psikologis marah (anger) pegawai pada masa persiapan pensiun di rsd mardiwaluyo kota blitar, pada desember 2008 sampai dengan januari 2009. perlakuan kontrol skor (%) skor (%) pre post pre post mean 25,63 26,88 26,25 25 sd 1,77 5,30 3,54 0,00 hasil analisis statistik wilcoxon signed ranks test (p=0,655) wilcoxon signed ranks test (p=0,317) mann whitney u test (p=0,317) nursalam tabel 3. respons psikologis tawar-menawar (bargaining) pegawai pada masa persiapan pensiun di rsd mardiwaluyo kota blitar, pada desember 2008 sampai dengan januari 2009. perlakuan kontrol skor (%) skor (%) pre post pre post mean 38,13 28,13 40,63 37,50 sd 15,10 8,84 17,27 12,25 hasil analisis statistik wilcoxon signed ranks test (p=0,068) wilcoxon signed ranks test (p=0,593) mann whitney u test (p=0,079) tabel 4. respons psikologis depresi (depression) pegawai pada masa persiapan pensiun di rsd mardiwaluyo kota blitar, pada desember 2008 sampai dengan januari 2009. perlakuan kontrol skor (%) skor (%) pre post pre post mean 35,05 27,98 39,03 26,79 sd 8,61 8,42 14,94 8,74 hasil analisis statistik wilcoxon signed ranks test (p=0,128) wilcoxon signed ranks test (p=0,138) mann whitney u test (p=0,300) tabel 5. respons psikologis penerimaan (acceptance) pegawai pada masa persiapan pensiun di rsd mardiwaluyo kota blitar, pada desember 2008 sampai dengan januari 2009. perlakuan kontrol skor (%) skor (%) pre post pre post mean 41,25 52,50 58,75 62,50 sd 8,35 8,84 16,64 21,21 hasil analisis statistik wilcoxon signed ranks test (p=0,798) wilcoxon signed ranks test (p=0,734) mann whitney u test (p=0,049) keterangan: 76-100% = maladaptif 56-75% = menuju maladaptif <56% = adaptif p = derajat kemaknaan sd = standar deviasi mean = rerata simpulan dan saran simpulan kegiatan peer group support berperan dalam perubahan respons psikologis yang ditunjukkan pada respons penerimaan pegawai dalam menghadapi masa persiapan pensiun (mpp). saran peneliti menyarankan supaya kegiatan peer group support dilakukan dapat dijadikan salah satu kegiatan di instansi rumah sakit sebagai pembekalan psikologis kepada pegawai dalam mempersiapkan masa pensiun, hasil penelitian ini dapat dijadikan sebagai informasi dan referensi serta dapat diaplikasikan dalam bentuk ceramah atau diskusi bersama untuk mencegah dampak dari kehilangan dalam menghadapi masa pensiun dan kegiatan peer group support dapat dijadikan sebagai teknik baru dalam memberikan asuhan keperawatan khususnya pada lansia yang mengalami kehilangan dan berduka pada fase masa persiapan pensiun (mpp). kepustakaan danko, j.m. 2002. effect of retirement on family relatianship and health, (online), (http://www.serpage.umbc.edu., diakses tanggal 10 oktober 2008, jam 22.15 wib). davidhizar, r. et al. 1998. the journal of geriatrical nursing, 48(2), 4-10. depdiknas. 2005. kamus besar bahasa indonesia, edisi ketiga, jakarta: balai pustaka, hlm. 850. eliana, r. 2003. konsep diri pensiunan, (online), (http://www.library.usu.ac.id., diakses tanggal 2 nopember 2008, jam 11.42 wib). friedman, r. and james, j.w. 2008. the myth of the stages of dying, death and grief. skeptic magazine, 14(2). gershon, r.r.m., lin, s., and li, x. 2002. work stress in aging police officers. journal of occupational and environmental medicine, (online), (http://www.joem.org., diakses tanggal 10 desember 2008, jam 13.30 wib). gitawati, d.s. 2007. pengaruh peer group support terhadap harga diri manula di panti sosial tresna werdha waluyo husodo tulungagung. skripsi tidak dipublikasikan. surabaya: program studi keperawatan fakultas keperwatan universitas airlangga. google search. hubungan kecerdasan emosi dengan kecemasan menghadapi pensiun pada pegawai, (online), (http://www.skripsitesis.com.htm., diakses tanggal 28 oktober 2008, jam 21.18 wib). sutarto, t.j. dan ismulcokro, c. 2008. pensiun bukan akhir segalanya. jakarta: gramedia pustaka utama, hlm. 11. kemp, s.k.t.s. 1995. anger theory and management a historical analysis. the american journal of psychology, 108 (3), 417-497. mayoclinique staff. 2005. depression, (online), (http://www.kidshealth.org/., diakses tanggal 22 november 2008, jam 23.00 wib). nurachmah, e. 1999. jurnal keperawatan indonesia ii, hlm. 189-194. nursalam dan kurniawati, n.d. 2007. asuhan keperawatan pada pasien dengan hiv/aids. jakarta: salemba medika, hlm. 15-16, 28-29. potter dan perry, 2005. buku ajar fundamental keperawatan konsep, proses dan praktik. edisi 4. jakarta: egc, hlm. 482, pp 585-587, 590. suliswati, et al. 2005. konsep dasar keperawatan kesehatan jiwa, jakarta: egc, hlm. 123-125. wikipedia. 2006. peer support, (online), (http://wikipedia.org/wiki/peer_suppor t., diakses tanggal 10 oktober 2008, jam 22.13 wib). http://www.serpage.umbc.edu/ http://www.library.usu.ac.id/ http://www.joem.org/ http://www.skripsi-tesis.com.htm/ http://www.skripsi-tesis.com.htm/ http://www.kidshealth.org/ http://wikipedia.org/wiki/peer_support http://wikipedia.org/wiki/peer_support authors index volume 18 nomor 1 march 2023 amir, heriyana, 16 nuntaboot, khanitta, 41 ardi, bangun mukti, 9 oducado, ryan michael flores, 26 arief, yuni sufiyanti, 3, 9 oktariza, rury t., 80 bistara, difran nobel, 71 olarte, princess mae`, 26 chan, chong mei, 1 palma, danish danielle, 26 chuang, yeu-hui, 71 pamungkas, akhmad yanuar fahmi, 88 desfiani, yofita refvinda, 64 pradana, krisnawan a., 80 fitryasari, rizki, 3 pramesti, dewita, 3 gusty, reni prima, 35 pranata, satriya, 71 has, eka mishbahatul mar’ah, 50 prawira, ricky, 101 heltty, heltty, 57 purwantari, kusuma e., 80 ismail, rifky, 101 rachmawati, praba diyan, 3 ismail, suhartini, 101 rahmawan, dzanuar, 80 johan, andrew, 101 rithpho, pratuma, 9 kalajanti, viskasari p., 80 sonontiko, essy, 88 krisnana, ilya, 9 sutawardana, jon hafan, 64 kurnia, iqlima dwi, 9 suwito, bambang e., 80 lee, bih-o, 16 thomas, deena clare, 3 liang, shu-yuan, 71 tonapa, santo imanuel, 16 lu, kuo-cheng, 71 triharini, mira, 50 mahardika, dwiky rizal, 88 veralia, veralia, 35 malini, hema, 35 visuddho, visuddho, 80 molanida, joshua eugene, 26 wahjudi, mariana, 80 mulyadi, mulyadi, 16 wang, tsae-jyy tiffany, 71 nastiti, aria aulia, 9 widayati, nur, 64 nawangsasi, peppy, 80 wilujeng, atik pramesti, 88 neyra, tisha jane amar, 26 wu, shu-fang vivienne, 71 nofita, gita, 50 zahalim, zahalim, 57 norada, paolo miguel, 26 nuntaboot, khanitta, 41 subject index volume 18 nomor 1 march 2023 a i activities of daily living; 57 illness representations; 16 addiction; 9 m adolescent; 3; 9 maternal health; 50 anemia; 50 maternity nursing; 50 b mental health; 3 blood glucose; 71 mental health; 9 blood pressure; 35 migrant workers; 3 c mild traumatic brain injury; 16 comfort; 35 n competence; 26 nursing skills; 26 conflict interaction; 9 nursing students; 26 coping strategies; 3 nursing; 16 covid-19 prevention behavior; 64 p covid-19; 88 pandemic; 26 d people with cancer; 41 diabetes distress; 71 personalize; 71 diabetes mellitus; 80 philippines; 26 diabetes; 71 physical activity; 35 f post-vaccination; 64 family support; 3 q fitness; 80 qualitative study; 41 functional independence; 57 r g resilience; 57 gaba; 80 s game online; 9 serotonin; 80 h stroke; 57 health belief model; 50 supportive care needs; 41 health literacy; 64 systematic review; 16 health promotion; 50 health risk; 80 healthcare service system; 41 holistic nursing care; 88 hypertension; 35 1 | author information pack march, 2022 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health related professions. jurnal ners is a scientific peer-reviewed nursing journal that is published biannually (april and october) by the faculty of nursing universitas airlangga, 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(hons), (scopus id: 56660628500); faculty of nursing, universitas airlangga, indonesia editor-in-chief: ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100); faculty of nursing, universitas airlangga, indonesia please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. author information pack update: march 2022 https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://suggestor.step.scopus.com/progresstracker/index.cfm?trackingid=b5f9e2c037ae75e9 https://drive.google.com/file/d/1gsa2j87z4weyeqlkf0w_bdqjkkd95q-y/view?usp=sharing https://drive.google.com/open?id=1xmj6hqvbhpeiqaubnh681o-zny94zyry javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/454') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/509') 2 | author information pack march, 2022 advisory international editorial boards: 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, bns., msc., p.hd., (scopus id: 8293647300); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172); college of nursing, university of the philippines manila, philippines 5. dr. david pickles, (scopus id: 57190150026); college of nursing & health sciences, flinders university, south australia, australia 6. dr. farhan alshammari, (scopus id: 57192298773); college of nursing, university of hail, saudi arabia 7. dr. chong mei chan, scm, bnsc, msc, phd, (scopus id: 57189591887); dept. of nursing faculty of health science, university of malaya, malaysia 8. dr. sonia reisenhofer, (scopus id: 16310818100); school of nursing and midwifery, la trobe university, australia, australia 9. assistant professor pei-lun hsieh, (scopus id: 57190748913); department of nursing, college of health, national taichung university of science and technology, taiwan editor 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100); faculty of nursing, universitas airlangga, indonesia 2. prof. dr ah yusuf, s.kp.m.kes, (scopus id: 57200914632); faculty of nursing universitas airlangga indonesia 3. yulis setiya dewi, s.kep.ns., m.ng., (scopus id: ); faculty of nursing universitas airlangga 4. dr. esti yunitasari, s. kp., m. kes., (scopus id: 57204561035); faculty of nursing, universitas airlangga, surabaya., indonesia 5. dr. rizki fitryasari, s. kep., ns., m. kep., (scopus id: 57200912279); faculty of nursing, universitas airlangga, surabaya, indonesia 6. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756); faculty of nursing, universitas airlangga, indonesia, indonesia 7. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 8. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); (web of science researcherid x1131-2019), faculty of nursing, universitas airlangga, indonesia 9. laily hidayati, s.kep., ns., m.kep., (scopus id: 57202743375); faculty of nursing, universitas airlangga, indonesia assistant editor: rifky octavia pradipta, s.kep., ns., m.kep, (scopus id : 57216705839); faculty of nursing, universitas airlangga, indonesia quality control editor: gading ekapuja aurizki, s.kep., ns., m.sc. 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stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on a priori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and meta-analyses will be dealt with as original articles are, as far as the editorial process is concerned. ethics in publication this journal follows the committee of publication ethics (cope) guidelines and requests authors to familarise themselves with these guidelines at: http://publicationethics.org/resources/guidelines. a few issues that authors need to pay particular attention to are set out below. it is ethically questionable to break up or segment data from a single study to create different papers for publication, a practice called salami slicinga. if the authors have legitimate reasons for reporting separately on different parts of the same study, or the same data set, they should justify that to the editor at the time of submission. equally, readers need to be aware that different aspects of the same study are being reported, thus the methods section of the submitted manuscript must clearly explain why the submitted paper is justified. double-blind peer review process the decision to publish a paper is based on an editorial assessment and peer review. initially, all papers are assessed by an editorial committee consisting of members of the editorial team. the prime purpose is to decide whether to send a paper for peer review and to give a rapid decision on those that are not. the rejection is based on the novelty or the relevancy with the scope of this journal. http://e-journal.unair.ac.id/index.php/jners http://publicationethics.org/resources/guidelines 4 | author information pack march, 2022 initial editorial assessment jurnal ners is eager to provide a rapid publication process through an initial assessment conducted by an editorial committee consisting of the editorial team members. the primary purpose is to decide whether to send the paper for peer-review or to reject it. the main point is scope, compliance with the guideline, and language. sometimes a paper will be returned to the author with a request for revisions with the purpose to help editors in deciding whether or not to send it out for review. authors may expect the decision of the initial editorial assessment from this stage of the review process within 1-2 weeks of submission. review process after passing the initial editorial assessment, the article will be sent to peer -reviewers. the peer-review process involved at least two reviewers for each manuscript selected based on their expertise. all reviewing process is done by the double-blind review, which means the authors and peer-reviewers do not know each other’s identity. the reviewers should complete the review within three weeks in each reviewing round after the review request was sent. decision-making process the decision to accept for publication is based on the peer reviewer's recommendations, based on which two acceptance recommendations are required. if there is a difference in the two reviewers’ recommendations, the editor has the right to seek the third reviewer's consideration. the final decision to publish is made by the editor-in-chief, editorial committee (national or international advisory board) by considering the advice from reviewers. review criteria each paper that the editor/s assess as suitable for peer review is allocated to two reviewers who are asked to assess the paper against one of the journal's three sets of reviewing criteria: articles submitted for review must be original works, and may not be submitted for review elsewhere whilst under review for the journal. after review, the editor-in-chief will inform the corresponding author on whether the paper has been accepted, rejected, or needs revision. categories of decision accept minor revisions (accept with revisions as advised by editors) major revisions (possible acceptance following major revision and resubmission) reject all efforts are made to provide fair and thorough reviews as speedily as possible. if an author(s) believes that a manuscript has been wrongly rejected, a detailed appeal letter that responds point-by-point to the reviewers' comments should be sent to the editor who, after having reviewed the referees' reports, will make the fina l decision. reviewed by editor-in-chief or editorial team only letter to the editor or a short comment on any topic of current interest for these types of submissions, the corresponding author will receive a fairly rapid decision on publication. language please write your text in good english (british or american or other english style usage is accepted). authors who feel their english language manuscript may require editing to eliminate possible grammatical or spelling errors and to conform to correct scientific english may wish to use the english language editing service. after receiving acceptance decision, author must send the manuscript to proofreaders that has been provide by editor through this link https://forms.gle/hdxuugycvntic4cfa . all of payment becomes author’s responsibility. production following acceptance of a manuscript; the corresponding author will receive an acknowledgement. the paper will then be edited to comply with house style, and typeset. the publisher will email a proof to the corresponding author for checking before it is published. the corresponding author is responsible for checking proofs thoroughly. by approving the proofs any editorial changes are being accepted. we also provide printed issues of jurnal ners. to purchase the printed issues, please fill this form https://goo.gl/forms/luhoutrvixqojybn2 and confirm your order to our whatsapp on +62 811-3287-877. our committee will process your order as soon as possible after your confirmation. https://forms.gle/hdxuugycvntic4cfa https://goo.gl/forms/luhoutrvixqojybn2 https://wa.me/qr/xtgu4colhec7e1 5 | author information pack march, 2022 submission of manuscripts all manuscripts, correspondence and editorial material for publication is submitted online at http://ejournal.unair.ac.id/index.php/jners simply need to "create a new account" (i.e., register) by following the online instructions, and using their own e-mail address and selected password. authors can submit manuscripts online. authors can expect an initial decision to undergo peer-review. revised submissions authors are requested to submit the revision within one month for all reviewing process i.e. rapid decision or in review stage. if not, the submission will be removed from the editorial system and needs to be submitted as a new submission. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, orcid id, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and postpublication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following:  introduction: one or two sentences on the background and purpose of the study.  method: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics).  results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals.  conclusions: should relate to the study aims and hypotheses.  keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. acknowledgment (optional) acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 6 | author information pack march, 2022 tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below:  observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/  qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq  quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/  randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/  study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/  systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/  systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 submission preparation checklist indicate that this submission is ready to be considered by this journal by checking off the following (comments to the editor can be added below). 1. as part of the submission process, authors are required to check off their submission's compliance with all of the following items. submissions may be returned to authors that do not adhere to these guidelines. 2. the author(s) haven’t suggested any personal information that may make the identity of the patient recognizable in any form of description, photograph or pedigree. when the photographs of the patient are essential and indispensable as scientific information, the author(s) must have received the consent in written form and have clearly stated such. 3. in case of experimenting on humans, the author(s) have certified that the process of the research is in accordance with the ethical standards of the helsinki declaration, as well as any domestic and foreign committees that preside over the experiment. if any doubts are raised as to whether the research proceeded in accordance with the helsinki declaration, then author(s) are required to explain it. in the case of experimenting on animals, the author(s) have certified that the author(s) had followed the necessary domestic and foreign guidelines related to experimenting on animals in a laboratory. 4. the author(s) have received consent from the author or editor of any pictures or table quoted from other journals or books. a portion or the entirety of the article must not have been published in other journals, nor must it have contributed to other journals or is still under review. 5. the author(s) undersigned hereby give the faculty of nursing universitas airlangga the rights as publisher, the right of first publication of all published material. it will be llicensed under a creative commons attribution 4.0 international license. 6. author(s) of the journal have clarified everything that may arise such as work, research expenses, consultant expenses, and intellectual property on the document in relation to the icmje form disclosure of conflicts of interest. copyright notice authors who publish with jurnal ners agree to the following terms: 1. authors transfer the copyright and grant jurnal ners the right of first publication with the work http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://mji.ui.ac.id/journal/public/journals/1/coi_disclosure.pdf http://mji.ui.ac.id/journal/public/journals/1/coi_disclosure.pdf 7 | author information pack march, 2022 simultaneously licensed under a creative commons attribution 4.0 international license that allows others to remix, adapt and build upon the work with an acknowledgment of the work's authorship and of the initial publication in jurnal ners. 2. authors are permitted to copy and redistribute the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in jurnal ners. jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your own records. your cooperation is essential and appreciated. any delay will result in a delay in publication. the form can be downloaded here. publication fee jurnal ners charges the author a publication fee amounted to idr 3.000.000 (indonesian author) and usd 200 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within a week. open access policy this journal retains copyright but provides immediate open access to its content on the principle that making research freely available to the public supports a greater global exchange of knowledge. this journal (p-issn:1858-3598; e-issn:2502-5791) is licensed under a creative commons attribution 4.0 international license. plagiarism check this journal follows the committee of publication ethics (cope) guidelines and requests authors to familarise themselves with these guidelines at: http://publicationethics.org/resources/guidelines. plagiarism is not acceptable in jurnal ners submissions. all the submitted manuscripts are checked for plagiarism before starting the review process. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): https://creativecommons.org/licenses/by/4.0/ https://drive.google.com/open?id=0b5ormcrmctnwcjrslunpyl9gueu http://issn.pdii.lipi.go.id/issn.cgi?daftar&1451966396&26&& http://issn.pdii.lipi.go.id/issn.cgi?daftar&1451966396&26&& http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ https://publicationethics.org/guidance/guidelines https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s http://creativecommons.org/licenses/by/4.0/ 8 | author information pack march, 2022 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number : 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number: 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number: 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orcid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ............................................................................................................................. ............................................................ h. funding source ............................................................................................................................................................... .......................... ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. https://orcid.org/ https://orcid.org/ https://orcid.org/ 9 | author information pack march, 2022 title page example modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : http://orcid.org/0000-0002-6669-0767 6. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/) 6. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/) 6. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): mailto:ah-yusuf@fkp.unair.ac.id http://orcid.org/0000-0002-6669-0767 mailto:hanik-e-n@fkp.unair.ac.id https://orcid.org/ mailto:krisna-e-k-2015@fkp.unair.ac.id https://orcid.org/ https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 10 | author information pack march, 2022 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, nonstandard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .......................................................................................................................... ........................................................................ ............................................................................................................................. ..................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... ................................................................................................. .............................................................. ................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ...................................................................................................................................................... ............................................ ...................................................................................... ......................................................................... ................................... results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .......................................................................................................................... ........................................................................ 11 | author information pack march, 2022 ............................................................................................................................. ..................................................................... equation: 𝐇′ = − ∑𝑠 (𝑃𝑖)(log2 𝑃𝑖) ...................................................................................................................................... (1) 𝑖=1 remarks: ............................................................................................................................. ....................................................... figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old age groups (years) type of care <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. ........................................................................... .................................................................................... ................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... 12 | author information pack march, 2022 conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. .......................................................................... ..................................................................................... ................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... .............................................................................................................................. .................................................................... acknowledgement (times new roman 11) this section is compulsory. grants, financial support and technical or other assistance are acknowledged at the end of the text before the references. all financial support for the project must be acknowledged. if there has been no financial assistance with the project, this must be clearly stated. the role(s) of the funding organisation, if any, in the collection of data, its analysis and interpretation, and in the right to approve or disapprove publication of the finished manuscript must be described in the methods section of the text. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .......................................................................................................................... ........................................................................ funding source (times new roman 11) you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .................................................................................................................... .............................................................................. conflict of interest (times new roman 11) when the proposed publication concerns any commercial product, either directly or indirectly, the author must include in the cover letter a statement (1) indicating that he or she has no financial or other interest in the product or distributor of the product or (2) explaining the nature of any relation between himself or herself and the manufacturer or distributor of the product. other kinds of associations, such as consultancies, stock ownership, or other equity interests or patent licensing arrangements, also must be disclosed. if, in the editor's judgment, the information disclosed represents a potential conflict of interest, it may be made available to reviewers and may be published at the editor's discretion; authors will be informed of the decision before publication. ................................................................................................................... ............................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................. ..................................................................... ................................................................................................................................... ............................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... https://www.mendeley.com/guides/harvard-citation-guide 13 | author information pack march, 2022 citation style: (nursalam et al., 2020) (who, 2021) (pemerintan ri, 2014) reference to a journal publication: nursalam, n. et al. (2020) ‘the effect of range of motion exercise on blood pressure, pulse and sleep quality among hypertensive patients’, international journal of innovation, creativity and change. faculty of nursing, universitas airlangga, mulyorejo street, campus c unair, surabaya, 60115, indonesia: primrose hall publishing group, 13(6), pp. 220–234. available at: https://www.scopus.com/inward/record.uri?eid=2-s2.085087361125&partnerid=40&md5=b7318712857248d9ea896f85f82d69c9. reference to a book: de virgilio, c. & grigorian, a. 2019, ‘surgery: a case based clinical review’ in surgery: a case based clinical review, pp. 1-689. reference to a book section/chapter: harper, m.s. 2021, ‘mental health and mental health services’ in services to the aging and aged: public policies and programs, pp. 283-297. reference to a website: who (2021) who coronavirus disease (covid-19) dashboard: situation by country, territory & area. reference in conference: yuarnistira, nursalam, n., rachmawati, p.d., efendi, f., pradanie, r. & hidayati, l. 2019, ‘factors influencing the feeding pattern of under-five children in coastal areas’, iop conference series: earth and environmental science. reference in statute: pemerintah ri (2014) undang-undang republik indonesia nomor 38 tahun 2014 tentang keperawatan. indonesia. available at: https://peraturan.go.id/common/dokumen/ln/2014/uu38-2014bt.pdf. 14 | author information pack march, 2022 vii. copyright transfer agreement jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your records. your cooperation is essential and appreciated. any delay will result in a delay in publication. please return this form after you complete it to: secretariat_jurnalners@fkp.unair.ac.id. or, upload it as supplementary file when submitting your manuscript to ojs. the format of the copyright transfer agreement is described below (or 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https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk ea44f6c7012405323910f2251b91fd84927e1557922b97f8b63184e958a5cea0.pdf 36642af34722666d5ae3b29ef2b4faa619b1b5e83b2efbb002c4f9a52cb09b31.pdf pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru jus mentimun (cucumis sativus) menurunkan tekanan darah penderita hipertensi essensial (cucumber juice decrease blood pressure on essensial hypertension patient) i ketut sudiana*, ira suarilah*, rusdianingseh** *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031)5913257 e-mail: ik.sudiana@yahoo.com abstract introduction: essential hypertension is an intermitten or sustained elevation of dyastolic or systolic blood pressure with unkwown aetiology (idiopathic). complication can occur such cerebro vascular accident (cva), heart failure, arterial aneurism till death. high blood pressure should be treaten with medicine or low salt and high potassium diet. one of high potassium diet is cucumber juice. the aimed of this study was to analyze the effect of cucumber juice on blood pressure regulation. method: a pra experimental (pre-post test one group) purposive sampling design was used in this study. population were citizen of pendil village who suffered essential hypertension which comprising 31 respondens. sample were 14 respondens who met to the inclusion criteria. the independent variable was cucumber (cucumis sativus) juice and dependent variable was blood pressure regulation. data were analyzed by using anova test with α=0.05 .result the result showed that cucumber juice has an effect on systolic blood pressure regulation (p=0.000) after first week of treatment, systolic blood pressure regulation (p=0.000) after second week of treatment and systolic blood pressure regulation (p=0.000) from first to second week.discussion: it can be concluded that cucumber juice consumption has an effect on blood pressure regulation among essential hypertension patients. the cucumber juice should be given in the best dose that can reduce blood pressure level, which is 2x200 g/day, as well as for treatment, it can regulate blood pressure level as long as consumed. further studies should be developed and include the variables of stress, activities and larger responden to obtain more accurate results. keywords: cucumber juice, blood pressure, essential hypertension pendahuluan penyakit hipertensi atau darah tinggi adalah keadaan dimana seseorang mengalami peningkatan tekanan darah di atas normal atau kronis dalam waktu yang lama (lenny, 2008). menurut robin (2005), tekanan darah tinggi atau hipertensi adalah peningkatan tekanan diastolik dan sistolik yang melebihi 140/90 mmhg. penyakit hipertensi disebabkan oleh banyak faktor, salah satunya adalah gaya hidup terutama dalam pengaturan diet sehari-hari. perubahan pola makan menjurus ke sajian siap santap yang mengandung lemak, protein dan garam tinggi tapi rendah serat pangan (dietary fiber), membawa konsekuensi terhadap berkembangnya penyakit degenerative (jantung, diabetes mellitus, kanker, osteoporosis) (astawan, 2008). diet merupakan pengobatan non farmakologis yang dapat dipakai sebagai pelengkap untuk mendapatkan efek pengobatan yang lebih baik (astawan, 2008). pada penderita hipertensi kronis dengan tekanan darah >150/90 mmhg dianjurkan mengkonsumsi obat antihipertensi dalam jangka waktu cukup lama. pada penderita hipertensi ringan tidak memerlukan pengobatan farmakologis. penderita dianjurkan mengatur diet sehari-hari dengan diet rendah garam yang diimbangi dengan diet tinggi kalium/potassium. konsumsi natrium yang tinggi dalam makanan untuk waktu lama dapat menyebabkan tekanan darah semakin tinggi. apabila hal tersebut tidak diobati akan menimbulkan risiko terjadinya stroke, serangan jantung, gagal jantung, aneurisme arterial, bahkan dapat menyebabkan kematian (smeltzer dan bare, 2003). berdasarkan studi pendahuluan diketahui bahwa penduduk desa pendil kabupaten probolinggo banyak menggunakan garam dan penyedap rasa dalam segala masakan dengan kadar yang cukup tinggi, sekitar 3-4 sendok teh. padahal konsumsi garam dapur (mengandung iodium) yang dianjurkan tidak lebih dari 6 gr/hari (satu sendok teh) (astawan, 2008). mereka tidak sadar akan bahaya yang dapat terjadi. disamping itu terdapat kebiasaan dari penduduk menkonsumsi mentimun 1-2 kali sehari karena mereka yakin hal tersebut dapat meminimalkan tekanan darah, meskipun mereka belum tahu pasti kandungan apa dalam mentimun yang dapat menurunkan tekanan darah. komponen penting dalam mentimun adalah air sekitar 96% dan potassium 147 mg dalam 100 gram mentimun yang diketahui sebagai natural diuretic (len, 2008). kalium merupakan ion utama di dalam cairan intraseluler yang cara kerjanya kebalikan dari natrium. peningkatan konsumsi kalium akan meningkatkan konsentrasi di dalam cairan intraseluler, sehingga cenderung menarik cairan dari bagian ekstraseluler dan dapat menurunkan tekanan darah karena efek vasodilatasi pembuluh darah (astawan, 2008). regulasi tekanan darah penderita hipertensi dengan pemberian jus mentimun dalam pengelolaan diet sampai saat ini belum dapat dijelaskan. penelitian tentang hal tersebut belum dilaporkan, meskipun dalam beberapa buku menyebutkan manfaaat mentimun terhadap regulasi tekanan darah. american heart association (aha) (dalam yayasan jantung indonesia, 2003) menyatakan, tekanan darah tinggi ditemukan satu dari setiap tiga orang atau 65 juta orang dan 28% atau 59 juta orang mengidap prehipertensi (sistolik 120-139 mmhg dan diastolik 80-89 mmhg). sekitar 85-95% penderita mengalami tekanan darah tinggi tanpa diketahui sebabnya, biasa disebut hipertensi primer (essensial). di negara berkembang seperti di indonesia diperkirakan sekitar 80% kenaikan kasus hipertensi. pada tahun 2025 dari jumlah 639 juta kasus di tahun 2000, diperkirakan menjadi 1,15 milyar kasus di tahun 2025 (ridwan, 2007). saat ini jumlah pasti penderita hipertensi di indonesia belum bisa dilaporkan, namun hasil penelitian terakhir, prevalensi di indonesia berkisar antara 17-22%. who (dalam yayasan jantung indonesia, 2003) menetapkan hipertensi sebagai faktor risiko ketiga penyebab kematian di dunia. di desa pendil jumlah penderita hipertensi essensial sampai akhir desember 2008 adalah 31 orang dan yang rutin kontrol cuma 4 orang (rekam medik puskesmas klenang kidul, 2008). prediksi di atas berdasarkan pada angka penderita hipertensi saat ini dan pertambahan penduduk. prevalensi terbanyak berkisar antara 6-15% (ridwan, 2007). berdasarkan penelitian yang telah dilakukan ternyata prevalensi (angka kejadian) hipertensi meningkat dengan bertambahnya usia. dari berbagai penelitian epidemiologis yang dilakukan di indonesia menunjukkan 1,8-28,6% penduduk yang berusia di atas 20 tahun adalah penderita hipertensi (yundini, 2006). angka prevalensi di indonesia telah banyak dikumpulkan dan menunjukkan di daerah pedesaan masih banyak penderita yang belum terjangkau oleh pelayanan kesehatan, sehingga angka kejadian terus meningkat. hal tersebut disebabkan oleh gaya hidup atau diet yang tidak mendukung seperti konsumsi tinggi natrium/garam dalam makanan yang bisa mempengaruhi peningkatan tekanan darah. hipertensi mudah dikendalikan jika ditangani sejak dini, namun kita sering tidak menyadari kalau mengidapnya. apabila hipertensi menjadi tidak terkendali maka dapat merusak organ vital seperti otak, mata, jantung, pembuluh darah dan ginjal (lili dan tantan, 2007). kerusakan berbagai organ tersebut berdampak pada aktifitas sehari-hari yang terganggu. penderita hipertensi memerlukan pengobatan yang rutin dan dalam waktu yang lama, sehingga memungkinkan penderita mengalami kebosanan. pengobatan alternatif/tradisional untuk hipertensi perlu dikembangkan, salah satunya dengan jus mentimun. peneliti mengambil jus mentimun dalam penelitian ini dikarenakan mentimun mudah didapat, harganya terjangkau dan sebagian besar masyarakat sudah mengenalnya. berdasarkan penjelasan di atas peneliti tertarik untuk mengetahui pengaruh i ketut pemberian jus mentimun terhadap regulasi tekanan darah pada penderita hipertensi essensial. bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah pra experimental one group pre-post test purposive sampling design. populasi pada penelitian ini adalah semua penderita hipertensi essensial di desa pendil wilayah kerja puskesmas klenang kidul kota probolinggo yang memenuhi kriteria inklusi. sampel diambil sesuai dengan kriteria inklusi dan diperoleh 14 responden yang sesuai dengan kriteria inklusi. adapun kriteria inklusi yang ditetapkan oleh peneliti yaitu 1) penderita hipertensi essensial yang didiagnosis ≤ 2 tahun, 2) mampu melakukan aktifitas seharihari atau pekerjaan rumah tangga, 3) tekanan darah ≥ 140/90 mmhg < 160/100 mmhg dan jenis kelamin perempuan, usia 30-50 tahun tanpa menggunakan kontrasepsi hormonal. variabel independen dalam penelitian ini adalah pemberian jus mentimun, sedangkan variabel dependen adalah nilai tekanan darah pada penderita hipertensi essensial. instrumen yang digunakan dalam penelitian ini adalah lembar observasi tekanan darah beserta alat pengukur tekanan darah (tensimeter atau sphygmomanometer dan stethoscope). satu kelompok yang memenuhi kriteria inklusi diobservasi tekanan darah (pre test), kemudian diberikan intervensi dengan pemberian jus mentimun dengan dosis 2x200 gram/sehari (pagi dan sore) selama 2 minggu. pemeriksaan tekanan darah dilakukan setelah pemberian jus mentimun pada minggu ke-1 dan minggu ke-2 (post test). data yang diperoleh ditabulasi kemudian dianalisis dengan menggunakan uji statistik anova dengan derajat kemaknaan <0,05. hasil pada tabel 1 dapat dilihat bahwa terdapat pengaruh pemberian jus mentimun terhadap regulasi tekanan darah sistolik pada penderita hipertensi essensial setelah 1 minggu maupun 2 minggu perlakuan. hasil tersebut ditunjukkan dengan nilai rerata tekanan sistolik sebelum perlakuan 146,43 mmhg (sd=4,97 mmhg) mengalami perubahan setelah 1 minggu perlakuan dengan nilai rerata tekanan sistolik 135,36 mmhg (sd=6,03 mmhg). paska 2 minggu perlakuan nilai rerata tekanan sistolik 122,66 mmhg (sd=6,71 mmhg). analisis statistik anova untuk kadar tekanan darah sistolik menunjukkan hasil p=0,000 setelah 1 sampai dengan 2 minggu perlakuan. terdapat pengaruh pemberian jus mentimun terhadap penurunan tekanan darah diastolik setelah 1 sampai dengan 2 minggu perlakuan yang ditunjukkan dengan hasil analisis statistik anova p=0,049. pada tabel 1 dapat dilihat nilai rerata tekanan diastolik sebelum perlakuan 91,43 mmhg (sd=3,63 mmhg) mengalami perubahan setelah 1 minggu perlakuan dengan nilai rerata tekanan diastolik 85 mmhg (sd=5,19 mmhg). paska 2 minggu perlakuan nilai rerata tekanan diastolik 80,71 mmhg (sd=7,30 mmhg). tabel 1. hasil tekanan darah (sistolik dan diastolik) pada penderita hipertensi essensial di desa pendil sebelum dan sesudah pemberian jus mentimun (cucumis sativus) sistolik diastolik pre test post test 1 post test 2 pre test post test 1 post test 2 mean 146,43 135,36 122,66 91,43 85 80,71 sd 4,97 6,03 6,71 3,63 5,19 7,30 hasil analisis statistik anova (p=0,000) anova (p=0,000) anova (p=0,004) anova (p=0,000) anova (p=0,000) anova (p=0,049) keterangan: mean = rerata sd = standar deviasi p = derajat kemaknaan pembahasan pada penelitian ini menunjukkan hasil bahwa pemberian jus mentimun 2x200 gram/hari setelah 1 minggu sampai dengan 2 minggu pada penderita hipertensi essensial efektif dalam menurunkan tekanan darah sistolik maupun diastolik. penurunan paling sedikit terjadi pada responden yang berumur antara 45-50 tahun dan berpendidikan sd. berdasarkan hasil observasi pengukuran tekanan darah, responden yang mengalami penurunan tekanan darah paling sedikit pada minggu ke2 adalah responden yang berumur 50 tahun. perubahan struktur dan fungsional pada sistem pembuluh darah perifer bertanggungjawab pada perubahan tekanan darah yang terjadi usia 50-55 tahun ke atas atau lanjut usia. perubahan tersebut meliputi aterosklerosis, hilangnya elastisitas jaringan ikat dan penurunan relaksasi otot polos pembuluh darah yang pada gilirannya menurunkan kemampuan distensi atau daya renggang pembuluh darah (smeltzer dan bare, 2003). hipertensi essensial biasanya dimulai sebagai proses labil (intermitten) pada individu di akhir umur 30-an dan awal umur 50-an dan secara bertahap menetap (guyton dan hall, 1997). etiologi hipertensi essensial sangat multifaktor. faktor genetik memegang peranan penting, gender juga berpengaruh pada terjadinya hipertensi, wanita lanjut usia lebih sensitif terhadap nacl dan memiliki curah jantung yang lebih besar dan tahanan perifer yang lebih rendah daripada pria lanjut usia (kaplan, 2002). tingkat pendidikan responden yang rendah juga mempengaruhi pola hidup mereka dalam mengatur diet yang seimbang terutama diet rendah garam untuk menjaga nilai tekanan darah dalam batas normal. intake garam yang meningkat telah lama diamati berperan dalam patogenesis hipertensi essensial. penumpukan garam dalam tubuh akan meningkatkan volume cairan ekstrasel sehingga meningkatkan tekanan darah (guyton dan hall, 1997). asupan garam berlebih dapat mengakibatkan penyempitan pembuluh darah arteri dan berujung pada peningkatan tekanan darah (lili dan tantan, 2007). kelebihan garam dalam tubuh mengakibatkan osmolalitas cairan tubuh akan meningkat, keadaan ini akan merangsang pusat haus yang membuat orang minum lebih banyak untuk mengencerkan garam dalam tubuh. hal ini akan meningkatkan volume cairan ekstrasel, selain itu juga merangsang sekresi kelenjar hipotalamus-hipofise posterior untuk mensekresikan lebih banyak hormon antidiuretik yang menyebabkan ginjal mereabsorbsi air dalam jumlah besar dari tubulus ginjal sebelum diekskresikan sebagai urine. volume urine dikurangi selama ada peningkatan volume cairan ekstrasel. mekanisme itulah yang menyebabkan garam berpengaruh pada peningkatan tekanan darah (guyton dan hall, 1997). variasi perubahan tekanan darah di atas diduga karena respons tubuh tiap orang berbeda dalam menerima terapi. beberapa faktor penyebab lain yaitu intake kalium sebelumnya belum adekuat. kandungan jus mentimun yang berperan dalam meregulasi tekanan darah adalah potasium/kalium dan air yang tinggi, bersifat sebagai natural diuretic. konsumsi kalium yang tinggi akan meningkatkan konsentrasi di dalam cairan intraseluler, sehingga cenderung menarik cairan dari bagian ekstraseluler dan menurunkan tekanan darah karena efek vasodilatasi pembuluh darah. kalium merupakan ion utama di dalam cairan intrasel yang bekerja berkebalikan dari natrium/garam (astawan, 2008). mekanisme lain yaitu membantu ginjal membuang garam dan air dalam bentuk urine, sehingga sedikit menurunkan volume sirkulasi darah dan mengalihkan sebagian tekanan keluar sistem (beevers, 2007). jus mentimun diberikan pada penderita hipertensi essensial dengan tekanan darah ≥140/90 <160/100 mmhg dan tanpa komplikasi penyakit lain. penderita hipertensi essensial dengan tekanan darah ≥160/100 mmhg atau hipertensi sekunder dengan komplikasi penyakit lain, tidak dianjurkan untuk mengkonsumsi jus mentimun sebagai pengobatan, namun dianjurkan mengkonsumsi obat antihipertensi untuk mencegah komplikasi lebih lanjut seperti stroke (cva). enam puluh persen penderita hipertensi merupakan wanita. hal tersebut dikaitkan dengan perubahan hormon menjelang menopause, kemungkinan lain i ketut karena faktor stres yang sering tidak dapat dikelola dengan baik (lili dan tantan, 2007). penurunan tekanan darah setelah 2 minggu pemberian jus mentimun lebih besar daripada setelah 1 minggu pemberian. hal tersebut disebabkan tubuh sudah mempunyai cukup cadangan kalium untuk melawan penumpukan natrium. penurunan tertinggi yaitu 30 mmhg tekanan sistolik dari nilai sebelum perlakuan. responden yang pada minggu pertama mengalami penurunan tekanan darah yang cukup signifikan, pada minggu kedua juga tetap mengalami penurunan yang cukup berarti. intake kalium dan air dalam jus mentimun yang cukup tinggi sudah mempengaruhi regulasi tekanan darah yang sudah dirasakan sejak minggu pertama. responden juga mengimbangi dengan mengurangi garam dalam diet harian. responden lain, yang pada minggu pertama mengalami sedikit penurunan tekanan sistolik, pada minggu kedua sudah mengalami penurunan cukup besar, berkisar antara 20-25 mmhg. melihat adanya penurunan tekanan darah pada minggu pertama, responden termotivasi untuk mulai mengurangi garam dalam diet dan menambah konsumsi kalium dari sayuran atau buahbuahan lain, sehingga mempengaruhi turunnya tekanan darah. diet yang dianjurkan bagi penderita hipertensi adalah diet yang dapat menurunkan atau sekurang-kurangnya mencegah agar tidak terjadi peningkatan tekanan darah. diet ini bertujuan untuk mengurangi asupan garam, kadar lemak dalam tubuh sehingga didapatkan berat badan yang sehat dan untuk mempertahankan agar tetap berada pada berat badan yang sehat. dash (dietary approaches to stop hipertension) menganjurkan makanan kaya padi-padian, buah-buahan, sayuran, susu rendah lemak dan memperbanyak kadar kalium, kalsium dan magnesium (lili & tantan, 2007). kebutuhan kalium ini dapat diperoleh salah satunya dari mentimun. tiap 100 gram mentimun mengandung 147 mg kalium dan 96% air (len, 2008). garam, lebih tepatnya natrium sangat berpengaruh dalam meningkatkan tekanan darah. natrium merupakan mineral yang sangat berperan dalam membantu keseimbangan cairan tubuh dan menghantarkan impuls/rangsangan saraf yang mengatur kontraksi dan relaksasi otot. kadar natrium dalam tubuh diatur oleh ginjal, jika terjadi penumpukan dalam darah maka natrium akan menahan air sehingga terjadi penambahan volume darah. jantung dan pembuluh darah pun bekerja lebih keras untuk mengalirkan volume yang meningkat tersebut. hal inilah yang menyebabkan meningkatnya tekanan darah (lili dan tantan, 2007). kandungan air dan kalium dalam jus mentimun akan menarik natrium ke dalam intraseluler dan bekerja dengan membuka pembuluh darah (vasodilatasi) yang dapat menurunkan tekanan darah (beevers, 2007). kandungan air dalam jus mentimun juga akan menurunkan tekanan darah yang tidak terkontrol dan menbuang lemak bersama urine, sehingga tidak memberikan efek samping seperti obat pengurang tekanan darah sintetik yang bisa mengiritasi ginjal jika dipakai dalam jangka waktu lama (tersono, 2008). terapi jus mentimun akan sangat menolong mengembalikan fungsi darah dan pembuluh darah dengan memberikan unsur vitamin dan mineral yang dibutuhkan oleh sel-sel di dalam tubuh. pada penelitian ini juga menunjukkan hasil penurunan pada tekanan diastolik pada minggu 1 sampai dengan kedua setelah pemberian jus mentimun. penelitian sebelumnya menyatakan bahwa tekanan sistolik tinggi mempunyai angka kematian 2,5x lebih tinggi daripada tekanan diastolik. tekanan sistolik adalah tekanan dalam arteri yang terjadi saat dipompanya darah dari jantung ke seluruh tubuh, sedangkan tekanan diastolik yaitu sisa tekanan dalam arteri saat jantung beristirahat. apabila tekanan sistolik tinggi, aliran darah ke seluruh tubuh, termasuk organ vital juga terganggu. hal ini menjelaskan mengapa angka kematian akibat tekanan darah sistolik tinggi lebih besar dari tekanan diastolik tinggi. berdasarkan hal tersebut, tekanan sistolik bisa dikatakan lebih bahaya daripada tekanan diastolik. hasil penurunan tekanan darah diastolik pada penelitian ini menjelaskan bahwa jus mentimun dapat dipakai untuk meregulasi tekanan darah penderita hipertensi essensial. jus mentimun harus dikonsumsi secara rutin sampai tekanan darah normal tercapai (sudjaswadi & i ketut sitanggang, 2008). seringkali pengobatan harus diulang jika ternyata tekanan darah yang sudah normal naik kembali, yaitu dengan pemberian jus mentimun 100 gram ditambah 50 ml air matang, diminum 3 kali seminggu (tersono, 2008). namun perlu diingat, pada masa pengobatan dengan jus mentimun ini, penderita hipertensi essensial harus menjalani cara hidup sehat, seperti olahraga teratur, diet seimbang dan rendah garam, istirahat yang cukup dan mengelola stres dengan koping yang positif. stres akan meningkatkan aktifitas saraf simpatis (guyton dan hall, 1997). apabila stres berlangsung lama dapat mengakibatkan peningkatan tekanan darah yang menetap, karena stres menyebabkan vasokontriksi dan peningkatan curah jantung (soeparman & sarwono, 2001). simpulan dan saran simpulan pemberian jus mentimun berpengaruh terhadap regulasi tekanan darah pada penderita hipertensi essensial di desa pendil, wilayah kerja puskesmas klenang kidul kota probolinggo. saran peneliti menyarankan supaya penelitian selanjutnya lebih mempertimbangkan faktor stres, diet dan aktivitas yang juga mempengaruhi tekanan darah serta dilaksanakan dalam jangka waktu yang lebih panjang. kepustakaan astawan. 2008. cegah hipertensi dengan pola makan, (online), (http://www.depkes.go.id, diakses tanggal 30 mei 2008, jam 20.30 wib). beevers, d.g. 2007. abc of hypertension, 5th edition. australia: blackwell publishing, pp. 4. guyton dan hall. 1997. buku ajar fisiologi kedokteran.edisi ix, (alih bahasa oleh irawati setiawan. jakarta: egc, hlm. 217-273, 293-294, 277-287. kaplan, n.m. 2002. kaplan’s clinical hypertension, 8th edition. philadelpia: lippincott, pp. 5-168. len. 2008. health benefits of cucumber, (online), (http://www.huppages.com, diakses tanggal 28 mei 2008, jam 20.00 wib). lenny. 2008. darah tinggi/hipertensi, (online), (http://www.infohidupsehat.com, diakses tanggal 25 mei 2008, jam 19.00 wib). lili dan tantan. 2007. hipertensi: 100 questions and answers, jakarta: pt elex media computindo, hlm. 44-45, 71. rekam medik puskesmas klenang kidul. 2008. data penderita hipertensi essensial di desa pendil desember. ridwan. 2007. hipertensi dan faktor risikonya dalam kajian, (online), (http://www.ridwanamiruddin.wordpre ss.com, diakses tanggal 25 mei 2008, jam 19.30 wib). robin, r.w. 2005. pathophisiology. incredibly easy, 3rd edition. philadelpia: lippincott, p. 232. smeltzer, s.c. dan bare, b. 2003. brunner dan suddarth buku ajar keperawatan medikal bedah. jakarta: buku kedokteran egc, hlm. 731, 896-899. soeparman dan sarwono. 2001. buku ajar ilmu penyakit dalam, jilid 2. jakarta: balai penerbit fkui, hlm. 453-471. sudjaswadi, w. dan sitanggang, m. 2008. tanaman obat untuk penyakit jantung, darah tinggi dan kolesterol. jakarta: pt agromedia pustaka, hlm. 56-57, 96-97. tersono, l. 2008. tanaman obat dan jus untuk mengatasi penyakit jantung, hipertensi, kolesterol dan stroke. jakarta: pt agromedis pustaka, hlm. 11-13, 221-222. yayasan jantung indonesia. 2003. tekanan darah tinggi (hipertensi), (online), (http://www.inaheart.or.id, diakses tanggal 20 mei 2008, jam 16.00 wib). yundini. 2006. faktor risiko terjadinya hipertensi, (online), (http://www.sukasukamu.com, diakses tanggal 20 mei 2008, jam 16.30 wib). http://www.depkes.go.id/ http://www.huppages.com/ http://www.infohidupsehat.com/ http://www.ridwanamiruddin.wordpress.com/ http://www.ridwanamiruddin.wordpress.com/ http://www.inaheart.or.id/ http://www.sukasukamu.com/ http://e-journal.unair.ac.id/jners | 55 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v14i1.9664 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research caring efficacy and nurse caring behavior in taking care of critical patients lukmanulhakim lukmanulhakim , afriyani afriyani , and ani haryani faletehan university, serang banten indonesia abstract introduction: critical patients have different needs compared to patients in other general inpatient wards, so they need extra treatments from a nurse. nurse caring behavior gived through an approach in which nurses work by improving their concern to patients. however, it is influenced by caring efficacy in which a nurse is confident to express his or her caring to patients. the aims of this study were to identify the correlation between caring efficacy with nurse caring behavior in taking care of critical patients at dr. dradjat prawiranegara serang hospital in banten province methods: this is a quantitative study with employed a correlation study. the sample size comprised 66 nurses of er, icu and hcu with total sampling technique. the instruments used are ces (caring efficacy scale) to measure caring efficacy and cba (caring behavior assessment) to measure nurse caring behavior. descriptive analysis using mean, standard deviation, percentage and frequency distribution. meanwhile, inferential analysis used pearson's correlation. results: the univariate analysis results showed the mean ± ds score of caring behavior is 87.6 ± 10.12. meanwhile, the mean ± ds score of caring efficacy is 86.23 ± 8.74. further, inferential analysis revealed a significant (p < 0.000) and moderate correlations (r = 0.448) between caring efficacy and nurse caring behavior. conclusion: higher of nurse's caring efficacy were followed by higher of nurse's caring behavior in taking care of critical patients. findings can be used by academic as a prospective nurse and health professionals, to implement a concept of caring efficacy to improve caring behavior. further research can be a focus on the nursing interventions based on nurses caring behavior to strengthen and increase in taking care of critical patients. article history received: sept 24, 2018 accepted: oct 20, 2019 keywords caring behavior; caring efficacy; critical patients; taking care contact lukmanulhakim  lukmanulhakimshodrudin@yahoo.com  faletehan university, serang banten, indonesia cite this as: lukmanulhakim, l., afriyani, a., haryani, a. (2019). caring efficacy and nurse caring behavior in taking care of critical patients. jurnal ners, 14(1),55-61. doi:http://dx.doi.org/10.20473/jn.v14i1.9664 introduction nursing service is a form of professional service and an integral part of health service, which is based on science and nursing tips to individuals, families, groups and society either in sick or healthy condition (ministry of health the republic of indonesia, 2017). nursing service quality greatly influences health service quality even becomes one of determining factors of the image of health service institution such as hospital. the improvement of nursing quality service is supported by nursing theories development; one of them is caring theory. nurse caring behavior means giving nursing care service through a nurse approach of improving care to patients. nurse attention, empathy, and concern to patients are the keys of nursing care service quality, it is very appropriate with the demand of people who expect a good and quality health service (putri, 2014). watson (2008) explained that caring is a service process which is conducted by health workers especially nurses. a nurse should have caring attitude in order to give a quality nursing care; thus, patients are satisfied with health service given (kusmiran, 2015). nevertheless, in reality, just like what have been stated by putra., saleh., & bahar (2014), many nurses have not applied caring behavior yet. and who said that the demand of society who hopes for a good https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i1.966412125 l. lukmanulhakim et al. 56 | pissn: 1858-3598  eissn: 2502-5791 and quality health service. a lot of research shows that nurse caring behavior in indonesia is still categorized low. it is previously written by zees (2012) who obtained that 62% of nurses have low level of caring behavior. the result is also similar to sukesi’s study (2013) that 72.4% of 52 respondents show a low caring behavior. critical patients have different needs compared to patients in other general inpatient wards. the patients are described in unstable condition and applied with distress-causing equipment, so they need extra treatments from a nurse. the statement is in line with jakimowich., & perry (2015) who said that patients in critical ward has been different form other ward. it can be seen from patients’ characteristic difference in critical condition, environment, particular medical equipment, and demand of giving biological, psychological, and social treatments. patients in critical condition possibly feel frightened, more alone, confused, and anxious. it is supported by the research findings of lukmanulhakim., & syukrowardi (2018) who have identified that the majority of critical patients are in an anxious condition as evidenced by have been found 17 or most of respondents (68.0%) in critical treatment wards are within a severe anxiety level, whereas 8 or almost half of respondents (32.0%) are within middle anxiety level. furthermore, lukmanulhakim., & syukrowardi (2018) have also explained that beside physical support, nurses also should have ability of giving emotional, social, and spiritual support. an attitude and behavior which are able to achieve all interventions is caring. critical treatment wards are ones of the most chalenging, distressed-able condition, and can cause emotional problem relating to anxiety and depression for patients and the family (rusinova, kukal, simek & cerny, 2014; lukmanulhakim, suryani, & anna, 2016). besides, the treatment in critical treatment wards is identical with noisy effect, light, and interruption within. noise is one of factors that cause uncomforting condition both for patients and for the family. during treatment, the issues of spiritual distress, death, family dysfunction, grief, despair, and many other emotional feelings can emerge as a part of individual copying mechanism of patients, health treatment team members, family, or next of kin. critical sickness does not only happen from physiological alteration but also from psychosocial process, development, and spirituality. critical sickness is also a threat for individuals and families. being parallel to improvement of technology using in health treatment, the accompanying humanization needs become more essential. humanization needs of health treatment parallels proof-based effective intervention more rather than plunges into tradition (morton., fontaine., hudak., & gallo, 2011). watson's theory (2007), has explained that caring behavior is a manifestation of attention to others, respect for self-esteem and humanity, a commitment to prevent a deterioration, love and bonding, always together, empathy and appreciation. furthermore, potter and perry (2009) have also explained that caring behavior is an attitude that gives full attention to patients when giving nursing care. nurse caring behavior aims to give nursing care service through an approach in which nurses work by improving their concern to patients. however, it is influenced by caring efficacy in which a nurse is confident to express his or her caring to patients and this is recognized by efficacy. according to reid (2012), caring efficacy is defined as nurse’s confidence or ability to behave caring and to build a good relationship with patient. caring efficacy is one’s confidence to express his or her concern to develop relationship with patient and confidence means one’s ability and belief to accomplish something in a situation. in addition, it is defined as one’s belief to concern with decisions of achievement or development result (coates, 1997 in reid, 2012). according to putra, saleh, and bahar (2014), nurses who work with good caring efficacy can get a satisfaction improvement for his or her job. the statement was supported by reid’s study (2011) which showed a positive correlation between nurse’s caring efficacy and working satisfaction. materials and methods study design it is a quantitative research with with employed a correlation study. correlation studies are intended to reveal correlation relationships between variables. correlation studies refer to the tendency that variations in a variable are followed by variations in other variables. (nursalam, 2011). this study used a cross-sectional approach. cross-sectional design is a type of study which intends to learn correlation dynamics between risk factors and the effects through an approach, observation, or data collection at the same time (notoatmodjo, 2010). setting the data collection was conducted from may to june 2018 at critical treatment wards including ermergency room (er), intensive care unit (icu), high care unit (hcu) of dr. dradjat prawiranegara hospital in serang city, banten province. before conducting the research, the researcher did coordination with related parties, such as head room of er, icu, and hcu and nurses practitioner from the third wards. then, the researcher determined the samples of the study; they are nurses practitioner of the wards. researcher explained the research purposes, the benefits, the time, the rights of the respondents, the time contract of the research process, and the informed consent. after she got the informed consent, the respondents filled questionnaires of ces (caring efficacy scale) and cba (caring behavior assessment) which the statements are scored by using likert scale. previously, the researcher has tested the validity and the reliability of the statement items. after getting the data form the jurnal ners http://e-journal.unair.ac.id/jners | 57 questionnaires, the researcher checked it and processed it. research subject the samples of the research are all nurses practitioner of er, icu, and hcu of dr. dradjat prawiranegara serang hospital, there were 66 nurses practitioner by using with total sampling technique in which the sample size is same as the available population (sugiyono, 2010). instruments the instrument used for caring efficacy variable is ces (caring efficacy scale) which was developed by coates (1997) and had been used by reid (2012). the statements within the questionnaire intends to identify nurses’ confidence in their own ability. then, the questionnaire was modified by the researcher after getting approval from previous researchers to be 26 question items based on the result of literature study relating to nurse’s confidence about his or her own ability to perform caring to patients with critical condition by considering mental, psychological, physical, and spiritual aspect and technology or equipment used to take care of a patient. the questionnaire employs likert scale with 6 choices of answer for positive statements, namely strongly disagree (score 1), disagree (score 2), somewhat disagree (score 3), somewhat agree (score 4), agree (score 5) and strongly agree (score 6). meanwhile, likert scale for negative statements are strongly disagree (score 6), disagree (score 5), somewhat disagree (score 4), somewhat agree (score 3), agree (score 2) and strongly agree (score 1). the questionnaire has validity values ranging from 0.497 0.779, and reliability test obtained alpha cronbach of 0.812. meanwhile, for caring behavior variable, the researcher employed cba (caring behavior assessment) questionnaire which was developed based on watson theory by cronin., & harrison and had been modified into indonesian language by mulyaningsih (2013). then, the questionnaire was remodified by the researcher after getting approval from previous researchers based on the result of literature study relating to critical patient’s needs, such as by considering mental, psychological, physical, and spiritual aspect, including technology or equipment used by patients. it has 34 statement items and uses likert scale with 4 answer options, namely always (score 4), often (score 3), seldom (score 2) and never (score 1). the validity test which employed 21 respondents obtained ranging form 0.434 0.728 and the reliability test obtained alpha cronbach of 0.899. ethical consideration ethical consideration was obtained from the committee of dr. dradjat prawiranegara hospital, serang for human research subjects with the letter number of 009/tu.1218/v/2018. this is intended to avoid any negative effects for the research since she did some anticipative steps, namely accomplishing research ethics principles. data analysis before doing the statistical test analysis, the researcher did normality assumption test of the data taken through the questionnaires by employing normal curve on histogram graph, and also employed skewness score divided by standard error of skewness, in which the score used to determine data normality are from -2 to +2 (dahlan, 2016). the result of data normality for caring efficacy variable is 1.33 after dividing skewness score with standard error. meanwhile, the result of nurse caring behavior is 1.46 and the histogram graph of the variable is bell shape. thus, in conclusion, the tests identified that the data is distributed normally. descriptive analysis using mean, standard deviation, percentage and frequency distribution. meanwhile, inferential analysis used pearson's correlation (dahlan, 2016). results descriptive analysis was done to see the description of characteristics nurses involved in this research. based on table 1 above, respondents in this study are all nurses those who work from third wards of er, icu and hcu. the age range of nurse ranged from 24 to 47 years with an average age of 32.26 years. then also obtained the length of work range of nurses ranged from 3 to 28 years with an average length of work of 7 years. further based on categorical data, shows most of 65% of 43 respondents are male, and with latest education background is diploma iii of nursing 63% of 42 respondents. table 2 above, shows in this study, half of the nurses (51.5%) were classified as having high efficacy with the average score of 92.41 ± 8.26. similarly, nurses caring behavior in taking care of critical patients was found that the most of nurses (59.0%) belonged to caring with an the average score of 89.69 ± 8.73. table 3 above, showed the results of pearson's product moment correlation analysis showed statistically significant (p = 0,000) and moderate correlation (r = 0.448) with a positive relationship between caring efficacy and nurse caring behavior in taking care critical patients. in other words, the alternative hypothesis (ha) is accepted, where higher caring efficacy of a nurse, it will increase of nurse caring behavior in taking care ciritical patients. discussion nurse’s caring efficacy in taking care of critical patients self-efficacy is defined as one’s confidence in his or her ability to produce an influential performance on phenomena which influence his or her life. l. lukmanulhakim et al. 58 | pissn: 1858-3598  eissn: 2502-5791 confidence can determine how someone feels, thinks, motivates and behaves. it will cause various effects through four main processes, including cognitive, motivation, affective, and selection process (bandura, 1994). nurses with a high caring efficacy tend to express their care easily to develop relationship with patients and to have belief of solving a problem in a particular situation. besides, they have belief and care about decisions to one’s achievement or result in the development (coates, 1997). the result of statistical analysis to caring efficacy of the nurses at critical treatment wards, including the er, icu, and hcu of dr dradjat prawiranegara hospital in serang, banten province showed that most of respondents have a high caring efficacy. it was identified from some statement items in the instrument that nurses with a high caring efficacy often feel confident in their ability to give medical interventions and to fulfill patient’s needs. nevertheless, the low caring efficacy was identified from statement items in which the nurses often feel unconfident to express their empathy, care, and communication. the research results surely are not detached from some factors influencing nurse’s caring efficacy, namely nurse’s characteristics. the results are parallel to what had been found by putra, saleh, & bahar (2014) who applied linear by linear association analysis to identify correlation among performance, caring efficacy, and respondents’ characteristics. they found that sex, education background, length of working, and employment status have correlation to caring efficacy and performance. however, there is no correlation to age. according to bandura (1994) in sufirmansyah (2015), efficacy refers to belief in one’s ability to organize and to do a required action to manage a willbe faced situation. thus, nurses who have a strong belief in their ability will be able to implement an excellent caring. the statement was supported by rustika (2012), that efficacy has a very important role in daily life. people will be able to use their potentials optimally if their self efficacy support them. one of life aspects influenced by self efficacy is achievement. efficacy in performing nurse’s caring behavior is wellknown as caring efficacy. reid (2011) stated that nurses who work with a good caring efficacy can increase satisfaction of their job. one of some efforts of building confidence, according to bandura (1994), is master experience. it is defined as an experience in mastering a thing, which is directly occurred, in which the success will increase self-efficacy and the failure will decrease it. the next is vicarious experience which more sees others’ experience in solving their problem to be an example. the last is social persuasion which also can be called as feedback on performance. arousal or physical and emotional confidence also can influence one’s self-efficacy level. nurse caring behavior in taking care of critical patients caring is an important part of nursing practice. morrison and burnard (2009) stated that caring in nursing as an essential interpersonal process requires nurses to do a specific role activity as a way of expressing specific emotions, including helping and serving people with special needs. they also explained nursing as a process of helping and serving, which is inseparable with caring process since at the same time they are identified to be practiced together. the research results identified that most of nurses at the er, icu, and hcu have caring behavior. the presence of nurse caring behavior is possibly influenced by respondents’ characteristic of 7 years working length average in which nurses often and know more patient’s background which makes their caring behavior better. the result is similar with the study of angelina, kumaat, & mulyadi (2017) who stated that most of nurses (76.7%) have caring behavior. the research result in detail showed that more than a half of respondents (59.0%) have caring behavior. the researcher reviewed some statement table 1. nurse characteristics in taking care of critical patients (n = 66) nurse’s characteristics the mean age 32,26 years age range 24 – 47 years the average length of working 7 years length of wroking range 3 – 28 years nurse’s characteristics f % sex male female 43 23 65 % 35 % education diploma bachelor professional nurse 42 5 19 63 % 8 % 29 % table 2. the mean of nurse caring efficacy and nurse caring behavior score in taking care of critical patients (n = 66) mean ± ds f % caring efficay low efficacy high efficacy 86.23 ± 8.74 82.66 ± 9.56 92.41 ± 8.26 32 34 48.5 % 51.5% caring behavior less caring caring 87.6 ± 10.12 81.22 ± 5.97 89.69 ± 8.73 27 39 41.0 % 59.0 % table 3. the correlation test result between caring efficacy and nurse caring behavior in taking care of critical patients (n = 66) nurse caring behavior in taking care critical patients (p) (r) caring efficacy 0.000 0.448 jurnal ners http://e-journal.unair.ac.id/jners | 59 items in ces instrument namely nurse’s ability in fulfilling patient’s needs, such as giving intervention suited to patient’s need, facilitating patient need of worshiping, creating a protecting environment such as bed, table, and surrounding cleanliness, always ensuring patient’s stability, and being able to receive either positive or negative feeling of patient such as being able to receive patient’s comment. hidayat (2008) asserted that a professional nurse is required to implement caring behavior in conducting nursing care. unless nurses implement a good caring behavior, such as differentiating patient, less caring and paying attention, and giving a slow and unstandardized service, they will cause harmful effects for patients, nurses, and hospital party who give nursing service. moreover, they will create an unpleased perception in patients to nursing service, in which patients may give a bad judgment to the hospital which has given nursing service. it surely will harm the hospital party which patients’ trust is decreased, so they are unwilling to visit and receive the hospital service. finally, the amount of patients’ visit to the hospital will be decreased too, then it will cause the decrease of financial income of the hospital. nurses are responsible to implement caring behavior. unless it is implemented, health service and relationship between nurse and patient are less. the effort of improving caring can be done through individual, psychological, and organizational approach. individual approach can be done by improving knowledge and skills through trainings, seminars, or formal education (indrastuti, 2010). organizational approach can be done through reward development plan which relates to nurses’ work satisfaction and an effective leadership in nursing (putri, 2014). however, the study showed that some respondents (41%) are in category of less caring. the result was shown by the assessment of nurse’s communication, in which not all nurses are common to do an intensive communication with patient, relating to expressing feeling, such as expressing care and empathy. communication is an important part in nursing care. a bad communication makes patient and the family to think that nurses’ role seems not good. one of nurses’ roles in critical treatment rooms is not only to give nursing service through emotional care but also to become a good communicator. without showing a good communication to patient’s family, it will be difficult to give comfort and to maintain emotional relationship with them. the proposition is similar with the statement of lukmanulhakim., suryani., & anna (2016) who argued that nurses’ role is critical in some patient’s family issues, such as helping them to identify their strength, to talk openly about patient’s condition, and to be realistic and honest about their condition. the scholars also stated that nurses should be careful in saying their fake hope; they should express their hope and trust that patient’s family are able to solve the critical situation. furthermore, nurses should help them to find a way to communicate with nurses and discuss the uniqueness happened to patient. the statements were also supported by the study of tumbuan, mulyadi, & kallo (2017) who stated that therapeutic communication can improve patient and the family’s trust to nurses. correlation between caring efficacy and nurse’s caring behavior in taking care critical patients caring efficacy is a trust of one’s ability in expressing care in order to develop care relationship to patients. health service giving based on nurse’s caring behavior is able to improve health service quality. caring implementation which is integrated to caring efficacy can improve individual health and facilitate nursing care service giving to patients. it is parallel to what had been explained by patricia, potter, & perry (2010), that nursing care becomes benchmark of service quality and patient’s or family’s satisfaction. service quality becomes determiner of the image of service institution, which later can improve patient’s and family’s satisfaction as the service receivers. the result of research analysis showed that caring efficacy can influence nurse’s caring behavior, in which it obtained different means of caring behavior between nurses with low caring efficacy and nurses with high caring efficacy. in other words, there is a meaningful correlation between caring efficacy and nurse’s caring behavior. in detail, there were 39 respondents (59%) who showed caring behavior; however, 21 of them showed a less caring behavior (41%). the finding surely will be risky for nursing service, which may impact on a poor nursing service. the proposition is supported by meilani, & fitri (2017) who stated that nurse’s caring behavior can give influence on a quality service to patients. it is important for nurses to build and apply caring efficacy into their selves. nurses who have confidence in their ability to perform caring behavior are urgently required. it does not only relate to their selves or others but also to their job and performance in giving a quality nursing care. coates (1997) in reid (2012) stated that nurses who work with a good caring efficacy will be able to improve the satisfaction of their job. the statement was supported by the study of putra, saleh, & bahar (2014) about correlation among caring efficacy, work satisfaction, and nurse’s performance in inpatient room. they found that a high caring efficacy can improve nurse’s performance. therefore, caring efficacy and nurse’s caring behavior can give benefits to health service since the issues can increase people’s trust. it also can give satisfaction to patients; thus, later the quantity of patients who come to hospital will be bigger. conclusion the research results showed that nurses with higher of caring efficacy will be easily confident to perform care, attention, and intervention suited to patient’s needs. thus, it can improve nurse’s performance in conducting their role as one of nursing worker who should improve nursing service to be better, which l. lukmanulhakim et al. 60 | pissn: 1858-3598  eissn: 2502-5791 will be seen through their behavior. nurse’s caring behavior can give benefits to service as it can increase nursing care quality and achieve an optimal health service. as the result, patient’s and family’s satisfaction and people’s trust will be achieved. findings of this research can be used by academic as a prospective nurse and health professionals, to implement a concept of caring efficacy to improve caring behavior in taking care of critical patients. the researcher suggested nurses in critical treatment wards to more development efforts in improving caring efficacy and caring behavior. similarly, nurse students also need to build and understand the concept underlying caring efficacy, started from nurse education level by improving caring behavior and implementing it in field study practice. further research can be a focus on the nursing interventions based on nurses caring behavior to strengthen and increase in taking care of critical patients references angelina, r., kumaat, l., & mulyadi. (2015). hubungan beban kerja perawat dengan caring perawat di instalasi gawat darurat medik prof. dr. r. d. kandou manado, jurnal keperawatan. 3(2): 1-8. retrieved from : https://ejournal.unsrat.ac.id/index.php/jkp/arti cle/view/8029 bandura, a. (1994). self-efficacy. in v. s. ramachaudran (ed.), encyclopedia of human behavior (vol. 4, pp. 71-81). new york: academic press. (reprinted in h. friedman [ed.], encyclopedia of mental health. san diego: academic press, 1998). coates, c. (1997). the caring efficacy scale: nurses’ self-reports of caring in practice settings. advanced practice nursing. 3(1): 53–9. retrieved maret 12, 2018, from : https://www.ncbi.nlm.nih.gov/pubmed/948578 1 dahlan, m, s. (2016). statistik untuk kedokteran dan kesehatan. edisi 6. seri 1. jakarta: epidemiologi indonesia depkes ri. (2008). indikator kinerja rumah sakit. retrieved maret 12, 2018, from : http://vaww.environmentalauditing.org/portal s/auditfiles/audithospitalwastemanagement1. pdf depkes ri (2011). instrumen standar evaluasi penerapan standar asugan keperawatan di rumah sakit, jakarta : direktorat bina pelayanan keperawatan dan keteknisan medik depkes ri. hidayat, a & uliyah, m, (2016). buku ajar ilmu keperawatan dasar. jakarta : salemba medika. indrastuti, yani. (2010). analisis hubungan perilaku caring dan motovasi dengan kinerja perawat pelaksana menerapkan prinsip etik keperawatan dalam asuhan. jakimowich, s., & perry, l. (2015). a concept analysis of patient centered nursing in the intensive care unit. journal of advanced nursing, 7(71), 14991517. doi : https://doi.org/10.1111/jan.12644 kemenkes ri (2017). pusat data dan informasi kementrian kesehatan republik indonesia, retrieved maret 13, 2018, from : http://www.pusdatin.kemkes.go.id. kusmiran, eny. (2015). soft skills caring dalam pelayanan keperawatan. jakarta: trans info media. lukmanulhakim., suryani., & anna, a. (2016). the relationship between communication of nurses and level of anxiety of patient’s family in emergency room dr. dradjat prawiranegara hospital, serang banten, indonesia. international journal of research in medical sciences. 4(12). 5456-5462. doi: http://dx.doi.org/10.18203/23206012.ijrms20164228 lukmanulhakim, l., & syukrowardi, d.a. (2018). the effects of spiritual counseling on the anxiety level of patient’s family at the intensive care unit (icu) of dr. dradjat prawiranegara hospital in serang, banten province, indonesia. belitung nursing journal, 4(4): 403-410. doi : http://dx.doi.org/10.33546/bnj.404 mailani, f., & fitri, n. (2017). hubungan perilaku caring perawat dengan tingkat kepuasan pasien bpjs di rsud dr. rasidin padang. journal endurance. 2(2): 203-208. doi : http://doi.org/10.22216/jen.v2i2.1882 morrison, p. & burnard, p. (2009). caring and communicating : the interpersonal relationship in nursing, 2nd ed. jakarta : egc morton, p.g., fontaine, d., hudak, c. m., gallo, b. m. (2011). keperawatan kritis, pendekatan asuhan holistik, ed, 8 vol.1. alih bahasa : nike budhi subekti, s.kp,ns. nurwahyu, s.kep, ns. eka anisa mardella, s.kep, & ns. pamilih eko karyuni, s.kep. jakarta: buku kedokteran egc. mulyaningsih, (2013). peningkatan perilaku caring melalui kemampuan berfikir kritis perawat. jurnal managemen keperawatan. 1(2): 100-106. retrieved from : https://jurnal.unimus.ac.id/index.php/jmk/arti cle/view/1005 notoatmodjo, s. (2010). metodologi penelitian kesehatan (ed. rev.). jakarta : rineka cipta. nursalam. (2011). konsep dan penerapan metodologi penelitian ilmu keperawatan. pedoman skripsi, tesis dan instrumen penelitian keperawata. ed.2. jakarta : salemba medika potter, p., & perry a.g. (2009). fundamental keperawatan. buku 2. edisi 7. alih bahasa: nggie a.f, albar m. jakarta: salemba medika putra, w., saleh, a., & bahar, b. (2014). the correlation of caring and job satisfaction with nurses performance in government hospital in palu city central sulawesi province. jst kesehatan. 4(4): 394-400. retrieved maret 18, 2018. from : http://pasca.unhas.ac.id/jurnal/files/ad0bb176 700720aa1b992b9966c01c6f.pdf https://ejournal.unsrat.ac.id/index.php/jkp/article/view/8029 https://ejournal.unsrat.ac.id/index.php/jkp/article/view/8029 https://www.ncbi.nlm.nih.gov/pubmed/9485781 https://www.ncbi.nlm.nih.gov/pubmed/9485781 http://vaww.environmentalauditing.org/portals/auditfiles/audithospitalwastemanagement1.pdf http://vaww.environmentalauditing.org/portals/auditfiles/audithospitalwastemanagement1.pdf http://vaww.environmentalauditing.org/portals/auditfiles/audithospitalwastemanagement1.pdf https://doi.org/10.1111/jan.12644 http://www.pusdatin.kemkes.go.id/ http://dx.doi.org/10.18203/2320-6012.ijrms20164228 http://dx.doi.org/10.18203/2320-6012.ijrms20164228 http://dx.doi.org/10.33546/bnj.404 http://doi.org/10.22216/jen.v2i2.1882 https://jurnal.unimus.ac.id/index.php/jmk/article/view/1005 https://jurnal.unimus.ac.id/index.php/jmk/article/view/1005 http://pasca.unhas.ac.id/jurnal/files/ad0bb176700720aa1b992b9966c01c6f.pdf http://pasca.unhas.ac.id/jurnal/files/ad0bb176700720aa1b992b9966c01c6f.pdf jurnal ners http://e-journal.unair.ac.id/jners | 61 putri, a.a. (2014). strategi budaya character caring of nursing. bogor : in media. reid, c. (2011). caring efficacy and job satisfaction in australian registered nurses. in ssti 41st bienneal convention, 29 october – 2 november 2011, grapevine, texas. unpublished. retrieved maret 18, 2018. from : https://eprints.qut.edu.au/58777/ reid, c. (2012). examination of relationship and mediating effects of self efficacy locus of control, coping and the practice enviropment on caring efficacy and job satisvication in australian registered nurse. disertasi. unpublished. retrieved maret 18, 2018. from : http://www.eprints.qut.edu.au/53139/1/car ol_reid_thesis.pdf rusinova, k.r., kukal, j., simek,j. r.,cerny,v. (2014). limited family members/staff communication in intensive care unit in the czech and slovak republics considerably increases anxiety in patients relatives the depress study. bmc psychiatry. 14(21): 2-7. doi : https://doi.org/10.1186/1471-244x-14-21 rustika, i.m. (2012). efikasi diri : tinjauan teori albert bandura. buletin psikologi. 20(2): 18-15. retrieved from : https://jurnal.ugm.ac.id/buletinpsikologi/articl e/view/11945/8799 sugiyono. (2010). metode penelitian kuantitatif kualitatif dan r & d. bandung : alfabeta. sukesi, n. ( 2013, mei 16 ). upaya peningkatan caring perawat terhadap kepuasan pasien di ruang rawat inap rs permata medika semarang. jurnal managemen keperawatan ppni. 1(1): 15-24. retrieved from : https://jurnal.unimus.ac.id/index.php/jmk/arti cle/view/945/997 tumbuan, f.c., mulyadi., kallo, v.d. (2017). hubungan komunikasi terapeutik perawat dengan tingkat kepercayaan keluarga pasien di intensive care unit (icu) rsu gmim kalooran amurang. jurnal keperawatan. 5(2): 1-6. retrieved from : https://ejournal.unsrat.ac.id/index.php/jkp/arti cle/view/14888/14452 watson, j. (2007). watson’s theory of human caring and subjective living experiences : carative factors/caritas processes as a disciplinary guide to the professional nursing practice. texto & contexto enfermagen, 16(1): 129-35. doi: http://dx.doi.org/10.1590/s010407072007000100016 watson, j. (2018). social justice and human caring: a model of caring sciences as a hopeful paradigm for moral justice for humanity. creative nursing. 24(supl.1): 1-8. doi: https://doi.org/10.1891/1078-4535.14.2.54 zees, r.f. (2012). analisis budaya organisasi yang berhubungan dengan perilaku caring perawat pelaksana di ruang rawat inap rsud prof dr. h. aloeisabue kota gorontalo. journal health and sport. 5(2): 1-14. retrieved from : http://ejurnal.ung.ac.id/index.php/jhs/article/ view/927/867 https://eprints.qut.edu.au/58777/ http://www.eprints.qut.edu.au/53139/1/car%20ol_reid_thesis.pdf http://www.eprints.qut.edu.au/53139/1/car%20ol_reid_thesis.pdf https://doi.org/10.1186/1471-244x-14-21 https://jurnal.ugm.ac.id/buletinpsikologi/article/view/11945/8799 https://jurnal.ugm.ac.id/buletinpsikologi/article/view/11945/8799 https://jurnal.unimus.ac.id/index.php/jmk/article/view/945/997 https://jurnal.unimus.ac.id/index.php/jmk/article/view/945/997 https://ejournal.unsrat.ac.id/index.php/jkp/article/view/14888/14452 https://ejournal.unsrat.ac.id/index.php/jkp/article/view/14888/14452 http://dx.doi.org/10.1590/s0104-07072007000100016 http://dx.doi.org/10.1590/s0104-07072007000100016 https://doi.org/10.1891/1078-4535.14.2.54 http://ejurnal.ung.ac.id/index.php/jhs/article/view/927/867 http://ejurnal.ung.ac.id/index.php/jhs/article/view/927/867 sirep sebagai immunomodulator pada lansia dengan gangguan pemenuhan tidur (sleep therapy as immunomodulator of elderly with sleep disorder) joni haryanto*, suhartono taat putra** * program studi s1 ilmu keperawatan fakultas kedokteran universitas airlangga. jl. prof. dr.moestopo 47 surabaya. telp/fax: (031) 5012496, e-mail: jurnalners_psikunair@yahoo.com ** fakultas kedokteran universitas airlangga. abstract introduction: sirep is one of the nursing intervention to solve sleep problems. moreover, sirep as immunomodulator for cortisol level, ifn-γr and il-10 is still unknown. sleep disorder can make decrease of immunity, concentration disability, decrease of coordination, alteration of personality, etc. decrease of immunity can caused by increase or imbalance of stress hormone (cortisol). increase of cortisol in along time can suppresed t lymphocytes. objective of this study was to analyze the effect of sleep therapy (sirep) as immunomodulator in elderly with sleep disorder method: this study used quasy-experimental pre-post test control group non randomised design. result: result showed that sleep therapy (sirep) can changed ifnr level in serum elderly with wilcoxon sign rank test had p<0.01 and mann whitney u-test had p<0.01. sleep therapy (sirep) can be change il-10 level serum of elderly could be concluded that there was significant difference with wilcoxon sign rank test had p<0.01 and mann whitney u-test not significant difference had p>0.01. discussion: sleep therapy of elderly can released cortisol level serum changing, so sleep therapy as immunomodulator in elderly with sleep dissorder was verified. discussion: sleep therapy must applied on elderly with sleep disorder, because sleep therapy become immunomodulator on elderly with sleep disorder was verified. keywords: sirep, sleep needed, elderly, immunity. pendahuluan kejadian multiple diseases pada lansia sangat erat kaitannya dengan atrofi kelenjar thimus dan gangguan tidur (darmojo dan martono, 1999). hypnotherapy mampu menidurkan seseorang sampai pada gelombang tetta atau tidur rems (nurindra, 2006). sirep merupakan terapi tidur dengan teknik menguasai bawah sadar dan mampu menidurkan pasien sampai gelombang delta (deep sleep), namun terapi sirep sebagai imunomodulator terhadap kadar kortisol, ifn-γr dan il-10 masih belum diketahui. terdapat 67 orang lansia yang menghuni panti unit pelayanan sosial tresna werdha tulungagung. data yang diperoleh dari panti sebanyak 32 orang mengalami gangguan tidur. carpenito, l.j. (2000) menyebutkan hasil penelitian damen, et.al, yang melaporkan bahwa orang–orang yang masih muda dilaporkan efisiensi tidurnya 80-90%, sementara lansia 67-70%. luce dan segal dalam carpenito, l.j. (2000) juga mengungkapkan bahwa pada kelompok lansia (40 tahun) hanya dijumpai 7% kasus yang mengeluh mengenai masalah tidur (hanya dapat tidur tidak lebih dari lima jam sehari). hal yang sama dijumpai pada 22% kasus pada kelompok usia 70 tahun (terbangun lebih awal dari pukul 05.00 pagi). terdapat 30% kelompok usia 70 tahun yang banyak terbangun di waktu malam hari. gangguan tidur dapat menimbulkan perilaku agresif, kurang dapat berkonsentrasi, koordinasi menurun, rasa capai, gelisah, gangguan persepsi, halusinasi, disorientasi dan perubahan kepribadian. imunitas klien dengan gangguan tidur rendah. hal tersebut disebabkan oleh tidak adanya keseimbangan hormon stres (cortisol), yang umumnya meningkat. kortisol meningkat dalam waktu tertentu dapat mensupresi limfosit t. kadar limfosit t yang rendah, mengkibatkan sistem imun yang lain mengalami penurunan, seperti monosit, makrofag, sel nk, cd4+, cd8+, limfosit b dan polimorfonuklear (pmn). menurut stites (1994) bahwa monosit, makrofag, sel nk, cd4+, cd8+ dan limfosit b mempunyai reseptor alfa interferon gamma (ifnr), apabila sitokin tersebut meningkat menunjukkan monosit, makrofag, sel nk, cd4+, cd8+ dan limfosit b mengalami peningkatan. interleukin 10 di hasilkan oleh th2, monosit, makrofag dan limfosit b yang berperan menimbulkan keseimbangan produksi sitokin oleh th1 dan sel nk. dampak yang terjadi apabila seseorang tidak mampu mencukupi kebutuhan tidur, maka akan menimbulkan perubahan kepribadian dan perilaku seperti agresif, menarik diri, atau depresi, rasa capai meningkat, gangguan persepsi, halusinasi pendengaran atau pandangan, bingung dan disorientasi terhadap tempat dan waktu, koordinasi menurun serta bicara tidak jelas, mudah tersinggung dan tidak rileks (priharjo, 1996). merujuk dari kondisi tersebut peneliti ingin mengetahui terapi sirep sebagai imunomodulator terhadap kadar kortisol, ifn-γr dan il-10. bahan dan metode penelitian ini menggunakan desain penelitian quasy experimental pre-post test control group non randomised design. pada penelitian ini teknik sampling yang digunakan adalah non probability sampling yaitu purposive sampling, dengan jumlah sampel 30 responden. penelitian dilaksanakan di panti unit pelayanan sosial tresna werdha tulungagung. kadar kortisol, ifnr, il-10 serum lansia diperiksa secara enzyme linked immunosorbent assay (elisa). elisa merupakan teknik pelabelan indikator dengan menggunakan enzim, yang mempunyai kelebihan cukup sensitif, mempunyai half life lebih panjang dari pada ria (radio immuno assay), dapat menggunakan spektrofotometer biasa dan mudah dilakukan automatisasi dan tidak mengandung bahaya radioaktif. prosedur indirek elisa sebagai berikut: dua kali pengenceran serial serum standar positif dan serum standar negatif dalam tabung, sepuluh kali pengenceran serial dari serum standar negatif dalam tabung, encerkan serum spesimen 1:100 dengan pbs-t dalam tabung (20 l + 2 ml), kosongkan seperti pada poin e-2, kemudian masukkanlah pbs-t 100 l / lubang ke a-1 dan b-1; 90 l/ lubang kesemua sisa lubang yang kosong, yang terakhir reaksikan pada temperatur ruangan selama 1 jam. pengambilan darah dilakukan sesuai dengan siklus diurnal kortisol 24 jam dimana terjadi peningkatan pada jam 08.00 wib (pagi) sebagai puncak kadar kortisol dan jam 24.00 wib (malam) sebagai kadar kortisol paling rendah. pada penelitian ini pengambilan darah sampel pagi dilakukan pada jam 09.00 wib untuk sebelum perlakuan dan setelah perlakuan darah sampel diambil jam 21.00 wib. variabel independen dari penelitian ini adalah teknik sirep, sedangkan variabel dependen adalah kadar kortisol, kadar ifnr dan il-10 serum lansia. data yang diperoleh dari laboratorium dianalisis dan diuji dengan wilcoxon signed rank test dan mannwhitney u-test. hasil data pada tabel 1 dapat dilihat adanya penurunan nilai rerata dari 18,95 g/dl menjadi 10,15 g/dl. nilai rerata pada kelompok kontrol sebelum diberikan terapi sirep adalah 18,98 g/dl dan nilai rerata post untuk kelompok kontrol 14,85 g/dl. pada hasil uji analisis statistik dengan menggunakan mann whitney u-test pada tingkat signifikansi =0,01 menunjukkan p<0,01. pada wilcoxon signed rank test didapatkan p<0,01 menunjukkan bahwa ada pengaruh pemberian terapi sirep terhadap kadar kortisol lansia. pengaruh pemberian terapi sirep pada lansia terhadap kadar il-10 menunjukkan adanya peningkatan nilai rerata dari 445,36 pg/ml menjadi 499,36 pg/ml. nilai rerata pada kelompok kontrol sebelum diberikan terapi sirep adalah 416 pg/ml dan nilai rerata post untuk kelompok kontrol mempunyai kadar il-10 sebanyak 422,80 pg/ml. dari hasil uji analisis statistik dengan tingkat signifikansi =0,01 pada mann whitney u-test didapatkan p>0,01 sedangkan dengan menggunakan uji wilcoxon signed rank test diperoleh p<0,01 (lihat tabel 2). pada tabel 3 dapat dilihat terdapat peningkatan nilai rerata ifn-r dari 24,09 pg/ml menjadi 29,45 pg/ml. nilai rerata pada kelompok kontrol sebelum diberikan terapi sirep adalah 25,70 pg/ml dan nilai rerata post untuk kelompok kontrol mempunyai kadar ifn-r sebanyak 26 pg/ml. dari hasil uji analisis statistik dengan tingkat signifikansi =0,01 pada uji mann whitney u-test di dapatkan p>0,01 dan dengan menggunakan uji wilcoxon signed rank test diperoleh p<0,01. hal ini menunjukkan bahwa ada pengaruh pemberian terapi sirep pada lansia terhadap kadar ifn-r di panti unit pelayanan sosial tresna werdha tulungagung. pembahasan tidur merupakan kebutuhan dasar yang dibutuhkan setiap manusia, namun dalam keadaan sakit kebutuhan tidur akan terganggu yang disebabkan oleh berbagai faktor yaitu faktor psikologis, faktor fisik dan faktor lingkungan. berdasarkan hasil penelitian kepada lansia yang mengalami gangguan pemenuhan kebutuhan tidur pada kelompok perlakuan terjadi peningkatan kebutuhan tidur. pada kelompok kontrol pemenuhan kebutuhan tidur lansia sebagian besar masih kurang. hal ini dipengaruhi oleh keadaan individu sendiri yang sedang sakit, keadaan lingkungan yang bising, maupun adanya gangguan psikologis. tabel 1. hasil uji analisis statistik pengaruh terapi sirep terhadap kadar kortisol (g/dl) pada lansia di panti unit pelayanan sosial tresna werdha tulungagung tabel 2. hasil uji analisis statistik pengaruh terapi sirep terhadap kadar il-10 (pg/ml) pada lansia di panti unit pelayanan sosial tresna werdha tulungagung keterangan: p = signifikansi sd = standar deviasi x = rerata perlakuan kontrol pre (jam 09.00) post ( jam 21.00) pre (jam 09.00) post ( jam 21.00) x=18,95 x=10,15 x=18,98 x=14,85 sd=2,13 sd=1,05 sd=2,26 sd=2,26 wilcoxon signed rank test p=0,003 wilcoxon signed rank test p=0,005 mann whitney u-test p=0,00001 perlakuan kontrol pre (jam 09.00) post ( jam 21.00) pre (jam 09.00) post ( jam 21.00) x=445,36 x=499,36 x=416,00 x=422,80 sd=45,04 sd=121,91 sd=35,36 sd=123,01 wilcoxon signed rank test (p=0,003) wilcoxon signed rank test (p=0,005) mann whitney u-test p=0,016 tabel 3. hasil uji analisis statistik pengaruh terapi sirep terhadap kadar ifn-r (pg/ml) pada lansia di panti unit pelayanan sosial tresna werdha tulungagung keterangan: p = derajat kemaknaan sd = standar deviasi x = rerata berdasarkan dari konsep dasar terapi sirep, terapi ini sebagai bentuk relaksasi yang dalam baik pikiran dan fisik, maka seseorang dalam keadaan sadar namun rileks, tenang, istirahat pikiran, otot–otot rileks dan pernafasan dalam teratur. keadaan ini menurunkan rangsangan dari luar terhadap formatio retikuler. perangsangan pada nuklei retikuler non spesifik yang mengelilingi thalamus dan nuklei dalam yang difus sering mampu mencetuskan gelombang dalam sistem thalamokortikal. relaksasi sebagai proses pengelolaan pernafasan, ventilasi, difusi dan perfusi menjadi terkontrol. pemusatan pikiran maka impuls dari stresor negatif bisa dialihkan sehingga secara tidak langsung akan membantu dalam menjaga keseimbangan homeostasis tubuh melalui jalan hpa axis, yang dapat merangsang produksi kortisol dalam batas normal. kortisol yang normal akan menciptakan keseimbangan neurotransmitter tubuh yang bermuara pada keseimbangan homeostasisnya (guyton dan hall,1997). hasil terapi sirep menunjukkan adanya keseimbangan kortisol yang dapat memfasilitasi il-10. interleukin 10 menghambat th1 dan sel nk untuk memproduksi sitokin (hamblin, 2003; theze,1999). sistem ketahanan tubuh seluler adalah limfosit t, yang terdiri atas subset tc, th, ts dan tr. peran tc (cd8 + ) telah diketahui sebagai sitolitik terhadap mikroorganisme endogenus obligate sedangkan th (cd4 + ) akan berdiferensiasi dan berproliferasi menjadi th1 dan th2 (mosmann and coffman, 1991 dalam sridharan, 2001). perubahan aktivitas sistem ketahanan tubuh yang didapat (adaptive) yaitu respons imun seluler menuju ke respons imun humoral memungkinkan terdapat hubungan dengan kadar kortisol. aktivitas imun seluler dikendalikan oleh sel t yaitu cd8 + dan cd4 + , sedangkan aktivitas imun humoral oleh sel b. pada lansia yang mengalami atrofi thimus dan mengalami kegagalan tidur yang dalam, sistem pertahanan alami dan cd8 + dalam melakukan proses sitolisis mikroorganisme mengalami kegagalan, maka th1 mengambil peran untuk proses aktivasi makrofag dan cd8 melalui ifn-γ bersama tnf dan th2 menghasilkan il-4, il-5 dan il-6 untuk menstimulasi sel b dan serum menghasilkan imunoglobulin spesifik, sedangkan il-10 dihasilkan oleh th2 untuk proses down regulate sitokin. terapi sirep dapat memfasilitasi il-10 yang dapat menghambat aktifitas yang berlebihan dari th1 dan menstimulasi limfosit b dan sel plasma untuk memproduksi imunoglobulin, sehingga daya tahan tubuh menjadi lebih optimal. berdasarkan data hasil penelitian pengaruh terapi sirep terhadap kadar ifnr pada lansia di panti unit pelayanan sosial tresna werdha tulungagung disebutkan terdapat kemaknaan perubahan. hal ini disebabkan oleh faktor il-10 yang dihasilkan oleh th-2 meningkat untuk proses down regulate sitokin, sehingga stimulasi untuk menghasilkan monosit, makrofag, sel nk, cd4, cd8 dan limfosit b sekaligus jumlahnya menurun. interferon gamma (ifnγ) reseptor alfa dipunyai oleh sel makrofag, monosit, cd8, th-2, limfosit b dan sel nk. semua sel tersebut merupakan sistem perlakuan kontrol pre (jam 09.00) post ( jam 21.00) pre (jam 09.00) post ( jam 21.00) x=24,09 x=29,45 x=25,70 x=26,00 sd=3,45 sd=5,72 sd=3,64 sd=5,44 wilcoxon signed rank test p=0,003 wilcoxon signed rank test p=0,221 mann whitney u-test p=0,114 pertahanan tubuh yang potensial untuk mempertahankan kesehatan dari berbagai mineral non-self. interleukin 10 menghambat th1 dan sel nk untuk memproduksi sitokin (hamblin, 2003 dalam theze, 1999). sistem ketahanan tubuh seluler adalah limfosit t, yang terdiri atas subset tc, th, ts dan tr. peran tc (cd8 + ) telah diketahui sebagai sitolitik terhadap mikroorganisme endogenus obligate sedangkan th (cd4 + ) akan berdiferensiasi dan berproliferasi menjadi th1 dan th2. simpulan dan saran simpulan terapi sirep terbukti merupakan imunomodulator pada lansia yang mengalami gangguan pemenuhan tidur. terapi sirep dapat menimbulkan perubahan kadar kortisol, ifn-γr dan il-10 dalam serum lansia yang mengalami gangguan tidur. hal ini terjadi oleh akibat sirep mampu menurunkan kadar kortisol tubuh sehingga dalam batas kesetimbangan dan mampu memfasilitasi kebangkitan il-10. saran peneliti menyarankan agar lansia yang mengalami gangguan pemenuhan tidur, sebaiknya menggunakan terapi sirep sebagai salah satu metode penanganan, diadakan sosialisasi terapi sirep kepada masyarakat, karena terapi sirep terbukti sebagai imunomodulator pada lansia yang mengalami gangguan pemenuhan tidur, perawat profesional harus berlatih terapi sirep dan dapat menerapkannya sebagai bentuk intervensi keperawatan, sehingga dapat menurunkan kejadian sakit lansia dan dapat membuat hormon stres dalam kondisi seimbang, serta perlu ada penelitian lanjutan dengan jumlah sampel yang memenuhi kualifikasi random, sehingga hasil dapat di generalisasi. kepustakaan abbas, a.k., et al. 2000. cellular and molecular immunology. fourth edition. philadelphia: wb saunders company. avidan, a. 2005. epidemiology, assesment, and treatment of insomnia in the elderly patient, (online) (http://www.medscape.com/viewarticl e/htm., diakses tanggal 14 desember 2006, jam 12.05 wib). baiturokhim. 2005. beberapa jenis gangguan tidur, (online), (http://www.kompascom/komps-cetak /0603/05/keluarga/2483490.htm., diakses tanggal 15 maret 2006, jam 15.17 wib). carpenito, l.j. 2000. diagnosa keperawatan aplikasi pada praktek klinis. jakarta: egc. darmojo dan martono. 1999. geriatri. jakarta: balai penerbit fk–ui fleming, j. 2006. nine rules of sleep hygiene in sleep treatment. toronto: mediresource inc. fogel, j. 2003. behavioral treatments for insomnia in primary care settings, (online), (http://www.medscape.com/viewarticl e/htm., diakses tanggal 14 desember 2006, jam 12.05 wib). guyton dan hall, 1997. buku ajar fisiologi kedokteran. jakarta: egc. hamblin, a.s. 2003. cytokines and cytokine receptors. departement of pathology and infectious diseases. new york: oxford university press. handoyo. 2003. pengantar imunoasai dasar. surabaya: airlangga university press. hister, a. 2006. growth hormones and the effect on sleep. toronto: mediresource inc. johnson, a.g. 1999. high-yield immunology. departement of medical and immunology university of minnesota. philadelphia: a wolters kluwer company. kirchner, j. 1999. itm2a is induced during thymocyte selection and t cell activation and causes downregulation of cd8 when overexpressed in cd4+cd8+ double positive thymocytes, seattle: departement of immunology, university of washington. lueckenotte, a.g. 1996. gerontologic nursing, st. louis: mosby-year book, pp. 23-32. http://www.kompas/ http://www.medscape.com/viewarticle/htm http://www.medscape.com/viewarticle/htm martha, d. 1995. panduan relaksasi dan reduksi stres. edisi 3. jakarta: egc. melissa. 2004. the relaxation response, (online), (http://stress.about.com/cs/relaxation.h tm., diakses tanggal 14 desember 2006, jam 12.05 wib). mosmann and coffman. 1991. heterogenecity of cytokine secretion patterns and functions of helper t cells. adv immunol, 46, 111-47. nurindra, y. 2006. hypnotherapy advant and stage of hypnosis. materi workshop: a journey to the sub conscious world. jakarta: yan nurindra-school of hypnotism. rahayu, r. 2002. karakteristik penyakit pada usia lanjut. naskah lengkap temu ilmiah nasional i dan konferensi kerja iii perhimpunan gerontologi medik indonesia (pergemi). semarang: badan penerbit universitas diponegoro. rantam. 2003. metode imunologi. surabaya: airlangga university press. roitt, et al. 2002. immunology. sixth edition, toronto: mosby inc. stites, et al. 1994. medical immunology. tenth edition. san francisco: lange /mcgraw-hill medical publishing division. theze, j.f.d. 1999. the cytokine network and immune functions. new york: oxford university press. tristram, g.p., et al. 2001. medical immunology. new york: lange medical book. yayasan bali galang. 2002. lontar usada pamugpug. denpasar: fakultas sastra universitas udayana. yayasan bali galang. 2003. usada kurantabolong. denpasar: fakultas sastra universitas udayana. http://stress.about.com/cs/relaxation.htm http://stress.about.com/cs/relaxation.htm pengaruh terapi aktifitas kelompok (tak) stimulasi persepsi modifikasi terhadap pengendalian halusinasi dengar pada 79 manfaat asuhan keperawatan keluarga dalam meningkatkan pengetahuan dan pencegahan kecacatan pasien kusta (the benefit of family nursing care in improve knowledge and prevent the deformity of leprosy patient) nursalam*, makhfudli*, indra alamsyah** abstract introduction : leprosy is one of contagious illness which generates complex situation. the main problem of this study was faced by family in taking care of leprosy. purpose of this research was to analyze the effect of applied family nursing care to knowledge and prevent dissability patient of leprosy. method : design used in this reseach was pre experiment. the population of this study was all family and patient of leprosy in puskesmas taliwang-nusa tenggara barat, whom deal directly with the client. data were analyzed using wilcoxon signed rank test and fisher exact probability test with level of significance α ≤ 0,05. result : results showed that applied family nursing care is an early preventing and continued care is one of the methods to increase family knowledge and prevent the dissability of leprosy reaction to the patient.discussion : it is recomended that the involvement of the family in caring is important. keywords: family nursing care, family knowledge, leprosy patient’s dissability. *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257e-mail: nursalam_psik@yahoo.com ** puskesmas taliwang, dinkes sumbawa barat pendahuluan asuhan keperawatan keluarga merupakan proses kompleks menggunakan pendekatan sistematik untuk bekerjasama dengan keluarga dan individu sebagai anggota keluarga. pelaksanaan asuhan keperawatan keluarga membangkitkan minat dan kepercayaan diri keluarga untuk mengadakan perbaikan kearah perilaku hidup sehat (mubarak, 2006 : 297). pengetahuan keluarga tentang pencegahan cacat dini dan perawatan cacat lanjut membantu perawat dalam menyelesaikan masalah cacat akibat kusta. kusta adalah salah satu penyakit menular yang menimbulkan masalah yang sangat kompleks (depkes. r.i, 2002). prevalensi kusta di kabupaten sumbawa barat 1,2 kasus/10.000 penduduk sedangkan di tingkat puskesmas taliwang prevalensi lebih tinggi yaitu 2,3 kasus/10.000 penduduk (dinkes. ksb, 2008). data dari wasor kusta dinas kesehatan kabupaten sumbawa barat, penderita kusta yang ditangani oleh dinas kesehatan kabupaten sumbawa barat belum mengalami penurunan yang signifikan. periode tahun 2007 sampai oktober 2008 tercatat sebanyak 20 kasus yang telah dan sedang ditangani. perawat pemegang program (p2) kusta puskesmas taliwang mengungkapkan bahwa sampai dengan oktober 2008 jumlah penderita yang sudah release from treatment (rft) sebanyak 3 penderita dan yang sedang dirawat berjumlah 12 kasus dengan rincian 1 (8,3 %) orang tidak cacat, 3 (25 %) orang cacat tingkat satu dan 8 (66,6 %) orang cacat tingkat dua. kecacatan atau kerusakan pada penderita kusta disebabkan oleh kerusakan fungsi saraf tepi pada tubuh manusia, baik karena kuman kusta maupun karena terjadinya peradangan sewaktu reaksi leprae. kerusakan saraf tepi, akan menyebabkan gangguan fungsi saraf tepi jurnal ners vol.4 no.1 april 2009: 79-82 80 meliputi sensorik, motorik dan otonom. kelainan fungsi sensorik menyebabkan terjadinya kurang/mati rasa (anestesi). kelainan fungsi motorik menyebabkan kekuatan otot tangan dan kaki menjadi lemah dan lumpuh serta semakin lama otot mengecil (atropi). kelainan fungsi otonom menyebabkan terjadinya gangguan pada kelenjar keringat, kelenjar minyak dan gangguan sirkulasi darah sehingga kulit menjadi kering, menebal, mengeras dan akhirnya dapat pecah-pecah. masyarakat mengenal penyakit kusta karena adanya cacat. kusta merupakan masalah kesehatan masyarakat tidak lain karena cacatnya, sedangkan hampir semua cacat dan kerusakan yang menetap dapat dicegah (depkes. r.i, 2006). keluarga merupakan perantara yang efektif dan mudah untuk berbagai usaha-usaha kesehatan masyarakat. perawat dapat menjangkau masyarakat hanya melalui keluarga yang berperan merawat pasien, mengambil keputusan dan merupakan lingkungan yang serasi untuk mengembangkan potensi tiap individu dalam keluarga. bahan dan metode penelitian metode penelitian yang digunakan pra-eksperimental dengan rancangan penelitian pra-pasca test dalam satu kelompok (one-group pre-post test design). populasi penelitian adalah keluarga dan pasien kusta yang sedang mengikuti program pengobatan di puskesmas taliwang kabupaten sumbawa barat dengan besar sampel sebanyak 12 keluarga. instrumen yang digunakan dalam pengumpulan data pelaksanaan asuhan keperawatan keluarga menggunakan lembar kuesioner dan observasi terstruktur. untuk penilaian pengetahuan, pengukuran menggunakan kuesioner dengan bentuk pertanyaan multiple choice mengacu pada satuan acara penyuluhan (sap). analisis data menggunakan statistik fisher exact probability dengan nilai kemaknaan α ≤ 0,05 hasil penelitian asuhan keperawatan keluarga adalah tahap dari proses keperawatan dimana perawat membangkitkan minat keluarga untuk mengadakan perbaikan kearah perilaku hidup sehat. hasil pelaksanaan asuhan keperawatan keluarga didapatkan bahwa terdapat peningkatan pengetahuan keluarga tentang penyakit kusta yaitu pada penilaian setelah diberikan asuhan keperawatan keluarga pengetahuan keluarga pada kategori cukup dan baik. tidak ada keluarga yang berpengetahuan kurang (tabel.1). tabel 1. pengaruh pelaksanaan asuhan keperawatan keluarga terhadap pengetahuan keluarga di wilayah kerja puskesmas taliwang kabupaten sumbawa barat tanggal 8 desember 2008 – 8 januari 2009 penilaian sebelum penilaian sesudah kategori nilai kategori nilai mean 58,33 72,50 sd 0,492 15,125 0,522 9,653 wilcoxon signed rank test p=0,002 tabel 2. pengaruh pelaksanaan asuhan keperawatan keluarga terhadap pencegahan kecacatan kusta di wilayah kerja puskesmas taliwang kabupaten sumbawa barat tanggal 8 desember 2008 – 8 januari 2009 keterangan : p = signifikansi penilaian pencegahan kecacatan kusta sebelum sesudah mean 5 4 sd 0,515 0,515 fisher exact p= 0,027 manfaat asuhan keperawatan keluarga (nursalam) 81 pembahasan terdapat perubahan yang bermakna pada pengetahuan keluarga tentang pencegahan cacat dini dan perawatan cacat lanjut, seperti yang ditunjukkan dalam tabel 1. artinya, ada pengaruh (p = 0,002) antara pelaksanaan asuhan keperawatan keluarga dengan pengetahuan keluarga. pemberian penyuluhan kesehatan dengan menggunakan berbagai media alat bantu dan tatacara penyampaian pendidikan kesehatan membantu keluarga untuk lebih cepat dan mudah memahami pesan yang disampaikan oleh perawat keluarga. demontrasi tindakan keperawatan akan membantu keluarga mengingat kembali materi yang diberikan. melaksanakan kunjungan rumah dapat menilai secara langsung tentang perawatan cacat dini dan lanjut sehingga dapat memberikan masukan pada keluarga. keluarga yang memiliki motivasi berprestasi dan motivasi instrinsik kemungkinan keluarga akan berusaha belajar dengan sungguh-sungguh sehingga tingkat kepatuhan kearah perilaku positif akan semakin meningkat. hal ini berarti petugas kesehatan hanya perlu memelihara semangat, perasaan dan keterlibatan ranah afektif tinggi, dalam hal ini guna memelihara keterlibatan belajar keluarga, motivasi intrinsik bersifat memelihara diri sendiri, dan dengan ketiga sifat tersebut perawat harus memelihara keterlibatan keluarga dalam belajar. dalam kaitannya dengan penanganan reaksi dan kecacatan akibat kusta, pengetahuan keluarga dijadikan sebagai output indicator yang merupakan proses dan aktifitas antara dan hipotesis dari hubungan sebab-akibat strategi (nursalam, 2007) dari keluarga untuk memperbaiki kemampuan internalnya. hal ini diperkuat oleh pendapat bloom yang dikutip oleh dimyati dan mujiono (2002 : 27) bahwa ranah afektif terdiri dari pengetahuan, pemahaman, penerapan, analisis, sintesis, dan evaluasi. keenam jenis perilaku ini bersifat hierarkis, artinya perilaku pengetahuan tergolong terendah dan prilaku evaluasi tergolong tertinggi. perilaku terendah merupakan perilaku yang harus dimiliki terlebih dahulu sebelum mempelajari perilaku yang lebih tinggi. menurut peneliti pendapat ini relevan dengan data umum responden yang memiliki tingkat pendidikan, sosial dan ekonomi yang relatif rendah sehingga kemampuan untuk menjangkau ranah kognitf yang lebih tinggi lebih sulit atau membutuhkan waktu yang lebih lama. dalam hal pencegahan kecacatan pasien kusta terdapat perubahan yang signifikan kearah yang lebih baik, hal ini ditunjukkan dengan hasil analisa uji fisher exact probability, didapatkan nilai p=0,027 yang berarti hipotesis penelitian ini diterima. nilai tersebut menunjukkan bahwa keluarga yang telah memiliki pengetahuan yang cukup tentang pencegahan cacat dini dan perawatan cacat lanjut melaksanakan tindakan perawatan keluarga mempengaruhi hasil pencegahan kecacatan kusta. pengetahuan responden (output indicator) akan mempengaruhi (outcome indicator) yakni kondisi (reaksi dan kecacatan kusta) sebagai fokus dari hasil kinerja pada akhir periode waktu atau aktifitas yang merefleksikan keberhasilan atau aktifitas dan keputusan yang telah dilaksanakan. menurut depkes (2005) tujuan pencegahan cacat lanjut adalah agar cacat yang sudah terlanjur ada, tidak akan bertambah berat. hal ini dapat dicapai dengan melatih keluarga dan penderita membiasakan diri melakukan perawatan diri secara mandiri. memberikan latihan perawatan diri akan memperbaiki gambaran atau persepsi terhadap kesehatan dan kebersihan, serta menciptakan penampilan yang sesuai dengan kebutuhan kesehatan. membuat rasa nyaman dan relaksasi dapat dilakukan untuk menghilangkan kelelahan serta mencegah infeksi, mencegah gangguan sirkulasi darah, dan mempertahankan integritas pada jaringan (alimul. h., 2006 : 116-117). simpulan dan saran simpulan asuhan keperawatan keluarga berdampak pada pengetahuan keluarga yang ditunjukkan pada penilaian pengetahuan keluarga (pencegahan cacat jurnal ners vol.4 no.1 april 2009: 79-82 82 dini dan perawatan cacat lanjut) dan pencegahan kecacatan pasien kusta yang ditunjukkan pada perubahan hasil pencatatan pencegahan kecacatan pasien kusta (reaksi kusta dan tingkat kecacatan). saran peneliti menyarankan agar 1) selama pasien kusta menjalani terapi mdt hendaknya keluarga dilibatkan dalam perawatan kesehatan anggota keluarga yang sakit, 2) pencegahan terjadinya kecacatan dan mengurangi kecacatan pada penderita kusta membutuhkan rencana strategi yang lebih terintegrasi dengan melibatkan pasien, keluarga dan petugas kesehatan 3) perawat pemegang program kusta perlu melaksanakan beberapa alternatif kegiatan upaya penyuluhan kesehatan melalui: media leaflet/booklet, melakukan demonstrasi cara perawatan diri dan kunjungan rumah serta diskusi dengan pasien kusta dan keluarganya tentang penyakit kusta dan cara penanganannya. kepustakaan alimul. h., 2006. pengantar kebutuhan dasar manusia : aplikasi konsep dan proses keperawatan, jakarta: salemba medika, hlm.116 – 117. departemen kesehatan r.i a, 2007. modul pelatihan program p2 kusta bagi unit pelayanan kesehatan. jakarta: sub direktorat kusta dan frambusia. departemen kesehatan r.i b, 2006. modul 1: epidemiologi dan program. makasar: pusat latihan kusta nasional (plkn). departemen kesehatan r.i. c, 2006. modul 3: reaksi kusta. makasar: pusat latihan kusta nasional (plkn). departemen kesehatan r.i. d, 2006. modul 4: kecacatan dan pencegahan cacat. makasar: pusat latihan kusta nasional (plkn). departemen kesehatan r.i. e, 2004. modul 5: pencatatan dan pelaporan program p2 kusta. makasar: pusat latihan kusta nasional (plkn). departemen kesehatan r.i. f, 2004. modul 6: pkm. makasar: pusat latihan kusta nasional (plkn). departemen kesehatan r.i. g, 2006. modul 7: supervisi (bimbingan teknis), monitoring dan evaluasi. makasar: pusat latihan kusta nasional (plkn). departemen kesehatan r.i. h, 2006. panduan pelayanan keperawatan kesehatan di rumah. jakarta: direktorat bina pelayanan keperawatan direktorat jenderal bina pelayanan medik. departemen kesehatan r.i i, 2002. buku panduan pelaksanaan program kusta bagi petugas unit pelayanan kesehatan. jakarta: direktorat kosasih., a., dkk (2006). kusta. makalah kesehatan mubarak, w.i., (2005). pengantar keperawatan komunitas 1. jakarta: sagung seto, hlm. 5060. mubarak., dkk., 2006. pengantar keperawatan komunitas 2. jakarta: sagung seto, hlm. 141-145, 150-159, 255-269, 285-303, 304-307. nursalam c., 2007. perencanaan pelayanan keperawatan di rumah sakit dengan metode balance scorecard (bsc). makalah keperawatan. 18 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.5690 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family-based maternal sensitivity model as a strategy to optimize family perception on the role of parents and the growth of infants diyan indriyani and susi wahyuning asih faculty of health sciences, university of muhammadiyah jember, jember, indonesia abstract introduction: family perceptions on the role of parents and the growth of infants must be seriously considered by healthcare workers since they can affect the role of family development in taking care of the babies. a family that has optimally understood the role of their development as a parent will be able to give the appropriate care for the babies. methods: the study aimed to find out the effects of a family-based maternal sensitivity models (msm) strategy for family perception optimization on the role of parents and the growth of infants. it used a quasi-experimental design with the samples of 50 families. the samples were obtained using purposive sampling technique. the data were analyzed using dependent t-test. results: it confirmed that the family-based maternal sensitivity models (msm) strategy significantly affects family perceptions on the role of parents with t-value 5.915 and p-value 0.000. msm also significantly affects family perceptions on the growth infants with the t-value -11.257 and p-value 0.000. conclusion: maternal sensitivity models (msm) can be well applied as one of the health models provided by healthcare workers to optimize parents’ perceptions and infants’ growth as well as to develop a competent family in giving care for their babies. article history received: august 27, 2017 accepted: april 18, 2018 keywords maternal sensitivity model; family perceptions; role of parents; growth of infants contact diyan indriyani  diyanindriyani@unmuhjember.ac.id  faculty of health sciences, university of muhammadiyah jember, jl. karimata 49 jember, east java, indonesia cite this as: indriyani, d., & asih, s. (2018). family-based maternal sensitivity model as a strategy to optimize family perception on the role of parents and the growth of infants. jurnal ners, 13(1), 18-23. doi:http://dx.doi.org/10.20473/jn.v13i1.5690 introduction the birth of a baby is a process that can change the life of the family. the presence of a new family member makes the family, especially parents, have new roles, duties and responsibilities. the process is a transitional period that can provide both physical and psychological impacts on the developmental stage of the family (wright and leahey, 2009).the transitional period of this stage becomes the trigger factor of stress and imbalance in the family if they are not able to play their new roles as parents (friedman, bowden and jones, 2010). every family has roles related to the responsibilities which must be accomplished in order to fulfill the needs of the family. the role of the family related to the baby is to provide infant care and to monitor infant growth (kaakinen et al., 2015). the family has an important role to support the parents in caring for their baby. however, most parents are less skilled in caring for babies, including how to monitor their growth and development. this is consistent with the 2004 infant health and development (ihdp) survey which found that parents are low-skilled in caring for their babies. such condition is caused by many factors, such as the dominance of the role of grandmother, grandfather and other family members (indriyani, asmuji and wahyuni, 2016). this phenomenon often occurs in most families in indonesia because it relates to the culture adopted by each family (asmuji and indriyani, 2014). the research (asmuji and indriyani, 2014) recommends the importance of policy makers in formulating programs related to the empowerment of families in optimizing their parenthood role. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:diyanindriyani@unmuhjember.ac.id http://dx.doi.org/10.20473/jn.v13i1.5690 jurnal ners http://e-journal.unair.ac.id/jners | 19 one of the efforts which can solve those problems is by improving the ability of families regarding a parent’s role and the ability to monitor the growth of infants. maternal sensitivity models (msm), developed by the researcher, can be performed to conduct those efforts by involving the family as social support. this model shows its advantages when the family perception increases and the family is actively involved in the efforts, in which the function of infant care will be better and more appropriate (dokken and ahmann, 2006). the increase will lead the family to work actively and to have expertise in providing support to the infant’s parents and monitoring infant growth. it will also contribute to the optimization of the health status of infants, which is actually the mother’s responsibility. the involvement of the family in caring for the infant is expected to reduce infant mortality rate. the present research is similar to the research conducted by mendelson et al. (2013) which showed that infant-based psychological intervention could prevent postpartum depression and affect social support. however, the previous research only involved mother and baby in preventing postpartum depression while family involvement has not been performed optimally. another similar research suggests that a continuing education program through public health nurses is important to be provided to the family, with limitation only for the families who have babies with very low birth weight (pridham et al., 2006). based on the background, the development of maternal sensitivity models (msm) is important to make the interventions more complete by involving the family to improve their competence in carrying out the role of parents and monitoring infant growth (pontoppidan, 2015). therefore, the aim of this study was to analyze the effects of maternal sensitivity models (msm) in regards to the optimization of family perceptions on parents’ role and infant growth. materials and methods the study used quantitative research with quasiexperiment design and aimed to analyze the effectiveness of maternal sensitivity models (msm) that have been formulated to optimize the family perception of parents’ role and infant growth. the study was conducted in march-june 2017 in sumbersari and sukorambi districts, jember, east java, indonesia. the data collection was started by measuring the family's perceptions on parents’ role and infant growth (pre-test) using questionnaires. after the pretest, the researchers performed the implementation of maternal sensitivity models (msm) which focused on training and education about parents’ role and stimulation of infant growth. it was implemented for three months with six interventions. the last stage was to evaluate the changes in family perceptions related to parents’ role and infant growth (post-test). the variables consisted of maternal sensitivity models (msm) as independent variable and family perceptions of parents’ role and family perceptions on infant growth as dependent variables. the population of the study was families who have babies aged 1-12 months. the sample was 50 families taken using purposive sampling with inclusions and exclusions criteria. the inclusion criteria were families who have babies and babies living at home with parents. meanwhile, the exclusion criteria were the baby being sick during the intervention and the husband was not at home. the instrument used was a questionnaires distribution about family perceptions on the optimization of parents’ role and infant growth developed by researcher. the scoring system of the instrument used numerical data from a score of 20100 with parameters measured being cognitive, affective and conative components. the reliability value of the questionnaire perceptions on the role of parents used cronbach’s alpha of 0.79 and reliability questionnaire perceptions on the growth infants of 0.81. the data analysis used dependent t-test with α (alpha) value of 5% (0.05). the study has passed ethical clearance with number 003/kepk/fikes/iii/2017 issued by the health research ethics committee, faculty of health sciences, university of muhammadiyah jember on march 4, 2017. thus, the implementation of research has also applied the principle of non-maleficence ethic where the researchers agree the time of implementation of the intervention with the families. another ethical principle is beneficence, by applying research benefits to respondents by explaining them the benefits of intervention. another ethical principle is also respect of human dignity by means of the researchers affording freedom to the families in thinking and deciding consciously and without applying pressure or coercion to take part or refusing participation in the present research, conducted by using informed consent. furthermore, the familybased maternal sensitivity models (msm) approach can be seen in the figure 1. results table 1 shows that the greatest number of age of family is 20-35 years old with 29 respondents (58%). the greatest number of the family profession is labor and trader with 18 respondents (36%). table 1 also shows that the greatest number of family education background is senior high school with 32 respondents (64%). table 2 shows that family-based maternal sensitivity models (msm) application significantly affects family perceptions on the role of the family in infant care with p-value 0.000. based on the table 3, it can be seen that familybased maternal sensitivity models (msm) application also significantly effects the family perceptions on infant growth with p-value 0.000. d. indriyani et al. 20 | pissn: 1858-3598  eissn: 2502-5791 discussion the family-based maternal sensitivity models (msm) have a significant effect on family perceptions on parents’ role in infant care. the family-based maternal sensitivity models (msm) approach in improving family perceptions on parent’s role is in accordance with nursing intervention step in nursing intervention classification (nics): designing educational programs based on family strength, identifying personal factors that impact on the success of the program (e.g., cultural values, negative experiences, time commitments, interests), facilitating family discussions on parenting methods, teaching the families about physiological, emotional and infant care, and helping the families to identify evaluation criteria for daily infant care. the concept is supported by the results of triple parenting program interventions that shows that infant care programs which are supported by family involvement are proven to be effective in increasing family satisfaction in carrying out the role of parenting (mcconnell, breitkreuz and savage, 2012; williams and hutchings, 2015). maternal sensitivity models (msm) interventions that make families as social support for other family members has formed a continuous interaction among family members in performing their roles, so that these conditions can effectively improve communication and harmony within the family. social support of the family (physical, emotional and instrumental supports) in a parenting role has formed cognitive and affective awareness of the family members so as to perform their role (padden et al., 2013; pender, murdaugh and parsons, 2015). it is also in accordance with the results of the research conducted by pontoppidan (2015) suggesting that family involvement programs in infant care are effective to overcome the physical and psychological problems of infants. family involvement programs in infant care also support the success of breastfeeding (langlois and smith-sharp, 2001; nuzulia, 2011; daniels et al., 2015; swigart et al., 2017). instrumental support (such as assisting infant care, complementary roles and tasks in fulfilling the role of infant care), emotional support (such as praise, loving relationship), and information support (such as ideas and suggestions) are the key support that contributes to the role of family care. therefore, family support is very important for families who have babies (hamilton, 2010) . this is consistent with the research (verhage, oosterman and schuengel, 2015) suggesting that family support affects the parents’ role in parenting, so that it affects the baby's temperament as well. in contrast, a research conducted by hegedus and mullan (2015) shows that, in australia, which is a developed country, the family support for baby care in supporting the breastfeeding process has not yet been performed optimally. family support is a key point in maternal sensitivity models (msm) so that family perceptions of the parent role can be increased. the family is the main social support for the developmental stage of figure 1. family-based maternal sensitivity model in optimization of infant care competence jurnal ners http://e-journal.unair.ac.id/jners | 21 the family with babies because there is a transition period into a new family at this stage that requires optimal support from other family members (kaakinen et al., 2015). the parents’ role in undertaking infant care is very important because it affects the physical and mental conditions of the baby (dokken and ahmann, 2006; day, bernheimer and weisner, 2007). the previous research shows that poor baby personality is associated with self-efficacy or parenting skills in infant care (padden et al., 2013; verhage et al., 2015).therefore, it needs family support from other family members to optimally realize the parents’ role (hickey et al., 2016).therefore, it needs powerful support from other family members in realizing the optimal parent role. maternal sensitivity models (msm) use family strength resources and family potential as key social support in enhancing the parental role so that msm is proven to improve family perceptions on the parental role. another result of the present research also confirms that family-based maternal sensitivity models (msm) have an effect on family perceptions on infant growth. it becomes something that is rarely noticed by families who have babies. the family perceptions on infant growth can be well improved through family-based maternal sensitivity models (msm). this is because the support provided by the family becomes a stimulus that can improve the perceptions of other family members, so that there is an exchange of information from each family member. also, it indicates that support given to families who have babies from other family members can improve the health status of the babies, one such is related to infant growth (adema, clarke and frey, 2016). the families who get full support from family members get many benefits for both the family and the baby. the family which supports the young mother in monitoring the growth of babies, e.g., accompanying the young mother in monitoring the height and weight and monitoring the development of infants in posyandu or in other healthcare services can create harmonious and happy conditions for families. programs involving family members, in infant care, are also evident by studies showing that family support greatly contributes to improving infant health and lowers stress levels while undergoing infant care (pontoppidan, 2015). one indicator of infant health is infant growth. it is influenced by many factors, one of which is the parent role. in accordance with the related theory, it shows that psychosocial factors are the ability of parents in stimulating the development of infants, as well as motivation in caring for babies and these can affect infant growth and development. parents who often table 1. frequency distribution of the age, the profession and education background of families (n=50) demographic data number percentage age < 20 years old 7 14.0 20-35 years old 29 58.0 > 35 years old 14 28.0 total 50 100.0 profession labor and trader 18 36.0 farmer 11 22.0 civil servants 9 18.0 self-employed 12 24.0 total 50 100.0 education background junior high school 14 28.0 senior high school 32 64.0 higher education 4 8.0 total 50 100.0 table 2. the effects of family-based maternal sensitivity models (msm) to family perceptions on parents’ role (n =50) variable mean std. deviation std. error mean p-value perceptions of the role of parents in infant care pre-test 61.00 7.626 1.079 0.00 post-test 71.80 8.497 1.202 table 3 the effects of family-based maternal sensitivity models (msm) to family perceptions on infant growth (n = 50) variable mean std. deviation std. error mean p-value perceptions on infant growth pre-test 60.60 7.117 1.007 0.00 post-test 76.40 6.627 0.937 d. indriyani et al. 22 | pissn: 1858-3598  eissn: 2502-5791 stimulate infant development will have a different impact on infant development than the parents who never give stimulation for infant growth (hockenberry and wilson, 2009). family perceptions on infant growth is important to be improved since it affects infant growth and development. maternal sensitivity models (msm) that make the family as the main social support of family perception about baby growth can be improved. this is due to the support provided by the family to other family members. this opinion is also supported by a meta-analysis study showing that nursing interventions given by involving families are more effective in improving parenting tasks, such as monitoring infant growth (tanninen et al., 2015). nurses who involve families in providing interventions have the virtue of being able to see the potential of the family and exploiting the potential of the family in supporting other family members to fulfill their duties and responsibilities in providing infant care, including about infant growth, so that infant growth can be achieved optimally. conclusions family is major social support in realizing and improving infant health status. a family-based maternal sensitivity models (msm) approach as the main social support for other family members significantly affects the family perceptions on the parent role and infant growth. references adema, w., clarke, c. and frey, v. (2016). paid parental leave and other supports for parents with young children: the united states in international comparison. international social security review, 69(2), pp. 29–51. https://doi.org/10.1111/issr.12100 asmuji, i.d. (2014). model edukasi postnatal melalui pendekatan fcmc sebagai strategi optimalisasi competence mothering dalam menurunkan angka kematian ibu dan bayi di kabupaten jember. jurnal keperawatan, 2. browne, j.v., langlois, a., ross, e.s. and smith-sharp, s. (2001). beginnings: an interim individualized family service plan for use in the intensive care nursery. infants & young children: an interdisciplinary journal of early childhood intervention, 14(2), pp.19–32. [online] available at: http://search.ebscohost.com/login.aspx?direct=t rue&db=cin20&an=106920225&site=ehost-live (accessed: june 24, 2017). daniels, l., heath, a.-l. m., williams, s. m., cameron, s. l., fleming, e. a., taylor, b. j., wheeler, b.j., gibson, r.s. and taylor, r. w. (2015). baby-led introduction to solids (bliss) study: a randomised controlled trial of a baby-led approach to complementary feeding. bmc pediatrics, 15(1), p. 179. https://doi.org/10.1186/s12887-015-0491-8 day, a., bernheimer, l. p. and weisner, t. s. (2007). let me just tell you what i do. infants & young children, 20(3), pp. 192–201. dokken, d. and ahmann, e. (2006). the many roles of family members in “family-centered care” -part i. pediatric nursing, 32(6), pp.562–565 [online] available at: http://search.ebscohost.com/login.aspx?direct=t rue&db=rzh&an=106268035&site=ehost-live (accessed:). friedman, m.m., bowden, m. and jones, k. (2010). buku ajar keperawatan keluarga: riset, teori, dan praktik. jakarta: egc. hamilton, k. (2010). parental physical activity: exploring the role of social support. american journal of health behavior, 34(5), pp. 573–84. https://doi.org/10.5993/ajhb.34.5.7 hegedus, j. and mullan, j. (2015). are we adequately providing support services for optimal infant nutrition in australia? a study in regional nsw. australian journal of primary health, 21(3), pp.293–298. https://doi.org/10.1071/py14044 hickey, g., mcgilloway, s., furlong, m., leckey, y., bywater, t. and donnelly, m. (2016). understanding the implementation and effectiveness of a group-based early parenting intervention: a process evaluation protocol. bmc health services research, 16(1), p. 490. https://doi.org/10.1186/s12913-016-1737-3 hockenberry, m.j. and wilson, d. (2009). wong’s essentials of pediatric nursing. 8th th ed. st louis: mosby. indriyani, d., asmuji and wahyuni, s. (2016). edukasi postnatal dengan pendekatan family centered maternity care (fcmc). yogyakarta: trans medika. kaakinen j r, coehlo d p, steele r, tobacco, a. and hanson, s. m. (2015). family health care nursing: theory, practice, and research 5th ed. philadelphia: davis company. mcconnell, d., breitkreuz, r. and savage, a. (2012). independent evaluation of the triple p positive parenting program in family support service settings. child and family social work, 17(1), pp. 43–54. https://doi.org/10.1111/j.13652206.2011.00771.x mendelson, t., leis, j. a., perry, d. f., stuart, e. a. and tandon, s. d. (2013). impact of a preventive intervention for perinatal depression on mood regulation, social support, and coping. archives of women’s mental health, 16(3), pp.211–218. https://doi.org/10.1007/s00737-013-0332-4 nuzulia, f. (2011). hubungan antara dukungan keluarga dengan pemberian asi eksklusif pada bayi di desa bebengan kecamatan boja kabupaten kendal, pp.1–8. padden, d. l., connors, r. a., posey, s. m., ricciardi, r. and agazio, j. g. (2013). factors influencing a health promoting lifestyle in spouses of active duty military. health care fpr women international, 34(8), pp. 674–693. https://doi.org/10.1080/07399332.2012.73657 2 jurnal ners http://e-journal.unair.ac.id/jners | 23 pender. n, murdaugh, c, and parsons, m, a. (2015). health promotion in nursing practice 7th ed. sidney: appleton & lange. pontoppidan, m. (2015). the effectiveness of the incredible yearstm parents and babies program as a universal prevention intervention for parents of infants in denmark: study protocol for a pilot randomized controlled trial. trials, 16(1), p. 386. https://doi.org/10.1186/s13063-015-0859-y pridham, k. f., limbo, r. k., schroeder, m., krolikowski, m. m. and henriques, j. b. (2006). a continuing education program for hospital and public health nurses to guide families of very low birth-weight infants in caregiving. journal of continuing education in nursing, 37(2), pp. 74–85. https://doi.org/10.3928/00220124-2006020105 swigart, t. m., bonvecchio, a., théodore, f. l., zamudio-haas, s., villanueva-borbolla, m. a. and thrasher, j. f. (2017). breastfeeding practices, beliefs, and social norms in low-resource communities in mexico: insights for how to improve future promotion strategies. plos one, 12(7), pp.1–22. https://doi.org/10.1371/journal.pone.0180185 tanninen, h.-m., häggman-laitila, a., pietilä, a.-m. and kangasniemi, m. (2015). the content and effectiveness of home-based nursing interventions to promote health and well-being in families with small children: a systematic review. scandinavian journal of caring sciences, (19). https://doi.org/10.1111/scs.12251 verhage, m. l., oosterman, m. and schuengel, c. (2015). the linkage between infant negative temperament and parenting self-efficacy: the role of resilience against negative performance feedback. british journal of developmental psychology, 33(4), pp. 506–518. https://doi.org/10.1111/bjdp.12113 williams, m. e. and hutchings, j. (2015). a pilot effectiveness study of the enhancing parenting skills (epas) 2014 programme for parents of children with behaviour problems: study protocol for a randomised controlled trial. trials, 16(1), pp. 1–10. https://doi.org/10.1186/s13063-0150741-y wright l.m. and leahey.m. (2009). nurses and families: a guide to family assessment and intervention. 5th ed. philadelphia: fa davis company. authors index volume 18 nomor 2 june 2023 ahmad, nazrin, 124 nuryanto, i kadek alshiekh, intisar, 159 pholanun, naphaklacha, 108 anakotta, ni olivya, 200 piyakong, duangporn, 108 apiratanawong, sangduan, 117 piyakong, duangporn, 117 ayumar, andi, 184 purwanto, djoko agus, 145 daengthern, laddawan, 192 putra, made mahaguna, 154 dewi, inggriane, 169 rochmawati, erna, 200 fatihuddin, m.fata, 145 rungreangkulkij, somporn, 131 fatmawati, ariani, 169 saidi, sanisah binti, 200 firdha, azizah amimathul, 145 sarirudi, tita indah, 169 fouly, howieda, 159 shodiq, muhammad ja'far, 145 hanifah, anny, 145 sismulyanto, sismulyanto, 154 hassan, hamidah, 124 suasing, chanikan, 117 hidrus, aizuddin, 124 suharjanti, isti, 145 jiyane, phyllis makoasha, 176 sutini, ni kadek, 110 kadir, fairrul, 124 suyasa i gede putu darma, 110 kamaryati, ni putu, 110 thojampa, somsak, 192 kasma, andi yulia, 184 udkhammee, kunchayarat, 192 khunou, sisinyana, 176 wahyuni, tri, 131 kim, beom joon, 145 wider, walton, 124 kumpeera, kittisak, 192 widianti, anggriyana tri, 169 machin, abdulloh, 145 wulandari, silfia, 169 masoud, ayat, 159 yulianita, marisna eka, 184 menap, menap, 154 zaghloul, mervat gaber, 159 subject index volume 18 nomor 2 june 2023 a i acute ischemic stroke; 145 improving health problems; 117 acute respiratory infection; 184 indonesia; 110 adolescent mothers; 131 k aged; 110 knowledge; 154 attitude; 154 l b life long; 192 basic immunization; 131 m breast cancer; 169 material resources; 176 breastfeeding; 131 m-health; 200 c mobile-app technology; 169 cancer; 200 modified conventional training method; 124 cardiac arrest; 124 n cardiopulmonary resuscitation; 124 nurses; 176 childbirth roadmap experience; 159 p children’s health status; 131 practice; 154 complementary intervention; 169 q covid-19; 154 qualitative; 131 d r dealing with illness; 192 reduction of stress exposure; 192 depression; 110 residents; 154 district health system; 117 s e s100ß; 145 ealth system management; 117 self-management; 200 effectiveness; 159 simple awarenes, 159 egcg; 145 stages of labor, 159 epidemiology; 110 success, 117 exercise as part of daily life; 192 systematic review, 200 experience, 176 t experimental, 124 toddler, 184 f w family health management, 184 women, 159 food type choices, 192 g green tea extract, 145 h health resources shortage; 176 healthcare providers; 124 hospital; 176 human resources; 176 1 | author information pack march, 2022 table of content i description ii focus and scope iii editorial board iv author guidelines v title page (download here) vi main manuscript template (download here) vii copyright transfer agreement (download here) i. description jurnal ners provides a forum for original research and scholarships relevant to nursing and other health related professions. jurnal ners is a scientific peer-reviewed nursing journal that is published biannually (april and october) by the faculty of nursing universitas airlangga, indonesia, in collaboration with the central board of the indonesian national nurses association. the journal particularly welcomes studies that aim to evaluate and understand the complex nursing care interventions which employ the most rigorous designs and methods appropriate for the research question of interest. the journal has been publishing original peer-reviewed articles of interest to the international nursing community since 2006, making it one of the longest standing repositories of scholarship in this field. jurnal ners offers authors the benefits of (1) a highly respected journal in the nursing field; (2) indexed in major databases, such as scopus, science and technology index (sinta); directory of open access journal (doaj); (3) rapid initial screening for suitability and editorial interest. jurnal ners has been accredited by the ministry of science, research, technology and higher education of indonesia (ristekdikti ri) since 2010. the updated accreditation number: 85/m/kpt/2020, valid until 2024 (download certificate). ii. focus and scope the scope of this journal includes studies that intend to examine and understand nursing health care interventions and health policies which utilize advanced nursing research from the asian perspective. jurnal ners publishes research related to clinical settings, community, and health policy in asia from comparative and international views. we aim to evaluated and understand the complex nursing care intervention on fundamentals of nursing, clinical nursing, community, and mental health nursing. the journal also committed to improving the high quality research by publishing analytic techniques, measures, and research methods, not an exception to systematic review papers. iii. editorial board executive editor: prof. dr. nursalam m.nurs. (hons), (scopus id: 56660628500); faculty of nursing, universitas airlangga, indonesia editor-in-chief: ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100); faculty of nursing, universitas airlangga, indonesia please read this author information pack carefully. any submission which is unsuitable with this information will be returned to the author. author information pack update: march 2022 https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://drive.google.com/drive/folders/12xd-huqxrembouaz0yz4cm4-zf8d824i?usp=sharing https://suggestor.step.scopus.com/progresstracker/index.cfm?trackingid=b5f9e2c037ae75e9 https://drive.google.com/file/d/1gsa2j87z4weyeqlkf0w_bdqjkkd95q-y/view?usp=sharing https://drive.google.com/open?id=1xmj6hqvbhpeiqaubnh681o-zny94zyry javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/454') javascript:openrtwindow('https://e-journal.unair.ac.id/jners/about/editorialteambio/509') 2 | author information pack march, 2022 advisory international editorial boards: 1. prof. angeline bushy, phd, rn, phcns-bc, faan, (scopus id: 7003851740); college of nursing, university of central florida, united states 2. prof. ching-min chen, rn, dns, (scopus id: 57154846200); department of nursing, institute of allied health sciences, national cheng kung university, taiwan 3. prof. eileen savage, bns., msc., p.hd., (scopus id: 8293647300); school of nursing and midwifery, university college cork, ireland, ireland 4. prof. josefina a. tuazon, rn, mn, drph, (scopus id: 6602856172); college of nursing, university of the philippines manila, philippines 5. dr. david pickles, (scopus id: 57190150026); college of nursing & health sciences, flinders university, south australia, australia 6. dr. farhan alshammari, (scopus id: 57192298773); college of nursing, university of hail, saudi arabia 7. dr. chong mei chan, scm, bnsc, msc, phd, (scopus id: 57189591887); dept. of nursing faculty of health science, university of malaya, malaysia 8. dr. sonia reisenhofer, (scopus id: 16310818100); school of nursing and midwifery, la trobe university, australia, australia 9. assistant professor pei-lun hsieh, (scopus id: 57190748913); department of nursing, college of health, national taichung university of science and technology, taiwan editor 1. ferry efendi, s.kep., ns., msc, phd, (scopus id: 55301269100); faculty of nursing, universitas airlangga, indonesia 2. prof. dr ah yusuf, s.kp.m.kes, (scopus id: 57200914632); faculty of nursing universitas airlangga indonesia 3. yulis setiya dewi, s.kep.ns., m.ng., (scopus id: ); faculty of nursing universitas airlangga 4. dr. esti yunitasari, s. kp., m. kes., (scopus id: 57204561035); faculty of nursing, universitas airlangga, surabaya., indonesia 5. dr. rizki fitryasari, s. kep., ns., m. kep., (scopus id: 57200912279); faculty of nursing, universitas airlangga, surabaya, indonesia 6. ilya krisnana, s. kep., ns., m. kep., (scopus id: 57204558756); faculty of nursing, universitas airlangga, indonesia, indonesia 7. retnayu pradanie, s.kep., ns., m.kep., (scopus id: 57201190282); faculty of nursing, universitas airlangga, indonesia 8. praba diyan rachmawati, s.kep., ns., m.kep., (scopus id: 57201182562); (web of science researcherid x1131-2019), faculty of nursing, universitas airlangga, indonesia 9. laily hidayati, s.kep., ns., m.kep., (scopus id: 57202743375); faculty of nursing, universitas airlangga, indonesia assistant editor: rifky octavia pradipta, s.kep., ns., m.kep, (scopus id : 57216705839); faculty of nursing, universitas airlangga, indonesia quality control editor: gading ekapuja aurizki, s.kep., ns., m.sc. 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stepwise through the creation and uploading of your files. the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. types of manuscript original articles original articles should report on original clinical studies or research not previously published or being considered for publication elsewhere. the text should not exceed 7000 words, including a list of authors and their affiliations, corresponding author, acknowledgements and figure legends, with an abstract of a maximum of 250 words, a list of a minimum of 25 references primarily from international journals indexed by scopus or web of science, and a maximum 5 figures/tables (see below for more details on the layout). systematic reviews systematic reviews are exhaustive, critical assessments of evidence from different data sources in relation to a given subject in the area of nursing. a systematic search of the relevant data sources should be carried out and the items collected should be carefully evaluated for inclusion based on a priori defined inclusion/exclusion criteria. a description and an analytical graphic representation of the process should be provided. the specific features of the participants' or patients' populations of the studies included in the review should be described as well as the measures of exposure and the outcome with indication towards the corresponding data sources. a structured abstract is required (the same as for short reviews). the text must not exceed 7,000 words including the acknowledgments, with no more than four tables and/or figures and a minimum of 40 references. meta-analyses meta-analyses should follow the same guidelines for systematic reviews. they are expected to provide exhaustive information and statistical assessment of the pooled estimates of pre-defined outcomes, study heterogeneity and quality, possible publication bias, meta-regression, and subgroup analyses when and where appropriate. depending on the type of study, the authors are invited to submit prisma flow diagrams or moose checklists. both systematic reviews and meta-analyses will be dealt with as original articles are, as far as the editorial process is concerned. ethics in publication this journal follows the committee of publication ethics (cope) guidelines and requests authors to familarise themselves with these guidelines at: http://publicationethics.org/resources/guidelines. a few issues that authors need to pay particular attention to are set out below. it is ethically questionable to break up or segment data from a single study to create different papers for publication, a practice called salami slicinga. if the authors have legitimate reasons for reporting separately on different parts of the same study, or the same data set, they should justify that to the editor at the time of submission. equally, readers need to be aware that different aspects of the same study are being reported, thus the methods section of the submitted manuscript must clearly explain why the submitted paper is justified. double-blind peer review process the decision to publish a paper is based on an editorial assessment and peer review. initially, all papers are assessed by an editorial committee consisting of members of the editorial team. the prime purpose is to decide whether to send a paper for peer review and to give a rapid decision on those that are not. the rejection is based on the novelty or the relevancy with the scope of this journal. http://e-journal.unair.ac.id/index.php/jners http://publicationethics.org/resources/guidelines 4 | author information pack march, 2022 initial editorial assessment jurnal ners is eager to provide a rapid publication process through an initial assessment conducted by an editorial committee consisting of the editorial team members. the primary purpose is to decide whether to send the paper for peer-review or to reject it. the main point is scope, compliance with the guideline, and language. sometimes a paper will be returned to the author with a request for revisions with the purpose to help editors in deciding whether or not to send it out for review. authors may expect the decision of the initial editorial assessment from this stage of the review process within 1-2 weeks of submission. review process after passing the initial editorial assessment, the article will be sent to peer -reviewers. the peer-review process involved at least two reviewers for each manuscript selected based on their expertise. all reviewing process is done by the double-blind review, which means the authors and peer-reviewers do not know each other’s identity. the reviewers should complete the review within three weeks in each reviewing round after the review request was sent. decision-making process the decision to accept for publication is based on the peer reviewer's recommendations, based on which two acceptance recommendations are required. if there is a difference in the two reviewers’ recommendations, the editor has the right to seek the third reviewer's consideration. the final decision to publish is made by the editor-in-chief, editorial committee (national or international advisory board) by considering the advice from reviewers. review criteria each paper that the editor/s assess as suitable for peer review is allocated to two reviewers who are asked to assess the paper against one of the journal's three sets of reviewing criteria: articles submitted for review must be original works, and may not be submitted for review elsewhere whilst under review for the journal. after review, the editor-in-chief will inform the corresponding author on whether the paper has been accepted, rejected, or needs revision. categories of decision accept minor revisions (accept with revisions as advised by editors) major revisions (possible acceptance following major revision and resubmission) reject all efforts are made to provide fair and thorough reviews as speedily as possible. if an author(s) believes that a manuscript has been wrongly rejected, a detailed appeal letter that responds point-by-point to the reviewers' comments should be sent to the editor who, after having reviewed the referees' reports, will make the fina l decision. reviewed by editor-in-chief or editorial team only letter to the editor or a short comment on any topic of current interest for these types of submissions, the corresponding author will receive a fairly rapid decision on publication. language please write your text in good english (british or american or other english style usage is accepted). authors who feel their english language manuscript may require editing to eliminate possible grammatical or spelling errors and to conform to correct scientific english may wish to use the english language editing service. after receiving acceptance decision, author must send the manuscript to proofreaders that has been provide by editor through this link https://forms.gle/hdxuugycvntic4cfa . all of payment becomes author’s responsibility. production following acceptance of a manuscript; the corresponding author will receive an acknowledgement. the paper will then be edited to comply with house style, and typeset. the publisher will email a proof to the corresponding author for checking before it is published. the corresponding author is responsible for checking proofs thoroughly. by approving the proofs any editorial changes are being accepted. we also provide printed issues of jurnal ners. to purchase the printed issues, please fill this form https://goo.gl/forms/luhoutrvixqojybn2 and confirm your order to our whatsapp on +62 811-3287-877. our committee will process your order as soon as possible after your confirmation. https://forms.gle/hdxuugycvntic4cfa https://goo.gl/forms/luhoutrvixqojybn2 https://wa.me/qr/xtgu4colhec7e1 5 | author information pack march, 2022 submission of manuscripts all manuscripts, correspondence and editorial material for publication is submitted online at http://ejournal.unair.ac.id/index.php/jners simply need to "create a new account" (i.e., register) by following the online instructions, and using their own e-mail address and selected password. authors can submit manuscripts online. authors can expect an initial decision to undergo peer-review. revised submissions authors are requested to submit the revision within one month for all reviewing process i.e. rapid decision or in review stage. if not, the submission will be removed from the editorial system and needs to be submitted as a new submission. title and authorship the title should describe the summary of the research (concise, informative, no abbreviations, and a maximum of 12 words). the authorship of articles should be limited to those who have contributed sufficiently to take on a level of public responsibility for the content. provided should be full names of authors (without academic title); author’s affiliation [name(s) of department(s) and institution(s)]; the corresponding author’s name, orcid id, mailing address, telephone, and fax numbers, and e-mail address. the corresponding author is the person responsible for any correspondence during the publication process and postpublication. abstract abstracts should be less than 250 words, and should not include references or abbreviations. they should be concise and accurate, highlighting the main points and importance of the article. in general, they should also include the following:  introduction: one or two sentences on the background and purpose of the study.  method: describe the research design, settings (please do not mention the actual location, but use geographic type or number if necessary); participants (details of how the study population was selected, inclusion and exclusion criteria, numbers entering and leaving the study, and any relevant clinical and demographic characteristics).  results: report the main outcome(s)/findings including (where relevant) levels of statistical significance and confidence intervals.  conclusions: should relate to the study aims and hypotheses.  keyword: provide between three and five keywords in alphabetical order, which accurately identify the paper's subject, purpose, method, and focus. text the text should be structured as follows: introduction, methods, results, discussion, and conclusion. footnotes are not advisable; their contents should be incorporated into the text. use only standard abbreviations; the use of nonstandard abbreviations can be confusing to readers. avoid abbreviations in the title of the manuscript. the spelled-out abbreviation followed by the abbreviation in parenthesis should be used on the first mention unless the abbreviation is a standard unit of measurement. if a sentence begins with a number, it should be spelled out. acknowledgment (optional) acknowledgments should be limited to the appropriate professionals who contributed to the paper, including technical help and financial or material support, as well as any general support by a department chairperson. http://e-journal.unair.ac.id/index.php/jners http://e-journal.unair.ac.id/index.php/jners 6 | author information pack march, 2022 tables and figures tables should be numbered in arabic numerals; and any captions should be brief, clearly indicating the purpose or content of each table. if your manuscript includes more than five tables in total, or for very large tables, these can be submitted as supplementary data and will be included in the online version of your article. reporting guideline the reporting guidelines endorsed by the journal are listed below:  observational cohort, case control, and cross sectional studies strobe strengthening the reporting of observational studies in epidemiology, http://www.equator-network.org/reportingguidelines/strobe/  qualitative studies coreq consolidated criteria for reporting qualitative research, http://www.equator-network.org/reporting-guidelines/coreq  quasi-experimental/non-randomised evaluations trend transparent reporting of evaluations with non-randomized designs, http://www.cdc.gov/trendstatement/  randomized (and quasi-randomised) controlled trial consort consolidated standards of reporting trials, http://www.equator-network.org/reporting-guidelines/consort/  study of diagnostic accuracy/assessment scale stard standards for the reporting of diagnostic accuracy studies, http://www.equator-network.org/reporting-guidelines/stard/  systematic review of controlled trials prisma preferred reporting items for systematic reviews and meta-analyses, http://www.equator-network.org/reporting-guidelines/prisma/  systematic review of observational studies moose meta-analysis of observational studies in epidemiology, http://www.ncbi.nlm.nih.gov/pubmed/10789670 submission preparation checklist indicate that this submission is ready to be considered by this journal by checking off the following (comments to the editor can be added below). 1. as part of the submission process, authors are required to check off their submission's compliance with all of the following items. submissions may be returned to authors that do not adhere to these guidelines. 2. the author(s) haven’t suggested any personal information that may make the identity of the patient recognizable in any form of description, photograph or pedigree. when the photographs of the patient are essential and indispensable as scientific information, the author(s) must have received the consent in written form and have clearly stated such. 3. in case of experimenting on humans, the author(s) have certified that the process of the research is in accordance with the ethical standards of the helsinki declaration, as well as any domestic and foreign committees that preside over the experiment. if any doubts are raised as to whether the research proceeded in accordance with the helsinki declaration, then author(s) are required to explain it. in the case of experimenting on animals, the author(s) have certified that the author(s) had followed the necessary domestic and foreign guidelines related to experimenting on animals in a laboratory. 4. the author(s) have received consent from the author or editor of any pictures or table quoted from other journals or books. a portion or the entirety of the article must not have been published in other journals, nor must it have contributed to other journals or is still under review. 5. the author(s) undersigned hereby give the faculty of nursing universitas airlangga the rights as publisher, the right of first publication of all published material. it will be llicensed under a creative commons attribution 4.0 international license. 6. author(s) of the journal have clarified everything that may arise such as work, research expenses, consultant expenses, and intellectual property on the document in relation to the icmje form disclosure of conflicts of interest. copyright notice authors who publish with jurnal ners agree to the following terms: 1. authors transfer the copyright and grant jurnal ners the right of first publication with the work http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/strobe/ http://www.equator-network.org/reporting-guidelines/coreq http://www.cdc.gov/trendstatement/ http://www.equator-network.org/reporting-guidelines/consort/ http://www.equator-network.org/reporting-guidelines/stard/ http://www.equator-network.org/reporting-guidelines/prisma/ http://www.ncbi.nlm.nih.gov/pubmed/10789670 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://mji.ui.ac.id/journal/public/journals/1/coi_disclosure.pdf http://mji.ui.ac.id/journal/public/journals/1/coi_disclosure.pdf 7 | author information pack march, 2022 simultaneously licensed under a creative commons attribution 4.0 international license that allows others to remix, adapt and build upon the work with an acknowledgment of the work's authorship and of the initial publication in jurnal ners. 2. authors are permitted to copy and redistribute the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in jurnal ners. jurnal ners requires a formal written declaration and transfer of copyright from the author(s) for each article published. we, therefore, ask you to complete and return this form, retaining a copy for your own records. your cooperation is essential and appreciated. any delay will result in a delay in publication. the form can be downloaded here. publication fee jurnal ners charges the author a publication fee amounted to idr 3.000.000 (indonesian author) and usd 200 (non-indonesian author) for each manuscript published in the journal. the author will be asked to pay the publication fee upon editorial acceptance. we consider individual waiver requests for articles in our journal, to apply for a waiver please request one during the submission process to our email address. a decision on the waiver will normally be made within a week. open access policy this journal retains copyright but provides immediate open access to its content on the principle that making research freely available to the public supports a greater global exchange of knowledge. this journal (p-issn:1858-3598; e-issn:2502-5791) is licensed under a creative commons attribution 4.0 international license. plagiarism check this journal follows the committee of publication ethics (cope) guidelines and requests authors to familarise themselves with these guidelines at: http://publicationethics.org/resources/guidelines. plagiarism is not acceptable in jurnal ners submissions. all the submitted manuscripts are checked for plagiarism before starting the review process. v. title page regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be mentioned only on the title page. the title page must be uploaded in the open journal system (ojs) as supplementary file. the format of the title page is described below (or can be downloaded here): https://creativecommons.org/licenses/by/4.0/ https://drive.google.com/open?id=0b5ormcrmctnwcjrslunpyl9gueu http://issn.pdii.lipi.go.id/issn.cgi?daftar&1451966396&26&& http://issn.pdii.lipi.go.id/issn.cgi?daftar&1451966396&26&& http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ https://publicationethics.org/guidance/guidelines https://drive.google.com/open?id=0b5ormcrmctnwx2zvzc0wn2fna2s http://creativecommons.org/licenses/by/4.0/ 8 | author information pack march, 2022 title page format must be written in times new roman font 12 a. manuscript title b. first author *, second author** and third author*** the manuscript has main author and co-authors. author names should not contain academic title or rank. indicate the corresponding author clearly for handling all stages of pre-publication and postpublication. consist of full name author and co-authors. a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. c. first author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number : 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ d. second author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number: 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ e. third author: 1. name : (author names should not contain academic title or rank) 2. affiliation : 3. e-mail : 4. phone number: 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/ ) 6. contribution to this manuscript: ............................................................................................................................. ............................................................ f. corresponding author name : (please mention one of the author[s] above) a corresponding author is a person who is willing to handle correspondence at all stages of refereeing and publication, also post-publication. the orcid id is compulsory for the corresponding author, while for the other author(s) is optional. g. acknowledgement ............................................................................................................................. ............................................................ h. funding source ............................................................................................................................................................... .......................... ………………………………………………………………………………………………………………. you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. https://orcid.org/ https://orcid.org/ https://orcid.org/ 9 | author information pack march, 2022 title page example modeling participant toward self-care deficit on schizophrenic clients ah yusuf*, hanik endang nihayati*, krisna eka kurniawan* first author: 1. name : ah yusuf 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : ah-yusuf@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : http://orcid.org/0000-0002-6669-0767 6. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. second author: 1. name : hanik endang nihayati 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : hanik-e-n@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/) 6. contribution to this manuscript: study conception and design; study supervision; critical revisions for important intellectual content. third author: 1. name : krisna eka kurniawan 2. affiliation : faculty of nursing universitas airlangga 3. e-mail : krisna-e-k-2015@fkp.unair.ac.id 4. phone number : +6281-xxxx-xxx-xx 5. orcid id : (if the author doesn’t have the id please register at https://orcid.org/) 6. contribution to this manuscript: data collection; literature review/analysis; manuscript writing; references. corresponding author 1. name : ah yusuf acknowledgement we thank mr. w and ms. x for their assistance in data acquisition and cleaning, mrs. y for her assistance with statistical measurement and analysis, and mr. z for his assistance with study administration. funding source rkat faculty of nursing universitas airlangga vi. main manuscript template regarding the double blind peer review policy, the author must separate any information about the author’s identity from the main manuscript. thus, all information related to the author(s) should be removed from your manuscript document. the author must upload the main manuscript document into the upload submission page. the format of the main manuscript template is described below (or can be downloaded here): mailto:ah-yusuf@fkp.unair.ac.id http://orcid.org/0000-0002-6669-0767 mailto:hanik-e-n@fkp.unair.ac.id https://orcid.org/ mailto:krisna-e-k-2015@fkp.unair.ac.id https://orcid.org/ https://drive.google.com/file/d/0b5ormcrmctnwn1nkcnp0rzk1uwm/view?usp=sharing 10 | author information pack march, 2022 main manuscript format must be written in times new roman font 12 title (times new roman 12) the title of the paper should be concise and informative. avoid abbreviations and formula where possible. it should be written clearly and concisely describing the contents of the research. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... abstract (times new roman 11) the abstract comes after title page in the manuscript. abstract must be integrated and independent which is consist of introduction and purpose, methods, results, conclusion and suggestion. however, the abstract should be written as a single paragraph without these headers. for this reason, references should be avoided. also, nonstandard or uncommon abbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. abstract must be written using 150 until 250 words which has no reference and accompanied keywords. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .......................................................................................................................... ........................................................................ ............................................................................................................................. ..................................................................... keywords (times new roman 11) the keywords should be avoiding general and plural terms and multiple concepts. do not use words or terms in the title as keywords. these keywords will be used for indexing purposes. keywords should not more than 5 words or phrases in alphabetical order. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... introduction (times new roman 11) state the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. explain how you addressed the problem and clearly state the aims of your study. as you compose the introduction, think of readers who are not experts in this field. please describe in narrative format and not using sub-chapter. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... ................................................................................................. .............................................................. ................................... materials and methods (times new roman 11) explain in detail about the research design, settings, time frame, variables, population, samples, sampling, instruments, data analysis, and information of ethical clearance fit test. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ...................................................................................................................................................... ............................................ ...................................................................................... ......................................................................... ................................... results (times new roman 11) result should be presented continuously start from main result until supporting results. unit of measurement used should follow the prevailing international system. it also allowed to present diagram, table, picture, and graphic followed by narration of them. ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .......................................................................................................................... ........................................................................ 11 | author information pack march, 2022 ............................................................................................................................. ..................................................................... equation: 𝐇′ = − ∑𝑠 (𝑃𝑖)(log2 𝑃𝑖) ...................................................................................................................................... (1) 𝑖=1 remarks: ............................................................................................................................. ....................................................... figures and tables placed separated in last page of manuscript and must be as follow: figures, tables, and diagram should be editable ones. figures’s remarks placed in bottom with before 4pt. the title of figures placed after the remarks with single space. the title of tables should be written first with times new roman 11, single space and after 6pt. content of the tables should be written using times new roman 10 single space and the remarks of tables placed in the bottom with times new roman 10, single space and before 4pt. table 1. effects of plant growth regulator types and concentrations on embryogenic callus induction from leaf tip explants of d. lowii cultured in ½ ms medium supplemented with 2.0 % (w/v) sucrose under continuous darkness at temperature of 25 ± 2 oc after 60 days of culture table 3. maternal and child health care-seeking behaviour for the last pregnancy in women aged 15 – 45 years old age groups (years) type of care <30 30 39 40 45 all age n % n % n % n % place for antenatal care village level service (posyandu, polindes or poskesdes) 1 9.1 1 4.6 1 3.5 3 4.8 district level service (puskesmas/pustu) 2 18.2 7 31.8 1 3.5 10 16.1 hospital, clinics, private doctor or obgyn 1 9.1 4 18.2 2 6.9 7 11.3 private midwife 7 63.6 10 45.5 25 86.2 42 67.7 place of birth hospital 5 50.0 5 22.7 4 13.8 14 23.0 birth clinic/clinic/private health professional 5 50.0 15 68.2 21 72.4 41 67.2 puskesmas or pustu 0 0.0 2 9.1 0 0 2 3.3 home or other place 0 0.0 0 0 4 13.8 4 6.6 ever breastmilk no 1 9.1 1 4.6 1 3.5 3 4.8 yes 10 90.9 21 95.5 28 96.6 59 95.2 exclusive breastfeeding no 4 36.4 10 45.5 18 62.1 32 51.6 yes 7 63.6 12 54.6 11 37.9 30 48.4 discussion (times new roman 11) describe the significance of your findings. consider the most important part of your paper. do not be verbose or repetitive, be concise and make your points clearly. follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section. use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense. if needed, use subheadings to help organize your discussion or to categorize your interpretations into themes. the content of the discussion section includes: the explanation of results, references to previous research, deduction, and hypothesis. ........................................................................... .................................................................................... ................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... 12 | author information pack march, 2022 conclusions (times new roman 11) conclusion should be explained clearly related to hypothesis and new findings. suggestion might be added contains a recommendation on the research done or an input that can be used directly by consumer. .......................................................................... ..................................................................................... ................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... .............................................................................................................................. .................................................................... acknowledgement (times new roman 11) this section is compulsory. grants, financial support and technical or other assistance are acknowledged at the end of the text before the references. all financial support for the project must be acknowledged. if there has been no financial assistance with the project, this must be clearly stated. the role(s) of the funding organisation, if any, in the collection of data, its analysis and interpretation, and in the right to approve or disapprove publication of the finished manuscript must be described in the methods section of the text. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .......................................................................................................................... ........................................................................ funding source (times new roman 11) you are requested to identify who provided financial support for the conduct of the research and/or preparation of the article and to briefly describe the role of the sponsor(s) in the whole research process. ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... .................................................................................................................... .............................................................................. conflict of interest (times new roman 11) when the proposed publication concerns any commercial product, either directly or indirectly, the author must include in the cover letter a statement (1) indicating that he or she has no financial or other interest in the product or distributor of the product or (2) explaining the nature of any relation between himself or herself and the manufacturer or distributor of the product. other kinds of associations, such as consultancies, stock ownership, or other equity interests or patent licensing arrangements, also must be disclosed. if, in the editor's judgment, the information disclosed represents a potential conflict of interest, it may be made available to reviewers and may be published at the editor's discretion; authors will be informed of the decision before publication. ................................................................................................................... ............................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... references (times new roman 11) the author-year notation system is required and completed. all reference mentioned should be written down in reference using harvard cite them right 10th edition style and arranged from a to z. articles have minimal 25 recent references (last 10 years) and 80% is journal. references from journal publication should be provided by doi. all cited references must be mentioned in in-text citation. if you are mendeley user, please download the reference style here https://www.mendeley.com/guides/harvard-citation-guide ............................................................................................................................. ..................................................................... ................................................................................................................................... ............................................................... ............................................................................................................................. ..................................................................... ............................................................................................................................................................... ................................... https://www.mendeley.com/guides/harvard-citation-guide 13 | author information pack march, 2022 citation style: (nursalam et al., 2020) (who, 2021) (pemerintan ri, 2014) reference to a journal publication: nursalam, n. et al. (2020) ‘the effect of range of motion exercise on blood pressure, pulse and sleep quality among hypertensive patients’, international journal of innovation, creativity and change. faculty of nursing, universitas airlangga, mulyorejo street, campus c unair, surabaya, 60115, indonesia: primrose hall publishing group, 13(6), pp. 220–234. available at: https://www.scopus.com/inward/record.uri?eid=2-s2.085087361125&partnerid=40&md5=b7318712857248d9ea896f85f82d69c9. reference to a book: de virgilio, c. & grigorian, a. 2019, ‘surgery: a case based clinical review’ in surgery: a case based clinical review, pp. 1-689. reference to a book section/chapter: harper, m.s. 2021, ‘mental health and mental health services’ in services to the aging and aged: public policies and programs, pp. 283-297. reference to a website: who (2021) who coronavirus disease (covid-19) dashboard: situation by country, territory & area. reference in conference: yuarnistira, nursalam, n., rachmawati, p.d., efendi, f., 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https://drive.google.com/open?id=0b5ormcrmctnwq0dix2dictffdlk 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 200 p-issn: 1858-3598  e-issn: 2502-5791 © 2023 jurnal ners. this is an open-access article distributed under the terms of the creative commons attribution 4.0 international license (https://creativecommons.org/licenses/by/4.0/). volume 18, issue 2, june 2023, p. 200-209 http://dx.doi.org/10.20473/jn.v18i2.46216 original article open access effectiveness of m-health based self-management on self-efficacy in patients with cancer: a systematic review and meta-analysis ni olivya anakotta 1 , erna rochmawati 1 * , and sanisah binti saidi 2 1 faculty of health sciences, universitas muhammadiyah yogyakarta, yogyakarta, indonesia 2 international islamic university malaysia, kuala lumpur, malaysia *correspondence: erna rochmawati. address: faculty of health sciences, universitas muhammadiyah yogyakarta, yogyakarta, indonesia. email: erochmaw@gmail.com responsible editor: ferry efendi received: 6 june 2023 ○ revised: 26 june 2023 ○ accepted: 26 june 2023 abstract introduction: m-health has been developed and tested through studies in various settings and found useful for providing knowledge and experience for nurses in cancer care settings. however, none has synthesized the effectiveness of m-health on self-management of patients with cancer. to evaluate the effect of interventions using mobile-based application on patient’s self-management, outcome measures were patients’ medical adherence, selfefficacy and self-management level and health literacy. methods: this is a systematic review and meta-analysis that is reported in accordance with the guidelines of the prisma statement. a systematic review was conducted in five databases. randomized controlled trials and quasi experimental trials evaluating self-efficacy in patients with cancer were included. critical appraisal was performed using the critical appraisal checklist from the joanna briggs institute. data were synthesized using review manager version 4.5. results: eight studies were included. there was a significant effect on self-efficacy after interventions using mobilebased applications (smd = 0.36, ci 95%, [0.16, 0.56], p < 0.00006). qualitative synthesis shows that the use of mhealth can improve changes in health behavior, health literacy and physical activity. conclusions: m-health-based self-management interventions may improve self-efficacy in cancer patients. meanwhile, changes in health behavior in patients can be significantly improved using m-health-based selfmanagement. m-health can be integrated into health services for the management of patients with cancer. keywords: cancer, m-health, self-management, systematic review introduction cancer increases every year, with the global cancer observatory data stating that there are 19.2 million new cases annually (iarc, 2020). patients with cancer experience suffering, physical, psychological and spiritual, that arises due to disease processes and treatment (iskandar et al., 2021). chemotherapy is one of the treatments for patients with cancer that results in the onset of significant side effects such as nausea, vomiting, and weakness (carnio et al., 2018; romero et al., 2018). in addition to the physical, patients may experience psychological effects including anxiety, fear, confusion, and distress (pitman et al., 2018; wang et al., 2020). these side effects could leads to a decrease in patients’ quality of life (guan et al., 2020). standard medical care is provided to minimize the side effects of the treatment. in providing services to patients with cancer, nurses play an important role in improving self-management and empowering patients so that they will be able to address the symptoms and side effects caused and this further could improve their quality of life (sedhom, 2020). self-management https://creativecommons.org/licenses/by/4.0/ mailto:erochmaw@gmail.com https://orcid.org/0000-0003-2193-6812 https://orcid.org/0000-0003-2193-6812 https://orcid.org/0000-0003-3984-9725 jurnal ners http://e-journal.unair.ac.id/jners 201 particularly is defined as one’s intrinsic motivation and ability to live with a chronic condition and its consequences and consists of the intrinsically controlled ability of being active, responsible, informed and autonomous (van de velde et al., 2019). according to bandura, self-efficacy is an important aspect in improving motivation which could lead to better selfmanagement (tan et al., 2021). in addition, one desired outcome of a self-management program is an improved self-efficacy (peters et al., 2019). ineffective self-management will affect a patient’s quality of life (kalemikerakis et al., 2021). previous studies demonstrate self-management interventions could improve a patient’s self-efficacy, behavior and knowledge ( hanlon et al., 2017; papadakos et al., 2018; budhwani et al., 2019). patients' self-management capability can be improved with various media, including the use of a mobile phone (ni et al., 2022). m-health is a provision of health services and information via mobile computing, mobile phones and communication technologies that aim to implement health programs for the community (istepanian et al., 2004; hallberg and salimi, 2020). m-health features information, photos and videos that can effectively help patients in self-management through changing attitudes and behaviors. this leads to the improvement of the patient's quality of life. such effects could be strengthened with the rapid development of digital technology (armbruster et al., 2022). over the last five years, m-health has been developed and tested through studies in various settings ( du et al., 2020; abasi et al., 2021; sunjaya et al., 2022). a systematic review of m-health-based selfmanagement among patients with cancer is useful for providing knowledge and experience for nurses in cancer care settings. available reviews analyzed the effectiveness of m-health on the delivery of care and psychological effect (escriva boulley et al., 2018; taylor et al., 2020). however, evidence on the efficacy of mhealth-based self-management among patients with cancer is still lacking. therefore, a systematic review study that aims to explore the effectiveness of m-healthbased self-management on patient's behavior is needed. materials and methods research design this is a systematic review and meta-analysis. the review process was guided and reported by the preferred reporting items for systematic reviews and meta-analysis (prisma) guidelines. the study protocol was registered to the international prospective register of systematic review (prospero) with registration number crd42022376972. search method and study selection we conducted a literature search from novemberdecember 2022 in the following databases: pubmed, scopus, proquest, sciencedirect, and cochrane. several keywords were used: m-health; self-management; self figure 1. prisma flow diagram anakotta and rochmawati (2023) 202 p-issn: 1858-3598  e-issn: 2502-5791 efficacy and self-ability using boolean or and and. relevant studies were imported to mendeley 1.19.4. the uploaded articles were then independently screened by two reviewers based on title and abstract using rayyan’s blind mode. following that, the two reviewers discussed studies against study eligibility. inclusion and exclusion criteria the inclusion criteria in this review are research articles that use quasi-experimental design and randomized controlled trials (rcts), adult research participants suffering from cancer aged >18 years, and the language used is english. the target objectives in the study are m-health, self-management, self-efficacy, and self-ability. the exclusion criteria are studies that measure the use of m-health apps in non-cancer care and non-experimental studies. data extraction the extracted data are created to determine the variables needed to answer the review question. the data are divided into several parts, namely study characteristics (author, year of publication, country of study), study design, number of participants during the study, type of cancer, interventions, outcome measurement and findings of the study. quality appraisal eight articles were independently assessed for their quality by two reviewers using joanna briggs institute critical appraisal tools namely rct and quasiexperiment. discussions were made between the reviewers if there were disagreements. the total score was then categorized as moderate to high quality (mostafaei et al., 2020). table 1 and 2 show the quality of the included studies. data synthesis to characterize the included studies, a narrative synthesis was performed. due to the heterogeneity of the publications' parameters, it was unable to include all of them in the meta-analysis. studies that could be further analyzed were synthesized using meta-analysis, with results reported as the mean value and standard deviation of post-intervention results. as the studies utilized different outcome measures, the standardized mean difference (smd) was calculated to estimate the impact of the intervention on the experimental group vs the control group. review manager software (version 5.4.1) was used to perform statistical analysis. the effects of m-health-based selfmanagement on self-management behavior were assessed. the heterogeneity of the included studies was determined statistically by examining forest plots and computing i2 tests. a value of 0% implies that no heterogeneity has been observed; increasing values indicate greater heterogeneity (higgins et al., 2003). studies were homogeneous, as i2 was 50%. random table 1. quality assessment for rcts rct baik et al., 2020 ormel et al.,2018 kim et al., 2018 wang et al., 2018 vandehout et al., 2020 xhu et al., 2018 q1 was true randomization used for assignment of participants to treatment groups? y y y y y y q2 was allocation to treatment groups concealed? n n n n n y q3 were treatment groups similar at the baseline? y y y y y y q4 were participants blind to treatment assignment? n n y y n n q5 were those delivering treatment blind to treatment assignment? n n n n n n q6 were outcomes assessors blind to treatment assignment? n n n n n n q7 were treatment groups treated identically other than the intervention of interest? y y y y y y q8 was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? y y n y n y q9 were participants analyzed in the groups to which they were randomized? y y y y n y q10 were outcomes measured in the same way for treatment groups? y y y y n y q11 were outcomes measured in a reliable way? y y y y n y q12 was appropriate statistical analysis used? y y y y n y q13 was the trial design appropriate, and any deviations from the standard rct design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial? y y y y y y percentage 69% 69% 61% 76% 30% 62% category medium medium medium m m m jurnal ners http://e-journal.unair.ac.id/jners 203 table 2. quality assessment for quasi-experiment quasiexperiment q1 q2 q3 q4 q5 q6 q7 q8 q9 percentage category is it clear in the study what is the ‘cause’ and what is the ‘effect’ (i.e. there is no confusion about which variable comes first)? were the participants included in any comparisons similar? were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? was there a control group? were there multiple measurements of the outcome both pre and post the intervention/ex posure? was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? were the outcomes of participants included in any comparisons measured in the same way? were outcomes measured in a reliable way? was appropriate statistical analysis used? park et al., 2022 y y y y y y y y y 100% high sundberg et al., 2021 y y y y y n y y y 88% high table 3. data extraction no author year setting design participant disease types intervention outcomes and outcome measurement outcome 1 park et al., 2022 university medical centre, south korea quasi-exp 60 enrolled and completed baseline assessment (t1). 30 assigned to intervention group, 30 assigned to control group breast cancer mobile web-based selfmanagement program outcome: self-efficacy instrument: the self-efficacy scale for selfmanagement of breast cancer (sessm-b) self-efficacy (self-efficacy scores did not show a significant difference by time point (f = 0.94, p = .386), nor did they show a significant difference by group (f = 0.33, p = .569)), qol improvement (qol scores differed significantly by time point (f = 4.19, p = .018) and by group (f = 7.42, p = .009)) 2 baik et al., 2020 hospital, italia rct 78 latina breast cancer survivors analyzed; inter 39 control 39 breast cancer patterns of use of smartphone-based interventions outcome: self-efficacy and knowledge instrument: the 12-item communication and attitudinal self-efficacy scale for cancer (case-cancer). the 16-item knowledge about breast cancer questionnaire the patterns of use of the my guide intervention app and my health attention-control app (hrqol, symptom burden, cancer-specific distress, cancerrelevant self-efficacy, and breast cancer knowledge) 3 ormel et al., 2018 medical oncology department of the umcg, netherland rct adult patients (n = 32). usual care (n = 16) with runkeeper (n = 16) testicular cancer (14), breast cancer (2) physical activity with a smartphone application outcome: physical activity instrument: physical activity scale for the elderly (pase) questionnaire self-monitoring pa with runkeeper is safe and feasible in cancer patients 4 kim et al., 2018 chung-ang university hospital, korea rct 76 patients with metastatic breast cancer, mobile game play group (game group, n=36) or a conventional education group (control group, n=40) breast cancer mobile game for selfmanagement outcome: medication adherence instrument: the korean version of the medication adherence rating scale (kmars) the mobile game group in this study showed a higher qol in various domains, including total health, physical health, psychological health, and environmental areas (the patients in the study group used approximately 40% of the game contents, and the overall satisfaction was acceptable. the game group also showed improved compliance to medications compared with the control group (kmars score, 7.6, sd 0.7 vs 6.5, sd 0.5; p<.001). the patients in the study group reported lower rates of physically adverse events, such as nausea (p=.02), fatigue (p=.02), and numbness in the hand or foot (p=.02).clinically significant adverse events, defined by grade ≥3 of common terminology criteria for anakotta and rochmawati (2023) 204 p-issn: 1858-3598  e-issn: 2502-5791 table 3. data extraction no author year setting design participant disease types intervention outcomes and outcome measurement outcome 4 compared with the control group (kmars score, 7.6, sd 0.7 vs 6.5, sd 0.5; p<.001). the patients in the study group reported lower rates of physically adverse events, such as nausea (p=.02), fatigue (p=.02), and numbness in the hand or foot (p=.02).clinically significant adverse events, defined by grade ≥3 of common terminology criteria for adverse events 3.0, including nausea (p=.02), fatigue (p=.002), and hair loss (p=.01) was shown to be lower in the game group. 5 sundberg et al.., 2021 university hospitals in sweden quasi-exp 130 agreed to participate; 66 patients were assigned to the intervention group and 64 patients were assigned to the control group. prostate cancer interactive app for symptom management outcome: health literacy instrument: the swedish functional health literacy scale (fhl), and the swedish communicative and critical health literacy scale (cchl) patients using an app for reporting and managing symptoms improved certain advanced skills of cognitive and critical health literacy (the intervention group had completed higher 188 levels of education compared to the control group (p =0.017). the 189 multinomial logistic regression showed no probability for higher 190 levels of education to result in a higher level of cchl (model χ2 191 =10.17, df 6, p = 0.118)) 6 wang et al, 2018 general hospitals in nanjing, china rct 212 patients; intervention group (n=106) or a control group (n=106) stoma home care mobile app on the outcomes of discharged patients outcome: self-efficacy instrument: stoma self-efficacy scale (sses) ostomy psychosocial adjustment = the intervention and control groups (t=0.20, p=0.06), stoma self-efficacy = the intervention group had significantly higher sses scores when compared with the control group, respectively at 1 month (t=2.81, p=0.01), 3 months (t=6.72, p<0.001) and 6 months (t=10.84, p<0.001) after discharge, stoma complication = the intervention group had a lower incidence rate of stoma complications than the control group at 1-month (χ2=0.39, p=0.53) 7 van der hout et al., 2020 hospital, netherland rct cancer survivors (n=625); intervention group (access to oncokompas, n= 320) or control group (6months waiting list, n= 305) breast cancer (66), colorectal cancer (80), head and neck cancer (99), lymphoma (75) ehealth self-management outcome: health literacy instrument: the patient activation measure (pam) cancer survivors with low to moderate self-efficacy, those with higher personal control, and those with higher health literacy showed larger hrqol benefits of oncokompas. (personal control also moderated the effect of oncokompas on hrqol (measurement group personal control, f(3,1481)=3.478, p =.015), health literacy moderated the effect of oncokompas on hrqol (measurement group health literacy, f(3,1478)=2.869, p = .035) 8 zhu et al., 2018 hunan cancer hospital, xiangya rct 114 women with breast cancer; intervention group (n=57) receiving breast cancer mobile breast cancer esupport program outcome: self-efficacy instrument: the chinese version of the stanford inventory of cancer patient adjustment (sicpa) the bcs program demonstrates its potential for dissemination globally to support women with breast cancer during chemotherapy jurnal ners http://e-journal.unair.ac.id/jners 205 table 3. data extraction no author year setting design participant disease types intervention outcomes and outcome measurement outcome oncokompas on hrqol (measurement group health literacy, f(3,1478)=2.869, p = .035) 8 zhu et al., 2018 hunan cancer hospital, xiangya school of medicine, central south university, changsha, china rct 114 women with breast cancer; intervention group (n=57) receiving breast cancer esupport plus care as usual or the control group (n=57) breast cancer mobile breast cancer esupport program outcome: self-efficacy instrument: the chinese version of the stanford inventory of cancer patient adjustment (sicpa) the bcs program demonstrates its potential for dissemination globally to support women with breast cancer during chemotherapy anakotta and rochmawati (2023) 206 p-issn: 1858-3598  e-issn: 2502-5791 effects and fixed effects were used in the analysis. p 0.05 was chosen as the criteria for statistical significance in the systematic review. results search results figure 1 shows the study selection process. a total of 5758 studies were included during the literature search. after removing 95 duplicates, 5663 studies were screened through titles and abstracts. thirty full texts were eligible for screening against inclusion criteria that resulted in eight included studies. articles found were based on research protocols compiled to be used as a reference in conducting systematic reviews. study characteristics table 1 presents the characteristics of the eight included studies. the publication years range from 2018-2020. all the included studies were conducted in developed countries; china (n=2) korea (n=2), netherlands (n=2), sweden (n=1) and italy (n=1). the study designs used in the articles that have been analyzed are rcts (n=6) and quasi-experiments (n=2). table 2 and table 3 show the quality of included studies. four studies focus on the application of m-health to the improvement of self-efficacy ( wang et al., 2018; zhu et al., 2018; j.h.park et al., 2022). four studies investigate the application of mobile-based applications in improving, communication and health literacy (kim et al., 2018; ormel et al., 2018; sundberg et al., 2021; van der hout et al., 2021). the interventions in the included studies were conducted for four weeks (baik et al., 2020) until six months (van der hout et al., 2021). m-healthbased self-management in the included studies provides education, hospital treatment and virtual support for physical activity and exercise. m-health-based self-management the features of m-health in the included studies involve; symptom management (sundberg et al., 2021; van der hout et al., 2021; park et al., 2022), activity monitoring (ormel et al., 2018), knowledge features about cancer through questionnaires (baik et al., 2020), video games that provide education about cancer (kim et al., 2018) and e-support (zhu et al., 2018). there are several outcomes of m-health based selfmanagement interventions measured in the included studies: self-efficacy (wang et al., 2018; zhu et al., 2018; baik et al., 2020; y. park et al., 2022); physical activity (ormel et al., 2018), and health literacy (baik et al., 2020; sundberg et al., 2021; van der hout et al., 2021). the use of m-health for improving self-efficacy two rcts (wang et al., 2018) and one quasiexperiment study (zhu et al., 2018; y. park et al., 2022) that included 376 patients with cancer evaluated the effectiveness of m-health-based self-management to improve self-efficacy. all these studies were synthesized for meta-analysis. different measurement tools were used such as the self-efficacy scale for self-management of breast cancer, the stoma self-efficacy scale and the stanford inventory cancer patient adjustment. the fixed effect model was conducted as the value of i2 is <50%. our meta‐analysis suggests there was a significant difference in self-efficacy after the provision of mhealth-based self-management (smd = 0.36 [ 0.16, 0.56], p < 0.00006) (figure 2). use of m-health for improving health behavior, health literacy and communication three studies with a total of 831 participants investigated the effectiveness of m-health on the improvement of health literacy and knowledge of cancer (baik et al., 2020; sundberg et al., 2021; van der hout et al., 2021). one study shows that the application of mhealth can improve physical activity among patients with cancer (ormel et al., 2018). discussions this study was conducted to determine the effect of m-health-based self-management on self-management behavior including self-efficacy, health literacy and physical activity. analysis and synthesis were carried out on three studies to see the effect of the application on self-efficacy. our meta-analysis shows significant improvement in patients' self-efficacy after the figure 2. meta-analysis on the effect of m-health based self-management of patient’s self-efficacy jurnal ners http://e-journal.unair.ac.id/jners 207 interventions. the finding is in line with the previous studies among patients with a life-limiting illness. for example, the use of m-health has a positive outcome on self-management (delva et al., 2021). in addition, selfmanagement among patients with chronic kidney disease increased in the intervention group after using m-health (li et al., 2020; markossian et al., 2021). both studies provide virtual clinics, education related to diseases, and peer support. this shows that the use of the m-health app can increase self-management and self-efficacy in patients with a life-limiting illness. four included studies show a positive outcome in the improvement of health behavior after the intervention. the interventions provided are related to drug adherence, monitoring of patients' physical activity, and information to improve health literacy. for example, medication adherence increases in the intervention group by using mobile reminders (kim et al., 2018). selfmonitoring can be linked to self-efficacy (rabbani et al., 2022). self-monitoring is carried out through an application so that it can be accessed by patients remotely. regulated apps support changes in health efficacy and behavior and also through the m-health app can provide a better understanding of a patient's chronic condition. monitoring of patients' physical activity monitoring is increasing with the help of applications but further research is needed to determine the concentration of the patient's physical activity. previous review on health apps shows that ab m-health app has the potential to increase physical activity (yerrakalva et al., 2019). in addition, a study investigating the use of m-health on physical activity shows that the use of m-health can increase physical activity in adults through selfmonitoring, social support, and behavior change techniques (mcgarrigle and todd, 2020). our reviews found that m-health has a positive outcome on patients' health behavior. one of the included studies shows that patients often access content with the theme of changing health behaviors (baik et al., 2020). improvement in health behaviors after using m-health is in line with findings of previous systematic reviews that show improvement in health behavior (han and lee, 2018; mckay et al., 2018). however, the use of m-health should be considered as a complementary intervention in addition to direct nursing intervention as suggested by bonn et al. (2019). implication and limitations this systematic review has a number of limitations. first, the quality of this review was compromised by the fact that no participant were blinded. second, the included trials had varying characteristics, which could lead to heterogeneity and affect the pooled data. the included studies involved different types of cancer, and the frequency and content of the m-health interventions varied. third, the exploration of the effect mechanism was constrained by the variety of available studies. therefore, uniform m-health standards and high-quality randomized controlled trials and quasi-experiment are required to investigate the precise mechanism of mhealth's effects. based on the results of a study of eight included studies, it was found that the provision of interventions for self-management in cancer patients can be done using m-health apps to improve patients' self-efficacy and health behaviors. the features provided can help patients improve self-management in undergoing cancer treatment. this intervention can be a collaborative option in implementing nursing care to help patients with cancer to meet their selfmanagement behaviors conclusions our meta-analysis demonstrated statistically significant effects of m‐health for patients with cancer patients on self-efficacy. qualitative synthesis shows the positive outcome of m-health on patients' physical activity, health behavior and health literacy. although, the quality of evidence range from moderate to high, the results should be considered cautiously as the standardization of m-health in term of frequency and content is still varied. further standardization on mhealth is warranted to investigate the effect of interventions. references abasi, s., yazdani, a., kiani, s., & mahmoudzadeh-sagheb, z. (2021) ‘effectiveness of mobile health-based self-management application for posttransplant cares: a systematic review’, health sci rep, 4(4), e434. https://doi.org/10.1002/hsr2.434 armbruster, c., knaub, m., farin-glattacker, e., & von der warth, r. (2022) ‘predictors of adherence to cancer-related mhealth apps in cancer patients undergoing oncological or follow-up treatment-a scoping review’, int j environ res public health, 19(20). https://doi.org/10.3390/ijerph192013689 baik, s. h., oswald, l. b., buscemi, j., buitrago, d., iacobelli, f., pereztamayo, a., guitelman, j., penedo, f. j., & yanez, b. (2020) ‘patterns of use of smartphone-based interventions among latina breast cancer survivors: secondary analysis of a pilot randomized controlled trial’, jmir cancer, 6(2), e17538. https://doi.org/10.2196/17538 bonn, s. e., löf, m., östenson, c. g., & trolle lagerros, y. (2019) ‘apptechnology to improve lifestyle behaviors among working adults anakotta and rochmawati (2023) 208 p-issn: 1858-3598  e-issn: 2502-5791 the health integrator study, a randomized controlled trial’, bmc public health, 19(1), 273. https://doi.org/10.1186/s12889-0196595-6 budhwani, s., wodchis, w. p., zimmermann, c., moineddin, r., & howell, d. (2019) ‘self-management, self-management support needs and interventions in advanced cancer: a scoping review’, bmj support palliat care, 9(1), 12-25. https://doi.org/10.1136/bmjspcare-2018-001529 carnio, s., galetta, d., scotti, v., cortinovis, d. l., antonuzzo, a., pisconti, s., rossi, a., martelli, o., cecere, f. l., lunghi, a., del conte, a., montagna, e. s., topulli, j., pelizzoni, d., rapetti, s. g., gianetta, m., pacchiana, m. v., pegoraro, v., cataldo, n., bria, e., & novello, s. (2018) ‘chemotherapy-induced nausea and vomiting (cinv) in patients with advanced lung cancer during the first-line treatment: assessment by physicians, nurses, and patients from an italian multicenter survey’, supportive care in cancer, 26(6), 1841-1849. https://doi.org/10.1007/s00520-017-4004-1 delva, s., waligora mendez, k. j., cajita, m., koirala, b., shan, r., wongvibulsin, s., vilarino, v., gilmore, d. r., & han, h. r. (2021) ‘efficacy of mobile health for self-management of cardiometabolic risk factors: a theory-guided systematic review’, journal of cardiovascular nursing, 36(1), 34-55. https://doi.org/10.1097/jcn.0000000000000659 du, s., liu, w., cai, s., hu, y., & dong, j. (2020) ‘the efficacy of e-health in the self-management of chronic low back pain: a meta analysis’, international journal of nursing studies, 106, 103507. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2019.103507 escriva boulley, g., leroy, t., bernetière, c., paquienseguy, f., desfriches-doria, o., & préau, m. (2018) ‘digital health interventions to help living with cancer: a systematic review of participants' engagement and psychosocial effects’, psychooncology, 27(12), 2677-2686. https://doi.org/10.1002/pon.4867 guan, t., santacroce, s. j., chen, d. g., & song, l. (2020) ‘illness uncertainty, coping, and quality of life among patients with prostate cancer’, psychooncology, 29(6), 1019-1025. https://doi.org/10.1002/pon.5372 hallberg, d., & salimi, n. (2020) ‘qualitative and quantitative analysis of definitions of e-health and m-health’, healthc inform res, 26(2), 119-128. https://doi.org/10.4258/hir.2020.26.2.119 han, m., & lee, e. (2018) ‘effectiveness of mobile health application use to improve health behavior changes: a systematic review of randomized controlled trials’, healthc inform res, 24(3), 207-226. https://doi.org/10.4258/hir.2018.24.3.207 hanlon, p., daines, l., campbell, c., mckinstry, b., weller, d., & pinnock, h. (2017) ‘telehealth interventions to support selfmanagement of long-term conditions: a systematic metareview of diabetes, heart failure, asthma, chronic obstructive pulmonary disease, and cancer’, j med internet res, 19(5), e172. https://doi.org/10.2196/jmir.6688 higgins, j. p., thompson, s. g., deeks, j. j., & altman, d. g. (2003) ‘measuring inconsistency in meta-analyses’, bmj, 327(7414), 557560. https://doi.org/10.1136/bmj.327.7414.557 iarc. (2020) ‘cancer fact sheet’, https://gco.iarc.fr/today/data/factsheets/cancers/39-allcancers-fact-sheet.pdf iskandar, a. c., rochmawati, e., & wiechula, r. (2021) ‘experiences and perspectives of suffering in cancer: a qualitative systematic review’, european journal of oncology nursing, 54, 102041. https://doi.org/10.1016/j.ejon.2021.102041 istepanian, r., jovanov, e., & zhang, y. t. (2004) ‘introduction to the special section on m-health: beyond seamless mobility and global wireless health-care connectivity’, ieee trans inf technol biomed, 8(4), 405-414. https://doi.org/10.1109/titb.2004.840019 kalemikerakis, i., evaggelakou, a., kavga, a., vastardi, m., konstantinidis, t., & govina, o. (2021) ‘diagnosis, treatment and quality of life in patients with cancer-related lymphedema’, j buon, 26(5), 1735-1741. kim, h. j., kim, s. m., shin, h., jang, j. s., kim, y. i., & han, d. h. (2018) ‘a mobile game for patients with breast cancer for chemotherapy self-management and quality-of-life improvement: randomized controlled trial’, j med internet res, 20(10), e273. https://doi.org/10.2196/jmir.9559 li, w. y., chiu, f. c., zeng, j. k., li, y. w., huang, s. h., yeh, h. c., cheng, b. w., & yang, f. j. (2020) ‘mobile health app with social media to support self-management for patients with chronic kidney disease: prospective randomized controlled study’, j med internet res, 22(12), e19452. https://doi.org/10.2196/19452 markossian, t. w., boyda, j., taylor, j., etingen, b., modave, f., price, r., & kramer, h. j. (2021) ‘a mobile app to support selfmanagement of chronic kidney disease: development study’, jmir hum factors, 8(4), e29197. https://doi.org/10.2196/29197 mcgarrigle, l., & todd, c. (2020) ‘promotion of physical activity in older people using mhealth and ehealth technologies: rapid review of reviews’, j med internet res, 22(12), e22201. https://doi.org/10.2196/22201 mckay, f. h., cheng, c., wright, a., shill, j., stephens, h., & uccellini, m. (2018) ‘evaluating mobile phone applications for health behaviour change: a systematic review’, journal of telemedicine and telecare, 24(1), 22-30. https://doi.org/10.1177/1357633x16673538 mostafaei, h., sadeghi-bazargani, h., hajebrahimi, s., salehipourmehr, h., ghojazadeh, m., onur, r., al mousa, r. t., & oelke, m. (2020) ‘prevalence of female urinary incontinence in the developing world: a systematic review and meta-analysis-a report from the developing world committee of the international continence society and iranian research center for evidence based medicine’, neurourology and urodynamics, 39(4), 1063-1086. https://doi.org/10.1002/nau.24342 ni, x., lou, y., hu, w., wang, h., xu, h., li, s., zhou, y., & ni, y. (2022) ‘development of mobile health-based self-management support for patients with lung cancer: a stepwise approach’, nurs open, 9(3), 1612-1624. https://doi.org/10.1002/nop2.1185 ormel, h. l., van der schoot, g. g. f., westerink, n. l., sluiter, w. j., gietema, j. a., & walenkamp, a. m. e. (2018) ‘self-monitoring physical activity with a smartphone application in cancer patients: a randomized feasibility study (smart-trial)’, supportive care in cancer, 26(11), 3915-3923. https://doi.org/10.1007/s00520-0184263-5 papadakos, j. k., hasan, s. m., barnsley, j., berta, w., fazelzad, r., papadakos, c. j., giuliani, m. e., & howell, d. (2018) ‘health literacy and cancer self-management behaviors: a scoping review’, cancer, 124(21), 4202-4210. https://doi.org/10.1002/cncr.31733 park, j. h., jung, y. s., kim, j. y., & bae, s. h. (2022) ‘mobile web-based self-management program for breast cancer patients with chemotherapy-induced amenorrhoea: a quasi-experimental study’, nurs open, 9(1), 655-665. https://doi.org/10.1002/nop2.1113 park, y., kim, s. r., so, h. y., jo, s., lee, s. h., hwang, y. s., kim, m. s., & chung, s. j. (2022) ‘effect of mobile health intervention for selfmanagement on self-efficacy, motor and non-motor symptoms, self-management, and quality of life in people with parkinson's disease: randomized controlled trial’, geriatric nursing, 46, 90-97. https://doi.org/https://doi.org/10.1016/j.gerinurse.2022.05.003 peters, m., potter, c. m., laura, k., peters, m., potter, c. m., kelly, l., & fitzpatrick, r. (2019) ‘self-efficacy and health-related quality of life: a cross-sectional study of primary care patients with multimorbidity’, health and quality of life outcomes, 17(1), 37. https://doi.org/10.1186/s12955-019-1103-3 pitman, a., suleman, s., hyde, n., & hodgkiss, a. (2018) ‘depression and anxiety in patients with cancer’, bmj, https://doi.org/doi: https://doi.org/10.1136/bmj.k1415 rabbani, m., tian, s., anik, a. a., luo, j., park, m. s., whittle, j., ahamed, s. i., & oh, h. (2022) ‘towards developing a voiceactivated self-monitoring application (vois) for adults with diabetes and hypertension’, proc compsac, 2022, 512-519. https://doi.org/10.1109/compsac54236.2022.00095 romero, s. a. d., jones, l., bauml, j. m., li, q. s., cohen, r. b., & mao, j. j. (2018) ‘the association between fatigue and pain symptoms and decreased physical activity after cancer’, supportive care in cancer, 26(10), 3423-3430. https://doi.org/10.1007/s00520-0184203-4 sedhom, r. (2020) ‘caring for the patient with cancer: body and soul’, journal of pain & symptom management, 60(5), 1066-1069. https://doi.org/10.1016/j.jpainsymman.2020.05.008 sundberg, k., lindström, v., petersson, l. m., & langius-eklöf, a. (2021) ‘supporting health literacy using an interactive app for symptom jurnal ners http://e-journal.unair.ac.id/jners 209 management during radiotherapy for prostate cancer’, patient education and counseling, 104(2), 381-386. https://doi.org/10.1016/j.pec.2020.08.003 sunjaya, a. p., sengupta, a., martin, a., di tanna, g. l., & jenkins, c. (2022) ‘efficacy of self-management mobile applications for patients with breathlessness: systematic review and quality assessment of publicly available applications’, respiratory medicine, 201, 106947. https://doi.org/10.1016/j.rmed.2022.106947 tan, f. c. j. h., oka, p., dambha-miller, h., & tan, n. c. (2021) ‘the association between self-efficacy and self-care in essential hypertension: a systematic review’, bmc family practice, 22(1), 44. https://doi.org/10.1186/s12875-021-01391-2 taylor, s., bellhouse, s., allsop, m., radford, j., & yorke, j. (2020) ‘the role of e-health in the delivery of care for patients with hematological cancers: a systematic literature review’, telemed j e health, 26(9), 1093-1105. https://doi.org/10.1089/tmj.2019.0231 van de velde, d., de zutter, f., satink, t., costa, u., janquart, s., senn, d., & de vriendt, p. (2019) ‘delineating the concept of selfmanagement in chronic conditions: a concept analysis’, bmj open, 9(7), e027775. https://doi.org/10.1136/bmjopen-2018027775 van der hout, a., holtmaat, k., jansen, f., lissenberg-witte, b. i., van uden-kraan, c. f., nieuwenhuijzen, g. a. p., hardillo, j. a., baatenburg de jong, r. j., tiren-verbeet, n. l., sommeijer, d. w., de heer, k., schaar, c. g., sedee, r. j. e., bosscha, k., van den brekel, m. w. m., petersen, j. f., westerman, m., honings, j., takes, r. p., houtenbos, i., van den broek, w. t., de bree, r., jansen, p., eerenstein, s. e. j., leemans, c. r., zijlstra, j. m., cuijpers, p., van de poll-franse, l. v., & verdonck-de leeuw, i. m. (2021) ‘the ehealth self-management application 'oncokompas' that supports cancer survivors to improve health-related quality of life and reduce symptoms: which groups benefit most?’, acta oncologica, 60(4), 403-411. https://doi.org/10.1080/0284186x.2020.1851764 wang, q. q., zhao, j., huo, x. r., wu, l., yang, l. f., li, j. y., & wang, j. (2018) ‘effects of a home care mobile app on the outcomes of discharged patients with a stoma: a randomised controlled trial’, journal of clinical nursing, 27(19-20), 3592-3602. https://doi.org/10.1111/jocn.14515 wang, y. h., li, j. q., shi, j. f., que, j. y., liu, j. j., lappin, j. m., leung, j., ravindran, a. v., chen, w. q., qiao, y. l., shi, j., lu, l., & bao, y. p. (2020) ‘depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies’, molecular psychiatry, 25(7), 1487-1499. https://doi.org/10.1038/s41380-019-0595-x yerrakalva, d., yerrakalva, d., hajna, s., & griffin, s. (2019) ‘effects of mobile health app interventions on sedentary time, physical activity, and fitness in older adults: systematic review and metaanalysis’, j med internet res, 21(11), e14343. https://doi.org/10.2196/14343 zhu, j., ebert, l., liu, x., wei, d., & chan, s. w. (2018) ‘mobile breast cancer e-support program for chinese women with breast cancer undergoing chemotherapy (part 2): multicenter randomized controlled trial’, jmir mhealth uhealth, 6(4), e104. https://doi.org/10.2196/mhealth.9438 how to cite this article: anakotta, n. o. and rochmawati, e. (2023) ‘effectiveness of m-health based self-management on selfefficacy in patients with cancer: a systematic review and metaanalysis’, jurnal ners, 18(2), pp. 200-209. doi: http://dx.doi.org/10.20473/jn.v18i2.46216 233 relationship between proactive coping and self-care management in patient with pulmonary tuberculosis tintin sukartini, febrina ramadhani, laily hidayati faculty of nursing, universitas airlangga kampus c mulyorejo surabaya, 60115, phone. (031)5913752, fax. (031)5913257 e-mail: tintin-s@fkp.unair.ac.id abstract introduction: patients with pulmonary tuberculosis not only experience physical problems but also face psychosocial problems, and this can get worse during the treatment phase that has an impact on the patients’ self-care. in order to prevent further impact on the patients, proactive coping is needed. this study aimed to identify the relationship between proactive coping and self-care management in pulmonary tuberculosis patients. methods: this study was a cross-sectional research study. as many as 105 respondents were taken with a consecutive sampling technique. the inclusion criteria of the respondents were that they were pulmonary tuberculosis patients both in the intensive and continuous phase. this research was conducted in three primary public health care centres in surabaya, east java, indonesia. the variables were proactive coping that was measured by proactive coping inventory (pci) and self-care management that was measured by the selfcare management questionnaire. the data was analysed using a spearman test. results: this study showed that proactive coping had a positive correlation with self-care management in patients with pulmonary tuberculosis (p= 0.000; r= 0,848). conclusion: this study shows a strong correlation between the variables, where the higher the level of proactive coping, the better the self-care management in pulmonary tuberculosis patients. further research can find out the factors that influence proactive coping in pulmonary tuberculosis patients, which can thus improve the self-care behaviour. keywords: coping proactive, self-care management, pulmonary tuberculosis introduction tuberculosis (tb) is a contagious bacterial infectious disease which has become a global concern. this disease is a major public health problem in indonesia although a government program of tb control has been carried out over the last few decades. indonesia is included in 14 countries with the world's highest burden of tuberculosis, tuberculosis-hiv, and tuberculosis-mdr (falzon, d. floyd, k. getahun, h. kanchar, a. mirzayev, f. raviglione, m. timimi, h. weyer, k. zignol, 2015). many means to control tuberculosis have already been undertaken and the incidents and deaths from tuberculosis have declined, but the worldwide death toll from tuberculosis is still high at 1.8 million people in 2016 (who, 2017). the tuberculosis epidemic is larger than previously estimated, according to the who in the 2016 global tuberculosis report. there are 10.4 million new tuberculosis incidence cases worldwide in the 2015 statistical data, equivalent to 28,500 people worldwide exposed to tuberculosis every day. indonesia is included in the 6 countries that account for 60% of new tuberculosis cases in the world. indonesia ranks second in the world as the largest contributor to tuberculosis patients after india (who, 2017). in 2015, the case detection rate (cdr) of pulmonary tuberculosis in indonesia was recorded at 125 cases per 100,000 population and in the last statistical data in 2015, there were 324,539 cases of tuberculosis in indonesia (kemenkes ri, 2016). statistical data of tuberculosis cases between provinces in 2015, east java province was ranked at second place with 110 cases per 100,000 population or equal to 21,475, and surabaya contributed as the largest cases of pulmonary tuberculosis in east java province as many as 2,330 cases of pulmonary tuberculosis (kemenkes ri, 2015). in 2016, the cases of pulmonary tuberculosis in surabaya did not decrease. the number of cases of pulmonary tuberculosis reached 2,382. the highest tuberculosis cases were found in north surabaya. in all three public health centres in north surabaya, there were 143 cases of pulmonary tuberculosis in 2016 and in the first quarter of 2017. during the treatment period of 6 months, there are not only the physical problems suffered in patients with pulmonary tuberculosis but they also face psychosocial problems and emotional changes due to the illness (dwidiyanti, noorratri and margawati, 2017). the psychosocial problems that can occur in patients with pulmonary tuberculosis are feeling isolated by friends and relatives and difficulty continuing work, thus causing them to choose being more secluded (williams & kaur, 2016). the occurrence of psychosocial problems in pulmonary jurnal ners vol. 12 no. 2 oktober 2017: 233-238 234 tuberculosis patients will affect the coping strategy to be used on the patient itself, to allow them to be able to withstand the stressors of the disease (yellappa et al., 2016). the proper and effective use of coping creates a balance by adjusting to the change or burden and this will create an improvement in the individual (mubarak and susanto, 2006). there has been a wide range of recent research on social cognition, social interaction, stress and coping aimed at analysing the process by which individuals can anticipate or detect potential stresses that will occur and have preventive measures to reduce the adverse consequences that will occur. such behaviour reflects one form of coping which is proactive coping (vaculikova, 2016). individuals with proactive coping will take advantage of social and non-social resources, have goals for the future, use positive emotional strategies, and prevent and modify potential future stresses. (schwarzer & taubert, 2002). proactive coping also positively correlates with social support and has a positive impact on individuals to improve their well-being (greenglass and fiksenbaum, 2009). the handling of pulmonary tuberculosis requires the patient and family's active role as a support system to improve the patient's own health status (kemenkes ri, 2016). the home health treatment or self-care management conducted by the patient will maintain or restore health, minimise disability from the illness and improve the patient’s independence. if self-care management is not done optimally, then there will be a decrease in the patient’s health status (clark, 2008). proactive coping is also one of the coping methods that has a direct relationship with self-efficacy which is one of the basic components to perform self-care actions (drummond suzanne, 2014). stanojević et al. (2014) also pointed out that proactive coping has a strong relationship with self-efficacy so as to improve self-care behaviour in patients with chronic diseases such as pulmonary tuberculosis. therefore, it can be expected that there is a relationship between the use of this proactive coping strategy and the management of self-care actions in pulmonary tuberculosis patients which will result in an improvement in the patient's health status (stanojević et al., 2014). it is necessary for the nurse as a caregiver and health care provider to provide better nursing intervention by improving pulmonary tuberculosis patients’ coping so that the pattern of pulmonary tuberculosis treatment will have more leverage. thus, the authors are interested in examining the relationship between proactive coping strategies and self-care management in patients with pulmonary tuberculosis, materials and methods this research study used the quantitative method with a cross-sectional approach. the sample of the respondents in this study was pulmonary tuberculosis patients who are undergoing treatment; as many as 105 respondents. this research was conducted from january to june 2017 in three primary public health care centres in surabaya, east java, indonesia. the data was collected using instrument tools in the form of a proactive coping inventory (pci) questionnaire and a self-care management list questionnaire in patients with pulmonary tuberculosis. the process of data analysis was using a spearman rank correlation test with α ≤ 0.05. this research had been approved by the health research ethics commission of the faculty of nursing, universitas airlangga, surabaya, indonesia on july 4 th , 2017 with the certificate number of ethics 410-kepk. results the majority of the respondents were male (51%), aged 46-55 years old (40%) with their most recent education being at primary level (47%). most of them were self-employed or a trader with an income less than 1 million rupiahs (table 1). the distribution of a highly proactive coping sub-scale was mostly found on the subscale of instrumental support seeking followed by the emotional support scale. a total of 52 respondents had a high level on the instrumental support subscale (table 2). 40.5% of the pulmonary tuberculosis patients had never been isolated as evidenced by the majority of the respondents never having paid any attention to the ventilation adequacy within the home. as many as 40.2% of respondents had rarely undertaken preventive measures, especially in the case of relationship between proactive coping and self-care... (tintin sukartini et al.) 235 hand washing, wearing masks and sputum disposal. the respondents still rarely do good nutrition management, where as many as 56.1% rarely consumed balanced nutrition in adequate proportions. a total of 47.9% of the respondents were good in terms of treatment, especially in taking drugs and routine checkups at the health services, but there were still many who rarely did any exercise (table 3). the results of the spearman correlation test obtained a level of significance p = 0.000, thus accepting the hypothesis which means that there is a relationship between proactive coping with self-care management in pulmonary tuberculosis patients. the correlation coefficient (r) showed a positive correlation (r = 0.848) which means that it had a high correlation. the direction of the relationship was positive, which indicates the higher the level of proactive coping then the higher the level of self-care management of the pulmonary tuberculosis patients. discussion based on table 2, it was found that 55 respondents had a moderate proactive coping rate and self-care management level, 31 respondents had a high proactive coping rate and high self-care management level. the results of this study indicate that there was a strong correlation between proactive coping with self-care management in pulmonary tuberculosis patients. this result is in line with the theory that proactive coping can improve self-care behaviour in patients with chronic diseases such as pulmonary tuberculosis (stanojević et al., 2014). based on table 3, the largest frequency at a high level was found in the instrumental support subscale. the instrumental support subscale is an individual’s focus for getting information, advice from others, support search and assistance when the individual is facing a stressor (vaculikova, 2016). according to greenglass and fiksenbaum (2009), instrumental support or social support is positively correlated with proactive coping so that it has a positive impact on the individual to improve their well-being. govender and mash (2009) also said that social support is one of the factors to improve treatment compliance evidenced by the existence of a positive relationship between social support and proactive coping. an example of an instrumental support search activity is where the pulmonary tuberculosis patients need information, advice, and help from others when problems occur. a total of 52 respondents stated that support such as advice and the assistance of others is needed when the pulmonary tuberculosis patients are undergoing treatment. the family is one aspect of this instrumental support table 1. demographic characteristics of the respondents characteristic n % age 15 – 25 y.o 22 21 26 – 35 y.o 23 22 36 – 45 y.o 18 17 46 – 55 y.o 42 40 sex male 53 51 female 52 49 educational background elementary school 51 47 junior high school 13 13 senior high school 38 36 university/ diploma 3 4 occupation entrepreneur/ merchant 48 46 private company 22 21 government employees 2 2 others (unemployed) 33 31 income <1 million 45 43 1 million < x < 2 million 8 8 ≥ 2 million 19 18 no income 33 31 table 2. proactive coping subscale in pulmonary tb patients subscale frequency high moderate low proactive coping scale 38 56 11 reflective coping scale 40 50 15 preventive coping scale 46 42 17 avoidance coping scale 42 48 15 strategic planning scale 47 44 14 instrument support seeking scale 52 40 13 emotional support scale 51 41 13 table 3. self care management in pulmonary tb patients sub-variable frequency (%) often rarely never isolation action 25,2 34,3 40,5 preventive action 39,6 40,2 20,2 nutrition management 30,8 56,1 13.1 medication & excercise 47,9 29,9 22,2 jurnal ners vol. 12 no. 2 oktober 2017: 233-238 236 quest. one example of family-provided assistance for pulmonary tuberculosis patients is accompaniment at the time of the ingestion of tb drugs. according to mufarokhah, putra and dewi (2016), the improvement of the level of coping and the intention of the selfmanagement program (self-management program) will change the individual's behaviour. changes in individual behaviour are influenced by behaviour control. de ridder et al. (2012) explained that high selfcontrol would shape the conductive behaviours to allow them to achieve a healthy life, so it is very profitable for the individual. thoolen et al. (2007) explained that individuals with proactive coping will perform self-regulation actions which are processes in which people control and direct their actions in order to fulfil their goals. ogden (2012) added that when a person has achieved their desired goal, it will increase self-efficacy that directly affects the individual self-care. drummond suzanne (2014) explained that self-efficacy is self-confidence and is one of the basic components to perform self-care nursing actions. the results of this study are consistent with the results of a study by weni (2014), which revealed that there is a significant association of proactive coping with diabetes self-care activities in elderly people with type 2 diabetes mellitus. patients with high proactive coping rates will increase their selfcare rates. in addition, proactive coping is a major predictor factor for coping mechanisms in patients with lower limb amputations (solgajová, sollár and vörösová, 2015). table 2 shows that most patients have moderate proactive coping rates. this suggests that most pulmonary tuberculosis patients use proactive coping in everyday life even at moderate levels. the level of self-care management is also the majority, at a moderate level. this is due to the level of awareness of patients with pulmonary tb being low related to preventive measures for the transmission of pulmonary tuberculosis infection. pulmonary tb patients only use masks at the time of taking tb drugs at the primary health care facilities when they meet the nurse or another health officer, and they still often dispose sputum indiscriminately. individuals with proactive coping see future events as a challenge and opportunity, by identifying collecting and utilising required resources (stanojević et al., 2014). thus, someone with proactive coping will take any action to be able to solve the challenge. based on the results of interviews and questionnaires, it was also found that the respondents thought that recovering from the pulmonary tuberculosis disease is a challenge by having to complete the treatment until they are completely healed and that they can go on to be as normally active as before. the respondents believe that taking regular and routine medication will cure the patients of the pulmonary tuberculosis disease. conclusions it can be concluded that most of the pulmonary tuberculosis clients in the three public health care centres in pegirian, pulo sawah, and perak east had moderate proactive coping rates and self-care management. proactive coping’s highest point was found on the subscale of an individual’s attempt to obtain information, advice, support, and assistance when the individual was facing a stressor. moreover, the self-care highest points were obtained from the client’s statement when taking anti-tb drugs and following the schedule of health check-ups routinely. high proactive coping rates have an impact on the patient's self-care or self-care measures. this indicates that the higher proactive coping level of patients with pulmonary tuberculosis makes the level of self-care management also increase. it is expected that there should be an effort to study the psychosocial aspects of pulmonary tuberculosis patients, one of which is the use of individual coping. health education about self-care at home related to pulmonary tuberculosis should not only be done when it is the first visit of the patients to the health services, but it must be sustained, so that it will create an effective treatment for the patients. it is expected for nurses to be able to table 4. the result of analysis level of proactive coping self-care management level good moderate bad low 6 5 0 moderate 2 55 2 high 1 3 31 spearman’s rho p = 0,000 ; r = 0,848 relationship between proactive coping and self-care... (tintin sukartini et al.) 237 increase the level of awareness of patients related to the transmission of pulmonary tb infection. for further research, it can be expected to analyse the factors that influence the level of proactive coping in improving health level through self-care or self-care management in pulmonary tuberculosis patients. references clark, m. j. d. (2008) community health nursing : advocacy for population health. 5th ed. upper saddle river n.j.: pearson prentice hall. drummond suzanne (2014) being proactive about proactive coping: exploring future-oriented coping and appraisal within a transactional framework | equella, thesis (phd doctorate), griffith university, brisbane. doi: https://www120.secure.griffith.edu.au/ rch/items/a419f1d2-c301-4f2b-a166efc7da07094c/1/drummond_2014_01 abstract.pdf. dwidiyanti, m., noorratri, e. d. and margawati, a. (2017) ‘improving self-efficacy and physical selfreliance of patients with pulmonary tuberculosis through mindfulness’, nurse media journal of nursing, 6(2), p. 81. doi: 10.14710/nmjn.v6i2.12585. falzon, d. floyd, k. getahun, h. kanchar, a. mirzayev, f. raviglione, m. timimi, h. weyer, k. zignol, m. (2015) use of high burden country lists for tb by who in the post-2015 era, who press. doi: http://www.who.int/tb/publications/glo bal_report/high_tb_burdencountrylists 2016-2020.pdf. govender, s. and mash, r. (2009) ‘what are the reasons for patients not adhering to their anti-tb treatment in a south african district hospital?’ greenglass, e. r. and fiksenbaum, l. (2009) ‘proactive coping, positive affect, and well-being’, european psychologist, 14(1), pp. 29–39. doi: 10.1027/1016-9040.14.1.29. kemenkes ri (2015) kementerian kesehatan republik indonesia. 24 maret. jakarta. kemenkes ri (2016) kementerian kesehatan republik indonesia. 2017th edn. jakarta: kementrerian kesehatan ri. 2017. mubarak, w. i. and susanto, b. a. (2006) buku ajar ilmu keperawatan komunitas 2 : teori &amp; aplikasi dalam praktik dengan pendekatan dan asuhan keperawatan komunitas, gerontik dan keluarga. 1st edn. jakarta: sagung seto. mufarokhah, h. m., putra, s. and dewi, y. (2016) ‘self management program meningkatkan koping, niat dan kepatuhan berobat pasien pjk setelah pemberian self management program’, jurnal ners, 11(1), p. 56. doi: 10.20473/jn.v11i12016.56-62. ogden, j. (2012) health psychology. mcgrawhill. de ridder, d. t. d. et al. (2012) ‘taking stock of self-control’, personality and social psychology review, 16(1), pp. 76–99. doi: 10.1177/1088868311418749. schwarzer ralf and taubert steffen (2002) ‘tenacious goal pursuits and striving toward personal growth: proactive coping’, freie universität berlin, pp. 19–35. doi: http://citeseerx.ist.psu.edu/viewdoc/do wnload?doi=10.1.1.533.5201&rep=rep 1&type=pdf. solgajová, a., sollár, t. and vörösová, g. (2015) ‘gender, age and proactive coping as predictors of coping in patients with limb amputation’, kontakt, 17(2), pp. e67–e72. doi: https://doi.org/10.1016/j.kontakt.2015. 01.005. stanojević, d. et al. (2014) ‘proactive coping as a mediator between resources and outcomes: a structural equations modeling analysis’, applied research in quality of life. springer netherlands, 9(4), pp. 871–885. doi: 10.1007/s11482-013-9274-2. thoolen, b. et al. (2007) ‘beyond good intentions: the development and evaluation of a proactive selfmanagement course for patients recently diagnosed with type 2 diabetes’, health education research, 23(1), pp. 53–61. doi: 10.1093/her/cyl160. vaculikova, j. (2016) ‘proactive coping jurnal ners vol. 12 no. 2 oktober 2017: 233-238 238 behavior in sample of university students in helping professions’. weni, m. w. (2014) hubungan koping proaktif dengan diabetes self care activities pada lansia dengan diabetes melitus tipe 2. universitas airlangga. who (2017) ‘global tuberculosis report 2016’, who. world health organization. available at: http://www.who.int/tb/publications/glo bal_report/gtbr2016_executive_summ ary.pdf. williams veena and kaur harbans (2016) ‘the psychosocial problems of pulmonary tuberculosis patientsundergoing dots therapy (direct observed treatment shortcourse therapy) in selected areas of jalandhar district, punjab.’, page 1 iosr journal of pharmacy and biological sciences (iosrjpbs). bunkasha, 1(1), pp. 44–49. yellappa, v. et al. (2016) ‘coping with tuberculosis and directly observed treatment: a qualitative study among patients from south india’, bmc health services research. biomed central, 16(1), p. 283. doi: 10.1186/s12913-016-1545-9. http://e-journal.unair.ac.id/jners | 49 jurnal ners vol. 15, no. 1, april 2020 http://dx.doi.org/10.20473/jn.v15i1.8175 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research family health tasks implementation and medication adherence of pulmonary tuberculosis patients: a correlational study tintin sukartini, nora dwi purwanti, and herdina mariyanti faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: non-adherence medication is found among patients with pulmonary tuberculosis. various factors influence patient adherence to medication. the purpose of this study was to analyze the relationship between family health tasks to medication adherence among patients with pulmonary tuberculosis. methods: the design of this study was cross-sectional, with 45 sample size of pulmonary tuberculosis patients at polyclinic of pulmonary disease in haji general hospital surabaya taken by using a purposive sampling technique. independent variables of this study were family health task which includes five dimensions, recognizing the family member health problem, making decisions for appropriate treatment measures, caring for sick family members, modifying the healthy environment and utilizing the healthcare facilities. the dependent variable was medication adherence. data were taken using the questionnaires then analyzed by spearman rho test. results: there was a relation between tasks of family health: recognizing the family member health problem (p=0.001), taking decisions for appropriate treatment measures (p=0.000), caring for sick family members (p=0.003), modifying the healthy environment (p=0.006), and utilizing the healthcare facilities (p=0.001) with medication adherence in patients with pulmonary tuberculosis. conclusion: the research of this study suggests the hospital arrange health education for the family and the patient to increase the quality of health services. the family can provide a conducive environment for the patient and further research can develop better research by using other methods such as direct observation, demonstration, and simulation. article history received: april 26, 2018 accepted: april 30, 2020 keywords family health task; medication adherence; pulmonary tuberculosis contact tintin sukartini  tintin-s@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: sukartini, t., purwanti, n, d., & mariyanti, h. (2020). family health tasks implementation and medication adherence of pulmonary tuberculosis patients: a correlational study. jurnal ners, 15(1). 49-58. doi:http://dx.doi.org/10.20473/jn.v15i1.8175 introduction non-adherence to medication was found as the cause of multidrug-resistant tb (mdr-tb). in 2013, the world health organization (who) declared mdr-tb as a worldwide crisis due to the number of new cases each year almost reached half a million and that cased continues to emerge with serious epidemics in some countries. moreover, there were detected amount 136,000 cases eligible for mdr-tb treatment (who, 2014). the surveillance of tb prevalence in indonesia reported positive tuberculosis smear amounted to 257 per 100,000 citizens with upper age 15 years old. the notification rate (cnr) in 2015 for all cases was 117 per 100,000 citizens (ministry of health republic of indonesia, 2016). the survey of tuberculosis prevalence in 2014, indonesia was noticed as the second largest contributor of tuberculosis patients after india. in 2015, the east java province of indonesia reported new cases of positive smear amounted to 23,183 patients, which revealed a case detection rate of t 56%, whereas the target was 70% (east java provincial health office, 2016). pulmonary tuberculosis is one of the world's health problems, although control efforts with the directly observed treatment, short-course (dots) strategy have been implemented in many countries since 1995 (kementerian kesehatan (kemenkes— moh), 2014). one of the main challenges to pulmonary tuberculosis control in indonesia is the presence of drug-resistance, especially multidrugresistant tb. tb resistance rates are currently low, https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:mundakir.ners@fik.um-surabaya.ac.id t. sukartini et al. 50 | pissn: 1858-3598  eissn: 2502-5791 but the number of mdr-tb cases tends to increase every year (deprtemen kesehatan republik indonesia, 2013). the who also stated that, by 2013, the world was experiencing a crisis of mdr-tb (world health organization, 2015). one of the contributing factors to the increase in mdr-tb cases is the lack of patient adherence in tb treatment (kementerian kesehatan (kemenkes—moh), 2014). non-adherence of patients in taking anti-tb drugs can be caused due to several factors, such as length of treatment period that causes boredom or feeling of healed so that patients tend to stop treatment unilaterally before the treatment program is complete (kementerian kesehatan (kemenkes— moh), 2014). the patient's personal experience of side effects from anti-tb drugs also influences the patient's compliance with the drug. another factor that causes noncompliance of tb patients in taking medication is due to inadequate oversight of the supervisors of swallowing drugs (ssd). the ssd is the person closest to the patient, as well as the health officer who oversees the patient in taking the medicine. in this case, the family is thought to be more effective in the patient's drug supervision, as the family is the immediate neighborhood of the patient. the results of interviews with some pulmonary tb patients at pulmonary poly, general hospital haji surabaya stated that they received good support from their families so that they were willing to undergo a prescribed treatment procedure, but others said that, during suffering from tuberculosis, they felt the lack of good care of their family green and kreuter’s (2005) behavioral theory of mentions three factors that influence the health behavior of individuals, namely (1) predisposing factors are factors that exist in the individual self, such as knowledge, attitudes, values, beliefs and others; (2) the enabling factor is a supporting factor of the individual environment, which includes the availability of human resources, accessibility to human resources, community / government regulations, priorities and commitment to health and so on; (3) the reinforcing factor is a factor that reinforces the occurrence of health behavior, family support, peers, teachers, community stores and attitudes of health care providers (green and kreuter, 2005). the factor in the formulation of medication behavior of pulmonary tuberculosis patients is the presence of family support, which can be evaluated through the implementation of family health tasks. the family has a health maintenance role, which includes five family health tasks: recognize health problems in the family, take decisions for appropriate treatment measures, care for sick family members, modify a healthy environment, as well as utilize the healthcare facilities that are available around the neighborhood to the maximum. the role of families in the implementation of family health tasks is needed in the treatment process. personal family is the main factor of patient healing. the role of the family in motivating the patient to take the medicine, explaining that the treatment is important, helping to get the medicine, to make the patient always take the medicine, give treatment and give the impetus to recover quickly (risnawati, 2016) will form patient compliance during treatment procedures. family can be an influential factor in determining the beliefs and value of individual health and establishing a treatment program they can receive (niven, 2012). a study conducted by (pameswari, halim and yustika, 2016) states that the role of the family as an ssd is necessary. the role of an ssd is to improve patient compliance to take medication regularly and uninterruptedly, increasing the patient's willingness to control and re-check the sputum according to the time specified, encouraging to recover, assisting costs (finances) for treatment, encouraging patients to rest, provide nutritious food for patients, and clean the house and environment well. (pameswari, halim and yustika, 2016) also explained that, based on the results of research, some respondents said the size of family support and always reminding to take medication on time were the main reason why they were obedient. the purpose of the study was to analyze the relationship between family health tasks to medication adherence among patients with pulmonary tuberculosis materials and methods this research uses correlational design with the cross-sectional approach. the population in this study was patients and families of pulmonary tuberculosis at polyclinic of pulmonary disease in haji general hospital surabaya, in july-september 2016. the inclusion criteria of this study were tb patients under intensive and advance treatment by age 18 to 54 years old with in-house family members. patients under treatment without family assistance, the family assistance member under 21 years old were included in the exclusion criteria. the sample was chosen by a purposive sampling technique based on inclusion and exclusion criteria which resulted in a large sample of 45 patients. the independent variable in this research is a family health task consisting of five dimensions of family health tasks: recognizing the family member health problem, taking decisions for appropriate treatment measures, caring for sick family members, modifying healthy environment and utilizing the healthcare facilities. the dependent variable is medication adherence. the data collecting process used the instrument to collect data from patients and family about patient and family demography, family task implementation in treating the family member with tb and patient adherence to taking medication. the instrument of family health task implementation contains 40 questions taken from research conducted by marwansyah (2012) with modifications from other researches. determination of answer was using likert scale, with a score range of 1 – 4. the classification of questionnaire assessment results in this study are: 1) jurnal ners http://e-journal.unair.ac.id/jners | 51 the highest score is the highest value weighted by the number of questions, 2) the lowest value is the lowest value weight of the number of questions, 3) range is the highest number of values minus the number of lowest values then created intervals is the range divided by the number of categories. the criteria categories are divided into three based on the mean value and standard deviation of the questionnaire question scores: 1) good: x > mean + standard deviation, 2) enough: mean-standard deviation < x < mean + standard deviation, and 3) less: x < meanstandard deviation instrument for adherence to medications uses mmas-8 (morisky medication adherence scale) that contains eight questions. this questionnaire was taken from the journal of clinical hypertension (okello et al., 2016). the questionnaire is most often used to measure compliance with the drug in hypertensive clients, but has been modified so that it can also be used to determine the level of compliance with some chronic diseases requiring long medication treatment (morisky, green and levne, 1986). determination of the answer was by using a guttman scale, where the respondent’s answer is only limited to the answer “yes” which is given a score of 1 and “no” which is given a score of 0. the patient and family filled the questions during waiting time to control with a doctor or after treatment without interruption during treatment. researchers went through several phases during data collection, including requesting permission for the research activities, identification of research respondents, informed consent to research respondents willing to follow the research, replenishment of questionnaires accompanied by mentoring during the filling of questionnaires, and short interviews to selected research respondents. data obtained were analyzed by using statistical test of spearman rho with degree of significance 0.05. the researcher obtained ethical permission from the ethics committee of the faculty of nursing, universitas airlangga, surabaya, with number 270kepk. results the results showed that most of the tb patients were aged between 46-55 years old (24.4%), most of them female (55.6%), with the highest level of education (senior high school) 46.7%. most tb patients were unemployed (28.9%) and most were currently undergoing tb treatment in an advanced phase (60%). the result of the research showed that most of the family members’ age was between 26-34 years old (33.3%), female (57.8%), with the highest level of education (senior high school) 57.8% and the most jobs were entrepreneurs (31.1%) (table 1). the results showed that most families had performed general family health tasks in good category with frequency (62.2%). family health tasks that have been well implemented are mostly caring for sick family members (66.7%), while family health tasks that have not been well implemented are recognizing health problems in the family and modifying a healthy environment (table 2). from the results of the research in the table above can be concluded that the medication adherence for patients of pulmonary tuberculosis treatment in pulmonary poly, general hospital haji surabaya is mostly in high category, as many as 25 patients (55.6%). in the research results, there are still respondents who have low adherence level, as many as one respondent (2.2%) (table 3). implementation of family health tasks in good category has high medication adherence category as many as 20 people (44.5%). in the research result, there are still families with the implementation of family health tasks in the enough category, but the level of medication adherence is low as many as one person (2.2%). the result of statistical analysis with spearman rho correlation test found that there is a relationship between the implementation of family health tasks with the medication adherence of tb patient. implementation of family health task ‘recognize the health problems of family members’ in the good category has the highest level of medication adherence as many as 13 people (28.9%). in the research result, there are still families with family health task implementation ‘recognize health problem of family members’ in the less category, but having medication adherence level of moderate category as many as three people (6.6%). the results of statistical analysis with spearman rho correlation test obtained there is a relationship between the implementation of family health task ‘recognize the health problems of family members’ with medication of pulmonary tuberculosis patients. implementation of family health task ‘taking decisions for appropriate treatment’ category has high levels of medication rate as many as 19 people (42.2%). in the research result, there are still families with the implementation of family health task ‘taking decision for the appropriate action’ in the less category, having low level of drug adherence compliance rate as many as one person (2.2%). the result of statistical analysis with spearman rho correlation test shows relationship between the implementation of family health task ‘take decisions for appropriate action’ with medication adherence of pulmonary tuberculosis patients (table 4). implementation of family health task ‘taking care for sick family members’ in the good category has a high adherence in the drinking category as many as 21 people (46.7%). in the research result there is still family with family health task implementation ‘taking care for a sick family member’ in the enough category, but having low medication adherence level, as many as one person (2.2%). the results of statistical analysis with spearman rho correlation test found there is a relationship between the implementation of family health task ‘taking care for a sick family member’ with medication adherence in pulmonary tuberculosis patients. implementation of family health task ‘modifying a healthy environment’ has t. sukartini et al. 52 | pissn: 1858-3598  eissn: 2502-5791 high categories of medication adherence as many as 16 people (35.6%). in the research result, there are still families with the implementation of family health tasks in the enough category, but the level of medication adherence is low as many as one person (2.2%). the result of statistical analysis with spearman rho correlation test showed that there was a relationship between the implementation of family health task ‘modifying a healthier environment’ with the adherence of taking the medicine for pulmonary tuberculosis patients. implementation of family health task ‘utilizing good health care facilities’ has a high level of adherence to taking medication category as many as 21 people (46.7%). in the research result, there is still family with family health task implementation ‘utilize health care facility’ in the enough category, but low level of adherence of medication as many as one person (2.2%). the results of statistical analysis with spearman rho correlation test found that there is a relationship between the implementation of family health task ‘utilize the available health care facilities’ with the adherence of taking medication for pulmonary tuberculosis patients (table 4). discussion relationship between family health tasks implementation and medication adherence the results of the study reveals a significant relation between family task implementation and patient adherence in taking medication. the adherence in taking medication will increase when the patient has the support from the other family members during treatment. in relation to the study, results declared that compliance in treatment will increase when patients get help from the family (ramizer cited in maulidia, 2014). the family is the first and closest unit to the patient, the family knows about the condition table 1. frequency distribution of tb patients’ characteristics demographic characteristics patients family n % n % age of respondents 17 – 25 26 – 35 36 – 45 46 – 55 56 – 65 7 9 8 11 10 15.6 20.0 17.8 24.4 22.2 15 10 14 6 33.3 22.2 31.1 13.3 gender male female 20 25 44.4 55.6 19 26 42.2 57.8 education level elementary school junior high school senior high school bachelor’s degree 16 3 21 5 35.6 6.7 46.7 11.1 7 5 26 7 15.6 11.1 57.8 15.6 occupation student unemployed housewife entrepreneur traders government employee private employee others 7 13 5 7 1 1 3 8 15.6 28.9 11.1 15.6 2.2 2.2 6.7 17.8 4 11 14 5 2 6 3 8.9 24.4 31.1 11.1 4.4 13.3 6.7 status in family husband wife child 16 18 11 35.6 40.0 24.4 16 16 13 35.6 35.6 28.9 treatment phase intensive advanced 18 27 40 60 table 2. frequency distribution of family health tasks implementation in tb patients family health tasks categories good enough less n % n % n % general family health task 28 62.2 17 37.8 0 0 recognize health problems in the family 16 35.6 25 55.6 4 8.9 take decisions for appropriate treatment 24 53.3 20 44.4 1 2.2 care for sick family members 30 66.7 15 33.3 0 0 modify a healthy environment 21 46.7 23 51.1 1 2.2 utilize the health care facilities 29 64.4 15 33.3 1 2.2 jurnal ners http://e-journal.unair.ac.id/jners | 53 of the patient's illness as well as most often communicates with the patient. open and two-way communication in the family will greatly support the tb patient, reminding each other and motivating the patient to continue the treatment can obtain the healing process. the family role in tb patient care can be a good social support for each family member (hannan and hidayat syaifurahman, 2013). it was found that the implementation of good category family health tasks mostly has high levels of medication adherence, but there is also the implementation of family health tasks in the enough category to have low adherence level of medication. the condition is due to the factors that underlie compliance behavior, not only from family factors alone, but many other factors become influential, for example, from an individual’s factors themselves. an individual who has an unhealthy behavior, even though his or her family's support is good, will still have an effect on the level of medication adherence. in this study, the family task implementation which was mostly good was caring for the sick family member, while the tasks about knowing family health problem and environment modification were less. the less understanding about those problems will result in the lower achievement of family task implementation in caring for a family member with tb. it’s also proven by freadman (2010 cited in nurhidayati, dhian, & khoirunisa,2016) who stated that families have a role to carry out healthcare practices, namely to prevent the occurrence of health problems and care for family members who are sick. table 3. frequency distribution of medication adherence in tb patients measured variables categories n % medication adherence high 25 55.6 medium 19 42.2 low 1 2.2 table 4. relationship between family health tasks implementation and medication adherence indicators medication adherence p r high medium low n % n % n % family health tasks implementation good enough less 20 5 0 44.5 11.1 0 8 11 0 17.7 24.5 0 0 1 0 0 2.2 0 0.004 0.423 total 25 55.6 19 42.2 1 2.2 recognize health problems in the family good enough less 13 12 0 28.9 26.8 0 3 13 3 6.6 28.9 6.6 0 0 1 0 0 2.2 0.001 0.475 total 25 55.7 19 42.1 1 2.2 taking decision for appropriate treatment good enough less 19 6 0 42.2 13.3 0 5 14 0 11.1 31.2 0 0 0 1 0 0 2.2 0.000 0.538 total 25 55.5 19 42.3 1 2.2 taking care for sick family member good enough less 21 4 0 46.7 8.9 0 9 10 0 20 22.2 0 0 1 0 0 2.2 0 0.003 0.426 total 25 55.6 19 42.2 1 2.2 modifying a healthy environment good enough low 16 9 0 35.6 20 0 5 13 1 11.1 28.9 2.2 0 1 0 0 2.2 0 0.006 0.407 total 25 55.6 19 42.2 1 2.2 utilizing health service facilities good enough less 21 4 0 46.7 8.9 0 8 10 1 17.8 22.2 2.2 0 1 0 0 2.2 0 0.001 0.474 total 25 55.6 19 42.2 1 2.2 t. sukartini et al. 54 | pissn: 1858-3598  eissn: 2502-5791 the ability of families to carry out healthcare or maintenance can be seen from family health tasks carried out. families who can perform good family health tasks means they are able to solve health problems that exist in family members. the role of the family in the implementation of good family health tasks is a powerful motivation or support in encouraging patients to seek treatment regularly as recommended (pare, amiruddin and leida, 2010). research conducted by herawati (2011) states that the family has an important role in the prevention of transmission of tb disease. green states that the health of a person or society is influenced by two factors, namely behavioral factors and environmental factors. one's own health behavior is influenced by three factors, namely predisposing factors, enabling and reinforcing. predisposing factors are internal factors that exist in the individual, enabling factors are supporting factors that encourage the realization of healthy behaviors such as healthcare facilities, while reinforcing factor is a strengthening factor such as support from family, teachers, community leaders, health workers and others (nursalam, 2014). the health behavior of tb patients in terms of medication adherence is also influenced by some factors. one of the important factors that plays an important role in the formation of patient medication behavior of pulmonary tuberculosis patients is the existence of family support, which can be evaluated through the implementation of family health tasks. family support greatly supports the success of one's treatment by always reminding the patient to take medication on a regular basis, providing good care during the patient's treatment process, giving understanding and passion to the patient to remain diligent and regular in treating. the presence of family health and duties and tasks will have a psychological impact on patient compliance in the treatment process. families who have been able to perform family health tasks well will establish good health behavior also, which in this case is behavior of medication adherence. relationship between family health task implementation: recognize health problems in the family and medication adherence recognizing family health issues is very important, because family health cannot be ignored (ayuningtiyas, 2013). the family acts as the first to recognize a health problem in one of the family members. health problems in the family can be resolved immediately if the family is able to recognize the health problems experienced by one member of the family. recognizing family members' health problems is a prelude to identifying family needs according to the situation (kausar, herawati and pertiwiwati, 2015). the health of family members is very important to note. health can be a great resource to meet the welfare of each family member. families should be able to understand every health problem that occurs in family members even though it is a small thing. the slightest changes experienced by family members will be a concern in family decision-making. the better the family's ability to familiarize themselves with family health problems the easier it will be for families to overcome the health problems experienced by a family member (handayani, 2014). family ability to recognize health problems is not only in the context of the disease alone, but the family must also be able to recognize how the treatment process is, the problems that may occur during the treatment process, prevention and what are likely to occur if the lung tb patient does not undergo the treatment process that has been established. families should be aware that long-term tb treatment processes will make tb patients feel bored with their treatment, so the family is expected to motivate and act as a supervisor in the patient taking the medicine in order to keep the patient obedient in taking the medicine (marwansyah, 2012) the result of the research showed that most tb patients’ family’s ability in polyclinic of pulmonary disease in haji general hospital, surabaya in recognizing health problem of family members is in the enough category (55.7%) with medication compliance level mostly in the medium category (28.9%). this is in accordance with handayani's statement (2014) that the family's ability to familiarize themselves with family health issues will affect the outcomes of family problem solving. the family's ability to recognize family health problems is one of the processes of gaining knowledge. knowledge is influenced by two factors: internal factors and external factors. internal factor includes education. the educational level of a person will have an effect on the understanding of an experience and stimuli provided through learning and other media. knowledge will affect one's behavior as intermediate impact of the given stimulus (zulfitri, agrina and herlina, 2012). wahyudi, upoyo, and kuswati (2008) also stated that the higher the education of a person, the better the knowledge related to health problems. the results obtained data that most of the family education is high school (46.7%), the level of education is not high, but also not classified as low. this is what causes the family's ability in knowing the health problems of family members to still be in the enough category. recognizing the health problems of family members is an early stage to determine the next action to address the health problems experienced. the family's ability to familiarize themselves with family health issues can help families establish what measures are appropriate for family members in order to improve their health status. if the family has been able to familiarize themselves with family health issues, particularly in tb patients, then they will consider the possibilities that may occur during the treatment process so that they can anticipate any problems. jurnal ners http://e-journal.unair.ac.id/jners | 55 relationship between family health task implementation: taking decisions for appropriate treatment and medication adherence the family is the primary key in decision-making and therapeutic care at every stage of sick family members (setiadi, 2008). the family's ability to make the right decisions is the primary family effort to seek appropriate help according to family circumstances, taking into account who among family members has the ability to perform this task. family health measures are expected to be appropriate to family circumstances (marwansyah and sholikhah, 2015). the family's ability to make the right decisions has an impact on the adherence of the pulmonary tuberculosis patient's medication. the accuracy and speed of the family in decision-making will affect the healing rate of tb patients. the sooner the family takes the decision, the sooner the family overcomes the health problems experienced by family members, in this case related to the adherence of taking the medicine for pulmonary tuberculosis patients (kausar, herawati and pertiwiwati, 2015) marwansyah and sholikhah (2015) also stated that the ability of families to make good decisions can have a positive impact on ailing family, while, if the ability of the family is less able to negatively impact a sick family member, the sufferer may feel unnoticed. wahyudi et al. (2008) explain that, in the implementation of this decision-making task, the family will feel disturbed by the illness experienced by the patient; therefore, the family is rich to find the right treatment for the patient so the patient will recover from his illness. the family also strives to keep an eye on patients in undergoing a prescribed treatment program so that the treatment runs smoothly and the patient becomes obedient so that will accelerate the healing of the disease. the family's ability in decision-making for appropriate action in this study was good (53.5%). it was also shown by the adherence of good or high tb drug patients (42.2%). these data suggest that the more accurate and quicker the decisions taken by the family will increase the compliance of tb patients in taking oat drugs. decision-making for appropriate action can help the family in resolving family members' health problems. the family's ability to interpret the illness experienced by family members is influenced by the family's experience of the disease. if the family has been able to recognize the illness suffered by family members, then the family will be able to decide and take the attitude to overcome the illness experienced. similar to tb patients, if the family has been able to recognize tb disease, including the old treatment process, the family will be able to make decisions when problems occur in patients during the treatment process. relationship between family health task implementation: taking care for sick family member and medication adherence the main function of the family is family care, where the family provides preventive health care and jointly cares for the family members who are sick. the ability of the family in carrying out healthcare or maintenance can be seen from the task of family health that it does (mubarak, chayatin and santosa, 2010). setiadi (2008) explains that the family, in carrying out its functions, must understand about the illness experienced by family members, know the nature and development of care needed, know the sources in the family, know the existence of facilities needed for care and family attitudes toward sick family members. the family can perform simple maintenance in accordance with the ability, whereby the care of this family can be attempted to prevent side effects or complications of the disease to a minimum. notoatmodjo (2003) states that, after someone knows the stimulus or health object, then they will implement and practice what they know. when families are aware of the health problems of their family members, families can help family members take proper care of the health problems experienced. the result of the research shows that the family health task that has been done well is taking care of a sick family member. this is because the family and patients of tb who seek treatment in polyclinic of pulmonary disease in haji general hospital surabaya always get assistance from the nurse on duty. the family always asks the nurse if problems occur or there are complaints during tb treatment. nurses in pulmonary poly, general hospital haji surabaya also always provide health education on how to care for pulmonary tuberculosis patients to overcome the complaints that occur during treatment. families in caring for pulmonary tuberculosis patients should know about pulmonary tuberculosis and treatment programs that the pulmonary tuberculosis patient must undergo. in the treatment process, pulmonary tuberculosis patients are required to take many drugs, some of which have various side effects. drug side effects that are too heavy will make tb patients reluctant to take the medicine again because they think it feels worse when taking the medicine. the family's ability to care for pulmonary tuberculosis patients has a major impact on the family's ability to cope with the side effects experienced. the better the family ability to overcome the side effects of taking medicine in pulmonary tb patients, the better the willingness of tb lung patients to complete the treatment program. the high motivation of the family with proper care will improve patient adherence in the prescribed treatment. t. sukartini et al. 56 | pissn: 1858-3598  eissn: 2502-5791 relationship between family health task implementation: modifying a healthy environment and medication adherence modifying the environment is identical to how to make the environment a therapeutic place for patient recovery. in addition to the physical environment, the psychological supportive environment for sick family members also needs attention (effendi and makhfudli, 2009). modifying the environment to ensure family health is also important in family health tasks, as the health of family members is influenced by lifestyles, stress and the environment. family health can be guaranteed by taking into account the environmental factors of residence (handayani, 2014). modifying the environment can help in the care of family members who experience health problems, in the form of home hygiene and creating comfort in order to rest in peace without any interference from outside. health improvement and maintenance is essential, especially through the commitment and modification of the environment and family lifestyle. this will increase the role of the family in carrying out its responsibilities to the health of family members (setiadi, 2008) the ability to modify a good environment will minimize transmission of tb disease to other family members. maintaining a healthy and conducive home environment will help tb patients to maintain their body resistance so that they can avoid other diseases during their treatment program. if a tb patient is suffering from another disease, it will allow them to take other medications. this will increase the amount of drugs consumed by patients, so it tends to potentially cause psychological problems in the patient, which will affect the patient's compliance in taking the drug. therefore, families are required to have good skills in modifying a healthy environment for tb patients in order to ensure better adherence to tb drug treatment. relationship between family health task implementation: utilizing health service facilities and medication adherence family perception about healthy pain is closely related to behavior seeking for treatment. family responses when there are family members who experience family health problems are very varied, ranging from not doing anything with the excuse not to interfere, performing certain actions such as treat yourself, seeking traditional medical facilities, finding drugs in drug stalls, seeking treatment to service facilities of modern health organized by the government or private, to seeking modern treatment organized by practicing physicians. this will affect whether or not health facilities are available (notoatmodjo, 2007) pulmonary tuberculosis is a disease with a lengthy period for the healing process, that is patients should consume drugs regularly and on time. if this is not the case, then the healing process will experience obstacles, or the other possibility is that there can be resistance to tb drugs (mdr-tb). resistance to tb drugs will cause tb patients to repeat the treatment process. the process of treatment will be extended longer, the number of drugs consumed will also be increase. this condition will lead to problems in the psychological condition of the patient that will lead to non-adherence with medication (m, rohmah and wicaksana, 2015). utilizing health care facilities needs to be done, not only to maintain the health stability of pulmonary tb patients, but also to ensure that drug taking is done on time. often the ability of families to reach health facilities becomes an obstacle for families to bring tb patients to health facilities. it also relates to the accuracy of pulmonary tb patient drug preparation (handayani, 2014) the family as a patient's medicinal overseer should ensure that patient drug taking should not depart from the schedule set by the health worker. delay in taking drugs will make the patient late also in taking the medicine, so if left continuously it will lead to resistance to tb treatment. this will make the tb patient repeat the treatment process with increased number of medicines and longer time span, which will make the patient feel bored because they have to consume drugs continuously. this condition will affect patient compliance in taking oat drugs. therefore, the family should be able to utilize the health service facilities that are well available to support the cure of patients with drug medicine in the high category. conclusion the results of data analysis with the spearman rho trial showed that there was a significant relationship between carrying out family task and medication adherence of tb patients. adherence to medication will increase when patient get help from family. the family is the first and closest unit to the patients, the family knows about the disease, and also the patients and is who most often communicates with the patients. open and two-way communication within the family will greatly support tb patients; asking for one another and motivating help to continue treatment can improve the healing process. the role of the family in the care of tb patients can be a social support for family members. implementation of family health tasks of pulmonary tuberculosis patients who seek treatment at pulmonary poly general hospital haji surabaya is mostly in the good category. medication adherence of pulmonary tuberculosis patients treated in pulmonary poly general hospital haji surabaya is included in the category of high compliance. family health tasks in caring of pulmonary tuberculosis patients have a significant relationship with the level of medication adherence of pulmonary tuberculosis patients in pulmonary poly general hospital haji surabaya. family health task ‘recognizing the health jurnal ners http://e-journal.unair.ac.id/jners | 57 problems of family members’ has a significant relationship with the medication adherence of pulmonary tuberculosis patients who seek treatment at pulmonary poly general hospital haji surabaya. family health task ‘making decisions for appropriate action’ has a significant relationship with medication adherence of pulmonary tb patients treated at pulmonary poly general hospital haji surabaya. family health task ‘taking care for sick family members’ has a significant relationship with the medication adherence of pulmonary tuberculosis patients who seek treatment at pulmonary poly general hospital haji surabaya. family health task ‘modifying the environment’ has a significant relationship with the medication adherence of pulmonary tuberculosis patients who seek treatment at pulmonary poly general hospital haji surabaya. family health task ‘utilizing available health care facilities’ has a significant relationship with medication adherence of pulmonary tb patients treated at pulmonary poly general hospital haji surabaya. references ayuningtiyas, l. w. (2013) hubungan pelaksanaan fungsi perawatan kesehatan keluarga dengan pencapaian tugas perkembangan balita di bina keluarga balita (bkb) glagahwero kecamatan kalisat jember. universitas jember. deprtemen kesehatan republik indonesia (2013) riset kesehatan dasar. jakarta. doi: 1 desember 2013. east java provincial health office (2016) profil kesehatan provinsi jawa timur tahun 2016. jakarta, indonesia. effendi, f. and makhfudli (2009) keperawatan kesehatan komunitas: teori dan pratek dalam keperawatan. jakarta: salemba medika. friedman, m., bowden, v. and jones, e. (2010) buku ajar keperawatan keluarga : riset, teori, dan praktik. 5th edn. edited by s. yani and hamid. jakarta: egc. green, l. w. and kreuter, m. w. (2005) health program planning: an educational and ecological approach. mcgraw-hill companies. handayani, p. k. (2014) ‘hubungan pelaksanaan tugas kesehatan keluarga dengan tingkat kecemasan penderitadiabetes mellitus tipe 2 (niddm) di poli dalam rsud dr. r. goenteng taroenadibrata purbalingga’, jurnal unsoed, 4, pp. 1–10. hannan, m. and hidayat syaifurahman (2013) ‘peran keluarga dalam perawatan penderita tuberkulosis paru di kecamatan gapura kabupaten sumenep.’, jurnal kesehatan wiraraja medika, pp. 16–20. kausar, l. i. e., herawati and pertiwiwati, e. (2015) ‘tugas kesehatan keluarga pada anggota keluarga yang menderita tb paru’, jurnal keperawatan dan kesehatan, 3(2), pp. 34–45. kementerian kesehatan (kemenkes—moh) (2014) national guidelines for tuberculosis control. jakarta indonesia: kemenkes ri. m, n. l., rohmah, s. and wicaksana, a. y. (2015) ‘upaya keluarga untuk mencegah penularan dalam perawatan anggota keluarga dengan tb paru’, jurnal keperawatan, 6(2), pp. 108–116. marwansyah (2012) pengaruh pemberdayaan keluarga penderita tb paru terhadap kemampuan melaksanakan tugas kesehatan keluarga di wilayah puskesmas martapuradan astambul kabupaten banjar. universitas airlangga. marwansyah and sholikhah, h. h. (2015) ‘pengaruh pemberdayaan keluarga penderita tb ( tuberculosis ) paru terhadap kemampuan melaksanakan tugas kesehatan keluarga di wilayah puskesmas martapura dan astambul kabupaten banjar ( the influence of empowering tb ( tuberculosis ) patients ’ family’, buletin kesehatan indonesia, 18(1), pp. 407–419. maulidia, d. f. (2014) hubungan antara dukungan keluarga dan kepatuhan minum obat pada penderita tuberkulosis di wilayah ciputat tahun 2014. universitas islam negeri syarif hidayatullah. ministry of health republic of indonesia (2016) ‘infodatin-tb-2016.pdf’. indonesia. morisky, d. e., green, l. w. and levne, d. m. (1986) ‘concurrent and predictive validity of a selfreported measure of medication adherence’, pp. 67–74. mubarak, w. i., chayatin, n. and santosa, b. a. (2010) ilmu keperawatan komunitas: konsep dan aplikasinya. jakarta: salemba medika. niven, n. (2012) health psychology: introduction to nurses and other health professions. jakarta: egc. notoatmodjo (2007) promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta. notoatmodjo (2010) pendidikan dan perilaku kesehatan. jakarta: rineka cipta. nurhidayati, i., dhian, a. and khoirunisa, h. (2016) ‘issn 2407-9189 the 3’, the 3rd university research collequium, pp. 364–373. nursalam (2014) metodelogi penelitian ilmu keperawatan. jakarta: salemba medika. okello, s. et al. (2016) ‘validity and reliability of a self-reported measure of antihypertensive medication adherence in uganda’, plos one, pp. 1– 11. doi: 10.5061/dryad.jd61j.funding. pameswari, halim and yustika (2016) ‘drug compliance levels in tuberculosis patients at major general h. a. thalib hospital, kerinci district’, journal of pharmaceutical & clinical science, pp. 116–121. pare, a. l., amiruddin, r. and leida, i. (2010) ‘hubungan antara pekerjaan, pmo, pelayanan kesehatan, dukungan keluarga dan diskriminasi dengan perilaku berobat pasien tb paru’, repository unhas. risnawati, i. (2016) ‘peran keluarga pada kepatuhan minum obat penderita tb di kawedanan pedan klaten’, jurnal arsi, 3(1), pp. 343–347. setiadi (2008) konsep dan proses keperawatan t. sukartini et al. 58 | pissn: 1858-3598  eissn: 2502-5791 keluarga. yogyakarta: graha ilmu. wahyudi, upoyo, a. s. and kuswati, a. (2008) ‘penilaian lima tugas kesehatan keluarga pada keluarga dengan anggota keluarga menderita tb paru di wilayah kerja bp magelang’, jurnal keperawatan soedirman (the soedirman journal of nursing), 3, pp. 144–148. who (2014) drug-resistant tb surveillance & response supplement: global tuberculosis report 2014 (who/hq/tb/2014.12). world health organization (2015) the end of tb strategy. geneva, switzerland, geneva. zulfitri, r., agrina and herlina (2012) ‘gambaran pelaksanaan fungsi perawatan kesehatan’, jurnal ners indonesia, 2(2), pp. 109–115 hubungan faktor risiko asma dan perilaku pencegahan 155 tradisi masyarakat lombok mempengaruhi perilaku asupan gizi ibu hamil (community of lombok’s tradition effects the nutrient intake behavior in pregnant woman) ni ketut alit armini*, retnayu pradanie*, putu widhi sudariani* abstract introduction: tradition about nutrient intake in pregnant women had being spreaded in the society and it can influence the behaviour of pregnant women in the fulfilment of nutrient intake in pregnancy. lombok area is still following the nutrient intake tradition. the objective of the study was examine the relation between tradition of lombok community with the nutrient intake behaviour in pregnant woman in the working area of public health center perampuan, labuapi district, west lombok regency. method: this study used cross sectional design. the population was all pregnant women that came to the puskesmas public health center perampuan, labuapi district, west lombok regency each month. sample formulation used purposive sampling. total sample were 45 respondents that were taken according to inclusion criteria. independent variable was tradition of lombok community and dependent variable was the nutrient intake behaviour in pregnant woman. data were collected using questionnaire, interview, respondent observation and dietary recall 24 hours. data were analyzed with correlation spearman rho, with significance value α≤0.05. result: the result showed that there were corelation between tradition of lombok community with the knowledge (p=0.002), attitude (p=0.001). analysis: the action of nutrient intake in pregnant woman of the fulfilment nutrient intake in pregnancy. discussion: further studies should do the research to change the negativity behaviour causes by tradition of community, specially for nutrient intake in pregnancy, such as continuously health education. keywords: tradition, nutrient intake, knowledge, attitude, action *fakultas keperawatan universitas airlangga. kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: alitnik@yahoo.com pendahuluan berbagai tradisi seputar kehamilan tentang asupan gizi saat hamil beredar luas di masyarakat dan dianggap sebagai suatu kebenaran, sehingga mempengaruhi perilaku ibu hamil. beberapa tradisi dapat bertahan karena memberikan nasehat yang sesuai dengan pengalaman sehari-hari, namun, berbagai tradisi tersebut terbukti salah atau tidak efektif jika ditinjau dengan kemajuan kedokteran dan teknologi (kissanti, 2007). terdapat berbagai pantangan atau adat kebiasaan yang sebenarnya bertentangan dengan norma gizi di kalangan masyarakat pedesaan, sehingga akan mempengaruhi sikap maupun perilaku ibu hamil dalam memenuhi nutrisi, padahal baik ibu dan janin sangat memerlukan nutrisi yang adekuat (manuaba, 1999). menurut studi pendahuluan yang telah dilakukan sebanyak 39 orang, di daerah lombok masih terdapat beberapa tradisi asupan gizi pada ibu hamil misalnya dilarang makan cumi-cumi, udang, kepiting, ayam, telur, daging, ikan pari, lele dan ikan laut karena dapat mempersulit proses kelahiran dan terjadi perdarahan saat melahirkan, selain itu ibu hamil dilarang makan durian, rambutan, tebu, timun, pisang, nangka karena dapat menyebabkan keguguran (komplikasi kehamilan). ibu hamil juga tidak diperbolehkan makan jeruk karena dapat meningkatkan lendir pada paru bayi dan resiko kuning saat bayi lahir, namun hubungan tradisi masyarakat lombok dengan perilaku asupan gizi pada ibu hamil sampai saat ini masih belum jelas. angka kematian ibu melahirkan di indonesia pada tahun 2006 termasuk tertinggi jurnal ners vol. 4 no. 2: 155-160 156 di kawasan asia, yaitu 307/100.000 kelahiran. propinsi penyumbang kasus kematian ibu melahirkan terbesar ialah papua 730/100.000 kelahiran, nusa tenggara barat 370/100.000 kelahiran, maluku 340/100.000 kelahiran (annas, 2007). angka kematian ibu adalah 70% untuk ibu-ibu yang anemia dan 19,7% untuk mereka yang non anemia. prevalensi anemia pada kehamilan di indonesia masih tinggi yaitu sekitar 40,1%, dari 31 orang wanita hamil pada trimester ii didapati 23 (74%) menderita anemia, dan 13 (42%) menderita kekurangan besi (amiruddin dkk., 2007). tahun 2003 pada daerah ntb dari 21.450 ibu hamil yang diperiksa terdapat 4.053 (18,90%) yang mengalami kurang energi knonis (kek), anemia 2.570 (11,98%) kasus, tahun 2004 didaerah lombok angka kematian bayi tercatat 89 orang per 1000 kelahiran hidup, dan tingkat kematian ibu hamil di daerah lombok masih sangat tinggi yaitu 400890 orang per 100.000 kelahiran hidup (the lancet, 2008. 215). pada tahun 2005, di ntb tercatat prevalensi ibu hamil kurang energi kronik 16,7%, ibu hamil dengan anemia gizi besi 45% (hernawardi, 2008). sedangkan kejadian bayi lahir dengan gizi buruk menurut dinas kesehatan kota mataram bulan januari sampai agustus 2007 berjumlah 82 orang yaitu pada bulan januari 14 orang, februari 24 orang, maret 18 orang, april 5 orang, mei 5 orang, juni 4 orang, dan agustus 12 orang (dinkes, 2007). perilaku ibu hamil terhadap tradisi yang ada di masyarakat khususnya dalam hal asupan gizi dapat terbentuk karena berbagai pengaruh atau rangsangan yang berupa pengetahuan dan sikap, pengalaman, kepercayaan, sosial, budaya, serta sarana fisik. pengaruh atau rangsangan itu bersifat internal dan eksternal dan diklasifikasikan menjadi faktor yang mempengaruhi perilaku sehat, yaitu faktor predisposisi (predispossing factors), faktor pemungkin (enabling factors), dan faktor pendorong (reinforcement factors) (winarsih, 2006). kepercayaankepercayaan dan pantangan-pantangan terhadap beberapa makanan akan berdampak negatif terhadap kesehatan ibu dan janin, sehingga anemia dan kurang gizi pada wanita hamil cukup tinggi terutama di daerah pedesaan (linda, 2004). banyak peneliti menemukan masalah kurang energi protein di daerah dimana pangan sumber protein tersedia cukup tinggi, tetapi karena kebiasaan kepercayaan dan ketidaktahuan terhadap gizi maka banyak jenis-jenis bahan makanan yang tidak dimanfaatkan (supariasa, 2001). perilaku mempunyai pengaruh yang sangat besar terhadap derajat kesehatan masyarakat. perilaku masyarakat tersebut biasanya bersifat lokal spesifik, terjadi pada golongan, ras atau daerah tertentu, dipengaruhi oleh lingkungan alam, serta sudah berlangsung selama bertahun-tahun. penyebab dari perilaku tersebut harus digali secara mendalam agar masyarakat dapat dilibatkan secara aktif dalam menanggulangi. berdasarkan konsep yang ada, penelitian ini dilaksanakan pada daerah lombok barat khususnya di wilayah kerja puskesmas perampuan kecamatan labuapi. hal ini dilakukan untuk menggali hubungan tradisi masyarakat lombok dengan perilaku asupan gizi pada ibu hamil. hasil dari penelitian ini dapat digunakan untuk mencari upaya yang tepat guna mengurangi perilaku masyarakat khususnya ibu hamil yang bertentangan dengan pola hidup sehat. bahan dan metode penelitian penelitian ini menggunakan crosssectional design dan purposive sampling. sampel yang memenuhi kiteria inklusi dan eksklusi sebanyak 45 orang. kriteria inklusi: 1) kehamilan fisiologis (skor poedji rochjati=2), 2) masyarakat asli lombok. kriteria eksklusi: 1) ibu hamil sedang menjalani rawat inap, 2) ibu hamil buta huruf. penelitian ini dilaksanakan pada bulan mei-juni 2008. variabel independen dalam penelitian ini adalah tradisi masyarakat lombo, sedangkan variabel dependen perilaku supan gizi pada ibu hamil. instrumen pengumpulan kedua jenis variabel tersebut menggunakan kuesioner. data yang diperoleh dianalisis menggunakan uji statistik korelasi spearman rho dengan tingkat signifikansi α≤0,05. hasil penelitian sebagian besar ibu hamil di puskesmas desa perampuan kecamatan labuapi kabupaten lombok barat mempunyai sikap negatif (mengikuti tradisi masyarakat lombok) sebanyak 24 responden (53%) dan yang memiliki sikap positif sebanyak 21 responden (47%). tingkat pengetahuan ibu hamil tradisi masyarakat lombok (ni ketut alit armini) 157 sebagian besar baik yaitu dari 45 responden didapatkan sebanyak 31 orang (68%), sedangkan yang memiliki tingkat pengetahuan cukup dan rendah sebanyak 7 responden (16%). sikap ibu hamil tentang gizi selama kehamilan positif sebanyak 23 responden (51%) dan 22 responden (49%) mempunyai sikap negatif. hasil observasi terhadap 45 responden, dapat dilihat bahwa responden yang mengkonsumsi nasi 45 responden (100%), konsumsi lauk 39 responden (93%), mengkonsumsi sayuran sebanyak 19 orang (42%), konsumsi buah-buahan sebanyak 15 orang (33%), konsumsi susu hamil hanya sebanyak 3 orang (7%), dan yang mengkonsumsi makanan selingan sebanyak 8 orang (18%). berdasarkan dietary recall sebagian besar kebutuhan ibu hamil tidak tercukupi 37 responden (82%), sedangkan kebutuhan ibu hamil yang tercukupi hanya 8 orang (18%). hasil wawancara 43 responden (93%) mengkonsumsi vitamin sedangkan hanya 3 responden (7%) yang tidak mengkonsumsi vitamin dan responden yang mengikuti tradisi asupan gizi saat hamil sebanyak 30 responden (67%), sedangkan yang tidak mengikuti tradisi asupan gizi pada saat hamil sebanyak 15 responden (33%). hasil uji statistik dengan menggunakan uji korelasi spearman rho (r) menunjukkan ada hubungan bermakna antara tradisi masyarakat lombok dengan tingkat pengetahuan ibu hamil (tabel 1), tradisi masyarakat lombok dengan sikap ibu hamil (tabel 2) dan tradisi masyarakat lombok dengan tindakan yang dilakukan ibu hamil dalam pemenuhan asupan gizi (tabel 3). tabel.1 hubungan tradisi masyarakat lombok dengan tingkat pengetahuan ibu hamil di puskesmas desa perampuan kecamatan labuapi kabupaten lombok barat juni 2008 sikap tradisi masyarakat lombok positif negatif total pengetahuan baik 19 (42%) 12 (26%) 31 (68%) cukup 2 (5%) 5 (11%) 7 (16%) kurang 0 (0%) 7 (16%) 7 (16%) total 21 (47%) 24 (53%) 45 (100%) uji spearman rho (r) : p=0,002 ; r=0,458 tabel. 2 hubungan tradisi masyarakat lombok dengan sikap ibu hamil di puskesmas desa perampuan kecamatan labuapi kabupaten lombok barat juni 2008 sikap tradisi masyarakat lombok positif negatif total sikap asupan gizi saat hamil positif 16 (36%) 7 (15%) 23 (51%) negatif 5 (11%) 17 (38%) 22 (49%) total 21 (47%) 24 (53%) 45(100%) uji spearman rho (r) : p=0,001 ; r=0,469 tabel. 3 hubungan tradisi masyarakat lombok dengan tindakan yang dilakukan ibu hamil di puskesmas desa perampuan kecamatan labuapi kabupaten lombok barat juni 2008 sikap tradisi masyarakat lombok positif negatif total tindakan asupan gizi saat hamil tercukupi 8 (18%) 0 (0%) 8 (18%) tidak tercukupi 7 (15%) 30 (67%) 37 (82%) total 15 (33%) 30 (67%) 45 (100%) keterangan : p = signifikansi r = koefisien korelasi pembahasan tradisi masyarakat lombok terhadap asupan gizi saat hamil diikuti sebagian besar ibu hamil yang asli lombok (suku sasak) yaitu dari 45 responden, 24 responden (53%) mengikuti tradisi masyarakat tersebut. hal ini dapat disebabkan karena tradisi masyarakat jurnal ners vol. 4 no. 2: 155-160 158 telah dijalani secara turun-temurun, selain itu dapat juga disebabkan oleh faktor pengalaman yang telah didapatkan sehingga mempengaruhi tradisi masyarakat lombok menjadi lebih kuat. sesuai dengan pendapat meutia (2001) bahwa sistem medis masyarakat merupakan kompleksitas dari beberapa unsur kebudayaan yang menjadi pandangan hidup anggota masyarakat yang bersangkutan terdiri dari ide, kepercayaan, dan pengetahuan yang mendasari perilaku kesehatan masyarakat. menurut pellegrino (1986) yang dikutip oleh meutia (2001) menyebutkan bahwa tiap kebudayaan telah mengembangkan sistem kesehatan yang mengandung hubungan timbal balik yang tidak terlepas dari pandangan hidup yang berlaku. menurut linda (2004) masalah kematian maupun kesakitan pada ibu dan anak tidak terlepas dari faktor sosial budaya dan lingkungan di dalam masyarakat dimana mereka berada. disadari atau tidak, faktor kepercayaan dan pengetahuan budaya seperti konsepsi mengenai berbagai pantangan, hubungan sebab akibat antara makanan dan kondisi sehat sakit, kebiasaan dan ketidaktahuan, seringkali membawa dampak baik positif maupun negatif terhadap kesehatan ibu dan anak. pola makan, misalnya, pada dasarnya adalah merupakan salah satu selera manusia dimana peran kebudayaan cukup besar. hal ini terlihat bahwa setiap daerah mempunyai pola makan tertentu, termasuk pola makan ibu hamil dan anak yang disertai dengan kepercayaan akan pantangan, tabu, dan anjuran terhadap beberapa makanan tertentu. pengetahuan ibu hamil tentang gizi pada masyarakat lombok adalah baik (68%). pengetahuan ibu cukup baik diperoleh dari pendidikan formal maupun informal dan kegiatan promosi kesehatan tentang makanan bergizi bagi ibu hamil. informasi promosi kesehatan diperoleh baik secara langsung oleh petugas kesehatan ataupun media masa seperti majalah, televisi, radio, koran. responden yang mempunyai pengetahuan kurang sebanyak 7 orang (16%), disebabkan responden berpendidikan sd dan smp, serta tidak bekerja. sesuai dengan pendapat kuncoroningrat yang dikutip nursalam & siti pariani (2001) bahwa makin tinggi pendidikan seseorang makin mudah menerima informasi sehingga makin banyak pula pengetahuan yang dimiliki. sebaliknya pendidikan yang kurang akan meghambat perkembangan sikap seseorang terhadap nilai baru yang diperkenalkan. demikian pula pendapat notoadmojo (2003) bahwa pada umumnya semakin tinggi pendidikan seseorang maka akan semakin baik pula tingkat pengetahuan. sebagian besar responden berpendidikan sd (65%) dan smp (33%). kondisi tersebut mengakibatkan penerimaan responden terhadap informasi terbatas pada tingkat tahu saja tentang gizi sedangkan penerapan dalam kehidupan masih kurang. sikap positif dengan sikap negatif ibu hamil memiliki perbedaan yang sangat tipis, terbukti dari 45 responden 23 orang (51%) memiliki sikap positif, sedangkan sikap negatif mengenai asupan gizi sebanyak 22 orang (49%). hal ini dapat disebabkan karena faktor tradisi masyarakat yang dianut selain itu dapat pula disebabkan karena pengalaman pribadi, orang yang dianggap penting, media masa, sosial ekonomi. sesuai dengan pendapat azwar (2007) ada beberapa faktor yang mempengaruhi sikap yaitu pengalaman pribadi, kebudayaan, orang lain yang dianggap penting, media masa, lembaga pendidikan dan lembaga agama serta faktor emosi dalam diri individu. sikap responden positif atau negatif tentang asupan gizi akan diikuti perilaku yang berbeda dari waktu kewaktu dan dari satu situasi ke situasi lain yang mempengaruhinya. menurut notoatmodjo (2007) sikap merupakan reaksi atau respon yang asih tertutup dari seseorang terhadap suatu stimulus atau objek. sikap itu tidak langsung dilihat, tetapi hanya dapat ditafsirkan terlebih dahulu dari perilaku tertutup. sikap secara nyata menunjukkan konotasi adanya kesesuaian reaksi terhadap stimulus tertentu dalam kehidupan sehari-hari atau merupakan reaksi yang bersifat emosional terhadap stimulus sosial. menurut newcomb, salah seorang ahli psikologis sosial yang dikutip oleh notoatmodjo (2007) menyatakan bahwa sikap merupakan kesiapan atau kesediaan untuk bertindak, dan bukan merupakan pelaksanaan motif tertentu. sikap belum merupakan suatu tindakan atau aktivitas, akan tetapi merupakan predisposisi tindakan suatu perilaku. hubungan tradisi masyarakat lombok dengan sikap ibu hamil dipengaruhi oleh pemahaman dan motivasi ibu hamil yang tradisi masyarakat lombok (ni ketut alit armini) 159 kurang dalam pemenuhan asupan gizi karena pengetahuan saja belum mampu membuat seseorang mengubah perilaku. faktor sosial ekonomi dan tradisi yang ada di masyarakat juga mempengaruhi sikap negatif tersebut. mayoritas responden percaya terhadap pantangan makanan selama kehamilan karena dapat mengganggu janin dalam kandungan dan kesehatan ibu hamil. sosial ekonomi yang rendah juga berdampak terhadap kemampuan keluarga untuk menyediakan makanan yang bergizi. keadaan ini tentu mengakibatkan gizi yang buruk pada anggota keluarga khususnya ibu hamil. melalui wawancara didapatkan sebagian besar ibu hamil kurang memperhatikan menu makanan yang dibutuhkan selama periode kehamilan. hasil observasi yang telah dilakukan peniliti ke rumah responden menunjukkan bahwa responden mengkonsumsi makanan sederhana seperti nasi, tempe/tahu goreng dan sayuransebagian besar responden tidak mengkonsumsi susu saat hamil. hasil wawancara menunjukkan sebagian besar responden mengatakan bahwa ”saya hanya makan nasi, lauk-pauk, sayuran....buah tidak saya makan, susu juga tidak” (15 responden). pemahaman dan motivasi yang kurang serta faktor sosial ekonomi yang rendah menyebabkan hal tersebut terjadi. sembilan belas (43%) responden memiliki penghasilan keluarga rp.500.000-1.000.000 per bulan. menurut notoatmodjo (2007) kesehatan merupakan hasil interaksi berbagai faktor, baik faktor internal (dari dalam diri manusia) maupun faktor eksternal (di luar diri manusia). faktor internal terdiri dari faktor fisik dan psikis. faktor eksternal terdiri dari berbagai faktor, antara lain sosial, budaya masyarakat, lingkungan fisik, politik, ekonomi dan pendidikan. responden yang mengikuti tradisi di masyarakat mengatakan” saya tidak pernah minum es, makan nangka, ikan lele, ikan pari, sama cumi-cumi” . hasil observasi di rumah responden mengenai menu makanan ibu hamil dalam sehari (dietary recall 24 jam) didapatkan 37 responden (82%) tidak memenuhi asupan gizi saat hamil (rerata angka kecukupan gizi = 1174,7 kkal per hari). menurut supariasa (2001) angka kecukupan gizi rata-rata yang dianjurkan per orang per hari untuk ibu hamil yang berumur 20-45 tahun sebesar 2485 kkal. literatur lain menjelaskan bahwa makanan yang harus dihindari atau dibatasi selama kehamilan antara lain minuman yang mengandung kafein seperti kopi dan teh, karena kopi dapat mempengaruhi berat badan rendah pada bayi (bblr), keguguran, selain itu cafein juga dapat mengurangi penyerapan zat besi (kissanti, 2007). sebagaimana yang dinungkapkan oleh linda (2004) menyebutkan bahwa salah satu faktor yang secara langsung dapat mempengaruhi kondisi kesehatan ibu dan bayi adalah makanan yang diberikan. dalam setiap masyarakat ada aturan yang menentukan kuantitas, kualitas dan jenis makanan yang seharusnya dan tidak seharusnya dikonsumsi oleh seseorang, sesuai dengan kedudukan, usia, jenis kelamin dan situasi tertentu, misalnya ibu yang sedang hamil tidak diperbolehkan atau dianjurkan untuk mengkonsumsi makanan tertentu. delapan orang (18%) dari 45 orang yang mengkonsumsi buah dan susu hamil secara rutin dan kebutuhan mereka akan asupan gizi saat kehamilan terpenuhi yaitu sebesar > 2485 kkal perharinya. hal ini dapat disebabkan karena pemahaman dan motivasi ibu hamil dalam pemenuhan asupan gizinya, pengalaman yang didapatkan ibu sebelumnya maupun karena orang yang dianggap penting. sesuai dengan pendapat notoatmodjo (2007) yaitu suatu sikap belum otomatis terwujud dalam suatu tindakan (overt behaviour). untuk mewujudkan sikap menjadi suatu perbuatan nyata diperlukan faktor pendukung atau suatu kondisi yang memungkinkan, antara lain adalah fasilitas dan support dari pihak lain misalnya suami, orang tua atau mertua, dan lain-lain. simpulan dan saran simpulan tradisi masyarakat lombok yang negatif tentang asupan gizi saat hamil masih diikuti sebagian besar ibu hamil yang asli lombok (suku sasak). walaupun sebagian besar pengetahuan ibu hamil mengenai aupan gizi selama kehamilan baik, namun sikap dan tindakan terhadap pemenuhan kebutuhan gizi pada ibu hamil masih kurang. saran jurnal ners vol. 4 no. 2: 155-160 160 saran yang dapat diberikan berdasarkan kesimpulan antara lain meningkatkan pemahaman ibu hamil tentang kebutuhan asupan gizi selama kehamilan melalui pendidikan ante natal yang berkelanjutan sehingga dengan pemahaman yang baik dapat merubah sikap dan tindakan yang negatif menjadi positif. peran dari anggota keluarga terdekat dan perawat sangat penting dalam hal pemantauan dan memberikan dorongan mengenai pemenuhan kebutuhan gizi pada ibu hamil. kepustakaan amiruddin, dkk, 2007. evidence based epidemologi anemia defisiensi zat besi pada ibu hami di indonesia, (online), (http://ridwanamiruddin.wordpress.com, diakses tanggal 17 mei 2008, jam 20.55 wib). annas, 2007. wanita dalam pembangunan, (online), (http://insidewinme.blogspot.com, diakses tanggal 17 mei 2008, jam 22.15 wib). azwar, saifuddin, 2007. sikap manusia. yogyakarta: pustaka pelajar, hlm.129, 154. swasono, meutia, 2001. kehamilan, kelahiran, perawatan ibu dan bayi dalam konteks budaya. jakarta: uip, hlm. 240-243. kissanti, annia, 2007. sembilan bulan yang penuh keajaiban. depok: araska. manuaba, i.b. gde, 1999. memahami kesehtan reproduksi wanita. jakarta: arcan, hlm. 126. notoatmodjo, 2007. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta. notoatmodjo, 2003. ilmu kesehatan masyarakat, jakarta: rineka cipta. nursalam & siti pariani, 2001. metodologi riset keperawatan. jakarta: info medika. supariasa, 2001. penilaian status gizi. jakarta: egc. maas, linda, 2004. kesehatan ibu dan anak: persepsi budaya dan dampak kesehatannya, (online), (http://library.usu.ac.id/download/fkm/fk m%20linda2.pdf, tanggal 1 maret 2008, jam 12.08 wib). winarsih, dkk., 2006. pendidikan kesehatan mengatasi keluhan hamil pada ibu-ibu hamil, skripsi tidak dipublikasikan. surakarta:universitas muhammadiyah. http://ridwanamiruddin.wordpress.com/ http://insidewinme.blogspot.com/ http://library.usu.ac.id/download/fkm/fkm%20linda2.pdf http://library.usu.ac.id/download/fkm/fkm%20linda2.pdf peran terapi al qur’an terhadap kecemasan dan imunitas pasien hospitalisasi 110 peran terapi al qur’an terhadap kecemasan dan imunitas pasien hospitalisasi (the role of the koran therapy on anxiety and immunity of hospitalized patients) hammad* abstract introduction: patient in the hospital faced with anxiety, in feel stronge with the hospital, medicine and treatment action although unsure prognosis of desease. the anxiety will inflict a financial loss because it will influence the attitude of the patient and immunology respons that will effect on how long the patient stay in the hospital and how much cost of treatment. this study was aimed to explain the anxiety level and imunity of patient in the hospital before and after the al qur’an therapy. method: this study used pre experiment pre-posttest design involved 7 respondents, taken by accidental sampling. the independent variable was the al qur’an therapy and the dependent variable were anxiety level and imunity (basofil, eosinofil, monocyt, limfocyt and leucocyt). anxiety level were collected by hamilton anxiey rating scale and the imunity were gotten from laboratory result of basofil, eosinofil, monocyt, limfocyt and leucocyt . data were analyzed using wilcoxon sign rank test for anxiety level and mc nemar for imunity with level of significance α ≤ 0.05.result: results showed that the al qur’an therapy has an effect on decreasing anxiety level (p=0.016). in contrast, there was no effect on imunity after therapy (p = 0,625). incision. analysis: it can be concluded that the koran therapy was proven to reduce anxiety level and increased on imunity on patients hospitalized. discussion: for future further studies should be developed and include larger responden to obtain more accurate results. keywords : anxiety level, immunity, the al qur’an theraphy * poltekes banjarmasin kalimantan selatan, e-mail: hammad_mtp@yahoo.co.id pendahuluan kecemasan dapat menimbulkan perubahan secara fisik maupun psikologis. kecemasan dapat mengaktifkan syaraf otonom yang berakibat detak jantung menjadi bertambah, tekanan darah naik, frekuensi nafas bertambah dan secara umum mengurangi tingkat energi pada klien, sehingga dapat merugikan individu (rothrock, 1999). berdasarkan konsep psikoneuroimunologi, kecemasan merupakan stressor yang dapat menurunkan sistem imunitas tubuh. hal ini terjadi melalui serangkaian aksi yang diperantarai oleh hpa-axis (hipotalamus, pituitari dan adrenal). stress akan merangsang hipotalamus untuk meningkatkan produksi crf (corticotropin releasing factor). crf ini selanjutnya akan merangsang kelenjar pituitari anterior untuk meningkatkan produksi acth (adreno cortico tropin hormon). hormon ini akan merangsang kortek adrenal untuk meningkatkan sekresi kortisol. kortisol inilah yang selanjutnya menekan sistem imun tubuh (ader, 1996). banyak teori yang mengemukakan bahwa noradrenalin, asam gamma aminobutiric dan sistem seretonergicneuronal di lobus prontal dan sistem limbik mempengaruhi secara patobiologis menyebabkan timbulnya gangguan kecemasan, jantung dan pernafasan. bagi umat islam, al qur’an adalah sumber pengobatan tertinggi dan paling diyakini bahwa al qur’an adalah sebagai asy syifaa (obat) dan konsep bahwa tiap penyakit ada obatnya. keyakinan yang kuat ini akan sangat membantu dalam memanfaatkan al qur’an dalam asuhan keperawatan pada pasien cemas. bagi masyarakat kalimantan selatan yang religius, terapi al qur’an merupakan terapi alternatif pertama yang dipilih. ini berarti juga bahwa al qur’an mailto:hammad_mtp@yahoo.co.id manfaat terapi al-qur’an (hammad) 111 dapat dijadikan sumber rujukan bagi perawat dalam membantu penanganan kesehatan pasien. tujuan umum penelitian mengidentifikasi pengaruh terapi al qur’an terhadap tingkat kecemasan dan respon imunitas pasien hospitalisasi. bahan dan metode penelitian jenis penelitian digunakan pra eksperimen dengan hipotesis “ada pengaruh terapi al qur’an terhadap tingkat kecemasan dan respon imunitas pasien hospitalisasi”. penelitian ini dilaksanakan bulan juni 2006 sampai april 2007 di rsud ratu zalecha martapura kabupaten banjar. populasi pada penelitian semua pasien rawat inap di ruang vip penyakit dalam rumah sakit ratu zalecha yang beragama islam dengan jumlah populasi 420 orang pasien. proses pengambilan sampel menggunakan dengan teknik purposive sampling. sampel diambil berdasar kriteria inklusi : 1) usia 15-65 tahun, 2) pasien baru, 3) non infection disease, 4) tidak menderita kanker/tumor, 5) sadar maupun post operasi dengan gcs 15, 6) tidak mengalami gangguan orientasi realita, 7) tidak cedera otak, 8) bebas dari pengaruh obat anastesi dan 9) tidak mendapat transfusi darah, terapi steroid, antibiotik dan supressan imun lainnya. berdasarkan kontrol yang ketat terhadap sampel didapatkan hanya 7 orang pasien. variabel independen dalam penelitian ini adalah terapi al qur’an (surat al fatihah dan surat yaasiin). variabel dependen yaitu tingkat kecemasan dan imunitas pasien (nilai basofil, eosinofil, monosit, limfosit dan leukosit). instrumen pengumpulan data menggunakan lembar observasi kecemasan dengan skala hamilton anxiety rating scale. instrumen imunitas pasien menggunakan data hasil laboratorium pemeriksaan darah. alat yang digunakan mp3 player dg merk a data yang diperdengarkan ke pasien. sedangkan pengambilan darah dan pemeriksaannya dilakukan bekerja sama dengan pihak laboratorium rsud ratu zalecha martapura prosedur awal pasien diukur tingkat kecemasan berupa respon ketegangan fisik dan psikis yang dirasakan pasien selama dirawat di rumah sakit menggunakan hamilton anxiety rating scale.nilai imunitas pasien sebelum memperdengarkan al qur’an juga diukur dengan melihat nilai basofil, eusinofil, monosit, limfosit dan leukosit. kemudian pasien diperdengarkan ayat suci al qur’an (surat al fatihah dan surat yaasiin) sampai selesai melalui mp3 player. terapi al qur’an dilakukan tiga kali sehari selama empat hari berturut-turut. pada hari keempat tingkat kecemasan dan nilai basofil, eosinofil, monosit, limfosit dan leukosit pasien diukur kembali. data yang terkumpul kemudian dianalisa secara deskriptif dan analitik dengan uji wilcoxon sign rank test untuk tingkat kecemasan dan mc. nemar untuk imunitas dengan tingkat kemaknaan α≤ 0,05. hasil penelitian berdasarkan hasil pengumpulan data dari 7 orang pasien sebagai responden didapat hasil tingkat kecemasan pasien sebelum diterapi al qur’an dalam tingkat kecemasan ringan 1 orang (14,3%) dan pada tingkat sedang 6 orang (85,7%). berdasarkan kerakteristik jenis kelamin responden perempuan mempunyai tingkat kecemasan sedang 4 orang (57,1 %) dan 2 orang (28,6%) laki-laki, sedangkan responden lakilaki masih ada yang mempunyai tingkat kecemasan ringan yaitu 1 orang (14,3 %). (tabel 1). setelah diberi terapi al qur’an didapat hasil tingkat kecemasan pasien menurun menjadi tidak cemas 2 orang (2,86 %) dan 5 orang (71,4 %) pada tingkat ringan. berdasarkan jenis kelamin setelah diberikan terapi al qur’an tingkat kecemasan pasien perempuan semuanya turun mejadi tingkat ringan 4 orang (57,1 %) sedangkan laki-laki menjadi tidak cemas sebanyak 2 orang (28,6 %) walaupun masih ada yang mempunyai tingkat kecemasan ringan yaitu 1 orang (14,3 %) berdasar uji statistik wilcoxon signed rank test di dapat p=0,016 yang berarti bahwa terdapat perbedaan tingkat kecemasan sebelum dan sesudah terapi al qur’an (tabel 1). jurnal ners vol.4 no.2: 110-115 112 tabel 1. tingkat kecemasan pasien sebelum dan sesudah diberikan terapi al qur’an di rsud ratu zalecha martapura tingkat cemas sebelum sesudah wanita laki-laki jumlah wanita laki-laki jumlah ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % tidak cemas 2 28,6 2 28,6 ringan 1 14,3 1 14,3 4 57,1 1 14,3 5 71,4 sedang 4 57,1 2 28,6 6 85,7 berat jumlah 4 57,1 2 42,9 7 100 4 57,1 3 24,9 7 100 uji wilcoxon signed rank test p=0,019 keterangan : ∑= jumlah %= prosentase p= signifikansi imunitas pasien dalam penelitian ini didasarkan pada hasil pemeriksaan basofil, eosinofil, monosit, limfosit dan leukosit dengan menggunakan sampel darah pasien dan dicek ke laborarorium rs ratu zalecha. hasil pemeriksaan pada pasien yang menjadi responden sebelum diberi terapi al qur’an adalah limfosit dalam keadaan tidak normal ada 5 orang (71,5%) terdiri dari 2 orang lakilaki dan 3 orang perempuan. leukosit dalam keadaan tidak normal ada 2 orang (28,6 %) yaitu1 orang perempuan dan 1orang laki-laki. hasil pemeriksaan pada eosinofil, basofil dan monosit sebelum terapi al qur’an dalam keadaan normal semua (tabel 2). setelah responden diberi terapi al qur’an hasil pemeriksaan limfosit dalam keadaan yang normal 4 orang (57,1 %) yaitu 2 orang perempuan dan 2 orang laki-laki dan tidak normal ada 3 orang (42,9 %) yaitu 2 orang perempuan dan 1 orang laki-laki. kadar leukosit setelah terapi dalam keadaan normal 5 orang (71,5%) yaitu 3 orang lakilaki dan 3 orang perempuan, namun masih ada kadar leukosit yang tidak normal sebanyak 2 orang (28,6%). melalui uji mc nemar didapat hasil p=0,625 pada limfosit dan p=0,5 pada leukosit. hal ini menujukkan tidak terdapat perbedaan signifikan sebelum dan sesudah terapi al qur’an (tabel 3). sedangkan pada pemeriksaan limfosit, eosinofil dan basofil tidak bisa dilakukan pengujian mc nemar karena tidak ada variasi nilainya. keadaan pasien hospitalisasi sebelum diberi terapi al qur’an sebagian besar pada tingkat kecemasan sedang dan ada 1 orang dengan tingkat ringan. kecemasan adalah pengalaman emosi yang tidak menyenangkan. kecemasan mungkin disertai dengan gangguan fisik dan selanjutnya menurunkan kapasitas seseorang untuk mengatasi stressor (stuart and sundeen, 1998). setelah diberi terapi al qur’an ditemui penurunan tingkat kecemasan pasien hospitalisasi menjadi tidak cemas sebanyak 2 orang (2,86 %) dan menjadi cemas ringan 5 orang (71,4 %) dan tidak ada lagi yang memiliki tingkat kecemasan sedang. penggunaan pendekatan spiritual dalam hal ini memperdengarkan ayat-ayat al qur’an pada saat memberikan asuhan keperawatan ternyata mampu menurunkan kecemasan pasien. mendengarkan ayat-ayat al qur’an dapat memberikan ketenangan dan kepasrahan pada yang maha kuasa. keyakinan yang kuat bahwa setiap penyakit ada obatnya dan al qur’an sebagai asy syifaa (obat) adalah sumber pengobatan tertinggi dan paling diyakini sangat membantu dalam menurunkan kecemasan pasien. situasi ini didukung oleh beberapa pendapat diantaranya adalah sharon wyatt, seorang peneliti pusat kesehatan universitas mississippi amerika serikat melakukan riset selama berbulan-bulan ke pusat-pusat peribadatan di mississipi. dia melakukan riset untuk menjawab sebuah pertanyaan : “ untuk apa berdoa, sembahyang dan ritual?”. akhirnya dia menyatakan bahwa agama dan spiritualitas tidak harus padam oleh silau modernitas. seperti dikutip oleh harian health day news, wyatt menyatakan “ agama dan spiritualitas, dalam banyak hal terbukti berguna untuk kesehatan. ia memiliki efek positif terhadap tekanan darah (republika, 2006). manfaat terapi al-qur’an (hammad) 113 tabel 2. imunitas pasien hospitalisasi sebelum diberi terapi al-qur’an berdasarkan jenis kelamin di rsud ratu zalecha martapura tabel 3. imunitas pasien hospitalisasi sesudah diberi terapi ayat al-qur’an di rsud ratu zalecha martapura jenis kelamin limfosit eosinofil monosit basofil leukosit n ab n ab n ab n ab n ab ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % lk 2 28,6 1 14,3 3 42,9 3 42,9 3 42,9 3 42,9 1 14,3 pr 2 28,6 2 28,6 3 42,9 1 14,2 4 57,2 4 57,2 2 28,6 1 14,3 jumlah 4 57,2 3 42,9 6 85,8 1 14,2 7 100 7 100 5 71,5 2 28,6 uji mc nemar test p=0,625 p=0,5 keterangan: p = signifikansi ab = abnormal n = normal pr = perempuan ∑= jumlah % = prosentase lk = laki-laki national center for health statistics tahun 2004 meneliti 31000 mantan pasien dewasa di as menunjukkan 62% pasien mengombinasikan perawatannya dengan pengobatan alternatif yang memasukkan unsur spiritualitas (doa dan kepasrahan). “doa sebagai terapi diyakini banyak warga as kini,“ tutur direktur national center for complementary and alternative medicine (stephen e strauss md, 2004). nilai limfosit pasien sebelum diberi terapi al qur’an 2 orang (28,6 %) dalam keadaan normal 1 orang perempuan dan 1 orang laki-laki dan 5 orang (71,4 %) mempunyai nilai abnormal. nilai limfosit pasien sesudah diberi terapi al qur’an menjadi normal 4 orang (57,1 %) yaitu perempuan 2 orang dan laki-laki 2 orang, tetapi masih ada yang mempunyai nilai tidak normal 3 orang (42,9 %) yaitu 2 orang perempuan dan 1 orang laki-laki. limfosit merupakan 20% dari semua leukosit dalam sirkulasi darah orang dewasa yang terdiri dari sel t dan sel b yang merupakan kunci pengontrol system imun. sel-sel tersebut dapat mengenal benda asing dan membedakannya dari sel jaringan sendiri. biasanya sel limfosit hanya memberikan reaksi terhadap benda asing, tetapi tidak terhadap sel sendiri. kemampuan mengenal limfosit tersebut disebabkan adanya reseptor permukaan (tcr). nilai monosit pasien sebelum dan sesudah terapi al qur’an masih dalam batas normal. sel monosit ini akan bermigrasi dari peredaran darah ke jaringan dan disana akan berdifferensiasi sebagai makrofag. makrofag masih membelah diri membentuk protein yang menempati jaringan/organ-organ tertentu. menurut fungsinya, makrofag dibagi menjadi 2 yaitu fagosit professional (berperan membunuh kuman dengan organ lisosom dan sebagai reseptor mif dan maf dan melepaskan komplemen, interferon dan monokin) dan sebagai apc (antigen presenting cell) yang berperan memakan antigen dan mempresentasikannya kepada sel limfosit dalam bentuk yang dapat dikenalnya. nilai basofil pasien sebelum dan sesudah terapi al qur’an tetap berada pada jenis kelamin limfosit eosinofil monosit basofil leukosit n ab n ab n ab n ab n ab ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % lakilaki 1 14,3 2 28,6 3 42,9 3 42,9 3 42,9 2 28,6 1 14,3 wanita 1 14,3 3 42,9 4 57,2 4 57,2 4 57,2 3 42,9 1 14,3 jumlah 2 28,6 5 71,5 1 100 7 100 7 100 5 71.5 2 28,6 jurnal ners vol.4 no.2: 110-115 114 rentang normal. jumlah sel basofil yang ditemukan dalam sirkulasi darah sangat sedikit, yaitu kurang dari 0,5 % seluruh sel darah putih. sel basofl diduga berfungsi sebagai sel fagosit, tetapi yang jelas sel tersebut berfungsi sebagai sel mediator. bersama sel mastosit, keduanya melepaskan bahan-bahan yang mempunyai aktivitas biologik, antara lain : meningkatkan permeabilitas vaskuler dan respon inflamasi serta mengerutkan otot polos bronkus. butir– butir kedua sel tersebut mengandung histamine, heparin, srs-a, dan ecf. degranulasi disebabkan antara lain terjadinya ikatan antara antigen dan ig e. hal ini biasa ditemui pada reaksi alergi. selain ditemukan imunitas dengan parasit. nilai eosinofil pasien sebelum dan sesudah terapi al qur’an tetap berada pada rentang normal. merupakan 2-5 % dari sel darah putih orang sehat tanpa alaergi. berfungsi dalam fagositosis. dapat dirangsang untuk degranulasi seperti halnya mastosit dan basofil. mediator–mediator yang dilepas pada degranulasi tersebut dapat menginaktifkan mediator-mediator yang dilepas oleh sel mastosit/basofil pada reaksi alergi. eosinofil mengandung berbagai granul seperti mbp, ecp, edn, dan eosinofil peroksidase yang bersifat toksik dan dapat menghancurkan sel sasaran bila dilepas. eosinofil diduga juga berperan pada imunitas cacing. eosinofil dapat mengikat skistosoma yang dilapisi ig g untuk kemudian melalui degranulasi melepaskan protein yang toksik. leukosit pasien sebelum terapi al qur’an dalam keadaan tidak normal ada 3 orang (42,9 %) kemudian setalah terapi al qur’an menjadi normal sebanyak 5 orang (71,5%), walaupun masih ada kadar leukosit yang tidak normal sebanyak 2 orang (28,6%). leukosit merupakan golongan sel asal ii yang terdiri dari sel imun non spesifik (fagosit mono dan polimorfonuklear, sel nk, sel k dan sel mediator/basofil mastosit) dan sel –sel imun spesifik yang terdiri atas sel t dan sel b. leukosit ini penting menilai terjadinya sirs (systemic inflammatoric respon syndrome) dan terjadinya sepsis dimana biasanya leukosit lebih dari 12.000 atau kurang dari 4000 mm³ (sholeh, m., 2006). respon emosional positif atau coping sangat penting dalam menjaga daya tahan tubuh. dengan kata lain, sistem imun tidak bisa hanya ditinjau dari fatkor fisik, materiil ataupun hanya ditinjau dari segi biologis saja. tetapi faktor psikologis, atau dalam hal ini pendekatan religius merupakan salah satu faktor penting yang sangat berperan dan tidak bisa diabaikan begitu saja dalam membantu meningkatkan status kesehatan pasien. secara psikoneuro imunologi interaksi demikian akan memicu proses adaptasi yang menghasilkan ketahanan tubuh yang lebih baik.keadaan ini akan mempercepat penyembuhan pasien. putra, st., 2002). simpulan dan saran simpulan terapi al qur’an dapat menurunkan tingkat kecemasan dan meningkatkan imunitas pasien yang sedang menjalani rawat inap di rumah sakit. melalui diperdengarkannya al qur’an pasien menjadi lebih tenang dan mendapatkan respon emosional positif (coping) yang dapat menghindarkan diri dari stress. saran peneliti memberikan saran : 1) diharapkan perawat pada layanan kesehatan dapat menerapkan asuhan keperawatan melalui pendekatan spiritual sebagai alternatif perawatan pasien, 2) kepada peneliti selanjutnya diharapkan dapat mengembangkan penelitian dengan restriksi yang lebih ketat terhadap faktor perancu dan indikator yang lebih mendalam, serta sampel yang lebih banyak sehingga didapatkan pengaruh yang signifikan dari terapi ini. kepustakaan catherine stoney, 2006. sehat dengan spiritualitas. republika, diakses tanggal 20 mei 2006. chitty, kay k., 1997. professional nursing, concepts and challenge. 2nd edition, philadelphia : w.b saunders co. manfaat terapi al-qur’an (hammad) 115 garna baratawidjaja, karnen, 2001. imunologi dasar. balai penerbit fkui. jakarta. kozier, b &; erb, glenora, 1991, fundamentals of nursing, concepts, proccess and practice. philadelphia: addison-wesley co. inc. latif, abdul, 2003. studi deskriptif tentang tindakan perawatan pre operatif dan tingkat kecemasan pasien di ruang bedah rsud ratu zalecha martapura. maramis, w.f., 2004. catatan kedokteran jiwa. edisi 8. jakarta. pratiknya, a.w., 2000. dasar-dasar metodologi penelitian kedokteran dan kesehatan. jakarta. putra, suhartono taat, 2002. pengantar psikoneuroimunologi. bahan ajar pni. surabaya. sholeh, moh., 2006. terapi sholat tahajut. jakarta : hikmah. stuart & sundeen, 1998. keperawatan jiwa. alih bahasa achir yani. edisi iii. cetakan i. jakarta : egc. dukungan keluarga yang baik menurunkan stress remaja pasca vonis penjara 24 hubungan penerapan metode lovaas dengan kepatuhan anak autis (the correlation of lovaas method application with the obedient of autism child) ah.yusuf *, khoridatul b*, laila isna* abstract introduction : autism is a behavioral dissorder which can be identified by three factors i.e.: communication, socialize and stereotyping. lovaas method was a structural method, having a wellcomposed material which can be implemented one on one with very clear instructional steps. this study was aimed to explain the correlation of lovaas method implementation with the obedience in children with autism. method : this study used cross sectional design involved 15 respondents for children with autism and 15 respondents of therapist who met inclusion criteria, taken by accidental sampling. the independent variable was lovaas method and the dependent variable was the obedience. data were collected by using observation and questionaire. data were analyzed using gamma and somers’d test with level of significance α ≤ 0.05. result : results showed that there was moderate correlation between lovaas method implementation with the obedience in children with autism (p = 0.026). analysis : it can be concluded that lovaas method has correlation with the obedience in children with autism. discussion : lovaas method can shape obedience with reinforcement when children can respond order from therapist which is having more authority in giving rewards. for further studies the implementation of lovaas method should be intended to reveal other possible capacity in children with autism keywords : lovaas method, obedience, autism *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: yusuf@fk.unair.ac.id pendahuluan autis merupakan salah satu gangguan perilaku atau perkembangan pada anak. gangguan autis pada anak timbul sebelum usia 36 bulan, dengan ciri fungsi abnormal dalam tiga bidang yaitu interaksi sosial, komunikasi, dan perilaku terbatas serta berulang (warkisi e, 2007). menurut handojo (2003) anak penyandang autis memiliki kelemahan dalam hal berhubungan dengan orang lain yaitu tidak merespon katakata dan perintah, anak cenderung kurang patuh terhadap perintah yang diberikan. bila anak autis tidak memiliki kepatuhan, anak cenderung memaksakan kehendak mereka sendiri (maulana m, 2008). sebaliknya apabila anak autis mampu patuh terhadap perintah, maka semakin mudah mengajarkan sesuatu pada anak (handojo, 2003).perilaku autis membutuhkan penanganan secara intensif dan komprehensif. salah satu metode intervensi dini paling banyak diterapkan di indonesia yaitu terapi modifikasi perilaku dengan penerapan metode lovaas (bhudiman m, 2000). melalui metode ini, anak autis dilatih melakukan berbagai keterampilan sebagai bekal hidup bermasyarakat, misalnya kesiapan belajar, penyesuaian diri, mengikuti perintah, menirukan gerakan, berkomunikasi, berinteraksi, dan sebagainya (maulana m, 2008). berdasarkan data awal diketahui bahwa sekolah kebutuhan khusus bangun bangsa surabaya menggunakan terapi perilaku dalam menangani anak autis. terapi perilaku khususnya dengan penerapan metode lovaas telah dikembangkan di sekolah kebutuhan khusus bangun bangsa sebanyak dua kali dalam seminggu dengan durasi waktu satu jam setiap kali pertemuan. secara teori pelaksanaan lovaas dilakukan selama 40 jam per minggu, namun hal ini penerapan metode lovaas (ah. yusuf) 25 tidak bisa dilakukan mengingat kondisi anak yang mudah teralihkan perhatiannya. sistem evaluasi dilaksanakan secara rutin setelah anak menjalani terapi dan evaluasi tri wulan dengan menggunakan lembar evaluasi terstuktur untuk mengukur perkembangan kemampuan anak. di sekolah kebutuhan khusus bangun bangsa terapi perilaku metode lovaas ini belum pernah diteliti dampak perilaku kepatuhan anak autis dari penerapan metode lovaas, sehingga perlu di evaluasi hubungan penerapan metode lovaas dengan kepatuhan pada anak autis di sekolah kebutuhan khusus bangun bangsa surabaya. autis terjadi pada 5 dari setiap 10000 kelahiran dimana jumlah penderita laki-laki empat kali lebih banyak dibandingkan penderita wanita. jumlah tersebut akan terus meningkat di indonesia diperkirakan sebesar 1 per 160 anak (mirza, 2007). berdasarkan observasi peneliti di sekolah kebutuhan khusus bangun bangsa surabaya jumlah siswa penyandang autis pada tahun 2007 sebanyak 21 anak. pada tahun 2008 mengalami peningkatan sebanyak 25% dari tahun sebelumnya menjadi 29 anak. sedangkan pada tahun 2009 jumlah anak autis di sekolah kebutuhan khusus bangun bangsa surabaya menjadi 25 anak. menurut sutadi (1997) sekitar 60% anak autis menunjukkan kepatuhan kurang pada terapis jika tidak diberikan suatu imbalan positif pada anak saat dilakukan latihan atau terapi. sekitar 64% anak autis juga memiliki gangguan dalam pemusatan perhatian, sehingga anak kurang merespon kata-kata dan perintah, anak cenderung kurang patuh terhadap perintah yang diberikan (maulana m, 2008). penerapan metode lovaas telah menunjukkan empat puluh tujuh persen (47%) keberhasilan anak autis murni kembali dalam kondisi normal sesuai dengan perkembangan kemampuan anak seusianya (handojo, 2003). anak autis bila tidak segera dilakukan terapi menyebabkan gejala-gejala khas diantaranya sering menyendiri, melamun, melakukan perilaku yang tidak wajar atau aneh dan anak asyik dengan dunianya sendiri. dampak perilaku autis dapat menimbulkan gangguan hubungan sosial, tidak dapat mandiri, tidak dapat melakukan komunikasi dua arah, dan tidak bisa sosialisasi ke dalam masyarakat umum sehingga anak menjadi depresi saat dewasa (retno, 2005). anak autis dapat ditangani dengan metode tatalaksana perilaku berdasarkan metode modifikasi perilaku yang dikenal dengan metode lovaas. metode ini didasari oleh teori model perilaku operant conditioning dan respondent conditioning (handojo, 2003). tatalaksana perilaku metode lovaas dengan operant conditioning menggunakan rumusan a-b-c (antecedentbehaviour-consequent). antecedent diartikan sebagai timbulnya suatu perilaku didahului oleh suatu sebab, behaviour mempelajari bagaimana cara seseorang bereaksi terhadap rangsangan, dan consequent terjadi sebagai reaksi atau akibat yang mempengaruhi kejadian dari sebuah perilaku (sutadi, 1997). sedangkan teori respondent conditioning menekankan pada suatu perilaku bila diberikan reinforcement atau imbalan akan semakin sering dilakukan, sebaliknya bila suatu perilaku tidak diberi imbalan perilaku tersebut akan terhenti. berdasarkan pertimbangan tersebut, maka peneliti tertarik untuk melakukan penelitian guna mengetahui hubungan antara penerapan metode lovaas dengan kepatuhan pada anak autis. bahan dan metode penelitian desain penelitian yang digunakan dalam penelitian ini adalah crosssectional purposive sampling design. populasi dalam penelitian adalah semua anak autis dan terapis di sekolah kebutuhan khusus bangun bangsa surabaya yang berjumlah 25 anak autis dan 18 orang untuk terapis sampel yang digunakan dalam penelitian ini adalah semua anak autis dan terapis di sekolah kebutuhan khusus bangun bangsa surabaya yang memenuhi kriteria inklusi. kriteria inklusi bagi anak auitis yaitu:1) anak autis dengan usia 6-12 tahun, 2) anak autis dalam keadaan sehat fisik, 3) anak autis yang telah menjalani terapi perilaku metode lovaas minimal 3 bulan di sekolah kebutuhan khusus bangun bangsa surabaya. kriteria inklusi untuk terapis yaitu: 1) tenaga pengajar yang menjadi terapis di sekolah kebutuhan khusus bangun bangsa surabaya, 2) terapis yang pernah mendapat pendidikan dan pelatihan metode lovaas, 3) terapis yang kooperatif, 4) terapis yang menggunakan metode lovaas dalam pelaksanaan terapi jurnal ners vol.4 no.1 april 2009: 24-30 26 minimal 4 bulan dan 5) terapis yang bersedia menjadi responden. . lokasi penelitian ini adalah di rumah tahanan negara kelas i, surabaya. pelaksanaan penelitian dan pengambilan data dilaksanakan di sekolah kebutuhan khusus bangun bangsa surabaya pada tanggal 8 sampai 27 juni 2009. variabel independen dalam penelitian ini yaitu penerapan metode lovaas pada anak autis. variabel dependen yaitu kepatuhan pada anak autis. instrumen yang digunakan dalam pengumpulan data penerapan metode loovas yaitu lembar observasi berdasarkan referensi dari handojo (2003) yang di modifikasi oleh peneliti. instrumen yang digunakan untuk kepatuhan berdasarkan kurikulum metode lovaas yang diterapkan oleh sekolah kebutuhan khusus bangun bangsa surabaya dan dimodifikasi oleh peneliti. peneliti mengikuti proses terapi selama 2 kali seminggu dengan durasi waktu 60 menit setiap kali pertemuan untuk mengobservasi perilaku kepatuhan anak dan mengobservasi para terapis untuk mengetahui penerapan metode lovaas. setelah 2 minggu peneliti memberikan penilaian dengan cara observasi terapis dan menyebarkan kuesioner pada terapis untuk mengetahui penerapan metode lovaas. kemudian mengobservasi kepatuhan pada anak autis yang dilakukan peneliti dengan bantuan terapis. data penerapan metode lovaas dan kepatuhan dianalisis menggunakan uji statistik gamma and somers’d dengan tingkat kemaknaan α≤0,05. hasil penelitian hasil penelitian menunjukkan bahwa didapatkan penerapan metode lovaas mayoritas menunjukkan kategori baik sebanyak 12 orang terapis (80%), kategori cukup sebanyak 3 orang terapis (20%), dan tidak ada satu pun (0%) yang menunjukkan penerapan metode lovaas kategori kurang maupun tidak baik. data kepatuhan anak autis menunjukkan sebagian besar kategori kepatuhan tinggi sebanyak 10 anak (67%), kategori kepatuhan sedang sebanyak 4 anak (27%), kategori kepatuhan rendah sebanyak 1 anak (6%), dan tidak ada satu anak pun (0%) yang menunjukkan kategori tidak patuh. hasil uji statistik gamma & somers’d didapatkan nilai koefisien korelasi 0,500 dan nilai signifikansi p=0,026. hal ini menunjukkan bahwa terdapat hubungan yang signifikan antara penerapan metode lovaas dengan kepatuhan pada anak autis di sekolah kebutuhan khusus bangun bangsa surabaya (tabel.1) pembahasan hasil penelitian observasi peneliti pada terapis untuk penerapan metode lovaas didapatkan hasil observasi 12 orang terapis (80%) dengan kategori penerapan metode lovaas baik. penerapan metode di dasarkan pada standart kriteria observasi seperti : 1) persiapan yang terdiri atas: mengiventarisasi berbagai item yang berefek imbalan pada anak (misalnya materi, verbal, taktil), melaksanakan terapi sesuai jadwal kegiatan, menyiapkan beberapa form program sebelum terapi, mengidentifikasi materi yang akan diberikan, menyiapkan alat peraga sesuai dengan materi, dan membuat suasana ruang bebas distraksi); 2) pelaksanaan terdiri atas: pelaksanaan terapi secara one on one, mengajarkan kesiapan diri pada anak untuk mengikuti pelajaran, memberikan instruksi dengan jelas, singkat, tegas, tuntas, dan sama, mengajarkan kepatuhan dan kontak mata sebelum memulai materi, melaksanakan siklus discrete trial training, memberikan bantuan dan stimulus jika anak tidak merespon instruksi, mengarahkan anak ke perilaku target dengan prompt penuh, mengurangi bantuan secara bertahap sampai anak mampu melakukan tanpa bantuan, mengajarkan suatu perilaku melalui tahaptahap pembentukan yang semakin mendekati perilaku target; 3) evaluasi terdiri atas: mengajarkan sesuai dengan protap, materi yang diajarkan sesuai dengan kebutuhan anak, durasi waktu pemberian sesuai dengan jadwal, melakukan maintenance (memelihara perilaku yang sudah bisa dilakukan, dengan melakukan pengulangan), melakukan pencatatan evaluasi secara terstruktur setelah melakukan kegiatan terapi, dan menyusun program materi untuk pertemuan selanjutnya. metode lovaas merupakan metode yang telah terstuktur dan materinya tersusun dengan baik (handojo, 2003). penerapan metode lovaas di sekolah kebutuhan khusus bangun bangsa surabaya dilakukan one on one yaitu satu terapis satu anak, pemberian instruksi kepada anak penerapan metode lovaas (ah. yusuf) 27 diberikan secara singkat, jelas, tegas, tuntas dan sama, mengajarkan kontak mata dan kesiapan belajar, mengajarkan siklus dari discrete trial training, dimulai dengan instruksi dan diakhiri dengan imbalan dengan waktu pemberian instruksi 3-5 detik, mengarahkan anak ke perilaku target dengan bantuan, mengajarkan suatu perilaku melalui tahap-tahap pembentukan yang semakin mendekati respon yang dituju yaitu perilaku target. penerapan metode lovaas yang baik tidak terlepas dari bekal dasar terapis sebelum dan sewaktu melakukan terapi, terapis harus mempunyai bekal seperti kasih sayang, profesionalisme, disiplin dan etika (handojo, 2003). pemberian metode lovaas memerlukan kasih sayang sebagai dasar penatalaksanaan terapi. kasih sayang yang tulus akan memberikan ketabahan dan ketahanan yang tinggi serta meminimalkan terjadinya tekanan pada terapis. selain itu seorang terapis harus memiliki profesionalisme dalam menjalankan pelaksanaan metode lovaas. sikap profesional dapat ditunjukkan dari pengetahuan dan keterampilan yang memadai dalam menerapkan metode yang dipakai. pendidikan yang tinggi memudahkan penerimaan informasi dari luar terutama tentang penanganan atau tatalaksana metode pengajaran untuk anak autis. sebagian besar terapis sebanyak 10 orang terapis (67%) telah mengikuti pelatihan metode lovaas sehingga terapis mengetahui bagaimana penerapan metode lovaas yang sesuai dengan standart. terapis juga harus melakukan simulasi dan praktek langsung kepada anak yang dapat menunjang ketrampilan terapis dalam penerapan metode lovaas. pelatihan bagi calon terapis memerlukan praktek langsung sekurang-kurangnya 40-45 sesi (satu sesi = 4 jam). sebagian besar terapis sebanyak 8 orang (53%) telah praktek mengajarkan metode lovaas > 45 sesi. masa kerja mempengaruhi keberhasilan penerapan metode lovaas. 10 orang terapis (67%) dengan masa kerja > 24 bulan yang berpengaruh pada keterampilan dan keahlian dalam penerapan metode lovaas. terapis juga harus memperhatikan kedisiplinan terutama berkaitan dengan waktu pelaksanaan metode lovaas. hal penting lainnya yang harus diperhatikan yaitu masalah etika dalam pemberian metode lovaas yaitu terapis berperilaku sesuai dengan aturan, serta memiliki kesadaran dan tangung jawab terhadap tugas. dari hasil penelitian masih didapatkan 3 orang terapis (20%) yang penerapan metode lovaas dalam kategori cukup. hal ini dikarenakan pengajaran kurang dilakukan sesuai standart, misalnya tidak mengajarkan suatu perilaku yang kompleks dipecah menjadi aktivitas kecil yang dirangkai secara berurutan, tidak membalik urutan dari aktivitas yang telah dirangkai, tidak menyediakan item pembanding untuk kemampuan tahap identifikasi, jarang melakukan maintenance (memelihara perilaku yang sudah bisa dilakukan, dengan melakukan pengulangan), jarang melakukan pencatatan evaluasi secara terstruktur setelah melakukan kegiatan terapi. format evalusi yang berbentuk narasi secara tertulis sehingga para terapis jarang mengisi lembar evaluasi karena dianggap kurang praktis dan efisien. tabel 1. hubungan penerapan metode lovaas dengan kepatuhan anak autis di sekolah kebutuhan khusus bangun bangsa surabaya pada 8-27 juni 2009 penerapan metode lovaas terapis kepatuhan anak baik cukup kurang tinggi sedang rendah ∑ % ∑ % ∑ % ∑ % ∑ % ∑ % 12 80 3 20 0 0 10 67 4 27 1 6 gamma & sommers’d p=0,0026 ; r=0,500 keterangan : p = signifikansi r = koefisien korelasi jurnal ners vol.4 no.1 april 2009: 24-30 28 menurut budhiman (1997) keberhasilan metode lovaas pada anak autis dapat dipengaruhi beberapa hal antara lain: berat ringan kelainan atau gejala, usia anak saat pertama kali ditangani secara benar dan teratur, intensitas penanganan, tingkat kemampuan berbicara dan berbahasa, serta kesehatan anak. berat ringan kelainan tergantung dari gangguan yang ada didalam sel otak. semakin berat kelainan pada anak semakin sulit dalam menangani anak. di sekolah kebutuhan khusus bangun bangsa sebagian besar sebanyak 11 anak (73%) tergolong jenis autis sedang, dan 4 anak (27%) tergolong jenis autis ringan. namun perlu diingat khususnya bagi penyandang autis, sekalipun derajat ringan, anak autis harus tetap mendapatkan terapi. sebab apabila tidak mendapatkan terapi, maka anak autis ringan bisa menjadi berat. usia juga berpengaruh terhadap keberhasilan metode lovaas. usia terbaik dalam menangani anak adalah 2-5 tahun, karena pada usia ini sel otak masih plastis dan lebih mudah menerima rangsangan untuk membentuk cabang-cabang neuron baru. bila terapi dimulai pada usia di atas 5 tahun tetap besar manfaatnya, namun hasil akan lebih lambat dan tidak sebaik bila dimulai sebelum usia 5 tahun. anak autis di sekolah kebutuhan khusus bangun bangsa surabaya usia terkecil yaitu 6 tahun, karena di sekolah ini baru dibuka kelas autis pada tahun 2006. namun sebagian besar anak autis tersebut sudah menjalani terapi di tempat lain sejak usia 3 tahun, sebelum mereka masuk di sekolah kebutuhan khusus bangun bangsa. intensitas penanganan juga terlibat sebagai salah satu faktor yang mempengaruhi keberhasilan metode lovaas. pelaksanaan terapi pada penyandang autis harus dilakukan secara intensif. secara rasional anak membutuhkan waktu 8 jam sehari untuk belajar di rumah dan sekolah. namun pelaksanaan metode lovaas dalam pembelajaran di sekolah kebutuhan khusus bangun bangsa surabaya dilakukan selama 2 kali seminggu dengan durasi waktu 60 menit untuk setiap kali pertemuan mengingat kondisi anak yang mudah teralihkan perhatiannya. tingkat kemampuan bicara dan berbahasa juga menjadi faktor penentu keberhasilan metode lovaas. tidak semua penyandang autis berhasil mengembangkan fungsi bicara dan berbahasanya. di sekolah kebutuhan khusus bangun bangsa surabaya rata-rata kemampuan bahasa dan bicara masih sulit dan kaku. namun ada pula yang bisa bicara dengan lancar. keadaan lain yang bisa mempengaruhi keberhasilan metode lovaas yaitu kondisi kesehatan anak. kondisi fisik anak perlu diperhatikan. hal ini mempengaruhi kesiapan anak untuk mengikuti terapi. sebagian siswa di sekolah kebutuhan khusus bangun bangsa surabaya ada yang menderita alergi terhadap makanan sehingga anak sering tidak mengikuti kegiatan terapi maupun proses pembelajaran kelas klasikal. kondisi ini dapat mempengaruhi perkembangan kemampuan anak, dan terapi yang dilakukan membutuhkan waktu yang lebih lama. hasil observasi untuk kepatuhan pada anak autis didapatkan 10 anak autis (67%) memiliki kepatuhan tinggi dengan kriteria observasi kepatuhan yaitu anak mampu melakukan perintah dari terapis dengan berbagai item aktivitas kemampuan seperti : kemampuan mengikuti pelajaran, menirukan (imitasi), bahasa reseptif, bahasa ekspresif, pre akademik dan kemampuan bina diri. kepatuhan adalah perubahan perilaku yang ditunjukkan dalam merespon perintah dari seseorang (feldman, 2003). kepatuhan pada anak autis adalah perubahan perilaku anak autis yang ditunjukkan dalam merespon atau melakukan apa yang dikatakan seorang terapis yang memiliki kekuasaan atau otoritas dalam pemberian reinforcement (imbalan). banyak hal yang dapat mempengaruhi cara seseorang bersikap dan bertingkah laku termasuk dalam kepatuhan. faktor yang mempengaruhi kepatuhan seseorang terhadap perintah menurut edwards (2006) antara lain : 1) faktor internal yaitu kondisi fisik, emosi, perkembangan, kesehatan, dan pemahaman terhadap instruksi, 2) faktor eksternal yaitu : dukungan keluarga, pendidikan, lingkungan, tenaga pengajar atau terapis, serta fasilitas. kondisi fisik sangat berpengaruh dalam membentuk kepatuhan misalnya kelengkapan indera pendengaran sangat berpengaruh terhadap bagaimana seseorang merespon orang lain. selain itu perkembangan seorang anak memiliki dampak penting dalam sikap mereka terhadap respon orang lain. usia 18 bulan sampai 3 tahun merupakan masa dimana penerapan metode lovaas (ah. yusuf) 29 seorang anak mengembangkan otonomi diri sehingga tidak jarang mereka menjadi menolak perintah yang diberikan kepadanya. semakin dewasa anak, respon terhadap sesuatu akan semakin terlihat. kesehatan juga berpengaruh pada kepatuhan anak autis. anak-anak yang mengalami masalah kesehatan kronis beresiko menjadi anak yang sulit diatur. pemahaman terhadap instruksi merupakan salah satu faktor internal yang mempengaruhi pembentukan kepatuhan pada anak autis. pemahaman terhadap instruksi merupakan hal penting dalam membentuk proses interaksi antara anak dengan terapis. proses interaksi yang efektif dapat membantu anak untuk mengerti dan memahami arti perintah dari orang lain. anak dapat dikatakan patuh jika mampu memahami aturan 65% sampai 85% waktu (sutadi, 1997). selain hal tersebut diatas faktor eksternal juga menjadi unsur pendukung dalam pembentukan kepatuhan pada anak autis antara lain dukungan keluarga. dukungan dan peran orang tua maupun keluarga merupakan hal yang sangat penting dalam membangun tingkat kepatuhan anak pada aturan. anak membutuhkan dukungan moril untuk meningkatkan rasa percaya diri dalam melakukan sesuatu. pendidikan juga berpengaruh pada pembentukan kepatuhan pada anak autis. pendidikan mempunyai arti yang lebih mengarahkan pada cara membangun pemahaman anak terhadap perintah atau instruksi yang diberikan oleh guru atau terapis. hal lain yang juga mempengaruhi yaitu lingkungan. lingkungan yang dimaksudkan disini yaitu lingkungan sekolah. situasi di sekolah jelas berbeda dengan di rumah. di sekolah, anak memiliki banyak teman yang menjadi acuan dalam menerapkan kepatuhan diri. reward dan punishment diberikan lebih tegas sehingga anak lebih patuh pada gurunya. anak di sekolah menjadi patuh karena ada kompetisi dengan teman untuk mendapatkan reward dari guru atau terapis. terapis merupakan salah satu orang yang berperan dalam membentuk kepatuhan anak. terapis menjadi salah satu figur yang mempunyai otoriter atau kekuasaan disekolah. fasilitas juga merupakan faktor eksternal yang penting dalam membentuk kepatuhan. fasilitas berkaitan dengan adanya reward dan punishment atas apa yang diperolehnya. reward dan punishment berarti reaksi timbal balik dalam hubungan manusia yang didasarkan pada hadiah dan hukuman. pemberian reward harus memperhatikan dua hal yaitu jenis imbalan dan cara bagaimana pemberian imbalan tersebut. dari hasil penelitian masih didapatkan anak autis yang memiliki kepatuhan cukup dan 1 anak autis (6%) memiliki kepatuhan yang rendah. keadaan ini dapat disebabkan karena pemberian imbalan dari terapis yang monoton membuat anak cenderung tidak patuh atau tidak mau melakukan apa yang diminta oleh terapis. imbalan harus diberikan secara konsisten dan variatif. keadaan emosi juga mempengaruhi respon seorang anak terhadap situasi yang sedang mereka hadapi. ketika seorang anak mengalami perasaan terluka, kecewa dan marah sehingga menimbulkan amukan (tantrum) saat proses terapi. kondisi ini membuat anak menjadi tidak merespon orang lain. hal lain yang membuat anak tidak patuh yaitu orang tua yang kurang konsisten untuk menerapkan aturan pada anak. orang tua memberikan kasih sayang yang berlebih karena kedudukan anak autis sebagian besar anak anak pertama dan 4 orang anak (27%) yang tidak memiliki saudara atau sebagai anak tunggal. kondisi seperti ini membuat orang tua tidak pernah menetapkan aturan yang keras pada anaknya. anak cenderung dimanjakan dan akibatnya anak berperilaku semaunya sendiri sesuai dengan kehendak dalam dirinya. simpulan dan saran simpulan penerapan metode lovaas yang sesuai dengan standar dan prosedur membentuk kepatuhan pada anak autis dalam merespon perintah dari terapis melalui penilaian aktivitas kemampuan anak. saran peneliti menyarankan: 1) mempertahankan penerapan metode lovaas sesuai dengan prosedur pelaksanaaan di sekolah kebutuhan khusus bangun bangsa surabaya, 2) terapis diharapkan menerapkan beberapa prosedur metode lovaas yang sering dilewatkan, 3) bagi pihak sekolah jurnal ners vol.4 no.1 april 2009: 24-30 30 diharapkan untuk menyusun kembali sistem evaluasi penerapan metode lovaas secara terstruktur, sehingga lebih mudah dalam mengetahui perkembangan dan kemampuan anak, 4) orang tua diharapkan menjadi support system dalam mendukung perannya dirumah untuk menerapkan aturan yang tegas, meningkatkan disiplin yang tinggi, bagi anak dalam menbentuk kepatuhan 5) orang tua diharapkan mengawasi pemberian makanan pada anak yang cenderung menimbulkan alergi untuk menjaga kesehatan anak yang mempengaruhi lama proses terapi dan 6) mengembangkan penelitian lebih lanjut mengenai penerapan metode lovaas dengan kemampuan lain yang bisa terbentuk dari metode lovaas. kepustakaan bhudiman, m., 2000. pengelolaan autis. makalah dalam simposium pengelolaan mutakhir autis pada anak secara terpadu. bandung, 21 november 2000. hlm. 1-15 bhudiman, m., 1997. tatalaksana terpadu pada autis. makalah dalam simposium tatakaksana autis. jakarta : yayasan autis indonesia, 22 november 1997. hlm. 2-11. edwards, c. d., 2006. ketika anak sulit diatur: panduan bagi orang tua untuk mengubah masalah perilaku anak, (online), (http://books.google.co.id/books? id=d2f_pgaacaaj&dq=panduan+ba gi+orang+tua+untuk+mengubah+masal ah+perilaku+anak, diakses tanggal 5 agustus 2009, jam 20.38 wib). feldman, robert s., 2003. essentials of understanding psycology. 5 ed. new york : mc graw hill, page 452. handojo, y., 2003. petunjuk praktis & pedoman materi untuk mengajar anak normal, autis & perilaku lain. jakarta : pt. bhuana ilmu populer kelompok gramedia, hlm. 11-16, 22-37, 44-45. maulana, m., 2008. anak autis : mendidik anak autis dan gangguan mental lain menuju anak cerdas dan sehat. yogyakarta : katahati, hlm. 14, 18, 21, 51-60. sutadi, r., 1997. tatalaksana perilaku pada penyandang autis. makalah simposium tatalaksana autis. jakarta : yayasan autis indonesia, 22 november 1997, hlm. 21, 24, 28-29. warsiki, e., 2007. gangguan autis dan penatalaksanaan psikiatrrik. jurnal psychologi indonesia, 23 (1), hlm. 75, 77-82. http://books.google.co/ http://books.google.co.id/books?id=d2f_pgaacaaj&dq=panduan+bagi+orang+tua+untuk+mengubah+masalah+perilaku+anak http://books.google.co.id/books?id=d2f_pgaacaaj&dq=panduan+bagi+orang+tua+untuk+mengubah+masalah+perilaku+anak http://books.google.co.id/books?id=d2f_pgaacaaj&dq=panduan+bagi+orang+tua+untuk+mengubah+masalah+perilaku+anak 261 analysis of the associated factors of boarding time in yellow zone patients in emergency department ahsan ahsan, fitrio deviantony, setyoadi setyoadi school of nursing, faculty of medicine, universitas brawijaya email: ahsanfkub@yahoo.com abstract introduction: patient’s visits to the emergency room increase in number every year. the increasing number of hospital visits is directly associated with the increasing number of patients who wait in the emergency department. the yellow zone is a part of the emergency room that has become a place for the most increased patients to enter. this situation causes boarding time patient longer than usual. the aim of this research was to analyse the various factors that have been associated with boarding time in the yellow zone emergency department. methods: this research was an analytic observational study with a cross-sectional approach. the number of samples was 78 respondents who were recruited with a non-probability sampling technique. the univariate and bivariate analysis was utilized to test the relationship between the variables. a further statistical test was conducted with linear regression to understand the most dominant factor. results: the results showed a significant relationship between transfer time, laboratory turnaround time, diagnostic time, time arrival, insurance coverage, ratio nurse and patient and boarding time. furthermore, multivariate analysis with linear regression showed a significant association between transfer time, laboratory turns around, and the ratio of nurses to patients with the boarding time. conclusions: the findings from this study show that patient boarding time in the yellow zone should consider several factors. this research provides the output of the initial data as one of the basic considerations for service management and team minimum service standards in hospitals. keywords: boarding time, emergency department, yellow zone introduction the visitation of patients in the emergency department (ed) is growing every year. the increase of this situation is by about 30% in hospitals around the world (bashkin et al., 2015). increasing the number of hospital visits clearly affects the increasing number of patients who enter the emergency room. the emergency room unit is an area located in the hospital that is used to perform standard emergency, acute and urgent care (geelhoed and de klerk, 2012). caring in the emergency phase is used to stabilize patients who have disorders from injuries and other sources that require resuscitation and patients who have a certain degree of injury and illness (australian college for emergency medicine, 2015). the data entry of patients who come into the ed in indonesia is approximately 4,402,205 patients or 13.3% of all visits to hospitals (moh, 2015). data for the ed patients who visited the emergency room in east java in 2014 amounted to 8,201,606 cases. looking at the district level, the data of the visits in tulungagung in 2014 was 29,877 cases (dinkes provinsi jatim, 2015). the patient condition who wait too long in the er will hamper the service process in the emergency department. fast and precise services are most needed in the emergency installation (ducharme et al., 2008). the length of time patients in the yellow zone could be due to a mismatch between the number of patients, patient beds and the number of health personnel. an excessive number of patients causes in increased check-up time for other patients, increased waiting time, and prolonged waiting time for returning patients, and patients who will be hospitalized. this condition is called boarding time (singer et al., 2011). quality control standard of rsud dr. iskak tulungagung explained that the patient waiting period after the inpatient decision becomes one of the indicators of hospital quality control. so this research focuses on it, as a further hospital evaluation material. the number of patients per day in the yellow zone can reach 36 patients per day, coming in during the morning, day and night shift. the number of beds in the yellow zone in the ed room is 9 beds with the total number of nurses in the yellow zone being 21 people divided into 5 people per shift. the number of patients boarding for more than 6 hours per day can reach 10 patients. the results of the interview with the team leader in the yellow zone can help to identify the causes of boarding due to the number of limited resources, not being well organised, the results of the laboratory requiring a lot of time, the time to diagnose the disease being longer than usual, the 262 number of patients who came in on the day shift being more than in other shifts, and the bed occupancy time for patients from the ed becoming a factor that causes the boarding time to be longer than usual. the speed of patient care in the emergency department can determine the prognosis of the next patient, and obtain optimal results in the care of the patient. the aim of this research was to analyse the various factors that have been associated with boarding time in the yellow zone emergency department. materials and methods this research used a cross-sectional study approach. the aim of this study was to identify the determinants factors related to health-related events and problems. data collection was taken from june to july 2017, and this research was conducted at the emergency unit of the rsud dr. iskak tulungagung. the population of this study was the patients who came to the yellow zone emergency room; 1,080 patients per month. the sampling technique used non-probability sampling which used the rule of thumb with the number of samples, which was 5 to 50 times the number of independent variables (sastroasmoro and ismael, 2011). the sample size for this research was 78 respondents. the subjects in this study have inclusion criteria; patients who were in the yellow zone of the ed > 6 hours. the exclusion criteria for this research were patients who were forced to leave the hospital, patients who had not been examined by the doctor and patients who were discharged or referred to another hospital. this research was conducted by direct observation method using the instrument of data collection sheet and observation guidance sheet table 1. demographic characteristic of the respondents n % gender men 43 55.1 women 35 44.9 insurance coverage general 43 55.1 bpjs 30 38.8 jasa raharja 5 6.4 number patient mean 16 min-max 9-28 age mean 52.4 min-max 13-76 table 2. result of the bivariate analysis variable test p-value r boarding time-transfer time pearson 0.000 0,747 boarding time-laboratory turn-around time pearson 0.000 0,693 boarding time-diagnostic time pearson 0.000 0,462 boarding time-time of arrival spearman 0.263 -0,128 boarding time-insurance coverage spearman 0.980 -0,003 boarding time-ratio between nurse-patient spearman 0.000 -0,638 table 3. multivariate analysis among the variables β se t p f adj r2 boarding time 16.342 .134 transfer time -.300 212.157 -3.784 .000 laboratory turnaround time .452 .199 4.367 .000 diagnostic time .129 .153 1.207 .231 ratio nurse and patient .155 1.136 2.163 .034 263 and validated by medical record. we analyzed the dependent and independent variable correlation using bivariate analysis with spearman test and multivariate analysis with linear regression test. p-value ≤0.05 was considered statistically significant. statistical analysis was performed under spss (statistical package for the social sciences) 14.0 (spss inc. chicago, il, usa). the study was carried out in accordance with the code of ethics of the world medical association (declaration of helsinki) for experiments in humans and approved by the ethics committee on faculty of medicine, universitas brawijaya. written informed consent was obtained from all study participants. results distribution of respondent characteristic the demographic characteristics showed that the respondents were mostly male (55.1%) and the rest female (44.9%). the types of insurance coverage held by the respondents were also identified. half of the respondents had no insurance (55.1%). the remaining respondents used bpjs (37.5%), and jasa raharja (6.4%). the average number of patients coming to the er was 16 patients per shift, with the minimum number recorded at the time of the shift guard change being 9 patients and the highest number of patients on one shift being 28 patients. the age of the respondents ranged from 13 years old to 76 years old, with the average age of the respondents being 52.4 years (table 1). variable of patient transfer time in rsud dr iskak tulungagung mostly had about 634.55 minutes or 10 hours 57 minutes. thus, the fastest time was 3 hours 41 minutes and the longest time was 22 hours. the return time of laboratory results was mostly done for 7 hours 9 minutes with the fastest time was 1.8 hours and the longest time is 13.6 hours. most diagnostic timings were performed for 57.77 minutes with the fastest diagnostic timing being 20 minutes and the longest diagnosis time of 98 minutes. the average value of the waiting time variable of patients after inpatient decision was decided about 909 minutes or 15.15 hours and the lowest patient waiting time after the inpatient decision was 365 minutes or 6 hours and the highest waiting time was 14.22 minutes or 23.7 hours. in table 2 the variables most closely related to the patient waiting time after the inpatient decision was the patient transfer time (0.747), laboratory return time (0.693) and diagnosis time (0.462). table 2 explained that there is a significant correlation between the dependent variable (boarding time) with the three independent variables (patient transfer time, laboratory turn-around time and diagnosis time), where the p-value = 0.00. a simple linear regression was calculated to estimate the association between boarding time and the other variables. table 3 explained that a significant regression equation found that transfer time (beta=-0.30 (212.15), p<0.000), laboratory turnaround time (beta=0.452 (0.199), p<0.000), and the ratio nurse and patient (beta=0.155 (1.136), p<0.034). in the multivariate test the following equations are obtained: y= constanta+a1x1+a2x2...............................+aixi y= 681.212+0.620 (patient transfer time)+2.636 (diagnostic time)-861.011 (comparison of nurses and patients) (see in the discussion below). discussion this study found out that the longer time it takes to order boarding time in the yellow zone, the faster it takes the patient's to move to the room. the boarding time recommended by the hospital is no more than six hours. this is in accordance with research which states that the decision-making process related to medical decisions in indonesia is determined by culture, where decision-makers related to medical treatment is the oldest member of the family. a similar study conducted by hodgins et al. (2011) mentioned that 41,256 patients treated in the er during full conditions that resulted in patient boarding time leading to death, decreased by more than 2 hours (hodgins, moore and legere, 2011). the univariate analysis of the laboratory turnaround time showed that the minimum time for the laboratory results to the ed was 110 minutes and the maximum value was 920 minutes. all patients treated should have laboratory tests carried out related to the 264 condition experienced by the patient. prior research in accordance with these results is shown in a study conducted by steindel & howanitz (2001) which states that laboratory tests were performed in > 50% of patients visiting the er and who were hospitalized, including those who were discharged (steindel and howanitz, 2001). the return time of the laboratory results is the period of time from the physician's order for a blood test until the results arrive at the er, with a target time of <60 minutes (hawkins, 2007). the study found that both variables also have a strong relationship with positive value. it means that the longer the diagnosis time is raised to, then the boarding time of the patient in the yellow zone will be longer, and vice versa when the diagnostic time is faster, then the patient waiting time in the yellow zone of the ed will be shorter as well. this is in accordance with the research put forward by boyle a et al., (2012), stating that the delay of diagnosis is defined as the time from the patient arriving up until the medical diagnosis arises(boyle et al., 2012). this variable also enters the framework described by (rabin et al., 2012), which is where this variable enters the throughput factor component in the described framework overcrowding model. the result of the bivariate test using a spearman test on arrival time with boarding time showed no statistical significance. differences in the results of the study as revealed by powell et al., (2012) are where the study explains that the arrival time during the day has the possibility of patient waiting time after the decision of hospitalisation being higher(powell et al., 2012). bashkin et al. (2015) in his study also explained the related matters where he found the result that 52% of patients enter the ed in the morning shift and 48% are divided into the day shift and night shift. the difference in this result is probably due to the homogenized sample size of the subject so that the variable has no significant relationship in relation to each shift. another thing that can cause the absence of a relationship between the variable of arrival time and boarding time is the number of patients experiencing boarding time on each shift. the result of the bivariate test analysis shows that there is no close relationship between the insurance ownership variable with patient boarding time. differences occurred when this result was compared with the research conducted by kennedy et al. (2004), where in his research described that in about 7.7% of the number of visits during the 12 months, there was a delay or a delay in the services in er (kennedy et al., 2004). this occurs due to problems such as service charges which are swollen, and insurance coverage will also cause delayed service, causing the patient’s boarding time to increase. in this study, another thing that also became an obstacle was if the patient did not have health insurance. patients who already have health insurance do not have to bother giving their data forward, saving time. this study found out that there was a strong correlation between the ratio of the nurses to the patients with the patient boarding time in which the direction of the relationship is negative. this means that when the ratio of nurses with patients per shift is greater, then the patient boarding time is smaller, and vice versa if the ratio of nurses with patients per shift is smaller then the patient waiting time value after the decision of becoming an inpatient is longer. a study described by wiler et al., (2012) explains how the ratio of nurses with patients on each shift becomes a thing that can affect the duration of service time and the workload of the nurses also increases(wiler et al., 2012). these results are in accordance with the journal articles published by zarea (2014) in iran, mentioning that 78.2% of nurses are not satisfied with their performance due to the increased workload, safety and salary (zarea et al., 2014). based on the results of the multivariable analysis, where this research used linear regression to predict patient boarding time in the yellow zone, there were the variables of patient transfer time, laboratory turnaround time, diagnostic time and the comparison of nurses with patients per shift. transfer time, diagnostic time and the proportion of the number of nurses with the patients became the significant factors of the patient's boarding time. this is because long diagnostic timing can lead to long transfer times since transfer decisions are decided when diagnoses are raised. this can be seen from the length of time of diagnosis and the length of 265 transfer time. this finding is in accordance with the research described by lo et al. (2014). based on the result above (the equations of the multivariate test) indicates that any delay in transferring the patient to an inpatient room within 60 minutes will increase the patient's boarding time by as much as 0.620 minutes in a patient with a strong correlation strength. this is due to the limitations of the treatment room, where it is characterised by a significant number of patients and a bor of 75%. these results indicate that bed utilisation in the inpatient wards is higher than the national standard of 60%. this will certainly affect the duration of the patient's boarding time in the er. with this equation model, it can estimate patient boarding time using the variable time of patient transfer, time of diagnosis determination and ratio of a nurse. the meaning of constant value is that if there is no trust value or variable value, then the participation value is equal to 681.212 minutes. for the variable time of patient transfer, for every addition of 1 minute then there will be an addition of 0,620 minutes. for the variable of the determination time of each diagnosis, there is the addition of 1 minute with an addition of 2,636 minutes. for the nurse comparison variables with patients, the number per guard must be calculated in advance of the number of nurses in one shift then divided by the number of patients in one shift. the bigger the ratio of nurses with patients per shift, is the p-value or waiting time of the patient and whether or not the hospitalisation decision will be smaller. the results of this study obtained information about the factors relating to patient boarding time in the yellow zone. the limitations in this study are that the researchers only look at the time when the patient was in the er without considering the amount of space taken and the type of illness that the patient suffers from, so the researchers cannot see which room is used the most to move patients. another limitation of this research is that the researcher only conducted research in one hospital only, so this research should go on to take time elsewhere with the same characteristics to be able to see the boarding time of patients in the yellow zone in other hospitals. conclusions the comparison factors of nurses with patients per shift, diagnostic time, and transfer time have a significant correlation to patient boarding time in the yellow zone. the benefits of this research are that it has identified multifactor causes that have a proximity relationship with patient boarding time in the yellow zone, in particular the time factor of patient transfer, the timing of the diagnosis and the comparison of the nurses and number of patients. it provides the output of the initial data as one of the basic considerations for service management and team minimum service standards for hospitals to enable them to improve the quality of their services and strategies that can be used as a basis for quality development. references australian college for emergency medicine (2015) specialist emergency medicine workforce and training activities 2014. melbourne: australian college for emergency medicine. bashkin, o., caspi, s., haligoa, r., mizrahi, s. and stalnikowicz, r. (2015) ‘organizational factors affecting length of stay in the emergency department: initial observational study’, israel journal of health policy research. biomed central, 4(1), p. 38. boyle, j., jessup, m., crilly, j., green, d., lind, j., wallis, m., miller, p. and fitzgerald, g. (2012) ‘predicting emergency department admissions’, emerg med j. bmj publishing group ltd and the british association for accident & emergency medicine, 29(5), pp. 358– 365. dinkes provinsi jatim (2015) profil kesehatan provinsi jawa timur tahun 2014. surabaya: dinkes provinsi jatim. ducharme j, tanabe p, homel p, miner jr, chang ak, lee j & todd kh. (2008). the influence of triage systems and triage scores on timeliness of ed analgesic administration. american journal of emergency medicine, 26 (8), 867-873. geelhoed, g. c. and de klerk, n. h. (2012) 266 ‘emergency department overcrowding, mortality and the 4-hour rule in western australia’, the medical journal of australia, 196(2), pp. 122–126. hawkins, r. c. (2007) ‘laboratory turnaround time’, the clinical biochemist reviews. the australian association of clinical biochemists, 28(4), p. 179. hodgins, m. j., moore, n. and legere, l. (2011) ‘who is sleeping in our beds? factors predicting the ed boarding of admitted patients for more than 2 hours’, journal of emergency nursing. elsevier, 37(3), pp. 225–230. kennedy, j., rhodes, k., walls, c. a. and asplin, b. r. (2004) ‘access to emergency care: restricted by long waiting times and cost and coverage concerns’, annals of emergency medicine. elsevier, 43(5), pp. 567–573. lo, s. m., choi, k. t. y., wong, e. m. l., lee, l. l. y., yeung, r. s. d., chan, j. t. s. and chair, s. y. (2014) ‘effectiveness of emergency medicine wards in reducing length of stay and overcrowding in emergency departments’, international emergency nursing. elsevier, 22(2), pp. 116–120. moh (2015) ‘data dan informasi tahun 2014 (profil kesehatan indonesia) [data and information in 2014 (health profile of indonesia)]’. edited by p. d. dan i. kemenkes. jakarta: kemenkes. powell, e. s., khare, r. k., venkatesh, a. k., van roo, b. d., adams, j. g. and reinhardt, g. (2012) ‘the relationship between inpatient discharge timing and emergency department boarding’, the journal of emergency medicine. elsevier, 42(2), pp. 186–196. rabin, e., kocher, k., mcclelland, m., pines, j., hwang, u., rathlev, n., asplin, b., trueger, n. s. and weber, e. (2012) ‘solutions to emergency department “boarding”and crowding are underused and may need to be legislated’, health affairs. health affairs, 31(8), pp. 1757– 1766. sastroasmoro, s. and ismael, s. (2011) dasardasar metodologi penelitian klinis. sagung seto, edisi 4. isbn 978-6028674-54-6. singer aj, thode hc, viccellio p & pines jm. (2011). the association between length of emergency department boarding and mortality. academic emergency medicine, 18 (12), 1324-1329. steindel, s. j. and howanitz, p. j. (2001) ‘physician satisfaction and emergency department laboratory test turnaround time: observations based on college of american pathologists q-probes studies’, archives of pathology & laboratory medicine, 125(7), pp. 863– 871. wiler, j. l., handel, d. a., ginde, a. a., aronsky, d., genes, n. g., hackman, j. l., hilton, j. a., hwang, u., kamali, m. and pines, j. m. (2012) ‘predictors of patient length of stay in 9 emergency departments’, the american journal of emergency medicine. elsevier, 30(9), pp. 1860–1864. zarea, k., beiranvand, s., sheini-jaberi, p. and nikbakht-nasrabadi, a. (2014) ‘disaster nursing in iran: challenges and opportunities’, australasian emergency nursing journal. elsevier, 17(4), pp. 190–196. pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru jurnal ners vol.3 no.1 april 2008: 42-48 bermain origami meningkatkan kreatifitas anak usia sekolah (playing origami enhance the creativity of school aged children) yuni sufyanti arief*, dhianita binarwati*, ratri ismiwiranti** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: yuni_psik@yahoo.com ** rsud abdoer rahem situbondo abstract introduction: critical period for creativity development happened at school aged. playing origami is a stimulation that can be done to develop child’s creativity optimally. the aimed of this study was to analyze the effect of playing origami toward creativity development at school age in 4 th grade elementary school krian, sidoarjo. method: this study was used a pre experimental and purposive sampling design. the populations were children who age in the sixth until seventh age in 4 th grade elementary school krian, sidoarjo. there were 41 respondents for this research who met the inclusion criteria. the independent variable was the playing origami while the dependent variable was creativity development of school age. data were collected by using questionnaire and figural creativity test to know the creativity level before and after intervention, and then analyzed by using wilcoxon signed rank test with significance level of 0.05. result: the result showed that there was an effect of play origami toward the creativity development of school age with significant level (p=0.000). discussion: it can be concluded that playing origami can develop the creativity of school aged children. every child should be facilitated by provide a chance, supportt and activity that can improve their creativity development that can be useful for them and other people. further study was recommended to analyze the effect of playing origami on decreasing stress hospitalization. keywords: playing origami, creativity development, school age pendahuluan anak usia sekolah, secara fisik memiliki tubuh yang proporsional. motorik halus pada anak usia sekolah mulai menunjukkan kematangan. mereka dapat menggunakan media serta berbagai alat yang membutuhkan motorik halus. aktifitas fisik yang dilakukan oleh anak akan membantu pertumbuhan. berbagai keterampilan yang dimiliki akan meningkatkan kepercayaan bahwa anak memiliki kemampuan dan hal ini menimbulkan kebanggaan pada diri (gustian, 2001). pada usia sekolah, anak dituntut untuk lebih mandiri serta mampu berpikir kreatif dalam menyelesaikan permasalahan yang dihadapi. referensi menyebutkan bahwa di dunia ini terdapat 10–15% anak berbakat yang memiliki kecerdasan atau kelebihan luar biasa termasuk sikap dan kemampuan berpikir kreatif (tridjaja, 1998). hasil studi pendahuluan tentang perkembangan kreatifitas anak yang dilakukan di sdn krian iv dengan menggunakan kuesioner ciri sikap kreatif, menunjukkan 37,74% anak kelas 1 memiliki tingkat kreatifitas berada di bawah rata-rata. salah satu upaya dalam meningkatkan kreatifitas anak usia sekolah dapat dilakukan dengan permainan. beberapa bentuk permainan yang dapat diberikan dalam upaya menstimulasi perkembangan kreatifitas anak melalui berkarya kreatif dengan menggunakan berbagai benda yang ada di sekitar seperti kertas koran, kertas majalah, karton bekas pasta gigi, kotak korek api, kertas lipat, plastisin, melukis bebas, lego, puzzle, dan sebagainya. salah satu model permainan yang dapat merangsang kreatifitas adalah origami (melipat kertas), di mana dengan melakukan kegiatan origami anak mampu mengekspresikan imajinasi dengan membuat model yang diinginkan. kegiatan origami ini juga terdapat di dalam ktsp origami dan kreatifitas anak sekolah (yuni sa) yuni s (kurikulum tingkat satuan pendidikan) sd/mi. di sdn krian iv kegiatan ini jarang dilaksanakan. oleh karena itu, peneliti belum dapat menjelaskan sejauh mana pengaruh bermain origami terhadap perkembangan kreatifitas anak usia sekolah. pribadi kreatif sangat diperlukan pada usia dini karena 50% kemampuan belajar tumbuh pada usia 4 tahun pertama, sebanyak 30% kemampuan belajar berkembang menjelang usia 8 tahun, sehingga usia ini merupakan usia emas untuk meletakkan landasan kreatif bagi proses belajar anak di masa depan (gustian, 2001). hasil studi pendahuluan yang dilakukan di sdn krian iv didapatkan 20 dari 53 anak yang memiliki sikap kreatif di bawah rerata, 29 anak berada pada tingkat rerata dan hanya 3 anak yang memiliki sikap kreatif di atas rerata. selain itu didapatkan pula bahwa lebih dari 50% anak pada saat bermain di rumah tidak didampingi oleh orang tua. kurang stimulasi dan komunikasi antara anak dengan orang tua, guru, serta lingkungan sekitar akan menyebabkan berbagai permasalahan pada perkembangan anak. anak yang tidak pernah diberi kesempatan untuk mengekspresikan diri sejak dini (lebih banyak menjadi pendengar pasif) akan cenderung mengalami masalah dalam perkembangan. penggunaan model pembelajaran yang kurang tepat juga akan berpengaruh terhadap perkembangan kreatifitas anak. pembelajaran yang dilakukan satu arah akan menyebabkan anak hanya akan terbiasa menerima gagasan atau masukan yang diberikan sehingga keinginan atau kesempatan anak untuk mengeksplorasi kemampuan yang ada pada diri menjadi berkurang. hal ini akan menyebabkan anak tidak terbiasa untuk menyelesaikan sebuah permasalahan yang akan berpengaruh terhadap kemampuan berpikir kreatif yakni kelancaran, keluwesan, dan mewujudkan orisinalitas dalam berpikir, serta mampu mengelaborasikan gagasan. supraptiningsih (1999) menegaskan bahwa stimulasi yang kurang serta penggunaan model pembelajaran yang kurang tepat akan berpengaruh terhadap penurunan kemampuan berpikir kreatif dan penurunan sikap kreatif (rasa selalu ingin tahu, tertarik akan tantangan, berani mengambil risiko, tidak mudah putus asa, menghargai keindahan, mempunyai rasa humor, ingin mencari pengalaman baru, dapat menghargai diri sendiri dan orang lain), apabila hal ini dibiarkan akan terjadi kebekuan kreatifitas. upaya untuk mengembangkan kreatifitas anak memerlukan peranan orang tua dan pendidik di dalam mendampingi, mengarahkan dan mengawasi anak. selain sikap dan kondisi lingkungan yang menunjang, dapat juga melalui berbagai kegiatan yang menyenangkan, mudah dan murah salah satunya adalah origami. teknik permainan origami merupakan salah satu bentuk kegiatan seni budaya dan keterampilan yang tercantum dalam ktsp sd/mi, digunakan untuk meningkatkan apresiasi siswa dalam seni rupa di mana siswa mampu mengenal bentuk dan membuat suatu kerajinan tangan (departemen pendidikan nasional, 2007). origami juga melatih anak berpikir matematis, belajar perbandingan, membaca diagram, membuat mainan sendiri, serta anak belajar menemukan solusi bagi permasalahan yang dihadapi. semua aspek ini akan membantu perkembangan kreatifitas anak. kegiatan ini dapat dilakukan di sekolah bersama guru atau di rumah bersama orang tua, sehingga dapat digunakan sebagai sarana membina kedekatan/komunikasi antara anak dan orang tua. oleh sebab itu peneliti, mengambil permainan ini sebagai salah satu sarana untuk mengembangkan kreatifitas terutama pada anak usia sekolah di sdn krian iv. bahan dan metode desain penelitian yang digunakan pada penelitian ini adalah pra eksperimental one group pre-posttest design. populasi terjangkau pada penelitian ini adalah anak usia sekolah kelas 1 di sdn krian iv. sampel yang memenuhi kriteria inklusi dalam penelitian ini sebesar 45 anak, namun pada saat posttest terdapat 4 orang anak yang tidak mengikuti, sehingga sesuai dengan kriteria eksklusi 4 anak tersebut di drop out. jumlah sampel yang memenuhi kriteria sampel adalah 41 orang. penelitian ini dilaksanakan pada bulan juni 2008. variabel independen dalam penelitian ini adalah teknik bermain origami (melipat kertas), sedangkan variabel jurnal ners vol.3 no.1 april 2008: 42-48 yuni s dependen pada penelitian ini adalah peningkatan perkembangan kreatifitas anak usia sekolah (usia 6-7 tahun). pengumpulan data pada penelitian ini menggunakan lembar tes kreatifitas figural yang diadaptasi dari torrance (2000) dalam buku guidance creativity, untuk mengetahui kreatifitas anak usia sekolah (kelas 1). materi tes kreatifitas figural ini terdiri dari tiga sub tes yaitu 1) membuat gambar (picture construction), sub tes ini mengukur keaslian (originalitas), dan kerincian (elaborasi) dalam berpikir kreatif. subyek diminta untuk menyelesaikan sebuah stimulus berupa bercak hitam melengkung yang belum selesai, 2) melengkapi gambar (picture completing), sub tes ini untuk mengukur kelenturan (flexibility) seseorang dalam berpikir kreatif yang diwujudkan dalam keanekaragaman jawaban yang diberikan, sekaligus juga mengukur keaslian (originalitas), kerincian (elaboration) sebagai tambahan, sedangkan kelancaran (fluency) sebagai faktor sampingan. pada subyek diminta untuk melengkapi gambar yang belum selesai sebanyak sepuluh gambar, dan 3) lingkaran, sub tes ini untuk mengukur kelancaran seseorang dalam memberikan gagasan, sekaligus juga mengukur keaslian, kerincian dan kelenturan sebagai perimbangan. subyek diminta untuk membuat gambar sebanyak mungkin dari lingkaran yang disediakan, yang berjumlah 36 lingkaran. data yang diperoleh dianalisis dengan menggunakan uji statistik wilcoxon signed rank test dengan tingkat kemaknaan α≤0,05. hasil hasil penelitian menunjukkan bahwa terdapat peningkatan perkembangan kreatifitas (lihat tabel 1) di mana pada saat pretest tingkat kreatifitasnya lebih banyak berada pada taraf rerata 53,66% (22 anak), sedangkan pada saat post test tingkat kreatifitas anak lebih banyak berada pada taraf sangat unggul 60,98% (25 anak). terdapat pengaruh bermain origami terhadap perkembangan kreatifitas anak usia sekolah (kelas 1) di sdn krian iv yang ditunjukkan dengan nilai mean pada saat pretest 93,29 yang berarti rerata tingkat kreatifitas anak sebelum intervensi berada pada taraf rerata dan pada saat post test nilai mean 130,00 yang berarti rerata tingkat kreatifitas anak pada saat post berada pada taraf sangat unggul. hasil uji stastik dengan wilcoxon signed rank test menunjukkan nilai kemaknaan α≤0,00. pembahasan tingkat kreatifitas anak kelas 1 di sdn krian iv sebelum dilakukan kegiatan bermain origami ditunjukkan lebih banyak pada tingkat rerata. keterbatasan kesempatan bagi anak untuk melakukan kegiatan sesuai dengan keinginan akan mengurangi kemampuan anak dalam mengembangkan daya kreatif. menurut munandar (2000), jika seorang anak kurang diberikan stimulasi untuk merangsang kemampuan berpikir kreatif akan menyebabkan anak tidak terbiasa berpikir, selain itu apabila seorang anak dituntut untuk selalu mengikuti perintah serta harus menyesuaikan diri dengan orang dewasa akan menyebabkan kebekuan kreatifitas, di mana kondisi ini seringkali terjadi pada saat anak mulai memasuki sekolah dasar (6-7 tahun) (hurlock, 2005). stimulasi yang kurang dan kekuasaan orang dewasa yang kuat akan menghambat perkembangan kreatifitas anak, terutama apabila seringkali orang tua lebih mengharapkan anak untuk diam di rumah daripada bermain bersama dengan teman. anak akan dapat berimajinasi serta berpikir diluar batas dunia nyata melalui kegiatan bermain sehingga kemampuan berpikir dan berperilaku kreatif anak akan semakin berkembang. pada penelitian ini ditemukan pula tingkat kreatifitas yang sangat unggul sebelum diberikan intervensi. hal ini disebabkan oleh beberapa faktor yang mempengaruhi perkembangan kreatifitas antara lain jenis kelamin. hurlock (2005) menyatakan bahwa anak laki-laki menunjukkan kreatifitas yang lebih besar daripada anak perempuan setelah masa kanak-kanak berlalu, sehingga pada usia sekolah tingkat kreatifitas anak laki-laki dan perempuan hampir sama. hal ini menunjukkan bahwa jenis kelamin bukanlah faktor mutlak yang mempengaruhi perkembangan kreatifitas, karena dalam hal ini kreatifitas lebih dipengaruhi oleh pengetahuan, serta kesempatan dan keinginan anak untuk mengembangkan daya kreatifnya. origami dan kreatifitas anak sekolah (yuni sa) perkembangan kreatifitas juga dipengaruhi oleh urutan kelahiran anak, studi tentang urutan kelahiran anak dan pengaruhnya terhadap tingkat kreatifitas menunjukkan hasil yang berbeda. perbedaan ini lebih dikarenakan oleh lingkungan daripada bawaan (hurlock, 2005). anak yang lahir setelah anak pertama memiliki tingkat kreatifitas sangat unggul. dengan demikian dapat diketahui bahwa anak yang lahir setelah anak pertama mempunyai kesempatan yang lebih besar untuk mengembangkan daya kreatif mereka, hal ini disebabkan perlakuan orang tua yang lebih fleksibel, dalam hal ini tuntutan orang tua lebih berkurang daripada kepada anak pertama serta anak yang lebih kecil (pada usia sekolah) biasanya mengidolakan saudara kandung yang lebih besar dan sering terjadi persaingan. sarana prasarana serta dukungan orang tua juga turut mempengaruhi perkembangan kreatifitas hal ini sangat erat berhubungan dengan status sosial ekonomi responden (hurlock, 2005). keadaan status sosial ekonomi yang cukup, anak akan memiliki kesempatan untuk mengembangkan daya kreatif lebih bebas. tingkat pendidikan orang tua pun turut mempengaruhi (hurlock, 2005), semakin tinggi tingkat pendidikan orang tua maka pola asuh akan semakin baik (demokratis) dan selalu memberikan kesempatan bagi perkembangan kreatifitas anak. perkembangan tingkat kreatifitas anak setelah bermain origami menunjukkan bahwa tingkat kreatifitas anak setelah dilakukan kegiatan permainan origami sebagian besar mengalami peningkatan perkembangan kreatifitas. hal ini disebabkan permainan origami dapat memberikan kesempatan kepada anak untuk mengembangkan daya kreatif mereka dengan membuat berbagai macam bentuk secara bebas sesuai dengan keinginan. anak dapat menghasilkan berbagai ide inovatif dengan memberikan kebebasan bagi daya kreatif anak untuk menuangkan imajinasi. hal inilah yang akan membuat anak berpikir kreatif (berbagai macam arah) yang akan menimbulkan sikap kreatif anak. kegiatan bermain origami yang dilakukan anak akan membantu perkembangan kreatifitas anak. permainan origami yang dilakukan akan membuat anak belajar untuk membuat sebuah bentuk dengan teknik yang paling mendasar yaitu meniru/mengikuti arahan. di saat bermain origami otak akan terstimulasi dan akan terjadi koordinasi dengan sensor motorik, sehingga anak menghasilkan bentuk. apabila kegiatan ini dilakukan berulang anak akan mahir dan membuat berbagai macam model, maka pada suatu saat anak akan memunculkan gagasan ingin membuat sesuatu dari berbagai teknik lipatan yang telah dibuat sebelumnya (ismayanti, 2004). pada akhirnya anak mampu membuat kreasi baru dan secara tidak langsung akan membantu perkembangan kreatifitas anak. tabel 1. hasil analisis statistik pengaruh bermain origami terhadap perkembangan kreatifitas anak usia sekolah di sdn krian iv sidoarjo pada tanggal 13-24 juni 2008 hasil pretest hasil posttest sangat lamban rerata sangat unggul sangat lamban rerata sangat unggul jumlah (anak) 14 22 5 5 11 25 mean 93,29 130,00 sd 32,531 33,459 hasil analisis statistik wilcoxon signed rank test p=0,000 keterangan: p = derajat kemaknaan sd = standar deviasi mean = rerata jurnal ners vol.3 no.1 april 2008: 42-48 keberhasilan anak dalam menghasilkan bentuk baru juga akan memberikan kepuasan kepada anak karena dalam hal ini berarti anak menguasai keterampilan baru (ismayanti, 2004). erikson menyatakan bahwa perkembangan sosio emosional anak berada pada fase industri vs inferioritas di mana pada masa ini anak berjuang untuk mendapatkan kompetensi dan keterampilan penting untuk berfungsi sama seperti orang dewasa dan mendapatkan keberhasilan positif (potter dan perry, 2005). stimulasi melalui kegiatan yang memfasilitasi anak untuk menguasai keterampilan, bebas berkreasi serta aktualisasi diri (dengan bermain origami) diperlukan dalam mempertahankan konsep diri positif bagi anak usia sekolah. beberapa kondisi yang mendukung perkembangan kreatifitas anak, yaitu waktu, kesempatan, dorongan, sarana, lingkungan yang menstimulasi, hubungan anak dan orang tua yang tidak terlalu posesif, cara mendidik anak, serta kesempatan untuk memperoleh pengetahuan (hurlock, 2005). kondisi yang meningkatkan kreatifitas dapat diciptakan di sekolah maupun di rumah dengan melakukan kegiatan yang menyenangkan dengan selalu melibatkan komunikasi antara anak dan orang tua/pendidik. anak harus diberikan waktu bebas dan kesempatan sendiri untuk bermain dengan berbagai gagasan dan konsep, serta mencoba bentuk baru yang orisinil untuk mengembangkan kreatifitas (hurlock, 2005). dalam penelitian ini peneliti memberikan kesempatan (waktu) secara bebas, bila anak tidak mampu menyelesaikan di sekolah anak dapat menyelesaikan tugas di rumah. pemberian waktu yang bebas ini sebagai upaya agar anak bebas menuangkan segala gagasannya untuk menghasilkan sebuah bentuk yang diinginkan. penjelasan cara bermain, dorongan dan sarana prasana juga diperlukan dalam upaya untuk membantu perkembangan kreatifitas anak. dalam penelitian ini sebelum melakukan kegiatan origami anak diajarkan tentang teknik dasar terlebih dahulu, memfasilitasi setiap anak dengan menyediakan semua sarana yang dibutuhkan oleh anak meliputi kertas lipat, buku gambar untuk menempel hasil karya, lem, kertas manila dan selalu mendorong anak untuk membuat berbagai bentuk bahkan memberikan reward yang positif ketika anak mampu membuat bentuk lain dengan menampilkan hasil karya terbaik mereka di kelas. anak pun diberikan kesempatan untuk menghias atau memberikan gambar yang sesuai dengan bentuk yang dia buat. hal ini sejalan dengan ungkapan hurlock (2005) bahwa lingkungan yang merangsang berupa dorongan dan sarana prasarana juga diperlukan untuk meningkatkan kreatifitas. lingkungan rumah dan sekolah harus mampu menstimulasi kreatifitas dengan memberikan bimbingan dan dorongan kepada anak untuk kreatif dan bebas dari ejekan dan kritik yang seringkali dilontarkan pada anak yang kreatif. sarana prasarana juga harus disediakan untuk merangsang dorongan eksperimentasi dan eksploitasi yang merupakan unsur penting dari kreatifitas. pemberian kesempatan bagi anak untuk mengembangkan daya kreatif akan menumbuhkan konsep diri positif serta kemampuan untuk mengaktualisasikan diri. anak akan mendapatkan kepuasan atas apa yang dibuat serta anak akan memiliki kesempatan untuk bebas membuat berbagai macam karya melalui permainan origami. kesempatan anak untuk memperoleh pengetahuan juga turut mempengaruhi perkembangan kreatifitas anak. kreatifitas seorang anak tidaklah muncul dalam kehampaan, semakin banyak pengetahuan yang dapat diperoleh anak semakin banyak pengetahuan yang diperoleh, semakin baik dasar untuk mencapai hasil yang kreatif (hurlock, 2005). kesempatan anak untuk memperoleh pengetahuan terutama berawal dari lingkungan rumah, apabila kondisi lingkungan di rumah serta orang tua memberikan kesempatan anak untuk mendapatkan pengetahuan dalam mengembangkan daya kreatif maka kreatifitas anak pun meningkat. penelitian ini memberikan kesempatan kepada anak untuk mendapatkan pengetahuan origami sebanyak-banyaknya tidak hanya di sekolah tetapi anak juga dapat memperoleh dari orang tua atau bersama saudara di rumah. hasil penelitian didapatkan bahwa pendidikan orang tua kebanyakan sma/stm yang memungkinkan orang tua cukup mempunyai pengetahuan untuk dibagikan kepada anak. hal ini didukung pula dengan orang tua (ibu) yang tidak bekerja (ibu rumah tangga) sehingga kesempatan bertemu dengan anak origami dan kreatifitas anak sekolah (yuni sa) yuni juga lebih besar. permainan origami menstimulasi kerja otak, kemudian otak akan mengolah informasi yang didapatkan sedemikian rupa sehingga cara kerja alami otak dilibatkan dari awal, dengan harapan bahwa anak akan lebih mudah mengingat dan menarik kesimpulan di kemudian hari (wiratih, 2008). menurut kawashima (2007), bermain origami sama seperti kegiatan merajut dan pertunjukan musik yang menghasilkan sesuatu. setelah anak menguasai teknik dasar origami ia akan berusaha untuk mengembangkan apa yang telah diterima sehingga kemampuan berpikir kreatif anak akan terasah. perkembangan kreatifitas anak pun dipengaruhi oleh usia, hal ini lebih menunjukkan tentang tingkat kematangan serta kesempatan anak untuk memperoleh pengalaman. pada usia 7 tahun perkembangan kreatifitas berada di tengah antara tahap pre operasional dan konkret operasional (potter dan perry, 2005). perkembangan kognitif anak usia 7 tahun sedikit lebih matang daripada anak usia 6 tahun, sehingga kemampuan berpikir dan perilaku kreatif juga sedikit lebih matang. dari semua faktor yang telah disebutkan dapat diketahui bahwa kreatifitas seseorang dapat terangsang dengan mengenal dan menghargai potensi kreatif (pribadi) dan penciptaan kondisi iklim lingkungan yang menunjang (dorongan internal dan eksternal) serta pemberian kesempatan untuk bersibuk diri secara kreatif (proses), maka berbagai produk kreatifitas yang konstruktif akan muncul. pada penelitian ini ditemukan penurunan tingkat kreatifitas (3 anak) setelah dilakukan stimulasi dengan bermain origami. anak belum tentu mampu mewujudkan potensi walaupun pembawaan anak bisa mencapai tingkat kreatifitas yang tinggi, terutama apabila lingkungan keluarga kurang memberikan stimulus, seperti orang tua yang bersikap otoriter, terlalu membatasi atau kurang memberikan kebebasan pada anak dan tidak terbiasa mendengarkan pendapat atau ide anak (munandar, 2000). penurunan kreatifitas anak pada penelitian ini dapat pula disebabkan oleh motivasi intrinsik (keinginan/rasa ingin tahu) dari anak mulai menurun untuk menuangkan ide saat melakukan post test atau anak sudah mulai bosan/jenuh. simpulan dan saran simpulan kegiatan bermain origami dapat meningkatkan kreatifitas anak dari rerata menjadi sangat unggul. hal ini disebabkan karena, dengan bermain origami, anak memiliki kesempatan untuk bebas mengungkapkan daya kreatif dan inovatif yang dimilikinya sehingga dapat memacu kreatifitas anak. saran berdasarkan hasil penelitian ini, peneliti menyarankan agar kegiatan bermain origami dilakukan oleh anak usia sekolah sebagai sarana pengembangan kreatifitas, sekolah hendaknya selalu mengembangkan kreatifitas anak dengan melakukan permainan kreatif baik melalui mata pelajaran seni budaya dan ketrampilan maupun mata pelajaran lain. perlu disediakan sarana prasarana yang membantu anak usia sekolah dalam mengembangkan kreatifitas seperti buku panduan origami, membuat kerajinan tangan dari barang bekas, catur, ruang kertaseni, dsb sebagai alternatif pengembangan kreatifitas anak. selanjutnya orang tua dan anggota keluarga lain hendaknya selalu memberikan dukungan serta stimulasi dengan bermain origami untuk membantu perkembangan kreatifitas anak. kepustakaan departemen pendidikan nasional. 2007. rencana pelaksanaan pembelajaran kurikulum tingkat satuan pendidikan (ktsp) sd/mi kelas i dan iv. jakarta: departemen pendidikan nasional, hlm. 213-216. gustian, e. 2001. mempersiapkan anak masuk sekolah. jakarta: puspa swara, hlm 135-137. hurlock, e.b. 2005. developmental psychology: a life-span approach. usa: mcgraw-hill inc, pp. 57-60. jurnal ners vol.3 no.1 april 2008: 42-48 ismayanti, f. 2004. origami dan anak bagian, (online), (http://www.sanggar-origami.com., diakses tanggal 10 november 2007, jam 14.10 wib). kawashima, r. 2007. mengaktifkan otak dengan origami. alih bahasa oleh ymg. retno arumsari widhaninggar. jakarta: pt grasindo, hlm. 58-63. munandar, s.c.u. 2000. pengembangan kreatifitas anak berbakat. jakarta: pt rineka cipta, hlm. 30-44. perry dan potter. 2005. buku ajar fundamental keperawatan: konsep, proses dan praktik. edisi 4. alih bahasa oleh yasmin asih. jakarta: egc, hlm. 506-508, 637-644, 688689. supraptiningsih. 1999. pengembangan kreatifitas anak usia prasekolah dan sekolah dasar. sekolah dasar (berkala). 8(2), (online), (http://journal.um.ac.id/index.php/seko lah-dasar/article., diakses tanggal 5 maret 2008, jam 12.00 wib) torrance, e.p. 2000. guiding creative talent, (online), (http://www.roberttoth.htm., diakses tanggal 3 maret 2008, jam 12.00 wib). tridjaja, c. 1998. studi korelasi antara kemampuan kreatif bermain balok dengan kemampuan berpikir kreatif pada anak usia sekolah di sd tarakanita jakarta selatan. tesis tidak dipublikasikan. bandung: institut teknologi bandung, hlm 54-60. wiratih, r. 2008. meningkatkan kreatifitas anak usia dini melalui peta pikiran, (online), (http://pkab.wordpress.com/2008/04/0 9/tingkatkan-kreatifitas-usia-dini/, diakses tanggal 03 mei 2008, jam 12.40 wib). http://www.sanggar-origami.com/ http://journal.um.ac.id/index.php/sekolah-dasar/article http://journal.um.ac.id/index.php/sekolah-dasar/article http://www.roberttoth.htm/ http://pkab.wordpress.com/2008/04/09/tingkatkan-kreativitas-usia-dini/ http://pkab.wordpress.com/2008/04/09/tingkatkan-kreativitas-usia-dini/ 114 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.6568 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research predictors of mortality among patients lost to follow up antiretroviral therapy putu dian prima kusuma dewi and gede budi widiarta stikes buleleng, bali, indonesia abstract introduction: the death of hiv/aids patients after receiving therapy in bali is the seventh highest percentage of deaths in indonesia. ltfu increases the risk of death in plha, given the saturation of people with hiv taking medication. the level of consistency in the treatment is very important to maintain the resilience and quality of life of people living with hiv. this study aims to determine the incidence rate, median time and predictors of death occurring in ltfu patients as seen from their sociodemographic and clinical characteristics. methods: this study used an analytical longitudinal approach with retrospective secondary data analysis in a cohort of hiv-positive patients receiving arv therapy at the buleleng district hospital in the period 2006-2015. the study used the survival analysis available within the stata se 12 software results: the result showed that the incidence rate of death in ltfu patients was 65.9 per 100 persons, with the median time occurrence of 0.2 years (2.53 months). the nnrti-class antiretroviral evapirens agents were shown to increase the risk of incidence of death in ltfu patients 3.92 times greater than the nevirapine group (hr 3.92; p = 0.007 (ci 1.46-10.51). each 1 kg increase in body weight decreased the risk of death in ltfu patients by 6% (hr 0.94; p = 0.035 (ci 0.89-0.99). conclusion: an evaluation and the monitoring of patient tracking with ltfu should be undertaken to improve sustainability. furthermore, an observation of the ltfu patient's final condition with primary data and qualitative research needs to be done so then it can explore more deeply the reasons behind ltfu. article history received: nov 14, 2017 accepted: august 02, 2018 keywords hiv/aids; buleleng district hospital; survival analysis contact putu dian prima kusuma dewi  dian_pkd@yahoo.co.id  stikes buleleng, bali, indonesia cite this as: kusuma dewi, p., & widiarta, g. (2018). predictors of mortality among patients lost to follow up antiretroviral therapy. jurnal ners, 13(1),114-121. doi:http://dx.doi.org/10.20473/jn.v13i1.6568 introduction the epidemic and mortality rate of human immunodeficiency virus (hiv) and acquired immune deficiency syndrome (aids) infections are still a global health problem. globally, with the presence of antiretroviral (arv) therapy, new infections and deaths are reported to have declined up to 2011 by 86% and 18%, respectively. contrary to the arv coverage, only 50% were treated and mostly adults were at a loss to follow up (ltfu). this condition indicates a gap in the access to antiretroviral therapy (unaids, 2013a). the retention rate for people taking antiretroviral therapy (art) has declined over time, from about 86% at 12 months to 72% at 60 months (unaids, 2013a). the death of hiv / aids patients after receiving therapy in bali is the seventh highest percentage in indonesia. this figure is still below the national death rate (18.04%), but is still far from the target of zero aids-related deaths (asean, 2011). the number of cumulative aids cases in bali is 4,261, with denpasar city having the highest number 2,113 (49,59%), second the regency of buleleng 593 (13,92%), and third, the regency of badung 550 (12,91%) (kemenkes ri, 2014). the data shows buleleng district as the second highest district for hiv / aids cases in bali with a higher cumulative number of ltfu patients compared with denpasar and badung regencies, at 211 (26.08%) out of 1394 plhas with arv therapy up to november 2013. this occurs considering that the area of buleleng is large with limited access to therapy. it is only available in singaraja town, namely rsud buleleng. buleleng is a high spot for hiv/aids cases with considerable access, such as to the gerokgak and sawan subhttps://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i1.6568 jurnal ners http://e-journal.unair.ac.id/jners | 115 districts (www.bulelengkab.go.id). the limited access make conditions and the discipline level of plha sufferers become strategic points that need to be studied, with the intention of reducing the risk of death and ltfu of plha. arv therapy requires high adherence and monitoring to suppress viral replication, to improve immunology and clinical outcomes, to reduce the risk of arv drug resistance, and to reduce the risk of hiv transmission (who, 2013). the level of consistency and adherence of plhas remains a problem in indonesia, including bali where there is a good hiv prevention program. however, little is known about the predictors of death in ltfu patients. data related to the death rate of ltfu patients has not been reported on yet, although the data is important in order to know the last condition of ltfu patients while they are undergoing therapy. death is the most common reason recorded for 233 (47.94%) of those experiencing ltfu (wubshet et al, 2013). ltfu increases the risk of death in plhas (alvarezuria et al, 2013). ltfu incidence continues to increase every year, given the saturation of plhas consuming drugs. the level of consistency in treatment is very important to maintain the resilience and quality of life of plhas. the incidence of ltfus in patients receiving antiretroviral therapy varies, according to several studies other countries indicating that the longer the antiretroviral therapy is received, then the incidence and percentage of ltfu is also greater (kate et al. 2014; mugisha et al., 2014). studies in african, european, american and asian countries reporting on the predictors of death in hiv/aids patients still show inconsistent results in relation to some of the variables. these variables include age (alvarez-uria et al., 2013), gender (odafe et al., 2012) and medication companion (lamb et al., 2012). longitudinal research is important to determine the success of the arv therapy programs that have been taking place. the ltfu indicator of the health facility setting of government hospitals is generally less than optimal for outreach programs, compared to private clinics. most of the population are local residents. this research is expected to identify the predictors of deaths in ltfu patients undergoing arv therapy in the general population in bali, especially buleleng district, which has not been done previously. this study will later contribute to practitioners and program holders on monitoring and evaluating the success of arv treatment of plhiv patients, especially in government hospitals. materials and methods this study aims to determine the incidence rate, median time and predictors of death occurring in ltfu patients as seen from the sociodemographic and clinical characteristics. the method of study was an analytical longitudinal study with retrospective secondary data analysis in a cohort of patients receiving arv therapy at the district general hospital of buleleng district from 2006 to 2015. this study used secondary data from the medical records of plha patients receiving art and arv registers contained in the vct polyclinic of buleleng hospital. surveys via telephone and home visits were made for special patients with ltfu accompanied by field officers from ngos. the survey aimed to check on the status of the ltfu patients recorded in the medical record, so that then we could more accurately know the person’s last condition (outcome) such as death, still live or loss. the extracted medical records, used as the study sample, were the patients receiving art in the period january 2006 to december 2015. the first step taken before the data extraction was to complete the permit application sent to the buleleng district hospital. the first step involved was to draw up a permit for research in buleleng district hospital, including the recommendation of research to the national unity and politics board buleleng district and the ethical clearance process of the ethics commission faculty of medicine udayana university/sanglah hospital denpasar. the numberletter of the permit for research in buleleng district hospital is no: 070/1958/sdm/vi/rsud/2017, the number of recommendation from the national unity and politics board buleleng district is no.070/279/bkbp/2017 and the number of the ethical clearance was no.2611/un.14.2/kep/2017. the data as shown in the figure 1 was collected by extraction from the medical records and the arv registers of each plha antiretroviral period from 2006 to december 2015 at the vct service edelweies buleleng district hospital, to form the inclusion criteria. next, the data was written in hard copy form and then made into a soft copy (in the form of microsoft excel). this research study was conducted in the vct eldeweies clinic of buleleng district hospital from hiv / aids patients arv therapy buleleng district hospital (2006-2015) 1306 people inclusion criteria : 1204 people (92%) patient in buleleng district hospital 1204 (92%) still arv therapy 842 (69.9%) died 112 (9.3%) ltfu 180 (14.9%) ltfu-died 37 (3.1%) ltfulife 6 (0.5%) stop treatment 5 (0.4%) refer out 22 (1.8%) exclusion criteria: age <15 years 43 people (3.3%) one visit 43 people (3.3%) pregnant women 16 (1.2%) total from ltfu 223 (18.5%) was detected died 37 (3.1%) figure 1 flow chart of respondents p. d. p. k. dewi et al. 116 | pissn: 1858-3598  eissn: 2502-5791 april 2017 to november 2017. the dependent variable was death in ltfu patients who had undergone arv therapy with the event date as the date or month of the last visit of the ltfu patient declared dead through the data on their medical records, arv registers and survey results (tracking) via telephone and home visits. the independent variable consisted of their sociodemographic and clinical characteristics. the characteristics of sociodemography consist of age, sex, work status and if they were a drug conservator (pmo). the clinical characteristics included their cd4 cell count, who stage, type of nrti arv, and nnrti arv type. the total population in the study up to july 31, 2014 was 1,013 patients. this population was limited via the inclusion criteria to hiv/aids patients receiving arv therapy under ltfu. the exclusion criteria established in this study were pregnant women, <15 years of age and non-random identities. the study will be limited to a specific timeframe from 2006 to 2014, and the recruitment of the study subjects was performed early with those receiving antiretroviral therapy as the baseline (initial observation). based on the large sample calculations, some of the most commonly found variables had links with those who had died in ltfu. it showed a minimum sample of 70 people with assumptions on the dead group (70 exposed groups) and the nondead (control group) group of 70 people. however, the sample to be used in this study consisted of all of the samples that met the inclusion criteria; as many as 1,204 patients with 223 patients included in ltfu so then the minimum sample size was met. all of the samples used were with consideration to the use of the secondary data to avoid incomplete data being available. consideration needed to be given as to the use of a larger sample. the samples used in the study met the inclusion criteria bearing in midn the consideration of avoiding incomplete or missing secondary data. the secondary data was in the form of a cohort of ltfu patients receiving arvs in the 2006 to 2015 period recorded in the medical records. the primary data was obtained through survey results (home visits and via telephone), assisted by field officers to determine the condition of the patients with ltfu. all of the samples that met the inclusion criteria were included as the study sample. this selection was done not to reduce the strength of research due to missing data that can be found in the patient's medical record but so then the missing data was not focused on the same variable in each patient. patients who had started arv therapy and met the inclusion criteria were included as the study sample. the analysis conducted in this study used survival analysis, using stata se 12 software. univariate analysis was used to obtain the incidence rate of death rate per 100 person according to a years and hazard ratio, in addition to the median time of ltfu occurrence from the beginning of the year of the patient using arv until the end of the observation year. the bivariate analysis resulted in a p value and survival rate that was used to see the significance of the differences between the respective groups. the value of the crude hazard ratio (hr), p specific, and p of hr crude from each independent variable to ltfu were performed using cox proportional hazard modified with a 95% confidence level. the parm test was used when the nominal independent variable was for three or more categories and we used a test for the trends when the ordinal data or intervals were in two or more categories. multivariate analysis with cox regression with the chosen selection method used was the backward method where one by one, the insignificant variables were removed from the model until the final model was obtained. the proportional hazard test was performed on the last multivariate model which aimed to check the proportional model produced when the model was said to be proportional, with a p > 0,05. results the results achieved from this study in accordance with the research objectives were as many as 1,306 patients treated in the period 2006 to december 2015. the data recorded until december 2015 descriptively analysed as many as 223 people (18.5%) patients with ltfu. the results of the study through the arv registery data and the survey conducted together with the field officer found that ltfu patients who died was as many as 37 people (3.1%), ltfu without further information was 180 people (14, 9%), and detected ltfu patients who were still alive but did not continue their treatment was as 6 people (0.5%). the data obtained was then input into the excel form in accordance with the predetermined variables for subsequent analysis using the stata se 12 software. the number of patients on antiretroviral therapy in buleleng district hospital from 2006 up to figure 2 kaplan meier graphic of ltfu patient death jurnal ners http://e-journal.unair.ac.id/jners | 117 december 2015 was 1,306 people. the number of samples meeting the inclusion criteria were 1,204 people (92%) who received therapy and had a minimum of two visits, while those not meeting the inclusion criteria consisted of 43 people (3.3%) with one visit, 16 people (1.2%) who were pregnant an 43 people ( 3.3%) under the <15 years old. the characteristics of the study subjects were described based on their sociodemographic and clinical characteristics. the sociodemographic and clinical characteristics was the data collected at the beginning of the observation. the related descriptions of the sample’s characteristics have been presented in tabular form, comparing the ltfu patient's death to each characteristic as in table 1. the number of plhas experiencing deaths in ltfu patients in buleleng district hospital was 37 people (3.1%). the incidencerate of death in ltfu patients was 65.9 per 100 people with a median time (50%) occurrence of 0.2 years (2.53 months). more than half of the respondents earned less than 2.4 million rupiah per month; 55.3% in the intervention group and 57.3% in control group. in terms of the relationship with the students, both groups were almost similar in that the respondents were taking care of their biological children, with the data showing 89.3% in the intervention group and 90.3% in the control group respectively kaplan meier's analysis in figure 2 above shows that for all of the plhas receiving antiretroviral therapy, 50% were at risk of death among the ltfu patients in the first year of therapy or around 2.53 months. this can be seen from the curve drawing of the median time for observation bivariate analysis of the nine variables at the beginning of observation in the table 2 showed that only two of the variables, weight and the group of nrtis (zidovudine), were statistically related. each 1 kg increase in weight reduced the risk of death in the ltfu patients by 6% with hr = 0.94; 95% ci 0.890.99; p = 0.02). patients taking zidovudine-type arvs reduced their risk of death in ltfu patients with hr = 0.32; 95% ci 0.15-0.69; p = 0.01). hiv-positive people who did not have a pmo were 1.57 times more at risk than those with a pmo (hr = 1.57; 95% ci 1.012.45; p = 0.045). furthermore, hiv-positive people who did not have a pmo were of the male gender 1.1 times more than the average, their functional status being ambulatory was 1.37 times greater and had a 1.47 times greater chance of death, but statistically, it showed no meaning. multivariate analysis was needed to look at the most powerful and significant relationship to death among the ltfu patients concerning several variables related to the bivariate analysis. the variables included in the multivariate analysis were the variables having p <0.25 and the correlated variables found through the reference studie,s which were age, body weight, gender, medication control, cd4 level, clinical stage, nrti class and nnrti group. table 1. sociodemographic and clinical characteristics of died in ltfu patients and no died in ltfu patients sociodemographic died in ltfu patients (n=37) n(%) not died in ltfu patients (n=1167) n(%) total n(%) 1 3 2 4 median of age (iqr)* 33 (30-38) 31 (27-37) 31(27-37) sex female 13 (2.9) 433 (97.1) 446 (100) male 24 (3.1) 734 (96.8) 758 (100) adherence support yes 30 (2.9) 1002 (97.1) 1032 (100) no 7 (4.1) 165 (95.9) 172 (100) fungtional status bed 8 (2.3) 334 (97.7) 342 (100) ambulatory 19 (3.8) 475 (96.1) 494 (100) working 9 (3.5) 245 (96.5) 254 (100) nrti tenofovir 11(5.5) 191 (94.5) 202 (100) stavudine 5 (5.4) 87 (94.6) 92 (100) zidovudine 21 (2.3) 881 (97.7) 902 (100) nnrti evapirens 12 (4.1) 277 (95.9) 289 (100) nevirapine 25 (2.8) 881 (97.2) 906 (100) who stage stadium 1 & 2 8 (3.7) 206 (96.3) 214 (100) stadium 3 & 4 27 (3.2) 811 (96.8) 838 (100) cd4 26 (17-50) 65(23-165) 64.5 (23-164.7) weight 47.5 (38.5-55) 50 (45-57) 50 (44-55) * test normality spahiro-wilk not normally distributed so used median (iqr) p. d. p. k. dewi et al. 118 | pissn: 1858-3598  eissn: 2502-5791 before doing the multivariate analysis, a collinearity test was conducted in order to know the effect of multi-collinearity. collinearities can be discovered if there is a variable that has a correlation coefficient of more than 0.6 (r> 0.6), which means that there is a strong correlation between the variables (sugiyono, 2011). in this analysis, there were no variables having a correlation> 0.6, so all covariate variables that met p <0.25 could be included in the multivariate analysis. certain types of nnrti-class antiretroviral evapirens have been shown to increase the incidences of death in ltfu patients 3.92 times greater than that of nevirapine (hr 3.92; p = 0.007 (ci 1.46-10.51). each 1 kg increase in body weight can reduce the risk of death in ltfu patients by 6 % (hr 0.94; p = 0.035 (ci 0.89-0.99) discussion the incidence rate of death in plhas experiencing ltfu within nine years at rsud buleleng was 65.4 per 100 people. this incidence rate is higher than that of 34.6 per 1,000 people over a period of five years (bekolo et al., 2013). the risk of death in ltfu patients was 20 times higher than that of outpatientss (ahr 22.03; 95% ci 20.05-24.21) (cornell et al., 2014). the incidence rate in this study was lower compared to the tahod data covering 18 sites in the asia pacific region of 21.4 per 100 py, but it was higher than the rate in southeast asian countries such as india (7.1 per 100 py) and vietnam ( 8.9 per 100 py) (zhou et al., 2012; alvarez-uria et al., 2013; tran et al., 2013). similarly, it can be compared with developed countries that tend to have lower incidence rates such as france (4.3 per 100 py) and europe (3.272 per 100 py) (lebouche et al., 2006; mocroft et al., 2008). this difference is also due to the different cut-offs in defining ltfu i.e. one year from the last visit. a comparison with countries in africa with the same cut off (≥ three months from the last visit) showed that the incidence rate for the findings in this study were lower, at 25.1 per 100 py (western kenya) (ochieng-ooko et al. 2010), 51.1 per 100 py (guinea bissau) (hønge et al., 2013) and 94.6 per 100 py (cameroon) (bekolo et al., 2013). the results of this study indicate that the ltfu patient death predictor that is statistically related to ltfu is nnrti weight and the group of evapirens. weight is a common reference used to assess nutritional status. ltfu plha deaths increased with a weight of 45 kilograms (somi et al., 2012). people with hiv who start arv therapy with a higher body weight will have a better health conditions. plhas with this condition tend to retain arv therapy because they have benefited from the therapy. people with hiv who start therapy weighing less than 45 kg are more at risk of death and attrition. losing weight> 10% is a common symptom experienced when infected with hiv (dalal et al., 2008). other health conditions that can be used as a measure other than weight is bmi (body mass index). bmi (body mass index) ≤ 18.5 kg / m2 indicates poor health condition that may decrease the patient’s table 2. predictor of death in loss to follow up patient variable crude hr 95 % ci p ahr 95% ci p 1 2 3 4 5 median of age (iqr)* 1.02 0.98 -1.06 0.175 sex female 1.00 (reff) male 1.1 0.56-2.17 0.76 adherence support yes 1.00 (reff) no 1.37 0.60-3.14 0.44 fungtional status bed 1.00 (reff) ambulator 1.37 0.60-3.13 0.45 working 1.47 0.56-3.81 0.43 nrti tenofovir 1.00 (reff) stavudine 0.70 0.23-2.12 0.53 zidovudine 0,32 0.15-0.69 0.01* nnrti nevirapine 1.00 (reff) 1,00(ref) evapirens 1.37 0.86-3.49 0.118 3.92 1.46-10.5 0.01 who stage stadium 1 & 2 1.00 (reff) stadium 3 & 4 0.83 0.37-1.84 0.66 cd4 0.99 0.99-1.00 0.43 weight 0.94 0.89-0.99 0.02* 0.94 0.89-0.99 0.035 *p-value <0.25 jurnal ners http://e-journal.unair.ac.id/jners | 119 confidence in therapy so that ltfu is greater (ahr 1.51; 95% ci 1,23-1,87), supporting also the incidences of oral candidiasis with a low bmi (hr 1.36 95% ci 1.02-1.82) (hønge et al., 2013; evans et al., 2013). in contrast, the increase in the bmi of each person decreased the incidence of ltfu (ahr, 0.97, 95% ci 0.88-1.03) but did not otherwise show a significant relationship. predictors among ltfu patients included bmi <17.5 (hr 2.4; 95% ci 1.8-3.1) (fox, brennan, maskew, macphail, & sanne, 2010). this is in line with the ethiopian study which stated that plhas who weighed ≥60 kg had a 76% lower risk for ltfu than those with a weight <40 kg (ahr 3.47 95% ci 1.02-11.83). those with a normal weight had confidence in their treatment and maintained it well (haile & mekelle, 2014). the arv regimen consists of nucleoside reverse transcriptase inhibitors (nrtis) and non-nucleoside reverse transcriptase (nnrti). groups that include the nrti regimen are zidovudine (azt), stavudine (d4t), lamivudine (3tc), didanosine (ddl), abacavir (abc), tenofovir (tdf) and emtricitabine (ftc). the nnrti regimens are nevirapine and efavirens. there is also a second line of protease inhibitor (pi) regimens such as lopinavir or ritonavir. arv regimens related to drug characteristics, side effects and easy access to arvs have an impact on the adherence of plhas (moh ri, 2011a). research conducted in cameroon said that the use of the nnrti nevirapine (nvp) regimen significantly reduced the risk of ltfu (ahr 0.75 ci0.57-0.99 p = 0.04), as well as on the use of the stavudine nrti regimen (ahr 0.55 ci 0.420.71) and zidovudine (azt) (ahr 0.59 ci 0.45-9.77) (bekolo et a, l., 2013). in contrast to studies in ethiopia, the use of azt increases ltfu risk by three times compared to the d4t regimens (haile & mekelle, 2014). hiv-positive people who received a substitution of their antiretroviral regimens during the treatment period were at a greater risk of ltfu (hr 5.2, 95% ci 3.6-7.3). this is similar to studies in india who reported that substitution could be a risk factor for art failure (alvarez-uria et al., 2013; berheto et al., 2014). the majority of regimen substitution cases are caused by drug reactions, such as when patients may become concerned about the side effects and effectiveness of the new drugs. conclusion the correct and complete recording of patient addresses and phone numbers, and reviewing the patient relationship with their pmo, was the most important part of recording for tracking purposes related o patient absence during scheduled visits. an evaluation and the monitoring of patient tracking with ltfu should be undertaken to improve sustainability. furthermore, an observation of the ltfu patient's final condition with primary data and qualitative research needs to be done so then it can explore more deeply the reasons behind ltfu. this is to know how to anticipate ltfu. observation time with the secondary data also needs to be added to better know the success of therapy. references alvarez-uria, g., naik, p. k., pakam, r., & midde, m. (2013). factors associated with attrition, mortality, and loss to follow up after antiretroviral therapy initiation: data from an hiv cohort study in india. global health action, 6, 21682. retrieved from http://www.pubmedcentral.nih.gov/articlerende r.fcgi?artid=3773168&tool=pmcentrez&renderty pe=abstract asean. (2011). asean declaration of commitment: getting to zero new hiv infection, zero discrimination, zero aids-related deaths., 1–9. bekolo, c. e., webster, j., batenganya, m., sume, g. e., & kollo, b. (2013). trends in mortality and loss to follow-up in hiv care at the nkongsamba regional hospital, cameroon. bmc research notes, 6(1), 512. https://doi.org/10.1186/1756-0500-6-512 berheto tezera moshago, demissew berihun haile, and s. m. (2014). predictors of loss to follow-up in patients living with hiv/aids after initiation of antiretroviral therapy. north american journal of medical sciences, 6(9), 453–459. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2531739 0 cornell, m., lessells, r., fox, m. p., garone, d. b., giddy, j., fenner, l., … boulle, a. (2014). mortality among adults transferred and lost to follow-up from antiretroviral therapy programmes in south africa: a multicenter cohort study. journal acquir immune defic syndrom, 67(2), e67–e75. dalal, r. p., macphail, c., mqhayi, m., wing, j., feldman, c., chersich, m. f., & venter, w. d. f. (2008). characteristics and outcomes of adult patients lost to follow-up at an antiretroviral treatment clinic in johannesburg, south africa. journal of acquired immune deficiency syndromes (1999), 47(1), 101– 7. https://doi.org/10.1097/qai.0b013e31815b833 a denise, e., mhairi, m., & ian, s. (2013). increased risk of mortality and loss to follow-up among hiv positive patients with oropharyngeal candidiasis and malnutrition prior to art initiation – a retrospective analysis from a large urban cohort in johannesburg, south africa. national institutes of health, 1–18. https://doi.org/10.1016/j.oooo.2011.09.004.incr eased deribe, k., hailekiros, f., biadgilign, s., amberbir, a., & beyene, b. k. (2008). defaulters from antiretroviral treatment in jimma university specialized hospital, southwest ethiopia. tropical medicine & international health : tm & ih, 13(3), 328–33. https://doi.org/10.1111/j.13653156.2008.02006.x edwards, j. k., cole, s. r., westreich, d., moore, r., mathews, c., geng, e., … mugavero, m. j. (2014). p. d. p. k. dewi et al. 120 | pissn: 1858-3598  eissn: 2502-5791 loss to clinic and five-year mortality among hivinfected antiretroviral therapy initiators. plos one, 9(7), e102305. https://doi.org/10.1371/journal.pone.0102305 fox, m. p., brennan, a., maskew, m., macphail, p., & sanne, i. (2010). using vital registration data to update mortality among patients lost to follow-up from art programmes: evidence from the themba lethu clinic, south africa. tropical medicine and international health. https://doi.org/10.1111/j.13653156.2010.02473.x haile, k. t. and f., & mekelle. (2014). predictors of loss to follow up of patients enrolled on antiretroviral therapy: a retrospective cohort study. journal of aids & clinical research, 5(12). https://doi.org/10.4172/2155-6113.1000393 hønge, b. l., jespersen, s., nordentoft, p. b., medina, c., da silva, d., da silva, z. j., … wejse, c. (2013). loss to follow-up occurs at all stages in the diagnostic and follow-up period among hiv-infected patients in guinea-bissau: a 7-year retrospective cohort study. bmj open, 3(10), e003499. https://doi.org/10.1136/bmjopen-2013-003499 kate clouse, audrey pettifor, mhairi maskew, jean bassett, annelies van rie, cyinthia gay, frieda behets, lan sanne, and m. p. f. (2014). initiating art when presenting with higher cd4 counts results in reduced loss to follow-up in a resourcelimited setting, 27(4), 645–650. https://doi.org/10.1097/qad.0b013e32835c12f 9.initiating kemenkes ri. (2011). pedoman nasional tatalaksana klinis infeksi hiv dan terapi antiretroviral pada orang dewasa. kemenkes ri. (2014). laporan situasi perkembangan hiv&aids di indonesia tahun 2014. lebouche, b., yazdanpanah, y., gerard, y., sissoko, d., ajana, f., alcaraz, i., … mouton, y. (2006). incidence rate and risk factors for loss to followup in a french clinical cohort of hiv-infected patients from january 1985 to january 1998, 140– 145. lwanga, s. k.; lemeshow, s. (1991). sample size determination in health studies: a practical manual. mocroft, a., kirk, o., aldins, p., chies, a., blaxhult, a., chentsova, n., … lundgren, j. d. (2008). loss to follow-up in an international, multicentre observational study. hiv medicine, 9(5), 261–9. https://doi.org/10.1111/j.14681293.2008.00557.x mugisha, v., teasdale, c. a, wang, c., lahuerta, m., nuwagaba-biribonwoha, h., tayebwa, e., … abrams, e. j. (2014). determinants of mortality and loss to follow-up among adults enrolled in hiv care services in rwanda. plos one, 9(1), e85774. https://doi.org/10.1371/journal.pone.0085774 ndiaye, b., ould, k., salleron, j., bataille, p., bonnevie, f., cochonat, k., … yazdanpanah, y. (2009). original article incidence rate and risk factors for loss to follow-up in hiv-infected patients from five french clinical centres in northern france – january 1997 to december 2006, (december 2006), 567–575. ochieng-ooko, v., ochieng, d., sidle, j. e., holdsworth, m., wools-kaloustian, k., siika, a. m., … braitstein, p. (2010). influence of gender on loss to follow-up in a large hiv treatment programme in western kenya. bulletin of the world health organization, 88(9), 681–8. https://doi.org/10.2471/blt.09.064329 odafe, s., idoko, o., badru, t., aiyenigba, b., suzuki, c., khamofu, h., … chabikuli, o. n. (2012a). patients’ demographic and clinical characteristics and level of care associated with lost to follow-up and mortality in adult patients on first-line art in nigerian hospitals. journal of the international aids society. https://doi.org/10.7448/ias.15.2.17424 odafe, s., idoko, o., badru, t., aiyenigba, b., suzuki, c., khamofu, h., … chabikuli, o. n. (2012b). patients’ demographic and clinical characteristics and level of care associated with lost to follow-up and mortality in adult patients on first-line art in nigerian hospitals. journal of the international aids society, 15(2), 17424. retrieved from http://www.pubmedcentral.nih.gov/articlerende r.fcgi?artid=3494164&tool=pmcentrez&renderty pe=abstract somi, g., keogh, s. c., todd, j., kilama, b., wringe, a, van den hombergh, j., … zaba, b. (2012). low mortality risk but high loss to follow-up among patients in the tanzanian national hiv care and treatment programme. tropical medicine & international health : tm & ih. https://doi.org/10.1111/j.13653156.2011.02952.x sugiyono. (2011). statistika untuk penelitian. bandung. tran, d. a., ngo, a. d., shakeshaft, a., wilson, d. p., doran, c., & zhang, l. (2013a). trends in and determinants of loss to follow up and early mortality in a rapid expansion of the antiretroviral treatment program in vietnam: findings from 13 outpatient clinics. plos one. https://doi.org/10.1371/journal.pone.0073181 tran, d. a., ngo, a. d., shakeshaft, a., wilson, d. p., doran, c., & zhang, l. (2013b). trends in and determinants of loss to follow up and early mortality in a rapid expansion of the antiretroviral treatment program in vietnam: findings from 13 outpatient clinics. plos one, 8(9), e73181. https://doi.org/10.1371/journal.pone.0073181 unaids. (2012). unaids world aids day report | 2012. unaids. (2013a). global update on hiv treatment 2013 :, (june). unaids. (2013b). hiv in asia and the pasific. retrieved from http://www.unaids.org who. (2013). consulidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection recommendations for a public health approach, (june). jurnal ners http://e-journal.unair.ac.id/jners | 121 wubshet, m., berhane, y., worku, a., & kebede, y. (2013). death and seeking alternative therapy largely accounted for lost to follow-up of patients on art in northwest ethiopia: a community tracking survey. plos one, 8(3), e59197. https://doi.org/10.1371/journal.pone.0059197 zhou, j., tanuma, j., chaiwarith, r., lee, c. k. c., law, m. g., kumarasamy, n., … lim, p. l. (2012). loss to followup in hiv-infected patients from asiapacific region: results from tahod. aids research and treatment, 2012, 375217. https://doi.org/10.1155/2012/375217 pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru jurnal ners vol.3 no.1 april 2008 : 8-13 8 progressive muscle relaxation meningkatkan aliran ekspirasi maksimum penderita penyakit paru obstruksi kronis (progressive muscle relaxation increase peak expiratory flow rate on chronic obstructive pulmonary disease patients) tintin sukartini*, ika yuni widyawati*, yani indah sari** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: tintin_bios@yahoo.com ** rs mitra keluarga darmo satelit, surabaya abstract introduction: limited progressive air flow in chronic obstructive pulmonary disease (copd) can caused by small airway disease (bronchiolitis obstructive) and loss of elasticity of the lung (emphysema). further it can be decreasing the quality of life in copd patients because dyspnea and uncomfortable in activity. progressive muscle relaxation (pmr) is one of the relaxation technique that can repair pulmonary ventilation by decreasing chronic constriction of the respiratory muscles. the objective of this study was to analyze the effect of progressive muscle relaxation on raised peak expiratory flow rate (pefr). method: a pre-experimental one group pre-post test design was used in this study. population was all of the copd patients at pulmonary specialist polyclinic dr mohamad soewandhie surabaya. there were 8 respondents taken by using purposive sampling. pefr was counted by using peak flow meter every six day. data were analyzed by using paired t-test with significance level p≤0.05. result: the result showed that pmr had significance level on increasing of pefr (p=0.012). discussion: it can be concluded that pmr has an effect on raise pefr. further studies are recommended to measure the effect of pmr on respiratory rate (rr), heart rate (hr) subjective dyspnoe symptoms, forced expiration volume on the first minute (fev1) and mid maximum flow rate (mmfr) in copd patients. keywords: copd, peak expiratory flow rate, progressive muscle relaxation pendahuluan penyakit paru obstruktif kronik (ppok) hingga kini terus meningkat dan menjadi ancaman baru sebagai penyebab kematian di dunia, termasuk indonesia (amin, 2004). pada penderita ppok ditemukan keterbatasan aliran udara yang bersifat progresif (mangunnegoro, 2001). keterbatasan ini disebabkan oleh campuran penyakit saluran nafas kecil (bronkiolitis obstruktif) dan kerusakan parenkim paru (emfisema) (baratawidjaja, 2007). keterbatasan ini menyebabkan penderita sering mengeluh sesak nafas dan rasa tidak nyaman dalam beraktivitas (yunus, 1997) yang kemudian jatuh pada keadaan kronik dan panik (casabury and petty, 1993). hal ini akan menyebabkan penurunan kemampuan fungsional dan kualitas hidup penderita ppok. program rehabilitasi paru dengan latihan relaksasi bertujuan mengurangi gejala sesak nafas dan memperbaiki kualitas hidup penderita ppok (mangunnegoro, 2001). tujuan latihan relaksasi pada penderita ppok adalah untuk memperbaiki ventilasi, memulihkan otot-otot yang mengalami konstriksi atau ketegangan kronik dan akhirnya mengurangi sesak nafas (baratawidjaja, 2007). progressive muscle relaxation adalah teknik relaksasi yang dianjurkan bagi penderita ppok (suharto, 2000), diciptakan bagi seseorang dengan ketegangan otot (greenberg, 2002). respons relaksasi ini menunjukkan penurunan pada tingkat sesak nafas, kecemasan dan rr (respiratory rate) (casabury and petty, 1993). selama ini di tatanan klinik untuk mengelola sesak nafas pada penderita ppok selain dengan pemberian obat-obatan juga telah dikombinasi dengan pemberian progresive muscle relaxation meningkatkan aliran ekspirasi maksimum (tintin s) 9 program rehabilitasi paru seperti breathing exercise (diafragma dan pursed lips), chest physical therapy (postural drainage), latihan fisik (jalan kaki, aerobic) dan latihan relaksasi yang telah terbukti efektif dalam mempertahankan kualitas hidup penderita ppok. pemberian latihan relaksasi khususnya progressive muscle relaxation memiliki tujuan utamanya untuk menurunkan tingkat kecemasan. renfroe (1992) menyatakan progressive muscle relaxation selain efektif menurunkan kecemasan juga menunjukkan hasil positif pada penurunan rr dan heart rate (hr) dalam waktu 4 minggu. hal ini diperkuat oleh pernyataan casabury (1993) seperti di atas sedangkan gift et al. (1997) menyatakan bahwa sesak, cemas dan obstruksi jalan nafas mengalami penurunan setelah melakukan relaksasi ini. hal ini semakin mendorong peneliti untuk menganalisis efektivitas progressive muscle relaxation dalam meningkatkan pefr pada penderita ppok. who memprediksi pada tahun 2020 angka kejadian ppok akan meningkat dari posisi 12 menjadi 5 sebagai penyakit terbanyak dan dari posisi 6 menjadi 3 sebagai penyebab kematian terbanyak di dunia (baratawidjaja, 2007). tercatat pasien ppok yang kontrol mencapai 30 orang di poli spesialis paru rsud dr mohamad soewandhie surabaya dalam bulan april-mei 2008, sekitar 93,3% orang laki-laki dan 6,8% perempuan dengan umur berkisar antara 4080 tahun. hampir seluruh pasien yang datang selalu mengeluh sesak nafas disertai batuk-batuk. pasien juga terlihat kurus, lemah dan memiliki banyak komplikasi lain (studi pendahuluan pengambilan data awal pada bulan mei 2008). angka di atas menunjukkan begitu penting program penanganan bagi ppok. terjadi penurunan elastisitas parenkim paru, hiperplasi dan hipertrofi kelenjar mukosa bronkus yang meningkatkan tahanan pada saluran nafas pada ppok. peningkatan tahanan saluran nafas akan meningkatkan kerja pernafasan (mulyono, 1997). hal ini ditandai dengan peningkatan frekuensi pernafasan, pemakaian otot bantu pernafasan, sesak dan pola nafas yang tidak terkoordinasi. keadaan ini menyebabkan ketegangan atau konstriksi kronik pada otototot pernafasan yang akan meningkatkan kebutuhan metabolisme energi, menurunkan aliran darah yang membawa suplai makanan dan oksigen, serta aktivitas neuromuskular (guyton dan hall, 1997). hal ini akan makin memperburuk sesak nafas yang ada. bila ini terus berlanjut maka bisa terjadi hipoksia, lebih berat lagi menyebabkan vasokonstriksi pembuluh darah paru, polisitemia dan hipertensi pulmonal yang bisa jatuh pada kor pulmonal (suyono et al., 2001). pemberian latihan progressive muscle relaxation bertujuan untuk menurunkan tegangan atau konstriksi kronik pada otot-otot pernafasan, terutama otot bantu pernafasan (mulyono, 1997). selain itu latihan ini juga mampu menurunkan rasa cemas karena sesak nafas serta memberikan sense of well being (patel, 1989). diharapkan dengan pemberian latihan ini akan mampu memperbaiki kualitas hidup penderita ppok. progressive muscle relaxation merupakan kombinasi latihan pernafasan terkontrol (diafragma breathing) dengan rangkaian kontraksi relaksasi sekelompok otot tubuh. pada diafragma breathing dapat terjadi pursed lips breathing. diafragma breathing merelaksasikan otot-otot pernafasan, menyimpan energi dan memperbaiki ventilasi sampai ke basal paru (casabury and petty, 1993). pursed lips breathing meningkatkan tekanan pada rongga mulut yang diteruskan melalui cabang bronkus sehingga mencegah air trapping dan kolaps bronkiolus pada saat ekspirasi (mulyono, 1997). kontraksi dan relaksasi sekelompok otot tubuh secara progresif membantu seseorang mengatasi ketegangan otot kronik yang terjadi, sehingga menurunkan kebutuhan metabolisme energi dan oksigen yang membuat nafas menjadi lebih pelan, dalam dan tidak cepat lelah. penggunaan metode progressive muscle relaxation diharapkan mampu memperbaiki sesak nafas pada penderita ppok yang ditandai dengan peningkatan pefr penderita ppok. tujuan dari penelitian ini adalah untuk menganalisis pengaruh progressive muscle relaxation terhadap penurunan sesak nafas pada penderita ppok bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah pra experimental jurnal ners vol.3 no.1 april 2008 : 8-13 10 one group pre-post test purposive sampling design. sampel diambil sesuai dengan kriteria inklusi yang telah ditentukan sebagai berikut: penderita ppok yang kooperatif dan bersedia menjadi responden, penderita ppok tanpa komplikasi (terutama gangguan vaskuler seperti hipertensi), penderita ppok yang tidak mengalami eksaserbasi akut, penderita ppok berusia >50 tahun dan penderita ppok tinggal di surabaya dan dapat dijangkau oleh peneliti. dalam penelitian ini diperoleh 8 responden yang sesuai dengan kriteria inklusi. penelitian dilakukan selama bulan juni sampai dengan juli 2008. variabel independen dalam penelitian ini adalah latihan relaksasi progressive muscle relaxation, sedangkan variabel dependen adalah penurunan sesak nafas dengan parameter pefr. latihan progressive muscle relaxation dilakukan sebanyak 2x seminggu setiap 3 hari sekali selama satu bulan, sedangkan pefr dihitung setiap 6 hari sekali. instrumen yang digunakan dalam penelitian ini adalah alat peak flow meter untuk pengukuran aliran ekspirasi maksimum dan lembar observasi. data yang diperoleh, dianalisis dengan menggunakan uji statistik paired ttest dengan derajat kemaknaan α<0,05. hasil setiap observasi terdapat peningkatan rerata nilai pefr sesuai dengan grafik pada tabel 1 yang ditunjukkan dengan nilai ∆ rerata post-pre yang terus meningkat hingga observasi terakhir meskipun berfluktuasi. peningkatan yang signifikan didapatkan pada observasi ke-5, 7 dan 8 sedangkan pada observasi ke-1 hingga 4 belum didapatkan hasil yang signifikan dimana nilai p>0,05. pada observasi ke 5 mulai didapatkan nilai yang bermakna dengan ∆ rerata post-pre 16,25 dan nilai p=0,042 meskipun pada observasi ke-6 menjadi kurang bermakna dengan ∆ rerata post-pre 10,00 dan p=0,121 namun di akhir observasi ke-7 dan 8 kembali didapatkan hasil yang berturut-turut signifikan dengan p<0,05 yaitu 0,031 dan 0,012. hal ini berarti ada pengaruh progressive muscle relaxation terhadap peningkatan pefr. tabel 1 menunjukkan rerata nilai pefr sebelum dan sesudah dilakukan latihan progressive muscle relaxation. pada setiap observasi terdapat peningkatan rerata nilai pefr sesuai dengan grafik pada gambar 1 yang ditunjukkan dengan nilai ∆ rerata postpre yang terus meningkat hingga observasi terakhir meskipun berfluktuasi. peningkatan yang signifikan didapatkan pada observasi ke-5, 7 dan 8 sedangkan pada observasi ke-1 hingga 4 belum didapatkan hasil yang signifikan dimana nilai p>0,05. pada observasi ke 5 mulai didapatkan nilai yang bermakna dengan ∆ rerata post-pre 16,25 dan nilai p=0,042 meskipun pada observasi ke-6 menjadi kurang bermakna dengan ∆ rerata post-pre 10,00 dan p=0,121. namun diakhir observasi ke-7 dan 8 kembali didapatkan hasil yang berturut-turut signifikan dengan p<0,05 yaitu 0,031 dan 0,012. hal ini berarti ada pengaruh progressive muscle relaxation terhadap peningkatan pefr. . tabel 1. hasil analisis statistik data pefr penderita ppok pre dan post latihan pmr di poli spesialis paru rsud dr mohamad soewandhie surabaya periode mei-juni 2008. observasi rerata pre rerata post ∆ rerata post-pre hasil analisis statistik (paired t test) 1 121,25 122,50 1,25 0,351 2 126,25 131,25 5,00 0,104 3 121,25 128,13 6,88 0,064 4 118,75 129,38 10,63 0,065 5 128,75 145,00 16,25 0,042 6 140,00 150,00 10,00 0,121 7 133,75 158,75 25,00 0,031 8 131,25 167,50 36,25 0,012 keterangan: p = signifikansi ∆ = selisih rerata post dengan pre progresive muscle relaxation meningkatkan aliran ekspirasi maksimum (tintin s) 11 pembahasan hasil penelitian menujukkan bahwa terdapat peningkatan pefr yang cukup signifikan pada penderita ppok setelah diberikan latihan progressive muscle relaxation. pada observasi ke-1 hingga 4 nilai pefr belum menunjukkan hasil yang bermakna namun pada observasi ke-5, 7 dan 8 mulai didapatkan nilai pefr yang lebih tinggi daripada awal observasi meskipun masih jauh dibawah normal (440 l/menit) meskipun pada observasi ke-6 peningkatan kembali tidak menunjukkan hasil yang bermakna. penyempitan saluran napas secara progresif pada ppok, berperan terhadap peningkatan resistensi aliran udara, hiperinflasi pulmoner, dan ketidakseimbangan ventilasi dan perfusi (v/q) (stein, 2001). penyempitan ini akan menghambat aliran udara selama inspirasi dan ekspirasi. pada saat ekspirasi menyebabkan penurunan pertukaran aliran udara untuk mencegah kembalinya tekanan alveolar terhadap tekanan atmosfer sehingga menyebabkan hiperinflasi dinamik (sudoyo et al., 2006). besarnya hiperinflasi menurunkan kapasitas inspirasi, sehingga kapasitas residu fungsional meningkat dan aliran ekspirasi maksimum menurun (baratawidjaja, 2007). penurunan nilai aliran ekspirasi maksimum merupakan kompleks antara peningkatan kemampuan kolaps jalan napas intratoraks selama ekshalasi paksa, penurunan rekoil elastik paru dan penurunan kaliber jalan napas akibat traksi radikal pada jalan napas (weinberger dan drazen, 2000 dalam isselbacher et al, 2000). hiperinflasi juga berhubungan erat dengan peningkatan aktivitas otot-otot pernapasan (sudoyo et al, 2006). sebagai hasil faal paru, nilai aliran ekspirasi maksimum atau pefr dipengaruhi oleh berbagai faktor diantaranya usia, jenis kelamin, tinggi badan dan ras. faal paru, termasuk pefr akan meningkat dengan bertambahnya usia sampai titik optimal antara usia 20-30 tahun, setelah itu akan terjadi penurunan termasuk difusi paru, ventilasi paru dan ambilan oksigen. umumnya kapasitas faal paru laki-laki lebih besar dari perempuan (weinberger dan drazen, 2000 dalam isselbacher et al., 2000). pemakaian bronkodilator sebagai obat pilihan utama pada ppok mampu meningkatkan aliran udara dan menstimulasi aktivitas paru (smith, 1994). beberapa keadaan penyulit lain seperti hipersensitivitas bronkus, infeksi dan faktor lingkungan yang berperan dalam eksaserbasi akut ppok ikut menentukan nilai pefr. setiap terjadi eksaserbasi akut maka nilai faal paru akan lebih menurun, nilai ini tidak akan kembali ke nilai dasar setelah fase eksaserbasi dilewati (yunus, 1993). progressive muscle relaxation (pmr) terdiri atas diafragma breathing, pursed lips serta kontraksi relaksasi otot tubuh secara progresif. latihan otot-otot pernapasan dalam pmr mampu meningkatkan kekuatan otot pernapasan dan tekanan pada saat ekspirasi sampai sekitar 37% (suharto, 2000). diafragma breathing menurunkan konstriksi otot polos pernapasan, menyimpan energi dan memperbaiki ventilasi sampai basal paru (casabury and petty, 1993) sehingga terjadi peningkatan volume tidal, penurunan kapasitas residu fungsional dan peningkatan ambilan oksigen menjadi optimal. pursed lips mencegah air trapping dan kolaps saluran napas kecil saat ekspirasi, ini akan menurunkan volume residu dan meningkatkan kapasitas vital sehingga memperbaiki pertukaran gas di alveoli (mulyono, 1997). selain itu efek bronkodilatasi yang ditimbulkan oleh ketiga komponen dalam pmr akibat perangsangan serat-serat simpatis oleh epineprin yang dilepaskan medulla adrenal menyebabkan dilatasi pada batang bronkus sehingga dapat meningkatkan laju aliran udara maksimum dengan resistensi minimum (alsagaff dan mukty, 2006). peningkatan pefr disebabkan oleh gabungan diafragma breathing, pursed lips serta kontraksi relaksasi otot tubuh secara progresif. diafragma breathing menurunkan konstriksi otot pernapasan, memaksimalkan penggunaan otot diafragma sebagai otot pernapasan yang meningkatkan pengembangan toraks sehingga ambilan oksigen menjadi lebih optimal, pursed lips mencegah kolaps bronkiolus sehingga aliran ekspirasi lebih optimal serta efek bronkodilatasi yang ditimbulkan oleh ketiga komponen dalam pmr yang menurunkan resistensi saluran napas, dimana hasil akhirnya adalah terjadi peningkatan laju 72 jurnal ners vol.3 no.1 april 2008 : 8-13 12 aliran udara maksimum. pada observasi ke-1 hingga 4 belum didapatkan hasil yang bermakna. hal ini mungkin disebabkan karena responden masih dalam tahap adaptasi, dimana responden belum dapat melakukan pmr dengan benar bila tidak didampingi oleh peneliti. keadaan lingkungan yang tidak kondusif seperti bising, rumah yang terlalu sempit, pencahayaan yang kurang atau berlebihan serta tingkat kedisiplinan yang kurang dalam melakukan pmr akibat rendahnya motivasi bisa menghambat tercapainya hasil yang optimal daripada pmr. pada observasi ke-5, 7 dan 8 mulai terjadi peningkatan dengan hasil yang bermakna. hal ini mungkin disebabkan proses adaptasi mulai mencapai titik optimal, dimana responden sudah mampu melakukan pmr dengan benar serta meningkatnya motivasi setelah benar-benar memahami manfaat daripada pmr. perlu diperhitungkan juga pemakaian bronkodilator pada pasien ppok, dimana efek bronkodilatasi yang ditimbulkannya juga mampu meningkatkan aliran udara maksimum serta merangsang aktivitas paru. meskipun demikian, semua proses yang dapat menurunkan resistensi saluran napas termasuk pmr akan mampu meningkatkan setiap volume paru tertentu, termasuk pefr meskipun sangat kecil peningkatannya. pada observasi ke-6 peningkatan tidak menunjukkan hasil yang bermakna. hal ini mungkin disebabkan oleh beberapa faktor antara lain riwayat hipersensitivitas yang dimiliki oleh beberapa responden, terutama terhadap dingin dan debu. pada pertengahan penelitian sebanyak 3 orang responden sempat mengalami eksaserbasi akut, terlihat pada peningkatan keluhan sesak serta keadaan pasien saat itu. reaksi hipersensitivitas yang mungkin muncul saat itu bisa menjadi faktor pemicu menurunnya nilai pefr, bronkokonstriksi yang disebabkannya akan meningkatkan resistensi saluran napas sehingga makin memperburuk aliran udara. faktor lingkungan sekitar seperti polusi udara yang tinggi, dimana mayoritas rumah responden terletak dekat dengan jalan raya yang dilewati kendaraan padat setiap harinya yang dapat memicu respons jalan napas akut. kebersihan yang kurang terkait dengan perumahan kumuh bisa mencetuskan infeksi yang memicu terjadi eksaserbasi serta aktivitas merokok yang kadang masih dilakukan oleh beberapa responden. dengan demikian dapat dijelaskan mengapa pada observasi ke-6 peningkatan nilai pefr tidak menunjukkan hasil yang bermakna. simpulan dan saran simpulan latihan progressive muscle relaxation secara kontinyu meningkatkan pefr karena mampu menurunkan resistensi pada saluran nafas. saran berdasar hasil penelitian ini, peneliti menyarankan agar latihan napas progressive muscle relaxation hendaknya dilakukan secara kontinyu untuk mengurangi gangguan pernafasan dan meningkatkan kualitas hidup. selanjutnya, hasil penelitian dapat menjadi dasar penetapan standar operasional (sop) latihan napas active cycle of breathing di poli spesialis paru rsud dr mohamad soewandhie surabaya dan 3) penelitian lebih lanjut dapat dilakukan tentang pengaruh latihan pernapasan progressive muscle relaxation terhadap peningkatan fev1 dan mmfr . kepustakaan alsagaff dan mukty. 2006. dasar-dasar ilmu penyakit paru. surabaya: airlangga university press, hlm. 6789. amin. 2004. penyakit paru obstruksi kronik: polusi udara, rokok dan alfa-1-antitripsin. surabaya: airlangga university press, hlm. 7785. baratawidjaja. 2007. ethical digest: ppok semijurnal farmasi dan kedokteran, 37, 18-29. casabury and petty. 1993. principle and practise of pulmonary rehabilitation. philadelphia: wb. saunders, pp. 366372. gift, et al. 1997. relaxation to reduce dispnea and anxiety in copd patients. european journal respiratory, 10(7), 1581. greenberg. 2002. comprehensive stress management seventh edition. new 75 progresive muscle relaxation meningkatkan aliran ekspirasi maksimum (tintin s) 13 york: mc graw hill higher education inc., pp. 179-190. guyton dan hall. 1997. buku ajar fisiologi kedokteran. alih bahasa oleh irawati. jakarta: egc, hlm. 645-654. isselbacher, et al. 2000. horison prinsipprinsip ilmu penyakit dalam. alih bahasa oleh asdi a.h. jakarta: egc, hlm. 1347-1353. mangunnegoro. 2001. pedoman diagnosis dan penatalaksanaan ppok di indonesia. jakarta: balai penerbit fkui, hlm. 1-35. mulyono. 1997. rehabilitasi pada penderita penyakit paru obstruksi menahun. cermin dunia kedokteran, 114, 33-36. patel. 1989. the complete guide to stress management. london: vermillion, pp. 109-113. renfroe. 1992. effect of progressive relaxation on dyspnea and state anxiety in patients with chronic obstructive pulmonary disease. european journal respiratory, 17(4), 90-100. smith. 1994. coping with bronchitis and emphysema. london: seldon press, pp. 45-50. stein. 2001. panduan klinik ilmu penyakit dalam. alih bahasa oleh nugroho e. jakarta: egc, hlm. 281-321. sudoyo. 2006. buku ajar ilmu penyakit dalam. jakarta: pusat penerbitan departemen ilmu penyakit dalam fkui, hlm. 65-78. suharto. 2000. fisioterapi pada emfisema. cermin dunia kedokteran, 128, 22-24. suyono, et al. 2001. buku ajar ilmu penyakit dalam. jakarta: balai penerbit fkui, hlm. 796-797. yunus. 1997. penatalaksanaan bronkitis kronik. cermin dunia kedokteran, 122, 36-39. yunus. 1993. uji faal paru penyakit paru obstruktif. cermin dunia kedokteran, 84, 19-21. 86 87 178 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.7824 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research improving self-protection knowledge against sexual abuse by using dreall healthy and animation video adelia pradita, arie kusumaningrum and jum natosba nursing science study program, faculty of medicine sriwijaya university, south sumatera, indonesia abstract introduction: the number of child sexual abuse cases in indonesia are still high, including in ogan komering ilir regency, south sumatera. one of the preventive effort that can be practiced is teaching them about children selfprotection knowledge from sexual abuse through sexual education using appropriate methods and media, such as watching animated video and dreall healthy. the aim of this research was to determine difference in dreall healthy and animated video about sexual education toward children self-protection knowledge from sexual abuse. methods: this research was a quantitative study and use quasi experiment design with pretest-postest group. samples in this research were 40 children in dreall healthy group and 37 children in the animated video group, the samples were taken using purposive sampling technique. the data were collected by using questionnaire and data analysis was using paired t test and independent t test. results: this research showed that there was difference in children selfprotection knowledge from sexual abuse before and after sexual education with dreall healthy and animated video with p value 0.000 (α ≤0.05) and there was difference in children self-protection knowledge from sexual abuse between dreall healthy and animated video with p value 0.014 (α ≤0.05). conclusion: sexual education with dreall healthy is more effective to increase children self-protection knowledge because it can stimulate the children’s brain nerves so that their memory could be better. it was expected that parents, public health center staffs, and counselor in schools be able to provide sexual education as early as possible to the children. article history received: march 12, 2018 accepted: dec 18, 2018 keywords sexual education; sexual abuse; self-protection; dreall healthy; animated video contact jum natosba  jumnatosba_bayd@yahoo.co.id  nursing science study program, faculty of medicine sriwijaya university, south sumatera, indonesia cite this as: pradita, a., natosba, j., & kusumaningrum, a. (2018). improving self-protection knowledge against sexual abuse by using dreall healthy and animation video. jurnal ners, 13(2), 178-183. doi:http://dx.doi.org/10.20473/jn.v13i2.7824 introduction sexual violence is any act of coercion of sexual intercourse in a way that is unnatural and disliked by a child, coercion of sexual intercourse with another person for a specific commercial or purposeful purpose (maharani et al., 2015). based on data from the national children's alliance (nca) there was an increasement in the number of sexual violence cases against children from 2014 to 2016. in 2014 the number of sexual violence cases against children reached to 205,438 cases. in 2015 the number of sexual violence cases against children increased to 206,768 cases and in 2016 the number of cases increased to 215,425 cases (national children’s alliance, 2016). in indonesia, according to data from the national commission for child protection, it shows that in 2015, cases of violence against children increased by 2,898 reports, 62% of which were sexual crimes and many unreported incidents (research center of dpr ri expertise agency, 2016). based on the data of the regional child protection commission of indonesia, palembang, in the period of january to august 2016, had 20 cases of which were mostly cases of sexual violence against children, such as fornication and rape. based on the data from the south sumatera provincial women's empowerment and child protection agency, ogan komering ilir district is included in 10 districts with the highest number of cases of violence against women and children. five https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 179 districts with the number of cases of violence against women and other children are musi banyuasin district, empat lawang, banyuasin, pali and muara enim. based on data from the office of women empowerment and child protection of ogan komering ilir district, the number of cases of violence and sexual abuse in 2016, including child abuse, amounted to 24 cases. the role of the country in overcoming violence against children, including child sexual abuse in indonesia, is the establishment of the indonesian child protection commission, ratifying the convention on the rights of the child, formulating laws on child protection, and forming a child-friendly city (yarrini, 2014). in 2016, unicef collaborated with the world health organization (who) and other international partners to develop a technical package entitled 'inspire: seven strategies to end violence against children including sexual violence, which is implementation and enforcement of laws, norms and values, safe environments , parent and caregiver support, income and economic strengthening, response and support services, education and lifeskills (unicef, 2017). some efforts that have been made by the indonesian child protection commission (kpai) to prevent violence and sexual harassment of children are by forming the selaras program (save and protect children from sexual violence), establishing an integrated child protection system, and building a city that was worthy for children (erlinda, 2016). based on data from nugraha and wibisono (2016), the high number of sexual violence cases was due to the lack of public knowledge about what can be taught to children to prevent acts of sexual violence and parents still feel taboo in providing sexual education to children, so that children have not gotten knowledge about sexual violence and how to protect themselves from sexual violence. prevention of sexual violence in children can be done by building a defend mechanism to provide knowledge and appreciation of their valuable body parts through the early sexual education (erlinda, 2016). sexual education can be provided to the children in the form of knowledge of self-protection skills of the occurrence of sexual abuse (jatmikowati, angin, & ernawati, 2015). one study conducted by jatmikowati et al (2015) shows that the subject matter of early childhood sex education includes themes: (1) me and my body; (2) me and my clothes; (3) families and people around me; and (4) how to care for and keep the body. sex education can be done with an open attitude and in a relaxed atmosphere. in providing sexual education, methods and learning media need to be considered in order to achieve the goals of sexual education (iskandar, suhadi, & maryati, 2014). the choice of learning methods and media, including providing sexual education, is adjusted to the age of the child. learning methods and media that can be provided for early childhood are audio visual media such as animated videos and image media in the form of single images or images that are radiant or a set of images that are interconnected with one another (zaman & eliyawati, 2010). dreall healthy is a form of puzzle game designed with a background that specifically contains content about health. dreall healthy games can motivate and stimulate children's thinking patterns in applying health values contained in the game background (rezky & hardianto, 2012). in addition, puzzles are called educational games because in puzzle games there are educational elements which can train and improve children's memory, introduce children with various images, colors, and character’s forms that are loved by children (soraya & rohmah, 2012). animated video is one of the learning media that can be provided for early childhood (zaman & eliyawati, 2010). animated video is one of the methods and media that has been used in providing sexual education to children released by the ministry of women's education and child protection and supported by unicef in 2014 through youtube. the video contains information about how to protect children from violence and sexual abuse. the effectiveness of animated video media in health education has been proven in a study that stated that animated videos effectively improve children's knowledge (andriany, novita, & aqmaliya, 2016). animated videos and educational games are media and methods that can be used to provide learning and sexual education to children. however, in the implementation, both methods and media have not been maximally realized by the community where there was still lack of knowledge of the community about what can be taught to children in preventing acts of sexual violence so that people have less knowledge about what can be taught to children in preventing the occurrence of sexual violence acts (rilianti & ima, 2011; notoatmodjo, 2012). based on the above background, researchers were interested to conduct a research focusing on the difference between the use of dreall healthy and animation videos about sexual education towards child's self-protection knowledge from sexual abuse. the purpose of this study was to determine differences in dreall healthy and animated video about sexual education toward children selfprotection knowledge from sexual abuse. materials and methods this research was a quantitative research with quasi experiment design with pre-test and post-test group. the sample of this study were 77 respondents obtained from the population of 1-2 grade children (age 6-7 years old) that collected on 30 march 2017, with total number of 1692 children in kayuagung sub-district. the sampling technique used was purposive sampling with inclusion criteria, namely; those 1-2 graders of elementary school (age 6-7 years) who were physically and mentally healthy, willing to be research respondents, able to read, a. pradita et al. 180 | pissn: 1858-3598  eissn: 2502-5791 have not received sexual education or information about child's self-protection yet, originally from kayuagung, and interested in playing puzzles and watching animation videos according to their respective groups. this research was conducted at two elementary schools in kayuagung. the sample was divided into 2 groups; dreall healthy intervention group and animation video intervention group. the data collection tools used were questionnaire and observation sheet. questionnaire was consisted of open-ended questions. the questionnaire used was adapted from the research of jatmikowati et al., (2015), which was modified by researchers. the questionnaire contains material about (1) me and my body; (2) me and my clothes; (3) families and people around me; and (4) how to care for and keep the body. the questionnaire consisted of 25 questions that have been proven valid and reliable. the validity test was carried out by researchers in april 2017. validity test was using the pearson product moment test. validity test results showed that there were 25 valid questions with r arithmetic > r table (0.5760), and reliability test results showed that 25 questions were reliable with cronbach's alpha value 0.755 (> 0.6). the study was conducted in the classroom according to the intervention group in 1 day which was consisted of 2 sessions. session 1 for dreall healthy interventions. before intervention, researchers and assistants distributed pre-test sheets. researchers and assistants interviewed participants using a 20-minutes pre-test sheet. then intervening dreall healthy games for 28 minutes and ended with an interview process using a post-test sheets. session 1 was carried out for 80 minutes. next, session 2 is an animation video intervention. before intervention, researchers and assistants distributed pre-test sheets. researchers and assistants interviewed participants using a 20 minutes pre-test sheet. then the next intervention, watching the animated video, was held for 13 minutes and ended with the interview process using the post-test sheets. session 2 was conducted for 60 minutes. the data collection procedure started from performing administrative procedures in the form of research implementation permission and distribution of informed consent sheet to the respondents' parents. furthermore, researchers and research assistants undertook preparation phase, which was environmental preparation such as lighting and noise, places and respondents. data collection was conducted before and after the intervention was conducted, and the observation of the research was conducted during the intervention process. data analysis used was univariate and bivariate analysis. univariate analysis describes the characteristics of respondents, and bivariate analysis used paired t test and independent t test using spss 16 software. this research has been in accordance with the research standards and has meets ethical criteria consisting of informed consent, anonymity, confidentiality, beneficiary and justice. results the characteristics of respondents based on their sex, in the dreall healthy group there were 40 respondents, consisted of 52.5% female and 47.5% male, in the animated video group there were 37 respondents, consisted of 45.95% female and 54 , 05% of male. from both groups, there were 50,65% male respondents and 49,35% female respondents.. all respondents were 7 years old. all respondents came from kayuagung, ogan komering ilir. all of the respondents have not had any information and any experience of sexual education about child’s selfprotection knowledge against sexual violence. before the analysis was conducted, the researcher first performed the data distribution test by using normality test. the normality test in this study used the shapiro-wilk test, because the number of samples for each group was less than 50 samples (dahlan, 2014). normality test results showed the obtained p value in dreall healthy group during pre-test was 0.159, and at post-test was 0.066. in the animation video group, the p value of the pre-test value was 0.131, and the post-test was 0.107. thus, dreall healthy group data and animation video during pre-test and post-test were normally distributed (p value ≥0.05). the average score of children's self-protection knowledge against sexual abuse before given sexual education through dreall healthy was 18.32 (sd ± 1.607), and the mean score after given sexual education was 22.60 (sd ± 1.499) which means that there was a significant improvement in respondents' knowledge of self-protection after being given sexual education through dreall healthy (table 1). based on the statistical analysis, it was found that there was a significant difference in score of children's self-protection knowledge against sexual abuse before and after sexual education through dreall healthy with p value 0.000 (α ≤0.05). based on the observation data, the respondents who played while learning, in this case played the puzzle, were more interested and more excited in preparing the puzzle pieces. in addition, respondents were very enthusiastic and curious about the results of the arrangement of the puzzle; therefore, respondents were more focused in viewing and reading the contents of the puzzle (table 1). the average score of child's self-protection knowledge against sexual abuse was 18.76 (sd ± 1.754), and the mean score after given sexual education was 22.27 (sd ± 1.610) which also means that there was a significant improvement in respondents' knowledge after being given sexual education through video animation (table 1). jurnal ners http://e-journal.unair.ac.id/jners | 181 based on the statistical analysis, it is also known that there was a significant difference in score of children's self-protection knowledge against sexual abuse before and after sex education through animated video with p value 0.000 (α ≤0.05). based on observation data, children became very interested in watching animated videos, especially in the form of cartoons. video with colorful display, with cartoon pictures that the respondents liked, and accompanied by sound, made respondents became more interested in watching the animation video. therefore, the process of delivering information was more easily accepted by respondents (table 1). based on the table 2, it can be seen that the difference of the average score of child's selfprotection knowledge against sexual abuse with dreall healthy intervention was 4.28 (sd ± 1.320). meanwhile, the difference of the average score of child's self-protection against sexual abuse with the animation video intervention was 3.51 (sd ± 1.325). from the result of the statistical analysis, it can be concluded that there was a significant difference on child's self-protection knowledge against sexual abuse between those who were taught se education through the dreall healthy and through animation video with p value 0.014 (α ≤0.05). the difference of dreall healthy group average score was greater than that of animation videos groups. therefore, it can be concluded that dreall healthy is more effective in increasing the child's knowledge about selfprotection against sexual abuse. discussion the media play an important role in practice, policy, and public perception of child sexual abuse, in part by the way in which news stories are framed (weatherreda, 2015). based on research conducted by walsh, zwi, woolfenden, and shlonsky, (2015), it shows that school-based sexual harassment prevention programs using video media and game methods are effective in increasing participants' skills in protective behavior and knowledge about the concept of preventing sexual harassment. the result of statistical test with paired t-test shows that there was a significant improvement in respondents' knowledge after being given sexual education through dreall healthy. this is in accordance with the results of research conducted by hariyanto dan sumini (2016) which revealed that nutrition education by using the media of balanced nutrition 'tumpeng' puzzle in kindergarten managed to improve the child's knowledge about balanced nutrition. dreall healthy is a form of puzzle game, but with different pieces of puzzle pieces, that is hexagonal shape (rezky & hardianto, 2012). puzzle game is a form of educational game for elementary school age children called the skill game. proficiency games are all forms of games and activities that require proficiency in controlled hands and eyes use (dorothy, 1985, quoted by simon, hartati, and arsilah, (2007). based on the data from trisyana and reza (2013), by playing puzzles the child's thinking and cognitive abilities will increase because when playing puzzle children will train their brain cells to develop their thinking skills and concentrate on completing pieces of the puzzle. there was a significant difference in score of children's self-protection knowledge against sexual abuse before and after sexual education through dreall healthy. this result is supported by research conducted by nurvita (2014) which explains that the puzzle game can develop the cognitive aspects of children in which children will be more interested to learn and to understand the contents of the puzzle. based on observations, respondents who were playing while learning, in this case, playing puzzles will be more interested and more enthusiastic in compiling the puzzle pieces. in addition, respondents were very enthusiastic and curious about the results of the puzzle arrangement so that the respondents were more focused on seeing and reading the contents of the puzzle. the result of statistical test with paired t-test shows that there was a significant improvement in respondents' knowledge after being given sexual education through video animation because in the delivery of messages through video animation make use of the visual and table 1. differences in score of child's self-protection knowledge against sexual abuse before and after given sexual education through dreall healthy groups n mean sd min-max 95% ci t df p value lower upper dreall healthy pre-test 40 18.32 1.607 15.22 17.18 18.84 -20.480 39 0.000 post-test 22.60 1.499 19.25 22.12 23.08 animation video pre-test 37 18.76 1.754 15.22 19.17 19.34 -16.125 36 0.000 post-test 22.27 1.610 1925 21.73 22.81 table 2. differences in average score of child's self-protection knowledge against sexual abuse between dreall healthy and animation groups. variable intervention n mean sd p value knowledge dreall healthy 40 4.28 1.320 0.014 animation videos 37 3.51 1.325 a. pradita et al. 182 | pissn: 1858-3598  eissn: 2502-5791 audio aspects so as to make it easier in storing information (noviyanto, juanengsih, & rosyidatun, 2015). the colorful display of videos, using animated images and accompanied by sound make respondents more interested to watch the animated video shows so that the process of delivering information will be more easily accepted by respondents. this result is in accordance with a research conducted by andriany et al., (2016) with the results of research showing the increased knowledge about dental and oral health on respondents after given counseling through animation media. it is also known that there was a significant difference in score of children's self-protection knowledge against sexual abuse before and after sex education through animated video. this is in accordance with the statement of andriany et al., (2016) that the improvement of oral and dental health knowledge due to animated cartoon animation media is able to stimulate children's curiosity and their interest in what they learn, thus, the purpose of the counseling media can achieve optimal results. from the result of the statistical analysis, it can be concluded that there was a significant difference on child's self-protection knowledge against sexual abuse between those who were taught education through the dreall healthy and through animation video. the difference of dreall healthy group average score was greater than that of animation videos groups. therefore, it can be concluded that dreall healthy is more effective in increasing the child's knowledge about self-protection against sexual abuse. dreall healthy games gives an effect in improving child's self-protection knowledge against sexual abuse because puzzle games are more interesting and more fun, so children are more likely to receive the information given (hikmawati, yasnani, & sya’ban, 2016). this is supported by research conducted by riadi dan supriyono (2014). their results showed that puzzle media have successfully increased the students' learning outcomes in each cycle and have made the students' achieve their success indicators. video is one of the tools in giving or delivering messages (notoatmodjo, 2012). the use of animated video media in delivering health education messages makes it easier to store information on cognitive structures because of the presentation of information that utilizes visual and audio aspects. in accordance with the theory that was put forward by piaget about cognitive learning theory, information is more meaningful in student memory and stored in long term memory in the right brain, therefore presentation of information needs to utilize visual and audio aspects (noviyanto et al., 2015). the results of research conducted by lubis (2016) showed that the audio visual method is more effective in improving knowledge of child dental caries care in the area of wonosegoro ii community health center. based on the data from miftahusaadah, (2016), video were influential and useful in increasing knowledge about the selection of snack foods for students at sd 01 gayamdompo, karanganyar district, karanganyar regency. this statement is supported by the results of the sinor (2011) which states that animated cartoons are more effective in conveying messages of oral health education compared to conventional methods in students at the upper terengganu school. however, at the time of the animation video intervention in observation data, not all children could focus on the animation video because many things could make children distracted while watching the video. therefore, not all children were able to receive information from the video. this is supported by the theory from kustandi dan sutjipto (2013) which explained that, when the video was continuously played, not all children can follow the information conveyed through the video. both methods are equally attractive to children in receiving learning. according to the theory proposed khadijah (2016), one of the methods in developing children's cognitive side is the method of play, because learning that does not use game on it, has not yet been able to improve cognitive ability (olii, 2013). conclusion dreall healthy and animated video can enhance the knowledge of children’s self-protection from sexual abuse where dreall healthy is more effective than animated video. sexual education with dreall healthy is more effective to increase children self-protection knowledge because it can stimulate the children’s brain nerves so that their memory could be better. it was expected that parents, public health center staffs, and counselor in schools be able to provide sexual education as early as possible to the children. for further researchers, it is expected that further research can create more interesting media for children and can involve parents directly in providing sexual education to children so that parents can more easily convey sexual education information and not be taboo on sexual education to children. acknowledgement we thank to headmaster of sdn 1 and 17 kayuagung for licensing of research sites. references andriany, p., novita, c. f., & aqmaliya, s. (2016). perbandingan efektivitas media penyuluhan poster dan kartun animasi terhadap pengetahuan kesehatan gigi dan mulut. journal of syiah kuala destistry society, 1(1), 65–72. dahlan, m. s. (2014). statistik untuk kedokteran dan kesehatan. jakarta: epidemiologi indonesia. erlinda. (2016). upaya peningkatan perlindungan anak dari bahaya kekerasan, pelecehan dan eksploitasi. jakarta: komisi perlindungan anak indonesia. hariyanto, & sumini. (2016). pengaruh pendidikan gizi menggunakan media puzzle tumpeng gizi seimbang terhadap pengetahuan gizi anak taman kanak-kanak. sain med, 8(1), 26–31. hikmawati, z., yasnani, & sya’ban, a. r. (2016). jurnal ners http://e-journal.unair.ac.id/jners | 183 pengaruh penyuluhan dengan media promosi puzzle gizi terhadap perilaku gizi seimbang pada siswa kelas v di sd negeri 06 poasia kota kendari. universitas halu oleo. iskandar, h., suhadi, & maryati. (2014). pengaruh modelling media video cuci tangan terhadap kemampuan cuci tangan pada siswa kelas 4 di sd wonosari 02 mangkang semarang. jurnal ilmu keperawatan dan ilmu kebidanan. jatmikowati, t. e., angin, r., & ernawati. (2015). model dan materi pendidikan seks anak usia dini perspektif gender untuk menghindarkan sexual abuse. cakrawala pendidikan, 24(3). khadijah. (2016). perkembangan kognitif anak usia dini. medan: perdana publishing. kustandi, c., & sutjipto, b. (2013). media pembelajaran manual dan digital edisi kedua. bogor: ghalia indonesia. lubis, f. s. (2016). perbedaan pendidikan kesehatan menggunakan metode ceramah dan audio visual terhadap tingkat pengetahuan dan sikap perawatan karies gigi anak di wilayah puskesmas wonosegoro ii. universitas muhammadiyah surakarta. maharani, f. d., setia, f., ranadireksa, a., raharjo, f. d., simatupang, d. f., susilowati, a., & rosmiati. (2015). anak adalah anugerah: stop kekerasan terhadap anak. jakarta: kementerian komunikasi dan informasi republik indonesia. miftahusaadah. (2016). pengaruh pendidikan tentang makanan jajanan menggunakan media video digital terhadap pengetahuan siswa di sdn 01 gayamdompo kecamatan karanganyar kabupaten karanganyar. universitas muhammadiyah surakarta. national children’s alliance. (2016). nca national statistics statistical report 2016. retrieved january 30, 2016, from http://www.nationalchildrensalliance.org/ (accessed: october 22, 2017). notoatmodjo, s. (2012). promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta. noviyanto, t. s. h., juanengsih, n., & rosyidatun, e. s. (2015). penggunaan media video animasi sistem pernapasan manusia untuk meningkatkan hasil belajar biologi. edusains, 7(1). nugraha, b. d., & wibisono, s. (2016). adik bayi datang dari mana? jakarta: noura books. nurvita, f. (2014). permainan puzzle berpengaruh terhadap perkembangan kognitif pada anak usia dini di tk pertiwi karanglor, manyaran, wonogiri tahun pelajaran 2013/2014. universitas muhammadiyah surakarta. olii, h. u. (2013). meningkatkan kemampuan kognitif anak melalui alat permainan edukatif di tk sis aljufrii 1 tatura palu. universitas tadulako. pusat penelitian badan keahlian dpr ri. (2016). kondisi sosial ekonomi dan kekerasan seksual pada anak, viii(9). rezky, m., & hardianto, d. p. (2012). v-hasop (villages healthy school programmes by using dreall healthy): penanaman pendidikan kesehatan melalui permainan dreall healthy pada anak usia sekolah di pedesaan. padang. riadi, m. e., & supriyono. (2014). penggunaan media puzzle untuk meningkatkan hasil belajar siswa pada tema lingkungan kelas ii sdn jajartunggal iii surabaya. jpgsd, 2(2). simon, r., hartati, t., & arsilah. (2007). model permainan di sekolah dasar berdasarkan pendekatan dap (developmentally appropriate practice). universitas pendidikan indonesia, bandung. soraya, a., & rohmah, n. (2012). pengaruh pendidikan kesehatan dengan media puzzle terhadap kemampuan mencuci tangan pada anak usia sekolah (6-12) tahun di kecamatan jelbuk kabupaten jember. universitas muhammadiyah jember. unicef. (2017). preventing and responding to violences against children and adolescents: theory of change. new york: unicef. walsh, k., zwi, k., woolfenden, s., & shlonsky, a. (2015). school-based education programmes for the prevention of child sexual abuse. the cochrane collaboration, (4). https://doi.org/10.1002/14651858.cd004380.p ub3. weatherreda, j. l. (2015). child sexual abuse and the media: a literature review. journal of child sexual abuse, 24(1), 16–34. https://doi.org/10.1080/10538712.2015.97630 2 yarrini, d. s. (2014). peran negara dalam upaya mengatasi tindak kekerasan terhadap anak. universitas islam negeri syarif hidayatullah. zaman, b., & eliyawati, c. (2010). media pembelajaran anak usia dini. universitas pendidikan indonesia. http://www.nationalchildrensalliance.org/ pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru purwaningsih peer group support mengubah persepsi gelandangan dan pengemis (peer group support change perception of homeless and beggar) purwaningsih*, eka mishbahatul mar’ah has*, lailatun ni’mah* * fakultas keperawatan universitas airlangga surabaya kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: jurnalners.psik@gmail.com abstract introduction: homeless and beggar are social problem in our society. the reason of people who becomes homeless and beggar can be influenced by internal factors such as lazy to work, mental and physical illness. meanwhile, it also can be influenced by external factors, such as economy, geography, social, education, pshycology, culture and religion. the aimed of this study was to analyze the effect of peer group support to perception about the homeless and beggar. method: a quasy experimental two group pre-post test purposive sampling design was used in this study. the subjects were homeless and beggar which stay at lingkungan pondok sosial (liponsos) keputihsurabaya for at least three day. there were 16 respondent who met to the inclusion criteria which divided into two group (controlled and treatment). data were analyzed by using wilcoxon signed rank test and mann whitney u test with significance level α≤0.05. result: the result showed that controlled group has significance level p=0.109 and treatment group has significance level p=0.017, statistically by using mann whitney u test showed p=0.021. discussion: it can be concluded that peer group support can change the perception about the homeless and beggar who stayed at liponsos surabaya. peer group support can used continuously as social activity at liponsos. keywords: peer group support, homeless, beggar pendahuluan peningkatan jumlah gelandangan dan pengemis (gepeng) di daerah perkotaan merupakan masalah sosial yang sampai saat ini belum teratasi (sundariningsih, 2006). faktor internal penyebab terjadi gelandangan dan pengemis meliputi sifat malas bekerja dan kecacatan (baik fisik maupun psikis), serta faktor eksternal seperti kondisi ekonomi, tingkat pendidikan, faktor geografi, psikologis, kultural, kurangnya dukungan sosial, pengaruh lingkungan dan agama (national coalition for the homeless, 1999). peer group support merupakan sekelompok orang dengan latar belakang sama berkumpul secara teratur untuk saling mendukung, berdiskusi dan menyelesaikan masalah secara bersama (training in human rights and citizenship education council of europe, 1997). fakta yang ada sampai saat ini pengaruh peer group support terhadap persepsi tentang gelandangan dan pengemis belum diketahui. data dinas sosial kota surabaya mencatat bahwa jumlah gepeng di kabupaten surabaya mencapai 313 orang pada tahun 2006 dengan kecenderungan yang terus meningkat setiap tahun. berdasarkan data lingkungan pondok sosial (liponsos) keputih kota surabaya, pada tahun 2008 jumlah gepeng yang menghuni liponsos mencapai 175 orang selama bulan februari, 183 orang masing-masing selama bulan maret dan april. berdasarkan studi pendahuluan diketahui bahwa sekitar 2-19 orang gepeng terkena razia petugas ketertiban setiap hari selama bulan mei 2008. masalah gepeng perlu mendapat penanganan sedini mungkin baik secara konseptual dan pragmatik agar tidak membawa dampak negatif dan mengganggu stabilitas politik, ekonomi, sosial budaya, keamanan, dan ketertiban masyarakat, serta menimbulkan citra negatif terhadap upaya pembangunan nasional (siregar, 2003). berdasarkan prosedur penanganan masalah di liponsos keputih kota surabaya (2007), klien atau penyandang masalah mailto:jurnalners.psik@gmail.com jurnal ners vol.3 no.1 april 2008 : 77-80 kesejahteraan sosial (pmks) yaitu gepeng, pekerja seks, anak jalanan, gelandangan penderita psikotik terlantar yang terkena penertiban aparat, akan diidentifikasi dan ditempatkan di asrama untuk mendapatkan pelayanan sosial dasar, bimbingan dan seleksi keterampilan untuk melihat apakah gepeng tersebut dapat produktif atau tidak. menurut peraturan pemerintah no. 31 tahun 1980 tentang penanggulangan gelandangan dan pengemis bab ii pasal 2, penanggulangan gepeng dapat meliputi usaha preventif, represif dan rehabilitatif untuk mengurangi jumlah gepeng, mencegah pengaruh yang luas akibat gelandangan dan pengemis, mengembalikan gepeng ke masyarakat sehingga menjadi anggota masyarakat yang produktif, serta memungkinkan pengembangan gepeng untuk memiliki kembali kehidupan dan penghidupan yang layak sesuai dengan harkat dan martabat manusia. liponsos secara terpadu mengadakan kegiatan bimbingan dengan melibatkan dinkes, polwil, depag dan lsm. bimbingan yang diberikan untuk gepeng meliputi bimbingan sosial, bimbingan mental rohani dan bimbingan fisik. upaya penanganan terhadap pmks seringkali hanya berhenti pada pendekatan punitif represif yaitu sekedar melakukan razia untuk menangkap pmks, tetapi tidak ditindaklanjuti dengan upaya pembinaan yang efektif karena tempat penampungan dan pelatihan bagi yang terkena razia yang kurang memadai (soetrisno, 2001). berdasarkan hasil wawancara dengan kepala liponsos keputih kota surabaya pada tanggal 14 mei 2008, diketahui bahwa kegiatan bimbingan tidak dapat dilaksanakan secara kontinyu karena pelaksanaan penertiban yang tidak terjadwal dan jumlah penghuni yang melebihi daya tampung. perubahan persepsi terhadap pekerjaan menjadi gepeng dapat dipengaruhi oleh dukungan sosial. dukungan sosial meliputi pasangan (suami/istri), orang tua, anak, keluarga, teman, tim kesehatan, atasan dan konselor. dukungan sosial dapat berupa dukungan emosional, penghargaan, instrumental dan informasi. pelaksanaan peer group support diharapkan merubah persepsi gepeng sehingga mereka dapat menjadi anggota masyarakat yang produktif. berdasarkan uraian di atas, peneliti tertarik untuk mengetahui pengaruh peer group support terhadap persepsi gelandangan dan pengemis di liponsos keputih kota surabaya. bahan dan metode penelitian ini menggunakan desain penelitian quasy experimental two group prepost test. populasi adalah gepeng yang ditempatkan di liponsos keputih kota surabaya. besar sampel 6 orang yang diperoleh dengan teknik purposive sampling dan mengeliminasi gepeng yang menderita gangguan kejiwaan. sampel dibedakan menjadi dua kelompok, yaitu kelompok kontrol dan perlakuan di mana masingmasing kelompok terdiri atas 8 orang. variabel independen dalam penelitian ini adalah peer group support, sedangkan variabel dependen adalah persepsi gepeng di liponsos keputih kota surabaya pada bulan juni 2008 sampai dengan juli 2008. sebelum diberikan perlakuan, kedua kelompok dilakukan pra tes dengan memberikan kuisioner untuk mengetahui persepsi awal mereka tentang gepeng. kemudian pada kelompok perlakuan dilakukan intervensi berupa peer group support sesuai sak tiga kali pertemuan (selama dilakukan penempatan di liponsos). pertemuan pertama dilakukan diskusi mengenai pendapat diri tentang menjadi gepeng, pertemuan kedua berdiskusi mengenai alasan menjadi gepeng dan pertemuan ketiga dilakukan penyelesaian masalah yaitu tentang pendapat diri, alasan dan alternatif pekerjaan lain selain menjadi gepeng. pada kelompok kontrol diberikan intervensi rutin yang dilakukan di liponsos. di akhir pertemuan ketiga kedua kelompok dilakukan paska tes. instrumen yang digunakan dalam penelitian ini adalah satuan acara kegiatan (sak) peer group support dan kuisioner. data yang diperoleh dari dianalisis dan diteliti dengan menggunakan uji statistik wilcoxon signed rank test dan mann withney u test dengan derajat kemaknaan α≤0,05. hasil distribusi gepeng yang menjadi sampel pada kelompok perlakuan peer group support mengubah persepsi (purwaningsih) berdasarkan lama menjadi gepeng <1 tahun sebanyak 50%, 1-5 tahun sebanyak 25%, 510 tahun sebanyak 12,5% dan > 10 tahun 12,5%. distribusi gepeng berdasarkan frekuensi terkena penertiban 1-3 kali sebanyak 62,5%, 4-6 kali 37,5%, sementara distribusi gepeng yang menjadi sampel pada kelompok kontrol berdasarkan lama menjadi gepeng <1 tahun sebanyak 62,5%, 5-10 tahun sebanyak 25%, dan 1-5 tahun sebanyak 12,5%. distribusi gepeng berdasarkan frekuensi terkena penertiban 1-3 kali 50% dan 4-6 kali sebanyak 50%. pada tabel 1 dapat dilihat pengaruh peer group support terhadap perubahan persepsi gepeng. dari 8 responden pada kelompok perlakuan menunjukkan 75% memiliki persepsi positif untuk tidak lagi menjadi gepeng dan 25% masih memiliki persepsi negatif. persepsi tentang gepeng mengalami perubahan yang bermakna setelah dilakukan peer group support yang ditunjukkan dengan hasil analisis statistik wilcoxon signed rank test p=0,017. pada kelompok kontrol, dari 8 responden menunjukkan sebanyak 37,5% memiliki persepsi positif dan sebanyak 62,5% masih memiliki persepsi negatif. persepsi tentang gepeng tidak mengalami perubahan yang bermakna pada kelompok kontrol yang ditunjukkan dengan hasil analisis statistik wilcoxon signed rank test p=0,109. perbandingan perubahan persepsi tentang gelandangan dan pengemis antara kelompok perlakuan setelah diberikan peer group support dan kelompok kontrol, dapat disimpulkan bahwa terdapat pengaruh peer group support terhadap perubahan persepsi tentang gepeng yang ditunjukkan dengan hasil analisis statistik mann withney u-test p=0,021. pembahasan berdasarkan hasil penelitian tampak perbedaan yang signifikan pada persepsi tentang gepeng antara sebelum dan sesudah dilakukan peer group support pada kelompok perlakuan. hal ini dikarenakan dalam peer group support responden bisa bertemu secara kontinyu untuk berdiskusi dan bertukar pendapat dengan rekan sesama gepeng mengenai pendapat pribadi tentang gepeng sebagai pekerjaan, penyebab menjadi gepeng, serta pekerjaan lain yang bisa dilakukan selain menjadi gepeng secara bersama-sama. tahapan dalam peer group support seperti checking in, presentasi masalah, klarifikasi masalah, penyampaian berbagai usulan, perencanaan tindakan dan checking out (training in human rights and citizenship education council of europe, 1997) dilakukan dengan baik. hal ini memungkinkan individu untuk menerima masukan dari individu lain, menyeleksi rangsangan, mengorganisasikan, menafsirkan, memberi arti dan mengambil keputusan untuk merubah persepsi tentang gepeng. sejumlah kecil responden dalam kelompok perlakuan tidak mengalami perubahan persepsi tentang gepeng setelah dilakukan peer group support. menurut alkatsar (1984), salah satu faktor penyebab seseorang menjadi gepeng adalah karena kondisi atau keterbatasan fisik yang membuat seseorang tidak memungkinkan lagi untuk bekerja. responden yang cenderung tidak berubah persepsi adalah responden berusia lanjut. penurunan kondisi biologis, kesehatan, psikologis, spiritualitas dan ekonomi mengakibatkan lansia merasa tidak memiliki alternatif pekerjaan yang lain, selain menjadi gepeng. selain itu, usia dapat mempengaruhi kemampuan individu dalam mempersepsikan sesuatu (walgito, 2004). hasil penelitian menunjukkan terdapat beberapa responden dalam kelompok kontrol yang mengalami perubahan persepsi tentang gepeng tanpa dilakukan peer group support. persepsi dapat dipengaruhi oleh pengalaman individu mengenai sesuatu (walgito, 2003). responden dengan berbagai pengalaman yang tidak menyenangkan ketika terkena razia ketertiban dan ditangkap secara paksa oleh satpol pp (satuan polisi pamong praja) cenderung merubah persepsi tentang gepeng. selain itu, peraturan di liponsos yang menegaskan bahwa gepeng yang kembali terkena razia ketertiban akan ditempatkan lebih lama di penampungan juga menjadi stimulus bagi responden untuk merubah persepsi tentang gepeng sebagai pekerjaan. jurnal ners vol.3 no.1 april 2008 : 77-80 tabel 1. hasil analisis statistik persepsi tentang gelandangan dan pengemis sebelum dan sesudah dilakukan peer group support di lingkungan pondok sosial (liponsos) keputih surabaya juni-juli 2008. perlakuan kontrol perlakuan kontrol pre post pre post post post mean 35,5 42,25 34,625 35,375 42,25 35,375 sd 2,72554 5,70088 4,03 3,93 5,70088 3,93 hasil analisis statistik wilcoxon signed rank test (p=0,017) wilcoxon signed rank test (p=0,109) mann whitney u test (p=0,021) keterangan: mean = rerata sd = standar deviasi p = derajat kemaknaan kegiatan peer group support dapat diterapkan pada gepeng yang terkena penertiban aparat di samping pembinaan bimbingan sosial, bimbingan mental rohani dan bimbingan fisik yang sudah ada. kegiatan peer group support dapat diterapkan dengan adanya dukungan fasilitas yang ada dan sesuai dengan tahapan peer group yaitu cheking in, presentasi masalah, klarifikasi masalah, berbagi usulan, perencanaan tindakan dan cheking out dengan bantuan fasilitator petugas liponsos atau dari mantan gepeng yang sudah mendapatkan pekerjaan baru dengan taraf hidup yang lebih baik. simpulan dan saran simpulan kegiatan peer group support dapat merubah persepsi tentang gepeng di liponsos keputih kota surabaya tahun 2008. anggota peer group support dapat memperoleh informasi tentang alternatif pekerjaan lain selain menjadi gelandangan dan pengemis serta dapat mengembangkan hubungan sosial, sehingga gepeng mampu menjadi anggota masyarakat yang produktif setelah dikeluarkan dari liponsos keputih kota surabaya. saran kegiatan peer group support merupakan salah satu kegiatan pembinaan sosial yang dapat dilakukan untuk gepeng yang terkena penertiban sesuai dengan sak (satuan acara kegiatan). liponsos dapat menerapan kegiatan peer group support ini dengan mempersiapkan fasilitas pendukung yang sesuai dengan tahapan peer group. kepustakaan alkatsar. 1984. gelandangan dan pengemis di daerah rural. yogyakarta: pustaka pelajar, hlm. 27. national coalition for the homeless. 1999. homeless people, (online), (http://www.ncfh.org., diakses tanggal 14 maret 2008, jam 11.25 wib). lingkungan pondok sosial. 2007. prosedur penanganan masalah di liponsos keputih kota surabaya. surabaya: lingkungan pondok sosial, hlm. 7788. siregar. 2003. analisis sosial ekonomi gelandangan dan pengemis di kota medan dalam pelaksanaan otonomi daerah, (online), (http://www.library.usu.ac.id., diakses tanggal 24 april 2008, jam 10.25 wib). soetrisno. 2001. pemberdayaan masyarakat dan upaya pembebasan kemiskinan. yogyakarta: philosophy press, hlm. 5. training in human rights and citizenship education council of europe, 1997. peer group support, (online), (http://www.dadalos.org., diakses tanggal 11 maret 2008, jam 11.00 wib). walgito. 2004. pengantar psikologi umum, yogyakarta: andi, hlm. 2-4. walgito. 2003. psikologi sosial (suatu pengantar cetakan keempat. yogyakarta: c.v andi offset, hlm. 1618. http://www.ncfh.org/ http://www.library.usu.ac.id/ http://www.dadalos.org/ peer group support mengubah persepsi (purwaningsih) 153 a comparative study of nursing educational system in indonesia and japan susiana nugraha,* mika tanaka,** ferry efendi*** * member of indonesian national nursing association ** faculty of nursing fukuoka university, 8-19-1 nanakuma, jonan-ku, fukuoka 814-0180, japan, (tel) +81-92-871-6631 ***faculty of nursing airlangga university indonesia, jl. mulyorejo kampus c unair surabaya 60115 tel/fax: (031) 5913257 e-mail: fefendi@gmail.com abstract introduction: according to the economic partnership agreement (epa) between the indonesian and japanese governments, the japanese government plans to recruit indonesian nurses and caregivers to fulfill the demands of those positions at hospitals and health centres. however, to be a qualified worker in japan, one has to pass a national examination that is conducted by the minister of health, labor, and welfare for a license as a registered nurse within 3 or 4 years of working as a nurse or caregiver, respectively. method: having considered that matter, a comparative study of the background of educational systems in indonesia and japan is discussed in this paper, with particular reference to the diploma 3 nursing program. result: there is no specific difference between the indonesian and japanese nursing education systems. discussion: however, the current health condition of the countries remains the focus of the curricula where indonesian nursing education is focused on communicable disease and surgery nursing, whereas the japanese system focuses on gerontology and chronic disease nursing. in terms of the qualification method, japanese nurses should undertake a national board examination to be a qualified nurse. on the other hand, there is no national board examination for indonesian nurses. keywords: nursing education system, indonesia, japan introduction japan and indonesia have been working towards an economic partnership agreement (epa), a comprehensive bilateral economic agreement that will include liberalisation of trade in goods and services, as well as cooperation in the fields of investment, competition policies and people movement (purnama, 2007). as a part of the implementation of article 7 of the epa regarding the “people movement”, the japanese government plans to recruit approximately 400 nurses and 600 caregivers within a two-year-period (mofa, 2008). on 5 th august 2008, the first group of indonesian nurses arrived in japan (bnp2tki, 2008). having been trained for japanese language and introduced to japanese nursing systems for the first six months after arrival, they had to face a national nursing board examination (mofa, 2008). the examination was conducted in japanese, using japanese characters and chinese characters (kanji). furthermore, the nurses and caregivers have to pass a national test within three and four years respectively, as a requirement to continue working in japan (mofa, 2008). the agreement has opened up an opportunity for indonesian nurses to find a new labour market. indonesian nursing educational institutions graduate approximately 15,000 nurses annually (nursalam and efendi, 2008). however, due to inappropriate health care and worker distribution systems, the indonesian labour market can only accept a minimum number of nurses (suwandono et al., 2005). this agreement also brings some benefits to jurnal ners vol. 3 no. 2 oktober 2008-maret 2009: 153-159 154 indonesian nurses and caregivers i.e. they gain new experiences and learn different systems in the nursing profession. therefore, these experiences can be applied in indonesia or internationally, and the quality of indonesian nurses will be considered consequently. according to okamoto (1992), improvement in living standards among japanese people and increases in medical care usage have caused a rapidly aging population, decreased the death rate caused by tuberculosis for all age groups and other infectious disease and caused falls in mortality among infants, adolescents and young adults. increasing the numbers in an aging population means an increase in demands on medical care. the demand for nursing workers has outpaced the supplies, due to the development of medicines, increasing the numbers of beds and aging patients (kanai-pak et al., 2008). additionally, a number of nursing workers are required in various areas. implementation of long-term care insurance encourages the place for treating and rehabilitating patients with chronic illnesses to be shifted from hospitals to facilities for long-term care, home medical care and visiting nursing (sawada, 1997). having considered those conditions, through the epa agreement, the japanese government has opened the labour market for foreign nurses as stipulated in the memorandum of understanding (mofa, 2008). success of epa implementation will bring a lot of benefit for both countries and to achieve that objective, both indonesian nurses and japanese nurses need to understand each other. indonesia and japan have different backgrounds in terms of language and culture. this is a big challenge for both nurses while working in the same hospital, although they have the same background in nursing. in terms of nursing skill, there is no question of the nurse‟s skill. this is because the nurse has the same background in nursing education. and each country has its own caring character. this paper describes indonesian and japanese nursing educational backgrounds in order to figure out a general description of their educational systems. having comprehended the educational systems, the capability of nurses in terms of knowledge and skill in nursing would be known. the other advantage is to complementing their liability and majority while caring the patients. comparison of educational background would be the first step to knowing their competence and potential in the working field. in advance, this comparison will figured their majority and shortage in nursing knowledge. by understanding this condition, japanese and indonesian nurses will be able to have mutual charge on knowledge and experience in the working field. besides this, during the epa agreement for nurse recruitment, indonesian and japanese nurses will be better prepared for future recruitment. a comparative descriptive study was performed based on databases of published materials and electronic journals. this comparison focused on a curriculum that was stipulated by government law for a diploma 3 (d-3) degree of nursing education. result indonesian nursing in general, nursing educational institutions in indonesia consist of two kinds of educational path, i.e. undergraduate program (s-1) and diploma program (d-3), after completing a basic educational program at senior high school (figure 1). these nursing schools provide curricula as stipulated by the national education systems no. 20/2003 of the ministry of education, which adopted the recommendation from the indonesian nurses‟ national association. the number of nursing educational institutions in indonesia is 427 and 173 for d-3 and s-1 levels, respectively, while the average number of graduates is 12,810 and 3,460 for d-3 and s-1 levels, respectively (nursalam and efendi, 2008). figure 1. indonesian nursing educational path high school university level/bachelo r pre-employment test being a nurse nursing school/diploma a comparative study of nursing educational system (susiana nugraha, dkk.) 155 the curriculum for the s-1 program consists of academic and professional phases. having completed the academic phase in 8 semesters, students are required to conduct research that will be examined at the end of the academic phase for a bachelor degree. furthermore, they have to continue to the professional phase for two semesters in order to get a ners degree. in this phase, students have to conduct nursing practices in a hospital under supervision in 9 divisions of nursing science, i.e. nursing management, emergency nursing, maternity nursing, medical surgical nursing, mental health nursing, pediatric nursing, family nursing, community nursing and geriatric nursing. on the other hand, the curriculum of d-3 also consists of the academic phase and the professional phase which can be fulfilled in 6 semesters, but in contrast to the s-1 program, both of the phases are integrated. at the end of each semester of academic activities, students are required to continue directly to nursing practices in hospitals under close supervision. the nursing practices from semester 1 to 4 are fulfilled by simple nursing practices, such as taking temperatures or measuring the blood pressure of patients. afterwards, for the whole of semesters 5 and 6, students are required to conduct comprehensive practices (nursalam and efendi, 2008). these educational institutions provide curricula for the applicable qualifications as stipulated by law. according to decree of the ministry of national education no. 139/u/1999, the d-3 program has 96 credits and consists of class lectures, laboratory practices and clinical training with a duration of over 4,800 hours (table 1) (nursalam and efendi, 2008). the nursing school curriculum guidelines stipulate the range of class hours per credit i.e. 18 hours for lectures, 36 hours for experiment and skill practices and 72 hours for clinical training. instead of the above curriculum, each institution has to apply some local curricula which are decided by each institution for 14–24 credits. each institution determines class hour equivalents to a credit (ministry of education and culture, 1999). having graduated from nursing school, one is qualified to work as a nurse in a hospital as a professional nurse. table 1. indonesian national curriculum for d-3 program group lectures subject credits total general lecture religion citizenship general ethics the five basic principal of the republic of indonesia 2 2 2 2 8 basic skill lecture anatomy physiology and biochemistry nutrition microbiology and paracytology pharmacology pathology 2 2 2 2 2 2 12 skill lecture and clinical training fundamentals of nursing basic human needs nursing ethics communication in nursing health promotion nursing documentation medical surgical nursing pediatric nursing maternity nursing mental nursing community nursing emergency family nursing emergency nursing geriatric nursing professional nursing management and leadership in nursing nursing research 4 8 2 2 2 2 17 6 5 5 9 3 3 2 2 2 2 76 total 96 nurses who graduate from bachelor of nursing programs are called professional nurses and nurses who graduate from diploma iii in nursing are called beginner professional nurses. a professional nurse is a person who passes the higher level of accredited education. the beginner professional nurse is a nurse who has good knowledge of intellectual, technical, interpersonal and moral, responsibilities in delivering nursing services based on valid regulations. currently, there is no national board examination for nursing qualifications in indonesia. the indonesian government and indonesian nurse association are working towards creating a national standardisation for nurses (hennessy et al., 2006). however, the current valid system is based on the regulation of decree of the ferry efendi jurnal ners vol. 3 no. 2 oktober 2008-maret 2009: 153-159 156 ministry of health no. 1239/2001 about nurse registration and practice. having graduated from nursing school (d-3 and s-1 programs), a student should apply for a nursing permit (surat ijin perawat) to the local government at least one month after graduation (ministry of health, 2001). since they hold the nursing permit, they can apply to work in the hospital or other health care centres. in addition, each hospital has its own standard for accepting a nurse. in general, nurses have to pass the hospital preemployment examination – a written and clinical practice test. having been accepted as an employee of a hospital or health care centre, the nurse should apply for a working permit (surat izin kerja) which is published according to the results of skill and knowledge assessments and compliance with nursing ethics. japanese nursing rapid growth in nursing at university level has contributed to the development of a nursing profession in japan (turale et al., 2008, turale et al., 2009). there are several educational institutions for becoming professional nurses in japan. for registered nurses, the basic route would be to complete senior high school, after that, study at a nursing university (four-year bachelor degree course), junior nursing college (three-year associate degree course) or nursing school (three-year course) (figure 2). besides a registered nurse, there is a two-year course for a nurse assistant. figure 2. japanese nursing educational path a nurse assistant is defined as a nurse engaged in providing nursing care under instruction from medical doctors or registered nurses (turale et al., 2008). in addition 6-month (normally one year) education is prepared in nursing schools and universities for public health nurses and midwives. students who graduate from these educational institutions are entitled to take the examination to become a registered nurse. in 2006, the numbers of nursing educational institutions in japan were 158 for universities, 37 for junior colleges and 512 for nursing schools. 11,906 or 32.7% of nurses graduated from universities, whereas 1,982 or 5.4% of nurses were from junior college and 22,549 or 61.9% were from nursing school. this part is focused on the curriculum for a registered nurse. the educational institutions provide curricula for the applicable qualifications as stipulated by law. the credits required to be entitled to take the governmental examination are 97 units for a registered nurse (in 2009, the public health nurse, midwife and nurse regulations were revised in credits for the enrichment of nursing skills and the ability to deal with nursing ethics, nursing administration and residential nursing in nursing students). the duration of the curricula is three years (over 3,000 hours of lectures and clinical training). each institution determines class hour equivalent to a credit. the nursing school curriculum guidelines stipulate the range of class hours per credit i.e. 15–30 hours for lectures, 30–45 hours for experiment and skill practices and 45 hours for clinical training (japanese nursing association, 2008). as shown in table 2, the total credits for the diploma three are 97 credits. a registered nurse is qualified as a professional nurse by government examination. having graduated from an educational institution that provides a curriculum for the applicable qualifications, graduates are entitled to take the governmental examination that was conducted by the minister of health, labor, and welfare, for a license as a registered nurse (japanese nursing association, 2008, mhlw, 1984) high school junior college university/ bachelor registered nurse national board examination work as a registered nurse nursing school/diploma a comparative study of nursing educational system (susiana nugraha, dkk.) 157 table 2. japanese national curriculum for d3 program . the national examination for registered nurses consists of essential questions (30 items), general questions (150 items) and questions concerning certain clinical cases (60 items). questions concerning clinical cases evaluate the ability of the nurse to understand and judge the situations which nurses would meet in hospital. information about the patient such as symptoms, physical and mental condition, age, sex and sociological background are given to answer the questions. areas of questions are the structure and function of the human body (anatomy, physiology, biochemistry, nutritional science), disease mechanisms and recovery promotion (pathology, pharmacology, microbiology), social security systems and people‟s health (public health, social welfare, related laws), fundamental nursing, residential nursing, adult nursing, geriatric nursing, pediatric health nursing, maternal nursing and mental health nursing. all items in the examination are multiple-choice (japanese nursing association, 2008). students are required to get a score over a pass standard. essential questions must be correctly answered in order to pass, otherwise in the case of errors in these questions the student will fail the examination. the examination pass rates were 90.6% in 2007 and 90.3% in 2008. discussion in terms of educational paths, there is no specific difference between indonesian and japanese nursing educational systems, as shown on table 3. the basic difference is in the method of qualification for nurses. japanese nurses have to undertake a national board examination to become a qualified nurse, whereas there is no national board examination for indonesian nurses. in addition, current health conditions in the countries remains the focus of each curriculum. indonesian nursing education focuses on communicable disease and surgery nursing, whereas the japanese education focuses on gerontology and chronic disease nursing. table 3. nursing educational background in japan and indonesia for d-3 program aspect indonesia japan content of curricula majority in medical surgical nursing majority in geriatric nursing and adult nursing qualificati on method no national board examination. the capability to work selected based on hospital preemployee examination. capability to work selected by the nursing national board examination. hospitals conduct an employment test to hire registered nurses. contents of the test written and clinical practice test written test midwife and public health nurse course separately given in different institution for minimum three year course. given after completing the nursing course for minimum of six months. group lectures subject credits total general lecture introduction to scientific approach understanding humans and human living society 13 13 basic skill lecture structure and functions of the human body disease mechanisms and recovery promotion social security systems and people‟s health 15 6 21 skill lecture and clinical training basic nursing adult health nursing geriatric nursing pediatric health nursing maternal nursing mental health nursing home health nursing integrated nursing and practice clinical training basic nursing adult health nursing geriatric nursing child health nursing maternal nursing mental health nursing home health nursing integrated nursing and practice 10 6 4 4 4 4 4 4 3 6 4 2 2 2 2 2 63 total 97 jurnal ners vol. 3 no. 2 oktober 2008-maret 2009: 153-159 158 to be qualified as a nurse in japan, indonesian nurses also have to pass a japanese nursing national board examination, which is held once a year at the end of february (japanese nursing association, 2008). upon arrival nurses and caregivers are taught the japanese language and introduced to japanese nursing systems for six months (mofa, 2008). for the first period of arrival in the middle of august, the nurse has three chances at the examination and finishes in the middle of february (clinder, 2008). the probability of indonesian nurses passing at the first chance of examination would be questionable, since they have no special preparation in the japanese language and japanese nursing systems before coming to japan. japanese people very much respect the psychological condition of the patients and japanese nurses always pay special attention to their psychological condition (japanese nursing association, 2008). therefore, intensive learning of the japanese language, culture and japanese nursing systems in the working field would be an important point to help indonesian nurses pass the nursing examination and be accepted for work as a real nurse. consequently, a regulation from the japanese government is needed for the hospitals which recruit foreign nurses to achieve this purpose. people believe it is unreasonable to insist that indonesian nurses take exactly the same examination that japanese nurses do and such a strict requirement could cause a lot of valuable workers to be simply thrown away (clinder, 2008). however, based on the long-term experiences of sending nurses abroad, most indonesian nurses have been acknowledged by receiving countries to have good personalities, such as being kind, having sympathetic attitudes for patients and being likely to have a good relationship with the patients and this, in turn, supports their job effectively. these conditions were believed to allow indonesian nurses to survive against the language barriers and differences in nursing systems. conclusion this paper describes insights about nursing education and the nursing systems of indonesia and japan. nevertheless, the illustration is only given in general; further research would be needed to describe it in detail. comprehension of educational backgrounds of nursing and the nursing systems of both countries will enhance the relationship between nurses from indonesia and japan references bnp2tki. 2008. bnp2tki membuka lowongan kerja ke jepang [online]. jakarta: bnp2tki. available: http://www.bnp2tki.go.id/read/89 94/bnp2tki-membukalowongan-kerja-ke-jepang.html [accessed december 26 2008]. clinder, j. 2008. indonesian nurse head to japan [online]. tokyo: japanprobe. available: http://www.japanprobe.com/?p=5 582 [accessed march 20 2008]. hennessy, d., hicks, c., hilan, a. & kawonal, y. 2006. the training and development needs of nurses in indonesia: paper 3 of 3. human resources for health, 4, 10. japanese nursing association. 2008. nursing in japan: nursing education in japan [online]. tokyo: japanese nursing association. available: http://www.nurse.or.jp/jna/english /nursing/education.html [accessed april 3 2008]. kanai-pak, m., aiken, l. h., sloane, d. m. & poghosyan, l. 2008. poor work environments and nurse inexperience are associated with burnout, job dissatisfaction and quality deficits in japanese hospitals. journal of clinical nursing, 17, 3324-3329. mhlw 1984. act on public health nurses, midwives, and nurses. in: (mhlw), m. o. h. a. l. w. http://www.bnp2tki.go.id/read/8994/bnp2tki-membuka-lowongan-kerja-ke-jepang.html http://www.bnp2tki.go.id/read/8994/bnp2tki-membuka-lowongan-kerja-ke-jepang.html http://www.bnp2tki.go.id/read/8994/bnp2tki-membuka-lowongan-kerja-ke-jepang.html http://www.japanprobe.com/?p=5582 http://www.japanprobe.com/?p=5582 http://www.nurse.or.jp/jna/english/nursing/education.html http://www.nurse.or.jp/jna/english/nursing/education.html a comparative study of nursing educational system (susiana nugraha, dkk.) 153 (ed.). japan: ministry of health and labour welfare (mhlw). ministry of education and culture 1999. permen no. 23/u/1999: kurikulum nasional program diploma iii keperawatan. jakarta: kemendikbud. ministry of health 2001. permen no. 1239/menkes/sk/xi/2001: nursing registration and practice. jakarta: departemen kesehatan. mofa 2008. memorandum of understanding between the national board for the placement and protection of indonesian overseas workers and the japan international corporation of welfare services on the deployment and acceptance of indonesian candidates for "kangoshi", indonesian candidates for "kaigofukushishi", indonesia "kangoshi" and indonesian "kaigofukushishi". in: kemlu (ed.). jakarta: kementerian luar negeri. nursalam & efendi, f. 2008. pendidikan dalam keperawatan [education in nursing], jakarta, salemba medika. okamoto, y. 1992. health care for the elderly in japan: medicine and welfare in an aging society facing a crisis in long term care. bmj: british medical journal, 305, 403. purnama, w. 2007. pertemuan tahap finalisasi indonesia-japan economic partnership agreement (ij-epa) tokyo, jepang, 21 antara news [online]. jakarta: antara news. available: http://www.antaranews.com/berit a/68607/pertemuan-tahapfinalisasi-indonesia-japaneconomic-partnership-agreementij-epa-tokyo-jepang-21 [accessed june 2 2008]. sawada, a. 1997. the nurse shortage problem in japan. nursing ethics, 4, 245-252. suwandono, a., muharso, m., achadi, a. & aryastami, k. 2005. human resources on health (hrh) for foreign countries: a case of nurse „surplus‟ in indonesia. asia pacific action alliance of human resources for health. srilanka: aaah. turale, s., ito, m., murakami, k. & nakao, f. 2009. nursing scholarship in japan: development, facilitators, and barriers. nursing and health sciences, 11, 166-173. turale, s., ito, m. & nakao, f. 2008. issues and challenges in nursing and nursing education in japan. nurse education in practice, 8, 1-4. http://www.antaranews.com/berita/68607/pertemuan-tahap-finalisasi-indonesia-japan-economic-partnership-agreement-ij-epa-tokyo-jepang-21 http://www.antaranews.com/berita/68607/pertemuan-tahap-finalisasi-indonesia-japan-economic-partnership-agreement-ij-epa-tokyo-jepang-21 http://www.antaranews.com/berita/68607/pertemuan-tahap-finalisasi-indonesia-japan-economic-partnership-agreement-ij-epa-tokyo-jepang-21 http://www.antaranews.com/berita/68607/pertemuan-tahap-finalisasi-indonesia-japan-economic-partnership-agreement-ij-epa-tokyo-jepang-21 http://www.antaranews.com/berita/68607/pertemuan-tahap-finalisasi-indonesia-japan-economic-partnership-agreement-ij-epa-tokyo-jepang-21 hubungan faktor risiko asma dan perilaku pencegahan 197 perbandingan penghitungan kebutuhan tenaga keperawatan berdasarkan metode douglas dan time and motion study (comparison of nursing staff calculation based on the time and motion study and douglas method) purwaningsih*, khoridatul bahiyah*, margaretha kewa lamak* abstract introduction: the increase of the quality of service requires human resource with good quality and quantity. in health service, nursing staff need can be calculated by using many methods, such as gillies method, ratio method, nursing workshop method, thailand and philippine method, nina method, and douglas method. besides those six methods, nursing staff need can be calculated by calculating worktime and workload. this method is called time and motion study. douglas method is used to calculate nursing staff need at irna bedah a dr. soetomo hospital. the objective of this study was to compare the calculation of nursing staff need using douglas method and time and motion study. method: this study used descriptive design with observational approach. samples, taken by total sampling, were 12 nurses at irna bedah a dr. soetomo hospital for time and motion study and all patients at irna bedah a. data for douglas method were collected by using classification of patient’s dependence into 3 categories, i.e; self care, partial care, and total care. data for time and motion study were collected by using observation of nurse’s activities and calculate nurse’s worktime and nurse’s workload. the results showed that according to douglas method, irna bedah a needed 16 nurses, and according to time and motion study, irna bedah a needed 14 nurses. the mean of patient’s dependence in one week was 13 patients with self care, 3 patients with partial care, and 4 patients with total care. result: total productive time of the nurses at irna bedah a was 3.83 hours in the morning, 2.37 hours in the afternoon, and 5.25 hours at night. nurse’s workload at irna bedah a was 34.62%. analysis: it can be concluded that calculation by using method douglas shows that irna bedah a needs more nurses compared with calculation by using time and motion study. discussion: time and motion study is more effective than douglas method to calculate nursing staff need. most patients at irna bedah a is self care. most nurse’s activity at irna bedah a is non-productive activity. most of the nurse’s activities at irna bedah a have done based on the standard of procedure. nurse’s workload at irna bedah a is underload. keywords: nursing staff need, douglas method, time and motion study * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: purwaningsih_ners@unair.ac.id pendahuluan kegiatan pelayanan keperawatan bergantung pada kualitas dan kuantitas perawat yang bertugas selama 24 jam di bangsal. diperlukan dukungan sumber daya manusia yang mampu mengemban tugas dan mengadakan perubahan untuk meningkatkan mutu pelayanan,. perencanaan baik jumlah dan klasifikasi tenaga kerja, serta pendayagunaan tenaga kerja sesuai dengan sistem pengelolaan sangat dibutuhkan dalam pelayanan. yang ada (suarli, 2008). perencanaan tenaga merupakan salah satu fungsi utama seorang pemimpin organisasi, termasuk organisasi keperawatan, keberhasilan suatu organisasi salah satunya ditentukan oleh kualitas sumber daya manusianya. hal ini berhubungan erat dengan bagaimana seorang pemimpin merencanakan ketenagaan di unit kerjanya (arwani, 2005). faktor ketenagaan keperawatan harus dipertimbangkan, meliputi jenis tenaga berdasarkan kemampuan dan jumlah tenaga keperawatan untuk dapat melakukan praktik keperawatan profesional, (sitorus, 2006). perencanaan sumber daya manusia (psdm) atau human resources planning merupakan fungsi pertama dan utama dari manajemen jurnal ners vol. 4 no. 2: 197-202 198 sumber daya manusia (msdm). tanpa rencana , kontrol tidak dapat dilakukan, dan tanpa kontrol, pelaksanaan rencana baik atau tidak, tidak dapat diketahui (hasibuan, 2008). kekurangan tenaga perawat di dalam negeri merupakan alasan utama suatu negara menerima tenaga dari luar negeri. di as, misalnya, pada 2005 mengalami kekurangan 150.000 perawat, pada 2010 jumlah tersebut diperkirakan menjadi 275.000, pada 2015 sejumlah 507.000, dan pada 2020 diperkirakan mencapai 808.000 perawat (hapsari, 2006). penghitungan kebutuhan personel yang tepat, akan lebih mudah melakukan koordinasi, mempermudah pekerjaan, terhindar dari kekurangan atau kelebihan tenaga, serta menciptakan efektivitas dan efisiensi kerja. kekurangan tenaga dapat menyebabkan kejengkelan, ketidakpastian dan kebingungan pada tenaga keperawatan. beberapa metode yang dapat digunakan untuk menghitung kebutuhan tenaga keperawatan yaitu metode gillies, metode rasio, metode lokakarya keperawatan, metode thailand dan filipina, metode nina, dan metode douglas. penghitungan kebutuhan tenaga keperawatan dapat juga dilakukan berdasarkan penggunaan waktu kerja dan beban kerja yaitu dengan time and motion study. peneliti memilih ruang irna bedah a rsud dr. soetomo karena menurut para perawat di ruang irna bedah a, ruangan ini mengalami kekurangan tenaga keperawatan sehingga belum mampu untuk melakukan model asuhan keperawatan profesional (makp). ruang irna bedah a rsud dr. soetomo memiliki tenaga keperawatan sebanyak 15 orang yang terdiri dari seorang kepala ruangan, wakil kepala ruangan, dan tigabelas orang perawat. kapasitas ruangan ini sebesar 38 pasien dan ruang irna bedah a memiliki spesifikasi yang tidak dimiliki oleh ruang bedah lain yaitu ruang irna bedah a dibagi menjadi tiga ruangan yaitu ruangan elektif, upi umum, dan upi torak. ruang elektif berisi pasien dengan kasus bedah antara lain bedah orthopedi, onkologi, kasus digestif anak dan dewasa, urologi, bedah plastik, dan lain-lain yang masih dalam rencana operasi. sedangkan upi umum berisi pasien anak dan dewasa post operasi dengan kasus bedah. sedangkan upi torak berisi pasien anak dan dewasa dengan kasus jantung. pada penelitian ini akan membandingkan hasil penghitungan kebutuhan tenaga keperawatan berdasarkan metode douglas dan time and motion study di ruang irna bedah a rsud dr. soetomo karena perawat di ruang irna bedah a rsud dr. soetomo menggunakan metode douglas untuk menentukan kebutuhan tenaga perawat. selain itu, kepala ruang irna bedah a juga menuturkan bahwa ruang irna bedah a hanya mengetahui beberapa metode saja untuk menghitung kebutuhan tenaga perawat. maka dari itu peneliti ingin membandingkan hasil penghitungan kebutuhan tenaga keperawatan dengan metode yang lain yaitu time and motion study yang lebih sering digunakan untuk menghitung kebutuhan tenaga kerja di industri manufaktur. kedua metode ini samasama dapat digunakan untuk menghitung kebutuhan tenaga keperawatan. namun kedua metode ini memiliki perbedaan yaitu metode douglas digunakan untuk menghitung kebutuhan tenaga keperawatan berdasarkan tingkat ketergantungan pasien yaitu self care, partial care, dan total care, sedangkan time and motion study digunakan untuk menghitung kebutuhan tenaga keperawatan berdasarkan penggunaan waktu kerja untuk melakukan kegiatan produktif (kegiatan langsung, kegiatan tak langsung, dan pengajaran kesehatan) dan kegiatan nonproduktif (kegiatan pribadi dan sela waktu). peneliti berharap dengan dilakukannya penelitian ini, maka dapat menjadi bahan pertimbangan dalam menentukan kebutuhan tenaga keperawatan yang tepat. bahan dan metode penelitian penelitian ini merupakan penelitian deskriptif melalui pendekatan observasional yaitu peneliti menjelaskan penggunaan waktu oleh tenaga keperawatan di ruang irna bedah a rsud dr. soetomo dengan mengobservasi kegiatan tenaga keperawatan di ruang irna bedah a rsud dr. soetomo yang meliputi kegiatan produktif (kegiatan langsung, kegiatan tak langsung, dan pengajaran kesehatan) dan kegiatan non-produktif (kegiatan pribadi dan sela waktu) selama shift pagi, sore, dan malam. populasi dalam penelitian ini adalah semua pasien yang dirawat dan perawat pelaksana yang bertugas pada shift pagi, sore, dan malam di ruang irna bedah a rsud dr. perhitungan kebutuhan tenaga keperawatan (purwaningsih) 199 soetomo. teknik sampling yang digunakan total sampling yaitu dengan memakai seluruh populasi dalam pelaksanaan penelitian. peneliti menggunakan dua macam instrumen yaitu lembar klasifikasi pasien dan lembar daftar kegiatan perawat. terdiri dari self care, partial care dan total care. kegiatan perawat dibedakan menjadi kegiatan produktif dan non produktif. hasil penelitian berdasarkan pengamatan peneliti selama 1 minggu, pasien di ruang irna bedah a sebagian besar memiliki tingkat ketergantungan self care dan dirawat di ruang elektif. pasien di ruang elektif sebagian besar merupakan pasien yang sedang menunggu acara operasi dan tindakan keperawatan yang dilakukan di ruangan ini antara lain injeksi per bolus, hanya beberapa pasien menjalani pengobatan kemoterapi dan terpasang infus. pasien dengan tingkat ketergantungan self care membutuhkan perawatan 1-2 jam per hari dan masih bisa melakukan kegiatan pribadi, kecuali minum obat harus tetap ditunggui, agar tidak salah obat. pasien masih bisa mandi sendiri, makan sendiri atau melakukan kebutuhan pribadi lainnya, jadi tak terlalu banyak waktu yang dibutuhkan untuk melayaninya. hasil penelitian menunjukkan bahwa pada shift pagi, sore, dan malam, kegiatan perawat lebih banyak pada kegiatan nonproduktif daripada kegiatan produktif yang hanya 34,62%. penghitungan kebutuhan tenaga keperawatan berdasarkan metode douglas di ruang irna bedah a rsud dr. soetomo dilakukan dengan mengategorikan pasien berdasarkan tingkat ketergantungan self care, partial care, dan total care per hari selama 7 hari kemudian dihitung rata-rata jumlah tenaga keperawatan yang dibutuhkan. hasil yang diperoleh jumlah kebutuhan tenaga perawat adalah sebanyak 16 orang. penghitungan kebutuhan tenaga keperawatan di irna bedah a rsud dr. soetomo dengan metode time and motion study didasarkan pada kegiatan perawat selama shift pagi, sore dan malam. kegiatan tersebut meliputi kegiatan produktif yaitu kegiatan langsung, kegiatan tak langsung dan pengajaran kesehatan. kegiatan non-produktif yaitu kegiatan pribadi dan sela waktu pada shift pagi, sore, dan malam. hasil yang didapat, ruang irna bedah a membutuhkan 14 orang tenaga perawat agar mencapai beban kerja ideal yaitu 80%. pembahasan metode douglas merupakan salah satu cara penghitungan kebutuhan tenaga keperawatan dengan mengklasifikasikan pasien berdasarkan tingkat ketergantungan self care, partial care, dan total care. sistem klasifikasi pasien ini berdasarkan pada jumlah dan kompleksitas syarat perawatan pasien. pasien dikelompokkan sesuai dengan ketergantungan mereka pada pemberi perawatan atau sesuai dengan waktu pemberian perawatan dan kemampuan yang diperlukan untuk memberikan perawatan. dengan hanya mengetahui diagnosa suatu kelompok pasien tidak dapat memberikan pengertian yang jelas mengenai beban kerja. kebutuhan jumlah perawat yang tidak tentu ini dipengaruhi oleh banyak sedikitnya pasien yang dirawat yang memiliki tingkat ketergantungan berbeda-beda. penghitungan kebutuhan tenaga perawat di ruang irna bedah a berdasarkan metode douglas tentunya tidak dapat dijadikan patokan sepenuhnya, karena jumlah pasien di ruang irna bedah a berubah-ubah disebabkan ruang irna bedah a, khususnya ruang upi umum dan upi torak, adalah ruangan transisi. bila keadaan pasien pasca operasi telah stabil, maka pasien dapat dipindahkan ke ruang elektif atau ke ruangan lain sesuai dengan kasus penyakitnya. penghitungan kebutuhan tenaga perawat dengan metode time and motion study dilakukan dengan mengamati dan mengikuti dengan cermat tentang kegiatan yang dilakukan oleh perawat yang sedang kita amati. penelitian dengan time and motion study dapat digunakan untuk evaluasi tingkat kualitas suatu pelatihan atau pendidikan yang bersifat keahlian. melalui penggunaan teknik ini kita dapat mengetahui waktu jam kerja sebenarnya yang digunakan untuk setiap kelompok kegiatan selama sehari-hari pengamatan, sehingga kita dapat mengetahui proporsi untuk kerja langsung, kegiatan tidak langsung, kegiatan yang relevan, kegiatan pribadi, dan kegiatan lainnya. personel bukanlah unit pengamatan, tetapi kegiatankegiatan yang dilakukan menjadi unit jurnal ners vol. 4 no. 2: 197-202 200 pengamatan yang menjadi obyek penelitian. sehingga bisa dilihat beban kerja yang kita amati. pengukuran waktu kerja dengan time and motion study dilakukan dengan metode jam henti (stop-watch time study). metode jam henti (stop-watch time study) sangat tepat diaplikasikan untuk pekerjaan-pekerjaan yang berlangsung singkat dan berulang-ulang. berdasar hasil pengukuran maka akan diperoleh waktu baku untuk menyelesaikan suatu siklus pekerjaan, yang mana waktu ini akan dipergunakan sebagai standar penyelesaian pekerjaan bagi semua pekerja yang akan melaksanakan pekerjaan yang sama seperti itu. hasil penghitungan kebutuhan tenaga keperawatan berdasarkan time and motion study di ruang irna bedah a menunjukkan bahwa jumlah perawat yang dibutuhkan lebih sedikit dibandingkan dengan penghitungan kebutuhan tenaga keperawatan berdasarkan metode douglas. hal ini dapat disebabkan karena penghitungan dengan time and motion study didasarkan pada penggunaan waktu kerja produktif perawat. hal ini menyebabkan meskipun pasien yang dirawat banyak, tetapi jika perawat belum optimal dalam menggunakan waktu kerja produktif, maka jumlah yang akan dihasilkan akan kecil. maka dari itu, jumlah waktu perawat untuk berinteraksi dengan pasien sangat berpengaruh terhadap jumlah kebutuhan tenaga perawat. pasien di ruang irna bedah a sebagian besar memiliki tingkat ketergantungan self care dan dirawat di ruang elektif. pasien dengan tingkat ketergantungan self care membutuhkan perawatan 1-2 jam per hari. kriteria pasien self care menurut douglas (1992) dalam sitorus (2006) yaitu kebersihan diri, mandi, ganti pakaian dilakukan sendiri; makan dan minum dilakukan sendiri; ambulasi dengan pengawasan; observasi tanda-tanda vital dilakukan setiap shift; pengobatan minimal dengan status psikologis stabil. besarnya jumlah pasien dengan tingkat ketergantungan self care di ruang irna bedah a dapat disebabkan karena kapasitas di ruang elektif sebesar 20 orang dan pasien yang dirawat sebagian besar adalah pasien yang kondisinya telah stabil setelah operasi dan pasien yang sedang menunggu acara operasi dan sifatnya menetap. berbeda dengan ruang upi umum dan upi torak yang masing-masing berkapasitas 10 dan 8 orang dan merupakan pasien pasca operasi sehingga jika keadaan pasien telah stabil, pasien dipindahkan ke ruangan lain disesuaikan dengan kasus bedahn dan dapat juga dipindahkan ke ruang elektif. sebaliknya, jika keadaan pasien yang dirawat di ruang elektif tiba-tiba memburuk (umumnya pasien dengan tingkat ketergantungan partial care) maka dapat dipindah ke ruang upi umum untuk mendapatkan observasi yang lebih ketat dibandingkan sebelumnya pada saat pasien dirawat di ruang elektif. hasil penelitian menunjukkan bahwa pada shift pagi, sore, dan malam, kegiatan perawat lebih banyak pada kegiatan nonproduktif daripada kegiatan produktif yang hanya 34,62%. produktivitas tenaga kerja tidak mungkin mencapai 100%, karena adanya faktor kelelahan dan kejenuhan dari tenaga kerja tersebut sebesar 15%, sehingga waktu kerja produktifnya hanya 85%. tenaga kerja dianggap produktif bila mampu menyelesaikan 80% dari beban tugasnya. operator akan sering menghentikan kerja dan membutuhkan waktuwaktu khusus untuk keperluan seperti personel needs, istirahat melepas lelah, dan alasan-alasan lain yang diluar kontrolnya. penggunaan waktu kerja produktif yang rendah ini dapat disebabkan karena tindakan perawat yang biasanya dilakukan pada jam tertentu seperti injeksi dan rawat luka yang dilakukan antara jam 8.30 sampai jam 11.00. selain itu, pada saat dilakukan penelitian, jumlah pasien yang sedang dirawat di ruang irna bedah a sedikit, terutama di ruang upi umum dan upi torak yang biasanya banyak terdapat pasien dengan tingkat ketergantungan partial care dan total care sehingga membutuhkan jam perawatan yang lebih banyak. hal lain yang menyebabkan waktu kerja produktif yang rendah yaitu adanya mahasiswa keperawatan yang sedang praktik sehingga pekerjaan perawat menjadi lebih ringan. kegiatan perawat pada shift pagi, sore, dan malam di ruang irna bedah a terutama kegiatan langsung, sebagian besar telah memenuhi sop yang telah ditetapkan oleh bidang keperawatan rsud dr. soetomo. tidak semua tindakan di ruang irna bedah a mempunyai sop. beberapa tindakan di ruang irna bedah a yang mempunyai sop dan sering dilakukan antara lain injeksi, rawat luka, memasang infus, mengukur tekanan darah, dan mengambil sampel darah. namun, ada juga beberapa tindakan yang tidak sesuai dengan sop antara lain penerimaan pasien baru. kegiatan penerimaan pasien baru dilakukan perhitungan kebutuhan tenaga keperawatan (purwaningsih) 201 belum sampai pada tahap orientasi ruangan dan perawat yang bertanggungjawab. standar operasional prosedur ialah pedoman atau tata cara bagi tenaga keperawatan dalam memberikan asuhan keperawatan yang paripurna. tujuan umum ditetapkannya sop oleh bidang keperawatan rsud dr. soetomo yaitu dengan adanya sop, diharapkan agar semua tenaga pelaksana keperawatan dapat memberikan asuhan keperawatan yang paripurna kepada individu, keluarga, dan masyarakat. sedangkan tujuan khususnya yaitu agar dapat memenuhi kebutuhan dasar pasien (makan, minum, oksigen), dapat melakukan tindakan keperawatan yang menyeluruh dan benar, dan dapat melakukan atau mengoperasikan alat serta perawatannya dengan benar. telah dilakukannya sebagian besar tindakan perawat sesuai dengan sop menunjukkan bahwa perawat telah menjadikan sop sebagai pedoman dalam melakukan tindakan kepada pasien. untuk kegiatan penerimaan pasien baru yang belum sesuai dengan sop kemungkinan dapat disebabkan karena kebiasaan dari perawat untuk melakukan penerimaan pasien baru yang belum sampai pada tahap orientasi ruangan dan perawat yang bertanggungjawab. beban kerja di ruang irna bedah a yaitu sebesar 34,62%. nilai beban kerja ini didapatkan dari waktu kerja (waktu riil) yang digunakan untuk melakukan kegiatan produktif dari keseluruhan waktu kerja. menurut lungberg (1999) dalam pudjirahardjo (2003) yang dikutip oleh gunawan (2006), seseorang dalam bekerja akan berfungsi secara optimal apabila kondisi beban kerja adalah ideal atau moderate dan kurang maksimal apabila dalam kondisi underload dan overload. dengan ketentuan overload bila beban kerja > 90% dari total waktu kerja, moderate atau ideal bila 8590% dari total waktu kerja, dan underload bila <85% dari total waktu kerja. berdasarkan standar beban kerja yang ada, maka beban kerja perawat di ruang irna bedah a termasuk underload atau beban kerja rendah. rendahnya beban kerja di ruang irna bedah a dapat disebabkan karena adanya mahasiswa keperawatan yang sedang praktik di ruang irna bedah a sehingga pekerjaan perawat menjadi lebih ringan. selain itu, diduga jumlah pasien yang dirawat di ruang irna bedah a juga turut mempengaruhi beban kerja perawat. pada saat jumlah pasien banyak tentunya akan menyita waktu perawat lebih banyak dibandingkan pada saat jumlah pasien sedikit. hal ini yang terjadi di ruang irna bedah a pada saat penelitian, bor rata-rata selama 1 minggu ialah 52,26%. nilai bor ini kemungkinan juga dapat mempengaruhi beban kerja perawat dalam melaksanakan tugasnya selain jumlah perawat yang bertanggungjawab terhadap pasien. simpulan dan saran simpulan hasil penghitungan kebutuhan tenaga keperawatan di ruang irna bedah a berdasarkan metode douglas menunjukkan bahwa jumlah perawat yang dibutuhkan lebih banyak dibandingkan dengan penghitungan kebutuhan tenaga keperawatan berdasarkan time and motion study. metode time and motion study lebih efektif untuk diterapkan dalam penghitungan kebutuhan tenaga keperawatan di ruang irna bedah a dibandingkan dengan metode douglas. saran berdasar hasil penelitian, maka peneliti memberi saran : 1) metode time and motion study dapat digunakan untuk menentukan kebutuhan jumlah tenaga keperawatan di ruang irna bedah a dengan melakukan observasi lebih lama dan 2) kepala ruangan dapat mencoba untuk memodifikasi rotasi atau jadwal dinas perawat yang sudah ada berdasarkan beban kerja untuk tiap shift agar perawat yang dinas untuk tiap shift dapat menggunakan waktu kerja dengan lebih produktif kepustakaan arwani, heru supriyanto. 2005. manajemen bangsal keperawatan. jakarta: egc. hapsari, elsi dwi, 2006. menyiapkan perawat yang siap berkompetisi di era pasar global, (online), (http://www.inovasionline.ca/final_research/ogc/pdf/obrien _final.pdf, diakses tanggal 2 juli 2009, jam 23.11 wib). hasibuan, h., 2008. manajemen sumber daya manusia. jakarta: bumi aksara. http://www.inovasi-online.ca/final_research/ogc/pdf/obrien_final.pdf http://www.inovasi-online.ca/final_research/ogc/pdf/obrien_final.pdf http://www.inovasi-online.ca/final_research/ogc/pdf/obrien_final.pdf jurnal ners vol. 4 no. 2: 197-202 202 sitorus, ratna, 2006. model praktik keperawatan profesional di rumah sakit: penataan truktur dan proses (sistem) pemberian asuhan keperawatan di ruang rawat. jakarta: egc. suarli, s & yanyan bahtiar, 2008. manajemen keperawatan dengan pendekatan praktis. jakarta: erlangga. http://e-journal.unair.ac.id/jners | 151 jurnal ners vol. 14, no. 2, october 2019 http://dx.doi.org/10.20473/jn.v14i2.9199 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effect of combination therapy of a warm ginger stew compress and ki. 3 point acupressure on the pain level of gout arthritis patients in indonesia enji meilia era pertiwi1, sidik awaludin2 and annas sumeru2 1 student of school of nursing, faculty of health science, jendral soedirman university, purwokerto, indonesia 2 lecturer of school of nursing, faculty of health science, jendral soedirman university, purwokerto, indonesia abstract introduction: gout arthritis is a systemic disease caused by deposition of monosodium urate crystals in the joints, causing pain. pain management may include complementary therapy such as combination therapy of a warm ginger stew compress and ki. 3 point acupressure to reduce pain. this research aimed to examine the effect of combination therapy of a warm ginger stew compress and ki. 3 point acupressure on the pain level of gout arthritis patients. methods: the research design for this study is a quasi-experiment pre-test and post-test, with a control group design for 30 respondents. the respondents were assigned to an experimental group with combination therapy of a warm ginger stew compress and ki. 3 point acupressure for about 30 minutes, and a control group with a warm ginger stew compress for about 15 minutes. each group consisted of 15 people. the data was analysed using a paired t-test, independent t-test, and mann whitney test. results: the mann whitney test showed an average decrease of pain level in the experimental group of 1,7333 and the control group of 1,0667 so, there were differences in the decreased of pain level before and after intervention between the two groups with p-value=0.013. conclusion: combination therapy of a warm ginger stew compress and ki. 3 point acupressure were effective in decreasing the pain level of gout arthritis patients in puskesmas 1 purwokerto timur. this therapy can be used for the gout arthritis patient to reduce pain level. article history received: february 25, 2019 accepted: december 23, 2019 keywords acupressure; ginger compress; gout arthritis contact annas sumeru  schumeru@gmail.com  faculty of health science, jendral soedirman university, purwokerto, indonesia cite this as: pertiwi, e. m. e., awaludin, s., & sumeru, a. (2019). the effect of combination therapy of a warm ginger stew compress and ki. 3 point acupressure on the pain level of gout arthritis patients in indonesia. jurnal ners, 14(2), 152-155. doi:http://dx.doi.org/10.20473/jn.v14i2.9199 introduction gout arthritis is a disease of the joints due to a metabolic disorder of uric acid that accumulates (hyperuricemia) in the body tissues (sustrani, nature, & hadibroto, 2007). gout arthritis occurs due to the deposition of monosodium nerves in the joints. the deposition of monosodium fibres (tophi) will cause inflammation. the prevalence of gout arthritis is expected to continue to increase. the prevalence of asymptomatic hyperuricemia in the general population in the usa is about 2-13%. based on the results of basic health research by riskesdas (2013), joint disease is currently the third (24.7%) leading disease that is not contagious after stroke (57.9%) and hypertension (36.8%), which increases as a person gets older. the prevalence of gout arthritis in bandungan, central java, as reported by the collaborative research of the world health organization international league of associations for rheumatology community oriented program for control of rheumatic disease (whoilar copcord) among 4,683 people aged 15-45 years, was 17.6% incidence of gout arthritis, experienced by men at 24.3% and women at 11.7% (kurniari, 2011). the results of a survey conducted in clinics 1 purwokerto timur, for 10 months (january-october 2017) found as many as 33 patients with hyperuricemia. the survey results showed severe pain (28.60%), moderate pain (42.85%), and mild pain (28,5%) of the joint. the definition of pain, according to the international association for the study of pain (iasp) is "as subjective knowledge and an unpleasant emotional experience associated with actual tissue damage or potential or perceived in the events which occurred https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.9199 e. m. e. pertiwi et al 152 | pissn: 1858-3598  eissn: 2502-5791 the damage" (iasp in potter & perry, 2005). pain that is not immediately handled could lead to discomfort, broad limitations in joint motion, distractions, and other activities of daily living (handono & richard, 2013). these impacts indicate that efforts need to be made to control the pain. it may be managed by pharmacological and nonpharmacological pain therapy. pharmacological therapy is often used to reduce joint pain, for example by non-steroidal anti-inflammatory drugs (nsaids) to control inflammation, which has a bitter taste (gliozzi, malara, muscoli, & mollace, 2016). there are some side effects from consuming these drugs such as nausea, vomiting, kidney failure, and even death if it is taken without proper instruction in the long term (misnadiarly, 2008). nonpharmacological therapy can be used as a complementary therapy, which is effective and safe, for example the use of warm ginger stew compress therapy and acupressure. the warm ginger stew compress is a warm compress combined with ginger that contains oleoresin, where there is substance in the oleoresin gingerol. gingerol serves as a compound that is not volatile. gingerol induces pharmacological and physiological effects of antioxidants that could inhibit prostaglandins and cyclooxygenase which may reduce pain (nahed & tavakkoli, 2015). in addition to the warm ginger stew compress, there are other therapies that can be used to handle pain, for example acupressure. the acupressure massage techniques through stimulation of acupressure points will enable the modulation of pain in opioid systems, non-opioid systems, and inhibition on sympathetic dystrophy to reduce nerve pain. in view of the benefit of warm ginger stew and acupressure to control pain rather than using only single method, this research was conducted to identify the effect of combination therapy of compress of the decoction of warm ginger and acupressure point ki. 3 on the level of pain among patients suffering from gout arthritis at clinics in region i of purwokerto timur. materials and methods this research used a quasi-experimental research design with pretest and posttest, with a control group design. the data was collected from march to april 2018 in the region and arcawinangun, mersi purwokerto. the sample in this study is 30 respondents, where the respondents are patients from clinics i purwokerto timur. the respondents were divided into experiments group with the combination therapy intervention compresses of warm ginger stew and acupressure point ki. 3 for 30 minutes and the control group with intervention therapy of warm ginger stew compress for 15 minutes. each arm of the of the intervention and control group had 15 respondents. the therapy was conducted by the researcher. the standard of operational procedure can be seen in the supplemental file of this manuscript. nonprobability sampling techniques of convenience sampling were used to recruit participants. the research was of the variable of a combination of warm ginger stew compress therapy and acupressure point ki. 3 against gout arthritis pain scale. the research instrument used was a numerical scale on the observation sheet. data were analysed using the mann whitney bivariate test. results table 1. shows the majority of respondents in this study were aged >60 years and the majority of uric acid levels of respondents were > 8.5 mg/dl. both groups showed a p-value of >0.05 meaning they are homogenous using the shapiro wilk test. table 2. indicates respondents of this research according to the gender of the majority of women, at 26 respondents (86.7%), and according to the majority who do not work totalled 17 respondents (56.7%). characteristics of respondents according to the gender and employment shows a p-value of 0.05 > meaning in both groups they are homogeneous using the chi square test. table 3. shows that the test based on the paired ttest experimental group and the control group had a p-value of 0.001. both the experimental group and the control group pain levels were decreased. however, it indicates that there is no difference in the scale of pain in experimental and control groups. after that, a mann whitney test was done to see the difference in decreased pain of both groups. table 1. respondent characteristics based on age and blood urea levels (n=30) characteristic experiment group control group p mean sd mean sd age 64,5 8,4 61,6 9,5 0,847 blood urea levels 8,7 2,3 8,6 1,8 0,620 table 2. respondents’ characteristics according to gender and jobs (n=30) characteristic experiment control p n % n % gender man women 2 13 13,3 86,7 2 13 13,3 86,7 1,00 0 jobs do not work work 8 7 53,3 46,7 9 6 60 40 0,71 3 jurnal ners http://e-journal.unair.ac.id/jners | 153 the table 4 test results showed mann whitney pvalue = 0,013 (p-value of 0.05 <) which means that there is a difference in the level of pain between the two groups after the intervention. those results were reinforced with a mean decrease in pain in the experimental group, i.e. 1.7333 and in the control group 1.0667. discussion the majority of respondents from this study were aged 60 years and above. the average age of respondents for intervention and control groups were respectively 64,47 ± 8,391 year and 61,60 ± 2,467 years. this is in line with the research by untari (2017) that shows the majority (85.71%, n=12) of respondent are women (86.7%, n=26). this is in accordance with the research by untari (2017) that shows that the majority (71.4%, n=10) of respondents experiencing gout arthritis older woman is aggregating. this is good for further research to know the differences of pain level between men or women who suffer from gout arthritis. hermawati & probosari (2015) showed that the majority of the respondents were women age 60years-old and above. the relationship of age increased with levels of uric acid due to the presence of the aging process resulting in decreased organ functions in the body, such as kidney filtration speed, excretion, and reabsorption against the metabolism of uric acid. increased levels of uric acid in women occur due to the process of the menopause that results in decreased production of the hormone oestrogen. the hormone oestrogen serves as an uricosuria agent that helps the expulsion of uric acid via the kidneys (setyoningsih, 2009). meiyetriani, hamza, & five (2016) explained that during puberty males have higher uric acid levels, whereas women will have an increase in uric acid level when approaching menopause due to oestrogen uricosuria. the uric acid levels of respondents showed a mean of uric acid levels of respondents of 8.720 ± 2.2693 mg / dl in the experimental group and 8.633 ± 1.7971 mg / dl in the control group. gout arthritis occurs due to the deposition of uric acid crystals in the joint tissues that affects the inflammatory reaction. the presence of uric acid crystals allows the interaction of the phospholipid membrane and the serum factors that contribute to the inflammatory reaction (martillo et al, 2014). the results showed most respondents did not work, at 17 respondents (56.7%). this is in contrast to the research of meiyetriani et al (2016) that showed the majority of arthritis gout experience was in those who were working, as much as 60% compared to not working as much as 11.7%. darmawan (2016) explains that less physical activity can cause metabolic syndrome which causes insulin resistance, leading to disorders of the excretion of uric acid. insulin resistance causes the occurrence of oxidative phosphorylation disorders which will increase the concentration of adenosine systemic resistance, i.e. sodium, fibres, and water. the results of the p-value show the experiment group and the control group equally mean the pain scale decreased. but based on the value of the mean, a significant decrease in pain occurred in the experimental groups. based on the test results of the p-value, this shows that the experimental group and the control group equally mean that the pain scale decreased. but based on the value of the mean, a significant decrease in pain occurred in experimental groups, obtaining a combination therapy of warm ginger stew compress and acupressure point ki. 3 than the control group who simply got the warm ginger stew compress therapy. the average decrease in pain in the experimental group is significantly more than the control group. chinomso & faluso’s research (2014) stated that a combination of massage therapy and hot compresses against chest pain on chronic bronchitis patients effectively lowers the pain with a p-value < 0.001. lestari et al.’s (2014) qualitative research also states that the granting of a therapeutic massage and ginger compresses provide stimulation of the skin and the relaxing effect so effectively as to lower osteoarthritis pain. according to hidayat & son (2016), ginger compresses effectively increase blood flow to get the analgesic and muscle relaxant effects of reducing inflammatory processes. this is confirmed by research from dwi putri et al. (2017) stating that the influence of giving a ginger compress against the intensity of the pain gout arthritis in the older people in the prosperous south kalimantan pstw budi is more effective than with a warm table 3. effect of the scale of pain before and after the intervention of the experimental and control group (n=30) group variable mean sd p experiment pretest pain level posttest pain level 6,5 4,8 1,8 1,5 0 control pretest pain level posttest pain level 5,0 3,9 2,2 2,1 0 table 4. the difference of pain scale decrease between experimental and control group (n=30) variable group mean sd p the difference pain scale of pre and post intervention experiment control 1,7 1,1 0,8 0,7 0,013 e. m. e. pertiwi et al 154 | pissn: 1858-3598  eissn: 2502-5791 compress, with p-value = 0.000. the research on acupressure points used is point ki. 3. it works by giving local effects in the form of decreased pain on the area around the point of emphasis. it stimulates that the receptor stimulation activates a system of modulation of pain in the central nervous system that will stimulate the hormone endorphins to suppress transmission and perception of pain so that pain can be reduced (majid & rini, 2016). research of combination therapy of warm ginger compresses stew and acupressure point ki. 3 proved effective in lowering pain. this has been supported by previous studies which prove that the warm ginger stew compress therapy and acupressure can be used as a selection for non-pharmacological therapy for reducing pain in sufferers of gout arthritis. conclusion the characteristics of respondents who experienced gout arthritis in the area of public health 1 purwokerto timur are mostly aged 60 years and above, with average levels of uric acid more than 8 mg/dl, most of them were female and not working. there is a significant difference in the scale of pain before and after intervention in the control group. the result from this study suggested that patients receiving combination therapy of warm ginger stew compresses and acupressure point ki. 3 had reduced their pain level more than the group that were only given the warm ginger stew compress therapy. references chinomso u, n. & foluso o, o., 2014, effectiveness of the combination of therapeutic chest massage and hot compress on chest pain among patients with chronic bronchitis: a nurse-led pilot study, international journal of scientific research, 3(3): 236-238. darmawan, p. s., kaligis, s. h. m., & assa, y. a., 2016, gambaran kadar asam urat darah pada pekerja kantor, jurnal e-biomedik, 4(2). dwi putri, s., q., rahmayanti, d., & diani, n., 2017, pengaruh pemberian kompres jahe terhadap intensitas nyeri gout artritis pada lasia di pstw budi sejahtera kalimantan selatan, dunia keperawatan, 5(2): 90-95. gliozzi, m., malara, n., muscoli, s., & mollace, v., 2016, the treatment of hyperuricemia, international journal of cardiology, 213: 23-27. handono, s. & richard, s. d., 2013, upaya menurunkan keluhan nyeri sendi lutut pada lansia di posyandu lansia sejahtera, jurnal stikes, 6(1): 63-73. hermawati, e. & probosari, e., 2015, hubungan asupan kafein dengan kadar asam urat di puskesmas banjarnegara, journal of nutrition college, 4(2): 480-485. hidayat, s. & putra, i. d. a., 2016, pengaruh terapi kompres jahe terhadap tingkat nyeri osteoartritis pada lansia di upt. puskesmas guluk-guluk, wiraraja medika, 6(2): 53-59. kementerian kesehatan republik indonesia, 2013, riset kesehatan dasar. diakses 7 november 2017 melalui http://www.depkes.go.id/resources/download/ general/hasil%20riskesdas%202013.pdf kurniari, p. k., kambayana, g., & raka putra, t., 2011, hubungan hiperurisemia dan fraction uric acid clearance di desa tenganan pegringsingan karangasem bali. journal of internal medicine, 12(2). lestari, i., nuryahati, y., & setiyajati, a., 2014, terapi kompres jahe dan massage pada osteoartritis di panti wreda st. theresia dharma bhakti kasih surakarta, skripsi, stikes kusuma husada, surakarta. majid, y. a. & rini, p. s., 2016, terapi akurpesur memberikan rasa tenang dan nyaman serta mampu menurunkan tekanan darah lansia, jurnal aisyah: jurnal ilmu kesehatan, 1(1): 79-86. martillo, m. a., nazzal, l., & crittenden, d. b., 2014, the crystallization of monosodium urate, current rheumatology reports, 16(2): 400. meiyetriani, e., hamzah, & lima, f., 2018, faktorfktor yang mempengaruhi kejadian asam urat di kelurahan pancuran mas depok jawa barat, averrous, 3(2), 78-88. misnadiarly, 2008, mengenal penyakit artritis, puslitbang biomedis dan farmasi, badan litbangkes, 57. nahed, a., & tavakkoli, 2015, ginger and its effect on inflammatory disease, departement of nutrition school of public health, 1(4). potter, p. a. & perry, a. g., 2005, buku ajar fundamental keperawatan, ed. 4, vol. 1, egc, jakarta. saputra, k., 2004, akupuntur klinik, airlangga university press, surabaya. saputra, k., 2012, buku ajar biofisika akupunktur dalam konsep kedokteran energi, salemba medika, jakarta. setyoningsih, r., 2009, faktor-faktor yang berhubungan dengan kejadian hiperurisemia pada pasien rawat jalan rsup dr. kariadi semarang, skripsi, undip, semarang. singh, s. k., patel, j. r., & bachle, d., 2014, a review on zingiber officinale: a natural gift, international journal of pharma and bio sciences, 5(3): 508525. sustrani, l., alam, s., dan hadibroto, i., 2007, asam urat, gramedia pustaka utama, jakarta. untari, i., sarifah, s., & sulastri, 2017, hubungan antara penyakit gout dengan jenis kelamin dan umur pada lansia, urecol, 267-272. hubungan faktor risiko asma dan perilaku pencegahan 83 analisis faktor tentang kesediaan lansia tinggal di panti werdha (factors analyze about willingness of elderly to stay in elderly folk home) i ketut sudiana*, retno indarwati*, diana rachmania* abstract introduction : moving to the new house is not easy for the elderly, especially moving to the elderly folk home. a lot of elderly refuse to stay in the elderly folk home. some conditions which make the elderly give their willingness to stay in the elderly hostels such as economic status, family condition, and self desire. but that factors are unclear until now. the aim of this study was to analyze factors related to willingness for elderly living in the elderly hostels. method : design used in this study was cross sectional. the population were all of the elderly live in elderly folk home hargo dedali surabaya. samples were taken using purposive sampling and there were 20 respondents. data were collected using structured questionnaire and then analyzed using spearman’s rho test and logistic regression test with level of significance α≤ 0.05. result : result showed that the dominant factor of willingness of elderly living in the eladerly folk home was self desire with level of significance ρ=0.02, followed by economic status (ρ=0.031) and than family condition (ρ=0.032). analysis : it can be concluded that self desire was the major factor related to willingness of elderly living in the elderly folk home. discussion : further studies should be appraising how far the motivation appear from the elderly until they decided to live in the elderly folk home. keyword : willingness of elderly, elderly folk home. *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail : ik.sudiana@yahoo.com pendahuluan rumah memiliki peran yang lebih daripada sekedar tempat berteduh. rumah menjadi bagian terbesar dari aktivitas seharihari orang-orang lanjut usia (lansia) setelah masa pensiun serta saat terjadi penurunan fungsi tubuh. pindah ke sebuah rumah yang lain bukan hal yang mudah bagi lansia. pertanyaan timbul karena suatu kondisi, lansia harus meninggalkan rumah mereka dan tinggal dalam suatu rumah tinggal bersama (dalam penelitian ini disebut sebagai panti werdha) (perwitasari, 2007). faktor yang menjadi penyebab keberadaan lansia di panti werdha masih belum jelas. banyak lansia lebih memilih untuk tinggal di rumah sendiri daripada di panti werdha (horner dan boldy, 2008). tidak ada lansia yang ingin tinggal di panti werdha, mereka lebih memilih untuk berada di rumah sendiri atau bersama keluarga (adib, 2008). berdasarkan hasil survey yang dilakukan peneliti di panti werdha hargo dedali surabaya, terdapat 36 lansia yang tinggal dalam panti tersebut yang semuanya adalah lansia perempuan. sebanyak 7 dari 20 lansia (35%) yang tinggal di panti werdha hargo dedali menyatakan tidak senang berada di panti dikarenakan ketidakcocokan dengan teman sekamar dan tidak pernah dijenguk keluarga. sebanyak 6 dari 20 lansia (30%) bersedia tinggal di panti werdha hargo dedali surabaya, bukan ke panti werdha yang lain karena panti werdha ini milik yayasan sehingga perawatannya lebih terjamin dan keadaan lingkungan yang bersih. sedangkan 14 lansia (60%) berada di panti werdha hargo dedali karena pasrah pada keputusan keluarga. keseluruhan lansia selalu mengikuti setiap kegiatan yang diadakan oleh panti werdha hargo dedali. hurlock (1997) mengatakan bahwa beberapa kondisi yang mempengaruhi pilihan pola hidup bagi lansia hingga akhirnya lansia tinggal di lembaga jurnal ners vol.4 no.1 april 2009: 83-88 84 khusus orang-orang lanjut diantaranya status ekonomi, status perkawinan, kesehatan, kemudahan dalam perawatan, jenis kelamin, anak-anak, keinginan untuk mempunyai teman, dan iklim. menurut peneliti, kemungkinan kondisi yang sesuai di indonesia sehingga lansia memutuskan bersedia tinggal di panti werdha adalah karena faktor status ekonomi, kondisi keluarga, dan keinginan pribadi. sejauh ini faktor yang berhubungan dengan kesediaan lansia tinggal di panti werdha masih belum diketahui dengan jelas sehingga perlu untuk diindentifikasi lebih lanjut. jumlah penduduk lansia di indonesia dari tahun ke tahun dalam dua dekade terakhir semakin meningkat. kementerian koordinator kesejahteraan rakyat (kesra) melaporkan, jika tahun 1980 usia harapan hidup (uhh) 52,2 tahun dan jumlah lansia 7.998.543 orang (5,45%) maka pada tahun 2006 menjadi 19 juta orang (8,90%) dan uhh juga meningkat (66,2 tahun). pada tahun 2010 perkiraan penduduk lansia di indonesia akan mencapai 23,9 juta atau 9,77% dan uhh sekitar 67,4 tahun. sepuluh tahun kemudian atau pada 2020 perkiraan penduduk lansia di indonesia mencapai 28,8 juta atau 11,34 % dengan uhh sekitar 71,1 tahun (hamid, 2007). menurut data dari departemen sosial 2008, jumlah lansia (penduduk yang berusia 60 tahun ke atas) pada tahun 2004 mencapai 16,5 juta jiwa. sedangkan pada tahun 2005 menjadi 17,6 juta jiwa. mereka memerlukan perhatian dalam hal tata cara berkehidupan, pendapatan, kesehatan fisik dan mental. penduduk lansia umumnya memerlukan bantuan dari keluarga (seperti anak, keponakan, cucu atau anggota keluarga yang lain) dan sangat bergantung dalam hal perumahan dan pemenuhan kebutuhan standar hidup. dari populasi lansia yang tercatat sebanyak 16.522.311 jiwa, sekitar 3.092.910 (20%) diantaranya adalah lansia terlantar (departemen sosial, 2008). berdasarkan data kemiskinan yang ada di indonesia, diduga banyak penduduk lansia yang hidup di bawah garis kemiskinan. sebagai gambaran, data dari badan pusat statistik (bps) menunjukkan jumlah penduduk miskin hingga maret 2007 sebanyak 37, 17 juta orang (hamid, 2007). peningkatan jumlah lansia di indonesia diikuti dengan peningkatan lansia yang dititipkan ke panti werdha. berdasarkan data dari tim yayasan abiyoso (2002) dalam perwitasari (2007) diketahui bahwa pada tahun 2001 jumlah panti werdha yang dikelola oleh pemerintah pusat sebanyak 2 panti dengan total jumlah penghuni sebanyak 182 lansia. sedangkan panti werdha yang dikelola pemerintah daerah sebanyak 69 panti dengan total jumlah penghuni sebanyak 4955 lansia. panti werdha yang dikelola oleh pihak swasta sebanyak 164 dengan total jumlah penghuni sebanyak 6260 lansia. tercatat pada juni 2009, panti werdha hargo dedali dihuni oleh 36 lansia. pergeseran struktur keluarga dan kekerabatan dari keluarga besar (ekstended family) kearah keluarga kecil (nueclear family) berdampak pada pengurangan fungsi-fungsi tertentu dalam keluarga seperti fungsi perawatan baik kepada anak ataupun lansia dan penurunan tanggung jawab moral keluarga untuk menyediakan tempat bagi anggota/kerabat yang lain. kekerabatan dan sistem kekeluargaan yang ekstended senantiasa menyedikan tempat bagi semua anggota keluarga atau kerabat. hal ini dikarenakan ada kemungkinan pihak keluarga/kerabat lain yang akan memiliki rasa tanggung jawab untuk menampung, merawat atau memberikan perlindungan. nilai kebersamaan dan tanggung jawab sosial semakin berkurang saat terjadi pergeseran akibat modernisasi dengan tuntutan materialisme yang semakin kuat. seseorang cenderung menjadi individualis dan tidak lagi memiliki tanggung jawab sosial terhadap keadaan yang dialami oleh kerabat yang lain. hubungan sosial baik masyarakat dan keluarga khususnya bagian terkecil adalah anak dan orang tua semakin berjarak akibat tuntutan ekonomi. tuntutan profesi atau pekerjaan menyita hampir semua waktu sehingga tidak lagi mempunyai kesempatan untuk memberikan perhatian dan perawatan kapada orang tua. menurut sari (2008), orang tua yang memasuki masa lanjut usia semakin terabaikan secara sosial, budaya dan psikologis. mereka menjadi kesepian dan terlantar dalam rumah. jika hal tersebut tidak segera ditangani maka bisa berdampak pada kesehatan fisik dan psikologis dari diri lansia berdasarkan pemikiran di atas perlu dilakukan penelitian tentang faktor yang berhubungan dengan kesediaan lansia tinggal di panti werdha mengingat kondisi lansia yang masih bisa produktif meskipun telah tinggal di panti werdha. jumlah lansia yang semakin kesediaan lansia tinggal di panti werdha (i ketut sudiana) 85 bertambah menjadi tantangan tersendiri bagi perawat dan pengelola panti werdha guna meningkatkan kualitas pelayanan di bidang kesejahteraan lansia. ketika panti werdha menjadi pilihan keluarga untuk menitipkan lansia, solusi yang dapat diberikan adalah dengan memberikan pengertian dan pemahaman kepada lansia bahwa mereka bukanlah sekumpulan orang yang terbuang. bahan dan metode penelitian rancangan penelitian yang digunakan yaitu cross sectional. sampel sebanyak 20 lansia yang inggal di panti werdha hargo dedali surabaya didapat dengan menggunakan purposive sampling. kriteria inklusi yang ditetapkan: 1) bersedia menjadi responden, 2) kooperatif, 3) dapat berkomunikasi dengan baik; dan kriteria eksklusi berupa lansia yang mengalami gangguan daya ingat. penelitian ini dilaksanakan pada tanggal bulan juni sampai juli 2009. variabel independen dalam penelitian ini yaitu faktor yang berhubungan dengan kesediaan lansia tinggal di panti werdha meliputi faktor status ekonomi, kondisi keluarga dan keinginan pribadi. variabel dependen berupa kesediaan lansia tinggal di panti werdha. data diperoleh dengan menggunakan kuesioner kemudian dianalisis dengan menggunakan uji korelasi spearmen’s rho (r) dan regresi logistik dengan derajat kemaknaan α≤0,05. hasil penelitian analisis menggunakan uji statistik spearman’s rho dengan tingkat kemaknaan α≤0,05, diperoleh nilai ρ=0,031 dengan koefisien korelasi negatif (r= -0,483), yang menunjukkan bahwa ada hubungan bermakna antara status ekonomi dengan kesediaan lansia tinggal di panti werdha hargo dedali surabaya (tabel 1). hubungan bermakna juga terlihat antara kondisi keluarga dengan kesediaan lansia tinggal di panti werdha hargo dedali yang dibuktikan dengan nilai ρ=0,032 (tabel 2). keinginan pribadi dengan kesediaan lansia tinggal di panti werdha hargo dedali juga menunjukkan hubungan yang bermakna dengan perolehan nilai ρ=0,02 (tabel 3). berdasarkan perbandingan antara koefisien korelasi dari ketiga variable dan penghitungan dengan analisis uji regresi logistik didapatkan faktor dominan yang berhubungan dengan kesediaan lansia tinggal di panti werdha adalah faktor keinginan pribadi. pembahasan hurlock (1997) menyatakan bahwa status ekonomi lansia yang semakin berkurang memungkinkan lansia pindah ke kehidupan yang kurang diinginkan (yaitu kesediaan untuk tinggal di panti werdha). pendapatan yang berkurang sering diartikan sebagai pindah ke dalam kehidupan yang lebih kecil dan kurang diinginkan, misal tinggal dengan anak yang sudah menikah atau hidup dalam lembaga penyantunan seperti panti werdha. secara keseluruhan skala pendapatan bagi kebanyakan pekerja lansia berada pada urutan paling bawah dan hanya sedikit sekali yang memperoleh pendapatan tinggi (stevens, 1999). tuntutan ekonomi tidak akan pernah berakhir seperti kebutuhan anak-anak yang semakin meningkat seiring usia yang semakin dewasa (biro pusat statistik, 1997). tabel 1. hubungan status ekonomi dengan kesediaan lansia tinggal di panti wredha hargo dedali surabaya juli 2009 kesediaan tinggal di panti werdha status ekonomi total > rp 1.000.000 rp 805.5001.000.000 rp 780.000805.500 < rp 780.000 sukarela 2 (10%) 0 0 10 (50%) 12 (60%) terpaksa 2 (10%) 1 (5%) 3 (15%) 2 (10%) 8 (40%) total 4 (20%) 1 (5%) 3 (15%) 12 (60%) 20 (100%) korelasi spearman’s rho p=0,031 r= -0.483 jurnal ners vol.4 no.1 april 2009: 83-88 86 tabel 2. hubungan kondisi keluarga dengan kesediaan lansia tinggal di panti wredha hargo dedali surabaya juli 2009 kesediaan tinggal di panti werdha kondisi keluarga total baik cukup kurang sukarela 1 (5%) 3 (15%) 8 (40%) 12 (60%) terpaksa 4 (20%) 2 (10%) 2 (10%) 8 (40%) total 5 (10%) 5 (10%) 10 (50%) 20 (100%) korelasi spearman’s rho p=0,032 r= -0.481 tabel 3. hubungan keinginan pribadi dengan kesediaan lansia tinggal di panti wredha hargo dedali surabaya, juli 2009 kesediaan tinggal di panti werdha keinginan pribadi total besar sedang rendah sukarela 8 (40%) 3 (15%) 1 (5%) 12 (60%) terpaksa 0 (0%) 4 (20%) 4 (20%) 8 (40%) total 8 (40%) 7 (35%) 5 (25%) 20 (100%) korelasi spearman’s rho p=0,02 r=0,662 keterangan : p = signifikansi r = koefisien korelasi hasil penelitian menunjukkan bahwa sebagian besar lansia yang tinggal di panti werdha hargo dedali berada pada status ekonomi rendah yaitu dengan penghasilan perbulan sebesar < rp 780.000,00 dan berstatus sendiri tanpa suami yaitu janda sebanyak 15 orang dan tidak menikah 5 orang. masalah ekonomi sering dihadapi wanita dengan status sendiri tanpa suami. keberadaan anak dan pekerjaan memberikan dampak yang besar bagi kondisi perekonomian lansia. jika lansia tidak memiliki perkerjaan atau uang pensiun yang bisa menjamin kebutuhan lansia, maka sulit bagi lansia untuk bisa merawat diri sendiri. lansia menjadi bergantung pada bantuan anak/kerabat. lansia yang tidak memiliki anak/kerabat tidak mampu mengatasi permasalahan ekonomi dan kemungkinan berada di panti werdha semakin besar. fakta yang terdapat di lapangan menunjukkan ada keterkaitan antara kedua variabel tersebut. keluarga adalah sistem atau unit (setiawati dan dermawan, 2005). keluarga terdiri dari orang-orang yang disatukan oleh perkawinan, darah dan ikatan adopsi dimana para anggota keluarga hidup bersama dalam satu rumah tangga, atau jika mereka hidup secara terpisah, mereka tetap menganggap rumah tanggga tersebut sebagai rumah mereka (burgess dkk, 1963 dalam friedman, 1998). sebagian besar lansia kurang memperhatikan anak mereka yang sudah dewasa sebagai teman yang bisa dimintai pertolongan seperti pada waktu masih kecil. hal ini disebabkan oleh sifat individu generasi modern yang kurang mempunyai kewajiban terhadap orang tua dibandingkan dengan generasi masa silam. sebagian kecil karena generasi sekarang sering berpindah tempat tinggal yang jauh dari orang tua sehingga sehingga menyebabkan hubungan antara lansia dengan anak menjadi kurang baik. hal ini dapat dilihat berdasarkan hubungan lansia dengan anak/kerabat yang kesediaan lansia tinggal di panti werdha (i ketut sudiana) 87 semakin berkurang dimana lansia enggan menyesuaikan sikap mereka dengan perkembangan serta kebutuhan anak yang berubah dan perhatian keluarga berkurang terhadap lansia (hurlock, 1997). sejalan dengan pembaruan dalam kehidupan berkeluarga, yang diperkuat dengan nilai keluarga kecil bahagia sejahtera, maka jumlah anak dalam keluarga menjadi sedikit dan total fertiliy rate kaum perempuan menurun. bila jumlah anak dalam keluarga mengecil, maka secara otomatis rasio ketergantungan lansia pada anak juga akan menurun. secara lugas dapat dikatakan bahwa lebih sedikit anak yang dapat menampung orangtua mereka yang sudah lansia. nilai-nilai kemandirian, tidak ingin berada dalam ketergantungan pada anak-anak, yang merupakan nilai-nilai masyarakat modern, telah banyak yang menganut dalam masyarakat lansia sendiri (patmonodewo, 2001). sebagian besar lansia yang tinggal di panti werdha hargo dedali tidak memiliki anak. kenyataan tersebut semakin menunjukkan bahwa kehadiran anak memiliki peranan yang sangat penting bagi kehidupan lansia khususnya bagi lansia yang telah hidup sendiri karena kematian salah satu pasangan hidup. bagi lansia, anak akan menjadi dasar kekuatan yang menopang kesejahteraan lansia. berdasarkan hasil pengisian kuesioner oleh lansia, diketahui bahwa sebagian besar lansia kurang memiliki hubungan yang baik dengan anak/kerabatnya. lansia juga kurang memperoleh perhatian dari anak/kerabat. perubahan berbagai nilai keluarga juga menjadi salah satu penyebab makin berkurangnya tingkat kedekatan hubungan lansia dengan keluarga. di jaman yang serba modern terjadi perubahan struktur keluarga besar menjadi keluarga inti. tuntutan profesi atau pekerjaan menyita hampir semua waktu bagi seorang anak/kerabat sehingga tidak lagi mempunyai kesempatan untuk memberikan perhatian dan perawatan kepada orang tua. orang tua yang memasuki masa lansia semakin terabaikan secara sosial, budaya dan psikologis. lansia merasa terasing, kesepian dan terlantar dalam rumah. hal ini menjadi salah satu bentuk pertimbangan yang membuat lansia memutuskan bersedia untuk tinggal di panti werdha. hurlock (1997) menyatakan, satu diantara penyesuaian utama yang harus dilakukan oleh lansia adalah penyesuaian karena kehilangan pasangan hidup. menurut sabri (2001), kemauan/keinginan merupakan kekuatan pikiran yang sadar dan hidup pada diri seseorang untuk berbuat atau menciptakan sesuatu berdasarkan perasaan dan pikiran. hal ini diarahkan untuk mencapai berbagai tujuan hidup tertentu yang dikendalikan oleh pertimbangan akal budi dan kemudian ditetapkan dalam diri seseorang berdasarkan suatu keputusan kata hati, setelah diadakan berbagai pertimbangan/pemilihan. hasil penelitian menunjukkan 8 orang lansia memiliki keinginan yang besar untuk tinggal di panti werdha. keinginan pribadi untuk tinggal di panti werdha ini di dasarkan pada kuesioner tentang kesepian yang dialami lansia sebelum tinggal di panti werdha. kesepian karena ditinggal oleh suami baik karena perceraian maupun kematian, kurangnya perhatian dari pihak keluarga, dan keinginan untuk tidak merepotkan keluarga. penyesuaian pada masa lansia makin sulit dilakukan, meliputi penyesuaian terhadap kematian pasangan atau terhadap perceraian. pasangan hidup yang telah meninggal dan orang yang telah lama bersama memiliki pengaruh yang sangat besar. lansia yang tinggal di panti werdha memilih hidup terpisah dari anak mereka dan tidak ingin merepotkan anak. hal ini yang membuat lansia menetapkan keinginan untuk tinggal sendiri atau di lembaga khusus lansia yaitu di panti werdha. simpulan dan saran simpulan faktor yang mempengaruhi kesediaan lansia tinggal di panti werdha antara lain: 1) status ekonomi dengan penghasilan rendah, 2) kondisi keluarga yang kurang baik dan 3) keinginan dari dalam diri yang kuat. keinginan pribadi menjadi faktor dominan yang menyebabkan lansia memutuskan bersedia tinggal di panti werdha hargo dedali. saran beberapa hal yang dapat disarankan dari penelitian ini: 1) panti werdha hendaknya berupaya untuk mengajak pihak keluarga agar tetap memberikan perhatian kepada lansia jurnal ners vol.4 no.1 april 2009: 83-88 88 meskipun lansia telah dititipkan ke panti werdha sehingga para lansia merasa masih masih mendapat perhatian dari keluarga, 2) perlu dilakukan penelitian lanjutan tentang usaha untuk mempertahankan kondisi keluarga yang kondusif meskipun lansia sudah berada di panti werdha, 3) penelitian selanjutnya diharapkan lebih mengulas tentang sejauh mana motivasi lansia menetapkan keinginan pribadi untuk tinggal di panti werdha. kepustakaan adib, m., 2008. penelitian lansia di perkotaan: tinggal bersama keluarga lebih nyaman, (online), (http://madib.blog.unair.ac.id/files/200 8/11/penelitian-lansia-diperkotaan.pdf, diakses tanggal 26 april 2009, jam 11.00 wib). biro pusat statistik, 1997. laporan sosial indonesia 1997, jakarta: biro pusat statistik, hlm. 62-63. departemen sosial (direktorat jendral pelayanan dan rehabilitasi sosial), 2008. data jumlah lansia terlantar di indonesia, (online), (http://www.yanrehsos.depsos.go.id. /index.php?option=com_content&task =view&id=243&itemid=1, diakses tanggal 4 april 2009, jam 15.55 wib). friedman, m., 1998. keperawatn keluarga teori dan praktik, alih bahasa: ina debora r.l & yoakim asy, jakarta: egc, hlm. 11-12. hamid, a., 2007. penduduk lanjut usia di indonesia dan masalah kesejahteraannya.(online) (http://www.depsos.go.id/modules.php ?name=news& file=article&sid=522, diakses tanggal 26 april 2009, jam 11.00 wib). horner & boldy, 2008. the benefit and burden of ageing-in-place in an aged care community. australian health review, 32, hlm. 356, (http://proquest.umi.com, diakses tanggal 28 april 2009, jam 09.45 wib). hurlock, eb., 1997. psikologi perkembangan: suatu pendekatan sepanjang rentang kehidupan, edisi.5, jakarta: erlangga, hlm. 380-400. patmonodewo, dkk, 2001. bunga rampai psikologi perkembangan pribadi: dari bayi sampai lanjut usia. jakarta: ui, hlm. 184-216. perwitasari, ag., 2008. well-being pada lansia yang tinggal di panti werdha, skripsi, universitas airlangga, tidak dipublisasikan. sabri, m., 2001. pengantar psikologi umum dan perkembangan: bahan kuliah dan diskusi mahasiswa. jakarta: cv pedoman ilmu jaya, hlm.118-127. sari, ac., 2008. penguatan eksistensi panti werdha di tengah pergeseran budaya dan keluarga, (online) (http://www.depsos.go.id/modules.php ? name=news&file=article&sid=704, diakses tanggal 26 april 2009, jam 11.00 wib). setiawati & dermawan, 2005. tuntunan praktis asuhan keperawatan keluarga. bandung: rizqi press, hlm. 5. stevens, et al, 1999. ilmu keperawatan. edisi. 2. jakarta: egc, hlm. 8-13. http://madib.blog.unair.ac.id/files/2008/11/penelitian-lansia-di-perkotaan.pdf http://madib.blog.unair.ac.id/files/2008/11/penelitian-lansia-di-perkotaan.pdf http://madib.blog.unair.ac.id/files/2008/11/penelitian-lansia-di-perkotaan.pdf http://www.yanrehsos.depsos.go.id/ http://www.depsos.go.id/modules.php?name=news&%20file=article&sid=522 http://www.depsos.go.id/modules.php?name=news&%20file=article&sid=522 http://proquest.umi.com/ http://www.depsos.go.id/modules.php?%20name=news&file=article&sid=704 http://www.depsos.go.id/modules.php?%20name=news&file=article&sid=704 discharge planning meningkatkan kepatuhan pengobatan pasien discharge planning meningkatkan kepatuhan pengobatan pasien (discharge palnning increase therapy obedient of patients) nursalam*, sumiatun**, amirul musrini** *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257 e-mail: nursalam_psik@yahoo.com **: rsud dr. soetomo surabaya abstract introduction: discharge planning is a nurses learning process of patients hospitalized in the hospital. discharge planning includes all treatments given to the patients from the time of admission, during hospitalization, until the time of discharge. the aimed of this study was to evaluate the patient’s compliance for therapy (oral and injection medicine, nutrition and activities). method: a quasy experimental purposive sampling design was used in this study. there were 14 respondents with dhf and ge who met to the inclusion criteria. the independent variable was discharge planning and the dependent variable was patient’s compliance for therapy. data were collected by using questionaire of medicine, nutrition and activity then analyzed by using wilcoxon signed rank test and mann whitney u test with significance level α≤0.05. result: the result showed that discharge planning had significance influence to patient’s compliance for therapy (p= 0.028). discussion: it can be concluded that discharge planning has an effect to increase patient’s compliance for therapy (oral and injection medicine, nutrition and activities). keywords: discharge planning, medicine, nutrition and activities, patient’s compliance pendahuluan perencanaan pulang merupakan suatu proses yang dinamis dan sistimatis dari penilaian, persiapan, serta koordinasi yang dilakukan untuk memberikan kemudahan pengawasan pelayanan kesehatan dan pelayanan sosial sebelum dan sesudah pulang (carpenito,1999). perencanaan pulang didapatkan dari proses interaksi perawat profesional, pasien dan keluarga berkolaborasi untuk memberikan dan mengatur kontinuitas keperawatan. perencanaan harus berpusat pada masalah pasien, yaitu pencegahan, terapeutik, rehabilitatif, serta perawatan rutin yang sebenarnya (swenberg, 2000). komunikasi merupakan inti discharge planning kepada pasien, dan merupakan kewajiban perawat bagi pasien terutama karena dengan perilaku caring dari perawat bisa menurunkan stress hospitalisasi pada pasien selama di rawat (putra, 2005). menurut supriyo(2006) kinerja perawat yang mempunyai pengetahuan baik menunjukkan peningkatan discharge planning pada pasien yang dirawat, serta sikap yang positip ditunjukkan perawat akan berdampak terhadap pelaksanaan penerapan discharge planning dalam memberi asuhan keperawatan, sehingga bukti layanan keperawatan akan memberikan citra yang baik pada rumah sakit di masa yang akan datang, serta terpenuhi kebutuhan perawatan berkesinambungan yang berdampak meminimalkan komplikasi yang terjadi. penyakit di ruang tropik infeksi wanita sebagian besar akut dan tingkat ratarata ketaatan minum obat dengan obat jangka pendek adalah 78% (sarafino,1990). taylor (1990) menyebut ketidaktaatan ini sebagai masalah medis yang berat, dan oleh karena itu sejak tahun 1960-an sudah mulai diteliti di berbagai negara industri. la greca dan stone (1985) menyatakan bahwa mentaati rekomendasi pengobatan merupakan masalah yang sangat penting (smet, 1994). pada kasus di ruangan dengan penyakit yang kadang dianggap remeh ini, pasien menjadi malas minum obat ketika dirasa badan sudah mulai enak, misalnya pasien kadang jadi enggan minum obat ketika sudah tidak ge. kejadian pada waktu peneliti dinas sore ditemukan obat vitamin yang seharusnya diminum jam 6 pagi tidak minum oleh pasien dan itu terjadi dua hari berturut-turut. hal ini terjadi karena pasien merasa sudah sembuh sehingga tidak perlu minum obat. peranan perawat di dalam perilaku kepatuhan sering diremehkan sehingga harus diperbaiki komunikasi antar petugas kesehatan yang disertai dukungan sosial dari keluarga sebagai pendukung mutlak diperlukan (taylor, 1990, sarafino, 1990), (ley, 1992 yang dikutip oleh smet, 1994). bahan dan metode desain penelitian yang digunakan dalam penelitian ini adalah quasy experiment post test only control group design yaitu satu kelompok dilakukan intervensi sesuai dengan metode yang dikehendaki ,sedangkan kelompok lain dilakukan intervensi seperti biasa (patricia ann d, arthur d.d, 2002). populasi pada penelitian ini adalah pasien dan keluarga pasien yang rawat inap di ruang tropik infeksi wanita rsu dr. soetomo surabaya sebanyak 15 orang. sampel yang digunakan dalam penelitian ini adalah 14 responden pasien dan keluarga pasien yang rawat inap di ruang tropik infeksi wanita rsu dr. soetomo surabaya yang memenuhi klriteria inklusi yaitu pasien baru yang masuk diruang tropik infeksi wanita, pasien dengan usia 20 tahun sampai dengan 60 tahun, tidak ada gangguan jiwa atau gangguan kesadaran, bersedia menjadi responden, pasien kooperatif, pasien dhf gr i dan ii, pasien ge tanpa komplikasi. penelitian ini dilakukan pada 15 januari 5 februari 2009. variabel independen dalam penelitian ini adalah pelaksanaan discharge planning mulai awal mrs, selama dirawat di ruangan dan sebelum krs, sedangkan variabel dependen adalah kepatuhan pengobatan selama pasien rawat inap di ruang tropik infeksi wanita. instrumen yang digunakan dalam penelitian ini adalah kuesioner kepatuhan pengobatan selama mrs pada kelompok perlakuan dan informasi lisan kepada kelompok kontrol meliputi penyakit dhf dan ge tentang nutrisi, aktivitas, data yang diperoleh ditabulasi kemudian dianalisis dengan menggunakan uji statistik wilcoxon signed rank test dan uji mann whitney u test dengan derajat kemaknaan α<0,05. hasil berikut ini akan disajikan data yang berkaitan dengan penerapan discharge planning terhadap kepatuhan pada pengobatan pada pasien dhf dan ge selama dirawat di ruang tropik infeksi wanita. pada kelompok kontrol sebelum dan sesudah diberikan uji kuesioner dengan tanpa informasi tertulis hanya lisan seperti yang sudah diterapkan di ruangan. kelompok perlakuan sebelum dan sesudah diadakan uji kuesioner dengan diberikan intervensi berupa informasi tertulis mulai awal mrs dengan pemberian penerimaan pasien baru secara tertulis kemudian diberikan penjelasan tentang pemberian obat, nutrisi dan aktivitas selama dirawat di ruangan kemudian di beri leafleat tentang masing-masing penyakit dhf atau ge kemudian dilakukan pengukuran tentang kepatuhan pada pengobatan dari kelompok kontrol dan perlakuan yang telah berikan discharge planning selama perawatan dibandingkan dengan kelompok tanpa discharge planning selama perawatan. pada tabel 1 dapat dilihat bahwa terdapat pengaruh discharge planning terhadap kepatuhan pengobatan (obat, nutrisi dan aktivitas) selama dirawat di ruang tropik infeksi wanita dengan nilai p=0.028 pada dhf kontrol dan p=0.025 pada dhf perlakuan yang berarti p≤0.05. pada tabel 2 dapat dilihat bahwa terdapat pengaruh discharge planning terhadap kepatuhan pengobatan (meliputi obat, nutrisi dan aktivitas) pada pasien ge selama di rawat di ruang tropik infeksi wanita, yaitu nilai p=0.012 pada kelompok kontrol dan p=0.027 pada kelompok perlakuan. nursalam tabel 1. pengaruh discharge planning terhadap kepatuhan pengobatan (meliputi obat, nutrisi dan aktifitas) pada dhf selama dirawat di ruang tropik infeksi wanita 15 januari – 5 pebruari 2009 kontrol perlakuan post pre post pre post post post mean 51.11 77.79 37.50 50.00 77.79 50.00 sd 24.91 33.33 47.87 57.74 33.33 57.74 uji wilcoxon signed ranks p= 0,028 wilcoxon signed ranks p=0,025 mann whitney u test p=0,028 tabel 2. pengaruh discharge planning terhadap kepatuhan pengobatan (meliputi obat, nutrisi dan aktifitas) pada ge selama dirawat di ruang tropik infeksi wanita 15 januari – 5 pebruari 2009. kontrol perlakuan post pre post pre post pos post mean 41.25 74.584 77.79 50.00 74.584 50.00 sd 34.45 18.15 33.33 57.74 18.15 57.74 uji wilcoxon signed ranks p=0,012 wilcoxon signed ranks p=0,027 mann whitney u test p=0,046 keterangan: mean = rerata sd = standar deviasi p = signifikansi pembahasan tingkat kepatuhan pada pengobatan pasien setelah diberikan discharge planning mengalami peningkatan yang signifikan. pada kelompok perlakuan hampir seluruh responden mengalami peningkatan kepatuhan terhadap pengobatan setelah diberikan discharge planning meliputi kepatuhan pada pemberian obat oral dan injeksi, nutrisi dan aktifitas yang disarankan selama dirawat. kepatuhan pada obat yang dikonsumsi pasien mutlak diperlukan dalam terapi terutama antibiotika untuk mencegah resistensi obat pada pasien sehingga peran perawat sebagai edukator diperlukan agar tidak terjadi kekambuhan pada pasien yang dirawat. pasien dhf yang menjadi kriteria inklusi dalam penelitian ini adalah grade i dan ii tanpa komplikasi, sehingga hanya mendapat vitamin baik oral maupun injeksi, dan infus dengan rl dan obat penurun panas karena rehidrasi dengan cairan infus merupakan inti perawatan dhf. tingkat kepatuhan terhadap aktifitas yang disarankan pada pasien dhf sangat baik yaitu mau menggunakan kursi roda ketika mau bab/bak saat kadar trombosit kurang dari 70.000 karena jika banyak aktifitas ditakutkan terjadi perdarahan. pengobatan merupakan suatu kegiatan yang dilaksanakan oleh kedokteran dan keperawatan berdasarkan uu no. 23 tahun 1992. kegiatan tersebut meliputi obat yang diterapi oleh dokter dan dilaksanakan oleh perawat dalam hal distribusi sampai terminum oleh pasien. upaya penyembuhan dengan cara apapun, baik dengan terapi pengobatan, operasi, penyinaran maupun terapi kombinasi, selalu memerlukan dukungan nutrisi karena kebutuhan pasien akan makanan harus terpenuhi. dukungan nutrisi hasil pengobatan lebih efisien, pasien lebih cepat sembuh sehingga lama perawatan bisa berkurang dan biaya bisa dihemat, waktu penyembuhan lebih cepat dan pasien dapat segera masuk kerja yang berarti produktifitas kerja bisa dicapai (tirtawinata, 2006). tetapi kepatuhan pada nutrisi yang disarankan petugas kadang sangat dipengaruhi oleh selera dan kebiasaan tata nilai yang ada pada diri pasien sendiri (otonomi), sehingga kesadaran merupakan hal yang harus dimunculkan oleh pasien dengan bantuan kita sebagai perawat. pemberian nutrisi yang adekuat merupakan jaminan yang paling baik pada penderita untuk mengatasi penyakitnya. jadi jelas bahwa nutrisi merupakan bagian integral dari pengobatan (tandra, h., 1993). kesukarelaan tentu harus pula dipicu oleh adanya motivasi yang harus dibangun oleh tenaga kesehatan misal pada pasien ge disarankan untuk makan bubur karena masih diare tetapi pada sebagian orang ada yang jika makan bubur malah muntah ,perawat hendaknya bisa menyelaraskan antara kesembuhan pasien dengan selera pasien. pasien dengan penyakit ge diberikan penyuluhan dalam bentuk pemberian leafleat terapi dengan oralit ini diberikan dengan rincian isi: air matang 200 cc ditambah 1 sendok teh gula pasir ditambah ¼ sendok teh garam. oralit ini akan sangat membantu ketika pasien masih di rumah belum mendapat pertolongan medis. nutrisi yang harus dimonitor oleh perawat dalam pelaksanaan kepatuhan akan diit misal pada pasien ge diberitahu untuk tidak minum susu dahulu selama diare dan menghindari makanan yang berserat tinggi. meskipun tugas tersebut telah ditangani oleh ahli gizi tetapi dalam observasi 24 jam tetap menjadi tugas perawat. aktifitas yang disarankan untuk ge ini adalah kesediaan untuk tidur ditempat tidur lubang karena melakukan monitor jumlah, warna dan juga konsistensi dari faeces yang dikeluarkan. sehingga untuk memudahkan pengukuran volume faeces yang dikeluarkan, juga untuk observasi tipe diare berdasarkan kuman penyebab. pasien ge dengan dehidrasi berat mudah taat pada aturan karena mereka datang dalam kondisi lemas dan kadang dirsertai syok hipovolemik. sedangkan pada pasien ge ketaatan untuk mau tidur di tempat tidur lubang mengalami penurunan pada post test karena pasien sudah bisa menahan ge sehinga mereka bisa bab dan bak ke kamar mandi. ketidak nyamanan ditempat tidur lubang disebabkan oleh bau, rasa sakit pada daerah pinggang biasanya dirasakan oleh pasien yang lama di tempat tidur lubang, tetapi bagi yang ge masih profus tempat tidur ini merupakan tempat yang aman karena pasien tidak usah sering ke kamar mandi karena dapat langsung buang air besar di lubang tersebut. proses pembentukan atau perubahan perilaku dipengaruhi oleh beberapa faktor yang berasal dari dalam individu. berbagai aspek komunikasi mempengaruhi tingkat ketidaktaatan pada diri pasien antara lain adalah komunikasi antara pasien dan dokter, juga antara pasien dan perawat. perawat mempunyai waktu 24 jam untuk bersama pasien sehingga perawat harus memfasilitasi kepatuhan pasien pada pengobatan selama dirawat, terutama dengan discharge planning. informasi tertulis dalam bentuk brosur atau leaflet dapat membantu menguatkan informasi yang telah diberikan pada pasien, sehingga dapat mengingatkan sikap dan tindakan mereka tentang apa yang seharusnya dilakukan di rumah dan apa yang harus dihindari. dokumentasi sangat dibutuhkan dalam menghadapi keluhan pasien, juga tuntutan yang mungkin terjadi jika sewaktu-waktu terjadi hal-hal yang tidak kita inginkan. penerapan discharge planning sangat diperlukan bagi pasien di rumah sakit dr. soetomo karena merupakan rumah sakit rujukan terbesar di indonesia bagian timur sehingga manajemen dan sumber daya yang ada merupakan aset terbesar dari rumah sakit tersebut. diharapkan pasien setelah pulang dari rumah sakit ini punya kesan yang baik terhadap pelayanan rumah sakit. informasi dan komunikasi merupakan ujung tombak pelayanan, dengan semboyan ”katakan pada orang lain kalau anda puas dan katakan kepada kami jika anda tidak puas”. semboyan tersebut sebagai pedoman dalam memperbaiki kualitas pelayanan sehari-hari demi tercipta hubungan yang harmonis antara pasien, perawat beserta keluarga yang terlibat dalam perawatan. pada akhirnya misi rumah sakit sebagai terdepan dalam pelayanan dan senantiasa mengutamakan kesehatan penderita dapat tercapai. nursalam nursalam simpulan dan saran simpulan discharge planning yang diberikan selama perawatan pasien dapat meningkatkan kepatuhan pasien dhf dan ge yang meliputi obat oral dan injeksi, nutrisi dan aktifitas selama pasien dirawat. saran peneliti menyarankan supaya discharge planning yang dilakukan mulai awal mrs, selama dirawat dan ketika mau krs, dapat dijadikan suatu acuan atau protap dalam memberikan asuhan keperawatan yang paripurna untuk meningkatkan kualitas pelayanan kepada masyarakat, bagi rumah sakit discharge planning ini merupakan alat untuk memberikan pelayanan yang prima sehingga mutu pelayanan bisa ditingkatkan, perlu dilakukan penelitian tentang pengaruh disharge planning terhadap mutu asuhan keperawatan dan pasien safety. kepustakaan putra.s. t. 2005. psikoneuroimunologi kedokteran. surabaya:gideon offset, hlm. 5-11. smet. 1994. psikologi kesehatan. jakarta: grasindo, hlm. 251-257. swansburg, russel c. 2000. pengantar kepemimpinan dan manajemen keperawatan. jakarta: egc, hlm. 282-284. supriyo. 2006. hubungan pengetahuan dan sikap perawat dalam penerapan discharge planning di ruang graha nuur afiah rs haji surabaya. skripsi tidak dipublikasikan. surabaya: program studi ilmu keperawatan fakultas kedokteran universitas airlangga, hlm. 25-27, 56. tirtawinata, ct. 2006. makanan dalam perspektif alquran dan ilmu gizi, jakarta: fkui, hlm. 12. taylor, et al. 1997. fundamentals of nursing the art and science of nursing care. philadelphia: lippincott, pp. 70-75. tandra, h. 1994. gizi klinik. surabaya:tim gizi klinik rsu dr. soetomo, hlm.75. pengaruh pernafasan active cycle of breathing terhadap peningkatan aliran ekspirasi maksimum pada penderita tuberkulosis paru ekstrak biji duwet (eugenia jambolana) mampu menurunkan kadar gula darah (eugenia jambolana seed decrease blood glucose level ) i ketut sudiana*, tintin sukartini*, hepta nur anugrahini** * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031)5913257 e-mail: ik.sudiana@unair.ac.id ** politeknik kesehatan soetomo surabaya abstract introduction: the incidence of diabetes mellitus still increasing and needed a cost-effective complementary therapies such as eugenia jambolana seeds. eugenia jambolana seeds contain of chromium and tannin. it has been reported that eugenia jambolana seeds has ability to decrease blood glucose, and increase hdl level significantly. the objective of this study was to investigate the effect of eugenia jambolana seed to exchange of blood glucose in streptozotocin-diabetic rats. method: a true experimental post test only control group design was used in this study. a number of 15 male albino wistar rats weighing 100-200 gram were divided into 3 group (normal group, diabetic group and experiment group), 5 rats in each group. normal group and diabetic group were given aqua 2ml/200 g bw as placebo. eksperiment group were fed eugenia jambolana seeds extract 500 mg/kg b.w for 15 days. data were analyzed by using one way anova with significance level α≤0.05.result: the result showed that blood glucose level of experiment group was significantly different from diabetic group (p=0,001). discussion: it can be concluded that eugenia jambolana seeds extract (500 mg/kg b.w) has an effect to decrease blood glucose level in streptozotocin-induced diabetic rats. keywords: eugenia jambolana, streptozotocin, diabetes mellitus, blood glucose pendahuluan diabetes mellitus (dm) merupakan gangguan metabolik yang dikarakteristikkan dengan abnormalitas metabolisme bahan bakar dalam tubuh yang terutama menghasilkan hiperglikemia dan dislipidemia. hiperglikemia menyebabkan berbagai komplikasi hingga menyebabkan kematian pada diabetesi (pittas & greenberg, 2003). kontrol yang baik pada hiperglikemia akan meningkatkan kualitas hidup diabetesi (penderita dm) (departemen kesehatan ri, 2005). penggunaan bahan alami dalam mengontrol berbagai penyakit termasuk dm (hiperglikemi) telah menjadi trend di seluruh dunia, tidak terkecuali di indonesia karena bahan alami memiliki efek samping dan toksisitas lebih rendah, efek terapi yang baik, mudah diperoleh serta ekonomis (balai pom, 2005). salah satu bahan alami tersebut adalah duwet (eugenia jambolana) (yupiter s., 2006; ipteknet, 2005; republika, 2004). mallick (2005) menyatakan bahwa duwet dapat digunakan untuk menurunkan hiperglikemia serta memperbaiki profil lipid pada dm. duwet pun mampu menurunkan risiko aterosklerosis 60-90% (ipteknet, 2005). efek farmakologis duwet dapat diperoleh dari penggunaan buah, biji dan kulit kayu (sagrawat, et al., 2006 dan pepato et al., 2001). di indonesia buah dan kulit kayu duwet banyak digunakan secara turun temurun sebagai antidiabet dan antikolesterol, tetapi bijinya masih jarang dimanfaatkan (ipteknet, 2005). beberapa mineral dan senyawa aktif yang terdapat pada buah-buahan bermanfaat sebagai antidiabetik dan dapat menurunkan kadar hdl serta meningkatkan kadar ldl (linder, et al., 1992 dalam chattopadhyay dan bandyopadhyay, 2005). senyawa aktif yang terkandung dalam 2 biji duwet (eugenia jambolana) antara lain tannin dan kromium (noomrio dan dahot, 2005; indrayan et al., 2005; safdar, et al., 2006; sagrawat et al., 2006) yang mampu meningkatkan kepekaan reseptor insulin, sehingga meningkatkan ambilan glukosa ke dalam sel (dey et al., 2002; gomes et al., 2005; wang et al., 2005). penelitian ilmiah tentang biji duwet sebagai antidiabetik dan antidislipidemia di indonesia belum dilakukan sehingga efeknya terhadap perubahan kadar glukosa belum dapat dijelaskan. saat ini lebih dari 180 juta orang di dunia menderita dm dan jumlah tersebut akan mengalami peningkatan dua kali lipat pada tahun 2030. khusus di negara berkembang, jumlah penderita dm meningkat 150% pada 25 tahun yang akan datang (who, 2006). menurut who, pada tahun 2005 indonesia menempati urutan ke empat terbesar dalam jumlah diabetesi dengan prevalensi 8,6% dari total penduduk. data dari depkes ri menunjukkan fakta bahwa jumlah diabetesi yang menjalani rawat inap maupun rawat jalan di rs menempati urutan pertama dari seluruh penyakit endokrin. diabetic federation mengestimasikan jumlah diabetesi pada tahun 2001 mencapai 5,6 juta untuk usia di atas 20 tahun dan akan meningkat menjadi 8,2 juta pada tahun 2020 (depkes ri, 2005). diabetesi memiliki risiko terserang penyakit vaskuler 2,4 kali lebih tinggi dibandingkan klien tanpa diabetes mellitus (cda, 2006). sekitar 70-80% kematian diabetesi disebabkan karena penyakit vaskuler (chattopadhyay and bandyopadhyay, 2005). pada klien dengan diabetes mellitus terjadi gangguan aktifitas insulin yang menyebabkan hiperglikemia. hiperglikemia kronis dapat menimbulkan berbagai komplikasi mikrovaskuler, makrovaskuler atau keduanya. kontrol yang baik terhadap hiperglikemia dapat mencegah dan meminimalkan berbagai komplikasi (black and hawks, 2005). hiperglikemia dan dislipidemia ini apabila tidak segera diatasi dapat menimbulkan berbagai komplikasi berupa berbagai penyakit vaskuler seperti penyakit jantung koroner, stroke, penyakit vaskuler perifer maupun hipertensi dapat terjadi (copstead and banasik, 2005; white and duncan, 2002). diabetes mellitus menyebabkan disabilitas sampai kematian bagi diabetesi. masalah psikososial dapat dialami oleh diabetesi maupun keluarganya terkait terkait dengan peningkatan biaya perawatan untuk komplikasi yang dialami diabetesi. peningkatan biaya perawatan pada sistem kesehatan ini berdampak pada perekonomian negara yaitu penggunaan pemasukan nasional untuk perawatan diabetes yang terus meningkat. jadi, diabetes mellitus dan komplikasinya menimbulkan dampak yang signifikan baik bagi diabetesi, keluarga, sistem kesehatan dan pemerintah (who, 2006). berdasarkan hal tersebut peneliti tertarik untuk mengetahui pengaruh ekstrak biji duwet terhadap perubahan kadar gula darah pada tikus wistar jantan yang dibuat diabet dengan diinjeksi streptozotosin (stz). tikus dipergunakan sebagai hewan coba karena hewan ini mudah dipegang dan dikendalikan, dapat diambil darahnya dalam jumlah yang relatif besar serta memiliki fisiologi yang diperkirakan sesuai dengan manusia. pemilihan tikus jantan karena tidak mengalami siklus ekstrus sehingga pengaruh hormonal bisa diminimalkan (kusumawati, 2004). bahan dan metode desain yang digunakan dalam penelitian ini adalah true experimental post test only control group design. populasi dalam penelitian ini adalah tikus wistar putih (rattus novergicus strain wistar) jantan dari koloni yang sama, umur 10 minggu dengan berat badan 100-200 gram. dari populasi tersebut dipilih beberapa ekor secara random sebagai sampel penelitian yang terdiri dari 3 kelompok, yaitu kelompok kontrol normal/k1 (tikus yang diinjeksi buffer sitrat 0,1 ml/kg berat badan/bb intraperitoneal/ip), kontrol positif/k2 (tikus yang diinduksi dengan dosis tunggal stz 50 mg/kg bb ip dan hanya dibari aqua 2 ml/200 gr bb) dan kelompok perlakuan/k3 (tikus yang diinduksi dengan dosis tunggal stz 50 mg/kg bb ip dan diberi ekstrak biji duwet yang dilarutkan dalam 2 ml aqua/200 gr bb dengan dosis 500 mg/kg bb /hari). besar sampel tiap kelompok minimal 6 ekor. penelitian dilakukan selama januari sampai dengan februari 2008. variabel independen dalam penelitian ini adalah ekstrak biji duwet 500 mg/kg bb sedangkan variabel dependen adalah kadar glukosa darah tikus wistar. variabel kendali dalam penelitian ini berupa umur tikus 10 minggu, jenis kelamin tikus jantan, berat badan tikus 100-200 gram, makanan berupa p3 cp 524 dan minuman tikus berupa air, perawatan dan sanitasi kandang serta darah yaitu serum yang dijadikan bahan penelitian. data yang diperoleh, dianalisis dengan menggunakan uji statistik anova satu arah, karena distribusi normal dengan derajat kemaknaan p<0,05. pada penelitian ini data variabel tergantung tidak homogen dengan α≤0,05 sedangkan syarat suatu data dikatakan homogen jika p>0,05, maka untuk mengetahui beda antar perlakuan dipergunakan uji dunnett t3 (steel dan tornie, 1991). hasil hasil penelitian ini menunjukkan bahwa kadar glukosa berbeda secara bermakna (p<0,05) antara kelompok kontrol negatif, kelompok kontrol positif dan kelompok perlakuan dengan pemberian ekstrak duwet 500 mg/kg bb (lihat tabel 1). terdapat perbedaan yang bermakna (p=0,001) untuk kadar glukosa antara kelompok kontrol negatif dengan kelompok kontrol positif. kadar glukosa darah pada kelompok kontrol positif dengan kelompok perlakuan pun berbeda secara bermakna (p=0,001), namun tidak terdapat perbedaan yang bermakna antara kelompok kontrol negatif dengan kelompok perlakuan (p=0,512). pembahasan hasil uji anova menunjukkan perbedaan kadar glukosa secara bermakna antar k1, k2 dan k3. kadar glukosa darah puasa tikus pada k3 yang diberi ekstrak biji duwet 500 mg/kg bb setelah diperiksa pada hari ke 21 mempunyai rerata 118,80 mg/dl. angka tersebut berada pada kisaran angka glukosa darah normal pada tikus yaitu 50-135 mg/dl (kusumawati, 2004). rerata tersebut tidak berbeda jauh dengan kadar glukosa pada k1 yaitu 107,42 mg/dl. hasil uji dunnet t3 menunjukkan bahwa tidak ada perbedaan yang bermakna antara kadar glukosa pada k1 dan k3. hal ini membuktikan bahwa pemberian ekstrak biji duwet 500 mg/kg bb dapat menurunkan kadar glukosa serum hingga mendekati normal. sridhar, et al. (2005) dalam penelitiannya menunjukkan bahwa ekstrak biji duwet 500 mg/kg bb efektif untuk menurunkan kadar glukosa darah puasa pada tikus wistar yang diabetes akibat diinjeksi stz. kemampuan ekstrak biji duwet dalam menurunkan kadar glukosa diduga karena kandungan kromium dan tanin. kromium dan tanin bekerja dengan meningkatkan kepekaan reseptor insulin, sehingga insulin yang beredar dalam sirkulasi dapat dengan mudah berikatan dengan reseptor insulin. selanjutnya akan terjadi mobilisasi glukosa transporter ke permukaan membran sel untuk mengangkut glukosa masuk ke dalam sel terutama sel adiposa, sehingga glukosa dalam darah akan berkurang (linder et al, 1992; dey et al., 2002; liu x. et al., 2004; gomes et al., 2005). tabel 1 kadar glukosa serum tikus wistar yang diperiksa pada hari ke 21 pada kelompok kontrol negatif, kontrol positif dan kelompok perlakuan. dunnett t3 (i) kelompok (j) kelompok rerata perbedaan (i-j) p-value k1 k2 k3 -252,80* -11,40 0,001 0,512 k2 k1 k3 252,80* 241,40* 0,001 0,001 k3 k1 k2 11,40 -241,40* 0,512 0,001 anova f. hitung=83,817 p=0,000 keterangan: k1 = kelompok normal/negatif k2 = kelompok positif k3 = kelompok perlakuan p = signifikansi * = selisih rerata perbedaan signifikan pada level 0,05 transporter glukosa yang mengangkut glukosa ke dalam sel adiposa adalah glut 4 (copstead and banasik, 2005). menurut dri (dietery reference ingestin) kadar kromium untuk manusia dewasa perhari 25-35 mcg (gomes et a.l, 2005). diabetisi membutuhkan tambahan suplemen kromium antara 125-200 mcg (gomes et al., 2005). 1 gram biji duwet mengandung 0,003% kromium yang setara dengan 30 mcg kromium (indrayan et al., 2005). ekstrak biji duwet 500 mg mengandung kromium 15 mcg. pada dosis ini kromodulin sudah mampu terikat pada active side reseptor insulin menyebabkan teraktivasi dan mengamplifikasi sinyal (vincent, 2000; cefalu and hu, 2004; gomes et al., 2005). kadar glukosa serum pada k1 dan k3 berbeda signifikan dengan k2, karena tikus pada k2 mengalami diabetes dan tidak mendapatkan pengobatan apapun, sehingga kadar glukosa serum tetap tinggi di atas 250 mg/dl. jadi dapat disimpulkan bahwa ekstrak biji duwet 500 mg/kg bb dapat digunakan sebagai antidiabetik. simpulan dan saran simpulan ekstrak biji duwet dapat menurunkan kadar glukosa pada tikus wistar putih yang mengalami diabetes akibat diinduksi stz. saran peneliti menyarankan agar kandungan kromium pada ekstrak biji duwet sebaiknya diketahui terlebih dulu sebelum digunakan sebagai bahan penelitian selanjutnya, model diabetes mellitus (dm) yang digunakan pada penelitian selanjutnya sebaiknya menggunakan model dm kronis, pada penelitian selanjutnya, waktu pemberian dan pengamatan dapat ditambah menjadi 2030 hari dan penggunaan beberapa dosis ekstrak biji duwet pada penelitian selanjutnya sehingga hasil dapat dibandingkan. kepustakaan balai pom. 2005. mengenal beberapa tanaman yang digunakan sebagai antidiabetika, (online), (http://www.javascript.co.id, diakses tanggal 12 nopember 2007, jam 09.00 wib). black and hawks. 2005. medical surgical nursing: clinical management for positive outcomes, 7th edition. missouri: elsevier saunders, pp. 12431288. canadian diabetes association (cda). 2006. dyslipidemia in adult with diabetes. canadian journal of diabetes, 30(3). pp. 230-240. cefalu and hu. 2004. role of chromium in human health and in diabetes, diabetes care, 27(11), hlm. 27412751. chattopadhyay, r.r. and badyoradhyay, m. 2005. effect of azadirochta indica leaf on serum lipid profile changes in normal and streptozotocin induced diabetic rats. african journal of biomedical research, 8(2), hlm. 101104. copstead and banasik. 2005. pathophysiology, missouri: elsevier saunders. pp. 398-402; 465-471; 10001025. depkes ri. 2005. diabetes mellitus masalah kesehatan masyarakat yang serius, (online), (http://www.depkes.go.id, diakses tanggal 12 nopember 2007, jam 09.20 wib). dey, l., anoja, s., attele and yuan, c.s. 2002. alternative therapies for type 2 diabetes. alternative medicine review, 7(1), pp. 45-58. gomes, m.r., rogero, m.m. and tirapegui, j. 2005. consideration about chromium, insulin and physical exercise. rev bras med esporte,11(5), pp. 246e-250e. indrayan, a.k., sharma, s., durgapal, d., kumar, n., and kumar m. 2005. detremination of nutritive value and analysis of mineral elements for some medicinally valued plants from uttarancal. current science, 84(7). pp. 1252-1255. ipteknet, 2005. jamblang, (online), (http://www.iptek.net.id, diakses http://www.javascript.co.id/ http://www.depkes.go.id/ http://www.iptek.net.id/ tintin sukartini tanggal 12 nopember 2007, jam 09.10 wib). kusumawati, d. 2004. bersahabat dengan hewan coba. yogyakarta: gadjah mada university press, pp. 8-10; 64. 68; 82-91. linder, m.c. et al. 1985. biokimia nutrisi dan metabolisme: dengan pemakaian secara klinis. terjemahan oleh aminudin parakkasi, 1992, jakarta: universitas indonesia press, hlm. 315; 587-622. liu, x., kim, j., li, y., li, j., liu, f. and chen, x. 2004. tannic acid stimulates glucose transport and inhibit adipocyte differentiation in 3t4-l1 cells, american society for nutritional science, hlm. 165.171. mallick, c., maiti, r., ghosh, d. 2005. comparative study on antihiperglicemic and antihiperlipidemic effect of sparate and composite exstract of seed of eugenia jambolana and root of musa paradisiaca in streptozotocin-induced diabetic male albino. iranian journal of pharmachology and therapeutics, 5 (1), hlm. 27-33. noomrio, m.h. and dahot, m.u. 2005. nutritive value of eugenia jambosa fruit. journal of islamic academia of science. 9(1), hlm. 9-12. pepato, m.t., folgado, v.b., kettelhut, i.c., and brunetti. 2001. lack of antidiabetic effect of eugenia jambolana leaf decoction on rat streptozotocin diabetes. journal of medical and biological research, 34, pp. 389-395. pittas, a.g. & greenberg, a.s. 2003. contemporary diagnosis and management of diabetes, newton pa: handbooks in health care co. republika. 2004. atasi mencret dan diabetes dengan jamblang, (online), (http://www.republika.co.id, diakses tanggal 12 november 2007, jam 09.20 wib). safdar, m., khan, a., and habibullah. 2006. effect of jaman fruit extract on serum glucose and lipid profile in type 2 diabetic individuals. pakistan journal of nutrition, 5(6), pp. 573576. sagrawat, h., mann, a.s. and kharya, m.d. 2006. phcog mag: review article pharmacological potential of eugenia jambolana. a review pharmacological magazine, 2(6), pp. 96-105. sridhar, s.b., sheetal, u. d., pai, m.r.s.m. and shastri, m.s. 2005. preclinical evaluation of the antidiabetic effect of eugenia jambolana seed powder in streptozotocin-diabetic rats. brazillian journal of medical and biological research, 38(3), pp. 463468. vincent, j.b. 2000. mechanism of chromium action: low-molecular-weight chromium-binding substance. journal of american college of nutrition, 18(1), pp. 6-12. wang, z.q., zhang, x.h., russel, j.c., hulver, m., cefalu, w.t. 2005. chromium picolinate enhances skeletal muscle cellular insulin signaling in vivo in obese, insulin resistance jcr:la-cp rats, the journal of nutrition, pp. 415-420. white, l. and duncan, g. 2002. medical surgical nursing: an integrated approach, 2nd edition. new york: delmar, pp. 696-710. world health organization (who). 2006. definition and diagnosis of diabetes mellitus and intermediate hyprglycemia, report of a who/idf consultation. yupiter, s. 2006. diabetes tumbang berkat jamblang, intisari no. 520 th. xliii, november 2006. http://www.republika.co.id/ 156 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.7712 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research perceived benefits and intakes of protein, vitamin c and iron in preventing anemia among pregnant women mira triharini1, nursalam nursalam1, agus sulistyono2, merryana adriani3 and pei-lun hsieh4 1 nursing faculty, universitas airlangga, surabaya, indonesia 2 dr. soetomo general hospital surabaya, indonesia 3 public health faculty, universitas airlangga, surabaya, indonesia 4 chung hwa university of medical technology, taiwan abstract introduction: nutritional adequacy is essential in ensuring the normal growth and development the fetus. perceived benefits will be able to strengthen pregnant women to meet optimum nutritional intake to prevent anemia. adequacy of protein, vitamin c and iron will reduce the risk of iron deficiency anemia in pregnancy. this study aims to examine the association between perceived benefits with protein, vitamin c, and iron intake in preventing pregnancy anemia. methods: this study used a cross sectional design and was conducted in augustoctober 2017 among 105 pregnant women. this study used the multistage random sampling method. the population of this study were pregnant women who had antenatal care in four community health centre in surabaya namely jagir, medokan ayu, sidotopo wetan, and gundih. results: the average daily protein intake was 76.34 (sd = 35.88) gram / day. there was a significant association between perceived benefits with protein intake (r = 0.272; p = 0.005). the average daily vitamin c intake was 90.67 (sd = 116.54) mg / day. there was no significant association between perceived benefits and vitamin c intake (r = 0.175; p = 0.074). the average daily iron intake was 64.73 (sd = 23.13) mg / day. there was a significant association between perceived benefits and iron intake (r = 0.219; p = 0.025). conclusion: the knowledge of pregnant women about the benefits of nutrition will affect the adequacy of pregnancy nutrition. health workers need to provide health education on the importance of nutrition for pregnant women to prevent anemia during pregnancy. article history received: feb 21, 2018 accepted: nov 28, 2018 keywords anemia during pregnancy; iron deficiency; perceived benefits; protein; vitamin c contact mira triharini  mira-t@fkp.unair.ac.id  nursing faculty, universitas airlangga, surabaya, indonesia cite this as: triharini, m., nursalam, n., sulistyono, a., adriani, m., & hsieh, p,l. (2018). perceived benefits and intakes of protein, vitamin c and iron in preventing anemia among pregnant women. jurnal ners, 13(2), 156-161. doi:http://dx.doi.org/10.20473/jn.v13i2.7712 introduction nutritional adequacy during pregnancy will affect the condition of the fetus. the incidence of malnutrition in pregnant mothers will lead to fetal development disorders, preterm labor, infant growth disorders, and the risk of development of chronic diseases (metgud, naik, & mallapur, 2012). preeclampsia and gestational diabetes are also associated with poor nutrition (acharya et al., 2016; ahmed & tseng, 2013). iron deficiency anemia remains a common problem in pregnancy. a study in the obstetric department of the first affiliated hospital of guangxi medical university showed that there were more than 70% of pregnant mothers having iron deficiency anemia. that study result showed the incidence of preterm deliveries and low birth weight babies were significantly more in mothers who were anemic in the third trimesters of pregnancy (huang, purvarshi, wang, zhong, & tang, 2015). several studies have shown factors related to the incidence of maternal anemia (mekuria, bekele, tilahun, & bekele, 2016; p. singh, khan, & mittal, 2013).study in nepal found as many as 41.02% of pregnant mothers had anemia and the prevalence was higher in the second trimester of pregnancy and at the age of 20-35 years(p. singh et al., 2013). a https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 157 research in southern ethiopia showed labor spacing of less than two years, iron supplementation, and the number of family members which is more than members two affected the incidence of anemia (mekuria et al., 2016). several studies supported the relationship between nutrition and hemoglobin levels (bahar, 2011; m. b. singh, fotedar, & lakshminarayana, 2009; thomson et al., 2011).a research in indonesia showed that maternal education level, nutritional status, and the intake of iron supplement, vitamin c were significantly associated with pregnancy anemia (bahar, 2011). research in indian western rajasthan shows the majority of pregnant women have anemia showed a lack of protein and iron (m. b. singh et al., 2009). nutritional problems in pregnant mothers can be caused by the presence of micronutrient interactions. interactions between micronutrients will affect the absorption and bioavailability, such as the negative effects of calcium on iron absorption, while on the other hand vitamin c will increase the absorption of iron. an understanding of the interactions between micronutrients in nutrient intake is necessary as it will help to reduce the risk of micronutrient deficiency, improve micronutrient status, and reduce the risk of deficiency (sandström, 2001). the adequacy of nutritional needs in pregnant mothers will be met if they understand about the importance of nutrition in pregnancy. knowledge of nutrition in pregnant mother sis influenced by several factors. a study at gote geda woreda, east wollega zone, ethiopia showed that the information on nutrition had a significant relationship with the knowledge of pregnant mothers about nutrition .that study showed women who had information about nutrition were 3.6 times more likely knowledgeable about nutrition as compared to the pregnant women with no information about nutrition during pregnancy (aor=3.59) (fekadu beyene, 2013).the adequacy of protein, vitamin c, and iron in the daily diet of pregnant mothers needs to be considered because it has a role to prevent anemia (abdelwahid, 2013; brown & shapiro, 1996; rivera-rodriguez, rodríguez-rivera, roman-julia, & raul, 2016; sriramanakoppa, sreenivas, & jayaram, 2015). pregnant mothers need to be givena health education about foods that contain of protein, vitamin c, and iron during antenatal care.midwivesplayan important role to improve the understanding ofpregnant mothers (arrish, yeatman, & williamson, 2017). health education for pregnant mothers which focus on the perceived benefits about healthy nutrition will improve the nutritional behavior (khodaveisi, omidi, farokhi, & soltanian, 2017). currently there are not many studies that see the association between perceived benefits and nutritional intake to prevent anemia. this study aimed to examine the association between perceived benefits and the intake of protein, vitamin c, and iron in preventing pregnancy anemia. materials and methods the population of this study were pregnant mothers who examined the pregnancy in four community health center in surabaya namely jagir, medokan ayu, sidotopo wetan, and gundih surabaya. this study used multistage random sampling. this study used a cross sectional design which was conducted in august-october 2017 among105 pregnant mothers. the inclusion criteria were pregnant mothers and those who had obtained iron tablet from community health center. the exclusion criteria were pregnant mothers who had complications that required medical treatment. the data collected in this research included perceived benefits and the intake of protein, vitamin c, and iron. the demographic characteristics questionnaire consists of several questions that include age, parity, education level, income, and gestational age. the questionnaires of perceived benefits were developed by researchers with items based on the theory of prevention of maternal anemia and the pender health-promotion model (hpm) (pender, 2011; sharma & shankar, 2010). whilst preparing the questionnaire contents, the researchers were assisted by two experienced nurses in the field of maternity nursing. translation was accomplished by a qualified translator from indonesia. perceived benefits were measured using a questionnaire based on health promotion model theory and anemia theory (sharma & shankar 2010; pender 2011). before use in data collection, the compiled questionnaires were tested for validity and reliability on 15 pregnant women who attended antenatal care at the community health centre of keputih surabaya. the questionnaire consists of six questions. the cronbach’s α was 0.911. the six questions featured a likert scale with the following option strongly agree, slightly agree, hesitate, slightly disagree, strongly disagree. measurement of the intake of protein, vitamin c, and iron was done by 1 x 24 hours of food recall method in which the result was expressed in grams and mg (supariasa, bakri, & fajar, 2002). sample recruited was conducted after obtaining ethical approval from health research ethics committee of faculty of public health airlangga university surabaya indonesia (no 123-kepk). informed consent was obtained after pregnant mothers agree to participate in this research. data analysis using spearman's rho was used to determine the association between the perceived benefits and the intake of protein, vitamin c and iron. descriptive statistics used frequency, percentage, mean and standard deviation to identify demographic characteristics, perceived benefits, and nutritional intake. the level of significance used alpha 0.05. the p value <0.05 indicated a significance. all data were analyzed using spss software. m. triharini et al. 158 | pissn: 1858-3598  eissn: 2502-5791 results table 1 shows the socio demographic characteristics and nutrition intake of protein, vitamin c, and iron. the majority of respondents (n = 73, 68%) were 2535 years old. most of respondents (n = 73, 69.5%) had parity 1-3. most of respondents (n = 81, 77.1%) had secondary education. the majority of respondents (n = 72, 68.6%) had an income below 3 million rupiah per month. most of the respondents (n = 88, 83.8%) had gestational age below 37 weeks. the greatest protein intake was in age 25-35 years (79.82 ± 38.09), parity was> 3 (93.90 ± 125.31), elementary education (79.04 ± 61.54), income was ≥ 3 million rupiah (80.56 ± 44.76), and gestational age was ≥ 37 weeks 81.02 ± 36.36). the greatest vitamin c intake was in age> 35 years (102.15 ± 130.03), parity was> 3 (209.70 ± 176.35), university education (116.58 ± 156.27), income was ≥ 3 million rupiah (101.42 ± 139.76) and gestational age was ≥ 37 weeks 81.02 ± 186.05). the greatest iron intake was in age > 35 years (66.11 ± 15.87), nullipara (322.3 ± 112.8), university education (65.42 ± 9.67), income was <3 million rupiah (65.81 ± 24.14) and gestational age was ≥ 37 weeks 71.98 ± 10.11). from five statements about the perceived benefits, the statement of "consumption of nutritious and high iron will make the baby healthy" has the highest score (4.48 ± 0.54) and "regular consumption of iron tablets can prevent infection" has the lowest score (4.10 ± 0.74) (table 2). the average score of perceived benefits was 25.64 (95% ci 25.08-26.20). the average protein intake of the study population was 76.34 (sd = 35.88) g/day. this was equivalent to 99.14 per cent of rda recommended value for pregnant mothers in this population. there was a significant association between perceived benefits and the protein intake with positive and moderate association (r = 0.272; p table 1. nutrition intake in pregnant mothers (n=105) no n(%) protein (gram/day) vitamin c (mg/day) iron (mg/day) mean sd mean sd mean sd age < 25 years 25 (23.8) 67.07 30.01 67.78 78.43 63.86 26.93 25-35 years 73 (69.5) 79.82 38.09 102.15 130.03 64.89 22.58 > 35 years 7 (6.7) 73.16 27.99 52.67 49.27 66.11 15.87 parity 0 30 (28.6) 73.77 35.31 106.49 119.33 65.14 26.07 1-3 73 (69.5) 76.92 36.56 80.91 113.38 64.64 22.01 >3 2 (1.9) 93.90 25.31 209.70 176.35 61.95 32.46 education elementary 14 (13.3) 77.49 31.76 115.25 166.31 65.26 33.86 secondary 81 (77.1) 75.81 32.89 83.22 100.83 64.55 22.34 university 10 (9.5) 79.04 61.54 116.58 156.27 65.42 9.67 income (rupiah) < 3 million 72 (68.6) 74.40 31.15 85.75 104.94 65.81 24.14 ≥ 3 million 33 (31.4) 80.56 44.76 101.42 139.76 62.37 20.94 gestasional age < 37 week 88 (83.8) 75.44 35.92 80.31 95.91 63.33 24.67 ≥ 37 week 17 (16.2) 81.02 36.36 144.30 186.05 71.98 10.11 note: 13.500 rupiahs equal to 1 us $ table 2. items of perceived benefits analysis (n=105) no items mean sd 1 consumption of nutritious foods and highiron will make the baby healthy 4.48 0.54 2 consumption of nutritious foods and highironwill make deliveries smooth 4.29 0.63 3 regular consumption of iron tablets will make mothers become not quickly tired 4.24 0.69 4 regular consumption of irontabletscan prevent infection 4.10 0.74 5 washing hands before eating is important in preventing anemia of pregnant mothers 4.18 0.83 6 using footwear when out of home is necessary for the health of pregnancy 4.36 0.69 table 3. the relationship between perceived benefits and nutritional intake (n=105) no variable mean sd rda value % of rda value min-max r p-value 1 perceived benefits 25.64 2.89 19-30 2 protein (gram) 76.34 35.88 77 99.14 76.34-250.9 0.272 0.005 3 vitamin c (milligram) 90.67 116.54 85 106.67 0.8-629.7 0.175 0.074 4 iron (milligram) 64.73 23.13 126 51.37 9.6-125.3 0.219 0.025 sd standard deviation; rda: recommended dietary allowance; r = spearman correlation coefficient; p< 0.05 jurnal ners http://e-journal.unair.ac.id/jners | 159 = 0.005). the average of vitamin c intake of the study population was 90.67 (sd = 116.54) mg/day. this was equivalent to 106.67 per cent of rda recommended value for pregnant mothers in this population. there was no significant association between perceived benefits and vitamin c intake (r = 0.175; p = 0.074). the average of iron intake of the study population was 64.73 (sd = 23.13) mg/day. this was equivalent to 51.37 per cent of rda recommended value for pregnant mothers in this population. there was a significant association between perceived benefits and iron intake with possitive and weak association (r = 0.219; p = 0.025) (table 3). discussion the result of this study found that the statement of "consumption of nutritious foods and high iron will make the baby healthy" had the highest score, while the statement of "regular consumption of iron tablets can prevent infection" had the lowest score. the knowledge of pregnant mothers about the prevention of anemia had been obtained by mothers through health education from healthcare providers during antenatal care, as well as from the mass media. pregnant mothers had understood the benefits of eating nutritious foods but had not fully figured out the benefits of the adherence to iron supplementation. there were still many pregnant mothers who did not adhere to taking iron supplementation although iron supplements have been shown to increase the levels of hemoglobin to prevent the occurrence of anemia (sajith et al., 2016). iron supplements need to be taken regularly by every pregnant mother every day during her pregnancy or at least 90 tablets. daily oral iron supplementation with 60 mg of elemental iron and 0.4 mg folic acid (health ministry of health, 2014). the adequacy of nutrients during pregnancy will contribute greatly to the health of the fetus and the well-being of pregnant mothers. however, the result of the study found that many pregnant mothers having not received adequate nutrition were those who were among the group of underweight or overweight/obese, smokers, adolescents, and those with previous unfavorable pregnancy outcomes (marangoni et al., 2016). underweight conditions during pregnancy are associated with poor fetal development, preterm, and an increased risk of chronic disease later in life, while pregnant mothers will be at risk of gestational diabetes and preeclampsia (ahmed & tseng, 2013). food recall in this study showed that the intake of protein and vitamin c in this population was in good category but the intake of iron was still in the low category. the adequacy of iron in the diet is influenced by maternal adherence to fe supplements. each iron supplement for pregnant mothers at least containing iron that was equivalent to 60 mg of iron elements (in the form of ferro sulfate, ferro fumarate or ferro gluconate) preparations; and folic acid 0.400 mg (health ministry of health, 2014).some studies supported the low iron adequacy in pregnant mothers (mosha et al., 2017; sato, fujimori, szarfarc, borges, & tsunechiro, 2010). the inadequacy of iron in the diet in this population might be influenced by the respondent's characteristics with the lowest mean intake of iron with more than 3 parities. the majority of respondents in this study had income less than 3 million. the provision of food in the family is closely related to the appetite of other family members and the priority of financial use. a study supported the relationship between socioeconomic and dietary patterns in pregnant mothers. a study showed the mother with higher level of financial resources to buy food, has higher consumption of saltwater fish, fruit, products being the source of animal protein (suliga, 2013; völgyi et al., 2013). the result showed a significant association between the perceived benefits and the intake of protein and iron. perceived benefits of actions reinforce consequences for certain health behaviors. perceived benefits can increase individual’s commitment in conducting health behavior. perceived benefit is a concept of pender health promotion model that supports 6 major components of healthy lifestyle. these components include health responsibility, physical activity, nutrition, spiritual growth, interpersonal support and stress management (eshah, bond, & sivarajan, 2010).the results of several studies supported that perceived benefits can improve health behavior in various areas (kim, ahn, & no, 2012; lovell, ansari, & parker, 2010; noroozi, esmaili, tahmasebi, & vahdat, 2017; salahshoori, sharifirad, hassanzadeh, & mostafavi, 2014). in this study perceived benefits were associated with the prevention behavior of anemia during pregnancy. pregnant women with good perceived benefits will try to meet the daily nutritional adequacy despite the obstacles experienced. pregnant mothers can experience many obstacles in fulfilling daily nutritional needs. a study of iron supplementation showed that the majority of pregnant mothers suffered from gastrointestinal disorders such as nausea, diarrhea and constipation (tolkien, stecher, mander, pereira, & powell, 2015).a study looked at the perception of anemia pregnancy and its prevention in several countries. that study showed pregnant mothers in bolivia, guatemala, and honduras had realized that the consequences of anemia were serious and anemia can be fatal for both mother and baby. result that study in indonesia showed that anemia was equal to the term low blood pressure. some pregnant mothers stated that consumption of iron supplements would increase blood and was associated with hypertension (galloway et al., 2002). the difference in perceptions of pregnant women about anemia shows the importance of health education about anemia to m. triharini et al. 160 | pissn: 1858-3598  eissn: 2502-5791 improve anemia prevention behavior in pregnant women. conclusion the finding from this study has confirm that mother with good perception on benefits will have better intake of protein and iron in pregnant mothers. health workers need to provide health education to every pregnant woman to increase the perceived benefits of preventing anemia. a good understanding of the importance of prevention of anemia, will improve the behavior of mothers in fulfilling daily nutritional needs, especially protein, vitamin c and iron. references abdelwahid, h. a. (2013). the role of multiple micronutrients in treatment of iron deficient anemic children. family medicine & medical science research, 1(1), 2–5. https://doi.org/10.4172/2327-4972.1000102 acharya, o., zotor, f. b., chaudhary, p., deepak, k., amuna, p., & ellahi, b. (2016). maternal nutritional status, food intake and pregnancy weight gain in nepal. journal of health management, 18(1), 1–12. https://doi.org/10.1177/0972063415625537 ahmed, f., & tseng, m. (2013). diet and nutritional status during pregnancy. public health nutrition, 16(8), 1337–1339. https://doi.org/10.1017/s1368980013001651 arrish, j., yeatman, h., & williamson, m. (2017). midwives’ role in providing nutrition advice during pregnancy: meeting the challenges? a qualitative study. nursing research and practice, 2017, 1–11. https://doi.org/10.1155/2017/7698510 bahar, f. v. h. b. (2011). pola konsumsi dan kadar hemoglobin pada ibu hamil di kabupaten maros , sulawesi selatan. kesehatan, 15(1), 31–36. brown, m. s., & shapiro, h. (1996). effect of protein intake on erythropoiesis during erythropoietin treatment of anemia of prematurity. j pediatr. eshah, n. f., bond, a. e., & sivarajan, e. (2010). the effects of a cardiovascular disease prevention program on knowledge and adoption of a heart healthy lifestyle in jordanian working adults. european journal of cardiovascular nursing, 9(4), 244–253. https://doi.org/10.1016/j.ejcnurse.2010.02.002 fekadu beyene, g. d. (2013). assessment of knowledge of pregnant mothers on maternal nutrition and associated factors in guto gida woreda, east wollega zone, ethiopia. journal of nutritional disorders & therapy, 04(01), 1–7. https://doi.org/10.4172/2161-0509.1000130 galloway, r., dusch, e., elder, l., achadi, e., grajeda, r., hurtado, e., … stephen, c. (2002). women’s perceptions of iron deficiency and anemia prevention and control in eight developing countries. social science & medicine, 55(4), 529– 544. https://doi.org/10.1016/s02779536(01)00185-x health ministry of health. (2014). pmk no. 88 tablet tambah darah. kemenkes 2014, (1), 1–5. https://doi.org/10.1007/s13398-014-0173-7.2 huang, l., purvarshi, g., wang, s., zhong, l., & tang, h. (2015). the influence of iron-deficiency anemia during the pregnancy on preterm birth and birth weight in south china. journal of food and nutrition research, 3(9), 570–574. https://doi.org/10.12691/jfnr-3-9-2 khodaveisi, m., omidi, a., farokhi, s., & soltanian, a. r. (2017). the effect of pender’s health promotion model in improving the nutritional behavior of overweight and obese women. international journal of community based nursing and midwifery, 5(2), 165–174. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2840917 0%0ahttp://www.pubmedcentral.nih.gov/article render.fcgi?artid=pmc5385239 kim, h.-s., ahn, j., & no, j.-k. (2012). applying the health belief model to college students’ health behavior. nutrition research and practicenutr res pract), 6(6), 551–558. https://doi.org/10.4162/nrp.2012.6.6.551 lovell, g. p., ansari, w. el, & parker, j. k. (2010). perceived exercise benefits and barriers of nonexercising female university students in the united kingdom. international journal of environmental research and public health, 7(3), 784–798. https://doi.org/10.3390/ijerph7030784 marangoni, f., cetin, i., verduci, e., canzone, g., giovannini, m., scollo, p., … poli, a. (2016). maternal diet and nutrient requirements in pregnancy and breastfeeding. an italian consensus document. nutrients, 8(10), 1–17. https://doi.org/10.3390/nu8100629 mekuria, a., bekele, a., tilahun, m., & bekele, a. (2016). prevalence of anemia and its associated factors among pregnant women attending antenatal care in health institutions of arbaminch town , gamo gofa zone , ethiopia : a crosssectional study. hindawi publishing corporation, 2016(2016), 10. https://doi.org/10.1155/2016/1073192 metgud, c. ., naik, v. ., & mallapur, m. . (2012). effect of maternal nutrition on birth weight of newborn-a community based study. the journal of family welfare, 58(2), 35–39. mosha, d., liu, e., hertzmark, e., chan, g., sudfeld, c., masanja, h., & fawzi, w. (2017). dietary iron and calcium intakes during pregnancy are associated with lower risk of prematurity, stillbirth and neonatal mortality among women in tanzania. public health nutrition, 20(4), 678–686. https://doi.org/10.1017/s1368980016002809 noroozi, a., esmaili, f., tahmasebi, r., & vahdat, k. (2017). the effect of education based on health promotion model (hpm) on adherence to antiretroviral therapy (art) in hiv-infected patients. health scope, (7), 1–10. jurnal ners http://e-journal.unair.ac.id/jners | 161 https://doi.org/10.5812/archneurosci.30362.re view pender, n. j. (2011). heath promotion model manual (pp. 4–6). chichago: university of michigan. rivera-rodriguez, k. m., rodríguez-rivera, a. v, roman-julia, r., & raul, h. (2016). effectiveness of vitamin c in the treatment of anemia in patients with chronic diseases : a case study. pharmacy & pharmaceutical sciences, 5(4), 31–35. sajith, m., nimbargi, v., shah, s., tekawade, s., agiwale, j., & pawar, a. (2016). correlations of adherence to iron supplements and prevalence of anemia in antenatal women. international journal of reproduction, contraception, obstetrics and gynecology, 5(10), 3448–3452. https://doi.org/http://dx.doi.org/10.18203/232 0-1770.ijrcog20163421 salahshoori, a., sharifirad, g., hassanzadeh, a., & mostafavi, f. (2014). an assessment of the role of perceived benefits, barriers and self-efficacy in predicting dietary behavior in male and female high school students in the city of izeh, iran. journal of education and health promotion. https://doi.org/10.4103/2277-9531.127558 sandström, b. (2001). micronutrient interactions: effects on absorption and bioavailability. british journal of nutrition, 85(s2), s181. https://doi.org/10.1049/bjn2000312 sato, a. p. s., fujimori, e., szarfarc, s. c., borges, a. l. v., & tsunechiro, m. a. (2010). food consumption and iron intake of pregnant and reproductive aged women. revista latino-americana de enfermagem, 18(2), 247–254. https://doi.org/10.1590/s010411692010000200016 sharma, j. b., & shankar, m. (2010). anemia in pregnancy. jimsa, 23(4), 253–260. singh, m. b., fotedar, r., & lakshminarayana, j. (2009). micronutrient deficiency status among women of desert areas of western rajasthan, india. public health nutrition, 12(5), 624–629. https://doi.org/10.1017/s1368980008002395 singh, p., khan, s., & mittal, r. k. (2013). anemia during pregnancy in the women of western nepal. bali medical journalbmj), 2(1), 14–16. retrieved from www.balimedicaljournal.com%0awww.ojs.unud. ac.id sriramanakoppa, n., sreenivas, & jayaram, s. (2015). study of anemia among protein energy malnourished children in mysore. journal of evidence based medicine and healthcare, 2. https://doi.org/10.18410/jebmh/174 suliga, e. (2013). economic and social factors and the quality of nutrition of pregnant women. studia medyczne, 29(2), 160–166. thomson, c. a., stanaway, j. d., neuhouser, m. l., snetselaar, l. g., stefanick, m. l., arendell, l., & chen, z. (2011). nutrient intake and anemia risk in the women’s health initiative observational study. journal of the american dietetic association, 111(4), 532–541. https://doi.org/10.1016/j.jada.2011.01.017 tolkien, z., stecher, l., mander, a. p., pereira, d. i. a., & powell, j. j. (2015). ferrous sulfate supplementation causes significant gastrointestinal side-effects in adults: a systematic review and meta-analysis. plos one, 10(2), 1–20. https://doi.org/10.1371/journal.pone.0117383 völgyi, e., carroll, k. n., hare, m. e., ringwald-smith, k., piyathilake, c., yoo, w., & tylavsky, f. a. (2013). dietary patterns in pregnancy and effects on nutrient intake in the mid-south: the conditions affecting neurocognitive development and learning in early childhood (candle) study. nutrients, 5(5), 1511–1530. https://doi.org/10.3390/nu5051511 jus kacang panjang (vigna sinensis l 116 jus kacang panjang (vigna sinensis l.) menurunkan kadar glukosa darah pasien diabetes mellitus (string bean juice decreases blood glucose level patients with diabetes mellitus) harmayetty*, ilya krisnana*, faida anisa* abstract introduction: type 2 diabetes mellitus is deficiency of insulin and caused by decreases of insulin receptor or bad quality of insulin. as a result, insulin hormone does not work effectively in blood glucose regulation. string bean juice contains thiamin and fiber may regulate blood glucose level. the aim of this study was to analyze the effect of string bean juice to decrease blood glucose level of patients with type 2 diabetes mellitus. method: this study employed a quasy-experimental prepost test control group design and purposive sampling. the population were all type 2 diabetes mellitus patients in puskesmas pacar keling surabaya. sample were 12 patients who met inclusion criteria. the independent variable was string bean juice and dependent variable was blood glucose level. data were analyzed by using paired t-test with significance level of α≤ 0.05 and independent t-test with significant level of α≤0.05. result: the results showed that string bean juice has an effect on decreasing blood glucose between pre test and post test for blood glucose with independent t-test is p=0.003. analysis: in conclusion, string bean juice has an effect on blood glucose level in patients with type 2 diabetes mellitus. discussion: the possible explanation for this findings is string bean juice contains two ingredients: thiamine and fiber. thiamine helps support insulin receptors and glucose transporter in cells hence glut-4 could translocated to the cell membrane brought glucouse enter to the intracellular compartment, that leads to blood glucouse level well regulated. dietary fiber reduces food transit time so slowing the glucose absorption. therefore blood glucose level will be decreased. keywords : diabetes mellitus type 2, blood glucose level, string bean juice * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257. e-mail: zanno-yet@yahoo.com pendahuluan diabetes mellitus (dm) merupakan suatu kelompok penyakit metabolik dengan karakteristik hiperglikemia (glukosa darah puasa ≥ 126 mg/dl dan glukosa darah sewaktu ≥ 200 mg/dl) yang terjadi karena kelainan sekresi insulin, kerja insulin, atau keduanya. menurut data who, pada tahun 2000 jumlah pasien dm di dunia (diatas umur 20 tahun) berjumlah 150 juta orang dan perkiraan pada tahun 2025 akan menjadi 300 juta orang, dengan angka kematian per tahun sekitar 6%. indonesia menempati urutan ke-4 terbesar dalam jumlah pasien dm di dunia pada tahun 2003 yaitu 8,5 juta orang (soegondo, 2008). pada tahun 2007 jumlah pasien dm di puskesmas pacar keling surabaya mencapai 1825 orang, dengan prosentase tertinggi pada umur 45-55 tahun (0,35%) dan umur 55-64 tahun (0,36%). kadar glukosa darah pasien dm yang baru berobat ke puskemas sekitar 200-600 mg/dl dan pada pasien dm yang tercatat lama berobat kadar glukosa darahnya relatif terkontrol atau terregulasi dengan baik, yaitu sekitar 244-263 mg/dl. pengelolaan dm yang diberikan puskesmas pada pasien adalah pemberian obat hipoglikemi, dan konsultasi (penyuluhan) tentang diet dan aktivitas sehari-hari (rekam medik puskesmas pacar keling). angka kejadian penyakit dm terus meningkat seiring dengan meningkatnya tingkat kemakmuran, berubahnya gaya hidup, pola makan, dan bertambah usia. kejadian tersebut salah satunya disebabkan karena kurangnya ketaaatan pasien dalam perencanaan diitnya yang menyangkut prinsip tepat 3j (jadwal-jenis-jumlah). mailto:zanno-yet@yahoo.com jus kacang panjang terhadap kadar glukosa (harmayetty) 117 jadwal makan pasien dm lebih sering dari 3x/hari dengan porsi makan yang lebih kecil untuk mencegah peningkatan kadar glukosa darah dan mencegah hipoglikemia bagi pasien yang memakai suntikan insulin. apabila terjadi keseimbangan antara makanan yang masuk dengan kebutuhan dan kemampuan tubuh untuk mengolah, maka diharapkan glukosa darah terkontrol. selain itu kesediaan energi untuk kegiatan seharihari pasien dan berat badan menjadi ideal. melalui strategi gizi (perencanaan diit) yang tepat dapat menjadi alternatif pengobatan bagi pasien dm sehingga tidak selalu bergantung dengan pemberian obat hipoglikemi oral dan insulin (budiyanto, 2002). serangkaian tes yang dilakukan oleh paavo airola, yang dikutip oleh heinerman (2005) menyatakan bahwa dengan pemberian jus kacang panjang dapat mengendalikan kadar glukosa darah agar tetap terkontrol pada pasien dm. menurut paavo, jus kacang panjang merangsang kerja sel-sel pulau langerhans yang banyak terdapat hormon endokrin dan membantu kerja organ pankreas, limpa, dan liver. kacang panjang merupakan sayuran yang paling banyak dikonsumsi masyarakat indonesia sehari-hari, yaitu di urutan ke-3 (30%) dari 8 jenis sayuran. pendayagunaan kacang panjang sangat beragam yakni dihidangkan untuk berbagai masakan dan biji-bijinya dibuat wajik. hal tersebut dikarenakan kacang panjang adalah sayuran yang murah dan mudah didapat. kacang panjang juga mempunyai berbagai manfaat yang baik untuk kesehatan. namun pengaruh pemberian jus kacang panjang terhadap penurunan kadar glukosa darah belum banyak diketahui dan diterapkan di indonesia. kadar glukosa darah puasa terkontrol antara 140-150 mg/dl, jika kadar glukosa darah ≥ 200 mg/dl gejala yang ditimbulkan meliputi rasa tidak nyaman dan sering buang air kecil sehingga menyebabkan dehidrasi. kadar glukosa darah ≥300 mg/dl mengarah ke ketoasidosis dan membutuhkan perawatan segera, dan kadar glukosa darah ≤ 60 mg/dl (hipoglikemia) dapat menyebabkan kejang atau kehilangan kesadaran. bila hal ini dibiarkan akan menimbulkan komplikasi baik akut maupun kronis. komplikasi kronis meliputi kerusakan pada pembuluh darah kecil (mikrovaskular): gagal ginjal (30% penyebab kematian), katarak, retinopati (30% mengalami kebutaan); pada pembuluh darah besar (makrovaskular): jantung koroner (50% penyebab kematian), pembuluh darah kaki (10% amputasi tungkai kaki), pembuluh darah otak; dan pada sistem saraf (neuropati). selain meningkatkan kecacatan dan menurunkan angka harapan hidup, penyakit dm juga meningkatkan biaya pemeliharaan kesehatan. pada tahun 2007, data dari who biaya untuk perawatan dm dan komplikasinya di dunia sebesar 215-375 miliar dolar as (soegondo, 2008). kacang panjang mengandung zat gizi yaitu thiamin (vitamin b1) dan serat yang dapat membantu mengendalikan kadar glukosa darah tinggi pada pasien dm. peran thiamin di dalam tubuh berkaitan dengan metabolisme karbohidrat dalam menghasilkan energi. bentuk aktif thiamin adalah di dalam koenzim kokarboksilase yang masuk dalam siklus krebs dan menghasilkan metabolit berenergi tinggi yaitu adenosine triphosphate (atp) (sediaoetama, 2006). thiamin juga berperan dalam memperbaiki kerja reseptor insulin dan transporter glukosa dalam sel. sehingga glut-4 dapat bertranslokasi ke membran sel membawa glukosa masuk ke intrasel dan kadar glukosa dalam darah dapat teregulasi dengan baik. pada serat terdapat efek hipoglikemik yaitu serat mampu memperlambat pengosongan lambung, memperlambat difusi glukosa, dan menurunkan waktu transit makanan sehingga absorbsi glukosa lambat. jumlah asupan serat menurut perkeni ±25 gr per hari (budiyanto, 2002). bahan dan metode penelitian penelitian ini menggunakan desain quasy-eksperiment pre-post test control group design, terdapat 2 kelompok yaitu kelompok yang tidak diberikan jus kacang panjang (kelompok kontrol) dan kelompok yang diberikan jus kacang panjang (kelompok perlakuan), kadar glukosa darah diobservasi sebelum dan sesudah diberikan jus kacang panjang selama 14 hari. penelitian ini dilaksanakan di puskesmas pacar keling surabaya dari tanggal 15-29 januari 2009. populasi pada penelitian pasien diabetes mellitus tipe 2 yang berobat di puskesmas pacar keling surabaya pada jurnal ners vol.4 no. 2: 116-121 118 bulan januari 2009 adalah 90 orang. proses pengambilan sampel menggunakan teknik non probabilitiy sampling dengan metode purposive. sampel pada penelitian ini diambil dari populasi yang sudah memenuhi kriteria inklusi sebanyak 12 orang. kriteria inklusi dalam penelitian ini antara lain: 1) pasien dm tipe 2 berumur 45-64 tahun, 2) kadar glukosa darah puasa 200-350 mg/dl, 3) tidak mengonsumsi obat hipoglikemi oral dan 4) tanpa komplikasi. variabel independen dalam penelitian ini yaitu jus kacang panjang. variabel dependen yaitu kadar glukosa darah pada pasien diabetes mellitus. instrumen pengumpulan data dengan menggunakan lembar observasi pada pemberian jus kacang panjang dan kadar glukosa darah. alat yang digunakan untuk melakukan pemeriksaan kadar glukosa darah adalah glukotest dan glukostik dari one call plus. prosedur penelitian diawali dengan pemeriksaan kadar glukosa darah pada kedua kelompok saat datang di puskesmas dan digunakan sebagai data observasi awal (pre). satu hari kemudian, kelompok perlakuan diberi jus kacang panjang pada pagi dan sore hari setelah makan (2-3 jam) pada periode yang sama sebanyak 100gr/50kgbb selama 14 hari. jus kacang panjang disiapkan oleh peneliti dan diantar ke rumah responden masing-masing. kelompok kontrol tidak diberikan jus kacang panjang. setelah 14 pemberian jus kacang panjang maka pada hari ke-15 kedua kelompok akan dilakukan pemeriksaan darah sebagai data observasi akhir (post). data yang terkumpul kemudian dianalisis uji statistik paired t-test dengan tingkat kemaknaan α≤0,05. uji statistik independent t-test dengan α≤0,05 dilakukan untuk mengetahui pengaruh dari jus kacang panjang terhadap penurunan kadar glukosa darah. hasil penelitian hasil penelitian didapatkan bahwa observasi kadar glukosa darah puasa responden pada kelompok perlakuan didapatkan rerata saat pre-test 276 mg/dl dan saat post-test 109 mg/dl dan pada kelompok kontrol rerata saat pre-test 257 mg/dl dan saat post-test 216 mg/dl. pada kelompok perlakuan terjadi rerata penurunan kadar glukosa darah sebesar 167,00mg/dl sedangkan pada kelompok kontrol terjadi rerata penurunan kadar glukosa darah sebesar 40,83 mg/dl. uji statistik dengan independent t-test α ≤ 0,05 didapatkan nilai p = 0,003 yang berarti terdapat pengaruh dari pemberian jus kacang panjang terhadap penurunan kadar glukosa darah pada pasien diabetes mellitus tipe 2 (tabel 1). pembahasan diabetes mellitus (dm) merupakan suatu kelompok penyakit metabolik dengan karakteristik hiperglikemia (glukosa darah puasa ≥ 126 mg/dl dan glukosa darah sewaktu ≥ 200 mg/dl) yang terjadi karena kelainan sekresi insulin, kerja insulin, atau keduanya (soegondo, 2008). diabetes mellitus tipe 1 memiliki reseptor insulin di jaringan perifer kuantitas dan kualitasnya cukup/normal yaitu antara 30.000-35.000 (pada orang normal jumlah reseptor insulin ±35.000) sedangkan pada dm tipe 2, diawali oleh kelainan jaringan perifer (resistensi insulin yang predominan dengan defisiensi insulin relatif) dan kemudian disusul dengan disfungsi sel beta pankreas (kelelahan pada sel beta) menuju defisiensi sekresi insulin yaitu dengan berkurangnya jumlah reseptor insulin atau kualitas yang jelek dan kerja insulin menjadi tidak efektif (tjokroprawiro, 2007). resistensi insulin timbul pada usia lanjut disebabkan oleh perubahan komposisi tubuh yang mengakibatkan menurunnya jumlah serta sensitivitas reseptor insulin; turunnya aktivitas yang berakibat pada penurunan jumlah reseptor insulin yang berikatan dengan insulin baik kecepatan maupun jumlah ambilan glukosa; perubahan pola makan pada usia lanjut yang disebabkan oleh berkurangnya gigi geligi sehingga persentase bahan makanan karbohidrat akan meningkat; dan perubahan neuro-hormonal, khususnya insulin-like growth factor-1 (igf-1) dan dehidroepandrosteron (dheas) plasma yang dapat mengakibatkan penurunan ambilan glukosa karena menurunnya sensitivitas reseptor insulin serta menurunnya aksi insulin (rochmah, 2006). hammad jus kacang panjang terhadap kadar glukosa (harmayetty) 119 tabel 1 hasil observasi kadar glukosa darah pada pasien diabetes mellitus tipe 2 dari tanggal 1529 januari 2009 di puskesmas pacar keling surabaya no perlakuan selisih (mg/dl) no kontrol selisih (mg/dl) pre (mg/dl) post (mg/dl) pre (mg/dl) post (mg/dl) 1 336 131 -205 1 306 204 -102 2 330 86 -244 2 212 240 28 3 300 102 -198 3 276 270 -6 4 205 99 -106 4 218 180 -38 5 200 117 -83 5 212 140 -72 6 286 120 -66 6 320 265 -55 mean 276,17 109,17 -167,00 mean 257,33 216,50 -40,83 sd 60,015 16,412 61,826 sd 49,601 51,201 46,632 uji paired t-test p=0,01 uji paired t-test p=0,085 uji independent t-test p=0,003 keterangan : p=tingkat signifikansi mean=nilai rerata sd=standar deviasi kadar glukosa darah puasa yang terkontrol antara 140-150 mg/dl, jika kadar glukosa darah ≥ 200 mg/dl gejala yang ditimbulkan meliputi rasa tidak nyaman dan sering buang air kecil sehingga menyebabkan dehidrasi, kadar glukosa darah ≥ 300 mg/dl biasanya mengarah ke ketoasidosis dan membutuhkan perawatan segera, dan kadar glukosa darah ≤ 60 mg/dl (hipoglikemia) dapat menyebabkan kejang atau kehilangan kesadaran. bila hal ini dibiarkan akan menimbulkan komplikasi baik akut maupun kronis. komplikasi kronis meliputi kerusakan pada pembuluh darah kecil (mikrovaskular): gagal ginjal (30% penyebab kematian), katarak, retinopati (30% mengalami kebutaan); pada pembuluh darah besar (makrovaskular): jantung koroner (50% penyebab kematian), pembuluh darah kaki (10% amputasi tungkai kaki), pembuluh darah otak; dan pada sistem saraf (neuropati). selain meningkatkan kecacatan dan menurunkan angka harapan hidup, penyakit dm juga meningkatkan biaya pemeliharaan kesehatan. pada tahun 2007, data dari who biaya untuk perawatan dm dan komplikasinya di dunia sebesar 215-375 miliar dolar as (soegondo, 2008). penatalaksanaan dasar terapi dm meliputi pentalogi terapi dm, yaitu terapi primer dan sekunder. pada terapi primer terdapat penyuluhan kesehatan masyarakat tentang dm, latihan fisik, dan diit. pada terapi sekunder terdapat pemberian obat hipoglikemi oral dan insulin, dan cangkok pankreas (tjokroprawiro, 2007). pada dm tipe 2, penanganan pada pasien lebih dititikberatkan dengan terapi primer. latihan fisik dan pola diit secara teratur diharapkan dapat mengendalikan kadar glukosa darah agar tidak tinggi. menurut pbb dan who, olahraga tidak harus menggunakan banyak fasilitas atau alat. dengan berjalan kaki selama 30 menit setiap hari dan dilakukan secara teratur sudah cukup untuk melatih fisik agar tetap sehat. hasil penelitian didapatkan kadar glukosa darah puasa responden pada kelompok perlakuan sesudah diberikan jus kacang panjang rerata 109 mg/dl dan responden pada kelompok kontrol rerata 216 mg/dl. responden pada kelompok perlakuan, sebagian besar mengalami penurunan kadar glukosa darah secara bertahap dan rentang nilai turunnya besar. namun terdapat 2 responden yang mengalami penurunan kadar glukosa darah tidak bertahap dan cenderung naik turun. hal ini dikarenakan oleh pola makan yang tidak jurnal ners vol.4 no. 2: 116-121 120 sesuai diit, olahraga yang tidak rutin, dan ketidakpatuhan responden selama penelitian. pada 2 responden penurunan kadar glukosa darahnya rerata 204 mg/dl dan 198 mg/dl. hal ini dikarenakan pola makan teratur yaitu makan 3x/hari dengan porsi yang sesuai dan ditambah dengan makanan snack (camilan) serta rutin berolahraga yaitu jalan kaki/jogging sebanyak 3x/minggu selama 30 menit. berbagai faktor yang dapat mempengaruhi kadar glukosa darah adalah pola makan, olahraga dan aktivitas, obat, penyakit, usia, dan alkohol (tandra, 2008). seperti yang diungkapkan oleh claude bernard (2007), seorang pakar fisiologi perancis, bahwa kesembuhan pasien dalam menghadapi penyakit lebih ditentukan oleh kemampuan beradaptasi dari tubuh orang itu sendiri daripada dari penyebab penyakitnya. selain memiliki tubuh yang mampu beradaptasi, pasien dm perlu bersahabat dengan penyakitnya yaitu dengan memahami sifat-sifatnya serta cara yang paling tepat untuk mengendalikannya jika “sahabat” tersebut memiliki sifat-sifat yang merugikan kesehatan. jika pasien dm dapat mengurangi beban kerja kelenjar pankreas dalam memproduksi hormon insulin, mengatur pola makan, dan aktivitas fisik tepat, maka pasien dapat hidup menggunakan obat hipoglikemi oral atau insulin dengan dosis berlebihan. hasil penelitian didapatkan pola makan responden pada kedua kelompok sebagian besar tidak sesuai diit. responden lebih memilih tidak banyak makan nasi dengan tujuan untuk menurunkan kadar glukosa darahnya, akan tetapi mereka sering makan makanan snack (camilan). seharusnya pasien dm makan lebih sering dari 3x sehari dengan porsi makan yang lebih kecil dan tepat jumlah-jenis-jadwal, sehingga dapat membantu glukosa teregulasi dengan baik dalam darah dan kerja dari hormon insulin tidak menjadi berat. selain itu, apabila terjadi keseimbangan antara makanan yang masuk dengan kebutuhan dan kemampuan tubuh untuk mengolahnya maka diharapkan glukosa darah terkontrol dalam batas-batas normal. penurunan kadar glukosa darah pada kelompok perlakuan (diberi jus kacang panjang) rerata 167 mg/dl, sedangkan pada kelompok kontrol (tidak diberi jus kacang panjang) hanya 41 mg/dl. berdasarkan hasil pemeriksaan kadar glukosa darah sebelum dan sesudah pemberian jus kacang panjang pada kelompok perlakuan didapatkan hasil bahwa keenam responden mengalami penurunan kadar glukosa darah. hasil uji statistik paired t-test α≤0,05 didapatkan nilai p=0,01, berarti terdapat penurunan kadar glukosa darah yang signifikan dari pemberian jus kacang panjang. kadar glukosa yang meningkat akan merangsang sel beta pulau langerhans untuk mensekresi hormon insulin. pada dm tipe 2, awal kelainan terletak pada jaringan perifer (resistensi insulin), kemudian sel β-pankreas mengalami disfungsi sehingga terjadi defisiensi sekresi insulin yaitu dengan berkurangnya jumlah reseptor insulin atau kualitas yang jelek dan kerja insulin menjadi tidak efektif (tjokroprawiro, 2007). pemberian jus kacang panjang dengan dosis 100gr/50kg bb secara teratur 2x sehari sehabis makan (2-3 jam), dapat membantu mengendalikan kadar glukosa darah pada pasien dm. kandungan gizi pada kacang panjang yaitu thiamin/vitamin b1 (0,17mg dalam 100gr kacang panjang) dapat memperbaiki kerja reseptor insulin dan transporter glukosa dalam sel. sehingga glut-4 dapat bertranslokasi ke membran sel membawa glukosa masuk ke intrasel dan kadar glukosa dalam darah menurun. kacang panjang juga terdapat kandungan gizi serat (2,8gr dalam 100gr kacang panjang) yang mempunyai efek hipoglikemik karena serat mampu memperlambat pengosongan lambung, mengubah gerakan peristaltik lambung, memperlambat difusi glukosa, menurunkan aktifitas α-amilase akibat meningkatnya viskositas dari isi usus, menurunkan waktu transit makanan sehingga absorbsi glukosa lambat. manfaat dari thiamin dan serat dapat membantu kadar glukosa dalam darah dapat teregulasi dengan baik (budiyanto, 2002). selama penelitian, tidak hanya responden pada kelompok perlakuan yang latihan fisik dan pola makan diatur oleh peneliti tetapi juga responden pada kelompok kontrol. menurut tandra (2008), olahraga dan pola makan dapat mempengaruhi kadar glukosa dalam darah. semua gerak badan dan olahraga dapat menurunkan kadar glukosa darah. olahraga mengurangi resistensi insulin sehingga kerja insulin lebih baik dan mempercepat pengangkutan glukosa masuk jus kacang panjang terhadap kadar glukosa (harmayetty) 121 ke dalam sel untuk kebutuhan energi. responden berolahraga dengan berjalan kaki 15-30 menit teratur setiap hari dan memperbanyak aktifitas untuk menggerakkan tubuh, responden harus mendapatkan istirahat cukup setiap harinya dan menghindari stress/pikiran yang terlalu membebankan. pola makan responden yaitu 3x/hari makan nasi (pokok) dan ditambah selingan makan makanan snack (camilan) serta jus kacang panjang (yang diberikan pada kelompok perlakuan). sehingga kadar glukosa darah pada responden kelompok kontrol dan kelompok perlakuan dapat turun dari nilai tes awal. responden dapat termotivasi dan berkooperatif baik dengan peneliti, sehingga diharapkan hasil penelitian ini dapat optimal. simpulan dan saran simpulan pemberian jus kacang panjang (vigna sinensis l.) dapat menurunkan kadar glukosa darah pasien diabetes mellitus tipe 2 melalui fungsi regulasi glukosa darah oleh thiamin dan serat dalam kacang panjang. saran peneliti memberikan saran : 1) pengelola program puskesmas dapat menjadikan pemberian jus kacang panjang sebagai bahan health education (he) dalam mengatur perencanaan diit pada pasien diabetes mellitus tipe 2, 2) bagi perawat diharapkan dapat mengembangkan pelayanan pada pasien diabetes mellitus tipe 2 dengan memanfaatkan kacang panjang sebagai salah satu alternatif terapi untuk menurunkan kadar glukosa darah pasien, 3) bagi peneliti selanjutnya dapat mengambil jumlah sampel yang lebih banyak dan menggunakan instrumen pengambilan tes hba1c agar hasil penelitian lebih optimal dan dapat generalisasi dari pasien diabetes mellitus tipe 2. kepustakaan budiyanto, a., 2002. gizi dan kesehatan. malang: umm press, hlm. 119-133. heinerman, j., 2005. ensiklopedia juice buah dan sayuran untuk penyembuhan. jakarta: pt pustaka delap ratasa, hlm. 245-247. sediaoetama, a., 2006. ilmu gizi 1. jakarta: pt dian rakyat, hlm. 31-185. soegondo, s., 2008. diabetes, the sillent killer, (online), http://medicastore.com/diabetes/#d ua, diakses tanggal 14 november, jam 09.45 wib). tandra, hans, 2008. segala sesuatu yang harus diketahui tentang diabetes. jakarta: pt gramedia pustaka utama. tjokroprawiro, a., 2007. ilmu penyakit dalam. surabaya: airlangga university press, hlm. 29-76. tjokronegoro, a., 2000. buku ajar ilmu penyakit dalam. jakarta: balai penerbit fkui, hlm. 571-693.. http://medicastore.com/diabetes/#dua http://medicastore.com/diabetes/#dua http://e-journal.unair.ac.id/jners | 1 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.6061 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research collaborative model of teachers, students and families to improve parents knowledge and skills on food safety of elementary school students sigit mulyono, elly nurachmah, junaiti sahar and sabarinah prasetyo faculty of nursing, universitas indonesia, depok, indonesia abstract introduction: school-age children in indonesia are at risk of health problems due to food insecurity. parents have a very important role in preparing safe food, both at home and for lunch at school. the aim of this study was to determine the effect of a collaboration model of teachers, students, and their families (kogusiga) towards the parents’ knowledge and skills on the food safety of elementary school students. methods: this study applied a quasi-experiment design preand post-test with a control group. the subject sample used was the total sampling method, involving 206 parents. the study was conducted for over 10 weeks, supported with modules for nurses and parents, textbooks for the students and their families, and a student workbook. results: the results showed that the kogusiga model is associated significantly with greater knowledge (p-value = 0.000; with a mean difference of 20.23) and the parent’s skills (p-value = 0.000; with a mean difference of 12.3) to do with food insecurity. conclusion: the kogusiga model tends to improve the knowledge and skills parents significantly, in relation to the food safety of the students. it is expected that the kogusiga model will be applied under the community health nursing/school health nurses’ supervision. article history received: oct 05, 2017 accepted: june 06, 2018 keywords school age children; parents; food safety; collaboration; school health nursing contact sigit mulyono  sigit@ui.ac.id  faculty of nursing, universitas indonesia, depok, indonesia cite this as: mulyono, s., nurachmah, e., sahar, j., & prasetyo, s. (2018). collaborative model of teachers, students, and families to improve parents knowledge and skills on food safety of elementary school students. jurnal ners, 13(1), 1-8. doi:http://dx.doi.org/10.20473/jn.v13i1.6061 introduction school-age is a phase when children are between 6 to 12 years of age (brown, et. al., 2005). during this phase, motor development is relatively fast yet not their intellectual development yet. while chool-age children start to develop logical thinking, they are still attached to perceptual facts (brown, et. al., 2005; wong, eaton, wilson, winkelstein, & schartz, 2008). consequently, school age children are not yet able to predict level of danger, including the hazard of unsafe food (brown, et. al., 2005; siburian, 2012). this fact is the main cause behind why most school-age children experience various kinds of health threat related to food safety, such as food-borne diseases, food ingredients containing dangerous substances, and not meeting their nutritional needs (fao/who, 2002). safe food is defined as food which is balanced in terms of the fulfilment of one’s daily energy, protein, mineral, vitamins, and other nutrition component needs, and not causing illness (gross, cohen, & kahan, 2006). the term “not causing illness” means that the food is safe from microorganism pollution that causes disease and is free from hazardous chemicals. many cases of sickness happen because the level of food safety is low. the results of the asia food safety conference held in malaysia in 2014 showed that cases of food-borne illnesses are still the main priority. food that was contaminated, especially by microorganisms, was the main cause (fao/who, 2004). food contaminated by e. coli bacteria was responsible for more 3,950 cases of illness and 53 deaths in european countries in 2017 (efsa, 2012). the effect of low food security is very dangerous for school age children, as it can lead to death. food poisoning cases in india caused the death of 23 elementary school students (nidm, 2013). in indonesia, cases of health problems related to food safety in children is relatively high. based on a research study by andarwulan et al. (2009), in https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:sigit@ui.ac.id http://dx.doi.org/10.20473/jn.v13i1.6061 s. mulyono et al. 2 | pissn: 1858-3598  eissn: 2502-5791 indonesia, health problems caused by food were experienced by 21.4% of children in bogor, indonesia, where 75.5% of them were school age children. food poisoning cases was at the top of the list. food-borne sickness is one example of poor safety food. these phenomena were the main issue of the discussed health topic and became one of the world spotlights declared by fao/who at the forum of safety regulation in morocco, 2002. the forum asserted that the diseases caused by food contribute to a number of illnesses and deaths in the population of school age children. aside from food-borne diseases because of food, the health problem cases caused by a lack of nutrition were also high. based on a research study conducted in 2011, out of 517 elementary schools or islamic elementary schools (mi) in the city of depok, there were 1,048 children with thin bodies and 7 children suffering from malnutrition (with a severely thin body) (dinas kesehatan kota depok, 2012). a survey conducted in one of the elementary schools in depok found that 36.76% of the school population was made up of malnutrition cases (kusumaningsih, 2010). in addition to food-borne diseases and the exposure to dangerous chemicals, the next food safety issue was nutrition intake, which does not meet the daily requirements, causing malnutrition. the lack of nutritional intake is a common problem in the school age children (stanhope & lancaster, 2004; allender & spradley, 2005). based on basic health research (riskesdas) in 2010 regarding nutrition, it showed that the level of nutrition fulfilment is still worrying (kementerian kesehatan republik indonesia, 2011). on a national scale, 40.7% of indonesian people consume less food than the minimum daily standard or do not meet the national standard nutritional adequacy rate. the problem of a lack of protein consumption happened in all age groups, especially school age children (kementerian kesehatan republik indonesia, 2011). the condition above has forced the efforts of nutrition fulfilment and food safety to be increased as much as possible. one of the efforts made by the who is the global strategy for food safety, and its main strategy is to provide and promote health campaigns. unfortunately, in indonesia, health campaign programs are not integrative, making them not fully effective. there needs to be an integrated health program, which is like the uks (school health unit) program. an effort towards a more comprehensive and integrative approach has been introduced by the ministry of health through the advocacy, cultivating atmosphere, and community empowerment model (advokasi, bina suasana, dan gerakan model pemberdayaan masyarakat or abg). the abg strategy is the main strategy set forth in all health promotion guides in various settings throughout indonesia, including in the institutional setting of education. one of the programs that it runs is uks. however, abg has not succeeded yet in improving the students' health condition. this can happen because the strategy of abg is still in the concept stage. there is no clear operational guidance, and there is even an absence of trained human resources to run it (mulyono, 2003). in addition, there is still no optimal coordination of teachers, families, and students in the implementation of the uks program (widjajanti, 2012). maclellan, taylor & freeze (2009) and ratnapradipa (2011) have suggested that parents and teachers are important role models for students in the formation of safe and balanced eating behaviour. this has caused the abg strategy through the uks program to still be difficult to apply in the field, especially when dealing with the problem of food safety in schools. therefore, an easy to implement program is needed by empowering the human resources that can collaborate with teachers, students and their families. this will play a role in the process of establishing healthy behaviour in schoolaged children, one of which is helped by a school health nurse (school health nursing). the researchers then developed a model of nursing care in schools that aims to improve the role of nurses in collaborating with teachers, students, and their families, which will trigger changes in food safety practice. the model being developed is called the teachers, students, and families collaboration (kolaborasi guru, siswa, dan keluarga or kogusiga). kogusiga emphasises on a food safety program to develop the habit of choosing, handling, and consuming healthy and safe food through the collaboration of teachers, students, and their families. the indonesian national agency of food and drug control (2005) explained that the use of hazardous additive substances or the contamination of other chemicals in food could happen because of a lack of understanding and poor family behaviour to do with food safety. the family is the micro system that interacts the most with a child and influences his/her behaviour. family plays an important role in determining healthy behaviour in everyday life, including children’s behaviour in terms of the fulfilment of nutritional needs. fao (2004) reported that the percentage of food sources that have caused food poisoning was 47.1% from household foods and 14.4% from snack foods. in addition, the secretariat general of the food intelligence network (2005) stated that the setting where food poisoning took place the most was in the home environment, which was 39.9%, and the school environment, which was 23.5%. a study by the minister of health also showed that the school and home environment could be the providers of less-healthy food (sekretariat jenderal jejaring intelijen pangan, 2005). therefore, the home environment (family) needs to be provided with education regarding food safety. the kosusiga model can be the alternative to family nursing interventions in order to improve the role of the family regarding the food safety program. parents are the role models for their children, and they can influence the behaviour of having a safe and balance diet in school age children. parents are also companions, as well as being educators for their jurnal ners http://e-journal.unair.ac.id/jners | 3 children while they are going about their daily activities. consequently, it is important for parents to acknowledge and understand possible health problems and disorders, which are relatively wide and complex, especially about food safety. this research aims to identify the influence of the kogusiga model on the improvement of the knowledge and skills of parents regarding food safety in elementary school students. materials and methods the design of this research was a quasi-experiment pre-post test. the research was conducted in an elementary school in depok, from april to june 2014. the taking of samples was carried out by using the total sampling technique, and the total samples were 206 respondents who were parents, who matched the inclusion criteria. there were 103 respondents in the intervention group and 103 respondents in the control group. selected respondents supplied personal informed consent prior to the study. the kogusiga intervention model was applied by the nurses, who had received the appropriate training according to particular stages. the nurses educated the parents, both mothers and fathers, in the class by inviting them to come into the school. the media used in this study was the modules, containing training materials about the nutritional needs of school age children, the selection of safe food, cooking safe food, serving safe food, storing safe food, choosing healthy snacks, and the washing of hands. the book was tested by bpom personnel, as well as the health promotion program, nutrition program, environmental health program, and the school health program. the media used was workbooks as an evaluation book, especially designed for parents and the students. the researcher was committed to the research ethics of each and every respondent participating. according to the national commission on the health research ethics of the indonesian minister of health (2006), there are four principal research ethics: beneficence, respect for persons, non-malfeasance, and justice. ethical clearance was issued by the research ethic committee of the faculty of nursing, of universitas indonesia. the process of data retrieval was done by the respondents filling out the questionnaires by way of an interview in the form of the parents’ and students’ demographic information, the parents’ knowledge and the parents’ skills. the questions regarding the demographic information (parents and the homeroom teachers) were to do with age, sex, level of education, level of economy based on salary, and the relationship to the students. the questions about the level of family knowledge consisted of 9 questions about nutritional content with pictures and 25 yes/no questions. the scale of family skills was also measured by using questionnaires, consisting of 25 “always – often – seldom – never” questions. the family skills questions were about the skills held on living a clean and healthy life (phbs), safe food, food handling, food storage, balanced diet, the nutritional content of food, and food serving. the maximum score before being given the intervention on the knowledge variables was 5, whereas after being given the intervention, the maximum score of knowledge increased to 7. the maximum score before being given the intervention on the skill variable was 26, whereas after being given the intervention, the maximum skill score increased to 55. to analyse the data, a specialised computer program was employed. to determine the change before and after the inclusion of the kogusiga intervention model, the data was analysed using a bivariate test. the paired t-test was used on the numeric data for a comparison between the two paired groups with a normal data distribution, and the alternative wilcoxon test was used for the abnormal data distribution. both the paired t-test and wilcoxon test were compared (dahlan, 2009). results the characteristic of the respondents based on the average age of the students’ parents in the intervention group was 38.3 years old and this was almost identical to the average of the control group, which was 40.1 years old. the youngest in the intervention group was 18 years old and the oldest was 71 years old (sd = 8.22), while in the control group, the youngest was 20 years old and the oldest was 62 years old (sd = 7.86) (table 1). in addition, the sex of the parents in the intervention group was dominated by females (79.6%), as well the control group by 73.8%. in terms of the level of education, in the intervention group, 47.6% of the respondents were high-school graduates while in the control group, more than half of the respondents (53.4%) were high-school graduates (table 2). the data on the parents’ income in the both intervention and control group was relatively identical. more than half of the respondents earned less than 2.4 million rupiah per month, with 55.3% in the intervention group and 57.3% in control group. in terms of the relationship with the students, both groups were almost similar in that the respondents were taking care of their biological children, with the data showing 89.3% in the intervention group and 90.3% in the control group respectively (table 3). the questionnaire analysis on the parents’ knowledge showed that the parents who were given the kogusiga intervention experienced an improvement in their awareness to do with the importance of having breakfast. before the intervention, the total percentage of the parents correctly responding to the statement “having breakfast does not affect focus in learning process” was only 39.8%. after the intervention, this increased to 78.6%. family knowledge about the importance of washing the ingredients before cooking them increased from 68.9% before the intervention to s. mulyono et al. 4 | pissn: 1858-3598  eissn: 2502-5791 91.3% after the intervention. however, the awareness of parents in using clean water was relatively high (87.4%) throughout. the results of the questionnaire analysis on parents’ skill showed an improvement in the knowledge regarding the importance of having breakfast, followed by an improvement in the skill of preparing a breakfast meal. this was proven by the increase in the percentage of parents responding with “always” for the statement “i prepare breakfast for my children”, from 40.8% before the intervention to 83.5% after the kogusiga intervention. the parents’ skill of choosing clean and safe wrapped food also improved. before the intervention, there were only 51.5% of parents responding with “always”, and after the intervention, this increased to 86.4%. a positive change in breakfast behaviour should be improved, since the number of school-age children who do not eat breakfast in several big cities is considerably low, at 16.9-59.0% (hardiansyah & aries, 2012). education on nutrition health education involving the parents in relation to kogusiga can be implemented in other schools in order to improve the habit of having breakfast among the students. a research study conducted by fries, martin, & horst (2017) table 1. distribution of the parents/guardians of the students by age in both the intervention and control group (n = 206) age variable n mean median min max sd p value intervention group 103 38.25 38.00 18 71 8.22 0.191 control group 103 40.07 39.00 20 62 7.86 table 2 distribution of the parents/guardians of the students by sex and level of education in both the intervention and control group (n = 206) variable intervention group control group p value n % n % gender male 21 20.4 27 26.2 0.323 female 82 79.6 76 73.8 total 103 100.0 103 100.0 level of education < senior high school 42 40.9 43 41.7 0.230 senior high school 49 47.6 55 53.4 college 12 11.7 5 4.9 total 103 100.0 103 100.0 table 3. parents/guardians of the students by income and the relationship with the children in both the intervention and control group (n = 206) variable intervention group control group p value n % n % income < umr* 57 55.3 59 57.3 0.780 ≥ umr* 46 44.7 44 42.7 total 103 100.0 103 100.0 relationship with student biological children 92 89.3 93 90.3 0.198 not the biological children 11 10.68 10 9.7 total 103 100.0 103 100,0 *umr: upah minimum regional (regional minimum wages) table 4. the effect of the kogusiga intervention model towards the knowledge and skills of families in the intervention and control groups (n =206) group n �̅� pre (%) s normality test ***** �̅� post (%) s normality test ***** % margin �̅� p-value 1-tailed pre-post knowledge intervention 103 12.9 (38,21) 5.39 0.000 19.87 (58.44) 3.81 0.013 20.23 0.000* control 103 20.66 (60.76) 3.87 0.030 20.64 (60.70) 3.97 0.014 -0.06 0.431* skills intervention 103 64.61 16.04 0.000 76.91 8.44 0.200 12.3 0.000* control 103 71.43 9.67 0.200 79.68 8.30 0.123 8.25 0.000** note: * wilcoxon test, ** t-test paired, ****t-test independent, *****kolmogorov-smirnov test, s: deviation standard jurnal ners http://e-journal.unair.ac.id/jners | 5 showed that the parents’ skill of preparing a packed meal was related to their children’s health. discussion the research showed that there was a significant improvement in the average knowledge and skills of parents in the intervention group after being treated with the kogusiga intervention model, whereas in the control group, there was no improvement shown in the knowledge and skills of the parents. the questionnaire analysis of the parents’ knowledge showed that parents who were given the kogusiga intervention experienced an improvement of their awareness about the importance of breakfast for the students. before the intervention, the total percentage of parents correctly responding to the statement “having breakfast does not affect focus in learning process” was only 39.8%, whereas after the intervention, it increased to 78.6%. family knowledge about the importance of washing the ingredients before cooking them increased from 68.9% before the intervention to 91.3% after the intervention. however, the awareness of parents in using clean water was relatively high (87.4%) in both groups. the control group had more male in the sample, and thus, more educated respondents. the results of this research are in accordance with the research conducted by prelip, thai, erausquin, & slusser (2011), stating that there was a significant improvement in the parents’ knowledge and nutrition skills when it came to improving the school-age children’s level of nutrition after being given education on nutrition and health for five hours a week. prelip, et al. believed that the effort to improve the school-age children’s level of nutrition must focus on the school-age children’s parents by educating them, so then the parents can be the role model when it comes to having a healthy diet for their school age children. the results of the kogusiga intervention also show that the student skill variable is not effective. this is supported by safriana's research (2012), which revealed that there is no clear relationship between nutritional knowledge and the schools in choosing snacks. things that can be explained by the knowledge obtained by the child is only limited to knowledge, while the effect of consuming unsafe food, unhealthy food, and a lack of nutrients was not sufficient. dixey et al. (2001) in ellis (2007) mentioned that children are good at learning what to expect, but children will still try to do what they like. eliasen (2007) said that the acceptance of new foods for children, and changing their eating habits is easy. intensive communication between the students and their parents is the way forward for mutual learning, based on a research study conducted by ratnapradipa, et. al (2011), using the child-to-parent instruction model. although overall there was an increase in knowledge, the parents’ level of knowledge about the definition of healthy food, which is food that has been cleanly served, was still low, even before and after the intervention. before the intervention, the parents who correctly responded only made up 4.9%. after the intervention, the level of knowledge about the given point did not show a significant improvement, with the respondents who correctly responded making up 16.5%. saadia (2015), in her research study, argued that there was no significant difference in the parents’ knowledge before and after the health education program. ahmad asserted that naturally, every parent has decent level of basic knowledge concerning the nutrition that is appropriate for their children. parents have the willingness to be able to provide safe and nutritious food, so they have to also figure out what should be served to their children. however, while there was no difference in the level of knowledge, it was not an indication that all parents showed a similar attitude to nutrition intake, since the knowledge that they possessed did not necessarily confirm that the parents would apply what they knew. to overcome this situation, it is needed to routinely evaluate and review the parents’ motivation to feed and serve food. in the kogusiga intervention model, parents and nurses routinely evaluated the students and families’ eating behavior using a workbook once a week. when the evaluation score was below average, teachers or nurses provided a consultation. hence, when implementing the kogusiga model in the future, the evaluation and consultation program must be prioritised. based on the concept of the health belief model by rosenstock (1990) cited by allender, rector, warner (2008), the individual’s ability to obtain nutritional fulfilment was determined by the students’ knowledge, attitude, and skill in relation to food safety. the kogusiga model adopted the health belief model by preparing the school-age children to improve their skills when it came to choosing safe food. in this model, there were attempts to transfer the knowledge about food safety to improve the awareness of the advantage of when students, teachers and families can fulfil their nutritional needs. the perception on the risks experienced when it comes to unhealthy food and snacks in the school environment forces students, teachers, and parents to adopt a healthier lifestyle. knowledge about the importance of monitoring nutritional adequacy that the parents acquired from the training and modules encouraged the improvement of the skill of monitoring nutrition. before the intervention, the number of parents responding with “always” and “often” was only 39.8% and 20.4% respectively, while after the intervention, the percentage increased to 69.9% and 25.2%. however, the improvement in knowledge about the importance of doing exercise was not followed by the skill improvement. before the intervention, only 14.6% of respondents responded with “always” to the statement “i do exercise regularly with my children”. after the intervention, there was no significant improvement, as it remained only 16.5%. developing s. mulyono et al. 6 | pissn: 1858-3598  eissn: 2502-5791 the habit of doing regular exercise is something that takes motivation, time, and is done gradually. rodearmel et al. (2006), in their research on the prevention of obesity in children 8-13 years old involving their parents, proved that it took 13 weeks and a gradual process to create a positive change in students and parents imt. we, as researchers, realised that this point was not maximised through the monitoring of students and family activity. regularly doing exercise is one of the indicators of a family with phbs, which means the family is capable of preserving, improving and protecting the health of each and every member of the family from the threat of disease and a less-conducive and unhealthy environment (kementerian kesehatan republik indonesia, 2011). in addition, the message of balanced nutrition (pgs) of 2014 suggested that physical activity is a part of the fulfilment of a balanced nutritional state. physical activity involving all kinds of body movement, including doing exercise, is one of the ways to balance the nutritional input and output within our bodies. aside from regular monitoring, through the kogusiga model, school nurses can cooperate with the community health nurse to improve the activity of students and families through the medium of regular exercise. the goal of health education on food safety in school-age children is to improve not only the knowledge, but also the skill, of school-age children regarding food safety (al-sahbib, husain, & khan, 2017). the kogusiga intervention model also affected the parent’s awareness regarding the students’ consumption behaviour of snack food by asking them what snack food they consumed on a daily basis. before the intervention, the percentage of parents asking their children was only 33%, but after the intervention, this improved to 72.8%. however, the parents were not motivated enough to ask the teachers to monitor the students’ behaviour on buying snack food while in school. before the intervention, the number of parents responding with “always” and “often” was 24.3% and 16.5%. after the intervention, there was only small incremental increase to 26.2% and 19.4%. consuming healthy food snacks is an indicator of phbs in the school environment (kementerian kesehatan republik indonesia, 2011). the scope and purpose of uks is the implementation of the good practice of phbs in schools, since it is composed of the behaviour practiced by students, teachers, and society surrounding the school on the basis of awareness as a result of the learning process. hence, the improvement of the parents’ awareness of the schoolage children’s behaviour in consuming safe food snacks in school needs to be boosted. the knowledge possessed by parents encourages them to try to apply the material that has been taught in order to fulfil their children’s nutritional needs. however, sometimes parents force their children to consume food that they do not like. this triggers the difficulty in children when it comes to liking that kind of food (gregory, paxton, &brozovic, 2010). according to the ecology system theory, there are several factors in the children’s environment that can affect safe nutritional fulfilment, which are microsystem, mesosystem, exosystem, and the macrosystem. the microsysystem is a part of an individual directly interacting with his/her social life, such as friends of the same age, family, neighbours, and the school. through the microsystem, school age children will learn a lot about health behaviour, and the children are not perceived as the passive receiver in this order. the fulfilment of school age children’s nutritional needs will also be affected by the mesosystem, which is the school environment including food-selling environments such as the school canteen or cafeteria. accordingly, in this research, it is necessary to conduct supervise the food-selling activities in schools so that they can fulfil the standards of safe and balance nutrition. the government, by the means of the closest health service units, which are puskesmas, is part of the exosystem that influences students when it comes to improving their health. in terms of the macrosystem, the part that affects students when it comes to increasing their health condition is culture or customs, religion or beliefs, wisdom and government regulations, and school policies and regulations. comprehensive school health is an integrated and continuous planning program between school affiliates, school activities and the school health service in order to improve the students’ physical health, social well-being, and education. this program involves the school community and family support that focuses on shaping the student’s behaviour. this development model will form a group process, and it is expected that the processed group will help in the making of a change in the school children’s behaviour when it comes to selecting safe and healthy food. the nurses comprehensively applied kogusiga using intervention strategies in order to improve the food safety of the students. the improvement of the food safety of the students can be seen from their knowledge of food safety, attitude towards food safety, skill of food safety, nutritional fulfilment and the students’ nutritional status. the expected health improvement happens gradually and takes time at every stage. it is based on transtheoretical theory, stating that there are five stages of health behaviour change: pre-contemplation, contemplation, preparation, action, and maintenance. all five stages are the basis of the stages of behaviour change in the concept of the kogusiga model. eating behaviour and nutritional intake is affected by several factors, including parenting, portions, drink consumption, choice of food (such as vegetarian), eating behaviour and eating frequency (the academy of nutrition and dietetics, 2014). parenting is very influential on a child’s eating behaviour. sometimes parents let their children not to consume the vegetables served, but although they know that vegetables are extremely important, the parents do not to force their children and prefer to give foods that they like, such as snacks. the jurnal ners http://e-journal.unair.ac.id/jners | 7 consumption of fruits and vegetables is capable of decreasing the risk of disease and death (arbury, jacklitsch, farquah, hodgson, & lamson, 2014). both attitudes, being too stern and too tolerant, become obstacles for parents making their children become accustomed to consuming fruits and/or vegetables, minimising unhealthy snacks and spending more time eating with their children. consequently in applying kogusiga model, the processed group is conducted through some activity to fulfill safe and balance nutrition that are fun and enjoyable to students, teachers and parents. the kogusiga intervention process is a form of cultivating an atmosphere to create a social environment that encourages the students to behave as expected: displaying better food safety consumption behaviour. conclusion the results of the study show that the kogusiga model was proven to significantly improve the parents’ knowledge and skills in the intervention group. the kogusiga model is a method of collaborative health education involving cooperation from all parts of the school. the kogusiga model can be a variation of a nursing intervention, which can be integrated by way of the method of health education as a preventive and promotive effort of the school health unit (uks). one main weakness was that the respondents were not randomly selected. based on the results of this research, community nurses and school nurses are needed. the implication of this research is to initiate the provision of school nurses to run the nursing care program, using a community nursing intervention to improve food safety in particular and school age children health in general. it was advised, directed to the minister of health, the minister of education and primary and secondary schools, the minister of religious affairs, and the ministry of internal affairs as the regulators, that the program of uks can increase the role of the school nurse by empowering nurses from puskesmas as the implementers of the school health program. references allender, j.a. & spradley, b.w. (2005). community health nursing promoting and protecting the public’s health 6th ed. philadelphia: lippincott william & wilkins. allender, j.a., rector, c., & warner, k.d. (2008). community health nursing promoting and protecting the public’s health 6th ed. philadelphia: lippincott williams & wilkins. al-shabib, n.a., husain, f.m., & khan, j.m. (2017). study on food safety concerns, knowledge and practices among university students in saudi arabia. food control, 73, 202–8. andarwulan et al. (2009). laporan penelitian: monitoring dan verifikasi profil keamanan pangan jajanan anak sekolah (pjas) nasional tahun 2008. bogor: southeast asian food and agricultural science and technology (seafast) center ipb dan direktorat surveilan dan penyuluhan keamanan pangan bpom ri. arbury, s., jacklitsch, b., farquah, o., hodgson, m., lamson, g. (2014). heat illness and death among workers — united states , 2012 – 2013. morbidity and mortality weekly report, 63(31), 2003–10. badan pengawasan obat dan makanan republik indonesia. (2005a). peraturan kepala badan pengawasan obat dan makanan republik indonesia nomor: hk.00.05.41.1384 tentang kriteria dan tata laksana pendaftaran obat tradisional, obat herbal terstandar dan fitofarmaka. retrieved january 5, 2015, from http//bpom.pom.go.id/. brown, j.e. et.al. (2005). nutrition through the life cycle. 2nd ed. wadsworth: usa. dahlan, s. (2009). statistik untuk kedokteran dan kesehatan. jakarta: penerbit salemba. dinas kesehatan kota depok. (2012). visi misi dinas kesehatan kota depok tahun 2011-2016. retrieved january 6, 2015, from: http://dinkes.depok.go.id/index.php. efsa. (2012). e.coli: rapid response in a crisis. retrieved january 6, 2015, from http://www.efsa.europa.eu/en/press/news/120 711.htm. eliassen, erin k,m.s., r.d., & wilson, mary w,phd., r.d. (2007). selecting appropriate elementary school nutrition education resources. american journal of health studies, 22(4), 224-227. retrieved from ellis. n. r (2007). the effect of nutrition knowledge on food choices and body mass index percentile rankings of elementary school children: results from an in-school nutrition education program. tesis. university of central florida, ann arbor (umi:3276356). fao/who. (2002). pan-european conference on food safety and quality. final report. rome: fao & who. fao/who. (2004). food safety for asia and the pacific. report year. rome: fao/who. fries, l.r., martin, n., & horst, k.v. (2017). physiology & behavior parent-child mealtime interactions associated with toddlers refusals of novel and familiar foods. physiol behav, 176, 93–100. gregory, j.e., paxton, s.j., & brozovic, a.m. (2010). pressure to eat and restriction are associated with child eating behaviours and maternal concern about child weight, but not child body mass index, in 2to 4-year-old children. appetite, 54(3), 550– 6. gross, s., cohen, h.a., & kahan, e. (2006). survey of parents, nurses, and school principals on their perceptions of the controversial role of schools in health promotion. pediatrics international: official journal of the japan pediatric society, 48(1), 44 – 7. hardinsyah & aries, m. (2012). jenis pangan sarapan dan sarapannya dalam asupan gizi harian anak usia 6 – 12 tahun di indonesia. jurnal gizi dan pangan, 7(2), 89–96. s. mulyono et al. 8 | pissn: 1858-3598  eissn: 2502-5791 kementerian kesehatan republik indonesia. (2011). pedoman perilaku hidup bersih dan sehat (phbs). retrieved january 6, 2015, from http://depkes.go.id/. kementerian kesehatan ri. (2014). panduan gizi seimbang 2014. jakarta: kementerian kesehatan ri. komisi nasional etik penelitian kesehatan departemen kesehatan ri. (2006). pedoman nasional etik penelitian kesehatan. retrieved january 6, 2015, from http://perpustakaan.depkes.go.id. kusumaningsih, i. (2010). pemberdayaan siswa sebagai motivator untuk mencegah gizi kurang pada kelompok anak sekolah dasar ratujaya iii di kelurahan ratujaya, kota depok. specialist’s final report. faculty of nursing universitas indonesia. maclellan, taylor, & freeze. (2009). developing school nutrition policies: enabling and barrier factors. can j diet pract res winter, 70(4), pp 16671 mulyono, s. (2003). evaluation of nutritional behavior change: an intervention study of rural extension clientele. thesis: canada. nidm. (2013). disaster update. retrieved january 6, 2015, from http://nidm.gov.in/pdf/du/2013/october/2410-13.pdf. prelip, m., thai, c.l., erausquin, j.t., & slusser, w. (2011). improving low-income parents’ fruit and vegetable intake and their potential to impact children’s nutrition. health education, 111(5), 391–411. ratnapradipa, quiliam, wier, & rhodes. (2011). food safety education: child-to-parent instruction in an immigrant population. journal of environmental health, 73(6), 70–5. rodearmel, s.j., et. al. (2006). a family-based approach to preventing excessive weight gain. obesity, 14(8), 393—401. saadia, a. (2015). comparison of knowledge, attitude, and behavior in parents of head start preschoolers before and after nutrition education, (dissertation on the internet). illinois: nothern illinois university. retrieved january 20, 2015, from proquest dissertations publishing. safriana. (2012). perilaku memilih jajanan pada siswa sekolah dasar di sdn garot kecamatan darul imarah, kabupaten aceh besar tahun 2012. skripsi: fkm ui. sekretariat jenderal jejaring intelijen pangan. (2005). kejadian luar biasa keracunan pangan. food watch sistem keamanan pangan terpadu. siburian. (2012). pengetahuan anak sekolah dasar terhadap pencegahan penyakit diare di sd 098167 rss perumnas kerasaan kec. pematang badar kab. simalungun, (bachelor’s thesis). universitas sumatera utara. stanhope, m. & lancaster, j. (2004). public health nursing: population-centered health care in the community, 6th ed. philadelphia: elsevier health sciences. the academy of nutrition and dietetics. (2014). position of the academy of nutrition and dietetics: nutrition guidance for healthy children ages 2 to 11 years. journal of the academy of nutrition and dietetics, 114(8), 1257–76. widjajati, w. (2012). pengembangan usaha kesehatan sekolah (uks). presentasi pada rapat kerja nasional (uks) 2012, jakarta. diunduh dari http://dikdas.kemdikbud.go.id/application/medi a/file/rakernas%20uks%202012/pengembang an%20usaha%20kesehatan%20sekolah%20%2 8uks%29.ppt. wong, d.l., eaton, m.h., wilson, d., winkelstein, m.l., & schartz, p. (2008). buku ajar keperawatan pediatrik wong. edisi 6. translator: sutarna a. jakarta: egc. 42 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.5765 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the influence of peer health education toward the decreasing risk of heart disease riza fikriana1 and al afik2 1 sekolah tinggi ilmu kesehatan kepanjen malang, jawa timur, indonesia 2 universitas muhammadiyah yogyakarta, d.i. yogyakarta, indonesia abstract introduction: heart disease is the number one cause of death in indonesia. promotional efforts through the provision of health education and counselling through peer health education is one of the primary prevention strategies that can be undertaken to prevent the occurrence of heart disease. the purpose of this study is to prove the influence of peer health education in reducing the risk of heart disease. methods: the research method used in this study was quasi-experimental with a pre-test-post-test non-equivalent control group design. the samples were taken from 56 people using the purposive sampling technique. the first group of 28 people was the experimental group and the second group of 28 people was the control group. before and after treatment, both groups were measured concerning their knowledge, lifestyle behaviour, blood pressure, blood glucose levels, blood cholesterol levels and risk assessment of heart disease. data analysis was done by using the friedman test with a 95% significance level. results: the results showed that peer health education was able to improve the respondents' knowledge about having a healthy lifestyle, changing the behaviour of the respondents, i.e. behaviour of consuming sweet foods, controlling blood pressure and decreasing the risk of heart disease. conclusion: based on the result, health promotion efforts through a peer health educator can continue to be done as one method to improve heart health in the community. thus, the expectation of morbidity and mortality due to heart disease can be lowered. article history received: sept 03, 2017 accepted: june 02, 2018 keywords peer health education; lifestyle behaviour; heart disease contact riza fikriana riza_fikriana@stikeskepanj en-pemkabmalang.ac.id  sekolah tinggi ilmu kesehatan kepanjen malang, jawa timur, indonesia cite this as: fikriana, r., & afik, a. (2018). the influence of peer health education toward the decreasing risk of heart disease. jurnal ners, 13(1), 42-49. doi: http://dx.doi.org/10.20473/jn.v13i1.5765 introduction heart disease is the number one cause of death in indonesia and around the world. based on valid data, each year approximately 17.3 million people die from a heart attack. it is estimated that by 2030, deaths from heart disease will reach 23.6 million inhabitants (mozaffarian et al, 2015). based on the basic health research data conducted by the ministry of health of the republic of indonesia in 2013, it is known that the prevalence of coronary heart disease in indonesia in 2013, based on doctor/symptom diagnosis, is 1.5% of the total population or about 2,650,340 people. in this data, it is known that most patients come from the east java province with a total of 375,127 people. in addition, based on the doctor's diagnosis, east java province is also the region with the highest number of heart failure patients in indonesia (center for data and information ministry of health, indonesian republic, 2014). heart disease is a disease caused by a disorder of the heart or the blood vessels. several risk factors such as age, gender, family history, and obesity, lack of exercise/lack of exercise, unhealthy diet, stress, hypertension, dyslipidemia and diabetes mellitus can lead to heart disease (bickley, 2015). quick and proper treatment is needed for patients in order to prevent the occurrence of morbidity and mortality of patients who have had a heart attack or are at risk of it. several attempts can be made to prevent the risk of heart attack. the american heart association recommends seven important keys to maintaining heart health, such as by quitting smoking, maintaining https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 43 a level of physical activity with regular exercise, maintaining a healthy diet, maintaining normal weight and controlling blood pressure, cholesterol and blood sugar levels in the body (mozaffarian et al, 2015). the world health organisation (who) in 2011 developed a framework of reference that can be used to prevent and control the occurrence of heart disease by making efforts to increase public awareness about the importance of heart health, through increased health promotion activities. in terms of reference, it is explained that the age group most at risk for heart disease is 30-70 years old. in this age range, it is very important to maintain heart health through healthy lifestyle behaviours (chestnov, 2011). health promotion through education and counselling activities is one of the efforts used to guide someone to undertake the necessary lifestyle changes to maintain heart health (bickley, 2015). to assist in the provision of health information, there are a variety of methods available. peer health education is one of the strategies that can be used to provide health education to people with certain characteristics. this activity is carried out by peer health educators, people with the same characteristics as the community groups, considered to have the ability to influence these groups so that efforts to improve knowledge, skills and behavioural changes are easier to produce. from previous research study results, peer health education can effectively be used to improve knowledge, skills and the ability to change one's own health behaviour (duncanson et al, 2014). in addition, peer education is able to improve attitude (khosravi et al, 2017; gurkan & komurcu, 2017), increase confidence in goal setting ability (gough & cassidy, 2017), and reduce anxiety (homan & chichester, 2016). based on the above background, the current researchers are interested in conducting a study on the influence of peer health education in relation to the modification of lifestyle against the risk of heart disease in a community at risk. the purpose of this study is to prove the effectiveness of peer health education in relation to the modification of lifestyle and the risk of heart disease in the community. materials and methods this study used a quasi-experimental with a pre-testpost-test non-equivalent control group design. research data retrieval activities were conducted in kepanjen, kepanjen district, malang, in june august 2017. the samples were taken by using the purposive sampling technique. there were 56 people divided into two groups, as the treatment group and control group respectively. the research instruments include questionnaires to measure knowledge, a checklist of healthy lifestyle behaviours, a checklist of the risk of cardiovascular heart disease the "jakarta cardiovascular score", a sphygmomanometer, blood cholesterol test and blood glucose test. the data collection process began with pre-test activity by asking the respondents to fill out a questionnaire about their knowledge and healthy lifestyle behaviours, to fill out a checklist of the risk factors for heart disease, and to measure their blood pressure, blood cholesterol and blood glucose. furthermore, the treatment group was given peer health education by peer health educators, as determined by the researchers. two weeks after the advent of peer health education, the researchers employed a second re-measurement of knowledge, healthy lifestyle behaviours, the calculation of the risk of heart disease, and blood pressure, blood glucose and blood cholesterol. two weeks later, a third remeasurement was employed. the questionnaire used in this study had been validity tested using a product momen pearson correlation and reliability test. the instrument's cronbach's alpha was 0.852. the three measurements were performed in both the treatment and control group. the data was then analysed using univariate and bivariate tests. in the univariate test, the data was analysed and presented in terms of percentage, mean, standard deviation, median, and minimum and maximum according to the data type. in the bivariate test, the data was analysed using the wilcoxon, mann-whitney or friedman test according to the type of data distribution related to each variable with a 95% significance level. this research study received ethical clearance approval from the health research commission of health polytechnic, of the health ministry of malang (no.002/kepkpolkesma/2017). results the research was conducted on 56 respondents divided into two groups. the first group was a control group of 28 respondents with an average age of 42.86 years. the second group of 28 respondents had an average age of 43.61 years. both groups are all female. knowledge of a healthy lifestyle to prevent heart disease knowledge of a healthy lifestyle to prevent heart disease in each group has been listed in table 1. in table 1, it was found that in the experimental group, there was a significant difference in the respondent’s knowledge between before and after, following the peer health education with a p-value equal to 0.004. in the control group, it was found that there was no knowledge difference between the first measurement and the measured knowledge two weeks after the first measurement with a pvalue of 0.172. this is in accordance with the results of the study listed in table 2, which explains that there is a significant difference in the knowledge of a healthy lifestyle to prevent heart disease in the experimental group and the control group with a p-value of 0.034. based results, it can be concluded that peer health education can increase one's knowledge about living a healthy lifestyle in order to prevent heart disease. r. fikriana et al. 44 | pissn: 1858-3598  eissn: 2502-5791 healthy lifestyle the behaviour of the modification of one’s lifestyle to prevent the occurrence of heart disease was measured based on the respondent’s behaviour regarding the consumption pattern of fatty foods and sweet foods, participation in activities/sports, stress/anxiety, smoking and alcohol consumption. the description of the respondent's behaviour in the experimental group and control groups has been listed in tables 3 and 4 respectively. based on table 3, it can be explained that only the pattern of consumption of sweet foods that has a p-value <0.05 can be interpreted to indicate that there is a significant difference in the consumption patterns of the respondents between the first, second and third measurements. the consumption behaviour of fatty foods, physical activity and stress/anxiety show no significantly different results between the first, second and third measurements. in relation to the measurement of smoking habits and alcohol consumption, it has a fixed value between the first, second and third measurements. table 4 shows that in the control group, there was no significant difference in the healthy lifestyle behaviour and all of the associated components (consumption of fatty foods, consumption of sweet foods, physical activity, stress/anxiety, smoking habits, and alcohol consumption habits) between the first, second and third measurement. table 5 shows that there were differences in the behaviour of the healthy lifestyle undertaken to prevent heart disease between the experimental group and the control group. the difference is in the pattern of consumption of fatty foods with a p-value of 0.041. the pattern of consumption of sweet foods, physical activity, stress/anxiety, smoking habits and alcohol consumption habits did not show any table 1. results of the wilcoxon test analysis of the knowledge of what is a healthy lifestyle before and after treatment in the experimental and control groups. knowledge median (minimummaximum) p-value experimental group before treatment two weeks after the treatment 7 (6 – 10) 8 (6 – 10) 0.004 control group first test two weeks after the first test 7 (4 – 10) 7 (4 – 10) 0.172 table 2. mann whitney test analysis results: differences in healthy life pattern knowledge between the experimental and control groups. knowledge median (minimum-maximum) p-value knowledge of experimental group knowledge of control group 8 (6 – 10) 7 (4 – 10) 0.034 table 3. behaviour of the modification of the experimental-group’s lifestyle no the behaviour of lifestyle modification pre n (%) post-1 n (%) post-2 n (%) p-valuea a consumption patterns of fatty foods >1 time/day 1-6 times/week <3 times/month 8 (28.6) 16 (57.1) 4 (14.3) 6 (21.4) 18 (64.3) 4 (14.3) 4 (14.3) 21 (75) 3 (10.7) 0.229 b consumption patterns of sweet foods >1 time/day 1-6 times/week <3 times/month 11 (39.3) 14 (50) 3 (10.7) 12 (42.9) 13 (46.4) 3 (10.7) 3 (10.7) 20 (71.4) 5 (17.9) 0.011 c physical activities active less active 6 (21.4) 22 (78.6) 3 (10.7) 25 (89.3) 4 (14.3) 24 (85.7) 0.368 d stress/anxiety every day often occasional never 2 (7.1) 2 (7.1) 23 (82.1) 1 (3.6) 1 (3.6) 4 (14.3) 22 (78.6) 1 (3.6) 7 (25) 2 (7.1) 18 (64.3) 7 (25) 0.308 e smoking habit every day occasional ex-smoker non-smoker 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 1.000 f alcohol consumption every day occasional ex-consumer never consume 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 1.000 note: a result of the friedman analysis jurnal ners http://e-journal.unair.ac.id/jners | 45 significant differences between the experimental and control groups. the measurement of blood pressure, blood cholesterol and blood glucose the results of the measurement of blood cholesterol, blood glucose and blood pressure levels between the experimental group and the control group have been listed in table 6. it can be explained that the results of the blood cholesterol and blood glucose level tests in both the experimental and control groups did not differ significantly between the measurements taken pre-test, post-test-1 and posttest-2. however, in relation to the blood pressure measurements in both the treatment and control groups, there was a significant difference between the measurements of pre-test, post-test-1 and post-test2. from the measurement of blood pressure, the pvalue of the treatment group was smaller than that of the control group, so it can be concluded that the change in blood pressure in the treatment group is more meaningful. the risk of heart disease the risk of cardiovascular disease in the experimental and control groups has been shown in tables 7, 8 and 9. table 7 shows a description of the risk of heart disease in the experimental and control groups. based on the above table, it shows that at the end of the measurement period, more than half of respondents in the experimental group equal to 53.6% -have a low risk of heart disease. the respondents who experienced a high risk decreased from 25% to 21.4%. in the control group, it showed table 4. behaviour of modification of the control group’s lifestyle patterns no the behaviour of lifestyle modification pre n (%) post-1 n (%) post-2 n (%) p-valuea a consumption patterns of fatty foods › 1 time/day 1-6 times/week ‹ 3 times/month 13 (46.4) 11 (39.3) 4 (14.3) 5 (17.9) 20 (71.4) 3 (10.7) 9 (32.1) 19 (67.9) 0 (0) 0.078 b consumption patterns of sweet foods › 1 time/day 1-6 times/week ‹ 3 times/month 14 (50) 12 (42.9) 2 (7.1) 7 (25) 20 (71.4) 1 (3.6) 5 (17.9) 22 (78.6) 1 (3.6) 0.084 c physical activities active less active 6 (21.4) 22 (78.6) 6 (21.4) 22 (78.6) 2 (7.1) 26 (92.9) 0.264 d stress/anxiety every day often occasional never 0 (0) 4 (14.3) 20 (71.4) 4 (14.3) 0 (0) 1 (3.6) 23 (82.1) 4 (14.3) 0 (0) 1 (3.6) 26 (92.9) 1 (3.6) 0.441 e smoking habit every day occasional ex-smoker non-smoker 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 1.000 f alcohol consumption every day occasional ex-consumer never consume 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 0 (0) 0 (0) 0 (0) 28 (100) 1.000 note: a result of the friedman analysis table 5. mann whitney test analysis results differences in the healthy lifestyle behaviour between the experimental and control groups lifestyle pattern p-value consumption patterns of fatty foods experimental group control group 0.041 consumption patterns of sweet foods experimental group control group 0.114 physical activities experimental group control group 0.392 stress/anxiety experimental group control group 0.221 smoking habit experimental group control group 1.000 alcohol consumption experimental group control group 1.000 r. fikriana et al. 46 | pissn: 1858-3598  eissn: 2502-5791 that at the end of the measurement period, the number amounted to 46.4% who had a low risk of heart disease. this indicates a decrease in the number of respondents with a low risk, while those at moderate risk increased between the first measurement and the third measurement from 28.8% to 32.1%. based on table 8, the difference in the risk of heart disease in the first, second and third measurements in the experimental group receiving peer health education showed a p-value of 0.060, which statistically means that there is no difference in risk of heart disease before and after the respondent underwent peer health education. however, when viewing the median and minimum values of each measurement period, positive changes from the first measurement to the last measurement indicate that the respondent tended to experience a decrease in the table 6. results of blood cholesterol level, blood glucose and blood pressure in the experimental and control group blood cholesterol levels pre mean (sd) post-1 mean (sd) post-2 mean(sd) p-value experimental group 195 (48.901) 204.86 (46.865) 212.14 (36.209) 0.291a control group 203.57 (52.907) 204.04 (63.093) 202.71 (69.967) 0.995a blood glucose pre median (min-max) post-1 median (min-max) post-2 median (min-max) p-value experimental group 106 (63-397) 102 (44-244) 102.5 (55-211) 0.503b control group 111.5 (78-416) 109 (70-341) 105.5 (70-478) 0.756b blood pressure pre n (%) post-1 n (%) post-2 n (%) experimental group normal pre-hypertension hypertension stage 1 hypertension stage 2 9 (32.1) 9 (32.1) 6 (21.4) 4 (14.3) 7 (25) 13 (46.4) 3 (10.7) 5 (17.9) 13 (46.4) 8 (28.6) 5 (17.9) 2 (7.1) 0.010c control group normal pre-hypertension hypertension stage 1 hypertension stage 2 10 (35.7) 10 (35.7) 6 (21.4) 2 (7.1) 14 (50) 9 (32.1) 4 (14.3) 1 (3.6) 14 (50) 10 (35.7) 3 (10.7) 1 (3.6) 0.045c note: a result of repeated anova analysis, b, c result of friedman analysis table 7. risk of heart disease in the experimental and control group risk of heart disease pre n (%) post-1 n (%) post-2 n (%) experimental group low risk medium risk high risk 15 (53.6) 6 (21.4) 7 (25) 16 (57.1) 6 (21.4) 8 (21.4) 15 (53.6) 7 (25) 6 (21.4) control group low risk medium risk high risk 14 (50) 8 (28.6) 6 (21.4) 16 (57.1) 7 (25) 5 (17.9) 13 (46.4) 9 (32.1) 6 (21.4) table 8. the result of friedman's test analysis score of the risk of heart disease in the experimental group heart disease risk score median (minimum-maximum) p-value pre-treatment 1 (-3 – 9) 0.060 two weeks after the treatment 0.5 (-5 – 9) four weeks after the treatment 0.5 (-5 – 9) friedman test. p value on post hoc wilcoxon: before treatment and two weeks after treatment 0.204; before treatment vs. four weeks after treatment of 0.150; two weeks vs. four weeks after treatment 0.679. table 9. the result of the friedman test analysis score on the risk of heart disease in the control group heart disease risk score median (minimum-maximum) p-value first test (pre) 1,5 (-4 – 9) 0.098 two weeks after the first test 1 (-6 – 9) four weeks after the first test 2 (-3 – 8) friedman test. p value on post hoc wilcoxon: before test vs. two weeks after the first test 0,516; before test vs. four weeks after the first test 0.414; two weeks after the first test vs four weeks after the first test 0.059 jurnal ners http://e-journal.unair.ac.id/jners | 47 risk of heart disease, from the lowest score of -3 to -5 and from the median value of 1 to 0.5. the results listed in table 9 focused on the difference in the risk score of heart disease in the control group in relation to the three measurements obtained a p-value of 0.098. statistically, this shows that there is no significant difference between the first, second, and third measurements. however, when viewed from the median value achieved at the beginning of the measurement, it showed that the risk of heart disease increased from the score of 1.5 to a score of 2 at the end of the measurement period. in addition, the minimum score also increased from -4 to -3. this suggests that the control group respondents tend to have an increased risk of developing heart disease at the end of the measurement period. discussion the behaviour of a person living a healthy lifestyle is influenced by several factors, one of which is the knowledge and understanding possessed by a person (mindy & alyson, 2015). therefore, to improve one's knowledge, it can be provided through health education. health education activities aim to increase one's knowledge and understanding so that they will be able to transform their behaviour into a healthier one (marianne et al, 2001). there are many methods used in health education, one of which is peer health education. peer health education involves a person who is considered to be able influence the community around them. by using the peer health education method, it is hoped that the communities around them will find it easier to understand and implement the knowledge that they have acquired (duncanson et al, 2014). this is in accordance with the results of the research as shown in table 1, which shows that peer health education can increase the knowledge of the respondents on what makes a healthy lifestyle to prevent heart disease (p-value 0,004). it also showed that for the respondents who did not get peer health education, their knowledge about utilising a healthy lifestyle to prevent heart disease tended to show no difference between the first measurements and the second measurement (p-value 0.172). so, from the analysis of both groups, it showed that there is a difference in the knowledge about using healthy lifestyles to prevent heart disease between the groups who underwent peer health education and those who did not get peer health education access (p-value 0.034). peer health education is an effective method in health education that is used to provide health information to a group of people with special characteristics, with the aim of achieving certain knowledge and skills used to achieve a health goal. a peer health educator is also able to motivate and facilitate members of their group to behave healthily in accordance with the expected goals. a peer health educator is also able to share information in an applicable, practical and appealing way to the audience and therefore it is often easier for them to produce behavioural changes (duncanson et al, 2014). good knowledge, an understanding of the community and an awareness of the attitude to healthy lifestyles in order to prevent heart disease will be able to affect their behaviour in daily life. the results of the research in table 3 shows that peer health education can influence the consumption pattern of sweet foods in the community group who are at risk of heart disease (p-value 0.011). in the first measurements, the peer health education action was given, and the pattern of the excessive consumption of sweet foods was more than once per day for as many as 39.3% of respondents. at the end of the measurements, the number decreased to 10.7% of the respondents. this shows that the pattern of the excessive consumption of sweet foods is one of the risk factors for heart disease. consuming excess sweet foods will increase the risk of increased blood pressure. the results of another study indicate that there is a significant relationship between the pattern of consumption of sweet foods with the occurrence of increased systolic blood pressure in patients with hypertension (fikriana, 2016). this happens because the consumption of excessive sweet foods will cause the levels of glucose and fructose in the blood to increase, which will affect the metabolism of a person's body, causing damage and the homeostasis of the blood vessel walls, affecting insulin disturbance in the body as well as increasing the occurrence of the lipogenesis process (siervo et al, 2013). table 6 shows that there was a difference in blood pressure before treatment and after treatment (pvalue 0.010). before the treatment was obtained, the number of respondents who had normal blood pressure was as many as 32.1%. after treatment, there was an increase in the number of respondents who had normal blood pressure, up to 46.4%. the respondents who had not had the treatment had blood pressure that fit the classification of hypertension stage 2, which decreased the number of respondents from the previous 14.3% to 7.1%. this shows that the peer health educator can motivate the respondents to control their blood pressure. the results of this study are in line with the research conducted by mindy & alyson (2015), which states that knowledge will affect a person's ability to control his or her blood pressure. the pattern of the excessive consumption of fatty foods, stress/anxiety and a lack of exercise are also risk factors that can cause heart disease. however, the results of this study indicate that there is no difference in the behaviour pattern of fast food consumption (p-value 0.078), physical activity (pvalue 0.268), and stress/anxiety (p-value 0.441) in the group receiving peer health education. this is in line with the results of the study in table 6, which shows no difference in blood cholesterol levels before treatment and after treatment (p-value 0.291). the increased knowledge obtained by the respondents does not directly affect the behaviour of the r. fikriana et al. 48 | pissn: 1858-3598  eissn: 2502-5791 respondents in relation to the pattern of fat consumption, stress/anxiety and exercise. knowledge and an understanding of what a healthy lifestyle is, is not balanced with the ability and awareness to change behaviour to generate a healthy life pattern (kaplan et al, 2006). the results of this study are not in line with the research that has been done by mindy & alyson (2015), which showed that there is a positive relationship between knowledge and the behaviour of someone doing physical activity/sports, healthy food consumption, and with a sensible blood glucose and blood cholesterol level. the lack of the influence of knowledge already gained from peer health education on the respondent’s behaviour can be caused by several factors. this can include individual internal factors such as self-awareness, self-motivation and habits. a person will tend to behave more carefully to live a healthy life if they are under threat of health problems. however, if a person is not actively having a health threat, they tend not to behave healthily. this is in accordance with the results of the research conducted by mosca et al (2006), which showed that the awareness of the threat of risk of heart disease in a person becomes a factor that determines whether or not a person will live a healthy life. the results of other studies explain that the susceptibility to and seriousness of heart disease as well as self-motivation will affect the way that a person to behaves in a healthy lifestyle (ali, 2002). several steps can be used to screen for heart disease, including screening for common risk factors, calculating the risk of heart disease for ten years and long-term risk calculation using an online calculator. risk calculations can be done using the framingham score (bickley, 2015). in addition, there are also other guidelines used to calculate the risk of heart disease in the next ten years, which is in relation to using the jakarta cardiovascular score. the jakarta cardiovascular score is a modification of the framingham score developed in indonesia (kanjilal et al, 2008). the results of the research shown in table 8 describe the median and minimum scores of the risks of heart disease, which shows a decrease in risk in the treatment group from median 1 to 0.5 and a minimum value of -3 to -5. this decline in risk scores suggests that peer health education reduces the risk of heart disease in risky people. while in a group and when not treated by peer health education, the risk of developing heart disease tended to increase in relation to the median and minimum values, which means that people who do not get peer health education tend to have an increased risk of heart disease. conclusion peer health education is an effective method used for health promotion in order to reduce the risk of heart disease. peer health education can increase knowledge about healthy lifestyles to prevent heart disease, to improve healthy life behaviours especially the sweet food consumption pattern, control blood pressure and reduce the risk of heart disease in risky groups. good knowledge of healthy lifestyles is accompanied by proper behaviour, maintaining a balanced pattern of food consumption and controlling the risk factors such as stress/ anxiety, smoking habits, sports activities and the consumption pattern of alcohol, which is a major factor that plays a role in the prevention of heart disease. therefore it is necessary to for all of the components to work together and to provide support so that people can learn how to live a healthy lifestyle in order to reduce the risk of heart disease. references ali, n. s. 2002. prediction of coronary heart disease preventive behaviors in women: a test of the health belief model. women and health, 35(1), pp.83–96. bickley, l. s. 2015. pemeriksaan fisik & riwayat kesehatan. jakarta : egc center for data and information ministry of health, indonesian republic. (2014). situasi kesehatan jantung. jakarta: ministry of health, indonesian republic chestnov, o. 2011. ncd global monitoring framework: ensuring progress on noncommunicable diseases in countries. world health organisation (who) duncanson, k., burrows, t., & collins, c. 2014. peer education is a feasible method of disseminating information related to child nutrition and feeding between new mothers. biomed central public health. 14: p.1262. doi: 10.1186/1471-2458-141262 fikriana, r. 2016. faktor – faktor yang diduga menjadi prediktor peningkatan tekanan darah sistolik pada penderita hipertensi. jurnal kesehatan mesencephalon, 2(4), pp.285-291 gough, a., & cassidy, k. 2017. toward psychosocial health in age-friendly communities : the fountain of health peer-led education series. mental health & prevention, 8(july), pp.14–19. doi: 10.1016/j.mhp.2017.08.002 gürkan, ö. c., & kömürcü, n. 2017. the effect of a peer education program on combating violence against women : a randomized controlled study. nurse education today, 57(49), pp.47–53. doi: 10.1016/j.nedt.2017.07.003 homan, n., & chichester, m. 2016. peer to peer education: ob visits the ed. ymen, 42(2), pp.125– 127. doi: 10.1016/j.jen.2015.09.015 kanjilal, s., rao, v. s., mukherjee, m., natesha, b. k., renuka, k. s., sibi, k., iyengar, s. s., & kakkar, v. v. 2008. application of cardiovascular disease risk prediction models and the relevance of novel biomarkers to risk stratification in asian indians. vascular health and risk management, 4(1), pp/199 – 211 kaplan, r. c., bhalodkar, n. c., brown, d. l., white, j., & brown, e. j. jr. 2006. differences by age and file:///c:/users/user/documents/10.1016/j.mhp.2017.08.002 jurnal ners http://e-journal.unair.ac.id/jners | 49 race/ethnicity in knowledge about hypercholesterolemia. cardiology in review, 14 (1), pp.1–6. khosravi, n., kolifarhood, g., shoghli, a., & pashaeypoor, s. 2017. effectiveness of peer education approach on improving hiv / aids related healthy behaviors among immigrant street children : a randomized controlled trial. clinical epidemiology and global health. doi: 10.1016/j.cegh.2017.09.004 marianne, a. b.v. d. s., walfaren, g. e., miligan, p. j., banya, w. a., ceesay, s. m., nyan, o. a., & mcadam, k. p. 2001.family history : an opportunity for early interventions and improved control of hypertension, obesity and diabetes. bulletin of the world health organization, 79(4), pp.321–328 mindy, m., & alyson, m. 2015. racial/ethnic differences in knowledge of personal and target levels of cardiovascular health indicators. journal community health, 40, pp.1024–1030. mosca, l., mochari, h., christian, a. 2006. national study of women’s awareness, preventive action, and barriers to cardiovascular health. circulation, 113(4), pp.525–534. mozaffarian, d., benjamin, e. j., go, a. s., et al. 2015. heart disease and stroke statistics—2015 update: a report from the american heart association. circulation, 131(4), e29-e322. doi: 10.1161/cir.0000000000000152. siervo, m., montagnese, c., mathers, j. c., soroka, k. r., stephan, b. c. m., & wells, j. c. k. 2013. sugar consumption and global prevalence of obesity and hypertension : an ecological analysis, 17(3), pp.587–596. doi: 10.1017/s1368980013000141. pengaruh pendidikan kesehatan pathways awareness’ brochure terhadap perilaku deteksi dini orang tua pada perkembangan awal anak 3-15 bulan 31 pathways awareness’ brochure sebagai deteksi dini perkembangan anak (pathways awareness’s brochure as early detection for child development) nursalam*, ilya krisnana*, nantiya pupuh satiti* abstract introduction:parental awareness of the earliest milestones considerably lower than of the later milestones. to raise parental awareness, pathways awareness’ brochure (pab) can be used by the parents. the objective of this study was to examine the effect of health education of pathways awareness’ brochure to the behavior of parental early identification in child (3-15 months) early development. method: this study used quasy-experimental design. population had taken from parents who have a child from 3 until 15 months. sample was comprised in to 30 individuals who fit with the inclusion criteria. sample was divided by two groups, one group as intervention group, and another one as control group. the independent variable in this study were health education of pathways awareness’ brochure. the dependent variable was the behavior of parental early identification in child (3-15 months) early development. data was collected by questionnaire of family knowledge, family attitude, and family action. they were analyzed by wilcoxon signed rank test with significance level α<0.05. result: according to the result by wilcoxon signed rank test, there was a significance difference between the behavior of parental early identification in child (3-15 months) early development before and after the intervention ( family knowledge p = 0,003; family attitude p = 0,034; family action p = 0,025).analysis:it conclusion, pathway awarness’ brochure foster the behavioural of the parents on early detection. discussion: it is recommended to explore study on cooperation of pab and kms. keywords: early identification, parental early identification, pathways awareness’ brochure *fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: nursalam_psik@yahoo.com pendahuluan masa balita merupakan tahap perkembangan kemampuan berbahasa, kreativitas, kesadaran sosial, emosional dan intelegensia berjalan sangat cepat dan merupakan landasan perkembangan berikutnya (soetjiningsih,1995). masa perkembangan anak di usia awal akan mempengaruhi dan menentukan perkembangan anak selanjutnya (rydz d, 2005). setiap kelainan atau penyimpangan sekecil apapun apabila tidak terdeteksi dan ditangani dengan baik, akan mengurangi kualitas sumber daya manusia di kemudian hari (soetjiningsih,1995). beberapa bayi usia muda dengan keterlambatan perkembangan atau mempunyai beberapa faktor yang dapat menghambat perkembangan tidak teridentifikasi oleh petugas kesehatan. ketika teridentifikasi, bayi terlanjur jarang mendapatkan intervensi awal yang tepat berkaitan dengan program perkembangan anak (king tm, 2003). interval antara identifikasi awal dan pemberian perawatan medis dalam banyak kasus berkisar antara lebih dari 12 bulan (flanagan o, 2001). laporan dari orang tua dapat mengidentifikasi keterlambatan perkembangan secara akurat (georgetown university, 1994). hasil dari studi pendahuluan di kelurahan manyar sabrangan, kelurahan mulyorejo surabaya, dari 30 sampel yang mailto:nursalam_psik@yahoo.com jurnal ners vol.4 no.1 april 2009: 31-35 32 diambil dari 4 posyandu, yaitu posyandu rw i rt 3-4, rw iii rt 5, rw iv rt 1, dan rw iv rt 2, didapatkan data bahwa sepertiga dari orang tua tidak mengetahui konsep dasar perkembangan, sepertiga mencampurkan konsep perkembangan dan pertumbuhan, dan sepertiga lainnya hanya memperkirakan perkembangan anaknya normal atau tidak. sehingga diperlukan perilaku deteksi dini orang tua untuk dapat melakukan pengidentifikasian perkembangan awal anak. pathways awareness foundation melakukan penelitian di children’s memorial hospital untuk menghasilkan sebuah brosur skrining perkembangan anak 3-15 bulan, yang kemudian telah disetujui oleh illinois chapter american academy of pediatric sebagai alat untuk deteksi dini perkembangan awal anak 315 bulan oleh orang tua. pathways awareness’ brochure telah digunakan lebih dari 2 juta orang tua dan professional kesehatan di seluruh dunia. negara-negara yang menggunakannya antara lain: spanyol, perancis, bosnia, cina, israel, jerman, jepang, polandia, rusia, brasil, portugal, dan amerika. (pathways awareness foundation, 2006). di indonesia belum terdapat penelitian mengenai pathways awareness’ brochure sebagai alat untuk meningkatkan kesadaran orang tua mengenai perkembangan anak 3-15 bulan. belum terdapat pula penjelasan mengenai pengaruh pendidikan kesehatan pathways awareness’ brochure terhadap perilaku orang tua pada deteksi dini perkembangan awal anak usia 3-15 bulan. menurut national internet survey dan children memorial hospital pada tahun 20022004, kesadaran orang tua untuk mengenali tahapan perkembangan awal anak yang tidak memenuhi tahapan perkembangan yang normal pada fase awal secara umum lebih rendah dari pada fase berikutnya. pada penelitian yang sama, juga didapatkan bahwa orang tua yang melaporkan kepada petugas kesehatan bahwa tahapan perkembangan awal anak tidak memenuhi tahapan perkembangan yang normal, pada fase awal perkembangan cenderung lebih rendah dari pada fase berikutnya. sebuah riset oleh glascoe fp (1995) di beberapa negara bagian amerika, melaporkan bahwa orang tua dapat digunakan sebagai sumber informasi klinik yang meliputi dua macam jenis data, yaitu data untuk penilaian (perhatian, perkiraan, dan prediksi) dan data untuk deskripsi (melaporkan dan mengingat kembali perkembangan anak). menurut chen ic (2001) terdapat indikasi pentingnya peran orang tua dalam mengidentifikasi keterlambatan motorik, bahasa, dan personal sosial pada anak. lothian nhs (1995), mengungkapkan kepercayaan diri orang tua, pengalaman mengasuh anak sebelumnya, dan keefektifan hubungan sosial dengan keluarga serta teman-teman adalah faktor penting dalam perilaku deteksi dini orang tua. penelitian oleh glascoe fp (1995) menegaskan bahwa peningkatan perilaku deteksi dini tidak meningkat secara signifikan dengan tingkat pendidikan orang tua atau variabel-variabel demografi lain. fenomena ini dapat dijadikan landasan bahwa kesadaran orang tua pada perkembangan anak dapat menjadi alat bantu untuk skrining perkembangan yang telah distandarisasi. perilaku deteksi dini perkembangan awal anak yang rendah juga dipengaruhi oleh sikap orang tua yang hanya melihat dan menunggu, meskipun tahapan perkembangan awal anak yang tidak memenuhi tahapan perkembangan yang normal (pathways awareness foundation, 2006). penilaian orang tua dapat digunakan sebagai standar untuk skrining dan membuat keputusan klinik yang rasional (glascoe, fp, 1997). berdasarkan riset, pendekatan yang efektif dan ringkas untuk memberikan pendidikan kesehatan bagi orang tua adalah pemberian informasi yang berfokus pada bidang spesifik yang harus dimengerti oleh keluarga. media seperti brosur dan poster, dapat meningkatkan ketertarikan orang tua. penyuluhan secara verbal juga sangat efektif untuk menyampaikan arahan dan informasi (glascoe, fp, 1998). pendidikan kesehatan tentang pathways awareness’ brochure yang berisi tahapan perkembangan awal normal anak usia 3-15 bulan dan tanda-tanda perkembangan anak 3-15 bulan yang harus diwaspadai dapat dilakukan untuk meningkatkan perilaku deteksi dini orang tua. bahan dan metode penelitian penelitian ini menggunakan metode penelitian quasy experiment design bentuk pre-post test randomized control group pathways awareness brochure (nursalam) 33 design populasi pada penelitian ini adalah keluarga dengan anak usia 3-15 bulan yang berada di wilayah kerja kelurahan manyar sabrangan, surabaya yang berjumlah 30 orang. sampel yang memenuhi kriteria inklusi dan eksklusi sebanyak 30 orang. penelitian ini dilaksanakan pada bulan juli 2009. variabel independen dalam penelitian ini adalah pendidikan kesehatan pathways awareness’ brochure, sedangkan variabel dependen adalah perilaku deteksi dini orang tua pada perkembangan awal anak 3-15 bulan meliputi : pengetahuan, sikap, dan tindakan. instrumen pengumpulan data dengan menggunakan kuisioner untuk pengetauan, sikap, dan tindakan orang tua pada perkembangan awal anak 3-15 bulan. data yang diperoleh ditabulasi dan dianalisis dengan menggunakan uji statistik wilcoxon signed rank test dan mann whitney u test dengan tingkat kemaknaan ≤0,05. hasil penelitian pada tabel 1 dapat dilihat hasil analisis statistik tingkat pengetahuan ibu pada deteksi dini perkembangan anak pada kelompok perlakuan dengan menggunakan wilcoxon signed rank test menunjukkan bahwa terdapat perbedaan sebelum dan sesudah diberikan intervensi dengan nilai signifikansi p=0,003, sedangkan pada kelompok kontrol tidak menunjukkan hasil yang signifikan. terdapat perbedaan antara kelompok perlakuan dan kelompok kontrol, hal ini ditunjukkan dengan hasil analisis statistik mann whitney u test p=0,001. pada tabel 2 dapat dilihat hasil analisis statistik tingkat sikap ibu pada deteksi dini perkembangan anak pada kelompok perlakuan dengan menggunakan wilcoxon signed rank test menunjukkan bahwa terdapat perbedaan sebelum dan sesudah diberikan intervensi dengan nilai signifikansi p=0,034, sedangkan pada kelompok kontrol tidak menunjukkan hasil yang signifikan. terdapat perbedaan antara kelompok perlakuan dan kelompok kontrol, hal ini ditunjukkan dengan hasil analisis statistik mann whitney u test p=0,011. pada tabel 3 dapat dilihat hasil analisis statistik tingkat tindakan ibu pada deteksi dini perkembangan anak pada kelompok perlakuan dengan menggunakan wilcoxon signed rank test menunjukkan bahwa terdapat perbedaan sebelum dan sesudah diberikan intervensi dengan nilai signifikansi p=0,025, sedangkan pada kelompok kontrol tidak menunjukkan hasil yang signifikan. terdapat perbedaan antara kelompok perlakuan dan kelompok kontrol, hal ini ditunjukkan dengan hasil analisis statistik mann whitney u test p=0,025. tabel.1 hasil analisis statistik tingkat pengetahuan ibu di kelurahan manyar sabrangan, kecamatan mulyorejo, surabaya, tanggal 11 juli sampai 22 juli. statistik perlakuan kontrol perlakuan kontrol pre post pre post post post mean 65,90 72,28 69 69 72,28 69 sd 7,777 7,59 7,049 7,049 7,59 7,049 analisis statistik wilcoxon signed rank test p=0,003 wilcoxon signed rank test p=1,000 mann-whitney u test p=0,001 tabel.2 hasil analisis statistik tingkat sikap ibu di kelurahan manyar sabrangan, kecamatan mulyorejo, surabaya, tanggal 11 juli sampai 22 juli. statistik perlakuan kontrol perlakuan kontrol pre post pre post post post mean 54,20 56,41 45,79 43,08 56,41 43,08 sd 9,37 6,29 9,00 8,79 6,29 8,79 analisis statistik wilcoxon signed rank test p=0,034 wilcoxon signed rank test p=1,000 mann-whitney u test p=0,011 jurnal ners vol.4 no.1 april 2009: 31-35 34 tabel.3 hasil analisis statistik tingkat tindakan ibu di kelurahan manyar sabrangan, kecamatan mulyorejo, surabaya, tanggal 11 juli sampai 22 juli. keterangan: statistik perlakuan kontrol perlakuan kontrol pre post pre post post post mean 60,55 71,03 59,45 59,45 60,55 71,03 sd 5,88 11,19 7,646 7,646 5,88 7,646 analisis statistik wilcoxon signed rank tes p = 0,025 wilcoxon signed rank test p = 1,000 mann-whitney u test p = 0,025 keterangan: p = signifikansi sd = standar deviasi mean = rerata pembahasan pendidikan keluarga merupakan faktor penting dalam tumbuh kembang anak karena pengetahuan yang baik tentang deteksi dini perkembangan anak berguna agar perkembangan anak dapat dipantau dengan baik (soetjiningsih, 1995). kemampuan orang tua menjalankan peran pengasuhan tidak hanya dipelajari secara formal, melainkan berdasarkan pengalaman dalam menjalankan peran tersebut secara trial and error dan mempelajari pengalaman orangtua lain atau terdahulu (wong, 2001). pengetahuan atau kognitif merupakan domain penting untuk terbentuknya tindakan seseorang (notoatmodjo, 2003). tingkat pengetahuan dipengaruhi oleh pembelajaran. pembelajaran dimaksudkan untuk memberikan pengetahuan kepada anak sehingga terjadi perubahan perilaku dalam hal ini deteksi dini perkembangan awal anak 3-15 bulan. sebelum dilakukan pendidikan kesehatan didapatkan bahwa pengetahuan deteksi dini perkembangan anak 3-15 bulan tidak dipengaruhi oleh tingkat pendidikan responden. pada kelompok intervensi sebelum dilakukan intervensi separuh dari ibu memiliki sikap yang positif, setelah dilakukan intervensi didapatkan peningkatan sikap positif pada mayoritas responden. hasil rerata sikap deteksi dini orang tua pada perkembangan awal anak usia 3-15 bulan sebelum dan sesudah diberikan intervensi mengalami sedikit peningkatan. menurut azwar (1995) sikap terdiri dari tiga komponen yang saling menunjang, yaitu komponen kognitif (cognitive), komponen afektif (affective), dan komponen konatif (conative). komponen kognitif merupakan representasi apa yang dipercayai oleh individu pemilik sikap, yang berisi persepsi, kepercayaan, dan sterotipe yang dimiliki individu menegenai sesuatu atau pengetahuan. adanya informasi yang baru memberikan landasan kognitif baru bagi terbentuknya sikap terhadap hal tersebut. sebelum pendidikan kesehatan, sikap ibu dalam stimulasi anak lebih dari setengahnya adalah positif, hal itu terjadi karena pada awalnya responden mempunyai pengetahuan yang cukup tentang pentingnya memantau perkembangan anak. tapi kemudian peningkatan pengetahuan akan meningkatkan pembentukan sikap yang lebih positif pada responden. sesudah dilakukan pendidikan kesehatan, sikap ibu mengalami sedikit peningkatan rerata kelompok. suatu sikap belum otomatis terwujud dalam suatu tindakan, untuk mewujudkan sikap menjadi suatu perbuatan nyata diperlukan faktor pendukung atau suatu kondisi yang memungkinkan, antara lain fasilitas dan dukungan sosial keluarga. menurut notoatmodjo (1993) dari pengalaman dan penelitian terbukti bahwa perilaku yang didasari oleh pengetahuan akan lebih langgeng daripada perilaku yang tidak didasari oleh pengetahuan. sebelum pendidikan kesehatan dilakukan, tindakan ibu lebih dari setengahnya berada pada taraf cukup, hal tersebut diduga karena pada pathways awareness’ brochure telah dicantumkan cara menggunakan brosur tersebut. setelah pendidikan kesehatan dilakukan, tindakan ibu mengalami peningkatan sampai taraf baik. simpulan dan saran pathways awareness brochure (nursalam) 35 simpulan pendidikan kesehatan pathways awareness’ brochure meningkatkan perilaku deteksi dini orang tua pada perkembangan awal anak 3-15 bulan. hal tersebut dapat dilihat pada semakin tinggi pengetahuan, semakin positif sikap yang terbentuk, dan semakin tinggi pula tindakan ibu pada deteksi dini perkembangan awal anak 3-15 bulan. saran peneliti menyarankan: 1) perawat dan tenaga kesehatan dapat melakukan pendidikan kesehatan dengan memberikan pendidikan kesehatan pathways awareness’ brochure sebagai salah satu upaya untuk meningkatkan perilaku deteksi dini orang tua pada perkembangan awal anak 3-15 bulan, 2) masyarakat dapat menggunakan pathways awareness’ brochure sebagai alat untuk memeriksa apakah perkembangan anak normal atau tidak, sehingga upaya tersebut diharapkan dapat memperpendek rentang identifikasi perkembangan anak, 3) keterlibatan posyandu dan puskesmas dapat berfungsi sebagai support system bagi ibu untuk melakukan deteksi dini perkembangan awal anak, dengan cara memasukkan pendidikan kesehatan pathways awareness’ brochure sebagai program kesehatan di masyarakat, 4) penelitian yang dapat dilakukan selanjutnya adalah perbandingan mengenai keefektifan antara pathways awareness’ brochure dan kms (kartu menuju sehat) dalam meningkatkan perilaku deteksi dini orang tua pada perkembangan awal anak. kepustakaan azwar, s., 1995. sikap manusia: teori dan pengukurannya ed.2. yogyakarta: pustaka pelajar, hlm. 139-157. chen ic, et all., 2001. the relationship between parental concerns and professional assessment in developmental delay in infants and children--a hospital-based study, (online),(http://content.pubmed.com/c ontent/full/786/75/1996., diakses tanggal 2 februari 2009, jam 18.00 wib). flanagan o & nuallain so, 2001. a study looking at the effectiveness of developmental screening in identifying learning disabilities in early childhood. irish medical journal, 94 (15), hlm. 148-150. georgetown university, national center for education in maternal and child health., 1994. bright futures: guidelines for health supervision of infants, children, and adolescents 2nd ed,(online),(http//.aap.org/brightfuture sguidelines/content/578/5., diakses tanggal 16 oktober 2008, jam 20.03 wib). glascoe fp., 1997. the value of parents' concerns to detect and address developmental and behavioural problems. pediatric child health, 35 (5), hlm. 1 –8. glascoe fp & dworkin ph., 1995. the role of parents in the detection of developmental and behavioral problems. pediatrics, 95 (28), hlm.829–836. king tm & glascoe fp., 2003. developmental surveillance of infants and young children in pediatric primary care. current opinion in pediatrics, 15 (3), hlm. 624-629. nhs lothian, 1995. what support do parents of young children need? a userfocused study. (online), (http://www.pubmed.com/http://w ww. pubmed.com /docs/egjo3/brisco01.html, diakses tanggal 2 februari 2009, jam 20.00 wib). pathways awareness foundation, 2006. assure the best for your baby’s physical development, (online), (www.pathwaysawareness.org, diakses tanggal 1 september 2008, jam 08.00 wib). rydz d, et all., 2005. developmental screening. journal of child neurology, 20 (7), hlm. 4-21. soetjiningsih., 1995. tumbuh kembang anak. jakarta: egc, hlm.2-11. http://www.pubmed.com/ http://www.aap.org/ http://www.pubmed.com/ http://www.pathwaysawareness.org/ musik klasik menurunkan tingkat stres dan tekanan darah dan nadi ibu primigravida trimester ketiga 161 brain storming dan demonstrasi merubah perilaku ibu terhadap pemberian makanan tambahan (brain storming and demonstration change mother’s behavior toward breastmilk companion food) mira triharini*, retnayu pradanie*, halimatus zahrah* abstract introduction: infant on 0-6 months must be gotten exclusive breast milk from their mother for growth and development status. it was mean that no other food for infant. the objective of this study was to expalain the the effect of brain storming and demonstration about exclusive breastfeding on mother’s behaviour ( knowledge, attitude and practice) in giving breastmilk companion food for infant (0-6 month) at bung baruh’s village, pamekasan. method: this study used one group pre-test post-test design. population were mothers in those area, and sample were 32 respondents who met the inclusion criteria. the independent variable were health education with brain storming and demonstration methods. the dependent variable were mother’s behaviour ( knowledge, attitude and practice) in giving food beside mother’s milk for infant. the data were analyzed by using wilcoxon signed rank test with significance level α≤ 0.05. result: the result showed that brain storming and demonstration had effect on mother’s behaviour (knowledge p=0.000; attitude p= 0.033; and practice p=0.000) in giving breastmilk companion food for infant (0-6 month). analysis: it can be concluded that brain storming and demonstration has an effect on mother’s behaviour ( knowledge, attitude and practice) in giving breastmilk companion food for infant (0-6 month). discussion: brainstorming can be alternative choice for changing mother’s health behaviour. keywords : brain storming, demonstration, infant, breastmilk companion food * fakultas keperawatan universitas airlangga kampus c mulyorejo surabaya. telp/fax: (031) 5913257, e-mail: mira.tri_ners@unair.ac.id pendahuluan pertumbuhan optimal pada bayi perlu status gizi yang baik dengan pemberian asi eksklusif pada usia 0-6 bulan. asi memelihara fungsi sel-sel otak serta dapat memperkuat sistem kekebalan tubuh, menurunkan risiko terjadi infeksi, dan alergi (kurniasari, 2009). status gizi yang buruk dapat menghambat pertumbuhan fisik, mental, kemampuan berfikir dan mudah terkena infeksi (feldman, 2003). hal ini terjadi apabila pemberian makanan pendamping asi terlalu dini atau terlambat, makanan tidak sesuai dengan angka kecukupan gizi (akg) rata-rata, frekuensi pemberian yang kurang dan pengolahan makanan yang kurang bersih (dep.kes, 2004). di amerika serikat, 20-35 juta kejadian diare terjadi setiap tahun (neilson, 2000). di pamekasan untuk tahun 2008 jumlah kasus gizi buruk mencapai 25 kasus. selama ini jika bayi menangis, warga desa bung baruh beranggapan anak kelaparan dan akan tidur nyenyak jika diberi makan, seperti kelapa muda, nasi yang dikunyah terlebih dahulu oleh ibunya, campuran bubur beras dengan sayur kelor, pisang yang diuleg, dan sebagainya. beberapa metode yang dapat digunakan untuk pemberian pendidikan kesehatan adalah pertama dengan metode perorangan meliputi bimbingan dan penyuluhan, serta wawancara. kedua dengan metode pendidikan kelompok yang terdiri dari kelompok besar, kelompok kecil, diskusi kelompok, bola salju, curah pendapat (brain storming), kelompok kecil-kecil, memainkan peran dan demonstrasi. ketiga dengan metode pendidikan massa yang meliputi ceramah, pidato-pidato kesehatan melalui media elektronik, simulasi dialog antar jurnal ners vol. 4 no. 2: 161-167 162 pasien petugas kesehatan, tulisan tentang kesehatan di majalah atau koran, dan bill board yang dipasang di pinggir jalan atau poster. berdasarkan hasil wawancara dengan kader kesehatan bahwa penyuluhan telah dilakukan dengan metode ceramah pada saat posyandu. hal ini kurang memberikan hasil optimal karena mayoritas ibu masih memberikan makanan pendamping asi pada bayinya yang berusia kurang dari 6 bulan. peneliti memilih pendidikan dengan metode brain storming dengan alat bantu vcd disertai demonstrasi tentang cara pemberian asi eksklusif karena metode ini lebih intensif dibanding dengan metode ceramah. dengan perpaduan metode tersebut dalam pemberian pendidian kesehatan, maka responden dapat mencurahkan pendapatnya satu sama lain dengan lebih intensif dan dengan metode demonstrasi responden dapat meniru keterampilan yang diajarkan oleh peneliti. penggunaan alat bantu vcd sebagai media pembelajaran akan meningkatkan perhatian bagi responden sehingga memberikan kemudahan bagi responden untuk memahami pendidikan kesehatan yang disampaikan. berdasarkan profil kesehatan dinas kesehatan republik indonesia pada tahun 2004, jumlah pencapaian target pemberian asi eksklusif di indonesia adalah kurang dari 2% dari jumlah total ibu melahirkan, dan di propinsi jawa timur pada tahun 2005 sebesar 50,6% (susenas 2007). target nasional pencapaian pemberian asi eksklusif sebesar 95% dan target pencapaian pemberian asi eksklusif di propinsi jawa timur 80%. di madura sendiri khususnya data dinas kesehatan pamekasan cakupan asi eksklusif tahun 2006 sebesar 29,2 %, tahun 2007 sebesar 19,25%, dan tahun 2008 sebesar 21,51%, data tersebut masih jauh dibawah target, sedangkan di puskesmas kadur kabupaten pamekasan terdapat 956 bayi, dari jumlah tersebut, jumlah bayi yang diberi asi eksklusif berjumlah 90 bayi (9,4%). berdasarkan hasil pengamatan peneliti selama ± 5 tahun bayi yang baru dilahirkan segera mungkin langsung diberikan mpasi berupa degan muda. hasil laporan puskesmas di desa bung baruh untuk periode dua bulan terakhir terdapat 43 bayi, dan dari jumlah tersebut bayi yang berada dibawah umur 6 bulan berjumlah 38 bayi (90%) yang telah diberikan mpasi dini (data laporan bidan). menurut data biro pusat statistik (bps) 2003, dari sekitar 5 juta anak balita terdapat kurang lebih 3,6 juta anak (19,2%) dalam tingkat gizi kurang, dan 1,5 juta anak (8,3%) dalam tingkat gizi buruk. (dep.kes, 2004). di pamekasan sendiri terdapat 25 kasus gizi buruk (din. kes. pamekasan 2008). makanan pendamping asi (mpasi) yang terlalu dini pada masyarakat kita merupakan problema yang sulit, dan pemberian mpasi tersebut pada usia dini adalah praktek yang disukai di masyarakat pedesaan. warga desa bung baruh rata-rata memiliki pengetahuan yang rendah tentang pentingnya asi eksklusif pada bayi, karena latar belakang pendidikan yang rata-rata sd. pendidikan kesehatan yang telah diberikan oleh tenaga kesehatan dalam posyandu kurang mendapat perhatian sehingga ibu-ibu tetap memberikan nutrisi yang salah dengan memberikan makanan pendamping asi pada bayi usia 0-6 bulan. perilaku tersebut sudah menjadi tradisi dan membudaya di desa bung baruh dimana ibu-ibu memberikan makanan tambahan setelah bayi dilahirkan berupa degan muda dengan menggunakan sendok dari daun pisang yang ditulisi anacarakan. praktek demikian diperkirakan memiliki dampak jangka panjang terhadap gizi dan kesehatan anak. pendidikan kesehatan penting untuk menunjang program kesehatan, terutama pada masyarakat pedesaan yang umumnya memiliki pendidikan dan pengetahuan rendah tentang pentingnya asi ekslusif pada bayi, agar dapat mengubah perilaku dari yang merugikan kesehatan ke arah tingkah laku yang menguntungkan kesehatan. maka dari itu peneliti tertarik untuk melakukan penelitian tentang pengaruh brain storming dan audio visual aids tentang asi eksklusif terhadap pengetahuan, sikap dan tindakan ibu dalam memberikan makanan tambahan pada bayi usia 0-6 bulan di desa bung baruh wilayah kerja puskesmas kadur kabupaten pamekasan. bahan dan metode penelitian desain yang digunakan dalam penelitian ini adalah pre experimental dengan pendekatan one-group pre-test-posttest design. populasi dalam penelitian ini adalah seluruh ibu yang mempunyai bayi usia 0-6 brain storming dan demonstrasi (mira triharini) 163 bulan di desa bung baruh wilayah kerja puskesmas kadur pamekasan sebanyak 38 orang. sampel diambil sesuai dengan kriteria inklusi dan diperoleh 32 responden. adapun kriteria inklusi yaitu 1) responden bersedia untuk diteliti, 2) responden yang bisa membaca dan menulis, 3) memiliki kebiasaan memberikan mpasi pada bayi dibawah usia 6 bulan dan 4) ibu masih bisa mengeluarkan asi yang cukup untuk bayi. variabel independen dalam penelitian ini adalah pendidikan kesehatan dengan metode brain storming dan demonstrasi menggunakan alat bantu audio visual tentang asi eksklusif. variabel dependen adalah perilaku ibu dalam memberikan mpasi pada bayi usia 0-6 bulan. pengumpulan data dalam penelitian ini melalui kuesioner dan observasi. setelah pengisian kuesioner data awal tentang pengetahuan, sikap dan tindakan, responden dibuat menjadi satu kelompok berjumlah 612 orang berbentuk lingkaran, kemudian dilakukan pemberian pendidikan kesehatan dengan metode brain storming. seluruh responden dibagi dalam 3 gelombang, dengan lama brain stoarming 30 menit setiap kelompok. selanjutnya dilakukan demonstrasi tentang cara menyusui yang benar. pada akhir kegiatan pendidikan kesehatan dilakukan pemutaran alat bantu vcd tentang asi eksklusif. pengumpulan data pengetahuan dan sikap post test dilakukan dua kali yaitu dua hari dan empat hari setelah pemberian intervensi dengan mendatangi rumah responden. kemudian satu minggu setelah pemberian pendidikan kesehatan peneliti mendatangi rumah responden dan dilakukan wawancara terstruktur untuk mengetahui perubahan tindakan ibu dalam memberikan mpasi pada bayi usia 0-6 bulan. hasil penelitian hasil analisis statistik dengan uji wilcoxon signed rank test tentang pengaruh brain storming dan demonstrasi menggunakan audio visual aid tentang asi eksklusif terhadap pengetahuan ibu dalam memberikan makanan tambahan pada bayi usia 0-6 bulan didapatkan hasil p=0,000, terhadap sikap ibu dalam memberikan makanan tambahan pada bayi usia 0-6 bulan didapatkan hasil p=0,000, dan terhadap tindakan ibu dalam memberikan makanan tambahan pada bayi usia 0-6 bulan didapatkan hasil p=0,000. ketiga hasil tersebut menunjukkan ada hubungan yang signifikan. distribusi pengetahuan, sikap, dan tindakan responden dapat dilihat pada tabel 1, 2 dan 3. tabel. 1 pengetahuan ibu sebelum dan sesudah pendidikan kesehatan dalam memberikan makanan tambahan pada bayi usia 0-6 bulan kategori pengetahuan ibu sebelum sesudah ∑ % ∑ % baik 9 28,1 27 84,4 cukup 15 46,9 5 15,6 kurang 8 25 0 0 total 32 100 32 100 uji wilcoxon sign rank test p=0,000 tabel. 2 sikap ibu sebelum dan sesudah pendidikan kesehatan dalam memberikan makanan tambahan pada bayi usia 0-6 bulan kategori sikap ibu sebelum sesudah ∑ % ∑ % positif 14 43,7 17 53 negatif 18 56,3 15 47 total 32 100 32 100 uji wilcoxon sign rank test p=0,033 jurnal ners vol. 4 no. 2: 161-167 164 tabel. 3 tindakan ibu sebelum dan sesudah pendidikan kesehatan dalam memberikan makanan tambahan pada bayi usia 0-6 bulan kategori tindakan ibu sebelum sesudah ∑ % ∑ % baik 2 6,3 12 37,5 cukup 20 62,5 19 59,4 kurang 10 31,3 1 6,3 total 32 100 32 100 uji wilcoxon sign rank test p=0,000 keterangan : p = signifikansi % = prosentase ∑= jumlah pembahasan hasil penelitian menunjukkan adanya pengaruh yang kuat dari pemberian pendidikan kesehatan dengan brainstoarming dan penggunaan audio visual aids terhadap pengetahuan ibu dalam memberikan makanan tambahan pada bayi usia 0-6 bulan yang ditunjukkan oleh hasil statistik dengan nilai signifikansi (p=0,000). pendidikan keluarga merupakan salah satu faktor penting dalam tumbuh kembang bayi karena dengan pengetahuan yang baik tentang pentingnya asi eksklusif dan bahaya mpasi dini maka orangtua dapat memiliki pengetahuan yang baik dalam hal memberikan asi dan mpasi terhadap bayi usia 0-6 bulan sehingga bayi dapat tumbuh sehat dan cerdas. kemampuan keluarga dalam merawat bayi juga dipengaruhi oleh pengalaman orangtua tentang pola asuh anak sebelumnya secara alamiah memberikan pengetahuan tersendiri bagaimana memberikan makanan yang baik (soetjiningsih 1998). sebelum diberikan pendidikan kesehatan, mayoritas responden mempunyai pengetahuan cukup dan sesudah diberikan pendidikan pengetahuan ibu mengalami peningkatan, mayoritas responden mempunyai pengetahuan baik. hal itu dapat disebabkan oleh berbagai faktor . faktor pertama adalah dari tingkat pendidikan ibu, dengan mayoritas pendidikan responden adalah slta. faktor kedua adalah urutan anak, karena dalam keluarga sebagian besar bayi merupakan anak pertama. perhatian ibu yang penuh kepada bayi memungkinkan ibu lebih terfokus merawat bayi dengan baik. faktor ketiga adalah materi yang diberikan pemberian dalam pendidikan kesehatan sesuai dengan kebutuhan ibu. faktor keempat adalah adanya ketertarikan responden pada materi yang disampaikan. media vcd yang digunakan oleh peneliti mampu ebih menarik perhatian dari responden dalam proses pembelajaran. faktor lain adalah metode yang digunakan dalam pemberian pendidikan kesehatan sesuai dengan kondisi atau kebutuhan responden. dalam penelitian ini digunakan metode brainstoarming dimana memberikan kesempatan pada para responden untuk menyampaikan pendapatnya secara bebas tentang pemberian makanan tambahan dan asi eksklusif. responden akan dapat belajar dari pengalaman yang baik dari responden lain. hasil penelitian menunjukkan adanya pengaruh yang kuat dari pemberian pendidikan kesehatan terhadap sikap ibu. berdasarkan teori yang dikemukakan oleh azwar (2007) menyatakan bahwa pembentukan sikap dipengaruhi oleh beberapa faktor yaitu ; 1) faktor budaya yang dianut oleh keluarga mempengaruhi penerapan pola asuh pada bayi termasuk cara memberikan makanan pada bayi usia 0-6 bulan. 2) perhatian yang diberikan orang tua/keluarga terhadap bayinya baik. teori yang dikemukakan azwar (2000) mendefinisikan sikap merupakan respon yang berhubungan dengan interest (perhatian), apresiasi (penghargaan), dan persepsi (perasaan). 3) lingkungan tempat tinggal yang merupakan faktor yang paling besar yang dapat mempengaruhi pembentukan sikap seseorang. 4) media massa sebagai sarana komunikasi yang dapat mempunyai pengaruh besar dalam pembentukan opini dan kepercayaan orang. informasi baru memberikan landasan kognitif yang baru bagi terbentuknya sikap terhadap hal tersebut. 5) lembaga agama sebagai suatu brain storming dan demonstrasi (mira triharini) 165 system mempunyai pengaruh dalam pembentukan sikap karena merupakan dasar pengertian dan konsep moral dalam diri individu orang lain yang dianggap penting dan 6) emosi, apabila terlalu tua atau terlalu muda mungkin tidak dapat menjalankan peran pengasuh secara optimal karena disinni diperlukan kekuatan psikis terutama dalam kaitannya dengan strategi koping yang dimiliki dalam menghadapi permasalahan bayi. emosi dalam diri individu terkait dalam penerapan pola asuh pada bayi termasuk bagaimana memberikan makan pada bayi usia 0-6 bulan. sebelum pemberian pendidikan kesehatan, sikap ibu dalam memberikan makan pada bayi usia 0-6 bulan lebih dari 50% negatif, hal itu terjadi karena terdapat pengetahuan kurang tentang pentingnya asi eksklusif 6 bulan sehingga ibu kurang perduli dalam memberikan asi eksklusif pada bayi sejak lahir sampai bayi berusia 6 bulan. budaya yang dianut mempengaruhi sikap ibu tersebut (misalnya dari hasil wawancara, ada beberapa responden yang menganggap bahwa bayi tidak akan sehat dan gemuk jika tidak diberikan makanan tambahan, ada juga yang mengatakan bayi menjadi kurus jika hanya diberi asi eksklusif saja, dan sebagainya). sesudah dilakukan pemberian pendidikan kesehatan, sikap ibu mengalami peningkatan. dari hasil observasi sikap ibu meningkat karena ada beberapa responden yang sebagian besar mempunyai 1 orang anak sehingga perhatian ibu masih berfokus pada anak, selain itu hampir seluruh responden mengatakan bahwa dirinya selalu berada di rumah, sehingga banyak waktu luang bersama bayinya. hasil penelitian menunjukkan bahwa mayoritas respoden berusia 18-20 tahun. usia yang masih muda menyebabkan kurangnya pengetahuan dan pengalaman tentang pemberian asi eksklusif. adanya keterbukaan dalam menerima informasi tersebut karena menganggap bahwa dirinya belum mempunyai cukup pengalaman menyebabkan meningkatnya sikap setelah pemberian pendidikan kesehatan. peningkatan sikap juga dipengaruhi oleh adanya seluruh responden yang menganut agama sesuai dengan kepercayaan yang ada di desa bung baruh. dari hasil wawancara mereka selalu mengkaitkan informasi itu sesuai dengan keyakinan agamanya dan bila bila dianggap baik maka informasi tersebut bisa diterima. terdapat beberapa responden yang tidak mengalami perubahan sikap setelah diberikan pendidikan kesehatan, hal ini dapat disebabkan oleh pengaruh keluarga yang kurang mendukung atau keyakinan yang kuat dengan kepercayaan terhadap tokoh agama atau tokoh masyarakat. hal lain yang mempengaruhi adalah perubahan sikap memerlukan proses internal yang membutuhkan waktu berbeda pada setiap individu untuk berubah. hasil penelitian menunjukkan bahwa adanya pengaruh yang kuat dari pemberian pendidikan kesehatan terhadap peningkatan tindakan ibu. notoatmojo (2003) mengungkapkan bahwa sebelum orang mengadopsi perilaku baru, di dalam diri orang tersebut terjadi proses berurutan yaitu : 1) awareness (kesadaran), yakni orang tersebut menyadari dalam arti mengetahui stimulus (objek) terlebih dahulu, 2)interest, yaknni orang mulai tertarik pada stimulus, 3) evaluation (menimbang-nimbang baik dan tidaknya stimulus tersebut terhadap dirinya). hal ini berarti sikap responden sudah lebih baik, 4)trial, orang telah mencoba perilaku baru, 5) adoption, subjek telah berperilaku baru sesuai pengalaman, kesadaran dan sikapnya terhadap stimulus. pendidikan kesehatan dengan metode brain storming dan penggunaan audio visual aids tentang asi eksklusif dapat merubah tindakan ibu menjadi lebih baik. hal ini disebabkan pengetahuan dan sikap ibu mengalami peningkatan setelah pendidikan kesehatan. perubahan tindakan pada ibu melalui beberapa tahapan. pada tahap pertama, setelah mendapat pengetahuan maka ibu memiliki kesadaran tentang manfaat dari asi serta bahaya pemberian makanan pendamping asi yang terlalu dini. tahap berikutnya adalah ketertarikan terhadap informasi baru yang didapatkan terkait dengan asi. setelah melalui tahap menimbang terhadap pentingnya asi dan bahaya makanan pendamping asi, maka ibu akan melakukan trial atau mencoba suatu tindakan baru sesuai dengan yang disarankan. tahap akhir yang dilalui oleh ibu dalam perubahan tindakan adalah adopsi yaitu menjadikan tindakan baru tersebut sebagai suatu kebiasaan dalam kehidupan sehari-hari jurnal ners vol. 4 no. 2: 161-167 166 dimana ibu tidak lagi memberikan makanan pendamping asi pada bayinya yang berusia kurang dari 6 bulan. simpulan dan saran simpulan pendidikan kesehatan dengan metode brain storming dan demonstrasi menggunakan audio visual aid tentang asi eksklusif dapat merubah perilaku ibu (pengetahuan, sikap dan tindakan) ke arah perilaku yang lebih baik terhadap pemberian makanan tambahan pada bayi usia 0-6 bulan. saran penulis menyarankan: 1) tenaga kesehatan hendaknya lebih meningkatkan promosi kesehatan tentang pemberian asi eksklusif pada bayi usia 0-6 bulan. kegiatan tersebut dapat dilakukan melalui pertemuan ibu-ibu yang sudah terbentuk di masyarakat, seperti posyandu, pkk, dasawisma dan sebagainya, 2) bagi para ibu diharapkan dapat tetap mempertahankan dan meningkatkan perannya dalam memberikan asi aksklusif dan makanan tambahan pada bayi usia 0-6 bulan untuk pertumbuhan dan perkembangan bayinya, 3) perlu penelitian lebih lanjut berupa studi komparasi tentang perkembangan bayi dalam berbagai aspek antara yang mendapatkan asi dengan yang mendapatkan makanan pendamping asi secara dini dalam kepustakaan azwar, m.a., 2000. pengantar epidemiologi kesehatan. jakarta : ecg. azwar, s., 2007. sikap manusia : teori dan pengukurannya. edisi ke-2. yogyakarta: pustaka pelajar. departemen kesehatan ri., 2004. gizi buruk akibat pemberian mpasi dini, (online), (http://pdfdatabase.com/download_ file_i.php?file=5551148&desc=15 0733-gizi+buruk+indonesia.pdf, diakses tanggal 14 oktober 2009, jam 21.12 wib). dinas kesehatan, 2008. data profil kesehatan kabupaten atau kota, (online), (http://pdfdatabase.com/download_ file_i.php?file=5551148&desc=20 0612selayang+pandang+kesehatan+pam ekasan.pdf, diakses tanggal 17 oktober 2009, jam 21.42 wib). feldman, r., 2003. direct and indirect effects of breast milk on the neurobehavioral and cognitive development of premature infants, (online), department of psychology, bar-ilan university, ramat-gan, israel. (http://www.ncbi.nlm.nih.gov/pub med/1543493?itool=entrezsystem 2.pentrez.pubmed.pubmed_result spanel.pubmed_rvdocsum&ordi nalpos=13, diakses tanggal 29 november 2009 ,jam 02.29 wib). kurniasari, d., 2009. nutrisi bagi bayi dan anak, (online), (http://asuh.wikia.com/wiki/asi_e ksklusif, diakses tanggal 17 oktober 2009, jam 20.23 wib). neilson, j., 2000. cara menyusui yang baik. cetakan vii. alih bahasa oleh gianto widianto&yustina rostiawati. jakarta : arcan. notoatmodjo, s., 2003. pendidikan dan perilaku kesehatan. jakarta : rineka cipta. soetjiningsih, 1998. tumbuh kembang anak. jakarta: egc, hlm. 1-11, 14-15, 29, 35, 64-65, 69-75. susenas, 2007. distribusi pemberian air susu ibu (asi) eksklusif pada bayi 0-6 bulan menurut provinsi, (online), (http://www.gizi.net.co.id/#hl=id& q=distribusi+pemberian+asi+eksk lusif&meta=&aq=&oq=distribusi+ pemberian+asi+eksklusif&fp=5af 74f93a1d43147, diakses tanggal 19 oktober 2009, jam 02.58 wib). http://pdfdatabase.com/download_file_i.php?file=5551148&desc=150733-gizi+buruk+indonesia.pdf http://pdfdatabase.com/download_file_i.php?file=5551148&desc=150733-gizi+buruk+indonesia.pdf http://pdfdatabase.com/download_file_i.php?file=5551148&desc=150733-gizi+buruk+indonesia.pdf http://pdfdatabase.com/download_file_i.php?file=5551148&desc=200612-selayang+pandang+kesehatan+pamekasan.pdf http://pdfdatabase.com/download_file_i.php?file=5551148&desc=200612-selayang+pandang+kesehatan+pamekasan.pdf http://pdfdatabase.com/download_file_i.php?file=5551148&desc=200612-selayang+pandang+kesehatan+pamekasan.pdf http://pdfdatabase.com/download_file_i.php?file=5551148&desc=200612-selayang+pandang+kesehatan+pamekasan.pdf http://pdfdatabase.com/download_file_i.php?file=5551148&desc=200612-selayang+pandang+kesehatan+pamekasan.pdf http://www.ncbi.nlm.nih.gov/pubmed/1543493?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=13 http://www.ncbi.nlm.nih.gov/pubmed/1543493?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=13 http://www.ncbi.nlm.nih.gov/pubmed/1543493?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=13 http://www.ncbi.nlm.nih.gov/pubmed/1543493?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=13 http://www.ncbi.nlm.nih.gov/pubmed/1543493?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=13 http://en.wordpress.com/tag/nutrisi/ http://asuh.wikia.com/wiki/asi_eksklusif http://asuh.wikia.com/wiki/asi_eksklusif http://www.gizi.net.co.id/#hl=id&q=distribusi+pemberian+asi+eksklusif&meta=&aq=&oq=distribusi+pemberian+asi+eksklusif&fp=5af74f93a1d43147 http://www.gizi.net.co.id/#hl=id&q=distribusi+pemberian+asi+eksklusif&meta=&aq=&oq=distribusi+pemberian+asi+eksklusif&fp=5af74f93a1d43147 http://www.gizi.net.co.id/#hl=id&q=distribusi+pemberian+asi+eksklusif&meta=&aq=&oq=distribusi+pemberian+asi+eksklusif&fp=5af74f93a1d43147 http://www.gizi.net.co.id/#hl=id&q=distribusi+pemberian+asi+eksklusif&meta=&aq=&oq=distribusi+pemberian+asi+eksklusif&fp=5af74f93a1d43147 http://www.gizi.net.co.id/#hl=id&q=distribusi+pemberian+asi+eksklusif&meta=&aq=&oq=distribusi+pemberian+asi+eksklusif&fp=5af74f93a1d43147 http://e-journal.unair.ac.id/jners | 171 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.9700 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the correlation between motivation and health locus of control with dietary adherence of diabetes kusnanto kusnanto1, retno dwi susanti1, lailatun ni’mah1 and hakim zulkarnain2 1 fakultas keperawatan universitas airlangga, indonesia 2 emmec, school of health, university of algarve, portugal abstract introduction: controlling blood sugar can be done by dietary adherence of dm. to control glycemic, it is necessary to have motivation and health locus of control to face boredom in dietary adherence of dm. the aim was to analyse the correlation between motivation and health locus of control with dietary adherence of dm. methods: cross-sectional design was conducted and involved 106 respondents from five public health centers in surabaya selected by random sampling. data were collected by questionnaire treatment self-regulation questionnaire (tsrq), multidimensional health locus of control scales” (mhlc), and diet adherence. the analysis data was using statistical spearman rho (α ≤ 0.05). results: there was no correlation between motivation and dietary adherence (p=0.178), and there was a correlation between health locus of control with dietary adherence (p = 0.002). conclusion: according to analysis, it can be concluded that motivation is influenced by many things to the role the forming of patient behavior in dietary adherence of dm while health locus of control has an influence to dietary adherence of dm. because of that, it is necessary to increase the factor that influences the behavior of dm control. one of it is health locus of control. so that the glycemic control with dietary adherence of dm can increase and be better. article history received: sept 14, 2018 accepted: december 14, 2018 keywords dietary adherence; glycemic control; health locus of control; motivation; diabetes mellitus contact kusnanto kusnanto  kusnanto@fkp.unair.ac.id  fakultas keperawatan universitas airlangga, indonesia cite this as: kusnanto, k., susanti, r.d., ni’mah, l., & zulkarnain, h. (2018). the correlation between motivation and health locus of control with dietary adherence of diabetes mellitus. jurnal ners, 13(2), 171-177. doi:http://dx.doi.org/10.20473/jn.v13i2.9700 introduction diabetes mellitus (dm) is a chronic metabolic disorder due to the pancreas being unable to produce enough insulin or the body cannot use insulin that is produced effectively (kementrian kesehatan ri, 2014). international diabetes federation (2017) reported that the number of dm patients in the world in 2017 reached 425 million adults with age ranged between 20-79 years. more than 79% of patients live in developing countries, and it is estimated that by 2045 the number of people with dm will increase to 629 million people. the international diabetes federation also reports that indonesia is among the top 10 countries with the highest number of dm with 10.3 million people and is estimated to increase to 16.7 million in 2045 (international diabetes federation, 2017). who predicts the increase in the number of people with diabetes in indonesia from 8.4 million in 2000 to around 21.3 million in 2030. the report shows an increase in the number of people with diabetes by 2-3 times by 2035 (perkeni, 2015). basic health research in 2013 showed that the prevalence of dm in east java was 2.1%, the prevalence experienced an increase in the prevalence of 1.1 when compared with the results of riskesdas in 2007. the number of dm patients increased from 2007 to 2013 amounting to 330,512 patients (kementrian kesehatan ri, 2014). the prevalence of diabetics in east java province ranks ninth with a prevalence of 6.8, while surabaya prevalence is higher than in east java, which is 7 (kominfo, 2015). the 2016 health office annual report shows 32,381 dm patients went to the health center in surabaya (dinkes jatim, 2016). preliminary study conducted by researchers on 24 to 25 april 2018 there were 2,195 dm patients from january to march 2018 and spread in five health centers with the highest number of dm in surabaya. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i2.9700 k. kusnanto et al. 172 | pissn: 1858-3598  eissn: 2502-5791 dm can be controlled well by diet, exercise, and antidiabetic drug therapy. setting diet and physical activity is the main thing in dm management (perkeni, 2015). diet and weight control are the basis of diabetes mellitus management. if dietary adherence is carried out by dm patients, primary and secondary treatment can be performed optimally. the world health organization (2003) explained that the average patient's adherence to long-term therapy for chronic diseases in developed countries was only 50% while in developing countries the number was even lower. patient adherence is needed to achieve therapeutic success, especially in diabetes mellitus. if a dm patient does not have self-awareness to be obedient, it can cause a failure in treatment which results in a decrease in health. non-adherence in maintaining health affects the complications of dm and can lead to death (saifunurmazah, 2013). international diabetes federation (2017) estimates that nearly 200 million people with diabetes are undiagnosed and more at risk of developing complications, which include kidney failure, blindness, amputation, heart disease, and stroke. diabetic complications can be prevented by optimal glycemic control, however, in indonesia, the target of achieving glycemic control is still not satisfactorily achieved, most of which is still above the desired target of 7% (perkeni, 2015). the research conducted by tera (2011) said that the determinants of diet disobedience of patients with type 2 diabetes from 13 respondents showed that there were no respondents who made a meal arrangement according to the amount of energy, type of food and recommended food schedule. controlling sugar levels by regulating diet in dm patients is not easy, boredom will certainly arise because the menu consumed is limited. motivation can control patients in regulating blood glucose levels. motivation is very important because it can make someone do something to achieve the desired goal (indarwati et al., 2012). research conducted by indarwati et al. (2012) stated that there was a significant relationship between motivation on the dm diet and respondents who were highly motivated to have 7 times the opportunity to comply with the diet compared to respondents with low motivation. in addition to motivational factors, health locus of control (hloc) also affects dm diet adherence. health locus of control (hloc) is a set of beliefs about a person who has an influence on health and is one of the factors that influence dm diet adherence (bonichini, axia and bornstein, 2009). health locus of control will affect the extent to which individuals will adhere to the diet being carried out (indriyati, d. s. & widyarini, 2012). hloc is divided into two, namely internal and external hloc. individuals with internal hloc will tend to work hard to take action to recover, always try to find problem solving, always think as effectively as possible and always have the perception that hard work must be done if they want to recover. meanwhile individuals with external health locus of control will be more passive, less have initiative, less seek information to solve problems and less like to try because individuals believe that the outside factors control themselves (adnyani, widyanthari, and kadek saputra, 2015). each individual has a different locus of control because individuals have different judgments and experiences that will affect their behavior. the purpose of the study was to identify the relationship between motivation and health locus of control with dietary adherence in patients with dm. materials and methods the research design used was descriptive correlation research with a cross-sectional approach. the data collection process was carried out on 3-14 july 2018 in five public health centers in surabaya. the variables of this study were motivation, health locus of control, and adherence with dm diets. the population used in this study were 2,195 dm patients from january to march 2018 and spread in five health centers with the highest number of dm in surabaya. samples were obtained using proportional random sampling with inclusion criteria: 1) dm patients aged 35-55 years old; 2) patients with dm who did not use insulin injection 3) patients diagnosed with dm for more than one year. the number of samples in this study was 106 respondents. data collection techniques were carried out using a questionnaire treatment self-regulation questionnaire (tsrq) by (butler, 2002). tsrq is used to measure patient motivation based on intrinsic motivation (autonomy) and extrinsic motivation (control). the questionnaire used was a modified questionnaire from zycinska et al. (2012) which consisted of 11 items used to measure motivation in the dm diet. modifications made were only using statement items related to dm diet motivation, and changing seven-point likert scale into four likert scales. the assessment uses a likert scale: 1) strongly disagree, 2) disagree, 3) agree, 4) strongly agree. total motivation score: 11-44. grouped into 2, namely: good (≥80% total value or 35.2) and not good (<80% total value or <35.2). the multidimensional health locus of control scales (mhlc) by walltson to measure health locus of control. this scale on this questionnaire is designed for health-related conditions and has 18 items with 3 independent subscales, namely internal health locus of control, powerful others health locus of control, chance health locus of control. there are alternative answers, namely 6) strongly disagree, 5) quite agree, 4) slightly agree, 3) slightly disagree, 2) enough disagree, 1) strongly disagree. grouped into 2, namely: height: x ≥ mean, low: x <mean dependent variable data were obtained from filling out the questionnaire about dietary compliance made by haryono (2009) and modified by permatasari (2014). the purpose of the questionnaire modification is to clarify the question jurnal ners http://e-journal.unair.ac.id/jners | 173 so that there is no mistake in understanding the questions in the questionnaire. the dietary compliance questionnaire contained: adherence to the meal schedule (4 items), adherence to choosing the type of food (8 items), compliance in the number of foods (1 item), adherence to maintaining weight (1 item) and adherence to medication (4 items). the diet compliance questionnaire consisted of 18 questions with alternative answers namely 4) always, 3) often, 2) rarely and 1) never. questions consist of positive and negative questions. positive number questions (1, 2, 8, 9, 10, 16, 17 and 18) negative number questions (3,4, 5, 6, 7, 12, 13, 14, and 15) with adherence scoring namely the range of scores 18-72 with the following categories: poor (18 <36), enough (36<54), good (54-72). data analysis using this study was analyzed in univariate and multivariate analysis tests using spearman rho which is α = 0.05. this study has passed the ethical review of the health research ethics commission of the faculty of nursing universitas airlangga and received approval of the research protocol with number 963-kepk. results the results of this study will be presented in table form. the results of this study will present data on the characteristics of respondents, motivation, health locus of control, dietary adherence of dm patients, the relationship of motivation with dietary adherence and health locus of control relationship with dm diet adherence. table 1 shows the characteristics of the research subjects, namely the respondents included in the highest age group were the elderly group (46-65 years) wherein this study there were 97 people (91.5%). this study dominated female respondents, namely some 88 (83%) respondents. the highest respondent status is with a married status of 79 (74.5%) respondents. the highest distribution of respondents seen from the length of diabetes mellitus is having a history of diabetes mellitus for 15.9 years, namely 81 (76.4%) respondents. the majority of respondents' education is basic education, namely 63 (59.4%) respondents. as well as judging from the consumption of drugs, the majority of respondents took the drug glibenclamide and metformin as many as 39 (36.8%) respondents. table 2 shows the motivational variables of 106 respondents, the percentage of motivations of the most respondents is poor extrinsic motivation as many as 99 (93.4%) respondents. extrinsic motivation is good for 7 (6.6%) respondents. intrinsic motivation is not good for 41 (38.7%) respondents and good intrinsic motivation 65 (61.3%). these data indicate that respondents from this study are more dominant, namely, motivation originating from themselves (intrinsic). table 1. distribution of demographic characteristics of respondents (n = 106) respondent characteristics f(x) % age 36-45 years 46-55 years 9 97 8.5 91.5 gender male female 18 88 17 83 marital status married widower 79 27 74.5 25.5 diabetes suffering period 1 – 5.9 years 6 – 10 years >10 years 81 18 7 76.4 17 6.6 education un formally educated elementary school junior to senior high school higher education 13 63 28 2 12.3 59.4 26.4 1.9 medicine consumed do not use herbal medicine glibenclamide glimepirin glukopak metformin glibenclamid & metformin metformin & acarbose metformin & glimepirin 5 1 13 6 1 23 39 1 17 4.7 0.9 12.3 5.7 0.9 21.7 36.8 0.9 16 table 2. frequency distribution of motivation, ealth locus of control, and diet adherence in people with diabetes mellitus variable sub variable category f % motivation intrinsic less 41 38.7 good 65 61.3 total 106 100 extrinsic less 99 934 good 7 6.6 total 106 100 health locus of control internal low 56 52.8 high 50 47.2 total 106 100 powerful others low 45 42.5 high 61 57.5 total 106 100 chance low 43 40.6 high 63 59.4 total 106 100 diet adherence in people with diabetes mellitus poor 7 6.6 fair 29 27.4 good 70 66 total 106 100 k. kusnanto et al. 174 | pissn: 1858-3598  eissn: 2502-5791 health locus of control shows that there are 56 (52.8%) having high internal health locus of control, namely patients who have control of their own health. 56 (52.8%) in the low category, namely the respondents who have confidence in their health control with outside influences are more dominant. in the powerful others health locus of control, there are 61 (57.5%) high patients who have confidence in health control all entrusted to others (health workers and family). in the powerful others health locus of control, there are 45 (42.5%) low, namely patients who have health control beliefs in addition to other factors that affect their health. there is 63 (59.4%) high health locus of control chance, that is, the patient believes more in fate, luck, luck, or opportunity that has a big influence on his health. 43 respondents (40.6%) were low, namely patients who had confidence in health control other than the factors of fate, luck or opportunities that affected their health. from the research data it can be explained that health locus control in patients with diabetes in surabaya has control over their health, the most dominant of which is health locus control chance, namely the patient has the confidence that the patient's control is in the factors of fate, luck or opportunities that affect his health. health locus of control is a continuum, sometimes a person can be "internal" and "external" at the same time (azlin, 2007). diet adherence in people with diabetes mellitus shows the distribution of the most respondents was good diet adherence in diabetes mellitus, namely 70 (66%) respondents. 29 (27.4%) had adequate dietary adherence, and 7 (6.6%) had poor dietary adherence. from the research data it can be explained that the most dominant are respondents who have good dietary adherence because patients think they still have the opportunity to improve their health, but when patients are out of control of their trust in destiny and tempted to the surrounding environment, patients can break the diet which must be done. table 3 shows that respondents who have poor intrinsic motivation, the majority have good dm diet adherence, namely 26 (24.5%) respondents, but also there are 6 (5.7%) respondents who have poor diet adherence. while respondents who have good intrinsic motivation there are 44 (41.5%) respondents who have a good dm diet adherence and only 1 (0.9%) respondents with good intrinsic motivation who have poor diet adherence. respondents who had extrinsic motivation were not good, the majority had good dm diet adherence, 64 (60.4%) respondents, and there were 7 (6.6%) respondents who had poor diet adherence. while respondents who had the good extrinsic motivation, there were 6 (5.7%) respondents who had a good diet adherence, and none of the respondents had a poor diet adherence that was equal to 0 (0%) respondents. the analysis results show that the proportion coefficient (p) is 0.178. thus p = 0.178 is greater t the hypothesis (h1) is rejected, that there is no relationship between motivation and dm diet adherence. table 4 shows that respondents who had a low internal health locus of control, the majority had a good dm diet adherence, namely 32 (30.2%) but also there were 7 (6.6%) respondents who had poor diet adherence. whereas respondents who had a high internal health locus of control, the majority were 38 (35.8%) respondents who had a good diet adherence, and there were no respondents with high internal health locus of control who had poor diet table 3. relationship of motivation with dm diet adherence variable sub variable category diet adherence in people with diabetes mellitus total poor fair good f % f % f % ʃ % motivation intrinsic less 6 5.7 9 8.5 26 24.5 41 38.7 good 1 0.9 20 18.9 44 41.5 65 61.3 extrinsic less 7 6.6 28 26.4 64 60.4 99 93.4 good 0 0 1 0.9 6 5.7 7 6.6 spearman p = 0.178 table 4. relationship of health locus of control with dm diet adherence variable sub variable category diet adherence in people with diabetes mellitus total poor fair good f % f % f % ʃ % health locus of control internal low 7 6.6 17 16 32 30.2 56 52.8 high 0 0 12 11.3 38 35.8 50 47.2 powerfull low 6 5.7 14 13.2 25 23.6 45 42.5 high 1 0.9 15 14.2 45 42.5 61 57.5 chance low 5 4.7 16 15.1 22 20.8 43 40.6 high 2 1.9 13 12.3 48 45.3 63 59.4 spearman p = 0.002 jurnal ners http://e-journal.unair.ac.id/jners | 175 adherence. respondents who had low others health locus of control, the majority had good dm diet adherence, namely 25 (23.6%) but also there were 6 (5.7%) respondents who had poor diet adherence. respondents who have powerful others health locus of control are high, the majority of which are 45 (42.5%) respondents have good diet adherence, and respondents with high powerful others health locus of control who have poor diet adherence only 1 (0.9 %). respondents who had a low chance of health locus of control, the majority had good adherence to the diabetes mellitus diet which was 22 (20.8%) and there were 5 (4.7%) respondents who had poor diet adherence. while respondents who had a high chance of health locus of control, the majority of them were 48 (45.3%) respondents who had a good diet adherence, and respondents with a high chance of health locus of control who had poor diet adherence were only 2 (1.9% ) the analysis results show that the proportion coefficient (p) is 0.002. this means that the hypothesis (h1) is accepted, that there is a relationship between health locus of control and dm diet adherence. discussion the results of a study in the relationship between dm diet motivation and adherence obtained p> α, which means that h1 was rejected in other words there was no relationship between motivation and adherence to dm patients' diets. basically, motivation is the interaction of a person with a particular situation he faces. notoatmodjo (2010) states that motivation is an impulse from within a person that causes the person to carry out certain activities to achieve a goal. in a person, there is a need or desire for an object outside the person. motivation has a very large role in the formation of dm patient behavior including adherence in carrying out a diet. motivation is a predictor of adherence in regimens and glycemic control (butler, 2002). some research shows that someone who has high motivation will show positive results in dm management such as increasing participation in physical exercise programs and reporting symptoms of low depression (wu, 2007). based on the results of the research obtained, researchers argue that the lack of meaningful motivation for adherence to dm diets, many factors influence motivation in adherence with dm diets. respondents who have good motivation do not guarantee that the respondent has a good dm diet. the fact that in the community that most respondents said that their biggest motivation to recover and comply with the dm diet was their family, but respondents still violated dm diet rules because they felt bored and tempted by the food served. the results of this study are in line with the research conducted by pujiastuti, 2016 at the internal medicine polyclinic of dr. rsud soehadi prijonegoro sragen also got results that there was no relationship between motivation and adherence to the dm diet program. according to the results of interviews with respondents, some respondents said that the respondent's family still provided food that should not be allowed or had to be reduced by dm sufferers, especially during the month of ramadan. respondents' families still provide sweet and highcalorie foods, such as compote and fried foods. this family has indeed reminded the respondents not to eat these foods, but the respondents continued to eat foods that dm patients should not eat. it affects the motivation of respondents in adherence with dm diets. this research is different from the results of research conducted by muflihatin, s. k & komala (2016) and research conducted risti and isnaeni (2017) which states that there is a significant relationship between self-motivation and dm diet adherence. behavioral attitudes in individual health are influenced by an individual's self-motivation to behave in a healthy manner. without motivation in the diet setting, dm patients will experience nonadherence in regulating their daily diet. respondents of good motivation have the opportunity to adhere to the dm diet for 329,667 times compared to respondents less motivation. individuals will be motivated to take action if the action has a purpose, is planned. motivation that exists within an individual is formed within a person and is influenced by two main factors, namely stimulus which is a factor that comes from outside a person (external factors) such as physical environmental factors such as social, cultural, habits, economic factors and responses from within self (internal factors) such as attention, observation, perception, motivation, fantasy, suggestion, depression and so on that respond to external stimuli. thus, factors that are embedded in themselves can affect selfresilience in maintaining motivation to achieve a goal. the results of study on the relationship of health locus of control and dm dietary adherence obtained p<α, which means that h1 was accepted in other words the relationship between health locus of control and dietary adherence of dm patients. the results of this analysis are supported by the results of research conducted by safitri (2013) namely there is a significant relationship between health locus of control and adherence to dm diet management. research conducted adnyani et al., (2015) there is a significant relationship between health locus of control and adherence to dm diet management. the behavior of a dm diet is determined by several internal factors such as a strong desire to recover within oneself, as well as external factors such as family support factors or support from health workers or from the environment, culture and information and knowledge possessed by someone related to health is considered as a capital for someone to behave healthily. k. kusnanto et al. 176 | pissn: 1858-3598  eissn: 2502-5791 the results of this study indicate that individuals who have the highest chance of locus of control have the highest health locus of control, others and internal. health locus of control chance is the patient is more confident in fate, fate, luck, or opportunity that has a big influence on his health. so this makes the respondents not feel depressed about the recommended diet and make respondents better in following dietary recommendations. the other high powerful health locus of control is the second most hloc. this is evidenced by the fact that some respondents in the study said that they always depend on health workers but are reluctant to take actions aimed at improving their health. this tendency occurs because the culture of the indonesian people are always dependent on each other and the experience and dependence of patients on health workers. high internal health locus of control is the third most hloc. this is evidenced by the fact that there are still research respondents who state that respondents are lazy and bored to follow the dm diet. this shows that the patient's control of himself is still lacking. this shows that respondents do not believe in themselves and there is no willingness of themselves to improve their health status. respondents were not aware that internal control had a big role in improving their health status. health locus of control is a continuum, sometimes a person can be "internal" and "external" at the same time (azlin, 2007). health locus of control (hloc) is something that is in someone personality that has an influence on health and is one of the factors that influence dm diet adherence. health locus of control also plays an important role in determining public health behavior (bonichini, axia and bornstein, 2009). the link between health locus of control and adherence is that individuals will not carry out health behaviors unless they have a strong desire to be healthy and at least have knowledge about health. in this study, researchers have argued about the link between health locus of control and adherence. the results showed that health locus of control had more obedience. this is inversely proportional to the research conducted by adnyani, i. a. p., widyanthari, d. m. & saputra (2011) that individuals with internal hloc are more adherent to the dm diet than individuals with external hloc. the average respondent said that there were no problems in eating arrangements and the patient did not feel tortured concerning the type and amount of food recommended, but at certain times the patient felt unable to follow dietary rules when there was a big event or family event. this shows that the patient's control of himself is still lacking and if this continues to be maintained, then the non-adherence of patients in undergoing a dm diet tends to decrease. conclusion motivation with dm diet adherence has no relationship with each other. this is evidenced by the presence of other factors that influence individual motivation in dietary adherence. health locus of control with dm diet adherence has a relationship with each other. this is evidenced by dm patients who have good health locus of control who do not feel pressured towards the recommended diet and make respondents better in following dietary recommendations. this study does not control the factors that influence perceptions of respondents' behavioral control, such as educational factors, age factors, cultural factors and environmental factors that can influence the filling of motivation questionnaires, health locus of control and dm dietary compliance. need for further research regarding the factors that influence motivation, health locus of control and dm dietary compliance. references adnyani, i. a. p. s., widyanthari, d. m. and kadek saputra (2015). hubungan health locus of control dengan kepatuhan penatalaksanaan diet dm tipe 2 di paguyuban dm puskesmas iii denpasar utara. journal, ners, 3(2), pp. 7–14. azlin (2007) ‘health locus of control among noncompliance 7’. bonichini, s., axia, g. and bornstein, m. h. (2009). validation of the parent health locus of control scales in an italian sample. italian journal of pediatrics, 35(13), pp. 1–5. doi: 10.1186/18247288-35-13. butler, h. a. (2002). motivation: the role in diabetes self-management in older adults. available at: http://proquest.umi.com/pqdweb. dinkes jatim (2016). laporan tahunan dinas kesehatan 2016. jawa timur: dinas kesehatan. indarwati, d., riskiana, rusmariana, a., & hartanti, r. d. (2012). hubungan motivasi dengan kepatuhan diet diabetes melitus pada pasien diabetes’. available at: https://caridokumen.com/queue/motivasidengan-kepatuhan-diet-dm_5a44a23fb7d7bc7b7a75f4d8_pdf?queue_id=-1. indriyati, d. s. & widyarini, n. (2012). pengaruh health locus of control terhadap kepatuhan diet pada penderita hipertensi’, pp. 1–8. international diabetes federation (2017). idf diabetes atlas eighth edition 2017, international diabetes federation. doi: 10.1016/j.diabres.2009.10.007. kementrian kesehatan ri (2014). infodatin (pusat data dan informasi kementrian kesehatan ri)’. jakarta: kemenkes ri. kominfo (2015). masih tinggi, prevalensi diabetes di jatim, 30 sep 2015. available at: http://kominfo.jatimprov.go.id/read/umum/mas ih-tinggi-prevalensi-diabetes-di-jatim-. muflihatin, s. k & komala, i. (2016). hubungan motivasi dengan kepatuhan diet diabetes pada pasien diabetes mellitus tipe ii di puskesmas sempaja samarinda. jurnal ilmu kesehatan, 4. jurnal ners http://e-journal.unair.ac.id/jners | 177 available at: http://ojs.stikesmuda.ac.id/index.php/ilmukesehatan/article/view/35/17. notoatmodjo (2010). ilmu perilaku kesehatan. jakarta: rineka cipta. perkeni (2015). konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. pb. perkeni. pujiastuti, e. (2016). hubungan pengetahuan dan motivasi dengan kepatuhan diet pada pasien diabetes mellitus tipe ii di poliklinik penyakit dalam rsud dr. soehadi prijonegoro sragen. stikes kusuma husada surakarta. risti, k., and isnaeni, f. (2017). hubungan motivasi diri dan pengetahuan gizi terhadap kepatuhan diet dm pada pasien diabetes mellitus tipe ii rawat jalan di rsud karanganyar’, jurnal kesehatan, 10(2), pp. 94–103. safitri, i. n. (2013). kepatuhan penderita diabetes mellitus tipe ii ditinjau dari locus of control’, jipt, 1(2), pp. 273–290. saifunurmazah, d. (2013). kepatuhan penderita diabetes mellitus. universitas negeri semarang. available at: lib.unnes.ac.id/17487/1/1550408022.pdf. tera, b. h. a. (2011). determinan ketidakpatuhan diet penderita diabetes melitus tipe 2’, 2. available at: http://eprints.undip.ac.id/32591/1/393_banu_h anifah_al_tera_g2c007014.pdf. world health organization (2003). adherence to long-term therapies : evidence for action adherence to long-term therapies. switzerland: who. wu, s. f. (2007). effectiveness of self-management for person with type 2 diabetes following the implementation of a self-efficacy enhancing intervention program in taiwan. queensland university of technology. available at: http://eprints.qut.edu.au/16385/1/shufang_wu_thesis.pdf. 194 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, april 2018 http://dx.doi.org/10.20473/jn.v13i2.8335 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research waist circumference as a predictor for menstrual cycle disturbance among college student ni nyoman trioka rtamagustini, bambang purwanto and hanifa erlin dharmayanti faculty of medicine, universitas airlangga, surabaya, indonesia abstract introduction: menstrual cycle disturbance is the sign of a reproductive health problem, yet the cause tends to be multifactorial. this study aimed to analyze the risk factors of menstrual cycle disturbance which related to nutrition status among college students. methods: this was an observational analytical study with a cross-sectional approach. there were 59 participants taken as samples according to inclusion criteria using proportionate stratified random sampling. data were analyzed with chi-square and multiple logistic regression test. results: results found that 35.6% of participants experienced menstrual cycle disturbance. bivariate analysis showed significant correlation between body fat percentage (p= 0.038, or: 2.417) and waist circumference (p= 0.003, or: 2.956) with menstrual cycle disturbance, otherwise no correlation found between body mass index (bmi) (p= 0.052, or: 2.145), subcutaneous fat thickness (p= 1, or: 1.279), and total cholesterol levels (p= 1, or: 1.063) with menstrual cycle disturbance. multiple logistic regression analysis showed that waist circumference became determinant factor among other variables predicting menstrual cycle disturbance in this study (p= 0.002, or: 7.260). conclusion: waist circumference and body fat percentage were both risk factors of menstrual cycle disturbance, yet waist circumference was found being a determinant predictor to predict menstrual cycle disturbance among college student. female students may pay particular attention to their waist circumference for detection of reproductive health problem earlier, especially regarding menstruation cycle disturbance. article history received: may 17, 2018 accepted: january 21, 2019 keywords college student; menstruation cycle; waist circumference contact bambang purwanto  bambangpurwanto@fk.unair.ac.id  faculty of medicine, airlangga university, surabaya, indonesia cite this as: rtamagustini, nnt., purwanto, b., & dharmayanti, he. (2018). waist circumference as a predictor for menstrual cycle disturbance among college student. jurnal ners, 13(2), 194-199. doi:http://dx.doi.org/10.20473/jn.v13i2.8335 introduction menstrual cycle disturbance is a symptom of reproductive health and other health problems such as infertility, tumours, cancer, obesity, hyperinsulinemia, diabetes mellitus, and cardiovascular disease (greenstein and wood, 2010; welch, 2011; santoso, 2014). generally, menstrual cycles tend to be irregular for several years after menarche then steadily regular at around 17-18 years old. frequent problems arose as irregular menstrual cycle disorders were polymenorrhea (a cycle is shorter than 21 days), oligomenorrhea (a menstrual cycle is longer than 35 days), and amenorrhea (menstrual absence for more than 6 months) (benson and pernoll, 2008; manuaba, et.al., 2010). there were 38.4% cases of menstrual cycle disturbance for women aged around 16 years old reported in sweden. despite, the problem was also still occurred on 29.7% of 26 years old women (west, et al., 2014). while in another study, menstrual cycle disturbance was found not only experienced by women with underweight, overweight, and obesity nutrition status but also occurred in normal nutrition status (rachmawati and murbawani, 2015; mustaqeem, et. al., 2015). it shows inconsistency regarding the correlation between nutrition status with menstrual cycle disturbance. based on that fact, a preliminary study was conducted among college which showed that 30% out of 10 respondents experienced menstrual cycle disturbance. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i2.8335 jurnal ners http://e-journal.unair.ac.id/jners | 195 the causes of menstrual cycle disturbance are multifactorial. commonly, it can be caused by a disruption in a hypothalamic-pituitary-ovarian axis which related to nutrition status, physical activity, stress, and some diseases including metabolic syndrome (rakhmawati and fithra, 2013; rachmawati and murbawani, 2015; arum, 2015; noviandari, 2016; yani, 2016). recently, adolescents are also vulnerable to type 2 diabetes mellitus and metabolic diseases. basic health research stated that 36.6% of the population aged around 15 years old and more had experienced abnormal fasting glucose level (fg), 29.9% had abnormal glucose tolerance, and 35.9% had abnormal total cholesterol level (departemen kesehatan republik indonesia, 2013). the varied risk factor of menstrual cycle disturbance might result from suboptimal prevention and management effort. determining risk factors related to nutrition status may enhance selfprevention and management effort among individuals. nutritional status can be identified by weight examination, body composition, and lipid profile. the research focused on menstrual cycle disturbance that related to nutrition status based on body mass index (bmi), waist circumference, body fat percentage, subcutaneous fat thickness, and total cholesterol levels is relatively rare to be found. therefore, this research might offer a solution as it attempted to analyse the risk factors of menstrual cycle disturbance based on nutritional status in the fertile female adolescent group this study aimed to analyze the risk factors of irregular menstruation cycle related to nutrition status. specifically, it purposed to analyze correlation between body massa index (bmi), waist circumference, body fat percentage, subcutaneous fat thickness, and total blood cholesterol levels with menstrual cycle disturbance on college students. materials and methods this research was an observational analytical research with a cross-sectional design. the population of this study were the female college of the undergraduate program who already experienced menarche, 19-21 years old, unmarried, and willing to be a research participant were included in this study. otherwise, those who had primary amenorrhoea, secondary amenorrhoea due to hyperprolactinemia or internal genetic tumours such as myomas and cysts, were pregnant, breastfeeding, iatrogenic menopause, using hormonal contraceptives, drugs or supplements that affect the menstrual cycle, consumed alcohol, and active smoking was excluded. anamnesis and abdominal examination through palpation were performed to eliminate the chance of having menstrual cycle disorder due to an organic disorder. the sample size was determined using hypothesis tests for two population proportion formulas (lemeshow and lwanga, 1990).total participants of 59 colleges taken using proportionate stratified random sampling technique.the study was conducted during september 2017-april 2018. independent variables of this study were bmi, waist circumference, body fat percentage, subcutaneous fat, and total cholesterol levels. based on indonesian health ministry nutrition guidelines, normal standard of bmi values was (>18.5<24.9) kg/m2, (< 80 cm) for waist circumference,(> 17.7% <29.6 %) for body fat percentage, (<200 mg/dl) for total cholesterol, and (14-21%) for subcutaneous fat thickness. the dependent variable of this research was menstrual cycle disturbance, defined as the absence of menstruation for more than 3 cycle, shorter or longer periods of the menstrual cycle in 24-38 days of range for a year (4-5 times). the subject was characterized on age, menarche, sleep duration, exercise, diet, anxiety stress, and menstrual profile. data were collected using structured questionnaires and examining required measurements such as height, weight, waist circumference, body fat percentage, subcutaneous fat thickness, and capillary blood sampling for fasting total cholesterol test (approximately 12 hours-fasting). this study used microtoise band to measure waist circumference, tanita scale innerscan body composition monitor and skinfold calliper to measure participants’ nutritional state. modified anxiety stress scales 42 (lovibond, 2011) was used to measure and categorize anxiety stress level of subjects into the low and normal level. structured measurements form was used to collect menstrual profile data then categorize into normal and menstrual cycle disturbance. collected data were analyzed using ibm® statistical package for the social sciences (spss) statistics 24 for univariate, bivariate, and multivariate analysis. univariate analysis was performed to look into the characteristics of participants and the frequency distribution of each variable in this study. bivariate analysis was performed using the chi-square test to identify correlation and collinearity between each independent variable with the dependent variable. multivariate analysis was performed using multiple logistic regression test which required more than two variables being correlated to analyze and had chi-square test value of >0.25 with α=0.05. this research has been approved ethically by the ethics committee of the faculty of medicine, universitas airlangga with letter number 336/ec/kepk/fkua/2017. results characteristics of participants are described in table 1. participants with menstrual cycle disturbance (35.6%) were found less than regular or normal menstrual cycle (64.4%). age distribution in this study ranged from 19 to 21 years old. participants whose age at around 19 and 20 years old (35.6% and 39.0%) were found more than those who were 21 years old (25.4%). age of menarche ranged from 10 nnt. rtamagustini et al. 196 | pissn: 1858-3598  eissn: 2502-5791 years old until 14 years old. majority of participants complained having bad sleep duration which was less than 8 hours/day (84.7%) and did not frequently exercise per week (88.1%). most of the participants had a normal level of stress (61.0%), with only (8.5%) participants mentioned having a moderate level of stress. most of the participants had a non-vegetarian diet (93.2%) and consumed soybean (93.2%). the result of chi-square analysis could be seen in table 2. the correlation was found on both analysis between waist circumference with menstrual cycle table 1. the distribution for characteristics of participants (n= 59) characteristics category frequency (n) percentage (%) age 19 years old 20 years old 21 years old 21 23 15 35.6 39.0 25.4 menarche 10 years old 11 years old 12 years old 13 years old 14 years old 2 14 15 12 16 3.4 23.7 25.4 20.3 27.1 sleep duration <8 hours/day >8 hours/day 50 9 84.7 15.3 exercise yes no 7 52 11.9 88.1 vegetarian yes no 4 55 6.8 93.2 soybean consumption yes no 55 4 93.2 6.8 stress normal low moderate 36 18 5 61.0 30.5 8.5 menstruation cycle irregular regular 21 38 35.6 64.4 table 2. the result of bivariate analysis using chi-square (n= 59) variable menstruation cycle total p-value odds ratio irregular regular (n) (%) (n) (%) (n) (%) bmi abnormal normal 11 10 52.4 47.6 9 29 23.7 76.3 20 39 33.9 66.1 0.052 2.145 waist circumference abnormal normal 11 10 52.4 47.6 5 33 13.2 86.8 16 43 27.1 72.9 0.003 2.956 body fat percentage abnormal normal 15 6 71.4 28.6 15 23 39.5 60.5 30 29 50.8 49.2 0.038 2.417 subcutaneous fat thickness abnormal normal 19 2 90.5 9.5 33 5 86.8 13.2 52 7 88.1 11.9 1 1.279 total cholesterol levels abnormal normal 3 18 14,3 85.7 5 33 13.2 86.8 8 51 13.6 86.4 1 1.063 table 3. the result of first step multiple regression logistic analysis variable b sig or ci 95% lower upper body fat percentage bmi 0.462 0.794 0.543 0.221 1.587 2.211 0.359 0.620 7.021 7.879 waist circumference 1.426 0.088 4.161 0.810 21.368 constant -1.569 0.002 0.208 table 4. the result of third step model regression logistic analysis variable b sig or ci 95% lower upper waist circumference 1.982 0.002 7.260 2.035 25.904 constant -1.194 0.001 0.303 jurnal ners http://e-journal.unair.ac.id/jners | 197 disturbance, and between body fat percentage with menstrual cycle disturbance with a p-value < 0.05 (p= 0.003 and p= 0.038). whereas different results were found on the correlation between bmi, subcutaneous fat thickness, and total cholesterol levels with menstrual cycle disturbance (p-value > 0.05). an odds ratio value of all variables were at more than one. an odds ratio value of 2.956 for correlation between waist circumference with menstrual cycle disturbance indicated college students with > 80 cm waist circumference had 2.956 times riskier than those with normal waist circumference. multiple logistic regression was performed to determine the predominant factor for menstrual cycle disturbance. the result could be seen on table 3 and 4. there were three variables as candidates of menstrual cycle disturbance predictor, as in body mass index, waist circumference, and body fat percentage. a variable with the greatest significant p-value is eliminated gradually until we obtained a model with significant value below to 0.05. the multiple regression model analysis resulted in only waist circumference as a determinat risk factor. it suggested that waist circumference as the only determinant risk factor of menstrual cycle disturbance on this study. based on multiple logistic regression with or value of 7.2, it could be suggested that college students who had abnormal waist circumference would be 7.2 times riskier to have menstrual cycle disturbance than those with normal waist circumference. discussion five independent variables were analysed as predictor candidates for menstrual cycle disturbance. there were three of five variables correlated to menstrual cycle disturbance, i.e. body mass index, waist circumference and body fat percentage.the previous study has exposed a significant correlation between irregular menstrual cycle and waist circumference. it assumed that waist circumference was associated with menstrual cycle disturbance (song, et. al., 2016). another previous study had a similar result, of which assumed that oligomenorrhea was correlated with waist circumference (seif, diamond, and nickkhoo-amiry, 2014). abnormal waist circumference indicates that there is an accumulation of fat stored exceeding its normal part in the abdomen. it is also called central obesity or central adiposity. therefore, central obesity occurs when there is an accumulation of fat around the abdomen region particularly at the abdomen cavity in the outer wall of the intestine (cahyono, 2008). obesity is determined using such bmi measurement which calculates weight and height, body fat percentage, subcutaneous fat thickness and waist circumference. measurement of waist circumference was relatively easier to do, but it was proved more accurate to describe central obesity than other variables (national health service, 2016). our findings confirmed that waist circumference was the only variable in the logistic regression model to predict menstrual cycle disturbance. in addition, obesity also as a risk factor of hormonal abnormality which correlates to a reproductive problems such as infertility, pcos, and menstrual irregularity. obesity was known as the risk of chronic anovulation (seif, diamond, and nickkhoo-amiry, 2014). due to obesity, chronic anovulation occurs in three ways as in high peripheral aromatization of androgens, low level of sex hormone binding globulin (shbg) production, and insulin resistance (fritz and speroff, 2011). high peripheral aromatization of androgens leads to chronically accelerated estrogen concentration. androgen also functions as estrogen precursor. therefore, estrogen is not only derived from the ovary but also from its precursor. while a low level of shbg production in the liver may increase circulating concentrations of free testosterone and estradiol in the blood. as for insulin resistance, it results in androgen production in the ovarian stroma. higher concentration of local androgen might disrupt the development of follicle. disturbances in the follicle process can cause chronic anovulation. particular weight loss program decreases blood insulin and androgen levels, it also restores the ovulatory function of menstrual cycles (fritz and speroff, 2011). the factors affecting waist circumference are age, physical activity, energy intake, genetic, alcohol, and stress (ranggadwipa and murbawani, 2014; rasdini, 2016). physical activity may decrease when someone gets older. excessive diet and lack of physical activity impair on increasing the waist circumference. excessive calories are found in fast foods, processed meats, margarine, canned vegetables, and recycled cooking oil.the type of foods that may trigger glucose production in large quantities. the pancreas has a function to secrete insulin and convert it into the energy that is essential for the cell metabolism. improper catabolism activity result in disruption of that function which leads to excessive fat stored in more parts of the body and eventually also leads to central obesity. while an individual may have a tendency to have fat accumulation in the abdomen genetically, but it may be avoidable if radical weight gain did not occur. on the other hand, alcohol consumption may result in decreasing fat burning efficiency. fat accumulation will occur if there is no lifestyle changing by reducing alcohol. at last, stress and lack of sleep can increase production of the cortisol hormone which disposes fat accumulating in the stomach. therefore, avoiding those risk factors may be beneficial to maintain normal waist circumference. fats disturb hormonal secretion level and balance that regulate menstruation cycle by shaping, converting, and storing reproductive hormones. excessive fat can cause blood vessel hyperplasia. the blood vessel will be suppressed by fat tissue nnt. rtamagustini et al. 198 | pissn: 1858-3598  eissn: 2502-5791 resulting in a disruption on blood circulation in the reproductive system becomes (rachmawati and murbawani, 2015). on the other hand, massive weight loss and underweight condition decrease gonadotropin hormones that secrete lh and fsh. it may also decrease the estrogen level and stimulate anovulatory condition which leads to the menstrual cycle disturbance (hidayah, rafliudin, and ronny, 2016). androgen excess in women with pcos and obesity may be accompanied by abnormal metabolic conditions, which is characterized by increasing abdominal fat and decreasing lipolysis in subcutaneous fat (kim et. al., 2014). lifestyle management by regulating considerable physical activity, reducing fast-food consumption, healthy eating habits, keeping the ideal bmi are few ways to improve reproductive health, particularly in maintaining regular menstrual cycle (jena, panda, mishra, and narahari, 2017). previous studies suggested that cholesterol has no correlation with menstrual irregularity. women with a history of menstrual cycle disorders had a higher risk to suffer from diabetes mellitus (dovom, et. al., 2016). similarly, this study showed that total cholesterol levels did not have a significant relationship with menstrual irregularity. normally, menstrual irregularity often occurs at the beginning of the menarche. despite menstrual cycle disorders are likely to occur in upcoming years, metabolic disorders screening may become beneficial for prevention efforts. conclusion this study showed a correlation between waist circumference and body fat percentage with menstrual cycle disturbance. otherwise, no correlation was found between bmi, subcutaneous fat, and total cholesterol level with menstrual cycle disturbance. while college student with abnormal waist circumference and body fat percentage were shown being at more risk to develop menstrual cycle disturbance. waist circumference was proven as a predictor to determine menstrual cycle disturbance among college student. future investigation is needed to explore more some variables which involve in menstrual cycle disturbance mechanism related to obesity such as free radicals, proinflammatory cytokine and hormones. acknowledgment we thank to midwifery department of the faculty of medicine, universitas airlangga, for the study administration. references arum, v. r. (2015). hubungan status gizi dengan kejadian oligomenore pada sisiwi di smk perintis 29 ungaran. semarang: div kebidanan stikes ngudi waluyo ungaran. benson, r. c., & pernoll, m. l. (2008). buku saku obstetri dan ginekologi. jakarta: egc. cahyono, s. b. (2008). gaya hidup dan penyakit modern. yogyakarta: kanisius. departemen kesehatan republik indonesia. (2013). riset kesehatan dasar 2013. [online] available at: www.depkes.go.id/resources/download/general /hasil%20riskesdas%202013.pdf. (accessed: september 2, 2017). dovom, r. m., tehrani, r. f., djalalinia, s., cheragi, l., gandavani, s. b., & azizi, f. (2016). menstrual cycle irregularity and metabolic disorders: a population-based prospective study. plos one, 11(12), e0168402. doi:10.1371/journal.pone.0168402. fritz, m. a., & speroff, l. (2011). clinical gynecology endocrinology and infertility (8th ed.). usa: lippincott williams & wilkins. greenstein, b., & wood, d. f. (2010). at a glance sistem endokrin (2nd ed.). jakarta: erlangga. hidayah, n., rafliudin, m. z., & ronny, a. (2016). hubungan status gizi, asupan gizi dan aktifitas fisik dengan siklus menstruasi remaja putri pondok pesantren salafiyah kauman kabupaten pemalang tahun 2016. jurnal kesehatan masyarakat, iv(4), 537-544. jena, p., panda, j., mishra, a., & narahari, a. (2017). menstrual pattern and body mass index in adolescent school girls; a cross-sectional study. global journal for research and analysis, vi(6), 29-31. doi:10.1186/s12905-016-0354-y. kim, m.-j., lim, n. k., choi, y. m., kim, j. j., hwang, k. r., chae, s. j., & kim, t. (2014). prevalence of metabolic syndrome is higher among non-obese pcos women with hyperandrogenism and menstrual irregularity in korea. plos one, ix(6), e99252. doi.org/10.1371/journal.pone.0099252. lemeshow, s., & lwanga, s. k. (1990). adequacy of sample size in health studies. singapore: john wiley & sons on behalf of world health organization. manuaba, i. g., manuaba, c. i., & manuaba, f. i. (2010). pengantar kuliah obstetri. jakarta: egc. mustaqeem, m., sadullah, s., waqar, w., farooq, m. z., khan, a., & fraz, t. r. (2015). obesity with irregular menstrual cycle in young girls. mymensingh medical journal, 24(1), 161-167. national health service. (2016). nhs choices. [online] available at: https://www.nhs.uk/conditions/obesity. (accessed: april 4, 2018). noviandari, i. (2016). hubungan antara status gizi dan anemia dengan siklus menstruasi pada remaja putri di sma batik 1 surakarta. [online] available at: http://onesearch.id/record/ios2728.44689. (accessed: september 2, 2017). rachmawati, p. a., & murbawani, e. a. (2015). hubungan asupan gizi, aktivitas fisik, persentase lemak tubuh dengan gangguan siklus menstruasi pada penari.[online] available at: http://www.depkes.go.id/resources/download/general/hasil%20riskesdas%202013.pdf http://www.depkes.go.id/resources/download/general/hasil%20riskesdas%202013.pdf https://www.nhs.uk/conditions/obesity http://onesearch.id/record/ios2728.44689 jurnal ners http://e-journal.unair.ac.id/jners | 199 http://onesearch.id/record/ios2852.45791?wid get=1. (accessed: september 2, 2017). rakhmawati, a., & fithra, d. f. (2013). hubungan obesitas dengan kejadian gangguan siklus menstruasi pada wanita dewasa muda. jurnal of nutrion college, 2(1), 214-222. ranggadwipa, d. d., & murbawani, e. a. (2014). hubungan aktivitas fisik dan asupan energi terhadap massa lemak tubuh dan lingkar pinggang pada mahasiswa fakultas kedokteran universitas diponegoro. [online] available at: http://eprints.undip.ac.id/44523/ (accessed: march 18, 2018). rasdini, i. g. (2016). hubungan lingkar pinggang dengan kadar kolesterol ldl pasien penyakit jantung koroner di ruang iccu rsup sanglah bali. jurnal kesehatan, vii(1), 46-51. [online] available at: https://www.poltekkestjk.ac.id/ejurnal/index.php/jk/article/view/117 /103. (accessed: january 2, 2018). rizki, n. (2015). hubungan status gizi dengan siklus menstruasi pada remaja putri kelas xi di smk n 4 yogyakarta.dissertation. yogyakarta: sekolah tinggi ilmu kesehatan 'aisyiyah. santoso, b. (2014). sindroma ovarium polikistik: problem reproduksi dan tantangannya terkait dengan gaya hidup perempuan indonesia. surabaya: universitas airlangga. seif, m. w., diamond, k., & nickkhoo-amiry, m. (2014). obesity and menstrual disorders. best practice and research clinical obstetrics and gynaecology, 516-527. hyperlink "https://doi.org/10.1016/j.bpobgyn.2014.10.010 " \t "_blank" \o "persistent link using digital object identifier" doi: 10.1016/j.bpobgyn.2014.10.010 song, j.-y., kim, m.-h., paik, j.-s., kim, h.-s., & na, k.-s. (2016). association between menstrual irregularity and dry eye dieses: a populationbased study. cornea, xxxv(2), 193-198.doi: 10.1097/ico.0000000000000941. welch, c. (2011). balance your hormones, balance your life. jakarta: penebar plus. west, s., lashen, h., bloigu, a., franks, s., puuka, k., ruokonen, a., . . . papunen, l. m. (2014). irregular menstruation and hyperandrogenaemia in adolescence are associated with polycystic ovary syndrome and infertility in later life: northern finland birth cohort 1986 study. human reproduction, 29(10), 2339-2351.doi: 10.1093/humrep/deu200 yani, n. g. (2016). hubungan aktivitas fisik dengan siklus menstruasi pada atlet kontingen pon xix jawa barat di koni sulawesi selatan. [online] available at: core:https://core.ac.uk/download/pdf/776268 35.pdf (accessed: september 2, 2017). http://onesearch.id/record/ios2852.45791?widget=1 http://onesearch.id/record/ios2852.45791?widget=1 http://eprints.undip.ac.id/44523/ https://www.poltekkes-tjk.ac.id/ejurnal/index.php/jk/article/view/117/103 https://www.poltekkes-tjk.ac.id/ejurnal/index.php/jk/article/view/117/103 https://www.poltekkes-tjk.ac.id/ejurnal/index.php/jk/article/view/117/103 https://core.ac.uk/download/pdf/77626835.pdf https://core.ac.uk/download/pdf/77626835.pdf 205 the effectiveness of a pain management program on intensity of pain and quality of life among cancer patients in myanmar hein thu*, tintin sukartini** *military institute of nursing and paramedical sciences, myanmar **faculty of nursing, universitas airlangga, indonesia email: johnthu22@gmail.com abstract introduction: cancer is one of the leading causes of death worldwide and is rapidly becoming a global pandemic. cancer pain significantly affects the diagnosis, quality of life and survival of patients with cancer. the aim of this study is to analyse the effect of a pain management program (pmp) on pain and quality of life in a patient with cancer. methods: this study used a quasi-experimental design with a randomised pre-post test design approach. the data was collected from cancer patients in no 2 military hospital (500-bedded), yangon, myanmar. the patients were recruited using a random allocation sampling technique and consisted of 30 respondents (experimental group) and 30 respondents (control group) taken according to the inclusion criteria. the short form-mcgill pain questionnaire 2 (sf-mpq 2) was used to assess pain, and the european organization for research and treatment of cancer quality of life questionnaire-core 30 (eortc qlqc30) was used to assess the quality of life. results: a manova test was used to analyse the effect of pmp. it showed that 1) pmp decreased the pain and 2) pmp increased the quality of life in patients with cancer. conclusions: improvements in the quality of life and to do with pain-related cancer suggests that the vicious cycle of chronic pain may be alleviated by pmp. as we look at the results, pmp can be an effective treatment to be used by nurses for decreasing pain and increasing the quality of life in patients with cancer. keywords: cancer, myanmar, pain management program, quality of life introduction cancer is a leading cause of death worldwide, having killed an estimated 8.2 million people in 2013 (world health organisation, 2014). world cancer reports estimate that the incidences of cancer will increase to 15 million new cases in 2020 (ashton-prolla et al., 2009). it was estimated that there were over 700,000 new cases of cancer and 500,000 cancer deaths in asean member countries each year and that this number is expected to increase (jan et al., 2012). in myanmar, non-communicable diseases are estimated to account for 59% of the total deaths (441,000) while the cancer mortality rate accounts for 11% (who, 2014). pain is one of the most common symptoms experienced by cancer patients; either because of the disease itself or the treatments that the cancer patients are receiving. research has revealed that approximately 43% to 63% of cancer patients and 58% to 73% of those experiencing an advanced stage suffer from chronic pain during active cancer therapy (van den beukenvan everdingen et al., 2007). unrelieved pain may prompt suicidal ideation among cancer patients. therefore, pain is the most feared consequence for many cancer patients (holtan et al., 2007). as much as 80% to 90% of cancer pain can be managed by various pharmacological and non-pharmacological methods (breivik et al., 2009), yet it is regrettable that up to 40% of cancer goes untreated (deandrea et al., 2008). quality of life (qol) can be described as the condition of well-being that consists of physical, psychological, social and spiritual aspects (kyranou et al., 2013). cancer patients not only experience physical problems, but also psychosocial and spiritual disorders that affect their quality of life (manuaba, 2008). higher pain intensity in cancer patients generally can cause symptoms of depression, anxiety, fatigue and stress. it can also contribute to the psychological factors that can affect the patient's pain experience and the quality of life of the patients (vallerand et al., 2007). therefore, care needs to be tailored to meet the needs of the cancer patients psychosocially that we can make pain management better and more functional. nowadays, pain management for cancer patients includes pharmacological and non-pharmacological methods. the world health organisation suggested a pain ladder for the treatment of cancer pain (who, 2014). given the existence of all of these methods of cancer pain management, it is unfortunate when cancer pain goes untreated or undertreated (deandrea et al., 2008). the pain management program (pmp) is a treatment of jurnal ners vol. 12 no. 2 oktober 2017: 205-211 206 choice which is based on the principles of cognitive behaviour for people with persistent pain that could make their quality of life worse. pmp aims to help clients manage pain better in the long term. pmp uses a combination of psychological, physical and practical methods to relieve the pain, physical disability and poor quality of life (the british pain society, 2013). in a military setting, no 2 military hospital (500-bedded) is responsible for the treatment of cancer patients and is one of the hospitals that can provide comprehensive treatment and healthcare facilities for the patients with cancer. as for the disease burden, according to the available data from the medical records department of no 2 military hospital, 1,914 patients were admitted to the oncology ward in 2015. in general, thirty patients a day were treated with chemotherapy, and forty-seven patients were treated with radiation therapy daily. according to thiha (2014), among the cancer patients with pain, the most common cancers with pain are breast cancer (27.4%) and lung cancer (23.29%). according to the description of the pain, the most obvious type of pain is somatic in origin (49.32%) and neuropathic pain at 13.7%. the usual complaints of symptoms are lower back pain and chest pain. according to the duration of pain, chronic pain (73%) is more common. cancer ultimately affects 72.60% of all cancer patients among other causes of cancer pain, treatment, debility, concurrent disorder. according to pain scores, the respondents showed moderate pain as much as 58.9% and severe pain as much as 30.14%. the results of the interviews with ten patients who were admitted to no 2 mh, yangon, approved the statements made by officers of the department that patients often suffer from pain, especially after undergoing chemotherapy and radiotherapy. at the time of the interview, there were three nasopharyngeal cancer patients with severe pain. the patients seemed to cry and moan in pain, holding the hands of their relatives to face their dying days. patients conveyed that the pain was felt at every moment, and it was so intense that they could not sleep or eat. regarding the hospital workload, about a hundred patients were admitted to the oncology ward and nine nursing personnel were assigned to this ward. the functions of the nurses in the oncology ward were mainly in a caregiver role focusing on direct health care services to the patients, health education to the patients and their families and supportive health care such as psychosocial support, spiritual care and symptom management (medical record department, 2015). pain management is crucial in caring for cancer patients, and it involves medication as well as non-pharmacological therapies to promote comfort. pain is the most common problem in patients with cancer, therefore giving effective and supportive treatment to those who suffer from pain is of critical importance. pmp has been developed by a team of health workers in the uk but is still not covering others. in addition, there has been no previous study applying pmp among cancer patients in myanmar. the findings of this study can be applicable to the development of pmp to reduce the intensity of pain and to improve the quality of life among cancer patients in myanmar, especially in the military setting. with regards to these results, the researchers recommend pmp as a form of alternative non-pharmacological therapy to reduce pain and to improve the quality of life of cancer patients in the no (2) military hospital (500-bedded) yangon, myanmar. materials and methods this study used a quasi-experimental design with a randomised pre-post test design approach. the data was collected from cancer patient in the no (2) military hospital (500bedded), yangon, myanmar. the patients were recruited by using a random allocation sampling technique and consisted of 30 respondents (in the experimental group with pmp and routine care) and 30 respondents (in the control group with routine care) taken according to the criteria. the samples were taken using the consecutive sampling method with inclusion and exclusion criteria. the inclusion criteria were cancer patients with mild to moderate pain, cancer patients who were undergoing treatment, such as chemotherapy, radiotherapy, surgical and a combination of the above. the independent variable was pmp. the dependent variables were pain and quality of life. confounding variables were age, sex, job, income and education level. the short the effectiveness of a pain management... (hein thu, tintin sukartini) 207 table 1: distribution of demographic characteristics of respondents (n= 60) in oncology unit, no (2) military hospital (500bedded), yangon, myanmar characteristics intervention group (n=30) control group (n=30) n % n % age 26 35 years 36 45 years 46 55 years > 55 years 4 8 11 7 13.3 26.7 36.7 23.3 3 5 14 8 10.0 16.7 46.7 26.7 sex male female 17 13 56.7 43.3 17 13 56.7 43.3 job soldier does not work private civil servant 13 12 4 1 43.3 40.0 13.3 3.3 13 14 3 0 43.3 46.7 10.0 0 rank family other rank officer 17 11 2 56.7 36.7 6.7 17 12 1 56.7 40.0 3.3 income* <200 200-400 > 400 8 18 4 26.7 60.0 13.3 3 23 4 10.0 76.7 13.3 education primary middle high graduate can read or write 10 12 2 4 2 33.3 40.0 6.7 13.3 6.7 6 19 4 1 0 20.0 63.3 13.3 3.3 0 intervention chemotherapy combination therapy 21 9 70.0 30.0 21 9 70.0 30.0 diagnosis lung cancer ca breast ca cervix ca rectum melanoma sarcoma sarcoma ca tongue 10 4 5 1 2 2 4 2 33.3 13.3 16.7 3.3 6.7 6.7 13.3 6.7 11 4 5 1 2 2 3 2 36.7 13.3 16.7 3.3 6.7 6.7 10.0 6.7 * in thousand kyats form-mcgill pain questionnaire 2 (sf-mpq 2) was used to assess the pain. this questionnaire consisted of a pain intensity scale ranging from 0 (none) to 10 (worst) (dworkin et al., 2009). this instrument has been tested regarding its validity and reliability by dworkin et al. (2009) and is widely used in many countries. the european organisation for research and treatment of cancer quality of life questionnaire-core 30 (eortc qlqc30) that was used for assessing the quality of life had several components. functional scales and symptoms were included in items number 1-28 with a score of 1 (never) to 4 (very often). meanwhile, items number 29-30 were about their general health status with a score of 1 as very poor to 7 as very good. the myanmar version of eortc qlq-c30 had been drawn up by eortc itself. the pmp survey was held for two weeks and was divided into four sections encompassing sections (1) education; section (2) guided practices, the implementation of progressive relaxation techniques; section (3) guided practices, the implementation of progressive visual distraction; section (4) evaluation. each meeting took about 60 minutes. after all of the data was collected, the researchers conducted data analysis. the socio-demographic characteristics of the respondents were analysed using descriptive statistics. in addition, the manova test was used to determine the effects of pmp and the confounding variables on pain and quality of life among respondents. approval and permission to conduct the study was obtained from the research ethics committee of the military institute of nursing and paramedical sciences, myanmar, as well as a recommendation for the protection of human rights and welfare in medical research from the ethical committee of the faculty of nursing, universitas airlangga, surabaya, indonesia and also from the commanding officer of the head of the oncology department and nursing superintendent of the no. (2) military hospital (500-bedded), yangon, myanmar. results as shown in table 1, there were a total of 60 respondents. 30 were in the control group, and 30 respondents were from the intervention group. the majority of the respondents from the intervention group 11(36.7%) were in the 46-55 age group. in relation to the gender grouping, 17 (56.7%) respondents were male. with regards to occupation, the highest proportion of respondents (43.3%) were soldiers. all of the respondents were not only military soldiers’ jurnal ners vol. 12 no. 2 oktober 2017: 205-211 208 and their wives but their parents and children. regarding the source of information from the respondents, 56.7% were family members of military soldiers. almost two thirds, 18 (60%) of the respondents, earned 200,000-400,000 kyats as their family income per month. the highest group of respondents in the intervention group (40%) had a middle school education level. more than two thirds, 21(70%), were undergoing chemotherapy. in addition, most of the respondents from the intervention group (10) (33.3%) were lung cancer patients. according to table 1, the data in the control group showed that most of the respondents (n=14, 46.7%) were in the 46-55 years age group, and most of them (56.7%) were male respondents. 14 out of 30 of the respondents (46.7), and 17 out of 30 (56.7%) were family members of military personnel. with regards to family income, more than twothirds of the respondents (76.7%) earned 200,000-400,000 kyats per month. 63.3% of respondents had a middle school education level. likewise in the intervention group, 70% of the total respondents were undergoing chemotherapy, and 11(36.7%) respondents were diagnosed with lung cancer. as shown in table 2, the mean pain score of the cancer patients in the intervention group was 4.37, and it decreased to 4.07. the control group gained a mean pain score in the pre-test of 4.07, and post-test this score was 4.37. it can be seen that the control group had a higher mean score of a pain than the intervention group. based on table 3, the mean score of the quality of life of cancer patients in the intervention group was 64.63, and this increased to 90.07, while the control group mean score of the quality of life in the pretest was 70.83 and post-test were 71.27. the results showed that the intervention group had a higher mean score of quality of life than the control group. based on table 4, it can be seen that, in general, there are differences in mean pain and the quality of life between the treatment and control groups. the results show that the value of hotteling's trace sig. 0.000 was smaller than α 0.05, so it is stated that there was a difference in pain and quality of life between the treatment group and the control group. table 5 shows that there was a difference in pain with p = 0.000 and quality of life with p = 0.013 between the treatment group and the control group. however, there was no significant difference between the functional scales (p= 0.186) and the symptomatic scales of quality of life (p= 0.051). there was only a significant difference in the general health scales (p=0.000). it can be seen that pmp reduces pain and improves qol only in relation to the general health scales. discussions the findings of this study confirmed that pmp reduced the intensity of pain in cancer patients. compared with the patients from the control group, the pain scores were significantly reduced. we found that the worst pain intensity in the intervention group was lower than in the control group and this showed a significant difference. these findings are in accordance with earlier studies that found that pmp decreased patients’ pain. based on the research conducted by tse et al. (2012) on patients in palliative care and cancer patients hospitalised in hong kong, it was found that after the implementation of a pmp (using prn drugs and non-pharmacological methods), the pain table 2: differences in pain of cancer patients in intervention group and control (n: 60) variable n intervention group control group mean sd min-max n mean sd min-max pain pre test 30 4.07 1.14 2-6 30 4.37 0.72 2-6 post test 30 3.53 0.97 1-5 30 4.7 0.92 3-6 table 3: differences in quality of life of cancer patients in intervention group and control (n=60) variable n intervention group control group mean sd min-max n mean sd min-max quality of life pre test 30 64.63 35.35 10-121 30 70.83 30.86 11-118 post test 30 90.07 32.55 19-145 30 71.27 23.16 29-115 the effectiveness of a pain management... (hein thu, tintin sukartini) 209 scale decreased significantly in the two groups (intervention and control), as well as significantly so in decreasing the barrier to pain management. pain is influenced by several factors. some of the factors that affect pain include physiological factors (age, gender, weakness or fatigue, genes, neurological function), social factors (attention, previous experience), spiritual factors, psychological factors (anxiety, coping technique), and cultural factors (meaning of pain, ethnicity). in the present study, the decrease in pain intensity after the pmp could be interpreted as a positive for patients with cancer. because the treatment of chronic pain in many cancer patients is difficult, this positive effect of pmp on pain intensity can be considered to be clinically important (eortc, 2003). according to the findings of this study, as well as in previous studies, we can conclude that performing pmp for patients with cancer can indirectly lead to the acceptance of pain for the patients as they mentioned in the sessions, or indirectly assist the healthcare providers in reducing the patient's pain. it is better to use non-pharmaceutical treatment alongside medication for the better management of pain (aubin et al., 2006; lai et al., 2004). based on the findings of this study, a majority of the respondents from the intervention group had quality of life in the poor category before being given the pmp, as found through the european organisation for research and treatment of cancer quality of life questionnaire-core 30 (eortc qlqc30) (scott et al., 2008). cancer is a lifechanging thing. for some people, cancer provides opportunities to self-introspect and enhance the meaning of life. but overall, cancer will affect the physical, social, psychological, and spiritual well-being of individuals (potter & perry, 2010). according to fitriana and ambarini (2012), most cancer patients feel that they are in a period of crisis that requires adjustment, and each patient will require different adjustments depending on their perceptions, attitudes and personal experiences related to self-acceptance to change. according to the researcher, the changes associated with the disease condition experienced were received differently in each patient, so this condition will affect the quality of life of cancer patients. in relation to the principle scoring of eortc qlq-c30, high scores showed that the higher the level of quality of life means a high score on a functional scale which showed that the higher the level of function of health, means that a high score in the health status and a generally high quality of life. a high score on the symptom scales showed a higher the level of problems or existing symptoms (aaronson et al., 1993). in addition, there is also the research and arguments indicating the influence of cultural factors on quality of life. in this study, by comparing the mean quality of life scores between both groups before and after the intervention, the patients’ quality of life improved in the intervention group and decreased in the control group. based on our results after the intervention, the scores related to the quality of life and general health scale increased significantly in the intervention group, while the functional scale and symptoms scale did not differ significantly table 4: differences test between intervention and control group (n=60) effect value f hypothesis df sig pmp pillai’s trace 0.284 11.293 b 2.000 0.000 wilk’s lambda 0.716 11.293 b 2.000 0.000 hotteling’s trace 0.396 11.293 b 2.000 0.000 roy’s largest root 0.396 11.293 b 2.000 0.000 table 5: results of analysis between intervention and control group (n=60) variable mean square df f p value pain 20.417 1 20.417 0.000 qol 5301.600 1 5301.600 0.013 qolfs 299.267 1 1.789 0.186 qolss 303.750 1 3.979 0.051 qolgh 1440.600 1 14.041 0.000 jurnal ners vol. 12 no. 2 oktober 2017: 205-211 210 compared with the control group. liang et al. (2015) revealed that the patients’ reports of pain intensity and pain interference were significantly correlated with quality of life. participants who experienced higher levels of pain and interference reported lower levels in the functional and global domain of quality of life and a higher level in the symptom domain of quality of life. the findings of this study showed that pmp reduced the intensity of pain in cancer patients. compared with patients from the control group, the pain scores were significantly reduced. it can be concluded that reducing pain intensity reflects an improving quality of life in cancer patients with pain. indeed, in patients who received pmp, the pain scores were significantly reduced, and there were improved qol scores after 2 weeks compared with those who received standard care in this study. conclusions to the best of our knowledge, this is the first study evaluating the effects of pmp in cancer patients experiencing pain in myanmar. the results of the present study showed that pmp decreased pain intensity and improved the quality of life of cancer patients. it is suggested that if it is introduced into clinical practices of standard care, this type of pmp could have the potential to improve the quality of pain management for the great majority of cancer patients. however, this study had some limitations. findings from this study may not be generalised to cancer patients in other settings or other countries. furthermore, the present study population was drawn from cancer patients from a military setting. therefore, the generalisation of these findings to individuals living in other geographic regions is limited. also, we studied a relatively small number of patients with cancer who had pain at a single institution. future studies may follow on from this study with a larger sample size from multiple institutions. in addition, we suggest a further comparison of the effectiveness of pmp with other types of nonpharmacological pain interventions among cancer patients. references aaronson, n. k. et al. (1993) ‘the european organisation for research and treatment of cancer qlq-c30: a quality-of-life instrument for use in international clinical trials in oncology’, journal of the national cancer institute, 85, pp. 365–376. doi: 10.1093/jnci/85.5.365. ashton-prolla, p. et al. (2009) ‘development and validation of a simple questionnaire for the identification of hereditary breast cancer in primary care’, bmc cancer, 9(1), p. 283. doi: 10.1186/1471-2407-9-283. aubin, m. et al. (2006) ‘impact of an educational program on pain management in patients with cancer living at home’, oncology nursing forum, 33(6), pp. 1183–1188. doi: 10.1188/06.onf.1183-1188. van den beuken-van everdingen, m. et al. (2007) ‘prevalence of pain in patients with cancer: a systematic review of the past 40 years’, annals of oncology, 18(9), pp. 1437–1449. doi: 10.1093/annonc/mdm056. breivik, h. et al. (2009) ‘cancer-related pain: a pan-european survey of prevalence, treatment, and patient attitudes’, annals of oncology, 20(8), pp. 1420– 1433. doi: 10.1093/annonc/mdp001. deandrea, s. et al. (2008) ‘prevalence of undertreatment in cancer pain. a review of published literature’, annals of oncology, 19(12), pp. 1985–1991. doi: 10.1093/annonc/mdn419. dworkin, r. h. et al. (2009) ‘development and initial validation of an expanded and revised version of the short-form mcgill pain questionnaire (sf-mpq2)’, pain. international association for the study of pain, 144(1–2), pp. 35– 42. doi: 10.1016/j.pain.2009.02.007. fitriana, n. a. and ambarini, t. k. (2012) ‘kualitas hidup pada penderita kanker serviks yang menjalani pengobatan radioterapi’, jurnal psikologi klinis dan kesehatan mental, 1(2), pp. 123–129. holtan, a. et al. (2007) ‘prevalence of pain in hospitalised cancer patients in norway: a national survey.’, palliative medicine, 21(1), pp. 7–13. doi: 10.1177/0269216306073127. jan, s. et al. (2012) ‘the socioeconomic burden of cancer in member countries of the association of southeast asian nations (asean)--stakeholder the effectiveness of a pain management... (hein thu, tintin sukartini) 211 meeting report’, asian pacific journal of cancer prevention : apjcp, 13(2), pp. 407–409. doi: 10.7314/apjcp.2012.13.2.411. kyranou, m. et al. (2013) ‘differences in depression, anxiety, and quality of life between women with and without breast pain prior to breast cancer surgery’, european journal of oncology nursing, 17(2), pp. 190– 195. doi: 10.1016/j.ejon.2012.06.001.difference s. lai, y. et al. (2004) ‘effects of brief pain education on hospitalized cancer patients with moderate to severe pain.’, supportive care in cancer, 12(9), pp. 645–652. doi: 10.1007/s00520-004-0626-1. liang, s. y. et al. (2015) ‘the impact of pain on the quality of life of taiwanese oncology patients’, pain management nursing. american society for pain management nursing, 16(2), pp. 128– 136. doi: 10.1016/j.pmn.2014.05.009. mahamed, f. (2012) ‘impact of family planning health education on the knowledge and attitude among yasoujian women’, 4(2), pp. 110– 118. doi: 10.5539/gjhs.v4n2p110. manuaba, t. w. (2008) masalah kanker di indonesia. universitas udayana. medical record department (2015) admission rate of oncology ward. yangon. scott, n. w. et al. (2008) ‘eortc qlq-c30 reference values’, eortc quality of life group, (july), p. 419. available at: https://pdfs.semanticscholar.org/71d3/ de2b6d58bf321da160a43a99777538a2 06d8.pdf%0ahttp://groups.eortc.be/qo l/sites/default/files/img/newsletter/refe rence_values_manual2008.pdf. the british pain society (2013) cancer pain management: a perspective from the british pain society, supported by the association for palliative medicine and the royal college of general practitioners, the british pain society's cancer pain management. london: the british pain society. thiha, s. (2014) clinical study of physical pain in cancer patients. dsma, mingalardon. tse, m. m. y. et al. (2012) ‘the effect of a pain management program on patients with cancer pain’, cancer nursing, 35(6). available at: http://journals.lww.com/cancernursing online/fulltext/2012/11000/the_effec t_of_a_pain_management_program_o n.7.aspx. vallerand, a. h. et al. (2007) ‘factors that affect functional status in patients with cancer-related pain’, pain, 132(1), pp. 82–90. doi: https://doi.org/10.1016/j.pain.2007.01. 029. who (2014) noncommunicable diseases (ncd) country profiles. geneva. doi: 10.4135/9781412994170.n207. world health organization (2014) cancer pain relief, cancer pain relief. available at: papers://d30f2a22-a1cf4822-92920ad49fba75fc/paper/p1288. 200 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.9292 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research red ginger (zingiber officinale var. rubrum) massage reduces stiffness and functional disability in elderly with osteoarthritis putu indraswari aryanti1, joni haryanto2 and elida ulfiana2 1 faculty of nursing, universitas katolik widya mandala surabaya, indonesia 2 faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: recent research has provided data on the efficacy of the massage therapy and the role of essential oil in the management of osteoarthritis (oa) symptoms. although both areas of research have demonstrated strong evidence that the muscles and massage with essential oil may affect oa symptoms, massage with essential oil applied on the quadriceps muscle has received no attention. the purpose of this study was to identify the effect of red ginger massage on joint stiffness and functional disability in elderly with osteoarthritis. methods: this study was a randomized control group pre-test and post-test experimental study design involving 62 elderly with osteoarthritis divided into two groups namely red ginger massage and control groups by random cluster sampling. the instrument used was western ontario and mcmaster universities osteoarthritis index (womac). statistical test used were paired t-test and mancova. results: baseline value of stiffness and functional disability in intervention group were 4.47 ± 1.717 and 35.93 ± 12.806. after 8 weeks stiffness and functional disability became 2.40 ± 1.380 and 19.50 ± 9.420 stiffness and functional disability were decreased on intervention group with p-value 0.000 and 0.004. it means there was influenced by red ginger massage on stiffness and functional disability in elderly with osteoarthritis. conclusion: red ginger massage can be applied as a complementary treatment to help reduced joint stiffness and functional disability in addition to standard drug treatment usage in osteoarthritis disease. article history received: august 3, 2018 accepted: january 7, 2019 keywords chronic disease; elderly; functional disability; osteoarthritis; red ginger massage; stiffness contact putu indraswari aryanti  putu.aryanti@ukwms.ac.id  faculty of nursing, universitas katolik widya mandala surabaya, indonesia cite this as: aryanti, p.i., haryanto, j., & ulfiana, e. (2018).red ginger (zingiber officinale var. rubrum) massage reduces stiffness and functional disability in elderly with osteoarthritis. jurnal ners, 13(2), 200-206. doi:http://dx.doi.org/10.20473/jn.v13i2.9292 introduction osteoarthritis is a progressive chronic disease which affected 178,415 elderly in indonesia (linton, 2012; ministry of health, 2013b). factors causing osteoarthritis are obesity, aging, trauma, genetic predisposition and work (amin, 2015; kruger, khumalo, & nadene, 2017). the prevalence of osteoarthritis was 45% in age 55-64 years old, 51,9% in age 65-74 years old and 54,8% in age more than 75 years old (ministry of health, 2013a). the majority of people with osteoarthritis worked as laborers (31.2%) professions (23.4%), employees (15.4%), self-employed (23.7%) and others (24% ) (ministry of health, 2016). management of osteoarthritis disease usually focuses on reducing pain and joint stiffness in which non-pharmacological treatment became the first priority (amin, 2015; pawanti, untari, & nansy, 2015). the therapy include educating clients about diseases, diet overweight counselling, physical therapy, use of tools and orthotics such as sticks, and surgical procedures (hamijoyo, 2012). if necessary, drug therapy may be administered to clients with osteoarthritis including analgesic drugs such as paracetamol and acetaminophen as first line therapy which is considered to be safest for long-term consumption (amin, 2015; dewanto, 2003). however, if not successful, it will be replaced by non-steroidal anti-inflammatory drugs or nsaids though it has adverse effects on liver and kidney organs (sukandar et al., 2013). the mildest side effects that may arise are nausea, gastric pain and dyspepsia and the most serious is lesions, bleeding https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 201 and perforation of the gastrointestinal tract (hussain & farnaz, 2013). these adverse effects encourage researchers to develop management of osteoarthritis without causing harmful effects to the patient. one of them is the utilization of ginger massage as a complementary treatment option. currently, there has been a trend in indonesian society, especially in urban communities to utilize traditional health services as they prefers a proactive approach for their well-being (hussain & farnaz, 2013; widowati & nurhayati, 2017). one of the alternatives is traditional medicine using herbs, including ginger that has been used in many parts of the world even since antiquity (dhanik, arya, & nand, 2017). red ginger with scientific name zingiber officinale var. rubrum has been used as a remedy in the chinese herbal tradition, ayurveda and tibb-unani (ali, blunden, tanira, & nemmar, 2008). among the benefits of red ginger, the effects of anti-inflammatory and circulatory stimulants are the most important for clients with osteoarthritis (ali et al., 2008). several experimental studies have shown that the gingerol content of red ginger inhibits the synthesis of pro-inflammatory mediators prostaglandin-e4 (pge4) (c. shen, hong, & kim, 2005) and nitric oxide in chondrocytes and leukotriene-b4 (ltb4) in vitro (blumenthal, 2003). in clinical explanations, it may decrease the level of pain and inflammation associated with osteoarthritis (leach & kumar, 2008). part of the ginger plant used is rhizomes, fresh, dried or extracted (dhanik et al., 2017). a study found that the use of moxibustion along with fresh mash ginger at the acupuncture point provides beneficial therapeutic effect for clients with arthritis (xie & lei, 2008). ding, leach, hons, & bradley (2013) mentioned that research on topical ginger application has been done on several different conditions including osteoarthritis and no adverse event being reported. however this review cannot conclude about the effectiveness of topical use of ginger for osteoarthritis. massage is known as the easiest affordable complementary treatment options in the community and has been used for many years due to its effectiveness (ali et al., 2017). massage is defined by fitzgerald & oatis (2004) as passive movements given in order to improve joint movement ability or decrease joint stiffness. massage is useful for supporting circulation and reverse veins, providing neurological effects, modifying muscle physiology in overcoming hypertonicity, spasm and decreasing musculoskeletal pain (green, 2013). field (2016) says that massage can be done to reduce the pain of osteoarthritis joints. the functioning massage generates the meridians, warms the deep ducts, removes the cold, and improves blood circulation, and makes significant improvements to knee function (shen & cui, 2015). aromatic massage with a mixture of orange and ginger essential oils in the elderly with osteoarthritis has been done by bing, chung, & tam (2008) found that massage was able to have a positive effect on the signs and symptoms of osteoarthritis (pain, stiffness and functional disability). atkins & eichler (2013) found that the dose of an effective massage for the elderly with knee osteoarthritis was 8 weeks in 2 sessions each week. additionally, the research conducted by nasiri, azim, & nobakht (2016) showed that the administration of aroma massage with essential oils as much as 3% was able to give positive effect to clients with osteoarthritis. so the combination of the use of massage with the use of red ginger essential oil is expected to give a positive impact on the reduction of stiffness and functional disability clients with osteoarthritis. however, the effect of red ginger massage on stiffness and functional disability in elderly with osteoarthritis has not been proven. respondents’ satisfaction and side effects from giving this massage will be noted. based on these findings, the authors considered that it is necessary to identify the effects of aromatic massage of pure red ginger of signs and symptoms of osteoarthritis. therefore, the purpose of this study was to identify the effect of red ginger massage on joint stiffness and functional disability in elderly with osteoarthritis. materials and methods study design and participants this study was a randomized control group with pre-test and post-test experimental design. single blinding was applied in this study. the research was carried out on a voluntary basis among members of the three public health centers (phc) in surabaya, indonesia. the participants were recruited via a list of elderly with osteoarthritis from each phc. sample size calculation performed based on different proportion of independent sample formula at α = 0.05. it was found that the expected total number of participants was 64 with 32 respondents in intervention and control group however, only 62 respondents can be involved in this study based on inclusion criteria for 4,419 population. the inclusion criteria were those who had knee joint pain over the past month, aged 60 85 years (based on elderly criteria in indonesia), used piroxicam and had good cognitive ability (mmse score 24-30). the participants were excluded if they were those who underwent physiotherapy for knee joint pain, did routine exercise more than once a week, had operated wound in joint and leg area over the past six months, were sufferred from cancer, rheumatoid arthritis, gout or any serious illness and were suffering from contagious skin illness. participants who were eligible and willing to participate in the study were requested to sign a consent form before undergoing treatment. participants were assigned to one of two groups based on their living area. p. i. aryanti et al. 202 | pissn: 1858-3598  eissn: 2502-5791 red ginger massage treatment protocols participants in the intervention group received a session of 20 minutes of red ginger massage on both lower limbs sixteen times within eight weeks. the intervention group received massage with red ginger oil (3.33% red ginger oil in virgin coconut oil). the red ginger essential oil obtained from laboratorium in yogyakarta, indonesia. virgin coconut oil was selected as the base because it was relatively less costly, safe for dry and delicate skins, easy to make and obtain compared to other carrier oils. the control group received no massage but conventional treatment during the study (piroxicam). however, the same massage session was given to the control group after study as a service. the same supply of oils and dilutions were used throughout the study. effleurage and petrissage were applied over the front and side of both legs of the participants. various muscles on the thigh were massaged: quadriceps femoris, gracillis, and biceps femoris. recommended pressure massage between 100118.7 mmhg. the massage treatment was given by a nurse with training in leg aroma-massage. their skill were assessed and evaluated by an experienced masseur. participants in the control group received same massage treatment after eight weeks. outcome measures demographic information of the respondents included age, sex, body mass index, herbal consumption, medicine consumption, long time of osteoarthritis diagnosed, exercise frequency per week, massage habit per 12 month. the primary outcome were knee joint stiffness intensity and physical functioning. they were measured by the western ontario and mcmaster universities osteoarthritis index (womac). it consisted of 19 questions assessed on likert scale, analyzed as 2 subscale with average score 2 questions on stiffness and 17 questions on physical function. some countries that have tested the validity and reliability of these instruments stated that the womac index is a very reliable and valid instrument for evaluating the signs and symptoms of osteoarthritis. womac already translated by the indonesian rheumatology association (ira) into indonesian language. by the every end of treatment completion, the participant were asked about their feedback about the intervention. data collection procedures womac questionnaires and cognitive assessments (mini mental state examination or mmse) were performed by third-year nursing students by face to face interviews. before doing interviews, the nursing students got an explanation and training for massage inform consent, womac and cognitive assessment. in this study, the data collector and all participants were blinded to the group allocation. besides, the nurse who gave the red ginger massage was not involved in the data collection of outcome measurements except the general feedback toward the massage process. data were collected at three time points namely before intervention (baseline assessment), one hour after the completion of treatment at week 8th and one hour after completion of every treatment schedule. data analysis normality checking of the outcome data was examined by the kolmogorov-smirnov test with p > 0.05 indicating that the data were normally distributed and that parametric statistic should be performed. subsequently, we compared the baseline characteristics of participants from the control and intervention group using paired t test and mancova to describe difference between the control and intervention group after 8 weeks intervention. the level of significance was 0.05 (one-tailed) for all test. all of the analyses were completed using spss. ethical clearance this research has been approved by the commission of health research ethics faculty of nursing universitas airlangga no. 685-kepk by date 7th march 2018. results participants socio-demographic and knee pain related characteristic of the 62 participants recruited in this study, 60 (96.7%) participants completed eight weeks intervention consisted of 16 session of red ginger massage. there were 2 drop-outs participant with private reasoned without any concerned with the study. the majority of the 60 participants were women (97.1%), the majority of the age category was 60-74 years (88.3%) and the majority category of bmi was normal. the rate of herb consumption were the same between the treatment and control group at 50%. the majority of the respondents took standard osteoarthritis therapy (piroxicam) once a day (60%). the majority of long time diagnosed of osteoarthritis are less than 1 year (38.3%), the majority of knee pain is left knee (40%), the frequency distribution of exercise per week was the same in the category never and once per week, and the majority of habitual massage in 12 months is 2-4 times (50%) (table 1). table 2 comparison of the mean change in the womac subscale among intervention and control groups from baseline to post an eight weeks. effect on knee stiffness relief and functional disability jurnal ners http://e-journal.unair.ac.id/jners | 203 the decrease of knee joint stiffness in treatment group had p=0.000 while control had p=0.161 after eight weeks. in addition, the difference between the control group and the treatment time over eight weeks was p=0.000. furthermore, the reduction of functional disability in the treatment group had p=0.000 while the control group had p=0.000 over eight weeks. the difference between control group and treatment after eight weeks was p=0.004 (table 2). discussion the analysis in each group found significant decreased in stiffness and functional disability at the post eight weeks after intervention for the intervention group, but not for the control group. these results are consistent with the results of the intervention study of ginger extract and aroma of ginger massage to decrease stiffness and functional disability in participants with osteoarthritis (bing, table 1. demographic characteristics of intervention and control groups at baseline sociodemographic data group intervention (n = 30) frequency (%) control (n = 30) frequency (%) age elderly 60 74 y.o 25 (83.33) 28 (93.33) older elderly 75 90 y.o 5 (16.67) 2 (6.67) sex female 27 (90) 28 (93.33) male 3 (10) 2 (6.67) body mass index (bmi) normal bmi ≥ 18.50 24.99 13 (43.33) 16 (53.33) overweight bmi ≥ 25.00 27.00 10 (33.33) 7 (23.33) obesity bmi ≥ 27.00 7 (23.33) 7 (23.33) herb consumption yes 15 (50) 15 (50) no 15 (50) 15 (50) drug consumption once a day 23 (76.67) 13 (43.33) twice a day 7 (23.33) 17 (56.67) long-time diagnosed with osteoarthritis ≤ one year 11 (36.67) 12 (40) 1 3 years 12 (40) 9 (30) 4 9 years 4 (13.33) 7 (23.33) ≥ ten years 3 (10) 2 (6.67) knee pain site unilateral knee 15 (50) 24 (30) bilateral knee 15 (50) 6 (20) exercise frequency per week never 15 (50) 15 (50) once 15 (50) 15 (50) massage habit per 12 months never 9 (30) 6 (20) once 5 (10) 9 (30) 2-4 times 15 (50) 15 (50) routine 3 (10) 0 table 2. comparison of the mean change in the womac subscale among intervention and control groups from baseline to post an eight weeks womac baseline (mean ± s.d.) post 8 week (mean ± s.d.) within group p-value a stiffness (0-8, ↑ worse) ig 4.47 ± 1.717 2.40 ± 1.380 0.000 cg 4.70 ± 1.601 4.63 ± 1.542 0.161 between-groups p-value b 0.000 function disability (0-68, ↑ worse) ig 35.93 ± 12.806 19.50 ± 9.420 0.000 cg 43.03 ± 10.975 28.33 ± 11.583 0.000 between-groups p-value b 0.004 cg = control group; ig = intervention group; s.d. = standard deviation; womac = western ontario and mcmaster universities osteoarthritis index; a = p-value calculated by paired t test for within group comparison; b = p-value calculated by mancova for between group comparison. p. i. aryanti et al. 204 | pissn: 1858-3598  eissn: 2502-5791 chung, & tam, 2008; masoud, ali, tayebeh, & shohreh, 2005; zakeri, izadi, bari, soltani, & narouie, 2011). it suggests that ginger may be used as an antiinflammatory and analgesic to relieve stiffness in the elderly with osteoarthritis. essential oils contain sesquiterpenoids (such as zingiberene, α-curcumene, β-bisabolene, α-farnesene), monoterpenoids (such as β-sesquiphellandrene and camphene), the phenolic concepts of sharp red ginger (gingerol and shogaol 5-8%) , lechitin, protein, starch (60%), vitamins, minerals and others (b. h. ali et al., 2008; ali hasan, 2012; young et al., 2006). the combination of massage movements was effleurage (circular motion carried out with the palm of the hand), tapotement (hands hit soft tissue with rhythmic rhythms) and friction. based on previous research, these massage movements able to improve physical function of participants with osteoarthritis (atkins & eichler, 2013; bing et al., 2008; juberg et al., 2015). combination of massage and essential oil works synergistically can affects the decrease in stiffness resulting in decreased functional disability. stiffness in osteoarthritis caused by osteophyte formation in the result of an inflammatory process involving leukotrin activation (sowers, karvonengutierrez, jacobson, jiang, & yosef, 2011). therefore using red ginger massage reduces inflammation in the area around the knee joint due to the massage process. in addition it will help reduce symptoms of joint stiffness in osteoarthritis. there were two participants who got the highest stiffness score in the treatment group and did not change after being given a mixture of red ginger for eight weeks. the initial situation in the respondent's joints is definitely not always the same. however, this study did not use radiological criteria in responding to osteoarthritis screening, so the researcher could not ensure whether the osteophytes in the respondent had occurred. based on the analysis result, differences in the functional disability in the control and treatment groups seen in several point of the womac subscale fuctional disability. on point such as the difficulty of participants in doing activities up and down stairs, standing, walking in a flat surface, and shopping. there are quite a number of changes in participant score. that question majority asking about respondent's knee function. in the treatment group that received red ginger massage in this study experienced a decrease in stiffness therefore the function of the quadriceps muscle knee joint to support body weight was better than before receiving the red ginger massage. furthermore on certain questions about the difficulty of respondents to stand up from sitting, bending the floor, getting out of bed, lie down in bed, sit down, heavy household chores and light household chores there are not many changes in value. the majority of the questions asked about whole joint function and were not specific to the knee function of the respondents. participants of red ginger massage intervention did not report any adverse event or allergies regarding the use of red ginger essential oil. therefore, we used the highest concentration of red ginger essential oil of 3%. according to previous study no adverse event reported of using ginger massage (bing et al., 2008; ding, leach, hons, & bradley, 2013). massage belongs to complementary and alternative treatments within the category of manipulative and body based (moquin, blackman, mitty, & flores, 2009). a massage is a form of cutaneous stimulation while the use of red ginger essential oil as anti-inflammatory and enhanced blood circulation in osteoarthritis and as an aromatic that provides a relaxing effect. massages have been shown to reduce pain and improve the health and wellbeing of the elderly as a professionally managed complementary therapy (mcfeeters, pront, cuthbertson, & king, 2016). according to louisiana in sparber (2011), complementary therapies describe the integrative nature of nursing practice and is a vast domain of healing sources that enable nurses to increase supportive or restorative care for life and well-being. conclusion in conclusion, the results of our study showed sixteen red ginger massage sessions using a mixture of red ginger essential oil and virgin coconut oil were able to reduce joint stiffness and functional disability in the elderly with osteoarthritis. no adverse event was reported during the study. therefore, red ginger massage can be recommended as one of the complementary methods for osteoarthritis treatment management. our findings on stiffness found that the initial state of joint stiffness in participants was not the same. several factors such as the inflammatory process and the formation of bone osteophytes also aggravate joint stiffness. however, this study did not use radiological criteria in osteoarthritis screening. thus, we recommend that future study including radiologic criteria in osteoarthritis screening. high concentration of red ginger oil usage, which is 3%, has not been evaluated for the duration of the effect for stiffness relief, expected that further studies needed to find the right dose for stiffness relief. references ali, a., rosenberger, l., weiss, t. r., milak, c., perlman, a. i., haven, n., & ali, a. (2017). massage therapy and quality of life in osteoarthritis of the knee : a qualitative study. pain medicine, 18(november), 1168–1175. https://doi.org/10.1093/pm/pnw217 ali, b. h., blunden, g., tanira, m. o., & nemmar, a. (2008). some phytochemical , pharmacological and toxicological properties of ginger ( zingiber officinale roscoe ): a review of recent research. food and chemical toxicology, 46, 409–420. https://doi.org/10.1016/j.fct.2007.09.085 ali hasan, h. (2012). chemical composition and https://doi.org/10.1093/pm/pnw217 https://doi.org/10.1016/j.fct.2007.09.085 jurnal ners http://e-journal.unair.ac.id/jners | 205 antimicrobial activity of the crude extracts isolated from zingiber officinale by different solvents. pharmaceutica analytica acta, 03(09), 1–6. https://doi.org/10.4172/21532435.1000184 amin, l. z. (2015). osteoartritis. medicinus, 28(2), 53–58. atkins, d. v, & eichler, d. a. (2013). the effects of self-massage on osteoarthritis of the knee : a randomized , controlled trial. international journal of therapeutic massage and bodywork, 6(1), 4–14. badan penelitian dan pengembangan kesehatan. (2013). riset kesehatan dasar. jakarta. bing, y., chung, a., & tam, y. (2008). an experimental study on the effectiveness of massage with aromatic ginger and orange essential oil for moderate-to-severe knee pain among the elderly in hong kong. complementary therapies in medicine, (16), 131—138. https://doi.org/10.1016/j.ctim.2007.12.003 blumenthal, m. (2003). the abc clinical guide to herbs. austin: tx: american botanical council. dewanto, g. (2003). patofisiologi nyeri. majalah kedokteran atmajaya, 3(2), 203. dhanik, j., arya, n., & nand, v. (2017). a review on zingiber officinale. journal of pharmacognosy and phytochemistry, 6(3), 174–184. ding, m., leach, m. j., hons, b. n., & bradley, h. (2013). a systematic review evidence for topical use of ginger. explore: the journal of science and healing, 9(6), 361–364. https://doi.org/10.1016/j.explore.2013.08.001 field, t. (2016). complementary therapies in clinical practice knee osteoarthritis pain in the elderly can be reduced by massage therapy , yoga and tai chi : a review. complementary therapies in clinical practice, 22, 87–92. https://doi.org/10.1016/j.ctcp.2016.01.001 fitzgerald, g. k., & oatis, c. (2004). role of physical therapy in management of knee osteoarthritis. current option in rheumatology, 18, 145. green, p. (2013). greenman’s principles of manual medicine. new york: lippincott williams and wilkins. hamijoyo, l. (2012). pengapuran sendi atau osteoartritis. [online] available at: http://reumatologi.or.id/reujurtail?id=22 (accessed: january 1, 2017). hussain, s., & farnaz, m. (2013). integration of complementary and traditional medicines in public health care systems: challenges and methodology. journal of medical plant research, 7(40), 2952–9. kruger, h., khumalo, v., & nadene, n. (2017). the prevalence of osteoarthritic symptoms of the hands amongst female massage therapists. health sa gesondheid, 22, 184–193. https://doi.org/10.1016/j.hsag.2017.01.006 kementrian kesehatan ri. (2013). gambaran kesehatan lanjut usia di indonesia. in n. abiskusno (ed.), gambaran kesehatan lanjut usia di indonesia (pp. 1–40). kementrian kesehatan ri. kementrian kesehatan ri. (2016). situasi lanjut usia (lansia). jakarta. https://doi.org/issn 2442-7659 leach, m. j., & kumar, s. (2008). the clinical effectiveness of ginger (zingiber officinale) in adults with osteoarthritis. international journal of evidence-based healthcare, 6(3), 311–320. https://doi.org/10.1111/j.17441609.2008.00106.x linton, a. d. (2012). introduction to medical-surgical nursing (5th ed.). missouri: elsevier inc. masoud, h., ali, k. m., tayebeh, t., & shohreh, j. (2005). comparing the effects of ginger (zingiber officinale) extract and ibuprofen on patients with osteoarthritis. archives of iranian medicine, 8(4), 267–271. mcfeeters, s., pront, l., cuthbertson, l., & king, l. (2016). massage, a complementary therapy effectively promoting the health and well‐being of older people in residential care settings: a review of the literature. international journal of older people nursing, 11(4), 266–283. retrieved from https://doi.org/10.1111/opn.12115 moquin, b., blackman, m. r., mitty, e., & flores, s. (2009). complementary and alternative medicine ( cam ). geriatric nursing, 30(3), 196–203. https://doi.org/10.1016/j.gerinurse.2009.03.002 nasiri, a., azim, m., & nobakht, z. (2016). complementary therapies in clinical practice effect of aromatherapy massage with lavender essential oil on pain in patients with osteoarthritis of the knee : a randomized controlled clinical trial. complementary therapies in clinical practice, 25, 75–80. https://doi.org/10.1016/j.ctcp.2016.08.002 pawanti, s., untari, e. k., & nansy, e. (2015). identifikasi obat osteoartritis dan biaya pada pasien geriatri di instalasi rawat jalan rsud sultan syarif mohamad alkadrie kota pontianak. universitas tanjungpura pontianak. ri, k. k. (2013). gambaran kesehatan lanjut usia di indonesia. in n. abiskusno (ed.), gambaran kesehatan lanjut usia di indonesia (pp. 1–40). kementrian kesehatan ri. shen, c., hong, k., & kim, s. (2005). comparative effects of ginger root (zingiber officinale rosc.) on the production of inflammatory mediators in normal and osteoarthrotic sow chondrocytes. j med food, 8(53), 149. shen, x., & cui, y. (2015). progress in traditional chinese and western medicine treatments and nursing care of knee osteoarthritis. chinese nursing research, 2(2–3), 71–74. https://doi.org/10.1016/j.cnre.2015.09.001 sowers, m. f., karvonen-gutierrez, c. a., jacobson, j. a., jiang, y., & yosef, m. (2011). associations of anatomical measures from mri with radiographically defined knee osteoarthritis score, pain, and physical functioning. the journal of bone & joint surgery, 93–a(3), 241–251. https://doi.org/10.2106/jbjs.i.00667 https://doi.org/10.4172/2153-2435.1000184 https://doi.org/10.4172/2153-2435.1000184 https://doi.org/10.1016/j.ctim.2007.12.003 https://doi.org/10.1016/j.explore.2013.08.001 https://doi.org/10.1016/j.ctcp.2016.01.001 http://reumatologi.or.id/reujurtail?id=22 https://doi.org/10.1016/j.hsag.2017.01.006 https://doi.org/10.1111/j.1744-1609.2008.00106.x https://doi.org/10.1111/j.1744-1609.2008.00106.x https://doi.org/10.1111/opn.12115 https://doi.org/10.1016/j.gerinurse.2009.03.002 https://doi.org/10.1016/j.ctcp.2016.08.002 https://doi.org/10.1016/j.cnre.2015.09.001 https://doi.org/10.2106/jbjs.i.00667 p. i. aryanti et al. 206 | pissn: 1858-3598  eissn: 2502-5791 sukandar, e. y., andrajati, r., sigit, j. i., adnyana, i. k., setiadi, a. a. p., & kusnandar. (2013). iso farmakoterapi. jakarta: pt. isfi penerbitan. widowati, l., & nurhayati. (2017). the use of traditional health care among indonesian family. health science journal of indonesia, 8(1), 30–35. young, h. ., liao, j. c., chang, y. s., luo, y. l., lu, m. c., & peng, w. h. (2006). synergistic effect of ginger and nifedipine on human platelet aggregation: a study in hypertensive patients and normal volunteers. am j chin med, 34(4), 545–551. https://doi.org/10.1142/s0192415x06004089 zakeri, z., izadi, s., bari, z., soltani, f., & narouie, b. (2011). evaluating the effects of ginger extract on knee pain , stiffness and difficulty in patients with knee osteoarthritis. journal of medicinal plants research, 5(15), 3375–3379. https://doi.org/10.1142/s0192415x06004089 212 improving nursing work services through development model of quality of nursing work life tri ismu pujiyanto*, suprihati suprihati**, nursalam nursalam***, anastasia ediyati** *stikes karya husada semarang, indonesia **diponegoro university, indonesia *** faculty of nursing, universitas airlangga, indonesia email: triismu@yahoo.co.id abstract introduction: the performance of nurses in a hospital is influenced by the mental and emotional state of the nurse; the higher the workload, the greater the work stress of the nurse. it is a necessity to conduct research to explain a quality of nursing work life model based on the context of indonesian nurses. methods: the research process consisted of two stages: observational analytic and model trial. the first phase used cross-sectional design with cluster random sampling technique and obtained 102 samples. the second stage used a quasi-experiment design with pre-post test with control group design and obtained 33 samples. the data was analysed by partial least squares and paired t-test analysis. results: it was found that the number of the nurses with burnout syndrome in the hospital was 67.6%. the depersonalisation indicator in the low category was 73.5%, and the high category of self-achievement indicators had 89.2%. conclusions: it can be concluded that improving the performance of care services is more effective through improving the quality of nursing work life. this study found that the nurses’ quality of life affected the increased nursing work service because their working scope involves interacting with other professions and the environment. keywords: quality of nursing work life model, burnout syndrome, self-achievement introduction the performance of nurses in a hospital is influenced by the mental and emotional state of the nurse; the higher the workload, the greater the work stress of the nurse. burnout syndrome is a manifestation of high stress in working; this term refers to the syndrome of prolonged stress that occurs in the workplace where the result is a combination of workers and their work (papalia, olds and feldman, 2007). based on the research of cañadas-de la fuente et al. (2015), the prevalence of burnout syndrome in from a mental fatigue aspect was 25% on the emotional fatigue dimension, 30% in the dimension of depersonalisation and 45% in the self-achievement dimension. indonesia ministry of health conducted a survey which found that 10% of patients felt dissatisfied with health services in hospitals (dinas kesehatan propinsi jawa tengah, 2012). according to ministerial decree no. 129 year 2008 on hospital minimum service standards, inpatient satisfaction standard was ≥ 90%, or patient dissatisfaction standard was ≤ 10% (abdurrouf, nursalam and purwaningsih, 2013). another research from suharti and daulima (2013) presented their research result in metropolitan jakarta hospital, in which most of the nurses had moderate (86.7%) and high (3.6%) burnout syndrome. based on the preliminary study held at one of regional public hospitals of semarang it was found that, from 20 nurses, there were eight experiencing burnout syndrome. this shows that the incidence rate of burnout syndrome in this hospital was about 40% out of 20 sample nurses. the prevalence of burnout syndrome was almost the same in most hospitals (de paiva et al., 2016); this is due to the high demand of hospitals to nurses to work according to the best standards, which requires great physical and psychological activity from nurses in giving nursing care. the nursing profession as an integral part of the healthcare system is a critical factor in the success of health services in general and the key to the success of hospital services in particular. nursing services still need many innovations, such as medical services to increase patient satisfaction as a consumer (nursalam, 2014). morsy and sabra (2015)said that 66.7% of nurses had experienced job dissatisfaction, which was influenced by organisational culture factors, nurse job characteristics, nursing work quality and burnout syndrome. burnout syndrome is a dominant factor in decreasing service performance in hospitals (gilbert khosa et al., 2014; khamisa et al., 2015; thulth and sayej, 2015). the low quality of nursing service can be caused by many factors, such as quality of nursing work life and burnout syndrome (manwatkar and mathew, 2016). a study of (suresh, 2013) conducted in several hospitals in india found that 48% of nurses had a bad jurnal ners vol. 12 no. 2 oktober 2017: 212-218 212 qnwl (quality nursing work life). khamisa et al. (2015) in africa, found nurses with emotional exhaustion contributed to 14% of treatment while emotional exhaustion and depersonalisation contributed 31% in reducing the performance of nursing service in the hospital. according to previous research by momeni et al. (2016) regarding quality of nursing work life in mazandaran, iran scored 27,2% of quality of nursing work life as low, 61.7% was categorised as average, and 6.7% had good quality of nursing work life. this situation shows that most of the quality of nursing work life is low, which can be an indicator of stress for nurses that work in the hospital. mark and smith (2012) stated that many factors cause stress in nurses, such as a conflict with a doctor, discrimination, over workload, handling many patients, patients’ death and problem with patients’ families. beh (2016) held a research about stress impact on nurses which showed that 52% resulted in headache, 43% caused anger, 38% caused fatigue, 38% caused low interpersonal interaction and 24% caused low concentration. on the other hand, nishitani, sakakibara and akiyama (2013) concluded that lack of sleep was one of the causes of depression for employees and anxiety syndrome for employees. efforts to reduce stress in nurses can be made through reforming the quality of nursing work life. a study by borhani et al. (2016) in teheran, iran, concluded that the reforming of quality of nursing work life can improve the nursing service that is given to patients and the quality of nursing work life can increase nurses’ role towards organisation of the nursing profession. the previous research shows the quality of nursing work life has positive impact and significance toward nursing work (manwatkar and mathew, 2016). meanwhile, borhani et al., (2016) concluded that the improvement of medical service in hospitals can be started from moral improvement and learning through the environment around the hospital. based on the description of the background above, it is necessary to develop a quality of nursing work life in accordance with the condition of nurses in indonesia. the development of this model will be a solution in reducing the level of nurse stressors in indonesia in providing therapeutic care in hospitals. materials and methods the research process consisted of two stages, the first was observational analytic research and the second was a quality of nursing work life model. the first phase used cross-sectional design with cluster random sampling technique. the sample population were 102 samples. the variables in this research were analysed by using structural equation modelling (sem), in such a way that the minimum samples needed were 100 – 150 subjects. the number of samples for the first research had six variables, so this research needed 17 indicators with six variables, which was equal to 102 samples. there were two variables in this research, exogenous and endogenous. the exogenous variable consists of organisational culture, nurse factors, job characteristics, and quality of nursing work life. meanwhile, endogenous consists of burnout syndrome and nursing service. the data analysis used univariate analysis and then analysed using pls (partial least square). pls is an indeterminacy factor of powerful analytical methods used to confirm the theory (ghozali, 2014). the second stage used a quasiexperiment design with pre-posttest with control group design. the method used in the intervention was a structural model which emphasised the process of socialisation, externalisation, combination and internalisation. the provision of interventions used modules. the number of samples was calculated based on sastroasmoro and ismael (2011) formula and obtained 33 samples then performed simple random sampling. data analysis used univariate analysis and bivariate analysis (paired t-test). data collection used questionnaires that contained questions according to the research variables. the study was conducted at the dr. adhyatama, mph regional public hospital of semarang in the surgical wards and paediatric wards around july september 2017. this research passed the ethical clearance conducted at faculty of medicine diponegoro university and was registered with number 454/ec/fk-rsdk/vii/2017. the researcher asked consent from improving nursing work services through ... (tri ismu pujiyanto et.al.) 213 respondents upon their agreement to participate on this study. results table 1 shows that the mean age of nurses is 32.76 years, which belong to the productive age. based on the educational status it was found that the largest percentage is nurses with a bachelor degree, or 54.9% while the lowest educational background is a master degree (1%). this situation indicates that most qualifications are bachelor degree, which is appropriately matched with the standard. marital status of respondents was mostly married (79.4%) table 2 shows the lowest organisational culture is the success criteria with the low category of 15.7% and the mean is 2.28. success criteria are an indicator of self-achievement for nurses. in addition to the success criteria, the organisational factors that are still low are the orientation of the organization, with 31.4% and an average of 2.42. this is followed by strategy emphasis indicator, which is equal with 33.3%, and 31.4% organisational orientation. organisational culture of nurses’ indicator of closeness of good category organisation showed a percentage of 75.5% with mean 2.63. table 3 shows that the characteristics of nurses on the medium criterion indicator is 49.0% with mean 3.67, while the mental indicator model in the good category has a percentage equal to 91.2% with mean 4.26. the mental model is an assumption held by every individual and organisation that can determine how to act. table 4 shows the indicator of job variation with the low criterion of 27.5% with the mean of 0.61, while the job feedback indicator on the good criterion is 42.2%. task table 1. demographic characteristic of the respondents characteristic of the nurse n % age 102 32.76±5.9 (mean & sd) education vocational degree bachelor degree master degree doctoral degree 45 56 1 0 44.1 54.9 1,0 0 marital status single married widower 18 81 3 17.6 79.4 2.9 table 2. distribution of organisational culture organisational culture criteria total (%) mean score good (%) moderate (%) bad (%) organisational orientation 66 (64.7) 32 (31.4) 4 (3.9) 102 (100) 2.42 1-3 organisational leadership 71 (69.6) 18 (17.6) 13 (12.7) 102 (100) 2.49 1-3 management of staff 55 (53.9) 35 (34.3) 12 (11.8) 102 (100) 2.46 1-3 organizational closeness 77 (75.5) 22 (21.6) 3 (2.9) 102 (100) 2.63 1-3 strategy emphasis 62 (60.8) 34 (33.3) 6 (5.9) 102 (100) 2.43 1-3 success criteria 51 (50.0) 35 (34.3) 16 (15.7) 102 (100) 2.28 1-3 table 3. distribution characteristics of nurses. characteristics of the nurse criteria total (%) mean score good (%) moderate (%) bad (%) commitment 82 (80.4) 20 (19.6) 0 (0.0) 102 (100) 3.88 1-5 mental model 93 (91.2) 6 (5.9) 3 (2.9) 102 (100) 4.26 1-5 motivation 81 (79.4) 21 (20.6) 0 (0.0) 102 (100) 3.94 1-5 attitude 52 (51.0) 50 (49.0) 0 (0.0) 102 (100) 3.67 1-5 table 4. distribution of job characteristics of nurses. job characteristics criteria total (%) mean score good (%) moderate (%) bad (%) work feedback 43 (42.2) 46 (45.1) 13 (12.7) 102 (100) 0.76 0-1 task variety 11 (10.8) 63 (61.8) 28 (27.5) 102 (100) 0.61 0-1 jurnal ners vol. 12 no. 2 oktober 2017: 212-218 214 variations include discussion with peers, seminars, workshops or continuing education. table 5 shows that the burnout syndrome among nurses with the indicator of low emotional fatigue category is 67.6% with the mean of 1.64. emotional fatigue is characterized by physical, mental or emotional fatigue that lasts for a long time. the depersonalisation indicator in the low category was 73.5% with an average of 1.24, characterised by less sensitivity or less care towards the patient and a tendency to withdraw from the work environment. the highest category of self-achievement indicators has a value of 89.2%, which includes feelings of helplessness, disrespect and feeling the tasks imposed on the official are too great. table 6 shows that service performance applied to the nursing care standard indicator is 99.0% with 4.54 average, as well as 100% professional performance standard with a mean of 4.52. based on the model analysis results obtained it shows that the organisational culture affects qnwl. characteristics of nurses significantly affect qnwl and qnwl significantly affects service performance. based on the model results, it can be concluded that improving the performance of care services can be done more effectively through qnwl. discussion the relationship of organisational culture to the performance of nurses in this study, the researcher found that there is a significant correlation between organisational culture and nurse performance. this situation can be caused by organisational culture that can cause changes in work rhythm, especially for nurses. the existence of a new policy can affect the work patterns of the hospital, such as leadership and system changes. in this study, the hospital that was chosen was a government hospital, so that service performance that is often perceived by society is lower than when compared with private hospitals. one fundamental difference is that the existing systems in government hospitals are different from those in private hospitals as well as there being different financing systems between government hospitals and private hospitals. this situation causes the service performance between public hospitals and private hospitals to be different. the results of this study are in line with previous research conducted by (sharma and kamra, 2013) the results of this study are in line with the opinion from qaisar, rehman and suffyan (2012) which states that organisational commitment among employees is an important aspect, as a result of which they perform better. low commitment can table 5. distribution of burnout syndrome nursing work service criteria total (%) mean score high (%) medium (%) low (%) emotional fatigue 2 (2.0) 31 (30.4) 69 (67.6) 102 (100) 1.64 0-6 depersonalisation 3 (2.9) 24 (23.5) 75 (73.5) 102 (100) 1.24 0-6 self-achievement 91 (89.2) 9 (8.8) 2 (2.0) 102 (100) 5.19 0-6 table 6. distribution of service performance service performance criteria total (%) mean score good (%) moderate (%) low (%) nursing care standard 101 (99.0) 1 (1.0) 0 (0.0) 102 (100) 4.54 1-5 professional performance standard 102 (100) 0 (0.0) 0 (0.0) 102 (100) 4.52 1-5 nursing satisfaction 31 (30.4) 69 (67.6) 2 (2.0) 102 (100) 3.43 1-5 table 7. results of the model development of the working quality model of nurses’ work (qnwl) on increased nursing work service at the hospital relationship between variables coefficient information organisational culture with qnwl 0.55 significant characteristics of the nurse with qnwl 0.33 significant qnwl with nurse performance -1.07 significant improving nursing work services through ... (tri ismu pujiyanto et.al.) 215 lead to poor service performance (hamdi and rajablu, 2012). nurses are human resources who participate in colouring health services in hospitals. therefore, nursing service has a contribution to this. relationship between characteristics of nurses and the quality of life of nurses’ work there is a significant correlation between nurses’ characteristics with the quality of work life of nurses. this situation can be caused by the emotional and spiritual circumstances of the nurse that affect the pattern of nurse perception in performing hospital care services. nursing work perceived as a burden is a source of stressor for the nurse, so that it impacts the pattern of life of nurses in the family and society. changes in life patterns can be seen from the attitude and behaviour of nurses in everyday life at home. nursing behaviour patterns in running care services can easily make nurses being emotional. changes in the work design are important for nurses to improve the quality of care that is provided for patients. according to previous research by nursalam (2012), design of the nursing work can be done principally in the efficiency of the work, so that the nursing service process does not cause a stressor. the efficiency of job design can be done with work shift management for nurses, work-off systems and reward systems. motivation of nurses in running the service can be a factor that affects the state of nurses’ life. motivation is an important factor for nurses in providing patient care services. previous research by faraji khiavi et al. (2015) states that the low motivation of nurses can cause low performance in the hospital. relationship of nurse characteristics with nurse performance based on the results of the analysis, it is found that the characteristic of nurses that most significantly affects the quality of working life is home dimension. based on the results of the analysis it is found that the most significant nurse characteristics affecting burnout syndrome is self-actualisation according to the results of the study, it is found that there is a relationship between job characteristics and the quality of life of nurses in hospitals. this situation can be caused by a variety of complex tasks imposed on the nurse and it is shown by the percentage of moderate to low category variation categories. the state of task variation can cause the nurses to experience fatigue in working, so that some aspects of the life needs of nurses is cyclically changed, such as time with family because, when they are in family time, they are still doing the task. this circumstance leads to changes in the quality of life of nurses. konstantinos and christina (2008) concluded that the characteristic factors of nurses related to job satisfaction include the characteristics of the organisation, relationship with staff and patient care related to work stress. collaboration between nurses and physicians is significantly related to work stress and a significant relation to job satisfaction. collaboration between nurses’ colleagues relates significantly to leadership and job satisfaction. thus, leadership is related to nurse job satisfaction. konstantinos and christina (2008) emphasise that the interaction aspects between individual circumstances (nurses), the environment of the nurse and the circumstances influence nurses’ work. individual circumstances include the characteristic state of the nurse, such as age, length of work, education, marital status and income. conditions associated with the organisation include leadership, nurse workload and issues related to the nursing organisation. environmental circumstances of the nurse include interaction between patient and nurse, interaction between nurse and doctor and nurse authority in providing care services. characteristics of nurses in burnout syndrome based on the results of research found that there is a significant relationship between job characteristics with burnout syndrome. this situation can be caused by a variety of tasks and the impact of the job as the source of stressor for nurses, which can be seen from the work of nurses which requires performing a comprehensive job regarding the patient. job feedback has an impact on the emotional and spiritual state of the nurse, which can be reflected in the results of this study, indicating the low attitudes and commitment of nurses in running care services. the nurse profession is central to the service centre given to the patient, so that the patient is concerned with the services provided jurnal ners vol. 12 no. 2 oktober 2017: 212-218 216 by the nurse to the patient. nursalam (2014) mentions that the main role of nurse professionals is to provide nursing care to the patient (as the main object of study of nursing philosophy, which includes: 1) paying attention to the individual in the context of the life and needs of the client; 2) nurses use the nursing process to identify nursing problems, including physical, psychological, social and spiritual examinations; 3) providing nursing care to clients (clients, families and communities) ranging from simple to complex. the complex role of a nursing and the holistic demands of service lead to an emotional change in the nurse. this situation is supported by the results of research that show the low attitudes of nurses to the service, so that the nurse is experiencing a distressed perception in running the service in the hospital. perception of pressure when working is the cause of burnout syndrome in nurses. characteristics of work with the performance of nurses the results show that job characteristics significantly affect the performance of nurses. this situation can be caused by a heavy burden of duty for the nurse and high task variations, which lead to burnout conditions, thereby degrading the quality of nursing work. the quality of nursing work is decreased due to fatigue experienced by nurses. the results of this study are in line with research by khamisa, peltzer and oldenburg (2013) which states that the impact of burnout syndrome can affect the health of the nurses themselves. the circumstances of burnout can be caused by the long-lasting state of stress experienced by nurse, so that burnout syndrome occurs. khamisa, peltzer and oldenburg (2013) mention that the cause of burnout syndrome in heavy workload has an impact of health itself. work-related stress can affect job satisfaction. the stressful state of work that lasts long will disrupt the health of nurses. factors associated with the health condition of nurses include the stress experienced by nurses, which affects the nursing work condition in the provision of services to the patient. the nurse's stress condition leads to a decrease in job satisfaction, which affects the health condition of the nurse in general. the relationship between nurse's quality of life and the performance of the nurse based on the results of the study it is found that nurses’ quality of life significantly affects the performance of services. circumstances can be caused by a nurse's work system, which always interacts with other professions and patients who change each day, causing the need for emotional skill in adapting to new circumstances. this situation causes pressure in the work so that it has an effect on the output of services provided by the nurse. the nursing profession is a fundamental profession in patient care in hospitals, so the quality of service in the hospital rests on providing services provided by nurses to patients. several previous researches conducted by borhani et al. (2016) in tehran, iran, concluded that improving the nurses’ quality of work life can improve the service performance provided by nurses to patients in the hospital. a study of sirin and sokmen (2015) in turkey mentioned there are five indicators used in measuring the quality of work life of a nurse; they are work environment, relationship with manager, job condition, job perception and service support. horrigan et al. (2013) state that quality of work life reveals the importance of respect for humans in their work environment. thus, the important role of quality of work life is to change the organisational climate in order to technically and humanely bring about a better quality of work life. quality of work life formulates every policy process decided by a company in response to what their employees desire and expect. the environmental factors of nurse work are important factors that influence the nurse's service to the patient. kivimäki et al. (2008) state that the nurses’ work environment factors include the physical environment in the workplace, home and various work rules that shape the atmosphere and working spirit of nurses that are implicated in performance. meanwhile, horrigan et al., (2013) stated that positive nursing work quality can support high-quality patient care and contribute to the continuation of the healthcare system. conclusions the quality of nursing work life model in accordance with the condition of indonesian improving nursing work services through ... (tri ismu pujiyanto et.al.) 217 nurses is influenced by organisational culture, nurse characteristics, job characteristics and efficient nursing life quality. it can be concluded that improving the performance of care services is more effective through the quality of nursing work life and in reducing the state of increased nursing work service among nurses is more effective through qnwl. the study found that the nurses’ quality of life affects the incidence of increasing nursing work service, because their working scope involves interacting with other professions and the environment. the benefit of intervention in quality of nursing work life is to improve understanding in working, so that it can encourage the learning process. the typical indonesian nurse qnwl model needs to be tested on other nurse work environments, so it can correct the possibility of imperfections in this research data. in addition, testing is required in the application of interventions to prevent burnout syndrome in nurses based on this model. references abdurrouf, m., nursalam and purwaningsih (2013) ‘islamic caring model on increase patient satisfaction’, jurnal ners, 8(1), pp. 153–164. doi: http://dx.doi.org/10.20473/jn.v8i1.3893. beh, l.-s. (2016) ‘job stress and coping mechanisms among nursing staff in public health services leap-han loo’, international journal of academic research in business and social sciences, 6(5), pp. 131–176. doi: 10.6007/ijarbss/v6-i5/2164. borhani, f. et al. (2016) ‘assessment of predictable productivity of nurses working in kerman university of medical sciences’ teaching hospitals via the dimensions of quality of work life’, global journal of health science, 8(10), p. 65. doi: 10.5539/gjhs.v8n10p65. cañadas-de la fuente, g. a. et al. (2015) ‘risk factors and prevalence of burnout syndrome in the nursing profession’, international journal of nursing studies, 52(1), pp. 240–249. doi: 10.1016/j.ijnurstu.2014.07.001. dinas kesehatan propinsi jawa tengah (2012) ‘buku profil kesehatan provinsi jawa tengah tahun 2012’, buku profil kesehatan provinsi jawa tengah tahun 2012, 3511351(24), pp. 1–118. faraji khiavi, f. et al. (2015) ‘effect of final evaluation on job motivation from the perspective of nurses in ahvaz hospitals in 2012.’, journal of medicine and life. carol davila university press, 8(spec iss 4), pp. 209–213. available at: http://www.ncbi.nlm.nih.gov/pubmed/2 8316733 (accessed: 18 november 2017). ghozali, i. (2014) partial least squares konsep, metode dan aplikasi menggunakan porgram warp pls 4.0. semarang: badan penerbit universitas diponegoro. gilbert khosa, m. et al. (2014) ‘impact of occupational stress and burnout on employee job performance: a study of nurses in rural clinics of bushbuckridge in mpumalanga province’, international journal of innovative research in management issn, 1(1), pp. 2319–6912. hamdi, s. and rajablu, m. (2012) ‘effect of supervisor-subordinate communication and leadership style on organizational commitment of nurses in health care setting’, international journal of business and management, 7(23), pp. 7–18. doi: 10.5539/ijbm.v7n23p7. horrigan, j. m. et al. (2013) ‘evaluating and improving nurses’ health and quality of work life’, workplace health & safety. sage publicationssage ca: los angeles, ca, 61(4), pp. 173–181. doi: 10.1177/216507991306100405. khamisa, n. et al. (2015) ‘work related stress, burnout, job satisfaction and general health of nurses’, international journal of environmental research and public health, 12(1), pp. 652–666. doi: 10.3390/ijerph120100652. khamisa, n., peltzer, k. and oldenburg, b. (2013) ‘burnout in relation to specific contributing factors and health outcomes among nurses: a systematic review’, international journal of environmental research and public health, 10(6), pp. 2214–2240. doi: 10.3390/ijerph10062214. kivimäki, m. et al. (2008) ‘job strain and ischaemic disease: does the inclusion of older employees in the cohort dilute the jurnal ners vol. 12 no. 2 oktober 2017: 212-218 218 association? the wolf stockholm study’, journal of epidemiology and community health, 62(4), p. 372 lp374. available at: http://jech.bmj.com/content/62/4/372.ab stract. konstantinos, n. and christina, o. (2008) ‘factors influencing stress and job satisfaction on nurses working in psychiatric unit: a research review’, heath science journal, 4, pp. 183–195. manwatkar, s. and mathew, s. (2016) ‘a study to assess the effectiveness of self instructional module among staff nurses regarding stress management in selected hospitals of the city’, iosr journal of nursing and health science, 5(4), pp. 01–03. doi: 10.9790/1959-0504050103. mark, g. and smith, a. p. (2012) ‘occupational stress, job characteristics, coping, and the mental health of nurses’, british journal of health psychology. blackwell publishing ltd, 17(3), pp. 505–521. doi: 10.1111/j.20448287.2011.02051.x. momeni, b. et al. (2016) ‘the relationship between the quality of work life and sleep in nurses at the intensive care units of teaching hospitals in mazandaran, iran’, mazujnms. department of medical-surgical nursing, nasibeh nursing & midwifery faculty, mazandaran university of medical sciences, sari, iran kw intensive care unit (icu) kw nurse kw quality of work life kw sleep quality, 3(1), pp. 28–34. doi: 10.18869/acadpub.jnms.3.1.28. morsy, s. m. and sabra, h. e. (2015) ‘relation between quality of work life and nurses job satisfaction at assiut university hospitals’, al-azhar assiut medical journal, 13(1). available at: http://www.aamj.eg.net/journals/pdf/234 6.pdf (accessed: 18 november 2017). nishitani, n., sakakibara, h. and akiyama, i. (2013) ‘short sleeping time and job stress in japanese white-collar workers’, the open sleep journal, 6(1), pp. 104–109. doi: 10.2174/1874620901306010104. nursalam (2012) keperawatan manajemen aplikasi dalam praktek keperawatan profesional. jakarta: salemba medika. nursalam (2014) metode penelitian ilmu keperawatan: pendekatan praktis. 3rd edn. jakarta: salemba medika. de paiva, l. c. et al. (2016) ‘risk factors identification for burnout syndrome in nurses’, international archives of medicine, pp. 1–7. doi: 10.3823/2199. papalia, d. e., olds, s. w. and feldman, r. d. (2007) human development. 10th edn. new york: mcgraw hill. qaisar, m. u., rehman, m. s. and suffyan, m. (2012) ‘exploring effects of organizational commitment on employee performance : implications for human resource strategy’, interdisciplinary journal of contemporary reserach in business, 3(2000), pp. 248–255. sastroasmoro, s. and ismael, s. (2011) dasardasar metodologi penelitian klinis. jakarta: binarupa aksara. sharma, s. and kamra, p. (2013) ‘patient satisfaction with nursing care in public and private hospitals’, nursing and midwifery research journal, 9(3), p. 130. sirin, m. and sokmen, s. m. (2015) ‘quality of nursing work life scale: the psychometric evaluation of the turkish version’, international journal of caring sciences, 8(3), pp. 543–554. available at: www.internationaljournalofcaringscienc es.org (accessed: 17 november 2017). suharti, n. and daulima, n. (2013) burnout dengan kinerja perawat di rumah sakit metropolitan medical centre jakarta. universitas indonesia. suresh, d. (2013) quality of nursing work life among nurses working in selected government and private hospitals in thiruvananthapuram. sree chitra tirunal institute for medical sciences & technology. available at: http://dspace.sctimst.ac.in/jspui/bitstrea m/123456789/2265/1/6282.pdf. thulth, a. s. and sayej, s. (2015) ‘selected organizational factors affecting performance of professional nurses in north west bank governmental hospitals’, 6(7), pp. 100–110. 150 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.7836 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the effectiveness of roy’s adaptation model for patients with chronic kidney disease undergoing pre-dialysis in indonesia tri hapsari retno agustiyowati1, ratna sitorus2, agung waluyo2 and besral besral3 1 politeknik kesehatan bandung, west java, indonesia 2 department of medical surgical nursing, faculty of nursing, universitas indonesia, indonesia 3 faculty of public health, universitas indonesia, indonesia abstract introduction: patients with chronic kidney disease (ckd) undergoing predialysis requires a good self-management to control low protein intake and maintain kidney function. adaptation to the existing stimulus through coping and adjustment mechanisms is important to maintaining good kidney function. however, few studies applied nursing theory based to guide intervention in helping the adaptation of patient ckd with their condition. the purpose of this study is to evaluate the effectiveness of roy’s adaptation model towards physiological and psychological adaptation response among patients with ckd undergoing pre-dialysis. methods: this study was conducted using a quasi-experiment to patients with ckd pre-dialysis, age over 18 years old. we modified roy’s adaptation model for patients with ckd undergoing pre-dialysis. results: a total of 70 subjects agreed to join the study, 38 subjects in intervention and 32 subjects in the control group. the mean of egfr ranged from 26.3 to 26.6 ml/min/1.73 m2. we found that roy’s adaptation model has significantly improved drinking behavior, reduce protein intake, blood creatinine, and psychosocial adaptation response after the intervention. conclusion: these study findings suggested that roy’s adaptation model is effective to help patients with ckd undergoing pre-dialysis improve their behavior and maintain kidneyfunction . model dissemination, advocacy to related units, and application in nursing care in patients with chronic kidney disease pre-dialysis are necessary. article history received: march 12, 2018 accepted: november 05, 2018 keywords chronic kidney disease; predialysis; physiological adaptation response; psychological adaptation behavior; roy’s adaptation model contact tri hapsari retno agustiyowati  trihapsariretno60@gmail.com  politeknik kesehatan bandung, west java, indonesia cite this as: agustiyowati, thr ., sitorus, r., waluyo, a ., & besral, b. (2018). the effectiveness of roy’s adaptation model for patients with chronic kidney disease undergoing pre-dialysis in indonesia. jurnal ners, 13(2), 150-155. doi:http://dx.doi.org/10.20473/jn.v13i2.7836 introduction chronic kidney disease (ckd) is defined as kidney damage over three months with glomerulus filtration rate (gfr) less than 60 ml/minute/1.73 m2 that consists of five stages (black and hawk, 2005; wein, kanvoussi, novick, partin, peters, 2007; thomas, 2008). patients with ckd recommend to perform hemodialysis if they are in stage 5 and predialysis for those in stage 3 or 4 (kdoqi guidelines, 2000; wein, kanvoussi, novick, partin and peters, 2007; daugirdas, blake and ing, 2007; ignatavicius, 2010). according to the data from indonesian nephrology association in 2011, it’s estimated about 25 million indonesian people had an impairment of kidney function. the indonesian hospital association (persi) reported that 500 per one million people diagnosed with chronic kidney disease and 60% of them were adults and older age. furthermore, according to the indonesian national health insurance data, around 70,000 patients with kidney disease required a dialysis, only 12,804 of them already perform a hemodialysis, and above 30,000 patients is recommended to do pre-dialysis. roy's adaptation model is one of the nursing theories focused on human adaptation based onstimulus from the internal and external environment. it is involved a processed that regulate by subsystem and cognitive as an adaptive system, in the form of physiology function, self-concept, role function, and interdependence (roy, 1991; tomey and alligood, 2006, meleis, 2007). roy considers the https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:trihapsariretno60@gmail.com http://dx.doi.org/10.20473/jn.v13i2.7836 jurnal ners http://e-journal.unair.ac.id/jners | 151 patient has adaptability in overcoming the problem, as a living system, open, and able to adjust. the adjustment made due to changes in elements, substances or materials contained in the environment. as a system, human beings are a unity, will get input from the inside and outside environment, namely focal, contextual and residual stimuli (roy, 1991; tomey and alligood, 2006; meleis, 2007). the role of nurses based on roy's theory is required to assess the adaptability of patients and help them adapt with changes due to the disease and its consequences (roy, 1991; tomey and alligood, 2006). previous studies have reported that roy's adaptation model can be used as a research framework to improve human behavior adaptation. a review of ten studies evaluated roy's adaptation model as a research framework in various research designs suggested that this model was effective to explore the human adaptation (sosha and al kaladeh, 2012). rogers and keller (2010) applied roy's adaptation model to develop physical activities program and showed improvement in the adaptation of physical strength and endurance. furthermore, roy's adaptation model used as a framework for developing intervention programs in patients performed intravenous catheter insertion found a positive adaptation response (wendler, 2002). among patients with ckd undergoing hemodialysis, roy's adaptation model used to develop health education program and showed a significant result in the improvement of physiological and role functions (afrasiabifar, karimi, and hassani, 2013). patients with ckd undergoing pre-dialysis requires good self-management to control low protein intake and maintain their kidney function (kresnawan & maskun, 2012; hase, 2012; branson, 2007). they are required to have the ability to adapt change, to the situation or negative stimulus to maintain the function of the kidney. a study conducted by fougue (2007) found that wellcontrolled protein intake can reduce the mortality rate and delayed initiation of dialysis up to 40%. maintaining good kidney function can be done by adapting to the existing stimulus through coping and adjustment mechanisms. however, few studies applied nursing theory to guide intervention to help patients with ckd undergoing pre-dialysis to adjust their condition. the purpose of this study was to evaluate the effectiveness of the developed roy's adaptation model for improving physiological and psychological adaptation response. materials and methods this study was conducted using quasiexsperimental, pre post test design with the control group. three referral hospitals in indonesia were used to develop intervention and measure outcome from june to december 2016. the outcome measures were assessed at baseline (pre-test), after intervention (post-test), and one month follow up. the inclusion criteria were patients diagnosed with ckd undergoing pre-dialysis phase ii and iv, conscious, without severe complication, and able to speak without cognitive and mentally disordered. a consecutive sampling was applied to select participants. a total of 70 patients with ckd predialysis were recruited, 38 in the intervention group and 32 in the control group. the intervention was modified according to roy’s adaptation theory for patients with ckd undergoing pre-dialysis developed by the author (agustiyowati et al, 2017). this intervention focus on providing comprehensive health education program which consists of seven steps (figure 1). the first step is to identify potential stimulus, including physical, psychological, and social, then created a goal setting together with the patients. the second step is a health education program to improve coping mechanism by understanding the disease, how to maintain health condition, and importance of a routine check-up and adherence to medication. the third step is focused on improving physiological adaptation behavior by providing health education related to food, diet, drinking pattern, urinate pattern, itchy management, and activities daily living. the fourth step is managed behavior adaptation of self-concept. the fifth step is to improve the behavior adaptation of role function. the sixth step is to improve interdependence adaptation behavior. the last step is to create and improve a family support for the patients. health education was performed for the patients and family in three sections, eight days for each figure 1. the developed roy’s adaptation behavior model for patients with ckd undergoing predialysis thr agustiyowati et al. 152 | pissn: 1858-3598  eissn: 2502-5791 table 1. demographic and clinical characteristics of patients with chronic kidney disease undergoing predialysis (n=70) variable intervention control p value n % n % gender male female 26 12 68.4 31.6 17 15 53.1 46.9 0.193 education not finished elementary school junior high school senior high school diploma iii/bachelor 1 10 6 12 9 2.6 26.3 15.8 31.6 23.7 2 6 7 6 11 6.3 18.8 21.9 18.8 34.4 0.851 employment government officer business private officer retired unemployed housework 2 3 6 13 6 8 5.3 7.9 15.8 34.2 15.8 21.1 1 3 1 14 7 6 3.1 9.4 3.1 43.8 21.9 18.8 0.278 health coverage national health insurance company coverage private insurance non-insurance 34 2 2 89.5 5.3 5.3 29 1 2 90.6 6.3 3.1 0.856 mean sd mean sd age (years) 60.1 14.8 65.2 11.1 0.111 egfr (ml/minute/1.73 m2) 26.3 12.7 25.6 13.1 0.710 protein intake (gram) 39.7 13.6 31.1 11.4 0.176 creatinine (umol/l) 2.9 1.3 2.8 1.1 0.704 table 2. the effectiveness of roy’s adaptation behaviour for patients with chronic kidney disease undergoing pre-dialysis on physiological adaptation response (n=70) intervention (n=38) control (n=32) p value mean sd mean sd protein intake pre-test 39.7 13.6 31.1 11.4 0.006 post-test 1 34.8 11.3 35.1 9.8 0.932 post-test 2 38.6 4.1 39.5 12.4 0.705 creatinine pre-test 2.9 1.3 2.8 1.1 0.693 post-test 1 2.6 1.3 2.4 1.5 0.423 post-test 2 2.5 1.2 3.2 1.3 0.036 ineffective of fluid intake (%) pre-test 37 97.4 32 100 0.543 post-test 1 36 94.7 32 100 0.056 post-test 2 1 2.6 30 93.7 0.001 table 3. the effectiveness of roy’s adaptation behaviour for patients with chronic kidney disease undergoing pre-dialysis on psychological adaptation response (n=70) intervention (n=38) control (n=32) p value mean sd mean sd self-concept pre-test 41.7 6.2 44.6 6.2 0.058 post-test 1 47.7 4.6 45.5 6.9 0.162 post-test 2 53.3 3.1 45.5 6.9 <0.001 role function pre-test 20.6 3.6 22.2 3.3 0.059 post-test 1 22.6 3.8 21.5 3.5 0.212 post-test 2 25.8 2.9 21.5 3.5 <0.001 interdependency pre-test 16.9 3.7 17.5 3.1 0.489 post-test 1 17.4 3.1 16.6 3.5 0.317 post-test 2 20.0 2.3 16.6 3.5 <0.001 jurnal ners http://e-journal.unair.ac.id/jners | 153 section, and 80 minutes to 120 minutes per days. we provide a book of the adaptive behavior for patients with ckd undergoing pre-dialysis that consists of a workbook for nurses, learning materials for nurses and booklets for patients and families. the demographic information was collected on enrolment: this information included age, gender, level of education, employment, and health coverage. the primary outcome of this study was the physiological and psychological adaptation response. the secondary outcome was knowledge and attitude chronic kidney disease pre-dialysis physiological adaptation response. the outcome measures of physiological adaptation response are protein intake, drinking pattern, and blood creatinine. laboratory data were exctracted from medical records including, blood creatinine, blood urea, and egfr. we also recorded 24 hours urine. in addition, patients required to fill out the sheet of food recalls to record 24 hour fluid, calories, and protein intake. to illustrate the amount of food intake using the household size that later converted to gram unit. psychosocial adaptation response questionnaire. the questionnaire was used to measure the behavior of psychosocial adaptation of patients with chronic kidney disease pre dialysis including a behavioral adaptation of self-concept, role function, and interdependence. this instrument was modified from the instrument of nursing assessment and intervention for adult hemodialysis patient: application of roy's adaptation model developed by keen, et al. (1998). a total of 27 items covered a 14 question about the self-concept, seven questions for role function, and six items questions for interdependency adaptation. the questionnaire is a likert scale from 1 to 4, one means never, and four is always. the total score for self-concept, role function, and interdependency adaptation ranged from 13 to 56, 7 to 28, and 6 to 24, respectively. the higher score reflected high or good adaptation behavior. item correlation ranged from 0.371 to 0. 680, and the cronbach alpha in the present study ranged from 0.673 0.729. this research has been approved by the ethics committee of the faculty of nursing, universitas indonesia (0342/un2.f12.d/hkp.02.04/2015). respondents who were willing and meeting inclusion criteria were given a pre-test as baseline data, post-test, and one month follows up. researcher and research assistant conducted an intervention and divided into three sections. the first section was an 80 minutes discussion to identify stimulus or stressor, established the goals to be achieved, and improves the coping mechanism. the second section was 120 minutes health education program focused on improving the adaptation behavior of physiology, self-concept, role function and interdependence and improve family support. the last section was evaluation and reviewed the educational materials. the comparation of characteristics and clinical variables in patients with ckd between intervention and control groups were determined using the chi squared and independent t test. the paired t-test was used to test the mean different out the outcome interest before and after the intervention. a general linear model with repeated measure was used to evaluate the effectiveness of the intervention after controlling the confounding factors. data were analyzed using the statistical package for the social sciences (spss) version 20.00 for windows. results demographic and clinical characteristic of patients with ckd undergoing pre-dialysis the majority of the subjects were male (68.4%) in the intervention group and 53.1% in the control group (table 1). the mean age of the two groups were 60.1 (sd=2.35) and 65.2 (sd=3.57), respectively. above 15% of the subjects were graduated from senior high school and almost half of the subjects were retired with over 90% covered by the national health insurance. the mean of egfr for the intervention groups was 26.3 (sd=12.7), 39.7 (sd=13.6) for protein intake, and 2.9 (sd=1.3) for creatinine. there were no significant differences between intervention and control group in term of a demographic characteristic, egfr, protein intake, and creatinine. effectiveness the behavior adaptation model to the outcome interest among patients ckd undergoing pre-dialysis the creatinine was reduced significantly from 2.9 (sd=1.3) before intervention to 2.5 (sd=1.2) after one month follow up (p value=0.036) (table 2). the proportion of patients who has ineffectiveness of fluid intake was decreased significantly among intervention group before and after intervention group (97.4% at baseline to 2.6% after one month follow up) compared to control group (100% at baseline to 93.7% after one month follow up). although protein intake did not show statistically significant, it’s decreased from 39.7 to 38.6 at one month follow up compared to a control group that showed an increase in protein intake at follow up time. table 3 showed the effectiveness of roy’s adaptation behavior model of psychological adaptive response, including self-concept, role function, and interdependence among patients ckd undergoing pre-dialysis. in the intervention group, the mean score of self-concept was increased significantly from 41.8 (sd=6.2) in pre-test to 53.4 (sd=3.1) at follow up (p<0.001).the mean score of role function and interdependency was improved in the intervention group after intervention from 20.6 (sd=3.6) to 25.8 (sd=2.9) and 16.9 (sd=3.7) to 20.0, respectively. thr agustiyowati et al. 154 | pissn: 1858-3598  eissn: 2502-5791 discussion we found that roy’s adaptation model was effective to improve fluid intake and creatinine among patients with chronic kidney disease (ckd) undergoing pre-dialysis. patient adherence to fluid intake is crucial for maintain kidney function (pang & chang, 2001). if they are non-adherence to fluid intake restriction, can lead to a greater risk of complications such as cardiovascular diseases and hypertension (barnett, yoong, pinikahana, si-yen, 2007). our health education program was designed to not only provide the information regarding how much the appropriate fluid for the patient with ckd undergoing pre-dialysis. a pprevious study suggested that education should also be accompanied by encouragement and support so that patients are willing to adhere on the restriction of fluid intake (barnett, yoong, pinikahana, si-yen (2007). therefore, health education guided by roy’s adaptation model is important to develop in a routine clinic setting to improve patient’s outcome. roy’s adaptation model for patients with chronic kidney undergoing pre-dialysis was significantly effective to improve psychological adaptation behavior, including self-concept, role function, and interdependency. self-concept refers to an understanding of how the individual views or judges his own personality as it really is. the process of forming self-concept is considered as a major asset and the main determinant of individual behavior. mental health problems, such as depression, loss of hope, demoralization, fear, anxiety, and stress were very common in patients with ckd (clarke., kissane., trauer., smith. 2005; cukor., cohen , peterson, kimmel, 2007). therefore, effective stress management and utilizing social support is essential to assist patients having good self-management (novak., constantini., schneider., beanlands, 2013). the role function is to recognize as the patterns of one's social interactions in relation to others, reflected in the primary, secondary and tertiary roles. the focus is on how one can act in society according to his position. chronic kidney disease is a condition that requires a treatment which are timeconsuming, high demanding, and even difficult for some patients and their families. these conditions have psychosocial consequences such as isolation from social life, career and occupational disruptions, lifestyle restrictions, decreased independence, declined expectations to meet long-term life goals (white, mcdonnell, 2014). several studies from other countries highlight that patients with ckd unable to continue their work due to their physical condition (van manen, et al., 2001, ekelund, et al. 2007 in white, mcdonnell, 2014). this limitation can lead to economic difficulties, thus the role of selfmanagement is very important to overcome the psychosocial constraints of the patients (novak, m., constantini., schneider., beanlands, 2013). the proportion of patients with ckd undergoing pre-dialysis showed improvement in the interdependency from 70.41 in pre-test to 83.30% after one month follow up. this research proves that roy’s adaptation behavior model developed for patients with ckd undergoing pre-dialysis is effective on interdependence adaptation behavior. interdependence is the balance between dependence and independence in receiving something for theirself. interdependence adaptation behavior focuses on relationships with others (individuals and groups) and the ability to give love, appreciation, values, guidance, knowledge, skills, commitments, possessions, time and talents (roy & heather 1991, roy & andrew, 1991 in tomey & alligood, 2006; roy, 2009). conclusion roy’s adaptation model developed for patients with ckd undergoing pre-dialysis was an effective model to improve physiological, especially fluid intake and creatinine level, and psychological adaptation response including self-concept, role function, and interdependency. this model can be applied in a clinical setting to guide nurse providing health education for patients with ckd undergoing predialysis. future study to test using rigorous methods and long-term follow up is warranted. references agustiyowati, t.h.r., sitorus, r., waluyo, a. and besral, b. (2017) efektifitas model perilaku adaptasi pasien penyakit ginjal predialisis, dissertation, universitas indonesia bodenheimer, t., lorig, k., holman, h., & grumbach, k. (2002). patient self-management of chronic disease in primary care. jana, (288), 2460–2475. branson m. (2007). pre dialysis ckd patient education. renal business today may 2007 well bound 401 castro street chen, s., tsai, y., sun, c., wu, t., & lee, c. (2011). the impact of self management support on the progression of chronic kidney diseasea prospective randomized controlled trial. nephrol dial transplant, 26, 3560–3566. clarke, d., kissane, d., trauer, t., & smith, g. (2005). demoralitation, anhedonia and grief in patients with severe physical illness. word psychiatry, 4, 96–105. cukor, d., cohen, s., peterson, r., & kimmel, p. (2007). psychological aspects of chronic disease: esrd as paradigmatic illness. j am soc nephrol, 18, 3042–3055. daugirdas, john t, blake, peter g, & ing, todd s. (2015). handbook of dialysis fifth edition. devins, g., mendelssohn, d., & yitzchak, m. (2003). predialysis psychoeducational intervention extends survival in ckd: a 20 year follow up. american jornal of kidney disease, 42(4), 693– 703. feehally, j., & khosravi, m. (2015). effects of acute and chronic hypohydration on kidney health and function. oxford university press on behalf of jurnal ners http://e-journal.unair.ac.id/jners | 155 international life sciences institute, 73(52), 110– 119. finkelstein, f., story, k., & firank, c. (2008). perceived knowledge among patients cared for by nephrologis about chronic kidneys disease and stage renal disease therapies. kidney inc, 74, 1178–1184. fisher, e., thorpe, c., devilles, b., & devilles, r. (2007). healthy coping, negative emotions, and diabetes management : a systematic review and appraisal. diabetes educ, 33, 1080–1103. fougue, d., & aparicio, m. (2007). eleven reason to control the protein intake of patients with chronic kidney disease. natur clin practice nephrol, 3(7), 383–92. hase. (2012). chonic kidney disease management: the action plan. medicine update vol 22 ignatavicius, d., & workman, m. (2010). medicalsurgical nursing: patient-centered collaborative care (6th ed.). st. louis misouri: saunders elsevier. keen et al. (1998). nursing assessment and intervention for adult hemodialysis patients: application of roy’s adaptation model. nephrology nursing journal. anna journal 25(3), 311-319 kidney disease outcome quality initiative (k/doqi). (2000). guidelines to chronic kidney disease. american journal of kidney disease, 35(6) kidney disease outcome quality initiative (k/doqi). (2000). guidelines nutrition to chronic kidney disease. 3 desember 2012. www.kidney.org/professionals/kdoqi/pdf/kdoq i2000 kresnawan t, markun mhs. diet rendah protein dan penggunaan protein nabati pada penyakit ginjal kronik. instalasi gizi dan divisi ginjal hipertensi rscm jakarta lai, se et al. (2015). effect of pertsonalized dietary intervention on nutritional, metabolic and vascular indices in patients with chronic kidney disease. europian review for medical and pharmacological sciences. 19, 33513359 leddy, s., & pepper, j. (1993). conceptual bases of professional nursing (3rd ed.). philadelphia: lippincott. lendray, mj et al. (2010). prediction of esrd and death among people with ckd: the chronic renal impairmant in birmingham. amj kidney disease. 56(6-2), 1082-1094 lopez-vargas, p et al. (2014). knowledge deficit of patients with stage 1-4: a focus group study. asian pasific sociaty nephrology. 19, 234-243 national kidney foundation (nkf). (2000). clinical guideline for chronic kidney disease outcome: evaluation, classification, and stratification kidney disease outcome quality initiative. amj kidney dis. 39(1) novak, m., constantini, l., schneider, s., & beanlands, h. (2013). patient education in chronic kidney disease and dialysis. seminars in dialysis, 26(2), 188–194. nygardh, a., malm, d., wikby, k., & ahlstrom, g. (2012). empowerment intervention in outpatient care of persons with chronic kidney disease predialysis. nephrology nursing journal, 39(4), 285– 294. orlando, l., owen, w., & db, m. (2007). relationship beetwen nephrologist care and progession of ckd. nc med journal, 68(1), 9–16. pernefri. (2011). report of indonesia renal registry. polsingchan, s. (2010). promoting behaviors in thai persons with chronic renal failure. university of texas. price, s.,a &wilson l.,m. (2000). patofisiologi konsep klinis proses-proses penyakit. edisi 4. jakarta: egc roy, s. (2009). the roy adaptation model (3rd ed.). new jersey: pearson education inc. roy, s., & heather, a. (1991). the roy adaptation model – the definitive statement. usa: appleton & lange. sacher, r., mc.pherson, & richard, a. (2002). tinjauan klinis hasil pemeriksaan laboratorium. jakarta: egc. tomey, am., & alligood, mr. (2006). nursing theorists and their work. (6th ed). st. louis, missouri: mosby elsevier tong, a., sathsburg, p., & chadbon, s. (2009). patients experiences and perspectives of living with ckd. am j kidney, 53, 689–700. tsai, y et al. (2013). is fluid overload more important than diabetes in renal progression in late chronic kidney disease. plos one 8 (12), 1-7 tucker, b., fabbian, f., & giles, m. (1997). left ventricular hyperthropy and ambulatory bllod prssure monitoring in chronic renal failure. nephrology dialysis transplantation, 12, 724– 728. walker, r., mark, r., marshall, & polascheck, n. (2013). improving self-management in chronic kidney disease: a pilot study. renal society of australasia journal, 9(3), 116–125. wein, kanvoussi, novick, partin, & peters. (2007). campbell-walsh urology (9th ed.). philadelphia: saunders elsevier. white, c., & mcdonnell, h. (2014). psychosocial distress in patients with end stage kidney disease. journal of renal care, 40(1), 74–81. 144 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.6607 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research development of the mind-body-spiritual nursing care model (mbs) for coronary heart disease patients ninuk dian kurniawati1, nursalam nursalam1 and suharto suharto2 1 faculty of nursing, universitas airlangga, surabaya, indonesia 2 faculty of medicine, universitas airlangga, surabaya, indonesia abstract introduction: patients with coronary heart disease (chd) may experience various physical, psychological or spiritual issues. a holistic mind-body spiritual nursing care (mbs) model is needed to help patients' cope with the issues. this study aimed to develop an mbs nursing care model for chd patients. method: the study employed a crossectional design with 110 chd patients participated in the study. respondents were asked to fill out questionnaires to gather the required data. criteria for respondent selection were moslem, aged 40-75 year, medical diagnosis of chd, and haemodynamically stable. the independent variables were focal, contextual and residual stimuli, while the dependent variables were coping and spirituality. data were analyzed using partial least square. results: the results show that the mind-body-spiritual nursing care formed focal stimuli. spirituality is formed by focal, contextual, residual stimuli and coping style. nursing care significantly affects spirituality, shown by t-statistics of 6.795. spirituality can be explained by patience, endeavour toward wellness, and offer the results only to the god by 72%, while the rest is explained by other factors. conclusion: mbs nursing care model has a strong relationship with spirituality. this model needs to be applied in a further research to see its effectiveness in improving spirituality and expression of cardiovascular risk inflammatory markers. article history received: november 17, 2017 accepted: october 02, 2018 keywords coronary heart disease; mind-body-spiritual; nursing care model; spirituality contact ninuk dian kurniawati  ninuk.dk@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: kurniawati, n., nursalam, n., & suharto, s. (2018). development of the mind-body-spiritual (mbs) nursing care model for coronary heart disease patients. jurnal ners, 13(2), 144-149. doi:http://dx.doi.org/10.20473/jn.v13i2.6607 introduction a provision of a mind-body-spiritual nursing care that emphasizes not only on physical aspect of care, but also psychological, and spiritual care are needed. however, a fit of a model of nursing care for patients treated in hospital has yet to be developed, hence, it is necessary to develop the mind-body-spiritual nursing care model. being treated in the hospital with the acute coronary syndrome can be very distressfull for patients, on several aspects. a qualitative study revealed that patients’ experiencing multiple issues during hospital stays and need help from nurses to help them cope with the issues (kurniawati, nursalam, & suharto, 2017). stress has been empirically shown to interfere with immunity, mainly through a so-called hypothalamus-pituitaryadrenal (hpa) axis. after the brain perceives the stressor, the hypothalamus releases corticotropinreleasing hormone (crh), which then stimulates the pituitary gland to release acth. this will, in turn, causes the adrenal cortex to express glucocorticoids. several studies have investigated the mind-body, spiritual intervention, but current research has not incorporated mind-body-spiritual intervention comprehensively in a series of nursing orders. psychological interventions proved to be effective in improving pain tolerance and postoperative immunologic resistance (rehatta, 2005), reducing postoperative pain, anxiety, tension and analgesic use in 20 studies involving a total of 1297 patients (nelson et al., 2013) and decreasing physical symptoms and mental in patients with chronic physical and mental pain, (vranceanu et al., 2014). https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 145 in addition to the mind-body intervention, studies have demonstrated the benefits of spiritualbased intervention in increasing hsp 72 (asiyah, putra, & kuntoro, 2011), increasing alpha waves in the brain and decreasing cortisol levels, decreasing stress and anxiety (barnby, bailey, chambers, & fitzgerald, 2015), decreasing depression in patients with acute coronary syndrome (warber et al., 2011), and lowering the cortisol levels of hiv patients (murray et al., 2007). therefore, the literature review supports the promising benefits of a comprehensive mind-bodyspiritual nursing care intervention for chd patients. this study aimed at developing a mind-bodyspiritual nursing care for coronary heart disease patients treated at hospitals. this is supported by the previously described literature review that highlights the promising benefits of the mind-bodyspiritual nursing care for the patients that until to date, is yet to be developed. materials and methods the research used an analytical explanatory design where required data were taken cross-sectionally approximately over six months period. the population of the study was all patients with coronary heart disease hospitalised in some hospitals in surabaya, indonesia. the sample was drawn from the population treated at various rooms in a top-referral-government-owned hospital in eastern indonesia, a university hospital and a big private hospital in surabaya. the inclusion criteria were chd patients with a stable hemodynamic status had been treated for at least two days and had a capacity to understand written information; whereas the exclusion criteria were chd patients with decreased level of consciousness and withdrew from the study for many reasons. participants of the study were selected randomly by simple random sampling. the sample size was calculated using statistical power and effect size adjusted to sem-pls model sample size table from sholihin & ratmono (2013). based on the preliminary model which consist of four big arrows, significant at 5% and minimum r2 of 0.50, the minimum sample size yielded from the table was 42. thus, the number of respondents in this study was 110 respondents. data were collected from february to april 2017 using questionnaires developed from a previous study (kurniawati et al., 2017) in 2017. questionnaires were tested for validity and reliability and they were all valid and reliable with r = 0,508-951, p = 0,0080,000, and cronbach alfa between 0,638927. all subjects were required to fill out the questionnaires once cross-sectionally and there was no follow up conducted by the authors. the collected data were tabulated and analysed using statistical analysis of smart partial least square with aimed to develop a statistical model of mbs nursing care. the study protocols were reviewed and approved by commissions of ethics from rumah sakit universitas airlangga number 023 / keh / 2016, dated august 6, 2016, and rsud dr. soetomo number 262 / panke.kke / iv / 2017, dated april 6, 2017. results table 1 shows participants' demographic data. it can be seen from the table 1 that the majority of respondents are male (68.18%), javanese (82.73%), from surabaya (54.5%), with medical diagnosis of stemi (42.73%), underwent second hospitalisation (51%), aged 56-70 years (54.55%) and on their third day of hospital stay (43.64%). variables examined in this study were focal stimuli (x1), contextual stimuli (x2), residual stimuli (x3), coping (y1) and spirituality (y2). the focal stimuli depicted by patient’s issues (x1.1) and the mind-body-spiritual nursing care (x1.2). the contextual stimuli had 3 indicators: hospital environment (x2.1), family support (x2.2), and past hospitalisation experience (x2.3). residual stimuli were measured through four aspects of indicators: education (x3.1), occupation (x3.2), health insurance (x3.3) and patients’ religious rituals (x3.4). coping was measured through two indicators: problemfocused coping (y1.1) and emotional-focused coping (y1.2). lastly, spirituality was defined by patients table 1. characteristics of respondents variables sub variables frequency % sex men 75 68.18 women 35 31.82 ethnicity banjar 2 1.82 batak 3 2.73 javanese 91 82.73 madurese 7 6.36 buginese 1 0.91 malay 2 1.82 sasak 1 0.91 sundanese 3 2.73 address east java 97 88.18 borneo 2 1.8 madura 8 7.3 west nusa tenggara 2 1.8 papua 1 0.9 age 40-50 28 22.45 51-60 47 42.73 61-70 35 31.82 medical diagnosis angina, uap 23 20.91 nstemi 13 11.82 stemi 47 42.73 omi 22 20.00 iskemia 5 4.55 number of hospitalisa tion 1 32 29.09 2 51 46.36 3 27 24.55 length of hospital stay 1 5 4.55 2 28 25.45 3 48 43.64 4 29 26.36 n. d. kurniawati et al. 146 | pissn: 1858-3598  eissn: 2502-5791 during illness, endeavour toward wellness, and a total submission toward the god’s will. table 2 summarises the data of focal and contextual stimuli. based on the table it can be concluded that the majority of respondents used a problem-focused coping style, rather than emotional-focused coping style with seeking information reported being the highest proportion (51.36%). the most common coping style was under emotional focused coping style that respondents never used was self-criticism (59.55%). most respondents reported always being patient (59.7%), endeavouring toward wellness (63.64%), and offering all the result of the treatment to god (65.15%). after the outer model was defined, the inner model was then analysed. the purpose of structural model analysis (inner model) was to examine the influence of exogenous factors on endogenous factors. the value used as a reference was the ttable 2. distribution of respondents of children and caregivers meeting the research criteria at ypac surakarta march-april 2017 (n= 23) variable indicator sub indicator category never sometimes often always total n % n % n % n % n % focal stimuli patients’s issue physical 4 3.64 24 21.82 55 50.00 27 24.55 110 100 psychological 46 41.82 36 32.73 27 24.55 1 0.91 110 100 social 71 64.55 31 28.18 8 7.27 0 0.00 110 100 spiritual 23 20.91 67 60.91 18 16.36 2 1.82 110 100 mbs nursing care assess 4 3.64 15 6.82 46 20.91 155 70.45 220 100 help meet the patient’s physical need 2 1.82 14 6.36 44 20.00 160 72.73 220 100 fascilitate the coping strategy 37 33.64 10 4.55 48 21.82 125 56.82 220 100 fascilitate spiritual activity 47 42.73 11 5.00 68 30.91 94 42.73 220 100 contextual stimuli hospital environment comfortness 2 0.61 36 10.91 119 36.06 173 52.42 330 100 nurse’s communication 0 0.00 15 6.82 62 28.18 143 65.00 220 100 nurse’s friendliness 0 0.00 33 15.00 63 28.64 124 56.36 220 100 family support emotional suppport 2 0.91 17 7.73 78 35.45 123 55.91 220 100 ducognitive suppport 6 2.73 34 15.45 54 24.55 126 57.27 220 100 material suppport 2 0.91 27 12.27 73 33.18 118 53.64 220 100 past experience satisfaction toward nursing care 89 40.45 48 21.82 71 32.27 12 5.45 220 100 effectiveness of previous coping style 124 56.36 40 18.18 48 21.82 8 3.64 220 100 coping problem focused coping planned-problem solving 12 5.45 52 23.64 65 29.55 91 41.36 220 100 direct action 4 1.82 34 15.45 98 44.55 84 38.18 220 100 seeking help 3 1.36 31 14.09 96 43.64 90 40.91 220 100 information seeking 3 1.36 27 12.27 77 35 113 51.36 220 100 emotional focused coping avoidance 61 27.73 129 58.64 19 8.64 11 5 220 100 deny 61 27.73 123 55.91 21 9.55 15 6.82 220 100 self-criticsm 131 59.55 45 20.45 31 14.09 13 5.91 220 100 look for silver lining 26 11.82 81 36.82 78 35.45 35 15.91 220 100 spirituality patience 0 0 30 9.09 103 31.21 197 59.70 330 100 endevour 11 3.33 11 3.33 98 29.7 210 63.64 330 100 submission to god 0 0 17 5.15 98 29.70 215 65.15 330 100 table 3. description of residual stimuli indicator sub indicator n % education non/elementary 26 23.64 high school 50 45.45 diploma 7 6.36 ≥ s1 27 24.55 occupation none/housewife 16 14.55 labor, retirement, farmer, driver 27 24.55 entrepreneur, private employee 57 51.82 goverment employee 10 9.09 health insurance govt health insurance class iii 5 4.55 govt health insurance class ii 45 40.91 govt health insurance class i 55 50.00 private insurance 5 4.55 religious rituals never 0 0 sometimes 5 4.55 often 40 36.36 always 65 59.09 jurnal ners http://e-journal.unair.ac.id/jners | 147 table value (109.025 = 1.96). exogenous factors were considered had an effect on endogenous factors if the t-statistic value was greater than a table with fault tolerance (α) = 5%. the result of the significance test is described in the following table. to develop a fit model, the structural equation model was analysed by measuring both the outer and inner model. the measurement model (outer model) was analyzed by testing the validity and reliability of the construct. as can be seen from table 4, patients' issues and occupation were statistically not significant in defining the model, thus those two indicators were removed from the model. it can be concluded from the table 5 that almost all exogenous variables had no significant effect on endogenous variables. only one exogenous variable had a significant effect on an endogenous variable, namely the focal stimuli variable of spirituality. figure 1 illustrates the model of nursing care of mbs on the spirituality of patients treated with chd. it can be seen from the figure that none of the exogenous factors has an influence on endogenous factors, except for the mind-body-spiritual nursing care itself (r-square value shows 0.720). therefore in providing patient of chd treated in hospital, the main focus of the nurses rely solely on the nursing care itself. the r-square value shows that the variable of spirituality can be explained by patience, table 2. convergent validity of the latent variables no latent variable indicator convergent validity loading factor (𝛌) t-statistic validity 1 focal stimuli mbs nursing care 1.000 valid 2 contextual stimuli hospital environment 0.803 1.330 valid family support 0.903 1.782 valid hospitalisation experience -0.620 0.954 valid 3 residual stimuli education 0.857 4.302 valid religious ritual 0.604 2.408 valid health insurance 0.725 3.102 valid 4 coping problem focused coping 0.999 2.813 valid emotional focused coping -0.586 1.254 valid 5 spirituality patience 0.917 34.652 valid endeavour toward wellness 0.914 33.456 valid submission to god 0.928 24.137 valid table 3. relationship between the exogenous factor and endogenous factor no pathway path coefficient tstatistic t-table significance 1 (x1) focal stimuli (y1) coping 0.189 1.260 1.96 not significant 2 (x2) contextual stimuli (y1) coping 0.129 0.778 1.96 not significant 3 (x3) residual stimuli (y1) coping 0.217 1.294 1.96 not significant 4 (x1) focal stimuli (y2) spirituality 0.720 6.795 1.96 significant 5 (x2) contextual stimuli (y2) spirituality -0.013 0.158 1.96 not significant 6 (x3) residual stimuli (y2) spirituality 0.187 1.857 1.96 not significant 7 (y1) coping (y2) spirituality 0.073 0.613 1.96 not significant figure 1. mind-body-spiritual nursing care model, pathway analysis n. d. kurniawati et al. 148 | pissn: 1858-3598  eissn: 2502-5791 endeavour, and submission to god by 72%, while the rest explained by other factors. to determine whether the mbs nursing care model has a good ability in predicting the improvement of someone’s spirituality, the goodness of fit (gof) test was performed and yielded a score of 0,6172. showing that the mbs nursing care model’s ability to explain its research variables very strongly. in another word, the size of the influence of variable is big. discussion the results show that the focal, contextual, and residual stimuli do not have any effect on coping. additionally, the contextual stimuli, residual stimuli, and coping also have no effect on spirituality. only focal stimuli have a significant effect on spirituality. these findings suggest that the patients’ spirituality can be enhanced directly by the provision of focal stimuli, which is the mind-body-spiritual nursing care. this is a very promising result because it highlights the strength of the study that proves the mbs nursing care may improve the patients’ spirituality although other aspects of care may less favourable. these findings are inconsistent with the previous theory that the desired adaptive response, spirituality, was not only influenced by focal stimuli, but also the contextual and residual stimuli. the results of siyoto, peristiowati, & agustin (2016) showed focal stimulus, contextual stimulus, and residual stimulus related to the coping mechanism in people living with hiv. several studies have also shown that spirituality is related to coping of cancer patients in iran (abuatiq, 2015; rezaei, adibhajbaghery, seyedfatemi, & hoseini, 2008), and african-american respondents subjected to racist treatment (cooper, thayer, & waldstein, 2014). the limitation of the study was the efficacy of the model has not been investigated; therefore, further study is required to prove the efficacy of the model in coronary heart disease patients treated in hospitals. conclusion based on the results of the study can be concluded that the focal stimuli, the mind-body-spiritual nursing care, affects spirituality directly without going through coping pathways. this is very beneficial because several variables that might affect spirituality can be ignored as long as the focal stimuli can be given by the nurse properly. however, as previously described in the discussion, this mind-body spiritual nursing care model firstly needs to be tested to patients with coronary heart disease to know its effectiveness in improving spirituality and other aspects before it can be used in clinical practice. references abuatiq, a. (2015). international journal of nursing & clinical practices spiritual care for critical care patients, 2, 2–5. asiyah, s., putra, s., & kuntoro. (2011). the increase of ehsp 72 in members of dzikir group. folia medica indonesiana, 47(3), 147–153. retrieved from http://journal.unair.ac.id/downloadfullpapers-02 10026 asiyahe _format fmi_.pdf barnby, j. m., bailey, n. w., chambers, r., & fitzgerald, p. b. (2015). how similar are the changes in neural activity resulting from mindfulness practice in contrast to spiritual practice? consciousness and cognition, 36, 219– 232. https://doi.org/10.1016/j.concog.2015.07.002 cooper, d. ., thayer, j. ., & waldstein, s. . (2014). coping with racism: the impact of prayer on cardiovascular reactivity and post-stress recovery in african american women. ann behav med., 47(2), 218–230. kurniawati, n. ., nursalam, & suharto. (2017). mindbody-spiritual nursing care in intensive care unit. in advances in health sciences research: 8th international nursing conference (vol. 3, pp. 223– 228). amsterdam: atlantis press. murray, s., kendall, m., grant, e., boyd, k., barclay, s., & sheikh, a. (2007). effects-of-faith-assuranceon-cortisol-levels-are-enhanced-by-a-spiritualmantram-intervention-in-adults-with-hiv-arandomized-trial_2009_journal-of-p. journal of pain and symptom management, 34(4), 393–402. nelson, e. a., dowsey, m. m., knowles, s. r., castle, d. j., salzberg, m. r., monshat, k., … choong, p. f. m. (2013). systematic review of the efficacy of presurgical mind-body based therapies on postoperative outcome measures. complementary therapies in medicine, 21(6), 697–711. https://doi.org/10.1016/j.ctim.2013.08.020 rehatta, n. m. (2005). pengaruh pendekatan psikologis pra bedah terhadap toleransi nyeri dan respons ketahanan imunologik pasca bedah. universitas airlangga. retrieved from http://adln.lib.unair.ac.id/go.php?id=jiptunairgdl-s3-2005-rehattanan-1413&q=rehatta rezaei, m., adib-hajbaghery, m., seyedfatemi, n., & hoseini, f. (2008). prayer in iranian cancer patients undergoing chemotherapy. complementary therapies in clinical practice, 14(2), 90–97. https://doi.org/10.1016/j.ctcp.2008.01.001 sholihin, m., & ratmono, d. (2013). analisis sem-pls dengan wrap pls 3.0 untuk hubungan nonlinear jurnal ners http://e-journal.unair.ac.id/jners | 149 dalam penelitian sosial dan bisnis. yogyakarta: penerbit andi. siyoto, s.-, peristiowati, y.-, & agustin, e.-. (2016). analisis faktor yang berhubungan dengan mekanisme koping pada odha dengan pendekatan teori adaptasi callista roy. jurnal ners, 11(2), 256–260. vranceanu, a. m., gonzalez, a., niles, h., fricchione, g., baim, m., yeung, a., … park, e. r. (2014). exploring the effectiveness of a modified comprehensive mind-body intervention for medical and psychologic symptom relief. psychosomatics, 55(4), 386–391. https://doi.org/10.1016/j.psym.2014.01.005 warber, s. l., ingerman, s., moura, v. l., wunder, j., northrop, a., gillespie, b. w., … rubenfire, m. (2011). healing the heart: a randomized pilot study of a spiritual retreat for depression in acute coronary syndrome patients. explore (new york, n.y.), 7(4), 222–33. https://doi.org/10.1016/j.explore.2011.04.002 184 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.7753 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research complaints in menopausal women and its correlation with lifestyle and stress ni ketut alit armini, lailatun ni’mah and baiq selly silviani faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: every woman will have menopausal experiences at the end of a biological process called menstrual cycles. several complaints can be aggravated by lifestyle and stress. this study was to analyze the relation of lifestyle and stress levels with a menopausal complaint in women. methods: this study was correlational with a cross-sectional approach. the study involved 101 menopausal women lived in a community selected by proportional random sampling. the independent variables were lifestyle and stress levels in menopausal women. the dependent variable was a menopausal complaint. this study used primary data provided by questionnaires and interviews. the data were analyzed using spearman’s rho. results: there was strong correlation between lifestyle (p=0.000; r=-0.424), stress levels (p=0.000; r=0.535), and complaint in a menopausal woman. conclusion: a healthy lifestyle, stress-controlled to minimize complaints in menopausal women. further research is needed on factors that increase stress in postmenopausal women. article history received: feb 25, 2018 accepted: dec 31, 2018 keywords lifestyle; stress; menopausal; complain; women contact ni ketut alit armini  nk.alita@fkp.unair.ac.id  faculty of nursing, universitas airlangga, surabaya, indonesia cite this as: armini, n. k. a., ni’mah, l., & silviani, b. s. (2018). complaints in menopausal women and its correlation with lifestyle and stress. jurnal ners, 13(2),184-189. doi:http://dx.doi.org/10.20473/jn.v13i2.7753 introduction life expectancy increased from 70.7 years in 2008 to 73.7 years in 2025 (kemenkes ri, 2016). women aged 45-55 years are generally going through menopause, which starts when the ovaries begin to reduce the production of estrogen and progesterone (curran, 2009). menopausal women will have climacteric complaints such as irritability, fear, anxiety, hot flushes, depression, headache, fatigue, difficulty in concentrating, forgetfulness, lack of energy, weight gain, pain in bones and muscles, obstipation, heart palpitations, impaired libido, tingling, and dizzy eyes (o’neill & eden, 2012). menopausal women can experience menopause syndrome complaint for 7 years during the menopause transition and 4.5 years during the final menstrual period (avis et al., 2015). lifestyle and modern diet which is today followed the turns are potentially vulnerable to damage the health and cause disease (stojanovska, apostolopoulos, polman, & borkoles, 2014). women entering menopause will be depressed by loss of their role as a woman and having to face old age. feelings of depression can be caused by physical, emotional, social, economic, or employment factors or circumstances, events, or experiences that are difficult to manage or survive. the prevalence of depression is higher in women than men throughout their reproductive years along with the menopausal transition (freeman, sammel, & sanders, 2014). stress affects the functional disorders of organ disorders, and psychological such as anxiety and or depression (curran, 2009; hawari, 2016). indonesian women experience five major symptoms during the climacteric, which are muscle and joint pain (77.7%), fatigue and missing energy (68.7%), loss of sexual desire (61.3%), wrinkles (60%), difficulty concentrating, and hot flushes (29.5%) (muharam, 2007). freeman, sammel, and sanders (2014) expressed that as many as 80% of women experience symptoms of hot flashes other and heart palpitations in the moderate to severe category during the menopausal transition. menopause occurs due to a decrease in estrogen produced by the ovaries. women are said to have undergone menopause when menstrual periods have stopped for 12 months (baziad, 2007). irregular ovarian function and fluctuating levels of estrogen during menopause cause women often to https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i2.7753 jurnal ners http://e-journal.unair.ac.id/jners | 185 experience symptoms called climacteric syndrome. menopausal symptoms include vasomotor symptoms with symptoms that appear in the form of a feeling of heat with sweating a lot at night (curran, 2009; mulyani, 2013). the decline in estrogen also causes a decrease in neurotransmitters in the brain that affect mood so that anxious feelings appear that trigger depression or stress (proverawati & sulistyawati, 2010). how that can be done in reducing menopausal complaints such as creating a healthy lifestyle (moon, hunter, moss-morris, & hughes, 2017). it is important for menopausal women to follow a healthy lifestyle in order to have an impact on the psychological effects (dorjgochoo, 2008). mansikkamaki et al. (2015) stated that women who carry out physical activities have a better perception of their own health, and better health and global quality of life (qol) compared to women who do not engage in physical activity. one of the ways to reduce menopausal complaints is to create a healthy lifestyle (priyoto, 2014). the importance of living a healthy lifestyle is that it can also have an impact on the psychology of menopausal women (rahmayani, wijaksono, & putri, 2016). the aim of this study was to describe the relationship between lifestyle, stress levels, and complaints in menopausal women. materials and methods the research was a correlational study with a crosssectional design. the population in this study were menopausal women aged 48-60 years in a community health center in surabaya. the sampling technique used proportional random sampling. samples were obtained by calculating the proportion of menopausal women in four community health services (posyandu) for elderly in surabaya. the sample size was 101 women who experienced menopause and live with their husbands. the independent variable in this study is lifestyle and stress levels. the dependent variable in this study is a menopause complaint. the data were collected using questionnaires in which the researchers interviewedthe respondents through the list of questions. the instrument used to measure menopausal complaints originates from the menopause rating scale (mrs) developed by the berlin center for epidemiology and health research so that the questions have been validated in content. the measuring instrument used in this study has been standardized based on the literature so that it does not need to be tested for validity and reliability (heinemann et al., 2014; heinemann, potthoff, & schneider, 2003). the mrs questionnaire consists of 5 choices: 0: none; 1: mild; 2: moderate; 3: severe; and 4: verheavy. the scale of this instrument can measure three groups of complaints. psychological complaints are in the form of heart palpitations, feelings of tension or pressure, difficulty sleeping, easy contact, easy panic, difficulty concentrating, and being easily tired. the categories for psychological complaints are 0-1: none; 2-3: mild; 4-6: moderate; ≥7: severe. somatic complaints are in the form of feeling dizzy, the body feeling depressed, part of the body feeling pierced by thorns, headaches, and muscle or joint aches. the categories for somatic complaints are 0-2: none; 3-4: mild, 5-8: moderate; ≥9: severe. vasomotor complaints are in the form of hot flushes and night sweats. the categories for vasomotor complaints are 0: none; 1: mild; 2-3: moderate; 4: severe. stress level data used a modified questionnaire from dass 42 (lovibond & lovibond, 1995) by choosing specific points to assess stress levels, consisting of 4 choices where 0: none; 1: sometimes; 2: often; and 3: always with 0-14 rating categories: normal; 15-18: light; 19-25: moderate; 26-33: severe; ≥34: very severe. lifestyle data consists of 4 component statements, namely diet, activity/exercise, sleep rest and smoking. there is a positive statement by way of valuation in the form of 4 = always; 3 = often; 2 = sometimes; 1 = never, and on negative statements the method of evaluation is 1 = always; 2 = often; 3 = sometimes; 4 = never, with 21-50 category = unhealthy; 51-80 = healthy. considering the data collection practices of research ethics, the study was approved by the ethics committee of health research, nursing faculty, universitas airlangga, with certificate number 590-kepk on december 4th 2017. results most respondents were aged 55-60 years, and there were as many as 61 respondents (60.4%). most of the respondents are housewives, as many as 85 respondents (84.2%). the most of respondents had experienced menopause for 1-5 years as many as 47 respondents (table 1) the majority of respondents had menopausal complaints in moderate category as many as 53 respondents (52.5%). most respondents live a healthy lifestyle, as many as 69 respondents (68.3%), while the level of stress experienced by respondents was mostly in the normal category, as many as 64 respondents (63.4%) (table 2). most respondents with a healthy lifestyle experienced menopausal complaints within the moderate category, that was 39 respondents (38.6%), and at least category of such respondents were in normal category as many as five respondents. most respondents who lived an unhealthy lifestyle experienced menopausal complaints within the severe category, as many as 17 respondents (16.8%), and no respondents had complaints of menopause in the mild category (table 3). statistical test results using spearman obtained significance level of p = 0.000 by assigning degrees of significance α≤0.05, which means that there is a relationship between lifestyle with complaints of menopausal women. the correlation coefficient was obtained -0.424, which means that the more healthy n. k. a. armini et al. 186 | pissn: 1858-3598  eissn: 2502-5791 lifestyle will lead to less menopausal complaints (table 3). a respondent who was at normal stress level was more likely to experience menopausal complaints in the moderate category, as many as 36 respondents (35.6%), and six respondents (5.9%) in the category had severe complaints. most respondents who are at mild stress level had complaints of menopause in the middle category, as many as nine respondents (9%). most respondents who were at moderate stress level experienced the severe category of complaints as many as 14 respondents (14%), and respondents who were at severe stress level have complaints of menopause in severe categories, as many as three respondents (3%) (table 4). statistical test results using spearman obtained significance level of p=0.000 with a degree of significance α≤0.05, which means there is a relationship between stress levels with symptoms in menopausal women. the correlation coefficient was obtained 0.535, which means that the lower stress level will lead to less menopausal complaints (table 4). discussion lifestyle-related complaints in postmenopausal women at as indicated by the statistical result that the value of p=0.000, which means getting healthier lifestyle menopausal women perceived grievance is reduced. in accordance with the study by moon, hunter, moss-morris, and hughes (2017), the symptoms of menopause are influenced by several factors such as lifestyle, social, and psychosocial. terauchi et al. (2010) found that sleep problems such as insomnia and difficulty sleeping well experienced by menopausal women with regard to the characteristic of lifestyle. the results of the study obtained 17 respondents who lead unhealthy lifestyles with severe menopausal complaints. the age of the 17 respondents were mostly in the range of 55-60 years, which is the age to the elderly stage where sleep problems began to be felt. when 17 respondents said sleep less than 8 hours, sleeplessness, like wake up at night and when awakened body feels sore. most menopause 6-10 years old where according to avis et al. (2015) stated menopausal women will experience menopausal complaints for 4.5 years after the cessation of menstruation and 7 years old during the long transition to menopause that the complaint is still perceived by the respondents. a total of 15 respondents out of 17 respondents were housewives. women who worked as housewives did less frequent sports activities independently at home as the majority of respondents stated that housework is also a form of exercise for them. some lifestyle patterns that can be seen are diet, exercise, rest and sleep, smoking, and drinking alcohol. research results obtained showed that respondents who have healthy lifestyles are mostly situated on the pattern of restful sleep respondents who do not take sleeping pills, it is associated with the majority of respondents who experience sleep problems that are in the category of mild to moderate during menopause where sleep problems in future associated with vasomotor menopausal complaints such as hot flushes and night sweating. the results obtained from interviews showed most respondents as housewives spend more time taking care of the house and some are involved in caring for grandchildren. most respondents said they took a nap for about 1-2 hours and at night began to sleep at 21:00 and woke up at 04.00 am, although sometimes they wake up at midnight to urinate. menopausal complaints can be aggravated by smoking and drinking alcoholic beverages due to the levels of estrogen and progesterone in menopausal women diminishing. cochran, gallicchio, miller, zacur, & flaws (2008) suggested that women with larger smoking status had complaints of menopause such as hot flushes and there are sleep problems in women smokers where estrogen and progesterone hormone levels are lower. oi & ohi (2012) found that smoking affects the occurrence of menopausal symptoms such as sweating in the night, hot flushes, insomnia, and other physical symptoms of menopause. smoking is actually lung exposure to combustion products of tobacco, which are toxic. the burning cigarette toxins will be carried by the blood and will cause it to malfunction for reproduction (hardy, 2000). the attack of hot flushes may be table 1. characteristics of respondents (n=101) characteristics n % age 48-54 years 55-60 years 40 61 39.6 60.4 employment housewife private self-employed 85 8 8 84.2 7.9 7.9 menopause experience 1-5 years 6-10 years 11-15 years 16-20 years 21-25 years 47 37 13 3 1 46.5 36.6 12.9 3.0 1.0 table 2. lifestyle, stress levels, and complaints in menopausal women (n=101) variables n % lifestyle healthy unhealthy 69 32 68.3 31.7 stress level normal mild moderate severe 64 14 19 4 63.4 13.9 18.8 4.0 menopause complaints none mild moderate severe 6 17 53 25 5.9 16.8 52.5 24.8 jurnal ners http://e-journal.unair.ac.id/jners | 187 increased due to toxic effects contained in the alcohol because alcohol can relax the muscles of blood vessels causing them to dilate and increase blood flow and the risk of a flush (mulyani, 2013). the results of this research found that most respondents who do not smoke and consume alcoholic beverages complain of hot flushes that are in the lightweight category did not even complain of hot flushes. complaints to do with sleep problems in this study are located mainly in the lightweight category. it also deals with the majority of respondents are moslem, but the majority of respondents said that smoking is the husband and/or children, where the chances of exposure to cigarette smoke and this may also affect the health of postmenopausal women. it is highly recommended that women who smoke should stop during menopause to reduce the occurrence of an increased likelihood of experiencing complaints such as hot flushes and insomnia. menopausal women who do not smoke but are in the neighborhood of those who do are advised to avoid smoke. physical activity is usually done by most respondents in the form of gymnastics, which are held once a week in posyandu, and doing daily homework independently. some respondents did not follow gymnastics for reasons to sell. less healthy lifestyles do most respondents is the lack of exercise habits, associated with discomfort in the joints and sexual problems. physical activity has benefits that can reduce a variety of complaints during menopause occurring as well as improving blood circulation, counteracting depression, making you sleep better, and increasing bone density in postmenopausal women. regular exercise of at least 30 minutes a day can increase life expectancy and improve overall health (mulyani, 2013; stojanovska et al., 2014). sternfeld et al. (2014) explained that physical activity in postmenopausal women did not significantly decrease vasomotor symptoms but can improve overall health and well-being feeling, and sleep quality, and reduce symptoms of insomnia and depression. diet is associated with a person’s lifestyle. a balanced diet is foods that contain nutrients in the type and amount the body needs. most respondents have a balanced diet, such as eating foods containing carbohydrates, fat, protein, and vitamins, and eat regularly three times a day a portion that is not excessive. in the results of the interviews, most of the respondents said that the diet commonly consumed is rice, tofu, tempeh, vegetables, eggs, and chicken. usually, respondents consumed fruit two to three times a week and rarely drink milk. the decline in estrogen and progesterone hormone levels affects the bad mood. it is important to consume foods that provide essential nutrients for healthy brain function. protein-containing foods may reduce the occurrence of complaints such as hot flushes and improve memory in menopausal women. estrogen is involved in memory function, while in menopause, the hormone estrogen is decreased, so women who consume protein will help in boosting the release of neurotransmitters that serve to convey the information in the brain and other body parts (mulyani, 2013). consuming fruits and vegetables is good for maintaining a healthy body because they contain vitamins, minerals, beta-carotene, and antioxidants that are important for the body (bauld & brown, 2009; gayatri, 2011). foods containing vitamin e may help reduce the complaints of hot flushes and vaginal dryness problems (muharam, 2007; mulyani, 2013). most of the respondents already have the habit of eating vegetables, but rarely eat fruits. in research by (anggrahini & handayani, 2014), menopausal women who consumed milk (soymilk) showed a decrease in menopausal complaints because the milk helps in table 3. lifestyle to menopausal complaints (n=101) lifestyle menopausal complaints none n (%) mild n (%) moderate n (%) severe n (%) total n (%) healthy 5 (4.9) 17 (16.8) 39 (38.6) 8 (7.0) 69 (68.3) unhealthy 1 (1.0) 0 (0.0) 14 (14.0) 17 (16.8) 32 (31.7) total 6 (5.9) 17 (16.8) 53 (52.5) 25 (24.0) 101 (100) spearman’s rho test: p=0.000; r=-0.424 table 4. level of stress to menopausal complaints (n=101) level of stress menopausal complaints none n (%) mild n (%) moderate n (%) severe n (%) total n (%) normal 6 (5.9) 16 (15.8) 36 (35.6) 6 (5.9) 64 (63.3) mild 0 (0.0) 1 (1.0) 9 (9.0) 2 (1.9) 12 (11.9) moderate 0 (0.0) 2 (1.9) 5 (4.9) 14 (14.0) 21 (20.8) severe 0 (0.0) 0 (0.0) 1 (1.0) 3 (3.0) 4 (4.0) total 6 (5.9) 19 (18.8) 51 (50.5) 25 (24.7) 101 (100) spearman’s rho test: p=0.000; r=0.535 n. k. a. armini et al. 188 | pissn: 1858-3598  eissn: 2502-5791 supplying the hormone estrogen, the lack of which is caused by decreased ovarian function. stress is an adaptive response through individual characteristics or psychological processes directly to the action, situation, and external events that give rise to the special demands of both physical and psychological issues question (hawari, 2016). stress is not only about dysfunction or abnormalities of organs, but it also has a psychological impact, for example anxiety and/or depression (yusuf, armini, & hardiyan, 2008). severe levels of stress can affect the cardiovascular system, causing symptoms such as heart palpitations, and blood vessel dilation or constriction; other than that the body feels hot flushes that aggravate the symptoms of hot flushes (bauld & brown, 2009). somatic symptoms are often seen as a symptom of follow up or a result of stress, anxiety, and depression is prolonged. someone in the field of sexual excitement can also be affected by stress (thurston & joffe, 2011). people who are stressed often complain of muscle sensations like tingling, aching, and strain. bone joint complaints are often experienced by, for example, feeling pain or stiffness when moving the limbs. decreased libido is also often experienced by someone with high stress (hawari, 2016). the results showed postmenopausal women with stress level category of moderate to severe respiratory symptoms sexual problems weight category. respondents who had complaints of discomfort in the joints and muscles are located mainly in the category of mild to severe with normal stress levels; the more severe a person’s stress level, grievance felt increasingly severe menopause. the majority of respondents said that the way to overcome the stress experienced was by worshiping, praying, and recreation with family. almost all respondents are housewives, where the frequency of socializing with neighbors and family is more flexible to follow the teaching activities and exercises organized by the posyandu. bauld & brown (2009) and moon et al. (2017) reported that negative events or emotions can worsen the symptoms of menopause, which demonstrates the importance of the effect of psychosocial factors on menopausal symptoms. there are three respondents who have highstress levels with severe menopausal complaints, seen from three respondents who have experienced menopause for 5-10 years. this is because the old woman with 7 years of experience of menopausal symptoms during the menopausal transition and 4.5 years after the cessation of menstruation, so the complaint can still be perceived by the respondents with a range of menopause 5-10 years old and is augmented with severe stress levels. all three respondents are housewives whose activities are mostly done at home, are likely to experience higher stress associated with marital problems, and rarely do sports with the family. there was one respondent to the level of stress but had complaints of menopause medium category. of respondents 60 years of age, at the age of postmenopausal women age limit towards medium. conclusion menopausal women with healthy lifestyleare more likely to have less menopausal complaints. menopausal women with lower stress levels experience reduction in menopausal complaints. respondents manage the stressors by peer socialization, recreation with family, and following health education. women in pre-menopause period should have motivation to maintain a healthy lifestyle, which involves a balanced diet, physical activity, restful sleep, avoiding smoking and drinking alcoholic beverages, and being able to manage stress in a positive direction to reduce menopausal complaints. further research can be developed for intervention models to improve healthy lifestyles and stress management in menopausal women. references anggrahini, k., & handayani, s. (2014). pengaruh konsumsi susu kedelai terhadap keluhan menopause. jurnal kebidanan, vi(02). avis, n. e., crawford, s. l., greendale, g., bromberger, j. t., everson-rose, s. a., gold, e. b., … thurston, r. c. (2015). duration of menopausal vasomotor symptoms over the menopause transition. jama intern med, 175(4), 531–539. bauld, r., & brown, r. f. (2009). stress, psychological distress, psychosocial factors, menopause symptoms and physical health in women. maturitas, 62, 160–165. baziad, a. (2007). pra, peri dan pasca menopause. (satgas endokrinologi reproduksi, ed.). jakarta: perkumpulan obstetri dan ginekologi indonesia. cochran, c. j., gallicchio, l., miller, s. r., zacur, h., & flaws, j. a. (2008). cigarette smoking, androgen levels, and hot flushes in midlife women. obstet gynecol, 112, 1037–1044. curran, d. (2009). menopause (health sys). ann arbor usa: university of michigan. dorjgochoo, t. (2008). dietary and lifestyle predictors of age at natural menopausal and reproductive span in the shanghai women’s health study. menopausal, 15(5), 925–933. freeman, e. w., sammel, m. d., & sanders, r. j. (2014). risk of long term hot flashes after natural menopause: evidence from the penn ovarian aging cohort. menopause, 21(9), 924– 932. gayatri. (2011). women’s guide. jakarta: gagas media. hardy, r. (2000). smoking, body mass index, socioeconomic status and the menopausal transition in a british national cohort. international journal epidemiol, 29(5), 845–851. hawari, d. (2016). manajemen stres, cemas dan depresi. jakarta: fkui. heinemann, k., ruebig, a., potthoff, p., schneider, h. jurnal ners http://e-journal.unair.ac.id/jners | 189 p., strelow, f., heinemann, l. a., & thai, d. m. (2014). the menopause rating scale (mrs) scale: a methodological review. health and quality life outcome, 2(45). heinemann, l. a. j., potthoff, p., & schneider, h. p. g. (2003). international version of the menopause rating scale (mrs). health and quality life outcome. kemenkes ri. (2016). situasi lanjut usia (lansia) di indonesia. jakarta. lovibond, s. h., & lovibond, p. f. (1995). manual for the depression anxiety stress scales (2nd ed.). sydney: sydney: psychology foundation. mansikkamaki, k., raitanen, j., malila, n., sarkeala, t., mannisto, fredman, j., … luoto, r. (2015). physical activity and menopause-related quality of life – a population-based cross-sectional study. maturitas, 80, 69–74. moon, z., hunter, m. s., moss-morris, r., & hughes, l. d. (2017). factors related to the experience of menopausal symptoms in women prescribed tamoxifen, journal of psychosomatic obstetrics & gynecology. journal of psychosomatic obstetrics & gynecology, 38(3), 226–235. muharam. (2007). simposium nasional perkumpulan menopause indonesia (permi) (p. 21–22 april 2007). jakarta. mulyani, n. s. (2013). menopause: akhir siklus pada wanita di usia pertengahan. yogyakarta: nuha medika. o’neill, s., & eden, j. (2012). the pathophysiology of menopausal symptoms. journal obstetrics gynaecology and reproductive medicine, 22(3), 63–69. oi, n., & ohi, k. (2012). a study of menopausal symptoms in relation to habits of smoking and make-up using in japanese women aged 35–59. international journal of cosmetic science, 34, 332–337. priyoto. (2014). teori sikap dan perilaku dalam kesehatan. yogyakarta: nuha medika. proveraati, a., & sulistyawati, e. (2010). menopause dan sindrom premenopause. yogyakarta: nuha medika. rahmayani, d., wijaksono, m. a., & putri, r. r. (2016). hubungan tingkat stress dan gaya hidup dengan kualitas tidur lansia si panti sosial tresna werdha (pstw) budi sejahtera banjarbaru. dinamika kesehatan, 7(1), 113–126. sternfeld, b., guthrie, k. a., ensrud, k. e., lacroix, a. z., larson, j. c., & dunn, a. l. (2014). efficacy of exercise for menopausal symptoms: a randomized controlled trial. menopause, 21, 330–338. stojanvska, l., apostolopoulos, v., polman, r., & borkoles, e. (2014). to exercise, or, not to exercise, during menopause and beyond. maturitas, 77, 318–323. terachi, m., obayashi, s., akiyoshi, m., kato, k., matsushima, e., & kubota, t. (2010). insomnia in japanese periand postmenopausal women. climacteric, 13, 479–496. thurston, r. c., & joffe, h. (2011). vasomotor symptoms and menopause: findings from the study of women’s health across the nation. obstet gynecol clin north am, 38(3), 489–501. yusuf, a., armini, n. k. a., & hardiyan, d. (2008). peer group support menurunkan tingkat depresi wanita menopause, jurnal ners unair. jurnal ners, 3(1), 61–66. 404 not found not found the requested url was not found on this server. apache/2.4.41 (ubuntu) server at e-journal.unair.ac.id port 80 the improvement of student competency in a clinical study in indonesia: what factors played an important role? muhammad hadi*, achir yani s. hamid**, sudijanto kamso***, sutoto sutoto****, ahmad watik pratiknya*****, nursalam nursalam******, ferry efendi****** * faculty of nursing, universitas muhammadiyah jakarta, indonesia ** indonesian national nurses association, indonesia *** faculty of public health, universitas indonesia, indonesia **** komite akreditasi rumah sakit, indonesia *****faculty of medicine and health sciences, universitas muhammadiyah jakarta, indonesia ****** faculty of nursing, universitas airlangga, indonesia email: hadi_bintang001@yahoo.co.id abstract background: the improvement of nursing student competency currently is still an issue for the majority of nursing education institutions in indonesia. this is due to their partnership with hospitals having not been supported by adequate policies and other factors. objectives: the purpose of this study is to identify the appropriate model for improving student competency in a clinical study. the design used in this study was an observational study with cross-sectional approach. methods: the research design used a cross-sectional approach involving five hospitals and five universities. three hundred and eighty-four participants were recruited from these sites. the data was analysed using multiple logistic regression. results: the results showed that the partnership contributed 3.36 times, the patient variations 2.96 times, the job description of the clinical educator 2.30 times, a role model 2.28 times, and the expertise of the faculty educator 2.08 times towards the achievement of student competency in the clinical study. conclusions: it can be concluded that the partnership aspect, patient variation, job description of the clinical educator, role model, the expertise of the faculty educator, and the level of education has a significant role to improve the achievements coming from the level of student competency in the clinical study. the results of this study can be used by nursing educational institutions, hospitals and the government to organise a nursing education model for the more optimal achievement of the student’s competencies. keywords: partnership, nursing education, competence, hospitals introduction the indonesian hospital association in 2012 recorded a number of hospitals throughout indonesia, as many as 1979, with the average annual growth being around 1.14% (azhary, 2009). the constraints faced by the hospitals includes the lack of competent health resources. this includes the number of nurses, high investment costs, geopolitical issues and public perception. this is still low in relation to the quality of the health services in indonesia (azhary, 2009). the growth of the number of hospitals was also followed by a rapid growth in the nursing education institutions (kurniati and efendi, 2012). the final report in 2011 from the health education project-directorate general of higher education mentioned that the number of nursing education institutions at a master’s degree level had increased to 12 institutions, and the number of professional education institutions had increased to 112 institutions. the existence of nursing education has not been matched by an adequate arrangement of practices in hospitals, clinics, public health centres, homes for the elderly and the community (aipni, 2010). besides that, the existence of nursing education has not been matched by an increase in the quality and quantity of the lecturer (aipni, 2010). the large number of nursing institution education practices compared with the practice availability currently is still a complicated issue (myrick and yonge, 2002). the problem is that the management of clinical education is still poor and the coordination of the achievement of the learning objectives for the students is not going well (nursalam and efendi, 2008). the weak management of nursing education is drawn from the results of a survey conducted by the association of indonesian nurses’ educational institutions and the indonesian national nurses association in 2010 among 33 provinces, which showed that 90% of nursing education had not met the standards of nursing education provision (health professional education quality-project, 2011). education institutions require hospitals to jurnal ners vol. 12 no. 2 oktober 2017: 151-157 152 increase their knowledge and to enhance the skills of students (canadian nurses association, 2014). the hospital requires educational institutions to develop science to improve the quality of care (davis and irvine, 2003). one of the problems found in indonesia is that the hospitals are not capable of facilitating clinical practice to increase the student’s competence optimally. this is characterised by weak policy support, a low awareness of the values of partnership and joint ownership, the limited human resources of both parties, and the lack of an ideal nursing practice model and the development of the nursing profession (aipni, 2010). the students are often confused when practicing in a hospital because of the unfamiliar situations encountered in hospitals (myrick and yonge, 2005; flanagan, baldwin and clarke, 2000). this condition causes the nursing students to find it difficult to develop their professional abilities because the clinical study environment has not been well-established previously (al-hussami et al., 2011). therefore, this situation encourages the researchers to design a clinical learning model that emphasises partnerships between hospitals and educational institutions to obtain an optimum competence level to do with clinical study. this research study combines the practice-research model of curtin university of technology (2001) and the collaborative clinical education epworth daekin model (2003) with the theoretical approach of king’s goal attainment (alligood & tomey, 2002). the purpose of this study was to identify the appropriate model for improving student competency in a clinical study. materials and methods the research was conducted in januaryseptember 2013 by a cross-sectional design approach involving five hospitals (fatmawati hospital jakarta, hasan sadikin hospital bandung, kariadi hospital semarang, sardjito hospital yogyakarta, and soetomo hospital surabaya) and five universities (universitas muhammadiyah jakarta, universitas padjadjaran bandung, universitas gadjah mada yogyakarta, universitas diponegoro semarang, and universitas airlangga surabaya). the research consisted of variables and demographics such as sex, age and education; support; faculty staff; mastery of the curriculum, the suitability of expertise and provide study guidelines; the fundamental values of collaboration; collegial partnership and collegial ownership; the availability of clinical learning resources; variations inpatient case, clinical facilities, libraries and standards of practice; nurse clinics; support facilities, nursing management, working conditions, career opportunities, job descriptions and role models with the last variable being the achievement of student learning competencies. the research instrument was validated through testing of validity (content and construct) and reliability (hastono, 2001; pratiknya, 2011). this research was done to prove that the variables that have been identified are instrumental in shaping a model for improving student competency in a clinical study in a hospital. the process modelling was done using multiple logistic regression as a method for obtaining the statistical relationship between several independent variables and the dependent variable with special features in the form of dichotomous dependent variables (hastono, 2001; tabachnick and fidell, 2001; supranto, 2004). prior to this analysis, the researcher selected the candidate variables by conducting a bivariate test. all of the respondents signed the consent agreement which was conducted voluntarily. this research was approved by the ethics committe of faculty of nursing universitas indonesia and the health research ethics committee of the medical faculty at diponegoro university. this study also obtained the permission of five hospitals and five universities where the research was conducted. results the demographic aspects showed that there was a high percentage of women (76.8%) with 24.5% age range between 35-40.9 years old. respondents’ higher education made up 64.8% of nurse graduated with 71.1% of the learner’s competence are high (table 1). univariate analysis of all of the variables showed that the policy support to the use of a hospital as a clinical study was high at 69%, the improvement of student competency in a clinical... (muhammad hadi, et.al.) 153 table 1. details of the variables and respondents (n=384) variables n % gender male female 89 295 23.2 76.8 age <35) yrs 35 – 40.9 yrs 41 – 44,9 yrs ≥ 45 yrs 92 94 72 126 24 24.5 18.8 3.8 education ners graduate/specialist doctor 249 132 3 64.8 34.4 0.8 learners competence low high 111 272 28.9 71.1 policy support low high 119 265 31 69 faculty members mastery of curriculum low high 175 209 45.6 54.4 study guides low high 166 218 43.2 56.8 expertise low high 172 212 44.8 55.2 values peer partnership low high 112 272 29.2 70.8 peer ownership low high 186 198 48.4 51.6 hospital facility cases variation low high 164 220 42.7 57.3 clinic facility low high 92 292 24 76 library low 139 36.2 jurnal ners vol. 12 no. 2 oktober 2017: 151-157 154 high 245 63.8 standard practice low high 46 338 12 88 clinical nurse facility support low high 205 179 53.4 46.6 nursing management low high 101 283 26.3 73.7 working condition low high 214 170 55.7 44.3 career opportunity low high 173 211 45.1 54.9 clarity of job descriptions low high 115 269 29.9 70.1 role model low high 197 187 51.3 48.7 table 2 the results of the variable selection of candidates variables p-value sex (cc) 1.000 age (lr) 0.319 education (lr) 0,001 clinical facilities (cc) 0.037 nursing management (cc) 0.017 standard of competency (cc) 0.677 role model (cc) 0.009 job description (cc) 0.001 career (cc) 0.001 working conditions (cc) 0.050 policy support (cc) 0.084 curriculum (cc) 0.001 compliance of expertise staff (cc) 0.001 learning guide (cc) 0.001 peer partnership (cc) 0.001 peer ownership (cc) 0.004 variation of case (cc) 0.001 hospital’s library (cc) 0.004 support facilities (cc) 0.021 note: cc= continuity correction, lr=likelihood ratio the improvement of student competency in a clinical... (muhammad hadi, et.al.) 155 while mastery of the curriculum to achieve the specified competencies was 54.4% high. study guides provided by the faculty were only at 56.8% high, expertise and skills made up 55.2%, peer partnerships 70.8% high, peer ownership 51.6% high, and variations in the cases at 57.3% were categorised as high. clinic facilities were at a 76% high, libraries were at a 63.8% high, 88% were working at more than the level of standard practice, the support facilities made up 53.4% of high, the implementation of nursing management 73.7% high, working conditions 55.7% low, career opportunities 54.9% high, 70.1% was made up by clarity of the job descriptions being high, and role models were at a 51.3% low. the selection of the candidate variables used for multiple logistic regression with the chi-square test has been shown in table 2. most of the identified variables have been entered as candidate variables except for gender and age. competency standards has not been included in the multiple logistic regression because it have a value of p < 0.250. the final results showed that the variables that contributed to the achievement of the student competencies in the clinical study was partnerships, the expertise of the faculty staff, patient variation, the job description, role models and education (table 3). the elements of the collaborative models that have a strong role in relation to the achievement of student competence were role models, job description clarity, suitability, the expertise of the faculty staff, peer partnership values, the availability of a variety of cases and education. the most dominant factor is the peer partnership variable. the suitability and expertise of the faculty staff were 2.08 times more likely to relate to the achievement of competence. the value of peer partnership has 3.36 times to relate to the attainment of competence. the availability of the variation in cases in the clinic 2.96 times relates to the achievement of competence. the job description of the clinical nurse relates by 2.23 times and is significantly associated with the achievement of competence. role models in the clinic are 2.28 times related and significantly associated with the achievement of competence in the learners. meanwhile the education up to master's degree, specialist and doctoral level negatively related to the achievement of student competence. the analytical statistics found out that there were no interaction between the role models and job description. the statistical test also found out that the variable of education was not a confounding variable. discussions partnership between the hospitals and educational institutions is a necessity as a way to increase student competence. educational institutions play a role in improving the quality of students from the aspect of knowledge, skills and attitudes (canadian nurses association, 2014; billings and halstead, 2012). the hospital serves the student as a way to apply knowledge, table 3 multiple logistic regression analysis of the achievement of student competence variable b s.e. wald df exp (b) suitability and expertise of faculty staff 0.733 0.282 6.744 1 2.08** peer partnership 1.215 0.272 19.993 1 3.36*** variation of case 1.086 0.266 16.670 1 2.96*** job description 0.802 0.282 8.092 1 2.23** role model 0.824 0.280 8.662 1 2.28** education 4.991 2 education(1) -0.594 0.280 4.495 1 0.55** education(2) -1.113 1.296 0.737 1 0.32 constant -1.431 0.359 15.911 1 0.23*** *p<0.05, **p<0.01, ***p<0.001. jurnal ners vol. 12 no. 2 oktober 2017: 151-157 156 training skills and to give them information about the development of knowledge in the hospital context (grove, burns and gray, 2013; mantzorou, 2004). the policy on educational partnerships with hospitals is effectively used to address health disparities issues, thus requiring all health services in an appropriate partnership to address wider health problems (world health organization, 2001, 2010; canadian nurses association, 2014). the variety of cases in the hospital played an important role in the achievement of student competence. students, in handling varied cases in nursing, are encouraged to be able to formulate nursing diagnoses with various cases (chickerella and lutz, 2010). the more varied cases encountered by the students is a way of increasing their ability to formulate the problem, and the actions that will subsequently be applied. for a clinical educator, the variations in the patient cases will guide the students to think about different aspects. the students not only focus on the completion of the main problem, but think about some of the problem’s details simultaneously (myrick and yonge, 2002). the clarity of the job description as a form of clinical educator provides convenience for the nurses that work in the hospitals to play two roles. the first role is to provide quality nursing care. the second role is to provide guidance to students who utilise the hospital where they work to train their clinical skills (cherry and jacob, 2014) the arrangement of the job description is important in order for the clinical educator to play both roles. the arrangements of the job description also provide comfort for the clinical educators and are a form of respect for them because it’s how they show they are a good nurse (burns et al., 2006). in this research, the results show that the duty of clinical educator is an important factor that contributes to the achievement of the student’s competence (chickerella and lutz, 2010). the role model in this research plays an important role in the achievement of student competence (bott, mohide and lawlor, 2011). currently, there is a lack of role models in nursing care (aipni, 2010). clinical nurses who are able to act as a role model have not been found much (health professional education quality-project, 2011). however, these factors are important to achieving student competence. the literature has shown that the clinical educator is a role model, mentor, and a mirror for the students. how to speak, act and behave, listen, work, and to make a decision in a specific situation in the nursing service would be an example for the students (adelman-mullally et al., 2013; canadian nurses association, 2014; kim and shin, 2017). the need of role model was compulsory in order to enhance the best outcome of student competency. the expertise of the clinical educators and faculty is one of the factors that plays an important role in the achievement of student competencies (myrick and yonge, 2002). clinical educators and the faculty staff are registered nurses who have special training or sufficient education to serve as a role model, resource and mentor for nursing students (yonge et al., 2012). they prepare the students to achieve a particular competence accordance to the hospital’s goals. nurse educators have a unique and important role in the educational process of the nursing profession (myrick and yonge, 2005). these findings further support the idea of the critical role of capable clinical educators and faculty members. conclusions the results of this study have concluded that the model for the improvement of student competency includes partnerships, expertise, and suitability faculty staff, the availability of variation in the cases in the clinic, the job description of the clinical nurse, role models and the education of the clinical and faculty educators. these findings suggest that student competencies in the clinical phase should take into account the complex healthcare environment. improvement can be made by targeting the identified factors that may contribute to the better achievement of student competency. references adelman-mullally, t. et al. (2013) ‘the clinical nurse educator as leader’, nurse education in practice. elsevier, 13(1), pp. 29–34. aipni (2010) kurikulum pendidikan ners; implementasi kurikulum kbk. jakarta. the improvement of student competency in a clinical... (muhammad hadi, et.al.) 157 al-hussami, m. et al. (2011) ‘evaluating the effectiveness of a clinical preceptorship program for registered nurses in jordan’, the journal of continuing education in nursing, 42(12), pp. 569–576. doi: 10.3928/00220124-20110901-01. alligood & tomey (2002) nursing theory aplication and utilization. 2nd edn. mosby, philadelphia. azhary, m. e. (2009) ‘potret bisnis rumah sakit indonesia. economic review’, economic review, (218). billings, d. m. and halstead, j. a. (2012) teaching in nursing, a guide for faculty. fifth. wb saunders company, an imprint of elsevier inc. bott, mohide and lawlor (2011) ‘a clinical teaching technique for nurse preceptors: the five minute preceptor’, journal of professional nursing, 27(1). doi: 10.1016/j.profnurs.2010.09.009. burns, c. et al. (2006) ‘no title’, journal of pediatric health care, 20(3), pp. 172– 183. doi: 10.1016/j.pedhc.2005.10.012. canadian nurses association (2014) achieving excellence in professional practice, a guide to preceptorship and mentorship. ottawa canada. cherry, b. and jacob, s. (2014) contemporary nursing, issues, trends & management. mosby, an inprint of elsevier inc. chickerella, b. g. and lutz, w. j. (2010) ‘professional nurturance: preceptorships for undergraduate nursing students’, american journal of nursing, 81(1). davis and irvine (2003) the role of the university hospital. los angeles, san diego, and san francisco. flanagan, j., baldwin, s. and clarke, d. (2000) ‘work-based learning as a means of developing and assessing nursing competence’, journal of clinical nursing, 9(3), pp. 360–368. doi: 10.1046/j.13652702.2000.00388.x. grove, s. k., burns, n. and gray, j. r. (2013) the practice of nursing research, appraisal, synthesis and generation of evidence. seven. sounders, an imprint of elsevier inc. hastono, s. p. (2001) analisis data. universitas indonesia. health professional eduction qaulity-project; (2011) laporan survey data dasar pendidikan keperawatan. kim, e.-k. and shin, s. (2017) ‘teaching efficacy of nurses in clinical practice education: a cross-sectional study’, nurse education today. elsevier, 54, pp. 64–68. kurniati, a. and efendi, f. (2012) kajian sumber daya manusia kesehatan di indonesia, salemba medika. jakarta: salemba medika. doi: 10.13140/rg.2.1.1440.6804. mantzorou (2004) ‘preceptorship in nursing education: is it a viable alternative method for clinical teaching?’, pp. 1–10. myrick, f. and yonge, o. (2005) nursing preceptorship connecting practice and education. edited by i. dana. philadelpia: lipincott, william & wilkinsis. myrick and yonge (2002) ‘preceptorship and critical thinking in nursing education’, journal of nursing education, 41(4), pp. 154–164. nursalam, n. and efendi, f. (2008) pendidikan dalam keperawatan. jakarta: salemba medika. pratiknya, a. w. (2011) dasar-dasar metodologi riset kedokteran dan kesehatan. jakarta: rajawali pers. supranto, j. (2004) analisis multivariat : arti dan interpretasi. jakarta: rineka cipta. tabachnick, b. g. and fidell, l. s. (2001) using multivariate statistics. usa: a pearson education company. world health organization (2001) nursing and midwifery workforce management. searo technical publication no 27. world health organization (2010) ‘framework for action on interprofessional education & collaborative practice’, health professional networks nursing & midwifery human resources for health,. yonge, o. et al. (2012) ‘preceptorship and mentorship’, 2012, pp. 2–4. doi: 10.1155/2012/790182. http://e-journal.unair.ac.id/jners | 233 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i2.9770 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research the perception of indonesian nursing students on the learning environment in clinical practice pepin nahariani 1, fahruddin kurdi 2 and ratna puji priyanti 2 1 department of fundamental nursing and nursing management, stikes pemkab jombang, east java, indonesia 2 department of medical-surgical and emergency nursing, stikes pemkab jombang, east java, indonesia abstract introduction: the clinical practice environment students have multiple roles as learners and service providers. at this time students are faced with a fluctuating, complex environment and far from the predictions and controls of academic teachers. the aim of this study was to evaluate nursing student satisfaction and perception of the learning environment in clinical practice. methods: this study used correlational analytic survey methods with cross-sectional approach. a total of 164 nursing student were selected using a convenience sampling. the data were collected in three schools of nursing in east java. data were obtained using the bahasa version of the clinical learning environment, supervisions and nurse teacher (cles+t). the instrument showed good validity and reliability. the data were analyzed using descriptive analytic, spearman rho correlation and logistic regression. results: respondents were 164 students, clinical learning practice is mainly determined by the role of nurse teacher (m = 3.82; sd = 0.496). student satisfaction obtained at 56.7%. there was a significant relationship between clinical practice learning and student satisfaction with p-value 0.000. the highest correlation value is the role of lecturer nurse (r = 0.544), with value r2 = 0.377, the coefficient of β adjusted highest to 2.075. conclusion: according to student perceptions, the content of supervisory relations, the pedagogy atmosphere in the ward/room and the role of the nurse lecturer contributed greatly to creating a conducive clinical learning environment. article history received: september 19, 2018 accepted: march 11, 2019 keywords clinical learning environment; nursing education; nursing students contact pepin nahariani  ns.ratnapuji@gmail.com  department of fundamental nursing and nursing management, stikes pemkab jombang, east java, indonesia cite this as: nahariani, p., kurdi., f., priyanti, r. p. (2018). the perception of indonesian nursing students on the learning environment in clinical practice. jurnal ners, 13(2), 233-237. doi:http://dx.doi.org/10.20473/jn.v13i2.9770 introduction clinical learning practice for nursing students is an important part of the learning process because of the gap between theory and practice (myrick & yonge, 2005). clinical teaching practice encourages students to prepare themselves in applying the theories gained during academic education into the clinical practice environment (allan, smith, & o’driscoll, 2011). during the student clinic learning to be very vulnerable (chan, 2001), nursing students were asked to apply theories directly to the patient as well as about the assessment of nursing staff regarding the actions taken (chan, 2003). while in the clinical practice environment students have multiple roles as learners and service providers (hoffman & donaldson, 2004). at this time students are faced in a fluctuating, complex environment and far from the predictions and controls of academic teachers. while in the clinical practice environment nursing student’s has a close bond with the real work environment, in which nursing students’ has multiple roles as learners https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ns.ratnapuji@gmail.com http://dx.doi.org/10.20473/jn.v13i2. p. nahariani et al. 234 | pissn: 1858-3598  eissn: 2502-5791 and service providers (allan et al., 2011; chan, 2003; ip & chan, 2005; papp, markkanen, & von bonsdorff, 2003). therefore, the nursing student faced conflict in clinical learning, besides the role conflict students are also faced with the fear of hurting patients and making mistakes (chan, so, & fong, 2009; elliott, 2002; moscaritolo, 2009). students feel that their limited knowledge and other anxieties will impact the mistakes they make in clinical learning on career paths when they graduate (elliott, 2002). all forms of conflict and challenges faced by students in clinical practice, of course, can not be separated from the guidance of academic lecturers. the role of nursing lecturers in clinical teaching practice is important. a nursing lecturer is someone who knows the nursing dedication, custody of clinical placement, as well as student skills and expertise (papp et al., 2003). however, the characteristics of the nurse lecturers that want perfection from student performance lead to another source of anxiety for students (saarikoski, warne, kaila, & leino-kilpi, 2009). thus, based on the perception of nursing students, the conducive clinical practice learning environment is highly conquered (antohe, riklikiene, tichelaar, & saarikoski, 2016). the environment in which the atmosphere supports students to learn recognizes wrongdoing, provides full moral support, as part of the learning process (warne et al., 2010). so they can build their full capacity during the learning process. for that, an evaluation of the clinical practice learning environment is needed. an assessment of the clinical practice learning environment of nursing student perceptions, and satisfaction of clinical practice learning as one of the strategies to create an effective and conducive learning environment. however, there is lack information about nursing student perceptions and satisfaction of clinical learning environment in indonesia. the aim of this study was to evaluate the nursing student satisfaction and perception of the learning environment in clinical practice and hospital-based supervision. materials and methods this study used correlational analytic survey method with a cross-sectional approached. the study population is the nursing student school of nursing in indonesia. the population was nursing students in three schools of nursing in east java province, indonesia, as many as 214 people. a total of 180 respondents was selected by a convenience sampling technique. convenience sampling is a type of nonprobability sampling where members of the target population that meet certain practical criteria, such as easy accessibility, geographical proximity, availability at a given time, or the willingness to participate in the study (etikan, musa, & alkassim, 2016). the clinical learning environment, supervision and nurse teacher variable was assessed by clinical learning environment scale + nurse teacher (cles+t) based on the fundamental theory of clinical learning (saarikoski, isoaho, warne, & leino-kilpi, 2008). the instrument consists of 34 statements divided into five sub-dimensions, namely the atmosphere of learning strategy (pedagogy) in ward (9 statements), supervision relationship (8 statements), headroom or ward managers (4 statements), and the role of lecturer nurse (9 statements). also, one sub-dimension was about student satisfaction in clinical practice. the nursing student assessment used ordinal scale: very dissatisfied, dissatisfied, neutral, satisfied and very satisfied. reliability for this instrument has been reported using cronbach's alpha with values ranging from 0.96 (height) to 0.77 (marginal) (saarikoski, 2002). the english version of the cles+t had been translated into backward-forward indonesian by using international guides (epstein, santo, & guilemin, 2015). the result of content validity indexfor scale (s-cvi) obtained 0.9405, while the validity test using principal component analysis (pca) test with n = 46, obtained eigenvalue and explanation percentage of 67%, and cronbach alpha of 0.786 (priyanti & nahariani, 2016). these results were similar to the results of validity and reliability in the development of english version of the instrument, pca 67% and cronbach alpha of 0.90 (saarikoski, 2002). data collection the data were collected from students practicing clinical learning from three schools of nursing in east java. all of those students were in the fifth year or doing professional nursing stage in hospital. they were offered to participate in this study by giving an explanation of research subject sheet. this explanation contained the research title and objectives, the name of principal investigator, and the address of the principal investigator. students filling out the inform consent were considered willing to participate in this study. in addition, prospective respondents would also get a procedure to answer the questionnaire. all data were analyzed using spss version 17 for windows and p values of less than 0.05 would be considered statistically significant. the data were analyzed using spearman rho correlation for bivariate analysis and logistic regression for multivariate analysis. ethical considerations the ethical clearance had been obtained from the faculty of nursing universitas airlangga’s health research ethics committee number 228-kepk dated august 12th, 2016. an anonymity, and coding systems are used in the analysis of research data to respect the rights and privacy of respondents. during the study, respondents were not forced to undergo research and did not have any impact on the respondents. jurnal ners http://e-journal.unair.ac.id/jners | 235 results the total of respondents collected from three schools of nursing was 180 out of 214 nursing students. in the tabulation and coding stage, 16 respondents were deleted due to missing data. thus, the total number of respondents without missing data that were analyzed by statistics was 164 respondents. respondents’ age ranged from 20 to 28 years, with more than half were 20-22 year-olds (89; 54.3%). in regards to the gender, the most of respondents were female (115; 70.1%). in addition, the most of respondents (62; 37.8%) practiced at medicalsurgical nursing stage which had the largest participants (table 1). the cles+t scale had mean values of each subdimension ranged from 3.64 to 3.83. the value of the content of the supervisory relationship is given the highest score with m = 3.83; sd = 0.426 (table 2). more than half of students were supervised by ward managers (92; 56.1%), and as many as 61 respondents (37.2%) obtained one supervisor same for one group. as many as 56 respondents (34.1%) stated that the supervision frequency was once in a week (table 3). student’s satisfaction with the clinical learning environment was also evaluated. more than half of the students said they were satisfied and very satisfied with the clinical learning process by 120 respondents (73.2%) (table 4). based on the result of bivariate table 1 characteristics of the respondents (n=164) variables n % age 20-22 years 89 54.3 23-35 years 70 42.7 26-28 years 5 3.0 gender male 49 29.9 female 115 70.1 practice stage mental health nursing 13 7.9 community nursing 33 20.1 medical-surgical nursing 62 37.8 pediatric nursing 26 15.9 maternity nursing 15 9.1 gerontological nursing 14 8.5 emergency nursing 1 0.6 table 2 clinical learning environment, supervision and nurse teacher cles+t (n=164) sub dimension m sd se pedagogical atmosphere in the ward 3.64 0.461 0.036 leadership style of the ward manager 3.76 0.539 0.042 premises of nursing on the ward 3.65 0.476 0.037 supervisory relationship 3.83 0.426 0.033 role of nurse teacher 3.82 0.496 0.039 table 3 supervisory relationship (n=164) variables n % title of supervisor nurse 33 20.1 nurse specialist 5 3.0 assistant ward manager 34 20.7 ward manager 92 56.1 supervisory status i did not have a supervisor at all 7 4.3 a personal supervisor was named, but the relationship with this person did not work during the placement 18 11.0 the named supervisor changed during the placement, even though no change had been planned 15 9.1 the supervisor varied according to shift or place of work 43 26.2 the same supervisor had several students and was a group supervisor rather than an individual supervisor 61 37.2 a personal supervisor was named and our relationship worked during this placement 20 12.2 supervision frequency not at all 39 23.8 once or twice during the course 39 23.8 less than once a week 20 12.2 about once a week 56 34.1 more often 10 6.1 p. nahariani et al. 236 | pissn: 1858-3598  eissn: 2502-5791 statistic analysis, there was a significant correlation between student satisfaction with the five subdimensions cles+t scales. the value ranges from 0.355-0.544. this coefficient correlation can be interpreted as low to moderate correlation (sugiyono, 2008). the role of the nurse teacher obtained the biggest value = 0.544 (table 5). the result of regression analysis as a whole between the five sub-dimensions of cles+t scale obtained significant value with value p-value 0.000 lower than α-value equal to 0.05, and value of f equal to 19.122, with value r2 = 0.377. among the five subdimensions of cles+t, the role of nurse teacher, get the positive result of β-adjusted coefficient of 2.075, with a significant value p-value 0.000 lower than αvalue of 0.05. based on these results, it can be interpreted that for every 1-unit increase in nurse teacher sub-dimension, the nursing students’ satisfaction will increase by the beta coefficient value (table 6). discussion nursing student perception of their clinical learning environment was described in five sub dimensions of the cles+t. the supervisory relationship has the highest average among others. most of the nursing student had describe that the supervisor as one supervisor for several students and the supervision meeting was once a week. in addition, most of nursing students were satisfied of the clinical learning environment. which, the nurse teacher role has the highest impact of nursing student’s satisfaction. in this study, students consider the role of the nurse teacher is very important for students in the achievement of the clinical learning process (kurdi, nahariani, & priyanti, 2018; saarikoski et al., 2009). this is not in accordance with previous research, it was mentioned that the connection of supervision, culture, organizational structure, and room atmosphere could affect the clinical learning environment (flott & linden, 2016; mikkonen, elo, kuivila, tuomikoski, & kääriäinen, 2016; saarikoski, 2002). service quality provides a great role in student clinical learning environments (dimitriadou, papastavrou, efstathiou, & theodorou, 2015; papastavrou, lambrinou, tsangari, saarikoski, & leino-kilpi, 2010; warne et al., 2010), and nursing staff as role models in providing professional services to patients (papp et al., 2003). the learning of nursing clinics, influenced by the atmosphere of the ward/room, organizational structure and supervision (saarikoski et al., 2008). the ward atmosphere is said to play an important role in the success of clinical learning (saarikoski et al., 2008; warne et al., 2010). the role of lecturers has little to do with clinical learning practices (papp et al., 2003). based on the results of the study, in indonesia, the role of nursing lecturers becomes very important for students in creating an effective clinical learning environment. students become satisfied with the learning process if nurse lecturers are actively involved in clinical practice learning. next is the atmosphere of learning in the room. the atmosphere table 4 students satisfaction in clinical practice (n = 164) category n % very dissatisfied 1 0.6 not satisfied 2 1.2 neutral 41 25 satisfied 93 56.7 very satisfied 27 16.5 total 164 100 table 5. student’s satisfaction with five sub-dimension of the cles+t scale sub-dimension r p pedagogical atmosphere in the ward 0.425 0.000 leadership style of the ward manager 0.355 0.000 premises of nursing on the ward 0.357 0.000 supervisory relationship 0.410 0.000 role of nurse teacher 0.544 0.000 total 0.497 <0.0001 table 6. regression analysis of student’s satisfaction with cles+t model unstandardized coefficients standardized coefficients t sig. b std. error beta (constant) 0.227 0.456 0.498 0.619 pedagogical atmosphere in the ward -0.696 0.218 -0.451 -3.191 0.002 leadership style of the ward manager -0.660 0.171 -0.500 -3.863 0.000 premises of nursing on the ward -0.875 0.213 -0.586 -4.103 0.000 supervisory relationship -0.705 0.222 -0.423 -3.183 0.002 role of nurse teacher 3.892 0.663 2.075 5.872 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 237 is not a conducive atmosphere, resulting in the students get their own pressure in doing clinical teaching practice. although it is mentioned that the preceptorship model according to previous researchers is considered to be most appropriate in clinical teaching practice (clayton, broome, & ellis, 1989; happell, 2009; myrick & yonge, 2005; udlis, 2008). the limited number of clinical preceptors, resulting in the supervisors who are assigned to the clinical practice learning is only one person for one group. moreover, the high workload of nurses, most nurses who served as supervisors are ward or head managers. the study has conducted as the basic information of student perception and satisfaction of clinical earning environment. this basic information can be used to evaluate the clinical learning environment. the result can be used to determine the conducive learning environment, and the suitable methods of clinical environment. the further study needs to determine the effectiveness of each methods of supervision and supervisor. nursing education curriculum in indonesia in addition to academic education, clinical learning is needed to improve the competence of graduates. clinical learning aims to equip students with a clinical competency, with a direct approach to patients to improve professional competence (allan et al., 2011; chan, 2003; elisabeth, christine, & ewa, 2009). in complex and unpredictable clinical learning, students become susceptible to stress and affecting the learning process (chan et al., 2009; elliott, 2002; ip & chan, 2005; moscaritolo, 2009; papp et al., 2003). therefore, creating conducive learning environment for nursing student is necessary. the selection of supervisors, type of supervision, room atmosphere and pedagogical atmosphere in clinical learning is an important consideration in planning clinical learning for nursing students. limitations this study has many limitations, one of which is the convenience sampling method and only three schools of nursing in one province. a small number of samples may also affect the results of the study. conclusion overall, according to student perceptions, the content of supervisory relations, the pedagogy atmosphere in the ward or room and the role of the nurse teacher dominantly contributed in creating a conducive clinical learning environment. so that the results of research can be used as information about the role of teachers in creating a conducive clinical practice environment for students. further research is suggested to use a larger sample size and can represent the clinical learning environment in indonesia as a whole. and using educational institutions with preceptorship learning model as a comparison with the method of learning one supervisor for one group. acknowledgment we thank to stikes pemkab jombang who has funded this research with the institutional research grant, dr. mikko saarikoski who has given permission in the use of instruments. references allan, h. t., smith, p., & o’driscoll, m. (2011). experiences of supernumerary status and the hidden curriculum in nursing: a new twist in the theory–practice gap? journal of clinical nursing, 20(5‐6), 847–855. antohe, i., riklikiene, o., tichelaar, e., & saarikoski, m. (2016). clinical education and training of student nurses in four moderately new european union countries: assessment of students’ satisfaction with the learning environment. nurse education in practice, 17, 139–144. chan, c. k. l., so, w. k. w., & fong, d. y. t. (2009). hong kong baccalaureate nursing students’ stress and their coping strategies in clinical practice. journal of professional nursing, 25(5), 307–313. chan, d. (2001). development of an innovative tool to assess hospital learning environments. nurse education today, 21(8), 624–631. chan, d. s. k. (2003). validation of the clinical learning environment inventory. western journal of nursing research, 25(5), 519–532. clayton, g. m., broome, m. e., & ellis, l. a. (1989). relationship between a preceptorship experience and role socialization of graduate nurses. journal of nursing education, 28(2), 72–75. dimitriadou, m., papastavrou, e., efstathiou, g., & theodorou, m. (2015). baccalaureate nursing students’ perceptions of learning and supervision in the clinical environment. nursing & health sciences, 17(2), 236–242. elisabeth, c., christine, w.-h., & ewa, p. (2009). teaching during clinical practice: strategies and techniques used by preceptors in nursing education. nurse education today, 29(5), 522– 526. elliott, m. (2002). clinical environment: a source of stress for undergraduate nurses. australian journal of advanced nursing, 20(1), 34–38. epstein, j., santo, r. ., & guilemin, f. (2015). epstein, j., santo, r. m., & guillemin, f. a review of guidelines for cross-cultural adaptation of questionnaires could not bring out a consensus. journal of clinical epidemiology, 68(4), 435–441. etikan, i., musa, s. a., & alkassim, r. s. (2016). comparison of convenience sampling and purposive sampling. american journal of theoretical and applied statistics, 5(1), 1–4. flott, e. a., & linden, l. (2016). the clinical learning environment in nursing education: a concept analysis. journal of advanced nursing, 72(3), 501– 513. happell, b. (2009). a model of preceptorship in nursing: reflecting the complex functions of the p. nahariani et al. 238 | pissn: 1858-3598  eissn: 2502-5791 role. nursing education perspectives, 30(6), 372– 376. hoffman, k. g., & donaldson, j. f. (2004). contextual tensions of the clinical environment and their influence on teaching and learning. medical education, 38(4), 448–454. ip, w. y., & chan, d. s. k. (2005). hong kong nursing students’ perception of the clinical environment: a questionnaire survey. international journal of nursing studies, 42(6), 665–672. kurdi, f., nahariani, p., & priyanti, r. p. (2018). komponen evaluasi lingkungan belajar klinik, supervisi dan dosen perawat. journal of health sciences, 11(1). mikkonen, k., elo, s., kuivila, h.-m., tuomikoski, a.-m., & kääriäinen, m. (2016). culturally and linguistically diverse healthcare students’ experiences of learning in a clinical environment: a systematic review of qualitative studies. international journal of nursing studies, 54, 173– 187. moscaritolo, l. m. (2009). interventional strategies to decrease nursing student anxiety in the clinical learning environment. journal of nursing education, 48(1), 17–23. myrick, f., & yonge, o. (2005). nursing preceptorship: connecting practice and education. lippincott williams & wilkins. papastavrou, e., lambrinou, e., tsangari, h., saarikoski, m., & leino-kilpi, h. (2010). student nurses experience of learning in the clinical environment. nurse education in practice, 10(3), 176–182. papp, i., markkanen, m., & von bonsdorff, m. (2003). clinical environment as a learning environment: student nurses’ perceptions concerning clinical learning experiences. nurse education today, 23(4), 262–268. priyanti, r. p., & nahariani, p. (2016). skala evaluasi lingkungan belajar klinik, supervisi dan dosen perawat (clinical learning environment, supervision and nurse teacher–cles+t) versi bahasa indonesia: validitas dan reliabilitas. journal of health sciences, 9(2). saarikoski, m. (2002). clinical learning environment and supervision. development and validation of the cles evaluation scale. university of turku. saarikoski, m., isoaho, h., warne, t., & leino-kilpi, h. (2008). the nurse teacher in clinical practice: developing the new sub-dimension to the clinical learning environment and supervision (cles) scale. international journal of nursing studies, 45(8), 1233–1237. saarikoski, m., warne, t., kaila, p., & leino-kilpi, h. (2009). the role of the nurse teacher in clinical practice: an empirical study of finnish student nurse experiences. nurse education today, 29(6), 595–600. sugiyono. (2008). metode penelitian pendidikan: (pendekatan kuantitatif, kualitatif dan r & d). alfabeta. retrieved from https://books.google.co.id/books?id=0xmcnqaa caaj udlis, k. a. (2008). preceptorship in undergraduate nursing education: an integrative review. journal of nursing education, 47(1), 20–29. warne, t., johansson, u.-b., papastavrou, e., tichelaar, e., tomietto, m., van den bossche, k., … saarikoski, m. (2010). an exploration of the clinical learning experience of nursing students in nine european countries. nurse education today, 30(8), 809–815. http://e-journal.unair.ac.id/jners | 101 jurnal ners vol. 14, no. 1, april 2019 http://dx.doi.org/10.20473/jn.v13i2.9373 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research effect of health lecture using media and peer-education on long acting and permanent methods of contraception helen ermalia1, jimmy yanuar annas2, samsriyaningsih handayani3 1 midwifery education program study, faculty of medicine, universitas airlangga, surabaya, indonesia 2 department of obstetrics and gynecology, faculty of medicine, universitas airlangga, surabaya indonesia 3 department of public health and preventive medicine, faculty of medicine, universitas airlangga, surabaya indonesia abstract introduction: long-acting and permanent methods of contraception (lapms) are known as highly-effective contraception. the department of health of east java province stated that lapm participation is still below target. one of the factors is the interpersonal communication (ipc) skill of the health practitioners. this study aimed to identify the influence of health lectures using media and peer-education on the knowledge and attitude of pregnant women regarding lapms. peer-education is the novelty of this study. methods: a two-group quasi experimental design was applied with all of the pregnant women at kesugihan public health center (phc) as the treatment group. they were given lectures with media inclusion (contraception booklets and visual aids) and peer-education during a pregnancy class. pregnant women at ngebel phc were the control group. one woman who had experience with lamps was trained as a peer-educator. thirty participants in each group were chosen using the total sampling technique. the data collected was analyzed using univariate and bivariate analyses by applying the wilcoxon signed-rank and mann-whitney tests. results: the participants showed an increased knowledge before and after the intervention in the treatment group (83%), while in control group, it was slightly increased (1%). attitude differences were also found in both groups (treatment = 56.7%, control = 13.3%). the mann-whitney test resulted in significant differences on knowledge (p <0.001) and attitude (p = 0.016) between the two groups. conclusion: the local department of health may optimize ipc using media and peer-education to improve the knowledge and attitude of pregnant women regarding lapm participation. article history received: august 12, 2018 accepted: november 27, 2019 keywords long-acting and permanent methods of contraception (lapms); knowledge of lapms; attitude about lapms; media; peereducation. contact samsriyanigsih handayani  samsri.handayani@gmail.com  faculty of medicine, universitas airlangga, surabaya, indonesia cite this as: ermalia, h. (2019). effect of health lecture using media and peer-education on long acting and permanent methods of contraception. jurnal ners, 14(1), 92-96. doi:http://dx.doi.org/10.20473/jn.v13i2.9373 introduction long acting and permanent methods of contraception (lapms) are known to be highly effective (kemenkes, ri, 2013), with a low rate of failure and more benefits compared to other methods of contraception (hartanto, 2010). lapms are contraception methods that can be used from 3 years up until a lifetime. these include intrauterine devices, hormonal implants, female sterilization and vasectomies (affandi, 2012). the department of health of east java province revealed that lapm participation is still below target. the data shows that only 22.4% of women use lapms from 5,576,723 as the total number of active contraceptive users. lapms are promoted by the government as an effort to lower the rate of population growth (bkkbn, 2016). the improper treatment of population growth will result in a population https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v13i2.9373 h. ermalia 102 | pissn: 1858-3598  eissn: 2502-5791 explosion which can leads to a negative impact on the demography. several issues that have impacted on the negative side of demography bonuses are less jobs for citizens, unemployment problems, a low education rate, severe social effects and a loss of momentum when it comes to money-saving, leading to extreme poverty (kominfo, 2014). health problems will also emerge, specifically for mothers and children (kemenkes ri, 2016). the increase in lapm participation can be the solution to preventing further problems. despite this fact, many factors are involved in lapm participation such as culture, society, the economy, educational background, health facilities and family planning programs. this is in addition to health practitioner-related issues (shodiq, 2016). the role of health practitioners is essential especially during health education and interpersonal communication (hic) related to lapm participation (hartanto, 2010). media presence and interactive messages can affect health education (notoatmodjo, 2010), contributing to the success rate of contraceptive use (hartanto, 2010). most of the hic conducted by health practitioners is interpersonal counseling focused on the contraception candidate acceptor (kemenkes ri, 2014). in this study, using peer-education as a novel method to introduce contraception, we sought to determine the importance of proper health education. this research thus aimed to analyze the influence of media usage and peer-education on the knowledge and attitude of pregnant women related to lapm participation. materials and methods the locations of this research study were 2 pregnancy classes in kesugihan public health center (phc) and ngebel public health center, ponorogo region. the research design for this study was quasiexperimental with a non-randomized control group pretest-posttest. the population of this study was all of the pregnant mothers in kesugihan phc as the treatment group and those in ngebel phc became the control group. the study variables were knowledge and attitude toward lapms among pregnant women. a total of 30 participants for each group were calculated using the federer formula and they were chosen using non-probability sampling as the total sampling technique. all of the pregnant women were chosen as the sample based on the selected inclusion criteria i.e. registered to a pregnancy class, spoke bahasa indonesia and they had graduated from middle school. pregnant mothers with a pathological history and who had experienced an obstetric emergency were excluded from the study. the intervention applied consisted of a 45-minute lecture, media (booklet) distribution that had previously been tested for its clarity and a 45-minute session of peer-education by a trained woman who had experience with lapms. the media (booklet) was written by the national family planning board (bkkbn) and it was tested for clarity. some modifications to the booklet were applied following the test results. the peer-educator was trained to share her experience guided by a list of topics. the intervention ended with a discussion. the data was collected by giving preand post-tests for both groups during a pregnancy class. the posttest was conducted at the end of the session. the preand post-tests were conducted on the same day without a recess. the questions in the preand posttests were tested for reliability and validity. the overall cronbach’s alpha for the 8 questions on knowledge were 0.644 and the coefficient for the 8 questions on attitude was 0.958. the validity test using the pearson product moment correlation revealed coefficients from 0.376 to 0.612 for the 8 questions on knowledge and 0.725 to 0.981 was found for the 8 questions on attitude. the data was analyzed using univariate and bivariate analyses. the wilcoxon signed-rank test was used to analyze the difference in knowledge levels and the attitude before and after treatment in each group. the mann whitney test was conducted to analyze the difference in their increased knowledge and the altered attitudes between the groups. ethical clearance was obtained from the ethical committee on health research of the medical faculty of universitas airlangga number331/ec/kepk/fkua/2017 and the badan kesatuan bangsadan politik of ponorogo district number 0721/01/405.30/2017. results the participants’ characteristics within the control and intervention groups are as shown in table 1. table 1 showed that the respondents from both groups had similar characteristics. the knowledge and attitude scores of the control and intervention groups are as shown in table 2. the wilcoxon signed-rank test resulted in a p of 0.00 (p<0.01) showing a significant knowledge difference before and after the intervention in the treatment group. the wilcoxon signed-rank test resulted in a p of 0.317 (p>0.05) for the control group, thus showing no difference between the pretest and post-test. the wilcoxon signed-rank test resulted in a p of 0.000 (p<0.05), indicating a significant attitude difference in the treatment group before and after the intervention and a p = 0.102 (p>0.05), suggesting no attitude difference in the control group. jurnal ners http://e-journal.unair.ac.id/jners | 103 the mann whitney test resulted in a p of 0.000 (p<0.01) concerning the influence of media usage and peer-education on the participants’ knowledge related to lapm participation. it showed there to be a significant difference in knowledge increase between the control and treatment groups. he mann whitney test resulted in a p value of 0.016 (p<0.05) for the attitude difference between the control and treatment groups. discussion the knowledge of the pregnant mothers in the treatment group showed a statistically significant increase after the intervention which proved that the information delivered likely affected the cognitive level of the individuals (maulana, 2009). the pretest, intervention and post-tests were conducted on the same day without recess. this did not give the participants a chance to gain knowledge from sources other than the intervention itself. it thus explained the knowledge difference that resulted from media usage and peer-education related to lapm participation between the control and treatment groups, which proved effective. this result was also similar to that of a previous study which found there to be an increase in the participants’ knowledge regarding the use of iuds after an audiovisual intervention among women of a reproductive age (19.49%) (ratnawati, 2016). despite the different media utilization, the stated findings supported the idea that better knowledge regarding contraceptive methods occurred after the media interventions. however, peer-educations table 1. participants’ characteristics in the control and intervention groups variable control group treatment group n p n % n % n % age 20-30 years-old 31-40 years-old 19 11 63.3 36.7 16 14 53.3 26.7 35 25 58.3 41.7 0.510 total 60 100 education middle school high school college 14 13 3 46.7 43.3 10 13 13 4 43.3 43.3 13.4 27 26 7 45 43.3 11.7 0.417 total 60 100 occupation unemployed employed 16 14 53.3 46.7 22 8 73.3 26.7 38 22 63.3 36.7 0.825 total 60 100 gravida primigravida multigravida 5 25 16.7 83.3 6 24 20 80 11 49 18.3 81.7 0.221 total 60 100 child alive nullipara 1 child 2 children 7 18 5 23.3 60 16.7 8 16 6 26.7 53.3 20 15 34 11 25 56.7 18.3 0.266 total 60 100 postpartum contraceptive plan permanent spacing the pregnancy postpone the pregnancy 2 5 23 6.7 16.7 76.7 4 26 0 13.3 86.7 0 6 31 23 10 51.7 38.3 0.495 total 60 100 contraceptive participations history at least once none 23 7 76.7 23.3 22 8 73.3 26.7 45 15 75 25 0.896 total 60 100 history of contraceptive methods lapms non lapms no history of contraceptives 7 16 7 23.3 53.4 23.3 4 18 8 13.3 60 26.7 11 34 15 18.3 56,7 25 0,663 total 60 100 reasons to withdraw contraception unmet need planning for pregnancy side effect others no history of contraception 2 21 0 0 7 6.7 70 0 0 23.3 3 16 1 2 8 10 53.3 3.3 6.7 26.7 5 37 1 2 15 8.3 61.7 1.7 3.3 25 0.618 total 60 100 h. ermalia 104 | pissn: 1858-3598  eissn: 2502-5791 among pregnant woman was a novelty so it cannot be compared to the other studies’ results. another study also found there to be similar results concerning attitude difference regarding family planning programs before and after the intervention (mahamed & parhkizar, 2012). an attitude difference was found in the treatment group. on the contrary, the control group showed there to be no significant difference between pre-test and post-test. booklets have a great impact in terms of creating judgments and beliefs in individuals. information from the media forms a cognitive foundation for attitude construction (azwar, 2013). if such particular information experiences a strong retention inside someone’s mind, then it is likely to contribute as an affective foundation for constructing judgment as part of a brand new attitude. this may result in a certain attitude towards something. in this study, this attitude is related to positive intention in terms of lapms participation. as the pre-test, intervention and posttest were conducted on the same day without any chances for the participants to interact with the outer world, it can be concluded that the intervention was solely responsible for the improved attitude. a difference in the knowledge levels among the pregnant mothers regarding lapms was found between the control and treatment groups in this study. another study also stated that interpersonal counseling (ipc) affected the women’s knowledge related to contraceptive methods (mahamed & parhkizar, 2012). another study in haiti showed that a peer-education intervention increased the knowledge on short-term contraceptives among women (loh, 2015). the result of knowing something is essential to finding out the answer to particular issues. knowledge is the result after a sensory process related to an object or issue occurs. it then constructs judgment, understanding and actions (potter & perry, 2009). the stated theories and the results of this study indicate that giving a lecture paired with media usage and peer-education has a positive impact when it comes to increasing the knowledge related to lapms. such a thing is possible because by giving a health lecture related to lapms, the participants in the intervention group became knowledgeable which can then be reflected in their mind, increasing their knowledge. things were different in the control group where no intervention was given. no additional lecture about lapms meant that there was no new knowledge. this study also showed there to be a significant difference in attitude between the control and treatment groups. this result was supported by a previous study which also found there to be an attitude difference in treatment group after being counseled on the family planning program and contraceptive methods (mahamed & parhkizar, 2012). another study in shanghai showed similar results after there was an intervention using booklets about health education in nulliparas. the participants’ had a contraception choice postintervention, whereas previously they did not have a choice (he, et al., 2017). there are 3 main components in attitude, with the cognitive factor being one of them. the cognitive component creates ideas that are trusted and that fit with the attitude. according to mann (1986), the cognitive factor comes from the perception and belief on what we call opinion and perception that is derived from several sources (azwar, 2013). compared with the theory stated by azwar, the results of this study show that the treatment group experienced proper information retention which means that they can construct positive opinions which improve the participants’ attitude. on the contrary, with no intervention given in the control group, there was no opinion created as a part of developing a particular attitude related to lapm participation. another factor that made the participants not support the attitude change was the fear of using lamps. another study in ethiopia showed similar results, i.e. the participants’ in the study had no desire to use implants because inserting and pulling them out was a painful process (meskele & mekonnen, 2014). the success of this study should not be separated from the provision of the intervention. the peer-education given by the woman who used lamps provided new insights for the participants. table 2 knowledge and attitude scores of the control and intervention groups intervention group control group pre-test post-test pre-test post-test knowledge mean 58.33 87.08 70.41 69.16 standard deviation 20.59 9.56 17.21 18.49 median 56.25 87.5 75 75 mode 37.5 87.5 75 75 attitude mean 53.83 57 47.33 47.71 standard deviation 6.17 7.30 11.50 11.56 median 57.3 59.57 48.24 49.37 mode 59.6 61.64 48.24 57.31 jurnal ners http://e-journal.unair.ac.id/jners | 105 conclusion this study suggests that knowledge and attitude improvements can be achieved through a combination of lectures, media use and peereducation. primary health centers are encouraged to apply this education method for better results. the longer term effects of such education need to be checked regularly in the community as knowledge levels and attitude may be affected by time as well as by other members of the community.. references affandi, b. (2012). buku panduan praktis pelayanan kontrasepsi (3 ed.). jakarta: pt. bina pustaka sarwono prawirohardjo. azwar, s. (2013). sikap manusia: teori dan pengukurannya edisi 2. yogyakarta: pustaka pelajar. bkkbn. (2016). laporan kinerja instansi pemerintah 2015. jakarta: badan kependudukan dan keluarga berencana. hartanto, h. (2010). keluarga berencana dan kontrasepsi edisi 7. jakarta: pustaka sinar harapan. he, y., zhang, n., wang, j., he, n., du, y., ding, j.-x., . . . hua, k.-q. (2017). evaluation of two intervention models on contraceptive attitudes and behaviors among nulliparous women in shanghai,china: a clustered randomized controlled trial. biomed central, 14(73), 1-11. doi: 10.1186/s12978-0170331-4. kemenkes ri. (2014). pedoman penejemen pelayanan keluarga berencana. jakarta: direktorat jendral bina kesehatan ibu dan anak kementrian kesehatan ri. kemenkes ri. (2016). 2015 profil kesehatan indonesia. jakarta: kementrian kesehatan republik indonesia. kemenkes, ri. (2013). situasi keluarga berencana di indonesia. buletin jendela data dan informasi kesehatan. kominfo. (2014). siapa mau bonus? peluang demografi indonesia. jakarta: direktorat jendral informasi dan komunikasu publik. loh, h. m. (2015). peer-informed learning on increasing contraceptive knowledge among women in rular haiti. pro quest. mahamed, f., & parhkizar, s. s. (2012). impact of family planning health education on the knowledge and attitude among yasoujian women. global jurnal of health science, 4, 110118. doi: 10.5539/gjhs.v4n2p110. maulana, h. (2009). promosi kesehatan. jakarta: penerbit buku kedokteran egc. meskele, m., & mekonnen, w. (2014). factors affecting women’s intention to use long acting and permanent contraceptive methods in wolaita zone, southern ethiopia. bio med central, 14(109), 1-9. doi: 10.1186/1472-6874-14-109. notoatmodjo, s. (2010). ilmu perilaku kesehatan. jakarta: rineka cipta. potter, p., & perry, a. (2009). fundamental of nursing "fundamental keperawatan". jakarta: salemba medika. ratnawati, i. n. (2016). pengaruh pendidikan kesehatan dengan ceramah menggunakan media audiovisual terhadap peningkatan pengetahuan wus dalam pemilihan kontrasepsi iud di desa manjung, kecamatan sawit, kabupaten boyolali. surakarta: fkm ums. shodiq, m. (2016). faktor yang mempengaruhi rendahnya kepesertaan kb melalui metode kontrasepsi jngka panjang (mkjp) di kabupaten tulang bawang barat. prosiding pertemuan ilmiah ikatan widyaiswara indonesia. 162 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 2, october 2018 http://dx.doi.org/10.20473/jn.v13i1.5613 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research hiv/aids-related knowledge and willingness to participate in voluntary counseling and testing among health sciences university students ni putu wulan purnama sari1 and anselmus aristo parut2 1 faculty of nursing, widya mandala catholic university surabaya, east java, indonesia 2 department of nursing, institute of health science bali, indonesia abstract introduction: health sciences university students (hsus) are susceptible to hiv infection due to frequent contact with patients whose hiv status is unknown. this study aimed to compare the hiv/aids-related knowledge and the willingness to participate in vct among hsus, analyzing the differences between groups, and correlation and effect between variables. methods: this cross-sectional study involved 357 hsus from the faculty of nursing, pharmacy, psychology and medicine at an accredited university. samples were selected using simple random sampling. data analysis used descriptive statistic, pearson correlation, one-way anova test, and linear regression test (α<0.05). results: most respondents were 20-21 years old single female who still live with parents, exposed to hiv/aids material twice/more via academic activities; lack of hiv/aids-related knowledge (51.5%), highest mean found in medical students (73.1%); willing enough to participate in vct (83.5%), highest mean found in nursing students (86.4%). no correlation found between variables (p=0.101), and the regression model was not significant (p=0.101). hiv/aidsrelated knowledge contributed only 0.8% influence on the willingness to participate in vct among hsus (r2=0.008), other unidentified factors possibly play a more important role. conclusion: beside knowledge, other factors like demographic factors, social determinants, close person, health education, fear, and hiv-related stigma may affect the willingness to participate in vct among hsus hsus's knowledge about hiv/aids was low but their willingness to participate in vct was quite high. hiv/aids-related knowledge has a slight contribution in determining hsus's willingness to participate in vct. further analysis of other potential factors is needed to determine stronger predictors. article history received: november 28, 2017 accepted: december 07, 2018 keywords health sciences university student; hiv; knowledge; vct; willingness to participate in vct contact ni putu wulan purnama sari wulanpurnama@ukwms.ac.id  faculty of nursing, widya mandala catholic university surabaya, east java, indonesia cite this as: sari, n.p.w.p., & parut, a. a. (2018). hiv/aids-related knowledge and willingness to participate in voluntary counseling and testing among health sciences university students. jurnal ners, 13(2), 162-170. doi:http://dx.doi.org/10.20473/jn.v13i2.6716 introduction young generations of both men and women aged 1524 are particularly vulnerable to infection with the hiv because young people / teenagers are in the experimental phase including in sexual matters (moore, 2000). students are particularly vulnerable to hiv infection due to lack of knowledge and also lack of parental supervision, especially students living far away from parents, giving them the opportunity to try new things including the sex experience (shiferaw, 2014). health sciences university students (hsus) are even more susceptible to hiv infection due to frequent contact with patients whose hiv status is unknown, especially in a clinical setting. globally, there were approximately 36.9 million people living with hiv at the end of 2017 with 1.8 million people becoming newly infected and 940,000 people died from hiv-related causes (who, 2018). in indonesia, the data from directorate general of disease control and environmental health of ministry of health (moh, 2017) showed that from january to april 2017 there were new cases of hiv found amounted to 10,376 and new cases of aids amounted to 673 individuals. the highest prevalence https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 163 of hiv was in the age group of 25-49 years old (69.6%), followed by a group of 20-24 years old (17.6%), and a group of ≥ 50 years old (6.7%). the highest prevalence of aids was in the age group of 30-39 years old (38.6%), followed by a group of 2029 years old (29.3%), and a group of 40-49 years old (16.5%). the proportion of male: female for hiv/aids was 2:1 (moh, 2017). since last quarter of 2015 until now, who in collaboration with four top universities in indonesia (udayana university, gadjah mada university, padjadjaran university, and atma jaya catholic university of indonesia) established and implemented the hati study (hiv awal/early test and treatment indonesia). the objective is to evaluate the feasibility of interventions aimed at increasing hiv testing and immediate anti retroviral therapy (art) initiation in key populations in indonesia, including men who have sex with men (msm), female sex workers (fsw), waria (shemale or ladyboy) and people who inject drugs (pwid). unfortunately, young generation in term of university students especially hsus was not considered as key population, therefore was not included in those study (who, 2018). men and women are equally likely to be infected with hiv, due to a lack of knowledge about hiv / aids and prevention of transmission. based on the basic health research data, only 13% of youth / adolescent girls and 12% of youth / adolescent boys have comprehensive knowledge about hiv / aids, while the millennium development goals (mdgs) target for youth knowledge is 95% (central bureau statistic, 2012). understanding how the mechanism of hiv transmission is the first step in the process of controlling or preventing hiv / aids infection. voluntary counseling and testing (vct), provider initiating test and counseling (pitc), and home-based hiv counseling and testing (hbct) are the means by which people can know their hiv status. hbct offers a novel approach to complement facility-based pitc and vct, and could greatly increase hiv prevention opportunities (kimaiyo, et al, 2010). vct is one method that is quite effective in reducing and controlling hiv transmission. vct is the key entry point to prevention, care, treatment and support services, where people learn whether they are infected or not and to understand the implications of their hiv status and make informed choices for the future (tsegay, et al, 2013). a study conducted by the world health organization (who, 2004) revealed that the number of people who do vct is very low in countries with high hiv / aids cases. it is estimated that currently only 75% of people with hiv know their status (who, 2018). availability of access to vct and public awareness of vct are keys so that patients with hiv/aids receive antiretroviral therapy (art), and prevent transmission with behavioural changes. counselling is designed to assist patients in interpreting the results of laboratory tests, to change behaviour aiming at prevention of hiv infection and transmission. one area that is the focus of who nowadays is testing and counselling which greatly play a role as the entrance of preventive and treatment stages (who, 2004). the main targets of a national strategy for sexual and reproductive education are to increase youth knowledge about reproductive health and safe sex, to promote and facilitate changes in young people's behaviour, including raising awareness about respect for others, and the ultimate goal is to provide young people with comprehensive knowledge, and motivation for good behaviour especially related to reproductive health (national aids commission, 2009). young people especially hsus have increased susceptibility to hiv infection due to age, low parental supervision, frequent contacts with patients whose hiv status is unknown, and several other factors. this study aimed to compare the hiv/aidsrelated knowledge and the willingness to participate in vct among hsus, analyzing the differences between groups, and correlation & effect between variables. materials and methods this study used a cross-sectional design. this design was implemented because it will produce a prevalence or effect of a phenomenon that is associated with a particular cause (nursalam, 2008). in the context of this study, the research team conducted a health survey at an accredited university in surabaya, indonesia. self-administered questionnaires were used for data collection. the target population was hsus who were active in even semester of 2016/2017 academic year. inclusion criteria were age ≥ 18 years old and willing to be respondent proved by informed consent. the sample size was 357 generated by specific formula measurement for known population size as proposed by nursalam (2008). simple random sampling was implemented. there were137 nursing students, 115 psychology students, 71 pharmacy students, and 34 medical students became study respondents (4 groups of students). the independent variable was the hiv-related knowledge assessed with the kq-18 instrument (carey & schroder, 2002). the kq-18 instrument initially consisted of 45 items developed by carey, morrison-beedy and johnson (1977), then taken only 18 items by carey & schroder (2002) and was named kq-18 after instrument testing procedure. the answer choices are right, wrong, and no idea. each correct answer will be given a score of 5.55; score range was 0-100. the result of instrument retesting to 42 university students in surabaya showed only 4 valid items with r = -0.333 0.336, and medium reliability with chronbach alpha = 0.588. the researcher team decided to keep using the 18 items of kq-18 because very few valid items indicated low levels of knowledge. the data scale was an interval, but to ease the data presentation in results section then the data of knowledge was n. p. w. p. sari et al. 164 | pissn: 1858-3598  eissn: 2502-5791 categorized into three knowledge level: 1) low (total score 0-49), 2) sufficient (total score 50-74), and 3) high (total score 75-100). the dependent variable was the willingness to participate in vct assessed by the general attitudes to vct instrument (mwangi, et al, 2014). this instrument was originally developed by boshamer & bruce (1999) and peltzer & mpofu (2002); then later revised by mwangi, et al (2014). initially the instrument consisted of 41 items in the likert scale format that examined 5 determinants of attitudes toward hiv testing that could indicate a person's willingness to participate in vct, namely: 1) selfperception and community, 2) assumptions of friends, 3) values related to hiv testing, 4) support and confidence, and 5) self-perceived vulnerability. response ranges provided were strongly disagree (score 1), disagree (score 2), relatively agree (score 3), agree (score 4), and strongly agree (score 5). score range was 32-160. instrument testing in kenya showed that there were 9 invalid items, so formed a new instrument consisting of 32 items. instrument retesting to 42 university students in surabaya showed only 18 valid items with r = 0.295 0.671, and high reliability with chronbach alpha = 0.728. the researcher team decided to keep using the 32 items to maintain the integrity of the attitude domain so that comprehensive data could be obtained. the data scale was interval, but to ease the data presentation in results section then the data of willingness to participate in vct was categorized into three willingness level: 1) less/low (total score 32-74), 2) enough/sufficient (total score 75-117), and 3) greatly/high (total score 118-160). ethical clearance issued by the faculty of nursing, universitas airlangga, surabaya (certificate number 360-kepk). other ethical aspects included informed consent, anonymity, and confidentiality. there was no conflict of interest between authors and study funder regarding this study and publication. before filling out the questionnaires, the respondents were given an explanation of the purpose and benefits of the study then they were asked to sign the informed consent sheet. researcher acted as a facilitator during the data collection process. data analysis used descriptive statistic, pearson correlation test, one-way anova test, and linear regression test (α<0.05). results table 1. demography characteristic (n = 357) characteristic faculty of nursing* faculty of pharmacy faculty of psychology faculty medicine frequen cy (n=137) percen tage (%) frequen cy (n=71) percen tage (%) frequen cy (n=115) percen tage (%) frequen cy (n=34) percenta ge (%) age (years old) 18 11 8.03 3 4.23 9 7.83 0 0 19 26 18.98 9 12.68 37 32.17 1 2.94 20 21 22 >22 38 37 17 8 27.74 7.01 12.41 5.84 18 22 14 5 25.35 30.99 19.72 7.04 29 23 7 10 25.22 32.39 6.09 8.70 8 18 4 2 23.53 58.06 11.76 5.88 gender male female 25 112 18.25 81.75 19 52 26.76 73.24 28 87 24.35 75.65 8 26 23.53 76.47 religion catholic christian islam others 60 34 40 3 43.80 24.82 29.20 2.19 25 23 22 1 35.21 32.39 30.99 1.41 39 53 20 3 33.91 46.09 17.39 2.61 14 13 7 0 41.18 38.24 20.59 0 ethnic origins java, sunda, madura batak, padang, mentawai chinese bali, dayak, toraja ntt, maluku, papua others 62 4 1 11 42 17 44.53 2.92 1.46 8.03 30.66 12.41 52 2 7 5 5 0 73.24 2.82 9.86 7.04 7.04 0 61 4 31 9 10 0 53.04 3.48 26.96 7.83 8.70 0 12 0 10 5 7 0 35.29 0 29.41 14.71 20.59 0 high school location surabaya 42 30.66 46 64.79 66 57.39 17 50.00 east java outside surabaya java outside east java outside java 23 2 70 16.79 1.46 51.09 11 2 12 15.49 2.82 16.90 26 4 19 22.61 3.48 8.70 7 3 7 20.59 8.82 20.59 jurnal ners http://e-journal.unair.ac.id/jners | 165 most respondents were 2nd-year students (54.90%), except for nursing students which mostly were freshmen. table 1 showed that in total the majority of respondents were aged 20-21 years old (54.06%) except psychology faculty (19 years), female sexuality (77.59%), single / unmarried / not in any relationship (74.51%), catholic (38.66%) except psychology faculty (christian), javanese (52.38%), marital status single in a relationship married 107 28 2 78.10 20.44 1.46 52 18 1 73.24 25.35 1.41 80 35 0 69.57 30.43 0 27 7 0 79.41 20.59 0 living with parents sibling extended family friends alone spouse others 52 5 21 20 38 1 0 37.96 3.65 15.33 14.60 27.74 0.73 0 28 2 4 15 19 0 3 39.44 2.82 5.63 21.13 26.76 0 4.23 62 7 17 12 11 0 6 53.91 6.09 14.78 10.43 9.57 0 5.22 15 1 4 1 13 0 0 44.18 2.94 11.76 2.94 38.24 0 0 parents monthly income (idr) 500,000 – 1 million > 1 – 3 million > 3 – 5 million > 5 million none 6 91 25 13 2 4.38 66.42 18.23 9.49 1.46 0 48 19 4 0 0 67.61 26.76 5.63 0 1 66 35 12 0 0.87 57.39 30.43 10.43 0 0 0 4 30 0 0 0 11.76 88.24 0 *study result of nursing faculty referred to sari & parut (2017). table 2. primary data characteristic faculty of nursing* faculty of pharmacy faculty of psychology faculty medicine frequen cy (n=137) percen tage (%) frequen cy (n=71) percen tage (%) frequen cy (n=115) percen tage (%) frequen cy (n=34) percen tage (%) exposure to hiv/aids material never once twice or more 9 41 87 6.57 29.93 63.50 7 14 50 9.86 19.72 70.42 22 41 52 19.13 35.65 45.22 1 7 26 2.94 20.59 76.47 media of information** printed media (book, journal, poster, etc) 13 9.49 20 28.17 16 13.91 2 5.88 electronic media (social media, tv, etc) 46 33.58 33 46.48 33 28.70 10 29.41 academic activity (class, lecture) 49 35.77 58 81.69 34 29.57 34 100.00 seminar/workshop 58 42.34 19 26.76 54 46.96 13 38.24 student activities (noncurricular) 4 2.92 1 1.41 8 6.96 0 0 close person (family, friend, teacher, etc) 28 20.44 15 21.13 16 13.91 2 5.88 health education from health care professional (hospital, primary care unit, etc) 43 31.39 10 14.08 19 16.52 2 5.88 hiv/aids-related knowledge*** high sufficient low 8 63 66 5.84 45.99 48.18 4 39 28 5.63 54.93 39.44 0 28 87 0 24.35 75.65 20 11 3 58.82 32.35 8.82 the willingness to participate in vct*** greatly/high enough/sufficient less/low 3 121 13 2.19 88.32 9.49 0 57 14 0 80.28 19.72 0 92 23 0 80.00 20.00 1 28 5 2.94 82.35 14.71 * study result of nursing faculty referred to sari & parut (2017). ** respondents were allowed to choose more than 1 answer. *** this category was made in order to ease the data presentation, and not for purposes of statistical analysis. n. p. w. p. sari et al. 166 | pissn: 1858-3598  eissn: 2502-5791 high school alumni of hs in surabaya (47.90%) except nursing faculty (hs of outside java), living with parents (43.98%), and total parent's income per month more than idr 1 3 million (57.42%) except medical students (> idr 5 million). table 2 showed that in total the majority of respondents had been exposed to hiv / aids material twice or more (59.94%). the majority of media used by respondents to obtain health information about hiv / aids was seminar / workshop activity for students of faculty of nursing and psychology (44.44%), while through academic activities for students of faculty of pharmacy and medicine (87.62%). most respondents of medical faculty possess high hiv/aids-related knowledge (58.82%). table 3 showed that the highest mean of hiv/aids-related knowledge was found in medical faculty (73.12 or sufficient), but the data is the most varied among all (sd=19.08). majority of low hiv/aids-related knowledge was found in the faculty of nursing and psychology (48.18% and 75.65% respectively). all data of hiv/aids-related knowledge was normally distributed (p = 0.138-0.719), except faculty of nursing (p = 0.014). most respondents were willing enough to participate in vct (83.47% in total). table 3 also showed that the highest mean of the willingness to participate in vct was found in faculty of nursing (86.37 or sufficient), but the least varied data was found in faculty of psychology (sd=9.57). all data of the willingness to participate in vct was normally distributed (p = 0.091-0.963). data variance was homogeneous for both variables (p = 0.527-0.817). the data of hiv/aidsrelated knowledge was linear to the data of the willingness to participate in vct (p = 0.597). therefore parametric test may be used for data analysis (pearson correlation test, one-way anova test, and linear regression test). the result of the pearson correlation test showed that there was no correlation found between hiv/aids-related knowledge and the willingness to participate in vct among hsus (p = 0.101). therefore there was no strong basis for pursuing linear regression analysis since this is an important assumption for the use of regression analysis. but, researchers need to make sure that hiv/aids-related knowledge even has no slight influence on the willingness to participate in vct. results turned out to the model of regression [y (willingness) = 86.288 – 0.050 x (knowledge)] was not significant (p=0.101). hiv/aids-related knowledge contributed only 0.8% influence on the willingness to participate in vct among hsus (r2=0.008), other unidentified factors possibly play a more important role. the result of one-way anova test showed that significant differences found among four groups of hsus regarding measured variables (p < 0.05), therefore lsd test was needed to specifically found those differences. table 4 showed that there was no significant difference of hiv/aids-related knowledge found between nursing and psychology students (p = 0.182), but this knowledge was significantly different with pharmacy and medical students (p = 0.007 and p = 0.000 respectively). knowledge of medical students was significantly different among the other faculties (p = 0.000 for each). also, there was no significant difference in the willingness to participate in vct found between medical students and the other faculties (p = 0.143 – 0.542). nursing students’ willingness to participate in vct was significantly different with pharmacy and psychology students (p = 0.006 and p = 0.001 respectively). discussion table 1 showed that most respondents were aged 20-21 years (54.06%). adolescents aged 15-24 are vulnerable to hiv infection due to the strong influence of peer pressure and the development of their sexual and social identity that often culminates in experiments (shiferaw, 2014). the majority of young people in this age group are at risk of hiv table 3. descriptive statistics faculty n hiv/aids-related knowledge willingness to participate in vct mean sd mean sd nursing 137 50.14 17.19 86.37 10.60 pharmacy 71 43.23 17.30 81.99 10.24 psychology 115 47.20 17.05 81.98 9.57 medicine 34 73.12 19.08 83.35 15.26 table 4. least significant difference (lsd) test results: multiple comparison faculty nursing pharmacy psychology medicine hiv/aids-related knowledge nursing 0.000 0.007 0.182 0.000 pharmacy 0.007 0.000 0.130 0.000 psychology 0.182 0.130 0.000 0.000 medicine 0.000 0.000 0.000 0.000 the willingness to participate in vct nursing 0.000 0.006 0.001 0.143 pharmacy 0.006 0.000 0.998 0.542 psychology 0.001 0.998 0.000 0.514 medicine 0.143 0.542 0.514 0.000 jurnal ners http://e-journal.unair.ac.id/jners | 167 infection due to their involvement in unsafe sex, injecting drug use, blood exposure and viral contaminated blood products or unsterile piercing procedures (who, 2004). a descriptive study in kenya proved that age is associated with the implementation of hiv testing (mugoya, 2012). table 1 showed that most respondents were females (77.59%). studies in kenya showed that there were significant differences between men and women in previous hiv testing status and hiv testing. hiv knowledge is higher in men than women. differences are found in stigma against hiv, with women reporting more stigmatization stance than men (mugoya, 2012). vct participants were more likely to be men in namibia (soroses, 2006). men were relatively more likely to take hiv testing than women through vct in rural ethiopia (teklehaimanot, et al, 2016). in this study, differences in knowledge about hiv / aids among male and female respondents were not analyzed further, given the proportion of male-to-female samples is highly imbalanced. table 1 showed that most respondents are single (78.10% in total). marital status was found to be associated with vct participation in namibia (soroses, 2006). the pattern of behaviour change seems to be consistent with marital status (oster, 2012). premarital sex among unmarried couples and high prevalence of hiv among men is associated with a willingness to be tested for hiv (wang, et al, 2010). only 2.52% of unmarried respondents ever had premarital sex in this study. table 1 showed that the study respondents vary in terms of ethnic and religious affiliation. in addition to gender, ethnicity and religion can affect the stigma against hiv that potentially affects willingness to participate in vct. study in namibia showed that cultural groups are significantly associated with vct participation (soroses, 2006); while another study in burkina paso showed that bwaba ethnicity was significantly associated with high hiv risk (sarker, et al, 2005). the broad cultural norms surrounding gender and stigma against hiv influence the behaviour of hiv testing and diagnosis seeking behaviour from marginalized risk populations (lofquist, 2012). cultural group or ethnic need to be further studied in connection to vct utilization, especially in the developing country. table 1 showed that most respondents completed their primary education outside java (30.25% in total). a cross-sectional study in rural ethiopia showed that behavioural factors and health services affect the utilization of vct in rural people. rural people who are better educated and have comprehensive knowledge without stigmatization are more likely to be willing to utilize vct. the origin of the state or province is also strongly associated with the utilization of vct in both men and women (teklehaimanot, et al, 2016). table 1 showed that most respondents still live with their parents (43.98% in total). university students are particularly vulnerable to hiv infection due to lack of knowledge and lack of parental supervision. students who stay away from their parents have the potential to have more opportunities to try new things, including the sex experience (shiferaw, 2014). if most of the study respondents are still living with their parents currently, it can be assumed that the respondents still get enough parental supervision. therefore the possibility to experience premarital sexual activity is less; only 2.52% respondents reported premarital sex. all respondents were not working at the time of data collection, not even being a part-timer. most of their time was spent on campus. the main financial supporters were their parents. individuals who have households with high socioeconomic status and work in non-agricultural sectors are more likely to use vct (teklehaimanot, et al, 2016). table 1 shows that most respondent parents earn a monthly salary of idr 1-3 million (57.42% in total, with the type of occupation, was not identified). this is below the regional minimum wage of surabaya in 2017 (idr 3.2 million). the residential status of respondents is mostly self-owned (46.78% in total). it can be assumed that the socio-economic or social status of the study respondents is lower middle-class. this can affect the accessibility of vct information and services that have the potency to cause fear and stigma against hiv in the community. table 2 showed that most respondents experienced health education of hiv/aids twice or more so far (59.94% in total). the seminar/workshop proved to be the easiest way to obtain hiv/aids-related knowledge among nursing and psychology students (44.44%) and via academic activities for pharmacy and medical students (87.62%). only 20.73% of respondents received health education from a health care professional. hiv-related topics were covered in their academic syllabus but in the different portion for each study program; medical students got more credits for hivrelated topic, followed by the pharmacy, nursing, and psychology students. this is confirmed by the results presented in table 3a which showed that the highest mean of hiv/aids-related knowledge was found in medical faculty (73.12). majority of low hiv/aidsrelated knowledge was found in the faculty of nursing and psychology (48.18% and 75.65% respectively). these two faculties need to more encourage hiv-related topics in their academic syllabus. a study at debre markos university, north west ethiopia (2011), showed that knowledge of hiv, suspected stigma, perceptions of risk, and having heard of the secrecy aspect in vct were associated with the use of vct services among students. their main sources of information are mass media and health care workers (tsegay, et al, 2013). information on hiv is most likely to be more effective if disseminated through mass media (printed or electronics) based on tsegay's study (2013) compared to health education activities alone n. p. w. p. sari et al. 168 | pissn: 1858-3598  eissn: 2502-5791 because of the scope and accessibility of young people today. dissemination of information mainly due to the asymptomatic nature of hiv infection has the potential to be very important in shaping the perceptions of risk, awareness, and willingness to participate in hiv testing (sarker, et al, 2005). most respondents were willing enough to participate in vct (83.47% in total). table 3b showed that the highest mean of the willingness to participate in vct was found in faculty of nursing (86.37). vct proves to be one of the most powerful weapons to stop the spread of hiv / aids. vct is known to be a very important component of hiv/aids prevention strategies, but some studies show low use of vct services especially in developing countries (tsegay, et al, 2013). several studies have also shown that knowledge of hiv is often associated with the individual's desire to participate in vct. table 2 showed that 51.54% of respondents have low hiv knowledge (in total), although most claimed to have been exposed to health education about twice or more so far. table 2 showed that only 1.12% of respondents indicated a strong willingness (greatly) to participate in vct. this is potentially due to low knowledge (51.54%), fear of hiv testing (expressed) and possible stigma against hiv. students who are knowledgeable about hiv have a 3.69 times higher likelihood of using vct services than those without or less knowledge (tsegay, et al, 2013). a study in kwazulu-natal, south africa, showed that despite having a very good knowledge of hiv, a large number of patients referred for vct did not perform hiv testing at the end (orisakwe et al., 2012). this is consistent with this study finding as shown in table 4 that no correlation found between hiv/aids-related knowledge and the willingness to participate in vct among hsus (p = .101). results showed that significant differences found among the four groups of hsus regarding hivrelated knowledge and the willingness to participate in vct (p = 0.000 and p = 0.005 respectively). this result was confirmed in table 4. table 4a showed that there was no significant difference of hiv/aidsrelated knowledge found between nursing and psychology students (p = 0.182), but this knowledge was significantly different with pharmacy and medical students (p = 0.007 and p = 0.000 respectively). knowledge of medical students was significantly different among the other faculties (p = 0.000 for each). however as shown in table 4b, it was shown that there was no significant difference in the willingness to participate in vct found between medical students and the other faculties (p = 0.143 – 0.542). nursing students’ willingness to participate in vct was significantly different with pharmacy and psychology students (p = 0.006 and p = 0.001 respectively). results also showed that there was no correlation found between hiv/aids-related knowledge and the willingness to participate in vct among hsus (p = 0.101). one reasonable explanation is that the knowledge level is very low for most except for medical students, and the willingness result is not as varied. this result was found because knowledge only contributed 0.8% influence in determining hsus willingness to participate in vct, as confirmed by linear regression test results which showed that knowledge of hiv/aids has very slight influence/effect on the willingness to participate in vct among hsus (r2 = 0.008; it means 0.8% influence); 51.54% respondents in total possess low hiv/aids-related knowledge and 15.41% respondents in total have low willingness to participate in vct. a cross-sectional study in northeastern china supports this finding, where greater knowledge about hiv transmission and the awareness that apparently healthy people can transmit hiv significantly associated with greater willingness to participate in free hiv testing (yuan et al, 2012). another descriptive study utilizing data from the demographic health survey in kenya in 2009/2010 also showed that knowledge of hiv, knowing someone who is infected with hiv/aids, and education level was positively associated with the use of hiv testing services and hiv-related stigma (mugoya, 2012). stigma potentially became one of the key factors determining a person's willingness to participate in vct, especially in young people, but unidentified in this study; 99.2% influences still in the hand of other unidentified factors. further study related to stigma towards hiv in young generations, especially hsus, is needed to prove this proposition. hsus is the young generation of health care professionals in the future. awareness of high hiv vulnerability among health care workers should make them more motivated to increase their knowledge about hiv/aids, avoid high-risk behaviours and adopt a healthy lifestyle. increased hiv/aids-related knowledge potentially has implications for lowering stigma against hiv, increasing the willingness to participate in vct, and providing high-quality health care services to the patients, especially for people who are living with hiv/aids. this study has some limitations also. the nature of cross-sectional study with a single time point data collection has made the pattern, consistency, and intensity of variables’ values over time was not assessed. future study needs to incorporate a longitudinal cohort design to improve the present research methodology. in addition, in indonesia there are two types of higher education institutions, one is a private university in which it is charityfunded, and the other is a public university which is government-funded. this study set was confined only to one of the charity-funded institution. therefore, a generalization of the results should be cautioned. dimensions of both questionnaires do not address local issues such as culture and habits. a modification and validation of scale study may be needed. jurnal ners http://e-journal.unair.ac.id/jners | 169 conclusion hiv/aids-related knowledge and the willingness to participate in vct differed significantly among the four groups of hsus in this study. medical students had the highest knowledge level compared to other faculties. most low knowledge levels was found in the faculty of nursing and psychology. as for the willingness to participate in vct, most sufficient willingness was found in all faculties. hiv/aidsrelated knowledge is uncorrelated with the willingness to participate in vct among hsus, but it has a slight influence on it. many other factors unidentified in this study possibly play a more important role in determining hsus's willingness to participate in vct. the use of printed and electronic mass media should be more considered to be a means of sharing information on hiv/aids and vct service utilization to hsus along with seminar/ workshop events on this topic useful for increasing their hiv/aidsrelated knowledge. faculty of nursing and psychology needs to encourage more hiv-related topics in their academic syllabus. another study contains further analysis of other potential factors determining individuals’ willingness to participate in vct should be conducted to identify stronger predictors than knowledge itself, such as stigma against hiv/aids, and provide a greater chance for factors’ modification, so that intervention could be developed to address this issue. references central bureau of statistics, national family parenthood coordination board. (2012). indonesia demographic and health survey: adolescent reproductive health. jakarta: bkkbn. carey, s. (2002). development and psychometric evaluation of the brief hiv knowledge questionnaire. aids education preventive, 14(2): 820172. ministry of health (moh). 2017. development report of hiv/aids and sexually transmitted disease in the first three months of 2017 (in bahasa indonesia). retrieved from: http://siha.depkes.go.id/portal/files_upload/lap oran_hiv_aids_tw_1_2017_rev.pdf directorate general of disease control and environmental health, ministry of health, republic of indonesia. (2017). statistics on hiv/aids cases in indonesia (in bahasa indonesia). retrieved from: www.spiritia.or.id/stats nursalam. (2008). concept and application of research methodology in nursing sciences: script guidelines, thesis, and nursing research instruments, 2nd edition (in bahasa indonesia). jakarta: salemba medika. kimaiyo, s., were, mc., shen, c., ndege, s., braitstein, p., sidle, j., mamlin, j. (2010). home-based hiv counseling and testing in western kenya. east afr med j., 87(3): 100-108. lofquist, da. (2012). hiv testing behaviors of at-risk populations in kenya. dissertation. retrieved from: www.proquest.com moore, s., parson, jt. (2000). a research agenda for adolescent risk-taking: where do we go from here?. journal of adolescence, 23(4): 371-376. mugoya, gct. (2012). social and cognitive factors associated with hiv/aids test uptake in kenya. dissertation. retrieved from: www.proquest.com mwangi, r., ngure, p., thiga, m., ngure, j. (2014). factors influencing the utilization of voluntary counseling and testing services among university students in kenya. glob j health sci., 6(4): 84-93. national aids commission. (2009). republic of indonesia country report on the follow-up to the declaration of commitment on hiv/aids; (ungass) reporting period 2008-2009, pg. 46. jakarta: national committee of hiv/aids management. orisakwe, ee., ross, aj., ocholla, pd. (2012). correlation between knowledge of hiv, attitudes and perceptions of hiv and willingness to test for hiv at a regional hospital in kwazulu-natal, south africa. afr j prim health care fam med., 4(1): #376. oster, e. (2012). hiv and sexual behavior change: why not africa?. journal of health economic, 31(1): 35-49. sari, npwp., parut, ap. (2017). the effect of hivrelated knowledge on the willingnes to participate in voluntary counseling and testing (vct) among nursing students. advances in health sciences research, vol. 3. retrieved from: http://www.atlantispress.com/php/pub.php?publication=inc-17 sarker, m., milkowski, a., slanger, t., gondos, a., sanou, a., kouyate, b., snow, r. (2005). the role of hiv-related knowledge and ethnicity in determining hiv risk perception and willingness to undergo hiv testing among rural women in burkina paso. aids and behavior, 9(2). retrieved from: www.proquest.com shiferaw, y., alemu, a., assefa, a., tesfaye, b., gibermedhin, e. (2014). perception of risk hiv and sexual risk behaviors among university students: implication for planning interventions. bmc research notes, 7(162): 1-8. soroses, fw. (2006). assessment of factors influencing participation in hiv/aids voluntary counseling and testing in namibia. retrieved from: www.proquest.com teklehaimanot, hd., teklehaimanot, a., yohannes, m., biratu, d. (2016). factors influencing the uptake of voluntary hiv counseling and testing in rural ethiopia: a cross-sectional study. bmc public health, 16(239). retrieved from: www.proquest.com tsegay, g., edris, m., meseret, s. (2013). assessment of voluntary counseling and testing service utilization and associated factors among debre markos university students, north west ethiopia: a cross-sectional survey in 2011. bmc public http://siha.depkes.go.id/portal/files_upload/laporan_hiv_aids_tw_1_2017_rev.pdf http://siha.depkes.go.id/portal/files_upload/laporan_hiv_aids_tw_1_2017_rev.pdf http://www.spiritia.or.id/stats http://www.proquest.com/ http://www.proquest.com/ http://www.atlantis-press.com/php/pub.php?publication=inc-17 http://www.atlantis-press.com/php/pub.php?publication=inc-17 http://www.proquest.com/ http://www.proquest.com/ http://www.proquest.com/ n. p. w. p. sari et al. 170 | pissn: 1858-3598  eissn: 2502-5791 health, 13(243). retrieved from: www.proquest.com wang, b., li, x., stanton, b., mcguire, j. (2010). correlates of hiv/std testing and willingness to test among rural-to-urban migrants in china. aids behav., 14: 891-903. world health organization (who). (2004). national aids programs: a guide to indicators for monitoring and evaluating national hiv/aids prevention programs for young people. geneva: who. world health organization (who). (2018). hiv/aids key facts. retrieved from: http://www.who.int/news-room/factsheets/detail/hiv-aids world health organization (who). (2018). hati study: “test and treat” to improve hiv cascade among key population. retrieved from: http://www.searo.who.int/indonesia/areas/com municable_diseases/hiv_cascade/en/ yuan, l., li, x., li, x-x, shi, j., jiang, l., zhang, c., yang, x., zhang, y., zhao, y. (2012). factors associated with willingness to participate in free hiv test among general residents in heilongjiang, northeast china. bmc infectious disease, 12(256). retrieved from: www.proquest.com. http://www.proquest.com/ http://www.who.int/news-room/fact-sheets/detail/hiv-aids http://www.who.int/news-room/fact-sheets/detail/hiv-aids http://www.searo.who.int/indonesia/areas/communicable_diseases/hiv_cascade/en/ http://www.searo.who.int/indonesia/areas/communicable_diseases/hiv_cascade/en/ http://www.proquest.com/ 224 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 14, no. 2, april 2019 http://dx.doi.org/10.20473/jn.v14i2.6154 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research comparison between the qrma measurement with the anamnesis and the capillary blood glucose test muflih muflih, suwarsi suwarsi, and fajarina lathu asmarani university of respati yogyakarta, central java, indonesia abstract introduction: the examination of patients with diabetes mellitus (dm) can be done by reviewing their complaints and through a capillary blood glucose level test to determine the value of their random blood glucose level. qrma (quantum resonance magnetic analyzer) is claimed to be able to check the patient’s bodily condition (including blood glucose) with an accuracy of 85%. the purpose of this study was to verify the validity of the qrma tool and its accuracy by comparing the results of the anamnesis and the examination conducted using the capillary blood glucose test method. methods: the research method used was a cross-sectional design. the total sample consisted of 44 respondents in the working area of the community health centers in yogyakarta with the risk factor being blood sugar level instability. the sampling technique used was purposive sampling. the main variable in this study was the value of the blood sugar level measured based on the coefficient value of the qrma tool and the value of random blood glucose obtained through the capillary blood glucose test. results: the blood glucose value was not correlated significantly with the coefficient value of qrma. the value of blood glucose when examined alongside the result of the respondent's anamnesis showed there to be a significant difference. the value of the qrma coefficient when examined against the results from the history of the respondents showed no significant difference. linear regression showed that the variables of height, body weight, and imt had a correlation with the qrma coefficient value. conclusion: the qrma tool was not able to provide a picture of the actual condition of the blood glucose level of the respondents when compared with the results of the anamnesis and the blood glucose value from the capillary blood glucose test. non-invasive health measurement devices such as qrma are not used by nurses as a standard for determining the health status of dm patients. article history received: october 10, 2017 accepted: january 13, 2020 keywords anamnesis, blood glucose, qrma (quantum resonance magnetic analyzer) contact muflih  muflih1986@gmail.com  university of respati yogyakarta, central java, indonesia cite this as: muflih, m., suwarsi, s., & asmarani, f. l. (2019). comparison between the qrma measurement with the anamnesis and the capillary blood glucose test. jurnal ners, 14(2), 224-230. doi:http://dx.doi.org/10.20473/jn.v14i2.6154 introduction one of the diseases that pose a global health threat is diabetes mellitus (dm). diabetes mellitus is a metabolic disease due to pancreatic beta-cell damage or a glucose uptake in the peripheral tissue due to insulin ineffectiveness (type-2 dm) or a lack of absolute insulin (type-1 dm) (tjokroprawiro, 2007). the diagnosis of diabetes mellitus is determined according to the tools used, which currently varies. one of the non-invasive diagnostic tools available is qrma which can display the coefficient value of the blood sugar level taken. this has not been scientifically tested. the number of dm patients in the world has increased from 346 million in 2004. it is estimated to have increased by 4.4% in 2030 (my & obese, 2004). data from the central bureau of statistics (badan pusat statistik/bps in indonesia) stated that dm patients in indonesia in 2003 totaled 13.7 million and that this figure is estimated to reach 20.1 million people in 2030 (rantung, yetti, & herawati, 2015). riskesdas data (2018) states that 2% of indonesia's population suffers from diabetes mellitus based on https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.20473/jn.v14i2.6154 jurnal ners http://e-journal.unair.ac.id/jners | 225 the doctor’s diagnosis at an age >15 years in the period 2013 – 2018 (kemenkes ri, 2018). blood glucose monitoring is important in order to control and prevent complications (“who guidelines on drawing blood : best practices in phlebotomy,” n.d.). early detection can be done through screening by checking the blood glucose level using a capillary blood glucose test (handelsman et al., 2015). the random blood glucose test is often performed on dm patients through an invasive capillary blood glucose test method focused on the fingertips. based on the tool manual, it is written that the non-invasive qrma inspection tool can display the results of the glucose coefficient in the blood. it is believed to have an accuracy level of 85%. the results of the measurement done with the qrma tool cannot be trusted because there is no scientific basis for it. up until now, no scientific studies have been published stating that this tool is equivalent to the capillary blood glucose test method. therefore, the validity of the measurement of the blood glucose level using the qrma tool should be confirmed by comparing it with the capillary blood glucose test. the comparison of these measurements is expected to provide scientific evidence related to the accuracy of the qrma tool. based on the above description, the purpose of this study is to determine the validity of the results produced by the qrma tool when compared with the results of the anamnesis (when the patient has been diagnosed with dm by a doctor before) and the resulting blood glucose. materials and methods this research study used a cross-sectional design. this study used both correlational and comparative tests in order to determine the validity of the qrma tool. the spearman rank correlation test was used in order see if there were any changes in the coefficient value of the qrma test when compared with the blood glucose value. the mann-whitney comparative test was used to compare the mean coefficient values of the qrma tool and blood glucose with the results of the anamnesis. the testing of the normality of the numerical data was done using the shapiro wilk test (table 2). this research study was carried out in the working area of the community health centers in yogyakarta in september 2017. the sample in this study consisted of the residents in the working area of the community health centers in ngemplak ii, depok, sleman, yogyakarta. they all had risk factors associated with blood sugar level instability. the sampling technique used was purposive sampling (figure 1). the main variable of this study was the coefficient of the blood glucose measured using the qrma tool and the blood glucose value from the capillary blood glucose test method (mg/dl). the confounding variables in this study were gender, age, height, weight, and body mass index (bmi). qrma (figure 2) is a non-invasive medical examination tool that functions to analyze the health of the internal organs by collecting the body's energy frequency using a magnetic field sensor through a hand grip and electrode sensor. the qrma tool used in this research was dm-916-c with application version 4.6.0. the use of qrma began by entering the data for birth time, age, height and weight. the data obtained from the sensor was compared to the health information in the database. this tool takes 1 minute to use with a claimed accuracy of 85%. qrma will show the blood glucose level and other conditions of the body as well as general advice as a precautionary measure (figure 3). figure 2. display tools and screens from qrma figure 3. display of the qrma analysis results related to blood sugar level sample level of accuracy of the qrma measurement qrma comparison with the standard check anamneses & capillary blood glucose level test blood glucose test the validity of the blood glucose measurement with qrma figure 1. research framework muflih et al. 226 | pissn: 1858-3598  eissn: 2502-5791 the capillary blood glucose test was chosen because this measurement is a reference for dm patients in the community. capillary blood glucose testing methods include invasive devices consisting of strips, batteries and a monitor as the main tools used to show the results of the measurements (niwinski, 2009). the capillary blood test can be performed on the little finger, ring finger or middle finger (muktabhant et al., 2012). the tool used in this research was an easy touch gcu. immediate capillary blood glucose measurements were performed after the examination with qrma. to avoid bias related to the limitations of the tool, the researchers ensured that the tool was a new product and that it worked well. the coefficient value of the blood sugar level from both the qrma tool and the capillary glucose test were listed on the researcher’s note sheet. results table 1 shows that the most common sex for the respondents was female (75.0%). a small proportion were confirmed to have diabetes mellitus (9.1%). table 2 shows that the mean age of the respondents was 13.54 ± 13.54 years old (range 1876 years old). the mean value for respondent height was 155.09 ± 6.38 centimeters (range 145-171 centimeters). the average value of the respondent's weight was 56.80 ± 10.70 kilograms (range 40-90 kilograms). the mean value for the respondent's bmi was 23.59 ± 4.09 (range 17.0-35.56). the mean blood glucose value for the respondents was 127.82 ± 57.29 mg/dl (range 53-390 mg/dl). the mean value of the qrma coefficient of the respondents was 4.91 ± 1.79 (range 2.15 ± 7.17). the normality test results showed that only age was normally table 1. distribution of sex and the results of the respondent's anamnesis, 2017 (n = 44) characteristics f % sex female male 33 11 75.0 25.0 anamnesis no yes 40 4 90.9 9.1 table 2. distribution of the age, height, weight, bmi, blood glucose and qrma coefficients, 2017 (n =44) variables min max mean sd ci 95% s-w normality test lower upper age 18 76 45.34 13.54 41.22 49.46 0.285 height 145 171 155.09 6.38 153.15 157.03 0.001 weight 40 90 56.80 10.70 53.54 60.05 0.000 bmi 17.30 35.56 23.59 4.09 22.36 24.85 0.000 blood glucose 53 390 127.82 57.29 110.40 145.24 0.000 qrma coefficient 2.16 7.17 4.91 1.79 4.36 5.45 0.002 description: height in centimeters; weight in kilograms; bmi: body mass index; random blood glucose level in mg /dl; qrma coefficient: quantum resonance magnetic analyzer coefficient table 3. correlation between age, height, weight and bmi with blood glucose and the qrma coefficient, 2017 (n = 44) variables blood glucose level qrma coefficient age 0.194 (0.200) 0.645 (0.071) height 0.478 (-0.110) 0.875 (-0.024) weight 0.803 (-0.039) 0.838 (-0.032) bmi 0.989 (-0.002) 0.803 (-0.039) blood glucose 0.316 (-0.155) description: p-value & (r value) from spearman rank test; random blood glucose level in mg /dl table 4. test of the differences in the blood glucose and coefficient qrma values with the results of the anamnesis, 2017 (n = 44) variables mean sd mean difference se mean ci 95% p-value* lower upper blood glucose yes 264.25 85.877 150.075 42.939 110.323 189.827 0.000 no 114.18 30.857 4.879 qrma coefficient yes 4.531 1.067 0.413 0.534 2.334 1.508 0.768 no 4.944 1.861 0.294 description : *) mann-whitney test jurnal ners http://e-journal.unair.ac.id/jners | 227 distributed (p value 0.285>0.05). the other variables were abnormal (range p value 0.000-0.002<0.05). table 3 shows that age (p-value 0.645), height (pvalue 0.875), body weight (p-value 0.838), bmi (pvalue 0.803), and blood glucose (p-value 0.316) does not have a significant correlation (>0.05) with the qrma coefficient value. similarly, the variables of age (p-value 0.194), body height (p-value 0.803), and bmi (p-value 0.989) showed no significant correlation with blood glucose. table 4 shows that there was a significant difference between the blood glucose values compared with the respondents' anamnesis (p-value 0.000<0.05). in contrast to the value of the qrma coefficient, there was no significant difference when it was compared with the results of the respondent's anamnesis (p-value 0.768> 0.05). the mean value of blood glucose in the respondents who had a blood glucose problem was 264.25 ± 85,877. this is higher than in the respondents who had no blood glucose problem (114.18 ± 30,857). the mean value of the qrma coefficient in the respondents who had a blood glucose problem was 4,531 ± 1,067, which is lower than that of those who did not have a blood glucose problem at 4,944 ± 1.861. table 5 shows the results of the multivariate test and the linear regression of sex, age, height, weight, blood glucose, bmi, and the result of the anamnesis with the qrma coefficient value. the variables with a p value under the alpha value of 0.05 must be removed. in the first stage, the age variable (p-value 0.694) issued. in the second stage, the anamnesis variable (p-value 0.470) was issued. the third stage was where the blood glucose variable (p-value 0.440) was issued. the fourth stage had the gender variables (p-value 0.124) issued. in the fifth stage, the remaining variables of height (p-value 0.044), body weight (p-value 0.040), and bmi (p-value 0.039) had p-values <0.05, so no more variables were issued. discussion the blood glucose value of the respondents did not correlate significantly with the qrma coefficient value. the change (increase or decrease) in the respondent's blood glucose value does not follow the same change as the qrma coefficient value. in the manual, it was described that qrma does not diagnose disease. it only analyzes the condition of the body based on electromagnetic waves. it is not in direct contact with the blood. the data from the qrma tool is analyzed related to blood glucose and the results are shown in the form of three coefficient values, namely insulin secretion, blood glucose, and glucose in the urine (figure 3). in this study, the value used was the coefficient of blood glucose. the normal value range of the blood glucose coefficient via the qrma device is 2,1637,321. a coefficient value >7321 is considered to show an increase in blood glucose and vice versa, a coefficient <2.163 is considered to show a decrease in blood glucose. there was no mention of the usage of frequency (hz) and wavelength (cm). in comparison, there are studies on recording electromagnetic wave radiation focused on objects ingested in the human digestive tract done by (chirwa, hammond, member, roy, & cumming, 2003). the study describes the frequency of the wave used as being 150 mhz and 1.2 ghz. this is in contrast to the qrma tool that came with no detailed explanation of the type and mechanism of how electromagnetic waves work in the qrma tool either in the form of manuals or in published scientific references. the coefficient value of the measurement of blood glucose level using electromagnetic waves through the qrma tool has not been explained. there are various types of electromagnetic wave. they are often used to help establish medical diagnoses in the world of health in the form of xrays (a. radiasi, bidang, untuk, masyarakat, & nuklir-batan, 2008). the use of electromagnetic waves is also in the form of ct-scans and linac therapy. the use of electromagnetic waves in humans will result in radiation. the absorption rate depends on frequency, wavelength, the electromagnetic field polarization, body spacing compared to the wave source and the electrical properties of the body (p. radiasi, elektromagnetik, & swamardika, 2009). complaints resulting from the use of this technology include chronic fatigue, headache, and ringing ears (kurniawan & wahyuni, 2008). damage to the human body due to electromagnetic waves is due to changes in the balance of free radicals in the biological system (victorya, 2015). the comparison of the qrma coefficient and blood glucose values with the results of the anamnesis the comparison between the qrma coefficient value and the results of the respondent's anamnesis showed there to be no significant difference. this means that the blood glucose problem complained of by the respondents does not match the value of the coefficient from the qrma. this can be seen from the average value of the lower qrma coefficients in the respondents who made a high blood glucose complaint. the assessment of the dm patients can be done through interviews related to the trigger factors, signs and symptoms complained of by the respondents (american diabetes association, 2014). the results of the comparison between the blood glucose value with the anamnesis of the respondents showed there to be a significant difference. this means that the changes in blood glucose value are in accordance with the complaints of the respondents related to their blood glucose problems. this can be seen from the average value of the blood glucose being higher in the respondents with blood glucose problems. the examination of the blood glucose level was done through testing the capillary blood plasma per muflih et al. 228 | pissn: 1858-3598  eissn: 2502-5791 mg / dl unit in accordance with the results of the anamnesis of the client (rajaratnam & pathmanathan, 2011; hillet al., 2011). this indicates that the early detection of dm can be done through an examination of the blood glucose level via the capillary blood test method (schifman et al.,2014; handelsman et al., 2015). the results of the study by (price, leary, & myburgh, 2005) focused on intensive care clients. the study found that there were statistical similarities between the capillary blood glucose measurements and those from venous blood. the capillary blood test method is the act of checking or screening for the level of a certain substance in the blood. the accuracy of results is up to 97% (kotwal & pandit, 2012). various factors can influence the results of the blood glucose measurements including operator technique, environmental exposure and client factors such as treatment, oxygen therapy, anemia, hypotension, and other disease states (tonyushkina & nichols, 2009). the capillary blood glucose measurement when performed by the client independently is likely to involve a faulty blood sampling procedure resulting in an incorrect data result (mazze et al., 1994; montagnana et al., 2009). the results of the study by muktabhant et al. (2012) found that the examination of blood glucose and fasting blood glucose through the capillary blood glucose test method still has low sensitivity. blood glucose measurements using capillary blood samples have been studied by boyd, leigh, & stuart (2005). they found that there was a small but significant difference between the measurement of capillary blood glucose level and that of venous blood. similar results were found by critchell et al. (2007) who stated that the capillary blood glucose level measured through the fingerstick method was not accurate when assessing clients in critical intensive care units (icus). the results did not meet the clinical and laboratory standards institute (clsi). blood glucose examination results from venous blood samples have thus become the most accurate reference available (holmer, ogden, burda, & norris, 2013). the measurement of the capillary blood glucose level can be attempted near to where the results of a venous blood sample examination were drawn by warming the hands of the clients before the examination (hospital, 1992). this is possible because of the effect of arterial vasodilation on the hands of the client. the examination of blood glucose levels performed in a non-invasive manner is still being developed. the results of a pilot study by larin, eledrisi, motamedi, & esenaliev, (2002) suggest that there is a significant correlation between changes in the non-invasive optical coherence tomography (oct) signals with the concentration of blood glucose during the trial. variables of height, weight and bmi are the determinants of qrma coefficient the results of the multivariate linear regression test showed that the variables of height, weight, and bmi have a correlation with the qrma coefficient value (table 5). this means that the three variables are the determinants, while blood glucose level and the results of the anamnesis are not in accordance with the value of the coefficient for qrma. this proves that dm is a metabolic disease that is hereditary, characterized by hyperglycemia and glycosuria and accompanied by or where there is the absence of acute or chronic clinical symptoms (c. p. guideline, n.d.). dm as a result of a lack of effective insulin in the body is a primary disorder that lies in the metabolism of carbohydrates that is usually accompanied by disorders related to fat and protein metabolism (h. c. guideline, 2014). the fat and protein conditions were estimated from the ratio of height, weight, and bmi. blood glucose levels are found to be influenced by both endogenous and exogenous factors (tirimacco et al., 2010). the endogenous factors refer to the hormonal factors such as insulin, glucagon, cortisol and the receptor system in the muscle and liver cells. the exogenous factors include the type and amount of food consumed and the level of physical activity performed. conclusion the limitation in this study was that it did not measure the last time that the respondents had a meal. this meal has an impact on the respondent’s blood glucose level. the qrma tool does not provide an accurate picture of the blood glucose levels of the respondents compared with the results of anamnesis and the blood glucose values determined through the capillary blood glucose test. the change in the respondent's blood glucose value did not follow the same change in the qrma coefficient value. the problem of blood glucose complained of by the respondents did not match the value of the qrma coefficient. the variables of height, weight and bmi are the determinants of qrma. acknowledgment we give our thanks to the ministry of research, technology and the university of the republic of indonesia for funding and supporting the implementation of this research references american diabetes association. (2014). diagnosis and classification of diabetes mellitus. diabetes care, 37((supplement 1) january), s81–s90. https://doi.org/10.2337/dc14-s081 boyd, r., leigh, b., & stuart, p. (2005). capillary versus venous bedside blood glucose estimations. emergency medicine journal, 22(3), jurnal ners http://e-journal.unair.ac.id/jners | 229 177–179. https://doi.org/10.1136/emj.2003.011619 chirwa, l. c., hammond, p. a., member, s., roy, s., & cumming, d. r. s. (2003). electromagnetic radiation from ingested sources in the human intestine between 150 mhz and 1 . 2 ghz. ieee transactions on biomedical engineering, 50(4), 484–492. critchell, c. d., savarese, v., callahan, a., aboud, c., jabbour, s., & marik, p. (2007). accuracy of bedside capillary blood glucose measurements in critically ill patients. intensive care medicine, 33(12), 2079–2084. https://doi.org/10.1007/s00134-007-0835-4 handelsman, y., bloomgarden, z. t., grunberger, g., umpierrez, g., zimmerman, r. s., bailey, t. s., … zangeneh, f. (2015). american association of clinical endocrinologists and american college of endocrinology – clinical practice guidelines for developing a diabetes mellitus comprehensive care plan – 2015. endocrine practice, 21((suppl 1) april), 1–87. hill, n. r., oliver, n. s., choudhary, p., levy, j. c., hindmarsh, p., & matthews, d. r. (2011). normal reference range for mean tissue glucose and glycemic variability derived from continuous glucose monitoring for subjects without diabetes in different ethnic groups. diabetes technology & therapeutics, 13(9), 921-928. holmer, h. k., ogden, l. a., burda, b. u., & norris, s. l. (2013). quality of clinical practice guidelines for glycemic control in type 2 diabetes mellitus. plos one, 8(4), 1–6. https://doi.org/10.1371/journal.pone.0058625 kemenkes ri. (2018). hasil utama riskesdas 2018. jakarta: kementrian kesehatan badan penelitian dan pengembangan kesehatan. kotwal, n., & pandit, a. (2012). variability of capillary blood glucose monitoring measured on home glucose monitoring devices. indian j endocrinol metab, 16(supplement 2), 248–251. kulkarni, a., saxena, m., price, g., o’leary, m. j., jacques, t., & myburgh, j. a. (2005). analysis of blood glucose measurements using capillary and arterial blood samples in intensive care patients. intensive care medicine, 31(1), 142–145. https://doi.org/10.1007/s00134-004-2500-5 kurniawan, b., & wahyuni, i. (2008). hubungan radiasi gelombang elektromagnetik dan faktor lain dengan keluhan subyektif pada tenaga kerja industri eletronik ge di yogyakarta. jurnal promosi kesehatan indonesia, 3(2), 127–133. larin, k. v., eledrisi, m. s., motamedi, m., & esenaliev, r. o. (2002). noninvasive blood glucose monitoring with optical coherence tomography. diabetes care, 25(12), 2263–2267. liu, d., moberg, e., kollind, m., lins, p. e., adamson, u., & macdonald, i. a. (1992). arterial, arterialized venous, venous and capillary blood glucose measurements in normal man during hyperinsulinaemic euglycaemia and hypoglycaemia. diabetologia, 35(3), 287–290. management of diabetes mellitus update working group. (2010). va/dod clinical practice guideline for the management of diabetes mellitus (version 4.). washington. mazze, r. s., ph, d., pasmantier, r., lucido, d., ph, d., murphy, j., … ph, d. (1994). reliability of blood glucose monitoring by patients with diabetes mellitus, 77(august), 211–217. montagnana, m., caputo, m., giavarina, d., & lippi, g. (2009). overview on self-monitoring of blood glucose. clinica chimica acta, 402(1-2), 7-13. muktabhant, b., sanchaisuriya, p., sarakarn, p., tawityanon, w., trakulwong, m., worawat, s., & schelp, f. p. (2012). use of glucometer and fasting blood glucose as screening tools for diabetes mellitus type 2 and glycated haemoglobin as clinical reference in rural community primary care settings of a middle income country. bmc public health, 12(1), 349. niwinski, n. (2009). capillary blood collection: best practices. labnotes, 20(1), 1–8. rajaratnam, h. n., & pathmanathan, s. (2011). how reliable are capillary blood glucose measurements ? sri lanka journal of diabetes endocrinology and metabolism, 1(1), 22–24. rantung, j., yetti, k., & herawati, t. (2015). hubungan self-care dengan kualitas hidup pasien diabetes melitus (dm) di persatuan diabetes indonesia (persadia) cabang cimahi. jurnal skolastik keperawatan, 1(1), 38–51. redmon, b., caccamo, d., flavin, p., michels, r., o’connor, p., roberts, j., … sperl-hillen, j. (2014). diagnosis and management of type 2 diabetes mellitus in adults. institute for clinical systems improvement, 16(7), 1–85. schifman, r. b., nguyen, t. t., & page, s. t. (2014). reliability of point-of-care capillary blood glucose measurements in the critical value range. archives of pathology and laboratory medicine, 138(7), 962-966. suyatno, f. (2008). aplikasi radiasi sinar-x di bidang kedokteran untuk menunjang kesehatan masyarakat. in seminar nasional iv sdm teknologi nuklir (pp. 25–26). yogyakarta. swamardika, i. b. a. (2009). pengaruh radiasi gelombang elektromagnetik terhadap kesehatan manusia. majalah ilmiah teknologi elektro, 8(1). tirimacco, r., tideman, p. a., dunbar, j., simpson, p. a., philpot, b., laatikainen, t., & janus, e. (2010). international journal of diabetes mellitus should capillary blood glucose measurements be used in population surveys ? international journal of diabetes mellitus, 2(1), 24–27. https://doi.org/10.1016/j.ijdm.2009.12.002 tjokroprawiro, a. (2007). buku ajar ilmu penyakit dalam. surabaya: airlangga university press. tonyushkina, k., & nichols, j. h. (2009). glucose meters: a review of technical challenges to obtaining accurate results, 3(4). victorya, r. m. (2015). effects of handphone ’ s electromagnetic wave exposure on seminiferous tubules. jurnal majority, 4(3). muflih et al. 230 | pissn: 1858-3598  eissn: 2502-5791 who. (2010). who guidelines on drawing blood : best practices in phlebotomy. genewa: who document production services. wild, s. h., roglic, g., green, a., sicree, r., & king, h. (2004). global prevalence of diabetes: estimates for the year 2000 and projections for 2030: response to rathman and giani. diabetes care, 27(10), 2569. 122 | pissn: 1858-3598  eissn: 2502-5791 jurnal ners vol. 13, no. 1, april 2018 http://dx.doi.org/10.20473/jn.v13i1.8368 this is an open access article distributed under the terms of the creative commons attribution 4.0 international license original research factors correlated with the intention of iron tablet consumption among female adolescents riri aprianti1, gadis meinar sari1 and tiyas kusumaningrum2 1 faculty of medicine universitas airlangga, surabaya, indonesia 2 faculty of nursing universitas airlangga, surabaya, indonesia abstract introduction: anaemia in female adolescents tends to have a negative impact that is likely to later arise in pregnancy, labour and childbirth. the prevalence of iron deficiency anaemia in female adolescents in indonesia is thirty percent. indonesia runs an iron tablet program for female adolescents. however, with the running of the program, it is not clear what factors are correlated with the intention of iron tablet consumption among female adolescents. the purpose of this study was to analyse the factors correlated with the intention of iron tablet consumption among female adolescents. methods: this research used a cross-sectional design. the sample consisted of 100 students in senior high school in surabaya, chosen by proportional random sampling. the independent variables were parent income, knowledge, perceived susceptibility, perceived seriousness, perceived threats, perceived benefits, perceived barriers, and perceived self-efficacy. the dependent variable was female adolescent intention related to consuming iron tablets. the data was collected using a questionnaire and analysed by a chi square test with a level of significance α<0.05. results: there was a significant correlation between perceived threat (p=0.02), perceived benefit (p=0.01), perceived barrier (p=0.02) and perceived self-efficacy (p=0.00) and female adolescent intention related to consuming iron tablets. there was no correlation between parental income, adolescent knowledge, perceived susceptibility, and perceived seriousness with the intention to consume iron tablets. conclusion: from this research, it has been concluded that the factors related to the intention to consume iron tablets in female adolescents were perceived threat, perceived benefit, perceived barrier and perceived self-efficacy. increasing the confidence of female adolescents in association with the importance of avoiding anaemia by consuming iron tablets is crucial so then they can maintain their health and prevent diseases due to anaemia later on. article history received: may 18, 2018 accepted: august 08, 2018 keywords anaemia; iron deficiency; adolescent; belief; self efficacy contact tiyas kusumaningrum  tiyas-k@fkp.unair.ac.id  faculty of nursing universitas airlangga, surabaya, indonesia cite this as: aprianti, r., sari, g., & kusumaningrum, t. (2018). factors correlated with the intention of iron tablet consumption among female adolescents. jurnal ners, 13(1). 122-127. doi:http://dx.doi.org/10.20473/jn.v13i1.8368 introduction young women are a human resource that will give birth to the future generations of the nation. a phenomenon occurs in indonesia where there is a high prevalence of iron deficiency anaemia in adolescent girls, at 30% (who 2011). anaemia is a problem that must be overcome in young women, because if it continues until pregnancy, labour and childbirth, then it can increase the risk of bleeding in maternal labour and postpartum women. it can also directly increase the risk of maternal mortality (kemenkes ri 2017). the high prevalence of iron deficiency anaemia in indonesian young women has resulted in indonesia being mandated by the world health organisation (who) to run an anaemia prevention program. the program provides iron tablets for girls aged 12-18 years old[9] (kemenkes ri 2014). the provision of iron tablets is at the minimum dose of 60 mg elemental iron and 0.4 mg of folic acid at a dose of once a week, increasing to once a day during menstruation (kemenkes ri 2014). one of the main targets of the national medium-term development plan (rpjmn) 2015 http://dx.doi.org/10.20473/jn.v13i1.8368 https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ jurnal ners http://e-journal.unair.ac.id/jners | 123 2019 in indonesia is an indicator of community nutrition improvement, one of which is the provision of iron supplements (ttd) for young women with a target of 30% by 2019 (kementrian ppn/bppn 2014). the access to the program by girls in school (junior high school and senior high school) is a good alternative choice (who 2011). an anaemia prevention program in surabaya senior high school has been implemented since october 2017, however it was not known how far the intention was of the young women willing to consume the tablets. according to the health belief model (hbm) theory, human intention for their personal health behavioural action is a result of a combination of individual beliefs (perceived susceptibility, perceived seriousness, perceived threat, perceived benefit, perceived barrier, and self efficacy), modifying factors (socioeconomic, knowledge, age, gender, ethnicity and personality), and cues for action (glanz et al. 2015). this study aims to analyse the factors associated with the intention of female adolescents to consume iron tablets as an anaemia prevention effort by using the theory of the health belief model. materials and methods the design used in this research study was a crosssectional approach. the research was done in a high school located in central surabaya. this high school is one of the high schools that have implemented an anaemia prevention programs for female students. this research used the proportional random sampling technique. the sample size was based on calculations, resulting in 100 participants. there were 20 classes in the senior high school where the research was conducted, so the proportion of the total samples related to each class resulted in 5 people. the independent variables in this study were the parents’ income, knowledge, perceived susceptibility, perceived seriousness, perceived threats, perceived benefits, perceived barriers and perceived self efficacy. the dependent variable was the intention of female adolescents to consume iron tablets. the data was collected using a questionnaire. the questionnaire was adapted from annisa and nurmala’s (2018) study. there were 54 questions in the questionnaire that consisted of questions about social economy (parents income), 10 questions about their knowledge of anaemia and iron tablets and questions on perceived susceptibility, perceived seriousness, perceived threats, perceived benefits, perceived barriers, perceived self efficacy, information sources and the intention to consume iron tablets. each participant filled out the questionnaire themselves. the research team was in charge of ensuring that the participants understood the content of the questionnaire and answered it completely. the data was then analysed using a chi square test with a level of significant α=0.05. the statistical software used was spss. results the result of this research showed that almost 58% of the participants had a weak intention to consume iron tablets, and the majority of the participants felt hesitance related to consuming iron tablets. the identification result of the participants’ sources of information about iron tablets showed that 66 people (66%) received information from their school, as many as 16% received information from their family, 11 % received information from their health personnel that is from physicians and 7% never got any information about iron tablets. the participant’s characteristics showed that most of the participants were between fifteen and sixteen years old (86%), were in class x, and most of their parents worked as entrepreneurs. only a small percentage of the parent’s jobs was related to health services. table 2 showed that the respondents who had parents with a low income per month (65.2%) had a weak intention related to consuming iron tablets. most of the participants had sufficient knowledge about anaemia and iron tablets, felt vulnerable to anaemia deficiency, and agreed that anaemia deficiency is a serious problem. however, based on the chi square test, there was no correlation between the parents’ income, knowledge, perceived susceptibility, and perceived seriousness with the intention of the female adolescents to consume iron tablets. based on the data for perceived threat, it showed that most of the participants do not feel threatened by anaemia, but it also revealed that the table 1. participants characteristic participants characteristic number percentage age: 14 15 16 17 total 2 33 53 12 100 2% 33% 53% 12% 100% level of education class x class xi total 53 47 100 53% 47% 100% parent’s job: civil servant entrepreneur sales private employee army physicians home maker university lecturer priest total 25 37 1 27 2 5 1 1 1 100 25% 37% 1% 27% 2% 5% 1% 1% 1% 100% source of information: school 66 66% family 16 16% health workers 11 11% never got information 7 7% total 100 100% r. aprianti et al. 124 | pissn: 1858-3598  eissn: 2502-5791 number of participants who felt threatened had the strong intention to consume iron tablets. the data of perceived benefit and perceived barrier showed that most of the participants didn’t consider iron tablets to be beneficial, and there were barriers to consuming iron tablets. the data on perceived efficacy showed that most of the participants believed that they were able to consume iron tablets beyond their beliefs about the benefits and barriers. the results of the statistical analysis revealed a significant correlation between perceived threat (p=0.02), perceived benefit (p=0.01), perceived barrier (p=0.02) and perceived self-efficacy (p=0.00) with the intention of female adolescents to consume iron tablets. the contingency coefficient on perceived threat, perceived benefit, and perceived barriers was around 0.23, which showed that individual belief and the intention of consuming iron tablets was not closely related. perceived self efficacy had a contingency coefficient of 0.41, meaning that it has a positive sufficient correlation with the intention of female adolescents to consume iron tablets. discussion the results of this study indicated that the factors associated with the intention of female adolescents to consume iron tablets based on hbm theory were individual beliefs, especially in relation to the components of perceived threat, perceived benefit, perceived barrier, and perceived self-efficacy. two other components of individual other beliefs were perceived susceptibility and perceived seriousness, which did not show any correlation with the intention significance. the modification factors of the knowledge and income of the parents, which were also examined in this study, were not shown to correlate to intention. the intention of female adolescents to consume iron tablets in this study shows that the majority of the participant’s intentions were at a weak level. in this study, it was found that the majority of the respondents had a good level of knowledge about anaemia and iron tablets, but generally did not have a strong intention for consumption. this could happen because the knowledge possessed by the adolescents does not provide enough information, so then the teenagers are motivated to consume the iron tablets (compaore et al. 2014). research in vietnam on the factors related to the consumption of supplements, including iron, shows that the intention of women to take supplements, especially iron, is still low outside of pregnancy (nechitilo et al. 2016). research carried out in tigray, ethiopia, revealed that adolescents do not consume iron tablets due to public awareness, misinterpreting that iron tablets are contraceptive pills, religious and moral influences, and a lack of trust in the value of the iron tablet (mulugeta et al. 2015). some studies suggest that anaemia prevention programs in female adolescents were more effective when school-based table 2. the correlation between factors and the intention on consuming iron tablet. female adolescent intention to consume iron tablet total p value contingency coefficient weak strong parents income (per month) n % n % n % low (< rp 3.296.212) 15 65.2 8 34.8 23 100 0.42 0.08 high (≥ rp 3.296.212) 43 55.8 34 44.2 77 100 knowledge: lack 2 100 0 0 2 100 0.46 0.15 sufficient 12 66.7 6 33.3 18 100 good 44 55 36 45 80 100 individual beliefs: perceived susceptibility not feeling vulnerable 30 68.2 14 31.8 44 100 0.67 0.18 feeling vulnerable 28 50 28 50 56 100 perceived seriousness not feeling severe 41 64.1 23 35.9 64 100 0.10 0,16 feeling severe 17 47.2 19 52.8 36 100 perceived threat not feeling threatened 39 68.4 18 31.6 57 100 0.02 0.24 feeling threatened 19 44.2 24 55.8 43 100 perceived benefit not feeling useful 47 67.1 23 32.9 70 100 0.01 0.27 feeling useful 11 36.7 19 63.3 30 100 perceived barrier feeling the barrier 36 69.2 16 30.8 52 100 0.02 0.23 not feel the barrier 22 45,8 26 54,2 48 100 perceived self efficacy do not believe in themselves 37 82.2 8 17.8 45 100 0.00 0.41 believe in themselves 21 38.2 34 61.8 55 100 jurnal ners http://e-journal.unair.ac.id/jners | 125 (mulugeta et al. 2015; rakesh et al. 2015). considering that, in this study, it was also found that most of the respondents get their knowledge about anaemia at school, thus health workers from both primary health services and school health units need to collaborate in school-based anaemia prevention programs. the results of this research showed that most of the respondents had not felt threatened by anaemia. however, for the respondents who considered anaemia to be a threatening thing for them, the intention level was strong. the positive correlation between perceived threat and intention in this research was in line with the results of a previous study by park (2011) , which stated that perceived threat was significantly associated with behavioural intention. this is also consistent with the results by hubbard (2017) which revealed that someone facing a high perceived threat will have more desire to find information about the situation at hand. however, in the contingency coefficient between perceived threat and intention, there was a low correlation. this happened because according to glanz et al. (2015), perceived threat is a combination of perceived susceptibility and perceived seriousness where the perceived susceptibility must be strong enough to produce behavioural changes. from the statistical analysis, it was revealed that in this research, perceived susceptibility and perceived seriousness were not significantly related to the intention of iron tablet consumption. the other significantly positive result in this study was the correlation between perceived benefit and perceived barrier with iron tablet consumption intention. most of the respondents indicated that they did not feel that consuming iron tablets would give them more benefits. however, when viewed from the percentage of the number of respondents related to the perceived benefits, it appears that the respondents who do not feel that they would benefit had a low intention. research related to anaemia prevention programs in india conducted by malhotra (2015) reveals the fact that the rejection by adolescents and their parents was associated with iron tablet supplementation in adolescents. this was because the administration of iron tablets causes side effects that are not well-known by teenagers and their parents. regarding health behaviour and puberty, the perceived benefits have proven to be one of the strongest predictors that can change adolescent health behaviour for the better (shirzadi et al. 2016). if there is a high level of perceived benefit followed by a low perceived barrier, then the better the behaviour that is displayed (shirzadi et al. 2016). perceived barriers are also said to be a cost of implementing new behaviour (araban et al. 2017). perceived barrier can also come from the environment and the people around (park 2011). from the questions on perceived barriers, it was revealed most of the participants were reluctant to consume iron tablets because of its unattractive packaging and the shape of the iron tablets (64%), and also because most of their friends did not consume them (58%). some of them did not like the taste of the iron tablets (44%). for teenagers, environmental influences can be very influential, especially when from their peers. most teenagers will try to adjust themselves to their social group, which can be about socialisation, style of dress, and even the food that they consume. the failure to adjust can make teenagers feel alien to their environment. this study has proven that there was a significant correlation between perceived self-efficacy with the intention of iron tablet consumption. the correlation tests showed that there was a close relationship at the medium level between perceived self-efficacy and the intention of female adolescents to consume iron tablets (r = 0.41). a similar study in indonesia about perceived self-efficacy and perceived benefits showed that there was a significant correlation between perceived self-efficacy and intention, while perceived benefit showed no correlation (annisa & nurmala 2018). gerdawati (2016) analysed the factors related to female adolescent attitude in relation to the prevention of cervical cancer by hpv vaccination at senior high schools in lampung, which found similar result explained that there was a significant correlation between self-efficacy against the attitude present in relation to the prevention of cervical cancer. her argument was that the result may be caused by the existence of peer support and reliable information. another study about predicting intention to take protective measures during hazing in singapore revealed that self-efficacy was associated with the intention to take protective measures during hazing (lin & bautista 2016). a meta analysis study by sheeran et al. (2016) suggested that a modification on attitudes, norms, and self-efficacy can change health behaviour effectively. a study of behavioural intention when conducting a health examination recommends that self-efficacy is the strongest factor affecting a person in relation to carrying out a health check, followed by knowledge about health. the study also mentioned that the various factors that exist in hbm that can influence behavioural intention. self-efficacy is one factor that can directly influence behavioural intention and other perceived factors (huang et al. 2016). self-efficacy is an internal mental process in a person that describes a person's ability to control his behavior (glanz et al. 2015). a person who is able to control his behaviour will increase his intention to carry out a healthy behaviour. conclusion from the results, we can conclude that perceived threat, perceived benefits, perceived barriers and perceived self-efficacy is associated with the intention of female adolescents in relation to consuming iron tablets. perceived self-efficacy is the most correlated factor related to producing intention in female adolescents to consume iron tablets. r. aprianti et al. 126 | pissn: 1858-3598  eissn: 2502-5791 in relation to the intention of female adolescents, it is recommended that the government, through its health department, runs a sustainable program distributing iron tablets for female adolescents, which includes comprehensive health education and a counseling component to improve self efficacy. it is also important that the iron tablet program collaborates with schools to achieve a better outcome. references annisa, f.n. & nurmala, i., (2018). influence perceived benefit and perceived self efficacy with intention of adolescent girls in consuming fe tablet. indian journal of public health research & development, 9(4), p.326. available at: http://www.indianjournals.com/ijor.aspx?target =ijor:ijphrd&volume=9&issue=4&article=063 (accessed: december 27, 2017). araban, m., baharzadeh, k. & karimy, m., (2017). nutrition modification aimed at enhancing dietary iron and folic acid intake: an application of health belief model in practice. the european journal of public health, 27(2), p.ckw238. available at: https://academic.oup.com/eurpub/articlelookup/doi/10.1093/eurpub/ckw238 (accessed: december 27, 2017). compaore, a. et al., (2014). “there is iron and iron…” burkinabè women’s perceptions of iron supplementation: a qualitative study. maternal and child health journal, 18(8), pp.1976–1984. available at: http://link.springer.com/10.1007/s10995-0141443-x (accessed: december 27, 2017). gerdawati, a.s., (2016). analisis faktor yang berhubungan dengan sikap remaja perempuan dalam pencegahan kanker serviks oleh vaksinasi hpv di sma sidomulyo lampung. surabaya: universitas airlangga. universitas airlangga. glanz, k., rimer, b.k. & viswanath, k., (2015). health behavior: theory, research, and practice, wiley. available at: https://books.google.co.id/books?id=phuwcgaa qbaj. (accessed: december 27, 2017). huang, h.-t. et al., (2016). structural factors affecting health examination behavioral intention. international journal of environmental research and public health, 13(4), p.395. available at: http://www.mdpi.com/16604601/13/4/395 (accessed: december 27, 2017). hubbard, a.k., (2017). relationship help-seeking and the health belief model: how the perception of threats and expectations are associated with help-seeking behavior. available at: http://krex.kstate.edu/dspace/handle/2097/38198 . (accessed: december 27, 2017). kemenkes ri, (2014). permenkes ri no 88 tahun 2014 tentang standar tablet tambah darah bagi wanita usia subur dan ibu hamil, available at: chromeextension://oemmndcbldboiebfnladdacbdfmada dm/http://sinforeg.litbang.depkes.go.id/upload/ regulasi/pmk_no._88_ttg_tablet_tambah_darah_. pdf. kemenkes ri, 2017. pusat data dan informasi: situasi kesehatan reproduksi indonesia. , p.8. kementrian ppn/bppn, (2014). rencana pembangunan jangka menengah nasional2015-2019, kementerian ppn/bppn. lin, t.t.c. & bautista, j.r., (2016). predicting intention to take protective measures during haze: the roles of efficacy, threat, media trust, and affective attitude. journal of health communication, 21(7), pp.790–799. available at: https://www.tandfonline.com/doi/full/10.1080/ 10810730.2016.1157657. malhotra, s. et al., (2015). challenges in scaling up successful public health interventions: lessons learnt from resistance to a nationwide roll-out of the weekly iron-folic acid supplementation programme for adolescents in india. the national medical journal of india, 28(2), pp.81–5. available at: http://www.ncbi.nlm.nih.gov/pubmed/2661215 2 (accessed: december 27, 2017). mulugeta, a. et al., (2015). examining means of reaching adolescent girls for iron supplementation in tigray, northern ethiopia. nutrients, 7(11), pp.9033–9045. available at: http://www.mdpi.com/2072-6643/7/11/5449 nechitilo, m. et al., (2016). a qualitative study of factors influencing initiation and adherence to micronutrient supplementation among women of reproductive age in vietnam. food and nutrition bulletin, 37(4), pp.461–474. available at: https://doi.org/10.1177/0379572116647830. park, d.-y., (2011). utilizing the health belief model to predicting female middle school students’ behavioral intention of weight reduction by weight status. nutrition research and practice, 5(4), pp.337–48. available at: http://www.ncbi.nlm.nih.gov/pubmed/2199452 9. (accessed: december 27, 2017). rakesh, p.s. et al., (2015). anaemia among schoolchildren from southern kerala, india: a cross-sectional study. national medical journal of india, 28(5), pp.225–227. sheeran, p. et al., (2016). the impact of changing attitudes, norms, and self-efficacy on healthrelated intentions and behavior: a meta-analysis. health psychology, 35(11), pp.1178–1188. available at: http://doi.apa.org/getdoi.cfm?doi=10.1037/hea0 000387. (accessed: december 27, 2017). shirzadi, s. et al., (2016). determinants of puberty health among female adolescents residing in boarding welfare centers in tehran: an application of health belief model. medical journal of the islamic republic of iran, 30(432), p.7. available at: jurnal ners http://e-journal.unair.ac.id/jners | 127 http://www.ncbi.nlm.nih.gov/pubmed/2821059 7. (accessed: december 27, 2017). who, (2011). prevention of iron deficiency anaemia in adolescents, world health organization, southeast asia regional office. available at: http://www.searo.who.int/entity/child_adolesce nt/documents/sea_cah_2/en/ issn 0000-0000 p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no: 64a/dikti/kep/2010 jurnal ners is a scientific peer reviewed nursing journal which publishes original research and scholarship relevant to nursing and other health related professions, published by faculty of nursing universitas airlangga, indonesia, in collaboration with indonesian national nurses association, east java province. editor-in-chief prof. dr. nursalam, m.nurs (hons) editor: ferry efendi, s.kep., ns., m.sc., phd retnayu pradanie, s.kep., ns., m.kep. praba diyan rachmawati, s.kep., ns., m.kep. laily hidayati, s.kep., ns., m.kep technical editor: gading ekapuja aurizki, s.kep., ns. nadia rohmatul laily, s.kep., ns., m.kep. lingga curnia dewi, s.kep., ns., m.kep. dimas dwi arbi, s.kom. editorial address: faculty of nursing universitas airlangga campus c jln. mulyorejo 60115 east java, indonesia phone/fax: (031) 5913257, 5913257, +62 812-5952-8787 e-mail: secretariat_jurnalners@fkp.unair.ac.id website: http://e-journal.unair.ac.id/index.php/jners publication schedule jurnal ners is published semi-annually (april and october). manuscript submission the manuscript should be written in ms. word format. figure, illustration, and picture are included in manuscript file. submit manuscript directly to http://e-journal.unair.ac.id/index.php/jners. jurnal ners will automatically reject any manuscript submitted via email or hardcopy. manuscript publishing the editorial board determines feasible manuscript after obtaining recommendations from peer reviewers. manuscript revision is author responsibility, and manuscripts that are not feasible will be returned to the author. acknowledgement to reviewers the editors gratefully acknowledge the assistance of the following people, who reviewed manuscripts for jurnal ners, vol. 12 no. 2 october 2017. 1. dr. abu bakar, s.kep., ns., m.kep., sp.kep.mb. universitas airlangga, indonesia 2. prof. angeline bushy, phd, rn, phcnsbc, faan university of central florida, united states 3. anna kurniati, s.km, ma bppsdmk, ministry of health, indonesia 4. dr. chong mei chan university of malaya, malaysia 5. elida ulfiana, s.kep., ns., m.kep. universitas airlangga, indonesia 6. joko gunawan, phd (cand.) chulalongkorn university, thailand 7. dr. kai-li chen tajen university, taiwan 8. kusman ibrahim, s.kp., mns, ph.d universitas padjadjaran, indonesia 9. prof. lisa mckenna, phd, rn, rm, facn la trobe university, australia 10. pei-lun hsieh, msn, rn, phd (cand.) national cheng kung university, taiwan 11. pi-ming yeh, bs, ms, phd, rn missouri western state university, united states 12. dr. retno indarwati, s.kep., ns., m.kep. universitas airlangga, indonesia 13. sam miller, b.a. (hons.), pg dip clin ed la trobe university, australia 14. s. suriadi, awcs, phd sekolah tinggi ilmu keperawatan muhammadiyah, indonesia 15. susy katikana sebayang, ph.d universitas airlangga, indonesia 16. dr. takdir tahir, s.kep., ns., m.kes. universitas hasanuddin, indonesia 17. dr. teuku tahlil, s.kp., ms. universitas syiah kuala, indonesia 18. dr. titin andri wihastuti, s.kp., m.kes. universitas brawijaya, indonesia 19. dr. wendy abigail flinders university, australia 20. ya-ping yang, ph.d kaohsiung medical university, taiwan p-issn: 1858-3598 e-issn: 2502-5791 accredited by decree of the directorate general of higher education the ministry of education and culture, republic of indonesia no: 64a/dikti/kep/2010 table of content 21. the improvement of student competency in a clinical study in indonesia: what factors played an important role? muhammad hadi, achir yani s hamid, sudijanto kamso, sutoto sutoto, ahmad watik pratiknya, nursalam nursalam, ferry efendi 151-157 22. development of supervision model based experiential learning for the implementation of patient safety goals at teaching hospital in surabaya ita maulidiawati, nursalam nursalam, hanik endang nihayati 158-163 23. improving the services quality of educational staff based on satisfaction and loyalty analysis of nursing students fresty africia, stefanus supriyanto, tiyas kusumaningrum 164-170 24. development of model on mothers self-efficacy in preventing recurrence of nonpneumonia acute respiratory infection among toddlers eliza zihni zatihulwani, tintin sukartini, ilya krisnana 171-179 25. family process with breast cancer patient in indonesia sarah kartika wulandari, yanti hermayanti, ahmad yamin, ferry efendi 180-188 26. the effect of education on parents' "speak up" knowledge regarding patients safety in hospital septy nur aini, sri mulatsih, patricia suti lasmani 189-195 27. physical function–tardive dyskinesia (patd) on critical patients in intensive care unit heru suwardianto, selvia david richard, awal prasetyo, reni sulung utami 196-204 28. the effectiveness of a pain management program on intensify of pain and quality of life among cancer patients in myanmar hein thu, tintin sukartini 205-211 29. improving nursing work services through development model of quality of nursing work life tri ismu pujiyanto, suprihati suprihati, nursalam nursalam, anastasia ediyati 212-218 30. the development of a six sigma–based ulcus decubitus prevention model to respond to adverse events martini sriwulaningdyah, erna dwi wahyuni 219-224 31. the elderly’s satisfaction with the service quality of a community geriatric health programme in indonesia: a cross-sectional study nursalam nursalam, mochamad cholid hanafi, elida ulfiana 225-232 32. relationship between proactive coping and self-care management in patient with pulmonary tuberculosis tintin sukartini, febrina ramadhani, laily hidayati 233-238 33. quality of life and characteristics of colostomy patients kusman ibrahim, skp., mns., phd, ayu prawesti priambodo, aan nur’aeni, sri hendrawati 239-246 34. protective effects of catechins isolate from gmb4 clone green tea against epc in type 2 diabetes mellitus yuly peristiowati 247-252 35. a comparative study of the effects of vibration and electrical stimulation therapies on the acceleration of wound healing in diabetic ulcers yunita sari, s. saryono, eman sutrisna, h. hartono 253-260 36. analysis of the associated factors of boarding time in yellow zone patients in emergency department ahsan ahsan, fitrio deviantony, setyoadi setyoadi 261-266 37. development of leadership and communication skill model on midwifery students in physiological delivery practice sri utami, rekawati susilaningrum, susilorini susilorini 267-277 38. effectiveness of health education family planning guidelines on health beliefs and behaviours regarding family planning methods among married men in myanmar zay yar tun, tintin sukartini 278-285 39. self-care needs in patients with physical immobilization novia shinthia dewie, eka misbahatul mar'ah has 286-295 40. competence of the civil service police unit (cspu) in providing emergency first aid assistance widodo widodo, sumardino sumardino, akhmad rifai 296-300 editorial the nurses have the high load works because of the high demand of healthcare services as well as the shortage of the nurse professionals. universal health coverage implementation in indonesia improve the access which leading to high utilization of health services. this situation would impact to high demand services from the customer side. discussing about the shortage, recent data from asia pacific observatory on health systems and policies review, in 2011, indonesia’s ratio of nurses to population was the lowest among countries in asian region. there are only three provinces, i.e. central java, east java, and west java, which achieve the minimum ratio recommended by who (1.58 nurses per 1000 population). moreover, the ratio in other provinces are still less than 1.00 which indicates that it can be a serious problem. furthermore, the high load lead to the increasing of burnout syndrome among nurses remain an important agenda. there are several factors related to the burnout including mental and emotional exhaustion and the lack of supporting system in the working environment. in responding this issue, christina maslach, a professor emerita of psychology at the university of california at berkeley, had developed a new perspective on burnout which is different and more valuable than the prior concept. she invented the maslach burnout inventory (mbi) which is widely used to measure burnout syndrome worldwide. the concept has broad contributions for healthcare services in general and the nurses’ welfare specifically. as this problem evolves into a serious issue both nationally and internationally, the policymaker also plays important role in creating the practical solutions to prevent the burnout occurrence and decrease its prevalence. besides, there are a lot of unexplored topics regarding the burnout syndrome. therefore, in supporting the decision making process, intensive research related to that topic is required. we encourage the researchers and academicians to conduct the research in order to provide evidence-based practices in decreasing the burnout cases in primary healthcare services, hospital, and other settings. we hope that these attempts could improve the healthcare services in indonesia and enhance the nurses’ performance.